resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
The Importance of Staying Focused
Our world is so full of over stimulation and constant information. We live in a fast paced, ever-changing society. If you seek you will receive.
The Urinary Bladder Official
The Bladder Official is known as the Official Who Controls the Storage of Water. In Western medical terms, this organ collects the urine excreted by the kidneys.
Eucommia Bark Helps Maintain Strong Bones
Eucommia bark is a major tonic herb used in Asia, and now throughout the world, that supports and helps mend the skeletal structure and its related tissues. Eucommia bark is collected from Eucommia ulmoides trees that are more than 10 years old.
News in Brief
Patriot Project: Serving Those Who Served; CTCA Chiropractor Receives Clinical Innovation Award.
Qigong to Empower Our Youth
Qigong is an ancient form of exercise and meditation used to promote longevity and health. This practice has traditionally been used by adults to balance the body through mindfulness, focused breathing and gentle movements.
Weighing in on Weight Loss
If your practice trends anything like the U.S. population, you are probably noticing over two-thirds of your patients could benefit from weight reduction, particularly if their main complaints include chronic back or joint pain.
Gaining an Independent Occupational Code with the U.S. Bureau of Labor Statistics
One of the most important national activities currently taking place in relation to the development of the field of AOM profession is the Department of Labor's Bureau of Labor Statistics' (BLS) revision of the 2010 Standard Occupational Classification (SOC) system.
Peer Points: Spreading The Word
Pedram Shojai describes his venture into Traditional Chinese Medicine as a journey led by various "mystical experiences." Shojai decided to change the course of his career when he looked deeper into the basics of TCM.
Using Facial and Scalp Acupuncture To Treat Neuromuscular Facial Conditions
As a practitioner and instructor of facial rejuvenation acupuncture I have gotten many calls over the past 10 years from individuals seeking help for various conditions affecting the facial muscles, nerves, and overall function of the face.
Don't Believe It
One of our staff came into my office last week, very concerned about an article she had just read on a news media website. The article suggested researchers found "no health benefits" associated with taking multivitamins.
Ever Heard of the Lateral Raphé?
We have all had acute patients enter our offices listing laterally to the side at the level of the lumbar spine or expressing pain on lateral lumbar bending.
Embracing the Light
Four years, ago I was diagnosed with a labral tear in my hip that was excruciating and "required surgery" according to an orthopedic surgeon. I tried everything and although the symptoms had mostly abated, I had to give up Yoga practice and everything that could exacerbate the tear.
Giving Testosterone Levels a Boost (Part 3)
Since testosterone and insulin status are inversely correlated, it's important to keep insulin low so testosterone will remain high.
The Deficiency Myth
If you went to the same kind of medical school I did and took the same kind of licensing exam I took, you were trained to seek out and expect to find primary deficiencies here in the U.S.
VA Names Sites for Pilot Chiropractic Residency Program
The Veterans Administration has announced the five VA medical facilities that will serve as initial sites for the administration's recently established pilot chiropractic residency program.
Asymmetrical Pronation: Effect on Adjustments
When your patients don't respond as well as expected to their chiropractic adjustments, oftentimes there is a source of interference in the pedal foundation – asymmetrical pronation.
Common Disorders of the Temporomandibular Joint
The evaluation and management of craniofacial pain is a complex endeavor, which often encompasses the presence of temporomandibular joint disorders.
Preserving the Natural Resources and Culture of Chinese Herbal Medicine
As the world experiences unprecedented population growth and ever-increasing ecological pressures, the topic of preserving Chinese medicine's natural resources has attracted steadily increasing attention from practitioners.
The Power of Words: DCs Share Drug-Free Approach
There's no doubt that words are powerful and important – especially in the chiropractic profession, where we have been struggling for years to find the right words to describe who we are and what we do.
Grape Seed Extract: A Multifaceted Herb for Promoting Healthy Circulation
One of my favorite herbs is grape seed. Modern research has identified some intriguing health benefits attributable to the seed of this ancient fruit. I particularly use grape seed as an extract standardized for OPCs (oligomeric procyanidins).
Managing Hallux Hypomobility Disorders (Part 2)
In part one of this series we discussed the unique properties and significance of the first toe in the propulsive phase of gait. In particular, we discussed the importance of the first metatarsophalangeal joint (MPJ).
Gallop Confidently Into The New Year
Happy New Year! As you may know, this is the year of the Wooden Horse. I received a wonderful gift for Christmas. It is a beautiful glass sculpture of a horse, by Luili Gong Fong, a Chinese artist.
Diagnosing Flexion-Intolerant Lower Back Pain (Part 2): Exercise Rehab
One of the things that has puzzled us for years is the presentation of the flexion-intolerant patient. We have realized there is a large overlap with sacroiliac indicators. In acute lumbar pain, the SI often twists, subluxes, goes haywire.
An Alternate Method For Choosing The Right Formula For Your Patients
A constant question for us in the clinic is when to make adjustments and when to stay the course. A patient comes in and says, "Things are the same as last week."
November, 2012, Vol. 12, Issue 11
The Peroneals: Anatomy and Function
By Nicole Nelson
The peroneals are a fascinating group of muscles which largely go unnoticed unless you've sprained your ankle. Many of us have two peroneal muscles, some of us have three: Peroneus longus, peroneus brevis, and the occasional individual has peroneus tertius.Peroneus Longus is responsible for everting the foot and helps with plantar flexion of the ankle (think bringing the outside of your foot off the ground while pointing your toes. This muscle attaches proximally on the upper fibula and wraps behind lateral malleolus (aka ankle), continues along the underside of the foot where it attaches distally on the first metatarsal and medial cuneiform. Peroneus brevis also everts the foot and assists in plantar flexion of the ankle. It lies deep to longus and attaches proximally at the lower portion of the fibula. Peroneus brevis wraps behind the lateral malleolus and attaches distally on the fifth metatarsal. Peroneus tertius is an everter of the foot; but unlike the other peroneal muscles, it assists in dorsiflexion of the ankle. Its proximal attachment is on the anterior distal fibula and runs anterior to the ankle, attaching distally to the 5th metatarsal.
Although the peroneals are chiefly regarded as everters of the foot, a lesser known, yet very cool fact about the peroneus longus muscle is that it helps in the stabilization of the big toe. This stabilization plays a large role in the appropriate winding of the plantar fascia during gait, known as the windlass effect. Any individual that is forced to move laterally (i.e. tennis or basketball player) places a high demand on these muscles as they act to stabilize and prevent inversion of the ankle. Running or walking on uneven surfaces such as a trail or soft sand will also challenge these muscles. When life is good, the peroneals, along with tibialis anterior and posterior, control inversion and eversion of the ankle and keep the structures of the foot and ankle out of harms way. As we all know, life isn't always good and injury results. Let's take a look at the peroneals involvement in ankle instability and go over some massage strategies that will help our clients reduce their pain possibly prevent future injury.
Ankle sprains are the most common athletic injury, with approximately 30,000 sprains per day in the U.S. (DiGiovanni et. al. 2004). Approximately 90% of these ankle injuries are inversion sprains. To make matters worse, 70% to 80% will suffer a subsequent ankle sprain (Yeung 1994). The potential for recurrent sprains is a likely consequence of structural trauma of the ligaments of the ankle, as well as decreased proprioceptive feedback and peroneal weakness (Lofvenberg et al 1995). This scenario creates the potential for chronic ankle instability and further weakening of the peroneal muscles. It seems that the feedback loop that communicates the location of the foot to the brain is off. Without this input, the brain is somewhat blinded to the local environment leaving the peroneal firing patterns ill-timed. This is problematic as the peroneals need to fire in an anticipatory manner in order to correct balance and absorb the impact of foot striking.
Now let's discuss some of the causes behind weakness of the peroneals. There are many reasons why peroneals become dysfunctional including structural anomalies of the foot and ankle, tendon subluxation, nerve entrapments and tendon tears. Given the complex nature of the ankle and foot, clients with pain in this area should be encouraged to see a physician before you begin any massage treatment. As soft tissue experts, we are looking at the fascial and muscle structures and possible nerve entrapments that may be causing peroneal issues. Vladamir Janda suggested that certain muscles have the potential to shorten and tighten (tonic muscles), while others tended to lengthen and weaken (phasic muscles). Janda's observations led him to put the peroneals in the phasic camp, suggesting that these muscles are prone to inhibition. This inhibition creates an environment of ankle instability.
On the other hand, Janda characterized the posterior tibialis, gastrocnemius and soleus muscles as tonic in nature. This imbalance of the lower leg not only destabilizes the ankle, but opens the door for other problems including plantar fasciitis, compartement syndromes, calcaneal bone spurs and achilles tendinosis. Additionally, the faulty movement patterns which result from the imbalance will create compensations that will surely travel up the kinetic chain and likely cause hip, lower back and neck issues.
Assessment and Treatment
As we all know, successful therapy begins with assessment and intake. If your client has had a history of ankle sprains and they mention discomfort around the ankle and/or along the lateral lower leg, the peroneals should be suspected as an area of issue. Let's go over a few treatment ideas for a client that has a history of ankle rolling and ankle pain.
Don't chase the pain! Given the peroneals propensity for weakness and the high percentage of inversion type sprains, I would caution against deep stripping and stretching of this group. I certainly do suggest relieving trigger points in these muscles with local compression. I would also recommend cross fiber friction to the areas that feel particularly glued down. For this work, I usually position clients in a sidelying position, with the involved leg up and bolstered. Sherrington's law of reciprocal inhibition states that a hypertonic antagonist muscle may be reflexively inhibiting it's corresponding agonist. If we consider this law in conjunction with Janda's insights, it stands to reason that most of the deep stripping should be performed on the posterior tibialis, gastrocnemius and the soleus muscles. Additionally, contract/relax methods of stretching will be helpful in normalizing these overly tightened tissues. Naturally, not everyone fits into the tonic/phasic mold outlined by Janda; therefore, each client should be assessed and evaluated for their unique set of tightness and restrictions.
Enlist the help of a corrective exercise specialist. According to DiGiovanni, the gold standard for ankle instability issues includes the RICE protocol, early range of motion, progressive weight bearing, peroneal strengthening as well as proprioceptive training (DiGiovanni et al 2006). This is supported by studies done by Holme and others. Their research reports that clients with a history of ankle sprains were twice as likely to suffer recurrent sprains if they did not engage in a balance and strengthening program (Holme et al 1999). This aspect of treatment will require you to pair up with someone with corrective exercise experience. A well directed strength program is an absolute necessity in order to restore balance to the stirrup musculature, improve proprioception and reclaim proper biomechanics.
Check the client's footwear. Unfortunately for clients with peroneal issues, their choice of footwear should come under some scrutiny. It is well known that elevated heels present a challenge to the body's ability to oppose gravity efficiently and places a wrench in optimal alignment and proper biomechanics of the ankle. Now, what about flip-flops? Sorry to put a crimp in casual Friday footwear, but these shoes probably present a greater threat to the foot than any type of high heel. Flip-Flops disrupt the windlass effect of the foot. When the windlass effect is in effect the big toe should dorsiflex; however, when wearing flip flops, the big toe actually plantar flexes in order to grab the flip-flop and prevent it from slipping off the foot. In other words, walking in flip flops encourages poor motor patterning of the muscles of the foot, including one of the big toe stabilizers, peroneus longus.
To sum it up, peroneal weakness and ankle sprains are closely linked and all too common. A little attention to these muscles will hopefully limit the muscle imbalance of the ankle and foot and help prevent future sprains.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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