Foot and Ankle Joint Mobilisation for the Gait Loading Strategy

Page Summary

• Foot and ankle joint mobilisation may produce short-term gains in ankle dorsiflexion and dynamic balance; these are thought to be mainly neurophysiological rather than mechanical in origin.
• Mobilisation techniques include malleolar and talar posterior glides, tibial internal rotation, talar anterior glide, subtalar lateral glide, talocrural manipulation and mobilisation with movement.
• Joint mobilisation is contraindicated with ankle instability, suspected fracture or tumour, severe lower-limb vascular disease, or glides that stretch an acutely injured ligament.
• Dorsiflexion restriction may arise from the joint, gastrocnemius, soleus, extrinsic toe flexors or peroneals; knee-straight versus knee-bent testing helps distinguish gastrocnemius involvement.

Original Editor - Ewa Jaraczewska based on the course by Ari Kaplan

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Manual therapy can produce short-term changes in movement and function. These changes are thought to be mainly neurophysiological in origin rather than mechanical. Although brief, they can create a window of opportunity to progress other treatments, such as exercise. This page introduces a range of mobilisation techniques for the foot and ankle, including for the tibiofibular, tibiofemoral, talocrural and subtalar joints.

Proposed Benefits of Foot and Ankle Manual Therapy

Various short-term manual therapy benefits have been proposed, including improved ankle dorsiflexion and dynamic balance. Research suggests that the effects on dorsiflexion may be greater in older adults, and repeated sessions appear more effective than a single session.

Contraindications and Precautions

Joint mobilisation and manipulation should not be used in the following situations:

• An unstable ankle (e.g. acute grade III ligament injury)
• A postoperative ankle where mobilisation is not permitted
• Mobilising in a direction that would stretch an acutely injured ligament (e.g. anterior glide of the talus after an acute inversion sprain involving the anterior talofibular ligament)
• A suspected or confirmed fracture or tumour in the foot or ankle
• Severe vascular disease affecting the lower limb

Thrust manipulations should be avoided in people with conditions that weaken bone or connective tissue, such as osteoporosis, rheumatoid arthritis and a prolonged history of corticosteroid use.

Remember, joint mobilisation techniques should not be painful. Pain suggests that the technique may not be being applied correctly. Consider adjusting the force, direction or your hand position, or pad the area if it is tender.

Assessment Before Mobilisation

Assessment helps the clinician decide what to mobilise and in which direction. The following tests can help to identify where restrictions occur:

• Functional screen (e.g. squats, gait).
• Active range of motion, considering both the amount and quality of the movement.
• Passive range of motion, noting deviation from the expected plane and feeling for tissue resistance.
• Closed-chain dorsiflexion (e.g. weight-bearing lunge test).

When measuring closed-chain dorsiflexion, watch for excessive compensations, such as the knee drifting medially or the rearfoot or midfoot collapsing. When these compensations occur, cueing "knee over second toe", or blocking the compensation manually, can show whether true sagittal-plane dorsiflexion is available.

Differentiating Joint vs. Muscle Restriction

Increased muscle tension can make a joint feel hypomobile, and a hypomobile joint can increase tension in the surrounding muscles. The two are closely linked.

Dorsiflexion can be restricted by the gastrocnemius, soleus, the joint itself, the extrinsic toe flexors (flexor hallucis longus and flexor digitorum longus), and the peroneals, which pass behind the lateral malleolus. The following tests help to identify the primary driver of a dorsiflexion restriction.

• Knee straight versus knee bent dorsiflexion (Silfverskiöld test): the gastrocnemius crosses the knee, so it is on stretch with the knee straight and taken off stretch with the knee bent. If dorsiflexion improves with the knee bent, the gastrocnemius is likely contributing. If it remains limited, the restriction is more likely from soleus or the joint, so assess accessory joint motion. Good joint mobility suggests soleus.
• Palpation: tautness and tenderness suggest a muscular contribution.
• Toe extension: passively extend the great toe and lesser toes, first with the ankle dorsiflexed and then with the ankle in neutral. A limitation with the ankle dorsiflexed suggests extrinsic muscle involvement. If the limitation persists in neutral, consider the intrinsic muscles or a joint-based cause.

Once a technique is chosen, each hypothesis can be tested through treatment. Treat for one to three minutes, then retest. If the expected change occurs, the hypothesis is likely correct. If not, reconsider and assess an alternative structure.

The Arthrokinematic Model

This page uses the classic arthrokinematic model where joint mobilisation techniques are chosen based on the shape of the articulating bone surfaces. For example, because the talus glides posteriorly in the mortise during dorsiflexion, a posterior glide is used to improve dorsiflexion. This is a useful starting framework, but it is not the whole picture. Because the effects of mobilisation are thought to be mainly neurophysiological, the clinician is not limited to the arthrokinematic direction. If a technique is not producing the expected change, trying the opposite glide may help. The exception is when the opposite direction would stress an injured structure, such as an anterior glide of the talus after an acute anterior talofibular ligament (ATFL) sprain.

Foot and Ankle Mobilisation Techniques

Tibiofibular Joint

For dorsiflexion to occur, the mortise needs to accommodate the talus, which is wider anteriorly. This is achieved through internal rotation of the tibia and posterior glide of the fibula.

Medial or lateral malleolus posterior glide technique: The patient's leg is resting on the table. Stabilise one malleolus and mobilise the other. To mobilise the medial malleolus, block the fibula with one hand underneath the leg. Place the thenar eminence of your other hand on the medial malleolus, lock your elbow, and use your body weight to drive downwards, rotating the tibia internally. To mobilise the lateral malleolus, reverse the set-up. Stabilise behind the medial malleolus, place your thenar eminence on the anterior edge of the lateral malleolus, and glide it posteriorly. The malleoli are frequently tender. Check in with your patient, slow down, or pad the contact with a towel if needed.

Medial malleolus posterior glide

Medial malleolus posterior glide

Tibiofemoral Joint: Rotation

The tibiofemoral joint is often overlooked in foot and ankle presentations. However, limited internal rotation of the knee (e.g. after knee surgery or due to knee osteoarthritis) can restrict distal internal rotation of the tibia at the mortise.

Tibial internal rotation technique: Place your fingers of one hand along the posterior fibula and the thenar eminence of your other hand on the proximal tibia. Grip the tibia directly and internally rotate. A common error is gripping the gastrocnemius-soleus complex and moving the soft tissue. Make sure the rotation occurs at the tibia.

Tibial internal rotation

Talocrural Joint: Anterior-to-Posterior Glide

Talus posterior glide technique: Support the lower leg with one hand under the calf and your thumb over the tibia. Grip the foot gently just distal to the talus, around the navicular and the metatarsals, lock your elbow and use your body weight to glide the talus posteriorly. You can place the web space directly over the talus instead, but many patients find this sensitive. To progress, mobilise in a more dorsiflexed position.

Note: supporting the lower leg makes the technique more comfortable, as the edge of the table can press into the leg. It also limits knee movement; movement at the knee makes it hard to produce and evaluate glide at the talocrural joint.

Talus posterior glide

Talocrural Joint: Posterior-to-Anterior Glide

If a posterior glide is not producing the expected change, an anterior glide of the talus may help.

Talus anterior glide technique: This glide can be performed in supine or prone. In supine, stabilise the tibia and fibula with one hand. With the other hand, grip the calcaneus and lift it anteriorly. In prone, place your thenar eminence on the calcaneus and use your body weight to glide it towards the floor. Put your hand or a cushion under the anterior tibia, as the edge of the table can be uncomfortable. The supine position is better suited to assessment, and prone is more suited to treatment, as it lets you use your body weight to achieve the glide.

Talus anterior glide in supine

Talus anterior glide in supine

Progressing to Manipulation: Talocrural Joint

Talocrural manipulation gaps the talus from the mortise. It may benefit people with dorsiflexion stiffness, particularly when there is anterior ankle discomfort or impingement on dorsiflexion. The clinician must be able to take the ankle to end-range dorsiflexion for the manipulation to be effective. If the ankle is still very stiff, mobilise first, as manipulation may otherwise flare symptoms.

Technique: Position the patient supine. Interlock your fingers over the talus, just distal to the ankle crease. Take the ankle into dorsiflexion and eversion, and apply traction to take up the slack. Hold briefly, then deliver a small, quick thrust in a scooping or J-shaped motion. The thrust gaps the joint while adding slight dorsiflexion. A straight pull tends to drift into plantar flexion instead.

Talocrural joint manipulation: thrust technique

Talocrural joint manipulation: thrust technique

Mobilisation with Movement (MWM)

MWMs can be applied in non-weight-bearing or weight-bearing positions, and can help improve dorsiflexion range of motion. Weight-bearing MWMs are performed in standing or kneeling, with the foot on the floor or a step. For larger restrictions, standard non-weight-bearing mobilisation may be more effective, as the joint surfaces are compressed in weight-bearing and there is less room for glide. Weight-bearing techniques can then be used as a progression.

MWMs should be pain-free. If symptoms are provoked, modify the glide direction, force or hand position.

Talocrural posterior glide with movement: Stabilise the talus while the patient lunges forward and back. To bias the medial or lateral malleolus, block the anterior aspect of that malleolus with the thenar eminence, and use the other hand on the posterior aspect of the opposite malleolus to guide it anteriorly, interlocking the fingers for stability. Performing the glide in weight-bearing helps restore dorsiflexion in a functional position relevant to gait.

Mobilisation with movement for talocrural joint

Mobilisation with movement for medial/lateral malleolus

Subtalar Joint: Lateral Glide

Rearfoot pronation during loading requires eversion of the calcaneus. This technique glides or tilts the calcaneus laterally. It is essential to firmly stabilise the talus. Without adequate stabilisation, the talus will tilt instead of the calcaneus and a subtalar restriction may be missed. It may also stretch the medial side, which is often already mobile in people with limited dorsiflexion whose talus adducts during gait.

Technique: In supine, stabilise the talus while placing the thenar eminence of your other hand on the medial calcaneus. Then, glide or tilt the calcaneus laterally. The supine position is suitable for assessment or lighter mobilisation. For higher-dose or sustained treatment, position the patient in side-lying with their treated leg underneath. Keep the same hand placement, lock your elbow and use your body weight to glide the calcaneus towards the table.

Subtalar joint lateral glide technique

Subtalar joint lateral glide technique in supine

Subtalar joint lateral glide technique in sidelying

Resources

• Principles of Joint Mobilisation