++
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.
++
++
The concave glenoid fossa receives the convex humeral head.
++
Resting position. The shoulder is abducted 55o, horizontally adducted 30o, 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
++
Testing; initial treatment (sustained grade II); pain control (grade I or II oscillations); general mobility (sustained grade III) (Fig. 5.14) VIDEO 5.1
.
++
++
Supine, with arm in the resting position. Support the forearm between your trunk and elbow.
++
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.
++
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
++
To increase abduction (sustained grade III); to reposition the humeral head if superiorly positioned (Fig. 5.15) VIDEO 5.2
.
++
++
++
Supine, with arm in the resting position. Support the forearm between your trunk and elbow.
++
++
With the superiorly placed hand, glide the humerus in an inferior direction.
+++
Glenohumeral Caudal Glide (Long Axis Traction)
++
Supine, with arm in the resting position. Support the forearm between your trunk and elbow.
++
The force comes from the hand around the arm, pulling caudally as you shift your body weight inferiorly.
+++
Glenohumeral Caudal Glide Progression
++
To increase abduction (Fig. 5.16).
++
++
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.
++
With the hand on the proximal humerus, glide the humerus in an inferior direction with respect to the scapula.
+++
Glenohumeral Elevation Progression
++
To increase elevation beyond 90° of abduction (Fig. 5.17).
++
++
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.
++
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
++
To increase flexion; to increase internal rotation (Fig. 5.18) VIDEO 5.3
.
++
++
++
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.
++
Glide the humeral head posteriorly by moving the entire arm as you bend your knees.
+++
Glenohumeral Posterior Glide Progression
++
To increase posterior gliding when flexion approaches 90°; to increase horizontal adduction (Fig. 5.19).
++
++
Supine, with the arm flexed to 90° and internally rotated and with the elbow flexed. The arm may also be placed in horizontal adduction.
++
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.
++
Glide the humerus posteriorly by pushing down at the elbow through the long axis of the humerus.
+++
Glenohumeral Anterior Glide, Resting Position
++
To increase extension; to increase external rotation (Fig. 5.20) VIDEO 5.4
.
++
++
++
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.
++
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
++
To increase external rotation (Fig. 5.21) VIDEO 5.5
.
++
++
++
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
++
Sitting or prone (Fig. 5.22).
++
++
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.
++
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
++
Posterior glide to increase retraction; superior glide to increase depression of the clavicle (Fig. 5.23).
++
++
++
+++
Sternoclavicular Anterior Glide and Caudal (Inferior) Glide
++
Anterior glide to increase protraction; caudal glide to increase elevation of the clavicle (Fig. 5.24).
++
++
Your fingers are placed superiorly and thumb inferiorly around the clavicle.
++
+++
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
++
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
).
++
++
++
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.
++
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.
++
Apply force against the proximal ulna at a 45° angle to the shaft of the bone.
+++
Humeroulnar Distal Glide
++
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.
++
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
++
To increase varus. This is an accessory motion of the joint that accompanies elbow flexion and is, therefore, used to progress flexion.
++
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.
++
Place the base of your proximal hand just distal to the elbow; support the distal forearm with your other hand.
++
Apply force against the ulna in a radial direction.
+++
Humeroulnar Ulnar Glide
++
To increase valgus. This is an accessory motion of the joint that accompanies elbow extension and is, therefore, used to progress extension.
++
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.
++
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
++
To increase mobility of the humeroradial joint; to manipulate a pushed elbow (proximal displacement of the radius) (Fig. 5.29).
++
++
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.
++
Pull the radius distally (long-axis traction causes joint traction).
+++
Humeroradial Dorsal/Volar Glides
++
Dorsal glide head of the radius to increase elbow extension; volar glide to increase flexion (Fig. 5.30).
++
++
Supine or sitting with the elbow extended and supinated to the end of the available range.
++
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.
++
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
++
To reduce a pulled elbow subluxation (Fig. 5.31).
++
++
++
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).
++
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
++
Dorsal glide to increase pronation; volar glide to increase supination (Fig. 5.32) VIDEO 5.8
.
++
++
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.
++
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.
++
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
++
Dorsal glide to increase supination; volar glide to increase pronation (Fig. 5.33).
++
++
Sitting, with the forearm on the treatment table. Begin in the resting position and progress to end-range pronation or supination.
++
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.
++
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).
++
++
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
++
Testing; initial treatment; pain control; general mobility of the wrist (Fig. 5.35).
++
++
Sitting, with the forearm supported on the treatment table, wrist over the edge of the table.
++
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.
++
Pull in a distal direction with respect to the arm.
+++
Radiocarpal Joint: General Glides and Progression
++
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.
++
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.
++
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.
++
++
Apply long-axis traction to the metacarpal.
+++
Carpometacarpal and Intermetacarpal: Volar Glide
++
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.
++
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)
++
Testing; initial treatment; pain control; general mobility.
++
The patient is positioned with forearm and hand resting on the treatment table.
++
++
++
Apply long-axis traction to separate the joint surfaces.
+++
Carpometacarpal Glides (Thumb)
++
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.
++
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
++
Testing; initial treatment; pain control; general mobility (Fig. 5.42).
++
++
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.
++
Apply long-axis traction to separate the joint surface.
+++
Metacarpophalangeal and Interphalangeal Glides and Progression
++
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.
++
++
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.
++
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.
++
++
Testing; initial treatment; pain control; general mobility.
++
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.
++
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.
++
To increase flexion; to increase internal rotation (Fig. 5.46) VIDEO 5.9
.
++
++
++
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.
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Keep your elbows extended and flex your knees; apply the force through your proximal hand in a posterior direction.
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To increase extension; to increase external rotation (Fig. 5.47) VIDEO 5.10
.
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Prone, with the trunk resting on the table and hips over the edge. The opposite foot is on the floor.
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Therapist Position and Hand Placement
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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.
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Keep your elbow extended and flex your knees; apply the force through your proximal hand in an anterior direction.
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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.
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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.
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Tibiofemoral Articulations
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The concave tibial plateaus articulate on the convex femoral condyles. Biomechanics of the knee joint are described in Chapter 21.
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Resting position. The resting position is 25° flexion.
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Treatment plane. The treatment plane is along the surface of the tibial plateaus; therefore, it moves with the tibia as the knee angle changes.
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Stabilization. In most cases, the femur is stabilized with a belt or by the table.
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Tibiofemoral Distraction: Long-Axis Traction
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Testing; initial treatment; pain control; general mobility (Fig. 5.49).
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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.
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Grasp around the distal leg, proximal to the malleoli with both hands.
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Pull on the long axis of the tibia to separate the joint surfaces.
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Tibiofemoral Posterior Glide
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Testing; to increase flexion (Fig. 5.50).
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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.
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Therapist Position and Hand Placement
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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.
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Extend your elbows and lean your body weight forward; push the tibia posteriorly with your thumbs.
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Tibiofemoral Posterior Glide: Alternate Positions and Progression
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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.
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Therapist Position and Hand Placement
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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.
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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.
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Tibiofemoral Anterior Glide
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To increase extension (Fig. 5.52) VIDEO 5.11
.
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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).
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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.
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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.
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Alternate Position and Technique
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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.
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The patella must have mobility to glide distally on the femur for normal knee flexion, and glide proximally for normal knee extension.
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Patellofemoral Joint, Distal Glide
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Supine, with knee extended; progress to positioning the knee at the end of the available range in flexion (Fig. 5.53).
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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.
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Glide the patella in a caudal direction, parallel to the femur.
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PRECAUTION: Do not compress the patella into the femoral condyles while performing this technique.
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Patellofemoral Medial or Lateral Glide
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To increase patellar mobility (Fig. 5.54).
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Supine with the knee extended. Side-lying may be used to apply a medial glide (see Fig. 21.3).
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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.
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Glide the patella in a medial or lateral direction, against the restriction.
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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.
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Proximal Tibiofibular Articulation: Anterior (Ventral) Glide
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To increase movement of the fibular head; to reposition a posteriorly subluxed head (Fig. 5.55).
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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.
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Therapist Position and Hand Placement
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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.
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Apply the force through the heel of your hand against the posterior aspect of the fibular head, in an anterior-lateral direction.
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Distal Tibiofibular Articulation: Anterior (Ventral) or Posterior (Dorsal) Glide
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To increase mobility of the mortise when it is restricting ankle dorsiflexion (Fig. 5.56).
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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.
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Press against the fibula in an anterior direction when prone and in a posterior direction when supine.
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Talocrural Joint (Upper Ankle Joint)
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The convex talus articulates with the concave mortise made up of the tibia and fibula (Fig. 5.57).
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Resting position. The resting position is 10° plantarflexion.
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Treatment plane. The treatment plane is in the mortise, in an anterior-posterior direction with respect to the leg.
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Stabilization. The tibia is strapped or held against the table.
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Talocrural Distraction
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Testing; initial treatment; pain control; general mobility (Fig. 5.58) VIDEO 5.12
.
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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.
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Therapist Position and Hand Placement
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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.
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Pull the foot along the long axis of the leg in a distal direction by leaning backward.
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Talocrural Dorsal (Posterior) Glide
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To increase dorsiflexion (Fig. 5.59).
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Supine, with the leg supported on the table and the heel over the edge.
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Therapist Position and Hand Placement
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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.
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Glide the talus posteriorly with respect to the tibia by pushing against the talus.
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Talocrural Ventral (Anterior) Glide
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To increase plantarflexion (Fig. 5.60).
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Prone, with the foot over the edge of the table.
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Therapist Position and Hand Placement
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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.
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Push against the calcaneus in an anterior direction (with respect to the tibia); this glides the talus anteriorly.
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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.
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Subtalar Joint (Talocalcaneal), Posterior Compartment
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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.
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Resting position. The resting position is midway between inversion and eversion.
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Treatment plane. The treatment plane is in the talus, parallel to the sole of the foot.
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Stabilization. Dorsiflexion of the ankle stabilizes the talus. Alternatively, the talus is stabilized with one of your hands.
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Testing; initial treatment; pain control; general mobility for inversion/eversion (Fig. 5.61) VIDEO 5.13
.
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Patient and Therapist Positions and Hand Placement
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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.
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Pull the calcaneus distally with respect to the long axis of the leg.
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Subtalar Medial Glide or Lateral Glide
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Medial glide to increase eversion; lateral glide to increase inversion (Fig. 5.62).
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The patient is side-lying or prone, with the leg supported on the table or with a towel roll.
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Therapist Position and Hand Placement
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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.
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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.
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Same as the position for distraction, moving the calcaneus in the medial or a lateral direction with the base of the hand.
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Intertarsal and Tarsometatarsal Joints
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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.
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Intertarsal and Tarsometatarsal Plantar Glide
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To increase plantarflexion accessory motions (necessary for supination) (Fig. 5.63).
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Supine, with hip and knee flexed, or sitting, with knee flexed over the edge of the table and heel resting on your lap.
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Stabilization and Hand Placement
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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.
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Push the distal bone in a plantar direction from the dorsum of the foot.
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Intertarsal and Tarsometatarsal Dorsal Glide
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To increase the dorsal gliding accessory motion (necessary for pronation).(Fig. 5.64)
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Stabilization and Hand Placement
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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.
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Push from the plantar surface in a dorsal direction.
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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.
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Intermetatarsal, Metatarsophalangeal, and Interphalangeal Joints
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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.