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Tibial Internal Rotator Manual Muscle Testing (MMT) for an Active Population
Tibial Internal Rotator Manual Muscle Testing (MMT) is a clinical strength assessment used to evaluate the strength of the Tibial Internal Rotator Muscle in an active population. Utilizing a manual testing protocol, the strength of the Tibial Internal Rotator Muscle is resisted by a clinician and/or a partner which is compared qualitatively to the strength of the named muscle on the opposite side. This test assesses the power and control of the Tibial Internal Rotator Muscle
Transcript
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This is Brent of the Brookbush Institute,
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and in this video we're doing tibial
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internal rotator manual muscle testing for an active or athletic population.
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Since we're dealing with this healthier population, we're going to go ahead and
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take that Kendall scale that's probably better for a clinical setting, and set it
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aside. We're going to replace it with strong, weak, with compensation or with
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pain, which I find a little bit more reliable for this active / athletic
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population. Now we're also going to take that popliteus manual muscle test and
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replace it with a tibial internal rotator manual muscle test, as i find
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this has a little higher transference to helping us determine which exercises we
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should use to correct the movement impairment we see. Things like feet turn
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out, or knees bow in. I'm going to have my friend Melissa come out, shes going to help me
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demonstrate this technique. First things first, we're going to have Melissa here
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sit in a long sit position, and then we're going to take the knee that we're
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testing or the tibial internal rotators that we're testing, and bend that knee to
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90 degrees. Now normally this would be the position, but i'm going to have
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Melissa go ahead and take this leg, drop it off the table, so you guys have clear
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line of her entire lower leg. The first problem we have in trying to create a
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test for these muscles, is we have to find a rigid lever to pull against. I
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don't want to just grab her skin and start twisting, that never really feels
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good. Or take her soft tissue and just mash it around her tibia, that's not
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going to feel good either. So we need a nice rigid lever, and I see her foot here
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and the only thing we have to do to make sure that her foot is a good lever, is
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take her all the way up into dorsiflexion an inversion, because down
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here in neutral, I'm going to pull it into a lot of eversion, inversion,
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pronation, supination. Her foot is very malleable down here, as soon as you get
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somebody completely into dorsiflexion, inversion of course locks up the
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forefoot, and dorsiflexion takes the talus and kind of mashes it back into
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the mortise of the ankle, and now you don't have a lot of motion there either.
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So as soon as I go into this maximal dorsiflexion and inversion, if I look at
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her tibial tuberosity, I can see that moving her foot actually moves
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her tibia. Whereas kind of down here, if I move her foot, her tibial tuberosity
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actually doesn't move much, it's all foot motion here. So dorsiflexion and
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inversion, you got it, can you hold that for me. Then going to take my fingers
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wrap them around her heel, and now i have my forearm as a nice stable steady lever.
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I don't need to crank real hard on these muscles, they're not particularly strong
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in this position, but I can say hey can you hold and put some pressure against
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my arm. I'm looking at her tibial tuberosity to make sure that I am
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assessing tibial rotation and not just inverter strength per se, and she looks
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kind of strong. But for Melissa I'm noticing our first compensation which in
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her case is her knees starting to do this a little bit. So Melissa being a
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great athlete always looks kind of strong when she does stuff, till you
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start tearing stuff apart a little bit, and you realize okay it might not be her
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tibial internal rotators that are really doing the job, she's actually in this
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position trying to use her adductors to pull my arm in this way, and fool me into
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thinking that she's passing this test. So now how do i get my overactive
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synergists out of this test, i'm going to use reciprocal inhibition. I'm going to
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go ahead and fire up right abductors and make sure her adductors can't do the job.
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The way I'm gonna do that is use the palm of this hand against the outside of
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her knee, as soon as she does that her gluteus medius kind of fires up, maybe
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the deep rotators of her hip. I know these guys aren't involved. I take her into
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dorsiflexion around my fingers around her heel, use that forearm as a nice
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rigid lever, and now I kind of cue her to do this thing, all right so knee goes
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this way, foot goes this way. Take a good look at her tibial tuberosity and see if
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she can maintain this position. Of course at that point if I could just push her
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out she'd be weak, if she could hold the position she'd be strong
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that'd be wonderful. If I felt pressure leave this hand
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right, she's starting to go back into that adduction. Even relatively
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speaking I'm just losing pressure, then we know this is with compensation and
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something we have to work on. Now the big compensation that goes with this test is
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very much like the tibialis anterior activation manual muscle test that we
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talked about, where it's not so much about compensation or just weak, its
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weak in that range of motion they don't have, or weak in that range of motion i
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should say they don't use. So I'm gonna have Melissa turn around here, she's
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going to show you what I mean So back up, i'll stand behind you. So you guys see
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people and they their feet turn out when they squat, or the feet turn out when
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they walk. And we'll make sure you can see here this piece of tape is right on
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the tibial crest, and she's a little bit rotated out there about 25 degrees. Now
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what we come across in this particular test is if I tested her in this position,
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she might actually test strong, this is a position that she's used to being in,
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it's a position that she's reinforced. So as soon as I go to apply a little
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pressure she's like, hey I got this, I do this all the time. I take her to neutral
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maybe, maybe I get a little weakness maybe, but here's where things really
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start to fall apart, is she strong through the entire range of tibial
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internal rotation that she should have, and guys once again you have to either
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look at this tibial crest or this tibial tuberosity. I don't want you you' just looking
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at the foot, because you'll mistake inversion or supination for tibial
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internal rotation. If I take her here, you can see how that tape moved in just a
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little bit, let's do that one more time for Melissa, So this is neutral, that's tibial
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internal rotation. If I take her here, and I start to apply pressure,
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that's where you'll see people fall apart. They either don't have strength in
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that range of motion, or it's so hard for them to maintain that position,
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against the hypertonicity and adaptive shortening of their tibial external
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rotators, being her TFL, biceps femoris and vastus lateralis,
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via fascial slips in the iliotibial band. It takes so much force just to
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overcome that resistance, that once I do this a little bit, she flops right back
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out. Alright so that might mean not only do we have to release and lengthen this
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stuff, but we're going to have to pay really really careful attention when we
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do our activation techniques, that it's just not from turned out to halfway,
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turned out to halfway, turned out to halfway, which a lot of people just kind
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of go through the motions, we need to make sure that when we teach this, it's
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all the way here. So taking all of this into consideration. When we do the test
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and have you spin back around, go ahead and flop this leg off, good pull up to 90
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degrees dorsiflexion, invert as far as you can, push out against this hand for
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me. I'm going to make sure she starts in tibial internal rotation, maximal tibial
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internal rotation. She should be a 15 to 20 degrees turned in. Now i'm gonna apply
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some pressure and be like can you hold this ,and believe it or not guys, she
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falls right back to neutral before I start getting any significant give. That
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would actually be for me a weak test. I would go ahead and call her weak for her
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tibial internal rotators. With compensation again, would have been
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with adduction and strong. She would have been able to hold it, but that's yeah,
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that's not what happened. I'm going to do it on the other side just so you guys
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can kind of see what both sides look like here, go ahead and bring this foot
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up for me alright. So once again guys I'm going to have her dorsiflex, invert, I'm
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taking my hand, wrapping it around her heel this way, you guys can now see my
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forearm is a nice stable rigid lever, this is easy for me to do all day. I'm then
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going to bring my elbow up nice and high, so that my forearm is directly in line
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with the force I'm trying to apply, and then I can go ahead and push out this
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way, turn in this way, and this side is actually a little
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stronger for her. Very interesting, we might have to work on this side a little bit.
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Or it's been the 25 takes we've done on this side that have basically wore her
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out, and that's why she can't do it. Guys the one thing I haven't mentioned, so we
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mentioned what strong looks like, what weak is likely to look like, which is
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just weakness at the end range, you guys know the compensation is
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probably going to look like the the knee trying to go in .Of course if i were to
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put Melissa into this test and she gave me a big OW with pain right now, I know
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I have not necessarily a strength and conditioning issue, I have more of a
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rehab issue potentially on my hands. If you're not a licensed professional you
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need to refer out, and if you are a licensed professional working with
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athletes, that's the time to go okay I might need to take a step back, maybe
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rewrite my strength training routine so it doesn't put so much pressure on the
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knee the tibial internal rotators. Maybe do a little upper body work, a little
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more upper body work for a little while. Get really focused on a rehab program
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and fix that problem before I move on. I hope you guys enjoyed this video. I look
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forward to hearing how you'll refine your exercise selection, and maybe you
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guys will look at that tibial internal rotator activation technique to follow
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this up, so you guys can kind of see a test, intervention, reassessment.
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