how physical therapy can enhance

7/27/2019 How Physical Therapy Can Enhance...

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HOW PHYSICAL THERAPY

CAN ENHANCE THEOUTCOMES OF THE

PODIATRIC PATIENT

LORI RUBENSTEIN, MAppSc, PT,

FAAOMPTLos Angeles, CA

Podiatry and Physical Therapy

We both recognize that

foot and ankledysfunction affects the

mechanics elsewhere in

the body.

Physical therapists areconsidered movement

specialists.

Toenail case

Case study

Patient referred for LBP

PMH: 7 years ago s/p left calcaneal ORIF

PT treatment focused on modalities for

swelling and pain management control. Present findings include -10 degrees

talocrural dorsiflexion resulting incompensatory gait pattern and

lumbosacral dysfunction.


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RESULTS

One physical therapy treatment with thetechniques well be discussing today

restored talocrural ROM to +5 degrees

dorsiflexion and eliminated compensatorygait pattern thus reducing her back pain.

Case study

There is a lot more that physical therapy

can do for your patients that may enhancetheir treatment outcomes and prevent

compensations elsewhere.

Introduction

Review of the podiatric and medical footand ankle literature usually references

physical therapy without specification as to

what types of physical therapy treatmentsare indicated. The aim of this lecture is to

discuss some of the physical therapy

interventions that are available and theirindications with relation to common foot

and ankle diagnoses.


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Outline

Modalities

Exercise

Gait

Physical Therapy evaluation

Joint mobilization

Neurodynamics: tibial and peroneal nerves

Common podiatric conditions1. Ankle inversion sprain

2. Cuboid syndrome

3. Bunionectomy

Modalities

Ultrasound

Phonophoresis

Iontophoresis

Electrical Stimulation

Contrast Baths

Light laser

Management of pain

and swelling

Reduce muscle

spasm

Reduce calcifications

within tendons

Enhance tissuehealing

EXERCISE

Stretching

Strengthening

Proprioceptive training (Podiatry Today, Denegar et al

2002, Osborne and Rizzo 2003, Verhagen et al 2004)

Balance

Neuromuscular re-education

Functional Training (Baxter 1995, Osborne and Rizzo 2003)

Sports specific training (Baxter 1995)


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GAIT

Gait training with

assistive device

Proper fitting of device

Post-op/Post-injury gait

training to avoid

compensatory patterns

(Rubenstein 1988)

PHYSICAL THERAPY EVALUATION

Observation

ROM (physiological)

Muscle testing/strength

Neurological

Palpation

Joint mobility/arthrokinematics (accessory mobility)

Gait

Function

Neurodynamics(Petty and Moore 2002)

Joint Mobilization/Arthrokinematics

Accessory mobilization to restore normalmobility to a joint.

Capsular restriction.


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Joint Mobility/Arthrokinematics

Common areas treated: Talocrural (restore talus posterior glide)

Cuboid (reduce plantarflexed cuboid)

Hallux (restore MTP glide to restore

physiological ROM)

( Hartman 1997, Petty and Moore 2002)

Joint Mobilization

Example: First MTP joint mobility

restriction Superior glide of

proximal phalanx onmetatarsal to restoredorsiflexion

Inferior glide of proximalphalanx on metatarsalto restore plantarflexion

Used in conjunctionwith physiologicalROM exercises

Mobilization

Dananberg et al 2000 reported twice thegains in dorsiflexion ROM following one

session of manipulation of the talocrural

and proximal tibiofibular joints versus 6months of calf stretching.(Dananberg et al 2000, Denegar et al 2002)


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Mobilization with Movement

MWM Brian Mulligan, New Zealand

Positional fault theory

Treatment must be pain-free!

When performed correctly MWM results in

immediate restoration of painfree ROM(Mulligan 2004)

MWM to restore dorsiflexion

In weightbearing, patient may experienceanterior impingement if the talus does not

glide posteriorly during dorsiflexion.

Therapist facilitates talar posterior glide

during active weightbearing dorsiflexion(Collins et al 2004, Denegar et al 2002, Mulligan 2004, Kavanagh 1999)


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Some causes of loss of ROM

Muscle length

Decreased accessory

mobility

Decreased nerve

mobility

Stretching

Joint mobilization

Neural mobilization

NEURODYNAMICS

Physical mobility of the nervous systemincluding spinal cord, meninges ,nerves.

Restricted mobility may result in traction orcompression and decreased blood flow to

the nerve, decreased axoplasmic flow,

decreased conductivity and symptoms oftingling or pain.

NEURODYNAMICS

Physical nervous system is a continuum.

Spinal cord must adapt to the 5-9cmchanges in spinal canal length that occurwith transition from extension to flexion.

Sciatic nerve must adapt to changes of atleast 12% its resting length during SLR.

Restriction of neural mobility can result inpain, nerve compression, neuropathy andtraction injury.


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Tests for LE neural mobility

Straight leg raise Tibial nerve bias

Peroneal nerve bias

(Butler 2000, Butler 1991, Hall et all 1998)

Straight leg raise tibial nerve bias

Patient lies supine, no pillow, with arms at sideor resting on abdomen.

Note resting symptoms.

Dorsiflex and evert foot. Note symptoms.

Maintain dorsiflexion and eversion whileapplying overpressure to knee extension.Note any change in symptoms.

Maintain dorsiflexion, eversion, and kneeextension while passively raising the leg intohip flexion. Feel for change in tension of themovement. Note any changes in symptoms.


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Straight leg raise tibial nerve bias

Normal response is to feel tension alongthe sciatic nerve.

Increase in symptoms distal to knee during

hip flexion maneuver indicates neural

tissue involvement.

Reproduction of patients symptoms

implicates neural tissue as source.

Straight leg raise peroneal nerve bias

Patient lies supine, no pillow, with arms at sideor resting on abdomen.

Note resting symptoms.

Plantarflex and invert foot. Note symptoms.Maintain plantarflexion and inversion whileapplying overpressure to knee extension. Noteany change in symptoms.

Maintain plantarflexion, inversion and kneeextension while raising leg into hip flexion. Feelfor change in tension of the movement. Notechange in symptoms.


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Straight leg raise peroneal nerve bias

Increase in symptoms distal to knee duringhip flexion component is a positive test for

neural tissue involvement.

Reproduction of patients symptoms

indicate neural tissue as source of

symptoms.


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Common LE neural restrictions

Nerve root compression from herniated disc

Sciatic nerve as it courses through piriformis muscle Common Peroneal nerve at fibular head Tibial nerve in tarsal tunnel

Deep peroneal nerve on dorsum of foot (Anterior TarsalTunnel Syndrome (Marinacci 1968, Dellon 1990)

Inferior calcaneal nerve between fascia of the abductorhallucis and quadratus plantae muscles

Interdigital compression (Mortons neuroma)

(Oh and Meyer 1999)

Example: Medial calcaneal nerve

MOTION

Dorsiflexion, eversion

Knee extension

Hip flexion 42

(Meyer et al 2002)

PATIENT RESPONSE

pull in calf

No change or mild

increase

Reproduction of

burning pain in medial

heel

Example: Peroneal nerve

MOTION

Plantarflex and invert foot

Overpressure kneeextension

Hip flexion 50 degrees

PATIENT RESPONSE

Lateral ankle pain

No change or slightincrease symptoms

Increase sharp painlateral ankle, may extend

to lateral calf


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Ankle Sprain/Neurodynamics

EMG studies and sensation testing insubjects s/p grade III ankle sprain showed:

-86% injured peroneal nerve

-83% injured tibial nerve

( Nitz et al 1985 as cited in Pahor and Toppenberg 1996)

Ankle Inversion Sprain

Re-injury rate s/p lateral ankle sprains inathletes as high as 80%

Chronic symptoms in up to 40% of patients

No correlation between mechanical andfunctional instability. 50% of functionalunstable ankles are mechanically stable.

Attributed to:-Abnormal joint mechanics

-poor proprioception

-functional instability(Baxter 1995, Denegar et al 2002, Jennings and Davies 2005, Osborneand Rizzo 2003)

Ankle Sprain Treatment

Proprioceptive and balance training

Joint mobilization to restore normal mechanics

Strengthening

Neural mobilization Functional training

Functional stability can be restored with use ofwobble board

(Baxter 1995, Osborne and Rizzo 2003, Rubenstein and Shay 1991, van Os et al 2005)


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Mulligan theory on Ankle Sprains

Theory: Ankle inversion injury may resultin anterior displacement of distal fibula

versus sprain of ATFL or CFL(Kavanagh 1999, Mulligan 2004)

MWM Ankle Sprain Test

Patient supine, foot off

edge of table

Stabilize tibia

Apply dorsal cephalad

glide of lateral malleolus

Foot will evert when force

is correctly applied

Maintain glide whileinverting foot

Glide and inversion

MUST be painfree

Positive Test:

Enables painfree

inversion/eversion ROM


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MWM Ankle Sprain Treatment

Repetitions

Taping to stabilize lateral malleolus posterior

Proprioceptive retraining

May need modalities for swelling control

Swelling usually resolves by next day

Do not immobilize

Can be performed at any time post-injury but

best immediately post-injury

Cuboid Syndrome

4% of athletes with foot pain

17% of professional ballet dancers

Cuboid manipulation effective to resolve

symptoms(Jennings and Davies 2005, Mooney and Maffey-Ward 1994)


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s/p Bunionectomy

TREATMENT:

Modalities to reduce swelling

Hallux AP and PA mobilization to restore normalarthrokinematics to the MTP joint

ROM

Gait training/ balance

Pool walking

Soft tissue mobilization

Taping

Bunion Taping


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For your consideration

Neural implications s/p bunionectomy

CASE STUDY Most treatment is performed with patient in long sit.

While working with a patient with a particularly stiff first MTP s/pbunionectomy (0-30 degrees, very stiff with pain) she reportedthat her sciatica had been acting up which she attributed to herantalgic gait. She had been receiving physical therapy for 2weeks with minimal changes in hallux ROM. Evaluationrevealed +SLR for lower back pain and stiff L4-5 spinalsegmental mobility. Treatment included 5 minutes of lumbarsegmental mobilization followed by sciatic nerve mobilization for3 minutes. We then immediately resumed hallux ROM andfound that ROM had improved to 10-0-75 degrees without pain.

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