Distal Tibiofibular Joint Anterior to Posterior Manual Mobilization

Set-Up

1. The patient should be supine, with heels extending just beyond the end of the table, and the practitioner standing at the end of the table on the patient's affected side.
2. The table should be at a height that allows the practitioner to have elbows extended when the practitioner's chest is over the patient's feet.

Anterior to Posterior Mobilization (Fibula on Tibia)

1. The practitioner can use their thigh to stabilize the foot and control dorsiflexion and inversion.
2. It may be helpful to look at a model or diagram of the distal tibiofibular joint when learning this mobilization technique. Take a moment to feel the details of the distal fibula (lateral malleolus), identify the posterior side of the fibula, the posterior fibular groove, the distal end of the fibula, and the tibiofibular joint line at the anteromedial aspect of the fibula.
3. Assessing joint play is easiest using your fingers, pulling up on the posterior side of the fibula with the fingertips, and pushing down on the anterior surface of the fibula with the thumb; however, this hand position is not recommended for the mobilization technique.
4. To perform the mobilization technique use the hand on the tibia side of the ankle to stabilize the tibia by pressing the tibia into the table using the soft thenar portion of the hand.
5. The other hand will be used to mobilize the fibula. Start by using the thenar eminence to gently pull some tissue from the lateral aspect of the fibula over the anterior portion of the fibula, creating some tissue slack so that skin and cutaneous nerves are not stretched when pressure is applied.
6. Gain purchase on the anterior surface of the lateral malleolus by pressing the lateral malleolus into the thenar eminence.
7. Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips so that the chest is over the affected ankle.
8. Force is generated by leaning forward and using body weight.

Mobilization:

1. Once you are comfortable with the hand position, start with small test oscillations to identify articular motion and any exquisite tenderness.
   • Be especially aware of any burning, tingling, or "electric" type pain, it is easy to accidentally stretch small cutaneous nerves in this area.
2. When satisfied with the feel of the technique, identify the amount of pressure needed to reach the first resistance barrier, just prior to articular motion. Then use more pressure to identify the end of articular motion. The point at which any further pressure fails to increase articular motion is the end of articular range, no additional pressure is required.
3. Identify the mid-point between the first resistance barrier and arthrokinematic end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
     • Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.
   • Grade IV - Small oscillations at 50% resistance.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until change in tissue resistance/joint stiffness is felt.