Thrust to tibiotalar joint supine Cup the

calcaneum and pull the foot into a neutral point between plantar and dorsiflexion. Push the tibia with the cephalic hand toward the table and allow the natural recoil of the tissues to cause it to spring back. The plane of the joint is not directly antero-posterior and it will be necessary to slightly internally rotate the hip to produce the optimum resistance for a thrust. If there is a barrier, several priming movements will be necessary before the thrust can be executed.

Tips: Most useful where the patient mentions the symptom that they are unable to achieve comfort in the ankle in any position and feels that the joint needs to 'crack'. Extra considerations: When a satisfactory thrust is attained with this technique, the amplitude of movement within the thrust will often be greater than expected and possibly alarming to the practitioner!

33.2 • Articulation to distal tibio-fibular joint supine Stand at the foot of the table and grasp the tibia and fibula between the index finger and thumb of each hand. Introduce antero-posterior and slight supero-inferior movements.

Tips: Most useful in cases where fibular mobility is particularly relevant, that is most ankle dysfunctions and some knee conditions. Extra considerations: Try dorsi-flexing the foot with the operator's thigh to produce the optimum tension in the joints.

33.5 • Thrust to tibio-talar joint prone Apply some pre-tension to the joint by gripping around the anterior aspect of the ankle while pulling forward on the calcaneum. Maintain a degree of dorsiflexion of the foot with your forearm and when the forces accumulate, execute a sharp adduction of your arms to cause a gapping at the joint.

Tips: Least useful for smaller operators, and for those where the necessary strength may be a problem. Extra considerations: Try circumducting the leg in the build-up to the technique, so that the perception of continuous tension for the patient is not too uncomfortable.

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