00:00:0600:00:09
This is Brent of the Brookbush Institute at
00:00:0600:00:09
the independent training spot in New
00:00:0900:00:12
York City, and we're going over more goniometric assessment. In this video
00:00:1200:00:16
we're going to do shoulder flexion, a range of motion that everybody should be
00:00:1600:00:20
very familiar with because of its correlation to function. Now we're going
00:00:2000:00:24
to go over both glenohumeral flexion, as well as shoulder complex flexion.i'm going to
00:00:2400:00:27
have my friend Melissa come out, she's going to help me demonstrate these
00:00:2700:00:30
techniques.
00:00:3000:00:33
Now notice I said glenohumeral and shoulder complex and I separated those
00:00:3300:00:37
numbers, I think some of the confusion and range of motion of the shoulder
00:00:3700:00:42
actually has to do with this particular technique. If you stabilize the scapula
00:00:4200:00:46
and you're testing just just the shoulder itself just the glenohumeral
00:00:4600:00:51
joint, you should be looking for about a hundred and twenty degrees. Now if we
00:00:5100:00:56
allow the scapula to move freely the entire shoulder complex, SC joint, AC
00:00:5600:01:00
joint and the glenohumeral joint, we should be looking at about a hundred and
00:01:0000:01:06
eighty degrees. Now regardless of which technique I'm doing I generally set up
00:01:0600:01:10
the same way, and to make sure her her arms nice and straight, and I start with
00:01:1000:01:15
her scapula depressor I know she's starting in a good position, and then i'm going to
00:01:1500:01:21
use this little groove between my thenar my hypothenar eminence,
00:01:2100:01:28
over the top of her little inferior angle of her scapula. Or I can use
00:01:2800:01:34
just my thumb, problem with just your thumb although it's easier on the
00:01:3400:01:38
physical therapist, sometimes it's harder on the patient because it's a little
00:01:3800:01:43
more pokey, but if I'm doing just glenohumeral right, I'm going to only
00:01:4300:01:47
take her shoulder up until I start to feel her scapula go up into upward
00:01:4700:01:52
rotation. I'm gonna try to brace it, make sure i get to my hard end feel, and then
00:01:5200:01:57
i'm going to take the measurement. Now if i'm looking for just general shoulder
00:01:5700:02:03
complex range of motion then i might keep my hand there just at a habits sake,
00:02:0300:02:08
but i'm going to go ahead and let her move and pull her straight into flexion.
00:02:0800:02:14
Now of course I'm only reaching across her so you guys can see on camera, if I
00:02:1400:02:18
was going to do this technique from my own personal measurements on one of my
00:02:1800:02:22
patients or clients, I'm going to have her scoot towards me as far as she can, and
00:02:2200:02:26
i'll usually use my leg and say you know scoot all the way to my leg. Her scapula
00:02:2600:02:30
should be on the table, her shoulder should be off the table right. I'm going to
00:02:3000:02:35
go ahead and feel for her scapula there and i guess i use the thumb a little bit
00:02:3500:02:40
more, once i get her to
00:02:4000:02:47
end range which is right there, I'm going to say hold that. Alright she's going to hold that
00:02:4700:02:54
for me. I'm going to go ahead and take my goniometer here and the stabilization
00:02:5400:02:58
arm is a mid-axillary line right, so you guys can think straight through the
00:02:5800:03:02
armpit down to the top of the iliac crest, that line would continue straight
00:03:0200:03:07
through the greater trochanter. My fulcrum is going to be as close to me
00:03:0700:03:14
estimating the middle of the glenohumeral joint, and then the movement
00:03:1400:03:18
arm goes straight through mid line in her arm, and she has a hundred and
00:03:1800:03:24
fifteen degrees of glenohumeral flexion. Now i'm going to show you guys because
00:03:2400:03:30
in both the instances i just showed you, both reaching across and this way being
00:03:3000:03:33
blocked by the board, I didn't show you guys great technique, but I'm going to
00:03:3300:03:37
have to turn my back on you to go through this properly. So
00:03:3700:03:41
once again I'm going to have her scoot all the way towards me, I'm going to block out with
00:03:4100:03:45
my leg here, make sure she doesn't slide right off the table. So her shoulders off,
00:03:4500:03:52
but her scapula's on. If i'm doing glenohumeral I'm going to use my thumb here
00:03:5200:03:59
alright, I'm going to pull her back just when I feel that end range. I'm going to
00:03:5900:04:04
have her hold. Now as i mentioned in other videos i want to get in eye line
00:04:0400:04:09
right with her shoulder now, my movement arm is going to go straight through the
00:04:0900:04:16
midline of her humerus, fulcrums going to line up through mid glenohumeral joint here, and
00:04:1600:04:20
then the mid-axillary line goes straight through the middle of the armpit to the
00:04:2000:04:28
top of the iliac crest, straight through the greater trochanter, and hold,, and I
00:04:2800:04:34
got 115 degrees. Now a nice general measurement like i said if i was doing
00:04:3400:04:42
shoulder complex right, 180 degrees would be a straight line. So i'd start her off,
00:04:4200:04:47
all right can she in straight plane go all the way back to the table, if she
00:04:4700:04:50
could we already know she has 180 degrees I don't even have to pull out
00:04:5000:04:55
the goniometer. If she had gotten stuck let's say here, hold that for me, I
00:04:5500:05:02
would just go back through the same technique. A line midway through the
00:05:0200:05:09
humerus, mid-axillary line and if she only had that much flexion that would be
00:05:0900:05:15
roughly a hundred and forty-five degrees. So hopefully you guys can now see how
00:05:1500:05:24
this technique is lined up. Thank you Melissa. Alright so we just did flexion
00:05:2400:05:28
goniometry, we got a hundred and forty-five made-up degrees restriction,
00:05:2800:05:33
now what do we do right, if we're going to do a test it better either clear us
00:05:3300:05:38
as like a lot of our diagnostic tests do, or better have an impact on exercise
00:05:3800:05:41
selection, otherwise why are we doing the test. If we're doing goniometry we're
00:05:4100:05:45
looking at restrictions, if she's only 145 degrees I know she's restricted
00:05:4500:05:51
in flexion. How am I going to get her to move better, well I have to start
00:05:5100:05:54
thinking about the things that could restrict flexion. Let's start with
00:05:5400:05:59
muscles. So we got some really big muscles right the lats, the teres major,
00:05:5900:06:08
part of the PEC major will all restrict shoulder flexion, the subscapularis right
00:06:0800:06:11
even though it's just it's an it's listed as an internal rotator in most of
00:06:1100:06:17
your textbooks, it will also restrict flexion. The posterior deltoids right as
00:06:1700:06:22
we especially get up into this in range can restrict flexion, it can also have a
00:06:2200:06:29
a big effect on arthorkinematics and not glide the humeral head posteriorly
00:06:2900:06:36
as we go into flexion. And then if we were only doing glenohumeral flexion
00:06:3600:06:43
that's would be where this list stopped. But if you did shoulder complex flexion
00:06:4300:06:48
right now night now you just don't have shoulder flexion, you have shoulder
00:06:4800:06:55
flexion with potentially upward rotation, and posterior tipping alright. So I
00:06:5500:07:00
listed the posterior are the anterior tippers here those things with that
00:07:0000:07:03
would restrict posterior tipping, which would be the PEC minor and levator
00:07:0300:07:11
scapulae. So if I know these muscles can restrict this motion I may start
00:07:1100:07:16
attacking these with release techniques, lengthening techniques, pin and stretch
00:07:1600:07:22
techniques right. I have put stars by subscapularis, post delt and PEC minor. I
00:07:2200:07:26
know those of you who've been in the clinic for a while and done a lot of manual
00:07:2600:07:32
therapy, these three for manual release work like magic to improve shoulder
00:07:3200:07:37
flexion, so that might be a note you want to take. Joints alright so let's talk
00:07:3700:07:42
about the glenohumeral joint here we have posterior capsule, posterior cord of
00:07:4200:07:47
the coracle humeral ligament, and the inferior capsule which could all
00:07:4700:07:53
restrict flexion. So now what am I going to do, well we start thinking towards our
00:07:5300:07:57
mobilization techniques, things like our anterior to posterior glide, may be
00:07:5700:08:02
inferior glides, may be more general lateral distractions to work
00:08:0200:08:12
that posterior capsule, and don't forget AC and SC joints here, you really have to
00:08:1200:08:16
start thinking beyond just the shoulder if you're working in shoulder flexion,
00:08:1600:08:20
realizing that if we're looking at that hundred and eighty degrees of shoulder
00:08:2000:08:26
complex flexion, the scapula is also involved. Inferior SC joint mobilizations,
00:08:2600:08:34
posterior to anterior AC joint mobilizations work wonderfully. Fascia
00:08:3400:08:43
your clavi-pectoral, pectoral fascia and axillary fascia, all could use maybe a
00:08:4300:08:48
little instrument assisted soft tissue mobilization, all could definitely use a
00:08:4800:08:56
little attention from our myofascial bag of tricks to help relieve some of
00:08:5600:09:04
this restriction, and then of course if somebody got some nerves stuff, we would
00:09:0400:09:07
want to go ahead and do neurodynamic test. Unfortunately this is such a
00:09:0700:09:13
general stretch to the brachial plexus which goes down through our scalenes, and
00:09:1300:09:16
then underneath or clavicle, between our clavicle and our first rib and then
00:09:1600:09:20
underneath our pectoralis minor than just doing this, there's so many places to
00:09:2000:09:27
become restricted this would be a bad test for any one nerve, but maybe a sign
00:09:2700:09:32
that we need to go ahead and test further. Now a personal thought on this
00:09:3200:09:38
test, this is one of those goniometric assessments that i'll use if i have to
00:09:3800:09:43
because somebody else told me I had to, and what I mean is if somebody else is
00:09:4300:09:48
relying on flexion as a number to get back to playing sports, or a surgeon is
00:09:4800:09:54
looking for this number, or if somebody came in and this was the range of motion
00:09:5400:09:59
they felt most limited in, of course I'll use this test. What you guys will notice
00:09:5900:10:05
from this graph though is it's not starkly different from external rotation.
00:10:0500:10:10
So because I don't get all that much additional information from this test, if
00:10:1000:10:14
I've already done external rotation, which for me it's real easy to do
00:10:1400:10:19
internal rotation and external rotation and write those numbers down, for
00:10:1900:10:24
me i'll use external rotation instead of this test sense from a practical
00:10:2400:10:31
application standpoint, I tend to get the same information. So with all of the
00:10:3100:10:34
videos guys I hope this isn't intimidating, that it gives you a ton of
00:10:3400:10:39
ideas. I hope you will use this technique immediately if not on your colleagues
00:10:3900:10:42
then your friends, and then your colleagues, then of course you'll start
00:10:4200:10:46
using on patients because unless you practice it you're not going to remember
00:10:4600:10:51
it, you're not going to use it, and you won't take advantage of all of this
00:10:5100:10:55
potential information that comes with it. I look forward to hearing from you guys