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This is Brent of the Brookbush Institute and in this video we're going over static release
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techniques for the flexor hallucis longus and flexor digitorum longus, also
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known as the FHL and the FDL or the long toe flexors. If you're watching this
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video I assume you're watching it for educational purposes and that you are a
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licensed manual practitioner. That means the laws in your state allow you to
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perform manual release techniques: mainly, physical therapists, athletic trainers,
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chiropractors and massage therapists. I'm going to have my friend Melissa come out,
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she's going to help me demonstrate this technique. Now, these muscles are deep and
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the posterior lower leg here is kind of sensitive when it comes to these manual
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release techniques. Before I attempt FHL or FDL release, I'm want to be fairly
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certain that these muscles are involved. So, Melissa, at this point, I'm going to have
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done assessment and she's going to exhibit signs of lower extremity
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dysfunction before I start poking around at these deeper muscles; that could be
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anything from feet flat, feet turn out, knees bow in, knees bow out or excessive
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forward lean on that overhead squat, a lack of dorsiflexion on goniometry. Maybe her
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manual muscle testing for her tibialis anterior or tibialis posterior came back a
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little weak.
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Maybe that gastroc/soleus muscle length test showed me some changes in
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extensibility in her plantar flexors. These would all be good reasons for me
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to dig a little deeper, start palpating and see if I could find some increased
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tissue tonicity or increased tissue density is what i'm actually going to
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feel, with palpating the FHL and FDL. Now, to help you guys with the palpation part,
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because that's probably the most difficult part of this technique.
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I'm going to have Melissa scoot down just a little bit. I want to be able to control dorsiflexion
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here with my thigh.
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Right, so then what I'm going to do is, I kind of know where my trigger points are
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for these muscles. I know that my FDL, it's kind of like a spot right between
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the lateral and medial gastroc, but
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a little higher than the lower border. It's like up a little bit. And then I
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know my FHL, you guys have probably felt your flexor hallucis longus trigger
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points or seen somebody try to roll at their flexor hallucis longus trigger points.
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It's kind of a spot that seems to be inside the Achilles tendon, so if you've
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ever seen somebody foam roll really low chances are that's not their gastoc or
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soleus. Their gastroc or soleus ends up, well their gastroc up here and soleus here.
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If they're just kind of rolling over what you thought was tendon,
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chances are it's the muscle belly of the flexor hallucis longus which
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lies deep to the Achilles tendon. What I'm going to do to palpate these is I
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know that my FDL is a little bit more medial. Just medial to my fibula
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here kind of on the lateral border of my tibia but pretty deep so I want to
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palpate through my gastoc and soleus and then I'm going to have Melissa
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wiggle her toes. No need for me to do guesswork here guys. If she wiggles
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her toes, what I want to be able to feel is eventually under my fingers is
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something that feels like this. Right if she just wiggles all of her toes,
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I should feel some fascicles jumping around underneath my fingers and I need
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to keep palpating until I feel that.
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And it's better to take a couple extra seconds than to just be wrong.
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All right, so I feel it right there. Now what I'm going to do is do my perpendicular
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palpations to look for tighter fascicles and then I'm going to, once I find a tight
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fascicle, I'm going to start looking for that nodule, that knot that I think
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is contributing to the tightness in that fascicle. And right about here,
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I find a nice little knot in Melissa's flexor digitorum longus. Now,
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from here I could just press deep, I could use my dummy thumb to create a
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nice, a nice thick palpatory spot and then push her into a little dorsiflexion
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making sure that I'm including her toes this time because I got to push her toes
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into extension to also lengthen those long toe flexors and then use my other
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hand to supply the pressure. So this thumb goes between my thenar eminences.
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Right, after I find that spot, nice broad palpation and I go right to the point of
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increased tissue density, right where that issue starts to give back a little bit,
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and I hold.
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This is going to be a tender one though if I'm sitting here and pressing through
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a lengthened gastroc and soleus. I'm going show you guys a trick here in a second
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that'll make this technique a little easier. Now once I've done that, I can go
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through, do the same thing with the FHL. Wiggle your toes for me.
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FHL is actually a little easier to find because rather than palpating through
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the thick gastroc and the thick soleus, you're really palpating through the
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very ends of these muscles, you know. The gastroc actually is probably
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has no fibers left down at this low. And the soleus is pretty thin here. I'm going to
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do my perpendicular palpation here,
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strumming those fascicles. Once I find a tight fascicle, I can then look for a nodule.
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And I found that one pretty quick. Once again I'm going to use my nice
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broad, whole thumb pad to push down on that trigger point. I'm going to put
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some length in that tissue to once again put some tension in that muscle.
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Or rather only goes to here, but put some tension in that muscle and
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stabilize that trigger point, so it doesn't keep flopping around. I don't want to play
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that finger tip on a marble game. And then press down. Again, I'm pushing through
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some muscle so this is going to be pretty tender. So here I want to show you
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guys a couple tricks so that you're not pushing through so much muscle. You do
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have to know who you're doing this on, though. The first technique I'm going
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show you, the individual needs to be a pretty stable, well-balanced individual
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and the second technique, you definitely have to be aware of body position. So the
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first thing I'm going to have Melissa do is get into a kneeling position. Now if she
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gets into a kneeling position, she flexes her knee, I'm going to have use this foam roll to
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get stable. I'm going have her put this leg out in front of her, right so the knee that
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we're going to, or the side that we're going to work on, that's the knee that's
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down. She has this leg in front of her to take on most of the weight.
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She can lean over this leg even a little bit. You want to make sure
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she's nice and stable so that she doesn't need knee flexion and extension
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to keep her balance and then what I've basically done, actually, move this leg
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back a little bit. What I've done is I've put her gastroc on slack. So now rather
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than trying to push through all this stretched out tissue, and I've been
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telling you guys for a few videos now with these manual release techniques, we
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put tension into tissue to actually stabilize trigger points. It
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increases tension. So to put some slack back now I can press straight down into
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this trigger point. There's, and you can see Melissa's face, there's no
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resistance until I hit her flexor digitorum longus. And now I can use the
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same technique.
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Same thing with her FHL, even though there's not as much muscle down
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here, it's still so much less tension in this system, that pushing down
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into her FHL is so much easier.
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And once again I can hold for 30 seconds or until I get a release going right up to
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that tissue barrier. I should start to feel it melt underneath my fingertips. If I'm
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in constant communication with my client, "Hey, Melissa you starting to feel that
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relax a little bit? Doesn't feel as bad as it did when I first pressed in. Good.
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All right so the last position that works well, guys, but you need to have a little
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bit of awareness and rapport with your client is this position, which kind of
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looks like our hip flexor stretch, does take some balance and you notice I have
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Melissa up on a treatment table, which becomes problematic if we're dealing
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with somebody who's not very well-balanced.The last thing I would
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want is Melissa to fall over this way as I'm doing all these techniques. Melissa
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could go down into quadruped. So go ahead and go in to quadruped.
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So quadruped does the exact same thing for me it's a very, very stable position.
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But I just want you guys to watch. Obviously Melissa and I are close, we're
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friends, we've been doing this a long time. If I push here and then put my
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dummy thumb here and I'm not careful where I'm looking
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my face is going to be very close to her backside which is not going to make
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either you or your client very comfortable. You can sit down.
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So although quadruped position is probably the best position to do that
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technique in, guys just make sure that if you're going to do that you have enough
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rapport with your client, with your patient to kind of explain to them the
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position that you guys are going to end up in and then make sure as you're
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pushing down maybe you practice this technique enough that you don't have to
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look at your hands so much. I would definitely move rather than being center,
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I would move off to the side of the table a little bit and then only lean so
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that this shoulders over your arm for your pressure rather than being center
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on. It's just a little uncomfortable and I don't want anybody getting in trouble
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for, you know, a stupid reason of just lack of body awareness. So next we're
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going to do our close-up review. So this is your close-up recap, guys, you can see
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that I have the FDL and FHL common trigger points mapped out for you.
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The FDL, the body of this muscle, where it's innervated by its nerve and where we
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think these acute points of dysfunction happen, is generally right between your
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medial and lateral gastrocnemius heads. Of course, deep to your gastroc and
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soleus. So when I look for this trigger point, I'm not even a mess around.
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I'm not going to try to hit it right on the money. I'm going to have my patient or
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client go ahead and wiggle their toes,
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you can even have them curl their toes against your thigh if you're in this
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once again, this position with their feet hanging off so that you can control
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the amount of dorsiflexion and plantar flexion. Keep going. And of course
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I feel right there. Once I have that spot, I want to make sure I push Melissa into
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dorsiflexion and toe extension. So you don't want your knee up here right, where
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you're pushing her into dorsiflexion but her toes can flex
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around your knee. You want to make sure they you almost got the toes pressed
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into extension first, because these are long toe flexors, and then dorsiflexion
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as you press down. That'll help stabilize where that trigger point is so you don't get
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that flopping back and forth. Then you can use dummy thumb and apply enough
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pressure to you all the way through gastroc and soleus until you start
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feeling the tissue melt away, the discomfort start to reduce. Now, of course
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this is FHL. FHL is a little easier to find as there's not so much tissue to get
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through here. We'll use our palpations across the fascicles first, look for the
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the densest fascicles. Move proximally and distally to try to find the nodule in
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those fascicles. Once we found it we can kind of push with a nice broad thumb. No
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need to press straight down and play the fingertip on top of a marble game.
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Put some tension in that system to help you stabilize the trigger point. Push up
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this way. I do find a little distal to proximal pressure, along with posterior
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to anterior pressure helps. And I can do the same thing pushing right up to that
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point where I see a big
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increase in tissue density. So we know that we have this kind of
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linear relationship where tissue density slowly increases as we press into tissue
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and then all of a sudden as we hit that trigger point, get deeper, all of a sudden
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tissue density ramps up real fast. We want to be just in that trough.
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And, of course I showed you guys the trick of getting some of this tissue,
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getting the calf issue out of the way. Well, the gastroc and soleus
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anyway and then adding a little bit of laxity back to the Achilles tendon by
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having your patient or client go into either a kneeling position or a quadruped
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position. Just be real careful on where you end up versus where they end up and
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and you're having that conversation about why you're doing what you're doing.
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You can see now just as I poke her gastoc here, there's no
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resistance and it's because we put some tension back into her gastroc. I can push
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straight down, almost like the first resistance I feel is her flexor
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digitorum longus. This is of course just thumb over thumb compression, which I
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wouldn't necessarily use on these techniques. We'd go back this way and then
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go hand over thumb and that helps save our thumbs a little bit. Once again, I
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could use 30 seconds or until I feel the tissue melt away or I could use those
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multiple repetitions of five second holds. Let's say she was so tender that I
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couldn't even get to that increase in tissue density, I could slowly work into
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it with five second holds until the tissue desensitized enough for me to
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actually get some sort of mechanical release. So there you guys have it. FHL and FDL
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static manual release technique. Great technique to add to your repertoire of
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very overlooked set of muscles. Muscles that do have a propensity to become
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synergistically dominant
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in lower extremity dysfunction. Ensure that you are doing assessment first and
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you're pretty sure that these muscles are involved because that back of that
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leg is a sensitive area to be pressing on and remember you're going to have to
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press through quite a bit of tissue through your gastroc, through your
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soleus. Be careful as you experiment with the other positions we showed you - the
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kneeling and the quadruped position. Make sure that you explain to your
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client what you're doing and where your body positions are going to end up so
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there are no misunderstandings. And of course grab some friends and get to
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practicing before you pull this out with patients and clients. I think just having
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it done on you as well as doing it to other people and then being able to
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compare with you and your colleagues is such a wonderful learning experience. As
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a profession, we don't do enough to work together in groups
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I really think that every clinic, every PT should have a group that they go to
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where we could do some maybe practice together because manual techniques done
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on manual therapists with interaction, that's some powerful learning. I look
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forward to hearing about your outcomes. I look forward to hearing about how this
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changed some of the outcomes you saw when you added it into your repertoire.