JOINT MOBILIZATION OF THE ANKLE AND THE FOOT. PART 2

Cập nhật lần cuối vào 17/03/2023

Phần 2 trình bày các kỹ thuật di động khớp cho khớp giữa cổ chân (midtarsal joint), khớp gian cổ chân (intertarsal joint), cổ- bàn chân (TMT), bàn- ngón chân (MTP) và liên ngón chân (IP).

XEM LẠI: JOINT MOBILIZATION OF THE ANKLE AND THE FOOT. PART 1

MIDTARSAL JOINT MOBILIZATIONS

Khớp giữa cổ chân (midtarsal joint) gồm khớp sên – ghe (Talonavicular) ở trong và gót – hộp (Calcaneocuboid).

Midtarsal (Talonavicular and Calcaneocuboid) Glide

Indications:

• Dorsal glide to improve midtarsal dorsiflex & inv / Trượt về phía mu để cải thiện gấp mu và vặn trong
• Plantar glide to improve midtarsal plantarflex & ev /Trượt về phía lòng để cải thiện gấp lòng và vặn ngoài

Accessory Motion Technique

• Patient Position:
  • Prone with foot on wedge (bệnh nhân nằm sấp, bàn chân ở mép giường)
  • Alternate position of supine with foot over edge of table & wedge supporting distal leg
• Clinician Position and Hand Placement:
  • Standing at foot of pt facing cephalad
  • Stabilizing contact:
    • Contact medial aspect of calcaneus & talus & fixate foot onto wedge for talonavicular mobilization. 
    • Contact lateral aspect of calcaneus & fixate foot on wedge for calcaneocuboid mobilization
  • Mobilizing contact: Pinch grip or full hand grip over:
    • Medial aspect of foot, grasping navicular for talonavicular mobilization
    • Lateral aspect of foot, grasping cuboid for calcaneocuboid mobilization
• Force Application:
  • Through your mobilization hand contact, apply a dorsal or plantar force through the navicular medially or cuboid laterally.

Accessory With Physiologic Motion Technique 

• Patient Position:  same position as previously described.
• Clinician Position and Hand Placement: The same positions are used as previously described.
• Force Application:
  • Apply a dorsal or plantar glide through the mobilization hand contact as active or passive ankle dorsiflexion and plantarflexion are performed, respectively.

INTERTARSAL JOINT MOBILIZATIONS

Intertarsal Glide

Indications:

• To improve all physiologic motions of ankle & foot

Accessory Motion Technique

• Patient Position:
  •  prone  with the foot over the edge of the table and a wedge supporting the joint to be mobilized. 
• Clinician Position and Hand Placement:
  • Stand on the medial side to mobilize the lateral aspect of the foot and stand on the lateral side to mobilize the medial aspect of the foot.
  • Stabilizing contact: Pinch grasp used to stabilize adjacent tarsal bone or open hand fixates foot on underlying wedge
  • Mobilizing contact: Pinch grasp used to engage tarsal bone to be mobilized
• Force Application:
  • Apply a plantar or dorsal glide as the adjacent tarsal bone is stabilized. 
  • Mobilization proceeds sequentially from proximal to distal along the medial column beginning with mobilization of the navicular on the stabilized talus, followed by mobilization of the medial, intermediate, and lateral cuneiforms on the stabilized navicular, and mobilization of the medial cuneiform on the stabilized intermediate cuneiform. 
  • Mobilization is then performed sequentially from proximal to distal along the lateral column, beginning with mobilization of the cuboid on the stabilized calcaneus, followed by mobilization of the lateral cuneiform on the stabilized cuboid.

Accessory With Physiologic Motion Technique 

• Patient Position: same position as previously described. The patient’s foot is over the edge of the table.
• Clinician Position and Hand Placement: same positions are used as previously described.
• Force Application: Apply glides to each tarsal bone while stabilizing each adjacent tarsal bone as passive or active motion in all directions is performed.

TARSOMETATARSAL JOINT MOBILIZATIONS

Tarsometatarsal Distraction and Glide/ Kéo tách và Trượt khớp cổ – bàn

Indications:

• To improve all physiologic motions of TMT joint & overall midfoot/forefoot mobility

Accessory Motion Technique

• Patient Position:
  • Supine with knee in flex & foot resting on wedge at joint to be mobilized
• Clinician Position and Hand Placement:
  • Standing on medial side of foot to mobilize laterally & standing on lateral side of foot to mobilize medially
  • Stabilizing contact: Pinch grasp used to stabilize tarsal bone or open hand fixates foot on underlying wedge
  • Mobilizing contact: Pinch grasp used to engage base of metatarsal to be mobilized
• Force Application:
  • While stabilizing the adjacent tarsal bone, apply a distraction force or glide in a plantar or dorsal direction through your mobilization contact to the base of the metatarsal. 
  • Metatarsals 1 through 3 are mobilized on the stabilized medial, intermediate, and lateral cuneiforms, respectively, and metatarsals 4 and 5 are mobilized upon the stabilized cuboid.

INTERMETATARSAL JOINT MOBILIZATIONS

Intermetatarsal Sweep /”Quét” giữa các xương bàn chân

Indications:

• To improve mobility of entire midfoot & forefoot that will assist with all physiologic motions of foot/ Để cảo thiện vận động của toàn bộ bàn chân giữa và bàn chân trước nhằm hỗ trợ cho các vận động sinh lý của bàn chân

Accessory Motion Technique

• Patient Position:
  • Supine with the foot over the edge of the table. 
• Clinician Position and Hand Placement:
  • Sit at the foot of the patient facing cephalad.   
  • Your fingers are placed horizontally over the dorsal or plantar aspects of the forefoot and your thumbs are placed on the opposite side.
• Force Application:
  • A sweeping motion is applied through your finger contacts which is designed to increase or decrease the plantar arch against the fulcrum of the opposing thumbs. 
  • The process is then reversed and the thumbs provide a sweeping motion against the fulcrum of the opposing fingers.

Accessory With Physiologic Motion Technique 

• Patient Position: Same position as previously described.
• Clinician Position and Hand Placement: same as previously described.
• Force Application:
  • The mobilization designed to increase the plantar arch is performed while the patient actively performs plantar flexion, and the mobilization designed to decrease the plantar arch is performed while the patient actively performs dorsiflexion. 
  • Mobilization force is maintained throughout the entire range of motion and sustained at end range.

METATARSOPHALANGEAL JOINT MOBILIZATIONS

Metatarsophalangeal Distraction and Glide/ Kéo tách và Trượt hớp Bàn- đốt (MTP)

Indications:

• Distraction to improve motion in all directions/ Kéo tách để cải thiện vận động mọi hướng
• Dorsal & plantar glide to improve MTP ext & flex, respectively/ Trượt mu và trượt lòng để cải thiện duỗi và gấp khớp MTP tương ứng

Accessory Motion Technique

• Patient Position:
  • Supine with knee in flex & foot resting on wedge
• Clinician Position and Hand Placement:
  • Standing at foot of pt
  • Stabilizing contact: Pinch grasp used to stabilize most distal aspect of metatarsal head
  •  Mobilizing contact: Pinch or hook grasp to engage most proximal aspect of distal phalanx
• Force Application:
  • While stabilizing the adjacent metatarsal, apply a distraction force or glide in a plantar or dorsal direction through your mobilization contact to the base of the proximal phalanx.

Accessory With Physiologic Motion Technique

• Patient Position: same position as previously described.
• Clinician Position and Hand Placement:
  • Clinician in same position as previously described
  • The proximal phalanx is contacted medially and laterally with the mobilization hand.
• Force Application:
  • Apply a distraction force during active or passive metatarsophalangeal flexion or extension. 
  • Apply a dorsal glide during active or passive extension or apply a plantar glide during active or passive flexion. A medial or, more commonly, lateral glide may also be applied during active extension or flexion depending on which is most limited and/or painful. 
  • Mobilization forces are maintained throughout the entire range of motion and sustained at end range.

INTERPHALANGEAL JOINT MOBILIZATIONS

Interphalangeal Distraction and Glide/ Kéo tách và Trượt khớp Gian đốt

Indications:

• Distraction & unicondylar glide to improve motion in all directions 
• Dorsal & plantar glide to improve I/P ext & flex, respectively

Accessory Motion Technique

• Patient Position:
  • Supine with knee in flex & foot resting on wedge
• Clinician Position and Hand Placement:
  • Standing at foot of pt facing cephalad
  •  Stabilizing contact: Pinch grasp used to stabilize most distal aspect of head of proximal or middle phalanx
  • Mobilizing contact: Pinch or hook grasp performed to engage most proximal aspect of base of middle (for PIP mobilization) or distal phalanx (for DIP mobilization)
• Force Application:
  • While stabilizing the adjacent phalanx, apply a distraction force or glide in a plantar or dorsal direction through your mobilization contact to the base of the middle or distal phalanx. 
  • Unicondylar glides may be performed by directing forces through either the medial or lateral aspects of the most proximal aspect of the base of the middle (for PIP mobilization) or distal phalanx (for DIP mobilization).

Midtarsal High Velocity Thrust (Whip Manipulation)

Indications: 

• To  improve mobility of midfoot &, more specifically, mobility of calcaneocuboid or talonavicular joints

Accessory Motion Technique:

• Patient Position:
  • Prone with knee in 45°–60° of flex near edge of table
• Clinician Position and Hand Placement:
  • Standing at foot of pt facing cephalad
  • Thumb-over-thumb contact made over plantar aspect of either cuboid or navicular & fingers of both hands wrapped around & resting on dorsum of foot
• Force Application:
  •  Apply force in a dorsal direction through both thumb contacts and maintain this force as you extend the patient’s knee and plantarflex the ankle toward end range.
  •  Once tissue resistance is engaged, a high velocity, low amplitude thrust is applied through the thumb contacts as the foot is brought through an elliptical arc of motion that is produced by ulnar deviation of your wrists.