Would you like to view this video?

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

00:00:0500:00:07
This is Brent of the Brookbush Institute, and in this
00:00:0500:00:07
video we're going to go over a joint
00:00:0700:00:11
based manual therapy technique. If you're watching this video I'm assuming you're
00:00:1100:00:14
watching it for educational purposes, and that you are a licensed professional
00:00:1400:00:20
with joint based techniques within your scope. That means osteopath's, chiropractors,
00:00:2000:00:24
physical therapists,, you're probably all in the clear. Physical therapy assistants,
00:00:2400:00:28
athletic trainers, massage therapists, you need to check with your governing body
00:00:2800:00:32
in your state or region to see whether this is within your scope of practice.
00:00:3200:00:36
Personal trainers this is definitely not within your scope of practice, of course
00:00:3600:00:41
all professions could use this video for purely educational purposes to help with
00:00:4100:00:46
learning biomechanics, anatomy and of course palpation. In this video we're
00:00:4600:00:50
going to do anterior to posterior talus mobilization that's talus on
00:00:5000:00:53
tibia. I'm going to have my friend Melissa come out, she's going to help me
00:00:5300:00:58
demonstrate. Now in this video we're going to do this mobilization likely
00:00:5800:01:04
with the idea that we're going to try to reduce arthrokinematic stiffness
00:01:0400:01:09
to improve dorsiflexion. Do you guys remember your convex on concave
00:01:0900:01:15
rule, that's glide opposite role, that's a pretty good foundation for the ankle.
00:01:1500:01:19
It doesn't always work out for every joint that the convex on concave rules
00:01:1900:01:22
work, but for the ankle it works out pretty good. We also have a lot of
00:01:2200:01:27
research to kind of back up that we get stiffness from anterior to posterior
00:01:2700:01:32
with the talus, the other motions not so much. You know some of like chronic
00:01:3200:01:36
ankle instability you'll even see where you'll be hypermobile in all other
00:01:3600:01:43
directions, but for some reason anterior to posterior motion still stiff. So now
00:01:4300:01:47
that we kind of have that set up, how am I going to go about setting up this
00:01:4700:01:49
mobilization. Well you're going to need to know your Anatomy, you should probably
00:01:4900:01:54
know what precautions you should have, you should be aware of, rather. You need
00:01:5400:01:58
to know what your hand position should be, and then of course we want to kind of
00:01:5800:02:02
talk about patient and your own set up body position wise for good technique.
00:02:0200:02:06
I'm going to have Melissa scoot down a little bit this way, she's going to throw
00:02:0600:02:10
this leg off the table right. Now I'm just having to throw that leg off the
00:02:1000:02:16
table, so you guys can see her ankle as far as palpation goes, just a real
00:02:1600:02:20
quick reminder guys the more palpation skills you have
00:02:2000:02:27
the easier getting your hand placement right is going to be. So things like
00:02:2700:02:30
knowing where your navicular tubercle is, and knowing how to fall off your
00:02:3000:02:33
navicular tubercle to the neck of your talus, or knowing where your
00:02:3300:02:38
sustenaculum tali is, or how to find your lateral and medial malleolus or your
00:02:3800:02:47
cuboid. All of that stuff helps for now my hands are down, where is what I'm
00:02:4700:02:52
looking for relative to where my hands are. Now the easiest way to find the neck
00:02:5200:02:56
of your talus is actually find the bottom of your medial malleolus, find the
00:02:5600:03:02
bottom of your lateral malleolus. Draw a line between your fingers an
00:03:0200:03:09
imaginary line, and put the web-space down right over the top of that line. Chances
00:03:0900:03:14
are your web-space is now over the neck of your talus which is where we're
00:03:1400:03:18
going to apply a force. Now when you're using your web space you would be
00:03:1800:03:23
surprised to find how the web space here, which I know you guys think of this
00:03:2300:03:29
loose skin, can feel like a chisel digging in the bone. You have to be
00:03:2900:03:32
careful when you're doing manual techniques. What you think might be soft
00:03:3200:03:38
doesn't feel soft, and I think the reason being is if you guys get real taut with
00:03:3800:03:42
the web-space and then come down straight this way, you're actually your
00:03:4200:03:47
your surface area there isn't very big all right. What I would suggest is
00:03:4700:03:52
keep your hand relaxed, you can kind of even fold it around the ankle, and then
00:03:5200:03:56
rather than use this part of your web-space I would flop your hand down so
00:03:5600:04:00
you're using this part of your web-space, that will feel a lot softer and you'll
00:04:0000:04:05
still be able to get more than enough force to drive this bone posteriorly.
00:04:0500:04:12
Now with this hand we're going to need to control the ankle, because although
00:04:1200:04:18
the tibia is supported by the table, we need to be able to control this so that
00:04:1800:04:23
we can get the direction of force that we're looking for. Now what I like to use
00:04:2300:04:27
is the same setup I use for the manual calf stretch which we showed in a
00:04:2700:04:34
previous video. I'm going to wrap my hand around the calcaneus and then bring my
00:04:3400:04:40
forearm underneath the ball of her foot just like so. Now stay away from doing
00:04:4000:04:45
this, I see a lot of people do this getting lazy because for some reason
00:04:4500:04:48
they can't quite get this figured out, and I know it's kind of a funky little
00:04:4800:04:52
hand position that you get there, but this is going to rip your fingers apart;
00:04:5200:04:57
and you're going to have to really try to muscle dorsiflexion. Going this way I
00:04:5700:05:02
can lock out my elbow and now I can control dorsiflexion just by leaning
00:05:0200:05:07
right, by swaying with my legs I can actually control eversion and inversion
00:05:0700:05:11
really well too. I mean I have like a good grip on her calcaneus. I had good
00:05:1100:05:16
control of her foot so that's this hand position here. We talked about this hand
00:05:1600:05:22
position here being right over the neck of the the talus, and I'm going to go
00:05:2200:05:25
ahead and pull her up to her first for the resistance barrier. We do have some
00:05:2500:05:30
research that's starting to suggest that maybe mobilization should be done at end
00:05:3000:05:34
range right, or end of available range providing it's pain-free.
00:05:3400:05:41
So anterior to posterior mobilization down here may not be as effective as an
00:05:4100:05:46
anterior to posterior mobilization here. So I'll pull her up to dorsiflexion.
00:05:4600:05:51
Now what else do I got to think about, all right patient's body position should
00:05:5100:05:55
look comfy right. So she's laying down, I kind of already put her in the right
00:05:5500:06:00
body position. Make sure guys that you have the calcaneus hanging off the table
00:06:0000:06:04
right, because if you put the calcaneus on the table your fingers are
00:06:0400:06:09
essentially going to get smashed. Your body position is important on this. I
00:06:0900:06:14
think you'll notice that I have to bend over just a little bit to get in good
00:06:1400:06:20
position here, that's actually purposeful because I'm not trying to pull up I'm
00:06:2000:06:26
trying to push down. So once I start doing my oscillatory mobilizations I
00:06:2600:06:32
want to be able to use my body weight to do that, and not be like trying to like
00:06:3200:06:37
manhandle an anterior to posterior mobilization. Although maybe I'm big
00:06:3700:06:41
enough and strong enough to pull that off, your ankle is a fairly strong stiff
00:06:4100:06:46
joint with some really big muscles that cross it, at least some really strong muscles
00:06:4600:06:51
that cross it. And I know some of you guys aren't necessarily as big a human
00:06:5100:06:55
being as I am, and some of you guys have to treat really really big people, you
00:06:5500:06:59
know you've got to use your body mechanics to your advantage. So I'm
00:06:5900:07:04
bending over just a little bit because I want my chest right over the top of my
00:07:0400:07:10
arms, so that now I can just do this. You guys see how that's nice and comfortable
00:07:1000:07:18
for me. If I need more dorsiflexion I can just sway, reposition my feet and I can
00:07:1800:07:24
just push down using my body weight. This is really easy for me. I feel like I
00:07:2400:07:29
could do this for at least a few minutes and as many times a day as I needed to.
00:07:2900:07:35
Now let's talk a little bit about protocols around mobilizations. I don't
00:07:3500:07:40
really want to set up a debate on which protocol is the best. I know some of you
00:07:4000:07:44
guys use more of like a static hold technique and I think that can be very
00:07:4400:07:50
effective. I've seen seven holds of seven seconds. I've seen ten five-second holds.
00:07:5000:07:55
I've seen all sorts of oscillatory techniques. I happen to be a Maitland
00:07:5500:08:03
certified therapist, so you know I use one to two oscillations per second doing
00:08:0300:08:11
those grade three and four mobilizations for increasing mobility. I don't really
00:08:1100:08:15
care what protocol you use as long as it's effective, as long as your
00:08:1500:08:19
reassessment is showing it's effective. I would say the biggest mistake I see
00:08:1900:08:23
students make is maybe they don't follow through with the whole protocol. So
00:08:2300:08:26
you're doing one to two oscillations per second, and you should be doing them for
00:08:2600:08:31
30 seconds. What I see is most people giving up after 10 or 15 seconds. It's
00:08:3100:08:35
not that they didn't follow the protocol up to that point, they just don't stick
00:08:3500:08:39
with it long enough. With that being said I think all of the techniques have
00:08:3900:08:44
something in common, which is they're very aware of resistance barriers. So
00:08:4400:08:48
when I get into this technique it's important that I start trying to feel
00:08:4800:08:54
the joint play, the motion of the talus, even if I have to move
00:08:5400:08:59
my hands around like you just saw me do. Alright okay, all right am I feeling
00:08:5900:09:03
what I what I think I'm feeling, okay good good, got it.
00:09:0300:09:07
Alright so there's my first resistance barrier is right there, and then if I
00:09:0700:09:14
push down I get end right there, and then most mobilization techniques occur at
00:09:1400:09:19
around the 50% range, somewhere between 50 percent resistance.
00:09:1900:09:25
Alright so halfway between first resistance barrier and end, so 50%, some
00:09:2500:09:30
go all the way to like way down towards the end range. Although that's a a bit
00:09:3000:09:34
more of an aggressive mobilization, just kind of be aware of what you're doing. I
00:09:3400:09:40
think the thing to take away from all of these protocols is be aware of your
00:09:4000:09:43
resistance barrier, be aware that most of your mobilizations are not going to
00:09:4300:09:49
happen at the absolute extreme of arthrokinematic motion. They're going to happen
00:09:4900:09:54
somewhere between your first resistance barrier and the end. And then of course
00:09:5400:10:00
guys whatever protocol you use -follow through. Make sure you do all of the
00:10:0000:10:05
protocols. So if it's seven second holds, then make sure you do all seven
00:10:0500:10:12
second holds right. If you're going to do oscillatory techniques, and it's important
00:10:1200:10:20
that I do oscillatory techniques long enough, that I start feeling a decrease
00:10:2000:10:27
in passive resistance, even if that takes 60 seconds.
00:10:2900:10:37
And of course after I'm done with this technique I'm going to reassess. As I've
00:10:3700:10:45
said so many times before in so many videos, assess address reassess. Just
00:10:4500:10:49
because I think I feel passive accessory stiffness,
00:10:4900:10:54
just because I think this might be good technique for Melissa, doesn't mean it
00:10:5400:10:58
actually is. If my goal was to increase dorsiflexion, or for example she had an
00:10:5800:11:01
excessive forward lean on her overhead squat, and I thought that increased
00:11:0100:11:06
dorsiflexion would help; and I get her up do the overhead squat it doesn't look
00:11:0600:11:09
better, do goniometry she hasn't gained any dorsiflexion, I need to start
00:11:0900:11:14
thinking about a different technique. Stay tuned for the close-up recap. For a
00:11:1400:11:19
close-up recap you guys can see here if I find the bottom of the medial
00:11:1900:11:24
malleolus, the bottom of the lateral malleolus I end up with a line between
00:11:2400:11:28
those two points. That puts me right over the neck of the talus.
00:11:2800:11:33
It's just like that, just right there and right in that angle of the ankle. I can
00:11:3300:11:37
actually if I if I just take one hand even, and kind of wrap around the bottom
00:11:3700:11:41
of the foot, I can even get a little bit of joint mobility there, I can steal the
00:11:4100:11:47
joint play. So if I put my web-space down over like this
00:11:4700:11:52
I grab the bottom of her calcaneus, put my forearm around the bottom of her foot.
00:11:5200:11:58
Now I'm all set up. My body is over the top of my hand so I'm ready to apply
00:11:5800:12:03
that anterior to posterior force. I probably should think real quick about
00:12:0300:12:09
my precautions when I first kind of start into this technique. Do I get any
00:12:0900:12:17
grunts/groans or extreme facial expressions, and so did I did I pinch on
00:12:1700:12:22
that peroneal nerve that we know is over here, and sometimes we'll will over
00:12:2200:12:25
stretch that nerve real quick and get at that shearing burning pain. If you guys
00:12:2500:12:27
do that just move your hands a little bit.
00:12:2700:12:30
Remember that nerves aren't very wide, you should be able to get other way
00:12:3000:12:35
pretty easy. The other thing we want to make sure is if I push down are they
00:12:3500:12:40
relaxed, because Melissa can you dorsiflex, I don't know if you guys, so right
00:12:4000:12:44
there guys, that's the tibialis anterior. And then if she started guarding on me
00:12:4400:12:50
with this jacked tibialis anterior of hers, this tendon is going to kick me
00:12:5000:12:53
right out of the neck of the talus. It's going to be real hard to get an
00:12:5300:12:58
anterior to posterior mobilization. I'm far more likely to just be molding her
00:12:5800:13:02
tibialis anterior tendon and I don't really know what the benefit of that
00:13:0200:13:08
would be. The other precaution we might think about is the ankle is one of
00:13:0800:13:14
those joints that can get locked, but still be hypermobile. Every once in a while
00:13:1400:13:19
you'll run into somebody who you know that they feel stiff at first, and if you
00:13:1900:13:24
get real aggressive with them you'll get a little pop or a click; they'll move a
00:13:2400:13:29
whole lot on you and you can pinch that capsule and that'll give you some
00:13:2900:13:34
swelling of the ankle, they would they will not be happy with you at all. So
00:13:3400:13:39
once you get your hand set up guys I would just just kind of start in nice
00:13:3900:13:47
and gentle, give a couple like tests pushes before you apply your full force
00:13:4700:13:52
of pressure. I'm not getting any kickback from Melissa here, so now I'm going to
00:13:5200:13:56
find my first resistance barrier. I'm going to go ahead and push down and find
00:13:5600:14:02
the end range there. Now this is the end range of arthrokinematic motion, not
00:14:0200:14:06
end range of dorsiflexion. So that's as far as I can push your talus posteriorly
00:14:0600:14:13
and then I'm just going to do my oscillatory techniques here, and I'm kind
00:14:1300:14:20
of going from just before 50% right now, to just after 50% resistance. I would say
00:14:2000:14:26
total I'm maybe moving a half a centimeter, and this would be like a
00:14:2600:14:31
grade three mobilization and I'm going to go ahead and hold this for 30 to 60
00:14:3100:14:38
seconds, or until I feel a decrease in resistance for her passive accessory
00:14:3800:14:44
motion. And then I'd probably pull out a ganiometer and check her dorsiflexion
00:14:4400:14:51
again, since I know dorsiflexion is a fairly reliable test. So once again guys
00:14:5100:14:56
web-space down over that imaginary line between the bottom of
00:14:5600:15:01
medial and lateral malleolus. I'm using this part of my web-space not this part
00:15:0100:15:06
of my web-space, because this is going to feel a lot softer in here than this is
00:15:0600:15:10
going to feel. And then of course I'm using this hand by hooking the calcaneus,
00:15:1000:15:16
and then bringing my forearm over the base of her or the ball of her foot, so that I
00:15:1600:15:20
can control eversion inversion, bring her to our first resistance barrier in
00:15:2000:15:28
dorsiflexion, and I'm all set up. So there you have it, assess address reassess. Make
00:15:2800:15:32
sure that every time you choose a joint based manual therapy technique it is
00:15:3200:15:36
based on an assessment, and that you return to that assessment after you've
00:15:3600:15:40
finished the intervention, to see if it was effective for the individual, the
00:15:4000:15:45
patient or client that you have in front of you. Ensure that you continue to learn
00:15:4500:15:50
your Anatomy because your Anatomy is going to help you with your hand
00:15:5000:15:55
placement, with understanding what a joint can do. With understanding what you
00:15:5500:16:01
may gain from this particular technique, and of course practice. You have to
00:16:0100:16:05
practice these techniques, hopefully not for the first time on a patient or
00:16:0500:16:10
client who just walked in the door. If you can find a more senior instructor or
00:16:1000:16:16
mentor, to give you some really good hands-on instruction use your peers for
00:16:1600:16:24
some good feedback, and of course always look for live education to help with
00:16:2400:16:28
your manual therapy techniques. I know these videos make education very
00:16:2800:16:34
convenient,, but there is no substitute for learning manual therapy in a live
00:16:3400:16:39
setting. I look forward to talking to you guys again soon.