Thursday, January 28, 2010

Cyriax Traction Recommendations

Traction can be used
1. as an adjunct
2. as a independent modality to treat

Traction as an adjunct treatment

Gentle forcing at almost any joint is tolerated well if the move¬ment is carried out during traction. However, traction as an adjuvant therapy can affect in the following ways

1. An attempt to reduce an intra-articular dis¬placement is much more likely to succeed if the bone-ends are brought apart as far as possible. This is because the loose fragment is now given room to move.
2. If the intra-articular dis¬placement projects beyond the articular edge, the tautening of the ligaments joining the bones during the traction exerts beneficial centripetal force on he fragment.
3. Distraction produces a suction which also exerts beneficial centripetal force on the fragment.
4. If the joint is held at mid-range during traction i.e. in a position that ensures that every ligament is lax, the bones are pulled apart and pressure on the displacement ceases. Pain is thus relieved and the muscles cease to guard the joint.
5. Traction protects the spinal cord and the anterior spinal artery especially at cervical and thoracic joints. At cervical and thoracic joints traction is particularly valuable & effective.

Traction as an adjuvant therapy in OM is used n following cases:

1. Cervical and thoracic joints
2. Displaced loose body (LB) at the knee (Even that LB which cannot be shifted during anesthesia by ordinary forced movements can be affected by traction.)
3. Carpal subluxation.

Traction Alone as an independent treatment

This is used at the spinal joints and at the shoulder.

A. Traction at Spinal joints:

At the neck intermittent traction can be given by suspension. It serves to settle a protrusion already reduced more accurately in place. A Zimmer machine can be employed to ease pain in an ambu¬lant patient and to maintain reduction in cases of great instability. Sustained traction in bed is the only effective treatment for the rare small nuclear disc protrusion at a cervical level.

At the thorax, the indication is the uncommon nuclear type of disc protrusion, a disc lesion at a very kyphotic joint or one adjacent to a wedge fracture of a vertebral body.

At the lumbar spine, the position is different. These large joints are so strong that manual traction is no longer effective as an adjuvant. Moreover, nuclear protrusions are quite common at the lumbar joints, in contradistinction to cervical and thoracic levels. It is now a question of manipulation or traction—manipulation for a displaced fragment of cartilaginous annul us, traction for a soft nuclear protrusion. Traction applies continuous suction to a pulpy herniation and, unless it is too large, draws it back into place a little more each day. Hence at least thirty minutes' treatment is required daily, with between 40 and 80 kg distraction force.

B. Traction at shoulder

At the shoulder, many cases of arthritis are unsuited to forcing. They require intra-articular hydrocortisone. If this is unobtainable, the physio¬therapist's best alternative is distraction of the humeral head from the glenoid. This lasts some seconds, then is released, and repeated again many times. During the first few attempts, muscle spasm keeps the bones in contact but, after a few minutes, they are felt to come apart. Relief ensues which continues after each session ceases.

Thursday, January 21, 2010

Cervical spine problems leading to Diaphragm weakness can be a self sustaining mechanism for cervical pain

Why a musculoskeletal physiotherapist should become familiar with assessment of the respiratory muscles? (Adpoted from the original source: Thorax 1995;50:1131-1135)

1. Firstly, because dyspnoea in patients in whom no pulmonary cause can be detected may be due to respiratory muscle weakness. Even moderately severe muscle weakness may be difficult to detect clinically and, indeed, it is possible to have total paralysis of the diaphragm without life threatening consequences.
2. Secondly, because patients with clearly documented generalised neuromuscular disease usually also have respiratory muscle weakness and, for selected cases, treatment in the form of non-invasive ventilation is indicated.
3. Finally, there has recently been increased awareness that respiratory muscle weakness can be a compounding factor in other disease processes such as malnutrition and steroid therapy.

For most patients the suspicion of clinically important respiratory muscle weakness may be confirmed or excluded by simple tests that can be performed without the purchase of expensive equipment, but in some patients complex tests in a specialised laboratory are necessary.

A case study of diaphragm weakness due to cervical disc disorder

Ralph B. Cloward; Diaphragm Paralysis from Cervical Disc Lesions British Journal of Neurosurgery (1988, Vol. 2, No. 3, Pages 395-399)

An opera singer, who “made her living with her diaphragm”, developed a post-traumatic unilateral radiculopathy due to cervical disc lesions, C3 to C6. During one year of severe neck and left arm pain she gradually lost the ability to sing difficult operatic passages which brought an end to her music career. Following a three level anterior cervical decompression and fusion, the neck and arm pain was immediately relieved. One week later her voice and singing ability returned to its full strength and power permitting her to resume her activities as a vocalist. The diagnosis of paresis of the left hemi-diaphragm as part of the cervical disc syndrome was implied by postoperative retrospective inference.

Diaphragm weakness: a cause of neck pain (A proposed mechanism by the author of this blog article)

1. Weakness of diaphragm due to cervical spine dysfunction
2. Accessory muscles recruitment to compensate diaphragm function
3. Accessory muscle recruitment alter the biomechanics of the cervical area
4. Cervical pain becomes self perpetuating due to diaphragm’s impaired respiratory mechanism
5. Local treatment of cervical spine + diaphragm strengthening should be the forte of the treatment.

The common clinical methods are: There are several clinical & laboratory tests one can go through them from the following journals:

1. Physical Therapy / Volume 75. Nuinber 11 / November 1995
2. Thorax 1995;50:1131-1135

How to know that Accessory muscles of respiration are compensating for Diaphragm? & How do you do a respiratory muscle strength assessment from observation?

See the figures above.

In a typical pattern called “apical” breathing, a tense pattern of breathing, in which the diaphragm muscle is, used less, while the neck and shoulder muscles are primarily relied on for respiration. Apical breathing recruits the upper trapezius, levator scapula, scalenes and sternocleidomastoid muscles for every breath taken. Repercussions of this type of breathing can be decreased oxygen intake and tightened, and thus shortened, neck and shoulder muscles. As Physiotherapists are aware, these tightened muscles can lead to temple headaches, upper back, neck and shoulder pain, and the emotional state of carrying the world’s stresses upon one’s shoulders.

“Diaphragmatic breathing is inherently relaxing. Without this diaphragmatic practice apical breathers will go to bed with tense neck muscles, and then spend all night using their neck muscles to breathe, rather than relax and recover from the stresses and strains of the day.”

Hoover's Sign and Recruitment of Accessory Muscles of the Neck
Patients with severe chronic obstructive pulmonary disease who have high degrees of hyperinflation can have diaphragms that become flattened such that the muscle fibers that normally run parallel to the rib cage in the zone of apposition run transversely inward across the costal margins. Contraction of these muscles can result in a net reduction in the transverse diameter of the rib cage, which is called Hoover's sign.

These patients generally must resort to accessory muscles of inspiration and depend on lifting the anterior chest wall with the neck muscles ("pump handle motion") for rib cage expansion. The neck muscles, particularly the Sternocleidomastoid and scalenus muscles, become grossly hypertrophied, and the patients learn to lean forward to support their upper girdle while standing. This compensatory maneuver enables them to more effectively use these muscles.

Therapeutic Solution- Teaching the diaphragmatic breathing:

Strengthening muscles that normally receive little attention can make a monumental impact on your client’s health. One of our forgotten, yet essential, muscles is the diaphragm. The diaphragm is the large muscle just posterior to the rib cage that is used for respiration, and it is often disregarded as an involuntary muscle.
Learning to use the diaphragm for respiration can add a great deal of benefit to the health of your apical breathing clients. Strengthening the actual diaphragm muscle can effectively break the apical breathing habit.

Restoration of normal abdominal (diaphragmatic) breathing can be accomplished by coaching your clients to engage their diaphragm. Have your client in a supine position while he/she places one hand on his/her belly (below the umbilicus), and one hand on his/her chest. Upon inhalation, have your client focus on belly expansion by being aware of the belly hand rising. Inhalation continues until he/she feels movement of the other hand on his/her chest. During the exhale, have your client focus on belly deflation, with that hand sinking towards the spine. This exercise can help strengthen diaphragmatic breathing. However, it may not be enough to break the cycle of apical breathing. Many apical breathers have difficulty learning to use their diaphragm (and thus strengthen it), or they forget about breathing into their belly when under stress.

Monday, January 18, 2010

Posture – Respiratory Interaction: Role of Diaphragm on spine stabilization mechanism

Several findings provide support for the proposed relationship between diaphragm EMG and postural control of trunk stability.

Anatomy of Diaphragm:

The diaphragmatic musculature and its fasciae imparts crucial function of respiration & postural control. The diaphragm is divided into 3 parts on the basis of these muscle fiber origins:

1. Sternal part: two muscular slips from the back of the xiphoid process.
2. Costal part: the inner surfaces of the cartilages and adjacent portions of the lower six ribs on either side, interdigitating with the Transversus abdominis.
3. Lumbar part: aponeurotic arches, named the lumbocostal arches, and from the lumbar vertebrae by two pillars or crura. There are two lumbocostal arches, a medial and a lateral, on either side.
The diaphragm is innervated by the phrenic nerve. It's a branch of C3,C4,and C5.

Crura and central tendon: At their origins the crura are tendinous in structure, and blend with the anterior longitudinal ligament of the vertebral column.The central tendon of the diaphragm is a thin but strong aponeurosis situated near the center of the vault formed by the muscle, but somewhat closer to the front than to the back of the thorax, so that the posterior muscular fibers are the longer.

Structurally the diaphragm can be compared to a round dome tent. All of the fibers originate from the ground, where the tent is staked down. The stakes in front are the xyphoid process, those in back are the lumbar vertebrae. The posterolateral stakes are the arcuate ligaments, while the anterolateral stakes are the ribs. They all insert into the central tendon, which is the top of the tent where everything comes together.

Important parts of diaphragm are:

1. Right crus: takes origin from L1-L3. It splits to enclose the esophagus, so the esophageal hiatus is (usually) entirely formed by the right crus. Fibers from the right crus intermingle with the fibers from the left crus at the aortic hiatus. (Latin, crus = resembling leg or legs)
2. Left crus: takes origin from L1-L2. It is smaller and shorter than the right crus. It sometimes contributes something to the esophageal hiatus. Fibers from the left crus intermingle with the fibers from the right crus at the aortic hiatus. (Latin, crus = resembling leg or legs)
3. Medial arcuate ligaments: thickening of psoas major fascia. Fibers taking origin from here, along with those from the lateral arcuate ligament, fill in the "gap" between the crura and the costal part of the diaphragm. They are labeled "medial lumbocostal arches" above. (Latin, arcuare = to bend like a bow)
4. Lateral arcuate ligaments: thickening of the quadratus lumborum fascia. Fibers taking origin from here, along with those from the medial arcuate ligament, fill in the "gap" between the crura and the costal part of the diaphragm. They are labeled "lateral lumbocostal arches" above. (Latin, arcuare = to bend like a bow)

Intra-thoracic & Intra-abdominal pressure changes during the diaphragm movement

The diaphragm is the primary muscle of respiration. Contraction of the fibers pulls the central tendon inferiorly, increasing the volume (and decreasing the pressure) of the thoracic cavity. This creates a pressure gradient between the inside and the outside, air rushes in to compensate. Secondary to this, the volume of the abdominal cavity is decreased, raising its pressure. During defecation or parturition diaphragm assist the abdominal wall muscles.

The diaphragm & Tr abdominis synergy:

Under normal condition diaphragm and transversus abdominis are antagonists. However, diaphragm contracts eccentrically, following the contraction of transversus abdominis and the other muscles acting on the abdomen (e.g. pelvic floor muscles). But, the length changes in either direction were relatively small, approximately 10% of initial diaphragm length (2).

Studies of trunk muscle recruitment in humans suggest that diaphragm and transversus abdominis activity, and the associated intra-abdominal pressure (IAP) contribute to the control of intervertebral motion. Elevated intra-abdominal pressure and contraction of diaphragm and transversus abdominis provide a mechanical contribution to the control of spinal intervertebral stiffness. Furthermore, the effect is modified by their muscular attachments to the spine (1).

The diaphragm & limb movement relation:

Contraction of the diaphragm precedes the onset of movement of the limb & it is hypothesized that this is a preparatory action to aid truncal stability. Diaphragmatic response requires a threshold magnitude of reactive forces resulting from the movement because studies have reported no diaphragmatic contraction with movement of the wrist, fingers or thumb while it did occur with shoulder and elbow movement.

An increase in IAP associated with arm movement is predominantly due to the contraction of the diaphragm and abdominal muscles. The diaphragm shorten initially consistent with an increase in activation but then lengthened as abdominal pressure rose.

How diaphragm controls the trunk stability:

1. Diaphragm controls the trunk stability indirectly via IAP (intra abdominal pressure): The diaphragm cannot move the trunk directly to oppose these forces, but it has been proposed that its contraction contributes to trunk stability via an increase in pressure in the abdominal cavity.

Intra-abdominal pressure mechanism for stabilizing the lumbar spine: According to a model proposed by Cholewicki & colleagues (1999) 2 distinct mechanisms were simulated separately and in combination to provide lumbar stability.

a. One was antagonistic flexor extensor muscle coactivation and
b. The second was abdominal muscle activation along with generation of IAP.

Both mechanisms were effective in stabilizing the lumbar spine. The critical load and therefore the stability of the spine increase with either increased antagonistic muscle coactivation forces or increased IAP along with increased abdominal force. Both mechanisms were also effective in providing mechanical stability to the spine when activated simultaneously.

However this model suggests that the IAP mechanism for stabilizing the lumbar spine appears preferable in tasks that demand trunk extensor moment such as lifting or jumping. This mechanism can increase spine stability without the additional coactivation of erector spinae muscles.

2. Diaphragm controls the trunk stability by maintaining the geometry of the abdominal muscles:
Diaphragmatic contraction could increase stability of the trunk by minimizing displacement of abdominal contents into the thorax, thus maintaining the hoop-like geometry of the abdominal muscles. These muscles could then increase spinal stability via tension in the thoraco-lumbar fascia (Farfan, 1973; McGill & Norman, 1987; Tesh et al. 1987).

3. Although previous animal studies have proposed that the costal and crural portions of the diaphragm may function independently (De Troyer, Sampson, Sigrist & Macklem, 1981; van Lunteren, Haxhiu, Cherniack & Goldman, 1985), the co-activation of the costal and crural portions of the diaphragm suggests that both regions of the diaphragm function together for their role in postural control.

The neural circuit for postural control via diaphragm:

Two previous human studies have provided indirect evidence of a contribution of the diaphragm to postural control.

1. Studies in decerebrate animals ware done for finding evidence of a postural role of the diaphragm. In this procedure evaluation of the response of the diaphragm to stimulation of the cerebellum (Massion et al. 1960) and stimulation of tonic cervicolabyrinthine postural reflexes (Massion, 1976), ware done.

It was found that the response in the diaphragm are preprogrammed by the CNS and initiated as part of the motor command for movement (Cordo & Nashner, 1982; Horak, Esselman, Anderson & Lynch, 1984; Bouisset & Zattara, 1987).

2. The phrenic motoneurone pool may be influenced by corticospinal pathways that do not involve pontomedullary respiratory centres both in animals (Colle & Massion, 1958; Planche & Bianche, 1972) and humans (Gandevia & Rothwell, 1987).

3. Diaphragm is activated via pathways involved in the control of postural activity associated with limb movement.

4. Co-activation of the diaphragm and transversus abdominis who have normal antagonistic function in respiration suggests that neural outputs other than those from 'classical' respiratory centres are likely to be involved in control of diaphragm movement.

5. Studies have shown that there is increase in EMG of the diaphragm which preced the onset of deltoid EMG regardless of the phase of respiration. This provides evidence that the postural function of the diaphragm interferes with the respiratory activity of this muscle.

Excluding diaphragm other respiratory muscles such as the intercostal muscles have been identified to have variation in respiratory activity due to postural changes (Rimmer et al. 1995). Contrastingly, variation in postural activity of the abdominal muscles also occurs due to changes in respiratory activity (Hodges et al. 1997).

Diaphragmatic strengthening exercises (source:

Diaphragm strengthening is recommended for all patients with less than normal vital capacity. Patients with lower thoracic or lumbar lesions and a fair or better grade of diaphragm strength are usually candidates for progressive resistive exercises until they regain full activity. Patients with cervical and high thoracic lesions and a less than fair grade of diaphragm strength are usually candidates for active-assistive exercises.

1. Progressive Resistive Exercises, with weights, manually, with positioning, and incentive inspiratory spriometry, for example, should allow the diaphragm to contract through its full range, to prevent altering the patient's normal breathing pattern, and should be done carefully to prevent fatiguing the diaphragm, with the patient in a lying position:

Weights - After the placing the patient in supine, the therapist places a diaphragm weight pan over the epigastric region, without the pan resting on the ribs which can prevent full excursion. The amount of weight used as resistance should allow the epigastric rise to be the same as before the weight is applied. If the diaphragm is innervated, 5 pound weights can usually be used at first. When the patient can maintain a coordinated, unaltered breathing pattern for 15 minutes, with full epigastric rise and without substituting the sternocleidomastoid muscles, the weight can be increased until the patient's strength reaches an acceptable plateau, such as vital capacity remaining the same in a subsequent evaluation, or the patient being able to tolerate full activity with early signs of fatigue.

Manually - As inspiratory capacity increases, the therapist can apply manual resistance while the patient breathes deeply. If the intercostal musculature is functional, the therapist can provide manual, visual, or verbal feedback on chest motions during inspiration to increase the ventilation of isolated lobes.

Positioning - Since resistance to the diaphragm provided by abdominal contents increases in the head-down position, resistive strengthening can be achieved by changing the patient's position. For example, a 15-degrees head-down incline supplies a resistive force equal to 10 pounds.

Incentive Spirometry - After placing the patient in the preferable supine position (the weaker the diaphragm, the greater the necessary incline), the therapist has the patient take 4 slow, easy breaths. Expiration after the first 3 breaths should be normal, but, after the 4th breath, the patient should exhale slowly until there is no more air to exhale. The patient then places the spirometer in the mouth, forms a tight seal, takes a slow, deep breath, watches the ball in the spirometer rise, maintains the rise as long as possible, removes the spirometer mouthpiece, and relaxes. This should be repeated 8-10 times and done during 3-4 sessions each day.

2. Active-Assistive Exercises are done with active-assistive devices, such as pneumobelts and corsets, after the patient with poor diaphragm strength begins to sit.

Pneumobelts - Also called exhalation belts, pneumobelts are used for patients with an initial vital capacity between 500 and 1000 cc in an upright position. They have inflatable bladders, placed over the abdomen, and connected, with a hose, to an easily adjustable positive pressure respirator. As the bladder is inflated, it pushes the abdominal contents in and up, which push the diaphragm into the optimal position for exhalation. When the patient has been upright and on an active program for 8 hours, with no signs of fatigue and/or sternocleidomastoid muscle substitution, the patient can begin to be phased off the pneumobelt, by decreasing the pressure in the bladder, first while the patient is inactive, and then while he/she is active.

Corsets - Corsets are used for patients with weak, or "less than fair" abdominal musculature, whose diaphragms therefore are in a descended position, which causes a decrease in inspiratory reserve volume. Corsets are placed just over the last two floating ribs and covering the iliac crest. They should be snug (but not too tight) to support the abdomen and displace the diaphragm to a higher resting position, with the lower buckles tighter than the upper ones. A hand should be able to be placed under the upper part of the corset. Blood pressure and heart rate should be carefully monitored for hypotension and blood pooling. If diaphragm strength improves or abdominal tone increases enough to adequately support the abdominal contents, the corset can be discontinued after the patient's vital capacity, breathing pattern, and vital signs (with the body positioned at a 45 degree incline and the head up) test the same with, and without, the corset.


1. Cholewicki J; Intra-abdominal pressure mechanism for stabilizing the lumbar spine .J Biomech. 1999 Jan;32(1):13-7.
2. Hodges P et al; Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies.Spine (Phila Pa 1976). 2003 Dec 1;28(23):2594-601.
3. Hodges P et al; Contraction of the human diaphragm during rapid postural adjustments. Journal of Physiology (1997), 505.2, pp.539-548

Monday, January 11, 2010

Why the quack "bone-setter" is able to flourish so exceedingly?

In my opinion the entire medical fraternity is to be blamed for it. Speaking generally, it may be said that the "bone-setter" flourishes not because people suffer injury, but on account of the treatment they receive.

A traditional bone setter’s friends & foes:

1. The doctrine of fixation, rest and splintage is his (traditional bone setter) great ally.
2. His (traditional bone setter) enemy is the treatment of recent injury by mobilisation.

How far traditional bone setters will sustain?

According to Dr.Mannell - until the time the old teaching of absolute and prolonged rest after injury is replaced with combination of justified rest with early mobilisation, the type of disability which fills the "bone-setter's" rooms will never decrease and hence they will flourish.

Sunday, January 10, 2010

Ankle joint biomechanical pearls

Ankle joint = tibio-talar joint, permits DF & PF

Dorsiflexion (DF) is performed by the tibialis anterior , EHL,EDL,and peroneus tertius.

DF limited by the tension of the tendocalcaneus , the posterior fibers of the medial ligament and the calcaneofibular ligament.
During dorsiflexion the wider anterior part of the articular surface of the talus is forced between the medial & lateral malleolus, causing them to separate slightly & tighten the ligaments of the distal tibiofibular joint.
This arrangement increases the stability of the ankle joint when the foot is in the initial position for major thrusting movements in running , jumping and walk .

Plantar flexion is performed by the gastrocnemius, soleus,plantaris, peroneus longus & brevis , tibialis posterior, flexor digitorum longus and flexor hallucis longus

It is limited by the tension of the opposing muscles , the anterior fibers of the medial ligament and the anterior talofibular ligament .

When the ankle is fully plantar flexed, the ligaments of the distal tibiofibular joint are less taut and small amounts of rotation , abduction & adduction are possible.

Tarsal joints that produce Inversion & eversion

1- Subtalar joint
It is between the inferior surface of the body of the talus and the facet on the middle of the upper surface of the calcaneum.
2- Talocalcaneonavicular joint
It is between the rounded head of the talus , the upper surface of the sustentaculum tali and the posterior concave surface of the navicular bone.
3- Calcaneocuboid joint
It is between the anterior end of the calcaneum & the posterior surface of the cuboid .
The talocalcaneonavicular & calcaneo-cuboid joints are together referred as midtarsal or transverse tarsal joints .
N.B. The inversion & eversion movements take place at the 3 previous joints.

Friday, January 8, 2010

The lateral ankle joint

Bony Anatomy

• Curved trochlear surface of talus produces a cone-shaped articulation whose apex is directed medially; thus the fan-shaped deltoid is all that is needed for support medially
• A larger area of movement and the subtalar joint articulation laterally dictates more soft tissue involvement to produce stability, thus, more commonly injured

Anatomy of Ligaments

• The lateral ligaments should include not only the ATFL, CFL, and PTFL of the tibiotalar joint, but should also include the subtalar joint which is supported by the CFL, inferior extensor retinaculum, the lateral talocalcaneal ligament, the cervical ligament, and the interosseous talocalcaneal ligament
• Note: the CFL is included in both these joints and is crucial to the proper biomechanics of both joints
• ATFL - originates at the distal anterior fibula and inserts on the body of the talus just anterior to the articular facet (not unto the talar neck). ATFL - Makes an angle of approximately 75° with the floor from its fibular origin
• PTFL - originates from the medial surface of the lateral malleolus and courses medially in a horizontal manner to nearly the entire posterior lip of the talus
• CFL - originates from the anterior border of the distal lateral malleolus just below the origin of the ATFL and courses medially, posteriorly, and inferiorly from its fibular origin. It’s attachment on the calcaneus blends with the peroneal tendon sheath and inserts on a small tubercle posterior and superior to the the peroneal tubercle. It runs approximately 10° to 45° posterior to the line of the longitudinal axis of the fibula
• Burks and Morgan showed ATFL and CFL had adjacent attachments on the anterior distal fibula 8 to 10 mm from the tip
• Inferior extensor retinaculum is composed of 3 (lateral , intermediate, and medial); the CFL, LTCL, and the lateral root constitutes the superficial ligamentous support of the subtalar joint
• Lateral talocalcaneal ligament- originates from the lateral wall of the calcaneus just anterior to the calcaneal origin of the CFL and inserts on the body of the talus just inferior to the ATFL. This often blends with the CFL and ATFL (arcuate type)
• Cervical ligament- lies in the sinus tarsi and connects the neck of the talus to the superior surface of the calcaneus
• Interosseous talocalcaneal ligament – located at the most medial aspect of the sinus tarsi and extends from a ridge at the sulcus tali
• The angle of CFL and ATFL in the sagittal plane averages 105°; this is clinically important in both the etiology of instability and for reconstruction
• Passing from dorsiflexion to plantarflexion causes a moment in time in which there may be decreased stability
• At 105° this is unusual, however, with an anatomical variant that displays a larger angle, there may be a larger interval of vulnerablity

Biomechanics of Ligaments

• CFL is parallel to the subtalar joint axis in the sagittal plane; as the ankle is dorsi and plantar flexed, CFL and subtalar relationship does not change
• CFL is designed to allow motion in two joints simultaneously
• Neutral position, CFL is angulated posteriorly; in dorsiflexion it is brought in line with the fibula and becomes a true collateral ligament
• CFL in plantar flexion becomes parallel with the ground, and thus provides little support with resisting inversion
• ATFL is in line with fibula when the ankle is plantar flexed: collateral ligament
• ATFL in dorsiflexion positions the ligament horizontal to the ground and provides little resistance to inversion

Biomechanics of Ligaments can be studied under

1. Relationship in neutral
2. Relationship in plantarflexion
3. Relationship in Dorsiflexion

• PTFL is maximally stressed in dorsiflexion and prevents external rotation in dorsiflexion
• Attarin et al. ATFL has a lower load to failure than the CFL (CFL 2-3.5 times greater)
• However, the ATFL is capable of undergoing greater strain which allows for the internal rotation of the talus during plantar flexion
• The ATFL inhibits internal rotation primarily; in plantar flexion it also prevents adduction
• CFL prohibits adduction and acts almost independently in the neutral and dorsiflexed positions. In plantar flexion it prevents adduction in conjunction with the ATFL

Biomechanics in Injury

• Forced dorsiflexion, PTFL ruptures
• Forced internal rotation ATFL ruptures followed by injury to the PTFL
• Extreme external rotation produces disruption of the deep deltoid lig.
• Adduction forces in neutral and dorsiflexion positions cause disruption of the CFL whereas in plantar flexion the ATFL is primarily injured
• Kjaersgaard-Anderson et al. – cutting of CFL increased talocalcaneal rotation by 20% and increased tibiotalar adduction by 61%-77%

Biomechanics: Subtalar motion

• Allows the leg to undergo an additional amount of internal and external rotation
• Joint moves around a single inclined axis and functions essentially like a hinge connecting the talus and calcaneus
• The axis in the transverse plane deviates approx. 23° medial to long axis of foot, and in the horizontal plane, the axis is approx. 41° to the floor
• CFL and subtalar joint relationship: subtalar deviates from medial to lateral as it passes from dorsal to plantar direction
• Axis is defined from head of talus to lateral calcaneus, and forms a cone shape motion with its apex intersecting with the calcaneal attachment site of the CFL
• This cone shape arc and the position of the CFL allows unrestricted motion of the ankle and subtalar joint
• Two boards attached with a 45° hinge illustrates a one to one relationship of torque.
• A more horizontal hinge creates more rotation of the horizontal member (acts much like a torque converter)
• To prevent the horizontal member from participating in the displacement, it can be divided into 2 members: a short proximal segment and long distal segment
• The distal segment remains stationary by pivoting with the short segment (the transverse tarsal joint): this short segment acts just like the subtalar joint
• Conversion of the distal segment into rays will create an anatomical foot model where external rotation of the leg causes inversion of the heel, elevation of the medial side of foot, and depression of lateral side.
• Clinical: Patients with pes planus have a more horizontal subtalar joint so that with little leg rotation, they have more supination and pronation

Epidemiology of injuries

• Acute sprains account for 16%-21% for all athletic injuries
• Lateral injuries account for 85% of all ankle sprains
• 10%-30% of all acute sprains result in chronic symptomatology
• Instability can be thought of in two ways: functional and mechanical
• Functional = subjective complaint with proprioceptive disorder that is rehab able
• Mechanical = objective instability that is determined by anterior drawer and talar tilt stress tests and often requires surgical intervention
• O’Donaghue classification most commonly used: Grade I, II, III

Examining the part

• Anterior drawer test- performed in relaxed plantar flexion
• Talar tilt test performed in neutral with hindfoot locked
• Freeman described modified Romberg’s test performed on injured and uninjured leg (positive = proprioceptive defects, rehab)
Telos stress test:
a. anterior draw > 10mm and talar tilt > 9°.
b. difference of anterior drawer of symptomatic ankle from asymptomatic should be > 3mm.
c. difference between talar tilt of symptomatic versus asymptomatic should be > 3°. Karlsson et al. found > 90% sensitivity, specificity, and predictive values with above criteria

What happens if the relaxation is not maintained during the passive movement?

1. In the absence of relaxation the movement of the joint is forced, and therefore strain is placed upon it. The result is that any synovitis or other pathological condition is perpetuated or increased.
2. There is great danger of inflicting further injury on the already damaged structures, so that adhesions of greater density and strength will ultimately form.
3. Repair is retarded owing to undue strain on the structures that are undergoing repair.
4. The muscles are strained, and possibly even torn, in their vain attempt to resist the movement.
5. The circulation of the venous blood and of the lymph may be assisted, but extravasation will be increased; and
6. The disorganisation of the vaso-motor system is increased as the result of repetition of trauma, and so oedema increases in proportion as repair decreases.
7. The joint-sense is outraged by repeated trauma, and all power of co-ordination is thereby destroyed.

Thursday, January 7, 2010

Reflex Action of Massage.

A. In Massage of the Limbs. Massage is a form of surface stimulation that can produce a muscular contraction by reflex; antagonistically it can also secure muscle relaxation. We invoke instinctively the aid of massage for its mechanical effect in day to day activity, for example rub our eyes hard to reduce intra-ocular tension, or press upon temple or forehead after a day of great fatigue.
B. In Massage for Diseases of the Nervous System -In the treatment of an irritable neurasthenic, the victim of insomnia.
C. In Abdominal Massage- According to Kleen mechanical stimulation of abdomen does not produce chemical stimulation in producing, secretion of active digestive juices.
It is possible that by mechanical means we can help empty a dilated stomach, and we can certainly assist in the softening and molding of scybala, in those very exceptional cases where they are palpable, and therefore amenable to manipulation. In this event we can also assist their passage along the bowel. However during general abdominal massage we must rely in the main on the reflex response to mechanical stimulation of the unstriped muscle to hasten the onflow of the contents of the bowel.
Other examples of reflex action of abdominal massage:
1. A certain stimulation of the skin over the abdomen can be shown to originate peristaltic movement in the stomach.
2. Stimulation of the skin round the spine of the fifth thoracic vertebra causes the pyloric sphincter to relax. Similar stimulation round the seventh cervical spine has the opposite effect.
3. The reflex contraction of the muscle in the rectum in response to sacral beating and to hacking over the left sciatic nerve where it emerges from the cover of the great sacro-sciatic notch.
4. It is possible that other abdominal organs can be influenced by reflex, e.g., the unstriped muscle of the spleen may contract in response to mechanical stimulation transmitted from the ribs, or applied to the organ itself if it is enlarged.
5. Professor Wide, of Stockholm, has shown by means of a blood-count, before and after treatment, that the number of red corpuscles in the blood is increased by abdominal massage. This, together with the general toning up of the vascular system, must re-act indirectly on all the abdominal organs.
6. The uterus is the abdominal organ to which massage treatment is very frequently applied. The reflex response to mechanical stimulation of the unstriped uterine muscle is a well-known aid to parturition.
7. The use of massage for stimulation of the heart is recognized in surgery, and it is performed in emergency by the "abdominal route." Reflex response by contraction to mechanical stimulation is thus more readily assured. It has been claimed that tapotement over the chest has the effect of lowering the rate of the heart-beat. This presumably is due to reflex action on the vagus.
Whenever massage treatment is ordered it is necessary to take the age of the patient into consideration, and more particularly when we are aiming solely to secure a reflex action. The reflex arc in the child is highly sensitive, and the fullest effect is thus secured rapidly. In the aged it is possible to cause fatigue with equal rapidity, and treatment then produces an irritative effect. In the young, therefore, and in the aged the duration of massage treatment should be curtailed.

Wednesday, January 6, 2010

Mannell’s Concept

An introduction to Mannel

Dr.James Mannell’s name is associated among the pioneers of physical therapeutics applied in modern medicine. James Mannell was a qualified medicine specialist & physician. First book of Mannell’s concept emerged in 1920 as a result of twelve years' experience of massage and its allied arts, and effects of treatment of six thousand medical cases of fracture. The book was named massage-its principles and practice which was forwarded by Dr. Robert Jones, then the major general of army medical services of United Kingdom.

The early experiences of James mannell was modified by following findings:

1. Positive out comes of effects of "early movement" on post-immobilization stiffness.

2. Effect of simple manual handling providing distraction at a particular joint (that was stiff post-fracture-immobilization) which seemed like a massage can attend joint mobility painlessly and without any attempt at force that are attained by the exercise of considerable force, and at the expense of much pain to the patient.

3. As a clinical assistant in the physical exercise department of St. Thomas' hospital he distinctly categorized physical treatments & massage into two distinct processes: one applicable to recent injury and the other to all cases not coming under this head.

4. Not hurting a patient by the treatment intended to cure: In the earliest part of his carrier while Dr mannell was in Paris to study with Championniere told him the mantra of a very successful medical masseur Anathema "I never hurt a patient!" through your therapies. That was all, but it started a new line of thought in Dr Mannell.

Sunday, January 3, 2010

2 cases that lead to rule of nerves & invention of chirpractice- Oh my GOD!!

Chiropractic was invented by a non-medico named DD palmer of USA. The literal meaning of chiropractic is "by hand". Hence treatment by hand is called chiropractic. treatment We in India never got to know what is chiropractic treatment? Yesterday i was preparing to teach my students "history of manual therapy", i happen to come across the following in classic encyclopedia(1911) & Wikipedia.

Read it & wonder (also feel for simon singh, UK who was sued for defaming chiropractic)

Rule of Nerves by DD Palmer

Palmer hypothesized that vertebral joint misalignments, which he termed vertebral subluxations ( his type of subluxations can not be seen on X-rays or such investigations) interfered with the body's function and its inborn (innate) ability to heal itself.

D.D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic. This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine from conventional medicine.

1st case & 2nd case that lead to the theory of nerves & invention of chiropractic treatment

1st case: DD Palmer unknowing slapped Harvey Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better who was suffering from a hearing problem. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice.

Controversy about whether a link actually could exist between the spinal adjustment and return of hearing. Critics asserted that a spinal adjustment cannot affect certain areas - like the brain - because the spinal nerves do not extend into the encephalon. Years later, V. Strang, D.C. illustrated several neurological explanations including the recognition that sympathetic nerves arising in the lateral horns of the upper thoracic levels of the spine form the upper cervical ganglion with postganglionic fibers ascending to supply, among other things, blood vessels of the brain, but still with no connection to hearing.

2nd case in DD palmer's words: "I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I adjusted the vertebra and gave immediate relief — nothing "accidental" or "crude" about this. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time."

i was beathless to read the whole article which was much bigger than what i have presented here. After regaining my breath the first thing that i could utter is OH MY GOD............................

Friday, January 1, 2010

Revisiting what Dr ATStill said in 1874- It sounds valid to me !!!

The Rule of Artery by AT still

Early osteopathy teaches that

1. Structural derangement (SD) of the body is the predisposing cause of disease
2. SD causes functional distortion (FD) of the vascular and nervous systems
3. Which further leads to
a. Weakening the nutritional processes and lowering the powers of resistance of the body
b. Production of congestion, either general or local, active or passive further depriving tissues of an adequate blood and lymph supply
c. impairs the rebuilding of cells and retards the elimination of waste products through body drainage
4. As drainage & elimination are affected, body is unable to withstand climatic changes or unhygienic and unsanitary surroundings, and offering a open medium for the invasion and propagation of pathogenic germs.

Dr. Still, the founder of osteopathy, said, "A disturbed artery marks the beginning to the hour and minute when disease begins to sow its seeds of destruction in the human body. The rule of the artery must be absolute, universal and unobstructed, or disease will be the result."

Classic encyclopedia, 1911