Home Exercise Programs for Musculoskeletal and Sports Injuries The Evidence-Based Guide for Practitioners 9781620701201, 9781617052972, 2019031671, 2019031672

Table of contents :
Cover
Title
Copyright
Contents
Contributors
Foreword
Introduction
References
Acknowledgments
List of Exercises
Shoulder
Elbow
Wrist and Hand
Hip
Knee
Ankle and Foot
Cervical Spine
Thoracic Spine
Lumbar Spine
Share: Home Exercise Programs for Musculoskeletal and Sports Injuries: The Evidence-Based Guide for Practitioners
Chapter 1: Home Exercise Programs for Shoulder Injuries
Introduction
Goals for Advancement of Exercise Program
Rotator Cuff Tendinopathy
Acromioclavicular Joint Pathology
Glenohumeral Joint Osteoarthritis
Glenohumeral Joint Instability
Adhesive Capsulitis/Frozen Shoulder
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional
References
Chapter 2: Home Exercise Programs for Elbow Injuries
Introduction
Goals for Advancement of Exercise Program
Lateral Epicondylosis
Medial Epicondylosis
Ligament Sprains
Distal Bicipital Tendinopathy
Ulnar Neuropathy at the Elbow
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional
References
Chapter 3: Home Exercise Programs for Wrist and Hand Injuries
Introduction
Goals for Advancement of Exercise Program
De Quervain’s Tenosynovitis
Carpal Tunnel Syndrome
Carpometacarpal Osteoarthritis
Extensor Carpi Ulnaris Tendinopathy
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional Exercises
Patient Education/Precautions/Activity Modification
References
Chapter 4: Home Exercise Programs for Hip Injuries
Introduction
Goals for Advancement of Exercise Program
Hip Osteoarthritis
Iliopsoas Tendinopathy/Bursitis
Greater Trochanteric Pain Syndrome
Hamstring Strain and Tendinopathy
Femoroacetabular Impingement and Labral Tears
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional
References
Chapter 5: Home Exercise Programs for Knee Injuries
Introduction
Goals for Advancement of Exercise Program
Knee Osteoarthritis
Patellofemoral Pain Syndrome
Quadriceps and Patellar Tendinopathy
Knee Ligament Sprain
Meniscal Tear
Iliotibial Band Syndrome
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional
References
Chapter 6: Home Exercise Programs for Ankle and Foot Injuries
Introduction
Goals for Advancement of Exercise Program
Ankle Sprain
Achilles Tendinopathy
Posterior Tibial Tendinopathy
Plantar Fasciosis
Handouts
Rom/Stretching/Mobility
Strengthening
Proprioception/Functional
References
Chapter 7: Home Exercise Programs for Cervical Spine Injuries
Introduction
Directional Preference
Goals for Advancement of Exercise Program
Cervical Facet Arthropathy
Cervical Disc Pathology
Cervical Radiculopathy
Upper Crossed Posture
Handouts
Rom/Flexibility/Mobility
Strengthening
Proprioception/Functional
References
Chapter 8: Home Exercise Programs for Thoracic Spine Injuries
Introduction
Goals for Advancement of Exercise Program
Thoracic Spine
Handouts
Rom/Flexibility/Mobility
Strengthening
Proprioception/Functional
References
Chapter 9: Home Exercise Programs for Lumbar Spine Injuries
Introduction
Directional Preference
Goals for Advancement of Exercise Program
Lumbar Facet Arthrosis
Lumbar Disc Pathology
Lumbar Radiculopathy
Lumbar Spondylolysis/spondylolisthesis
Lumbar Spinal Stenosis
Lower Crossed Syndrome
Handouts
Rom/Stretching/Postural Correction
Strengthening
Proprioceptive/Functional
References
Index

Citation preview

An Imprint of Springer Publishing

HOME EXERCISE PROGRAMS FOR MUSCULOSKELETAL AND SPORTS INJURIES THE EVIDENCE-BASED GUIDE FOR PRACTITIONERS

Ian W. Wendel

|

James F. Wyss

Home Exercise Programs for Musculoskeletal and Sports Injuries

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Home Exercise Programs for Musculoskeletal and Sports Injuries The Evidence-Based Guide for Practitioners Editors

Ian W. Wendel, DO, FAAPMR, CAQSM, RMSK Tri-Country Orthopedics Clinical Assistant Professor Rutgers New Jersey Medical School Ringside Physician New Jersey State Athletic Control Board Cedar Knolls, New Jersey

James F. Wyss, MD, PT Assistant Attending Physiatrist Assistant Professor of Rehabilitation Medicine NYP-Cornell Director of Education for HSS Physiatry Department Team Physiatrist Long Island Nets Hospital for Special Surgery New York, New York Photographs by Richard Bean

An Imprint of Springer Publishing

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Visit www.springerpub.com and http://connect.springerpub.com ISBN: 978-1-6207-0120-1 ebook ISBN: 978-1-6170-5297-2 DOI: 10.1891/9781617052972 Acquisitions Editor: Beth Barry Compositor: S4Carlisle Publishing Services Copyright © 2020 Springer Publishing Company. Demos Medical Publishing is an imprint of Springer Publishing Company, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Names: Wendel, Ian, editor. | Wyss, James, editor. Title: Home exercise programs for musculoskeletal and sports injuries : the evidence-based guide for practitioners / [edited by] Ian Wendel, James F. Wyss. Identifiers: LCCN 2019031671 (print) | LCCN 2019031672 (ebook) | ISBN 9781620701201 (paperback) | ISBN 9781617052972 (ebook) Subjects: MESH: Exercise Therapy | Athletic Injuries--therapy | Musculoskeletal Diseases--therapy | Patient Compliance | Self Management | Evidence-Based Practice Classification: LCC RM725 (print) | LCC RM725 (ebook) | NLM WB 541 | DDC 615.8/2--dc23 LC record available at https://lccn.loc.gov/2019031671 LC ebook record available at https://lccn.loc.gov/2019031672 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America. 19 20 21 22/5 4 3 2 1

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To my father and his love of books. -IWW

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CONTENTS

Contributors  xi Foreword  Joseph E. Herrera, DO, FAAPMR  xiii Introduction  xv Acknowledgments  xvii List of Exercises   xix Share: Home Exercise Programs For Musculoskeletal and Sports Injuries: The Evidence-Based Guide for Practitioners 1. Home Exercise Programs for Shoulder Injuries Jonathan Kirschner   1 Introduction  1 Goals for Advancement of Exercise Program   1 Rotator Cuff Tendinopathy  2 Acromioclavicular Joint Pathology   2 Glenohumeral Joint Osteoarthritis   3 Glenohumeral Joint Instability   4 Adhesive Capsulitis/Frozen Shoulder   4

Handouts  6 References  24

2. Home Exercise Programs for Elbow Injuries John Gallucci, Jr. and Taylor Rossillo   25 Introduction  25 Goals for Advancement of Exercise Program   25 Lateral Epicondylosis  26 Medial Epicondylosis  27 Ligament Sprains  27 Distal Bicipital Tendinopathy    28 Ulnar Neuropathy at the Elbow   29

Handouts  30 References  47

3.

Home Exercise Programs for Wrist and Hand Injuries Julia Doty

49

Introduction 49 Goals for Advancement of Exercise Program

49

De Quervain’s Tenosynovitis 49 Carpal Tunnel Syndrome 50 Carpometacarpal Osteoarthritis 51 Extensor Carpi Ulnaris Tendinopathy 52

Handouts References

4.

53 70

Home Exercise Programs for Hip Injuries Jessica Hettler and Astrid DiVincent Introduction 71 Goals for Advancement of Exercise Program

71

Hip Osteoarthritis 72 Iliopsoas Tendinopathy/Bursitis 72 Greater Trochanteric Pain Syndrome 73 Hamstring Strain and Tendinopathy 74 Femoroacetabular Impingement and Labral Tears

Handouts References

5.

71

75

77 99

Home Exercise Programs for Knee Injuries Jessica Hettler and Astrid DiVincent Introduction 101 Goals for Advancement of Exercise Program Knee Osteoarthritis 102 Patellofemoral Pain Syndrome 103 Quadriceps and Patellar Tendinopathy Knee Ligament Sprain 104 Meniscal Tear 105 Iliotibial Band Syndrome 106

Handouts References

6.

101

101

103

108 127

Home Exercise Programs for Ankle and Foot Injuries Ian W. Wendel

129

Introduction 129 Goals for Advancement of Exercise Program

129

Ankle Sprain 130 Achilles Tendinopathy 130 Posterior Tibial Tendinopathy 131 Plantar Fasciosis 132

Handouts References

viii

133 142

CONTENTS

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7.

Home Exercise Programs for Cervical Spine Injuries Gary Mascilak

143

Introduction 143 Directional Preference 143 Goals for Advancement of Exercise Program

144

Cervical Facet Arthropathy 144 Cervical Disc Pathology 145 Cervical Radiculopathy 146 Upper Crossed Posture 147

Handouts References

8.

149 167

Home Exercise Programs for Thoracic Spine Injuries Gary Mascilak

169

Introduction 169 Goals for Advancement of Exercise Program Thoracic Spine

Handouts References

9.

171

171

172 183

Home Exercise Programs for Lumbar Spine Injuries Amrish D. Patel

185

Introduction 185 Directional Preference 185 Goals for Advancement of Exercise Program Lumbar Facet Arthrosis 186 Lumbar Disc Pathology 187 Lumbar Radiculopathy 188 Lumbar Spondylolysis/Spondylolisthesis Lumbar Spinal Stenosis 190 Lower Crossed Syndrome 191

Handouts References

Index

186

189

193 219

221

CONTENTS

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CONTRIBUTORS

Astrid DiVincent, PT, DPT, OCS Advanced Clinician, Sports Rehabilitation and Performance Center, Hospital for Special Surgery, New York, New York Julia Doty OTR/L, CHT Senior Director, Orthopedic Physical Therapy Center, Hospital for Special Surgery, New York, New York John Gallucci, Jr., MS, ATC, PT, DPT Chief Executive Officer, JAG-ONE Physical Therapy; Medical Coordinator, Major League Soccer, New York Jessica Hettler, PT, DPT, MHA, ATC, SCS, OCS, Cert MDT Director, Sports Rehabilitation and Performance Center, Hospital for Special Surgery, New York, New York Jonathan Kirschner, MD, RMSK Fellowship Director, Spine and Sports Medicine, Hospital for Special Surgery, New York, New York; Associate Professor, Clinical Rehabilitation Medicine, Weill Cornell Medicine, New York, New York Gary Mascilak, DC, PT, CSCS Rehab and Performance Specialist, Sparta, New Jersey Amrish D. Patel, MD, PT Georgia

Physiatrist, Sports and Spine Institute, McDonough,

Taylor Rossillo, MBA, ATC Director of Athletic Training Services, JAG-ONE Physical Therapy, New Jersey Ian W. Wendel, DO, FAAPMR, CAQSM, RMSK Tri-Country Orthopedics, Cedar Knolls, New Jersey; Clinical Assistant Professor, Rutgers New Jersey Medical School, Newark, New Jersey; Ringside Physician, New Jersey State Athletic Control Board, Trenton, New Jersey

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FOREWORD

As we move into an age of evidence-based medicine and value-based care, many health systems, physicians, and other healthcare practitioners are trying to achieve the triple aim. The triple aim is a framework that helps organizations achieve improvement in patient care, improvement in population health, and a reduction in overall costs for the health system. The home exercise program is one of the tools that physicians and healthcare providers can use to realize the goals of the triple aim, but, unfortunately, it is often underutilized, and there is little consistency in execution. The use of exercise as a tool for treating both orthopedic and neurological diseases has been a practice that has stood the test of time. The current mechanism for using exercise as a treatment method is triggered by physician prescription and completed through physical or occupational therapists. Studies have shown that the use of physical therapy has decreased costs of treating appropriate diagnoses by 72% while effectively treating the condition. However, exercise and physical therapy still remain underused as options to treat common musculoskeletal conditions. The number of physical therapy sessions that a patient can attend is limited; patients’ hectic lives, increasing costs of copays, and caps in the number of allowable therapy sessions placed by insurance companies are all contributing factors. As a result, the need for evidence-based home exercise programs is higher than ever. This book, by Dr. Wendel and Dr. Wyss, addresses this need in a very structured and purposeful way that is user friendly for the patient and medical provider alike. This tool will educate practitioners in proper exercise prescription and teach patients how to effectively treat their musculoskeletal conditions through superb, detailed handouts with minimal time burden to the prescribing practitioner. Joseph E. Herrera, DO, FAAPMR Chairman and Lucy G. Moses Professor  Department of Rehabilitation and Human Performance  Mount Sinai Health System  Director of Sports Medicine Icahn School of Medicine at Mount Sinai, New York, New York

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INTRODUCTION

Rehabilitation exercises are one of the cruxes of treating musculoskeletal and sports injuries, and they are generally initiated soon after rest, medications, and modalities have been utilized. There is overwhelming literature supporting their role in the treatment of these injuries. However, one of the greatest barriers to patients benefiting from such rehabilitation exercises is getting the patient to perform regular, quality, effective, and evidence-based exercises. Too often a patient’s busy schedule precludes him or her from seeking guidance on exercise from a professional, such as a physical or occupational therapist. In other instances, the patient has sought this treatment and it is now time to be exercising independently. This is when a home exercise program must be employed and a healthcare professional must convey this information to the patient. This book was developed to assist healthcare professionals in providing evidence-based home exercise treatment programs and high-quality handouts to patients. The authors of this book felt that current home exercise program resources were not ideal and decided to develop their own. We also realize that many health professionals are not taught how to properly prescribe exercise, or they are early in training and yet not comfortable prescribing exercise. We wanted to develop a resource that guides healthcare professionals in prescribing effective, evidence-based home exercises in an efficient, self-explanatory manner so that valuable minutes of a patient encounter do not have to be wasted on explanation. Essentially, this book is of value to any healthcare professional who prescribes exercise to patients. Within a rehabilitation exercise program, a stepwise approach must be followed to lay the framework for more advanced exercise. The typical phases of rehabilitation are provided in Table 1 (1, 2): Table 1. Phases of Rehabilitation ▪ Phase I: Decrease pain and swelling (PRICE protocol) ▪ Phase II: Restore range of motion and normal arthrokinematics ▪ Phase III: Strength training ▪ Phase IV: Neuromuscular control and proprioceptive training ▪ Phase V: Functional or sport-specific training PRICE, Protection, Rest, Ice, Compression, and Elevation.

We feel that for a home exercise program, this approach can be cumbersome for patients. Instead, we decided to combine these into three phases, Foundational, Intermediate, and Advanced, where we list recommended exercises within each phase that are built upon and advanced as a patient progresses through his or her rehabilitation. We also list goals for advancement that healthcare professionals should try to identify in patients, if possible, before progressing the exercise program to the next level.

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Additionally, we provide concise, evidence-based background and treatment information on the different regions of the body and injuries within these regions. Furthermore, the exercise programs within each chapter explain how to effectively perform each exercise through guided steps with visual aids. How to Use This Book • Read the chapters to gain background knowledge on common musculoskeletal and sports injuries and pearls for prescribing exercise for treatment of these injuries. • Disseminate the chapters as handouts for patients: ▪ Provide the entire chapter to patients to provide more information on the clinical condition, ▪ Highlight the desired exercises from the List of Exercises section of the book to provide to patients along with the exercises from each chapter’s Handouts section, ▪ Mix and match exercises and develop custom handouts tailored to the patient’s needs. There is even a box to check or write numbers included within every exercise in the Handouts section from each chapter. Healthcare professionals will then confidently and efficiently provide high-quality information and resources to patients to aid in the recovery of musculoskeletal and sports injuries.

REFERENCES 1. Malanga GA, Ramirez-Del Toro JA, Bowen JE, et al. Sports medicine. In: Frontera RW, DeLisa JA, Gans BM, et al., eds. DeLisa’s Physical Medicine & Rehabilitation: Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1413–1436. 2. Wyss JF, Patel AD, Malanga GA. Phases of musculoskeletal rehabilitation. In: Wyss JF, Patel AD, eds. Therapeutic Programs for Musculoskeletal Disorders. New York, NY: Demos Medical Publishing; 2012:3–6.

xvi

INTRODUCTION

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ACKNOWLEDGMENTS

I want to thank my family, Shama, Averie, and Austin, for granting me the time to complete this book and for their unwavering support; my parents and brothers for helping to establish my values and work ethic; all of my teachers, especially those at Kessler/ NJMS and Mount Sinai, as this book is a compilation of your teachings; James Wyss, Shounuck Patel, and Rich Bean for all of your efforts to develop and provide the foundation for this book; all of the chapter contributors, whose expertise and diligence were invaluable; and all the people at Demos Medical, specifically Beth Barry and Jaclyn Shultz, for putting this book together. -IWW

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LIST OF EXERCISES

SHOULDER Rotator Cuff Tendinopathy

2

Recommended Exercises Foundational ROM/Stretching/Mobility: Corner stretch, sleeper stretch, stick shoulder extension, stick overhead shoulder stretch, stick shoulder abduction

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Scaption Strengthening: Low row, scapular retraction, straight arm lateral pull down, push-up with a plus, abducted shoulder external rotation

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Prone “T,” “Y,” ”I,” “W”; stability ball bird dog, stability ball plank, wall fall push-up

Acromioclavicular Joint Pathology

2

Recommended Exercises Foundational ROM/Stretching/Mobility: Corner stretch, sleeper stretch, stick shoulder rotation, stick shoulder extension

Intermediate Continue Foundational exercises Strengthening: Low row, straight arm lateral pull down, external rotation with a Theraband

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Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Prone “T,” “Y,” “I,” “W”; stability ball bird dog, wall fall push-up

Glenohumeral Joint Osteoarthritis

3

Recommended Exercises Foundational ROM/Stretching/Mobility: Corner stretch, sleeper stretch, reverse sleeper stretch, broom pull, stick shoulder rotation, stick overhead stretch, scaption

Intermediate Continue Foundational exercises Strengthening: Low row, straight arm lateral pull down

Advanced Continue Foundational and Intermediate exercises Strengthening: Push-up with a plus Proprioception/Functional: Prone “T,” “Y,” “I,” “W”’ stability ball bird dog

Glenohumeral Joint Instability

4

Recommended Exercises Foundational Strengthening: Isometric strengthening in all directions (external rotation, internal rotation, flexion, extension), scapular retraction

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Stick shoulder flexion, stick shoulder abduction, stick shoulder rotation Strengthening: Low row, straight arm lateral pull down, external rotation with a Theraband

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Prone “T,” “Y,” “I,” “W”; stability ball bird dog, wall ball push-up, stability ball planks, wall fall push-up

xx

LIST OF EXERCISES

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Adhesive Capsulitis/Frozen Shoulder

4

Recommended Exercises Foundational ROM/Stretching/Mobility: Stick shoulder abduction, stick shoulder rotation, stick overhead shoulder stretch, stick shoulder flexion

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Broom pull, stick shoulder extension Strengthening: Low row, straight arm lateral pull down

Advanced Continue Foundational and Intermediate exercises ROM/Stretching/Mobility: Scaption (with a weight or Theraband) Strengthening: External rotation with a Theraband Proprioception/Functional: Prone “T,” “Y,” “I,” “W”

ELBOW Lateral Epicondylosis

26

Recommended Exercises Foundational ROM/Stretching/Mobility: Wrist flexor stretch, wrist extensor stretch, triceps stretch

Intermediate Continue Foundational exercises Strengthening: Grip strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises Strengthening: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccentric strengthening Proprioception/Functional: Serratus punch, prone scapular retractions

LIST OF EXERCISES

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Medial Epicondylosis

27

Recommended Exercises Foundational ROM/Stretching/Mobility: Wrist flexor stretch, wrist extensor stretch, triceps stretch

Intermediate Continue Foundational exercises Strengthening: Grip strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises Strengthening: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccentric strengthening Proprioception/Functional: Serratus punch, prone scapular retractions

Ligament Sprains

27

Recommended Exercises Foundational ROM/Stretching/Mobility: Biceps stretch, triceps stretch, forearm supinators stretch, forearm pronators stretch

Intermediate Continue Foundational exercises Strengthening: Biceps isometric strengthening, triceps isometric strengthening, radial and ulnar deviation strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening

Advanced Continue Foundational and Intermediate exercises Strengthening: Wrist extensors eccentric strengthening, wrist flexors eccentric strengthening Proprioception/Functional: Shoulder diagonal pattern A and B, serratus punch, prone scapular retractions

Distal Bicipital Tendinopathy

28

Recommended Exercises Foundational ROM/Stretching/Mobility: Wrist extensors stretch, wrist flexors stretch, biceps stretch, triceps stretch, forearm pronators stretch, forearm supinators stretch

xxii

LIST OF EXERCISES

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Intermediate Continue Foundational exercises Strengthening: Biceps isometric strengthening, triceps isometric strengthening, wrist extensors concentric strengthening, wrist flexor concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises Strengthening: Bicep curls, triceps extensions, biceps eccentric strengthening Proprioception/Functional: Shoulder diagonal pattern A and B, serratus punch, prone scapular retractions

Ulnar Neuropathy at the Elbow

29

Recommended Exercises Foundational ROM/Stretching/Mobility: Wrist flexors stretch, wrist extensors stretch, biceps stretch, triceps stretch, forearm supinators stretch, forearm pronators stretch, ulnar nerve glides 1 to 5

Intermediate Continue Foundational exercises Strengthening: Biceps isometric strengthening, triceps isometric strengthening, grip strengthening, Tyler twist

WRIST AND HAND De Quervain’s Tenosynovitis

49

Recommended Exercises Foundational ROM/Stretching/Mobility: Wrist extension active range of motion (AROM), wrist flexion AROM, isolated thumb interphalangeal joint (IPJ) flexion/extension

Intermediate Continue Foundational exercises Strengthening: APL isometric strengthening, EPB isometric strengthening

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Elbow flexion with Theraband, elbow extension with Theraband, scapular retraction with Theraband, shoulder extension with Theraband, external rotation with Theraband

LIST OF EXERCISES xxiii

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Carpal Tunnel Syndrome

50

Recommended Exercises Foundational ROM/Stretching/Mobility: Tendon gliding, median nerve glides

Advanced Continue Foundational exercises Proprioception/Functional: Scapular retraction with Theraband, shoulder extension with Theraband

Carpometacarpal Osteoarthritis

51

Recommended Exercises Foundational ROM/Stretching/Mobility: Thumb opposition, thumb adductor massage, “C” exercise, web space stretch

Advanced Continue Foundational exercises Strengthening: First dorsal interossei strengthening

Extensor Carpi Ulnaris Tendinopathy

52

Recommended Exercises Foundational Strengthening: ECU isometric strengthening, ECU synergy exercise, wrist extensors concentric strengthening, ulnar deviation strengthening

Intermediate Continue Foundational exercises Strengthening: Wrist extensors eccentric strengthening

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Scapular retraction with Theraband, shoulder extension with Theraband, external rotation with Theraband

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LIST OF EXERCISES

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HIP Hip Osteoarthritis

72

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking Strengthening: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises Strengthening: Squat, bridge

Advanced Continue Foundational and Intermediate exercises Strengthening: Forward step up, forward step down Proprioception/Functional: Single leg balance

Iliopsoas Tendinopathy/Bursitis

72

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, Iliotibial band (ITB) stretch, foam roller to hip area Strengthening: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises Strengthening: Squat, bridge, clamshell, hip clocks Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Monster walk, side plank, forward step up, forward step down Proprioception/Functional: Windmill, single leg squat

LIST OF EXERCISES xxv

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Greater Trochanteric Pain Syndrome

73

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, foam roller to hip area Strengthening: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises Strengthening: Squat, bridge, clamshell, hip clocks, hip hiker Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Monster walk, forward step down Proprioception/Functional: Windmill

Hamstring Strain and Tendinopathy

74

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking, foam roller to hip area Strengthening: Hamstring isometrics

Intermediate Continue Foundational exercises Strengthening: Squat, bridge

Advanced Continue Foundational and Intermediate exercises Strengthening: Eccentric hamstring throw downs, hamstring curl on stability ball, hip hiker, forward step up, forward step down Proprioception/Functional: Lunge, single leg deadlifts

xxvi

LIST OF EXERCISES

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Femoroacetabular Impingement and Labral Tears

75

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch, foam roller to hip area Strengthening: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises Strengthening: Squat, bridge, hip clocks, clamshell Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Monster walk, side plank, hip hiker, forward step up, forward step down Proprioception/Functional: Windmill, single leg squat

KNEE Knee Osteoarthritis

102

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension Strengthening: Quadriceps set, straight leg raise, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Knee flexion chair stretch Strengthening: Bridge, squat, squat on wedge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Forward step up, forward step down Proprioception/Functional: Single leg squat

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Patellofemoral Pain Syndrome

103

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch Strengthening: Quadriceps set, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises Strengthening: Squat, bridge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Side plank, forward step up, forward step down Proprioception/Functional: Single leg squat, single leg deadlift

Quadriceps and Patellar Tendinopathy

103

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch Strengthening: Quadriceps set, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises Strengthening: Squat, bridge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Side plank, forward step up, forward step down, squat on a wedge (Level 3) Proprioception/Functional: Single leg deadlift, windmill

xxviii LIST OF EXERCISES

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Knee Ligament Sprain

104

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quad stretch, hip flexor stretch or two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension Strengthening: Quadriceps set, terminal knee extension, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Knee flexion chair stretch Strengthening: Squat, bridge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Side plank, forward step up, forward step down Proprioception/Functional: Single leg deadlift, windmill

Meniscal Tear

105

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension Strengthening: Quadriceps set, terminal knee extension, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises ROM/Stretching/Mobility: Knee flexion chair stretch Strengthening: Squat, bridge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Side plank, forward step up, forward step down Proprioception/Functional: Single leg squat, single leg deadlift, windmill

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Iliotibial Band Syndrome

106

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch Strengthening: Side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises Strengthening: Squat, bridge Proprioception/Functional: Single leg balance

Advanced Continue Foundational and Intermediate exercises Strengthening: Side plank, forward step up, forward step down Proprioception/Functional: Single leg squat, single leg deadlift, windmill

ANKLE AND FOOT Ankle Sprain

130

Recommended Exercises Foundational ROM/Stretching/Mobility: Calf stretch A or B, alphabets Strengthening: Marble pick-ups

Intermediate Continue Foundational exercises Strengthening: Concentric ankle inversion strengthening, concentric ankle eversion strengthening, concentric ankle dorsiflexion strengthening

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Single leg taps, single leg tennis ball catch, wobble board

Achilles Tendinopathy

130

Recommended Exercises Foundational ROM/Stretching/Mobility: Foam roller (lower leg), towel stretch, calf stretch A or B, soleus stretch Strengthening: Towel scrunches

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Intermediate Continue Foundational exercises Strengthening: Heel raises

Advanced Continue Foundational and Intermediate exercises Strengthening: Eccentric Achilles strengthening Proprioception/Functional: Single leg taps, single leg tennis ball catch

Posterior Tibial Tendinopathy

131

Recommended Exercises Foundational ROM/Stretching/Mobility: Foam roller (lower leg), towel stretch, calf stretch A or B Strengthening: Towel scrunches

Intermediate Continue Foundational exercises Strengthening: Concentric ankle inversion strengthening, heel raises

Advanced Continue Foundational and Intermediate exercises Strengthening: Eccentric posterior tibial tendon strengthening Proprioception/Functional: Single leg taps, single leg tennis ball catch

Plantar Fasciosis

132

Recommended Exercises Foundational ROM/Stretching/Mobility: Can roll, towel stretch, plantar fascia stretch Strengthening: Towel scrunches, marble pick-ups

Intermediate Continue Foundational exercises Strengthening: Heel raises

Advanced Continue Foundational and Intermediate exercises Strengthening: Eccentric Achilles strengthening Proprioception/Functional: Single leg taps, single leg tennis ball catch

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CERVICAL SPINE Cervical Facet Arthropathy

144

Recommended Exercises Foundational ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises Strengthening: Cervical isometrics: retraction/lateral flexion/flexion, deep cervical flexor strengthening Proprioception/Functional: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

Cervical Disc Pathology

145

Recommended Exercises Foundational ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises Strengthening: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening Proprioception/Functional: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

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Cervical Radiculopathy

146

Recommended Exercises Foundational ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises Strengthening: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening Proprioception/Functional: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

Upper Crossed Posture

147

Recommended Exercises Foundational ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retraction (chin glide), suboccipital stretch, levator scapula stretch, upper trapezius stretch, pectoral stretch, suboccipital release, prone pectoral release, levator scapula release

Intermediate Continue Foundational exercises Strengthening: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening Proprioception/Functional: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

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THORACIC SPINE Thoracic Spine

171

Recommended Exercises Foundational ROM/Flexibility/Mobility: Supine diaphragmatic breath (belly breath), seated postural correction (Bruegger’s), lacrosse ball massage, prayer stretch, cat camel stretch, open book, trunk rotations, seated thoracic rotation

Intermediate Continue Foundational exercises ROM/Flexibility/Mobility: Thoracic rotation mobility (thread the needle) Strengthening: Kneeling thoracic rotation

Advanced Continue Foundational and Intermediate exercises Proprioception/Functional: Thoracic rotation with core stabilization, inchworm

LUMBAR SPINE Lumbar Facet Arthrosis

186

Recommended Exercises Foundational ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion, cat camel stretch, trunk rotations Strengthening: Abdominal bracing (or pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

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Lumbar Disc Pathology

187

Recommended Exercises Foundational ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch, (either one), piriformis stretch, prone extensions (as long as it lessens pain) Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, opposite arm/opposite leg (bird dog), monster walk

Advanced Continue Foundational and Intermediate exercises Strengthening: Plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

Lumbar Radiculopathy

188

Recommended Exercises for Extension-Biased Program Foundational ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either one), prone extensions, standing extensions, side glides or alternative side glides if patient has a lateral shift (leaning over to one side due to pain) Strengthening: Abdominal bracing (or pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises Strengthening: Bridge, clamshells, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

Recommended Exercises for Flexion-Biased Program Foundational ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion, side glides or alternative side glides if patient has a lateral shift (leaning over to one side due to pain) Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercises

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Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

Recommended Exercises for a Neutral Spine Program Foundational ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch (either one), piriformis stretch Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, opposite arm/opposite leg (bird dog), monster walk

Advanced Continue Foundational and Intermediate exercises Strengthening: Plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

Lumbar Spondylolysis/Spondylolisthesis

189

Recommended Exercises for Spondylolysis Foundational ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either one), prone quadriceps stretch, piriformis stretch Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, Swiss ball marching, opposite arm/opposite leg (bird dog)

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Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Single leg deadlift, warrior one pose, warrior two pose

Recommended Exercises for Spondylolisthesis Foundational ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either one), prone quadriceps stretch, piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Single leg deadlift, warrior one pose, warrior two pose

Lumbar Spinal Stenosis

190

Recommended Exercises Foundational ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either one), prone quadriceps stretch, piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, clamshells, Swiss ball marching, opposite arm/opposite leg (bird dog)

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Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Warrior one pose, warrior two pose

Lower Crossed Syndrome

191

Recommended Exercises Foundational ROM/Stretching/Mobility: Good morning stretch, prone quadriceps stretch, hamstring stretch (both), hip flexor stretch (both), piriformis stretch, single (double) knee(s) to chest, child’s pose, cat camel stretch, trunk rotations Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises Strengthening: Curl up, bridge, opposite arm/opposite leg (bird dog), Swiss ball marching

Advanced Continue Foundational and Intermediate exercises Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank Proprioception/Functional: Single leg deadlift, warrior one pose, warrior two pose

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Home Exercise Programs for Musculoskeletal and Sports Injuries: The Evidence-Based Guide for Practitioners

CHAPTER

1

Home Exercise Programs for Shoulder Injuries Jonathan Kirschner

INTRODUCTION The shoulder joint is really made up of four articulations: the glenohumeral joint, acromioclavicular joint, sternoclavicular joint, and the scapulothoracic articulation. The anatomy of the shoulder allows for multiplanar movement at variable speeds, facilitating climbing, throwing, and carrying activities. The greater mobility without significant bony stability places the soft tissues around the shoulder under greater stresses, however, and can make them more susceptible to injury. Regardless of the mechanism of injury, most shoulder rehabilitation follows similar principles (1). It is important to restore passive and then active range of motion as early as possible. Scapular strength, stability, and the timing of periscapular muscle firing should be a key therapeutic target, correcting for any scapular dyskinesia (2,3). Scapular retractor strengthening, pectoralis minor stretching, and inhibition of the upper trapezius can help with postural correction and alignment, maximize the function of the rotator cuff, and facilitate improved shoulder range of motion (4). Finally, rotator cuff strengthening is important to keep the humeral head depressed in the glenoid and minimize subacromial impingement (5).

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational •

Improvement of range of motion

Intermediate • •

Restoration of normal range of motion Initiation of strengthening of shoulder musculature

Advanced • •

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Restoration of strengthening with focus on scapular stabilizers Restoration of proprioceptive control of scapular stabilizers

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ROTATOR CUFF TENDINOPATHY Rotator cuff tendinopathy is typically a chronic overuse condition associated with subacromial impingement syndrome. In subacromial impingement syndrome, the humeral head migrates superiorly and impinges the supraspinatus tendon and subacromial-subdeltoid bursa underneath the acromion. Risk factors include weakness of the rotator cuff, serratus anterior, or lower trapezius muscles, or a type II or III acromion. Subacromial bursitis can present very similarly and can be differentiated with ultrasound or MRI, which typically are not needed unless symptoms become chronic and persistent. Rehabilitation strategies for all three conditions are similar and start with a focus on restoring proper range of motion and flexibility, particularly of the posterior capsule and pectoralis minor (6). The next focus is scapular strength and stability, postural correction, and rotator cuff strengthening, followed by dynamic and proprioceptive exercise. It is important to promote scapular retraction and strengthen the serratus anterior and lower trapezius early on, then progress to distal muscles (4). Outcomes with rehabilitation are typically equal to surgery (7).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, stick shoulder extension, stick overhead shoulder stretch, stick shoulder abduction

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Scaption STRENGTHENING: Low row, scapular retraction, straight-arm lateral pull down, push-up with a plus, abducted shoulder external rotation

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, stability ball plank, wall fall push-up

ACROMIOCLAVICULAR JOINT PATHOLOGY Acromioclavicular joint pathology is typically traumatic, in the form of fractures or sprains, “shoulder separations,” or degenerative, in the form of osteoarthritis. Acromioclavicular joint pathology can be painful with adduction and overhead activities, and there may be a degree of instability. Rehabilitation should focus on upper trapezius and deltoid strengthening, as these have been shown to help stabilize the joint (8). It is important to keep the acromion depressed to maximize its ability to upwardly rotate.

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, stick shoulder rotation, stick shoulder extension

Intermediate Continue Foundational exercises STRENGTHENING: Low row, straight-arm lateral pull down, external rotation with a Theraband

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, wall fall push-up

GLENOHUMERAL JOINT OSTEOARTHRITIS It is important to reduce pain and inflammation to facilitate an active rehabilitation program. It is helpful to know if the patient has primary glenohumeral osteoarthritis (GH-OA), or secondary GH-OA due to rotator cuff arthropathy, caused by complete tears of the rotator cuff leading to secondary instability and degenerative changes. Once pain is manageable, the initial step is to maximize passive joint range of motion using a combination of stretching, joint mobilizations, and other manual therapy. Then, active range of motion is initiated. Scapular stability is the next goal, using isometric exercises at first and progressing to concentric and eccentric strengthening. Rotator cuff strengthening is next, followed by functional and proprioceptive exercises.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, reverse sleeper stretch, broom pull, stick shoulder rotation, stick overhead stretch, scaption

Intermediate Continue Foundational exercises STRENGTHENING: Low row, straight-arm lateral pull down

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Push-up with a plus PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog

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GLENOHUMERAL JOINT INSTABILITY Patients may have glenohumeral instability from chronic multidirectional instability due to ligamentous laxity or acute traumatic dislocations. In the first two weeks after a dislocation, early gentle range of motion is recommended. Then gentle isometric rotator cuff strengthening and concentric strengthening of the scapular stabilizers are performed. Finally, dynamic and proprioceptive exercises are encouraged, especially resisting the planes of motion the patients tend to sublux or dislocate into.

Recommended Exercises Foundational STRENGTHENING: Isometric strengthening in all directions (external rotation, internal rotation, flexion, extension), scapular retraction

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Stick shoulder flexion, stick shoulder abduction, stick shoulder rotation STRENGTHENING: Low row, straight-arm lateral pull down, external rotation with a Theraband

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, wall ball push-up, stability ball planks, wall fall push-up

ADHESIVE CAPSULITIS/FROZEN SHOULDER Adhesive capsulitis, also known as frozen shoulder, can be primary (idiopathic) or secondary to trauma, surgery, medical illness, or other conditions leading to disuse followed by contracture. Primary frozen shoulder is characterized by an initial inflammatory process, followed by synovitis, capsular hypertrophy and contracture, leading to pain, stiffness, and loss of motion (9). Angiofibroplastic metaplasia is seen similar to Dupuytren’s disease of the hands, and may coexist in up to 20% patients in some studies. Similar to GH-OA, the progression of rehabilitation with adhesive capsulitis is reduce pain, restore motion, then improve strength. Rehabilitation for adhesive capsulitis can be a long process, with extra time required for joint range of motion prior to strengthening exercises.

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Stick shoulder abduction, stick shoulder rotation, stick overhead shoulder stretch, stick shoulder flexion

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Broom pull, stick shoulder extension STRENGTHENING: Low row, straight-arm lateral pull down

Advanced Continue Foundational and Intermediate exercises ROM/STRETCHING/MOBILITY: Scaption (with a weight or Theraband) STRENGTHENING: External rotation with a Theraband PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W”

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HANDOUTS ROM/Stretching/Mobility

Stick Overhead Shoulder Stretch POSITION: Supine STEP 1: Lay on your back with a stick (broom or cane) held overhead. STEP 2: Lower your hands over your head and feel the stretch. STEP 3: Try to keep the back of your shoulders against the bench (or floor) and your core tightened throughout the movement. STEP 4: Hold for 5 to 10 seconds. STEP 5: Raise your arms overhead and repeat. REPS: Repeat 8 to 10 times. SETS: Three sets FREQUENCY: 3 to 5 times per week

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Stick Shoulder Abduction POSITION: Standing or supine (on back) STEP 1: Grab a stick (broom or cane) with palm on right hand pointing away from the body and with left palm facing the body, keeping your elbows straight and placed at your side.

STEP 2: Use the left arm to push the right arm up as high as it will go to the right side. STEP 3: Slowly lower the right and left arms and repeat to the left side, switching the hand position such that the left palm is away from the body and the right palm is facing the body.

REPS: Repeat 10 to 15 times to each side. SETS: Three sets FREQUENCY: 3 to 5 times per week

Stick Shoulder Rotation POSITION: Standing or supine (on back) STEP 1: Grab a stick (broom or cane) or towel with both hands, keeping your elbows bent to 90° and placed at your side.

STEP 2: Rotate your hands all the way to the right, then all the way to the left.

REPS: Repeat 10 to 15 times. SETS: Three sets FREQUENCY: 3 to 5 times per week

Copyright Springer Publishing Company

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Stick Shoulder Extension POSITION: Standing STEP 1: Hold a stick (can be a broom or cane) behind your back and extend your arms behind you.

STEP 2: Keep your shoulder blades squeezed together, and feel your chest muscles stretch, while avoiding tension and pain in your shoulders.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Broom Pull POSITION: Standing STEP 1: Grab a broomstick or towel with both hands, one above your head and one behind your back.

STEP 2: Pull with the top hand, feeling the lower arm and shoulder stretch. REPS: Hold for 15 to 30 seconds, then repeat with the other arm. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Stick Shoulder Flexion POSITION: Seated STEP 1: Hold a stick (broom or cane) upright in front of you.

STEP 2: Lean forward onto the stick, feeling your shoulders stretch in flexion.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Corner Stretch POSITION: Standing STEP 1: Place your arms bent at your side and lean into a corner of a room or alternatively a doorway. STEP 2: Squeeze your shoulder blades together and feel your chest muscles stretch, while avoiding tension and pain in your shoulders.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Copyright Springer Publishing Company

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Sleeper Stretch POSITION: Side lying STEP 1: Lay on the side of your affected shoulder with your shoulder blade against the laying surface and your shoulder and elbow bent at 90°.

STEP 2: Use your opposite hand to press your forearm down and feel the back of your symptomatic shoulder stretch.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Reverse Sleeper Stretch POSITION: Side lying STEP 1: Lay on the side of your affected shoulder with your shoulder blade against the laying surface and your shoulder and elbow bent at 90°.

STEP 2: Use your opposite hand to press your forearm up and feel the front of your symptomatic shoulder stretch.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Level 2

Level 3

Scaption POSITION: Standing STEP 1: Bring hands 20° to 30° in front of you with thumbs pointed toward the ceiling. STEP 2: Slowly raise hands overhead, while trying to keep your shoulders down and your shoulder blades and core activated.

STEP 3: Slowly return to starting position as in Step 1. REPS: Repeat 8 to 10 times. SETS: Three sets FREQUENCY: 3 to 5 times per week LEVEL 2: Add 1 or 2 lb weight. LEVEL 3: Stand in the middle of a Theraband and grab its ends.

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Strengthening Isometric Strengthening—External Rotation POSITION: Standing STEP 1: Bend elbow. STEP 2: Push outside of hand against doorway, while keeping elbow tucked into side.

STEP 3: Hold for a count of 5 to 10 seconds. STEP 4: Relax for 5 seconds. REPS: Repeat 8 to 10 times. SETS: One to three sets FREQUENCY: 3 to 5 times per week

Isometric Strengthening—Internal Rotation POSITION: Standing STEP 1: Bend elbow. STEP 2: Push inside of hand against doorway, while keeping elbow tucked into side.

STEP 3: Hold for a count of 5 to 10 seconds. STEP 4: Relax for 5 seconds. REPS: Repeat 8 to 10 times. SETS: One to three sets FREQUENCY: 3 to 5 times per week

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Isometric Strengthening—Flexion POSITION: Standing STEP 1: Keep arm straight. STEP 2: Push palm of hand against doorway, while keeping arm close to body. STEP 3: Hold for a count of 5 to 10 seconds. STEP 4: Relax for 5 seconds. REPS: Repeat 8 to 10 times. SETS: One to three sets FREQUENCY: 3 to 5 times per week

Isometric Strengthening—Extension POSITION: Standing STEP 1: Keep arm straight. STEP 2: Push back of hand against doorway, while keeping arm close to body. STEP 3: Hold for a count of 5 to 10 seconds. STEP 4: Relax for 5 seconds. REPS: Repeat 8 to 10 times. SETS: One to three sets FREQUENCY: 3 to 5 times per week

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Scapular Retraction POSITION: Standing STEP 1: Squeeze shoulder blades together as if you were trying to hold a tennis ball between blades. STEP 2: Hold for a count of 5 to 10 seconds. STEP 3: Relax for 5 seconds. REPS: Repeat 8 to 10 times. SETS: One to three sets FREQUENCY: 3 to 5 times per week

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Level 2

Low Row POSITION: Standing or seated on stability ball STEP 1: Attach a Theraband to a solid object. STEP 2: Squeeze your shoulder blades together, then reach backward with your elbows, pulling the Theraband toward you.

STEP 3: Allow the Theraband to retract forward again, but keep engaging your shoulder blades together. REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week LEVEL 2: Putting left arm and left knee on a bench (or can use exercise ball) with weight in right hand, bring weight to chest; then perform to left side when done with set.

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Straight-Arm Lateral Pull Down POSITION: Standing or seated on stability ball STEP 1: Attach a Theraband to a solid object. STEP 2: Squeeze your shoulder blades together, then reach backward with your elbows, pulling the Theraband toward you.

STEP 3: Allow the Theraband to retract forward again, but keep engaging your shoulder blades together. REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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Push-Up With a “Plus” POSITION: Standing, in push-up position, or push-up position on knees STEP 1: Get into a push-up position or remain standing and leaning against a wall. STEP 2: Activate your core. STEP 3: Do a push-up. STEP 4: At the top of the push-up, add a “plus” by pushing your shoulder blades out as far out as possible (protraction).

REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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External Rotation With a Theraband POSITION: Standing or seated on an exercise ball STEP 1: Use a Theraband or cable machine. STEP 2: Squeeze your shoulder blades together, while activating your core. STEP 3: Slowly rotate your arms outward, while keeping your elbows at your side. STEP 4: Slowly return to the starting position, trying to keep constant tension on the Theraband or cable. REPS: Repeat 10 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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Abducted Shoulder External Rotation POSITION: Seated on stability ball STEP 1: Use a Theraband anchored under your feet or a low cable machine. STEP 2: Bring your arms to shoulder height with your elbows bent at 90°. STEP 3: Rotate your hands backward so that your forearm is perpendicular to the ground at the top of the movement. STEP 4: Slowly lower your hands to the start, maintaining resistance at all times. REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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Proprioception/Functional

Prone “T,” “Y,” “I,” “W” POSITION: Face down on the floor with a towel under the forehead STEP 1: Engage the gluteal and abdominal muscles by drawing the belly button toward the spine. STEP 2: Place the arms straight out to the side at a 90° angle with the body and with thumbs up toward the ceiling. STEP 3: Draw the shoulder blades down and back, elevate the arms off the floor, and hold for a three count. STEP 4: Proceed to elevate the arms at progressive levels, resembling the letters “Y” and “I” before bending the elbows and bringing the arms to the side to make a “W”.

STEP 5: Hold all four positions for a three count with the thumbs pointed up toward the ceiling. STEP 6: Reset the gluteals, abdominals, and shoulder blades, and repeat. REPS: Repeat 3 to 5 times. SETS: Two to three FREQUENCY: 3 to 5 times per week NOTE: T and Y are likely of most value and should be concentrated on.

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Stability Ball Bird Dog POSITION: Prone on a stability ball STEP 1: Lay on your upper chest with your hands and feet in a “push-up” position.

STEP 2: Activate your core. STEP 3: Raise your right arm and left leg off the ball, then lower back to the ground.

STEP 4: Alternate by raising your left arm and right leg, trying to keep your trunk stable.

REPS: Repeat 10 to 15 times on each side. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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Wall Ball Push-Up POSITION: Standing STEP 1: Stand against a ball on a wall with your arm at shoulder level in a “push-up” position. STEP 2: Activate your core. STEP 3: Do a push-up with one or both arms. REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

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Stability Ball Plank POSITION: Plank STEP 1: Get into a plank position on a stability ball. STEP 2: Activate your core. STEP 3: Hold for 30 seconds. REPS: Repeat 3 to 5 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week

Wall Fall Push-Up POSITION: Standing STEP 1: Stand 6 to 12 inches from a wall, feet can be staggered (easier) or parallel (harder). STEP 2: Lean forward, bend your elbows, and keep your hands just below shoulder level. STEP 3: Fall forward onto your fingertips in a controlled manner. STEP 4: Do a 1/2 push-up propelling your hands off the wall, back to the starting position. STEP 5: Lean forward again and repeat. REPS: Repeat 10 to 15 times. SETS: Three to five sets FREQUENCY: 3 to 5 times per week LEVEL 2: To make this more challenging, stand 2 feet from the wall and do a complete push-up.

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REFERENCES 1. Kibler. WB. Shoulder rehabilitation: principles and practice. Med Sci Sports Exerc. 1998; 30(4 Suppl):S40–S50. doi:10.1097/00005768-199804001-00007. 2. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44(5):319–327. doi:10.1136/ bjsm.2009.058875. 3. Cools A, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance which exercises to prescribe? Am J Sports Med. 2007;35(10):1744–1751. doi:10.1177/0363546507303560. 4. Kibler BW, Sciasia A. Current concepts: scapular dyskinesis. Br J Sports Med. 2010;44:300– 305. doi:10.1136/bjsm.2009.058834. 5. Morrison DS, Frogameni AD, Woodworth P. Non-operative treatment of subacromial impingement syndrome. J Bone Joint Surg Am. 1997;79(5):732–737. doi:10.2106/00004623-199705000-00013. 6. Turgut E, Duzgun I, Baltaci G. Stretching exercises for shoulder impingement syndrome: effects of 6-week program on shoulder tightness, pain and disability status. J Sport Rehabil. 2017;1–20. doi:10.1123/jsr.2016-0182. 7. Haahr JP, Ostergaard S, Dalsgaard J, et al. Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Ann Rheum Dis. 2005;64:760–764. doi:10.1136/ard.2004.021188. 8. Beim GM. Acromioclavicular joint injuries. J Athl Train. 2000;35:261–267. PubMed PMID: 16558638. 9. Tamai K, Akutsu M, Yano Y. Primary frozen shoulder: brief review of pathology and imaging abnormalities. J Orthop Sci. 2014;19(1):1–5. doi:10.1007/s00776-013-0495-x.

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CHAPTER

2

Home Exercise Programs for Elbow Injuries John Gallucci, Jr. and Taylor Rossillo

INTRODUCTION Injuries to the elbow and its supporting structures occur frequently and result in significant loss of function, as well as missed time from athletics, work, and daily activities. As a result, economic burden in the form of lost workdays, healthcare costs, and work disability claims ensues. These injuries may be acute or chronic in nature and are commonly seen and studied in the overhead athlete, in sports that involve motions such as throwing, hitting, serving, and spiking (1–4). However, in recent years, injuries to the elbow have grown in occurrence among working-age individuals between the ages of 30 and 64, specifically in manual laborers, current or former smokers, and/or obese individuals (1,2,4). The mechanism of injury, whether it be in the athletic population, such as a baseball pitcher or tennis player, or in the working population, such as a construction worker who utilizes a hammer and screwdriver daily, can be attributed to the repetitive motion of the arm with or without application of force. The rehabilitative process following an elbow injury or surgery is a multiphase approach. This process begins with controlling pain and inflammation, and then progresses to restoring range of motion (ROM), flexibility, muscular strength and endurance, balance and proprioception, and cardiovascular endurance. It will conclude following the ultimate goal of returning the patient to functional, work, and sport-specific exercise. Benchmarks to be met along the way are regaining full flexion and extension at the elbow and wrist joints and increasing the strength of the supporting musculature, such as the biceps and triceps brachii and the flexor and extensor muscles of the forearm (5,6).

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • •

Restoration of ROM and flexibility Initiation of strengthening wrist extensors and flexors (lateral and medial epicondylosis)

Intermediate •

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Advanced • •

Restoration of strengthening, including eccentric strengthening if not already done Development of proximal musculature and scapular stabilizers

LATERAL EPICONDYLOSIS Lateral epicondylosis, also known as tennis elbow, lateral epicondylalgia, and lateral epicondylitis, is a common pathology among athletes and nonathletes and has an annual occurrence of 1% to 3% in the general population (2,4,7). Lateral epicondylosis, as its pseudo name implies, has a high association with tennis and the one-handed backstroke, but is also commonly seen in other athletics and some occupations where repetitive wrist extension occurs. Due to the complexities associated with the anatomy and biomechanics of the elbow and the lack of scientific evidence to support any treatment protocol, there is a lack of consensus on the best treatment plan. However, many practitioners agree that a conservative, nonoperative management plan including rest, ice, compression, elevation (RICE); nonsteroidal anti-inflammatory drugs (NSAIDs); technique modifications (in sport and work task ergonomics); and physical therapy aimed at stretching and more specifically strengthening the extensors of the forearm and the posterior muscles in the shoulder is the plan of choice and has shown a successful resolution of symptoms in 90% of patients within 6 to 12 months (2–5,7,8). Eccentric strengthening exercises may show greater benefit than the concentric strengthening or stretching portion of exercise (3). The use of steroidal injections did improve short-term patient outcomes, but at the 12-month point, the results were equal (compared to placebo) (4) and platelet-rich plasma (PRP) injections have shown greater long-term benefit compared to steroid injections (9). Additionally, surgical intervention was suggested in the literature only for patients showing no relief following 6 to 12 months of conservative treatment: that is, in about 5% of the population (2).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Wrist flexor stretch, wrist extensor stretch, triceps stretch

Intermediate Continue Foundational exercises STRENGTHENING: Grip strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises

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STRENGTHENING: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccentric strengthening PROPRIOCEPTION/FUNCTIONAL: Serratus punch, prone scapular retractions

MEDIAL EPICONDYLOSIS Medial epicondylosis, also known as golfer’s elbow, medial epicondylalgia, and medial epicondylitis, is less common than its lateral counterpart, affecting less than 1% of the general population, and presents with repetitive or forceful wrist flexion activities (4,10). Despite the eponym “golfers elbow,” this pathology is most common in throwing athletes, specifically baseball players, where the elbow’s medial structures sustain the most amount of stress and account for up to 97% of all elbow injuries (4). Treatment of medial epicondylosis parallels that of the above-mentioned principles of lateral epicondylosis with conservative, nonoperative treatment at the forefront. In contrast, medial epicondylosis rehabilitation should focus on the flexor muscles of the wrist (4,11).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Wrist flexor stretch, wrist extensor stretch, triceps stretch

Intermediate Continue Foundational exercises STRENGTHENING: Grip strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccentric strengthening PROPRIOCEPTION/FUNCTIONAL: Serratus punch, prone scapular retractions

LIGAMENT SPRAINS Ligamentous sprains of the elbow, in particular the medial (ulnar) collateral ligament, occur most often in the athletic population, especially in the overhead or throwing athlete, as a result of overuse (12). Treatment of a ligament sprain, in cases of early intervention and treatment, typically involves a conservative, nonoperative treatment plan developed around each individual’s demands and degree of injury. Surgical intervention (i.e., Tommy John surgery) and lengthened rehabilitation timelines are introduced when a ligament sprain is left untreated and develops into a complete ligament tear or the nonoperative

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treatment plan is not successful. In either course of action, operative versus nonoperative, rehabilitation focuses on ROM of the wrist, elbow, and shoulder region primarily, followed by muscular strengthening and endurance, technique modification, and a carefully supervised throwing program in athletes such as baseball pitchers and football quarterbacks (12,13).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Biceps stretch, triceps stretch, forearm supinators stretch, forearm pronators stretch

Intermediate Continue Foundational exercises STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, radial and ulnar deviation strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Wrist extensors eccentric strengthening, wrist flexors eccentric strengthening PROPRIOCEPTION/FUNCTIONAL: Shoulder diagonal pattern A and B, serratus punch, prone scapular retractions

DISTAL BICIPITAL TENDINOPATHY Distal biceps tendinitis or tendinosis is rarely seen and is a relatively uncommon diagnosis, especially when compared with the incidence of injury that occurs in the proximal tendon (4,14,15). Little evidence has been compiled, due to the uncommon clinical diagnosis, regarding effective treatment and rehabilitative plans. Recent research shows the effectiveness of eccentric training in tendinopathies in other areas of the body, such as the Achilles and patellar tendons, which leads clinicians to believe that eccentric training for the distal biceps tendinosis diagnosis is advantageous (14). Partial tears and complete avulsions are a more common pathology of a distal bicep tendon injury (4,14). Surgical intervention is most commonly utilized following a tear or avulsion. Rehabilitation focuses on passive elbow flexion and forearm pronation and supination initially, and progresses to active ROM exercises focusing on full ROM and minimizing the formation of scar tissue. Strength training exercises, specifically eccentric strength training, are gradually introduced, with the main focus on the biceps brachii and forearm pronator and supinator musculature (4,14,15).

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Wrist extensors stretch, wrist flexors stretch, biceps stretch, triceps stretch, forearm pronators stretch, forearm supinators stretch

Intermediate Continue Foundational exercises STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, wrist extensors concentric strengthening, wrist flexors concentric strengthening, forearm pronators and supinators strengthening

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Bicep curls, triceps extensions, biceps eccentric strengthening PROPRIOCEPTION/FUNCTIONAL: Shoulder diagonal pattern A and B, serratus punch, prone scapular retractions

ULNAR NEUROPATHY AT THE ELBOW Ulnar neuropathy at the elbow is the second most common entrapment neuropathy following carpal tunnel syndrome (16). Most commonly seen in patients with occupations that require prolonged periods of elbow flexion, ulnar neuropathy can be painful and debilitating if left untreated. Treatment ranges from conservative options, such as splinting devices, physical therapy, and activity modification, to surgical options followed by a rehabilitation protocol (15,16). Rehabilitation focuses on regaining full ROM at the shoulder, elbow, and wrist joints through passive and active stretching and strengthening exercises of the wrist flexors and extensors, as well as forearm pronator and supinator musculatures. It should be noted, however, that strengthening exercises should not be performed unless the patient is pain free.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Wrist flexors stretch, wrist extensors stretch, biceps stretch, triceps stretch, forearm supinators stretch, forearm pronators stretch, ulnar nerve glides 1–5

Intermediate Continue Foundational exercises STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, grip strengthening, Tyler twist

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HANDOUTS ROM/Stretching/Mobility

Wrist Flexors Stretch POSITION: Standing STEP 1: With palm facing the ceiling, grasp fingers on the palm side with opposite hand and slowly straighten elbow. STEP 2: Pull fingers and wrist down and back toward yourself until a stretch is felt. REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Wrist Extensors Stretch POSITION: Standing STEP 1: With palm facing the ground, grab the top side of fingers/hand and slowly straighten elbow.

STEP 2: Pull fingers and wrist down and back toward yourself until a stretch is felt.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Triceps Stretch POSITION: Sitting or Standing STEP 1: Raise both hands above your head. STEP 2: Bend arm at the elbow until hand is resting behind head. STEP 3: Grasp your elbow with opposite hand and gently pull. REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Biceps Stretch POSITION: Seated in a chair STEP 1: Place elbow on the edge of a table with palm facing the ceiling. STEP 2: Straighten elbow by applying a downward pressure on wrist/hand until a stretch is felt.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Forearm Supinators Stretch POSITION: Seated in a chair STEP 1: Flex elbow to 90°, rest wrist on the edge of the table, and place hand in a handshake position.

STEP 2: Using the opposite hand, grasp the involved hand and slowly rotate to a palm facing down position until a stretch is felt.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Forearm Pronators Stretch POSITION: Seated in a chair STEP 1: Flex elbow to 90°, rest wrist on the edge of the table, and place hand in a handshake position.

STEP 2: Using the opposite hand, grasp the involved hand and slowly rotate to a palm facing up position until a stretch is felt.

REPS: Hold for 30 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Ulnar Nerve Glide 1 POSITION: Standing STEP 1: Bend elbow with arm out to your side and palm facing outward. STEP 2: Actively bend wrist back (toward your ear). STEP 3: Straighten wrist back to neutral position. REPS: Perform 10 times. SETS: One set FREQUENCY: 2 to 3 times per day, 3 to 4 times per week

Ulnar Nerve Glide 2 POSITION: Standing STEP 1: Hold arm straight out in front of you with wrist extended (fingers pointing up), as if you are saying stop. STEP 2: Bend elbow and touch shoulder. STEP 3: Extend arm out into stop position. REPS: Perform 10 times. SETS: One set FREQUENCY: 2 to 3 times per day, 3 to 4 times per week

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Ulnar Nerve Glide 3 POSITION: Standing STEP 1: Raise arm out to side with wrist in extension, as if you are saying stop. STEP 2: Bend elbow in toward you and bend wrist away from you simultaneously. STEP 3: Return to starting “stop” position. REPS: Perform 10 times. SETS: One set FREQUENCY: 2 to 3 times per day, 3 to 4 times per week

Ulnar Nerve Glide 4 POSITION: Standing STEP 1: Begin with arm flush against side of body. STEP 2: Raise arm out to the side with palm facing outward. STEP 3: At the halfway mark, start to bend arm with hand aiming for the ear. STEP 4: Place hand over ear. STEP 5: Return to starting position by slowly lowering the arm. REPS: Perform 10 times. SETS: One set FREQUENCY: 2 to 3 times per day, 3 to 4 times per week 34

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Ulnar Nerve Glide 5 POSITION: Standing STEP 1: Begin with arm at side with thumb touching pointer finger making the “OK” sign. STEP 2: Raise extended arm up out to the side. STEP 3: At the halfway mark, bend your arm toward your face. STEP 4: Place your “OK” sign on your face with the “O” over your eye and the remaining fingers flat against your cheek. STEP 5: Return to starting position by slowly lowering the arm. REPS: Perform 10 times. SETS: One set FREQUENCY: 2 to 3 times per day, 3 to 4 times per week

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Strengthening Biceps Isometric Strengthening POSITION: Standing STEP 1: Press elbow lightly into side and flex arm to 90° with palm facing upward. STEP 2: Place opposite hand on top of the palm facing up. STEP 3: Provide a downward resistance with the top hand and push upward with the bottom hand.

STEP 4: Hold for 5 to 10 seconds, then relax. REPS: Perform 10 times. SETS: One set with 15 seconds between each rep FREQUENCY: 3 to 4 times per week

Triceps Isometric Strengthening POSITION: Standing STEP 1: Press elbow lightly into side and flex arm to 90° with hand in fist facing inward. STEP 2: Place opposite hand on the bottom of hand in fist. STEP 3: Provide an upward resistance with the bottom hand and push downward with the top hand.

STEP 4: Hold for 5 to 10 seconds, then relax. REPS: Perform 10 times. SETS: One set with 15 seconds between each rep FREQUENCY: 3 to 4 times per week

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Grip Strengthening POSITION: Sitting or Standing STEP 1: Using a rubber ball (or tennis ball), squeeze and hold for up to 60 seconds and then release and relax.

SETS: Three sets with work to rest ratio equal FREQUENCY: 3 to 4 times per week

Wrist Extensors Concentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move. STEP 2: Hold a light weight in hand with your palm facing down. STEP 3: Slowly raise wrist/hand up toward the ceiling over a 5-second count. STEP 4: Once you have reached the furthest point, use your opposite hand to lower your wrist/hand back to the starting position.

REPS: Perform 10 times. SETS: Three sets with seconds between sets FREQUENCY: 3 to 4 times per week

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Wrist Flexors Concentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move.

STEP 2: Hold a light weight in hand with your palm facing up.

STEP 3: Slowly raise wrist/hand up toward the ceiling over a 5-second count.

STEP 4: Once you have reached the furthest point, use your opposite hand to lower your wrist/hand back to the starting position.

REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

Biceps Curls POSITION: Standing with feet shoulder width apart and back and elbows straight STEP 1: Hold weight in hand(s) with palm facing away from you. STEP 2: Slowly bend elbow, bringing hand with weight toward shoulder, then return to starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Triceps Extensions POSITION: Lying on back STEP 1: Fully extend arms so that arms are perpendicular to the floor. STEP 2: Hold a weight in hand(s) with fist facing inward. STEP 3: Slowly lower the weight, bending at the elbow, toward your ears making sure to keep your shoulders stationary and your elbows tucked in. Return to the starting position by extending forearms at the elbows while still keeping shoulders stationary.

REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Radial and Ulnar Deviation Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move. STEP 2: Hold a light weight in your hand with your thumb pointing upward. STEP 3: Slowly move your hand up and then down, holding for a couple of seconds at each end point. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

Wrist Extensors Eccentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move. STEP 2: Hold a light weight in hand with your palm facing down. STEP 3: Use opposite hand to bend wrist/hand up toward the ceiling as far as you can go. STEP 4: Let go of hand and slowly lower the wrist/hand over a 5-second count. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Wrist Flexors Eccentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move.

STEP 2: Hold a light weight in hand with your palm facing up.

STEP 3: Use opposite hand to bend wrist/hand up toward the ceiling as far as you can go.

STEP 4: Let go of hand and slowly lower the wrist/hand over a 5-second count.

REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

Biceps Eccentric Strengthening POSITION: Standing with feet shoulder width apart, back straight with elbow bent, and hand near shoulder STEP 1: Place a light weight in hand with palm facing you. STEP 2: Slowly lower hand until elbow is straight. STEP 3: Use hand without weight to bring desired hand back to starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Tyler Twist POSITION: Standing STEP 1: Hold the FlexBar in involved hand with wrist bent back in full extension; elbow should be flexed and resting against your side.

STEP 2: Grab the other end of the FlexBar with your opposite hand. STEP 3: With the hand on top of the FlexBar twist your hand away from you, while maintaining the wrist extension in the bottom hand.

STEP 4: Bring your hands out in front of you, such that they are parallel to the floor, while maintaining the twist in the FlexBar.

STEP 5: Slowly allow the bar to untwist by allowing the involved wrist to move into flexion. REPS: Perform 15 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 4 to 5 times per week

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Forearm Pronators and Supinators Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move.

STEP 2: Hold a light weight (a hammer also works well) in your hand with your thumb pointing upward.

STEP 3: Slowly rotate the wrist inward as far as possible and then outward as far as possible while holding at each end point for a few seconds.

REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Proprioception/Functional

Shoulder Diagonal Pattern A (D2 Flexion) POSITION: Standing with feet shoulder width apart STEP 1: Hold tubing in one hand in front of your opposite side hip with palm facing inward. STEP 2: Raise your arm, moving across your body to the opposite side, stopping slightly above shoulder level with your palm facing outward.

STEP 3: Slowly lower the arm, moving across the body to your starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Shoulder Diagonal Pattern B (D2 Extension) POSITION: Standing with feet shoulder width apart STEP 1: Hold tubing in one hand overhead and out to the side slightly above shoulder level with palm facing outward.

STEP 2: Lower your arm, moving across your body to the opposite side, stopping when your hand is resting near your hip with your palm facing inward.

STEP 3: Slowly raise the arm, moving across your body to your starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Serratus Punch POSITION: Lying down on back STEP 1: Raise arms out in front of you with elbows straight and fists pointing toward ceiling (may hold light weight in hands). STEP 2: Raise the fists toward the ceiling, keeping the arms straight and the back flat against the floor. (The shoulders should come off the floor a couple of inches.)

STEP 3: Hold at the top for 2 seconds and then slowly lower to starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds in between sets FREQUENCY: 3 to 4 times per week

Prone Scapular Retractions POSITION: Lying on stomach with arms out to side and bent to 90° STEP 1: Squeeze your shoulder blades together by raising your arms and elbows toward the ceiling and keep your chest and forehead touching the floor or table at all times.

STEP 2: Hold at top for 2 seconds and then slowly lower to starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds in between sets FREQUENCY: 3 to 4 times per week

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REFERENCES 1. Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065–1074. doi:10.1093/aje/kwj325. 2. Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: one size does not fit all. J Orthop Sports Phys Ther. 2015;45(11):938–949. doi:10.2519/jospt.2015.5841. 3. Ellenbecker TS, Nirschl R, Renstrom P. Current concepts in examination and treatment of elbow tendon injury. Sports Health. 2013;5(2):186–194. doi:10.1177/1941738112464761. 4. Taylor SA, Hannafin JA. Evaluation and management of elbow tendinopathy. Sports Health. 2012;4(5):384–393. doi:10.1177/1941738112454651. 5. Wilk KE, Arrigo C, Andrews JR. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther. 1993;17(6):305–317. doi:10.2519/jospt.1993.17.6.305. 6. Gallucci J. Soccer Injury Prevention and Treatment: A Guide to Optimal Performance for Players, Parents and Coaches. New York, NY: Demos Medical Publishing, LLC; 2014. 7. Howitt SD. Lateral epicondylosis: a case study of conservative care utilizing ART and rehabilitation. J Can Chiropr Assoc. 2006;50(3):182–189. doi:0008-3194/2006/182-189. 8. Inagaki K. Current concepts of elbow-joint disorders and their treatment. J Orthop Sci. 2013;18(1):1–7. doi:10.1007/s00776-012-0333-6. 9. Peerbooms JC, Sluimer J, Bruijn DJ, et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: plateletrich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255–262. doi:10.1177/0363546509355445. 10. Descatha A, Leclerc A, Chastang JF, et al. Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. J Occup Environ Med. 2003;45(9):993–1001. doi:10.1097/01.jom.0000085888.37273.d9. 11. Tyler TF, Nicholas SJ, Schmitt BM, et al. Clinical outcomes of the addition of eccentrics for rehabilitation of previously failed treatments of golfers elbow. Int J Sports Phys Ther. 2014;9(3):365–370. PubMed PMID: 24944855. 12. Rahman RKK, Levine WN, Ahmad CS. Elbow medial collateral ligament injuries. Curr Rev Musculoskelet Med. 2008;1(3/4):197–204. doi:10.1007/s12178-008-9026-3. 13. Rettig AC, Sherrill C, Snead DS, et al. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med. 2001;29(1):15–17. doi:10.1177/0363546501029 0010601. 14. Jayaseelan DJ, Magrum EM. Eccentric training for the rehabilitation of a high level wrestler with distal biceps tendinosis: a case report. Int J Sports Phys Ther. 2012;7(4):413–424. PubMed PMID: 22893861. 15. Chew ML, Giuffrè BM. Disorders of the distal biceps brachii tendon. Radiographics. 2005;25(5):1227–1237. doi:10.1148/rg.255045160. 16. Padua L, Caliandro P, Torre GL, et al. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2007;(2):CD006839. doi:10.1002/14651858.cd006839.

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CHAPTER

3

Home Exercise Programs for Wrist and Hand Injuries Julia Doty

INTRODUCTION Musculoskeletal injuries of the hand and wrist can be complex to treat due to the inability to fully rest the hand. Practitioners should avoid symptom-provoking motions and discourage any aggravating activities of daily living (ADLs). Patient education on activity modification and ergonomics is critical for managing these injuries. Pain-free therapeutic exercises play an important role in restoring the functional use of the hand. Splinting may be a useful option for symptom relief, rest, or support. Proximal strengthening and posture should always be assessed and any deficits treated when dealing with the hand and wrist. General rehabilitation principles of decreasing pain, improving range of motion, restoration of strength, and return to all ADLs and sports should be applied to the hand and wrist.

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • •

Restoration of range of motion and flexibility Initiation of strengthening for tendinopathy

Intermediate •

Progression of strengthening and initiation of eccentrics

Advanced • •

Restoration of strengthening, including eccentric strengthening if not already done Development of proximal musculature and scapular stabilizers

DE QUERVAIN’S TENOSYNOVITIS Timelines and healing vary. However, general principles of rest/immobilization, patient education on activity modification, and progression to pain-free active range of motion (AROM) and strengthening exercises should be followed

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(1). A forearm-based thumb spica splint that leaves the interphalangeal joint (IPJ) free is recommended to allow for rest and pain-free use of the involved hand (1). Education on avoiding thumb composite flexion and extension with radial and ulnar deviation is essential for full recovery. Activities such as gripping, pinching, and twisting should also be avoided as the tissues are healing (2). Exercises should include pain-free isolated wrist flexion/extension AROM, thumb isolated IPJ flexion/extension, and isometric strengthening of abductor pollicis longus (APL) and extensor pollicis brevis (EPB). Proximal strengthening of the elbow, shoulder, and scapular stabilizers should be initiated immediately as long as the thumb and wrist are in the proper position when performing these exercises (1,2). Eccentric strengthening of the APL and EPB is not typically used for De Quervain’s tenosynovitis due to risk of causing reoccurrence of pain and/or injury (1).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Wrist extension AROM, wrist flexion AROM, isolated thumb IPJ flexion/extension

Intermediate Continue Foundational exercises STRENGTHENING: APL isometric strengthening, EPB isometric strengthening

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Elbow flexion with Theraband, elbow extension with Theraband, scapular retraction with Theraband, shoulder extension with Theraband, external rotation with Theraband

CARPAL TUNNEL SYNDROME Carpal tunnel syndrome (CTS) is the most common upper extremity compressive neuropathy. Patient education about exercises and positions to avoid is essential. Proper ergonomics should be discussed, including chair height, keyboard angle, and mouse use (3). Patients should also be instructed in minimizing repetitive finger flexion and keeping the wrist in a neutral position. Literature has also shown that nighttime splinting can provide symptom relief with patients with mild CTS (3). Splinting with the wrist in a neutral position can decrease carpal canal pressure, maximizing blood flow to the median nerve (3). Lumbrical incursion into the carpal tunnel when the fingers flex or relax may increase carpal canal pressure. A splint with the metacarpophalangeal joints (MCPJs) in extension and wrist in neutral position can prevent lumbrical migration into the carpal tunnel with finger grasp (3). Tendon and nerve gliding can be beneficial to maximize the excursion of the digital flexors and the median nerve through the carpal tunnel as long as symptoms of tingling and

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numbness are not reproduced (3–5). Avoid repetitive gripping and pinching, such as the use of putty, balls, or grippers. If weakness is present in the digital flexors, isometric strengthening to the affected muscles could be initiated as long as symptoms of tingling and/or numbness in the median nerve distribution are not reproduced (3). Proximal strengthening and postural reeducation should be introduced as well.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Tendon gliding, median nerve glides

Advanced Continue Foundational exercises PROPRIOCEPTION/FUNCTIONAL: Scapular retraction with Theraband, shoulder extension with Theraband

CARPOMETACARPAL OSTEOARTHRITIS Treatment for carpometacarpal osteoarthritis (CMC OA) can include education on joint protection techniques, use of adaptive equipment, exercises, splinting, and modalities. Exercises can help the thumb become more stable. Combining joint protection techniques and pain-free exercises has shown to cause increased hand function in patients with OA (6). Joint protection techniques, such as avoiding tight pinching, especially the lateral pinch, and the avoidance of aggravating ADLs should be discussed. Education on adaptive equipment (e.g., built-up pens, use of Dycem, electric staplers, and can openers) is critical as well (6,7). Exercises that focus on AROM are more effective than pinch strengthening (6). Stretching and gentle massage to widen the first web space can help to relax the adductor pollicis, thus preventing an adductor contracture of the thumb (6,8). Strengthening the first dorsal interosseous can assist in providing stability to the CMC joint (6,8). The literature advises against repetitive grip and pinch strengthening and emphasizes that all therapeutic exercises should be pain free and avoid deformity (6–8). There are numerous prefabricated and custom splinting options to provide support and pain relief to the CMC joint during rest and with functional use (6–8).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Thumb opposition, thumb adductor massage, “C” exercise, web space stretch

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Advanced Continue Foundational exercises STRENGTHENING: First dorsal interossei strengthening

EXTENSOR CARPI ULNARIS TENDINOPATHY Ulnar-sided wrist injuries are commonly seen in golf, hockey, baseball, and racquet sports such as tennis. Extensor carpi ulnaris (ECU) tendinopathy can be managed initially with a forearm-based ulnar gutter splint for rest and to assist in alleviating symptoms (1). Exercises should include pain-free isometric exercises and then progress to eccentric exercises (1,9). Isometric contraction of the ECU during resisted radial abduction of the thumb with the wrist in neutral and the forearm supinated, described in the literature as the ECU synergy test, can also be a beneficial way to reeducate the ECU (10,11). Since the ECU is a wrist extensor in full supination and an ulnar deviator of the wrist in full pronation, strengthening in these positions should be initiated once free of pain (11). Proximal strengthening should be incorporated as well. Patient instruction on avoiding repetitive ulnar deviation, combined supination and ulnar deviation, and proper ergonomics promoting a neutral wrist with both mouse and keyboard use should be discussed (1). The current literature shows that combined supination and wrist flexion should be avoided if there is any symptomatic subluxation of the ECU tendon (12).

Recommended Exercises Foundational STRENGTHENING: ECU isometric strengthening, ECU synergy exercise, wrist extensors concentric strengthening, ulnar deviation strengthening

Intermediate Continue Foundational exercises STRENGTHENING: Wrist extensors eccentric strengthening

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Scapular retraction with Theraband, shoulder extension with Theraband, external rotation with Theraband

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HANDOUTS ROM/Stretching/Mobility

Wrist Extension Active Range of Motion POSITION: Sitting STEP 1: With your palm down, curl your hand into a gentle fist and raise your hand while keeping your forearm on the table.

STEP 2: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

Wrist Flexion Active Range of Motion POSITION: Sitting STEP 1: With your palm down, bend your wrist toward the floor, keeping your fingers relaxed while keeping your forearm on the table.

STEP 2: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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Isolated Thumb Interphalangeal Joint Flexion/Extension POSITION: Sitting STEP 1: Hold your thumb just below the tip joint (IP) with your other hand. STEP 2: Bend the thumb tip down and hold for 3 to 5 seconds. STEP 3: Straighten the thumb tip and hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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Tendon Gliding POSITION: Sitting STEP 1: Keep your wrist straight. STEP 2: Starting with position #1, perform one repetition of each position before moving to the next position. STEP 3: Hold each position for 3 to 5 seconds. REPS: Move through each position, in sequence, 3 to 5 times. SETS: One FREQUENCY: 2 to 3 times a day

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Median Nerve Glides POSITION: Sitting (Bend your fingers and your thumb while keeping your wrist straight) STEP 1: Make a fist. STEP 2: Open your fingers, relax your thumb at the side of your hand, and keep your wrist straight. STEP 3: Bring your wrist back and keep your thumb relaxed at the side of your hand. STEP 4: Bring your thumb back while keeping your wrist and fingers back (extended). STEP 5: Turn your palm toward the ceiling such that you can see your palm, and keep your wrist, thumb, and fingers back.

STEP 6: Using the other hand, gently bring your thumb further back. STEP 7: Hold each of the above positions for 3 to 5 seconds. REPS: Move through each position in the sequence 3 to 5 times. SETS: One set FREQUENCY: 2 to 3 times a day NOTE: This exercise should not cause tingling and/or numbness.

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Thumb Opposition POSITION: Sitting STEP 1: Gently touch the tip of your thumb to the tip of each finger making an “O” shape by bending the metacarpophalangeal (MP) joint.

STEP 2: Hold for 5 seconds. REPS: Repeat five times. SETS: Two sets FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

Thumb Adductor Massage POSITION: Sitting STEP 1: Gently massage the muscle between your index finger and thumb.

STEP 2: Hold until this muscle softens and widen your web space between your index finger and thumb.

STEP 3: Hold for 3 to 5 minutes. FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

“C” Exercise POSITION: Sitting STEP 1: Slowly make a “C” using your thumb and fingers.

STEP 2: Hold for 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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Web Space Stretch POSITION: Sitting STEP 1: Touch the tips of your index, middle, ring, and little fingers of both hands. STEP 2: Open your thumbs and try to widen the web space between your thumb and index finger. STEP 3: Hold for 5 to 10 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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Strengthening Abductor Pollicis Longus Isometric Strengthening POSITION: Sitting STEP 1: Place your noninvolved index finger below the middle joint of your thumb.

STEP 2: The noninvolved index finger should be putting gentle pressure in and down.

STEP 3: Gently try to separate the thumb out and lift it up. STEP 4: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

Extensor Pollicis Brevis Isometric Strengthening POSITION: Sitting STEP 1: Place your noninvolved index finger on the back of the involved thumb right above the middle joint.

STEP 2: The noninvolved index finger should be putting gentle pressure pushing the thumb down toward the palm.

STEP 3: Gently try to lift the MP joint of the involved thumb up. STEP 4: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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First Dorsal Interossei Strengthening POSITION: Sitting STEP 1: Place your hand palm down and flat on the table. STEP 2: Move your index finger toward your thumb and away from your middle finger.

STEP 3: Using the other hand, apply resistance to the index finger in the direction toward the middle finger. (Look for a muscle bulge.)

STEP 4: Hold for 5 seconds. STEP 5: Slowly relax. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

Extensor Carpi Ulnaris Isometric Strengthening POSITION: Sitting STEP 1: Place your palm down and resting on the table for support. STEP 2: Place your noninvolved hand on the top of your hand below your pinky and gently push your hand down.

STEP 3: Gently try to lift your involved wrist up and toward your pinky. STEP 4: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

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ECU Synergy Exercise POSITION: Sitting STEP 1: Place your elbow on the table with your palm up and your wrist straight.

STEP 2: Use your noninvolved hand to gently push the thumb in toward your pinky.

STEP 3: Gently bring your thumb out away from your pinky. STEP 4: Hold for 3 to 5 seconds. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day NOTE: This should be pain free.

Wrist Extensors Concentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move. STEP 2: Hold a light weight in hand with your palm facing down. STEP 3: Slowly raise wrist/hand up toward the ceiling over a 5-second count. STEP 4: Once you have reached the furthest point, use your opposite hand to lower your wrist/hand back to the starting position.

REPS: Perform 10 times. SETS: Three sets with 30 seconds between sets FREQUENCY: 3 to 4 times per week

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Ulnar Deviation Strengthening POSITION: Sitting STEP 1: With your elbow relaxed and at 90° resting next to the side of your body, make sure your palm is down. STEP 2: Holding a weight in your hand, gently move your wrist toward your pinky side. STEP 3: Hold for 3 to 5 seconds. STEP 4: Move your wrist toward your thumb side to the starting position. REPS: Repeat five times. SETS: Two FREQUENCY: 2 to 3 times a day

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Wrist Extensors Eccentric Strengthening POSITION: Seated in a chair STEP 1: Flex elbow to 90° and rest wrist at the edge of the table such that only the hand can move. STEP 2: Hold a light weight in hand with your palm facing down. STEP 3: Use opposite hand to bend wrist/hand up toward the ceiling as far as you can go. STEP 4: Let go of hand and slowly lower the wrist/hand over a 5-second count. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 4 times per week NOTE: This should be pain free.

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Proprioception/Functional Exercises

Elbow Flexion With Theraband POSITION: Standing STEP 1: Place the Theraband securely under your foot. STEP 2: Slowly bend your elbow while keeping your wrist straight throughout the exercise. STEP 3: Hold for 2 to 3 seconds and then slowly return to the starting position. REPS: Perform 10 times. SETS: Two to three FREQUENCY: 3 to 4 times a week

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Elbow Extension With Theraband POSITION: Standing STEP 1: Hold onto the Theraband with both hands. STEP 2: Slowly straighten your elbow toward the floor and keep your wrist straight. STEP 3: Hold for 2 to 3 seconds. STEP 4: Slowly let your elbow bend back to the starting position. REPS: Perform 10 times. SETS: Two to three FREQUENCY: 3 to 4 times a week

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Scapular Retraction With Theraband POSITION: Standing STEP 1: Tie the Theraband to a solid object. STEP 2: Hold the Theraband in both hands with your wrists straight, and keep your elbows bent. STEP 3: Pull your arms backwards toward your sides, squeezing your shoulder blades together. STEP 4: Hold for 3 to 5 seconds, then relax. REPS: Repeat 10 times. SETS: Two to three FREQUENCY: 3 to 4 times a week NOTE: This exercise should not cause pain, tingling, or numbness.

Shoulder Extension With Theraband POSITION: Standing STEP 1: Tie the Theraband to a solid object. STEP 2: Hold the Theraband in both hands with your arms in front of your body, keeping your elbows and wrist straight.

STEP 3: Pull the Theraband down and toward you, squeezing your shoulder blades together.

STEP 4: Hold for 3 to 5 seconds, then relax. REPS: Repeat 10 times. SETS: Two to three FREQUENCY: 3 to 4 times a week NOTE: This exercise should not cause pain, tingling, or numbness.

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External Rotation With a Theraband POSITION: Standing or seated on an exercise ball STEP 1: Use a Theraband or cable machine. STEP 2: Squeeze your shoulder blades together while activating your core. STEP 3: Slowly rotate your arms outward while keeping your elbows at your side. STEP 4: Slowly return to the starting position, trying to keep constant tension on the Theraband or cable. REPS: Repeat 10 times. SETS: Three to five FREQUENCY: 3 to 5 times per week NOTE: This exercise should be pain free.

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Patient Education/Precautions/Activity Modification De Quervain’s Tenosynovitis Photo: 16.5 of Therapeutic Programs of Musculoskeletal Disorders, Wyss and Patel (Eds.) 1. Splinting for rest and pain relief. See photo 16.5 or picture of forearm-based thumb spica with IPJ free. 2. Avoid thumb flexion and ulnar deviation. 3. Avoid activities or motions that cause pain. 4. Avoid gripping, pinching, and twisting.

Carpal Tunnel Wrist splinting Photo: 17.3 and 17.4 of Therapeutic Programs of Musculoskeletal Disorders, Wyss and Patel (Eds.) 1. Avoid doing things that worsen your symptoms. These include the following: ▪ Heavy gripping and/or pinching such items as putty, grippers, or balls

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▪

Repetitive finger bending: Take more breaks from prolonged activities

▪

Keeping wrists in the same position for extended periods

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A

B

Carpometacarpal Osteoarthritis Photo: 18.5 of Therapeutic Programs of Musculoskeletal Disorders, Wyss and Patel (Eds.) 1. 2. 3. 4. 5.

Splint to provide support and pain relief. Avoid tight pinching, especially the lateral pinch. Take breaks as needed. Use tools or objects to help build up objects such as a pen, brush, keys, electric stapler, and can opener. Avoid activities or motions that cause pain.

Extensor Carpi Ulnaris Tendinopathy 1. Splinting for rest and pain relief 2. Avoid ulnar deviation (bending wrist toward pinky) or motions that cause pain. 3. Ergonomics: split keyboard and neutral mouse

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REFERENCES 1. Cooper C. Elbow, wrist and hand tendinopathies. In: Cooper C, ed. Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. 2nd ed. St. Louis, MO: Mosby; 2014:383–390. 2. Ilyas AM. Nonsurgical treatment for DeQuervain’s tenosynovitis. J Hand Surg. 2009;34: 928–929. doi:10.1016/j.jhsa.2008.12.030. 3. Evan R. Therapist’s management of carpal tunnel syndrome: practical approach. In: Osterman AL, Skirven TM, Fedorczyk JM, et al, eds. Rehabilitation of the Hand and Upper Extremity. Philadelphia, PA: Elsevier; 2011:666–677. 4. Akalin E, El O, Senocak O, et al. Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med Rehabil. 2002;81(2):108–113. doi:10.1097/00002060-200202000-00006. 5. Echigo A, Aoki, M, Ishiai S, et al. The excursion of the median nerve during nerve gliding exercise: an observation with high-resolution ultra-sonography. J Hand Ther. 2008;21(3): 221–228. doi:10.1197/j.jht.2007.11.001. 6. Beasley J. Arthritis. In: Cooper C, ed. Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. 2nd ed. St. Louis, MO: Mosby; 2014:457–478. 7. Melvin, JL. Therapist’s management of osteoarthritis in the hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis, MO: Mosby; 2002:1646–1663. 8. Albrecht J. Caring for the Painful Thumb: More Than a Splint. North Mankato, MN: Corporate Graphics; 2015. 9. Avery D, Rodner CM, Edgar CM. Sports-related wrist and hand injuries: a review. J Orthop Surg Res. 2016;11(1):99–114. doi:10.1186/s13018-016-0432-8. 10. Kaplan FTD. Examination of the ulnar wrist. In: Greenberg JA, ed. Ulnar Sided Wrist Pain: A Master Skills Publication. Chicago, IL: American Society for Surgery of the Hand; 2013:33–44. 11. Ghatan AC, Puri SG, Morse KW, et al. Relative contribution of the subsheath to extensor carpi ulnaris stability: implications for surgical reconstruction and rehabilitation. J Hand Surg Am. 2016;41(2):225–232. doi:10.1016/j.jhsa.2015.10.024. 12. Rutland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendinitis. J Hand Surg Am. 2008;33A:1777–1782. doi:10.1016/j.jhsa.2008.08.018.

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CHAPTER

4

Home Exercise Programs for Hip Injuries Jessica Hettler and Astrid DiVincent

INTRODUCTION The hip, the second largest joint in the human body, is susceptible to various traumatic and nontraumatic stresses. The hip complex consists of the coxofemoral joint and pelvic girdle, and plays a primary role in ambulation (1). As the only attachment of the lower extremity to the trunk, the hip complex requires both mobility and stability during gait, transfers, and postural support. Poor endurance and delayed firing of the hip extensors and abductors have been found in patients with lumbar pain, knee pathology, and chronic ankle sprains (2). Hip pathologies that are commonly seen include hip osteoarthritis, iliopsoas tendinopathy/bursitis, greater trochanteric pain syndrome, hamstring strains and tendinopathy, and femoroacetabular impingement and labral tears. Treating any of these pathologies requires a thorough examination to identify structural impairments and functional limitations throughout the kinetic chain. Selection of interventions should be done on a case-by-case basis. Guidelines for rehabilitation of the hip should focus on a clinically based progression. Initial rehabilitation should focus on pain reduction, restoration of joint mobility and flexibility, and integrated proprioception and kinesthetic awareness. Patients should be progressed as tolerated with isolated strengthening and core stabilization, while advancing toward unilateral loading. Once patients display improved kinematics through functional movements (i.e., functional squat, single leg stance), they can be progressed toward more plyometric- and agility-based training for safe return to activity.

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • •

Restoration of range of motion and flexibility Initiation of strengthening of pelvic girdle and core

Intermediate • •

Progression of strengthening of pelvic girdle and core Improvement of proprioception

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Advanced • •

Restoration of strengthening of pelvic girdle and core Restoration of proprioception and functional movements

HIP OSTEOARTHRITIS There is a lack of evidence in the literature to support the effects of specific exercises on pain, function, and quality of life in patients with osteoarthritis of the hip. However, according to the Ottawa Panel, “strength training exercise has the greatest improvement for pain, disability, physical function, stiffness and range of motion within a short time (8-12 weeks)” (3). Aerobic training, such as walking, swimming, or cycling, can help promote range of motion (ROM) of the hip, allowing nutrients in the joint fluid to get to the relatively avascular articular cartilage, a process called imbibition. It can also improve general physical fitness and should be included in the treatment of hip osteoarthritis (4). Due to the degenerative nature of this condition, it is important to focus on improving the stability of the hip joint through multiplanar hip strengthening and lumbopelvic stabilization exercises. Patients with hip osteoarthritis tend to lose hip extension ROM as the disease progresses (4). Treatment should focus on prevention of this deficit through anterior stretching of the flexors and quadriceps and activation of the gluteals to maintain a normal gait pattern.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking STRENGTHENING: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg balance

ILIOPSOAS TENDINOPATHY/BURSITIS Iliopsoas tendinopathy, iliopectineal bursitis, snapping hip, and iliopsoas impingement can all be categorized as “iliopsoas syndrome,” as they can be difficult to differentiate and often occur together (5,6). This syndrome is often

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seen in dancers and runners and is thought to be due to repetitive movement of the tendon over the pelvis and bursa as well as extreme ranges of motion required to perform certain tasks (5). Initially, activity modification is advised to reduce aggravation of irritated tissues. Subsequently, the iliopsoas should be progressively loaded beginning with supine hip flexion, then seated hip flexion with the knee flexed, and finally standing marches as tolerated (6). Patients with iliopsoas syndrome often lack terminal hip extension during gait due to shortening or tightening of the iliopsoas. Ensure that hip flexor stretching and myofascial release are part of the treatment plan. Impaired core stability should be addressed through a quadruped progression, standing core stabilization with upper extremity movements, and, finally, forward and side planking to ensure maximum pelvic control in all functional positions (6). Johnston et al. show that a gluteal and deep external rotator strengthening program in multiple positions improves activity levels and return to sport in this population (7). Once core stability and gluteal strength are improved, unloading the contralateral limb through single leg stance and single leg squats can improve dynamic hip stability.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, iliotibial band (ITB) stretch, foam roller to hip area STRENGTHENING: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge, clamshells, hip clocks PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Monster walk, side plank, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Windmill, single leg squat

GREATER TROCHANTERIC PAIN SYNDROME Greater trochanteric pain syndrome (GTPS) requires a good assessment of both static and dynamic movement to identify areas of dysfunction. Literature has shown poor standing posture with hanging on the hip and altered weight shift to one leg and collapse with a positive Trendelenburg sign when this syndrome occurs statically. Dynamically, patients display poor lateral pelvic

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control with forward step down and lack of ability to control adduction forces. This leads to higher tensile and compressive loads across the joint (8–10). It is important to address soft tissue restrictions through the deep rotators of the hip and identifying trigger points in the mid to distal thigh. Foam rolling is a great tool for self soft tissue mobilization, but one should avoid rolling directly over the ITB to prevent an increase in compressive loads over the affected area (11). Muscle strengthening should focus on the gluteus medius and maximus. The gluteus medius is important for stabilizing the pelvis in stance phase of gait and is the primary hip abductor. The gluteus maximus is also important as a hip extensor and lateral rotator. It will assist in explosive movement of the body in an upward direction as well as change of direction in sport (6,8,10,12).There is also an important role of eccentric muscle training, but evidence is minimal for eccentrics in the gluteus medius. This concept of strength building in a muscle tendon unit while lengthening that unit has been linked to reduction in degenerative tendinoses (6).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, foam roller to hip area STRENGTHENING: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge, clamshell, hip clocks, hip hiker PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Monster walk, forward step down PROPRIOCEPTION/FUNCTIONAL: Windmill

HAMSTRING STRAIN AND TENDINOPATHY Hamstring strains and chronic tendinopathy are commonly found in distance runners and in sports requiring change of direction (13,14). In sagittal plane activity, the hamstring muscle’s primary function during running is to eccentrically decelerate knee extension at the terminal swing phase (14).Unfortunately, these injuries have a high recurrence rate, so it is important to address strength of injured muscles, restore normal flexibility, and improve functional movement patterns (13). Rehabilitation should focus on addressing the kinetic chain and restoration of normal ROM and strength in hamstring and surrounding muscle

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groups. Research has found that gluteus maximus weakness can produce overload of the proximal hamstring tendon, and gluteus medius weakness will produce contralateral hip drop and increased hip adduction (14). Patients will benefit from exercise for trunk stabilization, gluteus maximus and medius strengthening, and other kinetic chain movements.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking, foam roller to hip area STRENGTHENING: Hamstring isometrics

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Eccentric hamstring throw downs, hamstring curl on stability ball, hip hiker, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Lunge, single leg deadlifts

FEMOROACETABULAR IMPINGEMENT AND LABRAL TEARS Femoroacetabular impingement (FAI) and labral tears are a common pathology found in young adults with hip pain (15). Some patients may respond well to conservative management, while some may go on to surgery. Conservative management includes activity modification, anti-inflammatory medications, improvements in hip mobility, and functional hip abduction strengthening (16). Additional focus should be spent on posture and core strengthening to improve mechanics from the lumbopelvic and hip girdle. Oftentimes, improved neuromuscular control and kinesthetic awareness in functional movement patterns can result in reduction of mechanical stress on hip joint (16). Exercises can progress from nonweight-bearing positions for gluteus medius and maximus firing toward functional movement patterns in a closed kinetic chain (17). Advancement of exercises will be specific to the clinical presentation and demands of the sport.

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch, foam roller to hip area STRENGTHENING: Gluteal isometrics, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge, hip clocks, clamshell PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Monster walk, side plank, hip hiker, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Windmill, single leg squat

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HANDOUTS ROM/Stretching/Mobility Hamstring Stretch With a Towel POSITION: Lie on your back with your legs straight. STEP 1: Loop a towel/strap around the arch of your foot (stretching leg).

STEP 2: Keeping your knee straight, slowly raise your leg off the floor toward the ceiling until a stretch is felt in your hamstrings/back of your thigh.

REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Prone Quadriceps Stretch POSITION: Lie on your stomach with a towel or strap looped around your ankle. STEP 1: Tighten your abdominals and gently squeeze your gluteals to keep your hips flat on the surface.

STEP 2: Hold the strap with your hand (same side), and gently pull your ankle toward your buttocks to bend your knee until a gentle stretch is felt in your thigh muscles, closer to your knee.

NOTE: Do not allow your back to arch. REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

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Hip Rotator Stretch POSITION: Lie on your back, knees bent, feet on the ground.

STEP 1: Cross involved leg so the ankle is near the knee of the opposite leg.

STEP 2: Place hands behind thigh of opposite leg (or on top of knee) and slowly lift it off the ground toward you, while engaging your abdominals so that you do not arch your back.

NOTE: You should feel a stretch in the buttocks of the crossed leg. REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Hip Flexor Stretch, Kneeling POSITION: Kneeling STEP 1: Kneel on the ground and put one foot forward into a lunge position.

STEP 2: While keeping your back straight, gently lean forward until you feel a stretch in the front of the hip of the back leg.

REPS: Hold that position for 30 seconds, then relax. SETS: Two to three times per leg FREQUENCY: 3 to 5 times per week

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Two-Joint Hip Flexor Stretch POSITION: Lying on your back on a bed/table, bend your knees, drop one leg over the side of the bed, and place a strap (you can also use a Theraband or towel) around your ankle. STEP 1: Tighten your abdominals to keep your back flat on the table.

STEP 2: Extend your hanging leg back and draw your foot toward your buttock to bend your knee until you feel a stretch in the front of your thigh, closer to your hip.

REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Quadruped Rocking POSITION: On your hands and knees, with your hands underneath your shoulders and your knees underneath your hips

STEP 1: Engage your abdominals, back flat; do not round or arch your back. STEP 2: Slowly rock backward while keeping your torso flat; stop before your back rounds. STEP 3: Tighten your abdominals and rock forward past your hands, keeping your torso flat. REPS: Hold for 10 seconds at end range, then slowly release stretch. SETS: Perform 10 times. FREQUENCY: 1 to 2 times per day

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Iliotibial Band Stretch POSITION: Stand with your legs crossed and holding onto a support. STEP 1: Keeping your body, knees, and feet facing forward, slide your back leg further across your body until you can feel the stretching on the outside of your hips and thighs.

STEP 2: Repeat with other leg. REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Foam Roller to Hip Area POSITION: Lie face down, on side, or on back depending on desired muscle. STEP 1: Roll across quadriceps, hip flexor, hamstring, glute, ITB, or calf.

STEP 2: Take a break if needed, and you can stretch muscle after rolling.

REPS: 3 to 5 minutes to each desired muscle FREQUENCY: Once per day NOTE: Avoid rolling directly over the ITB; try and roll a little in front or behind it.

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Strengthening

Gluteal (Buttock) Isometrics POSITION: Lying face down STEP 1: Squeeze your buttocks strongly together and tighten the muscles in your lower back, curving the spine as if forming a shallow “U.”

REPS: Hold for 10 seconds. SETS: Perform 10 times. FREQUENCY: 1 to 2 times per day

Hamstring Isometrics POSITION: Lie on back with involved knee bent partially. STEP 1: Press heel to floor. REPS: Hold for 5 to 15 seconds, 10 times. SETS: Two to three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Prone Hip Extension POSITION: Lie on belly with pillow under abdomen and pelvis. STEP 1: Raise involved leg off floor by squeezing the buttocks and keeping the knee straight. STEP 2: Hold for 2 seconds, then slowly relax leg back down. REPS: Perform 10 times. SETS: Three sets to desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Level 2

Level 2

Clam Shells POSITION: Lie on your side and bend your hips and knees 45°. STEP 1: Keep your heels together and slowly lift your top knee toward the ceiling. STEP 2: Hold that position for 3 to 5 seconds, then slowly return to the starting position. REPS: Repeat 10 times per leg. SETS: Two to three FREQUENCY: 2 to 3 times per day and 3 to 5 times per week LEVEL 2: Put a Theraband around your thighs to increase the resistance.

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Alternatively

Alternatively

Alternatively

Level 2

Squat POSITION: Stand with your feet hip-width apart while facing a mirror or having a partner watch you. STEP 1: Unlock your hips to sit down and back as far as you can comfortably. STEP 2: Return to standing position following the same path as you came down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Watch that your chest stays tall, your hips shift back, and your knees stay in line with the hips and ankles. Make sure you do not fold over or arch up; your eyes should follow the path of the motion. Keep your weight evenly distributed on both sides. To make it easier, do not go down as far, or you can use a chair behind you. ALTERNATIVELY: You can do this against a wall or squat onto a chair to make the exercise easier. LEVEL 2: You can try placing a miniband above the knees to get better buttock engagement.

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Side-Lying Hip Abduction With Towel Against Wall POSITION: Lie on side with bottom leg’s knee bent to hip level and top leg against wall, pushing into towel. STEP 1: As you push into towel, slowly lift leg, contracting your buttocks.

STEP 2: Slowly bring leg back down to parallel, keeping heel pushing into towel.

REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: This exercise can also be performed with a sock on against a wall.

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Level 2

Level 2

Level 3

Bridge POSITION: Lie on your back with both of your knees bent, your feet hip-distance apart, and arms relaxed by your side.

STEP 1: Tighten your abdominals and your buttocks. STEP 2: Lift your buttocks off the mat until your hips are level. STEP 3: Hold the position for 2 to 3 seconds and then slowly lower yourself down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: You should feel this in the buttocks. If your back hurts while doing this exercise, make sure you are contracting your abdominals and do not lift your hips as high. LEVEL 2: Perform bridge as described, then slowly march in place by lifting each foot off the mat in alternating fashion; focus on engaging the buttock of the leg that is down.

LEVEL 3: Perform a single leg bridge with the nonworking leg pointed straight out; alternate legs after 10 reps.

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Hamstring Curl on Stability Ball POSITION: Lie on your back on the floor with your heels and lower calves positioned on a stability ball. STEP 1: Tighten your abdominals and your buttocks. STEP 2: Lift your buttocks off the mat until your hips are level. STEP 3: Gradually roll the ball in toward your buttocks (bring your heels toward your butt) by bending your knees. STEP 4: Roll the ball slowly out while keeping your legs and torso steady. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Hip Hikers POSITION: Standing, with one leg off of a step and the other leg straight and on the step STEP 1: Slowly lift hip up in the air (leg that is off the step), keeping leg that is on the step straight. STEP 2: Hold for 1 to 2 seconds, then slowly lower back down. REPS: Perform 10 times on both sides. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Level 2

Forward Step Up POSITION: Stand in front of a 6- or 8-inch step with good posture. STEP 1: Tighten your abdominals and buttocks. STEP 2: Step up onto the step by squeezing your buttocks, keeping your torso steady and your hip, knee, and ankle in line.

STEP 3: Return to the starting position by steadily stepping back down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week LEVEL 2: When you can complete three sets of 10 reps with proper form on a 6-inch step, add 5-lb dumbbells, then 10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with proper form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

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Level 2

Forward Step Down POSITION: Stand on a 6- or 8-inch step, with your hands on your hips. STEP 1: Slowly lower your heel to the floor while keeping your hips level and the hip, knee, and ankle of the standing leg aligned, as you lower and land softly with control.

STEP 2: Return to starting position. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: This exercise is important for developing the ability to decelerate while maintaining good alignment. So perform slowly and with focus. Better to do fewer repetitions of good quality than rush through three sets of 10. LEVEL 2: When you can complete three sets of 10 reps with proper form on the 6-inch step, add 5-lb dumbbells, then 10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with proper form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

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Monster Walk POSITION: Stand with a taut Theraband around your ankles and feet shoulder-width apart in a slightly squatted position (ideally with hips flexed 20°–30°). STEP 1: Move one leg to the side, increasing the tension in the Theraband. STEP 2: Slowly bring your opposite leg to the starting stance. STEP 3: Take 10 steps in one direction, then reverse direction. SETS: Two to three FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, make sure your knees do not buckle toward each other and keep your knees over your toes the entire time.

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Hip Clocks Imagine you are standing on the face of a clock (12:00 is in front of you, 6:00 behind you). POSITION: Place a resistance band around your ankles (harder) or around your knees (easier). STEP 1: Stand with your feet about shoulder-width apart. STEP 2: Sit back into your hips and bend your knees slightly. STEP 3: Tighten your abdominals and buttocks. STEP 4: With your right leg, touch 1:00, 3:00, and 5:00 o’clock with your toe, while keeping your left leg steady by using your buttocks and torso.

STEP 3: Switch to your left leg and touch 11:00, 9:00, and 7:00 o’clock, with the same focus on stabilizing with the right buttock.

REPS: Perform five clocks with each leg. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Level 2

Level 3

Side Plank POSITION: Lie on your side, bend your knees to 90°. and put your arm with your elbow bent on the ground. STEP 1: Slowly bring your hips off the ground to where your body is straight. STEP 2: Hold that position for 30 seconds or as long as you can. SETS: Two to three FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, you should feel the muscles of your abdomen and hip on the side facing the ground contracting. The goal is to work your way to holding the position for 30 to 60 seconds at a time. LEVEL 2: This is similar to the first position, except that you extend your knees and lift your entire body and knees off the ground such that one elbow and the outside of your foot are touching the ground.

LEVEL 3: This is similar to Level 2, except that you lift your top leg and/or arm into the air in an abducted position (away from the body) with a straight knee or elbow.

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Eccentric Hamstring Throwdowns POSITION: Lie on stomach on table or bed with pillow under stomach and bend affected knee to 90°. STEP 1: Quickly straighten knee, stopping 2 to 3 inches from the table or bed. STEP 2: Bend knee back to 90° and repeat. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Proprioception/Functional Level 2

Single Leg Balance STEP 1: Stand on one leg with your knee slightly bent, hands on your hips while keeping your hips level and standing tall and straight.

STEP 2: Tighten your abdominals and hold your position.

NOTE: Make sure you do not sink into your hip or lean to the side. REPS: Hold for 30 seconds. SETS: Three sets on desired side with a 30-second break between sets

FREQUENCY: 3 to 5 times per week LEVEL 2: Slowly look side to side, and then up and down.

LEVEL 3: Move your raised leg out to the side a bit Level 3

Level 4

(do not hike your hip); then move leg back in.

LEVEL 4: Move your raised leg forward and backward from your hip, slowly.

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Level 2

Level 3

Single Leg Deadlift POSITION: Standing STEP 1: Stand on one leg with your knee slightly bent and tighten the buttock of the standing leg, while keeping your hips level and not sinking into your hip or leaning to the side.

STEP 2: Tighten your abdominals. STEP 3: Bend forward by hinging back on the hip of the standing leg, while keeping the knee of the stance leg slightly bent and keeping the buttock of the standing leg engaged such that your hip does not jut out to the side.

STEP 4: Extend your opposite leg out behind you as you go down to maintain a straight line with your body (head, neck, back, leg), and keep your hips even.

STEP 5: Keeping your back straight, bring yourself back up to the starting position by tightening your buttocks. REPS: Perform 10 times. SETS: Three sets on desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Lower only to a depth that allows you to maintain proper form. Stop when you feel your back start to round, your hip jut out, or a stretch in your hamstrings. LEVEL 2: You can hold a stick with both hands along your spine. The stick should not come off your back as you go down into the deadlift.

LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do not let the weight pull your back out of alignment; you must control the weight.

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Windmill POSITION: Standing STEP 1: Stand on one leg while stabilizing your glutes and core. STEP 2: Hinge from the hip such that your trunk is parallel to the floor, and place your arms out perpendicular to your trunk and parallel to the floor.

STEP 3: Bring one arm down toward the floor, then bring it back to start position. STEP 4: Alternate to the other arm. REPS: Alternate 10 repetitions on each arm, maintaining stability over the affected leg. SETS: Three sets on desired side(s) with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Lunge POSITION: Stand with feet hip-width apart and place hands on hips. STEP 1: Take a step forward with your left foot and lower your body as you bend your left hip and knee, keeping your right foot in line with your ankle.

STEP 2: At the same time, your left knee should bend into a half kneeling position, without letting your right knee touch the floor.

STEP 3: Push yourself back up into the starting position with your front foot. STEP 4: Repeat this exercise leading with your other (right) leg. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Keep your abdominals engaged and spine in a straight line. Keep your weight on your front leg—the back leg is just a kickstand. LEVEL 2: Hold weights in your hands.

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Single Leg Squat POSITION: Stand with feet apart and your knees slightly bent. STEP 1: Shift your weight such that you are standing on one leg. STEP 2: Slowly squat down on one leg, sitting back through the hips, bending your hip and knee. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Squat as deep as you can while maintaining balance, with hips even and hips/knees/ankles in line. Do not let your knee collapse in. OPTIONS: Try putting the other free leg in different positions: in front (harder), next to you, or behind you (easier).

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REFERENCES 1. Macovei LA, Rezus E. Anatomical and clinical observations on structural changes of the hip joint. Rev Med Chir Soc Med Nat Iasi. 2016;120(2):273–281. PubMed PMID: 27483704. 2. Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med Rep. 2008;7(1):39–44. doi:10.1097/01.CSMR.0000308663.13278.69. 3. Brosseau L, Wells GA, Pugh AG, et al. Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis. Clin Rehabil. 2016;30(10):935–946. doi:10.1177/0269215515606198. 4. Rannou F, Poiraudeau S. Non-pharmacological approaches for the treatment of osteoarthritis. Best Pract Res Clin Rheumatol. 2010;24:93–106. doi:10.1016/j.berh.2009.08.013. 5. Heiderscheit B, McClinton S. Evaluation and management of hip and pelvis injuries. Phys Med Rehabil Clin N Am. 2016;27(1):1–29. doi:10.1016/j.pmr.2015.08.003. 6. Tyler TF, Fukunaga T, Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis. Int J Sports Phys Ther. 2014;9(6):785–797. PubMed PMID: 25383247. 7. Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation strengthening program: a retrospective case series. J Orthop Sports Phys Ther. 1999;29(4): 218–224. doi:10.2519/jospt.1999.29.4.218. 8. Ho GW, Howard TM. Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction. Curr Sports Med Rep. 2012;11(5):232–238. doi:10.1249/JSR.0b013e3182698f47. 9. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med. 2015;45(8):1107–1119. doi:10.1007/ s40279-015-0336-5. 10. Boren K, Conrey C, Le Coguic J, et al. Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises. Int J Sports Phys Ther. 2011;6(3):206–223. PubMed PMID: 22034614. 11. Mulligan EP, Middleton EF, Brunette M. Evaluation and management of greater trochanter pain syndrome. Phys Ther Sport. 2015;16(3):205–214. doi:10.1016/j.ptsp.2014.11.002. 12. Distefano LJ, Blackburn JT, Marshall SW, et al. Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. 2009;39(7):532–540. doi:10.2519/ jospt.2009.2796. 13. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67–81. doi:10.2519/jospt.2010.3047. 14. Goom TSH, Malliaras P, Reiman MP, et al. Proximal hamstring tendinopathy: clinical aspects of assessment and management. J Orthop Sports Phys Ther. 2016;46(6):483–493. doi:10.2519/jospt.2016.5986. 15. Wall DH, Fernandez M, Griffin DR, et al. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM&R. 2013;5:418–426. doi:10.1016/j. pmrj.2013.02.005. 16. Bedi A, Kelly BT. Current concepts review: femoroacetabular impingement. J Bone Joint Surg Am. 2013;95:82–92. doi:10.2106/JBJS.K.01219. 17. Loudon JK, Reinman MP. Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Phys Ther Sport. 2014;15(2):82–90. doi:10.1016/j. ptsp.2014.02.004.

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CHAPTER

5

Home Exercise Programs for Knee Injuries Jessica Hettler and Astrid DiVincent

INTRODUCTION The knee consists of two separate yet interdependent joints, the tibiofemoral joint and the patellofemoral joint. Common knee pathologies include knee osteoarthritis (OA), patellofemoral pain syndrome (PFPS), quadriceps and patellar tendinopathy, ligament sprains, meniscal tears, and distal iliotibial band syndrome. Treating any knee pathology requires a thorough examination of the entire kinetic chain to identify structural impairments and functional limitations throughout the system. Selection of interventions should be tailored to a patient’s specific limitations, both structurally and functionally. Guidelines for rehabilitation of the knee should focus on a functional progression. The initial rehabilitation should focus on the reduction of pain and swelling, restoration of joint mobility and flexibility, multidirectional stability, and proprioceptive training. Patients should be progressed as tolerated with isolated strengthening of the hip, knee, and core. Treatment should proceed from bilateral loading to unilateral loading for functional movements and neuromuscular reeducation. Functional movement testing should be utilized to determine appropriate advancement to higher-level activities (i.e., running, cutting, jumping) (1). A component of rehabilitation that is often missed but should be included is eccentric strengthening, to ensure the patient’s ability to decelerate without compromising mechanics and causing further injury to the knee (2).

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • • •

Control edema Restoration of range of motion (ROM) and flexibility Initiation of strengthening of knee

Intermediate • •

Progression of strengthening of knee Improvement of proprioception

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Advanced • • • •

Restoration of strengthening of knee and progression to eccentric strengthening for tendinopathies Restoration of strengthening of core Restoration of proprioception and functional movements Restoration of multidirectional stability

KNEE OSTEOARTHRITIS OA of the knee is one of the most prevalent types of OA reported, affecting women and the elderly more often (3). The development of knee OA can be a product of aging, increased weight, genetics, and/or repetitive stress on the knee joint. Because of the degenerative nature of the disease, patients with knee OA report increasing pain and stiffness with weight-bearing activities such as walking, stair negotiation, and squatting. Therapeutic exercise involving aerobics, joint ROM, soft tissue flexibility, strength and endurance training, and proprioception training improve pain scores and function in this population (4). Exercise prescription should focus on strengthening the quadriceps and hamstrings for multiplanar knee joint stability as well as the gluteals and deep external rotators of the hip for optimal knee alignment in a loaded position (5). This population also tends to have a higher knee adduction movement during gait, which is indicative of increased loads through the medial compartment (6). Woollard et al. (7) have shown that patients with medial knee OA are more likely to slow the progression of medial joint space degeneration by strengthening their hip abductors.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension STRENGTHENING: Quadriceps set, straight leg raise, prone hip extension, side-lying hip abduction with towel against wall

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Knee flexion chair stretch STRENGTHENING: Bridge, squat, squat on wedge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg squat

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PATELLOFEMORAL PAIN SYNDROME PFPS is a common diagnosis seen in many PT and MD offices. It is typically reported as a gradual onset of knee pain that has limited the patients from participating in activities they enjoy (i.e., running, soccer, basketball, tennis, etc.). Men and women can both suffer from PFPS, but it is more often seen in women. Studies have shown that female runners with PFPS fall into hip adduction and internal rotation, therefore causing altered kinematics in the frontal and transverse planes (8). The dysfunctional movement patterns result in knee pain due to delayed activation in the gluteus medius and gluteus maximus muscles (8). Treatment for PFPS has moved away from only traditional quadriceps strengthening and has developed to include targeting hip muscle strengthening and movement strategies for trunk and lower limb. As a result, patients have demonstrated “improvements in pain, physical function, lower-limb and trunk kinematics, trunk muscle endurance, and eccentric strength of the hip and knee musculature” (9).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch STRENGTHENING: Quadriceps set, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Side plank, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift

QUADRICEPS AND PATELLAR TENDINOPATHY Tendinopathy is a term that describes pain and injury from within or around a tendon (10). Patellar and quadriceps tendinopathies are commonly seen in athletes as overuse injuries and in both basketball and volleyball players. It is important to modify activity and start the PRICE principles: Protection, Rest, Ice, Compression, Elevation, when managing these conditions. As the rehabilitation of the injury progresses and after starting to work on flexibility and concentric strengthening, eccentric exercises are commonly used for “lengthening a

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musculotendinous unit while application of a load occurs” (10). Results have been shown to decrease pain and improve tendon quality.There are many ways to emphasize eccentric loading when choosing exercises, including utilizing a decline board to squat or performing drop squats (11). It is also important to address other impairments commonly seen in athletes with jumper’s knee (patellar tendinopathy) and quadriceps tendinopathy, specifically core weakness, gluteus medius weakness, and poor quadriceps, hip flexor, and hamstring flexibility.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch STRENGTHENING: Quadriceps set, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Side plank, forward step up, forward step down, squat on a wedge (Level 3) PROPRIOCEPTION/FUNCTIONAL: Single leg deadlift, windmill

KNEE LIGAMENT SPRAIN Four major ligaments contribute to the stability of the knee joint: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). The knee is a trochoginglymos, or a gliding hinge joint, and requires the passive tension of these four ligaments for multidirectional stability during daily activities (12). Knee ligament sprains occur during contact injuries as well as during noncontact movements involving a knee that lacks muscular control. After a ligamentous sprain in the knee, patients can experience increased swelling in the joint resulting in quadriceps inhibition. Macleod et al. (13) found that patients with knee ligament sprains with improved quadricep motor control were more capable of returning to activity without surgical management. Therefore, it is a critical goal of rehabilitation after ligamentous injury to reactivate the quadriceps for both concentric and eccentric control for safe return to activity.

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Research also shows that neuromuscular reeducation focusing on improving frontal plane knee control to reduce dynamic knee valgus reduces the rate of knee injury (14). Hip abduction and external rotation strengthening has been found to decrease valgus stress in the knee and prevents further injury in a knee with ligamentous injury. Exercise programs involving standing or side-lying hip abduction, single leg balance, squatting, single leg squatting, forward step ups, and forward step downs effectively facilitate hip muscle activation to maintain healthy knee frontal plane alignment (15).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension STRENGTHENING: Quadriceps set, terminal knee extension, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Knee flexion chair stretch STRENGTHENING: Squat, bridge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Side plank, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg deadlift, windmill

MENISCAL TEAR The meniscus is an important structural component of the knee joint that assists in loading, absorption of forces, and stabilization of the knee joint. The menisci assist with transmission of forces that the knee sustains with every step. It assists in protection and prevention of wearing of the articular cartilage that lines the distal femur and tibia. Mechanism of injury for menisci occur with noncontact movements, such as deceleration, cutting, and jumping, but contact injuries do also occur. Degeneration may occur with increased age due to general wear and tear on the knee (16). Literature shows that weakness in the proximal hip (gluteal region) causes a loss of proximal stability, therefore making the knee susceptible to injury (17). Functional motor control and strengthening exercises for hip abductors have been shown to minimize valgus and internal rotation stresses across the knee

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joint (18). Exercises should focus on quadricep reeducation and eccentric control, proximal strengthening at hip, core stabilization, neuromuscular reeducation, and general lower extremity flexibility.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee extension STRENGTHENING: Quadriceps set, terminal knee extension, straight leg raise, side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises ROM/STRETCHING/MOBILITY: Knee flexion chair stretch STRENGTHENING: Squat, bridge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Side plank, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift, windmill

ILIOTIBIAL BAND SYNDROME Iliotibial band (ITB) syndrome is the most common cause of lateral knee pain in runners (19), though it can also affect nonrunners.The distal ITB can become irritated as it repeatedly passes over the LE of the femur at around 30° of knee flexion, such as during running. The etiology of this syndrome is unclear; however, proposed contributing factors are kinematic deviations in the frontal and transverse planes, weakness in the lateral and posterior hip musculatures, and surrounding muscle strains (19). Core stabilization and hip abductor strengthening have been seen to improve pelvic control and reduce abnormal kinematics at the knee, especially in single limb stance during gait and running. Treatment should focus on improving length–tension relationships throughout the lower quarter by stretching the quadriceps and the biceps femoris as well as the tensor fascia lata (19). Strengthening should be initiated with isometric and eccentric gluteus medius exercise without compensatory strategies (20). Progress to single-leg forward step downs, squats, and single leg dead lifts to enhance functional strength and neuromuscular control during impact activities (21).

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch STRENGTHENING: Side-lying hip abduction with towel against wall, prone hip extension

Intermediate Continue Foundational exercises STRENGTHENING: Squat, bridge PROPRIOCEPTION/FUNCTIONAL: Single leg balance

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Side plank, forward step up, forward step down PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift, windmill

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HANDOUTS ROM/Stretching/Mobility Hamstring Stretch With a Towel POSITION: Lie on your back with your legs straight. STEP 1: Loop a towel/strap around the arch of your foot (stretching leg).

STEP 2: Keeping your knee straight, slowly raise your leg off the floor toward the ceiling until a stretch is felt in your hamstrings/back of your thigh.

REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Prone Quadriceps Stretch POSITION: Lie on your stomach with a towel or strap looped around your ankle. STEP 1: Tighten your abdominals and gently squeeze your gluteals to keep your hips flat on the surface.

STEP 2: Hold the strap with your hand (same side), and gently pull your ankle toward your buttocks to bend your knee until a gentle stretch is felt in your thigh muscles, closer to your knee.

NOTE: Do not allow your back to arch. REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

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Hip Flexor Stretch, Kneeling POSITION: Kneeling STEP 1: Kneel on the ground and put one foot forward into a lunge position.

STEP 2: While keeping your back straight, gently lean forward until you feel a stretch in the front of the hip of the back leg. REPS: Hold that position for 30 seconds, then relax. SETS: Two to three times per leg FREQUENCY: 3 to 5 times per week

Two-Joint Hip Flexor Stretch POSITION: Lying on your back on a bed/table, bend your knees and drop one leg over the side of the bed and place a strap (can also use a Theraband or towel) around your ankle. STEP 1: Tighten your abdominals to keep your back flat on the table.

STEP 2: Extend your hanging leg back and draw your foot toward your buttock to bend your knee until you feel a stretch in the front of your thigh, closer to your hip.

REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

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ITB Stretch POSITION: Stand with your legs crossed and holding onto a support. STEP 1: Keeping your body, knees, and feet facing forward, slide your back leg further across your body until you can feel the stretching on the outside of your hips and thighs.

STEP 2: Repeat with other leg. REPS: Hold for 30 seconds at end range, then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

Assisted Knee Extension POSITION: Sit on edge of table or bed. STEP 1: Straighten involved knee with assistance of other leg.

STEP 2: Then slowly lower involved leg, assisting with other leg as needed.

REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Try to do as much of the work as possible with the involved leg.

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Assisted Knee Flexion POSITION: Sit on the edge of a table or chair. STEP 1: Cross ankles as shown, with the stiff knee at the bottom. STEP 2: Press downward with the upper leg so that you feel a stretch. STEP 3: Hold 10 seconds. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Knee Flexion Chair Stretch POSITION: Put affected leg up on chair, or a step stool if unable to reach chair height. STEP 1: Slowly rock forward using your hands to bring the body closer to the front leg. STEP 2: Hold for 10 seconds. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Passive Knee Extension POSITION: Place a rolled towel under your ankle while sitting with your legs out. STEP 1: Place an ice pack on your knee. STEP 2: Relax the leg and let the knee straighten. REPS: Hold for 10 to 15 minutes. FREQUENCY: Twice per day

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Strengthening Quadriceps Set POSITION: Sit or lie on your back with leg straight. STEP 1: Place a small, rolled towel under your involved knee.

STEP 2: Press the back of your knee downward by tightening your thigh muscle.

REPS: Hold for 10 seconds. SETS: Perform 10 times to desired leg(s). FREQUENCY: 3 to 5 times per day

Straight Leg Raise POSITION: Lie on back with involved knee straight and the other knee bent. STEP 1: Keep the leg completely straight, then raise it about 16 inches up to height of opposite knee.

STEP 2: Slowly lower the involved leg back to starting position.

REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Terminal Knee Extension POSITION: Standing up, make a loop with exercise band; securely attach one end at knee level to a fixed structure, place your knee inside the loop, and take up the slack. STEP 1: Slowly bend and straighten your knees, stretching the band as you extend your knee backward. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Keep the band wrapped above your knee joint.

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Prone Hip Extension POSITION: Lie on belly with pillow under abdomen and pelvis. STEP 1: Raise involved leg off floor by squeezing the buttocks and keeping the knee straight. STEP 2: Hold for 2 seconds, then slowly relax leg back down. REPS: Perform 10 times. SETS: Three sets to desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Alternatively

Alternatively

Level 2

Alternatively

Squat POSITION: Stand with your feet hip-width apart while facing a mirror or having a partner watch you. STEP 1: Unlock your hips to sit down and back as far as you can comfortably. STEP 2: Return to standing position following the same path as you came down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Watch that your chest stays tall, your hips shift back, and your knees stay in line with the hips and ankles. Make sure you do not fold over or arch up. Your eyes should follow the path of the motion. Keep your weight evenly distributed on both sides. To make it easier, do not go down as far or use a chair behind you. ALTERNATIVELY: You can do it against a wall or squat onto a chair to make exercise easier. LEVEL 2: You can try placing a mini band above the knees to get better buttock engagement.

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Level 2

Level 2

Level 3

Level 3

Squat on a Wedge POSITION: Stand with both feet on a 25° to 45° wedge or board, with your feet hip-width apart while supporting yourself with a hand rail or balance stick, if needed; face a mirror or have a partner watch you. STEP 1: Unlock your hips to sit down and back as far as you can comfortably. STEP 2: Return to standing position following the same path as you came down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Watch that your chest stays tall, your hips shift back, and your knees stay in line with the hips and ankles. Make sure you do not fold over or arch up. Your eyes should follow the path of the motion. Keep your weight evenly distributed on both sides. To make it easier, do not go down as far or use a chair behind you. LEVEL 2: You can try placing a mini band above the knees to get better buttock engagement. LEVEL 3: Perform with a single leg.

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Side-Lying Hip Abduction With Towel Against Wall POSITION: Lie on side with bottom leg’s knee bent to hip level and top leg against wall pushing into towel. STEP 1: As you push into towel, slowly lift leg, contracting your buttocks. STEP 2: Slowly bring leg back down to parallel, keeping heel pushing into towel. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: This exercise can also be performed with a sock on against a wall.

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Level 2

Level 2

Level 3

Bridge POSITION: Lie on your back with both knees bent, your feet hip-distance apart, and arms relaxed by your sides. STEP 1: Tighten your abdominals and your buttocks. STEP 2: Lift your buttocks off the mat until your hips are level. STEP 3: Hold the position for 2 to 3 seconds and then slowly lower yourself down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: You should feel this in the buttocks. If your back hurts while doing this exercise, make sure you are contracting your abdominals and do not lift your hips as high. LEVEL 2: Perform bridge as above, then slowly march in place by lifting each foot off the mat in alternating fashion; focus on engaging the buttock of the leg that is down.

LEVEL 3: Perform a single leg bridge with the nonworking leg pointed straight out, and alternate legs after 10 reps.

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Level 2

Forward Step Up POSITION: Stand in front of a 6- or 8-inch step with good posture. STEP 1: Tighten your abdominals and buttocks. STEP 2: Step up onto the step by squeezing your buttocks, keeping your torso steady and your hip, knee, and ankle in line.

STEP 3: Return to the starting position by steadily stepping back down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week LEVEL 2: When you can complete three sets of 10 reps with proper form on the 6-inch step, add 5-lb dumbbells, then 10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with proper form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

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Level 2

Forward Step Down POSITION: Stand on a 6- or 8-inch step with your hands on your hips. STEP 1: Slowly lower your heel to the floor, while keeping your hips level and the hip, knee, and ankle of the standing leg aligned as you lower and land softly with control.

STEP 2: Return to starting position. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: This exercise is important for developing the ability to decelerate while maintaining good alignment. So perform slowly and with focus. Better to do fewer repetitions of good quality than rush through three sets of 10 each. LEVEL 2: When you can complete three sets of 10 repetitions with proper form on the 6-inch step, add 5-lb dumbbells, then 10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with proper form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

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Level 2

Level 3

Side Plank POSITION: Lie on your side, bend your knees to 90°, and put your arm with your elbow bent on the ground. STEP 1: Slowly bring your hips off the ground to where your body is straight. STEP 2: Hold that position for 30 seconds or for as long as you can. SETS: Two or three FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, you should feel the muscles of your abdomen and hip on the side facing the ground contracting as well as your abdominal muscles. The goal is to work your way to holding the position for 30 to 60 seconds at a time. LEVEL 2: This is similar to the first position, except that you should extend your knees and lift your entire body and knees off the ground such that one elbow and the outside of your foot are touching the ground.

LEVEL 3: This is similar to Level 2, except that you should lift your top leg and/or arm into the air in an abducted position (away from the body) with a straight knee or elbow.

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Proprioception/Functional Level 2

Single Leg Balance POSITION: Standing STEP 1: Stand on one leg with your knee slightly bent and hands on your hips, while keeping your hips level and standing tall and straight.

STEP 2: Tighten your abdominals and hold your position.

NOTE: Make sure you do not sink into your hip or lean to the side. REPS: Hold for 30 seconds. SETS: Three sets on desired side with a 30-second break between sets

FREQUENCY: 3 to 5 times per week LEVEL 2: Slowly look side to side, and then up and down. Level 3

Level 4

LEVEL 3: Move your raised leg to the side a bit (do not hike your hip); then move leg back in.

LEVEL 4: Move your raised leg forward and backward from your hip slowly.

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Level 2

Level 3

Single Leg Deadlift POSITION: Standing STEP 1: Stand on one leg with your knee slightly bent and tighten the buttock of the standing leg, while keeping your hips level and not sinking into your hip or leaning to the side.

STEP 2: Tighten your abdominals. STEP 3: Bend forward by hinging back on the hip of the standing leg, while keeping the knee of the stance leg slightly bent and keeping the buttock of the standing leg engaged such that your hip does not jut out to the side.

STEP 4: Extend your opposite leg out behind you as you go down to maintain a straight line with your body (head, neck, back, leg), and keep your hips even.

STEP 5: Keeping your back straight, bring yourself back up to the starting position by tightening your buttocks. REPS: Perform 10 times. SETS: Three sets on desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Lower only to a depth that allows you to maintain proper form. Stop when you feel your back start to round, your hip jut out, or a stretch in your hamstrings. LEVEL 2: You can hold a stick with both hands along your spine. The stick should not come off your back as you go down into the deadlift.

LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do not let the weight pull your back out of alignment; you must control the weight.

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Windmill POSITION: Standing STEP 1: Stand on one leg while stabilizing your glutes and core. STEP 2: Hinge from the hip such that your trunk is parallel to the floor, and place your arms out perpendicular to your trunk and parallel to the floor.

STEP 3: Bring one arm down toward the floor, then bring it back to start position. STEP 4: Alternate to the other arm. REPS: Alternate 10 repetitions on each arm, maintaining stability over the affected leg. SETS: Three sets on desired side(s) with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Single Leg Squat POSITION: Stand with feet apart and your knees slightly bent. STEP 1: Shift your weight such that you are standing on one leg. STEP 2: Slowly squat down on one leg, sitting back through the hips, bending your hip and knee. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Squat as deep as you can while maintaining balance, hips even, and hips/knees/ankles in line. Do not let your knee collapse in. Furthermore, if you are trying to isolate the patella and/or quadriceps tendon, perform on a wedge as shown earlier. OPTIONS: Try putting the other free leg in different positions: in front (harder), next to you, or behind you (easier).

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REFERENCES 1. Logerstedt D, Arundale A, Lynch A, et al. A conceptual framework for a sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC). Braz J Phys Ther. 2015;19(5):340–359. doi:10.1590/bjpt-rbf.2014.0116. 2. Frizziero A, Trainito S, Oliva F, et al. The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull. 2014;110(1):47–75. doi:10.1093/bmb/ldu006. 3. Busija L, Bridgett L, Williams SRM, et al. Osteoarthritis. Best Pract Res Clin Rheumatol. 2010;24(6):757–768. doi:10.1016/j.berh.2010.11.001. 4. Rannou F, Poiraudeau S. Non-pharmacological approaches for the treatment of osteoarthritis. Best Pract Res Clin Rheumatol. 2010;24:93–106. doi:10.1016/j.berh.2009.08.013. 5. Nguyen C, Lefèvre-Colau MM, Poiraudeau S, et al. Rehabilitation (exercise and strength training) and osteoarthritis: a critical narrative review. Ann Phys Rehabil Med. 2016;59(3):190– 195. doi:10.1016/j.rehab.2016.02.010. 6. Baliunas AJ, Hurwitz DE, Ryals AB, et al. Increased knee joint loads during walking are present in subjects with knee osteoarthritis. Osteoarthritis Cartilage. 2002;10:573–579. doi:10.1053/joca.2002.0797. 7. Woollard JD, Gil AB, Sparto P, et al. Change in knee cartilage volume in individuals completing a therapeutic exercise program for knee osteoarthritis. J Orthop Sports Phys Ther. 2011;41(10):708–722. doi:10.2519/jospt.2011.3633. 8. Willson JD, Kernozek TW, Arndt RL, et al. Gluteal muscle activation during running in females with and without patellofemoral pain syndrome. Clin Biomech (Bristol, Avon). 2011;26(7):735–740. doi:10.1016/j.clinbiomech.2011.02.012. 9. Baldon Rde M, Serrão FV, Scattone Silva R, et al. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2014;44(4):240–A8. doi:10.2519/ jospt.2014.4940. 10. Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep. 2013;12(3):175–182. doi:10.1249/JSR.0b013e3182933761. 11. Schwartz A, Watson JN, Hutchinson MR. Patellar tendinopathy. Sports Health. 2015;7(5):415– 420. doi:10.1177/1941738114568775. 12. Hirschmann MT, Müller W. Complex function of the knee joint: the current understanding of the knee. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2780–2788. doi:10.1007/ s00167-015-3619-3. 13. Macleod TD, Snyder-Mackler L, Buchanan TS. Differences in neuromuscular control and quadriceps morphology between potential copers and noncopers following anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2014;44(2):76–84. doi:10.2519/ jospt.2014.4876. 14. Nilstad A, Krosshaug T, Mok KM, et al. Association between anatomical characteristics, knee laxity, muscle strength, and peak knee valgus during vertical drop-jump landings. J Orthop Sports Phys Ther. 2015;45(12):998–1005. doi:10.2519/jospt.2015.5612. 15. Lubahn AJ, Kernozek TW, Tyson TL, et al. Hip muscle activation and knee frontal plane motion during weight bearing therapeutic exercises. Int J Sports Phys Ther. 2011;6(2):92–103. PubMed PMID: 21713231. 16. Rath E, Richmond JC. The menisci: basic science and advances in treatment. Br J Sports Med. 2000;34(4):252–257. doi:10.1136/bjsm.34.4.252. 17. Kak HB, Park SJ, Park BJ. The effect of hip abductor exercise on muscle strength and trunk stability after an injury of the lower extremities. J Phys Ther Sci. 2016;28(3):932–935. doi:10.1589/jpts.28.932.

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18. Palmer K, Hebron C, Williams JM. A randomised trial into the effect of an isolated hip abductor strengthening programme and a functional motor control programme on knee kinematics and hip muscle strength. BMC Musculoskelet Disord. 2015;16:105. doi:10.1186/ s12891-015-0563-9. 19. Baker RL, Fredericson M. Iliotibial band syndrome in runners: biomechanical implications and exercise interventions. Phys Med Rehabil Clin N Am. 2016;27(1):53–77. doi:10.1016/j. pmr.2015.08.001. 20. Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;3:169–175. PubMed PMID: 10959926. 21. Distefano LJ, Blackburn JT, Marshall SW, et al. Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. 2009;7:532–540. doi:10.2519/jospt.2009.2796.

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CHAPTER

6

Home Exercise Programs for Ankle and Foot Injuries Ian W. Wendel

INTRODUCTION Ankle and foot injuries are different from many other musculoskeletal injuries as they are difficult to rest, given most people’s daily requirement for ambulation. While many practitioners may advocate for extensive nonweight-bearing for ankle and foot soft tissue injuries, there is no evidence to our knowledge to support this practice. However, there is evidence that early weight-bearing at 2 days and before 4 weeks shows no difference in outcomes of ankle sprains and Achilles tendon tears, respectively, and when weight-bearing at 2 days with an ankle sprain, there was less pain at 3 weeks (1,2). Similar findings have been seen in patients post ankle surgery (3). Accordingly, practitioners should avoid excessive nonweight-bearing and not be afraid to advance a patient’s exercise program with soft tissue ankle and foot injuries, as well as postsurgical patients, keeping in mind the surgeon’s restrictions. The basic stepwise rehabilitation principles of decreasing pain and improving range of motion (ROM), strength, and proprioception, followed by sport- or activity-related training, should be followed. General principles to follow for ankle and foot injuries when addressing exercise are to return ROM to preinjury level and improve heel cord ROM, improve proprioception, and address more proximal biomechanical deficits. Furthermore, in the setting of tendinopathy, progress to eccentric strengthening.

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • •

Restoration of ROM and flexibility (ankle dorsiflexion and gastrocnemius flexibility) Initiation of strengthening (foot intrinsics)

Intermediate •

Progression of strengthening (ankle)

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Advanced • •

Restoration of strengthening, including eccentric tendinopathies Improvement of ankle proprioception and coordination

strengthening

for

ANKLE SPRAIN Ankle sprains are a very common occurrence, and many people do not seek medical care and overcome the sprain with rest, ice, compression, and elevation. Unfortunately, these rehabilitation principles do not address ankle proprioception. In many cases when an ankle is sprained, ankle proprioception becomes impaired and can set the patient up for future sprains. Accordingly, particular attention should be paid to proprioception when treating ankle sprains to avoid chronic ankle instability (4,5). Furthermore, a dynamic exercise program with predictable and unpredictable changes in direction as well as landing from a hop may lead to better outcomes than less dynamic balance protocols (6). It has also been suggested in the literature that altered proximal muscle function and biomechanics have been seen following unilateral ankle sprains; therefore, it is important to address pelvic and core strength as well (7).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Calf stretch A or B, alphabets STRENGTHENING: Marble pick-ups

Intermediate Continue Foundational exercises STRENGTHENING: Concentric ankle inversion strengthening, concentric ankle eversion strengthening, concentric ankle dorsiflexion strengthening

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch, wobble board

ACHILLES TENDINOPATHY Achilles tendinopathy is a condition that plagues many patients as its rehabilitation can be lengthy and lead to procedures to alleviate symptoms. While the prior mentioned principles should be performed with rehabilitation of Achilles tendinopathy, the addition of eccentric strengthening of the Achilles tendon has been shown to be quite beneficial (8–11).

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Foam roller (lower leg), towel stretch, calf Stretch A or B, soleus stretch STRENGTHENING: Towel scrunches

Intermediate Continue Foundational exercises STRENGTHENING: Heel raises

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Eccentric Achilles strengthening PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch

POSTERIOR TIBIAL TENDINOPATHY Posterior tibial tendinopathy is less frequently encountered by the practitioner than the conditions mentioned earlier. With this in mind, strengthening of the tendon is important as with all tendinopathies. For the posterior tibial tendon, active resistance of foot abduction would be considered eccentric strengthening, while concentric strengthening would be foot adduction against resistance (12,13). Kulig et al. (12) have showed that eccentric strengthening of the posterior tibial tendon is more important than concentric strengthening or stretching in this condition.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Foam roller (lower leg), towel stretch, calf stretch A or B STRENGTHENING: Towel scrunches

Intermediate Continue Foundational exercises STRENGTHENING: Concentric ankle inversion strengthening, heel raises

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Eccentric posterior tibial tendon strengthening PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch

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PLANTAR FASCIOSIS Plantar fasciosis can be very difficult to treat.The literature suggests that stretching of the plantar fascia may be the most important exercise to help relieve a patient’s symptoms (14,15). Foot intrinsic strengthening should also be added to the basic foot and ankle exercise program, but the literature is not clear whether these exercises are beneficial.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Can roll, towel stretch, plantar fascia stretch STRENGTHENING: Towel scrunches, marble pick-ups

Intermediate Continue Foundational exercises STRENGTHENING: Heel raises

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Eccentric Achilles strengthening PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch

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HANDOUTS ROM/Stretching/Mobility Towel Stretch POSITION: Sitting STEP 1: Loop towel over ball of foot and stretch calf. STEP 2: Switch legs. REPS: Hold for 10 seconds. SETS: Three sets with a 30-second break between sets FREQUENCY: Once daily

Calf Stretch A POSITION: Standing STEP 1: Stand with one leg in front of the other. STEP 2: Bend the front knee while the back leg is straight; the heels should be on the ground.

STEP 3: Switch legs. REPS: Hold for 10 seconds. SETS: Three sets to both sides with a 30-second break between sets FREQUENCY: Once daily

Calf Stretch B POSITION: Get into a push-up–like position. STEP 1: Cross one leg over the other, with the bottom leg’s heel on the ground.

STEP 2: Switch legs. REPS: Hold for 10 seconds. SETS: Three sets to both sides with a 30-second break between sets

FREQUENCY: Once daily Copyright Springer Publishing Company

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Soleus Stretch POSITION: Standing STEP 1: Stand with one leg in front of the other. STEP 2: Bend the front knee while the back knee is also bent, and the heels should be on the ground.

STEP 3: Switch legs. REPS: Hold for 10 seconds. SETS: Three sets to both sides with a 30-second break between sets FREQUENCY: Once daily

Can Roll POSITION: Sit on a chair. STEP 1: Place can under sole of foot (can use a golf or lacrosse ball as well).

STEP 2: Roll back and forth. STEP 3: Switch legs. REPS: Perform for 2 minutes. SETS: One set to both sides FREQUENCY: Once daily

Alphabets POSITION: Sitting on chair STEP 1: Write out the alphabet in the air with the injured foot.

REPS: Go through entire alphabets. SETS: Three sets to injured side with a 30-second break between sets

FREQUENCY: Once daily

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Plantar Fascia Stretch POSITION: Sit on chair. STEP 1: Cross injured leg over uninjured leg. STEP 2: Grab heel and ball of foot and stretch apart. REPS: Hold for 10 seconds. SETS: Three sets to both sides with a 30-second break between sets FREQUENCY: Once daily

Foam Roller (lower leg) POSITION: Sitting or lying on side on the ground STEP 1: Place foam roller under calf or side of lower leg. STEP 2: Rock back and forth, massaging desired area. REPS: Perform for 1 to 2 minutes. SETS: One set to injured side FREQUENCY: Once daily

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Strengthening Towel Scrunches POSITION: Sitting on a chair STEP 1: Grab a towel with toes. STEP 2: Hold for 1 to 2 seconds, then relax. REPS: Perform with both feet 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Marble Pick-ups POSITION: Sitting on a chair STEP 1: Grab a marble (or similar sized objects) with toes. STEP 2: Move marbles to the left and the right and put them into a cup.

REPS: Perform 10 pick-ups. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Concentric Ankle Inversion Strengthening POSITION: Sitting on a chair STEP 1: Place Theraband loop around desired foot. STEP 2: Bring foot inward at the ankle and create increasing resistance in the band.

STEP 3: Slowly return to starting position. REPS: Perform 10 times. SETS: Three sets to desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Concentric Ankle Eversion Strengthening POSITION: Sitting on a chair STEP 1: Place Theraband loop around desired foot. STEP 2: Bring foot outward at the ankle and create increasing resistance in the band.

STEP 3: Slowly return to starting position. REPS: Perform 10 times. SETS: Three sets to desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Concentric Ankle Dorsiflexion Strengthening POSITION: Sitting on ground STEP 1: Place Theraband loop around desired foot. STEP 2: Bring foot toward you at the ankle and create increasing resistance in the band.

STEP 3: Slowly return to starting position. REPS: Perform 10 times. SETS: Three sets to desired side with a 30-second break between sets

FREQUENCY: 3 to 5 times per week

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Heel Raises POSITION: Standing STEP 1: Stand next to chair or table, if necessary, to aid with balance. STEP 2: Go up on toes, then lower oneself slowly. ALTERNATIVELY: To make this more challenging, perform on one leg at a time. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

Eccentric Achilles Strengthening POSITION: Standing on stair STEP 1: Use uninjured leg to position self on tippy toes on the edge of a step. STEP 2: Slowly lower body on injured side and lower past the level of the step, if possible. ALTERNATIVELY: Go up on toes with both feet and slowly lower self on the injured side past the level of step, if possible.

REPS: Perform 10 times to the injured side: may perform to both sides. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Eccentric Posterior Tibial Tendon Strengthening POSITION: Sitting on a table or bed holding a Theraband around forefoot in the neutral position STEP 1: Push forefoot down and in. STEP 2: Stretch Theraband to unilateral shoulder. STEP 3: Slowly return foot to starting position and go to up and out position. REPS: Perform 10 times to the injured side: may perform to both sides. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week

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Proprioception/Functional Single Leg Taps POSITION: Standing STEP 1: Stand on the injured leg. STEP 2: With the uninjured leg, slowly reach out in six different directions as far as you can, drawing an imaginary asterisk.

SETS: Perform five sets with a 30-second break between sets, and then perform to uninjured leg.

FREQUENCY: 3 to 5 times per week

Single Leg Tennis Ball Catch POSITION: Standing STEP 1: Stand on the injured leg. STEP 2: Throw a ball against a wall and catch it or have a partner throw a ball at you.

REPS: Catch ball 10 times. SETS: Three sets with a 30-second break between sets, and then perform to uninjured leg.

FREQUENCY: 3 to 5 times per week LEVEL 2: Stand on a pillow or piece of foam; the ball should be thrown to the sides such that the participant needs to reach to catch the ball.

LEVEL 3: Hop on one foot on level ground; the ball should be thrown to the sides such that the participant needs to reach to catch the ball.

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Wobble Board POSITION: Sit on chair with wobble board on the ground. STEP 1: Rotate wobble board in circles in each direction, keeping one edge continually on the ground. Then rock forward and back and side to side.

STEP 2: Stand on the wobble board for 1 minute using the chair for support.

STEP 3: Rest for 30 seconds. STEP 4: Stand on wobble board and rotate in circles in each direction, keeping one edge continually on the ground. Then rock forward and back and side to side for 2 minutes.

REPS: One to three times SETS: One to three FREQUENCY: 3 to 5 times per week

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REFERENCES 1. van der Eng DM, Schepers T, Goslings JC, et al. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot Ankle Surg. 2013;52(5):622–628. doi:10.1053/j.jfas.2013.03.027. 2. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. 1994;22(1):83–88. doi:10.1177/036354659402200115. 3. Lee DH, Lee KB, Jung ST, et al. Comparison of early versus delayed weightbearing outcomes after microfracture for small to midsized osteochondral lesions of the talus. Am J Sports Med. 2012;40(9):2023–2028. doi:10.1177/0363546512455316. 4. Eils E, Rosenbaum D. A multi-station proprioceptive exercise program in patients with ankle instability. Med Sci Sports Exerc. 2001;33(12):1991–1998. doi:10.1097/00005768-200112000-00003. 5. Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med. 2009;39(3):207–224. doi:10.2165/00007256-200939030-00003. 6. McKeon PO, Ingersoll CD, Kerrigan DC, et al. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008;40(10):1810–1819. doi:10.1249/MSS.0b013e31817e0f92. 7. Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 1994;74(1):17–28; discussion 28–31. doi:10.1093/ptj/74.1.17. 8. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38(1):8–11; discussion 11. doi:10.1136/bjsm.2001.000284. 9. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):4247. doi:10.1007/s001670000148. 10. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366. doi:10.1177/0 3635465980260030301. 11. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heeldrop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214–218. doi:10.1136/bjsports-2011-090035. 12. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009;89(1):26–37. doi:10.2522/ptj.20070242. 13. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006;45(5):508–521. doi:10.1093/rheumatology/kel046. 14. Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775–1781. doi:10.2106/JBJS.E.01281. 15. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85-A(7):1270–1277. doi:10.2106/00004623-200307000-00013.

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CHAPTER

7

Home Exercise Programs for Cervical Spine Injuries Gary Mascilak

INTRODUCTION An estimated 30% to 50% of the population experience some form of neck pain each year (1). In this chapter, we address four common disorders of the cervical spine, each condition unique to itself; however, some patients have multiple conditions presenting concomitantly. Once a diagnosis is made clinically, an appreciation for the specific individual characteristics of each patient must be considered in formulating a rehabilitation-based treatment plan. In best assisting these “cervical” patients, it is imperative that we accurately assess the contiguous areas of the body, such as the thoracic spine and scapular complex, to identify postural alignment, mobility, and stability dysfunctions so as to incorporate appropriate treatment and exercise-based interventions for these areas as well. It is still important to remember to progress patients in a stepwise manner through the rehabilitation program: first working on pain control, followed by working on range of motion (ROM), building strength and proprioception, then working on activity-related or sport-specific exercises. However, as many of us spend much of our day promoting poor posture, it is imperative that this be addressed at the initiation of the rehabilitation program.

DIRECTIONAL PREFERENCE Directional preference is an extremely important consideration in the design of any rehabilitation program involving the spine, particularly when considering the cervical spine’s vast degree of mobility in all cardinal planes. Simply stated, directional preference refers to the performance of exercises in a specific direction that reduces neck pain in this case, and if present, “centralizes” peripheral radicular symptoms toward the axial spine. Most clinicians treating mechanical pain are quite familiar with the McKenzie Classification method, which basically categorizes symptoms as derangement, dysfunction, or postural in nature (2). The McKenzie Diagnosis and Therapy (MDT) method is considered by many in the rehabilitation field to be the standard in diagnosing and treating patients who present with radicular symptoms, and focuses on doing exercises in the preferred direction.

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The preferred direction of treatment is determined following a thorough evaluation that uses sustained postures and/or specific repeated movements that reduce pain, and again demonstrate centralization of radicular symptoms if present. A flexion versus extension bias must be determined, as well as a frontal and transverse plane bias with lateral flexion and rotation respectively. Additionally, it is just as important in the assessment process to identify and determine which positions and movements cause peripheralization of symptoms, and then avoid these positions as well. Regardless of the underlying presentation, be it an acute disc herniation or degenerative foraminal stenosis causing radiculopathy, or myofascial or facet mediated referred pain, the clinically determined directional bias should be considered in the prescription of all ROM, stretching, and strengthening exercises in cervical spine patients that are appropriate for therapeutic exercise with no concern for instability of the cervical spine.

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • • •

Restoration of proper posture Determination of directional bias if applicable Restoration of cervical ROM and mobility

Intermediate •

Restoration of cervical and thoracic muscular strength, including stabilizing musculature

Advanced •

Improvement of proprioception and coordinated movements

CERVICAL FACET ARTHROPATHY Neck pain is the second most common musculoskeletal complaint, affecting approximately 30% to 50% of the population each year (3). Among patients with chronic neck pain, studies have cited the prevalence of zygapophyseal or facet-mediated pain to be between 25% to 65% (4–6). The cervical facet joints are formed from the articulation of the inferior articular process (IAP) of the vertebra above and the superior articular process (SAP) of the vertebra below, and have a rich nociceptive supply innervated by the medial branches of the cervical dorsal rami or variations of the medial branches at some levels. Facet pain can present with local symptoms, as well as a sclerotogenous referred pain. Certain motions that bring the involved joint(s) into a closed packed position can provoke facet-mediated pain, particularly during an acute inflammatory stage, and therefore should be avoided. Directional preference testing during initial evaluation will clearly reveal such provocative positions and ranges with the use of sustained postures and repeated motions. Typically, cervical extension and lateral flexion can irritate the cervical facet joints and provoke pain, and thus these exercises may want to be avoided initially, if not all together.

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Recommended Exercises Foundational ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises STRENGTHENING: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening PROPRIOCEPTION/FUNCTIONAL: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

CERVICAL DISC PATHOLOGY Estimates suggest that 20% of chronic neck pain may be due to cervical disc disruption (6). The cervical disc is comprised of a fibrous outer annulus and an inner, central jelly-like nucleus pulposus. A healthy, centrated nucleus pulposus allows for optimal discal shock attenuation with axial loads, while also offering generous ROM between the adjacent vertebral bodies. The posterolateral aspect of the annulus fibrosis of the disc is richly supplied with mechanoreceptors, as well as pain receptors that can allow for the perception of local neck pain and radiation of pain away from the axial spine toward the occiput, shoulder complex and/or upper extremity. Sustained computer and desk work, extended commute times in the car, even improper sleep postures can easily account for more than 75% of our day, and cause improper neck postures that result in prolonged static or repetitive microtraumas. This introduces stress to the disc and surrounding osseous, muscular, and ligamentous structures. Additionally, if the cervical spine is forcefully or traumatically moved in any direction, particularly flexion, cervical disc injury can ensue. Keeping the anatomy as well as the underlying cause(s) of the cervical disc pathology in mind is essential in prescribing exercises for a patient presenting with this condition. Exercises can be prescribed in a directional preference, or more commonly a neutral or isometric program is prescribed so as to not exacerbate symptoms.

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Recommended Exercises Foundational ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises STRENGTHENING: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening PROPRIOCEPTION/FUNCTIONAL: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

CERVICAL RADICULOPATHY Dysfunction or pathology of the nerve roots of the cervical spine is referred to as cervical radiculopathy. The prevalence of cervical radiculopathy is less frequent than lumbosacral radiculopathy, but estimated to still be as high as 85 per 100,000 (7). The most commonly affected roots are the C7 level, at 60% and C6, at approximately 25% (8). Managing pain is the first step in treatment, where activity modification is discussed with the patient. Anti-inflammatories and analgesic medications are often prescribed to assist the patient in initiating early mobility exercises, which studies demonstrate are often more effective in reducing pain and disability than the use of soft collars and recommendations for bedrest (9). Passive modalities such as heat, cold, ultrasound, and transcutaneous electrical nerve stimulation (TENS), once all contraindications are considered relative to each patient, can also have a positive effect in pain management in allowing initiation of early mobility and muscle lengthening. Other forms of treatment to assist in pain reduction and allow for earlier mobility activities to restore function are acupuncture, dry needling technique, and various forms of kinesiotaping. The MDT method, as discussed earlier, is based on the concept of centralization, where spinally produced peripheral, radicular symptoms are caused to move “centrally” toward the spine with performance of specific, examination-based repeated movements or by assuming a specific, sustained posture (10). The patient is also educated to avoid specific postures or repeated movements that are also identified on mechanical examination to be provocative of peripheral symptoms. Postural education and retraining is of the utmost importance in treating all spine-related disorders, particularly cervical radiculopathy.

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Oftentimes, a patient presenting with radicular symptoms may possess radiologic and/or advanced imaging evidence of both stenosis (central or lateral recess) from arthritic changes or cervical disc involvement. This demonstrates the significance for a thorough clinical examination that again incorporates the use of repeated movements to determine the directional preference for treatment (i.e., flexion vs. extension; contralateral lateral flexion vs. ipsilateral lateral flexion in reference to the side of radicular symptoms). This directional bias should be utilized in the consideration of all ROM, stretching, and strengthening exercises as well.

Recommended Exercises Foundational ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retractions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rotation mobility (thread the needle)

Intermediate Continue Foundational exercises STRENGTHENING: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening PROPRIOCEPTION/FUNCTIONAL: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

UPPER CROSSED POSTURE The problem with most cervical disorders is the commonly encountered forward head position (FHP) with rounded shoulders and a hyperkyphotic thoracic spine with loss of associated cervical extension and scapular retraction. Janda describes this presentation as an upper crossed syndrome (UCS), with predictable alternating patterns of muscle facilitation and inhibition (11). Attempting to strengthen the weak and inhibited rhomboids, middle and lower trapezius, and deep cervical neck flexors that are commonly seen in UCS will not be maximized until the facilitated and tight antagonist suboccipitals, pectoral, and upper trapezius muscles are properly released and lengthened. The next stage of treatment, as depicted in Assessment and Treatment of Muscle Imbalance: The Janda Approach, is to increase afferent input to facilitate reflexive stabilization with a specific progression of proprioceptively rich exercises,

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resulting in the ability to maintain proper muscle tone and coordinated movements. Finally, he believed that the endurance component needs to be addressed in repetitive, coordinated movement patterns.

Weak: Cervical flexors

Tight: Pectoralis

Tight: Suboccipitals Upper trapezius/ levator

Weak: Rhomboid Lower trapezius

Recommended Exercises Foundational ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retraction (chin glide), suboccipital stretch, levator scapula stretch, upper trapezius stretch, pectoral stretch, suboccipital release, prone pectoral release, levator scapula release

Intermediate Continue Foundational exercises STRENGTHENING: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical flexor strengthening PROPRIOCEPTION/FUNCTIONAL: Prone scapular retraction

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Wall stick-ups, Prone “T,” “Y,” “I,” “W”

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HANDOUTS ROM/Flexibility/Mobility Seated Posture Correction (Bruegger’s) POSITION: Seated forward on the edge of the chair STEP 1: Sit with palms up with thumbs pointing backward.

STEP 2: Lift the chest, separate the knees, and draw the shoulder blades down and backward while gliding the chin straight backward.

STEP 3: Hold for 5 to 10 seconds. REPS: Repeat three to five times. SETS: One FREQUENCY: Every hour during sustained sitting

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Cervical Retraction (Chin Glide) POSITION: Supine (progress to seated) STEP 1: Engage abdominals by drawing the belly button toward the spine. STEP 2: Glide the chin straight backward while maintaining the gaze horizontally forward and hold for a count of 3. (Remember to continue to breathe deeply into the abdomen while relaxing the neck and chest wall.)

REPS: Repeat 10 to 15 times. SETS: Two to three FREQUENCY: 2 to 3 times per day

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Cervical Flexion/Extension POSITION: Seated in a supportive chair (Face a mirror for visual feedback.) STEP 1: Lift through the chest and perform a chin glide straight backward. STEP 2: Slowly and progressively, first draw the head downward toward the chest, followed by bringing the head backward as if nodding in a “YES” manner. STEP 3: Maintain chin glide throughout the motion. REPS: Repeat 15 times (5 reps at 50%, 5 reps at 75%, and 5 reps at 100% pain-free ROM). SETS: One set prior to your stretches FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

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Cervical Lateral Flexion POSITION: Seated in a supportive chair (Face a mirror for visual feedback.) STEP 1: Lift through the chest and perform a chin glide straight backward. STEP 2: Maintaining the chin glide and with the nose pointed forward, gently and progressively tilt the ear toward the shoulder in each direction. (Avoid turning the head.)

REPS: Repeat 15 times (5 reps at 50%, 5 reps at 75%, and 5 reps at 100% pain-free ROM). SETS: One set prior to your stretches FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

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Cervical Rotation POSITION: Seated in a supportive chair (Face a mirror for visual feedback.) STEP 1: Lift through the chest and perform a chin glide straight backward. STEP 2: Maintaining the chin glide throughout, gently and progressively turn the head toward each side as if simulating a “NO” gesture.

REPS: Repeat 15 times (5 reps at 50%, 5 reps at 75% and 5 reps at 100% pain-free ROM). SETS: One set prior to your stretches FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

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Suboccipital Stretch POSITION: Seated STEP 1: Perform a chin glide to place the ear vertically in line with the shoulder. STEP 2: Place both hands over the top of the head as shown and gently bring the chin to the chest; hold for 30 to 60 seconds.

STEP 3: Keeping the chin to the chest, turn the head slightly to the right and again draw the chin toward the chest. STEP 4: Hold for 30 to 60 seconds and repeat to the left. SETS: One to three FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

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Level 2

Levator Scapula Stretch POSITION: Seated in a supportive chair, with a tall chest and chin glide to align ears over the shoulders STEP 1: To stretch the RIGHT side, anchor your right hand to the chair seat or sit on hand. STEP 2: Tilt your left ear to the shoulder, turn the head to the left, and look downward. STEP 3: Once the tension from step 2 diminishes, place your left hand on the top of the head and guide the chin further downward toward the left hip.

STEP 4: Hold for 30 seconds to 2 minutes (or until a release in tension is perceived) and repeat on the opposite side. SETS: One to three FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician. LEVEL 2: Take the RIGHT anchored hand and reach to touch the right shoulder as pictured.

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Upper Trapezius Stretch POSITION: Seated in a supportive chair, with a tall chest and chin glide to align ears over the shoulders STEP 1: To stretch the RIGHT side, anchor your right hand to the chair seat or sit on hand.

STEP 2: Tilt the left ear toward the left shoulder until stretch is perceived, then increase the tension by slowly turning the head to the right.

STEP 3: Place the left hand on top of the head, and gently guide the left ear down and forward toward the left hip.

STEP 4: Hold for 30 seconds to 2 minutes, or until a release in tension is perceived, and repeat on the opposite side.

SETS: One to three FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

Middle Scalene Stretch POSITION: Seated in a supportive chair, with a tall chest and chin glide to align ears over the shoulders STEP 1: To stretch the RIGHT side, anchor your right hand to the chair seat.

STEP 2: Slowly tilt the left ear to the left shoulder, keeping the nose pointed forward.

STEP 3: Place the left hand on top of the head and further assist the left ear to the shoulder until a comfortable stretch is perceived.

STEP 4: Hold for 30 seconds to 2 minutes or until a release in tension is perceived, and repeat on the opposite side.

SETS: One to three FREQUENCY: 2 to 3 times per day NOTE: If neck pain or peripheral symptoms are produced, discontinue and contact your clinician.

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Alternatively

Single Arm Pectoral Stretch POSITION: Standing slightly in front of the doorway, with one forearm/hand supported with elbow above shoulder level STEP 1: Draw in the abdominals to prevent the low back from arching and perform a chin glide to align the ears over the shoulders.

STEP 2: Slowly turn the torso away from the support arm until a tolerable stretch is perceived. STEP 3: Hold for 30 seconds to 2 minutes or until a release in tension is perceived, and repeat on opposite side. ALTERNATIVELY: Standing in doorway or corner of a room as earlier described, stretch both arms at once without turning torso; instead, lean forward slightly until stretch is perceived.

SETS: One to three FREQUENCY: 2 to 3 times per day NOTE: Do NOT lean forward excessively, especially with a history of an unstable shoulder.

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Thoracic Rotation Mobility (Thread the Needle) POSITION: Kneeling on hands and knees STEP 1: Perform a cervical chin glide and stiffen the abdominals to prevent the back from arching. STEP 2: Slide the arm under the body with the palm up. STEP 3: Next, reach vertically upward toward the ceiling, while extending through the support shoulder. STEP 4: Follow the moving hand with the eyes by turning the head throughout the movement. REPS: Repeat 10 to 15 times on each side. SETS: Two FREQUENCY: 3 to 5 times per week

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Suboccipital Release POSITION: Supine (on back) with pillow under the knees STEP 1: Place tennis balls in the toe end of a sock and use a rubber band to keep them in place (or tape the balls together in the shape of a peanut).

STEP 2: Place the balls under the base of the skull and perform a chin glide. STEP 3: Hold for 15 to 30 seconds, then release the chin glide. (REMEMBER TO UTILIZE DIAPHRAGMATIC BELLY BREATHS DURING THE RELEASE.) REPS: Repeat five times. SETS: one FREQUENCY: 2 to 3 times per day

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Prone Pectoral Release POSITION: Prone (on belly) with the arm out to the side and head turned away and supported as shown. STEP 1: Place a tennis ball under the chest seeking to locate tender points along the length of the pectoral muscle extending from the sternum to the front of the shoulder.

STEP 2: Hold each tender point for 30 to 90 seconds, and then move the arm slightly to continue to release the muscle from a different angle.

STEP 3: Move the ball to locate a new tender point. (REMEMBER TO UTILIZE PROPER DIAPHRAGMATIC BELLY BREATHS DURING THIS RELEASE.) FREQUENCY: 2 to 3 times per day

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Strengthening

Cervical Isometrics—Cervical Retraction POSITION: Standing STEP 1: Put hands behind head. STEP 2: Perform chin glide by retracting chin backward and resisting with hands. STEP 3: Hold for a count of 3 and release. REPS: Repeat 10 to 15 times. SETS: Two FREQUENCY: 3 to 5 times per week

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Cervical Isometrics—Lateral Side Bending POSITION: Standing STEP 1: Place right hand against right side of head. STEP 2: Push against right hand with head while resisting with right hand. STEP 3: Hold for a count of 3 and release. STEP 4: Switch to left side when finished with repetitions. REPS: Repeat 10 to 15 times to each side. SETS: Two FREQUENCY: 3 to 5 times per week

Cervical Isometrics—Cervical Flexion POSITION: Standing STEP 1: Place hands on forehead. STEP 2: Gently press the forehead into hands and resist with hands.

STEP 3: Hold for a count of 3 and release. REPS: Repeat 10 to 15 times. SETS: Two FREQUENCY: 3 to 5 times per week

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Deep Cervical Flexor Strengthening POSITION: Supine on the floor STEP 1: Perform a chin glide to align the ears with the shoulders, while maintaining a tall chest and engaging abdominal muscles.

STEP 2: Maintain the chin glide and segmentally lift the top of the head, drawing the chin toward the sternum while keeping the shoulder blades on the floor.

STEP 3: Pause at the top for a count of 2 and slowly lower from the bottom of the neck segmentally to the top of the head, again maintaining the chin tuck throughout the descent.

REPS: Repeat 10 to 15 times. SETS: Two FREQUENCY: 3 to 5 times per week NOTE: Discontinue and consult your clinician if pain or upper extremity symptoms are perceived.

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Proprioception/Functional

Prone Scapular Retractions POSITION: Lying on stomach with arms out to side and bent to 90°. STEP 1: Squeeze your shoulder blades together by raising your arms and elbows toward the ceiling, and keep your chest and forehead touching the floor or table at all times.

STEP 2: Hold at top for 2 seconds and then slowly lower to starting position. REPS: Perform 10 times. SETS: Three sets with 30 seconds in between sets FREQUENCY: 3 to 5 times per week

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Modification 1

Modification 2

Wall Stick-ups POSITION: Stand with back and neck against the wall, with the elbows flexed 90° to shoulder height and back of the hands touching the wall.

STEP 1: Perform a chin glide to align the ears with the shoulders, lift the chest, and stiffen the abdominals to bring the small of the back into the wall.

MODIFICATION 1: If this position is initially too difficult, bring the heels away from the wall and flex the knees and hips until the head and low back make contact with the wall.

MODIFICATION 2: If shoulder mobility is limited, the elbows can be straightened and the arms started in a lower position on the wall, again with the palms facing forward. STEP 2: Keeping your low back, forearms, and the back of the hand in contact with the wall, slowly slide the arms upward toward the ceiling as high as possible without losing contact with the wall.

STEP 3: Pause at the top and reset the muscles in Step 1 before slowly lowering the arms back down to the start position.

STEP 4: Remember to maintain good belly breathing throughout this exercise. REPS: Repeat 10 to 15 times. SETS: Two to three FREQUENCY: 3 to 5 times per week

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Prone “T,” “Y,” ”I,” “W” POSITION: Face down on the floor with a towel under the forehead STEP 1: Engage the gluteals and abdominal muscles by drawing the belly button toward the spine. STEP 2: Place the arms straight out to the side at a 90° angle with the body and with thumbs up toward the ceiling. STEP 3: Draw the shoulder blades down and back and elevate the arms off the floor, and hold for a count of 3. STEP 4: Proceed to elevate the arms at progressive levels to resemble the letters “Y” and “I,” before bending the elbows and bringing the arms to the side to make a “W”.

STEP 5: Hold all four positions for a count of 3, with the thumbs pointed up toward the ceiling. STEP 6: Reset the gluteals, abdominals, and shoulder blades and repeat. REPS: Repeat 3 to 5 times. SETS: Two to three FREQUENCY: 3 to 5 times per week NOTE: T and Y are likely of most value and should be concentrated on.

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REFERENCES 1. Wishart BD, Galgon HR, Benaquista Desipio GM. Chapter 40: Other cervical spine disorders. In: Wyss J, Patel A (Eds.), Therapeutic Programs for Musculoskeletal Disorders. New York, NY: Demos Publishing; 2013:289. 2. McKenzie RA. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Raumati Beach, New Zealand: Spinal Publications; 1990. 3. Ferrari R. Russell AS. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol. 2003;17(1):57–70. doi:10.1016/S1521-6942(02)00097-9. 4. Aprill C, Bogduk N. The prevalence of cervical zygoapophyseal joint pain. A first approximation. Spine (Phila Pa 1976). 1992;17:744–747. doi:10.1097/00007632-199207000-00003. 5. Barnsley L, Lord SM, Wallis BJ, et al. The prevalence of chronic cervical zygoapophyseal joint pain after whiplash. Spine (Phila Pa 1976). 1995;20(1):20–25; discussion 26. doi:10.1097/00007632-199501000-00004. 6. Braddon RL, Chan L, Harrast MA. Physical Medicine & Rehabilitation. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2011. 7. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. 1997;29(7):236–245. doi:10.1249/00005768-199707001-00006. 8. Radhakrishnan K, Litchy WJ, O’Fallon WM, et al. Epidemiology of cervical radiculopathy: a population based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117:325– 335. doi:10.1093/brain/117.2.325. 9. Mealy K, Brennan H, Fenelon DC. Early mobilization of acute whiplash injuries. Br Med J. 1986;292:656. doi:10.1136/bmj.292.6521.656. 10. McKenzie R. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikane, New Zealand: Spine Publications; 1981. 11. Page P, Frank C, Lardner F. Chapter 4: Pathomechanics of musculoskeletal pain and muscle imbalance. In: Assessment and Treatment of Muscle Imbalance: The Janda Approach. Champaign, IL: Human Kinetics; 2010:52–53.

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CHAPTER

8

Home Exercise Programs for Thoracic Spine Injuries Gary Mascilak

INTRODUCTION The thoracic spine has an unfounded identity crisis of sorts. It is often relatively ignored in comparison to the volume of attention and research its adjacent cervical and lumbar siblings receive in the literature. However, from a clinical perspective, the most knowledgeable biomechanical practitioners will always give the thoracic spine the due attention and respect it deserves, understanding its profound ability to affect movement and function throughout the body. The thoracic spine serves many functions based on its unique anatomic presentation; however, from a biomechanical standpoint, it is considered by many to “quietly” be the most important force-transfer junction that influences and optimizes functional movement throughout the body. The optimal degree of thoracic kyphosis, acting along with the optimal lordotic curves of the cervical and lumbar spines, assists the body in dissipating axial forces and, in the ideal world, preserves disc and facet joint integrity and function. The comparative relative decreased spinal mobility of the thoracic spine, in addition to its increased spinal canal diameter compared to the adjacent cervical and lumbar spines, results in an overall reduced incidence of thoracic disc disease and radiculopathy (1). Thus, this chapter does not focus on such diseases to the thoracic spine. In this chapter, we discuss the typical slouched postures we see in our society and the subsequent ill effects they exert, specifically on movement and function as pertaining to the thoracic spine. Poor and suboptimal inspiratory ventilation resulting from poor posture and the habit of becoming “chest breathers” not only adversely affects the cervical spine, but also affects the mechanical function of the thoracic spine by limiting the normal extension that should occur in this area of the spine with inspiration. Again, this is a problem compounded by the commonplace hyperkyphotic postures we see every day in society: starting in grammar schools, slouching on couches in front of television and gaming consoles, commuting in vehicles, seated in front of computers in offices and at the dinner tables in our homes, etc. Reminding patients of postural awareness at every single treatment session is so important, and having patients place “postural reminders” on their phones and laptops, the rearview mirrors of their car, their televisions, and the walls in rooms they frequently occupy when in seated postures can help. Gary Gray, P.T., does a masterful job in his seminars and writings of reminding practitioners that they can use this biomechanical “gift” of coupled motion to address restricted mobility in a vector that may be painful and not amenable to direct manual therapy or corrective exercise, by using manual therapy or creating an exercise-driven proprioceptive reaction in a desired, asymptomatic plane of motion to ultimately

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achieve improved function in the symptomatically dysfunctional plane of motion. For example, we may be able to drive thoracic rotation in an asymptomatic transverse plane to achieve the desired mobility and function in the previously restricted and painful sagittal plane of extension through this “gift” of coupled motion we are afforded anatomically (2). Gray also reminds us of the global ramifications of loss of mobility or stability in this ever important yet often clinically ignored thoracic spine when treating symptoms not only in adjacent areas of the axial skeleton, but especially when evaluating symptoms within the appendicular skeleton. Most clinicians appreciate how a sagittal plane–dominant thoracic deformity, such as seen in a hyperkyphotic patient, will adversely affect scapular positioning in a symptomatic shoulder impingement patient. Fewer understand, however, that this same spinal deformity significantly affects function further downstream in the elbow and wrist, and impacts function in the lower quarter. The ability of the hip to function optimally is impaired secondary to suboptimal loading of the gluteus medius/minimus in the frontal plane and the hip external rotators collectively in the ever important “functionally underappreciated” transverse plane. This proximal reactive kinetic chain disturbance at the hip can certainly lead to local hip symptomatology or to more distant symptoms elsewhere, again in either the lower or upper quarter. Further appreciation and utilization of triplane motion in the thoracic spine for mechanical assessment is seen with the McKenzie Classification method for the purpose of diagnosis and “direction” for subsequent treatment. This method utilizes mechanical assessment to determine provocative movements, identifying the presence of derangement, dysfunction, or a postural syndrome. Once determined, a mechanical treatment approach to address the specific tissue in the appropriate plane of motion is utilized for correction. This form of treatment has assisted many clinicians in helping their patients resolve symptoms and restore function in an effective and reproducible manner. Once pain has been modulated and manual therapy has improved alignment and soft tissue/articular mobility, the next step in achieving optimal functional outcomes is the introduction of therapeutic exercise to address flexibility, strength, and neuromuscular control/re-education. We must understand that the aforementioned assessment and treatment paradigms will ultimately all address the common posturally induced muscle imbalances in some fashion. We must appreciate and address the forward head, rounded shoulder, and protracted scapula presentation in the upper quarter and the associated structural and functional ramifications seen within the associated shortened musculature (upper trapezius, levator scapula, sternocleidomastoid, pectorals), as well as activating the inhibited musculature (deep cervical flexors, serratus anterior, middle and lower trapezius). It is imperative that we also account for the commonly seen anterior pelvic tilt and lumbar hyperlordotic presentation in the lower quarter, and address the associated shortened musculature as well (i.e., iliopsoas, rectus femoris, latissimus dorsi, thoracolumbar extensors), while again activating the inhibited and weak musculature (lower abdominals, gluteals). These aforementioned muscle imbalance patterns are well depicted in Dr. Vladimir Janda’s description of both the upper crossed (cervical) syndrome and lower crossed (pelvic) syndrome, and can be referenced in the Cervical and Lumbar Spine chapters of this book. Postural education is also an extremely important element to address as the patient acquires the “tools” to change and sustain a new and preferred posture. Only through this re-education and repetition can we expect to achieve long-lasting changes. Additionally, we MUST take the time to address the aberrant breathing patterns most patients present with, and achieve proper diaphragmatic breathing. We must ensure proper breathing for both a physiologic benefit of enhanced ventilation and subsequent tissue oxygenation necessary for normal function, especially tissue healing, as well as

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the structural and functional benefits to the thoracic spine through rib mobilization and optimal extension on inspiration. The upper thoracic spine functions similar to the cervical spine in movement and anatomy, while the lower thoracic spine functions similar to the lumbar spine. In the case of injury to these areas of the thoracic spine, principles and exercises, such as directional preference exercises, from the cervical and lumbar spine chapters can be applied; these, however, have not been repeated in this chapter.

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • •

Restoration of proper posture Restoration of thoracic range of motion and mobility

Intermediate •

Restoration of cervical and thoracic muscular strength, including stabilizing musculature

Advanced •

Improvement of proprioception and coordinated movements

THORACIC SPINE Recommended Exercises Foundational ROM/FLEXIBILITY/MOBILITY: Supine diaphragmatic breath (belly breath), seated postural correction (Bruegger’s), lacrosse ball massage, prayer stretch, cat camel stretch, open book, trunk rotations, seated thoracic rotation

Intermediate Continue Foundational exercises ROM/FLEXIBILITY/MOBILITY: Thoracic rotation mobility (thread the needle) STRENGTHENING: Kneeling thoracic rotation

Advanced Continue Foundational and Intermediate exercises PROPRIOCEPTION/FUNCTIONAL: Thoracic rotation with core stabilization, inchworm

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HANDOUTS ROM/Flexibility/Mobility Supine Diaphragmatic Breath (Belly Breath) POSITION: Supine with pillows under the knees STEP 1: After performing a chin glide, place one hand on the chest and the other on your stomach, as shown.

STEP 2: Breathe in slowly through your nose for a 2 to 3–second count, feeling the stomach rise into the hand on the abdomen while the hand on the chest remains as still as possible.

STEP 3: Gently tighten the stomach muscles, feeling them draw slightly inward as you exhale for a 4 to 6–second count through pursed lips, while the hand on the chest remains as still as possible.

REPS: Perform for 3 to 5 minutes initially, progressing to 10 to 15 minutes. FREQUENCY: 2 to 3 times per day

Seated Posture Correction (Bruegger’s) POSITION: Seated forward on the edge of the chair STEP 1: Sit with palms up with thumbs pointing backward. STEP 2: Lift the chest, separate the knees, and draw the shoulder blades down and backward while gliding the chin straight backward.

STEP 3: Hold for 5 to 10 seconds. REPS: Perform 3 to 5 times. SETS: One FREQUENCY: Every hour during sustained sitting

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Lacrosse Ball Massage POSITION: Standing next to a wall or lying supine on your back STEP 1: Put a lacrosse or tennis ball between you and the wall or floor. STEP 2: Position the ball such that it is over the tender muscles of back and neck.

STEP 3: Lean against the ball and move body up and down to help relax muscles; massage each muscle for 30 to 90 seconds.

SETS: One FREQUENCY: 2 to 3 times per day

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Prayer Stretch POSITION: On hands and knees STEP 1: Sit back on heels while keeping palms flat against the floor and arms extended. STEP 2: Hold for 15 to 45 seconds. STEP 3: Move hands to the left and hold for 15 to 45 seconds. STEP 4: Move hands to the right and hold for 15 to 45 seconds. STEP 5: Remember to belly breathe during the exercise. REPS: Perform 1 to 3 times. SETS: One FREQUENCY: 2 to 3 times per day

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Cat Camel Stretch POSITION: On hands and knees STEP 1: Round back up and bring it toward the ceiling while flexing the neck. STEP 2: Hold for a count of 3. STEP 3: Push belly toward the floor while extending the neck. STEP 4: Hold for a count of 3. STEP 5: Remember to belly breathe during the exercise. STEP 6: Return to Step 1. REPS: Perform 10 times. SETS: One FREQUENCY: 2 to 3 times per day

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Open Book POSITION: Lie on your right side with your arms extended forward, palms together, and hips and knees bent at 90° with a ball between the knees. STEP 1: While pressing the knees into the ball, lift the top left arm up toward the ceiling, continuing behind the body at shoulder level, attempting to reach the floor with the back of the left hand.

STEP 2: Press the arm and hand into the floor and hold for 3 breath cycles, and then return to start position. STEP 3: When finished with repetitions on this side, switch sides. REPS: Perform 10 times. SETS: One FREQUENCY: Daily

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Trunk Rotations POSITION: Lie on back with knees bent and heels on the floor or bed. STEP 1: Slowly rotate knees to one side while keeping shoulders flat against surface. STEP 2: Slowly bring knees back to neutral. STEP 3: Slowly rotate knees to other side as in Step 1. STEP 4: Slowly bring knees back to neutral. STEP 5: Repeat Step 1. REPS: Perform 10 times per side. SETS: Two to three FREQUENCY: Daily

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Seated Thoracic Rotation POSITION: Seated on a stool/ottoman or facing the back of the chair, with a ball between the knees and arms across the chest

STEP 1: Squeeze the ball between the knees and rotate the upper torso to the left until a comfortable tension is perceived.

STEP 2: Maintaining the rotation tension, tilt the upper torso to the left as shown. STEP 3: Hold for a count of 2, then repeat on the other side. REPS: Perform 10 times. SETS: Two FREQUENCY: Daily

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Thoracic Rotation Mobility (Thread the Needle) POSITION: On hands and knees STEP 1: Perform a cervical chin glide and stiffen the abdominals to prevent the back from arching. STEP 2: Slide the arm under the body with the palm up. STEP 3: Reach vertically upward toward the ceiling while extending through the support shoulder. STEP 4: Follow the moving hand with the eyes by turning the head throughout the movement. REPS: Perform 10 to 15 times on each side. SETS: Two FREQUENCY: 3 to 5 times per week

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Strengthening Kneeling Thoracic Rotation POSITION: On hands and knees, with chin glide and abdominal contraction to maintain a neutral spine STEP 1: Maintain a flat back as you sit back over the heels while preventing the back from rounding.

STEP 2: Place your left hand on the left side of your head and rotate the elbow toward the ceiling, while maintaining contraction of abdominals limiting the low back from rotating with the mid back.

STEP 3: Hold for a count of 2 and repeat. STEP 4: Perform to right side as above. REPS: Perform 10 times per side. SETS: Two FREQUENCY: Daily

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Proprioception/Functional

Thoracic Rotation with Core Stabilization POSITION: Lie face up with the upper torso on the exercise ball in a bridge position, while both arms are extended forward and squeezing a ball. STEP 1: Maintaining a chin glide, engage abdominal muscles with belly button drawn into the spine and buttocks muscles contracted to keep the hips in a tall bridge while squeezing a ball between knees.

STEP 2: Rotate the extended arms to one side while stabilizing the lower torso and pelvis and keeping it in place (neutral).

STEP 3: Return to start position and reset as per Step 1, and then rotate to the opposite side. REPS: Perform 10 times. SETS: Two to three FREQUENCY: Daily

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Modified

Modified

Inchworm POSITION: Start in a push-up position on the floor, or modified by putting the hands statically on a chair or bench. STEP 1: Perform a chin glide, engage the lower abdominal muscles to prevent the back from arching, and firm the thighs to keep the knees straight.

STEP 2: Lift and slide one foot forward a few inches while keeping the knees straight, press the heel into the floor, and pause for a count of 3.

STEP 3: Lift the opposite leg and bring the foot in line with the previous foot in Step 2, pressing the level heels on both sides into the floor while keeping the chin tucked, chest tall, back flat, and knees straight. (Pressing the hips up and back in this position helps to keep the heels down to maximize the benefit of the exercise.)

STEP 4: Continue to alternate legs until the feet level off and a moderate stretch is perceived. (Remember to keep the chest tall and shoulder blades down and backward.)

STEP 5: If performing on the floor, advance the hands alternately forward until you are in the starting push-up position again and repeat. (If hands are on a bench in a modified position, simply return the feet to the starting position and repeat.)

REPS: Perform twice. SETS: One to two FREQUENCY: Daily NOTE: This is an advanced exercise; to proceed, use caution and, possibly, seek further direction in a yoga class.

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REFERENCES 1. Wyss JF, Patel AD. Therapeutic Programs for Musculoskeletal Disorders. New York, NY: Demos Medical Publishing; 2013. 2. Gray G. Functional Manual Reaction (FMR), Thoracic Spine. v3.10. Adrian, MI: Functional Design Systems; 2005.

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CHAPTER

9

Home Exercise Programs for Lumbar Spine Injuries Amrish D. Patel

INTRODUCTION Low back pain is one of the most common reasons for a person to seek medical care. There are estimates that up to 85% to 90% of people will have an episode of back pain in his or her lifetime (1). There are many possible sources of low back pain, from the soft tissues down to the bones in the spine. In most cases, an episode of back pain will typically improve on its own over 6 to 8 weeks even if no intervention is applied. Often, back pain is initially treated with medications and stretches. However, an accurate diagnosis and the proper exercises based on that diagnosis are prudent to treatment and long-term management. This treatment can be often guided by a physical/occupational therapist or a physician with the capacity to make an accurate mechanical diagnosis. In a stepwise approach, the treatment program consists of decreasing pain and swelling, returning normal pain-free range of motion (ROM) and biomechanics, core strengthening, improving neuromuscular control and proprioception, and then a sports-specific program or program to help with performing activities of daily living (2).

DIRECTIONAL PREFERENCE Directional preference plays a key role in guiding any rehabilitation program of the spine and is often implemented by the patient instinctively. An example is when a patient notes radicular pain and finds that standing decreases symptoms and does this as much as possible, and in turn initiates an extension-biased spine program. Another example is patients with spinal stenosis and neurogenic claudication who walk in a grocery store and use a cart to lean on so that they can walk further to reduce their symptoms and initiate a flexion-biased spine program. Directional preference refers to performing exercises in the direction that either reduces back or leg pain and helps the pain “centralize” to the axial spine. Exercise protocols have been created that follow those specific treatment options for patients. Williams flexion exercises were created on the premise that a majority of issues occur at L5/S1 level and if the lumbar lordosis is reduced, this, in turn, should increase the central and neuroforaminal space to take pressure off the structures that could be pain generators (3). Its clinical applications have been applied to any program where flexing the spine improves symptoms.

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McKenzie-based therapy was developed to look at patients with pain that radiates down the leg and determines what repeated motions would alleviate the pain in the leg and centralize the pain to the axial spine. The McKenzie system does not only consist of extension exercises, but is often thought of synonymously with extension-biased spine exercises. The McKenzie method actually goes through many different motions to determine which direction alleviates/centralizes the symptoms and then creates a treatment regimen based on the direction to centralize and potentially eliminates symptoms (4).

GOALS FOR ADVANCEMENT OF EXERCISE PROGRAM Foundational • • •

Improvement of pain Restoration of ROM and flexibility Initiation of strengthening of core and pelvic girdle

Intermediate •

Progression of strengthening of core and pelvic girdle

Advanced • • •

Restoration of strengthening of pelvic girdle Restoration of proprioception and neuromuscular control Progression to functional activities and return to sport

LUMBAR FACET ARTHROSIS Low back pain caused by the facet joints as the pain generator has been found to be approximately 15% to 45% of patients with chronic low back pain (5,6). Facet joints are joints located in the posterior aspect of the spinal column and help limit motion of the spine. Typically, they limit hyperflexion and rotation of lumbar vertebrae, allowing decreased stress across the intervertebral discs (7). However, with repeated stress and low-grade trauma, like any joint, the hyaline cartilage can wear down and cause subchondral bone cysts, osteophyte formation, and synovial cyst formation. This, in turn, leads to pain signals from the joints and the release of substances that can cause pain. Typically, people affected by this condition complain of stiffness and pain when inactive or first becoming active, especially with lumbar extension, and report improvement with mild activity. The rehabilitation process should focus on creating a level of flexibility around the spine, strengthening and adding stability around the spine, and then progression to performing daily activities or sports-related activities while engaging core and neuromuscular control around the spine and pelvis (1). Often, lifestyle modifications should also be encouraged for optimal outcomes, including weight loss, healthy diet, good sleep hygiene, and smoking cessation.

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Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion, cat camel stretch, trunk rotations STRENGTHENING: Abdominal bracing (or pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

LUMBAR DISC PATHOLOGY Lumbar disc–mediated pain presents as axial back pain and is thought to stem from irritation to the nerve receptors that innervate the outer fibers of the annulus fibrosus, the cartilaginous end plates, and periosteum of the bone (8). Typically, disc-mediated pain comes from some degeneration or disruption of the disc without nerve root irritation. Typically, symptoms are axial in nature without radiation and worse with Valsalva, prolonged sitting, forward lumbar flexion, and could be worse with extension or side bending depending on where the disc pathology is located.

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch, (either one), piriformis stretch, prone extensions (as long as makes pain less) STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, opposite arm/opposite leg (bird dog), monster walk

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Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

LUMBAR RADICULOPATHY Lumbar radiculopathy presents with low back pain from a disc bulge or herniation and leads to nerve root irritation that will cause pain that typically travels down the leg in a dermatomal pattern (4). Depending on the type of herniation and location of disc material, pain can be worse with bending, sitting, standing, or lying down. The treatment should be based on directional preference to centralize symptoms and then progress to a strengthening program.

Recommended Exercises for Extension-Biased Program Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either one), prone extensions, standing extensions, side glides or alternative side glides if patient has a lateral shift (leaning over to one side due to pain) STRENGTHENING: Abdominal bracing (or pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises STRENGTHENING: Bridge, clam shells, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

Recommended Exercises for Flexion-Biased Program Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion, side glides or alternative side glides if patient has a lateral shift (leaning over to one side due to pain) STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercises

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Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

Recommended Exercises for a Neutral Spine Program Foundational ROM/STRETCHING/MOBILITY: Prone quadriceps stretch, hip flexor stretch (either one), hamstring stretch (either one), piriformis stretch STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing)

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, opposite arm/opposite leg (bird dog), monster walk

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

LUMBAR SPONDYLOLYSIS/SPONDYLOLISTHESIS Lumbar spondylolysis is a common source of low back pain in those with immature spines. This typically occurs from repetitive extension-based stressors leading to a pars interarticularis fracture (9,10). Lumbar spondylolisthesis is an anterior or posterior migration of the superior vertebral body in relation to the inferior vertebral body. This can occur for many reasons, and a spondylolisthesis will typically lead to back pain and occasionally leg pain exacerbated with transitional movements, standing, extension, and prone lying and is relieved with sitting or flexing forward.

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Recommended Exercises for Spondylolysis Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either one), prone quad stretch, piriformis stretch STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Single-leg deadlift, warrior one pose, warrior two pose

Recommended Exercises for Spondylolisthesis Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either one), prone quadriceps stretch, piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Single-leg deadlift, warrior one pose, warrior two pose

LUMBAR SPINAL STENOSIS Spinal stenosis is a narrowing of the spinal canal centrally, laterally, at the neural foramen, or all of the aforementioned areas. Some of the causes can be from ligamentum flavum hypertrophy due to disc height loss, facet arthrosis, and/or

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a disc herniation that leads to lumbar radiculopathy. Symptoms can present with low back and typically leg pain or neurogenic claudication with leg fatigue from standing and walking, improved with sitting or forward flexion (11).

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either one), prone quadriceps stretch, piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, clam shells, Swiss ball marching, opposite arm/opposite leg (bird dog)

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose

LOWER CROSSED SYNDROME Lower crossed syndrome (LCS) refers to muscular imbalances across the lumbar spine that lead to lower lumbar spine dysfunction. The imbalances seen in LCS include “facilitation” or tightness in the thoracolumbar extensors, rectus femoris, and hip flexors in conjunction with “inhibition” or weakness in the abdominal musculature (especially transversus abdominis) and gluteal muscles. These imbalances lead to an increased and shortened lordosis, and, in turn, increased forces throughout the lower lumbar spine, hips, and pelvis, and altered movement patterns (12). When this is addressed systematically, improved movement patterns can be seen that help reduce forces that lead to degeneration of the aforementioned joints and discs.

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Weak: Abdominals

Tight: Hip flexors

Tight: Thoracolumbar extensors

Weak: Gluteus maximus

Recommended Exercises Foundational ROM/STRETCHING/MOBILITY: Good morning stretch, prone quadriceps stretch, hamstring stretch (both), hip flexor stretch (both), piriformis stretch, single (double) knee(s) to chest, child’s pose, cat camel stretch, trunk rotations STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching exercise

Intermediate Continue Foundational exercises STRENGTHENING: Curl up, bridge, opposite arm/opposite leg (bird dog), Swiss ball marching

Advanced Continue Foundational and Intermediate exercises STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank PROPRIOCEPTION/FUNCTIONAL: Single-leg deadlift, warrior one pose, warrior two pose

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HANDOUTS ROM/Stretching/Postural Correction

Good Morning Stretch POSITION: Standing with hands clasped with fingers interlocked STEP 1: Slowly bring your hands over your head to stretch out your arms fully. STEP 2: Look up toward your hands. STEP 3: While holding that position, try to walk several steps. STEP 4: If unable to walk, hold position for 30 seconds. REPS: Repeat 2 to 3 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day

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Hamstring Wall Stretch POSITION: Lie on the ground with one leg against a doorframe with the other leg through the doorway. STEP 1: Place heel on the doorframe until you feel a gentle stretch in the hamstring. (You can move closer or further away from the wall to increase or decrease stretch, respectively.)

REPS: Hold that position for 30 seconds, then switch legs. SETS: Two to three per leg FREQUENCY: 3 to 5 times per week

Hamstring Stretch, Long Sitting Position POSITION: Sitting STEP 1: Sit up tall with back straight, one leg stretched out on the bed or table, and the other leg with your foot firmly planted on the ground.

STEP 2: Keeping your spine erect, lean forward as if you are trying to touch your belly button to your thigh until you feel a stretch in your leg.

REPS: Hold that position for 30 seconds, then switch legs. SETS: Two to three per leg FREQUENCY: 3 to 5 times per week

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Hip Flexor Stretch, Kneeling POSITION: Kneeling STEP 1: Kneel on the ground and put one foot forward in a lunge position.

STEP 2: While keeping your back straight, gently lean forward until you feel a stretch in the front of the hip of the back leg.

REPS: Hold that position for 30 seconds, then relax. SETS: Two to three times per leg FREQUENCY: 3 to 5 times per week

Two-Joint Hip Flexor Stretch POSITION: Lying on your back on a bed (or table), bend your knees, drop one leg over the side of the bed, and place a strap around your ankle. STEP 1: Tighten your abdominals to keep your back flat on the table.

STEP 2: Extend your hanging leg back and draw your foot toward your buttock to bend your knee until you feel a stretch in the front of your thigh, closer to your hip.

REPS: Hold for 30 seconds at end range; then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day

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Single (Double) Knee(s) to Chest POSITION: Lie on your back on a bed or on the ground. STEP 1: Slowly bring one knee (or both knees) toward your chest and use your hands to pull your knee(s) further toward your chest until you feel a gentle stretch in your gluteals.

REPS: Hold that position for 5 to 10 seconds, then switch legs. SETS: 5 to 10 per leg (or both legs) ALTERNATIVE: Hold position of stretch for 30 seconds and perform only two to three repetitions. FREQUENCY: Daily, can be repeated 2 to 3 times per day

Piriformis Stretch POSITION: Lie on your back on a bed or on the ground. STEP 1: Bring one knee up toward your chest. STEP 2: Use your hand to bring your knee toward your opposite shoulder until you feel a gentle stretch in the buttocks.

REPS: Hold that position for 30 seconds, then switch legs. SETS: Two to three per leg FREQUENCY: 3 to 5 times per week

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Prone Quadriceps Stretch POSITION: Lie on your stomach with a towel or strap looped around your ankle. STEP 1: Tighten your abdominals and gently squeeze your gluteals to keep your hips flat on the surface.

STEP 2: Hold the strap with your hand (same side), and gently pull your ankle toward your buttocks to bend your knee until a gentle stretch is felt in your thigh muscles, closer to your knee.

REPS: Hold for 30 seconds at end range; then slowly release stretch. SETS: Three sets with a 30-second break between sets FREQUENCY: 1 to 2 times per day NOTE: Do not allow your back to arch.

Child’s Pose POSITION: On your hands and knees STEP 1: Starting on your hands and knees, lower your buttocks until they touch your heels.

STEP 2: Keeping your heels on your buttocks, stretch your arms as far forward on the ground as you can while keeping your buttocks on your heels.

STEP 3: Lower your head to be parallel to your arms. REPS: Hold that position for 30 seconds, then return to your starting position. SETS: Two to three sets FREQUENCY: 3 to 5 times per week

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Seated Flexion POSITION: Sitting upright in a chair STEP 1: Slowly bend forward and try to touch your toes. STEP 2: Hold for 3 seconds. REPS: Perform 5 to 10 times. SETS: Two to three sets FREQUENCY: Daily

Cat Camel Stretch POSITION: On hands and knees STEP 1: Round back up and bring it toward the ceiling while flexing the neck. STEP 2: Hold for a count of 3. STEP 3: Push belly toward the floor while extending the neck. STEP 4: Hold for a count of 3. STEP 5: Remember to belly breathe during the exercise. STEP 6: Return to Step 1. REPS: Perform 10 times. SETS: One FREQUENCY: 2 to 3 times per day

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Alternatively

Prone Extensions (AKA prone press-up) POSITION: Lie on your belly and put your hands on the ground next to your shoulders almost in a push-up position. STEP 1: Slowly straighten your arms to lift only your chest off the ground. STEP 2: Go just to the point where you feel a pressure in your back. STEP 3: Hold for 2 to 3 seconds. STEP 4: Slowly lower yourself all the way down. REPS: Perform this activity 10 times. SETS: Two to three sets FREQUENCY: 3 to 5 times per day (as much as tolerated) NOTE: If you have radicular leg pain, then as you do the exercise, you should feel less pain in the leg and the pain should “centralize” toward the back, which can cause your back pain to become more intense. If the leg pain becomes more intense, contact your health professional. ALTERNATIVELY: If pushing up on hands is too difficult, rest on forearms while on belly for 30 seconds. Perform three times for two to three sets.

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Standing Extensions POSITION: Standing STEP 1: You can either put your hands on the small of your back or lean your back against a countertop.

STEP 2: Slowly lean backward to a point of comfort and hold for 2 to 3 seconds.

STEP 3: Return to an upright position. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 3 to 5 times per day NOTE: If you have radicular leg pain, then as you do the exercise you should feel less pain in the leg and the pain should “centralize” toward the back, which can cause your back pain to become more intense. If the leg pain becomes more intense, contact your health professional.

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Side Glides POSITION: Standing STEP 1: Stand with your hand on your hip to the side that is painful. STEP 2: Slowly slide your shoulders over to the side that is painful. (Slide over does not mean bend to the side!) STEP 3: Hold for 3 seconds, then slowly return to your starting position. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 3 to 5 times per day NOTE: If you feel more discomfort in your back and less in your leg, that is okay. If the pain increases in your leg, do not slide too far or try going in the opposite direction.

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Alternative Side Glides POSITION: Standing with one shoulder against a wall or doorframe (usually the shoulder of the side you do not have pain) STEP 1: Slowly move your hip to touch the wall. STEP 2: Hold for 3 seconds, then go back to starting position. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 3 to 5 times per day NOTE: If you feel more discomfort in your back and less in your leg, that is okay. If the pain increases in your leg, do not slide too far, or try going in the opposite direction.

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Trunk Rotations POSITION: Lying on back with knees bent and heels on the floor or bed STEP 1: Slowly rotate knees to one side while keeping shoulders flat against surface. STEP 2: Slowly bring knees back to neutral. STEP 3: Slowly rotate knees to other side as in Step 1. STEP 4: Slowly bring knees back to neutral. STEP 5: Repeat Step 1. REPS: Perform 10 times per side. SETS: Two to three FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Strengthening

Abdominal Bracing POSITION: Lie on your back with your knees bent and feet flat on the floor. STEP 1: Place hands around your waist. STEP 2: Tense abdominal muscles, like you are bracing to be hit in the stomach. STEP 3: Hold for 10 seconds. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Pelvic Tilts POSITION: Lie on your back with knees bent, or with legs straight out if you are looking for more of a challenge. STEP 1: Roll your hips/pelvis back such that you flatten your back against the ground by tightening your abdominal muscles, and then tighten your back and gluteal muscles.

STEP 2: Hold for 5 seconds and then relax. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: If you are doing this with legs straight out, do not push with your legs to flatten your back as you will not be strengthening your core muscles. Also, if doing this exercise makes your back pain worse, then try lying on your back and then slowly tightening your stomach, back, and gluteal muscles while slowly arching your back to lift it off the floor without lifting your hips off the floor.

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Abdominal Hollowing POSITION: Lie on your back with your knees bent and feet flat on the floor. STEP 1: Place hands on your lower abdomen. STEP 2: Take a deep slow breath in. STEP 3: Slowly exhale, pulling your lower abdominals inward and upward toward your spine. STEP 4: Hold for 10 seconds. REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

Curl Up POSITION: Lie on your back with knees bent and slide hands under your back to support your spine. STEP 1: Straighten out one leg while keeping your back flat on the floor. STEP 2: Without bending your neck or spine, lift your head and shoulders off the floor an inch or two. STEP 3: Hold the position for 8 seconds, then relax. REPS: Perform 10 times, then change legs and repeat. SETS: Two to three sets with each leg straightened FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Level 2

Level 2

Level 3

Bridge POSITION: Lie on your back with both your knees bent, your feet hip-distance apart, and arms relaxed by your side. STEP 1: Tighten your abdominals and your buttocks. STEP 2: Lift your buttocks off the mat until your hips are level. STEP 3: Hold the position for 2 to 3 seconds and then slowly lower yourself down. REPS: Perform 10 times. SETS: Three sets with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: You should feel this in the buttocks. If your back hurts while doing this exercise, make sure you are contracting your abdominals and do not lift your hips as high. LEVEL 2: Perform bridge as earlier; then slowly march in place by lifting each foot off the mat in alternating fashion; focus on engaging the buttock of the leg that is down.

LEVEL 3: Perform a single-leg bridge with the nonworking leg pointed straight out and alternate legs after 10 repetitions.

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Marching Exercise POSITION: Lie on your back. STEP 1: Perform a pelvic tilt (abdominal brace). STEP 2: Keep knee flexed, bend one hip up while maintaining your pelvic tilt. STEP 3: Hold for 3 seconds, then slowly lower to returning point. STEP 4: Perform with the opposite leg. REPS: Perform 10 times per limb. SETS: Two to three sets FREQUENCY: Two times per day and 3 to 5 times per week

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Swiss Ball Marching POSITION: Sit on the Swiss ball. STEP 1: Tighten stomach, back, and gluteals. STEP 2: Lift one arm and the opposite leg. STEP 3: Hold for 3 to 5 seconds (not allowing your back or hips to twist). STEP 4: Return to starting position, then do the opposite side. REPS: Perform 10 times per side. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 days per week

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Level 2

Level 2

Clam Shells POSITION: Lie on your side and bend your hips and knees 45°. STEP 1: Keep your heels together and slowly lift your top knee toward the ceiling. STEP 2: Hold that position for 3 to 5 seconds, then slowly return to the starting position. REPS: Perform 10 times per leg. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week LEVEL 2: Put a Theraband around your thighs to increase the resistance.

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Hip Abductor Wall Squat POSITION: Stand with back against a smooth surface or a physioball with legs shoulder-width apart and place a belt around your legs (preferably something like a braided belt you can buy at any clothing store). STEP 1: Push your legs outward against the belt and maintain that pressure throughout the squat. STEP 2: Slide down the wall until your hips and knees get to a 90° angle, or, if you cannot go this low, as low as you can go until you are unable to maintain the force against the belt with your legs. (Make sure that your knees do not go past your toes and that your knees track over your second and third toes.)

STEP 3: Hold the position for 3 to 5 seconds, then return to the start position while maintaining the force against the belt.

REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Hip Adductor Wall Squat POSITION: Stand with back against a smooth surface or a physioball with legs shoulder-width apart and place a basketball, yoga block, or soccer ball between your knees. STEP 1: Push your legs inward against the ball or yoga block and maintain that pressure throughout the squat. STEP 2: Slide down the wall until your hips and knees get to a 90° angle, or, if you cannot go this low, as low as you can go until you are unable to maintain the force against the ball or yoga block with your legs. (Make sure that your knees do not go past your toes and that your knees track over your second and third toes.)

STEP 3: Hold the position for 3 to 5 seconds, then return to the start position while maintaining the force against the ball or yoga block.

REPS: Perform 10 times. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Monster Walk POSITION: Stand with taut Theraband around your ankles and feet shoulder-width apart in a slightly squatted position (ideally with hips flexed 20° to 30°). STEP 1: Move one leg to the side, increasing the tension in the Theraband. STEP 2: Slowly bring your opposite leg into the starting stance. STEP 3: Take 10 steps in one direction, then reverse direction. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, make sure your knees do not buckle toward each other; keep your knees over your toes the entire time.

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Opposite Arm/Opposite Leg (Bird Dog) POSITION: Start on your hands and knees (AKA quadruped position), or, if you have a Swiss ball, start with the Swiss ball under your stomach and your hands and toes on the ground. STEP 1: Tighten your abdominal muscles, low back muscles, and gluteals to stabilize your spine. STEP 2: Slowly elevate one arm and the opposite leg without allowing your back or hips to rotate. STEP 3: Hold that position for 3 to 5 seconds, then slowly return to your starting position. REPS: Perform 10 times with each pair of arms and legs. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week

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Level 2

Level 3

Plank POSITION: Start on your elbows and knees. STEP 1: Slowly walk forward on your elbows, while keeping your knees planted, straightening out your body. STEP 2: Tighten your abdominal muscles, low back muscles, and gluteals to hold your body straight. STEP 3: Hold for 30 seconds or as long as you can. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, you should feel the muscles of your abdomen, low back, and pelvis contracting at the same time. The goal is to work your way to holding the position for 30 to 60 seconds at a time. LEVEL 2: This is similar to the first position except that you should extend your knees and lift your entire body and knees off the ground such that your elbows and toes are the only contacts with the ground.

LEVEL 3: Start with Level 2; then slowly lift one of your legs backward into the air with a straight knee in line with your body without allowing your back to arch. Switch legs on the next set.

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Level 2

Level 3

Side Plank POSITION: Lie on your side, bend your knees to 90°, and put your arm with your elbow bent on the ground. STEP 1: Slowly bring your hips off the ground to where your body is straight. STEP 2: Hold that position for 30 seconds or for as long as you can. SETS: Two to three sets FREQUENCY: 2 to 3 times per day and 3 to 5 times per week NOTE: While doing this exercise, you should feel the muscles of your abdomen and hip on the side facing the ground contracting as well as your abdominal muscles. The goal is to work your way to holding the position for 30 to 60 seconds at a time. LEVEL 2: This is similar to the first position except that you should extend your knees and lift your entire body and knees off the ground such that one elbow and the outside of your foot is touching the ground.

LEVEL 3: This is similar to Level 2 except that you should lift your top leg and/or arm into the air in an abducted position (away from the body) with a straight knee or elbow.

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Proprioceptive/Functional Level 2

Level 3

Single-Leg Deadlift POSITION: Standing STEP 1: Stand on one leg with your knee slightly bent and tighten the buttock of the standing leg, while keeping your hips level and not sinking into your hip or leaning to the side.

STEP 2: Tighten your abdominals. STEP 3: Bend forward by hinging back on the hip of the standing leg, while keeping the knee of the stance leg slightly bent and keeping the buttock of the standing leg engaged such that your hip does not jut out to the side.

STEP 4: Extend the opposite leg out behind you as you go down to maintain a straight line with your body (head, neck, beck, leg), and keep your hips even.

STEP 5: Keeping your back straight, bring yourself back up to the starting position by tightening your buttocks. REPS: Perform 10 times. SETS: Three sets on desired side with a 30-second break between sets FREQUENCY: 3 to 5 times per week NOTE: Lower only to a depth that allows you to maintain proper form; stop when you feel your back start to round, your hip jut out, or a stretch in your hamstrings. LEVEL 2: You can hold a stick with both hands along your spine. The stick should not come off your back as you go down into the deadlift.

LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do NOT let the weight pull your back out of alignment; you must control the weight.

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Warrior One Pose POSITION: Stand as if you just finished a lunge with one leg in front of the other and the front knee bent. STEP 1: Press hands firmly together and raise them over your head. STEP 2: With back foot firmly pressed into the ground, bend the front knee and hip to 90∘.

STEP 3: Hold position for 10 to 15 seconds. STEP 4: Straighten front hip and knee to return to starting position. REPS: Repeat 10 times per leg. SETS: Two to three per leg FREQUENCY: 3 to 5 times per week NOTE: As you develop strength, try to do fewer repetitions but hold the position for longer periods of time up to 30 seconds.

Warrior Two Pose POSITION: Stand in a position as if you just finished a lunge with one leg in front of the other, the front knee bent, and turn your back leg 90° such that your back foot is perpendicular to your front foot.

STEP 1: Bring your arms up perpendicular to your body with one arm in front and one behind you.

STEP 2: Bend your front hip and knee to 90°, while firmly pressing your back leg into the ground.

STEP 3: Hold position for 10 to 15 seconds. STEP 4: Straighten front hip and knee to return to starting position.

REPS: Repeat 10 times per leg. SETS: Two to three per leg FREQUENCY: 3 to 5 times per week NOTE: As you develop strength, try to do fewer repetitions but hold the position for longer periods of time up to 30 seconds. Also, as you advance more, you can transition directly from warrior one pose to warrior two pose.

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REFERENCES 1. Bono CM. Low back pain in athletes. J Bone Joint Surg. 2004;86(2):382–396. doi:10.2106/00004623-200402000-00027. 2. Malanga GA, Ramirez-Del Toro JA, Bowen JE, et al. Sports medicine. In: Frontera RW, DeLisa JA, Gans BM, et al, eds. DeLisa’s Physical Medicine & Rehabilitation: Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1413–1436. 3. Williams PC. The Lumbosacral Spine: Emphasizing Conservative Management. New York, NY: Blakiston Division, McGraw-Hill Book Co; 1965:202, 87 illus. 4. Mayer HM. Discogenic low back pain and degenerative lumbar spinal stenosis-how appropriate is surgical treatment? Schmerz. 2001;15(6):484–491. doi:10.1007/s004820100036. 5. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5(1):15. doi:10.1186/1471-2474-5-15. 6. Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995;54:100–106. doi:10.1136/ard.54.2.100. 7. Adams MA, Hutton HC. The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980;62B:358–362. doi:10.1302/0301-620x.62b3.6447702. 8. McKenzie R, May S. The Lumbar Spine Mechanical Diagnosis and Therapy. Vol 2. Waikanae, New Zealand: Spinal Publications; 2003:24–26. 9. Barr KP, Harrast MA. Low back pain. In: Braddom RL, Ed. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:883–972. 10. McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep. 2003;2(1):41-46. doi:10.1249/00149619-200302000 -00008. 11. Siebert E, Pruss H, Klingebiel R, et al. Lumbar spinal stenosis: syndrome, diagnostics and treatment. Nat Rev Neurosci. 2009;5(7):392–403. doi:10.1038/nrneurol.2009.90. 12. Janda V. Muscles and motor control in low back pain: assessment and management. In: Twomey LT, ed. Physical Therapy of the Low Back. New York, NY: Churchill Livingstone; 1987:253–278.

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INDEX

abductor pollicis longus (APL), 50 ACL. See anterior cruciate ligament acromioclavicular joint pathology, 3 active range of motion (AROM), 49–51 activities of daily living (ADLs), 49, 51 adhesive capsulitis/frozen shoulder, 4–5 ADLs. See activities of daily living ankle and foot injuries, 129–141 Achilles tendinopathy, 130–131 ankle sprain, 130 exercise program, 129–130 overview, 129 plantar fasciosis, 132 posterior tibial tendinopathy, 131 proprioception/functional single leg taps, 140 single leg tennis ball catch, 140 wobble board, 141 ROM/stretching/mobility alphabets, 134 calf stretch A and B, 133 can roll, 134 foam roller (lower leg), 135 plantar fascia stretch, 135 soleus stretch, 134 towel stretch, 133 strengthening concentric ankle dorsiflexion, 137 concentric ankle eversion, 137 concentric ankle inversion, 136 eccentric Achilles, 138 eccentric posterior tibial tendon, 139 heel raises, 138 marble pick-ups, 136 towel scrunches, 136 anterior cruciate ligament (ACL), 104 APL. See abductor pollicis longus AROM. See active range of motion

carpal tunnel syndrome (CTS), 50 carpometacarpal osteoarthritis (CMC OA), 51 cervical spine injuries cervical disc pathology, 145–146 cervical facet arthropathy, 144–145 cervical radiculopathy, 146–147 directional preference, 143–144 exercise program, 144 overview, 143 proprioception/functional prone scapular retractions, 164 prone “T,” “Y,” ”I,” “W,” 166 wall stick-ups, 165 ROM/flexibility/mobility cervical flexion/extension, 151 cervical lateral flexion, 152 cervical retraction (chin glide), 150 cervical rotation, 153 levator scapula stretch, 155 middle scalene stretch, 156 prone pectoral release, 160 seated posture correction (Bruegger’s), 149 single arm pectoral stretch, 157 suboccipital release, 159 suboccipital stretch, 154 thoracic rotation mobility (thread the needle), 158 upper trapezius stretch, 156 strengthening cervical isometrics—cervical flexion, 162 cervical isometrics—cervical retraction, 161 cervical isometrics—lateral side bending, 162 deep cervical flexor strengthening, 163 upper crossed posture, 147–148 CMC OA. See carpometacarpal osteoarthritis CTS. See carpal tunnel syndrome

biceps curls, 38 eccentric, 41 isometric, 36

ECRB. See extensor carpi radialis brevis ECRL. See extensor carpi radialis longus ECU. See extensor carpi ulnaris

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elbow injuries distal bicipital tendinopathy, 28–29 exercise program, 25–26 lateral epicondylosis, 26–27 ligament sprains, 27–28 medial epicondylosis, 27 overview, 25 proprioception/functional prone scapular retractions, 46 serratus punch, 46 shoulder diagonal pattern A (D2 flexion), 44 shoulder diagonal pattern B (D2 extension), 45 ROM/stretching/mobility, 30 biceps stretch, 31 forearm pronators stretch, 32 forearm supinators stretch, 32 triceps stretch, 31 ulnar nerve glide 1-5, 33–35 wrist extensors and flexors stretch, 30 strengthening exercises biceps curls, 38 eccentric, 41 isometric, 36 forearm pronators and supinators, 43 grip, 37 radial and ulnar deviation, 40 triceps extensions, 39 isometric, 36 tyler twist, 42 wrist extensors concentric and eccentric, 37–38, 40–41 ulnar neuropathy, 29 EPB. See extensor pollicis brevis extensor carpi ulnaris (ECU), 52, 60–61 extensor pollicis brevis (EPB), 50

FAI. See femoroacetabular impingement FCU. See flexor carpi ulnaris femoroacetabular impingement (FAI), 75 FHP. See forward head position forward head position (FHP), 147

GH-OA. See glenohumeral osteoarthritis glenohumeral joint instability, 4 glenohumeral osteoarthritis (GH-OA), 3–4 greater trochanteric pain syndrome (GTPS), 73–74 GTPS. See greater trochanteric pain syndrome

222

hip injuries exercise program, 71–72 femoroacetabular impingement and labral tears, 75–76 greater trochanteric pain syndrome, 73–74 hamstring strain and tendinopathy, 74–75 iliopsoas tendinopathy/bursitis, 72–73 osteoarthritis, 72 overview, 71 proprioception/functional lunge, 97 single leg balance, 94 single leg deadlift, 95 single leg squat, 98 windmill, 96 ROM/stretching/mobility, 77 foam roller to hip area, 80 hamstring stretch with a towel, 77 hip flexor stretch, kneeling, 78 hip rotator stretch, 78 iliotibial band stretch, 80 prone quadriceps stretch, 77 quadruped rocking, 79 two-joint hip flexor stretch, 79 strengthening bridge, 85 clam shells, 82 eccentric hamstring throwdowns, 93 forward step down, 89 forward step up, 88 gluteal (buttock) isometrics, 81 hamstring curl on stability ball, 86 hamstring isometrics, 81 hip clocks, 91 hip hikers, 87 monster walk, 90 prone hip extension, 82 side-lying hip abduction with towel against wall, 84 side plank, 92 squat, 83

IAP. See inferior articular process Iliotibial band (ITB), 73–74, 76, 106–107, 110 inferior articular process (IAP), 144 interphalangeal joint (IPJ), 50, 68 IPJ. See interphalangeal joint ITB. See Iliotibial band

knee injuries assisted knee extension and flexion, 110–111 exercise program, 101–102 hamstring stretch with a towel, 108

INDEX

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hip flexor stretch, kneeling, 109 iliotibial band syndrome, 106–107 ITB stretch, 110 knee flexion chair stretch, 111 ligament sprain, 104–105 meniscal tear, 105–106 osteoarthritis, 102 overview, 101 passive knee extension, 112 patellofemoral pain syndrome, 103 prone quadriceps stretch, 108 proprioception/functional, 123–126 single leg balance and deadlift, 123–124 single leg squat, 126 windmill, 125 quadriceps and patellar tendinopathy, 103–104 ROM/stretching/mobility, 108 strengthening, 113–122 bridge, 119 forward step down, 121 forward step up, 120 prone hip extension, 115 quadriceps Set, 113 side-lying hip abduction with towel against wall, 118 side plank, 122 squat, 116 squat on a wedge, 117 straight leg raise, 113 terminal knee extension, 114 two-joint hip flexor stretch, 109

lateral collateral ligament (LCL), 104 LCL. See lateral collateral ligament LCS. See lower crossed syndrome lower crossed syndrome (LCS), 191 lumbar spine injuries, 185–218 directional preference, 185–186 exercise program, 186 lower crossed syndrome, 191–192 lumbar disc pathology, 187–188 lumbar facet arthrosis, 186–187 lumbar radiculopathy, 188–189 lumbar spinal stenosis, 190–191 lumbar spondylolysis/spondylolisthesis, 189–190 overview, 185 proprioceptive/functional, 217–218 single-leg deadlift, 217 warrior one pose, 218 warrior two pose, 218 ROM/stretching/postural correction, 193–203

alternative side glides, 202 cat camel stretch, 198 child’s pose, 197 good morning stretch, 193 hamstring stretch, long sitting position, 194 hamstring wall stretch, 194 hip flexor stretch, kneeling, 195 piriformis stretch, 196 prone extensions (AKA prone press-up), 199 prone quadriceps stretch, 197 seated flexion, 198 side glides, 201 single (double) knee(s) to chest, 196 standing extensions, 200 trunk rotations, 203 two-joint hip flexor stretch, 195 strengthening, 204–216 abdominal bracing, 204 abdominal hollowing, 206 bridge, 207 clam shells, 210 curl up, 206 hip abductor wall squat, 211 hip adductor wall squat, 212 marching exercise, 208 monster walk, 213 opposite arm/opposite leg (bird dog), 214 pelvic tilts, 205 plank, 215 side plank, 216 Swiss ball marching, 209

McKenzie Diagnosis and Therapy (MDT), 143, 146 MCL. See medial collateral ligament MCPJs. See metacarpophalangeal joints MDT. See McKenzie Diagnosis and Therapy medial collateral ligament (MCL), 104 metacarpophalangeal joints (MCPJs), 50 metacarpophalangeal (MP), 50, 57, 59 MP. See metacarpophalangeal

nonsteroidal anti-inflammatory drugs (NSAIDs), 26 NSAIDs. See nonsteroidal anti-inflammatory drugs

OA. See osteoarthritis osteoarthritis (OA), 101–102

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patellofemoral pain syndrome (PFPS), 101, 103 PCL. See posterior cruciate ligament PFPS. See patellofemoral pain syndrome platelet-rich plasma (PRP), 26 posterior cruciate ligament (PCL), 104 PRP. See platelet-rich plasma

range of motion (ROM), 25–30, 71–77, 101–108, 129–133, 185–193. See also specific entries rest, ice, compression, elevation (RICE), 26 RICE. See rest, ice, compression, elevation ROM. See range of motion rotator cuff tendinopat, 2

SAP. See superior articular process shoulder injuries, 1–23 acromioclavicular joint pathology, 2–3 adhesive capsulitis/frozen shoulder, 4–5 exercise program, 1 glenohumeral joint instability and osteoarthritis, 3–4 overview, 1 proprioception/functional, 20–23 prone “T,” “Y,” “I,” “W,” 20 stability ball bird dog, 21 stability ball plank, 23 wall ball push-up, 22 wall fall push-up, 23 ROM/stretching/mobility, 6–11 broom pull, 8 corner stretch, 9 reverse sleeper stretch, 10 scaption, 11 sleeper stretch, 10 stick overhead shoulder stretch, 6 stick shoulder abduction, 7 stick shoulder extension, 8 stick shoulder flexion, 9 stick shoulder rotation, 7 rotator cuff tendinopathy, 2 strengthening exercises, 12–19 abducted shoulder external rotation, 18–19 isometric, 12–13 low row, 15 push-up with a “plus,” 17 scapular retraction, 14 straight-arm lateral pull down, 16 superior articular process (SAP), 144

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TENS. See transcutaneous electrical nerve stimulation thoracic spine injuries, 169–182 exercise program, 171 overview, 169–171 proprioception/functional, 181 inchworm, 182 thoracic rotation with core stabilization, 181 ROM/flexibility/mobility, 172 cat camel stretch, 175 lacrosse ball massage, 173 open book, 176 prayer stretch, 174 seated posture correction (Bruegger’s), 172 seated thoracic rotation, 178 supine diaphragmatic breath (Belly Breath), 172 thoracic rotation mobility (Thread the Needle), 179 trunk rotations, 177 strengthening, 180 kneeling thoracic rotation, 180 transcutaneous electrical nerve stimulation (TENS), 146

UCS. See upper crossed syndrome upper crossed syndrome (UCS), 147

wrist and hand injuries, 49–69 carpal tunnel syndrome, 50–51 carpometacarpal osteoarthritis, 51–52 De Quervain’s tenosynovitis, 49–50 exercise program, 49 extensor carpi ulnaris tendinopathy, 52 overview, 49 patient education/precautions/activity modification, 68–69 carpal tunnel, 68 carpometacarpal osteoarthritis, 69 De Quervain’s tenosynovitis, 68 extensor carpi ulnaris tendinopathy, 69 proprioception/functional exercises, 64–67 elbow extension and flexion with theraband, 64–65 external rotation with theraband, 67 scapular retraction with theraband, 66 shoulder extension with theraband, 66 ROM/stretching/mobility, 53–58

INDEX

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“C” exercise, 57 isolated thumb interphalangeal joint flexion/extension, 54 median nerve glides, 56 tendon gliding, 55 thumb adductor massage, 57 thumb opposition, 57 web space stretch, 58 wrist extension and flexion active range of motion, 53

strengthening, 59–63 abductor pollicis longus isometric, 59 ECU synergy exercise, 61 extensor carpi ulnaris isometric, 60 extensor pollicis brevis isometric, 59 first dorsal interossei, 60 ulnar deviation, 62 wrist extensors concentric, 61 wrist extensors eccentric, 63

INDEX 225

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