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This is Brent of the Brookbush Institute and in
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this video we're going over static
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manual release of the piriformis. Now, if
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you're watching this video, I'm assuming
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you're watching it for educational
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purposes and that you are a manual
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therapist, and in your state it
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specifies that manual release techniques
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are within your scope. Now, this probably
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goes for all athletic trainers, physical
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therapist, chiropractors, osteopaths,
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licensed massage therapists. You're all in
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the clear. However, personal trainers,
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probably not. Now, before I have a patient
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or a client on the table to do any
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release technique, any manual work, I'm
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going to be pretty sure from my
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assessments that that technique is
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necessary, especially when it comes to
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things like the piriformis or adductors,
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where we're getting into more sensitive
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areas. Obviously, if somebody came in for
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shoulder mobility issues or shoulder
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pain and you start palpating their
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backside, they're going to wonder what's
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up. Make sure you have a good working
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hypothesis before you're doing manual
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techniques. I'm going to have my friend,
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Brian, come out. He's going to help me
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demonstrate this technique. Now, all of
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these manual release techniques
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basically come down to locate the muscle,
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be able to palpate that muscle, and
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compress that muscle. You get bonus
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points if you know where the trigger
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points are, because those are your common
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points of tightness and having a general
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idea of where to place your hands will
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speed things up a little bit. I've
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done the due diligence of marking out
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some landmarks here that we need. I put
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this piece of tape over the posterior
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iliac spine, and then you can see it
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curves down here. Well, I hope you guys
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can see a little bit that it curves down
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here over the sacrum. If you can't, you'll
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get to see that in the close-up. And then
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here, we have the greater trochanter.
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The piriformis runs from anterior sacrum
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to greater trochanter. The last thing we
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need to consider, anatomically that is, is
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the fact that the piriformis is actually
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deeper than the glute max. So, we have to
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find a way of differentiating between
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glute max and piriformis fibers.
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My glute max fibers generally run this way,
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or vertical, whereas my piriformis is
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horizontal. So you guys should be able to
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notice that if you go this way, you can
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strum some glute max fibers. They're
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pretty thick. They're pretty broad-
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that's a big, thick muscle. Now, the
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piriformis fibers- if I go a little
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deeper and I go superior to inferior
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this way, then I start strumming. I have
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to get pretty deep though. You guys can
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tell if you go shallow and go superior
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to inferior, you don't get any- you don't
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feel fascicles, you don't feel strings of
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muscle fibers. Now, as far as finding the
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tense point, I'm going to go just below
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my iliac crest here. I'm going to go
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ahead and start around the sacrum. I
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happen to know that the piriformis
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trigger points are either generally very
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close to the sacrum, or right in the
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middle of the belly of the muscle. So if
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I take this nice, broad thumb this way,
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I can go from superior to inferior.
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I'm going to start by looking for really
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tight fascicles, because we're going to
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assume that even if it's a tight trigger
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point nodules, that they're still going to
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pull the fascicles they're attached to
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pretty tight. Once I found those tight
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fascicles, I'm going to go ahead and move
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maybe towards his greater trochanter if I
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feel like that's where the more of the
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tension is coming from. Once I find
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that nodule, I would then compress. Or if
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I feel like it's more towards the sacrum,
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I could move back all the way to his
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sacrum and see if pressing superior to
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inferior, a little medial to
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lateral there to find the most
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dense tissue until I find that trigger
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point, and then I could compress there. Now,
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I'm showing you guys all of this on this
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side so that you can see what I'm doing,
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but the truth of the matter is that from a
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technique standpoint, from a body
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position standpoint, I'm going to want to
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be on this side. I'm going to
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want to do the piriformis that
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is closer to me. I'm even going
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to show you guys a little bit of a trick
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here. If you have somebody in neutral
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position, their piriformis is actually
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tight. It's actually kind of in a
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neutral length, and if you just start
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pressing down, you might start playing
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that game of like trying to put your
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finger on top of a marble, or you may
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just press straight into mush. There's
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not a whole lot of feedback. So what I
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like to do, assuming that somebody has no
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knee issues, is go ahead and take them
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into knee flexion and then tuck their
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foot into my arm here, right in my elbow,
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on my armpit. And that way, as I'm
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palpating his piriformis, here, I can pull
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Brian into internal rotation, which is
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going to lengthen his piriformis and
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increase the tension a little bit, right
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so that now those fibers are pulled just
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a little taut. I'm not trying to stretch
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his piriformis this way, but I want
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those fibers pulled a little taut, so that
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when I go to press on that trigger point
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it doesn't do this to me. Alright, so I'll
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pull down. Once again, broad strokes. I'm
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going to go superior to inferior to find
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those fascicles, and then I'm going
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to go either proximally towards his
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sacrum, or distally towards his greater
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trochanter until I find the most tender
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point. I'm going to use this hand as my
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dummy thumb in this case. I'm
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going to go ahead and put the other hand
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to apply pressure. I'm going to try to
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straighten out my arms to get as much
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tension as I need here, and then I'm just
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going to lean in with my body weight
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until I feel that point where the tissue
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density really starts ramping up. I don't
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want to go all the way to the tissue end
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point. I don't want to go all the way to
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an end feel. I don't want so much pain
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that I actually get the muscle
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contracting under my fingers. Then I'll never
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get a release. But if I go right up to
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the point where I feel that increase in
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tissue density, and I lean until I feel a
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release underneath my fingers, that is a
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decrease in tissue density, or Brian
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tells me. You still feeling that? Alright,
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he's still feeling that. I'm going to
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hold for a few more seconds. If he
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says that
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he no longer feels the soreness, he
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no longer feels the uncomfortableness,
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the discomfort, then we can go ahead and
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move on. It's starting to let go, right? Yes, it's a lot looser now.
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Your piriformis was pretty
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jacked up. Alright, next up we'll do
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our close-up recap, guys, but I hope from
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this position you guys can see my
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body position. Manual therapists, you
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always have to be thinking about you
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first, and I know that sounds crazy. But
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notice once I had him in position, my
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arms were straight, I pulled him into
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as much internal rotation as I needed,
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and all I'm using is body weight.
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Specifically, this hand is pressing over
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this hand which is totally relaxed, so
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that I'm not wearing out joints. I'm not
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putting myself in a compromised position.
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Okay, guys, here's our close-up recap. You
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can see I've marked out the posterior
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ilium. I've marked out the sacrum, here, it's
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where this tape turns down. And then I've
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marked out the greater trochanter. We
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know his piriformis goes from anterior
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sacrum to greater trochanter, deep to
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those vertical glute fibers. To add
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tension to his piriformis so that I'm
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not playing the "try to put my finger
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down on a marble," or I'm not just pushing
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into mush because all of these muscles
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are relaxed in this position, I can add
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tension by pulling Brian into internal
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rotation here. So, I'm going to tuck his
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foot up in my arm. I'm going to strum
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superior to inferior to find those
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horizontal fibers. Once I find the
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tightest fascicles- it helps to know that
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most of your trigger points are going to
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be located either closer to the sacrum or
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in the middle of the belly of the muscle-
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so once I find those tightest fascicles, I'm
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going to move in one direction or the
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other until I find a nodule or acute
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point of increased tissue density. I'm
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then going to apply pressure by letting
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this hand relax and placing the other
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hand over top, straightening out my arms
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and leaning in.
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I'm then going to hold that until I feel a
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release or I can do the other protocol,
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which would be five seconds on, two
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seconds off, five seconds on, two seconds
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off. I think I've mentioned in previous
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videos that I do tend to gear towards
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the the static hold, and usually 30 seconds
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to 2 minutes does the trick. I hope you
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guys enjoyed this video. I hope you add
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static piriformis manual release to your
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repertoire and use it when necessary.
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Let's talk a second about what
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assessments would lead me to believe
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that the piriformis needs to be released.
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If we're talking about the overhead
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squat assessment, we're talking about
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knees bow out, an inadequate forward lean,
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a posterior pelvic tilt, or an
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asymmetrical weight shift, that would be
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the piriformis opposite the side of the
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shift. If we're looking at goniometry,
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we're looking at either a lack of
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internal rotation in prone, or if we're
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doing those supine tests, piriformis will
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actually cause a reduction in range of
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motion in either direction. That has to
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do with that weird action of the
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piriformis where if you get closer and
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closer to 90 degrees, it starts to become
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more and more of an internal rotator
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rather than external rotator. If you don't
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know what I'm talking about, look up the
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piriformis article in www.brentbrookbush.com
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and you guys will see. You could
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possibly consider something like the
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FABER test or the hip impingement test,
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which are both special tests for the hip,
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as also indications that this may be
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tight. From a pathology perspective,
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although I don't like to go from
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pathology to technique, if somebody had
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gotten diagnosed with piriformis
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syndrome or a sciatica, I would also
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definitely put this technique in my
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repertoire just to see if we could get
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any abatement from symptoms. Now, mind
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your scope, mind your technique as far as
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your body position, and, of course, stay
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specific to your assessments. I look
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forward to hearing your
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comments. Please leave your comments
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below. If you have any questions, if you
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think I left anything out, please let me
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know. I'll talk with you guys soon.