Manipulation

What do you think I was dealing with on the phone today?.... not quite in those words, but pretty close..... at least that is what the patients interpreted it as. One even commented they were told how good the evdence for manipulation was and how bad the evidence for the use of orthotics are ..... its that kind of BS that is going to stand in the way of a more widespread use of manipulation.

 

Hang on, what about Dr Tikker in the Napa Valley? He sounds like he is practicing a version of FMT.

The foot is prone to subluxation due to the fact that it has to bear the weight of the whole body under a massive variety of activities. I think it is unreasonable to expect a manipulative adjustment to 'hold' indefinitely considering the forces that come to bear on it. Many chiropractors incorporate orthotic assistance to help act like a 'safety net' to maintain the adjustment/FMT.

Interestingly, in the 60s and 70s much was explored in the use of spinal orthotic devices for spinal and abdominal support (read bracing/frames around the abdomen & spine). The conclusion drawn was (apart from the cumbersome nature of the devices) that the resulting muscle atrophy and weakness was actually detrimental to the patients' results.Hence the evolution of pilates and core strength approaches to postural stability.

I wonder if the artificial support of a foot orthosis can lead to the same type of result. Interesting to observe the number of clients using orthoses over the long term, needed to keep having updated devices with increased control. Was this due to decreased muscle strength due to reduced activity of the related muscles? Hmmm...

I use manual methods of mobilisation, manipulation, activator and drop piece tables to implement FMT. The critical step is assessing the case first of all, then treating the structural deficiency diagnosed. This is quite a process and has taken me about 10 years of practice to evolve an assessment procedure that I can confidently rely on. If your prime objective is only relief of pain, then you have to assess all of the possible etiological factors that can cause pain.

In our practice, we operate on the premise that 'everything works best when it's in the right place'. Our assessment and treatment procedures are designed to fulfil this premise. The tricky part is determining where exactly is the 'right place'. In my experience, FMT can play a pivotal role in achieving this objective.

Cheers,
Tedjed

 

Oh dear, I can see that this type of information is very dangerous on so many levels

 

Ted,
My limited understanding of hysteresis comes from stress/strain diagrams and the behaviour of plastic/elastic solids where the hysteresis curve is the non-return portion where the graph line does not show complete return after the application of a load to cause elongation of a particular structure....there is some small amount of permanent "stretch"......the change you are aiming for in a joint .
Regards Phill

 

Ah hah, and this is the sort of stretch that can occur with subluxation resulting in HYPERmobility which in my view, is a contraindication for FMT and is best served through orthotic therapy.

Thanks for the clarification Phil - we were practically on the same page.

 

It's a pretty fine zone you're talking about....the "feel" for this is something that early practitioners have no chance at all to achieve.
I spent fifteen years playing with feet, footbeds and ski or walking boots...and then showed up for my undergrad training.....here is the bit that might earn me some flack.....nobody at Uni was trying to teach "feel".....overtly anyway.

I had a "feel" for feet and what they will tolerate before I was a pod....but my formal training gives me a much better insight into how and what I should be aiming for in my work. Since being on the staff...teaching the orthoses manufacture units, I have tried to teach "feel" but it is very difficult and only appears to work with the very keen and uninhibited who are actually prepared to get their hands on loads of feet.

I often tell them it is a bit like wine tasting...just guzzling won't really further your insight...you need to talk about it, think about it compare feet and contrast feet...generally "toss on" about them which can feel a little odd to begin with....until you realise you are actually learning from the process, the human hand is a very sensitive instrument...it just that the calibration dials on the back of them can be a little hard to read.
And of course try to explain yellow to a blind person?.....people who don't have the feel probably have trouble believing it's real....not very scientific the whole concept is it?
This is the non-reproducible non-doubleblindable art component that so many are working to remove from health care....arguably for a bunch of good reasons in some cases.

Regards Phill

 

Yeah Phill, you are so right. Just like you can't teach experience, which is what develops 'feel'. Yet remedial therapists, physios and chiros do do specific palpation development work. One of our practitioners is a remedial therapist by training and it was such a difference training him compared to the pods who are much better developed visually and conceptually by comparison.

The irony lies in the fact that one shouldn't atempt to 'manipulate' without sufficient experience yet how is that experience gained without 'doing' it?

But it's not impossible... determination and perseverance were crucial for me to develope the necessaries..

Cheers,
Tedjed

 

I agree fully with you. By the way the mechanism for treatment of a "depressed" middle cuneiform to aid in the treatment of plantar fasciitis is related to the posterior tibial muscle. Check the muscle strength before and after treatment. Since the posterior tibial muscle also inserts into the middle cuneiform, contraction of the posterior tibial muscle will move the cuneiform more into deformity. There appears to be a reflex to prevent this increasing of the subluxation from happening.
Look for it and see if you find it also.

 

Ted i couldn't have said it better...thanks.

 

p.s i trained in dublin over the couse of a few days i guess it similar to the napa course.

 

[Imagine being able to offer a woman a treatment option that didn't require a limitation of her footwear. If she fits our criteria, then we will provide the service (with a guarantee)./]

I realise that this reply is an ancient thread but after nearly 20 yrs experience of feet I know that the biggest problem is the footwear and the real cause of nearly all these subluxed/rigid/deformed/supinatus feet is the ill fitting hideous things that people put on their feet, especially womens shoes. Until that is brought into this debate then all the maipulation/mobilisation in the world will not have any lasting benefit.
One of the key areas that is also ommitted is the 'type' of person we are dealing with. You can give advise about suitable treatments to many people and some will do exactly what you say but many nod their head and do the opposite. All the leaflets and advise that we give our patients about 'wearing in' etc is often ignored and some people refuse to wear orthoses in all their shoes. Once those heels go on and the narrow end of the talus moves forward increasing frontal plane movement we can forget about any meaningful control. Also once those orthoses end up in soft composition innersoles they just compensate themselves by bedding in. In the early days some of these female patients attended my treatment rooms with what they thought were sensible shoes and then proceeded to try and force the orthoses into fashion shoes of varying shapes and sizes.

I have seen demonstrated (by physios) some very impressive 'freeing up' of very rigid joints and also so of the quick manipulation techniques and feel sure that a combination of these types of hands-on manipulations with well produced orthoses could be a good treatment protocol but only in 'reasonable'
footwear with patients who will follow the advise.

All our treatments should involve a number of elements and these must be tailored to fit the individual.

Its those hypermobile feet that are the most difficult to treat!

 

Ahhh footwear...! Just yesterday, an elegantly attired businesswoman came to see me for her FMT session and wow, were her shoes sexy! I commented on them and she sheepishly replied '...I thought you wouldn't approve of these shoes but...' Oh my goodness! I replied '... oh no, don't get me wrong, I LOVE these shoes! They are just fabulous for business'

I think a strong stable foot will cope with the demands of fashion footwear much better than a weak unstable foot. Assessing the indivdual and their compliance is an important factor though...

But Phill, hypermobile joints; FMT is a contrindication and in these cases we concentrate on muscle strength, proprioceptive control and awareness, and orthotic assistance. Any mob/manip work on hypermobile joints is fraught with danger!

TedJed

 

Points and Heels?

Hi All,

That last one TedJed reminds me of a quote by Cameron in a Thread in Break Room.

Quote:- Cameron ................."Political Correct" as I have previously posted the idea of a sensible shoes arose in the late 1930s (post glamour) at the time of war and rationing. In the UK lower heels were considered patriotic (saving raw material for the war effort.................So heels were good then bad................................ The forboding comes in the form of scare mongering."


Can I add also by podiatrists if you read the whole Post!

Where's the SCIENTIFIC EVIDENCE THAT HIGH HEELS are bad for you, sorry The Ladies??? There must be some evidence, you of the Biomechanics??? Less stress on the knee joint perhaps???

Just an aside, Brick in the pool, a Heat-raiser perhaps?

Regards,

Colin.

PS. Full Post is at Break Room Forum Cameron K. (Ohh Ancient One! (Philip Clayton above!)) Thread 'Points and Heels'
Thread-post No.3.

PPS. Sorry Cameron, hope I haven't dropped you in it. Hints of the Emperor new clothes perhaps. (I am taking a short holiday!).

PPPS. Of course I must confess that I like High-heels, on a beautiful woman of course. I'm just politically incorrect you see at times! A breath of fresh air and all that occasionally!!! Another, some would say, 'Living in a house, a pack of cards!?!' I need some concrete Science based evidence please?

Big guns please in Podiatry, Manipulation, Biomechanics? Scientific Evidence High Heels and in this Thread I fear a lot more?

 

.....smokings not bad for you either.....
Regards Phill

 

Smoking is not bad for you either!

Hi Phill,

Can we add salt and sugar to the list! Have you noticed anything that gives pleasure is bad for you! A bit of SPICE and it must be stopped! The latest is four wheel drives over here, proposal, you will have to have a notice on the back of these types of vehicles because they can kill you!!! But never mind I still like to see a well turned ankle in a high heel!!! I don't believe they are bad for them to wear, it may be bad for my heart to watch? I do not believe it until I see it in black and white, (What am I saying?). Did you know that if you were to live to two hundred years of age the oxygen in the fresh air would kill you!

Back to Podiatry or something reassembling it???

Regards,

Colin.

 

I agree that the 'team' approach produces the best possible outcomes. I use joint mobilizations as a precursor to producing a good negative cast. I work with a multi-disciplinary group including physiotherapy, chiropractic,massage therapy, pedorthics and athletic therapy. Often on exam if I feel a foot has lost some ancillary joint movements (e.g.loss of dorsal glide at the cuboid articulations) then we will do some manual treatment prior to casting. I feel this gives us the best chance to produce an orthosis that will produce the best mechanical outcome for the foot and leg.

 

Back again. In addition to my last post, as a clinic we don't look at the mobolizations+\- manipulations as "the" treatment. We feel that to restore as much natural function of the foot, aided by the orthosis, joint mobs prior to negative casting produces the best results. The foot may need occasional "adjustments" after dispensing the devices, but that gets back to the team approach.

 

High Heels

I agree that aesthetically the high heel shoe can do a lot for a pair of legs - in fact it can do a lot for a middle aged man, but just like smoking some people will be totally blind to the damage they cause. We all know some one who has smoked 40 Woodbines a day for 80 years and lived but you must be kidding yourselves if you think high heels dont drastically alter gait.

I am also surprised that there has not been some 'proof' in one of the research papers because as we know we can always find one research paper to completey disagree with another one. Butter is good for you - butter is bad for you. Post the forefoot - dont post the forefoot, who's right and who is wrong?

I may sound synical but most times anybody posts a specific question they never get a specific reply just more pointers to obscure papers. I asked recently quite specifically how people would treat forefoot varus/supinatus type feet and patients with ankle equinus but found a strange reluctance for others to share their ideas, just 6th form sarcasm and the usual ha,ha we dont do it that way now.

 

Most of us hang on to our personally chosen myths very tightly don't we.
Regards Phill

 

What I need clarified is what is the "subluxation" that is being referred to. As far as I know there are 2 types - medical and chiropractic subluxation. The Chiropractic version is not used much as a concept nowadays when I have discussed this with Chiropractors ( I work with 3 ). It refers to alledged v small malpositionings of vertebrae which supposedly lead to nerve pressure that can give pain but is also alledged to cause illhealth such as the deafness famously cured by D Palmer the originator of Chiropractic. It is not used much because no 2 Chiropractors can usually agree on whether a patient has a subluxation as it is so hard to diagnose (done radiographically) and highly subjective. Because of the wishy-washyness of the definition it has been discredited as "quakery" ie made up terminology designed to impress. Hence many modern Chiropractors apply the very same type of manipulation that they would for a "subluxation" but now are aiming to address things such as range and quality of motion - ie stuff we can all understand.

Medical subluxation is a different kettle of fish and we all see this every day such as the talo-navicular subluxtion with STJ/MTJ excessive pronation clinically seen as talar bulging in the medial arch.

Are we saying that foot manipulation is able to "correct" this type of subluxation? I would think that the before and after photos on Ted's site are suggesting this is so. Ted also seems to be saying that many of our typical patients are candidates unless the have a degree of generalised hypermobility.

I think this is the "crux" of the issue - is foot manipulation being offered as a means of pain relief and a means of improving joint ROM - absolutely nothing wrong with that and if it works should be done by us all. Whether it is followed up by an orthotic is up to the pt/practitioner and although logical surely not obligatory. Ted is saying he chooses to only offer manipulation he does not want to do the orthotics and refers on, fair enough. I would have thought he must get a lot of pt's wandering off looking for a long term resolution.

Or, are we saying manipulation improves the position of the foot statically/dynamically resulting in a less pronated/supinated position such that an orthotic is not necessary and could even potentially inhibit natural muscular function? There's nothing wrong with that either and if possible I would have thought all patients would prefer it to wearing appliances. But its a pretty radical proposition that is diametrically opposite to current treatment philosophy ie the very need for orthoses. Because of this surely we need some substantiation of this claim - how long do the effects last, how much correction is attainable etc?

Can anybody clarify this?

 

"Orthotics (shoe inserts) do not correct the CAUSE of problems of the foot & leg, they only support them. At the F&LC we identify the true cause and fix it by X-ray analysis, joint mobilisation and corrective exercises."

But Ted,
I pulled the above quote from your website. Isn't this saying the same thing, kind of?

Also, and I don't want to misquote your business here, but I think you are saying that bodyweight and the forces associated with ambulation are responsible, in the main, for the problems you deal with?

Now that's kind of interesting too . Because I (and one or two others) happen to believe that the unnatural (for us since we have not evolved for a life on a hard, flat surface) surfaces we walk on, coupled with our "go anywhere - do anything" adaptable feet, are the main reason we see problems.

Phil, I agree with you BTW, that footwear causes problems too.

No problems with manipulations here - I do them myself. But orthoses (little more than an interface between the ground and the patient) are an important part of overall care.

Cheers,
davidh

 

It would seem the thread has moved to an orthoses therapy vs. manual therapy contest. This is not the point of using manual therapy. There is no argument that a normal foot with no positional, anatomical or mechanical deficit will respond well to manual therapy without foot othoses. As foot care professionals we seldom see those in our office. It is my contention that using joint mobilizations will enhance the effect of orthotic therapy and produce better outcomes which is why patients come to see us in the first place!

I think that there are few cases that we see where only one form of therapy cures all that ails. As mentioned in an earlier post, it is the combination of therapies that will produce the best outcomes.

Woodman

 

Hi David,

The specific 'cause' we focus on is subluxation of joint(s) in the foot and leg. We have found that orthotic therapy can be very effective in supporting subluxation, but it does not correct subluxation (much like reading glasses assist in eye sight disorders, so they only work while you are wearing them).

Subluxation occurs when a joint is exposed to more force than it can withstand. So forces from body weight, ambulation may contribute and events such as ankle sprains, injuries, poor posture, work related positions, strenuous actions can also contribute to subluxation.

If patients are experiencing musculoskeletal dysfunction due to compensation caused by other biomechanical factors such as femoral or tibial torsion, ligamentous laxity, plastic deformation of connective tissues then orthotic therapy is indicated. Our assessment process is designed to assess for the primary etiological factor and treat that accordingly. We use orthotic therapy where indicated and offer options for those patients who ask '...isn't there something else I can do to help myself?'

Hopefully you clicked on to the links from which you quoted to see how we determine the treatment options most suitable and help people determine if our services will suit them?

Bob, I agree with your observation that manual therapies can enhance orthotic therapy efficacy. So few podiatrists in Australia actually do this though.

Cheers,
TedJed

 

Dear Moderator and Members:

I came across this thread today, and will chime in on this since I do a lot of extremity joint manipulation. First, I want to say that some of the discussion regarding chiropractic is nauseating. Granted, chiropractic has suffered with its share of charletans, and it continues to harbor a contingent hung on dogmatic tennets. However, the majority of good, modern chiropractic doctors deserve some respect and professional consideration.

On the topic of manipulation of the foot and ankle, there is nothing mystical about it. It is what it is: joint manipulation. How it is applied, which joints are targeted, and how skilled the practitioner is makes the difference in a patient feeling better or not. Most foot and ankle pain issues that will respond to manipulation will likely do so in short order, not in weeks or months as someone highlighted in previous posts. It also is not a replacement for foot orthotics, is not a means to create a longitudinal arch, and is not a substitute for differential diagnosis or medical treatment. Duh!

Regarding manipulation for ankle sprain, it can safely be done to grade-2 inversion sprains, and combined with soft tissue mobilization and some light taping, either kinesiotaping or other proprioceptive taping, it is very effective in reducing pain and promoting immediate improvement in function. I am particularly interested in the common sequelae to inversion ankle sprain: functional instability. I have my ideas about how functional instability may be considered an acute dysfunction of the ankle that causes reflex inhibition to leg muscles (e.g. everters), and I'd be happy to chat about that. The inhibitory reflexes are well understood at other joints, particularly the knee. Regardless, high velocity manipulation is safe and effective for ankle sprains – those with and without obvious disruption of ligaments. The manipulation may be a way to eliminate the joint dysfunction and reduce the potential for sudden arthrogenic inhibition to the ankle muscles. Below are some references to consider.

'Regards,

Scott Gillman, DC, DACBSP
www.drgillman.com

1. Safran, M.R., et al., Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc, 1999. 31(7 Suppl): p. S429-37.
2. Hertel, J., et al., Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc, 1999. 31(11): p. 1501-8.
3. Palmieri, R.M., et al., Arthrogenic muscle response to a simulated ankle joint effusion. Br J Sports Med, 2004. 38(1): p. 26-30.
4. Shakespeare, D.T., et al., Reflex inhibition of the quadriceps after meniscectomy: lack of association with pain. Clin Physiol, 1985. 5(2): p. 137-44.
5. Dananberg, H.J., Manipulation of the ankle as a method of treatment for ankle and foot pain. J Am Podiatr Med Assoc, 2004. 94(4): p. 395-9.
6. Gillman, S., The Impact of Chiropractic Manipulative Therapy on Chronic Recurrent Lateral Ankle Sprain Syndrome in Two Young Athletes. Journal of Chiropractic Medicine, 2004. 4(3): p. 153-158.
7. Eisenhart, A.W., T.J. Gaeta, and D.P. Yens, Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc, 2003. 103(9): p. 417-21.
8. Pellow, J.E. and J.W. Brantingham, The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. J Manipulative Physiol Ther, 2001. 24(1): p. 17-24.

 

Foot Mobilisation Techniques (FMT) Courses will be conducted in England in April 2010.
Further information available at www.footmobilisation.com

 

Scott,

Welcome to the board.

 

Phill,
With dinner attire: "As the limits of passive joint movement are approached, additional resistance is encountered as the joint's elastic limits are challenged. Movement into this space, the end play zone (EPZ), may be induced by forced muscular effort by the patient or by additional overpressure (end play) applied by the examiner. If the forces applied at this point are removed, the joint springs back from its elastic limits. Movements into this region are valuable in assessing the elastic properties of the joint capsule and its periarticular soft tissues.
Movement beyond the EPZ is possible, but usually only after the fluid tension between the synovial surfaces has been overcome. This process is typically associated with an articular crack (cavitation). Sandoz has labeled this as the zone of paraphysiologic movement and identified its boundaries as the elastic and anatomic barriers." ~ from Chiropractic Technique: Peterson and Bergmann, 2nd ed.

Note the order: from active ROM>Passive ROM> Physiologic barrier>EPZ>Elastic Zone>Paraphysiologic Space>Anatomic Limit>Joint trauma or pathology

In a t-shirt explanation of paraphysiologic space: extend your index finger (active), then bend it back a little further with your palm (passive), feel it creak to a stop (physiologic barrier), slightly spring a little further back and feel the play (End Play zone). Now give it a quick, controlled spring and if you hear/feel it cavitate, congratulations - you have passed the elastic zone and made it to the Paraphysiologic space. I believe this is called "Cracking One's Knuckles" in jeans and flip-flops. "Jamming Your Finger Playing Basketball" is passing the anatomic limit and reaching joint trauma. Don't do that to yourself ~ a chiropractor would not, either.

Cheers!

 

Very nicely done Rabbit. Well articulated and described.
Ted:drinks

 

Was interested in reading this thread, as I attended a course run by Ted at his clinic in Adelaide earlier this year. I admit I was very sceptical but am always keen to learn more rather than discard something.
During the 2-day workshop I learnt, practiced, and underwent the mobilisation and manipulation techniques that were taught.
I have since being using these techniques in conjunction with other modailities and finding the results very pleasing, and agree with Dr Gillman's time reference. It still requires accurate diagnosis of the problem, and therefore the appropriate treatment modalities available. (another excample could be massage vs dry needling - I utilise both depending on varying factors including pt consent). I can not imagine ever using mobilisation as my only modality as I like Shane's analogy of the quiver...

 

TedJed,

I just explained it as my professor did to us on one of the first days of class - we were equally astounded at the simplicity;-)