This is Brent of the Brookbush Institute and in this video we're going over static release
techniques for the flexor hallucis longus and flexor digitorum longus, also
known as the FHL and the FDL or the long toe flexors. If you're watching this
video I assume you're watching it for educational purposes and that you are a
licensed manual practitioner. That means the laws in your state allow you to
perform manual release techniques: mainly, physical therapists, athletic trainers,
chiropractors and massage therapists. I'm going to have my friend Melissa come out,
she's going to help me demonstrate this technique. Now, these muscles are deep and
the posterior lower leg here is kind of sensitive when it comes to these manual
release techniques. Before I attempt FHL or FDL release, I'm want to be fairly
certain that these muscles are involved. So, Melissa, at this point, I'm going to have
done assessment and she's going to exhibit signs of lower extremity
dysfunction before I start poking around at these deeper muscles; that could be
anything from feet flat, feet turn out, knees bow in, knees bow out or excessive
forward lean on that overhead squat, a lack of dorsiflexion on goniometry. Maybe her
manual muscle testing for her tibialis anterior or tibialis posterior came back a
little weak.
Maybe that gastroc/soleus muscle length test showed me some changes in
extensibility in her plantar flexors. These would all be good reasons for me
to dig a little deeper, start palpating and see if I could find some increased
tissue tonicity or increased tissue density is what i'm actually going to
feel, with palpating the FHL and FDL. Now, to help you guys with the palpation part,
because that's probably the most difficult part of this technique.
I'm going to have Melissa scoot down just a little bit. I want to be able to control dorsiflexion
here with my thigh.
Right, so then what I'm going to do is, I kind of know where my trigger points are
for these muscles. I know that my FDL, it's kind of like a spot right between
the lateral and medial gastroc, but
a little higher than the lower border. It's like up a little bit. And then I
know my FHL, you guys have probably felt your flexor hallucis longus trigger
points or seen somebody try to roll at their flexor hallucis longus trigger points.
It's kind of a spot that seems to be inside the Achilles tendon, so if you've
ever seen somebody foam roll really low chances are that's not their gastoc or
soleus. Their gastroc or soleus ends up, well their gastroc up here and soleus here.
If they're just kind of rolling over what you thought was tendon,
chances are it's the muscle belly of the flexor hallucis longus which
lies deep to the Achilles tendon. What I'm going to do to palpate these is I
know that my FDL is a little bit more medial. Just medial to my fibula
here kind of on the lateral border of my tibia but pretty deep so I want to
palpate through my gastoc and soleus and then I'm going to have Melissa
wiggle her toes. No need for me to do guesswork here guys. If she wiggles
her toes, what I want to be able to feel is eventually under my fingers is
something that feels like this. Right if she just wiggles all of her toes,
I should feel some fascicles jumping around underneath my fingers and I need
to keep palpating until I feel that.
And it's better to take a couple extra seconds than to just be wrong.
All right, so I feel it right there. Now what I'm going to do is do my perpendicular
palpations to look for tighter fascicles and then I'm going to, once I find a tight
fascicle, I'm going to start looking for that nodule, that knot that I think
is contributing to the tightness in that fascicle. And right about here,
I find a nice little knot in Melissa's flexor digitorum longus. Now,
from here I could just press deep, I could use my dummy thumb to create a
nice, a nice thick palpatory spot and then push her into a little dorsiflexion
making sure that I'm including her toes this time because I got to push her toes
into extension to also lengthen those long toe flexors and then use my other
hand to supply the pressure. So this thumb goes between my thenar eminences.
Right, after I find that spot, nice broad palpation and I go right to the point of
increased tissue density, right where that issue starts to give back a little bit,
and I hold.
This is going to be a tender one though if I'm sitting here and pressing through
a lengthened gastroc and soleus. I'm going show you guys a trick here in a second
that'll make this technique a little easier. Now once I've done that, I can go
through, do the same thing with the FHL. Wiggle your toes for me.
FHL is actually a little easier to find because rather than palpating through
the thick gastroc and the thick soleus, you're really palpating through the
very ends of these muscles, you know. The gastroc actually is probably
has no fibers left down at this low. And the soleus is pretty thin here. I'm going to
do my perpendicular palpation here,
strumming those fascicles. Once I find a tight fascicle, I can then look for a nodule.
And I found that one pretty quick. Once again I'm going to use my nice
broad, whole thumb pad to push down on that trigger point. I'm going to put
some length in that tissue to once again put some tension in that muscle.
Or rather only goes to here, but put some tension in that muscle and
stabilize that trigger point, so it doesn't keep flopping around. I don't want to play
that finger tip on a marble game. And then press down. Again, I'm pushing through
some muscle so this is going to be pretty tender. So here I want to show you
guys a couple tricks so that you're not pushing through so much muscle. You do
have to know who you're doing this on, though. The first technique I'm going
show you, the individual needs to be a pretty stable, well-balanced individual
and the second technique, you definitely have to be aware of body position. So the
first thing I'm going to have Melissa do is get into a kneeling position. Now if she
gets into a kneeling position, she flexes her knee, I'm going to have use this foam roll to
get stable. I'm going have her put this leg out in front of her, right so the knee that
we're going to, or the side that we're going to work on, that's the knee that's
down. She has this leg in front of her to take on most of the weight.
She can lean over this leg even a little bit. You want to make sure
she's nice and stable so that she doesn't need knee flexion and extension
to keep her balance and then what I've basically done, actually, move this leg
back a little bit. What I've done is I've put her gastroc on slack. So now rather
than trying to push through all this stretched out tissue, and I've been
telling you guys for a few videos now with these manual release techniques, we
put tension into tissue to actually stabilize trigger points. It
increases tension. So to put some slack back now I can press straight down into
this trigger point. There's, and you can see Melissa's face, there's no
resistance until I hit her flexor digitorum longus. And now I can use the
same technique.
Same thing with her FHL, even though there's not as much muscle down
here, it's still so much less tension in this system, that pushing down
into her FHL is so much easier.
And once again I can hold for 30 seconds or until I get a release going right up to
that tissue barrier. I should start to feel it melt underneath my fingertips. If I'm
in constant communication with my client, "Hey, Melissa you starting to feel that
relax a little bit? Doesn't feel as bad as it did when I first pressed in. Good.
All right so the last position that works well, guys, but you need to have a little
bit of awareness and rapport with your client is this position, which kind of
looks like our hip flexor stretch, does take some balance and you notice I have
Melissa up on a treatment table, which becomes problematic if we're dealing
with somebody who's not very well-balanced.The last thing I would
want is Melissa to fall over this way as I'm doing all these techniques. Melissa
could go down into quadruped. So go ahead and go in to quadruped.
So quadruped does the exact same thing for me it's a very, very stable position.
But I just want you guys to watch. Obviously Melissa and I are close, we're
friends, we've been doing this a long time. If I push here and then put my
dummy thumb here and I'm not careful where I'm looking
my face is going to be very close to her backside which is not going to make
either you or your client very comfortable. You can sit down.
So although quadruped position is probably the best position to do that
technique in, guys just make sure that if you're going to do that you have enough
rapport with your client, with your patient to kind of explain to them the
position that you guys are going to end up in and then make sure as you're
pushing down maybe you practice this technique enough that you don't have to
look at your hands so much. I would definitely move rather than being center,
I would move off to the side of the table a little bit and then only lean so
that this shoulders over your arm for your pressure rather than being center
on. It's just a little uncomfortable and I don't want anybody getting in trouble
for, you know, a stupid reason of just lack of body awareness. So next we're
going to do our close-up review. So this is your close-up recap, guys, you can see
that I have the FDL and FHL common trigger points mapped out for you.
The FDL, the body of this muscle, where it's innervated by its nerve and where we
think these acute points of dysfunction happen, is generally right between your
medial and lateral gastrocnemius heads. Of course, deep to your gastroc and
soleus. So when I look for this trigger point, I'm not even a mess around.
I'm not going to try to hit it right on the money. I'm going to have my patient or
client go ahead and wiggle their toes,
you can even have them curl their toes against your thigh if you're in this
once again, this position with their feet hanging off so that you can control
the amount of dorsiflexion and plantar flexion. Keep going. And of course
I feel right there. Once I have that spot, I want to make sure I push Melissa into
dorsiflexion and toe extension. So you don't want your knee up here right, where
you're pushing her into dorsiflexion but her toes can flex
around your knee. You want to make sure they you almost got the toes pressed
into extension first, because these are long toe flexors, and then dorsiflexion
as you press down. That'll help stabilize where that trigger point is so you don't get
that flopping back and forth. Then you can use dummy thumb and apply enough
pressure to you all the way through gastroc and soleus until you start
feeling the tissue melt away, the discomfort start to reduce. Now, of course
this is FHL. FHL is a little easier to find as there's not so much tissue to get
through here. We'll use our palpations across the fascicles first, look for the
the densest fascicles. Move proximally and distally to try to find the nodule in
those fascicles. Once we found it we can kind of push with a nice broad thumb. No
need to press straight down and play the fingertip on top of a marble game.
Put some tension in that system to help you stabilize the trigger point. Push up
this way. I do find a little distal to proximal pressure, along with posterior
to anterior pressure helps. And I can do the same thing pushing right up to that
point where I see a big
increase in tissue density. So we know that we have this kind of
linear relationship where tissue density slowly increases as we press into tissue
and then all of a sudden as we hit that trigger point, get deeper, all of a sudden
tissue density ramps up real fast. We want to be just in that trough.
And, of course I showed you guys the trick of getting some of this tissue,
getting the calf issue out of the way. Well, the gastroc and soleus
anyway and then adding a little bit of laxity back to the Achilles tendon by
having your patient or client go into either a kneeling position or a quadruped
position. Just be real careful on where you end up versus where they end up and
and you're having that conversation about why you're doing what you're doing.
You can see now just as I poke her gastoc here, there's no
resistance and it's because we put some tension back into her gastroc. I can push
straight down, almost like the first resistance I feel is her flexor
digitorum longus. This is of course just thumb over thumb compression, which I
wouldn't necessarily use on these techniques. We'd go back this way and then
go hand over thumb and that helps save our thumbs a little bit. Once again, I
could use 30 seconds or until I feel the tissue melt away or I could use those
multiple repetitions of five second holds. Let's say she was so tender that I
couldn't even get to that increase in tissue density, I could slowly work into
it with five second holds until the tissue desensitized enough for me to
actually get some sort of mechanical release. So there you guys have it. FHL and FDL
static manual release technique. Great technique to add to your repertoire of
very overlooked set of muscles. Muscles that do have a propensity to become
synergistically dominant
in lower extremity dysfunction. Ensure that you are doing assessment first and
you're pretty sure that these muscles are involved because that back of that
leg is a sensitive area to be pressing on and remember you're going to have to
press through quite a bit of tissue through your gastroc, through your
soleus. Be careful as you experiment with the other positions we showed you - the
kneeling and the quadruped position. Make sure that you explain to your
client what you're doing and where your body positions are going to end up so
there are no misunderstandings. And of course grab some friends and get to
practicing before you pull this out with patients and clients. I think just having
it done on you as well as doing it to other people and then being able to
compare with you and your colleagues is such a wonderful learning experience. As
a profession, we don't do enough to work together in groups
I really think that every clinic, every PT should have a group that they go to
where we could do some maybe practice together because manual techniques done
on manual therapists with interaction, that's some powerful learning. I look
forward to hearing about your outcomes. I look forward to hearing about how this
changed some of the outcomes you saw when you added it into your repertoire.
I'll talk with you soon.