These operator viewpoint photographs show a hold for applying general mobilization to the mid foot. The thumbs are aligned along the shafts of one or more of the metatarsals. A torsional force is introduced to direct the articulation forces to the joint to be mobilized.
Tips: Try varying the spacing between the thumbs or making them more proximal or distal to reach different parts of the foot.
33.21, 33.22, 33.23 and 33.24 • (see next page) Articulation mid tarsus supine This series of photographs show the so-called 'figure of eight' technique in its various phases. Take the foot through an imaginary figure of eight, in a variety of planes, either vertically, horizontally or diagonally. Tension accumulates at the cross-over in the middle or at the outer edges of the figure as directions change. Visualize the eight as having a somewhat flat top and bottom.
Tips: Most useful in almost all cases of dysfunction causing restricted mobility in the foot. Extra considerations: Quite firm compression is usually necessary to the metatarsal heads by the operator's lower abdomen to help focus the technique.
33.25 • Articulation mid tarsus and fore foot supine The hands grasp firmly around the medial and lateral aspects of the foot. The foot is dorsi-flexed to stabilize the ankle. One hand can stabilize while the other mobilizes, or they can both drive the metatarsals up in the centre of the foot by fingertip pressure. At the same time the heels of the hands drive down the borders of the foot.
Tips: Try introducing twisting forces to direct the levers to different parts of the foot. With traction and firm moulding of the foot it is possible to reach most of the mid foot articulations.
33.26 • Thrust to mid tarsus supine Fix over the target joint with the centre of your interlocked hands. Apply some traction to put the area on tension. Then spread the foot with the thumbs to allow some space for the bone you wish to manipulate. The mid tarsal bones are somewhat wedge shaped and need a space to 'fall into'. The thrust is performed with a short tug in the long axis of the tibia.
Tips: Try using slight variations of abduction and adduction while accumulating the optimum forces.
33.27 • Thrust to middle or lateral cuneiform supine Shake hands with the foot, that is right hand to right foot, or left to left. Maintain the foot in a neutral position between dorsiflexion and plantarflexion by levering up with the back of your hand on the table. The other hand applies a firm pressure down on the cuneiform using your pisiform as the applicator. Ensure that the tendons are pushed to one side to avoid excess discomfort. Balance the tension between the hands and adjust the inversion, eversion, traction and abduction components with the underneath hand. The upper hand maintains the firm pressure, and at the optimum moment apply a thrust force to the cuneiform towards the heel.
Tips: Try varying the knee flexion to find the optimum sense of tension in the foot. It generally helps to have the foot closer to the side of the table than the hip so that the leg does not fall into external rotation.
33.28 • Thrust to middle and lateral cuneiforms supine This technique uses a similar principle to the one shown in photograph 33.27. The difference is that the operator is using a reinforced pisiform while a pad is performing the dorsiflexion resistance.
Tips: Most useful where the operator may not be able to develop the force sufficiently with the single-handed grip. The disadvantage is that part of the control of the inversion, eversion and traction is lost.
33.29, 33.30 and 33.31 Thrust to middle or lateral cuneiform supine These three sequence photographs show the foot pulled into dorsiflexion to lock the ankle. The upper hand then fixes the tibia to the table. The thrusting hand is then very rapidly pronated, and before the foot can drop into plantarflexion, it applies a force to the cuneiform with the thenar eminence. Note: This requires very fast movement by the operator to reach the cuneiform before the foot drops. Very few operators can achieve the amount of speed necessary, but if it can be developed, this is an extremely effective technique. If the thrust is performed on the cuneiform after the foot has dropped into plantarflexion, it may be very uncomfortable on the tissues on the front of the ankle.
33.32 and 33.33 • Articulation of medial border prone The foot is grasped with the target joint between the index finger of one hand and the fifth finger of the other. Fix the lateral border of the foot into your chest. Apply a dorsiflexion force with your distal hand, while holding a plantarflexion force with the other. Then reverse the movement.
Tips: Try using abduction or adduction, as well as traction, to amplify the primary levers. Extra considerations: If a suitable barrier accumulates, this hold can develop sufficient tension to perform a thrust.
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