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This is Brent of the Brookbush Institute,
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and in this video we're talking about
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tibialis anterior manual muscle testing
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for an active population. In this
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video, we're going to talk about more
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provocative ways to test the tibialis
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anterior for those individuals who
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started out active or athletic and end
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up coming to us with some postural
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dysfunction or some sort of pain. I think
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manual muscle testing has lost some
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favor with this group of professionals-
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being the sports medicine, orthopedic and
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human movement science professionals,
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because although that one through five
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grading scale is great in a clinical
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setting, once you really get into the
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3+ to 5, which is what we're using,
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it becomes a little ambiguous. We don't
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generally see those individuals who
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can't move a limb against gravity. We
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don't generally see those individuals
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whose "fair" on a test is going to be
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sufficient enough to get them back to
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their previous level of activity. We
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need to find ways of making these tests
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more provocative and find a grading
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scale that will work for us to help us
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track how our patients and clients are
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doing, as well as help determine what
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intervention we should be using or
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shouldn't be using with that individual.
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I'm going to have my friend, Melissa, come
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out. She's going to help me demonstrate.
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It is important that you learn the
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positions for manual muscle testing for
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each one of these muscles, regardless
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of whether they're active or not. We're
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going to be testing the tibialis
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anterior. It's important that you
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understand that if you had to take
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gravity out of this test, because their
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that weak, deconditioned, or there's some
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sort of neurological dysfunction, then that
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position would be on the side. If all you
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needed was a "fair" and you
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just need that person to be able to pick
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up their foot against gravity, all I'd
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have to do is flip Melissa's feet around,
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have her legs dangling and be able to
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pick up her feet. But then, we get into
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activity. Let's say Melissa has
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come in and
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is complaining about knee pain. I've
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had her do an overhead squat assessment, and
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I can see that her feet flattened.
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Under normal conditions, I think you'd
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all agree that if we just- "Dorisflex
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flex for me and invert. Good." If I just
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had her do this and I pulled, I could
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probably pull her off the table by her
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tibialis anterior. You're all going,
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"Wait a second, that means her tibialis
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anterior is strong." But like I said, she has
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feet flat. I know there's something wrong
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with her inverters. Let's go ahead and
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back up. We're going to find a way to
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make this test more provocative. With
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that being said, I'm no longer going to
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use 3+, 4, 4+, and 5. That's the
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Kendall scale. We're going to leave that
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with those tests. Those have been
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researched and we have some data on those
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scores. I'm going to use just a different
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very simple test. That testing score
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is- "Go ahead and pull up."
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One score is "strong"- she can hold the position
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I put her foot into, in this case, without
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any sort of compensation with a
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significant amount of resistance.
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Another score she could get is "weak"-
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when I pull on her foot, it
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gives with pretty
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minimal resistance. A very common one,
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and this is one that hopefully gets
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your anatomy geek-out, human
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movement science geek-out brains
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thinking is I have her pull up and I pull
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down on her foot. The first thing I
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see is her toes flare up and
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she pulls me into some eversion with her
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dorsiflexion. So, now we have "with
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compensation." We have "strong"- she
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maintains the optimal position; "weak"- she
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just breaks; and now we have "with
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compensation." I said that should
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make your anatomy geek brains work, because
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you need to start thinking about what muscles
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are trying to compensate,
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what muscles are
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synergistically dominant and are trying to take
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over for an inhibited tibialis anterior
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if we see additional toe extension and
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eversion. The last score
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I would give a test like this is- I pull
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on her foot and she goes, "Ow." She
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goes, "Ow," so that hurts, and that's
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going to be "with pain." If
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you're not a licensed professional, it's
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going to be a good indicator that you
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probably need to refer this person out
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to a licensed professional. If you are a
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licensed professional, obviously, we know
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that might mean that we have to go in a
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totally different direction with our
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testing. Let's get into the test
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itself. The traditional manual muscle
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test is- "Go ahead and dorsiflex and
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invert with me." I would then take my full
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hand, because I don't want pressure points here.
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That probably just hurts being
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poked with a finger. You want to
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take that whole hand and try to pull her
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down into dorsiflexion and eversion
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against her tibialis anterior. Can
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she hold that? Oh, she seems pretty
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strong. Like I said, I'm trying to find
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ways of making this more provocative. The
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common compensation pattern for the
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tibialis anterior involves this eversion
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and toes flare up. What dorsiflexors
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evert and extend the toes? You have
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extensor hallucis longus and extensor
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digitorum longus, your EHL and EDL, who
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have a propensity to become
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synergistically dominant. For a tibialis
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anterior, that's being inhibited by a
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short, overactive gastroc complex.
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How am I going to get those
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muscles out of this test? I'm going to
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have her pull up and in, flex her toes,
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and now I've reciprocally inhibited her
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long toe extensors. Now let's see if
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she can maintain. And all of a sudden,
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it's not so easy for her. She's actually
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breaking under fairly minimal resistance,
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considering how strong we need our
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tibialis anterior to be.
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Here's the last thing we're going to do to
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make this a little bit more provocative.
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We're all aware of this kind of
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relationship where if you're not strong
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and have good neuromuscular control
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within a certain range of motion, you're
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probably going to lose that range of
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motion. When Melissa came in to see me,
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she was lacking dorsiflexion. What I
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did today only fixed one of her
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ankles, because I figured it would be fun
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to watch her walk in circles. I only
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fixed her right ankle and here's why. Not
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only do I want her to be able to hold
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dorsiflexion and inversion with toes
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flexed, but I want her to be able to do that
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throughout her entire range of motion.
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She's not going to have as much
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strength in the shortened position or
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the maximally shorten position, but she
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should have some strength throughout
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that full range of motion. You'll
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find that you'll get somebody's
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mobility back, help them into
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dorsiflexion and inversion with toes
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down, and sometimes after you let go,
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you'll see them drop back into their
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comfortable or prior range of motion. You
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might find that it takes a little
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resistance, but the same thing- all of a
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sudden it's like- and then they stop at
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the range of motion they had
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neuromuscular control or strength in
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before. All of these particular signs
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as we've gone through this are
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indications of weakness. You might
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have to make some notes that say "only weak
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in new range of motion, five to
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15 degrees of dorsiflexion." These are
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definitely some results that give us an
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indication that maybe we should be doing
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a little bit more tibialis anterior
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activation or a little bit more
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tibialis anterior strengthening.
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Just because- "go ahead and throw both
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feet up" we could use the traditional
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test- "don't worry about your toes, just
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pull your feet up as hard as you can."
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Even though the traditional test would
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allow me to pull her right off the table
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by her tibialis anterior, if she's
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coming in here complaining
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of pain, she has flat foot, and when I'm a
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little bit more careful about how I do
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this test- I don't let her use her
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overactive synergists I make her go all
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the way to end range, and hold it, and
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then I apply pressure, and if there's a little
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weakness- we're not done. If
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returning back to "normal activity" for
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this individual includes any sort of
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sport, athletic endeavor, resistance
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training, then we have more work to do. There
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you have it. This isn't the
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traditional manual muscle testing, but it's
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manual muscle testing for an active
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population. We see that Melissa
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is testing a little weak at her end
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range. The other things we might
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see would be "strong," that's what we're
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working for. We could have seen
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"with compensation," which would have been
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toes flare and into eversion. We don't
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want that, which is why we also
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curl the toes on this test. Of
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course, the last result that you might
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get is "with pain," which, if you're not
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a licensed professional, that's probably
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time to refer out or at least check
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with a licensed professional to make
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sure that this person is safe to
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continue on with activity. I look forward
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to hearing about you guys using this
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test. I'll talk with you soon.