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Flexor Hallucis Longus and Flexor Digitorum Longus (FHL & FDL) Static Manual Release

The FHL & FDL Static Manual Release is a therapeutic exercise designed to diminish pain, improve mobility and reduce tissue adhesions in the ankle, foot and toes. Flexor Hallucis Longus (FHL) and Flexor Digitorum Longus (FDL) are two muscles that originate in the lower leg and insert into the tendons of the great toe and the other toes, respectively. The FHL & FDL Static Manual Release stretches and releases tight or shortened

Transcript

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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.