Practical Applications of Manual

Therapy for the Ankle and Foot

Ovidio Olivencia, PT, DPT

PHATS Annual Meeting 2014
Orlando, Florida

Outline
! Objectives
! Case Study
! What is Manual Therapy?
! Joint Mobilization
! Joint Mobilization Techniques
! Practical Applications

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Objectives
! Demonstrate safe and effective clinical use of oscillatory

and sustained distal lower extremity joint mobilization

! Recognize appropriate joint mobilization interventions for a
patient with ankle sprains
! Be able to utilize information and apply concepts in
practical situations

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Case Study
! History:
o 26-year-old hockey player
o Patient reported twisting his left ankle four days ago while participating

in an off -season agility program

o The mechanism of injury was ankle rolling outwards and the foot inward
(plantar flexion and inversion stress)
o Immediate post injury onset of swelling and (sharp) pain
o Pain described as ache pain on the lateral aspect of left foot with
localized tenderness
o Antalgic gait and pain with standing
o Pain relieved with ice, rest and NSAIDS
o History of multiple left ankle sprains
o VRS: 2/10 at rest, 4/10 with walking
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Case Study
AROM

PROM

MMT

5 deg
Limited

8 deg
Limited

5/5
Strength

Ankle Plantar 30 deg

flexion
Limited

Limited 35
degrees with
empty endfeel

5/5
Strength

Inversion

5 deg
Limited

Limited with
empty endfeel

4-/5
Strength

Eversion

5 deg
Limited

6 deg
Limited

4-/5 Strength
with pain

Ankle
Dorsiflexion

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Joint
Mobility

Case Study
! Tests and Measures:
! Observation and Structural Inspection: Bilateral pes planus

Navicular Drop Test: 6 mm

! Muscle length: Gastroc/soleus tightness
! Girth measurement (Figure 8): Left ankle: 51 cm, Right ankle: 50 cm
! Palpation: Grade 2 tenderness on the left anterior/lateral talar dome
and diffuse tenderness to the cuboid and 5th metatarsal base
! Special Tests: Negative findings for Kleigers, Talar tilt, and positive
for Anterior Drawer Test
! Functional Movement: Difficulty controlling hip adduction, internal
rotation and pronation during lunges and deep squats
! Missing arthrokinematic testing?
! Manual therapy evidence?
Ovidio Olivencia, PT, DPT
Nova Southeastern University

What is Manual Therapy?

! Skilled hand movements intended to improve ROM, tissue

extensibility, pain and induce relaxation

! Manual Interventions:
!Manual Traction
!Soft tissue Mobilization
!Muscle Energy Techniques
!Cranial- Sacral Therapy
!PROM and Stretching
!Manipulation/Mobilization
Guide to Physical Therapist Practice, 2003
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Joint Mobilization
! Systematic approach to examining and treating the osteokinematics

and arthrokinematics motions of the human body

!ROM: AROM,PROM, and End-Feels
!Joint Play: Involuntary interarticular motion present all synovial
joints ie. glide, compression, distraction etc..
! Structural inspection and biomechanics are examined, and evaluated
for possible dysfunction
! Joint mobilization requires the healthcare professional to passively
move a joint either by:
!Sustained stretch
!Applying rhythmic oscillations
! Goal is to restore full and painless ROM
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Joint Mobilization
! Indications:
!Lack of ROM
!Painful joints
!Muscle guarding
! Effects:
!Mechanical:
!Plastic deformation of inert and contractile tissue
!Remodeling of adhesions
!Pain Inhibition:
!Gate controlled theory
!Mechanoreceptors
!Joint Nutrition:
Ovidio Olivencia, PT, DPT
Nova Southeastern University

! Tibia/Fibula Techniques:
oProximal Tibia/Fibula Joint: A/P and P/A
oDistal Tibia/Fibula Joint: A/P and P/A
! Ankle Techniques
oTalocrural: A/P
oTalocrural: Weight-Bearing
oTalocrural: Distraction
! Foot Techniques
oSubtalar: Distraction
oSubtalar: Lateral glide
oCuboid: P/A
Ovidio Olivencia, PT, DPT
Nova Southeastern University

!Synovial joint
!Joint surface is flat or slightly

oval
!Capsule is strengthened by
anterior/posterior ligaments
!Proximal fibula glides on tibia
anterior/lateral and superior
during dorsiflexion
!Soavi et al., Foot Ankle Int,
2000
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Proximal Tibiofibular Joint (A/P and P/A)

! Patient Position:
o Supine with knee flexed and the foot on

the table
! Stabilization
o Grasping the tibia
! Action Hand:
o Therapist grasp the head of the fibula
with thumb and index finger
! Mobilization:
o Therapist applies an anterior and
posterior glide motion of the fibula head
on the tibia
Ovidio Olivencia, PT, DPT
Nova Southeastern University

!Syndesmosis joint
!No joint capsule
!Concave tibia on convex fibula facet
!Stability provided by posterior and

anterior tibiofibular ligaments and

interosseous membrane
!Distal fibula glides on tibia posterior
superior and lateral rotation during
dorsiflexion
!Soavi et al., Foot Ankle Int, 2000
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Distal Tibiofibular Joint (A/P and P/A)

! Patient Position:
o Supine foot off end of table
! Stabilization
o Grasping distal Tibia
o Use leg to to stabilize foot
! Action Hand:
o Contact distal fibula with thenar eminence

over lateral malleolus

! Mobilization:
o Therapist applies a posterior and anterior
glide motion of the distal fibula on the
tibia

Mobilization of the distal tibiofibular

joint has been shown to increase ankle
dorsiflexion ROM
Fujii et al., Man Ther, 2010

Ovidio Olivencia, PT, DPT

Nova Southeastern University

! Synovial hinge joint

! Talus wide anterior than posterior
! Body of talus has three articulating facets:
! Fibular
! Tibial
! Trochlear
! Thin capsule is strengthened by deltoid (medial),

anterior and posterior talofibular ligaments, and

calaneofibular ligament (lateral)
! Talus glides posterior and rotates externally with
dorsiflexion
! Levangle & Norkin, Joint Structure and Function,

2001
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Talocrural Posterior Glide

! Patient Position:
o Supine foot off end of table
! Stabilization
o Grasping distal Tib-Fib
! Action Hand:
o Contact talus with web space between

thumb and index finger

! Mobilization:
o Therapist applies a posterior glide

through web space contact while

maintaining plantarflexion
! Posterior glide of the talocrural joint
improves dorsiflexion ROM and Function

Collins et al, Man Ther, 2004

Cosby et al, J Man Manip Ther.
2011

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Weigh-bearing Mobilization
! Patient Position:
o Standing
! Stabilization
o Web space of one hand stabilizes the talus and

forefoot
o Other hand guides lower extremity
! Action Hand:
o The belt is placed around distal tibia and fibula
o Towel or foam needed for Achilles tendon protection
! Mobilization:
o Therapist applies an anterior glide through belt while

patient actively dorsiflexes (leaning forward)

o Dorsiflexion with movement significantly increases
ROM
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Collins et al
Man Ther, 2004

! Patient Position:
o Supine with knee extended
! Action Hand:
o Grasp talus
! Mobilization:
o Therapist applies a long axis

distraction of talus using hand

contacts and body weight for
assistance

Ovidio Olivencia, PT, DPT

Nova Southeastern University

! Synovial joint
! Calcaneus (posterior, middle, anterior facets) articulates

with talus
! One degree of freedom (inversion and eversion) some
dorsiflexion and plantarflexion
! The joint is strengthened primarily by deltoid (medial),
and calcaneal fibular ligament (lateral),and secondary by
the medial, posterior and lateral talocalcaneal ligaments
! Calcaneus inverts, everts and internally and externally
rotates
! Dorsiflexion: The calcaneus everts, externally rotates
and dorsiflexes
! Goto et. al., Foot & Ankle International, 2009
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Subtalar Lateral Glide

! Patient Position:
o Side lying on the involved lower

extremity
! Stabilization:
o Grasp tib/fib and talus
! Action Hand:
o Grasp the calcaneus with the thenar
eminence
! Mobilization:
o Therapist applies a lateral mobilization
force through the therapist's arm and
thenar eminence to the medial calcaneus
Ovidio Olivencia, PT, DPT
Nova Southeastern University

! Patient Position:
oProne with pillow between therapist

and leg
! Stabilization:
oGrasp talus from dorsal side
! Action Hand:
oGrasp the calcaneus between your
thumb and index finger with knee
flexed
! Mobilization:
oPush straight up towards ceiling
Ovidio Olivencia, PT, DPT
Nova Southeastern University

! Synovial joint
! Body of cuboid articulates with:
! Calcaneuous
! 4th and 5th metatarsals
! Navicular
! Lateral cuneiform
! Stability provided by dorsal and plantar:

cuboideonavicular, calcaneocuboid,
cubodeiometatarsal ligaments, and long plantar
ligament
! Movement of CC joint is medial and lateral rotation
(pronation and supination) in an anterior/posterior
axis.
! Boisen-Moller, J Anat, 1979
Ovidio Olivencia, PT, DPT
Nova Southeastern University

! Patient Position:
o Prone with knee in 70 deg. of flexion and 0 deg. of

dorsiflexion
! Stabilization:
o Interlocking fingers over the dorsum of foot
! Action Hand:
o Thumbs positioned on the plantar/medial aspect of

cuboid
! Mobilization:
o With the patients leg relaxed, extend the knee while
plantar flexing ankle with slight inversion of the
subtalar joint while delivering an P/A mobilization
! 6.7% of plantar flexion and inversion injury
! Jennings & Davies, J Orthop Sports Phys Ther,
2005
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Case Study Manual Therapy Interventions

AROM

PROM

Joint
Intervention
Hypomobility (Glides)

Ankle
Dorsiflexion

5 deg
Limited

8 deg
Limited

Prox Tib/Fib:!
Dist Tib/Fib:!
Talocrural:!
Subtalar:!

Ankle Plantar
flexion

30 deg
Limited

35 Limited
Anterior glide
Empty end -feel Hypermobility
Talocrural Joint

Subtalar
Inversion

5 deg
Limited

Limited with
empty end-feel

Subtalar
Eversion

5 deg
Limited

6 deg
Limited

Normal
Subtalar!

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Anterior
Posterior
Posterior
Lateral

NA

NA
Lateral
Distraction
Cuboid P/A

Practical Applications
! Chronic lateral Ankle Sprain
! Clinical Prediction Rules (CPR) for Chronic Ankle

Sprains
! Syndesmosis (High Ankle) Sprain

Ovidio Olivencia, PT, DPT

Nova Southeastern University

Chronic Lateral Ankle Sprain

! Recurrent ankle sprain demonstrate impairments in the

following joints:
!Proximal tibiofibular
!Beazell et. Al, J Orthop Sports Phys Ther, 2012
!Distal tibiofibular
!Positional Fault
! Hubbard & Hertel, Man Ther, 2008
!Talocrural
!Denegar, Hertel, Fonseca, J Orthop Sport Phys Ther, 2002
!Subtalar
!Greeman, Principles of Manual Medicine, 1996
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Clinical Prediction Rules

Manual Therapy and Exercise
! Symptoms worse with standing
! Symptoms worse during evening
! Navicular bone drop ! 5.0 mm
! Distal tibiofibular joint hypomobility
!" +LR 5.90 with a probability of success 95%
!Whitman et al., JOSPT, 2009

Ovidio Olivencia, PT, DPT

Nova Southeastern University

! History
o10% of all ankle injury
oDorsiflexion and lateral rotation of foot injury
oMay have widening mortise
oReturn: 10-52 days
oHockey average 45 days (6-147 days)
o74% of all ankle sprains
oWright et al., The AMJ of Sports Med,2004

Ovidio Olivencia, PT, DPT

Nova Southeastern University

! Physical Exam
oSwelling/edema
o! ROM
oPoint tenderness on distal tibiofibular

ligament or up the syndesmosis

oPositional fault of distal fibula (posterior
lateral)
! Special Tests: Squeeze or Kleiger
! Suggested Manual Interventions:
! Proximal Tib/fib: Posterior Glide
! Distal Tib/Fib: Anterior Glide
! Talocrural Joint: Posterior Glide
! Subtalar Joint: Lateral Glide
Ovidio Olivencia, PT, DPT
Nova Southeastern University

Questions?
Ovidio Olivencia, PT, DPT
Olivenci@nova.edu

Ovidio Olivencia, PT, DPT

Nova Southeastern University

References
! Akira G, Hisao M, Tomonobu I, Tesu W, Kazuomy S. Three dimensional in vivo

kinematics of the subtalar joint during dorsi-plantarflexion and inversioneversion. Foot & Ankle International. 2009; 30 (5):432-438.
! Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J.

Effects of a proximal or distal tibiofibular joint manipulation on ankle range of

motion and functional outcomes in individuals with chronic ankle instability. J
Orthop Sports Phys Ther. 2012; 42:125-134.
! Bojsen-Moller F. Calcaneocuboid joint and stability of the longitudinal arch of
the foot at high and low gear push off. J Anat. 1979;129:165-176.
! Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan's mobilisation
with movement technique on dorsiflexion and pain in subacute ankle sprains.
Man Ther. 2004; 9(2): 77-82.
! Cosby NL, Koroch M, Grindstaff TL, Parente W, Hertel J. Immediate effects of
anterior to posterior talocrural joint mobilizations following acute lateral ankle
sprain. J Man Manip Ther. 2011;19:76-83.

References
! Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on

dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop
Sports Phys Ther. 2002;32:166-173.
! Fujii M, Suzuki D, Uchiyama E, et al. Does distal tibiofibular joint mobilization
!
!
!
!

decrease limitation of ankle dorsiflexion? Man Ther. 2010;15:117-121.

Greenman P. Principles of Manual Medicine. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 1996.
Guide to Physical Therapist Practice. (2nd ed). Alexandria, VA: American
Physical Therapy Association; 2003.
Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral
ankle sprains. Man Ther. 2008;13:63-67.
Jennings J, Davies G.J. Treatment of cuboid syndrome secondary to lateral ankle
sprains: a case series. J Orthop Sports Phys Ther. 2005; 35(7):409-415.

! Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive

Analysis. 3rd ed. Philadelphia, PA: FA Davis Co; 2001:367402.

Ovidio Olivencia, PT, DPT
Nova Southeastern University

References
! Whitman JM, Cleland JA, Mintken P, Keirns M, Bieniek ML, Albin SR, Magel

J, McPoil TG. Predicting short-term response to thrust and non-thrust

manipulation and exercise in patients post inversion ankle sprain. J Orthop
Sports Phys Ther. 2009; 39 (3):188-200.
! Wright et al. Ankle syndesmosis sprains in National Hockey League players.
AMJ of Sports Med. 2004; 32 (8):1941-1947.

Ovidio Olivencia, PT, DPT

Nova Southeastern University