What s the Big Deal?

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Marianna Watson
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Improving Health & Performance: Restoring Ankle Motion Utilizing a Manual Therapy Approach What s the Big Deal?

- jogging is more effective than stretching for decreasing muscle stiffness around the ankle joint (McNair 1996).

1 Improving Health & Performance: Restoring Ankle Motion Utilizing a Manual Therapy Approach 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). Art Horne, MEd, ATC, CSCS & Pete Viteritti, DC - 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 DF Impacts Performance 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, 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) Limited ankle DF shifts power from hips to knee and will decrease power output. Running Requires degrees of DF (Lindsjo, 1985) 1

measure, middle of heel on tape measure, heel stays down,

line. Measurements taken to the closest ¼ inch with angle

, 1998) How Much DF Do We Need? 45 degrees?

strength, years competed, & activity level Having less

patelllar tendinopathy by 1.8 2.8 times.

Force Curves and the Pivots Foot (Gait) Heel Forefoot Case

2 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) 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 times. Only DF was associated with tendon injury. (Malliaras 2006). 4 Inches? SFMA suggest 4inches in their breakout of Deep Squat (Cook, pg.184) Example of a Force vs. Time (Load Pattern) Graph Relationship Between the Force Curves and the Pivots Foot (Gait) Heel Forefoot Case Study 1 Pre: 2.25 /36 degrees Post: 2.5 /40 degrees 1. Indicates a rapid initial loading. 2. A 50% drop in force or loading. 3. An increase to about 10% more than the 1 st peak. 4. A rapid decline in force to 0. 2

3 Gait Average Pre & Post Case Study 2 Pre: 2.25 /36 degrees Post: 2.5 /39 degrees Case Study 3 Pre: 1.25 Post: 2.0, 3 Days Post 2.0 Moss Load vs. Capacity 3

4 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? All musculoskeletal injury is an imbalance between and. SCALE 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. 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. Capacity is how much load the body can handle without damage, breakdown or dysfunction. Load vs. Capacity Training volume intensity frequency Constraint postures You only know where your capacity is by exceeding it. Healthy Balance 4

responds to excessive load in a predictable

Cumulative Injury Disorder Cumulative Injury

Nerve Entrapment Cartilage Degeneration Disc

5 muscle tendon Healthy Load vs. Capacity Balance Musculoskeletal Tissues ligament nerve cartilage disc bone Pathology/Dysfunction Each tissue type responds to excessive load in a predictable way producing a series of pathologies. Cumulative Injury Disorder Cumulative Injury Disorder 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 Can a normal load exceed capacity? Question Normal Diminish 5

The Audit Process and DF Limitations Gastrocnemius Check Dorsiflexion Functional & Weight Bearing Apply Treatment

Post Tibiotalar lig Seldom treated 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

muscle Key ankle and foot stabilizer, supports medial arch Produces inversion and plantar flexion Originates on

and ankle in PF Place contact on the portion of the ms to be treated, press through the soleus and draw tension

treated first Flexor Digitorum Longus One of deepest tissues in calf region Often involved in shin splints and

flexed and ankle in PF Place the contact on the portion of muscle to be treated, press through the soleus and draw

6 The Audit Process and DF Limitations Gastrocnemius 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 Seldom treated Treat prior to any underlying FDL, FHL and post. tib pathology Or Take out of equation by bending knee 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 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 2 nd - 4 th 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 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. 6

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

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 Posterior Ligaments Posterior

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

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

7 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 1 st 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 Posterior Ligaments 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 Mulligan forwards Approach on the tibia at 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 /- 3.1mm Uninvolved Side /- 3.4 mm Agreement with Mavi et al, measuring with MRI 7

Anterior Positional Fault of the Fibula After Sub-Acute Lateral Ankle Sprain Hubbard TJ, Hertel J.

4mm Uninvolved Side 17.1 +/- 3.2 mm Manipulation Method for the Treatment of Ankle Equinus Dananberg HJ, Shearstone J, Guiliano M.

2.7 degree change in DF Posterior talar glide restricted 12 weeks after ankle sprain Denegar et al, JOSPT, 2002. Conclusion: 1.

Consider treating in rehab Patients treated with posterior talar mobilization regained DF ROM quicker after ACUTE sprain Green et al, Phys Ther.

2003 Patients treated with posterior talar mobilization regained DF ROM quicker after acute sprain Green et al, Phys Ther.

8 Anterior Positional Fault of the Fibula After Sub-Acute Lateral Ankle Sprain Hubbard TJ, Hertel J. Manual Therapy 2008; 13: RESULTS -Fibula was positioned more anteriorly in the recently sprained ankles (p=.008) Involved Side /- 3.4mm Uninvolved Side /- 3.2 mm Manipulation Method for the Treatment of Ankle Equinus Dananberg HJ, Shearstone J, Guiliano M. J Am Podiatr Med Assoc 90(8): , 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 Posterior talar glide restricted 12 weeks after ankle sprain Denegar et al, JOSPT, Conclusion: 1. Talocrural arthrokinematics altered 2. Restriction may persist after DF has returned 3. Consider treating in rehab Patients treated with posterior talar mobilization regained DF ROM quicker after ACUTE sprain Green et al, Phys Ther Mulligan s MWM significantly increased DF initially in subacute ankle sprains. Collins et al, Manual Therapy Patients treated with posterior talar mobilization regained DF ROM quicker after acute sprain Green et al, Phys Ther Mulligan s MWM significantly increased DF initially in SUBACUTE ankle sprains. Collins et al, Manual Therapy Single application of grade III AP Talocrural jt mob increased DF ROM after 14 days of immobilization Landrum et al, J Manual & Manip Therapy, Talar mobilization immediately increased DF ROM in pt s with CAI Vicenzino et al, JOST,

9 Single application of grade III AP Talocrural jt mob increased DF ROM after 14 days of immobilization Landrum et al, J Manual & Manip Therapy, 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, 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 -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: 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): Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy. 2008;13: Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy. 2008;13: Imnan VT. The Joints of the Ankle. Baltimore, Md: williams & Wilkins: 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): Lirdsjo U. Danckwardt-Littiestrom G. Sahlstedt, B. Measurement of the motion range in the loaded ankle. Clin Orthop. 1985;199: Mulligan BR. Manual therapy: NAGS, SNAGS, MWMS, etc. 3rd ed. Wellington, New Zealand: Plane View Services LTD; 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, 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): 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): 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):

Biokinesiology of the Ankle Complex

Biokinesiology of the Ankle Complex Rehabilitation Considerations Following Ankle Fracture: Impact on Gait & Closed Kinetic Chain Function Disclosures David Nolan, PT, DPT, MS, OCS, SCS, CSCS I have no actual or potential conflict of interest