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

Gliding – translational movement.

Listhesis – antero/postero is in the sagital plane

- 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, PPT 20/04/2009

Diagnostic Criteria for the identification of Joint dysfunction

Pain and Tenderness

The perception of pain and tenderness is evaluated in terms of location, quality,
and intensity. Most primary musculoskeletal disorders manifest by a painful
response. The patient’s description of the pain and its location is obtained.
Furthermore, the location and intensity of tenderness produced by palpation of
osseous and soft tissue are noted. Pain and tenderness findings are identified
through observation, percussion, and palpation.

Daaljit Singh HS AMP, PPT 20/04/2009

Asymmetry
Asymmetric qualities are noted on a sectional or segmental level. This includes
observation of posture and gait, as well as palpation for misalignment of vertebral
segments and extremity joint structures. Asymmetry is identified through
observation (posture and gait analysis), static palpation and static radiography.

Range of Motion Abnormality

Changes in active, passive, and accessory joint motions are noted. These
changes may be reflected by increased, decreased, or aberrant motion. It is
thought that a decrease in motion is a common component of joint dysfunction.
Range of motion abnormalities are identified through motion palpation and stress
radiography.

Tone, Texture, and Temperature Abnormality

Changes in the characteristics of contiguous and associated soft tissues,
including skin, fascia, muscle, and ligaments, are noted. Tissue tone, texture,
and / or temperature changes are identified through observation, palpation,
instrumentation, and tests for length and strength.

Special Tests
Finally, diagnosis may require testing procedures that are specific to a technique
system.

Palpation

Palpation is the application of variable manual pressures, through the surface of

the body, to determine the shape, size, consistency, position and inherent motility
of the tissues beneath. Palpation is the oldest technique employed to detect
dysfunction and is still the most emphasized physical finding supportive of
dysfunction. Good palpation skills are the result of both physical abilities and
mental concentration.
Tenderness to pressure at bony landmarks that are close to articulations is
another proposed empirical sign of joint dysfunction. The relationship between
spinous and interspinous tenderness and dysfunction is speculated to result from
reflex sensitivity in tissues with shared segmental innervation, or as a result of
mechanical deformation in structures attaching at these bony sites.

Daaljit Singh HS AMP, PPT 20/04/2009

Soft Tissue Palpation
The major function of soft tissue palpation is to determine the contour,
consistency, quality, and the presence or absence of pain in the dermal,
subdermal, and deeper “functional” tissue layers. The dermal layer incorporates
the skin, subdermal layer, subcutaneous adipose, fasciae, nerves and vessels.
The functional layer consists of the muscles, tendons, tendon sheaths, bursae,
ligaments, fasciae, vessels, and nerves.

Palpation of the dermal layer is directed toward the assessment of temperature,

moisture, motility, consistency, and tissue sensitivity (e.g., hyperesthesia,
tenderness, etc.). Palpation techniques involve light, gentle exploration of the
skin with the palmar surfaces of the fingers or thumbs. When, manually
assessing temperature of superficial tissues, the dorsum of the hands are
typically used. Motility and sensitivity of the dermal layer may also be assessed
by the technique of skin rolling.

How to Use Your Palpation Tools

1. Use the least pressure possible. Your touch receptors are designed to
respond only when not pressed on too firmly; experiment with decreasing
pressure instead of increasing pressure, and your tactile perception may
improve.
2. Try not to cause pain if possible. Pain may induce protective muscle
splinting and make palpation more difficult.
3. Try not to lose skin contact before you are done with the palpation of the
area.
4. Use broad contacts whenever possible. For deep palpation, use broad
contacts to reach the desired tissues, then palpate with your palpation
finger, keeping the overlying tissue from expanding with the other fingers
of your palpation hand. Close your eyes to increase your palpatory
perception

Palpation Hints and Comments

1. Concentrate on the area and/or structure you want to palpate; do not
palpate casually.
2. Do not let your attention be carried away by unrelated sensations.
Concentrate on your fingers; do not feel what you see or expect to feel.
3. Keep an open mind and do not deceive yourself; never let your mind “out
palpate” your fingers.
4. Establish a palpation routine and stay with it.

Daaljit Singh HS AMP, PPT 20/04/2009

 5. Take every opportunity to add to your tactile “vocabulary” through
comparative experiences.
Accessory Joint Motion
Joint surfaces do not form true geometric shapes with matching articular
surfaces. As a result, movement occurs around a shifting axis, and the joint
capsule must allow sufficient play and separation between articular surfaces to
avoid abnormal joint friction,

Accessory joint movements are evaluated by the procedures of joint play and
end play (feel). End-play evaluation is the qualitative assessment of resistance at
the end point of passive joint movement, and joint play is the assessment of
resistance from a neutral and / or loose-packed joint position.

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.

End-play is assessed by applying additional overpressure to the specified joint at

the end range of passive movement. To execute end feel, evaluate the point at
which resistance is encountered, the quality of the resistance, and whether there
is any associated tenderness.

Loss of anticipated end-play elasticity is thought to be indicative of disorders

within the joint, its capsule, or periarticular soft tissue. Encountered end-play
resistance is a significant finding in the determination of joint dysfunction and
adjustive vector orientation.

Joint Play

During the performance of joint play; check for the presence or absence of pain,
the quality of movement, and the degree of encountered resistance. Joint play
should not induce pain, some resistance to movement should be encountered,
but the joint should yield to pressure, producing short-range gliding and
distracting movements. Increased resistance to joint play movements suggests
articular soft tissue contractures.

Daaljit Singh HS AMP, PPT 20/04/2009

Normal and Abnormal End Feels

Capsular
Firm but giving; resistance builds with lengthening, like stretching a piece of
leather
• Example: close-packed position of the joint; external rotation of shoulders.
• Abnormal example: capsular fibrosis and / or adhesions leading to a
capsular pattern of abnormal end feel.

Ligamentous
Like capsular but may have a slightly firmer quality
• Example: knee extention
• Abnormal example: noncapsular pattern of abnormal resistance due to
ligamentous shortening.

Soft Tissue Approximation

Giving, squeezing quality; results from the approximation of soft tissues;
typically painless.
• Example: elbow flexion
• Abnormal example: muscle hypertrophy, soft tissue swelling

Bony
Hard, nongiving abrupt stop
• Example: elbow extention
• Abnormal example: bony exostosis, articular hypertrophic changes

Mscular
Firm but giving, builds with elongation; not as stiff as capsular or ligamentous
• Normal example: hip flexion

Muscle Spasm
Guarded, resisted by muscle contraction; should feel muscle reaction. 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, joint mice

Daaljit Singh HS AMP, PPT 20/04/2009

Empty
Normal end feel resistance is missing; end feel is not encounter at normal point,
and /or the joint demonstrates unusual give and deformation.
• Abnormal example: joint injury or disease leading to hypermobility or
instability.

Clinical Features of Joint Dysfunction

1. Local pain: commonly changes with activity
2. Local tissue hypersensitivity
3. Altered Alignment
4. Decreased, increased, or aberrant joint movement
5. Altered joint play
6. Altered end-feel resistance
7. Local palpatory muscle rigidity

Outcome Measures for Subluxation/Dysfunction

1. Regional mobility measures
2. Pain reporting instruments
3. Physical capacity questionnaires
4. Physical performance measures

CLINICAL DOCUMENTATION
The total management of the patient includes clinical assessment, application of
necessary treatment, and patient education.

Assessment procedures are necessary to identify the nature, extent, and location
of the problem as well as to determine the course of action in treatment.

Errors in recording that have been identified include failure to record findings all
together, illegible handwriting, obscure abbreviations, improper terminology, and
bad grammar. It is imperative that though the clinical record comprises the
physician’s personal notations, it must be complete and translatable. If it is not
written down, it was not done.

A systematic and accurate record of evaluation facilitates quick reference to

salient findings during treatment.

Daaljit Singh HS AMP, PPT 20/04/2009

 It should be noted and emphasized that it is unacceptable to use and assign a
diagnosis for convenience. Most clinical entities have specific and expected signs
and symptoms. These findings need to be identified and recorded.
When performing an assessment manipulation, the clinician should keep
the following principles in mind:

1. The patient should exhibit no muscle guarding and should be relaxed as

possible.
2. The clinician should be efficient with body mechanics, and should stand
with the wide base of support. The manipulating force should be as close
to the clinician’s centre of gravity as possible. The force ideally should be
directed downward. If a downward force is not feasible, a horizontally
directed force should be attempted. This is especially true when treating
larger joints, 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.

3. The joint should be tested in the resting position if the patient is capable of
attaining that position. If not, the joint should be tested in the actual resting
position.
4. The clinician’s grasp should be firm yet painless.

5. One bone should be stabilized with the clinician’s hand or other body part,
a belt, a wedge, or the treatment table.
6. The other bone is manipulated with the clinician’s hand.

7. Both the stabilizing force and the manipulating force should be as close to
the joint surface as possible, to control the motion as closely as possible.
8. The patient’s pain should be monitored during the assessment, and
appropriate modification should be made based on the pain response.

9. Accessory motion should be assessed by comparison with the

corresponding joint on the other side of the body, whenever possible.

10.Only one movement should be performed at a time. For example, the

clinician should not manipulate a bone into dorsal glide from a ventrally
glided position, because it is more difficult to assess movement in this
manner.

11. Only one joint should be manipulated at a time.

12. Each technique is both an evaluative technique and a treatment

technique; therefore the clinician should continually evaluate during

Daaljit Singh HS AMP, PPT 20/04/2009

 treatment. Formal assessments also should be made before and after
treatment.

Contributors to the knowledge of manipulative therapy

Cyriax an orthopedic physician who contributed much to the
development of a system of physical examination in
which different tissues affected by orthopedic disorders
are techniques practiced today

Mennell Developed the concept that adhesions are a common cause

of joint dysfunction.

Maigne believed that a clinician should not perform a treatment that

increases the patient’s symptoms, and therefore
treatment should be administered in a direction
opposite the direction that reproduces pain.

Maitland developed oscillatory manipulation treatments and stated that

one should oscillate in the direction of reproducible
symptoms.

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

Paris proposed that the clinician should treat joint dysfunction and
minimize the role of pain.

Grades of Oscillations
Grade 1 Slow small-amplitude oscillatory movement parallel to the concave
joint surface that does not take the joint up to the first tissue stop
Grade 2 Slow larger-amplitude oscillatory movement parallel to the concave
joint surface that does not take the joint up to the first tissue stop
Grade 3 Slow, large-amplitude oscillatory movement parallel to the concave
joint surface that takes the joint up to and slightly through the first
tissue stop
Grade 4 Slow, 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, PPT 20/04/2009

Grade 5 Fast, small amplitude, 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, also called
a thrust manipulation.
Execution of Treatment

• All treatment oscillations are performed with at least grade 1 traction when
feasible to decrease compression of joint surfaces.

• Grades 1 and 2 oscillations are used for pain reduction.

• Grades 3 and 4 are used to reduce pain, increase periarticular

extensibility, correct positional faults, and release impinged meniscoid
tissue in the spine.

• All grades of oscillation increase nutrition to articular structures.

• If pain occurs before resistance is met with passive range of motion, then
Grades 1 and 2 oscillation techniques are indicated.

• If pain occurs at the same time in the range of motion as the first barrier to
motion, then the patient should be able to tolerate up to grade 3
oscillations and tractions.

• If pain occurs after the first motion barrier, 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, pain free movement

to a musculoskeletal system, which is in postural balance. This is accomplished
by;

Increasing joint extensibility

Correcting positional faults

Nutrition

Daaljit Singh HS AMP, PPT 20/04/2009

Pain control/Muscle relaxation

Psychological benefits

HIP JOINT.
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, 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. Distraction

• To increase overall range

• Clinician facing patient, with patient’s leg over clinician’s shoulder.
• Move femoral head away from acetabulum, elevate scapula to direct fem
head ventrally

2. Caudal Glide

• To increase hip abduction

• Pt supine, clinician grips distal thigh while facing hip
• Glide fem head in caudal direction.

3. Dorsal glide

• To increase hip flexion and internal rotation

• Pt. supine with leg supported between clinician’s arm and trunk
• Glide fem in dorsal direction with manipulating hand

Daaljit Singh HS AMP, PPT 20/04/2009

4. Ventral glide

• To increase hip extension and external rotation

• Pt prone with leg off treatment table, clinician facing hip
• Lean into distal thigh to glide femur ventrally
5. Lateral glide

• To increase internal rotation and hip adduction

• Pt supine with leg over clinician’s shoulder, clinician at pt’s side
• Glide femur in a lateral direction.

6.

7. Other techniques

KNEE JOINT (Tibio Femoral)

1. 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. Dorsal glide I

• To increase flexion
• Pt. Supine with knee in resting position. Clinician grips proximal tibia from
ventral side
• Glide tibia in dorsal direction

3. Dorsal Glide II

• To increase flexion
• Pt prone. Clinician’s hand on ventral surface of proximal tibia
• Glide tibia dorsally

Daaljit Singh HS AMP, PPT 20/04/2009

4. Ventral Glide I

• To increase extension
• Pt. Supine with knee in resting position. Clinician grips proximal tibia
• Glide tibia in ventral direction

5. Ventral Glide II

• To increase extension
• Pt. Supine with knee in resting position. Clinician grips proximal tibia
• Glide femur in dorsal direction

6. Ventral Glide III

• To increase extension
• Pt prone. Manipulating hand on proximal dorsal surface of tibia.
• Glide tibia ventrally

7. 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,
Glide proximal Tibia medially

8. 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,
glide proximal Tibia laterally

9.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,
Move lateral joint line medially

10. Lateral Gaping

Daaljit Singh HS AMP, PPT 20/04/2009

 • 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,
Move medial joint line laterally

(Patello Femoral)

10. 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.

11. 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. 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. Avoid compressing patella into the
femur

13. 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

Daaljit Singh HS AMP, PPT 20/04/2009

Lower leg
Proximal Tibiofibula joint
Distal Tibiofibula joint

Fibula glides cranially with dorsi flexion, and caudally with plantar flexion.
Fibula rotates laterally with dorsi flexion.
With Dorsi flexion, 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. in supine with knee supported in resting position on pillow/rolled towel
• Glide proximal fibula in dorsal direction

2. 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. Distraction: Spreading

• To increase joint play and dorsi flexion

• Pt in supine. Clinician at foot end, with hands on tibial and fibula distal
ends
• Move both tibia and fibula away from each other.

4. Dorsal Glide

Daaljit Singh HS AMP, PPT 20/04/2009

 • Increase joint play of distal TF jt and plantar flexion.
• Pt Supine, Clinician at foot end of treatment table
• Stabilize Tibia and Glide Lateral Malleolus in dorsal direction

5. Ventral Glide

• Increase joint play of distal TF jt and dorsi flexion.

• Pt Prone, Clinician at foot end of treatment table
• Stabilize Tibia and Glide Lateral Malleolus in ventral direction

6. Cranial Glide

• To increase dorsi flexion and joint play

• Pt in supine
• Stabilize Tibia and Glide fibula in cranial direction

7. Caudal Glide

• To increase plantar flexion and joint play

• Pt in supine
• Stabilize Tibia and Glide fibula in caudal direction

Ankle Joint
Dorsi flexion is restored by gliding talus dorsally
Plantar flexion is restored by gliding Talus Ventrally

1. Distraction

• To Increase overall joint play of Talo Crural joint

• Pt in Supine. Clinician grips proximal talus with both hands
• Move Talus distally by leaning backwards

2. Distraction II

• To improve joint play in subtalar joint

Daaljit Singh HS AMP, PPT 20/04/2009

 • Pt in Prone . Grip the talus ventrally and calcaneum dorsally
• Move calcaneum distally

3. Dorsal Glide

• To improve talocrural joint play and dorsi flexion

• Pt in Supine. Clinician grips talus ventrally and stabilizes lower leg dorsally
• Glide talus in dorsal direction

4. Ventral Glide I

• To improve talocrural joint play and increase plantar flexion

• Pt. in prone. Clinician grips talus dorsally and stabilizes lower leg Ventrally
• Glide Talus in a ventral direction

5. Ventral Glide II

• To improve talocrural joint play and increase plantar flexion

• Pt. in supine. Clinician grips talus ventrally and stabilizes lower leg Dorsally
• Glide Tibi and fibula in a dorsal direction

6. Eversion Mobilisation

• To increase subtalar joint play and subtalar eversion

• Pt in prone. Manipulating hand grips calcaneum dorsally
• Stabilise talus, Glide calcaneum in eversion direction simultaneously with
valgus direction of calcaneum

7. Inversion Mobilisation

• To increase subtalar joint play and subtalar inversion

• Pt in prone. Manipulating hand grips calcaneum dorsally
• Stabilise talus, Glide calcaneum in inversion direction simultaneously with
varus direction of calcaneum

Manipulation and Mobilization

Extremity and Spinal Techniques

Daaljit Singh HS AMP, PPT 20/04/2009

Susan L. Edmond, M.P.H., P.T.

Daaljit Singh HS AMP, PPT 20/04/2009