ANKLE:  Tips on increasing mobility

Gaining dorsiflexion in an ankle s/p fracture, especially with internal fixation, can be challenging.  Usually, simple stretching either manually or by the patient is not enough to accomplish a goal of symmetrical range of motion in 4 weeks.  I have had patients sent to me after 4-8 weeks of therapy elsewhere, and they are barely at neutral for DF!  The likelihood of never obtaining full range of motion increases the longer one waits for appropriate treatment.  Besides an obvious limp, think of all the other compensatory motions that will occur in the patients foot/knee/hip/pelvis to compensate for the lack of motion.

In order to achieve dorsiflexion, the wider anterior portion of the talus must  glide in a posterior fashion into the mortise created by the distal tibia and fibula.  In order to accept the talus, the distal tib-fib joint must spread.  Any limitation in either the ability of the talus to glide posteriorily, or the distal tib-fib to spread may limit dorsiflexion.  Make sure that the patient does not have a screw between the tibia and fibula, which will give you a false mobility test and obviously will not loosen!

Prior to mobilizing any joint, I feel it is imperative that you check the opposite side to give you a good idea what the mobility should be (given the opposite side does not have any medical history that would make it invalid).  If you do not have an opposite side to compare, then you will need to draw on your experience to make a judgment.  This is why, when beginning to practice therapy, I assessed mobility on every patient.  They may not have even needed mobility assessment, but I wanted to get a good feel for what is normal and abnormal.  Make sure you do not mobilize a joint that doesn’t need it!  You may achieve a quick success, but the patient will probably pay for it down the road!

Begin with the patient supine, and a towel roll under the achilles area.  Place the web space of your hand onto the anterior portion of the talus.  While locking your elbow, apply a posterior force to push the talus back into the mortise (Picture 1).  Once you have the patient relaxed, you can now rest their metatarsal heads against your thigh.  While gliding posterior,  use your body to push the foot into dorsiflexion, and then add contract-relax techniques (Picture 2).  This is a tiring mobilization and requires a decent amount of strength, but works great!

A method to increase mobility of the distal tib-fib joint is portrayed in Picture 3.  Apply an anterior force to the tibia while countering with a posterior force to the fibula.  Switch directions after about 3 or 4 repetitions.

The oblique MT joint provides a fair amount of DF motion also, so you need to assess the mobility of both the calcaneocuboid joint and talonavicular joints.  Keeping in mind the joint axis runs posterior-lateral-plantar to anterior-medial-dorsal, you can logically deduce the direction of force you need to apply when mobilizing these joints.  Picture 4 shows me mobilizing the talonavicular joint in the direction needed to increase PF.  I have stabilized the talus with the left hand, and use the right to apply the mobilizing force (this is a ball-and-socket type joint with 3 degrees of freedom).  Addressing deficits in these two joints can often result in a marked increase in DF.

Obtaining full inversion and eversion usually come in second after dorsiflexion.  Just remember the input to this motion from the TC, ST, and MT joints.  All these joints are tri-planar, and while some may demonstrate a majority of motion in a certain direction, they still have some input into inversion and eversion.   The ST joint, typically, provides almost equal amounts of frontal plane (IN/EV) motion and transverse plane motion (AD/AB).  Some individuals, according to Manter, Root, and Green, can have significant amounts of variation in their ST axis, ranging from 20-68.5 degrees!

The longitudinal axis of the MT joint allows almost pure IN/EV.  Picture 5 shows the method I use to mobilize this joint.  Keep in mind that the axis for this component of the MT joint lies 15 degrees to the transverse plane and 9 degrees to the sagital.