I saw a woman the other day who had two surgeries several months ago to remove a bone chip from her ankle and resolve an infection that had set in after the initial surgery. She’s young and active and had the surgery because of chronic ankle pain when the ankle moved into dorsiflexion (when the knee traveled over the foot). The same pain remained after the surgeries. Her therapy was able to increase her range of motion but it would always return to its tightened position along with the pain.
Initially I thought her lower leg muscles were not working properly, which they weren’t. But after correcting their length and function, the pain continued. While lengthening these muscles, I felt a definite mechanical block when bringing her foot into dorsiflexion. So I looked more closely at how she was moving into dorsiflexion when standing and saw something peculiar. Her foot did not seem to move into pronation when she dorsiflexed. Nor did her knee move inward–instead it moved straight ahead. The reason this is peculiar is that the talus bone in the the ankle joint is irregularly shaped, kind of like a cone, which should cause the tibia (the lower leg bone) to rotate and move inward while the ankle is moving into dorsiflexion. Hers was not doing this.
I wasn’t sure how to make this happen other than with my hands so I guided the tibia through what I felt to be an ideal movement pattern in hopes it would promote talar gliding and consequently foot pronation. After a couple repetitions of this she began to feel a stretching sensation in her peroneal and soleus muscles. This was a new sensation for her as her previous range of motion exercises only seemed to stretch or stress her ankle joint. She also experienced greater range of motion with no pain. We reinforced this pattern with her walking as well, altering her foot strike pattern to reproduce these movements (tibial internal rotation, knee adduction, and foot pronation). If she uses this pattern when walking then the stretching exercises will be reinforced and hopefully the ankle tightness will gradually diminish between therapy appointments.
To me, this was an important reminder to never forget that many joints have a rotational component to their movements. Restoring the rotation component can be just the thing to restore full range of motion or decrease pain. I believe if she continues this approach to her ankle with her therapists back home, that she’ll continue to see improvements in her function together with less pain.
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