Positional Release Therapy_Course 2_Sport Medics_Part2.pdf

FOOT: PLANTAR STRUCTURES Flexor Hallucis Brevis > continued PRT Clinician Procedure • Place the toes and forefoot in the sulcus of your hip to promote phalangeal flexion. • Place the ankle in marked plantar flexion. • Apply calcaneal caudal traction with your far hand while placing the forefinger o...

FOOT: PLANTAR STRUCTURES Flexor Hallucis Brevis > continued PRT Clinician Procedure • Place the toes and forefoot in the sulcus of your hip to promote phalangeal flexion. • Place the ankle in marked plantar flexion. • Apply calcaneal caudal traction with your far hand while placing the forefinger of the same hand over the flexor hallucis brevis, if possible. • Place the first metatarsal into plantar flexion with your near hand while applying inward rotation. • Both hands can apply a valgus force using the fore- and hindfoot for fine-tuning. • Corollary tissues treated: Plantar fascia, quadratus plantae, flexor digitorum brevis and longus, flexor hallucis longus, plantar interossei, lumbricals Flexor hallucis brevis PRT clinician procedure. See video 4.3 for the flexor hallucis brevis PRT procedure. Patient Self-Treatment Procedure Use the plantar fascia self-treatment with the exception of emphasizing first metatarsal plantar flexion and rotation. Flexor hallucis brevis patient selftreatment procedure. 58 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Abductor Hallucis The abductor hallucis muscle helps to form the medial arch of the foot and is one of the plantar muscles that is most easily palpable. Some people can abduct the great toe, which brings out the abductor hallucis’ distinct muscle belly. Flexor hallucis brevis Flexor digiti minimi Abductor hallucis Quadratus plantae Origin: Medial calcaneal tuberosity, plantar aponeurosis, flexor retinaculum Insertion: Base of the medial side of the first proximal phalanx, medial sesamoid, flexor hallucis brevis tendon Action: Big toe MP abduction and flexion Innervation: S1-S2 (medial plantar nerve) Second plantar layer 04.08/532026/JG/R1 PalpationE6296/Speicher/Fig. Procedure • Place the foot in relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate the bulk of this muscle at the posterior aspect of the medial heel and trace it forward to the big toe. • Plantar flexion of the big toe against resistance will bring out the muscle belly for palpation. • Note the location of any tender points or fasciculatory response at the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Abductor hallucis palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 59 FOOT: PLANTAR STRUCTURES Abductor Hallucis > continued PRT Clinician Procedure • The patient is prone with the knee flexed to ~60° and the ankle on your thigh. • Place the ankle in marked plantar flexion. • Grasp the heel with your near hand and the forefoot with your far hand to apply a valgus force at the midfoot. • Use a finger from either hand to monitor the tissue lesion. • While applying the valgus force, invert the heel with your near hand. • Apply compression of the calcaneus toward the toes with your near hand. • Rotate the first ray into flexion and internal rotation with your far hand. • Corollary tissues treated: Plantar navicular, plantar fascia, quadratus plantae, flexor digitorum brevis and longus, flexor hallucis longus, plantar interossei, lumbricals Abductor hallucis PRT clinician procedure. Patient Self-Treatment Procedure Use the self-treatment procedure for the plantar fascia, but focus on inverting the calcaneus while applying a valgus force at the forefoot while rotating the first ray into flexion and internal rotation. 60 Abductor hallucis patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Abductor Digiti Minimi The abductor digiti minimi is a superficial muscle that lies along the lateral border of the foot. Its orientation along the fifth toe and metatarsal allows it to both flex and abduct the fifth toe. Flexor hallucis brevis Flexor digiti minimi Flexor digitorum brevis Abductor digiti minimi Abductor hallucis Origin: Lateral and medial calcaneal processes of the tuberosity, plantar aponeurosis, intermuscular septum Insertion: Lateral aspect at the base of the fifth proximal phalanx Action: Abducts the big toe, flexes the fifth MP Innervation: S1-S3 (lateral plantar nerve) First plantar layer E6296/Speicher/Fig. Palpation Procedure 04.09/532030/JG/R1 • Place the foot in a relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate this muscle between the lateral heel and lateral plantar surface of the fifth toe. • Abduction and flexion of the fifth toe against resistance will accentuate the contraction of this muscle for palpation. • Note the location of any tender points or fasciculatory response of the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Abductor digiti minimi palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 61 FOOT: PLANTAR STRUCTURES Abductor Digiti Minimi > continued PRT Clinician Procedure • Position the patient prone with the ankle flexed on your thigh. • Place the ankle in slight plantar flexion. • With your near hand at the forefoot, grasp the heel with your other hand and use a finger from either hand to monitor the lesion. • Apply compression of the heel toward the toes with your far hand to promote phalangeal flexion. • Using both hands, apply a varus force to the midfoot by adducting the forefoot and hindfoot (the fifth ray should approximate toward the calcaneus). • Internally rotate the forefoot with the near hand for fine-tuning. • Corollary tissues treated: Plantar cuboid, plantar fascia, quadratus plantae, flexor digitorum longus Abductor digiti minimi PRT clinician procedure. See video 4.4 for the abductor digiti minimi PRT procedure. Patient Self-Treatment Procedure Use the self-treatment procedure for the plantar fascia, but focus on compressing the heel toward the toes while flexing, adducting, and rotating the forefoot towards the heel. Abductor digiti minimi patient selftreatment procedure. 62 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Plantar Interossei and Lumbricals The plantar interossei and lumbricals are deep intrinsic muscles that lie on the plantar surface of the metatarsals rather than between them, as seen with the dorsal interossei. They have been grouped here because the PRT treatment of these muscles affects the release of both. Deep palpation over these structures elicits their tenderness, and their fasciculation will be felt during treatment. Origin: Plantar interossei: Plantar surface of the third through fifth metatarsals Lumbricals: Flexor digitorum longus tendon Insertion: Plantar interossei: Medial side of the proximal phalange of the same toe, dorsal digital expansion Lumbricals: Proximal second through fifth phalanges, dorsal expansion of the extensor digitorum longus tendons Plantar interossei E6296/Speicher/Fig. 04.10a/532034/JG/R2 1st lumbrical 2nd lumbrical 3rd lumbrical Action: Plantar interossei: Third through fifth toe adduction, MP flexion; assists interphalangeal (IP) extension Lumbricals: Second through fifth metacarpal phalangeal (MP) flexion; assists proximal interphalangeal (PIP) and distal interphalangeal (DIP) extension Innervation: Plantar interossei: S2-S3 (lateral plantar nerve) 4th lumbrical First lumbrical: L5-S1 (medial plantar nerve) Second through fourth lumbricals: S2-S3 (deep branch of the lateral plantar nerve) Second plantar layer > continued E6296/Speicher/Fig. 4.10b/531993/JG/R1 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 63 FOOT: PLANTAR STRUCTURES Plantar Interossei and Lumbricals > continued Palpation Procedure • Place the foot in a relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate the density or firmness of the muscle contraction for these tissues over the plantar surfaces of the metatarsals while the patient flexes the toes against resistance. • Note the location of any tender points or fasciculatory response of the muscles and over the metatarsal shafts. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) or the thumbs at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to ~60° with the ankle on your thigh. • Cup the forefoot with your far hand while resting the dorsum of the foot on your thigh in maximal plantar flexion while your near hand monitors the lesion. • Compress the metatarsal shafts together with your far hand while applying toe flexion. • Apply rotation for fine-tuning with the far hand. • Corollary tissues treated: Flexor digitorum brevis and longus, flexor hallucis longus and brevis Plantar interossei and lumbricals palpation procedure. Plantar interossei and lumbricals PRT clinician procedure. See video 4.5 for the plantar interossei and lumbricals PRT procedure. Patient Self-Treatment Procedure • Use the self-treatment procedure for the plantar fascia, but do not translate the heel toward the toes. • The focus of the positioning should be on compressing the metatarsal shafts toward one another while applying toe flexion and rotation. 64 Plantar interossei and lumbricals patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. COMMON INJURY CONDITIONS Metatarsalgia Metatarsalgia, or forefoot pain, is considered a symptom of another condition in the foot, such as Morton’s neuroma (Bauer et al. 2014). The condition can be acute as a result of high-impact activities, but it typically results from an overload of the plantar foot structures over time from kinetic chain compensation. The clinician must first determine and address the causative factors for this condition to ensure that the releases are sustained. If the foot continues to be irritated, the tissue lesions will likely return. Common Signs and Symptoms • Pain at and between the metatarsal heads • Point tenderness over and between the metatarsal heads • Decreased ability to bear weight on the affected structures Common Differential Diagnoses • Morton’s neuroma • Sesamoid fracture • Metatarsal stress fracture • Hallucis rigidis Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty biomechanics, particularly at the first and second metatarsals, plantar warts, leg length discrepancy, training alteration, surface change, shoe alteration). • Consider requesting a radiograph or MRI to rule out fracture and nerve impingement at the forefoot and midfoot areas. • Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, base your treatment sequencing off the most dominant (tender) points first. • Follow PRT with thermal ultrasound or laser, joint and/or neural mobilization, and myofascial massage. Treatment Points and Sequencing 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Plantar interossei and lumbricals Flexor hallucis brevis Plantar aponeurosis Abductor hallucis Abductor digiti minimi Dorsal interossei Posterior tibialis Medial gastrocnemius Soleus Popliteus • Implement open- and closed-chain strengthening for the intrinsic foot, pretibial, hip, and core muscles. • Implement PNF stretching of the triceps surae complex and plantar foot tissues. • Consider using a metatarsal pad to spread and elevate the metatarsals, but base its use on patient response. • Address any other insulting factors or conditions. • Slowly progress the patient to dynamic physical activity. Patient Self-Treatment Interventions • Perform self-release on a daily basis or when irritated. • PNF stretch the plantar foot structures and triceps surae complex after exercise on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Perform self-massage for five to eight minutes daily after stretching. • Ice-massage the affected area when irritated. If greater relief occurs with heat, apply heat (e.g., warm whirlpool or Jacuzzi). (Note: Consult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.) T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 65 COMMON INJURY CONDITIONS Plantar Fasciitis When the arch is irritated, the engagement of the windlass mechanism places strain on the plantar tissues (Bolgla and Malone 2004), which can activate the myotatic reflex and reinitiate the inflammatory process. Therefore, the clinician must work to determine how best to limit reengagement of the myotatic reflex to prevent the patient from entering a chronic cycle of inflammation every time he takes a step or bears weight. Converse to the traditional therapeutic approach of using an aggressive stretching protocol to treat this condition, the PRT approach is to release the tissue lesions prior to stretching and to avoid causing pain with any therapeutic intervention because doing so often reengages the myotatic reflex and tissue lesions. Common Signs and Symptoms • Pain at the medial heel or within the arch (or both), particularly upon waking ambulation • Sharp, burning pain upon landing or pushoff, a dull constant pain at rest, or both • Pain that subsides with the cessation of weight bearing Common Differential Diagnoses • Heel spur • Posterior tarsal tunnel syndrome • Calcaneal fracture Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty biomechanics, movement faults, heel spur, leg length discrepancy, training, surface, shoe alteration). • Consider performing a biomechanical analysis to evaluate faulty mechanics that may be overloading the plantar fascia. • Consider requesting a radiograph to rule out a heel spur or calcaneal fracture if the pain is located at the heel and has been chronic. • Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, base your treatment sequencing off the most dominant (tender) points first. 66 Treatment Points and Sequencing 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Plantar aponeurosis Flexor hallucis brevis Plantar interossei and lumbricals Dorsal interossei Posterior tibialis Medial gastrocnemius Soleus Popliteus Semitendinosus Pes anserine Iliotibial band Adductor magnus Gluteus medius Piriformis Psoas • Follow PRT with thermal ultrasound, PNF stretching, and myofascial massage of the plantar fascia. • Using KT Tape or arch taping in the initial stage of rehabilitation helps to reduce pain in some patients. • Apply instrumented soft-tissue mobilization (ISTM) if recalcitrant tissue adhesions are present. • Implement open- and closed-chain strengthening for the intrinsic foot, pretibial, hip, and core muscles with a focus on controlling eccentric internal rotation during ambulation. • Have the patient use temporary or custom orthotics initially and, most important, upon waking ambulation and throughout the day to prevent reirritation. • Slowly progress the patient to dynamic physical activity. Patient Self-Treatment Interventions • Perform self-release on a daily basis or when irritated. Some patients report significant relief with self-release upon waking. • Use a supportive sandal or shoe upon waking to flatten the arch when stepping out of bed. • PNF stretch the plantar fascia and gastrocnemius soleus complex after exercise on a T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. COMMON INJURY CONDITIONS daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Use a night splint or plantar fasciitis sock if it helps. • Perform self-massage for five to eight minutes daily after stretching. • Ice-massage the plantar fascia on a stretch when irritated. If greater relief occurs with heat, apply heat (e.g., warm whirlpool or Jacuzzi). (Note: Consult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.) T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 67