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This is Brent of the Brookbush Institute, and in
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this video we're going to go over a
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joint based manual therapy technique. If you're watching this video I'm assuming
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you're watching it for educational purposes, and that you are a licensed
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professional with joint based techniques within your scope; that means osteopath's,
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chiropractors, physical therapists, you're probably all in the clear. Physical
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therapy assistants athletic trainers massage therapists you need to check
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with your governing body in your state or region to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice. Of course all professions could use this video for purely
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educational purposes to help with learning biomechanics, anatomy and of
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course palpation. In this video we're going over posterior to anterior fibula
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and tibia mobilization. Now this is proximal tibiofibular joint. I'm going to
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have my friend Melissa come out she's going to help me demonstrate. Now this is
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one of those techniques that you'll probably use rarely, but when somebody
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needs this technique it often results in a big change in their symptoms, or a big
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change in their dysfunction, so keep this in your back pocket. We can kind of see
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how this joint is really in the middle of a bunch of stuff going on. Research
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kind of shows that hyper or hypo mobility may be related to knee pain, but
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if we use just a little bit of knowledge of our anatomy, we could see how perhaps
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dysfunction of this joint could lead to lateral knee pain from the LCL being
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stressed right, the LCL attaches to the fibular head. We could see how
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overactivity of the TFL, vastus lateralis and biceps femoris might be related to
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dysfunction of this joint. So like I said keep this one in your back pocket, there
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is going to come a point where you're going to need this technique. Now
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assessment of this technique is going to have to rely on passive accessory motion
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exam, and I know there's been some consideration of how reliable that those
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those exams are, but we really don't have a better alternative. In order to do
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these passive accessory motion exams as well as in order to do this technique, we
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have to be able to palpate this joint and feel what's going on. So to
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find the fibular head my suggestion is find your patella. Yeah I think most
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people can find their patella, their kneecap. Most people know where their
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kneecap is, if you follow that down right you kind of feel the patellar tendon, and
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if you feel it all the way down a little bit further you'll feel this big bump on
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the tibia right, so patella, patella ligament I guess if you want to call it
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that, and then tibial tuberosity here is the big bump. Once you find that big bump
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you know you're on the tibia, and then we're going to kind of move laterally
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here, and you'll notice that as you move laterally there is kind of another bump
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which actually belongs to your fibula, it's a different bone. If you feel a
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little bit you can actually feel how the the tibia goes into the tibial plateau
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here, alright so if I come up like this I can kind of feel how it divots out and
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then the fibular head kind of connects right up into that, and I'm going to go
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ahead and use my thumb's to just trace that fibula out, I want to feel all the
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way around the fibular head; and remember guys you can do this with a patient or
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client, you don't have to just boom there's the fibular head, like you don't
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have to 100% accuracy on finding these these points every time. Remember your
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patient or client does not know how long it's supposed to take you to find
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something, you're better off being a little slower and right than trying to
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place your hands down and being wrong. So now that I've found the fibular head and
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I found the tibia, what I need to do is does this joint move and guys you need
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to be careful, because you have the peroneal nerves as well as a very tender
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soleus trigger point or common trigger point site right behind the fibular head.
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So as you guys go to push on this just use as broad a thumb stroke as you can.
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Right so I have all this tibia right here, I have my fibular head, I'm going to
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use this hand, I'm going to put this one down right between where I think the
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tibia and fibula head is, kind of where I think the joint line is, and then I'm
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going to go ahead and see does my fibula wiggle. Just like we were talking about
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with the distal tibiofibular joint, this joint doesn't move a lot, and if it does,
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and it does move easily you're hyper- mobile. Hypermobile no mobilization. If
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it doesn't move at all, or barely moves like you have to press pretty hard to
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get it to move what even feels like one millimeter, then this is probably a joint
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that you want to go ahead and mobilize. Now I don't feel a whole lot of motion, I
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do see some scrunching of the face so I need to be careful. Guys in most
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situations for this particular joint you're probably going to have to go
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ahead and do your your soleus release first, do some soft tissue release around
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the fibular head, because if you don't everytime you go to push on that joint
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you're just going to keep digging into that trigger point, you're going to watch
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your your clients face scrunch, and then they're going to guard and you're not
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going to get a whole lot of motion anyway. To do this technique with a
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little bit better hand position, I would suggest either trying to put the fibular
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head here in your thumb and kind of wrap around so that you have all this broad
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surface, or you could even try thenar eminence, hand over hand like
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this. Whichever way you do it, this like just using the point of your thumb is
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not going to work really well. Anytime I've tried to get that to work I get a
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lot of like a lot of guarding, it's just very painful it's very pokey. So I'm
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going to go ahead and try to wrap my, oh maybe not, I'm going to use my thenar
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eminence here, my thumb's are a little big to get to get around that fibular
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head. Once I found that that thenar eminence, notice guys my arms are nice
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and straight, and I'm just going to go ahead and push in a posterior to
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anterior direction. Now we talked about how my Maitland
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certified orthopedic manual therapist, so that's the protocol I know, I'm going to
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find that first resistance barrier, I'm going to find the arthrokinematic end
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range, assuming this is a stiffness dominant patient we're not looking at
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pain dominant, and then I'm going to back off to 50% and then that can either do
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my grade three mobilizations from first resistance barrier to around 50%, little
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larger amplitude, or I can go right up to 50% and use small amplitude right at
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that increased resistance, and see if I can get more movement there; and of
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course I'm going to do one to two oscillations per second until I feel a
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change in joint mobility. Now this is somewhat a challenging technique and
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sometimes you guys are going to have to mess with with foot placement, because
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what your clients going to want to do is either you can see kind of roll at the
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hips, or you go to push and they they they start moving here. So it's going to
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take a little bit of experimentation sometimes to get them into a position
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where you can use this technique, and get motion at the joint without just rocking
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their whole body. Remember all we're looking for is a little tiny bit of
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motion here, not thisl if you find you're doing one of these things to move the
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joint -I guarantee you've pests pressed well past arthrokinematic end range and
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now you're rocking their entire body, and that's probably not that effective of
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a technique. So let's kind of go through this again. Our contraindications
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are the peroneal nerve, and then we need to be aware of that soleus trigger point
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that's going to be real tender. We want to use a nice broad surface so
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either put the fibular head in the IP of your thumb and then wrap your
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thumb around it, or if you're like me and you can't quite get your thumb in there,
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maybe you want to use your thenar eminence. Experiment with position of the the knee,
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foot behind one foot, you can set up bolsters if you need to if you think
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that'll help. You can change the angle of their hips, but get into a position where
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you feel like when you push here you're getting motion of the fibular head on
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the tibia and not just motion of the whole body. I might even be able to brace
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her thigh a little bit and use one hand, so I suppose you could do that, but again
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thenar eminence, I'm pushing posterior to anterior, first resistance barrier now,
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end range is right about there, I'm going to back off the 50% and then I'm going
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to start with the grade three immobilization here, back off to nothing
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and go up to 50%, one to two oscillations per second, checking on my client making
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sure she isn't cringing because I'm on top of her peroneal nerve, or I'm on top
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of that soleus trigger point; and then I'm looking for a change in the amount
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of stiffness of this joint, and then as I explained in the distal tibiofibular
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joint mobilization it is a little hard to feel change with your thenar eminence,
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so I'm probably going to go back in and do my little test of how much wiggle I
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got with my fingertips here, and I got a little bit more wiggle.
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So whatever her test was after that that provoked her pain, I might have her do
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maybe she was having knee pain during a squat. to be like alright let's get up
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and squat and see how that felt. Of course if there was no change
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onto the next technique, if there was change it definitely want to make
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note, well either way I want to make note so that I keep doing that in successive
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sessions, to make sure that we're building the most effective program that
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we can. Stay tuned for the close of recap. The close-up recap of our proximal tibia
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fibula joint mobilization, thats a posterior to anterior mobilization of the fibula
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head. You guys can see here I actually have my thumb right on the fibular head
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but if you've never palpated the fibular head before, my suggestion is actually to
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start with something you you know how to palpate like the the patella right, you
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all know where your kneecap is, and then you can kind of follow the the patella
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ligament or patellar tendon down to the tibial tuberosity, that's that big bump
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right here where the patellar tendon attaches, and then if you go lateral from
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that you run into this bony prominence that if you feel around a little bit is
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kind of half spherical shape, that is your fibular head. Now what you're going
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to want to do is kind of palpate and explore so that you can get behind that
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joint that fibular head, and then kind of find in front of it so that your fingers
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are around it, and now you need to see if maybe you can wiggle that fibular head,
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alright so we're checking out how much motion do we have at the proximal tibiio-
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fibula joint, essentially doing a passive accessory
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motion assessment of some sort. Again this is this is one of those joints that
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just wiggles a little bit, if it Wwiggles a lot you're probably
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hypermobile and don't need this, if it wiggles really easy then maybe it's fine
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as long as it doesn't wiggle too much. If it seems really stiff and it seems like
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you have to apply quite a bit of pressure, that's where we're thinking okay
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maybe I need to mobilize this joint, maybe mobilizing this joint will help the
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knee move better or the ankle move better, or help reduce the tenacity in
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things like the TFL, vastus lateralis and biceps femoris which invest in the
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fibular head here. Things to keep in mind is there is a trigger point right behind
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the fibular head it's a soleus trigger point, so if you just keep pressing down on that
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you're doing your oscillatory mobilizations, you're not going to make
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your client or patient very happy. It might be a good idea to do some soft
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tissue work in the in the posterior lower leg here before before you do this
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technique. The other thing you have to be concerned with is the
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peroneal nerve which if you pinch on, your your client a patient's going to
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let you know; and of course nerves are pretty thin, so you should just be able
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to move your your hands around a little bit and get away from that nerve. You
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don't want to use thumbs like this because that's going to feel really
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really pokey, what you're going to need to do to do this mobilization is use
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either your thenar eminence, or as much of your thumb pad as you can. For people
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with a little smaller hands than mine I usually suggest them trying to put the
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fibular head kind of in their IP joint like so, and then you can actually kind
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of use this as a dummy thumb and put the other hand over it right, now your other
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hand is in the right direction to do a posterior to anterior mobilization. So in
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Melissa's case I did my little wiggle, she doesn't wiggle much, I'm going to put
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this dummy thumb like this, put my thenar eminence over like this, I'm going to
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find my first resistance barrier right there, the end of our arthrokinematic
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range which was right there, let me go at that a little bit slower so I can find
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50%, and then I can go from zero to 50% do my grade three mobilizations here,
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until I feel what I think is a reduction in joint stiffness; and then of course I
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could reassess. Now I did mention that it is a little bit of a challenge in this
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position to get pure fibular head motion on tibia and not just get somebody
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rocking back and forth, so don't be afraid to like hook one foot behind the
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other, bend the knee a little bit more, bend the
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knee a little bit less. Use bolsters change the position of their hip,
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whatever you have to do to try to get into a good position so that you can
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kind of block them out, and get some good fibular head motion. So there you have it
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assess, address, reassess. Make sure that every time you choose a joint based
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manual therapy technique it is based on an assessment, and that you return to
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that assessment after you've finished the intervention
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to see if it was effective for the individual, the patient or client that
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you have in front of you. Ensure that you continue to learn your Anatomy because
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your Anatomy is going to help you with your hand placement, with understanding
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what a joint can do, with understanding what you may gain from this particular
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technique; and of course practice you have to practice these techniques,
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hopefully not for the first time on a patient or client who just walked in the
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door. If you can find a more senior instructor or mentor to give you some
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really good hands-on instruction, use your peers for some good feedback, and of
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course always look for live education to help with your manual therapy techniques.
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I know these videos make education very convenient, but there is no substitute
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for learning manual therapy in a live setting, I look forward to talking to you