PERIPHERAL JOINT MOBILIZATION

Dr. Saad Alfawaz

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 Mobilization

• Mobilization is the passive movement of a

joint through its physiological or accessory
ranges of motion using slow, oscillatory
movements or sustained stretch and the patient
has the opportunity to stop the procedure if it
becomes uncomfortable.

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 Joint Mobilization

• Joint mobilization is the use of skilled graded

forces to move a joint in a desired direction.
The technique may use physiologic movement
or accessory movements.

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 Physiological Movement
Movements that the patient can do voluntarily
(e.g., the classic or traditional movements,
such as flexion, abduction, and rotation). The
term osteokinematics is used when these
motions of the bones are described

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 Accessory Movement
• Movements within the joint and surrounding
tissue that are necessary for normal range of
motion but that cannot performed by the
patient, such as component motions and joint
play.

• Component motions: those motions that

accompany active movement but are not under
voluntary control as upward rotation of the
scapula and rotation of the clavicle, which
occur with shoulder flexion.
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• Joint play: is the movement of the bone surface
within the joint allowed by capsular laxity, such
as distraction, sliding, compression and rolling of
the joint surface. They can be demonstrated
passively, but they cannot be performed actively
by the patient. The term arthrokinematics is used
when these motions of the bone surfaces within
the joint are described.

• N O T E: Procedures to distract or slide the joint surfaces

to decrease pain or restore joint play are the fundamental
joint mobilization techniques described in this text.

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• What is the difference between joint
mobilization and manipulation?

• Manipulation
Manipulation is a passive movement performed
using physiologic or accessory motions, which
may be applied with a sudden thrust or when
the patient is under anesthesia. This procedure
is often accompanied by a pop or click which is
the result of the release of pressure in the joint,
similar to cracking one's knuckles.

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 Manipulation under anesthesia :

Is a medical procedure used to restore full

ROM by breaking adhesions around a joint
while the patient is anesthetized. The
technique may be a rapid thrust or a passive
stretch using physiological or accessory
movements.

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 Thrust :
A sudden movement performed with a high
velocity short amplitude motion and the patient
cannot prevent the motion. The motion is
performed at the end of the pathological limit of
the joint and is intended to alter positional
relationships, snap adhesions, or stimulate joint
receptors. Pathological limit means the end of
the available ROM when there is restriction.

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Basic concepts of joint motion: Arthrokinematics:

Joint Shapes
The type of motion occurring between bony partners in a
jt is influenced by the shape of the jt surfaces. The
shape may be described as ovoid or sellar
• In ovoid jts one surface is convex, the other is concave
• In sellar jts, one surface is concave in one direction &
convex in the other, with the opposing surface convex
& concave, respectively; similar to a horseback rider
being in complementary opposition to the shape of a
saddle

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(A)With ovoid joints, one surface is convex, and the
other is concave. (B) With sellar joints, one surface is
concave in one direction and convex in the other,
with the opposing surface convex and concave,
respectively.

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Types of Motion

As a bony lever moves about an axis of motion, there is

also mov of the bone surface on the opposing bone
surface in the jt.

• The mov of the bony lever is called swing & is

classically described as flex, ext, abd, add, and rot. The
amount of mov can be measured in degrees with a
goniometer & is called ROM.

• Motion of the bone surfaces in the jt is a variable

combination of rolling & sliding, or spinning. These
accessory motions allow greater angulation of the bone
as it swings. For the rolling, sliding, or spinning to
occur, there must be adequate capsule laxity or jt play
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Types of Motion of bony surfaces
a. Rolling

• One bone rolls on another. The surfaces are incongruent.

• New points on one surface meet new points on the opposing surface.

• Results in angular motion (swing).

• Always rolling occur in the same direction of the mov.,

whether the surface is convex or concave.

• There’s compression of the surface on the side to which the bone is

angulating & separation on the other side.

• In normal functioning jts, pure rolling doesn’t occur alone, but in

combination with sliding & spinning.

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 b. Slide/Translation

• One bone slides across another.

• For pure slide, the surface must be congruent either flat or

curved.

• There’s no pure slide as jt surfaces aren’t completely

congruent.

• Same point on one surface comes into contact with new

points on the opposing surface.

• Direction of slides depends on whether the surface is

convex or concave.
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Representation of one surface sliding Representation of the concave-convex rule.
on another, whether (A) flat or (B) (A) If the surface of moving bone is convex,
curved. The same point on one surface sliding is in the direction opposite to
comes into contact with new points on that of angular mov of bone.
the opposing surface.
(B) If the surface of the moving bone is
concave, sliding is in the same direction
as the angular mov of bone.

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• N O T E: This mechanical relationship is
known as the convex-concave rule and is the
basis for determining the direction of the
mobilizing force when joint mobilization
gliding techniques are used

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Combined Rolling-Sliding in a Joint

• The more congruent the jt surfaces are, the more sliding there
is of one bony partner on the other with mov.

• The more incongruent the jt surfaces are, the more rolling

there is of one bony partner on the other with mov.

• When ms actively contract to move a bone, some of the ms

may cause or control the sliding mov of the jt surfaces.
For example, the caudal sliding motion of the humeral head
during shoulder abd is caused by the rotator cuff ms, & the
post sliding of tibia during knee flex is caused by hamstring
ms. If this function is lost, the resulting abnormal jt
mechanics may cause microtrauma & jt dysfunction.

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• The joint mobilization techniques described in
this chapter use the sliding component of joint
motion to restore joint play and reverse joint
hypomobility. Rolling (passive angular stretching)
is not used to stretch tight joint capsules because
it causes joint compression.

• N O T E: When the therapist passively moves the

articulating surface using the slide component of
joint motion, the technique is called translatoric
glide, translation, or simply glide. It is used to
control pain when applied gently or to stretch the
capsule when applied with a stretch force.
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Spinning:
Characteristics of one bone spinning on another include
the following.
• There is rot of a segment about a stationary mechanical
axis.

• The same point on the moving surface creates an arc of

a circle as the bone spins.

• Spinning rarely occurs alone in jts but in combination

with rolling & sliding.

• Three examples of spin occurring in jts of the body are:

1. Sh with flex/ext,
2. Hip with flex/ext,
3. RU jt with pron/sup .
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Representation of spinning. There is Examples of joint spin location in the body.
rotation of a segment about a
(A) Humerus with flexion/extension.
stationary mechanical axis.
(B) Femur with flexion/extension.
(C) Head of the radius with pronation/supination

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Passive-Angular Stretching Versus Joint-Glide
Stretching:

Passive-angular stretching procedures, as when the

bony lever is used to stretch a tight jt capsule, may
→ ↑ pain or jt trauma because:

• The use of a lever significantly magnifies the force

at the jt.
• The force → excessive jt compression in the
direction of the rolling bone .
• The roll without a slide does not replicate normal jt
mechanics.

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Joint glide (mobilization) stretching procedures, as when
the translatoric slide component of the bones is used to
stretch a tight capsule, are safer & more selective
because:
• The force is applied close to the jt surface & controlled
at intensity compatible with the pathology.
• The direction of the force replicates the sliding
component of the jt mechanics & does not compress the
cartilage.
• The amplitude of the motion is small yet specific to the
restricted or adherent portion of the capsule or
ligaments. Thus, the forces are selectively applied to the
desired tissue.

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Other Accessory Motions that Affect the Joint
Compression
• Compression is the ↓ in the jt space bet. bony partners.
• Compression normally occurs in the extremity & spinal
jts when wt bearing.
• Some compression occurs as ms contract,
which provides stability to the jts.
• As one bone rolls on the other, some compression also
occurs on the side to which the bone is angulating.
• Normal intermittent compressive loads help move
synovial fluid & thus help maintain cartilage health.
• Abnormally high compression loads may lead to articular
cartilage changes & deterioration

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Traction/Distraction
Traction & distraction are not synonymous. Traction is a
longitudinal pull. Distraction is a separation, or pulling
apart.
• Separation of jt surfaces (distraction) does not always
occur when a traction force is applied to the long axis of a
bone. E.g. if traction is applied to shaft of humerus, it
results in a glide of jt surface (Fig. 7A). Distraction of the
glenohumeral jt requires a pull at right angles to the
glenoid fossa .
• For clarity, whenever there is pulling on the long axis of a
bone, the term long-axis traction is used. Whenever the
surfaces are to be pulled apart, the term distraction, jt
traction, or jt separation is used.

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 Traction/Distraction

(A) Traction applied to humeral shaft results in caudal gliding of

jt surface. (B) Distraction of glenohumeral, jt requires separation
at right angles to the glenoid fossa.

N O T E: For jt mobilization techs, distraction is used to control or relieve pain

when applied gently, or to stretch the capsule when applied with a stretch force. A
slight distraction force is used when applying gliding techniques.

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What Happens to Joints That Lack Motion?

1. When a jt’s mobility is impaired, structure &

function of the region are changed.
2. Cartilage nutrition starts to ↓ within the jt leading to
its atrophy.
3. Muscles surrounding a stiff jt lose their ability to
contract & relax sufficiently & become tight.
4. Soon the whole region is involved in the dysfunction
surrounding the stiff jt.

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Causes of joint restriction

1. Spasm or shortening of surrounding ms

2. Shrinking or adhesion of jt capsule
3. ↓ extensibility of articular & periarticular
tissues
4. Entrapment of fat pads or meniscoides (inner
membrane of jt capsule) between articular
surfaces.

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What Benefits Are Derived From Joint Mobilization?

1. Improved jt mobility
2. Improved jt nutrition
3. Normalized jt function
4. ↓ ms spasms & tension
5. ↓ pain

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Indications of joint mobilization:

1-Pain, Muscle Guarding, and Spasm:

Painful joints, reflex muscle guarding, and muscle
spasm can be treated with gentle joint-play
techniques to stimulate neurophysiological and
mechanical effects

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Neurophysiological Effects:
Small-amplitude oscillatory and distraction movements are
used to stimulate the mechanoreceptors that may inhibit
the transmission of nociceptive stimuli at the spinal cord or
brain stem levels.

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• Mechanical Effects:
• Small-amplitude distraction or gliding movements
of the joint are used to cause synovial fluid
motion, which is the vehicle for bringing nutrients
to the avascular portions of the articular cartilage
(and intra-articular fibrocartilage when present).
• Gentle joint-play techniques help maintain
nutrient exchange and thus prevent the painful
and degenerating effects of stasis when a joint is
swollen or painful and cannot move through the
ROM.

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2-Reversible Joint Hypomobility
Reversible joint hypomobility can be treated with progressively
vigorous joint-play stretching techniques to elongate hypomobile
capsular and ligamentous connective tissue. Sustained or oscillatory
stretch forces are used to distend the shortened tissue mechanically

3-Progressive Limitation
Diseases that progressively limit movement can be treated with
joint-play techniques to maintain available motion or retard
progressive mechanical restrictions. The dosage of distraction or
glide is dictated by the patient’s response to treatment and the state
of the disease.

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4-Functional Immobility
When a patient cannot functionally move a joint for a period of
time, the joint can be treated with non stretch gliding or distraction
techniques to maintain available joint play and prevent the
degenerating and restricting effects of immobility.

Note:
Mobilization techniques cannot change the disease process of
disorders such as rheumatoid arthritis or the inflammatory process
of injury. In these cases, treatment is directed toward minimizing
pain, maintaining available joint play, and reducing the effects of
any mechanical limitations

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Contraindications:
1. Hypermobility due to lig & capsule laxity
2. Acute inflammation (arthritis, synovitis)
3. Joint effusion & swelling
4. Total jt replacement

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 Total Hip
Arthroplasty

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Conditions Requiring Special Precautions:
In most cases, joint mobilization techniques are safer than
passive angular stretching, in which the bony lever is used to
stretch tight tissue and joint compression results. Mobilization
may be used with extreme care in the following conditions if the
signs and the patient’s response are favorable.
• Malignancy
• Bone disease detectable on radiographs
• Unhealed fracture (depends on the site of fracture & stabilization
provided)
• Excessive pain (determine the cause of pain and modify
treatment accordingly)
• Hypermobility in associated joints (associated joints must be
properly stabilized so the mobilization force is not transmitted to
them)

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Conditions Requiring Special Precautions……………………continue

• Newly formed or weakened connective tissue such as

immediately after injury, surgery, or disuse or when the
patient is taking certain medications such as corticosteroids
(gentle progressive techniques within tissue tolerance help
align the developing fibrils, but forceful techniques are
destructive)

• Systemic connective tissue diseases such as rheumatoid

arthritis, in which the disease weakens the connective
tissue (gentle techniques may benefit restricted tissue, but
forceful techniques may rupture tissue and result in
instabilities)
•

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Dosage of mobilization
Mobilizations may be administered in various gradations or
degrees.
Graded oscillation techniques:
This tech may be done using physiologic motions or jt play.
Grade I : Small amplitude rhythmic oscillations are performed at the beginning of
the ROM.
Grade II: Large amplitude rhythmic oscillations are performed within the ROM,
not reaching the limit.
Grade III: Large amplitude rhythmic oscillations are performed up to the limit of
the available ROM.
Grade IV: Small amplitude rhythmic oscillations are performed at the limit of the
available ROM.

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 1. Graded Oscillation Tech. Dosage
Small amplitude rhythmic oscillations
Grade I at the beginning of ROM.

Large amplitude rhythmic oscillations

Grade II within the ROM, but not reaching the limitation.

Large amplitude rhythmic oscillations up to the limit

Grade III of available motion
& stressed into tissue resistance.

Small amplitude rhythmic oscillations, at the limit of

Grade IV the available motion
& stressed into tissue resistance.

Small amplitude, high velocity, thrust tech..

Performed to break adhesions
Grade V
at the level of available motion
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Ahmed Aboeleneen ). (Stretch) 48
 Grade I and II are used for treating joints limited by pain.
The oscillations may have an inhibitory effect on the
perception of painful stimuli by repetitively stimulating
mechanoreceptors that block nociceptive pathways at the
spinal cord or brain stem levels. These non stretch
motions help move synovial fluid to improve nutrition to
the cartilage.

 Grades III and IV are primarily used as stretching

maneuvers.

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Fig. (1): Graded oscillation technique.

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 I
II
III

IV

Graded oscillation
technique

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Sustained joint play technique:
This tech is used only with jt play to separate (traction) or glide
(slide) the jt surfaces.

• Grade I (loosen): Small-amplitude distraction is applied where no stress is

placed on the capsule. It equalizes cohesive forces, muscle tension, and
atmospheric pressure acting on the joint.

• Grade II (tighten): Enough distraction or glide is applied to tighten the

tissues around the joint. Kaltenborn called this “taking up the slack.”

• Grade III (stretch): A distraction or glide is applied with amplitude large

enough to place stretch on the joint capsule and surrounding periarticular
structures.

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Fig. (2): Graded sustained joint play technique
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• Grade I distraction is used with all gliding motions
and may be used for relief of pain.
• Grade II is used for the initial treatment to
determine how sensitive the joint is. Once the joint
reaction is known, the treatment dosage is
increased or decreased accordingly.
• Gentle grade II distraction applied intermittently
may be used to inhibit pain. Grade II glides may be
used to maintain joint play when ROM is not
allowed.
• Grade III distractions or glides are used to stretch
the joint structures and thus increase joint play.

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Grade I is used for relief of pain
Grade II is used for the initial ttt to determine
how sensitive the jt is.
Grade III: is used to stretch the jt structures,
&↑ jt play. I

II

III

Sustained translatory joint-play

technique

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• NOTES:
 The consistency between the dosages of the two grading systems is
grade I (no tension on the joint capsule or surroundings).
 Grade III (sustained stretch) & IV (oscillation) are similar in dosage
as they are applied with a stretch force at the limit of the motion.
 Using oscillating or sustained technique depends on the pt’s
response:
 Pain management: use oscillating technique.
 Loss of joint play & ↓ function: use sustained stretch technique.
 To maintain available ROM: Use either grade II oscillating or II
sustained technique.

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• Treatment Force and Direction of Movement
 The treatment force (either gentle or strong) is applied as close to the
opposing joint surfaces as possible. The larger the contact surface, the more
comfortable is the patient with the procedure. For example, instead of
forcing with your thumb, use the flat surface of your hand.
•
 The direction of movement during treatment is either parallel or
perpendicular to the treatment plane. Treatment plane was described by
Kaltenborn as a plane perpendicular to a line running from the axis of
rotation to the middle of the concave articular surface. The plane is in the
concave partner, so its position is determined by the position of the concave
bone (Fig. 10).

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Treatment plane (T.P.) is at right angles to a line drawn from the axis of
rotation to the center of the concave articulating surface and lies in the
concave surface. Joint traction (distraction) is applied perpendicular to and
glides parallel to the treatment plane

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 Distraction techniques are applied perpendicular to the treatment plane. The
entire bone is moved so the join surfaces are separated.
 Gliding techniques are applied parallel to the treatment plane. The direction
of gliding is easily determined by using the convex-concave rule. If the
surface of the moving bony partner is convex, the treatment glide should be
opposite to the direction in which the bone swings. If the surface of the
moving bony partner is concave, the treatment glide should be in the same
direction.
 The entire bone is moved so there is gliding of one joint surface on the
other. The bone should not be used as a lever; it should have no arcing
motion (swing), which would cause rolling and thus compression of the
joint surfaces.

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 websites
• https://youtu.be/usSpH97eO6c
• https://www.youtube.com/watch?v=hKjQw-
blrZ4
• https://www.youtube.com/watch?v=Iw-tkXYL-
B8
• https://www.youtube.com/watch?v=wUUSZW
tvB6M

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