Proximal Tibiofibular Joint Manipulation

Patient and Practitioner set-up

1. The patient should be lying supine, closer to the edge of the affected side, with the affected leg flexed at hip and knee.
2. The table should be at approximately the height of the practitioner's hip.
3. The practitioner should be standing on the patient's affected side.

Passive Motion Assessment

• 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 proximal tibiofibular mobilization may be used for arthrokinematic assessment.

Lockout Position:

1. Take a moment to palpate around the fibular head:
   1. Start by identifying the patella.
   2. Then move distally to identify the patellar ligament.
   3. Fall off the patellar ligament laterally into the soft fat pad that lies deep and lateral to the ligament.
   4. 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.
   5. Trace the tibial plateau to the lateral aspect of the knee and you should abut the rounded end of the fibular head.
   6. 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).
2. 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.
3. 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.
4. 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.
5. 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).

High-Velocity Thrust

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.