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Extensor Hallucis Longus and Extensor Digitorum Longus Static Manual Release (Soft Tissue Mobilization)
Extensor Hallucis Longus and Extensor Digitorum Longus Static Manual Release (Soft Tissue Mobilization) is an advanced technique used by physical and massage therapists to reduce tension in the Extensor Hallucis Longus and Extensor Digitorum Longus muscles. By gently stretching and manipulating the muscles with a hand-held instrument or the therapist’s hands, this mobilization brings increased circulation to the area, allowing the muscle fibers to relax. This can reduce chronic
Transcript
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This is Brent of the Brookbush Institute
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...blank
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and in this video we're going over
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static manual release of the extensor
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hallucis longus and extensor digitorum
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longus, also known as the long toe
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extensors. If you are doing this
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technique and you're watching this video, I'm
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assuming you're watching this video for
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educational purposes, and that you are a
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licensed manual practitioner following
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the laws determining your scope of
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practice in your state. If you're unsure
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on whether you're allowed to do manual
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release techniques, please check out
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those laws before you put your hands on
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a patient or client. I'm going to have my
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friend Melissa come out, she's going to
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help me demonstrate this technique.
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This is one of my favorite techniques
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the reason being, is that the
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extensor hallucis longus and extensor
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digitorum longus are muscles that are
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not easily addressed using
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self-administered techniques, so the
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responsibility falls on the manual
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therapists. This is one of the times we
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can really shine. The extensor hallucis
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longus and extensor digitorum longus
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also play a very interesting role in
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lower extremity dysfunction as they
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often become synergistically dominant
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for an inhibited tibialis anterior in
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those exhibiting lower extremity
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dysfunction. Whether that's a lack of
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dorsiflexion, excessive pronation, or
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we could get into pathologies like
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plantar fasciitis, shin splints, etc., this
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is a muscle that is often not addressed,
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and since it is often not addressed if
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you do address it and solve a problem,
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sometimes it's that missing link and you
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can look like a magician. Let's
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get into how to palpate this muscle,
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because that's probably the hardest part
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of this technique, just knowing how to
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palpate the extensor hallucis longus and
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extensor digitorum longus. If you see,
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I've got two marks right here. I know
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what some of you are thinking,
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'that's the tibialis anterior'. Well, the
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tibialis anterior is here - dorsiflex
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for me Melissa - you can see her tibialis
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anterior all of a sudden pop up right
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here, kind of to the side, and behind the
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tibialis anterior, or, lateral and deep
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to the tibialis anterior, is your
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extensor digitorum longus, and your
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extensor hallucis longus. The easiest way
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to find these muscles is get really good
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at palpating the tibialis anterior. Once
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again, dorsiflex, and there you've got
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that crest of your tibia.
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That's the medial border of the
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tibialis interior, and if she dorsiflexes,
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especially if she dorsiflexes with
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toes down, so I know her extensors are not
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involved, I can feel her lateral
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border of her tibialis anterior, and then
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all I need to do to get to her extensors,
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is fall off that muscle mass. Here's her
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tibialis anterior, I'm just going to
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fall off the muscle mass this way. Once
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again, I go down here -dorsiflex
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for me- and then I fall off the
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muscle mass. Again, you'll also
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note that the tibialis anterior is a
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fairly broad, if you guys remember the
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term, 'multipennate' muscle, whereas
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these are very tubular, stringy muscles,
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so they're going to feel a little bit
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more like your fibularis muscle which is
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right there. If you're still having a
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hard time palpating what you can do is
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- wiggle your toes for me - don't be
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afraid to ask somebody to wiggle
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their toes and confirm your palpation.
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You can have them
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push their toes up against your hand,
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not your foot into my thigh, but - there
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you go - alright, and then relax. Do it
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again. Then just move
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your thumb perpendicularly until
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you feel the change in tissue density as
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she goes from contract to relax, contract
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to relax. "Wiggle your toes," is probably
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the easiest way I think. Once you figure
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out where those muscles are, we go back
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to the same technique or protocol that
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we've been using for our static manual
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release techniques. Knowing your trigger
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points does help, it will help you be
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more accurate faster. What you're
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really looking for is increased tissue
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density
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in fascicles, and the muscles
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you're looking for, and if I kind of run
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my fingers perpendicular across the
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guitar strings that are her fascicles,
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and notice right in here I have a
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very taut band. I'm then going to move
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proximal and distal to see if I can find
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a nodule in that top band, or a knot
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that's pulling my fascicle tight. Once I
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find it, nice broad finger strokes, apply
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some pressure to to help stabilize that
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trigger point. Once again, I'm not
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putting my finger tip on top of a marble.
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I can put some tension, stretch those
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fibers by pressing her toes down, and
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pressing her ankle into plantar
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flexion. The one big downside of this
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technique is, it's a bit tough on
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the hands, because rather than being able
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to use dummy thumb and bodyweight
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pressure, I more or less have to
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stabilize her lower leg, and stabilize my
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hand on one side, and then use my thumb
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to apply pressure in both a lateral to
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medial direction, and a little bit of an
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anterior to posterior direction, and use
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the other hand to stretch the fibers.
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It's really my grip strength getting
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this done. I understand for some of my
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smaller practitioners who work on large
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bodies, this is not going to be easy. You
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can do the dummy thumb approach, but I think
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you're just going to find that the
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tissue gives away a little bit, and it
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might be a little harder to get a
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release, there's a little give and take
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there. So all I'm going to
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do is, once again, stretch these tissues
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out with this hand, and hold this way. I can
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also come in, and do it this way, same
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thing, I find that
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tissue, find that nodule, apply pressure,
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and then I can use my other hand.
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Once I have that nodule compressed, I'm
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going to go ahead and wait about 30
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seconds, until I feel the tissue start to
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melt under my fingertips. Sometimes it
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happens faster than 30 seconds. Sometimes
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you'll get releases really quickly in 5, 10, or 15
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seconds. Once I get a good release, I can
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then move from extensor digitorum
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longus, to, let's say, below the halfway
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point in the tibia, and start looking for
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extensor hallucis longus. -Wiggle your
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toes- There it is, right
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there. Lie on the fibers that
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are expressing a little increased tissue
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density, find my nodule, removing proximal
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distal again, go ahead and compress, and
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stretch out, and maybe this one I could
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use that other protocol of several
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five-second repetitions. That several
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five-second repetitions protocol works
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really well for somebody who has very
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active trigger points and is super
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sensitive. In that protocol
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I could start with a really light
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touch for five seconds, and then back off,
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and then a little harder touch for five
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seconds, and then back off, until I got to
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that more standard resistance from the
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tissue. I've explained this
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in other videos where you have that nice
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linear increase in tissue density as you
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get deeper and deeper, and then all of a
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sudden it spikes. All of the
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sudden the tissue density gets a lot
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more resistant, you're just going to push
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right into that resistance. If you
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push too hard, the muscle starts pushing
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back, and you'll never get a release. If
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you don't push enough, you also won't get
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a release. -How do you feel?
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-Good.
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-Feeling it kind of melt away, the
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decrease in discomfort? Then I
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could retest a range of motion, or retest
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tibialis anterior activation. For a
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close-up recap, you can see here I
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got the two trigger points marked out
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for extensor digitorum longus and
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extensor hallucis longus. It is helpful
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to know, where those trigger points are
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located, they are fairly consistent. They
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tend to be related to the neuromuscular
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junction, which is a fairly consistent
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point within the middle of the muscle
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belly of most muscles. You can see her
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tibial crest right here, go ahead and
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dorsiflex for me, there we go, you
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can see her tibialis anterior pump up a
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little bit, and she goes that way. The
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easiest way to get to the extensor hallucis
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longus, and extensor digitorum longus,
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is just to fall off the muscle belly of
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the tibialis anterior.
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-Relax... good.
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If I fall off, I didn't feel these
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stringier muscles right here, but
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still in front of her fibularis muscles,
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and feel these stringer your muscles. If
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I need to double check my palpation,
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-wiggle your toes- and feel their
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fibers kind of feels like fingers
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doing this, underneath my fingers.
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Then I can look for the most dense
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fascicles, assuming that there's a nodule
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within that fascicle that correlates with
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a trigger point, I can move proximal and
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distal, I can start using the other hand
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to push her toes down into flexion, as
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well as her ankle down in a plantar
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flexion, and then, unfortunately, with this
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one guys, I do kind of have to use my
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grip strength to get a release. It would
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be nice to be able to do dummy
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thumb and hand over thumb pressure, but
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if I do that, I lose my ability to
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lengthen tissue at the same time,
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increasing tension and stabilizing that
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trigger point for me to press against.
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Once I get a good release, maybe after a
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20 to 30 second hold, I can then start
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moving down a little bit, seeing if I can
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find more tight fascicles in her
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extensor hallucis longus. You
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can see this little dot I have right
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here is where I found the trigger point
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earlier. I've got to make sure this
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time, I lengthen her big toe. I flex
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her big toe, and push her into plantar
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flexion. Again, I'm going to use my grip
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strength. You could use either this grip,
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which is kind of an underhand grip, or if
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it was more comfortable for you to go
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the other way, and I put my left hand
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here, right hand here, as opposed to right
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hand, and left hand here. You can
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experiment with which direction
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is more comfortable for you. I don't
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think it particularly matters. I do find
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that anterior to posterior, with a
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little bit this way, like I'm driving
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towards the table, with some medial to
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lateral force, helps pin down those
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trigger points. So find them with
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your
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perpendicular palpations. Find the most
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tight fascicle, find the nodule, a little
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bit of anterior to posterior as well as
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lateral to medial,
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along with some stretch in the
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tissues, and you should get a nice
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release in about 30 seconds. In
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closing, extensor hallucis longus,
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and extensor digitorum longus static
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manual release, is one of those
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techniques that individuals have to rely
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on manual therapists for. It can make you
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look like a magician, because that
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extensor hallucis longus and extensor
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digitorum longus plays this overactive
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synergist role to the tibialis anterior
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in lower extremity dysfunction.
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Sometimes you release this muscle and
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all of a sudden everything else starts
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to work better. You start getting better
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releases in the gastroc and soleus
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complex, you start getting better muscle
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activation from your tibialis anterior.
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Make sure, before you put your hands on
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somebody, you have good reason to believe
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that this synergistic dominance of
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extensor hallucis longus and extensor
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digitorum longus does exist. They're
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showing signs of lower extremity
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dysfunction, whether that's knees bow in,
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knees bow out, feet flat, feet turn out,
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excessive forward lean on the overhead
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squat assessment, you're looking at
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possibly a lack of dorsiflexion on
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goniometric assessment, and, of course, maybe
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failing that gastroc-soleus length
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test in the sense that they're lacking
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dorsiflexion regardless of whether you
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bend the knee or straighten the leg. All
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of these tests could be good indicators
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for trying this particular technique. As
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with all manual techniques and all
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palpation techniques, try to practice on
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colleagues first. Grab a few friends, grab
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a few fellow professionals, and start testing
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this technique out on each other,
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comparing pressure and handholds, and
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trying to really define what feels good,
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and then what feels not so good. Maybe
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what feels professional is getting
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effective releases,
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versus what feels inconsistent and
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not confident, which is not going to help
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your outcomes. I look forward to
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hearing how you guys do with this
00:14:1300:14:15
technique, I look forward to hearing your
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questions about this technique, and I
00:14:1600:14:18
look forward to hearing what type of
00:14:1800:14:20
outcomes you get by adding this
00:14:2000:14:23
technique to your arsenal. Thank you.
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