BSMPG Summer Seminar 2012 5/13/2012
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Improving Health & Performance: Restoring Ankle Motion Utilizing a
Manual Therapy Approach
Art Horne, MEd, ATC, CSCS &
Pete Viteritti, DC
What’s the Big Deal?
DF & Static Stretching
- 20 min of static stretching of the calf muscles increased the ankle dorsiflexion angle, decreasing the stiffness of the ankle joint and tendon but actual muscle stiffness and elongation were unchanged (Kato 2010).
- static calf-stretching exercises produced no significant reduction in the passive mechanical resistance into ankle dorsiflexion in a group of young, healthy male subjects (Muir 1999).
- jogging is more effective than stretching for decreasing muscle stiffness around the ankle joint (McNair 1996).
- a 6Xweek once a day static stretching protocol is not sufficient to increase active ankle dorsiflexion ROM in healthy subjects (Youdas 2003).
- A two-minute static stretch was no more effective than either the one minute of 30 second stretches for increasing ankle DF ROM after acute lateral ankle sprain (Youdas 2008).
- A gastrocnemius-stretching program in this study did not affect ankle DF, knee extension, or gastrocnemius muscle during gait in subjects with limited DF ROM, especially noted during early to midstance (Johnson 2009).
- combined SS and US treatment increased ankle DF more than static stretching alone (Wessling 1987).
Loss of DF and Injury
• Regional Interdependence Model
(Wainner et al, 2007)
• Limited ankle DF contributes LE related injuries
(Neely 1998, Messier 1988, Malliaras 2006, Kaufman 1999)
• Considerations for ACL program
(Fong 2011)
DF Impacts Performance
Limited ankle DF shifts power from hips to knee and will decrease power output. Running Requires 20-30 degrees of DF (Lindsjo, 1985)
Hallux Interphalangeal Joint Range of Motion in Feet with and Without Limited First Metatarsophalangeal Joint Dorsiflexion.
Munuera PV, Trujillo P, Guiza L, Guiza I. J Am Podiatr Med Assoc. 102(1): 47-53, 2012.
BSMPG Summer Seminar 2012 5/13/2012
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Is there a Problem? • 60 NU athletes during spring
clearance
• Great toe on tape
measure, middle of heel on tape measure, heel stays down, no attempt to limit Pro/Sup – but knee had to touch wall in line.
• Measurements taken to the closest ¼ inch with angle
recorded using ITouch (Clinometer app)
(Bennell et al., 1998)
Sports Medicine & Performance
How Much DF Do We Need? 45 degrees? • 113 Male/Female VB players
• Sit & Reach, ankle DF, VJ, PF
strength, years competed, & activity level
• Having less than 45◦ of ankle dorsiflexion range increased
the risk of patelllar
tendinopathy by 1.8—2.8 times.
• Only DF was associated with
tendon injury. (Malliaras 2006).
4 Inches? • SFMA suggest 4inches in their
breakout of Deep Squat (Cook,
pg.184)
Sports Medicine & Performance
Sports Medicine & Performance
1 2
3 4
1. Indicates a rapid initial loading.
2. A 50% drop in force or loading.
3. An increase to about 10% more than the 1st peak.
4. A rapid decline in force to 0.
Example of a Force vs. Time (Load Pattern) Graph
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Relationship Between the Force Curves and the Pivots
Foot (Gait)
Forefoot
Heel
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Case Study 1 Pre: 2.25”/36 degrees Post: 2.5” /40 degrees
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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Gait Average – Pre & Post
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Case Study 2
Pre: 2.25”/36 degrees Post: 2.5” /39 degrees
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Case Study 3
Pre: 1.25”
Post: 2.0”, 3 Days Post 2.0”
Sports Medicine & Performance
Moss
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Load
vs. Capacity
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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Questions
1. Why did this happen to me?
2. How can I prevent this from happening
again
3. Why do I have to reduce my training
4. Why can’t I just rest it?
5. I no longer have any symptoms – why do
I need to continue treatment
6. Whey does this problem keep coming
back?
Sports Medicine & Performance
LOAD CAPACITY
SCALE
Sports Medicine & Performance
All musculoskeletal injury is
an imbalance between LOAD
and CAPACITY. LOAD CAPACITY
Load is simply how much you ask
your body to do. It’s a force
applied to the body that has
direction, magnitude and time.
Sports Medicine & Performance
LOAD CAPACITY
Load is simply how much you ask
your body to do. It’s a force
applied to the body that has
direction, magnitude and time.
Training •volume •intensity
Constraint postures
•frequency
Sports Medicine & Performance
LOAD CAPACITY
Capacity is how much load the
body can handle without damage,
breakdown or dysfunction.
You only know where
your capacity is by
exceeding it.
Sports Medicine & Performance
Load vs. Capacity
LOAD CAPACITY
Healthy Balance
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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Load vs. Capacity
LOAD CAPACITY
Musculoskeletal Tissues
•muscle
•tendon
•ligament
•nerve
•cartilage
•disc
•bone
Healthy
Balance
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Pathology/Dysfunction Each tissue
type responds to excessive
load in a
predictable way producing
a series of pathologies.
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LOAD
Cumulative Injury Disorder
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TISSUE TYPE DYSFUNCTION (chronic)
Muscle Adhesion
Tendon Tendinosis (not tendonitis)
Ligament Adhesion/Degeneration
Nerve Entrapment
Cartilage Degeneration
Disc IDD, Herniation
Bone Stress Response/Stress Fracture
Cumulative Injury Disorder
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Question
Can a
normal
load
exceed
capacity? Sports Medicine & Performance
Normal Diminish LOAD CAPACITY
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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The Audit Process and DF Limitations
• Check
Dorsiflexion – Functional & Weight
Bearing
• Apply Treatment
• Re-Check
Dorsiflexion
• 6 Possible Soft
Tissue Limitations 1. Soleus
2. Post. Tib
3. FHL
4. FDL
5. Post. Talofib lig
6. Post Tibiotalar lig
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Gastrocnemius
• Seldom treated
• Treat prior to any underlying FDL, FHL and post. tib pathology
• Or
• Take out of equation by
bending knee
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Soleus • Treat prior to any
underlying FDL, FHL and
post. tib pathology
• Pt positioned quadruped to remove gastroc tension and
isolate or
• Treat gastroc prior which lays overtop
• Common area of dysfunction is
musculotendon junction
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Posterior Tibialis
• Strongest and deepest central calf
muscle
• Key ankle and foot stabilizer, supports medial arch
– Produces inversion and plantar flexion
• Originates on medial borders of tib/fib, inserts at cuboid/cuneiform/base of 2nd-
4th metatarsals
• Patient is prone, knee flexed and ankle
in PF
• Place contact on the portion of the ms to be treated, press through the soleus
and draw tension proximally on the TP
• Maintain or increase tension & move the ankle into DF
• NOTE: Gastroc/Soleus must usually be
treated first
Sports Medicine & Performance
Flexor Digitorum
Longus • One of deepest tissues in calf region
• Often involved in ‘shin splints’ and
compartment syndromeTissue
becomes fibrous, increasing tension and likelihood of re-injury
• Begin sidelying, toes flexed and ankle in PF
• Place the contact on the portion of muscle to be treated, press through the
soleus and draw tension proximally.
• Maintain or increase tension & move the
ankle into DF and the toes into
extension.
• NOTE: Attachment on the posterior tibia
will usually exhibit the most serious
problems.
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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Flx Hallucis Longus • If shortened, may alter push off and
increase pronation during gait cycle
• Increases forces required for stabilization
• Originates at inferoposterior body of fibula, inserting on DIP of 1st digit
• Prone position, first toe in flexion and the ankle in PF
• Place contact on the portion of the muscle to be treated, press through
soleus and draw tension proximally
• Maintain or increase tension and
move the ankle into DF and the toe
into extension
• NOTE: Gastroc/Soleus must usually be
treated first
• Or treat in quadruped position to
relax
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Posterior Ligaments
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• Posterior Tibiotalar Lig. – Identification of tissue is paramount
– Begin seated & plantar flexed
– Contact posterior to flx tendons on
posterior process of the talus and draw tension along the lig anteriorly
– Maintain or increase tension and
move ankle into DF
NOTE: contact should be anterior to achilles tendon.
• Posterior Talofibular Lig.
– Seated and ankle in PF
– Line of tension is oblique compared to vertical orientation from above
– Start on posterior fib and move
directly behind
– Maintain or increase tension and move ankle into DF
Why doesn’t it stick?
a. Reflexive Treatment
b. Treated wrong tissue
c. Irreducible block
d. Mobility without Stability =
Instability
Arthrokinematic
Restrictions
Manual Therapy Techniques
When the foot is inverted beyond its normal range, the fibula is
wrenched forwards on the tibia at the inferior tibiofibular joint resulting in a positional fault
When the foot is inverted beyond its normal range, the fibula is
wrenched forwards on the tibia at
Mulligan Approach
Fibular Position In Individuals with Self-Reported Chronic Ankle Instability
Hubbard TJ, Hertel J, Sherbondy P.
Journal of Orthopaedic &Sports Physical Therapy
• ASSESSING DISTAL FIBULA
POSITION WITH FLUOROSCOPY
• -d=distance from anterior margin
of lateral malleolus to anterior
margin of medial malleolus
• -A smaller distance equals a
more anteriorly positioned distal fibula
RESULTS
• -Fibula was positioned more
anteriorly in the chronically unstable ankles (p<.05)
• Involved Side 14.3 +/- 3.1mm
• Uninvolved Side 16.8 +/- 3.4 mm
• Agreement with Mavi et al,
measuring with MRI
Sports Medicine & Performance
BSMPG Summer Seminar 2012 5/13/2012
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Anterior Positional Fault of the Fibula After Sub-Acute Lateral Ankle Sprain
Hubbard TJ, Hertel J. Manual Therapy 2008; 13: 63-67
RESULTS
• -Fibula was positioned more anteriorly in the recently sprained ankles (p=.008)
• Involved Side 14.2 +/- 3.4mm
• Uninvolved Side 17.1 +/- 3.2 mm
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Manipulation Method for the Treatment of Ankle Equinus
Dananberg HJ, Shearstone J, Guiliano M. J Am Podiatr Med Assoc 90(8):385-389, 2000
RESULTS
• Manip increased DF more than 5 degrees; opposed to stretching 5 min/day for 6 months which showed 2.7 degree change in DF
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• Posterior talar glide restricted 12 weeks after ankle sprain
Denegar et al, JOSPT, 2002.
• Conclusion:
1. Talocrural arthrokinematics altered
2. Restriction may persist after DF has returned
3. Consider treating in rehab
Sports Medicine & Performance
• Patients treated with posterior talar mobilization regained
DF ROM quicker after ACUTE sprain
Green et al, Phys Ther. 2001
• Mulligan’s MWM significantly increased DF initially in subacute ankle sprains.
Collins et al, Manual Therapy. 2003
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• Patients treated with posterior talar mobilization regained
DF ROM quicker after acute sprain
Green et al, Phys Ther. 2001
• Mulligan’s MWM significantly increased DF initially in SUBACUTE ankle sprains.
Collins et al, Manual Therapy. 2003
Sports Medicine & Performance
• Single application of grade III AP Talocrural jt mob increased DF
ROM after 14 days of immobilization
Landrum et al, J Manual & Manip
Therapy, 2008.
• Talar mobilization immediately increased DF ROM in pt’s with CAI
Vicenzino et al, JOST, 2006
BSMPG Summer Seminar 2012 5/13/2012
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Sports Medicine & Performance
• Single application of grade III AP Talocrural jt mob increased DF ROM after 14 days of immobilization
Landrum et al, J Manual & Manip
Therapy, 2008.
• Talar mobilization immediately increased DF ROM in pt’s with CAI
Vicenzino et al, JOST, 2006
Immediate Effects of Anterior to Posterior Talocrural Joint Mobilizations Following Acute Lateral Ankle Sprain
Crosby NL, Koroch M, Grindstaff TL, Parente W, Hertel J. J Man Manip Ther, 2011
• 17 volunteers (9 Tx / 8 Control w/ LAS; immobilized
1-7 days
• Controls: 30-second grade III AP talocrural jt mobilzation
• All groups (contror/mob) improved DF and function
regardless
• Significant improvement in pain 24-hr after mob
Sports Medicine & Performance
-Take Home - Mulligan
• Patients with previous ankle pathology
may have arthrokinematic restrictions • Joint mobilizations & manipulations
should be used with specific treatment goals in mind
• Joint mobilizations should be used as a part of a comprehensive treatment plan that includes therapeutic exercise
• If you don’t assess for restrictions, you won’t find them
Take Home - Overall
• What’s the tissue? • What is the pathology that is
affecting that tissue? • What is the most effective
treatment modality? • Good Tx: Increase Capacity
while normalizing Load
Thank You
Enjoy the Social tonight
References • Bennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH and Hall AJ: Intrarater and inter-rater
reliability of a weight bearing lunge measure of ankle dorsiflexion. Australian Journal of Physiotherapy 44: 175-180.
• Denegar, C., Hertel, J., Fonesca, J. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint Laxity. J Orthop Sports Phys Ther. 2002; 32(4):166-173.
• Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy. 2008;13:63-67.
• Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy. 2008;13:63-67.
• Imnan VT. The Joints of the Ankle. Baltimore, Md: williams & Wilkins: 1976.
• Landrum E, Kelln B, Parente W, Ingersoll C, Hertel J. Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. J Manual Manip Ther. 2008;16(2):100-105.
• Lirdsjo U. Danckwardt-Littiestrom G. Sahlstedt, B. Measurement of the motion range in the loaded ankle. Clin Orthop. 1985;199:68-71.
• Mulligan BR. Manual therapy: “NAGS,” “SNAGS,” “MWMS,” etc. 3rd ed. Wellington, New Zealand: Plane View Services LTD; 1995.
• Munuera PV, Trujillo P, Guiza L, Guiza I. Hallux Interphalangeal Joint Range of Motion in Feet with and Without Limited First Metatarsophalangeal Joint Dorsiflexion. J Am Podiatr Med Assoc. 102(1): 47-53, 2012.
• Wainner RS, Witman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660.
• Whitman J, Cleland J, McPoil T, et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther. 2009;39(3):188-200.
• Vincenzino, B., Branjerdporn, M., Teys, P., Jordan, K. Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle after Mobilization With Movement in Individuals with Recurrent Ankle Sprain. J
Orthop Sports Phys Ther. 2006;36(6):464-471.
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