The Transition Zone
by Tyrel Hummel, DC – The American Chiropractor – January 2014
In the vastly competitive world of Sports Chiropractic we are continuously searching for an edge to get the patient-athlete better, faster! Our thorough background in orthopedic tests, motor and sensory evaluation, range of motion, palpation, etc., frequently leaves us with a chart full of great clinical findings, yet we still may find ourselves stuck in the “transition zone” of what to do with all that data? Inevitably, there comes a point when a provider is asked to “fix” something fast so the athlete can return to competition…tomorrow?!! In order to fix it fast we must apply the “All or None” principle. You either fix it, or you don’t.
Here’s what I mean…
We had an 11 year old football player who presented on a Friday, the day after initial injury, with a grade 2 lateral ankle sprain. The boy asked if he would be able to play the following week. To which his father said, “I’m sure it would take a rocket scientist to put that back together”.
One of the most common injuries seen in the athletic world where the provider is asked to perform a near miracle is the sprained ankle. I recently read an article about ankle sprains the suggested approximately 85% of all ankle sprains result from an inversion mechanism and damage to the lateral ligamentous complex of the ankle(5). In addition, the amount of available dorsiflexion plays a key role in the cause of lower extremity injuries (7,13-22). And, limitation of dorsiflexion may be a predisposition to reinjury of the ankle (11,16) and several future lower limb injuries, including plantar fasciopathy (13,20,21) lateral ankle sprains, (13,15,17,19) iliotibial band syndrome (14), patellofemoral pain syndrome (18), patellar tendinopathy (22), and medial tibial stress syndrome (14). Restoring normal ankle dorsiflexion to minimize the risk of reinjury and quickly restoring full function were the key points in this article’s conclusion. The study provided evidence of interventions to restore ankle dorsiflexion in various stages of ankle-sprain conditions and suggested clinicians need to consider what may be the limiting factor of ankle dosiflexion in order to select the most appropriate treatments and interventions, such as stretching, manual therapy, electrotherapy, ultrasound and exercises to increase ankle dosiflexion. However, the interventions, or combination of interventions that most effectively improves ankle dorsiflexion has not been established…according to the study.
What if the limiting factor is the actual damage to the ligaments sprained that causes a shifting of the tarsals, or minimal posterior talar glide, tight peroneal muscles, foot instability, or whatever else we learned in school. What if our transition zone is stuck and we possibly need to “unlearn” some of the things that may cloud our decision of what the limiting factor actually is? After all, doesn’t the patient know? What if they’ve been telling us the whole time and we just don’t know how to listen? Wouldn’t you agree that, as Chiropractors, if we provide the body (or a structure) with an optimal environment to heal, it will do so, without distortion? If an ankle ligament is sprained, is it possible to unsprain it?
One anatomical perspective in which the underlying etiology of virtually every musculoskeletal injury is considered to be comprised of one or more of six specific pathological alterations of the body’s connective tissues (fascial bands, ligaments, tendons, retinacula, etc.) is called the Fascial Distortion Model. In the manual practice of FDM, each injury is envisioned through the model which is comprised of subjective complaints , body language, mechanism of injury and objective findings. These findings are then woven together to create a meaningful diagnosis that have practical applications. For instance, in contrast to the orthopedic model in which a sprained ankle is rested so ligaments can heal, in the FDM approach, the specific anatomical distortions of the capsule, ligaments, or surrounding fascia are physically reversed. Therefore, the anatomical injury no longer exists.
In the practice of modern medicine, pain is constantly attributed to inflammation. Whether the injury or condition is tendonitis (even if physical exam reveals no reproducible soft tissue crepitus), a sprained ankle, or low back pain, the underlying cause of discomfort of most musculoskeletal injuries is assumed to be swelling, or inflammation (particularly traumatic inflammation). Therefore, ice, and or NSAIDs are prescribed by doctors in virtually every clinical encounter to reduce inflammation or alleviate pain. But what about reversing the injured tissue instead, or at least, first? In the FDM approach, inflammation is considered to be a result of injured tissue and not the primary generator of pain. The distortions that are found are corrected so that the body can then go through its natural phases of healing at a superior rate. Once these distortions are corrected, the injured limb or other body part no longer hurts because the major pain producers, i.e., fascial distortions, no longer exists. This point is demonstrated in case histories and clinical examples are discussed for numerous injuries and conditions throughout the FDM text.
The inverted ankle sprain is the most common type of ankle sprain found. In theses cases the foot is inverted causing a lateral stretch of the ligaments connecting the foot and lateral malleolus. One of the most common presentations a patient will describe, or demonstrate, is pin-point pain along ligamentous attachments. Ligament and bone are considered as two opposite ends of one anatomical spectrum. Both structures are seen merely as compositional forms of each other. Bone is a fascial tissue with a large percentage of osseous material (think periosteum). Ligament, in contrast, is a fascial tissue with minimal bony products. The junction between fibers of a ligament that blend into the fibers of a bone contain both osseous and ligamentous physical properties. This intermediate section is called the transition zone. The stretching of the attachments causes a shift in the transition zone interface producing pin-point pain and is referred to as a Continuum Distortion (CDs).
In it’s neutral state the transition zone has physical properties of both ligament and bone which allows it to be more flexible than bone, but more rigid than ligament. This transition zone is capable of instantly responding to external forces altering the percentage of osseous components to protect against insult. For instance, when ligament and bone are subjected to unidirectional forces (compression), there is an osseous shift or structures into the transition zone to provide stability. This osseous configuration is stronger (but stiffer), which protects the ligamentous insertion from buckling. However, if the ligament-bone junction encounters multidirectional forces (such as circumduction of a joint), a ligamentous shift occurs where osseous components shift towards the bone allowing for absorption. This ligamentous configuration is less strong, but more flexible and shields against ligamentous tears. It is the shifting of the continuum back and forth through the transition zone which gives our bones and ligaments the facility to minimize serious injury.
How many times have you heard a patient say; “it’s like everything’s connected, huh?” To illustrate the ligament to bone continuum as one anatomical entity, I’ll use the ice/slush/water analogy. In the illustration below, ice represents bone which is solid, slush (snow flakes) represents the transition zone which is more pliable than ice, yet more solid than water. And water represents the pliable ligament. When the ligament-bone unit encounters forces from multiple directions, the transition zone shifts into the flexible ligamentous configuration. If forces instead are solely from one direction, the transition zone shifts into the stronger osseous configuration. Continuum Distortions form when the transition zone is subjected to simultaneous external unidirectional and multidirectional forces (inversion sprain). These uneven stresses result in one portion of the zone shifting into the ligamentous configuration and the other being held in the osseous configuration. If one of the external forces is sufficient enough, the corresponding portion of the transition zone will overshift and become stuck in that configuration.
I frequently treat ankle sprains on athletes ranging from pop-warner football to the NFL, as well as weekend warriors to Olympic Track athletes. Ankle dorsiflexion restoration is regained in the first visit, regardless of gender, sport, level of competition, or age by simply pushing the injured ligaments back to their normal position. The principles taught through the Fascial Distortion Model have allowed for a level of clarity and understanding with these types of injuries. In the past, I know my limiting factor was purely lacking the confidence to attempt to treat an acutely sprained ankle out of fear of causing more insult to the injury. Understanding what type of distortion has occurred makes it simple to choose the proper corrective technique.
In the case of the 11 year old football player, Continuum Distortions were treated on the first visit due to his pre-treatment presentation of pin-point pain over the anterior and lateral ankle ligaments. He also demonstrated an antalgic gait, moderate swelling over the lateral malleoulus, bruising along the lateral surface of the foot and moderately reduced dorsiflexion. When asked to stand on the injured foot only, he refused stating “it hurts too much.” After locating and treating the CDs in the ankle, normal dorsiflexion was restored and he could stand on the injured foot only, with no assistance. Before treatment on his follow-up visit on Monday he was walking without a limp, could stand on the injured foot only without assistance and had maintained normal dorsiflexion through the weekend. His presentation that day had changed from pin-point pain over the anterior and lateral ligaments to tightness and a pulling sensation on the lateral side of the lower leg and foot. The proper corrective techniques according to FDM were then utilized to ensure that all the initial distortions were corrected.
The day before his game that week on his third visit the boy said; “this isn’t rocket science ya know…it’s rocket fuel”.
Dr. Hummel experienced the typical sports related injuries as well as the constant rigors of training, recovery and rehabilitation as an All-Conference Defensive Back at Abilene Christian University in Abilene, TX. Though he never missed a practice or game, his collegiate injury list first prompted his quest to find “the truth” in the human body’s ability to recover at higher speeds. After completing two Bachelor Degrees (Exercise Science and Human Anatomy) Dr. Hummel finished his Chiropractic education at Parker University in Dallas, TX. He began his interest in FDM while doing research during his fellowship year in 2006, where he became the first Chiropractic Fellow to be trained in the Chiropractic Fellowship Program at the Texas Back Institute in Plano, TX. He holds Chiropractic Licensure in Texas and Kansas and is also a Certified Strength & Conditioning Specialist with the N.S.C.A. Dr. Hummel is passionate about teaching others the Fascial Distortion Model and shares “the truth” daily at his private practices in Wichita, KS.