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