Talonavicular and Cuneonavicular Joint Manipulations

Patient and Practitioner set-up

1. The patient should be lying supine, with the feet hanging just beyond the end of the table.
2. The table should be at the level of the practitioner's upper thigh for the downward thrust technique and at least waist height for the longitudinal thrust technique.
3. The practitioner should be standing at the end of the table on the patient's affected side.

Passive Motion Assessment

• The arthrokinematic motion assessed prior to manipulation is generally, anterior to posterior glide of the talonavicular joint and cuneonavicular joint. This motion is usually assessed using a pincer grip or using the same hand position used for the manipulation.

Lockout Position:

1. Take a moment to palpate the talar neck, the navicular bone, and the medial cuneiform.
   1. It may be helpful to look at a model or diagram of the talus and transverse tarsal joint as you attempt to identify 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 over the neck of the talus.
   4. Next, identify the relatively sharp bump of the navicular tubercle by palpating about a centimeter anterior and inferior to the medial malleolus.
   5. Using a pincer grip, slide your fingers to either side of the bone where you identified the navicular tubercle, grasping the navicular bone firmly. Use your other hand to stabilize for a passive accessory motion exam of the talonavicular joint.
   6. Once you have identified glide at the talonavicular joint, slide your hand distally so that the hand stabilizing the talus now stabilizes the navicular bone, and the other hand is used to identify the glide between the navicular bone and the bone just distal to the navicular bone. This bone is the medial cuneiform.

• 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.

Downward Thrust Technique

1. Stand on the patient's affected side with the patient's hip and knee flexed so that the foot is flat on the table.
2. Place the pisiform/hamate portion of the proximal hand on the bone you wish to manipulate; either the navicular bone or medial cuneiform.
3. Use dorsal to plantar force to stabilize this bone while following the next steps and achieving lock-out.
4. Wrap the fingers of the distal hand around the medial side and plantar surface of the patient's foot.
5. Use this hand to "take up" all of the available range of motion (ROM) for external rotation and dorsiflexion of either the distal half of the talonavicular or cuneonavicular joint (while stabilizing the proximal bone with the other hand.
   • High-Velocity Thrust
6. The high-velocity portion of this technique is a quick dorsal to plantar thrust just beyond the lock-out position achieved in previous steps. Most of the pressure comes from leaning forward, using the weight of your torso.
   • Remember, that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.

Longitudinal Thrust Technique

1. Stand on the patient's affected side just beyond the patient's foot.
2. Note: For the technique, the patient should be lying supine, legs straight, with the feet extending just beyond the end of the table.
3. Wrap the medial hand over the medial side of the foot, with the fingers firmly against the dorsal aspect of the foot. The other hand can be wrapped around the lateral side of the foot and over the medial hand for support.
4. The most important aspect of hand placement during this technique is the pinky of the medial hand must cover the distal bone of the joint you wish to manipulate. More or less, the pinky is the finger mobilizing the joint, and the rest of the fingers and hand are only used to stabilize the other bones of the foot.
5. Use your hands, with the pinky as the fulcrum, to take up all available ROM for external rotation and dorsiflexion of the joint you wish to manipulate.
   • High-Velocity Thrust
6. The high-velocity portion of this technique is a quick dorsal to plantar pull; a quick longitudinal distraction just beyond the lock-out position achieved in previous steps. The force is generated by leaning back and giving a quick tug.
   • Remember that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.