Peripheral Joint Mobilization
• Mobilization - is a passive movement performed
slowly by the athletic trainer/therapist, it is
controlled enough that the patient can stop the
movement any time
– Goal is to provide a safe and effective means for
restoring normal joint play and/or decreasing pain
• Manipulation - involves a sudden, short
amplitude, high velocity movement the patient
cannot prevent - not in ATC’s realm
Mobilization - Indications and Goals
• Indications
– Capsular pattern - pattern of motion loss
– Pain - small amplitude oscillations to treat
– Muscle spasm/guarding - gentle oscillations and
sustained stretch to maintain joint play
– Joint hypomobility/stiffness - oscillatory forces
used to stretch joint capsule
• Goals
– Gentle joint play techniques stimulate both
mechanical and neurophysiological effects
Examples of Capsular Patterns
• When a capsular pattern is present, full joint ROM
will not be attained until you address capsular
tightness
– Glenohumeral
• lateral rotation > abduction; abduction > flexion
– Hip
• medial rotation, abduction, & flexion > extension
– Knee
• flexion > extension
– Ankle
• PF > DF; INV > EV
> means motion is more limited
Mobilization
• Mechanical effects – increased nutrition to the avascular portions
of the articular cartilage
– physically stretching the capsule which
maintains the potential for normal ROM
• Neurophysiological effects – stimulate mechanoreceptors that inhibit
transmission of nociceptive stimuli – gate
control
– Golgi tendon organ – autogenic inhibition
Mobilization
• CONTRAINDICATIONS
–
–
–
–
Hypermobility
Joint effusion
Acute inflammation
Fractures/Osteoporosis
• LIMITATIONS
– techniques cannot change a disease process
• Be careful with unexplained pain syndromes
– therapist/athletic trainer skill will affect the outcome
Basic Concepts of Joint Motion
• Physiological movements - Osteokinematics
– the patient can perform these voluntarily
– “traditional” movements such as flexion, extension,
abduction, rotation
• Accessory movements - Arthrokinematics
– joint play and accessory motion
– necessary for and accompanying normal ROM, but
cannot be performed by the patient - examples are
slide, roll, spin, distraction, compression
Basic Concepts of Joint Motion
• Type of motion is influenced by the shapes of
the joint surfaces
– Ovoid - one surface is convex the other concave –
most common
– Sellar (saddle) - one surface is concave in
one direction and convex in the other,
being opposite of the other
joint surface
Arthrokinematics
– Roll
• Incongruent surfaces – new pts to new pts
• Rolling occurs in the same direction as physiological
movement
– Slide (Glide)
• Congruent surfaces – one pt to new point
• Concave-Convex Rule
– Spin
• Bone rotates around a stationary axis
RULE OF CONCAVE-CONVEX
• The shape of the joint surface influences the
direction of the accessory movement
– If surface of moving bone is convex, sliding is in
the opposite direction of the bone’s physiological
movement
– If the surface of the moving bone is concave,
sliding is in the same direction as the physiological
movement of the bone
RULE OF CONCAVE-CONVEX
INDICATIONS FOR JOINT
MOBILIZATION
• 1- Pain, Muscle Guarding, and Spasm can
be treated with gentle joint-play techniques
to stimulate;
• Neurophysiological Effects
• Small-amplitude oscillatory and distraction
movements stimulate mechanoreceptors
inhibt transmission of nociceptive stimuli at
the spinal cord
• Mechanical Effects
• Small-amplitude distraction or gliding
movement produce synovial fluid motion, for
bringing nutrients to the avascular portions
of the articular cartilage to prevent
degeneration of the joint surfaces
2- Reversible Joint Hypomobility
3- Positional Faults/Subluxations
4-Functional Immobility
LIMITATIONS OF JOINT
MOBILIZATION TECHNIQUES
• Mobilization techniques cannot change the
disease process(rheumatoid arthritis or the
inflammatory. In these cases, treatment is
directed toward minimizing pain,
maintaining available joint play,
CONTRAINDICATIONS
AND PRECAUTIONS
• Hypermobility
• Joint effusion
• Inflammation
10 simple steps
1.
2.
3.
4.
5.
6.
7.
8.
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10.
Evaluation and Assessment
Determine grades and dosage
Patient position
Joint position
Stabilization
Treatment force
Direction of movement
Speed and rhythm
Initiation of treatment
Reassessment
Grades of Oscillations (Maitland)
• Grade I - small amplitude movement at the
beginning of the range (pain and spasm)
• Grade II - large amplitude movement within the
midrange of the movement (pain and spasm)
• Grade III - large amplitude movement at the end of
the range (into restriction)
• Grade IV - small amplitude movement at end
range when tissue resistance (not pain) is limiting
• Grade V - small amplitude, quick thrust
manipulation at end range- only w/ training!
Normal motion
Grades of Oscillations (Maitland)
Mobilization
• If there is pain before tissue limitation, use gentle
techniques for decreasing pain and no stretching
– Grades I and II
• If pain is concurrent with tissue limitation, treat
cautiously with gentle techniques, then gradually
increase movement without exacerbating pain
– Grade I and II
• If pain is experienced after tissue limitation, a stiff
articulation can be aggressively mobilized with
joint play techniques
– Grades III and IV
Recommendations for using
the Grades
• Pain and spasm
– I and II
• Tissue resistance
– III and IV
• Treatment amplitude
– Low - I, IV
– High - II, III
• Treatment speed
– Fast – I, IV
– Slow – II, III
• Gentle techniques
– I, II
• Treatment force
– Low – I, II
– High – III, IV
Procedures for Application of Joint
Mobilization Techniques
• Position patient in a relaxed, distracted,
supported position so the joint capsule is lax
(loose(open)-packed position). Closepacked position is one in which there is
maximal contact of the articulating surfaces.
– Stabilize proximal bone
– Position joint in open (loose packed) position
– Apply treatment force close to the joint line as
possible (decrease lever)
• Use treatment plane
Open Pack Positions
• Knee – 20-25o flexion
• Ankle – 10o plantar flexion, mid range
eversion/inversion
• Hip – 30o flexion, 30o abduction
• Wrist - Neutral
• Elbow
– Humeroulnar/Radioulnar - 70o flexion (supination
varies)
– Humeroradial – Full extension and supination
• Shoulder – 55o flexion, 20-30o horiz. abduction
Treatment Plane
•Traction apply
perpendicular
•Gliding apply parallel
Technique
•2-3 oscillations per second
•Pain – 1 to 2 mins.
•Tightness – 20 to 60s