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Proximal Tibiofibular Joint Posterior to Anterior Manual Mobilization

Try this manual mobilization technique to open up the posterior to anterior movement of your proximal tibiofibular joint. Get improved mobility and flexibility with step-by-step instructions and visuals to follow.

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Transcript

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.

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