It’s all in the Shoes…

By: Stacy Soappman


Our treatment is only as good as the patient education that follows it. How many times have we identified the correct joint, performed a brilliant mobilization/manipulation, did the appropriate post manual treatment exercise and then sent the patient on their way? And how many times have they come back the next session to say “it still hurts” and you find that what you mobilized is once again “stuck?”

Let’s explore what is likely the most common ankle injury that we see in the clinic – The Lateral Ankle Sprain. The lateral ankle complex is composed of three ligaments, the anterior talofibular ligament, the calcaneal fibular ligament and the posterior talofibular ligament. Of the three, the anterior talofibular ligament is the one we most often injury in an inversion ankle sprain. As the name suggests, the anterior talofibular ligament runs between the talus and the fibula. Depending on the grade of the sprain and the amount of ligament disruption, we can see a multitude of different patient presentations in the clinic. We have patients who come walking in with only complaints of minimal pain and swelling to those who are on crutches because to weight bear is excruciating painful. The more severe the injury, the more likely the patient is to have subluxed their talus into a plantar flexed and internally rotated position. This happens because as the ligament tears, it often pulls the talus with it, leaving the talus stuck outside of the mortise neutral zone. When this happens, the only treatment that will fully restore full motion to the joint is a manipulation. If you look at the anatomy of the talus you will find that its shape is wider on the anterior side of the bone then the posterior side. If you are only mobilizing the joint, you are trying to shove the wide talus into a skinny mortise and that just is not going to work.

Once you have torn the anterior talofibular ligament you have lost part of the restraining system that helps to keep the talus in its neutral zone. What do you think is going to happen when you walk around in high heels all day? These shoes keep your foot in a constant plantar flexed position!

So back to my whole point – our treatment is only as good as the follow up education we give our patients. Statistics show that roughly 50-55% of the new gradate PTs are female. That leaves us with 45-50% that are male and are probably not the best versed in women’s shoe fashion. If your patient wants to wear fashionable shoes, let’s suggest a wedge heel vs other types of high heels to minimize the plantar excursion of the talus. We all say NAIOMT is eclectic and I think this just proves our point because how many of you thought your manual therapy education would include fashion tips?

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