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Treatment Tools

By Debbie Roberts, LMT

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Creating Better Performance: Investigating Dysfunction

I think the most exciting part about being a massage therapist is when a client walks in with an out of the box dysfunction and, in this case, a leftover dysfunction providing us with a very unique learning environment. As clinicians, we go to work applying a few tweaks here and a few tweaks there, and in one hour or less they go skipping out of our office. It doesn't happen every time or we would all be millionaires, but if it happens even 50% of the time, that is a lot of the populous being helped through touch and proper evaluation. Let's take a look at the importance of assessing above and below an ACL repair. We will go step-by-step into proper assessment and we will also take a glimpse at how surgery can disrupt the structural balance between joints. I invite you to read closely so you don't miss how applying a 10 minute tweak created instant performance and function for this client's ACL leftover.

History

A female with three left knee ACL repairs from playing soccer all her life. The first ACL tear was because she stepped into a hole on the field and twisted her knee. She thinks the second ACL tear happened because she took her knee brace off too early. The third tear happened when another player crashed into her knee. She is presently in her early 20's and enjoys playing travel soccer, participates in some 5K and 10K races, plus works standing all day at the hospital with her left foot elevated on a small stool for at least 12 hours charting.

soccer player - Copyright – Stock Photo / Register Mark Subjective

She came in to the office complaining of left knee pain pointing at the patellar tendon, some IT band discomfort and constant nagging right SI pain. She was concerned that maybe she had reinjured her ACL. Always rule out the worst first. In this case, doing an anterior draw test to make sure she had not re-injured her knee or disrupted her ACL repair. The test was negative.

Your objective findings should first start with observation in gravity. You cannot observe how a joint is loading for running or soccer if they are unloaded on a massage table. Begin any evaluation by looking at how they naturally stand. If one foot is in front of the other foot, then their pelvis is probably rotated. Compare the feet bilaterally and is one foot turned out more than the other? This means taking a look at the subtalar and talus joint comparing the two sides and looking further up the chain for hip tightness.

Are they standing with either foot in pronation or supination? Either position will tell you that the ankle joint is not moving properly during gait. Then proceed to watch how their body will load through the ankles, knees and hips. One of the best assessment tools for this is having the client perform a squat. To me, it is the simplest and quickest in the assessment tool box, but there are others you can use. A good evaluation question to ask is if there is pain or no pain while performing these assessments. Non-painful dysfunctional movements are just as important as painful dysfunctional movements.

What I found on observation was that during the squat assessment, she shifted her entire body weight on to her right side. Have you ever seen someone do a one legged squat? That is how much of a shift on to her right side there was, like she was trying to perform a one legged squat. It appeared that the left side of her body was not accepting any weight at all. She related that when working out at the gym, her partner was always trying to hold her hips in place so she would squat equally, but it never worked. She asked me a very direct question: do you think I ever be able to squat normally? At that point, I told her I didn't know. In my mind, I was thinking this really is one of the worse squats I had ever observed and by what she had already told me, the shifting on to her right side had been going on for a very long time. You will want to keep reading because that 10 minute tweak was pretty amazing. I also told her let's just keep assessing and see what else we can find that might be not allowing her to squat equally.

Below the ACL repair, her left foot position was extremely supinated. She relayed the wear pattern of her left running shoe was always on the outside. Maybe the ankle joint was damaged or disrupted in the original injury. Once you look below the knee, then it is time to further investigate if there is any dysfunction above the knee. Could her hip be a possible weak link in the chain not having enough strength and stability to accept the body's weight? Could three surgeries below the hip have caused the nerve signals to the hip to become muddled? The manual muscle testing comparing the right to the left showed her left was weaker than the right. Now think about this, if her left side is never loading properly, then her left hip has become weaker over time. But what part of the body needs to load properly in order for the hip to work? You guessed it: the foot and ankle.

The body is very crafty and self preserving when it comes to working around any false stability or mobility. The three ACL repairs are like having a superhuman knee joint. There will probably be miscommunication the minute the foot strikes the ground going up the kinetic chain. Go ahead and try it, walk right now with a super stiff knee joint and see what that feels like to your ankle and hip. Walk long enough to get a sense of what it is doing to the opposite side. In other words, try walking a mile in their shoes. Going further to give you an even better picture of what is happening, let's take a very common surgery such as a spinal fusion. As we have seen many times, the patient begins to complain of pain and discomfort above or below the fusion. These segments become less stable and more mobile making the back more susceptible to an injury.

Additional Evaluation

The second part of your evaluation process should be a motion test: comparing the right ankle joint to the left ankle looking for restricted motion. During the motion test, I found her left tarsal joint to be very restricted. She related once again that the first ACL repair was because she had stepped in a hole during soccer and twisted the knee. Throughout her physical therapy and returned doctors visits, there wasn't a foot to hip evaluation done to see if there was any left over's or unresolved trauma besides the obvious ACL tear. They just fixed the ACL tear and back out she went. Within two to three weeks after being released to play, her second tear occurred with no direct trauma. Now a question that might come to your mind is: what else could have contributed to her second tear? Was it the brace coming off a littler earlier than requested or could it have been the fact that no one addressed the subluxated tarsal joint and the injured muscles that perform a very important function of inversion/eversion?

The joints at which inversion and eversion primarily occur are the talo-calcaneo-navicular joint and the subtalar joint. One of the main reasons women have a higher incidence of ACL injury than men is their higher Q angle or knee valgus torque. The higher valgus position increases the built-in compression on the lateral side of the knee, which lowers the ground reaction force (GRF) necessary to cause an ACL injury. Therefore, women may require a lower GRF (e.g., five times body weight rather than seven times body weight) in combination with the faulty leg and body position for an ACL injury to occur. The athlete must land on the balls of the feet, with the trunk over the feet. The left over ankle misalignment would not have allowed her body to land appropriately. Just imagine for every few degrees the body is landing off its center of gravity the higher the GRF. This combination would have left her much more vulnerable to another ACL tear. During running, when the foot strikes the ground and collapses, it is designed to absorb shock and it becomes a loader of the rest of the body. When the foot goes through inversion and eversion appropriately, it allows the hip to internally rotate, then to abduct and helps the leg recover without extra force at the knee joint. In fact, when everything is working just right the big toe talks to the hip and the hip talks to the trunk and the knee is the happy guy in the middle.

The third part of your evaluation would be to perform manual muscle testing. You will want to apply this testing to every plane of the motion that an ankle joint is capable of doing. During the test, I found she could not resist me at all on inversion. She looked at me and said, "I know what you want me to do, but I just can't get it to work." Remember, inversion is the eccentric contraction that controls the amount of collapse and stops the knee from rotating medially. She also lacked strength on Dorsiflexion.

The fourth thing is to palpate looking for residual or leftover trauma to any muscles that are unable to give you resistance. In this case, I palpated all the muscles that perform inversion which are extensor hallucis longus, tibialis anterior, tibialis posterior, flexor digitorum longus and flexor hallucis longus and the tricep surae. She was extremely tender with very hard palpable knots along the medial border of the tibial shaft.

This is where you pull out your tools of the trade and do manual therapy. I did some deep longitudinal and cross fiber friction along with massage cupping to release these restrictions. You will want to keep performing the manual muscle testing. This will help you know how effective your choice of therapy has been in helping normalize and return the muscles ability to fire or stabilize. The last thing I did for the ankle joint was reset joint centration by using isometrics in all planes of motion. Joint centration means the proper alignment of the joints. Having good joint centration allows for the best possible distribution of loads at the articular surfaces. This in short helps to prevent future injuries.

Now, here is what you have been waiting for: the 10 minute tweak. After doing all the assessments, the foot seemed the most obvious to correct. Within 10 minutes of working with the myofascial restrictions, mobilizing the talus joint and doing isometrics in all planes for her ankle and hip, we retested her squat. This time, she performed it perfectly with absolutely no shift to the right at all! In addition, her foot was in a neutral relaxed position no longer in supination. I had her watch herself in the mirror to show her what we had accomplished. She could feel the more relaxed position of the foot and she said she felt more symmetrical. In just 10 minutes of working on the right things, her body was now accepting the load from the ground up, through the knee, allowing communication to the hip and pelvis. Immediate improved performance, yeah. Happy with those results we continued the rest of the session to address the residual tightness of the IT band, vastus lateralis and her right SI pain.

The final key component to maintain this improved joint centration is to have the client continue the isometrics at home. The goal is to regain coordination and stability within the weak and inhibited muscles. We also talked about changing her stance at work. I am happy to report that after two sessions and her diligence with her home exercises, it has allowed her to go back to running without having knee pain. Her workout partner no longer has to hold her hips in place; she can squat properly on her on. She now comes in to my office for an occasional tweak here and there.

An unknown author said, "Forget all the reasons why it won't work and believe the one reason why it will." When we do our homework, study and properly evaluate the human kinetic chain, this will and does raise the bar on our percentage of success even after surgery.

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