00:05 - 00:07This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
00:07 - 00:11based manual therapy technique. If you're watching this video I'm assuming you're
00:11 - 00:14watching it for educational purposes, and that you are a licensed professional
00:14 - 00:20with joint based techniques within your scope. That means osteopath's, chiropractors,
00:20 - 00:24physical therapists, you're probably all in the clear. Physical therapy assistants,
00:24 - 00:28athletic trainers, massage therapists, you need to check with your governing body
00:28 - 00:32in your state or region, to see whether this is within your scope of practice.
00:32 - 00:36Personal trainers this is definitely not within your scope of practice. Of course
00:36 - 00:41all professions could use this video for purely educational purposes, to help with
00:41 - 00:47learning biomechanics, anatomy and of course palpation. In this video we're
00:47 - 00:51going to do posterior to anterior tibia on femur, or rather let's do
00:51 - 00:54anterior to posterior femur on tibia mobilization since they're the same
00:54 - 01:00relative arthrokinematic motion, but the latter allows us to get in good
01:00 - 01:04body position making it easy for us to perform the technique. I'm going to have
01:04 - 01:07my friend Melissa come out, she's going to help me demonstrate this technique.
01:07 - 01:10Now if I'm doing this technique on Melissa I've already done some sort of
01:10 - 01:15passory excessive motion exam on her knee, and I've assessed her as having artho-
01:15 - 01:20kinematic stiffness right. We don't want to be using mobilizations on
01:20 - 01:24hypermobile joints, that's not going to make anybody feel better. The other joint
01:24 - 01:28action we need to check for because of the way this technique is set up, is if
01:28 - 01:34Melissa had beyond normal extension of the knee that's beyond five degrees of
01:34 - 01:38hyperextension, I also wouldn't use this technique because of the way I'm pushing
01:38 - 01:42down this way, I could end up making hyperextension,
01:42 - 01:47hypermobility worse, which is also not going to make anybody feel any better.
01:47 - 01:54Now traditionally this technique is used to increase extension of the knee so
01:54 - 01:59somebody who lacks full range of extension, and this is all based on
01:59 - 02:06concave on convex rules that's glide same as roll. However I think research is
02:06 - 02:10kind of pointed to the fact that those rules are not completely reliable when
02:10 - 02:14it comes to the knee. Now what does that mean, it probably means that mobilization
02:14 - 02:18in the either direction could potentially be effective for
02:18 - 02:24either extension or flexion, which I know creates some grey area but here's what
02:24 - 02:29you're going to do. This is the technique I fall back on most often because I find
02:29 - 02:35it most effective, most often. But if you wanted to try mobilization in the other
02:35 - 02:40direction the only thing I would ask is that you assess, do your intervention, and
02:40 - 02:46reassess; and then if you're going to try the other technique, do that and reassess
02:46 - 02:50again. You want to try to determine which technique, which direction of glide is
02:50 - 02:54most effective, write that down and continue to use that with your patient
02:54 - 02:58or client. Now I'm going to have Melissa go ahead and put her leg down so that
02:58 - 03:03you guys can see what I'm doing to Melissa's knee here, what my hand position
03:03 - 03:09is, what I'm palpating, and how I set this up. So we wanted to do a posterior to
03:09 - 03:15anterior glide on the tibia, or the tibia on the femur, and rather we turned it
03:15 - 03:18around. So we're going to do anterior to posterior on the femur so that we can
03:18 - 03:23push, because pushing is a lot easier than pulling. I don't want to manhandle
03:23 - 03:27and wear my hands out, or wear my body out trying to do this mobilization. In
03:27 - 03:33order to get myself a little space anterior to posterior I had to elevate
03:33 - 03:36Melissa's leg just a little bit, so that's where this half foam roll comes
03:36 - 03:41in, and guys I find half foam rolls to be the best thing for this technique; and
03:41 - 03:45notice this isn't one of those super hard like premium foam rolls, this is
03:45 - 03:52kind of a soft dish foam roll. So it's firm, but not so firm that it's
03:52 - 03:58mean on Melissa's calf. Alright you could use a pillow, like one of these round pillows
03:58 - 04:01that's under Melissa's head, just realize that if you use one of those round
04:01 - 04:05pillows you're going to have to push all the way through the pillow softness,
04:05 - 04:12before you're going to be palpating any sort of arthrokinematic motion. Now like
04:12 - 04:18all of our techniques for mobilizations and soft tissue techniques and sometimes
04:18 - 04:24even exercise, the more Anatomy you know the better. With the knee maybe you want
04:24 - 04:28to start by finding the patella, the kneecaps kind of easy to find.
04:28 - 04:33So I can start outlining the borders of her patella, I can find her patellar
04:33 - 04:37tendon or patellar ligament depending on what you want to particularly call it.
04:37 - 04:43I'll find her tibial tuberosity right here, I can find the top of her patella
04:43 - 04:49and then maybe I want to let my hand sink down medial and lateral, so that I
04:49 - 04:54can feel through her soft tissue and find those femoral condyles, which should
04:54 - 05:01feel like roundish bumps kind of on the superior half of where her patella was
05:01 - 05:06right -so the end of the femur. If I go lower than that I should be able to feel
05:06 - 05:10the tibia which is going to feel a little bit more ridgey, alright so your
05:10 - 05:14femoral condyles are nice and round, your tibia kind of comes up and then hits a
05:14 - 05:19plateau. Now if you visualize that you should be able to come to the end of
05:19 - 05:26those round bumps and the end of all those ridges, and find a depression
05:26 - 05:32that's a line, that's the joint line, this is going to be an important part of this
05:32 - 05:37technique, the thing that we really want to try to to palpate. So see if you can
05:37 - 05:43feel through that soft tissue in here nicely, don't jab your fingers into your
05:43 - 05:48your partner's clients or patients knee, that's not going to feel good, but gently
05:48 - 05:51kind of try to find that joint line. If you want you could have your patient
05:51 - 05:55like flex their knee a little bit and then straighten it, flex it and straighten it,
05:55 - 05:57flex it and straighten it, so that you can kind of find where that joint line
05:57 - 06:02is, there we go got it. Alright once I found her joint line I'm just going to
06:02 - 06:06set my hands down around her patella, because the last thing I want to do is
06:06 - 06:10this, if you guys know Clark's sign or Clark's test, or the patellar compression
06:10 - 06:15test, if you've ever done it, it just kind of hurts everybody, it's not a real great
06:15 - 06:19test. It's supposed to be a test for knee pain, but you push down on somebody's
06:19 - 06:23patella to have them extended it just freaking hurts so don't do that. Instead
06:23 - 06:27take your web spaces and just kind of put it around the patella, put your index
06:27 - 06:32fingers and your thumbs down over the joint line. Now you're going to apply
06:32 - 06:40pressure using the arm that's over the femur with the palm of your hand, and you
06:40 - 06:44really want to use a lot of the surface of your hand. I've
06:44 - 06:47explained this in some of your other in in some of our other videos you don't
06:47 - 06:50want to use fingertips to do mobilizations if you don't have to,
06:50 - 06:56because they're going to feel really pointy and even your webspace with it's
06:56 - 07:02very narrow surface area, can feel like a chisel into somebody's knee, it just
07:02 - 07:07doesn't feel good. Alright so hands down right around the
07:07 - 07:11patella just like so, we're going to put index fingers on the joint line, thumbs on
07:11 - 07:18the joint line, and I'm getting ready to push down here. Now is where we start
07:18 - 07:23thinking about okay do I have any contraindications to think about. Well
07:23 - 07:28obviously if I started pressing in, if I started in like this and Melissa
07:28 - 07:33immediately starts complaining of pain, that would be a bad thing. We might want
07:33 - 07:37to back off and find another technique, and of course if you have somebody who's
07:37 - 07:41come in after acute knee injury you got to start thinking about did they
07:41 - 07:48potentially tear any of the ligaments of the knee, even like just mild mild tears
07:48 - 07:52can cause a pretty significant amount of pain, and maybe you have to go back and
07:52 - 07:57do your special tests. Of course you could press down and impinge on
07:57 - 08:01nerves or impinge on some trigger points, generally those are easy to get around
08:01 - 08:08by just moving your hands a tiny bit. Remember trigger points aren't generally
08:08 - 08:14very large things and nerves are definitely not very large things right,
08:14 - 08:17they're very narrow, we're talking like millimeters. So usually you can just kind
08:17 - 08:20of reposition your hands and somebody like ahh,
08:20 - 08:25and I'm like well what happened, you're like right above my knee it hurt, okay
08:25 - 08:28let me let me move my hand around a little bit.
08:28 - 08:35Notice that the table is low enough so that I can get my chest over this
08:35 - 08:38technique, because once again I don't want to muscle this technique. Melissa
08:38 - 08:44has super strong legs and the knee is a nice big joint, so I want to be able to
08:44 - 08:50use my upper body mass to create the force, and now I'm just going to go back
08:50 - 08:54to whatever protocol it is that I use. Now I've mentioned in other videos I
08:54 - 08:57happen to be in certified orthopedic manual
08:57 - 09:04therapists through through Maitland, so I use the 50% grade three and four right.
09:04 - 09:09So grade three's would be larger amplitude at fifty percent, grade four
09:09 - 09:12would be smaller amplitude at fifty percent -now that's fifty percent between
09:12 - 09:16first resistance barrier and end of arthrokinematic range, and you're going
09:16 - 09:20to keep oscillating at one to two oscillations per second until you feel a
09:20 - 09:26decrease in joint stiffness. Now if you use another protocol that's fine, I think
09:26 - 09:32there's a lot of protocols out there, the thing they all have in common is finding
09:32 - 09:36first resistance barrier, so that's first resistance barrier for Melissa, and I'm
09:36 - 09:40palpating the joint line right now. So I should be able to really easily find
09:40 - 09:45where the end of arthokinematic range is, that is no matter how much
09:45 - 09:52harder I push right now, I'm not getting any more motion in glide, that's femur on
09:52 - 09:57tibia glide, no matter how much harder I push I'm not getting any more motion. So
09:57 - 10:02I know where the beginning is, I know where the end is. Most protocols have you
10:02 - 10:09mobilized somewhere in between whatever protocol you use, just make sure you go
10:09 - 10:11through with it. Alright make sure you do it from
10:11 - 10:18beginning to end, that you don't half-ass it per se right, that you actually do the
10:18 - 10:24protocol, give the technique a fair chance, so that when you go to reassess
10:24 - 10:30you know whether it was an effective technique, and it wasn't just bad form on
10:30 - 10:35your part that didn't get you the result that you were looking for. How does that
10:35 - 10:41feel? A little weird, it does feel a little weird to be pushed pushed into
10:41 - 10:47this direction right, like this is this is end range knee extension. Melissa does
10:47 - 10:51have a little bit of stiffness here though, so I'm going to see how it makes
10:51 - 10:57you feel upon reassessment. I'm thinking she'll feel a little bit better. Alright
10:57 - 11:00guys so I want to set that up for you one more time before we go to the close
11:00 - 11:05up recap. Notice that the table is low enough that when I palpate her knee I
11:05 - 11:08have to lean over just a little bit, that its
11:08 - 11:13purposeful so that I can use my upper body mass to create the force, and I'm
11:13 - 11:18not manhandling and using my upper body strength or the strength of my hand to
11:18 - 11:21get this mobilization done, that's not going to work.
11:21 - 11:25I then am going to find her patella, and I'm going to put my hands down around
11:25 - 11:30her patella, no Clark sign or Clark's test, like it's a bad idea it
11:30 - 11:36hurt so bad. Alright once I have my hands down around her patella I think
11:36 - 11:41it's good practice to find the joint line. It's going to make it so much
11:41 - 11:46easier to find your first resistance barrier and end arthrokinematic
11:46 - 11:51range. I'm not sure why it's not more common to teach palpation of the joint
11:51 - 11:55line for this technique when your hands are right here. You're then going to
11:55 - 12:00apply force through the arm on the femur right, this hand you can use to kind of
12:00 - 12:04make sure that the tibia doesn't rotate if you'd like, or to stabilize the tibia
12:04 - 12:10or you know, you could even adjust as you're going the foam roll in case like
12:10 - 12:15I press down and I press the foam roll right into a gastroc or a soleus trigger
12:15 - 12:19point, obviously I would move that. This hand essentially though it's just going
12:19 - 12:24to be there to stabilize, while this one applies the force. I'm going to find my
12:24 - 12:30first resistance barrier, find the end of arthrokinmatic range, back off to 50%, and
12:30 - 12:38if I was doing a grade 4 it would be a very small amplitude oscillation, one to
12:38 - 12:42two oscillations per second, and notice I'm just rocking my upper body, you guys
12:42 - 12:46don't see me doing this with my arms right, no pumping, not pumping her knee, I'm
12:46 - 12:51just rocking with my arms putting weight this way right so it's all coming down
12:51 - 12:58through this arm, with a nice large surface area created by the entirety of
12:58 - 13:03my palm, not my web space. Stay tuned for the close-up recap. So for a close-up
13:03 - 13:08recap guys once again it always helps to know your Anatomy. So we have Melissa's
13:08 - 13:15patella here, and then if I just kind of sink my hands down I can start feeling
13:15 - 13:19well there's the fibular head right there. If I follow the fibular head this
13:19 - 13:24nice rounded bony landmark here, I actually
13:24 - 13:31feel like a little guitar string right here, that's actually her LCL which leads
13:31 - 13:36right into her joint line which is exactly where I want my thumbs to be. Now
13:36 - 13:39notice how I've positioned my hands here guys I got both my thumb's over the
13:39 - 13:46joint line so that I can feel glide, but my hands themselves are around her
13:46 - 13:50patella; again we don't want to mimic Clark sign and give her patellar pain
13:50 - 13:57for no reason. Now as soon as I kind of get myself in good position, I got her
13:57 - 14:02leg nice and stable with my left hand here, with my right hand I'm just going
14:02 - 14:07to go ahead and apply a little bit of force until I start to feel some glide,
14:07 - 14:12and then I'm going to keep applying force until I feel the end of arthro-
14:12 - 14:18kinematic range of motion, I then can back off 50% and I can start doing my
14:18 - 14:24oscillations. Remember guys to keep your bodyweight over your hands, you're using
14:24 - 14:29the weight of your upper body mass, your torso to create these oscillations.
14:29 - 14:34You're not muscling it with your hands, or even trying to muscle it with your
14:34 - 14:40arms, it should be a nice sway that's applying all this force; and of course
14:40 - 14:44once I finished my mobilizations I could then go ahead and reassess. So there you
14:44 - 14:47have it assess, address, reassess. Make sure that
14:47 - 14:52every time you choose a joint based manual therapy technique it is based on
14:52 - 14:55an assessment, and that you return to that assessment after you've finished
14:55 - 15:00the intervention to see if it was effective for the individual, the patient
15:00 - 15:04or clients that you had in front of you. Ensure that you continue to learn your
15:04 - 15:09Anatomy because your Anatomy is going to help you with your hand placement, with
15:09 - 15:15understanding what a joint can do, with understanding what you may gain from
15:15 - 15:21this particular technique. And of course practice, you have to practice these
15:21 - 15:25techniques, hopefully not for the first time on a patient or client who just
15:25 - 15:30walked in the door. If you can, find a more senior instructor or a mentor to
15:30 - 15:36give you some really good hands-on instruction. Use your peers for some good
15:36 - 15:44feedback, and of course always look for live education to help with your manual
15:44 - 15:49therapy techniques. I know these videos make education very convenient, but there
15:49 - 15:54is no substitute for learning manual therapy in a live setting. I look
15:54 - 15:58forward to talking to you guys again soon.
16:04 - 16:06