by Mitch Hauschildt, MA, ATC, CSCS
In part 1 of this 2 part series, we discussed why we need Tibial Internal Rotation. If you missed it, click here.
Now that we understand the need for it, let’s talk about how we can improve it. If you are like me and use Selective Functional Movement Assessment (SFMA) methodology, it would be classified as a Joint Movement Dysfunction or JMD. My experience with most JMDs is that they are best improved with manual joint mobilizations. That’s not to say that they can’t be improved with self mobilizations on the part of the patient, but I find that if given the opportunity, they will improve more quickly and to a larger degree with manual therapy, so that’s where I choose to spend the majority of my correction time.
I have seen several different techniques for correcting a Tibial internal rotation restriction, but my “go to” is a sidelying joint mobilization.
It is performed with the patient lying on their side with the leg to be treated as their top leg. Thus, if you are treating the right leg, have them lying with their left side down and their right leg on top. Keep the lower leg straight or slightly bent with the top knee stacked on top of it. The top leg should be bent to 90 degrees or slightly more. This position effectively blocks any movement at the knee or above because when you take the lower leg into internal rotation, the knee is blocked by the bottom leg.
Once in this position, place the ankle into their end range dorsiflexion. This locks out the ankle and ensures that all of the rotational movement will take place in the lower leg and not in the foot. Not doing this is the number one mistake that I see with people performing this mobilization for the first time.
Hand placement to grip the ankle and foot becomes important at this point. It isn’t all that important that you use the same grip that I do (which may or may not be possible depending on the size of your hands and the size of the foot), but what is important is that you are able to control the calcaneus and keep the foot in dorsiflexion.
From there, the mobilization is pretty straight forward. Rotate the lower leg into internal rotation until you feel the end range of motion. Perform small oscillations to free up the joint. You can perform the sets and reps that you prefer and keep after it until they can actively reach 20 degrees or more of internal rotation. This make take several sessions depending on how their body responds to the treatment and how much improvement needs to be made.
My other preferred mobilization for Tibial internal rotation is a technique that I picked up from Erson Religioso, III, DPT, FAAOMPT. With the help of his mobility bands, you can perform a version of a Mulligan mobilization to work through their restriction. The advantage of this technique is that it is performed in a closed chain (as a general rule, the more I can do in closed chain the better), and once the patient understands the goals and technique, they can also perform it on their home if you choose to allow them to.
The position is half kneeling with the leg to be treated in front with the tibia vertical. I prefer to use a mobility band around the upper calf, but you don’t have to (all it is really doing in this movement is assisting you with gripping the lower leg by capturing a lot of tissue). The patient’s responsibility is to push their knee forward over their 2nd and 3rd toes, taking their ankle into dorsiflexion.
At the same time they are moving forward, you will manually internally rotate the lower leg (make sure you don’t take them into valgus at the knee while rotating them). The mobilization occurs with the repetitive dorsiflexion and internal rotation that happen in unison between you and the patient. It is a bit of a task to get them to coordinate with you at times, but with a little bit of practice, it can be done efficiently.
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