Posterior Fibular Head Somatic Dysfunction and Tibial Torsion

by Tyler Cymet, DO, FACOFP

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    00:00 Posterior fibular head is treated much the same way as anterior fibular head.

    00:05 Important difference is the diagnosis and the assessment.

    00:09 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.

    00:24 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.

    00:32 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.

    00:42 Here's a slide on the fibular head mechanics.

    00:45 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.

    00:58 We also gonna get some eversion and inversion.

    01:02 And those are good ways of seeing where you are.

    01:05 And the fibular head doesn't move like many other bones.

    01:09 It generally glides a little bit and that's why the motion is generally protected and limited.

    01:15 So here is a comparison of posterior and anterior fibular head muscle energy technique.

    01:23 So if posterior, you place the thenar eminence on the fibular head.

    01:28 And then you position the patient's hips and knees flexed at 90 degrees.

    01:32 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.

    01:44 And you hold it there and just generally rock it until you get it back into place.

    01:50 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.

    02:02 You position the hip and knee on the same way, flexed 90 degrees.

    02:05 And then you evert and dorsiflex the foot while you externally rotate the lower leg.

    02:12 And the patient may push if you wanna use muscle energy to help put it back into place.

    02:17 Although generally, i think the provider does that for the patient.

    02:22 So that's the anterior and posterior fibular head.

    02:25 Again, plantar flexion and dorsiflexion are what you're gonna be doing when you're moving the foot around trying to get it fixed.

    02:33 When you're treating a plantar flexion somatic dysfunction, generally you want to hold the foot by the malleoli.

    02:40 You wanna dorsiflex the foot so that you could see where the tenderness is.

    02:45 And then you tell the person to push their foot down into a plantar flexion direction and you push back into dorsiflexion.

    02:53 Do this for 3 to 5 seconds, have them relax, take up the slack and push again.

    02:58 And you do this until you no longer get enhanced motion.

    03:02 When you're dealing with dorsiflexion somatic dysfunction, you're gonna do the exact opposite.

    03:07 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.

    03:19 For muscle energy treatments of acute ankle somatic dysfunctions, you wanna deal with calcaneal eversion and inversion.

    03:27 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.

    03:41 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.

    03:55 They pull laterally, you give them resistance.

    03:58 And then you'll give them 3 to 5 seconds and you take up the slack.

    04:02 So if they're evert and you're having them push out.

    04:06 If they're inverted, you do the exact opposite.

    04:09 You still hold the heel with one hand and you grasp the forefoot with the other hand.

    04:15 And then you have them bring it to the barrier, deviating it laterally and then have them push.

    04:23 Do it for 3 to 5 seconds and repeat.

    04:26 Tibial torsion is when the tibia is twisted along it's longitudinal axis.

    04:31 And it's gonna curve from the hip issue or from an ankle issue.

    04:36 It's an abnormal association between the patella and the foot.

    04:40 And it will create toeing off when you walk in both feet.

    04:44 It can also cause spasm and pain in the toes.

    04:49 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.

    05:00 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.

    05:19 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.

    05:30 When you do have that, you check then for medial motion and internal rotation.

    05:36 And if you have full motion, you're gonna have more comfort in the region.

    05:41 You can do an articulatory technique which is when you have restricted tibia internal and external rotation.

    05:49 And basically for an articulatory technique, is you're going to move it through this range of motion and freeing it that way.

    05:57 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.

    06:04 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.

    06:11 And you don't manipulate in people who've had deep veinous thrombosis or have had bone cancer in that region.

    06:18 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.

    06:26 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.

    06:34 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.

    06:56 And then retest to see what kind of benefit you got.

    06:59 So if you wanna treat the knee with a knee mobility problem, you can do a myofascial release.

    07:05 A myofascial release is a gentle stretching, twisting and movement of the knee.

    07:10 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.

    07:18 And what you do is you basically take them through a range of motion.

    07:21 And you pull on the fascia, stretching the fascia each time you pull, enhancing motion.

    07:28 You don't wanna do this on someone who's had a fracture or DVT.

    07:31 But in general it's a soft technique and very effective.

    07:36 You could do a myofascial release with a patient either seated or supine.

    07:40 I generally like them supine by taking the weight off the knee and not having to worry about gravity.

    07:45 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.

    07:54 And you can also move the tibia as well because you're gonna rest your thenar imminence on the tibial plateau, on the bone.

    08:01 And that helps give you some stability and helps limit the pain that the patient has.

    08:07 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.

    08:16 You could do this indirectly, you don't take it to the pain and cause more pain.

    08:21 It's not like fascial distortion.

    08:23 It's a gentle stretching and pulling away.

    08:26 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.

    08:34 So I wanna quickly talk about knee flexion and extension dysfunction.

    08:38 If a person can't flex or extend their knee, then you could do a muscle energy procedure to enhance the motion.

    08:45 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.

    09:04 Repeat this three times in order to make sure you get the motion there and re-asses.

    09:08 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.

    09:18 And with the isometric resistance, you're gonna enhance motion and enhance freedom.

    09:24 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.

    09:31 And the counterstrain point for the patellar tendon is below the patella on the tendon.

    09:37 So it's just a little bit inferior towards the foot.

    09:40 And what you do is you find the tender point, extend the knee and then find tune with internal and external rotation.

    09:47 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 counterstrain treatment.

    10:04 When you talk about the medial meniscus, the counterstrain point is on the anterio-medial aspect of the meniscus on the medial joint line.

    10:13 Not far from where the tenderness is, just a little bit away.

    10:18 You induce some knee flexion to help take away the pain, make the patient more comfortable.

    10:24 And then once you get there, find the point of ease and hold it for 90 seconds.

    10:30 For the lateral meniscus, the tender point is on the lateral aspect of the meniscus, on the lateral joint line.

    10:37 So it's pretty central.

    10:39 Again, you wanna find the position of comfort and knee flexion is generally the position of most comfort.

    10:46 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.

    11:03 Again, give it 90 seconds.

    11:05 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.

    11:14 So when we talk about knee problems, ankle problems, hip problems in the lower extremity, it's all part of osteopathic medicine.

    11:21 It's all basic biomechanics of the musculoskeletal system.

    11:25 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.

    11:34 Thank you.

    About the Lecture

    The lecture Posterior Fibular Head Somatic Dysfunction and Tibial Torsion by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Posterior Fibular Head Somatic Dysfunction
    • Calcaneal Eversion and Inversion
    • Tibial Torsion

    Included Quiz Questions

    1. The patient's affected hip and knee are flexed to 90 degrees, and the physician inverts and plantar flexes the foot.
    2. The patient's affected hip and knee are flexed to 90 degrees, and the physician everts and dorsiflexes the foot and externally rotates the affected leg.
    3. The patient's affected hip and knee are extended, and the physician everts and dorsiflexes the foot and externally rotates the affected leg.
    4. The patient's affected hip and knee are extended, and the physician inverts and plantar flexes the foot.
    1. Acute fracture
    2. Joint hypermobility
    3. Severe knee osteoarthritis
    4. Ankle sprain
    5. Back pain
    1. Inferior to the patella on the patellar tendon
    2. On the anterior-medial aspect of the meniscus on the medial joint line
    3. On the lateral aspect of the meniscus on the lateral joint line
    4. On the superior aspect of the patella on the distal insertion site of the quadratus femoris tendon

    Author of lecture Posterior Fibular Head Somatic Dysfunction and Tibial Torsion

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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