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The Lung Official
The Lung is known as the "Official Who Receives the Pure Chi From the Heavens." The act of breathing in, known as inspiration, brings oxygen into the body from the atmosphere. Each exhalation or expiration removes and releases carbon dioxide, a waste product of the body, into the atmosphere.
Comparing Costs of Care: DCs, MDs or PTs - Who Costs More?
In a health care era where evidence is increasingly the benchmark for insurance coverage, patient care and even cultural authority, we get plenty of it courtesy of a retrospective cost analysis spanning 10 years, more than 660,000 "covered lives" and nearly 7.5 million claims from Blue Cross Blue Shield of North Carolina.
Putting POLITE Into Practice
First came the acronym RICE (Rest, Ice, Compression, Elevation), which eventually became PRICE (Protect, Rest, Ice, Compression, Elevation). Then in 2015, we started hearing POLICE (Protect, Optimal Loading, Ice, Compression, Elevation).
News in Brief
F4CP MEmbership Milestone Reached; ICA Challenging New California Vaccine Law; TCC Names New President; New Provost at UWS.
Concerns Regarding CDC Guidelines for Pain Management
In response to the epidemic rates of opioid and heroin addiction, the Centers for Disease Control and Prevention (CDC) set new guidelines for physicians regarding treatment for pain.
Dealing with a Pain in the Butt
The patient came into my office with the classic antalgic stoop. She was bent over almost to ninety degrees, leaning on her husband for support and staggering to walk. She had been under supportive care for a long time, but this new pain scared her.
Case Study: 2-Year-Old Suffering From Urinary Reflux
A19-month-old female child presented to my office for treatment. Her mother reported the child had been diagnosed with urinary reflux and associated urinary tract infections, recurrent bouts of otitis media and inability to sleep.
CE Regulations Are Hurting Chiropractic
During my 35 years in the chiropractic profession, I have been forced to attend available continuing-education programs that were occasionally incredibly beneficial, but frequently not worth my time.
The Most Important Vitamin You've Never Heard Of: K2
Imagine if one in every three patients who walked through your door was afflicted with a debilitating, yet completely preventable and treatable disease.
Forward Head Carriage and the Feet: What's the Connection? (Pt. 2)
Clinical evaluation of standing posture using relatively low-tech tools has been confirmed as valid and reliable by several studies. The original device used to evaluate posture was the plumb line, which served as a reference line for the effects of gravity on body alignment.
Acupuncture's Essential Role
Acupuncture should play a more prominent role in U.S. healthcare during and after this post-Affordable Care Act era when chronic care and population health management are key concerns for all healthcare providers.
Infertility: Managing Irregular Menses
Infertility is an area where Chinese medicine is particularly helpful. In the main, in women below the age of 38 without organic disturbance, the success rate using TCM (Traditional Chinese Medicine) should exceed 85%.
Acupuncture Earns BLS Unique Code
The United States Bureau of Labor Statistics recently announced that acupuncturists will have their own unique occupational code in the 2018 BLS Handbook. The new Standard Occupational Code (SOC) is 29-1291, will be included in the next edition of the BLS Occupational Handbook, which will be published in 2018.
The Drug Epidemic: Are You Guilty, Too?
Attention-deficit / hyperactivity disorder (ADHD) has become epidemic among children in the United States. According to the Centers for Disease Control and Prevention (CDC), the percentage of school-aged children diagnosed with ADHD has grown from 7.8 percent in 2003 to 11.0 percent in 2011.
HVLA Technique: Addressing Myths
In the annals of chiropractic history and literature, and in the imagination of the public, there is one manual adjusting technique that can produce a wide range of responses, both from patients and casual observers.
NBCE Fumbles Computerized Testing Process
Imagine being a student again, about to take one of the four tests required to become a doctor of chiropractic. You've studied almost nonstop for the past few weeks. You can feel your anxiety level rise as you sit down in front of the computer screen.
Physical Examination in an Evidence-Based World
I have always had a fascination with physical examination procedures, particularly orthopedic tests. The origin of my fascination began just after graduation when I began the chiropractic orthopedics program.
Patience vs. Patients
How long have you been in practice? I began my journey more than 20 years ago and opened my first acupuncture clinic in 2008. Just like you, I've learned a lot over the years. Recently, I sat in an interview and was asked what made me successful.
Why We Need to Fix the Mechanoreceptors (Part 2)
The muscle spindle, a particular type of mechanoreceptor, is located deep within the muscle belly, encapsulated in fascia made up of intrafusal fibers, all within the extrafusal muscle fibers.
Sacroiliac Joint Fusion: Where's the Wisdom?
We should be very skeptical of the purportedly less invasive version of the already defrocked sacroiliac fusion surgery, "minimally invasive" sacroiliac joint fusion; and concerned this procedure simply represents the device manufacturer's attempt to find yet another new market.
Letter to the Editor
On December 7, 1999, the U.S. FDA reclassified the status of acupuncture needles from class III (investigative devices subject to investigative device exemptions...) to class II (special controls).
We Get Letters & Email
Our Medicare Challenges Aren't an Education Issue; Passion to Succeed: More Pivotal Than GPA?
Six Things Every Chiropractor Should Know About Opioids
An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.
University of Bridgeport Acupuncture Students Make Rounds at Sisters of Notre Dame
Nuns are not stereotypical acupuncture patients, Dr. Jennifer Brett acknowledges with a laugh. But then again, acupuncture has gone mainstream, just like cappuccinos and recycling. "It's changed a lot from the '70s and '80s," said Brett.
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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