I had a question recently, about manual therapy in the foot and why I often use an indirect technique.
"It seems that in this case and others, even on yours and Rods online videos, that indirect techniques seem to be used for navicular? Does your experience show that it responds best to that?"
The key to accurate palpation of joint movement is first to identify barriers.
So let's look at a scenario. You're doing a local biomechanical evaluation of talonavicular arthrokinematics, or joint play. In larger joints like the hip, the above image allows for the assessment to reveal a large range of motion between first and second point of resistance. This larger range between R1 and R2 is often related to a "springy" feel, due to the elasticity of muscular and fascial tissue. In a smaller joint like the talo-navicular joint, however, there's no muscle or fascia limiting the range of movement - it's only ligament - so the joint play, the give, the movement, is going to be small, but there should be some movement. Think of a range of movement at the TN joint in both directions of one plane. Eg navicular pronation and supination. There is a resting position of the joint, with a central zone where there’s "a little give" either way before you meet resistance.
Let's say you move it one way from the central zone eg into supination, and you meet R1 straight away. And you release your fingers and “let it settle” back to the neutral zone. Then you move it into pronation and notice that there’s a little more give before R1 compared to supination. You decide they could do with more supination. The usual physiotherapy technique would be direct - that is to say, the technique would be to mobilise the bone in the direction of supination. For example, Maitland style grade 3-4 for stiffness, or grade 5 manipulation, also known as HVLA (high velocity low amplitude) or CMT (chiropractic manipulative therapy). Except the supination R1 came on immediately from neutral zone and R2 is probably at the same place as R1. And…. I'll bet that your Physio manual therapy education wouldn’t have taught you to feel for “give” and to note R1 and R2, and if it did, you wouldn’t have refined it for small joints like the talo-navicular joint, so you have no feel for supination give and all you know is grade 3-5 for stiffness, direct.
Now think about this. What if the navicular was already “hard up against the end range of supination”? I mean, what if R1 and R2 were met immediately that you moved the navicular into supination?
I have to ask you, "Will directly mobilising further against the hard end-feel, the hard barrier, create more give or will it create potential joint instability? (I don't believe it will create joint instability in this joint, it's so well packed and supported.) Or will the bony and ligamentous integrity be so strong that you simply don’t make any difference? So, what if you bring the navicular indirectly from the restricted direction, ie towards pronation, and then, in that “eased” position, you have created an opportunity for the nervous system to get to know this eased position, or to interpret the eased position as a position that feels easier? You can "make the nervous system aware of it" via cueing relaxed breathing while the navicular is eased, to "remember a motor control of that movement".
And then, here's the modification from typical osteopathic technique - in that eased position, the next thing you do with your manual therapy is that you involve the nervous system by having them do an active movement of the physiological movement they couldn’t do before, for about 5 reps. For example, if the person had lost some dorsiflexion mobility, you would ask them to do dorsiflexion towards as much as they could do.
In some ways it has similarities to a Mulligans MWT - a Mobilisation With (active) Movement. If the person does an active isometric contraction in the direction opposite the dysfunctional physiological direction, it’s an MET, and if they do it a concentric contraction in the directions originally described then it has reciprocal inhibition about it - useful if the limiting tissue is Myofascial.
Then, you re-check the supination accessory movement, or joint play, which will be a passive test. And then you check the physiological movement that was limited, in this case dorsiflexion, tested passively, first, and then active.
Did you change the accessory mobility dysfunction of supination, as per the local biomechanical examination?
Did that change of accessory mobility dysfunction change the passive physiological mobility dysfunction of the breakout that took you there?
Does the improved breakout change any top tier movements?
It often does.
That explains why I like indirect technique.
Coach Larson and I collaborated to make athletes better in professional sport in China. We wanted to do a good job for two reasons – to get results and to keep our job. We had access to most of our athletes most days of the week, and at times twice each day. We could have been forgiven for expecting to be able to manage and monitor so many variables to create exceptional programming. However, the truth of walking into a team with long-established ways of training and behaving meant that we had to get buy-in before we could get close to doing a good job. Therein lies the simple truth of what Coach Larson said – if the local athletes didn’t enjoy the training, lots of events would conspire against us doing a good job.
The consequences of athletes not enjoying what you provide include:
• Speaking negative comments to teammates about their experience with you;
• Speaking negative comments to other coaching staff about their experience with you;
• Limited in-session effort;
• Limited consistency of attendance.
Those four consequences will cost a coach clients, money and position. It is hard work getting a client, getting paid and advancing a career. The likelihood of a second chance at a client or a job position is zero percent which brings us to compromise.
To hear more about how Rett and I collaborate to get the best out of our athletes, check out our Warm-Up Masterclass below.
"Your listening hand/finger and motion-creating hand/finger, together, reveal the dysfunction."
This case study will suit the practitioner with SFMA level 2 experience, now available as an online course as a pre-requisite to a live course. If you haven't heard of the SFMA, you can briefly watch an intro to it here.
A client returns with a recurrence of LBP. A history is taken. A previous neuro scan and respiratory scan has been done and there is nothing to indicate any change. It is appropriate to proceed with a review of her movement assessment, ie the SFMA top tier.
Cx F DN
Cx E FN
Cx R FN Bilaterally
MSR DP Bilaterally, with right being less painful.
My entry breakout is the deep squat, which reveals bilateral ankle dorsiflexion MD's, eversion MD's, hip ER MD's bilaterally (with hips flexed), left worse than right. I'm cautious with the DP of MSR, but I want to know a little more about hip rotation with hips extended to help me understand if ER is restricted in two positions - this refines whether I'm biased towards checking tissue texture abnormality via the active tissue palpation taught in level 2, or for joint play reviewed in level 2. Prone hip rotations reveal MDs in ER bilaterally, but worse on the left (29 degrees), with IR of 25 degrees.
While prone, I do a static palpation assessment of the lumbo-sacral region and observe her lower lumbar spine is subtly rotated towards the left.
My reasoning is to do LBE of hip and feet.
I find that despite the left hip displaying MDs of the physiological movements (ie limited osteokinematics), the right hip displays more restricted accessory movements (ie arthrokinematics or joint play). They are limited in multiple accessory planes so I perform a long-axis hip traction of the right hip with MET, 3 reps.
Reassessment reveals the left hip physiological rotation is now in the high 30's for ER and IR. Treating the most limited joint play on the right hip changed the most limited physiological movement on the left hip that was revealed in the breakouts. I had come to that breakout because I chose a DN of ADDS and cautiously added breakouts of the DP pattern of MSR. By the way, in prone, right hip ER reproduced left low back pain pre-treatment, confirming the cautious approach and consistency with what was found in left MSR.
I then went to the feet. Notable findings, left navicular was limited into pronation, medial-to-lateral glide and inferior-to-superior glide. There were restrictions also in midfoot joints at navicular-cuneiform and particularly at the medial cuneiform-to-1st-metatarsal which had very limited dorsiflexion but could plantarflex.
I did an indirect technique, as a positional release, then with MET. Specifically, I mobilised the navicular where it was capable of going comfortably, ie into supination, lateral-to-medial glide. The superior-to-inferior glide was a trickier element to add in, so I just "stacked" two planes, to R1 - it took a lot of quieting to create motion and listen/feel for it. Then I had her cycle a breath. I released. I repeated, then added isometric ankle dorsiflexion, then released. I repeated a few times.
Ankle dorsiflexion "let go" and increased, as did the 1st TMT joint into dorsiflexion, as did the subtalar joint. Both manipulated easily with a gentle direct oscillation technique. The left hip ER in extension went well past 40 degrees with R1 and beyond 50 degrees with R2. Hip IR was well beyond 30 degrees. The lumbar spine was neutral. MSR was DN bilaterally, as was MSE and MSF. No pain.
The Reinforcing and retraining drills were 1x1 figure 4 horizontal and vertical bridges, then 2x1 and 2x2 hip extension with ER and IR, then 3x1 tall kneeling rotations with KB and half kneeling chops and lifts (3x3).
Hit me up with questions.