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Knee Joint Anterior to Posterior (Femur on Tibia) Manual Mobilization

Knee Joint Anterior to Posterior (Femur on Tibia) Manual Mobilization is a hands-on physical therapy technique used to enhance movement of the knee joint. This technique applies gentle yet firm pressure to the anterior and posterior aspects of the knee joint. This mobilization releases restrictions in the knee and surrounding soft tissues which can lead to improved range of motion, strength, and functional mobility. Patients may experience some mild discomfort during the procedure, but it is important to note that this

Transcript

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This is Brent of the Brookbush Institute, and in this
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video we're going to go over a joint
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based manual therapy technique. If you're watching this video I'm assuming you're
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watching it for educational purposes, and that you are a licensed professional
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with joint based techniques within your scope. That means osteopath's, chiropractors,
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physical therapists, you're probably all in the clear. Physical therapy assistants,
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athletic trainers, massage therapists, you need to check with your governing body
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in your state or region, to see whether this is within your scope of practice.
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Personal trainers this is definitely not within your scope of practice. Of course
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all professions could use this video for purely educational purposes, to help with
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learning biomechanics, anatomy and of course palpation. In this video we're
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going to do posterior to anterior tibia on femur, or rather let's do
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anterior to posterior femur on tibia mobilization since they're the same
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relative arthrokinematic motion, but the latter allows us to get in good
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body position making it easy for us to perform the technique. I'm going to have
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my friend Melissa come out, she's going to help me demonstrate this technique.
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Now if I'm doing this technique on Melissa I've already done some sort of
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passory excessive motion exam on her knee, and I've assessed her as having artho-
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kinematic stiffness right. We don't want to be using mobilizations on
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hypermobile joints, that's not going to make anybody feel better. The other joint
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action we need to check for because of the way this technique is set up, is if
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Melissa had beyond normal extension of the knee that's beyond five degrees of
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hyperextension, I also wouldn't use this technique because of the way I'm pushing
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down this way, I could end up making hyperextension,
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hypermobility worse, which is also not going to make anybody feel any better.
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Now traditionally this technique is used to increase extension of the knee so
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somebody who lacks full range of extension, and this is all based on
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concave on convex rules that's glide same as roll. However I think research is
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kind of pointed to the fact that those rules are not completely reliable when
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it comes to the knee. Now what does that mean, it probably means that mobilization
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in the either direction could potentially be effective for
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either extension or flexion, which I know creates some grey area but here's what
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you're going to do. This is the technique I fall back on most often because I find
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it most effective, most often. But if you wanted to try mobilization in the other
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direction the only thing I would ask is that you assess, do your intervention, and
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reassess; and then if you're going to try the other technique, do that and reassess
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again. You want to try to determine which technique, which direction of glide is
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most effective, write that down and continue to use that with your patient
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or client. Now I'm going to have Melissa go ahead and put her leg down so that
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you guys can see what I'm doing to Melissa's knee here, what my hand position
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is, what I'm palpating, and how I set this up. So we wanted to do a posterior to
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anterior glide on the tibia, or the tibia on the femur, and rather we turned it
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around. So we're going to do anterior to posterior on the femur so that we can
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push, because pushing is a lot easier than pulling. I don't want to manhandle
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and wear my hands out, or wear my body out trying to do this mobilization. In
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order to get myself a little space anterior to posterior I had to elevate
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Melissa's leg just a little bit, so that's where this half foam roll comes
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in, and guys I find half foam rolls to be the best thing for this technique; and
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notice this isn't one of those super hard like premium foam rolls, this is
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kind of a soft dish foam roll. So it's firm, but not so firm that it's
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mean on Melissa's calf. Alright you could use a pillow, like one of these round pillows
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that's under Melissa's head, just realize that if you use one of those round
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pillows you're going to have to push all the way through the pillow softness,
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before you're going to be palpating any sort of arthrokinematic motion. Now like
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all of our techniques for mobilizations and soft tissue techniques and sometimes
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even exercise, the more Anatomy you know the better. With the knee maybe you want
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to start by finding the patella, the kneecaps kind of easy to find.
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So I can start outlining the borders of her patella, I can find her patellar
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tendon or patellar ligament depending on what you want to particularly call it.
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I'll find her tibial tuberosity right here, I can find the top of her patella
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and then maybe I want to let my hand sink down medial and lateral, so that I
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can feel through her soft tissue and find those femoral condyles, which should
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feel like roundish bumps kind of on the superior half of where her patella was
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right -so the end of the femur. If I go lower than that I should be able to feel
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the tibia which is going to feel a little bit more ridgey, alright so your
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femoral condyles are nice and round, your tibia kind of comes up and then hits a
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plateau. Now if you visualize that you should be able to come to the end of
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those round bumps and the end of all those ridges, and find a depression
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that's a line, that's the joint line, this is going to be an important part of this
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technique, the thing that we really want to try to to palpate. So see if you can
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feel through that soft tissue in here nicely, don't jab your fingers into your
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your partner's clients or patients knee, that's not going to feel good, but gently
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kind of try to find that joint line. If you want you could have your patient
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like flex their knee a little bit and then straighten it, flex it and straighten it,
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flex it and straighten it, so that you can kind of find where that joint line
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is, there we go got it. Alright once I found her joint line I'm just going to
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set my hands down around her patella, because the last thing I want to do is
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this, if you guys know Clark's sign or Clark's test, or the patellar compression
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test, if you've ever done it, it just kind of hurts everybody, it's not a real great
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test. It's supposed to be a test for knee pain, but you push down on somebody's
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patella to have them extended it just freaking hurts so don't do that. Instead
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take your web spaces and just kind of put it around the patella, put your index
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fingers and your thumbs down over the joint line. Now you're going to apply
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pressure using the arm that's over the femur with the palm of your hand, and you
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really want to use a lot of the surface of your hand. I've
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explained this in some of your other in in some of our other videos you don't
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want to use fingertips to do mobilizations if you don't have to,
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because they're going to feel really pointy and even your webspace with it's
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very narrow surface area, can feel like a chisel into somebody's knee, it just
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doesn't feel good. Alright so hands down right around the
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patella just like so, we're going to put index fingers on the joint line, thumbs on
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the joint line, and I'm getting ready to push down here. Now is where we start
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thinking about okay do I have any contraindications to think about. Well
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obviously if I started pressing in, if I started in like this and Melissa
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immediately starts complaining of pain, that would be a bad thing. We might want
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to back off and find another technique, and of course if you have somebody who's
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come in after acute knee injury you got to start thinking about did they
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potentially tear any of the ligaments of the knee, even like just mild mild tears
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can cause a pretty significant amount of pain, and maybe you have to go back and
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do your special tests. Of course you could press down and impinge on
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nerves or impinge on some trigger points, generally those are easy to get around
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by just moving your hands a tiny bit. Remember trigger points aren't generally
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very large things and nerves are definitely not very large things right,
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they're very narrow, we're talking like millimeters. So usually you can just kind
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of reposition your hands and somebody like ahh,
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and I'm like well what happened, you're like right above my knee it hurt, okay
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let me let me move my hand around a little bit.
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Notice that the table is low enough so that I can get my chest over this
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technique, because once again I don't want to muscle this technique. Melissa
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has super strong legs and the knee is a nice big joint, so I want to be able to
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use my upper body mass to create the force, and now I'm just going to go back
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to whatever protocol it is that I use. Now I've mentioned in other videos I
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happen to be in certified orthopedic manual
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therapists through through Maitland, so I use the 50% grade three and four right.
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So grade three's would be larger amplitude at fifty percent, grade four
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would be smaller amplitude at fifty percent -now that's fifty percent between
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first resistance barrier and end of arthrokinematic range, and you're going
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to keep oscillating at one to two oscillations per second until you feel a
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decrease in joint stiffness. Now if you use another protocol that's fine, I think
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there's a lot of protocols out there, the thing they all have in common is finding
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first resistance barrier, so that's first resistance barrier for Melissa, and I'm
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palpating the joint line right now. So I should be able to really easily find
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where the end of arthokinematic range is, that is no matter how much
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harder I push right now, I'm not getting any more motion in glide, that's femur on
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tibia glide, no matter how much harder I push I'm not getting any more motion. So
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I know where the beginning is, I know where the end is. Most protocols have you
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mobilized somewhere in between whatever protocol you use, just make sure you go
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through with it. Alright make sure you do it from
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beginning to end, that you don't half-ass it per se right, that you actually do the
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protocol, give the technique a fair chance, so that when you go to reassess
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you know whether it was an effective technique, and it wasn't just bad form on
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your part that didn't get you the result that you were looking for. How does that
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feel? A little weird, it does feel a little weird to be pushed pushed into
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this direction right, like this is this is end range knee extension. Melissa does
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have a little bit of stiffness here though, so I'm going to see how it makes
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you feel upon reassessment. I'm thinking she'll feel a little bit better. Alright
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guys so I want to set that up for you one more time before we go to the close
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up recap. Notice that the table is low enough that when I palpate her knee I
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have to lean over just a little bit, that its
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purposeful so that I can use my upper body mass to create the force, and I'm
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not manhandling and using my upper body strength or the strength of my hand to
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get this mobilization done, that's not going to work.
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I then am going to find her patella, and I'm going to put my hands down around
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her patella, no Clark sign or Clark's test, like it's a bad idea it
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hurt so bad. Alright once I have my hands down around her patella I think
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it's good practice to find the joint line. It's going to make it so much
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easier to find your first resistance barrier and end arthrokinematic
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range. I'm not sure why it's not more common to teach palpation of the joint
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line for this technique when your hands are right here. You're then going to
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apply force through the arm on the femur right, this hand you can use to kind of
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make sure that the tibia doesn't rotate if you'd like, or to stabilize the tibia
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or you know, you could even adjust as you're going the foam roll in case like
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I press down and I press the foam roll right into a gastroc or a soleus trigger
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point, obviously I would move that. This hand essentially though it's just going
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to be there to stabilize, while this one applies the force. I'm going to find my
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first resistance barrier, find the end of arthrokinmatic range, back off to 50%, and
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if I was doing a grade 4 it would be a very small amplitude oscillation, one to
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two oscillations per second, and notice I'm just rocking my upper body, you guys
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don't see me doing this with my arms right, no pumping, not pumping her knee, I'm
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just rocking with my arms putting weight this way right so it's all coming down
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through this arm, with a nice large surface area created by the entirety of
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my palm, not my web space. Stay tuned for the close-up recap. So for a close-up
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recap guys once again it always helps to know your Anatomy. So we have Melissa's
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patella here, and then if I just kind of sink my hands down I can start feeling
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well there's the fibular head right there. If I follow the fibular head this
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nice rounded bony landmark here, I actually
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feel like a little guitar string right here, that's actually her LCL which leads
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right into her joint line which is exactly where I want my thumbs to be. Now
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notice how I've positioned my hands here guys I got both my thumb's over the
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joint line so that I can feel glide, but my hands themselves are around her
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patella; again we don't want to mimic Clark sign and give her patellar pain
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for no reason. Now as soon as I kind of get myself in good position, I got her
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leg nice and stable with my left hand here, with my right hand I'm just going
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to go ahead and apply a little bit of force until I start to feel some glide,
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and then I'm going to keep applying force until I feel the end of arthro-
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kinematic range of motion, I then can back off 50% and I can start doing my
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oscillations. Remember guys to keep your bodyweight over your hands, you're using
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the weight of your upper body mass, your torso to create these oscillations.
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You're not muscling it with your hands, or even trying to muscle it with your
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arms, it should be a nice sway that's applying all this force; and of course
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once I finished my mobilizations I could then go ahead and reassess. So there you
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have it assess, address, reassess. Make sure that
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every time you choose a joint based manual therapy technique it is based on
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an assessment, and that you return to that assessment after you've finished
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the intervention to see if it was effective for the individual, the patient
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or clients that you had in front of you. Ensure that you continue to learn your
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Anatomy because your Anatomy is going to help you with your hand placement, with
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understanding what a joint can do, with understanding what you may gain from
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this particular technique. And of course practice, you have to practice these
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techniques, hopefully not for the first time on a patient or client who just
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walked in the door. If you can, find a more senior instructor or a mentor to
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give you some really good hands-on instruction. Use your peers for some good
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feedback, and of course always look for live education to help with your manual
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therapy techniques. I know these videos make education very convenient, but there
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is no substitute for learning manual therapy in a live setting. I look
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forward to talking to you guys again soon.