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