Effect of Static Stretching and Joint Mobilization in Patients with - - PowerPoint PPT Presentation

Effect of Static Stretching and Joint Mobilization in Patients with Chronic Ankle Instability

Jay Hertel, PhD, ATC, FACSM,FNATA

Exercise & Sport Injury Laboratory Orthopedic Summit Las Vegas, NV December 8, 2017

Disclosures

 Textbook Royalties – Wolters Kluwer  Grant Support:

 National Institutes of Health

Ankle Sprains: Public Heath Issue

 Ankle sprains are the most common injury

in sports

 Also common in military personnel & the

general population

 Societal burden includes direct costs,

indirect costs, & long term consequences

Gribble et al, Br J Sports Med, 2016

Ankle Sprains as a Public Heath Issue

 Chronic ankle instability (CAI)  Repetitive sprains and “giving way”  Persistent symptoms  Diminished self-reported function  Prevalence = 40% of 1st time

sprainers at 12 month follow-up

(Dohertry et al, AJSM, 2016)

 College students with CAI take ~2000

less steps per day than their healthy counterparts

(Hubbard et al, JAT, 2015)

 Relationship between ankle sprain

history and development of

• steoarthritis

(Valderrabano et al, AJSM, 2006)

Hertel & Corbett (in press)

Assess ROM Assess Strength Assess Balance Assess Functional Activities Treat Functional Activities Treat Balance Treat Strength Treat ROM Re-assess ROM Re-assess Strength Re-assess Balance Re-assess Functional Activities

Chronic Ankle Instability Assessment & Treatment Algorithm

Donovan & Hertel, Physician & Sports Med, 2012

ROM Treatment

Assess ROM Arthrokinematic Deficit Treat with Mobilizations and Stretching Osteokinematic Deficit Treat with Stretching No Re-assess ROM

Donovan & Hertel, Physician & Sports Med, 2012

Joint Motion Algorithm

Physiological Movement (Osteokinematics) Hypomobile Accessory Movement (Arthrokinematics) Limited = Capsular Restriction Grade III/IV/V Mobs Normal = Contractile Restriction Stretch Contractile Tissue Hypermobile Strengthening & Neuromuscular Control Exercises Normal Evaluate at each relevant joint & assess functional movement of the lower extremity

Osteokinematic Assessment

STRETCHING WORKS, BUT…

 Stretching of the triceps surae muscles

results in increased ankle dorsiflexion ROM, but it is unlikely to address arthrokinematic restrictions

Joint Mobilizations: Indications & Contraindications

Indications:

 Pain  Joint

hypomobility

 Muscle inhibition

Contraindications:

 Hypermobility  Joint effusion (Grade I-II OK)  Intra-articular fixation  Osteoporosis  Healing fracture  Malignancy in spine or limb  Osteomyelitis  Rheumatoid Arthritis

Talocrural Distraction

 Grades I-II:

 Pain relief

 Grades III-V:

 Increase general

motion

 No research on

isolated use of this technque

Anterior-Posterior Talar Glides

 Talus must glide posteriorly

• n tibia during ankle

dorsiflexion

 By far, the most researched

joint mobilization concept at the ankle

 Dorsiflexion deficits

commonly reported after ankle sprain – WHY?

RESTRICTED POSTERIOR TALAR GLIDE

 Posterior talar glide restricted

12 weeks after ankle sprain

(Denegar et al, JOSPT, 2002)

 Patients treated with posterior

talar mobilization regained dorsiflexion ROM quicker after acute sprain

 7° more dorsiflexion after 3

treatment sessions

(Green et al, Phys Ther., 2001)

 Patients with CAI treated with

posterior talar mobilization had immediate increases in:

 Dorsiflexion ROM (26%)  Posterior talar glide (50%)

(Vicenzino et al, JOSPT, 2006)

Anterior-to-Posterior Talar Glide

J Orthop Res. 2012 During each session, each subject received 2, 2-min sets of Maitland Grade II talocrural joint traction and 4, 2-min sets of Maitland Grade III talocrural joint mobilization with 1 min

• f rest between sets.

 Direct comparison of talocrural joint

mobilizations, calf stretching, & plantar massage

Tibiofibular Joints

 Distal fibula is “stuck”

anteriorly and inferiorly

 Proximal fibula stuck

posteriorly (Mulligan)

 Mounting evidence

supports this phenomenon in some patients with lateral ankle instability

Talus Calcaneus

Tibia

Anterior to Posterior Distal Fibula Mobilization

Proximal Fibula Mobilization

J EMG Kines, 2011

Proximal tib-fib manipulation caused immediate increase in soleus motorneuron pool excitablility

 Significant increase in

soleus motorneuron pool excitability in the soleus fibular reposition taping

 No change found in

the peroneus longus

Manual Therapy, 2013

DISTAL JOINTS

 Subtalar*  Calcaneocuboid

(Jennings & Davies, 2005)

 Tarsometarsal*

 Lateral  1st ray

*No evidence for these techniques in isolation

Whitman et al, JOSPT 2009



6 manipulations –mobilizations

 Talocrural lateral glides  Proximal tib-fib manipulation  Distal tib-fib manipulation  Talocrural AP glides  Talocrural distraction

manipulation

 Rear foot distraction

manipulation

 Clinical Predictor Rule

developed to predict success with manual therapy

 Success = GROC of +5 to +7  Not Success = GRPC of -7 to

+4  4 significant predictors of

success:

 Symptoms worse when

standing

 Symptoms worse in evening  Navicular drop >5 mm  Distal tib-fib hypomobility

 If 3 of 4 predictors present:

 (+) LR = 5.9  95% probability of success

 Limitation: Shotgun

approach to manual therapy

Current Status of Evidence to Support Joint Mobilizations in Lateral Ankle Sprain/Instability Patients

 Very little research that assesses what

most skilled clinicians routinely do in clinical practice

 Assess osteokinematics & arthrokinematics at

multiple joints & treat appropriately

 Decent evidence to support use of AP

talar mobilization to increase DF ROM

 Long term follow-up studies do not exist

Conclusions

 Patients with ankle pathology may have

• steokinematic & arthrokinematic restrictions

 If you don’t assess for them, you won’t find them

 Calf stretches will improve dorsiflexion ROM  Joint mobilizations & manipulations should be

used with specific treatment goals in mind at joints with arthrokinematic restrictions

 Neither should be use in isolation, but rather as

part of a comprehensive treatment plan that includes therapeutic exercise

THANK YOU

Jhertel@virginia.edu @Jay_Hertel