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Mobilisation of the tibio-talar and sub-talar joints.

Introduction

The tibiotalar joint involves the talus moving in the ankle mortise. The major motions of this joint are described as dorsiflexion and plantar flexion. Minor motions occur with each posterior glide with dorsiflexion and anterior glide with plantar flexion. Dorsiflexion is functionally the more stable of the two positions because the talus is structurally wider anteriorly, and fits more securely with the posterior glide component.

Position

The tibiotalar joint axis passes distally to the tip of each malleolus; its position may be estimated by placing the tips of your fingers at the most distal ends of the malleoli. At this position the fingers would be over the transverse axis of the tibiotalar joint.

Plantar flexion

Plantar Flexion is accompanied by adduction and some supination of the foot. This motion also carries the lateral malleolus anteriorly. Through reciprocal action of the fibula, the proximal fibula head also glides posteriorly and inferiorly.

The talus glides anteriorly placing the narrow portion of the talus in the ankle mortis, a less stable position. Ankle sprains are more likely to occur when the tibiotalar joint is plantar flexed.

Dorsi flexion

Dorsi Flexion is accompanied by abduction and some pronation of the foot. This type of motion also carries the lateral malleolus posteriorly, through reciprocal action the fibula head glides anteriorly and superiorly. The talus glides posteriorly, placing the wider portion in the ankle mortis a more stable position. This stability is the reason strapping in the treatment or prevention of ankle sprains usually emphasises a dorsi flexion component.

Tibio Talar Joint HVT Anterior Tibia on Talus

Positional diagnosis

Tibia is wedged anterior on the talus. The ankle prefers plantar flexion.

Restriction

The tibia is restricted in gliding posteriorly on the talus. The ankle is restricted in dorsiflexion.

Objective

Restore physiological range of motion to the tibio talar joint. Specifically, full dorsi and plantar flexion of the ankle/posterior glide of the tibia over the talus.

Patient position

Supine

Procedure

1. Stand at the foot of the table, to the side of somatic dysfunction.

2. Grasp the patients heel and apply traction to it, dorsiflexing the ankle.

3. Grasp the distal end of the tibia with your other hand; palm over its anterior surface near the tibio talar joint care must be taken to avoid the anterior tibial artery.

4. Apply a high velocity low amplitude thrust posteriorly through the distal tibia, as the foot is dorsi flexed with the other hand on the heel.

5. Retest range of motion. Tibio Talar Joint Posterior Tibia on Talus (Ankle Tug)

Restriction

The tibia is restricted in gliding anteriorly on the talus. The ankle is restricted in dorsi flexion.

Objective

To restore physiological range of motion to the tibio talar joint, specifically to restore dorsi flexion of the ankle/anterior glide of the tibia over the talus.

Patient position

Supine

Procedure

1. Sit/stand at the foot of the table on the side of somatic dysfunction.

2. Grasp the patient's foot curling your fifth or fourth finger over the dorsal surface of the head of the talus. Also grasp the foot with your other hand and clasp your fingers so that the fifth or fourth finger supports the same finger of the opposite hand (over the head of the talus) care of self.

3. Place your thumbs over the ball of the foot and dorsi flex the foot at the ankle. This dorsi flexion of the ankle is maintained throughout this technique.

4. Apply traction with continued dorsi flexion and slight eversion at the ankle until all joint play is out of the ankle/ barrier engaged.

5. Apply a high velocity low amplitude tug to reset the talus in the mortise of the ankle.

6. Retest range of motion. NB; This type of somatic dysfunction may be accompanied by tissue congestion and spasm of the peroneus muscles and/or fibula head dysfunction.

Subtalarjoint

The subtalar joint (talocalcaneal jt.) is a major shock-absorbing joint, because in coordination with the intertarsal joints it determines the distribution of forces upon the skeleton and soft tissues of the foot. The strong talocalcaneal ligament stabilises the joint which is synovial with a single oblique axis that declines backward and laterally. This joint acts like a mitered hinge so that movement of the calcaneus produces leg rotation. Inversion of the calcaneus produces external rotation of the tibia while the talus glides posterolaterally over the calcaneus. Eversion of the calcaneus produces medial rotation of the tibia and anteromedial glide of the talus on the calcaneus.

Gliding

These mechanics explain the palpable talocalcaneal motions; posterolateral glide of the talus when the ankle is supinated and the anteromedial glide when the ankle is pronated.

Subtalar Axis

The average inclination of the subtalar axis from the horizontal plane 42[degrees] (ranging from 20[degrees] to 68[degrees]. If the inclination of the axis is 45[degrees], rotation of the tibia and calcaneus has a one-to-one relationship the more horizontal the axis, the more the calcaneus rotates and the less the leg rotates. This calcaneal rotation is not very obvious during walking because the metatarsals of the forefoo appear to remain stationary.

Mobilisation of the Subtalar Joint Side Lying

The patient lies on the affected side while the operator fixes the dorsiflexed foot against his inner thigh.

Hold it firmly against the table with the fixing hand.

Grasp the calcaneum with the opposite hand. Shear the calcaneum into inversion and eversion.

Subtalar Joint HVT Side Lying

The patient lies on the affected side.

The medial side of the dorsiflexed foot is inverted with your distal hand. Pressure is maintained towards the table with your other hand cupping the lateral malleolus.

The calcaneum is therefore a fulcrum.

This has the effect of putting stress on the subtalar joint on the medial aspect of the foot.

When a suitable barrier is engaged, high velocity low amplitude thrust is applied with your proximal hand to gap the subtalar joint. Retest motion.

References

Chaitow, L., 2006. Muscle Energy Techniques, 3rd edition: Churchill Livingstone.

Cailliet, R., 1992 Knee Pain and Disability, 3rd edition: F A Davis Co, Philadelphia, Pennsylvania.

Cailliet, R., 1996 Foot and Ankle Pain, 3rd edition: F A Davis Co, Philadelphia, Pennsylvania.

DiGiovanna, E., 2004. An Osteopathic Approach to Diagnosis and Treatment, 3rd edition: Lippincott Williams and Wilkins.

Lintonbon, D., 2013. The Art of HVT Introduction to Structural Osteopathic Technique

[Kindle DX Version] Myoproducts Media. Available at: Amazon.co.uk <http://www.amazon.co.uk> [Accessed 21 April 2013].
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Author:Lintonbon, David
Publication:Podiatry Review
Article Type:Report
Date:Sep 1, 2016
Words:1078
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