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I disagree. A foot with a laterally positioned STJ axis could be considered as a foot with an excessively supinated gait. Whether or not to add a forefoot valgus wedge would be dependent on the eversion range of motion of the forefoot in stance. If the person has a lot of eversion range of motoin available and is "oversupinated" or has a problem like peroneal tendonitis, then adding a forefoot valgus wedge would be quite beneficial. A foot with a laterally deviated STJ axis can have high pressures under lateral forefoot and have a large range of eversion range of motion available. Although a foot with a partially compensated varus will also tend to have high pressure sub 5th met. You can tell the difference between these feet with the Coleman block test or assessing maximum eversion height.
Eric
You could add a FF Valg Wdg, but that is often TOO late (LMS to Toe-Off Phase of Gait) to "catch" the rearfoot from inverting, rolling, or spraining; in order to prevent the RF from chronically inverting all too easily, especially in the laterally placed STJ-A, place a laterally based wedge of 2, 4, or 6mm, depending on the severity of the instability and the size of the patient.
"Intrinsic STJ-Instability (STJ-I) is eval'd by putting the STJ thru a ROM, and then one will feel either a smooth arc (normal), little to no motion (suspect coalition, either caritilaginous or ossseous), or as though there is a sharp "dell of the arc of ROM" and the ankle 'gives way laterally' (=STJ-I)...
Now, this is the rearfoot (ankle) that rolls/inverts/sprains--EVEN when sub 5th MT head is loaded and one places their other index finger sub proximal medial heel!! Yes, in heel contact to rearfoot loading phase of gait, one should [needs] to place a medial wedge in to ALL shoe gear and/or onto their Functional Foot Orthotics.
Any questions. Do this and your patients will luv you.
Also, place your patients into a Bioskin Biolok (low profile, ultra-breathable) ankle brace, with the straps reefed up/locked in place while the ankle/rearfoot is dorsiflexed & everted into the position of maximal stability. This is for work, play, exercise, and uneven terrain such as for military et al.
How do you like it know. The total package. Stability from the ground up and all around the ankle.
You could add a FF Valg Wdg, but that is often TOO late (LMS to Toe-Off Phase of Gait) to "catch" the rearfoot from inverting, rolling, or spraining; in order to prevent the RF from chronically inverting all too easily, especially in the laterally placed STJ-A, place a laterally based wedge of 2, 4, or 6mm, depending on the severity of the instability and the size of the patient.
I would agree that a valgus heel wedge would work sooner than a forefoot wedge in heel to toe gait. I don't understand why a forefoot valgus wedge working later is a problem. The effect of the forefoot wedge would be seen as soon as the forefoot hits the ground. If there is range of motion of the STJ available the forefoot valgus wedge will tend to put the STJ in a more pronated position and this will be accompanied by more internal leg rotation which will move the STJ axis to a more medial position. With the axis and the foot in that position the ground will be less likely to cause the STJ to invert and "roll". So, there is no reason not to use the forefoot valgus wedge if there is STJ range of motion available.
Quote:
Originally Posted by WillTrekker
"Intrinsic STJ-Instability (STJ-I) is eval'd by putting the STJ thru a ROM, and then one will feel either a smooth arc (normal), little to no motion (suspect coalition, either caritilaginous or ossseous), or as though there is a sharp "dell of the arc of ROM" and the ankle 'gives way laterally' (=STJ-I)...
The "dell of the arc" was something taught to me back in podiatry school. I looked at it a fair amount around that time, but I don't recall correlating that with the complaint of ankle instability in gait. We've had a couple of discussions about what causes the examiner to experience the "sharp" sensation. Having looked at a fair number of cadaver specimens, I haven't seen anything anatomical that could explain that sensation. My explanation is that when you move the STJ when holding the fifth metatarsal the position of the applied force changes more quickly than in feet without the sharp sensation. You also don't get the sharp sensation when you move the STJ when grasping the calcaneus.
What do you think causes the sharp sensation? Why do you think the sharp sensation would correlate with ankle instability?
Quote:
Originally Posted by WillTrekker
Now, this is the rearfoot (ankle) that rolls/inverts/sprains--EVEN when sub 5th MT head is loaded and one places their other index finger sub proximal medial heel!! Yes, in heel contact to rearfoot loading phase of gait, one should [needs] to place a medial wedge in to ALL shoe gear and/or onto their Functional Foot Orthotics.
Did you really mean to say medial wedge? In a foot with an extreme laterally positioned axis, the 5th met head may sit medial to the axis and force here will still cause supination. A valgus heel and forefoot wedge can help by decreasing supination moent from the ground by shifting the center of pressure more laterally. If there is range of motion, the valgus (lateral) wedge can move the axis more medial as explained above.
Of course, as you mentioned you can work use an ankle brace to apply moments to the STJ from something other than changing the location of ground reaction force.
This is a very interesting thread that I have monitored until now.
There seems to be agreement that there is a laterally deviated STJ Axis in play.
I am not sure if the forefoot position that is being discussed here is equally in agreement. Is it pronated or supinated?
I read that it is everted but I'm looking more for the sagittal plane component, as I'm not so sure that inversion forefoot moments are the real culprit.
In addition, there seems to be a greater supinatory moment produced in the UA compared to the its mate with the same injurious force. Perhaps this is indicative of an assymetry of the limbs where the short side is more inverted and therefore is more apt to sprain when challenged with supinatory moments.
Perhaps a lift on the UA might help or LLD should be considered as culpatory? After all, a 1/2" valgus wedge in the rearfoot with have a 1/4" lift effect.
Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability.
Hoch MC, Andreatta RD, Mullineaux DR, English RA, Medina McKeon JM, Mattacola CG, McKeon PO. J Orthop Res. 2012 May 18. doi: 10.1002/jor.22150.
Quote:
We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24-48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre-intervention measures or between the post-intervention and 1-week follow-up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week
Objective: The purpose of this study was to evaluate the effects of joint mobilization on ankle dorsiflexion range of motion, dynamic postural control, and self-reported patient outcomes in individuals with chronic ankle instability (CAI). A secondary purpose was to determine which contributing factor or factors can improve a participant’s performance on the Star Excursion Balance Test.
Design: This research study was a single-blinded, randomized control trial with one between factor (2 levels: intervention and control) and one within factor (pre- and post-intervention). Participants: Seventeen participants with self-reported unilateral CAI, between 18 and 35 years of age, were recruited from the University of Toledo community and were randomly allocated to two groups, intervention and control.
Methods: Participants completed one testing session that included a non-weight bearing dorsiflexion measurement using a bubble inclinometer, a weight-bearing dorsiflexion measurement using the Weight Bearing Lunge Test and dynamic postural control measured by the Star Excursion Balance Test (SEBT) pre- and post-intervention. The intervention consisted of a Maitland Grade IV oscillatory anterior-to-posterior talar joint mobilization.
Main Outcome Measures: The main outcome measures were dorsiflexion range of motion, dynamic postural control and self-reported patient outcomes. Factors contributing to the performance of the SEBT in individuals with CAI were also determined. Statistical Analysis: The means and standard deviations of the absolute change scores were used for statistical analysis. The independent sample t-test was used to compare each dependent variable between the intervention and control groups. A Cohen’s d effect size along with 95% confidence intervals (CI) was calculated for each comparison between groups and between pre-and post-intervention measurements to determine the magnitude of the joint mobilization effect. A multiple linear backward regression model analysis was also performed to determine which dependent variables influence the improvement of the SEBT performance.
Results: There were no statistically significant results for the main outcome measures. However, large effect sizes were identified for the anterior reach of the SEBT, non-weight bearing dorsiflexion and a reduction in pain when comparing the two groups. A large effect size was also determined for non-weight bearing dorsiflexion, pain, and stability when comparing pre- and post-intervention scores for the joint mobilization group and for weight-bearing dorsiflexion for the control group.
Conclusion: A single dose of a Maitland Grade IV anterior-posterior talar glide joint mobilization did not result in statistically significant improvements in DF range of motion, dynamic postural control, and self-reported patient outcomes, but some of the outcome measures resulted in large effect sizes. This indicates that joint mobilizations may provide potential clinical benefits for the improvement in DF range of motion, dynamic postural control, and pain in patients with CAI
In Vivo Kinematics of the Talocrural and Subtalar Joints With Functional Ankle Instability During Weight-Bearing Ankle Internal Rotation: A Pilot Study.
Kobayashi T, No Y, Yoneta K, Sadakiyo M, Gamada K. Foot Ankle Spec. 2013 Feb 25.
Quote:
Functional ankle instability (FAI) may involve abnormal kinematics. However, reliable quantitative data for kinematics of FAI have not been reported. The objective of this study was to determine if the abnormal kinematics exist in the talocrural and subtalar joints in patients with FAI. Five male subjects with unilateral FAI (a mean age of 33.4 ± 13.2 years) were enrolled. All subjects were examined with stress radiography and found to have no mechanical ankle instability (MAI). Lateral radiography at weight-bearing ankle internal rotation of 0° and 20° was taken with the ankle at 30° dorsiflexion and 30° plantar flexion. Patients underwent computed tomography scan at 1.0 mm slice pitch spanning distal one third of the lower leg and the distal end of the calcaneus. Three-dimensional (3D) kinematics of the talocrural and subtalar joints as well as the ankle joint complex (AJC) were determined using a 3D-to-2D registration technique using a 3D-to-2D registration technique with 3D bone models and plain radiography. FAI joints in ankle dorsiflexion demonstrated significantly greater subtalar internal rotation from 0° to 20° internal rotation. No statistical differences in plantar flexion were detected in talocrural, subtalar or ankle joint complex kinematics between the FAI and contralateral healthy joints. During ankle internal rotation in dorsiflexion, FAI joints demonstrated greater subtalar internal rotation. The FAI joints without mechanical instability presented abnormal kinematics. This suggests that abnormal kinematics of the FAI joints may contribute to chronic instability. FAI joints may involve unrecognized abnormal subtalar kinematics during internal rotation in ankle dorsiflexion which may contribute to chronic instability and frequent feelings of instability.
Effects of Chronic Ankle Instability on Energy Dissipation in the Lower Extremity
Terada, Masafumi; Pfile, Kate R.; Pietrosimone, Brian G.; Gribble, Phillip A. Medicine & Science in Sports & Exercise: 8 May 2013
Quote:
Purpose: To investigate the influence of chronic ankle instability (CAI) on lower extremity joint energy dissipation patterns during a stop-jump task.
Method: Nineteen participants with self-reported CAI and 19 healthy control participants volunteered. Participants performed 5 double-leg vertical stop-jump tasks onto a force plate. Lower extremity kinetics and kinematics were examined with an electromagnetic tracking system interfaced with a non-conductive force plate. Lower extremity joint energy dissipations were calculated for the hip, knee, and ankle in the sagittal plane during 50ms, 100ms, 150ms, and 200ms after initial contact (IC) with the force plate. Energy dissipation values were normalized to the product of body mass and height (J/N?m). Individual joint contribution to total lower extremity energy dissipation by the ankle, knee, and hip was reported as the percentage of energy dissipation by each joint over the total energy dissipation of all three joints. Independent t-tests and standard mean differences were conducted to assess differences in each dependent variable between the CAI and control groups. Significance was set a priori at p < 0.05.
Results: The CAI group demonstrated significantly less percentage of knee energy dissipation (p = 0.04) and higher percentage of ankle energy dissipation (p = 0.035) of the total energy dissipation during the 100ms immediately following IC compared to the control group.
Conclusion: We found altered energy dissipation patterns at the knee and ankle during a stop-jump task in the CAI group. These findings may provide insight into kinetic alterations that may be associated with CAI. Future research should consider this information as it may be used to develop more effective interventions to target these potentially modifiable energy dissipation patterns in those with CAI.
Re: Functional ankle instability
Re: Functional ankle instability
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