Home Exercise Programs For Musculoskeletal and Sports Injuries

An Imprint of Springer Publishing
HOME EXERCISE
PROGRAMS FOR
MUSCULOSKELETAL
AND SPORTS
INJURIES
THE EVIDENCE-BASED GUIDE FOR PRACTITIONERS
Ian W. Wendel | James F. Wyss

Home Exercise Programs
for Musculoskeletal and
Sports Injuries
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for Musculoskeletal and
Sports Injuries
The Evidence-Based Guide
for Practitioners
Editors
Ian W. Wendel, DO, FAAPMR, CAQSM, RMSK
Tri-Country Orthopedics
Clinical Assistant Professor
Rutgers New Jersey Medical School
Ringside Physician
New Jersey State Athletic Control Board
Cedar Knolls, New Jersey
James F. Wyss, MD, PT
Assistant Attending Physiatrist
Assistant Professor of Rehabilitation Medicine NYP-Cornell
Director of Education for HSS Physiatry Department
Team Physiatrist Long Island Nets
Hospital for Special Surgery
New York, New York
Photographs by Richard Bean
An Imprint of Springer Publishing
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ISBN: 978-1-6207-0120-1
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DOI: 10.1891/9781617052972
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Library of Congress Cataloging-in-Publication Data
Names: Wendel, Ian, editor. | Wyss, James, editor.

Title: Home exercise programs for musculoskeletal and sports injuries : the
evidence-based guide for practitioners / [edited by] Ian Wendel, James
F. Wyss.
Identifiers: LCCN 2019031671 (print) | LCCN 2019031672 (ebook) | ISBN
9781620701201 (paperback) | ISBN 9781617052972 (ebook)
Subjects: MESH: Exercise Therapy | Athletic Injuries--therapy |
Musculoskeletal Diseases--therapy | Patient Compliance | Self Management
| Evidence-Based Practice
Classification: LCC RM725 (print) | LCC RM725 (ebook) | NLM WB 541 | DDC
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19 20 21 22/5 4 3 2 1
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To my father and his love of books.
-IWW
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CONTENTS
Contributors xi
Foreword Joseph E. Herrera, DO, FAAPMR xiii
Introduction xv
Acknowledgments xvii
List of Exercises xix
Share: Home Exercise Programs For Musculoskeletal and Sports
Injuries: The Evidence-Based Guide for Practitioners
1. Home Exercise Programs for Shoulder Injuries

Jonathan Kirschner 1
Introduction 1
Goals for Advancement of Exercise Program 1
Rotator Cuff Tendinopathy 2
Acromioclavicular Joint Pathology 2
Glenohumeral Joint Osteoarthritis 3
Glenohumeral Joint Instability 4
Adhesive Capsulitis/Frozen Shoulder 4
Handouts 6
References 24
2. Home Exercise Programs for Elbow Injuries

John Gallucci, Jr. and Taylor Rossillo 25
Introduction 25
Lateral Epicondylosis 26
Medial Epicondylosis 27
Ligament Sprains 27
Distal Bicipital Tendinopathy 28
Ulnar Neuropathy at the Elbow 29
Handouts 30
References 47
3. Home Exercise Programs for Wrist and Hand Injuries
Julia Doty 49
Introduction 49
De Quervain’s Tenosynovitis 49
Carpal Tunnel Syndrome 50
Carpometacarpal Osteoarthritis 51
Extensor Carpi Ulnaris Tendinopathy 52
Handouts 53
References 70
4. Home Exercise Programs for Hip Injuries

Jessica Hettler and Astrid DiVincent 71
Introduction 71
Hip Osteoarthritis 72
Iliopsoas Tendinopathy/Bursitis 72
Greater Trochanteric Pain Syndrome 73
Hamstring Strain and Tendinopathy 74
Femoroacetabular Impingement and Labral Tears 75
Handouts 77
References 99
5. Home Exercise Programs for Knee Injuries

Jessica Hettler and Astrid DiVincent 101
Introduction 101
Knee Osteoarthritis 102
Patellofemoral Pain Syndrome 103
Quadriceps and Patellar Tendinopathy 103
Knee Ligament Sprain 104
Meniscal Tear 105
Iliotibial Band Syndrome 106
Handouts 108
References 127
6. Home Exercise Programs for Ankle and Foot Injuries

Ian W. Wendel 129
Introduction 129
Ankle Sprain 130
Achilles Tendinopathy 130
Posterior Tibial Tendinopathy 131
Plantar Fasciosis 132
Handouts 133
References 142
viii CONTENTS
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7. Home Exercise Programs for Cervical Spine Injuries
Gary Mascilak 143
Introduction 143
Directional Preference 143
Cervical Facet Arthropathy 144
Cervical Disc Pathology 145
Cervical Radiculopathy 146
Upper Crossed Posture 147
Handouts 149
References 167
8. Home Exercise Programs for Thoracic Spine Injuries

Gary Mascilak 169
Introduction 169
Thoracic Spine 171
Handouts 172
References 183
9. Home Exercise Programs for Lumbar Spine Injuries

Amrish D. Patel 185
Introduction 185
Directional Preference 185
Lumbar Facet Arthrosis 186
Lumbar Disc Pathology 187
Lumbar Radiculopathy 188
Lumbar Spondylolysis/Spondylolisthesis 189
Lumbar Spinal Stenosis 190
Lower Crossed Syndrome 191
Handouts 193
References 219
Index 221
CONTENTS ix
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CONTRIBUTORS
Astrid DiVincent, PT, DPT, OCS Advanced Clinician, Sports Rehabilitation and
Performance Center, Hospital for Special Surgery, New York, New York
Julia Doty OTR/L, CHT Senior Director, Orthopedic Physical Therapy Center,
Hospital for Special Surgery, New York, New York
John Gallucci, Jr., MS, ATC, PT, DPT Chief Executive Officer, JAG-ONE Physical
Therapy; Medical Coordinator, Major League Soccer, New York
Jessica Hettler, PT, DPT, MHA, ATC, SCS, OCS, Cert MDT Director, Sports
Rehabilitation and Performance Center, Hospital for Special Surgery, New York,
New York
Jonathan Kirschner, MD, RMSK Fellowship Director, Spine and Sports Medicine,
Hospital for Special Surgery, New York, New York; Associate Professor, Clinical
Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
Gary Mascilak, DC, PT, CSCS Rehab and Performance Specialist,

Sparta, New Jersey
Amrish D. Patel, MD, PT Physiatrist, Sports and Spine Institute, McDonough,

Georgia
Taylor Rossillo, MBA, ATC Director of Athletic Training Services, JAG-ONE

Physical Therapy, New Jersey
Ian W. Wendel, DO, FAAPMR, CAQSM, RMSK Tri-Country Orthopedics, Cedar

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

Chairman and Lucy G. Moses Professor
Department of Rehabilitation and Human Performance
Mount Sinai Health System
Director of Sports Medicine
Icahn School of Medicine at Mount Sinai, New York, New York
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INTRODUCTION
Rehabilitation exercises are one of the cruxes of treating musculoskeletal and sports in-
juries, and they are generally initiated soon after rest, medications, and modalities have
been utilized. There is overwhelming literature supporting their role in the treatment
of these injuries. However, one of the greatest barriers to patients benefiting from such
rehabilitation exercises is getting the patient to perform regular, quality, effective, and
evidence-based exercises. Too often a patient’s busy schedule precludes him or her from
seeking guidance on exercise from a professional, such as a physical or occupational
therapist. In other instances, the patient has sought this treatment and it is now time to
be exercising independently. This is when a home exercise program must be employed
and a healthcare professional must convey this information to the patient.
This book was developed to assist healthcare professionals in providing evi-
dence-based home exercise treatment programs and high-quality handouts to patients.
The authors of this book felt that current home exercise program resources were not
ideal and decided to develop their own. We also realize that many health profession-
als are not taught how to properly prescribe exercise, or they are early in training and
yet not comfortable prescribing exercise. We wanted to develop a resource that guides
healthcare professionals in prescribing effective, evidence-based home exercises in an
efficient, self-explanatory manner so that valuable minutes of a patient encounter do
not have to be wasted on explanation. Essentially, this book is of value to any healthcare
professional who prescribes exercise to patients.
Within a rehabilitation exercise program, a stepwise approach must be followed to
lay the framework for more advanced exercise. The typical phases of rehabilitation are
provided in Table 1 (1, 2):
Table 1. Phases of Rehabilitation

▪ Phase I: Decrease pain and swelling (PRICE protocol)
▪ Phase II: Restore range of motion and normal arthrokinematics
▪ Phase III: Strength training
▪ Phase IV: Neuromuscular control and proprioceptive training
▪ Phase V: Functional or sport-specific training
PRICE, Protection, Rest, Ice, Compression, and Elevation.
We feel that for a home exercise program, this approach can be cumbersome for
patients. Instead, we decided to combine these into three phases, Foundational, Inter-
mediate, and Advanced, where we list recommended exercises within each phase that
are built upon and advanced as a patient progresses through his or her rehabilitation.
We also list goals for advancement that healthcare professionals should try to iden-
tify in patients, if possible, before progressing the exercise program to the next level.
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Additionally, we provide concise, evidence-based background and treatment informa-
tion on the different regions of the body and injuries within these regions. Furthermore,
the exercise programs within each chapter explain how to effectively perform each ex-
ercise through guided steps with visual aids.
How to Use This Book
• Read the chapters to gain background knowledge on common musculoskele-
tal and sports injuries and pearls for prescribing exercise for treatment of these
injuries.
• Disseminate the chapters as handouts for patients:
▪ Provide the entire chapter to patients to provide more information on the
clinical condition,
▪ Highlight the desired exercises from the List of Exercises section of the
book to provide to patients along with the exercises from each chapter’s
Handouts section,
▪ Mix and match exercises and develop custom handouts tailored to the pa-
tient’s needs. There is even a box to check or write numbers included within
every exercise in the Handouts section from each chapter.
Healthcare professionals will then confidently and efficiently provide high-quality
information and resources to patients to aid in the recovery of musculoskeletal and
sports injuries.
REFERENCES
1. Malanga GA, Ramirez-Del Toro JA, Bowen JE, et al. Sports medicine. In: Frontera RW,
DeLisa JA, Gans BM, et al., eds. DeLisa’s Physical Medicine & Rehabilitation: Principles and
Practice. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1413–1436.
2. Wyss JF, Patel AD, Malanga GA. Phases of musculoskeletal rehabilitation. In: Wyss JF, Patel
AD, eds. Therapeutic Programs for Musculoskeletal Disorders. New York,
NY: Demos Medical Publishing; 2012:3–6.
xvi INTRODUCTION
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ACKNOWLEDGMENTS
I want to thank my family, Shama, Averie, and Austin, for granting me the time to com-
plete this book and for their unwavering support; my parents and brothers for helping
to establish my values and work ethic; all of my teachers, especially those at Kessler/
NJMS and Mount Sinai, as this book is a compilation of your teachings; James Wyss,
Shounuck Patel, and Rich Bean for all of your efforts to develop and provide the founda-
tion for this book; all of the chapter contributors, whose expertise and diligence were in-
valuable; and all the people at Demos Medical, specifically Beth Barry and Jaclyn Shultz,
for putting this book together.
-IWW
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LIST OF EXERCISES
SHOULDER
Rotator Cuff Tendinopathy 2
Recommended Exercises
Foundational
ROM/Stretching/Mobility: Corner stretch, sleeper stretch, stick shoulder extension,
stick overhead shoulder stretch, stick shoulder abduction
Intermediate
Continue Foundational exercises
ROM/Stretching/Mobility: Scaption
Strengthening: Low row, scapular retraction, straight arm lateral pull down, push-up
with a plus, abducted shoulder external rotation
Advanced
Continue Foundational and Intermediate exercises
Proprioception/Functional: Prone “T,” “Y,” ”I,” “W”; stability ball bird dog, stability
ball plank, wall fall push-up
Acromioclavicular Joint Pathology 2

Foundational
ROM/Stretching/Mobility: Corner stretch, sleeper stretch, stick shoulder rotation, stick
shoulder extension
Intermediate
Strengthening: Low row, straight arm lateral pull down, external rotation with a
Theraband
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Advanced
Proprioception/Functional: Prone “T,” “Y,” “I,” “W”; stability ball bird dog, wall fall
push-up
Glenohumeral Joint Osteoarthritis 3

Foundational
ROM/Stretching/Mobility: Corner stretch, sleeper stretch, reverse sleeper stretch,
broom pull, stick shoulder rotation, stick overhead stretch, scaption
Intermediate
Strengthening: Low row, straight arm lateral pull down
Advanced
Strengthening: Push-up with a plus
Proprioception/Functional: Prone “T,” “Y,” “I,” “W”’ stability ball bird dog
Glenohumeral Joint Instability 4

Foundational
Strengthening: Isometric strengthening in all directions (external rotation, internal ro-
tation, flexion, extension), scapular retraction
Intermediate
ROM/Stretching/Mobility: Stick shoulder flexion, stick shoulder abduction, stick
shoulder rotation
Strengthening: Low row, straight arm lateral pull down, external rotation with a
Theraband
Advanced
Proprioception/Functional: Prone “T,” “Y,” “I,” “W”; stability ball bird dog, wall ball
push-up, stability ball planks, wall fall push-up
xx LIST OF EXERCISES
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Adhesive Capsulitis/Frozen Shoulder 4
Foundational
ROM/Stretching/Mobility: Stick shoulder abduction, stick shoulder rotation, stick
overhead shoulder stretch, stick shoulder flexion
Intermediate
ROM/Stretching/Mobility: Broom pull, stick shoulder extension
Strengthening: Low row, straight arm lateral pull down
Advanced
ROM/Stretching/Mobility: Scaption (with a weight or Theraband)
Strengthening: External rotation with a Theraband
Proprioception/Functional: Prone “T,” “Y,” “I,” “W”
ELBOW
Lateral Epicondylosis 26
Foundational
ROM/Stretching/Mobility: Wrist flexor stretch, wrist extensor stretch, triceps stretch
Intermediate
Strengthening: Grip strengthening, wrist extensors concentric strengthening, wrist
flexors concentric strengthening, forearm pronators and supinators strengthening
Advanced
Strengthening: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccen-
tric strengthening
Proprioception/Functional: Serratus punch, prone scapular retractions
LIST OF EXERCISES xxi
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Medial Epicondylosis 27
Foundational
ROM/Stretching/Mobility: Wrist flexor stretch, wrist extensor stretch, triceps stretch
Intermediate
Strengthening: Grip strengthening, wrist extensors concentric strengthening, wrist
Advanced
Strengthening: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccen-
tric strengthening
Proprioception/Functional: Serratus punch, prone scapular retractions
Ligament Sprains 27
Foundational
ROM/Stretching/Mobility: Biceps stretch, triceps stretch, forearm supinators stretch,
forearm pronators stretch
Intermediate
Strengthening: Biceps isometric strengthening, triceps isometric strengthening, radial
and ulnar deviation strengthening, wrist extensors concentric strengthening, wrist flex-
ors concentric strengthening
Advanced
Strengthening: Wrist extensors eccentric strengthening, wrist flexors eccentric
strengthening
Proprioception/Functional: Shoulder diagonal pattern A and B, serratus punch, prone
scapular retractions
Distal Bicipital Tendinopathy 28

Foundational
ROM/Stretching/Mobility: Wrist extensors stretch, wrist flexors stretch, biceps stretch,
triceps stretch, forearm pronators stretch, forearm supinators stretch
xxii LIST OF EXERCISES
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Intermediate
Strengthening: Biceps isometric strengthening, triceps isometric strengthening, wrist
extensors concentric strengthening, wrist flexor concentric strengthening, forearm pro-
nators and supinators strengthening
Advanced
Strengthening: Bicep curls, triceps extensions, biceps eccentric strengthening
Proprioception/Functional: Shoulder diagonal pattern A and B, serratus punch, prone
scapular retractions
Ulnar Neuropathy at the Elbow 29

Foundational
ROM/Stretching/Mobility: Wrist flexors stretch, wrist extensors stretch, biceps stretch,
triceps stretch, forearm supinators stretch, forearm pronators stretch, ulnar nerve glides
1 to 5
Intermediate
Strengthening: Biceps isometric strengthening, triceps isometric strengthening, grip
strengthening, Tyler twist
WRIST AND HAND

De Quervain’s Tenosynovitis 49
Foundational
ROM/Stretching/Mobility: Wrist extension active range of motion (AROM), wrist flex-
ion AROM, isolated thumb interphalangeal joint (IPJ) flexion/extension
Intermediate
Strengthening: APL isometric strengthening, EPB isometric strengthening
Advanced
Proprioception/Functional: Elbow flexion with Theraband, elbow extension with
Theraband, scapular retraction with Theraband, shoulder extension with Theraband,
external rotation with Theraband
LIST OF EXERCISES xxiii
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Carpal Tunnel Syndrome 50
Foundational
ROM/Stretching/Mobility: Tendon gliding, median nerve glides
Advanced
Proprioception/Functional: Scapular retraction with Theraband, shoulder extension
with Theraband
Carpometacarpal Osteoarthritis 51
Foundational
ROM/Stretching/Mobility: Thumb opposition, thumb adductor massage, “C” exercise,
web space stretch
Advanced
Strengthening: First dorsal interossei strengthening
Extensor Carpi Ulnaris Tendinopathy 52

Foundational
Strengthening: ECU isometric strengthening, ECU synergy exercise, wrist extensors
concentric strengthening, ulnar deviation strengthening
Intermediate
Strengthening: Wrist extensors eccentric strengthening
Advanced
Proprioception/Functional: Scapular retraction with Theraband, shoulder extension
with Theraband, external rotation with Theraband
xxiv LIST OF EXERCISES
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HIP
Hip Osteoarthritis 72
Foundational
ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip rotator
stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking
Strengthening: Gluteal isometrics, prone hip extension, side-lying hip abduction with
towel against wall
Intermediate
Strengthening: Squat, bridge
Advanced
Strengthening: Forward step up, forward step down
Proprioception/Functional: Single leg balance
Iliopsoas Tendinopathy/Bursitis 72
Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, Iliotibial band (ITB) stretch,
foam roller to hip area
towel against wall
Intermediate
Strengthening: Squat, bridge, clamshell, hip clocks
Advanced
Strengthening: Monster walk, side plank, forward step up, forward step down
Proprioception/Functional: Windmill, single leg squat
LIST OF EXERCISES xxv
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Greater Trochanteric Pain Syndrome 73
Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, foam roller to hip area
towel against wall
Intermediate
Strengthening: Squat, bridge, clamshell, hip clocks, hip hiker
Advanced
Strengthening: Monster walk, forward step down
Proprioception/Functional: Windmill
Hamstring Strain and Tendinopathy 74

Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking, foam roller
to hip area
Strengthening: Hamstring isometrics
Intermediate
Advanced
Strengthening: Eccentric hamstring throw downs, hamstring curl on stability ball, hip
hiker, forward step up, forward step down
Proprioception/Functional: Lunge, single leg deadlifts
xxvi LIST OF EXERCISES
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Femoroacetabular Impingement and Labral Tears 75
Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch, foam roller to hip
area
towel against wall
Intermediate
Strengthening: Squat, bridge, hip clocks, clamshell
Advanced
Strengthening: Monster walk, side plank, hip hiker, forward step up, forward
step down
Proprioception/Functional: Windmill, single leg squat
KNEE
Knee Osteoarthritis 102
Foundational
ROM/Stretching/Mobility: Hamstring stretch, two-joint hip flexor stretch, assisted
knee extension, assisted knee flexion, passive knee extension
Strengthening: Quadriceps set, straight leg raise, prone hip extension, side-lying hip
abduction with towel against wall
Intermediate
ROM/Stretching/Mobility: Knee flexion chair stretch
Strengthening: Bridge, squat, squat on wedge
Advanced
Strengthening: Forward step up, forward step down
Proprioception/Functional: Single leg squat
LIST OF EXERCISES xxvii
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Patellofemoral Pain Syndrome 103
Foundational
ROM/Stretching/Mobility: Hamstring stretch, prone quadriceps stretch, hip flexor
stretch or two-joint hip flexor stretch
Strengthening: Quadriceps set, straight leg raise, side-lying hip abduction with towel
against wall, prone hip extension
Intermediate
Advanced
Strengthening: Side plank, forward step up, forward step down
Proprioception/Functional: Single leg squat, single leg deadlift
Quadriceps and Patellar Tendinopathy 103

Foundational
Strengthening: Quadriceps set, straight leg raise, side-lying hip abduction with towel
Intermediate
Advanced
Strengthening: Side plank, forward step up, forward step down, squat on a wedge
(Level 3)
Proprioception/Functional: Single leg deadlift, windmill
xxviii LIST OF EXERCISES
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Knee Ligament Sprain 104
Foundational
ROM/Stretching/Mobility: Hamstring stretch, prone quad stretch, hip flexor stretch or
two-joint hip flexor stretch, assisted knee extension, assisted knee flexion, passive knee
extension
Strengthening: Quadriceps set, terminal knee extension, straight leg raise, side-lying
hip abduction with towel against wall, prone hip extension
Intermediate
Advanced
Proprioception/Functional: Single leg deadlift, windmill
Meniscal Tear 105

Foundational
stretch or two-joint hip flexor stretch, assisted knee extension, assisted knee flexion,
passive knee extension
Strengthening: Quadriceps set, terminal knee extension, straight leg raise, side-lying
Intermediate
Advanced
Proprioception/Functional: Single leg squat, single leg deadlift, windmill
LIST OF EXERCISES xxix
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Iliotibial Band Syndrome 106
Foundational
stretch or two-joint hip flexor stretch, ITB stretch
Strengthening: Side-lying hip abduction with towel against wall, prone hip extension
Intermediate
Advanced
Proprioception/Functional: Single leg squat, single leg deadlift, windmill
ANKLE AND FOOT

Ankle Sprain 130
Foundational
ROM/Stretching/Mobility: Calf stretch A or B, alphabets
Strengthening: Marble pick-ups
Intermediate
Strengthening: Concentric ankle inversion strengthening, concentric ankle eversion
strengthening, concentric ankle dorsiflexion strengthening
Advanced
Proprioception/Functional: Single leg taps, single leg tennis ball catch, wobble board
Achilles Tendinopathy 130

Foundational
ROM/Stretching/Mobility: Foam roller (lower leg), towel stretch, calf stretch A or B,
soleus stretch
Strengthening: Towel scrunches
xxx LIST OF EXERCISES
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Intermediate
Strengthening: Heel raises
Advanced
Strengthening: Eccentric Achilles strengthening
Proprioception/Functional: Single leg taps, single leg tennis ball catch
Posterior Tibial Tendinopathy 131

Foundational
ROM/Stretching/Mobility: Foam roller (lower leg), towel stretch, calf stretch A or B
Strengthening: Towel scrunches
Intermediate
Strengthening: Concentric ankle inversion strengthening, heel raises
Advanced
Strengthening: Eccentric posterior tibial tendon strengthening
Plantar Fasciosis 132

Foundational
ROM/Stretching/Mobility: Can roll, towel stretch, plantar fascia stretch
Strengthening: Towel scrunches, marble pick-ups
Intermediate
Strengthening: Heel raises
Advanced
Strengthening: Eccentric Achilles strengthening
LIST OF EXERCISES xxxi
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CERVICAL SPINE
Cervical Facet Arthropathy 144
Foundational
ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retractions
(chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scap-
ula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic
rotation mobility (thread the needle)
Intermediate
Strengthening: Cervical isometrics: retraction/lateral flexion/flexion, deep cervical
flexor strengthening
Proprioception/Functional: Prone scapular retraction
Advanced
Proprioception/Functional: Wall stick-ups, Prone “T,” “Y,” “I,” “W”
Cervical Disc Pathology 145

Foundational
Intermediate
Strengthening: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical
Advanced
xxxii LIST OF EXERCISES
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Cervical Radiculopathy 146
Foundational
Intermediate
Advanced
Upper Crossed Posture 147

Foundational
ROM/Flexibility/Mobility: Seated postural correction (Bruegger’s), cervical retraction
(chin glide), suboccipital stretch, levator scapula stretch, upper trapezius stretch, pecto-
ral stretch, suboccipital release, prone pectoral release, levator scapula release
Intermediate
Advanced
LIST OF EXERCISES xxxiii
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THORACIC SPINE
Thoracic Spine 171
Foundational
ROM/Flexibility/Mobility: Supine diaphragmatic breath (belly breath), seated postural
correction (Bruegger’s), lacrosse ball massage, prayer stretch, cat camel stretch, open
book, trunk rotations, seated thoracic rotation
Intermediate
ROM/Flexibility/Mobility: Thoracic rotation mobility (thread the needle)
Strengthening: Kneeling thoracic rotation
Advanced
Proprioception/Functional: Thoracic rotation with core stabilization, inchworm
LUMBAR SPINE
Lumbar Facet Arthrosis 186
Foundational
ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one),
hamstring stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s
pose, seated flexion, cat camel stretch, trunk rotations
Strengthening: Abdominal bracing (or pelvic tilt or abdominal hollowing), marching
exercise
Intermediate
Strengthening: Curl up, bridge, clamshells, Swiss ball marching, opposite arm/oppo-
site leg (bird dog)
Advanced
Strengthening: Hip abductor wall squat, hip adductor wall squat, plank, side plank
Proprioception/Functional: Warrior one pose, warrior two pose
xxxiv LIST OF EXERCISES
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Lumbar Disc Pathology 187
Foundational
ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one), ham-
string stretch, (either one), piriformis stretch, prone extensions (as long as it lessens pain)
Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing)
Intermediate
Strengthening: Curl up, bridge, clamshells, opposite arm/opposite leg (bird dog),
monster walk
Advanced
Strengthening: Plank, side plank
Lumbar Radiculopathy 188

Recommended Exercises for Extension-Biased Program
Foundational
ROM/Stretching/Mobility: Hamstring stretch (either one), hip flexor stretch (either
one), prone extensions, standing extensions, side glides or alternative side glides if pa-
tient has a lateral shift (leaning over to one side due to pain)
Strengthening: Abdominal bracing (or pelvic tilt or abdominal hollowing)
Intermediate
Strengthening: Bridge, clamshells, opposite arm/opposite leg (bird dog)
Advanced
Recommended Exercises for Flexion-Biased Program

Foundational
one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion,
side glides or alternative side glides if patient has a lateral shift (leaning over to one side
due to pain)
Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing), marching
exercises
LIST OF EXERCISES xxxv
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Intermediate
site leg (bird dog)
Advanced
Recommended Exercises for a Neutral Spine Program

Foundational
ROM/Stretching/Mobility: Prone quadriceps stretch, hip flexor stretch (either one),
hamstring stretch (either one), piriformis stretch
Strengthening: Abdominal bracing (pelvic tilt or abdominal hollowing)
Intermediate
Strengthening: Curl up, bridge, clamshells, opposite arm/opposite leg (bird dog),
monster walk
Advanced
Strengthening: Plank, side plank
Lumbar Spondylolysis/Spondylolisthesis 189

Recommended Exercises for Spondylolysis
Foundational
one), prone quadriceps stretch, piriformis stretch
exercise
Intermediate
Strengthening: Curl up, bridge, Swiss ball marching, opposite arm/opposite leg
(bird dog)
xxxvi LIST OF EXERCISES
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Advanced
Proprioception/Functional: Single leg deadlift, warrior one pose, warrior two pose
Recommended Exercises for Spondylolisthesis

Foundational
one), prone quadriceps stretch, piriformis stretch, single (double) knee(s) to chest,
child’s pose, seated flexion
exercise
Intermediate
site leg (bird dog)
Advanced
Lumbar Spinal Stenosis 190

Foundational
exercise
Intermediate
site leg (bird dog)
LIST OF EXERCISES xxxvii
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Advanced
Lower Crossed Syndrome 191

Foundational
ROM/Stretching/Mobility: Good morning stretch, prone quadriceps stretch, hamstring
stretch (both), hip flexor stretch (both), piriformis stretch, single (double) knee(s) to
chest, child’s pose, cat camel stretch, trunk rotations
exercise
Intermediate
Strengthening: Curl up, bridge, opposite arm/opposite leg (bird dog), Swiss ball
marching
Advanced
xxxviii LIST OF EXERCISES
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Share
Home Exercise Programs for Musculoskeletal
and Sports Injuries: The Evidence-Based
Guide for Practitioners
CHAPTER 1
Home Exercise Programs for

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

Foundational
• Improvement of range of motion
Intermediate
• Restoration of normal range of motion
• Initiation of strengthening of shoulder musculature
Advanced
• Restoration of strengthening with focus on scapular stabilizers
• Restoration of proprioceptive control of scapular stabilizers
Wendel01201_PTR_CH01_1-24_09-06-19.indd 1 09-Sep-19 12:19:39 PM

ROTATOR CUFF TENDINOPATHY
Rotator cuff tendinopathy is typically a chronic overuse condition associated
with subacromial impingement syndrome. In subacromial impingement syn-
drome, the humeral head migrates superiorly and impinges the supraspina-
tus tendon and subacromial-subdeltoid bursa underneath the acromion. Risk
factors include weakness of the rotator cuff, serratus anterior, or lower trape-
zius muscles, or a type II or III acromion. Subacromial bursitis can present very
similarly and can be differentiated with ultrasound or MRI, which typically are
not needed unless symptoms become chronic and persistent. Rehabilitation
strategies for all three conditions are similar and start with a focus on restoring
proper range of motion and flexibility, particularly of the posterior capsule and
pectoralis minor (6). The next focus is scapular strength and stability, postural
correction, and rotator cuff strengthening, followed by dynamic and proprio-
ceptive exercise. It is important to promote scapular retraction and strengthen
the serratus anterior and lower trapezius early on, then progress to distal mus-
cles (4). Outcomes with rehabilitation are typically equal to surgery (7).
Foundational
ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, stick shoulder extension,
stick overhead shoulder stretch, stick shoulder abduction
Intermediate
ROM/STRETCHING/MOBILITY: Scaption
STRENGTHENING: Low row, scapular retraction, straight-arm lateral pull down, push-up
with a plus, abducted shoulder external rotation
Advanced
PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, stability
ball plank, wall fall push-up
ACROMIOCLAVICULAR JOINT PATHOLOGY

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

Foundational
ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, stick shoulder rotation, stick
shoulder extension
Intermediate
STRENGTHENING: Low row, straight-arm lateral pull down, external rotation with a
Theraband
Advanced
PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, wall fall
push-up
GLENOHUMERAL JOINT OSTEOARTHRITIS

It is important to reduce pain and inflammation to facilitate an active rehabil-
itation program. It is helpful to know if the patient has primary glenohumeral
osteoarthritis (GH-OA), or secondary GH-OA due to rotator cuff arthropathy,
caused by complete tears of the rotator cuff leading to secondary instabil-
ity and degenerative changes. Once pain is manageable, the initial step is
to maximize passive joint range of motion using a combination of stretching,
joint mobilizations, and other manual therapy. Then, active range of motion is
initiated. Scapular stability is the next goal, using isometric exercises at first and
progressing to concentric and eccentric strengthening. Rotator cuff strength-
ening is next, followed by functional and proprioceptive exercises.
Foundational
ROM/STRETCHING/MOBILITY: Corner stretch, sleeper stretch, reverse sleeper stretch,
broom pull, stick shoulder rotation, stick overhead stretch, scaption
Intermediate
STRENGTHENING: Low row, straight-arm lateral pull down
Advanced
STRENGTHENING: Push-up with a plus
PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog
HOME EXERCISE PROGRAMS FOR SHOULDER INJURIES 3

GLENOHUMERAL JOINT INSTABILITY
Patients may have glenohumeral instability from chronic multidirectional insta-
bility due to ligamentous laxity or acute traumatic dislocations. In the first two
weeks after a dislocation, early gentle range of motion is recommended. Then
gentle isometric rotator cuff strengthening and concentric strengthening of
the scapular stabilizers are performed. Finally, dynamic and proprioceptive ex-
ercises are encouraged, especially resisting the planes of motion the patients
tend to sublux or dislocate into.
Foundational
STRENGTHENING: Isometric strengthening in all directions (external rotation, internal ro-
tation, flexion, extension), scapular retraction
Intermediate
ROM/STRETCHING/MOBILITY: Stick shoulder flexion, stick shoulder abduction, stick shoul-
der rotation
STRENGTHENING: Low row, straight-arm lateral pull down, external rotation with a
Theraband
Advanced
PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W,” stability ball bird dog, wall ball
push-up, stability ball planks, wall fall push-up
ADHESIVE CAPSULITIS/FROZEN SHOULDER

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

Foundational
ROM/STRETCHING/MOBILITY: Stick shoulder abduction, stick shoulder rotation, stick
overhead shoulder stretch, stick shoulder flexion
Intermediate
ROM/STRETCHING/MOBILITY: Broom pull, stick shoulder extension
STRENGTHENING: Low row, straight-arm lateral pull down
Advanced
ROM/STRETCHING/MOBILITY: Scaption (with a weight or Theraband)
STRENGTHENING: External rotation with a Theraband
PROPRIOCEPTION/FUNCTIONAL: Prone “T,” “Y,” ”I,” “W”
HOME EXERCISE PROGRAMS FOR SHOULDER INJURIES 5

HANDOUTS
ROM/Stretching/Mobility
Stick Overhead Shoulder Stretch

POSITION: Supine
STEP 1: Lay on your back with a stick (broom or cane) held overhead.
STEP 2: Lower your hands over your head and feel the stretch.
STEP 3: Try to keep the back of your shoulders against the bench (or floor) and your core tightened throughout the
movement.
STEP 4: Hold for 5 to 10 seconds.

STEP 5: Raise your arms overhead and repeat.
REPS: Repeat 8 to 10 times.
SETS: Three sets
FREQUENCY: 3 to 5 times per week
6 HOME EXERCISE PROGRAMS FOR SHOULDER INJURIES Copyright Springer Publishing Company

Stick Shoulder Abduction
POSITION: Standing or supine (on back)
STEP 1: Grab a stick (broom or cane) with palm on right hand pointing away from the body and with left palm facing
the body, keeping your elbows straight and placed at your side.
STEP 2: Use the left arm to push the right arm up as high as it will go to the right side.
STEP 3: Slowly lower the right and left arms and repeat to the left side, switching the hand position such that the left
palm is away from the body and the right palm is facing the body.
REPS: Repeat 10 to 15 times to each side.

SETS: Three sets
Stick Shoulder Rotation

POSITION: Standing or supine (on back)
STEP 1: Grab a stick (broom or cane) or towel with both
hands, keeping your elbows bent to 90° and placed at
your side.
STEP 2: Rotate your hands all the way to the right, then
all the way to the left.

SETS: Three sets
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR SHOULDER INJURIES 7

Stick Shoulder Extension
POSITION: Standing
STEP 1: Hold a stick (can be a broom or cane) behind your back and extend
your arms behind you.
STEP 2: Keep your shoulder blades squeezed together, and feel your chest
muscles stretch, while avoiding tension and pain in your shoulders.
REPS: Hold for 30 seconds.

SETS: Three sets with a 30-second break between sets
Broom Pull
POSITION: Standing
STEP 1: Grab a broomstick or towel with both hands, one above your head
and one behind your back.
STEP 2: Pull with the top hand, feeling the lower arm and shoulder stretch.
REPS: Hold for 15 to 30 seconds, then repeat with the other arm.

Stick Shoulder Flexion
POSITION: Seated
STEP 1: Hold a stick (broom or cane) upright in front of
you.
STEP 2: Lean forward onto the stick, feeling your shoul-

ders stretch in flexion.

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


Sleeper Stretch
POSITION: Side lying
STEP 1: Lay on the side of your affected shoulder with
your shoulder blade against the laying surface and your
shoulder and elbow bent at 90°.
STEP 2: Use your opposite hand to press your forearm

down and feel the back of your symptomatic shoulder
stretch.

Reverse Sleeper Stretch

POSITION: Side lying
STEP 1: Lay on the side of your affected shoulder with
your shoulder blade against the laying surface and your
shoulder and elbow bent at 90°.
STEP 2: Use your opposite hand to press your forearm up

and feel the front of your symptomatic shoulder stretch.


Level 2 Level 3
Scaption
POSITION: Standing
STEP 1: Bring hands 20° to 30° in front of you with thumbs pointed toward the ceiling.
STEP 2: Slowly raise hands overhead, while trying to keep your shoulders down and your shoulder blades and core
activated.
STEP 3: Slowly return to starting position as in Step 1.

SETS: Three sets
LEVEL 2: Add 1 or 2 lb weight.
LEVEL 3: Stand in the middle of a Theraband and grab its ends.

Strengthening
Isometric Strengthening—External Rotation

POSITION: Standing
STEP 1: Bend elbow.
STEP 2: Push outside of hand against doorway, while keeping elbow tucked
into side.
STEP 3: Hold for a count of 5 to 10 seconds.

STEP 4: Relax for 5 seconds.
SETS: One to three sets
Isometric Strengthening—Internal
Rotation
POSITION: Standing
STEP 1: Bend elbow.
STEP 2: Push inside of hand against doorway, while
keeping elbow tucked into side.


Isometric Strengthening—Flexion
POSITION: Standing
STEP 1: Keep arm straight.
STEP 2: Push palm of hand against doorway, while keeping arm close to body.
Isometric Strengthening—Extension
POSITION: Standing
STEP 1: Keep arm straight.
STEP 2: Push back of hand against doorway, while keeping arm close to body.

Scapular Retraction
POSITION: Standing
STEP 1: Squeeze shoulder blades together as if you were trying to hold a tennis ball between blades.

Level 2
Low Row
POSITION: Standing or seated on stability ball
STEP 1: Attach a Theraband to a solid object.
STEP 2: Squeeze your shoulder blades together, then reach backward with your elbows, pulling the Theraband to-
ward you.
STEP 3: Allow the Theraband to retract forward again, but keep engaging your shoulder blades together.
SETS: Three to five sets
LEVEL 2: Putting left arm and left knee on a bench (or can use exercise ball) with weight in right hand, bring weight to
chest; then perform to left side when done with set.

Straight-Arm Lateral Pull Down
POSITION: Standing or seated on stability ball
STEP 1: Attach a Theraband to a solid object.
STEP 2: Squeeze your shoulder blades together, then reach backward with your elbows, pulling the Theraband
toward you.
STEP 3: Allow the Theraband to retract forward again, but keep engaging your shoulder blades together.

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


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

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

Proprioception/Functional
Prone “T,” “Y,” “I,” “W”

POSITION: Face down on the floor with a towel under the forehead
STEP 1: Engage the gluteal and abdominal muscles by drawing the belly button toward the spine.
STEP 2: Place the arms straight out to the side at a 90° angle with the body and with thumbs up toward the ceiling.
STEP 3: Draw the shoulder blades down and back, elevate the arms off the floor, and hold for a three count.
STEP 4: Proceed to elevate the arms at progressive levels, resembling the letters “Y” and “I” before bending the el-
bows and bringing the arms to the side to make a “W”.
STEP 5: Hold all four positions for a three count with the thumbs pointed up toward the ceiling.
STEP 6: Reset the gluteals, abdominals, and shoulder blades, and repeat.
SETS: Two to three
NOTE: T and Y are likely of most value and should be concentrated on.

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

STEP 3: Raise your right arm and left leg off the ball, then
lower back to the ground.
STEP 4: Alternate by raising your left arm and right leg,

trying to keep your trunk stable.
REPS: Repeat 10 to 15 times on each side.


Wall Ball Push-Up
POSITION: Standing
STEP 1: Stand against a ball on a wall with your arm at shoulder level in a “push-up” position.
STEP 3: Do a push-up with one or both arms.

Stability Ball Plank
POSITION: Plank
STEP 1: Get into a plank position on a stability ball.
STEP 3: Hold for 30 seconds.
Wall Fall Push-Up

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

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

CHAPTER 2

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

Foundational
• Restoration of ROM and flexibility
• Initiation of strengthening wrist extensors and flexors (lateral and medial
epicondylosis)
Intermediate
• Progression of strengthening and initiation of eccentrics

Advanced
• Restoration of strengthening, including eccentric strengthening if not already
done
• Development of proximal musculature and scapular stabilizers
LATERAL EPICONDYLOSIS
Lateral epicondylosis, also known as tennis elbow, lateral epicondylalgia, and
lateral epicondylitis, is a common pathology among athletes and nonathletes
and has an annual occurrence of 1% to 3% in the general population (2,4,7).
Lateral epicondylosis, as its pseudo name implies, has a high association with
tennis and the one-handed backstroke, but is also commonly seen in other
athletics and some occupations where repetitive wrist extension occurs. Due to
the complexities associated with the anatomy and biomechanics of the elbow
and the lack of scientific evidence to support any treatment protocol, there is
a lack of consensus on the best treatment plan. However, many practitioners
agree that a conservative, nonoperative management plan including rest, ice,
compression, elevation (RICE); nonsteroidal anti-inflammatory drugs (NSAIDs);
technique modifications (in sport and work task ergonomics); and physical
therapy aimed at stretching and more specifically strengthening the extensors
of the forearm and the posterior muscles in the shoulder is the plan of choice
and has shown a successful resolution of symptoms in 90% of patients within
6 to 12 months (2–5,7,8). Eccentric strengthening exercises may show greater
benefit than the concentric strengthening or stretching portion of exercise
(3). The use of steroidal injections did improve short-term patient outcomes,
but at the 12-month point, the results were equal (compared to placebo)
(4) and platelet-rich plasma (PRP) injections have shown greater long-term
benefit compared to steroid injections (9). Additionally, surgical intervention
was suggested in the literature only for patients showing no relief following 6 to
12 months of conservative treatment: that is, in about 5% of the population (2).
Foundational
ROM/STRETCHING/MOBILITY: Wrist flexor stretch, wrist extensor stretch, triceps stretch
Intermediate
STRENGTHENING: Grip strengthening, wrist extensors concentric strengthening, wrist
Advanced
26 HOME EXERCISE PROGRAMS FOR ELBOW INJURIES

STRENGTHENING: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccen-
tric strengthening
PROPRIOCEPTION/FUNCTIONAL: Serratus punch, prone scapular retractions
MEDIAL EPICONDYLOSIS
Medial epicondylosis, also known as golfer’s elbow, medial epicondylalgia,
and medial epicondylitis, is less common than its lateral counterpart, affecting
less than 1% of the general population, and presents with repetitive or forceful
wrist flexion activities (4,10). Despite the eponym “golfers elbow,” this pathology
is most common in throwing athletes, specifically baseball players, where the
elbow’s medial structures sustain the most amount of stress and account for
up to 97% of all elbow injuries (4). Treatment of medial epicondylosis parallels
that of the above-mentioned principles of lateral epicondylosis with conserva-
tive, nonoperative treatment at the forefront. In contrast, medial epicondylosis
rehabilitation should focus on the flexor muscles of the wrist (4,11).
Foundational
ROM/STRETCHING/MOBILITY: Wrist flexor stretch, wrist extensor stretch, triceps stretch
Intermediate
STRENGTHENING: Grip strengthening, wrist extensors concentric strengthening, wrist
Advanced
STRENGTHENING: Tyler twist, wrist extensors eccentric strengthening, wrist flexors eccen-
tric strengthening
PROPRIOCEPTION/FUNCTIONAL: Serratus punch, prone scapular retractions
LIGAMENT SPRAINS
Ligamentous sprains of the elbow, in particular the medial (ulnar) collateral lig-
ament, occur most often in the athletic population, especially in the overhead
or throwing athlete, as a result of overuse (12). Treatment of a ligament sprain,
in cases of early intervention and treatment, typically involves a conservative,
nonoperative treatment plan developed around each individual’s demands
and degree of injury. Surgical intervention (i.e., Tommy John surgery) and
lengthened rehabilitation timelines are introduced when a ligament sprain is
left untreated and develops into a complete ligament tear or the nonoperative
HOME EXERCISE PROGRAMS FOR ELBOW INJURIES 27

treatment plan is not successful. In either course of action, operative versus
nonoperative, rehabilitation focuses on ROM of the wrist, elbow, and shoulder
region primarily, followed by muscular strengthening and endurance, tech-
nique modification, and a carefully supervised throwing program in athletes
such as baseball pitchers and football quarterbacks (12,13).
Foundational
ROM/STRETCHING/MOBILITY: Biceps stretch, triceps stretch, forearm supinators stretch,
forearm pronators stretch
Intermediate
STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, radial
and ulnar deviation strengthening, wrist extensors concentric strengthening, wrist flex-
ors concentric strengthening
Advanced
STRENGTHENING: Wrist extensors eccentric strengthening, wrist flexors eccentric
strengthening
PROPRIOCEPTION/FUNCTIONAL: Shoulder diagonal pattern A and B, serratus punch,
prone scapular retractions
DISTAL BICIPITAL TENDINOPATHY

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

Foundational
ROM/STRETCHING/MOBILITY: Wrist extensors stretch, wrist flexors stretch, biceps stretch,
triceps stretch, forearm pronators stretch, forearm supinators stretch
Intermediate
STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, wrist
extensors concentric strengthening, wrist flexors concentric strengthening, forearm pro-
nators and supinators strengthening
Advanced
STRENGTHENING: Bicep curls, triceps extensions, biceps eccentric strengthening
PROPRIOCEPTION/FUNCTIONAL: Shoulder diagonal pattern A and B, serratus punch,
prone scapular retractions
ULNAR NEUROPATHY AT THE ELBOW

Ulnar neuropathy at the elbow is the second most common entrapment neu-
ropathy following carpal tunnel syndrome (16). Most commonly seen in pa-
tients with occupations that require prolonged periods of elbow flexion, ulnar
neuropathy can be painful and debilitating if left untreated. Treatment ranges
from conservative options, such as splinting devices, physical therapy, and
activity modification, to surgical options followed by a rehabilitation protocol
(15,16). Rehabilitation focuses on regaining full ROM at the shoulder, elbow,
and wrist joints through passive and active stretching and strengthening exer-
cises of the wrist flexors and extensors, as well as forearm pronator and supi-
nator musculatures. It should be noted, however, that strengthening exercises
should not be performed unless the patient is pain free.
Foundational
ROM/STRETCHING/MOBILITY: Wrist flexors stretch, wrist extensors stretch, biceps stretch,
triceps stretch, forearm supinators stretch, forearm pronators stretch, ulnar nerve
glides 1–5
Intermediate
STRENGTHENING: Biceps isometric strengthening, triceps isometric strengthening, grip
strengthening, Tyler twist

HANDOUTS
Wrist Flexors Stretch

POSITION: Standing
STEP 1: With palm facing the ceiling, grasp fingers on
the palm side with opposite hand and slowly straighten
elbow.
STEP 2: Pull fingers and wrist down and back toward

yourself until a stretch is felt.

Wrist Extensors Stretch

POSITION: Standing
STEP 1: With palm facing the ground, grab the top side of
fingers/hand and slowly straighten elbow.
STEP 2: Pull fingers and wrist down and back toward

yourself until a stretch is felt.

30 HOME EXERCISE PROGRAMS FOR ELBOW INJURIES Copyright Springer Publishing Company

Triceps Stretch
POSITION: Sitting or Standing
STEP 1: Raise both hands above your head.
STEP 2: Bend arm at the elbow until hand is resting behind head.
STEP 3: Grasp your elbow with opposite hand and gently pull.
Biceps Stretch
POSITION: Seated in a chair
STEP 1: Place elbow on the edge of a table with palm facing the ceiling.
STEP 2: Straighten elbow by applying a downward pressure on wrist/hand
until a stretch is felt.

Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR ELBOW INJURIES 31

Forearm Supinators Stretch
STEP 1: Flex elbow to 90°, rest wrist on the edge of the table, and place hand
in a handshake position.
STEP 2: Using the opposite hand, grasp the involved hand and slowly rotate
to a palm facing down position until a stretch is felt.

Forearm Pronators Stretch

STEP 1: Flex elbow to 90°, rest wrist on the edge of the
table, and place hand in a handshake position.
STEP 2: Using the opposite hand, grasp the involved

hand and slowly rotate to a palm facing up position until
a stretch is felt.


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

POSITION: Standing
STEP 1: Hold arm straight out in front of you with wrist extended (fingers pointing up), as if you are saying stop.
STEP 2: Bend elbow and touch shoulder.
STEP 3: Extend arm out into stop position.
SETS: One set

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

POSITION: Standing
STEP 1: Begin with arm flush against side of body.
STEP 2: Raise arm out to the side with palm facing outward.
STEP 3: At the halfway mark, start to bend arm with hand aiming for the ear.
STEP 4: Place hand over ear.
STEP 5: Return to starting position by slowly lowering the arm.
SETS: One set

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

SETS: One set

Strengthening
Biceps Isometric Strengthening

POSITION: Standing
STEP 1: Press elbow lightly into side and flex arm to 90° with palm
facing upward.
STEP 2: Place opposite hand on top of the palm facing up.

STEP 3: Provide a downward resistance with the top hand and push
upward with the bottom hand.
STEP 4: Hold for 5 to 10 seconds, then relax.

SETS: One set with 15 seconds between each rep
Triceps Isometric Strengthening

POSITION: Standing
STEP 1: Press elbow lightly into side and flex arm to 90° with hand
in
fist facing inward.
STEP 2: Place opposite hand on the bottom of hand in fist.

STEP 3: Provide an upward resistance with the bottom hand and
push downward with the top hand.

SETS: One set with 15 seconds between each rep

Grip Strengthening
POSITION: Sitting or Standing
STEP 1: Using a rubber ball (or tennis ball), squeeze and
hold for up to 60 seconds and then release and relax.
SETS: Three sets with work to rest ratio equal

Wrist Extensors Concentric Strengthening

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

SETS: Three sets with seconds between sets

Wrist Flexors Concentric
Strengthening
STEP 1: Flex elbow to 90° and rest wrist at the edge of the ta-
ble such that only the hand can move.
STEP 2: Hold a light weight in hand with your palm facing

up.
STEP 3: Slowly raise wrist/hand up toward the ceiling over a

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

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

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


Radial and Ulnar Deviation Strengthening
STEP 2: Hold a light weight in your hand with your thumb pointing upward.
STEP 3: Slowly move your hand up and then down, holding for a couple of seconds at each end point.
Wrist Extensors Eccentric Strengthening

STEP 3: Use opposite hand to bend wrist/hand up toward the ceiling as far as you can go.
STEP 4: Let go of hand and slowly lower the wrist/hand over a 5-second count.

Wrist Flexors Eccentric
Strengthening
STEP 1: Flex elbow to 90° and rest wrist at the edge of the
table such that only the hand can move.
STEP 2: Hold a light weight in hand with your palm fac-

ing up.
STEP 3: Use opposite hand to bend wrist/hand up to-

ward the ceiling as far as you can go.
STEP 4: Let go of hand and slowly lower the wrist/hand

over a 5-second count.

Biceps Eccentric Strengthening

POSITION: Standing with feet shoulder width apart, back straight with elbow bent, and hand near shoulder
STEP 1: Place a light weight in hand with palm facing you.
STEP 2: Slowly lower hand until elbow is straight.
STEP 3: Use hand without weight to bring desired hand back to starting position.

Tyler Twist
POSITION: Standing
STEP 1: Hold the FlexBar in involved hand with wrist bent back in full extension; elbow should be flexed
and resting against your side.
STEP 2: Grab the other end of the FlexBar with your opposite hand.
STEP 3: With the hand on top of the FlexBar twist your hand away from you, while maintaining the wrist extension
in the bottom hand.
STEP 4: Bring your hands out in front of you, such that they are parallel to the floor, while maintaining the twist
in the FlexBar.
STEP 5: Slowly allow the bar to untwist by allowing the involved wrist to move into flexion.

Forearm Pronators and
Supinators Strengthening
STEP 1: Flex elbow to 90° and rest wrist at the edge of
the table such that only the hand can move.
STEP 2: Hold a light weight (a hammer also works

well) in your hand with your thumb pointing upward.
STEP 3: Slowly rotate the wrist inward as far as possible

and then outward as far as possible while holding
at each end point for a few seconds.


Shoulder Diagonal Pattern A (D2 Flexion)

POSITION: Standing with feet shoulder width apart
STEP 1: Hold tubing in one hand in front of your opposite side hip with palm facing inward.
STEP 2: Raise your arm, moving across your body to the opposite side, stopping slightly above shoulder level
with your palm facing outward.
STEP 3: Slowly lower the arm, moving across the body to your starting position.

Shoulder Diagonal Pattern B (D2 Extension)
POSITION: Standing with feet shoulder width apart
STEP 1: Hold tubing in one hand overhead and out to the side slightly above shoulder level with palm
facing outward.
STEP 2: Lower your arm, moving across your body to the opposite side, stopping when your hand is
resting near your hip with your palm facing inward.
STEP 3: Slowly raise the arm, moving across your body to your starting position.

Serratus Punch
POSITION: Lying down on back
STEP 1: Raise arms out in front of you with elbows straight and fists pointing toward ceiling (may hold light
weight in hands).
STEP 2: Raise the fists toward the ceiling, keeping the arms straight and the back flat against the floor.
(The shoulders should come off the floor a couple of inches.)
STEP 3: Hold at the top for 2 seconds and then slowly lower to starting position.
SETS: Three sets with 30 seconds in between sets
Prone Scapular Retractions

POSITION: Lying on stomach with arms out to side and bent to 90°
STEP 1: Squeeze your shoulder blades together by raising your arms and elbows toward the ceiling and keep
your chest and forehead touching the floor or table at all times.
STEP 2: Hold at top for 2 seconds and then slowly lower to starting position.

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

CHAPTER 3

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

Foundational
• Restoration of range of motion and flexibility
• Initiation of strengthening for tendinopathy
Intermediate
• Progression of strengthening and initiation of eccentrics
Advanced
• Restoration of strengthening, including eccentric strengthening if not already
done
• Development of proximal musculature and scapular stabilizers
DE QUERVAIN’S TENOSYNOVITIS
Timelines and healing vary. However, general principles of rest/immobilization,
patient education on activity modification, and progression to pain-free ac-
tive range of motion (AROM) and strengthening exercises should be followed

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

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

numbness are not reproduced (3–5). Avoid repetitive gripping and pinching,
such as the use of putty, balls, or grippers. If weakness is present in the digital
flexors, isometric strengthening to the affected muscles could be initiated as
long as symptoms of tingling and/or numbness in the median nerve distribu-
tion are not reproduced (3). Proximal strengthening and postural reeducation
should be introduced as well.
Foundational
ROM/STRETCHING/MOBILITY: Tendon gliding, median nerve glides
Advanced
PROPRIOCEPTION/FUNCTIONAL: Scapular retraction with Theraband, shoulder extension
with Theraband
CARPOMETACARPAL OSTEOARTHRITIS
Treatment for carpometacarpal osteoarthritis (CMC OA) can include edu-
cation on joint protection techniques, use of adaptive equipment, exercises,
splinting, and modalities. Exercises can help the thumb become more stable.
Combining joint protection techniques and pain-free exercises has shown to
cause increased hand function in patients with OA (6). Joint protection tech-
niques, such as avoiding tight pinching, especially the lateral pinch, and the
avoidance of aggravating ADLs should be discussed. Education on adaptive
equipment (e.g., built-up pens, use of Dycem, electric staplers, and can open-
ers) is critical as well (6,7). Exercises that focus on AROM are more effective
than pinch strengthening (6). Stretching and gentle massage to widen the first
web space can help to relax the adductor pollicis, thus preventing an adduc-
tor contracture of the thumb (6,8). Strengthening the first dorsal interosseous
can assist in providing stability to the CMC joint (6,8). The literature advises
against repetitive grip and pinch strengthening and emphasizes that all ther-
apeutic exercises should be pain free and avoid deformity (6–8). There are
numerous prefabricated and custom splinting options to provide support and
pain relief to the CMC joint during rest and with functional use (6–8).
Foundational
ROM/STRETCHING/MOBILITY: Thumb opposition, thumb adductor massage, “C” exercise,
web space stretch
HOME EXERCISE PROGRAMS FOR WRIST AND HAND INJURIES 51

Advanced
STRENGTHENING: First dorsal interossei strengthening
EXTENSOR CARPI ULNARIS TENDINOPATHY

Ulnar-sided wrist injuries are commonly seen in golf, hockey, baseball, and rac-
quet sports such as tennis. Extensor carpi ulnaris (ECU) tendinopathy can be
managed initially with a forearm-based ulnar gutter splint for rest and to assist
in alleviating symptoms (1). Exercises should include pain-free isometric exer-
cises and then progress to eccentric exercises (1,9). Isometric contraction of
the ECU during resisted radial abduction of the thumb with the wrist in neutral
and the forearm supinated, described in the literature as the ECU synergy test,
can also be a beneficial way to reeducate the ECU (10,11). Since the ECU is a
wrist extensor in full supination and an ulnar deviator of the wrist in full prona-
tion, strengthening in these positions should be initiated once free of pain (11).
Proximal strengthening should be incorporated as well. Patient instruction on
avoiding repetitive ulnar deviation, combined supination and ulnar deviation,
and proper ergonomics promoting a neutral wrist with both mouse and key-
board use should be discussed (1). The current literature shows that combined
supination and wrist flexion should be avoided if there is any symptomatic
subluxation of the ECU tendon (12).
Foundational
STRENGTHENING: ECU isometric strengthening, ECU synergy exercise, wrist extensors
concentric strengthening, ulnar deviation strengthening
Intermediate
STRENGTHENING: Wrist extensors eccentric strengthening
Advanced
PROPRIOCEPTION/FUNCTIONAL: Scapular retraction with Theraband, shoulder extension
with Theraband, external rotation with Theraband

HANDOUTS
Wrist Extension Active Range

of Motion
POSITION: Sitting
STEP 1: With your palm down, curl your hand into a gen-
tle fist and raise your hand while keeping your forearm
on the table.

REPS: Repeat five times.
SETS: Two
FREQUENCY: 2 to 3 times a day
NOTE: This should be pain free.
Wrist Flexion Active Range

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

SETS: Two
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR WRIST AND HAND INJURIES 53

Isolated Thumb Interphalangeal Joint Flexion/Extension
POSITION: Sitting
STEP 1: Hold your thumb just below the tip joint (IP) with your other hand.
STEP 2: Bend the thumb tip down and hold for 3 to 5 seconds.
STEP 3: Straighten the thumb tip and hold for 3 to 5 seconds.
SETS: Two
54 HOME EXERCISE PROGRAMS FOR WRIST AND HAND INJURIES Copyright Springer Publishing Company

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

Median Nerve Glides
POSITION: Sitting (Bend your fingers and your thumb while keeping your wrist straight)
STEP 1: Make a fist.
STEP 2: Open your fingers, relax your thumb at the side of your hand, and keep your wrist straight.
STEP 3: Bring your wrist back and keep your thumb relaxed at the side of your hand.
STEP 4: Bring your thumb back while keeping your wrist and fingers back (extended).
STEP 5: Turn your palm toward the ceiling such that you can see your palm, and keep your wrist, thumb,
and fingers back.
STEP 6: Using the other hand, gently bring your thumb further back.
STEP 7: Hold each of the above positions for 3 to 5 seconds.
REPS: Move through each position in the sequence 3 to 5 times.
SETS: One set
NOTE: This exercise should not cause tingling and/or numbness.

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

SETS: Two sets
Thumb Adductor Massage

POSITION: Sitting
STEP 1: Gently massage the muscle between your index
finger and thumb.
STEP 2: Hold until this muscle softens and widen your

web space between your index finger and thumb.
STEP 3: Hold for 3 to 5 minutes.

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

SETS: Two

Web Space Stretch
POSITION: Sitting
STEP 1: Touch the tips of your index, middle, ring, and little fingers of both hands.
STEP 2: Open your thumbs and try to widen the web space between your thumb and index finger.
SETS: Two

Strengthening
Abductor Pollicis Longus Isometric

Strengthening
POSITION: Sitting
STEP 1: Place your noninvolved index finger below the middle joint of
your thumb.
STEP 2: The noninvolved index finger should be putting gentle pres-

sure in and down.
STEP 3: Gently try to separate the thumb out and lift it up.
SETS: Two
Extensor Pollicis Brevis Isometric

Strengthening
POSITION: Sitting
STEP 1: Place your noninvolved index finger on the back of the in-
volved thumb right above the middle joint.
STEP 2: The noninvolved index finger should be putting gentle pres-

sure pushing the thumb down toward the palm.
STEP 3: Gently try to lift the MP joint of the involved thumb up.
SETS: Two

First Dorsal Interossei Strengthening
POSITION: Sitting
STEP 1: Place your hand palm down and flat on the table.
STEP 2: Move your index finger toward your thumb and away
from your middle finger.
STEP 3: Using the other hand, apply resistance to the index

finger in the direction toward the middle finger. (Look for a
muscle bulge.)

STEP 5: Slowly relax.
SETS: Two
Extensor Carpi Ulnaris Isometric Strengthening

POSITION: Sitting
STEP 1: Place your palm down and resting on the table for support.
STEP 2: Place your noninvolved hand on the top of your hand below your
pinky and gently push your hand down.
STEP 3: Gently try to lift your involved wrist up and toward your pinky.
SETS: Two

ECU Synergy Exercise
POSITION: Sitting
STEP 1: Place your elbow on the table with your palm up and your wrist
straight.
STEP 2: Use your noninvolved hand to gently push the thumb in toward
your pinky.
STEP 3: Gently bring your thumb out away from your pinky.
SETS: Two
Wrist Extensors Concentric Strengthening

STEP 3: Slowly raise wrist/hand up toward the ceiling over a 5-second count.
STEP 4: Once you have reached the furthest point, use your opposite hand to lower your wrist/hand back to the start-
ing position.


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

Wrist Extensors Eccentric Strengthening
STEP 3: Use opposite hand to bend wrist/hand up toward the ceiling as far as you can go.
STEP 4: Let go of hand and slowly lower the wrist/hand over a 5-second count.

Proprioception/Functional Exercises
Elbow Flexion With Theraband

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

Elbow Extension With Theraband
POSITION: Standing
STEP 1: Hold onto the Theraband with both hands.
STEP 2: Slowly straighten your elbow toward the floor and keep your wrist straight.
STEP 4: Slowly let your elbow bend back to the starting position.
SETS: Two to three

Scapular Retraction With Theraband
POSITION: Standing
STEP 1: Tie the Theraband to a solid object.
STEP 2: Hold the Theraband in both hands with your wrists straight, and keep your elbows bent.
STEP 3: Pull your arms backwards toward your sides, squeezing your shoulder blades together.
SETS: Two to three
NOTE: This exercise should not cause pain, tingling, or numbness.
Shoulder Extension With Theraband

POSITION: Standing
STEP 1: Tie the Theraband to a solid object.
STEP 2: Hold the Theraband in both hands with your arms in front of your
body, keeping your elbows and wrist straight.
STEP 3: Pull the Theraband down and toward you, squeezing your shoulder
blades together.

SETS: Two to three
NOTE: This exercise should not cause pain, tingling, or numbness.

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

Patient Education/Precautions/Activity Modification
De Quervain’s Tenosynovitis
Photo: 16.5 of Therapeutic Programs of Musculoskeletal
Disorders, Wyss and Patel (Eds.)
1. Splinting for rest and pain relief. See photo 16.5 or picture
of forearm-based thumb spica with IPJ free.
2. Avoid thumb flexion and ulnar deviation.
3. Avoid activities or motions that cause pain.
4. Avoid gripping, pinching, and twisting.
Carpal Tunnel
Wrist splinting
Photo: 17.3 and 17.4 of Therapeutic Programs of Mus-
culoskeletal Disorders, Wyss and Patel (Eds.)
1. Avoid doing things that worsen your symptoms.
These include the following:
▪ Heavy gripping and/or pinching such items as
putty, grippers, or balls
▪ Repetitive finger bending: Take more breaks from
prolonged activities
▪ Keeping wrists in the same position for extended
periods

A B
Carpometacarpal Osteoarthritis
Photo: 18.5 of Therapeutic Programs of Musculoskeletal Disorders, Wyss and Patel (Eds.)
1. Splint to provide support and pain relief.
2. Avoid tight pinching, especially the lateral pinch.
3. Take breaks as needed.
4. Use tools or objects to help build up objects such as a pen, brush, keys, electric stapler, and can opener.
5. Avoid activities or motions that cause pain.
Extensor Carpi Ulnaris Tendinopathy

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

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

CHAPTER 4

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

Foundational
• Restoration of range of motion and flexibility
• Initiation of strengthening of pelvic girdle and core
Intermediate
• Progression of strengthening of pelvic girdle and core
• Improvement of proprioception

Advanced
• Restoration of strengthening of pelvic girdle and core
• Restoration of proprioception and functional movements
HIP OSTEOARTHRITIS
There is a lack of evidence in the literature to support the effects of specific ex-
ercises on pain, function, and quality of life in patients with osteoarthritis of the
hip. However, according to the Ottawa Panel, “strength training exercise has
the greatest improvement for pain, disability, physical function, stiffness and
range of motion within a short time (8-12 weeks)” (3). Aerobic training, such
as walking, swimming, or cycling, can help promote range of motion (ROM)
of the hip, allowing nutrients in the joint fluid to get to the relatively avascular
articular cartilage, a process called imbibition. It can also improve general
physical fitness and should be included in the treatment of hip osteoarthritis
(4). Due to the degenerative nature of this condition, it is important to focus on
improving the stability of the hip joint through multiplanar hip strengthening
and lumbopelvic stabilization exercises. Patients with hip osteoarthritis tend to
lose hip extension ROM as the disease progresses (4). Treatment should focus
on prevention of this deficit through anterior stretching of the flexors and quad-
riceps and activation of the gluteals to maintain a normal gait pattern.
Foundational
ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip rotator
stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking
STRENGTHENING: Gluteal isometrics, prone hip extension, side-lying hip abduction with
towel against wall
Intermediate
STRENGTHENING: Squat, bridge
Advanced
STRENGTHENING: Forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Single leg balance
ILIOPSOAS TENDINOPATHY/BURSITIS
Iliopsoas tendinopathy, iliopectineal bursitis, snapping hip, and iliopsoas im-
pingement can all be categorized as “iliopsoas syndrome,” as they can be
difficult to differentiate and often occur together (5,6). This syndrome is often
72 HOME EXERCISE PROGRAMS FOR HIP INJURIES

seen in dancers and runners and is thought to be due to repetitive move-
ment of the tendon over the pelvis and bursa as well as extreme ranges of
motion required to perform certain tasks (5). Initially, activity modification is
advised to reduce aggravation of irritated tissues. Subsequently, the iliopsoas
should be progressively loaded beginning with supine hip flexion, then seated
hip flexion with the knee flexed, and finally standing marches as tolerated (6).
Patients with iliopsoas syndrome often lack terminal hip extension during gait
due to shortening or tightening of the iliopsoas. Ensure that hip flexor stretching
and myofascial release are part of the treatment plan. Impaired core stability
should be addressed through a quadruped progression, standing core stabi-
lization with upper extremity movements, and, finally, forward and side plank-
ing to ensure maximum pelvic control in all functional positions (6). Johnston
et al. show that a gluteal and deep external rotator strengthening program in
multiple positions improves activity levels and return to sport in this population
(7). Once core stability and gluteal strength are improved, unloading the con-
tralateral limb through single leg stance and single leg squats can improve
dynamic hip stability.
Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, iliotibial band (ITB) stretch,
foam roller to hip area
towel against wall
Intermediate
STRENGTHENING: Squat, bridge, clamshells, hip clocks
Advanced
STRENGTHENING: Monster walk, side plank, forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Windmill, single leg squat
GREATER TROCHANTERIC PAIN SYNDROME

Greater trochanteric pain syndrome (GTPS) requires a good assessment of
both static and dynamic movement to identify areas of dysfunction. Literature
has shown poor standing posture with hanging on the hip and altered weight
shift to one leg and collapse with a positive Trendelenburg sign when this
syndrome occurs statically. Dynamically, patients display poor lateral pelvic
HOME EXERCISE PROGRAMS FOR HIP INJURIES 73

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

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

groups. Research has found that gluteus maximus weakness can produce
overload of the proximal hamstring tendon, and gluteus medius weakness will
produce contralateral hip drop and increased hip adduction (14). Patients
will benefit from exercise for trunk stabilization, gluteus maximus and medius
strengthening, and other kinetic chain movements.
Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, quadruped rocking, foam roller
to hip area
STRENGTHENING: Hamstring isometrics
Intermediate
Advanced
STRENGTHENING: Eccentric hamstring throw downs, hamstring curl on stability ball, hip
hiker, forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Lunge, single leg deadlifts
FEMOROACETABULAR IMPINGEMENT AND LABRAL TEARS

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

Foundational
stretch, hip flexor stretch or two-joint hip flexor stretch, ITB stretch, foam roller to hip area
towel against wall
Intermediate
STRENGTHENING: Squat, bridge, hip clocks, clamshell
Advanced
STRENGTHENING: Monster walk, side plank, hip hiker, forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Windmill, single leg squat

HANDOUTS
Hamstring Stretch With a Towel

POSITION: Lie on your back with your legs straight.
STEP 1: Loop a towel/strap around the arch of your
foot (stretching leg).
STEP 2: Keeping your knee straight, slowly raise your

leg off the floor toward the ceiling until a stretch is felt
in your hamstrings/back of your thigh.
REPS: Hold for 30 seconds at end range, then slowly

release stretch.

FREQUENCY: 1 to 2 times per day
Prone Quadriceps Stretch

POSITION: Lie on your stomach with a towel or strap
looped around your ankle.
STEP 1: Tighten your abdominals and gently squeeze

your gluteals to keep your hips flat on the surface.
STEP 2: Hold the strap with your hand (same side),

and gently pull your ankle toward your buttocks to
bend your knee until a gentle stretch is felt in your
thigh muscles, closer to your knee.
NOTE: Do not allow your back to arch.

REPS: Hold for 30 seconds at end range, then slowly
release stretch.

Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR HIP INJURIES 77

Hip Rotator Stretch
POSITION: Lie on your back, knees bent, feet on the
ground.
STEP 1: Cross involved leg so the ankle is near the knee

of the opposite leg.
STEP 2: Place hands behind thigh of opposite leg (or on

top of knee) and slowly lift it off the ground toward you,
while engaging your abdominals so that you do not arch
your back.
NOTE: You should feel a stretch in the buttocks of the

crossed leg.
REPS: Hold for 30 seconds at end range, then slowly re-

lease stretch.

Hip Flexor Stretch, Kneeling

POSITION: Kneeling
STEP 1: Kneel on the ground and put one foot forward into a lunge
position.
STEP 2: While keeping your back straight, gently lean forward until
you feel a stretch in the front of the hip of the back leg.
REPS: Hold that position for 30 seconds, then relax.

SETS: Two to three times per leg
78 HOME EXERCISE PROGRAMS FOR HIP INJURIES Copyright Springer Publishing Company

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

on the table.
STEP 2: Extend your hanging leg back and draw your

foot toward your buttock to bend your knee until you
feel a stretch in the front of your thigh, closer to your hip.

lease stretch.

Quadruped Rocking
POSITION: On your hands and knees, with your hands underneath your shoulders and your knees underneath
your hips
STEP 1: Engage your abdominals, back flat; do not round or arch your back.
STEP 2: Slowly rock backward while keeping your torso flat; stop before your back rounds.
STEP 3: Tighten your abdominals and rock forward past your hands, keeping your torso flat.
REPS: Hold for 10 seconds at end range, then slowly release stretch.
SETS: Perform 10 times.

Iliotibial Band Stretch
POSITION: Stand with your legs crossed and holding onto a support.
STEP 1: Keeping your body, knees, and feet facing forward, slide your back
leg further across your body until you can feel the stretching on the outside
of your hips and thighs.
STEP 2: Repeat with other leg.

Foam Roller to Hip Area

POSITION: Lie face down, on side, or on back depending
on desired muscle.
STEP 1: Roll across quadriceps, hip flexor, hamstring,

glute, ITB, or calf.
STEP 2: Take a break if needed, and you can stretch

muscle after rolling.
REPS: 3 to 5 minutes to each desired muscle

FREQUENCY: Once per day
NOTE: Avoid rolling directly over the ITB; try and roll a
little in front or behind it.

Strengthening
Gluteal (Buttock) Isometrics

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

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

Prone Hip Extension
POSITION: Lie on belly with pillow under abdomen and pelvis.
STEP 1: Raise involved leg off floor by squeezing the buttocks and keeping the knee straight.
STEP 2: Hold for 2 seconds, then slowly relax leg back down.
SETS: Three sets to desired side with a 30-second break between sets
Level 2 Level 2
Clam Shells
POSITION: Lie on your side and bend your hips and knees 45°.
STEP 1: Keep your heels together and slowly lift your top knee toward the ceiling.
STEP 2: Hold that position for 3 to 5 seconds, then slowly return to the starting position.
REPS: Repeat 10 times per leg.
SETS: Two to three
FREQUENCY: 2 to 3 times per day and 3 to 5 times per week
LEVEL 2: Put a Theraband around your thighs to increase the resistance.

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

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

contracting your buttocks.
STEP 2: Slowly bring leg back down to parallel, keeping

heel pushing into towel.

NOTE: This exercise can also be performed with a sock on
against a wall.

Level 2 Level 2
Level 3
Bridge
POSITION: Lie on your back with both of your knees bent, your feet hip-distance apart, and arms relaxed by
your side.
STEP 1: Tighten your abdominals and your buttocks.

STEP 2: Lift your buttocks off the mat until your hips are level.
STEP 3: Hold the position for 2 to 3 seconds and then slowly lower yourself down.
NOTE: You should feel this in the buttocks. If your back hurts while doing this exercise, make sure you are contracting
your abdominals and do not lift your hips as high.
LEVEL 2: Perform bridge as described, then slowly march in place by lifting each foot off the mat in alternating fash-
ion; focus on engaging the buttock of the leg that is down.
LEVEL 3: Perform a single leg bridge with the nonworking leg pointed straight out; alternate legs after 10 reps.

Hamstring Curl on Stability Ball
POSITION: Lie on your back on the floor with your heels and lower calves positioned on a stability ball.
STEP 3: Gradually roll the ball in toward your buttocks (bring your heels toward your butt) by bending your knees.
STEP 4: Roll the ball slowly out while keeping your legs and torso steady.

Hip Hikers
POSITION: Standing, with one leg off of a step and the other leg straight and on the step
STEP 1: Slowly lift hip up in the air (leg that is off the step), keeping leg that is on the step straight.
STEP 2: Hold for 1 to 2 seconds, then slowly lower back down.
REPS: Perform 10 times on both sides.

Level 2
Forward Step Up
POSITION: Stand in front of a 6- or 8-inch step with good posture.
STEP 1: Tighten your abdominals and buttocks.
STEP 2: Step up onto the step by squeezing your buttocks, keeping your torso steady and your hip, knee,
and ankle in line.
STEP 3: Return to the starting position by steadily stepping back down.

LEVEL 2: When you can complete three sets of 10 reps with proper form on a 6-inch step, add 5-lb dumbbells, then
10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with proper
form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

Level 2
Forward Step Down

POSITION: Stand on a 6- or 8-inch step, with your hands on your hips.
STEP 1: Slowly lower your heel to the floor while keeping your hips level and the hip, knee, and ankle of the standing
leg aligned, as you lower and land softly with control.
STEP 2: Return to starting position.

NOTE: This exercise is important for developing the ability to decelerate while maintaining good alignment. So per-
form slowly and with focus. Better to do fewer repetitions of good quality than rush through three sets of 10.
LEVEL 2: When you can complete three sets of 10 reps with proper form on the 6-inch step, add 5-lb dumbbells, then

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

Hip Clocks
Imagine you are standing on the face of a clock (12:00 is in front of you, 6:00 behind you).
POSITION: Place a resistance band around your ankles (harder) or around your knees (easier).
STEP 1: Stand with your feet about shoulder-width apart.
STEP 2: Sit back into your hips and bend your knees slightly.
STEP 4: With your right leg, touch 1:00, 3:00, and 5:00 o’clock with your toe, while keeping your left leg steady by
using your buttocks and torso.
STEP 3: Switch to your left leg and touch 11:00, 9:00, and 7:00 o’clock, with the same focus on stabilizing with
the right buttock.
REPS: Perform five clocks with each leg.


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

Eccentric Hamstring Throwdowns
POSITION: Lie on stomach on table or bed with pillow under stomach and bend affected knee to 90°.
STEP 1: Quickly straighten knee, stopping 2 to 3 inches from the table or bed.
STEP 2: Bend knee back to 90° and repeat.

Level 2
Single Leg Balance
STEP 1: Stand on one leg with your knee slightly
bent, hands on your hips while keeping your hips
level and standing tall and straight.
STEP 2: Tighten your abdominals and hold your

position.
NOTE: Make sure you do not sink into your hip or

lean to the side.

SETS: Three sets on desired side with a 30-second
break between sets

LEVEL 2: Slowly look side to side, and then up
and down.
LEVEL 3: Move your raised leg out to the side a bit

(do not hike your hip); then move leg back in.
Level 3 Level 4
LEVEL 4: Move your raised leg forward and back-
ward from your hip, slowly.

Level 2
Level 3
Single Leg Deadlift

POSITION: Standing
STEP 1: Stand on one leg with your knee slightly bent and tighten the buttock of the standing leg, while keeping
your hips level and not sinking into your hip or leaning to the side.
STEP 2: Tighten your abdominals.

STEP 3: Bend forward by hinging back on the hip of the standing leg, while keeping the knee of the stance leg slightly
bent and keeping the buttock of the standing leg engaged such that your hip does not jut out to the side.
STEP 4: Extend your opposite leg out behind you as you go down to maintain a straight line with your body (head,
neck, back, leg), and keep your hips even.
STEP 5: Keeping your back straight, bring yourself back up to the starting position by tightening your buttocks.
SETS: Three sets on desired side with a 30-second break between sets
NOTE: Lower only to a depth that allows you to maintain proper form. Stop when you feel your back start to round,
your hip jut out, or a stretch in your hamstrings.
LEVEL 2: You can hold a stick with both hands along your spine. The stick should not come off your back as you go
down into the deadlift.
LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do not let the weight pull your back out of align-
ment; you must control the weight.

Windmill
POSITION: Standing
STEP 1: Stand on one leg while stabilizing your glutes and core.
STEP 2: Hinge from the hip such that your trunk is parallel to the floor, and place your arms out perpendicular to
your trunk and parallel to the floor.
STEP 3: Bring one arm down toward the floor, then bring it back to start position.
STEP 4: Alternate to the other arm.
REPS: Alternate 10 repetitions on each arm, maintaining stability over the affected leg.
SETS: Three sets on desired side(s) with a 30-second break between sets

Lunge
POSITION: Stand with feet hip-width apart and place hands on hips.
STEP 1: Take a step forward with your left foot and lower your body as you bend your left hip and knee, keeping
your right foot in line with your ankle.
STEP 2: At the same time, your left knee should bend into a half kneeling position, without letting your right knee
touch the floor.
STEP 3: Push yourself back up into the starting position with your front foot.
STEP 4: Repeat this exercise leading with your other (right) leg.
NOTE: Keep your abdominals engaged and spine in a straight line. Keep your weight on your front leg—the back leg
is just a kickstand.
LEVEL 2: Hold weights in your hands.

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

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2. Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med
Rep. 2008;7(1):39–44. doi:10.1097/01.CSMR.0000308663.13278.69.
3. Brosseau L, Wells GA, Pugh AG, et al. Ottawa Panel evidence-based clinical practice
guidelines for therapeutic exercise in the management of hip osteoarthritis. Clin Rehabil.
2016;30(10):935–946. doi:10.1177/0269215515606198.
4. Rannou F, Poiraudeau S. Non-pharmacological approaches for the treatment of
osteoarthritis. Best Pract Res Clin Rheumatol. 2010;24:93–106. doi:10.1016/j.berh.2009.08.013.
5. Heiderscheit B, McClinton S. Evaluation and management of hip and pelvis injuries. Phys
Med Rehabil Clin N Am. 2016;27(1):1–29. doi:10.1016/j.pmr.2015.08.003.
6. Tyler TF, Fukunaga T, Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis. Int
J Sports Phys Ther. 2014;9(6):785–797. PubMed PMID: 25383247.
7. Johnston CA, Lindsay DM, Wiley JP. Treatment of iliopsoas syndrome with a hip rotation
strengthening program: a retrospective case series. J Orthop Sports Phys Ther. 1999;29(4):
218–224. doi:10.2519/jospt.1999.29.4.218.
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tract friction. Curr Sports Med Rep. 2012;11(5):232–238. doi:10.1249/JSR.0b013e3182698f47.
9. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: a review of mechanisms,
assessment and management. Sports Med. 2015;45(8):1107–1119. doi:10.1007/
s40279-015-0336-5.
10. Boren K, Conrey C, Le Coguic J, et al. Electromyographic analysis of gluteus medius and
gluteus maximus during rehabilitation exercises. Int J Sports Phys Ther. 2011;6(3):206–223.
PubMed PMID: 22034614.
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pain syndrome. Phys Ther Sport. 2015;16(3):205–214. doi:10.1016/j.ptsp.2014.11.002.
12. Distefano LJ, Blackburn JT, Marshall SW, et al. Gluteal muscle activation during common
therapeutic exercises. J Orthop Sports Phys Ther. 2009;39(7):532–540. doi:10.2519/
jospt.2009.2796.
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diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67–81.
doi:10.2519/jospt.2010.3047.
14. Goom TSH, Malliaras P, Reiman MP, et al. Proximal hamstring tendinopathy: clinical
aspects of assessment and management. J Orthop Sports Phys Ther. 2016;46(6):483–493.
doi:10.2519/jospt.2016.5986.
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impingement: a systematic review of the literature. PM&R. 2013;5:418–426. doi:10.1016/j.
pmrj.2013.02.005.
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(FAI) in the long distance runner. Phys Ther Sport. 2014;15(2):82–90. doi:10.1016/j.
ptsp.2014.02.004.

CHAPTER 5

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

Foundational
• Control edema
• Restoration of range of motion (ROM) and flexibility
• Initiation of strengthening of knee
Intermediate
• Progression of strengthening of knee
• Improvement of proprioception

Advanced
• Restoration of strengthening of knee and progression to eccentric strengthening
for tendinopathies
• Restoration of strengthening of core
• Restoration of proprioception and functional movements
• Restoration of multidirectional stability
KNEE OSTEOARTHRITIS
OA of the knee is one of the most prevalent types of OA reported, affecting
women and the elderly more often (3). The development of knee OA can be
a product of aging, increased weight, genetics, and/or repetitive stress on the
knee joint. Because of the degenerative nature of the disease, patients with
knee OA report increasing pain and stiffness with weight-bearing activities
such as walking, stair negotiation, and squatting. Therapeutic exercise involv-
ing aerobics, joint ROM, soft tissue flexibility, strength and endurance training,
and proprioception training improve pain scores and function in this popula-
tion (4). Exercise prescription should focus on strengthening the quadriceps
and hamstrings for multiplanar knee joint stability as well as the gluteals and
deep external rotators of the hip for optimal knee alignment in a loaded po-
sition (5). This population also tends to have a higher knee adduction move-
ment during gait, which is indicative of increased loads through the medial
compartment (6). Woollard et al. (7) have shown that patients with medial
knee OA are more likely to slow the progression of medial joint space degen-
eration by strengthening their hip abductors.
Foundational
ROM/STRETCHING/MOBILITY: Hamstring stretch, two-joint hip flexor stretch, assisted knee
extension, assisted knee flexion, passive knee extension
STRENGTHENING: Quadriceps set, straight leg raise, prone hip extension, side-lying hip
abduction with towel against wall
Intermediate
ROM/STRETCHING/MOBILITY: Knee flexion chair stretch
STRENGTHENING: Bridge, squat, squat on wedge
Advanced
STRENGTHENING: Forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Single leg squat
102 HOME EXERCISE PROGRAMS FOR KNEE INJURIES

PATELLOFEMORAL PAIN SYNDROME
PFPS is a common diagnosis seen in many PT and MD offices. It is typically re-
ported as a gradual onset of knee pain that has limited the patients from par-
ticipating in activities they enjoy (i.e., running, soccer, basketball, tennis, etc.).
Men and women can both suffer from PFPS, but it is more often seen in women.
Studies have shown that female runners with PFPS fall into hip adduction and
internal rotation, therefore causing altered kinematics in the frontal and trans-
verse planes (8). The dysfunctional movement patterns result in knee pain
due to delayed activation in the gluteus medius and gluteus maximus mus-
cles (8). Treatment for PFPS has moved away from only traditional quadriceps
strengthening and has developed to include targeting hip muscle strength-
ening and movement strategies for trunk and lower limb. As a result, patients
have demonstrated “improvements in pain, physical function, lower-limb and
trunk kinematics, trunk muscle endurance, and eccentric strength of the hip
and knee musculature” (9).
Foundational
ROM/STRETCHING/MOBILITY: Hamstring stretch, prone quadriceps stretch, hip flexor
STRENGTHENING: Quadriceps set, straight leg raise, side-lying hip abduction with towel
Intermediate
Advanced
STRENGTHENING: Side plank, forward step up, forward step down
PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift
QUADRICEPS AND PATELLAR TENDINOPATHY

Tendinopathy is a term that describes pain and injury from within or around
a tendon (10). Patellar and quadriceps tendinopathies are commonly seen in
athletes as overuse injuries and in both basketball and volleyball players. It is
important to modify activity and start the PRICE principles: Protection, Rest, Ice,
Compression, Elevation, when managing these conditions. As the rehabilitation
of the injury progresses and after starting to work on flexibility and concen-
tric strengthening, eccentric exercises are commonly used for “lengthening a
HOME EXERCISE PROGRAMS FOR KNEE INJURIES 103

musculotendinous unit while application of a load occurs” (10). Results have
been shown to decrease pain and improve tendon quality.There are many ways
to emphasize eccentric loading when choosing exercises, including utilizing a
decline board to squat or performing drop squats (11). It is also important to ad-
dress other impairments commonly seen in athletes with jumper’s knee (patellar
tendinopathy) and quadriceps tendinopathy, specifically core weakness, glu-
teus medius weakness, and poor quadriceps, hip flexor, and hamstring flexibility.
Foundational
STRENGTHENING: Quadriceps set, straight leg raise, side-lying hip abduction with towel
Intermediate
Advanced
STRENGTHENING: Side plank, forward step up, forward step down, squat on a wedge
(Level 3)
PROPRIOCEPTION/FUNCTIONAL: Single leg deadlift, windmill
KNEE LIGAMENT SPRAIN

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

Research also shows that neuromuscular reeducation focusing on improv-
ing frontal plane knee control to reduce dynamic knee valgus reduces the
rate of knee injury (14). Hip abduction and external rotation strengthening has
been found to decrease valgus stress in the knee and prevents further injury in
a knee with ligamentous injury. Exercise programs involving standing or side-ly-
ing hip abduction, single leg balance, squatting, single leg squatting, forward
step ups, and forward step downs effectively facilitate hip muscle activation to
maintain healthy knee frontal plane alignment (15).
Foundational
STRENGTHENING: Quadriceps set, terminal knee extension, straight leg raise, side-lying
Intermediate
Advanced
PROPRIOCEPTION/FUNCTIONAL: Single leg deadlift, windmill
MENISCAL TEAR
The meniscus is an important structural component of the knee joint that as-
sists in loading, absorption of forces, and stabilization of the knee joint. The
menisci assist with transmission of forces that the knee sustains with every step.
It assists in protection and prevention of wearing of the articular cartilage that
lines the distal femur and tibia. Mechanism of injury for menisci occur with non-
contact movements, such as deceleration, cutting, and jumping, but contact
injuries do also occur. Degeneration may occur with increased age due to
general wear and tear on the knee (16).
Literature shows that weakness in the proximal hip (gluteal region) causes
a loss of proximal stability, therefore making the knee susceptible to injury (17).
Functional motor control and strengthening exercises for hip abductors have
been shown to minimize valgus and internal rotation stresses across the knee

joint (18). Exercises should focus on quadricep reeducation and eccentric
control, proximal strengthening at hip, core stabilization, neuromuscular reedu-
cation, and general lower extremity flexibility.
Foundational
STRENGTHENING: Quadriceps set, terminal knee extension, straight leg raise, side-lying
Intermediate
Advanced
PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift, windmill
ILIOTIBIAL BAND SYNDROME

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

Foundational
stretch or two-joint hip flexor stretch, ITB stretch
STRENGTHENING: Side-lying hip abduction with towel against wall, prone hip extension
Intermediate
Advanced
PROPRIOCEPTION/FUNCTIONAL: Single leg squat, single leg deadlift, windmill

HANDOUTS
Hamstring Stretch With a Towel

POSITION: Lie on your back with your legs straight.
STEP 1: Loop a towel/strap around the arch of your foot
(stretching leg).
STEP 2: Keeping your knee straight, slowly raise your

leg off the floor toward the ceiling until a stretch is felt in
your hamstrings/back of your thigh.

lease stretch.



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

lease stretch.

108 HOME EXERCISE PROGRAMS FOR KNEE INJURIES Copyright Springer Publishing Company

POSITION: Kneeling
STEP 1: Kneel on the ground and put one foot forward into a lunge
position.
STEP 2: While keeping your back straight, gently lean forward until you
feel a stretch in the front of the hip of the back leg.


POSITION: Lying on your back on a bed/table, bend your
knees and drop one leg over the side of the bed and place
a strap (can also use a Theraband or towel) around your
ankle.

on the table.


lease stretch.

Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR KNEE INJURIES 109

ITB Stretch
POSITION: Stand with your legs crossed and holding onto a support.
STEP 1: Keeping your body, knees, and feet facing forward, slide your back
leg further across your body until you can feel the stretching on the outside
of your hips and thighs.
STEP 2: Repeat with other leg.

Assisted Knee Extension

POSITION: Sit on edge of table or bed.
STEP 1: Straighten involved knee with assistance of other
leg.
STEP 2: Then slowly lower involved leg, assisting with

other leg as needed.

NOTE: Try to do as much of the work as possible with the
involved leg.

Assisted Knee Flexion
POSITION: Sit on the edge of a table or chair.
STEP 1: Cross ankles as shown, with the stiff knee at the bottom.
STEP 2: Press downward with the upper leg so that you feel a stretch.
STEP 3: Hold 10 seconds.
Knee Flexion Chair Stretch

POSITION: Put affected leg up on chair, or a step stool if unable to reach chair height.
STEP 1: Slowly rock forward using your hands to bring the body closer to the front leg.

Passive Knee Extension
POSITION: Place a rolled towel under your ankle while
sitting with your legs out.
STEP 1: Place an ice pack on your knee.

STEP 2: Relax the leg and let the knee straighten.
REPS: Hold for 10 to 15 minutes.
FREQUENCY: Twice per day

Strengthening
Quadriceps Set
POSITION: Sit or lie on your back with leg straight.
STEP 1: Place a small, rolled towel under your involved
knee.
STEP 2: Press the back of your knee downward by tight-

ening your thigh muscle.

SETS: Perform 10 times to desired leg(s).
Straight Leg Raise

POSITION: Lie on back with involved knee straight and
the other knee bent.
STEP 1: Keep the leg completely straight, then raise it

about 16 inches up to height of opposite knee.
STEP 2: Slowly lower the involved leg back to starting

position.


Terminal Knee Extension
POSITION: Standing up, make a loop with exercise band; securely attach one end at knee level to a fixed structure,
place your knee inside the loop, and take up the slack.
STEP 1: Slowly bend and straighten your knees, stretching the band as you extend your knee backward.
NOTE: Keep the band wrapped above your knee joint.

Prone Hip Extension
POSITION: Lie on belly with pillow under abdomen and pelvis.
STEP 1: Raise involved leg off floor by squeezing the buttocks and keeping the knee straight.
STEP 2: Hold for 2 seconds, then slowly relax leg back down.

Alternatively
Alternatively Alternatively Level 2
Squat
POSITION: Stand with your feet hip-width apart while facing a mirror or having a partner watch you.
Make sure you do not fold over or arch up. Your eyes should follow the path of the motion. Keep your weight evenly
distributed on both sides. To make it easier, do not go down as far or use a chair behind you.
ALTERNATIVELY: You can do it against a wall or squat onto a chair to make exercise easier.
LEVEL 2: You can try placing a mini band above the knees to get better buttock engagement.

Level 2
Level 2 Level 3 Level 3
Squat on a Wedge
POSITION: Stand with both feet on a 25° to 45° wedge or board, with your feet hip-width apart while supporting
yourself with a hand rail or balance stick, if needed; face a mirror or have a partner watch you.
Make sure you do not fold over or arch up. Your eyes should follow the path of the motion. Keep your weight evenly
distributed on both sides. To make it easier, do not go down as far or use a chair behind you.
LEVEL 2: You can try placing a mini band above the knees to get better buttock engagement.
LEVEL 3: Perform with a single leg.

Side-Lying Hip Abduction With Towel Against Wall
POSITION: Lie on side with bottom leg’s knee bent to hip level and top leg against wall pushing into towel.
STEP 1: As you push into towel, slowly lift leg, contracting your buttocks.
STEP 2: Slowly bring leg back down to parallel, keeping heel pushing into towel.
NOTE: This exercise can also be performed with a sock on against a wall.

Level 2 Level 2
Level 3
Bridge
POSITION: Lie on your back with both knees bent, your feet hip-distance apart, and arms relaxed by your sides.
LEVEL 2: Perform bridge as above, then slowly march in place by lifting each foot off the mat in alternating fashion;
focus on engaging the buttock of the leg that is down.
LEVEL 3: Perform a single leg bridge with the nonworking leg pointed straight out, and alternate legs after 10 reps.

Level 2
Forward Step Up
POSITION: Stand in front of a 6- or 8-inch step with good posture.
STEP 2: Step up onto the step by squeezing your buttocks, keeping your torso steady and your hip, knee,
and ankle in line.
STEP 3: Return to the starting position by steadily stepping back down.

LEVEL 2: When you can complete three sets of 10 reps with proper form on the 6-inch step, add 5-lb dumbbells, then

Level 2
Forward Step Down

POSITION: Stand on a 6- or 8-inch step with your hands on your hips.
STEP 1: Slowly lower your heel to the floor, while keeping your hips level and the hip, knee, and ankle of the standing
leg aligned as you lower and land softly with control.
STEP 2: Return to starting position.

NOTE: This exercise is important for developing the ability to decelerate while maintaining good alignment. So per-
form slowly and with focus. Better to do fewer repetitions of good quality than rush through three sets of 10 each.
LEVEL 2: When you can complete three sets of 10 repetitions with proper form on the 6-inch step, add 5-lb dumbbells,
then 10-lb dumbbells. Progress to an 8-inch step without weights. When you can complete three sets of 10 reps with
proper form on the 8-inch step, add 5-lb dumbbells, then 10-lb dumbbells.

Level 2
Level 3
Side Plank
POSITION: Lie on your side, bend your knees to 90°, and put your arm with your elbow bent on the ground.
STEP 2: Hold that position for 30 seconds or for as long as you can.
SETS: Two or three
contracting as well as your abdominal muscles. The goal is to work your way to holding the position for 30 to 60 sec-
onds at a time.
LEVEL 2: This is similar to the first position, except that you should extend your knees and lift your entire body and
knees off the ground such that one elbow and the outside of your foot are touching the ground.
LEVEL 3: This is similar to Level 2, except that you should lift your top leg and/or arm into the air in an abducted po-
sition (away from the body) with a straight knee or elbow.

Level 2
Single Leg Balance
POSITION: Standing
STEP 1: Stand on one leg with your knee slightly
bent and hands on your hips, while keeping your
hips level and standing tall and straight.
STEP 2: Tighten your abdominals and hold your

position.
NOTE: Make sure you do not sink into your hip or

lean to the side.

SETS: Three sets on desired side with a 30-second
break between sets

LEVEL 2: Slowly look side to side, and then up
and down.
Level 3 Level 4
LEVEL 3: Move your raised leg to the side a bit (do
not hike your hip); then move leg back in.
LEVEL 4: Move your raised leg forward and back-

ward from your hip slowly.

Level 2
Level 3
Single Leg Deadlift

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

STEP 4: Extend your opposite leg out behind you as you go down to maintain a straight line with your body (head,
neck, back, leg), and keep your hips even.
NOTE: Lower only to a depth that allows you to maintain proper form. Stop when you feel your back start to round,
LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do not let the weight pull your back out of align-

Windmill
POSITION: Standing
STEP 1: Stand on one leg while stabilizing your glutes and core.
STEP 2: Hinge from the hip such that your trunk is parallel to the floor, and place your arms out perpendicular to
your trunk and parallel to the floor.
STEP 3: Bring one arm down toward the floor, then bring it back to start position.
STEP 4: Alternate to the other arm.
REPS: Alternate 10 repetitions on each arm, maintaining stability over the affected leg.
SETS: Three sets on desired side(s) with a 30-second break between sets

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

REFERENCES
1. Logerstedt D, Arundale A, Lynch A, et al. A conceptual framework for a sports knee
injury performance profile (SKIPP) and return to activity criteria (RTAC). Braz J Phys Ther.
2015;19(5):340–359. doi:10.1590/bjpt-rbf.2014.0116.
2. Frizziero A, Trainito S, Oliva F, et al. The role of eccentric exercise in sport injuries
rehabilitation. Br Med Bull. 2014;110(1):47–75. doi:10.1093/bmb/ldu006.
3. Busija L, Bridgett L, Williams SRM, et al. Osteoarthritis. Best Pract Res Clin Rheumatol.
2010;24(6):757–768. doi:10.1016/j.berh.2010.11.001.
4. Rannou F, Poiraudeau S. Non-pharmacological approaches for the treatment of
osteoarthritis. Best Pract Res Clin Rheumatol. 2010;24:93–106. doi:10.1016/j.berh.2009.08.013.
5. Nguyen C, Lefèvre-Colau MM, Poiraudeau S, et al. Rehabilitation (exercise and strength
training) and osteoarthritis: a critical narrative review. Ann Phys Rehabil Med. 2016;59(3):190–
195. doi:10.1016/j.rehab.2016.02.010.
6. Baliunas AJ, Hurwitz DE, Ryals AB, et al. Increased knee joint loads during walking
are present in subjects with knee osteoarthritis. Osteoarthritis Cartilage. 2002;10:573–579.
doi:10.1053/joca.2002.0797.
7. Woollard JD, Gil AB, Sparto P, et al. Change in knee cartilage volume in individuals
completing a therapeutic exercise program for knee osteoarthritis. J Orthop Sports Phys Ther.
2011;41(10):708–722. doi:10.2519/jospt.2011.3633.
8. Willson JD, Kernozek TW, Arndt RL, et al. Gluteal muscle activation during running in
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11. Schwartz A, Watson JN, Hutchinson MR. Patellar tendinopathy. Sports Health. 2015;7(5):415–
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s00167-015-3619-3.
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jospt.2014.4876.
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CHAPTER 6

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

Foundational
• Restoration of ROM and flexibility (ankle dorsiflexion and gastrocnemius
flexibility)
• Initiation of strengthening (foot intrinsics)
Intermediate
• Progression of strengthening (ankle)

Advanced
• Restoration of strengthening, including eccentric strengthening for
tendinopathies
• Improvement of ankle proprioception and coordination
ANKLE SPRAIN
Ankle sprains are a very common occurrence, and many people do not seek
medical care and overcome the sprain with rest, ice, compression, and ele-
vation. Unfortunately, these rehabilitation principles do not address ankle pro-
prioception. In many cases when an ankle is sprained, ankle proprioception
becomes impaired and can set the patient up for future sprains. Accordingly,
particular attention should be paid to proprioception when treating ankle
sprains to avoid chronic ankle instability (4,5). Furthermore, a dynamic exercise
program with predictable and unpredictable changes in direction as well as
landing from a hop may lead to better outcomes than less dynamic balance
protocols (6). It has also been suggested in the literature that altered proximal
muscle function and biomechanics have been seen following unilateral ankle
sprains; therefore, it is important to address pelvic and core strength as well (7).
Foundational
ROM/STRETCHING/MOBILITY: Calf stretch A or B, alphabets
STRENGTHENING: Marble pick-ups
Intermediate
STRENGTHENING: Concentric ankle inversion strengthening, concentric ankle eversion
strengthening, concentric ankle dorsiflexion strengthening
Advanced
PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch, wobble board
ACHILLES TENDINOPATHY
Achilles tendinopathy is a condition that plagues many patients as its rehabili-
tation can be lengthy and lead to procedures to alleviate symptoms. While the
prior mentioned principles should be performed with rehabilitation of Achilles
tendinopathy, the addition of eccentric strengthening of the Achilles tendon
has been shown to be quite beneficial (8–11).
130 HOME EXERCISE PROGRAMS FOR ANKLE AND FOOT INJURIES

Foundational
ROM/STRETCHING/MOBILITY: Foam roller (lower leg), towel stretch, calf Stretch A or B,
soleus stretch
STRENGTHENING: Towel scrunches
Intermediate
STRENGTHENING: Heel raises
Advanced
STRENGTHENING: Eccentric Achilles strengthening
PROPRIOCEPTION/FUNCTIONAL: Single leg taps, single leg tennis ball catch
POSTERIOR TIBIAL TENDINOPATHY

Posterior tibial tendinopathy is less frequently encountered by the practitioner
than the conditions mentioned earlier. With this in mind, strengthening of the
tendon is important as with all tendinopathies. For the posterior tibial tendon,
active resistance of foot abduction would be considered eccentric strength-
ening, while concentric strengthening would be foot adduction against resis-
tance (12,13). Kulig et al. (12) have showed that eccentric strengthening of
the posterior tibial tendon is more important than concentric strengthening or
stretching in this condition.
Foundational
ROM/STRETCHING/MOBILITY: Foam roller (lower leg), towel stretch, calf stretch A or B
STRENGTHENING: Towel scrunches
Intermediate
STRENGTHENING: Concentric ankle inversion strengthening, heel raises
Advanced
STRENGTHENING: Eccentric posterior tibial tendon strengthening
HOME EXERCISE PROGRAMS FOR ANKLE AND FOOT INJURIES 131

PLANTAR FASCIOSIS
Plantar fasciosis can be very difficult to treat.The literature suggests that stretch-
ing of the plantar fascia may be the most important exercise to help relieve a
patient’s symptoms (14,15). Foot intrinsic strengthening should also be added
to the basic foot and ankle exercise program, but the literature is not clear
whether these exercises are beneficial.
Foundational
ROM/STRETCHING/MOBILITY: Can roll, towel stretch, plantar fascia stretch
STRENGTHENING: Towel scrunches, marble pick-ups
Intermediate
STRENGTHENING: Heel raises
Advanced
STRENGTHENING: Eccentric Achilles strengthening

HANDOUTS
Towel Stretch
POSITION: Sitting
STEP 1: Loop towel over ball of foot and stretch calf.
STEP 2: Switch legs.
FREQUENCY: Once daily
Calf Stretch A
POSITION: Standing
STEP 1: Stand with one leg in front of the other.
STEP 2: Bend the front knee while the back leg is straight; the heels should be
on the ground.

SETS: Three sets to both sides with a 30-second break between sets
Calf Stretch B
POSITION: Get into a push-up–like position.
STEP 1: Cross one leg over the other, with the bottom
leg’s heel on the ground.

SETS: Three sets to both sides with a 30-second break
between sets
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR ANKLE AND FOOT INJURIES 133

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

SETS: Three sets to both sides with a 30-second break between sets
Can Roll
POSITION: Sit on a chair.
STEP 1: Place can under sole of foot (can use a golf or
lacrosse ball as well).
STEP 2: Roll back and forth.

REPS: Perform for 2 minutes.
SETS: One set to both sides
Alphabets
POSITION: Sitting on chair
STEP 1: Write out the alphabet in the air with the
injured foot.
REPS: Go through entire alphabets.

SETS: Three sets to injured side with a 30-second break
between sets
134 HOME EXERCISE PROGRAMS FOR ANKLE AND FOOT INJURIES Copyright Springer Publishing Company

Plantar Fascia Stretch
POSITION: Sit on chair.
STEP 1: Cross injured leg over uninjured leg.
STEP 2: Grab heel and ball of foot and stretch apart.
SETS: Three sets to both sides with a 30-second break
between sets
Foam Roller (lower leg)

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

Strengthening
Towel Scrunches
POSITION: Sitting on a chair
STEP 1: Grab a towel with toes.
REPS: Perform with both feet 10 times.
Marble Pick-ups
STEP 1: Grab a marble (or similar sized objects) with toes.
STEP 2: Move marbles to the left and the right and put
them into a cup.
REPS: Perform 10 pick-ups.

Concentric Ankle Inversion Strengthening

STEP 1: Place Theraband loop around desired foot.
STEP 2: Bring foot inward at the ankle and create increasing resistance in the
band.
STEP 3: Slowly return to starting position.


Concentric Ankle Eversion Strengthening
STEP 2: Bring foot outward at the ankle and create increasing resistance
in the band.

Concentric Ankle Dorsiflexion

Strengthening
POSITION: Sitting on ground
STEP 2: Bring foot toward you at the ankle and create
increasing resistance in the band.

SETS: Three sets to desired side with a 30-second break
between sets

Heel Raises
POSITION: Standing
STEP 1: Stand next to chair or table, if necessary, to aid with balance.
STEP 2: Go up on toes, then lower oneself slowly.
ALTERNATIVELY: To make this more challenging, perform on one leg at a time.
Eccentric Achilles Strengthening

POSITION: Standing on stair
STEP 1: Use uninjured leg to position self on tippy toes on the edge of a step.
STEP 2: Slowly lower body on injured side and lower past the level of the step, if possible.
ALTERNATIVELY: Go up on toes with both feet and slowly lower self on the injured side past the level of step,
if possible.
REPS: Perform 10 times to the injured side: may perform to both sides.

Eccentric Posterior Tibial Tendon Strengthening
POSITION: Sitting on a table or bed holding a Theraband around forefoot in the neutral position
STEP 1: Push forefoot down and in.
STEP 2: Stretch Theraband to unilateral shoulder.
STEP 3: Slowly return foot to starting position and go to up and out position.
REPS: Perform 10 times to the injured side: may perform to both sides.

Single Leg Taps

POSITION: Standing
STEP 1: Stand on the injured leg.
STEP 2: With the uninjured leg, slowly reach out in six
different directions as far as you can, drawing an imagi-
nary asterisk.
SETS: Perform five sets with a 30-second break between

sets, and then perform to uninjured leg.
Single Leg Tennis Ball Catch

POSITION: Standing
STEP 1: Stand on the injured leg.
STEP 2: Throw a ball against a wall and catch it or have a partner throw a ball
at you.
REPS: Catch ball 10 times.

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

LEVEL 2: Stand on a pillow or piece of foam; the ball should be thrown to the
sides such that the participant needs to reach to catch the ball.
LEVEL 3: Hop on one foot on level ground; the ball should be thrown to the
sides such that the participant needs to reach to catch the ball.

Wobble Board
POSITION: Sit on chair with wobble board on the ground.
STEP 1: Rotate wobble board in circles in each direction,
keeping one edge continually on the ground. Then rock
forward and back and side to side.
STEP 2: Stand on the wobble board for 1 minute using the

chair for support.
STEP 3: Rest for 30 seconds.

STEP 4: Stand on wobble board and rotate in circles in
each direction, keeping one edge continually on the
ground. Then rock forward and back and side to side for
2 minutes.
REPS: One to three times

SETS: One to three

REFERENCES
1. van der Eng DM, Schepers T, Goslings JC, et al. Rerupture rate after early weightbearing in
operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot
Ankle Surg. 2013;52(5):622–628. doi:10.1053/j.jfas.2013.03.027.
2. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of
lateral ankle sprains. Am J Sports Med. 1994;22(1):83–88. doi:10.1177/036354659402200115.
3. Lee DH, Lee KB, Jung ST, et al. Comparison of early versus delayed weightbearing
outcomes after microfracture for small to midsized osteochondral lesions of the talus. Am
J Sports Med. 2012;40(9):2023–2028. doi:10.1177/0363546512455316.
4. Eils E, Rosenbaum D. A multi-station proprioceptive exercise program in
patients with ankle instability. Med Sci Sports Exerc. 2001;33(12):1991–1998.
doi:10.1097/00005768-200112000-00003.
5. Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle
instability. Sports Med. 2009;39(3):207–224. doi:10.2165/00007256-200939030-00003.
6. McKeon PO, Ingersoll CD, Kerrigan DC, et al. Balance training improves function
and postural control in those with chronic ankle instability. Med Sci Sports Exerc.
2008;40(10):1810–1819. doi:10.1249/MSS.0b013e31817e0f92.
7. Bullock-Saxton JE. Local sensation changes and altered hip muscle function following
severe ankle sprain. Phys Ther. 1994;74(1):17–28; discussion 28–31. doi:10.1093/ptj/74.1.17.
8. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles
tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports
Med. 2004;38(1):8–11; discussion 11. doi:10.1136/bjsm.2001.000284.
9. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle
training compared to concentric training in a randomized prospective multicenter study on
patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42-
47. doi:10.1007/s001670000148.
10. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the
treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366. doi:10.1177/0
3635465980260030301.
11. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-
drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med.
2012;46(3):214–218. doi:10.1136/bjsports-2011-090035.
12. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon
dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther.
2009;89(1):26–37. doi:10.2522/ptj.20070242.
13. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders.
Rheumatology (Oxford). 2006;45(5):508–521. doi:10.1093/rheumatology/kel046.
14. Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise
improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with
two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775–1781. doi:10.2106/JBJS.E.01281.
15. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching
exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized
study. J Bone Joint Surg Am. 2003;85-A(7):1270–1277. doi:10.2106/00004623-200307000-00013.

CHAPTER 7

Cervical Spine Injuries
Gary Mascilak
INTRODUCTION
An estimated 30% to 50% of the population experience some form of neck pain each
year (1). In this chapter, we address four common disorders of the cervical spine, each
condition unique to itself; however, some patients have multiple conditions present-
ing concomitantly. Once a diagnosis is made clinically, an appreciation for the spe-
cific individual characteristics of each patient must be considered in formulating a
rehabilitation-based treatment plan. In best assisting these “cervical” patients, it is im-
perative that we accurately assess the contiguous areas of the body, such as the thoracic
spine and scapular complex, to identify postural alignment, mobility, and stability dys-
functions so as to incorporate appropriate treatment and exercise-based interventions
for these areas as well. It is still important to remember to progress patients in a stepwise
manner through the rehabilitation program: first working on pain control, followed by
working on range of motion (ROM), building strength and proprioception, then work-
ing on activity-related or sport-specific exercises. However, as many of us spend much
of our day promoting poor posture, it is imperative that this be addressed at the initia-
tion of the rehabilitation program.
DIRECTIONAL PREFERENCE
Directional preference is an extremely important consideration in the design of any re-
habilitation program involving the spine, particularly when considering the cervical
spine’s vast degree of mobility in all cardinal planes. Simply stated, directional prefer-
ence refers to the performance of exercises in a specific direction that reduces neck pain
in this case, and if present, “centralizes” peripheral radicular symptoms toward the axial
spine. Most clinicians treating mechanical pain are quite familiar with the McKenzie
Classification method, which basically categorizes symptoms as derangement, dysfunc-
tion, or postural in nature (2). The McKenzie Diagnosis and Therapy (MDT) method
is considered by many in the rehabilitation field to be the standard in diagnosing and
treating patients who present with radicular symptoms, and focuses on doing exercises
in the preferred direction.

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

Foundational
• Restoration of proper posture
• Determination of directional bias if applicable
• Restoration of cervical ROM and mobility
Intermediate
• Restoration of cervical and thoracic muscular strength, including stabilizing
musculature
Advanced
• Improvement of proprioception and coordinated movements
CERVICAL FACET ARTHROPATHY

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

Foundational
ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retractions
(chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator scapula
stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, thoracic rota-
tion mobility (thread the needle)
Intermediate
STRENGTHENING: Cervical isometrics: Retraction/lateral flexion/flexion, deep cervical
PROPRIOCEPTION/FUNCTIONAL: Prone scapular retraction
Advanced
PROPRIOCEPTION/FUNCTIONAL: Wall stick-ups, Prone “T,” “Y,” “I,” “W”
CERVICAL DISC PATHOLOGY

Estimates suggest that 20% of chronic neck pain may be due to cervical disc
disruption (6). The cervical disc is comprised of a fibrous outer annulus and an
inner, central jelly-like nucleus pulposus. A healthy, centrated nucleus pulposus
allows for optimal discal shock attenuation with axial loads, while also offer-
ing generous ROM between the adjacent vertebral bodies. The posterolateral
aspect of the annulus fibrosis of the disc is richly supplied with mechanore-
ceptors, as well as pain receptors that can allow for the perception of local
neck pain and radiation of pain away from the axial spine toward the occiput,
shoulder complex and/or upper extremity. Sustained computer and desk work,
extended commute times in the car, even improper sleep postures can easily
account for more than 75% of our day, and cause improper neck postures
that result in prolonged static or repetitive microtraumas. This introduces stress
to the disc and surrounding osseous, muscular, and ligamentous structures.
Additionally, if the cervical spine is forcefully or traumatically moved in any
direction, particularly flexion, cervical disc injury can ensue. Keeping the anat-
omy as well as the underlying cause(s) of the cervical disc pathology in mind
is essential in prescribing exercises for a patient presenting with this condition.
Exercises can be prescribed in a directional preference, or more commonly a
neutral or isometric program is prescribed so as to not exacerbate symptoms.
HOME EXERCISE PROGRAMS FOR CERVICAL SPINE INJURIES 145

Foundational
ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retrac-
tions (chin glides), cervical ROMs (flexion/extension, rotation, lateral flexion), levator
scapula stretch, upper trapezius stretch, middle scalene stretch, pectoral stretch, tho-
racic rotation mobility (thread the needle)
Intermediate
Advanced
CERVICAL RADICULOPATHY
Dysfunction or pathology of the nerve roots of the cervical spine is referred
to as cervical radiculopathy. The prevalence of cervical radiculopathy is less
frequent than lumbosacral radiculopathy, but estimated to still be as high as
85 per 100,000 (7). The most commonly affected roots are the C7 level, at 60%
and C6, at approximately 25% (8). Managing pain is the first step in treatment,
where activity modification is discussed with the patient. Anti-inflammatories
and analgesic medications are often prescribed to assist the patient in initiat-
ing early mobility exercises, which studies demonstrate are often more effective
in reducing pain and disability than the use of soft collars and recommenda-
tions for bedrest (9). Passive modalities such as heat, cold, ultrasound, and
transcutaneous electrical nerve stimulation (TENS), once all contraindications
are considered relative to each patient, can also have a positive effect in pain
management in allowing initiation of early mobility and muscle lengthening.
Other forms of treatment to assist in pain reduction and allow for earlier mobil-
ity activities to restore function are acupuncture, dry needling technique, and
various forms of kinesiotaping. The MDT method, as discussed earlier, is based
on the concept of centralization, where spinally produced peripheral, radic-
ular symptoms are caused to move “centrally” toward the spine with perfor-
mance of specific, examination-based repeated movements or by assuming a
specific, sustained posture (10). The patient is also educated to avoid specific
postures or repeated movements that are also identified on mechanical ex-
amination to be provocative of peripheral symptoms. Postural education and
retraining is of the utmost importance in treating all spine-related disorders,
particularly cervical radiculopathy.

Oftentimes, a patient presenting with radicular symptoms may possess
radiologic and/or advanced imaging evidence of both stenosis (central or
lateral recess) from arthritic changes or cervical disc involvement. This demon-
strates the significance for a thorough clinical examination that again incorpo-
rates the use of repeated movements to determine the directional preference
for treatment (i.e., flexion vs. extension; contralateral lateral flexion vs. ipsilateral
lateral flexion in reference to the side of radicular symptoms). This directional
bias should be utilized in the consideration of all ROM, stretching, and strength-
ening exercises as well.
Foundational
ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retractions
Intermediate
Advanced
UPPER CROSSED POSTURE

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

resulting in the ability to maintain proper muscle tone and coordinated move-
ments. Finally, he believed that the endurance component needs to be ad-
dressed in repetitive, coordinated movement patterns.
Weak: Tight:
Cervical Suboccipitals
flexors Upper trapezius/
levator
Weak:
Rhomboid
Tight:
Lower trapezius
Pectoralis
Foundational
ROM/FLEXIBILITY/MOBILITY: Seated postural correction (Bruegger’s), cervical retraction
(chin glide), suboccipital stretch, levator scapula stretch, upper trapezius stretch, pecto-
ral stretch, suboccipital release, prone pectoral release, levator scapula release
Intermediate
Advanced

HANDOUTS
ROM/Flexibility/Mobility
Seated Posture Correction

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

REPS: Repeat three to five times.
SETS: One
FREQUENCY: Every hour during sustained sitting
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR CERVICAL SPINE INJURIES 149

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

SETS: Two to three
150 HOME EXERCISE PROGRAMS FOR CERVICAL SPINE INJURIES Copyright Springer Publishing Company

Cervical Flexion/Extension
POSITION: Seated in a supportive chair (Face a mirror for visual feedback.)
STEP 1: Lift through the chest and perform a chin glide straight backward.
STEP 2: Slowly and progressively, first draw the head downward toward the chest, followed by bringing the head
backward as if nodding in a “YES” manner.
STEP 3: Maintain chin glide throughout the motion.

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

Cervical Lateral Flexion
STEP 2: Maintaining the chin glide and with the nose pointed forward, gently and progressively tilt the ear toward
the shoulder in each direction. (Avoid turning the head.)
REPS: Repeat 15 times (5 reps at 50%, 5 reps at 75%, and 5 reps at 100% pain-free ROM).

Cervical Rotation
STEP 2: Maintaining the chin glide throughout, gently and progressively turn the head toward each side as if simulat-
ing a “NO” gesture.
REPS: Repeat 15 times (5 reps at 50%, 5 reps at 75% and 5 reps at 100% pain-free ROM).

Suboccipital Stretch
POSITION: Seated
STEP 1: Perform a chin glide to place the ear vertically in line with the shoulder.
STEP 2: Place both hands over the top of the head as shown and gently bring the chin to the chest; hold for 30 to 60
seconds.
STEP 3: Keeping the chin to the chest, turn the head slightly to the right and again draw the chin toward the chest.
STEP 4: Hold for 30 to 60 seconds and repeat to the left.
SETS: One to three

Level 2
Levator Scapula Stretch

POSITION: Seated in a supportive chair, with a tall chest and chin glide to align ears over the shoulders
STEP 1: To stretch the RIGHT side, anchor your right hand to the chair seat or sit on hand.
STEP 2: Tilt your left ear to the shoulder, turn the head to the left, and look downward.
STEP 3: Once the tension from step 2 diminishes, place your left hand on the top of the head and guide the chin
further downward toward the left hip.
STEP 4: Hold for 30 seconds to 2 minutes (or until a release in tension is perceived) and repeat on the opposite side.
SETS: One to three
LEVEL 2: Take the RIGHT anchored hand and reach to touch the right shoulder as pictured.

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

hand to the chair seat or sit on hand.
STEP 2: Tilt the left ear toward the left shoulder until
stretch is perceived, then increase the tension by slowly
turning the head to the right.
STEP 3: Place the left hand on top of the head, and gently
guide the left ear down and forward toward the left hip.
STEP 4: Hold for 30 seconds to 2 minutes, or until a

release in tension is perceived, and repeat on the opposite
side.
SETS: One to three

NOTE: If neck pain or peripheral symptoms are produced,
discontinue and contact your clinician.
Middle Scalene Stretch

POSITION: Seated in a supportive chair, with a tall chest and chin glide
to align ears over the shoulders
STEP 1: To stretch the RIGHT side, anchor your right hand to the chair
seat.
STEP 2: Slowly tilt the left ear to the left shoulder, keeping the nose
pointed forward.
STEP 3: Place the left hand on top of the head and further assist the
left ear to the shoulder until a comfortable stretch is perceived.
STEP 4: Hold for 30 seconds to 2 minutes or until a release in tension is

perceived, and repeat on the opposite side.
SETS: One to three

NOTE: If neck pain or peripheral symptoms are produced, discontinue
and contact your clinician.

Alternatively
Single Arm Pectoral Stretch

POSITION: Standing slightly in front of the doorway, with one forearm/hand supported with elbow above
shoulder level
STEP 1: Draw in the abdominals to prevent the low back from arching and perform a chin glide to align the ears over
the shoulders.
STEP 2: Slowly turn the torso away from the support arm until a tolerable stretch is perceived.
STEP 3: Hold for 30 seconds to 2 minutes or until a release in tension is perceived, and repeat on opposite side.
ALTERNATIVELY: Standing in doorway or corner of a room as earlier described, stretch both arms at once without turn-
ing torso; instead, lean forward slightly until stretch is perceived.
SETS: One to three

NOTE: Do NOT lean forward excessively, especially with a history of an unstable shoulder.

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

Suboccipital Release
POSITION: Supine (on back) with pillow under the knees
STEP 1: Place tennis balls in the toe end of a sock and use a rubber band to keep them in place (or tape the balls
together in the shape of a peanut).
STEP 2: Place the balls under the base of the skull and perform a chin glide.
STEP 3: Hold for 15 to 30 seconds, then release the chin glide.
(REMEMBER TO UTILIZE DIAPHRAGMATIC BELLY BREATHS DURING THE RELEASE.)
SETS: one

Prone Pectoral Release
POSITION: Prone (on belly) with the arm out to the side and head turned away and supported as shown.
STEP 1: Place a tennis ball under the chest seeking to locate tender points along the length of the pectoral muscle
extending from the sternum to the front of the shoulder.
STEP 2: Hold each tender point for 30 to 90 seconds, and then move the arm slightly to continue to release the
muscle from a different angle.
STEP 3: Move the ball to locate a new tender point.

(REMEMBER TO UTILIZE PROPER DIAPHRAGMATIC BELLY BREATHS DURING THIS RELEASE.)

Strengthening
Cervical Isometrics—Cervical Retraction

POSITION: Standing
STEP 1: Put hands behind head.
STEP 2: Perform chin glide by retracting chin backward and resisting with hands.
STEP 3: Hold for a count of 3 and release.
SETS: Two

Cervical Isometrics—Lateral Side Bending
POSITION: Standing
STEP 1: Place right hand against right side of head.
STEP 2: Push against right hand with head while resisting with right hand.
STEP 4: Switch to left side when finished with repetitions.
REPS: Repeat 10 to 15 times to each side.
SETS: Two
Cervical Isometrics—Cervical
Flexion
POSITION: Standing
STEP 1: Place hands on forehead.
STEP 2: Gently press the forehead into hands and resist
with hands.

SETS: Two

Deep Cervical Flexor Strengthening
POSITION: Supine on the floor
STEP 1: Perform a chin glide to align the ears with the shoulders, while maintaining a tall chest and engaging abdom-
inal muscles.
STEP 2: Maintain the chin glide and segmentally lift the top of the head, drawing the chin toward the sternum while
keeping the shoulder blades on the floor.
STEP 3: Pause at the top for a count of 2 and slowly lower from the bottom of the neck segmentally to the top of the
head, again maintaining the chin tuck throughout the descent.

SETS: Two
NOTE: Discontinue and consult your clinician if pain or upper extremity symptoms are perceived.

Prone Scapular Retractions

POSITION: Lying on stomach with arms out to side and bent to 90°.
STEP 1: Squeeze your shoulder blades together by raising your arms and elbows toward the ceiling, and keep your
chest and forehead touching the floor or table at all times.
STEP 2: Hold at top for 2 seconds and then slowly lower to starting position.

Modification 1 Modification 2
Wall Stick-ups
POSITION: Stand with back and neck against the wall, with the elbows flexed 90° to shoulder height and back of the
hands touching the wall.
STEP 1: Perform a chin glide to align the ears with the shoulders, lift the chest, and stiffen the abdominals to bring the
small of the back into the wall.
MODIFICATION 1: If this position is initially too difficult, bring the heels away from the wall and flex the knees and
hips until the head and low back make contact with the wall.
MODIFICATION 2: If shoulder mobility is limited, the elbows can be straightened and the arms started in a lower posi-
tion on the wall, again with the palms facing forward.
STEP 2: Keeping your low back, forearms, and the back of the hand in contact with the wall, slowly slide the arms
upward toward the ceiling as high as possible without losing contact with the wall.
STEP 3: Pause at the top and reset the muscles in Step 1 before slowly lowering the arms back down to the start
position.
STEP 4: Remember to maintain good belly breathing throughout this exercise.

SETS: Two to three

Prone “T,” “Y,” ”I,” “W”
POSITION: Face down on the floor with a towel under the forehead
STEP 1: Engage the gluteals and abdominal muscles by drawing the belly button toward the spine.
STEP 2: Place the arms straight out to the side at a 90° angle with the body and with thumbs up toward the ceiling.
STEP 3: Draw the shoulder blades down and back and elevate the arms off the floor, and hold for a count of 3.
STEP 4: Proceed to elevate the arms at progressive levels to resemble the letters “Y” and “I,” before bending the
elbows and bringing the arms to the side to make a “W”.
STEP 5: Hold all four positions for a count of 3, with the thumbs pointed up toward the ceiling.
STEP 6: Reset the gluteals, abdominals, and shoulder blades and repeat.
SETS: Two to three
NOTE: T and Y are likely of most value and should be concentrated on.

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

CHAPTER 8

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

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

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

Foundational
• Restoration of proper posture
• Restoration of thoracic range of motion and mobility
Intermediate
• Restoration of cervical and thoracic muscular strength, including stabilizing
musculature
Advanced
• Improvement of proprioception and coordinated movements
THORACIC SPINE
Foundational
ROM/FLEXIBILITY/MOBILITY: Supine diaphragmatic breath (belly breath), seated postural
correction (Bruegger’s), lacrosse ball massage, prayer stretch, cat camel stretch, open
book, trunk rotations, seated thoracic rotation
Intermediate
ROM/FLEXIBILITY/MOBILITY: Thoracic rotation mobility (thread the needle)
STRENGTHENING: Kneeling thoracic rotation
Advanced
PROPRIOCEPTION/FUNCTIONAL: Thoracic rotation with core stabilization, inchworm
HOME EXERCISE PROGRAMS FOR THORACIC SPINE INJURIES 171

HANDOUTS
ROM/Flexibility/Mobility
Supine Diaphragmatic Breath

(Belly Breath)
POSITION: Supine with pillows under the knees
STEP 1: After performing a chin glide, place one hand on
the chest and the other on your stomach, as shown.
STEP 2: Breathe in slowly through your nose for a 2 to

3–second count, feeling the stomach rise into the hand on
the abdomen while the hand on the chest remains as still
as possible.
STEP 3: Gently tighten the stomach muscles, feeling them

draw slightly inward as you exhale for a 4 to 6–second
count through pursed lips, while the hand on the chest
remains as still as possible.
REPS: Perform for 3 to 5 minutes initially, progressing to

10 to 15 minutes.
Seated Posture Correction

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

REPS: Perform 3 to 5 times.
SETS: One
FREQUENCY: Every hour during sustained sitting
172 HOME EXERCISE PROGRAMS FOR THORACIC SPINE INJURIES Copyright Springer Publishing Company

Lacrosse Ball Massage
POSITION: Standing next to a wall or lying supine on your back
STEP 1: Put a lacrosse or tennis ball between you and the wall or floor.
STEP 2: Position the ball such that it is over the tender muscles of back
and neck.
STEP 3: Lean against the ball and move body up and down to help relax
muscles; massage each muscle for 30 to 90 seconds.
SETS: One
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR THORACIC SPINE INJURIES 173

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

Cat Camel Stretch
STEP 1: Round back up and bring it toward the ceiling while flexing the neck.
STEP 2: Hold for a count of 3.
STEP 3: Push belly toward the floor while extending the neck.
STEP 6: Return to Step 1.
SETS: One

Open Book
POSITION: Lie on your right side with your arms extended forward, palms together, and hips and knees bent at 90°
with a ball between the knees.
STEP 1: While pressing the knees into the ball, lift the top left arm up toward the ceiling, continuing behind the body
at shoulder level, attempting to reach the floor with the back of the left hand.
STEP 2: Press the arm and hand into the floor and hold for 3 breath cycles, and then return to start position.
STEP 3: When finished with repetitions on this side, switch sides.
SETS: One
FREQUENCY: Daily

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

Seated Thoracic Rotation
POSITION: Seated on a stool/ottoman or facing the back of the chair, with a ball between the knees and arms across
the chest
STEP 1: Squeeze the ball between the knees and rotate the upper torso to the left until a comfortable tension is
perceived.
STEP 2: Maintaining the rotation tension, tilt the upper torso to the left as shown.
STEP 3: Hold for a count of 2, then repeat on the other side.
SETS: Two
FREQUENCY: Daily

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

Strengthening
Kneeling Thoracic Rotation

POSITION: On hands and knees, with chin glide and
abdominal contraction to maintain a neutral spine
STEP 1: Maintain a flat back as you sit back over the heels
while preventing the back from rounding.
STEP 2: Place your left hand on the left side of your head
and rotate the elbow toward the ceiling, while maintain-
ing contraction of abdominals limiting the low back from
rotating with the mid back.
STEP 3: Hold for a count of 2 and repeat.

STEP 4: Perform to right side as above.
SETS: Two
FREQUENCY: Daily

Thoracic Rotation with Core Stabilization

POSITION: Lie face up with the upper torso on the exercise ball in a bridge position, while both arms are extended for-
ward and squeezing a ball.
STEP 1: Maintaining a chin glide, engage abdominal muscles with belly button drawn into the spine and buttocks
muscles contracted to keep the hips in a tall bridge while squeezing a ball between knees.
STEP 2: Rotate the extended arms to one side while stabilizing the lower torso and pelvis and keeping it in place
(neutral).
STEP 3: Return to start position and reset as per Step 1, and then rotate to the opposite side.
SETS: Two to three
FREQUENCY: Daily

Modified Modified
Inchworm
POSITION: Start in a push-up position on the floor, or modified by putting the hands statically on a chair or bench.
STEP 1: Perform a chin glide, engage the lower abdominal muscles to prevent the back from arching, and firm the
thighs to keep the knees straight.
STEP 2: Lift and slide one foot forward a few inches while keeping the knees straight, press the heel into the floor, and
pause for a count of 3.
STEP 3: Lift the opposite leg and bring the foot in line with the previous foot in Step 2, pressing the level heels on both
sides into the floor while keeping the chin tucked, chest tall, back flat, and knees straight. (Pressing the hips up and
back in this position helps to keep the heels down to maximize the benefit of the exercise.)
STEP 4: Continue to alternate legs until the feet level off and a moderate stretch is perceived. (Remember to keep the
chest tall and shoulder blades down and backward.)
STEP 5: If performing on the floor, advance the hands alternately forward until you are in the starting push-up posi-
tion again and repeat. (If hands are on a bench in a modified position, simply return the feet to the starting position
and repeat.)
REPS: Perform twice.

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

REFERENCES
1. Wyss JF, Patel AD. Therapeutic Programs for Musculoskeletal Disorders. New York, NY: Demos
Medical Publishing; 2013.
2. Gray G. Functional Manual Reaction (FMR), Thoracic Spine. v3.10. Adrian, MI: Functional
Design Systems; 2005.
HOME EXERCISE PROGRAMS FOR THORACIC SPINE INJURIES 183

CHAPTER 9

Lumbar Spine Injuries
Amrish D. Patel
INTRODUCTION
Low back pain is one of the most common reasons for a person to seek medical care.
There are estimates that up to 85% to 90% of people will have an episode of back pain
in his or her lifetime (1). There are many possible sources of low back pain, from the
soft tissues down to the bones in the spine. In most cases, an episode of back pain will
typically improve on its own over 6 to 8 weeks even if no intervention is applied. Often,
back pain is initially treated with medications and stretches. However, an accurate di-
agnosis and the proper exercises based on that diagnosis are prudent to treatment and
long-term management. This treatment can be often guided by a physical/occupational
therapist or a physician with the capacity to make an accurate mechanical diagnosis.
In a stepwise approach, the treatment program consists of decreasing pain and
swelling, returning normal pain-free range of motion (ROM) and biomechanics, core
strengthening, improving neuromuscular control and proprioception, and then a
sports-specific program or program to help with performing activities of daily living (2).
DIRECTIONAL PREFERENCE
Directional preference plays a key role in guiding any rehabilitation program of the
spine and is often implemented by the patient instinctively. An example is when a pa-
tient notes radicular pain and finds that standing decreases symptoms and does this
as much as possible, and in turn initiates an extension-biased spine program. Another
example is patients with spinal stenosis and neurogenic claudication who walk in a
grocery store and use a cart to lean on so that they can walk further to reduce their
symptoms and initiate a flexion-biased spine program.
Directional preference refers to performing exercises in the direction that either re-
duces back or leg pain and helps the pain “centralize” to the axial spine. Exercise proto-
cols have been created that follow those specific treatment options for patients. Williams
flexion exercises were created on the premise that a majority of issues occur at L5/S1
level and if the lumbar lordosis is reduced, this, in turn, should increase the central and
neuroforaminal space to take pressure off the structures that could be pain generators
(3). Its clinical applications have been applied to any program where flexing the spine
improves symptoms.

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

Foundational
• Improvement of pain
• Restoration of ROM and flexibility
• Initiation of strengthening of core and pelvic girdle
Intermediate
• Progression of strengthening of core and pelvic girdle
Advanced
• Restoration of strengthening of pelvic girdle
• Restoration of proprioception and neuromuscular control
• Progression to functional activities and return to sport
LUMBAR FACET ARTHROSIS

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

Foundational
ROM/STRETCHING/MOBILITY: Prone quadriceps stretch, hip flexor stretch (either one),
hamstring stretch (either one), piriformis stretch, single (double) knee(s) to chest, child’s
pose, seated flexion, cat camel stretch, trunk rotations
STRENGTHENING: Abdominal bracing (or pelvic tilt or abdominal hollowing), marching
exercise
Intermediate
STRENGTHENING: Curl up, bridge, clam shells, Swiss ball marching, opposite arm/oppo-
site leg (bird dog)
Advanced
STRENGTHENING: Hip abductor wall squat, hip adductor wall squat, plank, side plank
PROPRIOCEPTION/FUNCTIONAL: Warrior one pose, warrior two pose
LUMBAR DISC PATHOLOGY

Lumbar disc–mediated pain presents as axial back pain and is thought to
stem from irritation to the nerve receptors that innervate the outer fibers of the
annulus fibrosus, the cartilaginous end plates, and periosteum of the bone (8).
Typically, disc-mediated pain comes from some degeneration or disruption
of the disc without nerve root irritation. Typically, symptoms are axial in nature
without radiation and worse with Valsalva, prolonged sitting, forward lumbar
flexion, and could be worse with extension or side bending depending on
where the disc pathology is located.
Foundational
hamstring stretch, (either one), piriformis stretch, prone extensions (as long as makes
pain less)
STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing)
Intermediate
STRENGTHENING: Curl up, bridge, clam shells, opposite arm/opposite leg (bird dog),
monster walk
HOME EXERCISE PROGRAMS FOR LUMBAR SPINE INJURIES 187

Advanced
STRENGTHENING: Plank, side plank
LUMBAR RADICULOPATHY
Lumbar radiculopathy presents with low back pain from a disc bulge or herni-
ation and leads to nerve root irritation that will cause pain that typically travels
down the leg in a dermatomal pattern (4). Depending on the type of herni-
ation and location of disc material, pain can be worse with bending, sitting,
standing, or lying down. The treatment should be based on directional prefer-
ence to centralize symptoms and then progress to a strengthening program.
Recommended Exercises for Extension-Biased Program

Foundational
ROM/STRETCHING/MOBILITY: Hamstring stretch (either one), hip flexor stretch (either
one), prone extensions, standing extensions, side glides or alternative side glides if
patient has a lateral shift (leaning over to one side due to pain)
STRENGTHENING: Abdominal bracing (or pelvic tilt or abdominal hollowing)
Intermediate
STRENGTHENING: Bridge, clam shells, opposite arm/opposite leg (bird dog)
Advanced
Recommended Exercises for Flexion-Biased Program

Foundational
one), piriformis stretch, single (double) knee(s) to chest, child’s pose, seated flexion,
side glides or alternative side glides if patient has a lateral shift (leaning over to one side
due to pain)
STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing), marching
exercises

Intermediate
site leg (bird dog)
Advanced
Recommended Exercises for a Neutral Spine Program

Foundational
hamstring stretch (either one), piriformis stretch
STRENGTHENING: Abdominal bracing (pelvic tilt or abdominal hollowing)
Intermediate
STRENGTHENING: Curl up, bridge, clam shells, opposite arm/opposite leg (bird dog),
monster walk
Advanced
STRENGTHENING: Plank, side plank
LUMBAR SPONDYLOLYSIS/SPONDYLOLISTHESIS
Lumbar spondylolysis is a common source of low back pain in those with im-
mature spines. This typically occurs from repetitive extension-based stressors
leading to a pars interarticularis fracture (9,10). Lumbar spondylolisthesis is an
anterior or posterior migration of the superior vertebral body in relation to the
inferior vertebral body. This can occur for many reasons, and a spondylolisthe-
sis will typically lead to back pain and occasionally leg pain exacerbated with
transitional movements, standing, extension, and prone lying and is relieved
with sitting or flexing forward.

Recommended Exercises for Spondylolysis
Foundational
one), prone quad stretch, piriformis stretch
exercise
Intermediate
STRENGTHENING: Curl up, bridge, Swiss ball marching, opposite arm/opposite leg
(bird dog)
Advanced
PROPRIOCEPTION/FUNCTIONAL: Single-leg deadlift, warrior one pose, warrior two pose
Recommended Exercises for Spondylolisthesis

Foundational
exercise
Intermediate
site leg (bird dog)
Advanced
LUMBAR SPINAL STENOSIS

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

a disc herniation that leads to lumbar radiculopathy. Symptoms can present
with low back and typically leg pain or neurogenic claudication with leg fa-
tigue from standing and walking, improved with sitting or forward flexion (11).
Foundational
exercise
Intermediate
site leg (bird dog)
Advanced
LOWER CROSSED SYNDROME

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

Weak: Tight:
Abdominals Thoracolumbar
extensors
Weak:
Tight:
Gluteus maximus
Hip flexors
Foundational
ROM/STRETCHING/MOBILITY: Good morning stretch, prone quadriceps stretch, hamstring
stretch (both), hip flexor stretch (both), piriformis stretch, single (double) knee(s) to
chest, child’s pose, cat camel stretch, trunk rotations
exercise
Intermediate
STRENGTHENING: Curl up, bridge, opposite arm/opposite leg (bird dog), Swiss ball
marching
Advanced

HANDOUTS
ROM/Stretching/Postural Correction
Good Morning Stretch

POSITION: Standing with hands clasped with fingers interlocked
STEP 1: Slowly bring your hands over your head to stretch out your arms fully.
STEP 2: Look up toward your hands.
STEP 3: While holding that position, try to walk several steps.
STEP 4: If unable to walk, hold position for 30 seconds.
SETS: Two to three sets
Copyright Springer Publishing Company HOME EXERCISE PROGRAMS FOR LUMBAR SPINE INJURIES 193

Hamstring Wall Stretch
POSITION: Lie on the ground with one leg against a doorframe with the other
leg through the doorway.
STEP 1: Place heel on the doorframe until you feel a gentle stretch in the
hamstring. (You can move closer or further away from the wall to increase or
decrease stretch, respectively.)
REPS: Hold that position for 30 seconds, then switch legs.

SETS: Two to three per leg
Hamstring Stretch, Long Sitting

Position
POSITION: Sitting
STEP 1: Sit up tall with back straight, one leg stretched
out on the bed or table, and the other leg with your foot
firmly planted on the ground.
STEP 2: Keeping your spine erect, lean forward as if you

are trying to touch your belly button to your thigh until
you feel a stretch in your leg.

194 HOME EXERCISE PROGRAMS FOR LUMBAR SPINE INJURIES Copyright Springer Publishing Company

POSITION: Kneeling
STEP 1: Kneel on the ground and put one foot forward in a lunge
position.
STEP 2: While keeping your back straight, gently lean forward until you
feel a stretch in the front of the hip of the back leg.


POSITION: Lying on your back on a bed (or table), bend
your knees, drop one leg over the side of the bed, and
place a strap around your ankle.

on the table.

REPS: Hold for 30 seconds at end range; then slowly

release stretch.


Single (Double) Knee(s) to Chest
POSITION: Lie on your back on a bed or on the ground.
STEP 1: Slowly bring one knee (or both knees) toward your chest and use your hands to pull your knee(s) further
toward your chest until you feel a gentle stretch in your gluteals.
REPS: Hold that position for 5 to 10 seconds, then switch legs.

SETS: 5 to 10 per leg (or both legs)
ALTERNATIVE: Hold position of stretch for 30 seconds and perform only two to three repetitions.
FREQUENCY: Daily, can be repeated 2 to 3 times per day
Piriformis Stretch
POSITION: Lie on your back on a bed or on the ground.
STEP 1: Bring one knee up toward your chest.
STEP 2: Use your hand to bring your knee toward your opposite shoulder until you feel a gentle stretch in the
buttocks.



STEP 2: Hold the strap with your hand (same side), and
gently pull your ankle toward your buttocks to bend
your knee until a gentle stretch is felt in your thigh mus-
cles, closer to your knee.
REPS: Hold for 30 seconds at end range; then slowly re-

lease stretch.

Child’s Pose
POSITION: On your hands and knees
STEP 1: Starting on your hands and knees, lower your
buttocks until they touch your heels.
STEP 2: Keeping your heels on your buttocks, stretch

your arms as far forward on the ground as you can while
keeping your buttocks on your heels.
STEP 3: Lower your head to be parallel to your arms.

REPS: Hold that position for 30 seconds, then return to
your starting position.


Seated Flexion
POSITION: Sitting upright in a chair
STEP 1: Slowly bend forward and try to touch your toes.
FREQUENCY: Daily
Cat Camel Stretch

STEP 1: Round back up and bring it toward the ceiling while flexing the neck.
STEP 3: Push belly toward the floor while extending the neck.
STEP 6: Return to Step 1.
SETS: One

Alternatively
Prone Extensions (AKA prone press-up)

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

Standing Extensions
POSITION: Standing
STEP 1: You can either put your hands on the small of your back or lean your
back against a countertop.
STEP 2: Slowly lean backward to a point of comfort and hold for 2 to 3

seconds.
STEP 3: Return to an upright position.

NOTE: If you have radicular leg pain, then as you do the exercise you should
feel less pain in the leg and the pain should “centralize” toward the back,
which can cause your back pain to become more intense. If the leg pain be-
comes more intense, contact your health professional.

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

Alternative Side Glides
POSITION: Standing with one shoulder against a wall or doorframe (usually the shoulder of the side you do
not have pain)
STEP 1: Slowly move your hip to touch the wall.

STEP 2: Hold for 3 seconds, then go back to starting position.
NOTE: If you feel more discomfort in your back and less in your leg, that is okay. If the pain increases in your leg,
do not slide too far, or try going in the opposite direction.

Trunk Rotations
POSITION: Lying on back with knees bent and heels on the floor or bed
STEP 1: Slowly rotate knees to one side while keeping shoulders flat against surface.
STEP 3: Slowly rotate knees to other side as in Step 1.
STEP 5: Repeat Step 1.
SETS: Two to three

Strengthening
Abdominal Bracing
POSITION: Lie on your back with your knees bent and feet flat on the floor.
STEP 1: Place hands around your waist.
STEP 2: Tense abdominal muscles, like you are bracing to be hit in the stomach.

Pelvic Tilts
POSITION: Lie on your back with knees bent, or with legs straight out if you are looking for more of a challenge.
STEP 1: Roll your hips/pelvis back such that you flatten your back against the ground by tightening your abdominal
muscles, and then tighten your back and gluteal muscles.
STEP 2: Hold for 5 seconds and then relax.

NOTE: If you are doing this with legs straight out, do not push with your legs to flatten your back as you will not be
strengthening your core muscles.
Also, if doing this exercise makes your back pain worse, then try lying on your back and then slowly tightening your
stomach, back, and gluteal muscles while slowly arching your back to lift it off the floor without lifting your hips off
the floor.

Abdominal Hollowing
POSITION: Lie on your back with your knees bent and feet flat on the floor.
STEP 1: Place hands on your lower abdomen.
STEP 2: Take a deep slow breath in.
STEP 3: Slowly exhale, pulling your lower abdominals inward and upward toward your spine.
Curl Up
POSITION: Lie on your back with knees bent and slide hands under your back to support your spine.
STEP 1: Straighten out one leg while keeping your back flat on the floor.
STEP 2: Without bending your neck or spine, lift your head and shoulders off the floor an inch or two.
STEP 3: Hold the position for 8 seconds, then relax.
REPS: Perform 10 times, then change legs and repeat.
SETS: Two to three sets with each leg straightened

Level 2 Level 2
Level 3
Bridge
POSITION: Lie on your back with both your knees bent, your feet hip-distance apart, and arms relaxed by your side.
LEVEL 2: Perform bridge as earlier; then slowly march in place by lifting each foot off the mat in alternating fashion;
focus on engaging the buttock of the leg that is down.
LEVEL 3: Perform a single-leg bridge with the nonworking leg pointed straight out and alternate legs after 10
repetitions.

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

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

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

Hip Abductor Wall Squat
POSITION: Stand with back against a smooth surface or a physioball with legs shoulder-width apart and place a belt
around your legs (preferably something like a braided belt you can buy at any clothing store).
STEP 1: Push your legs outward against the belt and maintain that pressure throughout the squat.
STEP 2: Slide down the wall until your hips and knees get to a 90° angle, or, if you cannot go this low, as low as you
can go until you are unable to maintain the force against the belt with your legs. (Make sure that your knees do not go
past your toes and that your knees track over your second and third toes.)
STEP 3: Hold the position for 3 to 5 seconds, then return to the start position while maintaining the force against the
belt.


Hip Adductor Wall Squat
POSITION: Stand with back against a smooth surface or a physioball with legs shoulder-width apart and place a bas-
ketball, yoga block, or soccer ball between your knees.
STEP 1: Push your legs inward against the ball or yoga block and maintain that pressure throughout the squat.
STEP 2: Slide down the wall until your hips and knees get to a 90° angle, or, if you cannot go this low, as low as you
can go until you are unable to maintain the force against the ball or yoga block with your legs. (Make sure that your
knees do not go past your toes and that your knees track over your second and third toes.)
STEP 3: Hold the position for 3 to 5 seconds, then return to the start position while maintaining the force against the
ball or yoga block.


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

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

Level 2
Level 3
Plank
POSITION: Start on your elbows and knees.
STEP 1: Slowly walk forward on your elbows, while keeping your knees planted, straightening out your body.
STEP 2: Tighten your abdominal muscles, low back muscles, and gluteals to hold your body straight.
STEP 3: Hold for 30 seconds or as long as you can.
NOTE: While doing this exercise, you should feel the muscles of your abdomen, low back, and pelvis contracting at
the same time. The goal is to work your way to holding the position for 30 to 60 seconds at a time.
LEVEL 2: This is similar to the first position except that you should extend your knees and lift your entire body and
knees off the ground such that your elbows and toes are the only contacts with the ground.
LEVEL 3: Start with Level 2; then slowly lift one of your legs backward into the air with a straight knee in line with
your body without allowing your back to arch. Switch legs on the next set.

Level 2
Level 3
Side Plank
POSITION: Lie on your side, bend your knees to 90°, and put your arm with your elbow bent on the ground.
STEP 2: Hold that position for 30 seconds or for as long as you can.
contracting as well as your abdominal muscles. The goal is to work your way to holding the position for 30 to 60 sec-
onds at a time.
LEVEL 2: This is similar to the first position except that you should extend your knees and lift your entire body and
knees off the ground such that one elbow and the outside of your foot is touching the ground.
LEVEL 3: This is similar to Level 2 except that you should lift your top leg and/or arm into the air in an abducted
position (away from the body) with a straight knee or elbow.

Proprioceptive/Functional
Level 2
Level 3
Single-Leg Deadlift
POSITION: Standing
STEP 1: Stand on one leg with your knee slightly bent and tighten the buttock of the standing leg, while keeping your
hips level and not sinking into your hip or leaning to the side.

STEP 4: Extend the opposite leg out behind you as you go down to maintain a straight line with your body (head,
neck, beck, leg), and keep your hips even.
NOTE: Lower only to a depth that allows you to maintain proper form; stop when you feel your back start to round,
LEVEL 3: Hold a weight in the hand opposite to the standing leg. Do NOT let the weight pull your back out of align-

Warrior One Pose
POSITION: Stand as if you just finished a lunge with one leg in front of the
other and the front knee bent.
STEP 1: Press hands firmly together and raise them over your head.
STEP 2: With back foot firmly pressed into the ground, bend the front knee
and hip to 90∘.
STEP 3: Hold position for 10 to 15 seconds.

STEP 4: Straighten front hip and knee to return to starting position.
NOTE: As you develop strength, try to do fewer repetitions but hold the posi-
tion for longer periods of time up to 30 seconds.
Warrior Two Pose

POSITION: Stand in a position as if you just finished a
lunge with one leg in front of the other, the front knee
bent, and turn your back leg 90° such that your back foot
is perpendicular to your front foot.
STEP 1: Bring your arms up perpendicular to your body

with one arm in front and one behind you.
STEP 2: Bend your front hip and knee to 90°, while firmly
pressing your back leg into the ground.
STEP 3: Hold position for 10 to 15 seconds.

STEP 4: Straighten front hip and knee to return to starting
position.

NOTE: As you develop strength, try to do fewer repeti-
tions but hold the position for longer periods of time up
to 30 seconds. Also, as you advance more, you can transi-
tion directly from warrior one pose to warrior two pose.

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INDEX
abductor pollicis longus (APL), 50 carpal tunnel syndrome (CTS), 50

ACL. See anterior cruciate ligament carpometacarpal osteoarthritis (CMC OA), 51
acromioclavicular joint pathology, 3 cervical spine injuries
active range of motion (AROM), 49–51 cervical disc pathology, 145–146
activities of daily living (ADLs), 49, 51 cervical facet arthropathy, 144–145
adhesive capsulitis/frozen shoulder, 4–5 cervical radiculopathy, 146–147
ADLs. See activities of daily living directional preference, 143–144
ankle and foot injuries, 129–141 exercise program, 144
Achilles tendinopathy, 130–131 overview, 143
ankle sprain, 130 proprioception/functional
exercise program, 129–130 prone scapular retractions, 164
overview, 129 prone “T,” “Y,” ”I,” “W,” 166
plantar fasciosis, 132 wall stick-ups, 165
posterior tibial tendinopathy, 131 ROM/flexibility/mobility
proprioception/functional cervical flexion/extension, 151
single leg taps, 140 cervical lateral flexion, 152
single leg tennis ball catch, 140 cervical retraction (chin glide), 150
wobble board, 141 cervical rotation, 153
ROM/stretching/mobility levator scapula stretch, 155
alphabets, 134 middle scalene stretch, 156
calf stretch A and B, 133 prone pectoral release, 160
can roll, 134 seated posture correction
foam roller (lower leg), 135 (Bruegger’s), 149
plantar fascia stretch, 135 single arm pectoral stretch, 157
soleus stretch, 134 suboccipital release, 159
towel stretch, 133 suboccipital stretch, 154
strengthening thoracic rotation mobility (thread the
concentric ankle dorsiflexion, 137 needle), 158
concentric ankle eversion, 137 upper trapezius stretch, 156
concentric ankle inversion, 136 strengthening
eccentric Achilles, 138 cervical isometrics—cervical flexion, 162
eccentric posterior tibial tendon, 139 cervical isometrics—cervical retraction, 161
heel raises, 138 cervical isometrics—lateral side
marble pick-ups, 136 bending, 162
towel scrunches, 136 deep cervical flexor strengthening, 163
anterior cruciate ligament (ACL), 104 upper crossed posture, 147–148
APL. See abductor pollicis longus CMC OA. See carpometacarpal osteoarthritis
AROM. See active range of motion CTS. See carpal tunnel syndrome
biceps
curls, 38 ECRB. See extensor carpi radialis brevis
eccentric, 41 ECRL. See extensor carpi radialis longus
isometric, 36 ECU. See extensor carpi ulnaris
Wendel01201_PTR_INDEX_221-226_09-06-19.indd 221 07-Sep-19 10:40:17 AM

elbow injuries hip injuries
distal bicipital tendinopathy, 28–29 exercise program, 71–72
exercise program, 25–26 femoroacetabular impingement and labral
lateral epicondylosis, 26–27 tears, 75–76
ligament sprains, 27–28 greater trochanteric pain syndrome, 73–74
medial epicondylosis, 27 hamstring strain and tendinopathy, 74–75
overview, 25 iliopsoas tendinopathy/bursitis, 72–73
proprioception/functional osteoarthritis, 72
prone scapular retractions, 46 overview, 71
serratus punch, 46 proprioception/functional
shoulder diagonal pattern A lunge, 97
(D2 flexion), 44 single leg balance, 94
shoulder diagonal pattern B single leg deadlift, 95
(D2 extension), 45 single leg squat, 98
ROM/stretching/mobility, 30 windmill, 96
biceps stretch, 31 ROM/stretching/mobility, 77
forearm pronators stretch, 32 foam roller to hip area, 80
forearm supinators stretch, 32 hamstring stretch with a towel, 77
triceps stretch, 31 hip flexor stretch, kneeling, 78
ulnar nerve glide 1-5, 33–35 hip rotator stretch, 78
wrist extensors and flexors stretch, 30 iliotibial band stretch, 80
strengthening exercises prone quadriceps stretch, 77
biceps quadruped rocking, 79
curls, 38 two-joint hip flexor stretch, 79
eccentric, 41 strengthening
isometric, 36 bridge, 85
forearm pronators and supinators, 43 clam shells, 82
grip, 37 eccentric hamstring throwdowns, 93
radial and ulnar deviation, 40 forward step down, 89
triceps forward step up, 88
extensions, 39 gluteal (buttock) isometrics, 81
isometric, 36 hamstring curl on stability ball, 86
tyler twist, 42 hamstring isometrics, 81
wrist extensors hip clocks, 91
concentric and eccentric, 37–38, hip hikers, 87
40–41 monster walk, 90
ulnar neuropathy, 29 prone hip extension, 82
EPB. See extensor pollicis brevis side-lying hip abduction with towel
extensor carpi ulnaris (ECU), 52, 60–61 against wall, 84
extensor pollicis brevis (EPB), 50 side plank, 92
squat, 83
FAI. See femoroacetabular impingement

FCU. See flexor carpi ulnaris IAP. See inferior articular process
femoroacetabular impingement (FAI), 75 Iliotibial band (ITB), 73–74, 76, 106–107, 110
FHP. See forward head position inferior articular process (IAP), 144
forward head position (FHP), 147 interphalangeal joint (IPJ), 50, 68
IPJ. See interphalangeal joint
ITB. See Iliotibial band
GH-OA. See glenohumeral osteoarthritis
glenohumeral joint instability, 4
glenohumeral osteoarthritis (GH-OA), 3–4 knee injuries
greater trochanteric pain syndrome (GTPS), assisted knee extension and flexion, 110–111
73–74 exercise program, 101–102
GTPS. See greater trochanteric pain syndrome hamstring stretch with a towel, 108
222 INDEX

hip flexor stretch, kneeling, 109 alternative side glides, 202
iliotibial band syndrome, 106–107 cat camel stretch, 198
ITB stretch, 110 child’s pose, 197
knee flexion chair stretch, 111 good morning stretch, 193
ligament sprain, 104–105 hamstring stretch, long sitting
meniscal tear, 105–106 position, 194
osteoarthritis, 102 hamstring wall stretch, 194
overview, 101 hip flexor stretch, kneeling, 195
passive knee extension, 112 piriformis stretch, 196
patellofemoral pain syndrome, 103 prone extensions (AKA prone press-up), 199
prone quadriceps stretch, 108 prone quadriceps stretch, 197
proprioception/functional, 123–126 seated flexion, 198
single leg balance and deadlift, 123–124 side glides, 201
single leg squat, 126 single (double) knee(s) to chest, 196
windmill, 125 standing extensions, 200
quadriceps and patellar tendinopathy, trunk rotations, 203
103–104 two-joint hip flexor stretch, 195
ROM/stretching/mobility, 108 strengthening, 204–216
strengthening, 113–122 abdominal bracing, 204
bridge, 119 abdominal hollowing, 206
forward step down, 121 bridge, 207
forward step up, 120 clam shells, 210
prone hip extension, 115 curl up, 206
quadriceps Set, 113 hip abductor wall squat, 211
side-lying hip abduction with towel hip adductor wall squat, 212
against wall, 118 marching exercise, 208
side plank, 122 monster walk, 213
squat, 116 opposite arm/opposite leg
squat on a wedge, 117 (bird dog), 214
straight leg raise, 113 pelvic tilts, 205
terminal knee extension, 114 plank, 215
two-joint hip flexor stretch, 109 side plank, 216
Swiss ball marching, 209
lateral collateral ligament (LCL), 104

LCL. See lateral collateral ligament McKenzie Diagnosis and Therapy (MDT),
LCS. See lower crossed syndrome 143, 146
lower crossed syndrome (LCS), 191 MCL. See medial collateral ligament
lumbar spine injuries, 185–218 MCPJs. See metacarpophalangeal joints
directional preference, 185–186 MDT. See McKenzie Diagnosis and Therapy
exercise program, 186 medial collateral ligament (MCL), 104
lower crossed syndrome, 191–192 metacarpophalangeal joints (MCPJs), 50
lumbar disc pathology, 187–188 metacarpophalangeal (MP), 50, 57, 59
lumbar facet arthrosis, 186–187 MP. See metacarpophalangeal
lumbar radiculopathy, 188–189
lumbar spinal stenosis, 190–191
lumbar spondylolysis/spondylolisthesis,
189–190 nonsteroidal anti-inflammatory drugs
overview, 185 (NSAIDs), 26
proprioceptive/functional, 217–218 NSAIDs. See nonsteroidal anti-inflammatory
single-leg deadlift, 217 drugs
warrior one pose, 218
warrior two pose, 218
ROM/stretching/postural correction, OA. See osteoarthritis
193–203 osteoarthritis (OA), 101–102
INDEX 223

patellofemoral pain syndrome (PFPS), 101, 103 TENS. See transcutaneous electrical nerve
PCL. See posterior cruciate ligament stimulation
PFPS. See patellofemoral pain syndrome thoracic spine injuries, 169–182
platelet-rich plasma (PRP), 26 exercise program, 171
posterior cruciate ligament (PCL), 104 overview, 169–171
PRP. See platelet-rich plasma proprioception/functional, 181
inchworm, 182
thoracic rotation with core
range of motion (ROM), 25–30, 71–77, 101–108, stabilization, 181
129–133, 185–193. See also specific ROM/flexibility/mobility, 172
entries cat camel stretch, 175
rest, ice, compression, elevation (RICE), 26 lacrosse ball massage, 173
RICE. See rest, ice, compression, elevation open book, 176
ROM. See range of motion prayer stretch, 174
rotator cuff tendinopat, 2 seated posture correction
(Bruegger’s), 172
seated thoracic rotation, 178
SAP. See superior articular process supine diaphragmatic breath (Belly
shoulder injuries, 1–23 Breath), 172
acromioclavicular joint pathology, 2–3 thoracic rotation mobility (Thread the
adhesive capsulitis/frozen shoulder, 4–5 Needle), 179
exercise program, 1 trunk rotations, 177
glenohumeral joint instability and strengthening, 180
osteoarthritis, 3–4 kneeling thoracic rotation, 180
overview, 1 transcutaneous electrical nerve stimulation
proprioception/functional, 20–23 (TENS), 146
prone “T,” “Y,” “I,” “W,” 20
stability ball bird dog, 21
stability ball plank, 23 UCS. See upper crossed syndrome
wall ball push-up, 22 upper crossed syndrome (UCS), 147
wall fall push-up, 23
ROM/stretching/mobility, 6–11
broom pull, 8 wrist and hand injuries, 49–69
corner stretch, 9 carpal tunnel syndrome, 50–51
reverse sleeper stretch, 10 carpometacarpal osteoarthritis, 51–52
scaption, 11 De Quervain’s tenosynovitis, 49–50
sleeper stretch, 10 exercise program, 49
stick overhead shoulder stretch, 6 extensor carpi ulnaris tendinopathy, 52
stick shoulder abduction, 7 overview, 49
stick shoulder extension, 8 patient education/precautions/activity
stick shoulder flexion, 9 modification, 68–69
stick shoulder rotation, 7 carpal tunnel, 68
rotator cuff tendinopathy, 2 carpometacarpal osteoarthritis, 69
strengthening exercises, 12–19 De Quervain’s tenosynovitis, 68
abducted shoulder external rotation, extensor carpi ulnaris tendinopathy, 69
18–19 proprioception/functional exercises, 64–67
isometric, 12–13 elbow extension and flexion with
low row, 15 theraband, 64–65
push-up with a “plus,” 17 external rotation with theraband, 67
scapular retraction, 14 scapular retraction with theraband, 66
straight-arm lateral pull down, 16 shoulder extension with theraband, 66
superior articular process (SAP), 144 ROM/stretching/mobility, 53–58
224 INDEX

“C” exercise, 57 strengthening, 59–63
isolated thumb interphalangeal joint abductor pollicis longus
flexion/extension, 54 isometric, 59
median nerve glides, 56 ECU synergy exercise, 61
tendon gliding, 55 extensor carpi ulnaris isometric, 60
thumb adductor massage, 57 extensor pollicis brevis isometric, 59
thumb opposition, 57 first dorsal interossei, 60
web space stretch, 58 ulnar deviation, 62
wrist extension and flexion active range wrist extensors concentric, 61
of motion, 53 wrist extensors eccentric, 63
INDEX 225

Home Exercise Programs For Musculoskeletal and Sports Injuries

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Home Exercise Programs For Musculoskeletal and Sports Injuries

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An Imprint of Springer Publishing

Ian W. Wendel | James F. Wyss

Wendel01201_PTR_FM_i-xxxviii_09-06-19.indd i 13-Sep-19 4:00:00 PM

Photographs by Richard Bean

An Imprint of Springer Publishing

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Acquisitions Editor: Beth Barry

Copyright © 2020 Springer Publishing Company.

Demos Medical Publishing is an imprint of Springer Publishing Company, LLC.

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Names: Wendel, Ian, editor. | Wyss, James, editor.

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Printed in the United States of America.

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Wendel01201_PTR_FM_i-xxxviii_09-06-19.indd v 13-Sep-19 4:00:01 PM

1. Home Exercise Programs for Shoulder Injuries

2. Home Exercise Programs for Elbow Injuries

4. Home Exercise Programs for Hip Injuries

5. Home Exercise Programs for Knee Injuries

6. Home Exercise Programs for Ankle and Foot Injuries

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8. Home Exercise Programs for Thoracic Spine Injuries

9. Home Exercise Programs for Lumbar Spine Injuries

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Gary Mascilak, DC, PT, CSCS Rehab and Performance Specialist,

Amrish D. Patel, MD, PT Physiatrist, Sports and Spine Institute, McDonough,

Taylor Rossillo, MBA, ATC Director of Athletic Training Services, JAG-ONE

Ian W. Wendel, DO, FAAPMR, CAQSM, RMSK Tri-Country Orthopedics, Cedar

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Joseph E. Herrera, DO, FAAPMR

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Table 1. Phases of Rehabilitation

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Acromioclavicular Joint Pathology 2

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Glenohumeral Joint Osteoarthritis 3

Glenohumeral Joint Instability 4

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LIST OF EXERCISES xxi

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Distal Bicipital Tendinopathy 28

xxii LIST OF EXERCISES

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Ulnar Neuropathy at the Elbow 29

WRIST AND HAND

LIST OF EXERCISES xxiii

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Extensor Carpi Ulnaris Tendinopathy 52

xxiv LIST OF EXERCISES

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LIST OF EXERCISES xxv

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Hamstring Strain and Tendinopathy 74

xxvi LIST OF EXERCISES

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LIST OF EXERCISES xxvii

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Quadriceps and Patellar Tendinopathy 103

xxviii LIST OF EXERCISES

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Meniscal Tear 105