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• Theoretical basis

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Year 2012

SENSORIMOTORFUNCTION

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Proprioceptive insoletreatment in paediatricorthopaedics 3

Sensorimotor foot bed-ding - care for children via network 5

Sensorimotor foot bed-dings in the treatment of children 12

Sensorimotor insoles, a concept from head to toe? 15

The afference-stimulating insole 19

Anatomical and functional leg length differences 25

Sensorimotorfoot beddings in sport 29

Change of muscular activity by insoles with proprioceptive effect 38

Autors 44

Portrait of Springer 46

Editorial information 47

Contents:

CHILD PAIN SPORT

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3SENSORIMOTOR FUNCTION

In recent years a modern insole treatment in the form of proprio cep-tive insoles has proved successful inpaediatric orthopaedics. As a result ofthis flexible malpositions of the foot aswell as functional pain syndromes,particularly of the lower extremities,have been treated effec tively, quicklyand cost-effectively, provided thatthey are pathogenic and accompa-nied by malpositions of the foot.

The limit of this treatment is rea-ched with contracted malpositions.Here proprioceptive insoles are notpromising of success. The treatmentis based on the principle that by set-ting proprioceptive information in thefoot area, changes are caused in themuscle tension of the short muscula-ture of the foot and lower leg, whichon the one hand and in the context ofa chain syndrome make possible re-actions towards the proximal regionand also induce a learning effect atspinal cord level. In this way malposi-tions can also be corrected and elimi-nated long-term and permanently.

Before each insole treatment andin the course of progress a regular fol-low-up check on clinical progress, generally every 3 months, is indispen-sable. This follow-up check includesexamination of the child. In particu-lar, the feet and legs are tested in sitting position for capacity for cor-rection of visible malpositions of thefoot so that, if appropriate, instancesof muscular shortening can be deter-mined and neurological underlyingdiseases, such as spastic paralysis, canbe ruled out.

The second step is the examina-tion of the child standing up. Here, inaddition to the position of the footwith the child standing being assessedfrom the front, the side and from be-hind, the leg axis is to be assessed aswell.

Genu recurvatum or genu val-gum/genu varum can be diagnosedhere. A check on the leg length is alsonecessary.

Particular attention is to be placedon the position of the heel in relationto the lower leg. The examination ofthe knee with the patient walking iscarried out according to this. Obser-vation of the dynamics is the most im-portant part of the examination asgreater weight-bearing on the footand the lower extremity basicallytakes place on walking.

The rotation of the leg, the posi-tion of the knee in the course ofweight-bearing as well the positionand behaviour of the heel and thelongitudinal arch of the foot are assessed. These are to be describedclinically. In addition, in specific situations pedobarographic, dyna-mic measurement examinations canbe necessary.

With which symptoms are pro-prioceptive insoles used?

Severe talipes planoval-gus/pes valgus flat footTalipes planovalgus is a foot defor-mity, which is accompanied by a valgus position of the heel or a flatte-ning of the longitudinal arch. Attimes excessive pronantion of the fo-refoot in relation to the calcanealpart of the foot is evident. In the exa-mination attention is to be placed on the dynamics, in particular on theextent of the flattening of the longi-tudinal arch and the excessive pro-nation. With the patient walking ontiptoes it is observed whether theheel, starting in a valgus positionmoves into a varus leading position,i.e. straightens itself. If this is not thecase or if there is considerable exces-sive pronation, there are indicationsfor dynamic insole treatment, whichin particular must give rise to a

Proprioceptive insole treatment inpaediatric orthopaedicsProprioceptive insoles are a modern, efficient and cost-effective therapeutic agent in the elimina-tion of malpositions of the foot and functional pain syndromes in children.

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strengthening of the tibialis poste-rior/tibialis anterior muscle.

Congenital pes valgus flat foot, aso-called vertical talus, which is theresult of a highly contracted conge-nital deformity of the calcaneal partof the foot with complex scarring andis accompanied by a shortening ofthe Achilles tendon, is always to beruled out. A shortening of the Achil-les tendon can also be present in theevent of extensive talipes planoval-gus and pes valgus flat feet. Thisshortening is to be ruled out by cor-recting the valgus position of the heelwith the patient sitting. If this is pre-sent, physiotherapeutic exercisetreatment is also important for ex-tension of the shortening of theAchilles tendon.

Pes cavusWith pes cavus we understand amarkedly excessively high longitudi-nal arch. This is in part accompaniedby a varus position of the heel. Thereare indications for proprioceptive in-sole treatment with pes cavus if it isnot contracted and there is a varusposition of the heel on walking. Flat-tened pes cavus is an exception; herethere is a straight to varus position ofthe heel with marked longitudinalarch insufficiency. Here there are de-finitely indications for propriocep-tive insole treatment. The change intone takes place via the lateral chainof the peroneal musculature, the me-dial chain of the tibial group as wellas via the short musculature of thefoot.

As pes cavus is an osseous defor-mity, correction of the pes cavus isnot the aim of the treatment. It is rat-her the support of muscular stabilityin order to straighten the heel.

Talipes varusWith talipes varus there is a defor-mity of the foot with an adductionmalposition in the tarsal bones or inLisfranc's joint. The talipes varusmalposition is in part already presentfrom birth. Here, if there is pronoun-ced talipes varus, treatment must bestarted in infancy. I consider pro-prioceptive insole treatment to be in-dicated from a medical perspectivein infancy and childhood if the tali-pes varus is mobile, i.e. it can be cor-rected passively with slight pressure.The proprioceptive insole is far su-perior to the 3-jaw insole becauseduring the stepping movement therotation centre of the jaw shifts to theheight of the metatarsophalangealjoint of the toe and thus pressure isexerted by the insole only in parts ofthe stepping movement.

Functional pes equinus gaitpatternWe understand pes equinus to mean agait pattern that does not cause anystructural changes to subsequentlyoccur to the gastrocnemius, the Achil-les tendon or other tendon parts.

The limits to minimal brain dys-function as the expression of mini-mal infantile cerebral paresis are inpart fluent because abnormal strainof all muscles towards the proximalregion occurs due to a tiptoe gait pat-tern. There are indications for treat-ment here as well. Ideally this is to besolved by proprioceptive insoles be-cause as a result of pretension of theshort musculature of the foot, a re-duction in tone of the calf muscula-ture occurs due to toe strap andretrocapital support.

In this way normalisation of gaitpattern can be achieved very easilywith proprioceptive insoles in shoes.As with all proprioceptive insoles, itis particularly important that there isadequate children's footwear withsufficient support in the heel region.

Internal and external rotation gait patterns Basically these are torsion variants inthe hip joint region or in the lower legregion. By proprioceptive insoletreatment a cosmetic improvementof the gait pattern can be achieved.

A significant change of functionand detorsion of the joint axes is not

possible with insole treatment. Fur-thermore, it is doubtful whether acompulsory correction, especially ofthe internal rotation gait pattern inthe event of coxa antetorta does noteven hinder the natural straighteningof the longitudinal arch, therefore inmy opinion torsion malpositionalone does not represent any indica-tion for proprioceptive insoles.

Functional pain syndromeof the lower extremity Chondropathia patellae, chronicAchilles tendon symptoms and painsin the lateral region of the hip in particular are to be borne with ado-lescents. In my experience a consi-derable dysfunction of the foot isalways present here, which can becorrected actively and thus alleviatesthe symptoms. The majority of pa-tients become asymptomatic as a re-sult. At some point it is also possibleto dispense with insoles as a result ofthe proprioceptive learning effect. Inthe course of each insole treatmentcontinuous clinical follow-up exami-nations are necessary in order toadapt the insoles to the changingmalpositions of the foot and the dy-namic conditions. It has proved suc-cessful to carry this out every threemonths.

In summary, it can be said thatproprioceptive insole treatment is agood and appropriate method for thetreatment of correctable malpositi-ons of the foot and pain syndromesof the lower extremity.

As a result of the learning effectand adaption insole-free follow-uptreatment is possible at some point.

Dr. med. Andreas Heine

Address for the authors:

Dr. med. Andreas HeineSpecialist in Orthopaedics and TraumaSurgery,Specialist in Orthopaedics –Rheumatology, Paediatric Orthopaedics Hammerstr. 949740 Haselünne

SENSORIMOTOR FUNCTION4

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For more than four years in our sur-gery in joint special consultation cli-nics with the master craftsmanorthopaedic shoemaker children'sfeet have been are examined, patho-logical patterns diagnosed and in theevent of appropriate findings, thechildren have been treated with sen-sorimotor foot beddings. Regular fol-low-up checks are subsequentlycarried out. Thus a total of 628 chil-dren could be involved in a pro-gramme of observation of progress.

The follow-up check on the fin-dings was carried out after 3 months,6 months and 12 months at the la-test. The improvement in gait pat-tern, posture and status of the foot instanding position and dynamics wasassessed.

In addition, the children werequestioned about the comfort ofwear and the parents about thechange in the gait pattern and symp-tom pattern.

After one year in a total of 560children examined a marked impro-vement in the results could be achie-ved and verified by footprint, videoanalysis and inquiry directed at theparents.

After 12 months with 48 childrenthere was no improvement or onlyslight improvement in the movementpattern documented at the begin-ning of the treatment and in the pa-thologically changed structures.

Those primarily involved werechildren whose previous treatmentoften seemed inadequate or with pa-tients where there had previouslybeen an insufficient acceptance ofdaily usage.

Special foot consultationclinicThe physiological conditions shouldhave absolute priority in the treat-ment of children because of their

wide range of learning and develop-ment processes. This assumes thatgeneral physique, posture and co-or-dination are also always to be takeninto account in the assessment offoot and leg statics.

Therefore in our so-called specialfoot consultation clinics set up in oursurgery precisely these influencefactors are to be taken into conside-ration and clearly to be verified inconsultation between physician andmaster craftsman orthopaedic shoe-maker. It is only from this that the de-finitive treatment of the pathologicalpostural and movement patterns re-sults.

Close contact between physicianand master craftsman orthopaedicshoemaker is therefore not only im-portant and desirable in the contextof initial treatment. Co-operative ex-change during the follow-up exami-nations also proves very positive inthe sense of a qualified patient care.

The follow-up examinations arecarried out in our surgery on a stan-dardised basis, if appropriate beyondthe regular appointments, providedthat these are necessary due to pro-blems experienced by the patient onwearing the sensorimotor insoles,changes in gait pattern or in the statusof the foot as well as wear and tear ofthe material of the orthopaedic device.

Sensorimotor foot bedding –care for children via networkIdeally sensorimotor insoles are made for the patients in close co-operation between physician and ortho-paedic shoemaker. This type of co-operation is described below and results from four years of treatment ina surgery are presented.

1 In the special consultation clinic the patients are mutually assessed by Dr Udo Herberger(left) and Stefan Woltring (right)

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6 SENSORIMOTOR FUNCTION

Main focus of the treatmentThe 628 children treated/supportedshowed pathological foot and leg position and posture in addition toneurological symptoms (hemipare-sis/diparesis and tetraparesis).

The main focus of the indicationsand treatment were:– pathological talipes planovalgus

malposition– internal and external rotation gait

pattern, often accompanied by su-pination and pronation malposi-tion, not age-appropriate

– initial and complex talipes equinusgait pattern

– pes adductus– pes varus / valgus et adductus– muscular dysbalance with patho-

logical influence on the body sta-tics and dynamics of the child

– disturbance of co-ordination/per-ception and symmetry of the chil-dren

– 'so-called signs' of chondropathiapatellae, better: retropatellar painsyndrome, patellar apex syndrome

– hypotonic or hypertonic posturaldefect of the child (often treated inconnection with physiotherapeu-tic exercise treatment, physiothe-rapy and occupational therapy).

Overall the children treated were dif-ferentiated in age groups:

– Age 2 – 4 = 84 treatments – Age 5 – 10 = 323 treatments; – Age 11 – 15 = 175 treatments; – Age 16 – 18 = 46 treatments.

Production and FittingFor the production of sensorimotorfoot bedding CAD-milled EVA mate-rials on a carrier layer are used as arule.

Production takes place in an or-thopaedic workshop specialising inthe treatment of children in accord -ance with individual specificationsaccording to the diagnosis and thesubjectivity of the patients .

Within the special foot consulta-tion clinics the sensorimotor footbeddings are fitted and handed overto the patient and as far as possible,the way they take effect is explainedto the patients and the parents.

Regular follow-up examinations,modifications and follow-up cor-rections according to the symptompattern as well as possible modifica-tions due to wear and tear of the li-ning or the surface structure of thesensorimotor foot beddings are re-corded and carried out in accord -

ance with the regulations of qualifiedtreatment. In this the outline patienthistory sheet proves particularly hel-pful, here all information can be poo-led quickly and clearly.

This sheet is standardised or sub-mitted to the health insurance com-panies on request and it is regardedas a template by physician and master craftsman orthopaedic shoe-maker in the context of the co-ordi-nation of the special consultationclinic.

Result Now after four years of treatment ofchildren's feet on an interdiscipli-nary basis, a close co-operation between physician and mastercraftsman orthopaedic shoemakerresulted due to the specificity of thesensorimotor foot beddings andtheir detailed history, examination,assessment of findings as well as theinitiation of treatment and follow-upexamination.

Very good acceptan ce of thetreatment could be established withthe majority of the patients. The pro-gress of the abnormal statics of thefoot could be made significantlymore favourable and at times the du-ration of treatment could be short -ened considerably. Within the firstyear the so-called malrotation gaitpatterns could be improved or com-pletely corrected by up to 84%.

Pes adductus, without antivarusshoes and/or 3-jaw-insoles with medial jaw was improved or cor-rected completely.

In the early stage of adequatetreatment the functional talipesequinus gait patterns could be im-proved with approximately 90 per-cent of the patients and with2 Kids feet require special therapy particular attention

3 The wide range of learning and development processes requires physiological and child-

oriented treatment.

4 Autologous compensations – help to

self-help – are steered and guided

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approximately 50% of the patientsthey could be corrected completelywithin the first year after treatmenthad been carried out.

In the context of the treatmentwith sensorimotor foot bedding pos-tural insufficiencies, sensorimotordysfunction and postural weaknes-ses could be improved in the sameway as co-ordination and perceptualdisorders.

The assessments of the parents,teachers and therapists were also re-peatedly included in this.

By wearing the sensorimotor footbedding patients with preopera-tive/postoperative pes varus/valguset adductus improved their foot sta-tics as well.

ConclusionIt is therefore to be concluded thatwearing sensorimotor foot beddings,accompanied by the special footconsultation clinic in co-operationbetween physician and mastercraftsman orthopaedic shoemaker,brings about a considerable impro-vement in the pathological structu-res within a significantly shorterperiod of time. Not least the resultsidentified in the specialist orthopae-dic consultation clinics were able toconfirm the descriptions of the phy-siological orthopaedic principles ofafference-stimulating insole treat-ment (see amongst others Pfaff, Na-trup/Fischer, Bernius, Hafkemeyrand Woltring). In the context of thepaediatric treatment carried out byus it is therefore hard to imagine thistreatment without the use of senso-rimotor foot beddings

Udo Herberger, Stefan Woltring:

First published:

Orthopädieschuhtechnik

(Orthopaedic Footwear Technology)

12/2004, 5. 19 2 1

5 Feeling the correction capacity and sensitivity lies at beginning of eachtreatment with sensorimotor foot bedding.


OSM Stefan WoltringMotioncheckMettinger Straße 5049479 Ibbenbü[email protected]

www.proprio.info

Die Schule für richtigeBewegung!

The school for correctmovement!


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PROPRIO®

Foot beddings


For children an adolescents

Contact for individual consultation +49 30 - 49 00 03 43Production + dispatch within one week

PROPRIO® A1-0 A1-0 in connection with talipes planovalgus in

patients with neurological disease poor perceptionsevere deformities of the foot in children alsowithout neurological disease

SOME INDICATIONS

hypotonic/hypertonictalipes planovalgus in childrenfl at footneutral gait pattern/gait pattern with slight internal rotation

PROPRIO® A1-1 A1-1 in connection with talipes planovalgus/ talipe equinus in

patients with neurological diseasepoor perception

SOME INDICATIONS

hypertonic talipes equinushabitual talipes equinus gaitinfantile cerebral palsy

PROPRIO® A2-0 A2-0 in connection with fl exed pes cavus in

patients with neurological diseasepoor perceptionsevere deformities of the foot in children also without neurological disease

SOME INDICATIONS

hypotonic/hypertonicfl exed pes cavus in childrenfl at footneutral gait pattern/gait pattern with slight internal rotation

PROPRIO® A3-0 A3-0 in connection with talipes planovalgus andsevere valgus deformity of the heel in

patients with neurological diseasepoor perceptiongait pattern with internal rotation severe deformities of the foot in children also without neurological disease

SOME INDICATIONS

hypotonic/ hypertonictalipes planovalgus in childrenfl at footgait pattern with internal rotation

PROPRIO® A3-1 A3-1 in connection with talipes planovalgus and severevalgus deformity of the heel or fl exed pes cavus in

patients with neurological diseasepoor perceptiongait pattern with external rotationsevere deformities of the foot in children also without neurological disease

SOME INDICATIONS

hypotonic fl at valgus foot in childrensnapped off contracted footfl at footneutral gait pattern/gait pattern with external rotationrotating

PROPRIO® A3-2 A3-2 in connection with clubfeet which have been operated on in

forefoot adductiongait pattern with internal rotationvalgus/varus deformity of the heel

SOME INDICATIONS

rebellious clubfoottalipes varus

PROPRIO® A4-0 A4-0 in connection with clubfeet in

patients with neurological diseasepoor perceptiongait pattern with internal rotation

SOME INDICATIONS

clubfootpes cavuspes cavus/talipes varus

PROPRIO®.Foot beddings

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PROPRIO® B1-0 B1-0 in connection with normal feet with

gait pattern with internal rotation

SOME INDICATIONS

coxa valga et antetorta

PROPRIO® B2-0 B2-0 in connection with talipes planovalgus with

gait pattern with severe internal rotation

SOME INDICATIONS

talipes varussunken pes cavuscoxa valga et antetorta

PROPRIO® B3-0 B3-0 in connection with talipes planovalgus in

gait pattern with slight internal rotation

SOME INDICATIONS

talipes planovalgusfl at foot


gait pattern with severe external rotation

SOME INDICATIONS



neutral gait pattern

SOME INDICATIONS



For children an adolescents


PROPRIO®

Foot beddings

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MEASUREMENT

2D foot scan

pedography

CLIENT DATA

simple management without double entry

interface with other programs

transparent documentation of all procedures

ANALYSIS- AND ADVISEMENT MODULES

guidelines with all relevant historyparameters

automated analysis report with our own logo

illustrative example measurement

NAVIGATOR sets optimum model for construction

CHILDREN, SPORT, PAIN

complete PROPRIO® - model library in the background

RHEUMATISM

function tests specify stage I, II or III

NAVIGATOR recommends appropriate modules

DIABETES

recording of fi ndings based on the Working Group on the Diabetic Foot of the German Diabetes Society (DDG)

bedding construction for slight to moderately severe risk groups

Your market

ANALYSING AND ADVISINGMEASUREMENT AND MANAGEMENT

SPRINGERCAD Use your market chance

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LIBRARY BASIS MODULE

conservative and sensorimotor basic modules for children, sportsmen and pain

patients according to foot type

own models readable

INDIVIDUALISATION

simple construction in 4 minutes

set the longitudinal arch height

vary module in position and design, such as lowering, pad, retrocapital pad, level or toe strip

wide range of material

Your success

HAVE INSOLES MADE TO DO THE WORK EASY TO DESIGN AND CUSTOMISE

DELIVERY

proof of order for certifi cation

production within 3 working days in the SPRINGER MILLING CENTER

very fi ne milling quality

- with SPRINGERCAD CENTRAL MILLING

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In the meantime many patients havebeen treated with sensorimotor footbeddings in co-operation with phy-sicians and therapists. At the begin-ning of a treatment the indication-dependent criteria should be estab-lished.

These include:

– age of the patient– status of the foot, standing and indynamics

– overall status/posture, standingand in dynamics

– gait pattern barefoot and withshoes

– overall tone– pains– if appropriate underlying diseases– previous treatments and therapies– concomitant treatment and thera-pies

A patient history sheet can beused for recording this. Videos andphotographs are useful for establis-hing the actual condition and forchecking and assessing the progressof the treatment. Manual examina-tion of the foot, palpation, is carriedout. The foot is palpated for capacityfor correction and sensitivity of themuscle reactions. On the basis of thefindings gained, a treatment ob-jective and indication-related focalpoints of the treatment should be de-fined.

This applies in particular with pa-tients with a neurological underlyingdisease or with multiple abnormalweight-bearing or functional disor-ders. A neurological underlyingdisease is not a compelling conditionfor treatment with foot beddings withsensorimotor effect. The sensorimo-tor system also does not end withcompletion of the 18th year of life.

The necessary measurements arenow taken using the known media -blue print, step foam or pedography.Production of the sensorimotor footbeddings starts on the PC. The acqui-red data and documents are enteredor scanned. After that the sensori-motor foot bedding is constructedand produced by means of a CADmilling machine. Because these mil-ling systems are still very cost-inten-sive, there is the option of sendingthe measurement data and descrip-tion of the pathological findings tocentral offices and have the millingcarried out there after previous trai-ning. An important task is to adjustthe foot bedding, which was createdaccording to objective criteria, to thesubjectivity of the patient and thegiven conditions.

An orthopaedic device is only asgood as it is accepted by the patient.Sensorimotor insoles have to be ad-justed to the shoes, to the expecteddaily strain and to the patient's sen-sitivity. At the first follow-up checkthe strains on the foot beddings,which have been worn, can be iden-tified exactly and if appropriate cansubsequently be corrected after thepatient has become used to the initi-ally strange padding under the foot.Regular follow-up checks, if appro-priate by the physician or therapistproviding treatment, ensure opti-mum progress of the treatment aswell as the opportunity to react ingood time to changes in the symp-toms, foot growth or wear and tear ofthe foot beddings. With treatment ofchildren consultations with the pa-rents with regard to their impressionsand findings are often highly infor-mative.

Case study: TomThe way sensorimotor foot beddingtakes effect and its effectiveness areillustrated in two case studies below.

Tom - 7 years old - talipes plano-valgus on both sides:– incomplete straightening of thelongitudinal arch when standingon tiptoes

– slight internal rotation gait pattern– valgus malposition of the calca-neal part of the foot on theleft/right

– overall hypotonicFor 3 years Tom has been treated

with plastic shell insoles as well asconcomitant physiotherapy.

The objective of the treatment wasa lasting correction of the abnormalstatics of the foot and an improve-ment in overall tone. In producing thesensorimotor foot bedding it was ne-cessary to develop appropriately theindividual elements of the indication.

–> A medial pad in the calcanealpart of the foot is placed in such a waythat it mechanically forms a supportof the sustentaculum tali and simulta-neously exerts pressure on the tendonof the tibialis posterior muscle. Thethus generated relaxation of the mus-cle and the altered latency period haveas a result a higher level of muscle acti-vity and stimulate an active straighten -ing of the longitudinal arch of the foot.The tarsal joints as well as the shortmusculature of the foot do not receiveany complete underpinning and cancontinue to function freely.

–> A lateral pad in the calcanealpart of the foot forms a mechanicalcounter bearing to the medial infor-mation and thus it secures the posi-tioning of the heel on the footbedding. By pressure on the tendonof the peroneus longus muscle andthe peroneus brevis muscle the anta-

Sensorimotor foot beddings in thetreatment of childrenThe characteristic function of a living structure is more than all passively correcting influences. Thisbasic principle runs like a golden thread through many of our operations since we began to producesensorimotor foot beddings in 1999. The nature of the shoes, although in particular the nature of theinsoles, influence the development of the foot shape and gait pattern in children and are therefore of particular importance.

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gonist to the tibial musculature isactivated and thus helps to stabilisethe calcaneal part of the foot. At thesame time a stronger activation ofthe peroneal musculature stimulatesexternal rotation of the foot.

As in many cases the internal ro-tation gait of the child results fromthe position of the angle of the headof the femur to the femur (antetor-sion angle) and the CCD anglechanges with growth, an internal ro-tation gait pattern is in no way al-ways pathological and thereforeabsolutely requires specialist ortho-paedic assessment.

–> A retrocapital pad has to be at-tached exactly behind the second tofifth metatarsal bones. By a slight ele-vation in the course to the fifth me-tatarsal bone it brings aboutcountertorsion to the forefoot andthus counteracts adduction and in-ternal rotation. At the same time itimproves plantar contact withoutunnecessarily restricting the foot inits mobility.

–> A toe strip with a flatteningcourse to the apex of the foot bringsabout slight extension of the toes andimproved contact of the tips of thetoes. The tips of the toes comprise avast number of nerve cells and are anessential element of the subcon -scious co-ordination of gait.

Tom wore ready-made children's'shoes with good guiding of the calca-neal part of the foot and sufficient fo-refoot flexibility.

The result of the treatment was aspontaneous improvement in gaitpattern, an orthograde step develop-ment as well as good acceptance.This was also confirmed at subse-quent follow-up examinations. At theappointment for measurement forsubsequent treatment due to growthof the feet, it was to be establishedthat the status of the foot had impro-ved considerably, step developmentwas also orthograde in walking bare-foot and overall posture had cor-rected visibly according to theparents. Today Tom no longer wearsinsoles and no longer needs physio-therapy either.

Case study: AlinaAlina -3 1/2 years old– functional, non-contracted pesequinus

– muscular dysbalance – in plantigrade position childhoodage-appropriate talipes planoval-gus both sidesThe objective of the treatment

was a reduction of the muscle ten-sion to allow physiological planti-grade step development. Here - as inexample 1 - it was also necessary todevelop the indication-related ele-ments of sensorimotor foot bedding.

–> The pads in the calcaneal partof the foot are used reduced as thetension of the stapedius muscula-ture, the tibial muscle and peronealmuscle should not be increased. Ne-vertheless, holding and guiding astight as possible is necessary.

–> Strengthening of the retroca-pital second to fifth metatarsal bonesas well as the toe strip generate pre-tension over the plantar apaneurosis

1 a+b Footprints of Tom at the beginning of thetreatment

2 a+b Today Tom no longer needs any in-soles and physiotherapy


K I D

Training is child‘s play for our little ones!

strengthen footmuscles

achieve of posture improvement

train fi ne motor skills

121276_12_18 07.05.12 10:43 Seite 13


and flexor digitorium muscle, whichsimulates a tension situation to thegastrocnemius muscle via the mus-cle chain, before the actual weight-bearing takes place. The musclespindles, which register the longitu-dinal tension of the muscle, conductthe signal for relaxation, so that thetone is already reduced at the time ofthe real weight-bearing which fol-lows.

Alina wore ready-made shoeswith good guiding of the calcanealpart of the foot. With talipes equinusgait care is to be taken that the ready-made heel to toe movement of theshoe soles is not too pronounced as

otherwise the pretension generatedby the sensorimotor shoe beddingscan at times be eliminated. With thischild a spontaneous improvement ofgait pattern was not identifiable bywearing the foot beddings. In a tele-phone discussion after approxima-tely three weeks Alina's motherinformed us that Alina was onceagain always lowering her heels onwalking, which until then she hadnot done, despite physiotherapy.

At a further follow-up examina-tion 10 weeks later, it was shown thatwhen walking barefoot Alina loweredher forefoot in a splashing manner,although the heel received groundcontact with every step. The gait pat-tern with shoes and sensorimotorfoot bedding could be described asorthograde, even though slightly ab-ducted. With this child it was also tobe predicted that in the foreseeablefuture she would no longer requireany foot bedding and she would alsono longer require any physiotherapy.Treatment with botulinum toxin,which had already been considered,was not carried out.

It was also noted in passing herethat the relevant health insurancecompany rejected the application foracceptance of costs, which had beensubmitted, on the grounds that withthe existing indications, shell insolesin conventional form were sufficient.We are just learning to understandthat subconscious perception andwith it subconscious orientation inspace as well is stimulated by the me-chanoreceptors of the skin. However,just how insoles with shells for thecalcaneal part of the foot can be-come effective, has not been explai-ned to date despite enquiry.

With sensorimotor foot beddingformer natural events are simulated.The foot is again understood as agrasping organ. Via the receptors ofthe skin (exteroception = superficialsensation; mechanoreception, noci-ception, thermoception) as well asreceptors of deep sensation (pro-prioception, Golgi tendon organs,joint capsules, muscle spindles) thefoot is not only a part of the body,with which we walk and stand orscore a goal whilst playing football ifwe are lucky. The foot is an essentialorgan of our subconscious percep-tion and co-ordination. Learning tounderstand this must be a very im-portant focus of our attention, parti-cularly in the treatment of children's'feet.

Stefan Woltring

First published in:

Orthopädieschuhtechnik

(Orthopaedic Footwear

Technology) 6/2003

S. 55 – 57



4 After 10 weeks of wearing sensorimotor insolesAlina's talipes equinus gait pattern had improvedconsiderably.

5 a+b Production of sensorimotor food bedding which fits exactly in accordancewith the indications and the patient's senses are essential requirements for suc-cessful treatment.

3 a+b On palpation the sensation and capacityfor correction are palpated on the foot and theintended padding is simulated.

121276_12_18 07.05.12 10:43 Seite 14

Can an orthopaedic craftsman help apatient with symptoms in the jawand cervical vertebra?

Recently there have been increa-singly more frequent reports on networks, functional chains andfunctional connections and in medi-cine there has been more and moretalk of integrated treatment. Yet, whatis the significance of this for the or-thopaedic craftsman?

In order to answer this questionanatomical and physiological con-nections must first be discussed.

The body's centre ofgravityThe centre of gravity of the body in vertical position is approximately1 – 2 cm in front of the navicularbone between both feet. The centreof gravity of the body varies by 4 mmaround this point. Through the vi-sual, vestibular and proprioceptivesystem position changes are recor-ded and regulated from the centre(see box 1).

Muscle activities are necessary torestore balance. Thus, with medial/lateral displacements first reactionsoccur in the hip area (abductors andadductors), in the foot area the pero-neal muscles (in particular the pero-neus brevis muscle) are active.

A dorsal displacement is balan-ced by the activity of the tibialis an-terior muscle, with ventraldisplacement the activity in the gas-trocnemius, soleus and abductorhallucis muscles increases (Hoch-schild 2002).

Aetiology of pains withpostural problemsIn order to stabilise the trunk againstunsteady forces if there are long-sus-tained malpositions of the body,adaptations in the muscles are constantly required.

If there is fatigue of the muscula-ture, mechanical strain of pain-sen-sitive structures occurs (e.g. bypermanent extension of the liga-ments, joint capsules, or compres-sion of the blood vessels), thereforesensitive nerve endings become irri-tated and pain develops. If the me-chanical strain exceeds the capacityfor strain of the tissue, overexertionsyndromes occur (inflammatory re-actions, pain, functional limitation)without an appropriate injury beingidentifiable (Kisner, Colby 1997).With malpositions over a long periodthe strain can become too great forthe articular surfaces, therefore da-mage of the articular cartilage oc-curs. The surface of the cartilagebecomes irregular, axially correctmovement sequences are no longerensured. The cartilage becomes limpand loses its mechanical resistance.

Normal pressures already giverise to pain as the subchondral bonesections are no longer protected bysufficient cartilage padding. The abrasion can lead to inflammationsin the synovial tissue (secondary sy-novitis). As a result of the altered

pressure and tensile strain in thejoint, disturbances in proprioceptiveinput develop, which lead to new, ab-normal muscle tensions, the viciouscircle is complete (Frisch 2003).

In order to break through or pre-vent this vicious circle it is importantto strive for an integrated recordingof findings and treatment tailored tothis in the treatment/care of the pa-tient.

Potential functional connections with mal -positions of the footDeviations of the normal position ofthe foot are an important contribu-tory factor in the development ofmalpositions. Consequently, on thebasis of (bilateral) pes planus forexample, the potential effects of mal-positions of the foot on overall bodystatics should be made clear:

Primarily pes planus is to be at-tributed to a muscular insufficiencyof the tibialis posterior muscle, oreven more commonly of the pero-neus longus muscle. The transversearch of the foot, which is normallysupported by the tendon of the pero-neus longus muscle, flattens and themedial arch descends (see figure1)(Kapandji 1992)*

Due to reduced inclination angleof the metatarsal bone (medial < 20°),the talus shifts towards the plantarand medial regions so that the leg

Sensorimotor insoles, a conceptfrom head to toe?Deviations from the normal, physiological position of the foot are an important factor in the deve-lopment of malpositions. Problems with the cervical spine and the mandibular joint can also havetheir cause in the foot. The joints of the foot, knee, hip, vertebra and jaw are functionally connec-ted. It follows from this that treatment of malpositions of the foot should not only play an impor-tant role in rehabilitation in order to avoid further ascending symptom. On the basis of thedescription of the functional connections in the body it can be shown that sensorimotor insolesexert a positive influence on body statics and therefore they can also be suitable for treatment ofsymptoms in the jaw and cervical vertebra.

Sensorimotor function is the neurological forms the basis for the regulation of posture andmovement of our patients. Muscle tone regulation succeeds by integration of sensorimotorregulatory systems. Slight irritations of the regulatory circuits of the nervous system triggermusculoskeletal reactions, adaptations and compensations in the locomotor system.

(Schömer 2006)


121276_12_18 07.05.12 10:43 Seite 15


perpendicular strikes the groundmedially instead of in the centre ofthe calcaneum. This internal rotationposition of the malleolar mortisecontinues upwards, which leads to agenu valgum tendency in the kneejoint (Hochschild 2002).

Due to the increased internal ro-tation of the femur, the acetabulumof the pelvis is lowered and thus cau-ses the malpositions to affect thespine. The lumbar spine compensa-tes the tilting of the pelvis with hy-perlordosis, which is responded towith increased kyphosis in the thora-cic spine. If there is hyperkyphosis ofthe thoracic spine, the cervical spinehas to adopt hyperlordosis in orderto be able to face forwards.

Many patients with back painshow these types of malposition ofthe vertebral column. The pain prob -lems are intensified by, amongst others, the muscular dysbalanceswhich develop due to the malpositi-ons (see figure 2).

On the one hand stabilising mus-cles cannot function fully becausethey are closely positioned, othermuscle groups are overextended andtherefore do not offer any necessarystability (see box 2) (Kendall 2001).

The question asked at the begin-ning as to whether an orthopaediccraftsman can help a patient withsymptoms in the jaw and cervicalspine will be discussed in greater de-tail below.

The hyperlordosis of the cervicalspine and the ventrally directed headposition can bring about a change ofthe position of the mandible. Herethe mandible is pulled towards thedorsal region by the traction of theventral musculature and as a result ofthis the position of the jaw can be af-fected (see figure 3) (Rocabado 1985).In practice it is often to be seen thatthis malposition is a contributoryfactor in craniomandibular dys-function (malpositions or diseases ofthe mandibular joints and the masti-catory muscles).

In a study Valentino et. al. madeclear the functional relationship bet-ween occlusal plane (occlusion =clenching of the teeth) and foot archposition by using measurement tech-nology to record occlusion beforeand after the change of the foot archposition (pes planus, pes cavus). The

results showed significant changes inthe occlusal plane with the changedfoot arch positions in each case (Va-lentino et al. 1991). Furthermore, atone change of the masticatory mus-cles due to changed foot arch positi-ons could be established by usingEMG measurements (Valentino et al.2002).

However, it must be emphasisedthat these studies are only restrictedto a short period of time. To date thelonger-term effects of the malpositi-ons of the foot on the cervical spineand the mandibular joint region havenot been subjected to sufficientscientific examination in order to beable to make definite statements.

The question arises as to whethersensorimotor impulses (e.g. sensori-motor insoles) on the sole of the footcan exert a positive influence even asfar as into the region of the cervicalspine and the mandibular joint re-gion.

Ciuffolo et al. (2006) analysed thedirect effect of plantar stimulation onthe masticatory musculature as wellas the shoulder and neck muscula-ture. The test subjects of the testgroup wore insoles which were sup-posed to stimulate the plantar fascia,whilst the test subjects of the controlgroup wore placebo shoes. Measuredby EMG the tone changes in thenamed muscle groups were signifi-cant in the test group, which answersin the affirmative the question askedabove.

The change in the muscular acti-vities of the lower extremitiesbrought about by proprioceptive in-soles were tested on six test subjectsin the context of individual case ana-lyses. Using EMG measurements the

Short and strong muscle groups in hollow round back:- cervical extensors- hip flexors- extensors of the lumbar region

Extended and weak muscle groups in hollow round back:- cervical flexors- upper section of the erector spinae muscle- oblique abdominal musculature- hamstring musclesMuscular changes in hollow round back

1 Sinking of the longitudinal arch (Hochschild 2002)

2 Hollow roundback (Kendall2001)

3 Changes in the position of the headand their potential influence on the positi-on of the mandible

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tone changes in each case were de-termined on the tibialis anteriormuscle, peroneus longus muscle, thelateral head of the gastrocnemiusmuscle and the medial head of thegastrocnemius muscle. A positive in-fluence in terms of the planned mus-cle activation could be measuredwith all test subjects (Ludwig et al.2004). The number of test subjects istoo low to be of high diagnosticvalue; however, this study indicatesincreased activity of the desired mus-cles and could serve as a pilot studyfor a more extensive study.

Incel et al, (2002) analysed theconnection between hallux valgusdeformities and biomechanicalchanges in the lumbar region andfoot region. A significant connectionbetween hallux valgus and pes pla-nus deformities could be established,as well as a tendency towards increa-sed inclination to lordosis in the lum-bar spine region.

The interconnection of the mal-positions cited above can be de-monstrated in the following casestudy:

Ms S. (24 years old) works as ahairdresser in an occupation whichprimarily involves standing. Her lei-sure time is spent as a conductor.

The main symptoms comprisedtension headaches up to migraine,shoulder and neck tension and re-current spinal blocks. The headacheswere already present on waking up inthe morning.

In particular, the symptoms in-creased in periods of stress, at timesup to complete limitation of her fit-ness for work.

With regard to the treatment todate, it can be said that Ms S. had received physiotherapy for years, alt-hough without success. The con-stantly recurring symptoms in theform of blocks and enormous mus-cle tension disorders could be im-proved temporarily with Dorn-Breußtherapy. Long-term success with thistherapy was not possible.

In addition Ms S. has cranioman-dibular dysfunctions which, due togrinding of the teeth at night, perpe-tuated or increased the symptoms(headache, shoulder/neck tensionetc.). For relief of the mandibularjoints Ms S. wears a bite guard atnight. In this connection it is not wit-hout significance to point out that inchildhood Ms S. had undergone or-thodontic treatment, which was sup-posed to improve the position of herteeth.

However, the position of the teethchanged again in the course of theyears.

Treatment with shoe insoles hadnot been carried out up to this point.

On inspection (see figure 3) it isnoticeable in sagittal plane that Ms S.has a severe hollow round back, thehead is displaced ventrally, there isinternal rotation of the shoulders. Inthe knee region bilateral genu recur-vatum, which forces the ankle joints

4 Internal rotation position of the legs with genurecurvatum and genu valgum tendency, internalrotation of the shoulders and ventrally directedhead position can be seen.

5 Baropedography, asymmetrical step develop-ment, pes cavus, pes valgus, pes transversus onthe left/right, deviating gait line left/right


Gentle training to combat your tiredness!

ease headaches and backpains

improve body statics

train muscle balance

121276_12_18 07.05.12 10:43 Seite 17


into a slight plantar flexion positionin order to maintain balance.

The frontal view shows a ten-dency towards genu valgum (moreon the right than on the left) andmalpositions of the foot in the formof pes planus. There is slight internalrotation of the knee caps, which ex-plains the tendency of the lower ex-tremities towards internal rotation.The right gluteal fold is slightly lower,in the shoulder girdle region it is no-ticeable that the right shoulder"hangs".

The malposition of the vertebralcolumn is to be recognised (amongstothers) by the asymmetry of thewaist triangles and the different po-sition of the scapulae.

On closer examination a functio-nal leg length difference emerged,which could be compensated bychanging the sensorimotor input ofthe craniomandibular region.

It is not evident with which mal-positions the static changes began inMs S.

Several factors, such as for exam-ple unilateral exertion (work, hobby),insufficient muscular stability, incor-rect footwear, orthodontic treatmentand stress can influence the develop-ment of malpositions.

Ms S. was treated with sensori-motor insoles, which spontaneouslyhad a positive effect on her posture.As Ms S. mainly stands in her workand in her leisure time, provision ofinsoles is an important treatment,which should be used parallel totreatment comprising physiotherapyand manual therapy. Whether thetreatment with insoles alone can re-duce Ms S.'s problem, cannot be fo-reseen at this time.

Summary and conclusionThe studies cited illustrate thefunctional connections between thejoints of the foot, knee, hip, vertebraand jaw.

Therefore treatment of malposi-tions of the foot should not only playan important role in rehabilitation,but in prevention as well in order toavoid further ascending symptoms.

Whether a malposition of the footis initially present, which then, in anascending order, influences thejoints lying cranially due to the mal-position or whether a malposition injoints lying cranially, in a descendingorder, helps malformations of thefoot to develop, has not been suffi-ciently researched to date.

On the basis of the descriptionsof the functional connections in thebody and the scientific findings wecan conclude that sensorimotor in-soles exert a positive influence onbody statics and therefore it makesabsolute sense for a patient withsymptoms in the jaw and cervicalspine to go and see an orthopaediccraftsman.

Monika Knust

BibliographyCiuffolo F, Ferritto AL, Muratore F, Tec-co S, Testa M, D'Attilio M, Festa F. 2006:Immediate effects of plantar inputs onthe upper half muscles and upright po-sture: a preliminary study. Cranio. 2006Jan; 24(1):50-9. Frisch H. 2003: Programmierte Therapieam Bewegungsapparat. 4. Aufl. Berlin:Springer-Verlag. 2003 Hochschild J. 2002: Strukturen undFunktionen begreifen. Band 1. 3. Aufl.Stuttgart: Georg Thieme Verlag. 2002Incel NA, Genc H, Yorgancioglu ZR, Er-dem HR. 2002: Relation between halluxvalgus deformity and lumbar and lo-wer extremity biomechanics. Kaohsi-ung J Med Sci. 2002 Jul; 18(7): 329-333Kapandji IA. 1992: Funktionelle Anato-mie der Gelenke. Band 2 Untere Extre-mität. 2. Aufl. Stuttgart: Ferdinand En-ke Verlag. 1992 Kendall FP. 2001: Muskeln Funktionenund Tests. 4. Aufl. München: Urban &Fischer. 2001 Kisner C, Colby LA. 1997: Vom Griff zurBehandlung. Stuttgart: Georg ThiemeVerlag .1997 Ludwig O, Fuhr N. 2004: Änderung dermuskulären Aktivität durch proprio-zeptiv wirkende Einlegesohlen. Ortho-pädieschuhtechnik 2004;12:13-18 Rocabado M. 1985c: Diagnose und Be-handlung einer abnormalen kraniozer-vikalen und kraniomandibulären Me-chanik. In: Solberg W, Clark G. Kiefer-funktionen, Diagnostik und Therapie.Berlin: Quintessenz; 1985:145-162 Schömer G. 2006: Körperstatik undCMD. GZM - Praxis und Wissenschaft.11.Jg. 2/2006 Valentino B, Fabozzo A, Melito F. 1991:The functional relationship betweenthe occlusal plane and the plantar ar-ches. An EMG study. Surg Radiol Anat.1991;13(3):171-4.

Original article for this special edition

Address for the author:

Monika Knust/PhysiotherapistHenry-Moisand-Straße 2055130 Mainz

6 – 9 Examination and compensation of functional leg length difference by changing sensorimotor input of the craniomandibular region.

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The sensorimotor system is a com-plex set of rules. On the one hand itcomprises the peripheral and centralnervous system, on the other handthe related functions of the muscu-lature whereby the individual mus-culature and muscle groups areconnected to one another via the linkchain.

Via the nerve tracts the sensori-motor system transmits to the cen-tral nervous system all forces fromthe environment which, consciouslyas well as subconsciously, influenceour organism. It also registers all en-vironmental processes to which wehave a relationship. The nervous sys-tem also perceives things to whichwe, however, do not have to or so notwish to react.

In many cases reactions to for-ces/information from our environ-ment or from our body are alsoautomatically responded to or sup-pressed by the nervous system.

The impressions from the envi-ronment or from our body affectingour nervous system are called sti-muli.

Our nervous system has specialstimulus perception structures foreach type of stimulus. These are cal-led receptors (Latin recipere = to as-similate, feel).

Figure 1 shows a list of a series ofreceptors, which our nervous systemholds in order to be able registermeaningfully the stimuli from the

environment and our organismwhich have an effect us.

Physiology ofsensorimotor functionStimuli are received by our peripheralnervous system, conducted to the spi-nal cord, processed further there and

simultaneously transmitted to the dif-ferent control centres of our brain.

The 'Messages' of the receptorsfrom the periphery to the centralnervous system, which begin in thespinal cord and whose highest switchpoint is the cerebral cortex, are calledafferent stimuli.

The afference-stimulating insole –Effective corrective factor in the event of sensorimotor performance deficits and dysbalances as well as pains in the musculoskeletal system

Today afference-stimulating insoles are an important part of treatment, if, for example, co-ordination of allmuscle groups within the link chain is impaired by dysfunction of one muscle group and muscle dysbalances,muscle tensions, malpositions and further co-ordination and proprioceptive disorders resulting from it, also develop. In addition, in the event of damage of the nervous system, if the complex neuromotor interconnection is restricted and disorders (e.g. spasticity) in the movement sequence of the link chain result, afference-stimulating insoles can influence sensorimotor function by stimulating the proprioceptorsand exteroceptors with appropriate stimuli with the objective of correcting afferent input. The work withsensorimotor insoles still represents a science based on experience. However, the practical experiences are so sound that it is possible to create the insole according to the individual deficit found in the patient, sothat the muscle to be corrected is boosted in the right intensity, at the right time and in the right durationof activity.

1 important sensors of the body


sensory organs– eye– ear– balance– nose

skin/superficialsensation– mechanoreceptors(touch, pressure)

– thermoreceptors(temperature)

– nociceptors (pain)

deep sensation of theinternal organs– visceroreceptors

deep sensation of movement functionproprioceptors of the– musculature - muscle spindles(muscle extension, muscle length)

– tendon - Golgi tendon spindle(muscle tension, muscle strength)

– joint capsuleRuffini’s corpuscles(joint position, joint movement)

– tendon, joints, ligamentsVater-Paccini lamellar corpuscles (acceleration, vibration, angle position)

free nerve endingspressure, movement, pains in different tissue such as musculature, ligaments,joint capsule, skin

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PROPRIO® S1-0 S1-0 in connection with slightly lowered foot typefor minimally invasive treatment

slight talipes planovalgus slight pes cavus

SOME INDICATIONS

knee painback pain

PROPRIO® S1-1 S1-1 in connection with clearly lowered foot type

fl at foot splay foot slight pes cavus

SOME INDICATIONS

knee painback pain

PROPRIO® S1-2 S1-2 in connection with clearly lowered foot typeand valgus deformity of the heel

piede valgo con arco abbassato piede cavo di grado lieve piede traverso

SOME INDICATIONS

knee painback pain

PROPRIO® S3-0 S3-0 in connection with foot type with clearly high avulsion

moderate to severe pes cavus

SOME INDICATIONS

knee painback pain

PROPRIO® S2-0 S2-0 in connection with forefoot overexertion pain without padding

splay foot talipes planovalgus slight pes cavus

SOME INDICATIONS

forefoot overexertion painknee painback pain

PROPRIO® S3-1 S3-1 in connection with forefoot overexertion painwithout padding

splay foot moderate to severe pes cavus

SOME INDICATIONS

forefoot overexertion painknee painback pain

PROPRIO® S4-0 S4-0 in connection with hallux rigidus

splay foot fl at valgus foot slightly contracted foot

SOME INDICATIONS

hallux rigidusknee painback pain

PROPRIO® S3-6 S3-6 in connection with hallux rigidus


SOME INDICATIONS

hallux rigidusknee painback pain

PROPRIO®

Foot beddings

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121276_19_24 07.05.12 10:44 Seite 20

PROPRIO® S5-0 S5-0 in connection with tension pain

splay foot normal foot talipes planovalgus slight pes cavus

SOME INDICATIONS

knee pain back pain migraine tinnitus calf tension Achilles tendon

PROPRIO® S5-1 S5-1 in connection with tension pain


SOME INDICATIONS

knee pain back pain migraine tinnitus calf tension Achilles tendon

PROPRIO® S6-0 S6-0 in connection with medial arthrosisof the knee joint (varus stability)

splay foot pes cavus talipes planovalgus normal foot

SOME INDICATIONS

medial arthrosis of the knee jointknee painback pain

PROPRIO® S6-1 S6-1 in connection with lateral arthrosisof the knee joint (valgus stability)

splay foot contracted foot talipes planovalgus normal foot

SOME INDICATIONS

lateral arthrosis of the knee jointknee painback pain

PROPRIO® S7-2 S7-2 in connection with plantar fasciitis

splay foot slight pes cavus talipes planovalgus normal foot

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plantar fasciitisknee painback pain

PROPRIO® S7-3 S7-3 in connection with plantar fasciitis


SOME INDICATIONS

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PROPRIO® S8-0 S8-0 in connection with peroneal paresis slight clubfoot pes cavus rebellious clubfoot

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condition following stroke condition following head injury


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121276_19_24 07.05.12 10:44 Seite 21


In the brain stimuli are registeredand integrated, balanced with expe-riences, sensations and reflectionsand subsequently the stimulus res -ponse is conceived and sent as an efferent stimulus to the effector or-gans (e.g. musculature) located in theperiphery (figure 2).

Many stimulus responses alsooccur unconsciously via automa-tisms. On the one hand these auto-matisms are transmitted to usgenetically.

On the other hand they are modi-fied by conscious or unconsciouslearning processes (e.g. training) orby conscious or unconscious imita-ting of models. Walking, standing,posture and with posture, in particu-

lar work posture or movement se-quence at work or during sportingactivities, constitute automatisms ofthis type, which in different phases ofour life we sometimes have to learnwith difficulty initially.

Once learned we do not have tothink about it any more if, for exam-ple, we wish to walk, sit, cycle orsprint, throw the javelin, hammer orwrite.

As our nervous system is affectedby about 1 billion stimuli per secondwe also need a stimulus attenuationsystem because it is impossible for usto be able to react meaningfully andpractically to such a large number ofstimuli. This attenuation system, justlike the stimulus perception system,is multi-stage. It begins with the no-tion that a stimulus must have a cer-tain force to become accepted by thereceptor (all-or-none law). In thecourse of further progress there areother “switching stages” in the atte-nuation system of the spinal cordand the brain, which is not to be exa-mined in further detail here.

Finally, the nervous system alsoneeds feedback as to whether the ef-ferent reactions initiated by it havealso been performed as “arranged” orwhether any deviations/disturban-ces occurred. This is necessary inorder to react effectively and consis-tently again in accordance with thenew position/posture of the bodywhen the next stimulus occurs.

The sensorimotor system there-fore creates a mutually interlockingsystem of stimulus uptake, proces-sing and output (figure 2). The nerv-ous system receives and evaluates allsensory impressions which affect our

body or which our body itself gene-rates (sensory function).

The nervous system controls themuscular reaction (motor function)in response to the sensory impressi-ons (sensory stimuli).

The effects of sensorimo-tor function on the linkchainThe motor reaction of a musclegroup takes place according to theprinciple of agonist/antagonist (fi-gure 3). If a muscle group becomestense (e.g. the elbow flexors - in thiscase agonist), the antagonist musclegroup must relax to the same extentand at the same speed (in this caseelbow flexors - antagonist), so thatthe intended movement can also runfluently and smoothly.

The influence of the nervous sys-tem on all muscle groups occurs si-multaneously within the related linkchain (figure 3), so that our musclegroups can position and stabilise ourbody in space as planned.

In addition, the muscular linkchain is integrated in a complexmanner into several hierarchical sta-ges of control/order via the sensori-motor system.

All reactions to an efferent stimu-lus, which induces muscle movementfor example, are reported back to thenervous system as a feedback. By de-finition the feedback constitutes anew afferent stimulus. In response tothe feedback the nervous reacts againor it refrains from reacting if it is notnecessary and “notes” only the regis-tration of feedback.

Thus the manner of function ofthe sensorimotor system in each case

Basic principles of sensorimotor function

afferent info

proprio-ceptors

spinal cordposterior horn brain

issue of orders(efferent info)

no reaction reactionmuscle tensionmuscle lengthtendon tensionjoint position

calculation ofinput

nociceptors

exteroceptors - skin

eyeearbalance

stimulus

balance with:congenitallylearnedexperiencesemotionsconsiderations

monosynapticreflexes

sympathetic nervous system

spinal cordanterior horn

spinal cordanterior horn

feedback (afferent info) agonist antagonist

2 The sensorimotor system 3 The musculature works according to the principle of agonist/antagonist

Vicious circle between proprioceptive deficit in the sensorimotor system and pain development

sensorimotor deficit

resulting from proprioceptive dysfunction due to- disease (e.g. cerebral palsy, diabetes)- injury (e.g. sprain, fracture)- overloading of the musculature

muscular imbalances

muscular imbalances

muscle tension

malpositions

disorder of- co-ordination- movement programming- movement sequences

4 Vicious circle of pain development

The tension of a muscle affects the link chain according to the agonist/antagonist principle.

antagonist

agonist

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permits a meaningful and practicalreaction to

a) events in our environment wit-hout direct connection to our body

b) influences on our body fromoutside and

c) changes in our body itself (e.g.movement sequences).

Via the sensorimotor system ourbody’s functions and skills can becontrolled and utilised specificallyand consciously through intendedand planned reactions or throughautomatisms so that we can assertourselves in our environment.

In order to be able to carry outour body’s action or reaction to a sti-mulus as accurately and specificallyas possible the sensorimotor systemneeds as much information as possi-ble, which it receives via differentia-ted receptors for example. If theinformation is too vague or sparse,for example due to diseases or otherdisorders in the sensorimotor sys-tem, the efferent reaction to the in-complete (vague) afferent stimulusrange (not enough information) canonly take place incompletely (va-guely) or even incorrectly.

Example 1If the performance of the brain (cen-tral nervous system) is impaired dueto cerebral palsy in childhood, de-pending on the type of damage, timulus perception, stimulus atte-nuation and stimulus output can bedisturbed, so that from this, forexample, the different stages of spas-tic paralysis as a result of the dama-ged brain will develop. The damageof the nervous system obstructscomplex neuromotor intercon-

nection, from which result the disor-ders (e.g. spasticity) in the movementsequence of the link chain.

Example 2If the functionality of individualmuscles is for example impaired by aligament strain on the foot, a malleo-lar fracture or overexertion of theAchilles tendon etc., due to the dys-function of one muscle group, im-pairment of co-ordination of allmuscle groups within the link chainoccurs. As a result of the propriocep-tive deficits, muscle dysbalances,muscle tensions, malpositions andfurther co-ordination and proprio-ceptive disorders, which are also cau-sed by this, develop (figure 3).

Muscle dysbalances, muscle ten-sions and malpositions generatepain in the musculoskeletal system,which can spread beyond this via theinterconnection of the link chain. Inthis way pains can occur in the mus-culoskeletal system, which are appa-rently inexplicable initially because,due to the sensorimotor intercon-nection and the intervention of thelink chain, the pain region can lie along way away from the region of themuscular overexertion, the sprain orother musculoskeletal dysfunction.

The connections between pro-prioceptive deficit, effects on the linkchain and the development of painjust outlined constitute a vicious cir-cle (figure 4), which is virtually self-perpetuating and even becomesworse without meaningful therapeu-tic intervention.

Through the interconnection ofthe muscle groups via the link chainproprioceptive deficits and painful

muscle dysbalances as well as mal-positions also spread from the distalregion to the proximal region, i.e.from the foot towards the head forexample, although also in reverse di-rection (figure 3).

In order to break through the vi-cious circle outlined above there is apractical measure to influence andcorrect sensorimotor afferent input.

The sensorimotor insoleand its influence on thelink chainSensorimotor function can be influ-enced or stimulated by stimulatingthe proprioceptors and exterocep-tors with appropriate stimuli withthe objective of correcting the affe-rent input.

This effect can be achieved by or-thopaedic devices which are worn onspecific regions of the body (figure 5).

This sensorimotor stimulationtriggered by the orthopaedic devicesinfluences the muscle receptors, thetendon receptors and the exterocep-tors of the skin.

In addition, the orthopaedic de-vices psychodynamically bring abouta positive effect by an appealing de-sign and ease of use and convey theimpression of safety/protection tothe patient being treated with the de-vice. This effect motivates the patientto activity and simultaneously in-creases acceptance of the device.

The parameters cited in figure 6can be influenced by the orthopaedicdevice which provides sensorimotorstimulation.

Whilst with an orthosis worn onthe trunk, on the knee or on theelbow for example, sensorimotor

effect ofthe sensorimotor

input byorthopaedic devices

muscle building boosted

total activity boosted

feeling of securityactivity motivation

muscle activity boosted(time, intensity, duration)

posture correctionload centeringincreasedload reduction

thermoregulationimprovement of blood flow(skin and indirect musculature)

5 Sensorimotor simulation with orthopaedic devices 6 Manner of effect of afference stimulation by sensorimotor insoles

feet:sensorimotorinsoles

trunk:- corset- abdominal binder- supports

joints:- elastic orthoseswithout joint- non-elastic ortho-ses with joint,with and withoutmovement limit

Orthopaedic device close to the body with sensorimotor stimulation

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function can indeed be influenced ina positive way, albeit oriented in a re-latively untargeted manner, afferentsensorimotor stimulation on the footcan be initiated in a targeted manner.

With sensorimotor insoles sen-sory afference can be influenced veryprecisely and with great sophistica-tion depending on the requirementsof the muscular performance deficitsto be corrected.

The sensorimotor insoleas a useful building blockin the treatment conceptof diseases (e.g. cerebralpalsy) and other musculardysbalancesThe work with sensorimotor insolesstill largely constitutes a science basedon experiences. The evidence-basedtest results demanded nowadays arealready hard to obtain from an ethicalpoint of view. Because of a successionof competent experts, through whosepractical experiences, experienceswith regard to the correction of speci-fic deficit complexes (clinical charac-teristics of disease) have reached sucha level of maturity today that it is pos-sible to create the insole according tothe individual deficit found in the pa-tient so that through the insole treat-ment the muscle to be corrected isboosted in the right intensity, at theright time and in the right duration ofactivity. This knowledge is so wellfounded that it can be shared in ap-propriate courses/training program-mes and subsequently appliedconsistently by the course partici-pants.

On this basis treatment with sen-sorimotor insoles becomes a usefuland effective building block in thecomplex treatment of sensorimotordeficits caused by disease, injury andoverexertion. Following appropriatefunctional investigations the muscu-loskeletal pain generated by the defi-cits can also be treated in a targetedmanner with afference-stimulating in-soles. If function is boosted, the painsalso ease.

The role of sensorimotorfunction in the complex ofmodern pain therapyThere is no doubt that in the event ofdiseases, injuries, overexertion of themusculoskeletal system, active phy-

siotherapeutic/sports therapy treat-ment working with modern methodsin a targeted manner, as has beencarried out to date, is indicated forinfluencing functional disorders. Inthe event of pains, knowledge of mo-dern pain therapy is also to be ap-plied.

It is to be deduced from this thatif there are dysfunctions in the mus-culoskeletal system, the moderntreatment approaches demand acomplex of treatment methods. Inthis complex the afference-stimulat -ing insole constitutes the orthopae-dic device with which to carry out acorrection of the diagnosed perfor-mance deficit by specific change ofthe afference input in the event of adisorder in sensorimotor movementprogramming.

Therefore, in the context of thefunctional and activity-boosting treat-ment just outlined, in adulthood thepurely bedding insoles and in growthage the conventional growth-guidinginsoles, are not in a position to correctthe afferent input in a targeted man-ner and with short-term effect.

The advantage ofsensorimotor insoles compared with purelybedding insolesThe purely bedding insoles do notmeet the requirements of a functio-nal, afference-stimulating orthopae-dic device. On the other hand theafference-stimulating sensorimotorinsole brings about a very efficienttreatment effect in the treatment offunctional and painful sensorimotorfunction disorders in the musculos-keletal system. Whilst it is true thatwith the afference-stimulating in -soles, even without further treatmentmethods, it is only by the correctionof the afferent input that an initialbenefit, which also occurs short-term, can be achieved in the regionof the disorder to be treated. Thetreatment success is nevertheless significantly more effective if the afference-stimulating insole in com-bination with activating and functio-nally correcting physiotherapeutic/sports therapeutic treatment me-thods is integrated in a complextreatment programme.

The effect of the activating andcorrecting elements of movement

therapy is significantly boosted bythe simultaneous correction of affe-rent input by the sensorimotor insole. The treatment objective isachieved more rapidly. The sensori-motor insole thus also exerts a posi-tive effect on economy of treatmentand economy of time.

In addition, long-term usage ofthe insole prevents correction defi-cits.

In this sense the sensorimotor in-sole constitutes a very effective andultimately also economical treat-ment approach in the therapy com-plex for the treatment of an impairedsensorimotor system.

Professor Dr. med. Holger Hähnel

Original article for this special edition

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IntroductionThere is hardly any other everydayorthopaedic examination where somany incorrect diagnoses are madethan in the assessment of pelvic tilt -ing. The conclusion from pelvic tilt -ing that there is an anatomical leglength difference, which can be ba-lanced with insoles, often is drawn(too) quickly. The complex structureof the pelvis and the complex rangeof movement of its components (os-seous, ligamentary and muscular)are often readily ignored. However,the distinction between anatomicaland functional leg length difference,which both can lead to pelvic tilting,is not rocket science.

1. Functional differencesof leg lengthThe effect of functional deficits onleg length and pelvis position will beshown on the basis of the followingcase study. The young adult com-plains of persistent symptoms in theright lower lumbar spine and in theregion of the left sacroiliac joint. Adeeper examination shows severepain in the region of the small mus-culature of the right buttock. Here ty-pical trigger points of the gluteusmedius, gluteus minimus and piri-form muscles respond with a feelingsharp pain. In the region of the lowersacrum and the coccyx tenderness topressure also occurs. A postural ana-lysis shows a clear low position of theright posterior superior iliac spine(PSIS).

The lumbar spine compensatesthe low base with slight scoliotic de-viation towards the right. Figure 1shows the dorsal view with painzones marked in and the overlappingmalposition of the pelvis.

Classical treatment, as had al-ready been previously carried outthis patient, consists of the balancingof suspected leg length difference.The instruction to straighten the pel-vis again – or more precisely the iliaccrest and the PSIS, because the usualexamination is mainly concernedwith this - only led to treatment withinsoles with elevation by 6 mm onthe left side. However, an alleviationof symptoms was not achieved bythis during a period of several weeksof wearing the insoles.

Anatomical and functional leglength differencesThe distinction between anatomical and functional leg length differences is not always entirelystraightforward. Nevertheless there is hardly any other orthopaedic problem area where interdisci-plinary co-operation is so worthwhile than in the differential investigations and treatment of mal-positions of the pelvis. Only if the cause of pelvic tilting is found, can targeted and differentiatedtreatment be initiated. This includes orthopaedic insoles and treatment methods involving manualtherapy and physiotherapy as well as orthodontic interventions.

Fig. 1a. Low pelvis on the right, slight left convex lumbar spineb. Patient’s pain zonesc. Suspected position of the pelvis, beginning from the anatomical marker points

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If we examine the patient’s pos-ture more closely, we see that the lowposition of the right PSIS also doesnot simultaneously correspond witha low position of the right anteriorsuperior spine (ASIS) on the frontalside. Figure 2 shows an upright posi-tion of the ASIS without insole eleva-tion. In this case the perpendicularline also runs through the navel andapex of the sternum. However, withthe insole elevation, which straigh -tens the posterior pelvic region, theright SIAS tilts upwards.

With asymmetrical response ofthe posterior and anterior spines to a unilateral elevation, a functionalleg length difference is always su-spected. In this case the hip bone hascarried out a rotation movement(torsion). On the right side the pa-tient’s hip bone is in retroversion(backward tilting). If we view fromthe side the patient, who is lookingtowards the of the clock face, theright pelvic ring (marked in red in fi-

gure 3) has turned slightly anticlock-wise. The posterior superior spinethus lowers (figure 3 on the right) andsimulates a low position of the pelvis.If in addition to this twisting, a slightlowering of the right pelvic sectionoccurs, the anterior superior spinelowers to its original level again. Theiliac crest is then lower on the right,as is the posterior superior spine,whilst the anterior superior spine ison a neutral level (figure 4). However,as in most orthopaedic examinationsonly the iliac crest (pelvis scale!) orPSIS are tested, no differentiationbetween genuine anatomical legshortening and pelvic torsion is pos-sible.

The consequences of pelvic tor-sion are manifold. The sacrum isconnected in a springy manner withthe ilia via the two sacroiliac joints(shaded in figure 3 on the right). Theslight rocking movement is callednutation (Latin nutare - to nod). Thearticular surfaces of both sacroiliac

joints are complexly formed three-dimensionally, therefore no smoothsurfaces. As a result the range of mo-vement of a joint can already be im-paired with regard to sensation dueto slight “tilting”. In the event of pel-vic torsion, this type of joint blockingof one or both joints is not unusual.

In addition to the blocking of theleft sacroiliac joint, a more detailedexamination of the patient yieldedanother finding to be expected:

the musculature of the right hipabductors, in particular the gluteusmedius muscle, were painful con-tracted. Thus this muscle group pullsthe superior edge of the ilium slightlydownwards in the direction of thehead of the hip joint and the femur ina slight long-term abduction. Withthe leg rising up the right superior

Fig. 2 Left: without elevation perpendicular position of both anterior superior ili-ac spines (ASIS). Right: With elevation on the right by 6 mm raised position of theright ASIS. Laser perpendicular through pubic symphysis no longer hits the centreof the body (navel).

Fig. 4Pelvis situation, frontal view.If the right hip bone (red) lowers duringits retroversion by muscle contraction ofthe hip abductors, the two ASIS (yellowpoints) are at the same level. The asym-metry in the region of the pubic boneand sacral bone is visible.

Fig. 5a. Pelvis status at the time of the first assessment of findingsb. Pelvis status following treatment of the muscle tone and the sacroiliac joint, without elevation.

Fig. 3Left: Retroversion (backward tilting) ofthe right hip bone (red). With simultane-ous lowering the right and left ASIS areon the same level. Right: Pelvis situationfrom dorsal approach. Sacroiliac jointsare shaded, yellow the position of thesurface skin markers on the PSIS. In theevent of unilateral torsion of the righthip bone (red) blocking in the right sacroiliac joint. occurs. The tilting of thesacral bone and of the coccyx is clearly visible. The pubic symphysis (violet) is exposed to torsion.

without raising raising6 mm right

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edge of the pelvis (here the musclebegins) is thus pulled down towardsthe posterior region biomechanicallyand brings about the observed pelvicretroversion on the right side. Thelower lumbar vertebrae follow the sa-crum tilted towards the right, whichleads to the observed scoliosis. Theresult is increased tone of the lowerspinal column stabilising muscula-ture (erector spinae muscle), whichexplains the symptoms in the lowerback region. With the pubic symphy-sis the pelvic ring has a cartilaginoussupple connection, in which, torsionalso occurs if there is unilateral pel-vic torsion. With the sportsman thisarticular connection was also highlytender to pressure and blocked.

In the context of a differentiatedtreatment the existing elevation wasremoved. Every two days the musclesof the abductor group and of thelower lumbar spine were detoned(massage, TENS, passive extension).Both sacroiliac joints were regularlymobilised. After eight days the symp-toms had subsided and a further pos-ture analysis was carried out. Figure 5(on the right) shows the changed

posture: the pelvis is entirely straight,both at the level of the PSIS and ASIS,without a leg having had to be me-chanically elevated. Scoliosis is onlystill present in the region of the cer-vical spine.

Conclusion:The example shows very clearly howa malposition in the pelvis shouldhave been subjected to a differentia-ted examination prior to further the-rapy and treatment being carriedout. In this case the incorrect eleva-tion had set the retroversion of thepelvis (figure 6) because it takes ef-fect precisely in the same directionand thus worsens the symptoms.

For practical application, beforeestablishing treatment, the followingsequence is advisable:1. Test for low position of the PSIS2. If yes: Test for low position of the

ASIS on the same side3.Are PSIS and ASIS low to an equal

extent on the same side?4. If yes: pelvic tilting, repeat tests

with unilateral elevation (OST, OT)

5. If no: pelvic torsion, tests for blockade of the sacroiliac jointand muscle contractures (PT, physician)

Fig. 6a. Position of the virtual rotation axes of hip joint and sacroiliac jointb. As both axes do not lie on top of one another, a leg lengthening via insole ele-vation brings about a rotation moment.c. An elevation because of an incorrect diagnosis brings the hip bone into additio-nal retroversion and can cause blocking symptoms at the sacroiliac joint and canlock blockades

Fig. 7Patient with genuine anatomical legshortening on the left. Low position ofthe pelvis on the left, compensatory leftconvex scoliosis of the lumbar spine andthoracic spine.

Fig. 8Patient from frontal approach. Low posi-tion of the pelvis on the left. Laser per-pendicular goes through the pubic sym-physis, although no longer hits the na-vel, centre of the sternum, centre of theneck and nose.

raising

raising

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2. Anatomical differencesof leg lengthHowever, genuine anatomical legshortenings are often also connectedwith functional disorders. Then ashortening balance is an importanttreatment of choice, which must besupplemented by other forms oftreatment.

The second case study illustratesthis: the 15-year-boy also has symp-toms in the lower back as well as inthe right inguinal region. A nervoustemporary twitch in the form of arapid rotation of the head upwardstowards the right is occasionally noticeable.

A posture analysis clearly showsfrom the dorsal region clearly low PSISon the left side (figure 7). Compensa-tory twisting of the vertebral columntowards the left has occurred. Theimage is confirmed from the front:due to the pelvis tilted towards theleft, the entire symmetry of the trunkis simultaneously disturbed. The fron-tal vertical perpendicular line shouldbegin at the pubic symphysis and runthrough the navel, the sternum andthe tip of the nose. Due to the left-til-ted pelvis, the entire upper body isdisplaced towards the left (figure 8).The head is again slightly inclined to-wards the right side – here the centralnervous system unconsciously balan-ces malpositions of the lumbar spineand thoracic spine at the level of thecervical spine.

However, in the concrete case theboy’s body overcompensates. Whilstthe pelvis is tilted towards the left by approximately 3°, the bipupillarplane is tilted towards the right by 5°,the mandibular joint plane by 3° andthe occlusal plane (bite plane) like-wise by 3° (figure 9). To put it simply,the body has adjusted the head moreobliquely than would be necessarybecause of the pelvic tilting.

The muscle groups (sternocleido-mastoid muscle, scalene muscles) responsible for the inclination of thehead indirectly influence the posi-tion from maxilla to mandible and,due to long-term unilateral toning,have the effect of encouraging thedevelopment of craniomandibulardysfunction (CMD).

With the young patient, at thesame time as conventional insoleelevation of 5 mm, a brace was madeas an orthodontist had diagnoseddisturbances in tooth position and in occlusal overlay. Perpendicularstraightening of the trunk could already be achieved with theelevation (figure 10); however, thehead was still oblique by approxima-tely 3°. Due to the dental brace, theoblique posture disappeared within8 weeks (figure 9 on the right).

It was only with both treatmentssimultaneously that it was possibleto successfully normalise pelvis andvertebral column as well as the posi-tion of the head and jaw. The nervous

head twitches, which were con-nected with the unilateral muscletone of the head rotators, likewiselargely disappeared.

Conclusion:The example shows that in additionto a genuine anatomical difference,further functional disturbances canalso occur, which only permit a har-monious postural pattern when theywere exposed and eliminated. Whilstpelvis position and vertebral columndo balance themselves by unilateralelevation, if, however, there areasymmetries in the region of theshoulder or head, then a consultativeexamination of the status of thejoints of the head and jaw as well asthe eyes by a specialist is advisable.

Oliver Ludwig


Dr. Oliver LudwigAG Kid-Check derUniversität des SaarlandesHome-Office:Niederbexbacherstr. 3666539 [email protected]

Fig. 9Evaluation of head posture and face symmetry (corpus concepts measuring sys -tem). Asymmetrical position of the planes pupil and mandibular joint as well asbite plane in degrees to the horizontal line.a. Patient prior to treatmentb. Patient after treatment: elevation on the left 6 mm, brace

Fig. 10Pelvis status and vertebral column aftertreatment, no non-physiological devia-tions any longer

SENSORIMOTOR FUNCTION28

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For many years we have used senso-rimotor foot beddings to treat sports-men and sportswomen with theirtypical symptoms. Here the objectiveis to deal more appropriately withthe dynamic strains which occur insports. Sports-associated symptomsoften have a functional origin. Cau-sal connections are therefore to besought in the entire movementchain.

Body statics and body dynamicsbegin with the foot. In many cases itis possible to work via the foot onsymptoms, which are located in ad-joining or remote areas of the link,joint and muscle chains.

Sensorimotor foot beddings insport are intended to optimise thestatic and dynamic movement pro-cesses and to influence the latency ofthe muscles in the form of a strain-oriented muscle balance. Thus sym-biosis develops between sports-appropriate bedding and support ofthe feet with retention of maximumindependent dynamics.

Sensorimotor stimulus or toneinhibition supports autologous com-pensations in the form of the desiredeffect. The spectrum of the indicati-ons to be treated with orthopaedicshoe technology has changed signi-ficantly as a result of this.

As a result of experiences in pre-vious years some symptom patterns

in sports have crystallized as particu-larly predestined for treatment withsensorimotor foot beddings. In addi-tion to classic foot overexertion syn-dromes, we treat amongst others:– Chronic whiplash injuries with re-

lative ligament insufficiencies– Pathological excessive pronation

and supination strains– Tibial edge syndrome– Tibialis anterior/posterior

syndrome– Plantar fasciitis– Insertion tendinosis (and tendi-

nosis of the plantar aponeurosis,Achilles tendon, peroneus brevismuscle, tibialis anterior muscle,iliotibial tract…. )

– Achillodynia– Patellar apex syndrome– Femoropatellar pain syndrome– Meniscopathy– Chronic sacroiliac joint blocks.

Efficient treatment should bepreceded by an examination with simulation of sporting movement.Treadmill, video analysis, foot scan-ning and dynamic foot pressurestress measurement (pedography)rank amongst the indispensable pre-requisites for us. In addition to the important analysis findings, the vi-sualisation also helps the athlete inhis own understanding of his move-ment and symptom pattern.

I would like to illustrate the pos-sibilities for use of sensorimotor footbeddings in sport with an example.

Because of its technical specification, its capacity for interpretation of strains and abnormal strains as well as its craftsmanship in the subsequent conversion into efficient orthopaedic device, orthopaedic shoe technology is an important element in the care and treatment of sportsmen and sportswomen. These properties are also particularly in demand in the treatment of athletes with sensorimotor foot beddings.


1 + 2 The scan of the feet is normal.Only the pressure distribution measure-ment in the dynamics showed the medial increased strain in the heel.

Sensorimotor foot beddings in sport

Right

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PROPRIO® D1-0 D1-0 in connection with talipes planovalgus andslight overpronation

for injury prophylaxistreatment of sports-associated diseasesperformance optimisation

SOME INDICATIONS

slight talipes planovalgus slight pes cavusslight splay footnormal foot

PROPRIO® D1-1 D1-1 in connection with talipes planovalgus and severe overpronation

for injury prophylaxis treatment of sports-associated diseasesperformance optimisation

SOME INDICATIONS

talipes planovalgusfl exed pes cavussplay foot tibial edge syndrome

PROPRIO® D1-6 D1-6 in connection with talipes planovalgus and Achilles tendon symptoms

for injury prophylaxistreatment of sports-associated diseasesperformance optimisationi

SOME INDICATIONS

talipes planovalgusfl exed pes cavussplay foot achillodyniainduration of calf musculature

PROPRIO® D1-7 D1-7 in connection with talipes planovalgus, plantar fasciitis and calcaneal spur

for injury prophylaxistreatment of sports-associated diseasesperformance optimisationi

SOME INDICATIONS

talipes planovalgusfl exed pes cavussplay foot plantar fasciitiscalcaneal spur

PROPRIO® D2-1 D2-1 in connection with supination of step and overpronation


SOME INDICATIONS

pes cavustalipes planovalgussplay foottibial edge syndromepatellar apex syndrometendency to sprains

PROPRIO® D2-2 D2-2 in connection with pes cavus, varus deformity of the heel and gait pattern with severe supination


PRINCIPALI INDICAZIONI

pes cavussplay foot

For athletes of all sport types



PROPRIO®

Foot beddings

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PROPRIO® D2-3 D2-3 in connection with pes cavus, plantar fasciitis, calcaneal spur


SOME INDICATIONS

pes cavussplay footplantar fasciitiscalcaneal spur

PROPRIO® D2-4 D2-4 in connection with pes cavus and Achilles tendon symptoms


SOME INDICATIONS

pes cavussplay foot achillodynia

Activates and boosts thetibial group and stabilises the medial edge of the foot.

The light shell for the calcaneal part of the foot prevents shear forces and gives the athlete a secure feeling in step development.

Boosts the activity of the stapes musculature, strengthens the calcaneal part of the foot and prevents sprains.

The sports-appropriate retrocapital notch relaxes the calf musculature and reduces the traction onto the Achilles tendon.

The sports-appropriate, distinctlylight toe strip improves toe tip contact and gives the athlete a secure feeling.

For athletes of all sport types



PROPRIO®

Foot beddings

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Case study: footballA few weeks ago a professional foot-baller, accompanied by the team’sphysiotherapist, presented in ourcompany. The diagnosis describedwas: Morton’s neuralgia of the rightfoot as well as persistent Achilles ten-don pain on the right.

In football-mad Germany youcould now simply say the player is amember of the wrong club. The fewestfootball players are satisfied with that!

The foot scanning showed no ab-normalities with the exception ofslight splay foot. The subsequentvideo analysis also showed no signi-ficant change, which could be con-cluded from the symptoms reported.

Only the dynamic foot pressurestress measurement (pedography)showed medial increased strain ofthe heel in the „initial contact” on theright as well as increasingly greaterplantar pressure strain of the 2ndand 3rd metatarsal bones in the „ter-minal stance phase” on the right. Inaddition, a significantly intensifiedlowering of the longitudinal arch ofthe foot on exertion by walking be-came identifiable on the right.

The relative instability of the footdue to insufficient muscular com-pensation led to increased tensilestrain of the Achilles tendon as thepossible cause of the achillodynia.

An abnormal splay foot strainwith metatarsalgia and Morton’sneuralgia on the right followed thearch-static changes.

In this case the objective of treat-ment with sensorimotor foot bed-dings was to boost the balance of thestapedius musculature. Here the tibial muscle group in particularshould be stimulated.

In order to reduce further the ten-sile strain in the Achilles tendon, thetone in the triceps surae muscle onthe right should be reduced via pre-tension.

It was necessary to straighten theanterior transverse arch of the footvia retrocapital support and to re-lieve the head of the metatarsal byplantar soft bedding.

As material EVA was used insandwich structure, which has proved successful in many sportstreatments.

For stimulation of the tibial mus-culature the medial pad in the calca-neal part of the foot was placed insuch a way that it forms gentle sup-port of the sustentaculum tali.

The pressure point on the courseof the tibialis posterior muscle to-wards the tendon enthesis led to achange in latency and an increase intone intensity in the tibial musclegroup. (See also Dr. Oliver Ludwig

„Untersuchung zur Änderung dermuskulären Aktivität durch das Tra-gen propriozeptiv wir kender Einla-gen” [„Examination on the change inmuscular activity by wearing insoleswith proprioceptive effect”], OST12/2004).

The lateral pad in the calcanealpart of the foot was only slightly de-veloped.

The improved balance of the sta-pes muscles not only led to a stabili-sation of the longitudinal arch of thefoot, it also supported the raising ofthe heel in the secondary function.The gastrocnemius muscle and so-leus muscle received active support,which leads to the relief of the Achil-les tendon.

A retrocapital support and a toestrip flattening towards the dorsal re-gion were used for pre-tension. Thetension maximum in the tricepssurae muscle provoked early led to atone reduction at the time of exer-tion. The traction force of the Achil-les tendon was reduced.

The retrocapital support was de-veloped with an elevation in the re-gion of the 2nd and 3rd metatarsalbones and thus became a classicalelement of straightening of the trans-verse arch of the foot as well as a sen-sorimotor element of muscle toneregulation.

S P O R T


The fi tness studiofor your feet!

knee

lower leg

femurhip

lumbar spine thoracic spine

cervical spine

Achilles tendon

121276_29_33 07.05.12 10:46 Seite 32

For filtration of the impact forceswith minimal elevation of the heelfor tendon relief in the acute phase,a shock absorber glued to three quar-ters was used.

It was especially important to ad-just the overall design and outline of the insole to the reduced spaceconditions of a football shoe. Thepaddings affecting sensorimotorfunctions had to take into accountthe considerable increased strain ofthe sporting dynamics and in theircourses had to be used on a more re-duced scale than in the treatment ofchildren and adolescents.

The left foot, in identical foot bedconstruction, was provided with clearly reduced padding comparedwith the right foot.

Within a few days a significant re-duction in the Achilles tendon symp-toms and the forefoot strain painscould be achieved. In consultationwith the physiotherapist, at an appointment for a follow-up exami-nation the extent to which the individual components of the senso-rimotor insoles are to be adjusted tothe changing symptoms should bechecked. Stefan Woltring

First published in: Orthopädieschuh-technik (Orthopaedic Footwear Tech-nology) 10/2005 pp. 34 – 35

Contact



Vitaminsfor your feet!

activateknee- stabilising muscle chains

improve pressure distribution under the foot

avoidnumbness

3+4 The sensorimotor foot beddingspecifically takes effect on musclegroups in order to support the longitu-dinal arch, straighten the heel and relieve the Achilles tendon.

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FURTHER QUESTIONS ?Please write to us at [email protected]

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A change of movement assumeschanged muscular activity. Thereforeshould the kinematics of the heal-to-toe movement be changed, then ini-tially precise observation of thefunction of the muscle groups begin-ning at the foot is necessary.

Principles of muscularactivity in the joints of the footTalocrural jointThe tibialis anterior, extensor digito-rum longus and extensor hallucislongus muscles are responsible fordorsal flexion.

The dorsal flexors begin theiractivity in the pre-swing phase inorder to increase the foot/grounddistance (the so-called „clearance”)by flexion of the foot. In this thecourse of muscular activity shows aphasic pattern with a slight reductionin activity in the middle swing phaseand a further increase in the terminalswing phase. Here the foot is positio-ned and by eccentric activity in the initial support phase a „breakthrough movement” of the foot isprevented („heel rocker”).

In the middle support phase theactivity of the dorsal flexors ends

with the transfer of body weight ontothe supporting foot.

Plantar flexion of the foot isbrought about by a total of sevenmuscles, whereby the gastrocnemiusand soleus muscles generate theprincipal share of the torque. The so-leus muscle already begins its activityin the phase of exertion response(“loading response«) followed by thegastrocnemius muscle. Both reachthe most powerful activity in the ter-minal support phase (“terminalstance«), whereby they generate apart of the forward thrust, which isresponsible for the acceleration ofpace.

Talocalcaneonavicular joint(subtalar joint)Because of an oblique axis, the jointpermits a tilting movement of thefoot towards the medial region (ever-sion) and the lateral region (inver-sion). In particular the tibialisposterior, tibialis anterior, flexor digitorum longus, flexor hallucis longus and soleus muscles act as in-vertors (supinators). The activity ofthe tibialis posterior muscle as thestrongest invertor begins directly inthe phase of the exertion responseand runs in a biphasic manner withan activity peak at the end of thephase of the exertion response and inthe middle of the terminal supportphase.

The gastrocnemius, extensor di-gitorum longus, peroneus brevis andperoneus longus muscles take overthe function of the evertors (prona-tors). The latter begin their activitywith the exertion of the forefoot andend this in the pre-swing-phase.

In this study the change in muscular activity of test subjects participating in sporting activities willbe examined within the framework of individual case analyses. In this way evidence of the effecti-veness of the sensorimotor insole concept should be provided. The insoles were produced by OSMStefan Woltring using blanks manufactured by Springer, Berlin, and corrected following kinematicanalysis.

Change in muscular activity by insoles with proprioceptive effect

1. Dr. Oliver Ludwig fitting the sensors for the EMG measurement.

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Movement stabilisation by muscleactivityThe invertors are particularly impor-tant in the phase of initial groundcontact and in the load uptake, whenthe pronation movement in the talo-calcaneonavicular joint has to be slowed down by eccentric muscleactivity. This is primarily the task of the tibialis posterior muscle, al-though it is also the task of the tibialisanterior muscle and the soleus mus-cle. The dual function of the soleusmuscle in inversion and in plantarflexion makes clear that isolated con-templation of individual musclegroups is hardly ever meaningful.

In this study attention was focus-sed on the „muscular stapes” (tibialgroup + peroneal group).

Influencing of muscular activity bysensory informationThe „sensorimotor” insoles used arebased on blanks manufactured bySpringer, Berlin. They consist of athree-layered sandwich constru -ction:– uppermost material layer, 35 shorefor guiding, bedding and support;

– middle material layer, 25 shore forcushioning and shock absorption;

– lowest material layer, 50 shorefor processing of the insole shapeand as support material;

– including one shock absorber inthe heel area(Supersorb, 4 mm, partly glued).

Initially a biomechanical effectcan be attributed to the insoles onthe basis of the applied elements:– medial support of the calcanealpart of the foot on the calcaneumat the sustentaculum tali;

– lateral support of the calcanealpart of the foot as a mechanicalcounter-support to secure the cal-caneum;

– heel hollow for embedding of thecalcaneum;

– retrocapital support of the 2nd to5th metatarsal bones.

– toe strip with distal flatteningcourse for extension of the toes.In addition, in accordance with

the postulated effect concept of sen-sorimotor influencing, the followingproprioceptive/sensory influencesare expected, the effect of which willbe examined in this study:– afference-boosting and stimula-tion of the tibial muscle group bymedial support of the calcanealpart of the foot;

– afference-boosting and stimula-tion of the peroneal muscle groupand the oblique head of the ad-ductor hallucis muscle by lateralsupport of the calcaneal part ofthe foot.

Examination methodFour leg muscles were recorded byelectromyography (tibialis anteriormuscle, peroneus longus muscle, la-teral head of the gastrocnemius mus-

cle, medial head of the gas trocne-mius muscle).

Initially the muscle belly of themuscle to be recorded was palpated;in this the test subject was asked totense the muscle. The recordingpoints were set according to DELAGIET AL. (1989) and ZIPP (1982.) Thetwo electrodes necessary in bipolarrecordings (pregelled Ag/AgCl elect-rodes, manufactured by Nessler me-dical engineering, Innsbruck) werealways placed in the centre on themuscle belly. The distance betweenthe electrodes was approximately 3 cm (two finger-breadths); the elec -trodes were directed towards thecourse of the muscle fibre. An addi-tional electrode was attached to thepatella. The power cables were gui-ded to the dorsal region of the hipand fixed on the skin with Leukosilkplaster. In the region of the hip andknee joint relief loops were formed toprevent tension of the cables andtherefore tactile influencing of thetest subject.

In the hip region the cable bundlewas guided to the 12-lead EMG (ma-nufactured by Mörz, Saarbrücken),which was held by the test controllerbehind the test person walking onthe treadmill.

Data acquisition was carried outwith a scanning rate of 1000 Hz. Thedata was saved on a flash media cardin an electromyography device andtransferred to a PC after the end ofthe test. The electromyographicmeasurement was oriented towardsthe standardised guidelines of DELUCA (1997a, 1997b).

The six test subjects were provi-ded with their own running shoes,whose suitability (movement cor-rection in the region of the talocalca-

2, 3, 4 Foot bedding examples used in the study

Speed Movement correctionWalking (3,0 km/h) without with with

insoles sports insoles sensorimotor insoles

Running (6,5 km/h) without with withinsoles sports insoles sensorimotor insoles

Table 1: test structure for the 6 test subjects. As a rule six partial testswere carried out on each text subject.

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neonavicular joint, stability of thecalcaneal part of the foot, correct fle-xion in the forefoot, cushioningadapted to body weight) was che-cked beforehand. Before the begin-ning of the test the test subjectscould become accustomed to wal-king on the treadmill for five minutes(Woodway medical). As a rule sixsubtests were carried out on eachtest subject (table 1).

Furthermore, in addition to the„sensorimotor” insoles, four of the sixtest subjects were provide with „clas-sical” sports insoles in sandwich de-sign, which had already been worn.

Between the subtests changeswere made between the foot beddingsbelonging to the shoe, the sports in-soles and the „sensorimotor” insoles.The adhesive electrodes were not re-moved between the single subtests inorder to avoid measurement artefactsdue to changes in skin resistance ordifferent placing of electrodes.

Mathematical calculationof the dataThe raw data registered was treatedin accordance with the followingschedule:– filtering of the raw data with ahigh pass filter (base frequency 55 Hz, filter length 31 measure-ments);

– data rectification;– calculation of segment averagesfollowing equalisation with theroot-mean-square method (segment length 50 ms);

– calculation of the segmentaverage value over the duration ofthe supporting phase, averagedover 10 individual steps.

ResultsTable 2 shows an overview of the cor-rection results with the individualtest subjects. A tendency to positiveinfluencing of the muscular activityin the sense of planned muscle acti-vation could be found at least in allcases. In individual cases the changeof the motor programme was veryclearly pronounced and already oc-curred after a few paces.

Movement correction by lateralpressure pointIn cases, in which an increased in-version position of the calcaneal part

of the foot in the phase of the initialcontact was observed (often in com-bination with pes cavus symptoms,Achilles tendon angle < 6°), an in-creased activation of the peronealgroup should be effected on the partof the OST. This was attempted by in-tensified lateral development of theinsole „lateral information”).

There were only a few minutesbetween the two EMG recordings.The effect was reproducible whenthe insoles were changed again.

In one individual case the activityof the peroneus longus muscle waschanged remarkably with wearing ofthe sensorimotor insoles. The testsubject complains of symptoms in

5 Raw EMG of four superfici-ally recorded leg muscles ofone test subject. Left: withsports shoes, without insoles,right: with the same sportsshoes and sen sorimotor inso-les with lateral pressure point.The amplitude of the pero-neus longus muscle changesvisibly (arrows), increases arealso to be observed in the ac-tivity of the lateral head ofthe gastrocnemius.

Table 2: Corrective actions with the individual test subjects, therapeutic approach in insolesupport and measurable change in muscle activities.Key:5 significantly increased muscle activity ( p < 0.05)55 muscle activity highly significantly increased ( p < 0.01)= not significantly changed muscle activity6 significantly reduced muscle activity ( p < 0.05)66 highly significantly reduced muscle activity ( p < 0.01)

without insoles with sensorimotor insoles

Test Pathology Therapeutic Propriceptive Measured muscle activitysubect approach acting

element peroneus tibialis gastro-longus anterior cnemius

calcaneal part of the peroneus lateral infofoot in increased gastrocnemius calcaneal partinversion in initial of the footcontact + loading reinforced toeresponse, pes cavus, stripfrequent spraining

genu varum, calcaneal tibialis medial info caput lat:part of the foot in peroneus calcaneal partincreased pronation of the foot caput med:position in terminal swing/pre-contact

shin bone pain, peroneus medial infoincreased abduction tibialis calcaneal part harmon-+ pronation in the of the foot isation/determinal swing phase crease 2nd

peak

pes cavus peroneus lateral info

tibialis calcaneal part ofthe foot reinforcedtoe strip

severe pes valgus tibialis medial infosevere flat foot calcaneal part of

the foot reinforcedtoe strip

oversupination peroneus lateral info

tibialis calcaneal part of the foot reinforced toe strip

Key:significantly increased muscle activity (p < 0.05)highly significantly increased muscle activity (p < 0.01)

= not significantly changed muscle activity significantly reduced muscle activity (p < 0.05)highly significantly reduced muscle activity (p < 0.01)

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the region of the shin bone; the EMGindicates atypical biphasic activity ofthe peroneus longus muscle, whichgenerated additional everting le-verage in the swing phase, which re-sulted in increased abduction andpronation of the (fore)foot shortlybefore ground contact. This activa-tion pattern was also maintained onwearing sports insoles. With sensori-motor insoles the second activationpeak almost completely disappeared(figure 6).

In one case the effect of the in-creased peroneal activation was alsofound with the sport insole worn (cf.table 2), although more weakly pro-nounced than with the propriocep-tive insoles.

Movement correction by medialpressure pointIn the cases, in which excessively

strong pronation (eversion position)of the calcaneal part of the foot wasto be observed (Achilles tendonangle > 14°), an increased medialpressure point ("medial informa-tion") was inserted into the sole.Table 4 shows the change in muscu-lar activity of the tibialis anteriormuscle as invertor. An increase inactivity due to the sensorimotor in-soles could be observed. In one casethis effect was also found with we-aring of the classical sports insole,although slightly more weakly pro-nounced.

Adaption indications of muscularactivity in the course of timeThe measurable effects of the changein muscular activation pattern couldalready be observed after a few mi-nutes of wearing the sensorimotorinsoles.

Figure 7 shows the raw EMG ap-plication of a test subject directlyafter inserting the sensorimotor in-soles (t=0 s) and after 5 minutes ofwalking in the sole (t=5 min). In theconcrete case the peroneal muscleshould be intensified in its activity bylateral stimulation of the calcanealpart of the foot and the antagonist(tibialis anterior) should be loweredslightly.

This effect was to be observedafter a settling-in period of 5 minu-tes.

DiscussionMethodologyThis study examined relatively fewindividual treatments, therefore astatistical analysis was only possiblein an intraindividual comparison.Because a kinematic analysis of mo-vement patterns and step develop-ment was carried out parallel to themeasurements, an exact conceptionof the desired changes could be car-ried out prior to the insole treatment.Due to the constant feedback of themovement pattern changed by theinsole and the muscular activity, thestructure of the sensorimotor insolescould be corrected again in indivi-dual cases.

There is no doubt that this illus-trates a particularly fortunate case ofinsole adaption, which does notoccur in this way in craftsmanship ineveryday work. However, the desiredinfluencing of muscle activity could

Table 3: Change in the muscular activity of the peroneus longus muscle following attach-ment of a lateral support for the calcaneal part of the foot (»lateral information«) in the in-dividual case (muscle potentials after filtering rectification and RMS information, relativised

Table 4: Change in the muscular activity of the tibialis anterior muscle after following at-tachment of a medial support (»medial information«) in the individual case (muscle potenti-als after filtering’ rectification and RMS information,’ relativised values in brackets).

5 0.101 (100%) 0.140 (139%) 0.146 (144%)

2 0.069 (100%) -- 0.076 (110%)

3 0.088 (100%) 0.088 (100%) = 0.095 (108%)

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we worked out all the more precisely.Nevertheless the craftsman can ob-tain valuable information for the op-timisation of his orthopaedic devicevia kinematic analysis ("treadmillanalysis").

The advantage of a study analy-sing individual cases is that indivi-dual change can be documentedvery precisely.

Individual effects, which are cal-culated out in statistical averaging ofmany test subjects, remain preserved.

The experiences have shown thatin the case of treatment with insoles

with proprioceptive effect, the indi-vidual effects have to be examinedvery precisely because adaption of aplastic motor programme is can notalways be predictable in the indivi-dual case.

Adaption indications of the motorprogrammeSteering of the musculature by thecentral nervous system occurs in thecontext of a neuromuscular pro-gramme. By this we understand thetemporal activation of the involvedmuscles with a defined intensity. This

movement programme is learnedfrom childhood onwards and is va-riable and plastic. In this connectionvariable means the muscular pro-gramme's ability to adapt to actualcircumstances. Thus, for example,the muscular interaction of the legmusculature changes when carryingheavy loads or avoiding obstacles.With this we therefore understandthe short-term change of the motorprogramme for adaptation to envi-ronmental conditions which lastbriefly and occur suddenly.

6 Averaged and rectified activation pattern of the peroneus lon-gus muscle on walking (7.0 km/h) of a test subject with shin pain.Above: sports shoe without insoles. an atypical second activationpeak in the middle and terminal swing phase (arrows) is noticea -ble. Below: EMG under the same conditions, although with senso-rimotor insoles. The horizontal bars mark the support phase.

7. Adaption of muscular activity after inserting a sensorimotor in-sole with increased lateral stimulation. Left: partial graph: muscleactivity (raw EMG) immediately after inserting the insole. Right:partial graph: muscle activity after 5 minutes of walking. Changesare visible in particular in the activation of the peroneus longusmuscle (central line).

without insolesground contact

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On the other hand, plasticity isthe prerequisite for every learningprocess. Related to the process ofwalking this means a longer-termadaptation process, which adapts themotor program to changed conditi-ons. This includes, for example, "pro-tective positions", i.e. changedmovements, which are supposed tolead to the relief of certain joints ormuscle groups.

Sensorimotor information fromthe musculature, the tendons andjoints is necessary for the adaption ofthe individual task-specific movementpattern to current demands and forthe maintenance of learning ability.

Only with the help of this pro-prioceptive information flow can the

central nervous system compare theplanned movement pattern (targetcondition) with the actual movement(actual condition) and introduce cor-rections.

The ability to adapt to insoles,which produce changed propriocep-tive input signals, has to be ascribedto the first case. The changes obser-ved in the EMG tests occurred withinminutes and also disappeared in thisperiod of time when the insoles hadbeen changed. This change of themotor programme can be interpre-ted on the basis of changed afferentinformation. In the concrete case thisincludes not only proprioceptive in-puts from the musculature, the ten-dons and joints, it also includes in

particular changed pressure infor-mation from the corresponding sen-sory cells in the sole of the foot.

Quality of the correctionWith the test subjects examined thechange in the symptom pattern waschecked in the context of a medicaland therapeutic follow-up examina-tion after eight weeks. In all cases animprovement in the symptoms andtherefore a treatment success couldbe established.

ConclusionIn summary it can be recorded thatthe tested “sensorimotor” insoles in-duced a change in motor activationpattern. This change was differentia-

The authorsProf. Dr. Holger Hähnel

(died in 2010) was aspecialist in ortho-paedics and traumasurgery with the additional designa-tions of special or-thopaedic surgery,

special pain therapy, physical the-rapy, rehabilitation, social medicine.

He began his medical career bytraining in visceral and trauma sur-gery. Following his specialist trainingto be an orthopaedist and great ex-perience in orthopaedic surgery hebuilt up the spinal surgery depart-ment in the orthopaedic hospitalCharité in Berlin and, as its directorfor many years, led it to internationalrenown. This department was able toreach the spine via all operative ac-cess routes between the head and sa-crum, from the front and rear, and,by using these access routes, suc-cessfully treat operatively degenera-tive changes, scoliosis,osis, kyphosis,congenital and acquired malformati-ons, fractures, tumours and inflam-mations.

He completed his knowledge andskill during several periods of studywith Dr. Zielke in Bad Wildungen andwith Prof. Dr. Harms in Karlsbad-Langensteinbach. Also with Prof. Dr.

Ch. Hopf, today at Lübeck, at thattime at Mainz, he also learned theirinstrumentation technique. Periodsof study in the USA, Australia, Austriaand Sweden relating to spinal questi-ons also extended his knowledge. InDebrecen/Hungary with Prof. Dr.Krompecher, he studied cartilage andbone metabolism. At that time he re-searched the bisphosphonates usedfor osteoporosis treatment today. Inrecent years his research papers,which number over 200, primarilydealt with the results of spinal surgery.Prof. Hähnel also delivered more than300 lectures on this subject.

The spinal cord running in thevertebral column and the nerve rootsemerging from it are closely con-nected with spinal surgery. Via thisconnection the physiological and pathophysiological (disturbed)function of the nervous system be-came another of Prof. Hähnel's re-search subjects, especially becausehis specific interest in pain therapy ofcourse also deals with the functionalstructures of the nervous system.

His turning towards sensorimo-tor function and his work related toit were the result of this connection.Prof. Hähnel died in January 2010.We are deeply saddened by his earlydeath. In him we have lost a friend,

who was extremely modest about hisown achievements.

Dr. med. Andreas Heine,Born in 1967, spe-cialist in orthopae-dics and traumasurgery with thespecialisms rheu-matology and pae-diatric. He received

training in orthopaedics/rheumato-logy at the Northwest German Rheu-matology Centre in Sendenhorst.Further specialist areas include pae-diatric orthopaedics, sports medi-cine, manual medicine andacupuncture.

Monika KnustBorn in 1979, phy-siotherapist and ma-nual therapist, Bsc.She completed herstudies for Bachelorof Science in physio-therapy in the health

and rehabilitation centre Medicos inOsnabrück.

In 2006 she won first place in theInstitute for Communication’s Sci-ence Award in Bochum. Since 2006she has worked at the health centre»Centrumed« in Osnabrück, specia-

121276_38_45 07.05.12 10:48 Seite 44


ted and reversible and met the pre-dicted effects of the pressure pointshown on the insole. This is an im-portant point because each insole,regardless of construction type, na-turally always induces sensorimotorstimuli. Amongst Others this can beseen from the fact that in individualcases the conventional insoles alsochanged muscular activity – al-though not predictably. However,only if muscular activation changesin such a way, which is desired by thecraftsman, can a treatment conceptbe derived from it.

In the tested cases the activeprinciple of the ‘sensorimotor’ in -soles could be confirmed.

Oliver Ludwig, Norbert Fuhr

First published:Orthopädieschuhtechnik (Orthopaedic Footwear Technology)12/2004pp. 13 – 18


Dr. Oliver Ludwig AG Kid-Check derUniversität des SaarlandesHome-Office:Niederbexbacherstr. 3666539 [email protected]

lising in the field of treatment of cra-niomandibular and craniofacial dys-functions.

Publications:Knust M. Pilotstudie: Manuelle

Therapie versus Physiotherapie beider CMD-Behandlung. Physiothera-pie. 2006; 5:25-28

Knust M. Mögliche Dysfunktio-nen des Kiefergelenks – Darstellungfunktioneller Zusammenhänge undVernetzungen. Physiotherapie. 2007;3:15-22

Knust M. et al. Wirkung von Ma-nueller Therapie im Vergleich zueinem multimodalen Physiothera-pieprogramm beiPatientinnen mitkraniomandibulärer Dysfunktion.physioscience. 2007; 3:1-8

Dr. rer. nat. Oliver LudwigBorn in 1967, humanbiologist, completedhis doctorate in thefield of postural andmovement analysiswithin an interdisci-plinary research pro-

ject of the German ResearchFoundation. He is a lecturer in postu-ral and movement disorders at theUniversity of Saarland and has leadseveral scientific studies in this field.Dr. Ludwig serves as scientific director

of the Kid-Check postural analysesfor children and adolescents.

He is a co-founder of a researchand training academy. In addition tohis university functions, he works asa scientific adviser for a medicalcompany in the field of movementanalysis and obtained special per-mission. His specialist areas of workare paediatric and adolescent, ath-lete and spastic medical supplies.Co-developer of the fisch sport con-cept. Speaker and chairman of manylectures and seminars on the subjectof sensorimotor function in ortho-paedic craftsmanship for doctors,physiotherapists and health insur -ance funds.

Stefan Woltring:Born in 1962, masterorthopaedic shoe-maker, since 1992has managed the tra-ditional family busi-ness in Ibbenbürenand Osnabrück.

Of course an orthopaedic shoetechnician can not and should notcheck the effect of the orthopaedicdevice he supplies by electromyogra-phy - this is unrealistic. On the otherhand, a subtle change in muscle acti-vation cannot always be established

with a kinematic treadmill analysis.Here the measurable angle changesare too slight and the measuring me-thod is too fraught with error. Howe-ver, as in this study the effect ofsensorimotor insoles in individualcases could be proven, viewed withcommon sense, an effect can be ge-neralised if an individual insole isproduced according to this concept.

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powers of innovation with simultane-ously upholding traditional values.Thus our clients not only remain outstandingly successful, they also re-main satisfied partners over decades.

ConceptsIf the basics are right, the idea makesthe fine distinction. In order that or-thopaedic craftsmanship gains moreindependence, can appeal to interes-ting target groups and increase itssales, SPRINGER not only suppliesproducts, it supplies entire trainingand sales concepts for the four futuresegments of individual foot treat-ment - child, athlete, pain suffererand diabetic.

In addition, our company deve-lops and manufactures a large num-ber of customised models accordingto clients’ specifications. Functionalinsoles are manufactured to the highest quality for each treatment


108 years of innovation28 bones, 31 joints, 107 ligamentsand 19 muscles - the healthy foot isour company’s starting point and ourproduct design’s orientation point.Her mann Springer had an idea whenhe founded a production for medicalfoot supports in 1902. However, hisfeet never left the ground on whichhe stood. It was only in this way thatimagination and reliability couldcomplement one other.

Following these virtues the nameSPRINGER stands for the latest me-dical insole concepts today. Our pro-ducts combine the most up-to-datescientific knowledge, innovative de-sign and intelligent technique withour own fascination for consummatemanufacturing.

In this our standpoint is primarilya viewpoint as well. SPRINGERstands for »Made in Germany« inevery respect.

PhilosophyAll insoles, which have born the nameSPRINGER for 108 years, have anactive effect. They support metatarsalbones as well as sustentaculum tali ina scientifically recognised mannerand provide the muscle belly withroom to move. Meanwhile they caneven influence in particular musclereactions according to specific pro-prioceptive principle. We are the mar-ket leader in sensorimotor functionand wish to extend this position.

In addition, its landmark designis developed continuously. For onlythose who change survive. That al-ways did apply and still does apply toSPRINGER as a company and appliesjust as well to SPRINGER products.

Integrated quality awareness andthe will to carry out quality work con-dition our trading on a daily basis.

As a family business in the fifth ge-neration we combine the highest

Portrait of Springer –MADE IN GERMANY

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Hermann Springer1902 - 1946

Frank Springer1968 - 1988

Hans-Joachim Hepper Frank Heppersince 1982 since 2010

1944 - 1968 since 2001Paul Springer Martin Hepper

philosophy – from correcting to sen-sorimotor function.

Craftsmanship has no future wit-hout high tech. Modern recording,analysis and production systemsprovide craftsmanship with marke-ting, quality quality assurance andefficiency. SPRINGER’s exclusivepartnership with go-tec underpinsthe integrated approach.

ManufactureWith our insoles we always also document passion for detail and fas-cination with consummate manu-facturing.

From the craftsmanship traditiona demand results, which is still validtoday: form, function and manu-facture at the highest level as thebasic foundation of each product de-sign.

Craftsmanship skills combinedwith modern methods of manu-facturing – such as CNC milling, forexample as well as a high level ofclose customer relations – all this hasmade SRINGER a concept in the in-dustrial sector and have made ourproducts frequently copied models.

However, only the originals possessthe quality and the benefit whichsustained success brings.

GEBIOM / GO-TECThe company GeBioM Gesellschaftfür Biomechanik Münster mbH wasfounded in 1994 as a spin-off com-pany from the Institute of MotionSciences – Department of AppliedBiomechanics.

In the course of time the businesssectors could be developed extensi-vely. If at the beginning of the enter-prise only a few biomechanicalmeasuring systems for mattressesand car seats were developed andmarketed, i.e. clients from the indus-trial sector, with entry into the healthcare market an expansion of therange of products and servicesbegan: to this was added the deve-lopment and production of furthersystems for recording pressure distri-bution on different extremities andwith most varied applications, opti-cal measuring systems for recordingthe feet and back, user-friendly CADsoftware programs for the con-struction of shoe lasts and orthopae-

Publishing information:

SPRINGER AKTIV AGLengeder Str. 5213407 BerlinGermanyTel.: +49 30 49 000 3 - 0Fax: +49 30 49 000 3 - [email protected] under the number HRB 132603in the commercial register of Charlot-tenburg district courtChairman of the Supervisory Board:Prof. Dr. H.C. Bernhard MotzkusChairman of the Executive Board:Hans-Joachim HepperExecutive Board:Martin HepperFrank Hepper


dic/sensorimotor insoles as well asOEM production of CNC machinesfor the production of the aforemen-tioned insoles. Together with its ownsubsidiary company go-tec GmbHand its partner company SpringerAktiv AG the products are marketedworldwide.

The number of employees couldbe increased from 5 at the beginningof 1994 to on average 28 today.

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OUR PROGRAMME LEVELS

LEVEL

1BEGINNER

LEVEL

2 or

ADVANCED

LEVEL

3 or =

PROF-ESSIONAL

LEVEL

4EXPERT

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sensorimotor function - springer berlin · paediatric orthopaedics proprioceptive insoles are a...

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