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