Practical Applications of Manual Therapy for the Ankle and Foot...Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in

Ovidio Olivencia, PT, DPT PHATS Annual Meeting 2014

Orlando, Florida

Practical Applications of Manual Therapy for the Ankle and Foot

Outline

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

Ovidio Olivencia, PT, DPT Nova Southeastern University

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


Case Study ! History: o 26-year-old hockey player 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


Case Study AROM PROM MMT Joint

Mobility Ankle Dorsiflexion

5 deg Limited

8 deg Limited

5/5 Strength

?

Ankle Plantar flexion

30 deg Limited

Limited 35 degrees with empty end-feel

5/5 Strength

?

Inversion 5 deg Limited

Limited with empty end-feel

4-/5 Strength

?

Eversion 5 deg Limited

6 deg Limited

4-/5 Strength with pain

?


Case Study ! Tests and Measures:

! 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 5th 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?


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


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 Ovidio Olivencia, PT, DPT Nova Southeastern University

Joint Mobilization ! Indications:

! Lack of ROM ! Painful joints ! Muscle guarding

! Effects: ! Mechanical:

! Plastic deformation of inert and contractile tissue ! Remodeling of adhesions

! Pain Inhibition: ! Gate controlled theory ! Mechanoreceptors

! Joint Nutrition: Ovidio Olivencia, PT, DPT Nova Southeastern University

! 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


! 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


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


! 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

! 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

! 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 Ovidio Olivencia, PT, DPT Nova Southeastern University

Talocrural Posterior Glide ! Patient Position:

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

! 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


Weigh-bearing Mobilization

Collins et al Man Ther, 2004

! 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


! 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


Subtalar Lateral Glide ! Patient Position:

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


! 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


! Synovial joint ! Body of cuboid articulates with:

! Calcaneuous ! 4th and 5th 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


! 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


Case Study Manual Therapy Interventions AROM PROM Joint

Hypomobility Intervention (Glides)

Ankle Dorsiflexion

5 deg Limited

8 deg Limited

Prox Tib/Fib:! Dist Tib/Fib:! Talocrural:! Subtalar:!

Anterior Posterior Posterior Lateral

Ankle Plantar flexion

30 deg Limited

35° Limited Empty end -feel

Anterior glide Hypermobility Talocrural Joint

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


Practical Applications

! Chronic lateral Ankle Sprain ! Clinical Prediction Rules (CPR) for Chronic Ankle

Sprains ! Syndesmosis (High Ankle) Sprain


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


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


! History o 10% of all ankle injury o Dorsiflexion and lateral rotation of foot injury o May have widening mortise o Return: 10-52 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) ! 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


Ovidio Olivencia, PT, DPT [email protected]


Questions?

References ! Akira G, Hisao M, Tomonobu I, Tesu W, Kazuomy S. Three dimensional in vivo

kinematics of the subtalar joint during dorsi-plantarflexion and inversion-eversion. Foot & Ankle International. 2009; 30 (5):432-438.

! 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; 42:125-134.

! Bojsen-Moller F. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979;129:165-176.

! 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): 77-82.

! 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.

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;32:166-173.

! Fujii M, Suzuki D, Uchiyama E, et al. Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? Man Ther. 2010;15:117-121.

! Greenman P. Principles of Manual Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.

! Guide to Physical Therapist Practice. (2nd 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):409-415.

! Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 3rd ed. Philadelphia, PA: FA Davis Co; 2001:367–402.


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):188-200.

! Wright et al. Ankle syndesmosis sprains in National Hockey League players. AMJ of Sports Med. 2004; 32 (8):1941-1947.


Documents

Practical Applications of Manual Therapy for the Ankle and Foot...Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in