Dear Howard,

The Fryer paper actually manipulated ankles with restricted dorsiflexion
relative to the other ankle (unfortunately they do not appear to report this
in their abstract).  Therefore the authors were actually trying to increase
ROM in the ankle to normal alignment with the other ankle.

As for the different methods of manipulation, I cannot comment on this area
as I know relatively little about manipulation techniques.  However, all I
am commenting on is the methodology of the trials and the results of the
techniques.

In your trial, as Hylton rightly points out, the reliability of the ankle
measurements should have been assessed and reported as such measurements are
know to sometimes be unreliable.  Also, a control group should have been
included and appropriate blinding of the ankle ROM assessor as to which
group the participant belonged to.  The Fryer paper addresses this nicely.
On the whole, there was some room for bias in your trial.

Now, that does not mean I am saying that I am against manipulation.  I'm
just pointing out that the evidence for it is not the greatest at the
moment, particularly your technique.  You're certainly welcome to say that
the technique is simple, but not effective (in terms of evidence-based
medicine) at this stage.

Your trial shows some promise that manipulation will increase ankle ROM but
it may be as Craig has suggested that manipulation is actually producing a
different type of mechanical benefit.  However, what we really need is a
good quality randomised controlled trial looking at ankle manipulation on
foot pain (e.g. plantar fasciitis).  Once the technique is established as
effective for foot pain, I will embrace it with open arms! :)

Please, someone out there set this trial up!

Kind regards,

Joel.





-----Original Message-----
From: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]]On Behalf Of [log in to unmask]
Sent: Thursday, 23 September 2004 10:05 PM
To: [log in to unmask]
Subject: Ankle manipulation, was GRF on Forefoot, What Moves?


In a message dated 9/22/2004 11:24:00 PM Eastern Daylight Time,
[log in to unmask] writes:
If reading Howard's ankle manipulation JAPMA paper from 2000
(Sep;90(8):385-9), be sure to read Hylton's comment and Howard's response in
2001 (Feb;91(2):105-6).

Joel,

The paper that Hylton Menz cited in our discussion used subjects WITH NO
RESTRICTION to ankle joint dorsiflexion, as does the citation you provided.
So, what these papers proved was than manipulation on subjects who have
normal ROM would maintain them at normal.   BIG DEAL!!!   In addition, in
the Menz cited paper, the measurement of these subjects was done with the
knee in 90 degrees of flexion, while the study I produced maintained the
knee in the fully extended position.   Even the paper you referenced, the
manipulation is of the ankle and and NOT the proximal fibula as I described
in my study.

In the thousands of subjects whose fibula I have manipulated over the years,
I have yet to see a single negative effect other than a day or two of ankle
soreness during the coldest winter months.   It is the single most useful
technique that I use in my practice on a daily basis, and I have helped
countless patients who otherwise would be suffering from the effects of
equinus on the feet and posture.

I am not really sure why you and Hylton have such a hard time with a
technique that is so simple and effective.  Manipulation has been around
since Hipprocrates...it is not a new idea I invented.  It is a shame more do
not practice this....

Howard Dananberg, DPM
21 Eastman Avenue
Bedford, New Hampshire 03110
603-625-5772
fax 603-625-9889
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