JOINT MOBILIZATION OF THE ANKLE AND THE FOOT. PART 1

Cập nhật lần cuối vào 24/11/2022

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

Accessory motions of the talocrural joint in open chain, which includes A. posterior roll and anterior glide during plantarflexion and B. anterior roll and posterior glide during dorsiflexion.
The subtalar joint functions as a mitered hinge. Transverse plane motion

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.
Distal tibiofibular glide. 
Distal tibiofibular posterior glide. 

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.

Distal tibiofibular glide accessory with physiologic motion technique. 

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.
Talocrural distraction.
Talocrural distraction.

 

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.
Talocrural posterior glide. 

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 posterior glide accessory with physiologic motion in standing technique.   

  

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
Talocrural anterior glide. 

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.
Talocrural anterior glide accessory with physiologic motion technique. 

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.
Subtalar distraction, medial, and lateral glide. 
Subtalar distraction
Subtalar lateral glide in prone position
Subtalar lateral glide sidelying

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.
Subtalardistraction, medial, and lateral glide accessory with physiologic motion technique (calcaneal rocking)

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
    

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