0:05 This is Brent of the Brookbush Institute, and in this video we're going to go over a 0:07 joint based manual therapy technique. If you're watching this video I'm assuming 0:11 you're watching it for educational purposes, and that you are a licensed 0:14 professional with joint based techniques within your scope; that means osteopath's, 0:19 chiropractors, physical therapists, you're probably all in the clear. Physical 0:23 therapy assistants athletic trainers massage therapists you need to check 0:27 with your governing body in your state or region to see whether this is within 0:30 your scope of practice. Personal trainers this is definitely not within your scope 0:35 of practice. Of course all professions could use this video for purely 0:39 educational purposes to help with learning biomechanics, anatomy and of 0:45 course palpation. In this video we're going over posterior to anterior fibula 0:49 and tibia mobilization. Now this is proximal tibiofibular joint. I'm going to 0:53 have my friend Melissa come out she's going to help me demonstrate. Now this is 0:56 one of those techniques that you'll probably use rarely, but when somebody 1:00 needs this technique it often results in a big change in their symptoms, or a big 1:05 change in their dysfunction, so keep this in your back pocket. We can kind of see 1:09 how this joint is really in the middle of a bunch of stuff going on. Research 1:14 kind of shows that hyper or hypo mobility may be related to knee pain, but 1:20 if we use just a little bit of knowledge of our anatomy, we could see how perhaps 1:26 dysfunction of this joint could lead to lateral knee pain from the LCL being 1:32 stressed right, the LCL attaches to the fibular head. We could see how 1:37 overactivity of the TFL, vastus lateralis and biceps femoris might be related to 1:43 dysfunction of this joint. So like I said keep this one in your back pocket, there 1:49 is going to come a point where you're going to need this technique. Now 1:52 assessment of this technique is going to have to rely on passive accessory motion 1:57 exam, and I know there's been some consideration of how reliable that those 2:03 those exams are, but we really don't have a better alternative. In order to do 2:09 these passive accessory motion exams as well as in order to do this technique, we 2:14 have to be able to palpate this joint and feel what's going on. So to 2:18 find the fibular head my suggestion is find your patella. Yeah I think most 2:24 people can find their patella, their kneecap. Most people know where their 2:28 kneecap is, if you follow that down right you kind of feel the patellar tendon, and 2:33 if you feel it all the way down a little bit further you'll feel this big bump on 2:37 the tibia right, so patella, patella ligament I guess if you want to call it 2:43 that, and then tibial tuberosity here is the big bump. Once you find that big bump 2:49 you know you're on the tibia, and then we're going to kind of move laterally 2:52 here, and you'll notice that as you move laterally there is kind of another bump 3:00 which actually belongs to your fibula, it's a different bone. If you feel a 3:06 little bit you can actually feel how the the tibia goes into the tibial plateau 3:11 here, alright so if I come up like this I can kind of feel how it divots out and 3:16 then the fibular head kind of connects right up into that, and I'm going to go 3:21 ahead and use my thumb's to just trace that fibula out, I want to feel all the 3:27 way around the fibular head; and remember guys you can do this with a patient or 3:34 client, you don't have to just boom there's the fibular head, like you don't 3:39 have to 100% accuracy on finding these these points every time. Remember your 3:44 patient or client does not know how long it's supposed to take you to find 3:48 something, you're better off being a little slower and right than trying to 3:54 place your hands down and being wrong. So now that I've found the fibular head and 3:59 I found the tibia, what I need to do is does this joint move and guys you need 4:06 to be careful, because you have the peroneal nerves as well as a very tender 4:13 soleus trigger point or common trigger point site right behind the fibular head. 4:18 So as you guys go to push on this just use as broad a thumb stroke as you can. 4:25 Right so I have all this tibia right here, I have my fibular head, I'm going to 4:32 use this hand, I'm going to put this one down right between where I think the 4:36 tibia and fibula head is, kind of where I think the joint line is, and then I'm 4:40 going to go ahead and see does my fibula wiggle. Just like we were talking about 4:45 with the distal tibiofibular joint, this joint doesn't move a lot, and if it does, 4:52 and it does move easily you're hyper- mobile. Hypermobile no mobilization. If 4:59 it doesn't move at all, or barely moves like you have to press pretty hard to 5:05 get it to move what even feels like one millimeter, then this is probably a joint 5:10 that you want to go ahead and mobilize. Now I don't feel a whole lot of motion, I 5:17 do see some scrunching of the face so I need to be careful. Guys in most 5:22 situations for this particular joint you're probably going to have to go 5:25 ahead and do your your soleus release first, do some soft tissue release around 5:31 the fibular head, because if you don't everytime you go to push on that joint 5:34 you're just going to keep digging into that trigger point, you're going to watch 5:38 your your clients face scrunch, and then they're going to guard and you're not 5:41 going to get a whole lot of motion anyway. To do this technique with a 5:46 little bit better hand position, I would suggest either trying to put the fibular 5:52 head here in your thumb and kind of wrap around so that you have all this broad 5:55 surface, or you could even try thenar eminence, hand over hand like 6:04 this. Whichever way you do it, this like just using the point of your thumb is 6:11 not going to work really well. Anytime I've tried to get that to work I get a 6:16 lot of like a lot of guarding, it's just very painful it's very pokey. So I'm 6:22 going to go ahead and try to wrap my, oh maybe not, I'm going to use my thenar 6:26 eminence here, my thumb's are a little big to get to get around that fibular 6:30 head. Once I found that that thenar eminence, notice guys my arms are nice 6:34 and straight, and I'm just going to go ahead and push in a posterior to 6:40 anterior direction. Now we talked about how my Maitland 6:46 certified orthopedic manual therapist, so that's the protocol I know, I'm going to 6:50 find that first resistance barrier, I'm going to find the arthrokinematic end 6:56 range, assuming this is a stiffness dominant patient we're not looking at 6:59 pain dominant, and then I'm going to back off to 50% and then that can either do 7:05 my grade three mobilizations from first resistance barrier to around 50%, little 7:11 larger amplitude, or I can go right up to 50% and use small amplitude right at 7:18 that increased resistance, and see if I can get more movement there; and of 7:24 course I'm going to do one to two oscillations per second until I feel a 7:29 change in joint mobility. Now this is somewhat a challenging technique and 7:35 sometimes you guys are going to have to mess with with foot placement, because 7:39 what your clients going to want to do is either you can see kind of roll at the 7:45 hips, or you go to push and they they they start moving here. So it's going to 7:52 take a little bit of experimentation sometimes to get them into a position 8:00 where you can use this technique, and get motion at the joint without just rocking 8:10 their whole body. Remember all we're looking for is a little tiny bit of 8:15 motion here, not thisl if you find you're doing one of these things to move the 8:21 joint -I guarantee you've pests pressed well past arthrokinematic end range and 8:26 now you're rocking their entire body, and that's probably not that effective of 8:30 a technique. So let's kind of go through this again. Our contraindications 8:36 are the peroneal nerve, and then we need to be aware of that soleus trigger point 8:40 that's going to be real tender. We want to use a nice broad surface so 8:45 either put the fibular head in the IP of your thumb and then wrap your 8:50 thumb around it, or if you're like me and you can't quite get your thumb in there, 8:53 maybe you want to use your thenar eminence. Experiment with position of the the knee, 9:00 foot behind one foot, you can set up bolsters if you need to if you think 9:05 that'll help. You can change the angle of their hips, but get into a position where 9:11 you feel like when you push here you're getting motion of the fibular head on 9:15 the tibia and not just motion of the whole body. I might even be able to brace 9:20 her thigh a little bit and use one hand, so I suppose you could do that, but again 9:30 thenar eminence, I'm pushing posterior to anterior, first resistance barrier now, 9:36 end range is right about there, I'm going to back off the 50% and then I'm going 9:43 to start with the grade three immobilization here, back off to nothing 9:46 and go up to 50%, one to two oscillations per second, checking on my client making 9:52 sure she isn't cringing because I'm on top of her peroneal nerve, or I'm on top 9:59 of that soleus trigger point; and then I'm looking for a change in the amount 10:06 of stiffness of this joint, and then as I explained in the distal tibiofibular 10:13 joint mobilization it is a little hard to feel change with your thenar eminence, 10:18 so I'm probably going to go back in and do my little test of how much wiggle I 10:23 got with my fingertips here, and I got a little bit more wiggle. 10:27 So whatever her test was after that that provoked her pain, I might have her do 10:32 maybe she was having knee pain during a squat. to be like alright let's get up 10:34 and squat and see how that felt. Of course if there was no change 10:38 onto the next technique, if there was change it definitely want to make 10:42 note, well either way I want to make note so that I keep doing that in successive 10:46 sessions, to make sure that we're building the most effective program that 10:50 we can. Stay tuned for the close of recap. The close-up recap of our proximal tibia 10:55 fibula joint mobilization, thats a posterior to anterior mobilization of the fibula 11:00 head. You guys can see here I actually have my thumb right on the fibular head 11:04 but if you've never palpated the fibular head before, my suggestion is actually to 11:08 start with something you you know how to palpate like the the patella right, you 11:13 all know where your kneecap is, and then you can kind of follow the the patella 11:17 ligament or patellar tendon down to the tibial tuberosity, that's that big bump 11:22 right here where the patellar tendon attaches, and then if you go lateral from 11:26 that you run into this bony prominence that if you feel around a little bit is 11:32 kind of half spherical shape, that is your fibular head. Now what you're going 11:40 to want to do is kind of palpate and explore so that you can get behind that 11:46 joint that fibular head, and then kind of find in front of it so that your fingers 11:53 are around it, and now you need to see if maybe you can wiggle that fibular head, 11:57 alright so we're checking out how much motion do we have at the proximal tibiio- 12:04 fibula joint, essentially doing a passive accessory 12:08 motion assessment of some sort. Again this is this is one of those joints that 12:13 just wiggles a little bit, if it Wwiggles a lot you're probably 12:16 hypermobile and don't need this, if it wiggles really easy then maybe it's fine 12:22 as long as it doesn't wiggle too much. If it seems really stiff and it seems like 12:28 you have to apply quite a bit of pressure, that's where we're thinking okay 12:32 maybe I need to mobilize this joint, maybe mobilizing this joint will help the 12:37 knee move better or the ankle move better, or help reduce the tenacity in 12:42 things like the TFL, vastus lateralis and biceps femoris which invest in the 12:48 fibular head here. Things to keep in mind is there is a trigger point right behind 12:54 the fibular head it's a soleus trigger point, so if you just keep pressing down on that 12:59 you're doing your oscillatory mobilizations, you're not going to make 13:03 your client or patient very happy. It might be a good idea to do some soft 13:06 tissue work in the in the posterior lower leg here before before you do this 13:11 technique. The other thing you have to be concerned with is the 13:14 peroneal nerve which if you pinch on, your your client a patient's going to 13:18 let you know; and of course nerves are pretty thin, so you should just be able 13:21 to move your your hands around a little bit and get away from that nerve. You 13:27 don't want to use thumbs like this because that's going to feel really 13:30 really pokey, what you're going to need to do to do this mobilization is use 13:34 either your thenar eminence, or as much of your thumb pad as you can. For people 13:40 with a little smaller hands than mine I usually suggest them trying to put the 13:44 fibular head kind of in their IP joint like so, and then you can actually kind 13:49 of use this as a dummy thumb and put the other hand over it right, now your other 13:54 hand is in the right direction to do a posterior to anterior mobilization. So in 14:00 Melissa's case I did my little wiggle, she doesn't wiggle much, I'm going to put 14:06 this dummy thumb like this, put my thenar eminence over like this, I'm going to 14:12 find my first resistance barrier right there, the end of our arthrokinematic 14:17 range which was right there, let me go at that a little bit slower so I can find 14:22 50%, and then I can go from zero to 50% do my grade three mobilizations here, 14:29 until I feel what I think is a reduction in joint stiffness; and then of course I 14:38 could reassess. Now I did mention that it is a little bit of a challenge in this 14:43 position to get pure fibular head motion on tibia and not just get somebody 14:49 rocking back and forth, so don't be afraid to like hook one foot behind the 14:53 other, bend the knee a little bit more, bend the 14:56 knee a little bit less. Use bolsters change the position of their hip, 15:00 whatever you have to do to try to get into a good position so that you can 15:06 kind of block them out, and get some good fibular head motion. So there you have it 15:13 assess, address, reassess. Make sure that every time you choose a joint based 15:18 manual therapy technique it is based on an assessment, and that you return to 15:23 that assessment after you've finished the intervention 15:25 to see if it was effective for the individual, the patient or client that 15:30 you have in front of you. Ensure that you continue to learn your Anatomy because 15:34 your Anatomy is going to help you with your hand placement, with understanding 15:39 what a joint can do, with understanding what you may gain from this particular 15:45 technique; and of course practice you have to practice these techniques, 15:50 hopefully not for the first time on a patient or client who just walked in the 15:55 door. If you can find a more senior instructor or mentor to give you some 16:00 really good hands-on instruction, use your peers for some good feedback, and of 16:07 course always look for live education to help with your manual therapy techniques. 16:14 I know these videos make education very convenient, but there is no substitute 16:19 for learning manual therapy in a live setting, I look forward to talking to you 16:24 guys again soon.
