NEW THERAPIST CLINICAL TUTORIAL...• General back mobility • Daily stretches to incorporate in...

© PhysioProfessor.com

NEW THERAPIST

CLINICAL TUTORIAL

Written by Jason Bradley

© Physioprofessor.com.au


NEW THERAPIST CLINICAL TUTORIAL

CONTENTS

Common Problems ........................................................................................................ 3

Acute Neck Pain ............................................................................................................. 4

Chronic Neck Pain .......................................................................................................... 7

Acute/Traumatic Thoracic Pain...................................................................................... 9

Lumbar Disc Strain ....................................................................................................... 11

SIJ Pain ......................................................................................................................... 13

ACJ Sprain ..................................................................................................................... 16

Glenohumeral Instability ............................................................................................. 18

RC Strain ....................................................................................................................... 20

Post Elbow Dislocation Treatment............................................................................... 21

Extensor Tendinopathy ................................................................................................ 23

Flexor Tendinopathy .................................................................................................... 25

Hamstring Strain .......................................................................................................... 28

Common Causes of Knee Pain ..................................................................................... 29

Meniscal Injury ............................................................................................................. 30

Patellofemoral Pain ...................................................................................................... 32

Medial/Lateral ligament sprain of the knee ................................................................ 34

Calf Strain ..................................................................................................................... 36

Postero-medial Shin Splints ......................................................................................... 39

Ankle Inversion Sprain ................................................................................................. 40

Beat Back Pain with Core Stability Secrets .................................................................. 43

Knee Pain and Instability – Causes and Solutions ........................................................ 45


Common Problems

FOOT

Common problems: Plantarfascia, heel spurs, morton’s neuroma

Tests: Gaitscan, windlass, mobilisation interphalangeal, calf length

Quick treatment: lo die taping

Exercises: calf stretch, footeze roller

ANKLE

Common problems: 1) Sprain 2) Achilles tendonitis

Tests: 1)anterior drawer, inversion 2) calf length, gaitscan

Quick treatment: 1) Ultrasound, tubisock 2) ultrasound, lo-die taping

Exercises: 1) alphabet, calf stretch 2) calf stretch

SHIN

Common problems: 1) Shin Splint(lateral/medial tibial stress syndrome) 2) Stress

fracture

Tests: 1) calf length, gaitscan 2) gaitscan, referral for xray

Quick treatment: 1) lo-die taping, ultrasound 2) tubisock

Exercises: 1) calf stretch, toe/heel raises 2) calf stretch

KNEE

Common problems: 1) patellofemoral 2) meniscal 3) Ligamentous

Tests: Squat/1leg 1) PF mobs/compr, Thomas, gaitscan

2) Mcmurrays/palpation 3) lachmans, MCL/LCL stress tests

Quick treatment: 1) taping, ITB release 2) ultrasound, tubisock 3) Ultrasound,

tubisock

Exercises: SLR, toilet press, clam, bridge, 1) ITB roller

HIP

Common problems: 1) tight glutes/piriformis 2) Unco muscles 3) Internal joint

irritation

Tests: 1 leg squat, quadrant, glute/piriformis stretch, prone knee raise

Quick treatment: 1) trigger point, stretch 2) STM 3) lateral traction with hip

flexion with seatbelt.

Exercise: 1) stretch, bridge 2) PKR, bridge, clam 3) piri/glute stretch,

bridge, PKR.

LOW BACK

Common problems: 1) facet joint stiffness 2) core weakness 3) disc bulge

Quick tests: F/E, SLR+DF, ASLR

Quick treatment: 1) unilateral mobs, X-tape 2) exercises + stretches 3) unilateral

mobs, ultrasound, X tape

Exercises: 1) flexion/rotation, core 2) extension/rotation, core 3)

extension/rotation, core


THORACIC

Common problems: 1) facet/costovertebral joint sprain 2) Postural strain

Quick tests: 1) rotation, extension, palpation 2) rotation/ extension, posture

Pro

Quick treatment: 1) unilateral mobs, contract/relax 2) IV+ mobs

Exercises: 1) heat pack, rotation, towel extension 2) towel/foam roller,

rotation

CERVICAL

Common problems: 1) cervicogenic headache 2) acute wry neck

Quick tests: 1) upper cervical rotation in F/E, mobilisation, posture pro 2)

rotation, lateral flexion

Quick treatment: 1) unilateral mobs, sub-occip triggers 2) PPIVMs, mulligans

Exercise: 1) heat pack, all fours self mobs, DNF 2) rotation in lying, DNF

SHOULDER

Common problems: 1) Impingment 2) Instability 3) ACJ

Tests: 1) hawkins kennedy, empty/full can, HBB 2) apprehension 3)

mobs/ palpation

Quick treatment: 1) ultrasound, IV+, J mobs, tape 2) tape, IV+ 3) mobs AP/PA,

ultrasound, tape

Exercise: 1) RC, TX ext 2) RC, Tx ext 3) Tx ext

ELBOW/FOREARM

Common problems: 1) tennis elbow (lateral tendinopathy) 2) Golfer’s elbow (medial

tendinopathy)

Quick test: grip, stretch, finger resistence

Quick treatment: ultrasound, mulligans,

Exercises: stretch

WRIST

Common problems: 1) tendon sheath irritation 2) carpal joint sprain 3) capral tunnel

Quick test: 1) resisted through range, palpation 2) mobs, palpation, EROM

positons 3) EROM F, tinel’s, nerve tension

Quick Treatment: 1) friction, ultrasound 2) mobs, tape 3) nerve mobs, tape

Exercise: 1)stretch 2) wrist flexion/extension 3) self nerve mobs

Acute Neck Pain

Subjective

• Woke with pain, reports sharp pain with movements and background ache, may be

affecting ability to drive.

• Referral into the head/face (normally unilateral or one side greater than the other)

and possibly referral or changed sensation through the shoulders and arm.

• Bed type / sleeping position and pillow arrangements


• Ease: Heat, massage

• Agg: movements – usually unilateral

• Previous History: wry necks, recent trauma

Objective

• Restricted range of motion

• Muscle spasm

• Altered posture/head position� tilted neck posture

• Mobes- painful/tight often unilateral most provocative

• Altered sensation arms

• Assess thoracic spine for provoking factors e.g. hypomobility/bad posture

Initial Management (Sessions 1-3)

• Heat

• STM

• Mobs

• Snags/nags

• Traction

• Sleeping education

• PUS

• Perhaps postural taping

HEP

• ROM movements/stretches� neck, thoracic, traps

• DNF strengthening

• Self Nags with towel

• Traction at home

Progressive Management

• Posture education

• General back mobility

• Daily stretches to incorporate in exercise routine

Initial Exercises to Avoid

• Shrugs, gym ball exercises with pressure through neck, crunches, barbell

squat/lunge

Exercises which can still be performed

• Leg work, non-impact cardio eg bike, possibly rower and cross trainer.

Estimated Sessions per week

• 3x/week for 1 week


• 1x/week for 2 weeks


Plan for Non-progression

• If no progress by second week refer to GP for investigations

Special items to watch for

• Age 18-40 no previous history and no cause in history� possible red flag

• Trauma: fractures, ligament damage� likely to experience pain at time of incident

• Rheumatoid Arthritis, Downs syndrome

• Non-dermatomal neural symptoms, 5 D’s.

Asterix

• ROM

• Mobes

• Muscle spasms

Aids/Appliances

• SNAG belt, heat pack, exercise ball, lumbar roll, pillows, back ball.

Rehab Ex’s Gym Ex’s Avoid Cardio

Acute Chin tucks supine

Trap stretches and

general ROM exs

Suboccipital

stretches, towel ext,

Squats, lunges,

low chest press,

lats, abs done

with lower limb

movements

High impact

activities, crunches,

over head weights,

core work on ball

with pressure

through neck

Bike, stepper

Subacute Chin tuck with lift

supine and in

seated. Trap

stretches, ball

extensions, lower

traps

Legs, chest,

military press,

lats and inferior

traps.

Wide grip shoulder

weights, shrugs,

crunches

Treadmill

Bike

Cross trainer

Rower


Later

stage

Chin tucks,

stretches, ball ext,

reverse dips

Squats, Lunge,

most upper body

work,

preferentially do

close grip upper

body rather than

wide grip

Shrugs, crunches

without elbows

back out of sight.

Treadmill

Bike

Cross Trainer

Rower

Classes

Chronic Neck Pain

Subjective

• Episodic nature neck pain, worsening with certain activities or postures

• Likely to have previously sought help from other physios or health professionals.

• Maybe be associated with increasing work/study load.

• Dull or sharp pain in neck, with possible referral into the head or limbs

• May recall an initial incident from past eg MVA, sports injury, came on during HSC.

• Feels good in morning, worsens with stationary postures

• Agg: sitting, computer work, reading,

• Ease: movement, heat, massage

Objective

• Forward head on neck posture/decreased cervical lordosis/overall posture

alterations

• Decreased ROM

• Mobes: stiff plus painful

• DNF decreased activation, over activity SCM/Scalenes � biofeedback

• Tender/Tight in traps, scalenes, levator scapulae

Initial Management (sessions 1-3)

• Postural re-education + education DNF and role in stability.

• Mobes, SNAG/NAG

• Heat

• Massage� neck, sub-occipitals, traps, scalenes, SCM

• Traction

• Taping� Tx posture and traps inhibition


• General Fitness and weights program

• Lumbar role, adjust workplace/study setup

• Regular massages

• Mobes


• Progress stretches and strengthening exercises

Estimated sessions Per week




Plan for non progression

• At 4 weeks no progress refer to GP for investigation

Special Items

• OA� xrays

• Ligamentous damage� instability post trauma/ RA/ Down syndrome

• Non-dermatomal neural symptoms, 5 D’s

Asterix signs

• DNF function with biofeedback

• ROM

• Pain

• Functional ability to do task before pain onset

• Accessory stiffness

Other Aids

• NAG belt, lumbar roll, heat pack, exercise ball, back ball, gym membership


Acute Chin tuck supine

Then with lift

Towel ext

Inferior traps�

prone supermans

over ball

Sub-occipital, trap,

scalene and

levator scap

stretches

Self SNAG/Traction

Leg work,

decrease

overhead work

and use close grip

options as

opposed to wide

grip.

Exercise as

indicated by history

which aggravate

neck pain, shrugs

Treadmill

Stepper

Bike

Classes

Rower


Subacute Stretches

Tx rot

Woodchoppers

Cable press/pull

with rotation

Chin tuck, sitting, +

with lift

Ball ext

Leg and upper

body

Shrugs/neck

weights

Treadmill

Bike

Stepper

Classes

Rower

Later

stage

Chin tucks All Shrugs Treadmill

Bike

Cross Trainer

Rower

Classes

Acute/Traumatic Thoracic Pain

Major symptoms in history

• Pain/stiffness sensation often in between shoulder blades. May refer around ribs

and present as pure anterior chest pain or in combination. Pain may be elicited by

movements, breathing and coughing.

• May present with flexion deformity, unable to stand straight due to pain.

• Report a specific movement causing onset of symptoms.

Objective findings

• Large restriction rotation range and stiff through extension, may have limited

flexion.

• Tender + stiff costovertebral joints.

• Muscle spasm and tenderness overlying affected joints

• May be altered sensation along ribs at dermatomal level

Initial management (treatments 1-3)

• Ice

• Massage

• PUS

• Mobs� straight unilaterals or 4+ rotation mob, PPIVM’s

• May require pillows initially and then slowly remove till can lie flat on table


• Taping

• Muscle energy techniques

Home Strategies Initially

• Tx rot/glute stretches

• Tx arch over towel/ball

• Lumbar roll for work/driving

Progressive management strategies

• Stretching

• Massage

• Mobs/manips

• PPIVM’s

• Muscle energy- contract/release rotations

Estimated sessions per week and how many sessions

• 2-3x/week for 1 week


Plan for non-progression of symptoms (r/v by who/when)

• Refer after 2 weeks if no progress or worsening symptoms.


• Insidious onset with night pain, osteoporosis�crush #


Acute Towel/ball

extensions,

rotation on ball,

glute/tx stretch,

Core activation in

lying/kneeling/

standing

Legs

Supported rows

Presses

Deadlifts

Weighted

extensions

Unsupported rows

Treadmill

Bike

Stepper


Subacute Ball/ towel

extensions

Extensions

Core activation

with ball ex’s

Tx/Lx stretches,

bent knee

rotations with ball

1 arm cable

chest/shoulder

press and row.

Encourage

rotation.

Body weighted

extensions

Heavy chest press,

pull downs,

deablifts and beack

extensions.

Treadmill

Bike

Cross trainer

Rower

Classes

Later

stage

Extensions

Core with ball

Russian twists with

ball

Woodchopper,

Deadlifts/1 arm

Chest press, pull

downs, press/row

combination with

cables.

Treadmill

Bike

Cross Trainer

Rower

Classes

Lumbar Disc Strain

Subjective

• Often have mechanism of injury involving a combination of flexion/rotation/lateral

flexion.

• May have pain in back either central/bilateral or worse on one side +/- referred

symptoms through the buttock, groin, posterior thigh and through lower leg.

• P/N and loss/altered sensation may be present, weakness in lower limbs

• Bowel and bladder signs� Emergency review.

• Report stiffness and muscle spasm in back

• Agg: cough, sneeze, most often F, sometimes ext

• Ease: Ice, heat, laying flat, bending knees up.

Objective

• Posture: sway/flat/lordotic. Lateral shift present?

• Squat- clear hips/knees

• F cause pain, repeated flexion may increase pain level and peripheralise symptoms.

• E may cause pain, generally repeated flexion causes centralization of symptoms

unless non-reducing derangement.

• Lateral Flexion may increase pain.

• Stork test + Active SLR + compression/distraction test clear SIJ

• SLR : <40 deg disc, <70deg disc/neural Normal men >90, women >110 May present

with crossed symptoms


• Palpation: muscles tight/spasm

• Central and unilateral PA may reproduce pain

Initial management Strategies (Sessions 1-3)

• Massage/PUS

• Extension ex’s in standing/lying/sustained prone on elbows. At least 5-6times/day

• Side glides

• Basket weave taping

• Traction

• Dry needling

Progressive Management Strategies

• Extension exercises

• Core exercises

• Massage

• Taping

• Lumbar roll

• Lumbar/Tx rotation stretches

• Dry needling, neural mobilisation

Estimated visits


• 2x/wk 2 weeks

• 1x/wk for 2 weeks

Asterix signs

• Referral patterns, ROM, sitting tolerance


• At 4 weeks if no improvements refer to GP and surgeon


• Bowel and bladder changes

• Non-dermatomal P/N/N – glove symptoms

Additional aids etc

• lumbar roll

• Brace



Acute Extensions

Side Glides

Core activation in

lying/kneeling/

standing

Pull downs

Triceps

Light biceps

ER/IR cable

Presses

Squats/Lunges

Ab work

Deadlifts

Treadmill (walking)

Bike if able to

maintain posture.

Step ups

Subacute Extensions

Core activation

with ball ex’s

Tx/Lx stretches

Supported

weights machines

Cable press

Unsupported

weights

Treadmill

Bike

Cross trainer

Later

stage

Extensions

Core with ball

1 arm press

Woodchopper

Press/pull

Cable deadlift/1

leg

See Better Back

outline for full list

of possible exs

Treadmill

Bike

Cross Trainer

Rower

Classes

SIJ Pain

SIJ pain refers to inflammation of the joint, whereas dysfunction refers to

hyper/hypomobility of the SIJ, which may affect other areas and cause secondary

inflammation.

Subjective

• Mechanism may be unknown, impact on one leg, leg length discrepancy, look for

aggravating positions such as maintained hip flexion or extension eg football and

hockey players.

• Report deep LBP below L5, mostly localized to the SIJ and buttock region, may refer

to groin and anterolateral thigh, and rarely into the labia/scrotal area.


• Pain with stairs, rolling over in bed + the triad� pain over SIJ, tenderness

sacrotuberous/sacrospinous ligaments and pain reproduction of pubic symphysis.

Objective

• Assymetry in PSIS and ASIS, differing/abnormal nutation/counternutation through

flexion and one leg standing (stork test).

• ‘Squish’ test- pt supine move ilium posteriorly to test mobility

• Compression/distraction test- needs to be very firm and maintained pressure

• Posterior glide test- similar to quadrant, feel in around sacral sulcus for movement.

• ASLR then ASLR with compression� decreased pain: SIJ instability

• Gaenslan’s (pelvic torsion)

• Leg Length discrepancy � real or apparent


• Mobilisation� lumbar, sacral, ilium

• Taping to stabilize and decrease pain during exercise

• Massage/stretching to address tilt from soft tissues changes most common tight

psoas� cephalad longitudinal pressure with leg extension, rectus femoris plus

glutes.

• PUS

• Muscle energy techniques (Resisted abd/add at varying angles with knees bent +

others dependent on assessment findings)

• Traction through leg +/- compression/distraction with 2nd

therapist


• Massage

• Leg length discrepancy treatment

• Psoas and rec fem stretches

• SIJ belt

• Core exercises

• Cortisone injection

Estimated visits



Asterix Signs

• Redo previously provocative tests, alignment/stork test, subjective pain level


• At 4 weeks if no improvements refer to GP and specialist



• Bowel and bladder changes

• Non-dermatomal P/N/N – glove symptoms

Additional aids etc

• SIJ belt


Acute Rolled towel

between ilium

Leg extensions

Psoas stretches

Basic core

Leg lowers over

edge of bed

Adductor

Glute max/med,

supported upper

body work.

High impact

activities in single

leg stance, crunch

or activities overly

activating hip

flexors

Cross trainer

Rower

Subacute PNF Psoas stretch

Muscle energy

techniques

Core Ex’s with ball

Squat

Lunge

High Impact

activities

Treadmill

Bike

Cross trainer

Rower


Later

stage

Extensions

Cable/free weight

core ex’s

Squats, Lunge, all

upper body work

Treadmill

Bike

Cross Trainer

Rower

Classes

ACJ Sprain

Major symptoms in History/Examination

• CHx: fall on to point of shoulder/direct impact to ACJ. Complain of immediate P.

• Obs: Swelling/deformity ACJ, locally tender to palpate.

• Agg: weighted activities, movement esp. Hor Ad

• Ease: sling, ice

• AROM: all movements < ROM + P esp. Hor Ad

• Acc: AP/PA cause P.

• X-rays: may show widening between structures depending on the grade. > 25% to

uninjured side in grade 3.

• Modified Rookwood (6 grades). Grades 1-3 most common.

� Grade 1: capsular sprain

� Grade 2: complete tear AC ligament + sprain coracoacromial ligament.

� Grade 3-6: tears to AC, coracoacromial, conoid and trapezoid ligaments

with varying degrees of distal clavicular displacement.


• Ice \

• Taping > 2-3 days type 1 � 6 weeks severe grade 2-3

• Sling /

• Ultrasound/Interferential to decrease swelling

• If Chronic� Mobilisation, PUS. Traction though arm


• Gentle mobs to prevent adhesions

• Isometric strengthening when pain permits

• Postural correction and scapulohumeral rhythm assessment

• Proprioception eg wall push ups � push ups on unstable surfaces

• Return to play (RTP) when no localized tenderness + pain free ROM.

• Protective taping/padding on RTP.


Estimated sessions/week for how many weeks

• 3x/week for 1-2 weeks

• 1x/week for 4-7 weeks depending on severity

Plan for non-progression of symptoms (review by who and when)

• Generally grades 1-3 conservative, grades 4-6 surgical management.

• If unsatisfactory progress at 4 weeks surgical review, may require corticosteroid

injection/resection of distal clavicle

Special items to watch out for in this condition

• Osteolysis distal clavicle

• Rotator cuff impingement secondary to abnormal scapular position

• Nerve injury in more severe grades

• Adhesions

Asterix signs (Retest)

• Hor Ad

• Palpation

• PA

Other aids or appliances the may be useful (eg orthotics)

• Taping instruction� discuss with team coach/sports trainer� GAP sport program

• Shoulder braces initially if severe

• Protective braces/ padding for RTP

Stage

Rehab exercises

Gym exercises

Avoid

Cardio

options

Acute/Early Pendular

Isometrics

Scap setting

Lower traps on

ball

Towel ext Tx

Biceps/triceps

machines

All lower limb

Bench/chest press

Weights on

shoulders eg for

squats

Rower, X-trainer

Bike, treadmill

Classes –

avoiding arm

movements

Sub-acute RC work with

dumbbells or

cables

Wall push-ups

Ball TX

extensions

Narrow grip rows /

pulldowns,

Bench/chest press,

shoulder press

Bike

Treadmill

Rower

X-trainer

Avoid body

pump


Glenohumeral Instability

Subjective

• Insidious onset, chronic issue following dislocation/subluxation especially when

multiple occurrences. Complains of a dull ache, with sharp pain/anxious feeling with

EROM movements and certain positions.

• Past Hx: shoulder problems or past strains, hypermobility in other joints

• Agg: long lever resisted and open packed joint position activities, carrying heavy

weights through arm eg groceries.

• Ease: ice, supporting it

Objective

• Normal or decreased ROM

• Weakness on resisted movements

• Positive Relocation/apprehension test +/- positive inferior drawer test

• Kyphotic posture

• Tenderness anteriorly and through rotator tendons

• May be positive for SLAP lesions, and positive for bicipital tests.

• Possibly tight posterior capsule/cuff


• Supportive taping� T-pee style

• Ultrasound

• Massage

• AAROM/AROM exercises

• Posture Correction/Tx ax


• Taping to correct posture

• Massage, acupuncture, injection

Estimated sessions Per week



• 1x/fortnight 2 weeks


Later stage RC work with ball

and bosu eg bosu

pushups, cables,

sport specific

Presses

All upper limb

weights

Care should be taken

with shoulder

presses


• If initial incident resulted in dislocation or severe subluxation, if no significant

improvements within 6 weeks

Special Items

• SLAP/Bankart lesions, subluxation

Asterix signs

• Apprehension/relocation test ROM

• Strength

• Tenderness

Other Aids

• Sling/brace


Acute Isometric IR/ER

Towel ext

Adduction

Close grip rows,

biceps, triceps,

leg work, lat pull

downs

Above shoulder

work, painful

movements.

All ER

Treadmill

Stepper

Bike

Subacute Isotonic IR/ER

Ball ext

Inferior traps

Adduction

Close grip rows,

biceps, triceps,

leg work, lat pull

downs, military

press providing

no pain

Wide grip above

shoulder work eg

barbell press,

barbell chest press

with wide grip,

other painful

movements

Treadmill

Bike

Cross trainer

Rower

Stepper

Later

stage

PNF IR/ER

Inferior Traps

Ball extensions

Woodchoppers

Sport specific

Agility work

Pain free upper

body

Treadmill

Bike

Cross Trainer

Rower

Classes


RC Strain

Subjective

• Usually present with a known incident causing the strain eg Aching pain through

shoulder, through muscle belly and possibly a non-palpable ache through the

deltoid area. Sharp pain with some movements

• Past Hx: shoulder problems or past strains

• Agg: shoulder movements, laying on that shoulder

• Ease: ice, rest, keeping shoulder close to side and supported

Objective

• Decreased ROM, with pain, possibly painful arc

• Weakness on resisted movements

• Palpation: pain through muscle belly/tendon and possible at insertions.


• Supportive taping� T-pee style

• Ultrasound

• Massage

• AAROM/AROM exercises

• Posture Correction/Tx ax


• Taping to correct posture

• Massage, acupuncture, injection

Estimated sessions per week



• 1x/fortnight 2 weeks


• If profound loss of strength with large or full tear suspected, referral to GP then

surgeon for possible repair.

Special Items

• SLAP/Bankart lesions, subluxation

Asterix signs

• Pain free range

• Strength

• Tenderness

Other Aids


• Sling/brace


Acute Isometric IR/ER

Towel ext

Adduction

Close grip rows,

biceps, triceps,

leg work, lat pull

downs (narrow

grip)

Above shoulder

work, painful

movements.

Treadmill

Stepper

Bike

Subacute Isotonic IR/ER

Ball ext

Inferior traps

Adduction

Cuff synergy –

supine circles

Close grip rows,

biceps, triceps,

leg work, lat pull

downs, military

press providing

no pain

Wide grip above

shoulder work,

painful

movements,

Treadmill

Bike

Cross trainer

Rower

Stepper

Later

stage

PNF IR/ER

Inferior Traps

Ball extensions

Woodchoppers

Pain free upper

body

Treadmill

Bike

Cross Trainer

Rower

Classes

Post Elbow Dislocation Treatment

Assessment

• Ensure good xrays clear loose bodies and small fractures post relocation

• Capsular pattern F>E 30:10 deg.

• Establish cause of limitation: muscular elastic� elastic end feel (beware myositis

ossificans)

• Establish whether biceps or brachialis is cause of tightness.

• Palpate for haematoma in muscles

• Assess integrity of medial and lateral collateral ligaments

• Note neural changes secondary to displacement

Treatment Initially

• Ultrasound

• Ice

• Massage

• Gentle joint mobilization

• AROM/AAROM + overpressure


• Isometric strength exercises

Progressive Treatment

• Heat

• Stretches

• Strengthen wrist and shoulder muscles

• Isotonic elbow exercises. Home program to increase flexibility, endurance and

eccentric control.

• Joint mobes

Estimated Sessions




When to Refer on

• Development of haematoma/ worsening on ROM and haematoma symptoms

• Non progression at 2-3 weeks

• Plateau at unacceptable ROM

Special things to watch for

• Myositis ossificans

• Valgus contracture/superior radial migration

Asterix Signs

• ROM

Exercises to avoid initially

• Bicep curls and extensions, exercises placing large amounts of traction through joint

Exercises which can still be completed

• leg work, abs, good arm exercises


Acute Passive ROM

Leg work,

upper body

with other arm

Using injured side

for weights/use,

Classes

Treadmill

Bike

Stepper


Subacute AAROM/AROM

exs

Leg work,

upper body

uninjured side

Using injured side

Classes

Treadmill

Bike

Stepper

Later

stage

Bicep/tricep

stretches

F/E

strengthening

Legs, upper

body uninjured

side initially,

then injured

side at end of

late stage

Heavy traction or

weight through

elbow initially so

most upper body

work on that

side. Slowly

progress weight

with F/E strength

Treadmill

Bike

Cross Trainer

Classes at end of

stage

Extensor Tendinopathy

Major symptoms in History/Examination

• Chx: often insidious, P lateral humeral epicondyle, referred P lat forearm, dorsum of

hand ring and long fingers.

• Gradual onset pain with activity, but felt most afterwards. Most pts 35yrs+.

• P varies between dull ache/no pain at rest to sharp twinges or straining sensation

with activities.

• Agg: activities with repeated or prolonged wrist extension or grasping eg typing,

screwdriver.

• Ease: Ice, rest

• Commonly affects: ECRB, sometimes ECRL/ED and rarely ECU.

Objective Findings

• Obs: tender at common extensor insertion, may extend down into muscle belly,

warmth.

• Tests: Mill’s (resisted ext from pro/RD/F position) and passive PR/UD/F. ULTT rad

variation may be positive. Cervical spine often loss lat F with stiffness and

tenderness centrally and ipsilaterally.

• AROM: normally no P, wrist F with elbow E may elicit P from stretch, elbow

movements painless. Acc: full and painless


• Ice


• Ultrasound/Interferential

• Massage� trigger points + friction + longitudinal work through tight muscle bellys

• Resting splint if severely acute (3-5 days) with splint removal and slow gentle

movements several times daily.


• Stretching� no pain, elbow ext, with wrist F, UD, Pro.

• Dumbbell strengthening – eccentric program – pain free

• Treat cervical or neural tension component

• Counterforce bracing

• Alter predisposing factors�eg work habits, tennis stroke.

• Acupuncture

• Education re wrist position – optimize flexor/extensor balance

Estimated sessions/week for how many weeks

Acute condition

3x/week 1-2 weeks

2x/week 2 weeks

1x/week 2 weeks

Chronic condition

3x/wk 2 wks

2x/wk 3 wks

1x/wk 4 wks

Plan for non-progression of symptoms (review by who and when)

• Review by GP/sports doctor at 4 weeks, possible corticosteroid injection, surgery.

Special items to watch out for in this condition

Differential diagnosis: De quervain’s, pronator syndrome in forearm, radial nerve

entrapment, cervical referral.

Asterix signs (Retest)

• Mill’s

• Passive F/RD/Pro in elbow Ext

Other aids or appliances that may be useful (e.g. orthotics)

• Counterforce brace

• Wrist splint

• Padding for racquet/hammer to increase grip size

• Lat straps



Acute Stretches

Leg work, use lat

straps,

biceps/chest

press machine

with open hand

Gripping

weights/cables

Pump

Treadmill

Stepper

Bike

Classes (not pump)

Subacute Stretches

Eccentric

strengthening with

dumbbell/band

Leg work, upper

body with lat

strap

Gripping

weights/cables

Pump

Treadmill

Bike

Stepper

Classes (not pump)

Later

stage

Concentric

strengthening, grip

strength, stretches

Squats, Lunge, all

upper body work

use lat straps and

open hands

where possible

Treadmill

Bike

Cross Trainer

Rower

Classes

Flexor Tendinopathy


• Common golfer’s and tennis players with a lot of top spin on forehand shot.

• Gradual onset pain medial elbow/forearm, rarely into ulnar area of forearm.

• Pain varies from dull ache or no pain at rest to sharp twinges with activity.

• Agg: gripping/wrist flexion/pronation. Eg using a screw driver.

• Ease: ice, rest

Objective findings

• Localised painful area distal to medial epicondyle

• AROM may be painless

• Pain with resisted wrist flexion/pronation

• Pain/tightness sensation with full extension/supination

• Positive ULTT ulnar bias

• Grip strength before pain


• Ice

• Massage: friction, longitudinal


• Stretches

• Ultrasound

• Prevent aggravation-splint/alter techniques/work


• Ice

• Extension/supination stretch

• Rest

• Anti-inflammatories

• Resting splint


• Deep frictions/STM

• Specific advice on activity levels

• Dry needling

• Modify work/exercise technique� lat straps, larger grips

Progressive exercise/home

• Ecc strengthening program

• Ice

• Stretching

Gym exercise/activities to avoid initially

• Wrist curls, exercises requiring strong gripping action� lat straps: ensure proper

technique and wrist ext is maintained

• Avoid dumbbell and barbell presses

Gym exercises/activities that can still be completed

• Aerobic, leg work, presses with machines with open palm grip, pec pull over.


Acute condition

3x/week for 2 weeks

2x/week for 1 week

1x/week for 2 weeks

Chronic condition

3x/wk for 2 wks

2x/wk for 3 wks


If no improvements after 3 weeks send to GP, consider injection.


• Ulnar nerve entrapment

• Cx involvement

• Neural Tension components


Asterix signs

• Grip strength

• Stretch response

• Pain on palpation

Other aids and applications that may be useful (eg orthotics, braces etc)

• Resting brace

• Counterforce brace

• Lat straps


Acute Stretches

Leg work, use lat

straps,

biceps/chest

press machine

with open hand

Gripping

weights/cables

Pump

Treadmill

Stepper

Bike

Classes (not pump)

Subacute Stretches

Eccentric

strengthening with

dumbbell/band

Legs work, upper

body with lat

strap

Gripping

weights/cables

Pump

Treadmill

Bike

Stepper

Classes (not pump)

Later

stage

Concentric

strengthening, grip

strength, stretches

Squats, Lunge, all

upper body work

use lat straps and

open hands

where possible

Treadmill

Bike

Cross Trainer

Rower

Classes


Hamstring Strain


• Sudden pain/tearing sensation

• Commonly occurs during eccentric muscle contraction eg sprinting and bending to

scoop football.

• Reports knee snapped back into hyper ext and felt pain posteriorly.

• Pain with walking and hamstring stretching

• Predisposing factors: loading of the muscle (extremes of tension/length),

neuromotor attributes (LBP), Integrity of muscle (warm up, flexibility, eccentric ex,

time since previous injury, training�cause temporary alteration due to

regeneneration), poor core stability.

Objective findings

• Altered gait pattern

• Decreased straight leg raise, and 90/90

• Palpable gap in muscle

• Poor core stability/pelvic control.


• Ice

• Active knee extension to stretch (5 mins every few hours), achieve pain free ROM

asap.

• Tubigrip

• Pain relief only not NSAIDs

• No specific massage to injury site for at least 5 days, then STM, trigger points in

glutes.

• Ultrasound

• Cycle half/full revolutions no resistance - 5 minutes


• Active knee extension

• Ice

• Tubigrip


• Massage: DTM, frictions, myofascial

• Stretching

• Treat Lumbar spine abnormalities/hypomobility

• Neural tension

• Strengthening, esp eccentric


• -2+ times in first week, 2xweek for 2 weeks

• -1x/week 4 weeks


• -1x/fortnight for 2 fortnights if recurring or more serious.

Stage Rehab ex’s Gym ex’s Avoid

Cardio

Acute

Knee extension

Hamstring stretches

Core stability

Ball bridges

Any upper body,

calf raises

Squats, dead lift,

leg press,

sprinting, cycling

Classes

Boxing

Treadmill and

cross trainer

(light)

Bike

Sub-acute

Squats

bridging

lunges

Inclined extensions

1 leg squats

Bosu standing

Deadlifts

cables both legs

-Core work,

balance

All

Later stage

Sprints

Stop/start

Plymetric lunge and

squat + on bosu

Advanced core

1 leg deadlifts

Woodchoppers

with lunge

All

Common Causes of Knee Pain

1. Patellar-Femoral Syndrome

Onset: Running, stairs, repeated knee flexion extension (eg lunges, squats)

Pain: Vague (medial or lateral)

Knee giving way: occasional

Swelling: small effusion, above or below patella

2. Patellar Tendonitis (Jumper’s Knee)

Onset: activities involving jumping and landing

Pain: pain from inferior pole of patella to tibial tuberosity

Knee giving way: Rare

Swelling: Rare

3. Knee Osteoarthritis


Onset: gradual onset, pain with standing or knee flexion/extension; 40-50yrs+

Pain: pain reported to be ‘deep in knee’; night pain which causes patient to wake

up night; knee stiffness in morning.

Swelling: occasionally – depends on stage (usually late stage)

4. Meniscal Tears

Onset: sudden onset, twisting of the knee with foot anchored on ground.

Pain: delayed, increases after 24-48hrs; more serious tears cause pain

immediately.

Swelling: more noticeable after 24-48hrs.

Knee Locking: Intermittent locking (torn meniscus impinging b/w articular surfaces of

knee)

5. Ligament Injury

Onset: twisting of knee (external rotation of femur with internal rotation of tibia),

hyperextension, muscle induced (quads pull tibia forward e.g. skiing)

Pain: sudden, associated with ‘pop’, ‘crack’ or feeling of ‘something going out and

then going back’.

Swelling: large swelling within hours

Knee Locking: possibly as often associated with meniscal tears, otherwise unstable knee.

Meniscal Injury

Subjective

• May report a gradual onset of medial or lateral knee pain, with symptoms arising

after 20mins of so of exercise

• More commonly, twisting on a grounded foot, with varying pain at the time. Small

tears may cause increasing pain and swelling over 24 hours. May be degenerative in

older athletes. More severe� restricted ROM immediately, intermittent locking

with spontaneous unlocking, maybe associated with ligament injuries.

• Medial > lateral and less morbidity

Objective

• Squat� locking? Pain? Restricted ROM?

• Mc Murrays, Apleys, Grind/Traction

• Palpation: joint line tenderness, may feel small bulge at joint line (can be mistaken

for ITB bursa), posterolaterally degenerative lesion (farmer’s knee).

• Traction may relieve pain

• Effusion present

• MCL stress test may cause pain for medial meniscus

A Table guiding possible prognosis and treatment decisions

Factors indicating Conservative treatment Factors indicating Surgery


Symptoms develop over 24-48hrs

Able to weight bear

Minimal swelling

Full ROM, only pain at inner range F

Pain on McMurrays only at inner range F

Previous Hx rapid recovery from similar injury

Severe twisting mech, unable to cont play

Locked knee/severe restriction ROM

Positive McMurrays with palpable clunk

Positive McMurrays with minimal knee F

Presence of associated ACL tear

Little improvement after 3 weeks


• Massage

• Ice

• PUS

• Traction

• Tubigrip

• Dry needling

• Stretches� hamstring, ITB, calf


• Traction

• Massage

• PUS

• Mobes

• Stretches� add quads

• Mobes AP/PA + Patella femoral mobes

Estimated visits




Asterix Signs

• Mc Murrays, ROM


• At 4 weeks if no improvements, or in severe cases of locking refer to GP and

surgeon


• Locking, giving way, ACL/MCL damage, Meniscal cysts

Additional aids etc

• Crutches



Acute Co-contraction

hamstrings and

quads.

Toilet presses

Hamstring, quads

and calf

stretches.

Light leg press

Calf raises

Upper body

Shallow

squats/lunges

Deep squats and

lunges

High impact and

agility activities

Bike

Swimming

Boxing

Subacute Lunges

Wall ball squats

1 leg balance

Wobble

board/bosu

Core work

Upper and

lower body

Activities

involving high

agility and

impact

Heavily weighted

squats and

lunges

Treadmill

Bike

Cross trainer

Cycle classes

Later

stage

1 leg squats

Bosu balancing +

squats/lunges

multiple direction

Plyometrics

Advanced core

Running/sprinting

program as

appropriate

No restrictions,

emphasis on

squats, lunges

and deadlifts.

Treadmill

Bike

Cross Trainer

Rower

Classes

Patellofemoral Pain

Subjective

• May be gradual onset or specific event such as a blow to the knee or a period of

overuse of the joint (or period of decreased activity)

• Pain may be medial and superior as well as deep to the patella. In more severe

cases a constant sensation of pain, with increased intensity during aggravating

activities.

• Agg: sitting for long periods, stairs, cycling, breast stroke, STS, kneeling


• Ease: ice, rest

• Am: Acutely may feel bad in the morning due to present inflammation and improve

through day. Or worsen depending on activities performed.

• May cause pain when laying on side or stomach due to pull of ITB.

Objective

• Stability during/squat/lunge/single leg squat

• Unable to squat due to pain

• Note foot position� excessive pronation especially

• Resisted extension may cause pain

• Decreased VMO recruitment and bulk

• Tight ITB, bending the knee during test causes pain

• Patella compression may cause pain, compression + quads contraction � pain.

• Mobs: medial glide tight

• Palpation: check gutters for effusion present in severe cases, may be tender

medially through capsule and retinaculum, and laterally through ITB and its

insertion.


• Medial glide patella


• ITB release� roller at home + Ice

• PUS

• Massage

• ITB stretches + VMO activation exs


• Orthotics

• ITB release

• Medial Mobs

• McConnel Taping

Estimated visits




Asterix Signs

• Squat range with pain

• ROM

• Stability in squats/lunges





• Osteochondritis dessicans ???

Additional aids etc

• Knee brace, orthotics, ITB roller


Acute Straight leg VMO

Toilet press

Ball wall hip F

Upper body

ITB roller

ITB stretch

Ball bridge?

Bike, treadmill,

rower and

X trainer, stepper.

Avoid leg press/ext

Boxing,

swimming

(freestyle)

Subacute Ball wall squat

Step ups

Step downs

ITB roller

Core

Squat

Lunge

Upper body

Full stretch

routine

1 arm press,

woodchopper

pelvis still.

High duration

cycling (ensure

proper height),

rower, stepper.

Leg extension

Treadmill

Bike

Cross trainer

Later

stage

1 leg squat

Lunge with ball

ITB roller

Dynamic

multidirectional

squats and lunge,

all

upper body work,

leg press (toes

out), full stretch

routine.

Full woodchopper

, 1 arm press with

lunge.

Long duration bike

/rower

Treadmill

Bike

Cross Trainer

Rower

Classes

Medial/Lateral ligament sprain of the knee

Subjective


• Will report a traumatic mechanism of forced medial (LCL) or lateral (MC) angling of

the lower leg usually in a partially flexed position, +/- rotation and forward or

posterior translation.

• Will report immediate pain medially or laterally over suspected ligs, swelling

generally slow and localized, effusion and deep pain may indicate other structures

involved.

• Pts with large tears may complain of knee feeling unstable as if it might give way.

• Agg: placing leg in similar positions which caused injury, rolling out ankle(LCL),

squatting

• Ease: ice, bandage, rest

Objective

• Squat painful and ROM limited

• Medial/lateral stress test +ve (ACL/PCL and meniscal may also be present)

• May be effusion associated with medial tear, otherwise normally local swelling.

• AP/PA fibula cause pain (LCL)

• Palpation over ligament reveals tenderness, MCL particularly over medial femoral

condyle.


• Medial/lateral glide patella


• PUS

• Massage

• VMO activation exs + Hamstring/quads co-contraction exs

• Severe grade 2 and grade 3 if active brace with ROM Brace (0-30deg)

• Stretching


• Proprioception with wobble board + squats, lunges with ball,

• PUS, massage, patella mobs

• Taping

Estimated visits



• 1x/fortnight for 6 weeks

Asterix Signs

• Squat level without pain, palpation, swelling, VMO activation




• If severe instability or ACL/PCL/Meniscus suspected


• ACL/PCL, capsule tear, meniscus, fractures to the foot and ankle

Additional aids etc

• ROM Brace, biofeedback unit, wobble board, ex ball


Acute Straight leg VMO

Toilet press

ROM� dragging

heel up bed with

towel

Core

Stretches

Upper body

Ball squats

Small leg press

Classes, hip

add/abd

machines, rower.

Boxing, swimming

(freestyle)

Bike, treadmill

Subacute Ball wall squat

Step ups

Step downs

Core

Wobble board

Stretches

Squat

Step ups

Ball bridges

Shallow lunges

with co-contract.

Leg press, Cable

hamstrings,

deadlifts.

Add/abd hip

machines, High

impact classes

req agility

Treadmill

Bike

Cross trainer

Cycle classes

and pump with

modified lunge

Later

stage

1 leg squat

Lunge with

ball/bosu,

Core advanced

Sport specific drills

if req’d

Dynamic

multidirectional

squats and lunge

+ bosu, all upper

body work, leg

press (toes out),

full stretch

routine.

Woodchoppers

with lunge.

Agility sprints

Treadmill

Bike

Cross Trainer

Rower

Classes

Calf Strain Subjective

• Mechanism can involve taking off from DF position, or sudden eccentric DF eg

stepping on to a curb.


• Pt reports immediate stabbing/tearing sensation, usually in medial belly or at

myotendinous junction. May report sensation of being shot in the ankle in total

tendon rupture.

• Swelling, brusing develop quickly or over time, pain remains constant.

• Agg: walking

• Ease: ice, elevation

Objective

• Pain on palpation at site of tear

• Pain with calf stretch� knee straight: gastroc, knee bent: soleus

• Pain with resisted PF

• Grade 1: pain on unilateral calf raise/hop,

• Grade 2: AROM PF and bilateral heel raise cause pain, significant loss of DF. Grade 3:

Thomson’s test +ve, palpable defect� surgery

• Soleus strain more likely to come on gradually over days/weeks, walking/jogging

worse than sprinting, medial 1/3 fibres prone to becoming inflexible especially if

excessive subtalar pronation. Tenderness deep to gastrocs.


• Massage

• Ice

• Stretching – mm + neural

• Crutches, taping

• PUS

• Tubigrip

• Heel raise (bilateral)


• Strengthening exs

• Stretches

• Massage/PUS

• Proprioception

Estimated visits

Grade 1 Grade 2 Grade 3

2x/week for 1 weeks

1x/week for 3 weeks

3x/week for 2 weeks

2x/week for 3 weeks

Surgery referral

Follow up after Sx

Asterix Signs

• Heel raise strength and pain level, PF/DF ROM

• neural tension





• Myositis ossificans

Additional aids etc

• crutches

• heel raise

• orthotics


Acute Calf stretches

Concentric

bilateral heel

raises (?seated

initially)

Ankle AROM

Gentle neural

stretch

Upper body

Shallow squats

and leg press.

Pump� shallow

squat no lunge on

that side.

Classes, treadmill,

x-trainer, lunges,

weight heel raises

Boxing, swimming

(freestyle)

Bike,

Subacute Unilateral heel

raises

Wobble board

Calf stretches

Squat

Step ups

Ball bridges

Shallow lunges

Leg press, Cable

hamstrings,

deadlifts. Pump

Mobile classes

Weighted heel

raises

Treadmill

(walk/light job)

Bike

Cross trainer

Cycle classes

Later

stage

Eccentric heelraise,

hop + multiple

directions

Bosu balancing +

squats/lunges

Plyometrics

Dynamic

multidirectional

squats and lunge,

all upper body

work, full stretch

routine.

Heel raise light

weights.

Plyometrics

Treadmill

Bike

Cross Trainer

Rower

Classes


Postero-medial Shin Splints


• Chx: change of shoes, running surfaces, training intensity/volume.

• Pain along medial border of the tibia, worsening with activity, especially high impact

which requiring intense or prolonged plantar flexion eg running/attack classes. May

also complain of aching in the arch.

• Phx: ankle injuries, abnormal biomechanics, past episodes of medial calf pain, stress

fractures.

Objective Findings

• Pain calf raise, resisted inversion, 1st

toe flexion.

• Tenderness on medial border tibia, especially over insertion of tib post and

FHL/FDL. May have tenderness along tendons.

• Decreased calf length

• Flat/pronated feet


• Ice 3-4 times/day 15-20mins, rub an icecube along tibial border

• Pulsed ultrasound

• STM

• NSAIDs

• Arch support/anti-pronation taping


• Ice

• DF stretches

• Low impact activities, alter training surface/footwear

• STM

• Balance


• STM, ultrasound

• Orthotics

• Intrinsic foot muscle strengthening






• At 4-5 weeks if no improvement send to GP/Sports medicine for review



• Compartment syndrome

• Stress fractures- palpate bony areas for tenderness

• Tendinitis

Asterix signs

• DF/PF

• Balance time

• ability to perform functional activities without pain


• Orthotics- all patients should have Gaitscan, most would benefit from orthotics and

should be discussed with patients

Rehab ex Gym ex Avoid Cardio options

Acute Toe curls with

towel, picking up

pegs/marbles,

calf stretch,

resisted inv/pf

Calf raises with

correct foot

position, all

upper body

High impact

aerobic activities.

Bike

Rower

Cross trainer

Pump

Classes� take

low impact

options

Subacute Inv/pf in

standing, arch

correction

training.

Exerciese to

correct lower

limb

biomechanics as

required.

High impact

aerobic activites

Treadmill (short

duration slow

job)

Bike

Rower

Cross trainer

Classes� take

mostly low

impact options

Later-

stage

Sport specific

Return to

running

program,

Dynamic and

plyometric

exercises

All options as

tolerated- should

be wearing

orthotics if

required.

Ankle Inversion Sprain


• Chx: reports rolling ankle, experienced pain laterally and/or medially.

• Pt may report a crack/snap sound. Pain may be felt through peroneals.


• WB ability affected.

• Cause: landing on opponents foot, turn with planted foot, uneven ground

5th

metatarsal, or the navicular

An ankle x ray series is required only if there is any

pain in malleolar zone and any of these findings:

• bone tenderness at A

• bone tenderness at B

• inability to near weight both immediately

and in emergency department

A foot x ray series is required only if there is any

pain in midfoot zone and any of these findings:

• bone tenderness at C

• bone tenderness at D

• inability to near weight both immediately

and in emergency department

Ottawa rules for ankle, only need an x-ray if:

• Pain in the malleolar zone

• Bone tenderness of the posterior edge or

tip of the distal 6 cm of the lateral or

medial malleolus

• Totally unable to weight-bear both

immediately after the injury and for 4

steps in the emergency department

For the foot, only need an x-ray if:

• Pain in the mid-foot zone

• Bone tenderness at the base of the

• Totally unable to weight-bear both

immediately after the injury and for 4

steps in the emergency department

Objective Findings

• Swelling: gross/global or specific.

• Ant drawer/ inversion stress test positive

• ROM/strength decreased.

• Balance: one foot balance eyes open/ground, using wobble board

• Palpation: tender of ATFL/CFL, though peroneals, lateral/medial joint line.


• Ice 3-4 times/day 15-20mins.

• Tubigrip + elevation

• Pulsed ultrasound

• STM


• Mobs/mulligans

• NSAIDs


• Ice

• DF stretches

• Strengthening ex’s

• Inv/Ever movements

• Balance


• STM, frictions, ultrasound

• Proprioception/balance� wobble board, single leg squats, mini tramp

• Mobs/Mulligans� glide taping

Progressive exercise/home

• DF,PF, INV, EVER

�elastics, calf raises, tramps, cables (cable on contralateral foot)

• Functional activities: hopping, jumping, agility runs, sand walking.

Gym exercise/activities to avoid initially

• Jogging, multi-directional activities, step

• Lunges, weighted calf raises and heavily

Gym exercises/activities that can still be completed

• upper body, Pump (no lunges, squats unweighted), leg ext/curls, bike





• Review by GP if indicated by Ottawa rules

• At 3-4weeks if no improvement send to GP/Sports medicine for review


• Osteochondral fractures

• Impingement syndrome

• Greenstick

• Ruptured syndesmosis – ‘squeeze test’ and obtain stress views on x-ray

• Tarsal coalition

Asterix signs

• DF/PF

• Balance time


• ability to perform functional activities without pain


• ankle brace/taping�sports partners education

• proper shoes

Rehab ex Gym ex Avoid Cardio options

Acute DF ROM Inv/ever

with band

Heel raises

Calf stretches

1 leg balance

Heel raise

Squats

Classes requiring

high agility eg

attack/jam

Treadmill – until

N gait

Bike

Rower

Cross trainer

Subacute PNF strength

Body weighted

inver/ever

Bosu/wobble

board balance

Heel raise

Lunges

Classes requiring

high agility

Treadmill

Bike

Rower

Cross trainer

Later-

stage

Sport specific

Return to

running

Jump/hop drills

Agility work

1 leg cable exs

Squats, Dynamic

lunges

Taping for classes All options

Beat Back Pain with Core Stability Secrets

The problem

• Back pain affects up to 80% of people through their life

• Pelvic floor issues affect roughly 1/3 women at any time, increases with age.

• Core control, pelvic floor control, and cardiovascular health are all related

• Poor core stability is also a major risk factor/causative in many lower limb sports

injuries eg hamstring/quad strains.

Risk factors for poor core stability

• Previous back injury or chronic back pain

• Respiratory illness, bowel and bladder problems

• Poor range of motion lumbar spine

• Over emphasis of global abdominal muscles in training program- poor training over

activation of wrong muscles eg plank/hover performed improperly.

What is the core stability?


• The co-operative effort of both the internal unit (core) and outer unit (global

muscles) to maintain optimal control of the spine (retain vertebrae within neutral

zone).

• Internal unit: 4 groups of muscle working together to achieve ‘OPTIMAL’ control of

the spine. Trasversus Abdominus, multifidus, pelvic floor, diaphragm.

• Imagine a cylinder like a coke can suspended around your spine supporting it.

• Outer unit: Larger muscles utilised to produce movement through or around the

spine. Including: Glutes, lats, erector spinae, rectus abdominus, obliques,

hamstrings, rectus femoris.

• Optimal function cannot be achieved by either unit alone. They must function

together. Think about small wood blocks. Top figure, global muscles alone, bottom

figure includes core muscles.

Two simple tests for core stability

• Active straight leg raise - isometric

• 1 leg squat – functional application

4 best exercises to improve core control (See attached sheets)

1. TA activation

2. Supine bent knee lift

3. Bridge

4. Pointer


The Better Back Program

• 4 level exercise and evidence based program designed for people suffering with

lumbar pain whether it is of acute traumatic, postural, chronic, workplace or sports

related.

• Cardiovascular training throughout.

• Level 1- range of motion, most commonly including extension (number 1 stretch

prescribed by Australian Physiotherapists for Lumbar pain)

• Level 2- inner unit activation- may include the 4 exercises above with varying

options depending on client presentation.

• Level 3- addition of global muscle work. As stated working on creating a co-

operative action between inner and outer units to provide optimal stability. A large

focus is given to functional or work related actions. May utilise free weights, cables,

bands, balance boards and balls.

• Level 4: Sports or work specific activity, with high level exercises requiring skilled

control and co-ordination of inner and outer unit.

Knee Pain and Instability – Causes and Solutions

Traumatic Vs Non-traumatic

Knee pain is one of the most common injuries affecting the general and athletic population.

It is estimated around 25% of athletes experience anterior knee pain alone, not including

ligament and meniscal injuries. Due to its long lever, high load transfer and relatively poor

bony stability the knee is prone to overuse and stability issues.

Common traumatic injuries include:

• Ligament sprains: MCL/LCL and PCL often treated conservatively. ACL in most

people is total rupture requires surgery if continued multi direction activity is

desired. Previously rehab after this would be 9 months however new surgery

techniques are reducing this time.

• Meniscal tears: shock absorbers within the joint. Often treated conservatively

providing they are not blocking joint movement or creating instability.

• Patella dislocation: generally always lateral dislocation, conservative treatment with

bracing for first occurrence. Repeats may require surgical intervention.

• The Triad: commonly traumatic injuries involve multiple structures. Such as ACL,

medial meniscus and MCL.


Common Non-traumatic/overuse injuries include:

• Patellofemoral syndrome: patella tracks poorly in the femoral groove causing

wearing and inflammation. Often multifactorial.

• Patella tendinosus: inflammation and in chronic cases degeneration of patella

tendon.

• Runner’s knee: tightening and inflammation of the ITB caused by friction over lateral

bony structures.

The main focus of this seminar is on Non-traumatic injuries to the knee however many of

the exercises described below are often used in treating traumatic injuries as part of a

rehab program under the guidance of a physiotherapist.

Risk Factors – ITB, pronating, q-angle, pelvic/core control

1. Poor pelvic/hip: Good control creates strong foundation upon which muscles can

pull to cause action. Poor control of the core and pelvis creates increased load

through global muscles. The gluteal muscles in people with knee pain are often

under active or activation sequences between the core, glutes and hamstrings are

out.

2. Tight lateral structures: ITB and lateral quads often become tight and dominant

during extension of the knee. Creating a lateral pull of the patella. NB: the ITB is

NOT just a thick band, it has fascia extending out from it the combine into the fascia

covering the quads and hamstrings.

3. Pronation: increased pronation causes internal rotation of the tibia and therefore

knee joint. Studies have shown foot posture can have significant effects in the

development of injuries as high as the lumbar spine.

4. Q-Angle: this is the angle measured between the ASIS, centre of the knee joint and

the tibial tuberosity. Males below 20 deg and females below 25 is considered

normal, providing right is equal to left.

Testing

1. Thomas test: assesses muscle length of hip flexors, rectus femoris, lateral

structures.

2. 1 leg squat: assesses pelvic control/glutes and subjectively pronation in standing.

4 best exercises to improve knee strength and decrease pain

1. Toilet Press- targets activation VMO

2. Clam- targets glutes

3. Bridge- targets glutes and core

4. Foam Roller- useful for loosening soft tissues

Essential knee exercises:

When planning a general wellbeing or fitness program it is vital to consider the functionality

of an exercise. Eg leg extension vs. squat. Functional exercises are generally safer for the

joints (less shearing), better for bone mass development, utilise more muscles in a shorter

period of time and use your body in a way required in real life.

1. Squat:

2. Step-up


3. Deadlift

4. Lunge

If you are unfamiliar with these exercises, or just starting a program, see your health/fitness

professional. As with all exercises when done poorly these can cause the injuries intended

to prevent. Proper form and not high weight should always be you main priority.

NEW THERAPIST CLINICAL TUTORIAL...• General back mobility • Daily stretches to incorporate in...

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