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