A Neural Approach To Treating The Ankle Joint
If you’ve been looking at how to improve your client’s ankle mobility and function, then look no further than this week’s episode of the Unreal Results podcast. I go through the intricate world of the ankle joint, talking about the importance of understanding the anatomy and nerve entrapment sites to improve patient outcomes. You’ll hear specifics including common entrapment sites of various lower body nerves as well as treatment recommendations for each. While this episode is chock full of details regarding the ankle, you’ll also hear some updates from my biz and a heartfelt story regarding the family dog, Barrett. You won’t want to miss this episode as it’s full of knowledge and practical advice for movement professionals looking to improve their evaluation and treatment of the ankle joint.
Resources Mentioned In This Episode
Episode 8: Unlocking The Fibula
Exercise Video: Common Peroneal Nerve Glide
Exercise: Sural Nerve Glide
Exercise: Tibial Nerve Glide
Exercise: Femoral Nerve Glide
Book I Mention: Peripheral Nerve Entrapments: Clinical Diagnosis & Management by Andrea Trescot*
Learn the LTAP™ In-Person in one of my upcoming courses
*denotes that this link is an Amazon affiliate link, meaning I earn a commission from any qualifying purchases that you make
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello, and welcome to another episode of the Unreal Results podcast. Ah, here we are. I'm actually looking at this calendar I made for Christmas. I made my whole family the same custom calendar. It was pictures of the family dog, Barrett, um, and each month he was like wearing, or the background was like, Related to the holiday of the month or like the season of the month.
Um, it's something like whenever he went to the groomer his groomer would take a picture of him afterwards and like he'd wear like a Handkerchief with like, you know, next month's Valentine's Day. So it would be like hearts, handkerchief or whatever. Um, but he was getting older and um, I just thought it would be a fun Christmas present.
I've previously made pajamas and t shirts of him and uh, for the family. And so I made a calendar for everyone and I included myself. Unfortunately, the beginning of this week, um, which was January, what, 13th, 12th, um, he started not doing very well and, uh, I actually flew up to Sacramento because my sister was like, I don't think it's good.
You should come up. He's at the vet and, um, yeah, so I flew up and helped my sister and my nieces out and also. Yeah. Was able to spend a couple days with him to say my own goodbyes, and we ended up, um, Um, saying goodbye to him on Wednesday. So, kind of a bummer to see the calendar. Photos, I mean in one sense, like I'm so glad I made them, but I never intended for the calendars to be like memorial calendars for him, so.
And obviously since it's like a fresh, sad loss, um, for us, like seeing it just definitely brings tears to my eyes. So um, yeah, super tough. He was my sister's dog, so he wasn't my dog, but I can't have a dog, uh, because I travel so much. It just doesn't make sense. It would be very selfish to have a dog. I would love a dog.
I'm a, I'm a dog person. Um, so like historically whatever dog my sister gets ends up being like our dog. And I'm very close to them. You know, since my parents are both gone, my, my sister and I are like all we have. And so, um, that includes her whole family, which includes the dog. And I was there when they rescued him and, um, In fact, it was my idea, not necessarily to rescue, rescue him, but to go look at dogs.
They definitely didn't need one. Her husband didn't want one. Uh, and we were driving down the road one day and there was these dogs, this shelter was like at the local coffee shop. And I was like, oh, let's stop and look at the dogs. And then we saw Barret, and then my sister was like, we cannot leave without him.
So anyways, he was such a good boy, such a great dog. Literally like one of the best, calmest, more present demeanors in a dog that I've really ever seen. And he was just such a lover and was a really great companion for my sister and my nieces. And, uh, Yeah, it's a tough loss. So and whenever I was home he loved on me a lot like whenever I was there he would always sleep with me and cuddle with me and mainly because I took really good care of him paid attention to him probably a little bit more than my sister and my nieces did because I Didn't have a whole lot of other like things to focus on when I was there So so we did before we say goodbye to him on Wednesday.
I got to snuggle with him Monday and Tuesday night and uh, yeah, it was really, we were very, for the first couple of days we were really unsure if it was time for him, um, time for us to say goodbye to him, uh, and then Tuesday, or Wednesday morning when we woke up. I looked at him and I was like, Oh, buddy, like, I feel you, like, I felt his vibe, like it was the last day.
And I told my sister, I was like, so interesting. I was like, cause that's the same thing that kind of happened with my mom. Um, we woke up one morning and I was there and, you know, laying next to her. She was in like a hospital bed at that point in her room and I was in her bed, but. I woke up and I looked at her and the way her breathing was changing her, something about just her energy.
Like I just knew in that moment that it would be her last day and that's the same thing that it was for Barrett. Like I just looked at him and knew in that moment that it was, that was his last day with us. So I'm like, I get, you know, it's one of those things. Like I'm really observant. I also like feel like, I don't know, intuitively read.
beings well, and actually that's like I always had really deep connections with any dog. I'm around I'm like dogs love me like dog whisperer and so I just yeah, I knew and it was funny because even at the vet right before we say goodbye he like just sat and he stared into my eyes like deep into my soul and it was like he was communicating with me and it was like really interesting.
But also, my, um, oldest niece, who's actually in her twenties, she was with us, and she I was like, I, you are literally, even my sister said it too. She's like, you're the only person I've ever seen Barrett do that with. She's like, it's really interesting. And my mom, my sister was like, yeah, dogs like to communicate with Anna.
So, so anyways, I like, it's a tough decision to make as a pet owner. Um, so I just reassured my sister that like. I feel like she was making the right decision and the vet said it really nicely. He's like, it's a hard decision, but uh, the most compassionate one. And I was like, wow, that's a really It's a really good way to put it because it's not about like right or wrong, it's about doing what is the most compassionate thing for the dog and not being selfish and at that point like he really definitely needed like almost kind of like nursing care around the clock.
Like could we have kept him, you know, for a few more days? It's, maybe, like, picking him up and taking him out, picking him up and feeding him, picking him up and like, hydrating him and it's just like, that's not a very wonderful way to live and then it's also like, there's just not a whole lot of bandwidth for that.
So anyways, so I hate to start off tho pad with sad news but that's sort of what I'm at and
What I'm looking at at my desk. So for those of you watch on YouTube, I'm gonna show you real quick the calendar but this is Barrett. This is the January photo so whole calendar of him, but Yeah, tough times. So the rest of this week, um, that was the first three days. Unexpected. I was originally planning to just be in San Diego and be working on the foot and ankle course.
But I was in Sacramento instead and then I went to Las Vegas late. Wednesday night for a business mastermind event on Thursday and Friday with the strategy and scale mastermind crew Which is Jill Coleman aka JillFit's mastermind group that I'm part of this is my fourth year actually working with Jill and It was so fun Her motto for this year's mastermind is like a less corporate more cozy or casual and uh community and so that's really what it was.
I mean we did a we definitely did a lot of strategy um There was a lot of strategy. There was a lot of good masterminding. There's like I have so many ideas of like You know from a business standpoint, especially as I integrate more team members this year and, uh, But then also it was just fun and really nice to have some fun after, um, Some hard days of, of being full of sorrow and grief and, um, Yeah, she treated us to blow out at the dry bar and then we went to a Cirque du Soleil show that night.
We went to go see O, which is the Cirque du Soleil show at the Bellagio. I mean, it's been there forever. I remember, like, wanting to go see it, like, When I was like 24, and of course I never did. I haven't. I'm not a huge fan of Las Vegas to be honest. So I don't go very often. Um, when I do go, I always do really enjoy the shows but I've never been to that show and so super excited to go to that and it did not disappoint It was really amazing.
If you're not familiar with it It is a Cirque du Soleil show that is actually in water. So there is like this large pool and the pool has different like floors that come up and so at different parts of the show. It's different depths but the circus artists are actually also doing Um, you know, like traditional, uh, any Cirque du Soleil show, the circus artists are doing like contortionist stuff, like acrobatics, um, you know, like Lyra, like the on the rings, you know, the, the, the ribbon circus aerial moves, aerial moves on a, um, like a swing, the, uh, yeah, aerial in the circle, like they're doing the diving, like the, the Boards and the swings where they float each other around so like very like traditional Cirque du Soleil stuff.
In addition to, many of those moves turned into like high diving extravaganza into the pool and then synchronized swimming and it was just To see it all combined It was amazing. Like, what a, what a well done show. So, no wonder it's been going for over 20 years. Because it's just that good. So, 10 of 10 recommend.
I gambled. I'm not a big gambler, but I was, I had like 20 minutes to spare while I was waiting for everybody to get to the the O theater and so I did some slots and I won a little bit and then I lost it all, such is life at the casino, and that is why I don't like to gamble, but it was fun. Passed the time and, uh, yeah, so anyways, now I'm back at home for a couple days and then I'm back on the road.
I have a few, um, busy weeks coming up just between athlete stuff and then teaching and personal life. So lots of travel. So actually today I got a IV like a had a mobile IV come to the house and give me and I like immune support IV just because there are a lot of people that are sick out there and I just don't want to be one of them because I have the first I have my first in person LTAP Level 1 course coming up in two weeks in Tacoma, Washington.
So I want to be, I have a lot of travel in between now and that and I just want to make sure that I don't get run down and I am like fully 100 percent for that course. I'm super excited. The group of people that are going to be there is a great group so far. I actually still have three seats available.
So that's it. Only three spots left in that course. So if you're interested, if you're, especially if you're in the Pacific Northwest, like this is your chance to go to a course close to you. Um, I don't know when I'll be back in the Pacific Northwest again. So I know there are a lot of you that listen in Portland, um, just all parts of Oregon, Washington, Vancouver, Northern California.
This is a pretty close course for you, and, um, really reasonable costs, at least when I booked my, um, trip for rental cars and hotels and, and that kind of thing, and so, three spots left, come join us, especially if you want to get learning the LTAP Level 1 course. So, the online course, as some of you have been asking, the online course will be starting in September.
In April. So if you're looking forward to the online course, whether or not you're doing in person in addition to it, um, yes, that will be in April. So this is an opportunity to do the in person first and then join the online in April to like continue to further refine your skills, get your questions and cases answered, and like deepen your knowledge of the anatomy.
And then, um, Everyone else, I guess, actually the next in person course is the first weekend of April in Denver. Um, last I checked, I think there are seven, seven spots available? Six? And, um, it also, uh, occurs before the online course. So that's another opportunity to do the in person first and then the online course.
And then the other in person course that I have on the schedule, will end, or middle of May in Durham, North Carolina that that occurs after the online course so you can take the online course first and then attend the in person course. So there is not a right way to do it You know in person first or online first is really whatever works for you slash I recommend doing whatever's the soonest available, um, because I do only offer the online course twice a year, whereas in person courses, I will probably have five courses this year for the level one course.
Alright, so that's the update slash housekeeping sort of thing. Uh, I promised last episode that we would be a few episodes talking about the foot and ankle in preparation for the upcoming foot and ankle course that I will be launching. A long awaited overdue course. So, uh, today I wanted to talk about neural Like a neural, neural perspective of the ankle and foot and, um, for the sake of the podcast not being an exact replica of the course, as well as for the sake of time and for the sake of learning, when we're learning, especially in this auditory.
mode, we can only retain so much, um, I'm only going, I'm not going to go over all the pieces for today's topic, but I'm going to go over at least one very thoroughly so you can understand the concepts and some key takeaways from this episode. And also I'm picking the thing that sort of comes up the most in my practice, but, um, yeah.
So, anyways. When, one of the things I tell people is, if you don't have knowledge, or not knowledge, maybe knowledge is not the right word, if you don't have the education yet of the LTAP, the Locator Test Assessment Protocol, or you don't know how to do general listening from an osteopathic standpoint. The next best way to go about working with the human body is to still keep this whole organism lens of view in mind, meaning always considering the visceral and the nervous system in addition to the musculoskeletal system and the biomechanics and the orthopedic stuff.
And for some of you, it might be. Be an easier like, oh yeah, no, duh one. If you've been here a while, you're like, yes, Anna, you are now a broken record. Glad to hear that. . If you are a pelvic floor physical therapist, you're like, yeah, duh. Viscera, maybe you're even like, yeah, duh. Nerves. Um, if you are a pediatric pt, you're like, yeah, the nervous system, the nerves sensory.
This is how babies develop is through a sensory experience and if you're a non orthopedic practicing physical therapist, um, like an, you know, you're a neuro PT or you're an inpatient PT, you see a lot more related to neurological conditions and vascular conditions and conditions associated with disease processes and visceral issues.
So. If I'm speaking to you, you're like, yeah, it all makes sense. So let's dive in to see how it's applied from a, at a more orthopedic traditional like thought process around the limb joints. Uh, for the rest of us who are sort of like, mostly in the world of orthopedics and biomechanics. This, you know, this is the whole purpose of the podcast, is to open you up to a different lens of view.
One that is more whole organism that appreciates this. So ideally, we all are learning the locator test assessment protocol or something like general listening that allows us to listen to the body, to figure out the where the body wants to start. Because even with this, you're going to see if somebody has limited ankle mobility.
It could be from a nerve entrapment and by that or adverse neural tension of the nerves that innervate the joint or the nerves that innervate the muscles that affect function of the joint. But we won't know necessarily exactly where to go first unless we have a skill like the LTAP or general listening.
It really helps us to know exactly where. The problem lies, there are some orthopedic and special tests that can begin to give us a little bit better insight to, but there's nothing better and quicker in my opinion than using the LTAP and listening skills and, or it doesn't have, not, not and, or listening skills.
So, um, I just want to remind you that. You know, the whole premise is to get more specific and precise with our assessment specific and precise to the body in front of us And where the body is directing us. That's what the LTAP does and then we get specific and precise with our treatment and like treatment interventions Without having that, it is helpful to look at something orthopedic and go backwards and think about the relationships to the nervous system and the relationships to the viscera.
So this episode is going to be about the nervous system and next week we're going to talk about the viscera. So, um, and like I said, this is what I tell people, like, At the bare minimum, I would love for the next ankle that you see that has limited mobility, instead of just jumping in and doing joint mobs, or stretching, or however you decide to work on someone's mobility, whatever your go to technique is, I want you to take a step back and think about what nerves innervate that joint.
And then, not only what those nerves are, but where are common areas in the entire lower extremity that they can be entrapped or affected, right? Because this is going to be where we direct treatment first before we go and do our mobility treatment technique intervention. So when we're talking about the foot and ankle.
We've got many joints, right. The sort of general joints we have are the true ankle joint, which is considered, which is also called the talocrural joint. So the talocrural joint, right, is the joint between the talus and the leg. Crural, crura, crua, and crural, those words. I feel like post traumatic stress from my childhood because R's and L's were like the hardest consonants for me to say with my speech impediment.
So putting them together and then adding another hard consonant, like a C with it, is like my nightmare. Talocrural joint. Crua is Latin for legs. So it is the joint between the talus and the leg. Um, it is a, like, mortise hinge joint, and it makes up the tibia, fibula, and the talus. Right? The talocural joint.
provides ankle dorsiflexion and plantarflexion. It's a pretty like, I don't want to say like, dumb joint, but it's like pretty basic. Kind of like the knee, also a hinge joint. Then below the tower curl joint is the subtalar joint. Another name for the subtalar joint, um, well, The sub, meaning below, talar meaning talus, so below the talus joint.
But what the joint really is, is the joint between the talus and the calcaneus. So it is the talocalcaneal joint. It's not often called that, but it's important to remember that that is actually what the joint is. It's the, it's the relationship of movement between the talus and the calcaneus, which gives us inversion and eversion.
As well as some rotation of the joint. So there's a little bit more degrees of movement there. In general, most of the time when we're talking about ankle mobility, we're talking about those two joints. The talocrural joint and the subtalar joint. The other joint we must consider is on the other end of the crua.
Um, Which is the proximal joint between the tibia and the fibula, so the proximal tib fib joint. This is basically goes back to understanding the importance slash function of the fibula and its role as an ankle bone more than a knee bone, though it is also deeply connected to the knee joint. I did a whole entire episode on the fibula that I'm going to have Joe link in the show notes called Unlocking the Fibula, and we talk all about how the fibula is connected to the knee joint, the, via the arcuate ligament and the capsule of the knee, the meniscus, like
the lateral hamstrings. There's like so many connections to the knee joint, but also the fibula is very much part of both the talocrural joint and the subtalar joint. It is part of both because of where the ligaments attach from the lateral malleolus. to the talus, the lateral malleolus to the calcaneus, and the lateral malleolus, or not even the lateral malleolus, but the fibula to the tibia.
And so it's very much connected to all three of those bones, so it's going to influence two, at minimum two of those joints, the subtalar as well as the talocrural joint. So that's like the ankle joint. Now, the ankle joint does not work in a vacuum. It also relies on a foot that has good mobility and function in the foot.
We have many more joints, but in general, we can kind of boil it down to the joint between the talus and the navicular. It's like main part of the proximal midfoot, the midfoot itself, and then the forefoot. And then beyond that, we have the toes. What I'm not talking about in these. It's a few podcast episodes and what I'm not even talking about in the foot and ankle course is the toes because the, the toes, but more specifically the big toe can be its whole its own course.
Right. I might talk about it a bit, but like for the sake of we could spend a week on these things. We're not going to be talking about the toe too much.
We will in terms of how it functions in relationship to the midfoot, but not necessarily diving into the joint itself and the pathology and that kind of stuff in the podcast maybe in the foot and ankle course. I know there is a little bit about turf toe in it, so And also never say never. I'm sure at one point I will cover that on the podcast too, but just not in this like little series in the next few weeks.
So the other joints we talked about, right? We talked about the talonavicular joint and then the, um, there is also on the other side the calcaneal cuboid joint and then the mid foot and the forefoot. Um. Each of, within the midfoot and forefoot, we have joints between the tarsal bones and we have joints between the metatarsals and the tarsals too.
So, many little joints in there too, um, but we kind of lump them together because when we think about um, at least these neurological relationships, all of those joints are innervated by the same nerves. And so we don't necessarily need to parse them out for the, this purpose. For the sake of most bang for our buck and time, today we're going to talk primarily about the talocrural joint and
not fully the subtalar joint, but a little bit of the re a little bit about the calcaneofibular ligament at least. So the talocrural joint, actually we're going to talk about, we'll just talk about that first. When it comes to, obviously, when it comes to ankles, the majority of everyone has sprained their ankle, and um This is a concern because there's also research that tells us that, you know, anybody who is sprained their ankle and not had proper rehab, whatever the hell that means, um, they're more likely to get hurt again.
Maybe at the ankle again, maybe somewhere else up the chain. In fact, uh, not to get off topic, but I, I just recently had somebody, I just recently had a new grad PT post on one of my ads for the swelling reduction protocol and she was, I think it was a she, she was basically like, um, it's not good to have your athletes have no swelling in 24 hours after a lateral ankle sprain.
I'd love to see the re injury rates of your athletes. And I was like, bless your heart, bless your heart. Hard disagree. Uh, yeah. But anyways, it just made me laugh because I'm like, I get it. She's read, like she's learned that research in school. So she's like, and tissue healing, like if they have injury to those ligaments, it just, it doesn't, you can't heal it in a day.
Like you're full of shit. And I'm like, I'm not saying I'm healing the ligaments in a day. I'm saying I'm decreasing swelling in a day. Um, So, got it. I, I, I know the same research you're talking about and yes. So the interesting thing about the ankle, specifically the joint capsule of the talocrural joint and the subtalar joint and the lateral ligaments, right?
This is why we're talking about why I want you to go listen to the unlock the fibula episode if you haven't already. It's why I'm having Joe link in the show notes. It's very much a part of this. The lateral ligaments in the joint capsule of the talocrural joint and the subtalar joint are extensively full of mechanoreceptors, specifically type 2 and type 3 mechanoreceptors.
Um, and they are responsible for the majority of the proprioception coming from our ankle. That's a big deal. And specifically, 93 percent of these mechanoreceptors are found in the calcaneal fibular ligament. And I found that so interesting because of how powerful improving Fibular mobility is in improving not only people's ankle mobility, but just general awareness of their foot and ankle and lower extremity.
This is perhaps even why the little drill that I learned from my friend Missy Bunch, um, it's a Z health drill, like a neurology drill is a lateral ankle tilt. The lateral ankle tilt you can get even very specific and bias the calcaneofibular ligament more than the, um, fibular, talofibular ligament or the, you know, fibular ligaments that go to the other bones.
And, doing this has a profound effect all the way up the chain. Now, you could also argue it from a connection to the proxim to the fibula, and the connection of the fibula to the ankle to the knee joint, to the lateral hamstring, and therefore to the SI joint, and like fully up the chain, right? But it also could be simply that that ligament is very rich in mechanoreceptors that are telling us where we are in space.
So, there is a big connection between your calcaneofibular ligament and your brain, your cerebellum. And that is a really important thing to remember when you're working on someone's ankle or foot, no matter where in their ankle or foot hurts. Or wherever, or no matter where their ankle and foot you think is lacking mobility.
It probably would behoove you to address and or do manual therapy or exercise intervention or sensory stimulation to the area around the calcaneofibular ligament. So that is like kind of a gem of information. Um, I think that's all I want to say about that piece of it. And that is considering the nervous system from a different standpoint, from a different standpoint than the nerves.
It's considering the nervous system from a sensory standpoint of how, of knowing that the mechanoreceptors are in the fascia of that ligamentous tissue and actually travel to the spinal cord and the brain faster than the information on the nervous system. So, it's kind of part of the nervous system but not via the nerves, the long peripheral nerves that we're thinking of, right?
It's the different receptors within the fascial tissues. So, still kind of this neuro perspective, right? Alright, now, going back to the talocrural joint itself, and when we look at the talocrural joint and we look at what nerves innervate it, it's going to be the sural nerve. The sural nerve is a cutaneous sensory nerve only.
Yeah, cutaneous sensory nerve only, and it comes off of the tibial nerve. And yeah, it comes off the tibial nerve. I almost wonder if the lateral, I think the lateral sural nerve actually comes off of the common peroneal nerve. The medial sural nerve comes off of the tibial nerve. I'm pretty sure. Please hold while I look that up.
Okay, yes, that is correct. Um, the saphenous nerve is another nerve that innervates the talocrural joint. The saphenous nerve is also a cutaneous, like sensory nerve, uh, that comes off of the femoral nerve. The, then also the deep fibular, or deep peroneal nerve, the superficial, fibular or peroneal nerve and the tibial nerve itself also innervate the talocrural joint.
In addition, those three nerves, the deep fibular, the superficial fibular, they're branches of the common fibular nerve, the common peroneal nerve. And the tibial nerve, those are all mixed nerves, meaning they have a motor and a sensory component. And so those nerves also innervate motor to some of the muscles that control the talocrural joint too.
Okay. These nerves mostly
are associated from the nerve roots between L4 and S2.
It might even be more like L3 to S2, um, because of that saphenous nerve. Saphenous nerve, like I said, is part of the femoral nerve, so it's a little more like L3, L4. But either way, the lower lumbar and sacral nerves, right, it's part of the lumbosacral plexus. Um, So it's also important to realize that this is how issues coming from the central nervous system and or viscera and or musculoskeletally the spine can also drive mobility and performance like motor control issues at the ankle and foot itself.
Right. And I think even though we all know this, right, this is all part of the musculoskeletal system in orthopedics is the nerves. And even though we know this and learned it in school, when it comes to practical application, we tend to like forget about all of this. And I want to remind you that they're the more powerful thing in the body than us
the bones and the muscles. Without the nerves, those guys don't do much. Okay? So always going a step back is really helpful. Going a step back even to the spine sometimes is needed. Okay? And again, how would we differentiate if an issue is in the periphery or more central? Well, the LTAP does that for us.
But then also something like Michael Shocklock's, um, slump test with the double leg version also can give us indication if it's a peripheral nerve entrapment or peripheral nerve issue versus the more central nervous system issue. Those are specific to the nervous system. That's a very nervous system based test.
What it doesn't rule out is tells us that there's a visceral piece. Obviously, that's what the LTAP does for us. Because there can be visceral issues that are irritating these nerves as they exit the trunk, as they exit the spine, as they exit the pelvic bowl, and can have an effect on the knee and the foot.
Sorry, not just the, yes, the knee and the foot and the hip, the entire lower leg. But in, in this podcast we're talking about the foot and ankle. So this is the whole premise behind some of the visceral referral patterns in general.
When we can appreciate that these 1, 2, 3, 4, 5 nerves innervate the talocrural joint, now, the next time we see someone with a talocrural joint that is not moving very well, we can um, try to perform an intervention to the nerve itself and you have some options. You can do something very general like a nerve glide or a variation of a nerve glide that can be slacking the nerve, that can be gliding the nerve, that can be tensioning the nerve and you can do that on the longer
way, right? So the way we would go about that, we could do that on the sural nerve. We could do it on the femoral and saphenous nerve. Um, saphenous is a little harder positioning to get, so that's why I would recommend just going to the femoral nerve for it. You could also do it on the common peroneal nerve, and you could do it on the tibial nerve.
All of those are nerve glides that are um, easily demonstrated, easily done. The biggest mistake people make with those nerve glides is having too high of an intensity. Nerve glides should not feel like much. You should keep the intensity at a 3 out of 5, and intensity meaning the sensation of stretch should be no more than a 3 out of 10.
I said 3 out of 5, but I meant 3 out of 10. So, um, that's probably the biggest mistake people make with any sort of nerve glide is making it feel like. Um, I have some, um, of those nerve glides on YouTube and so I'll have Joe link those in the show notes. I believe I have a femoral nerve glide up there and I believe I have a tibial and a common peroneal.
I know for sure I have the common peroneal nerve glide up there and on Instagram I have sural nerve so I'll make sure some of those are in the show notes for you as well. But, we can get even more specific, especially when there is a peripheral nerve entrapment, when we know the most common areas of entrapment of these nerves.
Part of this is knowing the anatomy, and this is where most people are like, how do you know this? And I will tell you a secret. Before I sat down to do this podcast, I googled all of these. Some of them I knew, but the only way, like, Some of them I knew because what you're going to notice is these entrapment sites are also very common treatment locations for things like dry needling, um, ART, fascial manipulation, and also just spots that tend to be tender when you're doing regular massage, foam rolling, that kind of thing, all right?
So,
And if I didn't know them, I, yeah, I just looked them up. This is the beauty of the internet, everyone. You can look it up. You can read articles on the anatomy. That's actually my favorite thing to do is not only look it up, get the answer, but then click on the links that take me to the actual anatomical research article that shows me pictures of the cadavers and talks about percentage of variations and all those kinds of things like that.
There's also a book, actually when I was looking for this other day, there's this woman who was the editor of a peripheral neural entrapment book. I didn't even know existed and she was on ResearchGate and I don't know if you're familiar with the website ResearchGate, but um, authors can share their publications for free.
And so I downloaded like 15 chapters of her book. I also added her book to my books list on my Amazon store, so I'll have Joe link that in the show notes too. I can't vouch for the book, I don't know if it's any good, but the few chapters I've read of hers are really good. And, um, she's either like a co author or an editor on a lot of the chapters, um, but I think one of the main contributors is a man named Dr.
Michael Brown. So, And these, and, and these people who talk mostly about peripheral nerve entrapments tend to be pain docs. These are people, these are doctors that are doing injections to these nerve entrapment areas to relieve long standing pain in people that have not resolved from physical therapy or pharmaceuticals.
Most of the time when I'm teaching, one of my favorite websites to look at neural anatomy is the website NYSORA, N Y S O R A, and that is actually a pain doc, like where to put the injection website. So, it's funny to me how different Professions, both working with humans and pain from a musculoskeletal standpoint, haven't really like connected on how they could help each other.
And one of the main things I do treatment wise is addressing these entrapment spots with dynamic cupping, with dry needling, with neural manipulation, with regular massage, with myofascial release and very successful. Very successful. I don't think, I think a lot of people who probably end up going to these pain docs Probably could have gotten relief with these techniques if whoever they were working with knew where to go But that's my opinion.
So So let's talk about those spots So again, we're just talking today about the talocrural joint the common entrapment sites for the nerves that innervate the joint. So the first one the sural nerve. Sural nerve, it's going to be, it's a very superficial nerve, it's actually very, um, much like the saphenous nerve, saphenous nerve is also very superficial, they're going to be very associated with the superficial fascia, so dynamic cupping works great for these nerves.
Uh, the first spot of common entrapment for the sural nerve is the superficial sural aponeurosis. It's basically the space between, along the calf and the gastroc. So if you look at where the sural nerves are, the medial and lateral nerve, right? I told you the medial sural nerve relates to the tibial nerve and the lateral sural nerve relates to the common peroneal nerve.
And so they follow those paths. So because the medial sural nerve relates to the tibial nerve, it actually follows the very midline between the gastroc heads and it goes all the way down the leg. The lateral sural nerve follows like the lateral border of the lower leg kind of along the peroneals. Uh, the base of the fifth met is a common spot for the sural nerve to be entrapped.
There is a fascia that it splits through there and I think it might dive under a muscle there as well. So that's another common spot. I'd say more associated with foot pain than ankle, but sometimes you'll be surprised when you treat in the foot and it unlocks the ankle. So again, there's a, there's a reflexiveness to treating these nerves as well.
Making the sural nerve happy throughout the whole length of it often results in improved talocrural joint range of motion. And then another spot is going to be the lateral calf or crural fascia. So this kind of also relates to that superficial sural aponeurosis, um, but the, uh, crural fascia is a word for leg fascia, but really what they're referring to is the spots where the deep Leg fascia can be accessed.
And so if you look at the cross section of the lower leg, you're going to see the deep compartment or the posterior compartments and the anterior and lateral compartments separated by kind of a couple different like fascial containers. But that whole line that goes across the diameter of the lower leg, that is a great access point for the entire deep posterior compartment.
And so that is that crural fascial space. And then another spot is a fibrous arcade. Um, the fibrous arcade is in the distal third of the lower leg lateral posterior lateral to the achilles. This is actually a very common place that people complain of Achilles tendon problems, and it gets labeled as Achilles tendonitis and it's often a sal nerve irritation or sural nerve nerve sensory
experience of pain and tightness and discomfort. So those are the one, two, three, four most common spots for the sural nerve. The next nerve, the saphenous nerve, like I said, it's another superficial nerve. It can be related to superficial fascia in the skin. These are also continuous nerves, so that makes sense.
Uh, common entrapment sites for the saphenous nerve, you'll hear me actually talk about this nerve a lot in regards to the knee because a common entrapment site for it relates to to two branches of the saphenous nerve, the sartorial branch and the infrapatellar branch. So the infrapatellar branch innervates the patella tendon and the lateral side of the knee down below.
And then the sartorial branch innervates the subsartorial plexus area around the area of the adductor hiatus. So those are all common entrapment sites. So subsartorial plexus, adductor hiatus. Infrapatellar, um, sort of wrapping around from adductor hiatus to infrapatellar, that medial side of the knee joint.
Um, you can kind of think about where the medial retinaculum of the knee joint is. That is basically what it's getting entrapped in, I believe. Um, and then it can also be entrapped at the, um, Saphenous hiatus up in the femoral triangle underneath the inguinal ligament where it enters the adductor canal.
And then down low or closer to the ankle, it's often, um, entrapped in the medial shin. The medial shin gets really restricted from a fascial standpoint, superficial fascial standpoint, especially in my athletes, especially with anybody experiencing any fluid imbalance issues. And it's usually anterior to the medial malleolus, about halfway to the front of the ankle.
And then up a little bit about halfway the leg itself right along the tibia. That is another common spot for it. So all great spots to either needle or dynamic cup or, you know, regular massage. Really a lot of bang for your buck there. So those are the common spots for the saphenous nerve. The tibial nerve, um, The tibial nerve and the common peroneal nerve are the same entrapment spots in the proximal part of the leg because they are together in one sheath, that is what makes up the sciatic nerve.
So the sciatic nerve is commonly entrapped at the piriformis, both on the superior border and the inferior border, or on some people, right through the muscle itself. Medial to the greater trochanter, where the sciatic nerve comes sort of down through the groove there. The superior popliteal diamond, so where the hamstrings split, the sciatic nerve comes right out of there.
That's right where it starts to split and become the tibial nerve and the common peroneal nerve. And then, um, the popliteal split. base itself can be an entrapment for both of those nerves, though they're not in the same sheath now. The popliteal, like true middle popliteal space, tibial nerve is going to be more midline and common peroneal nerve is typically more lateral, but it just depends on the person.
Then, the common peroneal nerve gets entrapped at the proximal tib fib joint. And the, um, then it splits to the superficial. Peroneal and the deep peroneal nerve, and we'll talk about those in a second. Let me finish up the tibial nerve. The tibial nerve also gets entrapped at that deep crural fascia, so the deep fascia of the deep posterior compartment.
So those lateral and medial borders of the compartment are going to be key spots for the tibial nerve, even though it's going to be deep to that. Treating the medial sural nerve is going to be a way to treat the tibial nerve as well. We already talked about where that was at and then also at the posterior tibial nerve, which is in the tarsal tunnel.
That's probably the most well known nerve entrapment, pathology, or complaint, or pain, is, uh, tarsal tunnel syndrome, but that is an area of entrapment as well. So, now, breaking down the, the branches of the common peroneal nerve, the su the superficial peroneal nerve, also called fibular nerve, I've been interchanging them today.
It can get entrapped between the fibula and the peroneus longus. Um, there is a spot, um, just above the lateral ankle, where it's almost like a little divot, uh, right at the end of the tendon of the, not the end of the tendon, but like where the end, the muscle turns into more tendon down at the peroneus longus.
That's another, uh, spot. In the, like within the peroneus longus itself. And between the, so anterior to the lateral malleolus, between the lateral and anterior compartment. So between the peroneus brevis and the extensor digitorum longus. Then the deep peroneal nerve can also get entrapped at the anterior, anterior tarsal and really gets entrapped in three locations around the three bands of the extensor.
Um, extensor retinaculum of the ankle. So these three locations, um, are very common. And then it can also be entrapped between the first and second web spaces of the metatarsals, uh, around the area of extensor hallucis brevis. And between the talonovicular joint, novicular, not novicular, talonovicular joint and the extensor hallicis longus.
So actually, um, addressing extensor hallicis longus mobility and like skin stretch, skin excursion, um, can be a way to treat the deep peroneal. One of my favorite ways to do. to show people I'm magical and to treat the deep peroneal nerve and have a huge effect on the talocrural joint and even though I told you we weren't going to go over it, uh, the subtalar joint as well as the talonovicular joint and the midfoot and forefoot is to treat the deep fibular nerve in the easiest spot is quickly to do it in that web space and that web space, you can do it with the opposite heel.
So it's a exercise that people can do on themselves, a little skin stretch, um, through that web space. And it is oh, so powerful, or you can do a skin lift. So super powerful spots. And that's it. Um, that is all of the nerves related to the talocrural joint. Do you see why now? I'm not doing all the joints on this episode, but you see the point, right?
I've already told you the entrapment spots of a lot of them. So a lot of these nerves innervate the other joints too. Um, some nerves we didn't go over at all, like the plantar nerves. Uh, but I think we pretty much went over all the other nerves. So everything but the plantar nerves. There's a couple other cutaneous nerves that I didn't go over that could play a role.
Um, but for the most part, that covers a lot of the lower extremity as well as, spoil alert, not just the ankle and the foot, but the toes, the knee, the hip, and the SI joint. So nerves are powerful. Knowing nerve anatomy is. A big deal. Having treatment techniques that can support these areas of entrapment, game changers.
Knowing when and where to do it, so it doesn't take your whole session. Now, that is an important skill, and like I said, that's what the LTAP provides us, right? Because you see, I listed out a lot of common spots for all the different nerves. So, the LTAP gives us some tests where we can narrow it down and find the exact spot of entrapment very quickly.
And it's often actually not based on symptoms. So there's that. Have fun with this information. I hope it was helpful and I'm really looking forward to finishing the foot and ankle course coming up. I wish I had a date to tell you when it will go on sale, but I don't. And as soon as I know, you will know, but it will be within the next, uh, few weeks for sure.
So have a great day and we'll talk to you later.