Lakshmi NarayananTextbook of THERAPEUTIC EXERCISES masud.pdf · version 1

94 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 9.22: Relaxed passive movement of lumbar Fig. 9.23: Relaxed passive movement of lumbar extension rotation Holding: Position of the therapist: Standing beside the • Patient’s knee joint is flexed. patient. • Therapist’s right hand grasp the thighs of Holding: • Therapist’s right hand placed over the right the patient. • Therapist’s left hand stabilizes the upper thigh of the patient. • Left hand prevents the upper trunk motion trunk. Procedure: Both the thighs are lifted up until by applying the counter force over the right the anterior rotation of the pelvic occurs. shoulder region. Lumbar Rotation (Fig. 9.23) Procedure: Position of the patient: Crook lying. With right hand right thigh is pushed away from therapist’s side same time left hand applies the counter force on the right shoulder region.

10 CHAPTER Peripheral Joint Mobilization INTRODUCTION 1. Arthrokinematics The contribution in the field of orthopedic 2. Osteokinematics. medicine by the physiotherapy is highly com- mendable. When the orthopedic examination Arthrokinematics reveals the joint hypomobility or decreased Definition: Arthro— Joint, Kinematics—motion. ROM, there the mobilization plays its major The movement, which occurs in the joint role. There are two types of mobilizations: (a) surface, is called as an “arthrokinematics”. Joint mobilization (b) Soft tissue mobilization. • The articular surface undergoes for This chapter discusses about the joint movement and the other remains stable. mobilization techniques in the introductory • These arthrokinematic movements are level. The therapist should have the knowledge about the anatomy, kinematics, and ortho, called as “joint play movements”. neuro, and musculoskeletal disorders to Types of Arthrokinematics Movements perform the effective mobilization techniques. It is of the following types: 1. Rolling DEFINITION 2. Sliding (Gliding) It is a slow, repetitive, rhythmical, oscillatory 3. Spinning arthrokinematic and osteokinematics move- 4. Traction ment done by a therapist within the available 5. Compression. range and using various grading under the Rolling patient’s control. • Rolling occurs when the new equidistant KINEMATICS point of moving surface comes into contact Kinematics is the descriptions of motion and with the new equidistant points on the stable includes the time, space and mass aspects of a surface. moving object. It is of two types: • It occurs between the flat and curved surface. For example, ball rolling on the floor (Fig. 10.1). • Convex surface moves on concave surface or vice versa.

96 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.2: Square box is moving on flat surface Figs 10.1A to C: A. Ball is moving on flat surface, • Joint surfaces are congruent. B. Convex surface is moving on concave surface, • Pure gliding is impossible in human joints and C. Concave surface is moving on convex surface because there are no complete congruent • Joint surfaces are incongruent. surface joints. • Rolling results in angular motion. • Direction of gliding depends on whether the • If pure rolling occurs in any physiological moving surface is concave or convex. • Direction of gliding will be towards the movement, it results in compression of the physiological movement if the concave joint capsule towards the bony movement. surface moves on the convex surface. • Rolling combines with the gliding, spinning • Direction of gliding will be opposite to the during the physiological movement. physiological movement if the convex • Direction of the rolling will be towards the surface moves on the concave surface. physiological movement. CONVEX-CONCAVE RULE Gliding • More the congruent surface, more the • Glidingoccursbetweenthesurfaceswhenthe sliding occurs and more the incongruent same point of the moving surface comes into surface, more the rolling occurs. contact the new point on the stable surface. • While concave surface moves on convex • Gliding occurs between either the flat or surface gliding rolling occurs towards the curved surfaces. For example, square box is angular movement. moving on oblique floor (Fig. 10.2). • While convex surface moves on concave surface rolling occurs towards the angular movement and gliding occurs opposite to that (Fig. 10.3). Note: While practicing mobilization technique gliding movement has to be selected, based on the physiological movement. 1. In a joint if upward movement is restricted and the moving bone surface is convex then the treatment direction is downward (Fig. 10.4).

PERIPHERAL JOINT MOBILIZATION 97 Figs 10.3A and B: A. Convex surface is moving on concave surface—rolling, angular motion in one direction and the sliding in another side, B. Concave surface is moving on convex surface—rolling, angular motion, sliding occurs in the same direction Fig. 10.4: Treatment direction Spinning 2. In a joint if upward movement is restricted • Moving surface rotates on the stable and the moving bone surface is concave surface. then the treatment direction is upward (Fig. • Rotation occurs in the stationary mechanical 10.5). axis. • Spinning results in rotatory movement. • Spinning surface creates an arc of a circle. • It combines with the rolling and gliding and results in rotatory type of physiological movements. Example: Radio-humeral joint pronation and supination movement. Fig. 10.5: Treatment direction Figs 10.6A and B: A. Top is spinning on the floor, and B. Head of the humerus spinning on the glenoid cavity of the scapula Traction • Articular surfaces are drawn or pulled apart.

98 TEXTBOOK OF THERAPEUTIC EXERCISES OSTEOKINEMATICS Fig. 10.7: Distraction Definition • Normally distal bony surface is pulled apart Osteo—Bone, Kinematics—Movement/motion. The movement occurs in the bone rather than at right angle. the joints surface is called as “physiological • Movement takes place perpendicular to and movement”. Normally, particular joint ROM mentioned as physiological ROM. The physio- away from the treatment plane. logical movement may differ from one joint to • The joint space increases during traction. another due to the structure of the bony • It reduces the joint friction. alignment and the structure of the soft tissues • Enhancesthejointplaymovement(Fig.10.7). around the joint. Some joint has uniaxial Compression movement, some has biaxial and some has • Articular parts are pushed towards each triaxial. Due to some pathological disturbance some joints may have more mobility is called other. “hypermobile joints”. It is due to the laxity of • Distal articular bone surface moves towards the ligaments, reduced tension in the joint capsule and the soft tissues around the joint. the proximal articular bone surface. Mobilization techniques are totally contra- • Movement perpendicular to and towards the indicated for this variety. The joints, which have less mobility, are called “hypomobile joints”. It treatment plane. is due to spasm of the ligaments, muscles, • More common in the weight bearing joints. capsule or any other soft tissues around the • Articular surface will be having more joint and sometime may be due to adhesion formation. This type of joints has to undergo contact with each other. for the mobilization treatment. • Squeezing of the synovial fluid takes place These osteokinematics movements are the during compression. visible movements and are determined by the • Over compression leads to joint structure invisible arthrokinematics movements. It is believed that the arthrokinematic movements deterioration (Fig. 10.8). are very much needed for the effective osteokinematic movements. Where the joint play movements are lacking the joints said to be hypomobile. Because reduction of joint play in articular surface reduces the physiolo- gical movement and vice versa in the hyper- mobile. Fig. 10.8: Compression Manual Grading of Movement The joint movement can be graded by the below mentioned scale. Amount of the motion from the resting position can be measured by the goniometer. If the joints are hypermobile or hypomobile there shall be some change of normal joint ROM.

PERIPHERAL JOINT MOBILIZATION 99 Grade –0 – No movement (stiff joint) Fig. 10.9: Rotatory motion Grade –1— Considerable limited movement Grade –2— Slightly limited movement Fig. 10.10: Translatory motion Grade –3 – Normal • If it occurs in curved pathway is called Grade –4 – Slightly increased movement Grade –5 – Considerable increased movement “curvilinear motion” (Fig. 10.11). Grade –6 – Unstable (or) flial joint. To perform osteokinematic movement This scale has three (3) categories. there should be an axis and a plane. • 0, 1, 2 labeled as hypomobile • 3 normal • 4, 5, 6 labeled as hypermobile. Osteokinematic movements are: • Flexion • Extension • Abduction • Adduction • Medial rotation • Lateral rotation • Circumduction • Supination • Pronation • Opposition • Inversion • Eversion • Plantar flexion • Dorsiflexion • Forward bending • Backward bending • Lateral bending, etc. These osteokinematic movements are classified into two motions. 1. Rotatory motion (Fig. 10.9) • Otherwise called as angular motion. • Movement of an object around a fixed axis known as rotatory motion. • Each segment moves through the same angle, same time at a constant distance. 2. Translatory motion (Fig. 10.10) • Each segment or object moves in straight line. • Each segment moves through same dis- tance at the same time in parallel path. • If the movement occurs in straight line is called as “linear motion”.

100 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.11: Curvilinear motion PLANES AND AXES (FIG. 10.12) Planes Planes are the space or surface where the movements take place. Axis Fig. 10.12: Axes and planes An axis is the point by which the movements take place. The anatomical position (standing • Movement occurs in X-Y plane. erect with the head, toes and the palm of the • Movement occurs in sagittal axis or hand facing forwards and the finger extended.) is the correct position to discuss about the planes A-P axis. and axes. The imaginary planes are made to • Movements possible are abduction and each other perpendicular in the human body. These are called as “Cardinal planes”. They are: adduction. 1. Frontal plane (Coronal plane) 2. Sagittal plane 2. Sagittal plane (A-P plane) 3. Transverse plane (Horizontal plane). • The plane, which divides the body into equal right and left parts. 1. Frontal plane • The plane, which divides the body into • Movement occurs in Y-Z plane. equal front and back parts. • This plane passes through the sagittal • This plane passes through the coronal suture of the skull. suture of the skull. • Movements possible are flexion and extension. • Movement occurs in frontal axis or coronal axis.

PERIPHERAL JOINT MOBILIZATION 101 3. Transverse plane Actual Resting Position • The plane, which divides the body into An alternative resting position is adopted, since equal upper and lower parts. the resting position may not be obtained • Movement occurs in X-Z plane. effectively in some pathological and painful • Movements possible are medial and conditions of the joint. For example, in post- lateral rotation. traumatic stiffness, it is impossible to place the • Movement occurs in vertical axis. joint in resting position. So that alternative position is adopted to reduce the torque of the POSITION OF THE JOINTS joint. This position is meant as actual resting It deals about the position of the articular position. These actual resting positions are surfaces of the joint and its merits and demerits. useful for testing and treating the pathological The particular position of the joint has its own joint conditions. While, choosing the actual characteristics, values and properties. The resting position, an attempt should be made to therapist uses some position for examination, find out the loosest position of the joint. some for relaxation, and some for treatment purposes. They are: Close Packed Position (Tightly packed position) 1. Loose packed position The joint structures are maximum taut in this 2. Zero position position. The articular surfaces are having 3. Actual resting position maximum congruency between each other and 4. Tightly packed position (close packed). also the joint play movement will be very much difficult in this position. The close packed Resting Position (Loosed packed position) position is usually at the extreme end of the ROM, Joint structures are most relaxed in this during this position the synovial fluid moves to position. Contacts between the joint surfaces the other side as the synovial membrane gets are lesser, so more space is available for the compressed. This movement of the synovial fluid accommodation of the synovial fluid and more helps the capsule in getting extra nourishment. joint play movement also easily felt. For It is essential for the therapist, to have a sound example, the shoulder joint is totally relaxed knowledge about the close packed position of all and more joint play is felt in 30°-40° abducted the joint to avoid any of the mobilization position (See Table 10.1). techniques in this position (See Table 10.2). Zero Position (Starting position) PHYSIOLOGY OF JOINT MOTION This is the starting position of the joint. While measuring the ROM by the goniometer, the zero Nutrition position is taken as starting point of the Joint articular surfaces are avascular and it measurement. For example, to measure the receives the nutrition from synovial fluid. The shoulder joint movements like flexion, exten- synovial fluid circulates inside the capsule to sion, adduction, abduction with goniometer, the supply the nutrition to the articular surfaces. zero position we adopt is the arm kept by the side The synovial fluid movement occurs by the of the chest wall, and for the medial and lateral compression of the articular cartilage and rotations the adopted position is the shoulder in capsule. During the loading and unloading as 90° abduction with elbow in 90° flexion. well as the motion of the joint causes the synovial fluid movement inside the synovial

102 TEXTBOOK OF THERAPEUTIC EXERCISES Joints Table 10.1: Resting position Shoulder Position Sternoclavicular joint Slightly abduction of the shoulder 35º to 55º Acromioclavicular joint Clavicle is horizontal position Scapulothoracic joint Clavicle is in horizontal positon Humeroulnar Clavicle is in horizontal position and scapula is positioned from 2 to 7 ribs Humeroradial 70º flexion 10º supination Proximal radiaoulnar joint Full extension supination Distal radioulnar joint 35º supination 70º flexion Wrist 10º supination 1st carpometacarpal joint Neutral with slight ulnar deviation Metacarpophalangeal Midway between the flexion extension abduction and adduction Interphalangeal joint Slight flexion Hip PIP 10º flexion, DIP 30º flexion Knee 30º flexion 30º abduction slight external rotation Patellofemoral 25º flexion Proximal tibiofibular Full extension of knee Distal tibiofibular 25º knee flexion 10º plantar flexion Ankle 10º plantar flexion 5º inversion Subtalar 10º plantar flexion midway between inversion and eversion Midtarsal Midway between inversion eversion with10º plantar flexion Tarsometatarsal Midway between supination pronation with 10º plantar flexion Metatarsophalangeal Midway between supination and pronation Interphalangeal joint Midway between supination and pronation abduction and adduction Slight flexion Table 10.2: Closed packed position Joints Position Shoulder Maximum abduction and external rotation Sternoclavicular joint Arm maximum elevated Acromioclavicular joint Shoulder 90º abduction Scapulothoracic joint None Humeroulnar Full extension supination Humeroradial 90º flexion 5º supination Proximal radioulnar joint Full extension and 5ºsupination Distal radioulnar joint 5º supination Wrist Full extension 1st carpometacarpal joint Full opposition Carpometacarpal (2nd-5th) None Metacarpophalangeal 1st—Maximum extension Interphalangeal joint 2nd-5th—Maximum flexion Hip Maximum extension Knee Maximum extension, medial rotation and abduction Patellofemoral Maximum extension and external rotation Proximal tibiofibular Knee full extension Distal tibiofibular None Ankle None Subtalar Maximum dorsiflexion Midtarsal Full eversion Tarsometatarsal Full supination Metatarsophalangeal Full supination Interphalangeal joint Full extension Full extension

PERIPHERAL JOINT MOBILIZATION 103 cavity. The joint mobilization techniques also Table 10.3: Contd... doing the same as said above mechanism. So that the articular surface will be getting good Location: Superficial joint capsule, nutrition supply. Immobilization of the joint Response: periosteum, ligaments and may result in atrophy of the articular cartilage, tendons synovial membrane, and formation of adhesion. It provides static position, This can be cured by the mobilization techni- speed and velocity of the ques. movement Extensibility Type II Pacini or paciniform Joint mobility maintains the extensibility and Name: Dynamic tensile strength of the articular tissues. If the Quality: Activated by the changes in joint is immobilized, the ligaments, tendons and Stimulus: joint motion cartilages loose its extensibility property, which Activated more with leads to joint stiffness and hypomobile. Normal Characteristics: oscillatory techniques than joint movement prevents the contracture, Location: traction shortening, and thickening of the tissues. The Response: Low threshold, rapid mobilization techniques are also helpful to adaptive prevent the contracture and thickening of the Deep layer of capsule soft tissues and improve the extensibility Mainly in lumbar spine, property of the soft tissues. hand, foot, jaw Provides joint motion sense Joint Receptors Joint receptors transmit the impulses to the Type III Golgi or Golgi mazzoni afferent nervous system from the joint. The Name: Inhibitive joint receptors give the awareness of the Quality: During end range stretch position and movement of the joints. Injury, Stimulus: High threshold, very slow disease or immobilization of the joint may cause Characteristics: adaptive the lack of functioning of the joint receptors. Activated by joint There are four types of joint receptors (Table Location: mobilization technique 10.3). Response: Inner layer of joints, ligaments and tendons Sense of direction of movement Regulation of muscle tone Table 10.3: Different types of joint receptors Type IV Non-myelinated free nerve Name: endings Type I Ruffini Nociceptive Name: Postural Quality: Noxious mechanical stress Quality: Activated by the postural Stimulus: or biomechanical stress Stimulus: faults High threshold and non- Activated by the stress of the Characteristics: adaptive Characteristics: joint capsule Produces tonic contraction Activated by traction and Response: Located in most tissues like oscillatory techniques Location: blood vessels, synovial layer Low threshold and slow adaptive of the capsule, fat pads, Located mainly around the ligaments, tendons and knee, hip, and shoulder periosteum Contd...

104 TEXTBOOK OF THERAPEUTIC EXERCISES EFFECT OF PATHOLOGICAL Table 10.4: Effect of immobilization CHANGES OF THE JOINT Each and every structure of the joint is much Sl.No Structure Changes more important for the total functioning of the joint. Defect in any of the structure leads to 1. Bone Osteoporosis improper functioning of the joint. 2. Ligaments Osteoclastic activity leads to weak- Disease ness of the ligaments. Decreased Joint diseases like RA, OA, TB arthritis, matrix compound, degenerative psoriatic arthritis, ankylosing may cause changes in the ligaments lead some deformation of the some joint structures to deterioration of biomechanical results in the improper, imperfect movement activities. of the joint. For example, in RA the synovial membrane gets affected, so that there is 3. Cartilage Decreased proteoglycans, dec- alteration in the synovial fluid secretion. Joint reased water content, decreased lubrication altered and the joint structures may thickness, increased stiffness. not get proper nutrition. Lack of nutrition may cause deformation of the joint structures. In 4. Capsule Decreased proteoglycans, increa- osteoarthritis erosion or degeneration of the 5. Tendon sed water content, atrophy of the cartilages occurs. So, there will be restricted capsule. movement and painful movement. If the disease Decreased collagen content, progresses results in contracture of the muscles, atrophy, size of the collagen fiber weakness of the muscles, ligaments tightness, decreases. osteophytic formation over the articular surfaces, osteoporotic changes in the articular 6. Synovium Proliferation of fibro-fatty con- surface, makes the joints immovable. nective tissue and formation of adhesion. Injury Injury of the joint structure causes the improper mobility of the joint causes many changes over movement and improper gait pattern. Loading the joint structures. Normally, after immobili- and unloading of the joint will be painful. If the zation, contracture develops in the surrounding synovial membrane injured, it secretes more soft tissues, so that after the immobilization of synovium. Lacking of the stability comes due joint, it is impossible to attain normal range of to the ligament injury. Injury of capsules and motion (Table 10.4). cartilages results in lacking of loading and unloading. Any tendon injury may cause the These are the changes occur in the surroun- lack of movement over the joint. So, depends ding tissues of the joint. It may result in reduced on the structure injured the outcome of the ROM. Sometimes muscles may go for weakness effect may differ. But the net result will be or contracture due to the immobilization. So that improper or lack of movement of the joint. the joint cannot function normally. Immobilization Overuse Immobilization may be imposed by the plaster Prolonged standing, sitting or attaining one cast, bedrest, and fear of pain. Due to the non- particular posture or attaining one particular movement may create some strain and stress of the surrounding structures of the joint. Continuous loading of a joint tissue that is defor- med earlier may not get the time to recover. So that the tissue may be more prone to get overuse injury or syndrome. Normally, the cartilages, which is the most important connec- tive tissue for loading of a joint. If the deforma-

PERIPHERAL JOINT MOBILIZATION 105 tion and degeneration changes occur in the cartilage, the permeability of the cartilage will get decreased. It is believed that the overuse of the joint may results in osteoarthritis. INDICATIONS • Post-traumatic stiffness of the joint. • Postoperative stiffness of the joint. • Postimmobilization stiffness of the joint. • Adhesion formation around the joint. • Atrophy of the capsule. • Atrophy of the synovial membrane. • Painful joint. • Disuse atrophy of the joint structures. CONTRAINDICATIONS Figs 10.13A and B: A. Stress-strain curve, and • Synovial effusion. B. Tissue restriction on passive joint play test • Hemarthrosis. • Recent fractures around the joint. the external force is removed. Third phase is • Dislocation. “failure point”, the stretched tissue may be • Recent injuries around the joints. teared or separated. Normally, joint mobili- • Acute RA. zation techniques are done up to the limit of • Flial joint. the plastic range and sometimes about to • Malignant tumors. reaching the breaking point but without • Inflammatory joint disease like TB arthritis, causing any tissue damage. If the breaking point is felt, the treatment should be terminated psoriatic arthritis. (Figs 10.13A and B). • Immediately after surgery around the joint. • Total joint replacements. While mobilizing the stiff joint the therapist • Scoliotic spine. may feel the restriction by the surrounding • Spondylolisthesis. structures. Limitations may be due to capsule, ligaments, muscle, skin, fascia, cartilages or STRESS-STRAIN CURVE adhesions. The limitations or restrictions of The role of the extensibility of the soft tissue, movement, which is felt by the therapist, is the stress-strain curve gives the perfect called as first tissue stop. Normally, the passive knowledge about the load deformation of the movement can cross the first tissue stop. If the soft tissue. Whenever the external force is therapist adds more force after reaching first applied to a soft tissue, it goes for more stress tissue stop, he may feel again the restriction of and strain. The first phase is “elastic phase”, movement by some structures is called as the stretched tissue will go for normal position second tissue stop. If we apply force more than after removing the external force. The second the first tissue stop the tissue will be attaining phase is “plastic phase”, the stretched tissue may be remain in the elongated state when

106 TEXTBOOK OF THERAPEUTIC EXERCISES the plastic range. But if the therapist crosses TREATMENT PLANE the second tissue stop, the tissue may be It lies over the concave surface of the articular separated or teared. So, the joint mobilization surface. The treatment plane moves with the technique should be performed within the movement of the concave surface. It will be cons- second tissue stop. tant or stable while the convex surface moves. The treatment plane is perpendicular to the axis One more factor also influences on the joint of the rotation. The joint traction also will be extensibility, it can be gained by the rapid given perpendicular to the treatment plane (Fig. mobilization technique, which may increase the 10.14). extensibility of the tissue than the slow techniques. So that the stretch administered While assessing a joint movement or joint up to the plastic phase or attaining about to play, the parallel or perpendicular to the the second tissue stop may give good result than treatment plane should be performed. The the medium mobilization technique. Fig. 10.14: Treatment plane

PERIPHERAL JOINT MOBILIZATION 107 gliding or rolling tests are done parallel to the Treatment Direction treatment plane. Traction and distraction can The treatment direction may be parallel or per- be performed perpendicular to the treatment pendicular to the treatment plane. Distraction plane. This joint play movement decides the may be applied perpendicular to the treatment grade of the joint movement. plane. The oscillatory technique may be perfor- med parallel to the treatment plane. PRINCIPLES Relaxation Treatment Force and Range Patient has to be positioned in relaxed manner The treatment force will be depended on the before starting the treatment procedure. grade of the movement of the joint; it may be During the relaxed state there will not be any gentle or forcible. Range of the movement may muscle work and the total body part will be differ depends on the stiffness of the joint. fully relaxed and also the patient can cooperate Normally, the actual resting position may be for the treatment. If the patient feels incon- adopted for the treatment, because the resting venient by the position, he cannot cooperate and starting position may not be possible in for the treatment. So, the position of the patient the stiff or hypomobile joint. The treatment is strictly noticed before giving the treatment force is given within the second tissue stop or and also the position should not be altered within the plastic range or sometime about to during a treatment process. The therapist’s reach the breaking point of the tissue. position also plays an important role to treat the patient. The therapist has to adopt the walk TREATMENT TECHNIQUES standing position while treating the patient. Treatment is graded according to the amount of the motion and the joint play movement of Fixation the joint. There are two systems of grading of The joint, which is proximal to the mobilizing the mobilization. joint, should be fixed and avoid trick/vicarious 1. Traction technique movement. So, that the accessory movement 2. Oscillatory technique. may not occur in that joint which may reduce the ROM of the mobilizing joint and also the Traction Technique (Fig. 10.15) movement can be localized to one particular Grade I: Slow, small amplitude perpendicular joint. movement (distraction) to the concave joint surface performed within the first tissue stop. Support or Stabilization Grade II: Slow, large amplitude perpendicular The distal part of the joint being moved should movement (distraction) to the concave joint be supported or comfortably stabilized for the surface done up to the first tissue stop. relaxation and avoid the inconveniency. The Grade III: Slow, large amplitude perpendicular therapist should grasp firmly which may movement (distraction) to the concave joint stimulate the nerve endings and improves the surface performed up to the level of crossing condition as well as the psychological support the first tissue stop, but without reaching the of the patient. second tissue stop.

108 TEXTBOOK OF THERAPEUTIC EXERCISES Grade III: Slow, large amplitude oscillatory movement parallel to the concave joint surface performed up to reaching the first tissue stop. Grade IV: Slow, small amplitude oscillatory movement parallel to the concave joint surface performed slightly through the first tissue stop. Grade V: Slow, small amplitude, large velocity, thrust movement parallel to the concave joint surface performed to snap the adhesion and up to about to reach the second tissue stop. Fig. 10.15: Traction joint mobilization with gradings Uses Grades I and II: Reduces the pain. Uses Grades III and IV: Reduces the pain, increases Grade I: Used for reducing the pain. the periarticular extensibility, correct the Grade II: Used for pain reduction and increases postural faults, breaking the adhesion. the periarticular extensibility. Grade V: Reduces the spinal disc herniation and Grade III: Used for periarticular extensibility, breaking the adhesion. to correct the positional fault and reduces the spinal disc herniation. Traction is given for 10 seconds followed by rest period of several seconds. Oscillation is Oscillatory Technique (Fig. 10.16) given for 2 or 3 per second for about 1 minute. Grade I: Slow, small amplitude oscillatory Normally, the mobilization can be performed movement parallel to the concave joint surface combined with the other modalities like wax performed within the beginning range. bath, hot water fomentation, massage, IFT, Grade II: Slow, large amplitude oscillatory ultrasound, etc. movement parallel to the concave joint surface performed within the first tissue stop. MOBILIZATION PROCEDURES FOR INDIVIDUAL JOINTS Sternoclavicular Joint (Fig. 10.17) Type Synovial joint Variety Saddle variety Fig. 10.16: Oscillation joint mobilization with gradings Articular Surface • Medial end of clavicle (concavoconvex) • Clavicular notch of the manubrium sternum)

PERIPHERAL JOINT MOBILIZATION 109 Medial rotation • Levator scapular, rhomboidus major and minor • Latissimus dorsi Arthrokinematics Arthrokinematics relations with the osteo- kinematics movements are: • Elevation—caudal gliding • Depression—cranial gliding • Protraction—ventral gliding • Retraction—dorsal gliding. Fig. 10.17: Sternoclavicular joint Positions Starting position Ligaments • Clavicle lies in horizontal position. • Anterior-sternoclavicular joint Resting positing • Posterior-sternoclavicular joint • Clavicle lies in horizontal position. • Interclavicular ligament Close packed position • Costoclavicular ligament. • Full elevated position. Capsular pattern Movements • In full elevation it is restricted. • Elevation and depression Cranial Gliding (Fig. 10.18) • Protraction and retraction Goal • Rotation. • To increase the joint play movement of the Elevation • Trapezius (middle fibers) sternoclavicular joint. • Levator scapulae • To reduce the pain around the sternocla- • Rhomboidus major, minor. Depression vicular joint. • Latissimus dorsi, pectoralis major, • Serratus anterior, pectoralis minor Fig. 10.18: Sternoclavicular joint cranial gliding • Subclavius. Protraction • Serratus anterior, pectoralic major and minor. Retraction • Trapezius, rhomboidus major, minor Lateral rotation • Trapezius (middle fibers).

110 TEXTBOOK OF THERAPEUTIC EXERCISES • To increase the depression movement of the Support: Distal joint to the mobilizing joints shoulder. are supported already by the couch. Position of the therapist and grasping Position of the patient: Supine lying. • Therapist is standing besides the patient and Fixation : Sternum is fixed with the thoracic cage already. facing the patient’s sternoclavicular joint. Support: Distal joint to the mobilizing joints • Therapist’s both the thumbs are placed are supported already by the couch. Position of the therapist and grasping superior part of the medial end of the • Therapist is standing besides the patient and clavicle. Procedure facing the patient’s sternoclavicular joint. • Therapist’s both the thumbs are gliding the • Therapist’s both the thumbs are placed clavicle in the caudal direction. below the medial end of the clavicle. Ventral Gliding (Fig. 10.20) Procedure Goal • Therapist’s both the thumbs are gliding the • To increase the joint play movement of the clavicle in the cranial direction. sternoclavicular joint. • To reduce the pain around the sterno- Caudal Gliding (Fig. 10.19) Goal clavicular joint. • To increase the joint play movement of the • To increase the protraction movement of sternoclavicular joint. the shoulder. • To reduce the pain around the sternoclavi- Position of the patient: Supine lying. Fixation: Therapist’s right hand is fixing the cular joint. sternum. • To increase the elevation movement of the Support: The couch already supports distal joints. shoulder. Position of the therapist and grasping Position of the patient: Supine lying. • Therapist is standing besides the patient and Fixation: Sternum is fixed with the thoracic cage already. facing the patient’s sternoclavicular joint. Fig. 10.19: Sternoclavicular joint caudal gliding Fig. 10.20: Sternoclavicular joint ventral gliding

PERIPHERAL JOINT MOBILIZATION 111 • Therapist’s left hand is grasping the medial Acromioclavicular Joint (Fig. 10.22) two-thirds of clavicle with the thumb below Type and the fingers up. Synovial joint. Procedure Variety Therapist’s left hand pulls the clavicle up and Plane. gliding anteriorly. Dorsal Gliding (Fig. 10.21) Articular Surfaces Goal • Lateral end of clavicle (flat) • To increase the joint play movement of the • Medial margin of the acromian process of sternoclavicular joint. scapula (flat). • To reduce the pain around the sternocla- Ligaments vicular joint. • Acromioclavicular ligament • To increase the retraction movement of the • Coracoclavicular ligament. shoulder. Movements Position of the patient: Supine lying. Osteokinematics Fixation: The thoracic cage already fixes ster- • As said in sternoclavicular joint. num. Arthrokinematics Support: The couch already supports distal joints. Arthrokinematics relation with the osteo- kinematics. • Elevation—dorsal gliding • Depression—ventral gliding Fig. 10.21: Sternoclavicular joint dorsal gliding Fig. 10.22: Acromioclavicular joint Position of the therapist and grasping • Therapist is standing besides the patient and facing the patient’s sternoclavicular joint. • Therapist’s both the thumbs are placed over the anterior part of the medial end of the clavicle. Procedure Therapist’s thumbs are applying the pressure over the anterior part of the medial end of the clavicle and posteriorly gliding the clavicle.

112 TEXTBOOK OF THERAPEUTIC EXERCISES Position • Therapist’s right hand thumb is placed over Starting position the lateral end of the anterolateral aspect • Clavicle lies in horizontal position. of the clavicle. Resting position • Clavicle lies in horizontal position. Procedure: Therapist’s right hand thumb is Close packed position gliding the lateral end of the clavicle posteriorly. • 90° abduction of the shoulder. Capsular pattern Ventral Gliding (Fig. 10.24) • Full elevation is limited. Goal • To increase the joint play movement of the acromioclavicular joint. Dorsal Gliding (Fig. 10.23) Goal • To increase the joint play movement of the acromioclavicular joint. • To reduce the pain around the acromio- clavicular joint. • To increase the elevation movement of the shoulder. Fig. 10.23: Acromioclavicular joint dorsal gliding Fig. 10.24: Acromioclavicular joint ventral gliding Position of the patient: Long sitting. Fixation: Therapist’s left hand grasping the • To reduce the pain around the acromiocla- shoulder and the acromian process with thumb vicular joint. anteriorly and the fingers posteriorly. Support: No need of the support for the distal • To increase the depression movement of the parts. shoulder. Position of the therapist and grasping • Therapist is standing in front of the patient Position of the patient: Long sitting. Fixation: Therapist’s right hand grasping the and facing the patient’s acromioclavicular shoulder and the acromian process. joint. Support: No need of the support for the distal parts.

PERIPHERAL JOINT MOBILIZATION 113 Position of the therapist and grasping Resting position • Therapist is standing back to the patient • Clavicle is in horizontal position and scapula and facing the patient’s acromioclavicular is positioned from 2 to 7 ribs. joint. Close packed position • Therapist’s left hand thumb is placed over • Nothing the later end of the posterior aspect of the Capsular pattern clavicle with the fingers in the anterior • Nothing grasping. Procedure: Therapist’s left hand thumb glides Distraction (Fig. 10.25) the lateral end of the clavicle anteriorly. Goal • To increase the joint play movement of the Scapulothoracic Joint Type scapulothoracic joint. • Fibrous joint • To reduce the pain around the scapulo- Articular Surface thoracic joint. • Anterior surface of the scapula. Position of the patient: Side lying by facing the • Posterior portion of the ribs. therapist. Fixation: Therapist’s left hand fixing the Ligaments acromioclavicular joint. • None Support: Patient’s upper limb is resting on the therapist’s left forearm. Movements Fig. 10.25: Scapulothoracic joint distraction Osteokinematics Position of the therapist and grasping • As said in sternoclavicular joint. • Therapist is standing in front of the patient Arthrokinematics • Elevation—cranial gliding, lateral gliding and facing the scapulothoracic joint. • Depression—caudal gliding, medial gliding • Therapist’s right hand is fixing the acro- • Protraction—lateral gliding • Retraction—medial gliding mioclavicular joint. • Medial rotation—caudal gliding, medial gliding • Lateral rotation—cranial gliding, lateral gliding. Position Starting position • Clavicle is in horizontal position.

114 TEXTBOOK OF THERAPEUTIC EXERCISES • Therapist’s left hand grasping the inferior Procedure: Therapist’s left is performing the angle of the scapula. cranial gliding with the distraction. Procedure: Therapist’s left hand pulls the Caudal Gliding (Fig. 10.27) scapula from the rib. Goal • To increase the joint play movement of the Cranial Gliding (Fig. 10.26) Goal scapulothoracic joint. • To increase the joint play movement of the • To reduce the pain around the scapulo- scapulothoracic joint. thoracic joint. • To reduce the pain around the scapulo- • To increase the scapular depression and thoracic joint. medial rotation. • To increase the scapular elevation and lateral rotation. Fig. 10.27: Scapulothoracic joint caudal gliding Fig. 10.26: Scapulothoracic joint cranial gliding Position of the patient: Side lying. Fixation: Therapist’s left hand fixing the Position of the patient: Side lying. acromioclavicular joint. Fixation: Therapist’s left hand fixing the Support: Patient’s upper limb is resting on the acromioclavicular joint. therapist’s left forearm. Support: Patient’s upper limb is resting on the Position of the therapist and grasping therapist’s left forearm. • Therapist is standing in front of the patient Position of the therapist and grasping • Therapist is standing in front of the patient and facing the scapulothoracic joint. • Therapist’s right hand is fixing the acromio- and facing the scapulothoracic joint. • Therapist’s right hand is fixing the acromio- clavicular joint. • Therapist’s left hand grasping the inferior clavicular joint. • Therapist’s left hand grasping the inferior angle of the scapula. Procedure: Therapist’s left hand performs the angle of the scapula. caudal gliding of the scapulothoracic joint.

PERIPHERAL JOINT MOBILIZATION 115 • Therapist also applies the caudal gliding • To reduce the pain around the scapulo- force. thoracic joint. Medial Gliding (Fig. 10.28) • To increase the scapular protraction, Goal elevation and lateral rotation. • To increase the joint play movement of the scapulothoracic joint. • To reduce the pain around the scapulo- thoracic joint. • To increase the scapular retraction, medial rotation and depression. Fig. 10.28: Scapulothoracic joint medial gliding Fig. 10.29: Scapulothoracic joint lateral gliding Position of the patient: Side lying. Position of the patient: Side lying. Fixation: No need of the fixation for this Fixation: No need of the fixation for this technique. technique. Support: Patient’s upper limb is resting on the Support: Patient’s upper limb is resting on the therapist’s left forearm. therapist’s left forearm. Position of the therapist and grasping Position of the therapist and grasping Therapist’s both the hands are placed over the • Therapist is standing in front of the patient lateral border of the scapula one over the acromion process and another over the inferior and facing the scapulothoracic joint. angle of the scapula. • Therapist’s both hands and fingers are Procedure: Therapist’s both hands glide the scapula in medial direction. placed over the medial border of the scapula in spreader manner and the thumbs are Lateral Gliding (Fig. 10.29) placed over the lateral border. Goal Procedure: Therapist’s both the hands are • To increase the joint play movement of the gliding the scapula in lateral direction. scapulothoracic joint. Shoulder Joint (Fig. 10.30) Type Synovial joint. Variety Ball and socket (spheroid) Articular Surfaces • Glenoid cavity of scapula (concave) • Head of humerus (convex).

116 TEXTBOOK OF THERAPEUTIC EXERCISES Figs 10.30A and B: Shoulder joint. A. Diagram of shoulder joint anterior view, B. Sagittal section of shoulder joint Ligaments While convex surface moves on concave • Superior glenohumeral ligament surface, rolling occurs towards the angular • Middle glenohumeral ligament movements and the gliding will be opposite to • Inferior glenohumeral ligament the angular motion. • Coracohumeral ligament • Transverse humeral ligament Range of Motion (ROM) • Coracoacromial ligament. • Flexion 0º-180º (150º to 180º) Arthrokinematic • Extension 0º-45º (40º to 60º) Arthrokinematic relations with the osteo- • Abduction 0º-180º (150º to 180º) kinematics movements are: • Adduction 0º • Abduction—inferior gliding, superior rolling • Hyperadduction 0º-35º (25º to 35º) • Flexion—posterior gliding, anterior rolling • Internal rotation 0º-90º (70º to 90º) • Extension—anterior gliding, posterior • External rotation 0º-90º (80º to 90º) rolling Positions • Adduction—superior gliding, interior I. Starting position Upper limb hanging parallel to the trunk rolling. with elbow extension.

PERIPHERAL JOINT MOBILIZATION 117 Movements (Table 10.5) • To increase the joint space to improve joint Osteokinematics play. Table 10.5: Muscles responsible for shoulder movement Position of the patient: Supine lying with shoul- Sl. No Movement Muscle responsible for der adducted. Fixation: Scapula thoracic movements 01. Flexion 1. Clavicular head of pectorals restricted by the assistant or by the belt. major Support: Patient’s forearm and hand supported 2. Anterior fibers of deltoid by the therapist’s forearm. 3. Biceps 4. Coracobrachialis Fig. 10.31: Shoulder joint distraction 02. Extension 1. Posterior fibers of deltoid Therapist’s position 2. Triceps • Walk standing position and standing beside 3. Teres major 4. Latissimus dorsi the patient by facing the glenohumeral joint. 03. Abduction 1. Supraspinatus • Grasping the midpart of the humerus by the (Initiations of abduction 0o-15o) 2. Middle fibers of deltoid both hands. (15o-30o to 60o-90o) • Therapist’s right hand placed up and the left 3. Trapezius and serratus Anterior final degree hand down. of abduction (120-180) Procedure 04. Adduction 1. Latissimus dorsi • Articular surfaces are pulled apart by the 2. Teres major 3. Coracobrachialis therapist’s right hand. 4. Pectroralis major Caudal Gliding (Fig. 10.32) 5. Subscapularis Aims 05. Medial 1. Anterior fibers of deltoid • To increase joint play movements. rotation 2. Teres major • To improve the abduction ROM. 3. Pectoralis major Position of the patient: Supine lying and the 4. Subscapularis shoulder in adducted position. 5. Latissimus dorsi Fixation: Scapular movements restricted by the 06. Lateral 1. Posterior fibers of deltoid assistant or by the belt. rotation 2. Teres minor 3. Infraspinatus Some of the movements restricted by the 07. Circum- Combination of all the muscle couch already. duction II. Resting position Slightly abduction of the shoulder (35-55). III. Close packed position Extreme abduction and lateral rotation. IV. Capsular pattern Lateral rotation→abduction→medial rotation. Distraction (Fig. 10.31) Goal • To increase the joint play movements in the glenohumeral joint. • To break the adhesion formation.

118 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.32: Shoulder joint caudal gliding Fig. 10.33: Shoulder joint caudal gliding progression Therapist’s position Support: Distal part to the mobilizing joint is • Therapist standing behind the abducted or supported by the therapist’s forearm or positioning the patient’s forearm and hand mobilizing glenohumeral joint. between the therapist’s upper arm and trunk. • Therapist’s left hand with the web space Therapist’s position over the patient’s upper part of the humerus. • Standing side to the patient by the facing • Therapist’s right hand placed distal part of the glenohumeral joint. the humerus. • Grasping the upper part to the humerus by Mobilizing force • Traction applied by the right hand of the both the hands. Procedure therapist. • Therapist’s right hand performing traction • Caudal gliding done by the web space of the and the caudal gliding. left hand of the therapist. Note: Progression is achieved by the mobilizing (gliding) the joint in the available range. Caudal Gliding (Progression) (Fig. 10.33) Dorsal Gliding (Fig. 10.34) Aims Aims • To improve joint play movements. • To improve joint play movements. • To increase abduction ROM from the • To increase the flexion and internal rotation available range. ROM of the glenohumeral joint. Position of the patient: Supine lying and the Position of the patient: Supine lying with the mobilizing glenohumeral joint kept in available mobilized glenohumeral joint is slightly abduction range. abducted and placed in the end of the couch. Fixation: Scapular movements restricted by the Fixation: Scapular movements are restricted assistant or by the belt. by the assistant or by the belt. Support: The patient’s forearm and the hand Support: The patients forearm and hand is is placed between the therapist’s upper arm and resting on the therapist’s forearm. trunk.

PERIPHERAL JOINT MOBILIZATION 119 Position of the patient: Supine lying with the glenohumeral joint is available flexed position. Fixation: Scapular movements are restricted by the muscles and by placing the folded towel over the scapular region. Support: Patient’s hand is positioned on the chest wall of his own. Fig. 10.34: Shoulder joint dorsal gliding Therapist’s position Therapist’s position and holding • Therapist standing beside the patient by • Therapist standing beside the patient by facing the glenohumeral joint. facing the glenohumeral joint. • Therapist’s right hand positioned over the • Therapist’s right palm of the hand is olecranon process of the ulna. positioned on the upper part of the humerus. • Therapist’s left hand positioned in the • Therapist’s left hand grasping the distal part middle of the humerus. of the humerus. Procedure Procedure • Traction given by the therapist’s left hand • Traction applied by the therapist’s left hand. • Therapist’s right hand glides the humerus towards the lateral side. • Therapist’s right hand glides the humerus in the dorsal direction. in the posterior aspect. Dorsal Gliding (Progression) (Fig. 10.35) Aims Ventral Gliding (Fig. 10.36) • To improve joint play movements. Aims • To increase the flexion and internal rotation • To improve joint play movements of the from the available range. glenohumeral joint. • To increase the extension and external of the shoulder joint. Fig. 10.35: Shoulder joint dorsal gliding progression Fig. 10.36: Shoulder joint ventral gliding

120 TEXTBOOK OF THERAPEUTIC EXERCISES Position of the patient: Prone lying with the Fig. 10.37: A. Anterior view, and B. Posterior view of glenohumeral joint is slightly abducted position elbow joint and placed in the end of the couch. Fixation:Belt can be used to restrict the Arthrokinematics scapular movement. Arthrokinematics relations with the osteo- Support: Forearm and the hand of the patient kinematics are: remain kept handing. • Flexion: Medial gliding, lateral gliding of • The folded towels are supporting coracoid humerus ulnar joint and the ventral gliding process and the anterolateral chest wall. of the radiohumeral joint. Position of the therapist • Extension: Medial gliding, lateral gliding of • Standing beside the patient by facing the the ulnohumeral joint and the dorsal gliding of the radiohumeral joint. glenohumeral joint. • Abduction: Medial gliding. • Therapist’s right hand positioned in the • Adduction: Lateral gliding. proximal part of the humerus. Range of Motion • Therapist’s left hand holding the lower part • Flexion 0°-120° To 150° • Extension 0° of the arm. Mobilizing force Position • Traction applied by the therapist’s left hand. Ulnohumeral joint • Therapist’s right hand glides the humerus • Starting position: Forearm supinated and in the ventral direction. the elbow extended. • Resting position: Elbow 70° flexion and 10° Elbow Joint (Fig. 10.37) Type supination. Synovial joint • Close packed position: Elbow extension and Variety supination. Hinge variety • Capsular pattern: Flexion—Extension. 10° Articular Surface of extension limitation seen only when the 1. Lower end of the humerus (Convex) 90° flexion limitation. 2. Head of the radius (Concave) 3. Upper end of the ulnar (Concave). Ligaments • Ulnar collateral ligament • Radial collateral ligament. Movements Osteokinematics • Flexion—brachialis, biceps, brachioradialis. • Extension—triceps, anconeus.

PERIPHERAL JOINT MOBILIZATION 121 Radiohumeral joint Position of the patient: Supine lying or long • Starting position: Forearm supinated and sitting and the elbow is positioned in actual resting position. the elbow extended. • Resting position: Full extension and Fixation: Arm of the patient is fixed by the assistance or it may be fixed by the therapist’s supination. left hand. • Close packed position: 90° flexion and 5° Support: No need of support for the distal parts. supination. • Capsular pattern: Flexion and extension. 10° Position of the therapist and grasping • Therapist is standing near to the hip region of extension limitation seen when the 90° flexion limitation. of the patient. • Therapist’s right hand fingers grasping the Ulnohumeral Joint (Fig. 10.38) Joint distraction proximal end of the anterior aspect of the Goal patient. • To increase the ioint play movement of the • Therapist’s left hand reinforces the activity. elbow joint. Procedure: Therapist’s right hand applies long • To reduce the pain around the elbow joint. axis distraction force over the patient’s elbow in 45° flexion. Fig. 10.38: Ulnohumeral distraction Medial Gliding (Fig. 10.39) Goal • To increase the joint play movement of the ulnohumeral joint. • To reduce the pain around the ulnohumeral joint. • To increase the elbow extension and flexion of ulnohumeral joint. Position of the patient: Supine lying or long sitting. Fixation: Therapist’s left hand grasping the distal humerus and restricting the movement over the shoulder joint. Support: Patient’s forearm and hand is placed in between the trunk and arm of the therapist. Position of the therapist and grasping • Therapist is standing besides the patient and facing the elbow joint. • Therapist’s left hand grasping the distal humerus and restricting the proximal joint motion.

122 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.39: Ulnohumeral medial gliding Position of the patient: Supine lying or long • Therapist’s right hand and fingers are placed sitting. Fixation: Therapist’s left hand grasping the posteriorly and grasping the olecranon distal humerus and restricting the movement process of ulna and the thumb is placed over the shoulder joint. proximal part of anterior aspect of the ulna. Support: Patient’s forearm and hand is placed Procedure: Therapist’s right thumb applies in between the trunk and arm of the therapist. distraction force and the fingers grip the Position of the therapist and grasping olecranon and glides the ulna medially. • Therapist is standing beside the patient and Lateral Gliding (Fig. 10.40) Goal facing the elbow joint. • To increase the joint play movement of the • Therapist’s left hand grasping the distal ulnohumeral joint. • To reduce the pain around the ulnohumeral humerus and restricting the proximal joint joint. motion. • To increase the elbow extension and flexion. • Therapist’s right hand fingers placed • To increase the elbow adduction. posteriorly and grasping the olecranon process of ulna and the thumb is placed Fig. 10.40: Ulnohumeral lateral gliding proximal part of anterior aspect of the ulna. Procedure: Therapist’s right thumb applies the distraction force and the thumb web and fingers performing the lateral gliding of the ulna. Humeroradial Joint (Fig. 10.41) Distraction Goal • To increase the joint play movement of the humeroradial joint. • To reduce the pain around the humeroradial joint. • To increase the elbow extension and flexion. Position of the patient: Supine lying and long sitting. Fixation: Therapist’s left hand grasping the distal humerus and restricting the movement over the shoulder joint. Support: No need of support for this mobili- zation. Position of the therapist and grasping • Therapist is standing besides the patient and Facing the elbow joint.

PERIPHERAL JOINT MOBILIZATION 123 Fig. 10.41: Radiohumeral distraction Fig. 10.42A: Radiohumeral dorsal gliding Fixation: Therapist’s left hand grasping the • Therapist’s left hand grasping the distal distal humerus and restricting the movement humerus and restricting the proximal joint over the shoulder joint. motion. Support: Distal parts are already supported by the couch. • Therapist’s right hand grasping the lower Position of the therapist and grasping end of radius. • Therapist is standing besides the patient and Procedure: Therapist’s right hand pulls the facing the elbow joint. radius downwards and applying the distraction • Therapist’s right hand grasping the distal force. Dorsal gliding (Figs 10.42A and B) humerus and restricting the proximal joint Goal motion. • To increase the joint play movement of the • Therapist’s left hand grasping the proximal radius with the thumb anteriorly and fingers radiohumeral joint. posteriorly. • To reduce the pain around the radiohumeral Procedure: Therapist’s left hand glides the radius posteriorly. joint. Ventral gliding • To increase the elbow extension. Goal Position of the patient: Supine lying and long • To increase the joint play movement of the sitting. radiohumeral joint. • To reduce the pain around the radiohumeral joint. • To increase the elbow flexion. Position of the patient: Supine lying or long standing. Fixation: Therapist’s right hand grasping the distal humerus and restricting the movement over the shoulder joint.

124 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.42B: Radiohumeral ventral gliding Fig. 10.43: Radiohumeral compression Support: Distal parts are already supported by the couch. • Therapist’s right hand grasping the patient’s Position of the therapist and grasping hand. • Therapist is standing beside the patient and Procedure: Therapist’s right hand applying the facing the elbow joint. downward force and compresses the radio- • Therapist’s right hand grasping the distal humeral joint through wrist joint. humerus and restricting the proximal joint Radioulnar Joint motion. Proximal Radioulnar Joint • Therapist’s left hand grasping the proximal Dorsal gliding (Fig. 10.44) radius with the thumb anteriorly and fingers Goal posteriorly. • To increase the joint play movement of the Procedure: Therapist’s left hand glides the radius anteriorly. proximal radioulnar joint. Compression (Fig. 10.43) • To reduce the pain around the proximal Goal • To reduce the positional fault of the radius. radioulnar joint. Position of the patient: Supine lying with elbow • To increase the pronation of the proximal in 70-90° flexion. Fixation: Therapist’s left hand grasping the radioulnar joint. distal humerus and restricting the movement Position of the patient: Supine lying or long over the shoulder joint. sitting. Support: Therapist’s right hand grasping the patient’s hand and supporting the distal parts. Position of the therapist and grasping • Therapist is standing besides the patient and facing the elbow joint. • Therapist’s left hand grasping the distal humerus and restricting the proximal joint motion.

PERIPHERAL JOINT MOBILIZATION 125 Fig. 10.44: Proximal radioulnar joint dorsal gliding Fig. 10.45: Proximal radioulnar joint ventral gliding Fixation: Proximal ulna is fixed with the right Support: Distal part is stabilized by the couch hand of the therapist. itself. Support: Distal part is stabilized by the couch Position of the therapist and grasping itself. • Therapist is standing beside the patient and Position of the therapist and grasping • Therapist is standing beside the patient and facing the proximal radioulnar joint. • Therapist’s left hand fixing the proximal facing the proximal radioulnar joint. • Therapist’s right hand fixing the proximal ulna of the patient. • Therapist’s right hand grasping the proxi- ulna of the patient. • Therapist’s left hand grasping the proximal mal radius of the patient. Procedure: Therapist’s right hand glides the radius of the patient. radius in the dorsal and ventral direction. Procedure: Therapist’s left hand glides the radius in the dorsal and ventral direction. Distal Radioulnar Joint Ventral gliding (Fig. 10.45) Dorsal and ventral gliding (Fig. 10.46) Goal Goal • To increase the joint play movement of the • To increase the joint play movement of the proximal radioulnar joint. distal radioulnar joint. • To reduce the pain around the proximal • To reduce the pain around the distal radioulnar joint. radioulnar joint. • To increase the supination of the proximal • To increase the supination and pronation radioulnar joint. of the distal radioulnar joint. (Dorsal gliding increases pronation and ventral Position of the patient: Supine lying or long gliding increases the supination.) sitting. Position of the patient: Supine lying or long Fixation: Distal ulna is fixed with the right hand sitting. of the therapist. Fixation: Proximal ulna is fixed with the ulna Support: No need of the support. hand of the therapist.

126 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.46: Distal radioulnar joint dorsal and Fig. 10.47: Proximal and distal radioulnar joint ventral gliding Position of the therapist and grasping • Therapist is standing beside the patient and facing the proximal radioulnar joint. • Therapist’s right hand fixing the proximal ulna of the patient. • Therapist’s left hand grasping the proximal radius of the patient. Procedure: Therapist’s left hand glides the radius in the dorsal and ventral direction. Radioulnar Joint • Lower radioulnar joint Type Head of ulna (convex) • Upper radioulnar joint—synovial Ulnar notch of radius (concave). • Middle radioulnar joint—Fibrous • Lower radioulnar joint—synovial Movements Osteokinematics Variety • Supination—Biceps, supination, brachio- • Upper radioulnar joint—pivot • Middle radioulnar joint—syndesmosis radialis • Lower radioulnar joint—pivot • Pronation—Pronator teres, brachioradialis, Articular Surface flexor carpiradialis, palmaris longus, • Upper radioulnar joint (Fig. 10.47) pronator quadratus. Arthrokinematics Head of the radius (convex) Arthrokinematics relations with the osteo- Radial notch of ulna(concave) kinematics movements are: • Middle radioulnar joint Upper radioulnar joint Interosseous border of the ulna and Supination—Ventral gliding radius Pronation—Dorsal gliding

PERIPHERAL JOINT MOBILIZATION 127 Lower radioulnar joint • Palmar ulnocarpal ligaments Supination—Dorsal gliding • Dorsal radiocarpal ligaments Pronation—Ventral gliding. • Palmar radiocarpal ligaments. Range of motion Movements Supination—90° Pronation—80° Osteokinematics. Positions Flexion Starting position • Flexor carpi radialis • Arm is parallel to the trunk with the elbow • Flexor carpi ulnaris • Palmaris longus at right angle. • Flexor digitorum profundus Resting position • Flexor pollicis longus. • Proximal radioulnar joint supination 35° Extension flexion 70°. • Extensor carpi radialis longus • Distal radioulnar joint supination 10°. • Extensor carpi ulnaris Close packed position • Extensor digitorum • Proximal radioulnar joint full extension, • Extensor indicis • Extensor digitorum mini 5° supination. • Extensor pollicis longus. Capsular pattern • Proximal radioulnar joint resisted equally Ulnar Deviation • Flexion carpi ulnaris in both directions. • Extension carpi ulnaris. Supination—Pronation Radial Deviation Wrist Joint (Fig. 10.48) • Flexor carpi radialis Type • Extension carpi radialis longus Synovial joint • Flexor pollicis longus. Variety Arthrokinematics Ellipsoid Arthrokinematics relations with the osteo- kinematics movements are: Articular surfaces • Flexion—dorsal gliding • Lower end of radius—Proximally(concave) • Extension—ventral gliding • Scapoid, lunate and traquetral—Distally • Ulnar deviation—radial gliding • Radial deviation—ulnar gliding. (convex). Range of Motion Ligaments • Ulnar collateral ligaments Flexion 70°-90° • Radio-collateral ligaments Extension 60°-70° Ulnar deviation 45° Radial deviation15°-20°

128 TEXTBOOK OF THERAPEUTIC EXERCISES AB CD Figs 10.48A to D: A. Right hand and wrist, B. Intercarpal and carpometacarpal joint posterior view, C. Intercarpal and carpometacarpal joint anterior view, and D. Interphalangeal joint Position Capsular pattern Restricted equally in all directions. Starting position Distraction (Fig. 10.49) • Radius lower and the 3 metacarpal in Goal • To increase the joint play movement of the straight line. Resting position radiocarpal, ulnocarpal and intercarpal • Slight ulnar deviation. joint. Close packed position • To reduce the pain around the distal radio- • Maximum extension. carpal, ulnocarpal intercarpal joint.

PERIPHERAL JOINT MOBILIZATION 129 Fig. 10.49: Wrist distraction Fig. 10.50: Wrist ventral gliding Position of the patient: Long sitting and the • To increase the ROM of the radiocarpal, wrist is placed in the end of the couch and ulnocarpal and intercarpal joints. forearm in pronated position. Fixation: Distal ulna and radius of the patient Position of the patient: Long sitting and the is fixed with the therapist’s left hand. wrist is placed in the end of the couch. Support: Therapist’s right hand grasps the hand region of the patient. Fixation: Distal ulna and radius of the patient Position of the therapist and grasping is fixed with the therapist’s left hand. • Therapist is standing beside the patient and Support: Therapist’s right hand grasps the hand facing the wrist of the patient. region of the patient. • Therapist’s left hand grasping the distal ulna Position of the therapist and grasping and radius of the patient. • Therapist is standing beside the patient and • Therapist’s right hand grasps the meta- facing the wrist of the patient. carpal region of the patient. • Therapist’s left hand grasping the distal ulna Procedure: Therapist’s right hand performing the ventral gliding of the radiocarpal, ulnocarpal and radius of the patient. and intercarpal joints. • Therapist’s right hand grasps the meta- Dorsal gliding (Fig. 10.51) Goal carpal region of the patient. • To increase the joint play movement of the Procedure: Therapist’s right hand applies the radiocarpal, ulnocarpal and intercarpal distraction. joints. • To reduce the pain around the distal radio- Ventral Gliding (Fig. 10.50) carpal, ulnocarpal and intercarpal joints. Goal • To increase the wrist flexion. • To increase the joint play movement of the Position of the patient: Long sitting and the wrist is placed in the end of the couch and the radiocarpal, ulnocarpal and intercarpal forearm in supinated position. joints. • To reduce the pain around the distal radio- carpal, ulnocarpal and intercarpal joints. • To increase the wrist extension.

130 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.51: Wrist dorsal gliding Fig. 10.52: Wrist ulnar gliding Fixation: Distal ulna and radius of the patient Position of the therapist and grasping is fixed with the therapist’s left hand. • Therapist is standing beside the patient and Support: Therapist’s right hand grasps the hand region of the patient. facing the wrist of the patient Position of the therapist and grasping • Therapist’s left hand grasping the distal ulna • Therapist is standing beside the patient and and radius of the patient facing the wrist of the patient. • Therapist’s right hand grasps the meta- • Therapist’s left hand grasping the distal ulna carpal region of the patient. and radius of the patient. Procedure: Therapist’s right hand glides the • Therapist’s right hand grasps the meta- wrist in ulnar direction. Radial gliding (Fig. 10.53) carpal region of the patient. Goal Procedure: Therapist’s right hand performing • To increase the joint play of the wrist joint. the dorsal gliding of the radiocarpal, ulnocarpal • To reduce the pain over the wrist. and intercarpal joints. • To increase the ulnar deviation of the wrist Ulnar gliding (Fig. 10.52) Goal Fig. 10.53: Wrist radial gliding • To increase the joint play of the wrist joint. • To reduce the pain over the wrist. • To increase the radial deviation of the wrist. Position of the patient: Long sitting and the wrist is placed in the end of the couch. Patient’s forearm in mid prone position. Fixation: Distal ulna and radius of the patient is fixed with the therapist’s left hand. Support: Therapist’s right hand grasps the hand region of the patient.

PERIPHERAL JOINT MOBILIZATION 131 Position of the patient: Long sitting and the Extension: wrist is placed in the end of the couch. Patient’s • Extensor pollicis longus and brevis forearm in midprone position. • Abdutor pollicis longus and brevis. Fixation: Distal ulna and radius of the patient Abdution is fixed with the therapist’s left hand. • Abductor pollicis longus and brevis. Support: Therapist’s right hand grasps the hand Addution region of the patient. • Addutor pollicis longus and brevis. Position of the therapist and grasping Opponens • Therapist is standing beside the patient and • Opponens pollicis brevis. Arthrokinematic facing the wrist of the patient. Arthrokinematics relations with the osteo- • Therapist’s left hand grasping the distal ulna kinematics movement are: • Flexion—ulnar gliding and radius of the patient. • Extension—radial gliding • Therapist’s right hand grasps the meta- • Abduction—dorsal gliding • Adduction—ventral gliding. carpal region of the patient. Procedure: Therapist’s right hand glides the wrist in the radial direction. Thumb (1st carpometacarpal joint) Positions Type Starting position Synovial joint • Midway between flexion extension and Variety abduction and adduction. • Saddle Resting position Articular Surfaces • Midway between flexion extension and • Trapezium (concavoconvex) • Proximal part of metacarpal (concavoconvex) abduction and adduction. Close packed position • Movement is restricted in abduction and extension. • Abduction > extension. Ligaments Carpometalcarpal Joint (2nd-5th ) • Capsular ligament • Dorsal ligament Distraction (Fig. 10.54) • Palmar ligament Goal • Lateral ligament. • To increase the joint play in the 2nd to 5th Movements carpometacarpal joints. Osteokinematics • To increase the ROM of the 2nd to 5th Flexion: • Flexion pollicis longus and brevis carpometacarpal joints. • Opponens pollicis. • To reduce the pain around the 2nd to 5th carpometacarpal joints. Patient’s position: Sitting and hand is placed on the table.

132 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 10.54: Thumb joint—joint distraction Fig. 10.55: Carpometacarpal joint dorsal and ventral gliding Fixation: Carpal bones are fixed by therapist’s left hand with the thumb on the dorsal surface Fig. 10.56: Carpometacarpal joint (2nd-5th) dorsal and the finger on ventral surface. and ventral gliding Support/Stabilization: Distal part is supported by the table itself. Patient’s position: As said in distraction. Therapist’s position: Fixation: As said in distraction. • Therapist is standing near the patient and Support/Stabilization: As said in distraction. Therapist’s position: As said in distraction. facing the carpometacarpal joint. Procedure: Therapist’s right hand is gliding the • Therapist’s right hand is grasping the base metacarpals on the relevant carpal bone in the volar and dorsal diversion (i.e. 2nd metacarpal of the carpometacarpal with the thumb on on trapezoid, 3rd metacarpal on capital, hamate the dorsal surface and the flexion on the 5th metacarpal on hamate). ventral surface. Intermetacarpal Joint • Therapist’s left hand is grasping the distal Dorsal and ventral gliding (Fig. 10.57) row of the carpal bone with the thumb on Goal the dorsal surface and the finger on the • To increase the joint play around the ventral surface. Procedure: Therapist’s right hand is pulling the intermetacarpal joint. metacarpal distally from the relevant carpal bones, (i.e. 2nd metacarpal on trapezoid, 3rd on capitate, 4th on hamate, 5th on hamate). Dorsal and ventral gliding (Figs 10.55 and 10.56) Goal: • To increase the joint play around the 2nd to 5th carpometacapal joints. • To increase the flexion and extension of the 2nd to 5th (dorsal gliding increases flexion and ventral gliding increases extension of carpometacarpal joint). • To reduce the pain around the 2nd to 5th carpometacarpal joint.

PERIPHERAL JOINT MOBILIZATION 133 • To reduce the pain around the inter- Metacarpophalangeal Joint metacarpal joint. Type Synovial joint Variety Condyloid variety Articular Surface • Head of the metacarpal (convex) • Proximal end of proximal phalanx (concanve). Fig. 10.57: Intermetacarpal joint dorsal and Ligaments ventral gliding • Palmar ligament • Collateral ligament—medial, lateral. Patient’s position: As said in the distraction of the carpometacarpal joint. Movements Fixation: Therapist’s right hand is fixing the Osteokinematics adjacent mid shaft of the metacarpal with the • Flexion—Flexor pollicis longus and brevis thumb on the dorsal surface and the index • Extension—Extension pollicis longus and finger on the ventral surface. brevis Support/Stabilization: No need of support. • Abduction—Abductor pollicis longus and Therapist’s position: brevis • Therapist is standing near the patient and • Flexion facing the intermetacarpal joint. • 1st MCP—Flexion pollicis longus and • Therapist’s right hand is fixing the adjacent brevis mid-shaft of the metacarpal with the thumb • 2nd-5th MCP—Lumbricals, flexion on the dorsal surface and the index finger digitorum superficialis. on the ventral surface. • Therapist’s left hand is grasping the mid- • Extension shaft of the first metacarpal with the thumb • 1st MCP—Extensor pollicis longus and on the dorsal surface and index finger on brevis the ventral surface. • 2nd-5th MCP—Extensor digitorum, extensor digiminimi. Procedure: Therapist’s left hand is gliding the first metacarpal on the adjacent metacarpal in • Abduction the dorsal and ventral direction (2nd meta- • 1st MCP—Abduction pollicis brevis and carpal on the 3rd metacarpal, 4th metacarpal longus on the 3rd metacarpal, 5th metacarpal on the • 2nd–4th MCP—Dorsal interosseous 4th metacarpal). • 5th MCP—Abductor digitiminimi. • Adduction • 1st MCP—1st palmar interosseous • 2nd MCP—2nd interosseous

134 TEXTBOOK OF THERAPEUTIC EXERCISES • 4th MCP—3rd interosseous Fig. 10.58: Metacarpophalangeal • 5th MCP—4th interosseous. joint distraction Arthrokinematics: Arthrokinematic relations with the osteokine- Fixation: Therapist’s left hand is fixing the head matics. of the metacarpal with the thumb on the dorsal • Flexion—Ventral gliding surface and the index finger on the ventral • Extension—Dorsal gliding surface. • Abduction—1st –3rd MCP radial gliding Support/Stabilization: Not necessary. • Adduction—4th-5th MCP medial gliding. Therapist’s position: Adduction • Therapist is standing near to the patient • 1st-3rd medial gliding • 4th-5th radial gliding. and facing the metacarpophalangeal joint. • Therapist’s right hand is grasping the Range of Motion • Flexion—90° proximal end of the proximal phalanx with • Extension—15°-20° the thumb on the dorsal surface and the • Abduction—25°-35° index finger on the ventral surface. • Adduction—0° • Therapist’s left hand is fixing the head of the metacarpal with the thumb on the dorsal Positions surface and the index finger on the ventral Starting position surface. • Metacarpals and phalanx are in straight line. Procedure: Therapist’s right hand moves the Resting position proximal phalanx distally. • Slight flexion in all joints Close packed position Dorsal Gliding and Ventral Gliding (Fig. 10.59) • 1st MCP—maximum extension Goal: • 2nd –5th MCP—maximum flexion • To increase the joint play around the Capsular pattern • Restricted in all directions. metacarpophalangeal joint. • To increase the flexion and extension of the Distraction (Fig. 10.58) Goal metacarpophalangeal joint. • To increase the joint play around the (Dorsal gliding increases the extraction, ventral gliding increases the flexion). metacarpophalangeal joint. • To reduce the pain around the meta- carpophalangeal joint. • To increase the ROM of the metacarpopha- langeal joint. Patient’s position: As said in the distraction of the metacarpophalangeal joint.

PERIPHERAL JOINT MOBILIZATION 135 • To reduce the pain around the metacarpo- Support/Stabilization: As said in distraction. phalangeal joint. Therapist’s position: As said in distraction. Procedure: Therapist’s right hand glides the proximal phalanx in the medial and lateral direction. Interphalangeal Joint Type Synovial Variety Hinge Fig. 10.59: Metacarpophalangeal joint dorsal, Articular Surfaces ventral, medial and lateral gliding • Distal end of the proximal phalanx (convex) • Proximal end of the distal phalanx (concave). Patient’s position: As said in the distraction. Fixation: As said in the distraction. Ligaments Support/Stabilization: As said in the distraction. • Medial collateral ligament Therapist’s position: As said in the distraction. • Lateral collateral ligament Procedure: Therapist’s right hand is gliding the • Palmar collateral ligament. proximal phalanx on the metacarpal in the dorsal and ventral surfaces. Movements Osteokinematic Medial and Lateral Gliding Flexion Goal: • 1st IP—Flexion pollicis longus • To increase the joint play around the • 2nd-5th IP—Flexion digitorum profundus • 2nd IP—Flexion carpi radialis longus metacarpophalangeal joint. • 5th IP—Flexion carpi ulnaris. • To increase the ROM around the metacarpo- Extension • 1st IP—Extension pollicis longus phalangeal joint (Medial gliding increases • 2nd–5th IP—Extension digitorum the adduction of digit 1 and 2 ulnar abduction • 2nd IP—Extension carpi radialis longus, of digit 3, abduction of digit 4 and 5. Lateral gliding increases the abduction of digit 1 and extension indicis 2 radial abduction of digit 3, and abduction • 3rd IP—Extension carpi radialis brevis of digits 4 and 5.). • 5th IP—Extension carpi ulnaris. • Reduce the pain around the metacarpopha- langeal joint. Range of Motion Patient’s position: As said in distraction. • Flexion—90° Fixation: As said in distraction. • Extension—0°

136 TEXTBOOK OF THERAPEUTIC EXERCISES Positions • Therapist’s right hand is grasping the Starting position proximal end of the distal phalanx with the • Both the phalanx is in straight line. thumb on the dorsal surface and the index Resting position finger on the ventral surface. • Slight flexion in all joints. Close packed position • Therapist’s left hand is grasping the distal • Maximum extension. end of phalanx with the thumb on the dorsal Capsular pattern surface and the index finger on the ventral • Restricted in all directions. surface. • Flexion, extension. Procedure: Therapist’s right hand moves the Distraction (Fig. 10.60) distal phalanx distally. Goal: • To increase the joint play in the inter- Dorsal and Ventral Gliding (Fig. 10.61) Goal: phalangeal joint. • To increase the joint play around the inter- • To reduce the pain in the interphalangeal phalangeal joint . joint. • To increase the flexion and extension of the • To increase the ROM in the interphalangeal interphalangeal joint (Dorsal gliding increa- joint. ses the extension, ventral gliding increases the flexion). • To reduce the pain. Fig. 10.60: Interphalangeal joint distraction Fig. 10.61: Interphalangeal joint dorsal and Patient’s position: Sitting. ventral gliding Fixation: Therapist’s left hand is fixing the distal end of the proximal phalanx with the Patient’s position: As said in distraction. thumb on the dorsal surface and the index Fixation: As said in distraction. finger on the ventral surface. Support/Stabilization: As said in distraction. Support/Stabilization: Not necessary. Therapist’s position: As said in distraction. Therapist’s position: Procedure: Therapist’s right hand glides the • Therapist is facing the interphalangeal joint. distal phalanx on the proximal phalanx in the ventral and dorsal direction.

PERIPHERAL JOINT MOBILIZATION 137 Hip Joint Ligaments (Fig. 10.62) • Iliofemoral ligament Type • Pubofemoral ligament Synovial joint. • Ischiofemoral ligament • Transverse ligament Variety • Round ligament. Ball and socket joint. Movements Articular Surfaces Osteokinematic • Acetabulum of the hip bone (concave) • Head of the femur (convex). Figs 10.62A and B: Hip joints

138 TEXTBOOK OF THERAPEUTIC EXERCISES Flexion Resting position • Ilium, psoas major, sartorium, rectus • 30° hip flexion, 30° abduction, externally femoris, lateral part of pectineus. rotation. Close packed position Extension • Maximum extension, medial rotation, • Gluteus maximum, hamstrings. abduction. Abduction Capsular pattern • Gluteus medius, gluteus minimus • Restriction of the movements in this order • Sartorius, tensor fascia latae. • Medial rotation > extension >abduction > Adduction lateral rotation • Adductor longus, adductor brevis, adductor Distraction (Fig. 10.63) magnus Goal • Gracilis, pectineus. • To increase the ROM around the hip joint . • To increase the joint play around the hip. Lateral rotation • To reduce the pain around the hip. • Piriformis, obturator internus and externus, quadratus femoris. • Gluteus maximum, sartorius. Medial rotation • Iliac psoas, gluteus medius and minimus. Arthrokinematics Arthrokinematics relations with the osteoki- nematics movements are: • Flexion—Dorsal gliding • Extension—Ventral gliding • Abduction—Caudal gliding • Adduction—Lateral gliding • Lateral rotation—Ventral gliding • Medial rotation—Dorsal gliding. Range of Motion 20°-135° Flexion 45° Extension 45°-60° Abduction Adduction 0° Medial rotation 0°-45° Lateral rotation 0°-35° Position Fig. 10.63: Hip joint distraction Starting position Patient’s position: Supine lying. • Line drawn from ASIS to patella and the Fixation: Patient’s pelvic is fixed by the assis- tance or by the belt. two ASIS lies at right angle to each other.

PERIPHERAL JOINT MOBILIZATION 139 Support/Stabilization: Patient leg is kept on • Therapist’s both the hands are grasping the the therapist’s shoulder. ankle joint of the patient. Therapist’s position and holding • Therapist is standing foot end of the patient Procedure: Therapist’s both the hands are pulling the leg down and the caudal gliding with and facing the patient’s hip. mild distraction. • Therapist’s both the hands are grasping the Ventral Gliding (Fig. 10.65) upper thigh of the patient. Goal • Patient’s hips and knees are flexed and the • To increase the extension and external patient’s leg is kept on the therapist’s rotation of the hip. shoulder. • To increase the joint play around the hip. Procedure: Therapist’s both the hands are • To reduce the pain around the hip. applying the distraction force on the hip joint. Patient’s position: Half-prone lying and the lower joint to keep hanging in the bed end. Caudal Gliding (Fig. 10.64) Fixation: Patient’s pelvic is fixed by the Goal assistant or may not be necessary because the • To increase the hip abduction movement. • To increase the joint play around the hip. • To reduce pain around hip. Fig. 10.64: Hip joint caudal gliding Figs 10.65A and B: Hip joint ventral gliding Patient’s position: Supine lying. Fixation: Patient’s pelvic is fixed and the movement is restricted by the assistance or by the belt. Support/stabilization: There is no need of stabilization because the therapist’s holding is around the ankle of the patient. Therapist’s position • Therapist is standing foot end of the patient and facing the hip joint of the patient.

140 TEXTBOOK OF THERAPEUTIC EXERCISES pelvic movement will be restricted by the couch Support/Stabilization: Patient’s thigh and itself. lower leg is supported and stabilized by Support/Stabilization: Lower leg of the patient therapist’s left hand. is supported by the therapist’s right hand. Therapist’s position and holding Therapist’s position • Therapist is standing in the foot end of the • Therapist is standing at the foot end of the patient and facing the hip joint of the patient and facing the posterior aspect of patient. the hip of the patient. • Therapist’s right hand is placed on the • Therapist’s left hand is placed over the anterior aspect of the upper thigh of the posterior aspect of the upper thigh of the patient. patient. • Therapist’s left hand grasping around the • Therapist’s right hand is grasping the knee knee and the supporting the lower leg of joint of the patient and supports the lower the patient. leg of the patient. Procedure: Therapist’s right hand applies Procedure: Therapist’s left hand applies ante- posterior force and hand performing the dorsal rior force and performing the anterior sliding gliding of the hip of the patient with mild around the hip joint of the patient with mild distraction and the lower thigh of the patient distraction. is stabilized by the therapist’s left hand. Dorsal Gliding (Fig. 10.66) Lateral Gliding (Fig. 10.67) Goal Goal: • To increase the hip flexion and medial • To increase the internal rotation and rotation. adduction. • To increase the hip joint play movement. • To reduce the pain around the hip joint. • To reduce the hip pain. • To increase the joint play movement around Patient’s position: Supine lying patient’s hip is placed over the bed end. the hip. Fixation: Patient’s pelvis is already fixed to the couch. Fig. 10.66: Hip joint dorsal gliding Fig. 10.67: Hip joint lateral gliding

PERIPHERAL JOINT MOBILIZATION 141 Position of the patient: Supine position. Fig. 10.68A Fig. 10.68B Fixation: Pelvic is already fixed by the position- ing itself. Support/Stabilization: As said in distraction. Therapist’s position: • Therapist is standing near the patient’s lower extremity. • Therapist’s left and right hands are grasping the upper thigh of the patient. Procedure: Therapist’s both the hands are gliding the femur in lateral direction. Knee Joint Type Synovial Variety Condylar Articular Surfaces • Lower end of femur (convex) • Upper end of tibia ( concave). Ligaments (Fig. 10.68) • Meniscus—medial, lateral • Medial collateral ligament • Lateral collateral ligament • Arcuate ligament • Ligamentum patellae • Cruciate ligament(anterior, posterior). Movements Osteokinematics • Flexion—Hamstrings • Extension—Quadriceps • Medial rotators—Semi-membranosus • Lateral rotators—Biceps femoris

142 TEXTBOOK OF THERAPEUTIC EXERCISES Capsular pattern • Restriction of the movement • Flexion>Extension Tibiofibular Joint (Fig. 10.69) Type • Superior tibiofibular joint—synovial • Middle tibiofibular joint—fibrous joint • Inferior tibiofibular joint—fibrous. Variety • Superior tibiofibular joint—plane • Middle tibiofibular joint—syndesmosis • Inferior tibiofibular joint—syndesmosis Figs 10.68A to C: Knee joint Articular End Arthrokinematic Superior tibiofibular joint Arthrokinematic relations with the osteokine- • Lateral condyle of the articular facet of the matic movements are: • Flexion—Dorsal gliding tibia (concave) • Extension—Ventral gliding • Articular facet of the head of fibula (convex). • Medial rotators—Dorsal gliding • Lateral rotators—Ventral gliding. Range of Motion 135°– 150° Knee flexion 0° Knee extension 15° Medial rotation 45° Lateral rotation Positions Fig. 10.69: Proximal and distal tibiofibular joint Starting position • Neutral range Resting position • 25° of flexion Close packed position • Maximum exension and external rotation.

PERIPHERAL JOINT MOBILIZATION 143 Inferior tibiofibular joint Tibiofemoral Articulation • Lateral surface of the lower end of the tibia Distraction (Fig. 10.70) Goal (concave) • To increase the joint play around knee joint. • Medial surface of the lower end of the fibula • To increase the ROM around knee joint. • To reduce the pain around the knee joint. (convex) Middle tibiofibular joint • Shafts of tibia and fibula Ligaments • Superior tibiofibular joint • Anterior ligament • Posterior ligament • Anterior tibiofibular ligament • Posterior tibiofibular ligament • Inferior transverse ligament • Interosseous ligament. Movements • Osteokinematic • Superior tibiofibular joint • Gliding up and down help in knee flexion and extension. • Inferior tibiofibular joint. • Gliding up and down helps in dorsiflexion and plantar flexion. Positions Fig. 10.70: Tibiofemoral distraction Starting position • Neutral position of the ankle Patient’s position: Sitting in the bed end or stool Resting position end. • Superior tibiofibular Fixation: Already proximal joint is fixed some- time the lower thigh is fixed with the help of • 25° knee flexion, 10° plantar flexion the assistance. • Inferior tibiofibular Support/Stabilization: Therapist’s both the forearms are supporting the leg of the patient. • 10° plantar flexion, 5° inversion. Therapist’s position Close packed position • Therapist is sitting opposite to the patient • Superior tibiofibular—none • Inferior tibiofibular—none on the stool and facing the patient’s knee Capsular pattern joint. • Superior tibiofibular—none • Inferior tibiofibular—none.