0:04 This is Brent of the Brookbush Institute. 0:06 In this video we're going over static 0:08 manual release of the peroneals, or 0:10 fibularis muscles. This is an 0:13 educational video. I'm assuming that if 0:14 you're watching this video, you're a 0:15 licensed, manual practitioner, physical 0:18 therapist, athletic trainer, 0:20 chiropractor, or massage therapist, and 0:22 that you are going to pay attention to 0:23 the laws specific to your scope of 0:26 practice in your state. If you don't know 0:28 what those are, they might be worth 0:30 looking up before you try this on a 0:32 patient or client. I'm going to have my 0:34 friend Melissa come out, she's going to help 0:36 me demonstrate this technique. A 0:38 little general rule, if you're going 0:40 to put your hands on a patient or client, 0:42 it is good practice to know, within 0:47 80%, to have a good strong 0:50 hypothesis, that where you're going to 0:52 put your hands is involved in the 0:54 dysfunction or pathology that you're 0:57 treating. The only way to be able to do 0:59 that is to do some level of assessment. 1:01 If I'm thinking that the fibularis 1:03 muscles are involved in Melissa's 1:06 pathology or dysfunction, chances are 1:08 I've done something like an overhead 1:09 squat assessment, and maybe I've seen feet 1:12 flat, which would be an indicator of 1:15 fibularis muscles being overactive. Maybe 1:17 I've done dorsiflexion goniometery. 1:21 My fibularis muscles are plantar flexors, 1:24 which means that could also be an 1:26 indicator that they are overactive. If I did 1:29 that gastroc-soleus muscle length test, 1:31 if you go back to that video, you 1:33 can see where I mess with eversion and 1:35 inversion and, if you take up some slack 1:39 in the fibularis muscles, pushing the 1:41 ankle and the eversion, and that gives 1:43 you more dorsiflexion, that's also an 1:46 indication that the fibularis muscles 1:48 might be involved. Keep in mind, 1:51 before you get to this point with 1:53 your patient or client on a table and 1:55 you ready to put your hands down, you 1:57 should probably have a good idea that 1:58 those muscles are involved. In this 2:00 particular technique, I'm going to have 2:01 Melissa flip on her side. 2:04 That way my fibularis muscles, 2:07 which are on the lateral side of my 2:08 lower leg, are now facing me. The first 2:13 thing I need to know is how to palpate 2:15 the fibularis muscles. Your fibularis 2:17 muscles lie just anterior to your 2:20 soleus. If I want, I could have 2:22 Melissa go ahead and plantar flex, push 2:26 down into my thigh so her soleus pops out 2:29 right there, and then her fibularis 2:32 muscles would be the divot right in 2:34 front of it or just anterior to it. 2:37 In fact, if I put my fingers here, and I 2:39 kind of rub back and forth, you can 2:41 almost feel the soleus does this, 2:44 and then drops off, and then your 2:46 fibularis is this little bump, 2:50 this long half-circle right in 2:54 front of the border of the soleus. You 2:57 don't want to go any further anterior or 2:58 you run into that anterior mass, that's 3:00 your tibialis anterior and your long toe 3:04 extensors. Alright, so we got this right 3:06 here, the superior border, what I don't 3:09 want to go higher than, is my fibular 3:11 head, which if you rub your 3:14 fingers up towards the knee in a broad 3:16 fashion, eventually you're going to hit 3:18 this hard bump. That hard bump is 3:22 her fibular head. Right underneath that 3:25 you can start to feel the fibularis 3:28 fascicles. Anytime we find, or we are 3:33 looking for, a point to release, it is 3:35 helpful to know your trigger points. That 3:38 will give you a good general indication 3:40 of where you should be releasing. These 3:43 trigger points are really consistent. The 3:46 theory is that the dysfunction is 3:48 happening around the neuromuscular 3:50 junction, especially in these overactive 3:53 muscles, and that right around the 3:55 neuromuscular junction, we have this 3:57 point of localized hyperactivity that 4:01 releases with compression. So, knowing 4:04 those points is definitely helpful and, 4:06 I've actually put an X here on her 4:09 trigger point for her fibularis longus, 4:10 and a trigger point 4:12 for her fibularis brevis. If I didn't 4:15 have that memorized, I could still find 4:16 them. What I'm going to do is 4:19 strum across her fascicles, perpendicular 4:23 to those fibers. Her fibularis muscle 4:26 runs this way, I'm going to go ahead and 4:28 strum with a nice broad pat of my thumb 4:31 across those fibularis fibers, and what 4:36 I'm looking for is fibers that feel 4:38 more dense, that feel more 4:42 resistant. Now, you're fibularis 4:46 muscle isn't like your calf. If you've 4:48 watched that previous video from us, it's 4:50 not like your calf where you can compare 4:51 fibers within the same muscle. It's a 4:54 much narrower muscle. Chances are, 4:56 we're going to have to palpate a fair 4:58 number of fibularis muscles to 5:00 determine what's normal, and then what's 5:03 overactive. But, if I do this, I do feel a 5:06 little bit of over activity, and, 5:09 Melissa's fibularis longus here, and then 5:13 what I'm going to do is 5:14 start searching proximally and distally. 5:19 What I'm going to assume is 5:21 that that fascicle is being pulled tight 5:24 by a knot that is her trigger 5:28 point, and if I palpate, and I can see 5:34 right around here, all the 5:38 sudden I feel a 5:40 little nodule under my thumb. The way 5:43 I'm going to release this is, I'm going 5:45 to use a broad thumb this way. 5:48 I'm going to use this entire thumb pad, 5:50 other than trying to to poke at it, which 5:53 is a little bit like trying to put your 5:55 finger on top of a marble, it just 5:59 doesn't work, it just keeps slipping 6:01 either way. Let me use a nice broad thumb, 6:04 this way, I'm then going to push her into 6:06 a little bit of inversion and 6:08 dorsiflexion, because that's going to 6:09 help tighten up this muscle a little bit 6:12 so that the trigger point 6:14 stays centered. Between that 6:17 broad thumb stroke, and the tension I put 6:19 within the muscle, I now have a 6:21 stable trigger point to put some static 6:24 pressure against, which is going to 6:26 increase the likelihood that I actually 6:28 get a release. The way I get her into 6:31 inversion and dorsiflexion is, I'm 6:33 actually just going to use my thigh, I'm 6:35 going to bring my leg up a little bit 6:36 and then just drop it down. There's my 6:39 inversion, and then I can just lean 6:40 forward a little bit, and I have my 6:41 dorsiflexion. Broad thumb here, this is 6:44 going to be my dummy thumb, I'm then 6:46 going to put this dummy thumb right 6:49 in between my thenar eminences, 6:52 right here, and then all I have to 6:56 do is lean in until I feel that 7:00 increase in tissue tension 7:04 right there. I don't have to go to 7:05 maximal tension. Usually what 7:08 I'm feeling for is the 7:09 tension within tissues, there's a linear 7:11 increase, you get this slow 7:14 increase, you just kind of push into the 7:15 tissue, and then you reach a point where 7:17 all of a sudden going any further, 7:20 the tension increases very rapidly. I'm 7:22 just going up to that point. It 7:25 takes a little bit of practice because 7:28 if you push too hard your patient or 7:31 client will start guarding on you, the 7:33 muscle will really start fighting back, 7:34 and you'll never get a release. If 7:37 you don't use enough tension, you also 7:40 won't get a release. The thought 7:42 process there is, you're probably not 7:44 stimulating enough ruffini endings, 7:46 enough of that golgi tendon organ, to get 7:49 autogenic inhibition. I'm 7:52 going to hold this for 30 7:54 seconds. Usually what happens is, they get 7:58 a decrease in discomfort. They might even 8:00 ask you "did you let go, did you 8:02 lighten up" and you're just keeping 8:04 consistent pressure. What you'll feel 8:06 underneath your thumb is the trigger 8:10 point and the hypertonic fascicles, the 8:13 overactive fascicles will actually kind 8:14 of melt away underneath your thumb, 8:18 and that was it for Melissa. 8:22 Now I know she 8:25 has a fibularis longus and brevis, so I 8:26 could keep searching. Your fibularis 8:28 brevis starts a little lower, a little 8:31 lower than a the halfway mark of 8:34 your tibia. If I start going 8:38 across here, I feel some 8:42 overactive fascicles. It's just 8:43 finding where that nodule is, and 8:46 again, I marked these X's over her 8:49 trigger points, and I did that using of 8:51 course, my knowledge of where the common 8:53 trigger points are, and then I palpated 8:54 before the video started. But, I'm going 8:57 to do the same thing, I'm going to use a nice 8:58 broad thumb, little inversion, little 9:00 dorsiflexion, go ahead and put my hand 9:04 over my dummy thumb, apply pressure until 9:07 I feel that big increase in tissue 9:10 resistance, and I'm going to hold. 9:13 There is another protocol 9:14 that uses four to six 5 second holds, 9:19 and you can do that too, especially with 9:22 trigger points that are really 9:23 tender. We'll just push into that 9:25 tissue barrier, 2 -3 - 4 - 5, and let up, but, 9:33 I'm not moving my thumb. I want to keep 9:35 that position, 1- 2- 3- 4- 5, and let up, and 9:44 usually what you'll find is over 9:46 several reps, the tissue density and 9:50 activity will start to calm down. 9:52 I do prefer static holds myself, but try 9:57 them both. They're both effective 9:59 methodologies, both are backed up by some 10:03 pretty good theory, and supported by some 10:06 very effective practitioners. 10:08 This is 10:09 our close up recap. Notice, I already have 10:12 the fibularis longus and fibularis 10:14 brevis trigger points mapped out for us. 10:16 It does help to know where those trigger 10:18 points are at, but if I have Melissa go 10:21 ahead and plantar flex into my thigh, 10:24 you start to see this little 10:26 shadow pop up, and the shadow is just 10:31 anterior 10:32 to the anterior border of the soleus, and 10:35 it's caused by the contraction of the 10:37 fibularis muscles pulling down on that 10:40 crural fascia. If I palpate this way across 10:44 the fascia, I can actually feel - go 10:47 ahead and plantar flex again - I can feel 10:48 the anterior border of the soleus, and 10:52 then a little speed bump shape right here 10:55 of muscle tissue, kind of like a half 10:58 foam roll shape, and that is the 11:01 fibularis longus right there. If I go any 11:04 further anterior of course, I end up on 11:06 the anterior tibialis, and the long toe 11:09 extensors. 11:12 Once I know where this trough is, I can 11:15 start looking for hypertonic or 11:19 increased tissue density, increased 11:22 activity in this muscle, I can start by 11:26 going as proximal as I possibly can, and 11:29 I run right into her fibular head. That's bone that's not going anywhere. 11:33 Start palpating across transversely here, 11:37 and I feel a little increased tissue 11:39 density right here, so now I'm going to 11:41 start messing around, going distal, and 11:43 see if I can find a nodule or knot 11:48 contributing to the tautness in that band. 11:50 Right here I feel something, so what 11:54 I'm going to do is I'm going to help 11:55 stabilize that trigger point by pulling 11:59 these tissues a little tighter. The way 12:02 I'm going to do that is use this thigh 12:04 to push down into inversion, and then up 12:07 into dorsiflexion, and I can feel, 12:11 all of a sudden, it go "whoop", 12:14 and almost center that trigger point 12:16 for me, so that I can then use a nice 12:18 broad thumb to just push right up 12:22 against it. Then I can relax and use this 12:25 hand, straight arms, put my shoulders up 12:29 over my hands, press as hard as I need to 12:33 to get to just when that tissue starts 12:36 pushing back pretty good. I don't want to 12:38 go past that, just up to the point where 12:41 the tissue starts pushing back, 12:43 and hold. If i push too hard, her muscle 12:47 pushes back really hard, I'll feel it 12:50 increase in tissue density, and I'll 12:53 never get a release. If I don't push hard 12:56 enough, I probably won't stimulate enough 12:58 receptors to get autogenic inhibition 13:00 and get a release, so it does take a 13:03 little practice to know how much 13:05 pressure you should use. Once I get 13:09 that release, and I can feel the tissue 13:10 density kind of melting under my finger, 13:12 I can move on to my fibularis brevis, 13:15 which for the most part is going to 13:17 be on the lower half of the tibia. 13:23 Once again, I start doing my little cross 13:27 fiber palpation, oh there, that's 13:30 that's a nice increase in tissue density 13:33 right there, so now I start messing 13:35 around, and sure enough, find a little 13:41 nodule right there. Same thing, I'm going 13:44 to push down into inversion, up into 13:48 dorsiflexion, and then apply my pressure. 13:51 I could use, if Melissa was getting 13:55 really sensitive, that on-off 13:58 sort of protocol which is 5 14:02 seconds on, 2 to 3 seconds off. The only 14:05 times I tend to use that protocol 14:07 personally, is when somebody's so 14:08 sensitive that I can't get to that 14:12 increase in tissue resistance, so that I 14:14 can get that mechanical release I'm 14:16 looking for. I almost have to slowly 14:18 desensitize the tissue until I can get 14:21 deep enough. Last thing I want you 14:23 to notice is how this bottom leg 14:25 is positioned. Make sure that 14:28 you don't get somebody like this, because 14:29 you'll just put some lateral to medial 14:33 sheer force through their knee, which is 14:35 probably not going to feel very good. So 14:38 I have her lower leg braced 14:41 underneath this top leg. 14:43 There you 14:44 have it, that was static manual 14:47 release of the peroneals, or fibularis 14:49 muscles. Make sure that before you start 14:52 implementing this technique, you've 14:54 had a chance to 14:55 practice on some of your friends and 14:57 colleagues. You want to get your manual 15:00 skills pretty solid, because there's 15:03 nothing like a shaky hand to affect 15:08 patient confidence, and that's not going 15:10 to help your outcomes. Make sure that 15:12 before you put your hands on somebody, 15:13 that you're 80% sure 15:16 that that muscle is involved in the 15:19 dysfunction. You don't have to be 15:20 100% sure. You're not going to 15:21 get it right every time, but, one of my 15:24 biggest pet peeves is a practitioner 15:27 goes, 'okay lay on the table', as soon as 15:30 the patient or client walks in. You need 15:32 to assess. Whether it's the overhead 15:35 squat assessment, ganiometry, some 15:37 sort of special test, a muscle 15:40 length test... you need to have a good 15:42 working hypothesis before you start 15:44 poking and palpating and trying to 15:47 release some of these overactive 15:50 structures. I look forward to hearing 15:52 what type of outcomes you got from 15:54 this technique. Talk with you soon. 16:04
