Q&A Time! How Do You Improve Tibial IR? | Modern Manual Therapy Blog

Q&A Time! How Do You Improve Tibial IR?

starting position
Today's Q&A is from OMPT Channel subscriber who wants to know how to improve tibial IR.

look for supination, toes lifting off, assess actively and passively
make sure the knees/hips stay still!

The above pics are a great self screen to teaching patients!

Lack of tibial IR is a very common dysfunction in the lower quarter. This is a chicken or the egg thing, it could be due to a lack of dorsiflexion, leading to ankle eversion in stance phase, causing tibial ER. This could also be caused by inhibited or weak gluteus medius, this causing facilitation in the TFL and causing more tone in the ITB. This could lead to a further cycle of loss of tibial IR.

A lack of tibial IR could also cause a loss or pain with
  • knee flexion
  • ankle dorsiflexion
To improve tibial IR, I start with the EDGE and treat the lateral patterns of the upper and lower leg 2-5 minutes per pattern. A facilitated ITB could prevent tibial IR, and restrictions in the lower leg patterns (bony contours of the lateral tibia) could prevent fibular head antero-lateral glide, which is really a component of tibial IR.

I then teach the patient self tibial IR mobilization with movements, repetition and end range is key 

After the IASTM, I perform some open chain then progress to closed chain MWM for tibial IR then teach the patient this for HEP. You should see some rapid changes in knee flexion, but less so for ankle dorsiflexion. 

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  1. This is very interesting, I am a first year DPT student and when we were discussing tibial IT/ER rotation, it was sort of skimmed over and disregarded as a movement that might cause significant issues. It's refreshing to see a different take to what I have learned and see the big limitations that these small motions can cause

  2. Hey, you're lucky! I didn't have these resources when I was in school. I never even thought about it. Tibial IR is often thought of just a component without looking at is as a biomechanical limitation.

  3. Good post Dr. E! I was talking to a colleague this weekend about treating knees and told him I encouraged tibial IR (as he was saying to go more ER as the 'lock in mechanism'. I told her to try it and see what he thought...

    I like the mobilization with movement technique too as the patient performs active range. Honestly, I teach my students to think about the knee as a 3d component, rather than just a hinge joint. More than likely IR will work...but in some, you may have to incorporate ER. Just go by symptoms...

    I sometimes get the patient to "internally rotate the tibia" by performing more of an ankle inversion moment when he or she performs LAQ, SLR Flexion, etc. It works.

  4. In the self screen above, is the patient simply performing inversion while seated? I have enjoyed following your blog and have learned some great techniques

  5. Inversion, yes, making sure the feet stay flat, should be 10 deg IR and 10 deg ER.

  6. Thanks HV, I have used tibial ER with extension on occasion, but the common loss is of IR, wouldn't you agree?