Name: Proximal Tibiofibular Joint Manipulation
Uploaded: 2023-04-26T01:01:17.000Z
Duration: 11 min 22 s
Description: Learn how to safely and effectively perform Proximal Tibiofibular Joint Manipulation to reduce pain, improve ankle and knee mobility, and enhance lower limb function. This step-by-step video covers assessment techniques, mobilization methods, and integration with strength and stability techniques.

English captions

https://stream.mux.com/uAYWkwLxPcwEKHUBPnUDhiOHRCMdawT00Xoud2kw1CLI.m3u8

 Learn how to safely and effectively perform Proximal Tibiofibular Joint Manipulation to reduce pain, improve ankle and knee mobility, and enhance lower limb function. This step-by-step video covers assessment techniques, mobilization methods, and integration with strength and stability techniques.

Introduction to High-Velocity Thrust Techniques

Assessing for Proximal Tibiofibular Joint Manipulation

Techniques for Manipulating the Fibular Head

Alternative Techniques and Considerations

Close-Up Recap of Manipulation Process

Importance of Assessment and Education in Manipulation

Proximal Tibiofibular Joint Manipulation

This is Brent of the Brookbush Institute and in this video we're going to go over manipulations or high-velocity thrust techniques. I assume that if you're watching this video you're watching it for educational purposes and that you are a licensed professional with high velocity thrust or manipulation techniques in your scope of practice. If you are not sure check with your state board. Most physical therapists, chiropractors and osteopaths you're in the clear. I believe that ATC's you can't do manipulations in the United States, although other countries again check your scope.Of course massage therapists and personal trainers these are generally not within your scope, of course you could continue to watch these videos just for educational purposes, learn a little Anatomy, learn a little biomechanics. If you're going to do these techniques please make sure that you have a good rationale for putting your hands on a patient, this should be based on assessment, and if you're going to assess I'm hoping that you'll assess, use these interventions and reassess to ensure that you're getting the result that you're looking for and have good reason to continue using this technique. In this video we're going to do the proximal tibiofibula joint manipulation. I'm going to have my friend Yvette come out, she's going to help me demonstrate. Now if I'm doing the proximal tibiofibula joint manipulation chances are I'm basing it on a lot more than just subjective symptoms. I want to follow that up with objective tests like maybe my overhead squat assessment, maybe Yvette here had knees bow in, knees bow out or feet turnout on the overhead squat. Something that would lead me to believe that there's some sort of dysfunctional motion happening at the knee joint itself, and then maybe I'd follow up with something as simple as like that hamstring length goniometry so that i had some sort of continuous interval measure to actually address a progress and see some progress over time. So the next and last thing we would do is then palpation, we know palpation is our least reliable assessment but it is really important in the case of this joint. This joint has a tendency to both become stiff in some individuals and hypermobile in other individuals. In fact dislocation of this joint is not a totally uncommon diagnosis, so we have to make sure that we're not doing this technique on individuals that already have a very mobile proximal tibiofibula joint. So the first thing I'm going to show you how to do here is palpate the fibular head, and it's pretty easy. Usually I'll set somebody up at 90-degrees just like I was doing like an anterior or posterior drawer test. I'm going to go ahead and just use a pincer grip, if I go just below the joint line here of the knee you can feel the the fibular head right here. Now if I just grab on either side of my fibular head and give it a wiggle, that's actually pretty stiff right. So if you feel no motion, no wiggle or it's very hard to get it to wiggle that's probably a good indication to do this technique. Now if you grab it and it's pretty easy to wiggle and it's only going to be two or three millimeters, we're not talking about huge motion but that two or three millimeters happens really easy, don't do this technique. There's no need and obviously we don't want to promote hypermobility, that could potentially lead to dislocation which is going to be a whole another set of symptoms that we would have to try to address if that happened. Now the technique itself is pretty quick, and easy once you get the hang of it we're going to use our second MCP which this is a knuckle you need to get very used to using if you're doing manipulations, we're going to put this knuckle right over the fibular head. Now I'm going to show you this again in a close-up recap so don't worry if you can't totally see where I'm putting my hand, but I'm going to put that MCP over the fibular head and then what I'm going to do is I'm going to smash my hand in between Yvette's thigh and her calf. So rather than trying to create a manipulation force this way which is just it's awkward and hard to do that, we can literally just whip her lower leg, use this as kind of like a spacer on her fibula so that we get the rest of her leg moving, and hold her fibula back while we do this thing. You ready to see what that looks like? So for MCP I'm going to get nice and locked up, I want to make sure that I press in and I'm feeling her fibular head right up against that knuckle when I'm in that end range position. Once I know it's going to be there and a little trick, a little clinical gem for you, sometimes it helps to turn the tibia and external rotation. So I'm even further pressing the fibular head into my hand, I get right there, okay I know I'm going to lock out right there. I tell Yvette to give me a nice deep breath, and I mentioned before unless we're doing like spine manipulation, breath doesn't totally matter, but it's a great way to distract your patient so they don't guard on you. So take a deep breath, she takes a deep breath I get all locked out and then, and that's it. It's almost like I'm trying to get her to kick her own butt. Did you see how that worked? It's just that simple, boom. Sometimes you get a cavitation, sometimes you won't. Keep in mind cavitations aren't necessarily the indicator of a successful manipulation, the manipulation and reassessment right, what happened on your reassessment is indication of a successful manipulation. Now there is one other way to do this, right we could have a Yvette go ahead and turn over, and she's going to lie facedown. Now in this case we're going to get a little weird, we're going to use this knuckle against the fibular head, we're going to do the same thing, kind of lock up right, and then we can push down this way and we got a nice little pop there. So we did notice that that side was stiff, I did notice earlier that this side was not. The big problem with this technique and probably why I don't use it very often, is if somebody has any rectus femoris tightness, like you have a very hard time getting their leg far enough that you can actually smash their leg together enough for you to apply enough force to the fibular head. Does that make sense? So if we get here, like you can imagine if she was super tight I'd get here, and then I'd go to do my manipulation and I just don't have, I'm not actually squeezing anything together. So you can try this if somebody's fairly mobile, other than this one particular joint you might be able to get away with that. Otherwise go ahead and flip over back on your back, this tends to be the better technique. So one more time, second MCP over the top of fibular head, you can externally rotate a little bit to feel that fibular head push into that MCP. We're going to get all locked up so we know that when we do our final whip that we're getting pressure where we need it, and then of course once we get there take a nice deep breath and we just do a little, and that's it. All right so we're just swinging the leg a few centimeters to get basically a posterior to anterior force against the fibular head. Stay tuned for your close-up recap. All right for your close-up recap, starting with palpation if we have the knee joint line kind of like right here and this is where you would expect it to be, if we go down a little bit you can feel this bump right about here, that's the fibular head and if you pincer grip it you should be able to move it back and forth. Now of course we're going to base it on additional assessments, but if you were to feel stiffness that might be an indication to do this particular manipulation. What I'm going to try to do is if you see where this finger is right behind the fibular head, I'm now going to try to put my second MCP right there, so I'm going to just put my hand right up in there and getting through all of the soft tissue, and then I might even turn her tibia out. You can see I just kind of turned her foot out there and what I should feel is I turn that out like it presses the fibular head right into my MCP, and then I want to double check to make sure that if I press down is that going to increase tension or increase the amount of force on my MCP, and if I get that check then I'm going to go ahead and tell Yvette to take a deep breath, and I'm going to go ahead and just a real quick, and that's it. Just like she's trying to kick her own butt. I just have to remember to go a few centimeters, again one of the common mistakes that's made on manipulations is probably not moving enough. Although low amplitude means less motion and we're not doing high amplitude manipulations like we would move the whole leg. You still do need to move a good few centimeters to make sure you take up all tissue slack, to make sure that you're moving through all the soft tissue, maybe somebody's clothing and actually getting to the point where all that's left is motion at the bone to force it. So again for second MCP right behind the fibular head, I can even twist the tibia so that I press the fibular head into my MCP and then I'm going to press it up against her thigh make sure I got a good lock position once I'm set up, pop. A couple of points to recap, knowing your Anatomy and knowing your biomechanics will certainly help you choose the right technique for the right patient. If you're unsure whether manipulations are appropriate due to their higher intensity, it's okay to do mobilizations. Most research points to manipulations being slightly more effective, but mobilizations being very effective, and of course we have those videos for you if you want to start with those less intense techniques. Make sure that if you are doing any technique that it's based on assessment, and of course that you're reassessing ensuring that the technique is effective for the patient that you're working on, and when it comes to all manual techniques, manipulations maybe more than any other, look for opportunities to get live education. Although I know videos are convenient and I'm happy to have these up for you to watch, it would be so much more helpful to use those videos as a recap of one-on-one attention with somebody who's experienced with manipulation techniques. At the very least grab a colleague, grab a friend and start practicing these before you bring them into clinic and start using them on patients and clients. I hope you enjoyed this video, if you have any questions please leave them in the comment box below.

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Joint manipulations for the ankle, midfoot, and tibiofibular joint. Types of manipulations, manipulations vs. mobilizations of the cuboid, talonavicular, and proximal tibiofibular joint. Optimal intervention for chronic ankle instability, balance, ankle sprains, vertical jump height, heel pain, knee bow in, knee bow out, feet flatten, feet turn out, excessive forward lean, and asymmetrical weight shift. The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of ankle, midfoot, and tibiofibular manips.

Joint Manipulation: Ankle, Midfoot and Tibiofibular Joint

The patient should be lying supine, closer to the edge of the affected side, with the affected leg flexed at hip and knee.

The table should be at approximately the height of the practitioner's hip.

The practitioner should be standing on the patient's affected side.

Arthrokinematic motion of the proximal tibiofibular joint can be assessed using posterior-to-anterior (PA) or anterior-to-posterior (AP) mobilization. Generally, this is done with a pincer grip, with the patient positioned ready for the manipulation.

If there is no joint play (there is no "wiggle") this technique may be recommended. If the joint moves easily, even just 2 - 3mm, then this technique is not recommended. The proximal tibiofibular joint may become hypomobile or hypermobile. It is never recommended to perform manipulations on hypermobile joints.

Note: If mobilization is the intent, then the position used for 

 may be used for arthrokinematic assessment.

Take a moment to palpate around the fibular head:

Then move distally to identify the patellar ligament.

Fall off the patellar ligament laterally into the soft fat pad that lies deep and lateral to the ligament.

Pressing the fingers into the soft tissue just lateral to the patellar ligament, and sliding the fingers proximally/superiorly, you should feel a bony ridge. This ridge is the tibial plateau.

Trace the tibial plateau to the lateral aspect of the knee and you should abut the rounded end of the fibular head.

Take a moment to palpate around the fibular head, identifying the anterior, proximal, lateral, and posterior surfaces. (The LCL and biceps femoris tendon may also be palpated, as they invest into the posterior aspects of the fibular head).

With the patient's hip and knee flexed, the practitioner will place the hand closest to the patient's hip against the posterior aspect of the knee; in-between the mass of the gastrocnemius and distal hamstrings.

The practitioner will use the other hand to control the patient's lower leg by gripping the distal aspect of the tibia, just proximal to the ankle joint.

The practitioner will then use the 2nd metacarp0phalangeal joint (MCP) to apply posterior to anterior pressure against the posterior surface of the fibular head.

It may be helpful to slightly externally rotate the patient's tibia to aid in pressing the fibular head into the practitioner's 2nd MCP.

The practitioner will achieve "lock-out" position by maximally flexing the patient's knee, pressing the fibular head into the practitioner's 2nd MCP (compressing the entire hand).

Important Note: 90% of manipulation technique is set-up. If you do not feel the fibular head pressed into the MCP, having great "thrust technique" will be rendered useless.

The high-velocity portion of this technique is a quick over-pressure into knee flexion, using the hand that is controlling the lower leg at the ankle.

Essentially, the tibia and fibula are forced posteriorly and the practitioner's 2nd MCP "blocks" the fibular head, resulting in a quick tibia on the fibula anterior to posterior motion (relative posterior to anterior fibula motion).

Note: Remember that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.

Proximal Tibiofibular Joint Manipulation

Cuboid Manipulation

Sacroiliac Joint Chicago Technique

Thoracic Pistol Manipulation

Upper Cervical Manipulation

Radial Head Manipulation

Shotgun (Pubic Symphysis) Manipulation

Lumbar Spine Joint Manipulation (High Velocity Thrust)

Wrist Manipulation

Talocalcaneal Manipulation

Talonavicular and Cuneonavicular Joint Manipulations

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