0:05 This is Brent of the Brookbush Institute, and in this video we're going to go over a joint 0:07 based manual therapy technique. If you're watching this video I'm assuming you're 0:11 watching it for educational purposes, and that you are a licensed professional 0:14 with joint based techniques within your scope. That means osteopath's, chiropractors, 0:20 physical therapists, you're probably all in the clear. Physical therapy assistants, 0:24 athletic trainers, massage therapist's, you need to check with your governing body 0:28 in your state or region to see whether this is within your scope of practice. 0:32 Personal trainers this is definitely not within your scope of practice. Of course 0:36 all professions could use this video for purely educational purposes to help with 0:41 learning biomechanics, anatomy and of course palpation. In this video we're 0:46 going to do an anterior to posterior fibula tibia mobilization, that's the 0:50 distal tibiofibular joint. I'm going to have my friend Melissa come out, she's 0:53 going to help me demonstrate. Now this technique makes a great ancillary 0:57 technique to a technique we did in a previous video, which was the anterior to 1:00 posterior talus on tibia mobilization. The hypothesis being that the lateral 1:05 malleolus or distal fibula, has to follow the talus posteriorly as we dorsiflex 1:10 the ankle. So with that being said, although we want to do a passive 1:14 accessory motion exam and make sure that we have arthrokinematic stiffness 1:18 in the direction that we're trying to mobilize, you might also do this 1:22 technique as a means of maintaining, or trying to gain optimal dorsiflexion. Now 1:28 the position you're going to be in for this technique is going to be foot on 1:33 thigh; and the reason being is I want to be able to control dorsiflexion with my 1:38 thigh, and have both hands-free for this mobilization. I need one hand to 1:42 stabilize the tibia, and the other one to actually mobilize the fibula. You guys 1:46 can see here just by leaning forward I can actually push Melissa into a 1:50 few degrees of dorsiflexion. I can even control eversion and inversion a little 1:55 bit just by swaying, to make sure she's neutral. The palpation portion of this is 2:01 not totally complicated, but it is important that you guys kind of look 2:06 over your Anatomy, and you practice putting your hands down on the ankle and 2:12 trying to identify that Anatomy, specifically the lateral malleolus. For 2:17 this technique it's important that you not 2:20 only can find the lateral malleolus, but that you know the contours and edges of 2:26 the lateral malleolus. So find your lateral malleolus, find the bottom of the 2:31 lateral malleolus. So make sure you can feel that, go ahead and go to the 2:35 posterior part of the lateral malleolus, and you should feel a groove in the back 2:40 of the lateral malleolus, where your fibularis tendon runs through, and you 2:44 might be able to feel that a little bit. Go to the front of the lateral malleolus 2:48 and you'll notice that you run into a couple of tendons, those are the tendons 2:53 of your long toe extensors, but if you press into that soft tissue just a 3:01 little bit, you might be able to feel the joint line. Now the joint line is a nice 3:05 thing to feel for this technique, because what we want to see is does the fibula 3:11 move a little bit on the tibia, that's all we're trying to feel, does the fibula 3:16 wiggle. If we have no wiggle we need to mobilize, if we have lots of wiggle then 3:24 we don't want to mobilize. This joint the research kind of shows has one of two 3:28 propensities right, either gets stiff or it becomes hypermobile. It's important 3:35 that if we feel hypermobility, you feel more than a millimeter of motion here, 3:39 it's really easy to wiggle this joint, this is not a technique you're going to 3:43 do. Now if you feel good about your palpation, and you try to move the fibula 3:51 it doesn't seem to move, that's a good sign that you have stiffness and that 3:56 you probably should mobilize. It's really that simple, we don't need to get into 4:00 grades of stiffness or anything, it's just does it feel like it barely moves 4:06 or does it wiggle a lot. If it wiggles a lot, don't do this. Now once you felt 4:15 the motion of the fibula, and you guys can see here I'm just kind of lifting it 4:20 with these fingers, pushing it down with these fingers trying to kind of get my 4:26 hands like right up against the joint line, maybe put the rest of my hand on 4:32 the tibia here so that I can feel the amount of motion I have. Now Melissa's a 4:39 little stiff. I would not do the mobilization with that same hand 4:44 position guys. It's a little hard to feel how much movement you have with the 4:49 technique I'm going to show you, but using your fingertips to do 4:53 mobilizations just leads to pain. Just pushing your thumb down into this bony 4:59 prominence is going to make somebody cringe. You have to be careful alright, 5:05 trying to do something like this, is not a great idea. What we're actually going 5:10 to do is use our thenar eminence here, try to get as much surface area on the 5:15 lateral malleolus as we possibly can. What that usually ends up leading to is 5:19 we we do a little bit of mobilization, and then we check with our fingertips, 5:23 and we do a little mobilization, and then we check with our fingertips. So 5:28 again how are we going to do this technique? We're going to use our thenar 5:33 eminence, we're going to come over the top of our lateral malleolus. Now my 5:38 suggestion is, is as you do this you're going to pick up a little bit of skin, 5:44 before you press down. Alright so you guys I'm kind of smooshing some skin up 5:50 this way, before I push down this way. The reason being is if I grab a bunch of 5:55 skin and then pull down this way I stretch the skin out, and then I go to 5:59 push down and it stretches the skin even more, and that becomes really 6:02 uncomfortable. We want this to be as comfortable as possible otherwise 6:05 they're going to guard and this technique is going to be really really challenging. 6:09 Now the other contraindication that you have to be aware of, is you can really 6:14 send a nice little shock up somebody's leg, give somebody a nice little burn, 6:18 give somebody a really intense pinch by getting on that peroneal nerve. Of course 6:24 if you do that this nerve is not gigantic, it's it's very very narrow, 6:29 we're talking like a millimeter wide so you should be able to move your hand 6:33 around and get off it pretty easy. So I'm going to take my hand here, I'm going to 6:39 wrap it around Melissa's calcaneus, I'm going to make 6:44 sure that calcaneus is off the table so that I don't crunch my hand when I 6:48 start pushing down. I'm then going to grab a little bit of skin, just kind of 6:54 slide my hand up this way, then put my thenar eminence over the top of her 7:00 lateral malleolus, I'm going to kind of push her into dorsiflexion, this hand I'm 7:05 going to stabilize her tibia with, and then I'm going to use, you guys notice 7:11 I'm leaned forward here again, I'm just going to use my bodyweight to rock into 7:17 this mobilization. Now I mentioned in previous videos I'm a Maitland certified 7:23 orthopedic manual therapist, the protocols I know are the grades 1, 2, 3 & 7:28 4. Grade 3 & 4 being at 50% between the initial resistance and end of arthro- 7:36 kinematic range. If you guys have a different protocol that's fine, just make sure that 7:42 you are disciplined about using that protocol, that you assess, address and 7:45 reassess. If I went through this with my protocol, I'm going to go through 7:51 everything I just told you, grab the calcaneus, take up some skin, push down on 7:56 that lateral malleolus, ask my client did you, in any pain? This comfortable? Okay 8:02 I'm going to find that first resistance barrier, once I find that first 8:06 resistance barrier I'm going to start testing down, watching my clients face 8:11 making sure she doesn't cringe on me, until I find the end. Notice that as I'm 8:16 pushing down I have Melissa in at least neutral dorsiflexion with my thigh, so I 8:23 have good control of her foot and ankle, and then once I find first resistance 8:29 barrier, I find the end, I back off to 50%, now I'm just going to do 1 to 2 8:37 set, 1 to 2 pulses per second until I feel a change in arthrokinematic 8:45 stiffness. Now I mentioned a little earlier in this video, that is tough to 8:50 feel with my thenar eminence, chances are I'm going to go back and check with 8:54 my fingertips to see if I got an increase in range of motion. 9:00 That's arthrokinematic range-of-motion though. So we'll do this for 30 seconds, and then 9:09 I'm just going to use my fingertips here, did I get more range? If I got more range 9:14 great, if I didn't I might go back and do another set, or another two sets, and then 9:19 of course I'm going to want to follow this up with something a little bit more 9:21 reliable than passive accessory motion exam, maybe I do my dorsiflexion 9:26 goniometery. Alright so to go through hand position one more time, or body 9:32 position and hand position; foot on thigh, neutral or slightly dorsiflexed, this 9:39 hand's going to cup the calcaneus, pick up just a little bit of skin just kind 9:44 of sliding up the side of the ankle here, and then press down over the front of 9:49 the lateral malleolus, this hand is going to stabilize the tibia, and then I'm just 9:54 going to find 50% between initial resistance and end of arthrokinematic 10:00 range, back off to 50. I'm going to do my, this is going to be a grade 3 here 10:08 alright. So I'm going to take up almost back to zero in resistance and down into 10:15 50%. See if I can get a change in stiffness, check with my fingers. If I feel 10:24 like I've got a change in stiffness maybe I'd follow that up with a dorsiflexion 10:28 range of motion for goniometery, or maybe more of like a functional 10:32 assessment like the overhead squat assessment. So in our close-up recap 10:35 you'll notice my thighs against Melissa's foot here so that I can 10:39 control dorsiflexion as well as eversion and inversion, and you can see 10:45 her lateral malleolus right here. Now of course to assess this joint I 10:49 talked about just using the fingertips, getting your thumb kind of on the joint 10:54 line here. So if I start on her lateral malleolus and then fall off pushing the 11:00 tendons of her long toe extensors over, I can kind of feel the joint line and then 11:05 I'll usually just take these few fingers and kind of push up while my thumb 11:10 pushes down, see if there's any wiggle there; and then here's the really 11:15 important point that I was trying to make in the the further away shot, is as 11:20 you're going to mobilize this joint it's important that you kind of slide your 11:25 hand up this way, and you can see how her skin kind of crunches up, so that when I 11:30 press down her skin is back to its normal length, whereas if I pull down 11:34 from here, you can see I stretch out her skin trying to get pressure over the 11:41 anterior surface of her lateral malleolus. Now I'm going to come up like this, press 11:48 down, ask Melissa if she feels any pain, if she feels any tingling burning right, 11:53 we don't want to stretch that nerve. I can use the other hand to stabilize her 11:58 tibia, and then I can kind of find my resistance point, so first resistance end 12:05 of arthrokinematic range, and then of course all of our mobilization protocols 12:10 end up somewhere in the middle. I'll go from zero to 50% and a little larger 12:15 amplitude doing my grade three. I'll go for thirty seconds until I think I feel 12:21 a change in stiffness, and then I can go back to my assessment position of 12:28 feeling the joint line, seeing if I got any wiggle back. Alright guys so get 12:34 familiar with your lateral malleolus, feel all of its surfaces, find the the 12:40 inferior border, find the anterior border, try to feel that joint line, really try 12:46 to grab ahold of it with your fingertips, gently of course, so you don't hurt your 12:50 patient, client, or partner you're practicing on. Stabilize the tibia with 12:54 one hand, pick up a little tissue, make sure you follow through on your 13:00 protocols, and of course at the end of your technique make sure you assess. So 13:06 there you have it; assess, address, reassess. Make sure that 13:10 every time you choose a joint based manual therapy technique it is based on 13:14 an assessment, and that you return to that assessment after you've finished 13:18 the intervention to see if it was effective for the individual, the patient 13:23 or clients that you had in front of you. Ensure that you continue to 13:27 learn your Anatomy because your Anatomy is going to help you with your hand 13:31 placement, with understanding what a joint can do, with understanding what you 13:37 may gain from this particular technique, and of course practice. You have to 13:43 practice these techniques, hopefully not for the first time on a patient or 13:47 client who just walked in the door. If you can find a more senior instructor or 13:52 mentor to give you some really good hands-on instruction, use your peers for 13:58 some good feedback, and of course always look for live education to help with 14:06 your manual therapy techniques. I know these videos make education very 14:10 convenient, but there is no substitute for learning manual therapy in a live 14:16 setting. I look forward to talking to you guys again soon. 14:27
