| BackgroundLateral ankle sprain is one of the most common sports injuries in human body,accounting for about 25%of all musculoskeletal system injuries.According to traditional Chinese medicine,the pathological manifestation of ankle sprain is "Gu Cuo Feng and Jin Chu Cao(malocclusion of bone and trough of tendons)",which belongs to the category of "Jing Shang Chuo Jiao".Bone-setting manipulation of traditional Chinese medicine is a common method to treat this injury.Rotating-Traction-Poking technique is one of the most important methods for curing acute and chronic ankle sprain.The most common injury of ankle joint is the injury of lateral collateral ligament.The Rotating-Traction-Poking technique is the representative one for the treatment of ankle sprain by Qinggong Bone-setting.This technique runs through the characteristics of "light,delicate,soft and harmonious" throughout the operation.Rotation in manipulation can release the spastic muscular ligaments around the diseased joints,and make the soft tissues of contraction,torsion and dislocation"return to their position,perform their duties".Extension in manipulation can widen the gap between ankles and facilitate the repair of damaged gap tissues.Punching in manipulation can make local hematoma disperse,prevent the organization of hematoma,promote the absorption of hematoma,and at the same time.It also has the function of resetting.The combination and application of the various methods complement each other,which can repair the wrong suture,relax the tendons and tighten the tendons,and achieve the therapeutic purpose of relieving pain and restoring the normal activity of the ankle joint.According to the previous related studies and our group's previous clinical randomized controlled study,we found that the manipulation has significant clinical effect in improving the functional disorders of lateral ankle patients.However,reviewing the previous literature reports,we found that the research on manipulation treatment of lateral ankle sprain mainly focused on the clinical part.The mechanism of manipulation is mostly inference,and there is no objective experimental data to support it.It can be said that the basic research on manipulation of ankle sprain is still in the blank.The study of the mechanism of manipulation is helpful to improve the clinical effect of manipulation and promote the application and promotion of manipulation,so it is necessary to conduct in-depth study on it.At the same time,in the past,because of the lack of direct visual observation and research means,doctors almost completely depend on their personal experience and habits in choosing a method,so it is difficult to make an objective evaluation of the advantages and disadvantages of a certain method.The emergence of finite element analysis and computer visualization technology is the technology urgently needed in this field.The finite element method is used to study the ankle-foot manipulation.By simulating the extrusion and torsion of the ankle-foot under the manipulation,the deformation,stress distribution and strain of any part of the ankle-foot manipulation can be obtained,and the functional state of the internal structures of the ankle-foot under the manipulation can be quantitatively and non-invasively evaluated.It not only has the advantages of X-ray plain film for overall observation,but also has the high resolution of CT scanning for bone and soft tissue.This is more scientific and meaningful than the results obtained by traditional biomechanical methods.At present,with the continuous research of scholars at home and abroad,the establishment of digital ankle-foot model is becoming more and more perfect.The finite element model of ankle joint has also developed from a simplified two-dimensional model to a three-dimensional anatomical model,and from linear problems to non-linear problems.Most of these studies only concern the internal fixation of ankle and foot,not the treatment mechanism of bone-setting manipulation.The reason is that the structure of the spine is comparatively similar,and the range and angle of motion are limited.Therefore,the loads and stresses of the manipulation can be fully analyzed when the loading force is applied.In addition,most of the research models are limited to bone structures,neglecting soft tissue structures such as muscles and ligaments,resulting in errors in the research results.Therefore,the mechanism of ankle sprain treated by hand still needs to be further explored from the perspective of finite element analysis.In addition,the traditional Chinese medicine theory of "Gu Zheng Jin Rou(bone strengthening and tendons flexibility)" still has a profound impact and guiding value on the clinical practice of Orthopaedics and traumatology in traditional Chinese medicine.The theory of "Gu Zheng Jin Rou" is a classical exposition of the relationship between bones and tendons,and a refined summary of the relationship between bones and tendons and their normal physiological characteristics.It shows that the bones and muscles are a whole,and they complement and depend on each other.But if the external violence injury or chronic strain of the body itself leads to"Gu Cuo Feng and Jin Chu Cao",or both,that is the pathological state of muscle and bone disharmony,it will affect the normal operation of Qi and Xue,and the poor operation of Qi and Xue will lead to local pain,swelling and motor dysfunction.The malposition of ankle joint caused by ankle sprain belongs to the category of "Gu Cuo Feng".Pathological changes such as articular cartilage injury,ligament rupture,muscle edema and synovial incarceration belong to the category of "Jin Chu Cao".At present,traditional Chinese medicine Bone-setting manipulation is widely used in the treatment of tendons and injuries.The mechanism of this treatment is to change the pathological state of "Gu Cuo Feng and Jin Chu Cao" into the normal physiological state of "Gu Zheng Jin Rou".At present,some physicians use the theory of "Gu Zheng Jin Rou" to prevent and treat orthopedic and traumatic diseases.They intervene in the disease by changing the relationship between tendons and bones.Their specific treatment methods are mainly Bone-setting manipulation and functional exercise,and have achieved good clinical therapeutic effect.However,there are few reports on the theoretical mechanism of "Gu Zheng Jin Rou".What are the objective criteria of "Gu Zheng" and "Jin Rou"?How can manipulation make the body achieve the ideal state of "Gu Zheng Jin Rou"?Can biomechanics and finite element analysis be used to discover the mechanism?These problems still need to be explored and verified by new scientific methods.objective1.Based on CT imaging data of ankle joint,a normal three-dimensional finite element model of ankle joint was established and its validity was verified.2.Using motion capture system,self-developed mechanical gloves and Mechanical Kinematics synchronization module,the magnitude of the load and angle imposed on ankle joint in motion state is quantified.3.To explore the mechanism of Rotating-Traction-Poking manipulation in the treatment of lateral ankle sprain by finite element analysis,and to provide objective and scientific research support for the theory of "Gu Zheng Jin Rou".Methods1.Establishment of three-dimensional finite element model of ankleCT tomograms of patients with acute lateral ankle sprain were collected,and the acute ankle sprain model was established by using Mimics software and Abaqus software.The establishment of the model mainly includes the following steps:(1)point cloud processing:?image positioning:all CT images are vectorized,the two-dimensional information in DICOM format is transformed into three-dimensional information,and the boundary contours of each tomographic image are automatically formed.?Threshold definition:Bone thresholds are defined for the localized images to separate the bony structures and surrounding soft tissues.? Bone separation.?3D generation smoothing:Surface treatment and 3D image preservation.(2)Reverse Engineering:Using the three-dimensional modeling software solidworks,the point cloud data generated in Mimics will be processed in reverse.Reverse processing includes point cloud data derivation,surface generation and surface fitting.(3)mesh generation:HyperMesh software is used to mesh the bone structure,and finally three-dimensional mesh model is generated.Each skeletal layer is meshed according to cortical and cancellous bones,and material properties are added to the skeletal model.It is good for later calculation.(4)Establishment of finite element model as a whole:?Ligament addition.?Adding contact surface.?Adding cartilage.?Determine material parameters.2.Mechanical quantification of motion ankle joint and verification of finite element Model.(1)Development of gloves for manual mechanics measurement and synchronization system for data acquisition:A coin pressure sensor with symmetrical distribution was used,and two flat plates were installed at both ends of the sensor to form sensor modules.With the help of gyroscope and acceleration module,a glove for measuring force and acceleration by manual data was developed.Through BNC connector,Zigbee module and PC system,mechanics measurement and motion capture measurement are combined,so that mechanics and kinematics data can be collected synchronously in a single experiment.(2)Ankle motion force and angle acquisition:The operator exerts force on the patient's ankle with both thumbs,making it passive dorsiflexion,plantar flexion,varus,valgus,and the range of motion is the maximum range that the patient can bear.Synchronization system of mechanics and kinematics was used to collect the movement process of the affected ankle,the force exerted by the operator's thumbs and the angle of the ankle joint.The above experiments were carried out at three time points.The determination of time points was based on the time after ankle injury:?Initial sprain:1 day after injury(before manipulation treatment);?2 weeks after injury(immediately after the last manipulation treatment);?1 months after rehabilitation(2 weeks after manipulation treatment).In each test,the operator's force point is ensured to be the same.After signing the informed consent,the patients were treated with Rotating-Traction-Poking manipulation,totally 3 times,with a course of 2 weeks.(3)Verification of the finite element model:According to the actual motion state of ankle joints during the Rotating-Traction-Poking manipulation,the boundary conditions of the three-dimensional finite element model are determined,and then the force and angular parameters of the ankle joints after rehabilitation are loaded to verify the validity of the model.3.Finite element analysis of the mechanism of Rotating-Traction-Poking manipulation in the treatment of lateral ankle sprainOn the basis of guaranteeing the validity of the normal finite element model after rehabilitation,according to the force and angle parameters(back extension,plantar flexion,varus,valgus)of the above-mentioned patients'ankle injuries at different time points(before manipulation treatment,immediately after initial treatment and 2 weeks after the end of treatment),the working conditions of the model were loaded.By adjusting the parameters of anterior talofibular ligament,the elastic modulus,stress and stress of ankle joint contact surface under the four working conditions(dorsiflexion,plantar flexion,varus,valgus)were obtained,and the mechanism of the treatment of ankle sprain by Rotating-Traction-Poking manipulation was analyzed.Because the anterior talofibular ligament is the most common injury in ankle sprain,the anterior talofibular ligament is the main ligament in this finite element analysis.Results1.A three-dimensional finite element model of normal ankle was established,and the calculated results of the finite element motion angle were basically in agreement with the experimental angle data after rehabilitation,which confirmed that the finite element analysis model was reasonable and effective.2.A mechanical glove and a mechanical kinematics synchronization module were developed to quantify the magnitude of the load and angle applied under the ankle joint motion,which provided the loading simulation conditions for the finite element analysis.3.Finite element analysis of the mechanism of Rotating-Traction-Poking manipulation in the treatment of lateral ankle sprain:(1)From the point of view of the change of elastic modulus of anterior talofibular ligament:under four loading conditions(plantar flexion,dorsal extension,varus and valgus),the elastic modulus of anterior talofibular ligament before manipulation is 1.8-2 times that of normal model after rehabilitation,and the elastic modulus during treatment is 1.4-1.5 times that of normal model after rehabilitation,and its value is at different stages(before treatment).In the course of treatment and after rehabilitation,it tends to decrease gradually.(2)From the point of view of the change of mechanical parameters of anterior talofibular ligament,the maximum stress and total axial force of anterior talofibular ligament increased gradually in four different stages.(3)From the stress distribution of talus contact surface,the maximum stress between talus and tibia,talus and fibula increased gradually before treatment,during treatment and after rehabilitation.Moreover,the area of stress distribution nephogram(stress surface)is also gradually increasing,which indicates that the stress distribution is gradually becoming uniform.(4)From the point of view of micro-motion joint(tibial-talus joint):under four working conditions,the micro-motion angle of lateral ankle sprain tends to increase gradually before,during and after treatment,indicating that its range of motion is increasing gradually with the progress of treatment.Conclusions1.The maximum stress between talus and tibia,talus and fibula increases gradually before,during and after the treatment of Rotating-Traction-Poking manipulation.Moreover,the area of stress distribution nephogram(stress surface)is also gradually increasing,which indicates that the stress distribution is gradually becoming uniform.It shows that the local pain,swelling and poor alignment of the ankle points before manipulation make the stress of the whole ankle points less and mainly concentrated in the medial tibial talus joint.After manipulation treatment,the above symptoms and pathological changes were alleviated,the bearing capacity of ankle joint surface was increased,and the stress distribution of medial tibial talus joint and lateral fibular talus joint tended to be uniform gradually.Therefore,the stress distribution of the affected limbs and ankles can be effectively changed by Rotating-Traction-Poking manipulation,and the pathological state of "Gu Cuo Feng" can be transformed into the normal physiological state of "Gu Zheng".Based on this,the therapeutic mechanism of "Gu Zheng" by Rotating-Traction-Poking manipulation can be analyzed.2.The modulus of elasticity of anterior talofibular ligament decreases gradually with the treatment time,and the force it can bear increases gradually.This indicates that the spasm of anterior talofibular ligament is stiff and less stressed due to pain,swelling and poor alignment of ankle points before manipulation.After manipulation treatment,pain and swelling symptoms were alleviated,and ankle point alignment tended to be normal,so the talofibular anterior ligament gradually changed from stiffness to softness and the ability to withstand increased.Therefore,the Rotating-Traction-Poking technique can effectively change the elastic modulus and mechanical parameters of the anterior talofibular ligament of the affected limb,and can transform the pathological state of the "Jin Chu Cao" into the normal physiological state of the "Jin Rou" so as to analyze the treatment mechanism of the "Jin Rou" of the Rotating-Traction-Poking technique.3.This study proves that there is a pathological state of "Gu Cuo Feng and Jin Chu Cao" after sprain,and preliminarily reveals the mechanism of Rotating-Traction-Poking manipulation for ankle sprain,that is,the pathological state of malleolus joint and malleolus groove gradually changes to the physiological state of "Gu Zheng Jin Rou".Innovations1.A synchronous system for measuring gloves and data acquisition of manual mechanics has been developed,which provides a new quantitative method for the study of mechanics and kinematics of orthopaedic manipulation of ankle and foot.2.From the perspective of finite element analysis,the mechanism of Rotating-Traction-Poking manipulation in the treatment of lateral ankle sprain is clarified,and the validity and scientificity of Rotating-Traction-Poking manipulation are confirmed from the basic research level.3.From the perspective of biomechanics,it provides objective and scientific data support for the theory of "Gu Zheng Jin Rou". |
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