Osteopathic Manipulative Treatment: Muscle Energy and HVLA Procedures - Fibular Head Dysfunction

Anatomy and Physiology

The fibula is the narrow bone on the lateral aspect of the tibia in the leg.  It runs from the knee joint to the ankle joint and is involved in the biomechanics of both joints. The fibula is broken down into four parts: the head, neck, shaft, and distal end. The fibula is a non-weight-bearing bone, and its function is to provide stability to the ankle joint.[4] Proximally the fibular head articulates with the posterolateral surface of the proximal tibia. Distally, the fibula articulates with the distal tibia and the lateral talus forming the ankle joint. 

The proximal tibiofibular joint is surrounded by a fibrous joint capsule with distinct anterior and posterior tibiofibular ligaments.[5][6] The anterior ligament attaches anteroinferior to the fibular styloid and posteriorly to Gerdy's tubercle on the tibia. The posterior ligament is located inferior to the lateral joint space, and the fibular footprint is posterior to the insertion of the biceps femoris.[6] Additionally, the lateral collateral ligament, the tibiofibular interosseous membrane, the short head of the biceps femoris, fibular collateral ligament, popliteofibular ligament, and popliteus muscle all attach to the proximal tibiofibular joint to provide stability.

The primary function of the proximal tibiofibular joint is to disperse torsional loads applied to the ankle, reduce lateral tibial bending, and share axial loads from weight-bearing.  In knee flexion, the proximal fibula moves anteriorly due to the laxity of the lateral collateral ligament and biceps femoris tendons, whereas in knee extension, the lateral collateral ligament and biceps femoris tighten, which pulls the proximal fibula posteriorly.[7] 

The proximal tibiofibular joint has less support because the lateral collateral ligament and biceps tendon are both relaxed during knee flexion. It is more prone to injury with a flexed knee. Distally, the fibula and tibia are connected by the interosseous syndesmotic membrane.  During ankle dorsiflexion, the fibula must externally rotate to accommodate a wider anterior talus. The interosseous syndesmotic membrane also affects how the fibula moves with tibial rotation.  With internal tibial rotation, the fibular head translates posteriorly, and with external tibial rotation, the fibula translates anteriorly.[6]

The common peroneal nerve wraps around the head of the fibula as it travels distally down the leg.[8] As it wraps around the head of the fibula, the common peroneal nerve becomes susceptible to compression. Common peroneal nerve entrapment is the most prevalent entrapment neuropathy of the lower extremity.[4] Symptoms of a common peroneal neuropathy include foot drop, lateral leg sensory deficits, or sensory deficits in the foot.  

Indications

Fibular Head Muscle Energy

• Fibular head restriction associated with knee pain 
• Fibular neuritis 
• Ankle pain 
• Gait abnormality 

Anterior Fibular Head Thrust (HVLA)

• Anterior fibular head associated with lower extremity pain
• Gait abnormality 

Posterior Fibular Head Thrust (HVLA)

• Posterior fibular head associated with lower extremity pain
• Fibular neuritis 
• Gait abnormality

Contraindications

Fibular Head Muscle Energy

• Acute ankle sprain 
• Acute fibular fracture 
• Deep vein thrombosis 
• Ankle joint laxity 

Anterior Fibular Head Thrust (HVLA)

• Acute fibular fracture 
• Deep vein thrombosis 
• Knee instability 
• Knee inflammation

Posterior Fibular Head Thrust (HVLA)

• Acute ankle sprain
• Acute fibular fracture 
• Deep vein thrombosis 
• Knee instability 
• Knee inflammation 

Equipment

• OMT table, exam table, or massage table 
• Pillow for patient comfort 
• Gown or shorts so that the patient’s lower extremities can be exposed below the knee 
• Stool for physician comfort

Personnel

• A physician who has received the appropriate training in OMT while in medical school or post-graduate training
• A patient who has given consent to receiving OMT and who has no contraindications to receiving OMT safely

Preparation

Before proceeding with the exam and OMT, the clinician should inform the patient of the risks, benefits, and alternative treatment options. Once the patient has given informed consent, the physician should continue with the physical examination.  The clinician should first evaluate the fibular head before providing the patient with OMT. First, the clinician should palpate the fibular head, which is lateral and slightly distal to the knee. Next, the patient should be placed supine on the table with the knee flexed. The clinician should place their thumb and index finger on the anterior and posterior aspects of the fibular head, respectively. The clinician should then attempt to move the fibular head anterolaterally and posteromedially to identify any restrictions in motion. A restriction in anterolateral motion means the patient has a posterior fibular head, whereas a restriction in posteromedial motion means the patient has an anterior fibular head. 

Technique or Treatment

Fibular Head Muscle Energy

• The patient can be placed supine or seated
• Flex the knee to 90 degrees 
• Pull the fibular head anterolaterally for a posterior fibular head or posteromedially for an anterior fibular head while dorsiflexing the foot to its restrictive barrier.
• Ask the patient to plantarflex the foot against your equal resistance for 3 to 5 seconds. 
• Allow complete relaxation and slowly move the ankle to a new dorsiflexion barrier as you continue pulling the fibular head anterolaterally for a posterior fibular head or posteromedially for an anterior fibular head. 
• Repeat this isometric contraction and stretch 3 to 5 times or until the fibular head mobility returns 
• Retest fibular head motion 

Anterior Fibular Head Thrust (HVLA)

• The patient should be placed in a supine position 
• Place your thenar eminence on the anterior fibular head and grasp the distal aspect of the tibia with your other hand.
• Push the fibular head posteromedially by leaning into it with a rigid arm as you internally rotate the tibia to engage the restrictive barrier.
• Ask the patient to take a deep breath and, during exhalation, apply a short and quick posteromedial thrust into the fibular head.
• Retest fibular motion 

Posterior Fibular Head Thrust (HVLA)

• The patient should be placed in a supine position 
• Place your first metacarpal phalangeal joint posteromedial to the posterior fibular head and grasp the distal aspect of the tibia with your other hand. 
• Externally rotate the tibia to the restrictive barrier and flex the knee until your hand is wedged between the posterior fibular head and thigh. 
• Ask the patient to take a deep breath and during exhalation, apply a quick short thrust by flexing the knee.
• Retest fibular head motion

Complications

OMT to the fibular head is generally very safe. Common side effects of OMT are fatigue, headaches, localized soreness, or radiating pains. These side effects typically resolve within 24 hours following treatment.[9] Patients are encouraged to rest and hydrate to decrease post-OMT discomfort. 

Clinical Significance

Knee and ankle pain are complex issues that many patients face. NSAIDs, physical therapy, immobilization, and steroid injections are all conservative treatment options for pain, but in the presence of fibular head somatic dysfunction, OMT can be a useful tool. OMT is a low-risk option for patients to try in the office to treat their pain.

Enhancing Healthcare Team Outcomes

Osteopathic manipulative treatment is a form of manual therapy that can be used to decrease and treat pain. It is poorly understood among many healthcare professionals, but spreading the knowledge about OMT and teaching techniques among interdisciplinary teams can create a more common ground among providers. More understanding about OMT can also provide interprofessional healthcare team members with more tools for treating patients and providing patient-centered care. Osteopathic manipulative treatment can also reduce the number of pain medications a patient takes and improve patient outcomes.[10][11] 

When employing OMT for any condition, the treating clinician should communicate this to other team members so they are aware that the patient is receiving this procedure and can factor that into their own treatment decisions. OMT as a therapeutic intervention in the context of interprofessional cooperation can improve patient outcomes. [Level 5]