Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functio

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Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle Instability
James R. Beazell, Terry L. Grindstaff, Lindsay D. Sauer, Eric M. Magrum, Christopher D. Ingersoll, Jay Hertel
DOI: 10.2519/jospt.2012.3729

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability. BACKGROUND: Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function. METHODS: Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21). RESULTS: There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores. CONCLUSIONS: The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing. LEVEL OF EVIDENCE: Therapy, level 2b–.
J Orthop Sports Phys Ther 2012;42(2):125-134. doi:10.2519/jospt.2012.3729
KEY WORDS: ankle sprain, CAI, manual therapy, mobilization

The authors aim to determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability.

 

Spent every day this week working with an international rugby prop forward, doing amongst other things tib / fib mobilisations.... In fact he just left 5 minutes ago. hmmmm.

 

Yes, but dorsiflexion Stiffness might of been reduced

 

Dear Mike
Could you please explain exactly what dorsiflexion stiffness means/
Thanks
Paul Conneely
www.musmed.com.au

 

Stiffness is a measure of the amount of movement that occurs versus the applied force. The concept should be applied to a defined structure, for example, the ankle joint or the medial arch of the foot.

Stiffness is intimately entwined with range of motion. There has been a lot of discussion of ankle joint dorsiflexion stiffness. (Objects can have different stiffness values in different directions.) So, to measure stiffness of the ankle joint you would start in the maximally plantar flexed position and apply a force that would cause dorsiflexion of the joint. At the maximally plantar flexed position of the ankle joint, the stiffness will be very low because a small amount of force will cause movement of the joint. (Assuming that the person is not contracting their gastroc or soleus muscle.) Keep applying force and keep dorsiflexing the ankle. At some point you will develop passive tension in the Achilles tendon. As you apply force you will get less motion of the ankle joint, but you will still get motion. As you move the ankle joint furter into dorsiflexion, more and more force will be required to get motion.

We, here on the arena, have been focusing, in my opinion, a bit too much on stiffness alone. We used to focus soley on range of motion. Both concepts need to be applied simultaneously. We need to be asking at what point in the range of motion does the stiffness change. Measuring range of motion accurately is impossible unless we control for stiffness. (How hard do you push when you measure range of motion) And measuring stiffness will vary depending on where in the range of motion that stiffness is measured.

Eric

 

Dear Eric
Thank you.
I have coceptual problems regarding stiffness.
Who is measuring the changes? A 40Kg undergrad to a 120Kg Gym Junkie?
As I teach these things I have seen all manner of force being applied. Some people have no idea what the word gentle means.

Now a problem arises in the word stiffness. Where is what? By this I mean is the joint having a reduced ROM the cause or by the simple fact that a muscle length will meet the ROM of the joint it subtends
Thus if the joint has a reduced ROM so does the muscle have increased tension (Set length) so as to protect the joint from injury.

When an immobile joint is freed the muscle length increases immediately, so why are we measuring this 'stiffness'?
Regards
Paul Conneely

 

A large person and a small person can both apply 10Newtons of force. I agree that the word gentle may have many meanings. But, 10 Newtons has a definite meaning.

I'm not quite sure what you are saying here. As I pointed out in my previous post, muscle activation can change joint stiffness. For example, if you are measuring ankle joint stiffness by applying a dorsiflexion moment and the person decides to contrac their soleus muscle then you will measure a different stiffness.


Eric

 

Dear Eric

What I am saying is.
The role of a muscle is to protect the joint isubtends, nothing else.
Thus if a joint has a reduced ROM the muscle that subtends the joint will shorten to match that length.
Eg in the elbow normal ROM 180. Thus normal biceps will have a ROM of 180
If the elbow has a ROM of say 90 degrees, the biceps will have that lenght. Once the joint is made to have an increased ROM, say manipuation, to 135 degrees the biceps will automatically lengthen, again in a state of readiness to protect the joint from injury if the ROM is exceeded.

This Why people who have a lousy ROM of ankle joint motion, stretch the hell out of their gastrocs and hammies only to find the ROM is back to where it was the day before after a nights sleep.
I understand the principle of the patient tensioning their muscles and making things harder for you to move their joint.

I am at a loss why you want to know this 'stiffness' as I feel there are too many parameters involved.
These include the inert and active structures.
Regards
Paul Conneely
www.musmed.com.au

 

I think the point of stiffness is certainly one to consider (though as a non-engineering minded soul I still getting my head around it) but my own curiosity lies elsewhere in the paper abstract. Equally, I am not best at reading and interpreting research paper results. I am slightly curious as to a couple of things though:

1 Considering the nature of the subjects recurrent injuries why approach the matter of restoration of ankle dorsiflexion focusing on the Fibular alone? It may well be that they were trying to determine if motion at one (essentially) joint was more significant in recovery than another, I don't know. However other joints are also involved in this injury whose own stiffness or limitation post injury may be impacting upon the issue. If this is the case then I would have thought it might impact upon the outcome across the board.

2 Given the movements at the fibular joints (anterior/posterior, superior, inferior for both heads) plus the small expansion of the syndesmosis joint why isolate the subjects into superior and inferior fibular head groups. From a treatment perspective I would usually include both heads. Sometimes checking after each has been mobilised to determine any change. In addition the impacting stiffness in some might not be anterior/posterior motion but the inferior/superior motions. I am unclear as to which mobs were undertaken and which were not.

I'm not critiquing their results, just curious at the selection of joints in relation to the injury.

 

http://www.ncbi.nlm.nih.gov/m/pubmed/21460462/

 

Can we just ask the question, what do these results mean in terms of giving treatments for manipulations of the lower limbs?

How do we interpret these results, simply saying that stiffness should be factored into the equation, and if they havent the results are invalid, is merely telling a lie.

Should we rethink the use of fibular manipulations, or is giving half the treatment not enough (ie distal or proximal)?

Does anyone who has a lot of experience in manipulations of this area have any input please

 

Peter

I have to say that the above results does not change my approach to the use of mobs for the reasons I made in my post.

Fibular mobilisation is only one set of, at least, 14 of Maitland's mobs that can be used for the ankle complex. From the reading I have done (mainly Maitland, Mulligan, Hiss, Michaud), weight-bearing dorsiflexion as a motion is more a result a of a series of other motions occurring within the ankle complex. Reducing stiffness in other areas of the complex may allow a smoother glide of the joints which a patient benefits from in ways that are not just dorsiflexion oriented. For example, anecdotally, reducing stiffness in the superior fibular head has brought relief from hamstring discomfort or pain in some of my patients. It was not dorsiflexion that was the issue here.

In addition you can consider the active type of mobilisation techniques as explored by Brian Mulligan in the Mobilisations with Movement approach. Again these are quite different to the Maitland ones, likely used for different reasons.

I understand that in the Podiatric context of BMX we want a quality and range of dorsiflexion that may reduce stress to the foot and ankle. However, sometime it might be the improved quality of a restricted range that solves the problem and not just restoration of range.

Don't know, still learning.

I'm sure Stanley, Tedjed, Tom Michaud or Paul C might have more to say than me.

 

It means that the manipulations provided to the subjects in this study did not have a statistically significant effect on the outcome variables measured in the subjects in this study. This may infer that similar manipulations provided to other subjects who have similar demographics as the subjects within the study population may also demonstrate statistically insignificant changes with regard to these same outcomes measures. If you follow the exact same protocol that was applied in the study.

 

Ian, if we wanted to assess the effects of mobilisation on the "quality of a restricted range" how should we measure "quality"? Moreover, how does "quality" relate to tissue stress? If I was on your course and you said the above, those should be the type of questions I'd ask... Hint: I'd measure stiffness.

It's pretty easy to build a jig to measure ankle dorsiflexion stiffness, the hard bit is looking at and standardising rate of loading.

 

Jay Hertel is involved in most of the research I have seen regarding ankle or tib/fib manipulation. Some of these may have been in other threads?

http://www.ncbi.nlm.nih.gov/pubmed/21546263

http://www.ncbi.nlm.nih.gov/pubmed/19119395

http://www.ncbi.nlm.nih.gov/pubmed/20886654

http://www.ncbi.nlm.nih.gov/pubmed/16515420

 

Hi Simon

"Ian, if we wanted to assess the effects of mobilisation on the "quality of a restricted range" how should we measure "quality"? Moreover, how does "quality" relate to tissue stress? If I was on your course and you said the above, those should be the type of questions I'd ask... Hint: I'd measure stiffness."

It's a good point Simon and whilst it is something I have limitedly and lightly discussed with others I wouldn't mind working with someone on it. Certainly someone who has a better mind than mine on these things.

"It's pretty easy to build a jig to measure ankle dorsiflexion stiffness, the hard bit is looking at and standardising rate of loading"

Building things I don't do though. Well, things that work anyway. I have a lot of questions in my around this area but not clear enough to put down yet.

 

Yet in your clinical experience you must have a qualitative measure of, well, "quality of motion"...?

Let us define "quality of motion"
Certainly this was something that was mentioned during my undergraduate education. Can't remember the refs, but someone like Maitland must have defined some of the factors within "quality"? As memory serves, crepitus and clonus where in there... I think Root might have mentioned quality of motion too.

 

Hi Simon
Yes to the above but my impression was that, in relation to the jig, you were looking at something that may provide a less subjective assessment.

 

Here's my thinking, Ian: to what extent is joint stiffness a predictor of the more qualitative measures of quality of motion? In other words, can joint stiffness which is something that can be measured quantitatively, replace this qualitative, somewhat "touchy feely" measure we have called "quality of motion"? So, if we can define exactly what it is that we mean by "quality of motion" that might be a good start in answering this question. AND, since you brung it up- what do you mean by quality of motion?

 

Simon
I've copied and pasted your above comment into an email to myself as a reminder. I will pick it up, as much as I am able, tomorrow and try to come back with some thoughts. May not satisfactorily answer your probing questions though.

 

initials wouldn't be JW???

 

Dear Peter
I have been manipulating and or mobilising both superior and inferior tibiofibular joints in every ankle examination I make since 1991.

I can guarantee you you have missed the boat if you do not.

Think of the Tibia and fibula forming a distorted circle.
Put a life saver in your mouth and bite it (A life saver in Aus is a small donut shaped usually pepermint lolly)
IF you bite it you get 2 pieces minimum. That is there are two injuries at least.

Think of the broken jaw, the football player has. The papers always make a thing of the injury because they have two fractures. Good for them because if they only have one they have injured their TMJ-no good.

I could not tell you how many chronic ankle problems I have seen over the years where all the treatment is directed at where it hurts. Doomed failed

Treat dysfunction. The superior tib fib joints is always forgotten. In my 15 years of teaching foot mechanics I doubt more than 1% have ever examined this joint.

You will be suprised how the 'tricky' ankle can suddenly be rendered normal by mobilisation of the joint depending what direction it has its dysfunction.

In Ian Linaine's email he describes the various movement this bone and these joints make relative to the fibula.

I have seen plantar flexed feet when tested remain that way despite all the joints being mobilised until the superior tib fib joint was mobilised. This happened in a London workshop a few years back. It is not common but happens.

Regards
Paul Conneely

 

I agree that one of the roles of muscle is to protect joints. I'm sure that you'd agree that muscle also creates motion. That "nothing else" statement bothered me.

As was mentioned in some of the other posts, you can't measure range of motion unless you also think about stiffness.

In thinking about the lateral column of the foot, my personal sense is that there are some feet are more rigid than others. When looking at gait in the flexible feet you can see the heel lift off of the ground before the styloid process of the fifth metatarsal does. I would bet that there is not an abrupt change in stiffness in these feet. In more rigid feet you would see motion with force applied and then at a certain position you would see very little motion of the joints. The muscles will have to work harder in the more flexible foot to prevent injury. I believe this is an example where stiffness is important.

Eric

 

Simon, taking what I think are your main points is an odd order

1 “What do you mean by quality of motion?”

In relation to, say, the subtalar joint (Talus and Calcaneum) and one type of mobilisation technique. I would be comparing the affected foot against the “good foots” capacity for smooth glide in both anterior and posterior directions.

By smooth I mean the ease (level of practitioner force applied) and amount (in terms of available distance of glide within the joints given range) from starting point to the end of anterior motion with which the bad foot can be moved compared to the good foot. This is obviously subjective.

From the above I am suggesting “quality of motion” might be understood in part as the least amount of practitioner force that needs to be applied to glide one articulating surface in relation to the other, over a given distance. This is non-weight bearing and admittedly is presuming such ease of function is repeated in weight bearing.

Initially there may be a disparity between amount of ease and distance until possible inertia has been overcome. Ease and distance gained might occur only over a short amount but the aim would be to achieve ease and distance comparable to the “good foot” (if appropriate).


2 In other words, can joint stiffness which is something that can be measured quantitatively, replace this qualitative, somewhat "touchy feely" measure we have called "quality of motion"?

Firstly, as a non-engineer minded person, my honest answer is I don’t know! That is, I do not know how you construct or use the instrumentation.

Secondly, trying to pull my own fumblings together I would initially say I’m not sure that I see this as an either/or but more a both/and.

For example, in non-weight bearing ankle dorsiflexion where restricting stiffness between the Talus and low leg might be relatively easily measured, using a jig, then it may be a useful predictor of both the level of resistance (stiffness) of joint motion as well as the ultimate single amount of force that would need to be applied to over come that stiffness in one go. It may also be useful as an outcome measure later.

However, coming more from the mobilising perspective and not the high level thrust perspective, if the jig suggested I need to apply X amount of force to overcome stiffness in one go would it also:

• Tell me at what grade of oscillation I need to begin applying a force or increments of force?
• How long I need to apply a grade of oscillating force within a given limited range within the total available range of that joint?
• When to stop?

I would consider these to still be significant “touchy feely” matters.

The above is in relation to the Talus and low leg.

I am not so sure that the stiffness in the subtalar joint is so easily measured, being a set of glides that usually occur in weight bearing. I say this because whilst I might find a STJ somewhat stiff in general non-weight bearing assessment it would not be until I understood it to possibly have some weight bearing impact that I would treat it.

Best I can come up with at the moment Simon.

 

Woud you be surprised if I told you that what you have described above in 1) is stiffness!

 

I know one of the author's of this paper and have spoken with him on this and other similar papers he has worked on. I explained to him that I manipulate both proximal and distal for my AJ manipulations. They did not think to test it that way initially and I think the results show that. Only a retest of using Howard's technique ( JAPMA 2000 september) compared to the original test in the paper would tell for sure.

I plan to do some work with him on this in the near future both with emg and in-shoe before and after testing. I'll let you know how it pans out as we move forward.

Regarding stiffness: I saw an interesting abstract at ASB this summer on AJ ROM of high level sprinters and how they have much better DFion ROM at the AJ than lower level or less experienced or less talented sprinters.

I think stiffness if important but that we may often confuse stiffness in couple joint mechanics of a joint with less than adequate ROM with stiffness combined with adequate energy return in couple joint mechanics from a joint with excellent ROM. My meaning is that higher level sprinters both seem to perform better with higher AJ ROM scores. I think this is as much from the release of energy stored in the achiless complex from proper AJ ROM and from proper levels of stiffness at the proper time in the sprinting gait cycle. I think that less talented sprinters probably have slower times due to less power generated from a lack of energy return from the Achilles complex from a decrease in AJ ROM despite the strong possibility of maintaining similar stiffness in the foot and lower legs. This is my opinion and an early thought process. Poke holes as you like, but you have to take into account being able to maintain a proper level of stiffness in a timely manner while also being able to maximize energy return from joint coupling, especially where the AJ and achilles are concerned. IMHO.

Cheers
bruce

 

Eric,
I think you will often see an abrupt change in stiffness in the flexible flatfoot you referenced initially above. I see timing problems in CoF progression in these feet regularly and more often than not.
I will not disagree with you that a flatfoot can have a stiff lateral column or one that can quickly reach maximally dorsiflexed position so as to provide a stable position quickly enough to have little detriment in the timing of the forward and medial progression of the CoF. These feet are not uncommon. As well, there are many feet that likely have a laterally deviated STJ position and a very compliant or non-stiff lateral column that can and will cause problems with CoF progression and lead to stability issues depending on what that patient needs that foot to do.
Finally, the muscles may have to work harder to maintain stiffness and I think the ultimately leads to many of the issues we all deal with day in and out. The problem is that these muscle tendon areas are often over lengthened and lose their functional ability to provide adequate energy return despite aiding in stiffness. My opinion again.
cheers
Bruce

 

Dear Eric
I sent one reply in a massive thunderstorm the other night and it failed to send so here is another go.
As I posted the only role of a muscle is that of protection of the joint it subtends.
This may sound pedantic but here goes.
In the womb one develops a motor system called FRA, Flexion Reflex Afferents. This is the method that keeps one in the womb.
After birth it is called tickle. We all know what happens when those who are ticklish are tickled.
1. Knee flexion
2. Shoulder elevation
3. Hand supination
4. Biceps action
2-3-4-That is feeding oneself
5.Jaw clenching (increases muscle power)
6. Breath holding= diaphragm lowering (to 8-8th rib thus reduces the abdominal area) and also increases muscle power.
This is why we all love doing: biceps curls, dead lifts; quad strengthening, simply because it is easier to do as there is an inherent pathway that makes us stronger in this direction. That is motor cortex overrides the cerebellum.
Any other exercise is not liked. Two classic examples are triceps and hamstring strengthening.
This reflex stays with us. It becomes important in stroke patients where the extra pyramidal functions overrule the pyramidal (due to conduction damage).
But we need to escape from the enemy that wishes to eat us. We can at least become vertical and perform some locomotion and maybe get away from our predators. I know strokes would have been rare 120,000 years ago because old age was rare, but there would have been many a head injury from fights, falls etc.
An aside. Go to a nursing home and you will see elderly people who have: hip flexion deformities; all can breathe; all can chew; and have a vice like grip and tend to pull your arm towards them. They are just following the pathways laid out.
When a child is a couple of weeks old and NOT wrapped up like a present (so common today) they spend all their time testing their reflexes and improving on them. Most of this is occurring at the local level, from the Pancinian corpuscles in the skin to the Golgi tendon apparatus and annular flower spray in the muscles. I often wonder if this tight wrapping (swaddling) stops an excellent sportsperson from becoming an elite sportsperson.
I suspect that due to the infant spending most ‘cranial time’ on eye and hearing improvement (essential not to get eaten). I feel most of these limb movements are not augmented above the spinal cord level.
After a few months their uncoordinated motions of their limbs become more symmetrical and more powerful and deliberate and this I feel is when the brain has an increasing influence. (motor cortex)
Very early is the cerebellum activity. Best seen when a baby lies on its stomach and arches it back to lift its head to see their environment. Basically all motion that defies gravity are driven by the cerebellum. I call it the back half of you.
This is important as we are going to spend the rest of our lives repelling gravity so why not learn the rules first. The cerebellum is the part of the brain that I call hard wired and has the basic programmes for survival.
One can sit up but cannot feed oneself. The ‘front half of you’ has not developed yet. This is the motor cortex. This is the next step among many.
The muscles do not cause motion or antigravity activity, the brain does. This a secondary function of muscles.
The great late Vladimir Janda used to say on muscle movement, in the upper limb look at the agonists and antagonists, while in the lower limb look at the synergists for a successful rehabilitation outcome.
I also treat the antigravity muscles differently (Back half) to the Front half (motor cortex).
Regards
Paul Conneely
www.musmed.com.au

 

Dear Bruce
Stiffness is a variable event between joints (body sides) and individuals.
How about adopting the 9 point flexibility scale to assess whether a patient is hypomobile, normal to hypermobile for their overall flexibility.
Example: front row forward would be expected to have a flexibility of zero-1
average individual 2-3
Hypermobile person: 3+
For an example, normal external rotation of the shoulder is 90 degrees approx.
thus a front row forward would have a normal external rotation of 75-80 degrees. If they were greater there is a problem
On the other hand a ballerina with a 9/9 flexibility would have at least 105 degrees as normal, while 90 would be regarded as abnormal.
On the other hand why not just ask your patient does it feel the same as the opposite toe or whatever?
If people do not know what the 9 point flex scale is I will post it on pod arena
Regards
Paul Conneely
www.musmed.com.au