Positional Release Therapy_Course 2_Sport Medics_Part1.pdf

Clinical Guide to Positional Release Therapy The incidence of lower-quarter injury in athletic and recreational populations is staggering, as is its potential economic cost. Shibuya and colleagues (2014) reported that 280,933 foot and ankle fractures and dislocations occurred in the United States b...

Clinical Guide to Positional Release Therapy The incidence of lower-quarter injury in athletic and recreational populations is staggering, as is its potential economic cost. Shibuya and colleagues (2014) reported that 280,933 foot and ankle fractures and dislocations occurred in the United States between 2007 and 2011. Of those, 92.74% were non-work-related; 55.7% occurred at the ankle, and the greatest number occurred in the foot at the metatarsals (12.5%). Given the magnitude of fracture alone, it is not surprising that one in five middle-aged to older Americans suffers from foot pain (Thomas et al. 2011). Although extrinsic factors such as skill level, shoe type, and playing surface are important to take into account when evaluating a patient presenting with lower-quarter injury and somatic dysfunction, potentially modifiable intrinsic factors such as anatomical alignment, muscle tightness, range of motion, and strength and tissue imbalance may have the greatest potential to be influenced by PRT. The literature review by Murphy, Connolly, and Beynnon (2003) revealed little consensus among prospective studies on these factors; however, the literature suggests that these factors may play a role in the predisposition of lower-extremity (LE) injury and possibly the development of somatic dysfunction. It would stand to reason that if somatic dysfunction reduces strength, as seen in the Wong and Schauer-Alvarez hip study (2004), then it could also affect the stability and function of the lower-extremity articulations and tissues, specifically at the foot. However, the hip articulation is not the only driver of kinematic movement in the lower extremity. The role of distal kinematics and foot type or posture for the predisposition of lower-quarter injuries such as Achilles tendinopathy, patellofemoral syndrome, medial tibial stress syndrome (MTSS), and iliotibial band friction syndrome has received considerable attention (Dowling et al. 2014; Neal et al. 2014). However, most foot studies are retrospective and involve the analysis of static foot posture, which may lack clinical relevance once the patient ambulates (Dowling et al. 2014). A long-standing theoretical assumption has been that an increased navicular drop, or a “flat foot posture,” increases the risk for MTSS, and that a high arch, or pes cavus foot, increases limb stiffness. Both foot postures are thought to increase the risk of lower-extremity injury (Neal et al. 2014; Tong and Kong 2013). However, foot posture assessment methods such as the navicular drop test and foot posture index have resulted in mixed causation findings (Neal et al. 2013). It is 48 possible that these assessment methods are not sensitive enough to detect dynamic changes when the patient ambulates (Dowling et al. 2014). To date, systematic reviews of foot posture, either static or dynamic, have yielded only limited evidence to support the association between altered foot posture and the risk for lower-quarter injury. However, Neal and colleagues (2014) reported strong evidence for an increased risk of MTSS among patients with a static pronated foot posture with very limited evidence of a propensity for patellofemoral pain. As well, Dowling and colleagues (2014) found very limited evidence that dynamic foot function is a risk factor for the development of lower-extremity injury. The authors did indicate that the clinical assessment of lower-quarter kinematics was a significant challenge because most clinicians lack access to sophisticated kinematic analysis technology as well as expertise in using it and interpreting the outcomes. Kinematic research findings thus may not be clinically relevant based on the multifactorial nature of lower-quarter injury and the difficulty of assessment in the clinical environment. However, age and body composition are easily assessed in the clinical environment. As discussed in chapter 3, the older population may be more susceptible to injury as a result of the aging process. According to Hill and colleagues (2008), foot injury afflicts more than 30% of the aged population, which has been associated with falls (Spink et al. 2011). In a systematic review, losses in strength, range of motion, balance, and flexibility were assessed as potential risk factors that could be mitigated by the use of a foot and ankle (FA) exercise intervention program. Investigators, however, found only limited evidence to support the use of an FA exercise intervention program to reduce the risk of falling in this population. Significant improvements occurred only in balance and flexibility (Schwenk et al. 2013), which may improve foot function and reduce the risk of falling. Obese patients may be more susceptible to osteoarthritis from increased joint loading. Abnormal foot function has also been observed in the obese population (Butterworth et al. 2014). The authors found among the obese strong associations among decreased balance, increased dynamic pronation, and increased plantar pressure during ambulation. However, because of methodological variations in the assessment of foot structure across studies, a direct relationship between body composition (fat 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 TREATMENT Common Anatomical Areas and Conditions for PRT • Fibromyalgia • Sprains and strains • Osteoarthritis Dorsal Structures • Lisfranc sprain • Morton’s neuroma • Osteoarthritis Plantar Structures • Plantar fasciitis • Metatarsalgia • Morton’s neuroma • Tendinopathy • Bursitis • Dorsal compression syndrome • Turf toe • Sesamoiditis • Bone spur mass) and foot structure was not possible. Butterworth and colleagues (2013) posited that foot pain experienced in the obese population may be the result not only of altered foot mechanics but also of “metabolic and inflammatory mediators produced by adipose tissue” (p. 7), which, if coupled, may create somatic dysfunction of the lower quarter in this population. In my clinical observation of thousands of patients who have presented with lower-quarter somatic dysfunction, the majority of lesions are the result of compensatory biomechanical loading patterns such as prolonged stance pronation, weak hip abductors, leg length discrepancy, muscle imbalance, excessive weight, and prior injury. The somatic or myofascial lesion patterns often manifest from either a functional or structural abnormality, which overloads the tissues; the tissues respond by forming osteopathic lesions in defense. However, it is imperative that therapists consider other triggers in the assessment process to identify and address any underlying disease process, visceral facilitation, or neurological derangement. Unfortunately, at this time scant literature exists examining the effect of PRT on lowerextremity intrinsic and extrinsic factors in isolation or in combination. The body of PRT literature has tended to focus on facial, spinal, pelvic, and upper-quarter painful conditions (Wong 2012). Positional release therapy research is starting to gain a footing on explaining how the therapy provides significant pain relief and correction of somatic dysfunction. However, until the gaps in the PRT literature are filled, clinical experience and feedback from patients about what they value from their clinical experience with PRT will inform the positional release therapist about how to approach lower-quarter somatic dysfunction. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 49 FOOT: DORSAL STRUCTURES Dorsal Interossei The dorsal interossei are bipennate muscles, each with two heads. Their action occurs relative to the midline of the foot (second digit). Although the majority of the intrinsic lumbrical muscles lie on the plantar aspect of the foot, they may be indirectly palpated along with the dorsal interossei as a group between the metatarsal bones. Origin: Metatarsal bones (1-4) Insertion: First: Medial surface of the second proximal phalange and extensor digitorum tendons Second to fourth: Proximal phalanges and extensor digitorum tendons Action: Toe abduction and metatarsophalangeal (MP) joint extension Innervation: S2-S3 (lateral plantar nerve) Dorsal interossei Palpation Procedure • Place the foot in a relaxed position. plantar aspect of the forefoot with • Stabilize the04.01/532003/JG/R2 E6296/Speicher/Fig. one hand. • With the other hand, apply moderate pressure between the metatarsals with the fingers. • Palpate the entire length of the dorsal interossei along the metatarsal shaft. • Note the location of any tender points or fasciculatory response along the muscle. • 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. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • With the ulnar aspect of your far hand or forearm, apply downward compression over the forefoot, moving the ankle into dorsiflexion. • Use the fingers of your near hand to assess and monitor the treatment position and fasciculatory response. • Apply eversion and inversion of the forefoot with your far hand or forearm (a greater amount of inversion for the first through third metatarsals and eversion for the fourth and fifth metatarsals). • Alternate: Grasp the lateral forefoot with your far hand for positioning and force application. • Corollary tissues treated: Metatarsals 50 Dorsal interossei palpation procedure. Dorsal interossei PRT clinician procedure. See video 4.1 for the dorsal interossei PRT 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: DORSAL STRUCTURES Cuneiforms Talus Cuneiforms Navicular Tuberosity Calcaneus Three cuneiforms comprise the midfoot. Each lies behind its respective metatarsal (the first cuneiform behind the first metatarsal, and so on), and all communicate with the navicular bone. The first cuneiform serves as an attachment site for the tibialis anterior and tibialis posterior muscles. The cuneiforms are a common site of midfoot ligament sprains. Superior Palpation Procedure • PlaceE6296/Speicher/Fig. the foot in slight04.02/532006/JG/R2 dorsiflexion to relax the extensor structures of the dorsal foot. • Palpate the shaft of the first metatarsal up to its proximal base. • Glide your fingers just over the joint space or valley between the first metatarsal proximal base and the first cuneiform. • Moving medially onto the second, or middle, cuneiform, you will feel a distinct rise as you gain the ridge of the second cuneiform. • Continue to slide your fingers laterally off the ridge of the middle cuneiform and into the next valley, where you will find the third, or lateral, cuneiform behind the third metatarsal. • Note the location of any tender points or fasciculatory response between and over the cuneiforms. • 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. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • With your far hand or forearm, apply downward compression over the midfoot, moving the ankle into dorsiflexion. • Apply eversion and inversion of the midfoot with your far hand or forearm (greater inversion for the first and second cuneiforms, less for the third) for fine-tuning. • Alternate: Grasp the midfoot with your far hand for positioning. • Corollary tissues treated: Cuneiform interosseous ligaments and talus Cuneiform palpation procedure. Cuneiform PRT clinician 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. 51 FOOT: DORSAL STRUCTURES Talus The talus is a cube-shaped bone with a body, neck, and head configuration. The posterior portion of the talus is narrower than the front, and when the ankle is dorsiflexed, a wedge is formed within the talocrural joint. This moves the ankle into a closed-pack position, increasing the stability of the ankle and limiting inversion and eversion. Talus Navicular Cuneiforms Sesamoid Sustentaculum tali Calcaneus Medial Palpation Procedure E6296/Speicher/Fig. 04.03/532009/JG/R1 • Place the ankle in a relaxed open-pack position (plantar flexion). • Place your fingers at the center of the ankle joint at the level of the malleoli between the extensor tendons. This location is over the anterior dome of the talus. • While palpating on the bony surface of the talus, move the ankle through dorsiflexion and plantar flexion to feel the roll of the anterior dome. • The medial and lateral heads of the talus can be palpated by sliding the fingers in either direction from its anterior dome. To expose each head more fully, invert the foot to expose the lateral head and apply eversion to expose the medial head. Also, the medial head is located just proximal to the navicular tubercle. • Note the location of any tender points or fasciculatory response over the talus. • 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. PRT Clinician Procedure • The patient is prone with the knee flexed between 60 and 90° and the shin supported with either your thigh or a bolster. • Grasp the calcaneus with your far hand and apply compression downward while moving the ankle into dorsiflexion. • Apply inversion, eversion, and rotation with your far hand to fine-tune the treatment location. • Corollary tissues treated: Extensor digitorum tendons 52 Talus palpation procedure. Talus PRT clinician 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: DORSAL STRUCTURES Extensor Digitorum Longus Tendons The four extensor digitorum longus tendons are lateral to the extensor hallucis longus tendons on the dorsal foot and come together proximal to the ankle joint to form the common tendon of the extensor digitorum longus muscle. This muscle is sandwiched between the tibialis anterior and peroneal muscles. Superior extensor retinaculum Extensor hallucis longus Inferior peroneal retinaculum Inferior extensor retinaculum Extensor hallucis brevis Extensor digitorum brevis Anterior Origin: Lateral tibial condyle, upper three quarters of the medial shaft of the fibula, interosseous membrane, deep crural fascia Insertion: Second through fifth middle and distal phalanges Action: Extension of toes 2 through 5, ankle dorsiflexion (accessory), foot eversion (accessory) Innervation: L5-S1 (deep peroneal nerve) E6296/Speicher/Fig. 04.04/532012/JG/R1 Palpation Procedure • Place the ankle and foot in a relaxed but slightly dorsiflexed position. • Ask the patient to dorsiflex the ankle and extend the toes to visibly bring out the extensor tendons. • Either pince or strum over the tendons. • Note the location of any tender points or fasciculatory response between and over the tendons. • 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. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Grasp the calcaneus with your far hand and place the forearm of the same hand on the plantar foot with an emphasis on the second through fifth metatarsals, or rays. • Move the foot into dorsiflexion and apply toe extension with forearm pressure. • Apply eversion and inversion to the foot with your far forearm for fine-tuning. • Corollary tissues treated: Cuneiform interosseous ligaments, extensor hallucis longus Extensor digitorum longus tendon palpation procedure. Extensor digitorum longus tendon PRT clinician 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. 53 FOOT: DORSAL STRUCTURES Extensor Digitorum Brevis Peroneus longus Peroneus brevis Extensor digitorum longus Peroneus tertius Superior extensor retinaculum Inferior extensor retinaculum Superior peroneal retinaculum Inferior peroneal retinaculum Extensor digitorum brevis Lateral The extensor digitorum brevis muscle belly lies beneath the extensor digitorum longus tendons approximately 2 cm (about 3/4 in.) anterior to the lateral malleolus on the dorsolateral aspect of the foot. When the toes and ankle are extended, the small, round belly of this muscle becomes visible. Origin: Dorsal surface of the calcaneus, lateral talocalcaneal ligament, inferior aspect of the extensor retinaculum Insertion: Second through fourth toes via the extensor tendon longus tendons. Some consider the extensor hallucis tendon a part of the extensor digitorum brevis. Action: Second through fourth MP extension, great toe MP extension Innervation: L5-S1 (lateral branch of the deep peroneal nerve) E6296/Speicher/Fig. 04.05/532015/JG/R2 Palpation Procedure • Place the ankle and foot in a relaxed but slightly dorsiflexed position. • Move approximately 4 cm (1.5 in.) distal from the lateral malleolus toward the fifth toe while moving under the extensor tendons. • Ask the patient to extend the toes and ankle along with eversion to bring the muscle belly of the extensor digitorum brevis out over the cuboid. • Note the location of any tender points or fasciculatory response over the muscle. • 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. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Grasp the heel with your far hand and place your wrist and forearm of the same hand on the plantar foot. • Move the ankle into dorsiflexion and marked eversion with the far hand, wrist, and forearm. • Rotate externally and apply a compressive force downward with the far hand, wrist, and forearm. Extensor digitorum brevis palpation procedure. Extensor digitorum brevis PRT clinician procedure. • Corollary tissues treated: Peroneal tendons 54 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 Aponeurosis The plantar aponeurosis, also known as the plantar fascia, is a dense triangular avascular connective tissue that covers the majority of the foot’s plantar muscles. The plantar fascia stabilizes the arch during ambulation. Origin: Plantar aspect of the calcaneus. The central portion originates at the medial calcaneal tubercle, which is a common site for irritation. Insertion: Proximal phalanx on each side of the toes Plantar fascia Action: Stabilizes the arch through the windlass mechanism; assists in stabilizing the calcaneus during push-off during the gait cycle Innervation: S1-S2 (tibial nerve, medial and lateral branches) Calcaneus Plantar view E6296/Speicher/Fig. Palpation Procedure 04.06/532018/JG/R1 • Place the patient in a prone position with the foot in a relaxed position. • Ask the patient to pull the big toe toward the shin to accentuate the fibers of the plantar aponeurosis for palpation. • Strum across the aponeurosis with firm pressure from its distal insertions to its proximal origin at the medial calcaneus. • Note the location of any tender points or fasciculatory response of the tissue, particularly at its origin at the calcaneus. • 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. Plantar aponeurosis 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. 55 FOOT: PLANTAR STRUCTURES Plantar Aponeurosis > continued PRT Clinician Procedure • The patient is prone with knee flexed to ~60° and the shin supported with either your thigh or a bolster. • Place the toes in the sulcus of your dominant shoulder to promote phalangeal flexion. • Move the ankle into marked plantar flexion with your far hand. • Apply calcaneal caudal traction with the far hand. • Apply calcaneal eversion or inversion based on the location of the lesion with the far hand. • Also with the far hand, apply calcaneal internal or external rotation based on the location of the lesion. • Corollary tissues treated: Quadratus plantae, flexor digitorum brevis, flexor digitorum longus Plantar aponeurosis PRT clinician procedure. See video 4.2 for the plantar aponeurosis PRT procedure. Patient Self-Treatment Procedure • If there is adequate flexibility at the knee and hip, place the foot on the opposite thigh. If there is not enough flexibility to accomplish this positioning, place the foot on the opposite shin. • Grasp the dorsal forefoot and toes, moving them into flexion and abduction with a cupping or cradling mechanism. • Place the fingers of the other hand over the anterior aspect of the ankle and the thumb of the same hand at the back of the heel. • While flexing and compressing the forefoot and toes inward, translate the calcaneus toward the toes to encourage relaxation of the plantar fascia. If a finger of either hand can reach the area of tenderness, place it over this area to ascertain the fasciculatory response of the tissue. 56 Plantar aponeurosis 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 Flexor Hallucis Brevis Adductor hallucis: Transverse head Oblique head Flexor hallucis brevis Flexor digiti minimi The plantar muscles are arranged in four layers from superficial to deep based on the covering of them by the plantar fascia; the longer muscles are closer to the fascia. Even though the flexor hallucis brevis muscle is located within the deep third layer, its contraction can be palpated by having the patient flex the big toe against resistance. Origin: Plantar cuboid and third cuneiform surfaces, posterior tibialis tendon, medial intermuscular septum Insertion: Medial and lateral surfaces of the proximal phalanx of the first toe Action: First toe MP flexion and abduction Innervation: S1-S2 (medial plantar nerve) Third plantar layer E6296/Speicher/Fig. 04.07/532022/JG/R2 Palpation Procedure • The patient is prone with the foot in a relaxed position. • Strum across the flexor hallucis brevis proximal to the first metatarsal head, moving toward the plantar navicular. • Note the location of any tender points or fasciculatory response of the muscle. • 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. Flexor hallucis brevis 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. 57