resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
I Felt it in My Fingers First
I'm not afraid to say it. Massage therapists make better acupuncturists. I'll tell you how I know, but first I have a question: What do a microcurrent device, a laser and a hippie massage therapist have in common?
Taking the Freeze Out of Adhesive Capsulitis
Adhesive capsulitis or "frozen shoulder" is a relatively common condition resulting in severe shoulder pain and global loss of glenohumeral joint range of motion. Incidence of the condition is approximately 3 percent in the general population.
Professionalism and Evidence-Based Health Care
Today's chiropractors are facing a conundrum with the Affordable Care Act and its health care reform requirements, including evidence-based practice and health technology assessment.
The App Advantage: Get More for Less
You may have noticed the list of "app-exclusive" articles in the directory on the front page of the print issue and in the Table of Contents on page 4. You can't find these articles in print or even in our online archives.
Happy New Year 2015 Gong Hoy Fat Choi
Welcome to the year of the sheep! We begin a new year guided by the sign of a quietly and creatively organized animal.
Two for One: The Cervical Distraction Test
In today's healthcare system, diagnoses and treatment plans follow a western medical model - especially if you work with attorneys or insurance companies.
News in Brief
While indignation may be your immediate reaction to H.R. 5780, the Protecting the Integrity of Medicare Act of 2014, the American Chiropractic Association suggests the legislation is just what the chiropractic profession needs.
Movement Assessments: The DC's Sphygmomanometer
I think back to when I was going through chiropractic school outpatient clinic. I was embarrassed to have my family and friends come in for treatment because initial evaluations took three hours to complete.
The Conscious Evolution of Healing: Importance of Opening the Sensory Portals in Classical Chinese Medicine
The Chinese medical classics are not just clinical guides. They give advice; ways we can awaken more fully into conscious awareness.
Three for One: The Cervical Distraction Test
Taking the time to do an exam is important, but it is time spent. The exam serves as a way to physically validate your clinical impression following a history and clinical consultation.
Trouble Down Under: San Zhen Therapy for Lower Jiao Issues
In the last several columns, I have discussed many clinical options for utilizing San Zhen or Three Needle Therapy. In this installment, I will continue this trend and discuss several foundational patterns which can be found in several very common clinical presentations.
Helping to Create the Healthiest Generation
The imperative to create the "Healthiest Generation by 2030," envisioned by the American Public Health Association (APHA), was in full force at the APHA's 142nd Annual Meeting held in New Orleans from November 15-19, 2014.
Acupuncture and its Place in the Integrative Healthcare Practice: The Need to Move from Modality to Profession
Acupuncture and oriental medicine (AOM) has grown and flourished from its inception thousands of years ago in China. In surrounding regions of Asia, AOM developed as a response to differing cultural, pathological, health and wellness care needs.
Show Up and Show Respect
I was recently asked about my chiropractic philosophy. My answer surprised my questioner.
Age and Fertility: Why We Should Worry Less About Age and More About Overall Health
Recently, on one of the acupuncture alumni forums, the topic of age and fertility came up when a practitioner posted a question regarding a patient that was about to turn 40-years-old.
Animal Acupuncture Gaining in Popularity
We have just finished the year of the fire hoarse and now it is time to spend some time alone, daydreaming and thinking outside the box in terms of where our profession is headed. The sheep person is well organized and creative so this should not be difficult to do.
Fight Colorectal Cancer With Folic Acid
CRC is the second most common cause of cancer mortality in the U.S. and Canada. Although genetic susceptibility plays a role in the etiology of CRC, dietary factors, including certain vitamins, have also been shown to influence the development of the disease in various studies.
Right Back Where We Started?
More than 25 years after Judge Susan Getzendanner issued her historic opinion in the Wilk v AMA anti-trust case, evidence suggests that despite increasing collaboration between doctors of chiropractic and their allopathic medical counterparts, when it comes to organized medicine, we may be right back where we started.
AWB Makes a Difference in the Yucatan
We are in the sleepy town of Izamal, located about an hour from the Merida airport where our group arrived last night. Later that morning, on a bus winding through the dusty roads of the Yucatan, fourteen acupuncturists, two facilitators from AWB and two tour guides make their way to the small rustic town of Popola.
How to Use Online Video as a Tool to Market Your Practice
Health care practitioners, including chiropractors, should consider online videos as a key element of their Internet marketing strategy. In the next three years, videos are expected to account for nearly 70 percent of all consumer online traffic, according to Cisco.
The Way of Zen Performance Enhancement
Working with elite athletes and implementing various techniques to keep athletes focused and at their optimal performance for a sustained period of time includes incorporating various meditation techniques that counterbalance their sport-specific physical and mental demands, which is an important element of success throughout the years.
Environmental Toxins: Cause of Modern Illness, Part 2
In Part I of this article, we detailed the variety of environmental toxins assaulting our bodies. These include pesticides and herbicides; plastics; preservatives; cosmetics; gasoline additives, solvents and glues; and heavy metals.
Chiropractic Research in Review
Occupational LBP in Primary- and High-School Teachers; Treating MVA Complications With Chiropractic Care; Neck Pain: Immediate Effects of Active Scapular Correction; Taping Benefits Stride, Step Length in Fatigued Runners.
Ringing in the Billing New Year
What are the new modifiers that replace modifier 59? Will they allow doctors of chiropractic to be paid for 97140, manual therapy, when done with chiropractic manipulation?
The Static Postural Pelvic Exam
I include a static postural analysis in my evaluation routine whether you are a patient in pain or an elite-sport athlete in training. In my day-to-day practice, I require patients to stand still while I "just look" at them.
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.
Join the conversation
Comments are encouraged, but you must follow our User Agreementcomments powered by Disqus
Keep it civil and stay on topic. No profanity, vulgar, racist or hateful comments or personal attacks. Anyone who chooses to exercise poor judgement will be blocked. By posting your comment, you agree to allow MPA Media the right to republish your name and comment in additional MPA Media publications without any notification or payment.