0:05 This is Brent of the Brookbush Institute, and in this video we're doing tibial 0:07 internal rotator manual muscle testing for an active or athletic population. 0:12 Since we're dealing with this healthier population, we're going to go ahead and 0:15 take that Kendall scale that's probably better for a clinical setting, and set it 0:19 aside. We're going to replace it with strong, weak, with compensation or with 0:25 pain, which I find a little bit more reliable for this active / athletic 0:29 population. Now we're also going to take that popliteus manual muscle test and 0:33 replace it with a tibial internal rotator manual muscle test, as i find 0:38 this has a little higher transference to helping us determine which exercises we 0:43 should use to correct the movement impairment we see. Things like feet turn 0:48 out, or knees bow in. I'm going to have my friend Melissa come out, shes going to help me 0:52 demonstrate this technique. First things first, we're going to have Melissa here 0:57 sit in a long sit position, and then we're going to take the knee that we're 1:01 testing or the tibial internal rotators that we're testing, and bend that knee to 1:05 90 degrees. Now normally this would be the position, but i'm going to have 1:08 Melissa go ahead and take this leg, drop it off the table, so you guys have clear 1:12 line of her entire lower leg. The first problem we have in trying to create a 1:17 test for these muscles, is we have to find a rigid lever to pull against. I 1:21 don't want to just grab her skin and start twisting, that never really feels 1:25 good. Or take her soft tissue and just mash it around her tibia, that's not 1:29 going to feel good either. So we need a nice rigid lever, and I see her foot here 1:33 and the only thing we have to do to make sure that her foot is a good lever, is 1:36 take her all the way up into dorsiflexion an inversion, because down 1:42 here in neutral, I'm going to pull it into a lot of eversion, inversion, 1:46 pronation, supination. Her foot is very malleable down here, as soon as you get 1:51 somebody completely into dorsiflexion, inversion of course locks up the 1:55 forefoot, and dorsiflexion takes the talus and kind of mashes it back into 2:01 the mortise of the ankle, and now you don't have a lot of motion there either. 2:05 So as soon as I go into this maximal dorsiflexion and inversion, if I look at 2:10 her tibial tuberosity, I can see that moving her foot actually moves 2:14 her tibia. Whereas kind of down here, if I move her foot, her tibial tuberosity 2:19 actually doesn't move much, it's all foot motion here. So dorsiflexion and 2:26 inversion, you got it, can you hold that for me. Then going to take my fingers 2:30 wrap them around her heel, and now i have my forearm as a nice stable steady lever. 2:34 I don't need to crank real hard on these muscles, they're not particularly strong 2:38 in this position, but I can say hey can you hold and put some pressure against 2:42 my arm. I'm looking at her tibial tuberosity to make sure that I am 2:47 assessing tibial rotation and not just inverter strength per se, and she looks 2:55 kind of strong. But for Melissa I'm noticing our first compensation which in 3:01 her case is her knees starting to do this a little bit. So Melissa being a 3:07 great athlete always looks kind of strong when she does stuff, till you 3:12 start tearing stuff apart a little bit, and you realize okay it might not be her 3:17 tibial internal rotators that are really doing the job, she's actually in this 3:22 position trying to use her adductors to pull my arm in this way, and fool me into 3:29 thinking that she's passing this test. So now how do i get my overactive 3:35 synergists out of this test, i'm going to use reciprocal inhibition. I'm going to 3:39 go ahead and fire up right abductors and make sure her adductors can't do the job. 3:43 The way I'm gonna do that is use the palm of this hand against the outside of 3:47 her knee, as soon as she does that her gluteus medius kind of fires up, maybe 3:52 the deep rotators of her hip. I know these guys aren't involved. I take her into 3:56 dorsiflexion around my fingers around her heel, use that forearm as a nice 4:00 rigid lever, and now I kind of cue her to do this thing, all right so knee goes 4:04 this way, foot goes this way. Take a good look at her tibial tuberosity and see if 4:11 she can maintain this position. Of course at that point if I could just push her 4:14 out she'd be weak, if she could hold the position she'd be strong 4:19 that'd be wonderful. If I felt pressure leave this hand 4:22 right, she's starting to go back into that adduction. Even relatively 4:26 speaking I'm just losing pressure, then we know this is with compensation and 4:30 something we have to work on. Now the big compensation that goes with this test is 4:36 very much like the tibialis anterior activation manual muscle test that we 4:40 talked about, where it's not so much about compensation or just weak, its 4:46 weak in that range of motion they don't have, or weak in that range of motion i 4:50 should say they don't use. So I'm gonna have Melissa turn around here, she's 4:56 going to show you what I mean So back up, i'll stand behind you. So you guys see 5:02 people and they their feet turn out when they squat, or the feet turn out when 5:06 they walk. And we'll make sure you can see here this piece of tape is right on 5:11 the tibial crest, and she's a little bit rotated out there about 25 degrees. Now 5:16 what we come across in this particular test is if I tested her in this position, 5:20 she might actually test strong, this is a position that she's used to being in, 5:25 it's a position that she's reinforced. So as soon as I go to apply a little 5:31 pressure she's like, hey I got this, I do this all the time. I take her to neutral 5:36 maybe, maybe I get a little weakness maybe, but here's where things really 5:42 start to fall apart, is she strong through the entire range of tibial 5:47 internal rotation that she should have, and guys once again you have to either 5:51 look at this tibial crest or this tibial tuberosity. I don't want you you' just looking 5:55 at the foot, because you'll mistake inversion or supination for tibial 6:00 internal rotation. If I take her here, you can see how that tape moved in just a 6:05 little bit, let's do that one more time for Melissa, So this is neutral, that's tibial 6:09 internal rotation. If I take her here, and I start to apply pressure, 6:15 that's where you'll see people fall apart. They either don't have strength in 6:19 that range of motion, or it's so hard for them to maintain that position, 6:24 against the hypertonicity and adaptive shortening of their tibial external 6:29 rotators, being her TFL, biceps femoris and vastus lateralis, 6:33 via fascial slips in the iliotibial band. It takes so much force just to 6:38 overcome that resistance, that once I do this a little bit, she flops right back 6:43 out. Alright so that might mean not only do we have to release and lengthen this 6:48 stuff, but we're going to have to pay really really careful attention when we 6:52 do our activation techniques, that it's just not from turned out to halfway, 6:57 turned out to halfway, turned out to halfway, which a lot of people just kind 7:00 of go through the motions, we need to make sure that when we teach this, it's 7:03 all the way here. So taking all of this into consideration. When we do the test 7:08 and have you spin back around, go ahead and flop this leg off, good pull up to 90 7:16 degrees dorsiflexion, invert as far as you can, push out against this hand for 7:21 me. I'm going to make sure she starts in tibial internal rotation, maximal tibial 7:26 internal rotation. She should be a 15 to 20 degrees turned in. Now i'm gonna apply 7:32 some pressure and be like can you hold this ,and believe it or not guys, she 7:37 falls right back to neutral before I start getting any significant give. That 7:43 would actually be for me a weak test. I would go ahead and call her weak for her 7:48 tibial internal rotators. With compensation again, would have been 7:52 with adduction and strong. She would have been able to hold it, but that's yeah, 7:58 that's not what happened. I'm going to do it on the other side just so you guys 8:01 can kind of see what both sides look like here, go ahead and bring this foot 8:06 up for me alright. So once again guys I'm going to have her dorsiflex, invert, I'm 8:13 taking my hand, wrapping it around her heel this way, you guys can now see my 8:18 forearm is a nice stable rigid lever, this is easy for me to do all day. I'm then 8:23 going to bring my elbow up nice and high, so that my forearm is directly in line 8:28 with the force I'm trying to apply, and then I can go ahead and push out this 8:35 way, turn in this way, and this side is actually a little 8:39 stronger for her. Very interesting, we might have to work on this side a little bit. 8:43 Or it's been the 25 takes we've done on this side that have basically wore her 8:48 out, and that's why she can't do it. Guys the one thing I haven't mentioned, so we 8:54 mentioned what strong looks like, what weak is likely to look like, which is 8:57 just weakness at the end range, you guys know the compensation is 9:01 probably going to look like the the knee trying to go in .Of course if i were to 9:07 put Melissa into this test and she gave me a big OW with pain right now, I know 9:13 I have not necessarily a strength and conditioning issue, I have more of a 9:17 rehab issue potentially on my hands. If you're not a licensed professional you 9:22 need to refer out, and if you are a licensed professional working with 9:26 athletes, that's the time to go okay I might need to take a step back, maybe 9:31 rewrite my strength training routine so it doesn't put so much pressure on the 9:35 knee the tibial internal rotators. Maybe do a little upper body work, a little 9:39 more upper body work for a little while. Get really focused on a rehab program 9:43 and fix that problem before I move on. I hope you guys enjoyed this video. I look 9:48 forward to hearing how you'll refine your exercise selection, and maybe you 9:52 guys will look at that tibial internal rotator activation technique to follow 9:57 this up, so you guys can kind of see a test, intervention, reassessment. 10:11
