Proximal Tibiofibular Joint Posterior to Anterior Manual Mobilization

Set-Up

1. The patient should be side-lying, with knees bent, and the practitioner standing on the side of the table behind the patient's knee.
2. The table should be high, at a height that allows the practitioner to have elbows extended and press nearly horizontal during the technique.

Posterior to Anterior Mobilization (Fibula on Tibia)

1. It may be helpful to look at a model or diagram of the proximal tibiofibular joint when learning this mobilization technique.
2. 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 investing into the proximal and posterior aspects of the fibular head).
3. Place as much of the surface area of your thumb against the posterior aspect of the patient's fibular head. You may even be able to place the fibular head in the IP of your thumb and somewhat "wrap" your thumb around the fibular head. Use this thumb as a "dummy thumb", applying pressure with the other hand by placing the palm of the other hand over the palpating the thumb.
   • The peroneal nerve and a sensitive soleus trigger point lie behind the fibular head; be careful to not apply direct pressure to these structures. Of course if the patient feels burning, tingling, electric or numbing pain, move your thumb slightly until you can find a place to apply pressure that does not create these sensations. Further, the more surface area you can use the less likely you are to create discomfort for the patient.
4. Use the index finger of one hand to identify the joint line in-between the anterior surfaces of the fibular head and the tibia.
5. Use all of your other fingers to stabilize the anterior surface of the tibia.
6. To assess for motion, oscillate the fibular head. This joint may become hypermobile or hypomobile. If there is a significant amount of motion, or the joint moves with ease, this is not a recommended technique.
7. Ensure your elbows are near locked, spine is neutral, bending forward slightly at the hips, ready to lean into your palpation.
8. Force is generated by leaning forward, or rocking and using your body weight.

Mobilization:

1. Once you are comfortable with the hand position, start with small test oscillations to identify articular motion and identify any exquisite tenderness.
   • Be especially aware of any burning, tingling, or "electric" type pain, it is easy to accidentally stretch small nerves in the area.
2. When satisfied with the feel of the technique, identify the amount of pressure needed to reach the first resistance barrier, just prior to articular motion. Then use more pressure to identify the end of articular motion. The point at which any further pressure fails to increase articular motion is the end of articular range, no additional pressure is required.
3. Identify the mid-point between the first resistance barrier and arthrokinematic end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
     • Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.
   • Grade IV - Small oscillations at 50% resistance.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until change in tissue resistance/joint stiffness is felt.