Introduction

Research Corner Summary

Ankle Dysfunctions

Comparing Interventions

Combining Interventions

Systemic Changes, Performance and Self Mobilizations

Biomechanics

Efficacy, Systemic Effects, and Performance

Techniques

Joint Mobilization: Ankle and Tibiofibular Joints

PACE

AUSPHYSIO

TPTA

NYPT

AOTA

<h3>Introduction</h3>
<p>This course describes joint mobilizations for the ankle joint (a.k.a. tibiotalar, talocrural, mortise joint of the ankle, etc.) and tibiofibular joints (a.k.a. <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> tibiofibular joint and <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joints). Several terms and definitions have been used to describe the &quot;mobilizations&quot; (e.g. mobilisations) that are taught in this course. The Brookbush Institute uses a conventional definition of &quot;mobilization&quot; that includes low amplitude, low-velocity, oscillatory techniques intended to reduce the stiffness of joints exhibiting a decrease in passive accessory range of motion (a.k.a. <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> and specifically <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> or <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a>). Note, the term &quot;manipulation&quot; is reserved for high-velocity techniques taught in a separate set of courses.</p>
<p>This course includes several of the techniques most commonly used to address ankle joint stiffness and improve dorsiflexion range of motion (ROM). For example, <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> tibiotalar (talocrural) mobilizations may be used to address a loss of dorsiflexion following ankle sprain, as research has demonstrated that a history of ankle sprain is correlated with a loss of <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the talus on the tibia, incomplete recovery of dorsiflexion, and potentially a higher recurrence of ankle sprains (e.g. development of chronic ankle <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>). These techniques may also be used in an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach for <a href="https://brookbushinstitute.com/courses/lower-leg-dysfunction" title="Lower Extremity Dysfunction" target="_blank" rel="noopener">lower extremity dysfunctions</a> including plantar fasciitis, patellofemoral pain syndrome (PFPS), and hip impingement syndrome, and <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including pes planus, knee valgus, knee varus, and asymmetrical weight shift. Some evidence and clinical outcomes even suggest that addressing ankle dysfunction can have a significant effect on low back pain outcomes.&#xA0;</p>
<p>The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) with the intent of developing an <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a>, patient-centered, and outcome-driven approach.&#xA0;</p>
<h3>Techniques Covered in this Course</h3>
<ul>
  <li><a href="https://brookbushinstitute.com/video/ankle-tibiotalor-joint-anterior-to-posterior" target="_blank" rel="noopener">Ankle Mobilization</a></li>
  <li><a href="https://brookbushinstitute.com/video/distal-tibiofibular-joint-anterior-posterior-manual-mobilization" target="_blank" rel="noopener">Distal Tibiofibular Joint Mobilization</a></li>
  <li><a href="https://brookbushinstitute.com/video/proximal-tibiofibular-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Proximal Tibiofibular Joint Mobilization</a></li>
</ul>
<h3>Sample Intervention (Ankle Dorsiflexion Restriction)</h3>
<ul>
  <li><strong>Manual Release</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/gastroc-soleus-manuel-release" target="_blank" rel="noopener">Gastrocnemius and Soleus Static Manual Release</a></li>
      <li><a href="https://brookbushinstitute.com/video/fibularis-release" target="_blank" rel="noopener">Fibularis </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Static Manual Release</li>
      <li><a href="https://brookbushinstitute.com/video/ehl-edl-release" target="_blank" rel="noopener">Extensor Hallucis Longus (EHL) and Extensor Digitorum Longus (EDL) Static Manual Release</a></li>
      <li><a href="https://brookbushinstitute.com/video/fhl-fdl-release" target="_blank" rel="noopener">Flexor Hallucis Longus (FHL) and Flexor Digitorum Longus (FDL) Static Manual Release</a></li>
    </ul>
  </li>
  <li><strong>Mobilization or Manipulation</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/ankle-tibiotalor-joint-anterior-to-posterior" target="_blank" rel="noopener">Ankle Mobilization</a></li>
      <li><a href="https://brookbushinstitute.com/video/distal-tibiofibular-joint-anterior-posterior-manual-mobilization" target="_blank" rel="noopener">Distal Tibiofibular Joint Mobilization</a></li>
      <li><a href="https://brookbushinstitute.com/video/proximal-tibiofibular-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Proximal Tibiofibular Joint Mobilization</a></li>
    </ul>
  </li>
  <li><strong>Manual Lengthening</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/manual-calf-stretch" target="_blank" rel="noopener">Manual Calf Stretch</a></li>
    </ul>
  </li>
  <li><strong>Instrument Assisted Soft Tissue Mobilization</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/crural-fascia-instrument-assisted-soft-tissue-mobilization-iastm" target="_blank" rel="noopener">Crural Fascia</a></li>
    </ul>
  </li>
  <li><strong>Activation</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/article/tibialis-posterior-activation" target="_blank" rel="noopener">Tibialis </a><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Activation</li>
      <li><a href="https://brookbushinstitute.com/article/corrective-exercise-articles/activation/tibialis-anterior-activation/" target="_blank" rel="noopener">Tibialis </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
    </ul>
  </li>
  <li><strong>Reactive Activation:</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/tibialis-anterior-reactive-activation" target="_blank" rel="noopener">Heel walks</a></li>
    </ul>
  </li>
  <li><strong>Integration</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/single-leg-deadlift-touchdown" target="_blank" rel="noopener">Single-Leg Touchdown</a></li>
    </ul>
  </li>
</ul>
<h3>Related Courses</h3>
<p><strong>Additional Joint Mobilization Courses</strong></p>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-ankle-and-tibiofibular-joints" title="Ankle and Tibiofibular Joint Mobilization" target="_blank" rel="noopener">Joint Mobilizations: Ankle and Tibiofibular Joints</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-hip-and-knee" title="Knee and Hip Joint Mobilization" target="_blank" rel="noopener">Joint Mobilizations: Knee and Hip Joints</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-lumbar-spine-and-sacroiliac-joint" title="Lumbar Spine and Sacroiliac Joints" target="_blank" rel="noopener">Joint Mobilizations: Lumbar Spine and Sacroiliac Joints</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-cervical-and-thoracic-spine" title="Cervical and Thoracic Spine" target="_blank" rel="noopener">Joint Mobilizations: Cervical and Thoracic Spine</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-shoulder-joint-acromioclavicular-joint-and-sternoclavicular-joint" title="Joint Mobilization Shoulder SC and AC" target="_blank" rel="noopener">Joint Mobilizations: Shoulder, Sternoclavicular, and Acromioclavicular Joints</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-elbow-and-proximal-radioulnar-joint" title="Joint Mobilization Elbow and &lt;a id=" proximal" data-tip="1564" target="_blank" class="glossary">Proximal</a> Radioulnar Joint&quot; target=&quot;_blank&quot; rel=&quot;noopener&quot;&gt;Joint Mobilizations: Elbow and <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">Proximal</a> Radioulnar Joints</li>
</ul>
<p><strong>For an introduction to joint mobilizations and manipulations:</strong></p>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
  <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>

Course Description: Ankle and Tibiofibular Joint Mobilizations

<h2>For <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction:</a></h2>
<h3>For an introduction to joint mobilizations and manipulations:</h3>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
  <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>
<h3>Techniques Covered in this Course</h3>
<ul>
  <li><a href="https://brookbushinstitute.com/video/ankle-tibiotalor-joint-anterior-to-posterior" target="_blank" rel="noopener">Ankle Mobilization</a></li>
  <li><a href="https://brookbushinstitute.com/video/distal-tibiofibular-joint-anterior-posterior-manual-mobilization" target="_blank" rel="noopener">Distal Tibiofibular Joint Mobilization</a></li>
  <li><a href="https://brookbushinstitute.com/video/proximal-tibiofibular-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Proximal Tibiofibular Joint Mobilization</a></li>
</ul>
<h3><strong>Signs of correlated dysfunction:</strong></h3>
<ul>
  <li><strong><a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment:</a></strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-4-feet-flat-breakdown" target="_blank" rel="noopener">Feet Flatten</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-5-feet-turn-out-breakdown" target="_blank" rel="noopener">Feet Turn Out</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">Excessive Forward Lean</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees Bow Out</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">Asymmetrical Weight Shift</a></li>
    </ul>
  </li>
  <li><strong><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a></strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/knee-extension-goniometry" target="_blank" rel="noopener">Knee Extension Goniometry</a> &lt;0 - -5&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/knee-flexion-goniometry" target="_blank" rel="noopener">Knee Flexion Goniometry</a> &lt;135 - 150&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/dorsiflexion-goniometry" target="_blank" rel="noopener">Dorsiflexion Goniometr</a>y &lt;15 - 20&#xB0;</li>
    </ul>
  </li>
  <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener"><strong>Manual </strong></a><strong><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing MMT:</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/tibialis-anterior-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Tibialis </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Manual <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (MMT) - Weak or With Compensation (Eversion)</li>
      <li><a href="https://brookbushinstitute.com/video/posterior-tibialis-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Tibialis </a><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Manual <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (MMT) - Weak or With Compensation (Eversion)</li>
    </ul>
  </li>
</ul>
<h3>Sample Intervention (Ankle Dorsiflexion Restriction)</h3>
<ul>
  <li><strong>Manual Release</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/gastroc-soleus-manuel-release" target="_blank" rel="noopener">Gastrocnemius and Soleus Static Manual Release</a></li>
      <li><a href="https://brookbushinstitute.com/video/fibularis-release" target="_blank" rel="noopener">Fibularis </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Static Manual Release</li>
      <li><a href="https://brookbushinstitute.com/video/ehl-edl-release" target="_blank" rel="noopener">Extensor Hallucis Longus (EHL) and Extensor Digitorum Longus (EDL) Static Manual Release</a></li>
      <li><a href="https://brookbushinstitute.com/video/fhl-fdl-release" target="_blank" rel="noopener">Flexor Hallucis Longus (FHL) and Flexor Digitorum Longus (FDL) Static Manual Release</a></li>
    </ul>
  </li>
  <li><strong>Mobilization or Manipulation</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/ankle-tibiotalor-joint-anterior-to-posterior" target="_blank" rel="noopener">Ankle Mobilization</a></li>
      <li><a href="https://brookbushinstitute.com/video/distal-tibiofibular-joint-anterior-posterior-manual-mobilization" target="_blank" rel="noopener">Distal Tibiofibular Joint Mobilization</a></li>
      <li><a href="https://brookbushinstitute.com/video/proximal-tibiofibular-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Proximal Tibiofibular Joint Mobilization</a></li>
    </ul>
  </li>
  <li><strong>Manual Lengthening</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/manual-calf-stretch" target="_blank" rel="noopener">Manual Calf Stretch</a></li>
    </ul>
  </li>
  <li><strong>Instrument Assisted Soft Tissue Mobilization</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/crural-fascia-instrument-assisted-soft-tissue-mobilization-iastm" target="_blank" rel="noopener">Crural Fascia</a></li>
    </ul>
  </li>
  <li><strong>Activation</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/article/tibialis-posterior-activation" target="_blank" rel="noopener">Tibialis </a><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Activation</li>
      <li><a href="https://brookbushinstitute.com/article/corrective-exercise-articles/activation/tibialis-anterior-activation/" target="_blank" rel="noopener">Tibialis </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
    </ul>
  </li>
  <li><strong>Reactive Activation:</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/tibialis-anterior-reactive-activation" target="_blank" rel="noopener">Heel walks</a></li>
    </ul>
  </li>
  <li><strong>Integration</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/single-leg-deadlift-touchdown" target="_blank" rel="noopener">Single-Leg Touchdown</a></li>
    </ul>
  </li>
</ul>

<table>
  <tbody>
    <tr>
      <td>
        <h3>Summary</h3>
        <h3>Ankle Mobilization</h3>
        <ul>
          <li><strong>Efficacy</strong>
            <ul>
              <li><strong>Arthrokinematics:</strong> Research demonstrates that ankle mobilization is effective for treating <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> changes associated with ankle dysfunction including <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> laxity or <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> stiffness of the talus, a more <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> resting position of the talus, and a reduction in dorsiflexion range of motion (ROM).</li>
              <li><strong>Healthy Individuals:</strong> Younger individuals may be more likely to improve on <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> and functional outcomes, and mobilizations are likely more effective when used to address an assessed impairment.</li>
              <li><strong>Lateral Ankle Sprain:</strong> Treating <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">Lateral</a> ankle sprain with ankle mobilization is effective for reducing pain and treatment time to full recovery, increasing dorsiflexion function, and increasing function; however, outcomes are likely related to mechanical and not analgesic effect.</li>
              <li><strong>Chronic Ankle <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">Instability</a> (CAI):</strong> Treating CAI with ankle mobilization may improve limited dorsiflexion, calcaneus varus, and sagittal plane <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, but is less effective for treating pronation, frontal plane <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and generally assessed gait kinematics.</li>
              <li><strong>Ankle Dysfunction:</strong> Ankle mobilization is also an effective treatment for reducing limited dorsiflexion, improving ROM and function for individuals with a history of ankle injury, and ankle mobilization may be an effective treatment option for Morton&apos;s neuroma.</li>
            </ul>
          </li>
          <li><strong>Dose-Response:</strong> There is a trend in the evidence that may imply 1 session is not sufficient to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> benefit from mobilizations, and more than 3 sessions may be necessary to maximize benefits.</li>
          <li><strong>Comparing Interventions:</strong> Ankle mobilization is likely more effective than other modalities for the treatment of ankle dysfunction; however, Kinesio taping, exercise, stretching and plantar massage may also be effective. Note, comparing interventions based on outcomes for the treatment of a diagnosis is inherently flawed, deluding the effects any one technique may have on a <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> impairment.</li>
          <li><strong>Comparing Mobilizations: </strong>These studies likely imply that AP mobilizations, MWM, and high-velocity manipulations are equally effective for the treatment of ankle dysfunction; however, <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> mobilizations may not be effective.</li>
          <li><strong>Combining Interventions:</strong>
            <ul>
              <li><strong>Mobilization and Taping:</strong> These studies demonstrate that the addition of taping to mobilization for the treatment of ankle dysfunction may enhance outcomes, including pain, ROM, fibular position, <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and performance. Further, the addition of ankle mobilization and taping to conventional therapy/exercise may also improve outcomes.</li>
              <li><strong>Mobilization and Exercise:</strong> The addition of mobilization to exercise and conventional therapy for the treatment of ankle dysfunction may improve pain, ROM, and functional outcomes; however, the effect of mobilization may also be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> and the additional benefits may be due to the impact of reducing ROM restriction.</li>
              <li><strong>Mobilization and Stretching:</strong> The addition of mobilization to stretching results in larger improvements in ROM, talar <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>, gait, and function when compared to stretching alone for individuals with restricted dorsiflexion, excessive pronation, CAI, and potentially plantar fasciitis. Additional research should investigate the potential of ankle mobilization to affect back pain by improving dorsiflexion; further, research should consider when mobilization should be introduced into a treatment plan, and additionally which plantar fasciitis patients are likely to benefit from treatment.</li>
              <li><strong>Combination of Mobilizations: </strong>Studies may suggest that ankle mobilizations are effective, but skepticism is warranted on whether the addition of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> mobilization to AP mobilizations enhances outcomes.</li>
              <li><strong>Miscellaneous Combinations: </strong>Ankle mobilization enhances outcomes when combined with MET, contract/relax technique, plantar massage, or Paraffin wax; however, it is worth noting that further research is needed to determine whether ankle mobilization was the most or only effective technique in these studies.</li>
            </ul>
          </li>
          <li><strong>Systemic Changes:</strong> Ankle mobilization does not appear to result in the analgesic, reflexive neurologic, corticospinal or reflexive neuromuscular changes that are often correlated with joint mobilizations; however, further research is needed on the possibility of ankle mobilization and altered tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> activity.</li>
          <li><strong>Performance:</strong> Studies suggest that ankle mobilization has the potential to improve landing and gait mechanics, as well as jump performance, which could have a positive impact on sports performance. Further research is needed to determine whether the intervention must address an assessed impairment, or whether ankle mobilization has ergogenic benefits in individuals with <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> mechanics.</li>
          <li><strong>Self-administered Mobilization:</strong> A study by Cruz-Diaz et al. (65) suggests that self-administered ankle mobilization may have a positive effect on ROM and function when added to a warm-up prior to resistance training.</li>
        </ul>
        <h3>Tibiofibular Joint Mobilization</h3>
        <ul>
          <li><strong>Biomechanics:</strong> Studies have demonstrated a correlation between lower extremity loading, dorsiflexion, and motion of the tibiofibular joints. Further, studies have also demonstrated a correlation between ankle dysfunction, swelling, and altered tibiofibular joint motion/position.</li>
          <li><strong>Efficacy:</strong> Studies have demonstrated that the intention to mobilize the tibiofibular joint to improve dorsiflexion has validity; however, this intervention should likely be used as an adjunct modality for the treatment of ankle dysfunction.</li>
          <li><strong>Systemic Changes:</strong> Unlike studies investigating the neuromuscular effects of ankle mobilization, a study by Grindstaff et al. (73) suggests that tibiofibular joint mobilization has an effect on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, inhibiting the fibularis muscles and facilitating the soleus.</li>
          <li><strong>Performance:</strong> A study by Goto et al. (75) demonstrated tibiofibular joint mobilization resulted in an increase in dorsiflexion and standing broad jump performance in healthy individuals, suggesting <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> into movement preparation routines is worth consideration.</li>
        </ul>
      </td>
    </tr>
  </tbody>
</table>

Research Corner: Ankle

<h4><strong>Ankle Dysfunction and Altered Kinematics</strong></h4>
<p>Several studies have demonstrated that ankle dysfunction results in altered <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and resting position of the talus and fibula. Hubbard et al. compared ankles with chronic <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> (CAI) to controls, demonstrating that <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> talus <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> were similar; however, those with CAI exhibited excessive <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> of the talus (1). Deneger et al. compared the affected and unaffected ankles of athletes who had sprained one ankle in the last 6 months but had returned to the sport, demonstrating the athletes affected side exhibited normal dorsiflexion but residual ligamentous laxity of the talocrural and subtalar joints, and restricted <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> talar <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> (2). Wikstrom et al. used radiographs to demonstrate that the resting position of the talus was significantly more <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> for those with CAI when compared to unaffected ankles and matched control participants (3). Basnett et al. demonstrated a correlation between CAI and a reduction in dorsiflexion and Star Excursion <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">Balance</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (SEBT) scores, specifically forward and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> reach directions (4). These studies suggest that CAI is correlated with either <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> laxity or <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> stiffness of the talus, a more <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> resting position of the talus, and a reduction in range of motion (ROM), <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">Balance</a>, and function.</p>
<p>Several additional studies have demonstrated the effect of ankle mobilization on talus <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, ankle ROM and functional outcomes. Koh et al. demonstrated that ankle mobilization with movement (MWM) resulted in improvements in ankle dorsiflexion and talus position relative to the fibula in static standing (5). Vincenzino et al. demonstrated a correlation between recent <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, a reduction in dorsiflexion ROM, and a reduction in <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the talus, and these impairments improved following ankle MWM (6). Landrum et al. investigated the efficacy of grade III <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> (AP) ankle mobilization following 14+ days of immobilization and at least a 5&#xB0; dorsiflexion deficit, demonstrating that mobilization increased dorsiflexion and <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> of the talus (26). Further, Merlin et al. demonstrated that following <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, MWM increased dorsiflexion ROM, <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and <a id="cephalad" data-tip="1558" target="_blank" href="/glossary-term/cephalad" class="glossary">cephalad</a> position of the fibula (confirmed by MRI) when compared to controls (7). These studies demonstrate that mobilizations are an effective intervention for impairments correlated with an ankle injury, including altered talus <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and position, reduced ankle ROM and reduced function.</p>
<h4><strong>Healthy Individuals</strong></h4>
<p>Several studies have investigated the efficacy of ankle mobilizations on healthy individuals. Gong et al. demonstrated that healthy elderly women receiving 3 sessions of Maitland ankle joint mobilizations (similar to the mobilizations taught below) exhibited significant changes in ankle ROM and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> when compared to controls (8). Conversely, an RCT by Pertille et al. demonstrated that low-activity elderly women treated with a single session of grade III ankle mobilizations did not significantly change dorsiflexion ROM or <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> when compared to sham mobilization (9). Guo et al. demonstrated that dorsiflexion MWM performed on young healthy individuals resulted in significant changes in dorsiflexion ROM, as well as positive changes in step length, stride length, and <a id="base-of-support" data-tip="1195" target="_blank" href="/glossary-term/base-of-support" class="glossary">base of support</a> during gait, assessed at 48- and 72-hour follow-ups (10 ). And, an RCT by Tomruk et al. demonstrated ankle MWM performed on young healthy individuals had a significant effect on <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> but not on dorsiflexion ROM (11). These studies may imply that more than a single session is necessary to achieve results, that younger individuals may be more likely to improve on <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> and functional measures, and/or that mobilizations are more effective when used to address an assessed impairment.</p>
<h4><strong>Lateral Ankle Sprain</strong></h4>
<p>Studies investigating the use of mobilization to treat <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain have demonstrated efficacy. An RCT by Green et al. investigated the efficacy of ankle mobilization for the treatment of recent inversion sprains, demonstrating that mobilization resulted in fewer sessions to achieving full pain-free dorsiflexion and increased stride speed when compared to a rest, ice, <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a>, elevate (RICE) protocol (12). A double-blind RCT by Yeo et al. investigated mobilizations for the treatment of <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> sub-acute ankle sprain, demonstrating that ankle mobilization resulted in better outcomes for pain pressure threshold and dorsiflexion ROM than a sham control (13). A double-blind RCT by Collins et al. demonstrated that treating sub-acute <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain with a single session of MWM resulted in mechanical but not analgesic changes; improving dorsiflexion ROM, but not pain pressure threshold or thermal pain threshold (14). An RCT by Cosby investigated the immediate effects of a single ankle mobilization for the treatment of acute <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain following 1-7 days of immobilization, demonstrating that dorsiflexion, talar translation, and function did not improve significantly, but pain was significantly improved when compared to controls (15). These studies suggest that treating <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain with ankle mobilization is effective for reducing pain and treatment time to full recovery, increasing dorsiflexion function, and increasing function; however, outcomes are likely related to mechanical and not analgesic effects, and may require more than one session.</p>
<h4><strong>Chronic Ankle Instability (CAI)</strong></h4>
<p>Several studies have investigated the efficacy of ankle mobilization for the treatment of CAI; a condition usually resulting from repeated ankle injuries. Yoon et al. demonstrated that treating CAI with ankle joint mobilization improved dorsiflexion and gait parameters including weight-bearing distribution, <a id="ground-reaction-force" data-tip="1395" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">ground reaction force</a>, and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> (16). A double-blind RCT by Cruz-D&#xED;az et al. investigated the efficacy of 6 sessions (over 3 weeks) of ankle joint mobilizations to treat individuals with CAI, demonstrating improvements in dorsiflexion, <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and function when compared to sham control (17). Hoch et al. demonstrated that CAI patients treated with ankle mobilization for 2 weeks (6 sessions) showed significant signs of improvement in weight-bearing dorsiflexion ROM, dynamic <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> (SEBT), and self-reported function (18). These studies demonstrate that treating CAI with ankle mobilization results in the same improvements in ROM, <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and function as noted for other conditions. Kim et al. demonstrated that performing joint mobilizations on athletes with CAI, resulted in significant and immediate improvements in dorsiflexion ROM and rearfoot angle (calcaneus varus); however, larger studies are needed to further investigate trends toward improvement on the navicular drop <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> and shuttle run times (19). In a series of studies, Hoch et al. demonstrated that CAI patients exhibited altered kinematics and that mobilization had a significant effect on patient and clinician-oriented measures of pain, function, dorsiflexion ROM, and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, but not on video analysis of kinematics during gait (20). An RCT by Hoch et al. demonstrated that CAI treated with a single bout of Maitland Grade III AP joint mobilization resulted in significant improvements in dorsiflexion and improved <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> in the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> directions, however, improvements were not noted in the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> direction, and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> stiffness was not significantly affected (21). These studies including kinematic outcomes suggest that kinematic change following mobilization occur; however, the changes are <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a>, primarily occurring in the sagittal plane. Two studies by Gilbreath et al. demonstrated that 3 treatments of mobilization with movement for individuals with CAI did not improve ROM, <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, or self-reported function; however, there was an improvement in patient-centered reports of sporting function (22, 23). Harkey et al. demonstrated that a single session of ankle mobilization was effective for restoring dorsiflexion in participants with CAI; however, H-reflex, corticospinal pathways, and dynamic <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> control were unaffected (24). Considering these studies, the multi-session studies above may suggest that some changes occur following a single session, but to achieve all associated benefits multiple sessions are needed. In summary, treating CAI with ankle mobilizations may improve limited dorsiflexion, calcaneus varus, and sagittal plane <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, but is less effective for treating pronation, frontal plane <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and generally assessed gait kinematics. Further, some research suggests that 1 - 3 sessions may not be sufficient to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> results.</p>
<h4><strong>Ankle Dysfunction (General)</strong></h4>
<p>Additional studies have investigated the effects of joint mobilization on other ankle <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a>. An et al. demonstrated that ankle mobilization resulted in immediate improvements in dynamic <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> and proprioception in adults with limited dorsiflexion (25). Landrum et al. investigated the efficacy of grade III <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> (AP) ankle mobilization following 14+ days of immobilization and at least a 5&#xB0; dorsiflexion deficit, demonstrating that mobilization increased dorsiflexion and <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> of the talus (26). An RCT by Reid et al. investigated the effects of ankle MWM on patients with a history of ankle sprain and limited weight-bearing dorsiflexion, demonstrating that dorsiflexion improved significantly and was still improved during 1-week follow-up, even when compared to sham controls (27). These studies demonstrate that ankle mobilization improves dorsiflexion ROM, when limited ROM has been assessed. Gong et al. demonstrated that individuals with excessive supination receiving ankle joint mobilization exhibited improved <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, including reduced sway area, sway path length and sway max velocity when compared to controls during pre-test, post-test at 2 weeks of treatment, post-test at 4 weeks of treatment, and during 2-week follow-up (28). An RCT by Silva et al. investigated the effects of 6 sessions of grade III AP ankle mobilizations on patients with a history of chronic ankle injury, demonstrating that only the experimental group exhibited improvements in dorsiflexion, while both the experimental and sham groups demonstrated improvements in pain and function (29). An RCT by Govender et al. investigated the efficacy of ankle mobilization for the treatment of Morton&apos;s Neuroma, demonstrating significant decreases in pain and pain pressure threshold when compared to controls (de-tuned ultrasound) (30). Finally, Teixeira et al. demonstrated that treating ankle dysfunction with a single session of ankle mobilization improved ankle dorsiflexion, but not more than a sham contact treatment (31). These studies demonstrate that ankle mobilization is an effective treatment for reducing limited dorsiflexion, improving ROM and function for individuals with a history of an ankle injury, and ankle mobilization may be an effective treatment option for Morton&apos;s neuroma. Again, there is evidence to suggest that a single session may not be sufficient to achieve desired results.</p>

<p>Several studies have compared ankle mobilization techniques to other interventions. Gopal et al. compared Kinesio taping to ankle MWM for the treatment of sub-acute <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain in high school hockey players, demonstrating that both techniques improved dorsiflexion ROM; however, MWM resulted in significantly larger improvements (32). Sivakumar et al. compared 4 weeks of Mulligan mobilizations (similar to those taught below) to 4 weeks of <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and proprioception exercises for the treatment of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, demonstrating that Mulligan mobilizations resulted in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> improvements in dorsiflexion ROM and functional outcomes (33). Two interesting RCTs by Wikstrom et al. compared participants with CAI who responded to various interventions. The first study by Wikstrom et al. demonstrated that responders to ankle joint mobilization had deficits in self-reported function, decreased single-limb <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and a history of less than 5 previous sprains; responders to plantar massage exhibited weight-bearing&#x2013;dorsiflexion restrictions, and single-limb <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> deficits; and responders to calf stretching exhibited deficits in self-reported sport-related function (34). The second RCT by Wikstrom et al. demonstrated that participants with more than 3 <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> errors had a 73% probability of treatment success following ankle joint mobilizations, participants with a self-reported function between limb difference of less than 16.07% and who made more than 2.5 errors during <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> testing had a 99% probability of treatment success following plantar massage, and those who have sustained more than 11 ankle sprains had 94% probability of treatment success following calf stretching (35). In summary, these studies demonstrate that ankle mobilization is often more effective than other modalities; however, Kinesio taping, exercise, stretching and plantar massage may also be effective for the treatment of ankle dysfunction. Note, comparing interventions based on outcomes for the treatment of a diagnosis is inherently flawed, deluding the effects any one technique may have on a <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> impairment.</p>
<h4><strong>Comparing Mobilizations</strong></h4>
<p>A few studies have compared different ankle mobilization techniques. Cho et. al compared Gong&apos;s ankle mobilization to MWM ankle mobilization, demonstrating that both were equally effective for improving ankle dorsiflexion ROM (36). Powden et al. demonstrated participants with CAI receiving a single session of sustained or oscillatory<span>&#xA0;</span><strong>traction</strong><span>&#xA0;</span>mobilization did not exhibit changes in dorsiflexion or <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> when compared to sham controls (37). Marr&#xF3;n-G&#xF3;mez et al. compared a single session of ankle MWM to high-velocity talocrural manipulation for the treatment of CAI, demonstrating that both techniques were equally effective for improving dorsiflexion and that the results persisted for at least 48 hours (38). These studies likely imply that AP mobilizations, MWM, and high-velocity manipulations are equally effective for the treatment of ankle dysfunction; however, <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> mobilizations may not be effective.</p>

<h4><strong>Mobilization and Taping</strong></h4>
<p>Many studies have demonstrated additional benefits when mobilization is combined with other effective interventions. Abd et al. demonstrated that treating CAI with a combination of ankle MWM and Mulligan taping improved dorsiflexion, eversion ROM, inversion ROM and fibular position (39). Kotteeswaran et al. demonstrated that the combination of mobilization and kinesiotaping was effective for improving dorsiflexion and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> in dancers with ankle impingement syndrome (40). Ghadi et al. compared conventional therapy (RICE, ultrasound, and home exercise) with and without the combination of ankle MWM and fibular reposition taping for the treatment of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, demonstrating that the addition of ankle MWM and taping resulted in significantly larger improvements in general pain, pain pressure threshold and single-leg stance (41). An RCT by Jeong et al. compared treating soccer players with CAI with a combination of MWM and fibular reposition taping, MWM, and Kinesio taping, or control receiving no intervention, demonstrating that both intervention groups exhibited improvements in jump performance and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> when compared to controls, and further that fibular reposition taping resulted in larger improvements in <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> than Kinesio taping (42). These studies demonstrate that the addition of taping to mobilization for the treatment of ankle dysfunction may enhance outcomes, including pain, ROM, fibular position, <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and performance. Further, the addition of ankle mobilization and taping to conventional therapy/exercise may also improve outcomes.</p>
<h4><strong>Mobilization and Exercise</strong></h4>
<p>The combination of joint mobilization and exercise has been researched for most joints, and generally demonstrates better outcomes than either intervention alone. Cleland et al. demonstrated that the combination of mobilization and exercise was more effective than exercise alone for the treatment of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain during 4-week and 6-month follow-ups, including better outcomes on Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, FAAM sports subscale, Lower Extremity Functional Scale, and pain (43). Shih et al. compared exercise with and without ankle mobilization for the treatment of CAI, demonstrating that the addition of ankle mobilization improved self-reported severity of ankle <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>, dorsiflexion, and posterolateral balance; however, the effects on general pain and function, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation, and other <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> tasks were unclear (44). An RCT by Plaza-Manzano et al. compared 4 weeks of proprioceptive/strengthening exercises with and without manual therapy (joint and <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> mobilization), demonstrating that the addition of manual therapy resulted in greater improvements in pain, self-reported function, strength, and ROM (45). Sivakumar et al. investigated the treatment of acute ankle sprain, comparing conventional treatment (RICE), with either <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> exercises or ankle joint mobilization with strengthening exercises, demonstrating that the ankle joint mobilization and strengthening resulted in larger improvements in dorsiflexion and functional outcomes (46). Hern&#xE1;ndez-Guill&#xE9;n et al. demonstrated that the addition of foot and ankle mobilization to 4 weeks of <a id="stability-training" data-tip="1174" target="_blank" href="/glossary-term/stability-training" class="glossary">balance training</a> in healthy older adults, did not augment <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> improvements, but did improve dorsiflexion ROM (47). These studies demonstrate that the addition of mobilization to exercise and conventional therapy for the treatment of ankle dysfunction may improve pain, ROM, and functional outcomes; however, the effect of mobilization may also be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> and the additional benefits may be due to the impact of reducing ROM restriction.</p>
<h4><strong>Mobilization and Stretching</strong></h4>
<p>Research has also demonstrated that the addition of mobilization to stretching results in additional benefits for individuals with ankle dysfunction. Kang et al. demonstrated that calf stretching in conjunction with ankle mobilization resulted in significant changes in dorsiflexion ROM (48). An RCT by Kang et al. compared calve stretching with and without ankle mobilization for the treatment of restricted dorsiflexion, demonstrating that the mobilization group had larger improvements in dorsiflexion, <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> talar <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>, and dorsiflexion before heel-off during gait (49). Yoon et al. compared active calf stretching with and without ankle mobilization on individuals with pronated feet, demonstrating that the addition of ankle mobilization improved dorsiflexion ROM, and lumbar extension motion during gait, which may have an impact on low back pain (50). Feldbrugge et al. demonstrated that the combination of mobilization and stretching for the treatment of CAI may improve functional outcomes and dorsiflexion more than stretching alone; however, the use of mobilization early in the treatment period, or in the 2nd two weeks of the treatment period, did not have a significant impact on post-treatment outcomes (51). Celik et al. demonstrated that treating plantar fasciitis with steroid injection resulted in better pain and functional outcomes at 3-week, 6-week, and 12-week follow-ups; however, joint mobilization and stretching resulted in better outcomes for dorsiflexion ROM at all follow-ups and better pain and functional outcomes at 1-year follow-up (52). An RCT by Shashua et al. compared stretching exercises and ultrasound with and without ankle and midfoot mobilizations for the treatment of plantar fasciitis, demonstrating both groups made similar improvements in dorsiflexion, pain, and function (53). These studies suggest that the addition of mobilization to stretching results in larger improvements in ROM, talar <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>, gait, and function when compared to stretching alone for individuals with restricted dorsiflexion, excessive pronation, CAI, and potentially plantar fasciitis. Additional research should investigate the potential of ankle mobilization to affect back pain by improving dorsiflexion; further, research should consider when mobilization should be introduced into a treatment plan, and additionally which plantar fasciitis patients are likely to benefit from treatment.</p>
<h4><strong>Combination of mobilizations</strong></h4>
<p>A few studies have demonstrated that a combination of mobilizations may be effective. Chevutschi et al. demonstrated that talocrural and subtalar joint mobilization resulted in immediate improvements in static <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, but a decrease in dynamic <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> in healthy older adults (54). Cho et al. demonstrated that healthy older adults receiving a combination of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> and AP ankle mobilizations exhibited improvements in dorsiflexion, timed up-and-go, and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> tests when compared to controls (55) Conversely, Hoch et al. demonstrated that CAI patients receiving a combination of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> and AP ankle mobilizations exhibited no change in <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> control or <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> stiffness (56). These studies imply that a combination of mobilization techniques may be effective for improving ROM; however, these are not comparative studies, and a previously discussed study demonstrated that <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> mobilizations were not effective for improving outcomes. These studies may suggest that ankle mobilizations are effective, but skepticism is warranted on whether the addition of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> mobilization to AP mobilizations enhances outcomes.</p>
<h4><strong>Mobilization and Miscellaneous Interventions</strong></h4>
<p>Additional studies have investigated the addition of mobilizations to interventions not discussed above. An RCT by Vaillant et al. demonstrated that healthy older adults benefited from a combination of plantar massage and ankle mobilization including improvements in single-leg <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, timed up-and-go, and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> reach tests, when compared to a control group (57). Baidya et al. compared 4 weeks (3 times per week) of treatment with a combination of ankle MWM and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique or MWM and contract/relax technique for the treatment of sub-acute ankle sprain, demonstrating that both groups exhibited similar improvements in ROM, gait, and function (58, 59). An RCT by Rashid et al. compared 10 weeks of Paraffin wax with and without ankle mobilization for the treatment of post-traumatic ankle stiffness, demonstrating that both groups exhibited improvements in pain, the mobilization group had <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes for function, and only the mobilization group exhibited significant improvements in ROM (60). These studies likely demonstrate that ankle mobilization enhances outcomes when combined with MET, contract/relax technique, plantar massage, or Paraffin wax; however, it is worth noting that further research is needed to determine whether ankle mobilization was the most or only effective technique in these studies.</p>

<h3>Systemic Changes</h3>
<p>Unlike research on mobilizations of the spine, hips, and shoulders, ankle mobilization does not appear to result in systemic changes. As mentioned above, A double-blind RCT by Collins et al. demonstrated that treating sub-acute <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain with a single session of MWM resulted in mechanical but not analgesic changes; improving dorsiflexion ROM but not pain pressure threshold or thermal pain threshold (14). In another study mentioned above, Harkey et al. demonstrated that a single session of ankle mobilization was effective for restoring dorsiflexion in participants with CAI; however, H-reflex and corticospinal pathways were unaffected (24). An RCT by Fisher et al. compared high-velocity thrust manipulation, joint mobilization, and controls demonstrating that the thrust manipulation group had an increase in corticospinal <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a>, while corticospinal <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a> decreased in the mobilization group. Further, only the thrust manipulation group demonstrated a significant increase in the maximal motor-evoked potential (MEP) amplitude of the tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> (61). Additional studies have also demonstrated that mobilizations have little if any effect on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. As mentioned above, Shih et al. compared exercise with and without ankle mobilization for the treatment of CAI, demonstrating that the addition of ankle mobilization improved ROM, <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, and function, but the impact on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity was unclear (44). An interesting study by, Jung et al. compared several weeks of conventional therapy with and without ankle mobilization for the treatment of acute ankle sprain, demonstrating that ankle mobilization resulted in better hip flexor/extensor strength ratios and larger improvements in gait speed (62). Although this study demonstrates an effect on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, considering the muscles assessed do not cross the ankle, it is likely the improvements were due to the effects of other interventions with the added benefit of increased dorsiflexion. An RCT by Ersoy et al. demonstrated that grade III ankle mobilizations resulted in a significant increase in dorsiflexor <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength for at least 30 minutes, when compared to sham control (grade I mobilizations), in healthy individuals (63). This study and the study including manipulations may be evidence of a potential effect on tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity; however, an increase in strength could also be the result of a reduction in dorsiflexion restriction. In summary, ankle mobilization does not appear to result in the analgesic, reflexive neurologic, corticospinal or reflexive neuromuscular changes that are often correlated with joint mobilizations; however, further research is needed on the possibility of altered tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> activity.</p>
<h3>Performance</h3>
<p>A few studies have demonstrated the potential of joint mobilizations to have a positive impact on performance. As mentioned above, an RCT by Jeong et al. demonstrated that a combination of ankle MWM with taping for the treatment of soccer players with CAI had a positive impact on jump performance and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> when compared to controls (42). Delahunt et al. demonstrated that a combination of ankle MWM, Mulligan <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilization, and Maitland AP talus mobilization resulted in a significant decrease in plantar flexion angle at contact during a single-leg drop <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, presumably representing an improvement in landing mechanics post-intervention in athletes with CAI (64). And, the RCT mentioned under &quot;systemic changes&quot; by Ersoy et al. demonstrated that grade III ankle mobilizations resulted in an immediate increase in dorsiflexor <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength in healthy individuals (62). These studies suggest that ankle mobilization has the potential to improve landing and gait mechanics, as well as jump performance, which could have a positive impact on sports performance. Further research is needed to determine whether the intervention must address an assessed impairment, or whether ankle mobilization has ergogenic benefits in individuals with <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> mechanics.</p>
<table>
  <tbody>
    <tr>
      <td>
        <h4><strong>Self-mobilization</strong></h4>
        <p>Self-administered techniques are always encouraged in the pursuit of optimizing outcomes and patient independence; however, studies on self-administered mobilizations are rare. An RCT by Cruz-Diaz et al. compared self-management of CAI with a combination of ankle self-mobilization and CrossFit, CrossFit alone, or no intervention, demonstrating that the combination group had the largest improvements in dorsiflexion ROM, dynamic <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> control, and self-reported <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> (65). This study suggests that the addition of self-administered ankle mobilization may have a positive effect on ROM and function when added to a warm-up prior to resistance training.</p>
      </td>
    </tr>
  </tbody>
</table>

Research Corner: Tibiofibular Joint

<h3>Biomechanics</h3>
<p>Several studies correlate ankle dysfunction with changes in fibular position and/or altered <a id="arthrokinematics" data-tip="1859" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematics</a> of the tibiofibular joint. A cadaveric study by Scott et al. demonstrated that loading the lower extremity resulted in significant <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> motion of the <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> tibiofibular joint (66). Further, Koh et al. investigated tibiofibular joint motion during active dorsiflexion, demonstrating a correlation between a lack of tibiofibular <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> and limited dorsiflexion ROM in healthy individuals (67). Kavanagh, J. demonstrated that individuals with a history of <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> ankle sprain exhibited larger amounts of <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> motion of the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint during inversion (68). Hubbard et al. used <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> fluoroscopic imaging to demonstrate that subjects with CAI exhibited a fibula positioned significantly more <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> in relation to the tibia (69). In another study by Hubbard et al., sub-acute <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain was correlated with an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> position of the fibula when compared to the unaffected side, and further, a correlation was demonstrated between the most swollen ankles and the most anteriorly positioned fibula (70). A similar study by Fukuhara et al. demonstrated the same correlations between <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, swelling, and an anteriorly positioned fibula (71). In summary, studies have demonstrated a correlation between lower extremity loading, dorsiflexion, and motion of the tibiofibular joints. Further, studies have also demonstrated a correlation between ankle dysfunction, swelling, and altered tibiofibular joint motion/position.</p>

<h3>Efficacy</h3>
<p>Research has demonstrated the potential efficacy of tibiofibular joint mobilization for the treatment of ankle dysfunction. A cadaveric study by Fujii et al. demonstrated the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> of intending to use AP <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilizations to increase dorsiflexion, by performing machine cyclic loading on the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint on 7 cadaver legs, resulting in a mean increase of dorsiflexion of 7.2&#xB0; (72). Interestingly, an RCT by Beazell et al. demonstrated that treating CAI with 3 weeks of either <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> or <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilizations alone, did not increase dorsiflexion when compared to controls (73). An RCT by Douillet et al. demonstrated that a combination of <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilization and taping resulted in significant improvements in pain, dorsiflexion, and stiffness following acute ankle sprain (74). Two studies have investigated the combination of conventional therapy with tibiofibular joint mobilization. Nisha et al. compared conventional therapy with and without <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilization for the treatment of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> ankle sprain, demonstrating both groups exhibited improvements in pain, function and dorsiflexion; however, the mobilization group exhibited the largest improvements in dorsiflexion (75). And, Pradesh et al. demonstrated the for the treatment of knee osteoarthritis, the addition of tibiofibular joint mobilization to conventional therapy significantly improved ROM and function (76). These studies demonstrate that the intention of tibiofibular joint mobilization has validity; however, this intervention should likely be used as an adjunct modality for the treatment of ankle dysfunction.</p>
<h3>Systemic Effects</h3>
<p>A study by Grindstaff et al. demonstrated that immediately following and 30 minutes post-intervention both <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> and <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> tibiofibular joint mobilizations resulted in a decrease in fibularis longus H-wave/M-wave (H/M) ratio, and <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint mobilization also increased soleus H/M ratio (77). Unlike studies investigating the neuromuscular effects of ankle mobilization, this study suggests that tibiofibular joint mobilization has an effect on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, inhibiting the fibularis muscles and facilitating the soleus.</p>
<h3>Performance</h3>
<p>A study by Goto et al. investigated the effect of tibiofibular joint mobilization on performance, demonstrating mobilization resulted in an increase in dorsiflexion and standing broad jump performance in healthy individuals (78). Further study is needed, but these findings suggest integrating mobilizations into movement preparation routines is worth consideration.</p>

<p><iframe src="https://player.vimeo.com/video/226076154" frameborder="0" allowfullscreen="allowfullscreen"></iframe></p>
<h4><strong>Set-Up</strong></h4>
<ol>
  <li>The patient should be <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a>, with heels extending beyond the end of the table, and the practitioner standing at the end of the table on the patient&apos;s affected side.</li>
  <li>The table should be at a height that allows the practitioner to have elbows extended when the practitioner&apos;s chest is over the patient&apos;s feet.</li>
</ol>
<h4><strong>Anterior to Posterior Mobilization (talus on tibia)</strong></h4>
<ol>
  <li>If the practitioner is less familiar with ankle palpation:
    <ol>
      <li>It may be helpful to be looking at a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> or diagram of the talus as you attempt to identify the talar neck.</li>
      <li>Use the thumb and index finger of the hand closest to the patient&apos;s head to identify the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> malleoli (large bumps on either side of the ankle)</li>
      <li>Allow the thumb and index finger to <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a> past the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> portion of the malleoli until the webspace of your hand is over the angle (line where the ankle bends) of the ankle. Usually, this places the web space over the neck of the talus.</li>
      <li>If more <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> is required, identify the relatively sharp bump of the navicular tubercle by sliding your index finger along the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> foot, about a centimeter <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> and <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> to the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> border of the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> malleolus.</li>
      <li>Depressing the fingers into the soft tissue between the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> portion of the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> malleolus and the navicular tubercle, attempt to identify the <a id="concave" data-tip="1281" target="_blank" href="/glossary-term/concave" class="glossary">concave</a> surface of the talar neck.</li>
      <li>The neck of the talus is where the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> force will be applied during this mobilization.</li>
    </ol>
  </li>
  <li>Flatten the hand so the palmar surface of the web space is over the talar neck. The larger surface area will reduce point pressure and decrease discomfort for the patient, and the hand position is more comfortable for the practitioner.
    <ul>
      <li>Note, as soft as you may think the web space of your hand is, the small surface area of the side of the webspace can feel very sharp to the patient.</li>
    </ul>
  </li>
  <li>The other hand may stabilize the foot by wrapping your fingers over the patient&apos;s heel with the <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> surface in the palm of your hand and then shifting your forearm under the plantar surface of the foot. This hand position feels awkward initially, but it gives the practitioner excellent control over the patient&apos;s foot and ankle.</li>
  <li>The patient&apos;s tibia should be stabilized by the table; ensure that the patient only has enough of their tibia hanging off the end of the table for you to achieve a comfortable hand position. If the patient has too much of their foot hanging over the end of the table you will not have good control over their tibia.</li>
  <li>Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips so that the chest is over the affected ankle.</li>
  <li>Force is generated by leaning forward and using body weight.</li>
</ol>
<h4><strong>Mobilization:</strong></h4>
<ol>
  <li>Once you are comfortable with the hand position, start with small <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> oscillations to identify articular motion and any exquisite tenderness.</li>
  <li>When satisfied with the feel of the technique, identify the amount of pressure needed to reach the first resistance barrier, just prior to articular motion. Then use more pressure to identify the end of articular motion. The point at which any further pressure fails to increase articular motion, is the end of articular range, no additional pressure is required.</li>
  <li>Identify the mid-point between the first resistance barrier and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> end-range; approximately 50% resistance.
    <ul>
      <li>Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
        <ul>
          <li>Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.</li>
        </ul>
      </li>
      <li>Grade IV - Small oscillations at 50% resistance.</li>
    </ul>
  </li>
  <li>Oscillate at 1 - 2 pulses per second.</li>
  <li>Continue oscillating until change in tissue resistance/joint stiffness is felt.</li>
</ol>

Ankle (Tibiotalor) Joint Mobilization

<h3><iframe src="https://player.vimeo.com/video/228155015" frameborder="0" allowfullscreen="allowfullscreen"></iframe></h3>
<h4><strong>Set-Up</strong></h4>
<ol>
  <li>The patient should be <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a>, with heels extending just beyond the end of the table, and the practitioner standing at the end of the table on the patient&apos;s affected side.</li>
  <li>The table should be at a height that allows the practitioner to have elbows extended when the practitioner&apos;s chest is over the patient&apos;s feet.</li>
</ol>
<p><strong>Anterior to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Mobilization (Fibula on Tibia)</strong></p>
<ol>
  <li>The practitioner can use their thigh to stabilize the foot and control dorsiflexion and inversion.</li>
  <li>It may be helpful to look at a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> or diagram of the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> tibiofibular joint when learning this mobilization technique. Take a moment to feel the details of the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> fibula (<a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> malleolus), identify the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> side of the fibula, the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> fibular groove, the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> end of the fibula, and the tibiofibular joint line at the anteromedial aspect of the fibula.</li>
  <li>Assessing <a id="arthrokinematics" data-tip="1861" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">joint play</a> is easiest using your fingers, pulling up on the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> side of the fibula with the fingertips, and pushing down on the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> surface of the fibula with the thumb; however, this hand position is not recommended for the mobilization technique.</li>
  <li>To perform the mobilization technique use the hand on the tibia side of the ankle to stabilize the tibia by pressing the tibia into the table using the soft thenar portion of the hand.</li>
  <li>The other hand will be used to mobilize the fibula. Start by using the thenar eminence to gently pull some tissue from the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the fibula over the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> portion of the fibula, creating some tissue slack so that skin and cutaneous nerves are not stretched when pressure is applied.</li>
  <li>Gain purchase on the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> surface of the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> malleolus by pressing the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> malleolus into the thenar eminence.</li>
  <li>Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips so that the chest is over the affected ankle.</li>
  <li>Force is generated by leaning forward and using body weight.</li>
</ol>
<h4><strong>Mobilization:</strong></h4>
<ol>
  <li>Once you are comfortable with the hand position, start with small <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> oscillations to identify articular motion and any exquisite tenderness.
    <ul>
      <li>Be especially aware of any burning, tingling, or &quot;electric&quot; type pain, it is easy to accidentally stretch small cutaneous nerves in this area.</li>
    </ul>
  </li>
  <li>When satisfied with the feel of the technique, identify the amount of pressure needed to reach the first resistance barrier, just prior to articular motion. Then use more pressure to identify the end of articular motion. The point at which any further pressure fails to increase articular motion is the end of articular range, no additional pressure is required.</li>
  <li>Identify the mid-point between the first resistance barrier and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> end-range; approximately 50% resistance.
    <ul>
      <li>Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
        <ul>
          <li>Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.</li>
        </ul>
      </li>
      <li>Grade IV - Small oscillations at 50% resistance.</li>
    </ul>
  </li>
  <li>Oscillate at 1 - 2 pulses per second.</li>
  <li>Continue oscillating until change in tissue resistance/joint stiffness is felt.</li>
</ol>

Distal Tibiofibular Joint Mobilization

<h3><iframe src="https://player.vimeo.com/video/228157692" frameborder="0" allowfullscreen="allowfullscreen"></iframe></h3>
<h4><strong>Set-Up</strong></h4>
<ol>
  <li>The patient should be side-lying, with knees bent, and the practitioner standing on the side of the table behind the patient&apos;s knee.</li>
  <li>The table should be high, at a height that allows the practitioner to have elbows extended and press nearly horizontal during the technique.</li>
</ol>
<h4><strong>Posterior to Anterior Mobilization (Fibula on Tibia)</strong></h4>
<ol>
  <li>It may be helpful to look at a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> or diagram of the <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> tibiofibular joint when learning this mobilization technique.</li>
  <li>Take a moment to palpate around the fibular head:
    <ol>
      <li>Start by identifying the patella.</li>
      <li>Then move distally to identify the patellar ligament.</li>
      <li>Fall off the patellar ligament laterally into the soft fat pad that lies deep and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> to the ligament.</li>
      <li>Pressing the fingers into the soft tissue just <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> to the patellar ligament, and sliding the fingers proximally/superiorly, you should feel a bony ridge. This ridge is the tibial plateau.</li>
      <li>Trace the tibial plateau to the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the knee and you should abut the rounded end of the fibular head.</li>
      <li>Take a moment to palpate around the fibular head, identifying the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a>, <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a>, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a>, and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> surfaces. (The LCL and biceps femoris tendon may also be palpated investing into the <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> aspects of the fibular head).</li>
    </ol>
  </li>
  <li>Place as much of the surface area of your thumb against the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> aspect of the patient&apos;s fibular head. You may even be able to place the fibular head in the IP of your thumb and somewhat &quot;wrap&quot; your thumb around the fibular head. Use this thumb as a &quot;dummy thumb&quot;, applying pressure with the other hand by placing the palm of the other hand over the palpating the thumb.
    <ul>
      <li>The peroneal <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> and a <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> soleus <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> lie behind the fibular head; be careful to not apply direct pressure to these structures. Of course if the patient feels burning, tingling, electric or numbing pain, move your thumb slightly until you can find a place to apply pressure that does not create these sensations. Further, the more surface area you can use the less likely you are to create discomfort for the patient.</li>
    </ul>
  </li>
  <li>Use the index finger of one hand to identify the joint line in-between the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> surfaces of the fibular head and the tibia.</li>
  <li>Use all of your other fingers to stabilize the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> surface of the tibia.</li>
  <li>To <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> for motion, oscillate the fibular head. This joint may become <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a> or <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a>. If there is a significant amount of motion, or the joint moves with ease, this is not a recommended technique.</li>
  <li>Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips, ready to lean into your palpation.</li>
  <li>Force is generated by leaning forward, or rocking and using your body weight.</li>
</ol>
<h4><strong>Mobilization:</strong></h4>
<ol>
  <li>Once you are comfortable with the hand position, start with small <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> oscillations to identify articular motion and identify any exquisite tenderness.
    <ul>
      <li>Be especially aware of any burning, tingling, or &quot;electric&quot; type pain, it is easy to accidentally stretch small nerves in the area.</li>
    </ul>
  </li>
  <li>When satisfied with the feel of the technique, identify the amount of pressure needed to reach the first resistance barrier, just prior to articular motion. Then use more pressure to identify the end of articular motion. The point at which any further pressure fails to increase articular motion is the end of articular range, no additional pressure is required.</li>
  <li>Identify the mid-point between the first resistance barrier and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> end-range; approximately 50% resistance.
    <ul>
      <li>Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
        <ul>
          <li>Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.</li>
        </ul>
      </li>
      <li>Grade IV - Small oscillations at 50% resistance.</li>
    </ul>
  </li>
  <li>Oscillate at 1 - 2 pulses per second.</li>
  <li>Continue oscillating until change in tissue resistance/joint stiffness is felt.</li>
</ol>

Proximal Tibiofibular Joint Mobilization

Bibliography

<p>© 2020 Brent Brookbush</p>
<p>Questions, comments, and criticisms are welcomed and encouraged</p>

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

<strong>Accuracy</strong> - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

<strong>Adenosine triphosphatase (ATPase):</strong> is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

<b>Adenosine triphosphate (ATP): </b>The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

<strong>Algometry</strong> - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter  wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

<span class="_Tgc"><b>All-or-none</b> <b>principle</b> - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.</span>

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the <em>anterior</em> aspect of the head

<strong>Appendicular Skeleton</strong> - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

<strong>Arthrokinematic Motion</strong> - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

<strong>Assessment</strong><em> -</em> is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li><strong>"Clear" the Patient/Client for Intervention</strong> - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A <em>Calf Squeeze (Thompson) Test</em> is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li><strong>Highlight Contraindications - </strong>Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li><strong>Refine Exercise/Intervention Selection</strong>: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to <em>Refine Exercise/Intervention Selection</em>, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and <em>Clearance</em> to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of <em>Contraindicated Activities</em> from the physician. - <em>"When in doubt, refer out!"</em>

<strong>Axial Skeleton</strong> - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin <span class="foreign">axis</span> "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

<strong>Balance</strong> - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

<strong>Base of support (BoS)</strong> - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

<strong>Case-control Study</strong> - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. <i>American journal of epidemiology</i>, <i>134</i>(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed<em> caudally</em>.

<strong>Center of mass (CoM)</strong> - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

<b>Center of gravity (CoG)</b> - point where <b>gravity</b> appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed <em>cephalad</em>.

<strong>Cohort Study</strong> - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

<strong>Comparable Sign:</strong> A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

<strong>Concave (Concavity)</strong> - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

<strong>Concordant Sign</strong> - The patient's specific pain, symptom or complaint.<span style="color: #ff0000;"> </span>
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

<strong>Conductivity</strong>: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

<strong>Contractility: </strong>The ability to shorten (1).
<ul>
 	<li><strong>Contractility</strong>: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

<strong>Convex (Convexity)</strong> - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

<strong>Correlational Research</strong> - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. <em>J. Phys. Ther. Sci. </em>26: 961-964</a></li>
</ol>

<strong>Counter-nutation</strong> - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

<strong>Crossover (Study) Design</strong> - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. <em>Journal of Human Kinetics, 58, 197-206.</em> </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) <em>Journal of Medical Science</em> 5(1). 52-54</a></li>
</ol>

<strong>Cytokine</strong> - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength. <em> Journal of Manual &amp; Manipulative Therapy</em>. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the <em>distal</em> end of the leg.

An arthrokinematic motion - a <span class="_Tgc">force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.</span>

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the <em>dorsal</em> surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an<span class="_Tgc"> alteration of normal kinematics.</span>

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

<strong>Elasticity</strong>: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). <i>Anatomy &amp; physiology</i>. New York (NY): WCB/McGraw-Hill.</li>
</ol>

<strong>Equilibrium</strong> - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0"><strong>Evidence-based medicine (practice)</strong> is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. <i>Bmj</i>, <i>312</i>(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

<strong>Excitability:</strong> The ability of a cell to <span class="hvr">change</span> in <span class="hvr">membrane</span> <span class="hvr">conductance</span> as a <span class="hvr">response</span> to <span class="hvr">stimulation.
</span>
<ul>
 	<li><span class="hvr">For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</span></li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

<strong>Excitation threshold:</strong> The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

<strong>Exercise Progression</strong> - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

<strong>Exercise regression</strong> - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

<strong>Experimental Research</strong> - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. <em>Journal of Strength and Conditioning Research, 27</em>(11), 2997-3000.</a></li>
</ol>
&nbsp;

<strong>Extensibility</strong>: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

<strong>False Negative </strong>- the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

<strong>False Positive </strong>- the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

<strong>Fibromyalgia</strong> - A loosely defined diagnosis that is associated with a combination of widespread pain <i>in combination with</i> 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. <i>Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition</i>.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. <i>Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology</i>, <i>33</i>(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. <i>The Clinical journal of pain</i>, <i>27</i>(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. <i>PAIN®</i>, <i>145</i>(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. <i>Spine</i>, <i>20</i>(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. <i>Spine</i>, <i>20</i>(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

<strong>H-Band</strong> - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (<em>biological holism</em>) - (from Greek <i>holos</i> "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. <em class="EmphasisTypeItalic ">Holism and evolution</em>. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

<strong>Hormone: </strong>Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. <i>Scandinavian journal of clinical and laboratory investigation</i>, <i>60</i>(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

<strong>Hyperplasia</strong> is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

<strong>Muscular hypertrophy</strong> is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

<strong>I-Band</strong> - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. <em>International Journal of Health and Rehabilitation Sciences</em>. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is <em>inferior</em> to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

<strong>Intermuscular Coordination</strong> - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

<strong>Example: Role of Muscles during Hip Extension</strong>
<ul>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:</strong>  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: </strong><a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An <strong>isoform</strong>, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.<sup id="cite_ref-2" class="reference"></sup>
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior <em>kinetic chain</em>, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

<strong>Latent Trigger Point</strong> - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, <em>Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition</em>,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is <em>lateral</em> to the pectoralis major

<strong>Length/Tension Relationship</strong> - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. <i>The Journal of physiology</i>, <i>184</i>(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. <i>The Journal of Physiology</i>, <i>183</i>(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. <i>Journal of neurophysiology</i>, <i>71</i>(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). <i>Skeletal muscle structure, function, and plasticity</i>. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

<span class="_Tgc"><strong>Levels of Evidence</strong> - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.
</span>

The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. <i>Western Journal of Medicine</i>, <i>170</i>(6), 348.</li>
</ol>

<strong>Likelihood Ratios</strong> - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li><strong>Positive Likelihood Ratio (LR+)</strong> - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li><strong>Negative Likelihood Ratio (LR-)</strong> - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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