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Objective
The aim of this study was to investigate the behavior of the force applied during the Maitland grade III anteroposterior joint mobilization of the talus and its effect on dorsiflexion range of motion (ROM).
Methods
Two examiners performed measurements of dorsiflexion ROM on both ankles of healthy volunteers using a universal goniometer. The anteroposterior talus mobilization was first applied by examiner A for 30 seconds. Examiner B then repeated the same procedure. A platform was placed under the volunteer's leg to register the forces obtained during mobilization. After the procedure, examiner A assessed the ankle dorsiflexion.
Results
The results showed consistency regarding maximal forces applied throughout the 30 seconds of mobilization as well as low consistency upon the minimal forces. A significant increase in dorsiflexion ROM of the ankle was found immediately after joint mobilization.
Conclusions
The results of the present study have shown consistent maximal forces applied by one examiner and inconsistent minimal forces during an ankle mobilization in healthy volunteers when the same examiner was compared. Moreover, the applied force was able to increase dorsiflexion ROM after the Maitland grade III anteroposterior mobilization of the talus.
Ankle equinus is a well-known clinical entity that has previously been shown to compound a variety of foot and ankle conditions. Treatments for this disorder have included surgery to lengthen the Achilles tendon and daily stretching. This article describes a method of manual manipulation that can immediately and substantially increase ankle joint dorsiflexion. Patients treated with manipulation in the current study demonstrated nearly twice as much dorsiflexion motion as that demonstrated by patients in a prior study who were treated with a 5-minute daily stretching program for 6 months.
Manipulation Method for the Treatment of Ankle Equinus
Hylton B. Menz, BPod (Hons)
Division of Podiatry, Faculty of Health, University of Western Sydney–Macarthur, PO Box 555, Campbelltown, New South Wales 2560, Australia
To the Editor:
I read with great interest the article published in the September 2000 issue of the Journal by Howard J. Dananberg and colleagues on the use of manipulation to increase ankle joint dorsiflexion ("Manipulation Method for the Treatment of Ankle Equinus"). While I commend the authors for attempting to evaluate their clinical practice in a structured manner, the flaws in the study design cast doubt on the validity of the results.
First, previous studies that have addressed reliability of ankle joint dorsiflexion measurement using the goniometer have found the device to be subject to considerable error,1 so the differences in dorsiflexion before and after manipulation may simply reflect measurement error rather than the effect of the intervention. Although the authors took the average of two measurements, the intratester reliability of the measurements was not adequately evaluated or reported. Furthermore, bias on behalf of the clinician taking the ankle joint dorsiflexion measurements was not controlled for, so the greater range of dorsiflexion following manipulation may have been due to increased force exerted by the clinician compared with the baseline measurement. The validity of assisted dorsiflexion (ie, with the subject actively pulling the foot toward him or her) could also be questioned, as the ankle reaches its maximally dorsiflexed position at a period of the gait cycle when the anterior leg musculature is electromyographically silent.2
Second, the study used a pre-post design with no control group. This flaw could have been rectified by using the subject’s contralateral leg as the control. Interestingly, a previous article by Nield et al3 (which was not cited by Dananberg et al), employing a more rigorous method, reported no significant improvements in ankle joint dorsiflexion range of motion following manipulation. In this study, 20 asymptomatic subjects received a single longitudinal manipulation, with the contralateral leg acting as the control. Ankle joint dorsiflexion was measured at five different torques using the "Lidcombe Template," which has been shown to produce highly reliable (intraclass correlation coefficient, 0.91) results between clinicians.4 There were no significant changes in ankle dorsiflexion range of motion at any level of torque following the manipulation, leading the authors to conclude that while vertebral manipulation may increase joint range of motion, no such effect can be produced at the ankle joint.
Manipulative techniques are receiving increasing interest in the podiatric profession, despite the lack of supporting evidence for their use.5 Thus investigations into the effect of these therapies are desperately required, and Dananberg and colleagues are to be commended for conducting such a study. However, given the limitations of the study design, as well as the conflicting results obtained by Nield et al,3 I urge readers of the Journal to approach this article with an appropriate level of caution, and to consider carefully whether the weight of the evidence is sufficient to justify the use of this technique in clinical practice.
References
ROME K: Ankle joint dorsiflexion measurement studies: a review of the literature. JAPMA 86: 205, 1996.[Abstract]
ROSE J, GAMBLE JG: Human Walking, 2nd Ed, Williams and Wilkins, Baltimore, 1994.
NIELD S, DAVIS K, LATIMER J, ET AL: The effect of manipulation on range of movement at the ankle joint. Scand J Rehab Med 25: 161, 1993.[Medline]
MOSELEY A, ADAMS R: Measurement of ankle dorsiflexion: procedure and reliability. Aust J Physiother 37: 175, 1991.
MENZ HB: Manipulative therapy of the foot and ankle: science or mesmerism? Foot 8: 68, 1998.
Author’s Response
Howard J. Dananberg, DPM
21 Eastman Ave, Bedford, NH 03110
To the Editor:
Mr. Hylton Menz has questioned the accuracy of the results presented in our article, citing flaws in the study design and other studies on manipulation. I would like to respond to his comments.
Mr. Menz questions the study’s measurement technique as a way in which to evaluate changes in motions associated with ankle equinus. He cites an article by Rome1 previously published in JAPMA as showing differences between testers in measurement of the ankle with equinus with a goniometer. To address this issue, only one of the authors performed both pre- and post-treatment measurements on all subjects. This tester was completely blinded to the manipulation process. Additionally, the clinicians who performed the manipulations were blinded to the measurement process and were not present in the room when measurements were taken. The actual measurement procedure was practiced repeatedly prior to its actual performance until all of the authors and clinician participants were in agreement as to the method’s accuracy. The leg and foot were marked prior to evaluation, and the same marks were used for the post-treatment measurement. The test subject was then asked to dorsiflex the ankle using a cloth band, and the single tester then measured the response. At no time did the tester apply any force to the ankle to either encourage or discourage range of motion of the subject. We attempted to remove as much clinician bias as possible from the assessment process so as to ensure reasonable accuracy for this rather simple study. While it was recognized that errors in measurement were possible, the fact that increases in range of motion were so pronounced (an average of 5°, with the greatest increase being 17°) is more indicative of the technique’s effectiveness than of measurement inaccuracy. Further, in personal correspondence with Keith Rome, when questioned as to the potential accuracy of goniometer measurements, he replied, "I think that a single observer could reliably measure the same person as long as a standardized procedure is undertaken and the instrument is reliable."
The issue of the study lacking a control is a reasonable criticism, and was acknowledged in the article as a shortcoming of the study. It was our understanding that ankle equinus has never been shown to spontaneously resolve in the span of a single office visit without some type of intervention. Two pretreatment measurements were taken to ensure that the differences following manipulation were not due to chance. Mr. Menz suggests that the opposite side can be used as a control. Precisely that approach was taken in a prior calf-stretching study, and it was found that the range of motion of the unstretched side actually showed increases comparable to those of the stretched side. It would appear that some reflexive response to stretching occurs and that this can affect both sides. Considering this, we felt that the two-measurement approach would better demonstrate the consistency of motion prior to and following manipulation.
Mr. Menz, in justifying his argument of measurement inaccuracy for the substantial increases in motion reported, cites the study by Nield et al2 as demonstrating the failure of ankle manipulation to increase ankle motion. In this study, the authors used asymptomatic subjects without any restrictions in ankle joint ranges of motion. Following manipulation, they describe no change despite numerous and precise measurements. This can be likened to giving aspirin to people without fever, and then concluding that aspirin cannot lower body temperature because no change was found in a subject group that began the study with normal body temperature. The fact that no motion change was evident in a group without equinus does not in any way suggest outcomes of ankle manipulation in a group with known ankle equinus. In addition, the Nield et al study measured ankle range of motion with the knee in the flexed position, while the current study performed measurements with the knee extended. Even more significant, a very different manipulative technique was described. Nield et al manipulated only the distal ankle and did not attempt to manipulate the proximal fibular head as in the current study. Because the protocols, manipulation method, and patient selection criteria were so different, no justifiable comparison can be made between these two studies.
We strongly believe that our equinus study demonstrates that the two-pronged approach of manual manipulation of the fibular head and ankle joint results in a statistically significant increase in ankle joint dorsiflexion (with the knee extended) in those subjects diagnosed with ankle equinus. This study was intentionally designed in a very simple manner to demonstrate the clinical effect in the equinus population. If the clinician is properly trained, the procedure appears to be extremely valuable and without ill effects. The authors therefore feel justified in concluding that this form of manipulation is a safe and effective method of resolving ankle equinus.
References
ROME K: Ankle joint dorsiflexion measurement studies: a review of the literature. JAPMA 86: 205, 1996.
NIELD S, DAVIS K, LATIMER J, ET AL: The effect of manipulation on range of movement at the ankle joint. Scand J Rehab Med 25: 161, 1993.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
here is Hylton Menz's and Howard Dananberg's exchange in the letters-to-the-editor on this (subscription access required to view).
Here is the full dialogue:
Quote:
Letter to the Editor
Manipulation Method for the Treatment of Ankle Equinus
Hylton B. Menz, BPod (Hons)
Division of Podiatry, Faculty of Health, University of Western Sydney–Macarthur, PO Box 555, Campbelltown, New South Wales 2560, Australia
To the Editor:
I read with great interest the article published in the September 2000 issue of the Journal by Howard J. Dananberg and colleagues on the use of manipulation to increase ankle joint dorsiflexion ("Manipulation Method for the Treatment of Ankle Equinus"). While I commend the authors for attempting to evaluate their clinical practice in a structured manner, the flaws in the study design cast doubt on the validity of the results.
First, previous studies that have addressed reliability of ankle joint dorsiflexion measurement using the goniometer have found the device to be subject to considerable error,1 so the differences in dorsiflexion before and after manipulation may simply reflect measurement error rather than the effect of the intervention. Although the authors took the average of two measurements, the intratester reliability of the measurements was not adequately evaluated or reported. Furthermore, bias on behalf of the clinician taking the ankle joint dorsiflexion measurements was not controlled for, so the greater range of dorsiflexion following manipulation may have been due to increased force exerted by the clinician compared with the baseline measurement. The validity of assisted dorsiflexion (ie, with the subject actively pulling the foot toward him or her) could also be questioned, as the ankle reaches its maximally dorsiflexed position at a period of the gait cycle when the anterior leg musculature is electromyographically silent.2
Second, the study used a pre-post design with no control group. This flaw could have been rectified by using the subject’s contralateral leg as the control. Interestingly, a previous article by Nield et al3 (which was not cited by Dananberg et al), employing a more rigorous method, reported no significant improvements in ankle joint dorsiflexion range of motion following manipulation. In this study, 20 asymptomatic subjects received a single longitudinal manipulation, with the contralateral leg acting as the control. Ankle joint dorsiflexion was measured at five different torques using the "Lidcombe Template," which has been shown to produce highly reliable (intraclass correlation coefficient, 0.91) results between clinicians.4 There were no significant changes in ankle dorsiflexion range of motion at any level of torque following the manipulation, leading the authors to conclude that while vertebral manipulation may increase joint range of motion, no such effect can be produced at the ankle joint.
Manipulative techniques are receiving increasing interest in the podiatric profession, despite the lack of supporting evidence for their use.5 Thus investigations into the effect of these therapies are desperately required, and Dananberg and colleagues are to be commended for conducting such a study. However, given the limitations of the study design, as well as the conflicting results obtained by Nield et al,3 I urge readers of the Journal to approach this article with an appropriate level of caution, and to consider carefully whether the weight of the evidence is sufficient to justify the use of this technique in clinical practice.
References
ROME K: Ankle joint dorsiflexion measurement studies: a review of the literature. JAPMA 86: 205, 1996.[Abstract]
ROSE J, GAMBLE JG: Human Walking, 2nd Ed, Williams and Wilkins, Baltimore, 1994.
NIELD S, DAVIS K, LATIMER J, ET AL: The effect of manipulation on range of movement at the ankle joint. Scand J Rehab Med 25: 161, 1993.[Medline]
MOSELEY A, ADAMS R: Measurement of ankle dorsiflexion: procedure and reliability. Aust J Physiother 37: 175, 1991.
MENZ HB: Manipulative therapy of the foot and ankle: science or mesmerism? Foot 8: 68, 1998.
Author’s Response
Howard J. Dananberg, DPM
21 Eastman Ave, Bedford, NH 03110
To the Editor:
Mr. Hylton Menz has questioned the accuracy of the results presented in our article, citing flaws in the study design and other studies on manipulation. I would like to respond to his comments.
Mr. Menz questions the study’s measurement technique as a way in which to evaluate changes in motions associated with ankle equinus. He cites an article by Rome1 previously published in JAPMA as showing differences between testers in measurement of the ankle with equinus with a goniometer. To address this issue, only one of the authors performed both pre- and post-treatment measurements on all subjects. This tester was completely blinded to the manipulation process. Additionally, the clinicians who performed the manipulations were blinded to the measurement process and were not present in the room when measurements were taken. The actual measurement procedure was practiced repeatedly prior to its actual performance until all of the authors and clinician participants were in agreement as to the method’s accuracy. The leg and foot were marked prior to evaluation, and the same marks were used for the post-treatment measurement. The test subject was then asked to dorsiflex the ankle using a cloth band, and the single tester then measured the response. At no time did the tester apply any force to the ankle to either encourage or discourage range of motion of the subject. We attempted to remove as much clinician bias as possible from the assessment process so as to ensure reasonable accuracy for this rather simple study. While it was recognized that errors in measurement were possible, the fact that increases in range of motion were so pronounced (an average of 5°, with the greatest increase being 17°) is more indicative of the technique’s effectiveness than of measurement inaccuracy. Further, in personal correspondence with Keith Rome, when questioned as to the potential accuracy of goniometer measurements, he replied, "I think that a single observer could reliably measure the same person as long as a standardized procedure is undertaken and the instrument is reliable."
The issue of the study lacking a control is a reasonable criticism, and was acknowledged in the article as a shortcoming of the study. It was our understanding that ankle equinus has never been shown to spontaneously resolve in the span of a single office visit without some type of intervention. Two pretreatment measurements were taken to ensure that the differences following manipulation were not due to chance. Mr. Menz suggests that the opposite side can be used as a control. Precisely that approach was taken in a prior calf-stretching study, and it was found that the range of motion of the unstretched side actually showed increases comparable to those of the stretched side. It would appear that some reflexive response to stretching occurs and that this can affect both sides. Considering this, we felt that the two-measurement approach would better demonstrate the consistency of motion prior to and following manipulation.
Mr. Menz, in justifying his argument of measurement inaccuracy for the substantial increases in motion reported, cites the study by Nield et al2 as demonstrating the failure of ankle manipulation to increase ankle motion. In this study, the authors used asymptomatic subjects without any restrictions in ankle joint ranges of motion. Following manipulation, they describe no change despite numerous and precise measurements. This can be likened to giving aspirin to people without fever, and then concluding that aspirin cannot lower body temperature because no change was found in a subject group that began the study with normal body temperature. The fact that no motion change was evident in a group without equinus does not in any way suggest outcomes of ankle manipulation in a group with known ankle equinus. In addition, the Nield et al study measured ankle range of motion with the knee in the flexed position, while the current study performed measurements with the knee extended. Even more significant, a very different manipulative technique was described. Nield et al manipulated only the distal ankle and did not attempt to manipulate the proximal fibular head as in the current study. Because the protocols, manipulation method, and patient selection criteria were so different, no justifiable comparison can be made between these two studies.
We strongly believe that our equinus study demonstrates that the two-pronged approach of manual manipulation of the fibular head and ankle joint results in a statistically significant increase in ankle joint dorsiflexion (with the knee extended) in those subjects diagnosed with ankle equinus. This study was intentionally designed in a very simple manner to demonstrate the clinical effect in the equinus population. If the clinician is properly trained, the procedure appears to be extremely valuable and without ill effects. The authors therefore feel justified in concluding that this form of manipulation is a safe and effective method of resolving ankle equinus.
References
ROME K: Ankle joint dorsiflexion measurement studies: a review of the literature. JAPMA 86: 205, 1996.
NIELD S, DAVIS K, LATIMER J, ET AL: The effect of manipulation on range of movement at the ankle joint. Scand J Rehab Med 25: 161, 1993.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Are you just padding your posts now Kevin by listing this twice?
Craig did provide a link anyway you know!
Bruce
Yeah, Bruce, most of my posts are just done so I can try to retain my #1 position as poster on Podiatry Arena. It has nothing to do with my enjoyment in sharing my knowledge with my podiatric colleagues around the world.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Hylton questioned the internal validity of the article; but I question the clinical significance and EV to all ankle equinus presentations.
Danenburg's method is only applicable for a very small percentage of equinus presentations. Its the tip of the iceberg. Its the rare tool down the bottom of the tool-box that you might find useful once in a long while. Nothing more.
Hylton questioned the internal validity of the article; but I question the clinical significance and EV to all ankle equinus presentations.
Danenburg's method is only applicable for a very small percentage of equinus presentations. Its the tip of the iceberg. Its the rare tool down the bottom of the tool-box that you might find useful once in a long while. Nothing more.
References:
None.
Dear All including Axis and Atlas
How wrong you are.
Hopefully by Sunday aussie time, I can post the worlds first comparing foot pressure plate/ ankle dorsiflexion/ shoulder abduction pressures and CT 3D angle changes pre and post mobilisation and manipulations.
Many may cringe but few are chozen. I like this better than Craig's mumble.
Hylton questioned the internal validity of the article; but I question the clinical significance and EV to all ankle equinus presentations.
Danenburg's method is only applicable for a very small percentage of equinus presentations. Its the tip of the iceberg. Its the rare tool down the bottom of the tool-box that you might find useful once in a long while. Nothing more.
References:
None.
Atlas;
I greatly disagree with you. So much knee pain is perpetuated by unidentified AJE on a daily basis! In general, mobilising or manipulating the AJ will help tremendously to aid that patient population as well as most other foot complaints.
We all use different tools, but I would now be lost to achieve the outcomes I do for my patients without utilizing manipulation on a regular daily basis.
I greatly disagree with you. So much knee pain is perpetuated by unidentified AJE on a daily basis! In general, mobilising or manipulating the AJ will help tremendously to aid that patient population as well as most other foot complaints.
We all use different tools, but I would now be lost to achieve the outcomes I do for my patients without utilizing manipulation on a regular daily basis.
Sincerely;
Bruce
Bruce there are several ways to mobilise/manipulate an ankle joint. Danenburg and his superior tib-fib joint attention is not the only way. Danenburg's method as described in his article, would only improve to sufficient clinical significance a small percentage of ankle presentations. There are better, more effective means of increasing ankle joint dorsiflexion in a majority of presentations.
If you read my posting Bruce, I am not knocking mobilisation/manipulation; so I don't know what your are greatly disagreeing about.
Bruce there are several ways to mobilise/manipulate an ankle joint. Danenburg and his superior tib-fib joint attention is not the only way. Danenburg's method as described in his article, would only improve to sufficient clinical significance a small percentage of ankle presentations. There are better, more effective means of increasing ankle joint dorsiflexion in a majority of presentations.
If you have your ankle immobilised as per typical POP for 4-6 weeks, what tissues have been affected adversely (reduced length). Even a 2nd year student will rattle off "joint capsule, tib-post, peroneals, gastro-soleus etc...etc...".
But in the clinical world, why are we foolish enough to think that one joint based technique is going to be the magic trigger of a wonderful cascade of ankle dorsi-flexion attainment?
Come on...it aint rocket science. You have maitland mobilisations; you have mulligan mobilisations; you have chiropractic manipulation; you have distraction....and that is just for the passive tissues. I haven't even got on to addressing active tissue yet.
These dogmatic practitioners that believe everything is caused by one thing (and solved by one thing) are deluding themselves. Many chiropractors think everything is caused by matters spinal; many physiotherapists think that everything is caused by matters core.... and so on.
And Musmed, why wait for me? I am waiting for the 2nd coming Sunday 'aussie time'.
What time Sunday, I want to prepare myself and hide in the walk in robe with the laptop. That way I might be able to read something to its completion before the kids find me.
Cheers
Iona
If you have your ankle immobilised as per typical POP for 4-6 weeks, what tissues have been affected adversely (reduced length). Even a 2nd year student will rattle off "joint capsule, tib-post, peroneals, gastro-soleus etc...etc...".
But in the clinical world, why are we foolish enough to think that one joint based technique is going to be the magic trigger of a wonderful cascade of ankle dorsi-flexion attainment?
Come on...it aint rocket science. You have maitland mobilisations; you have mulligan mobilisations; you have chiropractic manipulation; you have distraction....and that is just for the passive tissues. I haven't even got on to addressing active tissue yet.
These dogmatic practitioners that believe everything is caused by one thing (and solved by one thing) are deluding themselves. Many chiropractors think everything is caused by matters spinal; many physiotherapists think that everything is caused by matters core.... and so on.
And Musmed, why wait for me? I am waiting for the 2nd coming Sunday 'aussie time'.
Dear Atlas
The paper Howard D wrote also included other procedures.
I feel unless I have missed something that you have still not answered Stanley's question.
I did not see anyone write about a leg in plaster....etc
I think that you are saying that we should look at all the tissues around the ankle.
The Plaster of Paris analogy is interesting, but the problem lies in what is the affected parts and how does it affect the ankle joint.
People that manipulate think that the joint has been knocked out of aligment, and it needs to be knocked in.
The Plaster of Paris analogy implies an immobilization etiology to the problem.
So do you treat all the structures around the ankle or do something else?
I noted what you say,I also note that there is salt in atlas
Paul C
I also note there is 'used me' in musmed. I hope those that attend the musculo-skeletal training workshops (delivered by ST and yourself) don't feel like such.
And Stanley, that is exactly what I am saying. Look at all structures, mainly the limiting one at the time. Regarding etiology, yes the POP analogy implies pre-existing immobilisation. However a typical impingement will not allow full ROM in a particular plane. A typical ankle sprain, with its inflammation etc around the joint will immobilise the region similarly. Here's another analogy...like a floating device that children wear around their arms; imagine this around a joint.
Pure and simple, most musculo-skeletal pathology anywhere in the body (neck, shoulder, knee, hip) will co-exist with some degree of immobilisation. If you wake up with a sore neck, how far can you move it? If you pain and this 'limited movement' were to exist for some time (weeks-months) you will have tissue shortening in affected and previously non-affected structures.
Stanley, that is exactly what I am saying. Look at all structures, mainly the limiting one at the time. Regarding etiology, yes the POP analogy implies pre-existing immobilisation. However a typical impingement will not allow full ROM in a particular plane. A typical ankle sprain, with its inflammation etc around the joint will immobilise the region similarly. Here's another analogy...like a floating device that children wear around their arms; imagine this around a joint.
Pure and simple, most musculo-skeletal pathology anywhere in the body (neck, shoulder, knee, hip) will co-exist with some degree of immobilisation. If you wake up with a sore neck, how far can you move it? If you pain and this 'limited movement' were to exist for some time (weeks-months) you will have tissue shortening in affected and previously non-affected structures.
Ron,
I see what you are trying to say:
If I wake up with a sore neck, I should treat the tight muscle.
Do you treat the cause of the tight muscle, or the tight muscle directly?
I see what you are trying to say:
If I wake up with a sore neck, I should treat the tight muscle.
Do you treat the cause of the tight muscle, or the tight muscle directly?
Regards,
Stanley
This is an acute situation Stanley. A disc pathology might need traction? Facet joint pathology might need manipulation/mobilisation? Muscular pathology....
So let's try again.
You wake up with a stiff neck, and as a result there is some immobilization which causes a secondary tight muscle two months later. You then see the patient and examine him and find there to be something wrong which is a result of the immobilization phase due to the spasm of the neck muscle. You treat the pathology you see.
My question is why did the patient develop the stiff neck, and what are you going to do to prevent it from happening again?
Hopefully by Sunday aussie time, I can post the worlds first comparing foot pressure plate/ ankle dorsiflexion/ shoulder abduction pressures and CT 3D angle changes pre and post mobilisation and manipulations.
Many may cringe but few are chozen. I like this better than Craig's mumble.
comeon sunday!
musmed
Paul:
Sunday came and went without us reading about the world's first study comparing foot pressure plate/ankle dorsiflexion/shoulder abduction pressures and CT 3D angle changes pre and post mobilisation and manipulations. What a disappointment. You build us up.....and.....nothing happened.
I just had to spend Sunday listening to biomechanics researchers who have published extensively speaking about their experimental data and its clinical interpretation at the San Diego PFOLA meeting.
Maybe ...... some other Aussie Sunday ....... the world will get what it has been waiting for.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
This ankle joint mobilisation patent was applied for in 2005, but was only granted this week:
Method and apparatus for anterior and posterior mobilization of the human ankle
Quote:
An apparatus for anterior and posterior mobilization of the human talocrural joints for rehabilitation and/or therapeutic utilization. A patient's foot is secured in an apparatus and an Ankle Mortise Strap is looped around the mortise of an ankle of the foot. A force strap is attached to the ends of the Ankle Ankle Mortise Strap. Anterior mobilization is achieved by moving the force strap ventrally from the foot so that the foot including the talus remains stationary while the tibia and fibula glide anteriorly. Posterior mobilizations are achieved by securing the foot, and looping an Ankle Mortise Strap around the front of the ankle. A force strap is attached to the ends of the Ankle Mortise Strap. Posterior mobilization is achieved by moving the force strap dorsally from the foot so that the foot including the talus remains stationary while the tibia and fibula glide posteriorly
Paul, just like Kevin and all following along I too was waiting for Sunday, what happened?
2005.....Dr. Spooner......not 3005......
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
So let's try again.
You wake up with a stiff neck, and as a result there is some immobilization which causes a secondary tight muscle two months later. You then see the patient and examine him and find there to be something wrong which is a result of the immobilization phase due to the spasm of the neck muscle. You treat the pathology you see.
My question is why did the patient develop the stiff neck, and what are you going to do to prevent it from happening again?
Regards,
Stanley
Stanley, we should stick to what we can control and assist; rather than sitting back and guestimating about what may have caused and contributed. Of course, when you assess and treat, underlying causes are always in your thoughts; but the time wasted on complex inaccurate theories and possibilities takes away from what we do best and with more certainty.
If the cause is simple and one-dimensional, then yes, it makes complete sense to address it.
If I am a patient with pain and stiffness, I don't care what your half-truth theories are; just get me right. If it returns again down the track, well, either the therapist must change tack, and/or more consideration can be given to recurrence. Common sense isn't it???
But to appease your penchant for underlying neck causes with the hypothetical neck sufferer...who awakes with a stiff neck? Is it the pillow and/or bed not being 100%? Is it what he/she lifted last night? Is it the sustained un-ergonomic position assumed for 5 minutes the day before? Is it the motor car accident 6 months ago? Is it the way they carried their school bag 3 years ago? Is it the way they style their hair every morning by flicking their head? And that is the tip of the iceberg.
Lets just worry about getting them as pain-free as we can, and as functional as we can. If you improve them, and they remain pain-free and fully functional, it would have been a waste of time to come up with a white-board tree diagram of 'possible' contributing factors.
Mobilisation and ankle joint range of motion
but the problem lies in what is the affected parts and how does it affect the ankle joint. 
or do something else?
Linear Mode
