Thrust to tibiotalar joint prone Put the

patient's foot over the end of the table and fix the tibia with your cephalic hand while taking up the slack with the other hand pushing down on the calcaneum. You can vary the dorsiflexion to achieve the optimum tension and then apply the thrust toward the floor.

Tips: Most useful for small operators as this technique relies on application of weight rather than use of levers and force. Extra considerations: Try using the operator's inner thigh to produce the relevant amount of dorsiflexion.

33.8 • Traction to tibio-talar joint supine Brace your elbow against your flexed knee on the table under the patient's flexed knee. Use your lower forearm as a fixed lever while your upper hand pulls the foot into dorsiflexion and drives it straight down over the edge of the table. The larger the space between your elbow and the patient's knee the stronger the lever will be to open the tibio-talar articulation.

Tips: Try gently mobilizing the foot in circumduction while it is under traction.

33.9 • Traction to tibio-talar joint supine Brace your elbow against the back of the patient's flexed thigh. Cup the calcaneum in the same hand and fix the talus and the rest of the foot with the other hand. Traction is produced by maintaining these holds and simply leaning back. The push of the patient's flexing thigh against your elbow performs the technique.

Tips: Least useful where the operator's arm is very short and the patient's leg is very long. Extra considerations: Try abducting the hip further as necessary or placing a pad between elbow and thigh.

33.10, 33.11 and 33.12 • (see also next page, top left and bottom left) Articulation to sub-talar joints supine This series shows the overlapping fingers hand hold in the shape of a letter 'W; then the hands applied to the foot can produce inversion, eversion and circumduction to influence the sub-talar joints. The operator viewpoint photographs show the pressure being applied with one thenar eminence and the opposite hypothenar eminence. This is then reversed to gap the medial and lateral sides of the joint respectively.

Tips: Try varying the angle of dorsiflexion using the operator's abdomen against the sole of the foot. Extra considerations: This hold requires a firmer grip than may be apparent; it also requires a good control of rhythm.

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