0:06 This is Brent of the BrookBush Institute at the Independent Training Spot going 0:10 over our next goniometric assessment video, which is supine 90-90 hip 0:14 internal rotation goniometry. Now I know what you're thinking we just went over 0:19 internal rotation goniometry in prone. These are not the same assessment. 0:24 They're both very commonly used, however what they're going to tell us about the 0:28 hip and the restrictions at the hip is slightly different, and could give us a 0:33 little bit more information to use when we create our intervention. I'm going to 0:37 have my friend Melissa come out, she is going to help me demonstrate 0:41 this goniometric assessment. Now the first thing we need to do is know where 0:44 our two lines are right, where is the line for the stabilization arm, where is 0:48 the line for the movement arm of our goniometer. Now stabilization arm is 0:53 going to go straight through the midline, or a line parallel to the midline of 0:58 Melissa's body here, or a line, you guys can think of a line that runs parallel 1:01 to this table, the edge of this table. The movement arm, you guys can see I put a 1:06 little tape here, the movement arm is going to go through the center of the 1:10 knee, and line up with the tibial tuberosity. This is the same line we 1:13 created in hip internal rotation in prone right. We don't want to just follow 1:17 the tibia because the crest of the tibia isn't straight, so that could lead to 1:22 some inaccuracy in our measurements. Now the way I like to do this guys is I like 1:27 to to go ahead and put my goniometer down to start, bring Melissa's hip here 1:33 in to 90 degrees, make sure her knee is directly over her hip, no adduction or 1:38 abduction, no flexion or extension, just right at 90 degrees. I'm going to 1:44 go ahead and take her into internal rotation until I get that firm end feel, 1:48 which is the normal end feel at the hip. Alright this will be a 1:52 slightly softer end feel than we felt in the prone hip internal rotation, but 1:58 still a firm end feel nonetheless. I'm then going to have Melissa try to give 2:02 me a little help, can you hold this position. This is not an easy position 2:06 for her to hold, so what I'm going to do is once i got my goniometer and i got 2:11 her kind of set up, I'm gonna wrap my arm around, i'm going to stabilize her leg, 2:15 kind of reposition. Make sure i'm as accurate as possible, that her knee is 2:19 directly over her hip, make sure she's at that end range, and then i'm going to go 2:24 ahead and line up my stabilization arm here, get my movement arm lined up, and I 2:31 got 36 degrees. So that's hip internal rotation goniometry 2:37 at 90 degrees. Let me do that one more time for you guys, real quick just 2:41 as I would do it in my own clinic. Hip flexion, no adduction or abduction. Good take 2:47 her to her end range. Can you hold that for me Melissa, good. Make sure your not hip 2:51 hiking for me. Good, setup my stabilization arm, my movement arm ,make 3:00 sure I have, go ahead and relax, make sure she's all lined up, and that time I got 3:10 38 degrees, good. If I wanted to be as accurate as possible I might take up to 3:16 three measurements and average those, but you guys can see how this measurement is 3:21 done. Now the next question is what do we do with it, thank you Melissa. Guys can 3:27 see the board back here? Again if we're doing goniometric assessment, remember 3:34 we have to assess for one of two reasons, we either assessing to clear our 3:38 patients and clients, and make sure that they are prepared for intervention, that 3:41 they're able to work with us, nothing's contraindicated, all right or we're 3:46 trying to figure out what we're going to do in our intervention, in whether it's 3:52 our exercise, or physical therapy, or athletic training, we need to figure out 3:55 how we're going to affect this test that we just did. Goniometry is a 4:00 flexibility assessment, so I need to think about what are the restrictions to 4:03 this goniometric assessment. In the case of hip internal rotation at 90 4:08 degrees this is a slightly confusing graph actually, we're going to start with 4:13 muscles. Alright so the first thing that restricts hip internal rotation at 90 4:19 degrees, and this is a puzzling one, it's probably your TFL and your gluteus 4:23 minimus, and I know what some of you guys are thinking, some of you guys were up on 4:26 your functional Anatomy, wait a second those are internal rotators, so how are 4:31 they going to restrict hip internal rotation? And that's a great question and 4:36 I'll give you guys my theory on that, which is the TFL and gluteus minimus can 4:41 also superiorly and anteriorly glide the femoral head in the acetabulum. 4:46 So we're probably seeing when we have somebody who's restricted in hip 4:50 internal rotation, is we start getting a little bit of impingement on that 4:54 capsule, or we start running out of room right where the the femoral head is 4:58 rolling, but not gliding posteriorly enough. So we're going to release these 5:03 muscles to actually help improve arthrokinematics. The next thing I'm 5:10 going to go after is the adductors, now which adductor? Great question. Once we 5:15 get into hip flexion at 90 degrees, we've lengthened the adductor Magnus, we've 5:19 shortened the anterior adductors right, but both seem to be able to restrict 5:26 this range of motion. So I'm going to go ahead and start releasing and thinking 5:31 about stretching those adductors. The next thing I'm going to go after is the 5:35 deep rotators, but for those of you guys were really really up on your 5:40 kinesiology, you guys might remember that the piriformis above 90 degrees is 5:44 actually a hip internal rotator. So it's not going to restrict this motion. So you 5:49 guys got TFL and glute min, adductors and deep rotators are probably the first 5:56 three muscles or three muscle groups that I'm going to go after. However don't 6:01 count out the psoas and iliacus, biceps femoris, and rectus femoris, these could 6:06 also contribute. Once I get through all of this muscle stuff, what if I still 6:11 have restriction in the hip? Well probably the most impactful thing is 6:19 when we get actual restriction in the joint capsule itself. So I'm going to 6:22 start looking for posterior and inferior capsule shortening, and the techniques 6:26 I'm going to use for that is either the self administered hip joint mobilization 6:30 I did in a previous video, or we're going to have to look towards some of those 6:34 manual techniques. I know you guys are familiar with like your lateral 6:37 distraction, or your posterior glide of the hip. The sacroiliac joint, I think 6:44 I've mentioned this in a couple videos since like the piriformis and some 6:49 other structures cross that sacroiliac joint, through either a fascial connection 6:54 or a direct connection. If that sacroiliac joint gets bound down, becomes 6:58 dysfunctional, it could change the tonicity of muscles that cross both the 7:02 sacroiliac joint and the hip, and affect our range of motion. So now I got all of 7:09 these muscles I could think of working on. I got these two joints that I could 7:13 think about working on. Don't forget about the fascial component alright, so my 7:17 lateral fascia lata, as well as my posterior hip. All of you guys using your 7:23 PIN and stretch techniques, and your instrument assisted soft tissue 7:26 mobilization, and your self administered myofascial release, think towards these 7:30 areas, and go well if I've already done the muscle stuff, and the hip stuff, maybe 7:35 I need to work on that fascial component. And of course we also need to think 7:40 nerves. Now goniometery is not a great assessment of which nerve is 7:46 restricted, or whether we had a nerve restriction. The most important thing to 7:50 remember is if I happen to be doing this, and Melissa had got paresthesia right, 7:54 she had got that pins and needles feeling, the tingling down the 7:59 back of her leg, do I have sciatic nerve impingement. So these deep rotators, 8:06 one of them is my gemellus superior, and then i have my piriformis, on top of that 8:09 my sciatic nerve runs between those two muscles. If I crank her into internal 8:14 rotation, what I do is I tighten my gemellus superior, and pinch up on my 8:19 sciatic nerve. Nerves that are normally functioning 8:23 will not cause paresthesia. If she has a dysfunctional sciatic nerve for some 8:29 reason and I impinge it, it's going to give her sensation, and I need to go 8:33 ahead and move on to my neurodynamic tests. We might also have some sensation in 8:37 the posterior femoral cutaneous nerve. So once again we had this huge complicated 8:43 graph, so let me kind of break this down for you guys. I use this goniometric 8:50 assessment probably more than any other assessment for the hip, and the reason 8:55 being is is it gives me all of these potential ways to correct hip 9:02 dysfunction, and what I find which is most important, is that if i can get hip 9:08 internal rotation at 90 degrees back to optimal, that I've probably done a really 9:15 good job at removing as many restrictions as I can at the hip. So 9:21 while the prone hip internal rotation is nice and gives me a lot of great 9:24 information, this is the one where I go okay if I got this one, I got them 9:31 back to close to normal and I know I'm on the right track. I hope i just gave 9:35 you guys a ton of information, a ton of things to think about, and i hope you 9:38 guys understand hip internal rotation goniometry at 90 degrees of hip 9:42 flexion. Thank you. 9:52
