Practical Applications of Manual Therapy for the Ankle and Foot

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1 Practical Applications of Manual Therapy for the Ankle and Foot PHATS Annual Meeting 2014 Orlando, Florida

2 Outline! Objectives! Case Study! What is Manual Therapy?! Joint Mobilization! Joint Mobilization Techniques! Practical Applications

3 Objectives! Demonstrate safe and effective clinical use of oscillatory and sustained distal lower extremity joint mobilization! Recognize appropriate joint mobilization interventions for a patient with ankle sprains! Be able to utilize information and apply concepts in practical situations

4 ! History: o 26-year-old hockey player Case Study o Patient reported twisting his left ankle four days ago while participating in an off -season agility program o The mechanism of injury was ankle rolling outwards and the foot inward (plantar flexion and inversion stress) o Immediate post injury onset of swelling and (sharp) pain o Pain described as ache pain on the lateral aspect of left foot with localized tenderness o Antalgic gait and pain with standing o Pain relieved with ice, rest and NSAIDS o History of multiple left ankle sprains o VRS: 2/10 at rest, 4/10 with walking

5 Case Study Ankle Dorsiflexion AROM PROM MMT Joint Mobility 5 deg Limited 8 deg Limited 5/5 Strength? Ankle Plantar flexion 30 deg Limited Limited 35 degrees with empty endfeel 5/5 Strength? Inversion 5 deg Limited Limited with empty endfeel 4-/5 Strength? Eversion 5 deg Limited 6 deg Limited 4-/5 Strength with pain?

6 ! Tests and Measures: Case Study! Observation and Structural Inspection: Bilateral pes planus Navicular Drop Test: 6 mm! Muscle length: Gastroc/soleus tightness! Girth measurement (Figure 8): Left ankle: 51 cm, Right ankle: 50 cm! Palpation: Grade 2 tenderness on the left anterior/lateral talar dome and diffuse tenderness to the cuboid and 5 th metatarsal base! Special Tests: Negative findings for Kleiger s, Talar tilt, and positive for Anterior Drawer Test! Functional Movement: Difficulty controlling hip adduction, internal rotation and pronation during lunges and deep squats! Missing arthrokinematic testing?! Manual therapy evidence?

7 What is Manual Therapy?! Skilled hand movements intended to improve ROM, tissue extensibility, pain and induce relaxation! Manual Interventions:! Manual Traction! Soft tissue Mobilization! Muscle Energy Techniques! Cranial- Sacral Therapy! PROM and Stretching! Manipulation/Mobilization Guide to Physical Therapist Practice, 2003

8 Joint Mobilization! Systematic approach to examining and treating the osteokinematics and arthrokinematics motions of the human body! ROM: AROM,PROM, and End-Feels! Joint Play: Involuntary interarticular motion present all synovial joints ie. glide, compression, distraction etc..! Structural inspection and biomechanics are examined, and evaluated for possible dysfunction! Joint mobilization requires the healthcare professional to passively move a joint either by:! Sustained stretch! Applying rhythmic oscillations! Goal is to restore full and painless ROM

9 ! Indications:! Lack of ROM! Painful joints! Muscle guarding! Effects:! Mechanical: Joint Mobilization! Plastic deformation of inert and contractile tissue! Remodeling of adhesions! Pain Inhibition:! Gate controlled theory! Mechanoreceptors! Joint Nutrition:

10 ! Tibia/Fibula Techniques: o Proximal Tibia/Fibula Joint: A/P and P/A o Distal Tibia/Fibula Joint: A/P and P/A! Ankle Techniques o Talocrural: A/P o Talocrural: Weight-Bearing o Talocrural: Distraction! Foot Techniques o Subtalar: Distraction o Subtalar: Lateral glide o Cuboid: P/A

11 ! Synovial joint! Joint surface is flat or slightly oval! Capsule is strengthened by anterior/posterior ligaments! Proximal fibula glides on tibia anterior/lateral and superior during dorsiflexion! Soavi et al., Foot Ankle Int, 2000

12 Proximal Tibiofibular Joint (A/P and P/A)! Patient Position: o Supine with knee flexed and the foot on the table! Stabilization o Grasping the tibia! Action Hand: o Therapist grasp the head of the fibula with thumb and index finger! Mobilization: o Therapist applies an anterior and posterior glide motion of the fibula head on the tibia

13 ! Syndesmosis joint! No joint capsule! Concave tibia on convex fibula facet! Stability provided by posterior and anterior tibiofibular ligaments and interosseous membrane! Distal fibula glides on tibia posterior superior and lateral rotation during dorsiflexion! Soavi et al., Foot Ankle Int, 2000

Distal Tibiofibular Joint (A/P and P/A)! Patient Position: o Supine foot off end of table! Stabilization o Grasping distal Tibia o Use leg to to stabilize foot!

14 Distal Tibiofibular Joint (A/P and P/A)! Patient Position: o Supine foot off end of table! Stabilization o Grasping distal Tibia o Use leg to to stabilize foot! Action Hand: o Contact distal fibula with thenar eminence over lateral malleolus! Mobilization: o Therapist applies a posterior and anterior glide motion of the distal fibula on the tibia Mobilization of the distal tibiofibular joint has been shown to increase ankle dorsiflexion ROM Fujii et al., Man Ther, 2010

15 ! Synovial hinge joint! Talus wide anterior than posterior! Body of talus has three articulating facets:! Fibular! Tibial! Trochlear! Thin capsule is strengthened by deltoid (medial), anterior and posterior talofibular ligaments, and calaneofibular ligament (lateral)! Talus glides posterior and rotates externally with dorsiflexion! Levangle & Norkin, Joint Structure and Function, 2001

! Patient Position: Talocrural Posterior Glide o Supine foot off end of table! Stabilization o Grasping distal Tib-Fib! Action Hand: o Contact talus with web space between thumb and index finger!

16 ! Patient Position: Talocrural Posterior Glide o Supine foot off end of table! Stabilization o Grasping distal Tib-Fib! Action Hand: o Contact talus with web space between thumb and index finger! Mobilization: o Therapist applies a posterior glide through web space contact while maintaining plantarflexion! Posterior glide of the talocrural joint improves dorsiflexion ROM and Function! Collins et al, Man Ther, 2004 Cosby et al, J Man Manip Ther. 2011

Weigh-bearing Mobilization! Patient Position: o Standing! Stabilization o Web space of one hand stabilizes the talus and forefoot o Other hand guides lower extremity!

17 Weigh-bearing Mobilization! Patient Position: o Standing! Stabilization o Web space of one hand stabilizes the talus and forefoot o Other hand guides lower extremity! Action Hand: o The belt is placed around distal tibia and fibula o Towel or foam needed for Achilles tendon protection! Mobilization: o Therapist applies an anterior glide through belt while patient actively dorsiflexes (leaning forward) o Dorsiflexion with movement significantly increases ROM Collins et al Man Ther, 2004

18 ! Patient Position: o Supine with knee extended! Action Hand: o Grasp talus! Mobilization: o Therapist applies a long axis distraction of talus using hand contacts and body weight for assistance

19 ! Synovial joint! Calcaneus (posterior, middle, anterior facets) articulates with talus! One degree of freedom (inversion and eversion) some dorsiflexion and plantarflexion! The joint is strengthened primarily by deltoid (medial), and calcaneal fibular ligament (lateral),and secondary by the medial, posterior and lateral talocalcaneal ligaments! Calcaneus inverts, everts and internally and externally rotates! Dorsiflexion: The calcaneus everts, externally rotates and dorsiflexes! Goto et. al., Foot & Ankle International, 2009

20 ! Patient Position: Subtalar Lateral Glide o Side lying on the involved lower extremity! Stabilization: o Grasp tib/fib and talus! Action Hand: o Grasp the calcaneus with the thenar eminence! Mobilization: o Therapist applies a lateral mobilization force through the therapist's arm and thenar eminence to the medial calcaneus

21 ! Patient Position: o Prone with pillow between therapist and leg! Stabilization: o Grasp talus from dorsal side! Action Hand: o Grasp the calcaneus between your thumb and index finger with knee flexed! Mobilization: o Push straight up towards ceiling

22 ! Synovial joint! Body of cuboid articulates with:! Calcaneuous! 4 th and 5 th metatarsals! Navicular! Lateral cuneiform! Stability provided by dorsal and plantar: cuboideonavicular, calcaneocuboid, cubodeiometatarsal ligaments, and long plantar ligament! Movement of CC joint is medial and lateral rotation (pronation and supination) in an anterior/posterior axis.! Boisen-Moller, J Anat, 1979

Action Hand: o Thumbs positioned on the plantar/medial aspect of cuboid!

23 ! Patient Position: o Prone with knee in 70 deg. of flexion and 0 deg. of dorsiflexion! Stabilization: o Interlocking fingers over the dorsum of foot! Action Hand: o Thumbs positioned on the plantar/medial aspect of cuboid! Mobilization: o With the patient s leg relaxed, extend the knee while plantar flexing ankle with slight inversion of the subtalar joint while delivering an P/A mobilization! 6.7% of plantar flexion and inversion injury! Jennings & Davies, J Orthop Sports Phys Ther, 2005

24 Case Study Manual Therapy Interventions Ankle Dorsiflexion Ankle Plantar flexion AROM PROM Joint Hypomobility 5 deg Limited 30 deg Limited 8 deg Limited 35 Limited Empty end -feel Prox Tib/Fib:! Dist Tib/Fib:! Talocrural:! Subtalar:! Anterior glide Hypermobility Talocrural Joint Intervention (Glides) Anterior Posterior Posterior Lateral NA Subtalar Inversion 5 deg Limited Limited with empty end-feel Normal NA Subtalar Eversion 5 deg Limited 6 deg Limited Subtalar! Lateral Distraction Cuboid P/A

25 Practical Applications! Chronic lateral Ankle Sprain! Clinical Prediction Rules (CPR) for Chronic Ankle Sprains! Syndesmosis (High Ankle) Sprain

26 Chronic Lateral Ankle Sprain! Recurrent ankle sprain demonstrate impairments in the following joints:! Proximal tibiofibular! Beazell et. Al, J Orthop Sports Phys Ther, 2012! Distal tibiofibular! Positional Fault! Hubbard & Hertel, Man Ther, 2008! Talocrural! Denegar, Hertel, Fonseca, J Orthop Sport Phys Ther, 2002! Subtalar! Greeman, Principles of Manual Medicine, 1996

27 Clinical Prediction Rules Manual Therapy and Exercise! Symptoms worse with standing! Symptoms worse during evening! Navicular bone drop! 5.0 mm! Distal tibiofibular joint hypomobility! " +LR 5.90 with a probability of success 95%! Whitman et al., JOSPT, 2009

28 ! History o 10% of all ankle injury o Dorsiflexion and lateral rotation of foot injury o May have widening mortise o Return: days o Hockey average 45 days (6-147 days) o 74% of all ankle sprains o Wright et al., The AMJ of Sports Med,2004

! Physical Exam o Swelling/edema o! ROM o Point tenderness on distal tibiofibular ligament or up the syndesmosis o Positional fault of distal fibula (posterior lateral)!

29 ! Physical Exam o Swelling/edema o! ROM o Point tenderness on distal tibiofibular ligament or up the syndesmosis o Positional fault of distal fibula (posterior lateral)! Special Tests: Squeeze or Kleiger! Suggested Manual Interventions:! Proximal Tib/fib: Posterior Glide! Distal Tib/Fib: Anterior Glide! Talocrural Joint: Posterior Glide! Subtalar Joint: Lateral Glide

30 Questions?

31 References! Akira G, Hisao M, Tomonobu I, Tesu W, Kazuomy S. Three dimensional in vivo kinematics of the subtalar joint during dorsi-plantarflexion and inversioneversion. Foot & Ankle International. 2009; 30 (5): ! Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2012; 42: ! Bojsen-Moller F. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979;129: ! Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan's mobilisation with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004; 9(2): ! Cosby NL, Koroch M, Grindstaff TL, Parente W, Hertel J. Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain. J Man Manip Ther. 2011;19:76-83.

32 References! Denegar CR, Hertel J, Fonseca 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: ! Fujii M, Suzuki D, Uchiyama E, et al. Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? Man Ther. 2010;15: ! Greenman P. Principles of Manual Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.! Guide to Physical Therapist Practice. (2 nd ed). Alexandria, VA: American Physical Therapy Association; 2003.! Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13:63-67.! Jennings J, Davies G.J. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J Orthop Sports Phys Ther. 2005; 35(7): ! Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 3rd ed. Philadelphia, PA: FA Davis Co; 2001:

33 References! Whitman JM, Cleland JA, Mintken P, Keirns M, Bieniek ML, Albin SR, Magel J, McPoil TG. Predicting short-term response to thrust and non-thrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther. 2009; 39 (3): ! Wright et al. Ankle syndesmosis sprains in National Hockey League players. AMJ of Sports Med. 2004; 32 (8):

Introduction. The primary function of the ankle and foot is to absorb shock and impart thrust to the body during walking.

Introduction. The primary function of the ankle and foot is to absorb shock and impart thrust to the body during walking. The ankle 1 Introduction The primary function of the ankle and foot is to absorb shock and impart thrust to the body during walking. OSTEOLOGRY The term ankle refers primarily to the talocrural joint,