Massage & Bodywork

MAY | JUNE 2020

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technique MYOSKELETAL ALIGNMENT TECHNIQUES 88 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 2 0 Superior Tib-Fib Fixation The Mystery Knee Pain Generator By Erik Dalton, PhD 1 2 Lateral knee pain is a common client complaint and is usually attributed to conditions such as iliotibial band friction syndrome, lateral meniscus lesions, and patellofemoral syndrome (runner's knee). However, an often-overlooked source of knee pain is hypomobility or instability at the proximal tibiofibular (tib-fib) joint (Image 1). In this article, I'll describe the biomechanics and injury mechanisms of the tib-fib joint and then present a case study of a client with chronic knee pain that originated from an awkward judo fall. TIB-FIB BIOMECHANICS One of the primary functions of the tib- fib synovial joint is to help dissipate lower leg torsional stresses during gait. When the knee is extended, the biceps femoris, popliteus, and lateral collateral ligaments provide good joint stability. But with the knee flexed, these connective tissues lose much of their supportive capability. That's one reason tib-fib injuries are most often seen in sports that involve twisting forces around the knee and ankle, such as football, wrestling, soccer, judo, gymnastics, long jumping, and skiing. In my nonathletic clients, tib-fib problems typically arise from overuse injuries on jobs that require repetitive activities. Clinically, I've found many Tib-fib joint with stabilizing muscles and ligaments. With the client's knee flexed and foot resting on the therapy table, my fingers palpate the fibular head and begin translating forward and back, assessing for lack of joint play. clients presenting with lateral tib- fib pain from overuse also have an underlying body structure deficit, such as overpronated feet and valgus knees. In these cases, forces accumulate that cannot be properly dissipated or, worse, may be misdirected into areas not intended to handle the load, as we will see in the case study presented later in this article. Common signs and symptoms of tib-fib dysfunction include: • Ankle movements that provoke lateral knee pain • Crepitus (grinding) during knee movement • Limited knee extension • Outer knee pain aggravated by direct pressure to the fibular head • Pain with one-legged weight bearing • Visible deformity PALPATION AND ASSESSMENT Yale University researcher John Ogden, MD, was the first to conduct studies evaluating the anteroposterior (A-P) motion of the proximal fibula and correlating it with positional changes of the knee. 1 He found that when the knee flexes, the proximal fibular head moves anteriorly, and during knee extension, the fibula translates posteriorly (approximately one centimeter in both directions). In Image 2, I demonstrate an assessment version of Ogden's A-P glide on my client Keith's right knee. With index finger and thumb, I first locate a medium-size bump on his lateral leg about 2 inches inferior to the knee. To confirm I'm palpating the proximal fibular head, I simply flex Keith's knee to 90 degrees, locate the biceps femoris hamstring tendon just behind the lateral knee, and apply resistance as he attempts knee flexion (Image 3). If I feel the biceps femoris tendon tighten, I know I'm in the right spot. KEITH'S CASE STUDY When assessing Keith's A-P glide, I noticed a restriction to anterior translation of the fibula on tibia accompanied by tenderness and a slight grinding noise. I recalled that during Keith's history intake he described a pretty significant inversion ankle sprain and hamstring contusion experienced during a judo fall that left

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