Archive for the ‘Foot/Ankle Injury’ Category

Myofascial Release Therapy is Effective in Treating Heel Pain (Plantar Fasciitis)

Renan-Ordine R, Alburquerque-Sendin F, de Souza DP, Cleland JA, Fernandez-de-Las-Penas C.  Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial.  J Orthop Sports Phys Ther. 2011 Feb;41(2):43-50. Epub 2011 Jan 31.

Note: The following article provides Level I evidence that use of myofascial release techniques in combination with static stretching is more effective than isolated static stretching in treating plantar fasciitis.

Rationale and Purpose:  Plantar fasciitis or heel pain is the most common foot pain conditions and can have debilitating consequences, especially for athletes performing repetitive jumping, landing and running.  Research indicates that inflammation does not characterize this condition, but rather noninflammatory degenerative changes in the plantar fascia are most characteristic.  The lack of inflammation associated with this condition suggests that interventions exclusively targeting inflammation may not be effective at decreasing pain/symptoms and restoring normal function.

There is moderate evidence that stretching of the gastrocnemius and plantar fascia can successfully improve symptoms and function in those with plantar fasciitis/heel pain.  However, this literature is mixed and the magnitude of improvement using isolated static stretching has been questioned.

The presence of myofascial/muscle trigger points in the gastrocnemius has been suggested to be a factor associated with plantar fasciitis/heel pain.  Thus, incorporating myofascial release techniques prior to static stretching may provide greater benefits than isolated static stretching.

Overview of Research Methods:  60 subjects were randomly assigned to the Isolated Stretching group or the Myofascial Release + Stretching group.  Subjects were all clinically diagnosed with unilateral plantar fasciitis/heel pain using a standard set of inclusion/exclusion criteria.

Dependent Variables: Multiple outcome measures related to physical function / body pain (SF-36) were measured as well as pressure pain threshold.  All measures were taken before and after the interventions.

Intervention Protocol: All participants attended 4 treatment sessions each week for a total of 4 weeks (16 total treatment sessions).  The Isolated Stretching group performed standing wall stretches for the gastrocnemius (knee straight), soleus (knee flexed), and plantar fascia self-stretching.  Each stretch was held for 20-seconds, followed 20 seconds rest for a total of 3 minutes (total stretching protocol lasted 9 minutes).  This was repeated 2 times per day.  The Myofascial Release + Stretching  group were examined for presence of active trigger points in the gastrocnemius (all subjects were found to have active trigger points upon inspection).  Prior to static stretching, manual pressure was applied over trigger point areas by the clinician.  The pressure was maintained until noting a release of the taut band, then pressure was increased and the process repeated for 90-seconds (usually 3 repetitions).  After trigger point release the clinician applied a longitudinal stroke over the gastrocnemius starting from the ankle to the knee.  Strokes were applied with moderate pressure, but were not painful.  The subjects then performed the identical static stretching protocol as performed by the isolated stretching group.

Key Findings:  Both the isolated stretching and myofascial release + stretching group demonstrated improved function and decreased pressure pain threshold.  However, the magnitude of improvement in the myofascial release + stetching group was significantly greater than the isolated stretching group.  The greater magnitude of improvement in the myofascial release + stretching group was considered to be clinically meaningful.

Clinical Implications:  These findings provide Level I evidence that an integrated program consisting of myofascial release followed by static stretching is superior to isolated stretching for improving function and decreasing pain threshold in those with plantar fasciitis/heel pain.  Based on these findings the incorporation of myofascial release techniques before static stretching is recommended in treating those with plantar fasciitis/heel pain.

It should be noted that the current study only looked at the short term effects and no long term follow up was performed.

Categories: Foot/Ankle Injury

Injury Prevention Training is Effective

Hubscher M, Zech A, Pfeifer K, Hansel F, Vogt L, Banzer W.  Neuromuscular training for sports injury prevention: a systematic review Med Sci Sports Exerc. 2010 Mar;42(3):413-21.

Rationale and Purpose: Over the past 10-15 years there have been multiple research studies published examining the effectiveness of injury prevention programs on reducing the incidence of various lower extremity injuries.  There are not consistent findings across these studies, thus calling into question the ability to prevent lower extremity injuries with an exercise based intervention.  It is difficult to synthesize the information in these different studies due to differences in type of exercises performed, duration of training program, volume of training program, type of injuries being monitored, methodologic quality, etc…  Thus, there is a need to better synthesize the current scientific literature in this area to improve our ability to prevent lower extremity injuries during sport.

The best scientific evidence to demonstrate the ability to prevent lower extremity includes use of a randomized controlled trial study design.  The second best type of evidence would be comparing a training group to a control group, but without randomization of subjects to either group.  Thus, the purpose of this article was to conduct a systematic review of the existing literature on lower extremity injury prevention and focus on the best scientific evidence (randomized controlled trials or controlled trials without randomization).

Overview of Research Methods:  A systematic literature review was conducted using a standard set of key words and databases.  Reference lists of all retrieved articles were also manually reviewed to ensure that all relevant articles were identified and included in the analysis. A total of 32 articles were originally retrieved following the literature search.  These articles were then reviewed and only articles that met the following criteria were included in the results: randomized controlled trial OR controlled trial (without randomization), athletes with and without previous injury were the subjects, only the intervention group received the exercise protocol, and the intervention group had to be compared with a control group that did not receive any other type of intervention.  All studies were required to evaluate injury incidence as the outcome.

Each of the retrieved articles were independently reviewed by two separate researchers for scientific quality.  Nine different criteria were used to evaluate the scientific quality of each study: 1) Randomization method, 2) Concealed treatment allocation (subjects blind to being in control or intervention group), 3) Intervention and control groups were similar at baseline testing, 4) blinding of assessors (researchers were blind as to who was in control or intervention group), 5) co-intervention (were other interventions being simultaneously given), 6) compliance, 7) dropout rate, 8. timing of the outcome assessment, and 9) intention to treat analysis.  A “High Quality” study was one that received a score of 5 or more on the scientific quality scale (out of 9 points possible).

A total of 7 studies were identified as “High Quality” studies and included in the final analysis.

Key Findings:  The included studies were separated into 2 groups based on the type of exercises performed: 1) Balance Training (isolated balance exercises) and 2) Multi-Intervention Training (combination of balance, strength, plyometric, and agility exercises).

  • Two studies focused on the effects of isolated Balance Training on the overall rate of sports injuries (all lower extremity injuries).  The overall rate of sports injuries was not significantly decreased with isolated Balance Training.
  • Three studies focused on the effects of isolated Balance Training on ankle sprain injuries.  There was a significant decrease in the rate of ankle sprain injuries following isolated Balance Training.
  • Two studies focused on the effects of Multi-Intervention Training on lower limb injuries.  There was a significant decrease in the rate of lower limb injuries following Multi-Intervention Training.
  • These same two studies also investigated the effects of Multi-Intervention Training on acute knee injuries and ankle sprain injuries.  There were significant decreases in both acute knee injuries and ankle sprain injuries following Multi-Intervention Training.

Clinical Implications:  Isolated balance training was effective at reducing the risk of ankle sprain injuries by 36%.  However, isolated balance training was NOT effective at reducing the risk of knee injuries.

Multi-intervention training programs were effective in reducing the risk of lower limb injuries by 39%, the risk of acute knee injuries by 54%, and the risk of ankle sprain injuries by 50%.  Thus, it appears that multi-intervention (integrated training) injury prevention programs provide the best method at preventing a variety of lower extremity injuries in young, athletic individuals.

The multi-intervention training programs involved a variety of exercises, such as: static stretching, strengthening, plyometrics, agility drills, balance training, movement technique training, and core stability.  The time needed to complete the multi-intervention training programs ranged from 10 minutes to 30 minutes.  Most of the the multi-intervention training programs were performed as part of a pre-practice warm up during the pre-season and in-season scheduleIt appears that all of the programs were performed in a team setting and programs were not individualized for the participants.  Thus, the use of a “one size fits all” type of injury prevention program incorporating multiple types of exercises is effective at reducing lower limb, knee, and ankle injuries.

There are many more questions that need to be answered to further improve the effectiveness of injury prevention programs. However, this systematic literature review provides solid evidence the injury rates can be decreased by implementing a multi-intervention injury prevention program as part of the pre-season and in-season conditioning programs.

Cuboid Subluxation and Lateral Ankle Sprains

In the article entitled “Cuboid subluxtion: a case study and review of the literature” by Adams & Madden they describe the potential for traumatic cuboid subluxation to occur during a plantarflexion and inversion ankle sprain.
Link to article on PubMed:

Mechanism of Injury: Cuboid subluxation most commonly occurs in a plantar direction (inferior displacement).  This is due to the anatomical relationship of the peroneus longus tendon that passes lateral and inferior to the cuboid as the tendon dives to it’s insertion point.  The cuboid serves as a fulcrum or pulley for the peroneus longus tendon.  Excessive tension within the peroneus longus, as would occur during a plantarflexion & inversion ankle sprain (eccentric contraction), forces the cuboid in a plantar and medial direction resulting in subluxation.

Evaluative Findings:
  • Pain in medial longitudinal arch towards, distally toward the 4th and 5th metatarsals, and proximally toward the ankle
  • Weakness and recreation of pain during toe off / push off of gait/running/jumping
  • Subtle cuboid displacement (inferior) and pain may be noted during palpation of cuboid
  • Recreation of pain during the following passive motions: combined plantarflexion, adduction, and inversion (supination)
  • Reduced plantar and dorsal gliding motion of cuboid may be present
Plantar direction cuboid subluxation must be corrected and normal bony alignment needs to be restored.  There are 2 basic techniques that can be utilized to return the cuboid to it’s normal position.
Cuboid Squeeze:  Place ankle in maximal plantarflexion.  Create a slight long axis distraction down the foot with the distal hand while simultaneous pressing the cuboid in a downward and lateral direction (“squeezing”).
Cuboid Whip: Interlock fingers over the dorsum of the foot to act as a fulcrum and position the thumbs side by side or overlapping over the plantar aspect of the cuboid.  Exert a dorsal force over the cuboid while swinging the foot into plantarflexion.  An audible pop or clunk may occur.
Taping to support the cuboid in place may also be utilized after mobilization.  The article by Adams and Madden also describes a taping procedure that can be used to facilitate cuboid support.
Additional articles on cuboid subluxations can be found at the articles listed below:

Categories: Foot/Ankle Injury
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