Massage & Bodywork

March | April 2014

Issue link: https://www.massageandbodyworkdigital.com/i/259468

Contents of this Issue

Navigation

Page 103 of 141

I t p a y s t o b e A B M P C e r t i f i e d : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 101 or medial tibial stress syndrome (MTSS). Muscles in this compartment include the tibialis posterior, flexor hallucis longus, and flexor digitorum longus (Image 2). The tibialis posterior is most commonly affected, so our investigation will focus on that muscle. However, recent studies also indicate that the soleus muscle attachments can contribute to pain in this region as well. One of the primary functions of the tibialis posterior muscle is to prevent overpronation in the foot, in which the foot rolls onto the medial side during the weight-bearing phase of a foot strike. It is the eccentric action of the tibialis posterior that prevents overpronation. An excessive wear pattern on the medial side of the shoe's sole is often evidence of overpronation, as seen in Denise's case. The tibialis posterior muscle is difficult to palpate because it is deep in the posterior compartment, which makes investigation of this muscle more challenging. Also, the foot must be everted to stretch the muscle in assessment, but bony structures limit the degree to which the foot can be everted. The tibialis posterior is one muscle that can never be fully stretched as much as it should, so any amount is particularly helpful. Now that we have a good understanding of some of the key areas that are likely to be involved, let's further evaluate the nature of Denise's primary complaint. ASSESSMENT AND EVALUATION Denise originally described the pain as being in the lower leg region, and more medial. This location would tend to implicate problems in the tibialis posterior more than the tibialis anterior. Overuse of the dorsiflexor group tends to cause pain in the upper anterior shin region where the dorsiflexor muscle bellies are located. When pain is felt in the distal lower leg, and especially if it is medial, it is more likely that the deep posterior compartment muscles— or distal portion of the soleus—are involved. Palpation plays a key role in confirming our suspicions about involvement of the deep posterior compartment muscles. Palpating the medial and distal region of the tibia reproduced some of the characteristic pain that Denise was experiencing, so it was likely we were on the right track. Having our initial assumptions confirmed about the location of pain, we explored further with physical examination. We had Denise perform a series of foot and ankle movements including dorsiflexion, plantar flexion, inversion, and eversion. She performed the movements first actively, then passively. These evaluations were performed by having her sit on the edge of the treatment table and move her foot in each of the prescribed directions. Following the active and passive movements, we also had her perform resisted dorsiflexion, plantar flexion, inversion, and eversion. Denise reported no pain with any of the evaluation procedures. This seemed unusual because she was having symptomatic complaints with activity, and it seemed she should have some symptoms when performing some of these motions. When a client has a pain complaint during certain motions but that pain is not reproduced with any of the movement evaluation procedures, then the problem may not be what was initially suspected. However, we couldn't rule the tibialis posterior out yet because there was another important possibility. In many cases of musculotendinous injury, the tissue can still be damaged but not cause pain during certain evaluation procedures because not enough stress is placed on the tissue. This is a common pattern with medial tibial stress syndrome, where our standard evaluation procedures do not reproduce the pain sensation because they simply do not stress the tissue enough. Muscles of the deep posterior compartment. Image is from 3D4Medical's Essential Anatomy application, available on the App Store. 2 flexor digitorum longus tibialis posterior flexor hallucis longus

Articles in this issue

Links on this page

Archives of this issue

view archives of Massage & Bodywork - March | April 2014