Unlocking the Fibula
Fun fact about the fibula- its name in Latin (fibula) and Greek (peroneal) means: "clasp." I love this fact because you can easily see why it was named that; not only does it look like a clasp or safety pin when it is next to the tibia, but its ability to move is imperative for optimal function because, like a safety pin, it connects things together. When it is locked, it can wreak havoc on things.
Spend 30min with me on a tour around the fibular anatomy. This small bone, written off by many, plays a big role in gait, ankle function, rotational knee stability, and hip and SI function.
Though it accounts for a small amount of load in weight-bearing, the fibula is a key player that, when not moving due to visceral, neural, or mechanical issues, drives a lot of faulty movement patterns and/or pain.
From the episode:
Yoga One San Diego YTT: https://www.yogaonesandiego.com/yoga-teacher-training
Brian Mulligan's book "Manual Therapy NAGS, SNAGS, MWMS": https://a.co/d/4xercTc
Missy Bunch: https://www.instagram.com/missybunch15/
Jean-Pierre Barral: https://www.barralinstitute.com/
Instagram reel of my treatment procedure (including lateral ankle tilt): https://www.instagram.com/reel/CniYETRqRRS/
Obturator Nerve Glide: https://youtu.be/LcHqK_cy12g
Anterior and lateral compartment self-massage: https://youtu.be/5j7ZVyp0Zxw
Common peroneal nerve glide: https://www.instagram.com/reel/CgZ_5wkF3Is/
Fibular reposition tape procedure: https://youtu.be/2pD-xbtoMSk
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole-body approach to care, however, it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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[00:00:00] Hey there, and welcome. I'm Anna Hartman and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone. Even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
[00:00:26] I'm glad you're here. Let's dive in.
[00:00:31] Hello there and welcome back to another episode of the Unreal Results Podcast. Uh, today we're talking about the fibula. Um, yesterday I was working on one of my athletes and, um, I ended up taping his fibula. , uh, to support some posterior glide at the distal fibula. And he was like, it's crazy how much [00:01:00] that makes my knee feel better.
[00:01:01] Takes the pressure off of my knee. And I was like, is it though, is it that crazy? Because the anatomy tells us it shouldn't be crazy at all. In fact, a lot of people's knee pain and. There is a dysfunction is driven by the fibula and all the things that influence the motion at the fibula through our gate cycle, you know, through our leg moving our ankle, going into dorsiflexion and plantar flexion.
[00:01:45] So, , let's dive in and talk about the fibula a little bit. Um, as I was writing down some notes of like, things I wanted to cover, I was like, you know what, let's just do a [00:02:00] quick Google search and see what comes up, um, about the fibula on the interwebs. And of course, so, you know, I read a couple. The beginnings of some research articles about different ligaments that attached to the fibula.
[00:02:17] And then I read just the general Wikipedia page about the fibula bone and a couple other random sources. But, um, What is fascinating, I'm, I'm always kind of fascinated at like how things were named or like what the Latin meaning of the words are and um, or Greek. So Latin and Greek are o often, like where a lot of anatomy terms come from.
[00:02:46] And so, uh, I thought it was interesting. So the fib. is Latin. The word fibula is Latin for clasp or broach. So like a safety pin, um, [00:03:00] something that holds things together. And it was named, like, named that for, um, how the bone looks. So the bone, you know, I've got the bones here. For those of you listening, you can see it on, um, see it on the old YouTube video.
[00:03:24] But you know, so the bones, the way the fibula attaches to the tibia, it looks, it makes that whole unit look a lot like a, a clasp look, A lot like a Burt or a safety pen. And so that makes sense. So the other interest. Thing, the word peronial, um, which is the name of the muscles around the fbri lab, but often, you know, so in fact actually the peronial muscles, um, recently [00:04:00] in the recent history were renamed the fibular muscles.
[00:04:04] Um, which is kind of funny, but the word peronial is Greek for clasp. So, um, they were basically saying the same thing. , peronial is Greek. Um, fibula is Latin, but both of them mean clasp. And the interesting thing too about that, um, when you, if you were to not look at, if you were to not know your anatomy, if you were, if I were to just hand you those two bones, and ask you what it was like.
[00:04:35] You might even tell me that it looks like it fastens something, right? Like it's a, it's a large fastener. And, um, this is interesting to me because oftentimes when we look at the shape of a bone, the structure of a bone or a joint, it can tell us a lot about the function. This is actually a practice. Um, that I first learned in a Franklin [00:05:00] Method workshop.
[00:05:00] The teacher took the bones and passed them around the class. And some people go to that, those classes without having any sort of, um, anatomy background. So the bones are like completely new to them. And you, you know, you, you're asked to describe them and ask what, what, you know, to describe what you think they do.
[00:05:21] Um, and actually when I. Anatomy for the yoga teacher training programs that I do. Shout out. Yoga One in San Diego. If you wanna come learn yoga and learn anatomy from me, definitely sign up for the yoga teacher train. Anyways, when I teach the anatomy to those students, I do the same thing. I hand out the bones and I ask them to describe what they see, and we talk about the function of the bones In that standpoint, you know, the structure dictates the function.
[00:05:55] And so if we're. Thinking about that, [00:06:00] the term clasp or broach when it comes to the fibia makes sense because it's sort of, um, I don't wanna say holds together, but it really does sort of fasten and help to. Hold together, the knee especially. But then the relationship between all the joints of the lower extremity, the fibula has a direct relationship to the ankle and foot, the knee, and the.
[00:06:39] Hip slash si joint. And so it really is sort of like the fastener that connects everything together. So I love, I love that little bit of knowledge that I'm sharing with you and learned today because, um, it just makes so much sense. So with that said, um, . The other reason I wanted to share about this [00:07:00] is when I was talking to my athlete yesterday about it and why he was like, it's crazy that it makes my knee feel so good.
[00:07:05] So good. And I said, really, because of the anatomy, it shouldn't be crazy is funny to me. How many healthcare professionals sort of right off the fibula like poo poo the fibula, like somebody you know will get an avulsion fracture. Of the fibula, you know, from spraining, their ankle or, um, just they'll sprain their ankle or even like, uh, hairline fracture of the fibula.
[00:07:35] And doctors will, sometimes doctors and rehab professionals will sometimes be like, ah, it's not that big of a deal. , because the fibula is only responsible for like 15% of weightbearing, like 10 to 15, um, percent of your weightbearing load. And so it's not as big of a deal as if you were to like, say, break your tibia.
[00:07:59] [00:08:00] And, um, so at some point, these, the, the story became, . Not that it wasn't important in weightbearing, but because it wasn't important in weightbearing, it wasn't important at all. And when people had, um, pain on their fibula or injury to the fibula, it's sort of dismissed and not considered, especially not considered when we're looking at the knee joint.
[00:08:33] Especially not considered when we're looking at ankle. and definitely not considered when we're looking at the SI joint and the hip joint. And so that is my goal for. Today's podcast is to like shine some light on the fibula and actually just how powerful it can be to restore normal joint arthro, chroma, arthro, [00:09:00] kinematics to that bone in the joints that it creates because it is such a fastener, a clasp to the entire lower extremity.
[00:09:14] And not only. The, is it a connector to the entire lower extremity like that? But it is a important piece of our rotational locomotive pattern. So the anatomy, I already showed you the bones, but in general, the fibula is a long, skinny bone. Um, it originates at the top of the. Tibia just below the knee joint.
[00:09:47] So this is why I think sometimes it's forgotten that it's part of the knee joint, because if you were to just look at it where it articulates with the tibia, it's much lower down than the tibial plateau. [00:10:00] And so since it's not near the tibial plateau, we don't think of it as being part of the knee joint, but we're gonna learn about the ligaments and you.
[00:10:09] Know that it is an important part of the, uh, knee joint. And then, um, the rest of the bone is like skinny. It's pretty flexible. Kind of, um, reminds me of like the flexibility of a, um, rib in a sense. Obviously the ribs are more flexible because they have a built-in curve and whenever we have a built-in curve that.
[00:10:32] is a bone that's extra flexible. It's kind of like a strut in the car, a shock in the car. It allows for a little bit more, um, shock absorbing capabilities, but the, the fibula is a lot like that too. Um, which then makes sense when we talk about it's rotational. Mechanic because if we're gonna have a bone that needs a lot of rotational force through it, [00:11:00] um, it needs to be flexible.
[00:11:01] That is also perhaps why it's not involved in a lot of body weight loading, because if we were to combine compression and load what happens to it, it will break. In fact, that is probably what creates a spiral fracture of the fibula. Is when you combine the rotational component with the compressive component.
[00:11:24] So, um, funny how that works. The other end of the fibula articulates, um, will make, you know, or also articulates with the tibia and it makes up the, um, talocrural joint. So, Let me see if I can hold it. So down here at the distal end, you see it makes up this crural joint for the talus to sit right in it, [00:12:00] right?
[00:12:00] So it makes that, um, mortar and pestle type. Joint upside down. So mortar would be like this, and then the pal comes inside there. So part of the fibula then also articulates with the talus in the ankle. That's why, um, I think it is more mainstream that people can accept the role of the fibula as part of the ankle joint than anything else.
[00:12:29] We're gonna talk about that a little bit too. But before we move on to the ankle component of it, let's talk about the attachments to the knee. So up at the proximal head of the fibula, the proximal head of the fibula is attached to the lateral collateral ligament of the knee, as well as the arcuate ligament.
[00:12:53] The arcuate ligament. Is like a y shaped, one of the, um, [00:13:00] branches goes to, to the popliteus, like the popliteus tendon. And then the other Y goes to the lateral horn of the meniscus, specifically I believe the posterior lateral horn of the meniscus. So, um, the arcuate ligament is part of the knee posterior knee joint capsule. So it is directly attached to the knee joint capsule.
[00:13:27] It also has extensions that directly connect the fascia, sort of connects directly to the popliteus itself. So it's two sort of connections, and then a third to the popliteus and the knee joint capsule via the popliteofibular ligament. The popliteofibular ligament, the pfl.
[00:13:54] Resist posterior translation in external rotation in the knee. So it's [00:14:00] a, all of these structures are a big component of our posterior lateral corner of our knee joint, and this is a common area that can be injured. With a traditional, um, rotary stability injury that might even tear the acl. And so in fact, if you start thinking about it, it made me wonder, it gives me the question, are part of the reason for non-contact ACL injuries perhaps, would it have led us back to a fibula that wasn't moving and the loss of the rotational control of the.
[00:14:40] I don't know if that's true, but it makes sense. So the other attachment on that proximal end is a lateral hamstring. So the lateral hamstring attaches here and then, um, obviously. extends up into the leg to the initial tuberosity of the innominate bone. So it doesn't have [00:15:00] a direct effect on the hip joint, but it sort of does because as we know, the hamstrings are one of our, um, hip extensors, a synergist to hip extender.
[00:15:11] Um, and then it's gonna affect, definitely gonna affect si joint motion because of that pull on the innominate bone. So, That proximal part, the lateral hamstring connection to the SI joint via. So if it goes lateral, hamstring attaches at the proximal fibula, goes up the hamstring to the issu tuberosity, and then the issue tuberosity turns into the sacra tubus ligament.
[00:15:44] A sacra tubus ligament is what then crosses us across to the other si. right the fibers and then wraps us around our trunk into the ipsilateral. Same side neck that I [00:16:00] described is half of the spiral line of our body. The other half is the part distal to that proximal head of the fibula, and that is the po peroneus longus as it comes down, goes underneath our our foot.
[00:16:16] Um, and then the um, sensor. Digitorum longest as it comes up the other side that creates, um, I believe that's the other muscle in that. But either way, those muscles, those long muscles of the leg wrap around the fibula and the arch of the foot, and this is that rotational pattern in our body that's transferred throughout our body.
[00:16:39] Originates actually more in the trunk than the legs, but vice versa can do both to create our rotational locomotion. And so the fibula plays a very important role on our gait pattern and our, the balance of our arches, the rotation of our hip, the rotation of our [00:17:00] trunk via the sacrum. So it's interesting.
[00:17:05] Going back to what I talked about at the beginning that people would argue that defibrillate does, it doesn't really matter. I would say that description of the anatomy tells us that it really matters. And so what we often see too is what, like one of the most common injuries that we see with our clients is a, a lateral ankle sprain, a sprain of the ligaments that attach the fib.
[00:17:30] The distal fibula to the tibia, the distal tibia, and to the talus and to the calcaneus and, um, even sometimes the, the, um, cuboid bone and the, the other, um, tarsal bones of the foot. So, so often though, when people roll their. People are like, no big deal. Just rub some dirt on it and [00:18:00] keep going. And if you look in the literature for like studies on back pain and a lot of more of like chronic things, arthritis in the hip, arthritis in the knee, one of the like main factors that leads someone, um, down that path is actually a history of an ankle sprain, specifically a history of ankle sprain that was not rehabilitated.
[00:18:25] in every single lateral ankle sprain I've seen. Um, the fibula has been displaced anterior and in fact, Mulligan Brian, Brian Mulligan, I think is his first name. Um, he is a physio out of Australia or New Zealand down, down under somewhere. And. , he's most famous, so, so he is most famous for like, um, spinal snags and nags.
[00:18:59] Um, like a [00:19:00] type of mobilization with movement. Same thing, like that's who first brought us, like mobilization of movement for the hip joint with the, like seatbelt. Those are mulligan. Straps, Mulligan mobilizations. And, um, he proposes in his book, by the way, which is like one of the best books. It's a really small, quick read, but it's packed full with great clinical information.
[00:19:24] So if you've not read it, I'll link it in the show notes because I feel like every physical therapist, every athletic trainer, sports healthcare provider should really have read Brian Mulligan's work. So, um, anyways, he proposes that even grade one ankle sprains, the grade one ankle sprains that don't really have a lot of tissue disruption in terms of like true, um, spraining of the ligaments, um, is a subluxation of the distal fibula.
[00:19:55] And it gets stuck in that anterior position. So when we look at the joint, you know, and [00:20:00] I'm going back to the model here. When we look at the joint, when we dorsiflex. The fibula needs to posteriorly glide to allow the talus to. Shift back in the joint. If the fibula is stuck, it's gonna prevent the normal motion that's happening at the talus because it not just posterior glide happens in the talus with dorsiflexion, but a rotation happens in the talus too.
[00:20:34] As we go into dorsiflexion, the talus needs to actually rotate as. And, um, if the fibula is stuck forward, it prevents that external rotation of the talus. And so then therefore, then it can't glide all the way back posteriorly and vice versa. When we plantar flex, the distal part of the fibula [00:21:00] needs to move anterior, and that's what happens, right?
[00:21:04] The mechanism of injury of ankle sprain is often an inversion with plantar flexion, and so that can just jam the fibula up and the fibula acts as the teeter-totter. So as one end moves, the other end has to move, right? Just like a teeter-totter, but vertical. So when the distal fibula glides anterior, the proximal guide posterior and the vice versa.
[00:21:32] When the distal fibula moves posterior, the proximal moves anterior. So you can imagine too, if the lateral hamstrings and the. Structures at the proximal fibula. All of those ligaments in the popliteus are not functioning great. Then the pull from those muscles are pretty strong and it sort [00:22:00] of locks the fibula from moving in that teeter-totter motion.
[00:22:04] It doesn't allow the proximal head to go anterior and inferior very well. So everything is sort of connected in that way. . One of the main things I see that limits ankle mobility is when the fibula gets locked down and the entire lower leg gets sort of stuck in extra rotation and, and when that pattern is present, I almost always see some sort of limitation in the tib fib joints proximal in the distal.
[00:22:38] And so it's, it's a matter of, of playing around with anatomy and figuring out where it's coming from so it can come from that old history of an ankle sprain. Um, any swelling in the area really jams that bone up too. It just like, right, because when they're swelling there, I always tell my athletes the swelling's kind of like glue.
[00:22:55] It sort of gets really sticky. And if you're not good about moving [00:23:00] through it, um, and getting the swelling out quickly, then it, it just sort of like bogs down the movement of the bones and everything around those joints. Um, and then, Two, the proximal tib-fib joint and popliteal connections. You know, if anybody has, um, is like post.
[00:23:26] Rotational injury. So for me, for example, I have a lot of posterior corner problems and a lot of my athletes who have had ACL tears, even if they're repaired, still have some rotational instability at that, uh, true knee joint. And so this puts a lot of strain on the popliteus and those ligaments to, to, uh, function well.
[00:23:56] And then, um, the proximal [00:24:00] tib-fib joint is also what Jean-Pierre Barral refers to as a, um, witness to visceral issues, specifically visceral issues in the urogenital organs. And so oftentimes when there's a visceral issue, it gets reflected down there and locks up that joint. Part of this is the relationship between.
[00:24:23] The viscera, the viscera and the SI joint, and then the SI joint innervations.. I believe this is exactly what creates that witness, is that the viscera gets irritated that message is relayed via the obturator nerve to the SI joint because the obturator nerve innervates, the parietal peritoneum also, some of those urogenital organs have, um, innervations from, like the ligaments have innervations from the sacral plexus and the sacral [00:25:00] plexus and the obturator nerve innervates the SI joint along with the lumbo sacral trunk.
[00:25:06] . The lumbo sacral trunk turns into the sciatic nerve, which is the tibial nerve and the common peroneal nerve. The common peroneal nerve is the nerve that innervates that proximal tib joint. And so when that nerve is irritated from something else, it can lock down that tib-fib joint and create issues. So, um, another common.
[00:25:33] Thing and it's, it becomes chicken or the egg, is it locked down proximal and stuck in external rotation. So then you're not moving through your ankle joint correctly. So then you're not using your flexor halucis longus, or because your flexor halucis longus because it's just. is is weak because it's weak, does it tighten up and hold the whole leg in [00:26:00] external rotation?
[00:26:00] That is a pattern I see too because the flexor halicus halucis goes from the big toe underneath the arch and the medial side behind the medial maleolus, but then crosses underneath the Achilles over to the lateral side and attach. To the, um, sort of in between the fibula and the tibia in that deep posterior compartment.
[00:26:23] And so oftentimes when the flexor halucis longus is tight, it also pulls the whole lower leg into external rotation and locks up that fibula. So again, going back to the original, like term of fibula and peroneal, the word fasten. , or sorry, clasp or broach. This is again, why, you know, it's seen as a lock.
[00:26:50] That's like the same thing, and this is what I see with mechanics in the ankle, in the knee, in the SI joint, is [00:27:00] if the fibula is locked and not moving, right? If the fastener is closed, that the clasp is closed and not able to open it. There is effects up and down the chain, or it's closed because of effects up and down the chain.
[00:27:14] Both visceral, peripheral nervous system, and then mechanical old injuries. Right? So, What do we do about it besides just knowing that it is there? My favorite things to do is first obturator nerve glide. So in case there is a visceral issue, I'm going to influence it. So obturator nerve glide, and then again, I'm always rechecking motion.
[00:27:38] if it changes or not, and I have a video on Instagram that I'll link in the show notes that that sort of shows this process so you can see it in real time. Sometimes I will do a tibialis anterior like self-massage in the area of that proximal tib-fib joint. This is really good. It's a common entrapment site site for the common peroneal nerve, so [00:28:00] that can be helpful in that area.
[00:28:03] Then I will do a. Sometimes a common peroneal nerve glide. So again, just targeting that proximal tib-fib joint, but the common peroneal nerve glide. It also sort of targets some other things along the way. Um, and then after the common peroneal nerve glide, I'll do lateral ankle tilts. Lateral ankle tilts are really good to open up the distal tib-fib joint.
[00:28:31] which sometimes is what unlocks the proximal. And um, it's interesting cuz the lateral ankle tilt I got from my friend Missy Bunch, who's trained in ZHealth and they use that drill specifically for lateral hamstring issues. Makes sense, right? Cuz the lateral hamstring attaches to the proximal fibula. Um, and then, and then finally, once I get that bone to move doing all those other things.
[00:28:56] will sometimes use the Mulligan tape [00:29:00] procedure called the Fibular Repositioning Tape Job to. not, I don't wanna say hold it into place because then we're just locked again. But to facilitate the motion that's sticky. Right? And whether you believe the tape is doing something or not, that's on you. How I describe it to my athletes is it's kind of like me being able to do joint mob on you.
[00:29:20] Every step you take, whether that's from a sensory thing or from actual mechanical thing, I don't care because it has the same effect and. Hands down, it is the most favorite tape job for every single athlete of mine. They, even when I don't think they need it, they love it, they want it. And so like, who am I not to give it to them because it does make a difference.
[00:29:46] And just like my athlete felt yesterday, when you put it on for me, the relief, the, the thing that changes is a bunch of pressure in the posterior lateral corner of my knee and. That is [00:30:00] way easier to do that tape job and these drills to get my fibula moving than, um, signing up and getting my ACL finally fixed to, um, maybe fix my posterior lateral corner instability.
[00:30:14] So anyways, I hope this was helpful, um, definitely threw out a lot of anatomy. Um, but hopefully maybe this just has you wanting to go back, dive in and look at it. This is exactly what I do in all of my education courses is. . We look at the anatomy in this way and, and then how it relates to the viscera, how it relates to the nervous system, how it relates to movement, and then what to do about it.
[00:30:39] So I'll link a lot of those correctives, I hate that word, I hate using correctives. I'll link, I'll link a lot of those drills for the fibula, unlocking the clasp of the fibula in the show notes and enjoy. Have a great day.
[00:30:58] [00:31:00]
