The value of exercise is so commonly recognized that individuals from professions ranging from health and education to acting promote and teach exercises. In many cases the only qualification of the instructor or promoter is that of celebrity status or salesmanship skill. Unfortunately, because exercises are promoted and taught by such a wide range of individuals and are so highly publicized, there is little appreciation for the complexity of (1) how specific exercises can affect different body segments, (2) how to select exercises that complement one another, (3) how to select specific exercises for the needs of different individuals, and (4) how to instruct individuals in correct performance of their exercises. The prevailing notion is that exercises are generic, or that “one size fits all.” It is true that everyone needs exercise, but not all exercises can be recommended for all individuals, and not all individuals will perform a specific exercise in the same way.
Exercises can address three major aspects of health:
1. Musculoskeletal movement health, which is achieved by providing optimal control of alignment and specific joint movements; this control is a necessary foundation upon which to add the strengthening and endurance exercises
2. Tissue health and optimal musculoskeletal strength by improving the contractile capacity of muscles
Control exercises provide the means of preventing and remediating musculoskeletal pain problems, which the individual must do to maintain a strengthening and endurance program of exercise that does not lead to problems. Strengthening cannot suffice for the control exercises. If it could, then athletes and those who perform weight-training exercises would not be injured; however, they are among those who are the most frequently injured. Control exercises must be selected for a specific individual based on a physical examination. The exercises must be taught very carefully, including monitoring the patient’s performance and assessing whether the desired outcome is being achieved. Although many exercise manuals are available, they lack the detailed discussion of the purposes of the exercises that are described, how they are to be used, and what special considerations are necessary depending upon the patient’s condition. Exercise programs do not have to be complex, but they must fit the patient’s needs and they must be performed correctly. Most often the simplest exercises are the most effective, but they can only be effective if all of the exercises are consistent in addressing the problem and if they have been well taught to the patient. Patient compliance with an exercise program is determined by whether the patient understands specifically how the exercise benefits his problem, experiences improvement in his or her condition, can easily learn how to perform the exercises correctly, and can perform the program within reasonable time constraints.
The following information describes the multiple purposes of what may seem like simple exercises. Many of these simple exercises are components of basic movements used in daily activities and will only be effective if the correct performance of the patient’s most frequently performed daily activities is also addressed in the treatment program. If good control of the trunk and pelvis is maintained, correction of daily movement patterns and postures that do not compromise this control are the keys to preventing and correcting musculoskeletal pain problems.
Forward Bending (Hip Flexion With Flat Lumbar Spine)
Forward bending with hand support:
• The patient performs hip flexion with a flat lumbar spine and limits the flexion of the remainder of the spine.
• The patient places the hands on a table or a countertop and bends forward by flexing the hip joints while keeping the spine straight (flat or less than the normal inward curve).
• The patient flexes the knees if necessary to alleviate the tension on the hamstring muscles.
• The patient allows the hips to sway backward slightly; this is beneficial if the heel cords are short.
• The patient places the weight of the upper body on the hands.
• The patient allows the elbows to flex while flexing at the hips.
Level 2: Forward bending without hand support.: The patient performs the Level 1 exercise without hand support.
Return to erect standing from forward bending.: This movement is primarily a hip extension movement because the spine is straight and the alignment of the trunk does not change. The patient returns to the erect position by initiating the movement with hip extension. Frequently seen performance errors include the following:
• The patient initiates the return motion with hip extension, but early in the movement sequence he or she commences lumbar extension and creates the momentum to bring the trunk over the hips.
• The patient initiates the return motion with hip extension, but early in the movement sequence he or she sways the pelvis forward and dorsiflexes the ankles to minimize the demands on the hip extensors. This type of compensation is very common in patients with a swayback posture who have weak gluteal muscles.
Osteoporosis.: Patients with osteoporosis should maintain a straight trunk, paying attention to keeping the thoracic spine straight and stiff and flexing through the hips. If necessary to facilitate hip flexion, the patient should simultaneously flex the knees. Patients with osteoporosis should avoid flexion forces on the thoracic spine or at the thoracolumbar junction because of the danger of compression fractures. Forward bending should be limited to flexion at the hips while maintaining extension of the thoracic spine.
Men.: It is important to distinguish between limitation in hip flexion that is secondary to hamstring shortness or because of impaired motor control of hip flexion. For many men it is a matter of muscle control, rather than short hamstrings, that limits their hip flexion range during forward bending. If the load of the upper body is large because of a long trunk or broad muscular shoulders, the activity of the hamstrings may be greater than necessary. To assess the presence of a control problem, have the patient place his hands on a table or counter top and use his arms to support his upper body and then bend forward as described in the Level 1 exercise. Very often, with the body weight of the torso supported on his hands, the patient will be able to flex his hips at least 80 degrees while his knees remain extended. This supports the belief that the limiting factor is control of the trunk and pelvis by the hip extensor muscles, not the length of the hamstrings. When the limiting factor is one of muscle control, hamstring-stretching exercises will not improve the performance of forward bending.
Teaching the patient to simultaneously flex his knees and hips during forward bending is the most effective way to increase hip flexion range and prevent the faulty hamstring strategy. Most men should be instructed in simultaneous hip and knee flexion during forward bending. This does not imply that heavy lifting should be performed in this manner, but it should be used for any activity that requires leaning over (e.g., working in the sink, picking up an object from the seat of a chair, or looking into the refrigerator).
• To increase spine flexibility, particularly in those persons who have limited thoracic and lumbar flexibility; do not prescribe in the presence of a thoracic kyphosis or osteoporosis
• To increase the hip flexion range and stretch the hip extensors
• To encourage the use of the gluteal muscles and minimize the use of the hamstrings during the hip extension phase of the return from forward bending
• To encourage the use of the hip extensors during the full range of hip extension, particularly during the last phase of the motion; this is a common deficit in patients who have a postural alignment of anterior pelvic tilt
• Patient reaches toward the floor.
• Patient reaches forward and slowly allows the neck, trunk, and hips to flex until the end of a comfortable range is reached.
• Patient returns from forward bending.
• Patient contracts the gluteal muscles and extends the hips throughout the range until erect. The patient should not initiate the motion by extending the spine and allowing the momentum of the trunk to complete the motion.
The patient places the hands at the lowest level of the rib cage but above the iliac crest and slowly bends to one side, primarily by tilting the shoulders rather than moving at the waist. The therapist assesses whether this method alleviates the patient’s symptoms and improves the pattern of performance by changing the motion to the thoracolumbar area rather than the lumbosacral area. The therapist also notes the quality of motion through the spinal segments. Very often in patients with back pain, the motion is a translation motion at one or two segments rather than side flexion involving all of the lumbar segments. The hand support acts as a mechanical block that limits motion at the most flexible segment and forces other less flexible segments to move.
The patient should be taught to laterally flex, primarily in the middle of the thoracic spine. Observation indicates that impairments in this motion are another reason why patients develop pain when sitting. Usually people lean sideways in their chairs or change positions by leaning from one side to the other, creating the impaired translation motion that has been described. This exercise can be done with the back against the wall to avoid any rotation or extension. If the emphasis is to be directed toward stretching the abdominal and latissimus dorsi muscles, then the patient should place the arms above the head while bending to the side. The motion should be pain free.
• The patient stands with the feet relatively close together because the center of gravity must coincide with the supporting foot.
• The patient flexes one hip and knee while standing on the other leg.
• The therapist observes the patient’s ability to perform the movement and maintain the alignment of the trunk, pelvis, and stance leg.
• The patient repeats the exercise on the opposite extremity.
Pelvic rotation.: In patients with back pain, when the lower lumbar spine has become the site of excessive rotation, compensatory motion can be seen in the spine. For example, during right hip flexion, the pelvis rotates to the right while the lumbar spine rotates to the left. This motion should not occur. The pelvis and trunk should maintain a constant position in the frontal plane during motions of the extremities.
To correct this error the patient contracts the abdominal muscles to prevent trunk rotation. If the movement of the pelvis is into anterior tilt on the side of hip flexion, then the patient can contract the gluteal and abdominal muscles. If the pelvis moves in a posterior tilt on the side of the hip that is flexing, then the patient should not contract his gluteal muscles because it will result in lateral rotation. The problem is most likely the stiffness of the hip extensors on the side of hip flexion.
Hip adduction.: During single-leg stance, the hip of the stance leg adducts because of weakness of the hip abductors. The pelvic tilt associated with hip adduction can result in lateral lumbar flexion, another indicator that the lumbar spine is the site of compensatory motion.
Another compensation for weakness of the hip abductors is lateral trunk flexion to the side of the stance leg. This type of compensation is considered an indicator of more severe weakness than that associated with a lateral pelvic tilt (hip adduction). To correct this movement fault, the patient tightens the gluteal muscles to prevent the pelvis from tilting laterally (hip adduction) and to prevent the associated lateral trunk flexion. In men, because of their broad shoulders, the lateral trunk flexion can be very subtle but must be carefully observed because constant repetition of this side bending will lead to hip abductor weakness.
Excessive hip medial rotation.: When excessive medial rotation of the femur occurs on the stance leg, the patient tightens the gluteal muscles to improve the control of the hip lateral rotators. The excessive hip medial rotation should be corrected because it will result in compensatory motion at the knee joint (between femur and tibia) or at the ankle and foot (pronated foot). In individuals with an immobile subtalar or mid foot, the compensatory rotation may occur between the tibia and talus rather than at the subtalar joint.
Genu varum.: The combination of excessive hip medial rotation and knee hyperextension can cause the knee to assume a varum alignment. When performing the exercises for these conditions, the patient should flex the knee slightly and then tighten the gluteal muscle to prevent hip medial rotation.
Genu valgum.: Excessive hip medial rotation without knee hyperextension can be a contributing factor in this condition. Before attempting to correct the valgum, the therapist must examine the patient for the presence of anteverted hips or tibial torsion to be sure that the valgum is not a structural condition that should not be corrected. During the single-leg stance, the patient should shift his or her weight laterally and contract the gluteal muscles to externally rotate the femur to the neutral position.
Pronated foot and hallux valgum.: Excessive hip medial rotation and excessive flexibility of the subtalar joint lead to pronation of the foot. The medial rotation causes the line of gravity to fall medially along the longitudinal arch, pronating the foot. When the weight line falls to the medial aspect of the foot instead of passing along the second metatarsal, it passes along the medial aspect of the great toe during walking, forcing the great toe into valgum. This exercise is important for correcting these conditions. During the single-leg stance, the patient should maintain the foot in a neutral position to increase his or her weight on the lateral border of the foot and contract the gluteal muscles to externally rotate the femur to the neutral position.
This exercise is used relatively infrequently because of the stress on the patellofemoral joint. The number of repetitions should be kept to a minimum.
• The patient stands with the feet comfortably spaced and flexes both knees while standing.
• The therapist observes each knee relative to each foot and instructs the patient to correct alignment impairments.
• When flexing the knees, the patient turns them outward by contracting the hip lateral rotators so that the path of the knees are in line with the second toes.
Hip medial rotation, pronated foot, and hallux valgus.: Excessive hip medial rotation is often a contributing factor to development of a pronated foot and hallux valgum as described in the prior exercise. This exercise must be used carefully because of the stress it places on the patellofemoral joint. The stress arises because the femur is directed forward of the tibia and into the patella. An alternative is to practice the movement from sitting to standing, preventing hip medial rotation. This is done by emphasizing lateral hip rotation by contracting the gluteal muscles and the hip lateral rotators. This activity is better than the squat because the femur is perpendicular to the tibia at initiation, and as the knee extends, it rolls on the tibia and is not associated with as much anterior shear force.
Hip Flexor Stretch (Hip and Knee Extension With Maximal Flexion of Contralateral Hip and Knee)
• The patient begins with the hips and knees flexed (hook lying).
• The patient holds one knee to the chest with the hands and slides the other leg down the table into complete extension.
• While extending the lower extremity, the patient contracts the abdominal muscles by “pulling the navel in toward the spine” to maintain the spine in a flat position.
• The movement into hip extension is stopped when the patient is no longer able to maintain the lumbar spine in a flat position or the femur begins to rotate or abduct to attain full hip extension.
• If the patient has a marked thoracic kyphosis, then a pillow should be placed under the upper thoracic spine and head to accommodate for the curvature. Without this the patient will not be able to flatten the lumbar spine.
• If the tensor fascia lata is short, then the patient may need to slide the lower extremity into extension with the hip in abduction. As the exercise is repeated and the muscle stretches, the patient can bring the hip into a more adducted position.
• The patient begins with the hips and knees flexed (hook lying).
• The patient slides one lower extremity into extension while contracting the abdominal muscles to hold the pelvis in a slight posterior tilt and the spine in the flat to neutral position, depending upon the patient’s alignment impairment.
• The patient lowers the other leg, setting the foot on the supporting surface and trying to minimize the participation of the iliopsoas.
• The patient extends the leg by sliding the foot along the supporting surface.
• The contraction of the abdominals should not cause the sternum to become depressed or the abdomen to become distended. For maximum participation of the external obliques, the abdomen should remain concave and the therapist and patient should be able to palpate the increased tension in the muscle (on the lateral side of the abdomen, beneath the rib cage and just medial to the anterior iliac spine).
• The patient returns to the starting position by sliding one leg at a time back into the flexed position.
• The patient starts with one lower extremity in extension and the other hip and knee flexed.
• The patient, using either the hands or a towel supporting the thigh, pulls the flexed knee toward the chest.
• The patient stops at the point where the lumbar spine begins to flex or when he or she experiences symptoms.
• The patient returns to the position of 90 degrees of hip flexion or, if necessary, sets the foot on the supporting surface.
• In some patients, any minimal contraction of the hip flexors results in symptoms. The passive exercise helps the patient to learn to move the lower extremity without bringing on symptoms.
• The patient may not be able to completely extend the lower extremity because of the pull of the hip flexors on the pelvis or the spine.
• To improve hip flexion range and decrease the flexibility of the lumbar spine
• To decrease the stresses of both flexion and extension on the spine and be able to move the lower extremities without eliciting symptoms of back or groin pain
• To learn to stabilize the lumbar spine with the abdominal muscles while controlling rotation of the pelvis and the spine
• The patient begins with both hips and knees extended.
• The patient flexes the hip and knee, bringing the knee toward the chest, while contracting the abdominal muscles to keep the lumbar spine in the neutral position. The foot should be slightly raised above the supporting surface.
• The patient monitors any movement of the anterior superior spines of his or her pelvis with the hands.
• The patient stops the motion if he or she experiences back pain, lumbar extension, or pelvic rotation of more than ½ inch.
• The patient reverses the motion to return to the starting position.
• If there is rotation of the pelvis (the anterior superior iliac spine [ASIS] moves more than ½ inch), the patient stabilizes the pelvis with the abdominal muscles to stop rotation. This exercise is designed to use the abdominal muscles to control rotation with the external oblique muscle contracting on one side and the internal oblique contracting on the other side.
• If the patient has symptoms when performing the hip and knee flexion that are alleviated if the pelvis is stabilized, then he or she may need to decrease the load on the hip flexor muscles by sliding the foot along the table rather than lifting and holding it above the supporting surface. This exercise can be progressed in difficulty when the patient can perform it without symptoms or without spinal or pelvic motions. The following progression is suggested:
1. Unilateral hip and knee flexion from extension as described above. The exercise is continued by then simultaneously extending the hip and knee while holding the foot above the supporting surface as the lower extremity returns to the starting position.
2. First extending the knee while the hip is flexed, and then extending the hip to return to the starting position.
3. Flexing one hip while contracting the abdominal muscles to stabilize the trunk, and then continuing trunk stabilization while flexing and extending the other hip and knee.
• While lying on the back with the hips and knees extended, the patient slowly slides one heel along the table to flex the hip and knee and contracts the abdominal muscles to prevent spine and trunk motions.
• If the patient is without symptoms upon completion of the flexion motion, he or she then slides the heel along the table to return the leg to the extended position.
• The patient repeats the exercise, alternating extremities.
• If the patient has a thoracic kyphosis, he or she will need a pillow under the upper thoracic spine and head.
• If the patient has pain while lying at rest with both lower extremities extended, then it is necessary to get the back completely flat as he or she attempts flexion and extension movements with one extremity.
This exercise is often indicated for patients with low back pain because it is designed to improve the performance of the external oblique muscles, which are important for control of posterior pelvic tilt and combined with the contralateral internal oblique, control of pelvic rotation. These muscles help to prevent the accessory or compensatory motions of the pelvis and spine that occur during movements of the lower extremity. The way the exercise is performed also helps to improve the performance of the transversus abdominis muscle that stabilizes the lumbar spine. An important consideration is that this exercise also necessitates participation of the hip flexors. Because contraction of the iliopsoas, in particular, creates compressive and anterior shear forces on the lumbar spine, the exercise must be carefully taught and performed and used with caution. Clinical observation has shown that more women than men have weak lower abdominal muscles. The proportionally larger pelvis and lower extremities of women as compared with men contributes to this situation. Pregnancy also contributes to weakness of the abdominal muscles when this is not addressed with postpartum exercises. This exercise should not be used if the patient has acute low back pain; easier forms of lower abdominal muscle exercise, such as heel slides, should be initiated. The patient should not have symptoms while performing the exercise.
This is a series of nine exercises of progressively increasing difficulty. The patient starts in a position of hip and knee flexion (hook lying). The patient contracts his or her abdominal muscles by pulling his or her navel toward the spine and then performs the motions described in each level. The patient must maintain the contraction of the abdominal muscles avoiding distention of the abdomen and keeping the back flat.
1. Level 0.3 (E1)—Lift one foot with the other foot on the floor.
2. Level 0.4 (E2)—Hold one knee to the chest, and lift the other foot.
3. Level 0.5—Lightly hold one knee toward the chest, and lift the other foot.
4. Level 1A—Flex the hip to greater than 90 degrees, and lift the other foot.
5. Level 1B—Flex the hip to 90 degrees, and lift the other foot.
6. Level 2—Flex one hip to 90 degrees, and lift and slide the other foot to extend the hip and knee.
7. Level 3—Flex one hip to 90 degrees, lift the foot, and extend the leg without touching the supporting surface.
8. Level 4—Slide both feet along the supporting surface into extension, and return to flexion.
9. Level 5—Lift both feet off the supporting surface, flex the hips to 90 degrees, extend the knees, and lower both lower extremities to the supporting surface.
Once the patient can correctly perform 10 repetitions at the easiest level, he or she progresses to the next level and stops performing the previous exercise. Each exercise starts in the supine position, lying on a table or floor mat with the hips and knees flexed and the feet on the floor. The patient should be able to move the leg without moving (arching) the back. The back should be held flat (no curve) against the floor during extremity motion. If unable to keep the back flat, the patient should hold it in a constant position, without motion, during the exercise. The patient should breathe normally during the exercise. He or she should exhale when moving the second leg. The patient should place the fingertips on each side of the abdomen, just above the pelvis and below the rib cage, to monitor the contraction of the external oblique muscles. The abdomen should stay flat and not distend.
• Lying in the position indicated, the patient contracts the abdominal muscles, flattening the abdomen and reducing the arch in the lumbar spine. To achieve this the patient is instructed to “pull the navel in toward the spine.”
• The patient flexes one hip while keeping the knee flexed. By having the hip flexed more than 90 degrees, the weight of the thigh is assisting the posterior pelvic tilt and maintaining a flat lumbar spine.
• The patient returns the lower extremity to the starting position and repeats the exercise with the other lower extremity.
• The patient is cautioned not to push the nonmoving foot into the supporting surface because this will substitute hip extension for abdominal muscle action. The back must remain flat, and there should not be symptoms during performance of the exercise. Some patients may be barely able to lift the foot before having to immediately return it to the starting position.
• Lying in the position indicated, the patient contracts the abdominal muscles, flattening the abdomen and reducing the arch in the lumbar spine. To achieve this, the patient is instructed to “pull the navel in toward the spine.”
• The patient flexes one hip and uses the hands to hold the knee to the chest. While maintaining the contraction of the abdominal muscles, he or she flexes the other hip (lifts the foot off the supporting surface). The patient holds for a count of three and then returns the leg to the starting position and rests. He or she performs the exercise with the other lower extremity.
• The patient repeats the exercise five to six times if the back remains flat and he or she remains symptom free.
• If the patient is able to use just one hand to hold the knee to the chest, he or she should use the other hand to palpate the abdominal muscles.
• Some patients may be able to perform this level correctly and not level 0.3. If this is the case, they should start with this series.
• Lying in the position indicated, the patient contracts the abdominal muscles, flattening the abdomen and reducing the arch in the lumbar spine. To achieve this the patient is instructed to “pull the navel in toward the spine.”
• The patient flexes one hip and uses one hand to hold the knee to the chest but holds it less firmly than in the previous level, requiring more abdominal activity. While maintaining the contraction of the abdominal muscles, he or she flexes the other hip (lifts the foot off the supporting surface). The patient holds for a count of three and then returns the leg to the starting position and rests.
He or she performs the exercise with the other lower extremity.
• The patient should repeat the exercise five to six times if the back remains flat and he or she remains symptom free. The patient should perform with the other extremity in the same manner.
• As a progression, the patient holds the hip in less flexion and less firmly as gauged by the effect on the back and on the symptoms.
• Lying in the position indicated, the patient contracts the abdominal muscles, flattening the abdomen and reducing the arch in the lumbar spine. To achieve this the patient is instructed to “pull the navel in toward the spine.” Contraction of the abdominals should be maintained while moving the lower extremity. If the patient is slow in performing the exercise, he or she should relax the abdominal muscles after lifting the first leg and then contract them again before lifting the second leg.
• The patient flexes one hip to greater than 90 degrees by lifting the foot from the table. By having the hip flexed more than 90 degrees, the weight of the thigh is assisting the posterior pelvic tilt and maintaining a flat lumbar spine. Optimally, the flexed extremity will maintain this position with minimal contraction of the hip flexor muscles. At this point the patient contracts the abdominal muscles and flexes the other hip by lifting the foot off the table.
• If the patient’s back begins to arch while lifting the second leg, he or she lowers the leg, relaxes, and tries again. The patient maintains the contraction of the abdominal muscles and constant position of the spine while lowering the legs, one at a time, to the starting position.
• The exercise is repeated by starting the sequence with the opposite leg.
• Starting from the position indicated above, the patient contracts the abdominal muscles and holds the spine constant while flexing one hip to 90 degrees (vertical position of the thigh with the foot lifted from the table).
• The patient contracts the abdominal muscles and lifts the other leg to the same position. While maintaining the contraction of the abdominal muscles, the patient lowers the legs one at a time to the starting position.
• If the patient performs the exercise slowly, he or she may need to relax the abdominal muscles before lowering the legs and then contract them again to lower them.
• The exercise is repeated by starting the sequence with the opposite leg. The patient repeats the exercise, alternating legs, until he or she can perform it correctly 10 times. The patient can then progress to Level 1B.
• Starting from the position indicated in Level 1, the patient contracts the abdominal muscles and flexes the hip to 90 degrees, lifting the foot from the table.
• While maintaining the contraction of the abdominal muscles and a constant back position, the patient lifts the other leg up to the same position. Maintaining one leg at 90 degrees, the patient places the other heel on the table and slowly slides the heel along the table until the hip and knee are extended.
• The leg is then returned to the starting position by sliding the heel along the table. The patient continues to hold the abdomen flat and back in a constant position while repeating the extension motion with the other leg and returning it to the starting position.
• The patient repeats the exercise, alternating legs, until he or she can perform it correctly 10 times. The patient can then progress to Level 2.
• Starting from the supine position of hip and knee flexion described in Level 1, the patient contracts the abdominal muscles and maintains a constant back position. The patient flexes the hip to 90 degrees, lifting the foot from the table.
• While maintaining the contraction of the abdominal muscles and a constant back position, the patient lifts the other leg up to the same position. Maintaining one hip at 90 degrees, the patient extends the hip and knee while holding the foot off the table until the hip and knee are resting in an extended position on the table.
• The patient returns the leg to the hip and knee flexed position. While maintaining the contraction of the abdominal muscles and a constant back position, the patient extends and lowers the other leg and then returns it to the 90-degree position. The exercise is repeated, alternating legs.
Most patients have adequate strength and control of their abdominal muscles if they can complete this level successfully. Progression to a higher level is not necessary for remediation of a pain problem. Further increases in the level of difficulty of these exercises should be primarily for improved levels of fitness. If indicated, this exercise is repeated until the patient can perform it correctly 10 times, and then he or she progresses to Level 3.
• The patient begins the exercise in the supine position with both legs in extension.
• The patient contracts the abdominal muscles to decrease the lumbar curve and to maintain this lumbar position while sliding his or her heels along the table, flexing both hips and knees while bringing them toward the chest.
• Once the hips and knees are flexed, the patient pauses, reinforces the abdominal contraction, and slides both legs back into extension. Maintaining the position of the lumbar spine is extremely important.
• The exercise is repeated until the patient can perform it correctly 10 times before progressing to Level 4.
• The patient begins this exercise in the lower extremity extended position described in Level 3.
• The patient begins by contracting the abdominal muscles to flatten the lumbar spine and to maintain the spine motionless while simultaneously flexing the hips and knees, lifting both feet off the table to bring the hips to 90 degrees.
• The patient reinforces the contraction of the abdominal muscles, extends the knees, and lowers the lower extremities to the table. He or she must be able to maintain a flat lumbar spine while performing this exercise.
• In the presence of an increased lumbar curve or excessive lumbar flexibility into extension (extension DSM), the emphasis of the program is maintaining a flat lumbar spine while performing the exercises. These exercises are not recommended when the patient has symptoms when lying supine with the hips and knees in extension. The exercise sequence for these patients should begin with the heel slide exercise.
• In the presence of a flat back but with poor control by the abdominal muscles, the lumbar spine should remain still, but flattening of the lumbar spine should not be emphasized. This exercise is particularly indicated for patients with a swayback posture in which the external obliques and the iliopsoas are long.
• Patients can test 100% for upper and lower abdominal muscle strength and still have poor control of pelvic rotation during unilateral lower extremity motion.
• Often patients who have strong rectus abdominis muscles have weak external obliques. This is believed to be because the rectus abdominis has been the primary muscle producing posterior pelvic tilt and its performance becomes more optimal than that of the external obliques. Because the rectus abdominis muscle cannot control rotation as it runs parallel to the axis of rotation, improving the performance of the external obliques is important because they participate with the internal oblique muscles for the control of pelvic rotation.
• Women should be advised not to push their head into the supporting surface. This type of inappropriate stabilization can occur in women who have very weak abdominal muscles or who have a small upper body and a large lower body.
This exercise is seldom prescribed for patients with low back pain. The main indication for this exercise is for physical fitness. The primary muscle groups participating in this exercise are the internal obliques and rectus abdominis for the trunk-curl, with the addition of the hip flexors for the sit-up phase and the external oblique muscles for posterior pelvic tilt. This exercise is more difficult for men than for women because of the higher center of gravity in men than women. This is such a popular exercise many people have been using it as part of their fitness program without the proper individual examination and guidance for correct performance.
Physical therapists should be very familiar with all of the considerations of correct performance of this exercise to address frequently encountered errors. One of the important considerations is the degree of spinal flexibility of the patient. If the patient has excessive spinal flexibility, he or she will be able to flex the spine through a large range of motion before the initiation of the hip flexion phase. If the patient’s spinal flexibility is limited, he or she will only be able to flex through a limited range of motion before the initiation of hip flexion. As the patient’s program is progressed in difficulty, the therapist must be sure that the patient flexes to the same point in the range before progressing to more advanced exercises.
There are two main factors that can make this exercise unsafe. One factor is the anterior shear stress exerted on the lumbar spine produced by contraction of the hip flexor muscles, particularly the iliopsoas. That is why the abdominal muscles must have enough strength to maintain flexion of the spine at the time of the hip flexor contraction. If the patient’s trunk extends as the hip flexion phase is initiated, he or she should perform an easier level of the exercise to protect the spine. The other factor is excessive lumbar flexion at the end of the sit-up phase. When the exercise is performed with the hips and knees flexed, the axis of rotation is shifted from the hip joints to the lumbar spine. The patient also must contract the hip extensors more strongly when the hips and knees are flexed than when they are extended. The hip extensor contraction is to prevent the feet from coming off the supporting surface when the hip flexors are contracting to flex the trunk. This is consistent with the shorter lever arm created by hip and knee flexion and the decrease in passive stabilization of the distal attachments of the hip flexor muscles. At the end of the sit-up phase, the hips are in approximately 100 to 120 degrees of flexion depending on the degree of hip flexion that the patient assumes for the starting position. If the sit-up is performed with the hips and knees extended, the hips only have to flex to 80 degrees at the end of the sit-up motion.
The safest but not the best way to perform this exercise is to limit the movement to a trunk-curl and have the hips and knees flexed. This does not place maximum demands on the internal obliques because those demands are made when the hip flexors contract, producing anterior pelvic tilt while the trunk is flexing. At this point, the upper abdominal muscles experience the greatest demands to maintain flexion of the spine and posterior pelvic tilt.
This exercise is a progression of four levels:
1. Level 1A—Trunk-curl only; spinal flexion; easy
2. Level 1B—Trunk-curl with sit-up; spinal and hip flexion; with arms extended; moderate
3. Level 2—Trunk-curl with sit-up; spinal and hip flexion; with arms folded on the chest; difficult
4. Level 3—Trunk-curl with sit-up; spinal and hip flexion; with hands on top of head; most difficult
With a careful analysis by a physical therapist, the following method is preferred:
• The patient assumes a supine position with hips and knees in extension. A small pillow may be placed under the knees. To limit the anterior shear on the lumbar spine, the spine must become flat and remain flat during the trunk curl motion.
• The patient must curl to the limit of his or her spine’s flexibility.
• The patient begins with the level established by the physical therapist’s testing and proceeds to Level 1A when he or she can perform the exercise correctly 10 times.
• The patient flexes the shoulders to 45 degrees with the elbows extended, as if to reach toward the feet.
• The patient lifts his or her head by bringing the chin toward the neck and slowly curling the trunk (flexing the spine). The correct movement of the head is to reverse the cervical curve by bringing the chin toward the neck.
• The patient must avoid excessive flexion of the lower cervical spine and translation motion of the vertebrae that can occur if the patient is attempting to bring the chin to the chest. He or she must not lead with the face, as if looking upward, because that motion is cervical extension.
• The patient must flex the thoracic and lumbar spines to the limit of their flexibility. He or she stops just before the initiation of the hip flexion phase.
• The patient flexes the shoulders to 45 degrees with the elbows extended, as if to reach toward the feet.
• The patient lifts his or her head by bringing the chin toward the neck and slowly curling the trunk (flexing the spine). The correct movement of the head is to reverse the cervical curve by bringing the chin toward the neck.
• The patient must avoid excessive flexion of the lower cervical spine and translation motion of the vertebrae that can occur if the patient is attempting to bring the chin to the chest. He or she must not lead with the face, as if looking upward, because that motion is cervical extension.
• The patient must flex the thoracic and lumbar spines to the limit of their flexibility and maintain this position as he or she completes the hip flexion motion (sit-up).
• The patient flexes (folds) the arms across his or her chest, flexes the cervical spine by bringing the chin toward the neck and slowly curls the trunk as he or she comes to a sitting position. The trunk curl is maintained throughout the movement.
• The exercise is repeated correctly 10 times before progressing to Level 3.
• The patient places both hands on top of the head and flexes the cervical spine by bringing his or her chin toward the neck and slowly curling the trunk to the limit of his or her spine’s flexibility. The patient maintains this position as he or she comes to the sitting position. The trunk curl is maintained throughout the movement.
• Care should be taken to be sure that the patient is not pushing down on his or her head and compressing the cervical spine as he or she curls the trunk.
• The patient should avoid bringing the elbows forward (horizontal adduction) during the trunk curl because this decreases the effort required.
• Patients with a thoracic kyphosis should not perform this exercise because it emphasizes maximum thoracic flexion. This exercise is contraindicated for patients with osteoporosis because the trunk flexion increases their risk of compression fractures.
• This exercise is contraindicated for patients with cervical disease because of the stress on the cervical spine.
• This exercise is contraindicated for conditions in which compression of the lumbar vertebrae is undesirable, such as low back pain.
• Patients with spondylolisthesis should not perform the hip flexion phase.
• Patients with excessive lumbar flexion should be carefully monitored and should do the exercise with their hips and knees extended.
• Patients with very limited spinal flexion should not do this exercise because of the exaggerated hip flexion phase. (The duration of the hip flexion phase exceeds that of the trunk flexion phase.)
• To learn to move the femur without moving the spine or pelvis
• To improve the control by the abdominal muscles in order to prevent pelvic and lumbar rotation associated with hip motion
• To stretch the hip adductor muscles
• To improve performance of the abdominal muscles, specifically isometric control of pelvic rotation
• The patient starts with one hip and knee extended and the other hip and knee flexed. He or she places the hands on the pelvis (in the region of the ASIS) to monitor any motion. The patient is instructed to contract the abdominal muscles by “pulling the navel in toward the spine.”
• The patient lets the flexed lower extremity move slowly into hip lateral rotation/abduction. The patient stops when he or she experiences symptoms or feels the pelvis begin to rotate. If the pelvis remains stationary, he or she allows the hip to abduct/laterally rotate as far as possible by relaxing the adductor muscles. The patient adducts and medially rotates the hip, returning to the starting position.
• The patient repeats the exercise, trying to increase the hip range while preventing pelvic rotation by contracting the abdominal muscles. The exercise can be repeated with the same extremity before switching to the contralateral lower extremity.
If the patient has minimal abduction without pelvic motion or has pain, it might be necessary to put pillows along the outside of the leg to allow the leg to relax against a support to prevent pelvic motion or pain.
Level 2.: When the patient is able to perform the full range of motion without pain or pelvic rotation, the following progression is suggested:
1. Hip abduction/lateral rotation, then extend knee. The patient contracts the abdominal muscles and lets the flexed lower extremity move into abduction/lateral rotation. At the end of the range, the patient extends the knee joint and tries to prevent the pelvic rotation forces that are increased by the longer lever of the extended knee. The patient flexes the knee and returns to the starting position.
2. Hip abduction/lateral rotation, then extend knee and perform hip flexion/adduction.
The patient contracts the abdominal muscles and lets the flexed lower extremity move into abduction/lateral rotation. At the end of the range, the patient extends the knee followed by hip flexion/adduction, returning the leg to the midline and flexing the knee to return to the starting position. The patient repeats the exercise 5 to 10 times with one extremity, and then the exercise is performed with the other lower extremity.
A Knee extended with hip flexion and return to starting position
1. The patient lies supine on a table or mat with both legs extended and in neutral rotation.
2. The patient contracts his or her abdominal muscles to flatten the lumbar spine and flexes one hip with the knee extended, raising the leg from the table.
3. The patient lowers the leg to the table while maintaining contraction of the abdominal muscles. The patient should not push down (hip extension) against the table with the nonmoving leg because it decreases the demands on the abdominal muscles.
4. The patient should monitor motion of the pelvic crests to be sure that rotation does not occur.
B Straight-leg lowering (Knee flexed with hip flexion and knee extended during return to hip extension in neutral rotation.)
1. The patient contracts the abdominal muscles to flatten the lumbar spine; flexes the hip and knee, bringing his knee to the chest; and extends the knee while maintaining hip flexion. The patient may use his or her hands to hold the thigh so that the hip remains flexed to 90 degrees.
2. Keeping the knee extended and the lumbar spine flat, the patient lowers the leg to the starting position.
• The patient should not perform this exercise if it causes pain.
• If the iliopsoas is particularly weak, the patient should laterally rotate the femur before performing hip flexion.
• If the tensor fascia lata is weak, the patient should medially rotate and abduct the femur before performing hip flexion.
• If the patient has weak abdominal muscles (<2/5), then he or she should flex one hip and knee to place the foot on the table. Then, while performing the straight-leg raise with the other leg, the patient should push the foot into the supporting surface to reduce the demands on the abdominal muscles and the anterior shear force on the spine associated with the hip flexor contraction.
• To stretch the hip flexor, tensor fascia lata, rectus femoris, and iliopsoas muscles
• To correct the compensatory anterior pelvic tilt or rotation motion of the lumbar spine and the pelvis associated with shortness or stiffness of the hip flexor muscles
• To correct the compensatory lateral rotation motion of the tibia associated with shortness of the tensor fascia lata
• The patient begins by lying close to the end of a firm table with both knees held to the chest and the lumbar spine flat. The position on the table should be such that when the thigh is in contact with the table, one half of its length should extend beyond the table.
• The patient first uses the hands and holds one knee to the chest to maintain a flat, nonflexed lumbar spine and then lowers the other limp into hip extension. Upon completion of the motion, with the lumbar spine flat and the thigh in contact with the table, the hip should be in 10 degrees of extension. The hip flexors should elongate enough to permit 10 degrees of extension.
• While holding one knee to the chest, the patient lowers the other limb into hip extension so that the thigh touches the table. The hip should be in neutral position, and the tibia should be in neutral rotation.
• If the tensor fascia lata is short, the range into hip extension will increase if the hip is abducted. If pelvic tilt is associated with the hip extension, abducting the hip will alleviate the pelvic tilt or delay its onset. If the rectus femoris muscle is short, the hip will not be completely extended when the hip is abducted and passive extension of the knee will increase the range into hip extension. If the hip is still not completely extended, the iliopsoas is short. Sometimes laterally rotating the hip will increase the hip extension, which further supports the belief that the iliopsoas is short.
The following are modifications that must be made in the test when shortness is present in the muscles that are listed or the lumbar spine is more flexible than the tested muscles are extensible:
1. Tensor fascia lata shortness and stiffness. The patient should allow the hip to abduct as the thigh is lowered into hip extension. At the end of the range of hip extension or when the thigh is in contact with the table, the patient should adduct the hip, being sure not to substitute with hip medial rotation. The patient should stop if he or she feels pain in the area of the knee. The patient should keep the pelvis from tilting anteriorly or rotating. If the knee is the most flexible segment and there is compensatory tibial lateral rotation during the adduction motion, then the patient should medially rotate the tibia (turn the foot inward) and maintain this position while adducting the hip. The stretch should be maintained for 20 to 30 seconds. The patient then returns the thigh to the abducted position and repeats the motion.
2. Rectus femoris shortness and stiffness. With the hip in maximum extension and the knee extended, the patient should flex the knee and allow the hip to extend. The stretch should be maintained for 20 to 30 seconds. The patient then returns to the starting position by extending the knee and repeats the motion.
3. Iliopsoas shortness and stiffness. The patient should allow the hip to extend as far as possible. While keeping the pelvis and lumbar spine from tilting anteriorly or rotating, the patient allows the weight of the lower limb to stretch the hip flexor. The patient should prevent hip lateral rotation. After allowing the hip to stretch for 20 to 30 seconds, the patient returns to the starting position and repeats the motion.
A This exercise is not often recommended because of the problem with finding a suitable surface for performing the exercise. The other exercises that stretch the hip flexors are usually sufficient and this one is not necessary. If the patient maintains an active exercise program that involves the use of the hip flexors in a shortened position, this exercise may be necessary. In most patients with musculoskeletal pain, the primary problem is the lack of suitable control of segments that become sites of compensatory motion. As explained in other sections of this text, the most important requirement for correction is to increase the stiffness or control by muscles that permit the compensatory motion. Other exercises that are used to stretch the hip flexors and to improve the control of abdominal stabilizing muscles are as follows:
a. Knee to chest with leg slides
b. Bilateral hip and knee extension while maintaining a posterior pelvic tilt
B The muscle groups that are most frequently short are the tensor fascia lata–iliotibial band, anterior gluteus medius, and gluteus minimus, which are the hip flexor, abductor, medial rotator muscles. Relatively few patients have shortness of the iliopsoas muscle as compared with those with shortness of the tensor fascia lata and its abductor synergists. Because these hip flexors are abductors, allowing abduction and reassessing the range into hip extension is important to determine which hip flexors are short.
C In the presence of iliopsoas shortness, some patients will laterally rotate the hip to reduce the stretch on the iliopsoas. The other muscle that laterally rotates the hip is the sartorius, but because this muscle flexes the knee, there will be resistance to passive knee extension when this muscle is short. Shortness of the sartorius is not very common.
The patient begins in the supine position with the hips and the knees flexed, the lumbar spine flat, and arms at the side.
1. The patient keeps the elbows extended while flexing both shoulders. He or she should keep the arms close to the ears and maintain shoulder lateral rotation (olecranons pointing toward the ceiling). The back must remain flat against the table.
2. The patient holds at the end of the range for 5 to 10 seconds and then returns the arms to his or her sides.
1. The patient performs as in A, except that once the shoulder has flexed to 90 degrees, the patient uses the opposite hand to hold the inferior angle of the scapula against the chest wall. This will prevent excessive anterior or lateral excursion of the scapula as he or she continues to flex the shoulder. The inferior angle of the scapula should not abduct more than the midaxillary border of the thorax or more than ½ inch laterally.
2. Once maximum shoulder flexion has been reached, the patient should hold this position for 5 to 10 seconds to let the weight of the arm stretch the teres muscles.
3. The patient repeats the exercise, alternating extremities after 10 repetitions.
C Glenohumeral dysfunction. The patient performs as above, except that he or she first flexes the elbow and then initiates shoulder flexion, allowing the elbow to extend after the shoulder flexes to 90 degrees. The patient may need to place a pillow above the shoulder alongside his or her head and slide the hand along a pillow during the phase of shoulder flexion from 90 degrees to 180 degrees.
• Patients with a kyphosis may need to place a pillow under their thoracic spine and head.
• If the patient has a large thorax and restricted scapular motion, the supine position may interfere with the scapular rotation. The patient may need to actively abduct and upwardly rotate the scapula, particularly if he or she notes pinching in the area of the acromion.
The patient assumes a starting position of flexion of the hips and knees with the lumbar spine flat and arms at the sides.
1. The patient maintains elbow extension and abducts the shoulders, bringing the arms overhead so that the final position is 120 degrees of abduction, with the arms resting on the table.
2. The patient should hold this position for 5 to 10 seconds and then lower the arms to the sides, trying to keep the scapulae adducted on the thorax.
B Abdominal muscle strengthening with upper extremity motion.
1. The starting position is 120 degrees of shoulder abduction. The patient uses a weight that provides appropriate resistance in his or her hand and horizontally adducts the shoulder, moving in a direction toward the opposite hip. The motion can cease when the arm is vertical. The patient contracts the abdominal muscles and maintains the contraction as he or she lifts and lowers the weights.
2. The patient repeats the exercise with the opposite extremity.
3. The patient can also perform the exercise with weights in both hands.
• The patient begins the exercise in a position of flexion of the hips and knees with the arms at the sides.
• The patient flexes the elbows, externally rotates the shoulders, and abducts the shoulders by sliding the arms over the head. The patient should keep the arms in contact with the table for an effective stretch of the medial rotator muscles.
• To stretch the lateral rotators of the shoulder
• To eliminate compensatory anterior tilt of the scapula with shoulder rotation
• To eliminate compensatory anterior glide of the humeral head during medial rotation of the shoulder
• To improve performance of the lateral rotator muscles of the shoulder
• The patient begins the exercise with the hips and knees flexed to stabilize the thorax or with the lower extremities in extension. The shoulder is abducted to 90 degrees and is in neutral rotation with the elbow flexed to 90 degrees.
• A folded towel can be placed under the arm, if needed, to lift the arm and align the humerus in the plane of the scapula. The patient uses the opposite hand to hold the shoulder down onto the table, preventing anterior motion of the head of the humerus or anterior tilt of the scapula as the exercise is performed.
• The patient medially rotates the humerus, allowing the forearm to drop toward the table without lifting the shoulder girdle from the table. The patient stops the movement if pain occurs or if the shoulder girdle or the humeral head lifts from the table.
• The arm is returned to the starting position and the movement is repeated slowly 6 to 10 times until maximum range has been achieved without pain or compensatory motions.
• If the range of motion is markedly limited and resists stretching, a small weight can be used to assist the stretch. The weight should be heavy enough to exert a rotational effect on the shoulder but light enough so that the patient does not have to actively hold the weight to prevent medial rotation.
• Limited medial rotation range or greater relative flexibility of the scapular or the glenohumeral motion is quite common. Shortness or stiffness of the lateral rotators is believed to be a precursor and a contributor to impingement pain problems.
• After the patient is able to perform the motion correctly, the addition of weights can be used to strengthen the lateral rotator muscles.
• The patient is positioned in the same manner as described above for medial rotation.
• The patient laterally rotates the humerus while maintaining a constant position of the scapula and not allowing the head of the humerus to move anteriorly against the hand.
• The arm is returned to the starting position, and the movement is repeated slowly until maximum rotation range has been achieved without pain or compensatory motions. The exercise is repeated 6 to 10 times and then performed with the other arm.
• After correct performance is achieved, the addition of weights can be used to strengthen the medial rotators.
• Excessive range of lateral rotation is more common than excessive range of medial rotation. When the range is excessive, the anterior glide of the humeral head is also excessive.
• Limited lateral rotation range is not a common finding when the shoulder is only flexed or abducted to 90 degrees.
• If the patient has pain at 90 degrees of abduction, the degree of abduction should be decreased. Supporting the arm on a towel and positioning the shoulder in some degree of horizontal flexion, which is usually in the plane of the scapula (30 degrees in the frontal plane), is another method of reducing pain at the glenohumeral joint.
• The patient begins the exercise in a position of hip and knee flexion recommended to stabilize the thorax or with the legs in extension. From the starting position of 90 degrees of abduction, the patient passively horizontally adducts the shoulder.
• When the shoulder is in a position of 90 degrees of flexion, the patient should passively adduct the humerus (pull across the chest) using the other hand by applying pressure at the olecranon.
• The patient holds the humerus in this position for 5 to 10 seconds, releases, and then pulls again. During the stretch, the scapula must remain in contact with the table. The patient should feel a pull in the posterior shoulder girdle muscles but should stop if pain occurs in the shoulder joint.
• The exercise is repeated 6 to 10 times and then performed with the other arm.
• When the scapulohumeral muscles are short, there is often compensatory scapular motion. Therefore the scapula needs to be stabilized during the motion.
• If anterior joint pain is present, the patient can exert a posterior pressure on the olecranon as he or she passively adducts the humerus. Ensuring that the shoulder flexor muscles are relaxed can also help to alleviate symptoms.
The patient begins the exercise with the hips and knees in flexion so that the back is flat and the arms are at the sides.
A Assisted stretch (lying on back)
1. The patient begins the exercise in a supine position on a firm surface with the arms at the sides. The assistant stands at the side of the table and places the “heels,” or thenar portions of the hands, over the coracoid processes of both scapulae. (Bilateral stretch usually minimizes the rotation of the thorax that can occur with unilateral stretching.) Often it is easier for the assistant if his or her hands are crossed (e.g., so that his or her right hand applies pressure to the patient’s right shoulder).
2. Pressure is applied in the direction of the muscle fibers, towards but not directly on the head of the humerus, pushing the shoulder away from the body and down toward the table. The pressure is held for 5 to 10 seconds, released, and repeated. The patient should be experiencing a stretching feeling on the chest but not pain at the area of direct pressure.
B Self-stretch (lying on back)
1. The patient rolls toward the side to be stretched.
2. The patient applies pressure to the coracoid process to fix the scapula against the floor. While maintaining the pressure on the coracoid process, the patient rotates the trunk away from the shoulder.
C Assisted stretch (lying face down)
1. The patient is lying face down with arms at the side. The assistant stands at the side and reaches from the top of the shoulder to place his or her fingers in the crease on the front of the shoulder. The other hand reaches through the axilla to place the fingers also on the crease of the shoulder. The assistant then lifts up on the shoulder and leans back at the same time to stretch the muscle.
2. The therapist should not pull on the arm. The stretch should be felt on the chest and not in the shoulder joint.
• The patient begins the exercise lying with trunk and pelvis perpendicular to the table and the pelvis in neutral tilt. The hip and the knee of the bottom leg should be flexed. The top leg should be in the same alignment, supported on a pillow placed between the knees.
• The patient slowly laterally rotates the hip of the top leg, being sure not to allow the pelvis to rotate. The patient holds this position for 3 to 5 seconds and then returns to the starting position.
• The patient repeats the exercise 5 to 10 times. The motion should only occur in the hip joint. The pelvis and trunk should not move. After 5 to 10 repetitions, the patient rolls onto the other side and repeats the exercise with the opposite leg.
• The most common error is simultaneous pelvic rotation with hip rotation.
• The patient can start with the pelvis rotated forward to facilitate the use of the posterior hip lateral rotators versus the sartorius, so that the posterior muscles will be working against gravity.
• For the patient who has back pain when lying on the side, a folded towel placed at the waist level just above the iliac crest will often alleviate the pain by eliminating the spinal curvature associated with the side-lying position.
LEVEL 1: HIP ABDUCTION WITHOUT LATERAL ROTATION
• To improve the performance of the gluteus medius muscles
• To improve the performance of the lateral abdominal muscles. If the primary reason for the exercise is to improve the performance of the lateral abdominal muscles, the hip lateral rotation is not important; if the patient has an anteverted hip, then this exercise is more appropriate than the one with lateral rotation
• To enable the patient to learn to perform hip motion independent of pelvic motion
• The patient begins with the trunk and pelvis rotated slightly forward, perpendicular to the table, with the pelvis in neutral tilt. The hip and the knee of the bottom leg should be flexed. The hip and the knee of the top leg should be in 45 degrees of flexion, supported on a pillow placed between the knees.
• The patient slowly abducts the entire lower extremity, lifting it off the pillow without rotating the femur or pushing down against the table with the lower leg. The patient holds the hip in abduction for 3 to 5 seconds and then slowly returns it to the pillow.
• The patient may need a folded towel under the side, placed at waist level above the iliac crest to align the spine, if he or she has back pain in the side-lying position.
• The patient should not perform a lateral pelvic tilt either during the abduction phase or during the return phase to the starting position.
• The degree of hip and knee flexion can be adjusted to increase or decrease the length of the lever arm to accommodate to the strength of the patient’s hip abductors.
• The hip can be placed in more flexion to alleviate pain that the patient may experience when abducting the hip.
• The patient begins the exercise in the supine position with the trunk and pelvis rotated slightly forward and perpendicular to the table with the pelvis in neutral tilt. The hip and knee of the bottom lower extremity should be flexed. The hip and knee of the top leg should be in 45 degrees of flexion and supported on a pillow placed between the knees.
• The patient laterally rotates and abducts the upper leg, lifting it from the pillow, holding the abducted position for 3 to 10 seconds and slowly returning the leg to the pillow.
• The patient can place his or her hand on the pelvis to monitor and ensure that the pelvis does not move during the motion.
• The patient should avoid abducting the lower leg (pushing it into the table), which would indicate that the contralateral hip abductor muscles are providing the stabilization of the pelvis rather than the lateral abdominal muscles.
• To strengthen the posterior gluteus medius and hip lateral rotator muscles (This exercise can be used as a progression of the Level 2 exercise. The knee extension increases the length of the lever arm and the difficulty of the exercise.)
• To stretch the iliotibial band by adducting (lowering) the leg toward the table
• The patient assumes a position with the trunk and the pelvis rotated slightly forward and the pelvis in neutral tilt. The hip and knee of the bottom extremity should be flexed. The hip and knee of the top lower extremity should be extended and resting on the lower leg.
• The patient laterally rotates the hip and turns the entire leg outward so that the knee faces slightly upward. He or she then abducts and slightly extends the hip. The pelvis and trunk should not move, and the patient should not abduct (push down) the lower leg.
• The patient holds the leg up for 3 to 5 seconds and then, maintaining the external rotation, slowly lowers the leg to the table. The hip should only adduct 15 degrees, and the leg may not touch the table.
• The therapist should be sure that the patient does not have hip antetorsion so that excessive lateral rotation is not expected of the patient.
• If the patient has excessive length of the hip abductors, he or she should begin with the upper leg supported on a pillow between the knees and only lower the leg to the pillow so that the hip abductors are not allowed to assume a lengthened position.
• Women are more likely to have excessive length of the hip abductors because of their wide pelvis and habit of sleeping on the side with the upper hip flexed and adducted. This sleeping position should be corrected with a pillow between the legs and a folded towel under the waist.
TENSOR FASCIA LATA—(ILIOTIBIAL BAND STRETCH) REMOVE THE PARENTHESES
• The patient assumes a position with the trunk and pelvis perpendicular to the table and the pelvis in neutral tilt. The hip and the knee of the bottom lower extremity should be flexed. The hip of the top lower extremity should be extended, and the knee should be flexed about 20 degrees. In some patients the exercise is more effective if the knee is flexed to 90 degrees than when it is flexed to 20 degrees.
• The patient laterally rotates and slightly abducts and extends the hip of the upper leg. While maintaining the hip in lateral rotation and extension, the patient allows the top lower extremity to adduct toward the table. The patient allows the leg to hang unsupported for at least 10 to 15 seconds. The pelvis must not laterally tilt, and the hip must not flex.
• The patient assumes a position with the trunk and pelvis perpendicular to the supporting surface. The hip and knee of the bottom lower extremity are extended while the hip of the upper leg is flexed and laterally rotated. The knee is flexed so that the foot can rest on the supporting surface.
• The patient adducts the lower leg as high as possible without allowing the pelvis to move. The position of adduction is held for 3 to 5 seconds, and then the leg is returned to the starting position to repeat the exercise.
Shoulder Flexion, Lateral Rotation, and Scapular Adduction
• The patient assumes a side-lying position with the hips and knees flexed and the trunk perpendicular to the supporting surface. Pillows are placed in front of the patient’s chest so that the patient’s arm and forearm can rest on the pillows with the elbow at shoulder height.
• The patient rests the upper extremity on the pillows with the elbow flexed. The patient flexes the shoulder by sliding his or her arm over his or her head and extending the elbow as the shoulder is flexed.
• The patient holds this position for 5 to 10 seconds before returning to the starting position.
• In the side-lying position, the patient’s hips and knees are flexed and the trunk is perpendicular to the supporting surface. Pillows are placed in front of the patient’s chest so that the patient’s arm and forearm can rest on the pillows. The shoulder should be flexed about 120 degrees and the elbow about 20 degrees.
• The patient upwardly rotates and adducts the scapula. He or she initiates the motion with upward rotation. The second phase of the motion is scapular adduction.
The most common substitution for scapular adduction is depression of the scapula using the latissimus dorsi muscle.
To provide resistive exercise to the shoulder lateral rotator muscles when the patient is unable to abduct the shoulder sufficiently (90 degrees) to perform rotation exercises comfortably in the prone position
• The patient assumes a side-lying position with the hips and knees flexed and the trunk perpendicular to the supporting surface. Pillows are placed in front of the patient’s chest so that the patient’s forearm can rest on the pillows.
• The patient’s arm is resting on the lateral side of the thorax, and the elbow is flexed to 90 degrees with the forearm pronated so that the palm faces the pillow. The patient laterally rotates the shoulder by lifting his or her hand off the pillow.
• At the end of his or her active range, the patient maintains the position for 5 to 10 seconds and returns the arm to the pillow.
• The patient assumes a side-lying position with the hips and knees flexed and the trunk perpendicular to the supporting surface. Pillows are placed in front of the patient’s chest so that the patient’s arm and forearm can rest on the pillows with the elbow at shoulder height.
• The shoulder is positioned in approximately 100 degrees of flexion with the elbow flexed about 45 degrees. The patient emphasizes abducting and upwardly rotating the scapula while performing shoulder flexion by sliding the arm along the pillows. The emphasis should be placed on the scapular motion, and minimal emphasis should be placed on the completion of glenohumeral flexion.
• The patient assumes a prone position with the hips extended and in neutral abduction/adduction and rotation. The knees are extended. The upper extremities can be positioned in any comfortable position.
• The patient contracts the abdominal muscles and flexes one knee as far as possible while keeping the pelvis and thigh stationary. The patient can monitor the degree of pelvic motion by either placing the hands on the buttocks or the finger tips under the ASIS.
• If the patient is unable to prevent the pelvic motion while contracting the abdominal muscles, he or she should stop the knee flexion at that point. Another alternative is to place a pillow under the patient’s abdomen but not under the hip joints.
• The patient returns the leg to the starting position of knee extension and performs the same exercise with the other leg. The exercise is repeated, alternating legs.
• In patients with shortness or stiffness of the tensor fascia lata muscle and iliotibial band, pelvic motion can be prevented by placing the limb in 15 to 20 degrees of hip abduction before starting the knee flexion motion.
• If the tibia laterally rotates during knee flexion, the patient can medially rotate the tibia during flexion or flex both knees at the same time while keeping both knees and ankles together to decrease the tibial rotation.
• The patient lies prone with hips and knees extended and hips in neutral rotation, neutral abduction, and adduction. A small pillow may be used under the patient’s waistline (but not hips) if the prone position causes an increase in the patient’s symptoms or if excessive lumbar extension is noted.
• The patient contacts the abdominal muscles and flexes one knee. While keeping the pelvis still, the patient rotates the hip laterally and then medially. If the range is limited, the patient holds the position for 5 to10 seconds and then returns the leg to the midline. The exercise is performed in the same manner with the opposite leg.
• While performing the rotation motion with the hip, the patient monitors the pelvis to prevent motion. The patient can do this by either placing both hands on the buttocks or with the finger tips of both hands placed beneath the ASIS. If the patient feels motion of the pelvis while rotating the thigh, he or she can attempt to control the pelvis by contracting the abdominal muscles.
• If lateral rotation of the tibia occurs during hip lateral rotation, the patient should rotate the foot medially (tibial medial rotation) while performing the hip motion. The tibial rotation is caused by tightness of the tensor fascia lata-iliotibial band (TFL-ITB) and excessive flexibility of the knee joint.
• If the knee is unstable and marked movement of the tibia is noted, this exercise may be contraindicated because the movement may be a lateral glide of the tibia on the femur.
• If the greater trochanter makes a large excursion during hip lateral rotation, the therapist can control it by placing a hand on the thigh below the buttock and restricting the motion of the greater trochanter. This faulty pattern of femoral motion is believed to be the hip flexing secondary to the shortness of the TFL-ITB.
• If the patient has hip antetorsion or retrotorsion, the therapist may only recommend one direction of rotation.
• To strengthen the gluteus maximus and hamstring muscles
• To train the patient to initiate the motion with the gluteus maximus muscle and increase its participation while decreasing the use of the hamstrings during hip extension
• To improve the control of the proximal femur so that the greater trochanter maintains a constant position and does not move excessively in an anterior glide during extension
• The patient assumes a prone position with hips and knees extended. The hips are in neutral rotation and neutral abduction/adduction. A small pillow may be used under the waistline (but not hips) if the prone position increases the patient’s symptoms or if there is excessive lumbar extension.
• The patient extends and slightly lateral rotates the hip while maintaining knee extension. The patient should “think about” contracting the gluteus maximus muscle to initiate the motion. The pelvis should remain in contact with the table. The hip extension range is only 10 degrees.
• The patient monitors the position of the pelvis by placing both hands on the buttocks or with the fingertips of both hands under the ASIS. If pelvic tilt or rotation is felt, the patient contracts the abdominal muscles before extending the hip to prevent pelvic motion.
• The patient holds the leg in extension for 3 to 5 seconds and slowly returns the leg to the table and performs the exercise with the opposite leg. The exercise is repeated, alternating legs.
• If the patient is in hip extension while standing, the therapist should use a pillow under the abdomen to allow the hip to be more flexed. The patient should not extend the hip more than 10 degrees.
• The patient must not substitute lumbar extension for hip extension.
• Contraction of the gluteus maximus muscle should occur before or simultaneously with the hamstring contraction.
• If the greater trochanter moves anteriorly during hip extension, the patient should laterally rotate the hip by contracting the gluteal muscles before initiating the extension movement.
• The patient assumes the same starting position described for the previous exercise.
• The patient flexes one knee to approximately 125 degrees. Ideally the patient should be able to relax the hamstrings, and the weight of the leg should keep the knee flexed. The patient then slightly laterally rotates and extends the hip 10 degrees. The patient holds the leg in extension for 5 to 10 seconds and then slowly lowers it to the table. He or she repeats the exercise with the same leg before performing with the other side.
• The patient should be instructed to prevent pelvic motion or hip flexion (pushing into table) with the contralateral limb. The patient should monitor pelvic motion by placing the finger tips of both hands on the ASIS. If pelvic tilt or rotation occurs, the patient contracts the abdominal muscles by “pulling the navel in toward the spine” before initiating hip extension.
• Because the rectus femoris muscle is maximally stretched in this position, the tendency to extend the lumbar spine during hip extension is increased and thus the patient must be carefully monitored.
• Patients who have anterior pelvic tilt in standing often have difficulty using their gluteus maximus muscles at the end of the range and will readily substitute with lumbar extension at the last phase of the movement. These patients need this exercise because they also do not extend the hip sufficiently on return from forward bending.
• A pillow may be placed under the abdomen, but if that is necessary, this level may be too difficult for the patient.
• If the patient has to contract the hamstrings to keep the knee flexed, he should use a strap around his leg that he can hold with his hand to keep the knee passively flexed.
• The patient assumes a prone position with hips and knees extended and hips in neutral abduction/adduction and rotation.
• The patient abducts the hip by sliding the leg out to the side as far as possible without tilting the pelvis or moving the spine. The patient holds the position for 5 to 10 seconds and then slowly returns the leg to the midline position.
• The patient can monitor the pelvis for movement by placing the hands on the buttocks or the finger tips on the anterior superior spine. The patient repeats the exercise with the other leg and alternates legs when continuing the exercise.
• Because this is a gravity-lessened exercise, it can be used when the posterior gluteus medius muscle is very weak. Because the patient is prone, he or she uses the extensor hip abductor more than the flexor abductors.
• This exercise is also good for initiating improved use of the hip extensors without the tendency for the patient to extend the lumbar spine, which occurs with hip extension.
• The patient lies prone with knees flexed and hips abducted and laterally rotated so that the medial borders of both feet touch.
• The patient performs isometric hip lateral rotation by pushing the feet together for 5 to 10 seconds and then relaxing them. The patient continues to push and relax the legs for the desired number of repetitions and then returns the legs to the extended position on the table.
It is possible to substitute hip flexion/medial rotation for lateral rotation; therefore the therapist should be sure to observe a change in contour of the gluteal muscles when the patient is performing the isometric contraction. The patient should also be taught to contract the gluteal muscles when performing the exercise.
Back Extensor Activation (Shoulder Flexion to Elicit Back Extensor Muscle Activity)
• Two pillows are placed lengthwise on the table. The patient lies in the prone position on top of the pillows with the lower extremities in extension. The arms are positioned on the table at the sides with the shoulders in extension and the elbows flexed so the forearms rest on the table. Towel rolls may need to be placed under the shoulders to correct positioning of the scapula.
• The patient flexes one shoulder while extending the elbow by sliding the arm up over the head. As the patient advances the arm, he or she is trying to emphasize the abduction and upward rotation of the scapula rather than thinking about lifting the weight of the arm. The patient visualizes a string running from the elbow to the inferior angle of the scapula, pulling the scapula out into abduction as the arm advances. The patient should not focus on achieving maximum shoulder flexion but should concentrate on the movement of the scapula.
• The patient returns the arm to the starting position before repeating the exercise with the opposite arm.
• This is a gravity-lessened exercise and should be the easiest position for performing scapular motion. Because the weight of the thorax is not resting on the scapula, the scapula should move more easily than if performed in the supine position.
• In this position, the therapist can observe the motion of the scapula to ensure that the desired movement pattern is occurring. The therapist can also assist the scapula if there is resistance to the movement from the rhomboid muscles.
• The patient begins in the prone position with shoulders and elbows flexed and hands on the head. Towel rolls are placed under each shoulder to correct any anterior tilt of the scapulae.
• The patient lifts the arms by adducting the scapulae. The patient should visualize a diagonal movement of the scapulae. The patient should not let the shoulders shrug, and he or she should hold the position for 5 to 10 seconds and then relax.
The common movement impairments are flexing the humerus without adducting the scapulae and depressing the shoulder girdle with the latissimus dorsi instead of depressing the scapulae with the lower trapezius.
LEVEL 2: SCAPULAR ADDUCTION FROM SHOULDER ABDUCTION WITH ELBOW FLEXED
• The patient assumes a prone position with the arms overhead and the elbows flexed.
• The patient adducts the scapulae by bringing the shoulder blades toward the spine. If the lower trapezius muscle action is being emphasized, the patient should also be instructed to pull the scapula down and towards the spine. The patient should lift the arm and hand while contracting the trapezius muscle. The hand should remain slightly higher than the elbow to emphasize lateral rotation.
• The patient should not shrug the shoulder as he or she lifts the arm.
• The scapula should not downwardly rotate, which would suggest rhomboid action.
LEVEL 3: SCAPULAR ADDUCTION FROM SHOULDER ABDUCTION WITH ELBOW EXTENDED
• The patient lies prone with the shoulders abducted to 120 degrees and the elbows extended with the forearms in a neutral position and the thumbs pointing upward.
• The patient adducts the scapulae by bringing the shoulder blades back and down toward the spine while lifting the arms from the table (1 to 2 inches). The patient holds the arms for 5 to 10 seconds and then relaxes and lowers them to the table.
• This exercise can also be performed with one arm at a time as well as with both arms simultaneously.
• The patient should not elevate (shrug) the shoulder when lifting the arm (upper trapezius substitution).
• The hand should stay higher than the arm.
• There should not be pain in the area of the acromion.
• The patient should not depress the shoulder girdle by substituting the latissimus dorsi for the lower trapezius.
• The patient begins in the prone position on a bed or table with the shoulder abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm hanging over the edge of the table. Folded towels should be placed under the proximal humerus to position the scapula and humerus in correct alignment. The scapula should not be abducted or tilted anteriorly, and the humerus should be in the plane of the scapula.
• The patient slowly laterally rotates the humerus at the glenohumeral joint so that the forearm moves toward his or her head. There should not be any movement of the scapula when the patient rotates the humerus. To assist the patient in isolating humeral movement, he or she is instructed to concentrate on letting the upper arm “turn about a fixed axis” rather than letting the scapula and humerus move together as a unit. The patient holds the motion for 5 to 10 seconds and slowly returns the arm to the starting position.
• The patient assumes the same position as listed in the previous exercise.
• The patient medially rotates the humerus so that the forearm moves toward the hip. The patient is instructed to do this by letting the humerus “turn about a fixed axis” without any movement of the scapula. The patient holds the maximum range achieved for 5 to 10 seconds and then slowly returns the arm to the neutral position.
Often the scapulae will abduct and move toward the humerus during lateral rotation because the lateral rotator action is not adequately counterbalanced by the scapular adductor muscles. If the patient reduces the “effort” during lateral rotation, the scapular movement will be diminished.
If improving the performance of the subscapularis muscle is the focus of the exercise, then the most important part of this exercise is the movement at the end of the medial rotation range.
• Pillows can be placed lengthwise under the patient so that the forearm and hand can be placed on the table when the shoulder is maximally medially rotated with the elbow flexed. Then the patient extends the elbow slightly while maintaining maximum medial rotation. The isometric control of the medial rotators is easier to achieve than the concentric activity.
• The patient can allow the shoulder to laterally rotate a few degrees and then medially rotate and return to the starting position. The patient repeats the exercise as necessary, gradually increasing the lateral and medial rotation ranges.
• To decrease the compressive forces on the spine in patients with low back pain
• To assist in correcting rotational malalignments of the spine (The lack of compressive forces with symmetric four-point support provided by the quadruped position enables the spine to self-adjust to a more structurally normal alignment. When rocking backward, the slight distraction on the spine and the associated stretch on the erector spinae muscles assist in correction of the alignment.)
• To stretch the one-joint hip extensor muscles (gluteus maximus, piriformis, etc.) and to address any differences in the relative stiffness of these muscles compared with the back extensor muscles and their effect on compensatory pelvic and spinal rotation
• To assist in decreasing compensatory flexibility of the lumbar spine associated with hip extensor stiffness or shortness
• To assist in correction of thoracic kyphosis; the lack of compressive forces allows the thoracic spine to reverse its exaggerated flexion curvature
• To shorten and improve the performance of the thoracic back extensors
• To stretch the short extensors of the lumbar spine
• To improve the patient’s “sense” of the correct alignment of the trunk
• To improve the performance of the serratus anterior muscle
• To train the patient to perform flexion and extension of the hips without moving the spine
• To improve the posterior glide of the femur in the acetabulum
• To improve the posterior glide of the humeral head
• The patient assumes a comfortable position on the hands and knees. The head should be level with the shoulders, the shoulders should be centered over the hands, the spine should be flat, the hip joints should be centered over the knees, the hip joints should be at 90 degrees, and the ankles should be plantar flexed. The knees should be comfortably apart and in the same plane.
• The therapist corrects the patient’s alignment faults. The patient practices assuming the correct pain-free position.
• If the patient has an extension syndrome or pain with contraction of the hip flexors, the patient should push back toward his or her heels with the hands rather than flex the hips to rock backward in order to avoid psoas contraction.
• The patient assumes the correct position and then rocks backward as far as directed. The motion should occur in the hip and shoulder joints only, not the back. The back should remain straight and still. The shoulders should flex as the patient flexes the hips beyond 100 degrees. The patient should stop if he or she experiences pain and return to the starting position.
• The head and neck should not extend when the patient rocks backward. If the head and cervical spine extend during the rocking backward motion, then the patient should pull the chin toward the neck and maintain the contraction of the neck flexors while rocking backward. The extension is the result of levator scapulae shortness. As the scapulae are upwardly rotating, the levator is being stretched bilaterally, which causes cervical and head extension.
• In the presence of asymmetric stiffness of the hip extensors, the patient may have to laterally rotate and abduct the hip with the stiff muscles so that the pelvis will remain level during the rocking backward movement. With repetitions of the movement, the stiffness should decrease and the hip joint alignment can be repositioned appropriately.
• If the patient has unilateral or bilateral hip antetorsion and the hips are in the anatomically neutral alignment, the hips may not flex sufficiently to keep the pelvis level. The patient should medially rotate the hip or hips with antetorsion to correct the motion.
• If spinal rotation occurs as the patient begins to flex the hips, this can also be the result of asymmetric stiffness of the hips, which is evident in either pelvic rotation or lateral tilt. The therapist should adjust the patient’s hip joint position accordingly. Spinal rotation is the result of asymmetric length of the paraspinal muscles. Often when the patient rocks backward, the rotation increases. The therapist should apply counter pressure to the spine as the patient rocks backward. Repetition of the rocking backward with the counter pressure can correct the asymmetry. The therapist should be sure that the counter pressure is not causing symptoms.
• If the patient has a large abdomen or heavy thighs, he or she will not be able to rock backward as far without compensatory hip and lumbar flexion.
• If the patient with back pain is markedly obese with a very large abdomen, the pendulous abdomen will likely contribute to anterior shear forces in this position and make this exercise contraindicated.
• If the patient has cardiac disease, this position may be too stressful for cardiac output and must be used with caution.
• If the patient has knee dysfunction, the range into hip and knee flexion can be limited.
• Hip joint disease with limited hip flexion will contribute to compensatory pelvic and lumbar rotation. The therapist should limit the excursion to avoid excessive flexibility of the lumbar spine.
This exercise is rarely used because of the undesirable stresses associated with end range extension of the lumbar spine.
• This movement is rarely used.
• The patient begins in the quadruped position as described previously. The patient rocks backward as far as possible and then flexes the shoulders as far as possible so that the arms are maximally stretched in front of the body.
• To rock forward, the patient should keep the elbows straight and rock forward as far as instructed by the therapist. He or she should contract the abdominal muscles while rocking forward.
• The patient must have good strength and control of the abdominal muscles if he or she is going to rock all the way forward. Look for even distribution of spinal extension. Avoid extension at one or two segments. If the patient’s abdominal muscles are weak, he or she may have excessive lumbar extension, particularly at the lumbosacral junction.
• The patient should not rock beyond the point at which the scapulae begin to wing. Winging of the scapulae indicate that the load imposed by the weight of the trunk exceeds the capacity of the serratus to maintain the scapulae against the thorax. Shortness of the scapulohumeral muscles and insufficient counterstabilization by the trapezius and rhomboids also contribute to the winging of the scapula.
• When rocking forward, the patient is probably using the hip flexor muscles to control the rate and degree of hip extension, which may contribute to the pain problem.
• The patient assumes the quadruped position as described previously. The patient contracts the abdominal muscles by pulling his or her navel toward the spine to prevent rotation of the trunk while flexing his or her humerus with the elbow extended. If the spine starts to rotate immediately upon initiating shoulder flexion, then the patient may have to limit the arm movement to barely lifting his or her hand off the supporting surface by flexing the elbow while contracting the abdominal muscles. This modification should enable the patient to control the associated movement impairment.
• The patient lifts the arm as far towards 170 degrees of shoulder flexion as possible without the occurrence of pain or trunk rotation. This position is held for 5 to 10 seconds, and then the arm is returned to the starting position.
• The primary objective is to prevent asymmetric or exaggerated trunk rotation. As mentioned previously, the lever that the patient is lifting can be adjusted by having the patient flex the elbow rather than flex the shoulder to decrease the demands on the abdominal muscles and back extensors. The instructions are based on the patient’s ability to control the rotation.
• The back extensor activity should be bilateral or may be slightly greater contralaterally as indicated by change in the muscle contour.
• If the patient flexes the hips more than 90 degrees, he or she will decrease the demands on the abdominal muscles and back extensors. This is another method of adjusting the demands of the exercise or can be a way in which the patient is unaware that he or she is modifying the exercise and decreasing its demands.
Hip extension with knee flexed.: The patient assumes the quadruped position as described previously with the hips slightly adducted so that during single lower limb support there will be less tendency for the pelvis to rotate. The patient contracts his abdominal muscles by pulling his or her navel toward the spine. The patient keeps the knee flexed and extends the hip while maintaining a constant position of the pelvis and spine. The patient must not extend the spine. The motion must be limited to the hip joint.
As with the other exercises, the purpose of this exercise is for the patient to be able to maintain a constant position of the pelvis and spine during extremity movements. The therapist must determine the appropriate level of difficulty for the patient to achieve this objective. The patient must not extend the lumbar spine so that he or she will avoid end-range extension.
• The patient is instructed to initially contract the abdominal muscles by “pulling the navel in toward the spine” and then flexing one shoulder while keeping the elbow extended. The patient then extends the contralateral hip and knee while maintaining a constant position of the pelvis and spine.
• For a more advanced level of performance, the patient contracts the abdominal muscles and then simultaneously flexes the shoulder and extends the hip and knee.
• The exercise is then performed with the other arm and leg.
• The patient should be able to perform single limb movements without spinal motion before attempting this exercise.
• The patient must be carefully instructed not to allow pelvic or spinal rotation during the limb movement. Most often patients cannot completely extend the hip without rotating the pelvis.
• Many patients perform this exercise incorrectly because it is commonly used in exercise classes. They must be carefully instructed regarding the correct technique.
• To stretch the neck extensor muscles, including the levator scapulae
• To improve the performance of the neck extensor muscles
• To assist the patient in learning to extend the cervical spine correctly and avoid posterior shear forces
• To assist the patient in learning to reverse the cervical curve for flexion rather than moving excessively at the lower cervical segments
• To learn to move in the correct segments of the cervical spine
The patient assumes the quadruped position as described previously. With the cervical spine in the normal cervical alignment, the patient is instructed to bring the chin toward the neck to reverse the cervical curvature. The patient holds this position for 5 to 10 seconds and then extends the cervical spine by “thinking about rotating his head about a rod running through the center of his or her head. The therapist is attempting to teach the patient to perform a rotational movement in the sagittal plane.” The axis should be in the middle of the cervical vertebrae.
• In some patients, marked asymmetry may be noted between the muscle bulk on the left and right sides of the cervical spine. Such asymmetry can be associated with swimming strokes performed with consistent head turning to one side only.
• In some patients the levator scapulae muscles may appear prominent in this position. This is interpreted as dominance of the levator scapula as a neck extensor and insufficient participation by the intrinsic neck extensor muscles.
• Some patients will perform extension with excessive movement of the lower cervical segments and insufficient participation of the upper segments.
The patient assumes the quadruped position as described previously. Starting from the neutral position of the cervical spine, the patient rotates his or her head to one side as far as possible without pain. The patient is instructed to “think about rotating about a rod running longitudinally through the head and neck.” The patient is to avoid any type of twisting motion. He or she should hold the position for 5 to 10 seconds and then rotate to the opposite side.
Knee Extension and Ankle Dorsiflexion
• To stretch the hamstrings and the calf muscles
• To correct muscle length discrepancies between the medial and lateral hamstring muscles
• To train the patient to control compensatory lumbar flexion and rotation associated with stretch of the hamstrings
• To train the patient to use the anterior tibialis muscle and to avoid use of the extensor digitorum longus, which can become a dominant dorsiflexor of the ankle
• To stretch the peroneal muscles
• To train the patient to avoid inappropriate recruitment of the tensor fascia lata muscles
• To train the patient to avoid excessive recruitment of the hip flexors to maintain the sitting position or during knee extension
• To train the patient to avoid hip medial rotation during knee extension
• To train the patient to avoid inappropriate co-contraction of the quadriceps and hamstring muscles
• To correct faulty lateral glide of the patella
• To improve the performance of the quadriceps and ankle dorsiflexor muscles
• To shorten and improve the performance of the lumbar back extensor muscles
• To train the patient to avoid lateral rotation of the tibia during knee extension
• The patient assumes a sitting position, preferably in a chair with a straight back. The hip joint is flexed to 90 degrees, the pelvis is vertical, and the lumbar spine is flat.
• The patient slowly extends one knee as far as possible without pain and without posterior tilting or rotation of the pelvis or flexion or rotation of the spine. If sitting with the back supported, he or she can be instructed to extend the upper back against the chair (isometric extension) while extending the knee. The patient’s hip should be maintained in neutral rotation. He or she should not have any contraction of the tensor fascia lata or hamstring muscles. When the knee is at maximum extension, the patient dorsiflexes the ankle, pointing the foot toward the knee. While dorsiflexing the ankle, the patient should avoid leading with the toes or everting the foot. The patient holds the position for 5 to 10 seconds and returns the leg to the starting position.
• If the medial hamstrings are stiffer than the lateral hamstrings, the patient will medially rotate the hip during knee extension. However, when instructed to maintain neutral rotation, the patient will be able to extend the knee through the full range. If the medial hamstrings are short, the knee extension will be limited when the patient maintains neutral rotation.
• If the patient extends the hip during knee extension, which will be evident by the depression of the thigh into the seat of the chair, he or she is probably co-contracting with the hamstrings. Passive extension of the knee will confirm or refute this hypothesis. If the patient is co-contracting the hamstrings, he or she should make an “easy” effort to extend the knee. A useful verbal cue is to ask the patient to think about “using only two fibers of the quadriceps” to extend the knee. This contraction pattern is often seen in patients who have frequently performed resisted knee extension exercises.
• If the patient displays pelvic or lumbar rotation during knee extension, abducting the hip before beginning the exercise often decreases the compensatory rotation. The stiffness or shortness of the gluteus maximus/iliotibial band is believed to be a contributing factor to this pattern.
• If the patient has patella alta or excessive lateral glide, he or she can stretch the shortened structures by assisting the gliding of the patella as the knee returns from extension to flexion.
• The best way of assessing the rotation of the thigh is by having the therapist place his or her hands on the top of the patient’s thigh during knee extension. If the patient medially rotates the hip during knee extension, there are two possible contributing factors: (1) shortness or stiffness of the medial hamstrings and (2) inappropriate recruitment of the tensor fascia lata. The patient will need to decrease the active effort of knee extension to eliminate the tensor fascia lata contraction.
• The patient with hammer toes will most likely initiate ankle dorsiflexion with the toe extensor muscles, and he or she should be trained to move at the ankle and not at the toes. The patient with a pronated foot often everts the foot while dorsiflexing the ankle. If the patient inverts instead of everts, he or she will feel a stretch along the lateral side of the leg because of stretch of the peroneal muscles.
• If the patient has limited ankle dorsiflexion, he or she can use a towel under the ball of the foot and pull on the towel with the hands to passively dorsiflex the ankle.
• The patient is seated with the hips at 90 degrees, the spine and pelvis erect, and the arms resting at the sides of the thighs. The patient is instructed to passively flex the hip by lifting the thigh toward the chest with his or her hands while keeping the spine and pelvis motionless. The exercise is performed passively to minimize the recruitment of the tensor fascia lata, sartorius, and rectus femoris muscles. At the end of the range of hip flexion, the patient contracts the hip flexors to maintain the flexion position and releases the hand support of the thigh. He or she tries to maintain the hip in a constant position for 5 to 10 seconds.
• If the patient is able to do this easily, then he or she is instructed to push with his or her hand against the knee, resisting the contraction of the hip flexor muscles for 3 to 5 seconds. The patient should be careful to keep the knee close to the midline and the thigh in neutral hip rotation. In some cases the patient may slightly laterally rotate the hip to further isolate the iliopsoas muscle.
• The patient slowly lowers the leg to the starting position and repeats the exercise, alternating the legs.
• This exercise is used primarily for patients who have hip pain associated with a weak or long iliopsoas muscle.
• This exercise is much easier to perform if one foot is touching the ground rather than when the patient is sitting on a table with both feet unsupported.
• This exercise requires support from the trunk muscles and can be used as a corrective exercise when there is asymmetric strength, as in patients with scoliosis.
• This exercise should be used with caution in patients with low back pain because of the compressive forces associated with iliopsoas contraction. In the sitting position, the anterior shear forces associated with contraction of the iliopsoas should be less than in the supine position.
Shoulder Flexion (Back Against Wall)
• To provide an orientation for normal alignment of the head, shoulders, and spine
• To decrease thoracic kyphosis or depressed chest
• To improve the performance of the shoulder flexor, pectoralis major, anterior deltoid, scapulohumeral, serratus anterior, and trapezius muscles
• To improve the control of glenohumeral lateral rotation by the teres minor, infraspinatus, and posterior deltoid muscles
• To stretch the latissimus dorsi muscle
• To improve the performance of the abdominal muscles
• To improve the technique of the return from glenohumeral joint flexion avoiding anterior tilt or abduction of scapula or thoracic flexion
• The patient assumes a position with the back, shoulders, and buttocks against the wall. The head should be in line with the shoulders. To bring the back of the head against the wall, the patient should avoid cervical extension, bring the chin toward the neck, and think about lifting the chest to bring the head and shoulders back to the wall. The feet should be apart with the heels about 3 inches away from the wall. The arms are at the sides with the cubital fossae facing anteriorly and the palms of the hands facing the sides of the body.
• The patient flexes the elbows, maintaining neutral rotation of the shoulder joint, and flexes the shoulders. After reaching 90 degrees of shoulder flexion, the patient extends the elbows while completing the motion of shoulder flexion as far as possible without pain. The patient should not shrug the shoulders (unless specifically instructed to do so) while flexing them, and he or she should try to keep the olecranon pointing anteriorly, which emphasizes lateral rotation. The patient should not allow the low back to extend. The patient can contract the abdominal muscles before he or she begins the motion to prevent the extension, or he or she can contract them upon completion of maximum shoulder flexion.
• The patient should hold the final position for 5 to 10 seconds and then reverse the movement pattern to return to the starting position. The patient should be careful to not allow the scapulae to tilt anteriorly or to flex the thorax, but he or she should try to move primarily in the glenohumeral joint.
• Because the elbow flexed position decreases the length of the lever that is being moved, this exercise is preferred if the patient has excessive superior glide of the humerus or inadequate upward rotation of the scapula.
• The patient should stop the motion if he or she feels pain in the area of the acromion. Women 50 years of age and older are especially susceptible to developing impingement pain with this exercise, particularly if they have large breasts, dropped shoulders, and deep indentations on their shoulders from bra straps. The patient can continue to perform the exercise but will need to stop the motion at the onset of pain. The patient should do repetitions of the exercises facing the wall which is more effective in depressing the humeral head during flexion.
• If the patient has a marked thoracic kyphosis, he or she will not be able to place the back of the head against the wall or be able to touch the wall with his or her arms at the completion of shoulder flexion. This patient should be advised that this is not the goal of the exercise in his or her case.
• If the patient has shoulder pain and a depressed chest or a thoracic kyphosis, the patient should attempt to reach the maximum pain-free range of shoulder flexion even though there is associated trunk motion. At the completion of the motion, the patient should contract the abdominal muscles to decrease the compensatory lumbar extension. The action of the external oblique abdominal muscles should be emphasized so that the patient is attempting to flatten the abdomen by narrowing his infrasternal angle and not allowing flexion of the thoracic spine and associated depression of the chest.
• This exercise is also helpful in training the patient to avoid excessive superior glide of the humerus during flexion because a limited portion of the deltoid is participating. In contrast, when the patient performs abduction the entire deltoid muscle is participating, therefore markedly increasing the superior glide forces acting on the humerus.
Starting from the position described in Level 1, the patient flexes the shoulders while maintaining elbow extension. While attempting to achieve the maximum pain-free range of flexion, the patient keeps the eyes level, avoiding cervical extension or tilting the head backward. The patient maintains this position for 5 to10 seconds while contracting the abdominal muscles and tries to flatten the back against the wall. The patient extends the shoulders slowly, lowering the arms to the sides, being careful to keep the shoulders against the wall.
This exercise is a progression of the Level 1 exercise because the extended elbow position increases the length of the lever that is being moved and increases the demands on the shoulder girdle muscles. The patient should be able to perform the previous level in an optimal manner before progressing to this exercise.
• To provide an orientation for normal alignment of the head, shoulders, and spine
• To decrease a thoracic kyphosis or depressed chest
• To lengthen the pectoralis major muscle
• To improve the performance of the trapezius muscle
• To train the patient to move the humerus without associated movement of the scapula and thorax during the return to neutral from shoulder flexion/abduction
• The patient assumes a position with the back, head, shoulders, and buttocks against the wall. The feet should be apart with the heels about 3 inches from the wall. The arms are at the side with the cubital fossae facing anteriorly and the palms of the hands facing the sides of the body.
• The patient flexes the elbows and then flexes and abducts the shoulders (diagonal movement) to 90 degrees of abduction with the elbows flexed. The scapulae and arms should be in contact with the wall. The patient slowly extends the elbows and elevates the shoulder by sliding the arms over his or her head. The patient keeps the arms in contact with the wall while achieving the maximum range of elevation. The patient holds this position for 5 to 10 seconds while contracting the abdominal muscles, pulling the abdomen up and in so that the back flattens against the wall. The patient reverses the movement to return to the starting position of the arms at the sides.
• If the patient has a thoracic kyphosis, he or she will not be able to get the arms back to the wall and should be advised not to extend the back to attempt to do so.
• If the patient has shortness of the pectoralis major or minor muscles, he or she may need to practice the movement of assuming the correct starting position of 90 degrees of abduction with the elbows flexed. The patient should try to have his or her shoulders stretch as broad as possible. Until this position can be assumed easily, the patient should not attempt to increase the degrees of abduction.
• If the patient experiences pain in the shoulder joint while attempting to achieve the position of 90 degrees of abduction, he or she can actively adduct the scapulae while moving the arms, which often alleviates this problem because it alleviates the impingement of the humerus on the posterior aspect of the glenoid.
• The therapist should monitor the patient’s glenohumeral joint to ensure that the humerus does not glide superiorly during the motion. If the humerus fails to maintain a constant axis of rotation, the therapist should suspect over-pull by the deltoid or shortness of the scapulohumeral capsular muscles.
Three methods are described that address different performance problems and in some situations are part of a progression to improve range of motion or control of scapular and glenohumeral motions.
• To increase the range of shoulder flexion
• To improve the performance of the serratus anterior muscle
• To improve the performance of the shoulder flexor muscles
• To reduce compensatory elevation of the shoulder girdle during shoulder flexion
• To encourage depression of the head of the humerus during shoulder flexion
This method is best suited for improving the mobility of the glenohumeral joint when the patient has restricted range of motion or excessive humeral superior glide. Another indication is marked weakness of the shoulder flexor muscles, such as with rotator cuff tears.
• The patient stands close to the wall with the feet comfortably apart. The shoulders are in a neutral position and the elbows are flexed with the ulnar side of the forearms and hands against the wall.
• With the ulnar border of his hands against the wall, the patient flexes the shoulders by sliding the hands along the wall. The patient should exert some pressure against the wall with the hands to create a force of depression and posterior glide at the humeral heads. The humerus should not medially rotate during the flexion motion. The patient should stop the motion when he or she experiences pain in the region of the acromion. The exercise is performed with one arm in the presence of a primary glenohumeral dysfunction and bilaterally if scapular dysfunction is the primary problem. The final position should be held for 5 to 10 seconds before reversing the movement to return to the starting position.
• If the patient has pain during active shoulder flexion, then he or she can use the contralateral hand to passively flex the shoulder while leaning into the wall, putting pressure against the hand of the painful shoulder to depress and posteriorly glide the humeral head.
• If the humerus medially rotates during flexion, the patient can use the contralateral hand at the lateral aspect of the olecranon to direct the elbow medially to maintain humeral lateral rotation and to prevent abduction.
• If the patient has marked weakness of the rotator cuff muscles, then he or she can use the contralateral hand to assist the shoulder flexion motion. If the complete range can be achieved, the patient can then lift the hand away from the wall, hold the arm in the vertical position, and lower the arm by sliding it back down the wall. This procedure uses the mechanical advantage of not having to lift the weight of the arm, because the vertical position reduces the weight of the extremity, and using eccentric contraction, which requires less development of active muscle tension to control the extremity.
• To emphasize the performance of the serratus anterior muscle, the patient should be instructed in how to “think about” abducting and upwardly rotating the scapula as the shoulder is flexed. The patient should not be concerned as much with the range of shoulder flexion as with the motion of the scapula. The therapist can assist the scapular motion passively, which also provides an indication of the resistance to scapular upward rotation from muscles such as the rhomboids.
The patient stands in a doorway so that his or her body is slightly forward of the doorway and the elbow is in full flexion with the forearm and hand resting against the door frame. The patient flexes the shoulder by sliding the ulnar side of the forearm up the door frame. The patient should push his or her hand into the door frame while sliding the hand up the door frame into full shoulder flexion and elbow extension. The position of the body forward of the shoulder and the resistance of the surface assists the patient in depressing and posteriorly gliding the humeral head and thus achieving the full range of shoulder flexion.
This method is used to assist the patient in maintaining or regaining range of motion through lateral rotation range of motion that has been compromised by rotator cuff dysfunction or capsular restriction.
The patient stands with one side of the body close to the wall and has the shoulder in lateral rotation with the elbow fully flexed and the dorsal aspect of the forearm and hand against the wall. The patient slides the arm up the wall into flexion with elbow extension. This positioning assists the patient in maintaining shoulder lateral rotation throughout the movement.
• Trapezius. The patient stands close to and facing the wall. The elbows should be flexed with the arms at the side of the body rather than in front of the body. The position requires lateral rotation of the humerus and adduction of the scapulae. The ulnar side of the forearm and hand should be against the wall.
• Upper trapezius. The patient is instructed to abduct the shoulders by sliding the forearms and hands up the wall. The motion follows the path of a diagonal. When the shoulders are abducted to 90 degrees, the patient should shrug his or her shoulders (bring the acromions toward the ears) while continuing the abduction/elevation motion. The shrugging motion is used to elicit activity of the upper trapezius. At the completion of the abduction motion, the patient should lift the hands off the wall by adducting the scapulae. The patient should hold this position for 5 to 10 seconds.
• Lower trapezius. The patient is instructed to abduct the shoulders by sliding the forearms and hands up the wall until he or she reaches a diagonally overhead position. The patient then lifts the hands off the wall by adducting and depressing the scapulae. He or she should hold this position for 5 to 10 seconds and then reverse the motion to return to the starting position. The patient can also return the hands to the wall while maintaining the abducted/elevated shoulder position and then repeat the scapular motion of adduction and depression.
• The therapist should ensure that the patient is adducting the scapula and not just moving at the glenohumeral joint or depressing the shoulder girdle with the latissimus dorsi muscle.
• The patient can also be instructed to adduct the scapulae without the depression component if the shoulders are not posturally elevated.
Control of Hip and Knee Medial Rotation
• The patient begins with an erect standing posture, looking straight ahead with the feet pointing slightly outward.
• The patient is instructed to contract the abdominal muscles by “pulling the navel in toward the spine.” The patient may also place the hands on the iliac crests to monitor the movements of the pelvis. The patient then practices walking while trying to prevent pelvic rotation. Often it is necessary for the patient to take smaller steps, particularly if the hip flexors are short and the abdominal muscles are weak.
The patient should not perform bilateral contraction of the gluteal muscles to posteriorly tilt the pelvis because this limits the ability to flex the hip.
• Lateral trunk flexion to the stance side is considered a sign of greater weakness of the gluteus medius muscle than hip adduction (drop). In this case, the patient may need a cane.
• The broader shoulders of men make it possible to have only a slight amount of lateral trunk flexion that alleviates the load on the hip abductors. This must be carefully observed by the physical therapist.
• The patient begins with an erect standing posture, looking straight ahead with the feet pointing slightly outward.
• At heel strike the patient is instructed not to let the knee hyperextend. As the patient brings the body forward into midstance, he or she pushes the ball of the foot into the floor to increase the use of the plantar flexor muscles.
The plantar flexor muscles assist in controlling the advance of the tibia during heel strike to midstance. Often the use of the plantar flexor muscles aids the control at the knee and helps to prevent the hyperextension at the knee. The timing is important because if the patient contracts his plantar flexor muscles too early, it will contribute to the hyperextension.
To teach the patient to be aware of and to control the position of the knee when his or her weight is shifted onto the stance leg
• The patient begins with an erect standing posture, looking straight ahead with the feet pointing slightly outward.
• The patient steps forward with the foot slightly turned outward. As the patient sets the heel down, he or she contracts the gluteal muscles to prevent medial rotation or hyperextension of the knee. As the patient shifts his or her weight forward and rolls over the foot, he or she needs to press the ball of the foot into the floor. The knee should be in slight flexion at heel contact and pointing straight ahead as the shift occurs. The knee then extends as the body moves forward over the foot and the gait progresses from heel contact to foot flat.
• Some medial rotation of the hip and knee is normal. Excessive rotation is important to identify.
• The therapist should differentiate between medial rotation of the entire lower extremity when the femur and tibia maintain a relatively constant relationship and when the femur is rotating excessively with respect to the tibia.
• Hip antetorsion contributes to the appearance of excessive hip medial rotation. This is a structural factor and should not be considered a dysfunctional position.
• The patient begins with an erect standing posture, looking straight ahead with the feet pointing slightly outward.
• At heel strike the patient thinks about pushing back on the floor to control the advance of the knee. From foot flat to toe off the patient contracts the plantar flexors to push the ball of the foot into the floor and lifts the heel.
• Patients with knee pain often can be helped by increasing plantar flexor activity from heel strike to foot flat.
• Patients who look like they have a shuffling gait often will benefit from instruction in increasing their push-off.
• Patients with Achilles tendonitis also often need instruction in correct push-off. If the forefoot flexors are particularly strong and calf muscles test weak, the patient should be instructed to “lift the heels” and not to “go up on the toes.”