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Distal Tibiofibular Joint Anterior to Posterior Manual Mobilization

This video will demonstrate the steps to safely perform large amplitude manual mobilizations of the distal tibiofibular joint - an effective treatment to restore range of motion and reduce pain.

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00:05 - 00:07This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
00:07 - 00:11based manual therapy technique. If you're watching this video I'm assuming you're
00:11 - 00:14watching it for educational purposes, and that you are a licensed professional
00:14 - 00:20with joint based techniques within your scope. That means osteopath's, chiropractors,
00:20 - 00:24physical therapists, you're probably all in the clear. Physical therapy assistants,
00:24 - 00:28athletic trainers, massage therapist's, you need to check with your governing body
00:28 - 00:32in your state or region to see whether this is within your scope of practice.
00:32 - 00:36Personal trainers this is definitely not within your scope of practice. Of course
00:36 - 00:41all professions could use this video for purely educational purposes to help with
00:41 - 00:46learning biomechanics, anatomy and of course palpation. In this video we're
00:46 - 00:50going to do an anterior to posterior fibula tibia mobilization, that's the
00:50 - 00:53distal tibiofibular joint. I'm going to have my friend Melissa come out, she's
00:53 - 00:57going to help me demonstrate. Now this technique makes a great ancillary
00:57 - 01:00technique to a technique we did in a previous video, which was the anterior to
01:00 - 01:05posterior talus on tibia mobilization. The hypothesis being that the lateral
01:05 - 01:10malleolus or distal fibula, has to follow the talus posteriorly as we dorsiflex
01:10 - 01:14the ankle. So with that being said, although we want to do a passive
01:14 - 01:18accessory motion exam and make sure that we have arthrokinematic stiffness
01:18 - 01:22in the direction that we're trying to mobilize, you might also do this
01:22 - 01:28technique as a means of maintaining, or trying to gain optimal dorsiflexion. Now
01:28 - 01:33the position you're going to be in for this technique is going to be foot on
01:33 - 01:38thigh; and the reason being is I want to be able to control dorsiflexion with my
01:38 - 01:42thigh, and have both hands-free for this mobilization. I need one hand to
01:42 - 01:46stabilize the tibia, and the other one to actually mobilize the fibula. You guys
01:46 - 01:50can see here just by leaning forward I can actually push Melissa into a
01:50 - 01:55few degrees of dorsiflexion. I can even control eversion and inversion a little
01:55 - 02:01bit just by swaying, to make sure she's neutral. The palpation portion of this is
02:01 - 02:06not totally complicated, but it is important that you guys kind of look
02:06 - 02:12over your Anatomy, and you practice putting your hands down on the ankle and
02:12 - 02:17trying to identify that Anatomy, specifically the lateral malleolus. For
02:17 - 02:20this technique it's important that you not
02:20 - 02:26only can find the lateral malleolus, but that you know the contours and edges of
02:26 - 02:31the lateral malleolus. So find your lateral malleolus, find the bottom of the
02:31 - 02:35lateral malleolus. So make sure you can feel that, go ahead and go to the
02:35 - 02:40posterior part of the lateral malleolus, and you should feel a groove in the back
02:40 - 02:44of the lateral malleolus, where your fibularis tendon runs through, and you
02:44 - 02:48might be able to feel that a little bit. Go to the front of the lateral malleolus
02:48 - 02:53and you'll notice that you run into a couple of tendons, those are the tendons
02:53 - 03:01of your long toe extensors, but if you press into that soft tissue just a
03:01 - 03:05little bit, you might be able to feel the joint line. Now the joint line is a nice
03:05 - 03:11thing to feel for this technique, because what we want to see is does the fibula
03:11 - 03:16move a little bit on the tibia, that's all we're trying to feel, does the fibula
03:16 - 03:24wiggle. If we have no wiggle we need to mobilize, if we have lots of wiggle then
03:24 - 03:28we don't want to mobilize. This joint the research kind of shows has one of two
03:28 - 03:35propensities right, either gets stiff or it becomes hypermobile. It's important
03:35 - 03:39that if we feel hypermobility, you feel more than a millimeter of motion here,
03:39 - 03:43it's really easy to wiggle this joint, this is not a technique you're going to
03:43 - 03:51do. Now if you feel good about your palpation, and you try to move the fibula
03:51 - 03:56it doesn't seem to move, that's a good sign that you have stiffness and that
03:56 - 04:00you probably should mobilize. It's really that simple, we don't need to get into
04:00 - 04:06grades of stiffness or anything, it's just does it feel like it barely moves
04:06 - 04:15or does it wiggle a lot. If it wiggles a lot, don't do this. Now once you felt
04:15 - 04:20the motion of the fibula, and you guys can see here I'm just kind of lifting it
04:20 - 04:26with these fingers, pushing it down with these fingers trying to kind of get my
04:26 - 04:32hands like right up against the joint line, maybe put the rest of my hand on
04:32 - 04:39the tibia here so that I can feel the amount of motion I have. Now Melissa's a
04:39 - 04:44little stiff. I would not do the mobilization with that same hand
04:44 - 04:49position guys. It's a little hard to feel how much movement you have with the
04:49 - 04:53technique I'm going to show you, but using your fingertips to do
04:53 - 04:59mobilizations just leads to pain. Just pushing your thumb down into this bony
04:59 - 05:05prominence is going to make somebody cringe. You have to be careful alright,
05:05 - 05:10trying to do something like this, is not a great idea. What we're actually going
05:10 - 05:15to do is use our thenar eminence here, try to get as much surface area on the
05:15 - 05:19lateral malleolus as we possibly can. What that usually ends up leading to is
05:19 - 05:23we we do a little bit of mobilization, and then we check with our fingertips,
05:23 - 05:28and we do a little mobilization, and then we check with our fingertips. So
05:28 - 05:33again how are we going to do this technique? We're going to use our thenar
05:33 - 05:38eminence, we're going to come over the top of our lateral malleolus. Now my
05:38 - 05:44suggestion is, is as you do this you're going to pick up a little bit of skin,
05:44 - 05:50before you press down. Alright so you guys I'm kind of smooshing some skin up
05:50 - 05:55this way, before I push down this way. The reason being is if I grab a bunch of
05:55 - 05:59skin and then pull down this way I stretch the skin out, and then I go to
05:59 - 06:02push down and it stretches the skin even more, and that becomes really
06:02 - 06:05uncomfortable. We want this to be as comfortable as possible otherwise
06:05 - 06:09they're going to guard and this technique is going to be really really challenging.
06:09 - 06:14Now the other contraindication that you have to be aware of, is you can really
06:14 - 06:18send a nice little shock up somebody's leg, give somebody a nice little burn,
06:18 - 06:24give somebody a really intense pinch by getting on that peroneal nerve. Of course
06:24 - 06:29if you do that this nerve is not gigantic, it's it's very very narrow,
06:29 - 06:33we're talking like a millimeter wide so you should be able to move your hand
06:33 - 06:39around and get off it pretty easy. So I'm going to take my hand here, I'm going to
06:39 - 06:44wrap it around Melissa's calcaneus, I'm going to make
06:44 - 06:48sure that calcaneus is off the table so that I don't crunch my hand when I
06:48 - 06:54start pushing down. I'm then going to grab a little bit of skin, just kind of
06:54 - 07:00slide my hand up this way, then put my thenar eminence over the top of her
07:00 - 07:05lateral malleolus, I'm going to kind of push her into dorsiflexion, this hand I'm
07:05 - 07:11going to stabilize her tibia with, and then I'm going to use, you guys notice
07:11 - 07:17I'm leaned forward here again, I'm just going to use my bodyweight to rock into
07:17 - 07:23this mobilization. Now I mentioned in previous videos I'm a Maitland certified
07:23 - 07:28orthopedic manual therapist, the protocols I know are the grades 1, 2, 3 &
07:28 - 07:364. Grade 3 & 4 being at 50% between the initial resistance and end of arthro-
07:36 - 07:42kinematic range. If you guys have a different protocol that's fine, just make sure that
07:42 - 07:45you are disciplined about using that protocol, that you assess, address and
07:45 - 07:51reassess. If I went through this with my protocol, I'm going to go through
07:51 - 07:56everything I just told you, grab the calcaneus, take up some skin, push down on
07:56 - 08:02that lateral malleolus, ask my client did you, in any pain? This comfortable? Okay
08:02 - 08:06I'm going to find that first resistance barrier, once I find that first
08:06 - 08:11resistance barrier I'm going to start testing down, watching my clients face
08:11 - 08:16making sure she doesn't cringe on me, until I find the end. Notice that as I'm
08:16 - 08:23pushing down I have Melissa in at least neutral dorsiflexion with my thigh, so I
08:23 - 08:29have good control of her foot and ankle, and then once I find first resistance
08:29 - 08:37barrier, I find the end, I back off to 50%, now I'm just going to do 1 to 2
08:37 - 08:45set, 1 to 2 pulses per second until I feel a change in arthrokinematic
08:45 - 08:50stiffness. Now I mentioned a little earlier in this video, that is tough to
08:50 - 08:54feel with my thenar eminence, chances are I'm going to go back and check with
08:54 - 09:00my fingertips to see if I got an increase in range of motion.
09:00 - 09:09That's arthrokinematic range-of-motion though. So we'll do this for 30 seconds, and then
09:09 - 09:14I'm just going to use my fingertips here, did I get more range? If I got more range
09:14 - 09:19great, if I didn't I might go back and do another set, or another two sets, and then
09:19 - 09:21of course I'm going to want to follow this up with something a little bit more
09:21 - 09:26reliable than passive accessory motion exam, maybe I do my dorsiflexion
09:26 - 09:32goniometery. Alright so to go through hand position one more time, or body
09:32 - 09:39position and hand position; foot on thigh, neutral or slightly dorsiflexed, this
09:39 - 09:44hand's going to cup the calcaneus, pick up just a little bit of skin just kind
09:44 - 09:49of sliding up the side of the ankle here, and then press down over the front of
09:49 - 09:54the lateral malleolus, this hand is going to stabilize the tibia, and then I'm just
09:54 - 10:00going to find 50% between initial resistance and end of arthrokinematic
10:00 - 10:08range, back off to 50. I'm going to do my, this is going to be a grade 3 here
10:08 - 10:15alright. So I'm going to take up almost back to zero in resistance and down into
10:15 - 10:2450%. See if I can get a change in stiffness, check with my fingers. If I feel
10:24 - 10:28like I've got a change in stiffness maybe I'd follow that up with a dorsiflexion
10:28 - 10:32range of motion for goniometery, or maybe more of like a functional
10:32 - 10:35assessment like the overhead squat assessment. So in our close-up recap
10:35 - 10:39you'll notice my thighs against Melissa's foot here so that I can
10:39 - 10:45control dorsiflexion as well as eversion and inversion, and you can see
10:45 - 10:49her lateral malleolus right here. Now of course to assess this joint I
10:49 - 10:54talked about just using the fingertips, getting your thumb kind of on the joint
10:54 - 11:00line here. So if I start on her lateral malleolus and then fall off pushing the
11:00 - 11:05tendons of her long toe extensors over, I can kind of feel the joint line and then
11:05 - 11:10I'll usually just take these few fingers and kind of push up while my thumb
11:10 - 11:15pushes down, see if there's any wiggle there; and then here's the really
11:15 - 11:20important point that I was trying to make in the the further away shot, is as
11:20 - 11:25you're going to mobilize this joint it's important that you kind of slide your
11:25 - 11:30hand up this way, and you can see how her skin kind of crunches up, so that when I
11:30 - 11:34press down her skin is back to its normal length, whereas if I pull down
11:34 - 11:41from here, you can see I stretch out her skin trying to get pressure over the
11:41 - 11:48anterior surface of her lateral malleolus. Now I'm going to come up like this, press
11:48 - 11:53down, ask Melissa if she feels any pain, if she feels any tingling burning right,
11:53 - 11:58we don't want to stretch that nerve. I can use the other hand to stabilize her
11:58 - 12:05tibia, and then I can kind of find my resistance point, so first resistance end
12:05 - 12:10of arthrokinematic range, and then of course all of our mobilization protocols
12:10 - 12:15end up somewhere in the middle. I'll go from zero to 50% and a little larger
12:15 - 12:21amplitude doing my grade three. I'll go for thirty seconds until I think I feel
12:21 - 12:28a change in stiffness, and then I can go back to my assessment position of
12:28 - 12:34feeling the joint line, seeing if I got any wiggle back. Alright guys so get
12:34 - 12:40familiar with your lateral malleolus, feel all of its surfaces, find the the
12:40 - 12:46inferior border, find the anterior border, try to feel that joint line, really try
12:46 - 12:50to grab ahold of it with your fingertips, gently of course, so you don't hurt your
12:50 - 12:54patient, client, or partner you're practicing on. Stabilize the tibia with
12:54 - 13:00one hand, pick up a little tissue, make sure you follow through on your
13:00 - 13:06protocols, and of course at the end of your technique make sure you assess. So
13:06 - 13:10there you have it; assess, address, reassess. Make sure that
13:10 - 13:14every time you choose a joint based manual therapy technique it is based on
13:14 - 13:18an assessment, and that you return to that assessment after you've finished
13:18 - 13:23the intervention to see if it was effective for the individual, the patient
13:23 - 13:27or clients that you had in front of you. Ensure that you continue to
13:27 - 13:31learn your Anatomy because your Anatomy is going to help you with your hand
13:31 - 13:37placement, with understanding what a joint can do, with understanding what you
13:37 - 13:43may gain from this particular technique, and of course practice. You have to
13:43 - 13:47practice these techniques, hopefully not for the first time on a patient or
13:47 - 13:52client who just walked in the door. If you can find a more senior instructor or
13:52 - 13:58mentor to give you some really good hands-on instruction, use your peers for
13:58 - 14:06some good feedback, and of course always look for live education to help with
14:06 - 14:10your manual therapy techniques. I know these videos make education very
14:10 - 14:16convenient, but there is no substitute for learning manual therapy in a live
14:16 - 14:20setting. I look forward to talking to you guys again soon.
14:27 - 14:29

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