0:06 This is Brent of the Brookbush Institute at the independent training spot in New 0:10 York City. Today we are doing goniometric assessments, so we're looking at 0:13 the range of motion of the knee and knee flexion. I'm going to have my friend Melissa 0:17 come out, she's gonna help me demonstrate this test, and then once I've showed you 0:20 how to do this test we'll talk about what could possibly restrict this range of 0:24 motion. So first things first I need my two lines and my pivot points. So i had a 0:29 mid femoral line that i'm going to use, a line that goes straight through my 0:33 fibula from fibular head to lateral malleolus, and my pivot point is actually 0:38 the lateral condyle of my femur. Now the way we're going to do knee flexion is we 0:44 have to do it in a little hip flexion so that this test doesn't become biased 0:49 towards just one muscle, which we'll talk about in a second with the Ely's test. So 0:54 real easy guys all you have to do is basically sandwich their leg together, a 1:00 normal end feel actually on this one a little different than some of the other 1:03 tests we did, is actually soft it should be a soft end feel, should be the 1:07 approximation of her hamstrings to her calves, a squishy feeling. Alright then i 1:15 would go ahead and put my stabilization arm through the femur, femoral head is my 1:23 pivot point, and my movement arm goes through the fibula, and we have a hundred 1:28 and thirty-seven degrees of the flexion, which is normal. Alright so let me show 1:35 you how I would actually do that test guys, because obviously I wouldn't just 1:37 lean over somebody and squish them from the other side. So 1:44 I would go ahead and start here, make sure I have a good position so I can 1:50 look straight down on her knee and make sure it's in alignment. Then take her into 1:53 hip flexion, make sure I don't pull her into internal rotation or external rotation, 1:56 I'm not pushing her into adduction as I do this. I just want nice pure knee 2:01 flexion, make sure I get a good end feel nice and soft, alright and then once I 2:07 have it there I can use her foot to plant if I want, or maybe with some 2:11 people you might have to hold it in place. I'm going to kneel down so that 2:16 I'm eye level with my goniometer and I can get as accurate a read as possible. 2:21 Make sure I line up those lines as well as I possibly can too. All right once 2:27 again pivot points femoral head, movement arm straight through the greater 2:31 trochanter, or I'm sorry stabilization arms straight through the greater 2:34 trochanter, move then arms straight through the fibula right down to that 2:38 lateral malleolus, and I actually got a bit more range of motion this time 2:45 about 145 degrees, and i'll have to watch the video to see how I messed that up 2:50 when I was on the other side, thank you Melissa. So fairly easy range of motion 2:57 to test with with knee flexion in hip flexion. The question is now what does 3:04 that show us restriction of? Well to tell you the truth muscular restriction is 3:11 not as common on this test, and you'll see the first muscle i have written up 3:16 here is the articularis genu which some of you may not have even heard of. 3:19 The articularis genu plays a role at the knee to help draw the anterior 3:26 capsule out of the way so it doesn't get pinched as we go into knee extension. If 3:32 it gets tight however it can tighten that anterior capsule and restrict us 3:36 from going all the way into knee flexion. Then I list all the vastus muscles, 3:41 because the vastus muscles don't really have a propensity to get tight in 3:45 individuals, and then you'll notice I list the rectus femoris because for 3:49 the rectus femoris to restrict that position, would be highly unlikely 3:53 considering we're shortening it at the hip. So once again guys 3:58 this particular range of motion muscular restriction not all that common, to be 4:05 quite honest if I had to guess the most common reason why knee flexion gets 4:08 restricted, it's going to be this fancy word for swelling right, a fusion. So you 4:13 get these people who kind of have chronic dysfunction at the knee and they 4:16 start to get the swelling, well that swelling fills up the joint capsule like 4:21 a balloon. Once you take up all of the stretch in the anterior capsule of the 4:26 knee you can't push it into flexion. In fact people sometimes feel it, they 4:30 almost feel like their knee is going to burst when you start pushing it into 4:33 that position. Of course for a fusion we might need to use ice, we might need to 4:39 use wraps, we might need just just some time, or if it's chronic we may need to 4:45 start looking towards referring out and finding out what else is going on inside 4:49 of that knee that keeps bringing this effusion back. After a fusion we have 4:53 anterior capsule tightness somewhat common, don't forget about your patella 4:59 femoral joint and joint mechanics. So something like patella Alta where you 5:05 have that rise of the patella because of a super tight rectus femoris, or super 5:10 tight vastus lateralis for that matter might be affecting the flexion, so that's 5:15 not necessarily the tibial femoral joint with the patella getting in the way, and 5:19 you might need to release and stretch your rectus femoris and vastus lateralis. 5:23 Your proximal tib/fib joint guys I put this up here not because it necessarily 5:28 restricts flexion as much as it can be a source of pain that you find it when you 5:36 squish somebody into flexion, as it gets somebody try that, the soft tissues 5:41 trying to push that proximal fibular head anteriorly and it does not want to 5:46 go. In fact this leads to the only nerve finding that I sometimes get in this 5:52 test which is sometimes you put somebody into flexion as far as you can, it 5:57 pinches all the soft tissues, shoves the proximal fibular head forward and 6:04 pinches on that common fibular nerve. Alright so now you know you have a 6:08 little bit of dysfunction at the knee, and the 6:11 proximal tib/fib joint. And of course fascial restrictions are my anterior fascia 6:17 lata. So all those pin and stretch, instrument assisted soft tissue 6:22 mobilization techniques we can do to help relieve any restriction we might 6:28 have. Now I do have to bring Melissa out here for one more knee test that I know 6:33 you all have seen. I'm going to have you lay on your belly this time. In another video I 6:40 actually already discussed this, we talked about the Eli test. All right and 6:45 then the Eli test I go ahead and palpate, all right the tops of her PSIS alright, and 6:51 I'm going to go ahead and push her knee until I feel her getting pulled into an 6:58 anterior pelvic tilt, which would push her PSIS that way, and I would feel it 7:01 in my fingers. Problem with this test as far as knee flexion goniometry is it 7:08 basically biases this test to almost a single muscle once you get past 7:14 a certain amount of degrees. I'm sure we could use this test for some other, to 7:18 implicate some other structures but right here what i'm doing right now, this 7:23 is all rectus femoris guys. So once I pull her all the way back in a neutral 7:27 hip extension, I have her rectus femoris lengthened up at the hip, and this is 7:31 just lengthening it even further. Great test, great test that you can use within 7:37 your assessments if you suspect rectus femoris tightness. But if you're just 7:43 looking for knee kinematics and you're just looking at what is going on to 7:46 restrict knee motion, I would once again have somebody flip over 7:53 and go right back to my knee flexion goniometry this way. I hope that 7:58 makes sense, i hope i have given you guys a ton of things to think about as far as 8:02 improving this range of motion. I did forget to mention one thing, we didn't 8:10 talk about ligaments at the knee. The ligaments at the knee guys and there is a 8:13 reason i didn't mention them, the ligaments of the knee almost all are 8:17 biased towards extension, I know some of you guys who've seen post-surgical 8:21 ligament repairs have seen a lot of restriction in flexion, and that's just 8:28 because a lot of the ligaments at the knee actually stayed taught throughout 8:32 the entirety of knee flexion or knee extension. So if you have an ACL or PCL 8:40 reconstruction, let's say you might have a limit in overall range of motion at 8:45 this knee in both extension and flexion, i think the thing to remember though is 8:49 if we're not talking about a reconstruction we're not talking about a 8:52 ligament damage, this doesn't implicate any particular ligament. Knee extension 8:59 does, knee flexion does not. I hope I gave you guys a ton of information to look at, 9:03 a ton of techniques to think about to improve this range of motion. I hope I've 9:07 helped your assessments go a little deeper so that your exercise selection 9:12 is that much more sophisticated. I'll look forward to hearing from you guys 9:14 soon.
