Chapter 5: Peripheral Joint Mobilization/Manipulation

Joint mobilization, also known as manipulation, refers to manual therapy techniques that are used to modulate pain and treat joint impairments that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint. The altered joint mechanics may be due to pain and muscle guarding, joint effusion, contractures or adhesions in the joint capsules or supporting ligaments, or aberrant joint motion.

Joint mobilization stretching techniques differ from other forms of passive or self-stretching (described in Chapter 4) in that they specifically address restricted capsular tissue by replicating normal joint mechanics while minimizing abnormal compressive stresses on the articular cartilage in the joint.¹⁵

Historically, mobilization has been the preferred term to use as therapists began using the passive, skilled joint techniques, because mobilization had a less aggressive connotation than manipulation. High-velocity thrust techniques, typically called manipulation, were not universally taught or used by most practitioners. However, with the increased level of education^2a,4 and current practice of physical therapy,² both non-thrust and thrust manipulation techniques are skills that therapists are learning and safely using in many practice settings. The Manipulation Education Manual for Physical Therapist Professional Degree Programs^2a as well as the Guide to Physical Therapist Practice² couple the terms "mobilization" and "manipulation" in order to demonstrate their common usage.

A recent editorial^22a described problems with using the terms interchangeably. The authors cited confusion in interpreting research and describing outcomes when the techniques used are not clearly defined. They also indicated possible confusion in communicating with patients and with referral sources. It is, therefore, critical that the practitioner clearly understands and defines the characteristics of the techniques used when referring to manipulative techniques.

In this text, the terms "mobilization" and "manipulation" will be used interchangeably, with the distinction made between non-thrust and thrust techniques. The procedures section in this chapter describes documentation and the importance of identifying rate, range, and direction of force application, as well as target, relative structural movement, and patient position whenever referring to mobilization/manipulation intervention techniques.²² This information should be used in all documentation and communication in order to minimize discrepancies in interpretation of outcomes.

To use joint mobilization/manipulation techniques for effective treatment, the practitioner must know and be able to examine the anatomy, arthrokinematics, and pathology of the neuromusculoskeletal system and to recognize when the techniques are indicated or when other techniques would be more effective for regaining lost motion. Indiscriminate use of joint techniques, when not indicated, could lead to potential harm to the patient's joints. We assume that, prior to learning the techniques presented in this text, the student or therapist has had (or will be concurrently learning) orthopedic examination and evaluation and, therefore, will be able to choose appropriate, safe techniques for treating the patient's impairments. The reader is referred to several resources for additional study of examination and evaluation procedures.^5,11,15,18 When indicated, joint manipulative techniques are safe, effective means of restoring or maintaining joint play and can also be used for treating pain.¹⁵

Definitions of Terms

Mobilization/Manipulation

As noted in the introductory paragraphs, mobilization and manipulation are two terms that have come to have the same meaning^2a,19 and are, therefore, interchangeable. In general, they are passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes.² The varying speeds and amplitudes can range from a small-amplitude force applied at fast velocity to a large-amplitude force applied at slow velocity—that is, there is a continuum of intensities and speeds at which the technique could be applied.²

Thrust manipulation/high-velocity thrust (HVT). Thrust refers to high-velocity, short-amplitude techniques.^11,26 The thrust is performed at the end of the pathological limit of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors.²⁶ Pathological limit means the end of the available ROM when there is restriction.

NOTE: The terms thrust and manipulation are often used interchangeably,⁴ but with the trend to use manipulation to include all manipulative techniques, including non-thrust techniques, this text will not use these two terms interchangeably.

Self-Mobilization (Auto-Mobilization)

Self-mobilization refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule. When indicated, these techniques are described in the chapters on specific regions of the body.

Mobilization with Movement

Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end-range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier. The techniques are always applied in a pain-free direction and are described as correcting joint tracking from a positional fault.^21,23 Brian Mulligan of New Zealand originally described these techniques.²³ MWM techniques related to specific peripheral joint regions are described in Chapters 17 through 22.

Physiological Movements

Physiological movements are movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and rotation). The term osteokinematics is used when these motions of the bones are described.

Accessory Movements

Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient.²⁴ Terms that relate to accessory movements are component motions and joint play.

Component motions. These are motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. For example, motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, and rotation of the fibula, which occurs with ankle motions, are component motions.

Joint play. Joint play describes the motions that occur between the joint surfaces and also the distensibility or "give" in the joint capsule, which allows the bones to move. The movements are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient.²⁶ The movements include distraction, sliding, compression, rolling, and spinning of the joint surfaces. The term arthrokinematics is used when these motions of the bone surfaces within the joint are described.

NOTE: Procedures to distract or slide the joint surfaces to decrease pain or restore joint play are the fundamental joint mobilization techniques described in this text.

Manipulation Under Anesthesia

Manipulation under anesthesia is a procedure used to restore full ROM by breaking adhesions around a joint while the patient is anesthetized. The technique may be a rapid thrust or a passive stretch using physiological or accessory movements. Therapists may assist surgeons in the application of these skilled techniques in the operating room and continue with follow-up care.

Muscle Energy

Muscle energy techniques use active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory motion. The technique requires the therapist to provide stabilization to the segment on which the distal aspect of the muscle attaches. A command for an isometric contraction of the muscle is given that causes accessory movement of the joint. Several specific muscle energy techniques are described for the subcranial region of the cervical spine in Chapter 16.

Basic Concepts of Joint Motion: Arthrokinematics

Joint Shapes

The type of motion occurring between bony partners in a joint is influenced by the shape of the joint surfaces. The shape may be described as ovoid or sellar.^15,17,29

• In ovoid joints one surface is convex, and the other is concave (Fig. 5.1 A).

• In sellar (saddle) joints, one surface is concave in one direction and convex in the other, with the opposing surface convex and concave, respectively—similar to a horseback rider being in complementary opposition to the shape of a saddle (Fig. 5.1 B).

Types of Motion

As a bony lever moves about an axis of motion, there is also movement of the bone surface on the opposing bone surface in the joint.

• The movement of the bony lever is called swing and is classically described as flexion, extension, abduction, adduction, and rotation. The amount of movement can be measured in degrees with a goniometer and is called ROM.

• Motion of the bone surfaces in the joint is a variable combination of rolling and sliding, or spinning.^15,17,29 These accessory motions allow greater angulation of the bone as it swings. For the rolling, sliding, or spinning to occur, there must be adequate capsule laxity or joint play.

Roll

Characteristics of one bone rolling on another (Fig. 5.2) are as follows.

• The surfaces are incongruent.

• New points on one surface meet new points on the opposing surface.

• Rolling results in angular motion of the bone (swing).

• Rolling is always in the same direction as the swinging bone motion whether the surface is convex (Fig. 5.3 A) or concave (Fig. 5.3 B).

• Rolling, if it occurs alone, causes compression of the surfaces on the side to which the bone is swinging and separation on the other side. Passive stretching using bone angulation alone may cause stressful compressive forces to portions of the joint surface, potentially leading to joint damage.

• In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning.

Slide/Translation

Characteristics of one bone sliding (translating) across another include the following.

• For a pure slide, the surfaces must be congruent, either flat (Fig. 5.4 A) or curved (Fig. 5.4 B).

• The same point on one surface comes into contact with the new points on the opposing surface.

• Pure sliding does not occur in joints, because the surfaces are not completely congruent.

• The direction in which sliding occurs depends on whether the moving surface is concave or convex. Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex (Fig. 5.5 A). Sliding is in the same direction as the angular movement of the bone if the moving surface is concave (Fig. 5.5 B).

NOTE: This mechanical relationship is known as the convex-concave rule and is the theoretical basis for determining the direction of the mobilizing force when joint gliding techniques are used.¹⁵

Combined Roll-Sliding in a Joint

• The more congruent the joint surfaces are, the more sliding there is of one bony partner on the other with movement.

• The more incongruent the joint surfaces are, the more rolling there is of one bony partner on the other with movement.

• When muscles actively contract to move a bone, some of the muscles may cause or control the sliding movement of the joint surfaces. For example, the caudal sliding motion of the humeral head during shoulder abduction is caused by the rotator cuff muscles, and the posterior sliding of the tibia during knee flexion is caused by the hamstring muscles. If this function is lost, the resulting abnormal joint mechanics may cause microtrauma and joint dysfunction.

• The joint mobilization techniques described in this chapter use the sliding component of joint motion to restore joint play and reverse joint hypomobility. Rolling (passive angular stretching) is not used to stretch tight joint capsules, because it causes joint compression.

Spin

Characteristics of one bone spinning on another include the following.

• There is rotation of a segment about a stationary mechanical axis (Fig. 5.6).

• The same point on the moving surface creates an arc of a circle as the bone spins.

• Spinning rarely occurs alone in joints but in combination with rolling and sliding.

• Three examples of spin occurring in joints of the body are the shoulder with flexion/extension, the hip with flexion/extension, and the radiohumeral joint with pronation/supination (Fig. 5.7).

Passive-Angular Stretching Versus Joint-Glide Stretching

• Passive-angular stretching procedures, as when the bony lever is used to stretch a tight joint capsule, may cause increased pain or joint trauma because:

  • The use of a lever magnifies the force at the joint.

  • The force causes compression of the joint surfaces in the direction of the rolling bone (see Fig. 5.3).

  • The roll without a slide does not replicate normal joint mechanics.

• Joint glide stretching procedures, as when the translatoric slide component of the joint function is used to stretch a tight capsule, are safer and more selective because:

  • The force is applied close to the joint surface and controlled at an intensity compatible with the pathology.

  • The direction of the force replicates the sliding component of the joint mechanics and does not compress the cartilage.

  • The amplitude of the motion is small yet specific to the restricted or adherent portion of the capsule or ligaments. Thus, the forces are selectively applied to the desired tissue.

Other Accessory Motions that Affect the Joint

Compression

Compression is the decrease in the joint space between bony partners.

• Compression normally occurs in the extremity and spinal joints when weight bearing.

• Some compression occurs as muscles contract, which provides stability to the joints.

• As one bone rolls on the other (see Fig. 5.3), some compression also occurs on the side to which the bone is angulating.

• Normal intermittent compressive loads help move synovial fluid and, thus, help maintain cartilage health.

• Abnormally high compression loads may lead to articular cartilage changes and deterioration.¹⁷

Traction/Distraction

Traction and distraction are not synonymous VIDEO 5.1 . Traction is a longitudinal pull. Distraction is a separation, or pulling apart.

• Separation of the joint surfaces (distraction) does not always occur when a traction force is applied to the long axis of a bone. For example, if traction is applied to the shaft of the humerus when the arm is at the side, it results in a glide of the joint surface (Fig. 5.8 A). Distraction of the glenohumeral joint requires a force to be applied at right angles to the glenoid fossa (Fig. 5.8 B).

• For clarity, whenever there is pulling on the long axis of a bone, the term long-axis traction is used. Whenever the surfaces are to be separated, the term distraction, joint traction, or joint separation is used.

Effects of Joint Motion

Joint motion stimulates biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intra-articular fibrocartilage of the menisci.¹⁷ Atrophy of the articular cartilage begins soon after immobilization is imposed on joints.^1,7,8

Extensibility and tensile strength of the articular and periarticular tissues are maintained with joint motion. With immobilization there is fibrofatty proliferation, which causes intra-articular adhesions as well as biochemical changes in tendon, ligament, and joint capsule tissue, which in turn causes joint contractures and ligamentous weakening.¹

Afferent nerve impulses from joint receptors transmit information to the central nervous system and, therefore, provide awareness of position and motion. With injury or joint degeneration, there is a potential decrease in an important source of proprioceptive feedback that may affect an individual's balance response.³⁰ Joint motion provides sensory input relative to^32,33:

• Static position and sense of speed of movement (type I receptors found in the superficial joint capsule).

• Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads).

• Sense of direction of movement (type I and III receptors; type III found in joint ligaments).

• Regulation of muscle tone (type I, II, and III receptors).

• Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum, and walls of blood vessels).

Indications and Limitations for Use of Joint Mobilization/manipulation

Gentle mobilizations may be used to treat pain and muscle guarding, whereas stretching techniques are used to treat restricted movement.

Pain, Muscle Guarding, and Spasm

Painful joints, reflex muscle guarding, and muscle spasm can be treated with gentle joint-play techniques to stimulate neurophysiological and mechanical effects.¹¹

Neurophysiological Effects

Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.^26,29

Mechanical Effects

Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present). Gentle joint-play techniques help maintain nutrient exchange and, thus, prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM. When applied to treat pain, muscle guarding, or muscle spasm, these techniques should not place stretch on the reactive tissues (see section on Contraindications and Precautions).

Reversible Joint Hypomobility

Reversible joint hypomobility can be treated with progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue. Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically.^11,15

Positional Faults/Subluxations

A faulty position of one bony partner with respect to its opposing surface may result in limited motion or pain. This can occur with a traumatic injury, after periods of immobility, or with muscle imbalances. The faulty positioning may be perpetuated with maladapted neuromuscular control across the joint, so whenever attempting active ROM, there is faulty tracking of the joint surfaces resulting in pain or limited motion. MWM techniques attempt to realign the bony partners while the person actively moves the joint through its ROM.²³ Thrust techniques are used to reposition an obvious subluxation, such as a pulled elbow or capitate-lunate subluxation.

Progressive Limitation

Diseases that progressively limit movement can be treated with joint-play techniques to maintain available motion or retard progressive mechanical restrictions. The dosage of distraction or glide is dictated by the patient's response to treatment and the state of the disease.

Functional Immobility

When a patient cannot functionally move a joint for a period of time, the joint can be treated with nonstretch gliding or distraction techniques to maintain available joint play and prevent the degenerating and restricting effects of immobility.

Limitations of Joint Mobilization/Manipulation Techniques

Joint techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury. In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations (see Chapter 11).

The skill of the therapist affects the outcome. The techniques described in this text are relatively safe if directions are followed and precautions are heeded. However, if these techniques are used indiscriminately on patients not properly examined and screened for such maneuvers or if they are applied too vigorously for the condition, joint trauma or hypermobility may result.

Contraindications and Precautions

The only true contraindications to mobilization/manipulation stretching techniques are hypermobility, joint effusion, and inflammation.

Hypermobility

• The joints of patients with potential necrosis of the ligaments or capsule should not be mobilized with stretching techniques.

• Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion. Stretching is not done.

Joint Effusion

There may be joint swelling (effusion) due to trauma or disease. Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia. Medical intervention is required for aspiration of the blood to minimize its necrotizing effect on the articular cartilage. Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis.

• Do not stretch a swollen joint with mobilization or passive stretching techniques. The capsule is already on a stretch by being distended to accommodate the extra fluid. The limited motion is from the extra fluid and muscle response to pain, not from shortened fibers.

• Gentle oscillating motions that do not stress or stretch the capsule may help block the transmission of a pain stimulus so it is not perceived and also may help improve fluid flow while maintaining available joint play.

• If the patient's response to gentle techniques results in increased pain or joint irritability, the techniques were applied too vigorously or should not have been done with the current state of pathology.

Inflammation

Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage. Gentle oscillating or distraction motions may temporarily inhibit the pain response. See Chapter 10 for an appropriate approach to treatment when inflammation is present.

Conditions Requiring Special Precautions for Stretching

In most cases, joint mobilization techniques are safer than passive angular stretching, in which the bony lever is used to stretch tight tissue and joint compression results. Mobilization may be used with extreme care in the following conditions if the signs and the patient's response are favorable.

• Malignancy.

• Bone disease detectable on radiographs.

• Unhealed fracture. (The site of the fracture and the stabilization provided will dictate whether or not manipulative techniques can be safely applied.)

• Excessive pain. (Determine the cause of pain and modify treatment accordingly.)

• Hypermobility in associated joints. (Associated joints must be properly stabilized so the mobilization force is not transmitted to them.)

• Total joint replacements. (The mechanism of the replacement is self-limiting, and, therefore, the mobilization techniques may be inappropriate.)

• Newly formed or weakened connective tissue such as immediately after injury, surgery, or disuse or when the patient is taking certain medications such as corticosteroids. (Gentle progressive techniques within the tolerance of the tissue help align the developing fibrils, but forceful techniques are destructive.)

• Systemic connective tissue diseases such as rheumatoid arthritis, in which the disease weakens the connective tissue. (Gentle techniques may benefit restricted tissue, but forceful techniques may rupture tissue and result in instabilities.)

• Elderly individuals with weakened connective tissue and diminished circulation. (Gentle techniques within the tolerance of the tissue may be beneficial to increase mobility.)

Procedures for Applying Passive Joint Techniques

Examination and Evaluation

If the patient has limited or painful motion, examine and decide which tissues are limiting function and the state of pathology. Determine whether treatment should be directed primarily toward relieving pain or stretching a joint or soft tissue limitation.^5,11

Quality of pain

The quality of pain when testing the ROM helps determine the stage of recovery and the dosage of techniques used for treatment (see Fig. 10.2).

• If pain is experienced before tissue limitation—such as the pain that occurs with muscle guarding after an acute injury or during the active stage of a disease—gentle pain-inhibiting joint techniques may be used. The same techniques also can help maintain joint play (see next section, 'Grades or Dosages of Movement'). Stretching under these circumstances is contraindicated.

• If pain is experienced concurrently with tissue limitation—such as the pain and limitation that occur when damaged tissue begins to heal—the limitation is treated cautiously. Gentle stretching techniques specific to the tight structure are used to improve movement gradually yet not exacer bate the pain by reinjuring the tissue.

• If pain is experienced after tissue limitation is met because of stretching of tight capsular or periarticular tissue, the stiff joint can be aggressively stretched with joint-play techniques and the periarticular tissue with the stretching techniques described in Chapter 4.

Capsular Restriction

The joint capsule is limiting motion and should respond to mobilization techniques if some or all of the following signs are present.

• The passive ROM for that joint is limited in a capsular pattern. (These patterns are described for each peripheral joint under the respective sections on joint problems in Chapters 17 through 22).

• There is a firm capsular end-feel when overpressure is applied to the tissues limiting the range.

• There is decreased joint-play movement when mobility tests (articulations) are performed.

• An adhered or contracted ligament is limiting motion if there is decreased joint play and pain when the fibers of the ligament are stressed; ligaments often respond to joint mobilization techniques if applied specific to their line of stress.

Subluxation or Dislocation

Subluxation or dislocation of one bony part on another and loose intra-articular structures that block normal motion may respond to thrust techniques. Some of the simpler thrust techniques for extremity joints are described in the respective chapters in this text; thrust techniques for the spine are described in Chapter 16.

Documentation

Use of standardized terminology for communication is recommended in order to facilitate research on effective outcomes using mobilization/manipulation. A task force formed by the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) published recommendations regarding the characteristics to use in the description of manipulative techniques.²² These are listed in Box 5.1.

The principles describing the rate of application of the force, location in range of available movement, and direction and target of force that the therapist applies are described in this section. The actual target of force, structural movement, and patient position are specific to each joint technique; these are described in the section on peripheral joint mobilization techniques in this chapter, for the temporomandibular joint in Chapter 15, and for the spine in Chapter 16.

Grades or Dosages of Movement for Non-Thrust and Thrust Techniques

Two systems of grading dosages (or rate of application) and their application in the range of available motion have been popularized.11,15

Non-Thrust Oscillation Techniques

The oscillations may be performed using physiological (osteokinematic) motions or joint-play (arthrokinematic) techniques (Fig. 5.9).

Dosage and Rate of Application

Grade I. Small-amplitude rhythmic oscillations are performed at the beginning of the range. They are usually rapid oscillations, like manual vibrations.

Grade II. Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit. They are usually performed at 2 or 3 per second for 1 to 2 minutes.

Grade III. Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance. They are usually performed at 2 or 3 per second for 1 to 2 minutes.

Grade IV. Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance. They are usually rapid oscillations, like manual vibrations.

Indications

• Grades I and II are primarily used for treating joints limited by pain or muscle guarding. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels.^26,34 These nonstretch motions help move synovial fluid to improve nutrition to the cartilage.

• Grades III and IV are primarily used as stretching maneuvers.

• Vary the speed of oscillations for different effects, such as low amplitude and high speed, to inhibit pain or slow speed to relax muscle guarding.

Non-Thrust Sustained Joint-Play Techniques

This grading system describes only joint-play techniques that separate (distract) or glide/translate (slide) the joint surfaces (Fig. 5.10).

Dosages and Rate of Application

As indicated by the name, rate of application is slow and sustained for several seconds followed by partial relaxation and then repeated depending on the indications.

Grade I (loosen). Small-amplitude distraction is applied when no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.

Grade II (tighten). Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn¹⁵ called this "taking up the slack."

Grade III (stretch). A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures.

Indications

• Grade I distraction is used with all gliding motions and may be used for relief of pain. Apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles. Note the response and either repeat or discontinue.

• Grade II distraction is used for the initial treatment to determine the sensitivity of the joint. Once the joint reaction is known, the treatment dosage is increased or decreased accordingly.

• Gentle grade II distraction applied intermittently may be used to inhibit pain. Grade II glides may be used to maintain joint play when ROM is not allowed.

• Grade III distractions or glides are used to stretch the joint structures and thus increase joint play. For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4-second intervals.

Comparison of Oscillation and Sustained Techniques

When using either grading system, dosages I and II are low-intensity and so do not cause a stretch force on the joint capsule or surrounding tissue, although by definition, sustained grade II techniques take up the slack of the tissues, whereas grade II oscillation techniques stay within the slack. Grades III and IV oscillations and grade III sustained stretch techniques are similar in intensity in that they all are applied with a stretch force at the limit of motion. The differences are related to the rhythm or speed of repetition of the stretch force.

• For clarity and consistency, when referring to dosages in this text, the notation graded oscillations means to use the dosages as described in the section on oscillation techniques. The notation sustained grade means to use the dosages as described in the section on sustained joint-play techniques.

• The choice of using oscillating or sustained techniques depends on the patient's response.

  • When dealing with managing pain, either grade I or II oscillation techniques or slow intermittent grade I or II sustained joint distraction techniques are recommended; the patient's response dictates the intensity and frequency of the joint-play technique.

  • When dealing with loss of joint play and thus decreased functional range, sustained techniques applied in a cyclic manner are recommended; the longer the stretch force can be maintained, the greater the creep and plastic deformation of the connective tissue.

  • When attempting to maintain available range by using joint-play techniques, either grade II oscillating or sustained grade II techniques can be used.

Thrust Manipulation/High Velocity Thrust (HVT)

HVT is a small-amplitude, high-velocity technique.

Application

• Prior to application, the joint is moved to the limit of the motion so that all slack is taken out of the tissue, then a quick thrust is applied to the restricting tissue. It is important to keep the amplitude of the thrust small so as not to damage unrelated tissues or lose control of the maneuver.

• HVT is applied with one repetition only.

Indications

HVT is used to snap adhesions or is applied to a dislocated structure to reposition the joint surfaces.

Positioning and Stabilization

• The patient and the extremity to be treated should be positioned so the patient can relax. To relax the muscles crossing the joint, techniques of inhibition (see Chapter 4) may be used prior to or between mobilization techniques.

• Examination of joint play and the first treatment are initially performed in the resting position for that joint, so the greatest capsule laxity is possible. In some cases, the position to use is the one in which the joint is least painful.

• With progression of treatment, the joint is positioned at or near the end of the available range prior to application of the mobilization force. This places the restricting tissue in its most lengthened position where the stretch force can be more specific and effective.¹⁵

• Firmly and comfortably stabilize one joint partner, usually the proximal bone. A belt, one of the therapist's hands, or an assistant holding the part may provide stabilization. Appropriate stabilization prevents unwanted stress to surrounding tissues and joints and makes the stretch force more specific and effective.

Direction and Target of Treatment Force

• The treatment force (either gentle or strong) is applied as close to the opposing joint surface as possible. It is imperative that the therapist be able to identify anatomical landmarks and use these as guides for accurate hand placement and force application. The larger the contact surface, the more comfortable the patient will be with the procedure. For example, instead of forcing with your thumb, use the flat surface of your hand.

• The direction of movement during treatment is either parallel or perpendicular to the treatment plane. Treatment plane was described by Kaltenborn¹⁵ as a plane perpendicular to a line running from the axis of rotation to the middle of the concave articular surface. The plane is in the concave partner, so its position is determined by the position of the concave bone (Fig. 5.11).

• Distraction techniques are applied perpendicular to the treatment plane. The entire bone is moved so the joint surfaces are separated.

• Gliding techniques are applied parallel to the treatment plane. The direction of gliding may be determined by using the convex-concave rule (described earlier in the chapter). If the surface of the moving bony partner is convex, the treatment glide should be opposite to the direction in which the bone swings. If the surface of the moving bony partner is concave, the treatment glide should be in the same direction (see Fig. 5.5).

• The entire bone is moved so there is gliding of one joint surface on the other. The bone should not be used as a lever; it should have no arcing motion (swing), which would cause rolling and thus compression of the joint surfaces.

Initiation and Progression of Treatment

1. The initial treatment is the same whether treating to decrease pain or increase joint play (Fig. 5.12). The purpose is to determine joint reactivity before proceeding. Use a sustained grade II distraction of the joint surfaces with the joint held in resting position or the position of greatest relaxation.¹⁵ Note the immediate joint response relative to irritability and range.

2. The next day, evaluate joint response or have the patient report the response at the next visit.

   • If there is increased pain and sensitivity, reduce the amplitude of treatment to grade I oscillations.

   • If the joint is the same or better, perform either of the following: Repeat the same maneuver if the goal of treatment is to maintain joint play, or progress the maneuver to stretching techniques if the goal of treatment is to increase joint play.

3. To maintain joint play by using gliding techniques when ROM techniques are contraindicated or not possible for a period of time, use sustained grade II or grade II oscillation techniques.

4. To progress the stretch technique, move the bone to the end of the available ROM¹⁵, then apply a sustained grade III distraction or glide technique. Progressions include prepositioning the bone at the end of the available range and rotating it prior to applying grade III distraction or glide techniques. The direction of the glide and rotation is dictated by the joint mechanics. For example, laterally rotate the humerus as shoulder abduction is progressed; medially rotate the tibia as knee flexion is progressed.

Patient Response

• Stretching maneuvers usually cause soreness. Perform the maneuvers on alternate days to allow the soreness to decrease and tissue healing to occur between stretching sessions. The patient should perform ROM into any newly gained range during this time.

• If there is increased pain lasting longer than 24 hours after stretching, the dosage (amplitude) or duration of treatment was too vigorous. Decrease the dosage or duration until the pain is under control.

• The patient's joint and ROM should be reassessed after treatment and again before the next treatment. Alterations in treatment are dictated by the joint response.

Total Program

Mobilization techniques are one part of a total treatment program when there is decreased function. If muscles or connective tissues are also limiting motion, PNF stretching and passive stretching techniques are alternated with joint mobilization during the same treatment session. Therapy should also include appropriate ROM, strengthening, and functional exercises, so the patient learns effective control and use of the gained mobility (Box 5.2).

Mobilization with Movement: Principles of Application

Brian Mulligan's concept of mobilization with movement (MWM) is the natural continuance of progression in the development of manual therapy from active self-stretching exercises to therapist-applied passive physiological movement to passive accessory mobilization techniques.²¹ MWM is the concurrent application of pain-free accessory mobilization with active and/or passive physiological movement.²³ Passive end-range overpressure or stretching is then applied without pain as a barrier. These techniques are applicable when:

• No contraindication for manual therapy exists (described earlier in the chapter).

• A full orthopedic examination has been completed, and evaluation of the results indicate local musculoskeletal pathology.

• A specific biomechanical analysis reveals localized loss of movement and/or pain associated with function.

• No pain is produced during or immediately after application of the technique.²⁰

Principles and Application of MWM in Clinical Practice

Comparable sign. One or more comparable signs are identified during the examination.¹¹ A comparable sign is a positive test sign that can be repeated after a therapeutic maneuver to determine the effectiveness of the maneuver. For example, a comparable sign may include loss of joint play movement, loss of ROM, or pain associated with movement during specific functional activities, such as lateral elbow pain with resisted wrist extension, painful restriction of ankle dorsiflexion, or pain with overhead reaching.

Passive techniques. A passive joint mobilization is applied using the principles described in the previous section following the principles of Kaltenborn.¹⁵ Utilizing knowledge of joint anatomy and mechanics, a sense of tissue tension, and sound clinical reasoning, the therapist investigates various combinations of parallel or perpendicular accessory glides to find the pain-free direction and grade of accessory movement. This may be a glide, spin, distraction, or combination of movements. This accessory motion must be pain-free.²³

Accessory glide with active comparable sign. While the therapist sustains the pain-free accessory force, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved—that is, there should be increased ROM, and the motion should be free of the original pain.²³

No pain. The therapist must continuously monitor the patient's reaction to ensure no pain is produced. Failure to improve the comparable sign would indicate that the therapist has not found the correct direction of accessory movement, the grade of movement, or that the technique is not indicated.

Repetitions. The previously restricted and/or painful motion or activity is repeated 6 to 10 times by the patient while the therapist continues to maintain the appropriate accessory mobilization. Further gains are expected with repetition during a treatment session, particularly when pain-free passive overpressure is applied to achieve end-range loading.

Description of techniques. Techniques applicable to the extremity joints are described throughout this text in the treatment sections for various conditions (see Chapters 17 through 22).

Patient Response and Progression

Pain as a guide. Successful MWM techniques should render the comparable sign painless while significantly improving function during the application of the technique.

Self treatment. Once patient response is determined, self-treatment is often possible using MWM principles with sports-type adhesive tape and/or the patient providing the mobilization component of the MWM concurrent with the active physiological movement.⁹

Total program. Having restored articular function with MWMs, the patient is progressed through the ensuing rehabilitation sequences of the recovery of muscular power, endurance, and neural control. Sustained improvements are necessary to justify ongoing intervention.

Theoretical Framework

Mulligan postulated a positional fault model to explain the results gained through his concept. Alternatively, inappropriate joint tracking mechanisms due to an altered instantaneous axis of rotation and neurophysiological response models have also been considered.^9,20,21,24 For further details of the application of the Mulligan concept as it applies to the spine and extremities, refer to Manual Therapy, "NAGS," "SNAGS," "MWMS," etc.²³

The following are suggested joint distraction and gliding techniques for use by entry-level therapists and those attempting to gain a foundation in joint mobilization of extremity joints. A variety of adaptations can be made from these techniques. Some adaptations are described in the respective chapters in which specific impairments and interventions are discussed (see Chapters 17 through 22). The distraction and glide techniques should be applied with respect to the dosage, frequency, progression, precautions, and procedures as described earlier in this chapter. Mobilization and manipulation/HVT techniques for the spine are described in Chapter 16.

NOTE: Terms, such as proximal hand, distal hand, lateral hand, or other descriptive terms, indicate that the therapist should use the hand that is more proximal, distal, or lateral to the patient or the patient's extremity.

Shoulder Girdle Complex

Joints of the shoulder girdle consist of three synovial articulations—sternoclavicular, acromioclavicular, and glenohumeral—and the functional articulation of the scapula gliding on the thorax. (Fig. 5.13) To gain full elevation of the humerus, the accessory and component motions of clavicular elevation and rotation, scapular rotation, and external rotation of the humerus as well as adequate joint play are necessary. The clavicular and scapular techniques are described following the glenohumeral joint techniques. For a review of the mechanics of the shoulder complex, see Chapter 17.

Glenohumeral Joint

The concave glenoid fossa receives the convex humeral head.

Resting position. The shoulder is abducted 55^o, horizontally adducted 30^o, and rotated so the forearm is in the horizontal plane with respect to the body (called plane of the scapula).

Treatment plane. The treatment plane is in the glenoid fossa and moves with the scapula as it rotates.

Stabilization. Fixate the scapula with a belt or have an assistant help.

Glenohumeral Distraction

Indications

Testing; initial treatment (sustained grade II); pain control (grade I or II oscillations); general mobility (sustained grade III) (Fig. 5.14) VIDEO 5.1 .

Patient Position

Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Hand Placement

• Use the hand nearer the part being treated (e.g., left hand if treating the patient's left shoulder) and place it in the patient's axilla with your thumb just distal to the joint margin anteriorly and fingers posteriorly.

• Your other hand supports the humerus from the lateral surface.

Mobilizing Force

With the hand in the axilla, move the humerus laterally.

NOTE: The entire arm moves in a translatoric motion away from the plane of the glenoid fossa. Distractions may be performed with the humerus in any position (see Figs. 5.17, 5.19, and 17.20). You must be aware of the amount of scapular rotation and adjust the distraction force against the humerus, so it is perpendicular to the plane of the glenoid fossa.

Glenohumeral Caudal Glide in Resting Position

Indications

To increase abduction (sustained grade III); to reposition the humeral head if superiorly positioned (Fig. 5.15) VIDEO 5.2 .

Patient Position

Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Hand Placement

• Place one hand in the patient's axilla to provide a grade I distraction.

• The web space of your other hand is placed just distal to the acromion process.

Mobilizing Force

With the superiorly placed hand, glide the humerus in an inferior direction.

Glenohumeral Caudal Glide (Long Axis Traction)

Hand Placement

Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Mobilizing Force

The force comes from the hand around the arm, pulling caudally as you shift your body weight inferiorly.

Glenohumeral Caudal Glide Progression

Indication

To increase abduction (Fig. 5.16).

Patient Position

• Supine or sitting, with the arm abducted to the end of its available range.

• External rotation of the humerus should be added to the end-range position as the arm approaches and goes beyond 90°.

Therapist Position and Hand Placement

• With the patient supine, stand facing the patient's feet and stabilize the patient's arm against your trunk with the hand farthest from the patient. Slight lateral motion of your trunk provides grade I distraction.

• With the patient sitting, stand behind the patient and cradle the distal humerus with the hand farthest from the patient; this hand provides a grade I distraction.

• Place the web space of your other hand just distal to the acromion process on the proximal humerus.

Mobilizing Force

With the hand on the proximal humerus, glide the humerus in an inferior direction with respect to the scapula.

Glenohumeral Elevation Progression

Indication

To increase elevation beyond 90° of abduction (Fig. 5.17).

Patient Position

Supine or sitting, with the arm abducted and externally rotated to the end of its available range.

Therapist Position and Hand Placement

• Hand placement is the same as for caudal glide progression.

• Adjust your body position so the hand applying the mobilizing force is aligned with the treatment plane in the glenoid fossa.

• With the hand grasping the elbow, apply a grade I distraction force.

Mobilizing Force

• With the hand on the proximal humerus, glide the humerus in a progressively anterior direction against the inferior folds of the capsule in the axilla.

• The direction of force with respect to the patient's body depends on the amount of upward rotation and protraction of the scapula.

Glenohumeral Posterior Glide, Resting Position

Indications

To increase flexion; to increase internal rotation (Fig. 5.18) VIDEO 5.3 .

Patient Position

Supine, with the arm in resting position.

Therapist Position and Hand Placement

• Stand with your back to the patient, between the patient's trunk and arm.

• Support the arm against your trunk, grasping the distal humerus with your lateral hand. This position provides grade I distraction to the joint.

• Place the lateral border of your top hand just distal to the anterior margin of the joint, with your fingers pointing superiorly. This hand gives the mobilizing force.

Mobilizing Force

Glide the humeral head posteriorly by moving the entire arm as you bend your knees.

Glenohumeral Posterior Glide Progression

Indications

To increase posterior gliding when flexion approaches 90°; to increase horizontal adduction (Fig. 5.19).

Patient Position

Supine, with the arm flexed to 90° and internally rotated and with the elbow flexed. The arm may also be placed in horizontal adduction.

Hand Placement

• Place padding under the scapula for stabilization.

• Place one hand across the proximal surface of the humerus to apply a grade I distraction.

• Place your other hand over the patient's elbow.

• A belt placed around your pelvis and the patient's humerus may be used to apply the distraction force.

Mobilizing Force

Glide the humerus posteriorly by pushing down at the elbow through the long axis of the humerus.

Glenohumeral Anterior Glide, Resting Position

Indications

To increase extension; to increase external rotation (Fig. 5.20) VIDEO 5.4 .

Patient Position

Prone, with the arm in resting position over the edge of the treatment table, supported on your thigh. Stabilize the acromion with padding. Supine position may also be used.

Therapist Position and Hand Placement

• Stand facing the top of the table with the leg closer to the table in a forward stride position.

• Support the patient's arm against your thigh with your outside hand; the arm positioned on your thigh provides a grade I distraction.

• Place the ulnar border of your other hand just distal to the posterior angle of the acromion process, with your fingers pointing superiorly; this hand gives the mobilizing force.

Mobilizing Force

Glide the humeral head in an anterior and slightly medial direction. Bend both knees so the entire arm moves anteriorly.

PRECAUTION: Do not lift the arm at the elbow and, thereby, cause angulation of the humerus. Such angulation could lead to anterior subluxation or dislocation of the humeral head. Do not use this position to progress external rotation. Placing the shoulder in 90° abduction with external rotation and applying an anterior glide may cause anterior subluxation of the humeral head.

Glenohumeral External Rotation Progressions

Indication

To increase external rotation (Fig. 5.21) VIDEO 5.5 .

Techniques

Because of the danger of subluxation when applying an anterior glide with the humerus externally rotated, use a distraction progression or elevation progression to gain range.

• Distraction progression: Begin with the shoulder in resting position; externally rotate the humerus to end-range; and then apply a grade III distraction perpendicular to the treatment plane in the glenoid fossa.

• Elevation progression (see Fig. 5.17): This technique incorporates end-range external rotation.

Acromioclavicular Joint

Indication. To increase mobility of the joint.

Stabilization. Fixate the scapula with your more lateral hand around the acromion process.

Anterior Glide of Clavicle on Acromion

Patient Position

Sitting or prone (Fig. 5.22).

Hand Placement

• With the patient sitting, stand behind the patient and stabilize the acromion process with the fingers of your lateral hand.

• The thumb of your other hand pushes downward through the upper trapezius and is placed posteriorly on the clavicle, just medial to the joint space.

• With the patient prone, stabilize the acromion with a towel roll under the shoulder.

Mobilizing Force

Push the clavicle anteriorly with your thumb.

Sternoclavicular Joint

Joint surfaces. The proximal articulating surface of the clavicle is convex superiorly/inferiorly and concave anteriorly/posteriorly with an articular disk between it and the manubrium

Treatment plane. For protraction/retraction, the treatment plane is in the clavicle. For elevation/depression, the treatment plane is in the manubrium of the sternum.

Patient position and stabilization. Supine; the thorax provides stability to the sternum.

Sternoclavicular Posterior Glide and Superior Glide

Indications

Posterior glide to increase retraction; superior glide to increase depression of the clavicle (Fig. 5.23).

Hand Placement

• Place your thumb on the anterior surface of the proximal end of the clavicle.

• Flex your index finger and place the middle phalanx along the caudal surface of the clavicle to support the thumb.

Mobilizing Force

• Posterior glide: Push with your thumb in a posterior direction.

• Superior glide: Push with your index finger in a superior direction

Sternoclavicular Anterior Glide and Caudal (Inferior) Glide

Indications

Anterior glide to increase protraction; caudal glide to increase elevation of the clavicle (Fig. 5.24).

Hand Placement

Your fingers are placed superiorly and thumb inferiorly around the clavicle.

Mobilizing Force

• Anterior glide: lift the clavicle anteriorly with your fingers and thumb.

• Caudal glide: press the clavicle inferiorly with your fingers.

Scapulothoracic Soft-Tissue Mobilization

The scapulothoracic articulation is not a true joint, but the soft tissue and muscles supporting the articulation are stretched to obtain scapular motions of elevation, depression, protraction, retraction, upward and downward rotation, and winging for normal shoulder girdle mobility (Fig. 5.25) VIDEO 5.6 .

Patient position. If there is considerable restriction in mobility, begin prone and progress to side-lying, with the patient facing you. Support the weight of the patient's arm by draping it over your inferior arm and allowing it to hang so the scapular muscles are relaxed.

Hand placement. Place your superior hand across the acromion process to control the direction of motion. With the fingers of your inferior hand, scoop under the medial border and under the inferior angle of the scapula.

Mobilizing force. Move the scapula in the desired direction by lifting from the inferior angle or by pushing on the acromion process.

Elbow and Forearm Complex

The elbow and forearm complex consists of four joints: humeroulnar, humeroradial, proximal radioulnar, and distal radioulnar (Fig. 5.26). For full elbow flexion and extension, accessory motions of varus and valgus (with radial and ulnar glides) are necessary. The techniques for each of the joints as well as accessory motions are described in this section. For a review of the joint mechanics, see Chapter 18.

Humeroulnar Articulation

The convex trochlea articulates with the concave olecranon fossa.

Resting position. Elbow is flexed 70°, and forearm is supinated 10°.

Treatment plane. The treatment plane is in the olecranon fossa, angled approximately 45° from the long axis of the ulna (Fig. 5.27).

Stabilization. Fixate the humerus against the treatment table with a belt or use an assistant to hold it. The patient may roll onto his or her side and fixate the humerus with the contralateral hand if muscle relaxation can be maintained around the elbow joint being mobilized.

Humeroulnar Distraction and Progression

Indications

Testing; initial treatment (sustained grade II); pain control (grade I or II oscillation); to increase flexion or extension (grade III or IV (Fig. 5.28 A) VIDEO 5.7 ).

Patient Position

Supine, with the elbow over the edge of the treatment table or supported with padding just proximal to the olecranon process. Rest the patient's wrist against your shoulder, allowing the elbow to be in resting position for the initial treatment. To stretch into either flexion or extension, position the joint at the end of its available range.

Hand Placement

When in the resting position or at end-range flexion, place the fingers of your medial hand over the proximal ulna on the volar surface; reinforce it with your other hand. When at end-range extension, stand and place the base of your proximal hand over the proximal portion of the ulna and support the distal forearm with your other hand.

Mobilizing Force

Apply force against the proximal ulna at a 45° angle to the shaft of the bone.

Humeroulnar Distal Glide

Indication

To increase flexion (Fig. 5.28 B).

Patient Position and Hand Placement

Supine, with the elbow over the edge of the treatment table. Begin with the elbow in resting position. Progress by positioning it at the end-range of flexion. Place the fingers of your medial hand over the proximal ulna on the volar surface; reinforce it with your other hand.

Mobilizing Force

First apply a distraction force to the joint at a 45° angle to the ulna, then while maintaining the distraction, direct the force in a distal direction along the long axis of the ulna using a scooping motion.

Humeroulnar Radial Glide

Indication

To increase varus. This is an accessory motion of the joint that accompanies elbow flexion and is, therefore, used to progress flexion.

Patient Position

• Side-lying on the arm to be mobilized, with the shoulder laterally rotated and the humerus supported on the table.

• Begin with the elbow in resting position; progress to end-range flexion.

Hand Placement

Place the base of your proximal hand just distal to the elbow; support the distal forearm with your other hand.

Mobilizing Force

Apply force against the ulna in a radial direction.

Humeroulnar Ulnar Glide

Indication

To increase valgus. This is an accessory motion of the joint that accompanies elbow extension and is, therefore, used to progress extension.

Patient Position

• Same as for radial glide except a block or wedge is placed under the proximal forearm for stabilization (using distal stabilization).

• Initially, the elbow is placed in resting position and is progressed to end-range extension.

Mobilizing Force

Apply force against the distal humerus in a radial direction, causing the ulna to glide ulnarly.

Humeroradial Articulation

The convex capitulum articulates with the concave radial head (see Fig. 5.26) VIDEO 5.8 .

Resting position. Elbow is extended, and forearm is supinated to the end of the available range.

Treatment plane. The treatment plane is in the concave radial head perpendicular to the long axis of the radius.

Stabilization. Fixate the humerus with one of your hands.

Humeroradial Distraction

Indications

To increase mobility of the humeroradial joint; to manipulate a pushed elbow (proximal displacement of the radius) (Fig. 5.29).

Patient Position

Supine or sitting, with the arm resting on the treatment table.

Therapist Position and Hand Placement

• Position yourself on the ulnar side of the patient's forearm so you are between the patient's hip and upper extremity.

• Stabilize the patient's humerus with your superior hand.

• Grasp around the distal radius with the fingers and thenar eminence of your inferior hand. Be sure you are not grasping around the distal ulna.

Mobilizing Force

Pull the radius distally (long-axis traction causes joint traction).

Humeroradial Dorsal/Volar Glides

Indications

Dorsal glide head of the radius to increase elbow extension; volar glide to increase flexion (Fig. 5.30).

Patient Position

Supine or sitting with the elbow extended and supinated to the end of the available range.

Hand Placement

• Stabilize the humerus with your hand that is on the medial side of the patient's arm.

• Place the palmar surface of your lateral hand on the volar aspect and your fingers on the dorsal aspect of the radial head.

Mobilizing Force

• Move the radial head dorsally with the palm of your hand or volarly with your fingers.

• If a stronger force is needed for the volar glide, realign your body and push with the base of your hand against the dorsal surface in a volar direction.

Humeroradial Compression

Indication

To reduce a pulled elbow subluxation (Fig. 5.31).

Patient Position

Sitting or supine.

Hand Placement

• Approach the patient right hand to right hand, or left hand to left hand. Stabilize the elbow posteriorly with the other hand. If supine, the stabilizing hand is under the elbow supported on the treatment table.

• Place your thenar eminence against the patient's thenar eminence (locking thumbs).

Mobilizing Force

Simultaneously, extend the patient's wrist, push against the thenar eminence, and compress the long axis of the radius while supinating the forearm.

NOTE: To replace an acute subluxation, a high-velocity thrust is used.

Proximal Radioulnar Joint

The convex rim of the radial head articulates with the concave radial notch on the ulna (see Fig. 5.26).

Resting position. The elbow is flexed 70° and the forearm supinated 35°.

Treatment plane. The treatment plane is in the radial notch of the ulna, parallel to the long axis of the ulna.

Stabilization. Proximal ulna is stabilized.

Proximal Radioulnar Dorsal/Volar Glides

Indications

Dorsal glide to increase pronation; volar glide to increase supination (Fig. 5.32) VIDEO 5.8 .

Patient Position

• Sitting or supine, begin with the elbow flexed 70° and the forearm supinated 35°.

• Progress by placing the forearm at the limit of the range of pronation or supination prior to administering the respective glide.

Hand Placement

• Approach the patient from the dorsal or volar aspect of the forearm. Fixate the ulna with your medial hand around the medial aspect of the forearm.

• With your other hand, grasp the head of the radius between your flexed fingers and palm of your hand.

Mobilizing Force

• Force the radial head volarly or dorsally by pushing with your palm or pulling with your fingers.

• If a stronger force is needed, rather than pulling with your fingers, move to the other side of the patient, switch hands, and apply the force with the palm of your hand.

Distal Radioulnar Joint

The concave ulnar notch of the radius articulates with the convex head of the ulna.

Resting position. The resting position is with the forearm supinated 10°.

Treatment plane. The treatment plane is the articulating surface of the radius, parallel to the long axis of the radius.

Stabilization. Distal ulna.

Distal Radioulnar Dorsal/Volar Glides

Indications

Dorsal glide to increase supination; volar glide to increase pronation (Fig. 5.33).

Patient Position

Sitting, with the forearm on the treatment table. Begin in the resting position and progress to end-range pronation or supination.

Hand Placement

Stabilize the distal ulna by placing the fingers of one hand on the dorsal surface and the thenar eminence and thumb on the volar surface. Place your other hand in the same manner around the distal radius.

Mobilizing Force

Glide the distal radius dorsally to increase supination or volarly to increase pronation parallel to the ulna.

Wrist and Hand Complex

When mobilizing the wrist, begin with general distractions and glides that include the proximal row and distal row of carpals as a group. For full ROM, individual carpal mobilizations/manipulations may be necessary. They are described following the general mobilizations. For a review of the mechanics of the wrist complex, see Chapter 19 (Fig. 5.34).

Radiocarpal Joint

The concave distal radius articulates with the convex proximal row of carpals, which is composed of the scaphoid, lunate, and triquetrum.

Resting position. The resting position is a straight line through the radius and third metacarpal with slight ulnar deviation.

Treatment plane. The treatment plane is in the articulating surface of the radius perpendicular to the long axis of the radius.

Stabilization. Distal radius and ulna.

Radiocarpal Distraction

Indications

Testing; initial treatment; pain control; general mobility of the wrist (Fig. 5.35).

Patient Position

Sitting, with the forearm supported on the treatment table, wrist over the edge of the table.

Hand Placement

• With the hand closest to the patient, grasp around the styloid processes and fixate the radius and ulna against the table.

• Grasp around the distal row of carpals with your other hand.

Mobilizing Force

Pull in a distal direction with respect to the arm.

Radiocarpal Joint: General Glides and Progression

Indications

Dorsal glide to increase flexion (Fig. 5.36 A); volar glide to increase extension (Fig. 5.36 B); radial glide to increase ulnar deviation; ulnar glide to increase radial deviation (Fig. 5.37).

Patient Position and Hand Placement

Sitting with forearm resting on the table in pronation for the dorsal and volar techniques and in midrange position for the radial and ulnar techniques. Progress by moving the wrist to the end of the available range and gliding in the defined direction. Specific carpal gliding techniques described in the next sections are used to increase mobility at isolated articulations.

Mobilizing Force

The force comes from the hand around the distal row of carpals.

Specific Carpal Mobilizations

Specific techniques to mobilize individual carpal bones may be necessary to gain full ROM of the wrist (Figs. 5.38 and 5.39). Specific biomechanics of the radiocarpal and intercarpal joints are described in Chapter 19. To glide one carpal on another or on the radius, utilize the following guidelines.

Patient and Therapist Positions

• The patient sits.

• Stand and grasp the patient's hand so the elbow hangs unsupported.

• The weight of the arm provides slight distraction to the joints, so you then need only to apply the glides.

Hand Placement and Indications

Identify the specific articulation to be mobilized and place your index fingers on the volar surface of the bone to be stabilized. Place the overlapping thumbs on the dorsal surface of the bone to be manipulated. The rest of your fingers hold the patient's hand so it is relaxed.

To increase extension. Place the stabilizing index fingers under the bone that is concave (on the volar surface). Overlap the thumbs and place on the dorsal surface of the bone that is convex. The thumbs provide the manipulating force.

• Thumbs on dorsum of convex scaphoid, index fingers stabilize radius.

• Thumbs on dorsum of convex lunate, index fingers stabilize radius.

• Thumbs on dorsum of convex scaphoid, index fingers stabilize trapezium-trapezoid unit.

• Thumbs on dorsum of convex capitate, index fingers stabilize lunate (see Fig. 5.39).

• Thumbs on dorsum of convex hamate, index fingers stabilize triquetrum.

To increase flexion. Place the stabilizing index fingers under the bone that is convex (on the volar surface), and the mobilizing thumbs overlapped on the dorsal surface of the bone that is concave.

• Thumbs on the dorsum of the concave radius, index fingers stabilize scaphoid.

• Thumbs on the dorsum of the concave radius, index fingers stabilize lunate (see Fig. 5.38).

• Thumbs on dorsum of trapezium-trapezoid unit, index fingers stabilize scaphoid.

• Thumbs on dorsum of concave lunate, index fingers stabilize capitate.

• Thumbs on dorsum of concave triquetrum, index fingers stabilize hamate.

Mobilizing Force

• In each case, the force comes from the overlapping thumbs on the dorsal surface.

• By applying force from the dorsal surface, pressure against the nerves, blood vessels, and tendons in the carpal tunnel and Guyon's canal is minimized, and a stronger mobilization force can be used without pain.

• An HVT technique can be used by providing a quick downward and upward flick of your wrists and hands while pressing against the respective carpals.

Ulnar-Meniscal-Triquetral Articulation

To unlock the articular disk, which may block motions of the wrist or forearm, apply a glide of the ulna volarly on a fixed triquetrum (see Fig. 19.7).

Carpometacarpal and Intermetacarpal Joints of Digits II–V

Opening and closing of the hand and maintenance of the arches in the hand requires general mobility between the carpals and metacarpals.

Carpometacarpal Distraction

Stabilization and Hand Placement

Stabilize the respective carpal with thumb and index finger of one hand (Fig. 5.40). With your other hand, grasp around the proximal portion of a metacarpal.

Mobilizing Force

Apply long-axis traction to the metacarpal.

Carpometacarpal and Intermetacarpal: Volar Glide

Indication

To increase mobility of the arch of the hand.

Stabilization and Hand Placement

Stabilize the carpals with the thumb and index finger of one hand; place the thenar eminence of your other hand along the dorsal aspect of the metacarpals to provide the mobilization force.

Mobilizing Force

Glide the proximal portion of the metacarpal volar ward. See also the stretching technique for cupping and flattening the arch of the hand described in Chapter 4.

Carpometacarpal Joint of the Thumb

The CMC of the thumb is a saddle joint. The trapezium is concave, and the proximal metacarpal is convex for abduction/adduction. The trapezium is convex, and the proximal metacarpal is concave for flexion/extension.

Resting position. The resting position is midway between flexion and extension and between abduction and adduction.

Stabilization. Fixate the trapezium with the hand that is closer to the patient.

Treatment plane. The treatment plane is in the trapezium for abduction-adduction and in the proximal metacarpal for flexion-extension.

Carpometacarpal Distraction (Thumb)

Indications

Testing; initial treatment; pain control; general mobility.

Patient Position

The patient is positioned with forearm and hand resting on the treatment table.

Hand Placement

• Fixate the trapezium with the hand that is closer to the patient.

• Grasp the patient's metacarpal by wrapping your fingers around it (see Fig. 5.41 A).

Mobilizing Force

Apply long-axis traction to separate the joint surfaces.

Carpometacarpal Glides (Thumb)

Indications

• Ulnar glide to increase flexion (Fig. 5.41)

• Radial glide to increase extension

• Dorsal glide to increase abduction

• Volar glide to increase adduction

Patient Position and Hand Placement

• Stabilize the trapezium by grasping it directly or by wrapping your fingers around the distal row of carpals.

• Place the thenar eminence of your other hand against the base of the patient's first metacarpal on the side opposite the desired glide. For example, as pictured in Fig. 5.41 A, the surface of the thenar eminence is on the radial side of the metacarpal to cause an ulnar glide.

Mobilizing Force

Apply the force with your thenar eminence against the base of the metacarpal. Adjust your body position to line up the force as illustrated in Figure 5.41 A through D.

Metacarpophalangeal and Interphalangeal Joints of the Fingers

In all cases, the distal end of the proximal articulating surface is convex, and the proximal end of the distal articulating surface is concave.

NOTE: Because all the articulating surfaces are the same for the digits, all techniques are applied in the same manner to each joint.

Resting position. The resting position is in light flexion for all joints.

Treatment plane. The treatment plane is in the distal articulating surface.

Stabilization. Rest the forearm and hand on the treatment table; fixate the proximal articulating surface with the fingers of one hand.

Metacarpophalangeal and Interphalangeal Distraction

Indications

Testing; initial treatment; pain control; general mobility (Fig. 5.42).

Hand Placement

Use your proximal hand to stabilize the proximal bone; wrap the fingers and thumb of your other hand around the distal bone close to the joint.

Mobilizing Force

Apply long-axis traction to separate the joint surface.

Metacarpophalangeal and Interphalangeal Glides and Progression

Indications

• Volar glide to increase flexion (Fig. 5.43)

• Dorsal glide to increase extension

• Radial or ulnar glide (depending on finger) to increase abduction or adduction.

Mobilizing Force

The glide force is applied by the thumb or thenar eminence against the proximal end of the bone to be moved. Progress by taking the joint to the end of its available range and applying slight distraction and the glide force. Rotation may be added prior to applying the gliding force.

Hip Joint

The concave acetabulum receives the convex femoral head. (Fig. 5.44) Biomechanics of the hip joint are reviewed in Chapter 20.

Resting position. The resting position is hip flexion 30°, abduction 30°, and slight external rotation.

Stabilization. Fixate the pelvis to the treatment table with belts.

Treatment plane. The treatment is in the acetabulum.

Hip Distraction of the Weight-Bearing Surface, Caudal Glide

Because of the deep configuration of this joint, traction applied perpendicular to the treatment plane causes lateral glide of the superior, weight-bearing surface (Fig. 5.45). To obtain separation of the weight-bearing surface, a caudal glide is used.

Indications

Testing; initial treatment; pain control; general mobility.

Patient Position

Supine, with the hip in resting position and the knee extended.

PRECAUTION: In the presence of knee dysfunction, this position should not be used; see alternate position following.

Therapist Position and Hand Placement

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.

Mobilizing Force

Apply a long-axis traction by pulling on the leg as you lean backward.

Alternate Position and Technique for Hip Caudal Glide

• Patient supine with hip and knee flexed and foot resting on table.

• Wrap your hands around the epicondyles of the femur and distal thigh. Do not compress the patella.

• 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 (Fig. 5.46) VIDEO 5.9 .

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 Anterior Glide

Indications

To increase extension; to increase external rotation (Fig. 5.47) VIDEO 5.10 .

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.

Alternate Position

• 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 Joint Complex

The knee joint consists of two articulating surfaces between the femoral condyles and tibial plateaus with a fibrocartilaginous disc between each articulation, as well as the articulation of the patella with the femoral groove (Fig. 5.48). As the knee flexes, medial rotation of the tibia occurs, and as it extends, lateral rotation of the tibia occurs. In addition, the patella must glide caudally against the femur during flexion and glide cranially during extension for normal knee mobility. These mechanics are described in Chapter 21.

Tibiofemoral Articulations

The concave tibial plateaus articulate on the convex femoral condyles. Biomechanics of the knee joint are described in Chapter 21.

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.

Tibiofemoral Distraction: Long-Axis Traction

Indications

Testing; initial treatment; pain control; general mobility (Fig. 5.49).

Patient Position

• Sitting, supine, or prone, beginning with the knee in the resting position.

• Progress to positioning the knee at the limit of the range of flexion or extension.

• 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 extension.

Hand Placement

Grasp around the distal leg, proximal to the malleoli with both hands.

Mobilizing Force

Pull on the long axis of the tibia to separate the joint surfaces.

Tibiofemoral Posterior Glide

Indications

Testing; to increase flexion (Fig. 5.50).

Patient Position

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.

Therapist Position and Hand Placement

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.

Mobilizing Force

Extend your elbows and lean your body weight forward; push the tibia posteriorly with your thumbs.

Tibiofemoral Posterior Glide: Alternate Positions and Progression

Patient Position

• 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 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.

Therapist Position and Hand Placement

• When in the 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 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.

• When prone, stabilize the femur with one hand and place the other hand along the border of the tibial plateaus.

Mobilizing Force

• Extend your elbow and lean your body weight onto the tibia, gliding it posteriorly.

• 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.

Tibiofemoral Anterior Glide

Indication

To increase extension (Fig. 5.52) VIDEO 5.11 .

Patient Positions

• Prone, beginning with the knee in resting position; progress to the end of the available range. Place a small pad under the distal femur to prevent patellar compression.

• 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).

Hand Placement

Grasp the distal tibia with the hand that is closer to it and place the palm of the proximal hand on the posterior aspect of the proximal tibia.

Mobilizing Force

Apply 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.

Alternate Position and Technique

• If the patient cannot be positioned prone, position him or her supine with a fixation pad under the tibia.

• The mobilizing force is placed against the femur in a posterior direction.

Patellofemoral Joint

The patella must have mobility to glide distally on the femur for normal knee flexion, and glide proximally for normal knee extension.

Patellofemoral Joint, Distal Glide

Patient Position

Supine, with knee extended; progress to positioning the knee at the end of the available range in flexion (Fig. 5.53).

Hand Placement

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.

Mobilizing Force

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 or Lateral Glide

Indication

To increase patellar mobility (Fig. 5.54).

Patient Position

Supine with the knee extended. Side-lying may be used to apply a medial glide (see Fig. 21.3).

Hand Placement

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.

Mobilizing Force

Glide the patella in a medial or lateral direction, against the restriction.

Leg and Ankle Joints

The joints of the leg consist of the proximal and distal tibiofibular joints; accessory motions at these joints occur during all ankle and subtalar joint motions. (see Fig. 5.48 and Fig. 5.57 A) The complex mechanics of the leg, foot, and ankle in weight-bearing and nonweight-bearing conditions are described in Chapter 22.

Tibiofibular Joints

Proximal Tibiofibular Articulation: Anterior (Ventral) Glide

Indications

To increase movement of the fibular head; to reposition a posteriorly subluxed head (Fig. 5.55).

Patient Position

• Side-lying, with the trunk and hips rotated partially toward prone.

• The top leg is flexed forward so the knee and lower leg are resting on the table or supported on a pillow.

Therapist Position and Hand Placement

• Stand behind the patient, placing one of your hands under the tibia to stabilize it.

• Place the base of your other hand posterior to the head of the fibula, wrapping your fingers anteriorly.

Mobilizing Force

Apply the force through 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

Indication

To increase mobility of the mortise when it is restricting ankle dorsiflexion (Fig. 5.56).

Patient Position

Supine or prone.

Hand Placement

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.

Mobilizing Force

Press against the fibula in an anterior direction when prone and in a posterior direction when supine.

Talocrural Joint (Upper Ankle Joint)

The convex talus articulates with the concave mortise made up of the tibia and fibula (Fig. 5.57).

Resting position. The resting position is 10° plantarflexion.

Treatment plane. The treatment plane is in the mortise, in an anterior-posterior direction with respect to the leg.

Stabilization. The tibia is strapped or held against the table.

Talocrural Distraction

Indications

Testing; initial treatment; pain control; general mobility (Fig. 5.58) VIDEO 5.12 .

Patient Position

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.

Therapist Position and Hand Placement

• 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.

Mobilizing Force

Pull the foot along the long axis of the leg in a distal direction by leaning backward.

Talocrural Dorsal (Posterior) Glide

Indication

To increase dorsiflexion (Fig. 5.59).

Patient Position

Supine, with the leg supported on the table and the heel over the edge.

Therapist Position and Hand Placement

• Stand to the side of the patient.

• Stabilize the leg with your cranial hand or use a belt to secure the leg to the table.

• Place the palmar aspect of the web space of your other hand over the talus just distal to the mortise.

• 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.

Mobilizing Force

Glide the talus posteriorly with respect to the tibia by pushing against the talus.

Talocrural Ventral (Anterior) Glide

Indication

To increase plantarflexion (Fig. 5.60).

Patient Position

Prone, with the foot over the edge of the table.

Therapist Position and Hand Placement

• 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.

Mobilizing Force

Push against the calcaneus in an anterior direction (with respect to the tibia); this glides the talus anteriorly.

Alternate Position

• Patient is supine. Stabilize the distal leg anterior to the mortise with your proximal hand.

• The distal hand cups under the calcaneus.

• When you pull against the calcaneus in an anterior direction, the talus glides anteriorly.

Subtalar Joint (Talocalcaneal), Posterior Compartment

The articulations between the calcaneus and talus are divided by the tarsal canal. The complex mechanics of these separate articulations are described in Chapter 22. Only mobilization of the posterior compartment is described here. 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.

Stabilization. Dorsiflexion of the ankle stabilizes the talus. Alternatively, the talus is stabilized with one of your hands.

Subtalar Distraction

Indications

Testing; initial treatment; pain control; general mobility for inversion/eversion (Fig. 5.61) VIDEO 5.13 .

Patient and Therapist Positions and Hand Placement

• The patient is placed in a supine position, with the leg supported on the table and heel over the edge.

• 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.

Mobilizing Force

Pull the calcaneus distally with respect to the long axis of the leg.

Subtalar Medial Glide or Lateral Glide

Indications

Medial glide to increase eversion; lateral glide to increase inversion (Fig. 5.62).

Patient Position

The patient is side-lying or prone, with the leg supported on the table or with a towel roll.

Therapist Position and Hand Placement

• Align your shoulder and arm parallel to the bottom of the foot.

• Stabilize the talus with your proximal hand.

• 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.

Mobilizing Force

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 plantar surface of the heel.

Alternate Position

Same as the position for distraction, moving the calcaneus in the medial or a lateral direction with the base of the hand.

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.

Intertarsal and Tarsometatarsal Plantar Glide

Indication

To increase plantarflexion accessory motions (necessary for supination) (Fig. 5.63).

Patient Position

Supine, with hip and knee flexed, or sitting, with knee flexed over the edge of the table and heel resting on your lap.

Stabilization and Hand Placement

• Fixate the more proximal bone with your index finger on the plantar surface of the bone.

• 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.

• 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 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.

Mobilizing Force

Push the distal bone in a plantar direction from the dorsum of the foot.

Intertarsal and Tarsometatarsal Dorsal Glide

Indication

To increase the dorsal gliding accessory motion (necessary for pronation).(Fig. 5.64)

Patient Position

Prone, with knee flexed.

Stabilization and Hand Placement

• Fixate the more proximal bone.

• 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).

• 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.

• Place your second metacarpophalangeal joint against the bone to be moved.

Mobilizing Force

Push from the plantar surface in a dorsal direction.

Alternate Technique

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.

Intermetatarsal, 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.

Critical Thinking and Discussion

1. An individual is immobilized in a cast for 4 to 6 weeks following a fracture. In general, what structures lose their elasticity, and what restrictions do you feel when testing range of motion, joint play, and flexibility?

2. Describe the normal arthrokinematic relationships for the extremity joints and define the location of the treatment plane for each joint.

3. Using the information from activity 1, define a specific fracture, such as a Colle's fracture of the distal forearm. Identify what techniques are necessary to gain joint mobility and range of motion in the related joints such as the wrist, forearm, and elbow joints, connective tissues, and muscles. Practice using each of the techniques.

4. Explain the rationale for using passive joint techniques to treat patients with limitations because of pain and muscle guarding or to treat patients with restricted capsular or ligamentous tissue. What is the difference in the way the techniques are applied in each case?

5. Describe how joint mobilization techniques fit into the total plan of therapeutic intervention for patients with impaired joint mobility.

6. Explain the difference between passive joint mobilization techniques and mobilization with movement techniques.

Laboratory Practice

With a partner, practice mobilizing each joint in the upper and lower extremities.

PRECAUTION: Do not practice on an individual with a hypermobile or unstable joint.

1. Begin with the joint in its resting position and apply distraction techniques at each intensity (sustained grades I, II, and III) to develop a feel for "very gentle," "taking up the slack," and "stretch." Do not apply a vigorous stretch to someone with a normal joint. Be sure to use appropriate stabilization.

2. With the joint in its resting position, practice all appropriate glides for that joint. Be sure to use a grade I distraction with each gliding technique. Vary the techniques between sustained and oscillation.

3. Practice progressing each technique by taking the joint to a point that you determine to be the "end of the range" and:

   • Apply a distraction technique with the extremity in that position.

   • Apply the appropriate glide at that range (be sure to apply a grade I distraction with each glide).

   • Add rotation (e.g., external rotation for shoulder abduction) and then apply the appropriate glide.