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This is Brent of the Brookbush Institute.
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In this video we're going over static
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manual release of the peroneals, or
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fibularis muscles. This is an
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educational video. I'm assuming that if
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you're watching this video, you're a
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licensed, manual practitioner, physical
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therapist, athletic trainer,
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chiropractor, or massage therapist, and
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that you are going to pay attention to
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the laws specific to your scope of
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practice in your state. If you don't know
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what those are, they might be worth
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looking up before you try this on a
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patient or client. I'm going to have my
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friend Melissa come out, she's going to help
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me demonstrate this technique. A
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little general rule, if you're going
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to put your hands on a patient or client,
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it is good practice to know, within
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80%, to have a good strong
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hypothesis, that where you're going to
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put your hands is involved in the
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dysfunction or pathology that you're
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treating. The only way to be able to do
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that is to do some level of assessment.
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If I'm thinking that the fibularis
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muscles are involved in Melissa's
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pathology or dysfunction, chances are
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I've done something like an overhead
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squat assessment, and maybe I've seen feet
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flat, which would be an indicator of
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fibularis muscles being overactive. Maybe
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I've done dorsiflexion goniometery.
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My fibularis muscles are plantar flexors,
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which means that could also be an
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indicator that they are overactive. If I did
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that gastroc-soleus muscle length test,
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if you go back to that video, you
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can see where I mess with eversion and
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inversion and, if you take up some slack
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in the fibularis muscles, pushing the
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ankle and the eversion, and that gives
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you more dorsiflexion, that's also an
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indication that the fibularis muscles
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might be involved. Keep in mind,
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before you get to this point with
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your patient or client on a table and
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you ready to put your hands down, you
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should probably have a good idea that
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those muscles are involved. In this
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particular technique, I'm going to have
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Melissa flip on her side.
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That way my fibularis muscles,
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which are on the lateral side of my
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lower leg, are now facing me. The first
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thing I need to know is how to palpate
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the fibularis muscles. Your fibularis
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muscles lie just anterior to your
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soleus. If I want, I could have
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Melissa go ahead and plantar flex, push
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down into my thigh so her soleus pops out
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right there, and then her fibularis
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muscles would be the divot right in
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front of it or just anterior to it.
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In fact, if I put my fingers here, and I
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kind of rub back and forth, you can
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almost feel the soleus does this,
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and then drops off, and then your
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fibularis is this little bump,
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this long half-circle right in
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front of the border of the soleus. You
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don't want to go any further anterior or
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you run into that anterior mass, that's
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your tibialis anterior and your long toe
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extensors. Alright, so we got this right
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here, the superior border, what I don't
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want to go higher than, is my fibular
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head, which if you rub your
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fingers up towards the knee in a broad
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fashion, eventually you're going to hit
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this hard bump. That hard bump is
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her fibular head. Right underneath that
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you can start to feel the fibularis
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fascicles. Anytime we find, or we are
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looking for, a point to release, it is
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helpful to know your trigger points. That
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will give you a good general indication
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of where you should be releasing. These
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trigger points are really consistent. The
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theory is that the dysfunction is
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happening around the neuromuscular
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junction, especially in these overactive
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muscles, and that right around the
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neuromuscular junction, we have this
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point of localized hyperactivity that
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releases with compression. So, knowing
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those points is definitely helpful and,
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I've actually put an X here on her
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trigger point for her fibularis longus,
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and a trigger point
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for her fibularis brevis. If I didn't
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have that memorized, I could still find
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them. What I'm going to do is
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strum across her fascicles, perpendicular
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to those fibers. Her fibularis muscle
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runs this way, I'm going to go ahead and
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strum with a nice broad pat of my thumb
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across those fibularis fibers, and what
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I'm looking for is fibers that feel
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more dense, that feel more
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resistant. Now, you're fibularis
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muscle isn't like your calf. If you've
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watched that previous video from us, it's
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not like your calf where you can compare
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fibers within the same muscle. It's a
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much narrower muscle. Chances are,
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we're going to have to palpate a fair
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number of fibularis muscles to
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determine what's normal, and then what's
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overactive. But, if I do this, I do feel a
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little bit of over activity, and,
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Melissa's fibularis longus here, and then
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what I'm going to do is
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start searching proximally and distally.
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What I'm going to assume is
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that that fascicle is being pulled tight
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by a knot that is her trigger
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point, and if I palpate, and I can see
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right around here, all the
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sudden I feel a
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little nodule under my thumb. The way
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I'm going to release this is, I'm going
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to use a broad thumb this way.
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I'm going to use this entire thumb pad,
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other than trying to to poke at it, which
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is a little bit like trying to put your
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finger on top of a marble, it just
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doesn't work, it just keeps slipping
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either way. Let me use a nice broad thumb,
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this way, I'm then going to push her into
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a little bit of inversion and
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dorsiflexion, because that's going to
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help tighten up this muscle a little bit
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so that the trigger point
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stays centered. Between that
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broad thumb stroke, and the tension I put
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within the muscle, I now have a
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stable trigger point to put some static
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pressure against, which is going to
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increase the likelihood that I actually
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get a release. The way I get her into
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inversion and dorsiflexion is, I'm
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actually just going to use my thigh, I'm
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going to bring my leg up a little bit
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and then just drop it down. There's my
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inversion, and then I can just lean
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forward a little bit, and I have my
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dorsiflexion. Broad thumb here, this is
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going to be my dummy thumb, I'm then
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going to put this dummy thumb right
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in between my thenar eminences,
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right here, and then all I have to
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do is lean in until I feel that
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increase in tissue tension
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right there. I don't have to go to
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maximal tension. Usually what
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I'm feeling for is the
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tension within tissues, there's a linear
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increase, you get this slow
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increase, you just kind of push into the
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tissue, and then you reach a point where
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all of a sudden going any further,
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the tension increases very rapidly. I'm
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just going up to that point. It
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takes a little bit of practice because
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if you push too hard your patient or
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client will start guarding on you, the
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muscle will really start fighting back,
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and you'll never get a release. If
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you don't use enough tension, you also
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won't get a release. The thought
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process there is, you're probably not
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stimulating enough ruffini endings,
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enough of that golgi tendon organ, to get
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autogenic inhibition. I'm
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going to hold this for 30
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seconds. Usually what happens is, they get
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a decrease in discomfort. They might even
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ask you "did you let go, did you
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lighten up" and you're just keeping
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consistent pressure. What you'll feel
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underneath your thumb is the trigger
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point and the hypertonic fascicles, the
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overactive fascicles will actually kind
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of melt away underneath your thumb,
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and that was it for Melissa.
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Now I know she
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has a fibularis longus and brevis, so I
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could keep searching. Your fibularis
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brevis starts a little lower, a little
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lower than a the halfway mark of
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your tibia. If I start going
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across here, I feel some
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overactive fascicles. It's just
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finding where that nodule is, and
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again, I marked these X's over her
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trigger points, and I did that using of
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course, my knowledge of where the common
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trigger points are, and then I palpated
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before the video started. But, I'm going
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to do the same thing, I'm going to use a nice
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broad thumb, little inversion, little
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dorsiflexion, go ahead and put my hand
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over my dummy thumb, apply pressure until
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I feel that big increase in tissue
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resistance, and I'm going to hold.
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There is another protocol
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that uses four to six 5 second holds,
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and you can do that too, especially with
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trigger points that are really
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tender. We'll just push into that
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tissue barrier, 2 -3 - 4 - 5, and let up, but,
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I'm not moving my thumb. I want to keep
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that position, 1- 2- 3- 4- 5, and let up, and
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usually what you'll find is over
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several reps, the tissue density and
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activity will start to calm down.
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I do prefer static holds myself, but try
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them both. They're both effective
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methodologies, both are backed up by some
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pretty good theory, and supported by some
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very effective practitioners.
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our close up recap. Notice, I already have
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the fibularis longus and fibularis
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brevis trigger points mapped out for us.
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It does help to know where those trigger
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points are at, but if I have Melissa go
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ahead and plantar flex into my thigh,
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you start to see this little
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shadow pop up, and the shadow is just
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to the anterior border of the soleus, and
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it's caused by the contraction of the
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fibularis muscles pulling down on that
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crural fascia. If I palpate this way across
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the fascia, I can actually feel - go
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ahead and plantar flex again - I can feel
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the anterior border of the soleus, and
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then a little speed bump shape right here
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of muscle tissue, kind of like a half
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foam roll shape, and that is the
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fibularis longus right there. If I go any
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further anterior of course, I end up on
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the anterior tibialis, and the long toe
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extensors.
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Once I know where this trough is, I can
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start looking for hypertonic or
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increased tissue density, increased
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activity in this muscle, I can start by
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going as proximal as I possibly can, and
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I run right into her fibular head. That's bone that's not going anywhere.
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Start palpating across transversely here,
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and I feel a little increased tissue
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density right here, so now I'm going to
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start messing around, going distal, and
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see if I can find a nodule or knot
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contributing to the tautness in that band.
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Right here I feel something, so what
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I'm going to do is I'm going to help
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stabilize that trigger point by pulling
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these tissues a little tighter. The way
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I'm going to do that is use this thigh
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to push down into inversion, and then up
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into dorsiflexion, and I can feel,
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all of a sudden, it go "whoop",
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and almost center that trigger point
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for me, so that I can then use a nice
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broad thumb to just push right up
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against it. Then I can relax and use this
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hand, straight arms, put my shoulders up
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over my hands, press as hard as I need to
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to get to just when that tissue starts
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pushing back pretty good. I don't want to
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go past that, just up to the point where
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the tissue starts pushing back,
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and hold. If i push too hard, her muscle
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pushes back really hard, I'll feel it
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increase in tissue density, and I'll
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never get a release. If I don't push hard
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enough, I probably won't stimulate enough
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receptors to get autogenic inhibition
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and get a release, so it does take a
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little practice to know how much
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pressure you should use. Once I get
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that release, and I can feel the tissue
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density kind of melting under my finger,
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I can move on to my fibularis brevis,
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which for the most part is going to
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be on the lower half of the tibia.
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Once again, I start doing my little cross
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fiber palpation, oh there, that's
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that's a nice increase in tissue density
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right there, so now I start messing
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around, and sure enough, find a little
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nodule right there. Same thing, I'm going
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to push down into inversion, up into
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dorsiflexion, and then apply my pressure.
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I could use, if Melissa was getting
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really sensitive, that on-off
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sort of protocol which is 5
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seconds on, 2 to 3 seconds off. The only
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times I tend to use that protocol
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personally, is when somebody's so
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sensitive that I can't get to that
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increase in tissue resistance, so that I
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can get that mechanical release I'm
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looking for. I almost have to slowly
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desensitize the tissue until I can get
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deep enough. Last thing I want you
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to notice is how this bottom leg
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is positioned. Make sure that
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you don't get somebody like this, because
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you'll just put some lateral to medial
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sheer force through their knee, which is
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probably not going to feel very good. So
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I have her lower leg braced
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underneath this top leg.
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There you
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have it, that was static manual
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release of the peroneals, or fibularis
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muscles. Make sure that before you start
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implementing this technique, you've
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had a chance to
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practice on some of your friends and
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colleagues. You want to get your manual
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skills pretty solid, because there's
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nothing like a shaky hand to affect
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patient confidence, and that's not going
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to help your outcomes. Make sure that
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before you put your hands on somebody,
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that you're 80% sure
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that that muscle is involved in the
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dysfunction. You don't have to be
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100% sure. You're not going to
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get it right every time, but, one of my
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biggest pet peeves is a practitioner
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goes, 'okay lay on the table', as soon as
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the patient or client walks in. You need
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to assess. Whether it's the overhead
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squat assessment, ganiometry, some
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sort of special test, a muscle
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length test... you need to have a good
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working hypothesis before you start
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poking and palpating and trying to
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release some of these overactive
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structures. I look forward to hearing
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what type of outcomes you got from
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this technique. Talk with you soon.