How Physical Therapy Can Enhance...
Content
HOW PHYSICAL THERAPY CAN ENHANCE THE OUTCOMES OF THE PODIATRIC PATIENT
LORI RUBENSTEIN, MAppSc, PT, FAAOMPT
Los Angeles, CA
Podiatry and Physical Therapy
• We both recognize that foot and ankle dysfunction affects the mechanics elsewhere in the body. • Physical therapists are considered movement specialists. • Toenail case
Case study
• Patient referred for LBP • PMH: 7 years ago s/p left calcaneal ORIF • PT treatment focused on modalities for swelling and pain management control. • Present findings include -10 degrees talocrural dorsiflexion resulting in compensatory gait pattern and lumbosacral dysfunction.
1
RESULTS
• One physical therapy treatment with the techniques we’ll be discussing today restored talocrural ROM to +5 degrees dorsiflexion and eliminated compensatory gait pattern thus reducing her back pain.
Case study
• There is a lot more that physical therapy can do for your patients that may enhance their treatment outcomes and prevent compensations elsewhere.
Introduction
• Review of the podiatric and medical foot and ankle literature usually references physical therapy without specification as to what types of physical therapy treatments are indicated. The aim of this lecture is to discuss some of the physical therapy interventions that are available and their indications with relation to common foot and ankle diagnoses.
2
Outline
• • • • • • • Modalities Exercise Gait Physical Therapy evaluation Joint mobilization Neurodynamics: tibial and peroneal nerves Common podiatric conditions
1. Ankle inversion sprain 2. Cuboid syndrome 3. Bunionectomy
Modalities
• • • • • • Ultrasound Phonophoresis Iontophoresis Electrical Stimulation Contrast Baths Light laser • Management of pain and swelling • Reduce muscle spasm • Reduce calcifications within tendons • Enhance tissue healing
EXERCISE
• Stretching • Strengthening • Proprioceptive training (Podiatry Today, Denegar et al
2002, Osborne and Rizzo 2003, Verhagen et al 2004)
• • • •
Balance Neuromuscular re-education Functional Training (Baxter 1995, Osborne and Rizzo 2003) Sports specific training (Baxter 1995)
3
GAIT
• Gait training with assistive device • Proper fitting of device • Post-op/Post-injury gait training to avoid compensatory patterns
(Rubenstein 1988)
PHYSICAL THERAPY EVALUATION
– – – – – – – – – Observation ROM (physiological) Muscle testing/strength Neurological Palpation Joint mobility/arthrokinematics (accessory mobility) Gait Function Neurodynamics
(Petty and Moore 2002)
Joint Mobilization/Arthrokinematics
• Accessory mobilization to restore normal mobility to a joint. • Capsular restriction.
4
Joint Mobility/Arthrokinematics
Common areas treated: • Talocrural (restore talus posterior glide) • Cuboid (reduce plantarflexed cuboid) • Hallux (restore MTP glide to restore physiological ROM)
( Hartman 1997, Petty and Moore 2002)
Joint Mobilization
Example:
– First MTP joint mobility restriction
• Superior glide of proximal phalanx on metatarsal to restore dorsiflexion • Inferior glide of proximal phalanx on metatarsal to restore plantarflexion
• Used in conjunction with physiological ROM exercises
Mobilization
• Dananberg et al 2000 reported twice the gains in dorsiflexion ROM following one session of manipulation of the talocrural and proximal tibiofibular joints versus 6 months of calf stretching.
(Dananberg et al 2000, Denegar et al 2002)
5
Mobilization with Movement
• • • • • MWM Brian Mulligan, New Zealand Positional fault theory Treatment must be pain-free! When performed correctly MWM results in immediate restoration of painfree ROM
(Mulligan 2004)
MWM to restore dorsiflexion
• In weightbearing, patient may experience anterior impingement if the talus does not glide posteriorly during dorsiflexion. • Therapist facilitates talar posterior glide during active weightbearing dorsiflexion
(Collins et al 2004, Denegar et al 2002, Mulligan 2004, Kavanagh 1999)
6
Some causes of loss of ROM
• Muscle length • Decreased accessory mobility • Decreased nerve mobility • Stretching • Joint mobilization • Neural mobilization
NEURODYNAMICS
• Physical mobility of the nervous system including spinal cord, meninges ,nerves. • Restricted mobility may result in traction or compression and decreased blood flow to the nerve, decreased axoplasmic flow, decreased conductivity and symptoms of tingling or pain.
NEURODYNAMICS
• Physical nervous system is a continuum. • Spinal cord must adapt to the 5-9cm changes in spinal canal length that occur with transition from extension to flexion. • Sciatic nerve must adapt to changes of at least 12% it’s resting length during SLR. • Restriction of neural mobility can result in pain, nerve compression, neuropathy and traction injury.
7
Tests for LE neural mobility
• Straight leg raise
– Tibial nerve bias – Peroneal nerve bias
(Butler 2000, Butler 1991, Hall et all 1998)
Straight leg raise tibial nerve bias
• • • • • Patient lies supine, no pillow, with arms at side or resting on abdomen. Note resting symptoms. Dorsiflex and evert foot. Note symptoms. Maintain dorsiflexion and eversion while applying overpressure to knee extension. Note any change in symptoms. Maintain dorsiflexion, eversion, and knee extension while passively raising the leg into hip flexion. Feel for change in tension of the movement. Note any changes in symptoms.
8
Straight leg raise tibial nerve bias
• Normal response is to feel tension along the sciatic nerve. • Increase in symptoms distal to knee during hip flexion maneuver indicates neural tissue involvement. • Reproduction of patient’s symptoms implicates neural tissue as source.
Straight leg raise peroneal nerve bias
• Patient lies supine, no pillow, with arms at side or resting on abdomen. • Note resting symptoms. • Plantarflex and invert foot. Note symptoms. Maintain plantarflexion and inversion while applying overpressure to knee extension. Note any change in symptoms. • Maintain plantarflexion, inversion and knee extension while raising leg into hip flexion. Feel for change in tension of the movement. Note change in symptoms.
9
Straight leg raise peroneal nerve bias
• Increase in symptoms distal to knee during hip flexion component is a positive test for neural tissue involvement. • Reproduction of patient’s symptoms indicate neural tissue as source of symptoms.
10
Common LE neural restrictions
• • • • • Nerve root compression from herniated disc Sciatic nerve as it courses through piriformis muscle Common Peroneal nerve at fibular head Tibial nerve in tarsal tunnel Deep peroneal nerve on dorsum of foot (Anterior Tarsal Tunnel Syndrome (Marinacci 1968, Dellon 1990) • Inferior calcaneal nerve between fascia of the abductor hallucis and quadratus plantae muscles • Interdigital compression (Morton’s neuroma)
(Oh and Meyer 1999)
Example: Medial calcaneal nerve
MOTION • Dorsiflexion, eversion • Knee extension • Hip flexion 42º PATIENT RESPONSE • “pull” in calf • No change or mild increase • Reproduction of burning pain in medial heel
(Meyer et al 2002)
Example: Peroneal nerve
MOTION
• Plantarflex and invert foot • Overpressure knee extension • Hip flexion 50 degrees
PATIENT RESPONSE
• Lateral ankle pain • No change or slight increase symptoms • Increase sharp pain lateral ankle, may extend to lateral calf
11
Ankle Sprain/Neurodynamics
• EMG studies and sensation testing in subjects s/p grade III ankle sprain showed: -86% injured peroneal nerve -83% injured tibial nerve
( Nitz et al 1985 as cited in Pahor and Toppenberg 1996)
Ankle Inversion Sprain
• • • • Re-injury rate s/p lateral ankle sprains in athletes as high as 80% Chronic symptoms in up to 40% of patients No correlation between mechanical and functional instability. 50% of functional unstable ankles are mechanically stable. Attributed to:
-Abnormal joint mechanics -poor proprioception -functional instability
(Baxter 1995, Denegar et al 2002, Jennings and Davies 2005, Osborne and Rizzo 2003)
Ankle Sprain Treatment
• • • • • • Proprioceptive and balance training Joint mobilization to restore normal mechanics Strengthening Neural mobilization Functional training Functional stability can be restored with use of wobble board
(Baxter 1995, Osborne and Rizzo 2003, Rubenstein and Shay 1991, van Os et al 2005)
12
Mulligan theory on “Ankle Sprains”
• Theory: Ankle inversion injury may result in anterior displacement of distal fibula versus sprain of ATFL or CFL
(Kavanagh 1999, Mulligan 2004)
MWM “Ankle Sprain” Test
• Patient supine, foot off edge of table • Stabilize tibia • Apply dorsal cephalad glide of lateral malleolus • Foot will evert when force is correctly applied • Maintain glide while inverting foot • Glide and inversion MUST be painfree • Positive Test: Enables painfree inversion/eversion ROM
13
MWM “Ankle Sprain” Treatment
• • • • • • • Repetitions Taping to stabilize lateral malleolus posterior Proprioceptive retraining May need modalities for swelling control Swelling usually resolves by next day Do not immobilize Can be performed at any time post-injury but best immediately post-injury
Cuboid Syndrome
• 4% of athletes with foot pain • 17% of professional ballet dancers • Cuboid manipulation effective to resolve symptoms
(Jennings and Davies 2005, Mooney and Maffey-Ward 1994)
14
s/p Bunionectomy
• TREATMENT: • Modalities to reduce swelling • Hallux AP and PA mobilization to restore normal arthrokinematics to the MTP joint • ROM • Gait training/ balance • Pool walking • Soft tissue mobilization • Taping
Bunion Taping
15
For your consideration
• Neural implications s/p bunionectomy
– CASE STUDY – Most treatment is performed with patient in long sit. – While working with a patient with a particularly stiff first MTP s/p bunionectomy (0-30 degrees, very stiff with pain) she reported that her sciatica had been acting up which she attributed to her antalgic gait. She had been receiving physical therapy for 2 weeks with minimal changes in hallux ROM. Evaluation revealed +SLR for lower back pain and stiff L4-5 spinal segmental mobility. Treatment included 5 minutes of lumbar segmental mobilization followed by sciatic nerve mobilization for 3 minutes. We then immediately resumed hallux ROM and found that ROM had improved to 10-0-75 degrees without pain.
16
LORI RUBENSTEIN, MAppSc, PT, FAAOMPT
Los Angeles, CA
Podiatry and Physical Therapy
• We both recognize that foot and ankle dysfunction affects the mechanics elsewhere in the body. • Physical therapists are considered movement specialists. • Toenail case
Case study
• Patient referred for LBP • PMH: 7 years ago s/p left calcaneal ORIF • PT treatment focused on modalities for swelling and pain management control. • Present findings include -10 degrees talocrural dorsiflexion resulting in compensatory gait pattern and lumbosacral dysfunction.
1
RESULTS
• One physical therapy treatment with the techniques we’ll be discussing today restored talocrural ROM to +5 degrees dorsiflexion and eliminated compensatory gait pattern thus reducing her back pain.
Case study
• There is a lot more that physical therapy can do for your patients that may enhance their treatment outcomes and prevent compensations elsewhere.
Introduction
• Review of the podiatric and medical foot and ankle literature usually references physical therapy without specification as to what types of physical therapy treatments are indicated. The aim of this lecture is to discuss some of the physical therapy interventions that are available and their indications with relation to common foot and ankle diagnoses.
2
Outline
• • • • • • • Modalities Exercise Gait Physical Therapy evaluation Joint mobilization Neurodynamics: tibial and peroneal nerves Common podiatric conditions
1. Ankle inversion sprain 2. Cuboid syndrome 3. Bunionectomy
Modalities
• • • • • • Ultrasound Phonophoresis Iontophoresis Electrical Stimulation Contrast Baths Light laser • Management of pain and swelling • Reduce muscle spasm • Reduce calcifications within tendons • Enhance tissue healing
EXERCISE
• Stretching • Strengthening • Proprioceptive training (Podiatry Today, Denegar et al
2002, Osborne and Rizzo 2003, Verhagen et al 2004)
• • • •
Balance Neuromuscular re-education Functional Training (Baxter 1995, Osborne and Rizzo 2003) Sports specific training (Baxter 1995)
3
GAIT
• Gait training with assistive device • Proper fitting of device • Post-op/Post-injury gait training to avoid compensatory patterns
(Rubenstein 1988)
PHYSICAL THERAPY EVALUATION
– – – – – – – – – Observation ROM (physiological) Muscle testing/strength Neurological Palpation Joint mobility/arthrokinematics (accessory mobility) Gait Function Neurodynamics
(Petty and Moore 2002)
Joint Mobilization/Arthrokinematics
• Accessory mobilization to restore normal mobility to a joint. • Capsular restriction.
4
Joint Mobility/Arthrokinematics
Common areas treated: • Talocrural (restore talus posterior glide) • Cuboid (reduce plantarflexed cuboid) • Hallux (restore MTP glide to restore physiological ROM)
( Hartman 1997, Petty and Moore 2002)
Joint Mobilization
Example:
– First MTP joint mobility restriction
• Superior glide of proximal phalanx on metatarsal to restore dorsiflexion • Inferior glide of proximal phalanx on metatarsal to restore plantarflexion
• Used in conjunction with physiological ROM exercises
Mobilization
• Dananberg et al 2000 reported twice the gains in dorsiflexion ROM following one session of manipulation of the talocrural and proximal tibiofibular joints versus 6 months of calf stretching.
(Dananberg et al 2000, Denegar et al 2002)
5
Mobilization with Movement
• • • • • MWM Brian Mulligan, New Zealand Positional fault theory Treatment must be pain-free! When performed correctly MWM results in immediate restoration of painfree ROM
(Mulligan 2004)
MWM to restore dorsiflexion
• In weightbearing, patient may experience anterior impingement if the talus does not glide posteriorly during dorsiflexion. • Therapist facilitates talar posterior glide during active weightbearing dorsiflexion
(Collins et al 2004, Denegar et al 2002, Mulligan 2004, Kavanagh 1999)
6
Some causes of loss of ROM
• Muscle length • Decreased accessory mobility • Decreased nerve mobility • Stretching • Joint mobilization • Neural mobilization
NEURODYNAMICS
• Physical mobility of the nervous system including spinal cord, meninges ,nerves. • Restricted mobility may result in traction or compression and decreased blood flow to the nerve, decreased axoplasmic flow, decreased conductivity and symptoms of tingling or pain.
NEURODYNAMICS
• Physical nervous system is a continuum. • Spinal cord must adapt to the 5-9cm changes in spinal canal length that occur with transition from extension to flexion. • Sciatic nerve must adapt to changes of at least 12% it’s resting length during SLR. • Restriction of neural mobility can result in pain, nerve compression, neuropathy and traction injury.
7
Tests for LE neural mobility
• Straight leg raise
– Tibial nerve bias – Peroneal nerve bias
(Butler 2000, Butler 1991, Hall et all 1998)
Straight leg raise tibial nerve bias
• • • • • Patient lies supine, no pillow, with arms at side or resting on abdomen. Note resting symptoms. Dorsiflex and evert foot. Note symptoms. Maintain dorsiflexion and eversion while applying overpressure to knee extension. Note any change in symptoms. Maintain dorsiflexion, eversion, and knee extension while passively raising the leg into hip flexion. Feel for change in tension of the movement. Note any changes in symptoms.
8
Straight leg raise tibial nerve bias
• Normal response is to feel tension along the sciatic nerve. • Increase in symptoms distal to knee during hip flexion maneuver indicates neural tissue involvement. • Reproduction of patient’s symptoms implicates neural tissue as source.
Straight leg raise peroneal nerve bias
• Patient lies supine, no pillow, with arms at side or resting on abdomen. • Note resting symptoms. • Plantarflex and invert foot. Note symptoms. Maintain plantarflexion and inversion while applying overpressure to knee extension. Note any change in symptoms. • Maintain plantarflexion, inversion and knee extension while raising leg into hip flexion. Feel for change in tension of the movement. Note change in symptoms.
9
Straight leg raise peroneal nerve bias
• Increase in symptoms distal to knee during hip flexion component is a positive test for neural tissue involvement. • Reproduction of patient’s symptoms indicate neural tissue as source of symptoms.
10
Common LE neural restrictions
• • • • • Nerve root compression from herniated disc Sciatic nerve as it courses through piriformis muscle Common Peroneal nerve at fibular head Tibial nerve in tarsal tunnel Deep peroneal nerve on dorsum of foot (Anterior Tarsal Tunnel Syndrome (Marinacci 1968, Dellon 1990) • Inferior calcaneal nerve between fascia of the abductor hallucis and quadratus plantae muscles • Interdigital compression (Morton’s neuroma)
(Oh and Meyer 1999)
Example: Medial calcaneal nerve
MOTION • Dorsiflexion, eversion • Knee extension • Hip flexion 42º PATIENT RESPONSE • “pull” in calf • No change or mild increase • Reproduction of burning pain in medial heel
(Meyer et al 2002)
Example: Peroneal nerve
MOTION
• Plantarflex and invert foot • Overpressure knee extension • Hip flexion 50 degrees
PATIENT RESPONSE
• Lateral ankle pain • No change or slight increase symptoms • Increase sharp pain lateral ankle, may extend to lateral calf
11
Ankle Sprain/Neurodynamics
• EMG studies and sensation testing in subjects s/p grade III ankle sprain showed: -86% injured peroneal nerve -83% injured tibial nerve
( Nitz et al 1985 as cited in Pahor and Toppenberg 1996)
Ankle Inversion Sprain
• • • • Re-injury rate s/p lateral ankle sprains in athletes as high as 80% Chronic symptoms in up to 40% of patients No correlation between mechanical and functional instability. 50% of functional unstable ankles are mechanically stable. Attributed to:
-Abnormal joint mechanics -poor proprioception -functional instability
(Baxter 1995, Denegar et al 2002, Jennings and Davies 2005, Osborne and Rizzo 2003)
Ankle Sprain Treatment
• • • • • • Proprioceptive and balance training Joint mobilization to restore normal mechanics Strengthening Neural mobilization Functional training Functional stability can be restored with use of wobble board
(Baxter 1995, Osborne and Rizzo 2003, Rubenstein and Shay 1991, van Os et al 2005)
12
Mulligan theory on “Ankle Sprains”
• Theory: Ankle inversion injury may result in anterior displacement of distal fibula versus sprain of ATFL or CFL
(Kavanagh 1999, Mulligan 2004)
MWM “Ankle Sprain” Test
• Patient supine, foot off edge of table • Stabilize tibia • Apply dorsal cephalad glide of lateral malleolus • Foot will evert when force is correctly applied • Maintain glide while inverting foot • Glide and inversion MUST be painfree • Positive Test: Enables painfree inversion/eversion ROM
13
MWM “Ankle Sprain” Treatment
• • • • • • • Repetitions Taping to stabilize lateral malleolus posterior Proprioceptive retraining May need modalities for swelling control Swelling usually resolves by next day Do not immobilize Can be performed at any time post-injury but best immediately post-injury
Cuboid Syndrome
• 4% of athletes with foot pain • 17% of professional ballet dancers • Cuboid manipulation effective to resolve symptoms
(Jennings and Davies 2005, Mooney and Maffey-Ward 1994)
14
s/p Bunionectomy
• TREATMENT: • Modalities to reduce swelling • Hallux AP and PA mobilization to restore normal arthrokinematics to the MTP joint • ROM • Gait training/ balance • Pool walking • Soft tissue mobilization • Taping
Bunion Taping
15
For your consideration
• Neural implications s/p bunionectomy
– CASE STUDY – Most treatment is performed with patient in long sit. – While working with a patient with a particularly stiff first MTP s/p bunionectomy (0-30 degrees, very stiff with pain) she reported that her sciatica had been acting up which she attributed to her antalgic gait. She had been receiving physical therapy for 2 weeks with minimal changes in hallux ROM. Evaluation revealed +SLR for lower back pain and stiff L4-5 spinal segmental mobility. Treatment included 5 minutes of lumbar segmental mobilization followed by sciatic nerve mobilization for 3 minutes. We then immediately resumed hallux ROM and found that ROM had improved to 10-0-75 degrees without pain.
16
