Clinical Measures/ Indicators

Tarik, What evaluations do you currently do for ITB syndrome and plantar plate tear?

Regards,

Stanley

 

Bruce,

It applies for the pattern of equinus and low ASIS on standing in RCSP. In NCSP, you will see a leveling of the ASIS. The manipulation just shows you that the problem exists. The trick is to do the things that prevent it from returning.
If you looked back at my post, I have minimized my initial biomechanical exam to Dorsiflexion and ASIS to Ground in NCSP, and RCSP. I also said PSIS to Ground in NCSP, and RCSP, but I have gotten away from this (in fact, I am thinking of eliminating ASIS to the ground in NCSP initially). The first step is to level the ASIS and eliminate the equinus.
By the way, the other patterns are unilateral equinus and ipsilateral high ASIS, unilateral High ASIS and normal dorsiflexion bilaterally, pathology with level ASIS and normal dorsiflexion bilaterally, and bilateral equinus.
We'll have a lot to talk about when we get together.

Regards,

Stanley

 

Stanley,
Could you perhaps describe this manipulation?? Or perhaps point us in the right direction to a reference for it?
Where did you pick this idea up from... or is it your own?
Cheers,
CT

 

If a clinician does not measure(intervention) then re-measure (post-intervention), then we have no idea as to whether we are having a beneficial or detremental influence on our patients.

If a clincian isn't prepared to measure and re-measure, then you might as well employ a beautician with a weekend biomechanics degree under his/her belt.





Craig P.

We now don't measure anything because:

1. They are almost all unreliable
I agree if we are measuring and splitting hairs by 1 or 2 degrees for instance.

However, I think when measuring the dorsi-flexion lunge test (incorporating a vertical wall, and a horizontal floor, taking note of skirting board, getting foot at 12 o'clock, making sure heel is in contact (fat pad spread), making sure knee is touching wall, taking note of site of restiction (subjective)) for instance, I am very sure clinically that intra-therapist and inter-therapist reliability can pick up a negative lunge, a mildly positive lunge (2cm), a moderately positive lunge (4cm+) etc.

In other words, lets not get pedantic with mm's, lets get realisting with cm's.

2. They are not predictive of dynamic function or orthotic responses
Clincially, I question this. If a person cannot lunge positively(knee to wall) watch them decend stairs; watch them run uphill.

3. Even if we did measure, we don't actually use the numbers for anything
I'd say justification as to whether physiotherapy, podiatry, chiro, osteo intervetion is doing anything. If my numbers don't improve after 2 sessions, they are off to another clinician and/or investigative radiology.

4. In most cases we do not even know what normal is (eg the myth of 10 degrees at the ankle), let alone sport or activity specific numbers
Craig, if a patient with unilateral ankle signs/symptoms presented; and by-the-way, the affected side had a negative lunge. We can assume that the contra-lateral ankle, with nil-past-history nor current signs and symptoms, is normal.

5. We treat patients with symptoms and don't treat numbers.
We also treat patents with signs, and some need to be assessed objectively, and re-assessed post-intervention.

6. There is no evidence that you get better outcomes if you measure vs not measure
Again, whether this is right or not, I don't know. But the clinician that does not measure will surely rely 100% on subjective findings on whether the intervention is positive, neutral or negative. 100% subjectivity is too much.

 

You are right about measuring outcomes to see if what we did works. That is different to taking angular measurements.

I was being a bit facetious in making an extreme statement about measurements to provoke thinking, especially the traditional measurements such as NCSP etc. The lunge test on and off orthotics is one measurement that I do do (it has been shown to be reliable; somewhat predictive of function; and predictive of injury)

The lunge test is THE ONE test that is potentially showing some predictability of a clinical response to a foot orthoses, but the work on has not yet been finished.

I think we may be talking about something different here - I was refering to the measurements that we traditionally used to do as bart of the bioeval and I think you are referring to clinical outcome measures (eg the number of single limb hops to produce symptoms before and after threatment.

I grew up beleiveing in the 10 degrees measured the traditional way. If the range was <10 I treated; if >10 I did not treat. We now know that 0 degrees is normal for some and we now know that for some they need 15 degrees - it obviously subject specific. The challenge is how to determine the subject specific range? We are not there yet, but the lunge test is pointing us in a direction that may lead to a better understanding of the subject specificness (we have a current project looking at this subject specificness)

Again I think we talking about something different - traditional clinical bioeval measures vs outcome measures.

BTW - Bruce - love the new avatar!

 

First of all, do not do any manipulations if there are contraindications to performing manipulations (hot joint, osteoporosis, spurring, fracture, tumor, etc.)
This being said, there are several ways to do this manipulation. Probably the easiest way to do it is by modifying the Hiss manipulation. Before you do this, you should re-check to see make sure there is a problem here.
1. Posture- you will find the low ASIS with the equinus on the same side.
2. Palpation- you can palpate the plantar aspect of the foot. You will feel the cuneiform slightly plantarly (about 2mm), and the patient will tell you there is tenderness there.
3. Range of motion-this is a little more difficult. Put one hand medial to a cuneiform and the other laterally and rotate one hand in the opposite direction of the other hand (in the sagittal plane). Compare it with adjacent metatarsals. If you have a good sense of feel you will notice the change.
4. Muscle testing- this is the most challenging of the tests. It takes time and skill to do this properly. Test the posterior tibial muscle's ability to perform an isometric contraction. Gradually increase the pressure on the medial aspect of the foot. Feel for the locking of the muscle. Now place your thumb over the lateral cuneiform, and push it plantar-medially. Quickly retest the muscle (you have about 5 seconds for the reflex for this test to remain active). There is a variation from one patient to the next. Some will lose the ability to meet your force (they will have an irregular contraction), some will have decrease in strength at the beginning of the range, others will have a loss through the entire range. Most importantly, you will feel the loss of the locking- you will feel the muscle lengthen. The difficulty in muscle testing is to use enough force to feel the spring of the muscle when it is locked, but not so much as to overpower the muscle. Also you have to have the muscle in the right position to test the muscle, and watch for the subtleties of muscle substitution (ie, dorsiflex the foot to have the anterior tibial assist the posterior tibial)
Once you have determined the lateral cuneiform is plantar, then you can perform the manipulation. The Hiss manipulation is the easiest to perform, and a variation of this can be used to manipulate most of the tarsus with minimal training. Have the patient face and place his hands on the wall. Have him bend his knee, so the affected foot is off the ground and the sole is facing you. Interlace your fingers on the dorsum of the foot, and cross your thumbs on the plantar aspect of the foot right on the tender spot. Have the patient relax his foot. I like to move the foot from side to side, and you will feel when the foot relaxes. The motion is performed by extending your elbows so the wrists move about 2-3" plantarly. Then at the end of this motion, the wrists rotate so as to continue the motion plantarly (like snapping a whip), and stop abruptly. The force is directed through your thumbs to the cuneiform.
This manipulation can be used for other foot joints by just moving the thumbs and the line of drive.

Last year, Kevin Miller told me to look at the cuneiforms. He does a different manipulation for it. All I did was see the pattern of the anterior innominate and equinus with it, and how they both change after the manipulation.
By the way, you will not always get a noise with the correction, which is indicative of either there is no problem with the joint (and you didn’t do anything), it is a quiet joint, or it is loose, and the joint slides "in and out" (hypermobile . Just go back and recheck your parameters-plantar cuneiform, equinus, and anterior innominate to see if you accomplished anything. .
Have fun playing with this.

Regards,

Stanley

 

Thank you Craig! I thought no one would notice!
Bruce
www.breakthroughpodiatry.com

 

Stanley;

very nice description. I would like clarification on a few things though.

Equinus on the same side of the low ASIS. in my interpretation that means on the short limb side. Is that a usual correct assumption?

Regarding the lateral Cuneiform. you are mainly trying to dorsiflex it so that it is back articulating correctly with the cuboid and middle cuneiform. Correct?

So, plantar displacement of the lateral cuneiform will effect the position and function of the lateral and medial columns how?

thanks Stanley
Bruce

 

Actually it means it is functionally short. Can you tell structural vs. functional shortage on the F-Scan?

Not dorsiflex it, but shift it (translation vs. rotation). Both the proximal and distal aspects of the cuneiform need correction. However, once in a while the problem is at the metatarsal cuniform joint (so the metatarsal is translated upwards relative to the cuneiform-look for this especially in Morton's neuroma {ever notice the high incidence of Morton's neuroma on a short side with equinus?}).

I hope this helps.

Regards,

Stanley

I don't know. That is Kevin Miller's work. He e-mailed me recently, and let me know that he will have his patents filed sometime in August. I just have a small understanding of its neuromuscular aspect. By the way, I just remembered it was you that showed me the manipulation for the lateral cuneiform . I was confused as to where I learned it because you told me that Kevin Miller showed it to you. You called it his bunion manipulation. If you remember, it was the manipulation for the posterior third metatarsal (that has displaced the lateral cuneiform posteriorly and separated the cuboid and navicular). I am sure it is moving plantarly also. The Hiss manipulation does put distal traction on this area (and to think about it so does the other manipulations I have seen even though one has a plantar distal vector, so I guess Kevin Miller is correct on what is happening.) Paul Conneely also showed me his manipulation, along with every other one in the foot. I don't have anywhere near his skill level to perform it properly.
I should have expounded more on the muscle testing for the posterior tibial muscle. Sometimes you will find the posterior tibial muscle unable to lock. This can be from many causes, but if it is related to the lateral cuneiform, pushing up on it will allow the muscle to lock. What is interesting is that muscle testing is normally performed non weight bearing. We do not test the muscles when the foot is weight bearing. The pushing of the bones allows us to see the effect of loading the joints in different directions, and its effect on the muscles.
A little more on the actual muscle test. If you ever watched an arm wrestling competition on TV, you will see that one of three things typically happens. One, the one competitor gets a jump on the other one and he wins quickly. This is because the other one didn't have a chance to summate (lock) the muscles. In the second instance you will see the competitors locked in a position until one fatigues. Even though one is stronger than the other, the locking effect allows weaker competitor to at least look competitive for a while. In the third situation, the one competitor is so much stronger, he just overpowers the other's lock (isometric contraction).

 

Hi Stanley,

For plantar plate tear, I rely a lot on patient Hx -"I feel like I'm walking on a pebble/ marble etc" and that they notice the toe(s) have changed position. Physical exam (along with x-rays) would include assessment of any 1st MTPj deformity, hammertoe development, any transverse plane deviation of prox phalanx on met head, reducibility of deformity, direct palpation, vertical stress test and get patient to walk up and down to assess foot function.

For ITB - the assessment I perform includes pretty much includes everything from assessment of lower limb ROM/ position (from pelvis to 1st MTPj), flexibility, assessment of neural tightness, LLD, palpation of surrounding area and area of pain. No measurements taken.

Cheers
Tarik

 

Had a patient yesterday and this illustrated a perfect example as to why one should measure, or gain objective info in addition to the subjective "better/same/worse".


This patient was operated on about 8 weeks ago for a posterior ankle clearance and more. Scar was posterior to lateral malleoli. He had 'progressed from cam-walker to brace and boots'. Subjectively, things were "good". Objectively, he had gone backwards in his lunge by 3 cm compared to 4 days prior.

Checked the inner of these boots, and there was a prominent seam and marked plastic ridge at the edge of the heel counter. I palpated the lateral achilles region, and a thick lump had emerged.

The surgical scar had rendered sensory perception of this area useless; as was his feedback about his progress.

 

Tarik, you sound extremely thorough. I do less than you do. For ITB, I palpate to make the diagnosis, then I look for tightness of the TFL and do my leg length and dorsiflexion evaluation to determine treatment. You mention assessment of neural tightness, could you expound on this?

Regards,

Stanley

 

Hi Stanley,
I started assessing for neural tightness after attending a physio lecture. I incorporate it as part of the flexibility testing. The tests specifically include the slump test, then this incorporated with extending the knees, lying supine and performing the straight leg raise. If I find that they have significant neural tightness, I usually send them off to the physio for massage and stretching. Im hopeing that an improvement in neuro-muscular flexibility will help with releaving the ITB pain.

 

Tarik,

Thanks.

Regards,

Stanley

 

Tarik


I agree entirely with your sentiment questioning the rational of taking a large number of measurements as a matter of course without regard for their sensitivity and specificity.

Your assertion regarding the plantar plate exam illustrates an interesting point regarding what is looked for and how it is measured.

Since I have learnt to image many foot structures with ultrasound I have increasingly questioned the reliabilty of my physical exam in accurately defining the extent of and even exact elements in musculoskeletal foot injury.

The plantar plate is relatively easy to evaluate for a complete (less so for partial) tear with high res ultrasound.

When a complete tear is present, the FDL tendon can be seen in sagittal plane (dynamically) pressing against the MTH without the 2-3mm separation normally provided by the plantar plate.

I have examined several MTHs in patients with the same physical findings which you described above with no signs of complete plantar plate tear.

Through routine use of MSK ultrasound measurement I have been humbled over the past year, realising that many of the assumptions derived from my physical exams were not as reliable as I had once believed.

regards

Martin

 

Which begs the question; how reliable is ultrasound diagnosis? I recall vaguely that has average reliablility in relation to rotator cuff partial tears for instance.

 

some research done in Australia and found to be as reliable as MRI.

 

I agree it might beg this question if you were inclined to use diagnostic ultrasound exams (DUS) as a sole method of diagnosis and with out attention to your level of expertise. I would not suggest this as wise, it is better used a part of the overall evidence. I contend though, that if you become skilled with DUS, it's weighting as part of the overall evidence can, with many problems, score very highly.

Partial tears of most foot structures (as I already mentioned) are one of the hardest things to be sure of with diagnostic ultrasound exams (DUS), and I would certainly not feel skilled enough to make unequivocal judgements regarding a PARTIAL plantar plate tear with my limited experience.

A FULL tear is obvious because the FDL tendon will position itself directly against the MTH surface. Observation with DUS allows easy dyanamic observation of the plantar plate and how it postions itself when the prox phallanx is dorsiflexed on the metatarsal.

As mentioned by Tarik, if you look carefully at the literature you will find that many diagnostic ultrasound exams (DUS) of the foot have been shown to be superior to MRI in both sensitivity and specificity. Part of the reason for this is that you can examine structures dynamically and in any plane which you might choose to.

DUS is notoriously and arguably the most user dependant imaging modality and for foot exams requires good equipement (13 Mz linear array probe). It requires a lot of practice and initially has a steep learning curve. There are many interpretative pitfalls to be aware of. If you are thoughtful and treat your interpretion with caution until you are justifably confident about it, DUS can be a very powerful tool.

cheers

Martin