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Greetings

I am interested in manipulative techniques for the foot and ankle. The only one that I am aware of is H. Dannaberg's article on ankle manipulation. Does anyone here uses manipulation in their practice and where can you find information about it? I learned nothing about this in school.

Ted Jedynak's practice(foot and leg) in Adelaide exclusively uses mobilisation and manipulation and is running a course commencing April. His website www.footandleg.net may give you further information
Iona Millar

Here is my $0.02 ....

There are two aspects to the use of "manipulation" in podiatry practice (its all borrowed from other disciplines, but I am talking about what we can use it
for)

1. There are certain pathologies that we see that can be very responsive to 'manual therapy' (of which manipulation is a part of) that physiotherapists are good at. Those first MPJ "aches" (with no real diagnosis) respond well; cuboid syndrome can respond to manipulation; chronic pain following trauma; manipulation can help patients with significant forefoot supinatus adapt to foot orthoses; there is some good data using ankle manips early post ankle sprain; there is the work that Howard D published on increasing ankle joint ROM with proximal and distal fibula manipulation; etc; ---- ie all quite specific indications (some more evidence based than others).

2. Then there is manipulation of the foot as a philosophy - I prefer to call this 'Functional Manipulative Therapy' (FMT) --- this is more a chiropractic approach - in which the whole sales pitch is about 'subluxations', 'adjustments' etc etc; claims are made about realigning the foot through a series of adjustments and that the patient has things like a "Grade 2 subluxation" (...dosen't that sound serious?). Claims are made about not needing to wear orthotics again etc etc

There are many clinicians using it and I have discussed it with many of them - I have no doubt it will become a more important modality at our disposal. We will be running course on it here at LTU ---- but it will be like the Bill O'Rielly show on Fox --- "the no spin zone" "the spin stops here" - there is so much spin and sales pitch (ie BS) associated with FMT that it is ruining the more widespread uptake of it into clinical practice.

Here are some of the issues I have:
1) The inventing of terminology (eg grade 2 subluxation) to make something sound serious (read any of the anti-chiropractic books out there on this tactic - The Naked Chiropractor is a good one)
2) The approach by some is to make the whole thing into some sort of 'religious' experience - the theosophy of the approach is so ingrained that it is not possible to have a discussion about it --- all you get is a sale pitch and not a discussion (BTW - many Podiatrists are also like that with foot orthoses :) )....
3) They have to stop making the claims about permanently correcting foot alignment. I have looked at the x-ray changes that are claimed to be made by the adjustments - all they are doing is strecthing out a forefoot supinatus -- so of course the arch height returns and maybe they can do without the foot orthoses ---- but something caused the supinatus!!! - the adjustments do not take away the cause! (but they claim it does).

There is no doubt FMT will become more widely used in the future, but the "spin" and "sales pitches" have to stop.

We will have a "no spin zone" FMT continuing ed course here at some stage.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

There is also the Napa Podiatry Worshops in California


PS. Those from Australia might notice the striking similarity between Dr Tikker on the Napa website and John Price from APodC .... is John moonlighting


Also Paul Conneely in Sydney.
www.musmed.com.au

Thank you for your responses. It has given me a lot of think about!

Before applying manual therapy via mobilisation or manipulation, think of what you are trying to achieve as a practitioner. One suitable aim is joint ROM increase. A pre-cursor to this aim however, is the accurate assessment of below-physiological joint motion. Applying the mobilising force to the affected joint should yield motion that is similar or better.


If the joint motion is worse on reassessment, then either the direction of force or the magnitude was not right. Perhaps even consider the joint needs immobilisation; the opposite of manual therapy.

Check out podiatric manipulation at:
http://health.groups.yahoo.com/group...-manipulation/

Ron - I was hoping you would come to this thread :)

I think what you are talking about applies to (1) in my message.

We need to catch up and have a chat about (2).

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I would be interested in your thoughts.



I am in the minority as a musculoskeletal practitioner, when I will invariably emphasise an initial 'cotton-wool' or protective phase post (acute) injury. Suggestions such as "bed rest" for LBP that is aggravated by any weightbearing, and that is better first thing in the morning, is under-prescribed in my opinion.

To use a building analogy; if the initial post acute management is the foundation, if the swelling/debris clearance is wall construction, if mobilisation and restoration of range of movement is the roof, if strength is the paint-work, and if specific functional rehabilitation is a landscaped garden....I think most houses out there have a nice garden, a beautifully painted house, a slight leak in the roof, walls that are slightly off-centre, on a sloppy foundation.

If they manage to do this then thats not bad as a start is it? If they can do it I wonder what it means for the orthotic long-term. Should we all be doing this?

The foot is not an iron bar though Lawrence. OK, lets assume that a supinatus can be corrected with hands-on manual therapy (manipulation, mobilisation etc), this, I think, is only relevant in NWB.

Get full body weight on that 1st ray in late-stance/early-propulsion, do we think that just because mobilisation has augmented more 1st ray plantarflexion, that this will magically resist dorsiflexion moments at this critical functional weightbearing position?

In other words, the chronic long-standing forefoot supinatus has incorporated a 1st ray that is dorsiflexed. Mobilising it the other way (plantar flexion), IMO, will not suddenly limit the available range of dorsiflexion that the 1st ray has been used to for such a long period.

So in terms of dynamic weightbearing foot function (ala windlass...1st mpj), I am not sold on the idea.





However, if the supinatus itself is directly causing tension or compressive pathology locally, then achieving more forefoot pronation may assist. In other words, usually joints are happier in a more neutral position.

Definitely!! - and to a limited extent, I do. However, its the claims by those who treat the supinatus as a "subluxation" that can be corrected without foot orthoses that I have the problem with. Their advertisments make these claims. In the short term it can work --- but you need regular "maintenace" therapy to maintain the correction ---- when orthotics will do the same thing better and at a fraction of the cost.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Hmmm

Atlas, personally I can only see the use of manipulation to improve foot shape/ROM and thereby function as a good thing. Reduce "supinatus" or whatever, facilitate fibular motion, stretch calves.

Scenario 1 Pain gone - fine. Scenario 2 Pain went but now has returned - more manipulation or orthoses - a decision for the practitioner or the patient????? No bits of plastic but I need "maintenance" tx or change my shoes and have bits of plastic - I can imagine many pts pondering that.

Certainly manipulation on its own for other areas eg spine/neck does give rapid relief of symptoms possibly through a neuro-feedback mechanism not a mechanical effect. Therefore it is possibly massively under-used in Podiatry.

Hi

I like manipulative intervention. But the assumptions behind all that has been written is that supinatus is a condition, when it could be a variation of normal (so are people correcting anything?) and, secondly, if supination is a variation of normal surely the problem is the ground we walk on.

Cheers
Ian

Not long after I graduated from podiatry i began seeing a chiropractor who happened to work with a podiatrist who practiced solely as a manipulating podiatrist.The long and the short of it is that i ended up seeing the pod for free twice a week when i saw the chiro (Think he wanted to show the new pod the enlightened way) Hmmmm, much better than paying 2K upfront like i hear some people do!

Now i have terrible feet. I was the student brought up in front of the class to show them what a "pronated" foot was. I can't go without my orthoses for longer than 10-15 minutes when standing etc etc.

So i went through this manipulation twice a week for 6 months, along the way being told that i probably didn't need my orthoses any more. Before and after X-Rays showed squat improvement. I have to admit that my foot became much more mobile and they did get rid of most of my supinatus. I also learnt to stabilise (plantarflex) my first ray better by using my peroneals. But my feet are still as flat as before!

Now what worries me is the people out there with feet like mine getting told to throw their orthoses out. (They should atleast just suggest to put them in a box )

Cheers


Tom

Hi All,

Has there been any evidence of improvements to ligaments in the manipulations etc. or in massage and the like, anecdotal or factual? Particularly when referring to the ligament holding the arch up and it's slight give on loading and also over time?

Regards,

Colin.

Tom

would you say you are better as a result of the manipulation? Do you feel it has added to the effect of your orthoses?

What I mean is, does a combination approach work better?

Harking back to Craig's original reply, I think a significant issue arising out of this business is that of the zealotry of some practitioners. To promote any singular approach to the treatment of complex issues is fraught with danger. It reeks of snake oil and prestidigitation.

I have no problem with the use of manipulation. In fact, I believe that we spend an awful lot of time on epidermal tissue (or the removal thereof) and not enough on the issues and tissues that lie beneath. By using manipulation wisely, safely and effectively, in combination with a range of therapeutic modalities, we have a great deal to offer our patients.

My problem lies with those practitioners who make claims that a specific treatment is 100% effective (gosh, wouldn't that be splendid). Who tell patients to 'throw away orthotics' (heck, I don't mind what patients do with their orthotics, but does it have to sound like a religious revival meeting?). And whose eyes shine bright with the fervour of the fundamentalist.

I honestly believe we as a profession are not yet on such solid ground that we can afford the singular approach.

Whew! I've got that off my chest.

Felicity

(OK, I confess, I think I've had to deal with a few too many people who have had some less-than-satisfactory experiences with a small percentage of our colleagues in this respect. I admit a bias, please feel free to covert me, or at least have a jolly good try).

Hi

I usually consider whether to mobilise or manipulate joints / soft tissue as part of the fitting and follow up process in orthotic supply. However, following the conversations on this thread can someone explain a number of things:

1. If the joints of the foot have been partly modeled by long term over pronation via a supinated forefoot, how does manipulation etc remodel these, to the extent that congruency occurs in an individuals new way of walking?

2. Again the question of assumptions arises in this in that who is to say that the supinatus is not normal to that individual (albeit more marked in various cases) and that by the above mentioned techniques mobilising etc we are forcing the foot into an unnatural position.

3. If you take the view that the surface for ambulation is a major contributor to foot pathology then mobilising as above can only be very temporary.

4. Can mobilising in the above way address the ligament laxity that can accompany many foot conditions.

Not sceptical just need to be convinced.

Cheers
Ian

Felicity

Religious fundamentalism; orgasmic curly-toes - whatever next? I hope you appreciate that our IT gatekeeper has now decreed Arena as having 'adult content' and blocked all access forthwith. It could be said though, that you’re responsible for maturing the profession single-handedly….but that’s possibly not the best way of putting it.

Keep it up!

Mark

I dont think that many chiropractors would say that through manipulation they are re-aligning the spine any more.

I think they suggest manipulation improves pain and swelling through a neuro feedback mechanism. Also it stimulates healing through its effect on circulatory system.

Sure it wont correct the foot deformity but if a pt has a supinatus their talus will be habitually moving in an anterior/medial direction in late midstance rather than a posterior/lateral direction. One could hypothesise that many soft tissues will become atrophied as a result and these could potentially be improved by "hands-on" therapy.

I dont know this, just ruminating...

hi,
i trainied in lower limb foot and ankle manipuation 18 months ago.i can honestly say that it has only improved my practice. i do not see it as a single treatment option but often combine it into a treatment programme which in many cases includes orthoses.
catch ya soon,
claire, belfast

That the crux of the "problem" and this thread - its either that integrative approach to practice or a philiosophy that takes over the practice.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

i have found that manipulation has helped alot of my patients in the acute phase of a pathology e.g lateral ankle sparin, plantar fasciitis etc as long as it continues to do so i see no harm in offering it as a treatment option. I do not suggest that biomechanics is ignored but addressed and treated appropriately. claire

How does manipulation help an acute lateral ankle sprain?

What joint are you manipulating? Which direction?

I'd be keen to hear a specific explanation of what specific tissue is being manipulated and what the reasoning is behind thinking it makes any difference at all and why it is thought this could have any lasting effect whatsoever......isn't standing and walking itself a manipulation of the foot? and how is occaisional manip by hand possibly going to counteract the magnitude and frequency of standing/walking?
Regards Phill Carter

I attended a manipulation course earlier this year, & during the course of it had my own feet manipulated. I was told that the ROM at my 1st MTPJs could be increased by manipulation. As I'd only just been shown weightbearing X-rays of my feet, which clearly showed a long 1st met & reduced joint space; & had been discussing the possibility of decompression osteotomy to relieve my symptoms (pain on walking), I was most intrigued. So I had my MTPJs manipulated - which I found VERY painful- my feet felt pretty good for about a few hours, but the pain returned on walking. I really doubt that the manipulation made a difference for me. That said, my colleague had manipulation to improve ankle joint dorsiflexion (which was limited following TA injury), & the improvement was astounding! In fact, 9 months on, the increase in ROM is still apparent. My conclusion: Manipulation is a treatment modality appropriate to some conditions, & it is not the cure for everything. (Mind you, I didn't have the surgery either!)

What a fabulous discussion to follow - I'm glad I stumbled upon it!

I am a passionate podiatrist who has specialised in the field of Foot Mobilisation Techniques (FMT) which includes manipulation. The religious fervour described so far would probably be attributed to myself by practitioners and clients alike.

I would like to contribute a few perspectives from someone who has decided to provide FMT as the primary service in his practice.

The perception that FMT is a 'cure all' cannot be justified. While FMT is the only service that we provide at the Foot & Leg Centre www.footandleg.net we certainly do not accept every case. The only cases we accept are those that present clinically with subluxation and have this confirmed radiologically. The FMT is then applied to correct the subluxation and this is confirmed with a post treatment x-ray. If FMT is not indicated, we refer the client on.

The comments raised about connective tissue adaptation to subluxation need to be addressed. Ligamentous tissue doesn't have the ability to contract and where the tissue has distorted beyond its ability to stabilise the joint, external assistance is required (read orthoses). Muscular tissue and other connective tissues however, will respond to the forces placed on them i.e. they become elongated or contracted. FMT is very effective in bringing about a change to these tissues which is the basis of alot of physiotherapy and chiropractic treatments.

Can clients be freed from their orthoses? I guess it depends on the etiological factor that the orthoses were provided for. In our practice, 92% of our clients function satisfactorily (according to their FHSQ results) and no longer need orthotic assistance. This is a biased group - those with high degrees of subluxation or high degrees of joint degeneration are advised to maintain their orthotic usage.

Imagine being able to offer a woman a treatment option that didn't require a limitation of her footwear. If she fits our criteria, then we will provide the service (with a guarantee). Having specialised in this field for 11 years now, I know what works when, how and why. I wonder how many other practitioners offer a money back guarantee on their services?

Cheers,

Ted Jedynak

PS isn't standing and walking itself a manipulation of the foot?

No, certainly not. Manipulation takes place at the paraphysiological limits of a joint and if you are walking on your joints at this limit you'll need more than FMT can offer. Mobilisation may occur with walking though.

PPS How does manipulation help an acute lateral ankle sprain?

An inversion sprain typically stretches/strains the lateral fibulo-talar and fibulo-calcaneal ligaments. The inversion force also subluxates the talus in an anterior direction (with lat or med involvement also possible. Manipulation/mobilisation of the talus in a posterior direction reduces the anterior tension from the subluxation permitting the tissues to re-organise and repair without the common post injury ankle laxity effect taking place. The lack of muscular attachments to the talus prevents the body's own homeostatic function from being able to restore the integrity of the joint's osseous relationship.

PPPS I dont think that many chiropractors would say that through manipulation they are re-aligning the spine any more.

May I suggest you look at Chiropractic Biophysics (CBP) and the growth in their data based on correcting spinal alignment. It is the fastest growing field within chiropractic today.

Did everyone see Sunrise this morning Channel 7 (Sydney Australia) Kosh had a manipulation from Podiatrists.

Don Scott

Thanks for your info Ted....what does "paraphysiological limits" mean when it's not wearing the dinner suit?
Regards Phill