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I am grateful to Bruce Williams for allowing this to be filmed at the PFOLA mtg:



There is more discussion in this previous thread:
Mobilisation and ankle joint range of motion

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Nicely done, Bruce......you know....there is still time for a career in television documentaries!

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Kevin

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brilliant-i wish i had been taught that stuff at college! thanks,peter mccloskey

I would understand this to be post-grad stuff. Does anyone know where can you go and learn how to do these maneuvers in the UK?

I remember reading an article on these exact maneuvers but being very disappointed with the outcome - the before and after photographs were 'doctored'; the fibular angle was different on the two pictures. However this does show quite definitively that it works!! Brilliant!!

Hi Bruce

Thanks for the video. Being a visual and kinesthetic learner it was good to see the technique.
I was interested in your pre and post treatment tests and wonder if you ever include patterned muscle movement tests as part of the pre and post assesment. I ask because I tend to use a number of Maitland techniques and would include these tests as part of the pre and post asessment, especially in the case of lateral ankle injuries strains etc. Just interested if others do similar.

Cheers
Ian

Hi Peter

I learnt my peripheral mobilistations via the society of sports therapists in the UK. Excellent weekend course for the low limb that extended as far as hip mobilisation. I suspect that much of this stuff is underused within podiatric BMX and certainly forms part of the foot and ankle rehab part of the BMX treatment plans I do

You could also look at the SOBART courses that are based, I think, near Nottingham. An internet search will pull them up. Actually been tempted to go and refresh the skill base again myself.
Cheers
Ian

Peter,

SOBSART are running a 2 part course next year that you may be interested in.

17 July 2010: Soft Tissue Manipulation and Mobilisation of the Foot & Ankle (Part 1)
04 Sept 2010: Soft Tissue Manipulation and Mobilisation of the Foot & Ankle (Part 2)

More info here

Ian

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hi Ian,

thanks very much,

Peter

My wife has always said I have a great face for radio!
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Ian;

can you explain what a patterned muscle movement test is to me please? I'm unfamiliar with that term.
Thanks
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Hi Bruce

The term may not be the most appropriate but it relates to the capacity of a patient to achieve ranges and direction of movement in a non-weight bearing position, for example, supine with the feet over the edge of the seat. It also relates to the capacity of the foot to combine two or more of its triplanar functions at the same time.

With the pt supine or seated upright:

1 Ask them to dorsiflex the foot, then ask them to invert the foot.

Enquire which of the movements seemed easier (if any). Although you may be interested in the injured foot/ankle I get them to do it bilateral (one at a time) and then bilateral (both at the same time). Note any differences in function between the two feet/ankles

2 Then ask them to combine dorsiflexion and invertion of the foot at the sametime, one at a time and then bilateral - usually slowly. This is the patterned movement you are checking. Dorsiflexion and inversion being one of the combined movements in our gait, this test gives an insight into any possible muscular or ligamentous (?) inhibition of function.

In pts with a history of lateral ankle injuries, performing the combined movement, I have found it common to see dorsflexion be okay but the inversion ability at the same time to be inhibited/delayed by comparison.

Additionally I have found similar issues with the markedly pronated foot pt where they are impacting on soft tissues around the lateral ankle or S. Tarsi.

Equally their peroneal power against resistence is frequently low.

I would then provide either massage to the area (sometimes as little as 2 minutes brings noticable benefit) or peripheral joint mobilisation or both, usually seeing a marked improvement both in restored range of movement, regained power against resistence and improved patterned function.

Seems to work for my folk but there may well be others who do similar under a different name.

Hope the explaination is reasonably clear.

Cheers
Ian

Ian;
I have not utilized that particular array of tests in that manner. I will definitely keep in mind though. Thanks for the explanation!
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Hi Bruce

Be interested if you ever come across similar results. Certainly did find your video helpful though.

Ian

Hi Ian and Bruce,

you say that the mobilisation/manipulation restores ankle dorsiflexion power (Bruce in video refers to increased peroneal power). Do you have any explanation for such an immediate restoration?

Secondly I read that patients with previous ankle injuries quite often loose muscle strength if not rehabilitated due to - reduced nerve conduction and reduced proprieception due to nerve damage. Do you have any feed back on this point?


Peter

hi. thanks for the video. very interesting.

when would you do this to a patient? also, is this a one off treatment to improve ankle joint ROM or would it reqire regular repetition?

does anyone know anyone who teaches this in AUS? any courses etc?

thanks

Phil

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Phil Marshman
Mackay, Queensland Australia

should check for it at every orthotic issue most seem to be one off; but some do need it again normally do it as part of Boot Camps, but not recently due to an unrelated chronic pain problem I got in my arms

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Department of Podiatry
La Trobe University
Melbourne, Australia
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How terrific to see footage of manual therapy techniques on YouTube. Well done Bruce.

A search of 'foot mobilisation' offers less than 6 practical examples of techniques for practitioners and the public to view.

Thank you too, Bruce, for inspiring me to get off my butt and adding to YouTube's storehouse.http://www.podiatry-arena.com/images/smilies/drinks.gif

www.youtube.com/watch?v=xlOQZHYX5us

I note Bruce, that your clip is titled 'Mobilisation' but you call your techniques 'Manipulations'. Based on the definitions used in chiropractic (Michaud) and physiotherapy (Maitland) the techniques you demonstrated are actually 'mobilisations', i.e. they are performed at a force and speed that the recipient could overcome. A manipulation is performed at a force and speed that the recipient cannot overcome - usually because it happens so fast (240-280msec) that it's all over before they can do anything about it.

I think the definitions are important because 'manipulation' often gets a bit of bad press when it is abused or not performed correctly. The public too, can raise their eyebrows at the mention of 'manipulation' let alone podiatrists.

'Mobilisations' are certainly safer for practitioners with limited experience in manual therapies and your demonstration shows how straightforward and beneficial manual techniques are. Like any new skill, with experience comes confidence.

www.footmobilisation.com might be a start. It is my field of interest Phil and I do have a vested interest in educating other practitioners. I don't have any other suggestions within podiatry.

Mark Charrette (chiropractor) runs an excellent 'Extremities Adjusting' course with Foot Levellers Co. but you have to be a chiro to register for it. I found his course the most useful manual techniques course I've done this millenium.
Paul Conneelly also runs an interesting course '2 days at the Talus'.

Good Luck,
Ted.

Peter;

from my perspective I think it has as much to do with the ability of the peroneals to be stretched completely in midstance with an increase in AJ Dfion as anything else. Dr. Dananberg has a great lecture on this and talks about the sesorimotor adn pain pathways and how he thinks the manipulation effects that. I agree with him.

Craig Payne and i talked this last weekend at PFOLA in Atlanta and Craig summed it up well. He said that once the three primary DFing muscles, also stabilizing muscles, of the foot / midfoot are functioning "normally" again, many problems associated with the achilles, PT "itis", peroneal problems and midfoot problems, seem to diminish or disappear.

Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Phil;

I manipulate the majority of my patients who have foot, ankle complaints. I don't usually manipulate those with warts, ingrown nails, nail problems and bunions and hammertoes or corns. Almost all others, if they will be treated with a CFO, will be initially treated with manipulation and taping.

I'll manipulate before CFO casting as well. I thnk the manipulation will help in positioning during casting. I will often manipulate at orthotic pickup as well.

Interesting to note, that rarely do I have to do more manipulation after this except when the prescription is not correct, or the patient is not wearing the devices regularly. Anectdotal, but interesting.
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Ted;
thanks much for the definition education between mobilization and manipulation. I call it manipulation b/c that is what Howard Dananberg calls it. He taught me, so it sticks.

I will note that I should probably add or send a video update to Craig b/c Howard now uses a different technique at the fibular head. He places the thenar portion of the hand on the fibular head, proximal, wiht the patients knee fully flexed adn then pushes the lower let towards the buttocks. This technique is much gentler on the practitioners hands adn wrists as I can surely attest after using the one I demonstrated in the video for the last 9-10 years or so!

Howard says that Paul Conneely is definitely one of the best at mobilization / manipulation he has ever seen. I did not have the pleasure of meeting him a few years ago and am surely the worse for that.

Cheers!
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

From your site, Ted: "Looking for proven alternative treatment options for biomechanical & musculo-skeletal conditions?"

Could you post the references for your "proof" please?

Thanks.

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Hi Bruce,
This is the technique I prefer too. It's simple, quick, easier for the practitioner to control the application of the manipulative force and, as you've noted, easier on the practitioner.
It can be performed with the patient sitting (Conneely) but I find this not as specific because of lateral instability of the patient's knee in the frontal plane when applying the manipulative force. It saves having to roll the patient over to a prone position though.

My preference is to do manual mob/manip with the patient prone because I can position their foot at the optimum height for me (mid sternum). I then roll the patient over to sitting up. Our treatment tables have built in 'drop piece' mechanisms which permit the delivery of a significant manipulative force while being very easy on the practitioner. This means you don't have to be too 'buff' to manipulate and you are delivering the force in a very safe and controlled manner; most important for manipulation.

Simon, Please see www.footmobilisation.com/01_references.html

Cheers,
Ted.

Ted, I am familiar with many of these references (many of them textbooks) but which of these references specifically prove the efficacy of manipulation / mobilisation in the treatment of biomechanical & musculo-skeletal conditions of the foot?

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Hi Simon,

If we agree that 'efficacy' is defined as ability to produce the necessary or desired results then we need to clarify the 'desired results'.

My view is that mobilisation and manipulation techniques are employed to reduce stiffness and joint hypomobility. This hypomobility resulting from connective tissue adaptation associated with reduced joint ROM is well documented as a physiological response (Akeson 1961, Woo et al 1975, Akeson et al 1977, Akeson 1980, Binkley 1982, Maitland 1991, Michaud 1993).

The 'desired result' in treating joint stiffness/hypomobility is to reduce the joint stiffness and increase the joint mobility. In my experience, joint stiffness and hypomobility are aetiological factors in many biomechanical and musculo-skeletal conditions of the foot and leg. This is supported by the research contained in Craig Payne's Clinical Bootcamp 2009.

Mobilisation and manipulation has been demonstrated to increase joint mobility and reduce joint stiffness in Bruce's video and in the following references; (Mennell 1970, Woo et al 1975, Wyke 1980, Lowther 1980, So 1986, Lantz 1989, Maitland 1991, Michaud 1993, Logan 1995).

These references explain the physiological responses of connective tissues to immobilisation and mobilisation. While these were researched and documented several decades ago and I think it is unlikely that the nature of connective tissue has changed in that time to discount the findings as 'too old.'

I do wonder though Simon, if you are more interested in research that is 'outcome based' using mobilisation and manipulation techniques for symptomatically labelled conditions. I know that many podiatrists ask me the question 'where's the research that proves that FMT works?' E.g. where's the research that FMT helps plantar fasciits?

To my knowledge, this evidence remains anecdotal and no rigorous RCT has been completed (yet). Dananberg's work might be the closest thing so far...

Manual therapy based professions (physiotherapy, chiropractic, remedial therapy) are largely based on the principles of immobility and mobilisation. I'm confident there's something in it and I'd like to see manual therapies employed within podiatry to a much greater degree than it is at the moment. I don't see any downside to this aim.

Cheers,
Ted

Very good idea, it would be nice to have more videos like this.
From Spain, thank you very much and congratulations.
Greetings

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Nice video Ted. Seeing in your recent paper in Podiatry Now you do a different talar mobilisation - can you elaborate?

Any update on the plans to come to the UK?

Thanks Lawrence.

Each mobilisation technique usually has several options. They may involve different positions of the practitioner and/or patient. It's not that one technique is necessarily better than another, rather, I think it's important which technique is most efficient for the practitioner and safest for achieving the desired result for the patient.

As I specialise in Foot Mobilisation Techniques (FMT) full time, I've found that some techniques can be more taxing on my body than others so I'm constantly on the lookout or experimenting with the techniques to achieve the desired result as efficiently as possible.

I'm about to post a clip on the Arena's YouTube channel after receiving a request for vision of the cuboid manipulation. I've selected 3 techniques and gone through the pros and cons of each. Stay tuned...

BTW, I've received a lot of interest from you gorgeous poms since the article. It seems that FMT has really struck a chord with you Brits. I'm planning on running some FMT Courses in the UK in April next year. I hope to catch up with you then for a

Cheers,
Ted.

Clever ! So its a case of knowing what force you want to apply to whatever joint you want to apply it to and then find the "best" way of doing so? How do you measure success?

Some of these colonials are actually quite clever chaps - must be because you're upside down all the time - all the blood goes to the brain?

Ted,
Thank you for your honest and open reply. I guess that I was "looking for proven alternative treatment options for biomechanical & musculo-skeletal conditions" I understand about immobilisation and it's effects on the tissues of the body, I also recognise that reduced range of motion at various joints has been identified among the predictors of certain foot pathologies, and indeed may define certain pathologies, i.e. hallux limitus. I was hoping, given the statement on your website, that you could provide references which show that mobilisation/ manipulation could alleviate the symptoms of named foot conditions. Or, references which demonstrated an equal or better success rate in the treatment of said conditions, so that we could view this as an "alternative". It is clear to me now that this is not yet the case.

Don't get me wrong, I have been using manual therapy in my clinical practice for many years and I do believe it is helpful as an adjunct to other therapies. I may even attend your course should you come to the UK.

Once again, thank you for your honest replies.

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Hi Simon,
What an inspirational word - 'YET'.

There seems to be numerous practitioners who find efficacy in applying FMT in their clinical practices while the sceptical population awaits for the 'evidence' before giving it a go. I'm not saying this is a bad thing, rather, just that it can be a little frustrating not having the 'accepted' form of evidence to backup what many of us find clinically.

I'm more of a 'hands on/put things into action' kinda guy and I always have to take a big breath before I can even consider the 'researching FMT' pathway.
Oh well, maybe someone else will run with this baton?

Precisely Lawrence! Utilising one's clinical skills, one determines where the joint hypomobility lies (that is due to connective tissue restrictions) and then devises a treatment plan to treat that region AND the related joints/tissues. It's SO important to remember the interconnectivity between different joints and their relations. E.g. in treating a subluxed cuboid, one MUST check the fibula and the head of the femur/greater trochanter because of the peroneus longus>Lat. hamstring/ITB connections.

We use several methods of recording changes pre- and post- treatment. I haven't found one definitive method that works every time. This is the nature of working with diverse human beings I guess.

Subjectively:
Client's chief complaint(s)
Foot Health Status Questionnaire (every case that we are able to accept and undertakes our service completes the FHSQ before, during and after treatment).

Objectively:
Clinical exam of ROM, QOM, Foot Posture Index, Gait analysis.
Static w/b x-ray analysis (to rule out FMT contraindications and record joint positions pre- and post- treatment. This does have some limitations though...)

Uniquely:
My hands. This is the 'art' of FMT. The qualitative 'feel' joints have pre- and post- treatment is just so difficult to record empirically. It's like trying to explain to someone what a banana tastes like if they have never tasted one! How do you do it??

We don't accept every case that comes to us because we know that FMT is not indicated in every case. It's up to our practitioners to make a professional assessment of the client and then assess the best recommendation from there. If we can't help a case, the best thing we can do is refer them on to someone who can help. (BTW, it's amazing how many WOM referrals we get from people we've never treated!)

!etam thgir ydoolb ooT

deT