This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
based manual therapy technique. If you're watching this video I'm assuming you're
watching it for educational purposes, and that you are a licensed professional
with joint based techniques within your scope. That means osteopaths, chiropractors,
physical therapists, you're probably all in the clear. Physical therapy assistants,
athletic trainers, massage therapists, you need to check with your governing body
in your state or region, to see whether this is within your scope of practice.
Personal trainers this is definitely not within your scope of practice. Of course,
all professions could use this video for purely educational purposes, to help with
learning biomechanics, anatomy and of course palpation. In this video, we're
going to do posterior to anterior tibia on femur, or rather let's do
anterior to posterior femur on tibia mobilization since they're the same
relative arthrokinematic motion, but the latter allows us to get in good
body position, making it easy for us to perform the technique. I'm going to have
my friend Melissa come out, she's going to help me demonstrate this technique.
Now if I'm doing this technique on Melissa I've already done some sort of
passory excessive motion exam on her knee, and I've assessed her as having
arthokinematic stiffness. We don't want to be using mobilizations on
hypermobile joints, that's not going to make anybody feel better. The other joint
action we need to check for because of the way this technique is set up, is if
Melissa had beyond normal extension of the knee that's beyond five degrees of
hyperextension, I also wouldn't use this technique because of the way I'm pushing
down this way, I could end up making hyperextension,
hypermobility worse, which is also not going to make anybody feel any better.
Now traditionally this technique is used to increase extension of the knee, so
somebody who lacks full range of extension, and this is all based on
concave on convex rules - that's glide same as roll. However, I think research is
kind of pointed to the fact that those rules are not completely reliable when
it comes to the knee. Now what does that mean? It probably means that mobilization
in the either direction could potentially be effective for
either extension or flexion, which I know creates some grey area but here's what
you're going to do. This is the technique I fall back on most often because I find
it most effective, most often. But if you wanted to try mobilization in the other
direction the only thing I would ask is that you assess, do your intervention, and
reassess. Then if you're going to try the other technique, do that and reassess
again. You want to try to determine which technique, which direction of glide is
most effective, write that down and continue to use that with your patient
or client. Now I'm going to have Melissa go ahead and put her leg down so that
you can see what I'm doing to Melissa's knee here, what my hand position
is, what I'm palpating, and how I set this up. So we wanted to do a posterior to
anterior glide on the tibia, or the tibia on the femur, and rather we turned it
around. So we're going to do anterior to posterior on the femur so that we can
push, because pushing is a lot easier than pulling. I don't want to manhandle
and wear my hands out, or wear my body out trying to do this mobilization. In
order to get myself a little space anterior to posterior I had to elevate
Melissa's leg just a little bit, so that's where this half foam roll comes
in, and I find half foam rolls to be the best thing for this technique and
notice this isn't one of those super hard like premium foam rolls, this is
kind of a soft-ish foam roll. So it's firm, but not so firm that it's
mean on Melissa's calf. Alright you could use a pillow, like one of these round pillows
that's under Melissa's head, just realize that if you use one of those round
pillows you're going to have to push all the way through the pillow's softness,
before you're going to be palpating any sort of arthrokinematic motion. Now like
all of our techniques for mobilizations and soft tissue techniques and sometimes
even exercise, the more anatomy you know, the better. With the knee, maybe you want
to start by finding the patella, the kneecaps kind of easy to find.
So I can start outlining the borders of her patella, I can find her patellar
tendon or patellar ligament depending on what you want to particularly call it.
I'll find her tibial tuberosity right here, I can find the top of her patella
and then maybe I want to let my hand sink down medial and lateral, so that I
can feel through her soft tissue and find those femoral condyles, which should
feel like roundish bumps kind of on the superior half of where her patella was
so the end of the femur. If I go lower than that I should be able to feel
the tibia which is going to feel a little bit more ridgey, alright so your
femoral condyles are nice and round, your tibia kind of comes up and then hits a
plateau. Now if you visualize that you should be able to come to the end of
those round bumps and the end of all those ridges, and find a depression
that's a line, that's the joint line. This is going to be an important part of this
technique, the thing that we really want to try to to palpate. So see if you can
feel through that soft tissue in here nicely, don't jab your fingers into your
your partner's, clients or patients knee, that's not going to feel good, but gently
kind of try to find that joint line. If you want you could have your patient
like flex their knee a little bit and then straighten it, flex it and straighten it,
flex it and straighten it, so that you can kind of find where that joint line
is, there we go, got it. Alright once I found her joint line I'm just going to
set my hands down around her patella, because the last thing I want to do is
this. If you know Clark's sign or Clark's test, or the patellar compression
test, if you've ever done it, it just kind of hurts everybody, it's not a real great
test. It's supposed to be a test for knee pain, but you push down on somebody's
patella to have them extended it just freaking hurts so don't do that. Instead,
take your web spaces and just kind of put it around the patella, put your index
fingers and your thumbs down over the joint line. Now you're going to apply
pressure using the arm that's over the femur with the palm of your hand, and you
really want to use a lot of the surface of your hand. I've
explained this in some of our other videos, you don't
want to use fingertips to do mobilizations if you don't have to,
because they're going to feel really pointy and even your webspace with it's
very narrow surface area, can feel like a chisel into somebody's knee. It just
doesn't feel good. Alright so hands down right around the
patella just like so, we're going to put index fingers on the joint line, thumbs on
the joint line, and I'm getting ready to push down here. Now is where we start
thinking about okay do I have any contraindications to think about. Well
obviously if I started pressing in, if I started in like this and Melissa
immediately starts complaining of pain, that would be a bad thing. We might want
to back off and find another technique, and of course if you have somebody who's
come in after acute knee injury you got to start thinking about did they
potentially tear any of the ligaments of the knee, even like just mild, mild tears
can cause a pretty significant amount of pain, and maybe you have to go back and
do your special tests. Of course, you could press down and impinge on
some nerves or impinge on some trigger points, generally those are easy to get around
by just moving your hands a tiny bit. Remember trigger points aren't generally
very large things and nerves are definitely not very large things right,
they're very narrow, we're talking like millimeters. So usually you can just kind
of reposition your hands and somebody like ahh,
and I'm like well what happened, you're like right above my knee it hurt, okay
let me let me move my hand around a little bit.
Notice that the table is low enough so that I can get my chest over this
technique, because once again I don't want to muscle this technique. Melissa
has super strong legs and the knee is a nice big joint, so I want to be able to
use my upper body mass to create the force, and now I'm just going to go back
to whatever protocol it is that I use. Now I've mentioned in other videos I
happen to be in Certified Orthopedic Manual
Therapist through through Maitland, so I use the 50% grade III and IV.
So grade III's would be larger amplitude at 50%, grade IV
would be smaller amplitude at 50%. Now, that's 50% between
first resistance barrier and end of arthrokinematic range, and you're going
to keep oscillating at one to two oscillations per second until you feel a
decrease in joint stiffness. Now if you use another protocol, that's fine. I think
there's a lot of protocols out there, the thing they all have in common is finding
first resistance barrier, so that's first resistance barrier for Melissa, and I'm
palpating the joint line right now, so I should be able to really easily find
where the end of arthokinematic range is, that is, no matter how much
harder I push right now, I'm not getting any more motion in glide, that's femur on
tibia glide, no matter how much harder I push I'm not getting any more motion. So
I know where the beginning is, I know where the end is. Most protocols have you
mobilize somewhere in between. Whatever protocol you use, just make sure you go
through with it. Alright make sure you do it from
beginning to end, that you don't half-ass it per se, that you actually do the
protocol, give the technique a fair chance, so that when you go to reassess,
you know whether it was an effective technique, and it wasn't just bad form on
your part that didn't get you the result that you were looking for. How does that
feel? A little weird, it does feel a little weird to be pushed pushed into
this direction right, like this is this is end range knee extension. Melissa does
have a little bit of stiffness here though, so I'm going to see how it makes
you feel upon reassessment. I'm thinking she'll feel a little bit better. Alright
guys so I want to set that up for you one more time before we go to the close
up recap. Notice that the table is low enough that when I palpate her knee I
have to lean over just a little bit, that is
purposeful so that I can use my upper body mass to create the force, and I'm
not manhandling and using my upper body strength or the strength of my hand to
get this mobilization done, that's not going to work.
I then am going to find her patella, and I'm going to put my hands down around
her patella, no Clark sign or Clark's test, like it's a bad idea, it
hurts so bad. Alright once I have my hands down around her patella, I think
it's good practice to find the joint line. It's going to make it so much
easier to find your first resistance barrier and end arthrokinematic
range. I'm not sure why it's not more common to teach palpation of the joint
line for this technique when your hands are right here. You're then going to
apply force through the arm on the femur. This hand you can use to kind of
make sure that the tibia doesn't rotate if you'd like, or to stabilize the tibia
or you know, you could even adjust as you're going, the foam roll in case like
I press down and I press the foam roll right into a gastroc or a soleus trigger
point, obviously I would move that. This hand essentially though it's just going
to be there to stabilize, while this one applies the force. I'm going to find my
first resistance barrier, find the end of arthrokinematic range, back off to 50% and
if I was doing a grade IV, it would be a very small amplitude oscillation, one to
two oscillations per second, and notice I'm just rocking my upper body, you guys
don't see me doing this with my arms right, no pumping, not pumping her knee. I'm
just rocking with my arms putting weight this way right so it's all coming down
through this arm, with a nice large surface area created by the entirety of
my palm, not my web space. Stay tuned for the close-up recap. So for a close-up
recap guys once again it always helps to know your anatomy. So we have Melissa's
patella here, and then if I just kind of sink my hands down I can start feeling
well there's the fibular head right there. If I follow the fibular head this
nice rounded bony landmark here, I actually
feel like a little guitar string right here, that's actually her LCL which leads
right into her joint line, which is exactly where I want my thumbs to be. Now
notice how I've positioned my hands here guys I got both my thumbs over the
joint line so that I can feel glide, but my hands themselves are around her
patella. Again we don't want to mimic Clark's sign and give her patellar pain
for no reason. Now as soon as I kind of get myself in good position, I got her
leg nice and stable with my left hand here, with my right hand I'm just going
to go ahead and apply a little bit of force until I start to feel some glide,
and then I'm going to keep applying force until I feel the end of arthro-
kinematic range of motion. I then can back off 50% and I can start doing my
oscillations. Remember guys to keep your bodyweight over your hands, you're using
the weight of your upper body mass, your torso to create these oscillations.
You're not muscling it with your hands, or even trying to muscle it with your
arms, it should be a nice sway that's applying all this force. And of course,
once I finished my mobilizations I could then go ahead and reassess. So there you
have it: assess, address, reassess. Make sure that
every time you choose a joint based manual therapy technique, it is based on
an assessment, and that you return to that assessment after you've finished
the intervention to see if it was effective for the individual, the patient
or client that you had in front of you. Ensure that you continue to learn your
anatomy because your anatomy is going to help you with your hand placement, with
understanding what a joint can do, with understanding what you may gain from
this particular technique. And of course practice. You have to practice these
techniques, hopefully not for the first time on a patient or client who just
walked in the door. If you can, find a more senior instructor or a mentor to
give you some really good hands-on instruction. Use your peers for some good
feedback, and of course always look for live education to help with your manual
therapy techniques. I know these videos make education very convenient, but there
is no substitute for learning manual therapy in a live setting. I look
forward to talking to you guys again soon.