0:04 This is Brent of the Brookbush Institute 0:06 and in this video we're going over 0:08 static manual release of the extensor 0:10 hallucis longus and extensor digitorum 0:11 longus, also known as the long toe 0:14 extensors. If you are doing this 0:17 technique and you're watching this video, I'm 0:18 assuming you're watching this video for 0:20 educational purposes, and that you are a 0:22 licensed manual practitioner following 0:26 the laws determining your scope of 0:28 practice in your state. If you're unsure 0:30 on whether you're allowed to do manual 0:33 release techniques, please check out 0:35 those laws before you put your hands on 0:38 a patient or client. I'm going to have my 0:40 friend Melissa come out, she's going to 0:41 help me demonstrate this technique. 0:43 This is one of my favorite techniques 0:45 the reason being, is that the 0:48 extensor hallucis longus and extensor 0:49 digitorum longus are muscles that are 0:53 not easily addressed using 0:55 self-administered techniques, so the 0:58 responsibility falls on the manual 1:00 therapists. This is one of the times we 1:03 can really shine. The extensor hallucis 1:05 longus and extensor digitorum longus 1:06 also play a very interesting role in 1:10 lower extremity dysfunction as they 1:12 often become synergistically dominant 1:14 for an inhibited tibialis anterior in 1:18 those exhibiting lower extremity 1:21 dysfunction. Whether that's a lack of 1:23 dorsiflexion, excessive pronation, or 1:26 we could get into pathologies like 1:28 plantar fasciitis, shin splints, etc., this 1:31 is a muscle that is often not addressed, 1:33 and since it is often not addressed if 1:37 you do address it and solve a problem, 1:39 sometimes it's that missing link and you 1:41 can look like a magician. Let's 1:44 get into how to palpate this muscle, 1:46 because that's probably the hardest part 1:47 of this technique, just knowing how to 1:49 palpate the extensor hallucis longus and 1:52 extensor digitorum longus. If you see, 1:57 I've got two marks right here. I know 1:59 what some of you are thinking, 2:00 'that's the tibialis anterior'. Well, the 2:03 tibialis anterior is here - dorsiflex 2:05 for me Melissa - you can see her tibialis 2:08 anterior all of a sudden pop up right 2:10 here, kind of to the side, and behind the 2:14 tibialis anterior, or, lateral and deep 2:17 to the tibialis anterior, is your 2:20 extensor digitorum longus, and your 2:22 extensor hallucis longus. The easiest way 2:25 to find these muscles is get really good 2:28 at palpating the tibialis anterior. Once 2:30 again, dorsiflex, and there you've got 2:33 that crest of your tibia. 2:37 That's the medial border of the 2:39 tibialis interior, and if she dorsiflexes, 2:41 especially if she dorsiflexes with 2:43 toes down, so I know her extensors are not 2:45 involved, I can feel her lateral 2:47 border of her tibialis anterior, and then 2:50 all I need to do to get to her extensors, 2:51 is fall off that muscle mass. Here's her 2:56 tibialis anterior, I'm just going to 2:58 fall off the muscle mass this way. Once 3:02 again, I go down here -dorsiflex 3:04 for me- and then I fall off the 3:07 muscle mass. Again, you'll also 3:09 note that the tibialis anterior is a 3:11 fairly broad, if you guys remember the 3:14 term, 'multipennate' muscle, whereas 3:18 these are very tubular, stringy muscles, 3:23 so they're going to feel a little bit 3:25 more like your fibularis muscle which is 3:28 right there. If you're still having a 3:31 hard time palpating what you can do is 3:34 - wiggle your toes for me - don't be 3:37 afraid to ask somebody to wiggle 3:39 their toes and confirm your palpation. 3:42 You can have them 3:44 push their toes up against your hand, 3:46 not your foot into my thigh, but - there 3:48 you go - alright, and then relax. Do it 3:51 again. Then just move 3:54 your thumb perpendicularly until 3:58 you feel the change in tissue density as 4:01 she goes from contract to relax, contract 4:03 to relax. "Wiggle your toes," is probably 4:05 the easiest way I think. Once you figure 4:09 out where those muscles are, we go back 4:11 to the same technique or protocol that 4:13 we've been using for our static manual 4:15 release techniques. Knowing your trigger 4:17 points does help, it will help you be 4:21 more accurate faster. What you're 4:24 really looking for is increased tissue 4:27 density 4:28 in fascicles, and the muscles 4:32 you're looking for, and if I kind of run 4:35 my fingers perpendicular across the 4:37 guitar strings that are her fascicles, 4:39 and notice right in here I have a 4:42 very taut band. I'm then going to move 4:46 proximal and distal to see if I can find 4:49 a nodule in that top band, or a knot 4:52 that's pulling my fascicle tight. Once I 4:56 find it, nice broad finger strokes, apply 5:00 some pressure to to help stabilize that 5:04 trigger point. Once again, I'm not 5:05 putting my finger tip on top of a marble. 5:08 I can put some tension, stretch those 5:14 fibers by pressing her toes down, and 5:17 pressing her ankle into plantar 5:18 flexion. The one big downside of this 5:21 technique is, it's a bit tough on 5:23 the hands, because rather than being able 5:25 to use dummy thumb and bodyweight 5:28 pressure, I more or less have to 5:30 stabilize her lower leg, and stabilize my 5:34 hand on one side, and then use my thumb 5:37 to apply pressure in both a lateral to 5:42 medial direction, and a little bit of an 5:43 anterior to posterior direction, and use 5:46 the other hand to stretch the fibers. 5:49 It's really my grip strength getting 5:50 this done. I understand for some of my 5:53 smaller practitioners who work on large 5:55 bodies, this is not going to be easy. You 5:57 can do the dummy thumb approach, but I think 6:01 you're just going to find that the 6:03 tissue gives away a little bit, and it 6:04 might be a little harder to get a 6:06 release, there's a little give and take 6:08 there. So all I'm going to 6:10 do is, once again, stretch these tissues 6:12 out with this hand, and hold this way. I can 6:17 also come in, and do it this way, same 6:19 thing, I find that 6:22 tissue, find that nodule, apply pressure, 6:25 and then I can use my other hand. 6:29 Once I have that nodule compressed, I'm 6:34 going to go ahead and wait about 30 6:36 seconds, until I feel the tissue start to 6:40 melt under my fingertips. Sometimes it 6:44 happens faster than 30 seconds. Sometimes 6:46 you'll get releases really quickly in 5, 10, or 15 6:49 seconds. Once I get a good release, I can 6:55 then move from extensor digitorum 6:57 longus, to, let's say, below the halfway 7:00 point in the tibia, and start looking for 7:04 extensor hallucis longus. -Wiggle your 7:07 toes- There it is, right 7:10 there. Lie on the fibers that 7:13 are expressing a little increased tissue 7:16 density, find my nodule, removing proximal 7:20 distal again, go ahead and compress, and 7:24 stretch out, and maybe this one I could 7:28 use that other protocol of several 7:30 five-second repetitions. That several 7:32 five-second repetitions protocol works 7:34 really well for somebody who has very 7:36 active trigger points and is super 7:38 sensitive. In that protocol 7:41 I could start with a really light 7:43 touch for five seconds, and then back off, 7:46 and then a little harder touch for five 7:48 seconds, and then back off, until I got to 7:51 that more standard resistance from the 7:58 tissue. I've explained this 8:00 in other videos where you have that nice 8:02 linear increase in tissue density as you 8:04 get deeper and deeper, and then all of a 8:06 sudden it spikes. All of the 8:08 sudden the tissue density gets a lot 8:11 more resistant, you're just going to push 8:13 right into that resistance. If you 8:17 push too hard, the muscle starts pushing 8:18 back, and you'll never get a release. If 8:21 you don't push enough, you also won't get 8:22 a release. -How do you feel? 8:24 -Good. 8:28 -Feeling it kind of melt away, the 8:32 decrease in discomfort? Then I 8:36 could retest a range of motion, or retest 8:38 tibialis anterior activation. For a 8:42 close-up recap, you can see here I 8:44 got the two trigger points marked out 8:46 for extensor digitorum longus and 8:48 extensor hallucis longus. It is helpful 8:51 to know, where those trigger points are 8:53 located, they are fairly consistent. They 8:56 tend to be related to the neuromuscular 8:57 junction, which is a fairly consistent 8:59 point within the middle of the muscle 9:01 belly of most muscles. You can see her 9:04 tibial crest right here, go ahead and 9:07 dorsiflex for me, there we go, you 9:10 can see her tibialis anterior pump up a 9:13 little bit, and she goes that way. The 9:16 easiest way to get to the extensor hallucis 9:19 longus, and extensor digitorum longus, 9:21 is just to fall off the muscle belly of 9:24 the tibialis anterior. 9:27 -Relax... good. 9:29 If I fall off, I didn't feel these 9:31 stringier muscles right here, but 9:35 still in front of her fibularis muscles, 9:37 and feel these stringer your muscles. If 9:39 I need to double check my palpation, 9:41 -wiggle your toes- and feel their 9:44 fibers kind of feels like fingers 9:47 doing this, underneath my fingers. 9:51 Then I can look for the most dense 9:55 fascicles, assuming that there's a nodule 9:57 within that fascicle that correlates with 10:00 a trigger point, I can move proximal and 10:02 distal, I can start using the other hand 10:07 to push her toes down into flexion, as 10:09 well as her ankle down in a plantar 10:11 flexion, and then, unfortunately, with this 10:13 one guys, I do kind of have to use my 10:15 grip strength to get a release. It would 10:19 be nice to be able to do dummy 10:21 thumb and hand over thumb pressure, but 10:26 if I do that, I lose my ability to 10:28 lengthen tissue at the same time, 10:30 increasing tension and stabilizing that 10:34 trigger point for me to press against. 10:36 Once I get a good release, maybe after a 10:39 20 to 30 second hold, I can then start 10:42 moving down a little bit, seeing if I can 10:46 find more tight fascicles in her 10:48 extensor hallucis longus. You 10:52 can see this little dot I have right 10:54 here is where I found the trigger point 10:56 earlier. I've got to make sure this 11:00 time, I lengthen her big toe. I flex 11:04 her big toe, and push her into plantar 11:06 flexion. Again, I'm going to use my grip 11:08 strength. You could use either this grip, 11:13 which is kind of an underhand grip, or if 11:15 it was more comfortable for you to go 11:17 the other way, and I put my left hand 11:19 here, right hand here, as opposed to right 11:22 hand, and left hand here. You can 11:24 experiment with which direction 11:26 is more comfortable for you. I don't 11:30 think it particularly matters. I do find 11:32 that anterior to posterior, with a 11:37 little bit this way, like I'm driving 11:39 towards the table, with some medial to 11:41 lateral force, helps pin down those 11:45 trigger points. So find them with 11:48 your 11:49 perpendicular palpations. Find the most 11:52 tight fascicle, find the nodule, a little 11:56 bit of anterior to posterior as well as 11:58 lateral to medial, 12:00 along with some stretch in the 12:03 tissues, and you should get a nice 12:05 release in about 30 seconds. In 12:09 closing, extensor hallucis longus, 12:11 and extensor digitorum longus static 12:14 manual release, is one of those 12:16 techniques that individuals have to rely 12:19 on manual therapists for. It can make you 12:22 look like a magician, because that 12:23 extensor hallucis longus and extensor 12:25 digitorum longus plays this overactive 12:27 synergist role to the tibialis anterior 12:29 in lower extremity dysfunction. 12:32 Sometimes you release this muscle and 12:34 all of a sudden everything else starts 12:37 to work better. You start getting better 12:38 releases in the gastroc and soleus 12:40 complex, you start getting better muscle 12:43 activation from your tibialis anterior. 12:46 Make sure, before you put your hands on 12:48 somebody, you have good reason to believe 12:51 that this synergistic dominance of 12:55 extensor hallucis longus and extensor 12:57 digitorum longus does exist. They're 12:59 showing signs of lower extremity 13:01 dysfunction, whether that's knees bow in, 13:03 knees bow out, feet flat, feet turn out, 13:06 excessive forward lean on the overhead 13:08 squat assessment, you're looking at 13:10 possibly a lack of dorsiflexion on 13:12 goniometric assessment, and, of course, maybe 13:15 failing that gastroc-soleus length 13:17 test in the sense that they're lacking 13:20 dorsiflexion regardless of whether you 13:22 bend the knee or straighten the leg. All 13:24 of these tests could be good indicators 13:26 for trying this particular technique. As 13:30 with all manual techniques and all 13:33 palpation techniques, try to practice on 13:36 colleagues first. Grab a few friends, grab 13:39 a few fellow professionals, and start testing 13:43 this technique out on each other, 13:44 comparing pressure and handholds, and 13:48 trying to really define what feels good, 13:52 and then what feels not so good. Maybe 13:58 what feels professional is getting 14:00 effective releases, 14:01 versus what feels inconsistent and 14:06 not confident, which is not going to help 14:10 your outcomes. I look forward to 14:12 hearing how you guys do with this 14:13 technique, I look forward to hearing your 14:15 questions about this technique, and I 14:16 look forward to hearing what type of 14:18 outcomes you get by adding this 14:20 technique to your arsenal. Thank you. 14:29
