peripheral mobs

Mobilisation of the Hip, Knee and Ankle

Daaljit Singh HS

Manipulation has been traced back 4000 years in Thai artwork. It is also mentioned as being used by Hippocrates in BC times.In the library of the Royal College of Surgeons in London is a book dated 1656 about Friar Moulton, an Augustinian monk, by Robert Turner titled The Complete Bonesetter. In 1745 the surgeons eventually separated from the city company of Barbers and Surgeons of London and became a new company. In the early nineteen century it became to be known as the Royal college of Surgeons of England

Aberration in structure (musculoskeletal) affects function (neurological) and hence the body’s sense of well being.The nervous system also interplays with the endocrine system to maintain a state of homeostasis, defined simply as physiological stability. Manual therapy is thought to improve the body’s ability to self regulate through affecting the nervous system and hence all other systems, thereby allowing the body to seek homeostasis.

Subluxation affects tone of the body. Tone is the efficiency of the nervous system and the ability of the body to self regulate its process properly.(Palmer 1845 – 1913)

A subluxation can serve as a noxious irritant to the body and its removal, therefore becomes necessary for optimal health.

Mechanics – study of forces and their effects.

Biomechanics – application of mechanical laws to living structures specifically to the locomotor system of the human body.

- Interrelation of the skeleton , muscles and joints

Kinematics – geometry of the motion of objects including displacement, velocity and acceleration.

Motion – continuous change in position of an object

Daaljit Singh HS AMP, PPT 20/04/2009

Gliding – translational movement.

Listhesis – antero/postero is in the sagital plane- Lateral is in the coronal plane

Distraction/Compression – altered interosseous space (Transverse Plane/ Y axis)

Curvilinear motion – combination of rotational and translational movement and is the most common motion produced by the joints of the body.


Diagnostic Criteria for the identification of Joint dysfunction

Pain and Tenderness The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary musculoskeletal disorders manifest by a painful response. The patient’s description of the pain and its location is obtained. Furthermore, the location and intensity of tenderness produced by palpation of osseous and soft tissue are noted. Pain and tenderness findings are identified through observation, percussion, and palpation.


AsymmetryAsymmetric qualities are noted on a sectional or segmental level. This includes observation of posture and gait, as well as palpation for misalignment of vertebral segments and extremity joint structures. Asymmetry is identified through observation (posture and gait analysis), static palpation and static radiography.

Range of Motion AbnormalityChanges in active, passive, and accessory joint motions are noted. These changes may be reflected by increased, decreased, or aberrant motion. It is thought that a decrease in motion is a common component of joint dysfunction. Range of motion abnormalities are identified through motion palpation and stress radiography.

Tone, Texture, and Temperature Abnormality Changes in the characteristics of contiguous and associated soft tissues, including skin, fascia, muscle, and ligaments, are noted. Tissue tone, texture, and / or temperature changes are identified through observation, palpation, instrumentation, and tests for length and strength.

Special TestsFinally, diagnosis may require testing procedures that are specific to a technique system.

Palpation

Palpation is the application of variable manual pressures, through the surface of the body, to determine the shape, size, consistency, position and inherent motility of the tissues beneath. Palpation is the oldest technique employed to detect dysfunction and is still the most emphasized physical finding supportive of dysfunction. Good palpation skills are the result of both physical abilities and mental concentration. Tenderness to pressure at bony landmarks that are close to articulations is another proposed empirical sign of joint dysfunction. The relationship between spinous and interspinous tenderness and dysfunction is speculated to result from reflex sensitivity in tissues with shared segmental innervation, or as a result of mechanical deformation in structures attaching at these bony sites.


Soft Tissue PalpationThe major function of soft tissue palpation is to determine the contour, consistency, quality, and the presence or absence of pain in the dermal, subdermal, and deeper “functional” tissue layers. The dermal layer incorporates the skin, subdermal layer, subcutaneous adipose, fasciae, nerves and vessels. The functional layer consists of the muscles, tendons, tendon sheaths, bursae, ligaments, fasciae, vessels, and nerves.

Palpation of the dermal layer is directed toward the assessment of temperature, moisture, motility, consistency, and tissue sensitivity (e.g., hyperesthesia, tenderness, etc.). Palpation techniques involve light, gentle exploration of the skin with the palmar surfaces of the fingers or thumbs. When, manually assessing temperature of superficial tissues, the dorsum of the hands are typically used. Motility and sensitivity of the dermal layer may also be assessed by the technique of skin rolling.

How to Use Your Palpation Tools1. Use the least pressure possible. Your touch receptors are designed to

respond only when not pressed on too firmly; experiment with decreasing pressure instead of increasing pressure, and your tactile perception may improve.

2. Try not to cause pain if possible. Pain may induce protective muscle splinting and make palpation more difficult.

3. Try not to lose skin contact before you are done with the palpation of the area.

4. Use broad contacts whenever possible. For deep palpation, use broad contacts to reach the desired tissues, then palpate with your palpation finger, keeping the overlying tissue from expanding with the other fingers of your palpation hand. Close your eyes to increase your palpatory perception

Palpation Hints and Comments1. Concentrate on the area and/or structure you want to palpate; do not

palpate casually. 2. Do not let your attention be carried away by unrelated sensations.

Concentrate on your fingers; do not feel what you see or expect to feel.3. Keep an open mind and do not deceive yourself; never let your mind “out

palpate” your fingers.4. Establish a palpation routine and stay with it.


5. Take every opportunity to add to your tactile “vocabulary” through comparative experiences.

Accessory Joint Motion Joint surfaces do not form true geometric shapes with matching articular surfaces. As a result, movement occurs around a shifting axis, and the joint capsule must allow sufficient play and separation between articular surfaces to avoid abnormal joint friction,

Accessory joint movements are evaluated by the procedures of joint play and end play (feel). End-play evaluation is the qualitative assessment of resistance at the end point of passive joint movement, and joint play is the assessment of resistance from a neutral and / or loose-packed joint position.

End Play

The end play zone is characterized by a sense of increasing resistance as it is approached (first stop) and second firmer resistance (second stop) as its limits are approached.

End-play is assessed by applying additional overpressure to the specified joint at the end range of passive movement. To execute end feel, evaluate the point at which resistance is encountered, the quality of the resistance, and whether there is any associated tenderness.

Loss of anticipated end-play elasticity is thought to be indicative of disorders within the joint, its capsule, or periarticular soft tissue. Encountered end-play resistance is a significant finding in the determination of joint dysfunction and adjustive vector orientation.

Joint Play

During the performance of joint play; check for the presence or absence of pain, the quality of movement, and the degree of encountered resistance. Joint play should not induce pain, some resistance to movement should be encountered, but the joint should yield to pressure, producing short-range gliding and distracting movements. Increased resistance to joint play movements suggests articular soft tissue contractures.


Normal and Abnormal End Feels

CapsularFirm but giving; resistance builds with lengthening, like stretching a piece of leather

Example: close-packed position of the joint; external rotation of shoulders. Abnormal example: capsular fibrosis and / or adhesions leading to a

capsular pattern of abnormal end feel.

LigamentousLike capsular but may have a slightly firmer quality

Example: knee extention Abnormal example: noncapsular pattern of abnormal resistance due to

ligamentous shortening.

Soft Tissue ApproximationGiving, squeezing quality; results from the approximation of soft tissues; typically painless.

Example: elbow flexion Abnormal example: muscle hypertrophy, soft tissue swelling

Bony Hard, nongiving abrupt stop

Example: elbow extention Abnormal example: bony exostosis, articular hypertrophic changes

Mscular Firm but giving, builds with elongation; not as stiff as capsular or ligamentous

Normal example: hip flexion

Muscle SpasmGuarded, resisted by muscle contraction; should feel muscle reaction. The end feel cannot be assessed because of pain and/ or guarding

Abnormal example: protective muscle splinting that is due to joint or soft tissue disease or injury

InterarticularBouncy springy quality

Abnormal example: meniscal tear, joint mice


EmptyNormal end feel resistance is missing; end feel is not encounter at normal point, and /or the joint demonstrates unusual give and deformation.

Abnormal example: joint injury or disease leading to hypermobility or instability.

Clinical Features of Joint Dysfunction1. Local pain: commonly changes with activity2. Local tissue hypersensitivity3. Altered Alignment4. Decreased, increased, or aberrant joint movement5. Altered joint play6. Altered end-feel resistance7. Local palpatory muscle rigidity

Outcome Measures for Subluxation/Dysfunction1. Regional mobility measures2. Pain reporting instruments3. Physical capacity questionnaires4. Physical performance measures

CLINICAL DOCUMENTATION

The total management of the patient includes clinical assessment, application of necessary treatment, and patient education.

Assessment procedures are necessary to identify the nature, extent, and location of the problem as well as to determine the course of action in treatment.

Errors in recording that have been identified include failure to record findings all together, illegible handwriting, obscure abbreviations, improper terminology, and bad grammar. It is imperative that though the clinical record comprises the physician’s personal notations, it must be complete and translatable. If it is not written down, it was not done.

A systematic and accurate record of evaluation facilitates quick reference to salient findings during treatment.


It should be noted and emphasized that it is unacceptable to use and assign a diagnosis for convenience. Most clinical entities have specific and expected signs and symptoms. These findings need to be identified and recorded.When performing an assessment manipulation, the clinician should keep the following principles in mind:

1. The patient should exhibit no muscle guarding and should be relaxed as possible.

2. The clinician should be efficient with body mechanics, and should stand with the wide base of support. The manipulating force should be as close to the clinician’s centre of gravity as possible. The force ideally should be directed downward. If a downward force is not feasible, a horizontally directed force should be attempted. This is especially true when treating larger joints, but is less important when evaluating the smaller joints of the hand and the foot. The clinician should use his or her weight to assist with the force of manipulation whenever possible.

3. The joint should be tested in the resting position if the patient is capable of attaining that position. If not, the joint should be tested in the actual resting position.

4. The clinician’s grasp should be firm yet painless.

5. One bone should be stabilized with the clinician’s hand or other body part, a belt, a wedge, or the treatment table.

6. The other bone is manipulated with the clinician’s hand.

7. Both the stabilizing force and the manipulating force should be as close to the joint surface as possible, to control the motion as closely as possible.

8. The patient’s pain should be monitored during the assessment, and appropriate modification should be made based on the pain response.

9. Accessory motion should be assessed by comparison with the corresponding joint on the other side of the body, whenever possible.

10.Only one movement should be performed at a time. For example, the clinician should not manipulate a bone into dorsal glide from a ventrally glided position, because it is more difficult to assess movement in this manner.

11. Only one joint should be manipulated at a time.

12. Each technique is both an evaluative technique and a treatment technique; therefore the clinician should continually evaluate during


treatment. Formal assessments also should be made before and after treatment.

Contributors to the knowledge of manipulative therapy

Cyriax an orthopedic physician who contributed much to the development of a system of physical examination in

which different tissues affected by orthopedic disorders are techniques practiced today

Mennell Developed the concept that adhesions are a common cause of joint dysfunction.

Maigne believed that a clinician should not perform a treatment that increases the patient’s symptoms, and therefore

treatment should be administered in a direction opposite the direction that reproduces pain.

Maitland developed oscillatory manipulation treatments and stated that one should oscillate in the direction of reproducible

symptoms.

Kaltenborn proposed that the clinician should treat with oscillations in a direction based on analysis of the restriction in range of

motion and the articular surface anatomy

Paris proposed that the clinician should treat joint dysfunction and minimize the role of pain.

Grades of Oscillations

Grade 1 Slow small-amplitude oscillatory movement parallel to the concave joint surface that does not take the joint up to the first tissue stop

Grade 2 Slow larger-amplitude oscillatory movement parallel to the concave joint surface that does not take the joint up to the first tissue stop

Grade 3 Slow, large-amplitude oscillatory movement parallel to the concave joint surface that takes the joint up to and slightly through the first tissue stop

Grade 4 Slow, small-amplitude oscillatory movement parallel to the concave joint surface that does not take the joint up to and slightly through the first tissue stop


Grade 5 Fast, small amplitude, and high velocity non oscillatory movement parallel to the concave joint surface that begins at the first tissue stop and then takes the joint through the first tissue stop, also called a thrust manipulation.

Execution of Treatment

All treatment oscillations are performed with at least grade 1 traction when feasible to decrease compression of joint surfaces.

Grades 1 and 2 oscillations are used for pain reduction.

Grades 3 and 4 are used to reduce pain, increase periarticular extensibility, correct positional faults, and release impinged meniscoid tissue in the spine.

All grades of oscillation increase nutrition to articular structures.

If pain occurs before resistance is met with passive range of motion, then Grades 1 and 2 oscillation techniques are indicated.

If pain occurs at the same time in the range of motion as the first barrier to motion, then the patient should be able to tolerate up to grade 3 oscillations and tractions.

If pain occurs after the first motion barrier, the patient should be able to tolerate up to grade 3 tractions and grades 4 and 5 oscillations

The goal of manipulation/mobilasation is to restore maximal, pain free movement to a musculoskeletal system, which is in postural balance. This is accomplished by;

Increasing joint extensibility

Correcting positional faults

Nutrition

Pain control/Muscle relaxation


Psychological benefits

HIP JOINT.

Flexion and Extension

Flexion is restored by dorsally (AP) gliding the femur and extension by ventrally (PA) gliding the femur

Abduction and Adduction

Abduction is restored by caudally gliding the femur, and adduction by laterally gliding the femur

Rotation

External rotation is restored by ventrally gliding the femur and internal rotation by dorsally and laterally gliding the femur

1. Distraction

To increase overall range Clinician facing patient, with patient’s leg over clinician’s shoulder. Move femoral head away from acetabulum, elevate scapula to direct fem

head ventrally

2. Caudal Glide

To increase hip abduction Pt supine, clinician grips distal thigh while facing hip Glide fem head in caudal direction.

3. Dorsal glide

To increase hip flexion and internal rotation Pt. supine with leg supported between clinician’s arm and trunk Glide fem in dorsal direction with manipulating hand

4. Ventral glide


To increase hip extension and external rotation Pt prone with leg off treatment table, clinician facing hip Lean into distal thigh to glide femur ventrally

5. Lateral glide

To increase internal rotation and hip adduction Pt supine with leg over clinician’s shoulder, clinician at pt’s side Glide femur in a lateral direction.

6.

7. Other techniques

KNEE JOINT (Tibio Femoral)

1. Distraction

To increase overall range of motion Pt sitting with knee(in resting position-25 degrees) off the edge of

treatment table Grip from medial and lateral sides of tibia and move distally

2. Dorsal glide I

To increase flexion Pt. Supine with knee in resting position. Clinician grips proximal tibia from

ventral side Glide tibia in dorsal direction

3. Dorsal Glide II

To increase flexion Pt prone. Clinician’s hand on ventral surface of proximal tibia Glide tibia dorsally

4. Ventral Glide I


To increase extension Pt. Supine with knee in resting position. Clinician grips proximal tibia Glide tibia in ventral direction

5. Ventral Glide II

To increase extension Pt. Supine with knee in resting position. Clinician grips proximal tibia Glide femur in dorsal direction

6. Ventral Glide III

To increase extension Pt prone. Manipulating hand on proximal dorsal surface of tibia. Glide tibia ventrally

7. Medial Glide

To improve overall range of motion Pt supine or sitting with knee in resting position Clinician at foot of treatment table with lower leg between arm and trunk,

Glide proximal Tibia medially

8. Lateral Glide


glide proximal Tibia laterally

9.Medial Gaping


Move lateral joint line medially

10. Lateral Gaping


Move medial joint line laterally


(Patello Femoral)

10. Cranial Glide

To increase knee extension and PF joint play Pt in supine with knee in slight flexion using rolled towel underneath Glide patella in a cranial direction.

11. Caudal Glide

To increase knee flexion and PF joint play Pt in supine with knee in slight flexion using rolled towel underneath Glide patella in a caudal direction. Avoid compressing patella into the

femur

12. Medial Glide


femur

13. Lateral Glide


femur


Lower leg

Proximal Tibiofibula jointDistal Tibiofibula joint

Fibula glides cranially with dorsi flexion, and caudally with plantar flexion.Fibula rotates laterally with dorsi flexion.With Dorsi flexion, the tibia and fibula spread slightly

Proximal Tibiofibular joint

1. Dorsal Glide of Fibular head

To reduce ventral positional fault of fibula and improve joint play Pt. in supine with knee supported in resting position on pillow/rolled towel Glide proximal fibula in dorsal direction

2. Ventral Glide of Fibular Head

To reduce dorsal positional fault of fibula and improve joint play Patient in prone with foot supported by pillow/rolled towel Glide proximal fibula in ventral direction

Distal Tibiofibular Joint

3. Distraction: Spreading

To increase joint play and dorsi flexion Pt in supine. Clinician at foot end, with hands on tibial and fibula distal

ends Move both tibia and fibula away from each other.

4. Dorsal Glide

Increase joint play of distal TF jt and plantar flexion. Pt Supine, Clinician at foot end of treatment table Stabilize Tibia and Glide Lateral Malleolus in dorsal direction


5. Ventral Glide

Increase joint play of distal TF jt and dorsi flexion. Pt Prone, Clinician at foot end of treatment table Stabilize Tibia and Glide Lateral Malleolus in ventral direction

6. Cranial Glide

To increase dorsi flexion and joint play Pt in supine Stabilize Tibia and Glide fibula in cranial direction

7. Caudal Glide

To increase plantar flexion and joint play Pt in supine Stabilize Tibia and Glide fibula in caudal direction

Ankle Joint

Dorsi flexion is restored by gliding talus dorsallyPlantar flexion is restored by gliding Talus Ventrally

1. Distraction

To Increase overall joint play of Talo Crural joint Pt in Supine. Clinician grips proximal talus with both hands Move Talus distally by leaning backwards

2. Distraction II

To improve joint play in subtalar joint Pt in Prone . Grip the talus ventrally and calcaneum dorsally Move calcaneum distally

3. Dorsal Glide

To improve talocrural joint play and dorsi flexion Pt in Supine. Clinician grips talus ventrally and stabilizes lower leg dorsally Glide talus in dorsal direction


4. Ventral Glide I

To improve talocrural joint play and increase plantar flexion Pt. in prone. Clinician grips talus dorsally and stabilizes lower leg Ventrally Glide Talus in a ventral direction

5. Ventral Glide II

To improve talocrural joint play and increase plantar flexion Pt. in supine. Clinician grips talus ventrally and stabilizes lower leg Dorsally Glide Tibi and fibula in a dorsal direction

6. Eversion Mobilisation

To increase subtalar joint play and subtalar eversion Pt in prone. Manipulating hand grips calcaneum dorsally Stabilise talus, Glide calcaneum in eversion direction simultaneously with

valgus direction of calcaneum

7. Inversion Mobilisation

To increase subtalar joint play and subtalar inversion Pt in prone. Manipulating hand grips calcaneum dorsally Stabilise talus, Glide calcaneum in inversion direction simultaneously with

varus direction of calcaneum

Manipulation and MobilizationExtremity and Spinal TechniquesSusan L. Edmond, M.P.H., P.T.


peripheral mobs

Documents

palpation palpation

motion palpation

static palpation

palpation of osseous

common motion

motion of objects

aberrant motion

good palpation skills