The close-packed position is one of stability. When the elbow and knee are fully extended, the ligaments and joint capsule are taut, allowing no freedom of movement. Therefore the knee and elbow in extension serve as two excellent examples of joints in the close-packed position. Any joint position other than the close-packed position is a loose-packed position. The loose-packed position is ideal for applying joint mobilization techniques, but painful, stiff, and dysfunctional joints are rarely in ideal resting positions for the application of joint mobilization.
Table lists resting and close-packed positions of major joints in the human body. If this dysfunctional movement pattern continues, a condition of muscle overuse can ensue. Anatomically, all articular surfaces are either convex or concave, 4, 21 although the surfaces of some joints are not overtly of either shape. In these cases, fibrocartilage enhances and modifies the contour of the joint surfaces. On the convex joint surface, more cartilage is found at the center of the surface; on a concave joint surface, more cartilage is found at the periphery.
Maitland 17 describes five grades of physiologic and accessory joint motions used in mobilization Fig. The terms velocity, oscillation, and amplitude of movement describe the degree of force and rate of motion used during any of the grades of mobilization, as follows:.
Grade I mobilization: A small oscillation or small amplitude joint motion that occurs only at the beginning of the available ROM. Grade III mobilization: A large amplitude motion that occurs from midrange of motion to the end of the available range. Choudhri, Frederick A. Boop, and James W. Mathew and Lawrence D. Kadam and Michael V. Nordli, Jr. Ferrie, and Chrysostomos P. Search Engine.
Average : rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star Your rating: none, Average: 0 0 votes. B, Close-packed position. Step length symmetry improved in both groups, reaching values close to symmetrical 0. Ratio of step length of uninjured limb to total stride length symmetry ratio.
There was no difference between groups in improvement in step length. The symmetry of single support time time spent on one leg alone also improved with both treatments Fig. The distributions of these data, however, are skewed and demonstrate considerable intersubject variability. Consequently, there were no differences, based on our statistical analysis.
Ratio of single support time on injured side to total time spent in single support. The median of the control group is represented by the filled circles, and the median of the experimental group is represented by the open squares.
Error bars represent 25th and 75th percentiles. Return to normal activity was monitored using the activity diary. Because not all questions were applicable to all subjects, the mean was calculated only for those subjects for whom a particular activity was relevant, and the number of subjects is indicated in parentheses.
In our study, we showed that when acute ankle inversion sprains were treated with AP mobilization of the talocrural joint in addition to the conventional RICE protocol, fewer treatments were required for pain-free dorsiflexion range of movement and stride speed to improve than when RICE alone was administered.
Although researchers in pilot studies have demonstrated that passive mobilization can improve pain-free ankle range of motion, 24 , 49 our trial is the first randomized controlled trial to demonstrate an effect of passive joint mobilization on sprained ankles. We noted an apparent continued improvement in pain-free dorsiflexion range of movement for both groups between treatment sessions Fig.
The measurements taken after one treatment and before the next treatment showed that dorsiflexion improved 5 to 6 degrees between treatment sessions for both groups. We believe that this improvement is likely to represent the rate of natural recovery from acute ankle sprain. The improvement conferred by the AP mobilization is unlikely to be accounted for by differences in the groups that existed before the study.
The 2 groups were similar at entry to the trial for most variables except that more subjects in the experimental group previously had sprains Tab. Although previous sprains might have worsened the prognosis, the experimental group improved more quickly than the control group. This finding suggests to us that passive mobilization is an effective additional treatment for improving pain-free range of movement and some gait variables.
Both groups reported good adherence to the home program. Adherence was calculated as the percentage of days enrolled in the trial in which subjects performed each aspect of the protocol as required, and not as a percentage of subjects. Different rates of adherence to the home program, therefore, are unlikely to explain the improvement with the passive mobilization treatment in the experimental group.
The reasons for the beneficial effects of mobilization are unclear, although several hypotheses have been advanced, including physiological modulation of pain and mechanical alteration of tissues. In our study, however, the mobilization was performed near the beginning of the joint's range of motion and not at the end of the range of motion. In addition, there was an immediate reduction in pain, as evidenced by the improvement in pain-free dorsiflexion range of movement, an unlikely response from a mechanical event.
The continued improvement of stride speed between treatment sessions indicates to us that the injury was resolving, and some benefits may or may not have been attributable to a treatment effect from the mobilization in the experimental group. In both groups, there were measurable improvements in walking speed following each treatment. The magnitude of the improvement was relatively greater after the first treatment than subsequent treatments, irrespective of the intervention.
This step speed gain is consistent with the finding of maximum effect on ankle dorsiflexion range of movement at the first treatment. The use of a symmetry index to examine the effect of the treatments on step length and single support time, in our opinion, diminishes some of the problems of intersubject variability.
It is clear that the symmetry index was not substantially influenced by the first treatment. The second experimental treatment, however, evoked an improvement in step length symmetry. Although there was a trend toward improvement in single support time symmetry in the experimental group, and an opposite trend in the control group, these data are not clearly distinct and no conclusion can be drawn concerning the effect of mobilization on the ability to spend a longer period bearing weight on the injured side.
Because the walking speed remained slow, the lack of a change in the first treatment may indicate that there was only a slight increase in the step length. This finding may reflect a pattern of improved range of movement and reduced pain on weight bearing, permitting a longer step on the uninjured side. Our research demonstrated that treatment which included AP mobilization improved pain-free ankle range of movement in dorsiflexion, as well as the functional outcome of stride speed.
The improvement occurred with fewer AP mobilization treatments than were required for the control group. Subjects in both groups improved in all variables tested, although the improvement was greater for the experimental group than for the control group.
Because a nontreatment group was not included in this trial for ethical reasons, it is unclear whether the improvements in the control group were achieved by the RICE protocol or by natural recovery. Ethical approval for the study was obtained from the human ethics committees of the University of Sydney and Calvary Hospital, Canberra.
Garrick JG. The frequency of injury mechanism of injury and epidemiology of ankle sprains. Am J Sports Med. Google Scholar. Hopper D. A survey of netball injuries and conditions related to these injuries. Australian Journal of Physiotherapy. A comparison of men's and women's professional basketball injuries.
Incidence and mechanisms of acute ankle inversion injuries in volleyball: a retrospective cohort study. Management and rehabilitation of ligamentous injuries to the ankle. Clin Sports Med. Brostrom L. Sprained ankles, I: anatomical lesions in recent sprains. Acta Chir Scand. Strain measurement in lateral ankle ligaments. Reid DC. Sports Injury Assessment and Rehabilitation. Google Preview. The natural history of inadequately treated ankle sprain. Long-term functional outcome after primary repair of the lateral ligaments of the ankle.
Inman VT. The Joints of the Ankle. Measurement of the motion range in the loaded ankle. Clin Orthop. A double-blind clinical trial of low power pulsed shortwave therapy in the treatment of a soft tissue injury. Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters. Gait Posture. Walking speed as a basis for normal and abnormal gait measurements. J Biomech.
A cooling method in the treatment of ankle sprains. Primary treatment of ankle trauma. The Physician and Sportsmedicine. Kay DB.
The sprained ankle: current therapy. Foot Ankle. Knight KL. Cryotherapy: Theory Technique and Physiology. Chattanooga, Tenn : Chattanooga Corp ; A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits. Starkey JA. Treatment of ankle sprains by simultaneous use of intermittent compression and ice packs. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation.
J Manipulative Physiol Ther. Brukner P , Kahn K. Clinical Sports Medicine. The 5 mobilization grades are defined as follows:. Gliding motions. A Glides of the convex segment should be in the direction opposite to the restriction.
B Glides of the concave segment should be in the direction of the restriction. Joint mobilization uses these oscillating gliding motions of one articulating joint surface in whatever direction is appropriate for the existing restriction. The appropriate direction for these oscillating glides is determined by the convex-concave rule, described previously.
When the concave surface is stationary and the convex surface is mobilized, a glide of the convex segment should be in the direction opposite to the restriction of joint movement Figure A. For example, the glenohumeral joint would be considered to be a convex joint with the convex humeral head moving on the concave glenoid. If shoulder abduction is restricted, the humerus should be glided in an inferior direction relative to the glenoid to alleviate the motion restriction.
When mobilizing the knee joint, the concave tibia should be glided anteriorly in cases where knee extension is restricted. If mobilization in the appropriate direction exacerbates complaints of pain or stiffness, the athletic trainer should apply the technique in the opposite direction until the patient can tolerate the appropriate direction.
Following an ankle sprain, accumulated scar tissue is preventing full plantar flexion. How can joint mobilization be used to help regain full ROM? Pain must be treated first and stiffness second. The purpose of the small-amplitude oscillations is to stimulate mechanoreceptors within the joint that can limit the transmission of pain perception at the spinal cord or brainstem levels. The athletic trainer must continuously reevaluate the joint to determine appropriate progression from one oscillation grade to another.
Traction vs glides. Traction is perpendicular to the treatment plane, whereas glides are parallel to the treatment plane. Indications for specific mobilization grades are relatively straightforward. If the patient complains of pain before the athletic trainer can apply any resistance to movement, it is too early, and all mobilization techniques should be avoided.
If resistance can be applied before pain is elicited, mobilization can be progressed to Grade IV. Mobilization should be done with both the patient and athletic trainer positioned in a comfortable and relaxed manner.
The athletic trainer should mobilize one joint at a time. The joint should be stabilized as near one articulating surface as possible, while moving the other segment with a firm, confident grasp. Techniques of mobilization and manipulation should not be used haphazardly. These techniques should generally not be used in cases of inflammatory arthritis, malignancy, bone disease, neurological involvement, bone fracture, congenital bone deformities, and vascular disorders of the vertebral artery.
Again, manipulation should be performed only by those athletic trainers specifically trained in the procedure because some special knowledge and judgment are required for effective treatment. Traction refers to a technique involving pulling on one articulating segment to produce some separation of the 2 joint surfaces.
Although mobilization glides are done parallel to the treatment plane, traction is performed perpendicular to the treatment plane Figure Like mobilization techniques, traction may be used either to decrease pain or to reduce joint hypomobility. Kaltenborn has proposed a system using traction combined with mobilization as a means of reducing pain or mobilizing hypomobile joints.
Kaltenborn referred to this looseness as slack. Some degree of slack is necessary for normal joint motion. Discuss joint arthrokinematics. Discuss how specific joint positions can enhance the effectiveness of the treatment technique. Discuss the basic techniques of joint mobilization. Discuss indications and contraindications for mobilization. There are basically 2 types of movements that govern motion about a joint. Perhaps the better known of the 2 types of movements are the physiologic movements that result from either concentric or eccentric active muscle contractions that move a bone or a joint.
This type of motion is referred to as osteokinematic motion. A bone can move about an axis of rotation, or a joint into flexion, extension, abduction, adduction, and rotation. The second type of motion is accessory motion. Accessory motions refer to the manner in which one articulating joint surface moves relative to another. Physiologic movement is voluntary, while accessory movements normally accompany physiologic movement.
Although accessory movements cannot occur independently, they may be produced by some external force. Normal accessory component motions must occur for full-range physiologic movement to take place. Traditionally in rehabilitation programs, we have tended to concentrate more on passive physiologic movements without paying much attention to accessory motions.
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