Peripheral joint mobilization
Made by Sajida Mazhar
Joint mobilization
• Joint mobilization refers to manual therapy
techniques that are used to
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modulate pain and
treat joint dysfunctions
regain range of motion (ROM)
addressing the altered mechanics of the joint.
• The altered joint mechanics may be due to
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pain
muscle guarding
joint effusion
Contractures
adhesions in the joint capsules
Adhesions in supporting ligaments
Malalignment
subluxation of the bony surfaces
Joint mobilization
• It differ from stretching in that they
▫ specifically address restricted capsular tissue by replicating normal
joint mechanics
▫ minimizing abnormal compressive stresses on the articular cartilage
in the joint.
• practitioner must know
▫ anatomy
▫ arthrokinematics and
▫ pathology of the neuromusculoskeletal system
▫ recognize when the techniques are indicated
▫ when other techniques would be more effective for regaining lost
motion.
▫ False use of may lead to potential harm to the patient’s
joints.
Mobilization/Manipulation
• They are passive skilled manual therapy
techniques
▫ applied to joints and related soft tissues
▫ at varying speeds and amplitudes using
physiological or accessory motions for therapeutic
purposes.
• speeds and amplitudes could range from
▫ a small-amplitude force applied at high velocity
▫ to a large-amplitude force applied at slow velocity
Self-Mobilization (Auto-mobilization)
• Self-mobilization refers to self-stretching
techniques
▫ specifically use joint traction or glides that direct
▫ the stretch force to the joint capsule.
Mobilization with Movement
• Mobilization with movement (MWM) is
▫ accessory mobilization Applied by a therapist
▫ an active physiological movement to end range
applied by the patient
The techniques are always applied in
▫ a pain-free direction and
▫ described as correcting joint tracking from a
positional fault
Physiological Movements
• Physiological movements are movements the
patient can do voluntarily
• (e.g., the classic or traditional movements,
• such as flexion, abduction, and rotation)
• term osteokinematics is used for these
Accessory Movements
• Accessory movements are movements in the joint
and surrounding tissues
▫ that are necessary for normal ROM
▫ cannot be actively performed by the patient.
• Component motions
▫ Accompany active motion
▫ but are not under voluntary control.
▫ E.g. motions such as upward rotation of the scapula
and rotation of the clavicle, which occur with shoulder
flexion, ext rotation of the tibia in knee extension.
Accessory Movements
• joint play.
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the motions that occur between the joint surfaces
the distensibility or “give” in the joint capsule
necessary for normal joint functioning through the ROM
Demonstrated passively
but they cannot be performed actively
The movements include
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distraction,
Sliding,
compression,
rolling,
spinning of the joint surfaces.
• The term arthrokinematics is used for these motions
Thrust
• Thrust is a high-velocity,
▫ short-amplitude motion
▫ that the patient cannot prevent the motion.
▫ The motion is performed at the end of the
pathological limit (end of the available ROM when
there is restriction.)
• Is alter positional relationships
▫ snap adhesions,
▫ stimulate joint receptors.
Manipulation Under Anesthesia
• Manipulation under anesthesia
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is a medical procedure
used to restore full ROM
by breaking adhesions around a joint
while the patient is anesthetized.
The technique may be a rapid thrust or a passive
stretch
▫ using physiological or accessory movements
Muscle Energy
• Muscle energy techniques use
▫ active contraction of deep muscles that attach near
the joint and
▫ whose line of pull can cause the desired accessory
motion.
▫ The therapist stabilize the segment on which the
distal aspect of the muscle attaches.
▫ A command for an isometric contraction of the
muscle, that causes accessory movement of the
joint
BASIC CONCEPTS OF JOINT
MOTION: ARTHROKINEMATICS
• Joint Shapes
▫ The type of motion occurring between bony
partners in a joint
▫ is influenced by the shape of the joint surfaces.
Joint Shapes
• In ovoid joints
▫ one surface is convex, the
▫ other is concave
• In sellar joints,
▫ one surface is concave in one
direction
▫ and convex in the other,
▫ with the opposing surface
convex and concave
Types of Motion
• As a bony lever moves about an axis of motion,
• also movement of the bone surface on the opposing bone surface
in the joint.
• The movement of the bony lever is called swing
▫ as flexion, extension, abduction, adduction, and rotation.
▫ measured in degrees with a goniometer and is called ROM.
• Motion of the bone surfaces in the joint is a combination of
rolling and sliding, or spinning.
▫ These accessory motions allow greater angulations of the bone as
it swings.
▫ For the rolling, sliding, or spinning
▫ There must adequate capsule laxity or joint play.
Types of Motion
• Roll
• Characteristics of one bone
rolling on another are as follows.
• The surfaces are incongruent.
• New points on one surface meet
new points on the opposing
surface.
• Rolling results in angular motion
of the bone (swing).
• Rolling is always in the same
direction as the swinging bone
motion whether the surface is
convex or concave.
Rolling
Rolling, if it occurs alone, causes
▫ compression of the surfaces on
the side to which the bone is
swinging
▫ separation on the other side.
▫ Passive stretching using
▫ bone angulations alone may
cause stressful compressive
forces to portions of the joint
surface,
▫ potentially leading to joint
damage.
• In normally functioning joints,
pure rolling does not occur alone
but in combination with joint
sliding and spinning
Slide/Translation
Slide/Translation
Characteristics of one bone
sliding (translating) across
another include the following.
• For a pure slide, the surfaces
must be congruent, either
• Flat or curved
• The same point on one surface
comes into contact with
• the new points on the
opposing surface.
Slide/Translation
• Pure sliding does not occur in
joints
• because the surfaces are not
completely congruent.
• The direction in which sliding
occurs depends on
• whether the moving surface is
concave or convex.
• Sliding is in the opposite
direction of the angular
movement of the bone if the
moving joint surface is convex.
• Sliding is in the same
direction
• as the angular movement of
the bone
• if the moving surface is
concave.
Combined Roll-Sliding in a Joint
• The more congruent the joint surfaces are, the
more sliding
• The more incongruent the joint surfaces are, the
more rolling
• Spin
• There is rotation of a segment
about a stationary mechanical
axis
• The same point on the moving
surface creates an arc of a
circle as the bone spins
• Spinning rarely occurs alone in
joints but
• in combination
• with rolling and sliding.
• Three examples of spin
occurring in joints of the body
• are the shoulder with
flexion/extension, the hip with
• flexion/extension, and the
radiohumeral joint with
• pronation/supination
Other Accessory Motions
• Compression
• Compression is the decrease in the
joint space between
• bony partners.
▫ weight bearing jts
▫ With muscle contration
(stabilization)
▫ With rolling
• help move synovial fluid and thus
help maintain cartilage health.
• Abnormally high loads may lead
• articular cartilage changes and
deterioration
• Traction/Distraction
• Traction isa longitudinal pull.
• Distraction is a separation, or
pulling apart
• if traction is applied
• to the shaft of the humerus, it
results in a glide of the joint
surface Distraction of the
glenohumeral
• joint requires a pull at right
angles to the glenoid fossa
• whenever there is pulling on
the long axis of a bone, the
term long-axis traction
• the surfaces are to be pulled
apart, the term distraction,
joint traction, or joint
separation is used.
Open and close pack position
Position patient in a relaxed, distracted,
supported position so the joint capsule is lax
(loose(open)-packed position).
Close-packed position is one in which
there is maximal contact of the articulating
surfaces.
Joint
Closed-packed Position Open-packed Position
Glenohumeral
90o ABD & Full ER combo
55o flexion w/ 20-30o HABD
Elbow
Humeroulnar
Humeroradial
Raduioulnar
Full Extension
90o flex w/ mid-pronation
Full pronation or supination
70o Flex w/ 10o supination
Full ext w/ full supination
70o flex w/ 35o supination
Full extension & radial
deviation or full flex
Neutral position
MCP joints
2-5
1
Full flexion
Full opposition
20o flexion
20o flexion
IP joints
Full Extension
20o flexion
Hip
Full IR, Ext & ABD
55o flex w20-30o HABD
Knee (tibiofemoral)
Full Ext & ER
20-25o flexion
Ankle Mortise
Full DF
10o PF
Subtalor
Full EV or INV
Midrange PF & DF
Forefoot
Full DF
1 MTP = 20o DF
2-5 MTP = 20o PF
IP’s = 20o PF
Distal Radiocarpal Joint
10 simple steps
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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-
Normal motion
Grades of Oscillations (Maitland)
INDICATIONS FOR JOINT
MOBILIZATION
• Pain, Muscle Guarding, and Spasm
▫ Painful joints, reflex muscle guarding, and muscle
spasm treated gentle joint-play techniques to
stimulate neurophysiological and mechanical
effects
• neurophysiological and mechanical effects
▫ stimulate the mechanoreceptors
▫ Inhibit nociceptive stimuli
• mechanical effects
▫ Synovial fluid motion provide neutrients to jts
• The small-amplitude joint techniques used to
• treat pain, muscle guarding, or muscle spasm
should not
• place stretch on the reactive tissues
• Reversible Joint Hypomobility
▫ joint-play stretching techniques to elongate
▫ hypomobile capsular and ligamentous connective
tissue
• Positional Faults/Subluxations
▫ Malposition / regain ROM
▫ realign the bony partners
• Progressive Limitation
▫ Diseases that progressively limit movement can be
treated with joint-play
• Functional Immobility
▫ Patient functionaly imobile
CONTRAINDICATIONS
AND PRECAUTIONS
• Hypermobility
• Joint Effusion
• Inflammation
Conditions Requiring Special
Precautions for Stretching
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Malignancy
Bone disease detectable on radiographs
Unhealed fracture
Excessive pain
Hypermobility in associated joints
Total joint replacements
Newly formed or weakened connective tissue
Systemic connective tissue diseases such as rheumatoid
Elderly individuals