Introduction
Ankle injuries are one of the most common injuries in the musculoskeletal system involving a partial or complete tear of the ankle's ligaments. They are particularly common in basketball, volleyball, soccer, modern dance, and ballet. Most of the patients recover completely, but 20 % to 40 % of patients develop chronic symptoms and instability. The term manipulation refers to the manual therapy techniques that are used in modulating pain and managing joint impairments that have a limited range of motion. This therapy specifically addresses the altered mechanics of the joint. In this article, we will discuss the evidence supporting the use of high-velocity, low-amplitude thrust manipulation techniques for the lower extremities.
What Are Ankle Sprains?
The stability of any joint depends on the existing limitations provided by the bony configuration and the active and passive soft tissue restrictions. The ankle joint is quite stable in the neutral position because of the wide anterior portion. The medial, lateral, and posterior ligaments and the syndesmosis provide support for the ankle. The lateral ankle ligaments having a complex anatomical structure, are most commonly involved in ankle sprains.
The most common mechanism of injury is an inversion and plantarflexion sprain, which injures the anterior talofibular ligament (ATF) rather than the calcaneofibular ligament (CF). A syndesmotic injury or “high ankle” sprain involves the anterior tibiofibular ligament more than the anterior talofibular ligament. The mechanism of the injury involves the foot being turned out or externally rotated.
What Are the Other Common Reasons for Heel Pain?
Other reasons for heel pain include plantar fasciitis, achilles tendinitis, tarsal tunnel syndrome, and other tendinopathies.
-
Plantar fasciitis:
Plantar fascia is a dense, fibrous connective tissue that provides important static support for the longitudinal arch of the foot. Degenerative changes of the plantar fascia due to wear and tear causes inflammation of the ligament resulting in heel pain. Clinical symptoms of plantar fascitis include the onset of gradual pain in the inferior and medial parts of the heel. Pain and stiffness worsen over time.
-
Achilles tendinitis:
Achilles tendon is a fibrous connective tissue band connecting the calf muscles to the heel bone. Overuse or repetitive strain over the Achilles tendon results in Achilles tendinitis. Pain begins as a mild ache above the heel after running or any sports activity; the pain usually progresses when the patient runs for a prolonged period of time.
-
Tarsal tunnel syndrome:
Compression of the posterior tibial nerve or its branches between the bony floor and ligamentous roof of the tarsal tunnel leads to heel pain and numbness over the bottom of the foot, especially at night.
What Is Joint Manipulation?
Joint manipulation is a passive, skilled manual therapy technique applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motion for therapeutic purposes. The varying speeds and amplitudes can range from a small amplitude force applied at a fast velocity to a large amplitude force applied at a slow velocity. There is a continuum of intensities and speeds at which the technique could be applied. The various types of joint manipulation are self-mobilization, mobilization with movement, physiological movements, accessory movements, and manipulation under anesthesia.
What Are the Contra-Indications of Joint Manipulation?
There are certain contra-indications for joint manipulation, such as:
-
The joints of patients with potential necrosis of the ligaments or capsule should not be mobilized with manipulation.
-
Rapid swelling of the joint usually indicates bleeding in the joint following a trauma or a disease. During these conditions, manipulation techniques are contra-indicated.
-
Whenever inflammation is present, manipulation of the joint increases pain and muscle guarding, resulting in greater tissue damage.
What Is Thrust Manipulation?
Thrust manipulation/high-velocity thrust refers to high-velocity, short-amplitude techniques. The thrust is performed at the end of the pathological limits of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors. The pathological limit refers to the end of the available range of motion when there is a restriction.
What Is Tarsal Twist Manipulation?
Cuboid syndrome, which disrupts the cuboid bone and subtle disruption of the calcaneocuboid joint, is believed to be improved by a manipulation technique called cuboid manipulation. Manipulation of the cuboid bone improves the mobility and compatibility of the cuboid, thereby improving its function and pain in patients with cuboid syndrome. This technique can only be performed if the swelling and bruise have significantly reduced and the injured ligaments are healed enough to tolerate the manipulation. Due to the limitations and lack of evidence in the cuboid manipulation technique, an alternative technique was needed for the cuboid syndrome and lower quarter dysfunctions.
In contrast to cuboid manipulation, the tarsal twist manipulation technique could be performed in acute phases of healing as well as sub-acute and chronic.
How Is the Tarsal Twist Manipulation Performed?
This high-velocity, low-amplitude thrust manipulation technique is performed by positioning the patient in the supine position. The involved lower extremity is relaxed, and hip is in flexion-abduction and externally rotated, and the knee is in flexion. Sometimes a towel roll is placed under the cuboid bone. Clinician stands facing the patient's foot. Firstly the clinician will place the thenar part of one hand on the medial aspect of the patient’s calcaneus. Then the doctor places the web space of the other hand in the medial proximal first metatarsal and grasps their fingers in the dorsum of the foot and thumb at the plantar aspect of the foot.
The clinician manufactures a barrier by everting calcaneus and inverting and abducting the forefoot simultaneously. Once the barrier is achieved, the clinician applies a high-velocity and low-amplitude thrust with the drive from the clinician’s sternum, contacting both the forefoot in the abduction and the calcaneus in the eversion. Therapeutic exercises are important for rehabilitating the tarsal joint. Still, if the exercises are coupled with the manipulation techniques like tarsal twist, it may be more beneficial than the exercises alone as an intervention.
Conclusion
Ankle joint and foot pain have become very common, especially in people engaging in sports activities, and they make up about 70 % of all injuries. Joint manipulation can not be used as a primary treatment option in any health condition; therefore, they are encouraged along with physical therapy and other traditional treatments. Recent studies suggest that Tarsal twist manipulation is believed to be used as an additional treatment option in treating lower quarter dysfunctions and as an alternative to cuboid manipulation.
