What is the proper setup and technique for an anterior fibular head High-Velocity, Low-Amplitude (HVLA) thrust manipulation?

Proper Setup and Technique for Anterior Fibular Head HVLA Manipulation

The proper setup for an anterior fibular head HVLA manipulation requires the patient in right lateral recumbent position with appropriate hip flexion (0° is optimal), therapist stabilizing the proximal fibula, and delivering a quick, precise posterior-directed thrust with minimal force to achieve joint cavitation.

Patient Positioning

• Patient position: Right lateral recumbent (side-lying) position 1
• Lower limb positioning:
  • Keep hips at 0° flexion for optimal results
  • This position produces the greatest amount of extension and the lowest axial rotation during the impulse 1
  • Avoid excessive hip flexion as it can alter spine kinematics and reduce technique effectiveness

Therapist Positioning and Hand Placement

• Therapist stance: Stand facing the patient at the level of the fibular head
• Contact hand: Use thumb or thenar eminence to contact the anterior aspect of the fibular head
• Stabilizing hand: Use to secure the proximal tibia/ankle to prevent excessive movement
• Direction of force: Position hands to deliver a posterior-directed thrust

Pre-manipulation Assessment

• Palpate the anterior aspect of the fibular head to identify its position
• Assess for any tenderness, inflammation, or instability at the proximal tibiofibular joint
• Ensure the patient can comfortably maintain the lateral recumbent position

Execution of the HVLA Technique

1. Pre-loading phase:

   • Apply gentle, progressive pressure to take up tissue slack
   • Maintain precise contact on the anterior aspect of the fibular head
   • Ensure patient is relaxed and comfortable

2. Thrust phase:

   • Deliver a quick, precise posterior-directed thrust
   • Use minimal amplitude (short distance of movement)
   • Apply high velocity (quick speed)
   • Thrust duration should be ≤150 ms for optimal results 2
   • Force should be appropriate to achieve joint cavitation without excessive pressure

Important Considerations

• Localization: Proper patient positioning and pre-loading are critical for localizing forces to the specific joint segment 3
• Force application: Use only the minimum force necessary to achieve the desired effect
• Patient comfort: Ensure the patient remains relaxed throughout the procedure to minimize muscle guarding
• Contraindications: Avoid this technique in cases of acute trauma, inflammation, or instability of the proximal tibiofibular joint

Common Pitfalls to Avoid

1. Excessive rotation: Can cause patient discomfort and resistance, leading to failed technique 3
2. Improper contact point: Ensure precise contact on the anterior fibular head
3. Excessive force: Using more force than necessary increases risk of patient discomfort
4. Poor stabilization: Inadequate stabilization of the proximal tibia can reduce effectiveness
5. Improper thrust duration: Thrusts lasting longer than 150 ms may reduce effectiveness 2

This technique requires practice to develop the proper speed, amplitude, and direction of force. When performed correctly, the HVLA manipulation of the anterior fibular head can be an effective treatment for appropriate musculoskeletal conditions affecting the proximal tibiofibular joint.