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

Earn CME/CE in your profession:

Continuing Education Activity

Fibular head somatic dysfunction can cause knee and ankle pain. This activity reviews the evaluation and treatment of fibular head somatic dysfunction. It also describes the muscle energy technique and high-velocity low-amplitude technique for treating fibular head somatic dysfunction.


  • Review the anatomy of the fibula and its motion.
  • Summarize how to evaluate fibular head motion.
  • Describe how to treat fibular head somatic dysfunction with muscle energy or high-velocity low-amplitude OMT.
  • Review some contraindications to treating fibular head somatic dysfunction with muscle energy or high-velocity low-amplitude OMT.


Osteopathic medicine is a branch of medical training that focuses on the mind, body, and spirit when treating patients.  It is formulated on the basis that the mind, body, and spirit are interconnected, and interruptions in the function of these components can lead to pain or other ailments. Osteopathic manipulative treatment (OMT) is a collection of manual manipulative techniques used to treat dysfunction in the body unit. Its goal is to improve the range of motion of muscles or joints, enhance neuromuscular function, decrease overall pain, and improve biochemical balance.[1]

Somatic dysfunction is an impaired function of the fundamental elements of the body. It can include the musculoskeletal, nervous, vascular, and lymphatic systems and combinations of these systems in affected areas of dysfunction.[2] The clinician can utilize OMT techniques in areas of somatic dysfunction to assist the body in self-healing. 

Fibular head somatic dysfunction is a potential cause of knee and ankle pain, as well as gait abnormalities. The fibula is a small bone that is part of the distal lower extremity, located laterally to the tibia, that plays a role in both the knee and ankle joint motion. When it is not moving properly, some patients can experience knee pain, ankle pain, or difficulties with their normal gait.

Two OMT techniques are commonly used to treat fibular head somatic dysfunction. These techniques are the muscle energy technique and the high-velocity low-amplitude technique. Muscle energy techniques are used to mobilize joints in which movement is restricted, strengthen weak muscles, stretch tight muscles and fascia, and improve local circulation.[3] 

Muscle energy is a direct and active technique that utilizes cooperation between the patient and the physician.  In this technique, the patient will be instructed to contract the target muscle while the physician provides a counterforce to that muscle. High-Velocity low-amplitude techniques are used to engage a restrictive barrier in one or more planes by applying a rapid, short force by the physician. This thrust is applied within the anatomic range of motion that is restricted. 

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.  


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


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 


  • 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


  • 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


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


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]



Nicole Decker


Alexander Pozun


3/8/2023 8:43:52 PM



Bodine WA. Osteopathic Manipulative Treatment: A Primary Care Approach. American family physician. 2019 Feb 15:99(4):214     [PubMed PMID: 30763051]


Ingold CJ, Ratay S. Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs. StatPearls. 2023 Jan:():     [PubMed PMID: 32965970]


Goodridge JP. Muscle energy technique: definition, explanation, methods of procedure. The Journal of the American Osteopathic Association. 1981 Dec:81(4):249-54     [PubMed PMID: 7319853]


Gupton M, Munjal A, Kang M. Anatomy, Bony Pelvis and Lower Limb: Fibula. StatPearls. 2023 Jan:():     [PubMed PMID: 29261984]


Resnick D, Newell JD, Guerra J Jr, Danzig LA, Niwayama G, Goergen TG. Proximal tibiofibular joint: anatomic-pathologic-radiographic correlation. AJR. American journal of roentgenology. 1978 Jul:131(1):133-8     [PubMed PMID: 97965]


Scott J, Lee H, Barsoum W, van den Bogert AJ. The effect of tibiofemoral loading on proximal tibiofibular joint motion. Journal of anatomy. 2007 Nov:211(5):647-53     [PubMed PMID: 17764523]


Ogden JA. The anatomy and function of the proximal tibiofibular joint. Clinical orthopaedics and related research. 1974 Jun:(101):186-91     [PubMed PMID: 4837930]


Poage C, Roth C, Scott B. Peroneal Nerve Palsy: Evaluation and Management. The Journal of the American Academy of Orthopaedic Surgeons. 2016 Jan:24(1):1-10. doi: 10.5435/JAAOS-D-14-00420. Epub     [PubMed PMID: 26700629]


Earley BE, Luce H. An introduction to clinical research in osteopathic medicine. Primary care. 2010 Mar:37(1):49-64. doi: 10.1016/j.pop.2009.09.001. Epub     [PubMed PMID: 20188997]


Prinsen JK, Hensel KL, Snow RJ. OMT associated with reduced analgesic prescribing and fewer missed work days in patients with low back pain: an observational study. The Journal of the American Osteopathic Association. 2014 Feb:114(2):90-8. doi: 10.7556/jaoa.2014.022. Epub     [PubMed PMID: 24481801]

Level 2 (mid-level) evidence


Johnson JC, Degenhardt BF. Who Uses Osteopathic Manipulative Treatment? A Prospective, Observational Study Conducted by DO-Touch.NET. The Journal of the American Osteopathic Association. 2019 Dec 1:119(12):802-812. doi: 10.7556/jaoa.2019.133. Epub     [PubMed PMID: 31790126]

Level 2 (mid-level) evidence


Waxenbaum JA, Lu M. Physiology, Muscle Energy. StatPearls. 2023 Jan:():     [PubMed PMID: 32644455]


Nichols JA, Baratta C, Reb CW. Biomechanical Sequelae of Syndesmosis Injury and Repair. Foot and ankle clinics. 2023 Mar:28(1):77-98. doi: 10.1016/j.fcl.2022.10.004. Epub 2023 Jan 2     [PubMed PMID: 36822690]


Huber T, Schmoelz W, Bölderl A. Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: A cadaver study. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. 2012 Sep:18(3):203-9. doi: 10.1016/j.fas.2011.11.003. Epub 2011 Dec 7     [PubMed PMID: 22857964]