Bottom left Thrust to cuboid prone

Cross the thumbs under the cuboid and dorsiflex the foot. Maintain the thumb pressure and plantar-flex, invert and adduct the foot with some compression. This hold can be applied to most of the mid tarsal joints by changing the position of the crossed thumbs.

Tips: Ensure the ankle is maintained in dorsiflexion throughout as otherwise the force will dissipate through the ankle joint and the mid tarsal joints will tend to lock in plantarflexion.

33.48 and 33.49 • (see next page, top left and bottom left) Thrust to cuboid prone leg over side Cross the thumbs and apply them under the cuboid. Overlap the fingers on the dorsum of the foot and push with both thenar eminences against the sole to maintain dorsiflexion at the ankle. Keep dorsiflexion constant, and flex and extend the patient's hip and knee. Maintain the tibia in an almost horizontal position and push the leg away and allow it to recoil. Midway through one of these recoil movements drive the thumbs against the cuboid while the fingers produce inversion, adduction and compression.

Tips: Least useful in patients who may find the position a problem. Extra considerations: The coordination necessary for this technique is rather difficult. Note that it is applied as the tibia comes towards the operator, not away. If it is applied as the tibia moves away it becomes an undesirable plantarflexion thrust. It is possible to perform this thrust in simple plantarflexion but there are several disadvantages in this; greater force will be required, it will not be as specific, and the ankle will come under some strain.

33.50 • Articulation to metatarsophalangeal joint of hallux supine Sit and rest the foot across your thigh. Fix the foot, particularly the first metatarsal, with your proximal hand and apply a traction and circumduction force to the first metatarso-phalangeal joint.

Tips: By gripping the distal end of the first metatarsal rather than the phalange the traction force will reach into the medial border of the foot.

33.51 • Traction to hallux supine Grip the first toe between your flexed fingers and hold back on the rest of the foot. This hold permits the use of traction, circumduction and rotation.

Tips: This grip allows a more comfortable hold than a simple clasping of the toe with finger and thumb.

33.52 • Thrust to metatarsophalangeal joints supine Fix on the body of the foot and apply a traction, then plantarflexion force to the toe. Small amounts of circumduction and rotation help localize the force.

Tips: Try using the finger under the toe as a fulcrum rather than just using traction or flexion.

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