0:06 This is Brent of the Brookbush Institute at the independent training spot. Today we're 0:09 doing shoulder extension goniometry. now for shoulder extension we have a 0:13 firm end feel, it's like pulling leather to its end range you get a lot of 0:17 resistance, and then a pretty firm stop, and you guys will notice that I have 20 0:22 to 25 degrees of shoulder extension written down as being optimal. Now if you 0:27 open up a textbook often shoulder extension goniometry is listed at 60 0:31 degrees. The reason being is that includes free motion of the shoulder 0:38 girdle, that is it allows anterior tipping to occur as much as it can, plus 0:43 glenohumeral extension. Now from what I've seen guys and you might work in a 0:49 different clinic with a different audience, and and that makes perfect 0:52 sense for what you're working on, what I see is a lot of this when people walk in. 0:56 They already have an excessive amount of anterior tipping, so if i'm going to do 1:01 shoulder extension I don't want to include a range they might be hyper 1:05 mobile in. Alright so they might be stealing range of motion from their scapula and 1:09 still be restricted at the shoulder, and I wouldn't know. So I do pure 1:14 glenohumeral shoulder extension, which is why you see such conservative numbers. 1:20 I'm going to have my friend Melissa come up she's going to help me demonstrate this 1:23 technique. Alright so the the different thing about this technique from some of 1:30 our other shoulder goniometry techniques is we have to not only 1:35 depress the scapula, but now we have to stabilize the scapula and keep it from 1:40 once again going into anterior tipping. So I'm gonna use my inner thenar 1:44 eminence here right, the space right here to press down on her inferior angle and 1:49 basically posterior tip it, flatten it down to her rib cage. I'm then going to 1:55 go ahead and pull her into shoulder extension but I'm not going to do it by 1:59 her wrist. If I do it by her wrist I'm going to heavily bias this test towards one 2:04 her biceps brachii, and two potentially some nerves right. This kind of looks 2:09 looks like the beginning of that radial and median nerve test if I were to flip 2:13 her over. So because I want to see everything that's kind of going on at 2:17 the shoulder, I want to see how her glenohumeral joint specifically is 2:21 affected, I'm going to go ahead and take two fingers lift her up at the elbow, 2:25 allow her to go into some elbow flexion so that at least those structures that 2:29 we just talked about the biceps brachii and some of the nerves of your arm, have 2:33 a little bit more room to move and I get a little bit more general sense of what 2:38 is blocking shoulder extension. So we're going to brace, press down into the 2:44 ribcage, and then pull her up by your elbow. I'm going to flip around here and 2:49 show you guys what this looks like. 2:54 Alright so I'm going to use this hand and hand closer to my patient, depress her 2:58 scapula, and then go ahead and push her into posterior tipping, basically 3:03 flattening her scapula into her rib cage. I'm then going to use this hand to pull 3:09 her into shoulder extension from the elbow, making sure I cue her to relax. This 3:13 is one of those those ranges of motion that people like to help you, and we want 3:18 to make sure we get passive range of motion here. I actually like to use my 3:21 thigh right up against the table to make sure they don't go into abduction. I can 3:27 kind of keep around the sagittal plane here making sure she doesn't try to 3:30 internally rotate and abduct, she doesn't externally rotate on me, I get nice pure 3:35 shoulder extension. Once I get her there, I'm going to have her hold, can you hold 3:39 that for me good. We're then going to line up our pivot point here with the 3:45 center of the the shoulder joint, as close as we can estimate. The movement 3:52 arm goes through this orange line that I've taped for you guys here which is 3:54 just the midline, the lateral midline of the humerus to lateral condyle, and then 4:01 the stabilization arm is mid-axillary line perpendicular to the table, make 4:08 sure I'm eye level with my measurement and I get 22 degrees. 4:13 So I'll show you guys that a little bit faster this time just like I would run 4:17 through it in my own practice. We're going to push down, stabilize, pull up, oh 4:24 don't help me, good can you hold that, cool all right 4:34 and that time I got 20 degrees. That's within 2 degrees, either way she has 4:41 normal range of motion right, she's she's within that 20 to 25 degrees. Thank you 4:46 Melissa. So let's talk about what it would mean if like let's say I did this 4:50 measurement and Melissa had 12 degrees of shoulder extension, well that means I 4:55 have some sort of restriction right. This goniometry in general helps us 5:01 identify structures that could be restricted that we could then create 5:06 interventions for. I'm going to take you guys through the same paradigm that I've 5:09 taken you through in all the other videos, we're going to do muscle, joint 5:12 fascia, nerve. Let's start with muscles, we got PEC major think about how many 5:18 individuals come in with a short and overactive PEC major right, this position. 5:24 Anterior deltoid, this is one of the few tests that we have that actually 5:28 implicates this structure which is kind of interesting, you know can somebody 5:33 have shortness and tightness in that anterior deltoid that maybe needs to be 5:37 treated out, so that we get optimal movement back and a reduction in symptoms. 5:41 The coracobrachialis another interesting muscle that isn't implicated many of our 5:47 other tests, our coracobrachialis is is one of those hidden structures that's 5:52 often forgotten, it may be worth checking out if you have somebody who's had a 5:56 little bit of stubborn shoulder pain, or they had that upper body dysfunction 6:00 that that you having a hard time relieving them of. Before I get to post 6:06 deltoid let's talk about joint real quick. So joint we have the anterior capsule 6:12 could be restricting, we have the coraco- humeral ligament which is probably 6:18 actually why we get a firm end feel on this particular range of motion. If we 6:23 probably hit a hard end to this ligaments extensibility. And then we get 6:29 down here guys and you'll see two structures that I have starred, and 6:34 that's the posterior capsule and posterior deltoid, and if you're thinking 6:38 through this like I am you guys are already going wait a second if I go on 6:42 to shoulder extension I'm shortening these two things, 6:46 why does he have listed as possible restrictions. Well the truth of the 6:52 matter is is what can happen for this range of motion, is often the humerus the 6:58 humeral head will shift anteriorly in the glenoid fossa all right, we have an 7:03 anterior migration of that humeral head which means the anterior capsule is 7:08 actually not short in that scenario it's been lengthened, but because it's already 7:14 been lengthened by for word translation, when you pull into extension you hit the 7:19 end of the anterior capsules extensibility. The reason that's 7:24 occurring is because we actually have posterior deltoid overactivity, an adaptive 7:30 shortening of the posterior capsule basically squeezing the humeral head 7:35 forward. So if you're looking at some of these structures, you've been working 7:41 with some of these structures with whatever techniques you're comfortable 7:44 with you're not getting your results, check this out. Sometimes all you have to 7:50 do is is that self-administered posterior deltoid release, maybe a little 7:55 bit of a sleeper stretch, and shoulder extension miraculously goes back to 8:00 optimal. Now fascia for all of all of you guys using ART and our 8:08 instrument assisted soft tissue mobilization, and pin and stretch and all 8:13 of the different fascial techniques that are out there, don't forget about all of 8:17 the covering fascia in this area right. You have all of this stuff, all of this 8:23 stuff all that fascia that comes down into that that pectoral deltoid triangle, 8:29 right all of this anterior deltoid fascia that tends to get restricted. You know if 8:35 we're going to come up with an example and all of my individuals who do this 8:38 all day, all right we might want to loosen or start unbinding all of that 8:46 tissue in there. And then of course guys if I had pulled Melissa up into shoulder 8:50 extension she started getting tingly and numb, tingling, numbness parasthesia, 8:55 pins and needles, I need to go ahead and break out into those upper limb 9:02 tension tests. I need to see if maybe my brachial plexus is involved in some of 9:07 this limitation, or some of the nerves of the arm. So once again big list, some 9:13 complicated arthrokinematics here, but nonetheless you know how I like you 9:18 guys to think of this. This isn't something for you guys to panic about, 9:21 it's not something for you guys to be overwhelmed by, I want you to look at 9:26 this chart and go I have a lot of opportunities and potential solutions to 9:32 help correct a movement impairment, in this particular video shoulder extension. 9:37 I hope to hear about great outcomes thank you. 9:47
