F.A.P.™ Lower Limb, Toronto Sept 18-19, 2010
F.A.P.™ Spine, Midland On Sept 25-26, 2010
F.A.P.™ Lower Limb, Ottawa Nov 6-7, 2010
F.A.P.™ Upper Limb, Toronto Nov 27-28, 2010
Functional Range Release™ soft tissue seminar, Lower Limb, Toronto Feb 5-6, 2011
In Part 1 & 2 of this 4 part interview on the FUNCTIONAL RANGE RELEASE™ soft tissue management system we outlined the concepts behind the creation of the soft tissue technique, followed by the body of research that enforces the key elements. In Part 3 below, we further explain, as well as discuss the research behind the fascial conditioning/rehab component of the system - Progressive Angular Isometric Loading (P.A.I.L.‘s)™
Thanks to everyone for the positive feedback. If you have a question, please post it to facebook as I am sure the rest of the group would also be interested in the answer…as always, questions and discussions are welcome. For information regarding upcoming seminars, please visit FunctionalAnatomySeminars.com. For those interested, remember that the coresponding Functional Anatomic Palpation Systems™ seminar is a pre-requisite to taking the Functional Range Release™ seminar.
In Part 1 of this 4 part interview on the FUNCTIONAL RANGE RELEASE™ soft tissue management system we reviewed the concepts leading to the creation of the technique. In Part 2 below, we review the scientific research backing the soft tissue treatment component of the technique (In Part 3, to be posted next week, we discuss the research behind the fascial conditioning/rehab component - Progressive Angular Isometric Loading (P.A.I.L.‘s)™)
As always, questions and discussions are welcome. For information regarding upcoming seminars, please visit FunctionalAnatomySeminars.com. For those interested, remember that the coresponding Functional Anatomic Palpation Systems™ seminar is a pre-requisite to taking the Functional Range Release™ seminar.
Since the announcement of our new soft tissue/fascial release and conditioning technique, FUNCTIONAL RANGE RELEASE™, the instructors and I have been asked several different questions on a number of occasions – What is it? Why was it created? What is the research to support it? What is Progressive Angular Isometric Loading (P.A.I.L.‘s)™? What makes it different from other soft tissue techniques/seminars? Is there certification…recertification?
In this 4 part interview, Dr. Spina answers several of these questions (and more) and provides references for claims made, as well as explains the physiologic/histologic basis for F.R.™ (parts 2-4 will be posted in the coming weeks)
As always, questions and discussions are welcome. For information regarding upcoming seminars, please visit FunctionalAnatomySeminars.com
PART 1: WHY WAS THE TECHNIQUE CREATED?
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1. The following describes the correct insertion(s) of the fibularis longus:
a. Base of the first metatarsal
b. The middle cuneiform
c. The medial cunieform
d. a & b
e. a & c
2. The above insertion points are common with which other muscle that plays an important role in ankle stability?
a. Tibialis posterior
b. Tibialis anterior
c. Peroneus Tertius
d. Quadratus Plantae
3. Which is the most important risk factor for ankle sprains?
a. A history of previous ankle sprain
b. Gender
c. Rear foot valgus
d. Short Achilles tendon
4. Which statement correctly reflects currently available evidence for the effectiveness of balance training in preventing ankle sprains?
a. There is no evidence to show that balance training reduces the risk of ankle sprains in athletes with a history of previous injury
b. There is evidence to show that balance training reduces the risk of ankle sprains in athletes with a history of previous injury
c. The preventative effects of balance training have been clearly documented, both for athletes with no prior ankle sprain and athletes with a history of previous ankle injury
d. Current evidence suggests that there is no effect of balance training in preventing ankle sprains
5. Which statement correctly reflects currently available evidence for the effectiveness of external ankle support (taping or bracing) in preventing ankle sprains?
a. There is insufficient evidence to support or refute the effectiveness of taping and bracing to prevent ankle sprains
b. The preventative effects of taping or bracing have been clearly documented, althought the evidence is more convincing for players with previous ankle injury than for healthy athletes
c. The preventative effects of taping or bracing have been clearly documented, both for athletes with no prior ankle sprain and athletes with a history of previous ankle injury
d. Current evidence suggests that there is no effect of taping and bracing in preventing ankle sprains
****NOTE: please participate in the poll at the end of the article
I have run into this presentation on several occasions, as have many of my collegues who also treat the running population. The patient presents with proximal hamstring pain, which upon examination is determined to be tendinosis of the proximal attachment. Upon further kinetic chain evaluation, it is very common, especially in the older population, to find an associated finding of hallux rigidus, or OA of the 1st ray metatarsophalangeal joint. As well, in the younger population, functional hallux limitus (FHL) is a common finding.
Both of the above scenarios lead to a decrease in extension of the first ray often leading to widespread compensatory alterations in gait. A decrease in joint motion in the loaded and unloaded foot is structural hallux limitus (which can be caused by OA). In regard to functional hallux limitus, there is limitation only when the foot is weightbearing or loaded.
The first condition is often clinically obvious as the patient complains of pain in the 1st ray with associated visible enlargement of the MTP; and often
Figure 1 - hallux valgus deformity
associated hallux valgus deformity (refers to the abnormal drifting or inward leaning of the great toe towards the second toe, which is also commonly associated with bunions) (Figure 1). The latter condition is often overlooked in clinical examination as pain and symptoms are often not associated with the 1st MTP joint, but rather in remote sites due to gait alterations.
The 1st MTP joint represents the primary pivotal site about which the majority of extension of the lower limb occurs. The base of the proximal phalanx also provides the insertion of the major medial slip of the plantar fascia that is vital for the creation of the Windlass effect during normal gait (this is the effect of the tightening of the plantar fascia leading to a forced supination of the the foot in preparation for the push off during gait) (Figure 2).
Figure 2 - The Windlass Effect
Considering that the during gait, the entire body is advancing past this single joint, the ability to dorsiflex, and subsequently rais the heel during single support phase while simultaneously supporting against the developing forces for forward motion is essential for normal, efficient gait. If this mechanism fails, sagittal plane compensation will be forced to occur. These can include:
- Delayed heel lift
- Absence of heel lift during single support phase
- Inversion compensation – whereby the person walks on the outside of the foot to avoid first ray function entirely
- Abduction compensation
The last compensation, Abduction compensation produces the classic pronated foot type and abducted stance position. Because the correct pathway of motion is blocked by the lack of 1st ray dorsiflexion, the person will produce an abducted foot in order to roll off the inside of the toe in order to allow for hip extension. It is this compensation, which I most often find related to the development of proximal hamstring tendonopathy.
Figure 3 - contraction of the biceps femoris with a bent knee causes external rotation of the tibia
Theoretically, during the second half of stance phase when the knee bends, external rotation of the tibia will allow for the abduction compensation to occur (along with increased pronation). Contraction of the biceps femoris (Figure 3) insertion onto the fibular head will provide such an effect. Thus, due to the repetitiveness of distance running, conceivably the constant over activity of this muscle can lead to the break down of tendon.
I find that assessment, and treatment of first ray motion (if it is indeed restricted) in addition to re-building the hamstring tendon is very effective in dealing with this condition.
Have you noticed this in your practice?
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For those who have experience treating power lifters….or if you lift yourself, you will be aware of these two scenario’s and how they should be avoided at all costs in order to prevent a low back ‘blow-out.’ For all of you new lifters, or doc’s who find themselves with a lifter on their table, these tips will be of great value to you and your patient.
The video reviews two concepts – 1st is the use ‘pre-loading’ or ‘feed forward tension’ which prepares the body for the lift (which will make you stronger) while simultaneously stiffening the spine to prevent spinal segmental buckling (“blowing out” your back); the 2nd the the idea of catching the weight to prevent the bounce when the weight is dropped.
Figure 1 - Increased moment arm during 'catch' leads to an increase in tissue stress and a greater spinal penalty
For more info on ‘pre-loading’ or ‘feed forward tension’, here is a good article to read. By lifting in this manner (coupled with holding your breath and bracing), not only will you be able to lift more weight, you will be more safe doing so.
I recently had a doc send me a question regarding squatting and knee injury:
Question: The issue of squats and knee pain has come up twice for us in clinic this week – one guy who has some meniscal irritation (I think – negative MRI but positive medial joint line tenderness, Thessaly and McMurray) and one guy with what I”m guessing is patellofemoral tracking problem b/c no tests are positive at all but I reproduced his pain by palpating the underside of his medial patella. Anyway, I remember hearing a sport doc saying that most people go down too low when they do squats and that there’s no need to actually go that low to train the muscle. And I’ve also heard that the Smith machine puts people in a bad position for their backs for squats. It seems like there are lots of ideas out there about squats but I”m not sure if there’s any “best” or “safest” way to do them. Maybe people with knee pain should find a different exercise to strengthen their quads?
Answer: From observations, I would say that 1% of people in any particular gym actually have the flexibility, coordination, balance, and most importantly KNOWLEDGE to actually perform a proper squat exercise. For these few, the full squat is considered the preferred lower body exercise for safety as well as athletic strength. The squat, when performed correctly, is probably one of the safest exercise for the knees and the best to build knee stability (as well as many, many other befits). The problem of course is when one of the 99% of the ‘others’ attempts to perform it and end up in your clinic. This is not a fault of the exercise…rather a fault of the individuals technique.
Regarding the knees….. A full squat is where the hips drop below level with the top of the patella. Any squat that is not deep, the ‘partial’ squats, stress the knee and the quads without stressing the glutes, the adductors, and the hamstrings. The hamstrings and adductors, when under the tension required for proper form exert a posterior tension on the tibia by way of their distal attachments, and the net effect of the anterior quadriceps tendon insertion is an anterior force against the tibial plateau. With sufficient depth (and with the correct form as described in the video – where hamstring/adductor tension is maintained during the lift), anterior and posterior forces on the knee are balanced. Thus the total shear force on the knee is nil. In partial squats, the anterior shear is allowed to occur without being ‘checked’ by the posterior pull of the hamstrings. It is the shearing forces that cause most of the problems that put the blame on “squats.” As described in the video below, when the knees translate forward, the distal hamstring insertion approximates the proximal insertion thus reducing total tension of the hamstrings and adductors (mainly magnus).
Taken from Starting Strength (2nd edition)
The strength coach below is the famed Mark Rippetoe. Author of Starting Strength, a book the I highly recommend if you would like to learn more about the basic barbell lifts (squats, dead lifts, cleans, bench, standing press). In the video below he discusses some of the important aspects of a properly performed squat (although there is much more information that is necessary in order to properly learn the lift). The second video is a clip of him coaching the lift.
I was recently asked to review a concept that was discussed at the Functional Anatomic Palpation Systems™ SPINE seminar regarding the Ligamentum Nuchae. At the seminar we review palpation and assessment, as well as discuss the clinical importance of this frequently ignored soft tissue structure….this of course is followed up in the Functional Range Release™ soft tissue SPINE seminar where treatment of this ligament is taught. Unfortunately (mostly for patients) the last time the ligament was considered for most manual practitioners was during anatomy class.
The ligamentum nuchae is a dense, bilaminar, triangular midline fibroelastic intermuscular septum. It extends from the external occipital protuberance to the spine of C7 and attaches to the median part of the external occipital crest, the posterior tubercle of C1 and the medial aspect of the cervical bifid spines. Distinct from the supraspinous and interspinous ligaments, the ligament is formed primarily from the aponeurotic attachments of the adjacent and subjacent cervical musculature. From superficial to deep, these muscles are the trapezius, rhomboid minor, splenius capitus, and the serratus posterior superior. Also of anatomical, and perhaps clinical importance, the ligament has been found to have direct fibrous attachments with the spinal dura between the occiput and C1, and between C1 and C2.1 This last point is of particular interest for those who commonly treat cervically related head pain due to the fact that although most of the cranial dura is innervated by the trigeminarl nerve (CN V), the infratentorial portion is innervated by upper cervical nerves.
***for more on the topic of cervical dysfunction and neck pain I suggest reading:
Bilateral Mechanical-Pain Sensitivity over the Trigeminal Region in Patients with Chronic Mechanical Neck Pain by La Touche R et al. – The Journal of Pain 2010; 11(3): 256-263
….also read on the Trigemino-cervical nucleus caudalis in the spinal gray matter of the spinal cord and its possible relation to head pain symptoms from the neck area.
As well as: Alix ME, Bates D. A proposed etiology of Cerivicogenic Headache: The Neurophysiologic Basis and Anatomic Relationship between the Dura Mater and the Rectus Capitus Posterior Minor Muscle. JMPT 1999; 22(8): 534-539.
Getting back to the topic…the Ligamentum Nuchae should be assessed and treated for several reasons. In terms of overt injury, the ligament can, and often 
does become injured during motor vehicle accidents where the ‘whiplash’ mechanism has taken place. In hyperflexion (>10 degrees from the vertical), the cervical interspinous ligaments, which blend with the Ligamentum Nuchae, are extended to their maximum physiologic range and are vulnerable to tears. Lack of treatment directed at the structure can result in healing with a predominance of restrictive fibrosis, which can lead to persistent pain and flexion restriction (the ligament is one of the main Functional Range Synergists for cervical flexion as outlined in the Functional Range Release™ soft tissue therapy system). In addition to this, due to the fact that the structure provides attachment for various other structures, the effect on the movement and biomechanics of the cervical spine are far spread.
In terms of non-acute pain in the cervical spine, connective tissue contraction surrounding the ligament can lead to restricted movement in forward flexion and rotation, which can persist even after release of the surrounding musculature has taken place. Such contraction may occur due to posturally related mechanisms, for example habitual postures involving increased cervical lordosis (as is often seen in the common ‘upper cross posture’) which maintains the structure in a shortened position; or due to prolonged tension/stress as would occur for example with aberrant sleep posture. The latter can occur in back sleepers using a large pillow maintaining the head in flexion.
1. Dean, N.A. and B.S. Mitchell 2002. Anatomic relation between the nuchal ligament (ligamentum nuchae) and the spinal dura mater in the craniocervical region. Clin. Anat. 15:182-185.
A practitioner recently requested a post on the topic of coronary ligament injury…..
Named after the Latin word corona, meaning crown (referring to their crown-like shape), the coronary ligaments are two in number and are termed medial and lateral coronary ligaments. These often forgotten, but clinically important ligaments are in truth part of the fibrous capsule of the knee
Figure 1 - The Lateral Coronary Ligament
joint.
The medial coronary ligament is that part of the capsule which connects the medial edge of the medial meniscus to the medial aspect of the medial tibial condyle just distal to the articular margin.
The lateral coronary ligament is that part of the capsule which connects the lateral edge of the lateral meniscus to the lateral aspect of the lateral tibial condyle just distal to the articular margin.
These ligaments are responsible for limiting rotation of the knee as well as for stabilizing the medial and lateral menisci. While they anchor the menisci to the tibia, they do allow for a controlled amount of anterior and posterior translation.
Clinically: Traumatic & Non-traumatic Injury
Injury to these structures is very common, however more commonly overlooked. Activities that particularly stress them involve rotation/torsion of the tibia on the femur as often occurs during sports such as dancing, martial arts, racquet sports, football, and soccer; particularly if the athlete has poor foot and/or knee alignment. Another pre-disposing factor is laxity in either the cruciate and/or collateral ligaments.
Injury to the coronary ligaments commonly stems from traumatic injury. For example, they are frequently ruptured in medial collateral ligament disruption and lateral collateral ligament complex tears; although injury to the structures can occur independently. Typically, the precipitating incident is a sudden and forceful medial or lateral twist of the knee occurring on a planted foot. The resultant pain is often sharp with sudden movements and may or may not be accompanied by mild swelling depending on the degree of the injury. In most cases flexion and extension ROM will remain full with discomfort at end range although with higher grades, effusion may restrict full end ranges.
As the coronary ligaments are not clearly described in most anatomy texts, many manual therapists are unaware of their significance. Injury to these structures are often confused with damage to other structures in the knee. For example, acute, traumatic injury is often misdiagnosed as meniscal tears, or collateral ligament sprains. Confounding the incidence of incorrect diagnoses is the misinterpretation of a widely utilized orthopedic test, namely ‘joint line tenderness.’ This test is performed by simply applying pressure to the medial or lateral joint line. Pain with pressure is often considered a positive test for meniscal tears/damage….however more often this represents injury to the collateral ligaments. This misinterpretation occurs, as coronary ligament damage can be present with meniscal injury, however from my clinical experience sole injury to the coronary ligaments is most often the case.
Perhaps even more important to manual practitioners are incidences of injury to these ligaments from non-traumatic factors. Such injuries can often develop slowly over time through constant pounding from some of the previously mentioned sports (in addition to distance running, especially if performed over inconsistent terrains). Clinically I have found these injuries to be very common and often mis-diagnosed for example as Iliotibial band syndrome at the lateral attachment to the knee. Chronic injury to the ligaments will result in connective tissue fibrosis/contraction, which then, in addition to causing pain, can limit proper translation of the menisci; this can theoretically lead to injury to the menisci, or the stabilizing ligaments of the knee due to altered biomechanics.
Diagnosis
Diagnosis of injury to these ligaments can be challenging. In order to stress these ligaments, the practitioner should utilize tibial torsion as done when
Figure 2 - Medial coronary ligament test with palpation
performing the ‘passive medial or lateral rotation tests’ (for the medial and lateral coronary ligaments respectively. These tests are done simply by rotating the tibia on the femur by way of applying rotational force via the foot. For traumatic type injuries, this will often reproduce pain symptoms in the joint line. However these tests also stress many other structures. Thus, the application of specific clinical palpation techniques is often needed in conjunction with these tests….and is often the only diagnostic procedure for non-traumatic cases. As demonstrated in figure 2 which demonstrate passive medial rotation, the movement causes anterior translation of the medial tibial plateau thus exposing the joint line and allowing the practitioner to apply inferior pressure on the plateau’s coronary ligament (figure taken from FUNCTIONAL ANATOMIC PALPATION SYSTEMS™ Lower Limb seminar – which teaches advanced assessment/palpation of the ligaments).
Treatment
Traumatic Injury:
- Manage histological components – inflammation, pain
- Limit connective tissue fibrosis – Functional Range Release™ following the acute phase
- If associated meniscal damage – Open operations to repair these structures are always indicated on the lateral side but the medial side usually heals and with it, the coronary ligament. The peripheral meniscal tears which may occur with severe medial collateral ligament ruptures are usually associated with damage to the coronary ligament. Open medial collateral repair or posteromedial repair must also address this peripheral meniscal avulsion and suture of the meniscus with either non-absorbable or Vicryl type sutures.
- Kinetic chain rehab as directed by examination
Non-traumatic Injury:
- Reduce connective tissue fibrosis and promote A-P meniscal motion – Functional Range Release™
- Kinetic chain rehabilitation as directed by examination
