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Ankle (Talus) Manual Joint Mobilization - Anterior to Posterior
Ankle (Talus) Manual Joint Mobilization Anterior to Posterior is a therapeutic technique used to improve tissue mobility, increase range of motion, and reduce pain in the ankle joint. During this procedure the therapist uses their hands to apply gliding pressure anteriorly at a right angle, then in a posterior direction. This gentle, rhythmic manipulation helps to increase the mobility of the talus and reduce any restrictions in the joint or surrounding soft tissues. It is commonly used to treat
Transcript
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This is Brent of the Brookbush Institute, and in this
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video we're going to go over a joint
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based manual therapy technique. If you're watching this video I'm assuming you're
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watching it for educational purposes, and that you are a licensed professional
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with joint based techniques within your scope. That means osteopath's, chiropractors,
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physical therapists,, you're probably all in the clear. Physical therapy assistants,
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athletic trainers, massage therapists, you need to check with your governing body
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in your state or region to see whether this is within your scope of practice.
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Personal trainers this is definitely not within your scope of practice, of course
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all professions could use this video for purely educational purposes to help with
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learning biomechanics, anatomy and of course palpation. In this video we're
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going to do anterior to posterior talus mobilization that's talus on
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tibia. I'm going to have my friend Melissa come out, she's going to help me
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demonstrate. Now in this video we're going to do this mobilization likely
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with the idea that we're going to try to reduce arthrokinematic stiffness
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to improve dorsiflexion. Do you guys remember your convex on concave
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rule, that's glide opposite role, that's a pretty good foundation for the ankle.
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It doesn't always work out for every joint that the convex on concave rules
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work, but for the ankle it works out pretty good. We also have a lot of
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research to kind of back up that we get stiffness from anterior to posterior
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with the talus, the other motions not so much. You know some of like chronic
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ankle instability you'll even see where you'll be hypermobile in all other
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directions, but for some reason anterior to posterior motion still stiff. So now
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that we kind of have that set up, how am I going to go about setting up this
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mobilization. Well you're going to need to know your Anatomy, you should probably
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know what precautions you should have, you should be aware of, rather. You need
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to know what your hand position should be, and then of course we want to kind of
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talk about patient and your own set up body position wise for good technique.
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I'm going to have Melissa scoot down a little bit this way, she's going to throw
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this leg off the table right. Now I'm just having to throw that leg off the
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table, so you guys can see her ankle as far as palpation goes, just a real
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quick reminder guys the more palpation skills you have
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the easier getting your hand placement right is going to be. So things like
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knowing where your navicular tubercle is, and knowing how to fall off your
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navicular tubercle to the neck of your talus, or knowing where your
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sustenaculum tali is, or how to find your lateral and medial malleolus or your
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cuboid. All of that stuff helps for now my hands are down, where is what I'm
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looking for relative to where my hands are. Now the easiest way to find the neck
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of your talus is actually find the bottom of your medial malleolus, find the
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bottom of your lateral malleolus. Draw a line between your fingers an
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imaginary line, and put the web-space down right over the top of that line. Chances
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are your web-space is now over the neck of your talus which is where we're
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going to apply a force. Now when you're using your web space you would be
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surprised to find how the web space here, which I know you guys think of this
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loose skin, can feel like a chisel digging in the bone. You have to be
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careful when you're doing manual techniques. What you think might be soft
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doesn't feel soft, and I think the reason being is if you guys get real taut with
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the web-space and then come down straight this way, you're actually your
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your surface area there isn't very big all right. What I would suggest is
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keep your hand relaxed, you can kind of even fold it around the ankle, and then
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rather than use this part of your web-space I would flop your hand down so
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you're using this part of your web-space, that will feel a lot softer and you'll
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still be able to get more than enough force to drive this bone posteriorly.
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Now with this hand we're going to need to control the ankle, because although
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the tibia is supported by the table, we need to be able to control this so that
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we can get the direction of force that we're looking for. Now what I like to use
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is the same setup I use for the manual calf stretch which we showed in a
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previous video. I'm going to wrap my hand around the calcaneus and then bring my
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forearm underneath the ball of her foot just like so. Now stay away from doing
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this, I see a lot of people do this getting lazy because for some reason
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they can't quite get this figured out, and I know it's kind of a funky little
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hand position that you get there, but this is going to rip your fingers apart;
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and you're going to have to really try to muscle dorsiflexion. Going this way I
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can lock out my elbow and now I can control dorsiflexion just by leaning
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right, by swaying with my legs I can actually control eversion and inversion
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really well too. I mean I have like a good grip on her calcaneus. I had good
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control of her foot so that's this hand position here. We talked about this hand
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position here being right over the neck of the the talus, and I'm going to go
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ahead and pull her up to her first for the resistance barrier. We do have some
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research that's starting to suggest that maybe mobilization should be done at end
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range right, or end of available range providing it's pain-free.
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So anterior to posterior mobilization down here may not be as effective as an
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anterior to posterior mobilization here. So I'll pull her up to dorsiflexion.
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Now what else do I got to think about, all right patient's body position should
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look comfy right. So she's laying down, I kind of already put her in the right
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body position. Make sure guys that you have the calcaneus hanging off the table
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right, because if you put the calcaneus on the table your fingers are
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essentially going to get smashed. Your body position is important on this. I
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think you'll notice that I have to bend over just a little bit to get in good
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position here, that's actually purposeful because I'm not trying to pull up I'm
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trying to push down. So once I start doing my oscillatory mobilizations I
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want to be able to use my body weight to do that, and not be like trying to like
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manhandle an anterior to posterior mobilization. Although maybe I'm big
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enough and strong enough to pull that off, your ankle is a fairly strong stiff
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joint with some really big muscles that cross it, at least some really strong muscles
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that cross it. And I know some of you guys aren't necessarily as big a human
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being as I am, and some of you guys have to treat really really big people, you
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know you've got to use your body mechanics to your advantage. So I'm
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bending over just a little bit because I want my chest right over the top of my
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arms, so that now I can just do this. You guys see how that's nice and comfortable
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for me. If I need more dorsiflexion I can just sway, reposition my feet and I can
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just push down using my body weight. This is really easy for me. I feel like I
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could do this for at least a few minutes and as many times a day as I needed to.
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Now let's talk a little bit about protocols around mobilizations. I don't
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really want to set up a debate on which protocol is the best. I know some of you
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guys use more of like a static hold technique and I think that can be very
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effective. I've seen seven holds of seven seconds. I've seen ten five-second holds.
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I've seen all sorts of oscillatory techniques. I happen to be a Maitland
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certified therapist, so you know I use one to two oscillations per second doing
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those grade three and four mobilizations for increasing mobility. I don't really
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care what protocol you use as long as it's effective, as long as your
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reassessment is showing it's effective. I would say the biggest mistake I see
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students make is maybe they don't follow through with the whole protocol. So
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you're doing one to two oscillations per second, and you should be doing them for
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30 seconds. What I see is most people giving up after 10 or 15 seconds. It's
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not that they didn't follow the protocol up to that point, they just don't stick
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with it long enough. With that being said I think all of the techniques have
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something in common, which is they're very aware of resistance barriers. So
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when I get into this technique it's important that I start trying to feel
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the joint play, the motion of the talus, even if I have to move
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my hands around like you just saw me do. Alright okay, all right am I feeling
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what I what I think I'm feeling, okay good good, got it.
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Alright so there's my first resistance barrier is right there, and then if I
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push down I get end right there, and then most mobilization techniques occur at
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around the 50% range, somewhere between 50 percent resistance.
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Alright so halfway between first resistance barrier and end, so 50%, some
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go all the way to like way down towards the end range. Although that's a a bit
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more of an aggressive mobilization, just kind of be aware of what you're doing. I
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think the thing to take away from all of these protocols is be aware of your
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resistance barrier, be aware that most of your mobilizations are not going to
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happen at the absolute extreme of arthrokinematic motion. They're going to happen
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somewhere between your first resistance barrier and the end. And then of course
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guys whatever protocol you use -follow through. Make sure you do all of the
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protocols. So if it's seven second holds, then make sure you do all seven
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second holds right. If you're going to do oscillatory techniques, and it's important
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that I do oscillatory techniques long enough, that I start feeling a decrease
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in passive resistance, even if that takes 60 seconds.
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And of course after I'm done with this technique I'm going to reassess. As I've
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said so many times before in so many videos, assess address reassess. Just
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because I think I feel passive accessory stiffness,
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just because I think this might be good technique for Melissa, doesn't mean it
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actually is. If my goal was to increase dorsiflexion, or for example she had an
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excessive forward lean on her overhead squat, and I thought that increased
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dorsiflexion would help; and I get her up do the overhead squat it doesn't look
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better, do goniometry she hasn't gained any dorsiflexion, I need to start
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thinking about a different technique. Stay tuned for the close-up recap. For a
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close-up recap you guys can see here if I find the bottom of the medial
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malleolus, the bottom of the lateral malleolus I end up with a line between
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those two points. That puts me right over the neck of the talus.
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It's just like that, just right there and right in that angle of the ankle. I can
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actually if I if I just take one hand even, and kind of wrap around the bottom
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of the foot, I can even get a little bit of joint mobility there, I can steal the
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joint play. So if I put my web-space down over like this
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I grab the bottom of her calcaneus, put my forearm around the bottom of her foot.
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Now I'm all set up. My body is over the top of my hand so I'm ready to apply
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that anterior to posterior force. I probably should think real quick about
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my precautions when I first kind of start into this technique. Do I get any
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grunts/groans or extreme facial expressions, and so did I did I pinch on
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that peroneal nerve that we know is over here, and sometimes we'll will over
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stretch that nerve real quick and get at that shearing burning pain. If you guys
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do that just move your hands a little bit.
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Remember that nerves aren't very wide, you should be able to get other way
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pretty easy. The other thing we want to make sure is if I push down are they
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relaxed, because Melissa can you dorsiflex, I don't know if you guys, so right
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there guys, that's the tibialis anterior. And then if she started guarding on me
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with this jacked tibialis anterior of hers, this tendon is going to kick me
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right out of the neck of the talus. It's going to be real hard to get an
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anterior to posterior mobilization. I'm far more likely to just be molding her
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tibialis anterior tendon and I don't really know what the benefit of that
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would be. The other precaution we might think about is the ankle is one of
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those joints that can get locked, but still be hypermobile. Every once in a while
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you'll run into somebody who you know that they feel stiff at first, and if you
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get real aggressive with them you'll get a little pop or a click; they'll move a
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whole lot on you and you can pinch that capsule and that'll give you some
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swelling of the ankle, they would they will not be happy with you at all. So
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once you get your hand set up guys I would just just kind of start in nice
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and gentle, give a couple like tests pushes before you apply your full force
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of pressure. I'm not getting any kickback from Melissa here, so now I'm going to
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find my first resistance barrier. I'm going to go ahead and push down and find
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the end range there. Now this is the end range of arthrokinematic motion, not
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end range of dorsiflexion. So that's as far as I can push your talus posteriorly
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and then I'm just going to do my oscillatory techniques here, and I'm kind
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of going from just before 50% right now, to just after 50% resistance. I would say
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total I'm maybe moving a half a centimeter, and this would be like a
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grade three mobilization and I'm going to go ahead and hold this for 30 to 60
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seconds, or until I feel a decrease in resistance for her passive accessory
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motion. And then I'd probably pull out a ganiometer and check her dorsiflexion
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again, since I know dorsiflexion is a fairly reliable test. So once again guys
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web-space down over that imaginary line between the bottom of
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medial and lateral malleolus. I'm using this part of my web-space not this part
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of my web-space, because this is going to feel a lot softer in here than this is
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going to feel. And then of course I'm using this hand by hooking the calcaneus,
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and then bringing my forearm over the base of her or the ball of her foot, so that I
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can control eversion inversion, bring her to our first resistance barrier in
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dorsiflexion, and I'm all set up. So there you have it, assess address reassess. Make
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sure that every time you choose a joint based manual therapy technique it is
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based on an assessment, and that you return to that assessment after you've
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finished the intervention, to see if it was effective for the individual, the
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patient or client that you have in front of you. Ensure that you continue to learn
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your Anatomy because your Anatomy is going to help you with your hand
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placement, with understanding what a joint can do. With understanding what you
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may gain from this particular technique, and of course practice. You have to
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practice these techniques, hopefully not for the first time on a patient or
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client who just walked in the door. If you can find a more senior instructor or
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mentor, to give you some really good hands-on instruction use your peers for
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some good feedback, and of course always look for live education to help with
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your manual therapy techniques. I know these videos make education very
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convenient,, but there is no substitute for learning manual therapy in a live
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setting. I look forward to talking to you guys again soon.
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