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
Listhesis – antero/postero is in the sagital plane . PPT 20/04/2009
.Gliding – translational movement.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.
Daaljit Singh HS AMP.
The patient’s description of the pain and its location is obtained. percussion.Diagnostic Criteria for the identification of Joint dysfunction
Pain and Tenderness The perception of pain and tenderness is evaluated in terms of location. and intensity. Most primary musculoskeletal disorders manifest by a painful response. Pain and tenderness findings are identified through observation. and palpation. Furthermore. the location and intensity of tenderness produced by palpation of osseous and soft tissue are noted. quality.
Daaljit Singh HS AMP. PPT 20/04/2009
as well as palpation for misalignment of vertebral segments and extremity joint structures. and accessory joint motions are noted. Palpation is the oldest technique employed to detect dysfunction and is still the most emphasized physical finding supportive of dysfunction. muscle. Special Tests Finally. The relationship between spinous and interspinous tenderness and dysfunction is speculated to result from reflex sensitivity in tissues with shared segmental innervation. It is thought that a decrease in motion is a common component of joint dysfunction. or aberrant motion. Good palpation skills are the result of both physical abilities and mental concentration. diagnosis may require testing procedures that are specific to a technique system. are noted. Range of Motion Abnormality Changes in active. passive. These changes may be reflected by increased. and ligaments. instrumentation. and / or temperature changes are identified through observation. Tenderness to pressure at bony landmarks that are close to articulations is another proposed empirical sign of joint dysfunction. position and inherent motility of the tissues beneath. Texture. Asymmetry is identified through observation (posture and gait analysis). texture. fascia. decreased. PPT 20/04/2009
. including skin. to determine the shape. This includes observation of posture and gait. Palpation Palpation is the application of variable manual pressures. palpation. through the surface of the body. size.Asymmetry Asymmetric qualities are noted on a sectional or segmental level. and tests for length and strength. static palpation and static radiography.
Daaljit Singh HS AMP. Tissue tone. and Temperature Abnormality Changes in the characteristics of contiguous and associated soft tissues. Range of motion abnormalities are identified through motion palpation and stress radiography. Tone. consistency. or as a result of mechanical deformation in structures attaching at these bony sites.
manually assessing temperature of superficial tissues. fasciae. and deeper “functional” tissue layers. keeping the overlying tissue from expanding with the other fingers of your palpation hand. the dorsum of the hands are typically used. Your touch receptors are designed to respond only when not pressed on too firmly. When. 3. and the presence or absence of pain in the dermal. Concentrate on the area and/or structure you want to palpate. ligaments. vessels. For deep palpation. fasciae. subdermal. 3. nerves and vessels. and nerves. Concentrate on your fingers. gentle exploration of the skin with the palmar surfaces of the fingers or thumbs. How to Use Your Palpation Tools 1. Motility and sensitivity of the dermal layer may also be assessed by the technique of skin rolling. do not palpate casually.Soft Tissue Palpation The major function of soft tissue palpation is to determine the contour. experiment with decreasing pressure instead of increasing pressure. Close your eyes to increase your palpatory perception Palpation Hints and Comments 1. 4. never let your mind “out palpate” your fingers. The functional layer consists of the muscles. subdermal layer. Pain may induce protective muscle splinting and make palpation more difficult. consistency. quality. etc.. and your tactile perception may improve. hyperesthesia. motility. tendons. use broad contacts to reach the desired tissues. Establish a palpation routine and stay with it.g. subcutaneous adipose. 2. PPT 20/04/2009
Daaljit Singh HS AMP. Use the least pressure possible. bursae. moisture. Palpation techniques involve light. do not feel what you see or expect to feel. Try not to cause pain if possible. The dermal layer incorporates the skin. Palpation of the dermal layer is directed toward the assessment of temperature. tenderness. Do not let your attention be carried away by unrelated sensations. Use broad contacts whenever possible. then palpate with your palpation finger. Keep an open mind and do not deceive yourself. 2.). Try not to lose skin contact before you are done with the palpation of the area. tendon sheaths. 4. and tissue sensitivity (e.
and whether there is any associated tenderness. To execute end feel. Loss of anticipated end-play elasticity is thought to be indicative of disorders within the joint.
Daaljit Singh HS AMP. the quality of movement. Take every opportunity to add to your tactile “vocabulary” through comparative experiences. and the joint capsule must allow sufficient play and separation between articular surfaces to avoid abnormal joint friction. check for the presence or absence of pain. movement occurs around a shifting axis. or periarticular soft tissue. End-play evaluation is the qualitative assessment of resistance at the end point of passive joint movement. some resistance to movement should be encountered. 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. the quality of the resistance. Joint Play During the performance of joint play. Accessory Joint Motion Joint surfaces do not form true geometric shapes with matching articular surfaces. and joint play is the assessment of resistance from a neutral and / or loose-packed joint position. Accessory joint movements are evaluated by the procedures of joint play and end play (feel). Encountered end-play resistance is a significant finding in the determination of joint dysfunction and adjustive vector orientation. Increased resistance to joint play movements suggests articular soft tissue contractures. and the degree of encountered resistance. Joint play should not induce pain. evaluate the point at which resistance is encountered. PPT 20/04/2009
. producing short-range gliding and distracting movements. its capsule. End-play is assessed by applying additional overpressure to the specified joint at the end range of passive movement.5. but the joint should yield to pressure. As a result.
external rotation of shoulders. resisted by muscle contraction. 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 Interarticular Bouncy springy quality • Abnormal example: meniscal tear. builds with elongation. typically painless. • Abnormal example: capsular fibrosis and / or adhesions leading to a capsular pattern of abnormal end feel. not as stiff as capsular or ligamentous • Normal example: hip flexion Muscle Spasm Guarded. articular hypertrophic changes Mscular Firm but giving. soft tissue swelling Bony Hard. should feel muscle reaction. joint mice
Daaljit Singh HS AMP. Ligamentous Like capsular but may have a slightly firmer quality • Example: knee extention • Abnormal example: noncapsular pattern of abnormal resistance due to ligamentous shortening. squeezing quality. • Example: elbow flexion • Abnormal example: muscle hypertrophy.Normal and Abnormal End Feels
Capsular Firm but giving. Soft Tissue Approximation Giving. results from the approximation of soft tissues. like stretching a piece of leather • Example: close-packed position of the joint. PPT 20/04/2009
. resistance builds with lengthening. nongiving abrupt stop • Example: elbow extention • Abnormal example: bony exostosis.
If it is not written down. illegible handwriting. increased. Errors in recording that have been identified include failure to record findings all together. improper terminology. application of necessary treatment. or aberrant joint movement 5. obscure abbreviations. and /or the joint demonstrates unusual give and deformation. end feel is not encounter at normal point. Assessment procedures are necessary to identify the nature. Regional mobility measures 2.
Daaljit Singh HS AMP. Clinical Features of Joint Dysfunction 1. Local tissue hypersensitivity 3. Altered Alignment 4. Altered end-feel resistance 7. Local palpatory muscle rigidity Outcome Measures for Subluxation/Dysfunction 1. it must be complete and translatable. it was not done. Physical capacity questionnaires 4. It is imperative that though the clinical record comprises the physician’s personal notations. Physical performance measures
The total management of the patient includes clinical assessment. Altered joint play 6. Pain reporting instruments 3. A systematic and accurate record of evaluation facilitates quick reference to salient findings during treatment. and bad grammar. • Abnormal example: joint injury or disease leading to hypermobility or instability. PPT 20/04/2009
. Decreased. and patient education.Empty Normal end feel resistance is missing. extent. Local pain: commonly changes with activity 2. and location of the problem as well as to determine the course of action in treatment.
3. 9. If a downward force is not feasible. Both the stabilizing force and the manipulating force should be as close to the joint surface as possible. Accessory motion should be assessed by comparison with the corresponding joint on the other side of the body. 4. The clinician should be efficient with body mechanics. 6. For example. 12.It should be noted and emphasized that it is unacceptable to use and assign a diagnosis for convenience. 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. Only one joint should be manipulated at a time. a horizontally directed force should be attempted. and appropriate modification should be made based on the pain response.Only one movement should be performed at a time. whenever possible. Each technique is both an evaluative technique and a treatment technique. 2. If not. 10. and should stand with the wide base of support. When performing an assessment manipulation. This is especially true when treating larger joints. The patient should exhibit no muscle guarding and should be relaxed as possible. the clinician should not manipulate a bone into dorsal glide from a ventrally glided position. Most clinical entities have specific and expected signs and symptoms. a belt. the clinician should keep the following principles in mind: 1. The patient’s pain should be monitored during the assessment. 11. One bone should be stabilized with the clinician’s hand or other body part. 7. 8. because it is more difficult to assess movement in this manner. a wedge. therefore the clinician should continually evaluate during
Daaljit Singh HS AMP. The clinician’s grasp should be firm yet painless. the joint should be tested in the actual resting position. or the treatment table. The manipulating force should be as close to the clinician’s centre of gravity as possible. PPT 20/04/2009
. 5. These findings need to be identified and recorded. to control the motion as closely as possible. The other bone is manipulated with the clinician’s hand. The force ideally should be directed downward. The joint should be tested in the resting position if the patient is capable of attaining that position.
treatment. developed oscillatory manipulation treatments and stated that one should oscillate in the direction of reproducible
Grades of Oscillations
Grade 1 Grade 2 Grade 3 Grade 4 Slow small-amplitude oscillatory movement parallel to the concave joint surface that does not take the joint up to the first tissue stop Slow larger-amplitude oscillatory movement parallel to the concave joint surface that does not take the joint up to the first tissue stop Slow. and therefore treatment should be administered in a direction opposite the direction that reproduces pain. Maitland symptoms. 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
Daaljit Singh HS AMP. 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 proposed that the clinician should treat joint dysfunction and minimize the role of pain.
believed that a clinician should not perform a treatment that increases the patient’s symptoms. large-amplitude oscillatory movement parallel to the concave joint surface that takes the joint up to and slightly through the first tissue stop Slow.
Contributors to the knowledge of manipulative therapy
Cyriax which are Mennell Maigne an orthopedic physician who contributed much to the development of a system of physical examination in different tissues affected by orthopedic disorders techniques practiced today Developed the concept that adhesions are a common cause of joint dysfunction. Formal assessments also should be made before and after treatment. PPT 20/04/2009
also called a thrust manipulation.Grade 5
Fast. • If pain occurs after the first motion barrier. small amplitude. • If pain occurs at the same time in the range of motion as the first barrier to motion. which is in postural balance.
• Grades 1 and 2 oscillations are used for pain reduction. and release impinged meniscoid tissue in the spine.
Increasing joint extensibility Correcting positional faults Nutrition
Daaljit Singh HS AMP. • If pain occurs before resistance is met with passive range of motion. 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. correct positional faults. • All grades of oscillation increase nutrition to articular structures. PPT 20/04/2009
. This is accomplished by. 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. increase periarticular extensibility. pain free movement to a musculoskeletal system.
Execution of Treatment
All treatment oscillations are performed with at least grade 1 traction when feasible to decrease compression of joint surfaces. • Grades 3 and 4 are used to reduce pain. then the patient should be able to tolerate up to grade 3 oscillations and tractions. then Grades 1 and 2 oscillation techniques are indicated.
elevate scapula to direct fem head ventrally 2. Distraction • To increase overall range • Clinician facing patient.Pain control/Muscle relaxation Psychological benefits
HIP JOINT. clinician grips distal thigh while facing hip • Glide fem head in caudal direction.
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. • Move femoral head away from acetabulum. 3. supine with leg supported between clinician’s arm and trunk • Glide fem in dorsal direction with manipulating hand
Daaljit Singh HS AMP. Dorsal glide • To increase hip flexion and internal rotation • Pt. Caudal Glide • To increase hip abduction • Pt supine. with patient’s leg over clinician’s shoulder. 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. PPT 20/04/2009
6. clinician at pt’s side • Glide femur in a lateral direction. Dorsal Glide II • To increase flexion • Pt prone.
7. clinician facing hip • Lean into distal thigh to glide femur ventrally 5. Dorsal glide I • To increase flexion • Pt. PPT 20/04/2009
.4. Lateral glide • To increase internal rotation and hip adduction • Pt supine with leg over clinician’s shoulder. 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. Ventral glide • To increase hip extension and external rotation • Pt prone with leg off treatment table. Clinician grips proximal tibia from ventral side • Glide tibia in dorsal direction 3. Clinician’s hand on ventral surface of proximal tibia • Glide tibia dorsally
Daaljit Singh HS AMP. Other techniques
KNEE JOINT (Tibio Femoral)
1. Supine with knee in resting position.
Supine with knee in resting position. Manipulating hand on proximal dorsal surface of tibia. Lateral 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.4. Ventral Glide III • To increase extension • Pt prone. Clinician grips proximal tibia • Glide femur in dorsal direction 6. PPT 20/04/2009
. Lateral Gaping
Daaljit Singh HS AMP.Medial Gaping • 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. Clinician grips proximal tibia • Glide tibia in ventral direction 5. Ventral Glide I
To increase extension • Pt. Supine with knee in resting position. Move lateral joint line medially 10. Glide proximal Tibia medially 8. 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. Ventral Glide II
To increase extension • Pt. glide proximal Tibia laterally 9. • Glide tibia ventrally 7.
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. Avoid compressing patella into the femur 12. Medial 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. 11. Lateral 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 13. PPT 20/04/2009
. 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.• 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. Avoid compressing patella into the femur
Daaljit Singh HS AMP. Move medial joint line laterally
Proximal Tibiofibula joint Distal Tibiofibula joint Fibula glides cranially with dorsi flexion. and caudally with plantar flexion. 4. Distraction: Spreading • To increase joint play and dorsi flexion • Pt in supine. Fibula rotates laterally with dorsi flexion. in supine with knee supported in resting position on pillow/rolled towel • Glide proximal fibula in dorsal direction 2. PPT 20/04/2009
. 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. Dorsal Glide
Daaljit Singh HS AMP. with hands on tibial and fibula distal ends • Move both tibia and fibula away from each other. With Dorsi flexion. 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. Clinician at foot end.
Ventral Glide • Increase joint play of distal TF jt and dorsi flexion. • Pt Supine. Cranial Glide • To increase dorsi flexion and joint play • Pt in supine • Stabilize Tibia and Glide fibula in cranial direction 7. Clinician grips proximal talus with both hands • Move Talus distally by leaning backwards 2.• Increase joint play of distal TF jt and plantar flexion. Clinician at foot end of treatment table • Stabilize Tibia and Glide Lateral Malleolus in ventral direction 6. • Pt Prone. Distraction • To Increase overall joint play of Talo Crural joint • Pt in Supine. Distraction II • To improve joint play in subtalar joint
Daaljit Singh HS AMP. PPT 20/04/2009
. Caudal Glide • To increase plantar flexion and joint play • Pt in supine • Stabilize Tibia and Glide fibula in caudal direction
Dorsi flexion is restored by gliding talus dorsally Plantar flexion is restored by gliding Talus Ventrally 1. Clinician at foot end of treatment table • Stabilize Tibia and Glide Lateral Malleolus in dorsal direction
Clinician grips talus ventrally and stabilizes lower leg dorsally • Glide talus in dorsal direction 4. Dorsal Glide • To improve talocrural joint play and dorsi flexion • Pt in Supine. Eversion Mobilisation • To increase subtalar joint play and subtalar eversion • Pt in prone. Clinician grips talus dorsally and stabilizes lower leg Ventrally • Glide Talus in a ventral direction 5. in prone. Glide calcaneum in inversion direction simultaneously with varus direction of calcaneum
Manipulation and Mobilization Extremity and Spinal Techniques
Daaljit Singh HS AMP. Glide calcaneum in eversion direction simultaneously with valgus direction of calcaneum 7. Manipulating hand grips calcaneum dorsally • Stabilise talus. Ventral Glide I • To improve talocrural joint play and increase plantar flexion • Pt. Clinician grips talus ventrally and stabilizes lower leg Dorsally • Glide Tibi and fibula in a dorsal direction 6. in supine. Grip the talus ventrally and calcaneum dorsally • Move calcaneum distally 3. Ventral Glide II • To improve talocrural joint play and increase plantar flexion • Pt. Manipulating hand grips calcaneum dorsally • Stabilise talus. Inversion Mobilisation • To increase subtalar joint play and subtalar inversion • Pt in prone.• Pt in Prone . PPT 20/04/2009
P. Edmond. PPT 20/04/2009
.T. M.Susan L. P..
Daaljit Singh HS AMP.H.