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Physical Therapeutics for Fibromyalgia | Central Chiropractor

Physical therapy often takes a hands-on approach, which might make you cringe if you're experiencing pain from several hypersensitive tender points. However, in managing your fibromyalgia symptoms, gentle and effective are used by physical therapy, and will most likely play a part in the recovery process.

Can physical therapy help ease fibromyalgia?
There are a variety of physical therapy techniques. Passive treatments include hydrotherapy, heat therapy, deep tissue massage, electrical muscle stimulation, and ultrasound and relax the body. Your physical therapy program will often start with passive treatments. When you feel ready, you will begin active treatments that protect against fibromyalgia pain and strengthen your body. Your physical therapist may work with you to develop a suitable strategy.

Passive Physical Therapy Treatments for Fibromyalgia
Deep Tissue Massage: Unless you're in an extreme amount of pain, deep tissue massage is an ideal fibromyalgia treatment because…

Ankle Mobility: Dorsiflexion & Science


Science chiropractor, Dr. Alexander Jimenez explores ankle movement -- and discusses why it is so Important

Introduction

Given that we're a bipedal bunch, the joint that connects the foot into the rest of our body is going to have a considerable influence on our movement.

Most men and women get pretty good at compensating for any motion deficiencies they might have. It seems, however, that one of the most troublesome moves to compensate for, without hurting oneself, is a lack of ankle dorsiflexion (DF) range of motion (RoM).

There is some evidence to suggest that a deficiency of DF will cause compensatory moves elsewhere. Understandably the research showing that these movement patterns lead directly to injury are few and far between, but there are a few.

So the logic seems sound, the evidence in 'normals' is suggestive and you'll find a small number of research pertaining directly to injury. On the other hand, the literature to demonstrate that enhancing deficiencies will really reduce following injury is nonexistent. I feel this should not stop us from pursuing our own logic, and therefore in many circumstances this will mean trying to 'normalize' an athlete's DF.

Identifying Hypomobility

Measurement of DF is straightforward enough (Figures 1 and 2), also supplying subjects keep their heels on the floor and foot nicely aligned I'd suggest it's also fairly reliable; one screening study working with sports folks agrees(1), and so does a study on validity and reliability from 2012(2). The test in Figure 1 is far more prone to cheating by athletes, as it is too tempting to push 'just that little bit farther'; nonetheless, the test from Figure 2 is somewhat slower. I find a camera may be helpful here; it is good for illustrating issues to athletes, and can be more compelling than a numerical measurement on a page when you return. This is very helpful when an athlete has a subsequent trauma, as you can both see where their older 'normal' was; if that is different to 'normal' in their other hand, this will provide you a much more valid dimension to use. In a clinical sports setting, we seldom let athletes operate until they are within 2cm of normal, so if they had a pre-injury side-to-side difference in RoM this can be quite relevant. Lining up the camera lens with the front of the knee is imperative to be able to prevent parallax error.




It is simpler, but to decide where 'normal' lies. I have a tendency to see 'normal' DF RoM as approximately 8cm plus, unless an athlete is particularly tall. 1 cricket study found a higher risk of harm if DF RoM was significantly less than 14cm(3). A study of patella tendinopathy in young basket ballers identified a DF angle of less than 36.5 deg to be a risk factor for injury(4) Naturally a angle is a more practical and legitimate measure but sadly they are far more difficult to measure.

There are certainly more functional DF tests with good reliability on the market (once testers are satisfactorily trained(5)), if that's a degree of screening you'd like to extend to. However, a very simple dimension of DF (like Figures 1 and 2) may add additional detail to the big picture if these functional tests (Figures 3 and 4) highlight deficiencies.

The Rationale

The rationale here is straightforward enough; athletes utilize triple flexion (in the hip, shoulder and knee) to attenuate the forces of landing, during running, jumping and cutting. When there is inadequate DF RoM from the ankle to get this done, another joint may then need to compensate, and musculotendinous structures will be functioning in a less than optimum position.

To be able to attenuate more pressure, the knee will tend to use either more flexion, more valgus/frontal airplane knee excursion (FKPE)(Figure 5) or both. (see SIB posts 102 and 110 to learn much more on FKPE and its own role in harm). Any structure above or below the ankle could of course end up bearing the additional weight here; consider (or see SIB 113) the spinal column (Figure 6), or the feet(6).




A lot of the literature is focused on how altered movement patterns will affect the knee as we see below:
  • Poorer movement patterns are associated with reduced DF RoM during a lateral step down task in healthy subjects(7);
  • Normal subjects with artificially limited DF on a double squat show increased FPKE(8);
  • In a study of soccer players, those with less DF RoM exhibited higher FPKE during a drop landing task(9) ;
  • A 2013 study showed that subjects with lower DF RoM altered their kinematics during vertical jump by lifting their heels and changing their trunk position(10).
Another possible factor here is that the institution of decreased DF RoM with poor balance. Put the last two studies together and you've got a scenario where an athlete with poor DF RoM is now raising WB through their feet during landing with decreased balance. This will place the knee at a particularly vulnerable position.

There are a variety of interesting studies showing restricted DF RoM to be associated with, or a risk factor for, injury. For example, away from the knee specifically, this is seen for lower limb injuries in Aussie rules players and Naval Trainers, and standard injury risk in cricketers(12,13,3). Soldiers with reduced DF RoM also had 4.6:1 odds of developing a metatarsal stress fracture compared to those without(6).

Decreased DF was also implicated in the development of patellofemoral pain syndrome (PFP) at runners(15); this could possibly be clarified by the current study previously(8) in which increased knee valgus/FPKE and decreased quadriceps activation were seen when DF was restricted, very similar to the typical demonstration of PFP.

Correction

I have encounter no noteworthy evidence either way for whether 'normalizing' that this dorsiflexion will lead to an actual reduced injury risk in our athletes. One 2013 study, however, did reveal that in chronic foot injuries, mobilization of DF facilitated improved joint angles during landing, resulting in a more positive foot position(16). So, with avoidance in mind, we will need to look at what we do understand and apply some logic.

It appears sensible that where any shortage is marked and unilateral (maybe the end result of an old/recent injury) there should be good profits to be made. Anecdotally, not just if changes come more easily, but asymmetries generally have a greater impact on motion patterns and injury risks. Where shortages are bilateral and more standing in character I feel that the profits will be harder to come by and less inclined to be effective, in order a preventative/screening problem it may be bad value for money.

The listing of structures that could be impacted by these compensations is infinite. I would include in this group any athlete having an greater strain or strain in any areas round the ankle. Any athlete with a famous DF deficit ought to be persuaded to have this sorted out to the good of not just their ankle but a lot besides.

Consequently, should you wish to enhance an athlete's DF, what resources do we have available to us? First let us talk my favorite techniques.

Patient-Generated Techniques


This ought to be the key muscle here, as it is the key musculotendinous restraint of DF. As always, very good alignment of the knee and foot (and buttocks, to prevent that habitual rectal pelvic tilt when possible)is essential.


The accession of great toe extension (easiest in running sneakers) provides quite a marked shift to the elongate and may target another potential restrictor of DF RoM.

Plantar Fascia Stretch

Extending the knee and feet should have the effect of tightening up the fascial structures (shallow back lineup) and helping place a bias on the plantar fascia.






The foam roller or the athlete's own knee will offer some firm pressure to target some particular areas of tightness that stretching won't reach. Both methods will allow active moves to be added as a progression.


A golf ball for the brave or something softer for yours truly. Again, this strikes any distinct troublesome spots and will also permit you to add in knee, knee, ankle or toe motions as a development.

Therapist-Generated Techniques

My favorite techniques are the ones which allow you to access a number of constructions in the 1 position and to add active motion whenever possible.


This is a good place to start, as it allows you to select the gastrocnemius off stretch and receive at the true ankle RoM. From here you are able to bring in a stretch of the delicate tissue and get the planar fascia and ankle soft tissue structures. You can even apply your torso to provide a force and leave both hands free to provide any variety of PNF, acupressure or myofascial release methods.

Step Lunging

This position is much more of a progression. Not only does this add weight-bearing to the mix, but it also allows for a few more practical and lively motion to be added.


From facing the athlete this provides a fantastic place for Mulligan's MWMs to be implemented. The talocrural and distal tibiofibular joints can both be mobilized here. With the ‘convex/ concave rule’ applied, an AP glide of the talus should (and does(18)) improve DF, adding some active DF will create an MWM. Equally a posterior glide of the fibula may well(19) correct Mulligan’s favorite positional fault(20) and allow more movement into DF. As an extra progression a seat belt can be added in lieu of a third hand.


From behind the patient (Figure 15), we get better access to the myofascial structures and the athlete can control any movement, leaving both of your hands free to provide any number of PNF, acupressure or myofascial release techniques.

Conclusion

For my money, these simple methods of identification and therapy are well worth the attempt. The tests only take a moment and once a deficit is identified the treatments are only a logical development. The remedies also have the benefit of between the athlete and keeping them active, which makes this a team effort rather than being overly passive. They also lead us nicely into a 'test, re-test' scenario so both you and the athlete could determine which techniques work to them and how they then change their more functional tests.

References
1. Dennis RJ, Finch CF, Elliott BC, Farhart PJ. The reliability of musculoskeletal screening tests used in cricket. Phys Ther Sport. 2008 Feb;9(1):25-33. Epub 2007 Nov 8.
2. Chisholm MD, Birmingham TB, Brown J, Macdermid J, Chesworth BM. Reliability and validity of a weight-bearing measure of ankle dorsiflexion range of motion. Physiother Can. 2012 Fall;64(4):347-55.
3. Dennis RJ, Finch CF, McIntosh AS, Elliott BC. Use of field-based tests to identify risk factors for injury to fast bowlers in cricket. Br J Sports Med. 2008 Jun;42(6):477-82. Epub 2008 Apr 7.
4. Backman LJ, Danielson P. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in juniorelite basketball players: a 1-year prospective study. Am J Sports Med. 2011 Dec;39(12):2626-33. 2011 Sep 14.
5. Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. Interrater reliability of the functional movement screen. J Strength Cond Res. 2010 Feb;24(2):479-86.
6. Hughes LY. Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures. J Orthop Sports Phys Ther. 1985;7(3):96-101.
7. Rabin A, Kozol Z. Measures of range of motion and strength among healthy women with differing quality of lower extremity movement during the lateral step-down test. J Orthop Sports Phys Ther. 2010 Dec;40(12):792-800. Epub 2010 Oct 22.
8. Macrum E, Bell DR, Boling M, Lewek M, Padua D. Limiting Ankle Dorsiflexion Range of Motion Alters Lower Extremity Kinematics and Muscle Activation Patterns during a Squat. J Sport Rehabil. 2011 Nov 15. (Epub ahead of print).
9. Sigward SM, Ota S, Powers CM. Predictors of frontal plane knee excursion during a drop land in young female soccer players. J Orthop Sports Phys Ther. 2008 Nov;38(11):661-667.
10. Papaiakovou G.Kinematic and kinetic differences in the execution of vertical jumps between people with good and poor ankle joint dorsiflexion. J Sports Sci. 2013;31(16):1789-96.
11. Basnett CR, Hanish MJ, Wheeler TJ, Miriovsky DJ, Danielson EL, Barr JB, Grindstaff TL. Ankle dorsiflexion range of motion influences dynamic balance in individuals with chronic ankle instability. Int J Sports Phys Ther. 2013 Apr;8(2):121-8.
12. Gabbe BJ, Finch CF, Wajswelner H, Bennell KL. Predictors of lower extremity injuries at the community level of Australian football. Clin J Sport Med. 2004 Mar;14(2):56-63.
13. Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. 1999 Sep-Oct; 27(5):585-93.
14. Malliaras P, Cook JL, Kent P.Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. J Sci Med Sport. 2006 Aug;9(4):304-9. Epub 2006 May 2.
15. Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D. Relation between running injury and static lower limb alignment in recreational runners. Br J Sports Med. 2004 Oct;38(5):576-80.
16. Delahunt E, Cusack K, Wilson L, Doherty C. Joint mobilization acutely improves landing kinematics in chronic ankle instability. Med Sci Sports Exerc. 2013 Mar;45(3):514-9.
17. Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med. 2014 Mar;48(5):365-70. doi: 10.1136/bjsports-2013-092763. Epub 2013 Aug 26.
18. Landrum EL, Kelln CB, Parente WR, Ingersoll CD, Hertel J. Immediate effects of anterior-toposterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. J Man Manip Ther. 2008;16(2):100-5.
19. Fujii M, Suzuki D, Uchiyama E, Muraki T, Teramoto A, Aoki M, Miyamoto S.J Man Manip Ther. 2008;16(2):100-5. Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? Man Ther. 2010 Feb;15(1):117-21.
Epub 2009 Oct 17.
20. Mulligan, BR. 1. Manual Therapy: NAGs, SNAGs, MWMs, etc. 6th Edition. New Zealand: Plane View Services Ltd.; 2010

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