Category Archives: Manual Therapy

The Ice-less Management of Acute Ankle Sprains

I’ve written several articles on the use of ice on injuries, the need for inflammation, and the intricate physiological process of tissue healing.  Despite the mounds of evidence that ice is not all it is cracked up to be, there still exists a dogmatic polarization that it has magical tissue-healing properties. I often get told “Prove to me that ice does not work.” No; that is not how evidence-based practice works. You need to prove that ice does work for the reasons you use it.

Read the comments I receive, and you will recognize our ice dependency. “If I don’t ice, then what do I replace it with?” That statement screams dependency. When we take away ice, we feel that a void must be filled. It doesn’t! The treatment decision is multifactorial; the injury type, severity, tissues involved, the person, etc., all play a role in how you treat that specific injury.

A 2013 position statement made by the National Athletic Trainers’ Association on the management of ankle sprains found ice therapies had a C-level of evidence 1. Meaning little or poor evidence exists. In an interview, the author of that article said: “I wish I could say that what we found is what is really being done in a clinical setting…. Maybe our European colleagues know 20151221_102243_resizedsomething we don’t…there is very little icing over there.”

The blog shows how I treated an acute ankle sprain without ice by using all of the fun little tools learned through school and further honed with clinical experiences, trial, and error. I did what I thought was best. This protocol should not be used for every ankle injury. My treatment and rehabilitation plan changed daily. Everything I did was based on my ankle needs. I did NOT use any biophysical or electromagnetic modalities. Everything I did was manual. This is not to say that I would not use other modalities, I just chose not to. My only rule? No ice. Continue reading

POS: Reduce Pain and Increase Performance

SwingDysfunction of one movement system can lead to a multitude of injuries. Treatment and care for one movement system can prevent our most common ailments. Most potential clients I interview complain of one or more of the following: sacroiliac joint (SIJ) pain and instability, non-specific low back pain (LBP), chronic hamstring strains or tightness, and peri-scapular and thoracic tightness or pain. Whether these complaints are isolated to one body part or involve many, the pain can typically be resolved by treating dysfunction of the Posterior Oblique Subsystem.

 

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Gamma Gain, Myofascial Pain Syndrome and Treatment Using Myofascial Release and Strain-Counterstrain

Introduction and Anatomical Overview:

Muscle is made up of two types of fibers, intrafusal and extrafusal. Extrafusal fibers are the contractile fibers and intermixed within the extrafusal fibers are intrafusal fibers. Housed within intrafusal fibers is a specific type of mechanoreceptor. Mechanoreceptors, in general, are interspersed through the entire body – hair, skin, ligaments – and are responsible for sensing tissue pressure and distortion and give our body a sense of proprioception by detecting position of our muscles, bones, and joint. There are many types of mechanoreceptors, but one specifically – the muscle spindle – lives within the intrafusal muscle fibers. The muscle spindle transmits sensory data regarding changes in muscle length, and therefore movement, to the central nervous system (CNS) via the primary afferent (sensory) neurons. The intrafusal fibers receive neural stimulation from gamma efferent (motor) neurons. Think of the gamma motor neuron as a type of sensitivity adjuster. The efferent input adjusts the length of the spindle so that it remains at an optimal length to detect changes within the muscle.

The Muscle Spindle

The Muscle Spindle

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Mechanotransduction

You have an athlete with a stress fracture. The physician prescribes active rest and places the athlete in a non-weight bearing boot. Sound familiar? Suppose I told you the better option is to place some load on that bone and non-weight bearing is not recommended. Would you think I am nuts? Maybe I can convince you otherwise. Let me explain but, before you read the next paragraph and decide to leave the page, bear with me. What follows this introductory piece may provide insight to further understanding of injury pathophysiology and could revolutionize the future of rehabilitation science.

In January 2013 the Annals of Human Genetics published an article that demonstrated Achilles Tendinopathy is associated with gene polymorphism (Abrahams, et al., 2013). I am not a geneticist by any stretch of the imagination, so pardon my basic explanation. COL51A is a gene that encodes the development and organization of Type V collagen. Type V collagen is a collagen that is distributed in tissues as a component of extracellular matrix and composed of one pro alpha 2 (V) and two pro alpha 1 (V) chains. This collagen can be found in ligaments, tendons, and connective tissue. COL51A plays an integral role in development and maintenance of connective tissue. Abrahams, et al. (2013) demonstrated that polymorphisms occur in the COL51A gene causing altered structure of collagen resulting in tendionpathy. Continue reading

Treatment for Pelvic Rotation and Low Back Pain

Do you have a patient with chronic low back pain, pelvic pain or lateral hip pain? The problem could be an oft-overlooked Anterior Innominate Lesion, commonly referred to as Anterior Iliac Rotation. This malalignment is hard to identify unless the clinician is specifically evaluating for body alignment.

Simply described, anterior innominate is anterior / inferior rotation of the ASIS when compared to the contralateral ASIS. This unilateral rotational movement of is often a result repetitive movement patterns. Repetitive movement results in hypertonicity of hip flexors (primarily the rectus femoris and TFL), hypotonicity of the abdominals, hamstrings, and glutes, as well as increased laxity of the sacrotuberous ligament. The force coupling caused by the hyper/hypotonic structures yields the unilateral rotary movement of the pelvis.

The result is a chronic, dull achy pain that is unrelenting at times. Pain is typically felt across the entire low back. Focal tenderness upon palpation is commonly unremarkable. The patient may also have complaints of thoracic pain, lateral hip pain and potentially groin. Pain maybe exacerbated with athletic activity, or static postures such as prolonged sitting and standing.

As with many postural disorders, treatment for anterior rotation is best served through the use of manual therapy techniques. In my experience, there are two quick and easy treatments: muscle energy techniques (MET) and spray and stretch. Spray and stretch technique is a nice way to inhibit and elongate tonic musculature. Ischemic pressure massage to active trigger points of involved muscles followed the application of a vapocoolant spray, during a passive stretch works well. Although both treatment forms are effective, I prefer MET, as it is fast, effective, and incorporate a semi-functional component through contraction and relaxation of muscle.

When it comes to MET (or most manual therapy techniques for that matter) I often refer to anything by Leon Chaitow’s methods. In this particular instance, I have provided a video clip of a MET that can help both anterior and posterior pelvic rotation in one treatment session. I think the physiotherapists across the Atlantic do a great job of manual therapy, thus I chose a video that was made in the UK.

It is not uncommon to relieve patient pain with just one application of MET. For patients with significant malalignment this treatment may need to be performed twice daily for several weeks in conjunction with traditional functional rehabilitation designed to enhance neuromuscular efficiency.

So, if you have been a patient complaining of low back pain, be sure to observe for postural malalignment. You might find anterior innominate rotation. If so, you can utilize these techniques to resolve the problem quickly and restore optimal function.

Prevent Dysfunctional Movement by Improving Ankle Mobility – A Research Review of Manual Therapy Techniques

Topic Overview:

A single joint with altered arthrokinematics can precipitate a kinetic chain domino effect that will wreck havoc on functional human movement.  One such joint is the ankle, where altered arthrokinematics has been linked to several forms of human movement dysfunction and subsequent musculoskeletal injury. Specifically, limited ankle dorsiflexion, has been associated with patellar tendionopathy, ipsilateral gluteus medius weakness, plantar fasciitis, medial tibial stress syndrome, contralateral shoulder pathologies, sacroiliac joint dysfunction, recurrent ankle sprains, chondromalacia, ACL tears, Iliotibial band syndrome, increasing frontal plane motion of the knee, external snapping hip syndrome and osteitis pubis (just to name a few).  In addition to the aforementioned injuries athletes ware at risk of significant performance declines in overall power, agility, and speed.  I am not saying that these are all caused from limited ankle dorsiflexion, but I am saying that limited ankle dorsiflexion can cause these issues.

These issues can create a huge headache for the athlete, health care practitioner, personal trainer or performance coach. So, the question is what can we do that to prevent or treat these dysfunctional patterns or injuries? Simple, increase ankle dorsiflexion. But how? There are several treatment methods so I began thinking what is the single best way to improve ankle dorsiflexion; static stretching, manual therapy, soft tissue release, dynamic flexibility? I could come up with only one solid, and universal one stop treatment option – manual therapy, specifically Movement with Mobilization (MWM). So I found a good research article to review that talks about MWM and the effect it has on ankle dorsiflexion.

Complete Reference: Vicenzino 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 Ortho Sports Phys Ther Jul 2006;36(7):464-71.

Introduction to the Study:

Mobilization with Movement  (MWM) techniques are commonly utilized to improve joint range of motion and reduce pain. Recent evidence indicates posterior glide of the talus and ankle dorsiflexion is deficient in patients suffering from recurrent ankle sprains. Clinicians have used MWM techniques as an effective tool to increase posterior talar glide and increase talocrural dorsiflexion. The purpose of this study is to evaluate effectiveness of two MWM techniques (weight-bearing and non-weight bearing) for treatment of recurrent ankle inversion ankle sprains.

Study Limitations:

  • Imaging studies have not been done to validate assessment of posterior talar glide.
  • Age range was limited to University’s student population age range of 18-27.
  • Time from injury only  9.4 months (mean) since most recent injury

Methods:

Subjects:

  • 16 subjects (8 male, 8 female) age 18-27 from University of Queensland student population. Subjects must have history of recurrent unilateral ankle sprains, must not have had injury on contralateral side and must not have had injury within the past 6 months.

Dependent Variables:

  • Posterior Talar Glide – Posterior glide was applied while passively dorsiflexing at the ankle and flexing the knee.  Posterior talar glide measured with use of tibial inclinometer.
  • Weight-Bearing Ankle Dorsiflexion – Standing lunge until anterior knee touches wall. Measurement taken via tape measurement of toe to wall distance was taken.

Independent Variables:

  • Weight Bearing  Mobilization with Movement (MWM-WB)
  • Non-Weight Bearing Mobilization With Movement (MWM-NWB)
  • Control Group               

Procedures:

  • Randomized, double-blind, repeated-measures, cross over control design.

Statistical Analysis:

  • Three repeated trials of posterior talar glide and dorsiflexion taken pre and post treatment.
  • Omnibus 3×2 repeated-measures ANOVA
  • Paired t tests to determine pretreatment differences of affected and unaffected limbs for intrastudy use.

Results:

  • Pretreatment:
    • Posterior Talar Glide – 2.4° for the affected side and 6.3° for unaffected side.
    • Dorsiflexion – 4.2° affected side and 6.4° unaffected side.
  • Post treatment :
    • Posterior talar glide increased to 4.0° or 55% following MWM-WB.
    • Posterior talar glide increased to 4.1° or 50% following MWM-NWB.
    • Dorsiflexion increased to 4.8° or 26% following MWM-WB.
    • Dorsiflexion increased to 4.8° or 26% following MWM-NWB.
    • Control group increased to 3.3° or 17% following MWM-WB
    • Control group increased to 4.4° or 9% following MWM-NWB

Conclusion:

Overall, both weight-bearing and non-weight-bearing MWM demonstrated significant positive effectiveness for improving posterior talar glide and ankle dorsiflexion. Maximum possible effect (MPE) for posterior talar glide utilizing Weight bearing MWM and non weight-bearing MWM was 55% and 50% respectively. MPE for ankle dorsiflexion was 26% for both weight-bearing and non-weight bearing MWM.  There was not a significant difference when comparing weight bearing and non-weight bearing MWM.

If you are an athlete, health care practitioner, personal trainer or performance coach and think that your issue might be associated with limited ankle mobility seek out a qualified practitioner. They will be able to identify if dorsiflexion limitations exist and will be able to treat that limitation properly and restore proper function.