#296 ‒ 足部健康：预防和治疗常见损伤、增强力量与灵活性、挑选鞋履等 | Courtney Conley, D.C.

我们顺便澄清一下，虽然很多人应该都知道，但当我们说肌腱时，指的是肌肉连接到骨头的部分。

We should just also clarify, I'm sure many people know this, but when we are referring to tendons, we're talking about the attachments of muscles to bones.

之前我们提到过韧带，那是骨头和骨头之间的连接结构。

Earlier we referred to ligaments, which are the attachments between bones.

对，就是这样。

Correct.

这样大家就清楚了。

So folks understand that.

大家都熟悉的跟腱，明显是个特别粗大的肌腱。

And the Achilles tendon, which everybody is familiar with is obviously a massive tendon.

我是说，以前见过跟腱断裂或撕裂时的样子，那真叫一个大。

I mean, I've seen the size of these things when they're injured, when they're severed.

我不确定它在全身肌腱里排第几，但肯定算最大的那几个之一。

I don't know where it ranks in tendon size for the body, but it is certainly one of the largest I would have to believe.

我特别喜欢聊跟腱这事儿。

I love talking about the Achilles tendon.

这太漂亮了。

It's beautiful.

你看，腓肠肌和比目鱼肌是互相缠绕的。

I mean, you have the gastroc and the soleus, they twist on each other.

它能形成非常强壮的肌腱。

It can become a very robust tendon.

实际上，比目鱼肌贡献的纤维比腓肠肌还要多。

And the soleus actually makes up larger fibers of the Achilles tendon than the gastroc.

比目鱼肌可是力量担当。

The soleus is a powerhouse.

再说回负荷问题，走路时是体重的四倍，一跑起来，这数字直接翻倍。

But getting back to that load, when we're walking four times, when you start running, those numbers double.

你脚弓内部，也就是跟舟骨区域，跑步时承受的力能达到体重的11倍。

So the inside of the arch, so the calcaneonavicular area, experiences loads of up to 11 times your body weight when you're running.

这力量简直吓人。

I mean, it's massive.

但最厉害的是，我们的脚天生就是为了应对这种压力设计的。

But here's the very cool thing is our foot was designed to handle it.

我的意思是，脚里的骨头、肌肉、肌腱，全都是为扛住这种负荷而生的。

I mean, we have all bone structure, muscle, tendon that was designed to handle that load.

问题是，你要是不用它，它就会退化。

The problem is is if you don't use it, you will lose it.

这挺有意思的。

It's interesting.

你说大部分足部损伤都发生在前脚掌，对吧？

You said that the majority of foot injuries are gonna occur in the forefoot.

按我算的，前脚掌那儿大概有十五块骨头左右？

Now by my math, there's about what, 15 in the forefoot?

前脚掌的骨头可多了。

Lots of bones in the forefoot.

对。

Yeah.

跖骨、趾骨、远节趾骨、近节趾骨。

Metatarsals, phalanx, distal phalanx, proximal phalanx.

哦，就是远端和近端那块儿。

Ah, distal and proximal there.

对。

Yeah.

明白了。

Okay.

除了大脚趾以外。

Except for the big toe.

是的。

Yeah.

好。

Okay.

发力时冲击力能达到体重的八倍。

Eight times our body weight at propulsion.

脚掌在蹬地时必须非常稳定，因为它承受的负荷太大了。

The forefoot has to be incredibly stable at push off because it handles so much load.

比如走路时，脚掌最常见的损伤就是所谓的跖痛症或者应力性骨折。

So when we're walking, for example, one of the most common injuries at the forefoot will be a generic diagnosis of metatarsalgia or stress fractures.

通常来说，第二和第三根跖骨最容易出现跖痛。

So two and three typically will be your metatarsalgia area.

而第一根是大脚趾。

And one being the big toe.

第一根是大脚趾，第五根是小脚趾。

One is the big Five

小脚趾嘛。

being the pinky toe.

是的。

Yeah.

咱们马上就能说到这个最常出问题的家伙了。

We'll get to that favorite guy right there.

三和四这两根脚趾骨，特别容易出现应力性骨折。

Three and four, typically your where you'll see a lot of stress fractures.

你给大伙儿解释一下，什么叫应力性骨折。

Tell people what a stress fracture is.

应力性骨折呢，一般就两种原因引起的。

A stress fracture basically can be caused by two different things.

一种是拉力，一种是压力。

Tensile strain or compressive loading.

就是骨头承受的力太大了，身体扛不住，组织就开始发炎，打个比方这么说。

It's when you have force going through the bone and the system just can't handle it, so it starts to irritate the tissue, if you will.

看脚的时候，从康复角度特别重要的一点是——骨折长在哪儿，基本就能判断是哪种应力性骨折。

When you look at the foot, and I think this is important from a rehab perspective, is depending upon where the fracture is, you'll know what type of stress fracture it is.

比如，有些人脚跟落地特别重，脚板硬邦邦的，活动性差，这种人就容易在跟骨上出现应力性骨折。

So for example, if you have patients that are hitting their heel very hot and heavy, so they might have a rigid foot, they might have one that doesn't have good mobility, and they hit the heel heavy, they can get a stress fracture in the calcaneus.

第五跖骨也是应力性骨折的高发区，因为那儿扛不住这种压缩力。

The fifth metatarsal, also very common location for these compressive loading stress fractures, because they can't handle that compression.

但另一边的脚，你还记得我们说过舟骨吗？

But on the other side of the foot, remember we talked about the navicular?

这个骨头理论上根本不该着地。

That guy technically should never hit the ground.

它可是内侧足弓的最高点，可还是会出应力性骨折。

It's the highest part of the medial arch, but he can get a stress fracture.

你可能会想：既然应力性骨折是压缩引起的，那这怎么说得通？

So you're saying to yourself, well, how is that possible if they're caused by compressive loading?

不是这个原因。

Not that guy.

这个是拉力造成的。

He's caused by tensile strain.

当脚内翻、旋转时，你身体扛不住这种动作，肌腱就会一直拉扯，舟骨那儿就慢慢出现应力反应，最后发展成应力性骨折。

When you can't handle the foot pronating and rotating and you can't handle the movement of the foot, the tendon will start to tug and you'll start to get that strain at the navicular stress reaction leading to stress fracture.

这真有意思。

So interesting.

我们总以为骨头特别能承受压力。

We think about bones as having this great capacity for contractile force.

对吧？

Right?

平时我们觉得骨骼主要承受的是轴向压力，其实它们承受的拉力也大得惊人。

So axial loading, we don't think of them as requiring as much tensile force, but of course, they're under tremendous tensile force

没错。

Oh, yeah.

相反的情况也是。

In the opposite.

我们总觉得骨骼就是用来扛压的。

We think of our skeleton as needed to support compressive load.

但实际上它们得同时应付这两种力，这其实挺了不起的。

But of course, they have to do both, which actually is a pretty remarkable material.

比如混凝土，就只扛压，不抗拉。

Like concrete, for example, is only strong under compression.

它在拉力下太弱了。

It's so weak under tension.

我想我以前在播客里提过一次，没有钢筋，混凝土根本没用。

I think I mentioned this once before in the podcast, without rebar concrete would be useless.

但我们的骨头却得同时应付这两种力。

Yet our bones have to do both.

所以你的意思是，你可以说——当然别太简单化——侧向损伤往往是受压造成的，而内侧损伤更可能是拉力导致的？

So you're saying that you can tell, I mean, not to oversimplify, but lateral injuries are likely to be more compressive, medial injuries might be more likely to be tensile.

再说一遍，我不确定这到底有多重要，除了它能解释受伤的原因之外。

And again, I don't know that that matters necessarily other than it explains what caused the injury.

对。

Yes.

而且这还关系到治疗方式。

But also with treatment.

因为你看那些受压型的应力性骨折，比如脚后跟、第五跖骨，就得用软垫来缓冲。

Because when you look at compressive loaded stress fractures, so at the heel, at the fifth metatarsal, you have to cushion those.

首先，让组织好好恢复。

Obviously, let the tissue heal.

但这个人可能需要一点能缓冲的东西。

But that person might need something that's gonna give a little bit.

舟骨、跖骨、籽骨这些应力性骨折，是因为拉力不稳才发生的，打个石膏没用，关键得后续做康复，强化足部力量——不是他们落地太重，而是控制不了动作。

The navicular stress fractures, the metatarsal stress fractures, the sesamoid stress fractures, because they happened due to an instability to a tensile strain, you can boot them, but your follow-up with them better be rehabbing the strength of their foot because it's not that they landed too heavy.

是因为他们没法稳定住脚部的运动。

It's because they couldn't control their motion.

所以像籽骨受伤的人就是这样。

That's why people with sesamoid injuries, for example.

籽骨就是大脚趾底下那两块小骨头。

So the sesamoids are the two little bones under the big toe.

它们跟膝盖骨有点像。

They're, similar to the patella.

籽骨嘛，我记得是指那种完全被肌腱包着的骨头。

Sesamoid refers to, if I recall, a bone that is completely surrounded by tendon.

对。

Yes.

就像一个小关节囊。

It's like a little joint capsule.

没错。

Yep.

骨头完全没露出来。

Nothing is exposed of the bone.

它完全被肌腱包在里面。

It's completely embedded within the tendons.

是这样吧？

Correct?

是的。

Yes.

对。

Yep.

一旦出现那种应力性骨折，疼得可真够呛。

When you get those stress fractures there, they can be extremely painful.

很多人会干脆不用大脚趾了，这点我们待会儿再聊。

And people stop using the big toe, which I'm sure we'll talk about.

但如果要让脚完全休息，这些人得连续穿三个月的康复靴。

But if you offload it, these people will be in boots for three months.

然后他们会说：骨头长好了，可以恢复正常活动了。

And they'll say, okay, the bones healed, go back activity.

哪有那么简单。

It doesn't work like that.

因为就算骨头长好了，肌肉反而更弱了。

Because even though the bone is healed, the muscles are now even weaker.

你之前那块地方的力量全丢了，更容易再次受伤。

You are more susceptible to the injury because you've lost whatever strength you once had there.

是的。

Yeah.

那最初是怎么发生的呢？

How did it happen in the first place?

对。

Okay.

咱们也聊聊脚部的肌肉吧，毕竟脚是个肌肉非常发达的结构。

So let's talk a little bit about the muscles in the foot as well because it is a very muscular structure.

我们平时不太这么想，因为一看就能看到骨头，好像皮肤底下就剩骨头了。

We don't think of it that way because we look at it and we can sort of see the bones through the skin.

但尤其是脚底，肌肉结构特别复杂，而且和小腿的情况息息相关。

But especially on the bottom, the musculature is incredibly complicated and it is really related to what's happening in the lower leg as well.

没错。

Oh yeah.

说到脚部肌肉，我觉得可以分内在肌和外在肌来说。

Well I think when we talk about muscles of the foot, we can talk about intrinsic muscles versus extrinsic.

内在肌呢，就是长在脚里面的那些肌肉。

So intrinsic muscles, they live in the foot.

它们起止都在脚上。

They start and they end in the foot.

那儿有四层肌肉。

We have four layers of muscles there.

简直难以置信。

It's just unbelievable.

确实如此。

It is.

我觉得脚特别妙的地方在于，你直接看就能看出来。

And I think the beautiful thing about the foot is you can look at the foot.

它是身体上唯一一个你能一眼看出不对劲的地方。

It's the only place in the body where you can look at it and say, something is going awry here.

比如长了拇囊炎、锤状趾、裁缝拇囊炎，你一看脚就知道：这不对劲，不该是这样。

Because you'll form things like bunions and hammer toes and tailor's bunions, and you'll be able to look at your foot and go, this isn't the way it's supposed to look.

也许我该重视一下了。

Maybe I should pay attention to it.

膝盖或髋关节可没这么直观，不拍X光根本看不出来。

You can't do that in a knee or hip unless you take an X-ray.

当你能亲手摸到那些还柔软的足部畸形时，就会立刻想到是肌肉失衡导致的。

And when you can get your hands on a foot where you start to see these deformities and they're flexible, you really think about it from a muscular imbalance.

那咱们就来看看足部的一些内在肌肉吧。

So if we wanted to look at some of the intrinsic muscles of the foot.

先说最大的一块儿——拇展肌。

So if we were to start with the big one, abductor hallucis.

它沿着大脚趾长着，主要负责把大脚趾拉直。

So he sits along the big toe and he's responsible for straightening the big toe.

我觉得咱们讲的时候，最好顺带提一下，每个医学生都得搞清楚内收肌和外展肌的区别。

And I think the other thing that will be helpful when we go through this is every medical student and whatnot has to learn what an adductor versus an abductor is.

而且这些名字里本来就藏着线索，我们一直记着：外展肌就是往外拉的。

And since they're always embedded within the names of the muscles, we always remember this as abductors abduct.

它们的作用就是把东西往外推开。

They take things away.

就像有人被劫持一样，其实是往身体外侧拉。

Like a person's being abducted, they pull away from the body, basically.

对。

Yes.

内收肌则是把东西往身体中间拉。

Adductor pulls back towards the body.

这么说的话，大家应该更容易记住这些术语了。

So with that said, hopefully, people will have an easier time remembering some of these terms.

我们来看前脚掌这里。

So we have our forefoot here.

这是大脚趾。

Here's the big toe.

所以拇展肌的作用就是伸直大脚趾。

So abductor hallucis is going to straighten the big toe.

另外还有一个

There's also a

还有中间的那块肌肉。

muscle to the middle.

把它往内拉，没错。

Pulls it towards Yep.

这个肌肉叫

The

有个叫内收拇趾肌的。

There's an adductor Hallises.

形状有点像倒过来的7。

It's kind of like a backwards seven.

当这些肌肉失衡时，比如你穿了某种鞋子——这个我们待会儿再说——会把脚趾挤在一起。

So when these guys get out of balance, for example, if I'm in a shoe, which we'll talk about later, that's going to squeeze my toes together.

比如芭蕾舞鞋。

Such as your ballet shoes.

对。

Yes.

或者大多数正装鞋。

Or most dress shoes.

对。

Yep.

我现在内收肌缩短了，而外展肌呢，

I have a d ductor now that's shortened, and I have a b ductor

它被拉长了。

It's lengthened.

被拉长了。

Is lengthened.

所以脚部开始失衡，接着就会看到脚部出现变化。

So you start to get this imbalance at the foot, and then you start to see changes in the foot.

拇外翻其实是脚部不稳导致的。

Bunions are a result of an instability in the foot.

是的。

Yeah.

那到底什么是拇外翻呢？

What exactly is a bunion?

谁都知道这玩意儿。

Everybody's heard of them.

很多人都有。

A lot of people have them.

这其实是横向的不稳，不是在你看到拇外翻的那个地方。

It's a transverse instability, not where you see the bunion.

在这儿。

Here.

就是第一跖骨和内侧楔骨交界的地方，当脚没法控制运动时就会出问题。

At the metatarsal medial cuneiform when someone can't control motion at the foot.

差不多就是中足和前足的连接处。

Sort of the junction between the midfoot and the forefoot.

对。

Correct.

然后就会开始出现这种不稳。

Then they will start to have this instability.

顺便说一句，拇外翻其实就是这块骨头往外偏移了。

All a bunion is, by the way, is this bone basically shifting to the outside.

是的。

Yeah.

所以但凡见过的人，都会注意到，当你俯视一个人的脚时，会看到脚最宽的地方突然鼓出一大块。

So anybody who's seen it, what you notice is you're looking down at a person's foot and you'll see this huge outpouching in what's otherwise the widest part of the foot.

看起来整只脚突然变宽了，还往外凸出来。

Looks like it just got a whole bunch wider and it's pointing out.

但要是看骨骼结构，就很容易明白为什么会这样了。

But when you see the skeleton, it's much easier to understand why that's happening.

对。

Yeah.

就是这块骨头往这边移了。

So it's this guy going that way.

很多人会去做手术来矫正这个问题。

A lot of people have these surgically repaired.

那手术具体是怎么做的呢？

What are they doing surgically to repair that?

这个话题我们可以聊上很久。

We could talk about this for a long time.

先说几个关于这些手术的基本事实。

Just some facts first with those surgeries.

很多手术其实效果并不好。

A lot of them are not successful.

手术确实有它的适用情况，但我要提醒你，别轻易为了脚上的不适就去做手术。

There is a time and a place, but I would be very cautious about getting foot surgeries for symptoms.

他们通常会把突出的骨头磨掉一部分，再把脚趾重新对齐。

So what they'll do is they can either shave part of the bone down and then realign the toe.

很多时候还会用钢钉把跖骨和楔骨固定住，来解决大多数人那里不稳的问题。

And oftentimes they will pin the metatarsal to the cuneiform so they stabilize where most people have that instability.

一旦你用钉子固定住，确实能改善脚型的对齐。

Once you start pinning things together, you might take care of alignment.

但你根本没去强化那些让脚变形的肌肉。

But you've done nothing to strengthen the muscle that allowed this to Correct.

去吧。

Get

那儿。

there.

我妈妈有拇外翻，我奶奶也有，可我的反应是：人出生的时候可不会有拇外翻。

The conversation of my mom has a bunion, my grandma has a bunion, and my response to that is you don't come out of the womb with a bunion.

你可能会遗传到韧带松弛，或者关节活动度过大这类问题。

You might inherit connective tissue laxity, for example, or there might be, hypermobility issues.

但如果我们知道这一点，就像之前说的那些孩子，越早干预越好，给他们穿对的鞋子。

But if we know that, just like we talked about with the kids earlier, the earlier interventions, you get them in the right footwear.

确保鞋子的脚趾部分够宽，能让脚趾自然舒展，尤其是当你妈妈就有拇外翻的时候。

You make sure they're in shoes, right, that have a toe box where the toes can actually splay, especially if you know that your mother has a bunion.

我觉得大脚趾特别有意思，你看它的甲床，有些长鸡眼的人，甲床会变得平平的，看起来像是往内收了。

I think what's fascinating about the big toe is if you look at your nail bed, some people that have bunions, the nail bed will be flat, and it'll just look like it's adducting.

这就是鸡眼的位置。

Here's the bunion.

哦，我懂你意思了。

Oh, I see what you mean.

对。

Yep.

但甲床确实是平的。

But the nail bed is flat.

看到这种情况，通常都是鞋子造成的。

When you see that, it's typically from footwear.

如果你看到甲床明显旋转了——有些人就是这样，甲床往里歪，看起来像是有旋转的问题。

When you see the nail bed and it's actually rotated because you see some of those people, right, where the nail bed's kind of turned in and there's a it looks like it's a rotational issue.

是的。

Yeah.

你知道吗，他们真的没法控制脚趾的旋转，这挺有意思的，现在你就明白了。

You know for certain they can't control rotation, which is cool because now you're like, okay.

我之所以开始研究这些，是因为我两只脚都有拇外翻，就是因为长期穿足尖鞋。

One of the reasons I got into all of this was I have bilateral bunions on both of my feet due to the fact that I was constantly in pointe shoes.

后来我解决的办法就是开始用矫形器固定双脚，因为太疼了。

And then my solution to that was I'm just gonna start bracing my feet because they hurt.

结果脚部肌肉反而越来越弱。

So they just got weaker and weaker.

然后我就觉得，这不对劲。

And then I was like, this is not right.

所以我们开始做强化训练，换上合适的鞋子，情况完全不一样了。

So we started strengthening them, getting us in the right shoes, and it's a different ballgame.

说到常见的足部问题，那锤状趾是什么情况？

And what's a hammer toe while we're at the topic of common pathology?

拇外翻，太常见了。

So bunion, very common.

锤状趾就是脚趾头往下砸地面。

Hammer toes are basically when the toes start to hammer the ground.

都是第二到第五脚趾吗？

All of them are just two through five?

对，第二到第五脚趾。

Two through five.

大脚趾也会这样，但没那么常见。

The big toe can hammer.

因为大脚趾出现这种情况比较少。

It's just not as common as two through five.

原因就在这儿。

This is why.

你看锤状趾，这是我的脚背这边。

When you look at hammer toes so this would be the top of my foot.

我们有伸肌，有短伸肌，也有长伸肌。

We have extensors, short toe extensors, but we also have long toe extensors.

所以脚背上，短趾伸肌在拼命工作，而长趾伸肌却没什么动静。

So on the top of the foot, the short toe extensors are doing a lot of work and the long toe extensors are not.

是的。

Yeah.

这事儿吧，如果你光听我们说，真的很难搞明白。

This is one of those things where if you're listening to us, this is very difficult to understand.

所以你看图跟着理解，就特别合理了。

It's why watching what you're saying makes a lot of sense.

再强调一下，让大家清楚点：伸肌是往回拉，屈肌才是往前弯。

And again, just so folks understand, the extensors would be pulling back, the flexors would curl forward.

那为啥会有人说，锤状趾居然跟这个伸肌有关？听起来完全反直觉啊。

And so it seems counterintuitive to say how can a hammer toe be in part driven by this extensor phenomenon?

其实啊，要是短伸肌绷得紧，长伸肌又松着，从外观上看，就特别像脚趾过度弯曲。

Well, if the short extensors, the ones that attach with a shorter moment arm are fired up and the long ones are relaxed, it actually looks like a hyperflexion.

对。

Yes.

如果脚底疼，尤其是跖骨区域，你可以把鞋垫拿出来看看，要是第二或第三跖骨底下磨损特别严重，那说明你走路时那里承受的压力太大了。

And for people who have pain along the bottom of their foot, so along their metatarsals, If you take out your insert of your shoe and you see a lot of wear underneath the second or third metatarsal, you know you're probably walking around with too much pressure going through there.

所以脚底的情况正好相反。

So on the bottom of the foot, it's the exact opposite.

我的短屈肌根本没在工作，反而是长屈肌在拼命发力。

I have my short flexors that aren't doing anything and my long flexors who are.

锤状趾本质上是脚部肌肉失衡造成的，根源在于脚部力量不足。

So hammer toes is a muscle imbalance due to a weakness in the foot.

那你觉得这个问题的根源在哪里？

And what do you attribute the root of that to?

拇外翻可能跟遗传有关，我们先不谈这些，单从环境因素来看——如果穿太窄的鞋把大脚趾往里挤是诱发拇外翻的原因，那最常导致锤状趾的环境因素又是什么？

If the bunion seems predisposed, not putting aside genetics and other things like that, but just environmentally, if the predisposing feature of a bunion is shoes that are pushing the big toe in, what is the environmental trigger that is most commonly driving a hammer toe?

我觉得是同一个原因。

I think it's the same thing.

我们太久没好好关注自己的脚了。

I think that we have not been paying attention to our feet for a very long period of time.

如果你戴着连指手套一走就是二十年，那你的手功能退化了也不该觉得奇怪。

And if you were to walk around with your hands in mittens for twenty years, you shouldn't be surprised when your hands don't function.

脚的情况其实和身体其他部位是一样的道理。

It's the same concept at the foot really than it is everywhere else in the body.

我觉得我们根本就没怎么在意过脚。

I think we just don't think

连指手套都算不上。

even mittens.

对吧？

Right?

你仔细想想，小时候戴连指手套，手指其实还是能动的。

If you really think about it, for most people, if you think back to being a kid, like you could still move your fingers in mittens.

真正限制手指活动的，是那种完全包死的连指手套。

It's actually mittens that don't allow you to move your fingers.

这才是更贴切的比喻。

That's the better analogy.

而且啊，如果你每天十二个小时都处在这种情况里，那肯定特别别扭。

And yeah, if you were to spend twelve hours a day in that situation, it would be obviously cumbersome.

那咱们再回头聊聊足部的内在肌肉。

So let's go back to the intrinsic musculature of the foot.

我知道等咱们到健身房的时候，还会更深入地讲足部的内在和外在稳定肌群。

I know we're gonna talk more about intrinsic and extrinsic foot stabilizers when we get into the gym.

有几块关键的肌肉。

There's a couple key muscles.

我觉得每一块都挺重要的，但咱们没时间一一细说。

I think they're all key, but we don't have time to go into all of them.

不过它们对足部功能影响特别大。

But that are responsible for a lot of our foot function.

比如，屈肌短肌就是我特别喜欢的一块。

So for example, flexor digitorum brevis is one of my favorites.

这块肌肉从脚跟出发，一直连到脚趾的指骨上。

So this guy runs from the heel and inserts up into the phalanx, so into the toes.

这块肌肉挺大的。

It's a big muscle.

它和足底筋膜是平行走向的。

It runs parallel to the plantar fascia.

走路时，它负责减缓脚趾伸展的速度。

He's responsible for decelerating toe extension when we walk.

记住，关键是控制动作，别让它们太快。

Remember, it's all about slowing things down.

我们得把这动作稳住。

We wanna control it.

如果这块肌肉力量不够，它就没办法分担足底筋膜的压力。

If I don't have good strength of that muscle, he shares load, if you will, with the plantar fascia.

所以，足底筋膜炎患者最常见的问题之一，就是这块叫屈肌的肌肉太弱。

So one of the biggest predictors for patients that have plantar fasciitis, so this would be an acute plantar fascial pain, is a weakness of flexor digitorum revus.

现在治疗足底筋膜炎的方案，大多只教人拉小腿，我不是说拉伸不好，但你也不能忽略脚部本身的肌力和稳定性。

When you look at treatment protocols on how to get people better with plantar fasciitis, it's like stretching their calves, and I'm not saying that's bad, but you also have to look at the strength and the stability at the foot.

而且它可是个关键角色。

And he is a very big player.

在足部稳定和减速足内翻方面特别重要。

Very big player in the stability of the foot and decelerating pronation.

你刚提到了足底筋膜炎。

You just referred to plantar fasciitis.

我们刚才还聊过这个。

We talked about it a second ago.

很多听众肯定都懂这个病。

It's clearly something many people listening will understand.

他们大概也能体会到，脚弓那里特别疼。

They will also probably have a ballpark sense of what it feels like and how there's a real tenderness in the arch.

但你能说说，足底筋膜具体是由哪些解剖结构组成的吗？

But can you explain the anatomic structures that make up the plantar fascia?

足底筋膜起自跟骨，一直延伸到前脚掌的深层横跖韧带。

So the plantar fascia is going to start at the calcaneus, and it's going to insert into the deep transverse metatarsal ligament up at the forefoot.

顺便说一句，足底筋膜在足部稳定性上起着关键作用。

The plantar fascia has a very key role, by the way, instability of the foot.

我来解释一下什么叫‘拉杆机制’。

I'm gonna explain something called a tie bar mechanism.

足部的拉杆机制是这样的——我觉得它特别妙，因为我们得好好利用它：有一条韧带横跨在跖骨之间。

So the tie bar mechanism of the foot is this, I like to call free because we need to take advantage of it, where we have a ligament that runs across the metatarsals.

当我们走路、脚掌进入中足承重阶段时，压力全压上来，足弓开始变平变宽，前脚掌也散开，这时候就会刺激到那条深横跖骨韧带里的感受器。

When our foot, when we're walking and we go into midfoot loading, so when all the pressure comes and our arch starts to flatten and widen, when the forefoot splays, it triggers receptors in that deep transverse metatarsal ligament.

而足底筋膜正是附着在这条韧带上的。

The plantar fascia inserts into that ligament.

所以它就像个‘T’字形。

So it's kind of like this T.

当脚掌散开时，就会激活这个机制，同时提供横向和纵向的稳定性。

So when the foot splays, it triggers this mechanism of horizontal stability as well as vertical stability.

因为足底筋膜在前脚掌这边，现在就像个三角形，一边被横向拉伸，一边又被纵向拉长。

Because the plantar fascia, like a triangle at the forefoot now begins to spread under tension while it's also being elongated vertically.

就像一把扇子一样。

It's like a fan.

所以脚掌展开的妙处就在于，它是个天然的机制，悄悄提醒你的大脑：嘿，你马上就要蹬地了。

So that's the beautiful thing about forefoot splay, is it's this free mechanism that's basically telling our brains, hey, you're about to push off.

你得赶紧发力，还得稳住，因为马上要承受八倍于你体重的冲击力。

You better get real strong and you better get real stable because we're about to take on eight times your body weight.

这真让我兴奋。

Gets me excited.

要是没了脚掌展开，那些感受器就哑火了——因为你再也感受不到深层横跖骨韧带的拉扯，也触发不了植物筋膜的反应。

You take that away, you take away forefoot splay, you can forget about the receptors talking to you because you're not getting the tug on them from the deep transverse metatarsal ligament, the splay, and you're also not signaling the plantar fascia.

那什么会妨碍这个过程呢？

What would oppose that?

脚上得施加多大的压力，比如穿太窄的鞋子，才会让脚掌没法充分展开，从而影响植物筋膜的激活？

How much compression needs to be on the foot, presumably in the form of a narrow shoe, that would prevent sufficient splaying to activate the plantar fascia in that regard?

已经有数据了。

There's numbers out there.

你说的是三到五毫米。

You say three to five millimeters.

我不是指望大家真去量这个。

You know, I don't expect people to get out and start measuring this.

但你可以这么看：把鞋里的原装鞋垫拿出来，把脚放上去，然后站上去，如果你的前脚掌撑开了

But a good way to look at this is if you were to take out the factory insert of your shoe and you place your foot on it and then stand on top of the factory insert, if your forefoot expands

比鞋垫还宽

over Wider than the insert

比鞋垫还宽

Wider than the insert

那就说明鞋太窄了。

It's too narrow.

那你的脚趾肯定被挤着了。

You can be pretty certain that those toes are getting squeezed.

这招真管用。

That's a great rule of thumb.

我敢打赌，我好多鞋都过不了这个测试。

I would bet that many of my shoes don't pass that test.

要说穿时尚鞋的话，稍微挤一点可能还能忍，但要是运动鞋，跑步、负重行军或者干重活的时候，那绝对不能接受。

Is it safe to say that it might be tolerable if it's a fashion shoe you're wearing, but you certainly wouldn't want that in an athletic shoe where you're running or rucking or doing something under load.

我的意思是

I mean

你肯定会说，这种鞋根本就不能穿。

You would argue never be in a shoe of that nature.

但是

But

我女儿12岁，她老跟我说：妈妈，为啥你非让我穿鸭嘴兽鞋啊？

My daughter is 12, so she always tells me, mom, why do you make me wear platypus shoes?

别人都穿耐克，就我穿这个。

Everybody else gets to wear Nikes.

我懂。

I get it.

但没错，我的意思是，我们能越多地让脚保持它本来该有的状态，对我们就越有好处。

But, yes, I mean, the more time we can spend allowing our foot to be in a position where it can function like it's supposed to, the better off we're gonna be.

不过说真的，考特尼，这事儿挺有意思的——虽然不是什么阴谋论，但鞋业里确实没什么东西是朝着这个方向去的。

It's very interesting though, Courtney, because, I mean, this is not conspiratorial, but there's clearly nothing in the shoe industry that is aligned with that.

我的意思是，鞋子一般都不会做得这么宽，对吧？

I mean, shoes are not typically designed to have that degree of width, are they?

对。

No.

确实不会。

They're not.

有意思的是，耐克最近刚推出了一款婴儿鞋。

And what's interesting, Nike just came out with a baby shoe.

就是几个月前的事。

This is a couple months ago.

他们在介绍这款鞋的时候说：我们做了充分的研究。

And in their report of the shoe, they said, we've done the research.

这双鞋能帮助孩子足部正常发育。

This shoe will help your child's development of their foot.

你说的婴儿鞋，是多大孩子的？

When you say baby shoe, what age?

学步期的孩子。

Toddler.

刚学会走路的时候。

First start walking.

明白了。

Okay.

但从理论上讲，你可能会说，他们根本没必要穿鞋，对吧？

Technically, you would argue maybe they shouldn't be in shoes at all though.

对吧？

Right?

没错。

Right.

就是那个年龄段。

At that age.

我的意思是，要是他们已经在走路了，其实没必要穿鞋。

I mean, they don't need to be if they're walking.

他们大部分时间走路又不在户外，不过也行吧。

Most of their walking is not outdoors, but okay.

文章里说，我们做了研究，设计出这种鞋，鞋头宽、鞋底薄又柔软，就是为了让孩子的脚能发挥它本来的功能。

In the article, they said, we've done the research, and we've created a shoe that has a wide toe box, a flexible thin sole, because we want your child's foot to do what it was designed to do.

我坐在那儿心想：对啊。

And I'm sitting there going, yes.

可问题是，为什么呢？

Like, but why

那为什么不能把这个理念延续到成年呢？

Why why would you not carry that through to adulthood?

没错。

Exactly.

但他们现在开始意识到这一点了。

But they're starting to realize it.

从鞋子的角度来看，说到底，我们都想要一双穿起来舒服的鞋。

And I think when you look at research from a shoe perspective, at the end of the day, we want something comfortable on our feet.

我觉得，只要我给我的每个病人换上能让脚趾自然舒展的鞋，他们都会说：这双鞋真的更舒服。

And I would argue that every single one of my patients, once I simply put them in a shoe that allows their toes to splay, they will always say, it feels more comfortable.

你再想想平衡这个问题。

And you think about it from balance.

这样穿，我们能站得更稳吗？

Are we gonna balance better like this?

那样穿，反而能站得更稳？

Are you gonna balance better like that?

这根本不用费劲说服人。

It's just not a hard sell.

那足底筋膜炎呢。

So plantar fasciitis.

这当然指的是足底筋膜发炎。

It is, of course, refers to inflammation of the plantar fascia.

最常见的原因有哪些？

What are the most common causes of it?

急性期你一般怎么处理？

And how do you think about treating it in the acute sense?

比如有人第一次来看病，症状刚出现，你怎么办？

So somebody shows up for the first time and they've got it.

你该怎么判断可能的其他病因？康复时又怎么设计方案，防止以后再复发？

What are your thoughts on the differential diagnosis for what led to it and how do you go about rehabbing it with an eye towards preventing it in the future?

首先得确认是不是这毛病。

First you have to make sure that's what it is.

脚后跟疼的原因可不止这一个。

There's a differential diagnosis of heel pain.

比如得先排除跟骨应力性骨折之类的可能。

I mean you have to rule out calcaneal stress fractures for example.

还有巴克斯特神经病变。

There's Baxter's neuropathy.

很多人一上网搜，立马就觉得自己得了足底筋膜炎。

So people will have Googled and they'll just immediately say I have plantar fasciitis.

所以最重要的是，你得先确认这确实就是病因。

So first and foremost, you just have to be certain that's what it is.

这主要靠临床判断。

And it's a clinical diagnosis.

没有哪项影像检查能直接确诊。

It's not like you've got an imaging study that confirms it.

就像你说的，得先把其他可能性排除掉。

You have to sort of exclude other things as you said.

对。

Yeah.

而且你还能看到足底筋膜增厚。

And you can see a thickening of the plantar fascia.

好的。

Okay.

不过这种情况很少见，我猜。

Although rarely I assume that's done.

对吧？

Correct?

没错。

You're Yes.

一般不会为了这个就让人去做核磁共振。

Not likely gonna put somebody in an MRI for that.

对。

No.

关于影像检查，我们后面再详细聊。

And we'll talk about imaging later with all that.

但‘足底筋膜炎’和‘足底筋膜病变’或者叫‘筋膜变性’，其实是两回事。

But there's a difference between an it is, plantar fasciitis, and plantar fasciopathy or fasciosis, I should say.

大多数人来我诊所的时候，已经不在急性期了。

By the time most people get into my office, it's no longer in an acute stage.

因为急性期指的是最初的受伤阶段。

Because in an acute stage, this is your initial injury.

所以治疗方法就完全不同了。

So it is treated very differently.

矫形器在急性损伤初期通常很有帮助，因为它能减轻负荷。

Orthotics often can help in those initial stages of an acute injury because you are offloading.

我再跟大家解释一下啊，抱歉我刚才思路有点跳，不过这块的解剖结构实在太复杂了，我觉得结合病理来讲会更容易讲明白。

Let's just explain to people again, I'm sorry I'm all over the place, but the anatomy here is so complicated that I think it helps to talk about pathology to explain it.

矫形鞋垫能快速见效，是因为它能防止足弓完全塌陷。

The reason an orthotic can be acutely helpful is because it prevents the full collapse of the arch.

这样就能减轻足底筋膜受到的拉扯力。

Therefore it takes some of the stretch off the plantar fascia.

是这个原理吧？

Is that why?

是的。

Yeah.

说到矫形鞋垫具体是怎么起作用的，目前还没定论。

And when you talk about what exactly an orthotic does, the jury's still out on that.

但我们知道，它跟力的分布有关。

But we know it has something to do with force.

当脚开始放松时，它其实是在调节受力。

So when the foot starts to unlock, it's a load modifier.

矫形鞋垫就是个受力调节器。

An orthotic is a load modifier.

它会改变脚后跟承受的力道。

So it's going to modify the load that's occurring at the heel.

所以在急性期，这确实很有效。

So in an acute situation, that's great.

但要是我每碰到一个二十年前为足底筋膜炎配的鞋垫就赚一毛钱，我早就是百万富翁了。

But if I had a penny for every time one of my patients came in with their orthotics that they got twenty years ago for their plantar fasciitis, I mean, I'd be a rich woman.

因为他们会说，这东西急性期确实管用，但研究显示，最多撑两周到一年，之后就得撤了。

Because they're like, well, it helped acutely, but research will say two weeks and at the most up to a year, and then it's time to get out of those things.

得有个退出计划才行。

There has to be an exit strategy.

在规划退出的同时，你得练脚部力量。

And while you're planning this exit strategy, you need to be strengthening the foot.

得练像趾短屈肌这样的肌肉，分担跖筋膜的压力。

You have to be strengthening things like flexor digitorum brevis to be able to share the load with the plantar fascia.

急性期的处理方式完全不一样。

So in an acute setting, they're treated very differently.

如果是长期脚跟疼，那就是退化性的，是反复受压造成的。

When it's more of a chronic heel pain, this is degenerative, this is repetitive load.

人一直踩在承受不了压力的脚上，组织自然就垮了。

They've been walking around on a foot that can't handle load, then the tissue starts to break down.

这种情况下，对我来说，关键就是力量、负荷，而不是减负。

And in those cases, for me, it is all strength, it's load, it's not deload.

哪怕只是一段时间吗？

Even for a period of time?

我是不太会走这条路的。

I mean, I tend not to go that route.

我们会好好聊聊。

And we have conversations.

这背后其实有很多知识要讲清楚。

I mean, there's a lot of education that goes behind this.

伊琳·戴维斯，你知道的，她现在

Irene Davis, who I know you know, she's

我之前请过伊琳做客播客。

I've had Irene on the podcast.

对，没错。

Yeah.

她和萨拉·里奇目前正在研究慢性脚跟痛患者的案例。

Her and Sarah Ridge are looking at research right now where they're looking at patients with chronic heel pain.

所以他们在研究慢性足底筋膜炎患者穿极简鞋后的情况，看看会有什么变化。

So chronic plantar fasciitis at implementing minimal footwear in getting these patients and seeing what happens with them.

你可以把足底筋膜看作是跟腱的延伸部分。

If you think of the plantar fascia as a connection to the Achilles tendon

应该是连着的吧？

And it is connected, I assume.

对。

Yes.

没错。

Yep.

跟骨就像是夹在足底筋膜和跟腱之间的一个缓冲垫。

The calcaneus, think of it like floats in between the plantar fascia and the Achilles tendon.

我们知道肌腱需要负荷刺激。

We know that tendons need load.

从足底筋膜的角度来看，也是一样的道理。

So think about that from the plantar fascia perspective.

你得给它施加负荷。

You have to load it.

只有让组织承受负荷，它才会变强。

You have to load the tissue in order for the tissue to get stronger.

如果组织没被切断，那负荷对修复也有必要吗？

And is the load also necessary to heal the tissue, assuming it's not cut?

是的。

Yeah.

我的意思是，要是我们聊到肌腱的负荷问题，谁得了肌腱病都知道，不能光休息。

I mean, if we wanted to jump into loading with tendons, it's not that anybody who's had a tendinopathy.

我们一直说，对肌腱来说，光休息没用。

We always say rest is not good for tendons.

也不是说休息不好。

It's not that rest is bad.

你去问问得了跟腱肌腱病的人，要是休息一周，他们准说：嘿，感觉好多了。

You talk to anybody who's had an Achilles tendinopathy, if they rest for a week, they're like, yeah, feels great.

问题是，如果他们还没给肌腱施加负荷就急着回归运动或走路，肯定会立刻回到原点。

The problem is that when they go to return to sport or they go to return to walk without having loaded the tendon, they're gonna be right back where they started from.

所以我们说肌腱负荷，其实是一种机械转导过程。

So when we talk about loading the tendons, it's a mechanotransduction.

当我给肌腱施加负荷时，筋膜就会发生滑动。

So when I load a tendon, there's a fascial gliding that occurs.

这种机械刺激会转化成化学信号。

So this mechanical stimulus that then gets converted to a chemical stimulus.

然后我们才能看到肌腱开始愈合。

And then we start to see tendon healing.

从这个角度看，它和骨骼非常相似。

So in that sense it's very similar to bones.

对。

Yeah.

我们在播客里聊过很多次，强化骨骼最关键的就是让骨头承受力。

I mean, we've talked a lot about this on the podcast where the most important thing for strengthening bones is force on the bone.

所以力量训练和摔跤，你可能想不到，其实是增强骨密度最好的两种运动。

And that's why weight training and grappling, believe it or not, are the two best exercises for bone density.

因为它们给骨头带来的压力最大，既有压缩力，也有拉伸力。

Because they put the most stress on the bone, both compressive and tensile.

骨头里的机械感受器感知到形变后，会利用雌激素作为化学信号，来促进骨组织生成。

And the mechanoreceptors in the bones, which sense the deformation, use estrogen as the chemical signal to signal bone building.

难怪雌激素在这里可以说是最重要的激素。

So of course why estrogen is arguably the most important hormone here.

道理其实是一样的。

So it's the same thing.

听起来，肌腱里可能用的是不同的化学传导机制，但也是靠机械形变来触发化学信号，促进组织修复。

It sounds like in tendons, presumably different chemical transduction systems, but it's mechanical deformation signals a chemical to build.

对。

Yeah.

肌腱里有肌腱细胞，它们就生活在肌腱纤维束里。

There's the tenocytes that kind of live within the fascicles of the tendon.

你刚说的完全对。

Exactly what you just said.

这种机械滑动会剪切细胞，引发化学信号，然后肌腱就开始发生变化，我觉得特别有意思。

This mechanical gliding kind of shears the cells, you get a chemical stimulus, and then you start to get the changes within the tendon, which I think is really fascinating.

那我们回到那个来看病的人。

So let's go back to the person who shows up.

你已经排除了其他可能性，确诊确实是足底筋膜炎。

So you've excluded other things, you've diagnosed them with indeed plantar fasciitis.

那对于年轻人、活跃的年轻人来说，最常见的原因是什么？

What are the most typical reasons for that presentation in, let's start within a young person, a young active person?

脚部力量不足肯定是原因之一。

Weakness to the foot for certain.

你说的‘力量不足’，具体是哪些肌肉？最典型的是哪几块？

And when you say weakness, specifically within which muscles, which are the prime examples of the muscular jersey?

他们来的时候，我总会用一个脚趾测力计。

So when they come in, I'll always I have a toe dynamometer.

就是这个小装置。

So it's this little device.

你今天带了吗？

Did you bring it today?

带了。

I did.

好。

Okay.

太好了。

Good.

我一直想试试这个东西。

I've always wanted to try one

这种的。

of these.

对。

Yes.

我不太好意思知道我到底怎么样，但咱们看看吧。

I'm embarrassed to find out where I stack up, but we'll see.

这玩意儿测的是你脚趾的力量。

It tests the strength of your toes.

就是一个小装置。

So it's a little device.

把一张卡片放在大脚趾底下，然后让病人用大脚趾往下压卡片。

You put a card underneath your big toe, and I'll have the patient press their big toe into the card.

你的大脚趾应该能产生相当于体重10%的力。

You should be able to produce 10% of your body weight through your big toe.

这叫拇长屈肌。

That's flexor hallucis longus.

要是卡片放在二到五趾底下，你应该能产生大约7%到8%体重的力。

When you put the card underneath two through five, you should be able to produce about seven to 8% of your body weight.

当他们用脚趾往下压的时候，有几点要注意。

When they're pressing their toes down, there's a couple rules.

他们不能抬脚跟，也不能用脚趾使劲抠地。

They can't lift up their heel, and they can't hammer the toes.

还记得我们之前说过的那种抠地现象吗？

Remember we talked about that hammering?

有些人就是喜欢用脚趾抠地，这是因为脚部力量不足，身体在补偿。

That's when you'll see people who love to hammer their toes because it's a compensation for weakness in the foot.

他们走路就是这个样子。

So that's how they walk.

就像用脚趾抓着地往前爬一样。

It's like I'm clawing my way forward.

所以他们一这么做，就必须把脚趾死死压在地上。

So when they do that, they have to press their toes down.

做大脚趾测试时，伸肌腱那部分，另外四个脚趾是该离地，还是只要不抠地、贴着地就行？

When you do the big toe, the extensor hallucis longus, are toes two through five, do they need to be off the ground or are they on the ground just not hammered?

贴着地。

On the ground.

脚掌贴地，但别扣脚趾，稍微用点力，大概10%就行。

On the ground, not hammered, but you're pressing down 10%.

话说回来，你了解我的，考特尼。

And by the way, you know me, Courtney.

我可太喜欢量化数据了。

I love metrics.

对吧？

Right?

因为只有量化的，才能管得好。

Because what gets measured gets managed.

这东西普通人能自己练，还是得买专门的设备？

Is this something anybody can go out and do, or you can buy these?

哦，不用。

Oh, no.

你可以直接买。

You can buy them.

我觉得另一个适合在家自己测的简单方法是我有个小激光扫描仪。

I think the other thing that's also easy to measure for if someone's gonna do it at home is I have a little laser scanning device.

我今天也带了这个，你站近墙边，测一下肚脐到墙的距离。

I also brought this today, where you would stand close to a wall, and you'd measure from your umbilicus to the wall.

然后身体保持挺直。

Then you keep your body straight.

让髋部和肩膀成一条直线，尽量往前靠向墙壁。

So your hips and shoulders are straight, and you lean into the wall as far as you can.

能让你不至于撞到脸的，其实是脚趾的力量。

It's your toe strength that stops you from smacking your face into the wall.

这个距离应该要达到4.5英寸以上。

That distance should be 4.5 inches or more.

明白了。

Got it.

换句话说，咱们其实可以算个三角函数，但简单说就是，你得能抵抗住某个角度下产生的力矩。

So in other words, we could do the trigonometry on that, but basically there's an angle at which you're creating a moment arm that you need to be able to resist.

对。

Correct.

这叫前倾极限范围。

It's called the anterior fall envelope.

厉害。

Cool.

我们今天会逐一测试这些动作

We'll test all these on

给你做。

you today.

天哪。

Oh, boy.

但真的特别有意思。

But it's really fascinating.

对吧？

Right?

顺便说一句，脚趾无力是我们老了以后跌倒的最重要预测因素。

Toe weakness, by the way, is the single biggest predictor of falls when we age.

真的吗？

Really?

这简直太棒了。

So this is really cool.

你以为跌倒都是因为蹦蹦跳跳，其实不然，就在这儿——

When you think about falling, it typically occurs we're jumping all over the place, by the way, here.

真正的问题在于起步的那一刻。

It's the initiation of gait.

如果我没有那个向前的平衡控制，脚趾又没力气，那我就停不下来。

So if I don't have that anterior falling elope, if my toes are weak, I'm gonna keep going.

所以脚趾无力不光可能预示足底筋膜炎这类问题，更被凯伦·默克尔等研究者证实，是预测跌倒最有效的指标之一，这意义可太大了。

And so not only can toe weakness be a predictor of things like plantar fasciitis, fasciitis, but also toe weakness can be and is researched by Karen Merkel, one of the single best predictors of falling, which is, I mean, massive.

是的。

Yeah.

我的意思是，咱们待会儿花几分钟聊聊这个，毕竟听这个播客的人，谁都不陌生跌倒预防的重要性。

I mean, I think we should spend a few minutes on that in a moment because obviously people who listen to this podcast are no strangers to the importance of fall prevention.

我们以前谈这个，通常都是从骨密度和肌肉量的角度切入。

We have talked about it typically through the lens of bone density and muscle mass.

骨密度低、肌肉量少，一旦跌倒后果会更严重。

So low bone density, low muscle mass lead to more catastrophic outcomes during falls.

当然，肌肉量本身也是预防跌倒的关键，但这里说的是一种特别的肌肉群。

Obviously the muscle mass is also a great way to help prevent falling, this is a very specific muscle mass.

要是有运动习惯的人或者活跃的人来找你，你诊断出问题是力量不足，那原因就明确了。

So athletic person shows up or active person shows up, you've diagnosed the problem, you have a culpable reason for it in weakness.

你刚才已经暗示了，你大概不会建议他们休息。

You've already alluded to the fact which says, look, I'm probably not going to rest you.

那你怎么决定是先用临时矫形器，还是直接上训练，不靠辅助工具？

What drives you towards temporary orthotic versus no orthotic and just get right to work.

我以前得足底筋膜炎的时候，从来就没用过矫形鞋垫。

So when I've had plantar fasciitis, we've never done an orthotic.

我这一辈子大概发过两次吧。

I've probably had two bouts of it in my life.

就是稍微减少点运动量，再做点手法治疗，冰敷一下，多练练脚部动作。

It's just been a bit of backing off some of the volume, some manual therapy, ice and more footwork.

你一般怎么处理？

What's your typical strategy?

这得因人而异。

It's very individual specific.

你得根据患者的实际状况来定方案。

You definitely have to meet the patient where they are.

他平时活动量大不大？

What is their activity level?

他愿意配合做哪些事？

What are they willing to do?

他多大年纪？

What age are they?