Posterior fibular head is treated much
the same way as anterior fibular head.
Important difference is the
diagnosis and the assessment.
If you feel the fibular head has moved
anteriorly, you know that the distal tibula
is also moving as well and you may
wanna do some springing, some rocking
and just general motion
'til you get it to slip back into place.
I also wanna test the talus
and the navicular bone,
making sure you're not having tenderness
because you don't wanna miss a break.
And you can also invert and plantarflex the
foot to give an additional sense of comfort
that all is good and it's just a
misalignment or misplacement.
Here's a slide on the
fibular head mechanics.
You can look it, what is an anterior fibular head
and what is a posterior fibular head?
And in assessing where the fibula is
and what you need to do to help it
be more comfortable
Yes, you wanna do
the pronation and supination.
We also gonna get some
eversion and inversion.
And those are good ways of seeing
where you are.
And the fibular head doesn't
move like many other bones.
It generally glides a little bit and that's why
the motion is generally protected and limited.
So here is a comparison of posterior and
anterior fibular head muscle energy technique.
So if posterior, you place the
thenar eminence on the fibular head.
And then you position the patient's
hips and knees flexed at 90 degrees.
Once you get that, you can
invert and plantarflex the foot
and see if you can induce motion so that the
posterior head of the fibula goes back into place.
And you hold it there and just generally
rock it until you get it back into place.
With an anterior fibular head,
you wanna hold the fibular head
between the thumb and the index finger
and you get a tighter control
because it's a little bit more
accessible when it's anterior.
You position the hip and knee
on the same way, flexed 90 degrees.
And then you evert and dorsiflex the foot
while you externally rotate the lower leg.
And the patient may push if you wanna use
muscle energy to help put it back into place.
Although generally, i think the
provider does that for the patient.
So that's the anterior
and posterior fibular head.
Again, plantar flexion and dorsiflexion
are what you're gonna be doing
when you're moving the foot
around trying to get it fixed.
When you're treating a plantar
flexion somatic dysfunction,
generally you want to hold
the foot by the malleoli.
You wanna dorsiflex the foot so that
you could see where the tenderness is.
And then you tell the person to push their
foot down into a plantar flexion direction
and you push back into dorsiflexion.
Do this for 3 to 5 seconds, have them
relax, take up the slack and push again.
And you do this until you no
longer get enhanced motion.
When you're dealing with dorsiflexion somatic
dysfunction, you're gonna do the exact opposite.
You're going to plantarflex the foot
and have them pull their foot up
until its barrier and holding it for 3 to
5 seconds, taking up the slack each time.
For muscle energy treatments
of acute ankle somatic dysfunctions,
you wanna deal with calcaneal
eversion and inversion.
For eversion where the foot is going
out, you wanna hold the foot in one hand
and grasp the patient's forefoot,
the toes and the metatarsal bones.
And then hold the calcaneus with your
other hand and I want you to have them,
where you've got the
foot grasped and steady,
you tell the person to push their
foot and their heel laterally.
They pull laterally, you
give them resistance.
And then you'll give them 3 to 5
seconds and you take up the slack.
So if they're evert and
you're having them push out.
If they're inverted,
you do the exact opposite.
You still hold the heel with one hand and
you grasp the forefoot with the other hand.
And then you have them bring it to the barrier,
deviating it laterally and then have them push.
Do it for 3 to 5 seconds and repeat.
Tibial torsion is when the tibia is
twisted along it's longitudinal axis.
And it's gonna curve from the hip issue
or from an ankle issue.
It's an abnormal association
between the patella and the foot.
And it will create toeing off
when you walk in both feet.
It can also cause spasm
and pain in the toes.
So if the tibial torsion, making
the diagnosis is important
and then treating it will help
alleviate some of the spasm and pain
people have in their feet.
So when you have a tibial torsion, you'll wanna
evaluate the patient by having him lie supine,
put your thumb and index finger of one hand
on the lateral margins of the patella
and then place the tip of your index finger on the
other hand on the midline of the tibial tuberosity
and you feel where the patella goes.
And you feel the connection
between the tibial tuberosity
and make sure you have the ability
to have external rotation of the tibia
and you do have some motion.
When you do have that, you check then for
medial motion and internal rotation.
And if you have full motion, you're
gonna have more comfort in the region.
You can do an articulatory technique
which is when you have restricted tibia
internal and external rotation.
And basically for an articulatory technique,
is you're going to move it through this
range of motion and freeing it that way.
You wanna make sure that you're not afraid
of having worsening of an ankle sprain,
worsening pain and you've
ruled out a fracture.
You also worry about this in people
who have joint hypermobility
who can extend more than a 180 degrees and
you've seen ligamentous laxity before.
And you don't manipulate in people
who've had deep veinous thrombosis
or have had bone cancer in that region.
When you talk about knee techniques,
we talk about the knee technique and it's
relation to the femur and to the ankle as well.
So if you wanna lift the distal femur
and have a bit of a bend in the knee,
it will free up motion and
let you see what's going on.
You wanna hold the anterior tibia below
the tibial tuberosity with your hand,
pull it out a little bit, feel the motion
and in one motion, you can flex the knee
and rotate the tibia until you feel a restriction
and then you'll extend it even further
Do this 3 to 5 times for 3 to 5 seconds
to enhance the joint motility.
And then retest to see
what kind of benefit you got.
So if you wanna treat the knee
with a knee mobility problem,
you can do a myofascial release.
A myofascial release is a gentle stretching,
twisting and movement of the knee.
I do this when I've got a patient with a restricted
knee flexion or restricted knee extension
and they've got some knee
pain and tenderness.
And what you do is you basically
take them through a range of motion.
And you pull on the fascia, stretching the
fascia each time you pull, enhancing motion.
You don't wanna do this on someone
who's had a fracture or DVT.
But in general it's a soft
technique and very effective.
You could do a myofascial release with
a patient either seated or supine.
I generally like them supine by taking the weight
off the knee and not having to worry about gravity.
But you can hold the leg either way and you
can pull on the fascia, twist the fascia
and see what kind of motion you get
by moving the fascia.
And you can also move the tibia as well
because you're gonna rest your thenar
imminence on the tibial plateau, on the bone.
And that helps give you some stability
and helps limit the pain that the patient has.
Gives some more of a sense of comfort
and just eases the fear a patient has
when you manipulate an area that's in pain.
You could do this indirectly, you don't
take it to the pain and cause more pain.
It's not like fascial distortion.
It's a gentle stretching and pulling away.
So you move it to a position of laxity,
a position of ease
and that should help with the knee pain
and then re-assess.
So I wanna quickly talk about knee flexion
and extension dysfunction.
If a person can't flex or extend their knee,
then you could do a muscle energy
procedure to enhance the motion.
Now what you do is you'd lay them supine, you can
have them seated as well but supine is better
'cause you get to take the weight off the knee
and you wanna flex the leg and hold the knee
and then have the person push their
leg out to help increase the motion.
Repeat this three times in order to make sure
you get the motion there and re-asses.
When they have an issue with
extension, you wanna flex the leg
and then you wanna go ahead and have
the patient extend the leg against pressure.
And with the isometric resistance, you're
gonna enhance motion and enhance freedom.
And the last point I wanna bring up
is the knee counterstrain points
because if I can't get a treatment done
any other way, I move to counterstrain.
And the counterstrain point for the patellar
tendon is below the patella on the tendon.
So it's just a little bit
inferior towards the foot.
And what you do is you find
the tender point, extend the knee
and then find tune with
internal and external rotation.
Well the knee doesn't have much
internal and external rotation,
it's mostly flexion and extension inducing just
small bits of internal and external rotation
will create more comfort and
help you get the pain gone enough
to do a tender point or
When you talk about the medial meniscus,
the counterstrain point is on the anterio-medial
aspect of the meniscus on the medial joint line.
Not far from where the tenderness
is, just a little bit away.
You induce some knee flexion to help take away
the pain, make the patient more comfortable.
And then once you get there, find the
point of ease and hold it for 90 seconds.
For the lateral meniscus,
the tender point is on the lateral aspect
of the meniscus, on the lateral joint line.
So it's pretty central.
Again, you wanna find
the position of comfort
and knee flexion is generally
the position of most comfort.
You may wanna internally rotate and slightly
ABduct it for the lateral meniscus
and that just takes some of the pressure off
and if the patient did have a locking
or clicking, you may free it up
but will give them a sense that they're no
longer locked in that specific position.
Again, give it 90 seconds.
It just start easing up after 45 to
60 seconds to hold at the 90 seconds,
bring it back to the general
position and re-assess.
So when we talk about knee problems, ankle
problems, hip problems in the lower extremity,
it's all part of osteopathic medicine.
It's all basic biomechanics of
the musculoskeletal system.
We wanna give you the ability to think
about the anatomy, think about the motion
and help ease the motion so that people
can function in a more comfortable way.