As a Red Sox fan, it is painstaking to put a picture of pinstripes on my blog, but the recently retired, future Hall of Famer and best closer in the history of Major League Baseball needs to get some love, no matter who you root for.  How does this relate to physical therapy?…

After showing my last intern the talocrural distraction manipulation on a patient who had 2 years of ankle pain with immediate improvement in ankle DF from 5 degrees to 15 degrees, she slated to throw out obscene words from the results, but instead politely uttered a phrse to the extent of:

If I would have known that, I would not have sweated for 20 minutes at my previous clinical to mobilize someone’s ankle.

I verbally express something to the ring of:

Sometimes you have to be like the New York Yankees and bring out the closer

Bottom line, sometimes you have to bring out Mariano Rivera to get the job done.   You don’t need to beat around the bush, but bring in the guy to get results and move on with the treatment. Okay, it sounds better in context but hope you know what I mean.

Most physical therapy training, academically or in continuing education, puts thrust joint manipulation at the bottom of force progression.  It is taught to, “always use as last resort”, “don’t use manipulation if mobilization can suffice”, “patient generated forces are better than clinician generated forces”, etc. The finger gets pointed and shaken your way as if it is shameful of you to use manipulation before mobilization.



Now don’t get me wrong, I am not saying to be a cowboy and manipulate everyone.  But, some joints respond better to mobilizing, and some to manipulating.  Your clinical expertise, the patient’s preference / values in front of you will tell you what is best.  Just don’t always follow the previous image, in many instances, the force progression can be sorted differently.


What do you think? I would like to hear from McKenzie and Maitland trained therapists at least !



  1. The talocrural distraction is one of my favorites! Even my mentor, now an MDT Diplomat, and responsible for starting both the MDT OMPT Fellowship and Daemen College’s OMPT Fellowship, loves that manip! He had to use that to pass his fellowship exam! I agree with manip being put on the bottom. Laurie Hartman, who taught osteopathic component technique to many clinicians prior to his accident said use manipulation as a shortcut. I present it as such… if I ever get around to doing joint work, which I do very little of these days (in lieu of IASTM and other techniques) I present 2 options 1) A very fast, often more comfortable stretch that takes less than 1 second or 2) repeated often less comfortable oscillations for several minutes,,,, which would you choose? Still, if the patient prefers one over the other, I’ll go with that.

    1. Hey Dr. E,
      Thanks for responding and providing such great insight. I think some patients respond better to it, then others do not. I hope to get CPRs or similar decision making tools to assist in detecting which type of patients would respond better.

      I didn’t realize Hartman was in an accident? I took one of his online courses through MedBridge and he was treating…


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