0:06 This is Brent of the Brookbush Institute at the independent training 0:08 spot in New York City, bringing you guys more goniometric assessment. In this 0:13 video we're going to do shoulder or glenohumeral external rotation. I'm going 0:17 to have my friend Melissa come out, she's going to help demonstrate this technique. 0:20 Now in this video we're looking for probably 90 to 95 degrees of external 0:26 rotation, that's an optimal range of motion I go for. I tend to be fairly 0:30 conservative because I'm very strict about how much shoulder girdle or 0:35 scapular elevation I will allow. If you guys look in texts you might find a slightly 0:39 wider range, and it might be up to your professional discretion to figure out 0:44 what is optimal for your clinic, studio, or gym that you're working at. The end 0:50 feel is firm, that means when I push your down to that end range, I shouldn't feel 0:54 soft squishiness, I shouldn't feel like there's more play there. I should be able 0:58 to get to an end range and then feel a pretty solid stop, like I lengthened out 1:03 a belt and came to the end like a leather belt came to the end, and it and 1:08 it stopped because I couldn't pull it any longer. Now as far as the technique 1:12 itself, we want a place for our movement arm, so our movement arm is going to 1:17 measure along her ulna from olecranon process to styloid process. Your 1:24 stabilization Iarm you can set up a couple of different ways, you can either 1:28 go horizontal alright so that your parallel with the table, or you can go 1:34 vertical perpendicular to the table. It depends on what you're comfortable with, 1:38 where you find that your most accurate with your eyeline. Now I'm going to flip 1:43 around the table, my head is going to get cut off here as I show you guys how to 1:46 do this measurement, I apologize for that. 1:52 First things first I want to set Melissa up at 90 degrees of abduction. Now I tend 2:00 to use this hand to make sure that she's depressed at the scapula, get her back in 2:05 the neutral position because so many people end up elevated like this as they 2:09 lie down. So get her nice and depressed all right, and then I'm going to go ahead 2:15 and let her relax but keep my hand there so she can't elevate any further. To keep 2:19 her from going into adduction as I pull her into external rotation, I'm going to 2:23 go ahead and put my thigh that's kind of a fulcrum. So now I have her stabilized 2:28 of the scapula, I have her stabilized here, now I get nice strict external 2:33 rotation. I'm going to go ahead and make sure I'm in neutral pronation and 2:38 supination here, push her back, find her end range which is right there, go ahead 2:45 and have her hold it for me. I'm going to make sure I keep my eye on that range so 2:50 she doesn't move, as I move into position to take my measurement and Melissa has 95 3:02 degrees. So I would call that optimal external rotation. Once again we'll go 3:06 through this nice and quick for you guys, depress the scapula, make sure she's 3:11 nice and neutral, hold her scapula there, go ahead and place my thigh here so she 3:16 can't go into adduction. Make sure she's in neutral pronation and supination, push 3:22 her to the end of external rotation, have her hold but keep my eye on it. 3:27 Stabilization on vertical, movement arm from olecranon process, the styloid 3:33 process, get eye level with my measurement, and that time I got 94 3:40 degrees. I think one degree margin of error is probably pretty good. Thank you 3:45 Melissa. So now that we've done a goniometric assessment, why do we do these 3:52 assessments. Obviously all of our assessments fall more or less into two 3:55 categories, it's either differential diagnosis clearing type assessments, is 4:00 this somebody we can help, or it's going to affect our exercise selection. 4:04 In this case this is a flexibility assessment, I'm starting to think towards 4:10 what mobility techniques I want to use, what structures could be potentially 4:14 limiting this range of motion. So starting with muscles, I think you guys 4:18 will find that the sub scapula is very very implicated when somebody has a limit in 4:24 external rotation in this strict test. So release techniques for the sub scapular. 4:35 Teres major can also restrict that external rotation, and I think you guys 4:39 know that those have a propensity towards over activity because of this 4:44 type of posture. Now we're doing glenohumeral joint external rotation but 4:52 it's really almost impossible to isolate the scapular motion, or the glenohumeral 4:58 motion from the scapular motion. We do need some PEC major and levator scapulae 5:04 mobility in this test to reach optimal, because as Melissa was lying there and I 5:09 pushed her into external rotation, her scapula needs to posteriorly tip a little bit as 5:13 well. So although these aren't going to have a huge impact on this number, if you 5:18 guys are missing a few degrees it may be worth going after those anterior tippers 5:23 of the scapula, maybe doing some release techniques, or somepin and stretch, or 5:27 even some static stretching to try to get that last bit of range. So now let's 5:33 go to the joint itself right, we have the glenohumeral ligaments, the coraco- 5:37 humeral ligaments, and the inferior capsule, which all can restrict external 5:42 rotation. Now I think these being kind of blended with that anterior capsule of 5:48 structure, we're not going to find tightness here all that often, but it is 5:52 possible. I think where you'll find more tightness is this posterior capsule, and 5:59 a lot of times people will even, they'll get back here, they'll feel restricted but 6:05 it's because of tightness or pinching they feel in the back of their shoulder, 6:08 and that has to do with the change in the arthrokinematics, they're not able 6:13 to spin any further, they're not able to posteriorly glide any further, 6:18 and they're almost impinging that posterior capsule, restricting their 6:22 external rotation. I know that seems a little counterintuitive, but if you just 6:26 can't figure out how to get that last bit of range, don't forget I mentioned 6:30 that posterior capsule, very similar to the PEC minor and levator scapulae like 6:35 I was talking before. AC and s SI joint mobilizations can be very helpful for that last few 6:42 degrees. Don't forget that these guys help get back here by allowing that 6:48 posterior tipping of the scapula. Fascia our clavipectoral and pectoral fascia. 6:54 So all this fascia in through our PEC, plus the fascia that goes underneath 6:59 our PEC and covers over our PEC minor, into this axial area. Fascia can 7:03 definitely get a little bound, a little restricted, that's where some of our 7:08 static static stretching techniques may come into play, as well as our pin and 7:12 stretch techniques, or instrument assisted soft tissue mobilization all 7:16 can be very helpful there. And then of course we want to just keep all of our 7:21 anatomy in mind here, so muscle, joint fascia, nerve. Although we can't 7:26 necessarily pinpoint one nerve here, just pulling down into depression and up into 7:32 abduction, is going to lengthen the brachial plexus. If somebody has a 7:37 brachial plexus and nerves going through their arm that are already a little 7:43 sensitized, and we happen to notice as they pull back this way we get some 7:48 tingling or or paresthesia, some some numbness, we might want to go ahead and 7:53 do our upper limb tension tests so that we can figure out which nerve is being 7:59 bothered, and what other potential problems we may have. In this test we 8:03 might have a little bias towards the median nerve, but pretty hard to tell 8:07 since we're already putting length all the way up here, and it could potentially 8:11 send sensation down any one of those nerves. Now as I said in all of these 8:16 goniometric assessment videos, I know these are huge graphs, that's not 8:21 something to be intimidated by. That should look like a board of 8:25 opportunities to you. These are all structures, they're all opportunities 8:29 for you to get somebody back to optimal range of motion, get them moving better, 8:34 get the feeling better. I hope I taught you guys a new technique in a clear 8:38 manner. I hope you guys will use this today right after watching this video, 8:43 and I hope I've given you some ideas on how you might be able to help somebody 8:48 that is under your care. I'll talk with you guys soon.
