0:06 This is Brent of the Brookbush Institute at the independent training spot in New 0:09 York City, and we're going over more goniometric assessment. In this video 0:12 we're going to do shoulder flexion, a range of motion that everybody should be 0:16 very familiar with because of its correlation to function. Now we're going 0:20 to go over both glenohumeral flexion, as well as shoulder complex flexion.i'm going to 0:24 have my friend Melissa come out, she's going to help me demonstrate these 0:27 techniques. 0:30 Now notice I said glenohumeral and shoulder complex and I separated those 0:33 numbers, I think some of the confusion and range of motion of the shoulder 0:37 actually has to do with this particular technique. If you stabilize the scapula 0:42 and you're testing just just the shoulder itself just the glenohumeral 0:46 joint, you should be looking for about a hundred and twenty degrees. Now if we 0:51 allow the scapula to move freely the entire shoulder complex, SC joint, AC 0:56 joint and the glenohumeral joint, we should be looking at about a hundred and 1:00 eighty degrees. Now regardless of which technique I'm doing I generally set up 1:06 the same way, and to make sure her her arms nice and straight, and I start with 1:10 her scapula depressor I know she's starting in a good position, and then i'm going to 1:15 use this little groove between my thenar my hypothenar eminence, 1:21 over the top of her little inferior angle of her scapula. Or I can use 1:28 just my thumb, problem with just your thumb although it's easier on the 1:34 physical therapist, sometimes it's harder on the patient because it's a little 1:38 more pokey, but if I'm doing just glenohumeral right, I'm going to only 1:43 take her shoulder up until I start to feel her scapula go up into upward 1:47 rotation. I'm gonna try to brace it, make sure i get to my hard end feel, and then 1:52 i'm going to take the measurement. Now if i'm looking for just general shoulder 1:57 complex range of motion then i might keep my hand there just at a habits sake, 2:03 but i'm going to go ahead and let her move and pull her straight into flexion. 2:08 Now of course I'm only reaching across her so you guys can see on camera, if I 2:14 was going to do this technique from my own personal measurements on one of my 2:18 patients or clients, I'm going to have her scoot towards me as far as she can, and 2:22 i'll usually use my leg and say you know scoot all the way to my leg. Her scapula 2:26 should be on the table, her shoulder should be off the table right. I'm going to 2:30 go ahead and feel for her scapula there and i guess i use the thumb a little bit 2:35 more, once i get her to 2:40 end range which is right there, I'm going to say hold that. Alright she's going to hold that 2:47 for me. I'm going to go ahead and take my goniometer here and the stabilization 2:54 arm is a mid-axillary line right, so you guys can think straight through the 2:58 armpit down to the top of the iliac crest, that line would continue straight 3:02 through the greater trochanter. My fulcrum is going to be as close to me 3:07 estimating the middle of the glenohumeral joint, and then the movement 3:14 arm goes straight through mid line in her arm, and she has a hundred and 3:18 fifteen degrees of glenohumeral flexion. Now i'm going to show you guys because 3:24 in both the instances i just showed you, both reaching across and this way being 3:30 blocked by the board, I didn't show you guys great technique, but I'm going to 3:33 have to turn my back on you to go through this properly. So 3:37 once again I'm going to have her scoot all the way towards me, I'm going to block out with 3:41 my leg here, make sure she doesn't slide right off the table. So her shoulders off, 3:45 but her scapula's on. If i'm doing glenohumeral I'm going to use my thumb here 3:52 alright, I'm going to pull her back just when I feel that end range. I'm going to 3:59 have her hold. Now as i mentioned in other videos i want to get in eye line 4:04 right with her shoulder now, my movement arm is going to go straight through the 4:09 midline of her humerus, fulcrums going to line up through mid glenohumeral joint here, and 4:16 then the mid-axillary line goes straight through the middle of the armpit to the 4:20 top of the iliac crest, straight through the greater trochanter, and hold,, and I 4:28 got 115 degrees. Now a nice general measurement like i said if i was doing 4:34 shoulder complex right, 180 degrees would be a straight line. So i'd start her off, 4:42 all right can she in straight plane go all the way back to the table, if she 4:47 could we already know she has 180 degrees I don't even have to pull out 4:50 the goniometer. If she had gotten stuck let's say here, hold that for me, I 4:55 would just go back through the same technique. A line midway through the 5:02 humerus, mid-axillary line and if she only had that much flexion that would be 5:09 roughly a hundred and forty-five degrees. So hopefully you guys can now see how 5:15 this technique is lined up. Thank you Melissa. Alright so we just did flexion 5:24 goniometry, we got a hundred and forty-five made-up degrees restriction, 5:28 now what do we do right, if we're going to do a test it better either clear us 5:33 as like a lot of our diagnostic tests do, or better have an impact on exercise 5:38 selection, otherwise why are we doing the test. If we're doing goniometry we're 5:41 looking at restrictions, if she's only 145 degrees I know she's restricted 5:45 in flexion. How am I going to get her to move better, well I have to start 5:51 thinking about the things that could restrict flexion. Let's start with 5:54 muscles. So we got some really big muscles right the lats, the teres major, 5:59 part of the PEC major will all restrict shoulder flexion, the subscapularis right 6:08 even though it's just it's an it's listed as an internal rotator in most of 6:11 your textbooks, it will also restrict flexion. The posterior deltoids right as 6:17 we especially get up into this in range can restrict flexion, it can also have a 6:22 a big effect on arthorkinematics and not glide the humeral head posteriorly 6:29 as we go into flexion. And then if we were only doing glenohumeral flexion 6:36 that's would be where this list stopped. But if you did shoulder complex flexion 6:43 right now night now you just don't have shoulder flexion, you have shoulder 6:48 flexion with potentially upward rotation, and posterior tipping alright. So I 6:55 listed the posterior are the anterior tippers here those things with that 7:00 would restrict posterior tipping, which would be the PEC minor and levator 7:03 scapulae. So if I know these muscles can restrict this motion I may start 7:11 attacking these with release techniques, lengthening techniques, pin and stretch 7:16 techniques right. I have put stars by subscapularis, post delt and PEC minor. I 7:22 know those of you who've been in the clinic for a while and done a lot of manual 7:26 therapy, these three for manual release work like magic to improve shoulder 7:32 flexion, so that might be a note you want to take. Joints alright so let's talk 7:37 about the glenohumeral joint here we have posterior capsule, posterior cord of 7:42 the coracle humeral ligament, and the inferior capsule which could all 7:47 restrict flexion. So now what am I going to do, well we start thinking towards our 7:53 mobilization techniques, things like our anterior to posterior glide, may be 7:57 inferior glides, may be more general lateral distractions to work 8:02 that posterior capsule, and don't forget AC and SC joints here, you really have to 8:12 start thinking beyond just the shoulder if you're working in shoulder flexion, 8:16 realizing that if we're looking at that hundred and eighty degrees of shoulder 8:20 complex flexion, the scapula is also involved. Inferior SC joint mobilizations, 8:26 posterior to anterior AC joint mobilizations work wonderfully. Fascia 8:34 your clavi-pectoral, pectoral fascia and axillary fascia, all could use maybe a 8:43 little instrument assisted soft tissue mobilization, all could definitely use a 8:48 little attention from our myofascial bag of tricks to help relieve some of 8:56 this restriction, and then of course if somebody got some nerves stuff, we would 9:04 want to go ahead and do neurodynamic test. Unfortunately this is such a 9:07 general stretch to the brachial plexus which goes down through our scalenes, and 9:13 then underneath or clavicle, between our clavicle and our first rib and then 9:16 underneath our pectoralis minor than just doing this, there's so many places to 9:20 become restricted this would be a bad test for any one nerve, but maybe a sign 9:27 that we need to go ahead and test further. Now a personal thought on this 9:32 test, this is one of those goniometric assessments that i'll use if i have to 9:38 because somebody else told me I had to, and what I mean is if somebody else is 9:43 relying on flexion as a number to get back to playing sports, or a surgeon is 9:48 looking for this number, or if somebody came in and this was the range of motion 9:54 they felt most limited in, of course I'll use this test. What you guys will notice 9:59 from this graph though is it's not starkly different from external rotation. 10:05 So because I don't get all that much additional information from this test, if 10:10 I've already done external rotation, which for me it's real easy to do 10:14 internal rotation and external rotation and write those numbers down, for 10:19 me i'll use external rotation instead of this test sense from a practical 10:24 application standpoint, I tend to get the same information. So with all of the 10:31 videos guys I hope this isn't intimidating, that it gives you a ton of 10:34 ideas. I hope you will use this technique immediately if not on your colleagues 10:39 then your friends, and then your colleagues, then of course you'll start 10:42 using on patients because unless you practice it you're not going to remember 10:46 it, you're not going to use it, and you won't take advantage of all of this 10:51 potential information that comes with it. I look forward to hearing from you guys 10:55 soon. 11:04
