·GENERAL STATEMENT The Postural Symptom-Complex is a distinct chmucal ontily THE CAUSE The Powery Pbase One particular ijpe of fool imbalance, muwd soll of Ibr fool and les produces a series of clated anatomical distortiops ubicb progress from belou spurtrds and combine to produce elongating trestors u bicb way be transaudied in 1arging degrees and locallons to ibe entire central narrows sysleni Tbe Secondary Plase After a roned ime lapse long copraxed dysfunc fron due to cgulation torsion and requality of weigbe wearing thay produce infamodion (non-infections) of 1 Norres (Neuritis) 2 Arteries and Vans (Arteritus and Phlebitis) 3 Aluscles (Myositis) 4 Fascia (Fibrositis) s Ligarrots (Periarthrites) 6 Jomis (Arthritis) THE SYMPTOMS Tbc Primary Pbase General Tosion produces generalized fasigue Local Torsior produces more rool response a single or multiple levels-mub rurable pressures producing different reactions IN THIS PHASE (Nerie tonssop only) CHANGE FROA ERECT TO RECUMBENT POSITION BRINGS PROMPT RELIEF Tbe Secondary Pbase To the card symptoms of None TORSION has be Added bose of secondary (scattered) mflammallons IN THIS PHASE, CHANGE IN POSITION MAY OR MAY NOT BRING RELIEF (aluats delayed) THE TREATMENT Tbe Primary Phase Fixed corrector (contosowsis nuniaxed) blocks Inu ard roll of ibe fool and leg breaks ibe cycle of renix lension and it lores Staploms The Secondary Pbase Adproot tberapy (of conventional types) should be added to correction 10 speed recorers Summary prepared for scientific ahibit-Fatigue and the Varied Neural gras National Convention - Amaian Medical Association, Chiago Illi DOLS, 1948

·THE POSTURAL COMPLEX
Observations as to Cause, Diagnosis and Treatment
By
LAURENCE JONES B.S, MD
Chid Onbopdus Moomb Hospha 1932-1943
Kasa CAT LSSONTİ
Visidag Onbosedie Colors of Libros Hosphal, 1944 1935
Ww) Hosphe 1948-1954
Los degelos Calsforzi
CHARLES C THOMAS
Springfield Illinois
PUBLISHER
U.S.A.

·CHARLES C THOMAS PUBLISHER
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·Eusry scientific sbeory must successfully uribstard i be tests of time and experience

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·Foreword THIS BOOK 1S an unique addition to the extensive literature on the relation of posture to acuralgic pain in various parts of the body As an internist especially interested in rheumatic diseases I have had to deal with many pa tients who would suffer as the day went on increasiog fatigue and pain in the nech, shoulders, bach, legs, and feet These patients would obtain more or less relief by lying dow'n or sitting down Accordingly my attention was arrested by Dr Laurence Jones exhibits on The Postunl Complex at the Conventions of the American Medical Association from 1946 to 1931 Dr Jones has been the first to recognize that the inward rotation of the foot during weight bearing is transmitted through the hip to produce a forward tilt of the pelvis This forward tult of the pelvis in turn exiggerates the exist ing curves of the spine. His observation that the basic mechanical fault lies in the inward rotation of the foot led him to develop 20 ingenious technique for obtaining correct weight bearing This very different technique stresses rigidity Lo spite of the fact I was convinced of the correctness of Dr Jones me chanxcal concepts I hesitated to apply them. The usual orthopedic measures had proved unsatisfactory in the severe cases so often that my patients, as well as myself were skeptial of obtaining mechanial help However in 1952 I had the opportunity to observe the author treat three auses of severe back and leg paios patients who were almost walking on their internal malleolu. The results of his treatment were astounding to me and I subsequently accepted his invitation to study his method with him The author describes his procedures in such detail that any interested physician can determine the corrections necessary for a patient and apply them in the proper shoes The physician will find in this method of treatment an effective solution to much of the problem of postural pain. The approach to the problen us new and much of the materul has never been published The author s original ideas are at variance with much of our accepted teachtags and should stimulate healthy controversy may well be many years before we understand the mechanism that produces neunlgic pains associated with poor posture There may well be a number of different mechanisms Our situation is similar to that of the East India Company when in 1601 it required its sailing ships to carry atrus frut to prevent scurvy among the cren (ni] It ·THE POSTURAL COMPLEX This empirical remedy was successfully used for over 300 years before scurvy 12s produced experimentally in animals It was nother 25 years before the chemical structure of vitamin C was established Even today 22 years Later we cannot say what role ascorbi zad plays at the molecular level 10 metabolism acept in its relation to tyrosiae During the internal between now and the time para mechiassons uc adequately understood, physicians who are called upon to treat paros Assocuted with faulty body mechanics will find in this work of Dr Jones, gratifyingly effective therapeutic measures ROBERT T POTTENGER, M.D Pasadena California ·Preface AN INVESTIGATION 12s started 15 years ago for the sole purpose of devis fog better methods for the relief of localued foot pain for a long time this observer had been profoundly dissatisfied with current methods-all still m widespread use. These rely on flexible shoes with built in flexible supports, varied types of movable urch supports, and other techniques that place their sole reliance on manipulation and exercises Since these methods based on flexibility are quite regularly ineffective it was deaded to go to the opposite extreme and stress rigidity is the major guiding pragple Accordingly it was decided to use only shoes that had a considerable measure of buult in stability and to fix all corrective devices immovably into these shoes Early interest was stimulated by a completely onespected traja of events Using this different method of treatment certain patients were not oply re- Lieved of previously intractable foot pain, but at the same time the commonly Associated nourigu of low back pain, or low back pain with scutia, was given simultaneous benefit. It was quite as difficult to give a logical reason for this connection as to explain why there were some outstanding successes and an almost equal number of fulures With the growth of clinical aperience and improved methods of dug 0051s and treatment, the process of postural serial distortion was recognized. Sbortly thereafter the technique of plastic scenforcement slowly evolved, and with this statistical results have improved in direct proportion to the elimina tron of flexibility with the full realization of the gaps that still exist, many aspects of the problem bave achieved sufficient durity to permit an account og Speculatioas have been reduced to a minimum consistent with proveo clinical evidence, and great stress has been lud on acturacy in the reporting of results Since this is a continung investigation, there will undoubtedly be revisions and additions Finally it should be distioctly understood that this text is aot reserved for orthopedists alone. All practitioners ure equally and vitally concerned Aith the complex problems of the neuralgus LAULENCE JONES M.D 403 Montb Bnford Duis Analy Hills Calderata

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·Acknowledgments GRATEFUL APPRECIATION must be accorded the large number of individ nals who have had a most significant part so the compilation of material. Particularly is this due the many physicians who have become interested in these problems and especially to such, in alphabetical order is M. Wesley Farr El Segundo Califomi3, P X. Krynich, Detroit, Michigan, Royal C. Payns Hollynood, Califomia, Harold E Petersen, San Fernando California, and Robert T Pottenger Pasadena, Califom By adopting this different 4pproach on a considerable scale, they have established invaluable confirma tron. This text has been aded by Norman C Lake, London, England, for per mission to reproduce dassical illustrations on The Evolution of the Foot, and Paul B Hocber New York publisher for permitting reproductions from that monumental contribution, Tbe Bron from Ape so don by Frederick Tilacy Many artists have contributed to the significant medical illustrations that ure such a major part of the text. Particular recognition is made to the earlier participants, such as Angela C. Bartenbock, Chicago Illinois, and Woodrow Wilson, Jr Deaver Colorado Virgiou M Scovell, of Los Angeles, Cali forou, in her first stunt as a medical artist, has performed brilliantly during the past two years to prepare the greater number of figures Wilfred M. Haiinger, staff photographer for the Elmer Belt Urologrcal Group of Los Angelos is responsible for all clinical photographs His special technique for photographic reproduction of radiographs is of exceptiooal character The arduous task of preliminary edition was supplied by Nondes Slocum for several years A special commendation must be awarded Lillian Dean Long Bach, California, un uuthor in her own right, who, fortunately for me, acquured a personal interest in this problem. Her persistent energy over the past two years provided enough irresistible force to not only counter ict the almost immovable procrastination of this writer but provided an additional amount needed to transform - great accumulation of material into a concise monograph. Finally the writer has been gratified by the long time personal interest in this problem of Charles C Thomas Publisher If the reader should con sider this to be an uresting presentation, then his organization should be accorded full measure of credit LJ [d]

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·Table of Contents Page TUL Foreword Preface Acknowledgments List of Illustrations THE POSTURAL COMPLEX Obseri d'OS ON PART 1 1 5 9 18 22 29 33 43 Postard Charge and Erolutionary Adapidions Chupier The General Erolationery Progression 2 The Differentiation of the Fore und Hind Lumbs 3 Bruin Development 4 The Sproal Column and Cord—The Contuner and Cootents PART II Caxses and Ascbanisms 5 The Postural Complex-General Considemtoos 6 Radiographxc Measurements of Pelvic Position 7 The Primary Trigger Mechanism PART ITI Dragnosis The Postural History and Physkal Examination PART IV Trednost 9 The Suutable Shoe-The Reenforcement and Outside Correction 10 The Individual Adjustment of the Sartable Reenforced Shoe 11 The Adjuvant Therapy 12 The Correction of Foot and Body Posture in Children PART V Clinica Erdrdion 13 As Enilution of a comparative Stady 14 A Compendnu of Ullastritive Case Histories 8 61 79 95 107 115 123 128 PART VI Summer 151 15 Summary References Lada 152 133 [w]

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·List of Illustrations 8 20 Pago Frontispiece General Statement-THE POSTURAL SYMPTOM-COMPLEX FIGURES The Evolution of Human Posture 9 2. The Reptilian Human Sheletal Analogies 10 3 Complete Fore and Hood Limb Similarity in the Lemuroids 11 4 The Dual Mechanism of Sapulo-Humeral Stabilization 13 5 Evolutionary Trend to Rigidity in the Primate Foot end the Relation to Body Posture 14 6 Physiologial Differences of Extremnity Movement 16 7 Comparative Effects of Different Body Functions on External Bruin Forms 19 A Comparative Study of Primate Posture and Cerebral Expansion 9 Five Alonth Premature Fetus with Brun and Spinal Cord Exposed 23 10 The Spunal Disparity 24 11 The Disproportionate Length and Width of the Spinal Cord in the Spinal Canal 23 12 The Postural Complex,The Complete Contrasting Mechanisms of Serul Deviation 30 31 13 Antero-Posterior Radiographs (standing) for Difference of Leg Leagths 34 14 Techniques of Radrographic Leg Length Measurement 36 15 Techaique of Standing Lateral Radiograpby A. In Correction 37 B O Platform 38 6 Uocorrected (barefoot) 39 16 AB The First Two Cases Radiographially Demonstratiog Lumbo-Sacral Shift 40-41 Stradard Noo Weight Bearing Nomenclatwe (foot movements) 44 The Complete Segmentul Synchronization of Normal Gut (2 views) 45 19 The Skeletal Rigidity of the Foot -Pliater und Medul Views 46 20 The Primary Maxculas Factors Controlling Foot Movement--The Tibul zod Peracal Shogs 47 21 A B-C The Comparative Effect of Rotatory Movements of Feet on Talar Posu tion 48-49 22 Locke Syocteconization of Lower Extremity Movement (standing) 51 23 Rotatory Movements of the Foot at the Aokle Joint in Euch of the Three Prunary Liner Positions 32 33 24 The Primary Trigger Mechanisto (oper imposed figures) --The Multi ple Effects of Internal Rotation of the Foot 54 "S A B-C A Comparative Study of Ankle Mortie Transections 56 26 ABC A Comparative Study of Ankle Mortre Transections (cootd) 57 27 The Postural Outline Forms Postural History 61 B The Postuns Physical Ermination 62 C Foot Examination 62 Estimation of Leg Loogth from 111c Crest Differentual 64 [r] 17 18 A 28 ·THE POSTULAL COLIPLEX 29 30 31 32 33 34. 33 36. 81 82 37 38 AB 39 40 41 42 43 44 45 46 47 48 49 50 51 52. The Confirmatory (spinal) Leg Tests—Io Supine and Prode Rerum beny 65 Dagnostic Localization-Posterior Surface of the Trunk A Surface Anatomy of Spinal Nerve Root Localization 66 B Fibrositec Pattern of Secondary Inflammatory Changes 67 The General Universal Bimaoul Rotatory Test 70 The Specul Fine or Deltate Test 71 Certain Common Types and Locations of Foot Callouses 72 Foot Inspection and Functional Tests 73 Serial Order for the Preparation of Foot (Measurement) Chart 74 Test und 1 Sumplified Terminology for the Suitable Shoe AB Tests to Determine Structural Strength CD Simplified Terminology for Sboc Structure 80 Examples of Sustable Dress and Walling Shoes of All Ages The Fitting of Shoes The Fiberglas Shell or Inside Counter 83 The Fiberglas Base of the Inside Counter (shell) Preluminary Assembly 84 The Preparation of the Plastic Chemical Compound 83 Chemical Treatment of the Shell (inside counter)-4 Phases 86 Lox Heat Treatment ( cold technique ) --2 Phases 87 The Final Processing 88 The Recogartion and Correction of Antero-Posterpor Shoe Instability 89 Certain Common Typos of Outside Shoe Corrections 90 91 92 Unsightly Metatarsal Bars 93 The Foot Chart-Sammanized Technique of Measurement 95 Armamentarium-Materials Used for Individualized Inside Correction of Sboos 96 Febriatiog Tools (for los de correction) 96 Motor Assembly-(Emery whed and Vacuum dener) 97 The Three Types and sizes of Spooge Rubber loserts (for inside correc tion) 98 Skeletal Structure of the Foot-Plutar and Medial Views 100 Illustrative Foot Chart 101 The Layout—The Assembly of Materials (for indmdualized inade cor rection) 101 The Techorque of Preliminary Measurement (ahoc) for Device Placement 102 The Tacho que und Routine Order of Device Placeoneat (naned phases uod views) 103 104 Rules for Placement of Combined Loog Arch Supports 104 Simplified Ruler Techosque for Checking Anterior Arch Messurement 104 The General Bimasual Rotatory Test (Hudding) for Determination of correction The Relation of Symptoms to the Degree of Correction Modified Bilateral Balanced or Russell Tractioa (on florron) 108 Manipulative Procedore for Metatapo-Phulsageal Firation 109 Slogle Deathermic (loductothermy) Appliator Techniques and Cerrial Maoupalative Procedures (5 views) 110-111 117 Soproe Stretching Everass 113 The Foot "Grusping* Position 114 Mousarepeat of Leg Length Difference in Children (2 ndrognpha) 116 The Correction of Intoeing by Truiamg Straps und Fired Postual Shoe Correction (SYCW) 117 118 A Comparare Statestial Analyse of Chronk Low Back Pun 124-123 Multaple Chronic Postunul Neunlgius (8 draial pbotographs) 1.9-130 33 54. 36 37 58 59 103 106 61 62. 63 65 66 67 AB 68 69 70

·LIST OR ILLUSTRATIONS
71
72
73
74
75
Multiple Postural Neuralgias-ffair Trigger Type (3 clinica
graphıs)
Chronk Low Back Pain and Sciatica--Post-operative Failure
(4 chincal photographs and a sadtograph)
Multiplc Postural Neuralgias complicated by Foot (shoc) Doro.
Chronic Lon Back Pain and ScratkaDix Protnsion and Pelv.
Latron-operative failure (4 radiographs)
Same Patient (cont d) Postural Neuralgias (post encephalitic)
Antero-Posterior Pclrre Radiograph-A Significant Differen
of Leg Lengths
Multiple Postural Neuralgias A Late Complicatoon of severe
myelits Deformities (5 clinical photographs)
Same Patient (cont d) Sercre Structural Scoliosis Corrective Chan
Pelik Angulation (3 radeographs)
Multiple Traumata-Chronic Postural Neuralgias (4 diaxcal pł
graphs)
Same Patient (cont d) Antero-Posteroor Peluxe Radiograph-A Sigi
cant Difference of Leg Lengths-Comminuted Fractures of Ilman
76
77
78
79

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·THE POSTURAL COMPLEX

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·PART I
OBSERVATIONS
ON POSTURAL CHANGE
AND EVOLUTIONARY
ADAPTATIONS
Pago
1
Chapter
The General Evolutionary Progression
2. The Differentiation of the Fore and Hind Limbs
3 Brun Development
The Sproul Columa und Cord-The Container and Contents
18
22

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·CHAPTER ONE The General Evolutionary Progression n a decade it has gradually become been included representing concepts in general ostural imbalance his assumed i ceptance These are not based as much on the ncreasing importance. This vice substantial sands of Darninun theory is on It of the observations that com solid rocks of modern geologial science differeat approaches to the manifold While many 2001ent skeptics have questioned gnosis and treatment time element in the varied religious accounts 1on will differ sharply from present Creation, a scientific parting from the ides of pinion which largely considers that past has given a strong impetus by Hutton in suses from a defect of local origla. oftquoted statement made just before the begins lence will be presented to show that of the Niocteenth Century that he saw no sigi on regularly gives rise to a gen a begioning, no prospect of an end. This col of symptoms, and that both ause but nebulous hypothesis was translated into s A indivisible ust. Great emphasis fact a few years later by William (Strata) Sur be the key that opened the door in the first geological map of the earth s la that deviations in foot planes cause (1799) and later a brief but epochal monogra erul changes in the superstructure. Although frequently described as the 'Father s most standard texts consider the English Gcology it would be more fitting to if it were a separate structure here side him us the Founder of Modern Geology tedly demonstrated that the foot is 1 dassical work he demonstrated conclusively gral part but is actually tbe founda the earth s surface was composed of successive lag or strata, ach containing imbedded fossil rem y recognized from this preliminary as individualized us finger prints Since then here will be described a relation of numerable confirmatory observations have veri Since primary and secondary these characteristic differences that ideatify be due to structural deficiencies, layer The deeper Layers contain the earlier slo it be identified before they can be forms while each of the superimposed succes ill be revealed that the greater cum layers contain related ones that gradually bec uy to the humanoid apright posture more complex. On this fundamental observatio ons are in some respects much like based our present ideas of the general evolution dels A series of gradual changes progression (super position) dert types Vestly more efficient than The demonstration of the geological layers gry ut the latest improved models will ally lengthened variable conjectures as to the i Tous inherent defacts Therefore, to elements of Creation Final conclusne proof a ute the present status of structures, at the beginning of the Twentieth Centurytudy the basic earlier forms and their Atomic Age- with the discovery of radium the details of this evolutionary pro radio-activity from the varied researches of Ro Hutton, Jumes Thon of the Earth. Loodoo, 1788 Lacompanying panoramic figure has Smith, William One of ibs St de Torte Ink (Figure 1) Only salient points have cusk Render Loodor, 1815 [3] SITES ·Cenozolo (Hooten) dag 21 -X hird's Mammo's Modern man Neanderthal man Ano man Chimpanzee Gonila THE POSTURAL CONPLEX ... Aprikes ko Figure 1 The Evolution of Human Posture. A tummary based entirely on geologic (#ratigraphic) evidence. In the center the line of the human soxccession. The lower portion from the wo cellular cumple through the long fish, amphibin and translocal reptiles to the tiny tree shrew at the base of the tree trunk is a general pre mammalen oos. The center line above through the lemur and tanier and the subsequent division is catirely primate. Other raduating lines from the tree shrew demonstrate the extreme diversity of mammalian development ·7 THE GENERAL EVOLUTIONARY PROGRESSION stics gen, Becquerel the Curies and Rutherford It was life was entirely marine From a growing aumber found that urnium orc the source of radium de- of living creatures the only representatives at that composed at i constant nate into lead and helium time with a spinal column was the fish Although By a mathematical formula, the exact age of there is much additional evidence to confirm this any given specimen of uranium ore was then deter starting point, by the simple process of circum mined with great accuracy by analyzing the radio stantial cludination, this representative must be con of urenrum to the disintegration products in any sidered as the progenitors of the entire vertebral In the last portion of this period, . fetu given specimen, namely the proportion of uranium to lad." hardy fish pioneers changed sufficiently to be able to breathe out of water and with further modifia Inspection of the square in the lower nght hand tion were able to make their first hesitant advance comer of the accompanying figure illustrates : series of strata traversed by two upright lines having onto dry land Further developmcat led to the first small umbrella līke tops. This demonstrates pic amphibians, and it ss noteworthy that some of these torually the lava of volcanic intrusion perietrating early vertebrates had not only 1 thoroughly differ antiated skeletal structure, but four atremities which pre-arsting layers with a spread on the surface. possession of This is the material that contains the time defining approximate human form even to the uranrum orç, the radio-active clock. Each of these termiaul segroents with five digits each deposits in tum, with the long lapse of time, are After this beginning of life on the land, there covered by the next succession of layers in certain developed a general swamp-like terrain that has be- Leas, undisturbed by major elevations or shufts, came the coal strata (Figure 1) This era of equable (mountains, valleys) intrusions can be studied climate from pole to pole, has been studied in largely in their original state. At many points suc tensively establishing information of the truositional Cessive zones have been demonstrated to be of great plant and animal life of this important point in depth, frequently more than 20 000 feet Analysis geological time of this uranrum content when present, gives the The oat great cathe Mesozok or Middle Age 1ge of each individual lager under study and when of geology- lasted approximately 150 million years these findings are correlated with the study of fossil Whereas in the earlier Paleozon phase there were remains, un extremely comple but detailed picture only fish and a few amphibian vertebrates this period of evolutioonry progression has finally emerged. is characterized by the development of a great pro- There is general agreement that the deeper layers fusion of differentiated cold blooded reptilian forms of the earth contain no visible remains of living Many of these became exclusively land dwellers creatures, but that simple one-celled and multi and a certain few have been identified us the forms cellular creatures leaving no imprints on the rocks, that preceded modern mammalia Towed the cod must have previously existed for long lepas of time of this period a few tiny rat-shaped mammals bave With this recognition of fossil remains it has been discovered. Stace these are the only represen become possible to divide all rocks into two great tatives found living at this particular period in geoclasses, the basal lifeless structures, and the later logical time, these most egun, by arcumstantial superimposed layers that contain fossil imprints elimination, be considered as the solc incestors of These upper sedimentary strata contain the geo the entire mammalian series Shortly after the first logral history of the earth and an be divided into apparence of this new type of warm-blooded animal tunc phases that coughly correspond with the periods that had hair and oured its young, the Cenozoic or of human history Modern era begros The first-Paleozoic or nogent history phase The branching lines from this small figure show lasted approximately 250 million years and during a few representative examples from the multitude the first and greater portion of this loog period all and demonstrate the puriable development of the Schuchett, Charles, uod Donbur Carlo mature mammalian series on the land, in the sea, Owlions of His tonice Grel o 1th ed. New York, John Wiley bod Sons, Joc, with a few even ardiog the au The line of Bet The Tedroactive Clock, PF 20-23 vertebrate progression that starts with the fish 10 ·8 THE POSTURAL COMPLEX the sea, proceeds on lead through the lung fish, conclusion that the rate of evolutionary progression transitional amphibian and reptile to the small BS increasing at a rapidly accelerating pace. It was mammal at the base of the trunk of the tree, is a slow in the long asaient history phase, picked up general pre mammalian ope. From this point on, speed in the middle ages and has become relatively the main line up the trunk of the tree and its kaleidoscopk in the modern cra. Consequently the breaches include only the various representatives of human of only a few thousand years hence may the primate ( chief" ) groups and is concerned well consider our appearance quite as incongruous solely with comparative phases leading to brumaa us modern man finds that of the Ape-man semanas development. From below uppards there are two from South Africa. All this served only to throw pre-sumun representaties the lemur on the trunk, und the tarsier in the fork of the tree From the into sharper perspective the fact that wbile sbe carib fork the tree branches into the two great final trunks is tery old ibe bunas race is mery joung of primate development to the right, the simian After ibis brief preliminary summary ** dienspi anthropoid division to the left, the representatives will be made to correlate Ibis 10 cortar sigurficaxi of primitive and modern man that probably became poisis in a long series of analonical alterations completely terrestrial about a million years ago Tbeir sum total is responsible for bolbibe strengtbs A study of the catire picture in its relatson to and weaknesses of that unique derergeri derelor the time element, leaves one with the inescapablement recognized as babitsally crect bonas postale ·CHAPTER Tro Are The Differentiation of the Fore and Hind Limbs THE PRECEDING chapter has been devoted to cer the differentiated artremities of the amphibians tain considerations concerning the general colu Although extremities replaced fins steeping protionary progression. To link these with the specific gression continued as these were still placed at the extremity changes that lead to human posture is side of the body rather than under it. It is of par simplified if one accepts the fundamental observa ticular interest bowever, that even in these early tion of Grafton Elliott Smith, It is a fact beyond reptilian forms skeletal structure bears a remark dispute that the divergent specialization of the able sunulanity to the human as regards each com Iruman limbs, one pair for progression, and the ponent part (Figure 2) The fore limbs other for prehension has played a large part in composed of a scapulz, huncrus two bones for the preparing the way for the emergence of the dis forearm, and a hand like terminal segment consist tactly human characteristics This statement 15 ing of small arpal bones and five distinct digits confirmed in the succeeding chapter on Bruin Devel Similarly the hind limbs consist of a true pelvic opment where it will be demonstrated that the hand gıdls, the posterior portion of this including the cannot fully perform its functions as a brava stranu fured lower end of the vertebral columa The remain lator until the foot completely liberates the hand der of the hiod limb and on each side has the fol from weght beariog duties lowing parts, a femur for the upper segmeat and Mans defects are not as usually described de two bones for the lower segment (tībla and fibula) rived only from close suman relatives bat often to which is fixed a terminal segment which is prec Hem from more distant progenitors As regards the trally a counterpart of that found in the forelimb locomotor apparatus one can divide these changes In these arliest specimens and subsequently to the into two separate classes, the first of which can be greater number of quadruped vertebrates fore and termed premammalun, and the second as primate bind limbs continue to have more similarities than changes that differentiate this group from other differences mammals From the great multitude of reptiles of the mid Retuming to Figure 1 10 the anaent history dle geologic ages only certain transitional types, (Paleozoic) phase of geology it will be seen that again by arcumstantul elimination, are considered the single vertebrate representative is the fish Pro as being in the line of eventual mammalmo develop gression through the water is accomplished by the ment. These (theriodont) reptiles have been selected sweep of pectoral and pelvic fins that proped the for two reasons jaw development, and terminal body through the water in much the same fashion limb segments that continue to have five digits as ours move a boat. Since we will be continuously These transitional forms have been described as concerned with the direction of extremity lines of half dog and half alligator force it sbould be noted that here they are directed The shifting of fore and hund limbs from the away from the body lateral position to one that is completely beneath the Toward the end of the ancient history phase there body represents a considerable improvement in the has a transition from the fins of the lung fish to mode of progression. Vaght beanag lines of force Smith, Grafton Elliotr The Erolutes of Ala Loodos, are now directed toward the body is the limbs Oxford Unirehty Pros, 1924 P 36. changed from ours to true supporting members [9] ·05 Shoulder girdle Pelvic girdle Figure Tbe Repoluo-Homo Skeletal Analoges. Qudrupedo Estremity Similare Versas Bipedal Dif ferentiatom (Cocular Lasert) The skeleton of a compla modern mimoilico quadruped (the bison) demonftrating that the trobationary tread torud fore and hiad lomb similarity in tho dess not only per but has become trosbed ·11 THE DIFFERENTIATION OF THE FORE AND HUND LIHBS Slender Loris h hand foot Lemur f n Lemur Potto Mongoz Tbe Figure 3 Complete Fore and Hind Limb Similarity in the Lemuroids. (Photographs in lower ther-Tulocy F Brann from Apr 10 Ma- VOL 1 PP 30-33 Permission of Hoeber Paul B., NY) In the line of the human succession, there was no scription of the series of extremity changes that la thus further change in the lines of atrenity force until finally lead to the present human forms the appearance of the first primates earliest representative the almost complete sumularity Although first found in the late Mesozoic, the of fore and hund limbs continues with the addition first cxample of true wurm blooded mammalian of two new features, the appearance of grasp (predevelopment is shown here at the base of the tree hension) in the terminal segments with function in the early Cenozoic. It is generally considered that improved by rotation in the joints corresponding to the dosest modern prototype to this tiny fellow is the elbows and the knees There is such a striking the tree shrew and from this small begianıng arose resemblance of form and function in fore and had All of the vast and varied types of the mammalian limbs whea the hands and feet are compared, it is order difficult to tell one from the other At the middle of the trunk of the tree and just In the fork of the tree is found another presimian above the tree shrew is the first representatives of -the tarsius or tarsier (Figure 1) Differentiation carly monkey like uunals, termed the presimians between fore and hind limbs begins with this par The primate series starts at this point, the word ticular animal in that it wasionally uses the hund primate being used to designate the first or highest limbs for hopping progression in much the same group of inimals The first of the prosimians is the manner as the langaroo at other times it con lemur i creeping quadruped progressing along 1 tiques lauroid progression of the creeping, lumb by means of a pinchung grasp in all four termi grasping type With further developmeat the next nal prehensile segments (Figure 3) This particular sumaan anthropoid examples, grasping creeping proanunal furnishes a logical starting point for a de STESSION us supplanted by shingog movement using ·12 THE POSTURAL COMPLEX the fore limbs only-(brachtation) In certain mem only slightly modified by ten years of added du bers of the simu tribe this has come to fuil flower ial asperience. The shoulder gudle consists of the for in these animals the fore limbs actually assume scapula and the clavicle linked together by 1 series command. In fact, so adept has thus group become of ligaments at the accordikoclavicular folat, and it in swinguog from place to place by means of the tached to the body in front only at the sternoclavrfore limbs, their ordinary movements put to shame cular junction All of its attachments to the costal the feats of the most accomplished aerialets age ve therefore muscular with the one exception. As regards the fore limbs this ayun changes or Attached to this structure at the gleord os the upper shifts the lines of force. In this mode they become extremity The sternal link is a freely movable joint, bipolar at times being directed away from the body and the net result is that in certain movements the un brachution, at others being directed towards the shoulder girdle seems to float in the art But hun body when quadruped stance is esamed The bind dreds of pounds of weight cannot be lifted on . lombs do not partake in this bipolar development shoulder girdle that boats in the air" It must be siace they continue to be supporting members with fixed and stable As its only siguificant connections the lines of force directed towards the body to the costal age are muscular then stabilization Before attempting to describe the present human must occur through muscular action. anatomial differences between upper and lower The effort stimulus presents many gradatrons and extremities preliminary attention should be directed combinations If effort demands that this Jout be to two particular wreas the shoulder for the upper stabilized, rendered immobile, then simultaneously atremity the foot for the lower Although there the glenoid and the head of the humcrus must be ure certain minor differences in human and simun fixed Just as it takes two parties to make a contract, shoulders comparative anatomy demonstrates com so does it take two point surfaces to make a joint clusively that they must have had the same origin One as the gleord, which belongs to the sapula, and namely the arboreal one But those differences, al the other as the articular surface of the head of the though slight, fumish certain duos as to the undehumerus. Thus, tad distinct muscle systems must be nuble superiority of simuan anthropoid functional involved, those connecting the sapula to the costal performance. It is quite possible that the functional age, and those connectiog the head of the humerus stimulus toward evolutionary wprovement of the to the scapula Let us attempt to aplain the first human shoulder joint was diminished when man left of these two complares. the trees somewhat less than a million years ago Tho is effected by synchronization of muscles During the same period the simuns coatmued to which ause the scapula and clavicle to be pulled improve fore lumb function by their continued resi firmly against the costal age. Once this is accondence in the branches plished the gleoord becomes a fixed point. The Io the human the hind limbs were forced to as chief musclos effecting this are the subdavius und sume more and more the duties of full waght bear the pectonlis minor acting us stabilizers soterrorly ing resulting in the present comparatively advanced the trapezius, major and minor rhomboids, posteri development of the lower extremity and the human orly and the serratus anterior which acts power foot Actually from this usme standpoint of com fully on the vertebral border of the scapula, although parative anatomy the human lower extremity differs it ongioatos anteriorly (Figure 4A) This combined far more than does the upper atremity when these mechanism resembles the guy ropos of a tent pole lumbs are compared with similar structures in bus 10 that, if they act simultan cously they stabilize by naurby coördinates (Figure 1) Let complete counter action thu comparative study by noting outstanding dif The second phase of this problem is, amely ferences of bumsa form and function now present stubilization of the articular sorface of the head of 10 the shoulder of the upper and the foot of the the humerus, the outer side of the joint, by muscles lowo atrenitie The poolder forat - Oberribors on the anatomy od lo 10 article, attention has previously been called porynology food, Laertoce Sore Gjim & Obg 75439 to cestun changes in concept of sboalder function 444 Oct. 1942.

·13 THE DIFFERENTIATION OF THE FORE AND HIND LIMIBS Rhombo dous minor m Rhomboideus major m. Subclavius m Trapezlus M Pectoralis minor Serratus ant me Serratus ant m Antenor view Scapular stabilizers Abstervor view -Anterior component Deltoid m Clavicle . Subscapularis m Humerus Scapula Temes minor m Infraopinatuam Suprospinatus m -Posrerror component Humeral stabilizers Figure 4. The Doul Mochanism of Sapulo-Huneral Stabilizatoo A. The scipulus Habilizers. B The homerul Habil IZCIL. copacting the scapula and the head This is accom become flat, deepened only by a vestigal thin laye plished so the prescace of severe mechanial disad of artilage All of this is the interest of a com vantage. That it can be done at all is a triumph of pletely free range of relaxed motion. But the effor evolutionary adaptation. The upper end of the bu syndrome alls for primary stabilization form fix merus has become a half spheroid the ball of atron of this rounded head 10 a fiat glenoid, and what is descobed us a ball and socket joint. this 13 accomplished by four muscles, usually de A better description would be that it is a ball scribed as short rotators There are actually the Without a socket The fact is that the glenoid has inner humeral components those arising from th ·14 THE POSTURAL COMPLEX THE FOOT kes MIGTAILED MONKEY GIBBON GORILLA MEANDERTHAL MAN MODERN LOW LAND HIGHLAND G s Y V GORILLA HUMAN MACAQUE GIBBON OHIMPANZEE GORILLA FORE FOOT VS HIND FOOT 5672 63% 6QZ 502 502 50% 307 37% 447 GILLOW CHIMPANZE COROLLA HU Figure 3 Evolutionary Treod to Rigidury in the Primate Foot and the Relation to Body Posture. A. Primite philos from the qudraped to crect bopedii posture. B The padual low of prehension (feability)-The shift from lerge toe abduction—The decrease of digat length C The skeletal shifts with locus of tanul nation - The Incorporation of the mettanuls into the rigid uch practure (Permiston, Laks Norman C Th For Figures 13-14 13 Williams & Wilkim, Badmors, Bid.)

·13 THE DIFFERENTIATION OF THE FORE AND HIND LIMBS front of the scapula- the subscapularisend the re- bility The orthopedic and pediatric exponents of maindet from the posterior surface the combined flexibility should recognize that, in no single in stance do the flexible or sem flexible feet of the supraspinatus and infraspinatusteres minor (F18 ure 4B) The dual mechanism of scapulohumeral simian-anthropoid group permit sustained completely morenent permits an almost universal range of erect posture motion in all planes with bipolar lines of force In the composite illustrations of Figure 6 ure Just as every change in the upper extremity would demonstrated the essential differences that have de seem to be designed to improve hand function, so veloped in upper and lower extremity form and every solutionary clunge in the loner extremity is function The dual mechanism of scapalo-humeral controls have been discussed and illustrated There in the direction of improving the function of its terminal segment, the foot A series of pictures se is a distinct and different synchronization at this one arranged from Lahe illustrate the significant rela point in which the scapula follows humeral move tionship of foot development to the acquisition of meat after the 45 abductive angle us attained in habitual crect posture (Figure 5 A, B and C) the ratio of one to three. As regards the remainder This series starts with the simian group and of the arm, the elbow joint or junction of the um igan Ulustrates the similarity of hands and feet in and forearm is almost a pure hinge-type jout. This the early representatives of the prinate series movement is considerably altered however by the the scale progresses through the preanthropoids radial articulation to the ulna, relatively unchanged (Gibbon) to the anthropoid representatives, (chim from the early fore limb of the presimun lemmur pazee and two types of gorillas) it appears that (Figure 1) This permits the radius to rotate around with increasing use of the lower extremities for the ulna and thus tuming of the forearm permits the movements of prodation and supination To favor weight bearing there is a progressive and marked series of shifts from the hand like sunilarity of the continuing prehensility of the hand, wrist joint mofoot touard its eventual human form Prog vely bility is enhanced by two rows of smell arpal bones the large toe loses its abducted thumb-like angula The fingers are completely prehensile. They not only tion to drift toward the present straight line posi can be opened and shut us 1 graspiag unit, but the thumb is placed at a wide angle from the remaining tion with its loag axis parallel to the shafts of the fingers so that it an be opposed to each finger for remaining metatarsi of particular interest, as purposes of fine movement. In short, the entire pointed out by Schultz is the difference that crists upper atremity has become a working unit with a between tho closely related gorillas who have a free universel range of motion designed to improve noticeable difference in their respective large toc the function of its terminal segment, the hand. A alignments when the proportional bone structure summary and postulate governing this particular and of this series of feet is analyzed, it is found that the different physiology of movement will be sumtoes progressively decrease in size losing their finger marized at the conclusion of this chapter like characteristics and, at the same time, the pro The component parts of the lower atremties will portionate size of the heel and other tersal bones be analyzed to complete the comparative study la incrases markedly whec their combined leagth stead of the movable shoulder girdle free of bony is compared to the overall length of the foot Not connections, the lower extremity is firmiy attached until the tarsal length becomes 50% of the total to the rigid pelyx girdle. Whereas the shoulder measurement does there occur the development of gudle is a musnomer in the humo as the scapulac the rigid bumao long arch (Figure 5C) Since the are not linked together as in birds, the two pelvic maintenance of flexbility of the foot has beca bones form an almost immovable unit not only stressed so heavily in the past, it might be well to linked to ach other in front, but to the sacrum beconfirm the observations of Lake and others that in biod. Such sharply limited motion as semains actu the trman foot the trend is steaduy away frou flexi illy aturs more from the movement of adjoining Satrulez, A H Soome distinguisting chanderista of the naghboring structures rather than from the com Douduin ponila. I Nord 151 1944 ponent parts of the pelvis per se The long funnel ·16 THE POSTURAL COUPLEX TABLE OF RELATIVE MOVEMENT RK SOCIZED SCAPHO- KERUL POSITIONS * RAY POUTON HUL ANU KASULAR ANOU Tot i 10 to 1 10 4 10 10 45 OR COMPARATIVE SCAPULAR RANGE a HUMERAL RANCE HALTUIAL LNE OF FORCE LIT PUPTUATION LEFT PROMATION Ailsar Figure 6 Phytologial Dillerences of Extremity Movement. A Se mental independence of morement in the Doo-neglat beanog upper a tremity B Segmentul syachronization of movercot in the weight beurtog lower extremity HABITUAL LINE OF FORCE 1 kuser ·THE DIFFERENTIATION OF THE FORE AND HIND LILIBS shape of previous types bas adapted itself to habitual all segments, as the evolutionary response to uni upright posture by becoming a shallow ead widened lateral independent weight bearing basin Movement is sharply restructed in the hip Self imposed experiments will conclusively de joint when this is compared to the shoulder Instead monstrate those differences Onc an demonstrate of the flat glenoid there is a cup-shaped acetabulum by ones own morements that the hand forearm, which saugly fits the rounded head of the femur to arm, and shoulder can be placed in an infinitely greatly improve the stability demanded by unilateral varied number of positions, as regards ach individ weight bearing ual joint, without the movement of one ausing 1 Rotation in the leg or lower portions of the ex change of position in the adjoining structures con tremity as found originally in the presimian lemur tinuing self-experiment, in the standing position und still present in the forearm of the human, bas inspect the bared foot and leg to a point above the completely disappeared in the leg The knee is a knee joint. First roll the foot toward its janer perfect hinge joint permitting only forward and border and then toward its outer border Note that backward motion without this being altered by rota with the slightest rotatory movement of the foot in tory movements of the tibia on the fibula. In fact, either inward or outward direction there is an a these two bones (tibia and fibula) are linked to each actly comparable and corresponding movement 10 other so tightly above and below as to become func the entire remaining segments of the lower extremity tronally a single bone The lower cad of these two from the ankle to the hup joint tightly conjoined bones unite to form the ankle These differences in the phystology of upper and mortice designed to snugly fit the uppermost of the tursal bones the talus Here agun, just us in the lower atremity movement ue illustrated in the combined illustrations of Figure 6 When the two knee jonnt, is a pure hinged type joint permatting fora'urd and backward movement, with little or no extremities are compared to this way the tremend lateral movement at this precise point. Benath the Ous differences wrought by evolutionary adaptation talus lies the aulanaus or heal boas, and here is the become evident. oaly point in the lower extremity in which, during In the upper extremity below the shoulder joint, weight bearing there is a small but completely optimum functional performance, freed from the synchrooized lateral movement Even hers, lateral duties of weight bearing, demands a complete seg movemcat has become severely restricted. mental independence of movement, Viz, molemens The foot has evolved into a ngid orgia with the in one segment is not transmitted to orbers la the tursal bones fused to the metatarsals to form 1 ngid lower extremity complete segmental synchronize loog arch, & milery structure designed to bear tbe tron of the component parts is a prime requisite to entire body weight urtbibe complete bipedal alter the primary function of independent voilateral ndion of sal Whereas the upper extremity has weight bearing, viz., roldory motowent of any one directed all evolutionary changes toward the main segment in the slading or u eigbi bearing position tenance of flexibility the lower extremity has is immediasily and equally transmitted to the online staadily developed towards an merased rigidity in structor ·CHAPTER THREE Brain Development The DeVELOPMENT of basic differences in the a translate these ideas into skilled acts This alonc im trecauties were accompanied by a comparable series mediately places the human race ja s distinct ate of changes in the central nervous system and the gory separating it from other living creatures by a vertebral columns In fact, the theory was first pro- chasm 2s wide as the Grand Canyon To control pounded by Smith, and later confirmed by Tilney' adequately the great differences of function in up that the improved type of primate brain was largely per and lower extremities there must be developed dependent on the information obtained by the pre an extremely improved and infinitely more complex housile hand When the head is completely freed brain. If examples of bruin development ia general from the duties of weight bearing by the develop are studied from the simplest to the more compler ment of a suitable (human) foot, the brain types it will be found that in all living things differ achieres the advanced development of the human aces in body function determine not only the in type. ternal structure but the gross shape of the brain as The human brain is aot only the foest product, well but the supreme achievement of comparative evolu A composite picture has been assembled and re trop It is this organ that enables us not only to uranged from Tilne sbon mg examples of these communicate concrete und abstract ideas but to changes in external form (Figure 7) In the upper line is the automatic mid bram of the fish, alipost Smith, Ghetoa Elliott Tor Esoletos of Mo Lodos. Su Gufton Elliott Smith, ALA, BID FRS 1871 1937 u without bighet centers In the second line are repreaquestionsbly the greatest figure in the study of comparttive sentatives of amphibian, reptilian, and bud brains cvolution of the boun. Over a period of 10 fans he wrote a which show the begioong development of the rent number of dental antico co Vous aspects of the higher centers (cerebrum and cerebellum) In the subject and ope mall volume designed for popular consumpthon, namely Tbr Es watios of Ala He wu the fire to ton third row are the varied mammalian brains that illusthe the scopalliam (or clouk) to dexibe the gradual de trate adequately that difference of function results meloponent of the cerebrum un corer for the saked old-brain 102 concomitaot change of form of the lower vertebrates Tulocy Frederick The Bron from Ap 10 Alor 2 rols. Returning to the base of the tree in the first figure, New York, Hoeber one will find the varied representatives of the prim- Frederick Tlocy w long time prolasor of neurologi ate succession (the presimuan, the umiao anthropoud, Columbus Uaireauty While he vi en nodepcadett inredator and human series) have one thing in common, preod coatempory of Smith, detr priority should be accorded hensile terminal sements for their fore and hund Smuth for fru formuladog this particular concept of evolu Iunbs tocary programuoa. Tilocy. Oncyclopedic two rolarne work It would seem, therefore, that they com Th Bw.fr 4 to Mut confront the audiet Obrerias mon ability to grasp objects, even in the client of South, uod fur farpur Smith encriptroos in both darity prosimians (lemmar and taster) determines the dos und form. La fact, this work 1 1 otros, if forebet begleded tractive primate shape of the brain. This particular momtife Interary accomplaburpent To add a persoal comment of Interest the virter while a poms, namely the relatron of pnmate posture and stodeot at the College of Phypcn cod Surprons Columbu function to brin development has been covered Uorreruty wu parkeed to atteod lectures of the Late proin an incomparable manner in the compartire pre fexor Tilocy Albought be most bene been preocrupsed the the probletny of amperative anatomy at that time it annot tures and aplanatory aptions from the classical be realled that he ever reaboard thema in his moy lectures work of Tilney (Figure 8) (10)

·HEU 200
BRAIN DEVELOPMENT
OSTACH
ALLIGATOR
RUHAN

·20 THE POSTURAL COUPLEX There is every reason to accept almost in its en govemor (steering mechanism) jurgely responsible tirety the Smith-Tilney hypothesis, namely that for our present position Chapters that precede und progressive evolutionary changes 10 the brain are follow will point out however that in many areas directly dependent or interdependent on improve the excessire cerebral demands on function balk ont ments that occur in primate posture With humanoid singped sbe organic changes utowgbe by progresun erect posture comes the present advanced develop polstrovary depralios ment. Unquestionably the brala has served as the MAN Human Horizon ORANG CHMEANZEE DORUA Anthropoid Horizon CBHON Proanthropoid Horizon MYCETES MACACUS BADOON Simian Horizon LIMA TARDUS Lemuroid Horizon Figure 8 A Comparative Study of Primate Pogurt and Cerebral Expansion (Tilney F Tbe Bree from Apr to dlar, Vol. 2 Figure 459 PP 988 989 Permbasion of Hoeber Paul B, NY) In this bgure cuch bruin w reduced to try-Hiraits actual site. The progredire expansion of the predicure (blue) u daardo demonstrated on exending from tursius to maa (Tilocy) Key Bloe, Prychic Regroo Red, Alator Regroo Green, Sensory Regtoo Yellow Visual Region Gay Auditory Region Red and Blue (Arped) Speech Are ·BRAIN DEVELOPMENT 21 ster EXPLANATORY NOTE TO FIGURE 8 (TILNEY) Illustratrons and matchog captions should read from below upwards The several horizons of cerebral development indicated by the figures on the opposite page requires some further comment with reference to theu evolutional signifkunce. V The Human Horizon demonstrates certain anthropomorphous conclusions which were first suggested in the proanthropod stage Effectul crect posture is at leogth attained the hands liberated from purposes of locomotion, seach acquired, and the frontal area of the brain greatly expanded. The primate tendency to obviously introduced on the Lemuroid Horizon his, under the influence of arborealization, progressed to i proanthropoid suure whose essential contribution is the inception of the crest posture. Two major lines of anthropord derivation induced the adaptatons which led respectively on the one hand to the great apes and on the other to mio Whether the anthropoid stem was a separate offshoot from the proanthropoid level, or whether several such offsboots developed us all i question. The morphological constituents of the brain strongly suggest that the departure of mea from the proanthropold level wus at first by a mmon with Chimpanzee und Gorille, with subsequeat bifurcatroa leading to the wide diverg mce between the human and his neighboriog coordinates among the great apes. TV The Anthropoid Horroa shows a further spedalization in the direction of the uldmate crect posture of man and the final freelag of the haods for purposes other than those of locomotion Arborealization will exerts such a potent influence upon all of the three great apes, that their advances in the direction of anthropord specialization are definitely rekrused by this factor While all of the three great apes Orang-Outing. Chimpanzee und Gorilla, habetually walk mu modified prodograde manner ung the knuckles of the entended hand for support in walking and moaning, there laurels are apable of strodiag, walking aod ninning opright. The erect posture, ander these drcumstances, has little of the perfection attained by mea. It is both ineffettual und upgamly Running and wallang ure done with a shufiling waddling gut, with tendency to come down upon all fours whenever speed is necessary The greut weight of the un thropad apes hus enforced upon then ua uborco-terrestrial mode of lfc. Thus a more particularly true of the Gorilla which, although it does not resort to anything approaching brachiation na ito arboreal locomotron, dors employ its mastire urms for reaching up to the branches, thus drawing itself opvud from the ground. All three of the great apes appear to be offeboots from the proanthropoid stem while still soother offsboot gave rise to the rices of men. III. The Prozothropoid Horroa is epochal in its effects. A new type of adaptation has reorganized the proportioos eod postures of the catire body Brichiatroa is not substituted for a pronograde locomotion in which latter the upper surfaces of the brioches are grasped by the baadlike fore rod hood extremities. Swinging from the brioches, us do the Gibbons, has produced a marked clongation of the hands, arms and trunk. It has further aused the body to esame a more perpendicular position in pusng through the trees and a real crect postare upon the ground. The Gibbon an in fact find, walk and run upright. It has, in addition, lost its tail, due todoubtedly to its well-extublabed habit of sit tmg upright in true Lothropoid futhlon The immal is, nevertheless, much inferior in its cerebral organization to the higher anthropord aper uod bence regarded as a representative of that proanthropod stage whose uboreal readjust ments told the foundations for the developmeat of the great apes and man II. The Sunian Hocmon illustrates the definite arystallization in cerebral uitecture of those structural features which resalt from the adaptatroas to erboreal babitat. It carly reflects the attainment of quadrum nous speculation, at the une tume disclosing the effects of certain restructive influences, such us propograde locomotion tod the us yet partul Liberation of the forelimbs from locomotory function (Old Lad New World Monkeys.) L The Lemonroid Horizon is bete considered the basic primate level. It contains many brun features, will in the crude, which become dominant in later development. It also illustrates such hesitations and radecisions u might be aberent in a modicatous transitional stage. Fuptly at larg, it shows the first feeble Impressoas imparted to the brain by adaptatloa to arboreal life cod indicates the general lines of cerebral advance consequent spon tree-lining habits.** (Tortius and Lemer ) ·CHAPTER FOUR The Spinal Column and Cord-The Container and Contents IF A POLL was taken as to the point of greatest Although unable to trace comparative pnmate dus weakness in the human anatomy the low bach se parity there is a pealth of information on the rela gion would be selected by an overwhelming major tive shortness of the humua spinal cord so its relation ity This choue would be dictated by the fact that a to the vertebral column. Rezmann and Johnson' high percentage of the entire adult population undmidually report measurements on 129 adult sped suffering from acute or chronic low back pain But mons At the same time they revised previous if individuals were asked the reason for this there studies made by in the order of their appearance, would be great diversity of Opinion. A. Thompson, 198 R. E McCotter 234 and G H It is gencrally recognized that the change from Needles, 240 totalling the considerable qumber of the quadrupedal stance to the bipedal onc entailed a 801 thift of the vertebral column from the bonitontal to In 1 these months fetus the spioal cord is appront u vertical one The resultant structural deficiencies mately the same length as the vertebral column are not explained by simply stating that the human That this shortening begins 10 mtra-uterine life os vertebral column is a quadruped one turned upright demonstrated 10 Figure 9 From this point of equal on its base. While correct as far as it goes, this feel longib wall full groulb is dained the rertebral to take into account certain specific defects that arise colunin sncreases 22 times ou total longit bile sbor from the upright position. Nor o it enough to come spinal cord increases only 12 times pare the human trunk to a tent that has its support The generally accepted level of termination has lag unt placed far betund the mechanically correct been fixed at the junction of the first and second centered position. It is true all weight s suspended lumbar vertebrae. Although it had been accepted on the front, counterbalanced only by a thin posterior that there must be coosiderable individual variation, wheet of muscular and ligamentous structures, but the range was wider than luad been anticipated, very thus does not in itself plain the cause of low bach ing from the middle of the twelfth thorack to the pain and the other viried neuralgas lower thud of the thud lumbar Only 31% ere There is an almost complete lack of information found in the zone between the junction of the mod die and lower thirds of the first lumbar the water la literature conxerauag the comparative anatomy of vertebral dis, and the functions of the upper lad spinal cord lengths. This does not apply to studies middle thirds of the second lumbar Particular at made on the boay vertebral structure Laboring un tention is alled to a most significant badiog that der the impression that this particular additional ini approximately 1540 ure quite short, ending at ponts formation could be supplied by two of the most above or even with the lune maslaog the juoction of prominent restigators in this ares, personal com the upper and middle thirds of the first lumbar munications were addressed to Sir Arthur Kerth, vertebral body Five percent of tins number are so Kent, England, and Professor A. H Schulz, The short as to terminate at or above the level of the Johns Hopkins University Both afforded me the lower margin of the twelfth thorac body courtesy of replies, but were unable to give the spe Loirang. Anbar Food JoboronBarty Vertebru kerel afic information requested of the termination of the uploal cord Art Roc 28 177 1942 [22] ·23 THE SPINAL COLUIIN AND CORDSTIE CONTAINER AND CONTENTS Figure 9 Five Mooth Premature Fetus with Brain and Spinal Cord Expoved. A. Lateral view--Early change from primary vertebral conventy B. Posterior vice-Eurly retraction of spinal cord to level of lumbosacral junction (pra) (Perotussion of Woerdering, AL W. Anatomical Museum, University of Amsterdam) There is a tendency for the spinal cord to be convexity the spinal cord has already retracted from slightly longer in females and in Negroes than in its onginal over all length, and not the loner end white malas No definite correlation was found to lies at the level of the lumbosacral junction axust between the height of the body or the length Further Uumination is obtained on these vital of the vertebral columa, or between cither of these points in the recently published Atlas of Ds and the relative leagth of the spinal cord. Woerdemann. Here, a dissection of the spinal cord It has just been noted that the vertebral column of a fourteen month old chuld reveals that at this and spinal cord are approaumately the same length stage it has already shortened to terminate at a point in the three month fetus In an attempt to determine only slightly loner than the final posi the aut time at which spinal cord shortening begros tion, viz., per the interspace between the first and m prenatal life, an unusual specimen is located in second lumbar vertebrae (Figure 10B) Even at the Aoatomial Museum, University of Amsterdam, thus carly point, the spiaal cord has become sela Holland A photograph of this five month premature Evely much sborter as evidenced by the long cauda fetus s reproduced (Figure 9) The brun and spaal equina needed to fill the defect. cord had been laboriously exposed and dissected But Woerdemana s figures demonstrate that in Although the vertebral column is only beginning to straighted from its position of catrame primary Woerdemann, 1. Aula of Immi dudosVol 2 Figures 392 393 Philadelphia, Toronto Blakstos, 1950 average adult ·24 THE POSTURAL COMPLEX 1 2 ter DEVELOPMENT OF THE SPINAL CURVES an only mean that, us has been mentioned, from top to bottom the vertebral column grows at & much faster rate thaa does the spinal cord, and thus des proportion increases more in the lower segments than in the upper ones An inspection of (Figure 11) wli show that even in the cervical region each nerve root must angulate downward sigbtly at first, to reach its respective opening of formen. Proceed ing from above downward, thus differential increases rapidly with each vertebral segment until at the bot tom, the difference is to great that the lowest segmental group the lumbar sacrul, and single coc ygeal nerves remain within the spinal coal for long distances before they an reach their final fon EMBRYO INFANT minal point of emergence. ADULT The final ncreased disproportion is m all prob ability aggravated by the development of adult bru man spinal curves (Figure 10 A und B) od the marked comparative inacased length of the human lower extremities (Figure 1) la summation, there is nothing more certain than that humanoid cract posture has resulted in a con siderable disproportion between the container the spinal column, sad its contents, the sploal cord. This difference, in combination with other points of in stability arising from bipedal crect stance 19d gait, would seem to account for the almost universal human predisposition to seuralgias at single or multiple levels As a direct outgrowth of this it will be propounded that to latent tension, postural devia tion will add increased tightnes that may affect 5 month foty 14 morth ch 14 Adult part or all of the catre central nervous system. It Figure 10. The Spinal Disparity A (Upper) Spaal.com may well be that the 15% having cords shorter than tour at different age level. B (Lower) The Relative Short the normal vrution may be the very ases that are ness of the sploul cord at three different age persoda refractory to treatment of any kind Souse tbe component parts of the control mervous the dissection of the adult vertebral column, al system - CONTITKOMS Structure it will be demor though the cord still ends at approximately Hrded ibal pbysical tension arising oxe port AS the same point, the auda equina has become com be transmitted 18 roble degrees to nearby amel parutively even looger This series of observations -LI LI 4 ST

·THE SPINAL COLUIN AND CORD-THE CONTAINER AND CONTENTS
25
Ist Thoracic
A
Ist Lumbar
Figure 11 The Disproportionate Length and Width of the
Spinal Cord in the Sploul Canal_The Progressive Nerve
Root Angulation from Above Dorawird.

·No text on this page.

·PART II
CAUSES AND MECHANISMS
Pago
29
Cbepler
5 The Postani Compla--General Considerations
Redrographic Magrement of Pelvic Positions
7 The Propery Trigger Mechanum
6
43

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·CHAPTER FIVE The Postural Complex-General Considerations & PRECEDING CHAPTERS have been devoted to a distortion demonstratos the extremely important ỹ of a variety of preliminary salient consid synchronrzed rolation of the foot and log (Ibe trg tons largely concerned with the evolutionary ger mechanism) This mechanism of ungulation iges that lead to humanoid posture The postural pressure will be analyzed latet in considerable dealance arising from the structural weaknesses of tail implete adaptation is a major ause of a definite Inaer circle (2) represents this unitary shift of widening pattern of symptoms that will be the vertical segment of the lower atremity (leg and ned the Postural Complex. Thus hypothesis has thigh) 25 exemplified by patellar and knee joint movement a given confirmation by the simple fact that rection of these deviations regularly brings ap Inner arcles (3-45) can be designated as the cuable beacfit. The uitles of successive scientific pelvic triad demonstrating that this synchronized ubits, from 1946 to 1951 dlostrate this gradual movement of the entire lower extremity--transverse leaing of horizons. As a necessary preliminary segmeat (foot) and the vertical segment (leg and asure, there will be described the serial anatomical thigh) arc communicated in measurable degree to nges that produce symptoms and those that sub- the pelvis Cercle (3) concerns the mechanism of atually modify them. pelvic angulation cod is of such inportance that it The accompanying diagramatic presentation con merits detailed analysis Evidence will be presented s of two central figures surrounded by two large that will correlate the fact that synchronized rotatory kentric arcles (Figure 12) The concepts on movements of the foot and leg cause corresponding ich they are based have been completely un changes in the pelvis the spinal columo and its con anged since these composite pictures were pre tents the spinal cord It should be noted that the red for the Chango chibit of 1948 It sbould pelvis u mounted centrally on the bip joints When noted that ach arcic, both poer zod outer con the mode of suspension is considered movement tutes 1 distinct but related unit. Together they of the pelvis must be of a type corresponding to that m a study in serial shifts whereby the change in of a wheel mounted on an axle When the top moves Thon at the bottom of ach is communiated to forward, the base must move backward in crictly c varied parts of the immediate and distrat super the ume arc and degree of movement. Incorporated ructure. The 10 figures to the left are accompanied in this figure is an important factor viz., the attach 10 matching captions on the right. In the center cat of the lucus muscle to the internal and ctwo skeletal figures that sunmarize the series of uterior surface of the uljac wing The widespread aanges depicted in the two concentric aircies fug like muscular fibres of origio unite joto 1 na Terve Tension, for the aner series-Nerve Release, row tendon which passes over the anterior surface of the outer of the pubes just lateral to the symphysis kod then The bottom figure of the inner arcle of serial nogulates sharply to finally rasert unto the wees Joga, Laarcoce Science Exhibia, Nional Coareotron upper surface of the femmur at the projating under ! tbc Aparica Bledical Asrocutise Science and Low Back trochanter Through this medium strong internal un Sen FREDCIXO Caldomu, 1946. Patigue and the Vaded kuulaus Chap Munoz, 1948 Nerre Touca od Lodio rotation of the upper ead of the femur would pull atrod Atlantx Gary 1947 Los Angela Californis, 1931 directly on the upper surface of the pelvis the force [29]

·INNER CIRCLE
THE CYCLE OF SERIAL DISTORTION
AND
NERVE TENSION
Hoottobre
Neurotros!
(Sobotics
Rackurts
NERVE
TENSION
Lunbar
Naurata
(Low Boot
Post
3
| Gron, The
and
Marathos
2
Unwrt
(Fool
Mouragos
Artis
ww
Coll)
Figure 12 The Postural ComplexIbt Coorplete Caatrigny Mechulabsch

·OUTER CIRCLE Release of Nerve Tensions THE CYCLE OF CORRECTION AND NERVE RELEASE 5 Variable Nerve Tensi Reduced Lumbo-Sacral Angle (X ray) 45° Increased Lumbo Socrol Angle A-ray) 60° NERVE RELEASE VIC, Patarian an Hip Jant Crest Forward 3 Pelvic Rotation on Hip Joint Crost Bachrord Base Forward Inward Roll of Leg from Top to Bottom 2 Inword Roll a Food and Angulation Outward Roll of Ley from Top to Bollam Outward Roll to Straight-Line Weight Beorng ·32 THE POSTURAL COMPLEX baog bergely overted in the region of the anterior The balance of the series outer arclos (3-43) superior spine. There are undoubtedly closely re Ulustrate the contrasting effects of correction on the lated factors acting in the hume na (wrtorius, rectus pelvic truad The first, arcle (3) revals the change femoris, etc.) which may ad ia pulling the crest in pelvic angulation when inward rotation of the of the pelvis forward and consequently cause a cor femur is replaced by outward roll With the release responding backward movement of the pelvie base of varied pulls the crest springs backward and the The second to the pelvic series, inner arde (4) base move forward in an exactly corresponding illustrates that this movement an be actually mea degree of wheel like movcinent Outer aircle (4) azred radiographically Such pictures are taken in illustrates the degree of shift as determined by the standing position by techniques that will be de actual radiographic measurements (Chapter Six) scribed in Chapter Six Outer arcle (3) the last of this pelvic tread illus The last of the trud, moet cude (5) illustrates trates the release of local and generalized nervous the important ducal effect of pelvic angulation system tensions that accompany combined sheetal namely that generalized elongating none tensions shifts that start at the ankle are agumented by the doubled In the center are two sheletal figures, one labeled shortening pressures that must accompany pelvic Nerve Tension the other Nerve Release Nerve shift. The upper component, vez, forward soove. tension arises from the composite effect of the serial ment of the pelvic creat causes the sacral base to deviations of the inner arcle. The companion pro press forward on the terminal roots of the cauda ture--Nerve Release correspondingly portrays the equina. This is oo¢ of the major factors in the result when correction at the base (foot) reverses the cusation of localized low back pain The loner serial distortions of the superstructure. The numbers component or backt kard movement at the base of attached to the central figures, (1) for the ankle the pelvis excits pressure on the sciatic nerve by (2) for the sciatic foramen, and (3) for the lumbo clevation of the sacrospioous ligament that closes sacral junction, represent the order of thar apper the lower apperture of the sciatic foramen. lo short, ance from belos upaards, but are not indicative of the same movement that causes low back pain may their respective importance It so happens that in produce sciatica, this combined mechanism aplain the light of our present knowledge (1) or the ankle ing their frequent association component, is undoubtedly the most important. But The series of figures comprising the outer circle the pressure at (3) the lumbosacral 1902, is consid is doigoedly connected by broken lines to indicate crably more important than that occuring at the that correction breaks a long terdependent vicious SCIALA zone (2) This conclusion is based on the arcle Outer arcle (1) reveals that external rott clinical and statistical observation that lon bach pain tion of the foot from the previously internally ro 25 a peuralgre symptom, not only outnumbers sa tated position tends to restore strught line Raght aber statistically but almost unably preceeds it bearing and equality of streuses on the respective by a long time interval component joint and neurovaxular structures of the In summation, she be central nervous system foot und solle. With thus there is the accompanying « contexOKS structure sepston 18 ONS area masi bir release of the primary angulating pressures at this frosted in rorfing degree to all orbers Com particular point. The second outer arcle (2) illus 1 ersely for ibo some reason relation of TORSION trates the effect of synchronous outward rotation of may caxse corresponding release al distant pomis the vertical components of the loner oxtremity as jodicated by patellar movement.

·CHAPTER SIX Radiographic Measurement of Pelvic Positions THE FINTINGS that live nolic from the radio From the standpoint of clinical value the anterographic mcasurements of the cluanges of pelvic posi posterior vien's taken to determine differences of icg trons have contributed greatly comard confirming the lengths have come to be far more important than the validity of the cntirc postural symptom complex lateral vient's made for purposes of measuring the Since these radically different radiographic toch changes of lumbosacral angles in our present day niques were first daised in 1946 an accumulation routine of examination intero-posterior vietu's are of evidence has confirmed the fact that postural de made in approximately 50% of all patients facts m the lower atremities are correspondingly The radiographic table is turned upright into the transmitted to the polues These arc of two distinctly vertical position. A plumb line is dropped from the different types Differences of leg lengths produce top midling, and the position of this is drawn on Lateral angulation, a hercas internal rotatory umbai the table. Two screws are then inserted into the ance frequently causes the two-pls antero-posterior table at the top and bottom as illustrated in Figure displacement described in the previous chapter (Fig 13) To these are attached a thin wire held taut and are 12) fat against the surface of the table by a spring later Difference in methods of radiographic examina posed at either the upper or loner end To prevent tion an only be properly cvaluated by first discuss movement, two thin strips of adhesive or cellophane mg the present status. Although pictures of the tape are affixed to the wire at its upper and lower pelvis and low back region probabis outnumber any end and also keeps it from being dislodged from the other single form of radiographic examination, fer true vertical plane by movement of the patient. For will deny that in a great number of cases they ful both antero-posterior and lateral radiographs the patieat stands as illustrated in Figures 13 and 16 A to give siguificant information B and C All pictures are taken using a rotating it is generally recognized that many low bach pains of postural or anode tube at a 42 inch target film distance. The tube static ongia becomes progres srvely worse on standing, and are relieved by lying The 42 inch distance has been found to be the most Is centered at or slightly above the sacroiliac dimples down. It is therefore paradoxical that almost with ourt exception diagnostic radiographs should be taken satisfactory to that magnification is slight and does not significantly interfere with measurement Greater in pain free secumbency rather than in the standing distankes may give hazy pictures, and the same obposition that is assocuted with pain jection frequently applies pictures taken with The deficiencies of recumbent examination have tubes of insuffiact penetration not been sufficiently stressed in the past since defects The actual technique of measurement as recently in alignment, such as spondylolisthesis, may com modified is as follows The antero-posterior peluc pletely escape recognition The general use of this radiograph is mounted on the illuminator and sith position, when combined with the lack of agree- 1 plastic geometric triangle a line is crected at a ment us to causation of lovy back pain and sciatica, right angle to the vertical starting at the upper hes uded in creating great diagnostic confusioo. margin of each acetabulum Then two similar addi lo contra-distinction, standing patures as pros tronal night angled lines are made using thc upper ently developed regularly give exact diagnostic find line of the 1126 arests as starting points The differ ungs which can be used for purposes of treatment ences of lengths can then be read off directly by [ 33 ] ·THE POSTURAL COMPLEX spring PETITI?. tapo A -PLUMB LINE detall showing how plumb llne lo hold taut by spring and tapo plumb fine RADIOGRAPHIC TABLE-VERTICAL 14** 17° PLATE TAKEN OF PELVIC AREA In illustration, left leg is shown as about 1/2" shorter ANTERO- POSTERIOR RADIOGRAPH FOR DIFFERENCE OF LEG LENGTH: PLATFORM BI HEICHNER 40 Figute 13 Aptaro-Posterior Radiographs for Difference of Leg Lengths ·RADIOGRAPHIC DICASUREMENT OF PELVIC POSITIONS 35 measurements on the central line The top of the practical as they require a series of pictures in which hip joint sochet is somen hat more exact than the the various component parts of the lower extremi bony head of the femur is the former includes thic ties are measured and the sums totaled thuckness of the cartilaginous covering of the had The chicf method for the determination of differ The sacroiliac joints cannot be used as they are fre enco in leg lengths non used almost worversally is quently difficult to visualize exactly The difference by exceedingly inaccurate tape measurements It us of leg lengths as found by radiograph examination routine practic to place the patient in the supune is incorporated into fixed postural correction by rais position and then attempt to line up both legs in a mg the under surface of the heel of the shoe ac strught plane in their relations to the mid line of cording to the follos ing rule In the great majority the body with a tape, the distance from the anterior of cases where the acetabular and iliac differences superior iliac spine to the lower margio of the inter comade for all measurements up to one inch, correc nal malleolus of the tibia is measured Measure tion is made for only one-half of the difference. For ments that start at the umbilicus contain greater exampis, if the left leg is one inch short, the left margin of error It is not difficult to prove this If heel is raised only one-half inch, as actual clinical several observers measure the same patient, one will Operience has demonstrated that full correction fre- get as many different answers us measurements Not quently aggravates the ongroal neuralgias, and may infrequently some of these opinions will vary as to Ten cuuse new ones The spinal curvatures which which leg is the shorter of the two are the invariable product of leg length difference Inaccuracy must be expected as a result of a great achieve i delicate balance that tolerates only limited number of variables To name only a few of the change. most important, the upper point of the anterior su If the difference in leg leogth is Y4 inch or less, perior spine of the liom and the lower point, the it is usually considered to be within pommal limits internal malleolus of the tibia, are both rounded und consequently aegligible. Further details of fixed thereby making it difficult to find aict starting and postural sboe correction will be covered in detul 10 end points The frequent difference in arcumfer Chapter IX cnce of legs will be included in the overall meas Two radiographic Figures 14 A and B illustrate urements Finally such measurements give the total the need for evaluating both acetabular and liac length without differentiating as to whether the deduferences with increasing experience it has been fiaency is below the hip joint, or in the pelvis laimed that there may be as great a difference in While antero-posterior pictures we made for the the illac wings us in the lengths of the legs Actu purpose of determining the difference of leg leagths, ally the difference in leg lengths is of importance lateral radiographs are used to determine the change simply for its effect on vertebral and spinel octve of pelvic zagulation. From the various parts of the root alignment. In the photographic reproduction pelvis only the place that is the top or base of the (Figure 14A) the difference in leg lengths (1310) sacrum bas been found suitable for use. The deter is not completely reflected by a similar change at mination of the change in lumbosacral angulation the sacroiliac levels (74) and the rause was corre produced by rotatory deviation of the lower atremspondingly decreased In this particular case 1 itios are taken in the following three positions Yg mich nuse was found to be entirely satisfactory In Figure 14B 1 reverse situation was found. Here Patient Haring sbocs with incorporated an acetabular leg length difference of wach was fixed postural correction, (Figure 134) 2 In the same shoes standing on a platform found issocuted with an iliac difference of ¥4 inch. Therefore, the full correction of a Yg ich heel which produces additional or maximum ex case was made to the short left leg to secure a satis ternal rotatioo (Figure 15B) factory and result. 3 la the uncorrected position pithout shoes, The writer us aware that there are other ndio (Figure 15C) graphic techniques for measurement, but these will Tbe torn crenzion as posed Figure 13B, denota "roll not be discussed acept to note that they are not ing outwu of the foot This is the text opposite of the tero u #socally used lo standard tati. 1 ·514 t ERECT R L 24 55 기업 Coute Figure 14 Tahu qocs of Radiographic Leg Length Meaturement A (Usp) The oboolete tech orque of neurement. Here the comparative shortness of the left iluc ming aggravate the one all shortness of the catere left lonta entremity indicating increased correctra B (Lord) Prescot modified technique for Randing Lotero-pottersor cururenents Here the based haght of the left luc ring compeastto Nightly for the bottoess of the left lower extremity requiring de creased correction 1

·37
RADIOGRAPHIC MEASUREMENT OF PELVIC POSITIONS
VIEW 2
-PLUMB LINE
13
-Plumb
Lino
L4
16
35
Sacrum
2011
in/
m
.
LATERAL RADIOGRAPH
IN CORRECTED SHOES (18 A)
(FOR LUMBO SACRAL ANGLE)
The partial angle relienng symptoms
PLATFORM
H. EICHNEL 10
Fimre 14
Tast... a

·38
THE POSTURAL CONPLEX
VIEW 3
II
L2
-PLUMB LINE
L3
L4
PLUMB
LINE
L5
307
Sacrum
BIRU
LATERAL
CORRECTED SHOES
ON EVERSION PLATFORM (13
EXTREME LIMIT OF OUTWARD ROLL
The marimum argle ndurung symptoms
10* ANGLE EVERSION
PLATFORM
HEICHN
Figore 13 (Cozusund)

·RAD OGRAPHIC MEASUREMENT OF PELVIC POSITIONS
39
VIEW 4
Plumb line
-PLUMB LINE
L3
RADIOGRAPHIG
TABLE
24
L5
Hiac
Crost
45
Sacrum
Lumbo
\sacroi
Vine
acetabulum
Lalu
LATERAL.
(13-C)
WITHOUT SHOES ROTATING
ANODE TUBE
The angle causing symptoms USING 10" 12"
FILM-6" CONE
AND
42" DISTANCE
PLATFORM
H EICHNER 4
Figure 15 (Cerimi)

·40 THE POSTURAL COUPLEX 3 D9 224 By 3 ho 251 S Sacnim 37 Sacrum Figure 16. The Fint Two Caxes Radiographically Demonstratiog Lumbo-Sacral Stuft. The change of pelvie position cured by fixed postural correction. A. Low back paza B (Ora rope) Scarica. A lateral view is taken at the same level and 10 ond vica's in the corrected shoes, with the third or the same manner as that described for the antero last picture taken in the upcorrected position with posterior view The technique of actual radiographk out soos Io certain so-called hair trigger back Mezgirements is us follows. A transverse line 15 causes the assumption of the barefoot (nacorrected) drawn at a 30 angle to the vertial at the level of position may immediately aate Latent lumbar mus the top of the upper articular surface of the sacrum cle spasm to give a false reading in subsequent Then a lioe is drawn parallel to the apper sacral pictures For this sme reasoo lateral pactures are level The angle between the troosters and sacral not taken in the early phases when pain and muscle line is then measured using a goniometer, or the spasms serve to lock the pelvis in malposition. As a common transparent geometric angular rule The result the high bopos originally held for the clinal same method of masurement is used for the second value of this particular test has steadily decreased, and third views to determine the changes in the in that they fail to give arly signifiant mformation lambosacral angle produced by alteration of foot that an be used for purposes of treatment. They are und leg rotation thaefore taken after the subsidence of symptoms Experience has taught us to take the first and sec particularly when there have been frequent recur ·RADIOGRAPHIC CASUREMENT OF PELVIC POSITIONS 41 2 2 3 라 5 90° 5 90* 30 to 62 S Figure 16B (Sre ligand or opposite page) rencos In such cases the second view on the outward intense generalged fatiguc. The severity of her com rotation platfom (Figure 15B) may give positive plants were such as to cause her to see almost con information that the recurrence comes from insuffi tinpous attention There had been great differences of cient correction. In association they demonstrate opinion is to causes of symptoms from excellent sources. conclusively that pelvx movement is definitely re- Here examination revealed severe internal rotatory deva lated to rotatory changes in the lower extremity and tron of the legs 15 a part of general postural imbalance. have been a keypowat 10 establishing the related With this dragooses the patient was gran fixed postural shoe correction to release local and generalized spinal anatomical mechanisms that cause neri e tensions cord tension, and adjutant therapy for aggravation due Of special interest are the first (no cases in which to secondary inflammation. At the end of sex weeks thus association was detected more than sese years there was complete relief of the panied pains coupled with disappenace of fatigue In an atteropt to deter Mrs C.E.A, had been suffering from the varred neu mine the possible effect of rotation of the legs on pelek salgras for more than 15 years Her chief compluat was nagulation the patient was placed in front of a vertical chronic low back pain, but with it mere lssociated upper plumb line and lumbosacral measurements were made in root neuralgus, nxb es tightness in the back of the the corrected shoes Another pature mas made at the ned, troglings in the arms paresthesias in the legs and ume tac barefoot Comparison of the two let's reveal ·42 THE POSTURAL COMPLEX that correction of internal rotatory deviation cared a predominant and is greater at this point than in the 12 shift in the lumbosacni angle (Figure 16A) adjacent sth and 4th vertebrze. It would seem that The second caseMr DLG, mis made shortis after this pelvic movement is communicated in lesser de the first one. Here the chief complaint was intractable gree to the sth lumbar vertebras, aith still loss to Sort of four sean daration. It had beco intermittent the 4th, and beyond this point, intero posterior during the first to share, but in the past two years had change in vertebral alignment from pelvic shift an been practically continuous Because of the senttity of not be demonstrated This is a normal phenomenon, his complaint he had been under continuous treatment and hen demonstrated on the operating tabls does from varied sources recen ing several positive dugnoses not constitute a valid reason for the performance of for disc protrusion with operation advised but deferred fusion This constant movement in this marrow by the patients decision Eumination here revealed vertebral segment may be one of the major rezons extreme third degree internal roll with mashed long for disc degeneration and protrusion. Most author urch descent, (extreme pes planas) Fixed postural shoc ities agree that the overwhelming majonty of sexh correction and adjuvant therapy brought complete redefects occur in these tho Interspaces beta'een the Thef in about two months. With the relief of pain and 4th and sth lumbar vertebras, and the 5th lambar muxlc sperm, comparative radiographs revealed 1 10 vertebrae and the sacrum. shift. Significantly this patient has been seen at inter vals for the past seven years sod still has a hair Standing radiograpbs by determining the peleto trigger spinal cord in that even Light correctne ag brings a wel position mibe antero-posterior and lderal plass med recurrence of symptoms (Figure 16B) ste in indispensable essentul 10 proper dugnosis and treatmeni Borb must be sourdely orduded A study of these patures and others that follow measured and corrected of substawild benefit is 10 will reveal that in every case pelric movement is be regularly oblared ·CHAPTER SEVEN The Primary Trigger Mechanism SYNCHRONIZED INTERNAL ROTATION range of motion at the ankle joint in dorsi and plan OF THE LOWER EXTRCMMY tar flexion Movements of the foot on the ankle in (FOOT LEG AND THIGH) the sitting or recumbent position are more compler THE PRECEDING CHAPTER has demonstrated that (see Figure 17) In this position (sitting) If that serual distortion of the entire superstructure is trig. portion of the lower extremity from the knee to the ankle (leg) is held in a fixed position, the foot can gered by a pamery internal rotation of the foot. That this particular mechanism is responsible in 2 be intoed or adducted or outtoed or abducted Main large measure for the varied symptoms that regularly taining the same position or fixation for the leg, now let the foot assume a position in which the sole is accompany postural imbalance will probably be clevated on its inner border Thu Ls variously termed greeted with considerable skepticism. If so, this will be considered as an entirely natural reaction, for the inversion or supination. Still maintaining leg fix tion, the foot is now rotated so that the outer border writer himself shared this view for a long number is elevated while the inner border of the sole remains of years However a ben the summation of evidence from personal and independent sources became over in contact with the floor This opposite rovement is whelming, there occurred a gradual transition from termed eversion or pronation. doubt to certainty Let us tamine two standard texts in which an Because of the relative importance of this start attempt is made to simplify what is obviously a com ing point it shall be dealt with in considerable de plicated problem Chaos is puled on confusion when tul, particularly as it is believed that synchronized these particular movements are considered in com rotation has not been previously recognized Once binations Quoting directly from Hauser 10 attention has been called to this physiological phe For the sake of clanty it is necessary to define other nomenon, one is puzzled to find reason why it has movements of the foot (other than plantar flexion und not been previously described dors flerton) supiration is a rotury moreneat in the As a basic preliminary one cannot appreciate the longitudinal uw in which the great toe is lifted away great variance in the concepts of physiological move from the floor whereus pronation is the opposite move tients without first Iumining those described in ment in which the small toe end outer margin of the current standard English texts In all of these the foot are elerated. Tbese movements take place on tbe terminology of movement is based on observations foot itself Siace pronation and abduction ere nearly made with the patient in the sitting position, or in always combined, either one of these terms is used to recumbercy rather than in the standing waght describe this combupatwon of movements In this text bearing position of function. It would seem assen the term eerson will be used for this combination of tul therefore, to devise a set of terms that should DOverdeats for the combination of superation had ad not only conform to the facts of functional anatomy doxtron the term mvcr1100 will be used and physiology but that they sbould be so contrived as to be radily understood by all. Such is not the On the same subject Lewin "1 states case ut this time as will be seen by the following House Emil, DV. Disnes of the Foot 20d ed. Philadelphia, Sapodes, 1950 Samples of textual coafusion Lewin, Pump Tbc Food and Ankle 3rd ed. Philadelphia, There is reasodably complete agreement on the La ind Febiger 1947 p [ 13 ] Page 20 16 ·44 THE POSTULAL COMPLEX 4 my woi swonis orber i bar ibost at the artle and ibr for JOURIS If this yet be correct, then the adoption of an yrelding and limiting footwear by man was fuoctionally but an anticipation of a general colutionary trend per haps the enforced restriction of proverent has tended to increase the degree of cvolutionary rigidity reached at the present day but it cronot be held respooble, us It so frequently is for all the many stata troubles affect ing the feet. The tender y of the modern foot to become rigid is an evolodonary one not depeodent upon the adoption of footwear It is difficult to leave this subject without reference to another aspect The modern ideas of the maintenance of bodily polke, overshadowed us they are by the import ance of postural toons, place the ligaments in a very 10 agnifiant and secondary position, and there can be no doubt that previously their importance has been mwar Adduction Straight line Abduction rantably exaggerated. When one observes the second Sitting position kreogth of many of the important ligaments, however Figure 17 Non neight bearing independent movements of it is impossible to escape the conviction that they foot at unkle joint, subserve a more important function thao mere runders up to the maxles, coming into action only ben the When a foot is everted and addected there is asu Latter fail The noo-iluc ligaments mentioned above ally an upward and outward rotation of the medial seemn to show that in certain arcumstances and positions boods of the mid tural region namely the scaphoid and they foon the first line of support, and it is oor arguthe first und second ameform bores This constitutes ment here that arch arcumstances and positions are also to be formd in the human foot nopination. If foot is everted and abducted, the reverse occurs, that is dowoward und ward rotation of The position taken in this monograph is very the medmal mud bursal boods, le, pronation. A foot close to that of Lahe, but it should be noted that in that is inverted adducted and supinated us in varus none of these is there mention of synchronization position, whereas a foot that is crerted, abducted and pronated u la vulgus position The following table will that fool movements cause corresponding movements be fouad useful ia cemembering these terms. of the other segments of the lower extremity (leg and thigh) This ultered concept of movement loversson Adductroni Sapination Vis should be preceded by un analysis of normal gut. Erersion Abduction Pronatroa Valgus This synchronization illustrated in the two ac Tbis is simplification? companying composite sets of Figures 18 A and B Jo the upper tier of five figures the propulsive phase In contra-distinction to these two opinions which of gut us viewed from the side, and in the compan Lay great stress on intrinsic movement Bithin the tive lower set, from the froat. In between each foot, the following quote (Lake 19) indicates the propulsive phase there is 2 swing or restrog period atreme diversity of opinion onder the sectional title This will not be described nor will it be necessary Destiny of the Human Foot to elaborate the fact that almost every structure of Indeed, we are forced to the conclusion that the cro the body eaters into normal gut. One exceedingly lutionary destiny of the human foot is to the production important factor is the shifting of the entire body of 1 ngid #rexture having an udbed form but doroid of weight to alternately lie over each propellmg lover P Like, Namin C The Four 3rd ed. Baltimore, Wilme artremity This smay tends to disappear when rapid od Wilkum, 1949 P 26 gut overcamos inatii ·45 THT PRIMARY TRIGGER MECHA LSH Tibia - Fibula External malleolus Achilles tendon Internal malla olus Cross sectional malleolar relationship Fibula -Tibia Mallcolor porolleisen Straight line Full weight- Straight line weightto bearing to wcightbearing (Inward roll) bearing Figure 18. The Complete Segmental Syochronizaton of Normal Gait A Propulsure phase--Lateral ner B Propul sive phase-dotero-posterior niet 1 The upper tier illustrates the previously described succeeding two figures illustrate the tendency to hed to toe phase of the gde as viewed from the retum to the straight line, as body weight is shufted side. In thu vien antero-posterior motion seerns to to the opposite leg predomioste, although close inspection all reveal The following basic conclusions control almost that rotatory movements accompany cach change of every aspect of dagnosis and treatment that will be postuion presented later In the lower tier the heel to toe gele B viened from the front, this rich giving a better demonstra Hunian gas is basically unstable m iba ue troo of the rotatory shifts that accompany each phase stand on firo feet bul talk on one-one fool a A IIRIC of propulsion As the heel touches the ground se have straight line weight bearing But as naght 2 The foot is an exceedingly small off center begins to fall on the foot it rolls towards its inner base for a very large superstruciare sbe body border accompanied by the synchronized equal rota 3 Pitb the complete alternation of bipeda gaur tion of the remainder of the loner extremity This at sbe mstant of full u ergbt bearing full body reaches its zenith at the moment of full independent ureigbt is directed touard sbe inside border of weght bearing Immedutely after this instant the the foot ·46 THE POSTURAL COMPLEX a rendahsha Metatarsal heads Ist Fibula 5th Tibia Talus Navicular, Metatarsal heads ist 5th Rounded tuberosity of calcaneus Weight bearing tripod Forefoor > Hindfoor... length height width Long orch Rounded tuberosity of calcaneus Plantar view Mediol view Figure 19 The Skeletal Rigidity of the Foot A. SLeletal structure of the foot-Plantar View B Skelaal structure of tbe foot-Medial new The spring structure of the loogtudinal arch of the foot. 4 Inu ard roll of the foot and leg is inescapable ished and, when will present, may constitute 1 5 Faults in foot postare in cartong degrees are significant defect by reison of aircular sag Such most universal fcet are properly termed weak or "fat feet, the The development of certain musculo-skeletal term meaning that babitual internal weigby deridrox structure of the entire lower extranities, and bas caused break in long ocb structure par tacularly in the foot, bere made this unique type of Our terminology of the intimate 201tomy of the humanoid bipedal gut possible. Io a preceding ideal, if not the normal foot, would seem to need chapter (Figure 5 A, B and C) there was dernoa SEVISLOM. Ordinarily the hind foot (tarsus) is de strated the evolutionary progression of pre-sim20, scribed us the collection of tarsal bogos aus distin anthropoid, and human feet, and the improvement gushed from the fore foot which consists of the five of posture that accompanied loss of prehensility viz., metatusi and their respective phalanges. The evohr the trend toward rigidity trocary trend towards rigidity is well advanced as the The accompanying figure (Figure 19 Ą B and bumo foot as now constituted has incorporated the C) Ulustrates on three different ways the fact that metatarsals into the tarsal bonds to form a unitary the human foot, even in its present incomplete stage structure The inner border us eccentrically devited of development has become practically a stogle rigid to form a longitudinal arch (Figure 19B) while structure from the metatarsal heads to the posterior the bords of the 2nd, 3rd, cod 4th Detabursi are uspect of the calcancus. Midtersal movement in ordi slightly elevated to fomn 2 transverse or metatarsal nary standing or weight bearing has pracially vao ach (Figure 19 A und B) The highest point of

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Figure o The Pomary Muscular Factors Controllog Foot
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ANTERIOR
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·48 THE POSTURAL COMPLEX Figure 21 The Comparative Effect of Rotatory Movements of Feet oo Telar Position A (Upper) Jotermal rotatico B (AUDIO) Neutral (straight line position) anatomical (ideal) Dorm C (Loxer) External rotation. UPRI.. . JPRIG R UPRIGH (Comunid ex opposite pago) ·49 THE PRINARY TRIGGER DICCIANISM 214 21B deberé Internal angulation bote whit Figure 21 (coxt) These lae drawings ilustrate the rated position of the foot (t105 Terse wegment) on the leg and thigh (laagitudioul regreat) whea the correspoodiag sadrographs on the oppoute page were taken Figure 21A (Upper left and appor radiographic ner) Thu ilustrates that internal rotattoo of the foot produce un internal angulation witbout ngnificant talar movement. Figure 218 (Upper nigby ond middle radiographic ) This is the strught Ire weight beanog position described elsewhere is an ideal anatomical dorm (Figure 21) with all compooents in straight line pouton Figure 21C (Lexo left and lower radiograpbre tier) Thus demonxtrates that orternal rotation produces external angulation, and the radiographs demonstrate that thus opposte povereat litere causes na tulu change with tular fixation, morement most be exclusively subtalar or calonal Thus rotatory force la transmitted to the renosloder of the foot through the cuboid and Gurkular to the catire unleary rigid loog rod Loteriar uch xructure, 210 External angulation the long arch is at the talo-navicular juaction being descendig rapidly as we approach the outer border placed slightly behind its center Laterally the cle of the foot to permit the bodies of the 4th and 5th vation of the long arch becomes slightly higher at metatarsals to make contact to the surface the 2nd and 3rd metatarsal shafts, with the lift in the ideally externally rotated meght beaning ·50 THE POSTURAL COMPLEX position there is reason to believe that the 4th parti rotates the foot toward its outer border Acom apates almost as much as the 5th to sustain the panjoa figure (Figure 20C) views the outer aspect greater portion of the body weight The shorter outer of the foot and leg to depict the origios and inser longitudinal or cuboid arch of the foot is actually trons of the peronews longus, breves and tertius. non-existant accept ja the bared skeleton is in life These grouped insertions form a lateral or perdaal this apparently open space is filled by the heavy sling which rotates the foot toauds its 100er borda plaabus ligumentous, muscular and autancows struc The universal tendency to innud roll o duc more tures to the off-center position of the foot and other 102 The unitery hypothesis of the arch structure of tomical factors than to inadequacy of the internal the foot will be visualized by projecting the central sling devation of the shafts of the 2nd, 3rd and 4th In the central figure (Figure 20B) is demon metatarsı forward to include the heads Of necos strated dugrammatically the calf muscle or major sity therefore, the heads of these bones will be propulsive factor (the combined gastrocnemius and correspondrogly devated to form an anterior of soleus) ading in combination with the balancing metatarsal arch. Tbis structure bas acquired a dig The insert depicts the fact that this is essentially a jateroal (tībal) and the external (peroneal) slings nity it does not actually possess since be atlerior arcb is only ibe front end of Ibe long arch In all simple physical lever of the first class, similar in its cffect to a croubar placed beneath a log. probability its solc function is to ac mechanically as a transverse spring just us do the loogitudnal of the balancing internal and external slungs as seen Figure 20D demonstrates the essentul syometry Components of the long arch (see Figure 19C). from in front and from behind Here particular at Although in most texts the toes are coasidered as tention is called to the external placement of the being of considerable importancs, it aduld seem beel bone in the posterior view another prime factor that in the buman they are sadıly losing their func predusposing to the universal loternal rotatory devia trooul importance and shriokog in size. All of the tion small too have become practically valueless save 25 a Whilc analyzing the details of the effects of rota means of preserving cosmetic symmetry and this is tion the following evidence pertains to the role of beginning to apply to the large toe is well. Com the talus Since it is completely without muscular firmation is afforded by sbe fact the patienis tbat COodation it has become a passive rather than 20 bare board ampuidions of all fise lors from iwnica active factor The next set of three figures (Figure traxmata frequently trek sormally wil bout ever 21 A, B and C) are accompanied by nadrographic ibe postige of a bump inserts illustrating the position of the talus in both With the rigid foot acting as a pruniry lever there antero-posterior and lateral views that accordpanies will be described the related musculo-skeletal struc synchronized movements La the center is an Ilus tures below the kace that control the propulsive trative study of the foot and log on the ideal neutral phase of guit. Figure 20 A, B C and D lastrates or anatomial position (Figure 21B) On the left different facets of this particular problem. In the (Figure 21A) there is a comparative study of infirst (Figure 204) u portrayed the inner aspect of ternal angulation, and on the right (Figure 21C) the foot and it with the origins and insertions of IS 1 similar set illustrating the effect of external angu the tibialus anterior and posterior Acting as a unit lation It should be noted that although there as a these combine to constitute a tibial sling which deviation in the lines of weight bearing and certen malleolar changes that have bece und will be de • The coocept to confirmed by core whelming rolome of dinical andence. To relyre interior arch descout pod meta sarbed again, there is no significat chaoge in talar turalgue the first requate to correct long och deviations. position. It has become, cetunly is regards rotatory Uonel fulure to recognize the pould reet to eccomtm deviation, like the fibuls a complete tibial atellite harge mesure for the millions of trocuc rufferers who have in that it fallows tibul movement while firmly a received only limited benefit from the present coordocal sconced in the tablo-fibulus mortice. This same lumita poethods of treatment (Loterror arch supports tlope without supplementary connection, fable sopports, feable shoes, etc.) troa docs not apply to entero-postenor Dovements.

·51 THE PRIMARY TRIGGER MECHANISHI Abduation Noutral or Adduction Cour-roeing) Anotomical (In toeing) Position Figure 22. Linear Synchronization of Lower Extremity Movement (Standing) Preliminary considerations would not be com left of this picture is illustrated the effect of internal plete without the locusion of an illustration (Figure rotation of the foot, and to the right, the effect of 22) and a series of actual photographs (Figure 23 external rotation A B and C) that demonstrate additionally that The series of photographs (Figure 23 A, B, every rotatory movement of the foot in the standing and C) illustrate a similar phenomenon when the position, causes correspoading movernents of the re entire lower atremity is in the catoed (adducted) mainder of the loner extremity from the ankle to neutral or outtoed (abducted) position. While the the hip This particular series demonstrates that ab degree of rotation of the foot on the ankle decreases duction (outtoeing) and adduction (intocing) are with abduction and CEO with adduction, the ab linar movements of the combined segments of the ducted position is more productive of symptoms as lower extremity acting as a unit. They are completely there is a greater deviation of naght towards the independent of the individual movement of the foot inside border of the foot. (transverse segment) on the remunder of the lower The effats of internal rotation of the foot on the extremity (longitudinal segment-leg and thigh) ankle joiat are demonstrated ia the ta'o superimin that these can occur in any one of the three post posed outlines of the foot and ankle (Figure 24) The figure enclosed by the straight liae represents For purposes of comparison there are placed in an ideal anatomical standard or norm, one approxı the center (Figure 23B) a photograph illastrating a mated by the foot and leg in the sitting or noa luacar Deutral or anatomical position in a hich the height bearing position The other endlosed by 100er borders of the feet parallel At the same tims broken line, demonstrates the composite effects of and in the same picture, the foot is also in the neutral weight bearing Tahing the ideal com as the start position in its relation to the remainder of the lon et ing point attention is alled to the following the extremity riz, straight line weight bearing To the mallcolar relationship and appearance, the strught trons ·r Figure 23 Rotatory Aloremeots of the Foot at the Ankle Joint in Each of the Three Primary Lineur Poutions. Laternal Rotation A-The Intoed (adducted) Lioeur Position External Rotation Straight line weight beanag (Coxinued on poste page) 1 Internal Rotation External Rotation B-Tbo Neutral Loar Portion (Inner barders of feet perill) Strught lige kaght bearing ·Figure 23 (con from opposite pago) Particular attention is called to the fact that in ach of the three primary linear synchroozed powtions vix (1) Lotoeing (2) Strught lope neutral, and (3) Outtociog, rotatory movements of the foot art distinctly codependeot Thu differs markedly from the usual text book descriptions (pp 43-44) which coa aders them to be dosely related Internal Rotzbog C-The Outtoed (abducted) Linear Position External Rotation Straight line weight bearing line of weight bearing and the retention of long the complete synchronization the ankle will rotate arch symmetry internally in eactly the same degree and amount of Taking these up 10 order in the sitting or non movement. In fact, after prolonged consideration, weight bearing position, the foot and ankle revert this series is the most important in demonstrating toward their idal or undistorted 201tamial rela the action of the primary trigger mechanism This tionsbip There is a retention of long ach symmetry pattem becomes appareat when other changes are If a vertical place were constructed that transversely analyzed bisected the leg at the ankle level the internal malle The malleolar relatiooshup changes radically 25 olus of the tibia will be found to be well anterior the internal malleolus (tibu) moves backward and whereas the external malleolus of the fibule will be slightly dowoward, while the external malleolus fouod to occupy a corresponding po.nt posterior to (fibula) moves forward and slightly upward When this artificial mid llac. Therefore, if a wire were to the synchronized foot and leg rotation reach the be inserted connecting the central points of the mal extreme physiological limits the two malleol be leoli, it would be found to make an angle of 30 come almost, but never completely parallel a condi to 40 from these transverse internal and extemal tion termed relative malleolar parallelism With this points Similarly if a line were drawn down the there is a significant diagnostic accompaniment, the anterior mid pout of the leg and foot this would external malleolar belge approximate a straight line. An onginal cross-section at the ankle joint has In the figure enclosed by the dotted line these been found to differ materially from those previously criteria are compared us they are affected by weight described Figure 254, is an outline reproduction banng The foot will roll ton urds its inside border derived from Grays Anatomy " The other later internal rotation With internal deviation of saight there is a lowering of the loag arch. With Gay Heart Awtomy of the Hora Body Priladelphia, New York, La Red Febiger 1918, Figur 357 L2 ·54 THE POSTULAL COMPLEX -Neuro vascular bundle 90 30 Fibula -Tibio 15 Erternal mollcolor bulge -Talus Novicular sog from long orch descent 04 Calcaneus 15" 30 Ideol posture (Anatomical norm) Internal rotation Arrows indicate malleolar rotatory shift Figure 24 The Primary Trigger Mechanism (superimposed figures) The Anatomical (ideal) Norm kod the Acalopte Effects of loterdal Rotation of the Foot. comparative study is sumilarly derived from Lea'in 5 The Mento-racula bundles are not in close (Figure 25B) Both of these outlines reveal contact usb ibe under surface of the se Tbo tales and calcaneus to be of approximately teplanlar shelf Boob sbou a slalod central agud size salo-celeased ligament 2 Tbir louer border of ibs idles and the opper border of tbr cdcasers or in complele con It is suggested that these two figures be compared Mut mibe subtalar point with the actual cross-section (Figure 264) The 3 Tbe sablala joint is sbourn a berrg predont differences are so profound that there is reason to nantly transmetse na plass ursb stabilisy oded believe that act only are these figures derived from by a slight cenrd copping each other but that they are dugrammatic apprott 4. In tbe first figurs (Figure 254) ibe lower mutsoas rather than actual anatomical specimens tip of the calcareks is pointed ubile in be la contre-distinction to the above the cross-sec second (Figure 23B) there is a platoning of tronal specimen (Figure 26A) reveals the following be calcarea iberostis The cellars is both relately and actually - Levis. Phalip Th Foer av dette 3rd ed much larger iba ibu halus Erdebympat and JoaPuladelphia, Lot und Foburts, 1947 2 Tbe taus und droud bodies ar mot IX COM FZETT 7 1 From ·THE PRIBLARY TRIGGER HECHANIS 35 plete contact tbrongbowl ibeir full extent but In this position there is no pressure on the neuroonly mibe oxter balf vascular bundles 3 Tbe sublalar jomi is not transfersely level, When Figure 26C is compared with Figure 26B there is illustrated the distortion that accompanies but slots sharply doufuard from uitbont mwards unb no trace of elbet a central cap weight beanng The calcaneus rolls towards its in ping or a central ido calcaneal liganieni ner border The slanting nature of the subtalus joint with its plane directed downwards from sts lateral 4 Tbe section is in front of ibe tuberosity of Ibe toward its medul aspect, uds and abets this univer calcaneus as indicated by a portion of the plan si inward rotation of the foot from weight stress far aponesrosis The primary trigger mechanism by which move- 3 All of the major planlar neuro-l asculer bunt ments of the foot cause changes in the remainder of Ples usb a single mmor and insignificant the lower extremity uod even in the superstructure, exception lie close to the inner border of ibe are better demonstrated in these illustrations than in calcanens tiro of thom lymg directly benealb any others That this movement is almost purely and m contact with the louer border of the rotatory is condusively demonstrated in that liga sbelf like sustentaculen tale mentous tension on the inner side of the ankle is matched by an exactly concomitant equal relaxation The two companion figures (Figure 26 B and C) on the outer surface. Of paramount importance is are diagrams based oo the actual cross section (Fig the effect of this sustentacular descent on the ocuroure 26A) To the left, in Figure 26B is illustrated vascular bundles immediately in contact with its in the trend ton ard straight line weight bearing found teraal under surface This is a highly critical angle in the sitting or non weight bearing position Asa in that at this exact point the terminal branches of result there is an equal distribution of weight bear the posterior tibial Acuro-vascular bundles shift from ing stresses in the ankle joint. It sbould be noted the longitudinal to the trasverse plane to become that only in this ideal position are the outer balvas the planter branches on the under surface of the foot of the lower artacular surfuce of the talus, and the They are therefore actually booked beneath the deupper atacular surface of the alaas in contact. scending sustentaculum.

·Study of Anke Afartia Trentec tron, FIGURE 2SA AND D Figure 15A. Schematic outline bared on 20 eurly cross sectional study B. Schematk outline baxd on a later cross sectional study Because of theu importance to the back anatomy and physiology of Hence and gast the three vanked portrayals of ankle mortice transectrons merit a detailed comparative Hudy For this reason certain descriptions found in the text (pp 33 34 and 55) will be repeated and implified The first two (23 A and B) are re-dawa from shodard texts the thurd (26 A) - un adual vertical cross-section on a line besecting the internal tibila malleolus The second (25 B) by perpetuating many signlácant erron would seem to be derived from the first (28 A) Both very xo grally from the actual aou-tection us to give the impression that they are diagrammatic approrimations rather than true nos tomical action. In the first (23 A) the subtalar joiat w slanted dowoward toward the bbular ude, in the second (23 B) it is slightly copped and both are in complete con tact. In the actual section the slant is reverted (downward toward the tibial malleolos) sad there be incomplete contact The centrel slooted ligament would completely block subtalar movement and a bigment of the artists imagoation Neither 23 A or B sbow the plantar spoocurosis basch begras ut the caterios mergia of the calapcal tuberosity a polot just posterior to this level (see Figure 19) The actual aost-section demonstrates deurly the beavy ligamentous connections fining the talu to both malleolu, probably the contookal bases for taler futoa Cer twoły is regarda rotatory motion thus bone has become almost as complete tibul satellite as the fibula The heiry ligunentous connection between the tibul malleolas and the nigten tuulun tali soggest the watomical mechsaiso of sochronized rotation (The Trium Macbonus) With susteatecola dexeot the main pull is dovoyard, but with talar fruation this const be tromated into a rotatory motion in the subtalar rout The results of thus descent and loalized pressure sustentaculer pressure. The frequent complarat "I on the blood vessels and done has been termed an walk five miles, but cant stand will for five angular compressio^ The retention of loog arch minutes aniy means that sustained pressure of symmetry by making this angle more acute, may standing rather thao the interattint one of walk actually increase pressure and symptors Clinical ing us more likely to produce symptoms such com observations tend to support this for while it boas plaints uc pathogaomic of postural neurrigus been found that lowered archies (Alat feet) predis The preceding portion of this text has been de pose to foot und leg pains the varied uppe neural voted to the punied ause of postural symptoms. glas are more frequently found in high arched feet. Different approaches to the complex problems of This same observation applies to viscular deficien diagnosis and treatment will be discussed in the fol aos primary caused or secondarily aggravated by lowing chapters ·A Competitive Study of Ankle Mortke Transections FIGURE 261, B AND C Fibula Tibra Talus Lig deltordeus Tendo m tibialis posterior Tendo m. peronaeus brevis Calcaneus Tendo m. flexor digitorum longus Lig laciniatum M abductor hallucis Tendo m peronorus longus Aponeurosis plantaris Tendo m flexor hallucis longus wo ern plantens medialis th quadrotus plontoe W, o ett plantoris loterolis L M obductor digiti quinti M fleror digitorum brevis External relaxation Internal tension Straight line Internal rotation weight-bearing with inward angulation Figure 261. Trommerse aoss-tectional #ody through the center of the enkle mortice. B-C Dlagtims based on cross- Kectronal study Lower left (26C)-The Angelor Compresor of the neuro-vascular bundles caused by the descent of the custentaculas sbelf through internal rotation of the alcaneus—THE PRIALARI TRIGGER ASECH ANISAI

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·PART III
DIAGNOSIS
Pag
Cbaplar
8 'The Postural History and Physical Enimaation
61

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·CHAPTER EIGHT The Postural History and Physical Examination POSTURAL DEVIATIONS east from the cradle to the Treatment directed toward the alleviation of grars, but the symptoms arising from distortion these symptoms, primarily aused or 18gravated by vury greatly at different age levels All generaliza postural imbalance, must be concerned with the cor tions are subject to exceptions but in the main, the rection of deviation, but before this cro begin muay defects of infancy childhood, and adolescence, are diagnostic points must be elicited through the his largely cosmetic. With the changes that accompany tory zod phystal ermination This chapter is age progression, these earlier defects give rise to a mainly concerned with adult diagnoses leaving spegreat variety of other symptoms cual techniques for children for a later chapter POSTURAL HISTORY (Figure 27A) ADOLESS REFERED BY TELEPHONE BUSINESS AGE BUSINESS TELEPHONE CHIEF COMPLAINT DURATION PRESENT HISTORY Generalized Fatigue (Type, Chantes, Effect of change of position, Allied Symptoms) Nearaiguas Upper (C 1 to D-2) Fixed (Pata or tightness at base of neck, etc) Movable (Neurit) Puestheses (Tinglogs, Numbaess of fingers, etc.) Middle (Tbordic) Fired Movable Parenthous Lower (Lumbo-sucral) Fured (Low back pain--Acute or chronic, Santia, Other pains un lover a tremity indading type of foot pun) Movable (Neustic) Puesthous (Burdings Numbness, Tioglings, etc.) PAST HISTORY (hinesses, lojuries, Operations, Previous treatment, etc.) Figure 27 Postural Outlioc Forms A Postural history B The postural physical examina tsoa. C Foot Camioation [61] ·62 THE POSTURAL COMPLEX THE POSTURAL PHYSICAL EXAMINATION (Figure 278) GENERAL APPEARANCE Weight Gut Stance SPINAL EXAMINATION Standlog Strught Curvatarc Functional or C-curve Structarul or S-curve Lordosis Spunal movement forward Side beoding Supine Jomt Lumination Hips haces, Anlles (Movements, measurements for differences) Straight leg rading tests Angle of limitation from tightness (hamstring contracture) Angle of lantation from pain and musde spasm Crossed leg tests (heel to opposite kocc) (Type of pain evoked and location) Prone (Note type of movement in changing from ruptc to prone position) Hyperextension leg tests Lumbosacral fution and made spasin Pun referral Rotatory leg tests (Knee beat) Fibrositic thickening Gluteal Lumbosacral area, etc. Cervical aren, etc. Finger fork tests to spisoas processes Segmental root permis Schat openings NEUROLOGICAL EXAMINATION Reflexes-kneejerla, heel jerks, etc. Sensory cramation RADIOGRAPHIC MEASUREMENTS (All pictures taken standing before vertical plumb Line copper wire, 42 distance, tube focused at lombowcral joint) Anteropostenor for difference in leg length (lo corrected shoes) the anglc back wird shift Latenl (ou eversion platform) angle of com plete nage of thift Lateral (without sboes) ancorrected angle of in wurd roll FOOT EXAMINATION (Figure 270) FOOT EXAMINATION STANDING FOOT AND LEG ALIGNMENT Strught legs Torsional deformities (Bow legs, knock knees, etc ) Habitual Position Intoelog (1, 2nd, or 3rd degree) Outtoeing (14, 2nd, or 3rd degree) FOOT CONTOUR Retention of symmetry Long arch desxcept (Pes plam) type and degree Hollow or daw foot (Pes arus) type and degree SPECIAL TESTS FOR INWARD ROTATION General bimanual rotatory test Individual (right and left) cximate of degree (mud, medium, sovere) Circulatory reaction (blanchung tune) Finger ( Fine ) plantar fascia tests FOOT EXAMINATION SITTING FOOT (SHOC) DEFORMITIES (Type and severity-night and left) Bunsons Benonettes Cullouses (dorsal or interphalangcal) Location of painful pressure points INIPOCTION OF METATARSAL AREA Metatarsal descent and mobility Toe contracture Movabic Fired (hammer to Size and location of I Relatne shortness HLEL CO LINOTH Pest night eagle To night angle Short of right toglc (5 10 15 ) ·PRESENT HISTORY 63 THE POSTURAL HISTORY AND PHYSICAL EXAMINATION A series of outline forms covering the specialized be primary canse is not in the bran, but in the fool detuls of the postumi history and physical examida The next topic in the history outline the neural tron have been prepared for office use (Figure 27 glas-constitutes by far the most common cause from A, B and C) In presentation, this chapter will fol which patients seek medial relief The word neu low this order malgia indicating altered nerve reaction rather then the term pan has been chosen advisedly Not CHIEF COMPLAINT infrequently oumboess tinglings or burning seasa The first point in the postural history will be the tions, may be quite as 1000ying as a pain of con hief or present complaint, the location, and dura siderable intensity Although questioning in cvery hon In a large number of cases it will be found that patient is directed toward clating wformation as the ocuralgia of the present chief complaint is only to the location of single or multiple nauralgias there one of a large number the one that is greatest at are certain characteristics that serve to identify pas that particular moment If the chief compluot is tural neuralgias from those due to other auses chronic low back pain, almost without exception, the Of the utmost importance is the finding that patient will give a history of repeated attacks of acute chaoge of position, Viz chaagrag from the optransient low back pain over a period of many years right to recumbency or vice versa, brings an altera tion of intensity Many patients will voluatcer that the sympton was formerly influenced by change of This secboo serves to amplify information con position but at present has become practically con cerong the chief complaint However because gen trouous This bus considerable diagnostic significance eralized faugue is so frequently associated with the indicating that secondary inflammatory changes have chronic neuralgias, there is close questioning as to the been added to those of primary spinal cord tension presence, or absence, of this importaat symptom Moveable pains and paresthesias ære ordinarily Many will at first deny its cuistence as it has been in.constant and are considered as due to tension with so slowly progressive as to escape notice Specific out secondary inflammation Conversely if from inquiry will reveal that the patient sides rather the onset change of position did not materually affect than walls even sbort distances In moy the fatigue the particular acuralgia under consideration thus is of such severity as to make it a presenting symptends to eliminate postural causes Diagnostic atten tion 13 then directed to the other causes of acrve tom, or even a chef complaint. Characteristically postural fatigue is promptly relieved by lying down, reaction (tumors systemic conditions producing Pains at dif to recur quite es quickly on rouming the upright alterations in nerve structure, etc.) position in the end stages a number have been forent levels constitute a pinding of considerable forced to a wheel chair or bed existence to secure significance particularly if ibey follou sbe set par relief tern to be described later In the presence of intense fatigue the questioning may be broadened to determine the mental, aad par This portion is devoted to recording past illnesses tacularly the emotional status of the patient Mental depression may be aggrerated by the all too frequent considerable information. The common childhood operations and previous treatments These may give diagnoses that their aumerous complaints are of diseases do not seem to have a grat influence on im imaginary or psychosomatic origin Particularly is balance This is not the case with poliomyelitus or thes the case if they he told that they have to tu the able condition and must Irve with it. This is a other diseases which in themselves cause many or aggravate pre-existing deviation Significantly deed a dheerless prospext well calculated to depress many report variable pains in childhood which when the mind The exponents of psychosomatic conflict severs, have beca diagnosed us cheumatic, when may ponder on the above statements May uell mild as gros ing pains. be iba iber bare been looking dsbe utong end All too frequently there is a past history of many PAST HISTORY ·THE POSTURAL COMPLEX Estimation of Leg Length sequeat dugnosis and treatment. The presence of lombar or sciatic lost-iex100 of knco hips, or spinal curvature toward the affected side--15 ianum ably associated with tension and often with mflammation of the lower lumbar roots, or thar kutic continuations SPINAL EXAMINATION The splne is bared to a point below the waist and foot und leg coverings removed. Examination is made in three different positions-standing, supine and prone recumbency la the Standing Position the spune is first examined with the hands at the side. The spinous processes of the vertebrae are respected to determine their relative positioos, whether there is normal alignment or de utron ud its act type If they are in a straight lue but if there are ab normal fornard curvitures (lordosis) or backward deviations (kyphosis) 10 any zone, thus anteropos terior displacement is recorded if there is a devu tron from the straight lins, lateral curvatures are noted and described as to typem total functional, C-curve, or structural Scurve If a C-curve, this is Figure 28. Estimation of Leg Length from Iliac Crest Differential described as being either a left or right totul conte The S-curve types are listed as mild, moderate, or operations for the relief of specific ocuralglas A severs, with description of the location of the very high percentage of females having acute or separate carves, (left cerviko dorsal, right dorso-lumchronic low back pun have had numerous woeffec bar etc.) Confirmatory evdesce of standing pos tire pelvic operations turel deviation is listed, such as forward shoulders, difference on haght of shoulders, abdominal pro- POSTURAL PHYSICAL EXAMINATION tuberance and determination of comparative ilac General Appelcaoce lo mioy cues long con cost levels (Figure 28) Where a crest difference is tinued chroak pain will be reflected in the pa found, or in the presence of Lay lateral curvature, an treats prausion, response to questioning, etc. The anteroposterior radiograph (standing) for exact de weight is noted, but in this technique great stress is termination of the difference in leg length becomes not placed on vrutions from the normal It may a dugnostic requisite (Chap 6) Prell be that patients who are seriously over or under The stund og omination is concluded by certain weight may be more subject to Deuralgus, but it functional tests The patient is instructed to bend forward as far as possible without bending the koces, would seem that this is an aggravating rather than a Primary factor (o may cause, as far as this individual 10 an attempt to touch the tips of the extended fingers to the floor Aotrog the partul or complete routiac of treatments concerned, the dietary factors success of this movement The degree of forward have been largely and purposely neglected without lombar curvature is noted, whether oormal or lun affecting in apprecuble mazare the results of treat ited. Similarly side bending first to one side and ment However it is realized that marked adiposity then the other is tested to determine verrations in Adds special difficulties to fured postural correction fuoctional performance Following each moveonent, Aboormalities of gut and since are noted and, the patient is questooed us to the localization and pot infrequently have considerable influence on sub type of pem refernl.

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·THE POSTURAL COMPLEX Trapezius muscle 7th Cervical 2nd Thoracic Scapula- 7th Thoracic Lust 12th Thoracic 2nd Lumbar Crest of llium- U U . Socroiliac dimple - 5th Lumbar Ischial tuberosity Sciatic opening Figure 40 Dugpotta Localization—Posterior Surface of the Trunk. A Surface anatomy of spioal perrt root localiza tron B (Opposite par) Fibrositic pattern of secondary inflammatory changer

·THE POSTURAL HLSTORY AND PHYSICAL EXAMINATION
67
4th Cervical
Confluent fibrositis ---
Nodular fibrositis
Central corvical
fibrasitis
2nd Thoracic
Lumbar muscle
spasms
ليدية
-12 th Thoracic
Central lumbo
socral fibrositis
Crest of Bium
Nodulor gluteal
fibrositis
confluenr gluteal -
Fibrositis
5th Lumbar
Gluteal crescent
Gluteal muscle
Sposms
Sciatic opening
Sacrum
Figure 70B (Su legend on opposite page)

·68 THE POSTURAL CONPLEX rotatory thrust causes pain it is usually indicative of duces the same effect on the opposite direction. Io acrve inflammation, both, stresses are applied in the loogitudinal plane The third portion of the spinal examination re und in themselves do not differentiate tension from quires that the patient shift from his previous one 10flammation. Both the Heel to Knce tot of supine of Supine Recumbency to one of Prone Recumbency recumbency and the Rotatory Leg test of the prone The mode of movement used by the patient to effect position se indirect rather than direct tests. The this change of position has great diagnostic sigoufi first causes a stretching of the hip jount ligurncobs, cance uod should be observed closely The patient the second a sharp rotatory impact of the had of the with genuine nerve tension, with or without second femmur Against the acetabulum. As such they give ury inflammation will effect thus by fits and starts, information as to the effect of nauby movement on usually described is breaks in the continuity of sciatic and lumbac nerves and therefore, if positive, movement The malinger however will upset bus jadiate that to crve tension has been added secood clum to have pains of great severity shifung in ary unfismmation The combined mformation of the one single casy movement leg tests serve to jafluence both prognosis and treat Just as there are two leg tests in the supine posi ment bon bere are tad other comparable tests made The information secured by inspection and palpa prone recumbency The first is the Hyperextension thon in the prooe position gives a salth of signifi Lag test (Figure 29C) This consists in first fleans and infomatroa (Figure 30 A and B) These the koee to the right angled position The ankle of particular fodings have gone for to establish the the leg to be tested is grasped with one hand while defiaste pattern of symptoms found in the Postural the other is placed on the lumbar area. The ankles Complex lifted strught upaned to hyperextend the thigh at The first of the companion figures (Figure 30A) the hip joint The effect of this movement u noted identify key points of surface anatomy The spioous for the following reactionsfirst, whether or not it processes of the vertebrae an be localized for de occsstops a bend at the lumbosacral joint and if scriptive purposes as follows The 7th carval at ngidity is accompanied by lumbar muscle spasm the base of the neck has the longest spisous process, Where the spason is intense, there may be no more termed the prominens With the arms at the side, meat whatsoever but in intermediate cases of mod the outer border of the scapular sprue and the incrate acrve tension, or tension with slight ofiamma ferior angle of the same bone are approximately at tron, there may be a small lastial spovement follored the same level us the 2nd and 7th thorac vertebral by complete rigidity Each leg is tested in tum re splnous processes respectively The lower margia of cording the type of reaction and pain referral, viz., the last floating 12th rib sacurately demarantes lumbar sciata, upper root levels, or combinations the 12th thoracic vertebral spinows process, and the of these one just below is the first lumbar spinous process. The fourth in the series as the pronc Rotwory Log The sacroiluc dimples are at the level of the sth test (Figure 29D) Thus was once known as the lumbar spinous process, and potats between these Hibbs test und s obsolete u 20 indicator for secto two are localized by counting upwards or down iluc reluation. With the log in the same position wards The lac crests and the relation of the subc us described for the Hypercutension test, the band formen to the ischul tuberosities are adequately grusping the ankle thrusts sharply from inside out, illustrated in Figure 304. These key poiats locale and the presence or absence of pain referral is the positive fiodlogs indicatiog the inflammatory poted rections in the abrutancous tissues noves mascles, The significance and importance of the four spinal ligaments and joints (Figure 30B) leg tests must be discussed as a group since they form Starting from below upwards, the lumboston a distinct diagnostic pattern The Strazbt Log Rar Lioe is palpeted. In a great aumber of cases there is IAS Sest of the recumbent position stretches the siatk i definite thickening at the base of the scrum benerve and communicates this tension to the spiaal tween the two sucroiliac dimplo This may be cord in flexion, whereas the Hyperextension test pro localized or extend laterally just below the luc ·aests, and Cascs 69 THE POSTURAL HISTORY AND PHYSICAL EXAMINATION may be either confluent or discretely gists or neurosurgeons with conflicting findings and nodular The common central lumbosacral fibrositus diagnoses may extead into the nearby corners of the gluteal The next point is the Radiological findings ordi muscles ausing a simulated or pseudo-sciatica. Pal narily limited at the time of first examination to an pation when continued above the lumbosacral level exact determination of the difference in leg lengths may demonstrate un or bulateral lumbar muscle This has been described in detail in chapter six spasm. When continued below pressure may dernon The postural examination continues with a de strate uni or bilateral gluteal muscle spasm, intensi tailed examination of the feet aod legs in the Stand fied by pressure over the sciatic openings ing Position As developed in this technique, the Palpation is continued upward on both sides of standing examination is divided foto three phases the spinous processes But in the vast majority of 1 Foot and leg alignment. all cases, there is scant fibrositic thickening until one 2 Foot Contour reaches the level of the second thorack spinous 3 Special tests for inward rotation process from this point upward to the 4th cervical process there can be found 10 a great auber of Before attempting to determine deviation onc an oval fusiform central cervical fibrositic must establish an ideal or standard position, not thickening frequently extremely painful on pressure. necessarily a normal one For this term, us ordi Extending from the upper border of this thickening narily used, describes the majority or average of 1 laterally to follow the upper border of the trapezius large number as na normal weight or height. Since ure thickenings which may be confluent or nodular postural fuolts are almost universal, a normal or At this point in the crimination the upper border average would therefore be a foot and leg showing of the trapezius muscles are grasped to determine if wried degrees of imbalance. An ideal, on the other there is muscle spasm While the tendency toward band, is an artificial standard in which there is nerve tension is almost equal in both sees the fibro little or no deviation in weight bearing lines sit thickenings are predominately female The lo 20 ideal position the feet are straight ahead, proac oamination is concluded by localizing the Aather outtoed nor intoed with their inner borders affected serve roots parallel. At the same time they are in the position The Finger Fork test derives its name from the of straight line weight bearing, neither inwardly nor use of finger tip pressure to the sides of ach spinous outwardly rotated. With this imagoary line in mind, process by the extended and forked indos and mid the first point of examination in the standing posi dic fingers This pressure is applied from below up tion consists in determining whether the patient has wards at potats about two inches from the mid line relatively straight legs or whether there is torsional The 5th, 4th, and 3rd lumbar etc, are tested in tum deformity in either upper or lower segments of the all the way from the lumbosacral line to the cervico lower atremities Net, habitual standing position capital junction at the base of the skull Wher a is determined vuz, the deviation of the foot and leg tender zone is found at any level, lumbar thoracic, from the combined straight 110c position (degree of or cerval, the tendemos of the two sides is com intoeing or outtocing) pared to determine whether right is greater than left, The nat point of the standing examination coo sists in determining foot contour or stape The ideal The Neurological Examination unless there are foot is certainly not a normal one The ideal foot special indications, consists of ooting any changes in should have the moner border of the long Arch well reflag-knce bed ankle clonus etc. Should the elevated and all of the toes in the straight line ana patient complan of sensory changes-oumbness, tin tomacal position. From thus soatomical or ideal glings, burnings etc these are mapped with cotton standard of contour the great majority of all feet applicator and pin pricks In the greater number of very gratly but ao be divided into two min these patients extensive neurologial examinations classes First, the weak, relaxed, or flat foot (pes have been made elsewhere by competent neurolo- plaaus) uod second, the opposite extreme the rigid or vice versi ·70 THE POSTURAL COMPLEX Delayed blanching nime Accelerated Donching time 661€ Thumb Thumb pres pres sure elle sure Inremol External angulation ste ongulotron bote Maximum inward Straight line External roll to Straight line to roll & angulation weight-bearing (Inner border weight-bearing elevation) Figure 31 The General Unrverul Biminal Rotatory Test hollow or dew foot (pes crus) characterized by a in the cotire lower extremities, from the coklc to long arch that is hugher than the standard. Sumple the hip joint Bot the test itself is based on the inspection should determine whether the foot be exact converse of this principis, namely that in the longs or tends toward the weak (flat) or high standing position every rotatory movement of the arched types Not only are there ianumerable v2012 leg auses i costesponding movement of the foot. bons but aot afrequeatly the feet in the same pe The leg to be tested us grasped firmly by both tient may vary greatly For example, one foot may hands at the knee joint and then rotated outward be bugh arched with a complete retention of sym In order to perform thus test satisfactonly it may be metry while the other may have a lowered or even necessary to request the patient to shift the major flattened long ench. The influence of the individual portion of his weight to the opposite leg to eliminate vuruation will be discussed later Whatever the foot the furatroo that accompanies full weight bearing at contour or correction, it is the degree of loward the same ture an assistant may be required to place rotation that is of prime importance a finger on the outer border of the foot to block the The mechania uod appearance of rotatory im tendency of the foot to slip outnud us this movebalance have been previously described and illus ment is performed as the leg rotatos outward longi trated (Figure 24) By means of Speaul Tests, the tudinally the foot rotates correspondingly in the degree and character of rotatory deviation of each transverse plane. As an accompaniment, weight will leg omust be tested separately in the standing posu shift from the inner border of the foot to permit an bon. For this purpose the General Bimandal Rota elettron of the depressed long arch. Although this tory test is routinely used (Figure 31) This is based will not occur completely in filat feet, where there on the physiologial phenomenon that has been is a major retention of symmetry the loog arch will previously described, namely that in the weight immediately spring back tato the roatomical post bearing position every rotatory movement of the foot tion. With this, malleolur distortion disappoio at ausos na cactly corresponding degree of rotatroti the unkle joint with the intercul malleolus moring

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·72 THE POSTURAL COMPLEX US Contracted toes lating adduction the otcat should be noted. In whether mild, moderate, or severe, and the effect of the displacement on the remainder of the sorall tocs la cases of maximum severity the large toe may ovalap to lie over or under the first small toe. The significance of major deformities on corrective precedures will be discussed later A bunsonette (tailors buoron) is an onlargement on the lateral surface of the head of the Sth soeta tersal. It derries its name from the sitting crossed leg position habitually used by tailors in which the Confluent Discreet weight falls for long periods on the outer surface of Plantar callouses the foot. Although the bes given this deformity its name, actually it is 10 extremely common lesional Dorial inter phalangeal callouses most zavariably due to il fitting shoes Foot allouses furnish conclusie cvidence of Figure 33 Certua Common Types and Locations of Foot Callouses. either past or prezent sboe pressure or deviatroa 1a Height bearing stress (Figure 33) Thar presence, knee is then rotated slightly outward and it will be type, and location should be noted, whether they found that there is an immediate relaxation. Fre are plantar dorsal, or interphalangeal. Toc callouses, quently the rotatory change aceded to effect this except those of the pisatar variety uc lavarably duc may be Very slight. Yet crea thu slight rotation may to shoe pressure and the greater member will disapbe the cause of distant symptoms per promptly when shoe pressures are removed Eumination us concluded by a series of observa There are, however a fer 10 hrch loog continued trous aod measuremeats made in the Sitting Position. sboc pressure has resulted in the development of a In this position the distortions that accompany unall underlying needle-like booy rostosos Certan weight bearing tends to disappear permitting the of these require that the interphalangeal costosos be foot to assume the anatomical or Ideal standard to rcmoved before relief can be obtained be approximated by correction. Visual inspection of the foot in the Sitting Posi The fiost point in the portion of the foot ovamına tion now concerns itself with the under surface. At too is a description of the presence or absence of this point finger pressures are used to confirm the postural foot (sboe) deformities, their type and findings of observaton to determine localized pain severity It os recogarzed that there is a large oumber ful pressure points These may be found under the of congenital anomalies that affect the feet, but this heel, long ach, or at any potat in the anterior ench s special problem not pertincat to our considera segment. The presence of planter allouses their tions This does not apply bowever to 1 maltitude of type and location is noted. Ideally but certucaly not shoe defoomities that may complicate the problems normally in the female foot when it us elevated to of foot correction se level, there Be Cocive clevation in the central The presence or absence of bunuons (Hullus rul portion between the two caterior points of the gus) should be listed sod whether they ure simple weight bearing tripod, riz, the beads of the 1st and costoses or body overgrowths accompanied by angu 5th metatarsal booss With descent, and its innan Lation. The promicace of the lateraal surface of the able accompaaunent toe contructure, clevation of the first metatarsal head should be described together foot to cge level will reveal that with central metu with the locatsoa and type of costosis (boay promi tansal descent, conavity hes been replaced by com nence) present, (lateral, dorul, or 10 combination) veuty (Figure 34, A und B) Thus central tres, va pod whether this is accompanied by secondary la result of internal weight derution, is occupied by flammation of the orelying burse. If there is angu series of discrete or beavy conflucat plantar callouses.

·THE POSTURAL HISTORY AND PHYSICAL EXAMINATION 73 Thumb pressure, as illustrated in (Figure 34C) will contractures are almost invariably associated with not only clerate the lonered central metatarsal heads, metatarsal descent the type and character of this lebut straighten the toes as well After the metatarsal sion should be determined at this time. The rigid regton has been examined for posture, mobility is fixed types arc termed hammer toes tested by extending the toes in the plantar direc The final point in the sitting examinatson of the tron (Figure 34D) At the same time the relative foot consists in a determination of individual heel length of the 1st and 2nd metatarsal bones can be cord lengths With the thigh and leg in the com determined in many chronx painful varieties mo pletely extended straight position the foot is etern troa will be sharply restricted or even fixed at the allo rotated to the straight line position The foot is metatarso-phalsageal junction Siace toe flexion dorsi flexed unul movement is blocked by heel cord पा Figure 34. Foot Inspection and Functional Tests A (Lpper left) Ideal metatarsal concavity B (Upper cento) Cea tral metatarsal descent and coorexity with a large confincat plantar callouse C (Upper nigbs) Thumb pressure elevat mog rentral heads zod strughtening toes. D (Lornleft) Pleatæ flexoa test of toes to determine mobility of axta carso-phaliageal junction. E (Loxer nigbr) Technique for testing beel cord lengths.

·Meta tarsal heads First inter space Fourth interspace Completion of antmark 3. Int malleatus of tibia Charr paper Transfer of ant mark to foot chart 411 51 Head of first metatarsal Os calcis Ila 10 JB Completed tracing AB - long arch D-ant arch 8 10. F gure 33 Serul Order for the Propertion of the Foot (Bleacurement) Chart Blaswements are 2l« 1 mude the littmg rather than the standing position With the elbouinstion of welght dus tortion all fest trad to return towards the costomcal graight line darm-the position dosely upproximated by correctioa.

·ton. THE POSTURAL HISTORY AND PHYSICAL EXAMINATION 75 tightness as illustrated in Figure 34E The point at descent and metatarsalgra, this exact point must be which this occurs is noted as to whether night angle located with extremne accuracy by determining the position is attained If the heel cords are too long cxact point at which thumb pressure produces the As in children, or too short, the degree of discrepancy greatest straightening effect for the toes If the pres from the night angle is noted (5 10 15 ) Each sure is made ather too far forward or backward foot is tested in tam and the results tabulated for there will be little or no effect on the adjoining pha ose in later correction Thus test is important in that leages When this precise point is located a linear uncorrected heel cord tension may loch the foot in transverse mark is made just in front of the thumb the internal rotatory devution causing symptoms (Figure 35 1) Two longitudinal marks are made The clinal evaluation of all of these findings will at night angles to this, the internal one directed to be considered in the chapter on Individual Correc Hards the interspace between the large nad first small toe, and the arternal one towards the inter The final step of the foot cxamination is the prep- space between the third and fourth small toes (Fig uration of the individual Foot Measurement Chart ure 35 2 and 3) In this manger the anterior por This is an essence a record of 1 series of foot messure tion of the weight bearing tripod, the had of the ments required for this differcat technique of fixed 1st and sth metatarsi are demarcated The foot is postural shoc correction. Other workers in this field now placed downward on the chart paper and the may wonder that this relatively simple procedure is mark just made makes its appearance by tok transfer sufficient. It is recognized that many practitioners (Figure 35 10) use more complicated methods, such as foot casts, The next madh is a perpendicular dropped from arbon tracings etc Casts record only primary the posterior end of the internal malleolus (Figure deformities much as do preliminary mouth impres 35 4 and 6) Radiographic studies dettoastrate sroos of the orthodontist before corrective measures that the posterior edge of the internal tibial malleobave been applied. Moreover they accumulate map lus corresponds to the anterior margin of the tuber idly cannot be made a part of a permanent record, osity of the alaneous The beel mark is made at the and in general are without useful purpose. cract point of skin contact with the chart paper As the prime purpose of this method of correction (Figure 35 ) From this point all other measure- Is to shift weight bearing lines the original faulty ments are computed Another perpendicular mark position is only 1 starting point for correction The is made just back of the head of the 1st metatarsal Foot Chart that contains these measurements re (Figure 35 7) Now the inside, outside, and front quires, for its production, only a blank sheet of borders of the foot are outlined (Figure 35 8 and paper and a fountain or ball pojat pen. It will be 9) The foot chart is 1 mirror image of ac foot demonstrated later that from these charts are deter us is the upper inner surface of the insole of the shoe. mined not only the type and size of the varied cor The onuct measuremeats of the size und shape of rective devues to be used, but their ultimate position interior and long and their respective distances from in the shoe All data that may influence both tenta the heel, constitute permaent record furnishing tive cod fioul prescriptions for each individual foot information essentul to the technique of fired pos is entered on this chart providing a permanent ref turul shoe correction erence record. The details by which this series of Additional informdion such as a radiographic measurements is made is described in the series of difference of leg lengobs sborlness of boel cords, Allastrations (Figure 35 [1 10]) torsional deformities peculiarities of medarsal do Certain salient points must be emphasized. First, scmt etc es entered on tbe foot cbat a sup the metatarsal heads are located by thumb pressure plementary information It will be found that all on the plantar surface of the foot As will later be serb formation may influence borb tentame and demonstrated in detail, where there is metatarsal final prescriptions for fixed postaral sbor corrections

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·PART IV
TREATMENT
Chapter
9 The Suitable Shoe The Reenforcement and Outside Correction
10 The Individual laude Adjustment of the Suitable Reenforced Shoe
11
The Adjuvaat Therapy
12. The Correctson of Foot and Body Posture ia Chidrea
Page
79
93
107
113

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·CHAPTER NINE The Suitable Shoe-The Reenforcement and Outside Correction It has been demonstrated that a great variety of of recognition is illustrated (Figure 36 A and B) symptoms stem from primary postural deviation of as well as simplified non technical terminology for the foot, anth secondary changes in the superstruc the use of practitioners interested in the problem ture Therefore, postural shoe correction is the most of shoe correction (Figure 36 C and D) important siagle step in the reversal of serial dis Suitable rigid shoes can be described as haviog tao tortions The corrected shoe must have sufficicat parts a sole and an upper The sole, or weight structural strength to continuously block intemal bearing surface, ordinarily consists of an inner and rotation of the feet and legs, and thus cannot be outer layer between which in the posterior portion, offected by the measures non cornmonly used, is a reenforciag ngid shank (Figure 36B) The upnamely flexible shoes, movable arch supports or by per segment of the shoe is affixed to the sole and manipulation or CCTCISES alone. designed to hold the foot in position Similarily it This different approach can be logically drided also consists of an inner and outer layer and between into two distiact categories The first is concerned these is interposed in its posterior portion, a suffen with the selection of the suutable shoe, its plastic re ing device or heel counter In the best types of enforcement, and subsequent outside correction of shoes this is considerably longer on the inside border the sole and heel The second phase is the individual than it is on the outside, ending just short of the correction of this specially prepared shoe weight baring portion of the sole (Figure 36B) Smace no two patients ue auctly alike, and all too Rigidity of the shank uod counter reenforcement frequently the legs and feet of the same individual of eng shoe may be tested by the following simple may differ considerably fixed postural shoe correc procedures The shoe is placed on a flat surface and tron has come to be highly individualized, not only downward pressure is made by the extended fingers for the different patients but for the two feet of the at a point just in front of the heel. If the shoe same patient. This corrective mechanism has been buckles in the center and the rear cod of heel tilts compared to a chain, the strength of Rhich is deter upward, the shoe is either without a shank or has a mraed by its weakest link. Consequently every phase flexible or setni flexible inadequate one (Figure in the series of corrective stops is relatively import 36A) If bowever atended finger pressure in the unt. same manna and at the same location is withstood As a starting pocot a suitable shoe having suffi without any movement whatsoever of the sole or cient built in structural streagth is selected Such heel, shank construction an be coosidered as adeshoes onust not only be properly fitted, but should quate (Figure 36B) have us an integral part of their construction, a ngid The strength of the counter must be tested oot steel shank and a long counter It is not pertinent to only for adequacy but for leagth as well to deter our considerations to attempt to describe the almost mine whether thus stiffening extends far enough wanumerable types of sboe construction. They can be forward on the inside border of the shoe The vast divided into three general dasses-fleable semi majonty of meas and chudren s shoes are made with flexible, and rigid Slace only ngid types can satis short counters automatically forang climination of fuctorily withstand weight bearing stress a technique mans of these for correction. The greater number of [79] ·80 THE POSTURAL COMPLEX A + Direction of prestur A inadequate counter and thrible or sami twxible hond B Rrald counter and nigd steel shank presor Site of factory cyelet Apex of weightbearing surface Welght bearing qurface of sole Toner flare Apex of tongue Outer flare Site of extra cyelet Eyelet flap Apex of inner flere Tongue Apex of outer flare Interspace Base of tongue Elevated wurface Yamp Base of weight Approximate weight broring line or hands of mentororsal's bearing surface Hee! bearing surfact Figure 36. Test od Seaplibed Temmology for the Sortable shoe. A Test to demonstrate structural waters in hocs B Tat demongratug adequate stroogtb ja sboes. C. Sunplubed teemmology for the upper D Sumplibed term Lology for the sole ·81 THIC SUITABLE SHOE—THE REENFORCEMENT AND OUTSIDE CORRECTION Figure 3Examples of Sutable Dress sad Walking Shoes of all ages. uomen s palking shoes have built in long counters adult women of all ages will endure the agonies of 25 manufacturers have found that this gives better such pain rather than wear ugly shoos Onc can support and fit to the smaller and more sleader fc sympathize with this attitude as all too frequentis male foot. such shoes are incongruous with style in the past A qumber of commercial brands of sutable shoes fen years a concerted demand for better styling having long counters and rigid shanks are illustrated aded by the armed services endorsement, has forced (Figure 37) and a list of camples is appended many sboc manufacturers to fabricate better looking If certain trade names have not been included, this shoes Oversight is not intentional as many of these may be In practice it has been found that certain blocks in equal or non superior to those listed psychology can be overcome by education. First, the Because of its claxcal importance one cannot quit female patient must be parned that she cannot rear the subject of shoes without discussing an extremely high-heeled dress shoes continuously in certain reimportant phase-the relation of correctn e shoos to sistant cases one must be satisfied if the adı dual the style complexos of romen This is anderstand will near corrected lon er heeled shoes for prolonged able particularly since many exponents of shoe co weight bearing in a great number of these the rection demand that women wear sboos that bear a relicf experienced as sufficient to affect a complete dostot resemblance to those som by school boys change of attitude In practice it has been found A fer elderls women made desperate by foot pain that if a dress shoe is corrected for sitting down mas wear this type of shoe but a great number of purposes at the same time that the patient is given a fully corrected walkiog shoe many women will con Florsheim (Custom loop counter type only) 1 Sabel, Thompson, South Stocroder, *ght Arch Preserier sent to the Hearing of both Psychologic resistance (look cluster type only) is lessened if the patient lams that personal appear Com cotronul Orthopedic or Briller Foot Deencher I Sabel, etr Sorutyle und Dress Muller Foot De ance is aided by improvement in body posture feader Sethy Matz, Drenac Not only must the shoe be of suitable construc For Colleo I Sabel Child Life Pred Paper etc tion, but it must be properly fitted It can be said For Men For Women ·87 THE POSTULAL COUPLEX (Figure 36D) at the moment of full weight bear ng expansion, the upper will not project over the sole (Figure 38B) The nat succeeding step in the series of correc tron as the plastic reenforcement of the suitable sboe. It has been demonstrated that in walking ach shoe must alternately sustain the full body weight. Tons of weight per mile canot be contained without structural breakdown even in the best of sboss. In fact this led to the conclusion that shoes were only stiffened leather bags The recognition of this bask structural weakness led to the technique of plastk reenforcement for all shocs as a structural prerequisite. It is thus par ticular feature, more than any other that differenti ates this method of correction from other types Shoe reenforcement was started early in 1947 when it was realized that even the best long countered shoes broke down. An office asistant, laring had er perience in airplane construction, suggested that additional structural strength might be afforded by addition of plastics However the plastic techniques used in aurplanes require high temperatures, obvi ously unsuited for leather shoes Considerable or perumentation has finally resulted in the developorteat of a satisfactory inside counter or shell There has already been described the stiffening devices, or counters, for the inner postenor border of the upper constructioa of shoes These are of two Figure 38. The Fitting of Shoes A (Uppn) External evi dext of improper fit-Teather loop prespore. B (Lord) types, long and short. Structurally there we com External evidence of proper fit. pletely inadequate to sustain prolonged and and lessly repeated weight bearing thrust of internal without fear of contradiction that faulty fit is the rotation With this techarque of plasta reenforce rule rather than the exception. Unless the shoe meat by the addition of the inside counter or shell, mugly bags the beel, particularly at its surrowest the structural strength of the sboc is mfinitely a posterior point rotation annot be controlled. Erron cesed (Figure 19) la fut, repeated Inspection in width and length however more than any single of shoes showing extreme wear realed that the Quse, ere productive of the shoe deformities from shell bus remained relatively intact. This reenforcepressure (bunions, buntonettes, hammer toes cal ment is applied indiscriminately to all shoes 4p louses, etc.) The prime consideration of fitting proved for corrective purposes. It is therefore not should be to note the position of the 18 metatarse! a odindual correctiog, but a supplencatary in bed (Arrow Figure 38A) If this is at the same provement to the fabrication of shoes. The actual level as the inner flare of the shoc, the widest part technique of installation is currently used will be of the foot is properly placed to coincide with the described and wlustrated. videst part of the shoe. If the shoe is too short, the A fiberglas cloth has been found to be an indos foot will project over the sides of the sole ausing. pensable biodrag ugent for the combined plastics leather loop pressure effect. If the head of the 1st • Fiberglus clotb-Bolt Deterlalbarier reist type No. mietiturul lies at the exact aper of the conet flere 132 143&, Mfg Orens-Compro .

·83 THE SUITABLE SHOE THE RENFORCEMENT AND OUTSDE CORRECTION Fiberglas shell Sole of shoe Figure 39 The Fiberglas Shell or Inside Counter The material used 3 of the closely woven type re further than a point one half inch short of the meta sembling heavy glistening a hite satin The tighter tarsophalangeal junction When it is extended beand heavier weaves have been found to be prefe yond this point it eliminates the bend of the shoe able to the lighter weight loosely roren ones which at the line connecting the inner and outer flares of not only tend to fray at the edges but fail to hold the sole, the metatarso-phalangeal junction, causing the plastic bond. lo actual practice the fiberglas 1 wooden shoe effect. material is impregnated in water and by means of Each stapled three layer insert is removed and un arbor press and stumpiog dies six sizes of fiber trimmed along the line previously marked by the glas, all of the same basic shaps arc cut (Figure glass or wax pencil. The edges are then beveled by 404) This method is deadedly preferable to hand trimming the under and succeeding layers to elimin catting with scissors as fiberglas dust may be ex atc terminal ridges (Figure 40D) After this preceedingly irritant to the skin of many individuals A sustable size is selected, one that is slightly liminary fitting the chemical plastic compound is larger than the area of the sboe insole and three prepared the proportions of which are illustrated Lasers are then stapled together at the front and (Figure 41) The components and properties as de back ends (Figure 40B) The smooth side of the veloped for this purpose are described by Steinman us follows staple is always placed upuard to distinguish the night from the left of ach pair after chemial treat The use of Postarex as an integral part of shoc cor ment The three layered inserts are then placed in rection is an adaptation of high strength products as the shoes for sizing and beveling Sizing consists aulaed by the arcraft industry The use of glass fiber of marking the coside flange border and the outside reinforced plastics has been widely accepted because of ar or heel flange with a gluss or a pencil so that its high strength, impact resistance, moisture resistance they extend about one-half inch above the inner and dutensional stability for such applications as auto. sole of the shoe (Figure 40C) It has been estab • The Thalco Compoy Steinman, Robert PhD Consult ing Chemist, 765 So Homard Boulerud Los Angeles S Call lished that the fiberglas insert should not extend forpu ·84 THE POSTURAL COMPLEX 31 33 35 37 39 Figure 40 The Fiberglu Bıx of the Inside Counter (sbell) A (Upper left) Preliminary istembly of the different sizes of fiberglas inserts, B (Uppo ngbr) The sapling of the tree layered insert C (Loxo loft) Sizing the insert to the individual sboe. D (Lower nigbr) Trimming and beveling the insert. mobile bodies, boats, fishing rods, fumiture and urplane the resin at the time of its rise to accelerate the cure of parts the resun in combinatron with the Garor BZP which is a There are three categral parts composing the Pos peroxide catalnt. The Gambo 100 speeds up the atahtı turer systern. The Posturex reso (Selectron) is a specul action of the Guror BZP on the Posturex roun. (A note formulation of polyester rain This material contains of cutron Garo BZP and Ganko 100 should not be styrene us a cross linking or thermosetting agent Under mored together prior to the addition to the Posture the inflaçace of the Garox BZP und Gunko 100 the resu This could cause a fire. Each logredxent, that , Posturex reso sets up bard and becomes the structural the Gamako 100 and the Guror BZP must be mored to und Thu hardening action changes the Posturas resin the resin separately just prior to use ) from a liquid to solid. The embedding of the glass fibed in this liquid rain before it hardens imparts the Garor BZP 1 dospersion of a pererade in a acutral Carrier which frautato the ause of solution of this aita desured strength cancerusties to the resun. A common analogy for this process is the reinforcing of concrete lytic agent in the Posturex resin. Under the influence of with steel bar und wure the Guraho 100 and beat the Gerox BZP breaks dova The Posturei reun is an alkyd resin based on glycols ito free rudals which in turn react with the titre und untorated dibas acids Thu alkyd is then dis phase of the Postures roua and hardens the Postura. solved 10 styrede monomer to produce a useable liquid The following table contuos typical physical proper maternal. Garako 100 i accelerator which is added to ties of the glass renforced Postures structure ·THE SUITABLE SHOE-THIC RECNFORCEMENT AND OUTSIDE CORRECTION 85 LICTION It top Garol -RraGerako 8.2. Room A 60 000 psi 42,000 psi 45 000 psi Figure 41 The Preparation of the Plastk Cheorical Compouod. Flexural Strength (bending) The stapled inserts are immersed for several min Compressive Strength (crushing) utes in the plastic mixture until thoroughly imprego Teosle Strength (pulling) nated (Figure 42A) They are then grasped by Impact Strength (ibs inches of width) 20 surgical forceps and hung above the pen to allon Moisture absorption (after 24 hrs.) 015 excess chemical to drin (Figure 42B) They are The mixture is prepared to a flat cake tro which placed on paper and turned over as often as neces has been lined with heavy wrapping paper so that sery to eliminate all eness plastic (Figure 42C) the left-ova hardened residue may be disarded The The thoroughly dried, but still flexible insert us basic plastic (Selectron rosin) in the desired quan folded once, held by the surgial forceps us ullus tity must be placed in the pan first and then in turn trated, and placed in contact with the upper pos the two catalysts (Garox and Garako) must be terror surface of the insole of the shoe (Figure added separately and only after each has been thor 42D) It is now moved into optimum position, at oughly stirred joto the solution. As mentioned by the same time brushing away any interposed ar Stenman, they must never be added directly to ach bubbles between the insert and the insole Should other for when so combined they form an oplosive even a drop of excess plastic be deposited outside compound the are to be seen forced, it should be removed im The proportion suggested (8 of Selection to medutely by a cloth dipped in acetone Unless this 142 tsp of Garox, and 2 tsp of Garako) has been is done # hule the plastic is still pliable, it will form a found to be satisfactory in produang an optimum hardened miss that can only be removed by grind gray compound Slight variation is permissi ing a hazardous procedure that may cause damage to necessary Each pair of shoes requires approxi the inner lining of the shoe mately one ounce of the reenforcing plastic Although this particular fiberglas plastic process bluish bic if ·86 THE POSTURAL COMPLEX + 12 Figure 2 Chemical Treatment of the Shell (Inde Counter) A (Upper left) Impregnation of the fibergles lagert. B (Lpper righ) Druning the acos plastic Auid. C (Lexorlofs) Drying the plastie unsett. D (Loror riper) Placa- Ident of the plegtie lorrt. us technically 2 cold one it is so only be compan treatment is sufficicat to dry the userts, the time son with others requiring high temperatures Unless interval as applied bere being controlled by an auto the plastk inserts are dried by los beat they will matic tumer (Munnapolis Honeywell) remao stucky for days and cannot be given final During the process of drying, the upper carface processing of grinding To fralstate the drying of the insert is reported several times with adde process 2 supple wooden bor has been lined with troaal layers of the plastic chemical compound, (Fig. asbestos sheeting and wired for the installation of ure 41B) Particular atteation is directed toward overhead infra red lamps (125 or 250 watts) (Fig beasily coating the points where there is a change ure 43A) The shoes containng the most inserts 10 direct100- the base of the mano pod outer are placed about two feet beneath the heat lamps flanges. Rebeating is necessary after each paroting atth the soterror portions projecting beyond the bat la the end the fiberglas shell or inner counter must zonos The thermometer sbould not aceed 135 be thoroughly dry and have a glass blush gray Fahrenhet as greater beat may cause shrokage or upperince cracking of the leather Ordinanlyn tao hour best The final processing of the dred shell coosists

·87
THE SUITABLE SHOLTE ACENFORCEMENT AND OUTSIDE COKRECTION
256
Figure 43 Low Heat Treatment ( Cold Techniq
A. The asbestos lined bent abodet ind automatx tur
(Froot Panel Remoted) B Reparating the drying i

·88
THE POSTULAL COMPLEX
1
Figure 11 The Final Proceming-The Smoothing of Rough Edgar A Power driven
(Hol gan specially dergoed burt B Grading the edge of the outer becl funge C
Grinding the edge of the one loag arcb fluore D Removal of fiberglas dust by
futon

·THE SUITABLC SHOE-THE REENFORCEMENT AND OUTSIDE CORRECTION 89 38097 T6014 Wedge to be Inserred here Shoe with markedly unbalanced hcel MIATT Shoe with balanced hcel THUH! HOLTE To be ground off --here ginn Shoe with slightly unbalanced heel Shoe with balanced heel Figure 45 The Recognution and Correction of Antero-Posterior Shoe Instability (Unbalanced Heels) 10 smoothing the rough edges For this purpose Particular attention must be paid to the outer heel power is furnished by 2 Black and Dechet ball flange 23 any residual roughness may cause irrita bearing holgun (Figure 44A) From experience tion (Figure 44C) this beavy duty type has been found to be vastly Fically the powder that accumulates from the superior to the ordinary small household bronze grinding of the edges is removed by vacuum uudion bearing types The grinding operation, formerly a (Figure 44D) tedious process has been facilitated by two modifica Once the stable shoe has been reenforced it tions First, the revolutions per minute have been must be tested to eliminate built in or factory insta increased from the standard 23 24 hundred to 34 36 bility for quite naturally rotatory deviation can hundred, aod second, a special cone shaped burr not be blocked by a sboc which rocks fore and aft, head has been designed having a long shank per or from side to side A technique for determining mitting use in forward points inside the shoe • The these defects and their correction is illustrated (Fig saw-toothed front and smooth base of the grinding ure 45) This figure is particularly concerned with head prevents scuffing of the inside lioing of the antero-posterior rocking or instability but lateral shoe from oudverteat contacts Starting at any given instability is determined 10 exactly the same manner point, the aircumfercatial borders of the insert are by roching the shoe from side to side The shoemaker ground until there are no rough edges (Figure 44B) is sastructed to correct gross inequality by inserts * Long shanked grinding bure (Sen crance)-Special design and minor defects by grinding Three different Postural Company 139 No Bedford Ave Beneily Hilla, Calle types of wedging corrections are applied in this specialized technique, namely jaside, outside, or forau.

·90 THE POSTURAL COMPLEX Left Shoe (inner border) logole 46A 2 Wedge Outer sole Right Shoe (inner border) 46A 1 Outer sole Insole Wedge on Belladoru. ווווווווווווווווווווווווזז Left Shoe (qutar border) Ingole 46B-2 tai illalli".... Wedge Outer sole Figare +6 Certain common types of outside shoe correctiom. A1 The inside medge before placement A 2. The in ude wedge is sits B-2 The outside werden vis ·THE SUITABLE SOETE RENFORCEMENT AND OUTSIDE CORRECTION Right Shoe (outer border) 46B-1 Ingole Wedge Outer solo 11131111.ferilt pr. 46C 2 ooo 46C 1 ///////// Figure 16 Costun comodoo types of outode shoe corrections (cov 1) B-1 The outside wedge before placement The beveled metatarsal wedge in Six C1 The shape of the beveled metatarul bur before placeoxot

·92
THE POSTURAL COMPLEX
16-D
46-E
عمر امه می
G
46-F
Figure 46 Certaio com000 types of outede shoe correctloos
(Ford) D Optimum position for the atta eyelet-opening by
leather puech-telet and clamp belos E Closure of eydet
usting cobblers damp F losde surface of closed andet ha siis

·THE SUITABLE SHOE THE REINFORCEMENT AND OUTSIDE CORRECTION 93 Figure 47 Unsightly Metatarsal Bars Left—Thomas anterior beel Right-Hauser comme bar 2002 1 1 central (metatarsal) wedges The clinical indica It is our opinion that there are certain common tions for each can be summarized in outlınc form as crrors in the wedglag of shoes such as gluing them follow's Inside nedging (Figure 46A' and A ) as to the outside of the shoe, or covering too small an an ad in In both of these instances there is either 1 failure or rapid loss of correction The recommenda Correction of all types of internal rotation of tion for sole wedging in the great number of pa the feet and legs acept those of minor degree 2 Correction of outtocing tients that have inflammatory conditions on ather the internal or external borders of the feet (internal 3 Correction of inflammatory condition on the inside border of the foot (bunions etc.) bunions external bunsonettes etc.) can be briefly summarized in that all exotoses are benefited by 4 Correction of internal torsional deformities (knoch knees) shifting weight and shoe pressure away from the inflammed area Outside wedging (Figure 46B1 and B”) as an It should be recognized that aternal wedging ud in the tends to throw the foot into internal rotation and Elimination of the over-correction found in therefore additional compensatory correction must slight degrees of internal roll be used inside the shoe to overcome this particular 2 Correction of intoeing thrust. It is also used in all cases in which rotation 3 Relief of unitative condition on the outside is slight, or where it is needed to combat the effects border of the foot (buntonettes etc ) of over-correction. In this particular technique ex 4 Correction of external torsional deformities ternal wedgrog is used only occasionally whereas (Box legs) internal nedging is almost a routine procedure Tbis constitutes a radical departare from detorsional Metatarsal nedging (Figure 46C1 and C) 23 20 seconiques (Leuin Hanset olc) ubo regularly indispensable and to the relief of prescribe as a romline procedure sbe conibmalion of 1 Metatarsalgia and toc flexion contracture the external u odging to the sole aub mlemnal sede Before describing each of these procedures atten ing of sbe beel It is believed that ibis practice uben tron os alled to the fact that the outside sole correc combined wib ibe recommended flexible sboes al toa used for intoeing or outtoeing is by seeming op- Most intuanably locks ibe fool and leg m ar in posites Intoeng requires atemal nedging whereas tonally rolated position the one that is ibe cause the opposite mechanism outtocing is uided by inter of tbe i arsed distant neuralgias Tbus mught be ibe reason tbal practilioners using ibis melbod of cor The illustrations (Figure 46 Al and A' and B! rection seldom report relief of low back par ser- 2nd B) depict the size and placement of nedges alia or apper root newralgias from fool correction as they are inserted between the layers of the sole. An outside shoe corrective technique frequently nal medging ·94 THE POSTURAL COMPLEX med is illustrated in Figure 46C1 zad olmey the rated in all shoes in which the heels bave con beveled metatarsal bar This differs adically and siderable height (women s shoes cowboy and eng has been found to be infinitely superior in certain Acer boots, etc.) Hedd tilting without shoe dator respects to other unsightly types usually recom tion can be affected by the use of internal sponge mended [Thomas bars, anterior heels, comma bars rubber beveled beel seats (Hauser) etc.] (Figure 47) The beveled meta The final point in the outside correction of sboos terual bar used 10 this technique us practially in consists in usuring that the foot o held souglsan visible. It u fashioned from sole leather approx the prescribed inside shoe correction To secure saug mately 14 inch thick at its center portion, and be enkle fit by adequate lacog, extra cyelets are n cled to a paper thuonoss at both interior and pos stalled between the upper and the nat succeeding terior borders This is fitted to a point just back of lower eyelet (Figure 46, D-E F) rather than abore the break on the sole of the shoc, viz., slightly the last eyelet us is fuctory custom (Figure 36C) posterior to the metatarsophaleogeal lins glued and The factory eyelet position is most unsatisfactory as fired into position by clamps By weight transfer it causes the top-most lace to strike the unprotected metatarsal pain is relieved. Although originally redorsum of the foot to additional feature uding served for the more resistant cases it has been so effective that it 15 DOH prescribed for practically all snug fit u secured by padding the tongue with an edhesive-becked felt insert. Its use is regularly preases having metatarsal palo at any point Slace this is frequently an exceedingly refractory condition, the scribed us soug laging may unitate the unpadded and furnished by this device has been of inestimable skin that covers the bony dorsum of the foot. value. The use of the extra eyelets usually means that Rowing the inside border of the heel (Thomas the laces supplied with the shoe may be too short by heels) is never used in this particular fixed postural a matter of 8 to 10 inchos Therefore, rolls of laang technique. Instead, grat emphasis is placed on material and taps are secured ja popular shades from keeping the external heel surface level to eliminate firms specializog in cobbler supplies. jastability at this very important point. Even alien Tbe suitable sbor baring brex carefully selected the heel is not wedged internally the tendency for renforced and gorer certain specific oxisode correo the heels to run over must be continuously checked 110hs as described in this chapter is nou ready for by heel ap replacement, 13 otherwise the shoe may tbe next link in tbe correctie cban namely sbe be completely thrown out of liac. This is a8g71 modniwalnood msido adjustment of ibe sbor ·CHAPTER TEN The Individual Inside Adjustment of the Suitable Reenforced Shoe The Final fixed postural shoe correction has come leled progress in the past thurty years the situation to be highly individualized it not only differs con regarding the problems associated with the correc siderably for each patient, but quite frequently is tion of foot posture, has not changed one iota. There not the same for the tho feet of the same patient. us today the same diversity of opinion, one school of The chore of the suitable shoe and its reenforce thought endorsing erch supports of varied types ment is a routine procedure applied indiscriminately while another group is unalterably opposed to any to all shoes for corrective purposes The inside and type of corrective support and place their reliance on outside shoe adjustments however are individual nonngid shoes, exercises and manipulations With onos determined by the findings of examination nire exceptions aside from this fixation of theoretical The statement has been made that this technique opinion in actual practice the entire problem as it differs considerably from any that have been previ concerns medical practitiooers has been relegated to ously described A comparative survey would there the chiropodests and arch makers In the end mil fore require a brief summary of the present unsatis lions of chrons sufferers wander in a great arcle factory situation before these differences can be vainly seeljag relief evaluated While medical science has made unparal In practice, with the growth of knowledge, al Anterior arch measurement Long bech measurement ACTUAL MEASUREMENTS FROM HEEL MARK Foot trading Hieel mark Posterior edge of It malleolus ma HELL MARK long orch Complete oot in of foot Head of firat netatarsal Figure 48 The Foot Chart Summanded Techarque of Measurement [95] ·SHOELACES HEYELETS INSOLE COVERS BEVELED HEEL SEATS Children. Women's Men's Bloot Down Smolliluodar) Large Hedro Longe 5 TONGUE PADS OUTSIDE HEEL LONO ARCH CORRECTIVE DEVICES FLANGE COVERS Smalll Lorge Smoll | How Longe /2 L14 R14 L15 R15 116 R16 SHOE LACE TIPS SHOE STRETCHERS ANTERIOR ARCH CORRECTIVE DEVICES Whre Black Brown 2/ | 22 23 || 25 | 26 | 27 EYELET INSOLE COVER OUTSIDE HEEL FLANCE COVER BEVELED HEEL SEAT LONG ARCH CORRECTIVE DEVICE TONQUE PAD SHOE STRETCHER ANTERIOR ARCH CORRECTIVE DEVICES SHOELACE TIP Figure 49 Armamentariam-Materials and Tools Used for Individualized los de Correction of Shoes. போ . Figure 50 Fabricating Tools Left to rightCurred sclators, leather celet punch, sboc caliper 4 und 12 och ruler, heamer Eyelet lamp corter key puller for removing gloed derkes closure dump for sboc lace tops puodt for smooth og rough inner surface of yelet, tomoure lubricattoo ao ured us contact for rubber carneat, Hubby brush appliator ·NU 97 TUIC INDIVIDUAL INSDC ADJUSTMENT OF THE SUITABLE REENFORCED SHOE though foot pain is a considerable problem, ac are radically from other thicker types used for the fabr not nearly as concerned with this symptom alonc as cation of removable arch supports that require ex was formerly the cise In fact, by far the greater tensive grinding Because of this basic throness they number of patients complaining of distant and can be combined or built up into the numerous ranied neuralgias may be completely without foot combinations dictated by the defiaite findings of pain Once this was realized, the prime purpose now Gamination. Tbe elimination of tbe sariable factor is the correction of internal rotation of the foot, thic of grinding bas made simple the doplication of cor trigger mechanism, as a means of correcting the rectional prescriptions serial distortion that uses symptoms at single or multiple levels in the final portion of the postural oumination (Chapter Eight) there was described the detailed preparation of a foot chart Because of its importance this has been reproduced in summary (Figure 48) As will be seen this is not only a roc ord of significant foot measurements but positive information is added determining both the tentative (first) and final prescriptions Once the foot measurements have been made by means of the foot chart, the reenforced shoe is now ready for individual correction. The equipment necessary to effect this is shown in the accompany mg illustration and photographs (Figures 49 50 and 31) In Figure 49 aumples are shown of the list of materials oceded to correct say shoe, from the smallest child to the largest adult In actual practice, Pigeon bolcs were constructed to contain the varied devices and materials in the accompanying pbotograph (Figure 50) the simple inexpensive tools needed for fabrication are shown. Finally (Figure 51) a slow-speed motor (1400 R.P.M.) and emery wheel is shown, attached to the work bench A metal hood is placed over the emery wheel to catch the rubber dast that results from grinding devices Below is a suction trap and vacuum dener The lighter hose is the suction, while the darker hose attached to the top of the tank delivers air pressure. The final correction of foot imbalance is affected by a series of prefabricated resulient devices (Figure 32) The best consistency is one gather too hard sor too soft. The present series ue especully designed for the use in plastically seenforced sboes and we quite this. They differ * All the Instruments Mlostruted in Figure 50 ao be pour chined from herdaure stores and fiims speculazig 10 shoe maker sopplies. The sole exception is the speculs dergoed shoe callper bich ao be purchased only from The Postural Figure 31 Motor Assembly Slow speed motor ud gruod Campeot 439 40 Bedford Beverly Hills, Californu. ing emery wheel, nicion trap tad vacuum deiner sponge rubber ·9s THE POSTURAL COMPLEX () 5 7 0: ၈ ISR IGL 2. Figure 32 The Three Types and Saes of Sponge Rubber loserts. Beveled beel reats-1 3 5 7 Long uch sopporth- 14 L & R 15 L & B, 16 L & R Loog ud adapters and children s loog uch fupports, 11 12 Antalor id mupport. 29 29 26 2 Aotenor arch adapter, 21 22. (Corretne devices are quite different from those used in the fabrication of remorablc arch supports ·THE INDIVIDUAL INSIDE AD JUSTIIENT OF THE SUITABLE REENFORCED SHOE 99 These sponge rubber devices are of three dis full correction may produce intense aggravation of tractly different classes i beveled heel seats 2 long local or distant symptoms In short, fixed postural arch supports and their adapters and 3 anterior shoe correction must be attained by easy stages In arch supports and their adapters each designed for a the middle aged or elderly patient, or in any patient specific and different purpose. The beveled heel seats where there is precedent inflammation the prelimi and long arch supports correct the primary trigger nary correction should be worn unchanged for a mechanism, the internal rotation of the foot The period of several weeks or at least until the sympbereled heel seat with its thicker internal border toms of initial aggravation have abated tilts the alaneus or heel bone outward and conse The foot measurement chart as prepared is actu quently the entire foot. The long arch support ally a mirror image of the plantar surface of each performs the same function by applying upward foot, as is the inner upper surface of the sole of the pressure to the inner border of the plantar surface shoe For this reason measurements can be trans of the foot. The anterior arch supports hare 20 en ferred directly from the foot chart to the shoe. The tirely different purpose, being designed solely to focal point is the heel mark at the posterior end The devate the heads of the 2nd, 3rd and 4th metatarsi length of the long arch as well as the width of the (Figure 33) The panaples that guide the func anterior arch are depicted on the foot chart with tion and placement of these devices can be under stood by a study of this diagram. their respective distances from the heel mark Let us take the foot chart of Mr J A Smith Each device and class have been given serial iden tification aumbers that facilitates the writing of cor (Figure 54) us an example. This patient had as rective prescriptions The first division, or heel seat his chief complaints two extremely painful feet, movable leg pains, ad chronic low back pain series, are numbered 1 3 5 7 (the range from 1 10) the second division, or long arch devices and X ray examination revealed left leg to be one half their adapters are numbered 11 12 144 14R, 151, inch sbort as compared to the right. Foot camina tion revaled marked metatarsal desceat, toe flexion 15R, 161, 16R (the range from 11 20) and the third division, or anterior arch support series and contractures with localized pain on pressure over the their adapters are numbered 21 22 23 25 26 27 2nd 3rd, and 4th metatarsal beads (the range from 21 30) (see Figure 52) The preliminary or tentative prescription made Only the larger of the long arch supports 14 s on 2/28/33 was as follows For the difference in 15 s, and 16's are differentuated for rights and lefts leg length and outside shoe correction a one-quarter All of the other devices are interchangeable in that inch left heel rusc To ad in the correction of sethey can be used for either foot The reason for this vere internal roll on the left foot, the inner border difference has been previously described in that the of the sole was raised one-eighth inch. Both heels highest point of the long arch, the talo-navicular and soles were balanced. For preliminary inside junction (Figure 53 Medul view) 1 not in the shoe correction the following devices were premiddle of the foot, but is eccentrically placed at scribed a number 7 beveled heel seat, a 16 R Lad L the suoction of the posterior and middle thirds of the long arch support and a 25 eatenor arch support. long arch measurement. In addition to being too The selection of the size of the particular devices thick, the interchangeable type of long arch support wus determined by placing them on the foot chart differs by having its highest point erroneously in the The two shoes and the devices selected are placed beside the respective foot chart as illustrated 10 (Fig The actual selection and manner of placement ure 55) a procedure tormed the layout of these devices is dictated entirely by the foot chart pose of illustration let us take the right shoe as an masurements The first preliminary or tentative example of a tentative (first) prescnption, and the correction is designedly a partul or under-corrected left sboe us a final or permanent onc Hers, in the que for experience has taught us that ua immediate case of Mr Smith, since the right 190ard roll was 1 The Postural Company 439 N Bedford Daire Bereth slight, the tentative prescription became the perma oet one. Routinely the first device selected for las middle For pur HL, Glforn.

·100 THE POSTURAL COMPLEX im GIN mlango length width Cross section of long orch support 5th Metatarsal heads ist Fibula Tibia Talus Navicular Metatarsal heads Ist 5th Forefoot ox Rounded tuberosity of calcaneus Weight bearing tripod Hindoor هامة length height width Long arch Rounded tuberosity of calcaneus Plantar view Medial view Figure 33 Skeletal Structure of the FootPlantar iad dledul Views. The relation of correcthe support arcu to the weight bearing tripod out is the notched leatheroid insert (Figure 55-1) of the distance from the posterior end of the loog arch a size adequate to cover the outer heel flange of the to the heel mark u mesured with a short 3 to 6 plastic shell A beveled beel seat of appropriate size inch rula This measurements likewise transferred was selected to fill the heel segments of the foot to the inside of the shoe and marked on its inside chart, in this instance a number 7 From the three border with a ball point pen. The use of the espeaadult right long arch supports the number 16 was ally designed caliper has considerably facilitated the found to be of approximately the same length as the process of anterior arch placement measurement shown on the foot chart. For an in We are not ready for the final placement of the terior arch support, the mumber 23 was found to be devices and thar COTTIS All are turned over and, of the same width us that shown on the foot chart with the use of an antomotive pressure lubricating Finally a leatheroid arch cover was selected and an and a stubby brush, rubber cement is applied to trimmed to adequately cover the jaside surface of the corrected shoe (Figure 55 right) both the modersurfaces of the devices and the upper Once the layout assembly has been completed the or inside surface of the shoes The cement, prefer shoe is ready to be marked for device placement ably of synthetic rubber must be allowed to dry watil (Figure 36) With a shoe caliper, the longth from it becomes stucky or tacky This process of quick the heel to the anterior arch mac is measured and drylogan be hestened by the use of the compressed the out tightened on the central bar This measure au bose of the vacuum clana mat is thea transferred to the insole of the shoe The series of steps in the placement of the comby scratch mach in the manner depacted. Similarly ponent parts that comprise both tentative and re ·THE INDIVIDUAL INSIDE ADJUSTMENT OF THE SUITABLE REENFORCED SHOE 101 mr J A Smith X-ray showe / shortining of the left leq Avere (third Agre) enwart roll-left Alight (fust degra) inward ibu-right Pretemnunary tentative) prescription 2/23/53 Race lift heel 4 only) and balance both & inude border left Gdjusted only Correction (3/14/53) Left - 7+3 16+04.25 Right- 716-75 1 16 25 Tongue pads and exalets for both left and right Left Right Figure 34. Mastrative Foot Chert. 0836 5 7 5 2 peter Right 2 1 Figure 33 The Layout-The Assembly of Materials u lodicated by the Foot Chart for the Individualized Inside Cor rection ·102 THE POSTURAL COMPLEX Metatarsal arch line -Ball-pointed pen Anterior end of long arch -- Shoe calipers السلسلمسلسلسليبيا Posterior end of long arch Heal mark : Outer heel Inner long flange arch flange Fiberglass shell Anterior margin (or inside counter) of shell Figure 36. The Technique of Prelurinary Measurement. Break of shoe (Metodorso-phatort geal junction) vised postural shoc corrections a single or multiple bune too long arch supports of different lengths take combinations are adequately illustrated in the suc one-third of the length differential from the posceeding set of figures (Figure 37 571 to F) At terior point of placement for the shorter ardi sop tention should be alled to the important tech- port, and the high points of ach will coroade niques of modifiation. In respect to the loog xuctly (Figure 58) urches, ane ardinal proaple should be kept con An extremely important point of ozodification us trawously in mind, namely that once the overall concerned with the placement of interior arch soplength is determined the highest point-the talo ports Although there is cousiderable margia for navicular junction lies exactly at the junction of the error in the placement of loog och supports, the posterior and middle thirds la fabricating the dics relief of symptoms in the anterior arch requues ex for moulding the sponge rubber long arch supports, ect placement of supports the interior urth locuina the highest point lies at endly the ume point, viz tion as determined by the ordinary foot chart (mk the junction of the posterior and ouddle therds. transfer) may not loalize with puffaent actitude To accommodate the different sizes of feet, the the point of optimum support. For if it is too far long arch wumbers differ by approsimately one-half formard by us uttle us one soxteenth of 20 inch, it inch, viz the womber 15 # 000 half ioch shorter will idully increase foot pain by presure on in than the number 16 the member 14 is one-half och tated structures If on the other hand, the interior shorter than the oumber 15 Therefore, the number uch is slightly in back of the proper position, con 14 us one och shorter than the number 16 To com tralized pain will continue frorna lack of clevitraa ·THE INDIVIDUAL INSIDE ADJUSTAIENT OF THE SUITABLE REENFORCED SHOE 103 Leatheroid - cover for OOOOO heel flange 37B 1 57A 2 оооооо 000000 View from back of shoc 57B-2 %7B-3 Brush 37A 1 Rubber cement in automobile lubricating can 57C 1 57D 1 0 0 OO oc оооооо 57C2 16 A Metatarsal arch line 25 Metatarsal arch line 16 14 37D2 Art 570 3 Muddle 14 16 Part Section through high point Figure 37 The Techorque and Routine Order of Device Placeurent A i Application of rubber cement to leatherold cover far outer heel Aange A 2 The leatheroid cover in situ B-1 Doubled bereled heel setts (rubber) In site-uperior view B-2. Sume devices us in B-1-lateral view B 3 Same devices u 10 B-1 and B-2--posterior view C 1 Combuded doubled hoog arch supports in situ superior VICK C2 Sume devices is LO C1-lateral en C3 Same devices us In C1 und C 2 before placement with aoss section through highest polat. Di Anterior urch support (rubber) in sir-superior D 2 Same device u in D 1-lateral Tex ·104 THE POSTURAL COUPLEX Corrective devices OOO Insole cov O Anterior arch No 15 57 E 37F Long arch Nos, 14 16 Heel szat No. 37 Figura 37 The Techaque and Route Order of Derkce Placement (cox/) E-Scagle set of dervos (Kr. long and inter or arch support) covered by leatherord Insole superior VW FDoubled beel keup and I ports with single anterior asch sopport covered by leatherond insole-superior ve 3rd small toes This point is marked and pen By means of a ruler used in them in Figure 59B the cract meafurement ! The actual technique is illustrated in Figure 59 A und B Direct thumb pressure is made over the central metatarsal region. If pressure is made in front of or behind this exact point there is little or no movement of the toes. Between the forward and backward position there is one finc point that auses a maximum draughtening of the 1st, 2nd sod Straightened toes Relaxed (or contract 20 Antentar Middle Abut Figure 5 Rules for Placemeat of Combiaed Diffcreat Loag Arch Supports to Give Locreased Hocht. Figuer 39 Sumplified Technique for Cocoa Arch Messurements. Determination of opy by thumb pressure B Technique for etect ra ·THE INDIVIDUAL INSIDE ADJUSTMENT OF THE SUITABLE REENFORCED SHOE 105 this point to the heel—In this case tlic line on the rotation of the leg at the lnce the deviation from ruler beta on the index finger and the heel (35% straight line weight bearing can be determined in inches) Transferring this measurement to a fixed shocs quite as effectively as without them (Figure aliper position the original position w chached If60) it is too far forward it u moved bach, and if sbort If symptoms persist after correction, and the a of the optimum position, it is moved forward In anination reveals that it is incomplete, then it must many cases relief may not occur until the height of be revised upwards This may involve a single ad the anterior arch is increased by placing an adapter justment or multiple ones If the inner borders of beneath it, (21 22) This predominately female the shoes have not been raised this may be added complaint may not be relieved until the beveled Heel stats and long arches may be doubled In short, metatarsal bar u added to the outside sole correction correction is increased by any and all means available In the cent that there is a continuation of recur In the cad the doser one approaches full correc tence of symptoms tests should be made to determine tion, the more one is likely to attain symptomatic if there as incomplete correction or a sag in correc relief Fortunately maag cases may get symptotoa from near The test is in reality quite simple matic relief at a point far short of full correction In It must actually correct the malposition of each indi others in so-called & slight vidual foot. This is based on the General Bimanual under-correction or sag in correction from war may Rotatory test, onginally described to determine the ather cause continuance or recurrence of symptoms degree of internal rotation of each leg By manual Ordinarily recurrences are more promptly relieved hair trigger ses External ongulonon Internal anqulotion é Maximum inward -toroll & angulation Straight line weight-bearing External roll -to- (Inner border elevation) Straight line weight-bearing Figure 60 The General Blmunud Rotatory Test (Standing) for Determinatson of the Degree of Correction in Sbocs.

·106 THE POSTURAL CONPLEX than the onginal symptoms in that they are not Tbe technique of madiridxalized fixed posted usually complicated by secondary soflammation sboe corredron bas been described in considerable If substantial beacfit has been obtained by partial delal 1x sbus ord i be procedung sbapır By ibese correction, one should hesitate to increase it Not 1ond measures ibo sboe is transformed nedo. frequently fuil correction may upset a fine balance broro boring suficient structed strengtb to end wad ause a distinct aggravation On the other hand lessly block tremendous weigbt stresses slower proroke 1s has beco mentioned, there are patients who must internal roldion of ibe foolede primary cause of be almost or fully corrected before they secure relief serie distortion and a great waltsplan of symp from their vicd complaints (Figure 01) loms INSUFFICIENT CORRECTION PERSISTENT SYMPTOMS FULL CORRECTION SYMPTOMATIC RELJEF Figure 61 Tbe Relation of Symptoms to the Degree of Correction ·CHAPTEX ELEVEN The Adjuvant Therapy THE TERMS adprant therapy mas be applied to any greater portion of the weight borne on the fulls type that is used for the relief of certain specific atended nght leg The affected left leg will be symptoms One of the most important of these u flexed at hip knes und ankle, with the neight the relief of intense muscle spasms and pan at sagle largels bome on the toes To complete the picture or stultiple levels This may be of such seterity as of universal fiction to relice acre tension from top to make noght bearing impossible and corrected to bottan, the spine also will be flered agd ulted shoes canot be expected to give benefit untsi thus by side bedding towards the affected side. condition has been at least partulls relicted Treat What is the ordinary treatment given for this ment by prolongad bed rest and the liberal use of symptomabc compla? The patient is put to bed sedstries has in the past fuled to give more than adhesive as applied to one or both cocapletely or slight temporary relief to meas of these cases tended legs and raghts are applied to one or both special procedure, a modified balanced or Russell legs in extensions In a recent case 35 pounds of Traction, has been most effective in giving substin Reight has been applied to ach leg an amount tul benefit and are complete relief so relatively sufficient to literally pull the patient out of bed Vith short periods of time. No originality is claired for lesser weights increased pain may be controlled by the use of this standard procedure originalls de we of sedatives, but all too frequently the physician signed for the treatment of lower extremity frac returas the next day to find that the patient has with turor Horever it has been so Largely modified that out authorization, removed the traction to get relief it is necessary to describe in detail the somen hat from intolerable aggravation different technique of procedure Sunulario head traction, another type of traction This routine approach for spasmodic pain is ap 10 extension, most frequaatly causes aggravatioa of pled indiscriminatels regardless of upper soot pains Many physicians, schooled by ex whether they be in the nech, or as is more frequeatly perience, hare learned to recommend interattent the case, in the lumbar or sets zonos With the rather than continuous traction, finding that this as HOROG apprecution of its effectiveness indications better tolerated The relatncly mfrequeat relief of for its use have been colarged to include cases found symptoms from traction in extension may correspond to be refractory to the ordinary procedures of fired in & 128 to the seasatrons experienced when a ught postural sboe correction, physiotherapy and appro shoe is removed prate medication The basis for its use is as follows Conversely bilateral balanced (Russell) traction, The postural mechanism producing peripheral or traction in flexion (Figure 62) relieves pain by root and spinal cord tension has been previously de placing the patient in the position already found to wribed. La a small percentage of cases a vious circiq se supuesto see The spine is fiered as well as A formed in which tension produces spasso, and both loter extremities at the hip and knee joints spas mo tura produces more tesision Tous condition lotermsttent traction has been found to be superior s manuested in patients having a schatk list This to the continuous ventets us ut lessens fatigue from stoptom as be diagnosed at a distance of fifty long continued muntcaance in one position. Ordı paces by simple observation Assuming for example paruf it is on tad hours off tho hours, with the that the left for a spinal segmeat (lumbar and sa patient sleeping out of traction The prescat coulinc REK) is affected, the patient will stand asth the is to apply this for a five day period, folloned by a (107) pain levels ·108 THE POSTURAL COMPLEX Figure 6.. Biodified Buaterd Balanced or Russell Tractioa (La Flexhoa) for lotractable Pain and Muscle Spas five day resting period, and then reapplied for a sec cords and two 7 to 9 lb. weights, and overhead trapere." ond five day period if there is a contiquance of soup The lateral erface of both legs are shared from the toms In the greater pumber of ases thd courses ankles to the knees. The skin surface is pointed hearily of traiment have been found to be sufficient to re with compound uocture of Beaxono. Four 2 to 3 inch Lieve continuous souscle spasm. This acts as thera #ript of mole shm udbeste are cut to extend from be los the knee peutic test differentiating symptoras arising from to e point one wodooc-half woches beyond postural imbalance from other causes the role of the foot The louer end is folded, wath the adbesne surface lasick, to make a grap of triple thuck TECHNIQUE OF APPLICATION The armamenterram which considerably foala Short sot ne applied to the feet and pulled up tates this procedure consists of the following (Fig cover the boas prominences of the malleat The stopt ure 62) are DOT applied to the lateral peinted surface of the legs and fored in place with roller clastic bandages. The Aa ordinary hospital bed, a single jounted longitudinal lost end of the mole skua strap 3 Dom pulled through oreched om attuched to the bed, sur separate short at the backlo ou esch side of the foot plate and these art ached transverse ums two knee Alings with spenating Gilbert Hyde Chick Sto FODOXO, Colfarn, ni 75ch Fokes, Pusey foot plates, separate pullies, renetan blood Are Oakland, Cellareis nosi ·TIL ADJUVANT THERAPY 109 is mechanically possible. If the leg is not supported firmly any mor entent in the early stages will cause ag graration To release the patient from traction for the tho hour rest periods, the vaghts are detached and placed on the floor the traction graps released from the foot plates, and the knee slings opened The loner end of the strap then tuched under the layers of the clastic bandage and the patient steps into specially corrected shoes. The patient is encouraged to be up and about during the two hour rest periods. This particular routine is not widely used in this area and can be applied quite us effectively in the home is lo the hospital The advent of cortisons, ACTH and their deriva tires have been found to materially shorten the treat ment periods It is particularly effective when used in combination with Russell Traction, but is also of value when used alone with fixed postural correction. Ordinarily it is prescribed as follows Tablets of 25 mgs of cortone three times daily for an eight day period only This is always accompanied by 5 to 10 grain tables of potassrum chloride or acetate to combat the adrerse effects of potassium deficiency An cight day rest period is followed by a second or even a third aght day course. In the sodividualized practice of the enter tho limited types of physiotherapy bas been found to be an essential part of adjuraot therapy Oac is the whirlpool bath for the treatment of the many pa tients suffering from the combined effects of neurovascular changes in the feet and legs The other is the use of the inductothcom or similar apparatı for Figure 63 Manipulative Procedure for Meta local application to varied areas exhibiting the effects urso-Phalangeal Fixation A. Position of aud of primary nerve tension or the pattern of secondary on plantar surface of foot. B Ac inflammatory changes in the adjoining structures tual techo que for reduction of toe flexion (Figure 30B) Mfost are familiar with the beneficial effects of the tightened so that the plantar surface of the foot rests firmly on the plate. The thun renetian blind cords run whirlpool bath as a stimulant to peripheral arcula tion. The automatic massage of easily through the pullies and are first attached to the moring air bubbles Longitudinal am of the fracce above the trapeze and in water of increased temperature is a standard form to from this point on es illustrated of physiotherapy that has most successfully sustained The raghts are light when compared to those often the tests of time. One has only to observe a leg imprescnbed varying from 7 lbs. (women) to 9 lbs. mersed in such medium for a period of fifteen min (makes) Traction is almays applied bilaterally to give utes to recognize that the shin belon the surface of marumum backward pelyk tilt. The thighs sod knees the water ohibits an intense erythema when com are fized und supported throughout their entire length pared to that portion of the leg above This treat on pillons or by raising the foot of the bed where this ment is regularly used for the relief of foot and leg dle fingers contructure.

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·سیر {, ·112 THE POSTURAL COMPLEX Figure 64 Single Duatherm (Inductothermy) Applicator and dlanipulative Techniques A Corco-dorsal mo B Lumbo-sucal zope, C Combaed Left lombo-saon) and xcriatic pont D Trapezes kneading for abrost E. Traperons stretching for muscle spust pains particularly where there is delayed bleaching the disseminated fibrositic pattern (Figure 30B) time of mflammatory changes below the knee 4 10 Slace in the greater number of chroox patients there to 15 muauto application is followed by appropriate are multiple areas treatment may be applied to the massags, manipulation, or both oeck, midtborac, low back, or scratic zones in the There has been discussed previously a casider same patient Such techo que requires single apple able detoul, the testaques of fixed postural sboe cor cator forms other than the double cuff method, as rections as they apply to the extremely common tad an indispensable tunc saver (Figure 64, A, B and predominantly femaine complaint of metatarsalgia C) Follot jog ten to tapaty moutes of such treat The manipulative procedure illustrated in Figure 63 ment, the patient is given message and speafic brani A and B is an invaluable supplement to speed recov pulations designed to release muscle spasons An cry from this resistaat deuralgia By increasing the important and regularly effective cumple o illus range of motion at the actitussophalangeal functian, trated (Figure 64 D und E) Thus routine contraved the fixed corrections become more effective m clerat for satuable periods permits a regular mspection of wag the ceatral metatarsal beads. fibrositic thickedogs and mascle spasms The sum The remainder of physiotherapeutic appliances total of these sepeated observations on a great oumroutinely used in our todividual techniques coasists ber of patients bare established our present iders in the application of modern types of dutbarmy to as to the disseminated fibrositic pattern and their ·THE ADJUVANT THERAPY 113 Figure 65 Supipe "Stretching Ererause for Release of Nerre Pressure from Pelvic Aogalation response to fixed postural correction and varied types A surple foot and leg exercise is prescribed solely of adrvant therapy for the purpose of avoiding the the malposition of Just as physiotherapy has become limited to the the trigger mechanism When standing without the two forms which have given demonstrable and so corrected shoes the patient is instructed at all times have recommended exercises been restricted to two to roll both fect towards their outside borders and somple munarvers directly desigacd to release nerve press the toes down in plantar flexion, as if picking tenisson. At the time the patients are first given their up the carpet (Figure 66) While this simple procorrected shoes they are routinely costructed to lie cedure may considerably strengthen intrinsic foot supune on 1 hard surface, grasp the knces and flex muscles it is not recommended solely for that dis them. They are then costructed to pull the knees tinct purpose Rather it maintains outward rotation bader the chin (jack-knife position) (Figure 65 of the feet and legs at all times when not wearing A and B) At no time are the legs extended during corrected sboos eliminating the nerve tension that the crcrcise period The patient performs this sterts in the foundation (the foot) In the past, too stretching exercise at least ten times morning and much emphasis has been placed on the value of exer Teong, and more, if substantial benefit is attained cises alonc as corrective measures The postural im by this maneuver This ofercise is designed solely for balance of an incorrect habitual standing position, of tilting the pelvic crest backward to 112., the extreme internal rotation, the short leg and nerve pressure at the lumbosacral other deformities cannot conceivably be corrected by angle with corresponding release in the sciatic zone aaaas alone The importance of adjunot therapy should not the purpose release angulating (Figure 12) ·114 THE POSTURAL COMPLEX obscure the fact that it is as the name implies simply postural imbalance continues to be derrations in libre i series of techniques giving secondary aid. The lou er extremities transmitted to the superstructure primary cause of the raned symplom 47g fron Figure 66 The Foot Grasping" Poutionto Correct laternal Devletion when Bure foot ·CHAPTER TELHE The Correction of Foot and Body Posture in Children THE JIIPORTANCE of correction of foot posture in as they pertain to torsional skeletal shifts in the children us it pertains to the improvement of body spinal column Adjust theraps usually is not se posture cannot be overemphasized As indicated by quired since the postural defects in children rarely the distinct confusion 10 methods of treatment, onc Occasion neuralgus of great intensity Further in group of practitioners aill recommend flexible shoes the presence of resilient structures there is little or und CCTCISOS, alule others endorse fued correction no tendency to secondary inflammatory changes for raned types of deformities such as rigid rentou The question is frequently asked When should able arch supports for the feet, braces for the legs ooc begin to correct foot and body posture io chil supports for spinal cunatures etc. Possibly the dren For some time the one has been before zdrxe most frequently given by pediatrists that de the child starts to walk This will occasion some formity can be neglected as the child will outgrow surprise, but it should be reculled that most infants, it" is 10 senous crror Eima casual observer at ang free from disease or coogenital anomalies will pull besh will perceive that the great majority of adults themselves crect usually about the ninth month lo are saffenog from postural deformity that nere not many a study of the standing position will reveal recroved by the normal process of growth Indeed, that one or both feet may deviate considerably from there is much evidence, particularly as regards spinal the straight line position when this is extrems, curvature, indicating that cautial deviations, if un muscle balance cannot be attained, delaying consid cortected, are actually aggravated by growth erably unaided walking In certain cases of sub- The problems of foot correction in children differ stantul delay there may develop a considerable ano considerably from those found in adults The tional and inferiority complex younger age groups rarely have associated symptoms Although there are certain differences basically except for occasional transient ncuralgus usually cr the correction of children s shoes resembles adult roocously characterized as growing pains Fatigue techniques These are first, the chose of the suitable however is not an uncommon symptom It may be sboc, the reenforcement, and outside correction, and recogrzed if the child dislikes active games and in secondly the individual inside correction of this certain cases lack of energy may be reflected in a suitably prepared shoe High shoes, except for dress seeming inattention and mental dullness purposes have been chosen as the suitable sboe for There has been previously described in great de children under the age of sıx, The small chubby tail, the role of foot and leg deviation in the produc feet of young children lacking bony prominence, hou of serial postural distortion (Figure 12) In cannot be secured firmly in low shoes After the age the great majority of cases adult posture is only the of sir, ordinarily low shoes may be satisfactorily end product of distortions acquired during the prescribed for correction. The rules for fitting are growth period Tbere is growing adence however precisely the same as for adults The first metatarso that growth will tend to eliminate deformities of phalangeal junction, or the promience at the base balance is reestablished as a concrete example, once of the inside border of the large toe should be stational deformities and strain is relieved on a slightly in front of the inner flare of the sole, viz., Shast leg the difference of length tends to disap the widest part of the foot should occups the widest pour This same observation applies tvith equl force part of the shoe. In addition, a snug heel fit is essen to detutional defornuties of the lower extremities Io the past there has been a false enphasis [115] ·R RECT L Vic -22 21 ( JIBRIGHT Figure 67 Measurement of Leg Leagth Difference in Children. A (Unpor) Astero poterlo redorsephLC Age 12-left leg one-half och stort. B (LSK) Antero posterior redographPG Age 3 left leg w loch abort.

·THIC CORRECTION OF FOOT AND BODY POSTURE IN CHILDREN 117 - 1:1 Ni ::||: IHIEFIT figure 68. The Correction of latcerng by Truning Straps and Fired Postural Sbor CorrectionsP Age 18 Mootba Frost new ilustrating in te duate correction from pelnic band, training straps and fixed postural shoe corrections E (Nai page) Six months later-coatmuing improvencat. Posterior 7c D Lateral view ·118 THE POSTURAL COMPLEX 7 the child does not have associated neuralgus or other inflammatory conditions to be aggrarited by full cor rection In one particular the correction of chuldren s posturc varies from adult procedures viz. in the cor section of rotational deformity of the legs usually described as intoeing or outtoeing Correction is regularly accomplished by the use of troung straps connected to the reenforced shoo . The preliminary deformity the end result, the details of the padded pelvic band, the location and direction of the rotatory training straps and the terminal fixa tion of the straps into the sboes are illustrated in the accompanying series of photographs (Figure 68 A, B C D and E) To control outtocing, the termaus is affixed to the inget border of the sole of the shoc, while for intocing 1 reverse fixation is used. It should be recalled that outside shoe correction is also effected by opposites, viz. for intocing the outer border of the sole is raised, for outtoeing the inner border This procedure, by shortening one set of muscles and Icngthening the opposite groups rapidly forces the child to accommodate his gait to this corrected posi Figure 68E. (Sor legend on preceding page) tron In some cases the change is effected in 2 matter of days, while in others it may require consider placed on the problem of foot growth To give addi tional room many shoe fitters interposed the width ably longer periods The younger the child the of the adult thumb between the top of the shoe and quicker the change. This method of correction has many adrantages the top of the large toe The use of this criterion means that many children are fitted in shoes that are over the braces orduaarily prescribed These are not too long Thus fits neatly rato a shoe fitting Comedy caly cumbersome, but quite regularly ineffective of Errors in that in the first at the shoos are fitted The training straps are inconspxuous and generally too largs, whereas in the last acts they are fitted too mrect with parent approval accompaniments not small found when braces are prescribed This different ap- Chidrens shoes are rechforced and corrected in proach to the problems of the correction of food and exactly the same manner us adults shoes, viz with body posture in children differs materially from plasta reenforcement and spooge rubber inserts ordinary techniques It is not enough to tell the child There is one difference bowever anterior urch cor to hold yourself strught, shoulders back when rorection is rarely required. The tests for adequate and tatory imbalance of the legs forces pelvic angulation inadequate correction are likewise determined in and its attendeat upper spinal deformities In addi the same manner by the use of the Bumanual Rota tion, since 40% of the entire population have tory Test (Figure 31) Similarly differcoce in substantial difference in leg leogths, it is impossible leg leogths we detected by measurements on an for the child having this difference to obey Let the teru-posterior radiographs (Figure 67 A and B) The timog straps Blustrated in the stroopaorios photo Differing from adalt rule which corrects for onlymphs. (Figaro 65, R Cod D) hrve been in wae for coo Liderable length of time at the Orthopedic Hospital, Los An one-half of the difference, 10 children s the hcel of rcles, Californ. Regretably the one of the originator could the show is given full correction This is possible us Dot be determbed.

·TUT CORRECTION OF TOT AND I) 1957 URI IN (111 TORIN 11 adult making thus unrcasonablc request roll both feet mward until Urc hnces touch then attempt to stand crect, stomach in, shoulders back with one foot on the curb and the other in the sitect Alloption of imprural method for this contre lion of boxly poster in chihlien may phraseul meaning to this phrase "ar Ilir innis in locul in this nec incliner'

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·PART V CLINICAL EVALUATION PAS Cbapler 13 A Clinical Eriluation Based on a Comparative Study 14 A Compendium of Illustrative Case Histories 123 128

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·fixed deuralgia. Obviously acute low back pain could not be used since great number of those sotherapy foxt, und cycn no treatmcat whatsosyet pains were likewise unsatisfactory 23 i statsstical CHAPTER THIRTEEN A Clinical Evaluation Based on a Comparative Study IN THE BEGINNING It was stated that the symptoms base since they vary considerably both in intensity arting from postural imbalance constitute a distinct and location For a time the use of sciatica alone was diarcal entity This different concept is largely based considered as a yard stick in that it was ordinarily 00 a comparati\c statistical analysis based on 500 constant and relatively intractable to treatment. This cuses of diron, loa bach pain All of the cases acre idea was discarded when it was realized that sciatica seta consecutively Half of these were contributed was largely only an accompaniment and complication from the practice of the writer embracing a period of chronic low back pain For these reasons it was from January 1 1946 to March 1 1949 For pur mutually agreed to accept for the purpose of statis poses of statistical comparison in approximately thic tical study only cases that had as thar chief com Sorte time period a similar nurnber of cases—250m plaint chronic low back paw of at least Dudety days 133 assembled from the joint practices of three inde continuous duration, and these must have been in pendent physicians using the same methods of diag tractable to previous treatment, noses and treatorent It should be particularly noted Starting with the so differential, the first column that the patients of one plysiqan nere not seen by on the left in the upper series, the males predomin the others cooperating in the combined study ate by approximately 10% whereas in the combined Tospation of the table (Figure 69) reveals that figures below there is a considerable fermale prethe 500 cases riere divided into two equal portions dominance-female 63% male 35% The predom upper section are 250 cases contributed by the inance in the upper series is in error due to the Witer and in the lower section are 250 cases from introduction of a considerable number of male Com the assembled practices of M Wiley Farm El Seg pensation Insurance cases, with the lower series unda, California, (85 cases) Royal C. Payne, Holly being closer to the true general population figure 10 Kood, California, (100 cases) and Harold E Peter that these cases come largely from private practice son, San Fernando California, (75 cases) The en In all probability the more exact figure on the sex bre oumber are analyzed from eight different stand ioadence of neuralgras would find a slight female ports Although this study is now five predopunance not to cyceed a 60 to 40 ratio one based on present day figures would not be me The age factor reveals marked similarities rather terually altered except as regards a considerable im than differences Although chronk low back pala is provement in the time element of therapy occasionally cacountered, it 13 a clinical macity before Any compantive study demands a fixed base, the age of twenty This symptom begins to appear the first of which is agreement on a standard or after the age of twenty five and then rapidly in creases in frequency until in the age period between thirty and sixty it affects a high percentage of the respood promptly to a variety of conservative treat entire adult population. It would scom iberefore ments such as drugs, manipulative procedures, phy that ibe loss of elasticit of soft 1155805 and orber changes ibat accompany age progression play a in other areas such as leg of cervical major role in bringing to be surface prerrously latent conditions Significantly if patients have not ( 123 ) In the yars old, Neuralgias ·124 THE POSTURAL COMPLEX COSTPARATIVE STATISTICAL ANALYSIS Bender Soo Ixtatek CAXI Cero Sa Groep Age Dinition of Chrook Low Back Pait Allied Soptoms loodepce 12% LAUKLICE JOYLL, MID Beverly Hills, Call Stando iron 230 Cuci Jun. 1 1946 to Yo 1 1919 Welt Female 10% 12 16% 10-20 21-30 SSX 31-40 41-50 51-60 61-10 71- I leur or Lon 1 to 5 Yah 5 to 10 1 an Over 10 Years 39 14 4 Frode Landes Fixed Biorible Pirothcous Sciatica Upper Root Pum Faed Blonible Puratberu 41 65 24 10 16 13 21 VELIT FAR NID El Segunda, Cerit (15 Cura) ROYAL C, PAL, MD Hollywood, Calif (100 Cases) Vaba HAROLD E. PITEX MIDFercale 2. Fanindo Culf (75 Cara) Combined Statata From 240 Caso Jan. 1 1947 to Alar 1 1949 10-20 21-30 35% | 31-10 65 51-60 61-0 71-60 1% 17 2 21 23 11 12% 13 14 11 25 Futbe Ler Acta Found Morable Parathon Scatch Upper Root Pain Fixed Alorable Paratham 1 Year or Lets I to Slan 5 to 10 Yan Over 10 1cm 26 30 41 12 14 Figure 69 developed low back pain before they reach the age larly occur at considerable distances and may be of 60 susceptibility to this symptom almost disap quite as important as the more prominent chief cont pears This has been found to be of considerable plaint (Figure 12) diagnostic valuc, for when chronic lou bach pain Although there is slight variation ben the two appears after the 4ge of 60 it is usually due to other sets of figures are compared, they bear essential ausos (malignant metastases, spinal cord tumors similarity The Jlied symptoms are grouped into etc ) four different desses, fatigue, leg aches, scratica, and The third column is devoted to the duration of apper root pains The higher figures of the upper symptoms The restruction of choice to those cases tables are thought to be due to the locreased 100 that had bad chronic low back pain continuously for deace of sciatica 48% for the upper 25% for the a period of ouncty days or longer resulted in the final lotver There are in reality only three groups sce selection of a group that had had this pastrular sciatica can be considered to be a fixed leg pan. It symptom for extremely long periods of time of is given a separate dassification because of its rela the total 300 ases less than 15% had had their pre tive importaoce as an individual presenting symp senting symptom for one year or las More than one-half of the repainder (85%) had had this These major groupings will be considered in their symptom for more than five years respective order It can be seen by a study of the Certam allied symptoms are found regularly in table that generalized fatigue os such a common dc 25sociation with chrook lon back pain A close companiment of chrooic low back pain that it as study of this particular category reveals a true and be considered as an outstanding diagnostic symptom complete pacture of the essentul unity of the Postural of the postural complex. Fatigue becomes progres Complex Each of these symptoms are not independ sively worse with increase of naunlgic intensity cot neuralgias due to a single solated pressure on For if one correlates the inadeat of scuta in the one or more nerves, but anse from a generalized upper table (48%) to the same syoiptom to the condition affecting the entire spiaal cord and appead lower table (25%) it will be found that the same ages Thus confirm the mechansons of the great relative proportion applies to fatigue (827 curcle pictures demonstrating that symptoms regu 46%) tom, ·A CLINICAL EVALUATION BASED ON A COMPARATIVE STUDY 125 OF CHRONIC JDI BACK PAI -Fron Fort Defront Sexdres Frequency of Dagtomis of Dix Protruon Analyals of Therapeutic Haruld Apalygs of Time Ekreat in Therapy Andyn of the Came of Fulure To Na Sultantul Benefit 11 Fulures Pontire Diagnols (By Others) with Oxatton Adried but Deferred Poport Diagnowu (By Othen) With Operaton Irod and Performed No Furion) Bacted by Concert atre Treatment Failures H 10 Dani a Lon 10 Days to I Vogth 1 to 3 Moothu 16. 3 to 6 Months 6 Months to I leur Pallure 16 Uncooperative 35 2 Friara Due to Coura 1 Other Thea Posture 1 16 Tecborcal Difficulties in Patent or Method 18 s Testir Correction Effective 11 33 10 m 84% ܘܠ Na Subsuntul Benefit 13% | Upcooperative 15 6 Ponore Dious (Br Orbery) with Operation Adried but Deferre! Pootre Duygnoni (Br Orhea) Irth Operation Adred and Performed Mo Falon) Benefited by Conkett itre Treatment Failures Faduro 87% 10 Days or Low 10 Days to 1 Month I to 3 Months 1370 3 to 6 Months 6 Months to 1 la Paylurea ಪoಳಷ್ಟ 35 . 1 13 Fluro Dire to Causa Odber Than Poxture 9 Hostural Correction Effedre in 87% Technical Difficulda im Patent or Method Causos The grouping of neuralgias or altered aerve re base of the neck, etc. The movable and pares actions other than sciatica are collected according thetic classifications were governed by the same rules to their distribution into two major groups upper described for the differentiation of the lower root and lower root pain In the tabulation under Allied paias or leg aches The high percentages of patients Symptoms the upper root pains are listed using this having varied combinations of upper and lower root same term, whereas the lower root pains are de neuralgues in association with chronic low back pain scribed under the generic term of Leg Aches This is most signifiant and should justify the conclusion condensation requires a word of explanation in that that the symptoms arising from postural imbalance both of the major groups are again subdivided into are due to a general rather than a series of loal three distinctly different classes, fixed pains movable poves, and paresthesias If the leg ache section is Scratia merited a separate classification as does used as an example, fixed pains are those that usu the nat ategory of disc protrusion They are not ally remain continuously in one localized area re mately connected as the diagnosis of one almost gardless of wbether this is in the metatarsal region automatically cookes a diagnosis of the other Of of the foot, the inside border of the knee, or in late, this position is shared by the greater number other fixed positions Pains that have a tendency to of cases baving chronx los back pain without sa dange position from day to day or even from bour atica in th: throughout the entire serio the same to boor are suitably placed in the movable class diagnosis was made elsewhere, not once but rc The third sub-group of neuralgras vere given the peatedly These are not included in this category as tide of paresthesus to include the many types of this portion of the analysis is rosened for those cases altered serve reactions other than pain Here were in which positive diagnosis was made by ather placed such symptoms us numbness burnings ting competent neurologists or neuro-surgeons, maay lings crawling sensations etc based on positive pantopaque studies Originally The upper root section applies to all neuralgias patients here not included that had had spinal fusion Puns were considered as with disc removal us at the time of compilation it was faxed above this level if they remained constantly at believed that restriction of lumbo-sacral movement 1 destinat level, or were fixed in one position at the from opentive fixation would bloch pelvic shift. bove the lumbar ures ·126 THE POSTURAL COMPLEX con- 16 At present, this restriction is no longer considered only for so long a tume us foued postural correction valid since many cases with operative fulure after is continuously maintained prior fusion have had release of tension from foot It will woquestionably occasio considerable sur and leg correction alone. Although recovery in oper prise that 15% of both groups of these exceedingly ative cases is slower foal roults have been improved chronic ases piete substantially relieved within ten by the recent development of adjuvant medication days, and 10 considerably more than 40% e simular (cortisone, etc.) The combined figures of this por result was reached in one month or less It would tion of the table can be multiplied by ten in the light therefore seem that in this group of auses, in spite of present expanded experience to confirm the con of the long duration of symptoms, norve tensioa ulose clusion that this diagnosis is made much too fre Hithout secondary inflammation is the predomin quently and on insufficent evidence ant cause of symptoms In the remaining 60% of Lo the first article written on the subject of lor the cases secondary inflammatory changes were an back Main and its relation to foot posture, the state aggravating factor Recovery 3 considerably ment was made that conservative treatment merits slower and ben it occurred an be described, quite I trial before operative waterference is Lccurately as following & slow frden type of des mended 14 With the lapse of time it is not possible appearance. This difference in reaction of treatment to elaborate further Conserrdne treatmeet alone therefore an only be due to the addition of thos wudly is not enougb it toast consist of a fixed pos secondary (inflammatory) factor In such cases the imral sbor correction that releases spied cord IOASIOR present improved methods of adjuvent therapy have The staternents repeated by many other observers in been particularly effective to decreasing both the vuried form, that 95% of sciatica " and all tune element of therapy and the overall number of low back pain are symptoms aused by inter fulures vertebral protrusion are completely fallacious in the The final, or cighth column, us concerned with light of present evidence. Tbere is obviously sucba an analysis of the auses of fulare Many of these sred margin of error in statistical studies of patients patients have been under different forms of treat ibat bere bad disc remord that the entire subject ment for long periods of time without securing sbould be gren a new and closer scruties permancat relief and are quite understandably The sixth colamo is a summary of therapeuta end skeptical of treatment in general, and particularly results with the next column analyzing the time ele of a new approach. Onginally there were mioy ment needed to secure this change. This particular uncooperative patients, but these have been con Category (eaalysis of the element therapy) siderably lessened with the gradually growing recog illustrates most graphically the value of comparative ditwon that this different method of treatment offers studies For they almost assume the appearance of a dostust possibilities There is a small percentage of mathematical formula The specific term used here, aises having low back pain dac to other causes namcly substantial bencft rather than With the recognition that these are not of postural has been chosen advisedly for the word cure origo, there has been corresponding decrease in the miscomer a ben used to describe the end results of percentage of failures The final ause of fulare, treatment. Although there are many cases in which tam technial difficulties ather in the patient symptoms may not recur for long periods of time, (jout fixations, etc.) or in the corrective techniques, there ure many others a bose symptoms are relieved have been somewhat reduced by improvements in the selection of sboes, the fabration of reenforce- "Joren, Laurace Lor back pour A difereot ause and IN NR 16.2 57-62, February 1917 ment, corrective devices and dew methods of adju "Dandy we Trestment of recurring ettede of lov want therapy badtecte without kata JA-14, 125 1173-1178, Aogost 26, study of this comparative table has been most lastructive. The past history of thus large group of Conxe, ti e uod operate treatment of lepoos patients reveal that ordinarily the patient will conof the laten menul dit so the lor bad. Smatry 17 2 291 sult practitioner for the relief of the peuralgia cure US 1 ttcnt 1941 hot TA 103 Februar 1913 ·A CLINICAL EVALUATION BASED ON A COMPARATIVE STUDY 127 that is causing great distress at that particular 170 cascs they receive a different local dugnosus for ment The ones that disturbed lim last noch lust cach separate neuralgia mooth, or m the years before, are quite consciently From this statistical table and the series of illus morimized or completely forgotten They cannot be tratus causes that adl follow one is justified in con blanised entirely for this failure to associate present cluding that at present great diagnostre confusion is md past neuralgias, for in the grater number of ide rule raiber Iban Ibe exception ·CHAPTER FOURTEEN A Compendium of Illustrative Case Histories IT HAS BEEN repeatedly mentioned in the preceding Case No 1 Me RS. Age 19 6/28/32 (Tigure 70 chapters that the concepts us to causs, diagnosis, and B C D E F G and H) treatment of symptoms arising from postural im Cbie Complant Multiple ocurilgus-Chronic low balance, differc materially from present day majonty back pain, leg uches localized foot pams Duration one opinion. Abstracts have been prepared from a series of Mostrative case histories to give point by practical Present History At the age of seventeen low back demonstration to these varied differences They were pains became continuous and progressive og Anoding selected from a large number as representing certain or crestion. Disappeared promptly with recumbency Lately moderate aches through the neck and aboulders sigaificant points of diagnosis and treatment. Al have been added on first arging. Flat feet from m though relatively small the group as a whole consti fancy bat these have not limited activities anti recently tutes a representative cross section of the important Pass History Negative except for a swollen und pliases of the postural problem painful right knee-point which pecesitated removal of The cleven anses to be presented can be drvided the internal semuuar artilage to yours . as representative of the folloring groups The first Genard ExamiriOR General physique relatively and second are used to illustrate certain common good slight left total curre apparent in standing posse problems of dugnosis and treatment The not five bon with the right 1c crest being slightls higher than cases were selected to demonstrate the tendency to the left Lumbar movements in the standing position overlook the generalized ause of symptoms when show a good range of motton without fixatron, but side one latcase segmental ocuralgua dominates the pac bending 10 cach direction refers pain to the opposite ture. The first of the group of five cases illustrates contralateral luobar regroo. Slight fibrositx thickenug the dominance of upper root pains, the second, mid jo the lateral areas adjacent to the sacrum. Definitely tender bilaterally to direct finger pressure over the 1st thoracic pains and the last three, the manifold prob- 3rd, and 4th lumbar roots about two inches from the lems associated with low back pain and its end midline On the left side hyperertension leg tests proproduct, scuatı neuntis roke increased lumber muscle spasm. Bilatetully there The final four anses will illustrate certain diagnos increased trapezrus muscle spason with moderate con tic problems frequently associated with the postural tral fibrositic thicentag on the right side complex Characteristic symptoms may fail of recog Neerologic ExaRiMUJOR Neurologie camination Dition when they are overshadowed by other con patellar and beel teadoo refleres definitely typeractive dittoos This is particularly true when the other Fool and log ExaRination Stordmg Straight legs, affection is of major severity To illustrate this point but atrade inward toll srth dexent of long arches and marked paricular sig these cases had such varied conditions is generalized Sitting There u bilateral severe toc contractures with 2thritis, poliomyelitis, encephalitis and severe in thick central conflucot plantar callouses. There is con jury siderable pain on plantar flexion movement of the toes In all of these the dicf complant, history sig at the metatuosophalangeal juxtion. nificant findings, and treatment will be briefly sumt Radiograpbic Examination Antero-posterior petric marized, followed by comment pertinent to the 74-10 significant difference in leg lengths individual ause Some will be accompanied by se DAGHOSAS Postunl ubalance, splaal cord tensson productions of significant radiographs and photo and loalued upper and lower root tension seuralgus, graph reproductions mbetetamulgi [128] ·AOPEND UM OF ILLUSTRATIE CASE HISTORIES 129 Figure 70 Case No 14-RS A Young Patient aith Multiple Chronk Postural Neurigus. A (Lpper left) Standing cuminationUocorrected position showing internal angulation und derution of naght bearing B (lppo ngbi) Standing in corrected strught lide reight beanng position C (Crnin lef) Toc contractura D (Lower 101) Thumb pressure determudung point of maximum toe straightcoing E (Crater nigbr) Ruler technique for determining exact distance of metatarsal correction from bel line. (Cormi "x sexi por) ·130 THE POSTURAL COMPLEX (CORISNed from preceding pa80) F (Left) Stending to corrected shoes Mustrating ankle bulge of upper op de uick G (Centr) Standing In corrected aboes Hlustrating bilateral lang takle bit by petos of toogue pads and extra eyelets H (Rigbi) Technique for full correction lo sbon is determined by Bimaqual Rotatory Test. Troue Patient was given gradually increased comprising oaly 1% of the total number (see Fig foxed postural shoc corrections, physs and adjuviat ure 69) therapy with unmedute relief of upper and lower neu Case No. 2 MA CG Age 43 2/13/48 (Figure 71 ragus. Residual foot porn however was not entirely A B and C) elomnated until the final fued postural shoe correction Cbref Complaint Chronrc low back pain. Inconstant was attained 13 follows scratka. Duration 10 yenas. Omsside sbor correction Bilaterally to loch raise Presret History Low back pala made its first appear to the inside border of the sole, beveled metatarsal axe ten years ago Origioal attacks were severe but bars, tongue pads, catre celets. inconstant la the past two years the low back pain has Inside sbor correction Double beveled beel wants become constant withoat free intervals Ordinarily is (7+3) doubled long and supports (16+15) in relieved by recumbency although of late u frequently terior arch support (26) awakened by movement dunng sleep Vuruble scutt. ndutron of pan affecting both sides, but more often Commons This patient is unusual for the fact that he has a full complement of varied neuralglas progressive, aggravated by standing or cocitot Has worse on the right. Generalized fatigue has become at different levels beginning at an extremely carly consulted many prectitioners in pext two years, two of 187. Also differing from the majority of other young whom made a positive diagnosis of disc protrusion with patients, Mr RS is a hair trigger type in that operation raummended, but deferred by the patient. At the slightest ng from wear in the corrected shoes Do tube bas bad foot pain or Deuralguas in upper seg ausas 10 immedute recurrence of symptoms in his ase matters have been compliated by recent ndoc Pbysical Examination Marked lumbar lordoso. Lo tron into the Army where he was forced to wear un alized pain on presence over 4th cod 5th lumbar root corrected shoes With ratense Deanlgte recurrence, bilaterally considerable lombar musde in spasm, creased by hyperextension leg tests, torte on ought in spite of his long previous history he was classe Pool and Lig EXORDION Symmetrical feat without fied, in the routine fashion of the Armed Services 25 e malingerer However after an exchange of significant shoe deformatics. High long arches. Small plantar allow under left anterior arch, Night toe coa correspondence be was given spooul permiso to trectures with good flexibility at the metatarsophalingual wear corrected shoes. Agun, symptom free he s in function full service Thu ause of unusual in that chronic X+ Exerindron Left leg Y och shorter thao the low back pain is sure in individuals under twenty right. Lateral nadographs taken for entero posterior mcnti.

·Crection afats 23 Eduk shift Such patients are a 1 dis A COMPENDIUM OF ILLUSTRATIIT CAST 11STORIES 131 Figure 71 Casc Mo 1-Mrs. CG Young Matron -nb Multiplc Postural Neuralgias-(Hair Tripper 'lyne) A (W) Standing camination—uncorrected position showing sliglit internal angulation is contri) standing a corrected positron-straight line weight bearing C (Right) Standing in semi hylc laced oxfordle-fixell pintura pehe shift revealed the following Uncorrected picture Cose No 3 Mr All C. Age 33 X/4/32 taken without shocs-lumbosacral angle—38 3 Cbul Cowplaini Comstant Intractabilc palli al luer mg corrected shoes-lumbosacral angle 35 of the neck radiating into bolo afroulders and arms Dugious Postural imbalance. Generalized spinal Duration 22 years cord tension-lambar und scutic tension neuralgus Prosemi History Constant upper ronx neuralgias Tredmens Patrent giren fixed postural shoc correc tightness of the neck“ wird in the morning ACHA tron, physio and adjuvant therapy Made a satisfactory panied by unglings at the time of the fingers and numi recovery being substantially free of symptoms in about ness of hand the hands feel swollen fait can for cels as regards both lon back pain and Kratica ing change Prior to the las 21/2 years the patient head The scuuuc pains and fatigue nere permanently climin transient upper root aches for 15 years with mint #109 uted, but she has an extremels sensitae hair trigger tone having prins at (xher levels w us ko lack of spmal cord on that there are recurrent twinges with the foot pains During this 15 year perund the patient hall slightest sag en correction This is confirmed by her long free intervals, one lasing atmine 7 year Winn bostory which means that she has returned at intervals of pain was present he was under continues tordral treat 60 days for the past six years for treatment and modifica ment from different pracerta mert Diagram Ianc (im ered the entire scale ranging from them s flas matory Connor! This patient his clinical interest in types--Abrostis neurstan und anhnitmo po the that very slight internal rotatory deviation of the extreme where his sgrifenere were (in uidered lot feet and legs caused a slos gradual increase of lum pure psychosorik origin bar neuralgas that finally became continuous The Gesed Eunsad Sorall so sulle sy dorate haur trigger response can only mean that very sligh bo walkı esulz wretcet let por fut There 11 maddesin lambar lordosi wrth the der er slightly greuterspa positoon both cause symptoms and relieve Had and strollers are full m the forward ther. This is thought to be due to an abnormally Exmuschir of the spice s vedra no ens its more PRICHT sbort spiral cord and a tight cauda equina The Lzt detade let kul care 5 i rizler der er fring eral radiographs confirm this is correction col; as extremely fastle primiry free reserves the beste flessity comprising stout 13 of the touil ups ot Es zorgere fisse utfont par carte ferd rp slight'y lue: te le "pre-pupp from tion of correction changes of میری ۹ سا مک و کم مسرع fat4 م ہ2 tr E.جه ·132 THE POSTURAL COMPLEX crve tension nght, with Deither movement cousing paio referral. Posi arm. Patient has had prror minor transient attacks of tive findings were entirely limited to the neck and upper lor back pain, but no foot or leg pains She has com dorul ucu. Moderate coatnil fuiform fibrositus attend plained of shortooss of breath accompanied by : chok rog from the 4th cerral to the ls dorsal sproous proc ing" sensation For some time pest there has beca esses The upper segments of the trapezius mascles above gradually increasing fatigue She consulted other the sapular spins were in spasm and tender from the physician before seeng Di Petersen, who made 1 pose base of the oed to the point of attachment at the outer tive diagnosis of carduc engine. Two different sets of border of the scapula. Direct finger pressure reveals electrocardxograms were taken, both reported as pega marked tenderness over the 3th, th, 7th, and 8th cervical ture. The last physician (Petersen) made a tentative roots on the nght side, with the same roots on left side diagnosis of thorack radikulitis, complicatmag postural bemg las painful There is also direct tendemes on pressure at the ocaprto-cervical juoction. Refleres, both Pbysical Extension Summary of significant find- 10 patellar and Achilles, are hyperactive bilaterally with ogs Tall, well buūt adult female who malks without 1 Auggestion of ankle clonos Examinabon of opper a lump or list Appeared to be in odleat health bat was tremity joints reveal no significant changes, and muscle apprehensive due to previous dagnosis of neuralgus of power was well preserved. ardımc ongin. Enunination failed to reveal nay fibro Foos ond Leg ExamsRC10X Standing Straight legs, sitk thickenings in any of the segmental areas, Dor was syminetrical feet without shoc deformities There is a there any limitation of motion or masce spason. How bilaterally moderate inward rotation of the feet and legs. Evet spinal cunation, prone, did reveal Derve root Silling Patient his slight toe contracturs, but fen tenderness on direct finger pressure on 6th 7th, and 8th ble fore foot Heel cords dorsiflex to a point just short dorsal roots on the left side. This pressure ansed pam of the night angle to radiate to the front of the chest. Dlagnosis Postural imbalance, generalized spinal Foot and Leg Exarrearon Reruled straight legs cord tension and loalized cervical dorsal root tension symmetrical feet, intemel derution of slight degree. ocuralgiassecondary inflammation (ligamentous and Durosis Postural imbalance thorac nd platus. muscular fibrositis) Trodnool Patient was given fired postural shoe cor Treomous Fixed postaral shoe correction and physio- rection and adjuvant reducation. All symptoms draptherapy consisting of manipulative message and stretch perred within two weeks and she resumed active work. mg applied to both trapeznis muscles. Adjuvant therapy She has been seen at intervals by Dr Petersen for other consated of several 8 day courses of combined cortisone conditoas for the past several years, but there hare med aton Symptoms were completely diminated at been no recurrences of thorack pains. the cod of three months treatment except for slight sense of neck stiffness on avakening Common Paticats with this particular isolated CORMON This case has many points of interest, symptom ordinarily do not coosult orthopedists, and the chief of which is the diagnostic conflict. This when they do they are usually referred by interests. In the ownerous cases where clectrocardsogruas are an be duplicated by a large number of similar hus tories of patients having chronic neuralgias at ang negative, it might be well to question the patient 13 level. The fact that these upper root acuralglas mere to the past history of other acuralgus Of course, never associated with symptoms at other levels since both conditions viz., postural nerve tension makes this an unusual case. ind aagunoid neuralgus affect a high percentage of the entire adult population, they might commonly Case No. 4. Mo. MCK. Age 29 2/13/48 Bank appear in the same patient 1A varied combinations. Taller Care referred by Dr H E Petersen, In certain of these fixed postural sboc corrections San Fernando Californu. might be considered not only as a treatment, but est Cbiof Complans Pun in left best. Duration cac therapeutic test. Differential dragnosis is not arded week by the fact that neuralgtes of both types are usually Present History One week before date of cumina than by Dr H E. Petersen, patient suffered severe dali promptly relieved by recumbency or rest. However pam in left che lo the beginning the occurred two or the history of past neunigus in other ares when three times a day but of late pain has becorde lacreet combined with the presence of localized thornac root ingly frequent With this, there is a pus at the box of tendemoss in the presence of a complete negative the neck paduating into the aboulder uod dort the left dectrocardiogram, should make one consider this ·A COMPENDIUU or ILLUSTRATIILE CASE HISTORICS 133 is an alternate possibility Since both cardiac decom Nexrologice Examination Patellar and heel jeris pensation and the generalized spinal cord tension of definitels hypoactive postural imbalance regularly causc sa crc fatigue the Tool and Leg Examadion Slawding Feet 10 presence of both in the same patient may result in Hightly cuttoed Retention of long arch syminetry Slight dorsal aostosis yet the head of the left 1st meta considerabic aggravation Relief of postural imbal tarsal Bind of redocss on the inner dorsal border of 1000 may therefore FIC substantul bonchit by break the left foot with a slon blancbing tone, thus lag belog me 1 vicious arcle considerably decreased by external rotation of the foot Case No. 5 Mr CCH Age 34 7/28/32 (Figure and leg (Bimanual Rotatory test) The same test reveals 72, A B C D and E) Case referred by Di that habitual internal rotation of the feet and legs were Robert T Pottenfer Pasadena, Califomu otimated as between the mild and moderate varieties Chef complaint Lou back pin Duration 35 years Sillig Blaterally slight to contractures, flexible Histor) Thirty fire years ago putrent suffered com forc fert, bee cords 10 short. presscon fracture of the lumbar vertebrae while playing ray Report Pelris Upright The nght side of football. Seren years later he lud an acute attack of the pelvis e elevated to abore the left as measured at soutaca listing ten years and then was free of symptoms the upper margias of the acetabalar indicating the right for about ten years Scutk neuntis rccurred in 1933 limb us * inch longer than the left. The ille crest og usme one month. After this, painful penods became the nght is 14 inch higher than the left. There is more frequent. In 1930 he was jointly operated by a evidence of old injury at the outer margins of the acc- DEUTO-surgeon and an onthopedist for disc protrusion. tabulum, possible old fractures on the night, 2 small When this was not found a fusion by bone grafts was separate ossicle is present Oo the left, there is a larger performed. The operation gave slight relief for a short fragment which appears partly fused to the upper outer period followed by an intense aggravation whkh has margin of the acetabulum Moderately adranced osteopersoned to date. In the past two years he was under arthritic changes are noted in the lumbosacral spine u the constant atication of Dr Robert T Portenger Pasa sualized in the 14p vien dena, Califoratu. Voder the diagnosis of rertebral arth (Dos Peha and Spishaloff Beverly Hills, California) nus, be was treated by diet and medication. Patkat 128 Diagnosis Postural imbalance, lambur root tension referred by Ds Pottenger to determine if postural im neuralgras with secoodary inflammation, osteoarthritis, balance was a factor in the continuince of symptoms. traumatic and post operative aggravation. Gexced EXAMINATION Rereals i tall well rauscled Tresort Feed postural shoe corrections adjuvant stult, walks with slight lump to the left and with a for therapy consisting of physiotherapy and massage Also ward bend to his entire spinal column green two 8 day courses of cortone and adjuvant medi Spread Exammwion Standing Total curre to the cation. Symptoms disappeared gradually by slow fade Jeft. Long posterior midline scar starting just above the reaction over a period of three months. He has beea setood lambas spinous process and extending to the SECA et frequent intervals during the past two stars and deft of the buttocks On forward bending the lambat has been substantially free from symptoms up to the pone is held in complete ngidity the fingers missing present tine. the floor by 18 inches On side bendmg movement is Also Kmerely restricted, and all movements refer intense CORRIEN This case has many points of interest diffuse pain to the lumbar area. The initial cause would ordinarily be considered as Sape Straight leg raising-bilateralls—to the 80 a trauma of major sougoitude with multiple fractures mogle without blockage by pain or misde spasm But once he had recovered from the initial injury the Crossed leg text-negatire--bilaterally Circular leg free intervals followed by a history of repeated, Deasurement at comparable levels reveal no significant gradually increasing attacks 15 particularly diag nostx for the acuralgias of postural origin When Proke Changes from the spine to the prone with these become continuous and constant secondary na many breaks in the continuity of movement No appre flammation can be considered as aggrarating the Over the base of the secun, on the lateral expansion, or in the gluteal crescents. No original generalized and localized nente tensions ondernes over the xunta opening Hyperextension leg The pelvic imbalance was of two distinct types To tests streal rigidity at the lumbosacral junction and in antero-posterior angulation from interaal leg rota tion was added a considerable lateral inclination derece table fibrosita thickening beasca constant suscle spasen ·134 THE POSTURAL COMPLEX Male LA Figure 72 Case No 6CH Aiddle Aged Male with Severe lor Back Pain und Schatica- Long Duratioa Fusion and Operative Failure. A (Upper left) Standiag Examination sbomag Hight internal cogulation, the course of severe symptoms. B (Upper ripbr) Stand- 108 mustoo-bioaud rotttory shilft prodvoog #raight line weight bearing C (Loxe lofi) Strading position-acteund height of ngbt liec ce--lambo-sian post-operative KK D (Loxo ngbi) Standing coumloutioo-posterior vier-fixed postural shoe correc too-beei lift-rugbt line waght bearing E (Opposite pas) Antero posterior audio grapb (treding) left leg ose half lach short ·A COMPENDIUM OF ILLUSTRATIVE CASE HISTORIES 133 37 ST Figure 72E (Sor logoud or opposite page) from 1 sbort leg With the correction of these two 15 always sharply localzed to the low bach region with defects there was some initial relief of pain from reout other radiation. No upper root pains are for oca $1onal laxation of nerve tensions Symptoms, however did numboess of the fingers For the past four not disappear substantially until adjuvant therapy months has been treated bş De Robert T Pottenger for relieved intense secondary inflammatory changes arthritis, cod was referred for postural foot correction. Gexeral Exonmdion Middle aged female who walks There are two lessons to be learned from this case, slowly but without limp or List. onc, that spinal operations should not be performed Spre Examination Standing forward bending antil the possibilities of this specialized type of lumbar segment is beld ngıdly with the only movement conservative treatment have been ahausted and two at the bips Side bending similarly limited, and 111 that even after operative fulure this different ap movements refers paun to the lower lumbar area. proach still gno hope that the patient may be given Sapone Without positive findings except that strught substantial benefit. leg nising test reveals moderate hamstring contactures, Proge Slight fibrositic thickcowg over the base of Case No. 6. Mrs LM. Age 31 4/3/32 (Figure 73 A the scrum extending into the lateral espanssons and the 1od B) Referred by Dr Robert T Pottenger gluteal crescents Hyperextension leg tests bring on in Paudena, California tense lumbar muscle spasm Direct finger pressure re- Chef Complant Multiple neuralguschroak lor reals decreasing bilateral tenderness us ooc proceeds patn 6% ya foot pala 20 years opward from the 5th to the 4th and 3rd lambar roots. History With prolonged standing patient (tercher) Fool ad Leg EURIRAIOR Marked multiple shoe soffered for many years with puns ia long and mett deformitos Large exostoses both dorsal tod lateral tusal areas of both feet. About 64 years ago she suf ter the bends of both 1st metatars with sorte adduc fered on saute attack of low back pain. This because tion deformity Also lateral costoses once the lads continuous on sodding bat wus wally relieved by of both sth metatarsal-double bunsonettes (tailon lyong down. Lately she no longer experiences this relief bonions) The large toes do not over or poderride the ind is watened by pain on movement during sleep. Pen Dost small toes, but have pushed them outward. In ·136 THE POSTURAL COMPLEX halluas tendon was then isolated from its position be neath the metatarsal bend und split leogthwise to make . double head The forked tendon was then stared to the upper and lower margins of the distal end of the capsule to pull the toe into the strught Ime abducted position The lateral exostoses, (bantonettes) were then resected. Patient wore plater slippers for 10 days Cor rated shoes were then worn opetxed down the front, with the lacing area extending almost to the top of the shoe Post operatre swelling gradually decreased over a period of two months. When thus had completely dosappeared it was possible for the first time to fit the patient with satisfactory sboos barog a mug hed lift From this point on, fored postural shoe correction has grven complete foot, leg, and back relief Coniment This case is of interest only in demonstrating conclusively the significance of foot (sboc) deformities When these are severe it may be im possible to satisfactorily correct body posture through the medrum of shoes The presence of severe burn kon deformities may make the foot so wide in front us to preclude the soug heel fit essential to the clini nation of internal rotatory deviations It has long been our custorn, when confrooted with siogle or double bunions of extreme character particularly where those over or underride the adjoining toes, to refuse to give such patients shoc correction until the Figure 73 Cuxe No. 6—Mrs. LM. Mulople Chronk Pos. foot deformities have beca relieved by operative pro tural Neuralglas and Foot Deformities. À (Upper) An ceduros This applies with equal force to severe fixed tero-posterior radiograph showing muldple sboc deform- (immovable) hammer toos The operation for the tules-adducted Hallux Valgi (bunsons) and bunicotter. B (Loxer) Anteto posterior radxograph- x months post correction of Hallux Valgus (bunion) described operative-corrected position maintained. above has beca repeatedly derpoostrated in the prac tace of the writer to be infinitely superior to other the standing positron the long arches are lowered with procedures The straightening of the large toe by navxcular mgr. Symmetry is reestablished by Bimanual restoration of muscle balance is quite as effective 15 rotation, with the devntion estimated as atreme Diagnosis the plastic procedures used for the correction of Postural imbalance-generalized spinal strabismus In spite of counterclaims, Hiss is to cord tensson, multiple lambur root tengon peuralgies, multiple shoe defomite-(bunroos bunsonettas) questionably the originator of this superior plastic Tren Patient giren fixed postaral aboe cortec repair Case No 7 Mr G.S.B Age 34 10/30/50 Mechanic, tion, but severely limited by multiple foot deformitia. With to two months was considerably but not entirely Compensation Coxe A42 13302 Emp Mut. Lab Las Co relveted of lower lumbar pain, while there remained considerable residium of foot pun. On March 7 1953 Cbrf Complant Chronic low back pain, left static Darition 10 months 1 double plastic bunuoactomy wis performed. This con sisted of tenotomizing the transverse head of the adduc History Injury occurred 8/29/49 efter lifting benry tor hallocis tendons at the same time freeing abrous wooden block. Although ajary did not edutdy fascial and joint contructures The capsule of the joint dosable him the followiog day low back pain became to was opened and the thin projecting roughened outude • His JN Hallux Valgusit Camse od Sumplised layer of the metatural head removed The abductor Tretreat 15 / 5 11 31 37 Jo. 1931 acurtos ·berming tecumbency gare short periods of relief and Ordinanly be slept well with increase of symptoms A COMPENDIUM OF ILLUSTRATIVE CASE HISTORIES 137 Errot L UPAIC 41 Figure 74 (Caxe No 7-G.S B. Chronic Low Back Pain and Sartice (Hair Trigger Type) Large Sale Disc Protru (Upper Info) Previous pintopaque stady-Large filling defect in interspace between the 5th lambar body and the base of the sacrum. B (Upper center Pastopaque study questionable filling defect at interspace between the 4th hand sth lumbar vertebral bodies c (Upper nigbi) Antero posterior radiograpb (standing)-right leg one half inch those D (Lower left) Lateral radiograph (standing)—Vertical Wire oxasurement--fixed postural shoe correction E (Louer ngbr) Same view in uncorrected (barefoot) poution-lumbo-staral angle 34 - three degree insufficient shift. ktere that he was hospitalized for one week. Oo return tient ou referred to neuro-sargial specialists in Santa on to light work symptoms gradually increased unul Ans, California, and under their direction paatopaque the months later there was radiation jato the left studies were made. These revealed a large filling de bustack and down the back of the left leg in the fect in the interspace between the 5th lumbar vertebrae and ist sacral segmeat (Figure 74 A and B) Pantopeque accusoped an unusually severe reaction charac 1 45 bambo-sacral angle 12 ·138 THE POSTURAL COMPLEX terized by herdaches uod in case of all symptoms. bral col. (S S Steinberg, Radiologist, Beverly Hills, Mental catation us o cxtreme that he has no recol California) lection of this penod, but was informed by his wife Du rosu Postural imbalance. General spmal cord that he had to be placed in restrunt. Now bendeches tension, left kuatic Denmalga, large intervertebral desc are present on twakening, but disappear with medica protrusion, left, in the interspace between the 5th lumtuon or food intale. When low beck pain becomes severe bar und the base of the secun. he has a sense of hightness in back of neck and shoul Treatment Patient given postural shoc correction us ders without other ndotron to the opper extremities determined by acamination, modified to mdode Fatigue is present in moderate intensity Although able Loch balanced heel rise to the left shoe. He was bosto work a full day it light duties he mast retire im pitalized 10/31/50 for five day period of intermitteat mediately after dinner Russell or balanced traction. Duniag this time mall Good Exordion Reveals a tall, thin adalt male doses of cortisone were given every sex bours with poteswho allo slowly but without discerable lomp or list sium clonde 3 gr. After one week rest period this States he lost 13 lbs. in past two weeks treatment was repeated for 20other five days There was Spind Exammalrod Slaing Spide has a total immediate improvement and after three weeks of office curve to left on forward bending a slight lombo-sacral treatment there was an almost complete disappearioce bead with practually all forward movement being lim of both subjective symptoms and objective signs With ited to the bip fonts. Side bending sharply limited bi subsidence of pain on 12/27/50 lateral radiographx laterally with all movement referring pain to low back measurements were made to the standing position de Add nght battock areus moostriting the change ia degree of pelvic cagulation Supine Straight leg rus105-right-clerates to right effected by fixed postural correction (Figure 74D) angle without pam referral left-elevates to 60 10gle Lateral radiographic pictures made in the standmg post with further movement blocked by pain and muscle tion and wearing the corrected sbocs reveal the lumbo spasm. Cross-leg test-right-negative left-pain us ucni angle to be 42 With the shoes removed a spilar referred to low back region. VIW rrals the lombo-sacral nogle to be 45 (Figure Prona Petreat changes from papiac to prone posi 74E) The conclusion at that time was that the 3 degree tron with slight breaks in continuity of movement. Pal peluk shift produced by correctioa was insufficient, and pation reveals no thickening over the base of the sacrum one that would predispose to recurrence. tre Lateral capansion, or gluteal crescents Lombar muscles seen at 60 day intervals and was found to be havnog are moderately tense on both udes. Direct finger pressure occasional slight lumber and cut twinges but was able reveals tender laus over the 4th and 5th lumbar roots to work without interruption. On 4/18/92, there was a bilaterally and pain on pressure over the left Kuatic retum of intense low back pain and scutxi. Patient opening Hyperextension leg testsbilaterally-slight states that poor to date of aggravation be had twisted lumbo-sacrul bend, bot immedutely thereafter there is the left foot had leg while walking on and Since the agidity from mcreased lumbar murcle spasm. Rotatory previous routine treatment had given relief he was agun leg tests bilaterally-aux alight twinges in low back referred to the bospital for balanced traction and ed regron. No cental cervical fibrosctus. funt therapy Again, there was relief of symptoms Nowrological Ecowndlon Kace reflaes-bilaterally cod be returned to work and coatmued without signif. hyperactive, more on left. Hed jerks hyperactive, aunt interruption until 12/1/32. In the interim he slight ankle donus on left. frequently returned to the office u be was neret com- Fool and Leg Eronndron Slanding Dorsal cros pletely symptom free, suffering low back and satxo tosos Oter the bends of both 1st metabanturger on twinges with the slightest corrective shoe ug from var left. The long urch symmetry furly well preserved th On 12/1/52, patient had intense recurrence of left xa the moer borders of the plantur fecue tight bilaterally atic pain iod geoccalired muscle spasm with marked Bumamual rotation-inward roll of 10 plos, left--10 kutte list. As conservative treatment had failed to give minus night satisfactory results, be wus referred to Dr Troy J Put Sating Bilaterally forefeet are fleuble without plan oum, Neuro-surgeon, Beverly Hills, California Ho tar aillousos Heel cords an be dorufered to a point conclusions were it was by impression that the patient slightly abort of the night angle. has bemuted intervertebral disc at LS or 4, or Xra Excordion Standing intero-posterior ndro both. He has certudly changed all possibilities for graph reveals that the right leg is 11 mms, shorter than conservative themipy and sdrise that surpal treatment the left (Figure 74C) There is optque on in the verte be arried out as soon us possible." On 12/11/32 ·A COMPENDIUM OF ILLUSTRATIVE CASE HISTORIES 139 Midway Hospital, Los Angeles, Califoma, 10 aplora become an outstanding symptom. As a result she was txon was performed. Exposure failed to reveal aos referred for fixed postural shoe correction is an adjuvant pathologral reason for the extremely large filling treatment shadow found at the intervertebral space betaten L3 Generd Pbysıcd Examination Rerals a young fe and S-1 There was however a large scale disc protru male of medium height and body weight who wals with swa entending completely across the next intervertebral great difficulty and obvously mifcnog severe pains The space above L-4 and L S seemingly pressing on both upper extremity examination reveals that in the right Left and night lombar nerve roots The protrusion #23 shoulder there is localized central pain on pressure just frable, necrotas, and had to be removed by curettement below the scrornio-davicular uch with a definite twinge There was jatense dural injection Patients post-opera on external rotation. Elbops do not appear to be thick the course was satisfactory in that there was immediate ened, but there are definste twinges at the extremos of relief of the latense lumbar and sciatic pain the range of motion. Comment The satisfaction resulting from this Sprral Exammator Standing Slight totul carve to post-operatne change was short lied Patient found the left with the aght illc crest bemg slightly to the that he could not all across the floor barefoot left Forward bending-has an excellent lambosacral without thinges in the lumbar and sciatic regions bend, being able to touch the tips of extended fingers to the floor Side bending equally well performed and As this is written, 4/20/34 he is still being treated all sending movements were accomplished without pain for a recurrence of lumbar neunlgas of moderate referral severity Residual scuatic intation is evidenced by Supine Straight leg naging bilaterally clevites to transient pains at the back of the left knee This the night angle without bloclage of movement or pain particular case is interesting in that it indicates that referral Cross leg test (heel to opposite knce) odgr all too frequently disc protrusion may be an a&gta trve. Emmimation of individual joints reveal that both vating rather than a primary factor in the cusation knees are reddened cod swollen. Mensurements mid of acuralgias Not only have many patients been patellar right—1545 left--1644 On both sides there given permanent substantial benefit in the presence was free flud present us ed by distinct patellar of positive pantopaque studies, but many suffer float. Anlles are also swollen mid-malleolar-right, earls or late recurrence of symptoms after the re- 10% left, 10%. The right kace is sharply limited at moval of a protruded disc. the extremos of the ringe of motion, the left slightly less. Both ankles are free in flexion but slightly restricted Caxe No S. Dios. LML Age 23 1/31/52 Referred at the extremes of range of atention. There is redness by Dr Robert T Pottenger Pasadena, California, end puffy swellings of the dorsal surfaces of both feet Chief Compluat Chroom arthritis Durition 8 years extcoding into the toes-Large and first small toes on History Patreat has had an almost continuous the mght-lurge ud first and second small toos on the hustory of wired point difficulties since the age of 16 left La the beginnmg bad transsent pain and swelling of both Fool and Leg Examination Standing Reveals by knees dugnosed as doc to rheumatic fever During lateralis 1 xvere synchronized internal rotatory devia this persod she was mn bed constantly for three years, and tron. Marked og of both long urches and moderate relatirdz jautive for a year after this. She was married metatarsal descent. pregoint in 1948 zod significantly wis relatively Radiological Report Standing radiograph reveals Y4 free from symptoms during this turne Two months after inch shortening of left leg Other redrographis reveal delivery puns recurred in aggravating and spreading slight reactive changes in the right sacroiluac joint and form to affect in addition to the knees the ankles and pompal degeneratire arthrite changes in both knees fest. For the first time transient pains made thar ap charpening of the articular margins of the tibuc. (Dr pelsince in both elbows and the right shoulder For J G Conti, Radtologist, Beverly Hills Califomia.) the past three years had been under continuous treat DMEROSIS Multiple postural acunigus Afuuple sent by wired speculists and wis givea settal courses rheumatord uthatidos of cortisode with only slight transient benefit. For the Trahert Because of atreme internal rotation and past four months was under the are of Dr Pottenger other devotional deformitres, fired postural shoe cor aod lost 13 lbs. from a reduction diet. There had been a rection was prescribed. Because of the intensity of the considerable decrease of symptoms, but sustained weight olmamation this was performed very gradually about berning was poorly tolerated and progressive fatigue bad two weeks elapsing between each appard revision Ad ·140 THE POSTURAL COMPLEX juvent physiotherapy for the loner extremties coasist instul high fever senere headache, und muscle spasons, ing of whirlpool baths and light massage. Medication al followed by a loss of consciousness. A dugnosis Tu wus restricted to mid sedation for pain. Follow-up made of cofectious cacophelstus From this there was in notes revealed i rosarkably rapid recovery considering unusually slow recovery Putrent was alonost completely the severity of symptoms and the long daration TXO bedfast for the first three years. In the subsequent three weeks after inutul shoe correction pains in the night years attempts to resume actints were bloched by the fol shoulder and both elbor's completely diappeared lowing symptoms intense neuralgras at the base of the Within one month erress fad vis ibsorbed from both neck uod lor back regron. Wheo pains were at their koce points and the marked swelling of the ankles and worst she could not find comfort in any postrog, ertbet the dorul surfaces of both feet and toes were greatly sitting or lying down with hot increase of exertion, reduced. Withro two months, with gradually improved fatigue imedutely became an outstanding symptom. correction, there was a complete disappearioce of all For example to the week before the above date she acuralgus and joint swellings Patient resumed full used a Tucurum dader for about one half bour From activity to such 10 citent that she was able to dance thus slight movement she was forced to seek bed rest for a persod of four days. Commons As a therapeutic test thus case reveals Pasi History Reveals no other significaat inesses or that fixed postural shoe correction is a dominant operations Pror to the case of encephalitos she had factor in the treatment of arthritis Patient had been ocasioned troskat foot pain, somocturnes frontal bed under continuous medianal treatment for more than sches. No other history of segmental acumulguis. three years, receIVIOS conventional treatment of Greerd Exanmdiox Reveals a middle aged female varied types induding prolonged administration of who seems to be mentally alert, and walls without lump cortisone on three differeat occasions In spite of or list. thus there had been otenstve aggravation of the dis Spoel Examindo# Standmg Total curve to the ease and considerable deterioration For test pur left with right illuc crest distinctly bigher than the left. Forward beodmg--pormal lambosacral cunt with a poses all specific medication *2 discontinued tended fogers almost touching the floor Side bending acept for mild sedation for pain The experience was buzterally well performed with none of these spinal derived from this first and subsequent cases con morements Closung pain referral. vinced Dr Pottenger 1 speculot of national repu Supra Examination of joints enkles, knees, md tation, that it was necessary to apply fixed postural hups reveal no aboomalities of shape or function shoe corrections to relieve postural imbalance sa the Straight leg rassing well perforoved bilaterally Cross grater number of cases having arthritis. In the leg test (beel to knee) performed witbout pain referral opinion of this water it is believed that arthritis is Prowe Changes from the spine to prove position benefited for two different reasons one local the easily Enmımtion of the spmous mudlide reveals a distinct fibrositic thickening over the base of the scrum other general Locally 20 ankle, knee hup und even which extends into the right laterul cxpansion without pelvic joint may suffer increased wear from deviation thakening in either gluteal crescents Finger fork test of weight bearing lunos Generells release of spinal reveals marked tenderness Oter the night stb lombar cord tension may act poa erfully to stummulate general In the midline of the nech, parting at the 4th body metabolism, including i restoration of de Cerrial and running to the 2nd thonck splnous process, pressed glandular functions Although there may be there as a central fusiform fibrosity thickening which is some difference of opinion between Pottenger and extremely tender on pressure Both trapezius mosdes myself as to the mechanism promoting recovery are in spason with some fibrosita thakening in their there is aone concerning the efficacy of postural cor outer upper borders. Tension in this trea is increased when camination is made to the sitting position raction Nerologice Exordion Koce, becl, buceps, and Core No 9 Muss MU Age 43 3/30/53 Referred triceps tendoa reflexes se exceedings hyperdire bt by Dr Emest Russell, Neurologist, laterally with moderate ankle clonus Santa Barbara, Californu. Fooi ond Ly Examirdan Stang Moderate Cbuef Corplant Encephalitis–Multiple seunigus knock knees. Slom feet without shoe deformities cicept --atense generalued fatigue. Duration 6 years. for considerable toe fezioa contridores Fairly good Preset H151oT) So years ago become scutely ill with retention of long arch sometry although mternal devu root ·A COMPENDIUM OF ILLUSTRATIVE CASE HISTORIES 141 tron of weight causes slight sag lovard rotation is balance-General spinal cord tension-multiple root farther demonstrated by slight puffs swelling below both tension neuralglas aternal 6bular mallcoli Bimanual rotatory tests reveal Treatnieni Patient has given gradually increased in tremne inward roll on the left a moderate one on fixed postural shoc correction with the shortness of left the night. leg partially corrected by a 14 inch balanced heel raise Solling Thin discrete plantar callouses Over the to the left shoc. Adjurant therapy consisting of two beads of the 2nd and 3rd metatarsals-night, bilaterally interrupted eight day courses of cortisone iod assistant flexible fore fect with short heel cords that permit medication Physiotherapy consisted of inductothermy dorsificaron to a point 10 short of the right angle and stretching exercises directed chiefly toward bilateral Radiograpbic Measurement Standing The tops of trapezius fibrositis and spasm. Recovery was exceed both acetabuli projected to the vertical wire reveal that ingly rapid considering the severity and long duration of the left leg is 32 inch shorter than the night This sime the original illness. After three months of treatment difference is found at the level of the sliac crests (Figure there was almost complete relief of both upper and 75) This figure (Figure 75) illustrates that at one time lonte root neuralgias with a corresponding decrease of three comparative measurements were projected to the fatigue. Six months later she resumed full time work vertical wire 12, the acetabular the iliac crests, and 25 2 secretery in San Francisco the angle of the sacroiliac joint Although this latter potot is dearly demonstrated in this particular radio Comment This case has special interest in that graph, ja many others it is difficult to determine this the onginal severity of the disease and its location aact point. (Lewis Peha, Radiologist, Beserly Hills, caused considerable diagnostic conflict as to the rea California.) son for the continuance of symptoms Most ob- Dugnosis Encephalitis complicated by Postural Im SCTVCTS reasoned that the multiple neuralgias were Yo 556 340 5K -3% Figure 73 Case No 2-M119 ALU Aloldple Postural Neuralgius Compliating Recovery from Severe Encephalitis. Antero-posterior radiograph depicting a sugaufiant difference of leg lengths.

·142 THE POSTURAL COMPLEX the direct result of chronic inflammatory (post-att Super Strught leg ruising sad cross leg tests are cephalitic) chunges The referring specialist (Rus- well performed bilaterally witbout para referral sell) questioned this Although excephalitis was Prone Changes from popune to prone position with unquestionably the activitiag mechanism that in out breaks in the continuity of moremeot. There is creased a lateat spinal cord tension, the final resolt slight fibrositx thackeng over the base of the sacrum of tratment proved that serual postural devuttons without atsion into the lateral expansions or the rather than the sains of onginal infection acre the glateal crexents. No pain on direct pressure over the aggravatag cause of symptoms. state openinge Finger fork tests real atende perte root teodeness on both sides of the vertebral sporoos Case No. 10 Mus ALP Age 41 3/8/49 processes from the sth doou to the 7th cemaal levels Cabref Compluat Polooselits and post possone Hyperextension and rotetory leg tests are begatire. latx deformities-38 fun. Malnple neuralgusm2 jeans Foor and Leg Exondron SHINE Thert is a mur Proseus Hutory Two years ago patreat had in mute face coldness of the night foot and leg us cordpared to attack of low back paio stuch originally mis consid the left The right foot has an iaterior kar fire mches cred as due to the retroversion of an cplarged vteros Conservative treatment gare some sdref Three months lang starting on the dorson of the foot and extending above the ankle. On the extansi surface there is a long ago paws in the neck shoulders, and loner chest region made their appearance. There were not constsat but lateral xut startnog sur noches above the ankle just be varied to the location sad intensity from day to day hund the external mulleolus and then turns to proceed down the lateral dorul border of the foot. There are As a puino teacher ste particularly complained that hand and arm morements for long perrods considerably saltered partial cod complae muscle paralysos of botó 1gravated simptoms cansing "an interlacmg of paris legs characterized on the night be a muked takmess of and a tightness in the nat" Gencralized fatigue on the quadriceps sad an almost complete absence of the Certron beaune progressively worse. Lorset antremuts anterior tibial group Op this side there o additionally puas were of the motable types in that they were tran a hyperextension of the Loore on muodot (back koce) srent, not of great severity and regularly rined in loca but a good post-operatore stabilization of the foot on the ton. Several motoths prior to examination sbe had enkle (eluation of previous "dropped foot) (Figure merupbron" on posterior surface of the ngbt thigh deg 76 B and C) posed us "shingles Shandong Stochronized maternal rotabory deviation Pass History Patent had palcomselitis at age of 25% of the night foot und ankle s slight. On the left ist. seass resulung la setent multiple deformities Bath ternal rotatory derution is extreide On the night there legs were ser modis affected, more wo on the aght, marked 13 Laterboe metatarsal descent and a confluent plantar by droppet" foot and back kore deformity Sproul callous OTTT the heads of the 2nd 3rd, aod #th mett curvature of extreme Scont structural type mode #3 appant and became rapidly worse during the growth Radiograpbic EXARDIO Astero-posterior ndio period. In 1949 a local orthopedest performed a triple Staph (stunding) of the cervical thoracic and lumbar urthrodesis of the aght foot and sokle resaltiog ma spines reveal an extreme structural (Score) scoloso utofactory fixturou for the pretrously dropped of (Figure 77A) After reljef of ouraines from fred dengle foot. Later 200ther orthopedist performed a postaral shoe correction lateral pelo nadographs Oerte crushing operation without los benefit what (standing ugaing the renical wre) were made with the folloring results. Latenul 17 (1) barefoot PbYurd Ercordion Reveals a short, middle aged, lumbosacral angle 65 (Figure 77B) lateral tich (2) slightly orein aght female bo walls with great diffe standing to the corrected boek lambosacral angle 30 cally without sbocs. (Figure 770) Spod Exampdson Standrog Patreat has extreme Dagnosis Extreme postural imbalsoce Malopke Scune dructural scoliosis, night-certio dorul, left. Ketere post polomerx deformouties affecting both loter dorso lonher (Figure 764) In addition tbete om catremities Lod structural colosis Generalzed sportal extremely sharp lumbar forward curse (lordoso) The cord tension-conltiple peripheral berre root toasted Jena crests seem to be of equal beigtat kod later antero detalgus. pusteroor radiographs taal so agoshoot difference in Treatment Patreat mus girea fired posturi shoe cor Let Length Side 1od forrud bendrag are al per rection which was quae diferent on the tuo ndo u formed and thout pam referral oducted by the codornaal bindings of foot and leg a tars. Sovet ·A COMPENDIUMI or ILLUSTRATIVE CASE HISTORIES 143 Figure 76. Case No 10-MISS MLP Muldple Postural Neuralgus us a Late Complication of Severe Poliomyelitic De formites. A (Upper left) Extreme post poliomyelitic structural scoliosis (S-curve) B (Upper cover) Antero-pos tercot view of feet and legsmarked differences on the two udos-nght, slight-left, extreme internal rotation C (UP per robi) Lateral view of feet and legs-extreme differentiels. D (Lower left) Antero-posterior view in corrected shoes-marked improvement in weight bearing lines. E (Low coster) Lateral view of improved posturc P (Loxer ngbr) Literal view of shoes difference in wedgings-placement of extra cyelets for mog indle fit. iminations. A very slight degree of correction was found and fatigue, 10 about two months. She has been seen at to be sufficient for the weaker right leg On this ads, frequcat intervals for most five years and it has been because of mascle weakness there was a tendency to found that symptoms racur with every slight sag from OTT-correction with even slight raises nertssitating en wear in the corrected shoes outside wedging of the sole of the shoe. On the left Coinment The substantial relief soured so this shoe considerably more correction was requred both inside and outside eren to an oude wedging of the case is particularly significant as it ulustrates that sole of the shoe. To jasure snug fit both shoo were sop generalized spinal cord tension and accompanying plemented by tongue pads extra agelets and longer peripheral root tension neuralgias can be released be lecos (Figure 76 D E ind F) The patient made 1 sur fixed postural shoe correction in spite of multiple de prisingly rapid recovery being substratually relieved of formities of the most extreme nature In fact, scoli her chief complaints, movable upper root neuralgus osis of every type that develops dunog the grouth ·144 THE POSTURAL COMPLEX 650 RUNT ANT Figure 77 A (Upper lei) Aptero-posterior radio grapb-maximal post-poliomyelitk #ructural colou. B (Upper rigbr) Lateral pelvic radiograph (standmg barefoot)-63 fumbo-Haki angie C (Loxm left) Lateral pelvic radiograph (tanding in corrected aboes) - marked shift to 30 lumbo-aaral cople. 50° ·A COMPENDIUM OF ILLUSTRATTVE CASE HISTORIES 143 period there is a miched accommodation of the fracture crest ilium Following discharge from hospital spinal cord and roots to the structural changes in the patient was completely bedfast for six months and his contract the spinal canal of the vertebral column had a high degree of purtul disability ever since. This opinion has been confirmed many times by Past History Before the above mjores patient grees similar rosults of treatment in other cases having no history of serious illoess or operation except for a hysterectomy in 1915 deformities of lesser sectits Interestingly cously, General Eramation Reveals middle-4ed female the relief of neuralguis occurring as a late sequel to rell de doped walls slonly and is in obrious pain. polotrychic deformities is usually accomplished Spind Examination Standing Left total C-curre-- promptly as tlicte secms to be littic tendeng to the nght iliac crest slightly higher than the left. Forward secondary inflammatory changes that delas recou cry bending relatively good retention of lumbosacral bend no other types of cases The 15 shift in the com and touches floor with atended fingers without pain parative lumbosacral anglos demonstrated in the referral Side bending well performed bilaterally but lateral pelvic radrographs (Figure 77 B and C) movement to the left ausos a right contra lateral los represents the maximum difference found to date, back twinge (Figure 78A) baring been cqualed but not surpassed This u beel Sapne Straight leg rasang-bilaterally-well per like mon ement of the pelvis test backnard and formed to 90 eagle without blockage of movement. base fora ard-qurte understandably relcises ten Crossed leg test-bilateralls—(heel to Lnee)-regativc. sxon throughout the entire central nervous system No significant swelliog or limitation of movements of Case No. 11 Mrs. ALS Age 41 7/21/53 hip ankle or hace joints Prone Corrf Complaint Serere traumata—multiple fractures Considerable fibrosita thickening over base -abdominal jojuries Multiple neuralglas Duration of the scrum which extends into the lateral expansions 7 years Case referred by Dr Phillip L Rossman, to but not into the gluteal crescents. No pain on pressure temust, Los Angeles, Calif over the soutk openings. Lumbar muscles are well re Present History Following multiple injuries suffered lured Hyperextcasion leg tests reveal a lumbosacral 3/9/47 patient has had satense chroni low back pain bend, and this morenent does not cause iacrased Of late these paras are not relieved on lying down and lumbar muscle spasm. Finger fod tests-bilaterallyfrequently awaken her during the night. Fatigue has tender over Sth and 4th lumbar roots with a decrease become progressively sesere and of such intensity that at the 3rd There is definite bat slighter tenderness to she qanot well for more than a blod without resting direct pressure of ull of the Derve roots belon the oth la the last month she has noted swelling of the ankles thoracic level No central fibrositk thidhering aborc pain in the ball" of the night foot The multiple this level at any point 10juries suffered on above date rere caused by the rear Neurological Erenmalion Refleros-konce and beel wheels of an automobile passing over her pelvis just jerka active and equal. No enhle doows above the bup joint. A traascript made from the original Foot and Leg Examination Standing Stands with hospital records (Mt Aubur Hospital, Cambridge feet outtoed 10 on both sidos No sigo ficant foot Brus.) reports the following 3/9/47 a commjarted fracture of the left innominate with some displeiements (shoe) deformities Retention of long erch symmetry of distal fagments. On 3/19/47 she began to expert Bimanual rotatory tests reveal a slightly more than mod trece palo nduting to the sboulder blades associated with crate inxird roll on the left, with the inward roll on coffee ground vomitus. Operation performed 3/27/47 the night being slightly less There are small bulges be wus reported us an emploration with cholecystosomy An lou both external malleoli Delayed blanding time on scutely loflamed gall bladder was found and druned. the dorsal surface of both fect is mirkedly lesseaed by At the time of operation there was noted extensite outward rotation of the feet sod legs (Figure 78 B retroperitonal benorshage and considerable edema Wounds were dosed and patient was given repeated Sutieg Bilaterally-fleuble fore feet, do significant blood transfusions On 3/31/47 there was noted well plantar callouses doruflexion reveals both hed cords 10g of left ankle Duagnosis at turde of discharge Acute are 10 short of the night angle traumatk cholecystitis hemiperitoneum and recent trau Radiograpbic Exsmuna100 The antero-posterior pel matk tear of the right renocolic ligament-traumatic VIC nedrograph in the standing position reveals the left oderna transverse coloa and posterior pentodeamtecent leg to be 14 inch shorter than the right at the acetabular and a und C) ·146 THE POSTURAL COMPLEX 11 Figure 78 Core Na 11-D. ALS. Mfuldple postural Neuralgius complicating Serere In jorter A (upper left) Slight total functional coliosis (C-curve) from difference of leg lengths. B (Lpper nigbr) Antero-posterior view of feet tod legs-the internal derution of weight bearing lines and ateroal malleolar bulge accomparing synchronized Internal rotation C (Loxor left) Aotero-posterior View-effect of Bimeoul Rotatoo-dominanoo of internal devuton of agbt being the doappearance of the malleolar bulge. D (Lero ngbr) Astero-posterior rume effect cootinuously maintained by complete fired por tural boe corrections ·A COMPENDIUM OF ILLUSTRATIVE CASE HISTORIES 147 UPRIGHT Figure 79 Aotero-posterior pelnc radiograph (Hundung)eft leg Klach short ut acetaba har levels- unch abort at level of illac cresta Major displacement accompanying severe commjanted fractures of the Ilium. Levels, and yg inch sborter at the level of the iluc crests realtor . type of work that requires long periods of (Figare 79) The pelvic fractures and separation of standing and walking. fagments remain us originally described Commont This case was selected from a large Dugnosis Postural imbalance-generalized spinal group of patients having intense neuralgias of varied cord tension--multiple root tension deuralgus Multiple types that followed intul trauma. The nature of in taumata of major seventy-commianted fractures of juries vary from those of great severity us in this ause, pelvis had multiple internal injano to others in which the lajury was of minor character Treument Patient was green gradually increased such as simple spruned ankles or fractures of leg fixed postaral shoe correction based on the findings bones without displacement. Many of these patients found by physxıl enmination. Adjupent therapy con give no history of significant neuralgies prior to the sisted of odchothermy and massage applied to the ansct of traum. All too frequently in a great num lambar aree Scoce there was considerable temporary ber of auses the most universal latent spinal cord 48tivation of symptoms lasting from a week to ten days with each upward corrective change, the final prestiptension is increased by the injury Then the postunul to kus oot attained for about sur weeks (Figure 78D) imbalance that has been aggravated by trauma main Adjuvant therapy consisting of three interrupted courses tains neuralgic symptoms long after the original in of cortisope and assistant mediation Substantial relief juries have healed. This is an exceedingly large of the multiple ocurilgus followed a slow fade type group and one that is quite regularly relieved of of reaction but at the end of two months she was almost acuralgias and associated symptoms by the fixed pos completely pain free She is now actively engaged us a tural shoe corrections that rcverse serul distortion.

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·PART VI SUMMARY Page 151 152 Chapter 15 Summary 153 References Inda

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·CHAPTER FIFTEEN Summary Al SHOULD 15TCC that the opening statemeat of Tbe first of Ibese calls attention lo tbe simple con this tort has been fulfilled There is much conflict in nection of the foot and log ord is a distinct orer the present methods for the diagnosis and treatment simplification Tbe follou ing analogy bas been found of postural imbalance, and this presentation does 10 be more pertinent to tbe understanding of bus differ matenalls from current majority opinion Cer specific pbase of tbe posteral problem I bas been tuin portions may be so dn ergent as to severely strain amply demonstrated that semnal soldion of the fool aedulas Confirmed shepties should remember that Canses an exactly corresponding shift ad ibe ankle, eiers torent screntific Ibeory nuwst successfully toutb knee and bop wib demonstrable changes at tbe lom sland be tests of ime and experience bosacral la el Resultant inequality of uoght to join! In the past, the correction of foot posture has been surfaces may be compared to ones en wear on an considered solely as a means for the relief of local axtomobile tire but can only be terminand by cor ized foot and ankle paias The precedent extensive evidence indicates that this different approach gives rection of wheel alsgament on tbe axle 11 bost sbis to the correction of foot posture an infinitely ander prelimu nary change aiompis at tiro repair are a waste application It nou becomes the leves by Rhich a of effort change of foot position accomplishes a simultaneous The second portion concerning the spinal cord shift in body posture. It must again be emphasized as a unit emphasizes a general falure to recognize that the great majority of cases the foot, the prim ibis simple fact but actually conceals a much greater wry Chuse of serial distortion 15 a silent factor in that error Tbe spmal cord is only a segment of a com it may not 10 itself be painful Quite as important is plate smiler Sirkeler that comprises ibe bram, the fact that symptorns may not arise from a definite spinal cord perspberal nerves and be sympat betre fault in posture Meny patients having excellent and parasympatbolic systemis A mecbarca lesson physiques by the most exacting standards, have a or een lansion at ang number of cutice ports com complete set of symptoms whereas others with mul concenabli affect the entire inter dependent system tiple defects of considerable severity may be com to disturb the fine balance between stimuldjon and pletely symptom free mbibition so essential lo normal function In the course of clinical discussion the statement In addition to the affections that have been de has been made with tonguc in check that this in scribed as amenable to postural correction, there arc restigation was based on two major discoveries indications that the scope of this problem may be the one that the foot is ataibed to tbe log and the considerably enlarged to include other coaditions other that ibe spinal cord is a continuons strectate caused, or aggravated by static factors It is hoped This of course is persuasive argument reduced to that the different approach will aid in the solution absurdity Hosever many bones a second look at the of the diagnostic and therapeutk problems that still obvious has recaled facts of considerable clinical surround many common symptoms arising from or aggravated by postural imbalance significance { 191] ·References 194 Duod VE Trement of recorn attacks of low because Titboot scutia /ANA, 19 1173-1178, Aug. 26, 1941 Grus Henry Loony of Ibu H**ss Body 20th ed. Phila delphie, der lak, La md Febiger 1916, Figure 137 Hooser Emil, D. Dusechs of the Fort 200 ed Pledel phue, Semden, 1930 Hie, J . Hallot valgus Ios anse uod semplised trut Deat. As / S7-11 31 37 Lan, 1931 Hattoo, Jumos Tbrors of the Eartb Loodoo, 1718. Jose, Lorence Low back pain A diferent cute and treat meat ludustrl MN. 1657-62. Feb., 19-47 Jones, Lorear The shoulder jolex - Oberritoo as the Lostomy od phrcolor Sor Gym & Old 75 43344, Oct. 19:42 Ket J Am Cooserrature and operative treatment of lacons of the Inter Tertebral disk in the low back. Sorry 17 191 303 Fob 19.45 Lake, A. C. The food and ed Bultenore, Willams and TIklms, 1943 p. 26. lom, Philip The Fow and Ankle 3rd ed. Philade La und Febiger 1947 Ramm, Arthur Fuod Johnson, Burrs Vertebral lado termmabon of the spinal cord dee Rn 12 Schubert, Charles and Dunbar Carl O. Oalns of sonrad Grolog 4th ad Now York, John Wicy and loc. Ref The Ledronctire Clock, PP 10-23 Schultz, H. Some distingu shung durctosto al mottus gorilla. Vad, 131 1944. Smith, Gaftoo Elliott: The Elder of La Loodoo, ford Uorreraty Press, 1974, P 36. Scarth, William Onder of the Stras and Their Ink Organic Rowates Loodor, 1815 Tlocs Frederkt Th Brate from AM to har 2 vol. Yark, Hoeber 1928 Foersemion, IL *.. Atlas of Hua Audny 2 robe. I delphia, Pludston, 1990 ·Index A E Encephalitu, 140 141 Eras coronoic, 6-8 cryptococ, 6, 7 Coroic, 66, il paleozoic, 6-8 Fiersion, 33 34, 43 44 Evolution brun 18-21 Cenoros, 6-8 cryptotouc, 6, 7 love catremity 9-17 3000x, 6-8 11 preraamoalan, 9 primate, & 9 paleobox, 60 spinal column and cord, 22 25 Stratigraphic evidence of 3-8 Evolutionary progression, goal, 5-8 Eximionboa foot (and leg) 9 73 postunl physial 64 spinal, 61 Exercores, 113, 114 (see Physrotherapy) External wgulaton of foot, 49 51 70 109 Adurant therapy 107 114 Calanol purs, 71 Anatomy Calaotus internal rotation, 3 propulsi e gat, 50 Call muscle lette 47 30 apulo-humeral stabilization, 12 13 Callouses trail cord dorul, 72 relik, 24 23 30-32 foot, 72 73 tension, 24 23 29-3 interphalangeal, 72 Anulomal Dorm of foot, 54 69 plantar 72 Angle, tombo- uanh, 29 32, 37-41 137 Case brgotias, illustrane, 128-147 144 Conroc 02, 6-8 Angular compresuon, 35-57 Charts, foot mengirements, 75 98 99 Ankle mortiet transactions, 33-57 100 102 Antensor (metaurul) urch, 46, 30 62,72 Child foot posture 73 97-104 109 128 Correçine differences, 113 116 Antero-posterior ndographs - difference training straps, 118 of lay lengths, 34, 4, 116, 133 Chronic arthritis 135 137 141 1447 bypertrophre, 71 Anthropond differentiation In fect, 13 rbeunatoid, 139-140 Anthropoid horizon (braun) 20 21 Cocinercial (suitable) shoes, 81 Arch Comparative per change, 15 17 asten (roetatarul) (see Anterior Compound plastic chetnial, 83 metatarul arch) Comprenon, nagular 33 Long (loogitudinal) structure of 46, Coocurity of roetatarsal (anterior) anch, 49 50, 100-101 72 73 support, sponge rubber 100-101, 130 Coats J G 139 Armerentarius-fabrzanting tools, 85 86, Controls, rapalo-bumerih, dal secto 8 97 um of, 12, 13 15 Arthritis, 139 140 Coon anity of metatarul arch, 72, 73 Correction, yde of 30-32 B Correction of shoes (s< Shoes, correction) Balance Hling (mucolar) of pat, 47 50 Cortisooc, 109 mternal (tibul) 47 Counter inside fiberglas hell of 83 84 Laleni (peronal) 47 Cross leg test (tupine) 65 peronal (lateral) 47 50 Cross-sectional studies of foot, 53-57 tubul (interpal) 1750 Cryptomai n (cvolution) 67 Becquerel, 47 Cycle of correction, 30-32 Bemowl rotatory test (foot and leg) TO, Cycle of setul distorborg, 29-32 71 105 106 135 D Berchetron (Sunun) 12 Brun Daody WE, 126, 132 Lothroporc, 19-21 Daun, Lilla, ni Golution 18-21 Descent, sustentacular 5 Development humm, 18-21 di cruity of mammalian, 6 tamaan, 1, 19 of baum, 18-21 proimun, 18-21 Duathermic applicator techniques 110-112 relation of form to function 1621 Differeotult, UK crot, 33 64 140 145 sptulan 18 19 let length, 34, 36, 116, 133 134 137 sumin, 19 21 141 147 Buodlos Deurvovascular Dos protagon, 125 126, 135 136 139 Bomooctte, 72, 136 Doral allouses, 72 Bunyoos (hallux valg) 72 116 Dunbar Curl 0 7 152 (133) Extremity entrapluies differentiation, 11 13 17 fore and hund mb similarito, 9 11 100 de functional components, 17 stotral trochronion, 17 Morenent theorem, 17 segmental spochrooiztoa, 13 16. 45-37 motorcut, physiologial dudercores 16 17 shift of lloa of force 9-12, 16 worlarity lcmoroids 11 quadrupedal, 9 10 uppet bipolar lines of force (brochutoa) 12 fupcDonal costponents, 13 monement theorem, 17 sapulo-huocl totoroaication, 15 thafts in Loss of forte 9-12 Erelets, en in shoc correction, 91 fish 18 19 F Fart sky x1, 123 121 ·154 THE POSTURAL COMPLEX Falgue, portarıl, 63 124, 130 132, 140, alf oocle herer 47 50 Hoover stabilizabon (sbookler bosat) 141, 145 meparso-phalopal, 73 13 14 chroon low back pea 100, 124 peronesl sling 47 50 Hutton, James, s 132 mausta sod, 124 primary motor factors, 47 50 Hyperextensioo kg test (prooc) 68 Feet, sottropoid dicantutioa, 15 tībul King 47 90 1 Fiberglas shell or muide commter 83, 84 Deutral strucht line position, 43, 44, 31 Fibrosios 52 37 Duc crest difcrepaak, 3, 64, 140 145 central corral 132, 140 plato faxua (fe) testa, 71 Lucos, macro angolation, 29 condocot, 69 postere a cola Inadeqare bocs, 79 discrete, 69 Coritare difcrences, 113 118 lodinstal indlede arterion of recoforca lombo-anıl, 68, 145 tabung strips, 116 shoes, 98-106 podular 69 pumante compartire Hody 14 15 Iodoctotheroy (sur Plopiothcopy) Fibrosibc pettem (postural) more of motiontero posterior Internal angolaton of foot, 1934 coollocat, 69 petdog. 44 Ioal rotathan podolar 69 standing 30-32 foot, 29.31 (scPrunury thera De Finger fork tert (proce) neidity in prunat, 14 citam) Fish progresson 9 nodity treod to 14 13 fee od thigh, 29-31 Fired ridiculita Totatory mencints in sochroorred, 29-31 43 43 +9 57 abducos, 33 laterratebal dose protruonoa, 125 126 lower lap parn, 123 12., 135 139 adduction, 32 173 136 139 apper root pain, 125 131, 132, 140 Flat feet (po avus) 46 strugt Lone portion 32 Lotocrog, 43, 44, 31 5 118 (sn Foot, accoction) Flerbility (foot) loss of, 14, 15 ruker metsurement, cetatarsal arch, 101, 105 Interlog, 43 44 Foot (od leg) abdochon, out-toring, 43, 44, 31 32 skeletal rigidity 44 46 J uddaction, in-tocop 43 44 51 52 Anight loe posbon (Loctomia Joboxon, Barry 22, 23 192 porm) 49 51 534 und le motemeats, bulance simgs. 47 Jornt talar min cincot, so SO boulder 12 24 taler foothon, 40-50 nogalar compression (sustentacular) rubalar, Fore cod hand limbs, differentation of 34,337 Jones, Laurence, 12, 29 124, 126, 132 2-17 Logalloa lemptond unilarity 11 K csterdal, 49 7, 105 ling of force 9 11 12 Keith, Artbar a medal, 49 4, 70, 105 Laterror (metatarul) arch, 44, YO repulito imulanty 9 hoy J A 126, 152 Foundation of boty chart, 95 L Fructure, alapla, 145 compete structure Functional xollosis, 61 Log in shoe correction, 94 Lathropold, 14 13 Lure, Noco C II, 14 4 137 human, 14, 15 G Leg (str Foot tod kp) Lepuroid, 11 Guit Log length did treptus mirn, 14, 15 Sormal, sepeoul stackraalration of loucuray of upe metsarement In. 33 Cross cctrogul stadics, 33-57 rubogarplexe meintinent, 33-36, 42, fasility lou of, 14, 15 propukion phase, 44-46 116, 136 137 147 foundation of body s Gepetal bumuom) robulocy test 70, 105 Le texts, 65 66 waspection 100 ftuctomul testo, 73 Geologal rate 5-7 finger fork, 69 internal rotatron (sociraized) 17 Glotal nokcie spesm, 137 138 metal, 70 19-31 4455 Goutha foot differcores, 15 spedal for or debate, "1 look (loogrodoml) anch structure, 44, Gray Henry 33 36, 132 spenal confortatory 63 68 46 100 Lemon 11 malleolar parellel.m, 45 5 H Lour Potto 11 MESOTCDCDt charts, 74 75 99 100, Hallux valgus, 72, 136 Lommer blogpor 11 102 Hapser Em D 43 93, 94, 152 Lemuroid trachon of Heel fore and baod limb similanty 11 long arch dactat 54 57 berele xents, 103 borong, 20 21 mallcolor (eternal) balga, 31, 37 cord lengtos tex, 73 Length dispody to spoil coleno od mertimal anch, 46, 50, 62, 72 73, 96 cord, 22 23 104 103 171 Tbomas, defects of 92, 04 Log alf scle (foot and leg) 47 50 metatrul X 91, 93 mbulanced and correction, 89 Lou, Phillp 43 30 31 1 93 13 in COCOD Hors. J IL 136, 152 Linor sochronantoa (lower extremity) abdorton, uttag. 44 Historia, cos, illustre, 128-17 50, 52 abduction coding. 51 33 Homla bocmo (brun) 20, 21 ourtwn uttr44 Houm postare, erojatno a 6 Jurbar 61 64 107 108 udduction standing. 51 33 Human repulia milogos, 9 10 latic, 64 107 100 Spot, 71 ·INDEX 15 Long urch Multiple neuralgias, 123 ? 129 136 pusie (aanipulatioa) 111 112 mechanism of 557 140 141 143 146 Iodoctothermt 11 ructure of 14 41 46 Muscle mase massa 112 Lou of dexitality (inox) 14 15 glotaal 131 131 birlpool bata, 109 lor het pm 40 41 42 63 123 124 har 130 133 137 138 Plantar callowe, 72 123 127 140 133-14 143 1447 trip1101, 128 131 140 145 Plantar fascia fine test, 71 1 factor IR 123 Plastet chemical compound 89 Plastre tenforcement of whoes, 82-86, 89 wote, 193 Nie soms, 124 125 Toodles, GH, 22 Poliomyelitis, 142 143 fatigue, 63 124 125 Note Postural complex, front piece 99-32 releax 9-11 postural history 41-64, 123 Postural corretton, 113 118 119 K diferential, 123 Root abgulatoa ia spinal cord, 22 Postoni fatigue, 63 130 132 140 141 Lora extremity tator, 29 31 boncol rotatory to, 70 71 103 Newalgiis multiple, 123 127 129 136, Postanl bistory 6175 lioner unchronization, 30 140 141 142 146 Postoral physical trimination, 61 Luntar last, 64 Noms scolar bandles, 95-97 Pottenger Robert Tv ni ni, 133 134 Luchar lordosh, 130, 13! norm, anatomical or idal, 31 54 139 140 Labar muscle spum, 150 133 137 138 Normal pit sgtriental socoronination Premammalian crolution, 9 Lumboumral mogle, n9 52 Prosuplans, It Lombo-hal shaft, 340 137 111 Primary muscular factors in foor more O fents, 47 50 Quttocine (foot) 4% 44, 31 32, 118 Primary there mechanism (fook) Malcoli (sto Foot, abduction) anatomical norms, differences from, 14 Entertul balfe 53 HST 146 cross-sectional studies, 34 77 relatric parallelison, 45 35 34 p volevomary developroent, 9-12, 14 15 Marc, 113 Pain long urch den ceat. 34 Blocotter R P. 22, 132 constant intractable, 131 malleolar bulge (ortertul) 34 Mararement in left chest, 132 pelnus angulation from, 39 40-42 rolet, ot tutorial arch, 104 Low back, 63 124 125 130 133, 134 sertat distortion mod correction, 29-32 tap, inactory of 33 rete, 123 Primate bor izotys (brala) 20 21 textumque of prelmary foot, 102, 103 are factor 123 Primate foot, ictibility in 14 Hochraren postural history 41-64, 123 Prounthropoid horizon (brir) 20 2 dual, of scapalo-bumeral control. 19 Kuba ind, 123 Procedure, 201pulation therapy 109 112 of long arch, 54, 57 30% differentul, 123 Praction (foot)--termicological mit of spraal cord, 31 32 psychosomat, 63 nomic 43, relare, 32 32 ridiculus Porchosomatx etror 63 131 tension, 29-32 lon a les 125 Putman, Tracy J, 138 petik egulation, 29 32 upper root, 125 R pittory trigget (5** Primary trigger Paleozoic or, & 7 9 10 mechanis) Perestrows Bdiculitis ther (se Primary thugget sectoros) Lore 17. 123 Lower les pains Mesorox 1,6 7 11 upper roof, 123 fred, 123 128 139 139 Metatarul (interior) arch, 16, 50 Pame, Ropal C, 123 14 mon ablc, 123 125 Cocinity 72 73 Pela sorelaton, 29-31 35 1042 parasthenes, 125 Contity 72, 73 dumnges from foued postural corrections thorax uod Logina, 132 cottatrre tomt, 73 129 130 33 37-42 opper root pain, 125 mobility tests, 73 112 Pelnc chiosc coroparatrs, 16, 17 fixed 132 140 ruber mapromeo, 104 Pelek lombo-aci, 30, 32 morable, 124 139 Metatarsal bar (shoc vole correction) 91 Pelek masurement (radiographus) 3033 parasthenis, 129 94 33 36, 40-42 Hadooprophic mcasarerent Metabriga, 30 Peline mecbmm, 29-12 of key length differentul, 33-35 42 lartce, tubro-fibolar 50 Pel x posit001, Dagurereat of 3442 116 plotable redaculitis lower kt par 123 Pelvic release (lombar end ruik) 19 pelvic insulation, Lateral, 35-36 125 31 33 1042 144 pelnic golavon, oftro posterior 3 Lorable redkolitis, upper root pas Petek ta, 29 31 41 142 141 Pavocal thing (foot and let) 47 50 Radiography Koreacts Petersen, Harold En 129 132 turcactos bona extretty luer stockroontun Popucaltamination cod postal distort technqpe of intero-posterior 5 H 61 5 36, 42 loox (sn Foot, movement) Prywattempt techniques of lateral, 33 40 41 42 rottory 46 strumbett defects 33 Halople fructe, 145 stile 113, 114 standing adiantage of 14139 CH ·156 THE POSTURAL COMPLEX for udobs X, 40 41 children, 116 Ronge of motron m foot sitting 44 standing, 30, 31 497 Ruforce a hoa 8-87 Rarang, Arthur P 22, 23 152 Relats, nerie, 29-31 Reptiles buna malogies, 9 10 progression 9 theriodoot, 9 transctxonal, 6 Rigidity lo human foot, 14, 44, 46 Roentgen, 6, 7 Rossm, Phillip W, 145 Roulon, internal stocoronited (foot) 29-31 Rotstory leg toa (prooe) 68 Rotatory monements of foot, 31 13 Rabber spooge inserts (see Sponge rut ber insert) Rossel Emes, 140 Rossell tractoa, 107 108 Rutberford, 6, 7 S Sapular Habilinton, mechanism of 12 13 Sapulo-bwoeral sablotron, 12, 13 aboucher fouet, 13 Schrochett, Charles, 7 152 Schultz, A. H 15 22, 192 Scutlar ucude neorit, 11 -12, 125 126, 130 13-4, 137 139 relatxoa to low back pun, 131, 136 137 Scalxc ut, 6-1 Scolo, 64, 114 Serul destron (distortion) dle of 29. 32 Shod COM.DOTTLI Do of 81 Correction eta etele m, 94 nude od postment, 98-106 Lucmfm. 91 matcruls in, 96, 98, 99 toane pads in 94 unbalanced beel m, 89 Atting of 62, 113 116, 118 plastx teenforcements, 62-86, m role (capo) 93 inde. 93 -meutarul ban, 93 94 outside, 99 tools for renforcemcot, 96, 99 umorable (com feable ferable) 79 Shoulder rot bruchutun humer 1 sublimion, 13 14 capolar blz1000, 12 kapalo-hurr | 12 14 Simian borizoa (brun) 20, 21 Tats Sámilarity repulun end bums entremi bunsoul roubory (foot and kr) 70, ta 3 10 71 133 Skeletal rigidity in foox (human) 14 14 crossed lek, opus, 65 finger fort (pdxculitos) 69 Sling or wing (onosalar) fonctional, 73 bulanco, 47 geoctal bemannal routory 103 internal (tibul) 17 heel cord leagth, 73 Laten! (peroogl) 17 hyperection, prone, 63 perenal (Lateral) 47 50 leg-confirmatory (pal) 65-68 tubul (internal) 17 50 proctal (verul) 70 Som th, Grafton Ellott, 9 18, 192 geutral orch, corrective, 73 129 130 Smith, William S 152 Sole vedgag shoe correction 93 21 metatarso-phelinçal mobility 73 112 Spinal colama uod cord, 22 25 plantar fusda fine or fager, 71 compuritne or th, 22 rotatur key prone, 68 developroept of 23 24 Tberapy fusson, 123, 126, 133 134 135 spusok. 107 114 length diganty 22 25 acrimos, 113 114 nerre root mgulitroa, 22 23 manipulative procedures, 109 112 release physio 109 112, 113 natomical 24 25 tractoa, in ertemuon, 107 mechanism, 31 32 tracton, Russell 10 Nexon, 107 1 osoa Tbonodont reptile, 9 anatomxal, 24 25 Tboos becl, defects of 93 94 mechanin, 29-32 Thompson, A. 22 arked levels of termination, 22 ) Tibco-fhaur mortree, 30 Spushakoff 133 Tubal sung. 47 30 Spooge rubber mserts, 97 99 100, 102, Tilocy F, 4, 11, 18-21 132 104-106 Toe ferro contoxtuto benched heel sats, 103 fixed (harder toc) 136 dere placement rules, 97 106 monable, 73 109 112 look arch supports, 103 104 Tongue pads Lo sboc Correction 91 metatarsal (noterior) arch supports, Tools for shoe correction, 96, 99 103 104 Traction Stabilotoo, bumeril of sboalder Jacot, bilateral balanced ( Ret) 107 109 13 14 Tenica, 107 Stabilization capolar mectamson, 12, 13 head, 107 Stabilonbon, sapulo-humeral, 12, 13 Truong straps for children, 118 Steinberk S S. 138 Transtooul reptile, 6 Stelpman, Robat, 83 84 Truperius leading for fibroutie 113 Straught les raising (supuse) 65 Theprous mode spas, 127, 131 133, Strict linc poution of foot, 49 31 32 140 145 14 Traperips gretching for muscle spasm, Strita, geological, 5-7 112 Structual xolioris, 61, 142 144 Trtura, 145 147 Structure, compute of foot, 11, 13 Tree Shrey 7 Structure of long och, 44, +6 Trigger machenden (1. Primuy tnater Sabular poudt, mechanis) Sortable shoc, outuck tod ude COCTEC U ton, 79-105 Unbalanced beels (sboe correction) 9 Superposition (poolopc) 56 Upper extremody differentiation, 11 15-17 Supatron (foot)tomologal mis Lpper root pers (certa) 125 (A pomer 43 44 Radicalige) Sostentacular descent, 33 37 Urmo time dock 7 T Talar fruttoa la foot, 48-50 Vertebral coloro (sor Spusl colono) Talar Denemcat in foot, so Touer (turn) : 11 Whirlpool bath, 109 Teostog, pene, 29-31 Woerden, V 23 24 152 ·This Book THE POSTURAL COMPLEX B) LAURENCE JONES B.S, MD ras se pred and bound by Tbe Pantagraph Printing and Slstromery Company of Bloonimglon Illinois Tur engrar ings were made by Capitol Engraring Company of Spring field Illinois Tbe page irini size is 842 * 11 incbes The 13pc page is 39 * 54 picas Tbe 13 pe face is Garamond set 11 point on 13 point Tb (ext paper is 70-11 Cansberland Gloss The core is Bancrofts 8x krom 3390 BARA Kents Pith THOMAS BOOKS careful attention is giren to all details of manufacturing and design It is the Pxblusbers desire 10 prosent books but are satisfactors a so ibeir pbyxa quelmes and artist! porrsbilities and appropriate for best pornes THOMAS BOOLS will be the 10 boss laus of quali bal assere a good name and good will

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