How Ankle Joint Manipulation Affects The Peroneal Tendons And Ankle Range Of Motion

In my previous DPM Blogs, I have discussed peroneal dysfunction (misnamed as cuboid syndrome) and medial column stiffness issues that are affected by the function of the peroneals. Today, I’d like to discuss ankle joint manipulation and its effects on the peroneals as well as ankle joint range of motion.

Having enough ankle joint dorsiflexion range of motion is a key to normal gait as well as overall foot and ankle function. Root has discussed the evils of ankle joint equinus in his texts.¹ While I do not consider ankle joint equinus as the root of all evil (pun intended), I do think it is definitely a contributor to foot dysfunction issues, especially with the peroneals.

A study in the Journal of Foot and Ankle Surgery noted that increased tension in the Achilles complex causes dysfunction of the peroneals.² In my last DPM Blog post, I discussed how important it is that the fibula translate superiorly at the ankle joint so the peroneals will gain tension in midstance to hold the first metatarsal stable against the ground in late midstance.³ To do this properly, though, the ankle joint must have available dorsiflexion range of motion.

Dananberg and colleagues published a study on ankle joint manipulation technique in the Journal of the American Podiatric Medical Association in 2000.⁴ Dananberg suggests starting with the fibular head movement, grasping the fibular head above and below the peroneal nerve, and then thrusting it anteriorly (see top left photo). You then move down to the talus and put your thumbs on the talar neck (see bottom right photo). As you dorsiflex the talus and the foot upward, you also thrust with your thumbs against the talar body to push it into the ankle joint mortise.

I add another manipulation of the cuboid and third cuneiform plantarly in the foot. I grasp the foot dorsally with both hands at the thumbs and then wrap my fingers around and deep into the plantar aspect of the cuboid-cuneiform articulation. I then rotate my fingers into the plantar space of that articulation several times to reset or loosen the articulation so the lateral column can now sit below the medial column and potentially allow for better subtalar joint alignment.

It is important to understand that this manipulation technique is not meant to last long. I expect it to assist in increasing ankle joint dorsiflexion motion but it is not intended to be a forever treatment although some practitioners refer to it that way. I see it as an adjunctive treatment that, with a proper orthotic prescription, will aid the patient’s proper foot function by reinstating good peroneal function and proper and adequate ankle joint range of motion.

Please consider using this technique to assist your patients with recalcitrant plantar pain in the plantar central and lateral column, those who keep having medial column pain and those with peroneal dysfunction. Some of these patients will still need a slight heel lift of 3 mm or so but not all will. The manipulation adds to the feel of pliability of the Achilles and the ankle joint according to patients, but it is by no means a cure all.

You can get paid for the manipulation as well with the CPT code of 98925 and use of the diagnosis code of m99.06 for segmental and somatic dysfunction of the lower extremity. Insurance pays about $25 or so, which is definitely worth it. Even more to the point, though, is that this technique really helps your treatment plan for patients in my opinion.

Cheers and see you next month.

References

1. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

2. Johnson CH, Christensen JC. Biomechanics of the first ray part V: The effect of equinus deformity. A 3-dimensional kinematic study on a cadaver model. J Foot Ankle Surg. 2005; 44(2):114–20.

3. Williams B. Peroneal function and fibular translation: assessing their impact on the first ray and ankle range of motion. Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/peroneal-function-and-fibular-translation-assessing-their-impact-first-ray-and-ankle-range . Published May 2, 2018.

4. Dananberg HJ, Shearstone J, Guillano M. Manipulation method for the treatment of ankle equinus. J Am Podiatr Med Assoc. 2000; 90(8):385-389.