00:05 - 00:07This is Brent of the Brookbush Institute, and in this video we're going to go over a
00:07 - 00:11joint based manual therapy technique. If you're watching this video I'm assuming
00:11 - 00:14you're watching it for educational purposes, and that you are a licensed
00:14 - 00:19professional with joint based techniques within your scope; that means osteopath's,
00:19 - 00:23chiropractors, physical therapists, you're probably all in the clear. Physical
00:23 - 00:27therapy assistants athletic trainers massage therapists you need to check
00:27 - 00:30with your governing body in your state or region to see whether this is within
00:30 - 00:35your scope of practice. Personal trainers this is definitely not within your scope
00:35 - 00:39of practice. Of course all professions could use this video for purely
00:39 - 00:45educational purposes to help with learning biomechanics, anatomy and of
00:45 - 00:49course palpation. In this video we're going over posterior to anterior fibula
00:49 - 00:53and tibia mobilization. Now this is proximal tibiofibular joint. I'm going to
00:53 - 00:56have my friend Melissa come out she's going to help me demonstrate. Now this is
00:56 - 01:00one of those techniques that you'll probably use rarely, but when somebody
01:00 - 01:05needs this technique it often results in a big change in their symptoms, or a big
01:05 - 01:09change in their dysfunction, so keep this in your back pocket. We can kind of see
01:09 - 01:14how this joint is really in the middle of a bunch of stuff going on. Research
01:14 - 01:20kind of shows that hyper or hypo mobility may be related to knee pain, but
01:20 - 01:26if we use just a little bit of knowledge of our anatomy, we could see how perhaps
01:26 - 01:32dysfunction of this joint could lead to lateral knee pain from the LCL being
01:32 - 01:37stressed right, the LCL attaches to the fibular head. We could see how
01:37 - 01:43overactivity of the TFL, vastus lateralis and biceps femoris might be related to
01:43 - 01:49dysfunction of this joint. So like I said keep this one in your back pocket, there
01:49 - 01:52is going to come a point where you're going to need this technique. Now
01:52 - 01:57assessment of this technique is going to have to rely on passive accessory motion
01:57 - 02:03exam, and I know there's been some consideration of how reliable that those
02:03 - 02:09those exams are, but we really don't have a better alternative. In order to do
02:09 - 02:14these passive accessory motion exams as well as in order to do this technique, we
02:14 - 02:18have to be able to palpate this joint and feel what's going on. So to
02:18 - 02:24find the fibular head my suggestion is find your patella. Yeah I think most
02:24 - 02:28people can find their patella, their kneecap. Most people know where their
02:28 - 02:33kneecap is, if you follow that down right you kind of feel the patellar tendon, and
02:33 - 02:37if you feel it all the way down a little bit further you'll feel this big bump on
02:37 - 02:43the tibia right, so patella, patella ligament I guess if you want to call it
02:43 - 02:49that, and then tibial tuberosity here is the big bump. Once you find that big bump
02:49 - 02:52you know you're on the tibia, and then we're going to kind of move laterally
02:52 - 03:00here, and you'll notice that as you move laterally there is kind of another bump
03:00 - 03:06which actually belongs to your fibula, it's a different bone. If you feel a
03:06 - 03:11little bit you can actually feel how the the tibia goes into the tibial plateau
03:11 - 03:16here, alright so if I come up like this I can kind of feel how it divots out and
03:16 - 03:21then the fibular head kind of connects right up into that, and I'm going to go
03:21 - 03:27ahead and use my thumb's to just trace that fibula out, I want to feel all the
03:27 - 03:34way around the fibular head; and remember guys you can do this with a patient or
03:34 - 03:39client, you don't have to just boom there's the fibular head, like you don't
03:39 - 03:44have to 100% accuracy on finding these these points every time. Remember your
03:44 - 03:48patient or client does not know how long it's supposed to take you to find
03:48 - 03:54something, you're better off being a little slower and right than trying to
03:54 - 03:59place your hands down and being wrong. So now that I've found the fibular head and
03:59 - 04:06I found the tibia, what I need to do is does this joint move and guys you need
04:06 - 04:13to be careful, because you have the peroneal nerves as well as a very tender
04:13 - 04:18soleus trigger point or common trigger point site right behind the fibular head.
04:18 - 04:25So as you guys go to push on this just use as broad a thumb stroke as you can.
04:25 - 04:32Right so I have all this tibia right here, I have my fibular head, I'm going to
04:32 - 04:36use this hand, I'm going to put this one down right between where I think the
04:36 - 04:40tibia and fibula head is, kind of where I think the joint line is, and then I'm
04:40 - 04:45going to go ahead and see does my fibula wiggle. Just like we were talking about
04:45 - 04:52with the distal tibiofibular joint, this joint doesn't move a lot, and if it does,
04:52 - 04:59and it does move easily you're hyper- mobile. Hypermobile no mobilization. If
04:59 - 05:05it doesn't move at all, or barely moves like you have to press pretty hard to
05:05 - 05:10get it to move what even feels like one millimeter, then this is probably a joint
05:10 - 05:17that you want to go ahead and mobilize. Now I don't feel a whole lot of motion, I
05:17 - 05:22do see some scrunching of the face so I need to be careful. Guys in most
05:22 - 05:25situations for this particular joint you're probably going to have to go
05:25 - 05:31ahead and do your your soleus release first, do some soft tissue release around
05:31 - 05:34the fibular head, because if you don't everytime you go to push on that joint
05:34 - 05:38you're just going to keep digging into that trigger point, you're going to watch
05:38 - 05:41your your clients face scrunch, and then they're going to guard and you're not
05:41 - 05:46going to get a whole lot of motion anyway. To do this technique with a
05:46 - 05:52little bit better hand position, I would suggest either trying to put the fibular
05:52 - 05:55head here in your thumb and kind of wrap around so that you have all this broad
05:55 - 06:04surface, or you could even try thenar eminence, hand over hand like
06:04 - 06:11this. Whichever way you do it, this like just using the point of your thumb is
06:11 - 06:16not going to work really well. Anytime I've tried to get that to work I get a
06:16 - 06:22lot of like a lot of guarding, it's just very painful it's very pokey. So I'm
06:22 - 06:26going to go ahead and try to wrap my, oh maybe not, I'm going to use my thenar
06:26 - 06:30eminence here, my thumb's are a little big to get to get around that fibular
06:30 - 06:34head. Once I found that that thenar eminence, notice guys my arms are nice
06:34 - 06:40and straight, and I'm just going to go ahead and push in a posterior to
06:40 - 06:46anterior direction. Now we talked about how my Maitland
06:46 - 06:50certified orthopedic manual therapist, so that's the protocol I know, I'm going to
06:50 - 06:56find that first resistance barrier, I'm going to find the arthrokinematic end
06:56 - 06:59range, assuming this is a stiffness dominant patient we're not looking at
06:59 - 07:05pain dominant, and then I'm going to back off to 50% and then that can either do
07:05 - 07:11my grade three mobilizations from first resistance barrier to around 50%, little
07:11 - 07:18larger amplitude, or I can go right up to 50% and use small amplitude right at
07:18 - 07:24that increased resistance, and see if I can get more movement there; and of
07:24 - 07:29course I'm going to do one to two oscillations per second until I feel a
07:29 - 07:35change in joint mobility. Now this is somewhat a challenging technique and
07:35 - 07:39sometimes you guys are going to have to mess with with foot placement, because
07:39 - 07:45what your clients going to want to do is either you can see kind of roll at the
07:45 - 07:52hips, or you go to push and they they they start moving here. So it's going to
07:52 - 08:00take a little bit of experimentation sometimes to get them into a position
08:00 - 08:10where you can use this technique, and get motion at the joint without just rocking
08:10 - 08:15their whole body. Remember all we're looking for is a little tiny bit of
08:15 - 08:21motion here, not thisl if you find you're doing one of these things to move the
08:21 - 08:26joint -I guarantee you've pests pressed well past arthrokinematic end range and
08:26 - 08:30now you're rocking their entire body, and that's probably not that effective of
08:30 - 08:36a technique. So let's kind of go through this again. Our contraindications
08:36 - 08:40are the peroneal nerve, and then we need to be aware of that soleus trigger point
08:40 - 08:45that's going to be real tender. We want to use a nice broad surface so
08:45 - 08:50either put the fibular head in the IP of your thumb and then wrap your
08:50 - 08:53thumb around it, or if you're like me and you can't quite get your thumb in there,
08:53 - 09:00maybe you want to use your thenar eminence. Experiment with position of the the knee,
09:00 - 09:05foot behind one foot, you can set up bolsters if you need to if you think
09:05 - 09:11that'll help. You can change the angle of their hips, but get into a position where
09:11 - 09:15you feel like when you push here you're getting motion of the fibular head on
09:15 - 09:20the tibia and not just motion of the whole body. I might even be able to brace
09:20 - 09:30her thigh a little bit and use one hand, so I suppose you could do that, but again
09:30 - 09:36thenar eminence, I'm pushing posterior to anterior, first resistance barrier now,
09:36 - 09:43end range is right about there, I'm going to back off the 50% and then I'm going
09:43 - 09:46to start with the grade three immobilization here, back off to nothing
09:46 - 09:52and go up to 50%, one to two oscillations per second, checking on my client making
09:52 - 09:59sure she isn't cringing because I'm on top of her peroneal nerve, or I'm on top
09:59 - 10:06of that soleus trigger point; and then I'm looking for a change in the amount
10:06 - 10:13of stiffness of this joint, and then as I explained in the distal tibiofibular
10:13 - 10:18joint mobilization it is a little hard to feel change with your thenar eminence,
10:18 - 10:23so I'm probably going to go back in and do my little test of how much wiggle I
10:23 - 10:27got with my fingertips here, and I got a little bit more wiggle.
10:27 - 10:32So whatever her test was after that that provoked her pain, I might have her do
10:32 - 10:34maybe she was having knee pain during a squat. to be like alright let's get up
10:34 - 10:38and squat and see how that felt. Of course if there was no change
10:38 - 10:42onto the next technique, if there was change it definitely want to make
10:42 - 10:46note, well either way I want to make note so that I keep doing that in successive
10:46 - 10:50sessions, to make sure that we're building the most effective program that
10:50 - 10:55we can. Stay tuned for the close of recap. The close-up recap of our proximal tibia
10:55 - 11:00fibula joint mobilization, thats a posterior to anterior mobilization of the fibula
11:00 - 11:04head. You guys can see here I actually have my thumb right on the fibular head
11:04 - 11:08but if you've never palpated the fibular head before, my suggestion is actually to
11:08 - 11:13start with something you you know how to palpate like the the patella right, you
11:13 - 11:17all know where your kneecap is, and then you can kind of follow the the patella
11:17 - 11:22ligament or patellar tendon down to the tibial tuberosity, that's that big bump
11:22 - 11:26right here where the patellar tendon attaches, and then if you go lateral from
11:26 - 11:32that you run into this bony prominence that if you feel around a little bit is
11:32 - 11:40kind of half spherical shape, that is your fibular head. Now what you're going
11:40 - 11:46to want to do is kind of palpate and explore so that you can get behind that
11:46 - 11:53joint that fibular head, and then kind of find in front of it so that your fingers
11:53 - 11:57are around it, and now you need to see if maybe you can wiggle that fibular head,
11:57 - 12:04alright so we're checking out how much motion do we have at the proximal tibiio-
12:04 - 12:08fibula joint, essentially doing a passive accessory
12:08 - 12:13motion assessment of some sort. Again this is this is one of those joints that
12:13 - 12:16just wiggles a little bit, if it Wwiggles a lot you're probably
12:16 - 12:22hypermobile and don't need this, if it wiggles really easy then maybe it's fine
12:22 - 12:28as long as it doesn't wiggle too much. If it seems really stiff and it seems like
12:28 - 12:32you have to apply quite a bit of pressure, that's where we're thinking okay
12:32 - 12:37maybe I need to mobilize this joint, maybe mobilizing this joint will help the
12:37 - 12:42knee move better or the ankle move better, or help reduce the tenacity in
12:42 - 12:48things like the TFL, vastus lateralis and biceps femoris which invest in the
12:48 - 12:54fibular head here. Things to keep in mind is there is a trigger point right behind
12:54 - 12:59the fibular head it's a soleus trigger point, so if you just keep pressing down on that
12:59 - 13:03you're doing your oscillatory mobilizations, you're not going to make
13:03 - 13:06your client or patient very happy. It might be a good idea to do some soft
13:06 - 13:11tissue work in the in the posterior lower leg here before before you do this
13:11 - 13:14technique. The other thing you have to be concerned with is the
13:14 - 13:18peroneal nerve which if you pinch on, your your client a patient's going to
13:18 - 13:21let you know; and of course nerves are pretty thin, so you should just be able
13:21 - 13:27to move your your hands around a little bit and get away from that nerve. You
13:27 - 13:30don't want to use thumbs like this because that's going to feel really
13:30 - 13:34really pokey, what you're going to need to do to do this mobilization is use
13:34 - 13:40either your thenar eminence, or as much of your thumb pad as you can. For people
13:40 - 13:44with a little smaller hands than mine I usually suggest them trying to put the
13:44 - 13:49fibular head kind of in their IP joint like so, and then you can actually kind
13:49 - 13:54of use this as a dummy thumb and put the other hand over it right, now your other
13:54 - 14:00hand is in the right direction to do a posterior to anterior mobilization. So in
14:00 - 14:06Melissa's case I did my little wiggle, she doesn't wiggle much, I'm going to put
14:06 - 14:12this dummy thumb like this, put my thenar eminence over like this, I'm going to
14:12 - 14:17find my first resistance barrier right there, the end of our arthrokinematic
14:17 - 14:22range which was right there, let me go at that a little bit slower so I can find
14:22 - 14:2950%, and then I can go from zero to 50% do my grade three mobilizations here,
14:29 - 14:38until I feel what I think is a reduction in joint stiffness; and then of course I
14:38 - 14:43could reassess. Now I did mention that it is a little bit of a challenge in this
14:43 - 14:49position to get pure fibular head motion on tibia and not just get somebody
14:49 - 14:53rocking back and forth, so don't be afraid to like hook one foot behind the
14:53 - 14:56other, bend the knee a little bit more, bend the
14:56 - 15:00knee a little bit less. Use bolsters change the position of their hip,
15:00 - 15:06whatever you have to do to try to get into a good position so that you can
15:06 - 15:13kind of block them out, and get some good fibular head motion. So there you have it
15:13 - 15:18assess, address, reassess. Make sure that every time you choose a joint based
15:18 - 15:23manual therapy technique it is based on an assessment, and that you return to
15:23 - 15:25that assessment after you've finished the intervention
15:25 - 15:30to see if it was effective for the individual, the patient or client that
15:30 - 15:34you have in front of you. Ensure that you continue to learn your Anatomy because
15:34 - 15:39your Anatomy is going to help you with your hand placement, with understanding
15:39 - 15:45what a joint can do, with understanding what you may gain from this particular
15:45 - 15:50technique; and of course practice you have to practice these techniques,
15:50 - 15:55hopefully not for the first time on a patient or client who just walked in the
15:55 - 16:00door. If you can find a more senior instructor or mentor to give you some
16:00 - 16:07really good hands-on instruction, use your peers for some good feedback, and of
16:07 - 16:14course always look for live education to help with your manual therapy techniques.
16:14 - 16:19I know these videos make education very convenient, but there is no substitute
16:19 - 16:24for learning manual therapy in a live setting, I look forward to talking to you
16:24 - 16:27guys again soon.