Modern Manual Therapy Blog

The MMT Team and I are taking a break for the holidays! I hope you guys are enjoying the blog this year and as always we have more awesome content coming your way as soon as next week! Everyone should be practicing gratitudes each day for well being and I am always grateful for all of your support, shares, and comments!



To give thanks, I am having a sale on all EDGE Mobility System products with the coupon code turkey20

This includes our popular and new EDGE Back SupportEDGE Suspension TrainerThe Occlusion Cuff for BFR, as well as our classics - The EDGE Mobility ToolMirror Box, and EDGE Mobility Bands!

Sale ends Nov 28, midnight EST. Click below to save!
Click here to apply the 20% off coupon to your cart! Ends Cyber Monday 11-28 midnight EST!


IASTM Technique 2.0 is 9.0 of training in IASTM, Compression Wrapping, and Functional Cupping! Eligible for CEUs and $50 off with the link below!

With our popular new MMT Webinars, full lectures from my MMT seminars, Q&A, live cases and hundreds of manual techniques, there hasn't been a better time to check out Modern Manual Therapy Premium! Save $20/year on yearly subscriptions and $2.00/month on monthly subscriptions by clicking on the links below.
MMT Sale Monthly
Thanks for all your support, comments, and questions! Keep them coming! I hope everyone in the USA has a safe and wonderful holiday and everywhere else, have an amazing week!
Keeping it Eclectic...




We know that performing eccentric hamstring exercises such as the Nordic Hamstring Exercise can be beneficial in hamstring strain rehabilitation and injury risk reduction. The problem is, you don't always have a partner willing to hold your legs down while performing the Nordic Hamstring Exercise.

This is just a short piece, a reflective piece, about a value that makes up the very core of what I believe in and what I strive to achieve as a Physiotherapist - empowering my patients with the knowledge and the skills they need to make them independent. This year has been hectic, trying to understand and adapt to working in America and personally accomodating to a new workload after studying for nearly two years. I'd be lying if I said I wasn't tired or that I didn't get lost in the daily grind. But not today! Today I am going to take a moment to reflect and to celebrate :)
These past few weeks have reminded me of a very special part of treating patients - discharging them. For months now I have worked intensely to help the small patient population I have contact with. After investing so much time in their development and progress, it is a magical moment when they come to me and say "I am not 100% better, but, I know what the problem is, I know how to make it better, what I need now is time to follow through on my goals and I can take it from here." 
What a pleasure it is to hear that. I know that no one will ever be 100% when it comes to discharge and I am fine with that. Firstly, I don't set "being 100% pain free" as a goal and secondly, I think we all suffer from pain at some point in time. What I feel is more important is for patients to functional normally and in the most ideal way for their lives.

STEP 1 - LET ME HELP STEER YOU IN THE RIGHT DIRECTION

It all starts at the beginning. Where life is altered by pain or injury and when patient's seek out care because they don't function in their normal way anymore. It can be tough sometimes to get the ball rolling, to retrain movement patterns and daily habits, to get pain levels under control, and to motivate patients to begin to drive their own recovery. The first step is showing patients what the problem is, setting milestones that help them identify with their own recovery process, and then guiding them through rehab until they reach step 2. 

STEP 2 - START TO TAKE THE WHEELS

Once pain is no longer driving their willingness to come to therapy, who is?
Sure ain't me. As I've said once before - I will sit beside you on this journey to recovery, but I will not drive you there. So step 2 is all about recognising what other barriers need to be overcome or goals need to be achieved before the patient can be functionally unrestricted. 

STEP 3 -  NOW IT'S YOUR TURN TO DRIVE

Once you are functioning well - do you know how to stay that way?
At this point in time I hope that my patients are developing a sound knowledge about how their bodies present/move/behave when they are both feeling good and feeling bad. Developing this self awareness is a key step towards understanding their bodies better and identifying where their rehab needs to go for them to be 100%.

STEP 4 - I AM NO LONGER A PASSENGER

If you're staying good and doing what you love - do you still need my help?
It is definitely sad to say goodbye sometimes but we have to set them free. This past week has been sprinkled with discharge assessments. Patients who come in smiling because they only have good news to report. They are playing the sports they love, they can use exercises to manage any niggles that may come up, they are no longer thinking about their injury or their body part, and they see the end goal in sight. And this is when I ask - do you still need my help to get to the end? And with a smile, they reply, I can take it from here. 
IMG_3118.JPG
So to my patients who shared these moments with me - thank you. Thank you for the months you invested in your own life. Thank you for driving the rehab in the direction you chose. Thank you for the endless open conversations trouble shooting problems and setting personal goals. Thank you for stepping up and being the lead part in your own story. Without this attitude, this approach would not be possible. 
And to my readers. Don't take for granted the immense impact we can have on someone's life as physiotherapists. Not for one second to I think I can help everyone and that everyone will get there, I am not that naive. But I am experienced enough to take a moment to celebrate the wins, because they make it all so worth while. 
The journey is always the reward.


Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

twitter @siansmale
instagram @siansmale_SF


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...



This blog is intended to discuss the overall concept of the Motion Guidance system.

Podcast: Download file | Play in new window

What happens when the therapist has an injury? Listen in to Jason sharing his story of how he treated himself for Achilles tendonitis.


Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.

Keeping it Eclectic...




How do you know if a patient has the capacity to fully pass a neurodynamic test? Passive testing with overpressure should be checked in each component (joint) of the test outside of the actual neurodynamic pattern.




It’s been a year, already?! Yup. Things just move that fast, these days. Last year, the APTA’s Private Practice Section conference was held in Las Vegas — you can check out our recap, HERE.


INTRODUCTION

Over the past four years there has been a resurgence in interest about a small little lateral ligament of the knee known as the anterolateral ligament (ALL). I’m not even sure I remember learning much about it during school, but with the number of ACL reconstructions associated with chronic rotational instability rising, researchers and surgeons have been diverting focus to understand what impact an ALL-deficient knee has on ACL recovery and regaining rotational stability. 
The ligament was first published in 1879, when French Surgeon Paul Segond described the ALL in-relation to an avulsion fracture known as a Segond Fracture (Pomajzl et al., 2015). For a long time there remained a paucity in the literature about the exact anatomy, histology and biomechanical function of the ALL. In 2015, Pomajzl et al conducted a systematic review on all articles prior to 2014 about the ALL. Only 13 papers met the inclusion criteria, but what these articles confirmed, is that there were several studies clearly defining the ALL as a distinct ligament and not a fibrous branch of the LCL or ITB. It was around this time that the ALL made its way back onto the map of the knee. The remainder of this blog is a refresher about the anatomy and biomechanical function of the ALL and what we currently know to be true about it’s role in rotational stability of the knee. 

ANATOMY

The anterolateral ligament (ALL) of the knee is a distinct ligament, separate to the lateral collateral ligament, that has fibres which span obliquely over the LCL connecting the lateral femoral condyle to Gerdy’s tubercle on the tibia (Bonanzinga et al., 2017). Vincent et al (2012, p.147) describe the anatomy in greater detail stating that:
  • The ALL begins near or on the poplitus tendon insertion on the lateral femoral condyle.
  • It inserts into the lateral meniscus and the tibial plateau 5mm distal to the articular surface and posterior to Gerdy’s tubercle. 
  • The average width is 8.3mm ± 1.5 mm.
  • The average length is 34.1 ± 3.4mm.
The ALL is not an anatomical anomaly, which begs the question as to why we seemed to have forgotten about it? Vincent et al (2012) found the ALL present in 100% of the test sample. These authors dissected 30 knees to find the ALL and after understanding its anatomical connections further, proposed that the ALL plays an important role in stability of the lateral meniscus “even in the absence of ACL pathology, including limiting anteroposterior translation during flexion and preventing meniscal extrusion” (Vincent et al, 2012., p.156). These statistics are consistent with other papers published in more recent years (Farhan, et al., 2017). 
Image source: (Vincent et al., 2012, p. 149)
Image source: (Vincent et al., 2012, p. 149)
Bonanzinga et al (2017a) published two papers after dissecting 10 fresh-frozen knees to establish the role that the anterolateral ligament (ALL) of the knee plays in rotational stability compared to the anterior cruciate ligament (ACL). What these authors found is that the ALL plays a key role in stabilization of tibial internal rotation but less anterior translation at the knee. They used three common clinical tests, the anterior draw, Lachman’s and pivot shift test to detect different degrees of stability in an ACL-impaired versus ACL & ALL - impaired knee. From these test conditions the authors were able to conclude that ‘the ALL plays a significant role in controlling static internal rotation and acceleration during pivot shift test… but, ALL resection does not produce any significant change in terms of anterior displacement’  (Bonanzinga et al., 2017a, p.1055). What this means is that the ALL plays a significant role as a biomechanical restraint to knee internal rotation. Holger Drews et al (2017) further specified that the ALL has the highest impact on rotational stability between 60-120 degrees of knee flexion. 
Song et al (2017) looked more closely at the correlation between instability on the pivot shift test and the prevalence of ALL injury on MRI. These authors found that when using the pivot shift test to assess an ACL-deficient knee, there is a strong correlation between more severe gradings on the pivot shift test and the presence of GR II and III injuries of the ALL. Interestingly, they also found that lateral compartment contusion was more commonly found in patients with a concomitant ALL injury.

CLINICAL RELEVANCE

As there has been some confusion about the anatomy and function of the ALL in recent years, many specialists are urging clinicians to consider the role of the ALL in anterolateral rotational stability of the knee, but also cautioning them to consider that many other structures contribute to this stability as well. These structures include the ITB, lateral meniscus, ACL and lateral capsule. It may be more helpful to be assessing these combines structures as an “anterolateral complex” of the knee than individual structures and to remember that ligamentous injury, meniscal lesions and bony morphology can all contribute to instability (Musahl, et al., 2017). Interestingly, while some authors have proposed that the ALL plays an important role to stability of the lateral meniscus (Vincent, et al., 2012), a lateral meniscal injury is associated with delayed ACL surgery rather than increases rotational instability (Hardy, et al., 2017). 
The goal of ACL reconstruction surgery is to abolish rotational and anterior translatory instability, detected on tests like the pivot shift and Lachman’s tests. Not all patients are able to abolish this instability following reconstruction, with 25-38% of patients continuing to have rotational instability (Hardy, et al, 2017, p1118). 
Theoretically, if the ALL plays an important role in knee stability, then surgical reconstruction of the ALL in combination with an ACLR would be logical in the ACL+ALL deficient knee. This would require changes to the current surgical technique involving a tendon graft from semitendinosis to reconstruct the ALL. Although this additional reconstruction is not standard practice, research is emerging to suggest that both reconstructions result in reduced rotational instability on the pivot shift test when a concomitant ALL injury is present (Bonanzingo et al., 2017b; Hardy et al., 2017). It appears that the patients who benefit most from this procedure sustained their injury under an explosive rotational mechanism, have a Segond fracture (makes sense) and exhibit >10mm of anterior translation during the anterior draw test (Hardy, et al., 2017, p.1118). 
Not all articles recommend surgical reconstruction (Stentz-Olesen., et al, 2017) but when reading such papers further it appears that the knees that were investigated were cadavers. Personally, I think it is difficult to know how much research from a non-living knee can be applied to or correlated with clinical instability in a live subject. Just something to keep in mind. 
Definitely a shorter blog this week from us, but hopefully an important reminder that coming back to anatomy can help us further understand the finer detail of injury management and improve our changes of successful rehabilitation. 
Sian - via Rayner and Smale

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

twitter @siansmale
instagram @siansmale_SF
REFERENCES:
Bonanzinga, T., Signorelli, C., Grassi, A., Lopomo, N., Bragonzoni, L., Zaffagnini, S., & Marcacci, M. (2017a). Kinematics of ACL and anterolateral ligament. Part I: Combined lesion. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1055-1061.
Bonanzinga, T., Signorelli, C., Grassi, A., Lopomo, N., Jain, M., Mosca, M., ... & Zaffagnini, S. (2017b). Kinematics of ACL and anterolateral ligament. Part II: anterolateral and anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1062-1067.
Cavaignac, E., Wytrykowski, K., Reina, N., Pailhé, R., Murgier, J., Faruch, M., & Chiron, P. (2016). Ultrasonographic identification of the anterolateral ligament of the knee. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(1), 120-126.
Claes, S., Vereecke, E., Maes, M., Victor, J., Verdonk, P., & Bellemans, J. (2013). Anatomy of the anterolateral ligament of the knee. Journal of anatomy, 223(4), 321-328.
Drews, B. H., Kessler, O., Franz, W., Dürselen, L., & Freutel, M. (2017). Function and strain of the anterolateral ligament part I: biomechanical analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 1-8.
Farhan, P. S., Sudhakaran, R., & Thilak, J. (2017). Solving the Mystery of the Antero Lateral Ligament. Journal of clinical and diagnostic research: JCDR, 11(3), AC01.
Hardy, A., Casabianca, L., Hardy, E., Grimaud, O., & Meyer, A. (2017). Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1117-1124.
Heckmann, N., Sivasundaram, L., Villacis, D., Kleiner, M., Yi, A., White, E., & Hatch, G. F. R. (2016). Radiographic landmarks for identifying the anterolateral ligament of the knee. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(5), 844-848.
Herbst, E., Albers, M., Burnham, J. M., Shaikh, H. S., Naendrup, J. H., Fu, F. H., & Musahl, V. (2017). The anterolateral complex of the knee: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1009-1014.
Lording, T., Stinton, S. K., Neyret, P., & Branch, T. P. (2017). Diagnostic findings caused by cutting of the iliotibial tract and anterolateral ligament in an ACL intact knee using a standardized and automated clinical knee examination. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1161-1169.
Musahl, V., Getgood, A., Neyret, P., Claes, S., Burnham, J. M., Batailler, C., ... & Karlsson, J. (2017). Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL Injury: a roundtable discussion. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 997-1008.
Neri, T., Palpacuer, F., Testa, R., Bergandi, F., Boyer, B., Farizon, F., & Philippot, R. (2017). The anterolateral ligament: Anatomic implications for its reconstruction. The Knee, 24(5), 1083-1089.
Pomajzl, R., Maerz, T., Shams, C., Guettler, J., & Bicos, J. (2015). A review of the anterolateral ligament of the knee: current knowledge regarding its incidence, anatomy, biomechanics, and surgical dissection. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 31(3), 583-591.
Smeets, K., Slane, J., Scheys, L., Forsyth, R., Claes, S., & Bellemans, J. (2017). The Anterolateral Ligament Has Similar Biomechanical and Histologic Properties to the Inferior Glenohumeral Ligament. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(5), 1028-1035.
Smeets, K., Bellemans, J., Scheys, L., Eijnde, B. O., Slane, J., & Claes, S. (2017). Mechanical Analysis of Extra-Articular Knee Ligaments. Part two: Tendon grafts used for knee ligament reconstruction. The Knee.
Song, G. Y., Zhang, H., Wu, G., Zhang, J., Liu, X., Xue, Z., ... & Feng, H. (2017). Patients with high-grade pivot-shift phenomenon are associated with higher prevalence of anterolateral ligament injury after acute anterior cruciate ligament injuries. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1111-1116.
Stentz-Olesen, K., Nielsen, E. T., de Raedt, S., Jørgensen, P. B., Sørensen, O. G., Kaptein, B., ... & Stilling, M. (2017). Reconstructing the anterolateral ligament does not decrease rotational knee laxity in ACL-reconstructed knees. Knee Surgery, Sports Traumatology, Arthroscopy, 25(4), 1125-1131.
Van der Watt, L., Khan, M., Rothrauff, B. B., Ayeni, O. R., Musahl, V., Getgood, A., & Peterson, D. (2015). The structure and function of the anterolateral ligament of the knee: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 31(3), 569-582.
Vincent, J. P., Magnussen, R. A., Gezmez, F., Uguen, A., Jacobi, M., Weppe, F., ... & Neyret, P. (2012). The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surgery, Sports Traumatology, Arthroscopy, 20(1), 147-152.




Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...