Set-Up
- The patient should be prone, with the practitioner standing on the patient's affected side.
- The table should be at a height that allows the practitioner to have their elbows extended when the practitioner's chest is over the patient's elbow.
Posterior to Anterior Mobilization (Humerus on Ulna)
Note: As far as we know, the humerus on ulna approach to this mobilization is a novel technique. We hope that you find this modification as helpful as we have, and we look forward to your feedback.
- If the practitioner is less familiar with the elbow anatomy, the practitioner can flex the patient's elbow to identify the olecranon process, humeral epicondyles, olecranon fossa, and joint line.
- The practitioner should wrap one hand around the proximal forearm with fingers between the patient's forearm and table, and place the thumb of that hand along the joint line. The thumb will serve as a guide to aid in identifying arthrokinematic motion during the mobilization.
- The proximal hand should be wrapped around the distal humerus with the palm ready to apply pressure on the posterior aspect of the distal humerus. Again the thumb can be used to aid in palpating the joint line.
- Asking the patient to "grab" the side of the table will help place the forearm and humerus in a good position for this technique. The forearm should be in neutral between supination and pronation, and the elbow should be slightly flexed.
- Towels or foam rolls may be used under the arm to allow for mobilization at various angles of elbow extension.
Mobilization:
- Once you are comfortable with palpating joint motion, start with small test oscillations to identify articular motions and any exquisite tenderness.
- When satisfied with the feel of the technique, identify the amount of pressure needed to feel the first resistance barrier just prior to articular motion, and then pressing harder, identify the amount of pressure at which any further pressure fails to increase articular motion.
- Note: The end of articular motion is the end of glide. Locate the point at which the joint will not glide any further without additional extension.
- Identify the mid-point between the first resistance barrier and articular 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 very small motions.
- Grade IV - Small oscillations at 50% resistance or more.
- Oscillate at 1 - 2 pulses per second.
- Continue oscillating until you feel a change in tissue resistance/joint stiffness.
- Note: Feeling resistance barriers and relative motion is challenging with this technique due to the hand position and relatively small amount of arthrokinematic motion allowed at the joint. Don't let perfect be the enemy of the good. Mobilizing the joint and decreasing stiffness is more important than a perfectly executed grade III, or being able to differentiate between a grade III and a grade IV.
