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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.