0:04 This is Brent of the Brookbush Institute and in this video we're going over static release 0:08 techniques for the flexor hallucis longus and flexor digitorum longus, also 0:12 known as the FHL and the FDL or the long toe flexors. If you're watching this 0:18 video I assume you're watching it for educational purposes and that you are a 0:22 licensed manual practitioner. That means the laws in your state allow you to 0:28 perform manual release techniques: mainly, physical therapists, athletic trainers, 0:32 chiropractors and massage therapists. I'm going to have my friend Melissa come out, 0:37 she's going to help me demonstrate this technique. Now, these muscles are deep and 0:43 the posterior lower leg here is kind of sensitive when it comes to these manual 0:49 release techniques. Before I attempt FHL or FDL release, I'm want to be fairly 0:55 certain that these muscles are involved. So, Melissa, at this point, I'm going to have 1:01 done assessment and she's going to exhibit signs of lower extremity 1:06 dysfunction before I start poking around at these deeper muscles; that could be 1:11 anything from feet flat, feet turn out, knees bow in, knees bow out or excessive 1:15 forward lean on that overhead squat, a lack of dorsiflexion on goniometry. Maybe her 1:20 manual muscle testing for her tibialis anterior or tibialis posterior came back a 1:25 little weak. 1:26 Maybe that gastroc/soleus muscle length test showed me some changes in 1:31 extensibility in her plantar flexors. These would all be good reasons for me 1:35 to dig a little deeper, start palpating and see if I could find some increased 1:41 tissue tonicity or increased tissue density is what i'm actually going to 1:45 feel, with palpating the FHL and FDL. Now, to help you guys with the palpation part, 1:52 because that's probably the most difficult part of this technique. 1:55 I'm going to have Melissa scoot down just a little bit. I want to be able to control dorsiflexion 2:02 here with my thigh. 2:04 Right, so then what I'm going to do is, I kind of know where my trigger points are 2:09 for these muscles. I know that my FDL, it's kind of like a spot right between 2:15 the lateral and medial gastroc, but 2:17 a little higher than the lower border. It's like up a little bit. And then I 2:23 know my FHL, you guys have probably felt your flexor hallucis longus trigger 2:27 points or seen somebody try to roll at their flexor hallucis longus trigger points. 2:33 It's kind of a spot that seems to be inside the Achilles tendon, so if you've 2:38 ever seen somebody foam roll really low chances are that's not their gastoc or 2:42 soleus. Their gastroc or soleus ends up, well their gastroc up here and soleus here. 2:46 If they're just kind of rolling over what you thought was tendon, 2:50 chances are it's the muscle belly of the flexor hallucis longus which 2:54 lies deep to the Achilles tendon. What I'm going to do to palpate these is I 3:01 know that my FDL is a little bit more medial. Just medial to my fibula 3:08 here kind of on the lateral border of my tibia but pretty deep so I want to 3:14 palpate through my gastoc and soleus and then I'm going to have Melissa 3:18 wiggle her toes. No need for me to do guesswork here guys. If she wiggles 3:25 her toes, what I want to be able to feel is eventually under my fingers is 3:29 something that feels like this. Right if she just wiggles all of her toes, 3:33 I should feel some fascicles jumping around underneath my fingers and I need 3:38 to keep palpating until I feel that. 3:43 And it's better to take a couple extra seconds than to just be wrong. 3:48 All right, so I feel it right there. Now what I'm going to do is do my perpendicular 3:55 palpations to look for tighter fascicles and then I'm going to, once I find a tight 4:03 fascicle, I'm going to start looking for that nodule, that knot that I think 4:08 is contributing to the tightness in that fascicle. And right about here, 4:14 I find a nice little knot in Melissa's flexor digitorum longus. Now, 4:21 from here I could just press deep, I could use my dummy thumb to create a 4:27 nice, a nice thick palpatory spot and then push her into a little dorsiflexion 4:33 making sure that I'm including her toes this time because I got to push her toes 4:37 into extension to also lengthen those long toe flexors and then use my other 4:43 hand to supply the pressure. So this thumb goes between my thenar eminences. 4:49 Right, after I find that spot, nice broad palpation and I go right to the point of 4:58 increased tissue density, right where that issue starts to give back a little bit, 5:03 and I hold. 5:08 This is going to be a tender one though if I'm sitting here and pressing through 5:12 a lengthened gastroc and soleus. I'm going show you guys a trick here in a second 5:17 that'll make this technique a little easier. Now once I've done that, I can go 5:22 through, do the same thing with the FHL. Wiggle your toes for me. 5:26 FHL is actually a little easier to find because rather than palpating through 5:30 the thick gastroc and the thick soleus, you're really palpating through the 5:36 very ends of these muscles, you know. The gastroc actually is probably 5:40 has no fibers left down at this low. And the soleus is pretty thin here. I'm going to 5:46 do my perpendicular palpation here, 5:50 strumming those fascicles. Once I find a tight fascicle, I can then look for a nodule. 5:56 And I found that one pretty quick. Once again I'm going to use my nice 6:00 broad, whole thumb pad to push down on that trigger point. I'm going to put 6:08 some length in that tissue to once again put some tension in that muscle. 6:14 Or rather only goes to here, but put some tension in that muscle and 6:18 stabilize that trigger point, so it doesn't keep flopping around. I don't want to play 6:21 that finger tip on a marble game. And then press down. Again, I'm pushing through 6:29 some muscle so this is going to be pretty tender. So here I want to show you 6:34 guys a couple tricks so that you're not pushing through so much muscle. You do 6:39 have to know who you're doing this on, though. The first technique I'm going 6:43 show you, the individual needs to be a pretty stable, well-balanced individual 6:48 and the second technique, you definitely have to be aware of body position. So the 6:53 first thing I'm going to have Melissa do is get into a kneeling position. Now if she 6:58 gets into a kneeling position, she flexes her knee, I'm going to have use this foam roll to 7:04 get stable. I'm going have her put this leg out in front of her, right so the knee that 7:11 we're going to, or the side that we're going to work on, that's the knee that's 7:13 down. She has this leg in front of her to take on most of the weight. 7:17 She can lean over this leg even a little bit. You want to make sure 7:20 she's nice and stable so that she doesn't need knee flexion and extension 7:24 to keep her balance and then what I've basically done, actually, move this leg 7:28 back a little bit. What I've done is I've put her gastroc on slack. So now rather 7:36 than trying to push through all this stretched out tissue, and I've been 7:40 telling you guys for a few videos now with these manual release techniques, we 7:43 put tension into tissue to actually stabilize trigger points. It 7:48 increases tension. So to put some slack back now I can press straight down into 7:53 this trigger point. There's, and you can see Melissa's face, there's no 7:57 resistance until I hit her flexor digitorum longus. And now I can use the 8:04 same technique. 8:07 Same thing with her FHL, even though there's not as much muscle down 8:14 here, it's still so much less tension in this system, that pushing down 8:20 into her FHL is so much easier. 8:28 And once again I can hold for 30 seconds or until I get a release going right up to 8:34 that tissue barrier. I should start to feel it melt underneath my fingertips. If I'm 8:40 in constant communication with my client, "Hey, Melissa you starting to feel that 8:44 relax a little bit? Doesn't feel as bad as it did when I first pressed in. Good. 8:50 All right so the last position that works well, guys, but you need to have a little 8:56 bit of awareness and rapport with your client is this position, which kind of 9:02 looks like our hip flexor stretch, does take some balance and you notice I have 9:07 Melissa up on a treatment table, which becomes problematic if we're dealing 9:12 with somebody who's not very well-balanced.The last thing I would 9:14 want is Melissa to fall over this way as I'm doing all these techniques. Melissa 9:20 could go down into quadruped. So go ahead and go in to quadruped. 9:26 So quadruped does the exact same thing for me it's a very, very stable position. 9:31 But I just want you guys to watch. Obviously Melissa and I are close, we're 9:38 friends, we've been doing this a long time. If I push here and then put my 9:43 dummy thumb here and I'm not careful where I'm looking 9:48 my face is going to be very close to her backside which is not going to make 9:52 either you or your client very comfortable. You can sit down. 9:57 So although quadruped position is probably the best position to do that 10:03 technique in, guys just make sure that if you're going to do that you have enough 10:07 rapport with your client, with your patient to kind of explain to them the 10:12 position that you guys are going to end up in and then make sure as you're 10:16 pushing down maybe you practice this technique enough that you don't have to 10:19 look at your hands so much. I would definitely move rather than being center, 10:26 I would move off to the side of the table a little bit and then only lean so 10:32 that this shoulders over your arm for your pressure rather than being center 10:36 on. It's just a little uncomfortable and I don't want anybody getting in trouble 10:41 for, you know, a stupid reason of just lack of body awareness. So next we're 10:48 going to do our close-up review. So this is your close-up recap, guys, you can see 10:53 that I have the FDL and FHL common trigger points mapped out for you. 10:59 The FDL, the body of this muscle, where it's innervated by its nerve and where we 11:04 think these acute points of dysfunction happen, is generally right between your 11:09 medial and lateral gastrocnemius heads. Of course, deep to your gastroc and 11:15 soleus. So when I look for this trigger point, I'm not even a mess around. 11:21 I'm not going to try to hit it right on the money. I'm going to have my patient or 11:25 client go ahead and wiggle their toes, 11:28 you can even have them curl their toes against your thigh if you're in this 11:32 once again, this position with their feet hanging off so that you can control 11:36 the amount of dorsiflexion and plantar flexion. Keep going. And of course 11:40 I feel right there. Once I have that spot, I want to make sure I push Melissa into 11:47 dorsiflexion and toe extension. So you don't want your knee up here right, where 11:52 you're pushing her into dorsiflexion but her toes can flex 11:57 around your knee. You want to make sure they you almost got the toes pressed 12:02 into extension first, because these are long toe flexors, and then dorsiflexion 12:08 as you press down. That'll help stabilize where that trigger point is so you don't get 12:15 that flopping back and forth. Then you can use dummy thumb and apply enough 12:20 pressure to you all the way through gastroc and soleus until you start 12:27 feeling the tissue melt away, the discomfort start to reduce. Now, of course 12:35 this is FHL. FHL is a little easier to find as there's not so much tissue to get 12:42 through here. We'll use our palpations across the fascicles first, look for the 12:48 the densest fascicles. Move proximally and distally to try to find the nodule in 12:54 those fascicles. Once we found it we can kind of push with a nice broad thumb. No 13:00 need to press straight down and play the fingertip on top of a marble game. 13:06 Put some tension in that system to help you stabilize the trigger point. Push up 13:11 this way. I do find a little distal to proximal pressure, along with posterior 13:19 to anterior pressure helps. And I can do the same thing pushing right up to that 13:25 point where I see a big 13:27 increase in tissue density. So we know that we have this kind of 13:32 linear relationship where tissue density slowly increases as we press into tissue 13:38 and then all of a sudden as we hit that trigger point, get deeper, all of a sudden 13:44 tissue density ramps up real fast. We want to be just in that trough. 13:49 And, of course I showed you guys the trick of getting some of this tissue, 13:56 getting the calf issue out of the way. Well, the gastroc and soleus 14:00 anyway and then adding a little bit of laxity back to the Achilles tendon by 14:05 having your patient or client go into either a kneeling position or a quadruped 14:11 position. Just be real careful on where you end up versus where they end up and 14:16 and you're having that conversation about why you're doing what you're doing. 14:22 You can see now just as I poke her gastoc here, there's no 14:27 resistance and it's because we put some tension back into her gastroc. I can push 14:33 straight down, almost like the first resistance I feel is her flexor 14:38 digitorum longus. This is of course just thumb over thumb compression, which I 14:45 wouldn't necessarily use on these techniques. We'd go back this way and then 14:51 go hand over thumb and that helps save our thumbs a little bit. Once again, I 14:56 could use 30 seconds or until I feel the tissue melt away or I could use those 15:01 multiple repetitions of five second holds. Let's say she was so tender that I 15:07 couldn't even get to that increase in tissue density, I could slowly work into 15:11 it with five second holds until the tissue desensitized enough for me to 15:17 actually get some sort of mechanical release. So there you guys have it. FHL and FDL 15:23 static manual release technique. Great technique to add to your repertoire of 15:29 very overlooked set of muscles. Muscles that do have a propensity to become 15:35 synergistically dominant 15:36 in lower extremity dysfunction. Ensure that you are doing assessment first and 15:41 you're pretty sure that these muscles are involved because that back of that 15:45 leg is a sensitive area to be pressing on and remember you're going to have to 15:50 press through quite a bit of tissue through your gastroc, through your 15:54 soleus. Be careful as you experiment with the other positions we showed you - the 15:57 kneeling and the quadruped position. Make sure that you explain to your 16:02 client what you're doing and where your body positions are going to end up so 16:05 there are no misunderstandings. And of course grab some friends and get to 16:10 practicing before you pull this out with patients and clients. I think just having 16:16 it done on you as well as doing it to other people and then being able to 16:22 compare with you and your colleagues is such a wonderful learning experience. As 16:28 a profession, we don't do enough to work together in groups 16:34 I really think that every clinic, every PT should have a group that they go to 16:42 where we could do some maybe practice together because manual techniques done 16:49 on manual therapists with interaction, that's some powerful learning. I look 16:55 forward to hearing about your outcomes. I look forward to hearing about how this 16:59 changed some of the outcomes you saw when you added it into your repertoire. 17:04 I'll talk with you soon.
