117: Ankle Issues

Episode Transcript

Key Points

– Introduction and podcast overview (0:00)

– Announcement about Til Luchau’s ankle issues course (1:00)

– Sponsorship message from Books of Discovery (3:00)

– Discussion about ankle anatomy and stability (4:00)

– Importance of ankle work in manual therapy (10:00)

– Discussion about the mortise and tenon structure of the ankle (12:00)

– Overview of ankle movements and joints (15:00)

– Discussion about valgus and varus alignments (19:00)

– Debate about the role of ligament injuries in ankle sprains (23:00)

– Discussion about nerve compression and tenosynovitis in the ankle (28:00)

– Practical strategies for addressing ankle injuries (34:00)

– Importance of educating clients about foot and ankle mobility (38:00)

– Discussion about the role of manual therapy in addressing ankle issues (41:00)

– Conclusion and closing remarks (45:00)

 

Transcript

Whitney Lowe:

Welcome to the Thinking Practitioner Podcast.

Til Luchau:

A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe:

I’m Whitney Lowe.

Til Luchau:

And I’m Til Luchau.

Whitney Lowe:

Welcome to The Thinking Practitioner.

Til Luchau:

Hi. This is Til Luchau. This summer I’ll be offering my ankle issues course via live stream. This will be the first time, this course, which is the latest in my Advanced Myofascial Technique series, will be available remotely or by recording. You can join us live. You can even bring a client and work on it, there with us in real time if you want CAMT credit or certification credit. Or the course is affordable enough that you can just sign up and watch the recording later at your leisure.

All those options will earn you NCB credit. And for a limited time, Thinking Practitioner listeners like you can save an extra 15% with the coupon TTP at checkout if you go to advanced-trainings.com and sign up for the ankle live stream. You’ll see all those options there.

Whitney Lowe:

That sounds like a great option. I might want to do that myself, I think even.

Til Luchau:

I’d be great to have you.

Whitney Lowe:

All right, and also keep in mind, Books of Discovery has been a part of the massage therapy and bodywork world for over 25 years. Nearly 3,000 schools around the globe teach with their textbooks, e-textbooks and digital resources. And Books of Discovery likes to say, “Learning adventures start here.” And they find that same spirit here on the Thinking Practitioner Podcast and are proud to support our work knowing we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession.

Til Luchau:

Instructors of manual therapy education programs can request complimentary copies of Books of Discovery’s textbooks to review for use in their programs. Please reach out at BooksofDiscovery.com. Listeners like you can explore their collection of learning resources for anatomy, pathology, kinesiology, physiology, ethics, and business mastery at BooksofDiscovery.com, where Thinking Practitioner listeners save 15% by entering Thinking at checkout. Whitney, how are you doing?

Whitney Lowe:

I’m doing very well. And how are you doing today, sir?

Til Luchau:

Well enough, thanks very much. What are we talking about today?

Whitney Lowe:

Well, as kind of a hat tip to your foot and ankle course, we thought maybe we should talk about the foot and ankle today. I don’t think we’ve done an episode on this in quite some time.

Til Luchau:

There you go.

Whitney Lowe:

We’re going to do a little bit of a deep dive into some locomotor foot and ankle issues today.

Til Luchau:

And you have some great ideas you sketched out for us and I’m looking forward to learning those along with your delivery. And I’ll add in a few things here and there, but you wanted to start us off with the anatomy of the ankle.

Well, before we do that, I’m wondering if I could just brainstorm with you for a second about why ankle work is even important in our practices, whether you’re a massage therapist or a structural integration worker or acupuncturist, whatever you do. The first thing that I think of is it’s the second most common amateur athletic injury after the only thing that the amateur athletes get more of hamstring tears apparently.

Whitney Lowe:

Interesting.

Til Luchau:

It’s super common.

Whitney Lowe:

It is supposed to be the first or the most common soft tissue lower extremity injury. So I wonder if that’s take out the amateur athletes and everybody sprained their ankle kind of thing.

Til Luchau:

Yep. Number one or number two, you’ll see a lot of them. And whether you’re involved in athletics or not, again, you’ve probably twisted your ankle, probably knows somebody who has and get clients in there. And it affects everything. The ankle isn’t just this funny little part between your foot and leg, it’s where you balance. It’s the most focused part of your weight transmission system through your skeleton, and there’s just too little surfaces there that are transmitting all of your weight and your overall mobility depends so much on what’s happening there. And it’s both your coordination and awareness to that area, but also how comfortable and how mobile it is as well.

Whitney Lowe:

It’s pretty remarkable when you think about this. We often study things like biomechanics in ways that are easy to study, like a flat force plate in a laboratory. But the way in which the foot and ankle complex adapts to alterations and ground surface or obstacles that you may step on or move over or things like that, it’s really fascinating and quite remarkable what it’s capable of doing and forced dissipation. When you think about the impact load of body weight on the ground over and over again from each foot strike, pretty substantial for being able to distribute those forces.

Til Luchau:

That’s right, and especially if people are trained in soft tissue therapy, sometimes the ankle is a blank spot in their map because there’s not a ton of soft tissue there or there is pretty dense, a lot of bone there. In fact, the ankle as I understand it, is the joint whose range of motion changes the least under anesthesia.

Whitney Lowe:

Oh really?

Til Luchau:

Yeah, it’s got the most structural components to it that aren’t affected by muscle tone.

Whitney Lowe:

Interesting.

Til Luchau:

So this range of motion stays pretty constant even in anesthesia, but something like the shoulder gets much more mobile and you have to be careful with those arms.

Whitney Lowe:

Well, I’ll certainly say this from the massage therapist perspective that I often tell people we look at the world through muscle-colored glasses because that’s how we learn everything. And we talk about the leg muscles, we talk about the foot muscles, but you don’t talk about the ankle muscles much because there really aren’t muscles in the ankle so much. It’s just everybody’s spanning across that joint. But there’s not muscles that we think of as much about ankle movement, I think.

Til Luchau:

Good point. Or if fascial structures are interesting, we’re learning more about those through my fascial-colored glasses.

Whitney Lowe:

That’s right.

Til Luchau:

I see a lot of those and we’ll talk about those. Your comment about on ankle muscles makes me think of the talus, which people say is the only bone that doesn’t have direct muscular attachments to it. Is that how you think of it, what do you think?

Whitney Lowe:

I have often heard that, but I also have to make the caveat, because somebody reminded me about this one time. The malleus, incus and stapes also have no muscle attachments.

Til Luchau:

The little bones in your ears?

Whitney Lowe:

Tiny little bones in your ears.

Til Luchau:

They don’t have any muscles in there either.

Whitney Lowe:

That’s right. But I think in the major, we can call about this in the locomotor skeleton, I think only muscle or only bones without muscle attachments to it.

Til Luchau:

Well, what else do we know about the ankle or its anatomy? What do you think?

Whitney Lowe:

Yeah, so we hit on a couple of things there with some of those bones. Of course, we talked about the talus, but of course when you talk about the ankle, the big ones that we have to think about are the major force distributing bones of the tibia, fibula, the talus of course underneath them, and then the calcaneus underneath the talus. Those are the major bones that are maintaining the structure and the design of the ankle.

And if you’re familiar with architectural terminology, the ankle is frequently referred to as a mortise and tenon structure. And that is one I always hark back to my fifth grade science project, which is the first time I learned about mortise and tenon structures when I was building a replica model of Stonehenge. So mortise and tenon is one where there’s a projection that sticks up and then a sort of a cup or an opening that that projection goes into to hold it in place.

Til Luchau:

Well, I’m hoping we can get a picture of that, Whitney, for our episode image of you in a science fair or tell us a little more how that relates to the ankle. What’s the part that sticks up and what’s the part-

Whitney Lowe:

Yeah, so the mortis is the cup or opening, and that is created by the tibia and fibula, their distal attachments sitting over the top of the talus, and the talus sticks up into them. So we can do that. Actually, I got a little model there.

Til Luchau:

I got a little bony model. Unfortunately, it doesn’t have a leg on it. I’ll try to describe it verbally for the audio listeners. You’re saying this, I got to get in the right place so I can see it too. This little thing is this sticking up talus and then the tibia and fibula fit down over it like a cup, you’re saying?

Whitney Lowe:

Yep. So they sit directly over the top. So that’s what creates a lot of… It creates some bony stability around there. But it does also play into some of the injury conditions that we’ll talk about a little bit later because that talus is wider towards its anterior and lower portion. And when you move your foot in dorsiflexion, that wide part rolls up underneath the tibia and fibula and can in a very severe traumatic injury, spread them apart. And we’ll talk about that in a little bit later.

Til Luchau:

This part, again, you’re saying the anterior portion of the talus is wider than the posterior portion. And so when you’re rolling through your movement, that actually could cause problems or in my way of thinking, could cause a movement limitation or restriction if the bones aren’t able to adapt around that extra width right there.

Whitney Lowe:

Yeah. And so one other thing while we’re talking about those two, maybe you can simulate this with your fingers in the hand on the model again. The talus, excuse me, the tibia and fibula, we said they cover the talus, but one of them extends farther distally than the other. The fibula extends a lot farther distally than the tibia does. You can see that on those of you who are not seeing our visuals got a great-

Til Luchau:

I don’t know if it’s helpful or not.

Whitney Lowe:

It is very helpful. It’s perfect. Perfect-

Til Luchau:

I’m going to show now the-

Whitney Lowe:

The fibula with his finger there sticking farther down than the tibia does. And that means now if you were to try to tilt that foot out into eversion, you see how that fibula stops that movement out there. But if you tilt your foot into inversion in the other direction, there’s not as much bony restriction there. And that’s one of the main reasons why you have so many more inversion or medial ankle sprains because the tibia is not sticking down as far to prevent that movement there, so important thing about bony structure with them.

Til Luchau:

That’s good.

Whitney Lowe:

While we’re noting that too, I just wanted to make a quick comment on the stability of those structures around the ankle. That a great deal of our ankle stability of course comes from the main ligaments around there. And if I was tasked with designing the ankle, I wouldn’t have done it the way that our bodies evolved into the current design because I would’ve put the really strong ligaments on the side that has the worst or the least stability.

But what happens is we have a group of ligaments on the medial side of the ankle called the deltoid ligament complex.

Til Luchau:

Over here, yeah.

Whitney Lowe:

Much stronger, much larger, much thicker and helps prevent a lot of your eversion or turning your foot out or medial ankle sprains. But the most common injuries occur from inversion sprains and you just have some really small thin ligaments there. Three main ones on the side, anterior talofibular, calcaneofibular and posterior talofibular ligaments that are not very large and they’re not very good at restraining excessive inversion movements. And I would say that’s probably one of the main reasons we see so many inversion ankle sprains.

Til Luchau:

Yeah, that and we have two legs and so that other leg is always medial to the standing foot and there’s nothing lateral. So you turn that in, fall that way as well. And like you said, there’s not as much bony structure out there, not as much ligaments, stout ligaments.

What about, you talked about some ligaments, what else do you want to know about anatomy?

Whitney Lowe:

Well, a couple other things around there that I think play a role in a number of the soft tissue problems that we see around there. And we talked a moment ago about some of the muscles that are in the leg that control the foot especially. So the muscles that are coming across the top surface of the foot that provide for dorsiflexion and toe extension movements, and then the muscles that go down around the medial and posterior side of the ankle down into the base of the foot to control the flexion movements of the foot and toes.

Each of those, all those tendons are basically taking a right angle turn as they go across the ankle, which means there’s a good chance for a lot of friction because in order for them to work efficiently, mechanically, you have to sort of bind those tendons close to the joint. And this is done with a retinaculum, which is that binding, restricting tissue across those tendons to hold them close to the joint.

And so the tendons have to slide smoothly through that motion there and that causes some potential challenges or problems for them.

Til Luchau:

Without the retinaculum, we’d have toe muscles going from our knee diagonally out to our toe like a big triangle instead the nice corner.

Whitney Lowe:

Top them right up there. And it’d be a lot less efficient in producing forces and there’s a lot of forces necessary for, let’s say propulsion and things like that with those tendons through there as well.

Til Luchau:

I think it’s next episode we’re going to have Rachel Clausen and Nicole Trombley coming in to talk to us. We got inspired by their retinacula article in the latest Massage and Bodywork. We’re going to talk some more about the retinacula and I’m sure they’re going to make the case that the retinacula are also sensory structures or sensing structures. They’re so embedded. In fact, Carla Stecco’s counts of nerve endings has found more mechanoreceptors embedded in the fascia of the retinacula than anywhere else in the body.

Whitney Lowe:

Wait, say that again? More sensory receptors or mechanoreceptors in the-

Til Luchau:

In the retinacula, yeah.

Whitney Lowe:

Interesting.

Til Luchau:

That’s right. I’m going to see if I got that right here. They’re the most innervated of the deep fascia, the deep fascia layer, that particular layer they’re part of and the retinacula are part of the crural fascia, just the stocking of fascia that goes around the leg and turns into the plantar fascia around the foot.

But they’re the thickenings there and they have really high concentrations of nerve endings that help us, again, probably they say help us perceive the movements and positions and forces there at the ankle and are part of the coordination story, about how we get so much information from all the forces going there.

Whitney Lowe:

Interesting. It begs the question too, does that maybe play a more significant role in cases of tenosynovitis and pain from tendon irritation as those tendons course underneath the retinacula if they’re so richly innervated that might be a part of that?

Til Luchau:

Absolutely. They’re sensitive because they’re sensory. It runs both ways. We get a lot of coordination information from them, but when they hurt, they really hurt because there’s so much signal there, so much potential to feel.

Whitney Lowe:

Do you know if its… I mean, I know there’s a whole lot in there, but you mentioned a moment ago, very high concentration of mechanoreceptors. Are there also very high concentrations of other sensory receptors in there as well as mechanical receptors?

Til Luchau:

I don’t know. Let’s ask Rachel next week or whenever next episode when we have minute about that. It’s a good question.

Whitney Lowe:

Yeah. All right. So that’s kind of I think going over in a nutshell some of the main things for us to think about in terms of anatomy structures in that area, the bones, the stabilizing ligaments, the tendons and the tendon sheaths around that.

Now of course, there are some other structures in there that don’t play as much of a mechanical role, but certainly have some important aspects when we talk about other types of pain problems around the areas. There’s some areas for potential nerve entrapment and there’s arterial and venous structures through there as well and other things.

Til Luchau:

Yeah. Can you tell us a bullet point about those? You’ve made some really good points in our plantar foot pain episode about that.

Whitney Lowe:

Yeah, so the big ones that we see most frequently involve the tibial nerve and its branches which courses down the medial side of the ankle around the posterior aspect of the medial malleolus on that side. And then it goes down into the plantar surface of the foot and then divides out into some other branches there.

But that nerve is very close to and adjacent to those tendon sheaths in that area. That’s of course, what we call the tarsal tunnel, similar to the carpal tunnel of the wrist. It’s the tarsal tunnel of the ankle. There’s a flexor retinaculum also that goes from the medial malleolus over to the calcaneus and then those nerves and tendons all course underneath that.

So inflammation, irritation in those tendons in their sheaths can certainly cause nerve compression in there as can some other structures becoming irritated and/or inflamed on the plantar surface of the foot causing nerve pain, which is certainly my experience, frequently misdiagnosed and misidentified as plantar fasciitis when it is in fact a nerve pain problem in there.

Til Luchau:

The nerve pain is so tricky because sometimes it’s really obvious to the person, to the client that it’s a nerve. It’s tingling, it’s numb, it’s electric. But other times, no, it can just be a hurt that’s hard to describe, hard to identify. Sometimes those do respond, like you say, to a more nerve-focused work where we’re thinking about gentle gliding or the happiness of the nerves more than the mechanical mobility of the bones and joints.

Whitney Lowe:

Right. How do we move at the ankle?

Til Luchau:

Yeah. How does this all work?

Whitney Lowe:

Do you want to talk about that or shall I?

Til Luchau:

Go for it, Whitney. I hope you don’t mind.

Whitney Lowe:

Okay, I’ll chat about that. We have four main movements that we’re focusing at in the ankle. Dorsiflexion and plantar flexion are the two main ones that we think about most commonly and they-

Til Luchau:

Pulling your toes, pulling your toes up.

Whitney Lowe:

Pulling your toes toward the knees in dorsiflexion and pointing your foot, pressing down the gas pedal in plantar flexion. And those motions occur primarily at the, I do not like this word because I always have trouble saying it, talocrural joint. I wish they had created a different word for that. Crural, C-R-U-R-A-L.

Til Luchau:

Talocrural joint. The joint between the talus and the crural is foot, or I believe Latin for foot.

Whitney Lowe:

Yeah. So this is the joint between tibia, fibula and the talus. So talocrural joint there. Those are our motions of dorsiflexion and plantar flexion. And then below that, the joint between the talus and calcaneus, we refer to as the subtalar joint.

And that’s where the majority of your inversion and eversion had come from. And the inversion, of course, the movement where the bottom surface or plantar surface of the foot is pulled inwards toward the midline. Eversion being the opposite, the bottom surface of the foot tilted out towards a lateral direction.

And we noted earlier, you obviously clearly have much more range of motion available to you, normal range of motion in inversion than you do in eversion for those other reasons that we mentioned earlier.

Til Luchau:

That’s a great description. And those movements, understanding where those movements are happening is really a great key to helping clients with obviously movement restrictions, limitations. If it’s hard for them to bend down and tie their shoes, dorsiflexion could be a real factor in that or of gait issues like a limp. Or when we give people even just a little more, a little easier dorsiflexion, sometimes they feel like they’re floating on air because it gets so much easier.

But then for lateral stability, rolling of the ankle, those kinds of things, that’s the next joint down, like you said, between the talus and the calcaneus.

Whitney Lowe:

Yeah. And one of the things, I don’t know, I was going to ask your take on this too. I remember learning this early, early on in massage school. They talked to us about when you’re trying to stretch somebody’s calf or get them to stretch their calf. It seems more prevalent at this area than other areas for some reason. But the fact that you can’t really stretch your gastroc and soleus muscles in dorsiflexion as much as another individual can do that when they add additional pressure to that. And then you get some additional stretch in there generally that you can’t produce actively very well with your own movement.

Til Luchau:

It sure feels better when someone else does it to me than what I’m doing to myself. I know that. There may be a leverage thing involved. It might be that you can’t tickle yourself principle. I don’t know what it is, but there’s sure things that people can do with me that I can’t quite seem to find myself.

Whitney Lowe:

And maybe that’s also some of that something else, because you can certainly do it on the stair methods or the mechanism of leaning over forward and that kind of thing that can do that. But when you do, we talked about this earlier a moment ago, just to keep in mind when you talk about the dorsiflexion movements in particular, that this does have a significant role in some ankle injuries, both the dorsiflexion and plantar flexion movements.

We see the ankle sprains a lot more common when people invert and plantar flex their foot. Not just the inversion, but this is the common injury of stepping in a hole, stepping off a curb, your foot turns inward, but it also plantar flexes, because that’s the movement that puts those ligaments at the most vulnerable position.

Til Luchau:

And the place that puts that talus in the least supported position in its joint too.

Whitney Lowe:

Exactly.

Til Luchau:

There’s less support, bony support from above as well. If I had to pick between plantar flexion and dorsiflexion as the only one I could have, I’d pick dorsiflexion.

Whitney Lowe:

Okay, you got to explain that, because I think you made me think about this for just a second. I’m going to definitely pick plantar flexion, so I want to hear why you picked dorsiflexion.

Til Luchau:

That’s why we’re doing this together. Without dorsiflexion, let’s say my dorsiflexion is limited, my head’s going to bob up and down pretty severely of every step I take. I got a dorsiflex to even have a smooth gait to be able to step through. It reminds me of high school when we were all wearing these monster hiking boots around and we’re bobbing up and down wherever we went.

Whitney Lowe:

You’d have to pick your feet up to clear the ground.

Til Luchau:

You would have to pick your feet up to clear the ground to avoid stubbing your toes all the time without dorsiflexion. Why did you say plantar flexion?

Whitney Lowe:

Because I like to move forward and you don’t even worry about your gait looking funny. You will not move forward at all with no plantar flexion.

Til Luchau:

You need to be to point your toe to reach for that ground out in front of you, you’re saying?

Whitney Lowe:

Well, yeah. And the propulsion phase of pushing forward is plantar flexion.

Til Luchau:

Of course. There you go. Okay, good thing we have both.

Whitney Lowe:

There’s good reasons for both, absolutely. And anybody who’s had neural disorders that limited their plantar flexion from nerve problems will certainly tell you it’s going to mess with your gait a lot. There’s some significant neural injuries that we see showing up that way too. So yeah, I want to have them both.

Til Luchau:

The movements there, especially the subtalar joint, are pretty complex and we don’t need to get lost in those weeds right now. But for sure in the live trainings we have some great animations we use and then some exercises we use to feel the oblique joint of that. I mean, sorry, oblique axis that those joints are moving around. It’s different at different phases of the joint. I think for today’s purpose it’s enough just to acknowledge that it’s a weird axis. It’s not like a typical hinge.

Whitney Lowe:

It isn’t, yeah.

Til Luchau:

And if you’re thinking mobility, you got to turn your head a little bit sideways and look at it a little differently.

Whitney Lowe:

For sure. And the illustrations, some of the very best illustrations of that, and you probably remember this, the book from Kapandji’s Atlas, some of the visual diagrams in that book about the motions of these joints are some of the best diagrams still that I’ve ever seen on there. But it’s messy and complex because it’s not just those simple single plane movements that we see in so many other joints.

Til Luchau:

Great.

Whitney Lowe:

Yeah. And you and I touched on this a little bit too, and I don’t remember the episode number, but we did do a deep dive on pronation a while back and we talked about that multi-planar movement in the ankle, which actually defines what pronation is. So well, maybe we’ll put that in the show notes or something and go all back to that.

Til Luchau:

Yeah, we’ll reference back to that to another episode. What did you want to say about valgus and varus alignments there?

Whitney Lowe:

Well, this is another thing in the ankle that I think plays a really important role in why people are susceptible to certain types of soft tissue injuries or even hard tissue, bone stress fractures and things like that. And there are some really misunderstood concepts around those two terms, valgus and varus alignment. So briefly, a valgus alignment is one in which there is a lateral deviation of the distal end of a bony segment, a lateral deviation of the distal end of a bony segment.

If we’re talking about the ankle complex, “Hey, can you pull your ankle up here for just a second again and turn around and heel toward the camera,” just like that. For those not watching, so if the lateral, excuse me, the distal end of the heel, the part that would be touching the ground deviates in a lateral direction, that would be a calcaneal valgus position. And we often see this with people who over-pronate or they walk over on the inside aspect of their foot, because their calcaneus is deviating there.

Til Luchau:

Then you’re talking about just the calcaneus or the whole calcaneal tolerance?

Whitney Lowe:

Mostly the… Well, it’s going to bring everything with it, so mostly the calcaneus, but it’s going to of course, begin to bring a lot of that stuff with it there.

Til Luchau:

A little bit rolled toward the inside, you’re saying, the valgus?

Whitney Lowe:

Then we too need to think about the kinetic chain properties because that calcaneal valgus almost always is going to have an associated effect at the knee and the hip and farther up that whole chain because other things are going to get out of that alignment position and they’re going to be having to try to balance and stabilize as a result of that.

And you often see that calcaneal valgus a lot with people who have a hallux valgus, which is the lateral deviation of the distal end of the hallux, often from the people who get bunions and the great toe is being forced over toward the midline there. And that now you’re rolling over towards the medial side of your foot and you don’t have the same degree of stability from the foot complex nor from the distal hallux complex. So that leads to overuse on the plantar fascia, overuse on the flexor muscles, possible sometimes stress fractures on metatarsals and numerous other complaints in there as well.

Til Luchau:

Okay, thank you. That’s very well described and clearly articulated. Can I play devil’s advocate?

Whitney Lowe:

Of course, I love that.

Til Luchau:

We may be repeating some of the things we talked about in our pronation episode, but that’s all right. There’s the correlation between arch height, which is kind of what you’re describing. You’re describing a valgus calcaneus that would lower the arch. The correlation between arch height and symptoms is not well established.

It’s been assumed for a long time that lower arches or this valgus position or collapsed arches or fallen arches correlate with more pain or performance. You couldn’t get into the military if your feet were too flat, lots of things like that. But it turns out that in some cases that may be true, but in not nearly as many as we thought. And there are some famous examples of people with really valgus feet that do amazing things without symptoms.

Whitney Lowe:

Yeah. And that’s a great point because it reinforces this idea that we really need to think about individuals and what they’re doing. For example, maybe you’ve got a person with pretty significant calcaneal valgus, maybe even a significant hallux valgus and lower extremity issues, and they’re kind of a sedentary office worker. And you look at their feet and they think, “Oh man, their feet are a mess,” but they’re not in a weight-bearing position for very much of the day. So, they don’t have anything that they’re doing.

And then they say like, “You know, I want to get in shape, I’m going to start running,” and they decide they’re going to start running on hard pavement surfaces with their particular structural alignment problem. What wasn’t an issue before might become an issue at that point because the load is changing and the management of that load is changing. I think we can’t just look at those structures alone and say that’s the problem. I think this is why looking at a person’s history and what they’re doing is so crucial as well.

Til Luchau:

Something that’s not in alignment might be a factor for someone who’s putting enough load or is frequently enough to make a problem, that might be a factor. But it’s not necessarily fate where it doesn’t explain all the issues we see with people either.

Whitney Lowe:

I think that’s true. Yeah.

Til Luchau:

This is a particular peeve of mine maybe because I have very low arches. For years, people would look and go, “Oh, do those collapsed arches give you problems?” And my Rolfers will all pick on that. And lots of things like that where it’s like, “No, I don’t have foot or ankle pain.” I’m not the fastest runner in the world, but I run here in my sixties. I’m still a runner. I’m a case in point of where, no, I got really exceptionally low arches. People who do the analysis go, “Oh man, that’s got to be a problem for you.” No, not at all.

Whitney Lowe:

And again, this is the issue back to adaptability. The body has so many capabilities to adapt. You and I should get together and do a foot show because I have extremely high arches and I have my toes. I don’t know if this is part of my mother’s Ehlers-Danlos that passed. She passed on to me with extreme flexibility, but I can pull my toes actively back into about 90 degrees of extension, and so I can tilt my foot up and carry a tray basically with my toes like that.

Til Luchau:

I want to see that at least. That’s good.

Whitney Lowe:

My wife always tells me about my deformed feet that are like that, but again, I don’t ever have any problems with them, so they work for me.

Til Luchau:

Yeah. So you say you have high arches. Would you describe the ligamentous resilience as firm or less firm?

Whitney Lowe:

Yeah, certainly less firm because like I said, I’ve got Ehlers-Danlos in my genetic tree, so that hypermobility tendency throughout, which also means I have sprained my ankle a lot because of just that extra degree of mobility in there. But why do I have high arches? I don’t know. It seemed like it might be the other way around.

Til Luchau:

That’s also a great case in point where our usual or stereotypical explanations of like, yeah, high arches are because of tight ligaments or muscles or something pulling everything up into an arch and classically thought of as being high and rigid. Yours is not describing that. In my arches, very low and “collapsed” or thought to be more hypermobile or less supported, that hasn’t been my experience. That’s not generally the case in my body either.

These correlations between arch height and tissue qualities, there’s lots of exceptions, which also calls into question our strategies or conventional strategies for working with them as hands-on therapists, you could say.

Whitney Lowe:

Yeah, so it comes back to this question, I think, oftentimes that we’ve been asking ourselves more and more, at least I will say that I have been asking myself more and more frequently, when does it matter? When do these things matter? And I think the idea that you can just look at structure and say like, “Oh, there’s a problem,” I’m not on board with that any longer because I just do think structure is not destiny.

Til Luchau:

And Greg Lehman’s point, we had him on a couple episodes, he says, “Well, manual therapy doesn’t have a real good track record of showing its ability to change those things. And so why are we worrying about them anyway?” There’s things we can change, things that maybe aren’t quite within our realm. I think a lot of Rolfers would probably debate that because what we’re about and that point of view is changing the structure. How much that’s happening, again, that’s the debate.

But there are certainly changes we can make in someone’s function, in their body awareness, in their coordination, in the adaptability of the tissues and joints that can make a big difference in certainly subjective experience like pain and the ease of movement. And there’s probably objective measures too that we have studied or haven’t yet studied that are really obviously the result of hands-on manipulation.

Whitney Lowe:

Yeah, I think that’s true. And we touched on this a little bit too in the last episode where we had Tom Myers with us and we were saying that a lot of us are leaning a little bit more, or maybe even sometimes a good bit more onto the role of neurology and neurological results, producing many of these kinds of changes that we had formerly and previously ascribed to manual loads or force loads changing tissues that there’s probably, yeah, we can probably do some things with manual therapy to work on things like posture and structure and things like that.

But it might be that what we’re really doing is changing more of neurological responses than we are of force pulling or force compressing or whatever it is tissues to make somebody’s posture change.

Til Luchau:

You make me think of a really specific example. It was one of the fascial congresses, I believe is not the one you and I went to in Montreal, but the prior one which probably would’ve been 2018 in Berlin. There was a very careful study of collagen supplements and ankle injury recovery, and they were doing some work on wobble boards. I’m sorry, I don’t remember the reference. I’ll try to go look it up and put it in the show notes. Doing some work on wobble boards and checking to see did people who took collagen have a better recovery because they had more of those specific amino acids and proteins available to repair the fascial damage that had happened.

And what they found surprisingly to everybody was that, no, there weren’t objective mobility chain differences between the two groups, but there were very clear functional measures between the two groups. They were different. There was much greater coordination and accurate control of the collagen group. And nobody can explain that. I don’t know if they’ve come with the explanation since, because we think of collagen as a structural protein, it’ll help the ligaments and tendons and fascial, perhaps regenerate. There’s some debate about that because it gets broken down and digested anyway.

But what they’re finding was that there wasn’t a structural change. There was a really big functional change.

Whitney Lowe:

Interesting. Yeah.

Til Luchau:

Again, they weren’t able to offer an explanation, but it made me think about how there’s so many things that make a difference and our explanation for them is pretty speculative. We can think about it structurally. We can think about it functionally, but what we know is we can help.

Whitney Lowe:

And I think that’s probably going to be some of the leading edge to looking at other more locally applied aspects of this in the future. Instead of orally, is there a way to target collagen supplementation to a damaged structure itself as opposed to it’s just like with taking muscle relaxants and say, “Okay, I’ve got a spasming splenius capitis muscle,” but when I take a muscle relaxant, I can’t say, “Hey, would you please just go to my splenius capitis and leave everything else alone so I don’t feel like I’ve been drugged or whatever,” but it is more global effects in there. I don’t know. I’m sure we’ll see that. We’ll see that in the future, I’m sure.

Til Luchau:

Did you get to say what you wanted to about ankle injuries?

Whitney Lowe:

Yeah, so we had kind of touched on ankle injuries before. The common ones that we see, especially frequently medial and lateral ankle sprains. We noted of course, lateral ankle sprains being much more common. The medial ones being, usually when you see medial ankle sprains, you’re talking about a much more severe injury, higher force loads, much more significant trauma. And oftentimes, you’ll see fractures associated with them just because the forces required to sprain. Those ligaments are often bad enough to cause bone fractures in there as well.

The one that we didn’t talk about as much, we mentioned this just briefly was the syndesmosis sprains. And this is sometimes referred to as a high ankle sprain, so it is the sprain or overstretching of the ligament, the distal tibiofibular syndesmosis, so that connective tissue between the distal tibia and fibula. And we talked about how the talus can roll up underneath those two. So, if I do it with my hands here sort of rolled up underneath there. Yeah, let’s put your foot model back on the screen.

Til Luchau:

I’ll find my little primitive model.

Whitney Lowe:

So tibia and fibula is sitting like that and is that wide talus rolls up underneath him. You see this in, especially in sports injuries like in football where they’ve got cleats on that are digging into the ground and a person is down in an extreme dorsiflexion like squatting down, and then their leg rotates in that position. You are in an extreme of dorsiflexion rolling that tibia, that talus up underneath the tibia and fibula and then you turn and rotate the foot that spreads those two distal bones apart and causes the high ankle sprain.

Til Luchau:

Basically a sprain between the tibia and fibula there.

Whitney Lowe:

Yeah. Hard one to mess with, hard one to treat, and usually they tend linger on for a bit longer too because they’re some pretty serious forces and they’re doing that.

Til Luchau:

Yeah, there’s pretty serious forces and like you said, there can be some bony fractures and things like that associated with that as well because those ligaments are so strong that they will hold the bones together even when the bones are being forced apart. Sometimes, the bones will give.

What do you think about the debate? And I don’t know if you’re familiar with it, but I’ve certainly heard a lot about it from my friend, colleague and former assistant, Jeremy Sutton, in Australia who coaches pretty high level amateur soccer. And his view is that most ankle injuries are injuries to the outer layers, not the ligaments. And that many times the ligament is assumed to be injured, but they respond even better when we treat them either with manual therapy or with different methods that he uses as if it’s the outer layers of superficial on deep fascia around the foot and leg.

Whitney Lowe:

That’s interesting. One of the things that I would want to ask, and this again is revealing my orthopedics bias, is there are some pretty good tests for testing the stability of those individual ankle ligaments for the motions that they-

Til Luchau:

Yeah, exactly.

Whitney Lowe:

Yeah, so the anterior drawer tests and the talar tilt test and those kinds of things are pretty accurate at doing that. What I don’t know is how much those other fascial tissues might be aiding the stability and might show up as a weak or mobile ligament when it’s really the more superficial tissues out there. And that would be something really good to study.

I don’t know the answer to that, but that’s how I would probably tend to look at that. And also getting a lot more specific with our palpatory examination because it’s pretty easy to zero in on those anterior talofibular ligament fibers or the calcaneofibular ligament and see if there’s anything right there. And then maybe the tissues between them, which there would still be significant fascial expanses between them.

If those aren’t as point tender as the ligament per se itself, that would kind of tend to point me in the direction of being more about the ligament. But the whole thing is tender, I would say that makes sense that there’s probably some other superficial tissues in there.

Til Luchau:

Well, I’m thinking there is a recording of him and I having this conversation in our library for our subscribers on our site, but briefly, his point is that the discoloration, the black and blue, the swelling, those are consistent with superficial tissue injury. The ligaments wouldn’t cause either one of those.

And so that often that’s what gets people’s attention and that’s obviously what people are seeing. And those recover with gentle movement, gentle challenge, gentle loading in ways that we might not think of doing with ligaments, where we’re immobilizing those kinds of things.

Whitney Lowe:

And again, this comes from our segmented and siloed attempts to learn anatomy because it’s really unlikely to say like, oh, when you have a pretty serious, let’s say ankle sprain, it just got the ligaments only.

Til Luchau:

There’s more than one thing, right.

Whitney Lowe:

So much other stuff in there that probably also got involved in. Yeah, that’s why you got a lot of swelling and that’s why you got discoloration and bruising and things like that because yes, you disrupted capillary beds and yes, you probably pulled on superficial fascial tissues and all those other things in there at the same time. But the ankle sprain is going to get the attention because that’s what we’ve learned to focus on.

Til Luchau:

This is trickling over into the ice debates I’m remembering now. He apprenticed with a rehab therapist, physical therapist that worked a lot with ankle injuries and this therapist method was distraction. And court side, field side injuries, just he had these interesting arrangements of giant rubber bands that would put a lot of distraction on the foot, basically traction on the ankle joint and people were getting up and getting back in the game. And they didn’t show ligament injury as the cause, but they were down for the count until he did this distraction with them.

Whitney Lowe:

Interesting.

Til Luchau:

I know it was bizarre. We were having this argument. I was at Jeremy’s house and we were hanging something in his ceiling and sure enough I twisted, I fell off that ladder and twisted my ankle. He went and got his rubber bands and put them on my foot and pulled on it. And I’ll be darned, but it popped and I felt better and I was back up doing stuff.

Whitney Lowe:

Interesting.

Til Luchau:

It was so weird.

Whitney Lowe:

Yes. So we need to do some more investigations on that and maybe that reframes our understanding of what the real pathologies or problems are that are occurring in those.

Til Luchau:

Of course, I’m not suggest… I should say this. I’m not suggesting you try that at home. Don’t go get up on your ladder and follow up, you just pull on it to be better, but there’s more going on than we realize sometimes.

Whitney Lowe:

Yeah. So I think, that’s kind of… And we talked to some others about the problems with nerve compression in this area like in the tarsal tunnel region around the ankle as well. And we mentioned the tendon sheaths that course underneath the retinaculum, often susceptible to something called tenosynovitis, which is an inflammation and irritation adhesions developing between the tendon and surrounding synovial sheath on the top of the foot.

A lot of times, this is sort of colloquially referred to as lace bite. Lace bite, it happens a lot in ice skaters and people wearing tight boots that are laced up really tight because they sort of dig into and cut into that retinaculum and the tendons are trying to slide back and forth inside there and they’re getting bound and restricted in those regions.

Til Luchau:

If that was the case, if there was an irritation caused by repeated compression or friction there that it didn’t like, we wouldn’t necessarily want to add more compression or friction at least not repeatedly to try to make it feel better.

Whitney Lowe:

I don’t know the answer to that and wonder about that. I keep digging into the research to try to answer this question. Is it a good idea to do friction massage to something like tenosynovitis? Are there really adhesions in there that we are breaking up that is allowing more freedom of movement there? What do you think about that?

Til Luchau:

Well, my goodness, Whitney, I’m glad you asked because this is an area of interest to mine. I think we had a whole episode on inflammation, so I’ll try not to give a whole episode answer. But basically, there’s a time for it and there’s a time not for it. A time for it might be someone who’s otherwise healthy, they’ve tried everything, they want to see what happens and maybe some, like you said, cross-friction or other kind of direct work on something that might be inflamed like that on the lower limb could make the difference.

The mechanism of how that works, maybe it’s restarting an inflammatory cycle that’s stuck in the wash cycle almost and keeping things agitated. Maybe by getting it agitated again with our work where you’re letting it restart so that it can go through the whole chain of events that leads to resolution. That’s the best explanation I have.

That’s an argument against continuing to wail away on someone’s sore bursitis session. Maybe we tried it once, maybe we tried it twice, but more than that we’re probably just keeping it irritated. And it can take quite a while, it can take weeks to recover from a too deep body work session on tissue. So we may not always have the time involved to assess, did this make it better or not, either if we just keep working on stuff that’s inflamed. Most of us know that.

Whitney Lowe:

I would say for me, in terms of strategies for treating something like that, I would stay a lot more away from something that was a perceived bursitis problem because there isn’t really a good reason that I can think of to want to do the additional compression in there. But when you’re talking about tenosynovitis, to me the jury is still kind of out and I don’t know the answers. Can we, in fact, with manual therapy break up adhesions between a tendon and a surrounding synovial sheath?

Clinically, we seem to get good results in a lot of instances, but is that really what we’re doing, I think, is where I get stuck.

Til Luchau:

Well, if adhesions, yeah, who knows? That’s certainly something some of us are thinking about and think we’re doing. Has that been tested or proven? Who knows? And are adhesions the only factor? I was answering more in inflammatory sense, inflammatory cycles, but the mechanical adhesion between layers that can happen through prolonged inflammation or even for other means, sometimes it’s a mystery why things adhese.

Yeah, there’s debate. There’s people that say we can, people that say we can’t. And probably the results are like that too. In some cases we can, some cases we can’t get results.

Whitney Lowe:

And as we were wrapping up, I was going to say this is a lot of what directs our treatment strategies, making some of those kinds of decisions about what do we think we’re going to be doing in here and is this basically… I think a lot of the work that we might do around this region has a lot to do with enhancing proprioception and improving overall awareness of the foot and ankle mobility with the things that we’re doing in addition to what we might do from a mechanical standpoint.

Til Luchau:

I think you’re right. I think you’re right, especially with this understanding of the retinacula deep fascia is highly innervated, some of the most highly innervated in the body. That’s where the brain stem presumably is getting a lot of its information about balance and movement. We’re talking to that pretty loudly with our hands.

And maybe we’re helping it reset its sensitivity levels. Maybe we’re helping refine its accuracy or acuity of perception or monitoring of movements and forces in those areas probably have some effect on all those things that could explain the great results people see even in acute situations, but especially in ankle sprains or injuries that haven’t healed over time. We get so much more results than are explained just by mobility changes which we can also get.

Whitney Lowe:

Yeah. So what other things do you feel key things for us to touch base on with? I mean I think you mentioned some things about the importance of educating our clients and some other things like that that are also critical in there.

Til Luchau:

Well, just something really practical level, maybe I am dorsiflexion biased. I want to make sure someone has that I’ve had a chance to address their dorsiflexion sensitivity or restrictions first because pronation is a way around dorsiflexion. If I’m bending down to, again, tie my shoes or something and I can’t dorsiflex or it hurts to dorsiflex, I’m going to pronate to get down there.

And I’m going to make my knee go medial and do all kinds of things to get down to the ground. If we’re just, again, starting from the ankle and looking at that zone, I’m going to make sure that dorsiflexion is available before I start assuming a lot of things are the problem in the foot itself.

Whitney Lowe:

And so just to kind of back up and sort of touch base on this, this is kind of I think what most people would tend to do. But when you see the limited dorsiflexion, is your primary strategy to look at gastroc and soleus as the muscles that tend to restrict dorsiflexion or what do you tend to look at as the key together?

Til Luchau:

Well, let’s say there’s a restriction. I say, “Can you do a little squat for me,” and their ankle angle doesn’t change much but they do most of it in their knees, say. Then I ask myself, is it a type one or a type two? Is it the back of the leg, the sural complex, the gastroc and all that which wraps around, plantar surface is part of that, is that not lengthening type one or is it that the tibia and fibula are not adapting around that widened part of the talus type two restriction?

And so sometimes it’s simple as asking, “Where do you feel that?” And they’ll point to the front of their ankle and go, “Oh, it feels like a pinch or jamming right here.” And that’s a big clue for me. Not definitive, but that gives me the strategic way to start. Or they’ll say, “Oh, the back of my leg, this is cramping up and tight.” And then I’ll go, “Okay, I’ll start there.” So strategically, that’s one way I might proceed there.

Whitney Lowe:

That makes sense. Yeah. So getting again, and that may lead you into some things that you would want to do with them in terms of home care suggestions and education too about can you think about your foot and ankle complex when you need to? Can you squat down on the ground or if you try to do that, can you think about what you’re feeling in there and try to maybe do that movement a little differently or something like that?

Til Luchau:

Yeah, there’s some fun ones where walking up to a wall and then touch the wall with your knee and then play with leaving your heel on the ground and touch your knee to the wall. And now touch the wall one inch lateral of there and now touch the wall one inch medial of there. You start to get that not only range, but the variation of angles in there. And that’ll not only increase mobility, but also increase the control and perception of what’s happening there at the ankle.

And I do think, honestly, I do think about the ability to move in an aligned plane, even though I’m no longer thinking about, let’s stack up those bones like I used to think about as an early Rolfer. I am thinking, “Can I find that pure sagittal plane? Can I let my knee go straight out over my second toe,” for example. Is that available to me and in a comfortable way? And if not, that’s something I want to try to help with before going onto a whole lot of other things.

Whitney Lowe:

Yeah.

Til Luchau:

I mean it does deserve mention that toe joints, the knee, hip joints, even the lower back will all reflect or be part of what’s going on at the ankle too, that if you have… I mean I’m dealing with a broken toe right now and it’s affecting everything. And certainly I’m not doing with my ankle what I used to do because I can’t bend my toe joints as much. It’s part of a bigger system that we’ve talked about in isolation here, but the relationships between all those things are really key.

Whitney Lowe:

And one little binder restriction in one part of that chain of complex can certainly affect how the rest of that stuff has to compensate for that further down the line just in the same way that you mentioned there. We want to look at all of those different factors. And again, just to put a plug in, one of the reasons that I think therapeutic manual therapy body workers have such a valid place in our system of giving care to people is because we spend enough time with people to go through these things and look at these different relationships and see how we might be able to help not only just the one area that they’re talking about having discomfort in, but the other things that are contributing to that all throughout the rest of the body as well.

Til Luchau:

And this holistic model is a W maybe that says use the whole foot. It says, can we engage, feel, and support ourselves through both the medial and lateral arches? That’s really key too to the happy ankle.

Whitney Lowe:

Yeah. Well, all right. I think we did a nice sort of survey over you diving into things going on with foot and ankle complex and just putting in one more quick plug, if you want to learn some more about that, come hop in on Til’s coming up class there.

Til Luchau:

Oh yeah, come sign up, advanced-trainings.com, for the live stream where I’m going to… This is like the 14th topic in our Advanced Myofascial Technique series. The only one I haven’t yet committed to tape hasn’t been recorded, so this will be a fun event to actually record it live and people can sign up and just come join us there. Check it on our site.

I’ll mention our other sponsor for the episode, which is ABMP, they do support our podcast. Associated Bodywork and Massage Professionals, their membership gives professional practitioners like you a package including individual liability insurance, free continuing education and quick reference apps, online scheduling and payments with PocketSuite and much more.

Whitney Lowe:

And ABMP CE courses, podcasts, and their Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession, including from both Til and myself. And thinking practitioners can of course save on joining ABMP at abmp.com/thinking. Once again, thank you to all of the listeners who hung out with us today and to our sponsors as well. You can stop by our sites for the video show notes, transcripts, and any extras. You can find that over on my site at academyofclinicalmassage.com. And Til, where can they find that with you?

Til Luchau:

That’s advanced-trainings.com. Again, that coupon if you want to sign up for the ankle live stream or the recordings afterwards is TTP. Just put that in a checkout, save on that enrollment. If you have comments or questions or things you’d like to hear us talk about here on the podcast, just email us or send a short voice memo to our email info at thethinkingpractitioner.com or look for us on social media. It’s always nice to hear from you there. You can find me at Til Luchau. Whitney, where can people find you?

Whitney Lowe:

Same thing on social media, you can find us over there under my name, Whitney Lowe on social media. And if you would take a moment out to rate us on Apple Podcasts, it really does help other people to find the show, helps keep us going here as well. You can hear us in other places such as on Spotify, Stitcher, Podbean, or wherever else you happen to listen. So please do share the word, tell a friend, and we will look forward to seeing you again in the next episode. So, happy ankles everyone.

Til Luchau:

Thank you, Whitney. See you later.

Whitney Lowe:

All right, sounds good.