This is Brent of the Brookbush Institute and in this video we're going to go over a joint
based manual therapy technique. If you're watching this video I'm assuming you're
watching it for educational purposes, and that you are a licensed professional
with joint based techniques within your scope; that means osteopath, chiropractors,
physical therapists, you're probably all in the clear. Physical therapy assistants,
athletic trainers, massage therapist, you need to check with your governing body
in your state or region to see whether this is within your scope of practice.
Personal trainers this is definitely not within your scope of practice. Of course
all professions could use this video for purely educational purposes to help with
learning biomechanics, anatomy, and of course palpation. In this video we're
going to go over anterior to posterior talus on tibial mobilization. I'm
going to have my friend Melissa come out, she's going to help me demonstrate. Now
if I'm doing a joint mobilization chances are I've already done some sort
of passive accessory motion exam, and I found stiffness in the direction I'm
trying to mobilize. We could use convex on concave rules and although they're
not totally reliable for all joints, they work out pretty good for the ankle.
Convex on concave would be glide opposite roles, so if I'm doing a
posterior glide that would help anterior role, which would increase dorsiflexion,
so maybe we want to use dorsiflexion as an assessment of the effectiveness of
this technique. We could also look at the research, and I think if you guys look at
the research on arthrokinematics and mobilizations of the ankle, the one
consistent thing is anterior to posterior motion of the talus seems
to get stiff, and that these anterior to posterior mobilizations generally
increase function. Now to show you guys this technique I'm going to have Melissa go ahead and
throw this leg off the table, I wouldn't normally do this technique with Melissa
in that position. The thing you're going to find with all of our joint
mobilization is just as with all soft tissue techniques and even most
exercises, is the more anatomy you know the better off you are. So if you don't
know some of the landmarks of the bones of the ankle, that would be a good thing
to review before you start practicing these techniques. I'm going to show you
guys where to find a few of them right off the bat here. So you can see the
medial malleolus here and then opposite the medial malleolus,
although I know you cant see at this angle, is the
lateral malleolus. You should be able to find those two big bumps
pretty easily, and you should be able to find
the bottom of those bumps pretty easily, that's going to help with this technique.
Another thing to find is the navicular tubercle, and that that's a that's a
pretty pretty sharp bump inferior and anterior to the medial malleolus, and
then if I go inferior and posterior, invert her foot a little bit, and go
through that soft tissue, I can find the sustentaculum tali. And the reason why
I'm trying to find all this, is get myself familiar with with where the
talus is and the shape of the talus, because I need to find the neck
of the talus, that's where I'm going to be applying my anterior to posterior
force. A couple ways to find that, you guys can find the bottom of the medial
malleolus, the bottom of the lateral malleolus, drop
your webspace down right over the line that you would draw between those two
points alright, right in the angle of the ankle. Generally speaking that will
put you right on top of the neck of the talus. Now if you want to get more
exacting, you could look for that space between the navicular tubercle and the
anterior inferior portion of the medial malleolus right. So you're going right
between the navicular tubercle and the medial malleolus, and you can look for
the convex surface in there, that's also the neck of the talus, and then you
could you could follow that convex surface all the way around to the
lateral malleolus. Of course you've got to jump over the, can you dorsiflex for
me, you've got to jump over this tibialis anterior tendon her but,
there's a couple other tendons in there you've got to jump over but, you guys can
kind of feel that convex surface if you really want to get exacting about where
you're going to put your webspace, which is again over the neck of the talus. A
comment on the neck on the webspace here guys, I know most people think that
the webspace is a flap of skin, and that it's not hard
and that it'll feel fine for a joint mobilization, but you have to be a little
bit more careful when you do these techniques. If you guys really stiffen
out your hand like this and then go straight down, you decrease the surface
area so much of your webspace on there their ankle here, that it basically feels
like a chisel going straight into bone. It actually hurts, you can actually
really pinch somebody with your webspace. So make sure that your hand is
soft alright, soft and supple and that you're just going to flip your hand down.
I would suggest that you press with this part of your web space, not this part of
your web space. Alright so you guys can see you flip your hand down just like
this. Alright so we got our anatomy and I'm already starting to explain the hand
position here, but what am I going to do with this hand,
how am I going to get my hand set up so that I'm ready to create this anterior
to posterior force and potentially increase dorsiflexion. Well you're also
going to want to be able to control the foot and the calcaneus, which is fairly
rigidly connected to the talus. I want you to take this hand and wrap it around
the calcaneus this way, alright so you got to, you got to really hook the
calcaneus there. Don't do this because this will pull your fingers out and
you'll you'll struggle just to keep your hand from sliding off their ankle, if you
hook this way you'll get a nice good grip, I mean you can feel like, I could
feel like I could just tear Melissa's calcaneus right off, which I'm sure is
exactly what you wanted to hear but you need a nice firm grip right. So you get a
nice firm grip of the calcaneus and then you need to do this little trick, get
your forearm underneath the ball of the foot alright, so don't do this, this is
tough, this is tough, you'll end up like trying to muscle stuff. Hook, come around,
and now I can control dorsiflexion just like this, I lock out my elbow and I can
shift my weight back and forth, I don't have to muscle this at all, and I also
just with internal and external rotation of my arm
have great control over eversion an inversion. Now this hand goes right back
where we were talking about, I can find my navicular tubercle, my
medial malleolus, drop my webspace right down in between there, pull into
dorsiflexion. We do have some research that's starting to suggest that maybe we
should be doing our joint mobilizations at our pain-free end range of motion, if
our goal is to increase range of motion. Alright so I could take her up to her
first resistance barrier here, and now my hands are all set up, hopefully you guys
can kind of see how that is. Now you might notice that to get into position
all right, so let's -we got palpation, we got hand position, let's talk about some
body position here. Notice Melissa is lying and comfortable that's fine, this
is an easy technique, there's not there's nothing major the patient has to do. Make
sure they're calcaneus is hanging off the table because if you try to set up
with our calcaneus on the table, as soon as you go to press down, you just end up
smashing their calcaneus into your hand and pinching your fingers, that doesn't
feel good. But notice how when I put myself in the position I had to lean
forward, that is purposeful. So this isn't, this isn't quite like a stretch where I
want to stand straight up and then just lean sideways, what I want to do is
create an anterior to posterior force. So I actually want some of my upper body
mass over the top of my straightened arms, so that all I have to do is
essentially rock this way. I'm not trying to muscle this mobilization because
that's going to wear out my hands. So calcaneus, ball of foot, alright and
find my navicular tubercle, medial malleolus, drop my webspace down,
and I flattened that out and kind of just left my hand supple. I leaned in to get a
much dorsiflexion as as I can take her into, first resistance barrier without
pain, and now I'm leaned forward, so to start this oscillation I just have to
lean a little further, that's it. Now a couple things that I'm going to want to
think about before I I start pushing as hard as I'm going to
for this technique, is do I feel this to tibialis anterior tendon popping me out
of the neck of her talus right. We have to consider, go ahead and
dorsiflex again, if she -if she guards, essentially if she doesn't want me to do
this technique and she starts like contracting these muscles, I'm just going
to end up mobilizing her tibialis anterior tendon, that's that's not
necessarily going to be helpful as my goal is to increase arthrokinematic
motion. So I need to be aware of that, and I think if you have somebody dorsiflex
with your hand over the neck of the talus, you'll feel it pushes you right
out. So make sure they're relaxed and if you have to kind of reset, maybe start
with a little less dorsiflexion, go for it. Maybe you're going to have to
kind of give a few few test oscillations, before you really go into
the technique just to get them to relax. Maybe have them tell you a story,
whatever you have to do to get their mind off what's going on here, and get
them to calm this muscle down. The other thing you could do, although it's not as
as common with this technique, is you do have your peroneal nerve which if you
shear it sometimes just the right way on this technique, is you put your hand into
position you'll stretch it, and that of course will give somebody a little singe
or a little burn, or or that nerve nerve, nerve sensation that just just isn't
very comfortable, of course if you do that just reposition your hand. This this
technique isn't isn't usually, it's usually not a problem on this technique,
so if you do happen to feel that, chances are you could move your hand a couple
millimeters in any direction and that will stop happening. So now what? Alright
so I got my hand position, body position, now we can talk about protocols.
Now I'm a maitland trained certified orthopedic manual therapist so what I
learned was the grade one, two, three and four mobilizations, one to two
oscillations per second, usually for thirty seconds to two minutes. Now I
don't want to make this a big thing about protocols, I think protocols should
probably be tested to see which one is the best,
but I would leave that to research. My big thing for you guys is all of these
protocols tend to have a couple things in common right, they tend to make sure
that you find the first resistance barrier, or the first sign of resistance
as you're pushing down, and then of course the end of arthrokinematic
range, so only far as you can glide the joint. And most of them do mobilization
somewhere around 50 percent, that is 50 percent between that first resistance
and the end of arthrokinematic range of motion; and then whatever protocol you're
using, just finish it. The biggest mistake I see from students is they'll they'll
kind of go all right so 1 to 2 oscillations per second , 50%, alright
dorsiflex, and you're like dude that was like 7 oscillations I think maybe
for 3 seconds, I think 30 seconds would probably be more appropriate for a
Maitland style technique; and if you're using something else that for example is
several five-second holds,then do all of them and then retest, just go through
with your protocol. So again if I'm going to use this Maitland protocol, I'm going
to go ahead and get the calcaneus going, I'm going to bring my forearm around which
is on the ball of her foot, now I have good control, I'm going to make sure
she's in neutral for inversion and eversion, I'm going to put my hand in
there, in the neck of our talus so right between navicular tubercle medial
malleolus, dorsiflex. Now again I'm going to move her talus posteriorly, so I
want to make sure I move all of me, all of her foot is going to come with me
alright, because we're going to move this whole thing on the tibia which is now
stabilized by the table. I'm going to find my first resistance barrier which
once I get through the table here, is right about there, then end of arthro-
kinematic range is there, and back off to 50%. I'm just going to do some some grade
threes here, okay so this is just a little larger
amplitude at 50% of resistance, and I'm going to keep going until I feel a
reduction in arthrokinematic stiffness. You feel any nerve stuff? No, I don't feel
her tibialis anterior tendon popping into my hand so she's not
guarding on me, and I'm just going to keep going until I feel like things are
softening up. Now I could do grade fours alright, start small oscillations right
at 50%. I could go grade four plus and go a
little closer to arthrokinematic end range, but again these, these are just
protocols. The big thing for you guys to get is hand position, understand the
technique, understand your body position, start feeling arthrokinematic motion,
and then staying consistent with whatever protocol you're going to use.
Stay tuned for the close-up recap. Now for our close-up recap you guys can see
the lateral malleolus right here, and you can see this like indentation right here,
right where the angle of the ankle is where it changes direction, the neck of
the talus is right underneath that. So you can see if I just slide my thumb
underneath the lateral malleolus there, it almost puts my webspace right on top
of the neck of the talus naturally, so I can create that anterior to posterior
force. Now the other hand is going to go around the bottom of the calcaneus, and
notice how I kind of hook the calcaneus like this, not only around from medial to
lateral, but I kind of hook on top of it to superior, and then I'm going to bring
my forearm around so that I have good control of now eversion and inversion,
which I'm going to keep that in neutral, I can bring Melissa into all of her
available dorsiflexion, that's pain-free dorsiflexion. Now I can put
this hand back over the neck of the tailus, straighten out my arms, and I'm
in good position to move her entire foot and talus as one
unit, so that I get a nice anterior to posterior mobilization of talus on
tibia, which is supported by the table. We talked about watching out for the
peroneal nerve, which sometimes if you're not careful you can kind of stretch or
impinge on and that causes a little bit of pain; and we talked about guarding,
Melissa go ahead and dorsiflex for me, now you guys see this right here, this right
here is your tibialis anterior tendon that'll pop your right out of the neck
of the talus, and you can even see here this is the tendon of her extensor
digitorum longus, and that will also pop you out of the neck of the talus. So
be careful that they're not guarding because that will make it real hard to
do your mobilization. But if we just slide in, once again slide that hand over,
forearm under, dorsiflexion. I can move through all, her foot all as one unit
through all available arthrokinematic range, noting here's my first
resistance barrier, there's the end of arthrokinematic range, back off to
50%, and now I can do like let's say a grade three mobilization which is my
larger amplitude from zero resistance to 50%, one to two oscillations per
second, until I feel a reduction in stiffness. To show you guys the other
side,
go ahead and drop this off, so again this side comes around like this alright,
notice that these two fingers are actually superior
to the calcaneus here or the tuberosity of the calcaneus, then i snake my forearm
around, this finger ends up going right between the bottom of the medial
malleolus, and the tubercle of the navicular bone. Alright so you saw how my
thumb went right under the lateral malleolus, my index finger goes right
under the medial malleolus, and then my webspace which I'm going to flop down
like this with nice soft hand, goes right over the neck of the talus, and I can
move that that whole foot as one unit, shearing the talus on the tibia. So
there you have it, assess, address, reassess. Make sure that every time you
choose a joint based manual therapy technique it is based on an assessment,
and that you return to that assessment after you've finished the intervention,
to see if it was effective for the individual, the patient, or client that
you had in front of you. Ensure that you continue to learn your Anatomy because
your Anatomy is going to help you with your hand placement,, with understanding
what a joint can do, with understanding what you may gain from this particular
technique. And of course practice, you have to practice these techniques,
hopefully not for the first time on a patient or client who just walked in the
door. If you can find a more senior instructor or mentor to give you some
really good hands-on instruction. Use your peers for some good feedback, and of
course always look for live education to help with your manual therapy techniques.
I know these videos make education very convenient, but there is no substitute
for learning manual therapy in a live setting. I look forward to talking to you
guys again soon.