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76 m a s s a g e & b o d y wo r k j u l y/a u g u s t 2 0 2 3 critical thinking | BODY OF WONDER "I hate walkers," muttered Dr. Gary Chimes, my friend and physiatrist. "The only thing they're good for is making you walk like an elderly person." Gary is right. You know the posture: upper body hunched forward, head looking at the ground, too much continuous pressure through the arms and shoulders. Then there's the lower body. Are the hips moving? Not so much. Often the knees are f lexed, shortening the tibialis anterior and hamstrings. Most importantly, and of particular interest, is the shuff ling of the feet. Is there any plantar and dorsif lexion happening? If there is, it's extremely limited and potentially limiting long-term recovery because those last items, the f lexor retinacula at the ankles, play a much bigger role in walking than most people realize. UNDERSTANDING THE RETINACULA Presented in the anatomy texts as separate bands of tissue, retinacula are decidedly not separate or discrete structures. They are a thickening in the crural fascia, the much larger fascial sheath of the leg. While it's quite possible to dissect the foot and ankle and make it look exactly like a textbook— I've done it myself—reviews of the literature in dozens of papers and myriad textbooks show no clear consensus on the exact size and shape, or topography if you will, of retinacula. In fact, sometimes the individual details vary. What is good is that today many references (including those online) are updating their facts to correctly identify retinacula as thickening of the fascia of the leg. What is less- than-good is that they are still referred to physiologically as both a tendon stabilizer and pulley system for the tendons of the tibiotarsal joint. While it is a matter of record that injuries to retinacula, like tears, can lead to subluxations/ dislocations of the tendon, these are more extreme injuries than the typical ankle strains and sprains. The pulley model goes all the way back to Andreas Vesalius in Padua, Italy, circa 1543. As much as there is to admire and be grateful for regarding Vesalius, this model is past its expiration date. So perhaps it's fitting that a group led by Carla Stecco at the University of Padua in 2010 performed a study on retinacula that has been instrumental to our change in thinking. The Ankle Retinacula Putting Your Best Foot Forward By David Lesondak The more traditional view (upper) contrasted with the new understanding (lower). The tendons follow the bony contours around the malleolus and are kept in place by the mechanoreceptive thickenings of the deep fascia. These thickenings, traditionally called retinacula, have both mechanical and sensory roles. Upper image courtesy of James Earls.

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