PERIPHERAL Joint Mobilization Chapter 5 Part 5

PERIPHERAL JOINT MOBILIZATION TECHNIQUES

Hip Joint

Hip Joint The concave acetabulum receives the convex femoral head. Resting Position flexion 30, abduction 30, and slight external rotation. Stabilization Fixate the pelvis to the treatment table with belts. HIP JOINT (Fig. 5.44) The concave acetabulum receives the convex femoral head. Biomechanics of the hip joint are reviewed in Chapter 20.   The resting position is hip flexion 30°, abduction 30°, and slight external rotation. Resting Position Fixate the pelvis to the treatment table with belts. Stabilization Bones and joints of the pelvis and hip.

Hip Distraction of the Weight-Bearing Surface, Caudal Glide Indications Testing Initial treatment Pain control General mobility P R E C A U T I O N : In the presence of knee dysfunction, this position should not be used; see alternate position Hip Distraction of the Weight-Bearing Surface, Caudal Glide (Fig. 5.45) NOTE: Because of the deep configuration of this joint, traction applied perpendicular to the treatment plane causes lateral glide of the superior, weight-bearing surface. To obtain separation of the weight-bearing surface, caudal glide is used.   Testing; initial treatment; pain control; general mobility. Indications Supine, with the hip in resting position and the knee extended. Patient Position PRECAUTION: In the presence of knee dysfunction, this position should not be used; see alternate position following. Stand at the end of the treatment table; place a belt around your trunk, then cross the belt over the patient's foot and around the ankle. Place your hands proximal to the malleoli, under the belt. The belt allows you to use your body weight to apply the mobilizing force. Therapist Position and Hand Placement Long-axis traction is applied by pulling on the leg as you lean backward. Mobilizing Force Hip joint: distraction of the weight-bearing surface.

Alternate Position for Hip Caudal Glide Indication To apply distraction to the weight-bearing surface of the hip joint when there is knee dysfunction. Patient Supine, with the hip and knee flexed. Alternate Position for Hip Caudal Glide Indication To apply distraction to the weight-bearing surface of the hip joint when there is knee dysfunction.   Patient Position Supine, with the hip and knee flexed. Therapist Position and Hand Placement Wrap your hands around the epicondyles of the femur and distal thigh. Do not compress the patella. Mobilizing Force The force comes from your hands and is applied in a caudal direction as you lean backward.

Hip Posterior Glide Indications To increase flexion To increase internal rotation Figure 5.46. Hip joint: posterior glide. Hip Posterior Glide (Fig. 5.46)   Indications To increase flexion; to increase internal rotation. Patient Position Supine, with hips at the end of the table. The patient helps stabilize the pelvis and lumbar spine by flexing the opposite hip and holding the thigh against the chest with the hands. Initially, the hip to be mobilized is in resting position; progress to the end of the range. Therapist Position and Hand Placement Stand on the medial side of the patient's thigh. Place a belt around your shoulder and under the patient's thigh to help hold the weight of the lower extremity. Place your distal hand under the belt and distal thigh. Place your proximal hand on the anterior surface of the proximal thigh. Mobilizing Force Keep your elbows extended and flex your knees; apply the force through your proximal hand in a posterior direction. Hip joint: posterior glide

Hip Anterior Glide Indications To increase extension To increase external rotation. Figure 5.47. Hip joint: anterior glide (A) prone Figure 5.47. (B) side-lying.   Hip Anterior Glide (Fig. 5.47) Indications To increase extension; to increase external rotation. Patient Position Prone, with the trunk resting on the table and hips over the edge. The opposite foot is on the floor. Therapist Position and Hand Placement Stand on the medial side of the patient's thigh. Place a belt around your shoulder and the patient's thigh to help support the weight of the leg. With your distal hand, hold the patient's leg. Place your proximal hand posteriorly on the proximal thigh just below the buttock. Mobilizing Force Keep your elbow extended and flex your knees; apply the force through your proximal hand in an anterior direction. Hip joint: anterior glide (A) prone

Hip Anterior Glide (Alternate Position) Alternate Position (Fig. 5.47 B) Position the patient side-lying with the thigh comfortably flexed and supported by pillows. Stand posterior to the patient and stabilize the pelvis across the anterior superior iliac spine with your cranial hand. Push against the posterior aspect of the greater trochanter in an anterior direction with your caudal hand.

Knee and Leg KNEE AND LEG (Fig. 5.48) Tibiofemoral Articulation   KNEE AND LEG (Fig. 5.48) The concave tibial plateaus articulate on the convex femoral condyles. Biomechanics of the knee joint are described in Chapter 21. Tibiofemoral Articulation The resting position is 25° flexion. Resting Position The treatment plane is along the surface of the tibial plateaus; therefore, it moves with the tibia as the knee angle changes. Treatment Plane In most cases, the femur is stabilized with a belt or by the table. Stabilization Tibiofemoral Distraction, Long-Axis Traction (Fig. 5.49) Testing; initial treatment; pain control; general mobility. Indications Progress to positioning the knee at the limit of the range of flexion or extension. Sitting, supine, or prone, beginning with the knee in the resting position. Patient Position Rotation of the tibia may be added prior to applying the traction force. Use internal rotation at end-range flexion and external rotation at end-range extention. Grasp around the distal leg, proximal to the malleoli with both hands. Hand Placement Pull on the long axis of the tibia to separate the joint surfaces. Mobilizing Force Tibiofemoral Posterior Glide (Fig. 5.50) Testing; to increase flexion. Supine, with the foot resting on the table. The position for the drawer test can be used to mobilize the tibia either anteriorly or posteriorly, although no grade I distraction can be applied with the glides. Sit on the table with your thigh fixating the patient's foot. With both hands, grasp around the tibia, fingers pointing posteriorly and thumbs anteriorly. Therapist Position and Hand Placement Extend your elbows and lean your body weight forward; push the tibia posteriorly with your thumbs. Tibiofemoral Posterior Glide: Alternate Positions and Progression (Fig. 5.51) To increase flexion. Indication Once the knee flexes past 90°, position the patient prone; place a small rolled towel proximal to the patella to minimize compression forces against the patella during the mobilization. Sitting, with the knee flexed over the edge of the treatment table, beginning in the resting position (Fig. 5.51). Progress to near 90° flexion with the tibia positioned in internal rotation. When near 90° sit on a low stool; stabilize the leg between your knees and place one hand on the anterior border of the tibial plateaus. Figure 5.48. Bones and joints of the knee and leg. When in resting position, stand on the medial side of the patient's leg. Hold the distal leg with your distal hand and place the palm of your proximal hand along the anterior border of the tibial plateaus. When prone, stabilize the femur with one hand and place the other hand along the border of the tibial plateaus. When progressing with medial rotation of the tibia at the end of the range of flexion, the force is applied in a posterior direction against the medial side of the tibia. Extend your elbow and lean your body weight onto the tibia, gliding it posteriorly. Figure 5.49. Tibiofemoral joint: distraction (A) sitting, (B) supine, and (C) prone. Tibiofemoral Anterior Glide (Fig. 5.52) To increase extension. • Place a small pad under the distal femur to prevent patellar compression. • The tibia may also be positioned in lateral rotation. • Prone, beginning with the knee in resting position; progress to the end of the available range. hand on the posterior aspect of the proximal tibia. Grasp the distal tibia with the hand that is closer to it and place the palm of the proximal • If the patient cannot be positioned prone, position him or her supine with a fixation pad under the tibia. Alternate Position Force with the hand on the proximal tibia in an anterior direction. The force may be directed to the lateral or medial tibial plateau to isolate one side of the joint. Figure 5.50. Tibiofemoral joint: posterior glide (drawer). Figure 5.51. Tibiofemoral joint: posterior glide, sitting. • The mobilizing force is placed against the femur in a posterior direction. Patellofemoral Joint, Distal Glide (Fig. 5.53) NOTE: The drawer test position can also be used. The mobilizing force comes from the fingers on the posterior tibia as you lean backward (see Fig. 5.50). To increase patellar mobility for knee flexion. Supine, with knee extended; progress to positioning the knee at the end of the available range in flexion. Stand next to the patient's thigh, facing the patient's feet. Place the web space of the hand that is closer to the thigh around the superior border of the patella. Use the other hand for reinforcement. Glide the patella in a caudal direction, parallel to the femur. PRECAUTION: Do not compress the patella into the femoral condyles while performing this technique. Patellofemoral Medial-Lateral Glide (Fig. 5.54) To increase patellar mobility. Supine with the knee extended. Side-lying may be used to apply a medial glide (see Fig. 21.3) Place the heel of your hand along either the medial or lateral aspect of the patella. Stand on the opposite side of the table to position your hand along the medial border and on the same side of the table to position your hand along the lateral border. Place the other hand under the femur to stabilize it. Glide the patella in a medial or lateral direction, against the restriction. Proximal Tibiofibular Articulation: Anterior (Ventral) Glide (Fig. 5.55) To increase movement of the fibular head; to reposition a posteriorly positioned head. The top leg is flexed forward so the knee and lower leg are resting on the table or supported on a pillow. Side-lying, with the trunk and hips rotated partially toward prone. Place the base of your other hand posterior to the head of the fibula, wrapping your fingers anteriorly. Stand behind the patient, placing one of your hands under the tibia to stabilize it. The force comes from the heel of your hand against the posterior aspect of the fibular head, in an anterior-lateral direction. Distal Tibiofibular Articulation: Anterior (Ventral) or Posterior (Dorsal) Glide (Fig. 5.56) To increase mobility of the mortise when it is restricting ankle dorsiflexion. Supine or prone. Working from the end of the table, place the fingers of the more medial hand under the tibia and the thumb over the tibia to stabilize it. Place the base of your other hand over the lateral malleolus, with the fingers underneath. Press against the fibula in an anterior direction when prone and in a posterior direction when supine. Figure 5.53. Patellofemoral joint: distal glide. Figure 5.52. Tibiofemoral joint: anterior glide. Figure 5.55. Proximal tibiofibular joint: anterior glide. Figure 5.54. Patellofemoral joint: lateral glide. Figure 5.56. Distal tibiofibular articulation: posterior glide. Figure 21.3. The Q-angle is the angle formed by the intersection of a line drawn from the center of the patella to the anterosuperior iliac spine and a line drawn from the center of the patella to the tibial tuberosity. These two lines represent the bowstring effect on the patella from the pull of the quadriceps femoris muscle and the patellar tendon. An increased Q-angle is a factor contributing to excessive lateral tracking of the patella. Ankle and Foot Joints (Fig. 5.57) Biomechanics of the ankle and foot are summarized in Chapter 22. Talocrural Joint (Upper Ankle Joint) The convex talus articulates with the concave mortise made up of the tibia and fibula. The resting position is 10° plantarflexion. The treatment plane is in the mortise, in an anterior-posterior direction with respect to the leg. The tibia is strapped or held against the table. Talocrural Distraction (Fig. 5.58) Supine, with the lower extremity extended. Begin with the ankle in resting position. Progress to the end of the available range of dorsiflexion or plantarflexion. Stand at the end of the table; wrap the fingers of both hands over the dorsum of the patient's foot, just distal to the mortise. Place your thumbs on the plantar surface of the foot to hold it in resting position. Mobilization Force Talocrural Dorsal (Posterior) Glide (Fig. 5.59) Pull the foot away from the long axis of the leg in a distal direction by leaning backward. To increase dorsiflexion. Supine, with the leg supported on the table and the heel over the edge. Stand to the side of the patient. Wrap your fingers and thumb around the foot to maintain the ankle in resting position. Grade I distraction force is applied in a caudal direction. Place the palmar aspect of the web space of your other hand over the talus just distal to the mortise. Stabilize the leg with your cranial hand or use a belt to secure the leg to the table. Glide the talus posteriorly with respect to the tibia by pushing against the talus. Talocrural Ventral (Anterior) Glide (Fig. 5.60) To increase plantarflexion. Prone, with the foot over the edge of the table. Working from the end of the table, place your lateral hand across the dorsum of the foot to apply a grade I distraction. Place the web space of your other hand just distal to the mortise on the posterior aspect of the talus and calcaneus. Push against the calcaneus in an anterior direction (with respect to the tibia); this glides the talus anteriorly. When you pull against the calcaneus in an anterior direction, the talus glides anteriorly. The distal hand cups under the calcaneus. Patient is supine. Stabilize the distal leg anterior to the mortise with your proximal hand. Subtalar Joint (Talocalcaneal), Posterior Compartment The calcaneus is convex, articulating with a concave talus in the posterior compartment. The resting position is midway between inversion and eversion. The treatment plane is in the talus, parallel to the sole of the foot. Subtalar Distraction (Fig. 5.61) Testing; initial treatment; pain control; general mobility for inversion/eversion. The patient is placed in a supine position, with the leg supported on the table and heel over the edge. Patient and Therapist Positions The hip is externally rotated so the talocrural joint can be stabilized in dorsiflexion with pressure from your thigh against the plantar surface of the patient's forefoot. The distal hand grasps around the calcaneus from the posterior aspect of the foot. The other hand fixes the talus and malleoli against the table. Pull the calcaneus distally with respect to the long axis of the leg. Subtalar Medial Glide or Lateral Glide (Fig. 5.62) Medial glide to increase eversion; lateral glide to increase inversion. The patient is side-lying or prone, with the leg supported on the table or with a towel roll. Stabilize the talus with your proximal hand. Align your shoulder and arm parallel to the bottom of the foot. Place the base of the distal hand on the side of the calcaneus medially to cause a lateral glide and laterally to cause a medial glide. Wrap the fingers around the plantar surface. Apply a grade I distraction force in a caudal direction, then push with the base of your hand against the side of the calcaneus parallel to the planter surface of the heel. Intertarsal and Tarsometatarsal Joints Same as the position for distraction, moving the calcaneus in the medial or a lateral direction with the base of the hand. When moving in a dorsal-plantar direction with respect to the foot, all of the articulating surfaces are concave and convex in the same direction. For example, the proximal articulating surface is convex and the distal articulating surface is concave. The technique for mobilizing each joint is the same. The hand placement is adjusted to stabilize the proximal bone partner so the distal bone partner can be moved. Intertarsal and Tarsometatarsal Plantar Glide (Fig. 5.63) To increase plantarflexion accessory motions (necessary for supination). Supine, with hip and knee flexed, or sitting, with knee flexed over the edge of the table and heel resting on your lap. Fixate the more proximal bone with your index finger on the plantar surface of the bone. Place your thenar eminence of the distal hand over the dorsal surface of the bone to be moved and wrap the fingers around the plantar surface. To mobilize the tarsal joints along the medial aspect of the foot, position yourself on the lateral side of the foot. Place the proximal hand on the dorsum of the foot with the fingers pointing medially so the index finger can be wrapped around and placed under the bone to be stabilized. To mobilize the lateral tarsal joints, position yourself on the medial side of the foot, point your fingers laterally, and position your hands around the bones as just described. Push the distal bone in a plantar direction from the dorsum of the foot. Intertarsal and Tarsometatarsal Dorsal Glide (Fig. 5.64) To increase the dorsal gliding accessory motion (necessary for pronation). Prone, with knee flexed. Fixate the more proximal bone. Place your second metacarpophalangeal joint against the bone to be moved. To mobilize the medial bones (e.g., navicular on talus), position yourself on the lateral side of the patient's leg and wrap your fingers around the medial aspect of the foot. To mobilize the lateral tarsal joints (e.g., cuboid on calcaneus), position yourself on the medial side of the patient's leg and wrap your fingers around the lateral side of the foot (as in Fig. 5.64). Push from the plantar surface in a dorsal direction. Same position and hand placements as for plantar glides, except the distal bone is stabilized and the proximal bone is forced in a plantar direction. This is a relative motion of the distal bone moving in a dorsal direction. Alternate Technique Figure 5.59. Talocrural joint: posterior glide. Figure 5.58. Talocrural joint: distraction. Figure 5.57. (A) Anterior view of the bones and joints of the lower leg and ankle. (B) Medial view. (C) Lateral view of the bones and joint relationships of the ankle and foot. Figure 5.60. Talocrural joint: anterior glide. The intermetatarsal, metatarsophalangeal, and interphalangeal joints of the toes are stabilized and mobilized in the same manner as the fingers. In each case, the articulating surface of the proximal bone is convex, and the articulating surface of the distal bone is concave. It is easiest to stabilize the proximal bone and glide the surface of the distal bone either plantarward for flexion, dorsalward for extension, and medially or laterally for adduction and abduction. Intermetarsal, Metatarsophalangeal, and Interphalangeal Joints Figure 5.61. Subtalar (talocalcaneal) joint: distraction. Figure 5.62. Subtalar joint: lateral glide: (A) prone and (B) side-lying. Figure 5.64. Dorsal gliding of a distal tarsal on a proximal tarsal. Shown is the cuboid bone on the calcaneus. Figure 5.63. Plantar glide of a distal tarsal bone on a stabilized proximal bone. Shown is the cuneiform bone on the navicular.

Knee and Leg Tibiofemoral Articulation The concave tibial plateaus articulate on the convex femoral condyles Resting Position The resting position is 25 flexion. Treatment Plane The treatment plane is along the surface of the tibial plateaus therefore, it moves with the tibia as the knee angle changes. Stabilization In most cases, the femur is stabilized with a belt or by the table. Bones and joints of the knee and leg.

Tibiofemoral Distraction, Long-Axis Traction Indications Testing initial treatment pain control general mobility. Tibiofemoral joint: distraction (A) sitting

Tibiofemoral Distraction, Long-Axis Traction Tibiofemoral joint: distraction supine,

Tibiofemoral Distraction, Long-Axis Traction Tibiofemoral joint: distraction PRONE

Tibiofemoral Posterior Glide Indications Testing to increase flexion. Tibiofemoral joint: posterior glide (drawer

Tibiofemoral Posterior Glide: Alternate Positions and Progression Indication To increase flexion Tibiofemoral joint: posterior glide, sitting.

Tibiofemoral Anterior Glide Indication To increase extension Tibiofemoral joint: anterior glide.

Tibiofemoral Anterior Glide (Alternate positions) The drawer test position can also be used. The mobilizing force comes from the fingers on the posterior tibia as you lean backward

Patellofemoral Joint, Distal Glide Indication To increase patellar mobility for knee flexion P R E C A U T I O N Do not compress the patella into the femoral condyles while performing this technique Patellofemoral joint: distal glide.

Patellofemoral Medial-Lateral Glide Indication To increase patellar mobility Patellofemoral joint: lateral glide.

Proximal Tibiofibular Articulation: Anterior (Ventral)Glide Indications To increase movement of the fibular head; to reposition a posteriorly positioned head Proximal tibiofibular joint: anterior glide

Distal Tibiofibular Articulation: Anterior(Ventral) or Posterior(Dorsal) Glide Indication To increase mobility of the mortise when it is restricting ankle dorsiflexion. Distal tibiofibular articulation: posterior glide

Ankle and Foot Joints

Ankle and Foot Joints Talocrural Joint (Upper Ankle Joint) The convex talus articulates with the concave mortise made up of the tibia and fibula. Resting Position The resting position is 10 plantarflexion Treatment Plane The treatment plane is in the mortise, in an anteriorposterior direction with respect to the leg. Stabilization The tibia is strapped or held against the table. (A) Anterior view of the bones and joints of the lower leg and ankle. (B) Medial view. (C) Lateral view of the bones and joint relationships of the ankle and foot.

Talocrural Distraction Indications Testing Initial Treatment Pain Control General Mobility. Talocrural joint: distraction.

Talocrural Dorsal (Posterior) Glide Indication To increase dorsiflexion Talocrural joint: posterior glide

Talocrural Ventral (Anterior) Glide Indication To increase plantarflexion Talocrural joint: anterior glide.

Subtalar Joint (Talocalcaneal), Posterior Compartment The calcaneus is convex, articulating with a concave talus in the posterior compartment Resting Position The resting position is midway between inversion and eversion. Treatment Plane The treatment plane is in the talus, parallel to the sole of the foot (A) Anterior view of the bones and joints of the lower leg and ankle. (B) Medial view. (C) Lateral view of the bones and joint relationships of the ankle and foot

Subtalar Distraction Indications Testing Initial treatment Pain control General mobility for inversion/eversion Subtalar (talocalcaneal) joint: distraction

Subtalar Medial Glide or Lateral Glide Indications Medial glide to increase eversion lateral glide to increase inversion. Subtalar joint: lateral glide: (A) prone and (B) side-lying.

Intertarsal and Tarsometatarsal Joints When moving in a dorsal-plantar direction with respect to the foot, all of the articulating surfaces are concave and convex in the same direction. For example, the proximal articulating surface is convex and the distal articulating surface is concave. The technique for mobilizing each joint is the same. The hand placement is adjusted to stabilize the proximal bone partner so the distal bone partner can be moved. (A) Anterior view of the bones and joints of the lower leg and ankle. (B) Medial view. (C) Lateral view of the bones and joint relationships of the ankle and foot

Intertarsal and Tarsometatarsal Plantar Glide Indication To increase plantarflexion accessory motions (necessary for supination). Plantar glide of a distal tarsal bone on a stabilized proximal bone. Shown is the cuneiform bone on the navicular

Intertarsal and Tarsometatarsal Dorsal Glide Indication To increase the dorsal gliding accessory motion (necessary for pronation). Dorsal gliding of a distal tarsal on a proximal tarsal. Shown is the cuboid bone on the calcaneus

Intermetarsal, Metatarsophalangeal, and Interphalangeal Joints The intermetatarsal, metatarsophalangeal, and interphalangeal joints of the toes are stabilized and mobilized in the same manner as the fingers. In each case, the articulating surface of the proximal bone is convex, and the articulating surface of the distal bone is concave. . It is easiest to stabilize the proximal bone and glide the surface of the distal bone either plantarward for flexion, dorsalward for extension, and medially or laterally for adduction and abduction