Basics

Proximal Tibiofibular Joints

The interosseous membrane connects the tibia and the fibula. Movement at the two joints is interrelated in a manner similar to that of the proximal and distal radioulnar joints of the forearm and likely affects movement at both the knee and ankle.

Joint orientation:

• Tibia: lateral, posterior, inferior
• Fibula: medial, anterior, superior

Concave joint surface:

Fibula

Resting position:

0 degrees of plantar flexion

Close-packed position:

Full dorsiflexion

Distal Tibiofibular Joints

Joint orientation:

• Tibia: lateral, posterior
• Fibula: medial, anterior

Concave joint surface:

Tibia

Talocrural Joint

The talocrural joint comprises the tibia and fibula and their articulation with the talus. Although triplanar motion occurs at this articulation, dorsiflexion and plantar flexion are the primary motions.

Joint orientation:

• Tibia: inferior, lateral
• Fibula: medial
• Talus: superior, medial, lateral

Concave joint surface:

Tibia and fibula

Resting position:

10 degrees plantar flexion and midway between inversion and eversion

Close-packed position:

Full dorsiflexion

Subtalar Joint

Inversion and eversion are the primary motions occurring at the subtalar joint, which consists of the articulation between the talus and the calcaneus.

Joint orientation:

• Talus: inferior, posterior, lateral
• Calcaneus: superior, anterior, medial

Concave joint surface:

None, this is a plane joint

Resting position:

10 degrees of plantar flexion and midway between inversion and eversion

Close-packed position:

Full inversion

Midtarsal Joints

The midtarsal joints consist of the talonavicular and calcaneocuboid joints and the cuneiform articulations. Plantar flexion and dorsiflexion and inversion and eversion predominate at these joints.

Intermetatarsal Joints

The metatarsals move on one another, causing the transverse arch of the foot to increase and flatten. The axis for this motion is the second metatarsal.

Toe Joints

Toe flexion and extension occur at the metatarsophalangeal and interphalangeal joints. The metatarsophalangeal joints also are capable of moving into abduction and adduction, although these movements are not considered important for functional activities.

Indications

• Ankle sprain
• Ankle fractures (post immobilization stiffness)
• Plantar heel pain (reduced dorsiflexion mobility can cause heel pain)
• Cuboid syndrome (plantar – dorsal manipulation in Lat. Ankle.Sprain)
• Foot and ankle tendinopathy
• Other disorders (metatarsalgia, hallux valgus, hallux rigidus)

Manipulations

Talocrural distraction thrust

Indication

Limited ankle dorsiflexion and limited posterior accessory glide of the talus.

Patient position

Supine lying with ankle off the end of the table.

Therapist position

Standing at the end of the treatment table in a walk standing position.

Procedure

Therapist grasps the patient ankle with fingers interlaced around the dorsum of the foot and thumbs on the plantar surface of the patient foot. The therapist induces dorsiflexion and pronation and takes up the slack in the inferior or distraction direction. Then, the therapist applies HVLA thrust in the inferior or caudal direction.

Proximal tibiofibular thrust manipulation

Indication

Restricted ankle dorsiflexion / Restricted accessory glide of the proximal TF joint

Patient position

Supine or prone with knee flexed.

Therapist position

Stands at the side of the treatment table in a walk or stride stance.

Procedure

• Therapist places his / her second metacarpophalangeal in the popliteal fossa and pulls the soft tissue laterally until the MCP is firmly stabilized behind the fibular head.
• Therapist uses his / her opposite hand to grasp the foot and ankle and externally rotated the leg and flexes the knee to the restrictive barrier.
• Once the restrictive barrier is met, HVLA is applied through the tibia (directing the heel towards buttock).

Cuboid thrust manipulation

Indication

Cuboid syndrome / Restricted accessory glide of the cuboid

Patient position

Prone position

Therapist position

Stands at the end of the table in a walk / stride stance.

Procedure

• Therapist flexes the patient knee and grasps the foot. Therapist places tips of the thumbs over the medial plantar surface of the cuboid.
• Slowly extends the knee and plantar flexes the foot with supination (takes up the slack).
• The therapist applies HVLA to the cuboid with both the thumbs in a dorsal lateral direction.
• Note: avoid excessive plantar flexion in patients with lateral ankle sprain.

First MTP thrust

Indication

limited great toe extension.

Patient position

supine

Procedure

Therapist grasps and stabilizes first metatarsal with one hand and hold the first phalangeal with the opposite hand. Then, the therapist executes HVLA in longitudinal to the metatarsal bone.

Mobilizations

Talocrural posterior glide

Indication

Limited dorsiflexion and restricted posterior accessory glide of ankle dorsiflexion.

Patient position

Supine lying with ankle off the end of the table.

Therapist position

Standing at the end of the treatment table in a walk standing position.

Procedure

• Therapist uses one hand to stabilize the lower leg firmly at the malleoli and grasps the anterior, medial and lateral talus with the web space of the opposite hand.
• The therapist now applies a low velocity anterior to posterior oscillatory force to the talus.

Talocrural lateral glide

Indication

Restricted inversion or eversion

Patient position

The patient is sidelying on involved side with the ankle / foot off the treatment table.

Therapist position

Standing at the end of the treatment table in a walk standing position.

Procedure

• The therapist grasps the patients medial malleoli just proximal to the talocrural joint with the index finger & thumb.
• The therapist also places the thenar eminence of the opposite hand on the medial surface of the talus just distal to the medial malleolus and grasps the rearfoot.
• Therapist uses his / her body to impart a low velocity oscillatory force to the talus through the arm and thenar eminence.

Subtalar joint lateral glide

Indication

Restricted talocalcaneal (subtalar) inversion or eversion.

Patient position

Sidelying on involved side with foot off the end of the treatment table.

Therapist position

Standing at the end of the treatment table in a walk standing position.

Procedure

• Grasp the patient’s talus just proximal to the subtalar joint with the index finger / thumb.
• Place the thenar eminence of the opposite hand on the calcaneus just distal to the talus.
• Use the body to impart a low velocity oscillatory force to the calcaneus through the arm and thenar eminence.

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1. James R. Beazell et al (2012)., Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle Instability.
2. Cesar fernandez-de-las-penas., Joshua A. Cleland., Jan Dommerholt., Manual Therapy for musculoskeletal pain syndromes.