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3 4 5 To confirm I've located the client's fibular head, I palpate the biceps femoris tendon behind the lateral knee and apply resistance as the client attempts knee flexion. Common peroneal nerve impingement due to a posteriorly fixated fibular head. I apply a basic hamstring stretching technique to address the client's chronic hamstring injury and to relieve posterior drag of the biceps femoris tendon on his fibula. him with a temporary limp, intermittent lateral knee pain, and lower leg numbness. Using a clinical reasoning approach, I intuited that his posteriorly fixated fibular head might have resulted from shortening of the biceps femoris muscle following his traumatic judo injury. Further, I reasoned that Keith's intermittent lower leg paresthesia might have been triggered by common peroneal nerve irritation due to his posteriorly fixated fibular head (Image 4). To validate my findings, I asked Keith to stand on the affected leg and bend his knee to 30 degrees. This maneuver did reproduce Keith's knee and leg symptoms and is a very good confirmation test for tib-fib joint dysfunction. In Image 5, I apply a graded exposure hamstring stretching technique (using movement enhancers) to help relieve posterior drag of the biceps tendon from Keith's fibula. This stretching maneuver is great for those biceps femoris muscle injuries in which there is accumulated scar tissue and the brain is protectively guarding the area. Once I was able to improve Keith's hamstring flexibility, I chose a simple myoskeletal technique to help move the fibula forward on the tibia, then retested for improved tib-fib mobility (Image 6). SUMMARY If you have a client with knee pain that fits some of the patterns outlined here, the tib-fib may be involved. In such cases, the first order of business is to determine the type and degree of tissue damage based on history, assessment, and clinical reasoning. Left untreated, tib-fib fixations can cause long-term difficulties, including pain, gait disturbance, and inferior sports performance. Hopefully, a better understanding of this often- neglected joint leads to less clinical error and improved client outcomes. Note 1. John A. Ogden, "Subluxation and Dislocation of the Proximal Tibiofibular Joint," Journal of Bone and Joint Surgery 56, no. 1 (January 1974): 145–54. Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com. 6 My middle and ring fingers hook under the client's fibular head. As my right hand flexes and abducts the client's knee, my fingers pull anteriorly on the fibula to help restore tib-fib joint play. N e w ! A B M P P o c k e t P a t h o l o g y a t w w w. a b m p . c o m / a b m p - p o c k e t - p a t h o l o g y - a p p . 89