0:06 This is Brent of the Brookbush Institute at the independent training spot in New 0:09 York City, going over goniometric assessment. Now in this video we're going 0:12 to go over knee extension goniometry which is something some of us are going 0:16 to use a little bit, and some of us are going to use a whole lot, especially if 0:19 you're in like an orthopedic rehab facility where you're doing a lot of 0:22 knee replacements. Either way it's an important to have this assessment in 0:27 your repertoire and have a good understanding of it, because just a 0:30 slight loss of knee extension can lead to pretty significant losses and 0:34 function, and definitely can lead to some knee pain. I'm going to have my friend 0:38 Melissa come out, she's going to help me demonstrate this assessment. Now just 0:42 like all of our other goniometric assessments we have a stabilization arm 0:47 line and we have a movement arm line, and these lines are actually the same lines 0:51 we've used for all of the other knee goniometry. So it's mid femur which 0:57 is greater trochanter, through lateral condyle, and then joint line here, and 1:02 then I just kept that line going straight through the fibular head and 1:05 the lateral malleolus, because that would be the midpoint of her lower leg there. 1:10 Now the fulcrum is going to be the joint line itself, the only caveat to this 1:14 technique is if you look at the range of motion that is normal for knee extension, 1:19 you'll see that this is 0 to 5 degrees. Now that's not five degrees this way 1:26 five degrees, that's actually five degrees of what some would term hyper 1:32 extension is normal right. So if I give her just a little bit of force this way 1:38 you can actually see that her knee bows up, and that's a totally normal range of 1:43 motion. Now to measure that I can't ask Melissa to hold hyper hold 1:47 hyperextension go ahead and hold it, it just feels weird right. So she ends up 1:52 contracting a lot of muscles to try to stabilize the joint, you probably end up 1:56 with more neutral. The easiest way to measure this is have something 1:59 underneath their ankles, I just grabbed a foam roll here because there's that's 2:04 convenient, there's lots of foam rolls around here at ITS. So if i push her 2:09 into her end range get that nice firm and feel i'm looking for, and she can 2:14 kind of relax into that end feel, now as soon as I pull my hands up, 2:17 she's where I need her to be for me to pull out my goniometer and take this 2:24 measurement. All right so stability arm, fulcrum through the joint line, and then 2:29 movement arm, and I got two degrees. Now of course doing goniometry like this is 2:36 really terrible technique, so I'm going to turn my back to you guys, once again 2:40 walk you through, walk you through this whole technique. So once again i got my 2:50 stabilization arm, i got my movement arm, and I know where my fulcrum is going to 2:54 be. I'm going to go ahead and throw her ankles up on this bolster or foam roll, 3:00 I'm going to go ahead and push and make sure i feel that firm and feel. Alright 3:06 once I know I have that firm and feel I'm going to go ahead and get down to eye 3:12 line here, now I have to keep in mind that the mid femoral line is not going 3:18 to be parallel to my table like it has been in other techniques we've used, it's 3:22 going to kind of slope down towards her hip. So I got to be careful that I 3:26 measure from that point, then as I go through my movement arm here, make sure 3:31 my fulcrums lined up, I actually get two degrees of hyper extension or a negative 3:39 2 degrees. Thank you Melissa. Now that's normal range of motion. But 3:48 what would have happened if I got five degrees the other way, somebody with five 3:52 degrees of less than optimal knee extension can't even lock their knee, and 3:59 that's going to potentially lead to some dysfunction right, think of how hard 4:03 your quads would have to work all the time even during standing, if you 4:07 couldn't even lock your knee. So if I have somebody who has a knee extension 4:10 restriction, I need to start thinking of all of those tissues that could restrict 4:14 that range of motion, and what techniques could I possibly use to improve that 4:20 range of motion. So starting with my muscles, I know that all of my flexors 4:24 are going to contribute to a lack of knee extension. So my hamstrings of 4:29 course and we know biceps femoris has a propensity to get over active in a lot 4:33 of individuals, my gastrocnemius, probably my lateral gastroc more specifically, and my 4:38 popliteus which has a propensity to get overactive and develop trigger points, 4:42 are all muscles that maybe I could release, maybe I could lengthen with some 4:46 stretching techniques. Then we move on to joint here and we see a whole lot of the 4:54 joint itself, the the capsule the ligaments that are holding my femur to 4:59 my tibia, a lot of them restrict extension. My popliteal ligaments, my 5:03 collateral ligaments, that's lateral and medial, my cruciate ligaments right 5:08 that's anterior and posterior. From the perspective of this guys, think about all 5:12 those individuals who go in for anterior cruciate ligament repairs or lateral 5:17 collateral ligament repairs like do you think they're going to have a limit of 5:21 knee extension? Probably. So now the question is how do we affect the joint 5:25 itself, when I start thinking about my arthrokinematics, start thinking about 5:30 the fact that the tibia right, my lower leg, has to glide anteriorly to and to 5:38 make sure i get to terminal extension. If I don't have that that gliding 5:43 anteriorly of the tibia, then I can hit end rage extension. A lot of the 5:47 individuals who end up with surgical repairs here, they lose that ability, 5:53 and then I have to start thinking about my techniques again after I get through 5:55 my soft tissue stuff. Maybe I'm going to do my femur on tibia anterior to 6:02 posterior mobilizations, or if they can flip them over into prone and I could 6:07 do my tibia on femur posterior to anterior mobilizations. And if I want to 6:12 get really fancy I can focus maybe more on the lateral compartment of the knee 6:18 joint, to make sure that I'm not stuck in tibial external rotation. I hope you guys 6:24 caught all that. Don't forget the patella femoral joint and the proximal tibia tibia, 6:32 sorry that should say tibiofibular joint here guys. Let me rewrite that all 6:38 right. So your proximal tibia fibula joint and your patella femoral joint 6:44 lock into all those soft tissues right, and if they they attached all these soft 6:52 tissues they can create overactivity, if their dysfunctional, so my proximal 6:57 fibula being stuck posteriorly, might need to be mobilized anteriorly. My patella 7:02 femoral of course we could go on for hours about patella femoral alignment, 7:06 and and how it moves and glides and and tilts. Make sure you get some of those 7:13 techniques in your repertoire. Fascia so all of those who are using fascial 7:18 techniques. The posterior fascia lata of course that fascia over my hamstrings, my 7:24 posterior crural fascia, the fascia over my calf. And my popliteal fascia, actually 7:28 the fascia in the back of my knee can all restrict terminal knee extension here. 7:35 And if you're using assisted instrument, assisted soft tissue mobilization, or 7:40 your pin and stretch techniques, or myofascial release techniques, these are 7:43 all areas to work on, but don't forget the lateral fascia lata on the iliotibial 7:47 band. There is kind of a cross over there guys where the iliotibial band will 7:53 assist in some flexion right, and if it's bound down, if it's tight, it 8:01 will resist extension right. I think that turnover happens at about 30 degrees, but 8:07 it's definitely worth investigating with your fascial techniques if you're having 8:10 a hard time getting somebody back to normal knee extension. Now of course if i 8:14 had pushed on Melissa's knee and i got any sort of nerve symptom, i might think 8:21 common fibular or tibial nerves. Now goniometric assessments aren't great ways 8:25 of assessing nerve neurodynamics, but if I started thinking okay wait a second 8:33 she's feeling something here, it seems to be kind of one of those nerve symptoms, I 8:36 need to do my neurodynamic tests, and I'm going to probably start 8:39 differentiating here. So guys there's a huge graph for a very small range of 8:47 motion that happens to be very important. I hope you guys will start using this 8:52 knee extension goniometry, at least experimenting with it on your colleagues, 8:55 see who has optimal and who doesn't, and start asking them about their history of 9:01 maybe knee pain, knee dysfunction, knee surgery, and see if you guys can start 9:05 putting some pieces together. And then of course with all of the graphs that are put 9:09 up here guys it's not to intimidate, it's not to make this look an overwhelming 9:14 amount of information, it's just to give you as many possibilities as you can 9:18 think of, as many tissues as I can think of to address, so that when somebody 9:23 comes in you have lots of tools in your toolbox, a huge arsenal to use to get 9:29 them back to optimal motion. I look forward to hearing about you guys's 9:32 results.
