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F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 99 Gait analysis is the best way to identify overpronation. It is not enough to look at how someone stands; they should be evaluated during movement. Often gait analysis is performed on a treadmill where the foot mechanics can be observed, usually by a physical therapist or sports orthopedist who has experience and equipment for this evaluation. Sometimes the wear pattern on the client's shoes provides evidence (wear on the medial side of the sole can indicate overpronation), but this is not always reliable, especially if the shoes are relatively new. ADDITIONAL ASSESSMENT STRATEGIES The visual observations described earlier are usually performed with the client in a standing position. It is relatively easy to see the overall potential for a broad pelvis, increased Q angle, and genu valgum. There are other factors that may be picked up during a more specific visual examination that could be indicative of alignment problems or structural dysfunction. For example, when looking over the foot and lower extremities, blisters, calluses, or bunions may indicate postural or biomechanical disorders in the foot and ankle complex. In particular, calluses near the head of the first metatarsal or the presence of a bunion are frequently associated with overpronation. Calcaneal valgus may also occur along with overpronation. This is an alignment disorder in which the distal calcaneus deviates in a lateral direction. In genu valgum, the knees are not aligned straight, but are more medial, which puts more weight on the medial side of the foot. Greater weight on the medial side of the foot forces the distal calcaneus to deviate laterally. Femoral anteversion is often evident because of the squinting patella. Yet, the functional result of femoral anteversion, squinting patella, or genu valgum is dysfunctional patellar tracking. In addition, in some cases the vastus lateralis pulls the patella in a lateral direction. A simple physical examination can be performed to evaluate for excessive soft-tissue pulling that is contributing to patellofemoral dysfunction. With the client supine, gently grasp the sides of the patella by placing your thumb on one side and your index finger on the other. Attempt to move the patella from side to side. Ideally, it should be able to move close to half its width to each side. Often, if there is excessive tightness of the vastus lateralis and a lateral tracking disorder, the patella will easily move in a lateral direction but won't easily move in a medial direction because the lateral tissues are holding it too tightly. Roughening or degeneration of the cartilage (chondromalacia) on the underside of the patella may also result from dysfunctional patellofemoral mechanics. This is often perceptible as crepitus or a grinding sensation during flexion and extension movements of the knee. To evaluate for this, have your client sit on the edge of the treatment table with the leg dropped toward the floor. Place your palm gently on the surface of the patella and instruct the client to slowly move the leg through flexion and extension while you maintain contact with the patella. If you feel grinding or grating sensations during movement, this could be indicative of cartilage damage associated with a tracking disorder. Numerous soft-tissue disorders can result from the entire cascade of MMS, but more often from just a few contributing conditions. In the next article, we will explore common treatment options for these various components, and the role of massage. It's very likely you have clients who have at least some of these disorders, and they will benefit greatly from your enhanced understanding of lower extremity biomechanics and knowledge of the treatment options. NOTES 1. D. Kaya and M. N. Doral, "Is There Any Relationship Between Q-angle and Lower Extremity Malalignment?" Acta Orthopaedica et Traumatologica Turcica 46, no. 6 (2012): 416–9. 2. P. Rodrigues et al., "Evaluating the Coupling Between Foot Pronation and Tibial Internal Rotation Continuously Using Vector Coding," Journal of Applied Biomechanics 31, no. 2 (April 2015): 88–94. Learn about Whitney Lowe's innovative, engaging, and interactive instructional designs. Lowe's texts and courses have benefited professionals and schools for more than 25 years. For more information, visit www.academyofclinicalmassage.com. CLINICAL APPS The distal femur angles medially while the distal tibia angles laterally in genu valgum. Image created from 3D4Medical's Essential Anatomy 5 application. 5