0:04 This is Brent of the Brookbush Institute, 0:06 and in this video we're talking about 0:08 tibialis anterior manual muscle testing 0:11 for an active population. In this 0:14 video, we're going to talk about more 0:16 provocative ways to test the tibialis 0:18 anterior for those individuals who 0:20 started out active or athletic and end 0:23 up coming to us with some postural 0:26 dysfunction or some sort of pain. I think 0:29 manual muscle testing has lost some 0:30 favor with this group of professionals- 0:34 being the sports medicine, orthopedic and 0:36 human movement science professionals, 0:38 because although that one through five 0:40 grading scale is great in a clinical 0:43 setting, once you really get into the 0:45 3+ to 5, which is what we're using, 0:48 it becomes a little ambiguous. We don't 0:51 generally see those individuals who 0:53 can't move a limb against gravity. We 0:55 don't generally see those individuals 0:57 whose "fair" on a test is going to be 0:59 sufficient enough to get them back to 1:02 their previous level of activity. We 1:05 need to find ways of making these tests 1:07 more provocative and find a grading 1:09 scale that will work for us to help us 1:13 track how our patients and clients are 1:16 doing, as well as help determine what 1:20 intervention we should be using or 1:22 shouldn't be using with that individual. 1:25 I'm going to have my friend, Melissa, come 1:26 out. She's going to help me demonstrate. 1:28 It is important that you learn the 1:32 positions for manual muscle testing for 1:34 each one of these muscles, regardless 1:37 of whether they're active or not. We're 1:38 going to be testing the tibialis 1:39 anterior. It's important that you 1:41 understand that if you had to take 1:43 gravity out of this test, because their 1:46 that weak, deconditioned, or there's some 1:49 sort of neurological dysfunction, then that 1:51 position would be on the side. If all you 1:54 needed was a "fair" and you 1:57 just need that person to be able to pick 1:58 up their foot against gravity, all I'd 2:00 have to do is flip Melissa's feet around, 2:02 have her legs dangling and be able to 2:04 pick up her feet. But then, we get into 2:08 activity. Let's say Melissa has 2:10 come in and 2:11 is complaining about knee pain. I've 2:13 had her do an overhead squat assessment, and 2:15 I can see that her feet flattened. 2:18 Under normal conditions, I think you'd 2:20 all agree that if we just- "Dorisflex 2:22 flex for me and invert. Good." If I just 2:25 had her do this and I pulled, I could 2:27 probably pull her off the table by her 2:29 tibialis anterior. You're all going, 2:32 "Wait a second, that means her tibialis 2:33 anterior is strong." But like I said, she has 2:36 feet flat. I know there's something wrong 2:38 with her inverters. Let's go ahead and 2:41 back up. We're going to find a way to 2:44 make this test more provocative. With 2:48 that being said, I'm no longer going to 2:49 use 3+, 4, 4+, and 5. That's the 2:54 Kendall scale. We're going to leave that 2:56 with those tests. Those have been 2:58 researched and we have some data on those 3:02 scores. I'm going to use just a different 3:04 very simple test. That testing score 3:07 is- "Go ahead and pull up." 3:10 One score is "strong"- she can hold the position 3:14 I put her foot into, in this case, without 3:17 any sort of compensation with a 3:20 significant amount of resistance. 3:22 Another score she could get is "weak"- 3:25 when I pull on her foot, it 3:28 gives with pretty 3:30 minimal resistance. A very common one, 3:33 and this is one that hopefully gets 3:35 your anatomy geek-out, human 3:38 movement science geek-out brains 3:40 thinking is I have her pull up and I pull 3:44 down on her foot. The first thing I 3:46 see is her toes flare up and 3:48 she pulls me into some eversion with her 3:51 dorsiflexion. So, now we have "with 3:54 compensation." We have "strong"- she 3:58 maintains the optimal position; "weak"- she 4:01 just breaks; and now we have "with 4:03 compensation." I said that should 4:06 make your anatomy geek brains work, because 4:08 you need to start thinking about what muscles 4:11 are trying to compensate, 4:13 what muscles are 4:14 synergistically dominant and are trying to take 4:16 over for an inhibited tibialis anterior 4:19 if we see additional toe extension and 4:24 eversion. The last score 4:27 I would give a test like this is- I pull 4:30 on her foot and she goes, "Ow." She 4:34 goes, "Ow," so that hurts, and that's 4:36 going to be "with pain." If 4:39 you're not a licensed professional, it's 4:41 going to be a good indicator that you 4:44 probably need to refer this person out 4:46 to a licensed professional. If you are a 4:48 licensed professional, obviously, we know 4:50 that might mean that we have to go in a 4:51 totally different direction with our 4:53 testing. Let's get into the test 4:56 itself. The traditional manual muscle 4:59 test is- "Go ahead and dorsiflex and 5:02 invert with me." I would then take my full 5:04 hand, because I don't want pressure points here. 5:05 That probably just hurts being 5:07 poked with a finger. You want to 5:09 take that whole hand and try to pull her 5:12 down into dorsiflexion and eversion 5:14 against her tibialis anterior. Can 5:18 she hold that? Oh, she seems pretty 5:21 strong. Like I said, I'm trying to find 5:24 ways of making this more provocative. The 5:26 common compensation pattern for the 5:28 tibialis anterior involves this eversion 5:31 and toes flare up. What dorsiflexors 5:35 evert and extend the toes? You have 5:37 extensor hallucis longus and extensor 5:39 digitorum longus, your EHL and EDL, who 5:42 have a propensity to become 5:44 synergistically dominant. For a tibialis 5:46 anterior, that's being inhibited by a 5:50 short, overactive gastroc complex. 5:54 How am I going to get those 5:55 muscles out of this test? I'm going to 5:58 have her pull up and in, flex her toes, 6:03 and now I've reciprocally inhibited her 6:06 long toe extensors. Now let's see if 6:09 she can maintain. And all of a sudden, 6:12 it's not so easy for her. She's actually 6:14 breaking under fairly minimal resistance, 6:17 considering how strong we need our 6:20 tibialis anterior to be. 6:22 Here's the last thing we're going to do to 6:26 make this a little bit more provocative. 6:28 We're all aware of this kind of 6:30 relationship where if you're not strong 6:32 and have good neuromuscular control 6:34 within a certain range of motion, you're 6:36 probably going to lose that range of 6:38 motion. When Melissa came in to see me, 6:40 she was lacking dorsiflexion. What I 6:44 did today only fixed one of her 6:49 ankles, because I figured it would be fun 6:51 to watch her walk in circles. I only 6:54 fixed her right ankle and here's why. Not 6:57 only do I want her to be able to hold 7:00 dorsiflexion and inversion with toes 7:03 flexed, but I want her to be able to do that 7:05 throughout her entire range of motion. 7:07 She's not going to have as much 7:09 strength in the shortened position or 7:13 the maximally shorten position, but she 7:15 should have some strength throughout 7:16 that full range of motion. You'll 7:18 find that you'll get somebody's 7:20 mobility back, help them into 7:23 dorsiflexion and inversion with toes 7:25 down, and sometimes after you let go, 7:29 you'll see them drop back into their 7:32 comfortable or prior range of motion. You 7:36 might find that it takes a little 7:38 resistance, but the same thing- all of a 7:41 sudden it's like- and then they stop at 7:44 the range of motion they had 7:45 neuromuscular control or strength in 7:47 before. All of these particular signs 7:52 as we've gone through this are 7:56 indications of weakness. You might 7:58 have to make some notes that say "only weak 8:00 in new range of motion, five to 8:03 15 degrees of dorsiflexion." These are 8:07 definitely some results that give us an 8:10 indication that maybe we should be doing 8:12 a little bit more tibialis anterior 8:14 activation or a little bit more 8:17 tibialis anterior strengthening. 8:20 Just because- "go ahead and throw both 8:21 feet up" we could use the traditional 8:23 test- "don't worry about your toes, just 8:24 pull your feet up as hard as you can." 8:25 Even though the traditional test would 8:27 allow me to pull her right off the table 8:29 by her tibialis anterior, if she's 8:32 coming in here complaining 8:34 of pain, she has flat foot, and when I'm a 8:37 little bit more careful about how I do 8:39 this test- I don't let her use her 8:41 overactive synergists I make her go all 8:44 the way to end range, and hold it, and 8:45 then I apply pressure, and if there's a little 8:47 weakness- we're not done. If 8:51 returning back to "normal activity" for 8:55 this individual includes any sort of 8:57 sport, athletic endeavor, resistance 9:01 training, then we have more work to do. There 9:04 you have it. This isn't the 9:07 traditional manual muscle testing, but it's 9:09 manual muscle testing for an active 9:11 population. We see that Melissa 9:15 is testing a little weak at her end 9:19 range. The other things we might 9:22 see would be "strong," that's what we're 9:24 working for. We could have seen 9:27 "with compensation," which would have been 9:29 toes flare and into eversion. We don't 9:32 want that, which is why we also 9:35 curl the toes on this test. Of 9:38 course, the last result that you might 9:39 get is "with pain," which, if you're not 9:44 a licensed professional, that's probably 9:46 time to refer out or at least check 9:48 with a licensed professional to make 9:50 sure that this person is safe to 9:52 continue on with activity. I look forward 9:54 to hearing about you guys using this 9:55 test. I'll talk with you soon. 10:04
