00:00:0600:00:10
This is Brent of the BrookBush Institute
00:00:0600:00:10
at the Independent Training Spot going
00:00:1000:00:14
over our next goniometric assessment video, which is supine 90-90 hip
00:00:1400:00:19
internal rotation goniometry. Now I know what you're thinking we just went over
00:00:1900:00:24
internal rotation goniometry in prone. These are not the same assessment.
00:00:2400:00:28
They're both very commonly used, however what they're going to tell us about the
00:00:2800:00:33
hip and the restrictions at the hip is slightly different, and could give us a
00:00:3300:00:37
little bit more information to use when we create our intervention. I'm going to
00:00:3700:00:41
have my friend Melissa come out, she is going to help me demonstrate
00:00:4100:00:44
this goniometric assessment. Now the first thing we need to do is know where
00:00:4400:00:48
our two lines are right, where is the line for the stabilization arm, where is
00:00:4800:00:53
the line for the movement arm of our goniometer. Now stabilization arm is
00:00:5300:00:58
going to go straight through the midline, or a line parallel to the midline of
00:00:5800:01:01
Melissa's body here, or a line, you guys can think of a line that runs parallel
00:01:0100:01:06
to this table, the edge of this table. The movement arm, you guys can see I put a
00:01:0600:01:10
little tape here, the movement arm is going to go through the center of the
00:01:1000:01:13
knee, and line up with the tibial tuberosity. This is the same line we
00:01:1300:01:17
created in hip internal rotation in prone right. We don't want to just follow
00:01:1700:01:22
the tibia because the crest of the tibia isn't straight, so that could lead to
00:01:2200:01:27
some inaccuracy in our measurements. Now the way I like to do this guys is I like
00:01:2700:01:33
to to go ahead and put my goniometer down to start, bring Melissa's hip here
00:01:3300:01:38
in to 90 degrees, make sure her knee is directly over her hip, no adduction or
00:01:3800:01:44
abduction, no flexion or extension, just right at 90 degrees. I'm going to
00:01:4400:01:48
go ahead and take her into internal rotation until I get that firm end feel,
00:01:4800:01:52
which is the normal end feel at the hip. Alright this will be a
00:01:5200:01:58
slightly softer end feel than we felt in the prone hip internal rotation, but
00:01:5800:02:02
still a firm end feel nonetheless. I'm then going to have Melissa try to give
00:02:0200:02:06
me a little help, can you hold this position. This is not an easy position
00:02:0600:02:11
for her to hold, so what I'm going to do is once i got my goniometer and i got
00:02:1100:02:15
her kind of set up, I'm gonna wrap my arm around, i'm going to stabilize her leg,
00:02:1500:02:19
kind of reposition. Make sure i'm as accurate as possible, that her knee is
00:02:1900:02:24
directly over her hip, make sure she's at that end range, and then i'm going to go
00:02:2400:02:31
ahead and line up my stabilization arm here, get my movement arm lined up, and I
00:02:3100:02:37
got 36 degrees. So that's hip internal rotation goniometry
00:02:3700:02:41
at 90 degrees. Let me do that one more time for you guys, real quick just
00:02:4100:02:47
as I would do it in my own clinic. Hip flexion, no adduction or abduction. Good take
00:02:4700:02:51
her to her end range. Can you hold that for me Melissa, good. Make sure your not hip
00:02:5100:03:00
hiking for me. Good, setup my stabilization arm, my movement arm ,make
00:03:0000:03:10
sure I have, go ahead and relax, make sure she's all lined up, and that time I got
00:03:1000:03:16
38 degrees, good. If I wanted to be as accurate as possible I might take up to
00:03:1600:03:21
three measurements and average those, but you guys can see how this measurement is
00:03:2100:03:27
done. Now the next question is what do we do with it, thank you Melissa. Guys can
00:03:2700:03:34
see the board back here? Again if we're doing goniometric assessment, remember
00:03:3400:03:38
we have to assess for one of two reasons, we either assessing to clear our
00:03:3800:03:41
patients and clients, and make sure that they are prepared for intervention, that
00:03:4100:03:46
they're able to work with us, nothing's contraindicated, all right or we're
00:03:4600:03:52
trying to figure out what we're going to do in our intervention, in whether it's
00:03:5200:03:55
our exercise, or physical therapy, or athletic training, we need to figure out
00:03:5500:04:00
how we're going to affect this test that we just did. Goniometry is a
00:04:0000:04:03
flexibility assessment, so I need to think about what are the restrictions to
00:04:0300:04:08
this goniometric assessment. In the case of hip internal rotation at 90
00:04:0800:04:13
degrees this is a slightly confusing graph actually, we're going to start with
00:04:1300:04:19
muscles. Alright so the first thing that restricts hip internal rotation at 90
00:04:1900:04:23
degrees, and this is a puzzling one, it's probably your TFL and your gluteus
00:04:2300:04:26
minimus, and I know what some of you guys are thinking, some of you guys were up on
00:04:2600:04:31
your functional Anatomy, wait a second those are internal rotators, so how are
00:04:3100:04:36
they going to restrict hip internal rotation? And that's a great question and
00:04:3600:04:41
I'll give you guys my theory on that, which is the TFL and gluteus minimus can
00:04:4100:04:46
also superiorly and anteriorly glide the femoral head in the acetabulum.
00:04:4600:04:50
So we're probably seeing when we have somebody who's restricted in hip
00:04:5000:04:54
internal rotation, is we start getting a little bit of impingement on that
00:04:5400:04:58
capsule, or we start running out of room right where the the femoral head is
00:04:5800:05:03
rolling, but not gliding posteriorly enough. So we're going to release these
00:05:0300:05:10
muscles to actually help improve arthrokinematics. The next thing I'm
00:05:1000:05:15
going to go after is the adductors, now which adductor? Great question. Once we
00:05:1500:05:19
get into hip flexion at 90 degrees, we've lengthened the adductor Magnus, we've
00:05:1900:05:26
shortened the anterior adductors right, but both seem to be able to restrict
00:05:2600:05:31
this range of motion. So I'm going to go ahead and start releasing and thinking
00:05:3100:05:35
about stretching those adductors. The next thing I'm going to go after is the
00:05:3500:05:40
deep rotators, but for those of you guys were really really up on your
00:05:4000:05:44
kinesiology, you guys might remember that the piriformis above 90 degrees is
00:05:4400:05:49
actually a hip internal rotator. So it's not going to restrict this motion. So you
00:05:4900:05:56
guys got TFL and glute min, adductors and deep rotators are probably the first
00:05:5600:06:01
three muscles or three muscle groups that I'm going to go after. However don't
00:06:0100:06:06
count out the psoas and iliacus, biceps femoris, and rectus femoris, these could
00:06:0600:06:11
also contribute. Once I get through all of this muscle stuff, what if I still
00:06:1100:06:19
have restriction in the hip? Well probably the most impactful thing is
00:06:1900:06:22
when we get actual restriction in the joint capsule itself. So I'm going to
00:06:2200:06:26
start looking for posterior and inferior capsule shortening, and the techniques
00:06:2600:06:30
I'm going to use for that is either the self administered hip joint mobilization
00:06:3000:06:34
I did in a previous video, or we're going to have to look towards some of those
00:06:3400:06:37
manual techniques. I know you guys are familiar with like your lateral
00:06:3700:06:44
distraction, or your posterior glide of the hip. The sacroiliac joint, I think
00:06:4400:06:49
I've mentioned this in a couple videos since like the piriformis and some
00:06:4900:06:54
other structures cross that sacroiliac joint, through either a fascial connection
00:06:5400:06:58
or a direct connection. If that sacroiliac joint gets bound down, becomes
00:06:5800:07:02
dysfunctional, it could change the tonicity of muscles that cross both the
00:07:0200:07:09
sacroiliac joint and the hip, and affect our range of motion. So now I got all of
00:07:0900:07:13
these muscles I could think of working on. I got these two joints that I could
00:07:1300:07:17
think about working on. Don't forget about the fascial component alright, so my
00:07:1700:07:23
lateral fascia lata, as well as my posterior hip. All of you guys using your
00:07:2300:07:26
PIN and stretch techniques, and your instrument assisted soft tissue
00:07:2600:07:30
mobilization, and your self administered myofascial release, think towards these
00:07:3000:07:35
areas, and go well if I've already done the muscle stuff, and the hip stuff, maybe
00:07:3500:07:40
I need to work on that fascial component. And of course we also need to think
00:07:4000:07:46
nerves. Now goniometery is not a great assessment of which nerve is
00:07:4600:07:50
restricted, or whether we had a nerve restriction. The most important thing to
00:07:5000:07:54
remember is if I happen to be doing this, and Melissa had got paresthesia right,
00:07:5400:07:59
she had got that pins and needles feeling, the tingling down the
00:07:5900:08:06
back of her leg, do I have sciatic nerve impingement. So these deep rotators,
00:08:0600:08:09
one of them is my gemellus superior, and then i have my piriformis, on top of that
00:08:0900:08:14
my sciatic nerve runs between those two muscles. If I crank her into internal
00:08:1400:08:19
rotation, what I do is I tighten my gemellus superior, and pinch up on my
00:08:1900:08:23
sciatic nerve. Nerves that are normally functioning
00:08:2300:08:29
will not cause paresthesia. If she has a dysfunctional sciatic nerve for some
00:08:2900:08:33
reason and I impinge it, it's going to give her sensation, and I need to go
00:08:3300:08:37
ahead and move on to my neurodynamic tests. We might also have some sensation in
00:08:3700:08:43
the posterior femoral cutaneous nerve. So once again we had this huge complicated
00:08:4300:08:50
graph, so let me kind of break this down for you guys. I use this goniometric
00:08:5000:08:55
assessment probably more than any other assessment for the hip, and the reason
00:08:5500:09:02
being is is it gives me all of these potential ways to correct hip
00:09:0200:09:08
dysfunction, and what I find which is most important, is that if i can get hip
00:09:0800:09:15
internal rotation at 90 degrees back to optimal, that I've probably done a really
00:09:1500:09:21
good job at removing as many restrictions as I can at the hip. So
00:09:2100:09:24
while the prone hip internal rotation is nice and gives me a lot of great
00:09:2400:09:31
information, this is the one where I go okay if I got this one, I got them
00:09:3100:09:35
back to close to normal and I know I'm on the right track. I hope i just gave
00:09:3500:09:38
you guys a ton of information, a ton of things to think about, and i hope you
00:09:3800:09:42
guys understand hip internal rotation goniometry at 90 degrees of hip
00:09:4200:09:46
flexion. Thank you.