As I work through my current academic semester at the Canadian Academy of Osteopathy I am confronted with a lot of work and little time to dedicate to anything else…which is perfect! I continue to look for information worth sharing so here I go – while listening to an anatomy lecture I had (to me at least) an interesting epiphany, the fibular head has the possibility to affect the sacrum.
First I will say that the fibular head has been described as prone to dysfunction via dysfunctions of the talus – one does not occur without the other. Now, also consider the structures that attach to the fibular head – the soleus (which extends down to the calcaneus via the achilles tendon that will also have relations to talar dysfunctions), the fibular collateral ligament, and the biceps femoris. The soleus also has attachments to the tibia which helps to begin highlighting how a fibular head dysfunction relates to knee dysfunction – do not stop here in your thought process though!
The next step in the line I am attempting to draw takes us up the biceps femoris to the ischial tuberosity. How do we get to the sacrum from the ischial tuberosity – the sacrotuberous ligament.
Now that we have gone from the talus to the sacrum along a primarily soft tissue line it is time to begin the practical thought process. The sacrum sits between the innominates and the ischial tuberosity is part of the innominate. The force transfer runs from the sacrum to the ischial tuberosity via the sacrotuberous ligament, both of which are highly affected by innominate dysfunction. From the innominate dysfunction there will be a mechanical alteration at the attachment site of the biceps femoris leading to an altered mechanical strain on the fibular head to then transfer altered force to the talus. There are a myriad of other connections here that all count – if there is an issue at the ischial tuberosity there will also be affects directly to the semitendinosus and semimembranosus beginning an altered pattern of strain through the knee in conjunction with the biceps femoris. Again, do not stop your thinking here – if the ischial tuberosity is malpositioned so is the rest of the innominate leading to altered lines of force through the quadriceps, adductors, pelvic floor, psoas and iliacus, quadratus lumborum, the abdominal group, the latissimus dorsi, as well as the erector mass.
Now that I have wandered around connections through the innominate I need to circle back and speak about the sacrum to talus line (it is after all what I am supposed to be talking about!). Correction of the talus is not completely feasible without correcting to the root of the force line. Without getting caught up in sacral lesioning or anything else I want to stress the basic principle of treatment – start from the base and work up and down, then work from the center out. The base is always the pelvis. The leg hangs from the pelvis and the foot hangs from the leg. Regardless of the etiology – a lesion that started at the foot via an injury or a sacral lesion – there is an alteration in the line of force that requires the correction begin at the base. Correct any pelvic lesioning to alter the mechanics and then work proximal to distal. By correcting the pelvic lesion there will be a sacral correction and a correction to the ischial tuberosity which then corrects the line from the biceps femoris to the fibular head, then to the soleus (don’t forget about fibularis longus and brevis as additional soft tissue connections), and then down to the talus (and the calcaneus via the soleus). Any issues that are left after the pelvis is truly corrected may be treated then.
For me this is an exercise in affirming the principles of treatment via a superficial anatomical line. I am doing as Dr. Still said to do, I am digging (albeit superficially at the moment – to get deeper in to the related issues neurology and vasculature must be considered as well). I am attempting to take the time now to draw the lines so that I may treat in a rational fashion.