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Volume 1The Reflex Therapy Series


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TOTAL HEALTH, LTD.3290 Hillrise DriveLas Cruces, New Mexico 88011-4778 (USA)

Copyright 2002, 2003, 2005 by Howard Sadowsky

ISBN 0-9742753-4-4 (eBook)ISBN 0-9742753-8-7 (pbk.)

Manufactured in the United States of America.This book printed on acid-free paper.

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All rights reserved. No part of this publication may be reproducedor transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any informationstorage and retrieval system, without permission in writing fromthe author and the publisher.

Library of Congress Cataloging-In-Publication Data

Stature: The Key 2 nd ed. / Howard Sadowskyp. cm.

Includes glossary and bibliographical references.

Podiatry, Orthopedics, Naturopathy, Massage, Physical Therapy.1. Non-fiction. 1. Title.

Library of Congress Control Number: 2003094580

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Contact Us:Email: [email protected]

On the Web: www.totlhealth.com Live USA Contact: (575)-521-1981


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To my wife Jeff,Whose beauty became even more radiant with pregnancy;

To our wonder children, Steve and Toby,Who give me infinite pride;

And to each of you

Namaste*

*Namaste (from Sanskrit, ancient language of India):

I honor the place in you wherein the entire universe dwells.I honor the place in you that is of Love, of Light, and of Peace.When you are in that place in you and I am in that place in me,

We are one.


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Other books by the same author:

Life Is A Trip A Hand Full of First Aid, Plus!

The Reflex Therapy Series: Body Reflex Therapies & Techniques Cranial Reflex Therapy & Techniques


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CONTENTS

By the Same authorPrefaceAcknowledgementsIntroductionNotice

PART ONEANATOMY AND PHYSIOLOGY 1

CHAPTER 1Vertebral Curvatures 3

The Cervical and Lumbar curves 3The Reference Position 4The Cervical and Lumbar Spine Relationship 5Variations of Lumbar Curves 6

Hyperlordosis (Three types) 6Lumbar Lordotic Inversion 8

Infant Posture 8Sciatic Amyelinization 9

Adult Stature 11

CHAPTER 2The Third Lumbar Vertebra 15

The Vertebral-Spinal Weight Index 15Ligament-Muscle Characteristics 17

The Ligament Viewpoint 17The Muscle Viewpoint 18

The Remarkable Point 21Lumbar Vertebra Three: The Spinal Pedestal 21The Integrator of the Lumbar Curve 23

White Muscle 25Red Muscle 25

The Functional Classification of Somatic Muscle 26Kinetic Muscles 27


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The Muscles of Stature 28Emotional Muscles 29

CHAPTER 3The Normal Foot 31

Static Foot Anatomy 31The Talus 34

The Framework of the Foot 35The Calcaneus 37The Summit 39The Metatarsal Palette 40The Tie Beam 41

Functional Foot Anatomy 42Statural Foot Framework 45The Lateral Arch 46The Medial Arch 47The Anterior Arch Problem 48

The Physiologic Plantar Imprint 49

CHAPTER 4The Proprioceptive Muscle Chain 51

The Pedal Proprioceptive Chain 52The Proprioceptive Captors 52

The Gamma Loop 54The Proprioceptive Chain in Lateral Balance 56

The Lateral Arch Muscles 57The Medial Arch Muscles 58The Leg Muscles 59The Somatic Muscles 61

The Proprioceptive Chain in Anterior-Posterior Balance 62The Center of Gravity (Anterior) 62The Center of Gravity (Posterior) 64

The Ligament-Muscle Proprioceptive Chain 65The Postural Proprioceptive Chain 69

The Spinal Proprioceptive Chain 72The Trunk Proprioceptive Chain 75The Cervical Proprioceptive Chain 78


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CHAPTER 5Normal Man 81

Examination of the Normal Foot 82Kinetic Foot Study 82Static Foot Study 82

Normal Man, Posterior Examination 85Normal Man, Anterior Examination 87

The Index Finger Tests 87Tibial and Femoral Torsion 88

Normal Man, Profile Examination 90The Gravity Plane 90The Scapular/Sacral Plane 90

Normal Man, Radiographic Examination 91The Foot 91The Ankle 96The Ankle and the Hindfoot 97The Knee 99The Pelvis 100The Spinal Column 104The Dorsal Spinal Column 106The Cervical Spinal Column 109

PART TWO:THE DEFECTS OF STATURESECONDARY TO PEDAL DEFORMITIESAND THEIR TREATMENT 111

CHAPTER 6STATURE AND PES PLANUS 112

Pes Planus 113The First Stage 113The Second Stage 117The Third Stage 120The Consequences of Pes Planus with Stature 122Calcanean Valgus 123

Statural Muscle Hypotonia 125Kinetic Muscle Contracture 126


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Radiographic Study of Pes Planus 127The Foot 128The Ankle 131The Knee 132Femoral Internal Rotation 133Pelvic Changes 134Spinal Transfers 135

The Treatment of Pes Planus 136Local Treatment 136Orthotics 138

The Reeducation Program 141Massage 142Articular Mobilization 142Active Retraining 142Auto-Reeducation: The 10-Minute Daily Plan 143

The Treatment Visit 147Massage Techniques 147Mobilization Maneuvers 150Pressure Points and Application Techniques 155

Activating the Distal Foot pressure Points 157Retraining Opposing Articulations and Ligaments 160Restoring Optimal Stature 161Daily exercises 162

If No Physical Therapist Specialist is Available 166Medical Treatment 168Naturopathic Treatment 168Addendum 168

CHAPTER 7STATURE AND PES CAVUS169

What About Pes Cavus 170 The Clinical Constitution of Pes Cavus 172

First Stage 172Second Stage 176Third Stage 179

Etiopathology of Global Pes Cavus 181First Stage 183


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Second Stage 185Third Stage 186Etiology of This Dysmorphic Variety 187

Etiopathology of Medial Pes Cavus 187First Stage 187Second Stage 189Third Stage 189Etiology of This Type Deformity 190

Clinical remarks Concerning Varus and Valgus 190The Consequences of Pes Cavus with Stature 192Radiographic Study of Pes Cavus and Its Consequences 196The Treatment of Pes Cavus 205

The Kinetic Muscle System 207Orthotics 208

Retraining 211The Clients 10-Minute Daily Program 211

The Four-Part Visit 213The Stretch-Pressure Technique 214The Stretch Procedure To Improve Stature 215

The Ankle Acupuncture Points 217The Governing Vessel Special Massages 218The Reflex Pain Points 223The Rolling Pinch Technique 225The Master Back Point 227

Medical Treatment 229Naturopathic Treatment 229

CHAPTER 8SUMMARY AND PRACTICAL CONCLUSIONS231

SUMMARY 232The Phenomenon of the Proprioceptive Pathway 232Anthropometry of the Dysmorphic Subject 233

Anthropometric Difficulties 233Measuring Accurately 237

Clinical and Anthropological Examination 240Inspection 240Dynamic Pedography 241


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Static Podoscopy 242Articular Measurement 242The Measurement of Vertebral Bodies 242Lower Extremity Measurements 243The Pelvic Plane Orientation 243Examination for Scoliosis 243Podiatric Examination 244

Statural and Podiatric Asymmetries 245Pes Planus of Both Feet 245Pes Cavus of Both Feet 249Pes Planus and Pes Cavus (Same Subject) 252

Radiologic Asymmetries 252Calcanean Valgus 252Calcanean Varus254Spiral Torsion 254Spinal Repercussions 255

PRACTICAL CONCLUSIONS 255Really? Are My Feet That Important? 255

Shoe Language and Its Interpretation 257Things We Must Never Forget 259

GLOSSARY 263APPENDIX A 275APPENDIX B 277BIBLIOGRAPHY 283QUICK ORDER FORM 297


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PREFACE

In this book, each page offers an essential principle, a new idea, ora spirited word. Built upon anatomical, physiological, and clinicalbases and framed by many investigations, it ends with precisetherapeutic proposals. To simply scan it will be as useless asreading only the beginning without reading the summary.

Although originally intended as a workbook primarily fornaturopaths, podiatrists, physical and massage therapists, we areaware that the first edition of Stature: The Key demonstratedusefulness to practitioners in other disciplines. We believe thissecond edition will serve as a textbook for all physicians as well asall practitioners who teach and who work with patients. Somesections of the United States require a prescription/order beforecertain therapies shown in this book may be applied. With thisbook the referring physician is enabled to write a more intelligentprescription and at the same time this volume serves as a

workbook for the practitioner.This second edition of Stature: The Key has been revised andexpanded. Appendices have also been added for DefectExaminations and for additional Special Pressure-Points that areeasily detected.

WHY WRITE ABOUT STATURE?

The education of a medical doctor, the largest health-deliverysystem in the United States of America, is directed toward care of the sick and injuredit is not pointedly aimed at care of thehealthy person.

If one follows the Darwin theory of evolution, the human is seen asthe highest stage of development. If one subscribes to the theorythat man is a unique and ever-evolving species of its own, thediscovery of the Zinjanthrope dates back 1,900,000 years. Boththeories see present-day man using the two lower extremities formobility. Feet became the foundation for a stature controlled by


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our brains, heretofore unheralded.

First we need to remember the physician, in general, does not goforth seeking patients. He waits until a person seeks his care forwhatever complaint is interrupting normal life activity. In theinitial meeting with a subject, the medical doctor will begin withqueries regarding why that individual has come before him. Hethen begins his physical examination. With an overall glance atgeneral appearance, posture and stature, he next looks at asubjects hands and fingernails. Does he examine the feet? Notunless it is a complaint.

Physicians are compelled by a time factor to get down tobusiness and provide care for that individuals prime need. By histraining, he will look first for the obvious signs of outwardbleeding, respiration and pain. Then he proceeds directly toattacking the initial complaint.

We hear so much of back trouble nowadays: it is rampant in

these United States, almost epidemic. Why? Why are there somany ills in human life today that we require a specialist for eachinvolved problem? Can a headache, poor vision, emotional attitudeand internal problems of organic nature all be related to a failure toexamine the feet?

Yes! I will show that any foot deviation from the norm, any foot deformity, will be telescoped to the third lumbar vertebra and thence it will attack the next weakest link . No, foot disorders arenot the be-all, end-all, of mans problems. But without a doubt,they are the foundation literally as well as physically. Andremember, the Family Physician and the Internist are trained toapproach the acute problem of the patient and must do so whileheeding the all-important time factor! So feet are relegated to anunimportant place in our care.

We have failed to educate the general population in caring forthemselves. My professional life has taught me that technologicaladvances overcome us in our desire to correct the health problemsbefore us. Keeping the healthy person healthy is not immediatelyremunerative financially in this society.


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In this book you will learn the reasons for many of the healthproblems we haveand I have provided a simple ten-minute self-help program that can help prevent the great majority of disordersif left unattended.

I have selected the title Stature: The Key because, after all,stature begins at the foot. It is the foot that permits man to be erect.The vertebral column is studied closely. It is the vertebral columnwith models from the primary era and remodeled by those thatfollowed in which we have shown that the essential part of ahealthy subject is the third lumbar vertebra. The third lumbarvertebra is truly the key to optimal stature.

We recall that the famous Sherlock Holmes based his crimediagnoses upon simple observance of ones shoes...some will besurprised, even disappointed, with the simplicity of the particularlyeffective therapeutics suggested in this book. All techniquespresented in this work are painless. It is not uncommon (afterproper examination) for a small wedge placed under a foot to

reduce a spinal deformityperhaps even to modify a personality!Whether it concerns the foot or the spinal column, one speaksespecially of small muscles, small tendons, and small articulations.All these organs are perfectly miniaturized: in this respect, thesympathetic system is similar to a computer and its chips. Olympicgymnasts do not miss their exercises. In their spinal columns, as intheir feet, sensory collectors, reflex mechanisms, and the smallmuscles of execution have all been trained in miniature!

Many of us would be transformed if we would devote ten minuteseach day with the simple general reeducation described herein.

Indeed, how different people could be who, suffering with a footdefect (or that of their family chain), would also devote fiveminutes each morning to themselves. It behooves you to read onand to master these simple but effective techniques


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ACKNOWLEDGMENTS

This is the most pleasurable part of writing. It truly comes from theheart; without angst regarding style, precision of terms, or therigidity required of quotations. I must first thank those who Iconsider my Masters and who have an important place in myprofessional life:

Paul F. M. Nogier, MD, acknowledged around the world as thefather of Auriculotherapy (and in Europe, as the father of a medicalspecialty: Auriculo-Medicine). Paul has turned on light after lightin my quest for knowledge in his magnificent revelations of the earand its secrets. Perplexed by his brash brilliance when he wouldsay, Forget what I showed you last weekdo this, it worksbetter! ...And it always worked better. A visited being?

Ren Bourdiol, MD, who hides his profound personality beneath adeserved professorial mantle, whose love of pan perdu, being left-handed, having back trouble, a heart that battles to survive and adesire to help all in need, are my claims to brotherhood with him.Ren has declared that as we render unto Caesar what is Caesars,so should we render unto Nogier, the Ear. Ren, my true Mentor!

Luciano Roccia, MD, Surgeon and Acupuncturist of Turin, Italy,who rode horseback as well as he anesthetized usingacupuncture. I image you riding into Heavenly Sunsets, Ciano...

Johannes J. Bischko, MD, student of Souli de Morant, and retiredHead of the Boltzmann Institute for Acupuncture, University of Vienna School of Medicine, Vienna, Austria. A gentle man, a kindman and a devoted teacher, renowned in his own right.

Frederick M. Worley, MD, Internist, Cardiologist, with whom Ispent so many hours discussing our work and its wonders that mydear wife frequently gave up and shuffled off to slumber ...Wherever you are in Heaven, Fred, I miss you.


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George Goodheart, DC, Chiropractor, who for years would forsakeour ideas of the Ear and its power until we proved its efficacy tohim.

John Lanear, Artist. You made my difficult requests reality, John.Surely you are drawing Heavenly Beings up there now.

James Clear, LMT, RMTI, NCTMB, CFS: A Massage Therapistpar excellence. A teacher who ascribes with both quality andaccuracy. President of Natural Therapies of Las Cruces, LasCruces, New Mexico. Without your hands, Jim, I would becrawling today.

First, last, and forever, to my wife: Jeff. Gratitude does not seemprofound enough a word for her patience and understanding of mynot leaving my desk when embroiled in my work: All my Love,Here and Hereafter.

All these wonderful people have proven to me that it does pay tobe in the right place at the right time ... I am truly blessed.

Howard Sadowsky


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INTRODUCTION

Searching the physical capacities of healthy subjects validatesthese biometric techniques, as does a complete neurologicalexamination. Investigations included the classic Pignet Test thatintegrates size, weight, and thoracic parameters to achieve an indexof sturdiness. Adding pulmonary vital capacity and cardio-respiratory resistance with the valuation of power measurement of somatic segmental forces completes the search.

Recognizing the importance of categorizing, the study of variousintelligence tests, of psycho-diagnostics, and perceivingprojections, was helpful in personality appreciation. Even moreimportantly, the work of Krestchmer 1 renders accounts of psychotic individuals affected by bipolar disorders presentingopposing morphological types. In order to determine someconstitutional morphology he utilizes an acromion-thoracic index,feminine attributes.

In Figure 1 following, we see the schizoid, in general, as a thin andlanky catabolic (asthenic) individual whose thick head of hair andremarkable nails run counter to the baldness, pendulous abdomenand anabolic robustness of the cycloid individual (pycnic).Kretschmer adds a third type: larger, stronger, and muscular(athletic), corresponding to pathological changes moreneurological than psychiatric, to which the qualification of elliptoid has long been attributed. Others use the terms of ectomorph, mesomorph, and endomorph.

One learns to consider the spine not as a clever vertebral assemblybut as an harmonious polyarticular ensemble; a train enjoined byspecific osteo-ligamentous elements such that no one can replacethe other.

1 Professor of Psychiatry, University of Tubingen, Germany.


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Athletic Asthenic

Figure 1: Kretschmerian Morphological Types


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Manual manipulative techniques (osteopathic, chiropractic, andnaturopathic) have shown how the body resists change (as patientor guinea pig), more or less relaxed or prepared. One senses acurious malaise during placement under tension, a certainsharpness (except for naturopathic maneuvers 2) and harshnesswith the terminal thrust.

It seems to get well quickly with a kind of struggle that does notcorrespond to my idea of a manual technique and which I assistwith a healing energy, following the now well-positionedarticulation. A manual technique has the purpose to restore acompromised articular mobility by direct maneuver (simple andnon-traumatic) in the absence of major contraindication and onlyafter precise diagnosis. This technique retains obligatory points of definition:

By direct maneuver: means non-instrumental,eliminating stretching and elongation (which explainsthe name of chiropractic).

Simple: utilizing placement under tension, followed bya brief manipulative thrust (whence the qualification of manipulations).

Non-traumatic: not exerting susceptible constraintinvolving ligament-capsular deterioration (whetherosteo-chondral or tendino-muscular).

In the absence of major contraindication: well markedby the obligation of a clinical symptomatology,

radiologic and biologic.

After precise diagnosis and never manipulative alone:(as did the bonesetter of old, with neither tactileknowledge nor a sense of limiting oneself).

2Naturopathic maneuvers may be described as taking up the slack when placing undertension, to minimize sharpness.


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I hold for myself to practice only as outlined here. It is more thanan articular or vertebral manipulation. It is certainly not a questionof neglecting manipulations. The work that follows preciseanatomic and physiologic studies has scrutinized the classicalprocedures of technical personnel performed in order to restore thephysiologic mobility of various amphiarthroses and otherdiarthroses.

I am interested in local treatment but I do not wish to hem inmyself. The essential objective remains the anatomic-pathologicdiagnosis of the malposition or malformation in the global entitythat is man. One must be armed with the most complete clinicalknowledge possible, without limitation by disease classification.One must also impress upon the patient the importance of compliance to achieve success.

To be a physician practicing thusly consists of joining the qualitiesof a good generalist, of an anthropologue, of an anatomist of theliving, without omitting the knowledge of a neurologist. For it is

finally the central nervous system that coordinates, balances andharmonizes the various body constituents.

To practice thusly occurs at the moment where conventionalmedicine loses its humane dimensions. We take the position tostudy deeply that which we hold as digging more deeply intoannexing disregarded knowledge. This is where one sees each dayimproved by narrowed compartmentalization between the variousdisciplines that which is no longer an art, but also has become ascience.

Each practitioner is seen as a true therapist who does not acceptoccupying oneself with a pathologic manifestation withoutbringing it within the nosologic and semiotic framework. One alsomust not consider an articulation without attempting to foresee theconsequences of its functional recovery or without striving toremedy a new subsequent mediocre weakness at the same level.This is the very heart of this work as a true therapist: fine-tuningthe body for optimal effect.


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No matter how well you understand the material in this book, itwill not make you a master clinician, skilled in the assessment andtreatment of pedal and related somatic disorders. To achieve thatlevel of competence, tutelage under an experienced practitioner of the methods described herein is necessary. This book has providedyou with the information necessary to advance your professionaleducation in this applied science that also constitutes an art.

The following work relates the fruit of over forty years of experience and clearly passes through four stages:

1. Awareness of the problem.2. The mechanical, functional stage.3. The penultimate explanation: neurological.4. The therapeutic stage, effective in the end.

We have made it our business to palliate the somatic deformitiesthus detected. For the readers convenience, terms that are of

particular significance have been highlighted in bold throughoutthe text.

_________ ! _________


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TO ORDER THIS BOOK, CDs, eBooks, or CHARTS:

PLEASE USE THE QUICK ORDER FORMIN THE BACK OF THIS BOOK

orCONTACT US:

Email: [email protected] the Web: www.totlhealth.com Live USA Contact: (575)-521-1981

NOTICE

Naturopathy is an ever-changing field. Safetyprecautions are to be followed. As new researchand experience expand our knowledge, changes intreatment and supplemental therapies may becomenecessary or more suitable. We advise readers tocheck the most current information available andverify recommended formulas, preparations,dosages, methods, and the duration of administration. It is the responsibility of thephysician and therapist attendant to the patient andtheir condition to determine treatment. The authorassumes no liability for any injury and/or damageto persons or property arising from thispublication.


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PART ONE:

ANATOMYAND

PHYSIOLOGY


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Chapter 1 Vertebral Curvatures2


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Chapter 1 Vertebral Curvatures 3

1VERTEBRAL CURVATURES

THE CERVICAL AND LUMBAR CURVES

Simple measurement of the cervical and lumbar curves in profile of anupright subject reveals they do not have the same value according to the

age of the subject. The human vertical station is that resulting from asuccession of short periods of immobility alternating with short periodsof mobility. A balancing of permanent and alternating muscle tonechanges characterizes these two cyclic modes.

This results from the constant proprioceptive struggle against bodyweight with each subject searching to find a stable balance with aminimum of fatigue. This occurs as if one is marching in place,

consisting of: A static phase lasting an average of 30 seconds, remaining

immobile, upright on rigid legs, as an unconscious whim soon topresent the next phase.

A transitory dynamic phase corresponding to physiologicalsagittal oscillations as well as stereotypical movements in the

The Cervical and Lumbar Curves

The Reference PositionThe Cervical Spine Its Relationship with theLumbar SpineVariations of Lumbar Curvatures

Hyperlordoses: The Statural MorphologiesLumbar Lordotic Inversion

Infant PostureSciatic Amyelinization

Adult Stature


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frontal plane. This presents as if there is a hip deformity: awaddling pattern.

It is the static phase that we take for the typical description. It ishowever, polymorphous. Each individual is upright in his own way withhis particular morphology, deformities, and racial circumstance, familialor otherwise. None of them appears to follow instinctively a rationalattitude that permits judicious piling of bodily segments in a more strictvertical position.

The simple measurement of the cervical and lumbar curves in profile of an upright subject reveals they do not have the same value according tothe age of the subject. We therefore use the following protocol for ourmeasurements:

The subject is standing and relaxed. The heels are touching, headheld normally and looking ahead (as in the Frankfurt Plane 1),shoulders level, arms falling naturally alongside the body in

anatomical position, palms forward.

This is the reference position used for comparisons of cervicaland lumbar curvatures (see figure 2 following). In a population of 3,417 caucasian subjects, men and women, ages 10 to 67 years, wehave found:

1. Cervical curvature: 6 cm. (Variation: 4 to 6.5cm.)2. Lumbar curvature: 4 cm. (Variation: 3.5 to 4.5 cm.).The

normal subject in this position when viewed laterallypresents in the same plane:

The inion (the external occipital protuberance). The most posterior part of the scapula. The sacrum.

THE CERVICAL SPINE AND LUMBAR SPINE RELATIONSHIP

Here an S-shaped deviation denotes a strong variability but a lesserspecificity. This deviation seems exaggerated with each increase of the

1 Frankfurt Plane (also known as the Auriculo-Orbital Plane, a classic in anthropology): Itis along the line uniting the superior point of the external auditory canal with the inferiororbital border.


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lumbar saddle , regardless of this saddle.

INION

SCAPULA

(most posterior part)

Dashed line indicates the level of L3 Intervertebral Disc ( THE KEY)

SACRUM

Figure 2: The Reference Position for Vertebral Curvatures(Illustrating in addition: The physiological vertebral bodies and the L3

Intervertebral Disc horizontal position in reference to the ground.)

It is totally different for the child: of 107 children studied, ages 2 to 6years, there appears a lumbar curvature of many variations.Modifications of the sacrum-to-scapula relationship are unclassifiableand contrary to the cervical curvature that is remarkably constant at fourcentimeters.

Further investigation reveals there exists an undeniable swing betweenvariability of one curvature, stability of another, and confirmed bychecking the foot. In fact, the cervical curve is all the more a fixed valuewhen the foot is pronated in the young child. It fluctuates in proportionopposite to the lumbar curve that does not truly stabilize itself until thefoot presents its characteristic arch and the age approaches five years.This indicates the necessity for a normal foot in order to have aconstant lumbar curvature.


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VARIATIONS OF LUMBAR CURVES:

The lumbar curve is marked by very weak variables. There are threestatural morphologies: three types of saddleback lumbar exaggerationscompared with normal stature and clearly shown in figure threefollowing.

1. Hyperlordosis (sacrum and scapula in the same verticalplane) . In general, individuals in this state of being all presentwith pronated feet.

2. Hyperlordosis (scapula posterior to the sacrum). In general,individuals in this group all present with pronated feet.Individuals in this group exhibit the greatest gaps between thedifferent muscle perimeters (abdominal, inferior thoracic, andpelvic) when in the standing position. Interestingly, we note asimilar morphology in the depressed person. In this case therepresents a lordosis of poor musculature, especially more

noticeable with asthenic and melancholic types.

3. Hyperlordosis (sacrum posterior to the scapula). Theindividual bearing this saddleback appears physiological forcertain members of the black race (Bushmen, Hottentots andBantus). In caucasians, however, this deformity occursfollowing spondylolisthesis. Here there exists a true lumbarirregularity. This is palpated easily as an abrupt drop just abovethe vertebra involved.

A posterior sacrum is also observed in certain cases of forefootdeformities. These deformities may be:

a. Mechanical/functional (hallux valgus or convex forefoot).b. Traumatic (sprain or fracture).c. Toxic (as found with gout).


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A B C D

Figure 3: Morphologic variations of the spinal column

A: Normal SubjectB: Hypertonic lordotic subject with high-arched feetC: Hyposthenic subject with pronated feetD: Spondylolisthesic subject

LUMBAR LORDOTIC INVERSION

In this instance, spinal curvatures are slightly increased when measuredby a plumbline. Here is found the classic flat back in which the archingis always less than three centimeters. Here the explanation is accepted as

horizontalization of the sacral plateau and consequently a pelvicretroversion. One can observe the lumbar spinal laxity manifestingexaggerated in the seated position. This is especially noticeable when thesubject sits upon the ground.

Paradoxically, the dorsal spine appears more rigid than in the normalposition while the cervical spine curvature is diminished in the majority


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of cases. However, one can be returned to the state of cervicalhyperlordosis due to compensating mechanisms. Foot deformities hereare not specific although it is apparent there are a majority of high-archedvarus feet.

INFANT POSTURE

Classically, the child is not yet complete:

1.

On the cerebral plane, the child presents with a bilateralBabinski sign, evidence of pyramidal immaturity.2. On the cerebellar plane, which determines posture:

The legs are apart for upright stability. The arms are extended laterally for balance. The head is forward with the buttocks behind.

SCIATIC AMYELINIZATION

Our representation depicts the infant as unique at the level of the lowerlimbs due to sciatic amyelinization : for it is at about the age of fiveyears before the sciatic nerve becomes completely efficient. Let uscompare the table of segmental innervation of the lower extremity withthe development of infantile motor control. They both advance in thesame sense. Notice that:

1. LI, L2, and L3 conditionally innervate the iliopsoas, pectineus,sartorius, external obturator, quadriceps, and adductors.(Actions of hip flexion, leg extension, and thigh adduction.)Hence the child may train itself to all-fours whether movingforward or backward.

2. L4-L5 reinforces the internal obturator, the pyramidalis, thehamstrings, and especially the gluteals. (Thigh external rotation;and while the buttocks may appear odd they are essential tomankind, with an erect vertebral column. It is a movement of thrust.)

It is the thighs that move us from one place to another. The legs, andespecially the feet, follow indifferently. In the same fashion, the childbecomes bipedal (albeit benefiting from obvious support). L5, S1, and S2


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lead the sciatic nerve to the rescue; but not wholly. In the first place, thesacral plexus collaterals complete their innervation of the pelvic andbuttock muscles. Then the sciatic trunk divides and the ischio-tibialscome into action. This permits the leg to bend upon the thigh inextension and so we have the first true steps, however awkward!

At the instant of maturation of the external popliteal nerve slowing canbegin; but with outstretched legs and uncertain balance since theposterior plane is not yet solid. Finally, the internal popliteal nerve

detaches and pedal support follows, with placement reliant upon theplantar proprioceptive captors and the possibility of embracing secondarysubjacent ways.

We now rediscover this maturation from superior-to-inferior byexploring our vertebral curvatures. The constancy of the cervicalcurvature of the child is but the mark of voluntary contraction, synergyof the muscles of the nape, the shoulders, and of the back. This it

performs flawlessly.

We cannot accept this cerebellar immaturity as descriptive of a child whoputs his finger into an electric socket. It is only the synergy of the infant,as with the classic hypotonia of cerebellar affections. Where then doesone find it? Certainly not with the child, for it is hypertonic. Its tightlydrawn legs are not only a sign of broadening quadrilateral support butalso the only means of support accommodating that which it finds.

Discovered: the quadriceps, gluteals, psoas, and adductors firmly upholdthe attitude. But the child does not possess the proprioceptive pathway of balancing at the point of departure since his internal popliteal nerve is notyet effective.

In order to maximize static instabilities more than dynamic the childtenses all the posterior erector musculature it now masters (the erectorsof the nape, the shoulders, and the back). Now the arms extend andabduct from the body, the head rights itself, and the shoulders drawbackand the cervical flexure becomes four centimeters. And the childconserves elsewhere this tenseness, whence it will fall heavily on itsbuttocks, either by fatigue or imbalance.


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Once sciatic myelinization is completed the legs have a less mechanicalrhythm; the articulations become supple and more functional. The upperbody then loses its rigidity and the erect position is observed with thenape musculature becoming slowly freer and the arms closer to the body.

The Babinski disappears since the plantar muscles will have acquired aphysiological tone now more important than their dorsal homologues.This is evidenced as the arch of the foot. The former is thus normalizedand the lumbar curvature will be able to normalize, as we have seen

previously.

In summary, normalization of the feet is linked to leg muscle tone (thiswill be detailed later) but also, and especially, the plantar muscles. Thisis most important because they present a large number of specificpressure-sensitive captors. The latter forms the point of departure of proprioceptive flux which will modulate the muscle tone; from which thelumbar curvature becomes constant. These reflex variations in muscle

tone obviously free the scapular belt and the brain: both support sensorialcaptors, whence the liberation of the cervical curvature.

ADULT STATURE

In search of a minimum of fatigue we will come to evoke the automaticposition of balance as well as standing posture. But before any bodyaction occurs there must also be a position of stable position in which thecenter of gravity of the different body segments would be found on thesame perpendicular plane supporting quadrilateral stance and passingthrough its middle. This is not a natural position, however, and it never isadopted for two reasons:

Balance thus achieved is precarious since the weight of the body istelescoped to the heels. Muscle spasm and exhaustion are generated atgreat expense of energy in this position.

When all corporal segments are immobilized each periarticular musclehas to contract as if the action asserts in the same sense as does theweight. To do this, a more contracted position becomes necessary whichpermits preserving composure at the cost of minimum musclecontraction. We know balance will be much better when the support base


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is greater and the center of gravity is lower.

It follows that a compensatory pelvic motion is applied here, as in a deepstooping position. Here the psoas major muscle is emphasized, for itparallels development of lumbar lordotic modifications. This study wascontinued by Gillot but decries the differing aspect of the muscle bodyfunction with the spinal column and its variations (psychological andsexual). He concludes that the frenum of the hyperlordosis assures morelateral spinal balance. It is the stabilizing component par excellence of

the lumbar column.

So the permanence of the lumbar curvature is now anatomicallyconfirmed; since the psoas muscle is inserted only on the lumbar bodiesand discs at the vertebral level. But many connections concern thismuscle. Some electromyographic traces confirm some of its constantswing. To the contrary, others say nothing. Moreover, the psoas iscomposed of long muscle fibers. But the Weber-Fick Law is positive:

this is a characteristic of kinetic muscles. It can perform high-speedmotions with great amplitude but relatively short duration.

Static muscles are entirely different with series of small fascicularbundles (like spinal muscles) or penniform (like certain tibial muscles).Basmajian, Joseph, Marinacci, Smith, and DeVries speak unanimously of a full swing during the immobile upright position. This full swing variesbetween subjects regarding body weight distribution, vertebral andpelvic configuration, morphological type, and even the moment in time.

There seems a predilection between T10 and T12 (the level of the dorso-lumbar articulation) that tends to reduce the role of the psoas muscleconsiderably in order to augment those of the transverse lamina. Itmanifests in constant fashion to the level of the leg muscles.

REFERENCES:

1. Aaron C & Gillot C. Psoas Muscle & Lumbar Curvatures.Bll.Ass.Anat. 160-169, 1962.

2. Basmajian J.V. & Stecko G. The roles of muscles in archsupport of the foot, J. Bone & Joint Surg.45-A,1184-1190,1963.


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3. Basmajian JV, De Luca CJ. Muscles Alive: Their FunctionsRevealed by Electromyography, 5th ed. Baltimore, Williams &Wilkins, 1985.

4. Devries HA. Muscle tonus in postural muscles.Am.J.Phys.Med. 44;275, 1965.

5. Gillot C. Differences between certain varieties of lumbar pain& the anatomic vertebral chain. Ann.Med.Phys. XV No.2:246-256, 1972.

6. Great H, Williams PL, Bannister LH. Grays Anatomy: The

Anatomical Basis of Medicine and Surgery. 38th ed. New York,Churchill Livingstone, 1995.7. Joseph J. Mans Posture. Electromyographic studies. C. Thomas

Ed. Springfield, 1960.8. Marinacci AA. Clinical Electromyography. San Lucas Press

Edit. Los Angeles, 1953.9. Moore KL. Persaud TVN. Before We Are Born: Essentials of

Embryology and Birth Defects, 5th ed. Philadelphia, WB

Saunders, 1998.10. Smith JV. Muscular control of the arches of the foot, standing,

an electromyographtc assessment. J Anat 88;152-162, 1954.11. Vandervael F. Analysis of movements of the human body.

Masson Edit. 5th ed Paris, 1966.12. Winckler G & Foroglou Ch. Manual of topographic and

functional anatomy. 2nd ed. Masson. Ed., Paris 1974.


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Chapter 2 The Third Lumbar Vertebra: The Key 15

2THE THIRD LUMBAR VERTEBRA:

THE KEY

THE VERTEBRAL-SPINAL COMPARATIVE WEIGHTINDEX

Basmajian and Hendrix agree and accept that man possesses a spinewhose every segment is all the more great, heavy, and resistant to thosesituated lower. This is contrary to the other primates and is due to mansupright station in life. Delmas and Pineau i demonstrate their interest inspinal weight differences by isolating each of the vertebrae; separatingthe weighty ones and attribute them to the total spinal weight using thefollowing formula:

Weight of the animal or human vertebra x 100Total weight of the spine to which the vertebra belongs

They thus obtain a graph specific to each species and presenting

Vertebral-Spinal Comparative Weight IndexLigament Muscle Characteristics

The Remarkable PointLumbar Vertebra 3: The Spinal PedestalThe Integrator of the Lumbar Curve

Voluntary and Involuntary Muscle TypesFunctional Classification of Somatic Muscles

Kinetic MusclesStatural MusclesEmotional Muscles


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Chapter 2 The Third Lumbar Vertebra: The Key16

fluctuations from one subject to another in the same zoological family.The graph indicates the relative weight and the functional value of eachvertebra at the same time. (See Figure 4).

The third lumbar vertebra occupies a characteristic place on this graph: Itlies at the top of the human curve; being the heaviest spinal vertebra.This occurs solely in man; other species do not show a pause in thelumbar ladder. However, this fact does not lie within the vertebral bodyitself because L4 is larger and weighs more. It is the weight of the neural

arc that makes the difference. The former is proportional to thedevelopment of the apophyses rooted there and which translate thefunctional importance of muscles that attach there.

It has been emphasized earlier that L3 in man will be an importantmuscle relay center. Since the differentiation at this level between manand animal is due to the upright carriage alone, one can conclude that L3occupies a privileged position in the static proprioceptive relay. It is

logical to attribute to L3 in man a muscle role comparable to othervertebrae exhibiting a similar peak. What is it then? Let us look at theindices shown in figure 4:

There is a spike at L3. Note that each of these peaks on thegraphbelongs to these specialized vertebrae, from the ligament-muscleviewpoint.

The spike at C2 underlines the cleavage between the specialmuscle entity of appropriate muscles of the nape and thesubjacent departure of the transverse lamina.

The spike at T1 (here the thorax appears) shows the functionalimportance of the upper extremity that attaches there, therespiratory muscles, etc.


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Figure 4: Variations of the Vertebral-Spinal Weight Index

LIGAMENT-MUSCLE CHARACTERISTICS

From the ligament viewpoint we note that L4 and L5 are tightly attachedat the os iliacus by the iliolumbar ligaments that will limit their motion.Because of this fact, the third lumbar vertebra becomes the first mobilespinal vertebra in the upright position. This, then, is the level wherepelvic tilting occurs, as well as the initiation of the duck-waddle gait; orcontrarily, the reprise of the bipedal stance. Other constraints are alsoexerted at this level. (Figure 5 follows.)


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Figure 5: The Sacroiliac-Lumbar Ligament System

KEY:1. Iliolumbar lig. 5. Oblique Sacroiliac lig.2. Transverse Iliosacral lig. 6. Great Sacrosciatic lig.3. Horizontal portion. 7. Sacrococcygeal lig.4. Posterior Sacroiliac lig.

From the muscle viewpoint we find a remarkable functional cleavage.

Recognize here the insertion of the diaphragmatic supports (crucesdiaphragmae) on the anterior face of the first three lumbar vertebrae tothe right and of the first two on the left. Some say these insertionsproduce a major lordosant action of this muscle. Electromyographictraces do not seem to favor a middling action of this type. We regardthere to be very little such action here. (See figure 6 following.)


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Figure 6: Paravertebral Muscle Attachments1. Diaphragm 4. Latissimus, lateral portion2. Sacrospinalis 5. Latissimus, iliolumbar portion3. Latissimus, median 6. Posterior-inferior Serratus


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Other authors insist on muscles such as the posterior inferior serratusmuscle (which does not descend below L3). In this instance, it concerns arespiratory muscle that pulls the sides toward the lower part. It is thespinalis muscle and the latissimus dorsi muscle that give such importanceto the third lumbar vertebra. Winckler ii describes clearly the followingdata: The spinalis muscle crosses (intertransversally) in primates. Itbecomes interspinous solely in man and its insertions make it a strongspinal erector. Connecting as it leaves the dorsal spines to their lumbarhomologues, it stops on L3.

Furthermore, two characteristics illustrate its phylogenetic importance inour skeletal make-up:

1. Although it has common origins with the latissimus dorsimuscle, it is distinguished by its innervation. It is innervated bythe internal ramus of the posterior branch of the spinal nerve,like all the spinal transversals that we perceive to be the masterharmonizing muscles of the spine. (The latissimus is innervated

by the external ramus). The somatic organization doubles inprinciple the innervations only for muscles that it judgesimportant.

2. Muscle fasciculi pass as a bridge over the spine of T10 withoutinserting there.

The latissimus dorsi muscle is more lateral and it has developed uniquelyin man. Now we understand that L3 is truly characterized by theinsertion of specific spinal erector muscles:

The two superior bundles of its lumbodorsal portion that originate at L2and L3 blend their vertebral insertions to those of the spinalis muscle.Here there results an erecting action as the principal determinant. Eachnew bundle with its distinct innervation thus enhances its command toerect the spine.

The two inferior bundles have a different pathway upon leaving L4 andL5 that leads from one part at the level of the transverse apophyses aloneand from another part at the level of ribs five through twelve. This resultsin a torsion action that fits into a proprioceptive circuit but not into thatwhich induces the erect state.


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The iliolumbar portion (occupying the lateral part of the lumbar lordosis)leaves from the inner face of the iliac bone and attaches on L3, thuspulling this vertebra posterior.

THE REMARKABLE POINT

A word to the wise: there is in acupuncture a Remarkable Point thatdoes not appear on charts. This point is just at the level of the tenththoracic vertebra. Needling this one point using a stutter 1 technique

restores vertebral harmony in the entire dorsolumbar spine from T2 toL3. Physicians who have trained with us know the procedure well andappreciate its efficacy.

LUMBAR VERTEBRA 3: THE SPINAL PEDESTAL

The third lumbar vertebra occupies a key position: it is in the center of the abdominal region. Winckler (Cf. bibliog.) clearly states that the

umbilicus corresponds with the intervertebral disc L3-4 and we concur.This central body position binds the generalized human pelvic wideningby the considerable development of the gluteal and iliac musculature dueto stature. This extension of the ilio-pelvic belt increases the wedgingbetween the sacroiliac joint and the coxofemoral articulation; thencebetween the (body) line of gravity and the vertical line passing by thefemur.

1 Stutter technique: Heating the head of an inserted needle using a cigarette lighter. Theflame is flashed over the needle head repeatedly until the precise moment when the

patient responds by withdrawal reaction (due to heat level). The needle is withdrawn atthat precise moment.


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Figure 6A here illustrates the relationship of the lumbar saddle and theL3 intervertebral disc to the somatic gravity line (vertical dashes) and tothe horizontal plane underfoot.

The lumbar saddle places the third lumbarvertebra on the vertical line passing through thegreater trochanter.

Thus the projection of L3 forward is one of the mechanical placementsthat sets a parallelism of the superior and inferior plateaus of the body of the vertebra and allows a more relaxed attitude and more stable balance .This projection appears to benefit L3 during any compression settling.Surgical statistics show that compression fractures of the vertebral bodyof L3 are far from being the most frequent; even when such trauma mayoccur from parachute landings, which increases craniosacral pressures.

Because of this fact of strict parallelism of its plateaus, impact forcesexerted upon L3 are well distributed. Such forces are generally directedto L1 and L2 that are trapezoidal at their posterior bases. L5 is alwayscuneiform at its anterior base.

The position of L2 and L3 in the spinal column does not predetermineplacement of the discs above and below. But this privileged position of


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L3 as the somatic center does have biomechanical consequences: the L3-4 intervertebral disc is always parallel to the ground, in keeping withphysiologic stature. (At first we thought L3 presented its plateaus parallelto the ground; but now it is obvious this applies solely to the L3-4intervertebral disc.) One now understands why any modification of thisspinal arrangement is pathological.

We note that form change does appear variable according to race: Caucasian Race: change of form between L2 and L3.

Yellow Race: change of form between L3 and L4. Black Race: change of form between L4 and L5.

However, this is not the form of the vertebrae making up the spinalcurvatures. The intervertebral discs are more or less cuneiform; theycontribute greatly to curvature determination. There is also a relationshipbetween disc and vertebra: some subjects have straight vertebrae whileretaining cuneiform discs in the lumbar saddle. (With Caucasian females,

the discs are curved in accord with their cuneiform vertebral bodies.)

THE INTEGRATOR OF THE LUMBAR CURVE

It is evident that L3 vertebra is the integrator of the lumbar curve at themiddle of postural musculature. In an excellent study, Perrin 2, a physicaltherapist, made a classic experiment more significant by asking subjectsto place upon their head a weight of five kilograms and hold it therewhile balancing for one minute and standing immobile.

He then observed there is a relaxation of the dorsal muscles, buttocks,and abdominal muscles. On the other hand, he also observed adiminution of the cervical and lumbar curves, and finally a vertebralstraightening. He concluded that a specific action of the transverse spinalmuscles is the cause; using the spinal column as a sinusoid stretchedalong its long axis.

Marinacci 3 completed a series of electromyograms simultaneously onspinal and on posterior abdominal muscles, under similar parameters. His

2 Perrin, R. Principles and practice of vertebral reeducation. Kinsit. Scient. No. 118, 25-32, Oct. 1974.3 Marinacci A.A. Clinical Electromyography. San Lucas Edit. Los Angeles, 1955.


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results were confirmed by Joseph (Cf. vii, bibliog.). Traces of bothauthors reveal:

1. The instinctive standing position translates only by classicposterior spinal activation.

2. The increase of constraints (the weight balanced upon the heador held by two hands) increases only spinal muscle tone. But inthis case the dorsal kyphosis is accentuated while the lumbarlordosis always obliterates itself in both these cases.

Due to all deep spinal musculature stemming from L3, we can conceiveperfectly well that L3 is the integrator of the lumbar curvature. We havepreviously mentioned that foot standardization will induce constancy of the lumbar flexure. Is this to say that any foot deformity will resound tothe level of the third lumbar vertebra? Exactly! To such an extent that allexperimental verification has led to the use of specific manipulations thatenable a very simple test:

The patient is correctly manipulated. We then ask him to stand barefoot afew minutes. This is sufficient to indicate any sign of blockage at L3, inthe case of a foot deformity. The foot plantar surface may be consideredthen, to carry proprioceptive impulses that ascend in spinal muscles andexit from L3. This returns the spinal curvatures to their proper state.

We have also mentioned previously this manner of transmitted impulseswith respect to the maturation of the internal popliteal nerve of the child.We use the same name (postural muscles). The formations arepenniform, fascicules that by the Weber-Fick Law articulate corporalstructures concerned in this proprioceptive pathway.

1. White muscle has been called kinetic. Its clearer color comesfrom packing together of myofibrils in the cellular unit. Itpossesses a remarkable contractile potentiality by an abundanceof myosine and actine. These are fast-train muscles but of necessarily brief activity. They must work in bursts and extractenergy from glycolysis. They are powerful, yet fragile. Whitemuscles can be termed true athletes.

White muscle is voluntary, active and rapid. It has precise,regulated, and controlled action. This is the reason for the term


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kinetic. As for qualifying white muscle, we say no more.The other muscle type can also be rapid. We prefer to label itstatural, for red muscle is static. This should help avoid anyimpression of slowness.

2. Red muscle is termed as postural here. Its color results fromsarcoplasm in abundance and from mitochondria rich inmyoglobin and cytochromes. Hence, it possesses importantenzymatic proteins necessary to its metabolism and is then able

to have a long and sustained action.

Red muscle does have fewer myofibrilles, but also morespecialized captors (neuromuscular and neurotendinous spindles)and Paccinian organs. Isometric tension variations of themyofibrilles place the specialized collectors in action. Theformer gives rise to its service with an impulse which modulatesthe motor nerve impulse ordering the functional muscle unit; and

which follows the classic short reflex arc.

Muscles of this type will have an action less sharp and stifferbeing less direct. They are termed slow muscles but in reality,their response to summation of the nervous order is as rapid as atendon reflex.

THE FUNCTIONAL CLASSIFICATION OF SOMATICMUSCLES

With trunk musculature, we find distinct functional units that respondperfectly to our dichotomy. However, this differentiation is far moredelicate in reference to the extremities. Such muscle may be kinetic orstatural or pass alternately from one type to the other according to themoment and function of bodily position. In truth, here each muscle iscomposed of a mlange of white and red fibers. It is the percentage of these two histological constituents, which determine the physiology.

Based only upon histological verification of a predominance of whitefibers in the body of the gastrocnemius muscle, one can leave to thesoleus muscle an odd role of substituting in case of a sustainedcontraction. This is considered in firing the sural agents of voluntary foot


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extension and confirmed by Basmajian (Cf. vi, bibliog.)

One should recognize that each muscle is seen as one or several afferentnerve fiber branches (proprioceptive sensory terminations) but equallyefferent (motor). Each of these nerve fibers devolves with a certain whiteor red muscle fiber, perhaps to a specific system content in one of thesemuscle fibers. The complexity of the problem will again be emphasizedby the fact that a share can exist of autonomic fibers. That reaches notonly these specific systems, but also other muscle fibers; of another part

of muscle fibers innervated proportionally with a precision requisite bythe contraction of the muscle that contributed to its formation.

Again, a certain predetermination may be conceived which facilitatesfunctional synthesis. The anatomic-physiologic study of the musclesystem leads us to define a third muscle type: emotional. Now we havea convenient classification of function. Under this classification we haveprecise therapeutic applications to follow. (Figure 7 depicts the

functional classification of somatic muscles and follows at the end of thischapter.)

KINETIC MUSCLES

This muscle system defines histological as a predominance of whitefibers with strong contractile potential, but of necessary brief action. Itsmetabolism is directly tied to the rate of the local glycogene. Thefunctional entity thus formed possesses marked activity with rapidresponses, excitation velocity, and intensity and power of the contraction.

On the neurological plane it is well-termed motor unit, where the pointof departure is the giant Betz Cell seated at the level of the motor cortexon the frontal ascendant. Certainly the intermediary neurons completethis cortico-muscular pathway. Nevertheless, the neoencephalic origin of this motor unit confers upon the kinetic muscle the double particularityof being partly in command while having to manifest a consciousfunction.

Recall that for those who use it voluntarily to undertake a precise act, itis always a perturbing element for the left-handed person. Suchlateralized individuals are constrained to resort to suppressed cerebral


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areas, then to the corpus callosum, in order to reestablish the situationcompromised by ones poor lateralization.

In this group we rank the masseter muscle, the muscles of the upperextremity, and those of the middle of the neck and trunk: the trapezius,the scalenes, the levator scapula, rhomboid, splenius, pectorals, serratusanterior, and the latissimus dorsi.

Certain muscles can be more kinetic than statural. The gastrocnemius has

been mentioned before. It is also the case of the gluteals, the adductors,and the quadriceps as well as muscles that form the anterior lateral wallof the abdomen. It should be noted that almost all muscles could enterinto this kinetic action under certain circumstances. Exception is madefor the muscles of the nape, the deep spinal muscles, the quadratuslumborum, and certain erectors (so-called emotional muscles).

STATURAL MUSCLES

This muscle system is determined histologically by a predominance of red muscle fibers, possessing a particular enzymatic arsenal that allows ita long and sustained action. From the neurological point of view, wehave previously emphasized its privileged affinity with proprioceptivecollectors as well as its circuit of return restoring those of theservomechanisms.

In order to perfect this image (extremely simplified) it is necessary to addthe subcortical formations. Included also are the central gray nuclei (thepallidum with its determinant action), the cerebellum, and the cerebraltrunk. This statural musculature is of the reflex type. Its order and controlare automatic (most often). They reach the conscience only under specialconditions and always are more or less pathological.

In this group are ranked the triceps surae, popliteus, spinalis, longissimusdorsi, transverse spinalis, semispinalis, interspinalis, intertransversarii,and the quadratus lumborum. We add here the appropriate muscles of thenape as well as some cranial muscles (such as the temporalis andoccipitalis). We note that the kinetic muscles become statural as theirfunction becomes automatic and their control escapes habitually to theconsciousness.


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EMOTIONAL MUSCLES

The emotional musculature is understood to depict the following fourspecial controlling factors:

1. It is semi-voluntary. (Travelers who pass through CustomsInspection may prefer to suppress the action that supports a smileor an expressionless face.)

2. It is not always felt in an aware fashion. (Here the thoughts of passage through Customs Inspection with taxes due are good

evidence.)3. It is served by muscles with soft tissue insertions.4. It is passed to the rhinencephalic cortex, motor, individual, the

cyrus cinguli, and to the special gray formations (the amygdalianand septal complexes).

Classed in this group are essentially the dermal and perineal muscles.However, most of the somatic muscles can be represented here: for

example, in the condition of depression. This condition is noticed asmuch by its silhouette, by its heavy bearing, and by its slowness, as by itscharacteristic physiognomy. (Figure 7 below depicts the functionalclassification of somatic muscles.)

Figure 7: The Functional Classification of Somatic Muscles


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REFERENCES

1. .Delmas A. Numeric and morphologic spinal variations. Theirpractical and theoretic concern: 111-120. Md.Ed.Phys. & Sport,1955.

2. Winckler G. Manual of topographic and functional anatomy, 2 nd ed., Masson. Edit. Paris, 1974.

3. Olivier G. Morphology and human types, Vigot Edit. Paris,1967.


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Chapter 3 The Normal Foot 31

3THE NORMAL FOOT

STATIC FOOT ANATOMY

This first part may surprise many confreres by its unconventionaldescriptions: the talus for example, will be posed in some measure as asuperstructure. Let us discuss its role as a superstructure and be moreexplicit.

The classic plantar arch of the normal foot is, at best, of morearchitectural worth than physiologic. Hence, the foot is describedarchitecturally with rafters (the calcaneus posterior and the anteriormetatarsal palette), a summit or high-point (the mid-tarsus), and a tiebeam (the ligaments).

This unit of twenty-six bones and thirty-one joints mobilized by nineteenmuscles may be compared to the foundation of a building. The foot is the

natural receiver of all gravitational vectors and their components. Itassumes this function during walking, running and all other dynamicactivities. When the foot is at rest it remains immobile and in anatomicalposition. The foot is in all aspects the essential element of balance.

Static Foot AnatomyThe Talus

Framework of the FootThe LigamentsFunctional Foot Anatomy

The Lateral ArchThe Medial ArchThe Anterior Arch Problem


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Chapter 3 The Normal Foot32

Figure 8A: Dorsal and Plantar Views of Foot Skeletal Anatomy(From Netter, FH. Atlas of Human Anatomy 2nd ed., 1997.)

These different characteristics condition foot morphology such than onemay divide it schematically into three constituents (figure 8):

1. The talus is the superstructure. It receives the weight of the bodyand distributes it.

2. The arch is the framework. It is formed by the calcaneus (inferiorand posterior), the bones of the tarsus (superior), and the


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metatarsal palette (inferior and anterior).

3. The ligament system (the shock-relieving system) is the tiebeam.

Figure 8: The Foot Framework

Top view: The skeletal configuration in profile.Center view: Architectural representation.Bottom view: The ligament system forming the pedal tie beam.

THE TALUS

The talus is distinguished by its morphology, its total absence of muscleinsertions, its physiologic role, as well as by its position in the ankle.During dorsiflexion and plantar flexion it behaves as a bone of the foot,since the axis of motion is found at the tibio-tarsal level. However,during motions of jostling it becomes an anklebone. It is held in amalleolar grip and does not participate in the motion taking place under


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it.

Figure 9: The Physiological Anatomy of the Talus

The Oliviers i relate the importance of the cuboid as fulcrum and central

point of pressures transmitted to the foot. Olivier employs the term'superstructure' in describing the talus, certainly apropos. Its morphologyemphasizes this structure encased in a tibio-peroneal 'clamp'. Itstrapezoidal body with its small posterior base becomes wedged, as itwere, in this mortise during dorsiflexion. Thus the talus strengthens itsrelations with the leg and improves overall stability.


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Conversely, during plantar flexion the narrowest part rests in the inter-

malleolar scheme. It renders possible an articular play, which amelioratesfoot orientation (among others). The talus becomes a quasi-indepcndentbone and can thus serve as a kinetic system adjuster. It remains stablewhile permitting varied calcaneal positions imposed by unequal surfacesor untimely constraints.

The talus distributes all the body weight it receives equally between theanterior and the posterior heel (see figure 10). Its overlapping of the

various bony structures below induces a more pronounced thrust alongthe first radius, increasing pressure at the head of the first metatarsal2.5:1 according to Jones and Wood ii. The talus induces equally thefunctional foot axis since the resultant passes along the second radius.

Unfortunately, the talus is the worst vascularized bone of the body 1. Thisimparts to it a special fragility considering the constraints already uponit. The relative rarity of its injury is evidence of the incessant

participation of the central nervous system in foot movement.

Figure 10: Schematic illustrating body weight distribution from thetalus.

1 Dolto B. The Body Between the Hands. Herman Edit. Paris, 1976.


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THE FRAMEWORK OF THE FOOT

Contrary to what one may think, it is not the hand but the foot that hasundergone the most important phylogenetic transformations i Boule , agreat paleontologist, wrote, The foot is one of the most distinctcharacteristics of the genus Homo.

The fundamental difference between the first men and monkeys is not somuch the larger cranial capacity or dental evolution as the adaptation to

the bipedal step and to stature. The former undergoes threetransformations:1. The disappearance of the prehensile function of the great toe.2. Reduction in size of the lateral toes . 3. The general parallelism of the metatarsals and the toes.

The term 'plantar arch' is not restricted to medicine. In architecture, anarch is a work formed by materials assembled in such a manner that the

weight of these parts assures form retention and together with a keystoneachieves solidity. The foot does not absolutely correspond with thisdefinition. In architecture the term 'framework' applies to those partssupporting a roof (i.e., two rafters joined at their base by a tie beamwhich prevents their separation). Let us now examine the framework of the foot as compared to this framework. (Refer to figure 8).

THE CALCANEUS: THE POSTERIOR RAFTER.

The calcaneus is horizontal in cynomorphs and anthropoids. In man, itsaxis always inclines downward and posterior. This presents an angulationwhose value is a racial characteristic according to Olivier v. He indicates aforty-five degree maximum for the White Race. This figure is theminimum for the Black Race. Thus, the only points of contact receivinghalf the body weight are the two posterior calcanean tuberosities (tubercalcanei).

The calcaneus is united with the talus by a trochoid articular system.Two distinct joints in two different planes with bends and invertedmorphological aspects form this system. They are separated by a deepgroove, the tarsal sinus (sinus tarsi):

The anterior articulation is in an inferior plane. It is formed of


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two articular surfaces, the anterior-lateral and the posterior-medial. (See figure 11 below.)

These two surfaces define a concave glenoidal surface where it rests, inpart, upon the head of the talus. The former will divide all calcaneaninternal tilting by inclining medially even more. All calcanean vaIguswill then be expressed:

1. By a sinking or lowering of the head of the talus, which thencollapses the medial arch.

2.

It also will be transferred as an internal rotation of the talus,which we accept as the most important by far.

Figure 11: The rotation and the movement of the talus.Left: Illustrating Sub-Talar Articulation (Axis A-B).

Right: Axis A-B depicts axial counter-clockwise rotation and forwardmovement.


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The posterior articulation is in a superior plane. It is shaped like a comma

but with an external tip and it is broad (convex). It allows lateralcalcanean movement by articulating with a surface congruent with thetalus. These are limited by the tension of the lateral ligaments of theankle (whence foot deformities are secondary to sprains).

They are also limited considerably by the talar-calcanean ligament (lig.talocalcaneum interosseum)) which lies deeply in the tarsal sinus. Thisdoes not allow a free torsion of the foot due to the downwardly oblique

axis, which is posterior and external. In a sense, this augments externalstability.

This talar-calcanean articular system, being trochoidal, permits one otherphysiological modification of importancc: the spreading of the forefoot.The helicoid shape of this articular system induces the widening of theforefoot. (The calcaneus inclines somewhat inside under load and turnsunder the talus.) Therefore, the talus rotates somewhat inside to all

calcaneal tilting; hence with its extreme anterior edge tending moreoutside. This explanation for the widening of the forefoot has a physio-pathologic importance we will soon appreciate. (Figure 11 illustrates therotation and movement of the talus.)

THE SUMMIT

The highest point (or summit) is represented by the middle tarsus bones.Shaped by the middle bones of the tarsus on the inside, three cuneiformsin the center, and the cuboid on the outside, the summit corresponds totwo systems of distinct articulations:

A median articular system, scaphoid-cuneiform. It forms a pseudo-archwith the external cuboid and has an inferior concavity. This system isheld tightly in place by a contingent ligament: it integrates andredistributes the various pressures exerted upon it. This is the principlesystem in foot positioning.

A lateral articular system, the medio-tarsal (a. tarsi transverse). It isdivided on the inside by the tarsal-scaphoid articulation and on theoutside by the calcaneo-cuboid articulation.


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One may call this a Chopart joint because physiologically it is held

together by the Y of Chopart (lig. bifurcatum). Its central dispositionand its anterior-posterior axis pivots; thus creating rotation in theanterior-posterior axis. This action provides foot lateral stability.

THE METATARSAL PALETTE: THE ANTERIOR RAFTER

The metatarsal palette represents the anterior rafter. It is composed of five metatarsals and fourteen phalanges. It fans out in front of the middle

tarsal bones with which it articulates irregularly (a. tarso-metatarsae).Studies by De Doncker and Kowalski enable its description as a centralpalette with its axis through the second radius. We know the importanceof the talus in the mechanical axis of the foot. In addition, the secondmetatarsal is secured in place by the tarsus and its attaching ligamentsand provides strong resistance.

These authors include a third radius in their studies. Thus the axial

palette is composed of the second and the third radius and is arthrodial.Its importance in foot positioning may be noted clinically. Glimet andRyckewaert v report a majority of fractures occurring from walking on thetwo metatarsals at the calcanean level (75-82%).

Two lateral palettes surround this postural axis. They establish stabilityas a supporting fulcrum. These palettes permit increased mobility bycondylar articulation, the medial and more powerful palette being formedby the first radius. The more lateral palette is contained in the fourth andfifth radii. We will study them more closely in the next part.

THE TIE BEAM

The plantar ligaments comprise the tie beam. Jones and Wood havedemonstrated on cadavers that if one places the foot under physiologicalload the section of plantar ligaments entrained in the collapse of theframework that the entire muscular system and even the aponeurosismust be previously excised. Here the pedal framework is composed of two ligaments:

1. The great plantar ligament (lig. calcaneo-cuboidean) holds thecuboid tightly, pulling it downward and posterior. During this


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action, its superficial layer opposes itself to the widening palette;

'spinning' in advance to attach to the four lateral metatarsals.2. The inferior calcaneo-scaphoidian ligament (lig.calcaneo-navicular plantare) opposes the internal drop of the calcaneus byinserting upon the sustentaculum-tali.

Electromyographic studies of Basmajian and Bentzon followed nineyears later by Basmajian and Stecko and confirmed by Mann and lnmannreveal the extrinsic muscles of the foot (like the intrinsics) are inactive

during the static phase of the erect position. It can show transitory actionalways during physiologic oscillations. Such action occurring, a fortiori,when one foot passes to the other, in a semi-squat position.

Smith ix demonstrates the absence of muscle participation in themaintenance of foot structure. He records action currents of regionalmuscles when assisted in static position by having the test-subject standwhile leaning slightly forward with outstretched fingers touching a chair-

back, (This stance cancels physiologic oscillations.)

FUNCTIONAL FOOT ANATOMY

The second part describes the foot functionally: it's physicalsubordination when under load. Here the middle truss has additionalsupport: it remains the main axial component but is aided by the medialand lateral arches as in a supported static fashion. This support enables acomplete display of the plantar imprint. When placed under load in thismanner the foot remains neither fixed nor rigid. Under the weight of thebody the talus apportions it to underlying bone structures (see figure 10).

It is exasperating that researchers debate percentages but not oneexperimenter finds the same proportional amount. It can be explainedsimply: either they do not study the same feet or perhaps not the samefoot at the same instant.

One needs to remember the foot is transitory: only at a given momentwill it be in a given state of balance. Thus, the skeletal triangulationindicates the talus transmits half the body weight to the subjacentcalcaneus. Or depending upon the overlying position of the subject: threedegrees of deviation in the plumb line of the tibial axis moves or


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displaces five percent weight. This eases the calcaneus (Hicks x).

The latter finds itself normally in a state of unstable balance: It is relegated to the outside of the axis of the leg. This external

deviation is subtended by the internal ankle ligaments as well asby the internal retro-malleolar course of the posterior tibialmuscle.

At the same time, this physiologic deviation of the posterior foot serves

as a device to reduce oscillation. The overhang is limited by the tensionof the internal lateral ligament. The tension of the posterior tibial musclewill provide a restoring force in reorganizing the lateral constraints: itstraightens the calcaneus.

It gets more interesting : the axial palette forms the postural pedal axis.But the triangulation shows us that it is not the bony structures thatsupport the maximum load. No researcher has obtained immutable

physiologic reports because the pedal framework itself is capable of important variations and is not obligatorily pathological.

It becomes necessary to review the anatomical study of this frameworkfrom a different viewpoint. We must integrate the changes that it canintroduce under the effect of physiologic servitude. This is the reason forreferring to functional foot anatomy.

If we link together the tarsus and the metatarsus (figure 12 follows), byfollowing the sagittal plane of each of the five radii we obtain fivelongitudinal profile shapes (figure 13).


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Figure 12: Framework of the Foot

Top: The five radii. Center: Lateral support, 4 th and 5 th radii.

Bottom: Medial Support, 1 st radius.


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Figure 13: Longitudinal schematic of the foot

(According to the sagittal plane of each of the five radii)


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THE STATURAL FOOT FRAMEWORK

Let profiles two and three of figure 13 represent the axial paddle. Theframework from the medial aspect then may be visualized thus:

The summit is scaphoido-cuneiform. It is solidly maintained by astrong ligamentous contingent. The large talo-navicular ligamentcovering it strengthens it even more.

The posterior rafter is the calcaneus. Its posterior lateral andmedial tubercles are specific parts of the second and third radii.

The arthrodial axial paddle forms the anterior rafter. We knowits strength and statural value.

The assembly forms a solid framework, tightly enclosed. This ensures itsprimacy in pedal posture. One now better understands the reducedpercentage that is attributed to the triangulation by noticing the paucityof its tie beam.

Indeed, the superficial confinement of the great plantar ligament unitesthe calcaneus with the base of the metatarsals and underlies thisassembly. The cuboid rests outside the system and exterior assistance isnecessary. It cannot be ligamentous since all the electromyogramsindicate muscle activity. Absent the calcaneus and the foot will rock onits anterior-posterior axis. A poor analogy, but one providing ease of perception, is that of a childs bicycle with outboard training wheelsattached as protection against lateral fall-dangers.

THE LATERAL ARCH

Let us look at the great plantar ligament (lig. plantare longum) in itsbivalved totality and its assistance in integration of the cuboid. (Profile 4of figure 13.) Immediately we notice that the framework in profile 5possesses the same powerful tie beam, while offering a particularimportance. It actually forms a buttressing arc since the highest pointand the posterior rafters are more medial than the anterior rafters.

We drop the buttressing description and use simply the word arch.Speaking architecturally the new term is inadequate; but orthopedically itis more customary to speak of the lateral arch. Purists will pleaseforgive the terminology.


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The striped area at the bottom of figure 12 illustrates this lateral arch. It

is a bit elevated with its highest point (the cuboid) overhanging theground only 3 to 5 millimeters. Because of the presence of the grandplantar ligament, the arch possesses a remarkable reserve and may belikened to the resistance of a short spring. For it is this external archwhich strains to work in supporting the weight of the body. It is thestatural foot element. There can be no doubt that its relative loweringfacilitates lateral support. It is this configuration that further limits fallsoutside the polygon of support.

THE MEDIAL ARCH

In figure 13, profile one shows the disappearance of the posterior rafters.Hence we have another buttressing arch which we will term the medialarch for the same reasons above. It is the longest and highest arch.

The scaphoid (os naviculare) is the highest point and it overhangs the

ground from 15 to 18 millimeters (Figure 12, bottom). This arch can belikened to the flexible, long and slim spring on a limousine that absorbs

jolts and smoothes the bumps. The foot owes its suppleness to its medialarch. When it is put under load, it lengthens and gently lowers. Further,this spring flexes when somatic force lines are too strongly applied onthe inside of the quadrilateral support.

Thus we have the dynamic foot element; winning all its value during astep. One must understand, however, that at rest the interest of this longflexible spring emerges during uni-pedal support. This is when thequadrilateral support is reduced to a single foot dimension. Besides, it isnecessary to note its preponderant role in maintaining stature.

We know the lateral or external translation from the calcaneus by itsrapport with the tibia. It is logical for all support to tend to bend or inflecton the inside, even if the external lateral ligaments and the inferiorcalcaneo-scaphoidian tend to limit this valgus. We know equally that allcalcaneal internal inflection induces an internal rotation upon the talusand hence an increased restraint transfers to the level of this arch.

Whence the addition of the sesamoid under the head of the firstmetatarsal. We will see in the next chapter that it is seen as a point of


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support which, lying under the phalangeal end on the ground, firmly

applies the great toe flatly on the ground. This perfects foot posture. Sowe underscore the importance of this medial arch in stature.

THE ANTERIOR ARCH PROBLEM

There are those who deny the existence of an anterior arch. Othersstrongly affirm it. Comparative anatomy teaches us that the cynomorphicfoot presents a longitudinal inward curve to an inferior concavity. It is

made so to surround a tree-branch in the sense that the length leans inorder to lie on a horizontal plane. One finds this arch in the anthropoidalso. It would seem the concavity is much less pronounced than with thetree-borne monkey. There may be a phylogenetic meaning here whichcan explain its disappearance in mankind.

It certainly exists in the foot kept largely off-ground. It seems to vanishfrom the metatarsal of the ground-supported foot. Radiographic studies

confirm this. The band of anterior metatarsal support is far morehomogeneous than that which is described classically. For our part, wethink more of a state of total muscle relaxation. That is, when theforefoot is only maintained by the intermediate plantar ligaments, theanterior arch does not exist.

THE PHYSIOLOGIC PLANTAR IMPRINT

Let us envisage only the static imprint of the sole of the foot (Figure 29).By placing a glass plate beneath the foot with a mirror opposite and anupward light source, we can visualize a static imprint of the sole. Weutilize the hyper-vascularized plantar teguments thus compressed uponthe plate to show the contrast created between the normal pink tissue andthe blanching of the compressed zones.

One can then describe the four zones of the imprint: The anterior digital supports; support of the five toes. The lack of

support of a toe means it has lost its function (by articularcollapse or by extensor hypotonia).

An anterior metatarsal band or anterior heel, corresponding tothe support of the five metatarsal heads. It occupies a surfaceequal to one-fourth of the total imprint, excluding the toes.


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A posterior support or heel-maker. This is fully more important

than the heel itself; ovoid evidence of pressures exerted by thecalcanean tubercle. A surface equal to one-third of the total width of the imprint. It

represents the support of the soft parts that join together herewith the external arch, underlining the proximity. Anyexaggeration or diminution of this band will translate to thelowering or the exaggeration of the osteo-ligamentous curvature.

REFERENCES Olivier G. & Olivier C. Articular Mechanics. Vigot Edit. Paris,

1970. Jones RL & Wood F. Structures and function as seen in the foot.

2nd ed. Baillre Tindall & Cox Edt. London, 1949. Dolto B. The body Between the Hands, Herman Edit Paris, 1976. Dedoncker and Kowalski C. The normal and the pathological

foot. Actaorthop, Belg. 36 Fasc. 4-5: 3770560, 1970. Glimet TJ and Ryckwaert A. Les aspects trompeurs de fracture

de fatigue, J.Med. & Chir.Prat., article 41192:650-653. Basmajian JV & Benton JW. An electromyographic study of

certain muscles of the leg and foot in the standing position.Surg.Gyn.Obst. 98:662-666, 1954.

Basmajian JV & Stecko G. The role of muscles in arch supportof the foot, J. Bone Joint Surg. 45-A:1184-1190, 1963

Mann R & Inmann VT. Phasic activity of intrinsic muscles of thefoot. Jbone Joint Surg 46-A:469, 1964.

Smith JV. Muscular control of the arches of the foot standing, anelectromyographic assessment. J Anat 88:152-162, 1954.

Hicks JH. The foot as a support. Acta Anat 25:35-36, 1955.


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