PERIPHERAL JOINT MOBILIZATION/MANIPULATION

Joint mobilization, also known as manipulation, refers to manual therapy techniques that are used to modulate pain and treat joint impairments that limit range of
motion (ROM) by specifically addressing the altered mechanics of the join.

INDICATION LIMITATIONS CONTRAINDICATIONS/PRECAUTION CONDITIONS REQUIRING

S SPECIAL ORECAUTIONS FOR
STRETCHING
 Pain, Mm guarding and  Joint techniques cannot  Hypermobility  Malignancy
Spasm change the disease  Joint Effusion  Bone disease detectable on
 Reversible joint process of disorders such  Inflammation radiographs
hypomobility as rheumatoid arthritis or  Unhealed fracture
 Positional the inflammatory process  Excessive pain
faults/subluxations of injury.  Hypermobility in associated
 Progressive limitation  The skill of the therapist joints
 Functional mobility affects the outcome  Total joint replacements
 Newly formed or weakened
connective tissue (after injury,
surgery or disuse)
 Systemic connective tissue (RA)
 Elderly individuals with
weakened connective tissue and
diminished circulation

INDICATION PATIENT POSITION THERAPIST AND HAND MOBILIZING FORCE

 PLACEMENT
GLENOHUMERAL JOINT
Resting position: The shoulder is abducted 55°, horizontally adducted 30°, and rotated so the forearm is in the horizontal plane with respect to the body (called plane of
the scapula).
Treatment plane: The treatment plane is in the glenoid fossa and moves with the scapula as it rotates.
Stabilization: Fixate the scapula with a belt or have an assistant help.

Glenohumeral  Testing; initial Supine, with arm in the resting position.  Stand at the patient’s side, With the hand in the axilla,
Distraction treatment facing toward his or her move the humerus laterally.
(sustained grade II) head.
 Pain control (grade  Use the hand nearer the
I or II oscillations) part being treated (e.g., left
 General mobility hand if treating the
(sustained grade patient’s left shoulder) and
III) place it in the patient’s
axilla with your thumb just
distal to the joint margin
anteriorly and fingers
posteriorly.
 Support the forearm
between your trunk and
elbow.
 Your other hand supports
the humerus from the
lateral surface.

Glenohumeral Caudal  To increase Supine, with arm in the resting position  Stand lateral to the With the superiorly placed
Glide in Resting abduction patient’s arm being treated hand, glide the humerus in an
Position (sustained grade and support the forearm inferior direction.
III) between your trunk and
 Reposition the elbow. Place one hand in
humeral head if the patient’s axilla to
superiorly provide a grade I
positioned distraction.
 The web space of your
other hand is placed just
distal to the acromion
process.

Glenohumeral Caudal Supine, with arm in the resting position Support the patient’s forearm between your trunk and elbow. Grasp
Glide (Long Axis around the distal arm with both hands and apply the force in a
Traction) caudal direction as you shift your body weight toward the patient’s
 feet.

Glenohumeral Caudal To increase abduction. Supine or sitting, with the arm abducted to  With the patient supine, With the hand on the
Glide Progression the end of its available range. stand facing the patient’s proximal humerus, glide the
External rotation of the humerus should be feet and stabilize the humerus in an inferior
added to the end- range position as the arm patient’s arm against your direction with respect to the
approaches and goes beyond 90°. trunk with the hand farthest glenoid fossa of the scapula.
from the patient. Slight
lateral motion of your trunk
provides grade I distraction
via a long-axis traction.
 With the patient sitting,
stand behind the patient
and cradle the distal
humerus with the hand
farthest from the patient;
this hand provides a grade I
distraction via a long-axis
traction.
 Place the web space of your
other hand just distal to the
acromion process on the
proximal humerus.

Glenohumeral To increase elevation Supine or sitting, with the arm abducted  Hand placement is the With the hand on the
Elevation Progression beyond 90° of abduction. and externally rotate to the end of its same as for caudal glide proximal humerus, glide the
available range. progression. humerus in a progressively
This is used when the  Adjust your body position anterior direction against the
range is greater than 90°. so the hand applying the inferior folds of the capsule
mobilizing force is aligned in the axilla.
with the treatment plane in The direction of force with
the glenoid fossa. respect to the patient’s body
 With the hand grasping the depends on the amount of
elbow, apply a grade I upward rotation and
distraction force protraction of the scapula.

Glenohumeral  To increase flexion Supine, with the arm in resting position.  Stand with your back to the Glide the humeral head
Posterior Glide,  increase internal patient between the posteriorly by moving the
Resting Position patient’s trunk and arm. entire arm as you bend your
 rotation.  Support the arm against knees.
your trunk, grasping the
distal humerus with your
lateral hand. This position
provides grade I distraction
to the joint.
 Place the lateral border of
your top hand just distal to
the anterior margin of the
joint, with your fingers
pointing superiorly. This
hand gives the mobilizing
force.

Glenohumeral  To increase Supine, with the arm flexed to 90° and  Place padding under the Glide the humerus
Posterior Glide posterior gliding internally rotated and with the elbow scapula for stabilization. posteriorly by pushing down
Progression when flexion flexed. The arm may also be placed in  Place one hand across the at the elbow through the long
approaches 90° horizontal adduction. proximal surface of the axis of the humerus.
 Increase horizontal humerus to apply a grade I
adduction distraction.
 Place your other hand over
the patient’s elbow.
 A belt placed around your
pelvis and the proximal
aspect of the patient’s
humerus may be used to
apply the distraction force.
Glenohumeral  To increase Prone, with the arm in resting position over  Stand facing the top of the Glide the humeral head in an
Anterior Glide, extension the edge of the treatment table, supported table with the leg closer to anterior and slightly medial
Resting Position  increase external on your thigh. Stabilize the acromion with the table in a forward stride direction. Bend both knees so
rotation. padding. The supine position may also be position. the entire arm moves
used.  Support the patient’s arm anteriorly.
against your thigh with
your outside hand; the arm
positioned on your thigh
provides a grade I
distraction.
 Place the ulnar border of
your other hand just distal
to the posterior angle of the
acromion process, with
your fingers pointing
superiorly; this hand gives
the mobilizing force.

Glenohumeral External To increase external Techniques

Rotation Progressions rotation. Because of the danger of subluxation when applying an anterior glide with the humerus externally rotated, use a
distraction progression or elevation progression to gain range.
 Distraction progression: Begin with the shoulder in resting position, externally rotate the humerus to end-
range, and then apply a grade III distraction perpendicular to the treatment plane in the glenoid fossa.
 Elevation progression: This technique incorporates end-range external rotation.
 Several research studies have documented increased external rotation by using a posterior glide. This is
particularly beneficial when the humeral head is anteriorly displaced in the glenoid fossa and the posterior
 capsule is tight.

ACROMIOCLAVICULAR JOINT
Indication: To increase mobility of the joint
Stabilization: Fixate the scapula with your more lateral hand around the acromion process.

Anterior Glide of Sitting or prone  With the patient sitting, Push the clavicle anteriorly
Clavicle on Acromion stand behind the patient with your thumb.
and stabilize the acromion
process with the fingers of
your lateral hand.
 The thumb of your other
hand pushes downward
through the upper trapezius
and is placed posteriorly on
the clavicle, just medial to
the joint space.
 With the patient prone,
stabilize the acromion with
a towel roll under the
shoulder.

STERNOCLAVICULAR JOINT
Joint surfaces: The proximal articulating surface of the clavicle is convex superiorly/inferiorly and concave anteriorly/ posteriorly with an articular disk between it and the
manubrium of the sternum.
Treatment plane: For protraction/retraction, the treatment plane is in the clavicle. For elevation/depression, the treatment plane is in the manubrium.
Patient position and stabilization: Supine; the thorax provides stability to the sternum.
Sternoclavicular  Posterior glide to  Place your thumb on the  Posterior glide: Push
Posterior Glide and increase retraction anterior surface of the with your thumb in a
Superior Glide  superior glide to proximal end of the posterior direction.
increase clavicle.  Superior glide: Push
depression of the  Flex your index finger and with your index
clavicle place the middle phalanx finger in a superior
along the caudal surface of direction
the clavicle to support the
thumb.

Sternoclavicular  Anterior glide to Your fingers are placed superiorly  Anterior glide: lift
Anterior Glide and increase and thumb inferiorly around the the clavicle
Caudal (Inferior) protraction clavicle. anteriorly with your
Glide  caudal glide to fingers and thumb.
increase elevation  Caudal glide: press
of the clavicle the clavicle inferiorly
with your fingers.

SCAPULOTHORACIC SOFT-TISSUE MOBILIZATION

Patient position: If there is considerable restriction in mobility, begin prone and progress to side-lying, with the patient facing you. Support the weight of the patient’s
arm by draping it over your inferior arm and allowing it to hang so the scapular muscles are relaxed.
Hand placement: Place your superior hand across the acromion process to control the direction of motion. With the fingers of your inferior hand, scoop under the medial
border and under the inferior angle of the scapula.
Mobilizing force: Move the scapula in the desired direction by lifting from the inferior angle or by pushing on the acromion process.

HUMEROULNAR ARTICULATION
Convex - trochlea articulates with the concave - olecranon fossa.
Resting position: Elbow is flexed 70°, and forearm is supinated 10°.
Treatment plane: The treatment plane is in the olecranon fossa, angled approximately 45° from the long axis of the ulna.
Stabilization: Fixate the humerus against the treatment table with a belt or use an assistant to hold it. The patient may roll onto his or her side and fixate the humerus with
the contralateral hand if muscle relaxation can be maintained around the elbow joint being mobilized.

Humeroulnar  Testing; initial Supine, with the elbow over the edge of the  When in the resting First apply a distraction force
Distraction and treatment treatment table or supported with padding position or at end-range to the joint at a 45° angle to
Progression (sustained grade II) just proximal to the olecranon process. Rest flexion, place the fingers of the ulna, then while
 Pain control (grade the patient’s wrist against your shoulder, your medial hand over the maintaining the distraction,
I or II oscillation) allowing the elbow to be in resting position proximal ulna on the volar direct the force in a distal
 Increase flexion or for the initial treatment. To stretch into surface; reinforce it with direction along the long axis
 extension (grade either flexion or extension, position the your other hand. of the ulna using a scooping
III or IV) joint at the end of its available range.  To isolate the mobilization motion.
force to the humeroulnar
articulation, be sure that
your hand is not in contact
with the proximal radius.
 When at end-range
extension, stand and place
the base of your proximal
hand over the proximal
portion of the ulna and
support the distal forearm
A. Distraction with your other hand.

Humeroulnar Distal To increase flexion.  Supine, with the elbow over the edge of the treatment table. First apply a distraction force
Glide Begin with the elbow in resting position. Progress by positioning it at the end- to the joint at a 45° angle to
range of flexion. the ulna, then while
 Place the fingers of your medial hand over the proximal maintaining the distraction,
ulna on the volar surface; reinforce it with your other hand. To isolate the direct the force in a distal
mobilization force to the humeroulnar articulation, be sure that your hand is not in direction along the long axis
contact with the proximal radius. of the ulna using a scooping
motion.

B. With distal glide (scooping

Humeroulnar Radial  To increase varus.  Side-lying on the arm to be Place the base of your proximal Apply force against the ulna
Glide  This is an mobilized, with the shoulder hand just distal to the elbow; in a radial direction.
(move ulna) accessory motion laterally rotated and the humerus support the distal forearm with your
of the joint that supported on the table. other hand.
accompanies  Begin with the elbow in resting
elbow flexion and position; progress to end- range
is therefore used to flexion.
progress flexion
Humeroulnar Ulnar  To increase valgus. Supine or sitting, with the arm resting on  Position yourself on the Pull the radius distally (long-
Glide the treatment table. ulnar side of the patient’s axis traction causes joint
(move radius)  This is an forearm so you are between traction).
accessory motion the patient’s hip and upper
of the joint that extremity.
accompanies  Stabilize the patient’s
elbow extension humerus with your superior
and is therefore hand.
used to progress  Grasp around the distal
extension. radius with the fingers and
thenar eminence of your
inferior hand. Be sure you
are not grasping around the
distal ulna.

HUMERORADIAL ARTICULATION
Convex: capitulum (articulates with)
Concave: radial head
Resting position: Elbow is extended and forearm is supinated to the end of the available range.
Treatment plane: The treatment plane is in the concave radial head perpendicular to the long axis of the radius.
Stabilization: Fixate the humerus with one of your hands.
Humeroradial  To increase Supine or sitting, with the arm resting on  Position yourself on the Pull the radius distally (long-
Distraction mobility of the the treatment table. ulnar side of the patient’s axis traction causes joint
humeroradial joint forearm so you are between traction)
 to manipulate a the patient’s hip and upper
pushed elbow extremity.
(proximal  Stabilize the patient’s
displacement of humerus with your superior
the radius) hand.
 Grasp around the distal
radius with the fingers and
thenar eminence of your
inferior hand. Be sure you
are not grasping around the
distal ulna.

Humeroradial  Dorsal glide head Supine or sitting with the elbow extended  Stabilize the humerus with  Move the radial head
Dorsal/Volar Glides of the radius to and supinated to the end of the available your hand that is on the dorsally with the
increase elbow range. medial side of the patient’s palm of your hand or
extension arm. volarly with your
 Volar glide to  Place the palmar surface of fingers.
 increase flexion your lateral hand on the  If a stronger force is
volar as- pect and your needed for the volar
fingers on the dorsal aspect glide, realign your
of the radial head. body and push with
the base of your hand
against the dorsal
surface in a volar
direction.

Humeroradial To reduce a pulled elbow Sitting or supine.  Approach the patient right Simultaneously, extend the
Compression subluxation. hand to right hand or left patient’s wrist, push against
hand to left hand. Stabilize the thenar eminence, and
the elbow posteriorly with compress the long axis of the
the other hand. If supine, radius while supinating the
the stabilizing hand is forearm.
under the elbow supported
on the treatment table.
 Place your thenar eminence
against the patient’s thenar
eminence (locking thumbs).

PROXIMAL RADIOULNAR JOINT

Convex: radial head articulates with
Concave: radial notch on the ulna
Resting position: The elbow is flexed 70°, and the forearm is supinated 35°.
Treatment plane: The treatment plane is in the radial notch of the ulna, parallel to the long axis of the ulna.
Stabilization: Proximal ulna is stabilized.
Proximal Radioulnar  Dorsal glide to  Sitting or supine, begin with the  Approach the patient from  Force the radial head
Dorsal/Volar Glides increase pronation elbow flexed 70° and the forearm the dorsal or volar aspect of volarly or dorsally by
 Volar glide to supinated 35°. the forearm. Fixate the ulna pushing with your
increase  Progress by placing the forearm at with your medial hand palm or pulling with
supination. the limit of the range of pronation around the medial aspect of your fingers.
or supination prior to administering the forearm.  If a stronger force is
the respective glide  With your other hand, needed, rather than
grasp the head of the radius pulling with your
between your flexed fingers fingers, move to the
and palm of your hand. other side of the
patient, switch
 hands, and apply the
force with the palm
of your hand.

DISTAL RADIOULNAR JOINT

Concave: ulnar notch of the radius articulates
Convex: head of the ulna
Resting position: Forearm supinated 10°.
Treatment plane: Articulating surface of the radius, parallel to the long axis of the radius.
Stabilization: Distal ulna.

Distal Radioulnar  Dorsal glide to  Sitting, with the forearm on the  Stabilize the distal ulna by  Glide the distal
Dorsal/Volar Glides increase supination treatment table. placing the fingers of one radius dorsally to
 Volar glide to  Begin in the resting position and hand on the dorsal surface increase supination
increase pronation. progress to end-range pronation or and the thenar eminence or volarly to increase
supination. and thumb on the volar pronation parallel to
surface. the ulna.
 Place your other hand in
the same manner around
the distal radius.

RADIOCARPAL JOINT
Concave: distal radius articulates with
Convex: proximal row of carpals (scaphoid, lunate, and triquetrum)
Resting position: A straight line through the radius and third metacarpal with slight ulnar deviation.
Treatment plane: In the articulating surface of the radius perpendicular to the long axis of the radius.
Stabilization: Distal radius and ulna.
Radiocarpal  Testing  Sitting, with the forearm supported  With the hand closest to the Pull in a distal direction with
Distraction  initial treatment on the treatment table and wrist patient, grasp around the respect to the arm.
 pain control over the edge of the table styloid processes and fixate
 general mobility of the radius and ulna against
 the wrist the table.
 Grasp around the distal row
of carpals with your other
hand.

Radiocarpal Joint:  Dorsal glide to  Sitting with forearm resting on the The force comes from the
General Glides and increase flexion table in pronation for the dorsal and hand around the distal row of
Progression  Volar glide to volar techniques and in midrange carpals.
increase extension position for the radial and ulnar
 Radial glide to techniques.
increase ulnar  Progress by moving the wrist to the
deviation end of the available range and
 Ulnar glide to gliding in the defined direction.
increase radial  Specific carpal gliding techniques
deviation described in the next sections are
used to increase mobility at isolated
articulations.

Specific Carpal To increase flexion: Place the  The patient sits.  In each case, the
Mobilizations stabilizing index fingers under
the bone that is convex (on the  Stand and grasp the patient’s hand so the elbow hangs unsupported. force comes from the
volar surface) and the mobilizing  The weight of the arm provides slight distraction to the joints, so you then overlapping thumbs
thumbs overlapped on the dorsal need only to apply the glides on the dorsal surface.
surface of the bone that is  By applying force
concave.
from the dorsal
surface, pressure
 Thumbs on the dorsum
of the concave radius,
against the nerves,
index fingers stabilize blood vessels, and
scaphoid. tendons in the carpal
tunnel and Guyon’s
 Thumbs on the dorsum canal is minimized,
of the concave radius, and a stronger
index fingers stabilize mobilization force
 can be used without
lunate pain.
 An HVT technique
 Thumbs on dorsum of can be used by
trapezium-trapezoid providing a quick
unit, index fingers
stabilize scaphoid. down- ward and
upward flick of your
 Thumbs on dorsum of wrists and hands
concave lunate, index while pressing
fingers stabilize against the respective
capitate. carpals.

 Thumbs on dorsum of
concave triquetrum,
index fingers stabilize
hamate

To increase extension. Place the

stabilizing index fingers under
the bone that is concave (on the
volar surface). Overlap the
thumbs and place on the dorsal
surface of the bone that is
convex. The thumbs provide the
manipulating force.
 Thumbs on dorsum of
convex scaphoid, index
fingers stabilize radius.
 Thumbs on dorsum of
convex lunate, index
fingers stabilize radius.
 Thumbs on dorsum of
convex scaphoid, index
fingers stabilize
trapezium-trapezoid
unit.
 Thumbs on dorsum of
convex capitate, index
fingers stabilize lunate
 Thumbs on dorsum of
convex hamate, index
fingers stabilize
triquetrum.

Ulnar-Meniscal-Triquetral Articulation
To unlock the articular disk, which may block motions of the wrist or forearm, apply a glide of the ulna volarly on a fixed triquetrum.
Carpometacarpal Stabilize the respective carpal with thumb and index finger of one hand. With your other hand, grasp around the Apply long-axis traction to
Distraction proximal portion of a metacarpal the metacarpal.

Carpometacarpal and To increase mobility of the Stabilize the carpals with the thumb and index finger of one hand; place the thenar Glide the proximal portion of
Intermetacarpal: arch of the hand. eminence of your other hand along the dorsal aspect of the metacarpals to provide the metacarpal volar ward
Volar Glide the mobilization force.

CARPOMETACARPAL JOINT OF THE THUMB

The CMC of the thumb is a saddle joint. The trapezium is concave, and the proximal metacarpal is convex for palmar abduction/adduction (metacarpal moving
perpendicular away from and toward the palm of the hand). The trapezium is convex, and the proximal metacarpal is concave for radial abduction/ adduction (metacarpal
moving in the plane of the hand away and toward the radius; previously called flexion/extension).
Resting position: Midway between radial abduction/adduction and between palmar abduction/ adduction.
Stabilization: Fixate the trapezium with the hand that is closer to the patient.
Treatment plane: The treatment plane is in the trapezium for abduction-adduction and in the proximal metacarpal for flexion-extension.

Carpometacarpal  Testing; initial  The patient is positioned with forearm and hand resting on the treatment Apply long-axis traction to
Distraction (Thumb) treatment table. separate the joint surfaces.
 pain control  Fixate the trapezium with the hand that is closer to the patient.
 general mobility.  Grasp the patient’s metacarpal by wrapping your fingers around it
Carpometacarpal  Ulnar glide to  Stabilize the trapezium by grasping it directly or by wrap- ping your Apply the force with your
Glides (Thumb) increase radial fingers around the distal row of carpals. thenar eminence against the
adduction.  Place the thenar eminence of your other hand against the base of the base of the metacarpal.
 Radial glide to patient’s first metacarpal on the side opposite the desired glide. For Adjust your body position to
increase radial example, as pictured in Figure 5.41 A, the surface of the thenar eminence line up the force as illustrated
abduction. is on the radial side of the metacarpal to cause an ulnar glide in Figure 5.41 A through D.
 Dorsal glide to
increase palmar
abduction.
 Volar glide to
increase palmar
adduction
METACARPOPHALANGEAL AND INTERPHALANGEAL JOINTS OF THE FINGERS
In all cases, the distal end of the proximal articulating surface is convex and the proximal end of the distal articulating surface is concave.
NOTE: Because all the articulating surfaces are the same for the digits, all techniques are applied in the same manner to each joint.
Resting position: Light flexion for all joints.
Treatment plane: the distalarticulating surface.
Stabilization: Rest the forearm and hand on the treatment table; fixate the proximal articulating surface with the fingers of one hand.

Metacarpophalangeal Testing; initial treatment; Use your proximal hand to stabilize the proximal bone; wrap the fingers and Apply long-axis traction to
and Interphalangeal pain control; general thumb of your other hand around the distal bone close to the joint separate the joint surface.
Distraction mobility

Metacarpophalangeal  Volar glide to The glide force is applied by the thumb or thenar eminence against the proximal end of the bone to be moved.
and Interphalangeal increase flexion Progress by taking the joint to the end of its available range and applying slight distraction and the glide force.
Glides and  Dorsal glide to Rotation may be added prior to applying the gliding force.
Progression increase extension.
 Radial or ulnar
glide (depending
on finger) to
increase abduction
or adduction

HIP JOINT
Concave: acetabulum
Convex: femoral head
Resting position: The resting position is hip flexion 30°, abduction 30°, and slight external rotation.
Stabilization: Fixate the pelvis to the treatment table with belts.
Treatment plane: The treatment is in the acetabulum.
Hip Distraction of the  Testing Supine, with the hip in resting position and  Stand at the end of the Apply a long-axis traction by
Weight-Bearing  Initial treatment the knee extended treatment table; place a belt pulling on the leg as you lean
Surface, Caudal Glide  Pain control around your trunk and then backward
 General mobility cross the belt over the
patient’s foot and around
the ankle.
 Place your hands proximal
to the malleoli, under the
belt.
 The belt allows you to use
your body weight to apply
the mobilizing force.

Alternate Position and Technique for Hip Caudal Glide

 Patient supine with hip and knee flexed and foot resting on table.
 Wrap your hands around the epicondyles of the femur and distal thigh. Do not compress the patella.
 The force comes from your hands and is applied in a caudal direction as you lean backward.
Hip Posterior Glide  To increase flexion  Supine, with hips at the end of the  Stand on the medial side of Keep your elbows extended
 To increase table. the patient’s thigh. and flex your knees; apply
internal rotation  The patient helps stabilize the  Place a belt around your the force through your
pelvis and lumbar spine by shoulder and under the proximal hand in a posterior
 flexing the opposite hip and patient’s thigh to help hold direction.
holding the thigh against the the weight of the lower
 chest with the hands. extremity.
 Initially, the hip to be mobilized is  Place your distal hand
in resting position; under the belt and distal
 progress to the end of the range. thigh. Place your proximal
hand on the anterior surface
of the proximal thigh.
Hip Anterior Glide  To increase Prone, with the trunk resting on the table  Stand on the medial side of Keep your elbow extended
extension and hips over the edge. The opposite foot is the patient’s thigh. and flex your knees; apply
 Increase external on the floor.  Place a belt around your the force through your
rotation. shoulder and the patient’s proximal hand in an anterior
thigh to help support the direction.
weight of the leg.
 With your distal hand, hold
the patient’s leg.
 Place your proximal hand
posteriorly on the proximal
thigh just below the
buttock.
B. Side-lying
a. Prone
Alternate Position
 Position the patient side-lying with the thigh comfortably flexed and supported by pillows.
 Stand posterior to the patient and stabilize the pelvis across the anterior superior iliac spine with your cranial hand.
 Push against the posterior aspect of the greater trochanter in an anterior direction with your caudal hand.

TIBIOFEMORAL ARTICULATION
Resting position. The resting position is 25° flexion.
Treatment plane. The treatment plane is along the surface of the tibial plateaus; therefore, it moves with the tibia as the knee angle changes.
Stabilization. In most cases, the femur is stabilized with a belt or by the table.
Tibiofemoral  Testing  Sitting, supine, or prone, beginning with the knee in the resting position. Pull on the long axis of the
Distraction: Long-  initial treatment  Progress to positioning the knee at the limit of the range of flexion or tibia to separate the joint
Axis Traction  pain control extension. surfaces.
 general mobility.  Rotation of the tibia may be added prior to applying the traction force.
 Use internal rotation at end-range flexion and external rotation at end-
range extension.
 Grasp around the distal leg, proximal to the malleoli with both hands.

A. Sitting B. Supine C. Prone

Tibiofemoral Testing; to increase Supine, with the foot resting on the table. Sit on the table with your thigh Extend your elbows and lean
Posterior Glide flexion. The position for the drawer test can be used fixating the patient’s foot. With your body weight forward;
to mobilize the tibia either anteriorly or both hands, grasp around the tibia, push the tibia posteriorly
posteriorly, although no grade I distraction fingers pointing posteriorly and with your thumbs.
can be applied with the glides in this thumbs anteriorly.
position.

Tibiofemoral Sitting, with the knee flexed over the edge of the treatment  When in the resting position, stand Extend your elbow and lean
Posterior Glide: table, beginning in the resting position. Progress to near 90° on the medial side of the patient’s your body weight onto the
Alternate Positions flexion with the tibia positioned in internal rotation. leg. Hold the distal leg with your tibia, gliding it posteriorly.
and Progression When the knee flexes past 90°, position the patient prone; place distal hand and place the palm of When progressing with
a small rolled towel proximal to the patella to minimize your proximal hand along the medial rotation of the tibia at
compression forces against the patella during the mobilization. anterior border of the tibial plateaus. the end of the range of
  When near 90°, sit on a low stool; flexion, the force is applied
stabilize the leg between your knees in a posterior direction
and place one hand on the anterior against the medial side of the
border of the tibial plateaus. tibia.
 When prone, stabilize the femur with
one hand and place the other hand
along the border of the tibial
plateaus.

Tibiofemoral To increase extension.  Prone, beginning with the knee in Grasp the distal tibia with the hand Apply force with the hand on
Anterior Glide resting position; progress to the end that is closer to it and place the the proximal tibia in an
of the available range. Place a small palm of the proximal hand on the anterior direction. The force
pad under the distal femur to posterior aspect of the proximal may be directed to the lateral
prevent patellar compression. tibia. or medial tibial plateau to
 The drawer test position can also be isolate one side of the joint.
used. The mobilizing force comes
from the fingers on the posterior Alternate Position and
tibia as you lean backward Technique
If the patient cannot be
positioned prone, position
him or her supine with a
fixation pad under the tibia.
The mobilizing force is
placed against the femur in a
posterior direction.

Patellofemoral Joint, Supine, with knee extended; progress to positioning the knee at the end of Stand next to the patient’s thigh, Glide the patella in a caudal
Distal Glide the available range in flexion. facing the patient’s feet. Place the direction, parallel to the
web space of the hand that is closer femur
to the thigh around the superior
border of the patella. Use the other
hand for reinforcement.

Patellofemoral Medial To increase patellar Supine with the knee extended. Side-lying Place the heel of your hand along Glide the patella in a medial
or Lateral Glide mobility may be used to apply a medial glide either the medial or lateral aspect of or lateral direction, against
the patella. Stand on the opposite the restriction.
side of the table to position your
hand along the medial border and
on the same side of the table to
position your hand along the lateral
border. Place the other hand under
the femur to stabilize it.

Proximal Tibiofibular To increase movement of Side-lying, with the trunk and hips rotated Stand behind the patient, placing Apply the force through the
Articulation: Anterior the fibular head; to partially toward prone. one of your hands under the tibia to heel of your hand against the
(Ventral) Glide reposition a posteriorly The top leg is flexed forward so the knee stabilize it. posterior aspect of the fibular
subluxed head. and lower leg are resting on the table or Place the base of your other hand head, in an anterior-lateral
supported on a pillow. posterior to the head of the fibula, direction.
wrapping your fingers anteriorly.

Distal Tibiofibular To increase mobility of the Supine or prone. Working from the end of the table, Press against the fibula in an
Articulation: Anterior mortise when it is place the fingers of the more medial anterior direction when prone
(Ventral) or Posterior restricting ankle hand under the tibia and the thumb and in a posterior direction
(Dorsal) Glide dorsiflexion. over the tibia to stabilize it. Place when supine
the base of your other hand over the
lateral malleolus, with the fingers
underneath.

TALOCRURAL JOINT (UPPER ANKLE JOINT)

Resting position: The resting position is 10°plantarflexion.
Treatment plane: The treatment plane is in the mortise, in an anterior-posterior direction with respect to the leg.
Stabilization: The tibia is strapped or held against the table.
Talocrural  Testing Supine, with the lower extremity extended.  Stand at the end of the Pull the foot along the long
Distraction  Initial treatment Begin with the ankle in resting position. table; wrap the fingers of axis of the leg in a distal
 Pain control Progress to the end of the available range of both hands over the dorsum direction by leaning
 General mobility. dorsiflexion or plantarflexion of the patient’s foot, just backward.
distal to the mortise.
 Place your thumbs on the
plantar surface of the foot
to hold it in resting
position.

Talocrural Dorsal To increase dorsiflexion Supine, with the leg supported on the table  Stand to the side of the Glide the talus posteriorly
(Posterior) Glide and the heel over the edge. patient. Stabilize the leg with respect to the tibia by
with your cranial hand or pushing against the talus.
use a belt to secure the leg
to the table.
 Place the palmar aspect of
the web space of your other
hand over the talus just
distal to the mortise.
 Wrap your fingers and
thumb around the foot to
maintain the ankle in
resting position. Grade I
distraction force is
  applied in a caudal
direction.

Talocrural Ventral To increase plantarflexion. Prone, with the foot over the edge of the Working from the end of the table, Push against the calcaneus in
(Anterior) Glide table. place your lateral hand across the an anterior direction (with
dorsum of the foot to apply a grade respect to the tibia); this
I distraction. glides the talus anteriorly.
Place the web space of your other
hand just distal to the mortise on Alternate Position
the posterior aspect of the talus and  Patient is supine.
calcaneus. Stabilize the distal
leg anterior to the
mortise with your
proximal hand.
 The distal hand cups
under the calcaneus.
 When you pull
against the calcaneus
in an anterior
direction, the talus
glides anteriorly.
SUBTALAR JOINT (TALOCALCANEAL), POSTERIOR COMPARTMENT
Resting position: The resting position is midway between inversion and eversion.
Treatment plane: The treatment plane is in the talus, par- allel to the sole of the foot.
Stabilization: Dorsiflexion of the ankle stabilizes the talus. Alternatively, the talus is stabilized with one of your hands.
Subtalar Distraction Testing; initial treatment;  Supine, with the leg supported on the table and heel over the edge. Pull the calcaneus distally
pain control; general  Externally rotate the patient’s hip so the talocrural joint can be stabilized with respect to the long axis
mobility for in dorsiflexion with pressure from your thigh against the plantar surface of of the leg.
inversion/eversion. the patient’s forefoot.
 The distal hand grasps around the calcaneus from the posterior aspect of
the foot. The other hand fixes the talus and malleoli against the table.
Subtalar Medial Indication: Medial glide to increase eversion; lateral glide to increase  Align your shoulder and Apply a grade I distraction
Glide or Lateral Glide inversion. arm parallel to the bottom force in a caudal direction
Side-lying or prone, with the leg supported on the table. of the foot. and then push with the base
 Stabilize the talus with of your hand against the side
your proximal hand. of the calcaneus parallel to
 Place the base of the distal the plantar surface of the
hand on the side of the heel.
calcaneus medially to cause
a lateral glide and laterally Alternate Position
to cause a medial glide. Same as the position for
 Wrap the fingers around distraction, moving the
the plantar surface. calcaneus in the medial or a
lateral direction with the base
of the hand.

Intertarsal and To increase plantarflexion Supine, with hip and knee flexed, or sitting,  Fixate the more proximal Push the distal bone in a
Tarsometatarsal accessory motions with knee flexed over the edge of the table bone with your index finger plantar direction from the
Plantar Glide (necessary for supination). and heel resting on your lap. on the plantar surface of the dorsum of the foot.
bone.
 To mobilize the tarsal
joints along the medial
aspect of the foot, position
yourself on the lateral side
of the foot. Place the
proximal hand on the
dorsum of the foot with the
 fingers pointing medially,
so the index finger can be
wrapped around and placed
under the bone to be
stabilized.
 Place your thenar eminence
of the distal hand over the
dorsal surface of the bone
to be moved and wrap the
fingers around the plantar
surface.
 To mobilize the lateral
tarsal joints, position
yourself on the medial side
of the foot, point your
fingers laterally, and
position your hands around
the bones as just described.

Intertarsal and Prone, with knee flexed.  Fixate the more proximal Push from the plantar surface
Tarsometatarsal Dorsal bone. in a dorsal direction.
Glide  To mobilize the lateral
tarsal joints (e.g., cuboid on Alternate Technique
calcaneus), position Same position and hand
yourself on the medial side placements as for plantar
of the patient’s leg and glides, except the distal bone
wrap your fingers around is stabilized and the proximal
the lateral side of the foot bone is forced in a plantar
 To mobilize the medial direction. This is a relative
bones (e.g., navicular on motion of the distal bone
talus), position yourself on moving in a dorsal direction.
the lateral side of the
patient’s leg and wrap your
fingers around the medial
aspect of the foot.
 Place your second
metacarpophalangeal joint
against the bone to be
moved.