Manual Therapy

11-9-09

"Infamous Ankle"
"You Don't Have Weak Ankles, You Have Stupid Ankles"
-Martyn Matthews

Week 7 in Manual therapy brings us to the ankle joint. Like the previous Monday's in manual therapy, we go over basic anatomy of the joint(i.e. bones, muscles, ligaments and other joints). The ankle joint(talocrural joint) is a synovial hinge joint meaning that it can move in two directions; plantar flexion or dorsiflexion. Another joint within the ankle and foot would be the subtalar joint. This is a plane synovial joint also known as a uniaxial hinge joint. The motion's that come from this joint are eversion and inversion. Next, we look at the mid-tarsal joints: talocalcaneofibular and calcaneocuboid. The functional motion for these joints would be to dorsiflex, plantarflex, invert, evert, abduct and adduct.

Now that we know the different joints within the ankle/foot joint we can go ahead and apply different mobilisations to regain ROM of these joints or help reduce pain.

There are 14 different mobilisations to choose from when dealing with a patient with an ankle problem.

Subtalar eversion mobilisation








Midtarsal supination mobilisation








plantarflexion mobilisation








PA of talus mobilisation








Dorsiflexion mobilisation








Subtalar inversion mobilisation








Intertarsal PA mobilisation








Midtarsal PA mobilisation








Midtarsal pronation mobilisation








Midtarsal AP mobilisation







PA of Tibia mobilisation

Intertarsal AP mobilisation







AP of Talus mobilisation









AP of tibia mobilisation



-------------------------------------------------------------------------------------------------

We went on to learn 10 deep transverse frictions that were applied to:
-deltoid ligament
-anterior talo-fibular ligament
-calcaneo-fibular ligament
-gastrocnemius muscle
-tendo-calcaneus tendinits
-tendo-calcaneus tendinitis( teno-osseous-calcaneus)
-tendo-calcaneus tenitis(lateral aspect of tendon)
-peroneus longus tendon
-peroneal tendons behind malleolus

Finally, we learn one manipulation that is applied when there is a chronic talo-fibular ligament sprain.

Functional Rehab

11-5-09

Consequences of Injury & Basic Concepts of Rehab

The first consequence that come with injury is inactivity. This will lead to atrophy of type II fibers along with loss of endurance and co-ordination. Essentially, all those combined will lead to a detraining effect on the athlete. The next idea we need to look at is immobilisation for the injured area. We already know it will have an affect on muscle with atrophy but also has effects on bone, ligament, joint and general fitness. According to Wolffe's law,bone in a healthy person or animal will adapt to the loads it is placed under. If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. But for our case we will look at the converse of that law: if the loading on a bone decreases, the bone will become weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for continued remodeling that is required to maintain bone mass. So basically, if your body doesn't need to use energy it won't. As for the joint, we see a loss of compression which in turn leads to a loss of lubrication and degeneration. The reason for this is because the articular cartilage is deprived of nutrients. Ligaments become weaker also because of Wolffe's law. Full remodeling of ligaments can take up to 12 months. Finally, it obviously will have an effect on our cardiovascular fitness. This will cause an increase in rested Heart Rate and stroke volume decrease.

Now going onto basics concepts of a rehab program. The aims of a rehab program provide an optimal environment for injury to heal. Rehab can also prevent recurrence of injury. Three basic goals of a rehab program:
1. restore function
2. prevent re-injury
3. correct any causative factors.

Manual Therapy

11-2-09

Knee!

At first glance the knee may look like a very simplistic joint but in reality is the largers and most complex joints in the human body. Not only is it a very complicated joint but one that encounters the most injuries as well.

As we did last time with the hip joint, Julian will begin the lecture in trivia fashion. This is a great way to review our basic anatomy of the joint.

Bones of the Knee(4 main ones)
-femur(thigh bone)
-tibia(shin bone)
-fibula(outer shine bone)
-patella(knee cap)
All of these bones are covered with articular cartilage .

Ligaments of the Knee
-medial collateral ligament(MCL)
-lateral collateral ligament(LCL)
-anterior cruciate ligament(ACL)
-posterio cruciate ligament(PCL)
-capsule
-medial coronary ligament
-lateral coronary ligament
-transverse ligament
-oblique popliteal ligament
-arcuate popliteal ligament
-anterior meniscofemoral ligament
-posterior meniscofemoral ligament
-ligamentum patellae(tendon)
These ligaments allow for stability of the knee to occur.

Menisci(knee cartilage)
-medial menisci
-lateral menisci
These are crescent shaped cartilages that lie on the superior surface of the tibia and as the names describe, one medially and one laterally. They act as shock absorbers as well as allowing for weight distrubution throughout the tibia and femur.


Joints(3)
-knee joint
-patellofemoral joint
-superior tibiofibular joint

Muscles
-quadriceps
-sartorius
-biceps femoris
-semimembranosus
-semitendinosus
-gracilis
-popliteus
-gastrocnemiusss

Ok, now we got the basic anatomy of the knee down we can go forth with our treatments.

When treating for a capsular pattern we will use five different techniques: medial rotation mobilisation, AP of tibia mobilisation, flexion mobilisation, PA of the femur mobilisation and extension mobilisation. See below diagrams(in order as listed)




Photos taken from Musculoskeletal Education: Manual Therapy Lower Limb. J.Hatcher. 2005
--------------------------------------------------------------------------------------------------
For non-capsular pattern treatments we may see loose body, meniscal tear, medial/lateral ligament sprain and contractile lesions to the quadriceps, hamstrings and gastrocnemius.

Loose Body
Key clinical features:

• twinges of pain
• sense of locking/giving way
• springy end feel in extension/flexion

Tx: loose body manoeuvre to knee joint

Warning:

• Always conduct full orthopaedic examination and history before applying any of these techniques.
• Ensure patient comfort & saftey at all times.

Directions:

1. Have patient lying on several pillows on flat bed first.
2. Using end of bed, flex hip and knee so the latter is resting over the edge of the bed (keep the bed up relatively high).
3. Place one hand directly over dorsum of foot, the other around back of ankle.
4. Apply traction to knee by squatting using your body weight (helps to have one leg up on bed frame).
5. Maintain traction with body weight and swing backwards and upwards taking leg through short range of extension, simultaneously rotating lower leg into3 flicks of motion. (Direction of rotation is into least painful direction).

Medial ligament sprain
Key clinical features:

• pain on valgus stress/lateral rotation of knee

Tx: RICE, deep transverse friction in max extension----->max flexion

Lateral ligament sprain
Key clinical features:

• pain on varus stress

Tx: deep transverse frictions

Meniscal tear
Key clinical features:

• similar to loose body
• pain with meniscus tests

Tx: refer to have surgery


Taken from Musculoskeletal Education: Manual Therapy Lower Limb. J.Hatcher. 2005
-------------------------------------------------------------------------------------------------

Contractile lesions

REFER TO TREATMENTS AROUND THE HIP; SAME CONCEPT

Manual Therapy

10-28-09


Practical. Worked in partners practicing the treatments of the hip.

Manual Therapy

10-26-09

Hip

The lecture in manual therapy was completely geared towards the hip(i.e. anatomy, pathology, mobilisations & manipulations). As a basic review we went over all the hip anatomy: joints, inert structures and contractile structures. We go on to talk about capsule and non-capsule patterns. When diagnosing a capsular pattern in the hip you will notice pain from the patient when they are flexed while medially rotated. There are three main causes for capsular pattern: Osteoarthrosis(OA), Rhematoid arthritis (RA) and Traumatic arthritis (TA). There are five different treatments we can do to the patient which are: lateral glide mobilisation, caudad longitudinal mobilisation, lateral rotation mobilisation, medial rotation mobilisation and felxion mobilisation. All of these treatments will be graded according to the clinical assessment findings.

Flexion Mobilisation


Lateral Rotation Mobilisation

Caudad Longitudinal Mobilisation in Flexion

Medial Rotation Mobilisation
Lateral Glide Mobilisation




The biggest indicator for a non-capsular pattern is restriction on flexion but not medially.

Loose body is one of the causes to non-capsular pattern. Clinical features to look for are springy end feel movement, locking/ giving way and twinges of pain. The Tx we would use is called Loose Body Manoeuvre of Hip Joint.

Another big indicator to non capsular pattern could be a contractile lesions. Three major muscles involved with contractile lesions being Adductor Longus, Quadriceps and Hamstring strain. The key clinical features to check for all three of these muscles are fairly similar. Adductor Longus you will have pain with resisted adduction as well as pain with passive abduction. For the Quads, you will find pain with resisted knee extension, passive knee flexion and maybe slight pain resisted hip flexion. Finally, looking at the hamstrings you will tend to have pain resisted knee flexion and hip extension. All of these strains/contusions will be given Tx of deep transverse friction directly to the muscle.

Manual Therapy

10-21-09

Thoracic spine was our topic today in manual therapy as well as what treatments can be performed. First test we learned was a mobilisation of the thoracic spine. So we first have the patient lie prone on the table where we go onto find the most prominent vertebra C-7 to give us a reference point so we can go up or down on the spine stopping where the patient has discomfort. Have bed level with superior aspect of patella while standing sideways over patient. Placing thumbs back to back over spinous process then apply PA (posterior---->anterior) movement using body weight over vertical arms and then grade accordingly. Next technique was a manipulation called the "Butterfly" (i.e. lying extension rotation). Have patient in prone position with feet resting over a pillow. Bed level with patella and locate C-7 spinous process and count accordingly to level at which patient feels discomfort. Than find transverse process of levels to be manipulated. From here you want to locate the scaphoid of your upper hand on lower segment and pisiform of lower hand on upper segment. Apply downward pressure and rotate hands together like a butterfly to take up soft tissue slack. Ask patient to take a deep breath in and out. On way out of patients follow the release of air with hands and at end of breath apply short amplitude thrust to receive a "crack" in patients back. Finally, the last technique was called "over hand technique." Essentially, this does the same thing as the butterfly but in a more complex way. Not going to type instructions out for this one because it's better to be in person. But you can look it up on youtube or come see me! Cheers!

Clinic

10-20-09

In clinic today, we began our day with a follow up assessment on the women in her mid thirties who complained of lower back pain. When we asked how the exercises we gave her last time were going, she told us that she could only get through one set with the prayer stretch. We then went on to re-assess her with lumbar mobilisations on T-12, L-1 & L-2 with Maitland's grades I & II on painful R side and grades III & IV on L side. These tests were done centrally and bilaterally. We noticed muscle spasms with in T-12, L-1 & L-2 R side. Her pain has gone down since last week when we last saw her. From there, we gave her some soft tissue massage and ending with giving her a revised Home Exercise Plan(HEP). On the HEP we took 2 out of the 3 sets in the prayer stretch seeing as how she could barely get through one last time but did add that if she felt capable of doing another set she should attempt. The next patient was also a follow up being a man in his early 70's complaining of lower back and R thigh pain. Since seeing him last week he has gone to get a MRI done but won't know his results till later next week. Doctors believe it could be spinalstenosis( spinal canal narrows & compresses the spinal cord along with the nerves) which would correlate with his pain into his thigh in regards with the nerve impingement. So we went on with a very light soft tissue massage over lumbar region. That is what we ended with and will wait till next week when we hopefully hear results from MRI. The following case dealt with a new patient, woman, in her later forties complaining of unstable R knee joint. Took her through some knee assessments and only found her to be quite laxity around the knee joint along with patellar misalignment to the medial aspect of knee. She has been a avid mountain hiker and cyclist but the only medical history she has had was from twelve years ago on a bike fall where she ended up braking her clavicle. Unfortunately, she has been living with this unstable knee for the last two years to the best of her knowledge and we can think it may be a degenerative disease. We did give her some strengthening exercises like the one legged squat but told her to only go down to 30 degrees. The last patient of the day was a N/P, woman, 18 year old footballer. Starting get pain around two months ago in L foot particularity the bottom of her heel as well as along the medial aspect of her foot. Pain is insidious so the patient is unaware of onset with lack of symptoms; just came about. The only medical history she has was she broke her L foot last year and was given orthodics for both feet but the orthodics turned out to be painful for her so she ended up not wearing them. Her tests that came up positive were resisted & passive inversion. We decided to refer her to the podiatrist as we though it was a mechanical problem on her gait analysis not a muscloskeletal problem.

Manual Therapy

10-19-09

Cervical and Lumbar Spine Manipulations

We continued our manual therapy class with spine assessments, along with different manipulations pertaining to the cervical spine as well as the lumbar spine. Cervical spine movements include: side to side, traction and gliding into extension. These cervical spine manipulations are usually performed in the supine position. Next, a interphangeal contact is positioned over the articulating pillar of the affected joint which is than placed at its end ROM where joint is locked out of play. It is than followed by a high velocity, low amplitude impulse. Moving onto the second half of class where we went on to learn lumbar spine manipulations. These like the cervical spine have some clinical effects following the appointment; for example, temporary relief of musculoskeletal pain, shorten time to recover, temporary increase passive ROM & physiological effects to the CNS. The sacroiliac joint manipulation is performed having the patient lie on their side with hip and knee fully flexed for the leg with the legion. Add counter pressure to patients shoulder & the fulcrum being the ischial tuberosity. The joint will than be stressed to its end ROM & lock out any joint. At this point, the practitioner will apply a very high velocity, low amplitude(like the cervical spine manipulations) impluse at end of ROM.

Functional Rehab 2

10-16-09

Sportsmetrics

Friday's Functional Rehab class is dedicated to applying what we learn the day before in lecture and using it in a practical way. We have been learning about sportsmetrics and how it helps athletes warm up in a very educated diverse way. When I say educated, I mean using not only stretching or running as a warm up but incorporating dynamics, plyometrics, stretches, strengthening and flexibility warm ups all in one. Technique is extremely important in sportsmetrics as we are essentially retraining our neuromuscular system hoping to decrease the likelihood of injury as well as improving sports performance. Quality over quantity is key. Not only does sportsmetrics help us in that aspect but gives the body a great 20 min cardio workout when we do all these exercises. I honestly was dripping sweat by the end of the 20 min. and I like to think of myself as a pretty fit guy. The reason why sportsmetrics does a great job at reducing risk of injury to an athlete is because the different manoeuvres perform relate directly to manoeuvres performed by the athlete on the field(i.e. cutting/turning/twisting/jumping/landing). So to talk about today, we did the twenty minute sportsmetric program in the gym and each had a partner so we could be evaluated on technique. The thing with retraining neuromuscular control is that you can relearn in a matter of days so each week we anticipate improvement.

Functional Rehab 2

10-15-09

Proprioception Training & Neuromuscular Control

Today's lecture was mainly about how important proprioception training is when incorporating it into an injury prevention exercise circuit. Let's define proprioception as the conscious and unconscious appreciation of joint position. When we look at traditional treatment methods there is a definite emphasis on pain restoration of ROM(range of motion) and strength/endurance; which makes perfect sense. BUT there isn't much account for proprioception and balance as well as tying everything together for the particular sport. In turn, it leads to incomplete restoration of function and increased risk of injury. To get back to proprioception, one can expand the term in regards to neuromuscular control: afferent stimulus (towards CNS) ---->reactive efferent output. When we injure proprioception, we will do it in one of two ways: Direct or Indirect. Direct involves trauma caused by a ruptured nerve fiber as indirect may involve someone with acute swelling around a ligament which leads to loss of reception due to pressure. Moving onto ankles, most common phrase correlated to ankle injuries would probably be "Can't help it, I have weak ankles." But my professor would beg to differ with that and correct that to "No you have stupid ankles." Because even strong ankles can be injured on uneven ground, if the neuromuscular system is not trained to react appropriately. On a final note, 20-50% of ankles injuries are reoccurring so what does that tell us? Did they properly rehab there ankle; ligamental, muscular, tendous and proprioceptive attributes, back to normal if not above normal? More than likely the answer will be no. Just a thought.

Sports Injury and Rehabilitation Clinic

10-13-09

Today was my second week working in the Sports Injury and Rehabilitation Clinic. I need to be there at 8:30 and don't get done till about 5:30. Long day, no doubt. This clinic is mainly for podiatry practice but on Monday and Tuesday's they share four rooms with us "rehabbers."
So there is nine of us sport rehab student's on Tuesday so we split up in pairs(one group of three) and see a patient off the street for an hour appointment. Keep in mind these patients are paying 12 pounds for their visit but do understand that this is also a learning experience for the students.
I got paired with Stacey this week and began our day with a women in her mid-thirties complaining of lower back pain. [NOTE: For every patient we begin with a medical history followed by a physical assessment. When we are done with that part Mike or Steve (Mike licensed practitioner at the clinic and Steve being a licensed practitioner as well as a Prof. at the Uni.) come in to give a diagnosis to what they believe is the problem and set up various exercises/stretches pertaining to the specific injury.]
After the women, we saw a male in his late twenties with medial collateral ligament damage due to martial arts. And the last patient we saw with actual injury was a women in her early twenties with what looks to be a subluxation in the hip joint; cause unknown but did inform us that she had an emergency caesarean section 14 months ago...The other four patients we had came in for a full body massage with minor complaints of stiffness. Honestly, four massages that are hour sessions takes a huge toll on the shoulders and back as I quickly found out.

Manual Therapy

To start the third week in Manual Therapy we begin learning different spine tests and what to look for while performing these tests. When checking the joints we will use passive tests(does it bring on pain). Then when checking roots signs we will use resistricted tests, looking for weakness in myotomes. The stroking test involves the therapist to literally stroke the dermatomes up and down on both sides; checking for any different sensations on either side of the patient. Reflex test will test the myotomes more specifically the nerve pathways; lower and upper motorneurons. Babinskies Reflex is the use of a sharp ended pointer that the therapist guides up the heel of the foot along the lateral aspect looking for flexion of the toes. Capsule pattern is inflammation from some pathological disease in Rheumatoid Arthritis (RA). RA=chronic systemic inflammatory disorder that may affect many tissues and organs but really attacks joints producing an inflammatory synovitis. Trauma Arthritis(TA)=caused by blunt force in an inappropriate motion of a joint. Osteoarthritis(OA)=a group of diseases and mechanical abnormalities involving degradation of joints including articular cartilage and the subchondral bone next to it. Finally, we talked about spondylolishesis which is an anterior displacement of vertebra column in relation to vertebra below(i.e. slippage).

Day 1 of classes

I start off my Junior year at Salford with my practical manual therapy class which is led by Julian Hatcher. Julian is a great guy who has helped me throughout this whole process of coming to England to study. He begins the class with a few jokes as he is a very humorous guy. A brief introduction of manual therapy is given as a obvious starting point for this class. Manual therapy is thought to be used as far back as 2000 B.C. with the ancient Greeks & Egyptians. Their theories per se had no scientific background but more down the lines of do these practices make the body feel better(reduce pain). Their theories can be related to our present day stance of manipulation and traction. It wasn't until the early 1800's that Europe would come across any such techniques in manual therapy. Julian then goes on in lecture given us some credible contemporary authors; each having their own opinion and technique of manual therapy. This is very beneficial as rehabing the musculoskeletal system is not specific in one technique but will incorporate several. In all, this class will give me the knowledge that a majority of American therapist don't incorporate into their practices.

The Beginning

Blogging, never thought the day would come for me.

To start off, I look at this more as an e-Journal; a place to record not only my time spent in the sports rehabilitation lab at the University of Salford but as well as my free time in Manchester, England. About six months ago I was approached by Brian Zeller(Athletic Training Professor at WSU) through a powerpoint presentation offering an exchange program to study at the University of Salford in Manchester. After, I knew this was a chance of a lifetime considering I would be just entering my Junior year, receiving 16 transfer credits towards my major of Athletic Training/Physical Therapy not to mention living in Manchester for a whole semester.

"Freshers Week"

Like most Universities, there is what we call a "Freshman Orientation Week"; a time for the freshman to get use to the whole idea of being at a University. Salford's fresher week came to an end yesterday with Lindsay Mitch and I( two other students from WSU on this exchange) program) at the campus pub playing British pool(smaller table & lighter balls; not so American). Throughout the week we had scheduled meeting times on main campus with our program leaders to give us a gist of what is to come this semester for class load. Well to be honest, after this freshers week I would say British student's mind sets are slightly different; play then work instead of work then play. Finally, as an American their are three essential rules to surviving in England: always look both ways when crossing the road, never assume one's football allegiance and if you don't drink beer it's the wrong country for you.