Ankle Stability – The Retinaculum Part 3

Injury To The Retinaculum

When functioning correctly, tendons glide under these retinacula without hindrance. With injury (trauma, repetitive strain), the retinaculum can become a site of tendon restriction, nerve impingement, and circulatory compression. Injury to the retinaculum will cause mechanical and neurological damage.

From a mechanical perspective, when tension is created between the retinaculum, and the structures that pass under them, a considerable amount of tension occurs. This tension can be a major problem since tension creates friction, which can cause micro-tears in the tissue, inflammation, and eventually adhesion formation. These adhesions inhibit relative motion, alter lower extremity biomechanics, and lead to a host of compensations.

From a neurological perspective, injury causes an alteration in neurological receptors (mechanoreceptors and proprioceptors). This leads to both ankle and foot instability. Instability of the ankle and foot creates abnormal motion patterns, compensations which can lead into numerous injuries throughout the body.

Treatment

Restrictions of the retinacula can be treated quite effectively with Manual Therapy (Active Release Techniques, Graston Technique, and Massage Therapy) and a series of corrective exercises. Treating with manual therapy involves breaking restrictions between the retinaculum and the tendon. Essentially the practitioner is restoring relative motion between the retinaculum and the tendons (and of course the muscles that the tendons are attached to).

The practitioners should also be focusing their treatment on the fascial lines of stress. Lines of stress in fascia are often created during injury in multiple locations not just at the site of pain. If these areas of fascial stress can be released, then normal fascial tension can be restored.

Restoring overall fascial tension, besides releasing adhesions between retinaculum and the soft tissues that pass under them, can have significant effects in resolving an injury.

Fascial interconnections are not theoretical entities; they are actual physical structures that have been mapped out. Researchers such as Thomas Meyers (Anatomy Trains) and Luigi, Carla, and Antonio Stecco (Fascial Manipulation) have spent decades researching these interconnections. During the last International Conference About Fascia at the University of Amsterdam, I had the privilege of listening to medical experts from around the world confirm this and related fascial research.

In my own clinical experience we have seen excellent results in improving ankle stability by removing adhesions at the retinaculum itself, but even better results when we work on restoring overall fascial tension

Next year I will be traveling to Italy (June and September) to do advanced training with Carla, and Antonio Stecco. I am sure that by next year I will have discovers even more about this fascinating subject.

Exercise

Exercise plays a significant role in the rehabilitation of a retinaculum injury. Strengthening and flexibility exercises are needed, but because a significant component of a retinatculum injury involves neurological receptors, balance and proprioception exercises are also essential for full recovery.

The following links are examples of exercises that we often recommend for out patients with injuries to the retinaculum (from Core Performance).

• Ankle PNF D2.2 (Theraband)
• Dorsiflexion Stretch - Half Kneeling

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Ankle Stability – The Retinaculum Part 2

In part two of this blog we continue by first covering the lateral and medial retinaculum and what structures pass underneath them.

Outside (Lateral) Ankle Retinaculum

Superior peroneal retinaculum:

• This band of fascia holds the tendons of two muscles the peroneous longus and brevis in place just behind the outer ankle bone (fibular malleolus).

Inferior peroneal retinaculum:

• This band also holds the tendons of the peroneous longus and brevis muscles in place. This retinaculum is continuous with the inferior extensor retinaculum.

Pain/Symptom pattern: Tension or a restriction in this area will often cause lateral ankle pain, altering both foot and ankle motion. This can easily lead to ongoing injury and a decrease in athletic performance.

Note: Peroneal retinacula are often injured during ankle sprains (inversion injury). Anytime there is persistent pain after an ankle sprain, a retinaculum injury should be considered. For more information on ankle sprains read my six part blog on Ankle Sprains (Inversion Sprain).

Inside (Medial) Ankle Retinaculum

Flexor retinaculum:

• This band holds the tendons of the following muscles in place: tibialis posterior, flexor digitorum longus, flexor hallicus longus, and the tibial nerve.

Pain/Symptom pattern:

• Restrictions of the flexor retinaculum are associated with what is known as Tarsal Tunnel Syndrome. In this syndrome people experience sensation of: Pain, tingling and altered sensation anywhere from the ankle, heel, bottom of the feet, to the toes.
• A person with this syndrome will often experience an electric shock sensation, which travels into the foot, when they tap directly over the retinaculum. This is also known as Tinel’s sign.

Tarsal Tunnel Syndrome (TTS): Tarsal Tunnel Syndrome refers to compression of the posterior tibial nerve in the flexor retinaculum.

• Persons with flat feet (fallen arches) are susceptible to TTS. Also any type of enlargement in the Tarsal Tunnel can cause this syndrome which includes swollen tendon, cysts, arthritic bone spur, varicose veins, or even inflammation in the surrounding area.
• If this syndrome is left to progress it can lead to permanent nerve damage.
• Conventional therapy can often be very effective in treating this syndrome (Rest, Ice, and Exercise). Active Release Techniques has developed some specific protocols the release the posterior tibial nerve in the Tarsal Tunnel.

In part three of Ankle Stability – The Retinaculum, we will injury and treatment.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Ankle Stability – The Retinaculum Part 1

Usually when we think about ankle problems, we think about sprained ankles or a strained muscle, not something called a retinaculum. Yet these fascial structures play a significant role in a wide variety of chronic ankle problems.

So what is a retinaculum? From one perspective a retinaculum is a band of thick deep fascia that holds the long tendons of your ankle (those that cross the ankle) in place. Retinaculum also acts as a pulley system increasing mechanical advantage.

From the second perspective retinaculum are a major source of neurological receptors involved in balance and proprioception. Essentially retinacula have been hypothesized as key structures in spatial control for foot and ankle movements.

The following section is an overview of specific retinacula and what structures pass underneath them. As you look over the individual sections of the retinaculum also think of these areas as part of one large fascial interconnecting unit.

Retinacula do not exist as they are illustrated

Last year at the second international fascia conference in Amsterdam it became very clear to me that retinacula do not exist as they are illustrated in textbooks. There is a lot of interconnecting fascia that has to be removed before retinaculum look the way they are presented in text books. Research is now showing that these fascial connections (which are removed by dissection) are very important for both force transmission and neurological function.

Retinaculum Anatomy:

Front (Anterior) Ankle Retinaculum

Extensor retinaculum (2 parts)

· Superior extensor retinaculum:

o This structure holds in place tendons from the following muscles; tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius.

o The deep peroneal nerve also passes under the retinaculum.

· Inferior extensor retinaculum:

o The inferor retinaculum is shaped like a Y (once the entire surrounding fascia is removed) and has a lower and upper portion. The Y shape has the function of preventing “Bowstringing” of the tendons during ankle motion.

Pain/Symptom pattern: If there is a restriction in an extensor retinaculum, (front of the ankle) you may experience the following symptoms:

• Localized pain or restriction on the front of ankle when running or walking. It is a very common symptom that I see with runners.
• Tension can also alter the muscle firing patterns in the lower extremity. This can create a host of injuries and result in a substantial decrease in athletic performance

In part two of Ankle Stability – The Retinaculum, we will cover the lateral and medial retinaculum.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Lateral Foot Pain - Cuboid Syndrome – Part Two

Symptoms

Patients who have cuboid syndrome often complain of lateral foot pain, or weakness in their feet. Pain from cuboid syndrome can also radiate to the front of the ankle. This pain is often more noticeable during time of exertion (toe-off portion of the gait cycle), or on impact.

The type of pain found in cuboid syndrome may not be a very good indication of this condition.Pain can be intermittent, or persistent, it can also develop suddenly or slowly over a period of time.

Diagnosis and Imaging

Upon physical examination, the patient may have pain directly over the cuboid bone (especially when pressure is applied dorsally on the plantar surface). In some cases there may be bruising, redness and swelling. Range of motion in the ankle is often limited in cuboid syndrome (dorsi and plantar flexion).

X-rays, CT scans or MRIs are of little value in the diagnosis of cuboid syndrome. The only reason an X-ray is of value in the diagnosis of this syndrome is to rule out fractures or some type of pathological condition.

Treatment

Several forms of manual therapy can be used in treating this condition. The sooner that treatment is implemented the faster the results will be.

• Manipulation: One of the most successful treatments we have found is manual manipulation. A therapist training in extremity manipulation (chiropractor, physiotherapist, podiatrist) can often reduce the pain of cuboid syndrome in a short period of time.

• Soft tissue techniques: Techniques such as Active Release, Graston, Massage Therapy, and Fascial Manipulation can also be of great help. The key is to work with all of the structures involved in the kinetic chain, not only at the site of pain.
• For example we know that the peroneus longus muscle is involved in plantar flexion of ankle, and that this greatly affects cuboid stability. A problem with the peroneus longus could create an alteration in the normal plantar flexion movement. Even though the peroneus longus is most likely involved in this injury, we cannot take it for granted that this is the only plantar flexor affected. Treatment of all plantar flexors and their antagonist muscles, the dorsi flexors, is often needed for a full resolution.
• Plantar flexors: Calf muscles (Gastrocnemius & Soleus), Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus, Peroneus Longus, Peroneus Brevis, and Plantaris.
• Dorsi flexors: Tibialis Anterior, Extensor Digitorum Longus, Extensor Hallucis Longus.
• Exercise: Exercises should focus on stretching the peroneus longus and the calf muscles.These stretches are combined with strengthening the extrinsic muscles of the foot. In addition, it is essential to perform balance exercises so that the injury does not reoccur.Please go to www.releaseyourbody.com for a specific exercise needed to rehabilitate this injury.
• Orthotics: Custom fit orthotics will help to correct abnormal pronation and supination that may be leading to cuboid syndrome.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77:638-642.

Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am J Sports Med.1992;20:169-175.

Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment and treatment. J Orthop Sports Phys Ther. 1994;20:220-226.

Newell SG, Woodle A. Cuboid syndrome. Phys Sports Med. 1981;9:71-76.

Lateral Foot Pain - Cuboid Syndrome - Part 1

Lateral Foot Pain - Cuboid Syndrome – Part One

Cuboid syndrome is a condition that causes lateral foot pain. In forty percent of cases Cuboid syndrome is associated with lateral ankle sprains (inversion sprain). This syndrome affects the joint (capsule), ligaments, and tendons (peroneus longus tendon).

This syndrome is defined as a “minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint”. In laymen’s terms, the cuboid bone has moved from its normal position in the joint.

It is a common syndrome, but not well-recognized by practitioners. Cuboid syndrome also goes by several other names: subluxated cuboid, dropped cuboid, cuboid fault syndrome, and lateral plantar neuritis.

Anatomy/Biomechanics

The calcaneocuboid joint is a vital link in lateral foot stability. This joint is susceptible to sudden injury or chronic strain, which can cause this joint to partially dislocate or subluxate.

The cuboid bone is one of the seven tarsal bones of the foot.

• Joint Anatomy: The cuboid articulates with the fourth and fifth metatarsals forming a joint (tarsometatarsal joint). It also articulates with the heel bone (calcaneus), forming a joint (calcaneocuboid joint). On the inside (medially) the cuboid articulates with two bones (lateral cuneiform and the navicular). An alteration of the cuboid can have a considerable effect on the joint biomechanics of the foot.

If we were to view the bottom of the cuboid bone we would see a groove where the tendon of the peroneus longus muscle runs along it.

• Peroneus Anatomy: The peroneus longus muscle originates on the lateral lower leg (upper one-third of the fibula). It then runs down around the outside of the ankle (lateral malleolus) then through the grove on the bottom of the cuboid. It then inserts into the base of the first metatarsal (and cuneiform).

The peroneus longus acts as a stabilizer of the forefoot. The cuboid bone acts as a pulley which increases mechanical advantage for the peroneus longus muscle.

Causes

A single impact injury or repetitive motion can cause this syndrome to occur. Runners and dancers (especially ballet dancers) are susceptible to this injury because of the high levels of repetitive impact. In addition basketball players or racquet sport players also are susceptible due to the lateral motions required to play these sports.

If a person abnormally pronates their foot during the push off phase of gait, they will be more susceptible to a cuboid injury. Excessive pronation causes an increase in force transferred to the cuboid bone which causes instability and a resultant injury.

In part two of Cuboid Syndrome we will cover, symptoms, examination, diagnosis, and treatment.

Lateral foot pain part two...

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)