This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
based manual therapy technique. If you're watching this video I'm assuming you're
watching it for educational purposes, and that you are a licensed professional
with joint based techniques within your scope. That means osteopath's, chiropractors,
physical therapists, you're probably all in the clear. Physical therapy assistants,
athletic trainers, massage therapist's, you need to check with your governing body
in your state or region to see whether this is within your scope of practice.
Personal trainers this is definitely not within your scope of practice. Of course
all professions could use this video for purely educational purposes to help with
learning biomechanics, anatomy and of course palpation. In this video we're
going to do an anterior to posterior fibula tibia mobilization, that's the
distal tibiofibular joint. I'm going to have my friend Melissa come out, she's
going to help me demonstrate. Now this technique makes a great ancillary
technique to a technique we did in a previous video, which was the anterior to
posterior talus on tibia mobilization. The hypothesis being that the lateral
malleolus or distal fibula, has to follow the talus posteriorly as we dorsiflex
the ankle. So with that being said, although we want to do a passive
accessory motion exam and make sure that we have arthrokinematic stiffness
in the direction that we're trying to mobilize, you might also do this
technique as a means of maintaining, or trying to gain optimal dorsiflexion. Now
the position you're going to be in for this technique is going to be foot on
thigh; and the reason being is I want to be able to control dorsiflexion with my
thigh, and have both hands-free for this mobilization. I need one hand to
stabilize the tibia, and the other one to actually mobilize the fibula. You guys
can see here just by leaning forward I can actually push Melissa into a
few degrees of dorsiflexion. I can even control eversion and inversion a little
bit just by swaying, to make sure she's neutral. The palpation portion of this is
not totally complicated, but it is important that you guys kind of look
over your Anatomy, and you practice putting your hands down on the ankle and
trying to identify that Anatomy, specifically the lateral malleolus. For
this technique it's important that you not
only can find the lateral malleolus, but that you know the contours and edges of
the lateral malleolus. So find your lateral malleolus, find the bottom of the
lateral malleolus. So make sure you can feel that, go ahead and go to the
posterior part of the lateral malleolus, and you should feel a groove in the back
of the lateral malleolus, where your fibularis tendon runs through, and you
might be able to feel that a little bit. Go to the front of the lateral malleolus
and you'll notice that you run into a couple of tendons, those are the tendons
of your long toe extensors, but if you press into that soft tissue just a
little bit, you might be able to feel the joint line. Now the joint line is a nice
thing to feel for this technique, because what we want to see is does the fibula
move a little bit on the tibia, that's all we're trying to feel, does the fibula
wiggle. If we have no wiggle we need to mobilize, if we have lots of wiggle then
we don't want to mobilize. This joint the research kind of shows has one of two
propensities right, either gets stiff or it becomes hypermobile. It's important
that if we feel hypermobility, you feel more than a millimeter of motion here,
it's really easy to wiggle this joint, this is not a technique you're going to
do. Now if you feel good about your palpation, and you try to move the fibula
it doesn't seem to move, that's a good sign that you have stiffness and that
you probably should mobilize. It's really that simple, we don't need to get into
grades of stiffness or anything, it's just does it feel like it barely moves
or does it wiggle a lot. If it wiggles a lot, don't do this. Now once you felt
the motion of the fibula, and you guys can see here I'm just kind of lifting it
with these fingers, pushing it down with these fingers trying to kind of get my
hands like right up against the joint line, maybe put the rest of my hand on
the tibia here so that I can feel the amount of motion I have. Now Melissa's a
little stiff. I would not do the mobilization with that same hand
position guys. It's a little hard to feel how much movement you have with the
technique I'm going to show you, but using your fingertips to do
mobilizations just leads to pain. Just pushing your thumb down into this bony
prominence is going to make somebody cringe. You have to be careful alright,
trying to do something like this, is not a great idea. What we're actually going
to do is use our thenar eminence here, try to get as much surface area on the
lateral malleolus as we possibly can. What that usually ends up leading to is
we we do a little bit of mobilization, and then we check with our fingertips,
and we do a little mobilization, and then we check with our fingertips. So
again how are we going to do this technique? We're going to use our thenar
eminence, we're going to come over the top of our lateral malleolus. Now my
suggestion is, is as you do this you're going to pick up a little bit of skin,
before you press down. Alright so you guys I'm kind of smooshing some skin up
this way, before I push down this way. The reason being is if I grab a bunch of
skin and then pull down this way I stretch the skin out, and then I go to
push down and it stretches the skin even more, and that becomes really
uncomfortable. We want this to be as comfortable as possible otherwise
they're going to guard and this technique is going to be really really challenging.
Now the other contraindication that you have to be aware of, is you can really
send a nice little shock up somebody's leg, give somebody a nice little burn,
give somebody a really intense pinch by getting on that peroneal nerve. Of course
if you do that this nerve is not gigantic, it's it's very very narrow,
we're talking like a millimeter wide so you should be able to move your hand
around and get off it pretty easy. So I'm going to take my hand here, I'm going to
wrap it around Melissa's calcaneus, I'm going to make
sure that calcaneus is off the table so that I don't crunch my hand when I
start pushing down. I'm then going to grab a little bit of skin, just kind of
slide my hand up this way, then put my thenar eminence over the top of her
lateral malleolus, I'm going to kind of push her into dorsiflexion, this hand I'm
going to stabilize her tibia with, and then I'm going to use, you guys notice
I'm leaned forward here again, I'm just going to use my bodyweight to rock into
this mobilization. Now I mentioned in previous videos I'm a Maitland certified
orthopedic manual therapist, the protocols I know are the grades 1, 2, 3 &
4. Grade 3 & 4 being at 50% between the initial resistance and end of arthro-
kinematic range. If you guys have a different protocol that's fine, just make sure that
you are disciplined about using that protocol, that you assess, address and
reassess. If I went through this with my protocol, I'm going to go through
everything I just told you, grab the calcaneus, take up some skin, push down on
that lateral malleolus, ask my client did you, in any pain? This comfortable? Okay
I'm going to find that first resistance barrier, once I find that first
resistance barrier I'm going to start testing down, watching my clients face
making sure she doesn't cringe on me, until I find the end. Notice that as I'm
pushing down I have Melissa in at least neutral dorsiflexion with my thigh, so I
have good control of her foot and ankle, and then once I find first resistance
barrier, I find the end, I back off to 50%, now I'm just going to do 1 to 2
set, 1 to 2 pulses per second until I feel a change in arthrokinematic
stiffness. Now I mentioned a little earlier in this video, that is tough to
feel with my thenar eminence, chances are I'm going to go back and check with
my fingertips to see if I got an increase in range of motion.
That's arthrokinematic range-of-motion though. So we'll do this for 30 seconds, and then
I'm just going to use my fingertips here, did I get more range? If I got more range
great, if I didn't I might go back and do another set, or another two sets, and then
of course I'm going to want to follow this up with something a little bit more
reliable than passive accessory motion exam, maybe I do my dorsiflexion
goniometery. Alright so to go through hand position one more time, or body
position and hand position; foot on thigh, neutral or slightly dorsiflexed, this
hand's going to cup the calcaneus, pick up just a little bit of skin just kind
of sliding up the side of the ankle here, and then press down over the front of
the lateral malleolus, this hand is going to stabilize the tibia, and then I'm just
going to find 50% between initial resistance and end of arthrokinematic
range, back off to 50. I'm going to do my, this is going to be a grade 3 here
alright. So I'm going to take up almost back to zero in resistance and down into
50%. See if I can get a change in stiffness, check with my fingers. If I feel
like I've got a change in stiffness maybe I'd follow that up with a dorsiflexion
range of motion for goniometery, or maybe more of like a functional
assessment like the overhead squat assessment. So in our close-up recap
you'll notice my thighs against Melissa's foot here so that I can
control dorsiflexion as well as eversion and inversion, and you can see
her lateral malleolus right here. Now of course to assess this joint I
talked about just using the fingertips, getting your thumb kind of on the joint
line here. So if I start on her lateral malleolus and then fall off pushing the
tendons of her long toe extensors over, I can kind of feel the joint line and then
I'll usually just take these few fingers and kind of push up while my thumb
pushes down, see if there's any wiggle there; and then here's the really
important point that I was trying to make in the the further away shot, is as
you're going to mobilize this joint it's important that you kind of slide your
hand up this way, and you can see how her skin kind of crunches up, so that when I
press down her skin is back to its normal length, whereas if I pull down
from here, you can see I stretch out her skin trying to get pressure over the
anterior surface of her lateral malleolus. Now I'm going to come up like this, press
down, ask Melissa if she feels any pain, if she feels any tingling burning right,
we don't want to stretch that nerve. I can use the other hand to stabilize her
tibia, and then I can kind of find my resistance point, so first resistance end
of arthrokinematic range, and then of course all of our mobilization protocols
end up somewhere in the middle. I'll go from zero to 50% and a little larger
amplitude doing my grade three. I'll go for thirty seconds until I think I feel
a change in stiffness, and then I can go back to my assessment position of
feeling the joint line, seeing if I got any wiggle back. Alright guys so get
familiar with your lateral malleolus, feel all of its surfaces, find the the
inferior border, find the anterior border, try to feel that joint line, really try
to grab ahold of it with your fingertips, gently of course, so you don't hurt your
patient, client, or partner you're practicing on. Stabilize the tibia with
one hand, pick up a little tissue, make sure you follow through on your
protocols, and of course at the end of your technique make sure you assess. So
there you have it; assess, address, reassess. Make sure that
every time you choose a joint based manual therapy technique it is based on
an assessment, and that you return to that assessment after you've finished
the intervention to see if it was effective for the individual, the patient
or clients that you had in front of you. Ensure that you continue to
learn your Anatomy because your Anatomy is going to help you with your hand
placement, with understanding what a joint can do, with understanding what you
may gain from this particular technique, and of course practice. You have to
practice these techniques, hopefully not for the first time on a patient or
client who just walked in the door. If you can find a more senior instructor or
mentor to give you some really good hands-on instruction, use your peers for
some good feedback, and of course always look for live education to help with
your manual therapy techniques. I know these videos make education very
convenient, but there is no substitute for learning manual therapy in a live
setting. I look forward to talking to you guys again soon.
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