JOINT MOBILIZATION OF THE ANKLE AND THE FOOT. PART 1

Cập nhật lần cuối vào 17/03/2023

Kỹ thuật di động khớp cổ chân và bàn chân. Phần 1 trình bày phần ôn lại các đặc điểm giải phẫu, kỹ thuật di động khớp chày- mác dưới, khớp cổ chân (sên – mác) và khớp dưới sên (sên – gót).

ANATOMY REVIEW

XEM THÊM: GIẢI PHẪU CHỨC NĂNG CỔ CHÂN VÀ BÀN CHÂN. XƯƠNG VÀ KHỚP

Bone and Joints

Terminology/Từ vựng:

• Tibia: Xương chày
• Fibula: Xương mác
• Malleolus: Mắt cá. Lateral malleolus: mắt cá ngoài; Medial malleolus: mắt cá trong
• Talus: xương sên
• Calcaneus: Xương gót
• Navicular: Xương ghe
• Cuneiforms: Các xương chêm (3 xương)
• Cuboid: Xương hộp (nằm ngoài)
• Metacarpals: Các xương bàn chân
• Phalanges: Các xương ngón (chân)

Physiologic (Osteokinematic) Motions of the Ankle

Các khớp:

• Talocrural joint: Khớp cổ chân, sên-mác: là khớp chủ yếu là bản lề
• Subtalar joint: Khớp dưới sên, sên- gót
• Midtarsal joint: Khớp giữa bàn chân
• Tarsometatarsal joint (TMT): Khớp cổ – bàn chân
• Metatarsal phalangeal joint (MTP): Khớp bàn – ngón chân
• Interphlangeal joint (IP): Khớp gian ngón (đốt) chân

Viết tắt:

• Dorsiflex: gấp mu bàn chân (DF) = duỗi cổ chân
• Plantarflex: gấp lòng bàn chân (PF) = gấp cổ chân
• Inv (Inversion): Vặn trong
• Ev (Eversion): Vặn ngoài
• Add (Adduction): Khép
• Abd (Abduction): Dạng
• Flex (Flexion): Gấp
• Ext (Extension): Duỗi

Accessory (Arthrokinematic) Motions of the Ankle & Foot

Notes/Ghi chú:

• Physiologic Motions: vận động sinh lý, chuyển động xương
• Accessory Motions: vận động phụ trợ, chuyển động học khớp, joint play
• OPP: Open Packed Position/ Tư thế khớp mở = resting position, tư thế khớp nghỉ: là tư thế thường dùng bắt đầu để di động khớp. Ghi nhớ quy luật mặt lồi/lõm
• CPP: Closed Packed Position/ Tư thế khớp khoá
• OKC: Open Kinetic Chain: Chuỗi động mở: Kỹ thuật di động khớp thường dùng ở chuỗi động mở để khu trú lên khớp được thực hiện
• Concave: lõm
• Convex: lồi
• Glide: trượt
• Distraction: kéo tách
• Trong kỹ thuật, kỹ thuật viên thực hiện cố định đầu gần/phần xương cố định: Dấu chéo đỏ
• Kỹ thuật viên thực hiện vận động phụ trợ: Mũi tên xanh
• Người bệnh có thể thực hiện vận động sinh lý phối hợp: Mũi tên vàng

Lưu ý:

• Khớp Sên- Mác (khớp cổ chân): 
  • Xương sên lồi hợp với gọng chày mác lõm.
  • Tư thế nghỉ (OPP): Gập lòng bàn chân 10 ̊.
  • Mặt phẳng điều trị: Mặt phẳng điều trị trong gọng chày mác
  • Cố định. Xương chày được cố định bằng đai hoặc bằng bàn điều trị.
• Khớp Dưới sên (Sên – Gót)/Subtalar Joint (Talocalcaneal),
  • Xương gót lồi khớp với xương sên lõm ở khoang sau.
  • Tư thế nghỉ: trung gian giữa vặn trong và vặn ngoài
  • Mặt phẳng điều trị trong xương sên, song song với bàn chân
  • Cố định: Gập mu cố định xương sên, hoặc là xương sên được cố định bằng bàn tay người điều trị.

DISTAL TIBIOFIBULAR JOINT MOBILIZATIONS

Distal Tibiofibular Glides/ Trượt khớp chày- mác dưới

Indications:

• To improve all motions of the talocrural joint/ Cải thiện các vận động của khớp cổ chân

Accessory Motion Technique

• Patient Position:
  • Supine with foot supported on table in neutral position
  • Posterior glide in supine, anterior glide in prone
• Clinician Position and Hand Placement:
  • Stand at the foot of pt facing cephalad
  • Stabilizing contact: Provided by table & “lumbrical grip” of clinician over tibia/fibula
  • Mobilizing contact: Heel of hand contacts distal aspect of tibia/fibula
• Force Application:
  • While stabilizing the tibia, a posterior or anterior glide is imparted to the fibula.
  • While stabilizing the fibula, a posterior or anterior glide is imparted to the tibia.

Accessory With Physiologic Motion Technique

• Patient Position:
  • same position as previously described.
• Clinician Position and Hand Placement:
  • the same as previously described.
• Force Application:
  • Apply anterior or posterior glide at the tibia or fibula as active or passive dorsiflexion is elicited.
  • Apply a posterior glide to the fibula as active or passive inversion is performed.
  • Force is maintained throughout the entire range of motion and sustained at end range.

TALOCRURAL JOINT MOBILIZATIONS

Talocrural Distraction/Kéo tách khớp cổ chân

Indications:

• Testing; initial treatment; pain control; general mobility

Accessory Motion Technique

• Patient Position:
  • Supine with the foot over the edge of the table.
• Clinician Position and Hand Placement:
  • Standing at foot of pt facing cephalad
  • Stabilizing Contact: Weight of body and mobilization strap may be used to stabilize distal leg
  • Mobilizing contact: Fingers interlaced over dorsum of foot & anterior talus, with thumbs on plantar surface of foot & forearms parallel to one another; mobilization belt may be used to reinforce hand contacts
• Force Application:
  • Through your hand contacts over the talus, a distraction force is provided in the direction of the forearms by leaning back.

 

Accessory With Physiologic Motion Technique 

• Patient Position: same position as that previously described.
• Clinician Position and Hand Placement: same as that previously described.
• Force Application:
  • Using your hand contacts, provide a fulcrum over the talus and apply a distraction force as the ankle is moved into greater ranges of dorsiflexion. 
  • Force is maintained throughout the entire range of motion and sustained at end range.

Talocrural Posterior Glide/ Trượt ra sau khớp cổ chân

Indications:

• To improve talocrural dorsiflex/ Để cải thiện gập mu cổ chân

Accessory Motion Technique

• Patient Position:
  • Supine with foot over edge of table
• Clinician Position and Hand Placement
  • Standing at foot of pt facing cephalad
  • Stabilizing contact: Clinician stabilizes distal leg by cupping calcaneus with hand 
  • Mobilizing contact: Web space contacts anterior aspect of talus
• Force Application:
  •  Apply a posteriorly directed force through your hand contact at the anterior aspect of the talus. 
  • You may also apply a posteriorly directed force to the talus while actively or passively moving the ankle into progressively greater ranges of dorsiflexion. 
  • As an alternate accessory with physiologic motion technique, mobilization force is maintained throughout the entire range of motion and sustained at end range.

Accessory With Physiologic Motion Technique

• Patient Position:
  • Stand in a lunge position with his or her foot on the side being mobilized on a stool..
• Clinician Position and Hand Placement:
  • You are in a stride stance position facing the patient. A mobilization belt may be used to provide additional force by placing it around the posterior aspect of the patient’s distal leg
  • The web space of both hands reinforce one another over the anterior aspect of the patient’s talus. Your forearms are in line with the posterior direction of force.
• Force Application:
  • The patient slowly shifts weight onto his or her front leg while maintaining the heel in contact with the ground as you apply a posteriorly directed force through the talus contact against the stabilization provided by the belt.
  • Mobilization force is maintained throughout the entire range of motion and sustained at end range.

  

Talocrural Anterior Glide/ Trượt ra trước ở khớp cổ chân

Indications:

• To improve talocrural plantarflex/ Để cải thiện gập lòng bàn chân

Accessory Motion Technique

• Patient Position:
  • Technique #1: Prone with foot over edge of table 
  •  Technique #2: Supine with hip & knee in flex
• Clinician Position and Hand Placement: 
• Technique #1:
  • Stabilizing contact: Clinician stabilizes distal leg
  • Mobilizing contact: Web space contacts posterior aspect of talus/calcaneus
• Technique #2:
  • Stabilizing contact: Clinician stabilizes tibia/fibula against wedge with ankle in plantarflex
  • Mobilizing contact: Clinician contacts anterior talus with web space of hand
• Force Application:
  •  Technique #1: Mobilizing hand exerts anteriorly directed force through calcaneal contact that mobilizes talus anteriorly
  • Technique #2: Proximal hand exerts anteriorly directed force through talus

Accessory With Physiologic Motion Technique

• Patient Position:
  • Supine with the hip and knee flexed and the foot resting on the table or wedge. 
• Clinician Position and Hand Placement:
  • Stabilize the distal leg against the wedge with the patient’s foot in plantar flexion.
  •  Grasp the patient’s talus with the web space of your mobilization hand with your forearm in the direction in which force is applied and prepared to move during the mobilization.
• Force Application:
  • With the distal leg stabilized the mobilization hand applies an anteriorly-directed force through the talus. 
  • Mobilization force is maintained throughout the entire range of motion and sustained at end range.

SUBTALAR JOINT MOBILIZATIONS

Subtalar (Talocalcaneal) Distraction, Medial, and Lateral Glide/ Kéo, Trượt vào trong và ra ngoài khớp dưới sên (sên -gót)

Indications:

• Distraction to improve all physiologic motions of subtalar joint 
• Medial & lateral glide to improve rearfoot ev & inv, respectively

Accessory Motion Technique:

• Patient Position:
  • Prone with dorsum of foot off edge of table
  •  Alternate position of side-lying with foot to be mobilized uppermost & knee flexed
• Clinician Position and Hand Placement:
  • Stand on the ipsilateral side of the foot being mobilized facing caudally or sitting on the table with the patient’s posterior thigh in contact with your back.
  • Stabilizing contact: Holds distal leg on table or stabilizes through flexed knee in contact with clinician’s body
  • Mobilizing contact: Grasps posterior calcaneus with heel of hand or both hands grasp calcaneus.
• Force Application:
  • Impart a caudally directed force parallel to the long axis of the leg through your mobilization hand or hands.

Accessory With Physiologic Motion Technique (Calcaneal rocking)

• Patient Position:
  • Sidelying with the foot being mobilized uppermost. 
  • The patient’s knee is flexed and his posterior thigh is stabilized by your trunk. 
• Clinician Position and Hand Placement:
  • Clinician sitting on the table facing away from the patient.
  • Both of your hands are grasping the patient’s calcaneus with the thumbs forming a “V” over the lateral aspect of the patient’s calcaneus and your forearms in the direction in which force is applied. Stabilization is provided by your trunk.
• Force Application:
  • Take up the slack in the joint and apply a distraction force through both hand contacts. Alternately, distraction in combination with a medial & lateral glide (known as rocking) may also be applied. Mobilization force is maintained throughout the entire range of motion and sustained at end range.

References:

• Christopher H. Wise, Dawn T. Gulick. Mobilization Notes: Rehabilitation Specialist’s Pocket Guide. F. A. Davis Company, 2009.
• Christopher H. Wise. Orthopaedic Manual Physical Therapy: FROM ART TO EVIDENCE. F. A. Davis Company. 2015.
• Carolyn Kisner, Lynn Allen Colby, John Borstad. Therapeutic exercise : foundations and techniques, Seventh edition. F.A. Davis Company. 2018