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

Anatomy and Physiology

The fibula, the narrow bone on the lateral aspect of the tibia in the leg, runs from the knee joint to the ankle joint and is involved in the biomechanics of both joints. The fibula is divided into 4 parts—the head, neck, shaft, and distal end. Despite being a non-weight-bearing bone, the fibula contributes to ankle joint stability.[5] At its proximal end, the fibular head articulates with the posterolateral surface of the proximal tibia, while distally, it forms the ankle joint by articulating with the distal tibia and the lateral talus. 

A fibrous joint capsule containing distinct anterior and posterior tibiofibular ligaments envelop the proximal tibiofibular joint.[6][7] The anterior ligament extends from the anteroinferior aspect of the fibular styloid to the Gerdy tubercle on the tibia, while the posterior ligament lies inferior to the lateral joint space, with the fibular attachment positioned posterior to the insertion of the biceps femoris.[7] The lateral collateral ligament, the tibiofibular interosseous membrane, the short head of the biceps femoris, the fibular collateral ligament, the popliteofibular ligament, and the 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.[8] 

The proximal tibiofibular joint experiences reduced support when the lateral collateral ligament and biceps tendon relax during knee flexion, increasing susceptibility to injury. Distally, the fibula and tibia are linked by the interosseous syndesmotic membrane. In ankle dorsiflexion, the fibula must externally rotate to accommodate a wider anterior talus. This syndesmotic membrane also influences the fibula's movement during tibial rotation; with internal rotation, the fibular head moves posteriorly, and with external rotation, it shifts anteriorly.[7]

The common peroneal nerve wraps around the head of the fibula as it travels distally down the leg.[9] 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.[5] Symptoms of a common peroneal neuropathy include foot drop, lateral leg sensory deficits, or sensory deficits in the foot.  

Understanding the motion of the fibula is crucial in diagnosing fibular somatic dysfunction. The proximal tibiofibular joint is a synovial joint that allows for minor anterolateral and posteromedial glides, also known as anterior and posterior glides. The fibula forms a syndesmosis at its distal end, allowing slight lateral movement away from the tibia to accommodate talus movement during dorsiflexion.[10] Injury to this joint often leads to high ankle sprains.[11] An anterior glide of the fibular head typically induces a reciprocal motion of the distal fibula, gliding posteriorly, and vice versa. External rotation of the tibia prompts anterior glide of the fibular head via the robust interosseous membrane.[11] Pronation of the foot results in the posterior glide of the distal talofibular joint (and, consequently, the anterior glide of the fibular head). Hence, fibular head somatic dysfunction arises when the fibular head's motion becomes restricted.

Having a foundational understanding of the physiology of the MET with post-isometric relaxation and the HVLA technique is essential, although it extends beyond the scope of this article. In MET, the patient is positioned toward the barrier and instructed to push against the physician's resistance. While there are 9 physiological principles of MET, this article will primarily address post-isometric relaxation, which leverages the Golgi tendon reflex to induce joint articulation changes.[4] In HVLA, the patient is placed into the barrier, and using a short, quick thrust, the range of motion and mechanics are corrected. This maneuver may produce an audible "pop" sound, which is theorized to be a nitrogen bubble escaping the joint space due to the thrust. From a neurophysiological perspective, it is believed that the sudden thrust triggers afferent signals from muscles to the CNS, leading to reflexive inhibitory impulses targeting the muscle spindles.[12]

Indications

MET and HVLA techniques applied to the fibular head are considered safe. Some common indications for these treatments include:

• Fibular head muscle energy: This technique is commonly utilized for addressing fibular head restriction associated with knee pain, fibular neuritis, ankle pain, and gait abnormality.

• Anterior fibular head thrust (HVLA): This technique is commonly utilized for addressing anterior fibular head associated with lower extremity pain and gait abnormality.

• Posterior fibular head thrust (HVLA): This technique is commonly utilized for addressing posterior fibular head associated with lower extremity pain, fibular neuritis, and gait abnormality.

Contraindications

Common contraindications for both MET and HVLA techniques include patient refusal, acute injuries where positioning could exacerbate the condition, and patient inability to adhere to instructions. Further specific contraindications are outlined below.

• Fibular head muscle energy: This technique is contraindicated for acute ankle sprain, acute fibular fractures, deep vein thrombosis, and ankle joint laxity.

• Anterior fibular head thrust (HVLA): This technique is contraindicated for acute fibular fractures, deep vein thrombosis, and knee instability and inflammation.

• Posterior fibular head thrust (HVLA): This technique is contraindicated for acute ankle sprain, acute fibular fractures, deep vein thrombosis, and knee instability and inflammation.

Equipment

To facilitate the MET and HVLA techniques effectively, healthcare providers should ensure the availability of these equipment for optimal setup—an OMT table, exam table, or massage table; a pillow for patient comfort; a gown or shorts for lower extremity exposure below the knee; and a stool for physician comfort.

Personnel

Personnel involved in OMT include:

• A physician who has received the appropriate training in OMT during medical school or post-graduate training.
• A patient who consented to receiving OMT has no contraindications to receiving the treatment safely.

Preparation

Before the examination and treatment, the clinician should ensure the patient is informed about the risks, benefits, and alternative treatment options. After obtaining the patient's consent, the physician can commence with the physical examination. Evaluation of the fibular head should precede the OMT provision. Initially, the clinician should palpate the fibular head, located laterally and slightly distal to the knee. Subsequently, the patient should assume a supine position 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. Anterolateral and posteromedial movements of the fibular head should be attempted to identify any motion restrictions. A restriction in anterolateral motion indicates a posterior fibular head, while a restriction in posteromedial motion suggests an anterior fibular head. 

Occasionally, assessing fibular head somatic dysfunction can pose challenges. Conducting motion tests for ankle supination and pronation can aid in evaluation. If supination is favored, the fibular head tends to be posterior, and vice versa. Inducing minimal rotation to the tibia can also provide insights; external rotation of the tibia suggests a posterior fibular head. Additionally, comparing the position of the fibular head to the tibial plateau can be beneficial to determine whether it is more anterior or posterior to the contralateral knee.

Technique or Treatment

The following techniques should be conducted in a manner as described below.

Fibular Head Muscle Energy

• The patient is positioned supine or seated.
• The knee is flexed to 90°.
• The fibular head is pulled anterolaterally for a posterior fibular head or posteromedially for an anterior fibular head. Simultaneously, the foot is plantarflexed/supinated (if restricted anteriorly) or dorsiflexed/pronated (if restricted posteriorly) to its restrictive barrier.
• The patient is instructed to resist ankle motion against resistance for 3 to 5 seconds. 
• Complete relaxation is allowed, and the ankle is gradually moved to a new barrier while repositioning the fibular head more anterolaterally for a posterior fibular head or posteromedially for an anterior fibular head. 
• This isometric contraction and stretch are repeated 3 to 5 times until fibular head mobility is restored. 
• Fibular head motion is retested. 

Anterior Fibular Head Thrust (HVLA)

• The patient should be placed in a supine position. 
• The practitioner places their thenar eminence on the anterior fibular head and grasps the distal aspect of the tibia with the other hand.
• The fibular head is pushed posteromedially by leaning into it with a rigid arm as the tibia is rotated to engage the restrictive barrier.
• The patient is instructed to take a deep breath, and during exhalation, a short and quick posteromedial thrust is applied into the fibular head.
• Fibular motion is retested. 

Posterior Fibular Head Thrust (HVLA)

• The patient should be placed in a supine position. 
• The practitioner places their first metacarpal phalangeal joint posteromedial to the posterior fibular head and grasps the distal aspect of the tibia with the other hand. 
• The tibia is externally rotated to the restrictive barrier, and the knee is flexed until the hand is wedged between the posterior fibular head and thigh. 
• The patient is instructed to take a deep breath, and during exhalation, a quick short thrust is applied by flexing the knee.
• Fibular head motion is retested.

Complications

OMT to the fibular head is generally considered a safe procedure. Common adverse effects of OMT include fatigue, headaches, localized soreness, or radiating pains. Fortunately, these adverse effects typically resolve within 24 hours following treatment.[13] Patients are advised to rest and stay hydrated to alleviate post-OMT discomfort. 

Clinical Significance

Knee and ankle pain pose complex challenges for numerous patients. While NSAIDs, physical therapy, immobilization, and steroid injections are common conservative treatment options, OMT can be particularly beneficial if fibular head somatic dysfunction is identified. OMT represents a low-risk intervention that patients can explore in the office to alleviate their pain.

Ankle sprains are a common cause of fibular head dysfunction often encountered in clinical settings. Fortunately, manipulation yields favorable outcomes in its management. The most prevalent type of ankle sprain is a supination or inversion ankle sprain.[14] During such sprains, the talus and distal fibula become restricted anteriorly, resulting in anterior translation of the distal fibular head and posterior translation of the fibular head. This condition leads to external rotation of the tibia, accompanied by the anteromedial glide of the tibial plateau, generating a torsional force coupled with internal femoral rotation. Consequently, femoral positioning may trigger posterior innominate rotation and sacral torsion. As the late Dr Philip Greenman from Michigan State University emphasized, "There is no such thing as a mild ankle sprain."

In cases of significant posterior fibular head dysfunction, patients might experience weakness in ankle dorsiflexion due to irritation of the common peroneal/fibular nerve. If manipulation of the fibular head proves excessively tender, using an indirect approach for treatment, such as the balanced ligamentous tension technique, may be considered. However, the detailed exploration of this technique lies beyond the scope of the current article.

Enhancing Healthcare Team Outcomes

OMT is a form of manual therapy that serves as a valuable approach for alleviating and managing pain. Despite being relatively misunderstood among healthcare professionals, disseminating knowledge about OMT and instructing techniques across interdisciplinary healthcare teams can foster greater consensus among providers. Enhanced comprehension of OMT provides interprofessional healthcare teams with additional resources for delivering patient-centered care and treating patients effectively. Moreover, OMT can potentially decrease patients' reliance on pain medications and enhance overall patient outcomes.[15][16] 

When utilizing OMT for any condition, the treating clinician must communicate this to other team members to ensure they know the patient's ongoing OMT treatment and can consider it when making treatment decisions. OMT, as a therapeutic intervention within the framework of interprofessional cooperation, has the potential to enhance patient outcomes significantly.