Department of Podiatry

Outline
Increased interest amongst podiatrists recently
History
Definitions
How does it work?
What has it been used for in the foot?
Practical examples (part two of this web guide)

Origins
Ancient Egyptians & Hippocrates
Leverage/traction techniques in the tx of spinal deformity

1600's on: 'bone setters'
Particularly renowned for successful tx of painful hands & feet

Origins: Osteopathy
Pioneered by Andrew Taylor Still
US: total school of medicine/Sx
Aust./UK: structural dx & manipulative therapy

Click here for more information on the history of osteopathy

Origins: Chiropractic
Daniel David Palmer
Included adjustive techniques of the foot in his 1910 text, The Science, Art and Philosophy of Chiropractic
'Straight': focus on vertebral manipulation
'Mixer': manipulation, physical therapy & dietary modification

Click here for more information on the history of chiropractic

"5% of all diseases are caused by displaced bones other than the vertebral column, more especially, those of the tarsus, metatarsus & phalanges" (Palmer, 1910)

Commonality between professions
Discrete dysfunction of the musculoskeletal system ('osteopathic lesion', 'chiropractic subluxation' or 'joint blockage')
may be responsible for the development of pathology elsewhere in the body (Menz, 1998)

Mobilisation & Manipulation: what's the difference?
"Manipulation occurs so rapidly that it may generate a negative pressure capable of pulling gases out of the synovial fluid" (Michaud, 1997). Mobilisation is 'gentler' (safer?)

Cavitation = cavity = vacuum
What is supposedly important is the breaking of collagen cross-fibrils associated with the separation of joint surfaces

Grading joint range of motion

Joint mobilisation & adjustment in one plane (Sandoz, 1976).

The five graded oscillations used during manual therapy. I = small amplitude movement near the starting position, II = large amplitude movement near the starting position, III = large amplitude movement ending at the elastic barrier, IV = small amplitude bordering on the elastic barrier, V = manipulation: a small amplitude, high-velocity thrust accessing the paraphysiological space but not exceeding the anatomical limit of movement (Michaud, 1997).

Techniques break down collagen cross-linkages
Enables lower extremity to 'more effectively dampen GRF's' during gait
For hypomobile, rigid foot
Joint subluxations (loss of relationship between two bones' leads to dysfunction by altering afferent feedback to the CNS)
Foot manipulation - restores 'normal' osseous alignment - normal neuro. feedback

Neurological?

Increase proprioceptive information via manipulation? (Hiss, 1949)
Hypomobile joint: leads to abnormal pattern of motor recruitment that is eventually reprogrammed into the CNS?

Vascular?

Manipulation aims to restore normal motion to the articulation, thereby leading to a reduction in symptoms, and allow better vascular perfusion. Don't knock yourself out trying to find any experimental evidence behind this theoretical mechanism (vascular) - I don't think there is any!

Is there any scientific basis to this?
Rabbit knees immobilised 9 wks, then mobilised - histological changes to the tissue that seemed to indicate a breakdown of collagen cross-linkages (Woo et al, 1975)
Not any other studies (that I know of) ...

"We do a disservice to the pioneers of manual therapy when we worship their words and fail to advance the scientific basis on which they first developed" (Rothstein, 1992)

(Nield et al, 1993)

AJ dorsiflexion
20 asymptomatic subjects
One foot manip, one foot control
No significant change
Small sample, asymptomatic subjects?

(Dananberg, Shearstone & Guiliano, 2000)

AJ dorsiflexion
22 symptomatic subjects (with AJ equinus)
Goniometric measurement of AJ DF
Manipulation performed (on fibular head and talus) on limbs that were deemed to have an AJ equinus
Significant increase in AJ motion (approx. 5° ± 4° SD)
Lack of control group?

Indications	Contraindications	Precautions
Generally, mobilisation and manipulation are accepted forms of treatment for pathologies that involve soft tissue contractures or adhesions that limit joint range of motion. Trigger points are often treated with mobilisation, and both techniques are believed to increase the blood supply to damaged areas. Conditions that it has been used for in the foot include: • Morton's neuroma • Plantar fasciitis • Pes planus • Post inversion ankle sprain • PT Tendonitis • Sesamoiditis • AJ equinus • Diabetic polyneuropathy	• Past fracture or stress fracture • DVT (Deep Venous Thrombosis) • Past history of osteotomy • Acute sprains & inflammation • Bony blocks	• Very hypermobile joints • Osteoporosis • The very old or the very young • Long term diabetes mellitus • Anticoagulant medication • Recent sprains • Tinea/Fungal skin infections (wear gloves) • 'High velocity thrust techniques should only be performed by those with sufficient clinical experience'

Summary
Foot manipulation has some scientific basis, but requires further investigation before its credibility can be fully established.
Little information on adverse effects of treatment.
'Emotional appeal' of tx.
No 'standard' guidelines & clinical indications exist.

However, foot mobilisation & manipulation has a long history of clinical efficacy, and is an important technique of which the basics should be known by every practising podiatrist.

Content Approved by: Head of Podiatry
Page maintained by: Podiatry Webmaster
Last Updated: August 20th, 2002