Why don’t some folks pay attention to anatomy?

Movement isn’t important…until you can’t…

Grey Cook

Manipulation of a joint appears to change the instantaneous axis of rotation of that joint (1). It would stand to reason that this change would effect muscle activation patterns (2). Can this be applied to the lower extremity? Apparently so, at least according to this paper (3). 

“…The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.”

So, what does this mean?

The peroneus longus contracts from just after midstance to pre swing to assist in descending the 1st ray and assist in supination. The soleus contracts from loading response (medial portion, eccentrically, to slow calcaneal eversion) until just after midstance (to assist in calcanel inversion and supination). 

The tibiofibular articulation is a dynamic structure during gait, and the fibula appears to move downward during the stance phase of gait (rather than upward, as previously thought from cadaver studies)(4), with the distal articulation having a rotational moment (5). 

Consider checking the integrity of these joints, and asuring their proper ranges of motion, particularly in patients with chronic ankle instability (6). A little joint motion can go a long way : ) 

1. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint LaxityCraig R. Denegar, Jay Hertel, Jose FonsecaJournal of Orthopaedic & Sports Physical Therapy 2002 32:4, 166-173 

2. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee painSuter, Esther et al.Journal of Manipulative & Physiological Therapeutics , Volume 22 , Issue 3 , 149 - 153

3. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability.Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel JJ Electromyogr Kinesiol. 2011 Aug;21(4):652-8. doi: 10.1016/j.jelekin.2011.03.011. Epub 2011 May 4.

4.  Dynamic function of the human fibula. Weinert, C. R., McMaster, J. H. and Ferguson, R. J. (1973), Am. J. Anat., 138: 145–149. doi: 10.1002/aja.1001380202

5. Kinematics of the distal tibiofibular syndesmosisAnnechien Beumer , Edward R Valstar , Eric H Garling , Ruud Niesing , Jonas Ranstam , Richard Löfvenberg , Bart A Swierstra  Acta Orthopaedica Scandinavica  Vol. 74, Iss. 3, 2003

6. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle InstabilityJames R. Beazell, Terry L. Grindstaff, Lindsay D. Sauer, Eric M. Magrum, Christopher D. Ingersoll, Jay HertelJournal of Orthopaedic & Sports Physical Therapy 2012 42:2, 125-134 


What were they thinking? Oh, they weren’t thinking…

Here is a simple case of knowing your anatomy. 

make sure to use the toggle bar to the right and left of the picture to see all the pictures : )

This woman came in with right sided lateral knee pain with hiking and skiing; worse with fatigue, better with rest. The pain was localized at the lateral joint line and at the tibial fibular joint. 

She had been previously been diagnosed with tibial fibular hypermobility and subsequently had an arthrodesis (fusion) performed at that joint for knee pain. The surgery helped for a short time and a newer, slightly different pain developed. 

Yes, she has a moderate genu valgus, R > L. Yes, she has a left, anatomically short (tibial) Left leg. Yes, she has has NO MOBILITY at the tib/fib articulation and the focus of pain is just above at the joint line and at the lateral aspect of the patello femoral joint. 

The tibial fibular joint is a syndesmosis (not a true synovial or diarthrodial joint) that is supposed to have a a superio/inferior gliding motion (see diagram) with ankle dorsiflexion, due to the wedge shape of the talar dome and talo crural articulation. It also is supposed to have an anterior/posterior gliding movement at the superior aspect of the joint and a reciprocal movement in the opposite direction at the ankle (see diagram).

Whenever we take away movement in one area, it needs to occur somewhere else; in this case, at the femoral tibial joint and patello femoral joints.

Does it make sense that her left sided leg would cause hypermobility on the right side with a supinatory moment of the foot on the left to attempt to lengthen the leg and a pronatory movement of the foot on the right, in addition to valgus angulation of the joint on the right to attempt to “shorten” that extremity? Would this increased valgus angluation of the knee, in turn, cause abnormal, lateral, tracking of the patella? Wouldn’t the increased pronatory moment cause a more supple foot on that side with increased requirements for “push off” on that side with increased calf recruitment? Do you think that may impair proprioception on that side?

What if you put a sole lift in the left shoe (like we did) to help to alleviate some of the discrepancy and gave her some anterior compartment exercises (toes up walking, lift/spread/reach exercises, heel walking, simple balance on 1 leg exercises? Her world becomes a much better place to live in and she can return to the activities she loves to do with her 65 year old friends, like hiking 14′ers, skiing and mountain biking,

What we do to one joint affects all the others. You cannot make one change without expecting others. Be on the lookout and know your anatomy! This case was relatively straight forward. Many are not. Do a thorough exam and expect the unexpected.