00:00:0000:00:04
This is Brent, coming at you with another
00:00:0400:00:08
or tibial internal rotator activation. I'm actually really excited
00:00:0800:00:13
about this one. I've been working at this for a long time, to come up with a
00:00:1300:00:18
successful exercise that doesn't also gear up all of those overactive synergists
00:00:1800:00:22
that can play a role in some of our postural dysfunction. My friend, Yvette, is
00:00:2200:00:26
going to come out and help me demonstrate this exercise. I'm going to
00:00:2600:00:30
show you both manual style techniques, as well as self-administered, or self
00:00:3000:00:35
resisted techniques here. Now, if I want to get at the medial tibial rotators,
00:00:3500:00:40
this is for everybody who has that dysfunction where their feet turn out,
00:00:4000:00:44
right, which means their medial internal or tibial rotators would be long and
00:00:4400:00:49
under active, or all of those individuals where their knees cave in, which is
00:00:4900:00:54
relative tibial external rotation and femoral internal rotation, which means
00:00:5400:00:58
once again these same muscles are long and under active. Now the hard part about
00:00:5800:01:02
that is, all of these muscles are secondary muscles, they are two joint
00:01:0200:01:07
muscles for the most part, and trying to get them recruited usually involves
00:01:0700:01:12
potentially recruiting a lot of other muscles that could already be shortened,
00:01:1200:01:18
overactive, in that same dysfunction. So, here's what we've got to do. We're going to
00:01:1800:01:23
have to go ahead and get our patient or client in this long sit position to
00:01:2300:01:26
start with. We're then going to go ahead and bend the leg to 90 degrees here, and
00:01:2600:01:32
the first problem that I started to work out, was the fact that if
00:01:3200:01:36
I wanted to get the gracilis active, I needed to find a way to do that without
00:01:3600:01:42
getting the rest of the adductor complex active. That's actually not that hard to
00:01:4200:01:48
drive out. All I have to do is make sure that I get a little bit of abduction,
00:01:4800:01:54
alright, so if I resist here, and have Yvette push out towards me, boom, adductors are
00:01:5400:02:00
now reciprocally inhibited. The next thing I have to do, is make sure biceps
00:02:0000:02:05
femoris stays out, and TFL stays out. Well, that's actually not that hard to do
00:02:0500:02:10
either because biceps femoris and TFL are tibial external rotators. So if I can
00:02:1000:02:14
ensure that I'm doing tibial internal rotation, those guys will
00:02:1400:02:20
automatically gear down. Now, the way to resist this becomes a little complicated,
00:02:2000:02:25
but not unsolvable. We're going to go ahead and use the foot as a lever arm.
00:02:2500:02:31
Now, to make sure that I'm getting tibial internal rotation, and not inversion, the
00:02:3100:02:36
way we figured this out is by going into dorsiflexion. I posteriorally shift
00:02:3600:02:41
the talis, kind of jam it into the mortise of the ankle, and now I can't get
00:02:4100:02:46
any motion out of the ankle. So now we can use this as a nice firm lever, and if
00:02:4600:02:51
I get her to internally rotate her tibia, I know that it's coming from tibial
00:02:5100:02:55
internal rotation, and not inversion. Now what I'll go ahead and do with this
00:02:5500:03:01
exercise is, since tibialis anterior is usually under active, the extensors
00:03:0100:03:05
hallucis longus, and extensor digitorum longus is usually overactive, I'm going
00:03:0500:03:09
to go ahead and have hear dorsiflex, but then bring down her toes, I can kill
00:03:0900:03:13
two birds with one stone by activating tibialis anterior. Alright, so here's the
00:03:1300:03:19
setup. We're at 90 degrees, roughly, of knee flexion. I'm in midline with the
00:03:1900:03:23
hip, I don't want this position. If I put her here, this is the same position
00:03:2300:03:27
as knees bow inward, so I've got her in this position, what I'm going to go ahead and
00:03:2700:03:32
do is, I'm going to go ahead and bring my fingers underneath her heel,
00:03:3200:03:36
because you can actually see me queue a little bit of extension too, to try to
00:03:3600:03:41
further get TFL out of the mix, I'm then going to place my hand along this border
00:03:4100:03:47
of her foot, so along that first ray, and then I'm going to place the palm
00:03:4700:03:51
of my hand just outside of her knee. First thing I'm going to have Yvette do
00:03:5100:03:55
is go ahead and push out against my hand a little bit, she doesn't have to kill me,
00:03:5500:03:59
and then I can use whatever activation protocol you guys are comfortable with,
00:03:5900:04:06
so you guys can use that 25, 50, 75, 100 protocol, you can use several isometric
00:04:0600:04:09
holds, you could do isometric holds of the beginning range, end range, but at the end
00:04:0900:04:14
of the day you're going to go, "go ahead and push out, alright, pull down, pull
00:04:1400:04:17
your heel down and into the bench a little bit, down against my fingers, and
00:04:1700:04:21
then I want you to internally rotate your foot against my forearm,
00:04:2100:04:26
good, hold that, push, don't let it go, push out against this hand, push against
00:04:2600:04:34
this arm, and relax". And then, for me, I'm going to keep ramping up the amount
00:04:3400:04:40
of effort she's putting in, as long as I can maintain optimal form, and I'm sure,
00:04:4000:04:45
and you guys can palpate to make sure, you can palpate here, making sure that
00:04:4500:04:49
semitendinosus, membranosis, and gracilis are nice and active, and that
00:04:4900:04:53
you actually have a little bit of a soft spot here, where that other adductor mass
00:04:5300:05:00
is. Alright, so one more here, I have her dorsiflexed, toes down, have her push down her
00:05:0000:05:06
heel into the table, good, push out here. I've got the inside of her foot braced, and
00:05:0600:05:10
she's going to push into my forearm. Now, this doesn't have to be a manual
00:05:1000:05:16
technique, she can do this on her own. All I've done here is wrapped a band around
00:05:1600:05:22
the table leg, I'm going to go ahead and flip this around her foot this way, she
00:05:2200:05:27
can scoot over a little bit to add a little bit more resistance, let's go down
00:05:2700:05:34
just a little this way, good. So go ahead and dorsiflex, good, toes down, now I'm
00:05:3400:05:38
going to have her use her hand to provide that abduction resistance to get
00:05:3800:05:43
adductor's down. Alright, now all she has to do is, let's go ahead and do 15 slow reps,
00:05:4300:05:51
of internal rotation, and there you guys go. You guys can see this is all tibial
00:05:5100:05:56
internal rotation. Keep dorsiflex. Alright, I can actually see a little bit of her
00:05:5600:06:00
tibial tuberosity, I don't know if you guys can see that in the camera. I can see a
00:06:0000:06:06
little bit of a tibial crest moving inward. If I wanted to palpate here, I can
00:06:0600:06:11
actually feel her semitendinosis, membranosis, and gracilis tendon, really, really
00:06:1100:06:16
geared up. What we would hope to find, of course, is if we've done all of
00:06:1600:06:21
our mobility work, we've done all of our release, stretching, joint mobilizations.
00:06:2100:06:25
We've done our other activation work, and Yvette had feet turn out, then after doing
00:06:2500:06:30
this exercise, we could have her redo whatever functional task assessment
00:06:3000:06:32
we're doing, maybe like a squat assessment, and we
00:06:3200:06:37
would see an improvement in her feet staying a little bit more in line. I hope
00:06:3700:06:42
you enjoy this activation technique, You could see this as
00:06:4200:06:46
somewhere between like a Pes anserinus activation, or a semimembranosus,
00:06:4600:06:50
tendinosis, gracilis, and popliteus activation. I hope you get huge