0:05 This is Brent of the Brookbush Institute, and in this video we're going to go over a joint 0:07 based manual therapy technique. If you're watching this video I'm assuming you're 0:11 watching it for educational purposes, and that you are a licensed professional 0:14 with joint based techniques within your scope. That means osteopath's, chiropractors, 0:20 physical therapists,, you're probably all in the clear. Physical therapy assistants, 0:24 athletic trainers, massage therapists, you need to check with your governing body 0:28 in your state or region to see whether this is within your scope of practice. 0:32 Personal trainers this is definitely not within your scope of practice, of course 0:36 all professions could use this video for purely educational purposes to help with 0:41 learning biomechanics, anatomy and of course palpation. In this video we're 0:46 going to do anterior to posterior talus mobilization that's talus on 0:50 tibia. I'm going to have my friend Melissa come out, she's going to help me 0:53 demonstrate. Now in this video we're going to do this mobilization likely 0:58 with the idea that we're going to try to reduce arthrokinematic stiffness 1:04 to improve dorsiflexion. Do you guys remember your convex on concave 1:09 rule, that's glide opposite role, that's a pretty good foundation for the ankle. 1:15 It doesn't always work out for every joint that the convex on concave rules 1:19 work, but for the ankle it works out pretty good. We also have a lot of 1:22 research to kind of back up that we get stiffness from anterior to posterior 1:27 with the talus, the other motions not so much. You know some of like chronic 1:32 ankle instability you'll even see where you'll be hypermobile in all other 1:36 directions, but for some reason anterior to posterior motion still stiff. So now 1:43 that we kind of have that set up, how am I going to go about setting up this 1:47 mobilization. Well you're going to need to know your Anatomy, you should probably 1:49 know what precautions you should have, you should be aware of, rather. You need 1:54 to know what your hand position should be, and then of course we want to kind of 1:58 talk about patient and your own set up body position wise for good technique. 2:02 I'm going to have Melissa scoot down a little bit this way, she's going to throw 2:06 this leg off the table right. Now I'm just having to throw that leg off the 2:10 table, so you guys can see her ankle as far as palpation goes, just a real 2:16 quick reminder guys the more palpation skills you have 2:20 the easier getting your hand placement right is going to be. So things like 2:27 knowing where your navicular tubercle is, and knowing how to fall off your 2:30 navicular tubercle to the neck of your talus, or knowing where your 2:33 sustenaculum tali is, or how to find your lateral and medial malleolus or your 2:38 cuboid. All of that stuff helps for now my hands are down, where is what I'm 2:47 looking for relative to where my hands are. Now the easiest way to find the neck 2:52 of your talus is actually find the bottom of your medial malleolus, find the 2:56 bottom of your lateral malleolus. Draw a line between your fingers an 3:02 imaginary line, and put the web-space down right over the top of that line. Chances 3:09 are your web-space is now over the neck of your talus which is where we're 3:14 going to apply a force. Now when you're using your web space you would be 3:18 surprised to find how the web space here, which I know you guys think of this 3:23 loose skin, can feel like a chisel digging in the bone. You have to be 3:29 careful when you're doing manual techniques. What you think might be soft 3:32 doesn't feel soft, and I think the reason being is if you guys get real taut with 3:38 the web-space and then come down straight this way, you're actually your 3:42 your surface area there isn't very big all right. What I would suggest is 3:47 keep your hand relaxed, you can kind of even fold it around the ankle, and then 3:52 rather than use this part of your web-space I would flop your hand down so 3:56 you're using this part of your web-space, that will feel a lot softer and you'll 4:00 still be able to get more than enough force to drive this bone posteriorly. 4:05 Now with this hand we're going to need to control the ankle, because although 4:12 the tibia is supported by the table, we need to be able to control this so that 4:18 we can get the direction of force that we're looking for. Now what I like to use 4:23 is the same setup I use for the manual calf stretch which we showed in a 4:27 previous video. I'm going to wrap my hand around the calcaneus and then bring my 4:34 forearm underneath the ball of her foot just like so. Now stay away from doing 4:40 this, I see a lot of people do this getting lazy because for some reason 4:45 they can't quite get this figured out, and I know it's kind of a funky little 4:48 hand position that you get there, but this is going to rip your fingers apart; 4:52 and you're going to have to really try to muscle dorsiflexion. Going this way I 4:57 can lock out my elbow and now I can control dorsiflexion just by leaning 5:02 right, by swaying with my legs I can actually control eversion and inversion 5:07 really well too. I mean I have like a good grip on her calcaneus. I had good 5:11 control of her foot so that's this hand position here. We talked about this hand 5:16 position here being right over the neck of the the talus, and I'm going to go 5:22 ahead and pull her up to her first for the resistance barrier. We do have some 5:25 research that's starting to suggest that maybe mobilization should be done at end 5:30 range right, or end of available range providing it's pain-free. 5:34 So anterior to posterior mobilization down here may not be as effective as an 5:41 anterior to posterior mobilization here. So I'll pull her up to dorsiflexion. 5:46 Now what else do I got to think about, all right patient's body position should 5:51 look comfy right. So she's laying down, I kind of already put her in the right 5:55 body position. Make sure guys that you have the calcaneus hanging off the table 6:00 right, because if you put the calcaneus on the table your fingers are 6:04 essentially going to get smashed. Your body position is important on this. I 6:09 think you'll notice that I have to bend over just a little bit to get in good 6:14 position here, that's actually purposeful because I'm not trying to pull up I'm 6:20 trying to push down. So once I start doing my oscillatory mobilizations I 6:26 want to be able to use my body weight to do that, and not be like trying to like 6:32 manhandle an anterior to posterior mobilization. Although maybe I'm big 6:37 enough and strong enough to pull that off, your ankle is a fairly strong stiff 6:41 joint with some really big muscles that cross it, at least some really strong muscles 6:46 that cross it. And I know some of you guys aren't necessarily as big a human 6:51 being as I am, and some of you guys have to treat really really big people, you 6:55 know you've got to use your body mechanics to your advantage. So I'm 6:59 bending over just a little bit because I want my chest right over the top of my 7:04 arms, so that now I can just do this. You guys see how that's nice and comfortable 7:10 for me. If I need more dorsiflexion I can just sway, reposition my feet and I can 7:18 just push down using my body weight. This is really easy for me. I feel like I 7:24 could do this for at least a few minutes and as many times a day as I needed to. 7:29 Now let's talk a little bit about protocols around mobilizations. I don't 7:35 really want to set up a debate on which protocol is the best. I know some of you 7:40 guys use more of like a static hold technique and I think that can be very 7:44 effective. I've seen seven holds of seven seconds. I've seen ten five-second holds. 7:50 I've seen all sorts of oscillatory techniques. I happen to be a Maitland 7:55 certified therapist, so you know I use one to two oscillations per second doing 8:03 those grade three and four mobilizations for increasing mobility. I don't really 8:11 care what protocol you use as long as it's effective, as long as your 8:15 reassessment is showing it's effective. I would say the biggest mistake I see 8:19 students make is maybe they don't follow through with the whole protocol. So 8:23 you're doing one to two oscillations per second, and you should be doing them for 8:26 30 seconds. What I see is most people giving up after 10 or 15 seconds. It's 8:31 not that they didn't follow the protocol up to that point, they just don't stick 8:35 with it long enough. With that being said I think all of the techniques have 8:39 something in common, which is they're very aware of resistance barriers. So 8:44 when I get into this technique it's important that I start trying to feel 8:48 the joint play, the motion of the talus, even if I have to move 8:54 my hands around like you just saw me do. Alright okay, all right am I feeling 8:59 what I what I think I'm feeling, okay good good, got it. 9:03 Alright so there's my first resistance barrier is right there, and then if I 9:07 push down I get end right there, and then most mobilization techniques occur at 9:14 around the 50% range, somewhere between 50 percent resistance. 9:19 Alright so halfway between first resistance barrier and end, so 50%, some 9:25 go all the way to like way down towards the end range. Although that's a a bit 9:30 more of an aggressive mobilization, just kind of be aware of what you're doing. I 9:34 think the thing to take away from all of these protocols is be aware of your 9:40 resistance barrier, be aware that most of your mobilizations are not going to 9:43 happen at the absolute extreme of arthrokinematic motion. They're going to happen 9:49 somewhere between your first resistance barrier and the end. And then of course 9:54 guys whatever protocol you use -follow through. Make sure you do all of the 10:00 protocols. So if it's seven second holds, then make sure you do all seven 10:05 second holds right. If you're going to do oscillatory techniques, and it's important 10:12 that I do oscillatory techniques long enough, that I start feeling a decrease 10:20 in passive resistance, even if that takes 60 seconds. 10:29 And of course after I'm done with this technique I'm going to reassess. As I've 10:37 said so many times before in so many videos, assess address reassess. Just 10:45 because I think I feel passive accessory stiffness, 10:49 just because I think this might be good technique for Melissa, doesn't mean it 10:54 actually is. If my goal was to increase dorsiflexion, or for example she had an 10:58 excessive forward lean on her overhead squat, and I thought that increased 11:01 dorsiflexion would help; and I get her up do the overhead squat it doesn't look 11:06 better, do goniometry she hasn't gained any dorsiflexion, I need to start 11:09 thinking about a different technique. Stay tuned for the close-up recap. For a 11:14 close-up recap you guys can see here if I find the bottom of the medial 11:19 malleolus, the bottom of the lateral malleolus I end up with a line between 11:24 those two points. That puts me right over the neck of the talus. 11:28 It's just like that, just right there and right in that angle of the ankle. I can 11:33 actually if I if I just take one hand even, and kind of wrap around the bottom 11:37 of the foot, I can even get a little bit of joint mobility there, I can steal the 11:41 joint play. So if I put my web-space down over like this 11:47 I grab the bottom of her calcaneus, put my forearm around the bottom of her foot. 11:52 Now I'm all set up. My body is over the top of my hand so I'm ready to apply 11:58 that anterior to posterior force. I probably should think real quick about 12:03 my precautions when I first kind of start into this technique. Do I get any 12:09 grunts/groans or extreme facial expressions, and so did I did I pinch on 12:17 that peroneal nerve that we know is over here, and sometimes we'll will over 12:22 stretch that nerve real quick and get at that shearing burning pain. If you guys 12:25 do that just move your hands a little bit. 12:27 Remember that nerves aren't very wide, you should be able to get other way 12:30 pretty easy. The other thing we want to make sure is if I push down are they 12:35 relaxed, because Melissa can you dorsiflex, I don't know if you guys, so right 12:40 there guys, that's the tibialis anterior. And then if she started guarding on me 12:44 with this jacked tibialis anterior of hers, this tendon is going to kick me 12:50 right out of the neck of the talus. It's going to be real hard to get an 12:53 anterior to posterior mobilization. I'm far more likely to just be molding her 12:58 tibialis anterior tendon and I don't really know what the benefit of that 13:02 would be. The other precaution we might think about is the ankle is one of 13:08 those joints that can get locked, but still be hypermobile. Every once in a while 13:14 you'll run into somebody who you know that they feel stiff at first, and if you 13:19 get real aggressive with them you'll get a little pop or a click; they'll move a 13:24 whole lot on you and you can pinch that capsule and that'll give you some 13:29 swelling of the ankle, they would they will not be happy with you at all. So 13:34 once you get your hand set up guys I would just just kind of start in nice 13:39 and gentle, give a couple like tests pushes before you apply your full force 13:47 of pressure. I'm not getting any kickback from Melissa here, so now I'm going to 13:52 find my first resistance barrier. I'm going to go ahead and push down and find 13:56 the end range there. Now this is the end range of arthrokinematic motion, not 14:02 end range of dorsiflexion. So that's as far as I can push your talus posteriorly 14:06 and then I'm just going to do my oscillatory techniques here, and I'm kind 14:13 of going from just before 50% right now, to just after 50% resistance. I would say 14:20 total I'm maybe moving a half a centimeter, and this would be like a 14:26 grade three mobilization and I'm going to go ahead and hold this for 30 to 60 14:31 seconds, or until I feel a decrease in resistance for her passive accessory 14:38 motion. And then I'd probably pull out a ganiometer and check her dorsiflexion 14:44 again, since I know dorsiflexion is a fairly reliable test. So once again guys 14:51 web-space down over that imaginary line between the bottom of 14:56 medial and lateral malleolus. I'm using this part of my web-space not this part 15:01 of my web-space, because this is going to feel a lot softer in here than this is 15:06 going to feel. And then of course I'm using this hand by hooking the calcaneus, 15:10 and then bringing my forearm over the base of her or the ball of her foot, so that I 15:16 can control eversion inversion, bring her to our first resistance barrier in 15:20 dorsiflexion, and I'm all set up. So there you have it, assess address reassess. Make 15:28 sure that every time you choose a joint based manual therapy technique it is 15:32 based on an assessment, and that you return to that assessment after you've 15:36 finished the intervention, to see if it was effective for the individual, the 15:40 patient or client that you have in front of you. Ensure that you continue to learn 15:45 your Anatomy because your Anatomy is going to help you with your hand 15:50 placement, with understanding what a joint can do. With understanding what you 15:55 may gain from this particular technique, and of course practice. You have to 16:01 practice these techniques, hopefully not for the first time on a patient or 16:05 client who just walked in the door. If you can find a more senior instructor or 16:10 mentor, to give you some really good hands-on instruction use your peers for 16:16 some good feedback, and of course always look for live education to help with 16:24 your manual therapy techniques. I know these videos make education very 16:28 convenient,, but there is no substitute for learning manual therapy in a live 16:34 setting. I look forward to talking to you guys again soon. 16:45
