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This is Brent of the Brookbush Institute at the
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independent training spot. Today we're
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doing shoulder extension goniometry. now for shoulder extension we have a
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firm end feel, it's like pulling leather to its end range you get a lot of
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resistance, and then a pretty firm stop, and you guys will notice that I have 20
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to 25 degrees of shoulder extension written down as being optimal. Now if you
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open up a textbook often shoulder extension goniometry is listed at 60
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degrees. The reason being is that includes free motion of the shoulder
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girdle, that is it allows anterior tipping to occur as much as it can, plus
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glenohumeral extension. Now from what I've seen guys and you might work in a
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different clinic with a different audience, and and that makes perfect
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sense for what you're working on, what I see is a lot of this when people walk in.
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They already have an excessive amount of anterior tipping, so if i'm going to do
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shoulder extension I don't want to include a range they might be hyper
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mobile in. Alright so they might be stealing range of motion from their scapula and
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still be restricted at the shoulder, and I wouldn't know. So I do pure
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glenohumeral shoulder extension, which is why you see such conservative numbers.
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I'm going to have my friend Melissa come up she's going to help me demonstrate this
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technique. Alright so the the different thing about this technique from some of
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our other shoulder goniometry techniques is we have to not only
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depress the scapula, but now we have to stabilize the scapula and keep it from
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once again going into anterior tipping. So I'm gonna use my inner thenar
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eminence here right, the space right here to press down on her inferior angle and
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basically posterior tip it, flatten it down to her rib cage. I'm then going to
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go ahead and pull her into shoulder extension but I'm not going to do it by
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her wrist. If I do it by her wrist I'm going to heavily bias this test towards one
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her biceps brachii, and two potentially some nerves right. This kind of looks
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looks like the beginning of that radial and median nerve test if I were to flip
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her over. So because I want to see everything that's kind of going on at
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the shoulder, I want to see how her glenohumeral joint specifically is
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affected, I'm going to go ahead and take two fingers lift her up at the elbow,
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allow her to go into some elbow flexion so that at least those structures that
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we just talked about the biceps brachii and some of the nerves of your arm, have
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a little bit more room to move and I get a little bit more general sense of what
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is blocking shoulder extension. So we're going to brace, press down into the
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ribcage, and then pull her up by your elbow. I'm going to flip around here and
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show you guys what this looks like.
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Alright so I'm going to use this hand and hand closer to my patient, depress her
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scapula, and then go ahead and push her into posterior tipping, basically
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flattening her scapula into her rib cage. I'm then going to use this hand to pull
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her into shoulder extension from the elbow, making sure I cue her to relax. This
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is one of those those ranges of motion that people like to help you, and we want
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to make sure we get passive range of motion here. I actually like to use my
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thigh right up against the table to make sure they don't go into abduction. I can
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kind of keep around the sagittal plane here making sure she doesn't try to
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internally rotate and abduct, she doesn't externally rotate on me, I get nice pure
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shoulder extension. Once I get her there, I'm going to have her hold, can you hold
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that for me good. We're then going to line up our pivot point here with the
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center of the the shoulder joint, as close as we can estimate. The movement
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arm goes through this orange line that I've taped for you guys here which is
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just the midline, the lateral midline of the humerus to lateral condyle, and then
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the stabilization arm is mid-axillary line perpendicular to the table, make
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sure I'm eye level with my measurement and I get 22 degrees.
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So I'll show you guys that a little bit faster this time just like I would run
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through it in my own practice. We're going to push down, stabilize, pull up, oh
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don't help me, good can you hold that, cool all right
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and that time I got 20 degrees. That's within 2 degrees, either way she has
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normal range of motion right, she's she's within that 20 to 25 degrees. Thank you
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Melissa. So let's talk about what it would mean if like let's say I did this
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measurement and Melissa had 12 degrees of shoulder extension, well that means I
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have some sort of restriction right. This goniometry in general helps us
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identify structures that could be restricted that we could then create
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interventions for. I'm going to take you guys through the same paradigm that I've
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taken you through in all the other videos, we're going to do muscle, joint
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fascia, nerve. Let's start with muscles, we got PEC major think about how many
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individuals come in with a short and overactive PEC major right, this position.
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Anterior deltoid, this is one of the few tests that we have that actually
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implicates this structure which is kind of interesting, you know can somebody
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have shortness and tightness in that anterior deltoid that maybe needs to be
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treated out, so that we get optimal movement back and a reduction in symptoms.
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The coracobrachialis another interesting muscle that isn't implicated many of our
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other tests, our coracobrachialis is is one of those hidden structures that's
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often forgotten, it may be worth checking out if you have somebody who's had a
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little bit of stubborn shoulder pain, or they had that upper body dysfunction
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that that you having a hard time relieving them of. Before I get to post
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deltoid let's talk about joint real quick. So joint we have the anterior capsule
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could be restricting, we have the coraco- humeral ligament which is probably
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actually why we get a firm end feel on this particular range of motion. If we
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probably hit a hard end to this ligaments extensibility. And then we get
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down here guys and you'll see two structures that I have starred, and
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that's the posterior capsule and posterior deltoid, and if you're thinking
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through this like I am you guys are already going wait a second if I go on
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to shoulder extension I'm shortening these two things,
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why does he have listed as possible restrictions. Well the truth of the
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matter is is what can happen for this range of motion, is often the humerus the
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humeral head will shift anteriorly in the glenoid fossa all right, we have an
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anterior migration of that humeral head which means the anterior capsule is
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actually not short in that scenario it's been lengthened, but because it's already
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been lengthened by for word translation, when you pull into extension you hit the
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end of the anterior capsules extensibility. The reason that's
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occurring is because we actually have posterior deltoid overactivity, an adaptive
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shortening of the posterior capsule basically squeezing the humeral head
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forward. So if you're looking at some of these structures, you've been working
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with some of these structures with whatever techniques you're comfortable
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with you're not getting your results, check this out. Sometimes all you have to
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do is is that self-administered posterior deltoid release, maybe a little
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bit of a sleeper stretch, and shoulder extension miraculously goes back to
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optimal. Now fascia for all of all of you guys using ART and our
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instrument assisted soft tissue mobilization, and pin and stretch and all
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of the different fascial techniques that are out there, don't forget about all of
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the covering fascia in this area right. You have all of this stuff, all of this
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stuff all that fascia that comes down into that that pectoral deltoid triangle,
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right all of this anterior deltoid fascia that tends to get restricted. You know if
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we're going to come up with an example and all of my individuals who do this
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all day, all right we might want to loosen or start unbinding all of that
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tissue in there. And then of course guys if I had pulled Melissa up into shoulder
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extension she started getting tingly and numb, tingling, numbness parasthesia,
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pins and needles, I need to go ahead and break out into those upper limb
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tension tests. I need to see if maybe my brachial plexus is involved in some of
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this limitation, or some of the nerves of the arm. So once again big list, some
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complicated arthrokinematics here, but nonetheless you know how I like you
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guys to think of this. This isn't something for you guys to panic about,
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it's not something for you guys to be overwhelmed by, I want you to look at
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this chart and go I have a lot of opportunities and potential solutions to
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help correct a movement impairment, in this particular video shoulder extension.
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I hope to hear about great outcomes thank you.