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Foot mobilisation and manipulation any evidence ?

Discussion in 'General Issues and Discussion Forum' started by Simon Spooner, Feb 14, 2011.

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  1. "“For 2,400 years,” wrote the historian of medicine David Wootton, “patients believed doctors were doing them good; for 2,300 years they were wrong.” Only in the past 100 years have treatments in the mainstream of medicine been consistently subject to clinical trial, to discover what works and what doesn't. "- Bee Wilson

    In their book "trick or treatment" Ernst and Singh look at acupuncture, another treatment which I had believed that had been around so long that if it didn't work, it would have died out ( I fell victim to the appeal to tradition fallacy, too). What I didn't realise was that according to Ernst and Singh it had virtually died out and was only resurrected by Chairman Mao, since he had promised health-care for all and this provided a cheap achievable way of doing it.

    So, manipulation was discussed in archaic texts pre-dating Hippocrates, how widely was it practised just prior to Palmer?

    With regard to mobilisations which paradigm do we feel offers the most valid approach: Maitland or Mulligan, Ted?
     
  2. David Wedemeyer

    David Wedemeyer Well-Known Member

    I'm wondering if Admin could split the responses on this thread where Simon and I are discussing chiropractic manipulation for low back pain?

    I have a study that I would like to post and have Simon comment on please.
     
  3. Just post it up David while I have some time to comment. Please remember though, my name is Simon Spooner, not Simon Singh: http://en.wikipedia.org/wiki/Simon_Singh
     
  4. David Wedemeyer

    David Wedemeyer Well-Known Member

    Here you go Simon:
     

    Attached Files:

  5. David, what is it that you want me to say which is different to what I have already stated? You have provided me with a single study. Of which I have thus far read the abstract. This was a pain in the ass to read because of the use of abbreviations by the authors. "One swallow does not a summer make", if we carried out a systematic review of the literature today, including this paper, what would the weight of evidence tell us? We seem to be going around the same stump, David.

    If we take all of the high quality trials (and this paper is probably one of those) what does the sum of the quality trials tell us....? Until we have a newer and /or better, systematic review than the one offered by Cochrane....

    Let me try to explain, since this is obviously a sticking point. Lets say we have 15 high quality trials; 11 of them show conclusion x and 4 of them show conclusion y, do we go with the weight of evidence, i.e. conclusion x, or do we go with the minority of evidence, conclusion y? What if the study you cited represents one of the studies within the minority representing conclusion y?

    "If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

    I appreciate that you are trying to defend your profession and your own actions, but you are barking up the wrong tree, I am not your enemy. I'm also not saying that the majority view is always right. Yet neither does that mean that the minority view is correct either... Which sets us up to a nice hypothetical: How many high quality studies does it take to change an individuals philosophy regarding treatment protocols?... Craig, listed some of the reasons for opposition to paradigm change within past, present , future... they are all relevant here, unless it's "Eight O’Clock in the Morning".
     
  6. TedJed

    TedJed Active Member

    Howard, I didn't mean to imply that you were saying that cartilage changes from manipulation. I was simply asking if you thought it was possible. Sorry for any misunderstanding.

    Howard, I'm curious to know what physiological changes you're aiming to achieve with your 1-2 treatments. Would you please describe what physiological changes occur with your treatment to, for example, increase the RoM and pain reduction? Are you looking to achieve anything else via your treatments?

    Thanks, Ted.
     
  7. David Wedemeyer

    David Wedemeyer Well-Known Member

    Simon isn’t providing the most current, quality randomized, blinded, controlled trial evaluating the effectiveness of spinal manipulative therapy (chiropractic) versus standard outpatient medical care of value to the discussion? It was published in one of the most prestigious scientific journals, SPINE in December and not included in the Cochrane review (completed in 2009). There is in fact new evidence to support that chiropractic manipulation is superior to allopathic care in treating acute low back pain complaints. I feel that is highly relevant. You disagreed based on the Cochrane review and in truth there are some problems with these types of studies. I had an email conversation with a colleague and he brought up some very valid points that are worthy of mention and in his own words:

    "The Cochrane review is a meta-analysis of studies on treatments. These types of studies have inherent strengths and weaknesses. For one, when you pool data from many studies you can detect subtle differences that may be statistically significant, but may not be clinically significant. Also, when combining studies you may obscure possible benefits to subgroups. Spine pain has been treated like it is one entity, but it may be that there are different subgroups - such as discogenic, muscular control problems, myofascial, etc. Imagine if we treated all chest pain like it was one entity, rather than if we first identified whether the chest pain patient had myocardial infarction, angina, aortic dissection, hiatal hernia, heartburn, costochondritis, etc. If we randomized all chest pain patients to one group getting beta-blockers, one group getting antacids, one group getting anti-inflammatories, etc. you can see how the results would be problematic. This is one of the flaws with back pain research."

    The other point that he made I had also noted upon finding the CHIRO RCT. The Cochrane review is out of date based on the RCT that I just posted, which was just published in December of 2010. It was not included in the Cochrane reviews you have provided and asked the specific question is chiropractic care more effective than traditional allopathic care in the treatment of acute low back pain? Prior to the Cochrane reviews that you referenced we have the Manga report, which reached a completely different conclusion based on all of the available research on low back pain. How do you resolve that except to say that Cochrane included very different data (some of which I’ve never even seen prior and I do read the literature).

    I realize that you're not Simon Singh and I do not see you as an enemy at all. Hopefully you don't see me as one; I am merely defending the position of my profession based on some comments that you made. I hope to shed light on some of your conclusions through both evidence and polite discussion. I feel that is fair, I'm sure you would agree.

    In that vein I retract the claim that I made that chiropractic has consistently shown to be more effective than other modalities in treating low back pain. I will state that there is now at least one study that supports my previous statement (and the previous Manga Report – a literature review) and that it is a high-quality RCT and more current than the Cochrane review. A review is a review and not sacrosanct; the inclusion data predicts the outcome and Ernst and Singh have shown intolerable bias towards my profession; and they appear to have profited from this, at least in Singh's case.

    I will also state until I find further evidence, that 1) chiropractic has shown to be as effective for the treatment of low back pain as multiple other modalities. 2) It has shown in at least one high-quality and current study (and at least one widely accepted, unbiasd review – Manga) to be more effective than traditional allopathic outpatient care in the acute phase and 3) that it is safe based on the statistics that I provided from the NIH as opposed to certain media personalities with an agenda.

    I may amend this as I sift through the literature and I hope that you would agree that those are fair statements to make based on our discussion and the evidence? I believe that if you are incorrect in making a statement or a claim or that if you have denounced a treatment based on the research, bias or current knowledge that you should correct it and I have; as should you. You commented:

    We have if you take the time to read the Manga Report and the CHIRO RCT Simon. I look forward to Cochrane's new review which includes this RCT.

    A frequent criticism of Cochrane and other systematic reviews is that in spite of their methodological rigor, they fail to provide clear clinical answers, or lack appropriate translation of the evidence into the realities of clinical practice. I hope in time we can revisit this as the research catches up with what we see in daily clinical practice.

    Our patients have a choice who to seek for care of a spinal related concern and that despite all of the sensational media, bias, rumors and arcane rhetoric, those same patients should have the real facts and evidence available to them to make that decision in an educated manner.

    Regards,
     
  8. Dananberg

    Dananberg Active Member

    Ted,

    My practice philosophy is to see patients as infrequently as possible. No one wants to go to the doctor, and I do my best to limit how often they have to see me.

    I can often reverse restricted ROM in a single visit, and then use stretching to maintain flexibiity and CFO's to restore function. If pain is foot based and chronic, I will often use the Vasyli-Dananberg product for a few months and let chronic swelling reduce before casting. I may mobilize them over the several f/u visits, but that usually does it. Even the orthotic is motion based, and the criteria is to mobilize the 1st MTP joint so that the windlass can facilitate timely supination. There are rare instances where motion is so limited, that a series of visits (3-4) are required to attain adequate mobility.

    The three major effects from manip/mobes as I see them are
    1. Restoration of ROM
    2. Muscular facilitation
    3. Nociceptive modulation

    I use a variety of techniques that I have learned over the years. Safety is paramount to me, and I use the most gentle approaches I have been able to been taught by a broad range of practitioners. As a clinical tool, it is terrific, but the effects are very skill based, and while apparently simple, do take years to reach an expertise. There is little doubt that using an equation to describe this type of practice misses the art of manual medicine. Clinical medicine is a blend of evidence basis, diagnostic ability, and a wide selection of care methods which "above all do no harm". The art is in the delivery.

    To conclude, in an old Simpson's cartoon episode, Homer came home and told his wife Marge, that he went to the chiropractor, and was told that he had to return 3 times/week for the rest of his life. I think the humor in this is a reflection of some underlying truth. I do understand that purely manual practices exists, and that frequent visits are the model. It is just not one which I choose to practice.

    Howard
     
  9. markleigh

    markleigh Active Member

    Howard I recall (I think) seeing a DVD of you performing manips/mobs. Is that correct & viewable somewhere? No offense but what I can recall it was only a few maneuvers which I liked. Have you changed what you do in technique?
     
  10. No, David. I didn't disagree based on the Cochrane review, what I said was that the evidence needs to be viewed as a whole, not on the basis of one study which forms part of the evidence pool.

    The Cochrane review is over a year old, new evidence will be published, that is why I said that I look forward to reading a new systematic review to include the most up to date evidence. Indeed, this is why Cochrane update their reviews. Yet you cannot simply strike off the findings of the Cochrane review because it is now over a year old, nor the findings of the studies that were included in that review and replace them with the results of the single trial you cited, since this would be falling for the argumentum ad novitam fallacy. At the same time we shouldn't consider that the older Manga report is any more accurate since this is to commit an argumentum ad antiquitam fallacy. We have to look at the evidence pool as a whole. So the Cochrane included very different data, was this due to it being produced after the Manga report?; was it because the search for available evidence was broader? I'm sure you do read the literature David, but the authors of the review performed a systematic search of it, perhaps that is the difference?

    Lets take another look at the comments I made: I asked Ted: "where is the plethora of evidence for chiropractic manipulation etc..?"; [N.B.: etc.] I also said regarding enthusiasm in medicine over science: "Tell that to the people who have been left dead or paralysed by the "enthusiasm" of any number of physicians over the years." I included a link to this website:
    http://www.skepdic.com/chiro.html Which talks about chiropractic and among other things gives a case of a patient who suffered a stroke following spinal manipulation. N.B. I didn't say "Tell that to the people who have been left dead or paralysed by the "enthusiasm" of any number of physicians from a specific profession over the years. I said "physicians", I also in a later post gave the example of the blood letting practices of the Dr's who attended George Washington. Here is another link to an article in which the authors seem to share the view expressed above: http://ebn.bmj.com/content/10/1/4.extract which states: "Sadly, there are many examples of doctors and other health professionals harming their patients because treatment decisions were not informed by what we consider now to be reliable evidence about the effects of treatments. With hindsight, health professionals in most, if not all, spheres of health care have harmed their patients inadvertently, sometimes on a very wide scale. Indeed, patients themselves have sometimes harmed other patients when, on the basis of untested theories and limited personal experiences, they have encouraged the use of treatments that have turned out to be harmful."

    I hope you see that I asked a fair question and made a "fair comment". The websites I've linked to are in the public domain, if you are unhappy with their content you should take that up with the person(s) who wrote them, not me.

    Since you hope to shed light on some of my conclusions, I'm sure you can state my conclusions for me.. since I have not stated any conclusions, merely asked a question and noted that people have died or been left paralysed by the action of physicians, and linked to some research reviews, exactly what are my conclusions upon which you are going to shed some light?
    Strong words: "intolerable bias", I thought it was deemed that Simon Singh had made "fair comment" not shown "intolerable bias"? Again if you have an issue with that, take it up with them, not me. Do you think you are showing any bias in your above statement? N.B. Ernst and Singh didn't carry out the review.
    Nobody is saying otherwise, David.
    Is there something you think I need to correct then, David?

    Yes, that right.
     
  11. ]
    mark Here is Bruce Williams some Mobs which I´m pretty sure Bruce said was taught to him by Howard.


    http://www.youtube.com/watch?v=s4gmw4EQ8OM


    Hope that helps.
     
  12. Dananberg

    Dananberg Active Member

    Mark,

    Check the link below. It will also refer you to other techniques. I believe that there are 5 or 6 videos of manips currently posted.


    http://www.youtube.com/watch?v=rjOqUNLBX8U

    Howard
     
  13. Here are the findings of a systematic review published in "Spine" 2009:
    "The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations."
    http://www.ncbi.nlm.nih.gov/pubmed/19444054

    Here is a list of other publications regarding safety:
    http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pubmed&uid=19444054
     
  14. David Wedemeyer

    David Wedemeyer Well-Known Member

    Simon I'll leave the discussion of stroke with first the American Chiropractic Association response to Medscape. It is not a response to the particular review that you have posted because those reviews have already been covered previously and found wanting. It is directed at Ernst who shows as I stated before an unscientific bias towards manual medicine and chiropractic specifically:

    http://www.acatoday.org/record_css.cfm?CID=4099

    Lastly one of the very best quality studies on the subject of VBA stroke was performed after the study you cited and was also published in Spine:

    http://www.ncbi.nlm.nih.gov/pubmed/18204390

    CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

    These are regrettable events but the data repeatedly shows there is no increased risk of vertebral artery dissection or stroke from spinal manipulation as performed by chiropractors; unless you believe Ernst and and a couple of minor authors that draw conclusions and lend opinions despite there being inconclusive evidence in their reviews, poor design inclusion, case studies etc.

    The Portuguese study was trampled after release, 115 of their included papers (the heaviest weight of their evidence) were case studies many of which the validity of who actually performed the manipulation could not be verified, causation could not be established etc.

    I'm satisfied that we could go round and round here so let's agree to disagree, if that is acceptable to you?
     
  15. Agreed. Now, what I'd really like to see is a study of the adverse events following manipulation /mobilisation of the foot. Not all adverse events following manipulations are strokes, as highlighted by the systematic review I linked to which showed that serious complications of spinal manipulation are rare, but that "33-60% of patients experienced milder short-term adverse effects" such as increased pain, radiation of pain, headaches, vertigo and loss of consciousness. http://www.ncbi.nlm.nih.gov/pubmed/19444054

    What proportion of patients experience increased pain and/or radiation of pain following manipulation of the foot / lower limb? There's a nice little study for you, Ted.
     
  16. David Wedemeyer

    David Wedemeyer Well-Known Member

    Good God man, get over that pile of guano review Dr. Simon! ;)

    I am kidding of course but I know of no other studies that draw epidemiological results in those ranges following spinal manipulation. Also remember spinal manipulation is a very broad term encompassing many other professions of varying ability and training.

    Is it intuitive to believe that if 33-60% of patients undergoing what appears to be all forms of spinal manipulation suffered some modest side-effect that our patients would return for care? I loathe that study Simon and their conclusions. If it had a lot of weight to it it would then progress to anathema status but on the whole I don't find that study useful.

    I'd love to cooperate with Ted on a lower extremity research study or studies. Perhaps you would aid us in the design Simon as I do trust and value your acumen in that arena? Simon are you familiar with Dr. Rue Tikker?

    Either that or Robert will inevitably have to get involved :D
     
  17. David, is it really me that needs to get over this? I didn't review the paper for spine and accept it for publication. The reviewers obviously believed it was worthy of inclusion in this "prestigious" journal. Similarly I didn't review the Lieberman paper for "Nature". Moreover, I don't perform spinal manipulations...so in all honesty, I'm really not that interested.

    Let me ask you this question, David: do you accept that "adverse events" do occur following spinal manipulation in some people? If the answer is yes, and I hope for my sanity as much as yours that you agree, then it might be useful to carry out a study of the adverse events which might occur following manipulation of the foot and ankle. So, let me turn it around... given your criticisms of the studies examining the safety of spinal manipulation, how would you design the study so as to avoid the short-comings which you believe these studies have?

    Regretfully, I've never heard of Rue Tikker. A quick google reveals a podiatrist by this name? Or is/ was (s)he a chiropractor?

    If you are serious about performing a research study I will help you, but only if you are serious. If you would prefer the assistance of Robert, ask him.

    P.S. to put into perspective the 30-60%, an older Cochrane review which has since been withdrawn as it was out of date reported that about 30% of patients were dissatisfied post hallux valgus surgery, yet lots of people were still undergoing hallux valgus surgery on a daily basis at the time when this review was current.
     
  18. David Wedemeyer

    David Wedemeyer Well-Known Member

    Simon I think we agree there is the potential to harm with any treatment, whether manual, medicine or surgery. No rational person would say otherwise. If I misunderstood the tenor of a part of your posts to be aimed at the chiropractic profession then I apologize. I read at least one of the comments that way but we've had this discussion and since this is a forum for podiatrists and I've made my point, I wont belabor the subject any further.

    Rue Tikker is a podiatrist who resides in Napa, CA. He is a graduate of CCPM I believe where Kevin and Eric are faculty. He ran clinics for an osteopath (Hiss) who is credited with developing many of the foot techniques widely practiced today from what I have read. These were strictly lower extremity treatment clinics and the numbers of patients that they reportedly saw weekly was staggering. He gave courses on foot and ankle manipulation in previous decades but I don't glean that the concept is as popular amongst U.S. podiatrists as it is abroad. I hope to spend some time learning his protocols and techniques soon. It would be very interesting to read what he has to say about the subject here if he were willing? I wonder if anyone reading knows him on a personal level?

    Keep in mind that manual techniques vary greatly and that there is a distinction between manipulation and mobilization. Going back to our previous conversation there is a greater risk for manipulation but also a greater reward when appropriate (and I admit bias here). I have not read many of the studies on foot and ankle manipulation to be honest, nor many pertaining to its safety. That could be a good starting point. Thank you for agreeing to help Simon.

    The part about Robert was a joke regarding Robert and Ted's pending meeting. :D
     
  19. I have heard of the legend of Rue Tikker, DPM, but never met the man. I do know that he has trained a number of podiatrists in these parts on manipulation. I have seen cuboid manipulations at the hands of Jack Morris, DPM, perform amazing miracles in feet of my patients when I was a Biomechanics Fellow , so there must be something physilogically going on, I am just not sure of what that is. Definitely these manipulations do work for many patients, but since I've never been good at doing them, I do them sparingly now.

    I think it is best to keep the mind open to such therapies since they work for many of my patients who see chiropractors regularly, but I just wish I knew what was actually occuring at the joint/microscopic/neurologic level that causes the improvement in pain that is reported so often.
     
  20. efuller

    efuller MVP

    I was on faculty, but am no more. I've also heard of Rue Tikker, but have never met him.

    Jack Morris also taught me a few manipulations. I had a subluxing 2nd cuneiform that he manipulated several times to make my foot feel better. I was traveling and had my cuneiform pop up and had to teach my wife to pop it back in. She was able to.

    A Jack Morris manipulation story. At CCPM we had a special problems clinic where local practitioners would refer their problem cases and a majority of the CCPM podiatry faculty would be there to help evaluate the patient and give suggestions. I wasn't present at this one, but it became school legend. There was a 12 year old boy who came in with some pain in his foot and was showing some early signs of CRPS. The foot was cold with some discoloration. The kid was presented to the group. Jack goes up, in front of a room full of people and performs a manipulation. The kid stands up start walking around with a smile on his face. The foot color returns to normal and warms up. A pretty amazing performance in front of a room full of skeptics.

    I think there is something to manipulation, but you're not going to make legs longer with it, as I've seen some claim.

    Eric
     
  21. A phrase I use in the conclusion to my talk on the use of orthoses for lower back pain may be relevant here.

    "Too much evidence to ignore, not enough to decide. "

    I am looking forward to working with Jed, desparately hoping to be able to get there. Might, however, be out of my hands.
     
  22. Ian Linane

    Ian Linane Well-Known Member

    Hi All

    I believe John Martin Hiss was both an orthopaedic surgeon and manipulator along more of the lines of osteopathy style approaches. Again I have understood that Rue Tikker may have trained alongside or under Hiss. (but may be mistaken)

    Hiss was renown for his clinics on foot and ankle manipulation and I understand him to have kept 10's of thousands of individual pt records (hand written). He was particularly interested in treating feet that were markedly limited in function due to arthritic change with, it seems, remarkable success. He certainly used x-rays within his work. I am not aware of him indicating that his approaches may reverse arthritic joint degeneration but then the ability to measure that at the time probably may not have been around. Equally I am reasonably sure that was not his intention.

    He was of the view that to restore mobility, of however a restricted joint, went a long way towards reducing pain, in function, related to arthritis and gained improved activity function for the patient. This fits for me in that some of my patients with arthritis will be happy with a 40% reduction in pain if its accompanied by a 70% improvement in function.

    His book on the foot and ankle (I have a copy) is a fascinating read though clearly dated having been written in the 1940's. One picture is quite fascinating. Hiss is seated on a practitioner chair surrounded by 7 patient treatment couches, each occupied by a patient in their Sunday best with their feet extended ready for treatment. Behind them are 3 rows of awaiting pts, approximately 10 pts per row, each in their Sunday best awaiting their turn to go and have their feet manipulated. Hiss is seated in the middle and simply rotates to each patient in turn!!

    I have previously trained in Hiss's manipulative techniques and occasionally use them. However, I am more comfortable using Maitland mobilisations and Paul Coneelly's foot and talus ones on a daily basis. I know of others that use Hiss's approach effectively and perhaps its what you are most comfortable with that partly dictates your choice of modality.

    Sorry if this is a bit brief and disjointed. Rushing a reply before I go and lead a couple of days on mobilisation techniques for Chiropractors ;). If people want the name of the book I'll post it when I come back but it is surely out of print now.
     
  23. TedJed

    TedJed Active Member

    This is an articulate summary of how the 'art' of manual therapies fits into our profession, Howard. In our EBM paradigm, it seems that the 'art' of our work may not get the acknowledgement it deserves.

    Dr David McCleave, the pioneer of ICUs in Australian Private Hospitals said: 'Medicine is not a science, it's an art. It requires great interpretive skills.'

    I'm interested in hearing more about this comment, Howard. What physiological changes occur to permit increased RoM in a single visit?

    Ted.
     
  24. Ted

    I note that you have yet to retract your claim that mobilisation reverses DJD. In light of the comments in this discussion would you care to clarify your position? It's interesting to read of the adverse effects having seen one patient a month or so back who had a particularly vigorous session with her chiropractor who had diagnosed a "locked cunieform joint" where she had in fact an ankylosis. Following manipulation (during which she described a popping sensation) she developed splayed 2nd and 3rd toes - similar to that of an advanced neuroma - I assume there's been disruption of the transmetatarsal ligament. Not a clever outcome. Do you see this much?

    Mark
     
  25. Dananberg

    Dananberg Active Member

    Eric,
     
  26. Dananberg

    Dananberg Active Member

    Eric,

    I have actually seen this affect many, many times. Rather astounding to those who have never seen this before. I can offer the following explanation.

    Nociceptors are the primary pain sensing nerves in the body. They do not, however, only transmit signals from distal to proximal, but are capable of antadromic function, which is a reversal of flow where signaling is from proximal to distal. Under this condition, free nerve endings secrete an array of neuropeptides which are both pain producing and vasoactive.

    In a CRPS or RSDS type case, often minor injuries (ie mild ankle sprain) can produce devastating symptoms. Since nociceptors synapse with proprioceptors at the wide dynamic range cells in the dorsal horn of the spinal cord, abnormal motion signaling can create antadromic effect and secretions at the distal ends of the nerve. This is what causes the intense pain and color/temp changes. It is for this reason that manips can create spontaneous changes and immediate resolution of both pain and color abnormalities.

    Howard
     
  27. TedJed

    TedJed Active Member

    Mark,

    I made this claim within a context you are not willing to consider. See Post #47:

    The track around the stump is well and truly worn out.:deadhorse:

    Ted.
     
  28. Ted - you should remember that what kills the skunk is the publicity it gives itself. Good luck in your endeavours.
     
  29. jesspt

    jesspt Member

    I realize that this thread appears to have died, and I got to hte party a bit late, but here are a few articles that have examined the use of manual therapy for treawtment of common foot/ankle conditions. None of them are of the highest quality of evidence, but they are more clinically relevant than much of what has been discussed previously.

    http://www.ncbi.nlm.nih.gov/pubmed/16108581

    http://www.ncbi.nlm.nih.gov/pubmed/19687575

    http://www.ncbi.nlm.nih.gov/pubmed/21285525

    http://www.ncbi.nlm.nih.gov/pubmed/19252260
     
  30. davsur08

    davsur08 Active Member

     
  31. efuller

    efuller MVP

    What I am familiar with is a dorsal subluxation. I'm not that excited about the explanation of the mechanism. Here it is. Tension in the peroneus longus tendon compresses the cuneiforms to gether causing the 2nd cuneiform to pop upward. If anyone has a better theory, I'm eager to listen to it.

    A dorsally subluxed 2nd cuneiform can be found by palpating up the shaft of the 2nd metatarsal and feeling a step up when you get to the cuneiform. When it is unilateral there can be quite a difference from one side to the other.
     
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