Talocalcaneal Manipulation

Patient and Practitioner set-up

1. The patient should be laying on their side, affected side down, with the ankle at and at the end of the table (the other hip and knee of the other leg may be flexed for comfort).
2. The practitioner should be standing at the end of the table, with the table at a height that allows the practitioner to get their chest over the ankle when their arms are straight and hands in position for the manipulation.

Passive Motion Assessment

• The arthrokinematic motion assessed prior to manipulation is a lateral glide or lateral tilt of the calcaneus on the talus. This motion is usually assessed by firmly grasping the talus in one hand and the heel in the other.
  • Note: This joint is naturally a stiff joint that does not move much. This technique is only recommended if there is no movement, or movement is abnormally difficult.

Lockout Position:

1. Take a moment to palpate the talus and the calcaneus.
   1. It may be helpful to look at a model or diagram of the talus and calcaneus as you palpate these bones.
   2. Use the thumb and index finger of one hand to identify the medial and lateral malleoli (large bumps on either side of the ankle).
   3. Allow your thumb and index finger to slide past the inferior portion of the malleoli until the webspace of your hand abuts the angle (line where the ankle bends) of the ankle. Usually, this places the webspace of your hand over the neck of the talus.
   4. For passive accessory motion assessment, use the thumb and index finger to pinch and stabilize the talus.
   5. The calcaneus is the bone-deep to the rough skin of the heel. Take a moment to identify the bone by pressing through the rough skin and soft tissue. Once you are comfortable with the shape and dimensions of the bone, grasp the calcaneus in your palm.
   6. Attempt to wiggle the calcaneus on the talus and identify the approximate location of the joint line.
2. The manipulation is performed with the affected foot flat on the table.
3. Place the pisiform/hamate portion of the hand closest to the patient's heel over the medial portion of the talus, close to the talar neck.
4. Place the pisiform/hamate portion of the hand closest to the patient's toes of the medial portion of the patient's heel.
   • Note: Your hands should be crossed. The force used for this manipulation is primarily down (medial to lateral), but also involves a bit of a "distraction" force.
5. Press down into the table to "take up" all of the available ROM of lateral tilt/glide. This is your "lock-out" position.

• Important Note: 90% of manipulation technique is set-up. If you do not achieve lock-out during set-up, you are unlikely to achieve a successful manipulation.

High-Velocity Thrust

• The high-velocity portion of this technique is a quick downward force, generated using the practitioner's body weight (Similar to the motion used for a thoracic manipulation ). The goal is to force the joint into further lateral tilt/glide, just beyond the lock-out position described above.
  • Remember, that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.