Tennis Elbow, an overuse injury of the extensor muscles of the forearm, causes pain at the outside of the elbow due to excessive repetitive motions involved in gripping, twisting, and carrying activities.  It can occur in adults, children, athletes and non-athletes; anyone who repeatedly uses their forearm for their job, recrational activities, or hobbies.

Common symptoms of Tennis Elbow include:

• Pain that radiates into your forearm and wrist
• Tenderness to touch at your elbow and the muscles of your foearm
• Pain with daily activities such as turning a door knob, opening a jar, shaking hands, carrying objects, holding a coffee cup
• Dropping objects
• Weakness in your arm

Treatment for Tennis Elbow may include:

• Resting your arm and avoiding painful activities and motions
• icing your elbow and forearm to decrease pain and inflammation
• Use of a compression brace
• Manual therapy techniques such as joint mobilization and massage
• Strengthening of weak muscles in your back, shoulder, and forearm
• Retraining your muscles so they work properly during motions using your elbow, forearm, and hand
•  Modification of your daily activities as needed to decrease pain and continued stress to the elbow

At All Access, assessing foot mechanics is an integral part of any lower body and spine evaluation.  Flat arches (known as ‘overpronation’) are common in many adults, and can contribute to many conditions including plantar fasciitis, shin splints, knee pain, sciatica, and low back pain. An excessive lowering of the inside arch of your foot during gait causes aberrant movement in the joints of your foot and leg, which results in abnormal stress on the tissue and muscles in the area. Over time, these repetitive mechanics can cause cumulative injuries through the affected joints. While stretching and strengthening exercises can improve the injury, an external arch support is an integral part of the treatment plan to correct the underlying arch problem. At All Access, we design Sole Supports custom orthotics (http://www.solesupports.com/PUBLICHOME/WhySoleSupports.aspx) . These are the highest level of custom orthotic that will not only provide your foot with the appropriate support, they will actually correct your gait and improve leg strength.  Schedule your free foot consultation today with an All Access physical therapist to see if Sole Supports custom orthotics can improve your posture! 

The gluteus maximus is the largest of a group of three gluteal muscles, including the gluteus medius and gluteus minimus.  These three gluteal muscles act together to provide stability and to produce mobility of the trunk and the legs in order to enable functional movement of the body. 

One of the most common problems associated with deficits in the gluteal muscle structure is the development of low back, hip, and knee pain.  This can occur as a result of inactivity or weakness of the muscles which render them powerless to carry out their stabilizing function.  In some cases, people inadvertently utilize the thigh muscles to conduct the functions of the gluteal muscles.  In this situation it is a challenge for the person to recruit the horsepower that strong gluteals could provide them.  Working on building gluteal strength could assist them in gaining success in athletic activity as well as reducing pain. 

Strengthening the gluteals is important if you have experienced any type of pain or discomfort your low back, hips, or knees due to inactivity or because there is an imbalance between your gluteal muscles and the muscles of your thigh.  Building additional strength in the gluteals will enable them to stabilize the upper and lower body at ease while allowing other muscles to do their job.  A correct application of muscle structure and mechanics will help reduce and eliminate low back pain, hip pain, and some knee pain. 

If you would like to rebuild strength in your back and hips, we can aide you by creating an individualized exercise plan to strengthen your gluteals based on your specific activity needs.  We will assess the current status of your muscular strength and muscular balance and recommend and exercise plan.  Our support through the process will enable you to get back on track to meet your specific goals.   

It can be argued that preseason conditioning is the most important part of an athlete’s sport season.  A proper preseason conditioning program addresses general conditioning and sport specific movements.  It is vital in reducing the risk of injury and preparing the athlete to be both physically and mentally prepared for the start of the regular season.  The 3 primary components of a well rounded preseason conditioning program include general fitness conditioning/strength training, endurance training, and agility/sport specific training. 

A general fitness program will not only increase an athlete’s strength but address possible muscular imbalances that may lead to injury during the regular season.   Enhancing an athlete’s flexibility will also lead to injury prevention.  Increasing a joint’s movement capabilities can help to prevent common injuries such as ankle sprains.

A proper preseason conditioning program should also address an athlete’s endurance capabilities to prepare them for practices and competitions.  Interval training increases conditioning by including short bursts of high intensity cardiovascular training combined with short rest periods.  Interval training can train the body more specifically for the individual demands of many sports. 

The final aspect of preseason conditioning is sport specific movement and agility training.  The preseason is the perfect time to address any skill deficits that might hinder performance during the regular season.  Practicing agility drills not only helps an athlete learn to change direction faster and safer, but it improves reaction time to various visual and verbal cues. 

A complete preseason conditioning program will address the physical needs of the athlete.  With training and skill improvement, a sense of confidence is built for the challenges the athlete will face in the upcoming season.  A consistent training routine will will get athletes out of their comfort zone in order to improve themselves as well as their team.  A physically and mentally prepared athlete is a winning athlete! 

Most anyone who played high school sports, had a paper route, or engaged in playground snowball warfare has thrown their fair share of objects.  As is true with all athletic endeavors, proper form and technique ensure good performance and safety.  But what exactly constitutes good throwing mechanics? 

First and foremost, the body needs to be positioned correctly in order to take advantage of the powerful muscles of the legs and trunk, not solely the arm.  In order to engage the trunk and leg muscles into the throw, you must place your front shoulder and front leg toward the target.  While stepping toward the target with your front leg by pushing off the rear leg, the throwing arm needs to be properly positioned to deliver the throw.  In essence, the arm should follow a circular path. 

This path begins at the waist and then follows back overhead with the elbow bent halfway.  In this position, it is important that the muscles of the shoulder blade be engaged to set the shoulder blade down and back, in it's most powerful position.  At this time the trunk muscles activate to turn the throwing arm toward the target. 

 As the final link of the chain, the arm then follows through toward the target.  This follow through should carry at a slight diagonal off of the vertical.  All of these elements combine to carry the most energy to the ball through utilization of the entire body. 

 Overlooking these basic elements of throwing can lead to overuse injuries of the arm, most often the shoulder and elbow.  The important stabilizing muscles of the shoulder, known collectively as the rotator cuff, are often the site of injury.  Injuries can occur here due to underutilization of the leg, trunk, and scapular muscles, which places too much stress on the relatively small muscles of the rotator cuff.  A rotator cuff that has been overused will often develop strength and motion imbalances, further predisposing an individual to injury. 

If you have a throwing injury or want to know more about how to prevent a throwing injury, please free to contact your All Access Physical Therapist or Fitness Professional. 

Sciatica refers to inflammation of the sciatic nerve, a nerve that exits the back and travels down the back of the leg even down to the foot.  When this nerve is inflamed the pain experienced can be described as sharp, shooting, burning, tingling, and even numb.  This nerve can become inflamed for many reasons, however, symptoms of sciatica stem from irritation at the level of the spine - usually from a disc herniation or due to tightness of a deep hip muscle known as the piriformis.  

Although this pain can be severe and disabling at first, there are many treatments you can try at home to manage the symptoms of sciatica.  The main treatment philosophy is to alleviate pressure on the nerve.  The best way to determine what exercises are right for you is to first recognize what make your sciatica worse. 

Acute Sciatic Flare Up

• Rest 1-2 days with only light activity such as stationary biking
• Ice low back with legs up on a chair for 15-20 minute intervals

Sciatica Symptoms Worse With Bending Forward or Prolonged Sitting

• Try to lie on your stomach - if this does not make your symptoms worse, try to press up onto your hands, keeping your hips on the bed/floor
• If your leg symptoms decrease try doing 10 slow repetitions, several times per day

Sciatica Symptoms Prominent in Hip/Buttock Region or Worse With Lying On Your Side

• Stretch your piriformis by lying on your back and bringing leg up and across your body - pull your foot towards you and push your knee away from you
• Hold this stretch for 20-30 seconds, perform 3 times several times/day

Contact your All Access Physical Therapist if you have sciatica symptoms and your shoulders look "shifted" to one side.  

Contact your Physician immediately if you are experiencing a change in your bowel/bladder control.

If these self treatment strategies do not resolve your symptoms, contact your All Access Physical Therapist.  More specific treatment techniques may be indicated.  

 Follow Our Simple Guidelines to Keep Your Child's Back Healthy This School Year...

1.  Your child should carry no more than 10-15% of their body weight

2.  Use a lightweight backpack

3.  Use both shoulder straps and make sure they are wide and padded

4.  Make sure your backpack has a padded back

5.  Use all the compartments to distribute the weight

6.  Use the waist strap

7.  Your child's backpack should cover no more than 3/4 the length of their back

If your child should develop neck, back, or shoulder pain during the school year, the team of expert Physical Therapists at All Access can help!

Follow Our Simple Guidelines to Keep Your Child’s Back Healthy This School Year!!!

 uld develop back or shoulder pain during the school year, our team of expert Physical Therapists can help!!! 

• hould carry no more than 10-15% of their body weight

Use a lightweight backpack

Use both shoulder straps and make sure they are wide and padded

r backpack has a padded back

Use all the compartments to distribute the weight

 the waist strap

Your child’s backpack should cover no more than ¾ the length of their back

The Anterior Cruciate Ligament (ACL) is one of the major stabilizing ligaments in the knee.  Its role is to prevent the forward motion of the shin bone (tibia) in relation to the thigh bone (femur).  It is essential for the control or the knee in pivoting movements.  Pivoting movements are required in many sports, especially soccer, basketball, and skiing.

 Whether a patient chooses surgical repair or conservative management of their ACL injury, an extensive rehabilitation program is required.  The decision to opt for surgery is based on the patient’s level of functional instability, their age, profession, level of activity, and the presence of associated injuries. 

 Rehabilitation programs for surgically managed repairs are largely dependent upon the technique used.  Exact time frames for rehabilitation milestones will vary but the overall goals will be the same:

• Maximize range of motion as early as possible in order to prevent excessive scar tissue formation
• Strengthen the muscles surrounding the knee to support and protect the ligaments and the joint
• Maintain flexibility of the muscles to reduce tension on the joint

 The average time for rehabilitation after ACL reconstruction to return to sport is around 6-9 months (2).  A sound rehabilitation program should always include specific drills and exercises designed to return the patient/athlete to their desired functional goals.  Core stability, proprioceptive and balance exercises are commonly used in ACL rehabilitation programs as well.

 All Access Physical Therapy provides expert care during all phases of ACL rehabilitation – from pre-hab to post operative management.  Our goal is always to return our patients to their highest level of functioning.  We are able to address prevention of ACL injuries through our many sports conditioning classes offered at the Fitness Academy.  For more information about ACL injury prevention or ACL rehabilitation, please contact All Access Physical Therapy at (508) 845-3500. 

 One of our primary concerns when treating our athletic clientele is further injury prevention.  We are very conscious of what we do within our treatment program that will help our athletic clients decrease their risk for other common yet traumatic injuries.  A common athletic injury that we frequently rehabilitate and work to prevent is an anterior cruciate ligament (ACL) tear. 

The ACL prevents the anterior (forward) movement of the tibia (shin bone) in respect to the femur (thigh bone) during walking, running, recreational and sports related activities.  ACL injuries occur as a result of both contact and non-contact  situations where the increase in force of movement is too much for the ligament to hold.  These movements place increased stress on the knee joint, typically with forces in the rotational and horizontal planes in respect to the knee, which causes the ACL to tear.

Research has shown that athletic women suffer this type of injury an average of 3 times more that men competing in the same sports.  It has been suggested that women are more likely to ACL tears due to the changes in hip and knee alignment they go through during adolescence.  As a result, women are more susceptible to the rotational and horizontal forces mentioned above during sports participation.  These forces are highest during cutting movements, quick direction changes, and when landing from a jump. 

A recent study by Imwalle et al., published in the Journal of Strength and Conditioning Research looked at the possible link between cutting movements and non-contact ACL injuries using a subject sample of high school female soccer players.  The study compared rotational forces placed on the hop and knee during 45 degree and 90 degree cutting movements.  The researchers found that hip and knee internal rotation were increased more during the 90 degree cut versus the 45 degree cut.  As a result, the subjects' knee abduction increased during a 90 degree cut putting the subjects at greater risk for an ACL injury.  The researchers concluded that targeted neuromuscular strength training to the trunk and hips may improve the athletes' ability to control knee and hip internal rotation during cutting movements, and therefore decrease their risk for ACL injury.

Our rehabilitation programs and strength and conditioning plans fall in line with this research. Our programs focus on core strength with targeted training for the low back, gluteus maximus, gluteus minimus, and abdominals.  Targeting these muscle groups improves the participants' ability to control hip and knee internal rotation during cutting movements.  Our therapists look at our clients' form during agility and plyometric (jumping) activities that put greater stress on the knees and correct that form as needed. 

Our Physical Therapists and Fitness Staff are experts at working with athletes during all stages of ACL injuries, from prevention to post operative rehabilitation.  Contact us if you have questions about how All Access can help you rehabilitate or prevent an ACL injury. 

 Reference: Relationship Between Hip and Knee Kinematics in Athletic Women During Cutting Maneuvers: A Possible Link to Non Contact Anterior Cruciate Ligament Injury and Prevention.  Lauren E. Imwalle, Gergory D. Meyer, Kevin R. Ford, and Timothy E. Hewett: Cincinnati Children's Hospital Research Foundation Sports Medicine Biodynamics Center and Human Performance Laboratory, The University of Cincinnati College of Medicine, Cincinnati, OH, and Graduate Program in Athletic Training, Rocky Mountain University of Health Professions, Provo, Utah.  Journal of Strength and Conditioning Research: Volume 23, Number 8, November 2009, pgs 2223-2230. 

The Facet joints are located at the back on either side of the spinal column, between the discs and the vertebral bodies. Each vertebra has bony prominences on each side that form a facet joint with the vertebra above and below. The role of the facet joints is to limit excessive movement and provide stability for the spine.

Facet joints are a potential source of pain which can affect the neck, middle back or lower back. Poor posture is commonly implicated in the development facet joint pain. Prolonged sitting and bending postures places an increased load on the facet joints which then become inflamed and painful. The muscles surrounding the spine also become affected. When considering how poor posture can affect the neck and thoracic spine (middle back) we can see that the thoracic spine becomes round, the shoulders hunch and the head pokes forwards; this leads to tightness of the muscles at the front of the chest and overload of the muscles around the shoulder blades and neck. The paraspinal muscles (long muscles which run the length of either side of the spine) in particular become knotted and tender ⁽¹⁾. 

How can foam rollers help with cervical and facet joint injuries?

A foam roller is a firm solid cylinder which is about 6 inches in diameter and 3 feet long. A roller can be used to isolate specific injured areas of the body and treat restrictions in the soft tissue⁽²⁾as well as perform balance training exercises, core activation exercises and stretching.

Stretching exercises on the foam roller for neck and thoracic facet joint pain.

This exercise is great for extending the middle back and neck and opening out across the front of the chest.

Lie on your back with the roller placed vertically along the length of the spine, feet on the floor and knees bent. Try to keep the spine in contact with the roller and open the arms out to the side. Feel the stretch across the front of the chest, lengthen the neck by tucking the chin inwards.

Muscle release techniques for the middle back using the foam roller

This exercise is to release tension in the muscles either side of the spine, it may feel a little uncomfortable initially but this does ease the more you do it.

Lie on your back with the roller placed horizontally between you and the floor. Your feet should be on the floor with your knees bent. Use the legs to push the body up and down the roller (like a rolling pin) to release tension within the muscles either side of the spine.

By improving your posture, the alignment of your spine is more efficient and the loads placed on the facet joins are reduced.

One of the major benefits of using a foam roller is that it is a relatively inexpensive way to treat injury on your own. It can be used to maintain joint alignment and muscle flexibility in between treatment sessions or for prevention of recurrence of symptoms.

For more information about the use of foam rollers to treat back and neck pain or to purchase a foam roller contact us at (508) 845-3500. 

References

1. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Fukui S, Ohseto K, Shiotani M, et al.  1996, Pain, Vol. 68 (1), pp. 79-83.

2. A comparison of the pressure exerted on soft tissue by 2 myofascial rollers. Curran, PF, Fiore, RD and Crisco, JJ. 2008, Journal of sports rehabilitation, Vol. 17, pp. 432-442. 

 Orthotics are inserts that fit inside a shoe to modify the position in which the foot functions.  Orthotics can be custom made or ‘off the shelf’ with custom orthotics generally being considered to be superior.  They are used to treat foot and ankle problems as well as knee, hip and back problems.  Any problem in which poor joint mechanics and or alignment is considered to be at fault can be treated with orthotic intervention. 

The basic premise behind the use of orthotics to treat such a wide range of conditions lies in the consideration of the kinetic chain.  The kinetic chain refers to the interaction between the muscles, joints, and other soft tissues of the body.  The correct position and alignment of one area is dependent on others for optimum joint mechanics and performance.  When adapting an individual’s foot position using an orthotic the position and alignment at other joints can be affected. 

There is good evidence to support the use of orthotics for painful foot conditions (1) and their use is advocated in the treatment of overuse running injuries with reported success rates between 70% and 90% (2).  Despite such positive reports, it would be wise of the clinician to show caution in the prescription of orthotics (3).  The individual needs of the patient, the severity of the problem and the circumstances surrounding the onset of the injury all need to be considered by the practitioner.  In some cases, the presenting problem can be effectively managed by manual therapy, stretching, and strengthening. 

Assessing your gait mechanics, foot posture, and your kinetic chain is standard practice at All Access Physical Therapy.  All of our Physical Therapists have received additional training in the assessment of foot and lower extremity biomechanics as well as casting for custom orthotics using the Sole Supports brand.  If you have questions about custom orthotics or would like to set up an appointment for an orthotic consultation, please contact our office at (508) 845-3500. 

References

1. Custom-made foot orthoses for the treatment of foot pain. Hawke, F, Burns, J and Radford, J A. 3, 2008, Cochrane database of systematic reviews.

2. The influence of custom foot orthoses on lower extremity running mechanics. Ferber, R. 3, 2007, International sports medicine journal, Vol. 8, pp. 97-106.

3. The flat footed child - To treat or not to treat what is the clinician to do? D'Amico, J C. 3, 2009, Journal of the American podiatric medical association, Vol. 99, pp. 267-268.

4. Foot orthoses and physiotherpay in the treatment of patellofemoral pain syndromme: randomised clinical trail. Collins, N, Crossley, K and Beller, E. 2008, British medical journal, Vol. 337. 

Patello-femoral syndrome is a relatively common condition which causes pain at the front of the knee. The pain is associated with positions of the knee which result in increased or misdirected mechanical forces between the kneecap (patella) and the thigh bone (femur) (1).

Despite being a common and relatively easy to diagnose injury there is much to learn about the exact pathology involved in the presentation of this condition. There are a number of probable causes which include:

• Muscle Tightness (calf, hamstrings, ITB)
• Weakness or lack of coordination in muscles that should help maintain normal patella tracking
• Altered hip, knee or foot posture
• Anatomic variations

Stability and normal function of the knee joint depends on precise interaction between the muscles, ligaments and fascia which surround and support the joint. Any tightness or weakness can cause an alteration in the normal mechanics which leads to pain. Exercise programs used to treat Patello-femoral pain syndrome should be based on sound biomechanical foundations and sensible exercise progression (2).

The quadriceps muscle group is directly involved in the mechanics of the patella-femoral joint as the patella is enclosed within the quadriceps tendon. Strengthening of the quadriceps is considered to be beneficial. However, the pain of patella-femoral pain syndrome is typically associated with movements which result in strong forces going through the joint so traditional knee extension exercises are not appropriate. Knee extension exercises will stress the already aggravated patella-femoral joint. Therefore, “closed chain exercises” (those where the foot is in contact with a solid surface) are preferred and should initially be performed within a pain free range of motion. Once larger ranges of motion are tolerated without pain, open chain exercises may be introduced. Research data tells us that between 0-50 degrees of knee flexion closed chain exercises produce less stress on the patella-femoral joint, beyond this range open chain exercises produce less stress (2).

Muscle coordination as well as overall muscle strength is important. The vastus medialis oblique (VMO) muscle forms part of the quadriceps muscle group and is the innermost muscle of the group. It is believed to help maintain the knee cap in its correct position (3). Specific focus should be placed on encouraging activity of this muscle when strengthening the overall quadriceps group. When prescribing strengthening exercise, those muscle groups not directly involved in patella-femoral joint mechanics should be considered as well, especially the “core” muscle group.

Concurrently to performing strengthening exercises, those structures which are tight must also be addressed. The calf muscles, hip flexors, hip rotators, and Iliotibial band are all commonly tight where patello-femoral pain is seen. Foam rolling, static stretches, and mobility drills are used to lengthen these tight structures. Full recovery and return to normal function can be achieved if exercises for managing patella-femoral pain syndrome are appropriately chosen and progressed.

 For more information about patello-femoral pain syndrome and how Physical Therapy can help you in your recovery from knee pain please contact Steve Messineo at (508) 845-3500 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Associates of physical function and pain in patients with patellofemoral pain syndromme. Piva, SR, Fitzgerald, GK and Irrgang, JJ. 2, 2009, Arch Phys Med Rehabil, Vol. 90, pp. 285-295.

2. Rehabilitation of patellofemoral joint disorders: A critical review. Powers, CM. 5, 1998, JOurnal of orthopaedic and sports physical therapy, Vol. 28, pp. 345-354.

3. Patellofemoral Disorders: A classification system and clinical guidelines for nonoperative rehabilitation. Wilk, KE, et al. 5, 1998, Journal of orthopaedic and sports physical therapy, Vol. 28.

Back pain can be the result of a range of conditions that affect muscles, tendons, ligaments, discs, nerves, other soft tissues or joints. There is still a lot that can be learnt about the causes and treatment of back pain. Most back pain does not have one simple cause, but may be due to a range of factors, such as poor posture, repetitive activity or trauma.

No matter what the particular cause of back injury, it is well documented that the resulting low back pain inhibits the deep abdominal muscles whose job it is to support the spine. A vicious downward spiral is created where injury causes back pain, which causes the muscles that support the spine to weaken which in turn leaves that back more vulnerable to further injury!  It is possible to break free from this cycle and specific lower abdominal stabilization training is a key component to winning the battle. This is where the physio ball comes in; the physio ball is a fairly common place piece of equipment in many gyms, studios and clinics. It may also be referred to as an exercise ball, gym ball, stability ball or therapy ball. It is effective in rehabilitation of the back because it helps strengthen and develop the core body muscles that help to stabilize the spine ⁽¹⁾.

It has been shown that the muscle activity required to perform a simple curl-up exercise is almost doubled when using a physio ball compared to the same exercise on a stable surface ⁽²⁾. Using equipment like the physio ball to perform abdominal exercises changes both the level of muscle activity and the way the muscles work together to stabilize the spine and whole body, this effect is exactly that which is required to counteract the negative effects that back pain has on the muscles.

The physio ball does not simply provide a method to restore the spinal stability that is lost in an episode of back pain. The range of exercises that can be performed when using it allows for expansive programme progression, making it suitable for use in very early remedial exercises to end stage functional rehabilitation. It is also possible to perform a range of mobility exercises to promote increased range of motion about the spine as well as improve stability.

To claim that one type of exercise approach is the panacea to all ills would be misleading; the evidence supporting the use of physio balls can be conflicting. Some exercise specialists and health professionals may question it’s suitability for functional rehabilitation. This negativity is likely to be the product of lack of understanding surrounding the use of the physio ball and inappropriate exercise selection. You cannot simply take any exercise and perform it on a physio ball to make it more effective. Whether using the physio ball for rehabilitation or general exercise, the choice of movement and the technique of how it is performed are paramount to achieving the desired result.  

The use of a physio ball is an excellent conservative back exercise treatment option for back pain sufferers. It is a readily available, inexpensive and versatile piece of equipment that can be used under the supervision of a health professional and/or as part of an independent management plan for back pain. Not only will its use help to resolve the presenting complaint, it will also help prevent further episodes of low back pain when used as part of a rehabilitation program.

References

1. Exercises on a "swiss ball" for chronic low back pain. Stankovic, A, Lazovic, M and Kocic, M. 2008, Proceedings of the 7th Mediterranean congress of physical an rehabilitation medicine, pp. 58-60.

2. Abdominal muscle response during curl-ups on both stable and labile surfaces. Garcia-Vera, FJ, Grenier, SG and McGill, SM. 6, 2000, Physical Therapy, Vol. 80, pp. 564-569. 

Physical Therapy Treatment of Ankle Injuries using Joint Mobilization

The ankle joint is susceptible to sprains or fractures which often result in restricted movement.  Mobilization with movement is a treatment technique which can be used to try and restore range of motion (ROM) at a joint. It is used in the rehabilitation of ankle injuries with reported positive results.

Anatomy of the Ankle Joint

The ankle joint consists of four bones, the tibia, fibula, talus and calcaneus. These four bones have three ‘articulations’ which are contained within the ankle joint. The three articulations are:

Talocrural Joint

This is a hinge joint formed by the distal (far) ends of the fibula and tibia and the talus. It allows dorsiflexion (pulling the toes up towards you) and plantarflexion (pointing the foot).

Inferior tibiofibular Joint

This is strong joint between the lower surfaces of the tibia and fibula. This is re-enforced by a ligament (ligaments attach bone to bone) called the inferior tibiofibular ligament.

Subtalar Joint

The subtalar joint is the joint between the talus and the calcaneus.  It provides shock absorption and the movements of inversion and eversion (inward and outward ankle movements respectively) occurs here.

Ankle Injury and the use of MWM

The ankle is fairly susceptible to injury, sprains and fractures are commonly seen at the ankle joint. Both these types of injury can result in a restriction of dorsiflexion. A limited ability to dorsiflex the ankle has many implications for normal function and can lead to chronic pain and instability. It has been suggested that following such injuries positional faults can occur within the articulations of the ankle joint (1).

Mobilization with movement (MWM) techniques can be used to help restore dorsiflexion. MWM is a manual therapy technique where a manual force is applied to a part of the body and sustained while a previously restricted and/or painful movement is performed. The aim of MWM is to restore normal range of motion, and reduce pain (2) by correcting positional faults.

The exact mechanism of how MWM’s help to improve range of motion and levels of pain are not fully understood; however what is clear is that by stabilizing one joint or body part whilst allowing another to move, appears to correct positional faults which have occurred as a result of injury. Several studies have shown MWM has a positive effect on ankle range of motion (particularly dorsiflexion) (3) (4). Due to the success of MWM to restore full range of motion at a joint, MWM’s are recommended as part of a thorough treatment plan for ankle sprains or fractures (5).

References

1. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Kavanagh, J. 1, 1999, Manual Therapy, Vol. 4, pp. 19-24.

2. Mobilisations with movement (MWM's). Mulligan, B R. 4, 1993, The journal of manual and manipulative therapy, Vol. 1, pp. 154-156.

3. The initial effects of a Mulligan's mobilization with movement technique on osiflexion on dorsiflexion and pain in subacute ankle spraind. Collins, N, Teys, P and Vicenzino, B. 2, 2004, Manual Therapy, Vol. 9.

4. Mulligan's mobilization-with-movement, poistional faults and pain relief: Current concepts from a critical review of literature. Vicenzino, B, Paungmali, A and Teys, O. 2, 2007, Manual Therapy, Vol. 12, pp. 98-108.

5. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Vicenzino, B, Branjerdporn, M and Teys, P. 7, 2006, Journal of orthopaedic and sports physical therapy, Vol. 36, pp. 464-471.

The Best Rehabilitation Approaches for Overcoming Shin Splints.

During this time of year when people are running more outdoors for exericse, shin splints are an extremely common problem. Anyone who has ever suffered from shin splints will tell you how frustrating and painful it can be.

Shin splints are a general term used to describe pain at the front of the lower leg. There are a number of different causes of shin pain, the most common of which is due to irritation of the lower leg muscles, (particularly Tibialis Posterior and Soleus) at the point where they join onto the shin bone (1). This type of problem is sometimes also known as medial tibial stress syndrome (MTSS) and should be differentiated from other causes of pain which may be due to stress fractures of the tibia or neural/vascular problems.

Symptoms should be checked by an appropriately qualified health professional for clarification of diagnosis. The evidence to support or contest the recommended treatments for shin splints is poor.  A recent critical review of the available literature concluded that rest was as effective as any other treatment tested (2) . It could be argued however that this conclusion is more a reflection of the quality and range of studies undertaken as opposed to the actual value of treatments. 

Physical Therapists offer number of treatment options to patients in an effort to cure shin splints which include:

• Massage
• Ice
• Orthotics/Insoles
• Strengthening
• Calf Stretching
• Surgery (via referral to orthopedic surgeon)
• Rest

The primary aim of treatment is to relieve the inflammatory changes that have occurred at the muscular attachment of the lower leg muscles. Massage, ice and rest are all used to help achieve this goal. Stretching and the use of insoles/orthotics aim to decrease the load placed on the muscles and thus reduce the traction forces at their point of attachment onto the shin.

Strengthening can be used to increase the body's ability to cope with the stresses placed upon it. Strengthening should focus not only on those muscles local to the area, but also on those further up the leg and the ‘core'.

In extreme cases surgery can be useful to reduce the pain associated with shin splints. This however is not an option to be considered lightly full uninhibited return to sport is not always achieved (3).

Prevention is better than cure (and often is the cure!)

Whichever treatments are utilized the recurrence rate of shin splints is high. Unfortunately too many people stop running and enjoying the exhilaration of exercise because of their shin pain, this is often an outcome of poor advice and a failure to completely rehabilitate their initial injury. There is no ‘blueprint' for exercises to correct the causes of shin splints; an individualized programme is required. Positive results have been demonstrated in the use of custom made orthotics (2) (4).

Despite mixed reports in the literature regarding the ‘best' interventions for the treatment of shin splints, what does seem to be clear is that a multi-faceted approach should be taken (5). Not only should the treating clinician aim to reverse the inflammatory changes causing symptoms, it is also important to identify and correct the causative factors to prevent recurrence and increase recovery time.

With a methodical and graduated approach which includes structured training plans, education and advice regarding appropriate selection of footwear and training surface alongside manual therapy, it is possible to cure shin splints and prevent recurrence.

References

1. Bradshaw, C, Hislop, M and Hutchinson, M. Shin Pain. [ed.] P Brukner and K Khan. Clinical Sports Medicine. 3rd Edition. Sydney : McGraw Hill Medical, 2006.

2. Medial Tibial Stress Syndromme - A critical review. Moen, M H, et al. 7, 2009, Vol. 39, pp. 523-546.

3. Outcome of surgical treatment of medial tibial stress syndromme. Yates, B, Allen, MJ and Barnes, MR. 10, 2003, Journal of bone and joint surgery - American Volume, Vol. 85, pp. 1974-1980.

4. Medial Tibial Stress Syndromme - Evidence based prevention. Craig, D I. 3, 2008, Journal of athletic training, Vol. 43.

5. Comprehensive management of medial tibial stress syndromme. Knenner, B J. 3, 2002, Journal of chiropractic medicine, Vol. 1.