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This is Brent of the Brookbush Institute
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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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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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-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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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
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technique, I look forward to hearing your
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questions about this technique, and I
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look forward to hearing what type of
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outcomes you get by adding this
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technique to your arsenal. Thank you.