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Proximal Tibiofibular Joint Manipulation

Relieve tibiofibular joint pain and increase mobility with our video on Proximal Tibiofibular Joint Manipulation. Learn how to assess, mobilize, and strengthen for improved function.

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00:04 - 00:07This is Brent of the Brookbush Institute and in this video we're going to go over
00:07 - 00:11manipulations or high-velocity thrust techniques. I assume that if you're
00:11 - 00:14watching this video you're watching it for educational purposes and that you
00:14 - 00:18are a licensed professional with high velocity thrust or manipulation
00:18 - 00:24techniques in your scope of practice. If you are not sure check with your state
00:24 - 00:28board. Most physical therapists, chiropractors and osteopaths you're in
00:28 - 00:33the clear. I believe that ATC's you can't do manipulations in the United States,
00:33 - 00:38although other countries again check your scope.Of course massage therapists
00:38 - 00:41and personal trainers these are generally not within your scope, of
00:41 - 00:47course you could continue to watch these videos just for educational purposes,
00:47 - 00:51learn a little Anatomy, learn a little biomechanics. If you're going to do these
00:51 - 00:56techniques please make sure that you have a good rationale for putting your
00:56 - 01:00hands on a patient, this should be based on assessment, and if you're going to
01:00 - 01:06assess I'm hoping that you'll assess, use these interventions and reassess to
01:06 - 01:09ensure that you're getting the result that you're looking for and have good
01:09 - 01:12reason to continue using this technique. In this video we're going to do the
01:12 - 01:16proximal tibiofibula joint manipulation. I'm going to have my friend Yvette come out,
01:16 - 01:20she's going to help me demonstrate. Now if I'm doing the proximal tibiofibula
01:20 - 01:24joint manipulation chances are I'm basing it on a lot more
01:24 - 01:28than just subjective symptoms. I want to follow that up with objective tests like
01:28 - 01:34maybe my overhead squat assessment, maybe Yvette here had knees bow in, knees bow
01:34 - 01:38out or feet turnout on the overhead squat. Something that would lead me to
01:38 - 01:42believe that there's some sort of dysfunctional motion happening at the
01:42 - 01:46knee joint itself, and then maybe I'd follow up with something as simple as
01:46 - 01:49like that hamstring length goniometry so that i had some sort of
01:49 - 01:54continuous interval measure to actually address a progress and see some progress
01:54 - 01:59over time. So the next and last thing we would do is then palpation, we know
01:59 - 02:02palpation is our least reliable assessment but it is really important in
02:02 - 02:06the case of this joint. This joint has a tendency to both become stiff in some
02:06 - 02:13individuals and hypermobile in other individuals. In fact dislocation of this
02:13 - 02:17joint is not a totally uncommon diagnosis, so we have to make sure that
02:17 - 02:20we're not doing this technique on individuals that
02:20 - 02:25already have a very mobile proximal tibiofibula joint. So the first thing
02:25 - 02:30I'm going to show you how to do here is palpate the fibular head, and it's
02:30 - 02:34pretty easy. Usually I'll set somebody up at 90-degrees just like I was doing like
02:34 - 02:39an anterior or posterior drawer test. I'm going to go ahead and just
02:39 - 02:44use a pincer grip, if I go just below the joint line here of the knee you can
02:44 - 02:50feel the the fibular head right here. Now if I just grab on either side of my
02:50 - 02:56fibular head and give it a wiggle, that's actually pretty stiff right. So if
02:56 - 03:00you feel no motion, no wiggle or it's very hard to get it to wiggle
03:00 - 03:07that's probably a good indication to do this technique. Now if you grab it and
03:07 - 03:10it's pretty easy to wiggle and it's only going to be two or three millimeters,
03:10 - 03:14we're not talking about huge motion but that two or three millimeters happens
03:14 - 03:19really easy, don't do this technique. There's no need and obviously we don't
03:19 - 03:22want to promote hypermobility, that could potentially lead to
03:22 - 03:25dislocation which is going to be a whole another set of symptoms that we would
03:25 - 03:31have to try to address if that happened. Now the technique itself is pretty quick,
03:31 - 03:37and easy once you get the hang of it we're going to use our second MCP which
03:37 - 03:42this is a knuckle you need to get very used to using if you're doing
03:42 - 03:48manipulations, we're going to put this knuckle right over the fibular head. Now
03:48 - 03:51I'm going to show you this again in a close-up recap so don't worry if you
03:51 - 03:56can't totally see where I'm putting my hand, but I'm going to put that MCP over the
03:56 - 04:03fibular head and then what I'm going to do is I'm going to smash my hand in between
04:03 - 04:08Yvette's thigh and her calf. So rather than trying to create a manipulation
04:08 - 04:13force this way which is just it's awkward and hard to do that, we can
04:13 - 04:19literally just whip her lower leg, use this as kind of like a
04:19 - 04:25spacer on her fibula so that we get the rest of her leg moving, and hold
04:25 - 04:30her fibula back while we do this thing. You ready to see what that looks
04:30 - 04:32like? So for
04:32 - 04:37MCP I'm going to get nice and locked up, I want to make sure that I press in and
04:37 - 04:44I'm feeling her fibular head right up against that knuckle when I'm in that
04:44 - 04:48end range position. Once I know it's going to be there and a little trick, a
04:48 - 04:52little clinical gem for you, sometimes it helps to turn the tibia and
04:52 - 04:56external rotation. So I'm even further pressing the fibular head into
04:56 - 05:00my hand, I get right there, okay I know I'm going to lock out right there.
05:00 - 05:04I tell Yvette to give me a nice deep breath, and I mentioned before
05:04 - 05:10unless we're doing like spine manipulation, breath doesn't totally matter, but it's a
05:10 - 05:14great way to distract your patient so they don't guard on you. So
05:14 - 05:18take a deep breath, she takes a deep breath I get all locked out and then, and
05:18 - 05:22that's it. It's almost like I'm trying to get her to kick her own butt.
05:22 - 05:27Did you see how that worked? It's just that simple, boom. Sometimes you get
05:27 - 05:32a cavitation, sometimes you won't. Keep in mind cavitations aren't necessarily the
05:32 - 05:40indicator of a successful manipulation, the manipulation and reassessment right,
05:40 - 05:44what happened on your reassessment is indication of a successful manipulation.
05:44 - 05:50Now there is one other way to do this, right we could have a Yvette go ahead and
05:50 - 05:54turn over, and she's going to lie facedown.
05:54 - 05:59Now in this case we're going to get a little weird, we're going to use this
05:59 - 06:05knuckle against the fibular head, we're going to do the same thing, kind of lock up
06:05 - 06:11right, and then we can push down this way and we got a nice little pop there.
06:11 - 06:14So we did notice that that side was stiff, I did notice earlier that this
06:14 - 06:19side was not. The big problem with this technique and probably why I don't use
06:19 - 06:25it very often, is if somebody has any rectus femoris tightness, like you have a
06:25 - 06:31very hard time getting their leg far enough that you can actually smash their
06:31 - 06:37leg together enough for you to apply enough force to the fibular head. Does
06:37 - 06:42that make sense? So if we get here, like you can imagine if she was super tight
06:42 - 06:45I'd get here, and then I'd go to do my manipulation
06:45 - 06:50and I just don't have, I'm not actually squeezing anything together. So you
06:50 - 06:55can try this if somebody's fairly mobile, other than this one particular joint you
06:55 - 06:58might be able to get away with that. Otherwise go ahead and flip over back on
06:58 - 07:06your back, this tends to be the better technique. So one more time,
07:06 - 07:11second MCP over the top of fibular head, you can externally rotate a little bit
07:11 - 07:18to feel that fibular head push into that MCP. We're going to get all locked up so we
07:18 - 07:23know that when we do our final whip that we're getting pressure where we need it,
07:23 - 07:28and then of course once we get there take a nice deep breath and we just do a
07:28 - 07:33little, and that's it. All right so we're just swinging the leg a few centimeters
07:33 - 07:39to get basically a posterior to anterior force against the fibular head. Stay
07:39 - 07:43tuned for your close-up recap. All right for your close-up recap, starting
07:43 - 07:47with palpation if we have the knee joint line kind of like right here and this is
07:47 - 07:51where you would expect it to be, if we go down a little bit you can
07:51 - 07:57feel this bump right about here, that's the fibular head and if you pincer grip
07:57 - 08:00it you should be able to move it back and forth. Now of course we're going to base
08:00 - 08:04it on additional assessments, but if you were to feel stiffness that might be an
08:04 - 08:08indication to do this particular manipulation. What I'm going to try to do is
08:08 - 08:12if you see where this finger is right behind the fibular head, I'm now going to
08:12 - 08:22try to put my second MCP right there, so I'm going to just put my
08:22 - 08:26hand right up in there and getting through all of the soft tissue, and then
08:26 - 08:32I might even turn her tibia out. You can see I just kind of turned her foot
08:32 - 08:36out there and what I should feel is I turn that out like it presses the
08:36 - 08:42fibular head right into my MCP, and then I want to double check to make sure that
08:42 - 08:47if I press down is that going to increase tension or increase the amount
08:47 - 08:52of force on my MCP, and if I get that check then I'm going to go ahead and
08:52 - 08:58tell Yvette to take a deep breath, and I'm going to go ahead and just a real
08:58 - 09:02quick, and that's it. Just like she's trying to kick her own butt.
09:02 - 09:08I just have to remember to go a few centimeters, again one of the common
09:08 - 09:13mistakes that's made on manipulations is probably not moving enough. Although low
09:13 - 09:18amplitude means less motion and we're not doing high amplitude manipulations like we
09:18 - 09:23would move the whole leg. You still do need to move a good few centimeters to
09:23 - 09:27make sure you take up all tissue slack, to make sure that you're moving through
09:27 - 09:32all the soft tissue, maybe somebody's clothing and actually getting to the
09:32 - 09:39point where all that's left is motion at the bone to force it. So again for second
09:39 - 09:44MCP right behind the fibular head, I can even twist the tibia so that I press the
09:44 - 09:48fibular head into my MCP and then I'm going to press it up against her thigh
09:48 - 09:53make sure I got a good lock position once I'm set up, pop. A couple of points
09:53 - 09:57to recap, knowing your Anatomy and knowing your biomechanics will certainly
09:57 - 10:01help you choose the right technique for the right patient. If you're unsure
10:01 - 10:07whether manipulations are appropriate due to their higher intensity, it's okay
10:07 - 10:11to do mobilizations. Most research points to manipulations being slightly more
10:11 - 10:16effective, but mobilizations being very effective, and of course we have those
10:16 - 10:21videos for you if you want to start with those less intense techniques. Make sure
10:21 - 10:25that if you are doing any technique that it's based on assessment, and of course
10:25 - 10:29that you're reassessing ensuring that the technique is effective for the
10:29 - 10:33patient that you're working on, and when it comes to all manual techniques,
10:33 - 10:38manipulations maybe more than any other, look for opportunities to get live
10:38 - 10:43education. Although I know videos are convenient and I'm happy to have these
10:43 - 10:49up for you to watch, it would be so much more helpful to use those videos as
10:49 - 10:55a recap of one-on-one attention with somebody who's experienced with
10:55 - 11:01manipulation techniques. At the very least grab a colleague, grab a friend and
11:01 - 11:06start practicing these before you bring them into clinic and start using them on
11:06 - 11:10patients and clients. I hope you enjoyed this video, if you have any questions
11:10 - 11:14please leave them in the comment box below.

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