resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Guidelines for the Use of Modifier -52
Modifier -52 identifies that a service or procedure has been partially reduced or eliminated at the physician's discretion. This is to indicate the basic service described by the procedure code has been performed, but not all aspects of the service have been performed.
MPA Media Wins More Publishing Awards
The American Society of Business Publication Editors (ASBPE) has honored Dynamic Chiropractic with a national award and two regional awards for editorial excellence, and sister publication DC Practice Insights with two regional awards for graphic design excellence.
Chiropractic in the Eyes of the Public: 2nd Gallup-Palmer Poll
The second Gallup / Palmer College poll has been completed, yielding significant additional data regarding Americans' experiences with and perceptions of chiropractic care.
Analyzing Acupuncture Case Studies
Confirm the answer quickly by the elimination method. Take this case study as an example. After two treatments for back pain, a patient presents for a third session complaining of rapid breathing and wheezing that is made worse during cold weather.
Time to Fight for Your Medicare Right
I have heard a lot of noise and a lot of debate about what is going on with Medicare. As an ACA delegate, I often get asked: 'What is the ACA even doing?'
What are the Meridians?
The meridian and collateral system (jing luo, hereinafter referred to as "Meridians") is comprised of the main meridian channels (jing mai) and the collateral vessels (luo mai). Jing takes from meaning of the Chinese word pathway (also jing) and are the main branches of the system.
International Congress on Integrative Medicine
"Bridging Research, Clinical Care, Education and Policy" was the theme for the International Congress on Integrative Medicine and Health 2016 (ICIMH).
The National Institutes of Health (NIH) lists more than 80 common autoimmune diseases including asthma, Crohn's disease, Guillain-Barré syndrome, multiple sclerosis, myasthenia gravis, psoriasis, rheumatoid arthritis, and lupus.
What's New in the NCCIH Strategic Plan
The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016.
Traditional Chinese Herbal Medicine in Taiwan Hospitals
This spring, a team of Western medical doctors and TCM practitioners from Cleveland Clinic traveled to Taiwan to visit Kaiser Pharmaceutical Co. (KP), and China Medical University (CMU), Taiwan's leading integrative medicine hospital.
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
Let's Talk About Biceps Injuries at the Elbow
While most muscles cross over only one joint, the biceps crosses two joints: the elbow and the shoulder. Injuries to the lower biceps cause considerable elbow pain. Here's how to assess and treat an injury to this area conservatively.
Less Time Than Required
Q: When is it appropriate to use a modifier -52? Can I use it for a timed service when I do less than the time required by the code?
Overuse Injuries in Young Athletes (Part 1)
More than 45 million children ages 6-18 participate in some form of organized athletics, and 75 percent of American families with school-aged children have at least one child participating in organized sports.
Don't Ignore the Lower Half of the Pelvis (Part 1)
When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis.
Are Probiotics Doing More Harm Than Good?
Considerable controversy exists concerning the efficacy of probiotic supplements. Very few human studies show any real positive impact on the microbiome or health. The "promise" of probiotics is based on the few animal studies that suggest a positive effect.
The Professional and Practice Benefits of Political Activism
Welcome to election season, a vital part of our American culture. Every two years, without fail, we are bombarded with TV, print materials and phone messages seeking our vote.
Adventures with the Pericardium
My previous column on the San Jiao deserves equal time for SJ's loving partner, the pericardium. I nicknamed SJ the travel meridian – but pericardium can also play a crucial role in air travel.
A Study of Relationships
Sa-Ahm's five element acupuncture method is known to be one of the most effective acupuncture techniques in Korea because it gives an instant response at the time of treatment and has a high success rate in resolving chronic problems.
Know Your Research: Tips for Evaluating Literature Reviews
Clinical and experimental studies are not the only types of published research we might encounter as we look for evidence to inform our practices. One of the most useful types is the literature review, which summarizes a group of studies.
Work Stress and Musculoskeletal Health: Do Your Patients Get the Connection?
Most people underestimate the impact their job has on their health, especially if that job isn't particularly physically demanding. Big mistake.
Illuminating the Hidden, Freeing the Source
Amongst the Primary Channels, from a classical point of view, the small intestine is perhaps the most important channel to understand. It is one of the least used acupuncture channels in modern acupuncture, yet it within it can be found a wealth of theories from the Ling Shu.
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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