Brian R. Mulligan Positional Fault Fact or...

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Positional FaultFact or Fiction?

Dr W.A. Hing

Horizon@AUT Musculoskeletal Diagnostic Imaging Unit

Brian R. Mulligan Brian R. Mulligan

Evolution of Evolution of OrthopaedicOrthopaedicManual TherapyManual Therapy

Evolution of Evolution of OrthopaedicOrthopaedicManual TherapyManual Therapy

MWMs …MWMs …

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Manual Therapy ConceptsManual Therapy Concepts

Explanations for treatment success ?Explanations for treatment success ?

In the relatively short history of the field of In the relatively short history of the field of manual therapy, there are many examples manual therapy, there are many examples

Neuromuscular models & Neuromuscular models & ‘Joint’ dysfunction models‘Joint’ dysfunction models

•• “trigger point / “trigger point / myofascialmyofascial release”release” TravellTravell•• “Strain/ “Strain/ CounterstrainCounterstrain” ” JonesJones•• “central sensitization”“central sensitization” Woolf 91Woolf 91

•• ““trackingtracking problems”problems” McConnellMcConnell

•• “displaced instantaneous axis of rotation”“displaced instantaneous axis of rotation” WhiteWhite--SahrmannSahrmann

•• ““pseudomyostaticpseudomyostatic contractures”contractures” Cummings 85Cummings 85

•• “Obstruction/ restriction”“Obstruction/ restriction” –– CyriaxCyriax

•• intervertebralintervertebral disc derangement phenomenon disc derangement phenomenon –– McKenzieMcKenzie

•• vertebral vertebral subluxationsubluxation theory theory -- PalmerPalmer

‘Hard working’ ‘Hard working’ VicenzinoVicenzino (Toby Hall 2009)(Toby Hall 2009)

NeurophysiologicalNeurophysiological

and / or and / or

BiomechanicalBiomechanical

Vicenzino 2nd May 2009

VicenzinoVicenzino Chicago 2009Chicago 2009

BiomechanicalBiomechanicalBiomechanicalBiomechanical

Vicenzino 2nd May 2009

Positional fault hypothesis ??Positional fault hypothesis ??

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Positional fault hypothesisPositional fault hypothesis

Matty & Pippi 2006

Mulligan’s TheoryMulligan’s Theory

•• Positional fault theory Positional fault theory Mulligan 95Mulligan 95

–– Joint alignment alteration due to injury or chronic/poor Joint alignment alteration due to injury or chronic/poor arthokinematicsarthokinematics

–– Inconsistent bony congruencies that occur after strain or Inconsistent bony congruencies that occur after strain or injuryinjury

–– Minor / subtle: Neither palpable nor evident on imaging?Minor / subtle: Neither palpable nor evident on imaging?–– Movement restrictions Movement restrictions -- pain resultspain results–– Responsible for movement restricted and painful jointsResponsible for movement restricted and painful joints

Positional fault hypothesisPositional fault hypothesis

MWM relocates joint in correct alignmentMWM relocates joint in correct alignment

Therefore immediate improvements in painTherefore immediate improvements in painTherefore immediate improvements in pain Therefore immediate improvements in pain and ROMand ROM

Mulligan’s explanation … is it that simple?Mulligan’s explanation … is it that simple?

Positional fault hypothesisPositional fault hypothesisPFH PFH -- EvidenceEvidence

Clinical success warrants its use Clinical success warrants its use (Mulligan)(Mulligan)

Mulligan encouraged others in the field toMulligan encouraged others in the field toMulligan encouraged others in the field to Mulligan encouraged others in the field to investigate its meritinvestigate its merit

Adequate in substantiating the PFH?Adequate in substantiating the PFH?

Evidence Based Medicine ?Evidence Based Medicine ?Positional fault hypothesisPositional fault hypothesisPFH PFH -- EvidenceEvidence

Clinical efficacy of MWMs underpinned by reasonable level of evidence (as Bill mentions!)

Less evidence to support the presence of positional faults

Is there evidence that practitioners are able to detect positional faults in their clinics with current level of technology?

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Investigation of PFInvestigation of PF

To date the direct MWM research has focused on the inferior tibiofibular joint

The proposal that the fibular exhibits an anterior (or posterior) positional fault

Investigation of PFInvestigation of PF

Fibular position Fibular position –– ankle sprain, chronic ankle ankle sprain, chronic ankle instabilityinstabilityFirstFirst metacarpophalangealmetacarpophalangeal jointjointFirst First metacarpophalangealmetacarpophalangeal jointjointPatellofemoralPatellofemoral jointjointSacroiliac jointSacroiliac jointCervical spineCervical spineGleonohumeralGleonohumeral jointjoint

Articles MRI CAT scans Force plates Fluoroscopy Cadaver dissections

? other

Hsieh et al. (2002) √

Kavanagh (1999) √

Eren et al. (2003) √

Hubbard et al. (2006) √

Articles grouped by mode –method of measuring positional fault

Hubbard and Hertel (2008) √

Berkowitz and Kim (2004) √ √

McDermott et al. (2004) √ √

Folk (2001) Pain and ROM

Ho & Hsu (2008) √

Scranton et al. (2000) √

MRI – magnetic resonance imaging; CT = computed tomography; AMI = axial malleolar index

Investigation of PFInvestigation of PFankle sprain / fibulaankle sprain / fibula

Position of fibula in relation to tibia following ankle sprain

Anterior and caudal displacement of fibula relative to tibia (Mulligan)

PF maintained due to swelling and adhesions (Hetherington 1996)


Berkowitz & Kim 2004

Histogram demonstrating bimodal distribution of AMI values in instability and control groups.

AMI values in patients with ankle instability cluster around 20◦. AMI values in control subjects cluster around 10◦

Berkowitz & Kim 2004

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Posteriorly positioned fibulaPatient with ankle sprain

Normal subject

Eren et al 2003


Anteriorly positioned fibula

Ant Injured 14mmFib

Tib

Hubbard et al 2006

Post

vsNormal 16mm

As Bill mentioned 2-4mm difference & reliable method

Thus injured more anterior


• Differences in methodology of measuring fibular position

• Axial malleolar index – false impression of posterior fault due to variation of position of talus

versus• Relationship of fibula to tibia • Recommendation: fibula postion should be

described in relation to tibia(Hubbard 2008)

Range of posterior glide (potentiometers)17 Normal, 6 acute sprains, 2 chronic instab

a significantly greater amount of movement g y gper unit force occurred in the patients with acutely sprained ankles (P= 0.01%, P= 0.09 %).

These results lend support to the hypothesis that a positional fault occurs at the inferior tibiofibular joint in ankle sprain patients.

Kavanagh 1999

Mavi 2002


• Support for positional fault of fibula

• Versus Posteriorly positioned fibula (Eren 2003, Berkowitz 2004)Berkowitz 2004)

• Inconsistent with Mulligan‘s PFH

versus

• Anteriorly positioned fibula (Kavanagh 1999, Mavi 2002, Hubbard 2006) Further supported Hubbard et al 2008

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Investigation of the position of the fibula in relation to the tibia by using fluoroscopy, CAT and MRI in patients with sub-acute ankle sprain and chronic ankle instability is available

There are discrepancies in the findings: •anteriorly positioned fibula•posteriorly positioned fibula •no positional fault

These discrepancies appear to be largely due to the method of measurement use?

i.e., the studies reporting an anteriorly positioned fibula h i th i d fl d d thhave in the main used fluoroscopy and measured the distance between the anterior edge of the lateral malleolus and the anterior edge of the tibia from a lateral view

whereas the studies reporting mixed or no positional displacement of the fibula used CAT and MRI derived indices of fibular position

Investigation of PFInvestigation of PFPatellofemoral pain syndromePatellofemoral pain syndrome

The concept of mal-tracking or lateral displacement of the patella, which is arguably an example of a positional fault, appears to have become widely accepted clinically as a factor in patellofemoral pain syndrome

MethodsRadiographMRIClinical measure


a) Lateral patellar displacement (LPD)b) Patello-femoral congruence ) gangle (PFCA)c) Lateral patellofemoral angle (LPFA)

Crossley et al 2000


Patella ‘positional fault’ considered when

- PFCA > +58 mm- LPFA = 18 mm- LPD = 1 mm

Crossley et al 2000


LPD quantifies position of patella in the frontal plane relative to the medial femoral condyle

(Ingersoll and Knight 1991)

Subjects with PFPS had 2mm more LPD than healthy controls (Macintyre, 2007)

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Clinical measureClinical measure

Herrington 2008


Clinical measure

Herrington 2008

Investigation of PFInvestigation of PFPatellofemoralPatellofemoral pain syndromepain syndrome

• Influence of:- Patellar width?- Tibiofemoral rotation angle?

… on contact area between patella and femur

accounts 46% of variance on contact area

• Patella contact area appears to be an interesting area for future research, particularly with respect to the Mulligan concept, as the Mulligan technique used to manage PFPS attempts to change tibiofemoral rotation rather patella alignment directly.

(Salsich et al 2007)

Investigation of PFInvestigation of PF1st MCP joint1st MCP joint

Positional fault of 4 deg pronation 1st MCP

Hsieh et al 2002

Investigation of PFInvestigation of PFsacroiliac joint dysfunctionsacroiliac joint dysfunction

Hungerford et al 2004

The ShoulderThe Shoulder

Measurement Measurement with ultrasoundwith ultrasound

Posterior view Posterior view Anterior viewAnterior viewSuperior viewSuperior view

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Alternative imaging views in the Alternative imaging views in the literatureliterature

Assessment of PA / AP translation Assessment of PA / AP translation Posterior view Posterior view –– humerushumerus and posterior and posterior glenoidglenoidAnterior viewAnterior view greatergreater tuberositytuberosity and anteriorand anteriorAnterior viewAnterior view–– greater greater tuberositytuberosity and anterior and anterior glenoidglenoid

Assessment of inferior translationAssessment of inferior translationSuperior view Superior view –– acromiohumeralacromiohumeral distancedistance

Posterior viewLandmarks:Dorsal glenoid rimDorsal edge of humerus

Jerosch et al 1991

Affected vs non-affected arm (patients with anterior instability)

Posterior viewAnterior translation significantly higher on affected side in subjects with anterior instability versus control (p<0 0001)

Jerosch et al 1991

Significant side differences: dominant vs non-dominant arm (healthy)

(p<0.0001)

Posterior viewPosterior viewassessment of glenohumeral assessment of glenohumeral laxitylaxity

Borsa et al 2005

Anterior translation Posterior translation

Posterior viewPosterior viewanterior translation of humerusanterior translation of humerus

posterior humeral head

Borsa et al 2005

Baseline; no force 15 dN anteriorly directed force

flat segment of scapula

posterior humeral head

posterior glenoid

y-axis: distance of humeral head from x-axis

Posterior view Posterior view ––assessing assessing glenohumeralglenohumeral laxitylaxity

position of the humeral head in relation to the position of the humeral head in relation to the glenoidglenoid

Flat segment of scapula

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Conclusion Posterior viewConclusion Posterior view

Literature shows that dynamic ultrasound is Literature shows that dynamic ultrasound is a repeatable and valid method for measuring a repeatable and valid method for measuring glenohumeralglenohumeral laxitylaxitygg yy

therefore may be used as a viable therefore may be used as a viable replacement for stress radiographyreplacement for stress radiography

Anterior viewAnterior view

Anterior humeral translationAnterior humeral translation

Krarup et al 1999


Anterior humeral translationAnterior humeral translationLandmarksLandmarks Distance between antero-superior

Portion of scapular neck and greater tuberosity

Court-Payen et al 1995, Krarup et al 1999


baseline Anterior translation of humerus withpassive force

Superior viewSuperior viewAcromial humeral distance (AHD) Multidirectional instability

Landmarks:AcromionHumeral head

Jerosch et al 1991

150 healthy subjects57 patients with instability

Measured at rest

Measured with inferior glide

Superior viewSuperior view

oSignificant increase in inferior translation instability vs controlo6.1mm versus 2.4mm.o mean AHD 13.4 mm in healthy population

Jerosch et al 1991

baseline Passive inferiorly directed force

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• It has been shown that the AHD ↓ during shoulder abduction using MRI

Acromiohumeral Distance AHD

•• AHD decreased with AHD decreased with shoulder impingement shoulder impingement syndrome (SIS)syndrome (SIS)

Hebert et al 2003

Acromio-Humeral Distance= AHD

Tangential distance between the humeral head surface and the lateral tip of the acromion

7 patients with SIS13 healthy subjects

Measurements at rest, 45° and 60 ° abduction

Desmeules et al (2004)

Definitive pattern of narrowing of the AHD with arm Abd

AHD values at rest tended to be higher in SIS group than in healthy group whilegroup, while

More pronounced narrowing occurred between 0º - 45º

Excessive superior translation of humeral head 0º - 45º

Desmeules et al (2004)

Sonography of Ssp tendon

young overhead athletes (basketball) in correlation with the main pathologic model of secondary SIS

Girometti et al (2006)

Measurement of SAD

Dynamic anterior impingement test (passive)

10 professional basketball players with sh pathology

10 non-athlete controls

l t l i i h l h d

Girometti et al (2006)

lateral view acromion - humeral headarm behind back position

Cutoff point < 7 mm: defined as decreased SAD (based on normative data derived from US and MRI)

Significant difference between groups only in SAD

57 patients with symptoms of unilateral SIS.

72 healthy control subjects.

Bil t l i ti i ll bj t

Cholewinsky et al (2008)

Bilateral examination in all subjects

Arm in neutral rotation

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AHD and RC thickness smaller in SIS versus non affected shoulder (p<,0.001)

AHD significantly smaller in SIS vs control group (p<0 001)

Cholewinsky et al (2008)

control group (p<0.001)

AHD of more than 2.1mm in comparison to the unaffected joint may point to the dysfunction of RC muscles

AHD enables measurements of superior translation of the humeral head

ConclusionConclusion

There is both direct research into the PFH as it relates to the MWM concept

Predominantl research has not foc sed on thePredominantly research has not focused on the MWM concept but do describe investigations into minor positional ‘incongruencies’ that highlights key aspects of the PFH

Brian R. Mulligan Positional Fault Fact or...

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