What’s the Big Deal? DF & Static Stretching · 2017-10-09 · • Regional Interdependence Model...

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.


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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)



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


Relationship Between the Force Curves and the Pivots

Foot (Gait)

Forefoot

Heel


Case Study 1 Pre: 2.25”/36 degrees Post: 2.5” /40 degrees



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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



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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?


LOAD CAPACITY

SCALE


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.


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


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.


Load vs. Capacity

LOAD CAPACITY

Healthy Balance



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Load vs. Capacity

LOAD CAPACITY

Musculoskeletal Tissues

•muscle

•tendon

•ligament

•nerve

•cartilage

•disc

•bone

Healthy

Balance


Pathology/Dysfunction Each tissue

type responds to excessive

load in a

predictable way producing

a series of pathologies.


LOAD

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

Cumulative Injury Disorder


Question

Can a

normal

load

exceed

capacity? Sports Medicine & Performance

Normal Diminish LOAD CAPACITY



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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

Sports Medicine & Performance Sports Medicine & Performance

Gastrocnemius

• 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 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


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.



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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


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 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



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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


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



• 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


• 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


• 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


• 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


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• 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


-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.

What’s the Big Deal? DF & Static Stretching · 2017-10-09 · • Regional Interdependence Model...

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