Ledbevægelse nr. 3: midttarsalleddet

Posted on 14. dec, 2015 by in Ikke kategoriseret

Indlæg nr. 3 om ledbevægelse: midttarsalleddet.

I dag skriver jeg om Midttarsalleddet. Som ved de tidligere 2 emner starter indlægget med et overblik over den viden, der har været tilgængelig og anset de seneste mange år. I slutningen – ovre på min blog – fortsætter jeg med videnskabelige undersøgelser, der enten underbygger eller kommer med den seneste nye viden, der udvider vores forståelse af midttarsalleddet som et komplekst kombineret led med 2 akser.

Midttarsalleddet.

Midttarsalleddet – også omtalt som det transverse tarsal- og/eller choparts led – består af kombinerede ledforbindelser mellem talus-naviculare og calcaneus-cuboideum. Disse led deler midtfoden både vertikalt og horisontalt og danner en S-formet kurve, når der ses på leddet via et røntgenbillede fra lateralsiden.

Midttarsalleddet fungerer som en enhed, der giver mulighed for treplansbevægelse, der sker omkring 2 tydeligt adskilte akser: en skrå akse og en længdeakse. Selvom der er individuelle forskelle ligger den skrå midttarsalledsakse 52° i forhold til det transverse plan og 57° til det sagitale plan, mens midttarsalleddets længdeakse ligger 15° til det transverse plan og 9° til det sagitale plan.

Beliggenheden af den skrå akse giver mulighed for store grader af bevægelse i det sagitale- og transverse plan (dorsalfleksion/plantarfleksion og adduktion/abduktion) med få grader i det frontale plan (inversion/eversion). Fordi længdeaksen er tæt på det transverse- og sagitale plan, sker der næsten kun ren inversion/eversion her.

Midttarsalleddet kan sammenlignes med et trefacets subtalarled på den måde, at der er en ossøs blokeringsmekanisme, der forbygger overdreven bevægelse. Mens bevægelse imod supination begrænses af bløddelsbegrænsningsmekanismer, stoppes bevægelse mod pronation brat når den superio-proximale kant af den pronerende cuboideum kommer i kontakt med den dorsale (overhængende) kant på calcaneus. Yderligere pronation begrænses af stramninger fra forskellige ligamenter (især lange- og korte plantare ligamenter, springligamentet og ligamentum bifurcatum). Pronation udover dette punkt er ikke muligt uden at overstrække ligamenterne og subluxere calcaneo-cuboideumleddet. Midttarsalleddets låsningsmekanisme er ligesom subtalarleddets låsningsmekanisme et unikt menneskelig t træk, der gør gang på 2 ben mulig.

Lad os se lidt nærmere på de enkelte led i midttarsalleddet:

Talo-naviculareleddet.

Talo-naviculareleddet består af en konveks caput tali, der hviler i den konkave acetabulum navicularis. Talo-naviculareleddet klassificeres ofte som et “ball and socket” led (et frit bevægende led, hvor kuglen på den ene knogle passer ind i en runding på den anden knogle) pga. dets konveks/konkave form, hvilket ikke er akkurat, da caput tali signifikant kan forskydes ud af naviculares acetabulum. Det vil være mere akkurat, at beskrive det som et glideled med en elipsekurve.

Calcaneo-cuboideumleddet.

calcaneo-cuboideumleddet har en relativ flad overflade med en knoglepivot, der peger ud medialt på cuboideum. Pga. det ret flade tallerkenformede ledforbindelse, der bevæges omkring en medial pivotpunkt er calcaneo-cuboideumleddet ofte klassificeret som et glideled, men det er mere korrekt, at beskrive det som et pivot-glideled.

Led mellem naviculare og cuboideum.

I nogle tilfælde har naviculare en lille ledfacet, med en modstående ledflade superiomedialt på cuboideum.

Bevægelse i midttarsalleddet.

Bevægelse i leddet er komplekst. Tilbage i 1886 beskrev Meyer en “horisontal” bevægeakse, der løb næsten på langs af foden, hvorom næsten ren bevægelse i frontalplanet var mulig. Dette er i kontrast til hvad Elftman og Manter beskrev som en akse i det transverse plan (som midtfoden hos en chimpanse) hvor næsten ren bevægelse i sagitalplanet var mulig. I 1941 foretog Manter et studie af præparater (er blevet den mest almindeligt refererede), hvor han fastgjorde calcaneus til en metalstand og placerede stålstave gennem talus. For at vise bevægelse omkring staven, placerede han markører på stavene med forbindelse til glasplader over og under fod-præparaterne. Ved at benytte denne primitive teknik, noterede Manter at talo-naviculareleddet og calcaneo-cuboideumleddet fungerer som en enhed med treplansbevægelse, der sker omkring 2 separate akser: den skrå midttarsalledsakse og midttarsalleddets længdeakse.

Selvom Manters beskrivelse af akser (nævnt tidligere) er blevet bekræftet af senere undersøgelser, foretog Van Langelaan et præparatstudie af bevægelse i talo-naviculare- og calcaneo-cubiodeumleddene og fastslog gennemsnitsaksen for talo-naviculare til at ligge 14,1° til det sagitale plan og 38,5° til det transverse, mens den gennemsnitlige akse for calcaneo-cuboideumleddet ligger 2,7° til det sagitale plan og 51,9° til det transverse plan. Men selvom Van Langelaan studerede de 2 midttarsalled separat, argumenterer Nester et al at trods den større grad af bevægelse, der er mulig i talo-naviculareleddet, så bevæger talo-naviculare og calcaneo-cubiodeumleddene sig som en funktionel enhed, og derfor skal midttarsalleddets akse betegnes som en enkelt akse. For at bestemme denne akse foretog Nester et al en in vivo undersøgelse af 25 individer forsynet med refleksmarkører, som blev fanget af infrarøde kameraer, og fastslog at naviculare og cuboideum bevæges omkring en enkelt akse lokaliseret 29° til det sagitale plan og 37,9° til det transverse plan. Forfatterne fastslog, at fordi de ikke var i stand til at filtrere bevægelse i metatarso-cuneiformeleddene, må den aktuelle lokalitet af enkeltaksen være signifikant tættere på det sagitale plan.

Selvom enkeltaksekonceptet er valid og giver mulighed for yderligere tredimensional undersøgelse, så kan denne model ikke forklare låsning og oplåsning af midttarsalleddet, der sker henholdsvis i tidlig- og sen standfase.

Elftman demonstrerede, at ændringer i talo-naviculare- og calcaneo-cuboideumleddene ændrer lokalitet af deres individuelle akser. Det betyder, at det begrænser bevægelse, når midttarsalleddet er supineret og øger bevægelse, når midttarsalleddet er proneret.

Langdon et al fastslog i et sammenlignende studie af midttarsalledsanatomi hos chimpanser, moderne mennesker og forskellige urfolk, at en evolutionær remodelering af talus har skabt en øget frontal tvist af caput tali (eversion), som gør det muligt at opnå malalignment mellem talo-navicualere- og calcaneo-cuboideumakserne, når mediale længdebue løftes. Forfatterne noterede at hos chimpanser ligger talus´ hals tæt på det transverse plan og dets vinkel forbliver stort set uændret, uanset om midttarsalleddet er supineret eller proneret. Denne næsten horisontale vinkel hindrer låsning af midtfoden og giver mulighed for stor bevægelse i sagitalplanet (især dorsalfleksion) og fører til ustabilitet. Det menneskelige caput tali er everteret ca. 38°, som gør låsning og oplåsning af leddet muligt, mens akserne for talo-naviculare og calcaneo-cuboideum skifter.

Uanset bevægeaksernes lokalisation, så vil talus´ hals glide inferiort langs sustentaculum tali, når caput tali bevæges ud af acetabulum på naviculare. Bevægelse stoppes af stramning af senen fra m. tibialis posterior (der har sin stærkeste tilhæftning på tuberositas navicularis) og især også af springligamentet, som er et tæt og stærkt ligament mellem sustentaculum tali og distalt på calcaneus, der dækker hele plantare aspekt af naviculare. Springligamentet samles medialt med ligamentum deltoideum og lateralt med ligamentum bifurcatum (nederste del). Netter refererer til en fibrøs bruskagtig plade inde i springligamentet, der beskytter caput tali. Fordi springligamentet kun har få elastiske fibre, foreslår Davis, at det kaldes for slyngeligamentet, da det fungerer som en slynge, der stabiliserer den droppende caput tali.

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