Ankle (Talus) Manual Joint Mobilization - Anterior to Posterior

Set-Up

1. The patient should be supine, with heels extending beyond the end of the table, and the practitioner standing at the end of the table on the patient's affected side.
2. The table should be at a height that allows the practitioner to have elbows extended when the practitioner's chest is over the patient's feet.

Anterior to Posterior Mobilization (talus on tibia)

1. If the practitioner is less familiar with ankle palpation:
   1. It may be helpful to be looking at a model or diagram of the talus as you attempt to identify the talar neck.
   2. Use the thumb and index finger of the hand closest to the patient's head to identify the medial and lateral malleoli (large bumps on either side of the ankle)
   3. Allow the thumb and index finger to slide past the inferior 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.
   4. If more accuracy is required, identify the relatively sharp bump of the navicular tubercle by sliding your index finger along the medial foot, about a centimeter anterior and inferior to the inferior border of the medial malleolus.
   5. Depressing the fingers into the soft tissue between the inferior portion of the medial malleolus and the navicular tubercle, attempt to identify the concave surface of the talar neck.
   6. The neck of the talus is where the anterior to posterior force will be applied during this mobilization.
2. 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.
   • 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.
3. The other hand may stabilize the foot by wrapping your fingers over the patient's heel with the medial 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's foot and ankle.
4. The patient'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.
5. Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips so that the chest is over the affected ankle.
6. Force is generated by leaning forward and using body weight.

Mobilization:

1. Once you are comfortable with the hand position, start with small test oscillations to identify articular motion and any exquisite tenderness.
2. 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.
3. Identify the mid-point between the first resistance barrier and arthrokinematic end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
     • Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.
   • Grade IV - Small oscillations at 50% resistance.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until change in tissue resistance/joint stiffness is felt.