Musculoskeletal Interventions Techniques For Therapeutic Exercises 3rd Ed .

Musculoskeletal
Interventions
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Third Edit ion
Musculoskeletal
Interven
tions
echniques for T erapeutic Exercise
Barbara J. Ho o g e nbo o m, EdD, PT, SCS, ATC

Pro fe sso r
De p a rt m e n t o f Ph ysica l Th e ra p y
Gra n d Va lle y St a t e Un ive rsit y
Gra n d Ra p id s, Mich ig a n
Michae l L. Vo ig ht, DHSc, PT, OCS, SCS, ATC, CSCS, FAPTA

Pro fe sso r
Sch o o l o f Ph ysica l Th e ra p y
Be lm o n t Un ive rsit y
Na sh ville , Te n n e sse e
William E. Pre ntice , PhD, PT, ATC, FNATA

Pro fe sso r
Co o rd in a t o r o f Sp o rt s Me d icin e Sp e cia liza t io n
De p a rt m e n t o f Exe rcise a n d Sp o rt Scie n ce
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Contents
Contributors vii 9 Impaired Neuromuscular Control: Reactive

Preface xi Neuromuscular Training 223
Acknowledgments xv Michae l L. Vo ig ht/ Gray Co o k
PAR 1 Foundations of the PAR 3 T e ools of Rehabilitation

Rehabilitation Process 10 Plyometric Exercise in Rehabilitation 265
Michae l L. Vo ig ht/ Ste ve n R. Tippe tt
1 Introduction to the Therapeutic Interventions:
The Guide to Physical Therapist 11 Open- versus Closed-Kinetic-Chain Exercise
Practice, Clinical Reasoning, and an in Rehabilitation 287
Algorithmic-Approach to Intervention 1 William E. Pre ntice
Barbara J. Ho o g e nbo o m/ Michae l L. Vo ig ht
12 Proprioceptive Neuromuscular Facilitation
2 Understanding and Managing the Healing Techniques in Rehabilitation 311
Process Through Rehabilitation 29 William E. Pre ntice
William E. Pre ntice
13 Joint Mobilization and Traction Techniques
3 Neuromuscular Scan Examination 63 in Rehabilitation 339
Jo hn S. Halle William E. Pre ntice
4 Impairments Caused By Pain 115 14 Regaining Postural Stability and Balance 371
Craig R. De ne g ar/ William E. Pre ntice Ke vin M. Guskie w icz
5 Impaired Posture and Function 135 15 Establishing Core Stability in

Phil Pag e Rehabilitation 407
Barbara J. Ho o g e nbo o m/ Jo le ne L. Be nne tt/
Mike Clark
PAR 2 reating Physiologic 16 Aquatic Therapy in Rehabilitation 435
Impairments During Rehabilitation Barbara J. Ho o g e nbo o m/
Nancy E. Lo max
6 Impaired Muscle Performance:
Regaining Muscular Strength, 17 Functional Movement Assessment 463
Endurance and Power 149 Barbara J. Ho o g e nbo o m/ Michae l L. Vo ig ht/
William E. Pre ntice Gray Co o k/ Gre g Ro se
7 Impaired Endurance: Maintaining Aerobic 18 Functional Exercise Progression and Functional

Capacity and Endurance 175 Testing in Rehabilitation 497
Patrick D. Se lls/ William E. Pre ntice Turne r A. Blackburn, Jr/ Jo hn A. Guido , Jr
8 Impaired Mobility: Restoring Range of Motion 19 Functional Training and Advanced

and Improving Flexibility 193 Rehabilitation 513
William E. Pre ntice Michae l L. Vo ig ht/ Barbara J. Ho o g e nbo o m/
Gray Co o k/ Gre g Ro se
v
vi Contents
PAR 4 Intervention Strategies 27 Cervical and Thoracic Spine 897

for Speci c Injuries Te rry L. Grindstaff/ Eric M. Mag rum
20 Rehabilitation of Shoulder Injuries 547 28 Rehabilitation of Injuries to the Lumbar

Jo se ph Mye rs/ Te rri Jo Rucinski/ and Sacral Spine 943
William E. Pre ntice / Ro b Schne ide r Danie l N. Ho o ke r/ William E. Pre ntice
21 Rehabilitation of the Elbow 613

To dd S. Elle nbe cke r/ Tad E. Pie czynski/
David Carfag no
PAR 5 Special Consideration
for Speci c Patient Populations
22 Rehabilitation of the Wrist, Hand,
and Digits 659 29 Rehabilitation Considerations for the
Je anine Be asle y/ Dianna Lunsfo rd Older Adult 987
Jo le ne L. Be nne tt/ Michae l J. Sho e make r
23 Rehabilitation of the Groin, Hip,
and Thigh 695 30 Considerations for the Pediatric Patient 1017
Timo thy F. Tyle r/ Ste phanie M. Squitie ri/ Ste ve n R. Tippe tt
Gre g o ry C. Tho mas
31 Considerations for the Physically
24 Rehabilitation of the Knee 727 Active Female 1041
Ro be rt C. Manske / B.J. Le he cka/ Barbara J. Ho o g e nbo o m/ Te re sa L. Schue mann/
Mark De Carlo / Ryan McDivitt Ro byn K. Smith
25 Rehabilitation of Lower-Leg Injuries 789 Index 1127

Christo phe r J. Hirth
26 Rehabilitation of the Ankle and Foot 823

Sco tt Mille r/ Stuart L. (Skip) Hunte r/
William E. Pre ntice
Contributors
Jeanine Beasley, EdD, OTR, CHT, FAOTA Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS
Associate Pro essor Senior Director o Medical Services
Certi ed Hand T erapist National Director o Clinical Research
Department o Occupational T erapy Physiotherapy Associates Scottsdale Sports Clinic
Grand Valley State University Physiotherapy Associates
Mary Free Bed Rehabilitation Hospital Scottsdale, Arizona
Rock ord, Michigan
Terry L. Grindstaff, PhD, PT, ATC, SCS, CSCS
Jolene L. Bennett, MA, PT, OCS, ATC, CertMDT Assistant Pro essor
Clinical Specialist or Orthopedics and Sports Medicine Department o Physical T erapy
Spectrum Health Rehabilitation and Sports Medicine Creighton University
Visser Family YMCA Omaha, Nebraska
Grandville, Michigan
John A. Guido, Jr., DPT, ATC
Turner A. Blackburn, Jr., MEd, PT, ATC Sports T erapist
Vice President Department o Outpatient Physical T erapy
Clemson Sports Medicine and Rehabilitation Ochsner Hospital
Manchester, Georgia New Orleans, Louisiana
David Carfagno, DO Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM

Board Certi ed Internal Medicine and Senior Associate Dean, College o Arts and Sciences
Sports Medicine Physician Pro essor
Scottsdale Sports Medicine Department o Exercise and Sport Science
Scottsdale, Arizona University o North Carolina
Chapel Hill, North Carolina
Mark De Carlo, PT, DPT, MHA, SCS, ATC
Director o Research and Clinical Education John S. Halle, PT, PhD, ECS
Accelerated Rehabilitation Centers Pro essor
Carmel, Indiana School o Physical T erapy
School o Physical T erapy, Belmont University
Mike Clark, DPT, MS, CES, PES Nashville, ennessee
Chairman, Founder, Chie Science O cer
Fusionetics Christopher J. Hirth, MSPT, PT, ATC
Alpharetta, Georgia Director o Rehabilitation
Physical T erapist/ Athletic rainer
Gray Cook, MSPT, OCS, CSCS Campus Health Service
Clinical Director University o North Carolina
Orthopedic and Sports Physical T erapy Chapel Hill, North Carolina
Danville, Virginia
Barbara J. Hoogenboom, EdD, PT, SCS, ATC
Craig R. Denegar, PhD, PT, ATC, FNATA Pro essor
Director o Physical T erapy Program Department o Physical T erapy
Pro essor o Kinesiology Grand Valley State University
Department o Physical T erapy Grand Rapids, Michigan
University o Connecticut
Storrs, Connecticut
vii
viii Contributors
Daniel N. Hooker, PhD, PT, ATC, SCS Joseph Myers, PhD, ATC
Physical T erapist/ Athletic rainer, Retired Associate Pro essor
Division o Sports Medicine Department o Exercise and Sport Science
University o North Carolina University o North Carolina at Chapel Hill
Chapel Hill, North Carolina Chapel Hill, North Carolina
Stuart L. (Skip) Hunter, PT, ATC Phil Page, PhD, PT, ATC, CSCS, FACSM
Owner Director o Research and Education
Clemson Sports Medicine Per ormance Health
Clemson, South Carolina Baton Rouge, Louisiana
B.J. Lehecka, DPT Tad E. Pieczynski, PT, MS, CSCS

Assistant Pro essor Assistant Clinic Director
Department o Physical T erapy/ Outpatient Orthopedic Physiotherapy Associates
Physical T erapy Scottsdale Sports Clinic
Wichita State University/ Via Christi Health Scottsdale, Arizona
Wichita, Kansas
William E. Prentice, PhD, PT, ATC, FNATA
Nancy E. Lomax, PT Pro essor
Staf Physical T erapist Coordinator o Sports Medicine Specialization
Spectrum Health Rehabilitation and Department o Exercise and Sport Science
Sports Medicine Services University o North Carolina at Chapel Hill
Visser Family YMCA Chapel Hill, North Carolina
Grandville, Michigan
Greg Rose, DC
Dianna Lunsford, OTD, MEd, OTR/L, CHT Co-Founder
Assistant Pro essor itleist Per ormance Institute
Department o Occupational T erapy Oceanside, Cali ornia
Grand Valley State University
Grand Rapids, Michigan Terri Jo Rucinski, MA, PT, ATC
Physical T erapist/ Athletic rainer
Eric M. Magrum, DPT, OCS, FAAOMPT Campus Health Service
Senior Physical T erapist and Director o Orthopedic Division o Sports Medicine
Residency Program University o North Carolina at Chapel Hill
University o Virginia/ Healthsouth Outpatient Chapel Hill, North Carolina
Sports Medicine
Charlottesville, Virginia Rob Schneider, MSPT, PT, ATC, SCS
Director
Robert C. Manske, DPT, PT, MEd, SCS, ATC, CSCS Proaxis T erapy
Pro essor and Chair Carrboro, North Carolina
Department o Physical T erapy/ Outpatient Orthopedic
Physical T erapy Teresa L. Schuemann, PT, SCS, ATC
Wichita State University/ Via Christi Health Program Director
Wichita, Kansas Evidence in Motion, Sports Physical T erapy Residency
Proaxis Physical T erapy
Ryan McDivitt, PT, DPT, ATC Fort Collins, Colorado
Facility Manager
Accelerated Rehabilitation Centers Patrick D. Sells, DA, ACSM
Avon, Indiana Assistant Pro essor
School o Physical T erapy
Scott Miller, MS, PT, SCS, CSCS Belmont University
Director o Clinical Operations Nashville, ennessee
Agility Health Physical T erapy and Sports Per ormance
Portage, Michigan
Contributors ix
Michael J. Shoemaker, PT, DPT, GCS Steven R. Tippett, PhD, PT, SCS, ATC
Assistant Pro essor Pro essor and Chair
Department o Physical T erapy Department o Physical T erapy and Health Science
Grand Valley State University Program in Physical T erapy Bradley University
Cook-DeVos Center or Health Sciences Peoria, Illinois
Grand Rapids, Michigan
Timothy F. Tyler, MSPT, ATC
Robyn K. Smith, MS, PT, SCS Clinical Research Associate
Staf Physical T erapist PRO Sports Physical T erapy o Westchester
Center or Physical Rehabilitation Nicholas Institute or Sports Medicine and
Belmont, Michigan Athletic rauma (NISMA )
Lenox Hill Hospital
Stephanie M. Squitieri, DPT, CSCS Scarsdale, New York
Senior Physical T erapist
PRO Sports Physical T erapy o Westchester Michael L. Voight, DHSc, PT, OCS, SCS, ATC, FAPTA
Scarsdale, New York Pro essor
School o Physical T erapy
Gregory C. Thomas, DPT, CSCS Belmont University
PRO Sports Physical T erapy Nashville, ennessee
Scarsdale, New York
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Preface
Movem ent is an integral part o human experience. Functional m ovem ent is necessary
or participation in all aspects o li e, including activities o daily living, work, occupation,
avocation, and sport. T is philosophy is evident in the new Vision Statem ent that was
adopted by the Am erican Physical T erapy Association House o Delegates in June 2013:
“ ransform ing society by optim izing m ovem ent to im prove the hum an experience.”
In the 7 years since the last edition o the textbook, the ocus o rehabilitation has
becom e increasingly related to human m ovem ent. T e editors and authors who have
contributed to this textbook have been on this path or years. ogether, we of er decades
o highly variant experience in order to produce a textbook that of ers a m ovem ent-based,
unctional perspective to the treatm ent o musculoskeletal dys unction and injury. T e
art and science o caring or a patient or client is rooted in evidence-based practice, but
requires knowledge o oundational sciences, application o theory, as well as skill, cre-
ativity, and innovation; however, above all we believe, it relates to m ovem ent. Several
areas within the current 31-chapter edition have been expanded to best re ect the con-
tem porary practice o physical therapy including clinical decision-making, algorithm ic
thinking, the neuromuscular scanning examination, unctional movement screening, and
the essentials o unctional exercise.
T e purpose o this text is to provide a comprehensive guide to assist practitioners in
the design, implementation, and progression o rehabilitation programs or patients with
musculoskeletal dys unction. T is includes dys unction that occurs due to imbalance, over-
use, injury, as well as postoperatively. It is intended or use in musculoskeletal interven-
tion courses that teach students the application o theory, decision-making in therapeutic
interventions, and rehabilitation progressions. However, it is equally well-suited or the
practicing physical therapist looking or novel ideas or therapeutic interventions. T e con-
tributing authors have attempted to use our collective expertise, creativity, and knowledge
to produce a textbook that encompasses many aspects o musculoskeletal rehabilitation
and positively af ects approaches to intervention, with a ocus on unction!
Organizat ion
T e text is divided into the same ve parts as the previous edition. In Part 1: T e Founda-
tions o the Rehabilitation Process a revised chapter has been provided (Chapter 1) that
summarizes T e Guide to Physical T erapist Practice, as well as the important skill o clinical
decision-making, highlighted by the use o algorithmic thinking. T e other two chapters on
tissue healing (Chapter 2) and the Neuromuscular Scan Examination (Chapter 3) complete
the oundational concepts portion o the text that provides the basis or each o the upcom-
ing sections. Very little time is spent on the process o examination in musculoskeletal prac-
tice, as the ocus o this text is intervention.
Part 2: reating Physiologic Impairments During Rehabilitation provides in-depth
in ormation about the general impairments that may need to be addressed throughout all
phases o rehabilitation. T ese chapters include in ormation about the management o pain
(Chapter 4); an updated chapter on posture and unction (Chapter 5); muscle per ormance
xi
xii Preface
(Chapter 6); endurance and aerobic capacity (Chapter 7); mobility and range o motion
(Chapter 8); and neuromuscular unction (Chapter 9). Each o these introductory chapters
highlights both methods or managing impairments described in the subsequent chap-
ters, as well as new “clinical pearl” boxes to highlight the authors experience with regard to
interventions.
Part 3: T e ools o Rehabilitation provides the reader with an overview o rehabili-
tation “tools” that can be used during the rehabilitation o m any types o patients or
clients. It provides the reader with detailed in orm ation on how each tool can be applied
throughout the rehabilitation process in order to achieve high-level outcom es that are
unctionally relevant. T e tools o rehabilitation covered in this part include: plyom et-
ric exercise (Chapter 10); open- and closed-kinetic chain interventions (Chapter 11);
proprioceptive neurom uscular acilitation techniques (Chapter 12); joint m obilization
(Chapter 13); postural stability and balance interventions (Chapter 14); core stabiliza-
tion training (Chapter 15); aquatic therapy (Chapter 16); unctional m ovem ent screening
(Chapter 17); un ctional exercise and progressions (Chapter 18); and the essentials o
unctional exercise interventions, including a novel exercise prescription and progres-
sion m atrix (Chapter 19). O n ote are the updated chapters on unctional m ovem ent
screening and unctional intervention, re ecting paradigm shi ts in practice.
T e ourth part o the text uses a regional approach to address speci c application o
intervention throughout the body. Part 4: Interventions or Speci c Injuries builds upon
the varied in orm ation presented in Part 3, by of ering applications o techniques and
interventions related to com m on overuse, traumatic, and postoperative musculoskeletal
dys unction. Included are detailed rehabilitation suggestions or conditions com m on to
the shoulder com plex (Chapter 20); the elbow (Chapter 21); the wrist, hand, and digits
(Chapter 22); the groin, hip, and thigh (Chapter 23); the knee (Chapter 24), the lower leg
(Chapter 25); the ankle and oot (Chapter 26); the cervical and thoracic spines (Chap-
ter 27); and the lum bar spine (Chapter 28). O note is the addition o the com prehensive
chapter on the cervical and thoracic region. Each o these regionally based chapters pro-
vides in-depth discussion o pathom echanics and injury m echanism s while ocusing on
rehabilitation strategies and concerns or speci c injuries and providing exam ple pro-
tocols. As the title indicates, this is a textbook dedicated to intervention. T us, it should
be noted that detailed exam ination strategies and special test procedures are not a part
o these regional chapters; there ore, it is likely that this text will accom pany a text on
exam ination, dif erential diagnosis, evaluation, and prognosis.
T e th part o the text, Part 5: Special Considerations or Speci c Populations, pro-
vides application o all the previous intervention strategies and how these may need to
be selected, adapted, and utilized in three unique groups o patients: the geriatric patient
(Chapter 29), the pediatric patient (Chapter 30), and the physically active emale (Chap-
ter 31). T e editors and authors believe that these groups o patients deserve special con-
sideration and attention during the rehabilitation process.
Updat ed, Evidence-based Int ervent ion St rat egies

Musculoskeletal Interventions: echniques for T erapeutic Exercise, 3rd ed, of ers a
state-o -the art com prehensive collection o rehabilitation techniques and strategies or
the physical therapist who intervenes with patients o all ages, abilities, and unctional
levels. T e contributing authors have made every attem pt to provide the reader with
updated, evidence-based strategies or patient managem ent, while re ecting our unique
experience and creativity. T e editors have assem bled a group o experienced and well-
respected clinicians, researchers, and academics/ educators in order to cover all aspects
o musculoskeletal rehabilitation. All updates were subm itted to critical editorial review
to ensure accuracy and relevancy.
Preface xiii
Learning Aids
T e learning aids provided in this text include:
Objectives—provided at the beginning o each chapter presented to identi y critical
concepts presented within each chapter.
ables— or presentation o concepts and organization o complex in ormation.
Figures—updated ull-color illustrations and gures are a eature o the third edition!
“Clinical Pearls,” new to this edition to assist the reader in application o concepts
and of er insights or connections between in ormation, as provided by the
authors o chapters.
Sum m ary points provided at the end o each chapter outlining major points within, or
the reader to determine their level o comprehension.
End of Chapter reatm ent Guidelines—present in the regionally organized chapters to
illustrate a possible sequence o interventions or a postoperative protocol.
References—a comprehensive, updated list o re erences is provided with each chapter.
Inst ruct or Resources

Power Points— ables and photographs in the text will be available as PowerPoints to
pro essors who adopt the text
Videos—Videos o critical skills in the text will be available to pro essors who
adopt the text and a larger selection o the video library will be available to
AccessPhysiotherapy subscribers
Enhanced Ebook—T is third edition will also be of ered as an enhanced ebook, which
will incorporate videos and include interactive quizzes.
Acknowledgments
T is textbook is all about movement: movement within the pro ession o physical therapy,
movement as a part o human unction, and movement in personal goals, dreams, and
career paths that occur during a li etime. T e process o preparing and editing the 31 chap-
ter manuscripts or this textbook was daunting in the ace o all o the other activities and
demands o li e. T e collaborative dedication o three editors with a common goal o pro-
ducing a unique, relevant, and current textbook on musculoskeletal intervention made this
revision possible. T e three editors o this text each bring a unique perspective regarding
writing, therapeutic exercise, clinical interventions, and the process o rehabilitation. Even
amid our dif erences we were able to work together, achieve a common vision, and have
this updated textbook to show or it!
We would like to personally thank each o the amazing contributing authors. T ey were
asked to contribute to this text because we have tremendous respect or them personally
and pro essionally. T ese individuals have distinguished themselves as educators, clini-
cians, and researchers, dedicated to the rehabilitation o a wide variety o individuals o all
abilities, ages, and walks o li e. We are exceedingly grate ul or their input and willingness
to share their ideas in writing and pictures.
Finally, we would collectively like to thank people important to us throughout our
careers and the process o revising and editing this textbook. o our many riends and col-
leagues who have contributed to “who we are today” with creative thinking, intellectual
challenges, and mentorship; you have shaped and in uenced us, or that we are grate ul.
You have instilled in each o us the desire to continue learning, to challenge others to learn,
grow, be change agents, and to seek continued improvement in the practice o physical
therapy. T ese same riends and colleagues constantly keep us growing (older), laughing,
loving li e, and enjoying the many blessings o careers in rehabilitation.
Barb would like thank her great amily; Dave, Lindsay, and Matthew—who continu-
ally support her during her crazy adventures; which o ten equate to time away rom home.
Barb would also like to thank her parents or their guidance, encouragement, and love o
education and writing. T eir examples have shaped a li etime o goals and dreams. Finally,
thanks to her sports physical therapy colleagues and the DP students at Grand Valley State
University who keep her moving, learning, and growing every day.
Mike would like to give special thanks to several individuals. First to his co-editors/
authors, Barb and Bill who put up with countless rewrites and missed deadlines while at the
same time constantly changing things—thanks, I owe both o them an extreme debt o grati-
tude; secondly, to John Halle and his colleagues at Belmont University. T ey have provided
him the academic reedom and time to pursue this project. T ey challenge him every day to
seek excellence. And lastly, to his close amily; his parents who started him down the right
path and gave him educational reedom ; to his mentor ab Blackburn, who has continued
to give him pro essional direction; and nally to his wi e Cissy, who has had to pay the price
or his passion or excellence while at the same time providing inspiring wisdom and end-
less support to help sustain his passion or being an educator.
xv
xvi Acknowledgments
Bill would like to thank his amily— ena, Brian, and Zachary—who make an ef ort such
as this worthwhile. T ey keep him grounded and help to maintain his ocus in both his per-
sonal and pro essional li e.
T ank-you to all—we enjoyed the ride and hope you enjoy the outcome!
Barbara J. Hoogenboom
Michael L. Voight
William E. Prentice
Introduction to
the T erapeutic
Interventions
The Guide to Physical The rapist
Practice , Clinical Re aso ning , and an
Alg o rithmic-Appro ach to Inte rve ntio n
Ba r b a r a J. Ho o g e n b o o m a n d M ich a e l L. Vo ig h t
Af t e r co m p le t io n o f t h is ch a p t e r, t h e p h y s ica l
OBJJECTIVE
ES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Describe components of The Guide to Physical Therapist Practice, and its relationship to the 4
elements of the disablement model as described by Saad Nagi.
Compare and contrast the disablement model, the medical model, and a functional movement
model of dealing with the effects of injury and dysfunction.
Identify the components of the examination process as de ned by The Guide.
Describe the components of and sequence of steps in the clinical decision-making process
related to evaluation, diagnosis, prognosis, and intervention.
Contrast novice and expert clinical reasoning and decision making in physical therapist practice.
Relate clinical reasoning to quality provision of physical therapy, in terms of both diagnosis and
selection of interventions.
(continued )
PAR 1 Foundations of the Rehabilitation Process

2 Chapte r 1 Introduction to the Therapeutic Interventions
OBJECTIVES (continued )
Relate evidence-based practice to clinical reasoning.
Describe the algorithmic approach to clinical reasoning for intervention selection.
Use sample basic algorithms to examine clinical reasoning for each of the 4 phases of
rehabilitation (acute, intermediate, advanced, and return to function).
Describe a basic algorithmic decision-making process based upon results of the examination.
Articulate a movement-based philosophy upon which to construct plans for intervention

in physical therapy practice.
Physical therapists play an exciting and vital role in the provision o health care. As a pro-
ession, physical therapists contribute in a variety o ways to the health care system. No
longer are physical therapists seen only as providers o rehabilitation, but also as partici-
pants in the processes o patient education, disease prevention, and promotion o health
and wellness. Physical therapists o the 21st century must have a united voice with regard
to our scope o practice, our models o health care delivery, and the types o patients and
clients we serve, as well as the types o examination measures and interventions we use
to remedy or prevent impairments, unctional limitations, and disabilities in our patients
and clients. We must be active, knowledgeable educators o the public, other health care
providers, third-party payers, and health policy makers as we advocate or the pro ession o
physical therapy.
T e Guide t o Physical T erapist Pract ice

T e Guide to Physical T erapist Practice (T e Guide) was f rst published in the November
1997 issue o Physical T erapy as a document to describe the practice o physical therapy.1
It was developed by consensus o an expert clinician panel, whose members were chosen
rom across the United States and who represented perspectives rom a variety o practice
settings. Prior to its publication, the document underwent extensive clinician review and
repeated edits. T e Guide is not a static document, rather it is a “living” document that
is intended to grow and change with the pro ession o physical therapy. A revision to the
original T e Guide was published in 2001.2 T is evolution represented the culmination o
input rom the panels, educators, and clinicians, and attempted to improve the utility o
T e Guide. Subsequently, in 2003, T e Interactive Guide to Physical T erapist Practice was
released on CD-ROM, allowing access to a digital version o T e Guide, search capabili-
ties, and cross-re erencing, as well as an index o tests and measures with hyperlinks to
reliability and validity studies and citations.3 Next, T e Guide is anticipated to be updated
to include the World Health Organization International Classif cation o Functioning, Dis-
ability, and Health (ICF) model.
T e Guide is not a cookbook. It provides a ram ework or physical therapy prac-
tice, but does n ot provide clinical guidelin es or protocols or intervention. Clin ical
guidelines m ust be developed based upon evidence, whereas the pre erred practice
Disablement Model 3
patterns contained in T e Guide are m erely patterns considered by T e Guide develop-
ers as m ost com m only used or m ost appropriate patterns o patient and client inter-
vention.7 Likewise, there is neither a recom m ended ee structure in T e Guide nor any
direct conn ection to current procedural term inology codes. Although som e (Interna-
tional Classif cation o Diseases) ICD-9 codes are listed and re erred to in Part 2, they
should not be used to code or billing purposes. T e Guide does not speci y the site o
care; rather, it uses the episode o care concept that crosses all rehabilitation settin gs
related to each episode. T e Guide also does not address the state-to-state variances in
the scope o practice.
Disablement Model
T e Guide was developed based upon the disablement model developed by Saad Nagi in
1969.22 It was designed to describe the e ects o disease and injury at both the personal and
societal levels as well as their unctional consequences. T e disablement model empha-
sizes the unctional and health status o individuals, with intervention based on improving
these aspects o the patient’s condition.1-3 T e model has 4 elements:
Pathology ↔ Im pairm ent ↔ Functional lim itation ↔ Disability
Pathology is the interruption o the normal cellular processes rom a biomechanical,
physiologic, or anatomic perspective.1-3 T e body o ten responds to an injury or pathol-
ogy with a de ensive reaction in order to restore the normal state. Examples o this include
hemarthrosis in the case o ligament rupture, or the in ammatory process in response to
connective tissue damage (tear/ stretch). Intervention at this level is generally handled by
physicians and is o ten pharmacologic and/ or surgical in nature.
Im pairm ent is any loss or abnormality o physiologic, psychological, or anatomic
structure or unction at the level o organs and body systems.1-3 Physical therapists typi-
cally measure the signs and symptoms that present in conjunction with an injury, illness,
or pathology, and identi y the subsequent impairments. Physical therapists o ten intervene
trying to attempt correctly identif ed impairments. Examples o physiologic impairments
include muscle weakness, range-o -motion loss, pain, and abnormal joint play. Anatomic
impairments include structural conditions such as genu recurvatum, scoliosis, emoral
anteversion, and alterations in oot alignment.
Functional lim itation is a deviation rom the normal behavior in per orming tasks and
activities rom that which would be considered traditional or expected or an individual.1-3
Functional limitations are tasks or activities that are not per ormed in the usual e cient or
skilled ashion. Problems with trans ers, standing, walking, running, and climbing stairs are
all examples o unctional limitations.
Disability is the incapacity in per orming a broad range o tasks and activities that are
usually expected in specif c social roles.1-3 Inability to unction as a spouse, student, parent,
or worker (in the home or outside o the home) constitutes a disability.
T e scope o physical therapist practice overlaps with many portions o the disable-
ment model, as shown in Figure 1-1.
T e disablement process is a 2-way continuum a ected by intraindividual and extrain-
dividual risk actors (Figure 1-2). Intraindividual actors include habits, li estyle, behavior,
psychosocial characteristics, age and sex, educational level and income, weight, and amily
history. Extraindividual actors comprise the medical care received, the pharmacologic and
other therapies available, the physical environment, and any external supports. T e rela-
tionship between these aspects will vary between individuals and will ultimately determine
the impact o the disease or injury.
He alth c are
Me dica l a s pe cts S ocia l a s pe cts
Do main o f phys ic al the rapis t prac tic e
P a thology/ Impa irme nt Functiona l Dis a bility

P a thophys iology limita tion
Ca rdiopulmona ry P hys ica l

Inte gume nta ry P s ychologica l
Mus culos ke le ta l S ocia l
Ne uromus cula r
Figure 1-1
The scope of physical therapist practice within the continuum of health care services and the
context of the disablement model. (Reproduced, with permission, from the American Physical Therapy
Association [APTA]. The guide to physical therapist practice. 2nd ed. Phys Ther. 2001;81(1):9-738.)
Most physical therapists have treated patients who had signif cant impairments but
remained extremely unctional. Most have also treated patients who were disabled by what
seemed to be minor impairments or unctional limitations. Un ortunately, there are ew
studies in the literature to show a direct cause-and-e ect relationship between impair-
ments, unctional limitations, and disability. In addition to the Nagi model, T e Guide is
also strongly in uenced by 2 additional conceptual rameworks: the integration o preven-
tion and wellness strategies and the patient/ client management model. T ese in uential
rameworks are discussed urther in subsequent sections.
Biologica l fa ctors De mogra phic fa ctors

Conge nita l conditions Age, s ex, e duca tion,
Ge ne tic pre dis pos itions income
Pa thology/ Functiona l
Impa irme nt Dis a bility
Pa thophys iology limita tions
Comorbidity P s ychologica l
He a lth ha bits a ttribute s
Pe rs ona l be haviors (motiva tion, coping)
Life s tyle s S ocia l s upport
P hys ica l a nd s ocia l e nvironme nt
Me dica l ca re Me dica tions /The ra pie s Re ha bilita tion

Mode of ons e t a nd dura tion
Preve ntio n and the Pro mo tio n o f He alth, We llne s s , and Fitne s s
Figure 1-2
An expanded disablement model showing interactions among individual and environmental factors, prevention, and the
promotion of health, wellness, and fitness. (Reproduced, with permission, from the APTA. The guide to physical therapist practice.
2nd ed. Phys Ther. 2001;81(1):9-738.)
Overview of The Guide: Part 1 5
Other Models of Patient Management

T e classic medical model o patient management is distinctly di erent rom the disable-
ment model. Many medical providers address a wide variety o disease processes, illnesses,
or injuries that patients present with, using the medical patient management model. T is
typically begins with the history and physical examination (not unlike that which occurs
during the disablement model), which is typically ollowed by some type o additional
invasive tests or measures such as lab work or diagnostic imaging. T e combination o the
history and physical and additional tests allow the practitioner to arrive at a cellular, struc-
tural, or systems level diagnosis. ypically, pharmacologic or other medical management is
utilized, or the patient or client is re erred to surgery, with the ultimate goal being cure or
repair o the tissue, system, or structure. In this model, re erral to other practitioners may
also accompany treatment, with the goal remaining cure or repair o the errant tissue, sys-
tem, or structure.
Finally, a new unctional movement model is emerging in physical therapist prac-
tice. T is model uses the analysis o basic unctional movements in order to determine i
a movement dys unction is present, as compared to attempting to describe dys unction
at the impairment level. T e strength o using this model is that the practitioner can work
algorithmically “backward” in order to determine the actual cause o the movement impair-
ment. T rough the use o systematic examination procedures and algorithmic thinking,
the clinician is able to arrive at the specif c impairment and then begin unctionally based
interventions that assist the patient or client in return to optimal unction. Algorithms are
discussed in the Introduction to Algorithm section o this chapter, while unctional move-
ment assessment and intervention is covered thoroughly in Chapters 19 and 20.
Overview of T e Guide: Part 1

T e original purpose o T e Guide was to improve the quality o physical therapy, promote
appropriate use o services, enhance customer satis action, and reduce unwarranted varia-
tions in physical therapy management. Prevention and wellness initiatives are also stressed
and will help decrease the need or services.1-3
Chapter 1 provides a description o “who” physical therapists are and “what” they do.
T is description includes the various practice settings in which a physical therapist may
practice, including some less traditional ones like corporate or industrial health centers and
f tness centers. In this chapter, the terms “patients” and “clients” are def ned as
• Patients are “individuals who are the recipients o physical therapy examination,
evaluation, diagnosis, prognosis, and intervention and who have a disease, disorder,
condition impairment, unctional limitation, or disability” (Re . 2, p. 689)
• Clients are “individuals who engage the services o a physical therapist and who can
benef t rom the physical therapist’s consultation, interventions, pro essional advice,
health promotion, f tness, wellness, or prevention services” (Re . 2, p. 685). Clients
are also businesses, school systems, and others to whom physical therapists provide
services.1-3
T e chapter continues with a general discussion o the scope o practice or physical

therapists, acknowledging that this varies by state. Physical therapists provide direct ser-
vices to patients as well as interact with other pro essionals, provide prevention and well-
ness services, consult, engage in critical inquiry (research), educate, administrate, and
supervise support personnel.
Physical therapy is an integral part o secondary and tertiary rehabilitative care. Chapter
1 o T e Guide expands on this model with a discussion o the physical therapist’s role in
primary care and in wellness. T e concepts o primary care and wellness involve restoring
health, alleviating pain, and preventing the onset o impairments, unctional limitations,
disabilities, or changes in physical unction and health status resulting rom injury, disease,
or other causes.1,2 Physical therapists play major roles in secondary and tertiary care o
those with conditions o the musculoskeletal, neuromuscular, cardiovascular/ pulmonary,
and integumentary systems that may have been treated primarily by another practitioner.
O ten, secondary care is provided in acute care and rehabilitation hospitals as well as out-
patient clinics, home health settings, and within school systems.2,3 ertiary care is o ten pro-
vided by physical therapists in more specialized, comprehensive, technologically advanced
settings in response to another health care practitioners’ request or consultation and spe-
cialized services o ered by the therapist.1-3
T e clinical decision-making process presented in T e Guide comprises the 5 elements
o the patient/ client management model (Figure 1-3): examination, evaluation, diagnosis,
prognosis, and intervention. T is clinical decision-making model is explored in greater
depth later in this chapter in the section titled Clinical Reasoning and Decision Making.
T e physical therapist begins with a thorough exam ination. Because the ocus o this
text is intervention, the examination process will not be described in detail.
T e next 3 steps in the process involve decision ma king. Using the in ormation gath-
ered through the examination, the physical therapist ormulates an evaluation. T is is the
clinical judgement that results rom assessing the situation in its entirety rom multiple
points o view. Factors such as loss o unction or presence o dys unctional movement
patterns, social considerations, and health status are taken into consideration when devel-
oping a diagnosis (cluster o signs and symptoms) and prognosis (optimal level o improve-
ment and time to get there), which guides the interventions that are chosen and per ormed
during comprehensive management o the patient.1
Intervention describes the skilled interaction o the physical therapist when per-
orm ing the therapeutic techniques an d/ or delegatin g and overseeing services. T e
goal is to produce a positive change in the condition or unctional per ormance o the
patient. Intervention strategies should be constantly evaluated and reevaluated or their
e ectiveness with goals o rem ediation o im pairm ents, im provem ent in unctional out-
com es, as well as secondary and tertiary prevention and the goal o long-term wellness.
Continued care is based on the patient’s response and progress toward the determ ined
goals.1-3
T ere are 3 important components to the intervention: (a) coordination, communication,
and documentation; (b) patient/ client-related instruction (education); and (c) procedural
interventions. Management o every patient will include some aspect o the f rst 2 interven-
tion components and o ten 1 or more procedural interventions. T ere are 9 procedural inter-
ventions, listed by level o importance and utilization in the practice o physical therapy:
• T erapeutic exercise (the ocus o this textbook)
• Functional training in sel -care and home management
• Functional training in work, community, and leisure integration or reintegration
• Manual therapy techniques, including mobilization/ manipulation
• Prescription, application, and, as appropriate, abrication o devices and equipment
• Airway clearance techniques
• Integumentary repair and protective techniques
• Electrotherapeutic modalities
• Physical agents and mechanical modalities
Overview of The Guide: Part 1 7
DIAGNOS IS
Both the proce s s a nd the e nd re s ult of eva lua ting
exa mina tion da ta , which the phys ica l the ra pis t
orga nize s into de fine d clus te rs, s yndrome s, or
ca te gorie s to he lp de te rmine the prognos is
(including the pla n of ca re ) a nd the mos t
a ppropria te inte rve ntion s tra te gie s.
EVALUATION PROGNOS IS
A dyna mic proce s s in which the (Including Plan o f Care )
phys ica l the ra pis t ma ke s clinica l De te rmina tion of the leve l of optima l
judgme nts ba s e d on da ta ga the re d improve me nt tha t may be a tta ine d
during the exa mina tion. This proce s s through inte rve ntion a nd the a mount of
a ls o may ide ntify pos s ible proble ms time re quire d to re a ch tha t leve l. The
tha t re quire cons ulta tion with or re fe rra l pla n of ca re s pe cifie s the inte rve ntions
to a nothe r provide r. to be us e d a nd the ir timing a nd
fre que ncy.
EXAMINATION INTERVENTION
The proce s s of obta ining a his tory, P urpos e ful a nd s kille d inte ra ction of
pe rforming a s ys te ms review, a nd the phys ica l the ra pis t with the pa tie nt/
s e le cting a nd a dminis te ring te s ts a nd clie nt a nd, if a ppropria te, with othe r
me a s ure s to ga the r da ta a bout the individua ls involve d in ca re of the
pa tie nt/clie nt. The initia l exa mina tion is pa tie nt/clie nt, us ing va rious phys ica l
a compre he ns ive s cre e ning a nd the ra py me thods a nd te chnique s to
s pe cific te s ting proce s s tha t le a ds to a produce cha nge s in the condition tha t
dia gnos tic cla s s ifica tion. The a re cons is te nt with the dia gnos is a nd
exa mina tion proce s s a ls o may ide ntify prognos is.The phys ica l the ra pis t
pos s ible proble ms tha t re quire conducts a re exa mina tion to de te rmine
cons ulta tion with or re fe rra l to a nothe r cha nge s in pa tie nt/clie nt s ta tus a nd to
provide r. modify or re dire ct inte rve ntion. The
de cis ion to re exa mine may be ba s e d
OUTCOMES on new clinica l findings or on la ck of
Re s ults of pa tie nt/clie nt ma na ge me nt, which pa tie nt/clie nt progre s s. The proce s s of
include the impa ct of phys ica l the ra py inte r- re exa mina tion a ls o may ide ntify the
ve ntions in the following doma ins : pa thology/ ne e d for cons ulta tion with or re fe rra l
pa thophys iology (dis e a s e, dis orde r, or condition); to a nothe r provide r.
impa irme nts, functiona l limita tions a nd
dis a bilitie s ; ris k re duction/preve ntion; he a lth,
we llne s s, a nd fitne s s ; s ocie ta l re s ource s ; a nd
pa tie nt/clie nt s a tis fa ction.
Figure 1-3 The patie nt/ clie nt manag e me nt mo de l
An expanded disablement model showing interactions among individual and environmental factors, prevention, and the
promotion of health, wellness, and fitness. (Reproduced, with permission, from the APTA. The guide to physical therapist practice.
2nd ed. Phys Ther. 2001;81(1):9-738.)
Examination f ndings, the evaluation, diagnosis, and prognosis and any available
research evidence should support the choice o intervention. Factors that might in uence
the choice o interventions as well as the prognosis include 1:
• Chronicity or severity o current condition
• Level o current impairment
• Functional limitation or disability
• Living environment
• Multisite or multisystem involvement

• Physical unction and health status
• Potential discharge destinations
• Preexisting conditions or diseases
• Social supports
• Stability o the condition(s)
Overview of T e Guide: Part 2

Part 2 o T e Guide has 4 sections, each dedicated to a system : musculoskeletal, neu-
romuscular, cardiopulmonary, and integumentary. T e 4 chapters in Part 2 are distin-
guished by a specif c graphic that relates to and depicts a structure within the content area.
Chapter 4 contains the musculoskeletal patterns, Chapter 5 contains the neuromuscular
patterns, Chapter 6 contains the cardiopulmonary patterns, and Chapter 7 contains the
integumentary patterns. O note to the reader o this textbook is Chapter 4, which contains
general in ormation and practice patterns describing provision o care or those with mus-
culoskeletal dys unction.
Musculoskelet al Pract ice Pat t erns 1-3

A group o experts rom a wide variety o musculoskeletal practice backgrounds assisted in
the development o the practice patterns. Patterns o disorders were considered, grouped
because o their similarities, and it was determined that many were managed similarly and
have comparable outcomes. T us, the development o the 10 pre erred musculoskeletal
practice patterns occurred.
T e musculoskeletal patterns are im pairm ent based and their titles re ect this.
Each has key associations to pathology and m edical/ surgical diagnoses noted within
the descriptive in ormation about the practice pattern. Primary prevention is a signif -
cant component to each pattern because the progression rom pathology to impairment,
unctional limitation, and disability is not inevitable. T e f rst pre erred practice pattern,
like the f rst in the other system s’ chapters, is a primary prevention pattern. T e aim o
such a pattern is not intervention or a preexisting condition, impairment, or unctional
limitation, rather prevention o each o these conditions. T e rest o the patterns are or
intervention in conditions that f t into the cluster o signs and sym ptom s that orm the
movement-based diagnosis. T e ollowing is a description o each pattern, the purpose o
which is to get a sense o which patients and diagnoses would all within this category o
practice patterns1-3:
4A. Primary prevention/ risk reduction or skeletal demineralization

4B. Impaired posture
4C. Impaired muscle per ormance
4D. Impaired joint mobility, motor unction, muscle per ormance, and range
o motion associated with connective tissue dys unction
4E. Impaired joint mobility, motor unction, muscle per ormance, and range
o motion associated with localized in ammation
4F. Impaired joint mobility, motor unction, muscle per ormance, range o motion,
and re ex integrity associated with spinal disorders
4G. Impaired joint mobility, motor unction, muscle per ormance, and range
o motion associated with racture
Clinical Reasoning and Decision Making 9
4H. Impaired joint mobility, motor unction, muscle per ormance, and range o
motion associated with joint arthroplasty
4I. Impaired joint mobility, motor unction, muscle per ormance, and range o motion
associated with bony or so t tissue surgery
4J. Impaired joint mobility, motor unction, muscle per ormance, gait, locomotion,
and balance associated with amputation
Clin ica l Pe a r l
Note that many of the rst descriptive words in Musculoskeletal Practice Patterns 4D-4J
are the same! They describe impairments and movement dysfunction commonly seen
and predictably related in similar diagnostic groups.
T e original T e Guide had areas o musculoskeletal practice not covered by the pre-
erred practice patterns. For instance, there was no pattern dealing with the management o
patients with impairments caused by upper-extremity amputations. Because T e Guide is
a uid document and is subject to updating and evolution, the second edition o T e Guide
included amputations o both the upper and the lower extremities. It is likely that other
diagnoses will be added to or placed in di erent practice patterns on a regular basis as prac-
tice evolves and T e Guide continues to evolve.
Overview of T e Guide: Parts 3 and 4

When the second edition and revision o T e Guide was initiated, a task orce o expert
clinicians and researchers was assembled to identi y the vast array o test and measures
used in examinations by a physical therapist and to collect the pertinent in ormation on
the reliability and validity o the tests or measures, as available in the peer-reviewed lit-
erature. Concom itantly, a second task orce was convened to identi y outcome m easures
relevant to physical therapist practice and provide sim ilar docum entation. T e work o
both groups was released on the CD-ROM version o T e Guide as the Catalog o ests
and Measures.3 T ese task orces also helped to create the outline o a m inimal data set
or initial examination and several templates or documentation, which can also be ound
in the second edition o T e Guide. Because the ocus o this textbook is intervention, the
reader is directed to other comprehensive texts that exist regarding examination in physi-
cal therapy or additional in ormation.
T e impact o T e Guide to Physical T erapist Practice on the pro ession o physi-
cal therapy is evident, although its utilization clinically and in academic institutions var-
ies. Ongoing incorporation o T e Guide into the practice o physical therapy will acilitate
dialogue and improved understanding o how clinicians classi y patients, develop clinical
diagnoses, and determine prognoses or common groups o patients and clients. T is docu-
ment will continue to be a part o the pro essional landscape will continue to in uence both
the practice o and public understanding o physical therapy in positive ways.
Clinical Reasoning and Decision Making

Physical therapists make decisions related to examination, evaluation, diagnosis, prog-
nosis, and intervention on a daily basis. Independent decision making is one o the hall-
marks o an autonomous pro ession, a status or which the pro ession o physical therapy
is striving.6 o make reasoned, independent decisions, the physical therapist must use
ref ned, well-developed, clinical reasoning skills. Higgs and Jones have def ned clinical rea-
soning as the practice used by the therapist to structure the health care process.12 Knowl-
edge, clinical data, patient pre erences, and pro essional judgment all play a role in clinical
reasoning. Clinical reasoning can also be described as the progression used by practitio-
ners to plan, direct, carry out, and re ect on patient care. Clearly clinical reasoning is not a
simple process; rather, it is a complex and multi aceted process o analysis and synthesis.
Such a process enables therapists to view the client and their rehabilitation with depth and
breadth o understanding.
Clinical reasoning is described by Edwards et al as “a way o thinking and taking action
within clinical practice” (Re . 6, p. 322). Clinical reasoning is o ten f rst utilized in the exami-
nation process and has both diagnostic and narrative components.6 T e construct known
as clinical reasoning has also been discussed in Chapter 3 in relationship to the scanning
examination. Once again, it is important to note that the clinical reasoning process cannot
be separated rom knowledge. I insu cient knowledge is present, it is likely that diagnoses
and decisions based on such knowledge will provide aulty conclusions. In other words, the
clinical reasoning process is only as strong and viable as the knowledge base rom which
the diagnosis or clinical decision is rendered.
Good clinical decision m aking is key to e ective patient/ client m anagem ent. Physi-
cal therapists play a critical role in assessing neurom usculoskeletal problem s, ormulat-
ing a com prehensive picture o the problem (s), and choosing interventions to e iciently
m anage the problem. As m ore patients enter the physical therapy system directly or via
the general practitioner, the ability o the therapist to skill ully assess patients and deter-
m ine the need or care is param ount. Many patients present or are re erred to therapy
without a clear diagnosis, especially in the realm o m usculoskeletal practice. At the
m ost basic level, the therapist m ust be able to m ake the crucial “keep–re er” decision
regarding whether the treatm ent n eeded is within their scope o practice. I the choice
is made to re er, the therapist must know how to do so in order to get the best care or
the patient.
Skill ul clinical decision making requires oundational knowledge o anatomy, kinesiol-
ogy, and biomechanics that is applied to each patient. T e use o such knowledge is critical
to assessing normal and abnormal movement, as well as understanding both the patho-
logic and normal healing processes. ogether, this rame o re erence helps the therapist
determine the diagnosis, prognosis, and plan o care.
acit knowledge combined with accumulated clinical experience contributes to the art
o the practice o physical therapy. Bruning, Schraw, and Ronning describe schem ata as the
complex representations o phenomenon by which individuals receive, store, and organize
in ormation.4 As schemata help therapists to organize and retrieve knowledge, scripts or
procedural rules help to guide thinking and organize common occurrences or events. Both
o these strategies support e ective processing o in ormation by providing e cient mental
rameworks or handling complex in ormation.
T ere are ew certainties in patient care. Rather, biologic, physiologic, and psychologi-
cal events occur in uncertain, but o ten in predictable patterns. Every problem solved or
decision made by a clinician is probabilistic11 and involves a combination o hypothesis
testing and pattern recognition. Hypothetic deductive reasoning and early hypothesis gen-
eration can occur with a limited database and is a way to structure the clinical examination
and thinking process. A hypothesis is really a clinical impression based on an assumption o
causality. By def nition, “a hypothesis is a testable idea—a tentative, but best, estimate that
only time can prove correct” (Re . 20, p. 1391). Hence, clinicians apply the clinical reason-
ing process to the clinical decision-making process or examination and diagnosis as well
as selection o interventions.
Clinical Reasoning and Decision Making 11
Clin ica l Pe a r l
Effective decision-making about evaluation, diagnosis, and prognosis requires approaching

the problem in a systematic and orderly fashion, and this approach can also carry over into
decisions about therapeutic interventions.
Clearly, reasoning does not occur in a “clinician induced vacuum.” Multiple actors play
a role in the clinical reasoning process, not the least o which is the identif ed problem as
it is seen and described by the patient. Narrative reasoning involves the ability to collect
and attempt to understand patients’ “stories,”6 experiences, perspectives, contexts, cultural
backgrounds, and belie s. It is important to remember that the patient’s personal descrip-
tive traits and characteristics, culture, past experiences and history, comorbidities, li e situ-
ation, and personal belie s all strongly a ect the process o clinical reasoning. Vital to the
process o treatment planning is taking into account the problems as they are seen by the
patient, named the patient-identif ed problems, as well as the non–patient-identif ed prob-
lems.19 Non–patient-identif ed problems are problems not identif ed by the patient that may
have been preexisting, unknown to a patient, or identif ed by the therapist or another. Iden-
tif cation o non–patient-identif ed problems are especially important or excellent care as
well as a prevention- and wellness-orientated practice o physical therapy as described in
T e Guide to Physical T erapist Practice ( able 1-1).1
T e second application o clinical reasoning is during the treatment planning and inter-
vention selection process. Edwards8 describes 6 types o reasoning that comprise decisions
made regarding management o patients and clients. T ese are procedural or intervention
reasoning, interactive patient–therapist rapport building reasoning, collaborative patient–
therapist reasoning, instructional reasoning, predictive reasoning, and ethical reasoning.
T e prior-listed clinical reasoning strategies are o ten used in combination. An emergent
able 1-1 HOAC II De nitio ns o f Pro ble ms
Type o f Pro ble m De nitio n Example s
PIPs Impairments, functional Pain, loss of ROM about

limitations, and disabilities, easily a joint, loss of strength,
identi ed by the patient impaired gait, impaired ADLs
NPIPs Problems identi ed by someone Postural impairments,

other than the patient such as a respiratory dysfunction,
health care provider, caregiver or general deconditioning,
family member musculoskeletal imbalances
Anticipated Problems that do not exist at the Secondary shortening of

problems current time, but may develop muscles because of poor
related to existing problems (both posture or gait deviations
PIPs and NPIPs); can be prevented
with proper management
ADL, Activities of daily living; NPIPs, non–patient-identi ed problems; PIPs, patient-identi ed problems;
ROM, range of motion.
Data from Rothstein J, Echternach J, Riddle D. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II):
a guide for patient management. Phys Ther. 2003;83:455-470.
dialectical model o clinical reasoning that includes cognitive and decision-making pro-
cesses (hypothetic-deductive reasoning), as well as reasoning skills necessary to interact
with patients in their individual unique sca old o experience, personality, and assump-
tions (narrative or communicative reasoning), has been reported in the literature.2,6,7,11,12
Although each individual must ultimately construct their own schemata and procedural
rules or clinical reasoning, tools exist that may assist practitioners to develop expert skills.20
Expert Versus Novice Decision Making

T ere is a well-developed body o literature about how experts make decisions.7,8,11,17 Expe-
rienced clinicians use a well-developed collection o clinical experiences or their reason-
ing, while novice clinicians rely on clear-cut patterns and clues. Experts see meaning ul
patterns, solve problems quickly, and rely on sel -monitoring (re ection).12
May and Dennis stated: “Experts, when compared with novices in the same f eld, exhibit
a superior structuring o knowledge into clinically relevant patterns that are unlocked by key
cues in the decision environment. Patterns stored in memory enable the expert to recognize
meaning ul relationships and generate likely hypotheses” (Re . 17, p. 191). In research across
many health pro essions, experts have been shown to excel within their specif c knowledge
domains, are able to see relationships, possess enhanced memory (relates to banked experi-
ence), are skilled in qualitative analysis, and have well-developed re ection skills.12
Likewise, researchers agree that novice decision makers unction di erently than their
expert counterparts. T ey tend to value quantitative data, likely have more error during the
process, and are slower in problem solving.12
How then do novices develop into competent decision makers and experts? Although
experience is necessary or the contextual problem-solving process used by experts, less is
known about the process o how problem-solving expertise is developed.13 A major distinc-
tion that has been described between expert and novice problem solvers is that experts
use orward reasoning rather than the backward reasoning or hypothetic-deductive process
used by novices.7,8 Forward reasoning is the application o a number o “i –then” rules to
a problem to move orward rom data to diagnosis or treatment intervention. An algorith-
mic approach seeks to use a number o “i –then” decisions to assist in problem solving. As
previously noted, any problem-solving model that attempts to assist novices and develop-
ing clinicians must take into account the knowledge base and organizational skills o the
individual. Practitioners with “high knowledge” make more in erences rom prior knowl-
edge than novices and intermediate level practioners.8 Interestingly, experts o ten seem to
do less problem solving than novices because they have a depth and breadth o previously
stored solutions to clinical problems that they recall and use.14 It should be noted, however,
that experience alone does not always provide accurate solutions to problems or enable
clinicians to make e cient, reasoned diagnoses. Although novices tend to solve problems
incorrectly or simplistically, experts can also develop patterned thinking and rely too heav-
ily on experience and make premature diagnoses without ully examining subtle possibili-
ties and varied data.15
Problem Solving, Clinical Decision Making,

and the Use of Evidence-Based Practice
Being a good problem solver is not su cient in this day and age. According to Miller,
Nyland, and Wormal, “rehabilitation clinicians must be creative problem solvers who can
translate relevant research into unctional interventions” (Re . 18, p. 453). It is important
Problem Solving, Clinical Decision Making, and the Use of Evidence-Based Practice 13
to remember that in contemporary physical therapy practice, decisions related to clinical
practice should be based on the best available evidence whenever possible.
Clinicians should use the available literature to determ ine the best treatm ent(s)
or their patients. Evidence-based practice has been def ned as “the conscientious and
judicious use o current best evidence in making decisions about the care o individual
patients.”21,25 Im plicit in this def nition is the need or a m ethod o determ ining what con-
stitutes the “best” evidence. Be ore evidence can be integrated into the managem ent o
patients, an appraisal o the quality o the evidence must be com pleted. A major problem
in the appraisal process is that o deciding whether the evidence is def nitive enough to
indicate an e ect other than chance. T e ability to judge and interpret the evidence or
intervention techniques is a skill that must be developed i a clinician wishes to becom e
evidenced based in their practice. T ere ore, the ability to interpret and evaluate the evi-
dence becomes an integral part in the clinical decision-making process. T e standard or
the assessm ent o the e cacy and value o intervention is the clinical trial. Most desirable
is the prospective study, which assesses the e ect and value o an intervention against
those ound in a control group, using human subjects.9 Un ortunately, many o the stud-
ies in the literature that address physical therapy topics are not clinical trials, as there
is no control to judge e cacy o the intervention and there are no interventions rom
which to draw com parisons.3 In addition to a control group, the ideal clinical trial uses
a blinded, random ized design, both or subject assignm ent to groups and or assess-
m ent o outcom es ( able 1-2).5 T e control can be a current standard practice, a placebo,
or no active intervention.9 Clinicians m ust constantly rem ind them selves that without
in ormation gathered rom controlled clinical trials, they have lim ited scientif c basis or
their interventions. Many interventions o ered by physical therapists use low levels o
evidence or worse, personal testim ony or the rationale behind their use. As the pro es-
sion grows and the evidence base rom which physical therapists can glean in ormation
able 1-2 Le ve ls o f Evide nce fo r Re se arch
Le ve l o f
Evide nce Type s o f Studie s
Level • High-quality randomized controlled trials

• Systematic review of level I randomized controlled trials
• Prospective studies (all patients enrolled at the same point in their
pathology with >80% follow-up of enrolled patients)
Level II • Prospective cohort studies

• Poor-quality randomized controlled trial (eg, no blinding, or improper
randomization, <80% follow-up)
• Systematic review of level II studies
• Retrospective study
• Study of untreated controls from a previous randomized controlled trial
Level III • Case-control studies

• Retrospective cohort studies
• Systematic review of level III studies
Level IV • Case series (no, or historical, control group)
Level V • Expert opinion
Data from the J Bone Joint Surg, instructions for Authors.

increases, the correctness, de ensibility, and ultimately the e ectiveness o chosen inter-
ventions can only increase.
Evidence-based practice is the standard to which physical therapists must strive or
direction in clinical decision-making and problem solving related to both diagnosis and
selection o interventions. Frequent, speedy use o evidence to answer clinical questions,
base decisions, or solve problems is mandatory as the pro ession o physical therapy con-
tinues to develop and grow.
Introduction to Algorithms
Algorithms are tools that assist practitioners in the development o expert skills. Encyclo-
pedia Britannica def nes an algorithm as “systematic procedure that produces—in a f nite
number o steps—the answer to a question or the solution o a problem.”10 An algorithm
provides a graphic, step-by-step procedure or guiding decision making. Alternately, algo-
rithms have been described as decision trees. In medical f elds, algorithms are developed
and used or clinical decision making related to the diagnostic process and management
o cases. Algorithms can provide structured care pathways and a systematic approach to
the selection o therapeutic interventions. Because algorithms are not prescriptive or proto-
col driven, they allow or clinical decisions and adjustments to be made during the clinical
reasoning and decision-making processes. Algorithmic thinking and the associated graphic
structure seems to f t the orward reasoning process previously described as being used
by experts. An algorithm is simply a decision tree f lled with “i –then” decisions related to
examination and intervention planning. Rothstein and Echternach 24 described a concep-
tual scheme or problem solving in physical therapy that they named the hypothesis-oriented
algorithm or clinicians (HOAC). T is algorithm-based scheme was designed to guide the
therapist rom evaluation to intervention planning with a logical sequence o activities. T e
HOAC requires the therapist to def ne goals or patient intervention and determine i they
have been met, thereby assisting in clinical decision making. It also requires that the thera-
pist generate hypotheses early in the examination process regarding the underlying cause(s)
o unctional limitations. Such a strategy is o ten used by expert physicians and therapists.
T e f rst part o the HOAC is a sequential guide to examination and planning o inter-
ventions. T e second part o the HOAC is a branching diagram (algorithm) that relates to
clinical decisions that must be made throughout the patient care interventions. T e HOAC
requires that the therapist relate all interventions to hypotheses, thereby orcing justif ca-
tion o all aspects o interventions. Use o such an algorithm-based approach should pro-
mote use o suitable, evidence-based interventions and discourage the use o “popular” or
routine interventions. In response to changes in the health care system and the practice
o physical therapy, the HOAC was revised and became the HOAC II (Figures 1-4 to 1-7).19
T e authors o the HOAC II contend that it links the use o evidence in decision making and
documentation o the type and scope o evidence used in the examination and intervention
processes. Such a linkage or connection between evidence and intervention selection and
planning is important in the current climate o health care. Physical therapists must jus-
ti y and provide evidence or selected interventions whenever possible. T e HOAC II also
provides the physical therapist with a tool or planning and evaluating activities intended
or prevention. Like the original HOAC, the second part o the HOAC II is an algorithm
that covers intervention, monitoring o intervention e ects, and altering the plan o care
appropriately to progress toward desired outcomes. Although a detailed discussion o the
HOAC and the HOAC II is beyond the scope o this chapter, both are valuable tools that
have in uenced the current authors thinking about use o algorithms in treatment planning
and intervention selection.
Introduction to Algorithms 15
Hypo the s is -Orie nte d Alg o rithm fo r Clinic ians II

(HOAC II–Part 1)
Co lle c t Initial Data

From re fe rra l informa tion, the me dica l re cord, via obs e rva tion be fore
a ny forma l eva lua tion is be gun, a nd from the inte rview
Ge ne rate Patie nt-Ide ntifie d Pro ble ms (PIPs ) Lis t

P roble ms lis te d a re a lmos t exclus ive ly de s criptions of functiona l limita tions a nd dis a bilitie s.
P roble ms a re de s cribe d s ole ly in pa tie nt-orie nte d te rms re fle cting the pa tie nt's views
of wha t he or s he ca n a nd ca nnot do.
Fo rmulate Examinatio n S trate g y

S tra te gy is ba s e d on a n initia l s e t of hypothe s e s ge ne ra te d from ava ila ble
da ta a nd the na ture of the pa tie nt-ide ntifie d proble ms.
Co nduc t the Examinatio n, Analyze Data, Re fine Hypo the s e s ,

Cons ulta tion
and Carry Out Additio nal Examinatio n Pro c e dure s
if ne e de d
Ne e de d to Co nfirm o r De ny Hypo the s e s
Add No n-Patie nt-Ide ntifie d Pro ble ms (NPIPs ) to the Pro ble m Lis t
The s e proble ms a re not ide ntifie d by the pa tie nt.
NP IP s a re ide ntifie d by the the ra pis t a nd othe rs working with the pa tie nt (this could include fa mily
me mbe rs ). NP IP s a re ofte n a nticipa te d proble ms. which, if not preve nte d from occurring,
will le a d to dis a bility a nd diminis he d he a lth s ta tus.
For Ea ch Exis ting For Ea ch Anticipa te d

P roble m P roble m
Ge ne rate a Hypo the s is (o r Hypo the s e s ) as Ide ntify the Ratio nale
to Why the Pro ble m Exis ts (by us e o f the o re tic al arg ume nts o r by us e o f data)
Hypothe s e s ofte n re pre s e nt the ide ntifica tion of a leve l of Fo r Be lieving Antic ipate d Pro ble ms Are Like ly
impa irme nt though to be ca us ing a proble m. S ome time s to Oc c ur Unle s s Inte rve ntio n Is Provide d
Hypothe s e s may be the ide ntifica tion of pa thologica l The jus tifica tion (ra tiona le ) for tre a ting a nticipa te d proble ms
proce s s e s ca us ing impa irme nts, functiona l limita tions, is the ca s e (a rgume nt) a s to why pa thologie s or
or dis a bilitie s. All hypothe s e s mus t be ve rifia ble through impa irme nts will le a d to functiona l limita tions a nd dis a bilitie s
obta ina ble me a s ure me nts. unle s s inte rve ntion is provide d.
Cons ulta tion Cons ulta tion

Go To “Re fine Pro ble m Lis t”
if ne e de d if ne e de d
Figure 1-4 HOAC II diag ram 1
The initial steps of part 1 of the HOAC II. (Reproduced, with permission, from the APTA, from Rothstein J, Echternach J, Riddle D.
The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83:455-470.)
(HOAC II–Part 1) (Co n tinu e d )
Re fine Pro ble m Lis t

Mos t proble ms will be ma inta ine d without modifica tion.
Ide ntify proble ms tha t s hould be tre a te d by othe r he a lth ca re worke rs (e limina te the s e proble ms
from the lis t), re fe r pa tie nt, a nd docume nt the ne e d for re fe rra l.
The proble m s ta te me nt s hould be a nnota te d s o tha t thos e proble ms not a me na ble to full
re s olution a re ide ntifie d a nd a modifie d proble m s ta te me nt ne e ds to be ge ne ra te d.
Cha nge s in the P IP s s hould only be done a fte r dis cus s ion with the pa tie nt a nd with
prope r docume nta tion.
Fo r Each Pro ble m: Es tablis h One o r Mo re Go als

Goa ls for exis ting proble ms us ua lly re pre s e nt me a s ura ble ta rge t leve ls of function (dis a bility)
tha t a pa tie nt will a chieve a s a re s ult of the inte rve ntion. The re mus t be a te mpora l e le me nt for e a ch
Re fe rra l
goa l (a n expe cta tion a s to whe n the goa l will be me t). Goa ls for a nticipa te d proble ms e s s e ntia lly
if ne e de d
cons is t of s ta te me nts a s to wha t proble ms will be avoide d a s a re s ult of inte rve ntion. Goa ls a re
a lways pa tie nt ce nte re d a nd a lways re pre s e nt outcome s tha t have va lue to the pa tie nt's curre nt
qua lity of life or future qua lity of life.
For Ea ch Exis ting For Ea ch Anticipa te d

P roble m P roble m
Es tablis h Te s ting Crite ria Es tablis h Pre dic tive Crite ria
Te s ting crite ria a re us e d to exa mine the corre ctne s s P re dictive crite ria a re ta rge t leve ls of me a s ure me nts
of the hypothe s e s. Te s ting crite ria us ua lly re pre s e nt or be haviora l a lte ra tions tha t ne e d to be obta ine d to
s pe cifie d leve ls (me a s ure me nts ) of a chieve me nts pre clude the occure nce of a nticipa te d proble ms.
(ofte n a t the impa irme nt leve l) tha t if obta ine d will re s ult Be ca us e a nticipa te d proble ms a nd re curre nce a re
in the re s olution of the proble m (a tta inme nt of the goa l), preve nte d, true te s ting of hypothe s e s re la te d to
but only if the hypothe s is is corre ct. a nticipa te d proble ms is not pos s ible.
Cons ulta tion Cons ulta tion

if ne e de d if ne e de d
Es tablis h a Plan to Re as s e s s Te s ting and Pre dic tive Crite ria
Es tablis h a Plan to As s e s s the S tatus o f Pro ble ms and Go als
The time inte rva l be twe e n a s s e s s me nt of cha nge s in the s ta tus of both type s of crite rion
me a s ure s (te s ting a nd pre dictive ) s hould be ba s e d on expe cte d cha nge s in thos e
me a s ure me nts, a nd thos e expe cta tions in turn s hould be ba s e d on the ore tica l a rgume nts
a nd da ta . Goa ls tha t ca n be expe cte d to be obta ine d s oone r may be te rme d “s hort-te rm
goa ls.” S hort- a nd long-te rm goa ls, the re fore, a re not diffe re nt in na ture but only in the time
pe riod expe cte d be fore they a re a chieve d.
Plan Inte rve ntio n S trate g y Bas e d o n Hypo the s e s and Antic ipate d Pro ble ms
Indica te why the s tra te gy s hould le a d to cha nge s in the crite rion me a s ure s.
Plan Tac tic s

Indica te how ta ctics a re expe cte d to a lte r crite rion me a s ure s (re la te e a ch ta ctic to a
crite rion me a s ure ). Indica te who will imple me nt ta ctics (e g. the ra pis ts, a s s is ta nts, a ide s,
fa mily me mbe rs, te a che rs, a nd the pa tie nt).
Cons ulta tion

Imple me nt Tac tic s
if ne e de d
The final steps of Part 1 of the HOAC II. (Reproduced, with permission, from the APTA, from Rothstein J, Echternach J, Riddle D.
The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83:455-470.)
Introduction to Algorithms 17
HOAC II – Part 2 (Exis ting Pro ble ms )
Re as s e s s me nt o f Exis ting Pro ble ms
Have Go als Be e n Me t?
No Ye s
Do Me as ure me nts Indic ate if the De te rmine whe the r me a s ure me nts indica te if the
Te s ting Crite ria Have Be e n Me t? te s ting crite ria ha ve be e n me t. Eva lua te
the cre dibility of the hypothe s e s ba s e d on
the me a s ure me nts .
No Ye s
Go als Have Be e n Ac hie ve d

Are Tac tic s Be ing Docume nt goa l a tta inme nt for e xis ting
Imple me nte d proble ms a nd note whe the r hypothe s is wa s
Co rre c tly? corre ct (re la te s ta tus of the crite rion
me a s ure to the s ta tus of the proble m).
Ye s For a ny goa l not me t, continue us ing the
No
a lgorithm. Whe n goa ls a re me t,
dis cha rge the pa tie nt.
Impro ve
Imple me ntatio n Are Tac tic s
Go to “Imple me nt Ta ctics ” Appro priate ?
s te p in P a rt 1.
Is Eac h Hypo the s is

Appro priate and Are
No Ye s
the Te s ting Crite ria
Co rre c t fo r That
Hypo the s is ?
Chang e
Tac tic s
Go to “P la n Ta ctics ” Is S trate g y
s te p in P a rt 1. Co rre c t? Hypothe s is Hypothe s is
Not Via ble Via ble
Re vis e the me a s ure me nt

Ye s Ge ne ra te ne w hypothe s is . us e d a s a te s ting crite ria ,
No
Go to “Ge ne ra te a Hypothe s is ” docume nt the re a s on, a nd go
s te p in P a rt 1. to “Imple me nt Ta ctics ”
Chang e s te p in P a rt 1.
S trate g y
Go to “P la n S tra te gy” Are Go als
s te p in P a rt 1. Viable ?
Nonvia ble Goa ls Via ble goa ls
Ge ne ra te ne w goa ls a fte r cons ulta tion with the Continue imple me nta tion
pa tie nt. Go to P a rt 1, docume nt the ne e d for of ta ctics a nd pla n
modifica tion a nd the na ture of the modifica tion. re a s s e s s me nt. Go to
If ne w hypothe s e s a re ne e de d, go to “Imple me nt Ta ctics ”
“Ge ne ra te a Hypothe s is ” s te p in P a rt 1. s te p in P a rt 1.
The algorithm for reassessment of existing problems in part 2 of the HOAC II. (Reproduced, with permission, from the
APTA, from Rothstein J, Echternach J, Riddle D. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient
management. Phys Ther. 2003;83:455-470.)
HOAC II – Part 2 (Antic ipate d Pro ble ms )
Re as s e s s me nt o f Antic ipate d Pro ble ms
Have Pro ble ms Oc c urre d?
No Ye s
Have Pre dic tive Crite ria Be e n Me t? Add proble m to me rge d proble m lis t in
P a rt 1. De te rmine whe the r
pre dictive crite ria we re me t. De te rmine
Ye s whe the r pre dictive crite ria we re a ppropria te .
No
Elimina te proble m from the lis t.

Are Pre dic tive Crite ria Appro priate ?
Appropria te Crite ria Ina ppropria te Crite ria
Are Tac tic s Be ing Re vis e Crite ria

Go to “Es ta blis h P re dictive Crite ria ”
Imple me nte d
Co rre c tly? s te p in P a rt 1. http://medical.dentalebooks.com
Go als Have Be e n Ac hie ve d
Docume nt goa l a tta inme nt.
Ye s For a nticipa te d proble ms , docume nt the
No
s ta tus of pre dictive crite ria .
For a ny goa l not me t, continue us ing the
a lgorithm. Whe n a ll goa ls a re me t,
Are Tac tic s
Impro ve dis cha rge the pa tie nt.
Appro priate ?
Imple me ntatio n
Go to “Imple me nt Ta ctics ”
s te p in P a rt 1. No Ye s
Is s trate g y
Chang e Co rre c t?
Tac tic s
Go to “P la n Ta ctics ”
s te p in P a rt 1. No Ye s
Are Go als
Chang e Viable ?
s trate g y
Go to “P la n S tra te gy”
s te p in P a rt 1.
Nonvia ble goa ls Via ble goa ls
Ge ne ra te ne w goa ls a fte r cons ulta tion with the Continue imple me nta tion
pa tie nt. Go to P a rt 1, docume nt the ne e d for of ta ctics a nd pla n
modifica tion a nd the na ture of the modifica tion. re a s s e s s me nt. Go to
If a ne w ra tiona le is ne e de d, go to “Imple me nt Ta ctics ”
“Re fine P roble m Lis t” s te p in P a rt 1. s te p in P a rt 1.
The algorithm for reassessment of anticipated problems in part 2 of the HOAC II. (Reproduced, with permission, from the
APTA, from Rothstein J, Echternach J, Riddle D. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient
management. Phys Ther. 2003;83:455-470.)
How to Construct an Algorithm 19
How to Construct an Algorithm

T e process o building a treatment algorithm is not complex. It involves using di er-
ently shaped boxes each representing or describing varied aspects o the algorithm.
able 1-3 shows and describes the three di erently shaped open orms, as described both
by Miller et al21 and Rothstein et al23 in the HOAC II-Part 2.
T ere are always 2 possible choices that arise rom the rectangular action/ intervention
or decision/ question box: a “yes” branch and a “no” branch. Based upon the answer to a
yes or no decision or question, the next path or trail down the algorithm is chosen. In the
Miller et al21 scheme, the yes or no treatment options or each path must be provided in the
algorithm, whereas in the Rothstein et al23 scheme, yes or no decisions may lead to another
question box or an intervention box. T e ollowing algorithm is a generic example o the
algorithms that will accompany each chapter and assist the reader in making and describ-
ing the many clinical decisions that combine to orm a cohesive therapeutic intervention.
T roughout the process o diagnostic reasoning, the identif cation o the specif c anatom-
ical structure or structures causing the impairment or dys unction prior to the initiation o an
intervention remains controversial. Cyriax7 designed his examination process to selectively
stress specif c tissues in order to identi y the structure involved and its stage o pathology. In
contrast, Maitland 18 and McKenzie 19 seldom identi y the involved structure, believing that it
is not always possible, or even necessary, or the prescription and sa e delivery o appropriate
therapeutic interventions. Based on the Maitland and McKenzie philosophy, the therapeutic
strategy is determined solely rom the responses obtained rom tissue loading and the e ect
that loading has on symptoms. Once these responses have been determined, the ocus o the
intervention is to provide sound and e ective sel -management strategies or patients that
avoid harm ul tissue overloading.16 Figure 1-8 is an example o an evaluation algorithm.
According to T e Guide to Physical T erapist Practice, an intervention is “the purpose ul
and skilled interaction o the physical therapist and the patient/ client and, when appropri-
ate, with other individuals involved in the patient/ client care, using various physical ther-
apy procedures and techniques to produce changes in the condition consistent with the
diagnosis and prognosis.”1 T e physical therapy intervention is composed o 3 interrelated
components: communication, coordination, and documentation; patient/ client-related
able 1-3 Shape s and De scriptio ns o f Alg o rithm Co mpo ne nts
Physical Re pre se ntatio n De scriptio n o f Fo rm Alte rnate Use o f Fo rms

o f Alg o rithm Shape Co nte nts (Mille r e t al21 ) (Ro thste in e t al23,24 )
http://medical.dentalebooks.com
The oval represents a clinical The oval represents an assessment
problem or entity. of an existing problem.
The rectangle represents an action The rectangle represents a decision

to be taken or an intervention to be or clinical question.
provided.
The hexagon represents a clinical The diamond represents

question that has become apparent, interventions, changes in
which leads to a decision based strategy or actions.
upon evidence, whenever possible.
Evaluatio n S c he me
Clinica l findings
Formula te working hypothe s is
S ta ge of he a ling S tructure involve d Move me nt/P os ition
Actue S uba cute Chronic Contra ctile Ine rt Aggra va ting Re lie ving
P a thoa na tomic P a thome cha nica l

dia gnos is dia gnos is
Figure 1-8 Ge ne ral e valuatio n sche me alg o rithm
instruction; and procedural interventions. As previously discussed, the patient/ client man-
agement model provides a structure within which interventions are chosen in relationship
to a movement-based categorization o signs and symptoms or a movement-based diagno-
sis (named in a pre erred practice pattern).
Choices related to physical therapy procedural interventions are most e ectively
addressed rom a problem-oriented approach, based on the knowledge o anatomy and
biomechanics, the evaluation, the patient’s unctional needs, and mutually agreed upon
goals.1 Decisions regarding the specif c interventions chosen are made in order to most
e ectively improve the patients’ ability to return to the previous level o unction. T e most
success ul intervention programs are those that are custom designed rom a blend o clini-
cal experience and scientif c data (see Chapter 19 or more in ormation on creating exercise
programs), with the level o improvement achieved related to goal setting and the attain-
ment o those goals.
Introduction to the 4-Phase

Approach to Rehabilitation
A number o principles should guide the intervention through the various stages o healing
and return to unction. T e comprehensive intervention usually ollows a 4-tiered approach,
beginning initially in the acute phase and progressing to subacute or intermediate phase,
then the advanced phase, and f nally, the return to unction. Within the 4-phase approach,
general intervention principles are applied. T ese are not listed in order o importance, but
instead re ect the sequence o application.
Acut e Phase (Figure 1-9)

Cont rol of Pain and In ammat ion
So t-tissue injuries are common in the general population and o ten are a reason or re er-
ral to physical therapy. T e results o most so t-tissue injuries include conditions o pain,
in ammation, and edema. Pain serves as the body’s protective mechanism, giving an
Introduction to the 4-Phase Approach to Rehabilitation 21
Inflammatio n/Pain
No Ye s
P a tie nt e duca tion & HEP P RICE/

(Re s trict a ctivitie s ? )(Bra ce or ta pe ? ) Mobiliza tions
Gra de I Gra de II
P rogre s s to mobility- Infla mma tion/P a in No

Ye s
ba s e d inte rve ntions De cre a s e s ? (try a ga in!)
Figure 1-9 In ammatio n/ pain alg o rithm
HEP, home exercise program.
individual cues as to protect the area rom additional tissue damage. At the simplest level,
the transmission o in ormation relating to pain rom the periphery to the central nervous
system depends upon integration at 3 levels: the spinal cord, the brainstem, and orebrain.
(Re er to Chapter 4 or an in-depth discussion o pain.)
In ammation and edema occur as a part o the healing process. T e in ammatory
response is a necessary initial response to an injury. Edema is a subsequent condition that
occurs as a result o the in ammatory response, which may inhibit healing and return to
unction. Consequently, the goals during this initial phase o intervention or an acute
injury are to decrease pain, control in ammation and edema, and protect the damaged
structures rom urther damage, while concurrently attempting to increase the range o
motion (ROM) and unction. During the acute phase o healing, the principles o PRICE
(protection, rest, ice, compression, and elevation) are recommended. In addition, manual
therapy and early motion are introduced to the rehabilitation process. Chapters 8 and 13
provide urther in ormation on ROM and manual techniques, respectively.
T e controlled application o a variety o techniques or control o pain, in ammation,
and edema can have many therapeutic benef ts. T ese benef ts are theoretically achieved
through :
• Mechanical stimulation o large-f ber joint a erents o the joint capsule, so t tissue,
and other structures that assists in pain reduction
• Stimulation o endogenous endorphins and enkephalins, which aid in pain reduction,
• Decrease o intraarticular pressure, which aids in pain reduction
• Mechanical e ects, which may improve joint mobility
• Positive e ects on remodeling o local connective tissue
• E ective gliding o tendons within their sheaths
• Increased joint lubrication, important or nourishment o articular cartilage.
Applicat ion of Int ervent ions t o Provide Early Mot ion

Early motion is important or:
• Reduction o the muscle atrophy that occurs primarily in type I f bers
• Maintenance o joint unction
• Prevention o ligamentous “creeping”
• Reduction o the chance o arthrof brosis or excessive so t tissue scarring
• Enhancement o cartilage nutrition and vascularization, crucial or healing.
Research has shown that joint motion is important or healing around a joint and early joint
motion stimulates collagen healing in the lines o orce, a kind o Wol law o ligaments.
Early ROM exercises may be per ormed actively or passively while protecting the healing
tissues.
Promot e and Progress Tissue Healing

issue repair ollows a predictable course in response to both internal and external pro-
cesses. Physical therapy cannot accelerate the healing process, but with correct interven-
tion choices can ensure that the healing process is not delayed or disrupted and occurs
optimally. T e support and sequence o tissue repair involve a care ul balance between pro-
tection and controlled application o unctional stresses to the healing tissue.
Clearly, the rehabilitation interventions used to assist during the repair process
di er, depen ding on the degree/ extent o the dam age, the tissue involved, and stage
o healing. Most tissues heal in a predictable m anner, with equally predictable m ark-
ers. T ese m arkers in orm the clinician as to the stage o the repair that the tissue is in.
Awareness o the various stages o healing is essential or determ ining the inten sity o
a particular intervention in order or clinician to avoid dam aging healing tissues. Deci-
sions to advance or change the rehabilitative process need to be based on the recogni-
tion o these signs and sym ptom s, and on an awareness o the tim e ram es associated
with each o the phases. For additional in orm ation on the phases o issue healing, re er
to Chapter 2.
Int ermediat e Phase (Figure 1-10)

T erapeutic exercise is the oundation o physical therapy and a primary component o the
bulk o interventions. In act, T e Guide to Physical T erapist Practice lists therapeutic exer-
cise as one o the 3 categories o procedural interventions that orms the core o most physi-
cal therapy plans o care.1 Prescribed appropriately, therapeutic exercise can be used to
regain, maintain, and advance a patient’s unctional status by increasing ROM and mobil-
ity ( exibility), muscle per ormance (strength, power, and endurance), and motor per or-
mance (neuromuscular skill).
T ere ore, as appropriate, it is the responsibility o the therapist to choose therapeutic
interventions and instruct the patient on a supplemental exercise program that
• Restores ull and pain- ree ROM. All clinicians would agree that the restoration o , or
improvement in, ROM is an important goal o the rehabilitation program. ROM may
be viewed as a combination o the amount o joint motion, joint play, and the degree
o extensibility o the periarticular and connective tissues that cross the joint, termed
f exibility.
Prior to intervention with aggressive ROM exercises, joint play must be normalized in
order to prevent complications that are likely to occur i abnormal osteo- and arthrokine-
matics during active and passive motion are present. In addition to general in ormation
available in Chapters 8 and 13, each regional chapter has specif c mobilization techniques
included.
Mo bility (ROM)
WNL?
No Ye s
Hype rmobile Hypomobile
Go to s ta bility Contra ctile

Ca ps ula r
(“S tre ngthe n” or Fa s cia l
S ta bilize rs )
J oint ROM
S tre tching &
mobiliza tions e xe rcis e s
s oft tis s ue
te chnique s
Gra de III Gra de IV
Re e va lua te
No P rogre s s to s ta bility &

(try a ga in!) Improve d ROM Ye s mus cle pe rforma nce
Figure 1-10 ROM alg o rithm
WNL, within normal limits.
A hierarchy exists or ROM during the subacute phase o healing to ensure that any pro-
gression is per ormed in a sa e and controlled ashion. T e hierarchy or the ROM exercises
is as ollows:
• Passive ROM
• Active-assisted ROM
• Active ROM
Advanced Phase (Figure 1-11)

In this phase o rehabilitation, the therapeutic exercise program must be progressed (both
in the clinic and at home), selecting interventions that
• Restore m uscular strength, power, and endurance. Like ROM, adequate muscular
strength, power, and endurance are prerequisites or unction. A wide variety o
interventions exist that address def cits o muscle per ormance, and the individual
therapist must decide what is the best intervention based upon a variety o patient
actors and characteristics. Physical therapists should be experts in selective exercise
prescription in order to increase all acets o muscle per ormance. Chapter 6 provides
the oundation or choices o therapeutic interventions or development o muscular
strength, power, and endurance.
S tability/Mus c le Pe rfo rmanc e
WNL?
No Ye s
Is ome trics Va ria ble s :

Mode
HEP P os ition
Corre ctive
Re s is ta nce type
e xe rcis e Wha te ve r you
S e ts /re ps
pa tte rns choos e …
Dura tion
Fre que ncy
Is otonics
Re s t
No S pe e d
(try a ga in!) Is okine tics
OKC/CKC
Ecce ntric
ove rloa d
Re e va lua te
P rogre s s to
S ta bility/s tre ngth
Ye s ne uromus cula r/functiona l
improve d?
tra ining**
Figure 1-11 Muscular stre ng th, po w e r, and e ndurance alg o rithm
**Note, neuromuscular and functional activities may be addressed during some of the
activities included in this phase. (CKC, closed kinetic chain; HEP, home exercise program;
OKC, open kinetic chain; WNL, within normal limits.)
T e hierarchy or the progression o resistive exercises or restoration o muscle per or-

mance impairments is
• Single-angle, submaximal isometrics per ormed in the neutral position
• Multiple-angle, submaximal isometrics per ormed at various angles o the range
• Multiple-angle maximal isometrics
• Submaximal, short arc, isotonic exercises
• Submaximal, ull ROM isotonic exercise
• Maximal short arc isotonic exercise, progressing to ull ROM maximal isotonics
• Open- and closed-kinetic chain exercises in the isotonic mode (re er to Chapter 11 or
more details on these topics)
• Isokinetics
Gentle resistive exercises can be introduced very early in the rehabilitative process.
At regular intervals, the clinician should ensure that
• T e patient is being compliant with the patient’s exercise program at home
• T e patient is aware o the rationale behind the exercise program
• T e patient is per orming the exercise program correctly and at the appropriate intensity
Ne uro mus c ular/Func tio nal Training
WNL
No Ye s
P NF
HEP
Ba la nce
tra ining
Dos a ge ,
NM re -e d s e ts ,
e xe rcis e s re ps ,
No e tc
(try a ga in!)
P lyome trics
ADL/s port
tra ining
Re e va lua te
Improve d ne uromus cula r function

Ye s D/C
a nd s ta bility? (to a cce pta ble le ve l)
Figure 1-12 Ne uro muscular e f cie ncy/ functio nal re turn alg o rithm
ADL, activities of daily living; D/C, discharge; HEP, home exercise program;
NM, neuromuscular; PNF, proprioceptive neuromuscular facilitation; Re-Ed, Re-education;
WNL, within normal limits.
• T e patient’s exercise program is being updated and appropriately based on clinical

f ndings and patient response.
Each regional chapter in this text also has many excellent suggestions or specif c thera-
peutic exercises or the advanced phase o rehabilitation where the ocus tends to be on
muscular per ormance enhancement.
Ret urn t o Funct ion Phase (Figure 1-12)

Assuming proper ROM and muscle per ormance, the f nal phase o rehabilitation involves
restoration o unction. In this phase, interventions are chosen that
• Restore neurom uscular e ciency and im prove the overall tness and unctional
outcom e o the patient. Restoration o neuromuscular control and e ciency is vital to
the unction o the patient. Complete ROM and exibility about a joint is not enough
or normal unction. Likewise, isolated muscular strengthening in any mode or

motion may not be su cient to provide the motor control and motor per ormance
necessary or the multitude o complex unctional tasks in which patients participate.
T ere ore, the f nal step o the rehabilitation process is the introduction o activities
that challenge neuromuscular unction in specif c motions, patterns, and tasks,
thereby assisting the patient to a return to the highest level o unction. Although
the restoration o neuromuscular e ciency and control is conceptually viewed as
the “last” part o the rehabilitation algorithm, it should be noted that techniques
to challenge the neuromuscular control system are present in several previous
intervention algorithms. For example, at the most basic level, active ROM challenges
the proprioceptive control system. Other exercises that are viewed primarily or
strengthening can also have a dual purpose o developing neuromuscular control.
Chapter 9 presents a detailed discussion o reactive neuromuscular training,
and Chapter 14 presents a comprehensive discussion o techniques to regain
postural stability and control. Likewise, Chapter 10 presents options or plyometric
interventions to challenge both muscular per ormance and neuromuscular
control. Additionally, each regional chapter has an excellent variety o advanced,
neuromuscular training interventions specif c to the region.
Functional Movement-Based T inking

T e authors o this chapter believe f rmly in the necessity o “ orward” or progressive unc-
tional thinking that must pervade the examination and rehabilitation process o all patients
and clients. T is will be urther addressed in the application o the concepts o mobility
and stability to both examination and intervention paradigms. Although perhaps obvious,
the gaps in examination intervention that are seen clinically are o ten a result o the lack o
ocus on unction and unctional outcomes. I the assessment o unctional movement is
used as the basic oundation or the physical therapy examination, it becomes easier to iso-
late the specif c impairments that contribute to the dys unction. T us, philosophically, the
authors adhere to a unctionally ocused examination (presented in Chapter 17). T rough-
out the text, the reader will notice the strong ocus on unction in the general intervention
sections, as well as in the regional intervention chapters. T is unctional ocus is specif cally
applied with regard to intervention, progression o intervention, and testing or return to
activities in Chapters 18 and 19.
Conclusion
Physical therapist practice changes rapidly. echniques, skills, and patterns o practice are
constantly evolving and changing. T e best physical therapists are those who grow and
change as practice changes, rely upon evidence-based practice, but maintain a systematic,
unctional approach to examination and intervention.
Clinical reasoning and decision-making are im portant to the e cient and e ec-
tive treatm ent o patients. T ese constructs develop over tim e, and can be enhanced by
the use o available m odels such as the patient-client managem ent m odel described in
T e Guide.
Algorithms are one way to illustrate the process o clinical reasoning. T ey are a graphic
representation o a series o “i / then” decisions that may assist clinicians in developing
diagnoses and selecting interventions. T ey serve to structure the process o clinical reason-
ing and illustrate the sequential nature o the clinical reasoning process used by therapists
Conclusion 27
with experience and expertise. Finally, because evidence in physical therapy is constantly
developing and changing, algorithms should not be viewed as static, rigid, or prescriptive
decision-making tools. T e clinical reasoning process is a complex, nonlinear process that
requires a su cient knowledge base and application o that knowledge in relation to an
ever-changing base o evidence.
SUMMARY
1. T e Guide to Physical T erapist Practice was published to describe the practice o physi-
cal therapy.
2. Subsequent revisions have made updates, improvements, and changes in the content
o T e Guide.
3. T e Guide is not a cookbook or provision care, but rather a document to describe ex-
amination, evaluation, and intervention possibilities, as well as to use clinical decision-
making to improve the quality o physical therapy services.
4. T e pre erred practice patterns are structured with diagnostic labels that are based
upon impairments.
5. T e quality o physical therapy provision, in terms o both diagnostic reasoning and
selection o interventions, may be impacted by the use o algorithms.
6. Clinical reasoning skills are strongly related to experience and develop over a career.
7. Clinical decision processes o experts and novices di er. Algorithms may be a tool to
enhance the process in novices and progress their skills toward that o experts.
8. All clinical reasoning should be an application o evidence-based practice.
9. T e algorithmic approach to clinical reasoning may be used to guide intervention se-
lection, in broad terms however, su cient evidence does not yet exist to allow them to
specif cally direct clinical intervention decisions.
10. Algorithmic thinking can be applied to all subsequent chapters and is use ul in the
4-phased rehabilitation model which includes:
• Acute phase
• Intermediate phase
• Advanced phase
• Return to unction
REFERENCES
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to physical therapist practice. Phys T er. 1997;77: coordination o theory and evidence in novice diagnostic
1163-1650. reasoning. Med Decis Making. 1993;13:198-211.
2. American Physical T erapy Association. T e Guide 5. Bloch R. Methodology in clinical back pain trials. Spine.
to Physical T erapist Practice. 2nd ed. Phys T er. 1987;12:430-432.
2001;81(1):9-738. 6. Bruning R, Schraw G, Ronning R. Cognitive Psychology. 3rd
3. American Physical T erapy Association. T e Interactive ed. Upper Saddle River, NJ: Merrill; 1999.
Guide to Physical T erapist Practice, with Catalog o ests 7. Cyriax J. T e diagnosis o so t tissue lesions. In: Cyriax J, ed.
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Physical T erapy Association; 2003. Woode Ballantyne; 1978.
8. Edwards I, Jones M, Carr J, Baunack-Mayer A, Jensen G. 17. Kahney H. Problem Solving: Current Issues. Buckingham,
Clinical reasoning strategies in physical therapy. Phys T er. UK: Open University Press; 1993.
2004;84(4):312-330. 18. Maitland GD. Maitland’s Vertebral Manipulation. 6th ed.
9. Elstein A, Schwarz A. Evidence base o clinical diagnosis: Ox ord, UK: Butterworth Heinemann; 2001.
clinical problem solving and diagnostic decision 19. McKenzie RA. T e Lum bar Spine: Mechanical Diagnosis
making—selective review o the cognitive literature. and T erapy. Waikanae, New Zealand: Spinal Publications;
BMJ. 2002;324:729-732. 1989.
10. Elstein A, Shulman L, Spra ka S. Medical problem 20. May B, Dennis J. Expert decision making in physical
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1990;13:5-36. 1991;71:190-216.
11. Friedman LM, Furberg CD, DeMets DL. Fundamentals o 21. Miller , Nyland J, Wormal W. T erapeutic exercise
clinical trials. St. Louis, MO: Mosby-Year Books; 1985. program design considerations: “Putting it all together.”
12. http:/ / www.britannica.com/ eb/ article-9005707?query= In: Nyland J, ed. Clinical Decisions in T erapeutic Exercise.
algorithm&ct=. Accessed on August 15, 2012. Upper Saddle River, NJ: Pearson Education; 2006.
13. Hack L. Foundations or modalities as procedural 22. Nagi SZ. Disability and Rehabilitation. Columbus,
interventions: principles o clinical decision making. OH: Ohio State University Press; 1969.
In: Michlovitz SL, Nolan P, ed. Modalities or T erapeutic 23. Rothstein J, Echternach J, Riddle D. T e hypothesis-
Intervention. 4th ed. Philadelphia, PA: FA Davis; 2005. oriented algorithm or clinicians II (HOAC II):
14. Higgs J, Jones M. Clinical reasoning in the health a guide or patient management. Phys T er. 2003;83:
pro essions. In: Higgs J, Jones M, eds. Clinical Reasoning in 455-470.
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Heinemann; 2000. algorithm or clinicians: a method or evaluation
15. Jensen G, Shepard K, Gwyer J, Hack L. Attribute and treatment planning. Phys T er. 1986;66:
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16. Jette A. Physical disablement concepts or physical therapy 312:71-72.
research and practice. Phys T er. 1994;74:375-382.
Understanding and
Managing the Healing
Process T rough
Rehabilitation
Willia m E. Pre n t ice
OBJJECTIVE
Describe the pathophysiology of the healing process.
Identify the factors that can impede the healing process.
Discuss the etiology and pathology of various musculoskeletal injuries associated with various
types of tissues.
Compare healing processes relative to speci c musculoskeletal structures.
Explain the importance of initial rst aid and injury management of these injuries and their
impact on the rehabilitation process.
Discuss the use of various analgesics, antiin ammatories, and antipyretics in facilitating the
healing process during a rehabilitation program.
29
30 Chapte r 2 Understanding and Managing the Healing Process Through Rehabilitation
Injury rehabilitation requires sound knowledge and understanding o the etiology and
pathology involved in various musculoskeletal injuries that may occur.24,84,93 When injury
occurs, the therapist is charged with designing, implementing, and supervising the reha-
bilitation program. Rehabilitation protocols and progressions must be based primarily on
the physiologic responses o the tissues to injury and on an understanding o how vari-
ous tissues heal.39,43,46 T us the therapist must understand the healing process to ef ectively
supervise the rehabilitative process. T is chapter discusses the healing process relative to
the various musculoskeletal injuries that may be encountered by an therapist.
Understanding the Healing Process

Rehabilitation programs must be based on the cycle o the healing process (Figure 2-1).
T e therapist must have a sound understanding o the sequence o the various phases o
the healing process.31 T e physiologic responses o the tissues to trauma ollow a predictable
sequence and time rame.41 Decisions on how and when to alter and progress a rehabilita-
tion program should be primarily based on recognition o signs and symptoms, as well as
on an awareness o the time rames associated with the various phases o healing.57,72
T e healing process consists o the in ammatory response phase, the broblastic repair
phase, and the maturation remodeling phase. It must be stressed that although the phases
TRAUMA
P RIMARY INJ URY

Blood
Gre a te r ris k of re injury Da ma ge d tis s ue Re duce d ris k of re injury
S ECONDARY RES P ONS E

Ede ma
He ma toma S ca b
Hypoxic da ma ge d tis s ue
Ble e ding
Re turn to a ctivity Re turn to full a ctivity
INFLAMMATION
P a in
S pa s m
Le s s tha n optima l Optima l re cove ry

REP AIR P HAS ES
re cove ry
S ubs tra te
Fibrobla s tic
Ma tura tion
Ina de qua te ATROP HY Ade qua te
REHABILITATION
Figure 2-1 A cycle o f spo rt-re late d injury
(From Booher and Thibadeau. Athletic Injury Assessment. Mosby; 1994.)

Understanding the Healing Process 31
o healing are presented as 3 separate entities, the healing process is a continuum. Phases o
the healing process overlap one another and have no de nitive beginning or end points.73
Primary Injury
Primary injuries are almost always described as being either chronic or acute in nature,
resulting rom macrotraumatic or microtraumatic orces. Injuries classi ed as macro-
traumatic occur as a result o acute trauma and produce immediate pain and disability.
Macrotraumatic injuries include ractures, dislocations, subluxations, sprains, strains, and
contusions. Microtraumatic injuries are most o ten called overuse injuries and result rom
repetitive overloading or incorrect mechanics associated with repeated motion.59 Micro-
traumatic injuries include tendinitis, tenosynovitis, bursitis, etc. A secondary injury is
essentially the in ammatory or hypoxia response that occurs with the primary injury.
In ammat ory Response Phase

Once a tissue is injured, the process o healing begins immediately (Figure 2-2A).16 T e
destruction o tissue produces direct injury to the cells o the various so t tissues.35 Cellular
injury results in altered metabolism and the liberation o materials that initiate the in am-
matory response. It is characterized symptomatically by redness, swelling, tenderness, and
increased temperature.18,54 T is initial in ammatory response is critical to the entire heal-
ing process.14 I this response does not accomplish what it is supposed to or i it does not
subside, normal healing cannot take place.37
In ammation is a process through which leukocytes and other phagocytic cells and
exudates are delivered to the injured tissue. T is cellular reaction is generally protective,
tending to localize or dispose o injury by-products (eg, blood and damaged cells) through
phagocytosis, thus setting the stage or repair. Local vascular ef ects, disturbances o uid
exchange, and migration o leukocytes rom the blood to the tissues occur.38
Clin ic a l Pe a r l
Immediate action to control swelling can expedite the healing process. The therapist should
rst provide compression and elevation. Applying ice, which decreases the metabolic
demands of the uninjured cells, can prevent secondary hypoxic injury. Ice also slows nerve
conduction velocity, which will decrease pain and thus limit muscle guarding.
Vascular React ion

T e vascular reaction involves vascular spasm, ormation o a platelet plug, blood coagula-
tion, and growth o brous tissue.77 T e immediate response to tissue damage is a vasocon-
striction o the vascular walls in the vessels leading away rom the site o injury that lasts or
approximately 5 to 10 minutes. T is vasoconstriction presses the opposing endothelial wall
linings together to produce a local anemia that is rapidly replaced by hyperemia o the area
as a result o vasodilation.11 T is increase in blood ow is transitory and gives way to slow-
ing o the ow in the dilated vessels, thus enabling the leukocytes to slow down and adhere
to the vascular endothelium. Eventually there is stagnation and stasis. T e initial ef usion o
blood and plasma lasts or 24 to 36 hours.
Chemical Mediat ors

T e events in the in ammatory response are initiated by a series o interactions involv-
ing several chemical mediators. Some o these chemical mediators are derived rom the
invading organism, some are released by the damaged tissue, others are generated by
several plasma enzyme systems, and still others are products o various white blood cells
Wound Blood clot
Epide rmis
of s kin
De rmis Ma cropha ge s
of s kin
Fibrobla s t
Ne utrophils
Le ukocyte
A Cut blood ve s s e ls ble e d into the wound. B Blood clot forms, a nd le ukocyte s cle a n wound.
Blood clot S ca b
http://medical.dentalebooks.com
Gra nula tion
tis s ue Re ge ne ra te d
s tra tum ba s a le
Ma cropha ge s (e pide rmis )
S ca r tis s ue
Re growth of
(fibros is )
blood ve s s e l
Fibrobla s t
Fibrobla s t
C Blood ve s s e ls re grow, a nd gra nula tion tis s ue forms. D S tra tum ba s a le re ge ne ra te s, a nd conne ctive tis s ue fibros is occurs.
Figure 2-2 Initial injury and in ammato ry re spo nse phase o f the he aling pro ce ss
A. Cut blood vessels bleed into the wound. B. Blood clot forms, and leukocytes clean the wound. C. Blood vessels regrow,
and granulation tissue forms in the fibroblastic repair phase of the healing process. D. Epithelium regenerates, and
connective tissue fibrosis occurs in the maturation-remodeling phase of the healing process. (Reproduced with permission
from Prentice. Principles of Athletic Training. 14th ed. New York: McGraw-Hill; 2011.)
participating in the in ammatory response. T ree chemical mediators—histamine, leukot-

rienes, and cytokines—are important in limiting the amount o exudate, and thus swell-
ing, a ter injury. Histamine, released rom the injured mast cells, causes vasodilation and
increased cell permeability, owing to a swelling o endothelial cells and then separation
between the cells. Leukotrienes and prostaglandins are responsible or margination, in
which leukocytes (neutrophils and macrophages) adhere along the cell walls. T ey also
increase cell permeability locally, thus af ecting the passage o the uid and white blood
cells through cell walls via diapedesis to orm exudate. Consequently, vasodilation and
active hyperemia are important in exudate (plasma) ormation and in supplying leukocytes
to the injured area. Cytokines, in particular chemokines and interleukin, are the major
regulators o leukocyte tra c and help to attract leukocytes to the actual site o in amma-
tion. Responding to the presence o chemokines, phagocytes enter the site o in ammation
within a ew hours. T e amount o swelling that occurs is directly related to the extent o
vessel damage.
Format ion of a Clot

Platelets do not normally adhere to the vascular wall. However, injury to a vessel disrupts
the endothelium and exposes the collagen bers. Platelets adhere to the collagen bers
to create a sticky matrix on the vascular wall, to which additional platelets and leukocytes
adhere and eventually orm a plug. T ese plugs obstruct local lymphatic uid drainage and
thus localize the injury response (see Figure 2-2B).
T e initial event that precipitates clot ormation is the conversion o brinogen to
brin. T is trans ormation occurs because o a cascading ef ect, beginning with the release
o a protein molecule called throm boplastin rom the damaged cell. T romboplastin causes
prothrombin to be changed into thrombin, which, in turn, causes the conversion o brino-
gen into a very sticky brin clot that shuts of blood supply to the injured area. Clot orma-
tion begins around 12 hours a ter injury and is completed within 48 hours.
As a result o a combination o these actors, the injured area becomes walled of during
the in ammatory stage o healing. T e leukocytes phagocytize most o the oreign debris
toward the end o the in ammatory phase, setting the stage or the broblastic phase. T is
initial in ammatory response lasts or approximately 2 to 4 days a ter initial injury.
It can take up to 3 or 4 days for the in ammatory response to subside. During this time,
the muscle is initializing repair by containing the injury by clot formation. Too much stress
during this time could increase the time it takes the muscle to heal. After that, it may take
a couple of weeks before broblastic and myoblastic activity has restored tissue strength to
a point where the tissue can withstand the stresses of exercise.
Chronic In ammat ion

A distinction must be made between the acute in ammatory response as previously
described and chronic in ammation. Chronic in ammation occurs when the acute in am-
matory response does not respond su ciently to eliminate the injuring agent and restore
tissue to its normal physiologic state. T us, only low concentrations o the chemical media-
tors are present. T e neutrophils that are normally present during acute in ammation are
replaced by macrophages, lymphocytes, broblasts, and plasma cells. As this low-grade
in ammation persists, damage occurs to connective tissue, resulting in tissue necrosis and
brosis prolonging the healing process. Chronic in ammation involves the production o
granulation tissue and brous connective tissue. T ese cells accumulate in a highly vas-
cularized and innervated loose connective tissue matrix in the area o injury.53 T e spe-
ci c mechanisms that cause an insu cient acute in ammatory response are unknown, but
they appear to be related to situations that involve overuse or overload with cumulative
microtrauma to a particular structure.28,53 T ere is no speci c time rame in which the acute
in ammation transitions to chronic in ammation. It does appear that chronic in amma-
tion is resistant to both physical and pharmacologic treatments.44
Use of Ant iin ammat ory Medicat ions

A physician will routin ely prescribe n on steroidal antiin am m atory drugs (NSAIDs)
or a patient who has sustained an injury.2 T ese m edications are certainly ef ective in
m inim izing pain and swelling associated with in am m ation an d can enhance return
to norm al activity. However, there are som e concerns that the use o NSAIDs acutely
ollowing injury m ight actually inter ere with in am m ation, thus delaying the healing
process.
Fibroblast ic Repair Phase

During the broblastic phase o healing, proli erative and regenerative activity leading to
scar ormation and repair o the injured tissue ollows the vascular and exudative phenom-
ena o in ammation (see Figure 2-2C).41 T e period o scar ormation re erred to as bro-
plasia begins within the rst ew hours a ter injury and can last as long as 4 to 6 weeks.
During this period, many o the signs and symptoms associated with the in ammatory
response subside. T e patient might still indicate some tenderness to touch and will usually
complain o pain when particular movements stress the injured structure. As scar orma-
tion progresses, complaints o tenderness or pain gradually disappear.39
During this phase, growth o endothelial capillary buds into the wound is stimulated
by a lack o oxygen, a ter which the wound is capable o healing aerobically.18 Along with
increased oxygen delivery comes an increase in blood ow, which delivers nutrients essen-
tial or tissue regeneration in the area.18
T e ormation o a delicate connective tissue called granulation tissue occurs with the
breakdown o the brin clot. Granulation tissue consists o broblasts, collagen, and capil-
laries. It appears as a reddish granular mass o connective tissue that lls in the gaps during
the healing process.
As the capillaries continue to grow into the area, broblasts accumulate at the wound
site, arranging themselves parallel to the capillaries. Fibroblastic cells begin to synthesize
an extracellular matrix that contains protein bers o collagen and elastin, a ground sub-
stance that consists o non brous proteins called proteoglycans, glycosaminoglycans, and
uid. On about day 6 or 7, broblasts also begin producing collagen bers that are depos-
ited in a random ashion throughout the orming scar. As the collagen continues to proli er-
ate, the tensile strength o the wound rapidly increases in proportion to the rate o collagen
synthesis. As the tensile strength increases, the number o broblasts diminishes, signaling
the beginning o the maturation phase.
T is normal sequence o events in the repair phase leads to the ormation o mini-
mal scar tissue. Occasionally, a persistent in ammatory response and continued release
o in ammatory products can promote extended broplasia and excessive brogenesis,
which can lead to irreversible tissue damage.97 Fibrosis can occur in synovial structures,
as with adhesive capsulitis in the shoulder, in extraarticular tissues including tendons and
ligaments, in bursa, or in muscle.
Muscle healing generally takes longer than ligament. While broblasts are laying down new
collagen for connective tissue repair, myoblasts are working to replace the contractile tissue.
The Import ance of Collagen

Collagen is a major structural protein that orms strong, exible, inelastic structures that
hold connective tissue together. T ere are at least 16 types o collagen, but 80% to 90% o
the collagen in the body consists o types I, II, and III. ype I collagen is ound in skin, as-
cia, tendon, bone, ligaments, cartilage, and interstitial tissues; type II can be ound in hya-
line cartilage and vertebral disks; and type III is ound in skin, smooth muscle, nerves, and
blood vessels. ype III collagen has less tensile strength than does type I, and tends to be
ound more in the broblastic repair phase. Collagen enables a tissue to resist mechani-
cal orces and de ormation. Elastin, however, produces highly elastic tissues that assist in
recovery rom de ormation. Collagen brils are the loadbearing elements o connective tis-
sue. T ey are arranged to accommodate tensile stress, but are not as capable o resisting
shear or compressive stress. Consequently, the direction o orientation o collagen bers is
along lines o tensile stress.93
Collagen has several mechanical and physical properties that allow it to respond to
loading and de ormation, permitting it to withstand high tensile stress. T e mechanical
properties o collagen include elasticity, which is the capability to recover normal length
a ter elongation; viscoelasticity, which allows or a slow return to normal length and shape
a ter de ormation; and plasticity, which allows or permanent change or de ormation. T e
physical properties include orce relaxation, which indicates the decrease in the amount o
orce needed to maintain a tissue at a set amount o displacement or de ormation over time;
creep response, which is the ability o a tissue to de orm over time while a constant load is
imposed; and hysteresis, which is the amount o relaxation a tissue has undergone during
de ormation and displacement. Injury results when the mechanical and physical limita-
tions o connective tissue are exceeded.103
Mat urat ion Remodeling Phase

T e maturation remodeling phase o healing is a long-term process (see Figure 2-2D). T is
phase eatures a realignment or remodeling o the collagen bers that make up scar tissue
according to the tensile orces to which that scar is subjected. Ongoing breakdown and syn-
thesis o collagen occur with a steady increase in the tensile strength o the scar matrix. With
increased stress and strain, the collagen bers realign in a position o maximum e ciency
parallel to the lines o tension.21 T e tissue gradually assumes normal appearance and unc-
tion, although a scar is rarely as strong as the normal injured tissue. Usually by the end o
approximately 3 weeks, a rm, strong, contracted, nonvascular scar exists. T e maturation
phase o healing might require several years to be totally complete.
Role of Progressive Cont rolled Mobilit y During t he Healing Process

T e Wolf law states that bone and so t tissue will respond to the physical demands placed
on them, causing them to remodel or realign along lines o tensile orce.101 Consequently,
it is critical that injured structures be exposed to progressively increasing loads throughout
the rehabilitative process.73
In animal models, controlled mobilization is superior to immobilization or scar or-
mation, revascularization, muscle regeneration, and reorientation o muscle bers and
tensile properties.71 However, a brie period o immobilization o the injured tissue dur-
ing the in ammatory response phase is recommended and will likely acilitate the process
o healing by controlling in ammation, thus reducing clinical symptoms. As healing pro-
gresses to the repair phase, controlled activity directed toward return to normal exibility
and strength should be combined with protective support or bracing.50 Generally, clinical
signs and symptoms disappear at the end o this phase.
As the remodeling phase begins, aggressive active range-o -motion and strengthening
exercises should be incorporated to acilitate tissue remodeling and realignment. o a great
extent, pain will dictate rate o progression. With initial injury, pain is intense; it tends to
decrease and eventually subside altogether as healing progresses. Any exacerbation o pain,
swelling, or other clinical symptoms during or a ter a particular exercise or activity indicate
that the load is too great or the level o tissue repair or remodeling. T e therapist must be
aware o the time required or the healing process and realize that being overly aggressive
can inter ere with that process.
Once an injured structure has progressed through the in ammatory phase and repair has
begun, suf cient tensile stress should be provided to ensure optimal repair and positioning
of the new bers (according to the Wolff law). Efforts should be made right away to avoid
the strength loss that comes with immobility because of pain.
Fact ors That Impede Healing

Ext ent of Injury
T e nature o the in ammatory response is determined by the extent o the tissue injury.
Microtears or so t tissue involve only minor damage and are most o ten associated with
overuse. Macrotears involve signi cantly greater destruction o so t tissue and result in
clinical symptoms and unctional alterations. Macrotears are generally caused by acute
trauma.19
Edema
T e increased pressure caused by swelling retards the healing process, causes separation
o tissues, inhibits neuromuscular control, produces re exive neurologic changes, and
impedes nutrition in the injured part. Edema is best controlled and managed during the
initial rst-aid management period, as described previously.17
Hemorrhage
Bleeding occurs with even the smallest amount o damage to the capillaries. Bleeding pro-
duces the same negative ef ects on healing as does the accumulation o edema, and its pres-
ence produces additional tissue damage and thus exacerbation o the injury.67
Poor Vascular Supply

Injuries to tissues with a poor vascular supply heal poorly and at a slow rate. T is response
is likely related to a ailure in the initial delivery o phagocytic cells and broblasts neces-
sary or scar ormation.67
Separat ion of Tissue

Mechanical separation o tissue can signi cantly impact the course o healing. A wound
that has smooth edges in good apposition will tend to heal by primary intention with mini-
mal scarring. Conversely, a wound that has jagged, separated edges must heal by secondary
intention, with granulation tissue lling the de ect, and excessive scarring.76
Muscle Spasm
Muscle spasm causes traction on the torn tissue, separates the 2 ends, and prevents
approximation. Local and generalized ischemia can result rom spasm.
At rophy
Wasting away o muscle tissue begins immediately with injury. Strengthening and early
mobilization o the injured structure retard atrophy.
Cort icost eroids

Use o corticosteroids in the treatment o in ammation is controversial. Steroid use in the
early stages o healing has been demonstrated to inhibit broplasia, capillary proli eration,
collagen synthesis, and increases in tensile strength o the healing scar. T eir use in the later
stages o healing and with chronic in ammation is debatable.
Injuries to Articular Structures 37
Keloids and Hypert rophic Scars

Keloids occur when the rate o collagen production exceeds the rate o collagen breakdown
during the maturation phase o healing. T is process leads to hypertrophy o scar tissue,
particularly around the periphery o the wound.
Infect ion
T e presence o bacteria in the wound can delay healing, causes excessive granulation tis-
sue, and requently causes large, de ormed scars.12
Humidit y, Climat e, and Oxygen Tension

Humidity signi cantly in uences the process o epithelization. Occlusive dressing stimu-
lates the epithelium to migrate twice as ast without crust or scab ormation. T e ormation
o a scab occurs with dehydration o the wound and traps wound drainage, which promotes
in ection. Keeping the wound moist provides an advantage or the necrotic debris to go to
the sur ace and be shed.
Oxygen tension relates to the neovascularization o the wound, which translates into
optimal saturation and maximal tensile strength development. Circulation to the wound
can be af ected by ischemia, venous stasis, hematomas, and vessel trauma.
Healt h, Age, and Nut rit ion

T e elastic qualities o the skin decrease with age. Degenerative diseases, such as diabetes
and arteriosclerosis, also become a concern o the older patient and can af ect wound heal-
ing. Nutrition is important or wound healing—in particular, vitamins C ( or collagen syn-
thesis and immune system), K ( or clotting), and A ( or the immune system); zinc ( or the
enzyme systems) and amino acids play critical roles in the healing process.
Injuries to Articular Structures

Be ore discussing injuries to the various articular struc-
tures, a review o joint structure is in order (Figure 2-3).66
All synovial joints are composed o 2 or more bones that
articulate with one another to allow motion in 1 or more
places. T e articulating sur aces o the bone are lined with
a very thin, smooth, cartilaginous covering called a hyaline
cartilage. All joints are entirely surrounded by a thick, liga-
P roxima l
mentous joint capsule. T e inner sur ace o this joint cap- pha la nx
sule is lined by a very thin synovial membrane that is highly
vascularized and innervated. T e synovial membrane
produces synovial uid, the unctions o which include
lubrication, shock absorption, and nutrition o the joint.89 Liga me nt
J oint ca vity Articula r
Some joints contain a thick brocartilage called a conta ining ca rtila ge s
m eniscus. T e knee joint, or example, contains 2 wedge- s ynovia l fluid
shaped menisci that deepen the articulation and provide Fibrous
P e rios te um
ca ps ule J oint
shock absorption in that joint. Finally, the main struc- Bone ca ps ule
S ynovia l
tural support and joint stability is provided by the liga- me mbra ne
Middle
ments, which may be either thickened portions o a joint pha la nx
capsule or totally separate bands.
Ligament Sprains
Ligam ents are com posed o dense connective tissue
Figure 2-3 Ge ne ral anato my o f a syno vial jo int
arranged in parallel bundles o collagen composed o (Reproduced with permission from Prentice. Principles of Athletic
rows o broblasts. Although bundles are arranged in Training. 14th ed. New York: McGraw-Hill; 2011.)
parallel, not all collagen bers are arranged in parallel.

Ligaments and tendons are very similar in structure.
Fe mur However, ligaments are usually more attened than ten-
Comple te dons, and collagen bers in ligaments are more compact.
Te a r T e anatomical positioning o the ligaments determines
(gra de 3) in part what motions a joint can make.
La te ra l
A sprain involves damage to a ligament that provides
me nis cus
La te ra l support to a joint. A ligament is a tough, relatively inelastic
colla te ra l
liga me nt
band o tissue that connects one bone to another. A liga-
Tlbia ment’s primary unction is three old: to provide stability to
Fibula
a joint, to provide control o the position o one articulat-
ing bone to another during normal joint motion, and to
provide proprioceptive input or a sense o joint position
Figure 2-4 Grade 3 lig ame nt sprain in the kne e through the unction o ree nerve endings or mechanore-
jo int ceptors located within the ligament.
I stress is applied to a joint that orces motion
(Reproduced with permission from Prentice. Principles of Athletic
Training. 14th ed. New York: McGraw-Hill; 2011.) beyond its normal limits or planes o movement, injury to
the ligament is likely (Figure 2-4).34 T e severity o dam-
age to the ligament is classi ed in many dif erent ways; however, the most commonly used
system involves 3 grades (degrees) o ligamentous sprain:
Grade 1 sprain : T ere is some stretching or perhaps tearing o the ligamentous bers,
with little or no joint instability. Mild pain, little swelling, and joint stif ness might
be apparent.
Grade 2 sprain : T ere is some tearing and separation o the ligamentous bers and
moderate instability o the joint. Moderate-to-severe pain, swelling, and joint
stif ness should be expected.
The presence of gross laxity would suggest a grade 3 sprain. The patient be referred to the
physician for further evaluation.
Grade 3 sprain : T ere is total rupture o the ligament, mani ested primarily by
gross instability o the joint. Severe pain might be present initially, ollowed
by little or no pain because o total disruption o nerve bers. Swelling might
be pro use, and thus the joint tends to become very stif some hours a ter the
injury. A third-degree sprain with marked instability usually requires some orm
o immobilization lasting several weeks. Frequently, the orce producing the
ligament injury is so great that other ligaments or structures surrounding the joint
are also injured. With cases in which there is injury to multiple joint structures,
surgical repair reconstruction may be necessary to correct an instability.
In a complete ligament tear, it is likely that the nerves in that structure will also be
completely disrupted. Therefore, no pain signals can be transmitted.
Physiology of Ligament Healing

T e healing process in the sprained ligament ollows the same course o repair as with other
vascular tissues. Immediately a ter injury and or approximately 72 hours there is a loss o
blood rom damaged vessels and attraction o in ammatory cells into the injured area. I a
ligament is sprained outside o a joint capsule (extraarticular ligament), bleeding occurs in a
Injuries to Articular Structures 39
subcutaneous space. I an intraarticular ligament is injured, bleeding occurs inside o the joint
capsule until either clotting occurs or the pressure becomes so great that bleeding ceases.
During the next 6 weeks, vascular proli eration with new capillary growth begins to
occur along with broblastic activity, resulting in the ormation o a brin clot. It is essential
that the torn ends o the ligament be reconnected by bridging this clot. Synthesis o collagen
and ground substance o proteoglycan as constituents o an intracellular matrix contrib-
utes to the proli eration o the scar that bridges between the torn ends o the ligament. T is
scar initially is so t and viscous but eventually becomes more elastic. Collagen bers are
arranged in a random woven pattern with little organization. Gradually there is a decrease
in broblastic activity, a decrease in vascularity, and an increase to a maximum in collagen
density o the scar.4 Failure to produce enough scar and ailure to reconnect the ligament
to the appropriate location on a bone are the two reasons why ligaments are likely to ail.
Over the next several months the scar continues to mature, with the realignment o
collagen occurring in response to progressive stresses and strains. T e maturation o the
scar may require as long as 12 months to complete.4 T e exact length o time required or
maturation depends on mechanical actors such as apposition o torn ends and length o
the period o immobilization.
Fact ors Affect ing Ligament Healing

Surgically repaired extraarticular ligaments have healed with decreased scar ormation and
are generally stronger than unrepaired ligaments initially, although this strength advantage
might not be maintained as time progresses. Unrepaired ligaments heal by brous scarring
ef ectively lengthening the ligament and producing some degree o joint instability. With
intraarticular ligament tears, the presence o synovial uid dilutes the hematoma, thus pre-
venting ormation o a brin clot and spontaneous healing.42
Several studies show that actively exercised ligaments are stronger than those that are
immobilized. Ligaments that are immobilized or periods o several weeks a ter injury tend
to decrease in tensile strength and also exhibit weakening o the insertion o the ligament to
bone.72 T us it is important to minimize periods o immobilization and progressively stress
the injured ligaments while exercising caution relative to biomechanical considerations or
speci c ligaments.4,68
It is not likely that the inherent stability o the joint provided by the ligament be ore
injury will be regained. T us, to restore stability to the joint, the other structures that sur-
round that joint, primarily muscles and their tendons, must be strengthened. T e increased
muscle tension provided by resistance training can improve stability o the injured joint.68,88
Cart ilage Damage

Cartilage is a type o rigid connective tissue that provides support and acts as a ramework
in many structures. It is composed o chondrocyte cells contained in small chambers called
lacunae, surrounded completely by an intracellular matrix. T e matrix consists o varying
ratios o collagen and elastin and a ground substance made o proteoglycans and glycos-
aminoglycans, which are non brous protein molecules. T ese proteoglycans act as sponges
and trap large quantities o water, which allow cartilage to spring back a ter being com-
pressed.96 Cartilage has a poor blood supply, thus healing a ter injury is very slow. T ere are
3 types o cartilage. Hyaline cartilage is ound on the articulating sur aces o bone and in the
so t part o the nose. It contains large quantities o collagen and proteoglycan. Fibrocarti-
lage orms the intervertebral disk and menisci located in several joint spaces. It has greater
amounts o collagen than proteoglycan and is capable o withstanding a great deal o pres-
sure. Elastic cartilage is ound in the auricle o the ear and the larynx. It is more exible than
the other types o cartilage and consists o collagen, proteoglycan, and elastin.79
Osteoarthrosis is a degenerative condition o bone and cartilage in and about the joint.
Arthritis should be de ned as primarily an in ammatory condition with possible secondary
destruction.6 Arthrosis is primarily a degenerative process with destruction o cartilage,

remodeling o bone, and possible secondary in ammatory components.
Cartilage brillates, that is, releases bers or groups o bers and ground substance
into the joint.29 Peripheral cartilage that is not exposed to weightbearing or compression–
decompression mechanisms is particularly likely to brillate. Fibrillation is typically ound
in the degenerative process associated with poor nutrition or disuse. T is process can then
extend even to weightbearing areas, with progressive destruction o cartilage proportional
to stresses applied on it. When orces are increased, thus increasing stress, osteochondral or
subchondral ractures can occur. Concentration o stress on small areas can produce pres-
sures that overwhelm the tissue’s capabilities. ypically, lower-limb joints have to handle
greater stresses, but their sur ace area is usually larger than the sur ace area o upper limbs.
T e articular cartilage is protected to some extent by the synovial uid, which acts as a lubri-
cant. It is also protected by the subchondral bone, which responds to stresses in an elastic
ashion. It is more compliant than compact bone, and micro ractures can be a means o
orce absorption. rabeculae might racture or might be displaced due to pressures applied
on the subchondral bone. In compact bone, racture can be a means o de ense to dissipate
orce. In the joint, orces might be absorbed by joint movement and eccentric contraction
o muscles.27
In the majority o joints where the sur aces are not congruent, the applied orces tend
to concentrate in certain areas, which increases joint degeneration. Osteophytosis occurs
as a bone attempts to increase its sur ace area to decrease contact orces. People typically
describe this growth as “bone spurs.” Chondromalacia is the nonprogressive trans orma-
tion o cartilage with irregular sur aces and areas o so tening. It typically occurs rst in
non-weightbearing areas and may progress to areas o excessive stress.26
In physically active individuals, certain joints maybe more susceptible to a response
resembling osteoarthrosis.70 T e proportion o body weight resting on the joint, the pull
o the musculotendinous unit, and any signi cant external orce applied to the joint are
predisposing actors. Altered joint mechanics caused by laxity or previous trauma are also
actors that come into play.45 T e intensity o orces can be great, as in the hip, where the
previously mentioned actors can produce pressures or orces 4 times that o body weight
and up to 10 times that o body weight on the knee.
ypically, muscle orces generate more stress than body weight itsel . Particular injuries
are conducive to osteoarthritic changes such as subluxation and dislocation o the patella,
osteochondritis dissecans, recurrent synovial ef usion, and hemarthrosis. Also, ligamen-
tous injuries can bring about a disruption o proprioceptive mechanisms, loss o adequate
joint alignment, and meniscal damage in the knees with removal o the injured meniscus.40
Other actors that have an impact are loss o ull range o motion, poor muscular power
and strength, and altered biomechanics o the joint. Spurring and spiking o bone are not
synonymous with osteoarthrosis i the joint space is maintained and the cartilage lining is
intact. It may simply be an adaptation to the increased stress o physical activity.29
Physiology of Cart ilage Healing

Cartilage has a relatively limited healing capacity. When chondrocytes are destroyed and
the matrix is disrupted, the course o healing is variable, depending on whether damage is
to cartilage alone or also to subchondral bone. Injuries to the articular cartilage alone ail to
elicit clot ormation or a cellular response. For the most part the chondrocytes adjacent to
the injury are the only cells that show any signs o proli eration and synthesis o matrix. T us
the de ect ails to heal, although the extent o the damage tends to remain the same.33,58
I subchondral bone is also af ected, in ammatory cells enter the damaged area and
ormulate granulation tissue. In this case, the healing process proceeds normally, with
dif erentiation o granulation tissue cells into chondrocytes occurring in approximately
2 weeks. At approximately 2 months, normal collagen has been ormed.
Injuries to Bone 41
Injuries to the knee articular cartilage are extremely common, and until recently, meth-
ods or treatment did not produce good long-term results.102 A better understanding o how
articular cartilage responds to injury has produced various techniques that hold promise or
long-term success.91 One such technique is autologous chondrocyte implantation, in which
a patient’s own cartilage cells are harvested, grown ex vivo, and reimplanted in a ull-thick-
ness articular sur ace de ect. Results are available with up to 10 years o ollow-up, and more
than 80% o patients have shown improvement with relatively ew complications.
Injuries to Bone
Bone is a type o connective tissue consist-
ing o both living cells and minerals deposited Articula r
in a matrix (Figure 2-5). Each bone consists ca rtila ge
o 3 major components. T e epiphysis is an
Epiphysis
expanded portion at each end o the bone that
articulates with another bone. Each articu- Re d bone
lating sur ace is covered by an articular, or ma rrow
hyaline, cartilage. T e diaphysis is the sha t Epiphys e a l
o the bone. T e epiphyseal or growth plate is line
the major site o bone growth and elongation. Ma rrow ca vity
Once bone growth ceases, the plate ossi es and
orms the epiphyseal line. With the exception o
Ye llow bone ma rrow
the articulating sur aces, the bone is completely
enclosed by the periosteum, a tough, highly
vascularized and innervated brous tissue.55 P e rios te um
T e 2 types o bone material are cancellous,
or spongy, bone and cortical, or compact, bone.
Nutrie nt fora me n
Cancellous bone contains a series o air spaces Dia phys is
re erred to as trabeculae, whereas cortical bone
is relatively solid. Cortical bone in the diaphysis
orms a hollow medullary canal in long bone,
which is lined with endosteum and lled with
bone marrow. Bone has rich blood supply that
certainly acilitates the healing process a ter S ite of e ndos te um
injury. Bone has the unctions o support, move-
ment, and protection. Furthermore, bone stores Compa ct bone
and releases calcium into the bloodstream and
manu actures red blood cells.93
S pongy bone
Fract ures Epiphys e a l

line
Epiphys is
Fractures are extrem ely com m on injuries
among the athletic population. T ey can be Articula r
ca rtila ge
generally classi ed as being either open or
closed. A closed racture involves little or no (a) Living (b) Drie d
displacement o bones and thus little or no so t-
tissue disruption. An open racture involves
enough displacement o the ractured ends that Figure 2-5 The g ro ss structure o f the lo ng bo ne s include s
the bone actually disrupts the cutaneous layers the diaphysis, e piphysis, articular cartilag e , and pe rio ste um
and breaks through the skin. Both ractures can (Reproduced with permission from Saladin. Anatomy and physiology. 5th ed.
be relatively serious i not managed properly, Dubuque, IA: McGraw-Hill; 2010.)
but an increased possibility o in ection exists in an open racture. Fractures may also be
considered complete, in which the bone is broken into at least 2 ragments, or incomplete,
where the racture does not extend completely across the bone.
T e varieties o ractures that can occur include greenstick, transverse, oblique, spiral,
comminuted, avulsion, and stress. A greenstick racture (Figure 2-6A) occurs most o ten in
children whose bones are still growing and have not yet had a chance to calci y and harden.
It is called a greenstick racture because o the resemblance to the splintering that occurs to
a tree twig that is bent to the point o breaking. Because the twig is green, it splinters but can
be bent without causing an actual break.
A transverse racture (see Figure 2-6B) involves a crack perpendicular to the longitudinal
axis o the bone that goes all the way through the bone. Displacement might occur; however,
because o the shape o the ractured ends, the surrounding so t tissue (eg, muscles, tendons,
and at) sustains relatively little damage.
A linear racture runs parallel to the long axis o a bone and is similar in severity to a
transverse racture (see Figure 2-6C).
An oblique racture (see Figure 2-6D) results in a diagonal crack across the bone and
2 very jagged, pointed ends that, i displaced, can potentially cause a good bit o so t- tissue
damage. Oblique and spiral ractures are the 2 types most likely to result in compound
ractures.
A spiral racture (see Figure 2-6E) is similar to an oblique racture in that the angle
o the racture is diagonal across the bone. In addition, an element o twisting or rotation
causes the racture to spiral along the longitudinal axis o the bone. Spiral ractures used to
be airly common in ski injuries occurring just above the top o the boot when the bindings
on the ski ailed to release when the oot was rotated. T ese injuries are now less common
as a result o improvements in equipment design.
A comminuted racture (see Figure 2-6F) is a serious problem that can require an
extremely long time or rehabilitation. In the comminuted racture, multiple ragments
o bone must be surgically repaired and xed with screws and wires. I a racture o this
type occurs to a weightbearing bone in the leg, a permanent discrepancy in leg length can
develop.
An avulsion racture occurs when a ragment o bone is pulled away at the bony attach-
ment o a muscle, tendon, or ligament. Avulsion ractures are common in the ngers and
some o the smaller bones but can also occur in larger bones where tendinous or ligamen-
tous attachments are subjected to a large amount o orce.
Gre e ns tick Tra ns ve rs e , nondis pla ce d Line a r Oblique , nondis pla ce d S pira l Comminute d
Figure 2-6 Fracture s o f bo ne
A. Greenstick. B. Transverse. C. Linear. D. Oblique. E. Spiral. F. Comminuted. (Reproduced with permission from Prentice.
Essentials of Athletic Injury Management. 9th ed. New York: McGraw-Hill; 2013.)
Injuries to Bone 43
Perhaps the most common racture resulting rom physical activity is the stress racture.
Unlike the other types o ractures that have been discussed, the stress racture results rom
overuse or atigue rather than acute trauma.49 Common sites or stress ractures include
the weightbearing bones o the leg and oot. In either case, repetitive orces transmitted
through the bones produce irritations and micro ractures at a speci c area in the bone. T e
pain usually begins as a dull ache that becomes progressively more pain ul day a ter day.
Initially, pain is most severe during activity. However, when a stress racture actually devel-
ops, pain tends to become worse a ter the activity is stopped.80
T e biggest problem with a stress racture is that o ten it does not show up on an X-ray
lm until the osteoblasts begin laying down subperiosteal callus or bone, at which point a
small white line, or a callus, appears. However, a bone scan might reveal a potential stress
racture in as little as 2 days a ter onset o symptoms. I a stress racture is suspected, the
patient should stop any activity that produces added stress or atigue to the area or a mini-
mum o 14 days. Stress ractures do not usually require casting but might become normal
ractures that must be immobilized i handled incorrectly.92 I a racture occurs, it should be
managed and rehabilitated by a quali ed orthopedist and physical therapist.
Physiology of Bone Healing

Healing o injured bone tissue is similar to so t-tissue healing in that all phases o the healing
process can be identi ed, although bone regeneration capabilities are somewhat limited.
However, the unctional elements o healing dif er signi cantly rom those o so t tissue.
ensile strength o the scar is the single most critical actor in so t-tissue healing, whereas
bone has to contend with a number o additional orces, including torsion, bending, and
compression.46 rauma to bone can vary rom contusions o the periosteum to closed, non-
displaced ractures to severely displaced open ractures that also involve signi cant so t-
tissue damage. When a racture occurs, blood vessels in the bone and the periosteum are
damaged, resulting in bleeding and subsequent clot ormation (Figure 2-7). Hemorrhag-
ing rom the marrow is contained by the periosteum and the surrounding so t tissue in the
Ma rrow
cavity
Fibroca rtila ge
Ha rd
ca llus
He ma toma S oft ca llus S pongy
bone
New blood
ve s s e ls
Compa ct bone
A He mato ma fo rmatio n B S o ft c allus fo rmatio n C Hard c allus fo rmatio n D Bo ne re mo de ling

The he ma toma is conve rte d De pos ition of colla ge n a nd Os te obla s ts de pos it a te mpora ry S ma ll bone fra gme nts a re
to gra nula tion tis s ue by inva s ion fibroca rtila ge conve rts gra nula tion bony colla r a round the fra cture to re move d by os te ocla s ts, while
of ce lls a nd blood ca pilla rie s. tis s ue to a s oft ca llus. unite the broke n pie ce s while os te obla s ts de pos it s pongy
os s ifica tion occurs. bone a nd the n conve rt it to
compa ct bone.
Figure 2-7 The he aling o f a fracture
A. Blood vessels are broken at the fracture line; the blood clots and forms a fracture hematoma. B. Blood vessels grow into
the fracture and a brocartilage soft callus forms. C. The brocartilage becomes ossi ed and forms a bony callus made
of spongy bone. D. Osteoclasts remove excess tissue from the bony callus and the bone eventually resembles its original
appearance. (Reproduced with permission from Prentice. Principles of Athletic Training. 14th ed. New York: McGraw-Hill; 2011.)
region o the racture. In approximately 1 week, broblasts begin laying down a brous col-
lagen network. T e brin strands within the clot serve as the ramework or proli erating
vessels. Chondroblast cells begin producing brocartilage, creating a callus between the
broken bones. At rst, the callus is so t and rm because it is composed primarily o collage-
nous brin. T e callus becomes rm and more rubbery as cartilage beings to predominate.
Bone-producing cells called osteoblasts begin to proli erate and enter the callus, orming
cancellous bone trabeculae, which eventually replace the cartilage. Finally the callus crys-
tallizes into bone, at which point remodeling o the bone begins. T e callus can be divided
into two portions, the external callus located around the periosteum on the outside o the
racture and the internal callus ound between the bone ragments. T e size o the callus is
proportional both to the damage and to the amount o irritation to the racture site during
the healing process. Also during this time osteoclasts begin to appear in the area to resorb
bone ragments and clean up debris.42,46,83
T e remodeling process is similar to the growth process o bone in that the brous car-
tilage is gradually replaced by brous bone and then by more structurally e cient lamel-
lar bone. Remodeling involves an ongoing process during which osteoblasts lay down new
bone and osteoclasts remove and break down bone according to the orces placed upon the
healing bone.62 T e Wolf law maintains that a bone will adapt to mechanical stresses and
strains by changing size, shape, and structure. T ere ore, once the cast is removed, the bone
must be subjected to normal stresses and strains so that tensile strength can be regained
be ore the healing process is complete.36,90
T e time required or bone healing is variable and based on a number o actors, such
as severity o the racture, site o the racture, extensiveness o the trauma, and age o the
patient. Normal periods o immobilization range rom as short as 3 weeks or the small
bones in the hands and eet to as long as 8 weeks or the long bones o the upper and lower
extremities. In some instances, such as ractures in the 4 small toes, immobilization might
not be required or healing. T e healing process is certainly not complete when the splint or
cast is removed. Osteoblastic and osteoclastic activity might continue or 2 to 3 years a ter
severe ractures.49,62
Injuries to Musculotendinous Structures

Muscle is o ten considered to be a type o connective tissue, but here it is treated as the third
o the undamental tissues. T e 3 types o muscles are sm ooth (involuntary), cardiac, and
skeletal (voluntary) muscles. Smooth muscle is ound with the viscera, where it orms the
walls o the internal organs, and within many hollow chambers. Cardiac muscle is ound
only in the heart and is responsible or its contraction. A signi cant characteristic o the car-
diac muscle is that it contracts as a single ber, unlike smooth and skeletal muscles, which
contract as separate units. T is characteristic orces the heart to work as a single unit con-
tinuously; there ore, i one portion o the muscle should die (as in myocardial in arction),
contraction o the heart does not cease.79
Skeletal muscle is the striated muscle within the body, responsible or the movement o
bony levers (Figure 2-8). Skeletal muscle consists o 2 portions: (a) the muscle belly, and (b)
its tendons, which are collectively re erred to as a musculotendinous unit. T e muscle belly
is composed o separate, parallel elastic bers called m yof brils. Myo brils are composed o
thousands o small sarcomeres, which are the unctional units o the muscle. Sarcomeres
contain the contractile elements o the muscle, as well as a substantial amount o connec-
tive tissue that holds the bers together. Myo laments are small contractile elements o
protein within the sarcomere. T ere are 2 distinct types o myo laments: thin actin m yo-
f lam ents and thicker m yosin m yof lam ents. Fingerlike projections, or crossbridges, connect
Injuries to Musculotendinous Structures 45
Mus cle
fibe r
Nucle us
A ba nd
I ba nd
Z dis c
Mitochondria Ope nings into

tra ns ve rs e tubule s
S a rcopla s mic
re ticulum
Tria d:
Te rmina l cis te rna e
Tra ns ve rs e tubule
S a rcole mma
Myofibrils
S a rcopla s m
Myofila me nts
A
Figure 2-8 Parts o f a muscle
A. Muscle is composed of individual muscle fibers (muscle cells). Each muscle fiber contains myofibrils in which
the banding patterns of the sarcomeres are seen. B. The myofibrils are composed of actin myofilament and myosin
myofilaments, which are formed from thousands of individual actin and myosin molecules. (Reproduced with permission
from Saladin. Anatomy and Physiology. 6th ed. New York: McGraw-Hill; 2012.)
the actin and myosin myo laments.83 When a muscle is stimulated to contract, the cross-
bridges pull the myo laments closer together, thus shortening the muscle and producing
movement at the joint that the muscle crosses.25
T e muscle tendon attaches the muscle directly to the bone. T e muscle tendon is
composed primarily o collagen bers and a matrix o proteoglycan, which is produced by
the tenocyte cell. T e collagen bers are grouped together into primary bundles. Groups o
primary bundles join together to orm hexagonal-shaped secondary bundles. Secondary
bundles are held together by intertwined loose connective tissue containing elastin, called
the endotenon. T e entire tendon is surrounded by a connective tissue layer, called the epi-
tenon. T e outermost layer o the tendon is the paratenon, which is a double-layer connec-
tive tissue sheath lined on the inside with synovial membrane (Figure 2-9).56
All skeletal muscles exhibit 4 characteristics: (a) elasticity, the ability to change in
length or stretch ; (b) extensibility, the ability to shorten and return to normal length ; (c)
excitability, the ability to respond to stimulation rom the nervous system ; and (d) contrac-
tility, the ability to shorten and contract in response to some neural command.55
Skeletal muscles show considerable varia-

tion in size and shape. Large muscles gener-
ally produce gross motor movements at large
joints, such as knee exion produced by con-
He a d
Ta il
traction o the large, bulky hamstring muscles.
Smaller skeletal muscles, such as the long ex-
ors o the ngers, produce ne motor move-
ments. Muscles producing movements that are
(a) Myo s in mo le c ule power ul in nature are usually thicker and lon-
ger, whereas those producing ner movements
Myos in he a d requiring coordination are thin and relatively
shorter. Other muscles may be at, round, or
an-shaped.42,83 Muscles may be connected to
a bone by a single tendon or by 2 or 3 sepa-
rate tendons at either end. Muscles that have
2 separate muscle and tendon attachm ents
are called biceps, and muscles with 3 separate
muscle and tendon attachments are called
triceps.
(b) Thick filame nt
Muscles contract in response to stimula-
tion by the central nervous system. An electrical
Tropomyos in Troponin complex G a ctin impulse transmitted rom the central nervous
system through a single motor nerve to a group
o muscle bers causes a depolarization o
those bers. T e motor nerve and the group o
muscle bers that it innervates are collectively
re erred to as a motor unit. An impulse coming
(c ) Thin filame nt rom the central nervous system and traveling
to a group o bers through a particular motor
Thick fila me nt nerve causes all the muscle bers in that motor
Thin fila me nt unit to depolarize and contract. T is is re erred
Ba re zone to as the all-or-none response and applies to all
skeletal muscles in the body.42
Muscle St rains
I a musculotendinous unit is overstretched or
orced to contract against too much resistance,
exceeding the extensibility limits or the tensile
capabilities o the weakest component within
the unit, damage can occur to the muscle
(d) Po rtio n o f a s arc o me re s howing the ove rlap bers, at the musculotendinous juncture, in the
o f thick and thin filame nts tendon, or at the tendinous attachment to the
B bone.34 Any o these injuries may be re erred
to as a strain (Figure 2-10). Muscle strains, like
ligament sprains, are subject to various classi -
Figure 2-8 (Co n t in u e d )
cation systems. T e ollowing is a simple system
o classi cation o muscle strains:
Grade 1 strain : Some muscle or tendon bers have been stretched or actually torn.
Active motion produces some tenderness and pain. Movement is pain ul, but ull
range o motion is usually possible.
Injuries to Musculotendinous Structures 47
Endote non
Te ndon fibe r
P rima ry
fa s cicle s P a ra te non
Epite non
Figure 2-9 Structure o f a te ndo n
Grade 2 strain : Some muscle or tendon bers have been torn and active contraction
o the muscle is extremely pain ul. Usually a palpable depression or divot exists
somewhere in the muscle belly at the spot where the muscle bers have been
torn. Some swelling might occur because o capillary bleeding.
Grade 3 strain : T ere is a complete rupture o muscle bers in the muscle belly, in
the area where the muscle becomes tendon, or at the tendinous attachment
to the bone. T e patient has signi cant impairment to, or perhaps total loss o ,
movement. Pain is intense initially but diminishes quickly because o complete
separation o the nerve bers. Musculotendinous ruptures are most common
in the biceps tendon o the upper arm or in the Achilles heel cord in the back
o the cal . When either o these tendons rupture, the muscle tends to bunch
toward its proximal attachment. With the exception o an Achilles rupture, which
is requently surgically repaired, the majority o third-degree strains are treated
conservatively with some period o immobilization.
Physiology of Muscle Healing

Injuries to muscle tissue involve similar processes o healing and repair as discussed or other
tissues. Initially there will be hemorrhage and edema ollowed almost immediately by phago-
cytosis to clear debris. Within a ew days there is a proli eration o ground substance, and
broblasts begin producing a gel-type matrix that surrounds the connective tissue, leading to
brosis and scarring. At the same time, myoblastic cells orm in the area o injury, which will
eventually lead to regeneration or new myo brils. T us regeneration o both connective tissue
and muscle tissue begins.13
Collagen bers undergo maturation and orient themselves along lines o tensile orce
according to the Wolf law. Active contraction o the muscle is critical in regaining normal
tensile strength.5,50
Regardless o the severity o the strain, the time required or rehabilitation is airly
lengthy. In many instances, rehabilitation time or a muscle strain is longer than that or a
ligament sprain. T ese incapacitating muscle strains occur most requently in the large, orce-
producing hamstring and quadriceps muscles o the lower extremity. T e treatment o ham-
string strains requires a healing period o at least 5 to 8 weeks and a considerable amount
o patience. Attempts to return to activity too soon

requently cause reinjury to the area o the muscu-
lotendinous unit that has been strained, and the
healing process must begin again.60
Glute us me dius
Tendinit is/Tendinosis
O all the overuse problems associated with physi-
cal activity, tendinitis is among the most common.48
Glute us ma ximus endinitis is a catchall term that can describe many
dif erent pathologic conditions or a tendon. It
essentially describes any in ammatory response
within the tendon without in ammation o the
Gra cilis paratenon.87 Paratenonitis involves in ammation
o the outer layer o the tendon only, and usually
Adductor ma gnus occurs when the tendon rubs over a bony promi-
nence. endinosis describes a tendon that has sig-
Mus cle Iliotibia l ba nd ni cant degenerative changes with no clinical or
s tra in
Va s tus la te ra lis histologic signs o an in ammatory response.20
In cases o what is most o ten called chronic
Ha ms tring group: tendinitis, there is evidence o signi cant tendon
Bice ps fe moris degeneration, loss o normal collagen structure,
Long he a d loss o cellularity in the area, but absolutely no
S hort he a d in ammatory cellular response in the tendon.81 T e
in ammatory process is an essential part o heal-
S e mite ndinos us
ing. In ammation is supposed to be a brie process
S e mime mbra nos us with an end point a ter its unction in the healing
process has been ul lled. T e point or the cause in
the pathologic process where the acute in amma-
tory cellular response terminates and the chronic
degeneration begins is di cult to determine.23 As
mentioned previously, with chronic tendinitis the
cellular response involves a replacement o leuko-
cytes with macrophages and plasma cells.99
Figure 2-10 A muscle strain re sults in te aring o r During muscle activity a tendon must move or
se paratio n o f be rs slide on other structures around it whenever the
muscle contracts. I a particular movement is per-
(Reproduced with permission from Prentice. Principles of Athletic Training. ormed repeatedly, the tendon becomes irritated
14th ed. New York: McGraw-Hill; 2011.)
and in amed. T is in ammation is mani ested
by pain on movement, swelling, possibly some
warmth, and usually crepitus. Crepitus is a crackling sound similar to the sound produced
by rolling hair between the ngers by the ear. Crepitus is usually caused by the adherence
o the paratenon to the surrounding structures as it slides back and orth. T is adhesion is
caused primarily by the chemical products o in ammation that accumulate on the irri-
tated tendon.20
T e key to treating tendinitis is rest. I the repetitive motion causing irritation to the
tendon is eliminated, chances are that the in ammatory process will allow the tendon to
heal.65 Un ortunately, a patient who is seriously involved with some physical activity might
have di culty in resting or 2 weeks or more while the tendinitis subsides. Antiin amma-
tory medications and therapeutic modalities are also help ul in reducing the in ammatory
responses. An alternative activity, such as bicycling or swimming, is necessary to maintain
tness levels to a certain degree, while allowing the tendon a chance to heal.30
Injuries to Nerve Tissue 49
endinitis most commonly occurs in the Achilles tendon in the back o the lower leg in
runners or in the rotator cuf tendons o the shoulder joint in swimmers or throwers, although
it can certainly are up in any tendon in which overuse and repetitive movements occur.
Tenosynovit is
enosynovitis is very similar to tendinitis in that the muscle tendons are involved in in am-
mation. However, many tendons are subject to an increased amount o riction as a result
o the tightness o the space through which they must move. In these areas o high riction,
tendons are usually surrounded by synovial sheaths that reduce riction on movement. I
the tendon sliding through a synovial sheath is subjected to overuse, in ammation is likely
to occur. T e in ammatory process produces by-products that are “sticky” and tend to
cause the sliding tendon to adhere to the synovial sheath surrounding it.51
Symptomatically, tenosynovitis is very similar to tendinitis, with pain on movement,
tenderness, swelling, and crepitus. Movement may be more limited with tenosynovitis
because the space provided or the tendon and its synovial covering is more limited. eno-
synovitis occurs most commonly in the long exor tendons o the ngers as they cross over
the wrist joint and in the biceps tendon around the shoulder joint. reatment or tenosyno-
vitis is the same as that or tendinitis. Because both conditions involve in ammation, mild
antiin ammatory drugs, such as aspirin, might be help ul in chronic cases.51
Physiology of Tendon Healing

Unlike most so t-tissue healing, tendon injuries pose a particular problem in rehabilita-
tion.40 T e injured tendon requires dense brous union o the separated ends and both
extensibility and exibility at the site o attachment. T us an abundance o collagen is
required to achieve good tensile strength. Un ortunately, collagen synthesis can become
excessive, resulting in brosis, in which adhesions orm in surrounding tissues and inter-
ere with the gliding that is essential or smooth motion. Fortunately, over a period o time
the scar tissue o the surrounding tissues becomes elongated in its structure because o
a breakdown in the crosslinks between brin units and thus allows the necessary gliding
motion. A tendon injury that occurs where the tendon is surrounded by a synovial sheath
can be potentially devastating.
A typical time rame or tendon healing would be that during the second week when the
healing tendon adheres to the surrounding tissue to orm a single mass and during the third
week when the tendon separates to varying degrees rom the surrounding tissues. However,
the tensile strength is not su cient to permit a strong pull on the tendon or at least 4 to
5 weeks, the danger being that a strong contraction can pull the tendon ends apart.85
Injuries to Nerve issue

T e nal undamental tissue is nerve tissue (Figure 2-11). T is tissue provides sensitivity
and communication rom the central nervous system (brain and spinal cord) to the mus-
cles, sensory organs, various systems, and the periphery. T e basic nerve cell is the neuron.
T e neuron cell body contains a large nucleus and branched extensions called dendrites,
which respond to neurotransmitter substances released rom other nerve cells. From each
nerve cell arises a single axon, which conducts the nerve impulses. Large axons ound in
peripheral nerves are enclosed in sheaths composed o Schwann cells, which are tightly
wound around the axon. A nerve is a bundle o nerve cells held together by some con-
nective tissue, usually a lipid-protein layer called the m yelin sheath, on the outside o the
axon.93 Neurology is an extremely complex science, and only a brie presentation o its rel-
evance to musculoskeletal injuries is made here.16
Nerve injuries usually involve either

contusions or in ammations. More seri-
ous injuries involve the crushing o a
nerve or complete division (severing).
T is type o injury can produce li elong
Dire ction physical disability, such as paraplegia
De ndrite s of ne rve impuls e
("input")
or quadriplegia, and thus should not be
overlooked in any circumstance.
Chroma tophilic
s ubs ta nce s O critical concern to the therapist is
Nucle olus the importance o the nervous system in
Nucle us proprioception and neuromuscular con-
trol o movement as an integral part o
Ce ll body
a rehabilitation program. Chapter 4 dis-
cusses this in great detail.
Axon hillock
Physiology of Nerve Healing

Nerve cell tissue is specialized and can-
not regenerate once the nerve cell dies.
Dire ction
of ne rve impuls e
In an injured peripheral nerve, how-
("output") ever, the nerve ber can regenerate sig-
ni cantly i the injury does not af ect the
cell body (Figure 2-12). T e proximity
o the axonal injury to the cell body can
Axon Axon colla te ra l
signi cantly af ect the time required or
healing. T e closer an injury is to the cell
body, the more di cult is the regenera-
Ne urole mmocyte
tive process. In the case o severed nerve,
Ne urofibril node surgical intervention can m arkedly
enhance regeneration.79
For regeneration to occur, an opti-
mal environment or healing must exist.
When a nerve is cut, several degenera-
tive changes occur that inter ere with
the neural pathways (see Figure 2-12).
Mye lin s he a th Within the rst 3 to 5 days the portion
o the axon distal to the cut begins to
Te lode ndria
degenerate and breaks into irregular
segments. T ere is also a concomitant
S yna ptic knobs increase in metabolism and protein pro-
duction by the nerve cell body to acili-
Input
tate the regenerative process. T e neuron
Output
in the cell body contains the genetic
material and produces chemicals neces-
sary or maintenance o the axon. T ese
substances cannot be transmitted to the
Figure 2-11 Structural fe ature s o f a ne rve ce ll distal part o the axon, and eventually
there will be complete degeneration.83
(Reproduced with permission from Prentice. Principles of Athletic Training.
14th ed. New York: McGraw-Hill; 2011.) In addition, the myelin portion o
the Schwann cells around the degen-
erating axon also degenerates, and the
myelin is phagocytized. T e Schwann
Injuries to Nerve Tissue 51
Figure 2-12 Ne uro n re g e ne ratio n
A. If a neuron is severed through a myelinated axon, the proximal portion may survive,
but (B) the distal portion will degenerate through phagocytosis. C and D. The myelin
layer provides a pathway for regeneration of the axon, and (E) innervation is restored.
(Reproduced with permission from Prentice. Principles of Athletic Training. 14th ed. New York:
McGraw-Hill; 2011.)
cells divide, orming a column o cells in place o the axon. I the cut ends o the axon con-
tact this column o Schwann cells, the chances are good that an axon may eventually rein-
nervate distal structures. I the proximal end o the axon does not make contact with the
column o Schwann cells, reinnervation will not occur.
Peripheral nerves are likely to regenerate if the cell body has not been damaged. The closer
the injury is to the cell body, the more dif cult the healing process is. If a nerve is severed,
surgical intervention can signi cantly improve chances of regeneration.
T e axon proximal to the cut has minimal degeneration initially and then begins the
regenerative process with growth rom the proximal axon. Bulbous enlargem ents and
several axon sprouts orm at the end o the proximal axon. Within approximately 2 weeks,
these sprouts grow across the scar that has developed in the area o the cut and enter the
column o Schwann cells. Only one o these sprouts will orm the new axon, while the oth-
ers will degenerate. Once the axon grows through the Schwann cell colum ns, remaining
Schwann cells proli erate along the length o the degenerating ber and orm new myelin
around the growing axon, which will eventually reinnervate distal structures.42
Regeneration is slow, at a rate o only 3 to 4 mm/ day. Axon regeneration can be
obstructed by scar ormation caused by excessive broplasia. Damaged nerves within the
central nervous system regenerate very poorly compared to nerves in the peripheral ner-
vous system. Central nervous system axons lack connective tissue sheaths, and the myelin-
producing Schwann cells ail to proli erate.42,83
Additional Musculoskeletal Injuries
Dislocat ions and Subluxat ions

A dislocation occurs when at least 1 bone in an articulation is orced out o its normal and
proper alignment and stays out until it is either manually or surgically put back into place or
reduced.10 Dislocations most commonly occur in the shoulder joint, elbow, and ngers, but
they can occur wherever 2 bones articulate.15,64,82
A subluxation is like a dislocation except that in this situation a bone pops out o its nor-
mal articulation but then goes right back into place. Subluxations most commonly occur in
the shoulder joint, as well as in the kneecap in emales.
Dislocations should never be reduced immediately, regardless o where they occur. T e
patient should have an X-ray to rule out ractures or other problems be ore reduction. Inap-
propriate techniques o reduction might only exacerbate the problem. Return to activity
a ter dislocation or subluxation is largely dependent on the degree o so t-tissue damage.15
Bursit is
In many areas, particularly around joints, riction occurs between tendons and bones, skin
and bone, or 2 muscles. Without some mechanism o protection in these high- riction
areas, chronic irritation would be likely.93
Bursae are essentially pieces o synovial membrane that contain small amounts o
synovial uid. T is presence o synovium permits motion o surrounding structures without
riction. I excessive movement or perhaps some acute trauma occurs around these bur-
sae, they become irritated and in amed and begin producing large amounts o synovial
uid. T e longer the irritation continues or the more severe the acute trauma, the more
uid is produced. As the uid continues to accumulate in a limited space, pressure tends to
increase and causes irritation o the pain receptors in the area.
Bursitis can be extremely pain ul and can severely restrict movement, especially i
it occurs around a joint. Synovial uid continues to be produced until the movement or
trauma producing the irritation is eliminated.
A bursa that occasionally completely surrounds a tendon to allow more reedom o
movement in a tight area is re erred to as a synovial sheath. Irritation o this synovial sheath
may restrict tendon motion.
All joints have many bursae surrounding them. Perhaps the 3 bursae most commonly
irritated as a result o various types o physical activity are the subacromial bursa in the
shoulder joint, the olecranon bursa on the tip o the elbow, and the prepatellar bursa on the
ront sur ace o the patella. All 3 o these bursae have produced large amounts o synovial
uid, af ecting motion at their respective joints.
Additional Musculoskeletal Injuries 53
Muscle Soreness
Overexertion in strenuous muscular exercise o ten results in muscular pain. At one time or
another, almost everyone has experienced muscle soreness, usually resulting rom some
physical activity to which we are unaccustomed.
T ere are 2 types o muscle soreness. T e rst type o muscle pain is acute and accom-
panies atigue. It is transient and occurs during and immediately a ter exercise. T e sec-
ond type o soreness involves delayed muscle pain that appears approximately 12 hours
a ter injury. It becomes most intense a ter 24 to 48 hours and then gradually subsides so
that the muscle becomes symptom- ree a ter 3 or 4 days. T is second type o pain may best
be described as a syndrome o delayed muscle pain, leading to increased muscle tension,
edema ormation, increased stif ness, and resistance to stretching.61
T e cause o delayed-onset muscle soreness (DOMS) has been debated. Initially, it was
hypothesized that soreness was caused by an excessive buildup o lactic acid in exercised
muscles. However, recent evidence essentially rules out this theory.1
It has also been hypothesized that DOMS is caused by the tonic, localized spasm o
motor units, varying in number with the severity o pain. T is theory maintains that exer-
cise causes varying degrees o ischemia in the working muscles. T is ischemia causes pain,
which results in re ex tonic muscle contraction that increases and prolongs the ischemia.
Consequently a cycle o increasing severity is begun.25 As with the lactic acid theory, the
spasm theory has also been discounted.
Currently there are 2 schools o thought relative to the cause o DOMS. DOMS seems to
occur rom very small tears in the muscle tissue, which seem to be more likely with eccen-
tric or isometric contractions.1 It is generally believed that the initial damage caused by
eccentric exercise is mechanical damage to either the muscular or the connective tissue.
Edema accumulation and delays in the rate o glycogen repletion are secondary reactions
to mechanical damage.69
DOMS might be caused by structural damage to the elastic components o connective
tissue at the musculotendinous junction. T is damage results in the presence o hydroxy-
proline, a protein by-product o collagen breakdown, in blood and urine.19 It has also been
documented that structural damage to the muscle bers results in an increase in blood
serum levels o various protein/ enzymes, including creatine kinase. T is increase indicates
that there is likely some damage to the muscle ber as a result o strenuous exercise.1
Muscle soreness can best be prevented by beginning at a moderate level o activity and
gradually progressing the intensity o the exercise over time. reatment o muscle soreness
usually also involves some type o stretching activity.39 As or other conditions discussed in
this chapter, ice is important as a treatment or muscle soreness, particularly within the rst
48 to 72 hours.
Cont usions
Contusion is synonymous with bruise. T e mechanism that produces a contusion is a blow
rom some external object that causes so t tissues (eg, skin, at, muscle, ligaments, joint cap-
sule) to be compressed against the hard bone underneath.100 I the blow is hard enough,
capillaries rupture and allow bleeding into the tissues. T e bleeding, i super cial enough,
causes a bluish-purple discoloration o the skin that persists or several days. T e contusion
may be very sore to the touch. I damage has occurred to muscle, pain may be elicited on
active movement. In most cases the pain ceases within a ew days, and discoloration disap-
pears in usually 2 to 3 weeks.
T e major problem with contusions occurs where an area is subjected to repeated
blows. I the same area, or more speci cally the same muscle, is bruised repeatedly, small
calcium deposits might begin to accumulate in the injured area. T ese pieces o calcium
might be ound between several bers in the muscle belly, or calcium might orm a spur
that projects rom the underlying bone. T ese calcium ormations, which can signi cantly
impair movement, are re erred to as myositis ossi cans. In some cases myositis ossi cans
develops rom a single trauma.8
T e key to preventing myositis ossi cans rom occurring rom repeated contusions is
protection o the injured area by padding.8 I the area is properly protected a ter the rst
contusion, myositis ossi cans might never develop. Protection, along with rest, might allow
the calcium to be reabsorbed and eliminate any need or surgical intervention. T e 2 areas
that seem to be the most vulnerable to repeated contusions during physical activity are the
quadriceps muscle group on the ront o the thigh and the biceps muscle on the ront o the
upper arm.100 T e ormation o myositis ossi cans in either o these or any other areas can
be detected on radiograph lms.
Incorporating T erapeutic Exercise to A ect

the Healing Process
Rehabilitation exercise progressions can generally be subdivided into 3 phases, based pri-
marily on the 3 stages o the healing process: phase 1, the acute phase; phase 2, the repair
phase; and phase 3, the remodeling phase. Depending on the type and extent o injury and
the individual response to healing, phases will usually overlap. Each phase must include
care ully considered goals and criteria or progressing rom one phase to another.72
Presurgical Exercise Phase

T is phase would apply only to those patients who sustain injuries that require surgery.
I surgery can be postponed, exercise may be used as a means to improve its outcome. By
allowing the initial in ammatory response phase to resolve, by maintaining or, in some
cases, increasing muscle strength and exibility, levels o
cardiorespiratory tness, and improving neuromuscular
control, the patient may be better prepared to continue the
exercise rehabilitative program a ter surgery.
Phase 1: The Acut e Injury Phase

Phase 1 begins immediately when injury occurs and can
last as long as 4 days ollowing injury. During this phase,
the in ammatory stage o the healing process is attempt-
ing to “clean up the mess,” thus creating an environment
that is conducive to the broblastic stage. As indicated in
Chapter 1, the primary ocus o rehabilitation during this
stage is to control swelling and to modulate pain by using
the PRICE (Protection, Restricted activity, Ice, Compres-
sion, and Elevation) technique immediately ollowing
injury. Ice, compression, and elevation should be used as
much as possible during this phase (Figure 2-13).73
Rest o the injured part is critical during this phase. It
Figure 2-13 is widely accepted that early mobility during rehabilita-
tion is essential. However, i the therapist becomes overly
Musculoskeletal injuries should be treated initially with aggressive during the rst 48 hours ollowing injury, and
protection, restricted activity, ice, compression, and elevation. does not allow the injured part to be rested during the
Incorporating Therapeutic Exercise to Affect the Healing Process 55
in ammatory stage o healing, the in ammatory process never really gets a chance to
accomplish what it is supposed to. Consequently, the length o time required or in am-
mation might be extended. T ere ore, immobility during the rst 24 to 48 hours ollowing
injury is necessary to control in ammation. I the injury involves the lower extremity, the
patient should be encouraged to be non-weightbearing or the rst 24 hours and progres-
sively bear more weight as pain permits.
By day 2 or 3, swelling begins to subside and eventually stops altogether. T e injured
area may eel warm to the touch, and some discoloration is usually apparent. T e injury is
still pain ul to the touch, and some pain is elicited on movement o the injured part.98 Fol-
lowing injury there will almost always be some loss in range o motion. Acutely, that loss
can be attributed primarily to pain and thus modalities (ie, ice, electrical stimulation) that
modulate pain should be routinely incorporated into each treatment session. At this point
the patient should begin active mobility exercises, working through a pain- ree range o
motion. In this phase, strengthening is less important than regaining range o motion, but
should not be entirely ignored.
A physician may choose to have the patient take NSAIDs to help control swelling and
in ammation. It is usually help ul to continue this medication throughout the rehabilitative
process.2
Phase 2: The Repair Phase

Once the in ammatory response has subsided, the repair phase begins. During this stage o
the healing process, broblastic cells are laying down a matrix o collagen bers and orm-
ing scar tissue. T is stage might begin as early as 2 days a ter the injury and can last or
several weeks. At this point, swelling has stopped completely. T e injury is still tender to the
touch but is not as pain ul as it was during the previous stage. T ere is less pain on active
and passive motion.73
As soon as in ammation is controlled, the therapist should immediately begin to
incorporate into the rehabilitation program activities that can maintain levels o cardiore-
spiratory tness, restore ull range o motion, restore or increase strength, and reestablish
neuromuscular control. T e therapist should design exercises that simultaneously chal-
lenge the neural, muscular, and articular systems to help the patient regain neuromuscular
control. As neuromuscular control improves strength will also improve. T e patient very
quickly “ orgets” how to correctly execute even simple motor patterns such as walking, and
the central nervous system must relearn how to integrate visual, proprioceptive, and kine-
matic in ormation that collectively produces coordinated movement.
As in the acute phase, modalities should be used to control pain and swelling. Cryo-
therapy should still be used during the early portion o this phase to reduce the likelihood
o swelling.52 Electrical stimulating currents can help with controlling pain and improving
strength and range o motion.73
Phase 3: The Remodeling Phase

T e remodeling phase is the longest o the 3 phases and can last or several years, depend-
ing on the severity o the injury. T e ultimate goal during this maturation stage o the
healing process is return to activity. T e injury is no longer pain ul to the touch, although
some progressively decreasing pain might still be elt on motion. T e collagen bers must
be realigned according to tensile stresses and strains placed upon them during unctional
exercises.
T e ocus during this phase should be on regaining unctional skills. Functional training
involves the repeated per ormance o movement or skill or the purpose o per ecting that
skill. Strengthening exercises should progressively place on the injured structures stresses
and strains that would normally be encountered during activity. Plyometric strengthening
exercises can be used to improve muscle power and explosiveness.40 Functional testing
should be done to determine speci c skill weaknesses that need to be addressed prior to
normal activity return.
At this point some type o heating modality is bene cial to the healing process. T e
deep-heating modalities, ultrasound, or the diathermies should be used to increase circu-
lation to the deeper tissues. Massage and gentle mobilization may also be used to reduce
guarding, increase circulation, and reduce pain. Increased blood ow delivers the essential
nutrients to the injured area to promote healing, and increased lymphatic ow assists in
breakdown and removal o waste products.73
Using Medications to A ect

the Healing Process
Medications are most commonly used in rehabilitation or pain relie . A patient may be
continuously in pain that can be associated with even minor injury.
T e over-the-counter nonnarcotic analgesics o ten used include aspirin (salicylate),
acetaminophen, naproxen sodium ketopro en, and ibupro en. T ese belong to the group
o drugs called NSAIDs. Aspirin is one o the most commonly used drugs in the world.78
Because o its easy availability, it is also likely the most misused drug. Aspirin is a derivative
o salicylic acid and is used or its analgesic, antiin ammatory, and antipyretic capabilities.
Analgesia can result rom several mechanisms. Aspirin can inter ere with the trans-
mission o pain ul impulses in the thalamus.78 So t-tissue injury leads to tissue necrosis.
T is tissue injury causes the release o arachidonic acid rom phospholipid cell walls.
Oxygenation o arachidonic acid by cyclooxygenase produces a variety o prostaglandins,
thromboxane, and prostacyclin that mediate the subsequent in ammatory reaction.2 T e
predominant mechanism o action o aspirin and other NSAIDs is the inhibition o pros-
taglandin synthesis by blocking the cyclooxygenase pathway.95 Pain and in am mation
are reduced by the blockage o accumulation o proin ammatory prostaglandins in the
synovium or cartilage.
Stabilization o the lysosomal membrane also occurs, preventing the e ux o destruc-
tive lysosomal enzymes into the joints.47 Aspirin is the only NSAID that irreversibly inhibits
cyclooxygenase; the other NSAIDs provide reversible inhibition. Aspirin can also reduce
ever by altering sympathetic out ow rom the hypothalamus, which produces increased
vasodilation and heat loss through sweating.22,47 Among the side ef ects o aspirin usage are
gastric distress, heartburn, some nausea, tinnitus, headache, and diarrhea. More serious
consequences can develop with prolonged use or high dosages.3
A patient should be very cautious about selecting aspirin as a pain reliever, or a num-
ber o reasons. Aspirin inhibits aggregation o platelets and thus impairs the clotting mech-
anism should injury occur.3 Aspirin’s irreversible inhibition o cyclooxygenase, which leads
to reduced production o clotting actors, creates a bleeding risk not present with the other
NSAIDs.94 Prolonged bleeding at an injured site will increase the amount o swelling, which
has a direct ef ect on the time required or rehabilitation.
Use o aspirin as an antiin ammatory medication should be recommended with cau-
tion. Other antiin ammatory medications do not produce as many undesirable side ef ects
as aspirin. Generally prescription antiin ammatories are considered to be equally ef ective.
Aspirin sometimes produces gastric discom ort. Buf ered aspirin is no less irritating to
the stomach than regular aspirin, but enteric-coated tablets resist aspirin breakdown in the
stomach and might minimize gastric discom ort. Regardless o the orm o aspirin ingested,
Using Medications to Affect the Healing Process 57
it should be taken with meals or with large quantities o water (8 to 10 oz/ tablet) to reduce
the likelihood o gastric irritation.
Ibupro en is classi ed as an NSAID; however, it also has analgesic and antipyretic
ef ects, including the potential or gastric irritation. It does not af ect platelet aggregation
as aspirin does. Ibupro en administered at a dose o 200 mg does not require a prescription
and at that dosage may be used or analgesia. At a dose o 400 mg, the ef ects are both anal-
gesic and antiin ammatory.9 Dosage orms greater than 200 mg require a prescription. For
names and recommended doses o prescription NSAIDs, re er to able 2-1.
Acetaminophen, like aspirin, has both analgesic and antipyretic ef ects, but it does
not have signi cant antiin ammatory capabilities. Acetaminophen is indicated or relie
able 2-1 Fre que ntly Use d NSAIDs
Maximum
Ge ne ric Name Drug / Trade Name Do sag e Rang e (mg ) and Fre que ncy Daily Do se (mg )
Celecoxib Celebrex 100–200 mg twice a day 200
Aspirin Aspirin 325–650 mg every 4 hours 4,000
Diclofenac Voltaren 50–75 mg twice a day 200
Diclofenac Cata am 50–75 mg twice a day 200
Di unasil Dolobid 500–1,000 mg followed by 250–500 mg 1,500

2 or 3 times a day
Fenoprofen Nalfon 300–600 mg 3 or 4 times a day 3,200
Ibuprofen Motrin 400–800 mg 3 or 4 times a day 3,200
Indomethacin Indocin 5–150 mg a day in 3 or 4 divided doses 200
Ketoprofen Orudis 75 mg 3 times a day or 50 mg 4 times a day 300
Mefenamic acid Ponstel 500 mg followed by 250 mg every 6 hours 1,000
Naproxen Naprosyn 250–500 mg twice a day 1,250
Naproxen Anaprox 550 mg followed by 275 mg every 6 to 8 hours 1,375
Piroxicam Feldene 20 mg a day 20
Sulindac Clinoril 200 mg twice a day 400
Tolmetin Tolectin 400 mg 3 or 4 times a day 1,800
Nabumatone Relafen 1,000 mg once or twice a day 2,000
Flurbiprofen Ansaid 50–100 mg 2 or 3 times a day 300
Keterolac Toradol 10 mg every 4 to 6 hours for pain; 40

not to be used for more than 5 days
Etudolac Lodine 200–400 mg every 6 to 8 hours 1,200
Meloxicam Mobic 7.5 mg once a day 15
Oxaprosin Daypro 1,200 mg once a day 1,800
(Reproduced with permission from Prentice. Principles of Athletic Training. 14th ed. New York: McGraw-Hill; 2011.)
o mild somatic pain and ever reduction through mechanisms similar to those o aspirin.3
T e primary advantage o acetaminophen is that it does not produce gastritis, irrita-
tion, or gastrointestinal bleeding. Likewise, it does not af ect platelet aggregation and thus
does not increase clotting time a ter an injury.75
For the patient who is not in need o an antiin ammatory medication but who requires
some pain-relieving medication or an antipyretic, acetaminophen should be the drug o
choice. I in ammation is a consideration, physician may elect to use a type o NSAID. Most
NSAIDs are prescription medications that, like aspirin, have not only antiin ammatory but
also analgesic and antipyretic ef ects.47 T ey are ef ective or patients who cannot tolerate
aspirin because o associated gastrointestinal distress. Patients who have the aspirin allergy
triad o (a) nasal polyps, (b) associated bronchospasms/ asthma, and (c) history o anaphy-
laxis should not receive any NSAID. Caution is advised when using NSAIDs in persons who
might be subject to dehydration. NSAIDs inhibit prostaglandin synthesis and there ore can
compromise the elaboration o prostaglandins within the kidney during salt and/ or water
de cits. T is can lead to ischemia within the kidney.47,63 Adequate hydration is essential to
reduce the risk o renal toxicity in patients taking NSAIDs.
NSAID antiin ammatory capabilities are thought to be equal to those o aspirin,
their advantages being that NSAIDs have ewer side ef ects and relatively longer duration
o action. NSAIDs have analgesic and antipyretic capabilities; the short-acting over-the-
counter NSAIDs may be used in cases o mild headache or increased body temperature in
place o aspirin or acetaminophen. T ey can be used to relieve many other mildly to mod-
erately pain ul somatic conditions like menstrual cramps and so t-tissue injury.9
It has been recommended that patients receiving long-acting NSAIDs have monitoring
o liver unction enzymes during the course o therapy because o case reports o hepatic
ailure associated with the use o long-acting NSAIDs.74
T e NSAIDs are used primarily or reducing the pain, stif ness, swelling, redness, and
ever associated with localized in ammation, most likely by inhibiting the synthesis o pros-
taglandins.9 T e therapist must be aware that in ammation is simply a response to some
underlying trauma or condition and that the source o irritation must be corrected or elimi-
nated or these antiin ammatory medications to be ef ective.86 Both naproxen and ketopro-
en (now available without a prescription) have been shown to provide additional bene t
when administered concomitantly with physical therapy.63
Muscle guarding accompanies many musculoskeletal injuries. Elimination o this
guarding should acilitate programs o rehabilitation. In many situations, centrally acting
oral muscle relaxants are used to reduce guarding. However, to date the e cacy o using
muscle relaxants has not been substantiated, and they do not appear to be superior to anal-
gesics or sedatives in either acute or chronic conditions.7
Many analgesics and antiin ammatory products are available over the counter in com-
bination products (ie, those containing 2 or more nonnarcotic analgesics with or without
caf eine). Chronic use o analgesics containing aspirin and phenacetin or acetaminophen
contributes to the development o papillary necrosis and analgesic-associated nephropa-
thy. T e presence o caf eine plays a role in dependency on these products leading to
chronic use.
Rehabilitation Philosophy
he rehabilitation philosophy relative to in lam m ation an d healin g a ter in jury is to
assist the natural process o the body while doin g n o harm .53 he course o rehabili-
tation chosen by therapist m ust ocus on their kn owledge o the healin g process an d
Rehabilitation Philosophy 59
its therapeutic m odi iers to guide, direct, an d stim ulate th e structural un ction an d
integrity o the in jured part. he prim ary goal should be to have a positive in luen ce
on the in lam m ation an d repair process to expedite recovery o un ction in term s o
ran ge o m otion , m uscular stren gth an d en duran ce, n eurom uscular control, an d car-
diorespiratory en duran ce.29,32 he therapist m ust try to m in im ize the early e ects o
excessive in lam m atory processes in cludin g pain m odulation , edem a con trol, an d
reduction o associated m uscle spasm , which can produce loss o joint m otion an d
contracture. Finally, the therapist should concentrate on preventing the recurren ce o
in jury by in luen cing the structural ability o the in jured tissue to resist uture overloads
by incorporating various therapeutic exercises.53 he subsequent chapters o this book
can serve as a guide or the therapist in usin g the m an y di erent rehabilitation tools
available.
SUMMARY
1. T e 3 phases o the healing process are the in ammatory response phase, the broblas-
tic repair phase, and the maturation remodeling phase. T ese occur in sequence, but
overlap one another in a continuum.
2. Factors that can impede the healing process include edema, hemorrhage, lack o vas-
cular supply, separation o tissue, muscle spasm, atrophy, corticosteroids, hypertrophic
scars, in ection, climate and humidity, age, health, and nutrition.
3. Ligament sprains involve stretching or tearing the bers that provide stability at the
joint.
4. Fractures can be classi ed as greenstick, transverse, oblique, spiral, comminuted, im-
pacted, avulsive, or stress.
5. Osteoarthritis involves degeneration o the articular cartilage or subchondral bone.
6. Muscle strains involve a stretching or tearing o muscle bers and their tendons and
cause impairment to active movement.
7. endinitis, an in ammation o a muscle tendon that causes pain on movement, usually
occurs because o overuse.
8. enosynovitis is an in ammation o the synovial sheath through which a tendon must
slide during motion.
9. Dislocations and subluxations involve disruption o the joint capsule and ligamentous
structures surrounding the joint.
10. Bursitis is an in ammation o the synovial mem branes located in areas where riction
occurs between various anatomic structures.
11. Muscle soreness can be caused by spasm, connective tissue damage, muscle tissue
damage, or some combination o these.
12. Repeated contusions can lead to the development o myositis ossi cans.
13. All injuries should be initially managed with protection, rest, ice, compression, and el-
evation to control swelling and thus reduce the time required or rehabilitation.
14. A patient who requires an analgesic or pain relie should be given acetaminophen be-
cause aspirin may produce gastric upset and slow clotting time.
15. For treating in ammation, NSAIDs are recommended because they do not produce
many o the side ef ects associated with aspirin use.
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Neuromuscular Scan
Examination
Jo h n S. Ha lle
OBJJECTIVE
List and discuss the basic purposes of a scan exam as outlined in this chapter.
Describe how a scan exam is fundamentally different from an algorithm.
Discuss the potential role of a prescreening questionnaire in a scan examination.
Compare and contrast the basic elements of a scan examination to the “ ve elements of
patient/client management,” that are described in The Guide to Physical Therapy Practice.
List the 5 elements of the scan examination outlined in this chapter, and summarize the key
information that should be obtained from each of those topic areas.
Describe the vital informational elements derived from each of the following items that are part
of the patient history portion of the examination:
Age Family history Mechanism of Nature of pain
Gender Past medical injury Training history
Ethnic makeup history AM/PM pattern
Morphology Medications of pain
Within a scan examination, “ clearing tests” are typically used. Explain the role and limitations
associated with clearing tests.
Explain what is meant by the terms, “ yellow ags” and “ red ags.” Additionally, when a yellow
or red ag nding is identi ed, discuss the response options available.
63
64 Chapte r 3 Neuromuscular Scan Examination
Purpose of a Scan Examination

Everyone h s conce t in their ind bout sc nning given situ tion. When driving nd
intersections re encountered, syste is e loyed th t ex ines wh t is occurring of in
the dist nce, s well s ny otenti l issues th t ight be co ing ro the right nd le t.
Attention is lso id to the existence o signs or tr c lights, ny obst cles like rked
c rs or debris in the ro dw y, nd nything out o the ordin ry th t could sign l high risk,
such s children l ying with b ll. Addition lly, in the b ck o the driver’s ind, ctors
such s the ount o light v il ble bec use o the ti e o d y, the condition o the ro d,
we ther conditions, nd the ty e o vehicle being driven, re ll ctored into the ix. With
this in or tion, the driver is ble to success ully sc n the intersection nd ke ll needed
djust ents to either sto nd res ond to otenti l e ergency or ss through this oint
in s ce.
T e 2 ost i ort nt ele ents th t llow the sc n described bove to work ti e ter
ti e re the e loy ent o syste nd ex erience. When st rting to drive, ost indi-
vidu ls le rn the rules o the ro d nd know to obey tr c lights. When light turns green,
ove ent into the intersection is st rted, nd, on r re occ sion, the c r is bro dsided.
T is ccident occurs bec use even though the driver w s obeying the rules o the ro d, the
li ited syste o the ty ic l neo hyte driver does not t ke the ti e to ddition lly check
th t the other vehicles in their vicinity re lso co lying with the rules nd not trying to
ush th t yellow-red light th t they h ve encountered. T is co es with ex erience, nd
ex erience t kes ti e nd r ctice.
Wh t does the bove h ve to do with sc n ex in tion er or ed on tient? It
is et hor th t illustr tes sever l i ort nt oints. First, everyone is ili r with the
conce t o sc nning so ething. A sc n is n e cient nd rel tively quick r is l o
situ tion th t does not look or every ct, but works extre ely h rd to identi y key cts
nd insure th t ll high-risk situ tions re identi ed nd ddressed. Second, the sc n is
b sed on syste . Without syste , holes will develo nd so e o the key cts identi-
ed in oint nu ber 1 will be issed. When ut in the context o tient c re, the oten-
ti l l ck o syste results in less-th n-o ti l c re, nd, on occ sion, will result in
neg tive outco e or the tient. In situ tions like driving, these syste s o ten develo
over ti e with ex erience nd re l rgely b sed on visu l in or tion. In the re l o
tient c re, the sc n ex in tion is bi sed to he vier did ctic b se th t requires the
link ge o s eci c knowledge with thologies/ injuries. Although this i roves with
ex erience, the syste should ide lly be very tight ro the beginning or the rovision
o co etent edic l c re ro the rst tient seen to the ost recently ev lu ted.
T is requires study nd syste th t is both si le enough to be i le ented with ll
tients ex ined, nd exible enough th t it llows odi c tion b sed on the region o
the body ev lu ted or on the s eci c situ tion. T e in or tion g ined ro this syste
will be used to develo working hy othesis reg rding wh t ight be underlying c use
o the tient’s roble . T ird, while quick nd nonexh ustive r is l o the situ -
tion, the sc n or s the ound tion l ele ents or ore det iled ex in tion, either
t the initi l visit or during ollow-u visit. Fourth, i le ent tion o sc n ex is
n e cient w y to g in n underst nding o the re son th t the tient is seeking c re.
T e sc n ex rovides enough in or tion to develo n excellent gr s o wh t the
tient is seeking nd whether or not they h ve co e to the he lth c re rovider th t is
best suited to ddress the issue. L st, nd erh s ost i ort ntly, the sc n ex in tion
looks or otenti l thology th t requires re err l or i edi te c re, so th t serious or
li e-thre tening thology is not issed. T is key oint goes directly to oint th t is o ten
(incorrectly) credited to the Hi ocr tic o th o “ rst, do no h r .”26 (While “do no h r ”
ex resses so e o the gener l senti ent o the Hi ocr tic o th nd is ri ry go l o
Purpose of a Scan Examination 65
ll he lth c re roviders, the hr se is not included s rt o the o th, but r ther s rt
o nother writing o Hi ocr tes.26)
Purposes of t he Scan Exam

• Used to develo working hy othesis ( ssists with ruling otenti l c uses “in” or “out”).
• Is b sed on syste th t is both n ge ble (si le) nd d t ble.
• Provides the b sis o why the tient h s resented or c re.
• Identi es thologies/ roble s th t require i edi te c re or re err l ( key ur ose
o the sc n ex !).
Caveat s t o Consider When Performing a Scan Exam

Prior to getting into the “the s eci c ieces” th t keu the ty ic l sc n ex , there re
ew c ve ts th t should be ddressed. First, while sc n ex is by design quick nd e -
cient, it is not nother n e or t king shortcuts. Whenever the res onsibility or ex ining
tient is cce ted, the tient deserves the he lth c re r ctitioner’s ull ttention nd
review in w y th t will serve the tient ro erly.
T is le ds to the second c ve t o h ving syste th t is i le ented every tim e
tient is ex ined. Only with syste will ll the b sic ele ents needed to sc n the
tient be included every ti e. T e syste lso kee s the r ctitioner ro being yo ic;
ex ining only wh t e rs to be obvious. Inste d, syste requires th t outside ossi-
bilities involving other biologic syste s be reviewed every ti e n ev lu tion is er or ed,
nd, occ sion lly, this is the truly i ort nt in or tion.
T ird, t ke notes or use te l te while er or ing the sc n ex . Rese rch shows
th t he lth c re roviders do better job o ccur tely su rizing wh t w s observed
during the ex in tion i they record in or tion once nd do not try to reconstruct nd-
ings ro e ory t l ter ti e.88,97,99 I you re b sing decisions on your ev lu tion, then
you re oblig ted to t ke notes long the w y to insure th t the su ry re ort is ccur te.
Fourth, the sc n ex in tion is not n lgorith . R ther, it is r ework th t h s
s eci c oints th t c n be lied to v riety o situ tions. Bec use it is r ework, it is
s d t ble s required nd c n be used or n u er-qu rter ev lu tion, lower-qu rter
ev lu tion, or s rt o so e other require ent. For the ur oses o this descri tion, ost
o the ex les rovided will be with either u er- or lower-qu rter ex in tions, s they
re the ost co on lic tion o the sc n ex in tion rocess.
L st, hysic l ex in tion rocedures re used s rt o the sc n ex in tion th t re
occ sion lly c lled “cle ring tests.” T e b sic ur ose o these tests is to ssist in ruling n
re in or out, s source o the tient’s roble . An ex le in the u er-qu rter screen
is or in l encro ch ent (S urling) test, which is intended to rovoke sy to s in
tients with r diculo thy c used by n intervertebr l or in l stenosis (Figure 3-1). A
ositive or in l encro ch ent test suggests th t working hy othesis o cervic l r dicu-
lo thy is vi ble consider tion nd th t urther tests should be er or ed to see i there
is ny coll bor tive evidence. Few r ctitioners h ve di culty building on the results o
ositive test. Neg tive ndings or test o this ty e re o ten inter reted s “ruling out”
the cervic l s ine s source o the tient’s roble . T is is where the c ve t or w rn-
ing needs to be st ted. Bec use no hysic l ex test h s bsolute sensitivity or s eci city
( nd ny h ve only ir to good sensitivity nd s eci city), neg tive nding is only one
iece o coll bor tive in or tion th t needs to be viewed in light o ll the in or tion.
T us, in the resence o neg tive or in l encro ch ent test, the neck h s not been
ruled out. R ther, cle r-cut neck roble h s not been de onstr ted, but the entirety
o the in or tion rovided by the sc n ex needs to

be reviewed nd tterns or tests th t coll bor te e ch
other need to be identi ed, nd lied to the working
hy othesis.
Concept ual Similarit ies and

Differences Bet ween a Scan Exam
and t he “Five Element s of Pat ient /
Client Management ” That Are
Described in The Guide t o Physical
Therapy Pract ice
Both the sc n ex nd the ele ents o tient/
client n ge ent outlined in T e Guide to Physical
T erapy Practice (2nd ed. t . 133),6 re syste ic w ys
o ro ching tient in n tte t to rovide high
qu lity c re. T us, these 2 syste s re uch ore
si il r th n they re dif erent. T e key dif erence is th t
the sc n ex in tion is n ro ch th t is ty ic lly
lied to tients resenting with neuro usculoskel-
et l co l ints nd it is er or ed s either n u er-
Figure 3-1 Example o f a Spurling te st (fo raminal or lower-qu rter screen. T e Guide to Physical T erapy
e ncro achme nt te st) Practice (T e Guide), on the other h nd, h s develo ed
the 5 ele ents o tient/ client n ge ent th t
c n be used s syste to ro ch virtu lly ny ty e o tient, r nging ro edi t-
ric tient with er nent neurologic condition to tient with serious injury to the
integu ent, such s burn tient. T us, while the sc n ex s outlined here is d t ble
beyond the u er nd lower qu rter, those 2 regions re the ri ry ocus o sc n ex s.
In h ving th t ocus, the syste built will rob bly h ve little ore s eci city or tient’s
th t ll into the neuro usculoskelet l re l , r ther th n T e Guide’s syste th t is li-
c ble to ll tient c tegories.
Addition lly, s ll ele ents o the ex in tion re h ndled little dif erently by e ch
o these ro ches. Both syste s begin the ev lu tion with history nd both lso con-
sider wide r nge o ossible re sons or the resenting roble . T e sc n ex ty ic lly
h s so e built-in “syste s review” questions th t re rt o the history, while T e Guide
outlines the “syste s review” s second ste th t i edi tely ollows the history. T is
ex le o s ll dif erence is l rgely se ntic one, however, s e ch is working to
cco lish the s e t sk o recognizing the underlying re son or the tient’s resen-
t tion to insure ttern o intervention or re err l th t is b sed on cts th t s n e ch
o the jor syste s o c rdiov scul r/ ul on ry, integu ent ry, usculoskelet l, nd
neuro uscul r. A second se ntic dif erence is th t the sc n ex in tion described here
will work to identi y s eci c tho n to ic l dys unction, while T e Guide works within
ove ent-b sed di gnostic c tegories known s r ctice tterns.6 T e tho n to ic l
ro ch is the historic l w y o ddressing neuro uscul r nd usculoskelet l roble s
within elds like ortho edics nd s orts edicine. Within those re s, tho n to ic l
ocus nd descri tion hel s cilit te cle r co unic tion. H ving de th t observ tion,
well-rounded r ctitioner will be ble to rticul te the tient’s roble with the l n-
gu ge ssoci ted with either o these 2 odels, de ending on the environ ent. T us, it
could be e sily rgued th t the sc n ex in tion to be described below is si ly re ck-
ged version o the Five Elem ents o Patient/ Client Managem ent Model ([1] ex in tion,
Step 1 of the Scan Exam: Subjective, or the Patient History 67
[2] ev lu tion, [3] di gnosis, [4] rognosis, nd [5] intervention), th t lso recognizes
th t e ch individu l will ro ch tients in his or her own unique w y with his or her
own individu lized syste . While king th t recognition, the strength o both o these
ro ches is th t they re holistic nd use syste to rovide qu lity tient c re.
Overview of the Scan Exam

As entioned reviously, 2 o the e tures needed or n ef ective sc n ex in tion re
th t the ex needs to be rel tively e sy to re e ber nd d t ble. Although the l bels
ssigned s e ory rkers c n be nything th t kes sense to the ex iner, the il-
i r SOAP (subjective, objective, ssess ent, nd l n), note or t will be used here, with
1 odi c tion. R ther th n the tr dition l SOAP or t, SOAGP (with the “g” re resent-
ing go ls), will be used s the r ework or the sc n ex in tion. Addition lly, bec use
the ocus o this ch ter is on the ex in tion nd not on tre t ent o tions, the e h sis
is on the initi l 3 ele ents o subjective, objective, nd ssess ent, with only inor cover-
ge o the go ls nd l ns. (Although go ls nd l ns re dee h sized here, there is no
suggestion th t these ele ents re not i ort nt. Other ch ters o this book ddress these
sections o the entire ex rocess in gre ter det il.
T e b sic ele ents o sc n ex in tion odel used re:
1. Subjective—History, syste s review, yellow nd red gs36; the tient’s b sic
in or tion nd sy to s
2. Objective—Ev lu tive tests nd signs elicited ro the tient
3. Assessm ent—Re ne ent o working hy othesis(es) (nor lly vi deductive thinking),
into 1 or ore s eci c roble s/ dys unctions, th t re su orted by coll bor tive
in or tion
4. Goal—B sed on tient’s desires nd needs, within the re l o re son; should be
st ted in ter s o both short- nd long-ter go ls
5. Plan—Me sur ble ste s designed to cco lish the “go l” listed bove
T e bove rovide r ework o l bels th t describe the b sic ele ents o the ex i-
n tion rocess. T e det il or e ch section is rovided below.
Step 1 of the Scan Exam:

Subjective, or the Patient History
An old xio th t “ch nce (or luck) vors the re red ind”82 lies strongly to this
ortion o the ex in tion rocess. While the tient history ight be viewed s ti e to
sk the tient si ly, “Why re you here?”, well-done history is ound tion l to the sc n
ex in tion. I r nked in hier rchy, this y be the ost i ort nt ele ent o the entire
ex in tion rocess or sever l re sons. It h s been s id th t roxi tely 80% o the
in or tion needed to deter ine wh t is wrong with tient c n be gle ned ro well-
org nized history.44,96 Addition lly, this is the ri ry l ce in the ex in tion where the
ev lu tor h s the o ortunity to underst nd the tient’s concerns, identi y otenti l yel-
low nd red gs,36 nd ost e sily cco lish quick syste s review. T us, the tient
history should be ro ched with the underst nding th t the ti e s ent is v lu ble nd
with cle r ur ose to every question sked. An ef ective tient history will occur only i
the ev lu tor e loys well-org nized syste nd i the ev lu tor h s the did ctic b ck-
ground to convert the res onses obt ined ro the tient into working hy otheses b sed
on the body’s hysiologic res onse to so e or o bnor l n to y. For ex le, i
tient with cervic l in th t r di tes to the shoulder indic tes th t the in is l rgely
relieved when resting the involved ore r on their he d, they h ve rovided v lu ble
in or tion on working r diculo thy hy othesis. T e bducted osition o the shoulder
llows the cervic l nerve roots to be in osition o rel tive sl ck nd o ten decre ses the
sy to s ssoci ted with intervertebr l or in l encro ch ent. T is in or tion c n be
ctored into the ndings, i the ev lu tor is w re o wh t the tient is telling the with
the revious descri tion.
T e history ty ic lly st rts with so e o the housekee ing in or tion th t is needed
to int icture o the tient. F ctors such s the tient’s ge, gender, nd ethnic b ck-
ground re scert ined. T ese ieces o in or tion re v lu ble in th t s eci c roble s
occur either to uch gre ter requency, or exclusively, in individu ls o cert in ge, gen-
der, or ethnic grou . As n ex le, sli ed c it l e or l e i hysis ty ic lly occurs in
individu ls between 10 nd 15 ye rs o ge, nd is twice s co on in les s e les.95
T us, both ge nd gender re key ele ents th t re ctored into the re red ind when
considering the resenting tient. Addition lly, while getting slightly he d o the devel-
o ent o this section, these tients will lso re ort th t they h ve thigh or knee in,
bec use o the re err l ttern o in ro the e or l he d.95 T us, the n to ic ch r c-
teristics o re erred in nd the high index o sus icion o the joint bove nd joint below,
need to be considered when listening to the tient.
In n ef ort to kee the subjective ortion o the sc n ex in tion brie , ny i not ll
o these i ort nt b ckground ieces o in or tion c n be obt ined through question-
n ire th t the tient lls out rior to being interviewed. Using questionn ire h s nu -
ber o dv nt ges, including the ollowing: the questionn ire ( ) rovides built-in syste
th t revents i ort nt in or tion ro being overlooked, (b) rovides docu ent tion
without t king the he lth c re rovider’s ti e, (c) utilizes the tient’s ti e while they re
w iting to be seen, nd (d) is e cient nd is w y to ccur tely collect uch ore in or-
tion th n ty ic lly will be obt ined by sking individu l questions. It h s been shown
th t in hysic l ther y ortho edic setting, the over ll ercent ge o gree ent cross
questionn ire ite s done s rt o sel - d inistered questionn ire versus det iled
tient-sel re ort by n ex erienced he lth c re r ctitioner, w s 96%.13 In light o the
ti e s vings nd docu ent tion bene ts of ered by this ty e o questionn ire, its use in
clinic l setting should be seriously considered ( ble 3-1 is n ex le o question-
n ire th t could be used with en nd wo en; other excellent questionn ires re rovided
elsewhere 13,62,81).
Once the b sic in or tion on the tient h s been obt ined, the history turns to the
s eci c re son th t the tient h s sought c re. T is h se o the history ty ic lly begins
with o en-ended questions designed to elicit, in the tient’s words, wh t is wrong.
O en-ended questions re those th t llow the tient to describe in their own ter s
wh t the roble is, how they believed it occurred, nd how long they h ve been living
with the sy to s th t re resent. While roviding this ti e or o en-ended questions,
the clinici n y need to work to kee the tient ocused on in or tion relev nt to the
sc n ex . Bec use ti e is in short su ly, the ti e s ent with o en-ended questions
should not be ti e o idle convers tion, but ti e th t ints icture o the roble .
able 3-1 Pre e valuatio n Que stio nnaire
Date:
Patient’s Name DOB Age:
Diagnosis Date of Onset
Physician Therapist
Precautions:
Me dical Histo ry Do No t Co mple te : Fo r the The rapist
Have yo u o r any imme diate family Re latio n to Date o f Curre nt

me mbe r e ve r be e n to ld yo u have Circle o ne Patie nt Onse t Status
Cancer Yes No
Diabetes Yes No
Hypoglycemia Yes No
High blood pressure Yes No
Heart disease Yes No
Angina or chest pain Yes No
Shortness of breath Yes No
Stroke Yes No
Kidney disease/stones Yes No
Urinary tract infection Yes No
Allergies Yes No
Asthma, hay fever Yes No
Rheumatic/scarlet fever Yes No
Hepatitis/jaundice Yes No
Cirrhosis/liver disease Yes No
Polio Yes No
Chronic bronchitis Yes No
Pneumonia Yes No
Emphysema Yes No
Migraine headaches Yes No
Anemia Yes No
Ulcers/stomach problems Yes No
Arthritis/gout Yes No
Other Yes No
(continued )
able 3-1 Pre e valuatio n Que stio nnaire (Continued )

Me dical Te sting
1. Are you taking any prescription or over-the-counter medications? Yes No
If yes, please list:
2. Have you had any x-rays or other scans (eg, MRI, etc) done Yes No
recently?
If yes, when and what were the results?
3. Have you had any laboratory work done recently (eg, urinalysis or Yes No
blood tests)
If yes, when and what were the results?
4. Please list any operations that you have had and the
approximate date of the surgery(ies):
Ge ne ral He alth
1. Have you had any recent illnesses within the last 3 weeks Yes No
(eg, colds, in uenza, bladder or kidney infection, other?)
2. Have you noticed any lumps or thickening of skin or muscle Yes No

anywhere on your body?
3. Do you have any sores that have not healed or any changes in size, Yes No
shape, or color of a wart or mole?
4. Have you had any unexplained weight loss in the past several Yes No
months?
5. Do you smoke or chew tobacco? Yes No
If yes, how many packs per day?
For how many months or years?
6. Do you drink alcohol? Yes No
If yes, how much do you typically drink in the course of a week?
7. Do you consume caffeine? Yes No
If yes, how much in a typical week? (to include coffee, tea, chocolate, and soft drinks)
8. Are you on any special diet prescribed by a physician? Yes No
Spe cial Que stio ns fo r Wo me n
1. Date of last Pap smear examination:
2. Date of last breast examination by a physician:
3. Do you perform monthly self-breast examinations? Yes No
4. Do you take birth control pills or use an intrauterine device? Yes No

(continued )
able 3-1 Pre e valuatio n Que stio nnaire (Continued )

Spe cial Que stio ns fo r Me n

1. Do you ever have dif culty with urination? (eg, starting Yes No
or stopping the ow of urine, or have a very slow ow)
2. Do you every have blood in your urine? Yes No
3. Do you every have pain on urination? Yes No
Wo rk Enviro nme nt
1. Occupation:
2. Does your job involve:
a. Prolonged sitting (eg, desk, computer, truck driver) Yes No
b. Prolonged standing (eg, equipment operator, sales clerk) Yes No
c. Prolonged walking (eg, delivery service, etc) Yes No
d. Frequent and repetitive use of large or small equipment Yes No
e . Prolonged lifting, bending, twisting, climbing, turning Yes No
f. Exposure to chemicals or gases Yes No
g . Other: please describe
3. Do you use any special supports, such as:
a. Back cushion or neck support Yes No
b. Back brace or corset Yes No
c. Other kind of brace or support for any body part Yes No
Fo r the Physical The rapist:
Vital signs:
Resting heart rate:
Oral temperature:
Blood pressure:
Source: Adapted from Goodman C, Snyder T. Differential Diagnosis in Physical Therapy. Philadelphia, PA: Saunders; 1990, with permission.39
Once th t icture h s been inted, it is ti e or the ther ist to begin sking s eci c
closed-ended questions th t require very brie res onses. T ese questions should ll h ve
s eci c ur ose nd otenti lly reve l so ething bout the tient’s underlying rob-
le . For ex le, sking wh t kes the in (ty ic lly wh t brings tient into the
clinic) better or worse ddresses b sic truis ssoci ted with neuro usculoskelet l
thology: vi ositioning, r nge o otion, or ressure neuro usculoskelet l roble
c n h ve the n ture o in ch nged. I , on the other h nd, there is no ch nge in in in
ny osition or osture, then serious consider tion needs to be given to the ct th t this
roble y lie outside o the sco e o ther ist nd re err l ight be w rr nted.
T ese robing questions re gener lly close-ended, they rovide the ther ist with n
o ortunity to ex lore otenti l yellow or red gs, nd they re used to ex lore brie
syste s review ( ble 3-2). Ef ectively er or ed, this questioning rocess will be built
on syste , er it individu liz tion or e ch tient seen, nd be cco lished nd
recorded in 5 to 10 inutes.
Prior to roviding n ex le o the subjective (history) ortion o the ex in tion, it
is i ort nt to ddress sever l other oints including:
1. Recognizing th t lthough the l bel ost requently used with this section is
“subjective,” it does not e n th t the in or tion rovided by tient is either o
less v lue th n th t obt ined by hysic l ex in tion, or th t the in or tion is
even subjective. Rothstein, in n editori l on subjective nd objective e sures,89
eloquently describes e sures th t re o ten considered to be entirely subjective,
such s in, c n be qu nti ed in very objective w y. Addition lly, in or tion th t
is ty ic lly grou ed under the he ding o “subjective,” such s ge, r ce, nd gender,
re not subjective in or tion t ll. In ct, those y be ex les o the ost
objective in or tion obt ined in the entire ex in tion. T ere ore, the occ sion l
tendency to vor in or tion obt ined during the hysic l ex ortion (objective)
over th t obt ined ro the tient should be resisted. Both sources o in or tion re
vit l. P rt o the rt ssoci ted with the inter ret tion o the in or tion collected is
to recognize th t while dif ering ele ents o the tot l sc n ex y be ore reli ble
th n others, it is not s si le s elev ting the objective ortion o the ex in tion
over the subjective ortion.89
2. Recognizing th t in or l ck o unction is wh t ty ic lly brings tient in to
be seen, but th t the in is not the roble . T ere is n underlying c use o the
tient’s in or l ck o unction. A key ur ose o the sc n ex in tion is to tte t
to identi y the underlying c use, nd then bring orth l n th t is ble to ddress
the roble . T ere ore, cknowledge th t in is n i ort nt sy to , but do
not be led by it. Res ect it, nd then tte t to deter ine its underlying c use.
Acknowledge it or the tient’s v lid tion, but do not ocus on it s the h ll rk o
success o ilure ssoci ted with the intervention. Although ore will be s id on this
l ter, scen rios c n be develo ed in which tient would h ve n incre sed ount
o in in ollow-u visit, yet the ther ist could be le sed with the rogress. In
the tre t ent o r dicul r low b ck in with in r di ting down the glute l region,
osterior thigh, to the o lite l oss , n intervention ight be McKenzie style 67 b ck
extension exercises. On ollow-u visit, the in ight be centr lized to only the low
b ck region, with in in th t region s gre t or gre ter th n wh t w s ex erienced
initi lly. Yet, s result o the centr liz tion o sy to s, this ight be considered
ositive develo ent nd th t tre t ent l n rein orced nd continued. H d
the ther ist been led only by in, the incre se in in would h ve resulted in n
b ndon ent o their ro ch th t w s intended to ddress the underlying c use o
the initi l in.
3. Requiring s eci city when tient’s rovide nswers to s eci c questions, such s
“Are you ex eriencing ny tingling or decre sed sens tion?” o question like the
receding one, ny tients will ex ress so ething like, “I h ve nu bness in y
right h nd.” T e ollow-u questions th t require s eci city will ocus in on ite s
like: ( ) Which side o the h nd is f ected ( l r s ect, dors l s ect, or both)?
(b) Which nger or ngers is/ re f ected? (c) Are the ngerti s f ected? (d) Is
the re f ected truly nu b, or i in is stuck in it will you eel it? nd (e) Is the
ltered sens tion const nt or ssoci ted with given ti e o d y or ctivity? Fro
this ty e o ollow-u th t requires very s eci c res onses, the ex iner is ble to
sort out der to es, innerv tion tterns o s eci c cut neous nerves, otenti l
olyneuro thies, otenti l v scul r involve ent nd ositioning or te or l
able 3-2 Ye llo w and Re d Flag s and an Abridg e d List o f Ye llo w and Re d Flag Ite ms
Ye llo w Flag s: A yellow ag is metaphorically similar to a yield sign. It indicates a nding that requires some additional
attention and follow-up, and may warrant a referral to a specialist. (Follow-up questions and the rest of the physical
examination will help determine if the nding is manageable in the current environment, or if outside consultation is
warranted. Common sense and experience assist greatly in sorting out yellow ags).
Ab rid g e d list o f ye llo w - ag nding s:
1. Asymmetrical muscle stretch re exes (old name = DTRs)
2. Present pathologic re exes (eg, Babinski, Hoffman)
3. Pain of unknown etiology
4. Fatigue
5. Pain that does not t any dermatomal or cutaneous nerve distribution pattern
6. Pain disproportionate to the ndings on physical examination
7. “ Give-way weakness” (patient is not able to provide an accurate status of their underlying condition, secondary to
pain or some other limitation)
8. Lump or mass in a region like the wrist (need to determine if it is a new problem, if it is gradually resolving over time,
the relationship to problem patient is seeking care for, etc)
9. Asymmetrical joint laxity (need to determine time of injury, other treatment, etc)
10. Positive ndings on special tests (eg, positive McMurray test implicating a torn meniscus—if de nitive diagnosis
required over the short-term, then referral would be warranted)
11. Night pain
12. Signi cant structural scoliosis (needs to be viewed in light of age of patient and past history with this condition)
Re d Flag s: A red ag is a nding that is clearly outside of the scope of expertise of the therapist, and appropriate care
for the patient is dependent on coordination with another health care professional. (While the examination may be
continued following identifying a “ red ag,” a course of action at the completion of the examination will be to refer
the patient. In some cases, the referral could be immediate, with care directly coordinated between the therapist and
the physician referred to. As was the case with yellow ags, common sense and experience assist greatly in identifying
ndings that require immediate referral.
Ab rid g e d list o f re d- ag nding s:
1. Loss of bowel or bladder control
2. Fever or chills
3. Dysphagia of unexplained origin
4. Unexplained weight loss
5. Clear and expected changes in vision (eg, diplopia)
6. Symptoms that are constant and cannot be altered by activity or rest
7. Sudden onset of dizziness or balance problems
8. Sudden weakness or lack of coordination
9. Frequent nausea or vomiting, hemoptysis
10. Night sweats
11. Skin rash of unexplained origin
12. Redness and/or swelling in a joint without any history of injury
events th t enh nce the sy to s. T is will be level o s eci city th t the tient
is not used to, nd will o ten be et with the h ving to think bout wh t ex ctly
is involved. Yet, in the h nds o n ev lu tor th t h s r did ctic gr s o their
n to y nd tho hysiology, this line o s eci c questioning will er it the
or ul tion o cle r hy otheses th t c n be directly tested.
4. Requiring s eci city ro the tient when the tient is describing the ech nis
o injury. T e tient is seeking hel nd the tient knows rior to king n
oint ent th t the he lth c re rovider will w nt to know “How did this h en?”
Bec use the tient ntici tes this, the tient will think b ck nd try to ssoci te
ny re son ble te or l event with his or her current roble . It ight be th t the
individu l resenting with low b ck in rec lls th t week be ore the sy to s
develo ed the tient w s on n use ent rk ride. While no disco ort w s
noted t the ti e, in thinking b ck, th t w s the only event out o the ordin ry nd
the tient there ore ttributes the tient’s sy to s to this event. Although
intended to hel the ev lu tor, this in or tion could be counter roductive,
bec use rt ro ti ing, there is nothing th t re lly links this event to this e isode
o low b ck in. S eci city in questioning is required to deter ine i there is
cle r ech nis o injury, or i the tient is si ly trying to be hel ul. A cle r
ech nis o injury ssists the ex iner. A ossible ech nis o injury needs to
be viewed s just th t, ossible c use o injury with the equ lly true ossibility th t
the event nd this e isode o in re not rel ted. Bec use in o unknown etiology
is t le st yellow g, this second ty e o res onse needs to be ent lly gged
nd viewed in light o the other in or tion obt ined over the course o the entire
sc n ex in tion.
5. Using the in or tion obt ined during the subjective ortion o the ex in tion
to gener te working hy othesis or hy otheses. T e d nger here is to beco e too
yo ic too st. While the subjective ex in tion y rovide u to 80% o the
in or tion needed to deter ine the n ture o the tient’s roble , it is just rt
o the sc n ex in tion. Use the syste develo ed to st y o en- inded, so th t less
obvious or second ry issues re not issed. A et hor th t illustr tes this is the
instruction th t r diologist rovided to neo hyte he lth c re roviders in how to
re d x-r ys. He noted th t when r diogr hic nding is distinct, the eye is dr wn
to it nd unless individu l re ding the x-r y is disci lined nd is using syste ,
less obvious ( nd o ten ore serious) nding will be issed. T ere ore, he urged
th t x-r ys should be viewed in syste tic w y, to insure th t ro er ttention is
id to ll ele ents visu lized. Likewise, when develo ing hy othesis or sever l
hy otheses, st ying o en- inded will best serve the interests o the tient who h s
entrusted hi - or hersel to your c re. ( ble 3-3 rovides n bridged list o questions
used s rt o the subjective ex in tion.)
Example of Quest ions Typically Found as Part of

t he Subject ive Exam or Pat ient Hist ory—Abridged List
ble 3-1 rovides n ex le o one questionn ire th t could be used s rt o the
ex in tion.
1. Age: As entioned reviously with sli ed c it l e or l e i hysis, there re
cert in dise ses or injuries th t re ore rev lent in individu ls o given ge.
P tients re ching the 35- to 55-ye r-old ge r nge, or ex le, re still e sily c ble
o subst nti l re etitive ctivity like running the dist nces ssoci ted with r thon
tr ining. As result o the biologic ch nges ssoci ted with the loss o cushioning
able 3-3 Abridg e d List o f Que stio ns Use d as Part o f the Subje ctive Examinatio n
Re d o r
Que stio n Re aso n Info rmatio n So ug ht Example Ye llo w Flag
What is your age? Age speci city present with some Vertebral body epiphyseal –
diseases aseptic necrosis
(Scheuermann disease)
Sex? (Typically observed and Sex speci city present with some Juvenile rheumatoid arthritis –
noted, not asked) diseases
Current occupation? Occupation may relate to either Heavy industrial worker versus –
the onset of symptoms or serve as secretary
a factor in treatment
What problem has caused you Identi es the patient’s perception Trauma versus problem of –
to seek medical care? and location of the current insidious onset
dysfunction
Onset of this problem? Identi ed the length of time Acute versus chronic condition –
current dysfunction has been
present
Any past medical history of Provides insight into past history Recurring rib dysfunction –
similar or related problem? of dysfunction, rehabilitation
(If so, how was the condition status, and effectiveness of prior
treated and what was the treatment
result?)
How is your general health? Provides insight into other possible Rheumatoid arthritis, cancer, **
Have you experienced any problems that may contribute to cardiac problems, etc
unexplained weight loss? the current problem
Any recent infections, fever, or Provides information regarding Recent history of bladder **
surgery? systemic disease that may be infection related to low thoracic
related to this problem or lumbar pain
What aggravates your The pathomechanics of provoked Flexion of the cervical spine –
symptoms? pain are identi ed by the patient reproducing upper thoracic pain
What relieves your symptoms? Provides additional insight into Lying on the affected side **
pathomechanics and possible decreases pain (this is called
treatment approach autospinting and may suggest
pleuropulmonary involvement). 36
Also, beware of nothing
relieving symptoms—suggests
nonmechanical problem
Is there a speci c pattern of Mechanical problems tend to Muscle strain aggravated by –

pain over a 24-hour period? become worse throughout the day repetitive use
and are relieved by rest
Does the pain ever wake you Provides information about the Osteoid osteoma (pattern of **
from a sound sleep? pattern of pain and alerts the night pain, typically relieved by
If so, are you able to roll over examiner to the possibility of aspirin)40
and go back to sleep? nonmechanical problem
(continued )
able 3-3 Abridg e d List o f Que stio ns Use d as Part o f the Subje ctive Examinatio n (Continued )
Re d o r
Que stio n Re aso n Info rmatio n So ug ht Example Ye llo w Flag
What hobbies or recreational May relate to onset of Serious rugby player versus avid –
pursuits do you engage in? symptoms or identify factors reader
that will need to be considered
in treatment
Are you aware of strength or Provides insight into function of C5 dermatome identi ed as –
sensory changes? the neuromusculoskeletal system area of decreased sensation
Any episodes of dizziness or Symptoms may be present with Vertebral artery problem **
vertigo? vestibular or vertebral artery
problems
Current medications? Relates potentially to both this Steroids—long-term use may be –

problem and other medical associated with osteoporosis
problems
Have x-rays or other special Provides a more complete picture X-rays, laboratory work –
tests been performed? If so, of what has already been done obtained
do you know the results?
On a scale of 1 to 10, with 10 Provides a pseudo-objective level Pain currently at 4/10 –

representing excruciating pain of the patient’s current perception
and 1 representing minimal of pain, which can be used to
pain, where would you rate gauge progress at a later point in
your pain over the past 24 time
hours?
**Potential yellow or red ags that may suggest additional work-up or referral to an appropriate medical specialist.
Source: Adapted from Halle J. Neuromuscular scan examination with selected related topics. In: Flynn T, ed. The Thoracic Spine and Rib Cage:
Musculoskeletal Evaluation and Treatment. Boston, MA: Butterworth-Heinemann; 1996:121-146, with permission.
in the heel d nd ch nges in connective tissue, this grou o older joggers tend
to h ve n incre sed rev lence o l nt r sciitis.65 T ese re just 2 o liter lly
thous nds o conditions where ge l ys ctor th t should be considered in the ix
o in or tion collected in the sc n ex . Pro er underst nding o li e s n issues
requires n excellent did ctic b ckground in the tho hysiology ssoci ted with
dise se nd injury.
One other c ve t th t should be entioned with ge, is the w y th t this
in or tion is obt ined. T e st nd rd w y o sking question bout ge is, “How old
re you?” While there re ti es in our lives when we re looking orw rd to getting
older, or so eone beyond the young dult st ge, this question y i ly th t their
ge is the roble . wo w ys o obt ining this in or tion in ore neutr l w y re
to use the questionn ire re erred to reviously th t requests the d y, onth, nd ye r
o birth, or sk the s e question without ny re erence to being old, such s, “Wh t
is your ge?” Although very s ll oint, rt o your job s success ul ev lu tor is
to ke the tient eel co ort ble nd not t ll de ensive. I so eone is sensitive
bout their ge, one o these inor ch nges in ro ch ight hel cilit te the
convers tion.
2. Gender: Like ge, given dise ses or injuries re ore co on in one gender th n
the other. T e ore entioned sli ed c it l e or l e i hysis is illustr tive o
roble th t is uch ore co on in les. Other conditions, like rheu toid
rthritis or bro y lgi , re ore co on in e les.48,58,93 Addition lly, there re
conditions th t re restricted to one gender or the other th t o ten h ve sy to s
suggestive o neuro usculoskelet l co l int. A le older th n the ge o
40 ye rs resenting with low b ck in without cle r ech nis o injury, should
be questioned bout their genitourin ry syste , s eci c lly bout their rost te.
T is is i ort nt bec use the rost te c n re er in to the low b ck.10 Si il rly,
wo en o childbe ring ge, resenting with low b ck in should be questioned
bout their enstru l cycle, s regn ncy nd the lter tion in hor on l levels c n
lso be res onsible or low b ck in.14,94,100 T ese re but 2 o otenti lly thous nds
o conditions th t h ve redis osition or one gender over the other. An excellent
underst nding o tho hysiology nd the role o gender is needed by the ex iner
to success ully ev lu te the tients they see. Although ull descri tion o this
to ic is beyond the sco e o this ch ter, the interested re der is re erred to sever l
excellent texts.37,41
3. Ethnic m akeup: T e ethnicity o the tient is lso ctor th t needs to be considered
when ex ining the individu l ro holistic ers ective. It should be recognized
th t like ge nd gender, ethnicity c n be ctor in the rev lence o the he lth
roble th t the tient is seeking ssist nce with. It is well recognized th t there
re ethnic dif erences in the bone iner l content o v rious r ces, with whites
ex eriencing higher r cture r tes th n either Asi ns or A ric n A eric ns.7 Other
injury nd dise se st tes, such s hy ertension nd ren l dise se, re ore rev lent
in A ric n A eric n o ul tions th n ong whites.27,31 Although these re but
2 ex les, they illustr te th t the genetics ssoci ted with the individu l re n
i ort nt ctor to kee in ind when considering v rious hy otheses nd the
likelihood o s eci c roble in the tient th t is resenting or c re.
Closely rel ted to ethnic keu , is the issue o cultur l nd socioecono ic
ctors th t c n l y role in he lth nd dise se. In recent study ex ining inti te
rtner violence in N tive A eric n wo en, it w s ound th t ore th n h l o the
wo en (58.7%) receiving c re t trib lly o er ted clinic in southwest Okl ho ,
re orted li eti e hysic l nd/ or sexu l buse.63 Al ost s striking s the over ll
li eti e ercent ge, w s the nding th t 30.1% o these wo en re orted hysic l or
sexu l inti te rtner violence in the revious 12 onths.63 T ese re exce tion lly
high r tes o inti te rtner violence nd illustr te the need or he lth c re workers
to h ve n underst nding o the co unities th t they serve. T is one ex le serves
to drive ho e the oint th t the individu ls th t re served in he lth c re cility
re not si ly biologic beings th t y h ve dys unction o so e ty e, but they re
otenti lly f ected by the tot lity o their d y-to-d y existence, including li estyle,
genetics, culture, nd the ores o the co unity in which they live.
4. Morphology: T e body ty e o n individu l resenting or n ex in tion is lso
ctor in the likelihood o develo ing given injury or dys unction. T e reviously
described sli ed c it l e or l e i hysis lso h s or hology i lic tions, s it
tends to occur ore in youngsters who re either t ll or thin, or short nd obese.95 T is
is thought to be to the result o otenti l hor on l i b l nce th t y be occurring
during eriod o growth. Here, g in, there re otenti lly thous nds o conditions
th t re rel ted to body ty e or structur l keu , such s incre sed incidence o
tello e or l in in individu ls with lign ent or r nge o otion issues.3,21,59
T is is bro d l bel nd includes less-th n- er ect bio ech nics resent in
ny individu ls, such s leg-length discre ncies, r nge o otion restrictions,
uscle i b l nces, in ddition to the gener l body ty e o the individu l. T e key

oint here is th t the ex iner needs to be w re o the otenti l role o or hology
or bio ech nics, ke ent l note o ny ch r cteristics observed, nd ollow-u
with ex in tion rocedures th t work to either con r or reject ny working
hy otheses gener ted.
5. Fam ily history: F ily history, like ll o the c tegories discussed bove, is key ctor
in er or ing ny sc n ex in tion. T e old d ge, “the le doesn’t ll too r
ro the tree,” is lic ble to edic l conditions s well s erson lity tr its. An
individu l with ily history o di betes is ore likely to develo olyneuro thy
second ry to di betes, th n n individu l without this ily history.20,34 Individu ls
with rents who h ve docu ented Ch rcot-M rie- ooth, re t risk or inheriting
the gene res onsible or this ixed otor nd sensory neuro thy, nd the ex iner
needs to consider the tient’s co l int in light o this in or tion.12,53 T e role o
ily history, rticul rly those conditions with known recessive or do in nt gene
inherit nce tterns, needs to be n i ort nt iece o in or tion used to gener te
working hy otheses. Ag in, to e ciently use this in or tion, the ex iner needs
to h ve excellent did ctic re r tion nd syste where they re ble to quickly
re erence questions th t rise. A list o s eci c conditions ssoci ted with ily
history is beyond the sco e o this ch ter, nd the interested re der is re erred to
Good n, Boissonn ult, nd Fuller.37
6. Past m edical history: T e truis o “history tends to re e t itsel ,”1 is very lic ble
when ev lu ting tients. T e st edic l history will o ten rovide iece o
in or tion th t is directly lic ble to why the tient who is being ev lu ted
h s current roble . It y be so ething s str ight orw rd s history o c r l
tunnel syndro e in the right h nd, when the tient is now resenting with le t-h nd
lter tions in sens tion nd strength. Bec use there is signi c ntly incre sed odds
r tio o tients with docu ented c r l tunnel syndro e (dist l edi n neuro thy)
h ving involve ent o the contr l ter l side,8,24,47 the in or tion rovided y give
vit l clue. Although the c r l tunnel c se is one in which the tient rob bly lso
h d high index o sus icion, there re other ti es when the tient y h ve not
de ny link ge between st edic l roble nd the tient’s current roble .
A second ex le o this is the surgic l re ov l o li o ro the dors l sur ce o
the lower neck. Over ti e, shoulder in develo s on th t side th t the tient does
not rel te to the li o resection. An stute ex iner will y rticul r ttention
to the nu l uscle testing o the u er trunk, s it is not unknown or the s in l
ccessory nerve to be ccident lly resected, resulting in shoulder in c used by n
in bility o the tr ezius uscle to contribute to nor l hu er l-sc ul r rhyth .
In ddition, the tient y h ve h d this ex ct roble be ore, nd the tient
y lso know wh t hel ed the tient to recover ro the roble reviously. S ge
questioning y rovide solution to the roble with which the tient resents.
7. Medications: Knowledge o the edic tions th t erson is t king is i ort nt or
v riety o re sons. T e edic tions give you in or tion th t the tient y not h ve
thought w s i ort nt nd did not rovide to you, even though sked. For ex le,
erson y not ention th t they h ve ny c rdiov scul r roble s, but i you nd
out th t they re on bet blocker, ollow-u question c n be sked th t cl ri es the
ur ose o this edic tion. With th t ex le, it is lso i ort nt to know th t the
r nge o the tient’s he rt r te is li ited t the u er extre e, so th t ny exercise
rescri tion develo ed or the individu l would need to t ke the edic tion into
ccount. T is one ex le is co ounded by the ct th t ny individu ls tod y
re on ulti le edic tions. Prior to er or ing n ev lu tion, it is incu bent u on
the ex iner to t ke the ti e to nd out both wh t the tient is t king nd why the
tient is t king those edic tions. (I the ex iner is unsure, the Physician’s Desk
Re erence is n excellent source o in or tion on edic tions.2)
8. Mechanism o injury: In those c ses where tient is ble to ccur tely describe how
his or her injury occurred, the tient c n rovide the ex iner with tre endous
insight into wh t is going on. A si le ex le is n individu l who underwent n
inversion s r in o the nkle nd is ble to rel te th t he or she “rolled over onto the
outside o his or her oot, with resulting nkle in.” Knowledge o the n to y nd
the tho hysiology o nkle s r ins llows the ex iner to s ecul te (hy othesize)
s to which l ter l lig ents o the nkle h ve been injured, with the ost co on
ttern being the nterior t lo bul r lig ent rst, the c lc neo bul r lig ent
second, nd the osterior t lo bul r lig ent third. With good descri tion o the
ech nis o injury, e ch o these structures c n be ev lu ted nd the extent o the
injury logic lly deduced.
T ere y be other c ses where the ech nis o injury is not rticul rly cle r
to the tient, but the tient’s descri tion will still id gre t de l. T e re son th t
the ech nis y not be cle r is th t the injury h ened too st. T is is o ten the
c se in knee injuries on n thletic eld, where there w s so e sudden event, such
s collision, with result nt knee in. T e ct th t the erson he rd “ o ” t the
ti e o the injury, nd th t they ex erienced signi c nt knee joint ef usion within n
hour o the event, however, is very telling. It h s been s id th t with these two ieces
o in or tion, the logic l deduction th t will be correct the jority o the ti e is
th t the individu l h s sust ined n nterior cruci te lig ent injury. T ere ore, sk
questions th t will g ther ll the known in or tion th t occurred t or round the
ti e o the injury.
Be w re, th t in the tient’s desire to ssist you by telling you wh t h ened,
the tient y not be truly w re o wh t occurred. A c se th t lso involves the
knee is the individu l th t sust ins tell r disloc tion. It is not unusu l or erson
who h s sust ined disloc tion to re ort th t the tell disloc ted edi lly, then
reloc ted in the trochle r groove. Although edi l disloc tion is ossible, the
jority o tell r disloc tions occur l ter lly bec use the knee is ch r cterized by
v lgus.77,98 T e tient y re ort disloc tion to the inside o the knee bec use th t
side o the knee hurts s result o the edi l retin culu th t h s torn to llow the
tell to disloc te. T e oint th t this illustr tes is th t even though tient believes
he or she knows wh t h ened, the injury y occur so st th t the tient’s
erce tion is not entirely ccur te. T ere ore, listen to wh t the tient h s to s y nd
ev lu te the in or tion obt ined with critic l ind, ctoring in wh t is known
bout the ost co on ech nis s o injury to rticul r re .
A l st oint is the ore entioned c se o the tient desiring to hel identi y
the c use o their roble . When cle r-cut ech nis o injury is not cle r, so e
individu ls will think b ck to ll the events th t occurred bout the s e ti e s the
onset o their sy to s. I this is their “best guess,” r ther th n known ech nis
o injury, then this should rob bly be tre ted s n idio thic c use o their roble .
At the very le st, in o unknown origin should be tre ted s yellow g, nd
in ny c ses, viewed s red g. T us, just bec use tient thinks th t they
know wh t c used their in, the ev lu tor is still required to critic lly ev lu te this
in or tion nd give it the r nge o credibility th t it w rr nts.
9. AM / PMpattern o pain : T e ttern o in th t the tient describes c n be very use ul
in develo ing working hy othesis bec use ost neuro usculoskelet l dys unctions
c n be relieved by osition or rest. It would be ex ected th t in second ry to
so tic dys unction could be both rovoked (see l ter section on rovoc tive tests),
nd decre sed or eli in ted by ro er ositioning nd rest. So tic dys unction
c n be de ned s “i ired or ltered unction o rel ted co onents o the so tic

(body r ework) syste ; skelet l, rthrodi l, nd yo sci l structures; nd rel ted
v scul r, ly h tic nd neur l ele ents.15 T us, the ttern o in th t is ty ic lly
re orted or ost neuro usculoskelet l disorders is ctivity or osition de endent
nd relieved by rest or ositioning th t re oves stress ro the f ected structure.
P in th t c nnot be in uenced by osition or rest, or in th t w kes tient ro
sound slee nd kee s the w ke, is t ini u yellow g. An ex le o
this ty e o in is n osteoid osteo , which ccounts or 10% to 12% o benign bone
tu ors.38 Bec use the in ro this ty e o lesion is not directly f ected by osition
nd is consistent irrit tion t night when rest should be working to relieve in, the
clinici n h s to ctor the ttern o in into the clinici n’s thought rocess. T e
jority, i not ll, o tients with cle r ttern o incre sed in t night th t is not
relieved by osition, should be re erred or ddition l work-u .
While the a m/ pm ttern o in should be ddressed in n ef ort to cl ri y the
tient’s co l int, there re cou le o other rinci les th t need to be ctored into
the icture th t the tient is telling. First, ny conditions h ve n a m/ pm ttern o
in th t is not yellow or red g, such s e rly rthritic ch nges. T ese tients will
o ten describe th t they re stif ( in ul) e rly in the orning, loosen u s they ove
round, nd then tend to stif en u nd beco e in ul g in tow rd the end o the
d y, when they re tired. T is ttern o in is logic l, nd i it ts with ll o the other
coll bor tive in or tion, then it h s rovided one ore con r tion o the tient’s
resenting roble . Another ex le o logic l a m/ pm ttern o in is the tient
with c r l tunnel syndro e. T ese tients o ten describe “tingling in the h nd th t
interru ts slee ,”68 nd in th t is rti lly relieved by sh king their h nds b ck nd
orth. T is ttern o in is ex l ined by the ct th t ny individu ls ssu e
curled-u osition when they slee , resulting in exed-wrist osture th t restricts
the needed blood ow to n lre dy co ro ised edi n nerve th t is ssing under
the tr nsverse c r l lig ent. Ag in, this ttern o in is logic l, c n be ex l ined,
nd even or s the b sis or conserv tive tre t ent with resting night s lint, nd is
not yellow or red g.
A second consider tion is th t the br in tends to st y ctive, even when the
tient is tte ting to rel x. T e ty ic l individu l is const ntly on the go throughout
the d y, with the eyes roviding visu l in or tion, the e rs he ring ll th t is going
on round the individu l, the te er ture o the ir being const ntly ssessed, the
individu l’s joints roviding eedb ck reg rding osition, s eed, or so e other
v ri ble, in ddition to the ch llenges nd concerns o the d y. When trying to rel x
nd go to slee t night, vision is eli in ted with the eyes closed, the environ ent
is nor lly quiet, te er ture is o ti lly regul ted, nd joints re not oving.
T ere ore, the br in th t is still receiving f erent in ut will h ve tendency to ocus
on the inco ing in or tion rovided, nd the re son bly n ge ble level o in
y e r ore ronounced to the tient in the evening. T is is o ten the c se with
individu ls with shoulder bursitis or other joint in tion rocess. T is ttern
o in is lso logic l nd ts with the ex ected ch r cteristics o tient with
so tic dys unction. Focused questioning will identi y the ttern o in s kee ing
with the coll bor tive evidence g thered in the ex in tion.
It should lso be noted th t in th t w kes n individu l ro sound slee
is not the key ele ent th t elev tes the a m/ pm ttern o in to yellow or red
g. T e tient described in the receding r gr h y w ke ro sound
slee i the tient rolls over onto the in ed shoulder. Although this w kes the
tient u , the tient is ble to re osition in w y th t t kes stress of the shoulder,
llowing the tient to ll b ck to slee . T e key oint th t elev tes tient to
otenti l yellow or red g, is when the tient consistently w kens in the iddle
o the night nd once w ke, is not ble to go b ck to slee . T is suggests so ething
other th n so tic dys unction nd work-u by s eci list with the tools to
ex lore syste ic conditions or viscer l roble s should be considered. When this
is cou led with ttern o in th t is not f ected by rest or ositioning, re err l is
rob bly w rr nted.
10. Nature o pain : P in is i ort nt bec use it is ty ic lly wh t brings the tient into the
clinic. P in c n hel guide the rocess, nd it needs to be res ected when tre ting
tient. H ving s id th t, key rinci le is to not be led by in (see revious section,
oint 2, under the subjective ex in tion). Let in be one iece o in or tion, but
do not h ve the in ex erienced by the tient be the ocus o either the ex in tion
or the tre t ent l n.
T e n ture o the in c n o ten rovide gre t de l o in or tion th t will
hel identi y otenti l roble . As result o the loc tion o rece tors in the body
nd the w y th t we re hysiologic lly wired, in c used by su er ci l structure
tends to be ore e sily loc ted.28 P in c used by viscer l structures is o ten re erred.69
Regions o the body, such s viscer l leur , re insensitive to in.72 So e structures,
such s nerves, o ten h ve in th t r di tes.92 P in c used by nerve origin y lso
h ve descri tive ch r cteristics th t hel identi y nerve s the structure involved,
such s “bright” or “sh r ” in.4,46 A ull descri tion o the n ture o in is beyond
the sco e o this ch ter, but co on ch r cteristics ssoci ted with in h ve been
described elsewhere or the interested re der.36,40,43,50,62 T e key oint is th t in c n
rovide v lu ble clues to wh t is going on with the tient. Listen to the in or tion
rovided, know wh t v rious descri tions o in e n, nd dd this s one iece o
the uzzle when sse bling the in or tion th t will ho e ully le d to coll bor tive
icture o the tient’s roble .
11. raining history: I the tient is eng ged in ny thletic, voc tion l, household re ir,
or recre tion l ctivities th t require hysic l l bor, sk bout the n ture, requency,
dur tion, nd intensity o the ctivity. Addition lly, sk bout ny ch nges in the
tre t ent regi en. Individu ls resenting or c re bec use o overuse injuries re
signi c nt ercent ge o the tient o ul tion seen. Rese rch shows th t errors
in tr ining, ccount or signi c nt ercent ge o the injuries th t re ttributed to
overuse roble s.51,54 T e ost co on error ssoci ted with the tr ining rescri tion
( ctivity, requency, dur tion, nd intensity), is incre sing the tot l volu e o the
ctivity too quickly, by r ing u the dur tion o the ctivity in too l rge o incre ents.
While h ving unre listic ex ect tions bout how st ile ge or re etitions or
sets or so e other v ri ble c n be dded, there re ny other tr ining errors th t will
beco e evident when listening to tient’s tr ining history. I once h d tient who
co l ined o knee in. When sked bout wh t he did recre tion lly, he indic ted
th t he w s jogger. A ollow-u question sked bout his tr ining ile ge, nd he
indic ted th t he h d run 16 iles yesterd y. When questioned urther bout his
ty ic l tr ining week, he indic ted th t over the st 3 d ys, he h d run 16 iles e ch
d y. Although well-educ ted individu l ( l wyer), he did not see the need to llow
his body ch nce to recover ro tr ining events th t were cle rly stress ul to his
body. When ore b l nced tr ining rogr w s develo ed, his sy to s cle red
u nd his er or nce i roved.
r ining errors re nu erous nd co lete list is beyond the sco e o this
ch ter. One n l thought, however, is th t the otenti l errors re not restricted
to the tr ining rescri tion v ri bles listed bove. An ex le with running th t
should be considered in the questioning rocess is the ty e nd ge o the shoes
worn. M ny recre tion l joggers will we r their shoes or uch longer eriods o
ti e th n they were designed to be worn. T us, the shoe h s lost ll cushioning
ro erties nd ddition l stress is being directly tr ns erred to the jogger. Also,

jogger y switch shoes to new br nd, nd gr du lly develo sy to s th t
they do not ttribute to the ch nge in shoes. An i ort nt oint is to recognize th t
tr ining errors re co on nd th t the tient will o ten cle rly describe wh t
ch nge h s brought on s eci c roble , not recognizing the connection between
their beh vior nd the injury.
Bot t om Line
T e bove list o 11 ite s is n bridged list o so e o the v ri bles th t y be consid-
ered in subjective ex in tion. E ch ev lu tor will build list over ti e th t suits the
ev lu tor’s style nd the ty ic l tient o ul tion with who the ev lu tor is working.
Although the ex ct ite s y v ry ro ther ist to ther ist, there re sever l truis s
th t re resent with everyone. First, s h s been stressed re e tedly, there should be
cle r syste ssoci ted with the subjective ev lu tion, so th t key ite s re not issed.
Second, or every question sked, there should be s eci c ur ose or the question. Use
the in or tion rovided to c tegorize sy to s nd other in or tion into work ble
hy othesis(es). T ird, b sed on this in or tion, the objective ortion o the sc n ex in -
tion is l nned. L st, know when the in or tion rovided indic tes th t the roble y
be outside o the ev lu tor’s re o ex ertise. “T e rk o true ro ession l is to know
the li its o his/ her bilities, nd to re er, when ro ri te.”42
Objective/ Physical Examination

T e objective ex in tion builds on the in or tion rovided in the subjective/ history
ortion o the sc n ex , with odi c tions designed in s needed. T e objective ex i-
n tion is uid rocess whereby the ex iner c n begin to test the hy otheses gener ted
ro the res onses th t the tient rovided to the ther ist. Although uid rocess, it
c nnot be stressed enough th t this ev lu tion is er or ed within the context o syste
th t h s key ite s th t should be ev lu ted with every tient. T e syste is required to
insure th t the ocus o the ex in tion re ins bro d (so th t so e key in or tion is
not overlooked), i ort nt in or tion is not in dvertently issed, nd so th t the rocess
o ex ining the tient is e cient (eg, not h ving the ch nge ositions b ck nd orth
nu erous ti es, etc).
Met horic lly, or those ili r with gol , this rocess is little like ro ching
gol course. A skilled gol er ro ches the round with l n (the syste ). T is individu l
knows where the h z rds re, which side o the irw y is o ti l to drive to, wh t regions
re out-o -bounds, nd h s identi ed o ortunities or either conserv tive or bold l y.
While e ch gol course is dif erent, the b sic ele ents o wh tever syste used by th t indi-
vidu l will be in evidence with every course l yed. Note th t this i lies th t not ll eo le
will utilize the s e syste when ev lu ting gol course, bec use their unique ro ch
will be b sed on their rticul r strengths nd we knesses. T is is lso true or the objective
ex in tion, where the syste used by dif erent skilled ro ession ls will not be ex ctly
the s e, even though e ch syste will cont in virtu lly ll o the s e ele ents. Addi-
tion lly, s in gol , while the l n (syste ) re ects th t or r 4, there is drive, second
shot to the green, nd 2- utt, th t l n will be odi ed s needed s erson rogresses
through the round. T e rt nd skill o er or ing t high level utilizes well–thought-
out l n th t c n be cre tively odi ed s needed to cco lish the t sk t h nd. In gol ,
this y e n knowing when to chi b ck out into the irw y, or when it is ro ri te to
tte t to bl st shot over trees on dog-legged irw y. In the ex in tion rocess, this
is knowing when to dd on to the r ework utilized in the sc n ex in tion nd ollow-u
Objective/Physical Examination 83
on le d th t will er it ore de nitive deter in tion o the tient’s roble . T e
syste rovides the r ework or l n. B sed on th t in or tion, the ev lu tor needs to
re in exible nd res ond to the in or tion rovided, both ro the subjective (history)
nd ro the hysic l ex in tion itsel . Note th t this uid rocess is signi c ntly dif er-
ent ro ollowing n lgorith th t h s redeter ined sequence o ste s th t re l rgely
dhered to without gre t de l o inter ret tion. A strong did ctic b se, cou led with sys-
te nd the bility to gener te nd ev lu te ulti le hy otheses si ult neously, is needed
to er or co etent objective ex in tion.
Although ll the in or tion in the receding r gr h is ccur te, it lso correctly
i lies th t skilled ev lu tor h s ex erience. So, wh t bout the neo hyte ther ist st rt-
ing out with the er or nce o objective ex in tions? T ree suggestions re s ollows:
( ) Develo or or series o or s th t serve to ro t the ev lu tion, to insure th t no
i ort nt ste s or ieces o in or tion re orgotten. Bec use e ch individu l ro ches
the hysic l ex in tion in his or her own w y, individu lize this syste to t the style
nd needs o the erson er or ing the ex in tion. (b) Whenever ossible, seek out nd
develo rel tionshi with entor. Everyone will run into questions or situ tions th t re
not cle r, where n outside ers ective is needed. Develo this ty e o rel tionshi nd ide-
lly h ve the bility to seek out in or tion on n “ s-needed” b sis, s well s est blish ti e
where regul r exch nges nd reviews o tients c n t ke l ce. (c) H ve re l nned syste
th t er its ste ing out o the ex in tion roo nd going to nother loc tion to look u
in or tion th t is needed to co lete thought or to review in or tion ssoci ted with
rticul r condition. T is y be s si le s s ying, “Excuse e. I need to ollow u on so e
tient in or tion. I will be b ck in inute.” I this llows obt ining in or tion s needed,
it will result in both le rning nd i roved c re rovided or the tient being seen.
Record as You Go
Record s you go during the objective ex in tion rocess. Rese rch shows th t no one is
ble to er or co lex ex in tion th t includes odi c tions on the y, nd re e -
ber ll o the det ils ssoci ted with th t ex in tion.88 It is not we kness to use or
ew seconds during the ev lu tion, nd jot down ny ertinent ndings. My erson l re -
erence is to nnot te ny ndings th t re not o ti l. T is includes ny subtle li it tions
o r nge o otion, ny identi ed re s o less-th n- er ect sens tion, or ny other nding
ssoci ted with ny s ect o the hysic l ex in tion. T e dv nt ge o this is th t when
ev lu ting ost tients, the jority o their ndings will be nor l. T ere ore, by record-
ing ll ele ents th t devi te ro nor l s you go, you re constructing in your ind
co lete icture b sed on ll o the d t resented. T en, t so e l ter ti e, such s the
end o the entire ev lu tion rocess or ter the tient h s been tre ted, the ther ist is
ble to sit down nd gener te ro er record o the visit, with ll d t (both nor l nd
less th n o ti l) incor or ted into the note.
In ddition to being e cient nd ssisting with reconstructing n ccur te icture o
the entire ev lu tion, this rocess o gener ting cursory nnot tion ollowed by or l
note rovides the dv nt ge o reviewing the teri l twice. An i ort nt ele ent o
skilled clinici n is the insight rovided by re ecting on the ndings resented. In the rst
ss, ll otenti l ndings re collected in seri l rocess nd tested g inst the working
hy othesis. When then looking t the entirety o the d t t the end o the ev lu tion, it is
not unusu l or r dig shi t in thinking to occur, with new hy othesis le ding to di -
erent conclusion nd tre t ent ro ch. An ccur te ev lu tion is built u on excellent
in or tion nd re ection. T is will only be cco lished by stidiously recording s you
roceed through the ex in tion.
wo l st oints need to be de ssoci ted with recording the in or tion. First,
i you did not record it, ro leg l st nd oint, you did not do it. Annot tion is critic l
to subst nti te your ndings nd tre t ent l n. Second, nnot te in such w y th t the
in or tion rovided is e cient, use ul, nd indic tes th t thorough ev lu tion w s
done. In the re ce to T e Four-Minute Neurologic Exam ,35 Ste hen Goldberg, MD, kes
the observ tion th t “Neuro WNL” (“the neurologic ex is within nor l li its”) is co -
only the l st not tion on hysic l ex re ort. Regret ully, Dr. Goldberg oints out th t
this o ten e ns th t virtu lly no neurologic ex took l ce. T e in ul joke in so e
clinic l settings is th t the crony WNL e ns “We never looked.” When roviding su -
ry o the ndings, rovide enough det il on the tests er or ed th t it is cle r wh t w s
done nd wh t the ndings were. Although this y t ke n extr inute or two, it shows
ttention to det il nd the ct th t the objective ex in tion w s t ken seriously. Addi-
tion lly, it rovides ny other ev lu tors th t ollow with n excellent ro d , identi ying
where th t tient’s roble w s on given d te.
Basic Element s of Most Physical Examinat ions

T e ollowing is n bridged list o so e o the b sic ele ents th t should be included in
virtu lly ll sc nning ex in tions. De ending on the ty es o tients rticul r r c-
tice sees, this list y not be su cient nd nu ber o other ite s should be dded. T ere
re sever l excellent guides th t outline ny ddition l ex in tion tests, such s Rich-
rd B xter’s Pocket Guide to Musculoskeletal Assessm ent 9 nd M rk Dutton’s Orthopaedic
Exam ination, Evaluation, and Intervention.25 T ese re erences nd other ocket guides45
nd texts,64,101 c n be used to ef ectively build u on the sc nt r ework o “sc n ex i-
n tion.” As h s been described reviously, the sc n ex is not intended to be thorough
ex in tion, but r ther to rovide syste where quick ev lu tion c n be er or ed
th t, t ini u , identi es th t the roble e rs to n ge ble within the neuro-
usculoskelet l re l , or th t the roble is one th t requires re err l or i edi te tten-
tion. Fro the r ework rovided by the sc n ex in tion, other ele ents c n be dded
to work tow rd the desired thorough ev lu tion, s ti e er its. At ini u , the ollow-
ing should be incor or ted into the sc n ex in tion:
1. Observation : T e observ tion begins when w lking out to the w iting roo to eet
the tient. W tch how the tient oves ro sitting to st nding, the cont ct th t the
tient kes when sh king h nds, nd the w y th t the tient oves b ck to the
ex in tion re . Bec use everyone res onds in little dif erent w y when they know
they re being w tched, work to c rry on le s nt convers tion while surre titiously
ying close ttention to the tient’s ove ents. T e si le n logy o t king
so eone’s icture when they don’t know th t you re w tching rovides uch ore
re listic view th n the “ osed” st te o s ying “cheese” to rti ci lly look rel xed.
Si il rly, i the clinici n sks the tient to w lk while w tching the , the tient’s
g it y or y not rovide the in or tion th t you re lly w nt. Do s uch s you
c n while the tient is er or ing nor l ctivities.
Observ tion lso includes looking t the individu l ro ostur l ers ective,
noting ny sy etries in their skelet l r e or uscul ture. T is e ns th t ll
regions o the body being investig ted need to be ro ri tely ex osed, int ining
ro er decoru or the tient. Be syste tic here lso, st rting t loc tion like
the lleoli o the nkles, nd syste tic lly working u to the he d. Look or equ l
lign ent o cle r bony l nd rks like the bul r he ds, gre ter troch nters, ischi l
tuberosities, di les ssoci ted with the osterior in erior ili c s ines, the ili c crests,
etc. Look or olds o the skin th t y be resent on one side o the trunk but not the
other, th t could suggest scoliosis or other issue nd re nother w y to identi y
otenti l structur l bnor lity. Addition lly, look or signs o tro hy, sc rs, ede ,
or ny other bnor lity th t rovides evidence o st or current roble . One
ex le o c se where observ tion c n l y key role is the reviously entioned
i trogenic nerve lesion, tr ns ction o the s in l ccessory nerve.71 During the
history, st surgeries y h ve been sked bout, nd the tient y rel te th t
nothing h s been done to their shoulder, which is the re son they re being seen. By
observing sc r over their right u er thor x, question c n be sked bout the c use
o th t sc r. T e tient rel tes, “Oh, th t re lly w s nothing, just benign li o th t
w s re oved ro y b ck.” I the ther ist recognizes th t s in l ccessory nerve
y h ve been in dvertently tr nsected through this ty e o inor surgery nd th t
r lysis o the tr ezius c n c use shoulder in, otenti l link ge between the sc r
nd the tient’s roble needs to be ex lored. T e botto line is th t the ther ist is
required to t ke the ti e to dequ tely observe the
tient, through the use o syste , both st tic lly
nd ctively (Figure 3-2).
2. Range o m otion : Bec use this is sc n
ex in tion, the key objective is to see i there
re ny signi c nt li it tions nd nnot te those.
T e si lest w y to ssess this is to h ve syste
th t incor or tes ny otions si ult neously
nd h ve the tient ctively er or th t ctivity
or ctivities. For ex le, i tient is ble to
re ch sy etric lly behind nd u their b cks,
re ching the id-sc ul r region with both h nds,
then they h ve de onstr ted nor l or ne r
nor l intern l rot tion nd extension o their
shoulders (Figure 3-3). By re ching u over their
he ds with their r s (nor l exion), then ro
this osition re ching s r down their b cks
s they c n to t le st the id-sc ul r region, Figure 3-2 Obse rvatio n o f iliac cre st he ig ht,
shoulder bduction nd extern l rot tion re lso lo o king po ste rio r to ante rio r
ssessed. Elbow, wrist nd h nd otion will be
si ult neously ssessed during the u co ing
strength ssess ents. I ll o the bove is nor l,
then the sc n ex c n rob bly roceed to the
next ele ent o the ev lu tor’s syste .
In the c se where ctive r nge o otion is
either not sy etric l or i cle r or subtle r nge
li it tion is identi ed, the ex iner is oblig ted
to both note it nd ollow u with ore det iled
ex in tion. I we kness h ens to the tient’s
key roble , this y involve n ctive- ssistive
ro ch to scert in the true r nge o otion
t given joint. More in or tion y lso be
obt ined by er or ing ssive r nge o otion,
nd t the end o the r nge, roviding gentle
over ressure. T ese ollow u rocedures c n be
used to ssess the true st tus o the joint nd the
surrounding inert nd contr ctile structures.22
T e key ur ose o the r nge o otion ortion
o the sc n ex in tion is to deter ine i the
tient oves nor lly or not. I ove ent is
not nor l, identi y the li it tion. T en, i ti e Figure 3-3 Scan e xam active -rang e -o f-mo tio n
er its, ollow u the b sic ssess ent with ore asse ssme nt o f the uppe r e xtre mitie s
det iled nu l rocedures to deter ine the true st te o the joint nd surrounding
structures.
In ddition to the extent o the r nge o otion v il ble, the qu lity o the otion
lso needs to be ssessed. Did the ove ent ow s oothly without interru tion,
or did the tient gri ce with r nge o otion th t st rted nd slowed in h lting
shion? Assess wh t the tient is tte ting to convey through their ove ent, nd
work to ctor this into the working hy othesis. Work to identi y ove ent tterns
th t re li ited bec use o we kness nd other tterns th t re li ited bec use o
in. T rough the qu lity o the otion, the tient will o ten tell the ex iner s
uch in or tion s is rovided through the history or the ctu l r nge-o - otion
nu bers obt ined visu lly or with gonio eter.
A l st oint ssoci ted with sc n ex in tion is th t the r nge-o - otion
ssess ent is nor lly done visu lly, nd not ssessed in ure l nes s is ty ic lly
done when recording r nge o otion with gonio eter. T e sc n ex ’s ur ose
is to identi y i ove ent is nor l, or i sy etric l or li ited, where this is
occurring. y ic lly, the only ti e gonio eter would be used during sc n
ex in tion is s ty e o ollow-u , to nnot te the reviously identi ed li it tion
in r nge o otion.
3. Strength: T e go l o sc n ex in tion with strength testing is si il r to th t o
r nge o otion: to identi y ny cle r de ciencies or sy etries. o th t end, the
ty ic l sc n ex in tion does not involve nu l uscle test o ll the uscles in
given region, but r ther sc ns the jor uscle grou s. For the u er extre ities,
this y involve the ollowing ( ll o which c n be done in sitting osition):
a. Resisted shoulder bduction—tests deltoid grou nd sc ul r rot tors
(Figure 3-4).
b. Resisted shoulder exion—tests shoulder exors nd sc ul r st bilizers.
c. Resisted rotr ction—to ssess the serr tus nterior (Figure 3-5).
Figure 3-4 Manual muscle te st o f the abducto rs o f the sho ulde r

Figure 3-5 Manual muscle te st o f the se rratus ante rio r— Figure 3-6 Manual muscle te st
insuring that the scapula do e s no t “w ing ” o f re siste d ng e r abductio n
d. Resisted shoulder intern l nd extern l rot tion—tests shoulder rot tors.

e. Resisted elbow exion nd extension—tests uscles o the r .
f. Resisted elbow su in tion nd ron tion—tests su in tors nd ron tors.
g. Resisted wrist extension nd exion—tests ore r uscles.
h. Gri strength— ssesses extrinsic uscles o the nterior ore r .
i. Resisted nger bduction—tests dors l interossei nd bductors o the thu b
nd little nger (Figure 3-6).
j. Ability to ke n “O” with the thu b nd index nger, nd resist—tests uscles
innerv ted by the nterior interosseous br nch o the edi n nerve (Figure 3-7).
k. Resisted shoulder shrug— ssesses the u er
tr ezius.
l. M y lso w nt to ssess resisted neck
ove ents ( exion, extension, rot tion nd
side bending), i ro ri te—de ends on the
tient’s resent tion.
T ese uscle grou s re ty ic lly tested
in idr nge osition bec use th t is where
the tient will h ve ne r-o ti l strength s
redicted by the length–tension curve.29,86 T e
resisted contr ctions re ty ic lly iso etric
contr ctions, s they c n be er or ed quickly
nd rovide re son ble e sure o the
ount o resist nce th t the tient is ble to
gener te. T ere is not re lly need to h ve the
tient de onstr te th t he or she c n ove ny
rticul r uscle grou through the ull r nge o
otion, s this should h ve lre dy been ssessed Figure 3-7 The “O” sig n—asse ssing fo r ante rio r
during the r nge-o - otion ortion o the sc n inte ro sse o us ne rve inte g rity
ex in tion. Addition lly, note th t the bove sche e

is working to ssess unction l uscle grou s, r ther
th n individu l uscles. I we kness is identi ed, in
ddition to nnot ting th t, the clinici n is oblig ted
to go b ck t so e oint nd er or ore in-de th
ex in tion. T e sc n ex in tion rovides good
overview o the region under investig tion, nd the
r ework u on which ore det iled ex in tion
c n be built.
A si il r sche e to the 12 uscle grou s outlined
bove c n e sily be devised or the lower extre ities
(Figure 3-8). T is y roceed in nner si il r
to the uscle grou s identi ed bove, working down
ro the hi s, or it y involve co bin tion o
uscle grou tests nd unction l tests. For ex le,
it is rob bly ore e ning ul to h ve tient
w lk on his or her toes nd then on his or her heels
th n it is to resist l nt r exion or dorsi exion. T is
Figure 3-8 Manual muscle te st o f the
is bec use the tient’s body weight ( rticul rly
quadrice ps—illustrate d o ut o f the “clo se d-packe d”
with toe w lking) will rovide ore resist nce th n
po sitio n
ty ic lly will be rovided with grou nu l uscle
test. I there is ny issue with toe w lking, qu nti y
the otenti l we kness with the nu ber o unil ter l
heel r ises th t the tient is ble to er or , u to
xi u o 25, which is considered nor l.85
One other unction l test th t c n be used is dee
squ t, returning to st nding osition. For young nd
exible tients who c n e sily er or this neuver,
in or tion is rovided bout the knee extensors nd
hi extensors. When this is co bined with select grou
uscle tests, syste c n be devised th t quickly
rovides gre t de l o in or tion on ll o the jor
uscle grou s o the lower extre ity. Bec use this is
sc n ex in tion, devise syste th t is thorough,
but voids needless redund ncy. I unction l test
is incor or ted into the syste used with thletic
individu ls, then dro out grou uscle test th t
would be redund nt (Figure 3-9). On the other h nd,
i the tient is n 80-ye r-old who would ty ic lly
h ve di culty er or ing dee squ t, h ve enough
exibility in your syste so th t ge- ro ri te
t sks re requested, while still ex ining ll desired
uscle grou s.
As w s the c se with n u er-qu rter sc n
ex in tion, ny identi ed de ciencies will need
to be ollowed u t so e other ti e with ore
det iled ev lu tion. At the ti e o the ore det iled
ollow-u , it is both ro ri te nd ex ected th t
individu l nu l uscle tests will be er or ed.
T ere re nu ber o excellent texts th t rovide
gre t det il on the correct w y to er or nu l
Figure 3-9 Example o f a functio nal te st uscle testing.23,56,85
In nishing the overview o this ele ent o the sc n ex in tion, the role o
in in sc nning the strength o jor uscle grou s should be ddressed. I
tient “yields to in” during resisted iso etric contr ction, then nothing c n
re lly be s id bout the st tus o the contr ctile unit ( uscle, tendon, nd tendon-
erioste l insertion).22 T is is bec use the strength could be nor l, but the tient
is yielding bec use o disco ort. o record the strength s less th n nor l would
then be in ccur te. All th t the clinici n c n re lly do is nnot te th t they could not
ccur tely ssess the strength o the uscle grou in question, bec use the tient
yielded in res onse to in. It y be v lu ble to st te the level o resist nce rovided
rior to yielding (eg, un ble to ssess tient’s true elbow exion resist nce, but
tient rovided elbow exion resist nce o 4/ 5 rior to yielding second ry to in),
but th t is erson l re erence nd judg ent c ll. T e key oint is to recognize th t
to rovide strength e sure ent, it needs to be re ective o the tient’s best ef orts
without the overl y o in or so e other ctor.
4. Sensation : Most o the ti e i erson h s signi c nt sensory de cit, this ty ic lly
will be reve led during the history ortion o the ev lu tion. T ere ore, insure th t
the question is sked nd listen closely to the tient’s res onse. Addition lly, s w s
outlined reviously, require the tient to be recise nd identi y s eci c sides o the
li b, s eci c digits, nd where ny sensory bnor lity begins or ends.
Although the history will rovide signi c nt insight into ost sensory issues, the
clinici n re ins oblig ted to er or , t ini u , sensory sc n ex in tion o
the region in question. o do this, the re to be tested should be ex osed, the tient
should be rel xed nd co ort ble, nd, in kee ing with in or ed consent, should
h ve h d the sensory test ex l ined nd consented to, rior to the ex in tion.
T en, the sensory ex in tion should roceed in syste tic w y, usu lly dist l
to roxi l. T e re s ssessed should cover ll cut neous eri her l nerves nd
der to es o the region under investig tion (see re erence 70 or s eci c cut neous
nerve elds nd der to es).
T e e siest od lity to use or this ssess ent is light touch, s this c n be
done with the clinici n’s ngerti s. In the v st jority o c ses, bec use o the
initi l st te ent th t sensory de cits re usu lly identi ed in the history, sc n
with light touch is dequ te nd ti e e cient. T e co bin tion o both nor l
history o sens tion nd nor l light touch over region like the u er extre ity
in n u er qu rter screen, rovides strong ound tion to ove on to the next
ele ent in the over ll sc n ex in tion. H ving st ted th t, the ex iner h s
to recognize th t dif erent od lities re c rried by dif erent sensory syste s.
A tient could h ve roble like syringo yeli th t f ects the nterior white
co issures t sever l levels in the s in l cord, disru ting the nterol ter l
sensory syste . In this tient, light touch should be nor l, but the od lities
o in nd te er ture sens tion would be ltered. T ere ore, or this tient,
who is resenting ty ic lly with ltered sens tion in region like the shoulders
bil ter lly (“sh wl” or “bre st l te” sensory de cit),90 it is i er tive th t the
clinici n ddition lly er or “sh r -dull” or so e other sensory test th t
ev lu tes the od lities c rried by the nterol ter l syste .33 Ag in, sc n
ex in tion is to rovide n overview nd is used to identi y de cits. I sensory
de ciency is identi ed by either the history or the light touch sc n, then the
ev lu tor is oblig ted to recognize th t ddition l ollow-u y need to be done
nd th t sens tion involves sever l syste s th t re best ev lu ted by their unique
od lities. Addition lly, lthough ty ic lly ke t in the b ck o the clinici n’s ind,
there re lso other rocedures, such s the extinction heno en ,80 th t y need
to be utilized in r re c ses where centr l nervous syste involve ent is sus ected
(see re erence 35 or ddition l det ils).
Sensory testing c n dd gre t de l to the testing o working hy othesis,

i the ev lu tor h s cle r icture o the distributions rovided by both
der to es nd cut neous eri her l nerves. Gener lly, der to es re the
extension o roble s origin ting t the root or lexus level, nd roughly ollow
the s outlined in n to y tl ses like Netter’s or Gr nt’s tl s o n to y.5,76
Der to es lso overl , so i only 1 root level is f ected, there y be no cle r
sensory involve ent, or the re involved would e r s ller th n the n to y
tl ses ty ic lly convey. For der to es, it ty ic lly requires th t t le st 2 levels
be f ected to h ve co lete sensory loss in der to l distribution. With
cut neous eri her l nerves, however, d ge to given nerve c n result in
cle r sensory loss when only th t 1 nerve h s been co ro ised. For ex le,
i tient sust ined cut or r cture th t severed the su er ci l r di l nerve
bove the wrist, then sensory loss would occur in region on the dorsu o the
h nd between the thu b nd index nger.70 T is loss is unique to this eri her l
cut neous nerve nd is in kee ing with the ore dist l site o injury. Bec use this
is sensory nerve t this oint (still h s so e utono ic otor bers within the
nerve, so it is not ure sensory nerve 70), there will not be ny dist l uscles th t
c n be coll bor tively tested. C re ul sensory testing will rovide coll bor tive
in or tion th t c n be used with the d t ro the rest o the ex in tion to hel
identi y the underlying roble .
An ddition l oint with sensory testing is th t the ev lu tor needs to cle rly
scert in the n ture o the sensory dys unction. For so e tients, they h ve
nor l sens tion but y lso co l in o tingling. T us, there re lly is no
de cit, but the tient still is identi ying region th t does not eel nor l. So e
tient’s will describe distributions th t c n only be ex l ined by v scul r
dys unction, so in ddition to knowing der to es nd eri her l cut neous
nerves, the ev lu tor needs to be w re o v scul r regions nd the ni est tions
o less th n o ti l v scul r syste . Fin lly, there will be so e tients with
hy esthesi or llodyni ssoci ted with their sensory syste . T ese re
ty ic lly c used by conditions like co lex region l in syndro e (old n e
or sy thetic re ex dystro hy) th t f ect the sensory syste by roducing n
incre se in the erceived sens tion. Conditions such s co lex region l in
syndro e illustr te the need or the ev lu tor to h ve n excellent ound tion l
n to ic l nd hysiologic b se, underst nding the role o utono ic bers
in ixed nerves, in ddition to the ore requently considered gener l sensory
f erents. By st ying o en- inded, collecting the d t s it resents, nd then
working to distill the in or tion within the context o working hy otheses, the
ev lu ting clinici n will o ten be ble to use sens tion to coll bor te the rest o the
objective ex in tion.
5. Palpation : T e history should h ve rovided insight into the region where the tient
st tes the in is loc ted, i in is jor ctor in the tient’s resent tion or c re.
It is the job o the ev lu ting clinici n to know the n to y o the re well enough
th t the structures th t c n be e sily l ted re identi ed nd ssessed with touch
in syste tic w y. As h s been the c se with ll ele ents o the ev lu tion, the
history should h ve rovided the clinici n with set o working hy otheses th t need
to be distilled down to the one or two ost likely involved structures. Addition lly, the
clinici n should h ve insisted during the history th t the tient identi y “the bull’s-
eye” oint o in. In other words, require through questioning th t the individu l
rovide s eci c loc tion where the tient believes the in is e n ting ro ,
r ther th n er itting the tient to si ly re ort th t “the shoulder hurts.” Wh t
is the s eci c loc tion o the center oint o in? With this in or tion, it is uch
e sier to l n the syste tic l tion ssess ent.
Once the oc l oint o the l tion ssess ent h s been identi ed, the l nned
ev lu tion should begin w y ro this oint. T e re sons or beginning w y ro
this centr lized oint o in re:
a. It ssists in kee ing the ev lu tor ro beco ing yo ic. I the syste tic
l tion ssess ent i edi tely ocuses in on the sus ected re or structure
involved, it is too e sy to sto the ssess ent s soon s the tient ex resses
th t the ther ist’s l tion c uses in. I this is done, other otenti lly
involved re s or structures re not investig ted nd otenti lly i ort nt d t
re issed.
b. By its very n ture, l tion is rovoc tive test th t is e nt to re roduce
the in th t the tient is seeking to sto . T ere ore, s rt o the rocess o
er or ing sound ev lu tion nd est blishing xi u r ort with the
tient, it kes sense to not i edi tely re ch out nd ress on n re th t the
ther ist believes will re roduce in. St rt on structures outside o the key re
o interest, nd syste tic lly work tow rds wh t is believed to be the involved
structure. T e tient then h s the knowledge th t the ther ists is ev lu ting
nu erous structures in the re nd th t the key go l is not to i edi tely
re roduce in. When structure is l ted th t is in ul, this c n be co red
to the other structures th t h ve been l ted nd questions sked bout the
n ture o the in roduced. For ex le, r l tion to the cor coid rocess
in the shoulder is unco ort ble or the nor l erson. I this is re orted s
in ul, the ollow-u questions should ssess i this re roduces the in th t
h s c used the tient to resent or c re, or i this is si ly structure or re
th t is unco ort ble when l ted. In n ide l world, the go l o l tion
is to identi y 1 structure or 1 s ll re th t re roduces the s e in th t h s
ro ted the tient to seek edic l c re.
c. Bec use l tion is ex ected to be in ul, it is rob bly good ide to le ve
the l tion to l te in the hysic l ex in tion. T is is closely rel ted to oint
b bove, where key go l is to est blish xi u r ort nd not i edi tely
re ch out nd er or rocedures th t the ther ist ex ects will hurt the tient.
Be gentle, ex l in wh t is being done, rovide syste tic ssess ent, nd
work to design the l tion o region so th t it is tow rds the end o the over ll
ex in tion nd ide lly ends with the l tion o the 1 or 2 structures th t re
the ri ry working hy otheses.
wo n l c ve ts re:
a. P l ting n re rovides n excellent o ortunity or very close visu l
ins ection o the region. Look or ny swelling, otenti l joint ef usion, ch nges
in skin color or texture, tro hy, or evidence o old sc rs or other sign o injury. I
nything out o the ordin ry is observed, sk ertinent questions nd work those
res onses into the working hy otheses. Use this ti e to ully ex ine the region
nd ke co lete ssess ent.
b. Underst nd the otenti l i ct o re erred in nd how it y f ect the
ssess ent. I in is re erred, there is good ch nce th t the l tion o
given region will not re roduce the tient’s described in. T is is logic l, s
the re l source o the in is in nother region o the body. For ex le, s
result o the e bryologic distribution o root levels ssoci ted with the hrenic
nerve, n irrit tion or injury c using in in the region o the di hr g y
re er in to the C3 through C5 der to es o the neck nd shoulder.69 Although
this is where the tient eels in, this is not the source o the tient’s in,
nd l tion will not shed ny ddition l light on the tter. It y be th t the
key nding ro this neg tive result is to ro t the ev lu tor to think beyond
the one region being investig ted nd consider re erred in s key source
o the roble . I this is the c se, nd bec use re erred in i o ten ssoci ted
with viscer l structures, n ddition l question th t needs to be sked h s to do
with the n ture o the resenting roble . I it is neuro usculoskelet l, then it
y still be within the do in o the ther ist er or ing the ev lu tion. I it is
outside o th t s here, then re err l to n ro ri te s eci list y be the ide l
course o tre t ent. Ag in, key ele ent ssoci ted with nyone er or ing
sc nning ex in tions is to underst nd the li its o their skills nd ro ession l
sco e o r ctice, nd utilize other e bers o the he lth c re te when
ro ri te.
6. Provocative tests: P l tion w s otenti lly rovoc tive test, bec use by design, the
ev lu tor ho es to be ble to ut ressure on n involved structure nd re roduce
the in th t h s brought the tient into the clinic. T us, i the clinici n is ble to
re roduce the tient’s ex ct in, nd i there is n underst nding o the structures
involved when the in is re roduced, then the c use o the in c n be understood.
In other words, the go l o rovoc tive test is to re roduce the tient’s sy to s, in
controlled environ ent, where the ctors th t contribute to the gener tion o in
c n be understood.
A cl ssic ex le o rovoc tive test is the contr ctile versus inert tissue
test described by Cyri x.22 In hy othetic l c se where clinici n is ev lu ting
shoulder in nd h s s working hy otheses otenti l subdeltoid bursitis versus
su r s in tus tendonitis, rovoc tive test c n be used to otenti lly distinguish
between these 2 clinic l roble s. T e rovoc tive test will re lly involve 2 ele ents,
one th t tests the contr ctile ele ents ( uscle, tendon, nd teno erioste l ele ents),
nd one th t tests the inert structures ( burs would be n ex le o n inert
structure). For ex le, with the r held t the tient’s side, the tient is sked
to strongly bduct their shoulder while the shoulder is being iso etric lly st bilized.
In the c se o su r s in tus tendonitis, this “contr ctile” structure will be stressed,
c using in th t re roduces the tient’s sy to s. Bec use no ove ent took
l ce (which is the role o the inert burs ), it would not be ex ected th t this iso etric
contr ction would c use ny in, i the involved structure w s the subdeltoid burs .
On the b sis o this in or tion g ined by in- roducing ( rovoc tive) test, the
ev lu ting clinici n c n ke judg ent reg rding the structure ost likely involved
in this tient.
T e i side o this ssess ent is to h ve the tient co letely rel x her
shoulder, utting ll o the contr ctile structures in st te where they re not stressed.
T en, the clinici n c n gently ove the shoulder into bduction, through the 50- to
130-degree r nge o otion where burs is o ten irrit ted.73 I this c uses in where
the revious iso etric contr ction did not elicit in, it suggests th t the burs is the
involved n to ic l structure.
Note 5 oints in the receding ex le.
• A test w s used to intention lly rovoke the tient’s sy to s, in n ef ort to
underst nd wh t is c using the in. Both o these tests should not result in
nding o in re roduction, s they re testing dif erent structures. T e ore
s eci c given rovoc tive test is, the better the underst nding is o the otenti l
c use o in when it is re roduced.
• T e decision trix used by the ex erienced clinici n is built u on the
coll bor tive ndings o the 2 receding tests, s well s ny other rovoc tive
tests th t re thought to be ro ri te. No one nu l test h s er ect sensitivity
or s eci city. T ere ore, in n ef ort to do the best job o identi ying the c use
o tient’s sy to s, the otenti l c use o the roble should be looked t
through the use o sever l tests, nd the results ro e ch ev lu ted g inst the
working hy otheses in coll bor tive nner.
• T ere should be cle r co unic tion with the tient th t so e o the testing
done y ctu lly cre te so e disco ort, but this is being intention lly done in
n ef ort to better underst nd the ech nis s involved in cre ting the roble .
I there is cle r co unic tion with the tient, nd they know he d o ti e th t
while the ev lu tor is being s gentle s ossible they y still ex erience in, it
is e sier or the to toler te these tests. As h s been st ted be ore, this ssists with
the develo ent o est blishing r ort nd ids in the in or tion l exch nge.
• T e clinici n needs to know i the in c used by rovoc tive test is the s e
in th t brought the tient into the clinic. For ex le, i the tient h d been
describing r dicul r in ro the shoulder, down the l ter l s ect o the r ,
into the uln r s ect o the ore r , does the rovoc tive test cre te this ty e
o in? I the in cre ted is li ited to the b se o the neck with no r dicul r
sy to s, then wh tever rovoc tive test w s used h s not rovided gre t
de l o insight into the tient’s ri ry roble . On the other h nd, i the test
e loyed did re roduce these sy to s, then the ther ist h s n incre sed
underst nding o the ech nics involved nd is in uch better osition to
design tre t ent rogr to truly tre t the roble .
• Underst nd th t when ev lu ting the neuro usculoskelet l syste , ost c uses
o in c n be ech nic lly rovoked. I t the end o the rovoc tive testing there
h s not been nything th t w s ble to re roduce the tient’s sy to s, the
clinici n needs to strongly consider th t the c use o the in y not be ssoci ted
with neuro usculoskelet l syste roble . As w s entioned in the receding
section on in, this y be strong indic tor th t re err l y be w rr nted.
T ere re ny rovoc tive tests th t c n be e loyed, de ending on the region
ev lu ted. T e cl ssics re rocedures like the or in l encro ch ent test60,66
(the S urling test; see Figure 3-1) or otenti l cervic l r diculo thies, the str ight-
leg test 84 or lu b r or s cr l nerve root roble s (Figure 3-10), or the ily o
Figure 3-10 Example o f a straig ht-le g raising te st

thor cic outlet tests57,78,83 (Figure 3-11). T e

ur ose o this ch ter is not to list ll o these
tests, but r ther to oint out their contribution
to the ev lu tion rocess. A rovoc tive test th t
is well understood in ter s o the structures
involved when it is e loyed, rovides
nu l testing rocedure th t gives the clinici n
tre endous insight into the ech nis o
the tient’s roble . When co bined with
other tests in coll bor tive shion, strongly
de end ble hy othesis c n be gener ted th t c n
direct highly ef ective tre t ent rogr . (T e
interested re der should see the texts by B xter,9
Dutton,25 Flynn,30 nd others th t rovide ore
co lete listing o rovoc tive tests nd the
ech nis s behind the .)
7. Clearing tests: A gener l rinci le o
neuro usculoskelet l ssess ent is to lw ys
Figure 3-11 Example o f a tho racic o utle t te st ev lu te the region (or joint) bove nd below
the ri ry re o interest. T e intent o
this rinci le is to re in bro d in the initi l
ev lu tion so th t re s th t o ten re er in re not in dvertently issed, nd to
kee the ev lu tion ro beco ing too yo ic in its ocus. T us, cle ring tests re
e loyed to “cle r” given region s the otenti l source o the tient’s roble , or
to “cle r” structures th t y otenti lly cre te d nger or tient i rticul r
rocedure is e loyed l ter in the ev lu tion or tre t ent h se.87 wo ex les re
rovided below to de onstr te these two uses o cle ring tests.
In tre ting n individu l with shoulder in, the neck should lw ys be ex ined. It
is co on or tient to describe in in the shoulder or r th t is c used by nerve
root or other i inge ent in the cervic l s ine. o cle r the neck, one o the tests used
is the ore entioned or in l encro ch ent test (S urling test). T is test, through
the co bin tion o neck side bending, rot tion, nd extension, unctions to decre se
the s ce rovided by the intervertebr l or en (close down the intervertebr l s ce).
In the c se o n i inged or irrit ted nerve root, this should irrit te the nerve root,
re roduce the tient’s sy to s, nd serve s ty e o rovoc tive test. On the other
h nd, i this rocedure does not elicit ny disco ort th t r di tes tow rd the shoulder,
the ndings suggest th t the neck c n be cle red s n obvious source o this tient’s
shoulder in. T us, the neg tive nding with the S urling test, co bined with neg tive
ndings o ny other screening tests used with the cervic l s ine, work to collectively
cle r the neck s likely source o this tient’s in.
St ying with the cervic l s ine, second cle ring test th t is o ten used in n ef ort
to ro ote xi u s ety or the tient is vertebr l rtery test. T e co bined
ositioning o the su ine tient in n extended, side bent nd rot ted osition or
u to 30 seconds,60 is intended to rule out the vertebr l rtery s source o concern
should ni ul tion or other nu l rocedures be used to tre t the cervic l s ine
(Figure 3-12). A ositive nding with this test suggests th t the tient h s otenti l
restriction o the vertebr l rtery nd should be re erred or ddition l ev lu tion. On
the other h nd, neg tive nding (eg, no n use , dizziness, di lo i , etc) is used s
w y to cle r the vertebr l rtery nd rovide the ex iner with d t th t suggests th t
ni ul ting the cervic l s ine should be s e. By e loying this vertebr l rtery test,
the ther ist is working to ro ote s ety nd cle r ny identi ble otenti l d ngers
rior to beginning the tre t ent rogr .
Figure 3-12 Ve rte bral arte ry te st po sitio n
Although the go ls ssoci ted with the cle ring tests re d ir ble, the stute
ev lu tor should underst nd th t neg tive ndings in the 2 co only used cle ring
tests do not truly “cle r” the neck. An individu l c n h ve cervic l r diculo thy
in the resence o neg tive S urling test. Addition lly, rese rch cle rly shows th t
the vertebr l rtery test is r ro s eci c when tte ting to identi y tient’s
with vertebr l rtery restrictions, nd neg tive nding with this test does not
necess rily rule out the ossibility o vertebrob sil r insu ciency or rovide
s e environ ent or cervic l ni ul tion.17,87 T ese cle ring tests re si ly one
ore bit o coll bor tive in or tion th t should be ev lu ted within the context
o the entire ex in tion. In the resence o neg tive cle ring tests, region like
the cervic l s ine y dro ro being the ri e hy othesis being investig ted,
but the cervic l s ine still needs to be ke t in the b ck o the ex iner’s ind s
second ry or terti ry hy othesis. T en, s ore d t re collected, considered
judg ent c n be de on the best working hy othesis. T ere should never be
ti e, however, when the ev lu tor dis isses region like the neck s otenti l
contributor to the roble t h nd, si ly bec use the results o 1 or 2 cle ring
tests were neg tive.
An ddition l oint th t w s i lied in the section bove is th t the
c tegoriz tion o tests is not discrete. T e S urling test is both rovoc tive test nd
cle ring test. T e l bel design tor ssigned t ny oint in ti e is re lly the intended
use o the test. Reg rdless o the l bel ssigned, the test re ins the s e nd both
ty es o in or tion ( rovoc tive nd cle ring) re rovided when the nu l test is
e loyed. T e skilled ex iner h s well–thought-out syste th t st ys consistent
in its key ele ents nd utilizes tests th t rovide the d t u on which de end ble
judg ents c n be de. T e l beling o test y ssist with descri tion o one o the
ur oses o given test to others, or rovide r tion le or ssigning tests to rticul r
l ces in n ev lu tion sche e, but the otenti lly ulti le uses o given rocedure
should be cle rly recognized by the ev lu tor er or ing these tests.
8. Muscle stretch ref exes: Muscle stretch re exes test the integrity o the seg ent l level
re ex rc, s well s rovide in or tion on the centr l nervous syste inter cting
with the re ex rc. In its si lest or , the uscle stretch re ex consists o sensory
rece tor ( uscle s indle), n f erent neuron, syn se, n ef erent neuron, nd the
ef ector org n o skelet l uscle. When uscle is bru tly stretched, s is the c se
when re ex h er dis l ces tendon, the uscle s indles in the ho ony ous
uscle re stretched nd gener te n ction otenti l th t is conveyed to the s in l
cord. T is sign l brought into the centr l nervous syste is the ost co on
ex le o onosyn tic re ex, syn sing directly onto l h otor neurons o
the uscle o origin.55 T is excit tory sti ulus ty ic lly results in the gener tion o n
ction otenti l down the ef erent neuron, cre ting contr ction in ll o the uscle
bers innerv ted by th t rticul r otor unit. T e end result, is visible uscle
contr ction o the uscle ssoci ted with the tendon struck, indic ting th t the re ex
rc is int ct (Figure 3-13).
Although the receding r gr h identi ed the key ele ents involved with
eliciting seg ent l level re ex, it iled to convey so e o the in or tion l
richness th t c n be obt ined ro this si le test. In ny c se where the re exes re
not sy etric l, the ndings need to be viewed in light o ny other coll bor tive
in or tion v il ble. Addition lly, in so e c ses where the re ex ndings re
sy etric l but either elev ted or de ressed, these ndings lso need to viewed
in light o the other coll bor tive in or tion. Sever l illustr tive ex les will be
rovided in the r gr hs below to ssist in the inter ret tion o ndings ssoci ted
with uscle stretch re exes (MSRs).
Gener lly, n sy etric lly de ressed or bsent re ex is suggestive o thology
th t is i cting the re ex rc directly, such s lower otor neuron roble .
T e converse is gener lly true or elev ted or “brisk” re exes, which re co only
viewed s indic ting th t the centr l nervous syste ’s nor l role o integr ting
re exes (serving s governor) h s been disru ted. T us, n sy etric l brisk
re ex is ty ic lly indic tive o n u er otor neuron ( re otor neuron) roble .91
In both o the st te ents de in this r gr h, the ter asym m etrical h s been
used bec use it illustr tes the i ort nt oint th t not everyone will h ve the s e
res onse to re ex h er t ing given tendon or uscle belly. So e individu ls
h ve bil ter lly de ressed or even bsent re exes, but these re sy etric l nd not
La mina e I, II
Dors ola te ra l fa s ciculus
Ge ne ra l s oma tic a ffe re nt (proprioce ptive ) fibe r
Ante rior white
commis s ure Ge ne ra l s oma tic a ffe re nt (exte roce ptive ) fibe r
Ge ne ra l vis ce ra l a ffe re nt (inte roce ptive ) fibe r
Dors a l root
Inte rme diola te ra l
Dors a l root
ce ll column P roprioce ptive
ga nglion
e ndings
S pina l ne rve Nocice ptive

a nd the rma l
Ve ntra l root e ndings
Vis ce romotor
e ndings
Gray
Ge ne ra l vis ce ra l e ffe re nt
Ante rola te ra l communica ting
pre ga nglionic fibe r
s ys te m ra mus
Ge ne ra l s oma tic Vis ce ros e ns ory White S ke le ta l
e ffe re nt fibe r re ce ptor communica ting mus cle
ra mus
Figure 3-13 Typical spinal ne rve w ith re e x arc
(Reproduced with permission from Prentice. Therapeutic Modalities. 3rd Ed. New York: McGraw-Hill; 2005.)
restricted to only one o the ny MSRs th t c n be tested. In si il r vein, so e

individu ls h ve bil ter lly brisk re exes, but this is lso rel tively uni or throughout
ll o their re exes. T ere ore, the resence o sy etric l re exes, suggests
thology nd urther investig tion. Addition lly, while the resence o cle rly
de ressed or cle rly elev ted re exes c n be nor l nding, the stute clinici n
ust kee this in or tion in the b ck o their ind nd is oblig ted to investig te
urther, s this y be subtle sign o syste ic or sy etric l roble . A ew
ex les re rovided below.
Depressed ref exes: In c ses where there is co lete d ge to ny ele ent o the
re ex rc, such s the f erent or ef erent li b, no re ex will be elicited. T is
would be the c se or n individu l with severed eri her l nerve, f ecting
both the f erent nd ef erent bers. T us, no sign l would ever re ch the s in l
cord, nd no ef erent sign l would consequently be gener ted. T e bsence o
re ex, in this c se, indic tes so e ty e o structur l roble th t the clinici n
would need to investig te urther. In this si le c se, the severed nerve would be
cco nied with host o other ndings, such s cle r tro hy, sensory loss,
nd we kness th t should ke the source o the roble evident ( ble 3-4
su rizes u er otor neuron/ lower otor neuron signs/ sy to s).
A ore subtle nding is de ressed, yet int ct MSR. T is is usu lly indic tive
o so e ty e o structur l roble th t i edes the unction o so e o the xons
within ixed s in l nerve, with other xons continuing to unction nor lly.
A co on ex le o this is the tient with herni ted disk in their lower
b ck. T e disk rotrusion th t co resses the exiting nerve root decre ents the
unction o ercent ge o the xons cont ined within th t ixed s in l nerve, so
able 3-4 Co mmo n Uppe r Mo to r Ne uro n/ Lo w e r Mo to r Ne uro n Sig ns

and Sympto ms
Lo w e r Mo to r Ne uro n (Abridg e d List) Uppe r Mo to r Ne uro n (Abridg e d List)
Weakness and/or paralysis ( accid) Weakness and/or paralysis (spastic)
Hypore exia (or are exia) Hyperre exia
Rapid muscle atrophy No clear muscle atrophy (or slowly developing

atrophy that is secondary to disuse)
No pathologic re exes Pathologic re exes (eg, Babinski, Hoffman)
Fasciculations and brillations Altered or loss of voluntary motion
th t while the re ex sign l is ble to be both received vi f erents nd ex ressed

b ck to the eri hery through ef erents, the size o the res onse is s ller th n
th t ound on the un f ected side. In individu ls with so e ty e o nerve root
co ression t the intervertebr l or en, this ty e o de ressed re ex is the
ex ected nding. In severe c ses o nerve root i inge ent, no re ex c n be
elicited, suggesting th t jority o xons cont ined within th t ixed s in l
nerve root re involved.
Note th t both the f erent nd ef erent li b o the re ex rc were included
in the discussion o the i ct on the re ex rc. Although ny clinici ns view
de ressed re ex s being synony ous with lower otor neuron roble , it
should be recognized th t ny condition th t f ects ny ele ent o this rc c n
result in MSR ndings th t re not nor l. While r re, n individu l with t bes
dors lis (terti ry sy hilis) will h ve selective destruction o the dors l colu ns o
the s in l cord nd the neurons th t roject into the dors l colu ns.32 Bec use
these re the s e neurons th t bring the f erent ction otenti ls into the s in l
cord, the de th o these neurons e ns th t the f erent li b o the re ex rc is
disru ted with ini l or bsent MSRs, in the resence o co letely he lthy
lower otor neurons. T is “ rti ci l” ex le is rovided to illustr te 2 oints.
First, ny dys unction within the re ex rc c n result in de ressed or bsent
re ex, so it c nnot be considered to be ure indic tor o lower otor neuron
roble . Second, in c se like t bes dors lis, the de ression or bsence o MSRs
is bil ter l nd wides re d, suggesting th t there re other coll bor tive d t
v il ble. T us, the de ressed re ex does not st nd lone, but is one i ort nt
iece o the uzzle th t is ed into ev lu tion nd co red g inst the v ried
working hy otheses th t re in l y.
Elevated ref exes: In nor lly unctioning nervous syste , the centr l nervous
syste (br in nd s in l cord), ct s ty e o “governor” th t hel s regul te
nd control the ctivity gener ted by the seg ent l level re ex. I th t nor l
rel tionshi is disru ted by n insult th t f ects the centr l nervous syste ,
then the re ex rc is unction lly “rele sed” ro this governor. T is results in n
elev ted or brisk re ex, when MSR is elicited.
In the c se o condition, such s cerebr l v scul r ccident (stroke),
f ecting one side o the centr l nervous syste , the sy etric l nding o
n elev ted MSR on one side would be ex ected. With ore sy etric l
lesion, such s s in l stenosis n rrowing the vertebr l or en (c n l) th t
w s f ecting the entirety o the s in l cord, bil ter lly elev ted MSRs would be
ex ected. Both o these c ses de onstr te th t n ltered nd elev ted MSR
rovide the clinici n with in or tion th t the centr l nervous syste is not
unctioning in the ex ected w y with the seg ent l level re ex rc, nd th t the
eri her l nervous syste is rob bly not the source o this tient’s co l int.
T e key issue ssoci ted with the MSR testing described bove is th t it
rovides the clinici n with direct w y o ssessing the eri her l nervous
syste , nd n indirect w y o ex ining the centr l nervous syste . T is ty e
o testing would not re lly be needed or the cle r-cut ex le o n individu l
with severed nerve; the n ture o the roble would be obvious. Si il rly, this
ty e o testing is not re lly necess ry or the tient th t h s cle rly ex erienced
cerebr l v scul r ccident, since g in; the n ture o the roble would be
obvious. However, or the ty ic l tient who is seeking n ev lu tion or
roble th t is not directly obvious, h ving tool th t is ble to si ult neously
rovide in or tion bout both the eri her l nd centr l nervous syste is
inv lu ble. And, the in or tion rovided c n o ten be the key th t hel s
unlock the uzzle. wo ex les illustr te this with rel tively obscure c ses:
( ) A tient resents with sy etric lly brisk tell r tendon MSRs nd Achilles
tendon MSRs, while si ult neously h ving bsent MSRs in the u er extre ity.
T is odd nding could result in ddition l investig tion th t un ortun tely
de onstr tes th t the tient is suf ering ro yotro hic l ter l sclerosis (Lou
Gering’s dise se), ixed u er- nd lower- otor-neuron thology; the MSR
ndings hel direct the rest o the ex in tion nd re err ls. (b) A second tient,
re erred or nterior knee in, is ound to h ve very brisk tell r tendon MSRs
bil ter lly. U on urther questioning, the tient lso discloses th t there h ve
been e isodes o uctu ting we kness nd di lo i (double vision). A ro ri te
re err l nd ollow-u testing ight reve l th t this tient is in the e rly st ges o
ulti le sclerosis nd the incre se in tone o the lower extre ity ssoci ted with
this condition is res onsible or the knee in.
T ese 2 r re c ses illustr te th t clinici n will not nd wh t the clinici n is
not looking or. T e only w y to gu rd g inst issing ex les is to be syste tic
nd know the n to y nd hysiology behind the test being e loyed. MSRs o
the region being ex ined (eg, u er extre ity or lower extre ity), should be
rt o every ev lu tion done, exce t erh s the thletic injury th t the clinici n
erson lly witnessed. T is in or tion should be noted nd ctored in s rt o
the working hy otheses being considered.
Com m only tested MSRs and how they are recorded: In the u er extre ity, 3 MSRs
re co only tested: bice s br chii ( redo in ntly C5), br chior di lis
( redo in ntly C6), nd the trice s br chii ( redo in ntly C7). In the lower
extre ity, there re 2 co only tested MSRs nd 1 less requently used MSR.
T e 2 co only used re exes re the qu drice s ( redo in ntly L4) nd
the g strocne ius-soleus ( redo in ntly S1). T e less co only e loyed
h string re ex is redo in ntly L5. T e h string re ex is not used s o ten
bec use it is uch ore di cult to elicit nd is there ore less reli ble nd use ul.
ble 3-5 lists the co only used re exes nd their gr ding.
T e re exes re ty ic lly gr ded on 5- oint sc le, r nging ro 0, indic ting
n bsent re ex, to 4, indic ting n extre ely brisk re ex.62 A 2, is considered
nor l, with nything bove or below th t v lue indic tive o nding th t is
elev ted or de ressed to so e extent. Ag in, the key nding is not th t re ex
devi tes ro the 2 level. T e key ndings re th t there is sy etry between
li bs, or the sy etric l but unusu l MSR is ssoci ted with other coll bor tive
ndings reve led during the sc n ex in tion.
able 3-5 Co mmo nly Use d Muscle Stre tch Re e xe s a
Uppe r Extre mity Lo w e r Extre mity
Biceps brachii re ex (C5,6) Patellar tendon re ex (L2-4)
Brachioradialis re ex (C5,6) Hamstring re ex (L5, S1-2)
Triceps brachii re ex (C6,7,8) Achilles tendon re ex (L5, S1-2)
a
Bo lding indicates most prominent root level.
9. Pathologic ref exes: P thologic re ex testing is djunctive to the MSRs described

bove. For those tients with n u er- otor-neuron roble , it would be ex ected
th t thologic re ex could be elicited. T e thologic re ex co only sought
in the lower extre ity is the B binski re ex, which is er or ed by stroking blunt
object cross the sole o the oot, ro the l ter l side tow rd the gre t toe. A “ resent
B binski” is when this c uses the gre t toe to extend nd the other toes to extend nd
bduct. A res onse th t c uses exion o the gre t toe nd other toes, or withdr w l
o the oot is nor l res onse, nd is recorded s “B binski not resent.” T e
ore co on elicit tion o this re ex th t involves stroking the l ter l side o the
oot rogressing to the b ll o the oot, is re lly co bin tion o 2 thologic re exes,
the Ch ddock nd B binski.18 For ore co lete descri tion o the technique nd
ndings ssoci ted with these 2 re exes nd other re exes o the lower extre ity
(eg, O enhei nd Gordon), see Cow n et l.18
T e u er li b equiv lent to the B binski is the Hof n sign (or re ex). T is is
elicited by h ving rel xed nd su orted h nd, nd the dist l s ect o the iddle
nger is i ed u in the direction o the ngern il.18 In n individu l who does not
h ve n u er otor neuron lesion, this does not elicit uch o res onse in the
rel xed thu b nd index nger o the tested side. In erson with n u er- otor-
neuron lesion, the thu b nd index nger tend to contr ct, in otion th t dr ws
these 2 digits tow rd one nother.18 Bec use slight contr ction o the thu b nd
index nger c n occur in n individu l th t h s n tur l tendency or incre sed
re exes, it is i ort nt to co re one side to the other. I sy etry is identi ed,
then this resent Hof n re ex needs to be viewed in light o the other coll bor tive
in or tion nd ro inently gures into the working hy otheses.
U er qu rter sc n ex in tions should lw ys include testing or the thologic
Hof n sign, nd lower qu rter sc n ex in tions should lw ys include testing or the
thologic B binski re ex. In ddition to this ini l level o screening, there re tient
conditions in the u er extre ity where B binski re ex should lso be elicited. In the
reviously entioned c se o n individu l with vertebr l or en s in l stenosis in
the cervic l region, with sy to s redo in ntly f ecting the u er extre ities,
B binski re ex should be obt ined. T e de onstr tion o unil ter l or bil ter lly resent
B binski re exes rovides gre t de l o insight into the loc tion o the ri ry roble
(s in l cord co ression in the cervic l or u er thor cic region with u er otor
neuron involve ent), nd indic tes th t re err l to he lth c re rovider who c n
ddress the b se roble is w rr nted. T e botto line is, thologic re exes should
lw ys be er or ed in the region o interest, nd B binski or other ro ri te lower-
extre ity thologic re ex should ddition lly be elicited or those u er-extre ity
roble s where the working hy otheses involve the s in l cord or other ele ents o the
centr l nervous syste (eg, the reviously entioned c se o ulti le sclerosis).
Assessment 101
10. Special tests: A sc n ex in tion is by de nition, syste tic nd e cient
(i lying brie ), ev lu tion o rticul r re o interest. Although the 2 ost
co on lic tions o the sc n ex in tion re u er- nd lower-qu rter screens,
the sc n ex in tion is d t ble to ll regions o the body, such s ex ining the
knee joint or wrist. Recognized within this lic tion to s eci c joint or region is
the need to lw ys consider the joint or region i edi tely roxi l nd dist l to th t
re , s it is co on to h ve re erred in nd n initi lly yo ic ev lu tion does not
serve the tient well.
Recognizing th t the st nd rd sc n ex in tion is by design brie nd e cient,
there needs to be dequ te exibility built into the design o the sc n ex in tion to
er it ddition l investig tion nd ollow-u o n re o rticul r interest. T is is
where s eci l tests co e into l y. In the c se o n individu l with knee in nd
history th t suggests d ge to the lig ents nd c sule surrounding the joint, or
structures ssoci ted with the joint such s burs , urther investig tion is w rr nted.
T e skilled clinici n should e loy the ro ri te tests to hel rogress to the next
st ge o the sc n ex in tion, which is the ssess ent. T ese tests will ssist with the
revision or re ne ent o the working hy otheses into one best hy othesis. T e yri d
o v il ble s eci l tests is beyond the sco e o this ch ter, nd the interested re der
is re erred to other sources th t rovide uch ore det il on s eci c tests.25,37,41,61,64,101
Final Caveat Prior t o t he Assessment

T e go l o the sc n ex in tion to this oint h s been to collect d t . As the clinici n
roceeds to the ssess ent, there is need to be re ective, reex ine ent lly e ch bit
o in or tion to deter ine how it rel tes to the v riety o working hy otheses in l y,
nd, ho e ully, distill this d t into one best hy othesis th t is consistent with the history
nd objective ndings obt ined during the ex in tion. T is working hy othesis c n be
ex ressed s n n to ic l or structur l roble , the tr dition l edic l di gnosis, or s
listing o hysic l ther y di gnoses th t de onstr te the unction l neuro usculoskel-
et l roble s th t c n be ddressed. In either c se, the clinici n needs to decide wh t the
roble (s) is( re), nd begin to or ul te course o ction. T is le ds to the ssess ent.
Assessment
T e ssess ent ty ic lly is the one hy othesis th t is ost consistent with ll the d t col-
lected in the receding sc n ex in tion. In ost c ses, there is single ex l n tion th t h s
brought tient in or c re. In r re c ses, however, there y be sever l dys unctions th t
re occurring si ult neously, nd the stute clinici n needs to h ve exible enough syste
to both look or nd llow or this ossibility. Once ll the d t h ve been reviewed, deci-
sion h s to be de on wh t the roble is; identi c tion o one or ore issues is necess ry
to r e n ro ch on the best w y to ddress the identi ed roble . T e docu ent tion
nd co unic tion o the ssess ent y t ke one o sever l or s, including the ollowing:
1. One tr dition l edic l di gnosis th t rovides tho hysiologic structure th t c n

be ddressed by the ev lu ting clinici n ( n n to ic l or structur l di gnosis).
2. wo or ore edic l di gnoses th t rovide sever l tho hysiologic structures
th t c n be ddressed by the ev lu ting clinici n ( g in, n n to ic l or structur l
di gnosis).
3. A hysic l ther y di gnosis th t de onstr tes cle r bio ech nic l or
neuro usculoskelet l shortco ings th t c n be ddressed nd th t is consistent with
the tient’s resenting roble . T ese issues y r nge ro uscle we kness to
r nge-o - otion li it tions, to leg-length discre ncies, to yri d other ndings
th t beco e evident during the sc n ex in tion with ro ri te s eci l tests or

ollow-u .6
4. A decision th t re err l to nother he lth c re rovider is w rr nted. As h s been
stressed throughout this ch ter, the h ll rk o true ro ession ls is knowing the
li its o their re s o ex ertise.42 A ro er re err l c n be tre endously v lu ble
service to tient seeking c re.
5. A decision to schedule ollow-u oint ent to collect ddition l d t nd re ne
the working hy othesis. A re lity o li e is th t there is not in nite ti e to er or
the ost det iled nd involved ev lu tion to investig te every ossible dys unction
with e ch tient. T e key ur ose o the sc n ex in tion is to e loy syste tic
ev lu tion so s not to iss otenti l thology th t requires re err l or i edi te
c re. A second ry ur ose o the ex in tion is to llow the exibility or ore
in-de th ex in tion t second or third tient visit. T is e ns th t i ore
in or tion is required, recognize this need nd build the collection o the d t into
subsequent tient visit. T e willingness to d it th t not ll d t c n or should be
collected during the initi l visit er its the ti e or urther re ection, entorshi
consult tion, nd consider tion o the otenti l role o other key syste s, such s
c rdio ul on ry, neurologic l nd integu ent ry.
T e choice o the w y to ex ress the ssessed ndings y be dict ted by the envi-
ron ent th t the clinici n works in, or it y be erson l re erence. As h s been lluded
to bove, there is current drive to ex ress hysic l ther y ndings in or th t rec-
ognizes th t hysic l ther y di gnosis ( ssess ent) dif ers ro edic l di gnosis
( ssess ent).6 Physic l ther ists c nnot ty ic lly order tests like x-r ys, bones sc ns, nd
gnetic reson nce i ging, or er or rthrosco ic ex lor tions, so they do not h ve the
tools to di gnose r ctures, stress re ctions o bone, torn enisci, or l br l te rs. Recogniz-
ing th t this is bsolutely true, it is lso true th t tient with cle rly ositive L ch n
test nd ivot shi t test to the knee, with history o he ring “ o ” nd ex eriencing n
cute right knee ef usion, rob bly h s, t ini u , torn nterior cruci te lig ent.
T ese coll bor tive ndings c n be ex ressed in the ssess ent s list o the hysic l
ther y li it tions ssoci ted with this condition, such s:
Assess ent #1: (1) li ited knee joint r nge o otion o the right knee, (2) knee in,
(3) knee joint ef usion, (4) nt lgic g it, (5) qu drice s uscle we kness, nd (6) ltered
neuro uscul r control; grou ed under Pre erred Pr ctice P ttern 4D, I ired joint
obility, otor unction, uscle er or nce, nd r nge o otion ssoci ted with
connective tissue dys unction.
T is is the no encl ture ssoci ted with T e Guide to Physical T erapy Practice.6 T is
ssess ent would rob bly lso result in re err l to he lth c re ro ession l, like n
ortho edic surgeon, or the ddition l testing needed to ke de nitive di gnosis.
A second w y o ex ressing these ndings in the ssess ent would be to rovide
rob ble n to ic l c use o the dys unction, long with list o the s eci c ite s th t
hysic l ther y would work to ddress. An ex le o this or o ssess ent with the
s e tient described bove would be:
Assess ent #2: Rule out torn right nterior cruci te lig ent
Physic l T er y issues: (1) li ited knee joint r nge o otion, (2) knee in,
(3) knee joint ef usion, (4) nt lgic g it, (5) qu drice s uscle we kness, nd (6) ltered
neuro uscul r control.
Other: Re er to n ortho edic surgeon or other ro ri te he lth c re ro es-
sion l or de nitive di gnosis.
Neither o these ro ches is bsolutely correct or incorrect. Assess ent #1 ollows

the b sic tenets o T e Guide to Physical T erapy Practice, which is the ro ession’s de nitive
Goal 103
docu ent describing the sco e o hysic l ther y r ctice.6 In those settings where this
ty e o descri tion works, it should rob bly be the ro ch used, s this is in kee ing
with the reco end tions o T e Guide.6 H ving recognized the key role nd i ort nce o
T e Guide, it is lso i ort nt to recognize th t there re li it tions ssoci ted with using
list o ndings to describe the hysic l ther y di gnosis. Met horic lly, or those entities
or which we h ve est blished l bels recognized by ll rties, it is e sier to convey in or -
tion by using the l bel th n by using list o descri tors. It is e sier to s y th t there is n
ele h nt in the b cky rd, th n to try to describe big ni l th t is gr y, wrinkled, ossess-
ing t il, with e rs bigger th n ost ni ls. Although hysic l ther ists c nnot ex ine
the genetic code to veri y the s ecies o ele h nt, they re ble to identi y the b sic cre ture
nd then convey ny s eci c ttributes o th t ni l th t y rel te to s eci c s ecies.
Cle rly, gre t liberty h s been t ken with the ele h nt et hor, but it illustr tes th t hys-
ic l ther ists do not unction in v cuu , but re rt o the tr dition l edic l co -
unity. T ere ore, the co unic tion tends to be uch ore str ight orw rd with other
he lth ro ession ls when tr dition l l bels like “rule out nterior cruci te lig ent te r”
re used. T ese c n be st ted in w y th t de onstr tes th t this is not de nitive di gno-
sis, but r ther strong working hy othesis. When su le ented with the list o ttributes
th t the sc n ex in tion h s identi ed th t c n be ddressed by hysic l ther y, then
the co unic tion nd, i w rr nted, re err l, re cle rer or ll involved. Consequently,
in those settings where the or t o Assess ent #2 kes sense, it should be considered.
T e botto line o the ssess ent is to identi y nd l bel the s eci c ite s th t should
be ddressed during the next 2 h ses o the sc n ex in tion: the go l nd the l n.
Goal
T e “go l” is wh t the clinici n nd the tient w nt to chieve. It is l ced in this syste
in loc tion th t dif ers ro the tr dition l SOAP (subjective, objective, ssess ent, nd
l n) note or t. T e r tion le or this tr ns osition o l ce in the ex in tion rocess is
th t the clinici n needs to know where they w nt to go (the go l), rior to develo ing l n
to get there. Met horic lly, no one would ever look t nd l n to he d out o town
on s eci c highw y, i they h d not rst deter ined where they w nted to end u t the
co letion o the tri . In si il r vein, the clinici n, in consult tion with the tient, needs
to est blish 1 or ore go ls th t eet t le st the ollowing ini l list o ex ect tions, i
the clinici n h s deter ined th t the c re needed c n be rovided within the clinici n’s
sco e o r ctice. T ese 5 ex ect tions re: ( ) the go ls re re listic, (b) the go ls eet the
tient’s ex ect tions, (c) the go ls de ne wh t will be chieved in the short ter , (d) the
go ls de ne wh t will be chieved in the long ter , nd (e) the go ls re e sur ble. When
the c re or ddition l ev lu tion needs to be done by nother he lth c re ro ession l, the
go l y ch nge to linking the tient with the best he lth c re rovider or the .
T e initi l ex ect tion ssoci ted with go ls is th t they re re listic. o l rge degree,
this is b sed on the ex erience nd judg ent o the clinici n, dr wing ro the in or tion
rovided during the sc n ex ev lu tion. It is not re listic to ssu e th t the go l(s) sso-
ci ted with c re re to h ve e ch tient return to n o ti l level o unction. A tient
encountered by the uthor e rly in his c reer w s gentle n in his e rly to id-seventies,
with longst nding di betes nd bil ter l bove-knee ut tions. He loved to ride tr ins,
nd h d been re erred or tr ns er tr ining, gener l conditioning, nd household obility
tr ining. He h d been in wheelch ir or ore th n ye r, nd h d new rosthetic li bs.
Although the sc n ex er or ed on hi utilized the syste outlined in this ch ter (in
ter s o history, re red questions, nd hysic l ex in tion), the d t collected were
vit l to deter ining his current hysic l st tus, oint where tre t ent l n should be
initi ted, nd wh t go ls ight be sought. While blurring the oint o being re listic with
the next r gr h on the tient’s ex ect tions, this collected d t needs to be viewed
in light o the wishes o the tient. In this c se, b ck in the l te 1970s, the only w y to
bo rd the ste engine tr ins th t he w nted to ride w s to w lk u the ste s onto the tr in.
T us, he c e to the clinic with n ex ect tion th t he would be ssisted in le rning to
w lk g in, so th t he could w lk to the tr in, bo rd it, nd ride. Bec use o his ge, level o
conditioning, nd the extre e energy costs ssoci ted with bul ting with the rostheses
ssoci ted with du l bove-knee ut tions, this w s not re listic go l. T e in or -
tion obt ined ro the sc n ex rovided st rting oint to begin or ul ting wh t w s
re listic. T is led to the next ex ect tion o the go l(s) est blished, working to eet the
tient’s ex ect tions.
Serving the tient nd working to eet the tient’s needs nd ex ect tions is re lly
the und ent l re son th t he lth c re is rovided. o chieve these ele ents o c re,
clinici ns need to t ke the ti e to nd out wh t the tient w nts nd ex ects. T e in or-
tion rovided by the tient, cou led with the d t obt ined during the sc n ex in -
tion, llows erging o the tient’s go ls with the clinici n’s ther eutic go ls. When
co bined in this w y, the 2 ele ents synergistic lly cre te set o go ls th t re “ orce
ulti lier,” in ter s o chieving re listic, e sur ble, results. Re erring b ck to the ex -
le in the r gr h bove, it w s not re listic th t the tient would be ble to w lk to
the tr in, cli b short series o st irs, nd bul te to his se t on the tr in. Although th t
go l w s out o re ch, this individu l e red c ble o tr ns ers, short-dist nce bul -
tion, nd the bility to n vig te 2 or 3 ste s. Following r nk discussion, utu lly greed
u on set o ex ect tions were outlined nd greed to. T ese rovided the b sis or short-
nd long-ter go l develo ent, with e sur ble/ objective l nd rks. T t these go ls
took the tient’s w nts nd ex ect tions into ccount hel ed to cre te n environ ent
in which this individu l’s otiv tion nd drive re still so ething th t I e sily rec ll ore
th n 30 ye rs l ter.
A ore co on ex le o the need to t ke the tient’s w nts nd ex ect tions into
ccount is when de ling with thletes. Athletic tients who re used to tr ining regul rly
nd re injured with so e ty e o overuse roble ty ic lly will not settle or l n th t
involves rest. Most o these tients w nt to continue to tr in, nd while they will be olite
to the he lth c re ro ession l who reco ends rest, they will o ten le ve the o ce nd
st rt the se rch or nother he lth c re rovider who underst nds their rticul r needs.
T e clinici n who t kes the ti e to nd out wh t the tient w nts nd ex ects should be in
osition to educ te the tient on wh t is re listic ro the tho hysiologic ers ective,
while lso letting the tient know th t the clinici n is coll bor tively working to chieve
the tient’s go ls. T is y e n resting the involved structure or li b while eng ging in
“ ctive rest” th t llows the tient’s conditioning to be int ined by so e sort o lter-
n te ctivity. T e botto line here is th t the go ls est blished need to be in line with the
tient’s ex ect tions to enh nce co li nce nd otiv tion, yet structured within the
r ework o wh t the clinici n knows is re listic. T is cre tes n environ ent in which
both individu ls—the tient nd the clinici n— re working together s te or s e-
ci c ur ose (or outco e).
T e utu lly est blished go ls should ide lly be ex ressed s both short-ter nd
long-ter go ls. Met horic lly, no one is co ort ble with glob l go l like “co leting
gr du te school,” or “losing 35 ounds.” On the sur ce, these go ls e r so l rge nd
un tt in ble, th t it would be extre ely e sy or the individu l working to cco lish the
go l to beco e overwhel ed nd discour ged. It kes uch ore sense to set series
o short-ter go ls th t over ti e le d to the cco lish ent o the glob l (or long-ter )
go l. In the c se o tient go ls, the initi l short-ter go ls set should be so ething th t
c n be cco lished within ew tre t ent sessions or ti e eriod o week or less.
T e go l should be re listic, e sur ble, nd in the direction o the long-ter go l. For
Plan 105
the clinici n to st y eng ged in the tient’s rogress, the short-ter go l should ide lly
be linked with recheck o so e ty e, so th t there is continuing di logue between the
2 e bers o this te . T is ty e o exch nge nd di logue lso er its the necess ry
djust ents nd reest blish ent o new sets o short-ter go ls, on the w y to cco -
lishing the over ll go l.
T e long-ter go l serves s the nish line. T e long-ter go l is the destin tion th t
the tient nd rovider re trying to re ch. T is go l is lso est blished initi lly, so th t
it is cle r wh t both the tient nd he lth c re rovider re striving to chieve. In ddi-
tion to serving s ro d nd r ework or djusting the short-ter go ls on the w y
to chieving the n l go l, this gives both e bers o this reh bilit tion te eel or
where they re on this journey. Achieve ent o the long-ter go l is logic l ti e to dis-
continue c re.
A oint th t w s lluded to in the receding r gr hs is th t ll st ted go ls ust be
e sur ble. T is is needed both s w y to objectively tr ck rogress nd bec use third-
rty yers o ten require it. As the ex ert in this re , work to identi y criteri th t re reli-
ble, e sily obt ined, nd directly rel ted to the tient’s condition. In ddition to being
e sur ble, short-ter nd long-ter go ls should h ve cle r ti elines ssoci ted with
the . Although not ll the ele ents o the cl ssic “beh vior l objective” will lw ys be in
evidence or e ch go l st ted, they should t le st be i lied, i not ex licitly st ted. For
ex le, i short-ter go l is to h ve “10 degrees o ddition l shoulder exion in 1 week,”
the cl ssic ele ents o who will do wh t, by when, nd to wh t extent, re ll either st ted or
i lied. In this c se, the “who” is the tient, so it does not need to be ex licitly st ted. T e
“do wh t,” is chieve n ddition l 10 degrees o shoulder exion. T e “by when,” is re ected
in the ti e s eci c tion o 1 week, nd the “to wh t extent” i lies th t the clinici n will
e loy st nd rd ssess ent ethodology nd will require ro er or (no substitution).
T us, utiliz tion o n objective syste o this ty e llows rogress to be tr cked nd both
e bers o the reh bilit tion te to know where they re t in ter s o the n l go l.
In those c ses where the sc n ex in tion reve ls th t either the tient’s or the clini-
ci n’s go ls ll outside o the current he lth c re rovider’s re o ex ertise, re err l is
indic ted. T e h ll rk o true ro ession ls is knowing their own li it tions nd re erring
to other e bers o the he lth c re te when ro ri te.42 In this c se, re err l works
tow rd the go l o roviding the tient with the best ossible c re or the tient’s rticu-
l r condition, nd it strengthens the entire he lth c re ily by h ving ro ession ls work
with e ch other nd dr w on s eci c strengths.
Plan
Once the short-ter nd long-ter go ls re identi ed, it is rel tively str ight orw rd ro-
cess to deter ine how to get there. I the et hor o tri is considered, once the desti-
n tion is cle r, the c n be looked t nd the ost e cient tri lotted. Extending this
et hor, i there is s eci c sight or erson th t the budding tr velers w nt to see s rt
o their tri , th t detour c n be built into the l n.
Fro the he lth c re rovider’s ers ective, the b sic l n is wh t should be done,
t ught, nd reco ended to the tient. T is will be b sed on v riety o ctors, includ-
ing, but not li ited to, the clinici n’s ex erience level, equi ent v il ble, nu ber o
visits llowed by third- rty yers, dist nce th t the tient lives ro the clinic, nd v il-
bility o child c re or de endents. Within this context, the he lth c re rovider is in osi-
tion to s eci y tre t ent rogr , identi y where it will be done (eg, in the clinic, t ho e,
or in both loc tions), identi y how o ten ite s o this tre t ent rogr re er or ed,
nd ny s eci cs ssoci ted with the rogr , such s intensity or c utions. T e cl ssic
exercise rescri tion should be in evidence here: ( ) s eci city (wh t should be done),
(b) requency (how o ten the ctivity should be done, or the nu ber o re etitions nd sets
ex ected), (c) dur tion (how long the ctivity should be er or ed), nd (d) intensity (wh t
level o er or nce is ex ected). When this is rovided to the tient in cle r nner
nd with s eci c ex ect tions, the likelihood o success o the l n incre ses dr tic lly.
Other ele ents th t lso work tow rd ro oting success re to go through the l n with
the tient, h ving the tient de onstr te ny ctivities th t the tient will be doing t
ho e. Inste d o si ly sking the tient to verb lly cknowledge th t the tient under-
st nds wh t to do, rovide constructive critique nd give the tient n o ortunity to
sk questions nd de onstr te underst nding. T en rovide the l n in writing, su orted
with ro ri te h ndouts, videot es, or other ediu th t of ers cle r re inder or
the tient when the tient is trying to do these t ho e. Addition lly, give the tient
s eci c nu ber or e- il th t the tient c n use i questions rise, nd ensure th t you
ddress the t le st once d y.
A ho e rogr should be included in l ost ll tre t ent rogr s, bec use it
rovides nu ber o dv nt ges. First, in tod y’s he lth c re environ ent, no tient
will be uthorized to co e into the clinic or ll o the tient’s c re. It h s to be recog-
nized th t whether the tre t ent is elev tion o swollen li b, bul tion instruction,
or so e or o ther eutic exercise, the tient will do the jority o this c re outside
o the clinic’s w lls. Consequently, ke use o this re lity nd h ve the rogr er-
or ed whenever it is ro ri te, within the tient’s nor l environ ent. Second, nd
erh s ore i ort ntly, there is need to eng ge the tient in the tient’s own c re
nd ke the tient res onsible or the outco e. T ere is tendency tod y to ssu e
th t tient will seek c re nd th t the he lth c re ro ession l will “ x the tient.” T is
uts ll the res onsibility on the he lth c re rovider nd none on the tient. T e re lity
is th t the jority o c re will t ke l ce outside o the clinic, nd the tient needs to be
both eng ged in th t c re nd t ke res onsibility or seeing th t it is en cted. A et hor
used e rlier described the reh bilit tion “te ,” where the he lth c re rovider serves
s the co ch nd the tient unctions like the l yer. Although the co ch y be ble
to reco end the ount o weight th t should be li ted, the s eci c exercises, w r -
u s, etc, it is the job o the l yer to er or the ctivities to beco e stronger, ster,
ore exible, etc. T e tient ust ssu e the bulk o the res onsibility or the tient’s
c re, or it should be understood th t ost tre t ent interventions will not be success-
ul. While erh s oor et hor, ew would rgue th t even i tient rr nged nd
ke t regul r dent l checku s every 6 onths, i the tient did not brush or oss between
those checku s, it would be ludicrous to think th t the resulting dent l dec y nd gin-
givitis w s bec use the dentist h d iled the tient. In si il r vein, the tient ust
be eng ged in the tient’s own tre t ent l n, or the ch nces or o ti l success dro
log rith ic lly.
Along with the s eci c ele ents o the tre t ent l n, both within nd outside o
the clinic, there needs to be cle r recheck syste . T is should s eci y when the he lth
c re rovider nd the tient will next eet nd ssess rogress, nd when rti l or
ull re ssess ent will be er or ed. T is gives the tient concrete vision o when the
tient will h ve re dy ccess to the tient’s he lth c re rovider nd the tient c n
re re questions nd concerns or this d te. Fro the he lth c re rovider’s ers ec-
tive, this lso llows the rovider to ex ine wh t is ossible nd ke l ns or those
exch nges with the tient. A use ul consider tion rior to ny recheck oint ent is
or clinici ns to sk the selves 3 b sic questions: ( ) Wh t should be done i the tient
s ys th t they re better? (b) Wh t should be done i the tient s ys th t there h s not
been ch nge in their st tus? (c) Wh t should be done i the tient indic tes th t the
roble h s worsened? Over the course o week, the r cticing clinici n will he r ll
o those res onses. As “luck (ch nce) vors the re red ind,”82 i these o tions h ve
been thought through in dv nce, the clinici n will not e r to be stu ed in ront o
Plan 107
the tient. R ther, the clinici n will h ve thought through otenti l o tions nd be ble
to ro ri tely res ond to the v st jority o ndings t the ti e o recheck. T is is
so ewh t n logous to the skilled chess l yer who is not concerned only with the next
ove, but h s considered ll o tions ssoci ted with the next sever l oves. Antici ting
wh t ight occur to the tient, considering o tions, nd being in osition to res ond
to wh tever rises during the recheck, works to incre se the knowledge b se nd skill o
the clinici n. Ulti tely, this le ds to i roved tient c re nd, ho e ully, the chieve-
ent o the jority o utu lly st ted go ls o the tient nd clinici n.
With cle r l n nd recheck syste , c re is rovided, nd regul r ev lu tion o
the tient’s st tus is i le ented. Judg ents re de, nd the cycle o reev lu tion,
ssess ent o current short-ter go ls, nd l n odi c tion is er or ed. It is ho ed
th t through the use o syste , such s the one outlined here with the sc n ex in -
tion, th t the c re rovided will be b sed on objective in or tion, utu lly deter ined
go ls, nd th t the l n will success ully ddress the tient’s neuro usculoskelet l
roble .
Clin ica l Pe a r ls
1. Kno w se nsatio n patte rns e xtre me ly w e ll and de mand spe ci city w he n patie nts
are de scribing se nso ry alte ratio ns. This “ clinical pearl” revolves around the
realization that patients will often present with some pattern of altered sensation, but
it will be presented by them in a very general way. For example, patients will present
and state that their hand is numb or has some other form of altered sensation. When
pressed on this issue and asked to state if the sensory alteration impacts the palm of
the hand or the dorsum of the hand, the response is often a bit of confusion and a
statement to the effect of “ I hadn’t really considered that.” Further follow-up questions
that require additional speci city, such as is the alteration on the thumb side or the
little nger side of the hand, may also be met with a lack of clarity. With sensation
alterations, requiring the patient to be very speci c, while not leading the patient, is
critical when working to develop a hypothesis regarding the pathoanatomical reason
for the de ciency being described.
Although different modalities are carried by axons that constitute the dorsal
column medial lemniscal system and the anterolateral system (see point 4 under “ Basic
Elements of Most Physical Examinations” above), the 2 primary sensory distributions
that are most useful when sorting out altered sensation patterns are dermatomes and
peripheral cutaneous nerves. Dermatomes arise from a single nerve root and their
sensory patterns have some overlap, which typically makes a noted de ciency an
alteration rather than a loss of sensation.74 Peripheral cutaneous nerve distributions,
on the other hand, represent the region of skin where a traceable nerve provides
sensation to a discrete portion of skin.74 Should a peripheral nerve be completely
compromised, it would be expected to not deliver sensation from its distribution. In
the more likely case that there is a compromise of some but not all axons, the degree
of sensation alteration would be proportional, but the pattern will remain the same.
So this pattern is the key and is the reason why the examiner needs to know both
dermatomes and peripheral cutaneous nerve distributions extremely well. Using the
hand and forearm again as an example, if a patient describes altered sensation limited
to the palmar surface of the hand, involving the thumb and index nger, and the
lateral aspect of the forearm, this is not fully compatible with a potential median nerve
problem. The key discrepancy here is that the median nerve cutaneous distribution
is limited to the region from the crease of the wrist distally and the lateral forearm
should not be involved. In this particular case, with the stated sensory pattern, a more
likely cause would be a C6 radiculopathy. If the examiner knows their anatomy and
is able to demand that the patient be very speci c in identifying the region of any
sensory alterations, this can be extremely useful information in determining the nature
of the patient’s presenting problem.
Two nal caveats regarding sensation are that there are other patterns
in addition to dermatomes and peripheral cutaneous nerves, and even in the
presence of an expected normal side, both sides should be examined. Although
dermatomes and peripheral cutaneous nerves are the most common patterns that
are being distinguished on a scan examination, other patterns can present, such
as the “ stocking-glove” pattern of a polyneuropathy. If a patient presents with
altered sensation that is symmetrical, particularly of the distal extremities, consider
a peripheral neuropathy (polyneuropathy). With the frequency of diabetes in
Western societies, this would not be an unexpected complaint when examining
patients. 16 These symptoms typically present rst in the feet, then the hands, but it
is the pattern that distinguishes the problem and leads to the working hypothesis.
Second, always test both sides. For most patients, this comparison is to provide a
compare and contrast between a normal side and a side that is involved with the
presenting complaint. If that is the case, this is a useful comparison and it should be
documented. But for some conditions, such as the previously referenced potential
median neuropathy (eg, carpal tunnel syndrome), research shows that if one side is
involved, the likelihood of involvement of the contralateral side may be as high as
90% .47,79 A careful examination of the contralateral side may identify or suggest the
potential of a mild and developing dysfunction that can be addressed early, before it
becomes a signi cant problem.
2. Use the re so urce s (pro fe ssio nals) w ithin yo ur ne tw o rk to re ne yo ur
e valuative skills. The easiest way to summarize this “ clinical pearl” is through the
analogy of the way evidenced-based information is obtained from libraries. In high
school, students learn to use the Readers Guide to Periodical Literature. In college,
they learn to use Index Medicus (PubMed). In graduate school, they learn to use
the librarians. While this analogy is a bit tongue-in-cheek, it illustrates that the
evolution of seeking information becomes more re ned over time and it recognizes
the willingness to use professionals to speed up the process. In medicine, there are
at least 2 clear realities that have the potential to dramatically increase the accuracy
of the examinations performed. First, we are moving into an age of digital records
where imaging tests will be available to the health care team. Take the time to review
these and work to link the evaluation performed with imaging and other tests that
either collaborate or refute the working hypotheses that were developed. Only by
testing the hypotheses against defendable standards will any examiner re ne their
skills. Feedback is required, and this is a good way to obtain it. Second, take the
time to develop a network of professionals who can be learned from. To extend the
medical imaging example, there are many radiologists who are more than willing to
answer questions about what they can deduce from the imaging tests that have been
performed. As opportunities present, work to develop a relationship with some of
these other members of the health care team so that when questions arise, there is a
chance to pose questions and learn from those individuals. This is ideally a two-way
exchange, but because most professionals are excited about their specialty area, most
are also willing to help mentor other health care professionals who are striving to
provide their patient with the best possible care. Although it requires a bit of effort
and potentially stepping out of a “ comfort zone,” obtaining additional information,
feedback, and mentoring are all critical in the process of developing increased clinical
competence.
3. Ke e p an o pe n mind, be cause so me o f w hat w e think w e kno w , w e do no t
kno w . The easiest example of this is provided by what was a known “ truism” at the
time of World War II and the Vietnam War. It was then “ known” that individuals
with at feet (low-arched feet) were susceptible to an increased injury incidence and
this perception negatively impacted their classi cation status on tness for active
Concluding Thoughts 109
duty. 11 But when the issue was studied, the nding was that this assumption was
not grounded in fact. 19,52 The nding from the Cowan et al article was that “ [t]hese
ndings do not support the hypothesis that low-arched individuals are at increased
risk of injury.” 19 This interesting historical example demonstrates that it is important
to keep an open mind, and continue to look for evidenced-based information
upon which decisions are made. Just collect the data and use it to develop the best
working hypothesis(es), and base the subsequent treatment approaches on that
information.
4. Do n’t be intimidate d by “cranial ne rve s” w he n pe rfo rming scan e xaminatio ns.
Although the anatomy and function of cranial nerves initially takes a bit of effort to
master, realize that virtually every upper-quarter screen exam will at least examine
cranial nerve XI (spinal accessory), as a quick manual muscle test is a shoulder shrug.
Additionally, you will be listening to the patient answer questions that will indirectly
involve tongue function (cranial nerve XII—hypoglossal), and swallowing (which
involves cranial nerves IX and X—glossopharyngeal and vagus). Balance and hearing
are assessed with walking and talking, providing information on cranial nerve XIII
(vestibulocochlear). If a patient can smile symmetrically, then this nding suggests
that the motor portion of cranial nerve VII (facial) is intact. Sensation to the face and
muscles of mastication are key roles of cranial nerve V (trigeminal). Tracking of the
eyes addresses cranial nerves III, IV, and VI (oculomotor, trochlear, and abducens,
respectively). And, the ability to see is a measure that cranial nerve II (optic) is
functioning.75 Although very cursory and most of these tasks are simply observational,
some information is provided for 11 of the 12 cranial nerves by performing a shoulder
shrug manual muscle test, being a good observer, and knowing what you are looking
for. The one nerve that is not assessed in this quick scan is cranial nerve I (olfactory),
which assesses the sense of smell. The point of this “ clinical pearl” is to illustrate
that cranial nerve function can be reasonably monitored during a scan examination,
and should any data suggest that a more in-depth follow-up is needed, then a true
cranial nerve evaluation can be performed. By keeping an open mind and collecting
as much information as possible during a scan examination, it is much less likely that
a signi cant nding will be missed.
Concluding T oughts
T e key ele ent o ny sc n ex in tion is syste tic lly lied ev lu tion to insure
th t i ort nt in or tion is not in dvertently overlooked. T is ent ils ro ching the
ex in tion with n o en ind th t is const ntly working to ssure th t i red or yellow
gs re identi ed, they re nnot ted nd ro ri tely ex lored. Both o these e tures
re en cted within the context o n ev lu tion th t is ti e e cient, while re ining ex-
ible, so th t d t th t oints to given working hy othesis c n be ex lored in ore det il
where there is the o ortunity or ddition l evidence to either coll bor te or re ute th t
hy othesis. T e d t so obt ined, rovides the r ework or the go ls nd l n to ddress
the tient’s resenting condition.
A ew concluding thoughts th t the novice ex iner ight nd use ul re the ollowing:
1. “When hoo be ts re he rd, think bout horses r ther th n zebr s.”49 Wh t this
e ns is th t when d t st rt ointing to sever l otenti l hy otheses, the ost likely
c use is the ost co only occurring hy othesis. I there is nother hy othesis th t
rel tes to rel tively obscure condition ( zebr ), continue to ex lore the ore likely
hy othesis rst, nd in ost c ses, this will le d to solution. H ving s id th t, le the
ltern tive hy othesis w y, bec use on r re occ sion, you will see zebr nd don’t
w nt to be so yo ic th t ll th t is seen is horse.
2. Don’t ro ch re erring tient to nother he lth c re ro ession l s not being
success ul. All he lth c re ro ession ls h ve s heres o ex ertise nd ll he lth c re
roviders should ide lly be working to insure th t the tient is seen by the ost
ro ri te he lth c re rovider. As h s been st ted reviously, the h ll rk o true
ro ession ls is knowing their own li it tions.42
3. Although e ch he lth c re ro ession l will develo his or her own syste , syste
should lw ys be used. T is h s been stressed throughout this ch ter bec use it is
th t i ort nt. T e only w y th t d t will be syste tic lly collected, joints bove
nd below the region o interest will be ex lored, nd the ossibilities o viscer l or
re erred c uses o the tient’s roble will be ke t within the hy otheses ex lored,
is through syste . Use o syste will ssist in not issing key ele ents nd in
roviding higher qu lity he lth c re.
4. All the ev lu tive rocedures used (b sic sc n ex nd ny ollow-u s eci l tests)
re b sed on strong ound tion l knowledge o n to y, histology, bio ech nics,
hysiology, neuroscience, nd the other ound tion l ele ents needed to underst nd
the workings o the hu n body. T roughout your c reer, continue to be student
nd work to build u on the knowledge b se o the ro ession nd the v rious
interrel tionshi s th t exist cross ll o the b sic sciences. T is ty e o curiosity will
ulti tely work to the tient’s dv nt ge by h ving the tient seen by highly
qu li ed ro ession l.
SUMMARY
1. Use syste to insure th t ex in tions re thorough nd re roducible.
2. Listen to the tient nd the tient’s concerns—the history nd the in or tion ob-
t ined re vit l to the ev lu tion.
3. St rt bro d, with n o en ind—let the ndings guide your hy otheses.
4. H ve r tion le or every question sked nd every hysic l ex test er or ed, so
th t this in or tion c n be tr nsl ted into us ble d t .
5. Know your re s o ex ertise nd your li it tions— h ll rk o true ro ession l is
knowing when to re er (work within the ull he lth c re te ).
6. Record s you go throughout the ex in tion to incre se ccur cy.
7. Underst nd th t while “cle ring tests” re i ort nt, they do not truly rule out ny re-
gion o the body.
8. Although ost dys unctions re li ited to single roble , be w re th t co orbidi-
ties re re l ossibility.
9. Develo l n th t eets both the go ls o the tient nd o the reh bilit tion
ro ession l.
10. At the ti e o go l l nning, lw ys consider the ollowing o tions or the ollow-u
oint ent:
a. Wh t should be the res onse i the tient is better?
b. Wh t should be the res onse i there is no ch nge in the tient?
c. Wh t should be the res onse i the tient’s roble is worse?
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Impairments Caused
By Pain
Cr a ig R. De n e g a r a n d Willia m E. Pre n t ice
OBJJE C T I V E S t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Compare the various types of pain and appraise their positive and negative effects.
Choose a technique for assessing pain.
Analyze the characteristics of sensory receptors.
Examine how the nervous system relays information about painful stimuli.
Distinguish between the different neurophysiologic mechanisms for pain control for the
therapeutic modalities used by clinicians.
Predict how pain perception can be modi ed by cognitive factors.
115
116 Chapte r 4 Impairments Caused By Pain
Understanding Pain
T e International Association or the Study o Pain def nes pain as “an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or described
in terms o such damage.”1 Pain is a subjective sensation, with more than 1 dimension and
an abundance o descriptors o its qualities and characteristics. In spite o its universality,
pain is composed o a variety o human discom orts, rather than being a single entity.2 T e
perception o pain can be subjectively modif ed by past experiences and expectations.37
Much o what we do to treat patients’ pain is to change their perceptions o pain.3
Pain does have a purpose. It warns us that something is wrong and can provoke a with-
drawal response to avoid urther injury. It also results in muscle spasm and guards or protects
the injured part. Pain, however, can persist a ter it is no longer use ul. It can become a means
o enhancing disability and inhibiting e orts to rehabilitate the patient.4 Prolonged spasm,
which leads to circulatory def ciency, muscle atrophy, disuse habits, and conscious or uncon-
scious guarding, may lead to a severe loss o unction.5 Chronic pain may become a disease
state in itsel . O ten lacking an identif able cause, chronic pain can totally disable a patient.
Research in recent years has led to a better understanding o pain and pain relie , as
well as the psychology o pain, o ering new approaches to the treatment o musculoskeletal
injury and pain.6 T e evolution o the treatment o pain is, however, incomplete.
T e control o pain is an essential aspect o caring or an injured patient. T is chapter
does not provide a complete explanation o neurophysiology, pain, and pain relie . Several
physiology textbooks provide extensive discussions o human neurophysiology and neuro-
biology to supplement this chapter. Instead, this chapter presents an overview o some the-
ories o pain control, which are intended to provide a stimulus or the clinician to develop
his or her own rationale or managing pain.8
Types of Pain
Acut e Versus Chronic Pain
raditionally, pain has been categorized as either acute or chronic. Acute pain is experi-
enced when tissue damage is impending and a ter injury has occurred. Pain lasting or
more than 6 months is generally classif ed as chronic.9 More recently, the term persistent
pain has been used to di erentiate chronic pain that def es intervention rom conditions in
which continuing (persistent) pain is a symptom o a treatable condition.10,11 More research
is devoted to chronic pain and its treatment, but acute and persistent pain con ronts the
clinician most o ten.12
Referred Pain
Re erred pain, which also may be either acute or chronic, is pain that is perceived to be in
an area that seems to have little relation to the existing pathology. For example, injury to the
spleen o ten results in pain in the le t shoulder. T is pattern, known as the Kehr sign, is use-
ul or identi ying this serious injury and arranging prompt emergency care. Re erred pain
can outlast the causative events because o altered re ex patterns, continuing mechanical
stress on muscles, learned habits o guarding, or the development o hypersensitive areas,
called trigger points.
Radiat ing Pain

Irritation o nerves and nerve roots can cause radiating pain. Pressure on the lumbar nerve
roots associated with a herniated disc or a contusion o the sciatic nerve can result in pain
radiating down the lower extremity to the oot.
Pain Assessment 117
Deep Somat ic Pain

Deep som atic pain is a type that seems to be sclerotomic (associated with a sclerotome, a
segment o bone innervated by a spinal segment). T ere is o ten a discrepancy between the
site o the disorder and the site o the pain.
Pain Assessment
Pain is a complex phenomenon that is di cult to evaluate and quanti y because it is subjec-
tive and is in uenced by attitudes and belie s o the clinician and the patient. Quantif ca-
tion is hindered by the act that pain is a very di cult concept to put into words.13
Obtaining an accurate and standardized assessment o pain is problematic. Several
tools have been developed. T ese pain prof les identi y the type o pain, quanti y the inten-
sity o pain, evaluate the e ect o the pain experience on the patient’s level o unction, and/
or assess the psychosocial impact o pain.
T e pain prof les are use ul because they compel the patient to verbalize the pain and
thereby provide an outlet or the patient and also provide the clinician with a better under-
standing o the pain experience. T ey assess the psychosocial response to pain and injury.
T e pain prof le can assist with the evaluation process by improving communication and
directing the clinician toward appropriate diagnostic tests. Finally, these prof les provide a
standard measure to monitor treatment progress.10
Pain Assessment Scales

T e ollowing prof les are used in the evaluation o acute and chronic pain associated with
illnesses and injuries.
Visual Analog Scales

Visual analog scales are quick and simple tests to be completed by the patient (Figure 4-1).
T ese scales consist o a line, usually 10 cm in length, the extremes o which are taken to
represent the limits o the pain experience.14 One end is def ned as “No Pain” and the other
as “Severe Pain.” T e patient is asked to mark the line at a point corresponding to the sever-
ity o the pain. T e distance between “No Pain” and the mark represents pain severity.
A similar scale can be used to assess treatment e ectiveness by placing “No Pain Relie ” at
one end o the scale and “Complete Pain Relie ” at the other. T ese scales can be completed
daily or more o ten as pretreatment and posttreatment assessments.15
Pain Chart s
Pain charts can be used to establish spatial properties o
pain. T ese 2-dimensional graphic portrayals are com-
pleted by the patient to assess the location o pain and a None S e ve re
number o subjective components. Simple line drawings
o the body in several postural positions are presented to
the patient (Figure 4-2). On these drawings, the patient
draws or colors in areas that correspond to the patient’s No pa in Comple te pa in
pain experience. Di erent colors are used or di er- re lie f re lie f
ent sensations— or example, blue or aching pain, yel-
low or numbness or tingling, red or burning pain, and
green or cramping pain. Descriptions can be added to
Figure 4-1 Visual analo g scale s
the orm to enhance the communication value. T e orm (Reproduced with permission from Prentice. Therapeutic Modalities in
could be completed daily.16 Rehabilitation. 4th ed. New York: McGraw-Hill; 2011.)
Right Le ft Le ft
Le ft
Right Le ft
Right
Right Le ft
Le ft
Le ft Right
Right
Right
Le ft
Right Le ft
Figure 4-2 The pain chart
Use the following instructions: “Please use all of the gures to show me exactly where all your
pains are, and where they radiate to. Shade or draw with blue marker. Only the patient is to ll
out this sheet. Please be as precise and detailed as possible. Use yellow marker for numbness
and tingling. Use red marker for burning or hot areas, and green marker for cramping. Please
remember: blue = pain, yellow = numbness and tingling, red = burning or hot areas,
green = cramping.” (Used with permission from Margoles MS. The pain chart: spatial properties of
pain. In: Melzack R, ed. Pain Measurement and Assessment. New York, NY: Raven Press; 1983.)
McGill Pain Quest ionnaire

T e McGill Pain Questionnaire is a tool with 78 words that describe pain (Figure 4-3). T ese
words are grouped into 20 sets that are divided into 4 categories representing dimensions o
the pain experience. Although completion o the McGill Pain Questionnaire may take only
20 minutes, it is o ten rustrating or patients who do not speak English well. T e McGill Pain
Questionnaire is commonly administered to patients with low back pain. When adminis-
tered every 2 to 4 weeks, it demonstrates changes in status very clearly.2
Act ivit y Pat t ern Indicat ors Pain Pro le

T e Activity Pattern Indicators Pain Prof le measures patient activity. It is a 64-question,
sel -report tool that may be used to assess unctional impairment associated with pain. T e
instrument measures the requency o certain behaviors such as housework, recreation,
and social activities.10
Numeric Pain Scale

T e most common acute pain prof le is a num eric pain scale. T e patient is asked to rate his
or her pain on a scale rom 1 to 10, with 10 representing the worst pain the patient has expe-
rienced or could imagine (Figure 4-4). T e question is asked be ore and a ter treatment.
When treatments provide pain relie , patients are asked about the extent and duration o the
relie . In addition, patients may be asked to estimate the portion o the day that they expe-
rience pain and about specif c activities that increase or decrease their pain. When pain
a ects sleep, patients may be asked to estimate the amount o sleep they got in the previous
24 hours. In addition, the amount o medication required or pain can be noted. T is in or-
mation helps the clinician assess changes in pain, select appropriate treatments, and com-
municate more clearly with the patient about the course o recovery rom injury or surgery.
Pain Assessment 119
Mc Gill Pain Que s tio nnaire
Pa tie nt’s Na me Da te Time a .m./p.m.
P RI: S A E M P RI (T) PPI

(1–10) (11–15) (16) (17–20) (1–20)
1 Flicke ring 11 Tiring Brie f Rhythmic Continuous

Quive ring Exha us ting Mome nta ry Pe riodic S te a dy
P uls ing Tra ns ie nt Inte rmitte nt Cons ta nt
Throbbing 12 S icke ning
Be a ting S uffoca ting
Pounding 13 Fe a rful
2 Jumping Frightful
Fla s hing Te rrifying
S hooting 14 P unis hing
3 P ricking Grue lling
Boring Crue l
Drilling Vicious
S ta bbing Killing
La ncina ting 15 Wre tche d
Blinding
4 S ha rp
Cutting 16 Annoying
La ce ra ting Trouble s ome
Mis e ra ble
5 P inching
Inte ns e
P re s s ing
Unbe a ra ble
Gnawing
Cra mping 17 S pre a ding
Crus hing Ra dia ting
6 Tugging Pe ne tra ting
P ulling P ie rcing
Wre nching 18 Tight
7 Hot Numb
Burning Drawing
S que e zing E = Exte rna l
S ca lding
Te a ring I = Inte rna l
S e a ring
19 Cool
8 Tingling
Cold
Itchy
Fre e zing
S ma rting
S tinging 20 Na gging Comme nts :
Na us e a ting
9 Dull
Agonizing
S ore
Dre a dful
Hurting
Torturing
Aching
He avy PPI
0 No Pa in
10 Te nde r 1 Mild
Ta ut 2 Dis comforting
Ra s ping 3 Dis tre s s ing
S plitting 4 Horrible
5 Excrucia ting
Figure 4-3 McGill pain que stio nnaire
The descriptors fall into 4 major groups: sensory, 1 to 10; affective, 11 to 15; evaluative, 16; and
miscellaneous, 17 to 20. The rank value for each descriptor is based on its position in the word
set. The sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI)
is based on a scale of 0 to 5. (Reproduced with permission from Prentice. Therapeutic Modalities in
Rehabilitation. 4th ed. New York: McGraw-Hill; 2011.)
All o these scales help patients communicate the severity and duration o their pain
and appreciate changes that occur. O ten in a long recovery, patients lose sight o how much
progress has been made in terms o the pain experience and return to unctional activities.
A review o these pain scales o ten can serve to reassure the patient; oster a brighter, more
positive outlook; and rein orce the commitment to the plan o treatment.
Nume ric Rating S c ale -NRS
0 1 2 3 4 5 6 7 8 9 10
No Mode ra te Wors t pa in
pa in pa in e ve r
Figure 4-4
The Numeric Rating Scale (NRS) is the most common acute
pain pro le. (Reproduced with permission from Prentice. Therapeutic
Modalities in Rehabilitation. 4th ed. New York: McGraw-Hill; 2011.)
Clin ica l Pe a r l
A number of pain scales are available, including visual analog scales, pain charts, the
McGill Pain Questionnaire, the Activity Pattern Indicators Pain Pro le, and numeric pain
scales. Numeric pain scales, in which the patient is asked to rate his or her pain on a scale
from 1 to 10, are perhaps the most widely used in the clinical setting.
Document at ion
T e e cacy o many o the treatments used by clinicians has not been ully substanti-
ated. T ese scales are one source o data that can help clinicians identi y the most e ective
approaches to managing common injuries. T ese assessment tools can also be use ul when
reviewing a patient’s progress with physicians, and third-party payers. T us, pain assess-
ments should be routinely included as documentation in the patient’s note.
Goals in Managing Pain

Regardless o the cause o pain, its reduction is an essential part o treatment. Pain signals
the patient to seek assistance and is o ten use ul in establishing a diagnosis. Once the injury
or illness is diagnosed, pain serves little purpose. Medical or surgical treatment or immo-
bilization is necessary to treat some conditions, but physical therapy and an early return to
activity are appropriate ollowing many injuries.35 T e clinician’s objectives are to encourage
the body to heal through exercise designed to progressively increase unctional capacity and
to return the patient to work, recreational, and other activities as swi tly and sa ely as pos-
sible. Pain will inhibit therapeutic exercise. T e challenge or the clinician is to control acute
pain and protect the patient rom urther injury while encouraging progressive exercise in a
supervised environment.
Pain Perception
T e patient’s perception o pain can di er markedly rom person to person, as can the termi-
nology used to describe the type o pain the patient is experiencing. T e clinician commonly
asks the patient to describe what the patient’s pain eels like during an injury evaluation. T e
Pain Perception 121
patient o ten uses terms such as sharp, dull, aching, throbbing, burning, piercing, localized,
and generalized. It is sometimes di cult or the clinician to in er what exactly is causing a
particular type o pain. For example, “burning” pain is o ten associated with some injury to
a nerve, but certainly other injuries may produce what the patient is perceiving as “burning”
pain. T us, verbal descriptions o the type o pain should be applied with caution.
Sensory Recept ors

A nerve ending is the termination o a nerve f ber in a peripheral structure. It may be a
sensory ending (receptor) or a motor ending (e ector). Sensory endings can be capsulated
(eg, ree nerve endings, Merkel corpuscles) or encapsulated (eg, end bulbs o Krause or
Meissner corpuscles).
T ere are several types o sensory receptors in the body, and the clinician should be
aware o their existence as well as o the types o stimuli that activate them ( able 4-1). Acti-
vation o some o these sense organs with therapeutic agents will decrease the patients per-
ception o pain.
Six di erent types o receptor nerve endings are commonly described:
1. Meissner corpuscles are activated by light touch.
2. Pacinian corpuscles respond to deep pressure.
3. Merkel corpuscles respond to deep pressure, but more slowly than Pacinian
corpuscles, and also are activated by hair ollicle de ection.
4. Ru ni corpuscles in the skin are sensitive to touch, tension, and possibly heat; those
in the joint capsules and ligaments are sensitive to change in position.
Table 4-1 So me Characte ristics o f Se le cte d Se nso ry Re ce pto rs
Stimulus Re ce pto r
Type o f Se nso ry
Re ce pto rs Ge ne ral Te rm Spe ci c Nature Te rm Lo catio n
Mechanoreceptors Pressure Movement of hair Afferent nerve ber Base of hair follicles
in a hair follicle Meissner corpuscle Skin
Light pressure Pacinian corpuscle Skin
Deep pressure Merkel touch Skin
Touch corpuscle
Nociceptors Pain Distension (stretch) Free nerve endings Wall of gastrointestinal tract,
pharynx skin
Proprioceptors Tension Distension Corpuscles of Ruf ni Skin and capsules in joints and
Length changes Muscle spindles ligaments
Tension changes Golgi tendon organs Skeletal muscle
Between muscles and tendons
Thermoreceptors Temperature Cold End bulbs of Krause Skin

change Heat Corpuscles of Ruf ni Skin and capsules in joints
and ligaments
Source: Reproduced with permission from Previte J. Human Physiology. New York, NY: McGraw-Hill; 1983.
5. End bulbs o Krause are thermoreceptors that react to a decrease in temperature and
touch.17
6. Pain receptors, called nociceptors or ree nerve endings, are sensitive to extreme
mechanical, thermal, or chemical energy.3 T ey respond to noxious stimuli—in other
words, to impending or actual tissue damage (eg, cuts, burns, sprains, and so on).
T e term nociceptive is rom the Latin nocere, to damage, and is used to imply pain
in ormation. T ese organs respond to superf cial orms o heat and cold, analgesic
balms, and massage.
Proprioceptors ound in muscles, joint capsules, ligaments, and tendons provide in or-
mation regarding joint position and muscle tone. T e muscle spindles react to changes in
length and tension when the muscle is stretched or contracted. T e Golgi tendon organs
also react to changes in length and tension within the muscle. See able 4-1 or a more
complete listing.
Some sensory receptors respond to phasic activity and produce an impulse when the
stimulus is increasing or decreasing, but not during a sustained stimulus. T ey adapt to
a constant stimulus. Meissner corpuscles and Pacinian corpuscles are examples o such
receptors.
onic receptors produce impulses as long as the stimulus is present. Examples o tonic
receptors are muscle spindles, ree nerve endings, and end bulbs o Krause. T e initial
impulse is at a higher requency than later impulses that occur during sustained stimulation.
Accommodation is the decline in generator potential and the reduction o requency
that occur with a prolonged stimulus or with requently repeated stimuli. I some physical
agents are used too o ten or or too long, the receptors may adapt to or accommodate the
stimulus and reduce their impulses. T e accom m odation phenomenon can be observed
with the use o superf cial hot and cold agents, such as ice packs and hydrocollator packs.
As a stimulus becomes stronger, the number o receptors excited increases, and the
requency o the impulses increases. T is provides more electrical activity at the spinal cord
level, which may acilitate the e ects o some physical agents.
Cognit ive In uences

Pain perception and the response to a pain ul experience may be in uenced by a variety o
cognitive processes, including anxiety, attention, depression, past pain experiences, and
cultural in uences.18 T ese individual aspects o pain expression are mediated by higher
centers in the cortex in ways that are not clearly understood.3 T ey may in uence both the
sensory discriminative and motivational a ective dimensions o pain.
Many mental processes modulate the perception o pain through descending systems.
Behavior modif cation, the excitement o the moment, happiness, positive eelings, ocusing
(directed attention toward specif c stimuli), hypnosis, and suggestion may modulate pain
perception. Past experiences, cultural background, personality, motivation to play, aggres-
sion, anger, and ear are all actors that could acilitate or inhibit pain perception. Strong
central inhibition may mask severe injury or a period o time.3 At such times, evaluation o
the injury is quite di cult.
Patients with chronic pain may become very depressed and experience a loss o f tness.
T ey tend to be less active and may have altered appetites and sleep habits. T ey have a
decreased will to work and exercise and o ten develop a reduced sex drive. T ey may turn to
sel -abusive patterns o behavior. ricyclic drugs are o ten used to inhibit serotonin deple-
tion or the patient with chronic pain.
Just as pain may be inhibited by central modulation, it may also arise rom central ori-
gins. Phobias, ear, depression, anger, grie , and hostility are all capable o producing pain
in the absence o local pathologic processes. In addition, pain memory, which is associated
Neural Transmission 123
with old injuries, may result in pain perception and pain response that are out o proportion
to a new, o ten minor, injury. Substance abuse can also alter and con ound the perception
o pain. Substance abuse may cause the chronic pain patient to become more depressed or
may lead to depression and psychosomatic pain.
Neural Transmission
A erent nerve f bers transmit impulses rom the sensory receptors toward the brain whereas
e erent f bers, such as motor neurons, transmit impulses rom the brain toward the periph-
ery.7 First-order or primary a erents transmit the impulses rom the sensory receptor to
the dorsal horn o the spinal cord (Figure 4-5). T ere are
4 di erent types o f rst-order neurons ( able 4-2). Aα and
Aβ are large-diameter a erents that have a high ( ast) con- S e ns ory
cortex
duction velocity, and Aδ and C f bers are small-diameter Third-orde r
Ne uron
f bers with low (slow) conduction velocity.
Second-order a erent f bers carry sensory messages
up the spinal cord to the brain. T ey are categorized as
wide dynam ic range or nociceptive specif c. T e wide
dynamic range second-order a erents receive input rom S e cond-orde r
Aβ, Aδ, and C f bers. T ese second-order a erents serve Ne uron
relatively large, overlapping receptor f elds. T e nocicep-
tive specif c second-order a erents respond exclusively to
noxious stimulation. T ey receive input only rom Aδ and
C f bers. T ese a erents serve smaller receptor f elds that
do not overlap. All o these neurons synapse with third-
order neurons, which carry in ormation to various brain
centers where the input is integrated, interpreted, and
acted upon.
Facilit at ors and Inhibit ors of Synapt ic

Transmission
For in ormation to pass between neurons, a transmitter
Firs t-orde r
substance must be released rom the end o one neuron ter- Ne uron
minal (presynaptic membrane), enter the synaptic cle t, and
attach to a receptor site on the next neuron (postsynaptic
membrane) (Figure 4-6). In the past, all the activity within
the synapse was attributed to neurotransm itters, such as
acetylcholine. T e neurotransmitters, when released in su -
f cient quantities, are known to cause depolarization o the
Nocice ptor
postsynaptic neuron. In the absence o the neurotransmit- (fre e ne rve e nding)
ter, no depolarization occurs.
It is now apparent that several compounds that are
not true neurotransmitters can acilitate or inhibit syn- Figure 4-5 Ne ural affe re nt transmissio n
aptic activity. Serotonin, norepinephrine, enkephalin,
β-endorphin, dynorphin, and substance P are each impor- Sensory (pain) information from free nerve endings is
tant in the body’s pain control mechanism.19 transmitted to the sensory cortex in the brain via first-,
Enkephalin is an endogenous (made by the body) second-, and third-order neurons. (Reproduced with
opioid that inhibits the depolarization o second-order permission from Prentice. Therapeutic Modalities in Rehabilitation.
nociceptive nerve f bers. It is released rom interneurons, 4th ed. New York: McGraw-Hill; 2011.)
Table 4-2 Classi catio n o f Affe re nt Ne uro ns
Diame te r Co nductio n
Size Type Gro up Subg ro up (µm) Ve lo city (m/ s) Re ce pto r Stimulus
Large Aα I 1a 13 to 22 70 to 120 Proprioceptive Muscle velocity and

mechanoreceptor length change,
muscle shortening
of rapid speed
Aα I 1b Proprioceptive Muscle length
mechanoreceptor information from
Cutaneous receptors touch and pacinian
corpuscles
Aβ II Muscle 8 to 13 40 to 70
Aβ II Skin
Aδ III Muscle 1 to 4 5 to 15 75% mechanoreceptors Touch, vibration, hair
and thermoreceptors receptors
Temperature change
Small Aδ III Skin 25% nociceptors, Noxious, mechanical,

mechanoreceptors, and temperature
and thermoreceptors (>45°C, <10°C)
(hot and cold)
C IV Muscle 0.2 to 1.0 0.2 to 2.0 50% mechanoreceptors Touch and
and thermoreceptors temperature
enkephalin neurons with short axons. T e enkephalins are stored in nerve-ending vesicles
ound in the substantia gelatinosa and in several areas o the brain. When released, enkeph-
alin may bind to presynaptic or postsynaptic membranes.19
Norepinephrine is released by the depolarization o some neurons and binds to the
postsynaptic membranes. It is ound in several areas o the nervous system, including a
tract that descends rom the pons, which inhibits synaptic transmission between f rst- and
second-order nociceptive f bers, thus decreasing pain sensation.20
Other endogenous opioids may be active analgesic agents. T ese neuroactive peptides
are released into the central nervous system and have an action similar to that o morphine,
an opiate analgesic. T ere are specif c opiate receptors located at strategic sites, called bind-
ing sites, to receive these compounds. β-Endorphin and dynorphin have potent analgesic
e ects. T ese are released within the central nervous system by mechanisms that are not
ully understood at this time.
Nocicept ion
A nociceptor is a peripheral pain receptor. Its cell body is in the dorsal root ganglion near the
spinal cord. Pain is initiated when there is injury to a cell causing a release o 3 chemicals,
substance P, prostaglandin, and leukotrienes, that sensitize the nociceptors in and around
the area o injury by lowering their depolarization threshold. T is is re erred to as prim ary
hyperalgesia, in which the nerve’s threshold to noxious stimuli is lowered, thus enhancing
the pain response.5 Over a period o several hours, secondary hyperalgesia occurs, as chemi-
cals spread throughout the surrounding tissues, increasing the size o the pain ul area and
creating hypersensitivity.
Neural Transmission 125
Ne rve impuls e
Axon of pre s ynaptic ne uro n
Ele ctrica l S mooth

Mitochondria
s yna ps e mus cle ce lls
Pre s ynaptic Po s ts ynaptic Ca lcium Microtubule s

c e ll c e ll (Ca 2+) ions of cytos ke le ton
Ga p junction Volta ge -re gula te d S yna ptic ve s icle s

ca lcium (Ca 2+) conta ining
Loca l curre nt cha nne l a ce tylcholine (ACh)
+ +
+ + S yna ptic
+ +
+ cle ft
+ ++
+
+
+
+++
+
+ + +
+
Ace tylcholine
Pos itive ly Ace tylcholine binds
cha rge d ions Connexons
to re ce ptor prote in, Pos ts yna ptic
ca us ing ion ga te s S odium me mbra ne
to ope n (Na +) ions
Inne r s urfa ce Re ce ptor prote in
P la s ma me mbra ne of pla s ma Po s ts ynaptic ne uro n
me mbra ne
A. Ele c tric al s ynaps e B. Che mic al s ynaps e
Figure 4-6 Synaptic transmissio n
(Reproduced with permission from McKinley M, O’Loughlin VD. Human Anatomy. 2nd ed. New York, NY: McGraw-Hill; 2008.)
Nociceptors initiate the electrical impulses along 2 a erent f bers toward the spinal
cord. Aδ and C f bers transmit sensations o pain and temperature rom peripheral nocicep-
tors. T e majority o the f bers are C f bers. Aδ f bers have larger diameters and aster con-
duction velocities. T is di erence results in 2 qualitatively di erent types o pain, termed
acute and chronic.19 Acute pain is rapidly transmitted over the larger, aster-conducting
Aδ a erent neurons and originates rom receptors located in the skin.19 It is localized and
short, lasting only as long as there is a stimulus, such as the initial pain o an unexpected
pinprick. Chronic pain is transmitted by the C f ber a erent neurons and originates rom
both superf cial skin tissue and deeper ligament and muscle tissue. T is pain is an aching,
throbbing, or burning sensation that is poorly localized and less specif cally related to the
stimulus. T ere is a delay in the perception o pain ollowing injury, but the pain will con-
tinue long a ter the noxious stimulus is removed.5
T e various types o a erent f bers ollow di erent courses as they ascend toward the
brain. Some Aδ and most C a erent neurons enter the spinal cord through the dorsal horn
o the spinal cord and synapse in the substantia gelatinosa with a second-order neuron
(Figure 4-7).20 Most nociceptive second-order neurons ascend to higher centers along 1 o
the 3 tracts—the lateral spinothalamic tract, the spinoreticular tract, or the spinoencephalic
tract—with the remainder ascending along the spinocervical tract.20 Approximately 80% o
nociceptive second-order neurons ascend to higher centers along the lateral spinothalamic
tract.20 Approximately 90% o the second-order a erents terminate in the thalamus.20 T ird-
order neurons project to the sensory cortex and numerous other centers in the central ner-
vous system (see Figure 4-5).
Right s ide of body Le ft s ide of body
P rima ry s e ns ory
Ce re brum corte x
Third-o rde r
ne uro n
Tha la mus
Midbra in
S e c o nd-o rde r
ne uro n
P ons
Me dulla
A-δ a nd
C fibe rs from S pinore ticula r tra ct
pa in re ce ptors
La te ra l
Firs t-o rde r ne uro n s pinotha lmic tra ct
P os te rior horn
S pina l cord
Figure 4-7
The ascending lateral spinothalamic and spinoreticular tract in the spinal cord carries pain
information to the cortex. (Reproduced with permission from Prentice. Therapeutic Modalities in
T ese projections allow us to perceive pain. T ey also permit the integration o past
experiences and emotions that orm our response to the pain experience. T ese connec-
tions are also believed to be parts o complex circuits that the clinician may stimulate to
manage pain. Most analgesic physical agents are believed to slow or block the impulses
ascending along the Aδ and C a erent neuron pathways through direct input into the dorsal
horn or through descending mechanisms. T ese pathways are discussed in more detail in
the ollowing section.
Neurophysiologic Explanations of Pain Control 127
Neurophysiologic Explanations of Pain Control

T e neurophysiologic mechanisms o pain control through stimulation o cutaneous recep-
tors have not been ully explained.21 Much o what is known—and current theory—is the
result o work involving electroacupuncture and transcutaneous electrical nerve stimula-
tion. However, this in ormation o ten provides an explanation or the analgesic response to
other modalities, such as massage, analgesic balms, and moist heat.
T e concepts o the analgesic response to cutaneous receptor stimulation presented
here were f rst proposed by Melzack and Wall22 and Castel.23 T ese models essentially pres-
ent 3 analgesic mechanisms:
1. Stimulation rom ascending Aβ a erents results in blocking impulses at the spinal
cord level o pain messages carried along Aδ and C a erent f bers (gate control).
2. Stimulation o descending pathways in the dorsolateral tract o the spinal cord by
Aδ and C f ber a erent input results in a blocking o the impulses carried along the
Aδ and C a erent f bers.
3. T e stimulation o Aδ and C a erent f bers causes the release o endogenous
opioids (β-endorphin), resulting in a prolonged activation o descending analgesic
pathways.
T ese theories or m odels are not necessarily mutually exclusive. Recent evidence
suggests that pain relie may result rom combinations o dorsal horn and central nervous
system activity.24,25
The Gat e Cont rol Theory of Pain

T e gate control theory explains how a stimulus that
activates only nonnociceptive nerves can inhibit pain
Pos te rior
(Figure 4-8).22 T ree peripheral nerve f bers are involved in
this mechanism o pain control: Aδ f bers, which transmit Firs t-orde r S ubs ta ntia
ne urons ge la tinos a To s e ns ory
noxious impulses associated with intense pain; C f bers,
cortex
which carry noxious impulses associated with long-term or Dors a l
Aδ Clos ing
horn
chronic pain; and Aβ f bers, which carry sensory in ormation C the ga te
Aβ me cha nis m
rom cutaneous receptors but are nonnociceptive and do not As ce nding
S e cond-orde r la te ra l
transmit pain. Impulses ascending on these f bers stimulate –
+– ne urons s pinotha la mic
the substantia gelatinosa as they enter the dorsal horn o the tra ct
spinal cord. Essentially, the nonnociceptive Aβ f bers inhibit
the e ects o the Aδ and C pain f bers, e ectively “closing a
gate” to the transmission o their stimuli to the second-order
interneurons. T us, the only in ormation that is transmitted
+ = Tra ns mitte d Ante rior
on the second-order neurons through the ascending lateral
– = Inhibite d
spinothalamic tract to the cortex is the in ormation rom
the Aβ f bers. T e “pain message” carried along the smaller-
diameter Aδ and C f bers is not transmitted to the second- Figure 4-8 Gate co ntro l the o ry
order neurons and never reaches sensory centers.
T e discovery and isolation o endogenous opioids in Sensory information carried on Aβ fibers “closes the gate”
the 1970s led to new theories o pain relie . Castel intro- to pain information carried on Aδ and C fibers in the
duced an endogenous opioid analog to the gate control the- substantia gelatinosa preventing transmission of pain to
ory.23 T is theory proposes that increased neural activity in sensory centers in the cortex. (Reproduced with permission
Aβ primary a erent pathways triggers a release o enkepha- from Prentice. Therapeutic Modalities in Rehabilitation. 4th ed.
lin rom enkephalin interneurons ound in the dorsal horn. New York: McGraw-Hill; 2011.)
T ese neuroactive amines inhibit synaptic transmission in the Aδ and C f ber a erent path-
ways. T e end result, as in the gate control theory, is that the pain message is blocked be ore
it reaches sensory levels.
T e concept o sensory stimulation or pain relie , as proposed by the gate control the-
ory, has empirical support. Rubbing a contusion, applying moist heat, or massaging sore
muscles decreases the perception o pain. T e analgesic response to these treatments is
attributed to the increased stimulation o Aβ a erent f bers. A decrease in input along noci-
ceptive Aδ and C a erents also results in pain relie . Cooling a erent f bers decreases the
rate at which they conduct impulses. T us, a 20-minute application o cold is e ective in
relieving pain because o the decrease in activity, rather than an increase in activity along
a erent pathways.
Descending Pain Cont rol

A second mechanism o pain control essentially expands the original gate control theory
o pain control and involves input rom higher centers in the brain through a descending
system (Figure 4-9).26 Emotions (such as anger, ear, stress), previous experiences, sensory
perceptions, and other actors coming rom the thalamus in the cerebrum stimulate the
periaqueductal gray (PAG) matter o the midbrain. T e pathway over which this pain reduc-
tion takes place is a dorsal lateral projection rom cells in the PAG to an area in the medulla
o the brainstem called the raphe nucleus. When the PAG f res, the raphe nucleus also f res.
Serotonergic e erent pathways rom the raphe nucleus project to the dorsal horn along the
entire length o the spinal cord where they synapse with enkephalin interneurons located in
the substantia gelitanosa.27 T e activation o enkephalin interneuron synapses by serotonin
suppresses the release o the neurotransmitter substance P rom Aδ and C f bers used by
the sensory neurons involved in the perception o chronic and/ or intense pain. Addition-
ally, enkephalin is released into the synapse between the enkephalin interneuron and the
second-order neuron that inhibits synaptic transmission o impulses rom incoming Aδ and
C f bers to the second-order a erent neurons that transmit the pain signal up the lateral
spinothalamic tract to the thalamus (Figure 4-10).28
A second descending, noradrenergic pathway projecting rom the pons to the dor-
sal horn has also been identif ed.20 T e signif cance o these parallel pathways is not ully
understood. It is also not known i these noradrenergic f bers directly inhibit dorsal horn
synapses or stimulate the enkephalin interneurons.
T is model provides a physiologic explanation or the analgesic response to brie ,
intense stimulation. T e analgesia ollowing acupressure and the use o some transcuta-
neous electrical nerve stimulators ( ENS), such as point stimulators, is attributed to this
descending pain control mechanism.38,39,40
β-Endorphin and Dynorphin in Pain Cont rol

T ere is evidence that stimulation o the small-diameter a erents (Aδ and C) can stimu-
late the release o other endogenous opioids called endorphins.7,17,21,22,25,26,29 β-Endorphin
and dynorphin are endogenous opioid peptide neurotransmitters ound in the neurons o
both the central and peripheral nervous system.30 T e mechanisms regulating the release
o β-endorphin and dynorphin have not been ully elucidated. However, it is apparent that
these endogenous substances play a role in the analgesic response to some orms o stimuli
used in the treatment o patients in pain.
β-Endorphin is released into the blood rom the anterior pituitary gland and into the
brain and spinal cord rom the hypothalamus.30 In the anterior pituitary gland, it shares
a prohormone with adrenocorticotropin. T us, when β-endorphin is released, so, too, is
Neurophysiologic Explanations of Pain Control 129
Ce re brum
Tha la mus
Pe ria que ducta l

gray (PAG)
Midbra in
Dors a l la te ra l
proje ction
Pons
2nd de s ce nding Ra phe nucle us

proje ction
Me dulla
As ce nding
la te ra l
s pinotha lmic
tra ct
Aδ + C fibe rs
Enke pha lin
re le a s e d
S ubs ta ntia
ge la tinos a
S e cond-
orde r
ve rs ion
Figure 4-9 De sce nding pain co ntro l
In uence from the thalamus stimulates the periaqueductal gray, the raphe nucleus, and the
pons to inhibit the transmission of pain impulses through the ascending tracts. (Reproduced
with permission from Prentice. Therapeutic Modalities in Rehabilitation. 4th ed. New York:
McGraw-Hill; 2011.)
adrenocorticotropin. β-Endorphin does not readily cross the blood–brain barrier,19 and
thus the anterior pituitary gland is not the sole source o β-endorphin.31,41
As stated previously, pain in ormation is transm itted to the brainstem and thala-
mus primarily on 2 di erent pathways, the spinothalam ic and spinoreticular tracts.
Spinothalamic input is thought to e ect the conscious

From PAG a nd sensation o pain, and the spinoreticular tract is thought
ra phe nucle us
to e ect the arousal and em otional aspects o pain.
Pain stimuli rom these two tracts stimulate the release
Dors a l horn o β-endorphin rom the hypothalamus (Figure 4-11).
β-Endorphin released into the nervous system binds
Aδ fibe rs
to specif c opiate-binding sites in the nervous system.
C fibe rs
T e neurons in the hypothalamus that send projections
S e rotonin to the PAG and noradrenergic nuclei in the brainstem
re le a s e d
contain β-endorphin. Prolonged (20 to 40 m inutes)
Enke pha lin small-diameter a erent f ber stimulation via electroacu-
re le a s e d S ubs ta nce P
re le a s e puncture has been thought to trigger the release o
S e cond-orde r s upre s s e d β-endorphin.21,41 It is likely that β-endorphin released
ne uron to
rom these neurons by stimulation o the hypothalamus
a s ce nding
Enke pha lin is responsible or initiating the same mechanisms in the
tra cts
inte rne uron
spinal cord as previously described with other descend-
ing m echanism s o pain control.36,43 Once again, urther
research is needed to clari y where and how these sub-
stances are released and how the release o β-endorphin
a ects neural activity and pain perception.
Figure 4-10 Dynorphin, a more recently isolated endogenous opi-
oid, is ound in the PAG, rostroventral medulla, and the
The enkephalin interneuron functions to inhibit transmission dorsal horn.20 It has been demonstrated that dynorphin
of pain between the Aδ and C fibers and the second-order is released during electroacupuncture.32 Dynorphin may
neuron to the ascending tracts. (Reproduced with permission be responsible or suppressing the response to noxious
from Prentice. Therapeutic Modalities in Rehabilitation. 4th ed. mechanical stimulation.20
New York: McGraw-Hill; 2011.)
Summary of Pain Cont rol Mechanisms

T e body’s pain control mechanisms are probably not mutually exclusive. Rather, analgesia
is the result o overlapping processes. It is also important to realize that the theories pre-
sented are only models. T ey are use ul in conceptualizing the perception o pain and pain
relie . T ese models will help the clinician understand the e ects o therapeutic modalities
and orm a sound rationale or modality application.8 As more research is conducted and as
the mysteries o pain and neurophysiology are solved, new models will emerge. T e clini-
cian should adapt these models to f t new developments.
Pain Management
How should the clinician approach pain? First, the source o the pain must be identif ed.
Unidentif ed pain may hide a serious disorder, and treatment o such pain may delay the
appropriate treatment o the disorder.33 Once a diagnosis has been made, the clinician must
select the therapeutic technique that is most appropriate or each patient, based on their
knowledge and pro essional judgment.34
T e therapist may choose rom a variety o use ul pain control strategies including the
ollowing:
1. Encourage cognitive processes that in uence pain perception, such as motivation,
tension diversion, ocusing, relaxation techniques, positive thinking, thought
stopping, and sel -control.
Pain Management 131
Ce re brum
β-e ndorphin Hypotha la mus

re le a s e d
Pe ria que ducta l

gray
Midbra in
Dynorphin
re le a s e d
Pons
2nd de s ce nding La te ra l
proje ction S pinotha la mic
a nd s pinore ticula r
Me dulla tra cts
Dynorphin
re le a s e d
Enke pha lin

re le a s e d
Figure 4 - 1 1
β-Endorphin released from the hypothalamus, and dynorphin released from the PAG and
the medulla modulate. (Reproduced with permission from Prentice. Therapeutic Modalities in
2. Minimize the tissue damage through the application o proper f rst aid and
immobilization.
3. Maintain a line o communication with the patient. Let the patient know what
to expect ollowing an injury. Pain, swelling, dys unction, and atrophy will occur
ollowing injury. T e patient’s anxiety over these events will increase the patient’s
perception o pain. O ten, a patient who has been told what to expect by someone
the patient trusts will be less anxious and su er less pain.
4. Recognize that all pain, even psychosomatic pain, is very real to the patient.
5. Encourage supervised exercise to encourage blood ow, promote nutrition, increase
metabolic activity, and reduce sti ness and guarding i the activity will not cause
urther harm to the patient.
6. Incorporate appropriate physical agents into the treatment plan. In general, physical
agents can be used to:42
a. stimulate large-diameter a erent f bers (Aβ)—this can be done with ENS,
massage, and analgesic balms;
b. decrease pain f ber transmission velocity with cold or ultrasound;
c. stimulate small-diameter a erent f bers (Aδ and C) and descending pain control
mechanisms with acupressure, deep massage, or ENS over acupuncture points
or trigger points;
d. stimulate a release o β-endorphin and dynorphin or other endogenous opioids
through prolonged small-diameter f ber stimulation with ENS.17
T e physician may choose to prescribe oral or injectable medications in the treatment
o the patient. T e most commonly used medications are classif ed as analgesics, antiin-
ammatory agents, or both. T e clinician should become amiliar with these drugs and
note whether the patient is taking any medications. It is also important to work with the
re erring physician to assure that the patient takes the medications appropriately.
T e clinician’s approach to the patient has a great impact on the success o the treat-
ment. T e patient will not be convinced o the e cacy and importance o the treatment
unless the clinician appears conf dent about it. T e clinician must make the patient a par-
ticipant rather than a passive spectator in the treatment and rehabilitation process.
T e goal o most treatment programs is to encourage early pain- ree exercise. T e phys-
ical agents used to control pain do little to promote tissue healing. T ey should be used
to relieve acute pain ollowing injury or surgery or to control pain and other symptoms,
such as swelling, to promote progressive exercise. T e clinician should not lose sight o the
e ects o the physical agents or the importance o progressive exercise in restoring the pa-
tient’s unctional ability.
Clin ica l Pe a r l
Stimulating the trigger point with an electrical stimulating current will trigger the release
of a chemical (β-endorphin) in the brain that will act to modulate pain.
Reducing the perception o pain is as much an art as a science. Selection o the ap-
propriate pain control intervention, proper application, and marketing are all important
and will continue to be so even as we increase our understanding o the neurophysiology o
pain. T ere is still the need or a good empirical rationale or the use o a specif c pain man-
agement approach. T e clinician is encouraged to keep abreast o the neurophysiology o
pain and the physiology o tissue healing to maintain a current scientif c basis or managing
the pain experienced by his or her patients.
Clin ica l Pe a r l
A modality should provide a signi cant amount of cutaneous input that would be
transmitted to the spinal cord along Aβ bers. The modalities of choice may include vari-
ous types of heat or cold, electrical stimulating currents, counterirritants (analgesic balms),
or massage.
Pain Management 133
SUMMARY
1. Pain is a response to a noxious stimulus that is subjectively modif ed by past experi-
ences and expectations.
2. Pain is classif ed as either acute or chronic and can exhibit many di erent patterns.
3. Early reduction o pain in a treatment program will acilitate therapeutic exercise.
4. Stimulation o sensory receptors can modi y the patient’s perception o pain.
5. T ere are 3 mechanisms o pain control:
a. dorsal horn modulation due to the input rom large-diameter a erents through a
gate control system, the release o enkephalins, or both ;
b. descending e erent f ber activation due to the e ects o small-f ber a erent input
on higher centers, including the thalamus, raphe nucleus, and PAG region;
c. the release o endogenous opioids including β-endorphin through prolonged
small-diameter a erent stimulation.
6. Pain perception may be in uenced by a variety o cognitive processes mediated by the
higher brain centers.
7. T e selection o a therapeutic modality or controlling pain should be based on current
knowledge o neurophysiology and the psychology o pain.
8. T e application o specif c techniques or the control o pain should not occur until the
diagnosis o the injury has been established.
9. T e selection o a therapeutic intervention or managing pain should be based on
establishing the primary cause o pain.
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Impaired Posture
and Function
Ph il Pa g e
OBJJECTIVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Describe the interaction of posture and proprioception.
Articulate the role of posture in functional movement.
Relate alterations in posture to musculoskeletal pathology.
Identify key components of a postural assessment.
135
136 Chapte r 5 Impaired Posture and Function
Introduction and Background

Postural assessment is a mainstay in any evaluation o a patient or client with musculoskel-
etal pain. T e late physical therapist Florence Kendall was a pioneer and clinical guru in
postural assessment. Her classic textbook, Muscle esting and Function, serves as the re -
erence or many students and practicing therapists who assess posture. By her def nition,
posture is the composite alignment o all the joints in the body at any given movement in
time.25 Furthermore, Kendall25 def ned ideal posture as skeletal alignment with minimal
stress and strain, conducive to maximal e ciency.
aking a structural and biomechanical approach, Kendall ocused on using a plumb
line to identi y asymmetries in posture through observations o skeletal alignment. She sug-
gested that a plumb line enabled a therapist to see the postural deviations that occur with
respect to the orces o gravity. T is static view o the musculoskeletal system is very help ul
in observing the relationship between anterior–posterior and medial–lateral orce imbal-
ances. For example, a orward head posture indicated by position o the head in ront o
the rontal plane bisecting the body would create extra work or the posterior spine and
muscles to support the head.
Although Kendall’s structural approach to postural assessment provides a biomechani-
cal assessment o the musculoskeletal system, the late Vladimir Janda, MD, saw postural
assessment as a unctional impression o the status o the sensorimotor system. According
to Janda, the sensorimotor system is 1 unctional unit comprised o the a erent sensory sys-
tem and the e erent motor system ; 2 systems that cannot be considered to unction inde-
pendent o each other.34 He noted that changes in muscle tension are the f rst response o
the system to nociception. By combining static biomechanical assessment popularized by
Kendall with his observation o muscle unction, Janda was able to orm an early observa-
tional description o the possible cause o the patient’s musculoskeletal pain rom a neuro-
logical perspective.34
Clin ica l Pe a r l
Postural assessment is often a rst impression of the status of the sensorimotor system,
and should subsequently lead the diagnostic pathway with regard to musculoskeletal
dysfunction.
T e Role of Proprioception in Posture

Proprioception is vital to maintaining postural alignment, both statically and dynamically.
T e a erent in ormation rom joint mechanoreceptors and muscular receptors provides
valuable in ormation needed to maintain postural re exes and to acilitate normal posture
and movement patterns. Dr. Janda proposed 3 key areas o proprioception in the body that
provide strong in uences on posture: the sole o the oot, sacroiliac joint, and cervical spine.
T e position o the oot in uences posture,14 while cutaneous and muscle spindle a er-
ents in uence upright posture and gait.9,24,45 T e sacroiliac joint 18,51 and cervical spine 1,31
joint capsules are rich in proprioceptors that serve to constantly provide in ormation on
joint alignment, which contributes to the maintenance o upright posture. Janda noted the
importance o normalizing proprioception rom these 3 key areas early in the rehabilitation
process because o their role in posture and unction.
The Role of Posture in Function 137
“Postural stability,” sometimes re erred to as “balance,” can be def ned as the ability to
maintain one’s center o gravity within their base o support. Standing balance results rom
equilibrium o orces throughout the musculoskeletal system that results in an upright pos-
ture in relation to gravity. Postural stability can be urther classif ed into static or dynamic
postural stability. Static postures are observed with the body at rest, whereas dynamic pos-
tures are observed during movement.
From a structural perspective, aulty postures resulting rom segments aligned outside
the body’s center o gravity may result in postural instability. For example, subjects with
increased thoracic kyphosis demonstrate poor postural control44; however, inducing a or-
ward head posture in otherwise young healthy subjects does not reduce postural stability.41
Postural stability can be considered a “window” into the unction o the sensorimotor
system. Proper proprioceptive input is critical to maintain postural stability via the somato-
sensory system.43 Janda noted that the central nervous system is the primary mediator o
chronic musculoskeletal pain.19 For example, patients with chronic low back pain 39 or neck
pain 38 demonstrate poor postural stability; there ore, posture and balance assessments can
provide valuable clues to therapists treating patients with chronic musculoskeletal pain.
T e Role of Posture in Function

Posture evolves in a predictable manner during the development o a baby, progressing
rom re exive mechanisms to integrated mature postural strategies. Postural re exes such
as the asymmetrical tonic neck re ex, symmetrical tonic neck re ex, and the crossed exten-
sor re exes help provide re exive movement patterns and alignment during early muscu-
loskeletal development. Posture is highly in uenced by neuro exive mechanisms early in
development; however, these mechanisms reduce their in uence over time as they become
more integrated during maturation. Other postural re exes, such as righting reactions and
automatic postural reactions, are eventually used to maintain upright posture or unction,
even in adults.
Normal, progressive, human development is essential or proper posture. As it matures,
the musculoskeletal system requires appropriate stress and strain or normal development.
Maturation o the central nervous system goes hand-in-hand with the development o the
musculoskeletal system.13 Without balanced and adequate orces experienced as a child,
postural deviations and aults may present in the adult the musculoskeletal system. T is is
commonly seen in the posture o a person with a disability where central nervous system
maturation has been impaired.
Posture di ers between individuals and can change over time. Genetics obviously plays
a role in human structure, providing natural variability o “normal” posture. T is variability
is observable within a population. Posture changes over time as a result o activity or aging.
Kuo et al26 ound greater orward head posture (FHP) and increased thoracic kyphosis in
healthy older adults, as compared to younger adults.
Athletes, particularly throwers, demonstrate di erent scapular and shoulder complex
postures than nonathletic individuals. For example, overhead athletes exhibit increased
scapular internal rotation and anterior tilt in their dominant shoulder as compared to the
nondominant shoulder.33,48 In addition, collegiate baseball players demonstrate di erent
scapular position than high school players.49 T ese postural adaptations appear to be a nor-
mal progression over sustained participation by these athletes.40,48
From a unctional perspective, proper posture supports normal joint range o motion,
helps place the limbs in appropriate positions or unctional activity, and protects the mus-
culoskeletal system rom excessive orce. For example, a “neutral” position o the lumbar
spine and pelvis can help minimize stress on lumbar discs and acets while li ting a heavy
object. Similarly, neutral alignment o the scapula is recommended because scapular ori-
entation can in uence glenohumeral congruency and may a ect shoulder complex muscle
activation.35,47
Postural alignment also helps explain the concept o “regional interdependence.” Move-
ment o one segment o the body may be a ected by the positioning o another regional
segment either proximally or distally. Some researchers report altered scapular muscle acti-
vation with upper extremity tasks in subjects with FHP,37,47,53 while others32 report normal
shoulder kinematics in healthy subjects despite scapular position asymmetries.
Poor posture can impede range o motion in adjacent joints. For example, FHP is asso-
ciated with reduced cervical range o motion.8,11 Quek et al36 reported that both increased
thoracic kyphosis and FHP contribute to decreased cervical range o motion in older
adults. Severe kyphotic postures reduce the subacromial space in the shoulder 17; however,
Bullock et al5 ound that an erect sitting posture increased shoulder exion range o motion
by an average o 9 degrees in patients with shoulder impingement. T us, the role o posture
in contribution to, as well as prevention and management o musculoskeletal injuries is an
important consideration or clinicians.
T e Role of Posture in Pathology

T e human body was designed or hom eostasis and structural/ m echanical balance. All
critical system s in the body can unction automatically without conscious control. Previ-
ously m entioned re exes, such as the crossed-extensor re ex, acilitate automatic and
characteristic responses o the muscular system or protection in response to a pain-
ul stim ulus. In act, it is possible that som e re exes are com ponents o longstanding
chronic musculoskeletal pain syndrom es. Autonom ic responses such as “f ght or ight”
also have subconscious in uence on the muscular system. Interestingly, the m uscular
system receives in orm ation rom both the central nervous system and the peripheral
nervous system, and there ore is in uenced both by automatic and voluntary control.
Based on these phenom ena, Janda noted that muscles have characteristic and predict-
able responses to pain and pathology which can lead to characteristic postural changes
which he described as the “upper crossed”21 and “lower crossed”20 m uscle im balance
syndrom es.
Prolonged muscle imbalance and poor posture can lead to structural changes in mus-
cle. Borstad 3 ound a link between pectoralis minor tightness and altered thoracic and scap-
ular postures. Adaptive shortening occurs when muscle that is relatively shorted or a long
period o time as a result o poor posture becomes structurally shorter; conversely, adaptive
lengthening occurs when a muscle is elongated over a prolonged period o time.25 Janda
noted that both o these posture-related changes in muscle are closely associated with mus-
cle imbalance and result in shi ts o the muscle length–tension curve, thus reducing overall
muscle strength throughout the ull excursion o the muscle, and presenting clinically as
“weak” muscles.22
Di erences in muscular tension on opposite sides o joints can cause muscle imbal-
ance. Muscle imbalances are o ten propagated by poor posture, creating a vicious cycle.
T is ultimately can lead to joint dys unction caused by unbalanced joint stress and patho-
logic movement (Figure 5-1).
Muscular imbalance may lead to changes in joint orientation that are sometimes
re ected in posture. Although muscle imbalance is o ten seen in arthritic joints, there is lit-
tle evidence to suggest that muscle imbalance is causative o arthritis, because no prospec-
tive studies have been completed. Muscle imbalances are usually associated with postural
deviations19,25; however, ew, i any, prospective cohort studies have established a cause-
and-e ect relationship between posture and muscle imbalance.
The Role of Posture in Pathology 139
P oor pos ture
Mus cle
P a in
imba la nce
Abnorma l
J oint
move me nt
dys function
pa tte rn
Figure 5-1 Vicio us cycle o f muscle imbalance
T e ability to relate posture to pathology is limited by the ability to quanti y postural

deviations. Most literature evaluates sagittal plane posture, particularly in the cervico-
thoracic region by determining the presence o FHP. T ere appears to be a relationship
between cervical pain syndromes and postural def cits. FHP is related to neck pain.16,23,42,46,55
Lau et al27 reported that greater thoracic kyphosis was associated with cervical dys unction
and disability.
In addition to neck pain, several researchers have demonstrated a relationship between
FHP and headaches o various types.11,12,16,52 emporal-mandibular joint dys unction,28
cranio acial pain,4 and even carpal tunnel syndrome 8 are associated with FHP. Despite
many studies demonstrating the relationship o poor posture and cervical dys unction,
some researchers have ound no such relationship.10,50,56
Low back pain is also related to postural def cits, typically involvin g in creased
lum bar lordosis or pelvic tilt.2,6,7,54 Interestingly, Christie et al7 noted FHP and increased
thoracic kyphosis in patients with acute low back pain com pared to those with chronic
low back pain.
Although there appears to be a relationship between poor posture and spinal dys unc-
tion, shoulder posture and shoulder pain are not as clearly related in the literature. Altered
scapular posture, including downward rotation, protraction, and anterior tilt, can decrease
the subacromial space.29 While improving posture in shoulder impingement patients
increased active shoulder range o motion,5,30 postural def cits may not be observed clini-
cally in all patients with shoulder dys unction.15
In summarizing the literature, it is important to recognize that postural def cits may be
related to pathology, as well as be in uenced by both aging and activity. Postural assess-
ment should provide the clinician with a “window” to the status o the musculoskeletal
system rom both a structural and unctional perspective; however, it should never be diag-
nostic when used alone.
Assessment of Posture
T e standard method o observing posture is in quiet standing. However, posture should
not be considered only in standing, but also in prone, supine, side-lying, sitting, and quad-
ruped positions. In particular, clinicians should consider the posture most commonly
utilized by patients, such as the sitting posture used by an o ce/ desk worker. Di erent pos-
tural positions can be associated with di erent patterns o muscle inhibition or acilitation.
For example, a acilitated upper trapezius muscle in a patient with chronic neck pain may
become less activated in a supine position.
Clin ica l Pe a r l
Consider assessing posture in positions other than standing in order to incorporate

developmental postures that may offer a window into proprioception or motor control.
When assessing static standing posture, it is best to have the patient stand quietly in
a well-lit room with as little clothing on as possible. Postural assessment should include
both a structural (“alignment”) viewpoint and a unctional (“muscle tension”) viewpoint.
Structurally, observe the alignment o structures in relation to gravity; as previously men-
tioned, Kendall et al25 advocate or the use o a plumb line or assessing static symmetry in
standing posture with relation to a known, static re erence system. Functionally, visual skills
are the key to postural assessment, as the clinician observes symmetry, contour, and tone
o muscles. Dr. Janda suggested that muscles with higher tone (tight muscles) present with
a relatively convex appearance, whereas muscles with lower tone (weak muscles) present
with a relative concave appearance.34 Bilateral comparison is a valuable tool in assessing
postural muscle unction. Subtle visual clues can provide the clinician with valuable in or-
mation on the presence o possible muscle imbalance syndromes.
Standing posture should be observed rom the posterior, anterior, and lateral views;
urthermore, the postural assessment should begin rom the pelvis with each view and
progress to the lower quarter, then the upper quarter, using a standard and reproducible
system. I necessary, therapists should consider including a plumb-line structural assess-
ment as described by Kendall. able 5-1 lists 10 key points or each o the 3 views recom-
mended to ocus on muscle imbalances.
Post erior View

Static postural assessment in standing begins by observing the dorsal aspect. Begin by
ocusing on the position o the pelvis as most dys unction is f rst evident at the pelvis.
Elevation o the pelvis on one side indicates possible leg-length discrepancy or a tight
quadratus lumborum on that side. Note the level o the posterior superior iliac spine or
sacroiliac position. A lateral shi t o the pelvis may indicate gluteal weakness with a ren-
delenburg compensation, or the patient may be compensating or a lumbar disc pathology.
Next, examine the gluteus maximus or atrophy, comparing both sides. Generally, smaller
muscle size or atrophy specif cally o the upper lateral quadrant o the gluteus maximus
Assessment of Posture 141
able 5-1 Thirty-Po int Po stural Asse ssme nt: 10 Po ints in 3 Vie w s
Po ste rio r Ante rio r Late ral
1. Pelvis and core Pelvis Pelvis Lumbar spine

Gluteals Abdominals
Low Back Ribs
2. Lower quarter Adductors Quads (vastus Iliotibial band

Hamstrings medialis obliquus) Knee (hyperextension)
Gastroc-soleus Tibialis anterior Midfoot
Rearfoot Foot
3. Upper quarter Shoulder/deltoid Face/head Head

Scapula Neck Cervical lordosis
Head Pectorals Shoulder
Arms and hands Thoracic/scapula
Arms and hands
suggests gluteal atrophy and weakness (Figure 5-2). Above the gluteus maximus, examine
the lumbar area or asymmetrical atrophy o the region o the multif dus or hypertrophy o
the thoracolumbar extensor muscles. Gluteus maximus inhibition is o ten associated with
ipsilateral thoracolumbar hypertrophy as a compensatory mechanism to stabilize the spine
and extend the hip during gait.
Next, examine the lower quarter rom the posterior view. T e inner thigh should be a
shallow S-shaped curve. I the upper part o the curve near the groin is more “bulky” creat-
ing a deeper S-shaped curve, the one-joint pectineus muscle may be tight (Figure 5-3).
Figure 5-2 Uppe r late ral g lute us maximus atro phy sug g e sts g lute al
atro phy and w e akne ss
Conversely, i there is no S-shaped curve, the

2-joint gracilis muscle may be tight. Next, observe
the lower two-thirds o the hamstring above the
knee crease; hypertrophy in this region indicates
tight ham strings and is usually associated with
weakness o the gluteus maximus on the same side.
Moving distally, observe the gastroc-soleus region.
I the soleus is tight, it will reduce the demarcation
o the gastroc-soleus anastomosis, creating more o
a straight line or even a bulge on the medial aspect
(Figure 5-4). Finally, observe the rear oot or valgus
or varus position, and or navicular drop in the case
o over pronation, particularly noting any side-to-
side di erences.
Move to the upper quarter rom a posterior
view. Note asymmetrical elevation o the shoul-
der, indicating tightness o the upper trapezius
and weakness o the lower trapezius. Patients with
severe bilateral tightness o the upper trapezius
may appear to have “gothic” shoulders, re ect-
ing the style o windows on gothic churches. A
small “notch” above the insertion o the leva-
Figure 5-3 One -jo int adducto r tig htne ss is indicate d tor scapula into the superior angle o the scapula
by a bulky rig ht pe ctine us and de e pe r S-shape d curve indicates tightness. Next, observe the scapulae or
their position in 3 dimensions, noting asymmetries
Figure 5-4 Fro m the po ste rio r, rig ht so le us tig htne ss is indicate d by a
straig ht line me dial to g astro cne mius muscle be lly and Achille s re g io n
Assessment of Posture 143
in protraction/ retraction (internal/ external rotation), upward/ downward rotation, and
anterior/ posterior tilt. Note any alterations in scapular position or attening o the mid-
scapular area. Scapular position can provide clues about scapular muscle tightness and
weakness. Finally, observe any rotation o the head to one side or the other; the trapezius
on the side opposite the direction o cervical rotation may be tight.
Ant erior View

As with the posterior view, begin the anterior view by observing the pelvis. Look or asym-
metry o the anterior superior iliac spines that might indicate a pelvic rotation, upshi t, or
leg-length discrepancy. Next, examine the abdominal wall or a “lateral line” just to the side
o the umbilicus, indicating hypertonicity o the oblique muscles (Figure 5-5).
Janda described a “pseudohernia” where the lateral abdominal wall slightly pro-
trudes above the waist, indicating a possibly inhibited transverse abdominis muscle (see
Figure 5-5). Observe the position o the in erior-lateral rib cage or symmetry and position.
An inspiratory position o the ribs indicated by protrusion o the ribs signals possible dia-
phragm dys unction (Figure 5-6).
Next, observe the vastus medialis muscle above the knee; bulkiness indicates repetitive
knee hyperextension. Moving distally, examine the anterior tibialis or atrophy indicated
by a groove rather than bulk over the anterior shin. Look or excessive activity o the tibialis
anterior or extensor digitorum muscles in ront o the ankle and oot, which may indicate a
balance dys unction. Finally, observe the general posture o the eet including pes planus or
pes cavus, noting asymmetry.
At the head, examine the ace or asymmetries. Janda noted that the middle o the ore-
head, bridge o the nose, mid-mouth, and mid-jaw should be in a straight line; deviations
Figure 5-5 Ante rio r vie w o f abdo me n re ve als a late ral line (le ft o blique
tig htne ss) and pse udo he rnia (rig ht transve rsus abdo minis w e akne ss)
Figure 5-6 Protracted inferior ribs in an inspi- Figure 5-7 Hig he r nipple le ve l indicate s le ft
ratory position suggest diaphragm dysfunction pe cto ral tig htne ss
indicate general body asymmetry and subsequent compensations. Note any rotation or
abnormal positioning o the head, which may indicate cervical muscle tightness. Observe
the anterior neck muscles, particularly noting the sternocleidomastoid (SCM) during respi-
ration. I the clavicular attachment o the SCM is visible, it indicates hypertrophy. A groove
medial to the SCM indicates weakness o the deep neck exors. Next, observe the pectoral
region; an increased bulk o one pectoralis muscle under-
neath the clavicle or near the axillary groove indicates hyper-
trophy. In males, the level o the nipple line may indicate
pectoral tightness i one is higher than the other (Figure 5-7).
Finally, note the position o the hands and arms. Internally
rotated arms (palms acing backward) indicate tightness o
the pectorals and/ or latissimus dorsi (Figure 5-8).
Lat eral View

Begin the lateral view at the pelvis, noting anterior or poste-
rior pelvic tilt, and pelvic inclination between the anterior
superior iliac spines and posterior superior iliac spine. Note
the amount o lumbar lordosis (hypo- or hyperlordosis) and
the presence o a “swayback” posture. An increased lordosis
may be caused by tight hip exors, and a reduced lordosis
may be related to tight hamstrings. Also note the position o
the arms and hands. I the arms are positioned anterior to the
middle o the body, the pectorals may be tight.
Next, examine the iliotibial tract or atness or a groove,
indicating tightness o the iliotibial band. Janda noted
Figure 5-8 Hand ro tatio n and slig ht abduc- that women tend to present with atness o the iliotibial
tio n sug g e sts right pe cto ral tig htne ss band, whereas males present with a groove. ake note any
Conclusion 145
hyperextension o the knee, which may indicate general hypermobility. Observe the oot
again or the height o the arch and navicular bone, noting asymmetry.
Finally, observe the position o the head in relation to the body, noting a FHP, which
is typically associated with tightness o the SCM and suboccipital extensor muscles. Note
the amount o cervical lordosis both in the upper and lower segments; an increased upper
cervical lordosis is generally associated with a FHP. Observe the position o the shoulder,
more specif cally, the relationship o the head o the humerus to the acromion. Normally,
one-third o the width o the humerus should be anterior to the acromion; a more anterior
humerus indicates tightness o the pectoralis major. Finally, note the amount o thoracic
kyphosis, as well as the presence o any scapular malposition.
Conclusion
Good posture is essential or e cient movement and or protecting the musculoskeletal
system rom excessive stress and strain both at rest and during movement. Although there
appears to be a link between posture and cervical dys unction, the relationship between
posture and other musculoskeletal pain remains less clear in the literature. Postural assess-
ment gives clinicians the f rst clues to the structure and unction in musculoskeletal pain.
By combining a traditional “plumb-line” assessment o structure with a perspective o mus-
cle balance through patterns o muscle tightness and weakness, clinicians can get a better
picture o the status o the sensorimotor system and its in uence on musculoskeletal pain
syndromes.
SUMMARY
1. Proprioception plays an important role in posture and postural stability.
2. Standing posture gives an impression o the status o the sensorimotor system, but may
not be diagnostic when used alone.
3. Consider assessing posture in several postures, including sitting and quadruped.
4. Muscle imbalance syndromes are o ten associated with postural def cits, but cause and
e ect between imbalance and posture has not been established.
5. Postural analysis including key points rom di erent views can provide clues to muscle
imbalances.
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2011 Nov 16. [Epub ahead o print] 51. Vilensky JA, O’Connor BL, Fortin JD, et al. Histologic
41. Silva AG, Johnson MI. Does orward head posture a ect analysis o neural elements in the human sacroiliac joint.
postural control in human healthy volunteers? Gait Spine (Phila Pa 1976). 2002;27(11):1202-1207.
Posture. 2012 Dec 6. [Epub ahead o print] 52. Watson DH, rott PH. Cervical headache: an investigation
42. Silva AG, Punt D, Sharples P, Vilas-Boas JP, Johnson MI. o natural head posture and upper cervical exor muscle
Head posture and neck pain o chronic nontraumatic per ormance. Cephalalgia. 1993;13(4):272-284; discussion
origin: a comparison between patients and pain- ree 232.
persons. Arch Phys Med Rehabil. 2009;90(4):669-674. 53. Weon JH, Oh JS, Cynn HS, Kim YW, Kwon OY, Yi CH.
43. Simoneau GG, Ulbrecht JS, Derr JA, Cavanagh PR. Role In uence o orward head posture on scapular upward
o somatosensory input in the control o human posture. rotators during isometric shoulder exion. J Bodyw Mov
Gait Posture. 1995;3:115-122. T er. 2010;14(4):367-374.
44. Sinaki M, Brey RH, Hughes CA, Larson DR, Kau man KR. 54. Yahia A, Jribi S, Ghroubi S, Elleuch M, Baklouti S, Habib
Balance disorder and increased risk o alls in osteoporosis Elleuch M. Evaluation o the posture and muscular
and kyphosis: signif cance o kyphotic posture and muscle strength o the trunk and in erior members o patients with
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45. Sorensen KL, Hollands MA, Patla E. T e e ects o human 55. Yip CH, Chiu , Poon A . T e relationship between head
ankle muscle vibration on posture and balance during posture and severity and disability o patients with neck
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Impaired Muscle
Performance
Re g aining Muscular Stre ng th,
Endurance and Po w e r
OBJJECTIVE
De ne muscular strength, endurance, and power, and discuss their importance in a program
of rehabilitation following injury.
Discuss the anatomy and physiology of skeletal muscle.
Discuss the physiology of strength development and factors that determine strength.
Describe speci c methods for improving muscular strength.
Differentiate between muscle strength and muscle endurance.
Discuss differences between males and females in terms of strength development.
PAR 2 Treating Physiologic Impairments During Rehabilitation

150 Chapte r 6 Impaired Muscle Performance
Following all musculoskeletal injuries, there will be some degree o impairment in muscular
strength and endurance. For the therapist supervising a rehabilitation program, regaining,
and in many instances improving, levels o strength and endurance are critical or discharg-
ing and returning the patient to a unctional level ollowing injury.
By def nition, m uscular strength is the ability o a muscle to generate orce against some
resistance. Maintenance o at least a normal level o strength in a given muscle or muscle
group is important or normal healthy living. Muscle weakness or imbalance can result
in abnormal movement or gait and can impair normal unctional movement. Resistance
training plays a critical role in injury rehabilitation.
Muscular strength is closely associated with muscular endurance. Muscular endurance
is the ability to per orm repetitive muscular contractions against some resistance or an
extended period o time. As we will see later, as muscular strength increases, there tends to
be a corresponding increase in endurance. For the average person in the population, devel-
oping muscular endurance is likely more important than developing muscular strength
because muscular endurance is probably more critical in carrying out the everyday activi-
ties o living. T is statement becomes increasingly true with age.
ypes of Skeletal Muscle Contraction

Skeletal muscle is capable o 3 di erent types o contraction: isom etric contraction, con-
centric contraction, and eccentric contraction. An isometric contraction occurs when the
muscle contracts to produce tension, but there is no change in muscle length. Consider-
able orce can be generated against some immovable resistance even though no movement
occurs. In a concentric contraction, the muscle shortens in length while tension increases
to overcome or move some resistance. In an eccentric contraction, the resistance is greater
than the muscular orce being produced, and the muscle lengthens while producing ten-
sion. Concentric and eccentric contractions are considered dynamic movements.56
Recently, econcentric contraction, which combines both a controlled concentric and a
concurrent eccentric contraction o the same muscle over 2 separate joints, has been intro-
duced.19,30 An econcentric contraction is possible only in muscles that cross at least 2 joints.
An example o an econcentric contraction is a prone, open-kinetic-chain hamstring curl.
T e hamstrings contract concentrically to ex the knee, while the hip tends to ex eccentri-
cally, lengthening the hamstring. Rehabilitation exercises have traditionally concentrated
on strengthening isolated single-joint motions, despite the act that the same muscle is
unctioning at a second joint simultaneously. Consequently, it has been recommended that
the strengthening program includes exercises that strengthen the muscle in the manner in
which it contracts unctionally. raditional strength-training programs have been designed
to develop strength in individual muscles, in a single plane o motion. However, because all
muscles unction concentrically, eccentrically, and isometrically in 3 planes o motion, a
strengthening program should be multiplanar, concentrating on all 3 types o contraction.15
Factors T at Determine Levels of Muscular

Strength, Endurance, and Power
Size of t he Muscle
Muscular strength is proportional to the cross-sectional diameter o the muscle f bers. T e
greater the cross-sectional diameter or the bigger a particular muscle, the stronger it is, and
thus the more orce it is capable o generating. T e size o a muscle tends to increase in
Factors That Determine Levels of Muscular Strength, Endurance, and Power 151
cross-sectional diameter with resistance training. T is increase in muscle size is re erred to
as hypertrophy.42 A decrease in the size o a muscle is re erred to as atrophy.
Number of Muscle Fibers

Strength is a unction o the number and diameter o muscle f bers composing a given mus-
cle. T e number o f bers is an inherited characteristic; thus, a person with a large number
o muscle f bers to begin with has the potential to hypertrophy to a much greater degree
than does someone with relatively ew f bers.38
Neuromuscular Ef ciency
Strength is also directly related to the e ciency o the neuromuscular system and the
unction o the motor unit in producing muscular orce.46 Initial increases in strength dur-
ing the f rst 8 to 10 weeks o a resistance training program can be attributed primarily to
increased neuromuscular e ciency.59 Resistance training will increase neuromuscular
e ciency in 3 ways: there is an increase in the number o motor units being recruited, in
the f ring rate o each motor unit, and in the synchronization o motor unit f ring.7
Biomechanical Considerat ions

Strength in a given muscle is determined not only by the physical properties o the muscle
but also by biomechanical actors that dictate how much orce can be generated through a
system o levers to an external object.31,38,63
Posit ion of Tendon At t achment

I we think o the elbow joint as one o these lever systems, we would have the biceps mus-
cle producing exion o this joint (Figure 6-1). T e position o attachment o the biceps
muscle on the orearm will largely determine how much orce this muscle is capable o
Bice ps Bice ps
24 cm 22 cm
Effort a rm Effort a rm
A B
Figure 6-1
The position of attachment of the muscle tendon on the lever arm can affect the ability
of that muscle to generate force. B should be able to generate greater force than A because
the tendon attachment on the lever arm is closer to the resistance. (Reproduced with permission
from Prentice. Principles of Athletic Training. 14th ed. New York: McGraw-Hill; 2011.)
generating. I there are 2 individuals, A and B, and A has a biceps attachment that is closer
to the ulcrum (the elbow joint) than does B, then A must produce a greater e ort with the
biceps muscle to hold the weight at a right angle, because the length o the e ort arm will
be greater than that or B.
Lengt h–Tension Relat ionship

T e length o a muscle determines the tension that can be generated. By varying the length
o a muscle, di erent tensions can be produced.31 Figure 6-2 illustrates this length–tension
relationship. At position B in the curve, the interaction o the crossbridges between the
actin and myosin myof laments within the sarcomere is at maximum. Setting a muscle at
this particular length will produce the greatest amount o tension. At position A, the muscle
is shortened, and at position C, the muscle is lengthened. In either case, the interaction
between the actin and myosin myof laments through the crossbridges is greatly reduced,
thus the muscle is not capable o generating signif cant tension.
Clin ica l Pe a r l
The patient who is able to move more weight has a mechanical advantage. For example, if
the tendinous insertion of the hamstrings is more distal, a longer lever arm is created and
thus less force is required to move the same resistance.
Age
T e ability to generate muscular orce is also related to age.4 Both men and women seem to
be able to increase strength throughout puberty and adolescence, reaching a peak around
20 to 25 years o age, at which time, this ability begins to level o , and in some cases decline.
A ter about age 25, a person generally loses an average o 1% o his or her
maximal remaining strength each year. T us, at age 65 years, a person
would have only approximately 60% o the strength he or she had at age
B 25 years.45 T is loss in muscle strength is def nitely related to individual
levels o physical activity. People who are more active, or perhaps continue
to strength-train, considerably decrease this tendency toward declin-
ing muscle strength. In addition to retarding this decrease in muscular
n
strength, exercise can also have an e ect in slowing the decrease in cardio-
o
i
s
n
respiratory endurance and exibility, as well as slowing increases in body
e
T
A C at. T us, strength maintenance is important or all individuals regardless
o age or achieving total wellness and good health as well as in rehabilita-
tion a ter injury.62
Mus cle le ngth Overt raining

Overtraining in a physically active patient can have a negative e ect on
Figure 6-2 The le ng th–te nsio n the developm ent o muscular strength. Overtraining is an im balance
re latio n o f the muscle between exercise and recovery in which the training program exceeds
the body’s physiologic and psychological lim its. Overtraining can result
Greatest tension is developed at point in psychological breakdown (staleness) or physiologic breakdown that
B, with less tension developed at points can involve m usculoskeletal injury, atigue, or sickness. Engaging in
A and C. (Reproduced with permission from proper and e cient resistance training, eating a proper diet, and get-
Prentice. Principles of Athletic Training. 14th ed. ting appropriate rest can all m inim ize the potential negative e ects o
New York: McGraw-Hill; 2011.) overtraining.
The Physiology of Strength Development 153
Fast -Twit ch Versus Slow-Twit ch Fibers

All f bers in a particular motor unit are either slow-twitch f bers or ast-twitch f bers. Each
kind has distinctive metabolic and contractile capabilities.
Slow-Twit ch Fibers
Slow-twitch f bers are also re erred to as type I or slow-oxidative f bers. T ey are more resis-
tant to atigue than ast-twitch f bers; however, the time required to generate orce is much
greater in slow-twitch f bers.29 Because they are relatively atigue resistant, slow-twitch
f bers are associated primarily with long-duration, aerobic-type activities.
Fast -Twit ch Fibers

Fast-twitch f bers are capable o producing quick, orce ul contractions but have a tendency
to atigue more rapidly than slow-twitch f bers. Fast-twitch f bers are use ul in short-term,
high-intensity activities, which mainly involve the anaerobic system. Fast-twitch f bers are
capable o producing power ul contractions, whereas slow-twitch f bers produce a long-
endurance orce. T ere are 2 subdivisions o ast-twitch f bers. Although both types o
ast-twitch f bers are capable o rapid contraction, type IIa f bers or ast-oxidative-glycolytic
f bers are moderately resistant to atigue, whereas type IIb f bers or ast-glycolytic f bers
atigue rapidly and are considered the “true” ast-twitch f bers. Recently, a third group o
ast-twitch f bers, type IIx, has been identif ed in animal models. ype IIx f bers are atigue
resistant and are thought to have a maximum power capacity less than that o type IIb but
greater than that o type IIa f bers.45
Rat io in Muscle
Within a particular muscle are both types o f bers, and the ratio o the 2 types in an individ-
ual muscle varies with each person.32 Muscles whose primary unction is to maintain pos-
ture against gravity require more endurance and have a higher percentage o slow-twitch
f bers. Muscles that produce power ul, rapid, explosive strength movements tend to have a
much higher percentage o ast-twitch f bers.
Because this ratio is genetically determined, it can play a large role in determining abil-
ity or a given sport activity. Sprinters and weightli ters, or example, have a large percent-
age o ast-twitch f bers in relation to slow-twitch f bers.16 Conversely, marathon runners
generally have a higher percentage o slow-twitch f bers. T e question o whether f ber
types can change as a result o training has to date not been conclusively resolved.10 How-
ever, both types o f bers can improve their metabolic capabilities through specif c strength
and endurance training.7
T e Physiology of Strength Development
Muscle Hypert rophy

T ere is no question that resistance training to improve muscular strength results in an
increased size, or hypertrophy, o a muscle. What causes a muscle to hypertrophy? A num-
ber o theories have been proposed to explain this increase in muscle size.22
First, some evidence exists that there is an increase in the num ber o m uscle f bers
(hyperplasia) as a result o f bers splitting in response to training.39 However, this research
has been conducted in animals and should not be generalized to humans. It is generally
accepted that the number o f bers is genetically determined and does not seem to increase
with training.
S a rcome re S a rcome re
Myofibril
Cros s bridge s Thick myos in Thin a ctin Cros s bridge s

fila me nts fila me nts
Figure 6-3
Muscles contract when an electrical impulse from the central nervous system causes the
myofilaments in a muscle fiber to move closer together.
Second, it has been hypothesized that because the muscle is working harder in resis-
tance training, more blood is required to supply that muscle with oxygen and other nutri-
ents. T us, it is thought that the num ber o capillaries is increased. T is hypothesis is only
partially correct; no new capillaries are ormed during resistance training; however, a num-
ber o dormant capillaries might become f lled with blood to meet this increased demand
or blood supply.45
A third theory to explain this increase in muscle size seems the most credible. Muscle
f bers are composed primarily o small protein f laments, called m yof lam ents, which are
contractile elements in muscle. Myof laments are small contractile elements o protein
within the sarcomere. T ere are 2 distinct types o myof laments: thin actin myof laments
and thicker m yosin myof laments. Fingerlike projections, or crossbridges, connect the
actin and myosin myof laments. When a muscle is stimulated to contract, the crossbridges
pull the myof laments closer together, thus shortening the muscle and producing move-
ment at the joint that the muscle crosses (Figure 6-3).5
Clin ica l Pe a r l
Individuals have a particular ratio of fast-twitch to slow-twitch muscle bers. Those who
have a higher ratio of slow-twitch to fast-twitch bers are better at endurance activities.
Because this ratio is genetically determined, it would be surprising if someone who is good
at endurance activity could also be good at sprint-type activities.
T ese m yof lam ents increase in size and num ber as a result o resistance training, caus-
ing the individual muscle f bers to increase in cross-sectional diameter.58 T is increase is
particularly present in men, although women will also see some increase in muscle size.
More research is needed to urther clari y and determine the specif c reasons or muscle
hypertrophy.
Reversibilit y
I resistance training is discontinued or interrupted, the muscle will atrophy, decreasing in
both strength and mass. Adaptations in skeletal muscle that occur in response to resistance
training can begin to reverse in as little as 48 hours. It does appear that consistent exercise
o a muscle is essential to prevent reversal o the hypertrophy that occurs rom strength
training.
Techniques of Resistance Training 155
Ot her Physiologic Adapt at ions t o Resist ance Exercise

In addition to muscle hypertrophy, there are a number o other physiologic adaptations to
resistance training.40 T e strength o noncontractile structures, including tendons and liga-
ments, is increased. T e mineral content o bone is increased, thus making the bone stron-
ger and more resistant to racture. Maximal oxygen uptake is improved when resistance
training is o su cient intensity to elicit heart rates at or above training levels. However, it
must be emphasized that these increases are minimal and that i increased maximal oxygen
uptake is the goal, aerobic exercise rather than resistance training is recommended. T ere
is also an increase in several enzymes important in aerobic and anaerobic metabolism.3,25,26
All o these adaptations contribute to strength and endurance.
echniques of Resistance raining

T ere are a number o di erent techniques o resistance training or strength improvement,
including unctional strength training, isometric exercise, progressive resistive exercise, iso-
kinetic training, circuit training, plyometric exercise, and calisthenic exercise. Regardless o the
specif c strength-training technique used, the therapist should integrate unctional strength-
ening activities that involve multiplanar, eccentric, concentric, and isometric contractions.
The Overload Principle

Regardless o which o these techniques is used, one basic principle o reconditioning is
extremely important. For a muscle to improve in strength, it must be orced to work at a
higher level than it is accustomed to. In other words, the muscle must be overloaded. With-
out overload, the muscle will be able to maintain strength as long as training is continued
against a resistance to which the muscle is accustomed, but no additional strength gains will
be realized. T is maintenance o existing levels o muscular strength may be more impor-
tant in resistance programs that emphasize muscular endurance rather than strength gains.
Many individuals can benef t more in terms o overall health by concentrating on improving
muscular endurance. However, to most e ectively build muscular strength, resistance train-
ing requires a consistent, increasing e ort against progressively increasing resistance.38,56
Resistive exercise is based primarily on the principles o overload and progression. I
these principles are applied, all o the ollowing resistance training techniques will produce
improvement o muscular strength over time.
In a rehabilitation setting, progressive overload is limited to some degree by the heal-
ing process. I the therapist takes an aggressive approach to rehabilitation, the rate o pro-
gression is perhaps best determined by the injured patient’s response to a specif c exercise.
Exacerbation o pain or increased swelling should alert the therapist that their rate o pro-
gression is too aggressive.
Funct ional St rengt h Training

For many years, the strength-training techniques in conditioning or rehabilitation pro-
grams have ocused on isolated, single-plane exercises used to elicit muscle hypertrophy
in a specif c muscle. T ese exercises have a very low neuromuscular demand because they
are per ormed primarily with the rest o the body artif cially stabilized on stable pieces o
equipment.15 T e central nervous system controls the ability to integrate the proprioceptive
unction o a number o individual muscles that must act collectively to produce a specif c
movement pattern that occurs in three planes o motion. I the body is designed to move
in 3 planes o motion, then isolated training does little to improve unctional ability. When
strength training using isolated, single-plane, artif cially stabilized exercises, the entire body
is not being prepared to deal with the imposed demands o normal daily activities (walking
up or down stairs, getting groceries out o the trunk, etc).26 Functional strength training pro-
vides a unique approach that may revolutionize the way the sports medicine community
thinks about strength training. o understand the approach to unctional strength training,
the athletic trainer must understand the concept o the kinetic chain and must realize that the
entire kinetic chain is an integrated unctional unit. T e kinetic chain is composed o not only
muscle, tendons, asciae, and ligaments but also the articular system and the neural system.
All o these systems unction simultaneously as an integrated unit to allow or structural
and unctional e ciency. I any system within the kinetic chain is not working e ciently,
the other systems are orced to adapt and compensate; this can lead to tissue overload,
decreased per ormance, and predictable patterns o injury. T e unctional integration o
the systems allows or optimal neuromuscular e ciency during unctional activities.15
During unctional movements, some muscles contract concentrically (shorten) to produce
movement, others contract eccentrically (lengthen) to allow movement to occur, and still
other muscles contract isometrically to create a stable base on which the unctional move-
ment occurs. T ese unctional movements occur in 3 planes. Functional strength training
uses integrated exercises designed to improve unctional movement patterns in terms o
not only increased strength and improved neuromuscular control but also high levels o
stabilization strength and dynamic exibility.15
Unlike traditional strength-training techniques, which use barbells, dumbbells, or exercise
machines and single-plane exercises day a ter day, a primary principle o unctional strength
training is to make use o training variations to orce constant neural adaptations instead o
concentrating solely on morphologic changes. Exercise variables that can be changed include
the plane o motion, body position, base o support, upper- or lower-extremity symmetry, the
type o balance modality, and the type o external resistance.15 able 6-1 lists these exercise
training variables. Figure 6-4 provides examples o unctional strengthening exercises.
able 6-1 Exe rcise Training Variable s
Plane o f Bo dy Base o f Uppe r-Extre mity Lo w e r-Extre mity Balance Exte rnal
Mo tio n Po sitio n Suppo rt Symme try Symme try Mo dality Re sistance
Sagittal Supine Exercise bench 2 arms 2 legs Floor Barbell
Frontal Prone Stability ball Alternate arms Staggered stance Sport beam Dumbbell
Transverse Sidelying Balance 1 arm 1 leg ½ foam Cable

modality roll machines
Combination Sitting Other 1 arm 2-leg unstable Airex pad Tubing

w/rotation
Kneeling Staggered Dyna disc Medicine

stance unstable balls
Half kneeling 1-leg unstable BOSU Power balls
Standing Proprio Bodyblade

shoes
Sand Other
A B C
D E F
Figure 6-4 Functio nal stre ng the ning e xe rcise s use simultane o us mo ve me nts (co nce ntric, e cce ntric, and
iso me tric co ntractio ns) in 3 plane s o n e ithe r stable o r unstable surface s
A. Stability ball diagonal rotations with weighted ball. B. Tandem stance on DynaDisc with trunk rotation. C. Standing
diagonal rotations with cable or tubing resistance. D. Weight-resisted multiplanar lunges. E. Front lunge balance to one-arm
press. F. Weighted-ball double arm rotation toss from squat.
Isomet ric Exercise

An isom etric exercise involves a muscle contraction in which the length o the muscle
remains constant while tension develops toward a maximal orce against an immovable
resistance (Figure 6-5).6 An isometric contraction provides stabilization strength that helps
maintain normal length–tension and orce–couple relationships that are critical or normal
joint arthrokinematics. Isometric exercises are capable o increasing muscular strength.54
However, strength gains are relatively specif c, with as much as a 20% over ow to the joint
angle at which training is per ormed. At other angles, the strength curve drops o dramati-
cally because o a lack o motor activity at that angle. T us, strength is increased at the spe-
cif c angle o exertion, but there is no corresponding increase in strength at other positions
in the range o motion.
Another major disadvantage o these isometric

exercises is that they tend to produce a spike in systolic
blood pressure that can result in potentially li e-threat-
ening cardiovascular accidents.29 T is sharp increase in
systolic blood pressure results rom a Valsalva maneu-
ver, which increases intrathoracic pressure. o avoid or
minimize this e ect, it is recommended that breathing
be done during the maximal contraction to prevent this
increase in pressure.
T e use o isom etric exercises in injury rehabilita-
tion or reconditioning is widely practiced. T ere are
a num ber o conditions or ailm ents resulting rom
trauma or overuse that must be treated with strength-
ening exercises. Un ortunately, these problem s can
be exacerbated with ull range-o -m otion resistance
exercises. It m ight be m ore desirable to m ake use
o positional or unctional isom etric exercises that
involve the application o isom etric orce at multiple
angles throughout the range o m otion. Functional
isom etrics should be used until the healing process
has progressed to the point that ull-range activities
can be per orm ed.
During rehabilitation, it is o ten recommended that
a muscle be contracted isometrically or 10 seconds at a
time at a requency o 10 or more contractions per hour.
Isometric exercises can also o er signif cant benef t in
Figure 6-5 Iso me tric e xe rcise s invo lve co ntrac- a strengthening program.64
tio n ag ainst so me immo vable re sistance T ere are certain instances in which an isom etric
contraction can greatly en hance a particular m ove-
m ent. For exam ple, on e o the exercises in power
weight li ting is a squat. A squat is an exercise in
which the weight is supported on the shoulders in a standing position. T e knees are
then exed, and the weight is lowered to a three-quarter squat position, rom which the
li ter must stand com pletely straight once again.
It is not uncommon or there to be one particular angle in the range o motion at which
smooth movement is di cult because o insu cient strength. T is joint angle is re erred to
as a sticking point. A power li ter will typically use an isometric contraction against some
immovable resistance to increase strength at this sticking point. I strength can be improved
at this joint angle, then a smooth, coordinated power li t can be per ormed through a ull
range o movement.
Clin ica l Pe a r l
Doing isometric exercise will help a patient gain strength for that speci c tension point.
Progressive Resist ive Exercise

A secon d techn ique o resistan ce train in g is perhaps the m ost com m on ly used and
m ost popular techn ique or im proving m uscular strength in a rehabilitation program.
Progressive resistive exercise uses exercises that strengthen muscles through a contraction
that overcom es som e f xed resistance such as with dum bbells, barbells, various exer-
cise machines, or resistive elastic tubing. Progressive resistive exercise uses isotonic, or
isodynam ic, contraction s in which orce is generated while the m uscle is changin g in
length.
Concent ric Versus Eccent ric Cont ract ions

Isotonic contractions can be concentric or eccentric. In per orming a bicep curl, to li t the
weight rom the starting position the biceps muscle must contract and shorten in length.
T is shortening contraction is re erred to as a concentric or positive contraction. I the
biceps muscle does not remain contracted when the weight is being lowered, gravity would
cause this weight to simply all back to the starting position. T us, to control the weight as
it is being lowered, the biceps muscle must continue to contract while at the same time
gradually lengthening. A contraction in which the muscle is lengthening while still applying
orce is called an eccentric or negative contraction.
It is possible to generate greater am ounts o orce against resistance with an eccentric
contraction than with a concentric contraction, because eccentric contractions require
a much lower level o m otor unit activity to achieve a certain orce than do concentric
contractions. Because ewer m otor units are f ring to produce a specif c orce, additional
motor units can be recruited to generate increased orce. In addition, oxygen use is much
lower during eccentric exercise than in com parable concentric exercise. T us, eccentric
contractions are less resistant to atigue than concentric contractions. T e m echani-
cal e ciency o eccentric exercise can be several tim es higher than that o concentric
exercise.56
raditionally, progressive resistive exercise has concentrated primarily on the con-
centric com ponent without paying much attention to the im portance o the eccentric
component.56 T e use o eccentric contractions, particularly in rehabilitation o various
sport-related injuries, has received considerable em phasis in recent years. Eccentric
contractions are critical or deceleration o lim b m otion, especially during high-velocity
dynam ic activities.35 For exam ple, a baseball pitcher relies on an eccentric contraction o
the external rotators o the glenohumeral joint to decelerate the humerus, which might be
internally rotating at speeds as high as 8000 degrees per second. Certainly, strength def -
cits or an inability o a muscle to tolerate these eccentric orces can predispose an injury.
T us, in a rehabilitation program, the therapist should incorporate eccentric strengthen-
ing exercises. Eccentric contractions are possible with all ree weights, with the majority
o isotonic exercise machines, and with m ost isokinetic devices. Eccentric contractions
are used with plyometric exercise discussed in Chapter 10 and can also be incorporated
with unctional proprioceptive neuromuscular acilitation strengthening patterns dis-
cussed in Chapter 12.
In progressive resistive exercise, it is essential to incorporate both concentric and
eccentric contractions.33 Research has clearly demonstrated that the muscle should be
overloaded and atigued both concentrically and eccentrically or the greatest strength
improvement to occur.4,22,45 When training specif cally or the development o muscular
strength, the concentric portion o the exercise should require 1 to 2 seconds, while the
eccentric portion o the li t should require 2 to 4 seconds. T e ratio o the concentric com-
ponent to the eccentric component should be approximately 1:2. Physiologically, the mus-
cle will atigue much more rapidly concentrically than eccentrically.
Free Weight s Versus Exercise Machines

Various types o exercise equipment can be used with progressive resistive exercise, includ-
ing ree weights (barbells and dumbbells) and exercise machines such as Cybex, Universal,
Paramount, ough Stu , Icarian Fitness, King Fitness, Body Solid, Pro-Elite, Li e Fitness,
A B
Figure 6-6 Iso to nic e quipme nt
A. Most exercise machines are isotonic. B. Resistance can be easily changed by changing the key in the stack of weights.
Nautilus, BodyCra t, Yukon, Flex, CamBar, GymPros,

Nugym, BodyWorks, DP, Solo ex, and Body Master
(Figure 6-6). Dumbbells and barbells require the use o
iron plates o varying weights that can be easily changed
by adding or subtracting equal amounts o weight to
both sides o the bar. T e exercise machines or the
most part have stacks o weights that are li ted through a
series o levers or pulleys. T e stack o weights slides up
and down on a pair o bars that restrict the movement
to only one plane. Weight can be increased or decreased
simply by changing the position o a weight key.
T ere are advantages and disadvantages to ree
weights and m achines. T e exercise m achines are
relatively sa e to use in com parison with ree weights.
For exam ple, a bench press with ree weights requires
a partner to help li t the weight back onto the sup-
port racks i the li ter does not have enough strength
to com plete the li t ; otherwise the weight m ight be
dropped on the chest. With the machines the weight
can be easily and sa ely dropped without ear o injury
(Figure 6-7).
Figure 6-7 Be nch pre ss e xe rcise machine w ith It is also a simple process to increase or decrease
a stack o f w e ig hts the weight by moving a single weight key with the
exercise machines, although changes can generally be
made only in increments o 10 or 15 pounds. With ree
weights, iron plates must be added or removed rom
each side o the barbell.
he biggest disadvantage in using exercise
machines is that with ew exceptions the design con-
straints o the machine allow only single-plane motion,
limiting or controlling more unctional movements that
occur in multiple planes simultaneously.
Anyone who has strength-trained using ree weights
and exercise machines realizes the di erence in the
amount o weight that can be li ted. Unlike the machines,
ree weights have no restricted motion and can thus
move in many di erent directions, depending on the
orces applied. With ree weights, an element o neuro-
muscular control on the part o the li ter to stabilize the
weight and prevent it rom moving in any other direction
than vertical will usually decrease the amount o weight
that can be li ted.66
Surgical Tubing or Thera-Band

Surgical tubing or T era-Band, as a means o provid-
ing resistance, has been widely used in rehabilitation
(Figure 6-8). T e advantage o exercising with surgical
tubing or T era-Band is that movement can occur in
multiple planes simultaneously. T us, exercise can be Figure 6-8 Stre ng the ning e xe rcise s using
done against resistance in more unctional movement surg ical tubing are w ide ly use d in re habilitatio n
planes. Chapters 10 and 12 discuss the use o surgical
tubing exercise in plyometrics and proprioceptive neuromuscular acilitation strengthen-
ing techniques. Surgical tubing can be used to provide resistance with the majority o the
strengthening exercises shown in Chapters 25-32.
Regardless o which type o equipment is used, the same principles o progressive resis-
tive exercise may be applied.
Clin ica l Pe a r l
Exercise machines typically are safer and more comfortable than free weights. It is easier to
change the resistance, and the weight increments are small for easy progressions. Many of
the machines utilize some type of cam for accommodating resistance. However, they are
expensive and can be used only for one speci c joint movement. Dumbbells or free weights
are more versatile as well as cheaper. They also implement an additional aspect of training,
as it requires neuromuscular control to balance the weight throughout the full range of
motion.
Variable Resist ance

One problem o ten mentioned in relation to progressive resistive exercise reconditioning
is that the amount o orce necessary to move a weight through a range o motion changes
according to the angle o pull o the contracting muscle. It is greatest when the angle o pull
is approximately 90 degrees. In addition, once the inertia o the weight has been overcome
and momentum has been established, the orce required to move the resistance varies
according to the orce the muscle can produce through the range o motion. T us, it has
been argued that a disadvantage o any type o isotonic exercise is that the orce required to
move the resistance is constantly changing throughout the range o movement. T is change
in resistance at di erent points in the range o motion has been labeled accom m odating
resistance or variable resistance.
A number o exercise machine manu acturers have attempted to alleviate this prob-
lem o changing orce capabilities by using a cam in the machine’s pulley system. T e
cam is individually designed or each piece o equipment so that the resistance is variable
throughout the movement. T e cam is intended to alter resistance so that the muscle can
handle a greater load, but at the points where the joint angle or muscle length is mechani-
cally disadvantageous, it reduces the resistance to muscle movement. Whether this design
does what it claims is debatable.
Progressive Resist ive Exercise Techniques

Perhaps the single most con using aspect o progressive resistive exercise is the terminol-
ogy used to describe specif c programs.32 T e ollowing list o terms with their operational
def nitions may help clari y the con usion:
Repetitions: T e number o times a specif c movement is repeated
Repetition m axim um (RM): T e maximum number o repetitions at a given weight
Set: A particular number o repetitions
Intensity: T e amount o weight or resistance li ted
Recovery period: T e rest interval between sets
Frequency: T e number o times an exercise is done in a week’s period
Recommended Techniques of Resist ance Training

Specif c recommendations or techniques o improving muscular strength are controversial
among therapists. A considerable amount o research has been done in the area o resis-
tance training relative to (a) the amount o weight to be used; (b) the number o repetitions;
(c) the number o sets; and (d) the requency o training.
A variety o specif c programs have been proposed that recommend the optimal
amount o weight, number o sets, number o repetitions, and requency or producing
maximal gains in levels o muscular strength. However, regardless o the techniques used,
the healing process must dictate the specif cs o any strength-training program. Certainly,
to improve strength, the muscle must be progressively overloaded. T e amount o weight
used and the number o repetitions must be su cient to make the muscle work at higher
intensity than it is accustomed to. T is actor is the most critical in any resistance training
program. T e resistance training program must also be designed to ultimately meet the spe-
cif c competitive needs o the patient.
Resistance training programs were initially designed by power li ters and body-
builders. Programs or routines commonly used in training and conditioning include the
ollowing:
Single set: One set o 8 to 12 repetitions o a particular exercise per ormed at a slow
speed.
ri-sets: A group o 3 exercises or the same muscle group per ormed using 2 to 4 sets
o each exercise with no rest between sets.
Multiple sets: wo or 3 warm-up sets with progressively increasing resistance ollowed
by several sets at the same resistance.
Supersets: Either 1 set o 8 to 10 repetitions o several exercises able 6-2 The De Lo rme Pro g ram
or the same muscle group per ormed one a ter another,
or several sets o 8 to 10 repetitions o 2 exercises or the
same muscle group with no rest between sets. Se t Amo unt o f We ig ht Re pe titio ns
Pyram ids: One set o 8 to 12 repetitions with light resistance, 1 50% of 10 RM 10
then an increase in resistance over 4 to 6 sets until only
1 or 2 repetitions can be per ormed. T e pyramid can also 2 75% of 10 RM 10
be reversed going rom heavy to light resistance. 3 100% of 10 RM 10
Split routine: Workouts exercise di erent muscle groups
on successive days. For example, Monday, Wednesday,
and Friday might be used or upper-body muscles,
and uesday, T ursday, and Saturday or lower-body able 6-3 The Oxfo rd Te chnique
muscles.
Circuit training: T is technique may be use ul to the therapist
Se t Amo unt o f We ig ht Re pe titio ns
or maintaining or perhaps improving levels o muscular
strength or endurance in other parts o the body while 1 100% of 10 RM 10
the patient allows or healing and reconditioning o
2 75% of 10 RM 10
an injured body part. Circuit training uses a series o
exercise stations, each o which involves weight training, 3 50% of 10 RM 10
exibility, calisthenics, or brie aerobic exercises. Circuits
can be designed to accomplish many di erent training
goals. With circuit training the patient moves rapidly rom
one station to the next, per orming whatever exercise is able 6-4 The McQue e n Te chnique
to be done at that station within a specif ed time period.
A typical circuit would consist o 8 to 12 stations, and the
entire circuit would be repeated three times. Amo unt
Se t o f We ig ht Re pe titio ns
Circuit training is most def nitely an e ective technique or
3 (Beginning/ 100% of 10
improving strength and exibility. Certainly, i the pace or time
intermediate) 10 RM
interval between stations is rapid and i workload is maintained at
a high level o intensity with heart rates at or above target training 4 to 5 100% of 2 to 3
levels, the cardiorespiratory system may benef t rom this circuit. (Advanced) 2 to 3 RM
However, there is little research evidence that circuit training is
very e ective in improving cardiorespiratory endurance. It should
be, and is most o ten, used as a technique or developing and
improving muscular strength and endurance.27 able 6-5 The Sande rs Pro g ram
Techniques of Resist ance Training

Amo unt
Used in Rehabilit at ion Se ts o f We ig ht Re pe titio ns
One o the f rst widely accepted strength-development programs
Total of 4 100% of 5 RM 5
to be used in a rehabilitation program was developed by DeLorme
sets (3 times
and was based on a repetition maximum (RM) o 10.18 T e amount per week)
o weight used is what can be li ted exactly 10 times ( able 6-2).
Zinovie proposed the Ox ord technique, which, like the Day 1 , 4 sets 100% of 5 RM 5
DeLorme program, was designed to be used in beginning, inter- Day 2 , 4 sets 100% of 3 RM 5
mediate, and advanced levels o rehabilitation.68 T e only di er-
ence is that the percentage o maximum was reversed in the 3 sets Day 3 , 1 set 100% of 5 RM 5
( able 6-3). T e McQueen technique 48 di erentiates between begin- 2 sets 100% of 3 RM 5
ning to intermediate and advanced levels, as in shown in able 6-4.
T e Sanders program ( able 6-5) was designed to be used in 2 sets 100% of 2 RM 5
the advanced stages o rehabilitation and was based on a ormula
able 6-6 Knig ht’s DAPRE Pro g ram that used a percentage o body weight to determine starting
weights.56 T e ollowing percentages represent median start-
ing points or di erent exercises:
Se ts Amo unt o f We ig ht Re pe titio ns
Barbell squat—45% o body weight
1 50% of RM 10 Barbell bench press—30% o body weight
2 7 5 % of RM 6 Leg extension—20% o body weight
3 100% of RM Maximum Universal bench press—30% o body weight
Universal leg extension—20% o body weight
4 Adjusted working weight a Maximum
Universal leg curl—10% to 15% o body weight
Universal leg press—50% o body weight
a
See Table 6-7.
Upright rowing—20% o body weight
Knight applied the concept o progressive resistive exer-

able 6-7 DAPRE Adjuste d Working We ight cise in rehabilitation. His Daily Adjusted Progressive Resis-
tive Exercise (DAPRE) program ( ables 6-6 and 6-7) allows or
individual di erences in the rates at which patients progress in
Number of Adjuste d their rehabilitation programs.37
Repetitions Wo rking Ne xt Berger proposed a technique that is adjustable within
Performed We ig ht During Exe rcise individual limitations ( able 6-8). For any given exercise,
During Third Set Fo urth Se t Se ssio n the amount o weight selected should be su cient to allow
0 to 2 −5 to 10 lb −5 to 10 lb 6 to 8 RM in each o the 3 sets, with a recovery period o 60 to
90 seconds between sets. Initial selection o a starting weight
3 to 4 −0 to 5 lb Same weight might require some trial and error to achieve this 6 to 8 RM
5 to 6 Same weight ±0 to 10 lb range. I at least 3 sets o 6 RM cannot be completed, the
weight is too heavy and should be reduced. I it is possible
7 to 10 ±5 to 10 lb ±5 to 15 lb to do more than 3 sets o 8 RM, the weight is too light and
11 ±10 to 15 lb ±10 to 20 lb should be increased.8 Progression to heavier weights is then
determined by the ability to per orm at least 8 RM in each o
3 sets. When progressing weight, an increase o approximately
10% o the current weight being li ted should still allow at
least 6 RM in each o 3 sets.9
able 6-8 The Be rg e r Adjustme nt Te chnique For rehabilitation purposes, strengthening exercises
should be per ormed on a daily basis initially, with the amount
o weight, number o sets, and number o repetitions governed
Amo unt by the injured patient’s response to the exercise. As the healing
Se ts o f We ig ht Re pe titio ns process progresses and pain or swelling is no longer an issue,
a particular muscle or muscle group should be exercised con-
3 100% of 10 RM 6 to 8
sistently every other day. At that point, the requency o weight
training should be at least 3 times per week but no more than
4 times per week. It is common or serious weightli ters to li t
every day; however, they exercise di erent muscle groups on
successive days.
It has been suggested that i training is done properly,
using both concentric and eccentric contractions, resistance training is necessary only
twice each week. However, this schedule has not been su ciently documented.
Isokinet ic Exercise
An isokinetic exercise involves a muscle contraction in which the length o the muscle is
changing while the contraction is per ormed at a constant velocity.11 In theory, maximal
resistance is provided throughout the range o motion by the machine. T e resistance pro-
vided by the machine will move only at some preset speed, regardless o the torque applied
to it by the individual. T us, the key to isokinetic exercise is not the resistance but the speed
at which resistance can be moved.
Few isokinetic devices are still available commercially (Figure 6-9). In general, they rely
on hydraulic, pneumatic, and mechanical pressure systems to produce this constant veloc-
ity o motion. Most isokinetic devices are capable o resisting concentric and eccentric con-
tractions at a f xed speed to exercise a muscle.
Isokinet ics as a Condit ioning Tool

Isokinetic devices are designed so that regardless o the amount o orce applied against a
resistance, it can only be moved at a certain speed. T at speed will be the same whether
maximal orce or only hal the maximal orce is applied. Consequently, in isokinetic train-
ing, it is absolutely necessary to exert as much orce against the resistance as possible
(maximal e ort) or maximal strength gains to occur.11 Maximal e ort is one o the major
problems with an isokinetic strength-training program.
Anyone who has been involved in a resistance training program knows that on some
days it is di cult to f nd the motivation to work out. Because isokinetic training requires a
maximal e ort, it is very easy to “cheat” and not go through the workout at a high level o
intensity. In a progressive resistive exercise program, the patient knows how much weight
has to be li ted or how many repetitions. T us, isokinetic training is o ten more e ective i
Figure 6-9 The Bio de x is an iso kine tic de vice that pro vide s re sistance at a
co nstant ve lo city
a partner system is used, primarily as a means o motivation toward a maximal e ort. When
isokinetic training is done properly with a maximal e ort, it is theoretically possible that
maximal strength gains are best achieved through the isokinetic training method in which
the velocity and orce o the resistance are equal throughout the range o motion. However,
there is no conclusive research to support this theory.
Whether this changing orce capability is a deterrent to improving the ability to gener-
ate orce against some resistance is debatable. In real li e, it does not matter whether the
resistance is changing; what is important is that an individual develops enough strength to
move objects rom one place to another.
Another major disadvantage o using isokinetic devices as a conditioning tool is their
cost. With initial purchase costs ranging between $50,000 and $80,000 and the necessity o
regular maintenance and so tware upgrades, the use o an isokinetic device or general con-
ditioning or resistance training is, or the most part, unrealistic. T us, isokinetic exercises
are primarily used as a diagnostic and rehabilitative tool.
Isokinet ics in Rehabilit at ion

Isokinetic strength testing gained a great deal o popularity throughout the 1980s in reha-
bilitation settings. T is trend stems rom its providing an objective means o quanti ying
existing levels o muscular strength and thus becoming use ul as a diagnostic tool.49
Because the capability exists or training at specif c speeds, com parisons have been
made regarding the relative advantages o training at ast or slow speeds in a rehabili-
tation program. T e research literature seem s to indicate that strength increases rom
slow-speed training are relatively specif c to the velocity used in training. Conversely,
training at aster speeds seem s to produce a m ore generalized increase in torque values
at all velocities. Minimal hypertrophy was observed only while training at ast speeds,
a ecting only type II or ast-twitch f bers.17,52 An increase in neuromuscular e ciency
caused by m ore e ective m otor unit f ring patterns has been dem onstrated with slow-
speed training.45
During the early 1990s, the value o isokinetic devices or quanti ying torque values at
unctional speeds was questioned.
Plyomet ric Exercise

Plyom etric exercise has also been re erred to in the literature as reactive neurom uscu-
lar training. It is a technique that is being increasingly incorporated into later stages o
the rehabilitation program by therapists. Plyom etric training includes specif c exercises
that encom pass a rapid stretch o a m uscle eccentrically, ollowed im m ediately by a
rapid concentric contraction o that m uscle to acilitate and develop a orce ul explo-
sive m ovem ent over a short period o tim e.13,20 T e greater the stretch put on the muscle
rom its restin g length im m ediately be ore the concentric contraction, the greater the
resistance the m uscle can overcom e. Plyom etrics em phasize the speed o the eccentric
phase. T e rate o stretch is m ore critical than the magnitude o the stretch. An advan-
tage to using plyom etric exercises is that they can help to develop eccentric control in
dynam ic m ovem ents.43
Plyometric exercises involve hops, bounds, and depth jumping or the lower extremity
and the use o medicine balls and other types o weighted equipment or the upper extrem-
ity.12,14 Depth jumping is an example o a plyometric exercise in which an individual jumps
to the ground rom a specif ed height and then quickly jumps again as soon as ground con-
tact is made (Figure 6-10).53
Plyometrics tend to place a great deal o stress on the musculoskeletal system. T e
learning and per ection o specif c jumping skills and other plyometric exercises must be
A B
Figure 6-10 Plyo me tric e xe rcise s
A. Upper extremity plyometric exercise using a medicine ball. B. Depth jumping lower extremity plyometric exercise.
technically correct and specif c to one’s age, activity,

physical, and skill development. Chapter 10 discusses
plyometric exercise in detail.
A
Calist henic St rengt hening Exercises

Calisthenics, or ree exercise, is one o the more easily
available means o developing strength. Isotonic move-
ment exercises can be graded according to intensity by
using gravity as an aid, by ruling gravity out, by moving
against gravity, or by using the body or a body part as a
resistance against gravity. Most calisthenics require the
individual to support the body or move the total body B
against the orce o gravity. Pushups are a good example
o a vigorous antigravity exercise (Figure 6-11A). Cal-
isthenic-like exercises are used in unctional strength
training, which was discussed earlier. o be considered
maximally e ective, the isotonic calisthenic exercise,
like all types o exercise, must be per ormed in an exact-
ing manner and in ull range o motion. In most cases,
10 or more repetitions are per ormed or each exercise
and are repeated in sets o 2 or 3. Some ree exercises
use an isometric, or holding, phase instead o a ull
range o motion. Examples o these exercises are back Figure 6-11 Calisthe nic e xe rcise s use bo dy
extensions and situps (Figure 6-11B). When the exercise w e ig ht as re sistance
produces maximum muscle tension, it is held between
6 and 10 seconds and then repeated 1 to 3 times. A. Pushups. B. Situps.
Core Stabilization Strengthening

A dynamic core stabilization training program should be a undamental component o
all comprehensive strengthening as well as injury rehabilitation programs.34,36 T e core is
def ned as the lumbo–pelvic–hip complex. T e core is where the center o gravity is located
and where all movement begins. T ere are 29 muscles that have their attachment to the
lumbo–pelvic–hip complex.
A core stabilization strengthening program can help to improve dynamic postural
control; ensure appropriate muscular balance and joint movement around the lumbo–
pelvic–hip complex; allow or the expression o dynamic unctional strength ; and improve
neuromuscular e ciency throughout the entire body. Collectively, these actors contrib-
ute to optimal acceleration, deceleration, and dynamic stabilization o the entire kinetic
chain during unctional movements. Core stabilization also provides proximal stability or
e cient lower-extremity movements. Greater neuromuscular control and stabilization
strength will o er a more biomechanically e cient position or the entire kinetic chain,
there ore allowing optimal neuromuscular e ciency throughout the kinetic chain. T is
approach acilitates a balanced muscular unctioning o the entire kinetic chain.15
Many patients develop the unctional strength, power, neuromuscular control, and
muscular endurance in specif c muscles to per orm unctional activities. However, rela-
tively ew patients have developed the muscles required or stabilization. T e body’s sta-
bilization system has to be unctioning optimally to e ectively utilize the strength, power,
neuromuscular control, and muscular endurance that they have developed in their prime
movers. I the extremity muscles are strong and the core is weak, then there will not be
enough orce created to produce e cient movements. A weak core is a undamental prob-
lem o ine cient movements that leads to injury.15 Chapter 15 discusses core stabilization
techniques in detail.
Open Versus Closed Kinetic Chain Exercises

T e concept o the kinetic chain deals with the anatomical unctional relationships that
exist in the upper and lower extremities. In a weightbearing position, the lower extremity
kinetic chain involves the transmission o orces among the oot, ankle, lower leg, knee,
thigh, and hip. In the upper extrem ity, when the hand is in contact with a weightbear-
ing sur ace, orces are transmitted to the wrist, orearm, elbow, upper arm, and shoulder
girdle.
An open kinetic chain exists when the oot or hand is not in contact with the ground or
some other sur ace. In a closed kinetic chain, the oot or hand is weight bearing. Movements
o the more proximal anatomical segments are a ected by these open versus closed kinetic
chain positions. For example, the rotational components o the ankle, knee, and hip reverse
direction when changing rom open to closed kinetic chain activity. In a closed kinetic
chain, the orces begin at the ground and work their way up through each joint. Also, in a
closed kinetic chain, orces must be absorbed by various tissues and anatomical structures,
rather than simply dissipating as would occur in an open chain.
In rehabilitation, the use o closed-chain strengthening techniques has become a treat-
ment o choice or many therapist. Most unctional activities involve some aspect o weight
bearing with the oot in contact with the ground or the hand in a weightbearing position, so
closed kinetic chain strengthening activities are more unctional than open-chain activities.
Consequently, rehabilitative exercises should be incorporated that emphasize strengthen-
ing o the entire kinetic chain rather than an isolated body segment. Chapter 11 discusses
closed-kinetic-chain activities in detail.
Resistance Training Differences Between Males and Females 169
raining for Muscular Strength

Versus Muscular Endurance
Muscular endurance was def ned as the ability to per orm repeated muscle contractions
against resistance or an extended period o time. Most resistance-training experts believe
that muscular strength and muscular endurance are closely related.21,50,57 As one improves,
there is a tendency or the other to also improve.
It is generally accepted that when resistance training or strength, heavier weights with
a lower number o repetitions should be used.65 Conversely, endurance training uses rela-
tively lighter weights with a greater number o repetitions.
It has been suggested that endurance training should consist o 3 sets o 10 to 15 repeti-
tions,9 using the same criteria or weight-selection progression and requency as recom-
mended or progressive resistive exercise. T us, suggested training regimens or muscular
strength and endurance are similar in terms o sets and numbers o repetitions.55 Persons
who possess great levels o strength tend to also exhibit greater muscular endurance when
asked to per orm repeated contractions against resistance.48
Resistance raining Di erences

Between Males and Females
T e approach to strength training is no di erent or emales than or males. However, some
obvious physiologic di erences exist between the genders.
T e average emale will not build signif cant muscle bulk through resistance training.
Signif cant muscle hypertrophy is dependent on the presence o the steroidal hormone
testosterone. estosterone is considered a male hormone, although all emales possess
some level o testosterone in their systems. Women with higher testosterone levels tend to
have more masculine characteristics, such as increased acial and body hair, a deeper voice,
and the potential to develop a little more muscle bulk.23,50 For the average emale, develop-
ing large, bulky muscles through strength training is unlikely, although muscle tone can
be improved. Muscle tone basically re ers to the f rmness o tension o the muscle during a
resting state.
T e initial stages o a resistance training program are likely to rapidly produce dramatic
increases in levels o strength.1 For a muscle to contract, an impulse must be transmitted
rom the nervous system to the muscle. Each muscle f ber is innervated by a specif c motor
unit. By overloading a particular muscle, as in weight training, the muscle is orced to work
more e ciently. E ciency is achieved by getting more motor units to f re, thus causing
more muscle f bers to contract, which results in a stronger contraction o the muscle. Con-
sequently, both women and men o ten see extremely rapid gains in strength when a weight-
training program is f rst begun.28 In emales, these initial strength gains, which can be
attributed to improved neuromuscular e ciency, tend to plateau, and minimal improve-
ment in muscular strength is realized during a continuing resistance training program.
T ese initial neuromuscular strength gains are also seen in males, although their strength
continues to increase with appropriate training.1 Again, emales who possess higher testos-
terone levels have the potential to increase their strength urther because they are able to
develop greater muscle bulk.
Di erences in strength levels between males and emales are best illustrated when
strength is expressed in relation to body weight minus at. T e reduced strength-to-bodyweight
ratio in women is the result o their percentage o body at. T e strength-to-bodyweight ratio
can be signif cantly improved through resistance training by decreasing the body at per-
centage while increasing lean weight.45
T e absolute strength di erences are considerably reduced when body size and com-
position are considered. Leg strength can actually be stronger in emales than in males,
although upper extremity strength is much greater in males.45
Resistance raining in the Adolescent

T e principles o resistance training discussed previously may be applied to adolescents.
T ere are certainly a number o sociologic questions regarding the advantages and disad-
vantages o younger, in particular prepubescent, individuals engaging in rigorous strength-
training programs. From a physiologic perspective, experts have or years debated the value
o strength training in adolescents. Recently, a number o studies have indicated that i
properly supervised, adolescents can improve strength, power, endurance, balance, and
proprioception; develop a positive body image; improve sport per ormance; and prevent
injuries.41 A prepubescent child can experience gains in levels o muscle strength without
muscle hypertrophy.51
A therapist supervising a rehabilitation program or an injured adolescent should cer-
tainly incorporate resistive exercise into the program. However, close supervision, proper
instruction, and appropriate modif cation o progression and intensity based on the extent o
physical maturation o the individual is critical to the e ectiveness o the resistive exercises.41
Speci c Resistive Exercises Used

in Rehabilitation
Because muscle contractions results in joint movement, the goal o resistance training in
a rehabilitation program should be either to regain and perhaps increase the strength o
a specif c muscle that has been injured or to increase the e ciency o movement about a
given joint.45
T e exercises included throughout Chapters 25-32 show exercises or all motions about
a particular joint rather than or each specif c muscle. T ese exercises are demonstrated
using ree weights (dumbbells or bar weights) and some exercise machines. Other strength-
ening techniques widely used or injury rehabilitation involving isokinetic exercise, plyomet-
rics, core stability training, closed kinetic chain exercises, and proprioceptive neuromuscular
acilitation strengthening techniques are discussed in greater detail in subsequent chapters.
SUMMARY
1. Muscular strength may be def ned as the maximal orce that can be generated against
resistance by a muscle during a single maximal contraction.
2. Muscular endurance is the ability to per orm repeated isotonic or isokinetic muscle
contractions or to sustain an isometric contraction without undue atigue.
3. Muscular endurance tends to improve with muscular strength, thus training tech-
niques or these 2 components are similar.
4. Muscular strength and endurance are essential components o any rehabilitation
program.
Speci c Resistive Exercises Used in Rehabilitation 171
5. Muscular power involves the speed with which a orce ul muscle contraction is
per ormed.
6. T e ability to generate orce is dependent on the physical properties o the muscle, neu-
romuscular e ciency, as well as the mechanical actors that dictate how much orce
can be generated through the lever system to an external object.
7. Hypertrophy o a muscle is caused by increases in the size and perhaps the number o
actin and myosin protein myof laments, which result in an increased cross-sectional
diameter o the muscle.
8. T e key to improving strength through resistance training is using the principle o over-
load within the constraints o the healing process.
9. Five resistance training techniques that can improve muscular strength are isometric
exercise, progressive resistive exercise, isokinetic training, circuit training, and plyo-
metric training.
10. Improvements in strength with isometric exercise occur at specif c joint angles.
11. Progressive resistive exercise is the most common strengthening technique used by the
therapist or rehabilitation a ter injury.
12. Circuit training involves a series o exercise stations consisting o resistance training,
exibility, and calisthenic exercises that can be designed to maintain f tness while re-
conditioning an injured body part.
13. Isokinetic training provides resistance to a muscle at a f xed speed.
14. Plyometric exercise uses a quick eccentric stretch to acilitate a concentric contraction.
15. Closed kinetic chain exercises might provide a more unctional technique or strength-
ening o injured muscles and joints in the athletic population.
16. Females can signif cantly increase their strength levels but generally will not build mus-
cle bulk as a result o strength training because o their relative lack o the hormone
testosterone.
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Impaired Endurance
Maintaining Ae ro bic
Capacity and Endurance
Pa t r ick D. Se lls a n d Willia m E. Pre n t ice
OBJJE C T I V E S t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Explain the relationships between heart rate, stroke volume, cardiac output, and rate
of oxygen use.
Describe the function of the heart, blood vessels, and lungs in oxygen transport.
Describe the oxygen transport system and the concept of maximal rate of oxygen use.
Describe the principles of continuous and interval training and the potential of each technique
for improving aerobic activity.
Describe the difference between aerobic and anaerobic activity.
Describe the principles of reversibility and detraining.
Describe caloric threshold goals associated with various stages of exercise programming.
175
176 Chapte r 7 Impaired Endurance
Alth ugh strength and f exibility are c mm nly regarded as essential c mp nents in any
injury rehabilitati n pr gram, ten relatively little c nsiderati n is given t ward maintain-
ing aer bic capacity and cardi respirat ry endurance. When muscul skeletal injury ccurs,
the patient is rced t decrease physical activity and levels cardi respirat ry endurance
may decrease rapidly. T us, the therapist must design r substitute alternative activities that
all w the individual t maintain existing levels aer bic capacity during the rehabilitati n
peri d. Furtherm re, the imp rtance maintaining and impr ving uncti nal capacity is
bec ming increasingly evident regardless muscul skeletal injury. Recent research dem-
nstrates a reducti n in risk r cardi vascular disease is ass ciated with impr ved levels
aer bic capacity. Sandvik et al46 rep rted m rtality rates acc rding t tness quartiles ver
16 years ll w-up. T e number deaths in the least- t p rti n the study utnum-
bered the deaths the m st t by a margin 61 t 11 deaths r m cardi vascular causes.46
Myers et al studied 6213 subjects re erred r treadmill testing and c ncluded that exercise
capacity is a m re p wer ul predict r m rtality am ng men than ther established risk
act rs r cardi vascular disease.41
By de niti n, cardiorespiratory endurance is the ability t per rm wh le-b dy activi-
ties r extended peri ds time with ut undue atigue.11,16 T e cardi respirat ry system
pr vides a means by which xygen is supplied t the vari us tissues the b dy. With-
ut xygen, the cells within the human b dy cann t p ssibly uncti n and ultimately cell
death will ccur. T us, the cardi respirat ry system is the basic li e-supp rt system
the b dy.2,11
raining E ects on the

Cardiorespiratory System
Basically, transp rt xygen thr ugh ut the b dy inv lves the c rdinated uncti n
4 c mp nents: heart, bl d vessels, bl d, and lungs. T e impr vement cardi respi-
rat ry endurance thr ugh training ccurs because increased capability each these
4 elements in pr viding necessary xygen t the w rking tissues.56 A basic discussi n the
training e ects and resp nse t exercise that ccur in the heart, bl d vessels, bl d, and
lungs sh uld make it easier t understand why the training techniques discussed later are
e ective in impr ving cardi respirat ry endurance.
Adapt at ion of t he Heart t o Exercise

T e heart is the main pumping mechanism and circulates xygenated bl d thr ugh ut the
b dy t the w rking tissues. T e heart receives de xygenated bl d r m the ven us sys-
tem and then pumps the bl d thr ugh the pulm nary vessels t the lungs, where carb n
di xide is exchanged r xygen. T e xygenated bl d then returns t the le t atrium the
heart, int the le t ventricle, r m which it exits thr ugh the a rta t the arterial system and
is circulated thr ugh ut the b dy, supplying xygen t the tissues.
Heart Rat e
As the b dy begins t exercise, the w rking tissues require an increased supply xygen
(via transp rt n red bl d cells) t m eet the increased m etab lic dem and (cardiac ut-
put). he w rking tissues use the decreasing c ncentrati n xygen as a signal t vas -
dilate the bl d vessels in the tissue. his decreases the resistan ce t bl d l w and
all ws r a decrease vel city l w, and thereby increasing O2 extracti n.49 Increases
in heart rate ccur as ne resp nse t m eet the demand. he heart is capable adapting
Training Effects on the Cardiorespiratory System 177
t this increased dem and thr ugh several m echanism s.
Heart rate sh ws a gradual adaptati n t an increased
w rkl ad by in creasin g pr p rti nally t the intensity
the exercise an d will plateau at a given level a ter
appr ximately 2 t 3 m inutes (Figure 7-1).12 In creases in
e
t
a
r
heart rate pr duced by exercise are m et by a decrease
t
r
a
in diast lic illing tim e. Heart rate param eters chan ge
e
h
l
with age, b dy p siti n, type exercise, cardi vascu-
a
m
xi
lar disease, heat and hum idity, m edicati ns, and bl d
a
m
v lum e. C nditi ns that exist in an y patient sh uld be
b
u
S
taken int c n siderati n when prescribin g exercise t
im pr ve aer bic endurance. he c m m nly used equa-
ti n t predict m axim al heart rate (MHR) is 220 − age
r healthy m en and w m en. H wever, the rm ula has 2–3 minute s
lim itati ns t pers ns wh all utside the “apparently Time
healthy” classi icati n and sh uld be used with cauti n.
M nit ring heart rate is an indirect m eth d estimating
xygen c n sum pti n .16 Additi nally, an y m edicati n s Figure 7-1 Plate au he art rate
sh uld be c nsidered pri r t assessm ent r evaluati n
heart rate resp nse. F r exam ple, patients taking beta For the heart rate to plateau at a given level, 2 to 3 minutes
bl ckers will have an attenuated heart rate resp nse t are required.
exercise. In gen eral, heart rate an d xygen c n sum p-
ti n have a lin ear relati nship with exercise inten sity.
he greater the inten sity the exercise, the higher the
heart rate. his relati nship is least c nsistent at very-
l w an d very-high intensities exercise (Figure 7-2).
y
t
i
During higher-intensity activities, MHR m ay be achieved
c
a
p
be re m axim um xygen c nsum pti n, which can c n-
a
c
c
tinue t rise despite reachin g an age predicted heart
i
b
o
rate.38 Because these existing relati n ships, it sh uld
r
e
a
be apparent that the rate xygen c nsum pti n can be
m
u
estim ated by m nit ring the heart rate.13
m
xi
a
M
%
St roke Volume
A sec nd m echanism by which the cardi vascular sys- Ma ximum
tem is able t adapt t increased dem ands cardiac He a rt ra te (% ma ximum)
utput during exercise is t increase stroke volum e (the
v lum e bl d being pum ped ut with each beat).12
Str ke v lum e is equal t the di erence between end Figure 7-2 Maximum he art rate
diast lic v lum e and end syst lic v lum e. yical values
Maximum heart rate is achieved at about the same time
r str ke v lum e range r m 60 t 100 m L per beat at rest
as maximal aerobic capacity.
and 100 t 120 m L per beat at maximum.18 Str ke v lum e
will c ntinue t increase nly t the p int at which dia-
st lic lling tim e is sim ply t sh rt t all w adequate lling. T is ccurs at appr xi-
m ately 40% t 50% m axim al aer bic capacity, r at a heart rate 110 t 120 beats
per m inute; ab ve this level, increases in the cadiac utput are acc unted r by increases
in heart rate (Figure 7-3).18
Cardiac Out put

Str ke v lume and heart rate c llectively determine the v lume bl d being pumped
thr ugh the heart in a given unit time. Appr ximately 5 L bl d are pumped thr ugh
the heart during each minute at rest. T is is re erred t as

the cardiac output, which indicates h w much bl d the
heart is capable pumping in exactly 1 minute. T us car-
diac utput is the primary determinant the maximal
rate xygen c nsumpti n p ssible (Figure 7-4). During
exercise, cardiac utput increases t appr ximately 4 times
e
m
u
that experienced during rest (t appr ximately 20 L) in the
l
o
v
n rmal individual, and may increase as much as 6 times in
e
k
o
the elite endurance athlete (t appr ximately 31 L).
r
t
S
Cardiac output = stroke volum e × heart rate
T e ab ve equati n illustrates that any act r that will

40% impact heart rate r str ke v lume can either increase
He a rt ra te r decrease cardiac utput. F r example, an increase in
ven us return bl d r m w rking muscle will increase
the end diast lic v lum e. T is increased v lum e will
Figure 7-3 Stro ke vo lume plate aus increase str ke v lume via the Frank Starling mechanism 49
and, there re, cardiac utput.57 Heart rate is regulated by
Stroke volume plateaus at approximately 40% of maximal the aut n mic nerv us system as well as circulating levels
heart rate. Epinephrine secreted r m the adrenal medulla. C n-
versely, c nditi ns that resist ventricular utf w (high
bl d pressure r an increase in a terl ad) will result in a
decrease in cardiac utput. C nversely, a c nditi n that
Ma ximum
w uld decrease ven us return (peripheral artery disease)
w uld decrease str ke v lume and attenuate cardiac ut-
put. Figure 7-5 utlines the act rs that regulate b th str ke
t
v lume and heart rate.
u
p
t
u
A c mm nly rep rted bene t aer bic c nditi n-
o
c
ing is a reduced resting heart rate and a reduced heart rate
a
i
d
r
at a standard exercise l ad. T is reducti n in heart rate is
a
C
explained by an increase in str ke v lume br ught ab ut
by increased ven us return and t increased c ntractile
c nditi ns in the my cardium. T e heart bec mes m re
Ma ximum e cient because it is capable pumping m re bl d with
Oxyge n cons umption
each str ke. Because the heart is a muscle, it can hypertr -
phy, r increase in size and strength as a result aer bic
Figure 7-4 Cardiac o utput limits maximal exercise, t s me extent, but this is in n way a negative
ae ro bic capacity e ect training.
Training Effect
Increased stroke volum e × decreased heart rate = cardiac output
During exercise, emales tend t have a 5% t 10% higher cardiac utput than males at all
intensities. T is is likely the result a l wer c ncentrati n hem gl bin in the emale,
which is c mpensated r during exercise by an increased cardiac utput.59
Adapt at ion in Blood Flow

T e am unt bl d f wing t the vari us rgans increases during exercise. H wever, there
is a change in verall distributi n cardiac utput: the percentage t tal cardiac utput
t the n nessential rgans is decreased, whereas it is increased t active skeletal muscle.
Training Effects on the Cardiorespiratory System 179
Cardiac o utput
He a rt ra te S troke volume
Influe nce d by ra te of Influe nce d by force of

de pola riza tion in ca rdia c ce lls contra ction in ca rdia c mus cle
De cre s e d by Incre a s e d by Le ngth-te ns ion

Contra ctility re la tions hip
pa ra s ympa the tic s ympa the tic
ne rvous s ys te m ne rvous s ys te m
Va rie s with
Ephe drine from ve nous re turn
a dre na l gla nd
Mus cle Re s pira tory

pumping pump
Figure 7-5 The facto rs e ffe cting cardiac o utput
V lume bl d f w t the heart muscle r my cardium increases substantially during

exercise, even th ugh the percentage t tal cardiac utput supplying the heart muscle
remains unchanged. T e increase in f w t skeletal muscle is br ught ab ut by withdrawal
sympathetic stimulati n t arteri les, and vas dilati n is maintained by intrinsic meta-
b lic c ntr l.40 rained pers ns have a higher capillary density than their untrained c unter-
parts t better acc mm date the increased supply and demand. In skeletal muscle, there is
increased rmati n bl d vessels r capillaries, alth ugh it is n t clear whether new nes
rm r d rmant nes simply pen up and ll with bl d.49
T e t tal peripheral resistance ( PR) is the sum all rces that resist bl d f w within
the vascular system. PR decreases during exercise primarily because vessel vas dilati n
in the active skeletal muscles.
Blood Pressure
Bl d pressure in the arterial system is determined by the cardiac utput in relati n t PR
t bl d f w as ll ws:
BP = CO × PR
where BP = bl d pressure, CO = cardiac utput, and PR = t tal peripheral resistance.
Bl d pressure is created by c ntracti n the my cardium. C ntracti n the ven-
tricles the heart creates syst lic pressure, and relaxati n the heart creates diast lic
pressure. Bl d pressure is regulated centrally by neural activity n peripheral arteri les
and l cally by metab lites pr duced during exercise. During exercise, there is a decrease in
PR (via decreased vas c nstricti n) and an increase in cardiac utput. Syst lic pressure
increases in pr p rti n t xygen c nsumpti n and cardiac utput, whereas diast lic pres-
sure sh ws little r n increase.6 Failure syst lic pressure t increase with increased exer-
cise intensity is c nsidered an abn rmal resp nse t exercise and is a general indicati n t
st p an exercise test r sessi n.1 Bl d pressure alls bel w preexercise levels a ter exercise
and may stay l w r several h urs. T ere is general agreement that engaging in c nsistent
aer bic exercise will pr duce m dest reducti ns in b th syst lic and diast lic bl d pres-
sure at rest as well as during submaximal exercise.10,15
Adapt at ions in t he Blood

Oxygen is transp rted thr ugh ut the system b und t hem oglobin. F und in red bl d
cells, hem gl bin is an ir n-c ntaining pr tein that has the capability easily accepting
r giving up m lecules xygen as needed. raining r impr vement cardi respirat ry
endurance pr duces an increase in t tal bl d v lume, with a c rresp nding increase in
the am unt hem gl bin. T e c ncentrati n hem gl bin in circulating bl d d es n t
change with training; it may actually decrease slightly.
Adapt at ion of t he Lungs

As a result training, pulm nary uncti n is impr ved in the trained individual relative t the
untrained individual. T e v lume air that can be inspired in a single maximal ventilati n
is increased. T e di using capacity the lungs is als increased, acilitating the exchange
xygen and carb n di xide. Pulm nary resistance t air f w is als decreased.35
Maximal Aerobic Capacity

T e maximal am unt xygen that can be used during .exercise is re erred t as m axim al
aerobic capacity (exercise physi l gists re er t this as Vo 2max). It is c nsidered t be the
best indicat r the level cardi respirat ry endurance. Maximal aer bic capacity is m st
ten presented in terms the v lume xygen used relative t b dy weight per unit
time (mL × kg−1 × min −1).3
It is c mm n t see aer bic capacity expressed in metab lic equivalents (ME s). Rest-
−1 −1
ing xygen c nsumpti n is generally c nsidered t be 3.5 mL . × kg × min r 1 ME .
T ere re, an exercise intensity 10 ME s is equivalent t a Vo 2 35 mL × kg−1 × min −1.
A n rmal maximal aer bic capacity r m st c llegiate men and w men w uld all in the
range 35 t 50 mL × kg−1 × min −1.35
Rat e of Oxygen Consumpt ion

T e per rmance any activity requires a certain rate
xygen c nsum pti n, which is ab ut the sam e r all per-
s ns, depending n their present level tness. Gener-
ally, the greater the rate r intensity the per rmance
an activity, the greater will be the xygen c nsum pti n.
Each pers n has his r her wn maximal rate xygen
e
m
c nsum pti n. T e pers n’s ability t per rm an activity
i
T
is cl sely related t the am unt xygen required by that
activity. T is ability is limited by the maximal am unt
xygen the pers n is capable delivering int the lungs.
Fatigue ccurs when insu cient xygen is supplied t
muscles. It sh uld be apparent that the greater the per-
centage m axim al aer bic capacity required during
% Ma xima l a e robic ca pa city re quire d
during a n a ctivity
an activity, the less tim e the activity may be per rm ed
(see Figure 7-6).
T ree act rs determ ine the m aximal rate at which
Figure 7-6 Maximal ae ro bic capacity re quire d xygen can be used: (a) external respirati n, inv lving the
during activity ventilat ry pr cess r pulm nary uncti n; (b) gas trans-
p rt, which is acc m plished by the cardi vascular system
The greater the percentage of maximal aerobic capacity (that is, the heart, bl d vessels, and bl d); and (c) inter-
required during an activity, the less time that activity nal (cellular) respirati n, which inv lves the use xy-
can be performed. gen by the cells t pr duce energy. Exercise physi l gists
Maximal Aerobic Capacity 181
generally discuss the lim iting act rs maximal aer bic capacity based n healthy
human subjects in a c ntr lled envir nm ent.4,27,28 Under these c nditi ns, research pres-
ents agreement that the ability t transp rt xygen thr ugh the heart, lungs, and bl d
is the limiting act r t the verall rate xygen c nsumpti n. T .is indicates that this is
n t the ability the m it ch ndria t c nsum e xygen that lim its Vo 2max. A high maximal
aer bic capacity within a pers n’s range indicates that all 3 system s are w rking well.
Maximal Aerobic Capacit y: An Inherit ed Charact erist ic

T e maximal rate at which xygen can be used is a genetically determined characteristic; we
inherit a certain range maximal aer bic capacity, and the m re active we are, the higher the
existing maximal aer bic capacity will be within that range.47,58 T ere re, a training pr gram
is capable increasing maximal aer bic capacity t its highest limit within ur range.43,50,58
Fast -Twit ch Versus Slow-Twit ch Muscle Fibers

T e range maximal aer bic capacity inherited is in a large part determined by the meta-
b lic and uncti nal pr perties skeletal muscle bers. As discussed in detail in Chapter 6,
there are 3 distinct types muscle bers, slow-twitch and 2 variati ns ast-twitch bers,
each which has distinctive metab lic and c ntractile capabilities. Because they are rel-
atively atigue resistant, sl w-twitch bers are ass ciated primarily with l ng-durati n,
aer bic-type activities. T e sl w-twitch bers depend n xidative ph sph rylati n t gen-
erate aden sine triph sphate (A P) t pr vide the energy needed r muscle c ntracti n.
Fast-twitch bers are use ul in sh rt-term, high-intensity activities, which mainly inv lve
the anaer bic system. Intermediated ast-twitch bers dem nstrate a reliance n glyc ly-
sis t pr duce A P. T ese intermediate bers als have the ability t adapt based n spe-
ci c training regimens.49 In general, i a patient has a high rati sl w-twitch t ast-twitch
muscle bers, the patient will be able t use xygen m re e ciently and thus will have a
higher maximal aer bic capacity.
Cardiorespirat ory Endurance

A
50
and Work Abilit y
Cardi respirat ry en duran ce plays a criti-
cal r le in ur ability t carry ut n rm al B
)
40
n
daily activities.40 Fatigue is cl sely related t
i
m
/
the percentage m axim al aer bic capac-
kg
/
l
ity that a particular w rkl ad dem an ds.49
m
Work
(
y
F r exam ple, Figure 7-7 presents 2 pe ple, 30
t
i
loa d
c
a
A and B. A has m axim al aer bic capacity
p
a
c
50 m L/ kg per m inute, whereas B has a m axi-
c
i
b
m al aer bic capacity nly 40 m L/ kg per
o
20
r
e
m inute. I b th A and B are exercising at the
a
m
sam e inten sity, then A will be w rking at a
u
m
xi
m uch l wer percentage m axim al aer bic
a
10
M
capacity than B. C n sequently, A sh uld be
able t sustain his r her activity ver a m uch
l nger peri d tim e. Everyday activities may
0
be adversely a ected i the ability t use xy- % Ma xima l a e robic ca pa city
gen e ciently is im paired. T us, im pr ve-
m ent cardi respirat ry endurance sh uld
be an essential c m p nent any c nditi n- Figure 7-7
ing pr gram and m ust be in cluded as part
the rehabilitati n pr gram r the injured Patient A should be able to work longer than patient B as a result of
patient.9 a lower percentage use of maximal aerobic capacity.
Regardless the training technique used r the impr vement cardi respirat ry
endurance, ne principal g al remains the same: to increase the ability o the cardiorespira-
tory system to supply a suf cient am ount o oxygen to working m uscles. With ut xygen, the
b dy is incapable pr ducing energy r an extended peri d time.
Producing Energy for Exercise

All living systems need t per rm a variety activities, such as gr wing, generating energy,
repairing damaged tissues, and eliminating wastes. All these activities are re erred t as
being metab lic r as cellular m etabolism .
Muscles are metab lically active and must generate energy t m ve. Energy is pr -
duced r m the breakd wn certain nutrients r m dstu s. T is energy is st red in a
c mp und called A P, which is the ultimate usable rm energy r muscular activity.
A P is pr duced in the muscle tissue r m bl d gluc se r glyc gen. Fats and pr teins
can als be metab lized t generate A P. Gluc se n t needed immediately can be st red as
glyc gen in the resting muscle and liver. St red glyc gen in the liver can later be c nverted
back t gluc se and trans erred t the bl d t meet the b dy’s energy needs.7
It is imp rtant t understand that the intensity and durati n exercise selected as an
interventi n will have implicati ns n the s urce “ uel” t engage in the activity. T e
“ uel” is the A P needed r muscular c ntracti n. Exercise intensity and durati n e ect
the s urce r pathway that is used t supply the A P; that is, d es the A P c me r m the
breakd wn circulating bl d gluc se (glyc lysis) r r m the Krebs cycle and the electr n
transp rt chain ( xidative ph sph rlizati n)? .
I the c mbinati n durati n and intensity is l w (40% t 50% Vo 2max), the b dy
relies m re heavily n ats st red in adip se tissue t meet its energy needs. T e l nger
the durati n an activity, the greater the am unt at used, especially during the later
stages endurance events. During rest and submaximal exerti n, b th at and carb hy-
drates are used t pr vide energy in appr ximately a 60%-t -40% rati . Carb hydrate must
be available t use at. I glyc gen is t tally depleted, at cann t be c mpletely metab lized.
Regardless the nutrient s urce that pr duces A P, it is always available in the cell as an
immediate energy s urce. When all available s urces A P are used, m re must be gener-
ated r muscular c ntracti n t c ntinue.8,29
Vari us sp rts activities inv lve speci c demands r energy. F r example, sprint-
ing and jumping are high-energy- utput activities, requiring a relatively large pr ducti n
energy r a sh rt time. L ng-distance running and swimming, n the ther hand, are
m stly l w-energy- utput activities per unit time, requiring energy pr ducti n r a pr -
l nged time. Other physical activities demand a blend b th high- and l w-energy utput.
T ese vari us energy demands can be met by the di erent pr cesses in which energy can
be supplied t the skeletal muscles.17
Anaerobic Versus Aerobic Met abolism

w maj r energy-generating systems uncti n in muscle tissue: anaer bic and aer bic
metab lism. Each these systems pr duces A P.21 Activities that demand intensive, sh rt-
term exercise need A P that is rapidly available and metab lized t meet energy needs.
T e primary s urce r A P pr ducti n in sh rt-term high-intensity exercise is ph sph -
creatine system. issues nly st re en ugh ph sph creatine t generate A P r events last-
ing appr ximately 10 sec nds r less. A ter a ew sec nds intensive exercise, h wever,
the small st res A P are used up. T e b dy then utilizes st red glyc gen as an energy
s urce. Glyc gen can be br ken d wn t supply gluc se, which is then metab lized within
the muscle cells t generate A P r muscle c ntracti ns.38
Techniques for Maintaining Cardiorespiratory Endurance 183
Gluc se can be metab lized t generate small am unts A P energy with ut the need
r xygen. T is energy system is re erred t as anaerobic m etabolism ( ccurring in the absence
xygen). As exercise c ntinues, the b dy has t rely n a m re c mplex rm carb hy-
drate and at metab lism t generate A P. T is sec nd energy system requires xygen and is
there re re erred t as aerobic m etabolism ( ccurring in the presence xygen). T e aer bic
system pr ducing energy generates c nsiderably m re A P than the anaer bic ne.
In m st activities, b th aer bic and anaer bic systems uncti n simultane usly. T e
degree t which the 2 maj r energy systems are inv lved is determined by the intensity and
durati n the activity.55 I the intensity the activity is such that su cient xygen can be
supplied t meet the demands w rking tissues, the activity is c nsidered t be aerobic.
C nversely, i the activity is high-en ugh intensity, r the durati n is such that there is
insu cient xygen available t meet energy demands, the activity bec mes anaerobic.51
Excess Post exercise Oxygen Consumpt ion

As the intensity the exercise increases and insu cient am unts xygen are available t
the tissues, an xygen de cit is incurred. Oxygen de cit ccurs in the beginning exercise
(within the rst 2 t 3 minutes) when the xygen demand is greater than the xygen sup-
plied. It was been hyp thesized that this xygen debt was caused by lactic acid pr duced
during anaer bic activity, and this debt must be “paid back” during the p stexercise peri d.
H wever, there is presently a di erent rati nale r this xygen de cit, which is currently
re erred t as “excess p stexercise xygen c nsumpti n.” It is the retically caused by dis-
turbances in mit ch ndrial uncti n r m an increase in temperature.38 Additi nal expla-
nati ns include evidence b th a “ ast” and a “sl w” c mp nent. T e ast c mp nents
include the rest rati n ph sph creatine levels depleted in the earliest sec nds exer-
cise, and replacing st red muscle and bl d xygen c ntent. T e sl w p rti n is acc unted
r by pr viding the energy r the elevated respirat ry rate and heart rate, elevated levels
catech lamines and gluc ne genesis, the c nversi n lactic acid t gluc se.44
echniques for Maintaining

Cardiorespiratory Endurance
Several di erent training techniques may be inc rp rated int a rehabilitati n pr gram
thr ugh which cardi respirat ry endurance can be maintained. Certainly, a primary c n-
siderati n r the therapist is whether the injury inv lves the upper r l wer extremity.
With injuries that inv lve the upper extremity, weightbearing activities can be used, such
as walking, running, stair climbing, and m di ed aer bics. H wever, i the injury is t the
l wer extremity, alternative n n-weightbearing activities, such as swimming r stati nary
cycling, may be necessary. T e g al the therapist is t try t maintain cardi respirat ry
endurance thr ugh ut the rehabilitati n pr cess.
T e principles the training techniques discussed next can be applied t running,
cycling, swimming, stair climbing, r any ther activity designed t maintain levels car-
di respirat ry tness.
Cont inuous Training

Continuous training inv lves the ll wing c nsiderati ns:
• T e requency the activity
• T e intensity the activity
• T e type activity
• T e time (durati n) the activity
Frequency of Training
T e American C llege Sp rts Medicine (ACSM) rec mmends that m st adults engage in
m derate-intensity cardi respirat ry exercise training r ≥30 min·day−1 n ≥5 days·wk−1 r a
t tal ≥150 min·wk−1, vig r us-intensity cardi respirat ry exercise training r ≥20 min·day−1
n ≥3 days·wk−1 (≥75 min·wk−1), r a c mbinati n m derate- and vig r us-intensity exer-
cise t achieve a t tal energy expenditure ≥500 t 1000 ME ·min·wk−1.1 A c mpetitive ath-
lete sh uld be prepared t train as ten as 6 times per week. Every ne sh uld take at least
1 day per week t give damaged tissues a chance t repair themselves.
Int ensit y of Training

T e intensity exercise is als a critical act r, alth ugh rec mmendati ns regarding
training intensities vary.25 T is statement is particularly true in the early stages train-
ing, when the b dy is rced t make a magnitude adjustments t increased w rkl ad
demands. T e ACSM guidelines regarding intensity exercise rec mmend the .ll wing:
55%/ 65% t 90% MHR, r 40%/ 50% t 85% maximum . xygen uptake reserve (Vo 2R) r
MHR reserve (hear rate reserve [HRR]). HRR and Vo 2R are calculated . r m the di erence
between resting and maximum heart rate and resting and maximum Vo 2, respectively.
estimate training
. intensity, a percentage this value is added. t the resting heart rate and/
r resting Vo 2 and is expressed
. as a percentage HRR r Vo 2R. T e l wer-intensity values,
that is, 40% t 49% Vo 2R r HRR and 55% t 64% MHR, are m st applicable t individu-
als wh are quite un t. T ese intensities require the therapist t either kn w the pers n’s
maximal values r use a predicti n equati n t estimate these intensities. A great rule
thumb is t always g with actual data ver predicti n data when available. T ere are many
limitati ns t predicti n equati ns. Because the linear relati nship between heart rate,
xygen c nsumpti n, and exercise intensity, it bec mes a relatively simple pr cess t iden-
ti y a speci c w rkl ad (pace) that will make the heart rate plateau at the desired level.52
By m nit ring heart rate, we kn w whether the pace is t ast r t sl w t achieve the
desired range intensity.33 Pri r t selecting an exercise intensity, the therapist sh uld
c nsider several act rs, including current level tness, medicati ns, cardi vascular risk
pr le, an individual’s likes and dislikes, and patient’s g als and bjectives.1
Monitoring Heart Rate T ere are several meth ds r measuring heart rate resp nse
during exercise. T ese include, but are n t limited t , palpati n the heart rate at the radial
r car tid artery, pulse ximetry, telemetry (heart rate m nit rs), and electr cardi graphy.
One the easiest meth ds is t palpate the radial artery. T is assessment can be d ne by
the patient r the therapist. T e car tid artery is simple t nd, especially during exercise.
H wever, there are pressure (bar ) recept rs l cated in the car tid artery that, i subjected
t hard pressure r m the 2 ngers, will sl w d wn the heart rate, giving a alse indicati n
exactly what the heart rate is. T us, the pulse at the radial artery pr ves the m st accurate
measure heart rate. Regardless where the heart rate is taken, it sh uld be rec rded
pri r t exercise, during exercise t ensure target intensities, and m nit red ll wing exer-
cise t ensure rec very. An ther act r must be c nsidered when measuring heart rate dur-
ing exercise. T e patient is trying t elevate heart rate t a speci c target rate and maintain it
at that level during the entire w rk ut.22 Heart rate can be increased r decreased by speed-
ing up r sl wing d wn the pace. Based n the act that heart rates will attain a steady state
r plateau t a prescribed w rk rate in 2 t 3 minutes, the therapist sh uld all w su cient
time pri r t assessment heart rate. T us, the patient sh uld be actively engaged in the
w rk ut r 2 t 3 minutes be re measuring pulse.61
T ere are several rmulas that will easily all w the therapist t identi y a target training
heart rate.42 Exact determinati n MHR inv lves exercising a patient at a maximal level
and m nit ring the heart rate using an electr cardi graphy. T is pr cess is di cult utside
a lab rat ry. H wever, an appr ximate estimate MHR r b th males and emales in
the p pulati n is th ught t be 220 beats per minute.45 MHR is related t age. With aging,
Techniques for Maintaining Cardiorespiratory Endurance 185
MHR decreases.34 T us, a relatively simple estimate MHR w uld be MHR = 220 − age. F r
a 40-year- ld patient, MHR w uld be appr ximately 180 beats per minute (220 − 40 = 180).
I y u are interested in w rking at 70% y ur MHR, the target heart rate can be calculated
by multiplying .0.7 × (220 − age). T e intensity range 70% t 85% MHR appr ximates
55% t 75% Vo 2max. Again using a 40-year- ld pers n as an example, a target heart rate
w uld be 126 beats per minute (0.7 × [220 − 40] = 126).
An ther c mm nly used rmula that takes int acc unt y ur current level f tness is
the Karv nen equati n, s metimes re erred t as the HRR meth d.26,30
arget training HR = Resting HR + (0.6[Maxim um HR − Resting HR])
Resting heart rate generally alls between 60 and 80 beats per minute. A 40-year- ld
patient with a resting pulse 70 beats per minute, acc rding t the Karv nen equati n,
w uld have a target training heart rate 136 beats per minute (70 + 0.6[180 − 70] = 136).
Regardless the rmula used, t see minimal impr vement in cardi respirat ry
endurance, the patient must train with the heart rate elevated t at least 60% its maximal
rate.1,23,31 Exercising at a 70% level is c nsidered m derate, because activity can be c ntin-
ued r a l ng peri d time with little disc m rt and still pr duce a training e ect.39 In a
trained individual, it is n t di cult t sustain a heart rate at the 85% level.14
In the event that the physical therapist has data indicating that the heart rate is at the
ventilatory threshold, that rate can be used to prescribe exercise. The risk of a cardiac
event increases, the closer the heart rate is to the ventilatory threshold; therefore,
prescribing exercise 10 beats per minute below that level will keep the risk low.
Rating of Perceived Exertion Rating perceived exerti n able 7-1 Rating o f Pe rce ive d Exe rtio n
can be used in additi n t m nit ring heart rate t indicate
exercise intensity.5 During exercise, individuals are asked t rate
Scale Ve rbal Rating
subjectively n a numerical scale r m 6 t 20 exactly h w they
eel relative t their level exerti n ( able 7-1). M re intense 6
exercise that requires a higher level xygen c nsumpti n and 7 Very, very light
energy expenditure is directly related t higher subjective ratings
8
perceived exerti n. T e use a rating- -perceived-exerti n
scale is the pre erred meth d m nit ring the exercise inten- 9 Very light
sity individuals wh are taking medicati ns, beta bl ckers r 10
example, that attenuate the n rmal heart rate resp nse t exer-
11 Fairly light
cise. Over a peri d time, patients can be taught t exercise at a
specif c rating perceived exerti n that relates directly t m re 12
bjective measures exercise intensity.20,40 13 Somewhat hard
14
Type of Exercise 15 Hard
T e type activity used in c ntinu us training must be aer bic.
16
Aer bic activities are activities that generally inv lve repetitive,
wh le-b dy, large-muscle m vements that are rhythmical in 17 Very hard
nature and use large am unts xygen, elevate the heart rate, 18
and maintain it at that level r an extended peri d time. Exam- 19 Very, very hard
ples aer bic activities are walking, running, j gging, cycling,
swimming, r pe skipping, stepping, aer bic dance exercise, r ll- 20
erblading, and cr ss-c untry skiing.
T e advantage these aer bic activities as pp sed t m re Source: Borg GA. Psychophysical basis of perceived
intermittent activities, such as racquetball, squash, basketball, r exertion. Med Sci Sports Exerc 1982;14:377.
tennis, is that aer bic activities are easy t regulate in intensity by either speeding up r
sl wing d wn the pace.37 Because we already kn w that a given intensity the w rkl ad
elicits a given heart rate, these aer bic activities all w us t maintain heart rate at a speci-
f ed r target level. Intermittent activities inv lve variable speeds and intensities that cause
the heart rate t uctuate c nsiderably. Alth ugh these intermittent activities will impr ve
cardi respirat ry endurance, they are much m re di cult t m nit r in terms intensity.
It is imp rtant t p int ut that any type activity, r m gardening t aer bic exercise, can
impr ve f tness.42
Time (Durat ion)

F r minimal impr vement t ccur, the patient must participate in at least 20 minutes
c ntinu us activity with the heart rate elevated t its w rking level. T e ACSM rec m-
mends durati n training t be 20 t 60 minutes c ntinu us r intermittent (minimum
10-minute b uts accumulated thr ugh ut the day) aer bic activity. Durati n varies with
the intensity the activity. L wer-intensity activity sh uld be c nducted ver a l nger
peri d time (30 minutes r m re). Patients training at higher levels intensity sh uld
train at least 20 minutes r l nger “because the imp rtance ‘t tal f tness’ and that it is
m re readily attained with exercise sessi ns l nger durati n and because the p tential
hazards and adherence pr blems ass ciated with high-intensity activity, m derate-inten-
sity activity l nger durati n is rec mmended r adults n t training r athletic c mpeti-
ti n” (see the Appendix).
Generally, the greater the durati n the w rk ut, the greater the impr vement in car-
di respirat ry endurance.
Int erval Training

Unlike c ntinu us training, interval training inv lves activities that are m re intermittent.
Interval training c nsists alternating peri ds relatively intense w rk and active rec v-
ery. It all ws r per rmance much m re w rk at a m re intense w rkl ad ver a l nger
peri d time than i w rking c ntinu usly. It is m st desirable in c ntinu us training t
w rk at an intensity appr ximately 60% t 80% MHR. Obvi usly, sustaining activity at
a relatively high intensity ver a 20-minute peri d is extremely di cult. T e advantage
interval training is that it all ws w rk at this 80% r higher level r a sh rt peri d time
ll wed by an active peri d rec very during which y u may be w rking at nly 30% t
45% MHR. T us, the intensity the w rk ut and its durati n can be greater than with
c ntinu us training.
T ere are several imp rtant c nsiderati ns in interval training. T e training peri d
is the am unt time in which c ntinu us activity is actually being per rmed, and the
rec very peri d is the time between training peri ds. A set is a gr up c mbined training
and rec very peri ds, and a repetiti n is the number training/ rec very peri ds per set.
raining time r distance re ers t the rate r distance the training peri d. T e training/
rec very rati indicates a time rati r training versus rec very.
An exam ple interval training is a patient exercising n a stati nary bike. An inter-
val w rk ut inv lves 10 repetiti ns pedaling at a m axim um speed r 20 sec nds l-
l wed by pedaling at 40% maximum speed r 90 sec nds. During this interval training
sessi n, heart rate will pr bably increase t 85% t 95% maximal level while pedaling
at m axim um speed an d will pr bably all t the 35% t 45% level during the rec very
peri d.
Older adults sh uld exercise s me cauti n when using interval training as a meth d
r impr ving cardi respirat ry endurance. T e intensity levels attained during the active
peri ds may be t high and create undue risk r the lder adult.
Detraining 187
Caloric T resholds and argets

T e interplay between the durati n, intensity, and requency exercise creates a cal ric
expenditure r m exercise sessi ns. T e am unt cal ric expenditure is imp rtant t a
wide range patients, including th se interested in weight l ss, as well as th se under very
strenu us training regimens. General acceptance exists such that the health benef ts and
training changes ass ciated with exercise pr grams are related t the t tal am unt w rk
(indicated by cal ric expenditure) c mpleted. during training.1 T ese cal ric thresh lds
may be di erent t elicit impr vements in Vo 2max, weight l ss, r risk premature chr nic
disease. T e ACSM rec mmends a range 150 t 400 cal ries energy expenditure per
day in exercise r physical activity. Expenditure 1000 kcal per week sh uld be the initial
g al r th se n t previ usly engaged in regular activity. Patients sh uld be m ved t ward
the upper end the rec mmendati n (300 t 400 kcal per day) t btain ptimal f tness.
T e estimati n cal ric expenditure is easily acc mplished using the ME s ass ciated
with a given activity and the rmula 1:
(ME × 3.5 × body weight in kg)/ 200 = kcal/ m in
Numer us charts and tables exist that estimate activities in terms intensity require-
ments expressed in ME s. I a weekly g al 1000 kcal is established r a 70-kg pers n at an
intensity 6 ME s, the cal ric expenditure w uld be calculated as ll ws:
(6 × 3.5 × 70 kg)/ 200 = kcal/ m in
At an exercise intensity 6 ME s, the patient w uld need t exercise 136 minutes t

achieve the 1000 kcal g al. I the patient wants t exercise 4 days each week, 34 minutes
exercise each the 4 days will be required.
T e primary g al weight l ss is t c nsume r burn m re cal ries than are taken in
(eaten). T e cal ries used during exercise can be added t the cal ries cut r m the diet
t calculate t tal cal ric def cit needed t create weight l ss. T e a rementi ned patient
c uld reduce his r her cal ric intake by 400 kcal each day. T is will t tal 2800 kcal that have
been restricted r m the diet. T ese cal ries are then added t the 1000 kcal used r exer-
cise. A p und at is equivalent t 3500 kcal. T e c mbinati n reduced cal ric intake
and increased used kcal r exercise in the example is 3800 kcal, r slightly m re than 1
p und weight l ss in 1 week.
Combining Continuous and Interval raining

As indicated previ usly, m st physical activities inv lve s me c mbinati n aer bic and
anaer bic metab lism.60 C ntinu us training is generally d ne at an intensity level that pri-
marily uses the aer bic system. In interval training, the intensity is su cient t necessitate
a greater percentage anaer bic metab lism.19 T ere re, r the physically active patient,
the therapist sh uld inc rp rate b th training techniques int a rehabilitati n pr gram t
maximize cardi respirat ry f tness.
Detraining
Physical training pr m tes a wide range physi l gic training. T ese include increased
size and number mit ch ndria, increased capillary bed density, changes in resting
and exercise heart rate, bl d pressure, my cardial xygen c nsumpti n, and impr ved
.
Vo 2max t menti n a ew. It w uld seem l gical that i the stimulus (exercise) is rem ved,
these changes will dissipate. L ng peri ds inactivity are ass ciated with the reversal
the a rementi ned changes. Impr vements may be l st in as little as 12 days t as l ng as
several m nths t see a c mplete reversal changes.
SUMMARY
1. T e therapist sh uld r utinely inc rp rate activities that will help maintain levels
cardi respirat ry endurance int the rehabilitati n pr gram.
2. Cardi respirat ry endurance inv lves the c rdinated uncti n the heart, lungs,
bl d, and bl d vessels t supply su cient am unts xygen t the w rking tissues.
3. T e best indicat r h w e ciently the cardi respirat ry system uncti ns is the maxi-
mal rate at which xygen can be used by the tissues.
4. Heart rate is directly related t the rate xygen c nsumpti n. It is there re p ssi-
ble t predict the intensity the w rk in terms a rate xygen use by m nit ring
heart rate.
5. Aer bic exercise inv lves an activity in which the level intensity and durati n is l w
en ugh t pr vide a su cient am unt xygen t supply the demands the w rking
tissues.
6. In anaer bic exercise, the intensity the activity is s high that xygen is being used
m re quickly than it can be supplied; thus, an xygen debt is incurred that must be re-
paid be re w rking tissue can return t its n rmal resting state.
7. C ntinu us r sustained training r maintenance cardi respirat ry endurance in-
v lves selecting an activity that is aer bic in nature and training at least 3 times per
week r a time peri d n less than 20 minutes with the heart rate elevated t at least
60% maximal rate.
8. Interval training inv lves alternating peri ds relatively intense w rk ll wed by ac-
tive rec very peri ds. Interval training all ws per rmance m re w rk at a relatively
higher w rkl ad than c ntinu us training.
9. Aer bic exercise is a very p wer ul t l when c nsidering the decreased m rtality and
m rbidity ass ciated with impr vements in uncti nal capacity. T e therapist with a
w rking kn wledge the principles exercise prescripti n and testing are best ca-
pable ensuring the sa ety and e ectiveness interventi ns.
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Appendix
Med Sci Sports Exerc. 2011;43(7):1334-1359.
American College of Sport s Medicine Posit ion St and

Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory,
Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for
Prescribing Exercise
Car l Ewing Garber, PhD, FACSM, (Chair); Bryan Blissmer, PhD; Michael R. Deschenes,
PhD, FACSM; Barry A. Franklin, PhD, FACSM; Michael J. Lam nte, PhD, FACSM; I-Min Lee,
MD, ScD, FACSM; David C. Nieman, PhD, FACSM; David P. Swain, PhD, FACSM
Summary
T e purp se this P siti n Stand is t pr vide guidance t pr essi nals wh c unsel and
prescribe individualized exercise t apparently healthy adults all ages. T ese rec mmen-
dati ns als may apply t adults with certain chr nic diseases r disabilities, when appr -
priately evaluated and advised by a health pr essi nal. T is d cument supersedes the 1998
American C llege Sp rts Medicine (ACSM) P siti n Stand, “T e Rec mmended Quantity
Appendix 191
and Quality Exercise r Devel ping and Maintaining Cardi respirat ry and Muscular
Fitness, and Flexibility in Healthy Adults.” T e scientif c evidence dem nstrating the ben-
ef cial e ects exercise is indisputable, and the benef ts exercise ar utweigh the risks
in m st adults. A pr gram regular exercise that includes cardi respirat ry, resistance,
exibility, and neur m t r exercise training beyond activities daily living t impr ve and
maintain physical f tness and health is essential r m st adults. T e ACSM rec mmends
that m st adults engage in m derate-intensity cardi respirat ry exercise training r
≥30 min·day−1 n ≥5 days·wk−1 r a t tal ≥150 min·wk−1, vig r us-intensity cardi respi-
rat ry exercise training r ≥20 min·day−1 n ≥3 days·wk−1 (≥75 min·wk−1), r a c mbinati n
m derate- and vig r us-intensity exercise t achieve a t tal energy expenditure ≥500
t 1000 ME ·min·wk−1. On 2 t 3 days·wk−1, adults sh uld als per rm resistance exercises
r each the maj r muscle gr ups, and neur m t r exercise inv lving balance, agility,
and c rdinati n. Crucial t maintaining j int range m vement, c mpleting a series
exibility exercises r each the maj r muscle-tend n gr ups (a t tal 60 s per exercise) n
≥2 days·wk−1 is rec mmended. T e exercise pr gram sh uld be m dif ed acc rding t an
individual’s habitual physical activity, physical uncti n, health status, exercise resp nses,
and stated g als. Adults wh are unable r unwilling t meet the exercise targets utlined
here still can benef t r m engaging in am unts exercise less than rec mmended. In addi-
ti n t exercising regularly, there are health benef ts in c ncurrently reducing t tal time
engaged in sedentary pursuits and als by interspersing requent, sh rt b uts standing
and physical activity between peri ds sedentary activity, even in physically active adults.
Behavi rally based exercise interventi ns, the use behavi r change strategies, supervi-
si n by an experienced f tness instruct r, and exercise that is pleasant and enj yable can
impr ve ad pti n and adherence t prescribed exercise pr grams. Educating adults ab ut
and screening r signs and sympt ms CHD (c r nary heart disease) and gradual pr -
gressi n exercise intensity and v lume may reduce the risks exercise.54 C nsultati ns
with a medical pr essi nal and diagn stic exercise testing r CHD are use ul when clini-
cally indicated but are n t rec mmended r universal screening t enhance the sa ety
exercise.
Many pe ple are currently inv lved in cardi respirat ry f tness and resistance train-
ing pr grams, and e rts t pr m te participati n in all rms physical activity are
being devel ped and implemented. T us, the need r guidelines r exercise prescripti n
is apparent. Based n the existing evidence c ncerning exercise prescripti n r healthy
adults and the need r guidelines, the ACSM makes ew rec mmendati ns r the quantity
and quality training r devel ping and maintaining cardi respirat ry f tness, b dy c m-
p siti n, muscular strength and endurance, and exibility in the healthy adult.
How Much Physical Act ivit y is Needed t o

Improve Healt h and Cardiorespirat ory Fit ness?
Several studies have supp rted a d se–resp nse relati nship between chr nic physical
activity levels and health utc mes,24,62 such that greater benef t is ass ciated with higher
am unts physical activity. Data regarding the specif c quantity and quality physical
activity r the attainment the health benef ts are less clear. Epidemi l gic studies have
estimated the volum e physical activity needed t achieve specif c health benef ts, typically
expressed as kil cal ries per week (kcal·wk−1), ME -minutes per week (ME ·min·wk−1), r
ME -h urs per week (ME ·h·wk−1). Large pr spective c h rt studies diverse p pula-
ti ns32,36,48,53 clearly sh w that an energy expenditure appr ximately 1000 kcal·wk−1
m derate-intensity physical activity ( r ab ut 150 min·wk−1) is ass ciated with l wer rates
CVD (cardi vascular disease) and premature m rtality. T is is equivalent t an intensity
ab ut 3 t 5.9 ME s ( r pe ple weighing 68 t 91 kg) and 10 ME ·h·wk−1. en ME -
h urs per week can als be achieved with ≥20 min·day−1 vig r us-intensity (≥ 6 ME s)
physical activity per rmed ≥3 days·wk−1 r r a t tal 75 min·wk−1. Previ us investi-

gati ns have suggested that there may be a d se–resp nse relati nship between energy
expenditure and depressi n, but additi nal study is needed t c nf rm this p ssibility.25
Muscular St rengt h and Endurance, Body Composit ion, and Flexibilit y

1. Resistance training. Resistance training sh uld be an integral part an adult f tness
pr gram and a su cient intensity t enhance strength, muscular endurance,
and maintain at- ree mass. Resistance training sh uld be pr gressive in nature,
individualized, and pr vide a stimulus t all the maj r muscle gr ups. One set
8 t 10 exercises that c nditi ns the maj r muscle gr ups 2 t 3 days per week
is rec mmended. Multiple-set regimens may pr vide greater benef ts i time
all ws. M st pers ns sh uld c mplete 8 t 12 repetiti ns each exercise; h wever,
r lder and m re rail pers ns (aged appr ximately 50 t 60 years and ab ve),
10 t 15 repetiti ns may be m re appr priate.
2. Flexibility training. Flexibility exercises sh uld be inc rp rated int the verall
f tness pr gram su cient t devel p and maintain range m ti n. T ese exercises
sh uld stretch the maj r muscle gr ups and be per rmed a minimum 2 t 3 days
per week. Stretching sh uld include appr priate static and/ r dynamic techniques.
Impaired Mobility
Re sto ring Rang e o f Mo tio n
and Impro ving Fle xibility
OBJJECTIVE
De ne exibility and describe its importance in injury rehabilitation.
Identify factors that limit exibility.
Differentiate between active and passive range of motion.
Explain the difference between dynamic, static, and proprioceptive neuromuscular facilitation
stretching.
Discuss the neurophysiologic principles of stretching.
Describe stretching exercises that may be used to improve exibility at speci c joints throughout
the body.
Compare and contrast the various manual therapy techniques including myofascial release,
strain/counterstrain, positional release, soft tissue mobilization, and massage that can be used
to improve mobility and range of motion.
193
194 Chapte r 8 Impaired Mobility
When injury occurs, there is alm ost always som e associated loss o the ability to m ove
normally. Loss o m otion may be a result o pain, swelling, muscle guarding, or spasm ;
inactivity resulting in shortening o connective tissue and muscle; loss o neuromuscular
control; or som e combination o these actors. Restoring normal range o motion ollow-
ing injury is one o the primary goals in any rehabilitation program.90 T us the therapist
must routinely include exercise designed to restore normal range o motion to regain nor-
mal unction.
Flexibility has been def ned as the ability to move a joint or series o joints through a
ull, nonrestricted, pain- ree range o motion.2,3,28,40,46,72,88 Flexibility is dependent on a com-
bination o (a) joint range o motion, which may be limited by the shape o the articulating
sur aces and by capsular and ligamentous structures surrounding that joint; and (b) muscle
exibility, or the ability o the musculotendinous unit to lengthen.102 Flexibility involves the
ability o the neuromuscular system to allow or e cient movement o a joint through a
range o motion.3,31,48,52,83,105
Flexibility can be discussed in relation to movement involving only 1 joint, such as the
knees, or movement involving a whole series o joints, such as the spinal vertebral joints,
that must all move together to allow smooth bending or rotation o the trunk. Lack o ex-
ibility in 1 joint or movement can a ect the entire kinetic chain. A person might have good
range o motion in the ankles, knees, hips, back, and one shoulder joint but lack normal
movement in the other shoulder joint; this is a problem that needs to be corrected be ore
the person can unction normally.11,20
T is chapter concentrates prim arily on rehabilitative techniques used to increase
the length o the musculotendinous unit and its associated ascia, as well as restricted
n eural tissue. In addition , a discussion o a variety o m anual therapy techn iques
in cludin g m yo ascial release, strain / counterstrain , positional release therapy, so t-
tissue m obilization, and massage as they relate to im proving m obility will be included.
Joint m obilization and traction techniques used to address tightness in the joint cap-
sule and surrounding ligam ents are discussed in Chapter 13. Loss o the ability to con-
trol m ovem ent as a result o im pairm ent in n eurom uscular control was discussed in
Chapter 9 .
Importance of Flexibility to the Patient

Maintaining a ull, nonrestricted range o motion has long been recognized as essential to
normal daily living. Lack o exibility can also create uncoordinated or awkward movement
patterns resulting rom lost neuromuscular control. In most patients, unctional activities
require relatively “normal” amounts o exibility.77 However some sport activities, such
as gymnastics, ballet, diving, karate, and especially dance require increased exibility or
superior per ormance 23 (Figure 8-1).
It has also been generally accepted that exibility is essential or improving per or-
mance in physical activities.25 However, a review o the evidence-based in ormation in the
literature looking at the relationship between exibility and improved per ormance is, at
best, con icting and inconclusive.43,59,104 Although many studies done over the years have
suggested that stretching improves per ormance,11,59,76,111 several recent studies have ound
that stretching causes decreases in per ormance parameters such as strength, endurance,
power, joint position sense, and reaction times.9,13,30,42,43,61,65,70,78,83,85,93,106,110
T e same can be said when examining the relationship between exibility and reduc-
ing the incidence o injury. While it is generally accepted that good exibility reduces the
likelihood o injury, a true cause-and-e ect relationship has not been clearly established in
the literature.4,5,19,76,107,110
Anatomic Factors That Limit Flexibility 195
Figure 8-1 Extre me e xibility
Certain dance and athletic activities require extreme flexibility for

successful performance.
Anatomic Factors T at Limit Flexibility

A number o anatomic actors can limit the ability o a joint to move through a ull, unre-
stricted range o m otion.84 Muscles and their tendons, along with their surrounding as-
cial sheaths, are most o ten responsible or lim iting range o motion. When per orming
stretching exercises to im prove exibility about a particular joint, you are attem pting
to take advantage o the highly elastic properties o a muscle. Over time it is possible to
increase the elasticity, or the length that a given muscle can be stretched. Persons who
have a good deal o movement at a particular joint tend to have highly elastic and exible
muscles.
Connective tissue surrounding the joint, such as ligaments on the joint capsule, can be
subject to contractures. Ligaments and joint capsules have some elasticity; however, i a
joint is immobilized or a period o time, these structures tend to lose some elasticity and
actually shorten. T is condition is most commonly seen a ter surgical repair o an unstable
joint, but it can also result rom long periods o inactivity.
It is also possible or a person to have relatively slack

ligaments and joint capsules. T ese people are generally
re erred to as being loose-jointed. Examples o this trait
would be an elbow or knee that hyperextends beyond
180 degrees (Figure 8-2). Frequently, there is instabil-
ity associated with loose-jointedness that can present as
great a problem in movement as ligamentous or capsular
contractures.
Bony structure can restrict the end point in the range.
Figure 8-2 An elbow that has been ractured through the joint might
lay down excess calcium in the joint space, causing the
Excessive joint motion, such as the hyperextended elbow, joint to lose its ability to ully extend. However, in many
can predispose a joint to injury. instances we rely on bony prominences to stop move-
ments at normal end points in the range.
Fat can also limit the ability to move through a ull
range o motion. A person who has a large amount o at on the abdomen might have
severely restricted trunk exion when asked to bend orward and touch the toes. T e at can
act as a wedge between 2 lever arms, restricting movement wherever it is ound.
Skin might also be responsible or limiting movement. For example, a person who has
had some type o injury or surgery involving a tearing incision or laceration o the skin,
particularly over a joint, will have inelastic scar tissue ormed at that site. T is scar tissue is
incapable o stretching with joint movement.
Over time, skin contractures caused by scarring o ligaments, joint capsules, and mus-
culotendinous units are capable o improving elasticity to varying degrees through stretch-
ing. With the exception o bone structure, age, and gender, all the other actors that limit
exibility can be altered to increase range o joint motion.
Neural tissue tightness resulting rom acute compression, chronic repetitive micro-
trauma, muscle imbalances, joint dys unction, or poor posture can create morphologic
changes in neural tissues. T ese changes might include intraneural edema, tissue hypoxia,
chemical irritation, or microvascular stasis—all o which could stimulate nociceptors, cre-
ating pain. Pain causes muscle guarding and spasm to protect the in amed neural struc-
tures, and this alters normal movement patterns. Eventually neural f brosis results, which
decreases the elasticity o neural tissue and prevents normal movement within surrounding
tissues.21
Active and Passive Range of Motion

Active range o m otion, also called dynam ic f exibility, re ers to the degree to which a
joint can be m oved by a muscle contraction, usually through the m idrange o movem ent.
Dynam ic exibility is not necessarily a good indicator o the sti ness or looseness o a
joint because it applies to the ability to m ove a joint e ciently, with little resistance to
motion.48
Passive range o motion, sometimes called static f exibility, re ers to the degree to which
a joint can be passively moved to the end points in the range o motion. No muscle contrac-
tion is involved to move a joint through a passive range.
When a muscle actively contracts, it produces a joint movement through a specif c
range o motion.83,100 However, i passive pressure is applied to an extremity, it is capable o
moving arther in the range o motion. It is essential in sports activities that an extremity be
capable o moving through a nonrestricted range o motion.87
Passive range o motion is important or injury prevention. T ere are many situations in
physical activity in which a muscle is orced to stretch beyond its normal active limits. I the
Stretching to Improve Mobility 197
A B
Figure 8-3
Measurement of active knee joint flexion using (A) a universal goniometer, or (B) a digital goniometer.
muscle does not have enough elasticity to compensate or this additional stretch, it is likely
that the musculotendinous unit will be injured.
Assessment of Act ive and Passive Range of Mot ion

Accurate measurement o active and passive range o joint motion is di cult.50 Various
devices have been designed to accommodate variations in the size o the joints, as well
as the complexity o movements in articulations that involve more than 1 joint.50 O these
devices, the simplest and most widely used is the goniom eter (Figure 8-3).
A goniometer is a large protractor with measurements in degrees. By aligning the indi-
vidual arms o the goniometer parallel to the longitudinal axis o the 2 segments involved
in motion about a specif c joint, it is possible to obtain reasonably accurate measurement
o range o movement. o enhance reliability, standardization o measurement techniques
and methods o recording active and passive ranges o motion are critical in individual
clinics where successive measurements might be taken by di erent therapists to assess
progress.49 able 8-1 provides a list o what would be considered normal active ranges or
movements at various joints.
T e goniometer has an important place in a rehabilitation setting, where it is essential
to assess improvement in joint exibility to modi y injury rehabilitation programs.
In some clinics a digital inclinometer is used instead o a goniometer. An inclinometer
is a more precise measuring instrument with high reliability that has most o ten been used
in research settings. Digital inclinometers are a ordable and can easily be used to accu-
rately measure range o motion o all joints o the body rom complex movements o the
spine and large joints o the extremities to the small joints o f ngers and toes.
Stretching to Improve Mobility

T e goal o any e ective stretching program should be to improve the range o motion at
a given articulation by altering the extensibility o the neuromusculotendinous units that
produce movement at that joint. It is well documented that exercises that stretch these
able 8-1 Active Rang e s o f Jo int Mo tio ns
Jo int Actio n De g re e s o f Mo tio n
Shoulder Flexion 0 to 180

Extension 0 to 50
Abduction 0 to 180
Medial rotation 0 to 90
Lateral rotation 0 to 90
Flexion 0 to 90
Elbow Flexion 0 to 160
Forearm Pronation 0 to 90
Supination 0 to 90
Wrist Flexion 0 to 90
Extension 0 to 70
Abduction 0 to 25
Adduction 0 to 65
Hip Flexion 0 to 125

Extension 0 to 15
Abduction 0 to 45
Adduction 0 to 15
Medial rotation 0 to 45
Lateral rotation 0 to 45
Knee Flexion 0 to 140
Ankle Plantar exion 0 to 45

Dorsi exion 0 to 20
Foot Inversion 0 to 30
Eversion 0 to 10
neuromusculotendinous units and their ascia over time will increase the range o move-
ment possible about a given joint.41,80
For many years the e cacy o stretching in improving range o m otion has been theo-
retically attributed to neurophysiologic phenom ena involving the stretch re ex. However,
a recent study that extensively reviewed the existing literature suggested that im prove-
m ents in range o m otion resulting rom stretching must be explained by m echanism s
other than the stretch re ex.19 Studies reviewed indicate that changes in the ability to
tolerate stretch and/ or the viscoelastic properties o the stretched muscle are possible
m echanism s.
Clin ica l Pe a r l
A goniometer can be used to measure the angle be tween the femur and the bula, giving
you degrees of exion and extension. To maximize consistency in measurement, it is helpful
if the same person takes sequential goniometric measurement.
Effects of Stretching on the Physical and Mechanical Properties of Muscle 199
Neurophysiologic Basis of Stretching

Every muscle in the body contains various types o mechanoreceptors that, when stimu-
lated, in orm the central nervous system o what is happening with that muscle.22 wo o
these mechanoreceptors are important in the stretch re ex: the m uscle spindle and the
Golgi tendon organ. Both types o receptors are sensitive to changes in muscle length. T e
Golgi tendon organs are also a ected by changes in muscle tension.15
When a muscle is stretched, both the muscle spindles and the Golgi tendon organs
immediately begin sending a volley o sensory impulses to the spinal cord. Initially impulses
coming rom the muscle spindles in orm the central nervous system that the muscle is
being stretched. Impulses return to the muscle rom the spinal cord, causing the muscle
to re exively contract, thus resisting the stretch.68 T e Golgi tendon organs respond to the
change in length and the increase in tension by f ring o sensory impulses o their own to
the spinal cord. I the stretch o the muscle continues or an extended period o time (at
least 6 seconds), impulses rom the Golgi tendon organs begin to override muscle spindle
impulses. T e impulses rom the Golgi tendon organs, unlike the signals rom the muscle
spindle, cause a re ex relaxation o the antagonist muscle. T is re ex relaxation serves as
a protective mechanism that will allow the muscle to stretch through relaxation without
exceeding the extensibility limits, which could damage the muscle f bers.12 T is relaxation
o the antagonist muscle during contractions is re erred to as autogenic inhibition.
In any synergistic muscle group, a contraction o the agonist causes a re ex relaxation
in the antagonist muscle, allowing it to stretch and protecting it rom injury. T is phenom-
enon is re erred to as reciprocal inhibition 92 (see Figure 12-32).
E ects of Stretching on the Physical

and Mechanical Properties of Muscle
T e neurophysiologic m echanism s o both autogenic and reciprocal inhibition result in
re ex relaxation with subsequent lengthening o a m uscle. T us the m echanical prop-
erties o that muscle that physically allow lengthening to occur are dictated via neural
input.
Both muscle and tendon are composed largely o noncontractile collagen and elastin
f bers. Collagen enables a tissue to resist mechanical orces and de ormation, whereas elas-
tin composes highly elastic tissues that assist in recovery rom de ormation.62
Collagen has several mechanical and physical properties that allow it to respond to
loading and de ormation, permitting it to withstand high tensile stress.103 T e mechanical
properties o collagen include (a) elasticity, which is the capability to recover normal length
a ter elongation; (b) viscoelasticity, which allows or a slow return to normal length and
shape a ter de ormation; and (c) plasticity, which allows or permanent change or de orma-
tion. T e physical properties include (a) orce-relaxation, which indicates the decrease in
the amount o orce needed to maintain a tissue at a set amount o displacement or de or-
mation over time; (b) the creep response, which is the ability o a tissue to de orm over time
while a constant load is imposed; and (c) hysteresis, which is the amount o relaxation a tis-
sue has undergone during de ormation and displacement. I the mechanical and physical
limitations o connective tissue are exceeded, injury results.
Unlike tendon, muscle also has active contractile components that are the actin and
myosin myof laments. Collectively the contractile and noncontractile elements determine
the muscle’s capability o de orming and recovering rom de ormation.112
Both the contractile and the noncontractile components appear to resist de ormation
when a muscle is stretched or lengthened. T e percentage o their individual contribution to
resisting de ormation depends on the degree to which the muscle is stretched or de ormed
and on the velocity o de ormation. T e noncontractile elements are primarily resistant to
the degree o lengthening, while the contractile elements limit high-velocity de ormation.
T e greater the stretch, the more the noncontractile components contribute.103
Lengthening o a muscle via stretching allows or viscoelastic and plastic changes to
occur in the collagen and elastin f bers. T e viscoelastic changes that allow slow de orma-
tion with imper ect recovery are not permanent. However, plastic changes, although di -
cult to achieve, result in residual or permanent change in length due to de ormation created
by long periods o stretching.
T e greater the velocity o de ormation, the greater the chance or exceeding that
tissue’s capability to undergo viscoelastic and plastic change.112
E ects of Stretching on the Kinetic Chain

Joint hypom obility is one o the m ost requently treated causes o pain. However, the
etiology can usually be traced to aulty posture, muscular im balances, and abnormal
neuromuscular control. Once a particular joint has lost its normal arthrokinematics,
the muscles around that joint attem pt to m inim ize the stress at that involved segm ent.
Certain muscles becom e tight and hypertonic to prevent additional joint translation. I
one muscle becom es tight or changes its degree o activation, then synergists, stabilizers,
and neutralizers have to com pensate, leading to the ormation o com plex neuromuscu-
loskeletal dys unctions.
Muscle tightness and hypertonicity have a signif cant impact on neuromuscular con-
trol. Muscle tightness a ects the normal length–tension relationships. When one muscle
in a orce-couple becomes tight or hypertonic, it alters the normal arthrokinematics o the
involved joint. T is a ects the synergistic unction o the entire kinetic chain, leading to
abnormal joint stress, so t-tissue dys unction, neural compromise, and vascular/ lymphatic
stasis. T ese result in alterations in recruitment strategies and stabilization strength. Such
compensations and adaptations a ect neuromuscular e ciency throughout the kinetic
chain. Decreased neuromuscular control alters the activation sequence or f ring order o
di erent muscles involved, and a specif c movement is disturbed. Prime movers may be
slow to activate, while synergists, stabilizers, and neutralizers substitute and become over-
active. When this is the case, new joint stresses will be encountered.21 For example, i the
psoas is tight or hyperactive, then the gluteus maximus will have decreased neural drive.
I the gluteus maximus (prime mover during hip extension) has decreased neural drive,
then synergists (hamstrings), stabilizers (erector spinae), and neutralizers (piri ormis) sub-
stitute and become overactive (synergistic dominance). T is creates abnormal joint stress
and decreased neuromuscular control during unctional movements.
Muscle tightness also causes reciprocal inhibition. Increased muscle spindle activ-
ity in a specif c m uscle will cause decreased neural drive to that muscle’s unctional
antagonist. T is alters the normal orce-couple activity, which, in turn, a ects the nor-
m al arthrokinematics o the involved segm ent. For exam ple, i a patient has tightness
or hypertonicity in the psoas, then the unctional antagonist (gluteus maximus) can be
inhibited (decreased neural drive), causing decreased neuromuscular control. T is, in
turn, leads to synergistic dom inance—the neuromuscular phenom enon that occurs when
synergists com pensate or a weak and/ or inhibited muscle to maintain orce production
capabilities.21 T is process alters the normal orce-couple relationships, which, in turn,
creates a chain reaction.
Stretching Techniques 201
Importance of Increasing Muscle

emperature Prior to Stretching
o most e ectively stretch a muscle during a program o rehabilitation, intramuscular
temperature should be increased prior to stretching.75 Increasing the temperature has
a positive e ect on the ability o the collagen and elastin components within the muscu-
lotendinous unit to de orm. Also, the capability o the Golgi tendon organs to re exively
relax the muscle through autogenic inhibition is enhanced when the muscle is heated. It
appears that the optimal temperature o muscle to achieve these benef cial e ects is 39°C
(103°F). T is increase in intramuscular temperature can be achieved either through low-
intensity warm-up–type exercise or through the use o various therapeutic modalities.27,44,91
It is recommended that exercise be used as the primary means or increasing intramuscular
temperature.
T e use o cold prior to stretching also has been recommended.26 Cold appears to be
most use ul when there is some muscle guarding associated with delayed-onset muscle
soreness.82
Clin ica l Pe a r l
Applying certain therapeutic modalities, such as ice and/or electrical stimulating

currents, can decrease pain and discourage muscle guarding to increase range of
motion. Delayed-onset muscle soreness will usually begin to subside at about 48 hours
following a workout.
Stretching echniques
Stretching techniques or improving exibility have evolved over the years.57 T e oldest
technique or stretching is dynam ic stretching (ballistic), which makes use o repetitive
bouncing motions. A second technique, known as static stretching, involves stretching a
muscle to the point o discom ort and then holding it at that point or an extended time.
T is technique has been used or many years. Another group o stretching techniques
known collectively as proprioceptive neurom uscular acilitation (PNF) techniques, involv-
ing alternating contractions and stretches, also has been recommended (Figure 8-4).58,108
Most recently, emphasis has been on the contribution o stretching m yo ascial tissue, as well
as stretching tight neural tissue, in enhancing the ability o the neuromuscular system to
e ciently control movement through a ull range o motion. Researchers have had consid-
erable discussion about which o these techniques is most e ective or improving range o
motion, and no clear-cut consensus currently exists.11,32,41,66,80,86
Agonist Versus Ant agonist Muscles

Be ore discussing the di erent stretching techniques, it is essential to def ne the term s
agonist m uscle and antagonist m uscle. Most joints in the body are capable o m ore than
1 m ovem ent. T e knee joint, or exam ple, is capable o exion and extension. Contrac-
tion o the quadriceps group o muscles on the ront o the thigh causes knee exten-
sion, whereas contraction o the ham string muscles on the back o the thigh produces
knee exion.
A B
Figure 8-4 Ne ural te nsio n stre tche s
A. Median nerve. B. Radial nerve. C. Sciatic nerve. D. Slump position.
o achieve knee extension, the quadriceps group contracts while the hamstring muscles
relax and stretch. Muscles that work in concert with one another in this manner are called
synergistic m uscle groups.8 T e muscle that contracts to produce a movement, in this case the
quadriceps, is re erred to as the agonist m uscle. T e muscle being stretched in response to con-
traction o the agonist muscle is called the antagonist m uscle.40 In this example o knee exten-
sion, the antagonist muscle would be the hamstring group. Some degree o balance in strength
must exist between agonist and antagonist muscle groups. T is balance is necessary or normal,
smooth, coordinated movement, as well as or reducing the likelihood o muscle strain caused
Stretching Techniques 203
by muscular imbalance. Comprehension o this synergistic muscle action is essential to
understanding the various techniques o stretching.
Dynamic St ret ching

In dynamic stretching, repetitive contractions o the ago nist muscle are used to produce
quick stretches o the antagonist muscle.
Over the years, many f tness experts have questioned the sa ety o the dynamic stretch-
ing technique.47,68 T eir concerns have been primarily based on the idea that dynamic
stretching creates somewhat uncontrolled orces within the muscle that can exceed the
extensibility limits o the muscle f ber, thus producing small microtears within the muscu-
lotendinous unit.35,39,74,112 Certainly this might be true in sedentary individuals or perhaps
in individuals who have sustained muscle injuries.
However, m any physical activities are dynam ic and require a repeated dynam ic
contraction o the agon ist m uscle. T e antagon ist contracting eccentrically to decel-
erate the dynam ic stretching o the antagon ist m uscle be ore en gaging in this type o
activity should allow the muscle to gradually adapt to the im posed dem ands and reduce
the likelihood o in jury. Because dynam ic stretchin g is m ore un ctional, it should
be integrated into a reconditioning program during the later stages o healin g when
appropriate.
A progressive velocity exibility program has been proposed that takes the patient
through a series o stretching exercises where the velocity o the stretch and the range o
lengthening are progressively controlled.81 T e stretching exercises progress rom slow static
stretching to slow, short, end-range stretching, to slow, ull-range stretching, to ast, short,
end-range stretching, and to ast, ull-range stretching. T is program allows the patient to
control both the range and the speed with no assistance rom a therapist.
Clin ica l Pe a r l
Ballistic stretching is dynamic stretching that is use ful prior to activity because it is a
functional stretch. It mimics activity that will be performed during com petition. However,
there is some speculation that because it is an uncontrolled stretch, it may lead to injury,
especially in sedentary individuals. Static stretching is convenient because it can be done
on any muscle and it doesn’t require a partner. It is not very functional. PNF stretching
will most likely provide the greatest increase in range of motion, but it is a little more
time-consuming and requires a partner.
St at ic St ret ching
T e static stretching technique is another extremely e ective and widely used technique
o stretching.52 T is technique involves stretching a given antagonist muscle passively by
placing it in a maximal position o stretch and holding it there or an extended time. Recom-
mendations or the optimal time or holding this stretched position vary, ranging rom as
short as 3 seconds to as long as 60 seconds.48 Several studies indicate that holding a stretch
or 15 to 30 seconds is the most e ective or increasing muscle exibility.6,64,67 Stretches
lasting longer than 30 seconds seem to be uncom ortable. A static stretch o each muscle
should be repeated 3 or 4 times. A static stretch can be accomplished by using a contraction
o the agonist muscle to place the antagonist muscle in a position o stretch. A passive static
stretch requires the use o body weight, assistance rom a therapist or partner, or use o a
T-bar, primarily or stretching the upper extremity.
Clin ica l Pe a r l
A static stretch should be held for approximately 30 seconds. This allows time for the Golgi
tendon organs to override the muscle spindles and produce a re ex muscle relaxation. The
patient should stretch to the point where tightness or resistance to stretch is felt but it
should not be painful. The stretch should be repeated 3 to 5 times.
Propriocept ive Neuromuscular

Facilit at ion St ret ching Techniques
Proprioceptive neuromuscular acilitation techniques were f rst used by therapists
or treating patients who had various neuromuscular disorders.58 More recently, PNF
stretching exercises have increasingly been used as a stretching technique or improving
exibility.15,24,64,71,73
T ere are 3 di erent PNF techniques used or stretching: contract-relax, hold-relax
techniques, and slow reversal-hold-relax.102 All 3 techn iques involve som e com bina-
tion o alternating isom etric or isotonic contractions and relaxation o both agonist and
antagonist muscles (a 10-second pushing phase ollowed by a 10-second relaxing phase).
Contract-relax is a stretching technique that moves the body part passively into the ago-
nist pattern. T e patient is instructed to push by contracting the antagonist (the muscle
that will be stretched) isotonically against the resistance o the therapist. T e patient then
relaxes the antagonist while the therapist moves the part passively through as much range
as possible to the point where limitation is again elt. T is contract-relax technique is ben-
ef cial when range o motion is limited by muscle tightness.
Hold-relax is very similar to the contract-relax technique. It begins with an isometric
contraction o the antagonist (the muscle that will be stretched) against resistance, com-
bined with light pressure rom the therapist to produce maximal stretch o the antagonist.
T is technique is appropriate when there is muscle tension on one side o a joint and may
be used with either the agonist or the antagonist. T is techniques is also re erred to as a
m uscle energy technique and will be discussed in Chapter 12.16
Slow reversal-hold-relax, also occasionally re erred to as the contract-relax-agonist-
contraction technique, begins with an isotonic contraction o the agonist, which o ten limits
range o motion in the agonist pattern, ollowed by an isometric contraction o the antag-
onist (the muscle that will be stretched) during the push phase. During the relax phase,
the antagonists are relaxed while the agonists are contracting, causing movement in the
direction o the agonist pattern and thus stretching the antagonist. T is technique, like the
contract-relax and hold-relax, is use ul or increasing range o motion when the primary
limiting actor is the antagonistic muscle group.
PNF stretching techniques can be used to stretch any muscle in the body.11,28,29,34,71,74,79,
82,86,102
PNF stretching techniques are perhaps best per ormed with a partner, although they
may also be done using a wall as resistance.
Comparing St ret ching Techniques

Although all 3 stretching techniques discussed to this point have been demonstrated
to e ectively improve exibility, there is still considerable debate as to which technique
produces the greatest increases in range o movement.7 T e dynamic technique is recom-
mended or anyone who is involved in dynamic activity, despite its potential or causing
muscle soreness in the sedentary individual. In physically active individuals, it is unlikely
that dynamic stretching will result in muscle soreness.
Speci c Stretching Exercises 205
Static stretching is perhaps the most widely used technique. It is a simple technique and
does not require a partner. A ully nonrestricted range o motion can be attained through
static stretching over time.
Much research has been done comparing dynamic and static stretching techniques or
the improvement o exibility. Static and dynamic stretching appear to be equally e ective
in increasing exibility, and there is no signif cant di erence between the two.36 However,
much o the literature states that with static stretching there is less danger o exceeding the
extensibility limits o the involved joints because the stretch is more controlled. Most o the
literature indicates that dynamic stretching is apt to cause muscular soreness, especially
in sedentary individuals, whereas static stretching generally does not cause soreness and
is commonly used in injury rehabilitation o sore or strained muscles.35,109 Static stretch-
ing is likely a much sa er stretching technique, especially or sedentary individuals. How-
ever, because many physical activities involve dynamic movement, stretching in a warm-up
should begin with static stretching ollowed by dynamic stretching, which more closely
resembles the dynamic activity. PNF stretching techniques are capable o producing dra-
matic increases in range o motion during one stretching session.14 Studies comparing static
and PNF stretching suggest that PNF stretching is capable o producing greater improve-
ment in exibility over an extended training period.45,46,82 T e major disadvantage o PNF
stretching is that a partner is usually required to assist with the stretch, although stretching
with a therapist or partner can have some motivational advantages.
How long increases in muscle exibility can be sustained once stretching stops is debat-
able.38,94,113 One study indicated that a signif cant loss o exibility was evident a ter only 2
weeks.113 It was recommended that exibility can be maintained by engaging in stretching
activities at least once a week. However, to see improvement in exibility, stretching must
be done 3 to 5 times per week.37
St ret ching Neural St ruct ures

T e therapist should be able to di erentiate between tightness in the musculotendinous unit
and abnormal neural tension. T e patient should per orm both active and passive multipla-
nar movements that create tension in the neural structures that are exacerbating pain, limit-
ing range o motion, and increasing neural symptoms, including numbness and tingling.21 For
example, the straight-leg raising test not only applies pressure to the sacroiliac joint cell but
also may indicate a problem in the sciatic nerve (Figure 8-4C). Internally rotating and adduct-
ing the hip increases the tension on the neural structures in both the greater sciatic notch and
the intervertebral oramen. An exacerbation o pain rom 30 degrees to 60 degrees indicates
some sciatic nerve involvement. I dorsi exing the ankle with maximum straight leg raising
increases the pain, then the pain is likely caused by some nerve root (L3-4, S1-3) or sciatic
nerve irritation. Figure 8-4 shows the assessment and stretching positions or neural tension
in the median, radial, and sciatic nerves as well as the vertebral nerve roots in the spine.
Speci c Stretching Exercises

Chapters 25 to 32 include various stretching exercises that may be used to improve ex-
ibility at specif c joints or in specif c muscle groups throughout the body. T e stretching
exercises shown in Figure 8-5 are examples that may be done statically; they may also be
done with a partner using a PNF technique. T ere are many possible variations to each o
these exercises.54 T e patient may also per orm static stretching exercises using a stabil-
ity ball (Figure 8-6). T e exercises selected are those that seem to be the most e ective or
stretching o various muscle groups. able 8-2 provides a list o guidelines and precautions
or stretching.
B C
Figure 8-5
Examples of stretching exercises that may be done statically or using a PNF technique. A. Quadriceps. B. Hip abductors.
C. Piriformis.
Alternative Stretching echniques
The Pilat es Met hod of St ret ching

T e Pilates m ethod is a som ewhat di erent approach to stretching or im proving ex-
ibility. T is m ethod has becom e extrem ely popular and widely used am ong personal
f tness trainers, physical therapists, and som e therapists. Pilates is an exercise technique
devised by German-born Joseph Pilates, who established the f rst Pilates studio in the
Un ited States be ore World War II. T e Pilates m ethod is a conditioning program that
im proves m uscle control, exibility, coordination, strength, and tone.10 T e basic prin-
ciples o Pilates exercise are to make patients m ore aware o their bodies as single inte-
grated un its, to im prove body align m ent and breathing, an d to in crease e ciency o
m ovem ent. Unlike other exercise program s, the Pilates m ethod does not require the rep-
etition o exercises but instead consists o a sequence o care ully per ormed m ovem ents,
som e o which are carried out on specially designed equipm ent (Figure 8-7). However,
Alternative Stretching Techniques 207
A B
Figure 8-6 Static stre tching using a stability ball
A. Back extension. B. Standing abductor stretch. C. Latissimus dorsi stretch. D. Piriformis stretch. E. Seated hamstring
stretch.
the m ajority o Pilates exercises are per orm ed on a m at or oor without equipm ent
(Figure 8-8). Each exercise is designed to stretch and strengthen the m uscles involved.
T ere is a specif c breathing pattern or each exercise to help direct energy to the areas
being worked, while relaxing the rest o the body. T e Pilates m ethod works m any o the
deeper muscles together, im proving coordination and balance, to achieve e cient and
grace ul m ovem ent. T e goal or the patient is to develop a healthy sel -image through
the attain m ent o better posture, proper coordination, an d im proved exibility. T is
able 8-2 Guide line s and Pre cautio ns fo r a So und Stre tching Pro g ram 60,96,97,101
• Warm up using a slow jog or fast walk before stretching vigorously.

• To increase exibility, the muscle must be stretched within pain tolerances and tissue
healing limitations to attain functional or normal range of motion.
• Stretch only to the point where tightness or resistance to stretch, or perhaps some
discomfort, is felt. Stretching should not be painful.1
• Increases in range of motion will be speci c to whatever muscle or joint is being
stretched.
• Exercise caution when stretching muscles that surround painful joints. Pain is an
indication that something is wrong and should not be ignored.
• Avoid overstretching the ligaments and capsules that surround joints.
• Exercise caution when stretching the low back and neck. Exercises that compress the
vertebrae and their discs can cause damage.
• Stretching from a seated rather than a standing position takes stress off the low back
and decreases the chances of back injury.
• Be sure to continue normal breathing during a stretch. Do not hold your breath.
• Static and PNF techniques are most often recommended for individuals who want to
improve their range of motion.
• Dynamic stretching should be done only by those who are already exible or
accustomed to stretching, and should be done only after static stretching.
A B
Figure 8-7 Pilate s te chnique s using e quipme nt
A. Reformer. B. Wunda chair. C. Magic ring.

Alternative Stretching Techniques 209
A A1
B1
C C1
Figure 8-8 Pilate s o o r e xe rcise s
A. Alternating arm, opposite-leg extensions. B. Push-up to a side plank. C. Alternating leg scissors.
m ethod concentrates on body alignm ent, lengthening all the muscles o the body into a
balanced whole, and building endurance and strength without putting undue stress on
the lungs and heart. Pilates instructors believe that problem s such as so t-tissue injuries
can cause bad posture, which can lead to pain and discom ort. Pilates exercises aim to
correct this.
Yoga
Yoga originated in India approxim ately 6000 years ago. Its basic philosophy is that m ost
illness is related to poor m ental attitudes, posture, and diet. Practitioners o yoga m ain-
tain that stress can be reduced through com bined m ental and physical approaches. Yoga
can help an individual cope with stress-induced behaviors like overeating, hyperten-
sion, and sm oking. Yoga’s m editative aspects are believed to help alleviate psychoso-
matic illnesses. Yoga aim s to unite the body and m ind to reduce stress.56 For exam ple,
Dr. Chandra Patel, a yoga expert, has ound that persons who practice yoga can reduce
their blood pressure indef nitely as long as they continue to practice yoga. Yoga involves
various body postures and breathing exercises. Hatha yoga uses a num ber o positions
through which the practitioner m ay progress, beginning with the sim plest and m oving
to the m ore com plex ( Figure 8-9). T e various positions are intended to increase m obil-
ity and exibility. However, practitioners must use caution when per orm ing yoga posi-
tions. Som e positions can be dangerous, particularly or som eone who is inexperienced
in yoga technique.
Slow, deep, diaphragmatic breathing is an important part o yoga. Many people take
shallow breaths; however, breathing deeply and ully expanding the chest when inhaling
helps lower blood pressure and heart rate. Deep breathing has a calming e ect on the body.
It also increases production o endorphins.56
Manual T erapy echniques

for Increasing Mobility
Following injury, so t tissue loses some o its ability to tolerate the demands o unctional
loading. A major part o the management o so t-tissue dys unction lies in promoting so t-
tissue adaptation to restore the tissue’s ability to cope with unctional loading.53 Specif c
so t-tissue m obilization involves specif c, graded, and progressive application o orce
using physiologic, accessory, or com bined techniques either to prom ote collagen syn-
thesis, orientation, and bonding in the early stages o the healing process or to promote
changes in the viscoelastic response o the tissue in the later stages o healing. So t-tissue
mobilization should be applied in combination with rehabilitation regimes to restore the
kinetic control o the tissue.53
A variety o manual therapy techniques can be used in injury rehabilitation to improve
mobility and range o motion.
Myofascial Release St ret ching

Myo ascial release is a term that re ers to a group o techniques used or the purpose o
relieving so t tissue rom the abnormal grip o tight ascia.57 It is essentially a orm o stretch-
ing that has been reported to have signif cant impact in treating a variety o conditions.73
Some specialized training is necessary or the therapist to understand specif c techniques
o myo ascial release.89 It is also essential to have an in-depth understanding o the ascial
system.
Fascia is a type o connective tissue that surrounds m uscles, tendons, nerves, bones,
and organs. It is essentially continuous rom head to toe and is interconnected in vari-
ous sheaths or planes. Fascia is com posed prim arily o collagen along with som e elastic
f bers. During m ovem ent the ascia m ust stretch and m ove reely. I there is dam age to
the ascia owing to injury, disease, or in am mation, it will not only a ect local adjacent
structures but may also a ect areas ar rem oved rom the site o the injury.69 T us it m ay
be necessary to release tightness both in the area o injury and in distant areas. It will
tend to so ten and release in response to gentle pressure over a relatively long period
o tim e.
Myo ascial release has also been re erred to as so t-tissue m obilization. So t- tissue
m obilization should not be con used with joint m obilization, although it must be
Manual Therapy Techniques for Increasing Mobility 211
A B C
D E F
G H I
L J
M N
Figure 8-9 Yo g a po sitio ns
A. Tree. B. Triangle. C. Dancer. D. Chair. E. Extended hand to big toe. F. Big mountain. G. Lotus. H. Cobra.
I. Downward facing dog. J. Static squat. K. Pigeon. L. Child. M. Runner’s lunge with twist. N. Cat.
emphasized that the two are closely related.57 Joint m obilization is used to restore nor-
mal joint arthrokinematics, and specif c rules exist regarding direction o movement and
joint position based on the shape o the articulating sur aces (see Chapter 13). Myo ascial
restrictions are considerably more unpredictable and may occur in many di erent planes
and directions.98 Myo ascial treatm ent is based on localizing the restriction and m oving
into the direction o the restriction, regardless o whether that ollows the arthrokinemat-
ics o a nearby joint. T us, myo ascial manipulation is considerably more subjective and
relies heavily on the experience o the therapist.69 Myo ascial manipulation ocuses on
large treatment areas, whereas joint mobilization ocuses on a specif c joint. Releasing
myo ascial restrictions over a large treatment area can have a signif cant impact on joint
mobility.73 T e progression o the technique is to work rom superf cial ascial restrictions
to deeper restriction. Once more superf cial restrictions are released, the deep restrictions
can be located and released without causing any damage to superf cial tissue. Joint mobi-
lization should ollow myo ascial release and will likely be more e ective once so t-tissue
restrictions are eliminated.
As extensibility is improved in the myo ascia, elongation and stretching o the muscu-
lotendinous unit should be incorporated. In addition, strengthening exercises are recom-
mended to enhance neuromuscular reeducation, which helps promote new, more e cient
movement patterns. As reedom o movement improves, postural reeducation may help
ensure the maintenance o the less-restricted movement patterns.
Generally, acute cases tend to resolve in just a ew treatments. T e longer a condition
has been present, the longer it will take to resolve. Occasionally, dramatic results will occur
immediately a ter treatment. It is usually recommended that treatment be done at least
3 times per week.
Myo ascial release can be done manually by a therapist or by the patient stretching
using a oam roller.89 Figure 8-10 shows examples o stretching using the oam roller.
St rain-Count erst rain Technique

Strain-counterstrain is an approach to decreasing muscle tension and guarding that may be
used to normalize muscle unction. It is a passive technique that places the body in a posi-
tion o greatest com ort, thereby relieving pain.1,55
In this technique, the therapist locates “tender points” on the patient’s body that cor-
respond to areas o dys unction in specif c joints or muscles that are in need o treatment.99
T ese tender points are not located in or just beneath the skin, as are many acupuncture
points, but instead are deeper in muscle, tendon, ligament, or ascia. T ey are characterized
by tense, tender, edematous spots on the body. T ey are 1 cm or less in diameter, with the
most acute points being 3 mm in diameter, although they may be a ew centimeters long
within a muscle. T ere can be multiple points or 1 specif c joint dys unction. Points might
be arranged in a chain, and they are o ten ound in a painless area opposite the site o pain
and/ or weakness.55
T e therapist monitors the tension and level o pain elicited by the tender point while
moving the patient into a position o ease or com ort. T is is accomplished by markedly
shortening the muscle.99 When this position o ease is ound, the tender point is no longer
tense or tender. When this position is maintained or a minimum o 90 seconds, the ten-
sion in the tender point and in the corresponding joint or muscle is reduced or cleared.
By slowly returning to a neutral position, the tender point and the corresponding joint or
muscle remains pain- ree with normal tension. For example, with neck pain and/ or tension
headaches, the tender point may be ound on either the ront or back o the patient’s neck
and shoulders. T e therapist will have the patient lie on the patient’s back and will gently
A B
C D
E F
Figure 8-10 Myo fascial re le ase stre tching using a fo am ro lle r o r rm ball
A. Hamstrings. B. Piriformis. C. Adductors. D. Quadriceps. E. Latissimus dorsi. F. Rhomboids.
and slowly bend the patient’s neck until that tender point is no longer tender. A ter holding
that position or 90 seconds, the therapist gently and slowly returns the neck to its resting
position. When that tender point is pressed again, the patient should notice a signif cant
decrease in pain there (Figure 8-11).99
T e physiologic rationale or the e ectiveness o the strain-counterstrain technique
can be explained by the stretch re ex.2 When a muscle is placed in a stretched position,
impulses rom the muscle spindles create a re ex contraction o the muscle in response to
stretch. With strain-counterstrain, the joint or muscle is placed not in a position o stretch
but instead in a slack position. T us, muscle spindle input is reduced and the muscle is
relaxed, allowing or a decrease in tension and pain.2
Posit ional Release Therapy

Positional release therapy is based on the strain-coun-
terstrain technique. T e primary di erence between
the two is the use o a acilitating orce (compression) to
enhance the e ect o the positioning.17,18,90,95
Like strain-counterstrain, positional release ther-
apy is an osteopathic mobilization technique in which
the body part is moved into a position o greatest relax-
ation.33 T e therapist f nds the position o greatest
com ort and muscle relaxation or each joint with the
help o m ovement tests and diagnostic tender points.
Once located, the tender point is maintained with the
palpating f nger at a subthreshold pressure. T e patient
is then passively placed in a position that reduces the
Figure 8-11 Strain-co unte rstrain te chnique tension under the palpating f nger producing a subjec-
tive reduction in tenderness as reported by the patient.
The body part is placed in a position of comfort for T is specif c position is adjusted throughout the
90 seconds and then slowly moved back to a neutral position. 90-second treatment period. It has been suggested that
maintaining contact with the tender point during the
treatment period exerts a therapeutic e ect.17,18 T is
technique is one o the most e ective and gentle methods or the treatment o acute and
chronic musculoskeletal dys unction (Figure 8-12).90
Act ive Release Technique

T e active release technique is a relatively new type o manual therapy that has been
developed to correct so t-tissue problem s in muscle, tendon, and ascia caused by the
ormation o f brotic adhesions that result rom acute injury, repetitive or overuse inju-
ries, constant pressure, or tension injuries.63 When a muscle, tendon, ascia, or ligament is
torn (strained or sprained) or a nerve is damaged, the tissues heal with adhesions or scar
tissue orm ation rather than the ormation o brand
new tissue. Scar tissue is weaker, less elastic, less pli-
able, and m ore pain-sensitive than healthy tissue.
T ese f brotic adhesions disrupt the normal muscle
unction, which, in turn, a ects the biomechanics o
the joint complex and can lead to pain and dys unc-
tion. So t-tissue mobilization provides a way to diagnose
and treat the underlying causes o cumulative trauma
disorders that, le t uncorrected, can lead to in amma-
tion, adhesions, f brosis, and muscle imbalances. All o
these can result in weak and tense tissues, decreased
circulation, hypoxia, and symptoms o peripheral nerve
entrapment, including numbness, tingling, burning, and
aching.63 So t-tissue mobilization is a deep-tissue tech-
nique used or breaking down scar tissue/ adhesions and
restoring unction and movement.63 In so t-tissue mobi-
Figure 8-12 lization, the therapist f rst locates through palpation
those adhesions in the muscle, tendon, or ascia that
The positional release technique places the muscle in a are causing the problem. Once these are located, the
position of comfort with the finger or thumb exerting therapist traps the a ected muscle by applying pressure
submaximal pressure on a myofascial trigger point. or tension with the thumb or f nger over these lesions
A B
Figure 8-13 So ft-tissue mo bilizatio n te chnique
The muscle is elongated from a shortened position while static pressure is applied to the
tender point.
in the direction o the f bers. T en the patient is asked to actively move the body part such
that the musculature is elongated rom a shortened position while the therapist continues to
apply tension to the lesion (Figure 8-13). T is should be repeated 3 to 5 times per treatment
session. By breaking up the adhesions, the technique improves the patient’s condition by
so tening and stretching the scar tissue, resulting in increased range o motion, increased
strength, and improved circulation, optimizing healing. reatments tend to be uncom ort-
able during the movement phases as the scar tissue or adhesions tear apart.63 T is is tempo-
rary and subsides almost immediately a ter the treatment. An important part o so t-tissue
mobilization is or the patient to heed the therapist’s recommendations regarding activity
modif cation, stretching, and exercise.
Grast on Technique
T e Graston echnique is an instrument-assisted so t-tissue mobilization that enables clini-
cians to e ectively break down scar tissue and ascial restrictions as well as stretch connec-
tive tissue and muscle f bers (Figure 8-14).36,51 T e technique utilizes 6 hand-held specially
designed stainless steel instruments shaped to f t the contour o the body, to scan an
area, locate, and then treat the injured tissue that is causing pain and restricting motion.51
A clinician normally will palpate a pain ul area looking or usual nodules, restrictive barri-
ers or tissue tensions. T e instruments help to magni y existing restrictions and the clini-
cian can eel these through the instruments.36 T en the clinician can utilize the instruments
to supply precise pressure to break up scar tissue, relieving the discom ort and helping to
restore normal unction. T e instruments, with a narrow sur ace area at their edge, have the
ability to separate f bers.
A specially designed lubricant is applied to the skin prior to using the instrument,
allowing the instrument to glide over the skin without causing irritation. Using a cross-
riction massage in multiple directions, which involves using the instruments to stroke or
rub against the grain o the scar tissue, the clinician creates small amounts o trauma to
the a ected area.36 T is temporarily causes in ammation in the area, increasing the rate
and amount o blood ow in and around the area. T e theory is that this process helps
initiate and promote the healing process o the a ected so t tissues. It is common or the
patient to experience some discom ort during the procedure and possibly some bruising.
A B
C D
Figure 8-14
The Graston Technique uses handheld stainless steel instruments to locate and then separate existing restrictions within
a muscle. (Courtesy of The Graston Technique.)
Ice application ollowing the treatment may ease the dis-

com ort. It is recommended that an exercise, stretching,
and strengthening program be used in conjunction with
the technique to help the injured tissues heal.
Massage
Massage is a mechanical stimulation o the tissues by
means o rhythmically applied pressure and stretching
(Figure 8-15).83 Over the years, many claims have been
made relative to the therapeutic benef ts o massage, but
ew are based on well-controlled, well-designed stud-
ies. T erapists have used massage to increase exibility
and coordination as well as to increase pain threshold; to
decrease neuromuscular excitability in the muscle being
Figure 8-15 massaged; to stimulate circulation, thus improving energy
transport to the muscle; to acilitate healing and restore
Massage can be an extremely effective technique for joint mobility; and to remove lactic acid, thus alleviating
improving mobility and range of motion. muscle cramps.83
How these e ects can be accomplished is determined by the specif c approaches used
with massage techniques and how they are applied. Generally, the e ects o massage are
either ref exive or m echanical. T e e ect o massage on the nervous system di ers greatly
according to the method employed, the pressure exerted, and the duration o applications.
T rough the re ex mechanism, sedation is induced. Slow, gentle, rhythmical, and super-
f cial e eurage may relieve tension and soothe, rendering the muscles more relaxed. T is
indicates an e ect on sensory and motor nerves locally and some central nervous system
response. T e mechanical approach seeks to make mechanical or histologic changes in
myo ascial structures through direct orce applied superf cially.83
Among the massage techniques used by therapists are the ollowing83:
1. Ho a m assage—the classic orm o massage, strokes include e eurage, petrissage,
percussion or tapotement, and vibration.
2. Friction m assage—used to increase the in ammatory response, particularly in case
o chronic tendinitis or tenosynovitis.
3. Acupressure—massage o acupuncture and trigger points, used to reduce pain and
irritation in anatomical areas known to be associated with specif c points.
4. Connective tissue m assage—a stroking technique used on layers o connective tissue,
a relatively new orm o treatment in this country, primarily a ecting circulatory
pathologies.
5. Myo ascial release—used or the purpose o relieving so t tissue rom the abnormal
grip o tight ascia.
6. Rol ng—a system devised to correct ine cient structure by balancing the body within
a gravitational f eld through a technique involving manual so t-tissue manipulation.
7. rager—attempts to establish neuromuscular control so that more normal movement
patterns can be routinely per ormed.
SUMMARY
1. Flexibility is the ability o the neuromuscular system to allow or e cient movement o
a joint or a series o joints smoothly through a ull range o motion.
2. Flexibility is specif c to a given joint, and the term good f exibility implies that there are
no joint abnormalities restricting movement.
3. Flexibility can be limited by muscles and tendons and their ascia, joint capsules or
ligaments, at, bone structure, skin, or neural tissue.
4. Passive range o m otion re ers to the degree to which a joint can be passively moved
to the end points in the range o motion. Active range o m otion re ers to movement
through the midrange o motion resulting rom active contraction.
5. Measurement o joint exibility is accomplished through the use o a goniometer or an
inclinometer.
6. An agonist muscle is one that contracts to produce joint motion, while the antagonist
muscle is stretched with contraction o the agonist.
7. Increases in exibility can be attributed to neurophysiologic adaptations involving the
stretch re ex and associated muscle spindles and Golgi tendon organs, changes in the
viscoelastic and plastic properties o muscle, adaptations and changes in the kinetic
chain, and alterations in intramuscular temperature.
8. Dynamic, static, and PNF techniques have all been used as stretching techniques or
improving exibility.
9. Stretching o tight neural structures and myo ascial release stretching are also used to
reestablish a ull range o motion.
10. Strain-counterstrain is a passive technique that places a body part in a position o great-
est com ort to decrease muscle tension and guarding, and to relieve pain.
11. Positional release therapy is similar to strain-counterstrain. Pressure is maintained on
a tender point with the body part in a position o com ort or 90 seconds.
12. T e active release technique is a deep-tissue technique used or breaking down scar
tissue and adhesions and restoring unction and movement.
13. Massage is the mechanical stimulation o tissue by means o rhythmically applied
pressure and stretching. It allows the therapist, as a health care provider, to help a
patient overcome pain and relax through the application o the therapeutic massage
techniques.
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Impaired
Neuromuscular Control
Re active Ne uro muscular Training
M ich a e l L. Vo ig h t a n d Gr a y Co o k
OBJJECTIVE
Explain why neuromuscular control is important in the rehabilitation process.
De ne and discuss the importance of proprioception in the neuromuscular control process.
De ne and discuss the different levels of central nervous system motor control and the neural
pathways responsible for the transmission of afferent and efferent information at each level.
De ne and discuss the 2 motor mechanisms involved with interpreting afferent information
and coordinating an efferent response.
Develop a rehabilitation program that uses various techniques of neuromuscular control

exercises.
223
224 Chapte r 9 Impaired Neuromuscular Control
What Is Neuromuscular Control

and Why Is It Important?
T e basic goal in rehabilitation is to enhance one’s ability to unction within the environ-
ment and to per orm the specif c activities o daily living (ADL). T e entire rehabilitation
process should be ocused on improving the unctional status o the patient. T e concept o
unctional training is not new. In act, unctional training has been around or many years.
It is widely accepted that to get better at a specif c activity, or to get stronger or an activ-
ity, one must practice that specif c activity. T ere ore, the unctional progression or return
to ADL can be def ned as breaking the specif c activities down into a hierarchy and then
per orming them in a sequence that allows or the acquisition or reacquisition o that skill.
From a historical perspective, the rehabilitation process ollowing injury has ocused
upon the restoration o muscular strength, endurance, and joint exibility without any
consideration o the role o the neuromuscular mechanism. T is is a common error in the
rehabilitation process. We cannot assume that clinical programs alone using traditional
methods will lead to a sa e return to unction. Limiting the rehabilitation program to these
traditional programs alone o ten results in an incomplete restoration o ability and quite
possibly leads to an increased risk o reinjury.
T e overall objective o the unctional exercise program is to return the patient to the
preinjury level as quickly and as sa ely as possible. Specif c training activities should be
designed to restore both dynamic stability about the joint and specif c ADL skills. o accom-
plish this objective, a basic tenet o exercise physiology is employed. T e SAID (specif c
adaptations to imposed demands) principle states that the body will adapt to the stress and
strain placed upon it.130 Patients cannot succeed in ADL i they have not been prepared to
meet all o the demands o their specif c activity.130 Reactive neuromuscular training (RN )
is not intended to replace traditional rehabilitation, but rather to help bridge the gap le t
by traditional rehabilitation in a complementary ashion via proprioceptive and balance
training in order to promote a more unctional return to activity.130 T e main objective o
the RN program is to acilitate the unconscious process o interpreting and integrating the
peripheral sensations received by the central nervous system (CNS) into appropriate motor
responses.
Terminology: What Do We Really

Need to Know?
Success in skilled per ormance depends upon how e ectively the individual detects, per-
ceives, and uses relevant sensory in ormation. Knowing exactly where our limbs are in space
and how much muscular e ort is required to per orm a particular action is critical or the
success ul per ormance in all activities requiring intricate coordination o the various body
parts. Fortunately, in ormation about the position and movement o various body parts is
available rom the peripheral receptors located in and around the articular structures.
About the normal healthy joint, both static and dynamic stabilizers serve to provide
support. T e role o the capsule-ligamentous tissues in the dynamic restraint o the joint
has been well established in the literature.2,3,19,33,45-50,110 Although the primary role o these
structures is mechanical in nature by providing structural support and stabilization to the
joint, the capsuloligamentous tissues also play an important sensory role by detecting joint
position and motion.33,34,105 Sensory a erent eedback rom the receptors in the capsulo-
ligamentous structures projects directly to the re ex and cortical pathways, thereby mediat-
ing reactive muscle activity or dynamic restraint.2,3,33,34,67 T e e erent motor response that
Physiology of Proprioception 225
ensues rom the sensory in ormation is called neuromuscular control. Sensory in ormation
is sent to the CNS to be processed, and appropriate motor activities are executed.
Physiology of Proprioception
Although there has been no def nitive def nition o proprioception, Beard et al described
proprioception as consisting o 3 similar components: (a) a static awareness o joint posi-
tion, (b) kinesthetic awareness, and (c) a closed-loop e erent re ex response required or
the regulation o muscle tone and activity.7 From a physiologic perspective, proprioception
is a specialized variation o the sensory modality o touch. Specif cally def ned, propriocep-
tion is the cumulative neural input to the CNS rom mechanoreceptors in the joint capsules,
ligaments, muscles, tendons, and skin.
A rehabilitation program that addresses the need or restoring normal joint stability
and proprioception cannot be constructed until one has a total appreciation o both the
mechanical and sensory unctions o the articular structures.12 Knowledge o the basic
physiology o how these muscular and joint mechanoreceptors work together in the pro-
duction o smooth controlled coordinated motion is critical in developing a rehabilitation
training program. T is is because the role o the joint musculature extends beyond abso-
lute strength and the capacity to resist atigue. Simply restoring mechanical restraints or
strengthening the associated muscles neglects the smooth coordinated neuromuscular
controlling mechanisms required or joint stability.12 T e complexity o joint motion neces-
sitates synergy and synchrony o muscle f ring patterns, thereby permitting proper joint
stabilization, especially during sudden changes in joint position, which is common in unc-
tional activities. Understanding these relationships and unctional implications will allow
the clinician greater variability and success in returning patients sa ely back to their playing
environment.
Sherrington f rst described the term proprioception in the early 1900s when he noted
the presence o receptors in the joint capsular structures that were primarily re exive in
nature.77,105 Since that time, mechanoreceptors have been morphohistologically identif ed
about the articular structures in both animal and human models. Mechanoreceptors are
specialized end organs that unction as biologic transducers that can convert the mechani-
cal energy o physical de ormation (elongation, compression, and pressure) into action
nerve potentials yielding proprioceptive in ormation.45 Although receptor discharge varies
according to the intensity o the distortion, mechanoreceptors can also be based upon their
discharge rates. Quickly adapting receptors cease discharging shortly a ter the onset o a
stimulus, while slowly adapting receptors continue to discharge while the stimulus is pres-
ent.21,33,45 About the healthy joint, quickly adapting receptors are responsible or providing
conscious and unconscious kinesthetic sensations in response to joint movement or accel-
eration, while slowly adapting mechanoreceptors provide continuous eedback and thus
proprioceptive in ormation relative to joint position.21,45,71
Once stimulated, mechanoreceptors are able to adapt. With constant stimulation, the
requency o the neural impulses decreases. T e unctional implication is that mechano-
receptors detect change and rates o change, as opposed to steady-state conditions.104 T is
input is then analyzed in the CNS or joint position and movement.139 T e status o the artic-
ular structures is sent to the CNS so that in ormation regarding static versus dynamic condi-
tions, equilibrium versus disequilibrium, or biomechanical stress and strain relations can
be evaluated.129,130 Once processed and evaluated, this proprioceptive in ormation becomes
capable o in uencing muscle tone, motor execution programs, and cognitive somatic
perceptions or kinesthetic awareness.92 Proprioceptive in ormation also protects the joint
rom damage caused by movement exceeding the normal physiologic range o motion and
helps to determine the appropriate balance o synergistic and antagonistic orces. All o this
in ormation helps to generate a somatosensory image within the CNS. T ere ore, the so t
tissues surrounding a joint serve a double purpose: they provide biomechanical support
to the bony partners making up the joint, keeping them in relative anatomic alignment,
and through an extensive a erent neurologic network, they provide valuable propriocep-
tive in ormation.
Be ore the 1970s, articular receptors in the joint capsule were held primarily respon-
sible or joint proprioception.104 Since then there has been considerable debate as to
whether muscular and articular mechanoreceptors interact. As originally described, the
articular m echanoreceptors were located primarily on the parts o the joint capsule that
are stretched the most when the joint is m oved. T is led investigators to believe that these
receptors were primarily responsible or perception o joint motion. Skoglund ound indi-
vidual receptors that were active at very specif c locations in the range o limb m ovement
(eg, rom 150 to 180 degrees o joint angle or a particular cell).113 Another cell would f re
at a di erent set o joint angles. By integrating the in ormation, the CNS could “know”
where the lim b was in space by detecting which receptors were active. T e problem with
this theory is that several studies have shown that the majority o the capsular receptors
only respond at the extrem es o the range o m otion or during other situations when a
strong stimulus is im parted onto the structures such as distraction or compression.21,43,48,49
Furtherm ore, other studies ound that the nature o the f ring pattern is dependent on
whether the m ovement is active or passive.14 In addition, the m echanoreceptor f ring is
dependent on the direction o m otion rom the joint.115 T e act that the f ring pattern
o the joint receptors is dependent on actors other than sim ple position sense has seri-
ously challenged the thought that the articular mechanoreceptors alone are the means by
which the system determ ines joint position.
A more contemporary viewpoint is that muscle receptors play a more important role in
signaling joint position.25,42 T ere are 2 main types o muscle receptors that provide comple-
mentary in ormation about the state o the muscles. T e muscle spindle is located within
the muscle f bers and is most active when the muscle is stretched. T e Golgi tendon organ
(G O) is located in the junction between the muscle and the tendon, and is most active
when the muscle contracts.
Muscle Spindle
T e muscle spindle consists o 3 main components: small muscle f bers called intra usal
f bers that are innervated by the gamma e erent motor neurons, and types Ia and II a erent
neurons (Figure 9-1). T e intra usal f bers are made up o 2 types—bag and chain f bers—
the polar ends o which provide a tension on the central region o the spindle, called the
equatorial region. T e sensory receptors located here are sensitive to the length o the equa-
torial region when the spindle is stretched. T e major neurologic connection to this sensory
region is the Ia a erent f ber, whose output is related to the length o the equatorial region
(position in ormation) as well as to the rate o change in length o this region (velocity in or-
mation). T e spindle connects to the alpha motor neurons or the same muscle, providing
excitation to the muscle when it is stretched.
T ere has been a great deal o controversy about what the spindle actually signals to the
CNS.36 A major conceptual problem in the past was that the output o the Ia a erent that
presumably signals stretch or velocity is related to 2 separate actors.102 First, Ia output is
increased by the elongation o the overall muscle via elongation o the spindle as a whole.
However, the Ia output is also related to the stretch placed on the equatorial region by the
intra usal f bers by the gamma motor neurons. T ere ore, the CNS would have di culty
in interpreting changes in the Ia output as being caused by changes in the overall muscle
length with a constant gamma motor neuron activity, changes in gamma motor neuron
activity with a constant muscle length, or perhaps changes in both.102 Another problem was
Physiology of Proprioception 227
P rima ry a ffe re nt (Ia )
Effe re nt
S e conda ry γ (d)
a ffe re nt
(II) Effe re nt
γ (s )
Nucle a r ba g
fibe r
Nucle a r cha in
fibe r
Figure 9-1 The anato my o f muscle re ce pto rs
Muscle spindle and GTO. (Reproduced, with permission, from Shumway-Cook A, Woollacott M.
Physiology of motor control. In: Shumway-Cook A, Woollacott M, eds. Motor Control: Theory and
Practical Applications. Baltimore, MD: Williams & Wilkins; 1995:53.)
presented by Gel an and Carter, who suggested that there was no strong evidence that the
Ia a erent f bers actually sent their in ormation to the primary sensory cortex.39 Because o
these actors, it was widely held that the muscle spindle was not important or the conscious
perception o movement or position.
Goodwin et al were the f rst to re ute this viewpoint.43 T ey ound as much as
40 degrees o m isalignm ent o arm that had vibration applied to the biceps tendon.43
T e vibration o the tendon produces a small, rapid, alternating stretch and release o the
tendon, which a ects the muscle spindle and distorts the output o the Ia a erents rom the
spindles located in the vibrated muscle. T e interpretation was that the vibration distorted
the Ia in ormation com ing rom the sam e muscle, which led to a misperception o the
limb’s position. Others have ound the same results when applying vibration to a muscle
tendon.97,108,109 T is in ormation supports the idea that the muscle spindle is important in
providing in ormation to the CNS about limb position and velocity o movement.
Golgi Tendon Organ

T e G Os are tiny receptors located in the junction where the muscle “blends into” the
tendon. T ey are ideally located to provide in ormation about the tension within the
muscles because they lie in series with the muscle orce-producing contractile elements.
T e G O has been shown to produce an inhibition o the muscle in which it is located when
a stretch to the active muscle is produced. T e act that a stretch orce near the physio-
logic limit o the muscle was required to induce the tendon organ to f re led to the specula-
tion that this receptor was primarily a protective receptor that would prevent the muscle
rom contracting so orcibly that it would rupture the tendon. Houk and Henneman 62 and
Stuart et al119 have provided a more precise understanding o the sensitivity o the G Os.
Anatomic evidence reveals that each organ is connected to only a small group (3 to 25) o
muscle f bers, not to the entire muscle as had been previously suspected. T ere ore, the
G O appears to be in a good position to sense the tensions produced in a limited number
o individual motor units, not in the whole muscle. Houk and Henneman determined that
the tendon organs could respond to orces o less than 0.1 G.62 T ere ore, the G Os are very
sensitive detectors or active tension in localized portions o a muscle, in addition to having
a protective unction.
It is m ost likely that the muscle and joint receptors work com plem entarily to
one another in this complex a erent system, with each modi ying the unction o the
other.15,46,52,61 An important concept is that any one o the receptors in isolation rom the
others is generally ine ective in signaling in ormation about the movements o the body.
T e reason or this is that the various receptors are o ten sensitive to a variety o aspects o
body motion at the same time. For example, the G Os probably cannot signal in ormation
about movement, because they cannot di erentiate between the orces produced in a static
contraction and the same orces produced when the limb is moving.102 Although the spin-
dle is sensitive to muscle length, it is also sensitive to the rate o change in length (velocity)
and to the activity in the intra usal f bers that are known to be active during contractions.
T ere ore, the spindle con ounds in ormation about the position o the limb and the level o
contraction o the muscle. T e joint receptors are sensitive to joint position, but their output
can be a ected by the tensions applied and by the direction o movement.
Because both the articular and muscle receptors have well-described cortical connec-
tions to substantiate a central role in proprioception, some have suggested that the CNS
combines and integrates the in ormation in some way to resolve the ambiguity in the sig-
nals produced by any one o the receptors.102,138 Producing an ensemble o in ormation by
combining the various separate sources could enable the generation o less ambiguous
in ormation about movement.36 T ere ore, the sensory mechanoreceptors may represent
a continuum rather than separate distinct classes o receptor.105 T is concept is urther
illustrated by research that demonstrated a relationship between the muscle spindle sen-
sory a erent and joint mechanoreceptors.18 McCloskey has also demonstrated a relation-
ship between the cutaneous a erent and joint mechanoreceptors.78 T ese studies suggest
a complex role or the joint mechanoreceptors in smooth, coordinated, and controlled
movement.
Neural Pat hways

In ormation generated and encoded by the mechanoreceptors in the muscle tendon units
is projected upward via specialized pathways toward the cortex, where it is urther ana-
lyzed and integrated with other sensory inputs.99 Proprioceptive in ormation is relayed
to the cerebral cortex via 1 o 2 major ascending systems: the dorsal column and the spi-
nothalamic tract. Both o these pathways involve 3 orders o neurons and 3 synapses in
transmitting sensory input rom the periphery to the cortex. T e primary a erent, which
is connected to the peripheral receptor, synapses with a second neuron in the spinal cord
or lower brain, depending upon the type o sensation. Be ore reaching the cerebral cortex,
all sensory in ormation passes through an important group o nuclei located in the area o
the brain called the diencephalon. It is within this group o more than 30 nuclei, collectively
called the thalam us, that neurophysiologists consider the initial stages o sensory integra-
tion and perceptual awareness to begin. T ere ore, the second neuron then conveys the
in ormation to the thalamus where it synapses with the third and f nal neuron in the area o
the thalamus called the ventroposterolateral area. T e thalamus achieves these unctions by
“gating out” irrelevant sensory inputs and directing those that are relevant to an impending
or ongoing action toward primary sensory areas within the cortex. T e sensory pathways
f nally terminate in the primary sensory areas located in di erent regions o the cortex. It is
at this point that we become consciously aware o the sensations.
Assessment of Joint Proprioception 229
T e f nal perception o what is occurring in the environm ent around us is achieved
a ter all o these sensations are integrated and then interpreted by the association areas
that lie adjacent to the various prim ary sen sory areas associated with the di erent
types o sensory input. With the assistance o m em ory, objects seen or elt can be inter-
preted in a m eaning ul way. T e dorsal colum n plays an im portant role in m otor control
because o its speed in transm ission. For proprioception to play a protective role through
re ex m uscle splinting, the in ormation must be transm itted and processed rapidly. T e
heavily myelinated and wide-diam eter axons within this system transm it at speeds o
80 to 100 m / s. T is characteristic acilitates rapid sam pling o the environm ent, which
enhances the accuracy o m otor actions about to be executed and o those already in
progress. By com parison , nociceptor tran sm ission occurs at a rate o approxim ately
1 m / s. T us proprioceptive in ormation may play a m ore signif cant role than pain in the
prevention o injuries.
In contrast to the transmission properties associated with the dorsal column system,
neurons that make up the spinothalamic tract are small in diameter (some o which are
unmyelinated) and conduct slowly (1 to 40 m/ s). T e 4 spinocerebellar tracts also convey
important proprioceptive in ormation rom the neuromuscular receptors to the cerebel-
lum. Unlike the dorsal column, these pathways do not synapse in either the thalamus or
cerebral cortex. As a result, the proprioceptive in ormation conveyed by the spinocerebel-
lar tracts does not lead to conscious perceptions o limb position. T e a erent sources are
believed to contribute to kinesthesia.
Assessment of Joint Proprioception

Assessment o proprioception is valuable or identi ying proprioceptive def cits. I def cien-
cies in proprioception can be clinically diagnosed in a reliable manner, a clinician would
know when and i a problem exists and when the problem has been corrected.130 T ere are
several ways to measure or assess proprioception about a joint. From an anatomic perspec-
tive, histologic studies can be conducted to identi y mechanoreceptors within the specif c
joint structures. Neurophysiologic testing can assess sensory thresholds and nerve conduc-
tion velocities.6,20,31 From a clinical perspective, proprioception can be assessed by measur-
ing the components that make up the proprioceptive mechanism : kinesthesia (perception
o motion) and joint position sensibility (perception o joint position).17
Measuring either the angle or time threshold to detection o passive motion can assess
kinesthetic sensibility.112 With the subject seated, the patient’s limb is mechanically rotated
at a slow constant angular velocity (2 degrees per second). With passive motion, the capsu-
loligamentous structures come under tension and de orm the mechanoreceptors located
within. T e mechanoreceptor de ormation is converted into an electrical impulse, which is
then processed within the CNS. Patients are instructed to stop the lever arm movement as
soon as they perceive motion. Depending on which measurement is used, either the time to
detection or degrees o angular displacement is recorded.
Joint position sense is assessed through the reproduction o both active and passive
joint repositioning. T e examiner places the limb at a preset target angle and holds it there
or a minimum o 10 seconds to allow the patient to mentally process the target angle.
Following this, the limb is returned to the starting position. T e patient is asked to either
actively reproduce or stop the device when passive repositioning o the angle has been
achieved (Figure 9-2). T e examiner measures the ability o an individual to accurately
reproduce the preset target angle position. T e angular displacement is recorded as the
error in degrees rom the preset target angle. Active angle reproduction measures the ability
o both the muscle and capsular receptors while passive repositioning primarily measures
the capsular receptors. With both tests o proprioception, the patient is blind olded during
Figure 9-2 Ope n-chain pro prio ce ptive te sting Figure 9-3 EMG asse ssme nt o f re fle x muscle
using the Bio de x dynamo me te r firing as a re sult o f pe rturbatio n o n the Ne uro Co m
EquiTe st
testing to eliminate all visual cueing. In patients with unilateral involvement, the contralat-
eral uninjured limb can serve as an external control or comparison.
T e main limitation to current proprioceptive testing is that neither time/ angle thresh-
old to detection o passive motion provides an assessment o the unconscious re ex arc
believed to provide dynamic joint stability. T e assessment o re ex capabilities is usually
per ormed by measuring the latency o muscular activation to involuntary perturbation
through electromyogram (EMG) interpretation o f ring patterns o those muscles crossing
the respective joint (Figure 9-3).132 T e ability to quanti y the sequence o muscle f ring can
provide a valuable tool or the assessment o asynchronous neuromuscular activation pat-
terns ollowing injury.74,140 A delay or lag in the f ring time o the dynamic stabilizers about
the joint can result in recurrent joint subluxation and joint deterioration.
Proprioception and Motor Control

T e e erent response that is produced as the result o the proprioceptive a erent input is
termed neurom uscular control. In general, there are 2 motor control mechanisms involved
in the interpretation o a erent in ormation and coordinating an e erent response.54 One o
the ways in which motor control is achieved relies heavily on the concept that sensory eed-
back in ormation is used to regulate our movements. T is is a more traditional viewpoint
o motor control. T e closed-loop system o motor control emphasizes the essential role
Proprioception and Motor Control 231
o the reactive or sensory eedback in the planning, execution, and modif cation o action.
T e closed-loop systems involve the processing o eedback against a re erence o correct-
ness, the determination o error, and a subsequent correction.102 T e eedback mechanism
o motor control relies on the numerous re ex pathways in an attempt to continuously
adjust ongoing muscle activation.29,102 T e receptors or the eedback supplied to closed-
loop systems are the eyes, vestibular apparatus, joint receptors, and muscle receptors. One
important point to note about the closed-loop system o eedback motor control is that this
loop requires a great deal o time or a stimulus to be processed and yield a response. Rapid
actions do not provide su cient time or the system to (a) generate an error, (b) detect the
error, (c) determine the correction, (d) initiate the correction, and (e) correct the move-
ment be ore a rapid movement is completed.102 T e best example o this concept is dem-
onstrated by the le t jab o ormer boxing champion Muhammad Ali. T e movement itsel
was approximately 40 milliseconds, yet visually detecting an aiming error and correcting it
during the same movement should require approximately 200 milliseconds.102 T e move-
ment is f nished be ore any correction can begin. T ere ore, closed-loop eedback control
models seem to have their greatest strength in explaining movements that are very slow in
time or that have very high movement accuracy requirements.102
In contrast, a more contemporary theory emphasizes the open-loop system, which
ocuses upon the a priori generation o action plans in anticipation o movement produced
by a central executor somewhere in the cerebral cortex.102 T e ability to prepare the mus-
cles prior to movement is called pretuning or eed- orward m otor control. T e springlike
qualities o a muscle can be exploited (through preactivation) by the CNS in anticipation o
movements and joint loads. T is concept has been termed eed- orward motor control, in
which prior sensory eedback (experience) concerning a task is ed orward to preprogram
muscle activation patterns.62 Vision serves an important eed- orward unction by prepar-
ing the motor system in advance o the actual movement. Preactivated muscles can provide
quick compensation or external loads and are critical or dynamic joint stability. Research-
ers have shown that corrections or rapid changes in body position can occur ar more rap-
idly (30 to 80 milliseconds) than the closed-loop latencies o 200 milliseconds that were
previously reported.27,63,69 T ere ore, the motor control system operates with a eed- orward
mode in order to send some signals “ahead o ” the movement that (a) readies the system
or the upcoming motor command and/ or (b) readies the system or the receipt o some
particular kind o eedback in ormation.
Anticipatory muscle activity contributes to the dynamic restraint system in several
capacities. By increasing muscle activation levels in anticipation o an external load, the
sti ness properties o the entire muscular unit can be increased.84 Sti ness is one o the
measures used to describe the characteristics o elastic materials. It is def ned in terms o
the amount o tension increase required to increase the length o the object by a certain
amount. From a mechanical perspective, muscle sti ness can be def ned as the ratio o
the change o orce to the change in length. I a spring is very sti , a great deal o tension
is needed to increase its length by a given amount; or a less-sti spring, much less ten-
sion is required. When a muscle is stretched, the change in tension is instantaneous, just
as the change in length o a spring. An increase in tension would o set the perturbation or
de orming orce and bring the system back to its original position. Research demonstrates
that the muscle spindle is responsible or the maintenance o the muscle sti ness when
the muscle is stretched, so that it can still act as a spring in the control o an unexpected
perturbation.60,63,86 T ere ore, sti muscles can resist stretching episodes more e ectively,
have greater tone, and provide a more e ective dynamic restraint to joint displacement.
Increased muscle sti ness can improve the stretch sensitivity o the muscle spindle system
while at the same time reduce the electromechanical delay required to develop muscle ten-
sion.28,60,80,84 Heightening the stretch sensitivity can improve the reactive capabilities o the
muscle by providing additional sensory eedback.28
Central Nervous System Motor

Control Integration
It has already been established that the CNS input provided by the peripheral mechanore-
ceptors and the visual and vestibular receptors is integrated by the CNS to generate a motor
response.26 In addition to the many conscious modif cations that can be made while move-
ment is in progress, certain neural connections within the CNS contribute to the modif ca-
tion o movements in progress by providing sensory in ormation at a subconscious level.
T e in uence o some o these re exive loops is limited to local control o muscle orce,
but others are capable o in uencing orce levels in muscle groups quite distant rom those
originally stimulated. T ese longer re ex loops are there ore capable o modi ying move-
ments to a much larger extent than the shorter re ex loops that are conf ned to single seg-
ments within the spinal cord.
In general, the CNS response alls under 3 categories or levels o motor control: spinal
re exes, brainstem processing, and cognitive cerebral cortex program planning. T e goal
o the rehabilitation process is to retrain the altered a erent pathways so as to enhance the
neuromuscular control system. o accomplish this goal, the objective o the rehabilitation
program should be to hyperstimulate the joint and muscle receptors so as to encourage
maximal a erent discharge to the respective CNS levels.12,71,122,126,127
First Level of Int egrat ion: The M1 Re ex

When aced with an unexpected load, the f rst re exive m uscle respon se is a burst o
EMG activity that occurs a ter between 30 and 50 m illiseconds. T e a erent f bers o the
m echanoreceptors synapse with the spinal interneurons and produce a re exive acilita-
tion or inhibition o the m otor neurons.122,126,131 T e m onosynaptic stretch re ex or M1
re ex is one o the m ost rapid re exes underlying lim b control (Figure 9-4). T e latency
or tim e o this response is very short because it involves only 1 synapse and the in orma-
tion has a relatively short distance to travel. Un ortunately, the m uscle response is brie ,
which does not result in much added contraction o the muscle. T e M1 short re ex loop
is m ost o ten called into play when m inute adjustm ents in muscle length are needed. T e
stimulus o small muscular stretches occurs during postural sways or when our lim bs are
subjected to unanticipated loads. T ere ore, this m echanism is responsible or regulat-
ing m otor control o the antagonistic and synergistic patterns o m uscle contraction.99
T ese adjustm ents are necessary when m isalignm ent exists between intended m uscle
length and actual m uscle length. T is m isalignm ent is m ost likely to occur in situations
where unexpected orces are applied to the lim b or the muscle begins to atigue. In the
situation o involuntary and undesirable lengthening o m uscles about a joint during
conditions o abnormal stress, the short M1 loop must provide or re ex muscle splinting
in order to prevent injury rom occurring. T e M1 re ex occurs at an unconscious level
and is not a ected by outside actors. T ese responses can occur simultaneously to con-
trol lim b position and posture. Because they can occur at the sam e tim e, are in parallel,
are subconscious, and are without cortical inter erence, they do not require attention
and are thus automatic.
T ere are 2 important short re ex loops acting in the body: the stretch re ex and
the gamma re ex loop. T e stretch re ex (Figure 9-5) is triggered when the length o an
extra usal muscle f ber is altered, causing the sensory endings within the muscle spindle
to be mechanically de ormed. Once de ormed, these sensory endings f re, sending nerve
impulses into the spinal cord via an a erent sensory neuron located just outside the spinal
cord. T e in ormation rom the Ia a erent is sent essentially to 2 places: to the alpha motor
Central Nervous System Motor Control Integration 233
Toe s Up-4 De gre e s
−100 0 100 200 300 ms e c
250 µV S L1 S L2 ML1 ML2

M2
M1 ML2 ML2 ms 32 50 79 138
S L1 S L2 µV 21 14 48 21
pe a k 148 163
µVs 1.3 4.9
L-GAS TROC
M3
500 µV
LL1 LL2
ms 138 273
LL1
µV 67 21
LL2
pe a k 470
L-TIB µVs 23.2
Figure 9-4 CNS le ve ls o f inte g ratio n: sho rt- and lo ng -lo o p po stural re fle xe s
The components of the evoked postural assessment: (M1) myotatic reflex (SL1, SL2), (M2) segmental (polysynaptic)
response (ML1, ML2), and (M3) long-loop response (LL1, LL2) involving the brainstem, cortex, and ascending
and descending spinal pathways (LL, long loop; ML, mediam loop; SL, short loop). (Reproduced, with permission,
from NeuroCom International, Clackamas, OR.)
neurons in the same muscle and upward to the various sensory regions in the cerebral cor-
tex. As soon as these impulses reach the spinal cord, they are trans erred to alpha motor
neurons that innervate the very same muscle that houses the activated muscle spindles.
T e loop time, or the time rom the initial stretch until the extra usal f bers are increased in
their innervation, is approximately 30 to 40 milliseconds in humans.102 Stimulation o the
muscle spindle ceases when the muscle contracts, because the spindle f bers, which lie par-
allel to the extra usal f bers, return to their original length. It is through the operation o this
re ex that we are able to continuously alter muscle tone and/ or make subtle adjustments in
muscle length during movement. T ese latter adjustments may be in response to external
actors producing unexpected loads or orces on the moving limbs.
Con sider, or exam ple, what happen s when an additional load is applied to an
already loaded lim b being held in a given position in space.27 T e m uscles o the lim b
are set at a given length, and alpha m otor neurons are f ring so as to maintain the desired
lim b position in spite o the load and gravity. Now an additional load is added to the
end o the lim b, causing the m uscles to lengthen as the lim b drops. T is stretching o
the extra usal m uscle f bers results in alm ost sim ultan eous stretching o the m uscle
spindle, which then f res and sends signals to the spinal cord and alpha m otor neurons
that serve the sam e m uscle. T e f ring rate o these alpha m otor neurons is subsequently
increased, causing the m uscles in the dropping lim b to be urther contracted, and the
lim b is restored to its previous position. Visual in orm ation to the stim ulus o loading
would also lead to increased contraction in the alling lim b, but initiating the correc-
tive response con sciously would involve con siderably lon ger delays because o addi-
tional processing at the cortical level.27 T e short-loop M1 stretch re ex response tim es
Alpha motor
ne uron
Ia a ffe re nt
Ia inhibitory
inte rne uron Inhibite d
S pindle
Anta gonis t
Homonymous
mus cle Re s is ta nce
Pa s s ive
S yne rgis t s tre tch
A B C
Figure 9-5 Excitatio n o f the muscle spindle is re spo nsible fo r the stre tch re fle x
A. Ia afferent fibers making monosynaptic excitatory connections to alpha motor neurons innervating the same muscle
from which they arise and motor neurons innervating synergist muscles. They also inhibit motor neurons to antagonist
muscles through an inhibitory interneuron. B. When a muscle is stretched, the Ia afferents increase their firing rate.
C. This leads to contraction of the same muscle and its synergists and relaxation of the antagonist. The reflex therefore
tends to counteract the stretch, enhancing the springlike properties of the muscle. (Reproduced, with permission, from
Gordon J, Ghez C. Muscle receptors and stretch re exes. In: Kandel E, et al, eds. Principles of Neural Science. 3rd ed. East Norwalk, CT,
Appleton & Lange; 1991:576.)
are possible within 30 to 50 m illisecon ds.58 Visual-based corrections involved correc-

tive delays on the order o 150 to 200 m illiseconds.58 Given that the rapid correction is
required or injury prevention, it is im portant that these short-loop re ex pathways are
available or use.
Muscle spindles also play an important role in the ongoing control and modif cation o
movement by virtue o their involvement in a spinal re ex loop known as the gamma re ex
loop. T e a erent in ormation rom the muscle spindle synapses with both the alpha and
gamma motor neurons. T e alpha motor neuron sends the in ormation it receives to the
muscles involved in the movements. T e gamma motor neuron sends the same in orma-
tion back to the muscle spindle, which can be stimulated to begin f ring at its polar ends.
T e independent innervation o the muscle spindle by the gamma motor neuron is thought
to be important during muscle contractions when the intra usal f bers o the spindle would
normally be slack. Gamma activation o the spindle results in stretching o the intra usal
f bers even though the extra usal f bers are contracting. In essence, the gamma system takes
up the slack in the spindle caused by muscle contraction, thereby making corrections in
minute changes in length o the muscle more quickly.
In the short-loop system o spinal control, the activity o the Ia a erent f bers is deter-
mined by 2 things: (a) the length and the rate o the stretch o the extra usal muscle f bers,
and (b) the amount o tension in the intra usal f bers, which is determined by the f ring
o the gam ma e erent f bers. Both alpha and gamma motor neurons can be controlled
by higher motor centers, and are thought to be “coordinated” in their action by a process
termed alpha–gam m a coactivation.44,98 T ere ore, the output to the main body o the
muscle is determined by (a) the level o innervation provided directly rom higher centers
and (b) the amount o added innervation provided indirectly rom the Ia a erent.102 T is
helps to explain how an individual can respond quickly to an unexpected event without
conscious involvement o the CNS. When an unexpected event or perturbation causes a
muscle to stretch, the spindle’s sensory receptors are stimulated. T e resulting Ia a erent
f ring causes a stretch re ex that will increase the activity in the main muscle, all within
40 m illiseconds. All o this activity occurs at the sam e level o the spinal cord as did the
innervation o the muscle in the f rst place. Consequently, no high centers are involved in
this 40-millisecond loop.
At this level o motor control, activities to encourage short-loop re ex joint stabiliza-
tion should dominate.12,71,110,126 T ese activities are characterized by sudden alterations in
joint position that require re ex muscle stabilization. With sudden alterations or perturba-
tions, both the articular and muscular mechanoreceptors are stimulated or the production
o re ex stabilization. Rhythmic stabilization exercises encourage monosynaptic cocon-
traction o the musculature, thereby producing a dynamic neuromuscular stabilization.114
T ese exercises serve to build a oundation or dynamic stability.
Second Level of Int egrat ion: The M2 Re ex

For larger adjustm ents in lim b and overall body position, it is necessary to involve the
longer re ex loops that extend beyond single segm ents within the spinal cord. When the
muscle spindle is stretched and the Ia a erent f bers are activated, the in orm ation is
relayed to the spinal cord, where it synapses with the alpha m otor neuron. Additionally,
in ormation is sent to higher levels o control, where the Ia in ormation is integrated with
other in orm ation in the sensory and m otor centers in the cerebral cortex to produce a
m ore com plete response to the im posed stretch. Approxim ately 50 to 80 m illiseconds
a ter an unexpected stimulus, there is a second burst o EMG activity (see Figure 9-4).
Because the pathways involved in these neural circuits travel to the m ore distant subcor-
tical and cortical levels o the CNS to connect with structures such as the m otor cortex
and cerebellum within the larger projection system, the re ex requires m ore tim e or has
a longer latency.51 T ere ore, the 80-m illisecond loop tim e or this activity corresponds
not only to the additional distance that the im pulses have to travel, but also to the m ul-
tiple synapses that must take place to close the circuit. Both the M1 and M2 responses
are responsible or the re ex response that occurs when a tendon is tapped. An exam ple
o this occurs when the patellar tendon is tapped with a re ex ham m er. T e quadriceps
m uscle is stretched, initiating a re ex response that contracts the quadriceps and pro-
duces an involuntary extension o the lower leg.
Even though there is a tim e lapse or the lon ger-loop re exes to take place, there
are 2 im portant advantages or these re exes. First, the EMG activity rom the long-loop
re ex is ar stron ger than that involved in the m onosynaptic stretch re ex. T e early
short-loop m onosynaptic re ex system does not result in much actual increase in orce.
T e long-loop re ex can, however, produce enough orce to m ove the lim b/ joint back
into a m ore neutral position. Second, because the long-loop re exes are organized in a
higher center, they are m ore exible than the m onosynaptic re ex. By allowing or the
involvem ent o a ew other sources o sensory in ormation during the response, an indi-
vidual can voluntarily adjust the size or am plitude o the M2 response or a given input
to generate a power ul response when the goal is to hold the joint as f rm ly as possible,
or to produce no response i the goal is to release under the increasing load. T e ability
to regulate this response allows an individual to prepare the lim b to con orm to di erent
environm ental demands.
T e second level o m otor control interaction is at the level o the brainstem.11,122,130
At this level, a erent m echanoreceptors interact with the vestibular system and visual
input rom the eyes to control or acilitate postural stability and equilibrium o the
body.12,71,122,127,130 A erent m echanoreceptor input also works in concert with the mus-
cle spindle com plex by inhibiting antagonistic muscle activity under conditions o rapid
lengthening and periarticular distortion, both o which accom pany postural disrup-
tion.92,126 In conditions o disequilibrium where simultaneous neural input exists, a neural
pattern is generated that a ects the muscular stabilizers, thereby returning equilibrium
to the body’s center o gravity.122 T ere ore, balance is in uenced by the sam e peripheral
a erent m echanism that mediates joint proprioception and is at least partially dependent
upon the individual’s inherent ability to integrate joint position sense with neuromuscu-
lar control.120
Int egrat ion of Balance Training: The Second Level of Mot or Cont rol
Both proprioception and balance training have been advocated to restore motor con-
trol to the lower extremity. In the clinic, the term “balance” is o ten used without a clear
def nition.30 It is important to remember that proprioception and balance are not the same.
Proprioception is a precursor o good balance and adequate unction. Balance is the pro-
cess by which we control the body’s center o mass with respect to the base o support,
whether it is stationary or moving.
Berg attempted to def ne balance in 3 ways: the ability to maintain a position, the abil-
ity to voluntarily move, and the ability to react to a perturbation.9 All 3 o these components
o balance are important in the maintenance o upright posture. Static balance re ers to
an individual’s ability to maintain a stable antigravity position while at rest by maintaining
the center o mass within the available base o support. Dynamic balance involves auto-
matic postural responses to the disruption o the center o mass position. Reactive postural
responses are activated to recapture stability when an unexpected orce displaces the cen-
ter o mass.85
Postural sway is a commonly used indicator o the integrity o the postural control sys-
tem. Horak def ned postural control as the ability to maintain equilibrium and orientation
in the presence o gravity.57,142 Researchers measure postural sway as either the maximum or
the total excursion o center o pressure while standing on a orceplate. Little change is noted
in healthy adults in quiet standing, but the requency, amplitude, and total area o sway
increase with advancing age or when vision or proprioceptive inputs are altered.32,59,89,91
o maintain balance, the body must make continual adjustments. Most o what is cur-
rently known about postural control is based upon stereotypical postural strategies acti-
vated in response to anteroposterior perturbation.57,58,85 Horak and Nashner described
several di erent strategies used to maintain balance.58 T ese strategies include the ankle,
hip, and stepping strategies. T ese strategies adjust the body’s center o gravity so that the
body is maintained within the base o support to prevent the loss o balance or alling. T ere
are several actors that determine which strategy would be the most e ective response to
postural challenge: speed and intensity o the displacing orces, characteristics o the sup-
port sur ace, and magnitude o the displacement o the center o mass. T e automatic pos-
tural responses can be categorized as a class o unctionally organized long-loop responses
that produce muscle activation that brings the body’s center o mass into a state o equilib-
rium.85 Each o the strategies has re ex, automatic, and volitional components that interact
to match the response to the challenge.
Small disturbances in the center o gravity can be com pensated by m otion at the
ankle. T e ankle strategy repositions the center o mass a ter small displacements caused
by slow-speed perturbations, which usually occur on a large, f rm, supporting sur ace.
T e oscillations around the ankle joint with normal postural sway are an exam ple o the
ankle strategy. Anterior sway o the body is counteracted by gastrocnemius activity, which
pulls the body posterior. Conversely, posterior sway o the body is counteracted by con-
traction o the anterior tibial muscles. I the disturbance in the center o gravity is too
great to be counteracted by m otion at the ankle, the patient will use a hip or stepping
strategy to maintain the center o gravity within the base o support.82 T e hip strategy
uses rapid com pensatory hip exion or extension to redistribute the body weight within
the available base o support when the center o mass is near the edge o the sway enve-
lope. T e hip strategy is usually in response to a m oderate or large postural disturbance,
especially on an uneven, narrow, or moving sur ace. T e hip strategy is o ten employed
while standing on a bus that is rapidly accelerating. When sudden, large-amplitude orces
displace the center o mass beyond the lim its o control, a step is used to enlarge the base
o support and redef ne a new sway envelope. New postural control can then be reestab-
lished. An exam ple o the stepping strategy is the uncoordinated step that o ten ollows a
stum ble on an unexpected or uneven sidewalk.
T e maintenance o balance requires the integration o sensory in ormation rom
a num ber o di erent system s: vision, vestibular, and proprioception. For m ost healthy
adults, the pre erred sense or postural control comes rom proprioceptive in ormation.
T ere ore, i proprioception is altered or dim inished, balance will also be altered. T e
unctional assessm ent o the com bined peripheral, visual, and vestibular contributions
to neuromuscular control can be m easured with com puterized balance m easures o
postural stability.23 T e sensory organization test protocol is used to evaluate the rela-
tive contribution o vision, vestibular, and proprioceptive input to the control o postural
stability when con icting sensory input occurs.85 Postural sway is assessed (NeuroCom
Smart System ) under 6 increasingly challenging conditions (Figure 9-6). Baseline sway is
recorded in quiet standing with the eyes open. T e reliance on vision is evaluated by ask-
ing the patient to close the eyes. A signif cant increase in sway or loss o balance suggests
an overreliance on visual input.85,107,143 Sensory integration is evaluated when the visual
surround m oves in concert with sway (sway-re erenced vision), creating inaccurate visual
input.103 T e patient is then retested on a support sur ace that m oves with sway (sway-
re erenced support), thereby reducing the quality and availability o proprioceptive input
or sensory integration. With the eyes open, vision and vestibular input contribute to the
postural responses. With the eyes closed, vestibular input is the primary source o in or-
mation, because proprioceptive input is altered. T e most challenging condition includes
sway-re erenced vision and sway-re erenced support sur ace.57,85,107
Balance activities, both with and without visual input, will enhance motor unction at
the brainstem level.11,122 It is important that these activities remain specif c to the types o
activities or skills that will be required o the athlete upon return to sport.96 Static balance
activities should be used as a precursor to more dynamic skill activity.96 Static balance skills
can be initiated once the individual is able to bear weight on the lower extremity. T e gen-
eral progression o static balance activities is to progress rom bilateral to unilateral and
rom eyes open to eyes closed.71,96,122,133,134 With balance training, it is important to remem-
ber that sensory systems respond to environmental manipulation. o stimulate or acilitate
the proprioceptive system, vision must be disadvantaged. T is can be accomplished in sev-
eral ways: remove vision with either the eyes closed or blind olded, destabilize vision by
demanding hand and eye movements (ball toss) or moving the visual surround, or con use
vision with unstable visual cues that disagree with the proprioceptive and vestibular inputs
(sway re erencing).
S e ns o ry Org anizatio n Te s t (S OT)
1. 2. 3.
4. 5. 6.
Figure 9-6
The sensory organization conditions integrating vestibular, visual, and somatosensory
contributions to balance. (Reproduced, with permission, from NeuroCom International, Clackamas, OR.)
o stimulate vision, proprioception must be either destabilized or con used. T e logical

progression to destabilize proprioception is to progress the balance training rom a stable
sur ace to an unstable sur ace such as a minitramp, balance board, or dynamic stabilization
trainer.71,122,130 As joint position changes, dynamic stabilization must occur or the patient
to control the unstable sur ace (Figure 9-7). Vision can be con used during balance training
by having the patient stand on a compliant sur ace such as a oam mat or using a sway-
re erenced moving orceplate. Disadvantaging both vision and proprioceptive in ormation
can stimulate the vestibular system. T is can be accomplished by several di erent methods.
Absent vision with an unstable or compliant sur ace is achieved with eyes-closed training
on an unstable sur ace. Demanding hand and eye movements while on a oor mat or oam
pad will destabilize both vision and proprioception. A moving surround with a moving or-
ceplate will con use both vision and proprioceptive input.
T e patients should initially per orm the static balance activities while concentrating
on the specif c task (position sense and neuromuscular control) to acilitate and maximize
sensory output. As the task becomes easier, activities to distract the athlete’s concentration
(catching a ball or per orming mental exercises) should be incorporated into the training
program. T is will help to acilitate the conversion o conscious to unconscious motor pro-
gramming.122,130 Balance training exercises should induce joint perturbations in order to
acilitate re ex muscle activation.
Figure 9-7
Unstable surface training on the Biodex Stability Trainer.
Several studies have assessed the e ect o lower-quarter injury on standing balance.
Usually the balance characteristics o the injured extrem ity are com pared to those o the
uninjured extrem ity. Mizuta et al m easured postural sway in 2 groups: a unctionally
stable group and a unctionally unstable group, both o which had unilateral anterior
cruciate ligam ent (ACL)-def cient knees.83 An additional group o individuals was also
studied to serve as a control group. When com pared to the control group, im pairm ent
in standing balance was ound in the unctionally unstable group, but not in the unc-
tionally stable group. T ese results suggest that stabiliom etry was a use ul tool in the
assessm ent o unctional knee stability. Both Friden et al and Gau n et al dem onstrated
im paired standing balance during unilateral stance in individuals with chronic ACL-
def cient knees.35,38 Following injury to the lower quarter, im paired standing balance may
be caused by the loss o muscular coordination, which could have resulted rom the loss
o normal proprioceptive eedback.4,67
Third Level of Int egrat ion: The Volunt ary

React ion—Time Response (M3)
T e f nal response that occurs when an unexpected load is applied to the limb is the
voluntary long-loop reaction or M3 response (see Figure 9-4). Seen as the third burst o
EMG activity, it is a power ul and sustained response that brings the limb back into the
desired position. T e latency o the M3 response is approximately 120 to 180 milliseconds,
depending upon the task and the circumstances. In ormation is processed at the cerebral
cortex, where the mechanoreceptors interact and in uence cognitive awareness o body
position and movement in which motor commands are initiated or voluntary move-
ments.12,92,99,122 It is in this region o the primary sensory cortex that there is a high degree o
spatial orientation.
T e M3 response is very exible and can be modif ed by a host o actors such as ver-
bal instructions or anticipation o the incoming sensory in ormation. T e delay in the M3
response makes it sensitive to a number o stimulus alternatives. T ere ore, the individual’s
ability to respond will require some conscious attention. raining at this level o the cerebral
cortex stimulates the conversion o conscious programming to unconscious programming.
T ese responses have o ten been re erred to as triggered reactions. riggered reactions are
prestructured, coordinated reactions in the same or closely related musculature that are
“triggered” into action by the mechanoreceptors. T e triggered reaction may bypass the
in ormation-processing centers because the reaction is stereotyped, predictable, and well
practiced. T ese reactions have latencies rom 80 to 180 milliseconds and are ar more
variable than the latencies o the aster re exes.102 T e triggered reactions can be learned
and can become a more or less automatic response. T e individual does not have to spend
time processing a response reaction and programming; the reaction is just “triggered o ”
almost as i it were automatic.101 T us, with training, the speed o the M3 response could be
increased so as to produce a more automatic re ex response.
T e appreciation o joint position at the highest or cognitive level needs to be included
in the RN program. T ese types o activities are initiated on the cognitive level and include
programming motor commands or voluntary movement. T e repetitions o these move-
ments will maximally stimulate the conversion o conscious programming to unconscious
programming.12,71,122,126,127,130 T e term or this type o training is the orced-use paradigm .
By making a task signif cantly more di cult or asking or multiple tasks, we bombard the
CNS with input. T e CNS attempts to sort and process this overload in ormation by open-
ing additional neural pathways. When the individual goes back to a basic task o ADL,
the task becomes easier. T is in ormation can then be stored as a central command and
ultimately per ormed without continuous re erence to the conscious mind as a “triggered
response.”12,71,122,126,127 As with all training, the single greatest obstacle to motor learning is
the conscious mind. We must get the conscious mind out o the act!
Coordinating the Muscle Response

with Unexpected Loads
T e relative roles o these 3 m uscle responses depend upon the duration o the m ove-
m ent. As previously discussed, the quickest action occurring in the body has a m ove-
m ent tim e o approxim ately 40 m illiseconds. When this type or action occurs, the M2
response is incapable o com pleting or m odi ying the activity once it is initiated. Even
the M1 response has only enough tim e to begin in uencing the muscles near the end o
the m ovem ent. As the m ovem ent tim e increases, there is a greater potential or the M1
and M2 responses to contribute to the intended action. Movem ents that take a longer
tim e to be com pleted (>100 m illiseconds) allow both the M1 an d M2 responses su -
cient tim e to contribute to all levels o the action. Only when the duration o the m ove-
m ent is 300 m illiseconds or longer is there potential or the M3 long-loop response to be
involved in am endin g the m ovem ent. T ere ore, or m ovem ents that take lon ger than
300 m illiseconds or individuals to com plete, closed-loop control is possible at several
levels o integration at the sam e tim e.
Why Is Response Time Important? 241
Why Is Response Time Important?

When an unexpected load is placed upon a joint, ligamentous damage occurs a ter the
passing o between 70 and 90 milliseconds unless an appropriate response ensues.7,94,140
T ere ore, reactive muscle activity must occur with su cient magnitude in the 40- to
80-millisecond time rame a ter loading begins, in order to protect the capsuloligamentous
structures. T e closed-loop system o CNS integration may not be ast enough to produce a
response to increase muscle sti ness. Simply, there is no time or the system to process the
in ormation and process the eedback about the condition. Failure o the dynamic restraint
system to control these abnormal orces will expose the static structures to excessive orces.
In this case, the open-loop system o anticipation becomes more important in producing
the desired response. Preparatory muscle activity in anticipation o joint loading can in u-
ence the reactive muscle activation patterns. Anticipatory activation increases the sensitiv-
ity o the muscle spindles, thereby allowing the unexpected perturbations to be detected
more quickly.29
Very quick movements are completed be ore eedback can be used to produce an
action to alter the course o movement.61 T ere ore, i the movement is ast enough, a
mechanism like a motor program would have to be used to control the entire action, with
the movement being carried out without any eedback. Fortunately, the open-loop control
system allows the motor control system to organize an entire action ahead o time. For this
to occur, previous knowledge o the ollowing needs to be preprogrammed into the primary
sensory cortex:
• T e particular muscles that are needed to produce an action.

• T e order in which these muscles need to be activated.
• T e relative orces o the various muscle contractions.
• T e relative timing and sequencing o these actions.
• T e duration o the respective contractions.
In the open-loop system, m ovem ent is organized in advance by a program that sets
up som e kind o neural m echanism or network that is preprogram m ed. A classic exam ple
o this occurs in the body as postural adjustm ents are made be ore the intended m ove-
m ent. When an individual raises the arm up into orward exion, the f rst muscle groups
to f re are not even in the shoulder girdle region. T e f rst m uscles to contract are those
in the lower back and legs (approximately 80 m illiseconds be ore noticeable activity in
the shoulder).8 Because the shoulder m uscles are linked to the rest o the body, their
contraction a ects posture. I no preparatory com pensations in posture were made, rais-
ing the arm would shi t the center o gravity orward, causing a slight loss o balance. T e
eed- orward motor control system takes care o this potential problem by preprogram -
m ing the appropriate postural m odif cation f rst, rather than requiring the body to make
adjustm ents a ter the arm begins to m ove.
Lee has demonstrated that these preparatory postural adjustments are not indepen-
dent o the arm movement, but rather a part o the total motor pattern.70 When the arm
movements are organized, the motor instructions are preprogrammed to adjust posture
f rst and then move the arm. T ere ore, arm movement and postural control are not sepa-
rate events, but rather di erent parts o an integrated action that raises the arm while main-
taining balance. Lee showed that these EMG preparatory postural adjustments disappear
when the individual leans against some type o support prior to raising the arm. T e motor
control system recognizes that advance preparation o postural control is not needed when
the body is supported against the wall.
It is important to remember that most motor tasks are a complex blend o both open-
and closed-loop operations. T ere ore, both types o control are o ten at work simultane-
ously. Both eed- orward and eedback neuromuscular control can enhance dynamic
stability i the sensory and motor pathways are requently stimulated.71 Each time a signal
passes through a sequence o synapses, the synapses become more capable o transmitting
the same signal.50,56 When these pathways are “ acilitated” regularly, memory o that signal
is created and can be recalled to program uture movements.50,102
Reestablishing Proprioception
and Neuromuscular Control
Although the concept and value o proprioceptive mechanoreceptors have been docu-
mented in the literature, treatment techniques directed at improving their unction gener-
ally have not been incorporated into the overall rehabilitation program. T e neurosensory
unction o the capsuloligamentous structures has taken a backseat to the mechanical
structural role. T is is mainly a result o the lack o in ormation about how mechanorecep-
tors contribute to the specif c unctional activities and how they can be specif cally acti-
vated.37,42 Following injury to the capsuloligamentous structures, it is thought that a partial
dea erentation o the joint occurs as the mechanoreceptors become disrupted. T is par-
tial dea erentation, which is secondary to injury, may be related to either direct or indirect
injury. Direct trauma e ects include disruption o the joint capsule or ligaments, whereas
posttraumatic joint e usion or hemarthrosis67 can illustrate indirect e ects.
Whether a direct or indirect cause, the resultant partial dea erentation alters the a er-
ent in ormation into the CNS and, there ore, the resulting re ex pathways to the dynamic
stabilizing structures. T ese pathways are required by both the eed- orward and eedback
motor control systems to dynamically stabilize the joint. A disruption in the proprioceptive
pathway will result in an alteration o position and kinesthesia.4,111 Barrack et al showed an
increase in the threshold to detect passive motion in a majority o patients with ACL rupture
and unctional instability.4 Corrigan et al, who also ound diminished proprioception a ter
ACL rupture, conf rmed this f nding.24 Diminished proprioceptive sensitivity also has been
shown to cause giving way or episodes o instability in the ACL-def cient knee.13 Injury to
the capsuloligamentous structures not only reduces the joint’s mechanical stability but also
diminishes the capability o the dynamic neuromuscular restraint system. Consequently,
any aberration in joint motion and position sense will impact both the eed- orward and
eedback neuromuscular control systems. Without adequate anticipatory muscle activity,
the static structures may be exposed to insult unless the reactive muscle activity can be ini-
tiated to contribute to dynamic restraint.
Def cits in the neuromuscular re ex pathways may have a detrimental e ect on the
motor control system as a protective mechanism. Diminished sensory eedback can alter
the re ex stabilization pathways, thereby causing a latent motor response when aced with
unexpected orces or trauma. Beard et al demonstrated disruption o the protective re ex
arc in subjects with ACL def ciency.7 A signif cant def cit in re ex activation o the hamstring
muscles a ter a 100-newton anterior shear orce in a single-legged closed-chain position
was identif ed, as compared to the contralateral uninjured limb.7 Beard demonstrated that
the latency was directly related to the degree o knee instability; the greater the instability,
the greater the latency. Other researchers ound similar alterations in the muscle-f ring pat-
terns in the ACL-def cient patient.65,116,140 Solomonow et al ound that a direct stress applied
to the ACL resulted in re ex hamstring activity, thereby contributing to the maintenance o
joint stability.116 Although this response was also present in ACL-def cient knees, the re ex
was signif cantly slower.
Reestablishing Proprioception and Neuromuscular Control 243
Although it has been dem onstrated that a proprioceptive def cit occurs ollowing
knee injury, both kinesthetic awareness and reposition sense can be at least partially
restored with surgery and rehabilitation. A num ber o studies have exam ined proprio-
ception ollowing ACL reconstruction. Barrett m easured proprioception a ter autogenous
gra t repair and ound that the proprioception was better than that o the average ACL-
def cient patient, but still signif cantly worse than the proprioception in the normal knee.5
Barrett urther noted that the patient’s satis action was m ore closely correlated with the
patient’s proprioception than with the patient’s clinical score.5 Harter et al could not
dem onstrate a signif cant di erence in the reproduction o passive positioning between
the operative and nonoperative knee at an average o 3 years a ter ACL reconstruction.53
Kinesthesia has been reported to be restored a ter surgery as detected by the threshold
to the detection o passive m otion in the midrange o m otion.4 A longer threshold to the
detection o passive m otion was observed in the ACL-reconstructed knee com pared
with the contralateral uninvolved knee when tested at the end range o m otion.4 Lephart
et al ound sim ilar results in patients a ter either arthroscopically assisted patellar tendon
autogra t or allogra t ACL reconstruction.74 T e im portance o incorporating a proprio-
ceptive elem ent in any comprehensive rehabilitation program is justif ed based upon the
results o these studies.
T e e ects o how surgical and nonsurgical interventions m ay acilitate the resto-
ration o the neurosensory roles is unclear; however, it has been shown that ligam en-
tous retensioning coupled with rehabilitation can restore proprioceptive sensitivity.72
As a erent input is altered a ter joint injury, proprioceptive rehabilitation m ust ocus
on restoring proprioceptive sensitivity to retrain these altered a erent pathways and
enhance the sensation o joint m ovem ent. Restoration may be acilitated by (a) enhanc-
ing m echanoreceptor sensitivity, (b) increasing the num ber o m echanoreceptors stimu-
lated, and (c) enhancing the com pensatory sensation rom the secondary receptor sites.
Research should be directed toward developing new techniques to im prove propriocep-
tive sensitivity.
Methods to im prove proprioception a ter injury or surgery could im prove unction
and decrease the risk or reinjury. Ihara and Nakayama dem onstrated a reduction in the
neuromuscular lag tim e with dynam ic joint control ollowing a 3-week training period
on an unstable board.65 T e maintenance o equilibrium and im provem ent in reaction
to sudden perturbations on the unstable board served to im prove the neuromuscular
coordination. T is phenom enon was f rst reported by Freeman and Wyke in 1967, when
they ound that proprioceptive def cits could be reduced with training on an unstable sur-
ace.33 T ey ound that proprioceptive training through stabiliom etry, or training on an
unstable sur ace, signif cantly reduced the episodes o giving way ollowing ankle sprains.
ropp et al conf rmed the work o Freeman by dem onstrating that the results o stabili-
om etry could be im proved with coordination training on an unstable board.124 Hocher-
man et al also showed an improvem ent in the m ovement amplitude on an unstable board
and the weight distribution on the eet ound in hem iplegic patients who received train-
ing on an unstable board.55
Barrett 5 has demonstrated the relationship between proprioception and unction.
Barrett’s study suggests that limb unction relies more on proprioceptive input than on
strength during activity. Borsa et al also ound a high correlation between diminished
kinesthesia with the single-leg hop test.12 T e single-leg hop test was chosen or its integra-
tive measure o neuromuscular control, because a high degree o proprioceptive sensibility
and unctional ability is required to success ully propel the body orward and land sa ely
on the limb. Giove et al reported a higher success rate in returning athletes to competitive
sports through adequate hamstring rehabilitation.40 ibone et al and Ihara and Nakayama
ound that simple hamstring strengthening alone was not adequate; it was necessary to
obtain voluntary or re ex-level control on knee instability in order to return to unctional
activities.65,121 Walla et al ound that 95% o patients were able to success ully avoid surgery
a ter ACL injury when they were able to achieve “re ex-level” hamstring control.136 Ihara
and Nakayama ound that the re ex arc between stressing the ACL and hamstring contrac-
tion could be shortened with training.65 With the use o unstable boards, the researchers
were able to success ully decrease the reaction time. Because a erent input is altered a ter
joint injury, proprioceptive sensitivity to retrain these altered a erent pathways is critical
to shorten the time lag o muscular reaction so as to counteract the excessive strain on the
passive structures and to guard against injury.
What About Muscle Fat igue?

It has been well established in the literature that muscle atigue can play a major role
in destabilizing a joint.100,111,117,129 With atigue, an increase in knee joint laxity has been
noted in both males and emales.100,117,118 More im portantly, the body’s ability to receive
and accurately process proprioceptive in ormation is a ected by muscular atigue. T ere
is evidence that exercise to the point o clinical atigue does have an e ect on proprio-
ception.111,129 Research dem onstrates that the ability to learn or make im provem ent in
joint position sense is severely im paired with muscle atigue.75,100 Likewise, muscle
atigue alters both kinesthesia and joint position sense.2,111,129 Skinner et al showed that
the reproduction o passive positioning was signif cantly dim inished ollowing a atigue
protocol.111 Voight et al also dem onstrated a signif cant proprioceptive def cit ollowing
a atigue protocol.129 T is suggests that patients who are atigued may have a change in
their proprioceptive abilities and are m ore prone to injury. Following a lower-quarter
isokinetic atigue protocol, postural sway as m easured with EMG and orceplates is also
increased ollowing muscular atigue.66,129 T is suggests that muscular atigue results in a
possible m otor control def cit. In addition to disruption balance or postural sway, Nyland
et al also demonstrated on EMG that muscular atigue a ects muscle activity by extend-
ing the latency o the muscle f ring.87
Modifying Afferent /Efferent Charact erist ics:

How Do We Do It ?
T e m echanoreceptors in and around the respective joints o er in ormation about the
change o position, m otion, and loading o the joint to the CNS, which, in turn, stimulates
the muscles around the joint to unction.65 I a tim e lag exists in the neuromuscular reac-
tion, injury may occur. T e shorter the time lag, the less stress to the ligam ents and other
so t-tissue structures about the joint. T ere ore, the oundation o neuromuscular con-
trol is to acilitate the integration o peripheral sensations relative to joint position and
then process this in ormation into an e ective e erent m otor response. T e main objec-
tive o the rehabilitation program or neuromuscular control is to develop or reestablish
the a erent and e erent characteristics about the joint that are essential or dynam ic
restraint.71
T ere are several di erent a erent and e erent characteristics that contribute to the
e cient regulation o motor control. As discussed previously, these characteristics include
the sensitivity o the mechanoreceptors and acilitation o the a erent neural pathways,
enhancing muscle sti ness, and the production o re ex muscle activation. T e specif c
rehabilitation techniques must also take into consideration the levels o CNS integration.
For the rehabilitation program to be complete, each o the 3 levels must be addressed in
order to produce dynamic stability. T e plasticity o the neuromuscular system permits
rapid adaptations during the rehabilitation program that enhance preparatory and reac-
tive activity.7,56,65,71,74,141 Specif c rehabilitation techniques that produce adaptations that
Objectives of Neuromuscular Control: Reactive Neuromuscular Training 245
enhance the e ciency o these neuromuscular techniques include balance training,
bio eedback training, re ex acilitation through reactive training, and eccentric and high-
repetition/ low-load exercises.41,71
Objectives of Neuromuscular Control:

Reactive Neuromuscular Training
RN activities are designed to restore unctional stability about the joint and to enhance
motor control skills. T e RN program centers around the stimulation o both the periph-
eral and central re ex pathways to the skeletal muscles. T e f rst objective that should be
addressed in the RN program is the restoration o dynamic stability. Reliable kinesthetic
and proprioceptive in ormation provides the oundation on which dynamic stability and
motor control are based. It has already been established that altered a erent in ormation
into the CNS can alter the eed- orward and eedback motor control systems. T ere ore,
the f rst objective o the RN program is to restore the neurosensory properties o the dam-
aged structures while at the same time enhancing the sensitivity o the secondary periph-
eral a erents.74 T e restoration o dynamic stability allows or the control o abnormal joint
translation during unctional activities. For this to occur, the reestablishment o dynamic
stability is dependent upon the CNS receiving appropriate in ormation rom the peripheral
receptors. I the in ormation into the system is altered or inappropriate or the stimulus, a
bad motor response will ensue.
o acilitate appropriate kinesthetic and proprioceptive in ormation to the CNS, joint
reposition exercises should be used to provide a maximal stimulation o the peripheral
mechanoreceptors.135 T e use o closed kinetic chain activities creates axial loads that maxi-
mally stimulate the articular mechanoreceptors via the increase in compressive orces.22,45
T e use o closed-chain exercises not only enhances joint congruency and neurosensory
eedback but also minimizes the shearing stresses about the joint.128 At the same time, the
muscle receptors are acilitated by both the change in length and tension.22,45 T e objec-
tive is to induce unanticipated perturbations, thereby stimulating re ex stabilization. T e
persistent use o these pathways will decrease the response time when aced with an unan-
ticipated joint load.88 In addition to weightbearing exercises, joint repositioning exercises
can be used to enhance the conscious appreciation o proprioception. Rhythmic stabiliza-
tion exercises can be included early in the RN program to enhance neuromuscular coor-
dination in response to unexpected joint translation. T e intensity o the exercises can be
manipulated by increasing either the weight loaded across the joint or the size o the per-
turbation. T e addition o a compressive sleeve, wrap, or taping about the joint can also
provide additional proprioceptive in ormation by stimulating the cutaneous mechanore-
ceptors.5,71,76,90 Following the restoration o range o motion and strength, dynamic stability
can be enhanced with re ex stabilization and basic motor learning exercises.
T e second objective o the RN program is to encourage preparatory agonist–
antagonist cocontraction. E cient coactivation o the musculature restores the normal
orce couples that are necessary to balance joint orces and increase joint congruency,
thereby reducing the loads imparted onto the static structures.71 T e cornerstone o reha-
bilitation during this phase is postural stability training. Environmental conditions are
manipulated to produce a sensory response. Specif cally, the 3 variables o balance that are
manipulated include bilateral to unilateral stance, eyes open to eyes closed, and stable to
unstable sur aces. T e use o unstable sur aces allows the clinician to use positions o com-
promise in order to produce maximal a erent input into the spinal cord, thereby producing
a re ex response. Dynamic coactivation o the muscles about the joint to produce a stabiliz-
ing orce requires both the eed- orward and eedback motor control systems. In order to
acilitate these pathways, the joint must be placed into positions o compromise in order or
the patient to develop reactive stabilizing strategies. Although it was once believed that the
speed o the stretch re exes could not be directly enhanced, e orts to do so have been suc-
cess ul in human and animal studies. T is has signif cant implications or reestablishing the
reactive capability o the dynamic restraint system. Reducing the electromechanical delay
between joint loading and the protective muscle activation can increase dynamic stability.
In the controlled clinical environment, positions o vulnerability can be used sa ely.
Proprioceptive training or unctionally unstable joints ollowing injury has been docu-
mented in the literature.65,106,123,125,135 ropp et al124 and Wester et al137 reported that ankle disk
training signif cantly reduced the incidence o ankle sprain. Concerning the mechanism o
e ects, ropp et al suggested that unstable sur ace training reduced the proprioceptive def -
cit.124 Sheth et al demonstrated changes with healthy adults in the patterns o contractions on
the inversion and eversion musculature be ore and a ter training on an unstable sur ace.106
T ey concluded that the changes would be supported by the concept o reciprocal Ia inhi-
bition via the mechanoreceptors in the muscles. Konradsen and Ravin also suggested that
the a erent input rom the cal musculature was responsible or dynamic protection against
sudden ankle inversion stress.68 Pinstaar et al reported that postural sway was restored a ter 8
weeks o ankle disk training when carried out 3 to 5 times a week.93 ropp and Odenrick also
showed that postural control improved a ter 6 weeks o training when per ormed 15 minutes
per day.125 Bernier and Perrin, whose program consisted o balance exercises progressing
rom simple to complex sessions (3 times a week or 10 minutes), also ound that postural
sway was improved a ter 6 weeks o training.10 Although there were some di erences in each
o these training programs, the postural control improved a ter 6 to 8 weeks o proprioceptive
training or participants with unctional instability o the ankle.
Once dynamic stability has been achieved, the ocus o the RN program is to restore
ADL and sport-specif c skills. Exercise and training drills should be incorporated into the
program that will ref ne the physiologic parameters that are required or the return to pre-
injury levels o unction. Emphasis in the RN program must be placed upon a progression
rom simple to complex neuromotor patterns that are specif c to the demands placed upon
the patient during unction. T e training program should begin with simple activities, such
as walking/ running, and then progress to highly complex motor skills requiring ref ned
neuromuscular mechanisms including proprioceptive and kinesthetic awareness that pro-
vide re ex joint stabilization.
Exercise Program/ Progression

Dynamic reactive neuromuscular control activities should be initiated into the overall reha-
bilitation program once adequate healing has occurred. T e progression to these activities
is predicated on the athlete satis actorily completing the activities that are considered pre-
requisites or the activity being considered. Keeping this in mind, the progression o activi-
ties must be goal-oriented and specif c to the tasks that will be expected o the athlete.
T e general progression or activities to develop dynamic reactive neuromuscular con-
trol is rom slow-speed to ast-speed activities, rom low- orce to high- orce activities, and
rom controlled to uncontrolled activities. Initially, these exercises should evoke a balance
reaction or weight shi t in the lower extremities and ultimately progress to a movement pat-
tern. T ese reactions can be as simple as a static control with little or no visible movement
or as complex as a dynamic plyometric response requiring explosive acceleration, decelera-
tion, or change in direction. T e exercises will allow the clinician to challenge the patient
using visual and/ or proprioceptive input via tubing and other devices (medicine balls, oam
rolls, visual obstacles). Although these exercises will improve physiologic parameters, they
are specif cally designed to acilitate neuromuscular reactions. T ere ore, the clinician must
Exercise Program/Progression 247
be concerned with the kinesthetic input and quality o the movement patterns rather than
the particular number o sets and repetitions. Once atigue occurs, motor control becomes
poor and all training e ects are lost. T ere ore, during the exercise progression, all aspects
o normal motor control/ movement should be observed. T ese should include isometric,
concentric, and eccentric muscle control; articular loading and unloading; balance control
during weight shi ting and direction changes; controlled acceleration and deceleration; and
demonstration o both conscious and unconscious control.
Phase I: St at ic St abilizat ion (Closed-Chain Loading/Unloading)

Phase I involves minimal joint motion and should always ollow a complete open-chain
exercise program that restores near- ull active range o motion. T e patient should stand
bearing ull weight with equal distribution on the a ected and una ected lower extremity.
T e eet should be positioned approximately shoulder-width apart. Greater emphasis can
be placed on the a ected lower extremity by having the patient put the una ected lower
extremity on a 6- to 8-inch stool or step bench. T is exes the hip and knee and orces a
greater weight shi t to the a ected side, yet allows the una ected extremity to assist with
balance reactions (Figure 9-8). T e weightbearing status then progresses to having the
una ected extremity suspended in ront or behind the body, orcing a single-leg stance on
the a ected side (Figure 9-9). T e patient is then asked to continue the single-leg stance
while shi ting weight to the ore oot and toes by li ting the heel and plantar exing the ankle.
T is places the complete responsibility or weightbearing and balance reactions on the
a ected lower extremity. T is position will also require slight exion o the hip and knee.
Support devices are o ten help ul and can minimize con usion. When the patient is f rst
Figure 9-8 Static stabilizatio n Figure 9-9

Weight shifting technique to enhance transfer onto Static stabilization: Uniplanar anterior
the left leg. weight shift.
asked to progress weight bearing to the ore oot and toes, a heel
li t device can be used. A support device can also be used to
place the ankle in dorsi exion, inversion, or eversion to increase
kinesthetic input or decrease biomechanical stresses on the hip,
knee, and ankle.
At each progression, the clinician may ask that the patient
train with eyes closed to decrease the visual input and increase
kinesthetic awareness. T e clinician may also use an unstable
sur ace with training in this phase to increase the demands on
the mechanoreceptor system. T e unstable sur ace will acilitate
the re ex pathways mediated by the peripheral e erent recep-
tors. Single or multidirectional rocker devices will assist the pro-
gression to the next phase (Figure 9-10).
T e physiologic rationale or this phase o RN is the use o
static compression o the articular structures to produce maximal
output o the mechanoreceptors, thereby acilitating isometric
contractions o the musculature and providing a dynamic re ex
stabilization. T e sel -generated oscillations will help increase
the interplay between visual, mechanoreceptor, and equilibrium
reaction. Changes in the isometric muscle tension will assist in
the sensitization o the muscle spindle (gamma bias).
T e exercise tubing technique used in this phase is called
oscillating technique or isom etric stabilization (O IS). T e tech-
Figure 9-10 nique can be used to stimulate muscle spindle and mechano-
receptor activity. T e exercises involve continuously loaded
Static stabilization: Single-leg stance/unstable surface.
short-arc movements o 1 body part, which, in turn, causes an
isometric stabilization reaction o the involved body part. T is
is accomplished by pulling 2 pieces o tubing toward the body and returning the tubing to
a start position in a smooth rhythmical ashion with increasing speeds. Resistance builds
as the tubing is stretched. T is orces a trans er o weight in the direction o the tubing.
Because the involved body part is only required to react or respond to a simple stimulus, the
oscillating stimulus will produce an isometric contraction in the lower extremity that must
produce a stabilizing orce in the direction opposite to the tubing pull. T e purpose o this
technique is to quickly involve the proprioceptive system with minimal verbal and visual
cueing. Ognibene et al demonstrated a signif cant improvement in both single-leg postural
stability and reaction time with a 4-week training program using O IS techniques.88
Change in direction—according to anterior, posterior, medial, and lateral weight
shi ting—will create specif c planar demands. Each technique is given a name, which is
related to the weight shi t produced by the applied tension. T e body will then react with
an equal and opposite stabilization response. Consequently, the exercise is named or the
cause and not the e ect. T e goal during this phase is static stabilization. Numerous success-
ul repetitions demonstrating stability are required to achieve motor learning and control.
Uniplanar Exercise
Anterior Weight Shift T e patient aces the tubing and pulls the tubing toward the body
using a smooth, com ortable motion. T is causes orward weight shi t that is stabilized with
an isometric counter orce consisting o hip extension, knee extension, and ankle plan-
tar exion. T ere should be little or no movement noted in the lower extremity. I movement
is noted, resistance should be decreased to achieve the desired stability (see Figure 9-9).
Lateral Weight Shift T e patient stands with the a ected side acing the tubing. T e
tubing is pulled by 1 hand in ront o the body and by the other hand behind the body to
equalize the orce and minimize the rotation. T is causes a lateral weight shi t (LWS), which
is stabilized with an isometric counter orce consisting o hip abduction, knee cocontrac-
tion, and ankle eversion.
Medial Weight Shift T e patient stands with the una ected side acing the tubing. T e
tubing is pulled in the same ashion as above. T is causes a medial weight shi t (MWS),
which is stabilized with an isometric counter orce consisting o hip adduction, knee cocon-
traction, and ankle inversion.
Posterior Weight Shift T e patient stands with his/ her back to the tubing in the rontal
plane. T e tubing is pulled to the body rom behind, causing a posterior weight shi t (PWS),
which is stabilized by an isometric counter orce consisting o hip exion, knee exion, and
ankle dorsi exion.
Mult iplanar Exercise

T e basic exercise program can be progressed to multiplanar activity by combining the pro-
prioceptive neuromuscular acilitation chop and li t patterns o the upper extremities. T e
chop patterns rom the a ected and una ected side will cause a multiplanar stress requir-
ing isometric stabilization. T e patient will now be orced to automatically integrate the iso-
metric responses that were developed in the previous uniplanar exercises. T e orce will
be representative o the proprioceptive neuromuscular acilitation diagonals o the lower
extremities (Figure 9-11). T e li t patterns rom the a ected to the una ected side will add
multiplanar stress in the opposite direction (Figure 9-12). Changing the resistance, speed
o movement, or spatial orientation relative to the resistance can make modif cations to the
multiplanar exercise. I resistance is increased, the movement speed should be decreased
to allow or a strong stabilizing counter orce. I the speed o movement is increased, then
Figure 9-11 Figure 9-12

Static stabilization: Multiplanar PNF chop Static stabilization: Multiplanar PNF lift technique
technique to provide rotational stress. to provide rotation stress.
resistance should be decreased to allow or a quick coun-

ter orce response. By altering the angle o the body in
relation to the resistance, the quality o the movement
is changed. A greater emphasis can be placed on one
component while reducing the em phasis on another
component.
Technique Modi cat ion

T ese techniques can also be used with medicine ball
exercises. T e posture and position are nearly the same,
but the medicine ball does not allow or the oscilla-
tions provided by the tubing. T e medicine ball provides
impulse activity and a more complex gradient o loading
and unloading (Figure 9-13). T is is re erred to as impulse
technique or isometric stabilization (I IS). As described,
the patient is positioned to achieve the desired stress. T e
medicine ball is then used with a rebounding device or
thrown by the clinician. Progression to ball toss while sta-
Figure 9-13 Static stabilizatio n
bilizing on an unstable sur ace will disrupt concentration,
thereby acilitating the conversion to unconscious re ex
ITIS technique in unilateral stance using a Plyoball and
adaptation.
plyoback for an impulse stimulus.
T e elastic tubing and medicine ball techniques are
similar in position but di er somewhat in physiologic
demands. T ere ore, they should be used to complement each other and not replace or
substitute the other at random. When per orming an I IS activity with a medicine ball,
the orce exerted by the exercise device names the weight shi t. T e tubing will exert a pull
and the ball will exert a push ; there ore, they will be per ormed rom the opposite sides to
achieve the same weight shi t.
Phase II: Transit ional St abilizat ion

(Conscious Cont rolled Mot ion Wit hout Impact )
Phase II replaces isometric activity with controlled concentric and eccentric activity pro-
gressing through a ull range o unctional motion. T e orces o gravity are coupled with
tubing to simulate stress in both the vertical and horizontal planes. In phase I, gravitational
orces statically load the neuromuscular system. Varying degrees o imposed lateral stress
via the tubing are used to stimulate isometric stabilization. Phase II requires that the move-
ment occur in the presence o varying degrees o imposed lateral stress. T e movement
stimulates the mechanoreceptors in 2 ways: (a) articular movement causes capsular stretch
in a given direction at a given speed and (b) the changes in the body position cause loading
and unloading o the articular structures and pressure changes in the intracapsular uid.
T e exercises in this phase use simple movements such as the squat and lunge. T e addi-
tion o tubing adds a horizontal stress. Other simple movements such as walking, sidestep-
ping, and the lateral slide board can also be emphasized to stimulate a more e cient and
controlled movement.
T e physiologic rationales or activities in this phase are the stimulation o dynam ic
postural responses and acilitation o concentric and eccentric contractions via the
com pression and translation o the articular structures. T is, in turn, helps to in crease
m uscle sti ness, which has a signif cant role in producing dynam ic stabilization about
the joint by resisting and absorbing joint loads.80,81 Research has established that eccen-
tric loading increases both muscle sti ness and tone.16,95 Chronic overloading o the
musculotendinous unit via eccentric contractions will result in not only connective tis-
sue proli eration but also a desensitization o the G O and increased muscle spindle
activity.64
T e sel -generated movements require dynamic control in the midrange and static
control at the end range o motion. Because a change in direction is required at the end
ranges o motion, the interplay between visual, mechanoreceptor, and equilibrium reac-
tions continues to increase. T e “gamma bias” now responds to changes in both length and
tension o the involved musculature.
Assisted techniques can also be used in this phase to progress patients who may f nd
phase II exercise atiguing or di cult. Assisted exercise is used to reduce the e ect o gravity
on the body or an extremity to allow or an increase in the quality or quantity o a desired
movement. T e assisted technique will o set the weight o the body or extremity by a per-
centage o the total weight. T is will allow improved range o motion, a reduction in sub-
stitution, minimal eccentric stress, and a reduction in atigue. T e closed-chain tubing
program can also benef t rom assisted techniques, which allow or a reduction in vertical
orces by decreasing relative body weight on one or both lower extremities.
T e need or assisted exercise is only transitional in nature. T e goal is to progress rom
unweighted to weight with overloading. T e tubing, i used e ectively, can also provide an
overloading e ect by causing exaggerated weight shi ting. T is overloading will be re erred
to as resisted techniques or all closed-chain applications. T e 2 basic exercises used are the
squat and the lunge.
Squat
T e squat is used f rst because it em ploys symm etrical m ovem ent o the lower extremi-
ties. T is allows the a ected lower extrem ity to benef t rom the visual and propriocep-
tive eedback rom the una ected lower extrem ity. T e clinician
should observe the patient’s posture and look or weight shi ting,
which alm ost always occurs away rom the a ected lim b. Each
joint can be compared to its una ected counterpart. In per orm-
ing the squat, a weight shi t may be provided in 1 o 4 di erent
directions. T e tubing is used to assist, resist, and modi y move-
m ent patterns. T e PWS works to identi y closed-chain ankle
dorsi exion. A chair or bench can be used as a range-o -motion
block (range-lim iting device) when necessary. T is m inim izes
ear and increases sa ety. T e anterior weight shi t (AWS) provides
an anterior pull that helps acilitate the hip exion mobility dur-
ing the descent. Medial and lateral changes may be provided with
resistance in order to prom ote weight bearing on the involved
side or decrease weight bearing on the involved side as progres-
sion is made (Figure 9-14). T e varying weight shi ts may be used
to intentionally increase the load or resistance on a particular
side or m eans o strengthening or to acilitate a neuromuscular
response on the opposite side. For example, an individual who is
reluctant to weight bear on the involved side may be helped in
doing so by causing increased weight shi t to the uninvolved side.
T is will create the need to shi t weight to the involved side, thus
encouraging a joint response to the required stimulus.
Assisted Technique T e patient aces the tubing, which is Figure 9-14 Transitio nal stabilizatio n
placed at a descending angle and is attached to a belt. T e belt
is placed under the buttocks to simulate a swing. A bench is used Resisted squat with an LWS in the home health
to allow a proper stopping point. T e elastic tension o the tubing setting.
is at its greatest when the patient is in the seated position and decreases as the mechanical
advantage increases. T ere ore, the tension curve o the tubing complements the needs o
the patient. T e next 4 exercises ollow the assisted squat in di culty. T e tubing is now
used to cause weight shi ting and demands a small amount o dynamic stability.
Anterior Weight Shift T e patient aces the tubing, which com es rom a level hal -
way between the hips and the knees and attaches to a belt. T e belt is worn around the
waist and causes an AWS. During the squat movement, the ankles plantar ex as the knees
extend.
Posterior Weight Shift T e patient aces away rom the tubing at the same level as above
and attaches to a belt. T e belt is worn around the waist and causes a PWS. T is places a
greater emphasis on the hip extensors and less emphasis on the knee extensors and plantar
exors.
Medial Weight Shift T e patient stands with the una ected side toward the tubing at
the same level as above. T e belt is around the waist and causes an MWS. T is places less
stress on the a ected lower extremity and allows the patient to lean onto the a ected lower
extremity without incurring excessive stress or loading.
Lateral Weight Shift T e patient stands with the a ected side toward the tubing that is at
the same level as above. T e belt is worn around the waist, which causes a weight shi t onto
the a ected lower extremity. T is exercise will place a greater stress on the a ected lower
extremity, thereby demanding increased balance and control. T e exercise simulates a
single-leg squat but adds balance and sa ety by allowing the una ected extremity to remain
on the ground.
Lunge
T e lunge is m ore specif c in that it simulates sports and normal activity. T e exercise
decreases the base while at the same time producing the need or independent disasso-
ciation. T e range o motion can be stressed to a slightly higher degree. I the patient is
asked to alternate the lunge rom the right to the le t leg, the clinician can easily compare
the quality o the movement between the limbs. When per orming the lunge, the patient
may o ten use exaggerated extension movements o the lumbar region to assist weak or
uncoordinated hip extension. T is substitution is not produced during the squat exercise.
T ere ore, the lunge must be used not only as an exercise but also as a part o the unc-
tional assessment. T e substitution must be addressed by asking the patient to maintain a
vertical torso (note that the assisted technique will assist the clinician in minimizing this
substitution).
Assisted Technique—Forward Lunge T e patient aces away rom the tubing, which
descends at a sharp angle (approximately 60 degrees). T is angle parallels the patient’s cen-
ter o gravity, which moves orward and down (Figure 9-15). T is places a stretch on the
tubing and assists the patient up rom the low point o the lunge position. T e ability to per-
orm a lunge with correct technique is o ten negated as a result o the inability to support
one’s body weight. T e assisted lunge corrects this by modi ying the load required o the
patient, thus improving the quality o the movement. T e assistance also minimizes eccen-
tric demands or deceleration when lowering and provides balance assistance by helping
the patient ocus on the center o gravity (anatomically located within the hip and pelvic
region). T e patient is asked to f rst alternate the activity to provide kinesthetic eedback.
T e clinician can then use variations o ull and partial motion to stimulate the appropriate
control be ore moving on to the next exercise.
Figure 9-15 Figure 9-16 Transitional stabilization
Transitional stabilization: Assisted lunge Resisted forward lunge to facilitate

technique. deceleration stress.
Resisted Technique—Forward Lunge T e patient aces the tubing, which is at an

ascending angle rom the oor to the level o the waist (Figure 9-16). T e tubing will now
increase the eccentric loading on the quadriceps with the deceleration or the downward
movement. For the upward movement, the patient is asked to ocus on hip extension and
not knee extension. T e patient must learn to initiate movement rom the hip and not rom
lum bar hyperextension or excessive knee extension. Initiation o hip extension should
automatically stimulate isometric lumbar stabilization along with the appropriate amounts
o knee extension and ankle plantar exion. A oam block is o ten used to protect the rear
knee rom exing beyond 90 degrees and touching the oor. T e block can also be made
larger to limit range o motion at any point in the lunge.
Resisted Technique—Lateral and Medial Weight Shift Forward lunges can be per-
ormed to stimulate static lateral and medial stabilization during dynamic exion and
extension movements o the lower extremities. T e LWS lunge is per ormed by positioning
the patient with the a ected lower extremity toward the direction o resistance. T e tubing
is placed at a level hal way between the waist and the ankle. T e patient is then asked to
per orm a lunge with minimal lateral movement. T is movement stimulates static lateral
stabilization o the hip, knee, ankle, and oot during dynamic exion (unloading) and exten-
sion (loading). T e MWS lunge is per ormed by positioning the patient with the a ected
extremity opposite to the resistance. T e tubing is attached as described in the LWS. T e
movement stimulates static medial stabilization o the a ected lower extremity in the pres-
ence o dynamic exion and extension.
T e lunge techniques teach weight shi ting onto the a ected lower extremity during
lateral body movements. T e assisted technique lateral lunge complements the assisted
technique orward lunge, because it also reduces relative body weight while allowing
closed-chain unction. T e prime mover is the una ected lower extremity that moves the
center o gravity over the a ected lower extremity or the sole purpose o visual and pro-
prioceptive input prior to excessive loading. T e resisted technique lateral lunge comple-
ments the resisted technique orward lunge, because it also provides an overloading e ect
on the a ected lower extremity. In this exercise, the a ected lower extremity is the prime
mover, as well as the primary weightbearing extremity. T e a ected lower extremity must
not only produce the weight shi t but also react, respond, and repeat the movement. Sets,
repetitions, and resistance or all o the exercises described are selected by the clinician to
produce the appropriate reaction without pain or atigue.
Technique Modi cat ion

As in phase I, the medicine ball can be used to add variety and increase stimulation. How-
ever, it is used to stimulate control in the beginning, middle, and end ranges o the squat
and lunges. T e tubing can also be used to create I IS and O IS applications to rein orce
stability throughout the range o motion.
Funct ional Test ing

Functional testing provides objective criteria and can help the clinician to justi y a pro-
gression to phase III or an indication that the patient should continue working in phase II.
A single-leg body weight squat or lunge can be per ormed. T e quality and quantity o the
repetitions are compared to the una ected lower extremity and a def cit can be calculated.
An isotonic leg press machine can also be used in this manner by setting the weight at the
patient’s body weight and comparing the repetitions. Open-chain isotonic and isokinetic
testing can also be help ul in identi ying problem areas when specif city is needed. Regard-
less o the mode o testing, it is recommended that the a ected lower extremity display 70%
to 80% o the capacity demonstrated by the una ected lower extremity, or no more than a
20% to 30% strength def cit. When the patient has met these criteria, the patient can move
sa ely into phase III.
Phase III: Dynamic St abilizat ion (Unconscious Cont rol/Loading)

Phase III introduces impact and ballistic exercise to the patient. T is movement will pro-
duce a stretch-shortening cycle that has been described in plyometric exercises. Plyometric
unction is not a result o the magnitude o the prestretch, but rather relies on the rate o
stretch to produce a more orce ul contraction. T is is done in 2 ways.
1. he stretch re lex is a neurom uscular respon se to ten sion produced in the m uscle
passively. he m uscle respon ds with an im m ediate contraction to reorient itsel
to the n ew position , protect it, an d m aintain posture. I a voluntary contraction
is added in con jun ction with this re lex, a m ore orce ul contraction can be
produced.
2. T e elastic properties o the tendon allow it to temporarily store energy and release it.
When a quick prestretch is ollowed by a voluntary contraction, the tendon will add
to the strength o the contraction by providing orce in the direction opposite to the
prestretch.
Dynamic training at this level can increase the descending cortical drive to the large
motor nerves o the skeletal muscles as well as the small e erent nerves o the muscle spin-
dle.79 I both the muscle tension and e erent output to the muscle spindles are increased,
the stretch sensitivity o the muscle spindle will also be increased, thereby reducing the
re ex latency.64 Both eed- orward and eedback loops are used concurrently to superim-
pose stretch re exes on preprogrammed motor activity.
As has been previously discussed, there have been previous studies that were directed
toward reducing muscle reaction times.7,65,141 Ihara and Nakayama signif cantly reduced the
latency o muscle reaction times with a 3-week training period o unanticipated perturba-
tions via the use o unstable wobble boards.65 Both Beard et al and Wojtys et al ound similar
results when comparing agility training with traditional strength training.7,141 Reducing the
muscle reaction time in order to produce a protective response ollowing an abnormal joint
load will enhance dynamic stability about the joint.
Be ore the patient is asked to learn any new techniques, the patient is instructed to
demonstrate unconscious control by per orming various phase II activities while throwing
and catching the medicine ball. T e squat and lunge exercises are per ormed with various
applications o tubing at the waist level. T is activity removes the attention rom the lower
extremity exercise, thereby stimulating unconscious control. T e orces added by throw-
ing and catching the medicine ball stimulate balance reactions needed or the progression
to plyometric activities. Simple rope jumping is another transitional exercise that can be
used to provide early plyometric in ormation. T e double-leg rope jumping is done f rst.
T e patient is then asked to per orm alternating leg jumping. Rope jumping is e ective in
building conf dence and restoring a plyometric rhythm to movement. Four-way resisted
stationary running is an exercise technique used to orient the patient to light plyometric
activity.
Resist ed Walking
Resisted walking uses the same primary components as in gait training. T e applied resis-
tance o the tubing, however, allows or a reactive response unavailable in nonresisted
activities. For example, a patient may present with a slight rendelenburg gait associated
with a weak gluteus medius. By initiating a program that would incorporate a progression
such as that used with the squat, the patient should be able to progress to resisted walking.
T e addition o resistance permits or increased loading and also brings about the need or
improved balance and weight shi t.
Resist ed Hopping
Bilateral hopping should be introduced ollowing adequate training with the jump rope,
then ollowed by increased unilateral training. T e use o resistance in the hopping tech-
nique is to promote increased resistance in 1 o 4 directions. T is increased resistance is
used to simulate those orces normally seen on the f eld or court in the return to activity.
Introduction o the program should begin with bilateral training and then progress to a uni-
lateral ormat, which may be accommodated with box drills or diagonal training. At higher
levels, implementing cones, hurdles, and/ or oam rolls may be used in order to increase the
plyometric demands during the hopping drills.
Resist ed Running
Resisted running simply involves jogging or running in place with tubing attached to a belt
around the waist. T e clinician can analyze the jogging or running activity because it is a
stationary drill. T e tubing resistance is applied in 4 di erent directions, providing simu-
lation o the di erent orces that the patient will experience as the patient returns to ull
activity.
1. T e PWS run causes a balance reaction that results in an AWS (opposite direction)
and simulates the acceleration phase o jogging or running (Figure 9-17). T e patient
aces opposite the direction o the tubing resistance and should be encouraged to
stay on the toes ( or all running exercises). T e initial light stepping activity can be
progressed to jogging and then running. T e most advanced orm o the PWS run
involves the exaggeration o the hip exion called “high knees.” Exaggeration o hip
exion helps to stimulate a plyometric action in

the hip extensors, thus acilitating acceleration.
T is orm o exercise lends itsel to slow, controlled
endurance conditioning (greater than 3 minutes),
or interval training, which depends greatly on the
intensity o the resistance, cadence, and rest periods.
T e interval-training program is most e ective and
shows the greatest short-term gains. Intervals can be
10 seconds to 1 minute; however, the most common
drills are 15 to 30 seconds in length. T e patient is
usually allowed a 1- to 2-minute rest and is required
to per orm 3 to 5 sets. o make sure that the patient is
delivering maximum intensity, the clinician should
count the number o oot touches (repetitions) that
occur during the interval. T e clinician needs to only
count the touches o the a ected lower extremity.
T e patient is then asked to equal or exceed the
amount o oot touches on the next interval (set).
T is is also extremely e ective as a unctional test or
acceleration. T e interval time/ repetitions can be
recorded and compared to uture tests. T e clinician
should note that the PWS places particular emphasis
on the hip exors and extensors, as well as the
plantar exors o the ankle.
2. T e MWS run ollows the same progression as the
PWS run ( rom light jogging to high knees) with the
Figure 9-17 resistance now applied medial to the a ected lower
extremity (which causes an automatic weight shi t
Dynamic stabilization—stationary run with a posterior weight
laterally). Endurance training, interval training, and
shift.
testing should also be per ormed or this technique.
T is technique simulates the orces that the patient
will experience when cutting or turning quickly away rom the a ected side. T is drill
is the same as in phase I MWS. Although the phase I MWS is static, the same muscles
are responsible or dynamic stability. T is exercise represents the orces that the
patient will encounter when sprinting into a turn on the a ected side.
3. T e LWS run should ollow the same progression as above except that the resistance
is now lateral to the a ected lower extremity (which causes an automatic MWS).
T is technique simulates the orces that the patient will experience when cutting or
turning quickly toward the a ected side.
When per orming the MWS and LWS runs, high knees should be used when
working on acceleration. Instructing the patient to per orm exaggerated knee
exion or “butt kicks” can emphasize deceleration. T e exaggeration o knee exion
places greater plyometric stress on the knee, which has a large amount o eccentric
responsibility during deceleration. T is exercise represents the orces that the patient
will encounter when sprinting into a turn on the una ected side.
4. he AWS run is probably the m ost di icult technique to per orm correctly and is
there ore taught last. he tubing that is set to pull the patient orward stim ulates
a PWS. his technique sim ulates deceleration and eccentric loading o the knee
extensors. he patient should start with light jogging on the toes and progress
to butt kicks. his is a plyom etric exercise that incorporates exaggerated knee
lexion and extension. his exercise serves to assist the patient in developing the
eccentric/ concentric reactions that are required in unction. he clinician should
note that injuries occur m ore requently during deceleration and direction changes
than on acceleration or straight orward running. here ore, AWS training is
extrem ely im portant to the athlete returning to the court or ield.
Resist ed Bounding
T e bounding exercise is a progression taken rom both the hopping and running exercise
to increase demands placed on the horizontal component. T ere ore, bounding is an exer-
cise technique that places greater emphasis on the lateral movements. T e progression o
the bounding exercises ollows the same weight-shi ting sequence as the previous running
exercise. Side-to-side bounding in a lateral resisted exercise promotes symmetrical balance
and endurance required or progression to higher-level strength and power applications.
Distraction activities also may be included in the bounding and/ or running exercises in
order to promote increased upper extremity demands and to detract rom visual and/ or
verbal re erence needed on the lower extremity.
It is suggested that the patient be taught how to per orm the bounding exercise without
the tubing f rst. A oam roll, cone, or other obstacle can be used to simulate jump height
and/ or distance. T e tubing can then be added to provide the secondary orces to cause
anterior, lateral, medial, or posterior weight shi ting. Bounding should be taught as a jump
rom one oot to another. A single lateral bound can be used as a supplementary unctional
test. Measurements can be taken or a le t and right lateral bound. Bounding is only consid-
ered valid i the patient can maintain his or her balance when landing. o standardize the
bounding exercise, the body height is used or the bound stride and markers can be placed
or the le t and right oot landings.
1. T e AWS lateral combines lateral motion with an automatic PWS or deceleration
reaction. It is slightly more demanding than the stationary running exercises because
the body weight is driven to a greater distance.
2. T e LWS bound causes an excessive lateral plyometric orce and will help to develop
lateral acceleration and deceleration in the a ected lower extremity. T is is the
most strenuous o the lateral bounding activities because it actually accelerates the
body weight onto the a ected lower extremity. T is is, however, necessary so that
the clinician can observe the ability o the a ected limb to per orm a quick direction
change and controlled acceleration/ deceleration.
3. T e MWS bound is used as an assisted plyometric exercise. T e patient works with
the total body weight but impact is greatly lowered by reducing both acceleration
and deceleration orces. T is exercise is an excellent transitional exercise at the end
o phase II as well as at the beginning o phase III. It also serves as a warm-up drill
providing submaximal stimulation o the proprioceptive system prior to a phase III
exercise session.
4. he PWS bound acilitates an anterior lateral push-o o each leg and stim ulates
an AWS. his exercise assists in teaching acceleration and lateral cutting
m ovem ents.
Mult idirect ional Drills

Multidirectional drills include jumping (2- oot takeo ollowed by a 2- oot landing), hop-
ping (1- oot takeo ollowed by a landing on the same oot), and bounding (1- oot takeo
ollowed by an opposite- oot landing). A series o oor markers can be placed in various
patterns to simulate unctional movements. A weight shi t can be produced in any direc-
tion by the orientation o the tubing. Obstacles can also be used to make the exercise more
complicated.
T e jumping exercise can be developed to simulate downhill skiing, while the hopping
exercise can be designed to stress single-leg push-o or vertical jumping sports such as
basketball and volleyball.
SUMMARY
1. T ere has been increased attention to the developm ent o balance and propriocep-
tion in the rehabilitation and reconditioning o athletes ollowing injury. It is believed
that injury results in altered som atosensory input that in uences neuromuscular
control.
2. I static and dynamic balance and neuromuscular control are not reestablished ollow-
ing injury, then the patient will be susceptible to recurrent injury and the patient’s per-
ormance may decline.
3. T e ollowing rules should be employed when designing the RN program :
• Make sure that the exercise program is specif c to the patient’s needs. T e most
important thing to consider during the rehabilitation o patients is that they should
be per orming unctional activities that simulate their ADL requirements. T is rule
applies to not only the specif c joints involved but also the speed and amplitude o
movement required in ADL.
• Practice does appear to be task specif c in both athletes and people who have motor-
control def cits.73 As retraining o balance continues, it is best to practice complex
skills in their entirety rather than in isolation, because the skills will trans er more
e ectively.1
• Make sure to include a signif cant amount o “controlled chaos” in the program.
Unexpected activities with the ADL are by nature unstable. T e more the patient
rehearses in this type o environment, the better the patient will react under
unrehearsed conditions.
• Progress rom straight-plane to multiplane movement patterns. In ADL, movement
does not occur along a single joint or plane o movement. T ere ore, exercise or the
kinetic chain must involve all 3 planes simultaneously.
• Begin your loading rom the inside out. Load the system f rst with body weight and
then progress to external resistance. T e core o the body must be developed be ore
the extremities.
• Have causative cures as a part o the rehabilitation process. T e cause o the injury
must eventually become a part o the cure. I rotation and deceleration were
the cause o the injury, then use this as a part o the rehabilitation program in
preparation or return to activity.
• Be progressive in nature. Remember to progress rom simple to complex. T e
unction progression breaks an activity down into its component parts and then
per orms them in a sequence that allows or the acquisition or reacquisition o the
activity. Basic conditioning and skill acquisition must be acquired be ore advanced
conditioning and skill acquisition.
• Always ask: Does the program make sense? I it does not make sense, chances are
that it is not unctional and there ore not optimally e ective.
• Make the rehabilitation program un. T e f rst 3 letters o unctional are FUN. I it is
not un, then compliance will su er and so will the results.
• An organized progression is the key to success. Failing to plan is planning to ail.
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Plyometric Exercise
in Rehabilitation
M ich a e l L. Vo ig h t a n d St e v e n R. Tip p e t t
OBJJECTII VES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
De ne plyometric exercise and identify its function in a rehabilitation program.
Describe the mechanical, neurophysiologic, and neuromuscular control mechanisms involved in

plyometric training.
Discuss how biomechanical evaluation, stability, dynamic movement, and exibility should be
assessed before beginning a plyometric program.
Explain how a plyometric program can be modi ed by changing intensity, volume, frequency,
and recovery.
Discuss how plyometrics can be integrated into a rehabilitation program.
Recognize the value of different plyometric exercises in rehabilitation.
PART 3 The Tools of Rehabilitation

266 Chapte r 10 Plyometric Exercise in Rehabilitation
What Is Plyometric Exercise?

In sports training and rehabilitation o athletic injuries, the concept o specif city has
emerged as an important parameter in determining the proper choice and sequence
o exercise in a training program. T e jumping movement is inherent in numerous sport
activities such as basketball, volleyball, gymnastics, and aerobic dancing. Even running is a
repeated series o jump-landing cycles. Consequently, jump training should be used in the
design and implementation o the overall training program.
Peak per ormance in sport requires technical skill and power. Skill in most activities
combines natural athletic ability and learned specialized prof ciency in an activity. Success
in most activities is dependent upon the speed at which muscular orce or power can be
generated. Strength and conditioning programs throughout the years have attempted to
augment the orce production system to maximize the power generation. Because power
combines strength and speed, it can be increased by increasing the amount o work or orce
that is produced by the muscles or by decreasing the amount o time required to produce
the orce. Although weight training can produce increased gains in strength, the speed o
movement is limited. T e amount o time required to produce muscular orce is an impor-
tant variable or increasing the power output. Plyometrics is a orm o training that attempts
to combine speed o movement with strength.
T e roots o plyometric training can be traced to Eastern Europe, where it was known
simply as jump training.19,20,39–41 T e term plyom etrics was coined by an American track
and f eld coach, Fred Wilt.46 T e development o the term is con using. Plyo- comes rom
the Greek word plythein , which means “to increase.” Plio is the Greek word or “ore,” and
metric literally means “to measure.” Practically, plyometrics is def ned as a quick, power ul
movement involving prestretching the muscle and activating the stretch-shortening cycle
to produce a subsequently stronger concentric contraction. It takes advantage o the length-
shortening cycle to increase muscular power.12
In the late 1960s and early 1970s, when the Eastern Bloc countries began to domi-
nate sports requiring power, their training methods became the ocus o attention. A ter
the 1972 Olym pics, articles began to appear in coaching magazines outlining a strange
new system o jumps and bounds that had been used by the Soviets to increase speed.
Valery Borzov, the 100-meter gold medalist, credited plyometric exercise or his success.
As it turns out, the Eastern Bloc countries were not the originators o plyometrics, just the
organizers. T is system o hops and jumps has been used by American coaches or years as
a method o conditioning. Both rope jumping and bench hops have been used to improve
quickness and reaction times. T e organization o this training method has been credited
to the legendary Soviet jump coach Yuri Verhoshanski, who, during the late 1960s, began to
tie this method o miscellaneous hops and jumps into an organized training plan.39–41 T e
main purpose o plyometric training is to heighten the excitability o the nervous system
or improved reactive ability o the neuromuscular system.43 T ere ore, any type o exercise
that uses the myotatic stretch re ex to produce a more power ul response o the contract-
ing muscle is plyometric in nature. All movement patterns in both athletes and activities o
daily living involve repeated stretch-shortening cycles. Picture a jumping athlete preparing
to trans er orward energy to upward energy. As the f nal step is taken be ore jumping, the
loaded leg must stop the orward momentum and change it into an upward direction. As
this happens, the muscle undergoes a lengthening eccentric contraction to decelerate the
movement and prestretch the muscle. T is prestretch energy is then immediately released
in an equal and opposite reaction, thereby producing kinetic energy. T e neuromuscular
system must react quickly to produce the concentric shortening contraction to prevent all-
ing and produce the upward change in direction. Most elite athletes will naturally exhibit
with great ease this ability to use stored kinetic energy. Less-gi ted athletes can train this
Biomechanical and Physiologic Principles of Plyometric Training 267
ability and enhance their production o power. Consequently, specif c unctional exercise
to emphasize this rapid change o direction must be used to prepare patients and athletes
or return to activity.17 Because plyometric exercises train specif c movements in a biome-
chanically accurate manner, the muscles, tendons, and ligaments are all strengthened in a
unctional manner.
Most o the literature to date on plyometric training has ocused on the lower quarter.1
Because all movements in athletics involve a repeated series o stretch-shortening cycles,
adaptation o the plyometric principles can be used to enhance the specif city o training in
other sports or activities that require a maximum amount o muscular orce in a minimal
amount o time. Whether the athlete is jumping or throwing, the musculature around the
involved joints must f rst stretch and then contract to produce the explosive movement.
Because o the muscular demands during the overhead throw, plyometrics have been advo-
cated as a orm o conditioning or the overhead throwing athlete.42,45 Although the prin-
ciples are similar, di erent orms o plyometric exercises should be applied to the upper
extremity to train the stretch-shortening cycle. Additionally, the intensity o the upper
extremity plyometric program is usually less than that o the lower extremity, as a result o
the smaller muscle mass and type o muscle unction o the upper extremity compared to
the lower extremity.
T e role o the core muscles o the abdominal region and the lumbar spine in provid-
ing a vital link or stability and power cannot be overlooked. Plyometric training or these
muscles can be incorporated in isolated drills as well as unctional activities.
Biomechanical and Physiologic

Principles of Plyometric Training
T e goal o plyometric training is to decrease the amount o time required between the
yielding eccentric muscle contraction and the initiation o the overcoming concentric con-
traction. Normal physiologic movement rarely begins rom a static starting position, but
rather is preceded by an eccentric prestretch that loads the muscle and prepares it or the
ensuing concentric contraction.11 T e coupling o this eccentric-concentric muscle con-
traction is known as the stretch-shortening cycle. T e physiology o this stretch-shortening
cycle can be broken down into 2 components: proprioceptive re exes and the elastic prop-
erties o muscle f bers.43 T ese components work together to produce a response, but they
are discussed separately to aid understanding.
Mechanical Charact erist ics

T e mechanical characteristics o a muscle can best be
represented by a 3-component model (Figure 10-1). A con- P EC
tractile component, a series elastic component (SEC), and
a parallel elastic component all interact to produce a orce
output. Although the contractile component is usually the Force
ocal point o motor control, the SEC and parallel elastic
component also play an important role in providing stabil-
ity and integrity to the individual f bers when a muscle is S EC CC
lengthened.43 During this lengthening process, energy is
stored within the musculature in the orm o kinetic energy.
When a muscle contracts in a concentric ashion,
most o the orce that is produced comes rom the muscle
f ber f laments sliding past one another. Force is registered Figure 10-1 Thre e -co mpo ne nt mo de l
externally by being trans erred through the SEC. When eccentric contraction occurs, the
muscle lengthens like a spring. With this lengthening, the SEC is also stretched and allowed
to contribute to the overall orce production. T ere ore, the total orce production is the
sum o the orce produced by the contractile component and the stretching o the SEC.
An analogy would be the stretching o a rubber band. When a stretch is applied, potential
energy is stored and applied as it returns to its original length when the stretch is released.
Signif cant increases in concentric muscle orce production have been documented when
immediately preceded by an eccentric contraction.2,4,9 T is increase might be partly a
result o the storage o elastic energy, because the muscles are able to use the orce pro-
duced by the SEC. When the muscle contracts in a concentric manner, the elastic energy
that is stored in the SEC can be recovered and used to augment the shortening contraction.
T e ability to use this stored elastic energy is a ected by 3 variables: time, magnitude o
stretch, and velocity o stretch.23 T e concentric contraction can be magnif ed only i the
preceding eccentric contraction is o short range and per ormed quickly without delay.2,4,9
Bosco and Komi proved this concept experimentally when they compared damped versus
undamped jumps.4 Undamped jumps produced minimal knee exion upon landing and
were ollowed by an immediate rebound jump. With damped jumps, the knee exion angle
increased signif cantly. T e power output was much higher with the undamped jumps. T e
increased knee exion seen in the damped jumps decreased elastic behavior o the muscle,
and the potential elastic energy stored in the SEC was lost as heat. Similar investigations
produced greater vertical jump height when the movement was preceded by a counter-
movement as opposed to a static jump.2,5,6,29
T e type o muscle f ber involved in the contraction can also a ect storage o elastic
energy. Bosco et al noted a di erence in the recoil o elastic energy in slow-twitch versus
ast-twitch muscle f bers.7 T is study indicates that ast-twitch muscle f bers respond to
a high-speed, small-am plitude prestretch. T e am ount o elastic energy used was pro-
portional to the am ount stored. When a long, slow stretch is applied to muscle, slow-
and ast-twitch f bers exhibit a sim ilar am ount o stored elastic energy; however, this
stored energy is used to a greater extent with the slow-twitch f bers. T is trend would
suggest that slow-twitch muscle f bers m ight be able to use elastic energy m ore e -
ciently in ballistic m ovem ent characterized by long and slow prestretching in the stretch-
shortening cycle.
Neurophysiologic Mechanisms
T e proprioceptive stretch re ex is the other mechanism by which orce can be produced
during the stretch-shortening cycle.10 Mechanoreceptors located within the muscle provide
in ormation about the degree o muscular stretch. T is in ormation is transmitted to the
central nervous system and becomes capable o in uencing muscle tone, motor execution
programs, and kinesthetic awareness.43 T e mechanoreceptors that are primarily respon-
sible or the stretch re ex are the Golgi tendon organs and muscle spindles.31 T e muscle
spindle is a complex stretch receptor that is located in parallel within the muscle f bers.
Sensory in ormation regarding the length o the muscle spindle and the rate o the applied
stretch is transmitted to the central nervous system. I the length o the surrounding
muscle f bers is less than that o the spindle, the requency o the nerve impulses rom
the spindle is reduced. When the muscle spindle becomes stretched, an a erent sensory
response is produced and transmitted to the central nervous system.
Neurologic impulses are, in turn, sent back to the muscle, causing a motor response.
As the muscle contracts, the stretch on the muscle spindle is relieved, thereby removing the
original stimulus. T e strength o the muscle spindle response is determined by the rate o
stretch.31 T e more rapidly the load is applied to the muscle, the greater the f ring requency
o the spindle and resultant re exive muscle contraction.
Biomechanical and Physiologic Principles of Plyometric Training 269
T e Golgi tendon organ lies within the muscle tendon near the point o attachment o
the muscle f ber to the tendon. Unlike the acilitatory action o the muscle spindle, the Golgi
tendon organ has an inhibitory e ect on the muscle by contributing to a tension-limiting
re ex. Because the Golgi tendon organs are in series alignment with the contracting muscle
f bers, they become activated with tension or stretch within the muscle. Upon activation,
sensory impulses are transmitted to the central nervous system. T ese sensory impulses
cause an inhibition o the alpha motor neurons o the contracting muscle and its syner-
gists, thereby limiting the amount o orce produced. With a concentric muscle contrac-
tion, the activity o the muscle spindle is reduced because the surrounding muscle f bers
are shortening. During an eccentric muscle contraction, the muscle stretch re ex generates
more tension in the lengthening muscle. When the tension within the muscle reaches a
potentially harm ul level, the Golgi tendon organ f res, thereby reducing the excitation o
the muscle. T e muscle spindle and Golgi tendon organ systems oppose each other, and
increasing orce is produced. T e descending neural pathways rom the brain help to bal-
ance these orces and ultimately control which re ex will dominate.34
T e degree o muscle f ber elongation is dependent upon 3 physiologic actors. Fiber
length is proportional to the amount o stretching orce applied to the muscle. T e ultimate
elongation or de ormation is also dependent upon the absolute strength o the individual
muscle f bers. T e stronger the tensile strength, the less elongation that will occur. T e last
actor or elongation is the ability o the muscle spindle to produce a neurophysiologic
response. A muscle spindle with a low sensitivity level will result in a di culty in overcom-
ing the rapid elongation and there ore produce a less power ul response. Plyometric train-
ing will assist in enhancing muscular control within the neurologic system.10
T e increased orce production seen during the stretch-shortening cycle is a result
o the combined e ects o the storage o elastic energy and the myotatic re ex activation
o the muscle.2,4,5,8,9,30,36 T e percentage o contribution rom each component is unknown.5
T e increased amount o orce production is dependent upon the time rame between the
eccentric and concentric contractions.9 T is time rame can be def ned as the amortiza-
tion phase.15 T e amortization phase is the electromechanical delay between eccentric
and concentric contraction during which time the muscle must switch rom overcoming
work to acceleration in the opposite direction. Komi ound that the greatest amount o ten-
sion developed within the muscle during the stretch-shortening cycle occurred during the
phase o muscle lengthening just be ore the concentric contraction.28 T e conclusion rom
this study was that an increased time in the amortization phase would lead to a decrease in
orce production.
Physiologic per ormance can be improved by several mechanisms with plyometric
training. Although there has been documented evidence o increased speed o the stretch
re ex, the increased intensity o the subsequent muscle contraction might be best attrib-
uted to better recruitment o additional motor units.13,21 T e orce-velocity relationship
states that the aster a muscle is loaded or lengthened eccentrically, the greater the resultant
orce output. Eccentric lengthening will also place a load on the elastic components o the
muscle f bers. T e stretch re ex might also increase the sti ness o the muscular spring by
recruiting additional muscle f bers.13,21 T is additional sti ness might allow the muscular
system to use more external stress in the orm o elastic recoil.13
Another possible mechanism by which plyometric training can increase the orce or
power output involves the inhibitory e ect o the Golgi tendon organs on orce production.
Because the Golgi tendon organ serves as a tension-limiting re ex, restricting the amount o
orce that can be produced, the stimulation threshold or the Golgi tendon organ becomes
a limiting actor. Bosco and Komi have suggested that plyometric training can desensitize
the Golgi tendon organ, thereby raising the level o inhibition.4 I the level o inhibition is
raised, a greater amount o orce production and load can be applied to the musculoskeletal
system.
Neuromuscular Coordinat ion

T e last mechanism in which plyometric training might improve muscular per ormance
centers around neuromuscular coordination. T e speed o muscular contraction can be
limited by neuromuscular coordination. In other words, the body can move only within
a set speed range, no matter how strong the muscles are. raining with an explosive pre-
stretch o the muscle can improve the neural e ciency, thereby increasing neuromuscular
per ormance. Plyometric training can promote changes within the neuromuscular system
that allow the individual to have better control o the contracting muscle and its synergists,
yielding a greater net orce even in the absence o morphologic adaptation o the muscle.
T is neural adaptation can increase per ormance by enhancing the nervous system to
become more automatic.
In summary, e ective plyometric training relies more on the rate o stretch than on the
length o stretch. Emphasis should center on the reduction o the amortization phase. I the
amortization phase is slow, the elastic energy is lost as heat and the stretch re ex is not acti-
vated. Conversely, the quicker the individual is able to switch rom yielding eccentric work
to overcoming concentric work, the more power ul the response.
Program Development
Specif city is the key concept in any training program. Sport-specif c activities should be
analyzed and broken down into basic movement patterns. T ese specif c movement pat-
terns should then be stressed in a gradual ashion, based upon individual tolerance to these
activities. Development o a plyometric program should begin by establishing an adequate
strength base that will allow the body to withstand the large stress that will be placed upon
it. A greater strength base will allow or greater orce production because o increased mus-
cular cross-sectional area. Additionally, a larger cross-sectional area can contribute to the
SEC and subsequently store a greater amount o elastic energy.
Plyometric exercises can be characterized as rapid eccentric loading o the musculo-
skeletal complex.13 T is type o exercise trains the neuromuscular system by teaching it to
more readily accept the increased strength loads.3 Also, the nervous system is more read-
ily able to react with maximal speed to the lengthening muscle by exploiting the stretch
re ex. Plyometric training attempts to f ne tune the neuromuscular system, so all train-
ing programs should be designed with specif city in mind.33 T is goal will help to ensure
that the body is prepared to accept the stress that will be placed upon it during return to
unction.
Plyomet ric Prerequisit es

Biomechanical Examinat ion
Be ore beginning a plyometric training program, a cursory biomechanical examination and
a battery o unctional tests should be per ormed to identi y potential contraindications or
precautions. Lower-quarter biomechanics should be sound to help ensure a stable base o
support and normal orce transmission. Biomechanical abnormalities o the lower quar-
ter are not contraindications or plyometrics but can contribute to stress ailure-overuse
injury i not addressed. Be ore initiating plyometric training, an adequate strength base o
the stabilizing musculature must be present. Functional tests are very e ective to screen or
an adequate strength base be ore initiating plyometrics. Poor strength in the lower extremi-
ties will result in a loss o stability when landing and also increase the amount o stress
that is absorbed by the weightbearing tissues with high-impact orces, which will reduce
per ormance and increase the risk o injury. T e Eastern Bloc countries arbitrarily placed
Program Development 271
a 1-repetition maximum in the squat at 1.5 to 2 times the individual’s body weight be ore
initiating lower-quarter plyometrics.3 I this were to hold true, a 200-pound individual
would have to squat 300–400 pounds be ore beginning plyometrics. Un ortunately, not
many individuals would meet this minimal criteria. Clinical and practical experience has
demonstrated that plyometrics can be started without that kind o leg strength.13 A simple
unctional parameter to use in determining whether an individual is strong enough to initi-
ate a plyometric training program has been advocated by Chu.14 Power squat testing with a
weight equal to 60% o the individual’s body weight is used. T e individual is asked to per-
orm 5 squat repetitions in 5 seconds. I the individual cannot per orm this task, emphasis
in the training program should again center on the strength-training program to develop an
adequate base.
Because eccentric muscle strength is an important component to plyometric training,
it is especially important to ensure an adequate eccentric strength base is present. Be ore
an individual is allowed to begin a plyometric regimen, a program o closed-chain stabil-
ity training that ocuses on eccentric lower-quarter strength should be initiated. In addi-
tion to strengthening in a unctional manner, closed-chain weightbearing exercises also
allow the individual to use unctional movement patterns. T e same holds true or ade-
quate upper-extremity strength prior to initiating an upper-extremity plyometric program.
Closed-chain activities, such as wall pushups, traditional pushups, and their modif cation,
as well as unctional tests, can be utilized to ascertain readiness or upper-extremity plyo-
metrics.24,37,38 Once cleared to participate in the plyometric program, precautionary sa ety
tips should be adhered to.
PLYOM ETRIC STATIC STABILITY TESTING
Sin g le -le g st an ce — 30 se co n d s Sin g le -le g 25% sq u at — 30 se co n d s Sin g le -le g 50% sq u at — 30 se co n d s

• Eye s o p e n • Eye s o p e n • Eye s o p e n
• Eye s clo se d • Eye s clo se d • Eye s clo se d
St abilit y Test ing

Stability testing be ore initiating plyometric training can be divided into 2 subcategories:
static stability and dynamic movement testing. Static stability testing determines the indi-
vidual’s ability to stabilize and control the body. T e muscles o postural support must be
strong enough to withstand the stress o explosive training. Static stability testing should
begin with simple movements o low motor complexity and progress to more di cult high
motor skills. T e basis or lower-quarter stability centers around single-leg strength. Di -
f culty can be increased by having the individual close his or her eyes. T e basic static tests
are one-leg standing and single-leg quarter squats that are held or 30 seconds. An indi-
vidual should be able to per orm one-leg standing or 30 seconds with eyes open and closed
be ore the initiation o plyometric training. T e individual should be observed or shak-
ing or wobbling o the extremity joints. I there is more movement o a weightbearing joint
in one direction than the other, the musculature producing the movement in the opposite
direction needs to be assessed or specif c weakness. I weakness is determined, the indi-
vidual’s program should be limited and emphasis placed on isolated strengthening o the
weak muscles. For dynamic jump exercises to be initiated, there should be no wobbling o
the support leg during the quarter knee squats.
A ter an individual has satis actorily demonstrated both single-leg static stance and
a single-leg quarter squat, more dynamic tests o eccentric capabilities can be initiated.
Once an individual has stabilization strength, the concern shi ts toward developing
and evaluating eccentric strength. T e limiting actor in high-intensity, high-volume
plyometrics is eccentric capabilities. Eccentric strength can be assessed with stabilization
jump tests. I an individual has an excessively long amortization phase or a slow switch-
ing rom eccentric to concentric contractions, the eccentric strength levels are insu cient.
Dynamic Movement Test ing

Dynamic movement testing assesses the individual’s ability to produce explosive, coordi-
nated movement. Vertical or single-leg jumping or distance can be used or the lower quar-
ter. Researchers have investigated the use o single-leg hop or distance and a determinant
or return to play a ter knee injury. A passing score on their test is 85% in regard to sym-
metry. T e involved leg is tested twice, and the average between the two trials is recorded.
T e noninvolved leg is tested in the same ashion, and then the scores o the noninvolved
leg are divided by the scores o the involved leg and multiplied by 100. T is provides the
symmetry index score. Another unctional test that can be used to determine whether an
individual is ready or plyometric training is the ability to long jump a distance equal to the
individual’s height.
In the upper quarter, the medicine ball toss is used as a unctional assessment. T e
seated chest press is used as a measure o upper body power. o per orm this test, the
patient sits tall with their back against the back rest o a chair. While holding onto a medi-
cine ball (4 kg or men and 2 kg or women and juniors), the patient tries to chest pass the
ball as ar as possible keeping their back in contact with the chair. T is should be repeated
until the longest pass has been measured. Use the distance rom where the ball bounces to
the patient’s chest as the distance. As can be seen in able 10-1, under 17 eet or men and
15 eet or women is an indicator o power weakness.
T e situp-and-throw test is a great test to assess abdominal and lat power. T e situp
evaluates core power, while the overhead throw evaluates the lat and trunk power. o
per orm this test, the patient lies supine with the patient’s knees bent and eet at on the
ground, while holding onto a medicine ball with both hands (4 kg or men and 2 kg or
women and juniors) with the ball directly over the patient’s head like a soccer throw-in.
Next, have the patient try to sit up and throw the ball as ar as possible. T is should be
repeated until the longest pass has been measured. Use the distance rom where the ball
bounces to the patient’s chest as the distance ( able 10-2).
Table 10-1 Se ate d Che st Pass Te st
Distance in Fe e t
Exce lle nt Go o d Ave rag e Ne e ds Wo rk
Fe male
Adult >21 17 to 21 15 to 17 <15
Junior (<16) >19 16 to 19 14 to 16 <14
Male
Adult >24 20 to 24 17 to 20 <17
Junior (<16 years) >20 18 to 20 15 to 18 <15

Plyometric Program Design 273
Table 10-2 Situp-and-Thro w Te st
Distance in Fe e t
Exce lle nt Go o d Ave rag e Ne e ds Wo rk
Fe male
Adult >21 17 to 21 15 to 17 <15
Junior (<16) >19 16 to 19 14 to 16 <14
Male
Adult >24 20 to 24 17 to 20 <17
Junior (<16) >20 18 to 20 15 to 18 <15
Flexibilit y
Another important prerequisite or plyometric training is general and specif c exibility,
because a high amount o stress is applied to the musculoskeletal system. Consequently, all
plyometric training sessions should begin with a general warm-up and exibility exercise
program. T e warm-up should produce mild sweating.26 T e exibility exercise program
should address muscle groups involved in the plyometric program and should include
static and short dynamic stretching techniques.25
Plyometric Prerequisites Summary When the individual can demonstrate static and
dynamic control o their body weight with single-leg squats or adequate medicine ball throws
or the upper extremity and core, low-intensity in-place plyometrics can be initiated. Plyo-
metric training should consist o low-intensity drills and progress slowly in deliberate ashion.
As skill and strength oundation increase, moderate-intensity plyometrics can be introduced.
Mature patients with strong weight-training backgrounds can be introduced to ballistic-
reactive plyometric exercises o high intensity.14 Once the individual has been classif ed as
beginner, intermediate, or advanced, the plyometric program can be designed and initiated.
Plyometric Program Design

As with any conditioning program, the plyometric training program can be manipulated
through training variables: direction o body movement, weight o the individual, speed o the
execution, external load, intensity, volume, requency, training age, and recovery ( able 10-3).
Direct ion of Body Movement

Horizontal body movement is less stress ul than vertical movement. T is is dependent upon
the weight o the patient and the technical prof ciency demonstrated during the jumps.
Weight of t he Pat ient

T e heavier the patient, the greater the training demand placed on the patient. What might
be a low-demand in-place jump or a lightweight patient might be a high-demand activity
or a heavyweight patient.
Table 10-3 Chu’s Plyo me tric Cate g o rie s Speed of Execut ion of t he Exercise
Increased speed o execution on exercises like single-leg
hops or alternate-leg bounding raises the training demand
In-place jumping
on the individual.
Standing jumps
Multiple-response jumps and hops

Ext ernal Load
In-depth jumping and box drills
Adding an external load can signif cantly raise the training
Bounding demand. Do not raise the external load to a level that will sig-
High-stress sport-speci c drills nif cantly slow the speed o movement.
Int ensit y
Intensity can be def ned as the amount o e ort exerted. With
traditional weight li ting, intensity can be modif ed by chang-
ing the amount o weight that is li ted. With plyometric training, intensity can be controlled
by the type o exercise that is per ormed. Double-leg jumping is less stress ul than single-leg
jumping. As with all unctional exercise, the plyometric exercise program should progress
rom simple to complex activities. Intensity can be urther increased by altering the specif c
exercises. T e addition o external weight or raising the height o the step or box will also
increase the exercise intensity.22
Volume
Volume is the total amount o work that is per ormed in a single workout session. With
weight training, volume would be recorded as the total amount o weight that was li ted
(weight times repetitions). Volume o plyometric training is measured by counting the total
number o oot contacts. T e recommended volume o oot contacts in any one session will
vary inversely with the intensity o the exercise. A beginner should start with low-intensity
exercise with a volume o approximately 75- to 100- oot contacts. As ability is increased, the
volume is increased to 200- to 250- oot contacts o low-to-moderate intensity.
Frequency
Frequency is the number o times an exercise session is per ormed during a training
cycle. With weight training, the requency o exercise has typically been 3 times weekly.
Un ortunately, research on the requency o plyometric exercise has not been conducted.
T ere ore, the optimum requency or increased per ormance is not known. It has been
suggested that 48 to 72 hours o rest are necessary or ull recovery be ore the next training
stimulus.14 Intensity, however, plays a major role in determining the requency o training.
I an adequate recovery period does not occur, muscle atigue will result with a correspond-
ing increase in neuromuscular reaction times. T e beginner should allow at least 48 hours
between training sessions.
Training Age
raining age is the number o years an individual has been in a ormal training program.
At younger training ages, the overall training demand should be kept low. Prepubescent
and pubescent individuals o both genders are engaged in more intense physical train-
ing programs. Many o these programs contain plyometric drills. Because youth sports
involve plyometric movements, training or these sports should also involve plyometric
activities. T e literature does not have long-term data looking at the e ects o plyometric
activities on human articular cartilage and long bone growth. Research demonstrates that
plyometric training does indeed result in strength gains in prepubescent individuals, and
that plyometric training may in act contribute to increased bone mineral content in young
emales.18,47
Recovery
Recovery is the rest time used between exercise sets. Manipulation o this variable will
depend on whether the goal is to increase power or muscular endurance. Because plyo-
metric training is anaerobic in nature, a longer recovery period should be used to allow
restoration o metabolic stores. With power training, a work rest ratio o 1:3 or 1:4 should
be used. T is time rame will allow maximal recovery between sets. For endurance train-
ing, this work-to-rest ratio can be shortened to 1:1 or 1:2. Endurance training typically uses
circuit training, where the individual moves rom one exercise set to another with minimal
rest in between.
T e beginning plyometric program should emphasize the importance o eccentric
versus concentric muscle contractions. T e relevance o the stretch-shortening cycle with
decreased amortization time should be stressed. Initiation o lower-quarter plyometric
training begins with low-intensity in-place and multiple-response jumps. T e individual
should be instructed in proper exercise technique. T e eet should be nearly at in all
landings, and the individual should be encouraged to “touch and go.” An analogy would
be landing on a hot bed o coals. T e goal is to reverse the landing as quickly as possible,
spending only a minimal amount o time on the ground.
Success o the plyometric program will depend on how well the training variables
are controlled, modif ed, and manipulated. In general, as the intensity o the exercise is
increased, the volume is decreased. T e corollary to this is that as volume increases, the
intensity is decreased. T e overall key to success ully controlling these variables is to
be exible and listen to what the individual’s body is telling you. T e body’s response to the
program will dictate the speed o progression. Whenever in doubt as to the exercise inten-
sity or volume, it is better to underestimate to prevent injury.
Be ore implementing a plyometric program, the athletic trainer should assess the type
o patient that is being rehabilitated and whether plyometrics are suitable or that indi-
vidual. In most cases, plyometrics should be used in the latter phases o rehabilitation,
starting in the advanced strengthening phase once the patient has obtained an appropri-
ate strength base.36,38 When utilizing plyometric training in the uninjured population, the
application o plyometric exercise should ollow the concept o periodization.43 T e con-
cept o periodization re ers to the year-round sequence and progression o strength train-
ing, conditioning, and sport-specif c skills.45 T ere are 4 specif c phases in the year-round
periodization model: the competitive season, postseason training, the preparation phase,
and the transitional phase.43 Plyometric exercises should be per ormed in the latter stages
o the preparation phase and during the transitional phase or optimal results and sa ety.
o obtain the benef ts o a plyometric program, the individual should (a) be well condi-
tioned with su cient strength and endurance, (b) exhibit athletic abilities, (c) exhibit coor-
dination and proprioceptive abilities, and (d) be ree o pain rom any physical injury or
condition.
It should be remembered that the plyometric program is not designed to be an exclu-
sive training program or the individual. Rather, it should be one part o a well-structured
Table 10-4 Uppe r-Extre mity Plyo me tric Drills
I. Warm-up drills Plyoball trunk rotation

Plyoball side bends
Plyoball wood chops
External rotation (ER)/internal rotation (IR) with tubing
Proprioceptive neuromuscular feedback (PNF) D2 pattern
with tubing
II. Throwing Two-hand chest pass

movements— Two-hand overhead soccer throw
standing position Two-hand side throw overhead
Tubing ER/IR (Both at side and 90-degree abduction)
Tubing PNF D2 pattern
One-hand baseball throw
One-hand IR side throw
One-hand ER side throw
Plyo pushup (against wall)
III. Throwing Two-hand overhead soccer throw

movements— Two-hand side-to-side throw
seated position Two-hand chest pass
IV. Trunk drills Plyoball sit-ups

Plyoball sit-up and throw
Plyoball back extension
Plyoball long sitting side throws
V. Partner drills Overhead soccer throw

Plyoball back-to-back twists
Overhead pullover throw
Kneeling side throw
Backward throw
Chest pass throw
VI. Wall drills Two-hand chest throw

Two-hand overhead soccer throw
Two-hand underhand side-to-side throw
One-hand wall dribble
VII. Endurance drills One-hand wall dribble

Around-the-back circles
Figure 8 through the legs
Single-arm ball ips
training program that includes strength training, exibility training, cardiovascular f t-

ness, and sport-specif c training or skill enhancement and coordination. By combining
the plyometric program with other training techniques, the e ects o training are greatly
enhanced.
ables 10-4 and 10-5 suggest upper-extremity and lower-extremity plyometric drills.
Table 10-5 Lo w e r-Extre mity Plyo me tric Drills
I. Warm-up drills Double-leg squats

Double-leg leg press
Double-leg squat-jumps
Jumping jacks
II. Entry-level drills—two-legged Two-legged drills

Side to side ( oor/line)
Diagonal jumps ( oor/4 corners)
Diagonal jumps (4 spots)
Diagonal zig-zag (6 spots)
Plyo leg press
Plyo leg press (four corners)
III. Intermediate-level drills Two-legged box jumps

One-box side jump
Two-box side jumps
Two-box side jumps with foam
Four-box diagonal jumps
Two-box with rotation
One-/2-box with catch
One-/two-box with catch (foam)
Single-leg movements
Single-leg plyo leg press
Single-leg side jumps ( oor)
Single-leg side-to-side jumps ( oor/4 corners)
Single-leg diagonal jumps ( oor/4 corners)
IV. Advanced-level drills Single-leg box jumps

One-box side jumps
Two-box side jumps
Single-leg plyo leg press (4 corners)
Two-box side jumps with foam
Four-box diagonal jumps
One-box side jumps with rotation
Two-box side jumps with rotation
One-box side jump with catch
One-box side jump rotation with catch
Two-box side jump with catch
Two-box side jump rotation with catch
V. Endurance/agility plyometrics Side-to-side bounding (20 ft)

Side jump lunges (cone)
Side jump lunges (cone with foam)
Altering rapid step-up (forward)
Lateral step-overs
High stepping (forward)
High stepping (backward)
Depth jump with rebound jump
Depth jump with catch
Jump and catch (Plyoball)
Guidelines for Plyometric Programs

he proper execution o the plyom etric exercise program m ust continually be stressed.
A soun d techn ical oun dation rom which higher-inten sity work can build should
be established. It m ust be rem em bered that jum pin g is a continuous interchan ge
between orce reduction and orce production . his interchange takes place through-
out the entire body: ankle, knee, hip, trunk, and arm s. he tim ing and coordination o
these body segm ents yields a positive ground reaction that will result in a high rate o
orce production.16
As the plyometric program is initiated, the individual must be made aware o several
guidelines.43 Any deviation rom these guidelines will result in minimal improvement and
increased risk or injury. T ese guidelines include the ollowing:
1. Plyometric training should be specif c to the individual goals. Activity-specif c

movement patterns should be trained. T ese sport-specif c skills should be broken
down and trained in their smaller components and then rebuilt into a coordinated
activity-specif c movement pattern.
2. T e quality o work is more important than the quantity o work. T e intensity o the
exercise should be kept at a maximal level.
3. T e greater the exercise intensity level, the greater the recovery time.
4. Plyometric training can have its greatest benef t at the conclusion o the normal
workout. T is pattern will best replicate exercise under a partial to total atigue
environment that is specif c to activity. Only low- to medium-stress plyometrics
should be used at the conclusion o a workout, because o the increased potential o
injury with high-stress drills.
5. When proper technique can no longer be demonstrated, maximum volume has been
achieved and the exercise must be stopped. raining improperly or with atigue can
lead to injury.
6. T e plyometric training program should be progressive in nature. T e volume and
intensity can be modif ed in several ways:
a. Increase the number o exercises.
b. Increase the number o repetitions and sets.
c. Decrease the rest period between sets o exercise.
7. Plyom etric training sessions should be conducted no m ore than 3 tim es
weekly in the preseason phase o training. During this phase, volum e should
prevail. During the com petitive season, the requency o plyom etric training
should be reduced to twice weekly, with the intensity o the exercise becom in g
m ore im portant.
8. Dynamic testing o the individual on a regular basis will provide important
progression and motivational eedback.
9. In addition to proper technique and exercise dosage, proper equipment is
also required. Equipment should allow or the sa e per ormance o the activity,
landing sur aces should be even and allow or as much shock absorption
as possible, and ootwear should provide adequate shock absorption and
ore oot support.
T e key element in the execution o proper technique is the eccentric or landing phase.
T e shock o landing rom a jump is not absorbed exclusively by the oot but rather is a
combination o the ankle, knee, and hip joints all working together to absorb the shock o
landing and then trans erring the orce.
Integrating Plyometrics into the Rehabilitation Program: Clinical Concerns 279
Integrating Plyometrics into the

Rehabilitation Program: Clinical Concerns
When used judiciously, plyometrics are a valuable asset in the sports rehabilitation program.35
Clinical plyometrics should involve loading o the healing tissue. T ese activities may include
(a) medial/ lateral loading, (b) rotational loading, and (c) shock absorption/ deceleration
loading. In addition, plyometric drills will be divided into (a) in-place activities (activities that
can be per ormed in essentially the same or small amount o space), (b) dynamic distance
drills (activities that occur across a given distance), and (c) depth jumping (jumping down
rom a predetermined height and per orming a variety o activities upon landing). Simple
jumping drills (bilateral activities) can be progressed to hopping (unilateral activities).
Medial-Lat eral Loading

Virtually all sporting activities involve cutting maneuvers. Inherent to cutting activities is
adequate unction in the medial and lateral directions. A plyometric program designed to
stress the individual’s ability to accept weight on the
involved lower extremity and then per orm cutting
activities o that leg is imperative. Individuals who
have su ered sprains to the medial or lateral capsu-
lar and ligamentous complex o the ankle and knee,
as well as the hip abductor/ adductor and ankle
invertor/ evertor muscle strains, are candidates or
m edial-lateral plyom etric loading. Medial-lateral
loading drills should be im plem ented ollowing
injury to the medial so t tissue around the knee a ter
a valgus stress. By gradually imparting progressive
valgus loads, tissue tensile strength is augmented.48
In the rehabilitation setting, bilateral support drills A
can be progressed to unilateral valgus loading
e orts. Specif cally, lateral jum ping drills are pro-
gressed to lateral hopping activities. However, the
m edial structures must also be trained to accept
greater valgus loads sustained during cutting activi-
ties. As a prerequisite to ull-speed cutting, lateral
bounding drills should be per ormed. T ese e orts
are progressed to activities that add acceleration,
deceleration, and momentum. Lateral sliding activi-
ties that require the individual to cover a greater dis-
tance can be per ormed on a slide board. I a slide
board is not available, the same movement pattern
can be stressed with plyometrics (Figure 10-2).
In-Place Act ivit ies

• Lateral bounding (quick step valgus loading) B
• Slide bounds
Figure 10-2
Dynamic Dist ance Drills
• Crossovers A. Slideboard ice skater glides. B. Ice skaters.
Rot at ional Loading

Because rotation in the knee is controlled by the cruciate ligaments, menisci, and capsule,
plyometric activities with a rotational component are instrumental in the rehabilitation
program a ter injury to any o these structures. As previously discussed, care must be taken
not to exceed healing time constraints when using plyometric training.

• Spin jumps
Dynamic Dist ance Drills

• Lateral hopping
Shock Absorpt ion (Decelerat ion Loading)

Perhaps some o the most physically demanding plyometric activities are shock absorption
activities, which place a tremendous amount o stress upon muscle, tendon, and articu-
lar cartilage. As previously stated, the majority o lower-quarter sport unction occurs in
the closed kinetic chain. Lower-extremity plyometrics are an e ective unctional closed-
chain exercise that can be incorporated into the rehabilitation program. T rough the eccen-
tric prestretch, plyometrics place added stress on the tendinous portion o the contractile
unit. Eccentric loading is benef cial in the management o tendinitis.44 T rough a gradu-
ally progressed eccentric loading program, healing tendinous tissue is stressed, yielding an
increase in ultimate tensile strength.
T is eccentric load can be applied through jump-down exercises (see Figure 10-6)
T ere ore, in the f nal preparation or a return to sports involving repetitive jumping and
hopping, shock absorption drills should be included in the rehabilitation program.27
One way to prepare the individual or shock absorption drills is to gradually maximize
the e ects o gravity, such as beginning in a gravity-minimized position and progressing to
per ormance against gravity. Popular activities to minimize gravity include water activities
or assisted e orts through unloading jumps and hops in the supine position on a leg press
or similar device.

• Cycle jumps
• Five-dot drill
Dept h Jumping Preparat ion

• Jump-downs
Speci c Plyomet ric Exercises

Plyometric drills can be categorized into (a) weighted ball toss plyometric exercises
(Figure 10-3); (b) dynamic weighted ball plyometric exercises (Figure 10-4); (c) in-place
jumping plyometric exercises (Figure 10-5), which involve activities that can be per ormed
in essentially the same or small amount o space; and (d) depth jumping and bounding
plyometric exercises (Figure 10-6) that may involve jumping down rom a predetermined
height and per orming a variety o activities upon landing or activities that occur across a
given distance. In-place jumping drills (bilateral activities) can be progressed to hopping
(unilateral activities).
A B
C D E
Figure 10-3
A. Single-arm weight ball throw. B. Weighted ball two-arm chest pass. C. Weighted ball reverse toss with
rotation. D. Back extension-rotation weighted ball throw. E. Overhead weighted ball throw.
A B
Figure 10-4
A. Plyoback standing single-arm ball toss. B. Plyoback two-arm toss with rotation.
A B
C D
Figure 10-5
A. Squat jumps. B. Two-leg tuck jumps. C. Two-leg butt kicks. D. Single-leg hops.
T e exercises in Figures 10-3 through 10-6 are a good starting point rom which to
develop a clinical plyometric program. Manipulations o volume, requency, and intensity
can advance the program appropriately. Proper progression is o prime importance when
using plyometrics in the rehabilitation program. T ese progressive activities are reinjuries
waiting to happen i the progression does not allow or adequate healing or development
o an adequate strength base.32 A close working relationship ostering open communica-
tion and acute observation skills is vital in helping ensure that the program is not overly
aggressive.
A B
C D
Figure 10-6
A. Depth jump to vertical jump. B. Depth jump to bounding. C. Repeat two-leg standing
long jumps. D. Single-leg hops for distance. E. Three-hurdle jumps.
SUMMARY
1. Although the e ects o plyometric training are not yet ully understood, it still remains
a widely used orm o combining strength with speed training to unctionally increase
power. Although the research is somewhat contradictory, the neurophysiologic con-
cept o plyometric training is based on a sound oundation.
2. A success ul plyometric training program should be care ully designed and imple-
mented a ter establishing an adequate strength base.
3. T e e ects o this type o high-intensity training can be achieved sa ely i the individual
is supervised by a knowledgeable person who uses common sense and ollows the pre-
scribed training regimen.
4. T e plyometric training program should use a large variety o di erent exercises, be-
cause year-round training o ten results in boredom and a lack o motivation.
5. Program variety can be manipulated with di erent types o equipment or kinds o
movement per ormed.
6. Continued motivation and an organized progression are the keys to success ul training.
7. Plyometrics are also a valuable asset in the rehabilitation program a ter a sport injury.
8. Used a ter both upper- and lower-quarter injury, plyometrics are e ective in acilitating
joint awareness, strengthening tissue during the healing process, and increasing sport-
specif c strength and power.
9. T e most important considerations in the plyometric program are common sense and
experience.
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Physiol Scand . 1979;106:467. 17. Curwin S, Stannish WD. endinitis: Its Etiology and
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PV, ed. Exercise and Sports Biology. Champaign, IL: 18. Diallo O, Dore E, Duchercise P, et al. E ects o plyometric
Human Kinetics; 1982;191-197. training ollowed by a reduced training programme on
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24-31. J Sport Rehabil. 2000;9:35-45.
11. Chmielewski , Myer G, Kau man D. Plyometric exercise 25. Javorek I. Plyometrics. Strength Cond J. 1989;11:52.
in the rehabilitation o athletes: physiological responses 26. Jensen C. Pertinent acts about warming. Athl J. 1975;56:72.
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Collamore Press; 1984;81-122. 41. Verkhoshanski Y. Perspectives in the improvement o
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35. Shiner J, Bishop , Cosgarea A. Integrating low-intensity 46. Wilt F. Plyometrics—what it is and how it works. Athl J.
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Strength Cond J. 2005;27(6):10. 47. Witzke K, Snow C. E ects o plyometric jump training
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Strength Cond J. 1988;10:49. 2000;32:1051-57.
37. ippett S. Closed chain exercise. Orthop Phys T er Clin N 48. Woo SL, Inoue M, McGurk-Burleson E, et al. reatment
Am . 1992;1:253-267. o the medial collateral ligament injury: Structure and
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Rehabilitation . Champaign, IL: Human Kinetics; 1995. regimens. Am J Sports Med. 1987;15(1):22-29.
Open- versus
Closed-Kinetic-
Chain Exercise in
Rehabilitation
OBJJEC
C TIVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Differentiate between the concepts of an open kinetic chain and a closed kinetic chain.
Contrast the advantages and disadvantages of using open- versus closed-kinetic-chain exercise.
Recognize how closed-kinetic-chain exercises can be used to regain neuromuscular control.
Analyze the biomechanics of closed-kinetic-chain exercise in the lower extremity.
Compare how both open- and closed-kinetic-chain exercises should be used in rehabilitation
of the lower extremity.
Identify the various closed-kinetic-chain exercises for the lower extremity.
Examine the biomechanics of closed-kinetic-chain exercises in the upper extremity.
Explain how closed-kinetic-chain exercises are used in rehabilitation of the upper extremity.
Recognize the various types of closed-kinetic-chain exercises for the upper extremity.
287
288 Chapte r 11 Open- versus Closed-Kinetic-Chain Exercise in Rehabilitation
Over the years, the concept o closed-kinetic-chain exercise has received considerable atten-
tion as a use ul and ef ective technique o rehabilitation, particularly or injuries involving
the lower extremity.81 T e ankle, knee, and hip joints constitute the kinetic chain or the
lower extremity. When the distal segment o the lower extremity is stabilized or xed, as
is the case when the oot is weight bearing on the ground, the kinetic chain is said to be
closed. Conversely, in an open kinetic chain , the distal segment is mobile and not xed. ra-
ditionally, rehabilitation strengthening protocols have used open-kinetic-chain exercises
such as knee exion and extension on a knee machine.71
Closed-kinetic-chain exercises are used more o ten in rehabilitation o injuries to
the lower extremity, but they are also use ul in rehabilitation protocols or certain upper-
extremity activities. For the most part, the upper extremity unctions in an open kinetic
chain with the hand moving reely. But there are a number o activities in which the upper
extremity unctions in a closed kinetic chain.80
Despite the recent popularity o closed-kinetic-chain exercises, it must be stressed that
both open- and closed-kinetic-chain exercises have their place in the rehabilitative pro-
cess.21 T is chapter clari es the role o both open- and closed-kinetic-chain exercises in
that process.
Concept of the Kinetic Chain

T e concept o the kinetic chain was rst proposed in the 1970s and initially re erred to
as the link system by m echanical engineers.69 In this link system , pin joints con nect a
series o overlapping, rigid segm ents ( Figure 11-1). I both ends o this system are con-
nected to an im m ovable ram e, there is no m ovem ent o either the proximal or the distal
end. In this closed link system , each m oving body segm ent receives orces rom, an d
trans ers orces to, adjacent body segm ents and thus either af ects or is af ected by the
m otion o those com ponents.29 In a closed link system, m ovem ent at one joint produces
predictable m ovem ent at all other joints.69 In reality, this type o closed link system
does not exist in either the upper or the lower extrem ity. However, when the distal
segm ent in an extrem ity (that is, the oot or hand) m eets resistance or is xed, muscle
A recruitm ent patterns and joint m ovem ents are dif erent than when the distal segm ent
Fixe d
m oves reely.69 T us, 2 system s—a closed system an d an open system —have been
proposed.
Whenever the oot or the hand meets resistance or is xed, as is the case in a closed
B Moving kinetic chain, movement o the more proximal segments occurs in a predictable pattern.
I the oot or hand moves reely in space as in an open kinetic chain, movements occur-
ring in other segments within the chain are not necessarily predictable.13
o a large extent, the term closed-kinetic-chain exercise has come to mean “weight-
C Moving bearing exercise.” However, although all weightbearing exercises involve some elements
o closed-kinetic-chain activities, not all closed-kinetic-chain activities are weight
bearing.67
D Fixe d
Muscle Act ions in t he Kinet ic Chain
Muscle actions that occur during open-kinetic-chain activities are usually reversed dur-
Figure 11-1 ing closed-kinetic-chain activities. In open-kinetic-chain exercise, the origin is xed and
muscle contraction produces movement at the insertion. In closed-kinetic-chain exer-
If both ends of a link system cise, the insertion is xed and the muscle acts to move the origin. Although this may
are fixed, movement at one be important biomechanically, physiologically the muscle can lengthen, shorten, or
joint produces predictable remain the same length, and thus it makes little dif erence whether the origin or inser-
movement at all other joints. tion is moving in terms o the way the muscle contracts.
Advantages and Disadvantages of Open- versus Closed-Kinetic-Chain Exercises 289
Concurrent Shift in a Kinet ic Chain

T e concept o the concurrent shift applies to biarticular muscles that have distinctive
muscle actions within the kinetic chain during weightbearing activities.39 For example, in
a closed kinetic chain simultaneous hip and knee extension occur when a person stands
rom a seated position. o produce this m ovem ent, the rectus em oris shortens across
the knee while it lengthens across the hip. Conversely, the hamstrings shorten across the
hip and simultaneously lengthen across the knee. T e resulting concentric and eccen-
tric contractions at opposite ends o the muscle produce the concurrent shi t. T is type
o contraction occurs during unctional activities including walking, stair clim bing, and
jum ping and cannot be reproduced by isolated open-kinetic-chain knee exion and
extension exercises.39
T e concepts o the reversibility o muscle actions and the concurrent shi t are hall-
marks o closed-kinetic-chain exercises.67
Advantages and Disadvantages of

Open- versus Closed-Kinetic-Chain Exercises
Open- and closed-kinetic-chain exercises of er distinct advantages and disadvantages in
the rehabilitation process. T e choice to use one or the other depends on the desired treat-
ment goal. Characteristics o closed-kinetic-chain exercises include increased joint com-
pressive orces, increased joint congruency (and thus stability) decreased shear orces,
decreased acceleration orces, large resistance orces, stimulation o proprioceptors, and
enhanced dynamic stability—all o which are associated with weight bearing. Characteris-
tics o open-kinetic-chain exercises include increased acceleration orces, decreased resis-
tance orces, increased distraction and rotational orces, increased de ormation o joint
and muscle mechanoreceptors, concentric acceleration and eccentric deceleration orces,
and promotion o unctional activity. T ese are typical o non-weightbearing activities.46
From a biomechanical perspective, it has been suggested that closed-kinetic-chain
exercises are sa er and produce stresses and orces that are potentially less o a threat to
healing structures than open-kinetic-chain exercises.62 Coactivation or cocontraction o
agonist and antagonist muscles must occur during normal movements to provide joint sta-
bilization. Cocontraction, which occurs during closed-kinetic-chain exercise, decreases the
shear orces acting on the joint, thus protecting healing so t-tissue structures that might
otherwise be damaged by open-chain exercises.29 Additionally, weightbearing activity
increases joint compressive orces, urther enhancing joint stability.
It has also been suggested that closed-kinetic-chain exercises, particularly those
involving the lower extremity, tend to be more unctional than open-kinetic-chain exer-
cises because they involve weightbearing activities.79 T e majority o activities per ormed in
daily living, such as walking, climbing, and rising to a standing position, as well as in most
sport activities, involve a closed-kinetic-chain system. Because the oot is usually in contact
with the ground, activities that make use o this closed system are said to be more unc-
tional. With the exception o a kicking movement, there is no question that closed-kinetic-
chain exercises are more activity speci c, involving exercise that more closely approximates
the desired activity. For example, knee extensor muscle strength in a closed kinetic chain
is more closely related to jumping ability than knee extensor strength in a closed kinetic
chain.8 In a clinical setting, speci city o training must be emphasized to maximize carry-
over to unctional activities.67
With open-kinetic-chain exercises, m otion is usually isolated to a single joint. Open-
kinetic-chain activities may include exercises to im prove strength or range o m otion.34
T ey may be applied to a single joint manually, as in proprioceptive neuromuscular
acilitation or joint mobilization techniques, or through some external resistance using an

exercise machine. Isolation-type exercises typically use a contraction o a speci c mus-
cle or group o muscles that produces usually single plane and occasionally multiplanar
movement.32 Isokinetic exercise and testing is usually done in an open kinetic chain and
can provide im portant in ormation relative to the torque production capability o that
isolated joint.4
When there is some dys unction associated with injury, the predictable pattern o
movement that occurs during closed-kinetic-chain activity might not be possible because
o pain, swelling, muscle weakness, or limited range o motion. T us, movement compen-
sations result that inter ere with normal motion and muscle activity. I only closed-kinetic-
chain exercise is used, the joints proximal or distal to the injury might not show an existing
de cit. Without using open-kinetic-chain exercises that isolate speci c joint movements,
the de cit might go uncorrected, thus inter ering with total rehabilitation.19 T e thera-
pist should use the most appropriate open- or closed-kinetic-chain exercise or the given
situation.
Closed-kinetic-chain exercises use varying combinations o isometric, concentric, and
eccentric contractions that must occur simultaneously in dif erent muscle groups, creat-
ing multiplanar motion at each o the joints within the kinetic chain. Closed-kinetic-chain
activities require synchronicity o more complex agonist and antagonist muscle actions.27
Clin ica l Pe a r l
An exercise bike is a good tool when rehabilitating lower-extremity injuries. The patient
can work through a full range of motion without bearing weight. The seat height can
be adjusted to target a speci c range of motion. And most muscles of the leg are
utilized. Most bikes have an option of upper-body activity as well. A stair-climber or
elliptical machine provides weightbearing exercise that is nonimpact. Later in closed-
chain progression, lateral step-ups can be used for neuromuscular control and increased
quadriceps ring.
Using Closed-Kinetic-Chain Exercises

to Regain Neuromuscular Control
Chapter 9 stressed that proprioception, joint position sense, and kinesthesia are critical to
the neuromuscular control o body segments within the kinetic chain. o per orm a motor
skill, muscular orces, occurring at the correct moment and magnitude, interact to move
body parts in a coordinated manner.56 Coordinated movement is controlled by the cen-
tral nervous system that integrates input rom joint and muscle mechanoreceptors acting
within the kinetic chain. Smooth coordinated movement requires constant integration o
receptor, eedback, and control center in ormation.56
In the lower extremity, a unctional weightbearing activity requires muscles and joints
to work in synchrony and in synergy with one another. For example, taking a single step
requires concentric, eccentric, and isometric muscle contractions to produce supination
and pronation in the oot; ankle dorsi exion and plantar exion; knee exion, extension,
and rotation; and hip exion, extension, and rotation. Lack o normal motion secondary to
injury in one joint will af ect the way another joint or segment moves.56
o per orm this single step in a coordinated manner, all o the joints and muscles must
work together. T us, exercises that act to integrate, rather than isolate, all o these unction-
ing elements would seem to be the most appropriate. Closed-kinetic-chain exercises, which
recruit oot, ankle, knee, and hip muscles in a manner that reproduces normal loading
Biomechanics of Open- versus Closed-Kinetic-Chain Activities in the Lower Extremity 291
and movement orces in all o the joints within the kinetic chain, are similar to unctional
mechanics and would appear to be most use ul.56
Quite o ten, open-kinetic-chain exercises are used primarily to develop muscular
strength while little attention is given to the importance o including exercises that reestab-
lish proprioception and joint position sense.1 Closed-kinetic-chain activities acilitate the
integration o proprioceptive eedback coming rom Pacinian corpuscles, Ru ni endings,
Golgi-Mazzoni corpuscles, Golgi-tendon organs, and Golgi-ligament endings through the
unctional use o multijoint and multiplanar movements.13
Biomechanics of Open- versus Closed-Kinetic-

Chain Activities in the Lower Extremity
Open- and closed-kinetic-chain exercises have dif erent biomechanical ef ects on the joints
o the lower extremity.18 Walking along with the ability to change direction requires coor-
dinated joint motion and a complex series o well-timed muscle activations. Biomechani-
cally, shock absorption, oot exibility, oot stabilization, acceleration and deceleration,
multiplanar motion, and joint stabilization must occur in each o the joints in the lower
extremity or normal unction.33,56 Some understanding o how these biomechanical events
occur during both open- and closed-kinetic-chain activities is essential or the therapist.
Foot and Ankle

T e oot’s unction in the support phase o weight bearing during gait is two old. At heel
strike, the oot must act as a shock absorber to the impact or ground reaction orces and
then adapt to the uneven sur aces. Subsequently, at push-of , the oot unctions as a rigid
lever to transmit the explosive orce rom the lower extremity to the ground.77
As the oot becomes weight bearing at heel strike, creating a closed kinetic chain, the
subtalar joint moves into a pronated position in which the talus adducts and the plantar
exes while the calcaneus everts. Pronation o the oot unlocks the midtarsal joint and
allows the oot to assist in shock absorption. It is important during initial impact to reduce
the ground reaction orces and distribute the load evenly on many dif erent anatomical
structures throughout the lower-extremity kinetic chain. As pronation occurs at the subtalar
joint, there is obligatory internal rotation o the tibia and slight exion at the knee. T e dor-
si exors contract eccentrically to decelerate plantar exion. In an open kinetic chain, when
the oot pronates, the talus is stationary while the oot everts, abducts, and dorsi exes. T e
muscles that evert the oot appear to be most active.77
T e oot changes its unction rom being a shock absorber to being a rigid lever system
as the oot begins to push of the ground. In weight bearing in a closed kinetic chain, supi-
nation consists o the talus abducting and dorsi exing on the calcaneus while the calca-
neus inverts on the talus. T e tibia externally rotates and produces knee extension. During
supination the plantar exors stabilize the oot, decelerate the tibia, and ex the knee. In
an open kinetic chain, supination consists o the calcaneus inverting as the talus adducts
and plantar exes. T e oot moves into adduction and plantar exion, around the stabilized
talus.77 Changes in oot position (ie, pronation or supination) appear to have little or no
ef ect on the electromyogram (EMG) activity o the vastus medialis or the vastus lateralis.37
Knee Joint
It is essential or the therapist to understand orces that occur around the knee joint. Palmi-
tier et al proposed a biomechanical model o the lower extremity that quanti es 2 critical
S S he a r =
Compre s s ion =
C
A B C D
Figure 11-3 Re sistive fo rce s applie d in

diffe re nt po sitio ns alte r the mag nitude o f the
she ar and co mpre ssive fo rce s
A. Resistive force applied distally. B. Resistive force applied

RF
proximally. C. Resistive force applied axially. D. Resistive
force applied distally with hamstring cocontraction.
orces at the knee joint (Figure 11-2).53 A shear force occurs in a posterior
Figure 11-2 direction that would cause the tibia to translate anteriorly i not checked by
so t-tissue constraints, primarily the anterior cruciate ligament (ACL).14 T e
Mathematical model showing shear second orce is a com pressive force directed along a longitudinal axis o the
and compressive force vectors. tibia. Weightbearing exercises increase joint compression, which enhances
C, compressive; S, shear. joint stability.
In an open-kinetic-chain seated knee-joint exercise, as a resistive orce is
applied to the distal tibia, the shear and compressive orces would be maxi-
mized ( Figure 11-3A). When a resistive orce is applied more proximally, shear orce is
signi cantly reduced, as is the compressive orce (Figure 11-3B).30 I the resistive orce is
applied in a more axial direction, the shear orce is also smaller (Figure 11-3C). I a ham-
string cocontraction occurs, the shear orce is minimized (Figure 11-3D).
Closed-kinetic-chain exercises induce ham strin g contraction by creating a exion
m om ent at both the hip and the knee, with the contracting ham strings stabilizing the
hip and the quadriceps stabilizing the knee.74 A m om ent is the product o orce and dis-
tance rom the axis o rotation. Also re erred to as torque, it describes the turning ef ect
produced when a orce is exerted on the body that is pivoted about som e xed point
( Figure 11-4). Cocontraction o the ham string m uscles helps to counteract the tendency
o the quadriceps to cause anterior tibial translation.73 Cocontraction o the ham strings
is m ost e cient in reducing shear orce when the resistive orce is directed in an axial
orientation relative to the tibia, as is the case in a weightbearing exercise.53 Several stud-
ies have shown that cocontraction is use ul in stabilizing the knee joint and decreasing
shear orces.36,41,54,68
T e tension in the hamstrings can be urther enhanced with slight anterior exion o
the trunk.50 runk exion moves the center o gravity anteriorly, decreasing the knee ex-
ion moment and thus reducing knee shear orce and decreasing patello emoral compres-
sion orces.52 Closed-kinetic-chain exercises try to minimize the exion moment at the knee
while increasing the exion moment at the hip.
Closed-Kinetic-Chain Exercises for Rehabilitation of Lower-Extremity Injuries 293
A exion moment is also created at the ankle when the resistive orce
is applied to the bottom o the oot. T e soleus stabilizes ankle exion and
creates a knee extension moment, which again helps to neutralize ante-
rior shear orce (see Figure 11-4). T us the entire lower-extremity kinetic
A
chain is recruited by applying an axial orce at the distal segment.
In an open-kinetic-chain exercise involving seated leg extensions,
the resistive orce is applied to the distal tibia, creating a exion moment
at the knee only.70 T is negates the ef ects o a hamstring cocontraction
and produces maximal shear orce at the knee joint. Shear orces created
by isometric open-kinetic-chain knee exion and extension at 30 and 60
degrees o knee exion are greater than those with closed-kinetic-chain
exercises.47 Decreased anterior tibial displacement during isom etric
B
closed-kinetic-chain knee exion at 30 degrees when measured by knee
arthrometry has also been demonstrated.78
Pat ellofemoral Joint

T e ef ects o open- versus closed-kinetic-chain exercises on the patel-
lo em oral joint m ust also be considered. In open-kinetic-chain knee
extension exercise, the exion m om ent increases as the knee extends
rom 90 degrees o exion to ull exten sion , increasin g ten sion in
the quadriceps and patellar ten don .6 T us the patello em oral joint C
reaction orces are increased, with peak orce occurring at 36 degrees
o joint exion.25 As the knee m oves toward ull extension, the patel-
lo em oral contact area decreases, causing increased contact stress per
unit area.7,38 RF
In closed-kinetic-chain exercise, the exion moment increases as the
knee exes, once again causing increased quadriceps and patellar ten-
don tension and thus an increase in patello emoral joint reaction orces.61 Figure 11-4
However, the patella has a much larger sur ace contact area with the
emur, and contact stress is minimized.7,25,38 Closed-kinetic-chain exer- Closed-kinetic-chain exercises induce
cises might be better tolerated in the patello emoral joint because contact hamstring contraction by creating a flexion
stress is minimized.6 moment at (A) hip, (B) knee, and (C) ankle.
Closed-Kinetic-Chain Exercises for

Rehabilitation of Lower-Extremity Injuries
For many years, therapists have made use o open-kinetic-chain exercises or lower-
extremity strengthening. T is practice has been partly a result o design constraints o
existing resistive exercise machines. However, the current popularity o closed-kinetic-
chain exercises can be attributed primarily to a better understanding o the kinesiology
and biomechanics, along with the neuromuscular control actors, involved in rehabilita-
tion o lower-extremity injuries.
For exam ple, the course o rehabilitation a ter injury to the anterior ACL has changed
drastically over the years. (Speci c rehabilitation protocols are discussed in detail in
Chapter 29.) echnologic advan ces have created signi cant im provem ent in surgical
techniques, and this has allowed therapists to change their philosophy o rehabilitation.
T e current literature provides a great deal o support or accelerated rehabilitation pro-
gram s that recom m end the extensive use o closed-kinetic-chain exercises.9,15,20,25,48,62,75,82
Because o the biomechanical and unctional advantages o closed-kinetic-chain exer-

cises described earlier, these activities are perhaps best suited to rehabilitation o the ACL.35
T e majority o these studies also indicate that closed-kinetic-chain exercises can be sa ely
incorporated into the rehabilitation protocols very early.57 Some therapists recommend
beginning within the rst ew days a ter surgery.
Several dif erent closed-kinetic-chain exercises have gained popularity and have been
incorporated into rehabilitation protocols.43 Among those exercises commonly used are the
minisquat, wall slides, lunges, leg press, stair-climbing machines, lateral step-up, terminal
knee extension using tubing, and stationary bicycling, slide boards, biomechanical ankle
plat orm system (BAPS) boards, and the Fitter.
Minisquat s, Wall Slides, and Lunges

T e minisquat (Figure 11-5) or wall slide (Figure 11-6) involves simultaneous hip and knee
extension and is per ormed in a 0- to 40-degree range.82 As the hip extends, the rectus emo-
ris contracts eccentrically while the hamstrings contract concentrically. Concurrently, as
the knee extends, the hamstrings contract eccentrically while the rectus emoris contracts
concentrically. Both concentric and eccentric contractions occur simultaneously at either
end o both muscles, producing a concurrent shi t contraction. T is type o contraction is
necessary during weightbearing activities.63 It will be elicited with all closed-kinetic-chain
exercises and is impossible with isolation exercises.69
T ese concurrent shi t contractions m inim ize the exion m om ent at the knee. T e
eccentric contraction o the ham strings helps to neutralize the ef ects o a concentric
quadriceps contraction in producing anterior translation o the tibia.22 Henning et al
ound that the hal squat produced signi cantly less anterior shear at the knee than did
an open-chain exercise in ull extension.31 A ull squat markedly increases the exion
Figure 11-5 Minisquat pe rfo rme d in 0- to Figure 11-6 Standing w all

40-de g re e rang e slide
moment at the knee and thus increases anterior shear
o the tibia. As m entioned previously, slightly ex-
ing the trunk anteriorly will also increase the hip
exion m om ent and decrease the knee m om ent. It
appears that increasing the width o the stance in a
wall squat has no ef ect on EMG activity in the quad-
riceps.2 However, m oving the eet orward does seem
to increase activity in the quadriceps as well as the
plantar exors.11
Lunges should be used later in a rehabilitation
program to acilitate eccentric strengthening o the
quadriceps to act as a decelerator (Figure 11-7).24,81
Like the minisquat and wall slide, it acilitates cocon-
traction o the hamstring muscles.23
Leg Press
T eoretically, the leg press takes ull advantage o the
kinetic chain and at the same time provides stabil-
ity, which decreases strain on the lower back.45 It also
allows exercise with resistance lower than body weight
and the capability o exercising each leg indepen-
dently (Figure 11-8).53 It has been recommended that Figure 11-7 Lung e s are do ne to stre ng the n
leg-press exercises be per ormed in a 0- to 60-degree quadrice ps e cce ntrically
range o knee exion.82
It has also been recom mended that leg-press
machines allow ull hip extension to take maximum advantage o the kinetic chain.5 Full
hip extension can only be achieved in a supine position. In this position, ull hip and knee
exion and extension can occur, thus reproducing the concurrent shi t and ensuring appro-
priate hamstring recruitment.53
Figure 11-8 Le g -pre ss

T e ootplates should also be designed to move in an arc o motion

rather than in a straight line. T is movement would acilitate ham-
string recruitment by increasing the hip exion moment and decreas-
ing the knee moment. Footplates should be xed perpendicular to the
rontal plane o the hip to maximize the knee extension moment cre-
ated by the soleus.
St air Climbing
Stair-climbing machines have gained a great deal o popularity, not
only as a closed-kinetic-chain exercise device use ul in rehabilita-
tion, but also as a m eans o im proving cardiorespiratory endur-
ance ( Figure 11-9). Stair-clim bing machines have two basic designs.
One involves a series o rotating steps sim ilar to a departm ent store
escalator, while the other uses 2 ootplates that m ove up and down
to simulate a stepping-type m ovem ent. With the latter type o stair
climber, also som etimes re erred to as a stepping machine, the oot
never leaves the ootplate, making it a true closed-kinetic-chain exer-
cise device.
Stair climbing involves many o the same biomechanical prin-
ciples identi ed with the leg-press exercise.51 When exercising on the
stair climber, the body should be held erect with only slight trunk ex-
ion, thus maximizing hamstring recruitment through concurrent shi t
Figure 11-9 Ste pping machine contractions while increasing the hip exion moment and decreasing
the knee exion moment.
(Courtesy Diamandback Fitness.)
Exercise on a stepping machine produces increased EMG activ-
ity in the gastrocnemius.84 Because the gastrocnemius attaches to the
posterior aspect o the emoral condyles, increased activity o this muscle could produce
a exion moment o the emur on the tibia. T is motion would cause posterior translation
o the emur on the tibia, increasing strain on the ACL. Peak ring o the quadriceps might
of set the ef ects o increased EMG activity in the gastronemius.17
St ep-ups
Lateral, orward, and backward step-ups are widely used closed-kinetic-chain exercises
(Figure 11-10). Lateral step-ups seem to be used more o ten clinically than orward step-
ups. Step height can be adjusted to patient capabilities and generally progresses up to about
8 inches. Heights greater than 8 inches create a large exion moment at the knee, increasing
anterior shear orce and making hamstring cocontraction more di cult.12,17
Step-ups elicit signi cantly greater m ean ham string EMG activity than a stepping
m achine, whereas the quadriceps are m ore active during stair clim bing.85 When per-
orm ing a step-up, the entire body weight must be raised and lowered, whereas on the
stepping machine the center o gravity is maintained at a relatively constant height. T e
lateral step-up can produce increased muscle and joint shear orces com pared to step-
ping exercise.17 Caution should be exercised by the therapist in using the lateral step-up
in cases where m inim izing anterior shear orces is essential. Contraction o the ham -
strings appears to be o insu cient magnitude to neutralize the shear orce produced
by the quadriceps.12 In situations where strengthening o the quadriceps is the goal, the
lateral step-up has been recom m ended as a bene cial exercise.86 However, lateral step-
ping exercises have ailed to increase isokinetic strength o the quadriceps muscle. It also
appears that concentric quadriceps contractions produce more EMG activity than eccen-
tric contractions in a lateral step-up.60
Figure 11-10 Late ral ste p-ups Figure 11-11 Te rminal kne e e xte nsio ns using
surg ical tubing re sistance
Terminal Knee Ext ensions Using Surgical Tubing

It has been reported in num erous studies that the greatest amount o anterior tib-
ial translation occurs between 0 and 30 degrees o exion during open-kinetic-chain
exercise.26,28,40,51,54,55,82 At one time, therapists avoided open-kinetic-chain terminal knee
extension a ter surgery. Un ortunately, this practice led to quadriceps weakness, exion
contracture, and patello emoral pain.58
Closed-kinetic-chain terminal knee extensions using surgical tubing resistance have
created a means o sa ely strengthening terminal knee extension (Figure 11-11).59 Appli-
cation o resistance anteriorly at the emur produces anterior shear o the emur, which
eliminates any anterior translation o the tibia. T is type o exercise per ormed in the 0- to
30-degree range also minimizes the knee exion moment, urther reducing anterior shear
o the tibia. T e use o rubber tubing produces an eccentric contraction o the quadri-
ceps when moving into knee exion. Weightbearing terminal knee extensions with tubing
increase the EMG activity in the quadriceps.85
St at ionary Bicycling
T e stationary bicycle can be o signi cant value as a closed-kinetic-chain exercise device
(Figure 11-12).
T e advantage o stationary bicycling over other closed-kinetic-chain exercises or
rehabilitation is that the amount o the weightbearing orce exerted by the injured lower
Figure 11-12 Statio nary bicycle Figure 11-13 BAPS bo ard e xe rcise
extremity can be adapted within patient limitations. T e seat

height should be care ully adjusted to minimize the knee
exion moment on the downstroke. However, i the station-
ary bike is being used to regain range o motion in exion,
the seat height should be adjusted to a lower position that
uses passive motion o the injured extremity. oe clips will
acilitate hamstring contractions on the upstroke.
BAPS Board and Minit ramp

T e BAPS board ( Figure 11-13) an d m initram p ( Fig-
ure 11-14) both provide an unstable base o support that
helps to acilitate reestablishing proprioception and joint
position sense in addition to strengthening. Working on
the BAPS board allows the therapist to provide stress to the
lower extrem ity in a progressive and controlled manner.13
It allows the patient to work simultaneously on strengthen-
ing and range o m otion, while trying to regain neuromus-
cular control and balance. T e m initram p may be used to
accomplish the same goals, but it can also be used or more
advanced plyom etric training.
Slide Boards and Fit t er

Figure 11-14
Shi ting the body weight rom side to side during a more
Minitramp provides an unstable base of support to which unctional activity on either a slide board (Figure 11-15) or
other functional plyometric activities may be added. a Fitter (Figure 11-16) helps to reestablish dynamic control
Biomechanics of Open- versus Closed-Kinetic-Chain Activities in the Upper Extremity 299
Figure 11-15 Slide bo ard training
as well as improve cardiorespiratory tness.13 T ese motions produce val- Figure 11-16 The tte r is
gus and varus stresses and strains to the joint that are somewhat unique use ful fo r w e ig ht shifting
to these 2 pieces o equipment. Lateral slide exercises have been shown to
improve knee extension strength ollowing ACL reconstruction.10 (Courtesy Fitter International, Inc.)
Clin ica l Pe a r l
Neuromuscular control and balance are crucial to performance. The BAPS board and
minitramp provide unstable surfaces on which the patient is required to stand. Such
controlled systems are ideal because they challenge proprioception more than the stable
ground. The patient who has mastered balance on an apparatus such as the minitramp
can be progressed to functional activity such as catching a ball while balancing on an
unstable surface.
Clin ica l Pe a r l
Unique to the slide board are the valgus and varus strains elicited by the movement. Too
much valgus stress while the ligament and musculature are still weak could exacerbate
the injury.
Biomechanics of Open- versus Closed-Kinetic-

Chain Activities in the Upper Extremity
Although it is true that closed-kinetic-chain exercises are m ost o ten used in rehabilita-
tion o lower-extrem ity injuries, there are many injury situations where closed-kinetic-
chain exercises should be incorporated into upper-extrem ity rehabilitation protocols.64
Unlike the lower extrem ity, the upper extrem ity is m ost unctional as an open-kinetic-
chain system. Most activities involve m ovem ent o the upper extrem ity in which the hand
m oves reely. T ese activities are generally dynam ic m ovem ents. In these m ovem ents,
the proxim al segm ents o the kinetic chain are used or stabilization , while the distal
segm ents have a high degree o m obility. Pushups, chinning exercises, and handstands
in gym nastics are all exam ples o closed-kinetic-chain activities in the upper extrem -
ity. In these cases, the hand is stabilized, and m uscular contractions around the m ore
proximal segm ents, the elbow and shoulder, unction to raise and lower the body. Still
other activities such as swim m ing and cross-country skiing involve rapid successions o
alternating open-and closed-kinetic-chain m ovem ents, m uch in the sam e way as run-
ning does in the lower extrem ity.83
For the m ost part in rehabilitation, closed-kinetic-chain exercises are used primarily
or strengthening and establishing neurom uscular control o those m uscles that act to
stabilize the shoulder girdle.76 In particular, the scapular stabilizers and the rotator cuf
m uscles unction at one tim e or another to control m ovem ents about the shoulder. It is
essential to develop both strength and neurom uscular control in these muscle groups,
thus allowing them to provide a stable base or m ore m obile and dynam ic m ovem ents
that occur in the distal segm ents.76
It m ust also be em phasized that although traditional upper-extrem ity rehabilita-
tion program s have concentrated on treating and identi ying the involved structures,
the body does not operate in isolated segm ents but instead works as a dynam ic unit.49
More recently, rehabilitation program s have integrated closed-kinetic-chain exercises
with core stabilization exercises and m ore unctional m ovem ent program s.65 T erapists
should recognize the need to address the im portance o the legs and trunk as contribu-
tors to upper-extrem ity unction and routin ely incorporate therapeutic exercises that
address the entire kinetic chain.49
Clin ica l Pe a r l
Closed-chain exercises in which the arm is xed and the shoulder joint is perturbed cause
contraction of the scapular stabilizers and the rotator cuff. This encourages overall stability
of the joint.
Shoulder Complex Joint

Closed-kinetic-chain weightbearing activities can be used to both prom ote and enhance
dynam ic joint stability. Most o ten closed-kinetic-chain exercises are used with the hand
xed and thus with no m otion occurring. T e resistance is then applied either axially or
rotationally. T ese exercises produce both joint com pression and approximation, which
act to enhance muscular cocontraction about the joint producing dynam ic stability.83
wo essential orce couples must be reestablished around the glenohumeral joint:
the anterior deltoid along with the in raspinatus and teres minor in the rontal plane, and
the subscapularis counterbalanced by the in raspinatus and teres minor in the transverse
plane. T ese opposing muscles act to stabilize the glenohumeral joint by compressing the
humeral head within the glenoid via muscular cocontraction.
T e scapular m uscles unction to dynam ically position the glenoid relative to the
position o the m ovin g hum erus, resultin g in a n orm al scapulohum eral rhythm o
m ovem ent. However, they must also provide a stable base on which the highly m obile
hum erus can un ction. I the scapula is hyperm obile, the unction o the entire upper
extrem ity will be im paired. T us orce couples between the in erior trapezius counter-
balanced by the upper trapezius and levator scapula—and the rhom boids and m iddle
Open- and Closed-Kinetic-Chain Exercises for Rehabilitation of Upper-Extremity Injuries 301
trapezius counterbalanced by the serratus anterior—are critical in maintaining scapular
stability. Again, closed-kinetic-chain activities done with the hand xed should be used
to enhance scapular stability.44
Elbow
T e elbow is a hinged joint that is capable o 145 degrees o exion rom a ully extended
position. In som e cases o joint hyperelasticity, the joint can hyperextend a ew degrees
beyond neutral. T e elbow consists o the hum eroulnar, humeroradial, and radioulnar
articulations. T e concave radial head articulates with the convex sur ace o the capitel-
lum o the distal hum erus and is connected to the proximal ulna via the annular liga-
ment. T e proximal radioulnar joint constitutes the orearm that permits approximately
90 degrees o pronation and 80 degrees o supination when working in conjunction with
the elbow joint.
In some activities, the elbow unctions in an open kinetic chain. In other activities, the
elbow must possess static stability and adequate dynamic strength to be able to trans er
orce to a hitting implement.42
Open- and Closed-Kinetic-Chain Exercises

for Rehabilitation of Upper-Extremity Injuries
Most typically, closed-kinetic-chain glenohum eral joint exercises are used during the
early phases o a rehabilitation program, particularly in the case o an unstable shoulder
to prom ote cocontraction and muscle recruitm ent, in addition to preventing shutdown o
the rotator cuf secondary to pain and/ or in ammation.3,66 Likewise, closed-kinetic-chain
exercise should be used during the late phases o a rehabilitation program to prom ote
muscular endurance o muscles surrounding the glenohum eral and scapulothoracic
joints. T ey may also be used during the later stages o rehabilitation in conjunction
with open-kinetic-chain activities to enhance som e degree o stability, on which highly
dynam ic and ballistic motions may be superim posed. At som e point during the m iddle
stages o the rehabilitation program, traditional open-kinetic-chain strengthening exer-
cises or the rotator cuf , deltoid, and other glenohum eral and scapular muscles must be
incorporated.34,83
In the elbow, exercises should also be designed to enhance muscular balance and
neuromuscular control o the surrounding agonists and antagonists. Closed-kinetic-chain
exercise should be used to improve dynamic stability o the more proximal muscles sur-
rounding the elbow in those activities where the elbow must provide some degree o proxi-
mal stability. Open-kinetic-chain exercises or strengthening exion, extension, pronation,
and supination are essential to regain high-velocity dynamic movements o the elbow that
are necessary in throwing-type activities.
Clin ica l Pe a r l
Open-chain exercises will allow you to apply signi cant resistance and isolate the muscle.
With side-lying exercises it is easy to teach the patient to isolate the muscle. Once that is
accomplished, more functional closed-chain exercises can be implemented. Closed-chain
exercises will encourage neuromuscular control, as the patient is expected to balance in
addition to targeting the particular muscle.
A B
C D
Figure 11-17 We ig ht shifting
A. Standing. B. Quadruped. C. Tripod. D. Opposite knee and arm.
Weight Shift ing

A variety o weight-shi ting exercises can be done to assist in acilitating glenohumeral and
scapulothoracic dynam ic stability through the use o axial com pression.16 Weight shi t-
ing can be done in standing, quadruped, tripod, or biped (opposite leg and arm), with
weight supported on a stable sur ace such as the wall or a treatment table ( Figure 11-17),
or on a movable, unstable sur ace such as a BAPS board, a wobble board, stability ball, or a
Plyoball (Figure 11-18). Shi ting may be done side to side, orward and backwards, or on a
diagonal. Hand position may be adjusted rom a wide base o support to one hand placed
on top o the other to increase di culty. T e patient can adjust the amount o weight being
supported as tolerated. T e therapist can provide manual orce o resistance in a random
manner to which the patient must rhythmically stabilize and adapt. A diagonal 2 (D2) pro-
prioceptive neuromuscular acilitation pattern may be used in a tripod to orce the con-
tralateral support limb to produce a co-contraction and thus stabilization ( Figure 11-19).83
Rhythm ic stabilization can also be used regain neuromuscular control o the scapular
muscles with the hand in a closed kinetic chain and random pressure applied to the scap-
ular borders ( Figure 11-20).
A B
Figure 11-18 We ig ht shifting
A. On a BAPS board. B. On a Bosu Balance Trainer. C. On a stability ball. D. On a Plyoball.
Figure 11-19 Figure 11-20 Rhythmic stabilizatio n fo r the

scapular muscle s
D2 proprioceptive neuromuscular facilitation pattern
in a tripod to produce stabilization in the contralateral
support limb.
Figure 11-21 Pushups do ne o n a Plyo ball Figure 11-22 Pushups do ne o n a stability ball
Pushups, Pushups wit h a Plus, Press-ups, St ep-ups

Pushups and/ or press-ups are also done to reestablish neurom uscular control. Pushups
don e on an un stable sur ace such as on a Plyoball require a good deal o stren gth in
addition to providing an axial load that requires cocontraction o agonist an d antago-
nist orce couples aroun d the glen ohum eral an d scapulothoracic joints, while the distal
part o the extrem ity has som e lim ited m ovem ent ( Figure 11-21). A variation o a stan-
dard pushup would be to have the patient use a stability ball ( Figure 11-22) or doin g
wall or corn er pushups ( Figure 11-23). Pushups with a plus are don e to stren gthen the
serratus anterior, which is critical or scapular dynam ic stability in overhead activities
( Figure 11-24). Press-ups involve an isom etric contraction o the glenohum eral stabiliz-
ers ( Figure 11-25).
Figure 11-23 Wall pushups Figure 11-24 Pushups w ith a plus

Figure 11-25 Pre ss-ups Figure 11-26 Slide bo ard stre ng the ning e xe rcise
Clin ica l Pe a r l
Any exercise that perturbs the shoulder complex will cause the scapular stabilizers to re.
Pushups with a plus are done to strengthen the serratus anterior. Pushups performed on
a BAPS board or on a Plyoball also promote stability and neuromuscular control of the
shoulder complex.
Slide Board
Upper-extremity closed-kinetic-chain exercises per ormed on a slide board are use ul not
only or promoting strength and stability but also or improving muscular endurance.72,83
In a kneeling position, the patient uses a reciprocating motion, sliding the hands orward
and backward, side to side, in a “wax on-wax of ” circular pattern, or both hands laterally
(Figure 11-26). It is also possible to do wall slides in a standing position.
SUMMARY
1. A closed-kinetic-chain exercise is one in which the distal segment o the extremity is
xed or stabilized. In an open kinetic chain, the distal segment is mobile and not xed.
2. Both open- and closed-kinetic-chain exercises have their place in the rehabilitative
process.
3. T e concepts o the reversibility o muscle actions and the concurrent shi t are hall-
marks o closed-kinetic-chain exercises.
4. Open- and closed-kinetic-chain exercises of er distinct advantages and disadvantages
in the rehabilitation process. T e choice to use one or the other depends on the desired
treatment goal.
5. It has been suggested that closed-kinetic-chain exercises are sa er because o muscle

cocontraction and joint compression; that closed-kinetic-chain exercises tend to be
more unctional; and that they acilitate the integration o proprioceptive and joint po-
sition sense eedback more ef ectively than open-kinetic-chain exercises.
6. Open- and closed-kinetic-chain exercises have dif erent biomechanical ef ects on the
joints o the lower extremity.
7. Closed-kinetic-chain exercises in the lower extremity decrease the shear orces, reduc-
ing anterior tibial translation, and increase the compressive orces that increase stabil-
ity around the knee joint.
8. Minisquat, wall slides, lunges, leg press, stair-climbing machines, lateral step-up, ter-
minal knee extension using tubing, stationary bicycling, slide boards, BAPS boards, and
the Fitter are all examples o closed-kinetic-chain activities or the lower extremity.
9. Although it is true that closed-kinetic-chain exercises are most o ten used in rehabilita-
tion o lower-extremity injuries, there are many injury situations where closed-kinetic-
chain exercises should be incorporated into upper-extremity rehabilitation protocols.
10. Closed-kinetic-chain exercises in the upper extremity are used primarily or strength-
ening and establishing neuromuscular control o those muscles that act to stabilize the
shoulder girdle.
11. Closed-kinetic-chain activities, such as pushups, press-ups, weight shi ting, and slide
board exercises, are strengthening exercises used primarily or improving shoulder sta-
bilization in the upper extremity.
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Proprioceptive
Neuromuscular
Facilitation Techniques
in Rehabilitation
Explain the neurophysiologic basis of proprioceptive neuromuscular facilitation (PNF) techniques.
Discuss the rationale for use of PNF techniques.
Identify the basic principles of using PNF in rehabilitation.
Demonstrate the various PNF strengthening and stretching techniques.
Describe PNF patterns for the upper and lower extremity, for the upper and lower trunk, and for
the neck.
Discuss the concept of muscle energy technique and explain how it is similar to PNF.
311
312 Chapte r 12 Proprioceptive Neuromuscular Facilitation Techniques in Rehabilitation
Proprioceptive neuromuscular acilitation (PNF) is an approach to therapeutic exercise

based on the principles o unctional human anatomy and neurophysiology.10 It uses pro-
prioceptive, cutaneous, and auditory input to produce unctional improvement in motor out-
put and can be a vital element in the rehabilitation process o many conditions and injuries.
T e therapeutic techniques o PNF were f rst used in the treatment o patients with
paralysis and various neuromuscular disorders in the 1950s. Originally the PNF techniques
were used or strengthening and enhancing neuromuscular control. Since the early 1970s,
the PNF techniques have also been used extensively as a technique or increasing exibility
and range o motion.8,9,16,17,18,30,34,36,45,54,67,71
T is discussion should guide the therapist in using the principles and techniques o
PNF as a component o a rehabilitation program.
Proprioceptive Neuromuscular Facilitation

as a Technique for Improving Strength and
Enhancing Neuromuscular Control
Original Concept s of Facilit at ion and Inhibit ion

Most o the principles underlying modern therapeutic exercise techniques can be attributed
to the work o Sherrington,63 who f rst def ned the concepts o acilitation and inhibition.
According to Sherrington, an impulse traveling down the corticospinal tract or an a er-
ent impulse traveling up rom peripheral receptors in the muscle causes an impulse volley
that results in the discharge o a limited number o specif c motor neurons, as well as the
discharge o additional surrounding (anatomically close) motor neurons in the subliminal
ringe area. An impulse causing the recruitment and discharge o additional motor neu-
rons within the subliminal ringe is said to be acilitatory. Any stimulus that causes motor
neurons to drop out o the discharge zone and away rom the subliminal ringe is said to be
inhibitory.40 Facilitation results in increased excitability, and inhibition results in decreased
excitability o motor neurons.75 T us, the unction o weak muscles would be aided by acili-
tation, and muscle spasticity would be decreased by inhibition.26
Sherrington attributed the impulses transmitted rom the peripheral stretch recep-
tors via the a erent system as being the strongest in uence on the alpha motor neurons.63
T ere ore, the therapist should be able to modi y the input rom the peripheral receptors
and thus in uence the excitability o the alpha motor neurons. T e discharge o motor neu-
rons can be acilitated by peripheral stimulation, which causes a erent impulses to make
contact with excitatory neurons and results in increased muscle tone or strength o vol-
untary contraction. Motor neurons can also be inhibited by peripheral stimulation, which
causes a erent impulses to make contact with inhibitory neurons, resulting in muscle
relaxation and allowing or stretching o the muscle.63 PNF should be used to indicate any
technique in which input rom peripheral receptors is used to acilitate or inhibit.26
Several di erent approaches to therapeutic exercise based on the principles o acilita-
tion and inhibition have been proposed. Among these are the Bobath method,5,6 Brunnstrom
method,60 Rood method,58 and Knott and Voss method,37 which they called PNF. Although
each o these techniques is important and use ul, the PNF approach o Knott and Voss
probably makes the most explicit use o proprioceptive stimulation.37
Rat ionale for Use

As a positive approach to injury rehabilitation, PNF is aim ed at what the patient can
do physically within the lim itations o the injury. It is perhaps best used to decrease
Basic Principles of Proprioceptive Neuromuscular Facilitation 313
def ciencies in strength, exibility, and neuromuscular coordination in response to
demands that are placed on the neuromuscular system.39 T e emphasis is on selective
reeducation o individual motor elements through development o neuromuscular control,
joint stability, and coordinated mobility. Each movement is learned and then rein orced
through repetition in an appropriately demanding and intense rehabilitative program.59
T e body tends to respond to the demands placed on it. T e principles o PNF attempt
to provide a maximal response or increasing strength and neuromuscular control.69,70
T ese principles should be applied with consideration o their appropriateness in achiev-
ing a particular goal. It is well accepted that the continued activity during a rehabilitation
program is essential or maintaining or improving strength. T ere ore, an intense program
should o er the greatest potential or recovery.53
T e PNF approach is holistic, integrating sensory, motor, and psychological aspects o
a rehabilitation program. It incorporates re ex activities rom the spinal levels and upward,
either inhibiting or acilitating them as appropriate.
T e brain recognizes only gross joint m ovem ent and not individual muscle action.
Moreover, the strength o a muscle contraction is directly proportional to the activated
m otor units. T ere ore, to in crease the strength o a m uscle, the m aximum num ber o
m otor units m ust be stim ulated to strengthen the rem ainin g m uscle f bers.30,37 T is
“irradiation,” or over ow e ect, can occur when the stronger m uscle groups help the
weaker groups in com pleting a particular m ovem ent. T is cooperation leads to the reha-
bilitation goal o return to optim al unction. 4,37 T e principles o PNF, as discussed in the
next section, should be applied to reach that ultimate goal.
Clin ica l Pe a r l
PNF is used to strengthen gross motor patterns instead of speci c muscle actions.
Basic Principles of Proprioceptive

Neuromuscular Facilitation
Margret Knott, in her text on PNF,37 emphasized the importance o the principles rather
than specif c techniques in a rehabilitation program. T ese principles are the basis o PNF
that must be superimposed on any specif c technique. T e principles o PNF are based on
sound neurophysiologic and kinesiologic principles and clinical experience.59 Application
o the ollowing principles can help promote a desired response in the patient being treated.
1. T e patient must be taught the PNF patterns regarding the sequential movements rom
starting position to terminal position. T e therapist has to keep instructions brie and
simple. It is sometimes help ul or the therapist to passively move the patient through
the desired movement pattern to demonstrate precisely what is to be done. T e patterns
should be used along with the techniques to increase the e ects o the treatment.
2. When learning the patterns, the patient is o ten helped by looking at the moving limb.
T is visual stimulus o ers the patient eedback or directional and positional control.
3. Verbal cues are used to coordinate voluntary e ort with re ex responses. Commands
should be f rm and simple. Commands most commonly used with PNF techniques
are “push” and “pull,” which ask or an isotonic contraction; “hold,” which asks or an
isometric or stabilizing contraction; and “relax.”
4. Manual contact with appropriate pressure is essential or in uencing direction o
motion and acilitating a maximal response because re ex responses are greatly
a ected by pressure receptors. Manual contact should be f rm and conf dent to give
the patient a eeling o security. T e manner in which the therapist touches the patient
in uences their conf dence as well as the appropriateness o the motor response or
relaxation.59 A movement response may be acilitated by the hand over the muscle
being contracted to acilitate a movement or a stabilizing contraction.
5. Proper mechanics and body positioning o the therapist are essential in applying
pressure and resistance. T e therapist should stand in a position that is in line with the
direction o movement in the diagonal movement pattern. T e knees should be bent
and close to the patient such that the direction o resistance can easily be applied or
altered appropriately throughout the range.
6. T e amount o resistance given should acilitate a maximal response that allows
smooth, coordinated motion. T e appropriate resistance depends to a large extent
on the capabilities o the patient. It may also change at di erent points throughout
the range o motion. Maximal resistance may be applied with techniques that use
isometric contractions to restrict motion to a specif c point; it may also be used in
isotonic contractions throughout a ull range o movement.
7. Rotational movement is a critical component in all o the PNF patterns because
maximal contraction is impossible without it.
8. Normal timing is the sequence o muscle contraction that occurs in any normal motor
activity resulting in coordinated movement.37 T e distal movements o the patterns
should occur f rst. T e distal movement components should be completed no later
than hal way through the total PNF pattern. o accomplish this, appropriate verbal
commands should be timed with manual commands. Normal timing may be used
with maximal resistance or without resistance rom the therapist.
9. iming or emphasis is used primarily with isotonic contractions. T is principle
superimposes maximal resistance, at specif c points in the range, upon the patterns
o acilitation, allowing over ow or irradiation to the weaker components o a
movement pattern. T e stronger components are emphasized to acilitate the weaker
components o a movement pattern.
10. Specif c joints may be acilitated by using traction or approximation. raction
spreads apart the joint articulations, and approximation presses them together.
Both techniques stimulate the joint proprioceptors. raction increases the muscular
response, promotes movement, assists isotonic contractions, and is used with
most exion antigravity movements. raction must be maintained throughout the
pattern. Approximation increases the muscular response, promotes stability, assists
isometric contractions, and is used most with extension (gravity-assisted) movements.
Approximation may be quick or gradual and repeated during a pattern.
11. Giving a quick stretch to the muscle be ore muscle contraction acilitates a muscle
to respond with greater orce through the mechanisms o the stretch re ex. It is most
e ective i all the components o a movement are stretched simultaneously. However,
this quick stretch can be contraindicated in many orthopedic conditions because the
extensibility limits o a damaged musculotendinous unit or joint structure might be
exceeded, exacerbating the injury.
Basic St rengt hening Techniques

Each o the principles described in the previous section should be applied to the specif c
techniques o PNF. T ese techniques may be used in a rehabilitation program to strengthen
or acilitate a particular agonistic muscle group.29,43,44 T e choice o a specif c technique
depends on the def cits o a particular patient.56 Specif c techniques or combinations o
techniques should be selected on the basis o the patient’s problem.3
Basic Principles of Proprioceptive Neuromuscular Facilitation 315
Clin ica l Pe a r l
The rhythmic initiation technique promotes strength by rst introducing the movement
pattern passively. The patient will slowly progress to active assistive and then resistive
exercises through the movement pattern.
T e ollowing techniques are most appropriately used or the development o muscular

strength and endurance, as well as or reestablishing neuromuscular control.
Rhyt hmic Init iat ion

T e rhythmic initiation technique involves a progression o initial passive, then active-
assistive, ollowed by active movement against resistance through the agonist pattern.
Movement is slow, goes through the available range o motion, and avoids activation o a
quick stretch. It is used or patients who are unable to initiate movement and who have a
limited range o motion because o increased tone. It may also be used to teach the patient
a movement pattern.
Repeat ed Cont ract ion

Repeated contraction is use ul when a patient has weakness either at a specif c point or
throughout the entire range. It is used to correct imbalances that occur within the range
by repeating the weakest portion o the total range. T e patient moves isotonically against
maximal resistance repeatedly until atigue is evidenced in the weaker components o the
motion. When atigue o the weak components becomes apparent, a stretch at that point in
the range should acilitate the weaker muscles and result in a smoother, more coordinated
motion. Again, quick stretch may be contraindicated with some musculoskeletal injuries.
T e amount o resistance to motion given by the therapist should be modif ed to accom-
modate the strength o the muscle group. T e patient is commanded to push by using the
agonist concentrically and eccentrically throughout the range.
Slow Reversal
Slow reversal involves an isotonic contraction o the agonist ollowed immediately by an
isotonic contraction o the antagonist. T e initial contraction o the agonist muscle group
acilitates the succeeding contraction o the antagonist muscles. T e slow-reversal tech-
nique can be used or developing active range o motion o the agonists and normal recip-
rocal timing between the antagonists and agonists, which is critical or normal coordinated
motion.55 T e patient should be commanded to push against maximal resistance by using
the antagonist and then to pull by using the agonist. T e initial agonistic push acilitates the
succeeding antagonist contraction.
Slow-Reversal-Hold
Slow-reversal-hold is an isotonic contraction o the agonist ollowed immediately by an iso-
metric contraction, with a hold command given at the end o each active movement. T e
direction o the pattern is reversed by using the same sequence o contraction with no relax-
ation be ore shi ting to the antagonistic pattern. T is technique can be especially use ul in
developing strength at a specif c point in the range o motion.
Rhyt hmic St abilizat ion

Rhythm ic stabilization uses an isom etric contraction o the agonist, ollowed by an
isom etric contraction o the antagon ist to produce cocontraction and stability o the
2 opposin g m uscle groups. T e com m an d given is always “hold,” an d m ovem ent is
resisted in each direction. Rhythm ic stabilization results in an increase in the holding
power to a point where the position cannot be broken. Holding should em phasize cocon-
traction o agonists and antagonists.
Clin ica l Pe a r l
Rhythmic stabilization can be used to facilitate strength and stability at a joint by

stimulating cocontraction of the opposing muscles that support the joint. PNF
strengthening using the D1 and D2 patterns will encourage control in overhead activities.
Clin ica l Pe a r l
The movements required for sport are multiplanar movements. PNF strengthening is more
functional and is not limited by the design constraints of an exercise machine. Also, PNF
technique allows the therapist to adjust the amount of manual resistance throughout the
range of motion according to the patient’s capabilities.
Treat ing Speci c Problems wit h Propriocept ive

Neuromuscular Facilit at ion Techniques
PNF-strengthening techniques can be use ul in a variety o di erent conditions. o some
extent the choice o the most e ective technique or a given situation is dictated by the state
o the existing condition and the capabilities and limitations o the individual patient.72
T ere are some advantages to using PNF techniques in general.
Relative to strengthening, the PNF techniques are not encumbered by the design con-
straints o commercial exercise machines, although some o the newer exercise machines
have been designed to accommodate triplanar motion and thus will allow or PNF pat-
terned motion.9 With the PNF patterns, movement can occur in 3 planes simultaneously,
thus more closely resembling a unctional movement pattern. T e amount o resistance
applied by the therapist can be easily adjusted and altered at di erent points through
the range o motion to meet patient capabilities.38 T e therapist can choose to concen-
trate on the strengthening through the entire range o motion or through a very specif c
range. Combinations o several strengthening techniques can be used concurrently within
the same PNF pattern.51 Rhythmic initiation is use ul in the early stages o rehabilitation
when the patient is having di culty moving actively through a pain- ree arc. Passive move-
ment can allow the patient to maintain a ull range while using an active contraction to
move through the available pain- ree range. Slow reversal should be used to help improve
muscular endurance. Slow-reversal-hold is used to correct existing weakness at specif c
points in the range o motion through isometric strengthening.
Rhythmic stabilization is used to achieve stability and neuromuscular control about a
joint.11,21 T is technique requires cocontraction o opposing muscle groups and is use ul in
creating a balance in the existing orce couples.
Clin ica l Pe a r l
Proper body and hand positioning will maximize the therapist ability to provide suf cient
resistance. The therapist should stand in a position that is in line with the direction of
movement in the diagonal movement pattern. The knees should be bent and the stance
close to the patient, so that the direction and amount of resistance can easily be applied or
altered appropriately throughout the range of movement.
Proprioceptive Neuromuscular Facilitation Patterns 317
Proprioceptive Neuromuscular
Facilitation Patterns
T e PNF patterns are concerned with gross movement as opposed to specif c muscle
actions. T e techniques identif ed previously can be superimposed on any o the PNF pat-
terns. T e techniques o PNF are composed o both rotational and diagonal exercise pat-
terns that are similar to the motions required in most sports and normal daily activities.
T e exercise patterns have 3 component movements: exion–extension, abduction–
adduction, and internal–external rotation. Human movement is patterned and rarely
involves straight motion because all muscles are spiral in nature and lie in diagonal
directions.
T e PNF patterns described by Knott and Voss37 involve distinct diagonal and rota-
tional movements o the upper extremity, lower extremity, upper trunk, lower trunk, and
neck. T e exercise pattern is initiated with the muscle groups in the lengthened or stretched
position. T e muscle group is then contracted, moving the body part through the range o
motion to a shortened position.
T e upper and lower extremities all have 2 separate patterns o diagonal movement or
each part o the body, which are re erred to as the diagonal 1 (D1) and diagonal 2 (D2) pat-
terns. T ese diagonal patterns are subdivided into D1 moving into exion, D1 moving into
extension, D2 moving into exion, and D2 moving into extension. Figures 12-1 and 12-2
illustrate the PNF patterns or the upper and lower extremities, respectively. T e patterns
are named according to the proximal pivots at either the shoulder or the hip ( or example,
the glenohumeral joint or emoroacetabular joint).
ables 12-1 and 12-2 describe specif c movements in the D1 and D2 patterns or the
upper extremities. Figures 12-3 through 12-10 show starting and terminal positions or each
o the diagonal patterns in the upper extremity.
D1 FLEXION D2 FLEXION
S houlde r—Flex. S houlde r—Flex.
Add. Abd.
Ext. Rot. Ext. Rot.
Fore a rm—S up. Fore a rm—S up.
Wris t—Ra dia l Flex. Wris t—Ra dia l Ext.
D 1 S houlde r flexion D 2
Finge rs —Flex. Finge rs —Ext.
Exte rna l rota tion
Wris t s upina tion
S houlde r a dduction S houlde r a bduction

S HOULDER
Wris t flexion Wris t exte ns ion
PIVOT
Finge r flexion Finge r exte ns ion
S houlde r exte ns ion

Inte rna l rota tion
D2 EXTENS ION D 2 Wris t prona tion D 1 D1 EXTENS ION
S houlde r—Ext. S houlde r—Ext.
Add. Abd.
Int. Rot. Int. Rot.
Fore a rm—P ron. Fore a rm—P ron.
Wris t—Ulna r Ext. Wris t—Ulna r Ext.
Finge rs —Flex. Finge rs —Flex.
Figure 12-1 PNF patte rns o f the uppe r e xtre mity

D1 FLEXION D2 FLEXION
Hip—Flex. Hip—Flex.
Add. Abd.
Ext. Rot. Int. Rot.
Ank.—Dors i. Foot—Dors i.
Inve r. Eve r.
D 1 Hip flexion D 2
Toe s —Ext. Toe s —Ext.
Foot dors iflexion
Toe exte ns ion
Hip a dduction Hip a bduction

HIP
Exte rna l rota tion Inte rna l rota tion
PIVOT
Foot inve rs ion Foot eve rs ion
Hip exte ns ion

Foot pla nta r flexion
D2 EXTENS ION D 2 Toe flexion D 1 D1 EXTENS ION
Hip—Ext. Hip—Ext.
Add. Abd.
Ext. Rot. Int. Rot.
Foot—P la nt. Flex. Foot—P la nt. Flex.
Inve r. Eve r.
Toe s —Flex. Toe s —Flex.
Figure 12-2 PNF patte rns o f the lo w e r e xtre mity
ables 12-3 and 12-4 describe specif c movements in the D1 and D2 patterns or the
lower extremities. Figures 12-11 through 12-18 show the starting and terminal positions or
each o the diagonal patterns in the lower extremity.
able 12-5 describes the rotational movement o the upper trunk moving into extension
(also called chopping) and moving into exion (also called li ting). Figures 12-19 and 12-20
show the starting and terminal positions o the upper-extremity chopping pattern moving
into exion to the right. Figures 12-21 and 12-22 show the starting and terminal positions
or the upper-extremity li ting pattern moving into extension to the right.
able 12-6 describes rotational movement o the lower extremities moving into posi-
tions o exion and extension. Figures 12-23 and 12-24 show the lower-extremity pattern
moving into exion to the le t. Figures 12-25 and 12-26 show the lower-extremity pattern
moving into extension to the le t.
T e neck patterns involve simply exion and rotation to one side (Figures 12-27 and
12-28) with extension and rotation to the opposite side (Figures 12-29 and 12-30). T e
patient should ollow the direction o the movement with their eyes.
T e principles and techniques o PNF, when used appropriately with specif c pat-
terns, can be an extremely e ective tool or rehabilitation o injuries.65 T ey can be used
to strengthen weak muscles or muscle groups and to improve the neuromuscular control
about an injured joint. Specif c techniques selected or use should depend on individual
patient needs and may be modif ed accordingly.14,15
Table 12-1 D1 Uppe r-Extre mity Mo ve me nt Patte rns
Mo ving into Fle xio n Mo ving into Exte nsio n
Starting Po sitio n Te rminal Po sitio n Starting Po sitio n Te rminal Po sitio n

Bo dy Part (Fig ure 12-3 ) (Fig ure 12-4 ) (Fig ure 12-5 ) (Fig ure 12-6 )
Shoulder Extended Flexed Flexed Extended

Abducted Adducted Adducted Adducted
Internally rotated Externally rotated Externally rotated Internally rotated
Scapula Depressed Flexed Elevated Depressed

Retracted Protracted Protracted Retracted
Downwardly rotated Upwardly rotated Upwardly rotated Downwardly rotated
Forearm Pronated Supinated Supinated Pronated
Wrist Ulnar extended Radially exed Radially exed Ulnar extended
Finger and thumb Extended Flexed Flexed Extended

Abducted Adducted Adducted Abducted
Hand position for therapist a Left and inside of volar surface of hand Left hand on back of elbow on humerus
Right hand underneath arm in cubital fossa Right hand on dorsum of hand
of elbow
Verbal command Pull Push
a For patient’s right arm.
Table 12-2 D2 Uppe r-Extre mity Mo ve me nt Patte rns

Shoulder Extended Flexed Flexed Extended

Abducted Adducted Adducted Adducted
Scapula Depressed Flexed Elevated Depressed

Retracted Protracted Protracted Retracted
Downwardly rotated Upwardly rotated Upwardly rotated Downwardly rotated
Forearm Pronated Supinated Supinated Pronated
Wrist Ulnar extended Radially exed Radially exed Ulnar extended
Finger and thumb Flexed Extended Extended Flexed

Hand position for therapist a Left and on back of humerus Left hand on volar surface of humerus
Right hand on dorsum of hand Right hand on cubital fossa of elbow
Verbal command Push Pull
a For patient’s right arm.


D1 upper-extremity movement pattern moving into flexion. D1 upper-extremity movement pattern moving into flexion.
Starting position. Terminal position.

D1 upper-extremity movement pattern moving into D1 upper-extremity movement pattern moving into
extension. Starting position. extension. Terminal position.

D2 upper-extremity movement pattern moving into flexion. D2 upper-extremity movement pattern moving into flexion.

D2 upper-extremity movement pattern moving into D2 upper-extremity movement pattern moving into
Table 12-3 D1 Lo w e r-Extre mity Mo ve me nt Patte rns

Hip Extended Flexed Flexed Extended

Knee Extended Flexed Flexed Extended
Position of tibia Externally rotated Internally rotated Internally rotated Externally rotated
Ankle and foot Plantar exed Dorsi exed Dorsi exed Plantar exed
Everted Inverted Inverted Everted
Toes Flexed Extended Extended Flexed
Hand position for therapist a Right hand on dorsomedial surface of foot Right hand on lateral plantar surface of foot
Left hand on anteromedial thigh near Left hand on posterolateral thigh near
patella popliteal crease
a For patient’s right leg.
Table 12-4 D2 Lo w e r-Extre mity Mo ve me nt Patte rns

Hip Extended Flexed Flexed Extended

Adducted Abducted Abducted Adducted
Externally rotated Internally rotated Internally rotated Externally rotated
Knee Extended Flexed Flexed Extended
Position of tibia Externally rotated Internally rotated Internally rotated Externally rotated
Ankle and foot Plantar exed Dorsi exed Dorsi exed Plantar exed
Inverted Everted Everted Inverted
Hand position for therapist a Right hand on dorsolateral surface of foot Right hand on medial plantar surface of foot
Left hand on anterolateral thigh near patella Left hand on posteromedial thigh near
popliteal crease
a For
patient’s right leg.

D1 lower-extremity movement pattern moving into flexion. D1 lower-extremity movement pattern moving into flexion.

D1 lower-extremity movement pattern moving into D1 lower-extremity movement pattern moving into

D1 lower-extremity movement pattern moving into flexion. D2 lower-extremity movement pattern moving into flexion.

D2 lower-extremity movement pattern moving into D2 lower-extremity movement pattern moving into
Table 12-5 Uppe r-Trunk Mo ve me nt Patte rns
Mo ving into Fle xio n (Cho pping )a Mo ving into Exte nsio n (Lifting )a

Right upper extremity Flexed Extended Extended Flexed

Adducted Abducted Adducted Abducted
Internally rotated Externally rotated Internally rotated Externally rotated
Left upper extremity (left Flexed Extended Extended Flexed

hand grasps right forearm) Abducted Adducted Abducted Adducted
Externally rotated Internally rotated Externally rotated Internally rotated
Trunk Rotated and Rotated and exed Rotated and exed Rotated and
extended to left to right to left extended to right
Head Rotated and Rotated and exed Rotated and exed Rotated and
extended to left to right to left extended to right
Hand position of therapist Left hand on right anterolateral surface Right hand on dorsum of right hand
of forehead Left hand on posterolateral surface of head
Right hand on dorsum of right hand
Verbal command Pull down Push up
a
Patient’s rotation is to the right.

Upper-trunk pattern moving into flexion or chopping. Upper-trunk pattern moving into flexion or chopping.

Upper-trunk pattern moving into flexion or lifting. Starting Upper-trunk pattern moving into flexion or lifting. Terminal
position. position.
Table 12-6 Lo w e r Trunk Mo ve me nt Patte rns
Mo ving into Fle xio n a Mo ving into Exte nsio n b

Right hip Extended Flexed Flexed Extended

Externally rotated Internally rotated Internally rotated Externally rotated
Left hip Extended Flexed Flexed Extended

Adducted Abducted Abducted Adducted
Ankles Plantar exed Dorsi exed Dorsi exed Plantar exed
Hand position of therapist Right hand on dorsum of feet Right hand on plantar surface of foot
Left hand on anterolateral surface of left knee Left hand on posterolateral surface of
right knee
Verbal command Pull up and in Push down and out
a
Patient’s rotation is to the right.
b
Patient’s rotation is to the right in extension.

Lower-trunk pattern moving into flexion to the left. Starting Lower-trunk pattern moving into flexion to the left. Terminal
position. position.

Lower-trunk pattern moving into extension to the left. Lower-trunk pattern moving into extension to the left.

Neck flexion and rotation to the left. Starting position. Neck flexion and rotation to the left. Terminal position.

Neck extension and rotation to the right. Starting position. Neck extension and rotation to the right. Terminal position.
Proprioceptive Neuromuscular Facilitation as a Technique of Stretching for Improving Range of Motion 329
Proprioceptive Neuromuscular Facilitation as

a Technique of Stretching for Improving Range
of Motion
As indicated previously, PNF techniques can also be used or stretching to increase range
o motion.
Evolut ion of t he Theoret ical Basis for Using Propriocept ive

Neuromuscular Facilit at ion as a St ret ching Technique
A review o the current literature seems to indicate that many clinicians believe that the
PNF-stretching techniques can be an e ective treatment modality or improving exibility
and thus use them regularly in clinical practice.4,18,26,35,49,52,61,62 Over the years, various theo-
ries have been proposed to explain the neurologic and physical mechanisms through which
the PNF techniques improve exibility.13 However, to date no consensus agreement exists
that embraces a single theoretical explanation.
Neurophysiologic Basis of Propriocept ive

Neuromuscular Facilit at ion St ret ching
PNF gained popularity as a stretching technique in the 1970s.45,54,71 T e PNF research that
has traditionally appeared in the literature since that time has attributed increases in range o
motion primarily to neurophysiologic mechanisms involving the stretch re ex.13 More recent
studies question the validity o this theoretical explanation.1,13,32,33,68 Nevertheless, a brie
review o the stretch re ex will serve as a springboard or more currently accepted theories.
T e stretch re ex involves 2 types o receptors: (a) muscle spindles that are sensitive to
a change in length, as well as the rate o change in length o the muscle f ber; and (b) Golgi
tendon organs that detect changes in tension (Figure 12-31).
Stretching a given muscle causes an increase in the requency o impulses transmit-
ted to the spinal cord rom the muscle spindle along Ia f bers, which, in turn, produces an
increase in the requency o motor nerve impulses returning to that same muscle, along
alpha motor neurons, thus re exively resisting the stretch (see Figure 12-31). However, the
development o excessive tension within the muscle activates the Golgi tendon organs,
whose sensory impulses are carried back to the spinal cord along Ib f bers. T ese impulses
have an inhibitory e ect on the motor impulses returning to the muscles and cause that
muscle to relax (Figure 12-32).12
wo neurophysiologic phenom ena have been proposed to explain acilitation and
inhibition o the neuromuscular systems. T e f rst, autogenic inhibition, is def ned as inhi-
bition mediated by a erent f bers rom a stretched muscle acting on the alpha motor neu-
rons supplying that muscle, causing it to relax. When a muscle is stretched, motor neurons
supplying that muscle receive both excitatory and inhibitory impulses rom the receptors.
I the stretch is continued or a slightly extended period o time, the inhibitory signals rom
the Golgi tendon organs eventually override the excitatory impulses and there ore cause
relaxation. Because inhibitory m otor neurons receive im pulses rom the Golgi tendon
organs while the muscle spindle creates an initial re ex excitation leading to contraction,
the Golgi tendon organs apparently send inhibitory impulses that last or the duration o
increased tension (resulting rom either passive stretch or active contraction) and even-
tually dominate the weaker im pulses rom the muscle spindle. T is inhibition seem s to
protect the muscle against injury rom re ex contractions resulting rom excessive stretch.
Excita tory
Inhibitory
2 Mus cle s tre tch s timula te s s e ns ory ne rve s igna ls S pina l cord
to trave l to the CNS on Type Ia fibe rs.
S e ns ory
ne uron
α motor ne rve Inte rne uron

Intra fus a l
e ndings to mus cle fibe r
extra fus a l γ motor ne uron
mus cle fibe rs to mus cle s pindle
γ motor ne rve
e ndings to
mus cle s pindle
Extra fus a l
Mus cle mus cle fibe r
s pindle
α motor ne urons to
S e ns ory ne rve extra fus a l mus cle fibe rs
e ndings 3 S e ns ory ne uron
syna ps e s on α motor
4 α motor ne urons tra ns mit ne rve ne urons.
1 Mus cle s pindle s igna ls to extra fus a l mus cle
de te cts s tre tch. fibe rs , re s ulting in contra ction
of the mus cle s (in re s pons e to
be ing s tre tche d).
5 Inte rne urons syna ps e

with α motor ne urons to
a nta gonis t mus cle s,
inhibiting mus cle contra ction
(re ciproca l inhibition).
Figure 12-31 Diag rammatic re pre se ntatio n o f the stre tch re e x
(Reproduced with permission from McKinley M, O’Loughlin V. Human Anatomy. 3rd ed. New York: McGraw-Hill; 2012.)
A second mechanism, reciprocal inhibition, deals with the relationships o the ago-
nist and antagonist muscles (see Figure 12-31). T e muscles that contract to produce
joint motion are re erred to as agonists, and the resulting movement is called an agonistic
pattern . T e muscles that stretch to allow the agonist pattern to occur are re erred to as
antagonists. Movement that occurs directly opposite to the agonist pattern is called the
antagonist pattern .
When motor neurons o the agonist muscle receive excitatory impulses rom a erent
nerves, the motor neurons that supply the antagonist muscles are inhibited by a erent
impulses.4 T us, contraction or extended stretch o the agonist muscle has been said to
elicit relaxation or inhibit the antagonist. Likewise, a quick stretch o the antagonist muscle
acilitates a contraction o the agonist.
T e PNF literature has traditionally asserted that isometric or isotonic submaximal
contraction o a target muscle (muscle to be stretched) prior to a passive stretch o that
same muscle, or contraction o opposing muscles (agonists) during muscle stretch, pro-
duces relaxation o the stretched muscle through activation o the mechanisms o the
stretch re ex that include autogenic inhibition and reciprocal inhibition.13
However, a number o studies done since the early 1990s suggest that relaxation ol-
lowing a contraction o a stretched muscle is not a result o the inhibition o muscle spindle
activity or subsequent activation o Golgi tendon organs.1,2,12,13,23,24,29,46,51
Conclusions are based on the act that when slowly stretching a muscle to a long length,
as in the PNF-stretching techniques, the re ex-generated muscle electrical activation rom
Proprioceptive Neuromuscular Facilitation as a Technique of Stretching for Improving Range of Motion 331
1 Mus cle contra ction or s tre tch

incre a s e s te ns ion to
te ndons, de te cte d by
Golgi te ndon orga n.
Te ndon
Mus cle
Golgi te ndon orga n
Excita tory
Axon of s e ns ory Inhibitory
ne uron
S pina l cord
2 Mus cle contra ction s timula te s

s e ns ory ne rve s igna ls tha t trave l
to the CNS on Type Ib fibe rs. 3 S e ns ory ne urons
S e ns ory syna ps e with
ne uron inte rne urons.
Inte rne urons
α motor
ne uron
Qua drice ps fe moris

α motor ne uron
to a nta gonis tic
5a Mus cle re la xe s a nd mus cle
the re is re lie f of
te ns ion on te ndon. 4a Inte rne urons inhibit
α motor ne urons
Ha ms trings to mus cle.
5b Mus cle contra cts
(re ciproca l a ctiva tion).
4b Inte rne urons s timula te

α motor ne urons to
a nta gonis tic mus cle s.
Figure 12-32 Diag rammatic re pre se ntatio n o f re cipro cal inhibitio n
(Reproduced with permission from McKinley M, O’Loughlin V. Human Anatomy. 3rd ed. New York: McGraw-Hill; 2012.)
the muscle spindles (as indicated by electromyogram) is very small and clinically insignif -
cant, and not likely to e ectively resist an applied muscle lengthening orce.13,28,31,35,41 Fur-
thermore, when a muscle relaxes ollowing an isometric contraction, Golgi tendon organ
f ring is decreased or even becomes silent.20,73 T us, Golgi tendon organs would not be able
to inhibit the target muscle in the seconds ollowing contraction when the slow therapeu-
tic stretch would be applied.13 It is apparent that, in general, there is a lack o research-
based evidence to support the theory that Golgi tendon organ and muscle spindle re exes
are able to relax target muscles during any o the PNF-stretching techniques.13 T us, other
mechanisms have been proposed that may explain increases in range o motion with PNF-
stretching exercises.19
Presynapt ic Inhibit ion

In the PNF-stretching techniques, the contraction and subsequent relaxation o the target
muscle is ollowed by a slow passive stretch o that muscle to a longer length. It has been
suggested that lengthening is associated with an increase in presynaptic inhibition o the
sensory signal rom the muscle spindle.13,22,25 T is occurs with inhibition o the release o
a neurotransmitter rom the synaptic terminals o the muscle spindle Ia sensory f bers that
limits activation in that muscle.
Viscoelast ic Changes in Response t o St ret ching

It has been proposed that viscoelastic changes that occur in a muscle, and not a decrease
in m uscle activation m ediated by Golgi tendon organs, is the m echanism that may
explain increases in range o m otion associated with the PNF techniques.8 T e viscoelas-
tic properties o collagen in muscle are discussed brie y in Chapter 8. T e orce that is
required to produce a change in length o a muscle is determ ined by its elastic stif ness.72
Because o the viscous properties o muscle, less orce is needed to elongate a muscle i
that orce is applied slowly rather than rapidly.72 Also, the orce that resists elongation is
reduced i the muscle is held at a stretched length over a period o tim e, thus producing
stress relaxation.64 As stress relaxation occurs, the muscle will elongate urther producing
creep. T ese properties have been dem onstrated in muscles with no signif cant electrical
activity.41,42,47
As the viscoelastic properties within a muscle are changed during a PNF-stretching pro-
cedure, there is an altered perception o stretch and a greater range o motion and greater
torque can be achieved be ore the onset o pain is perceived.42,74 T is is thought to occur
because lengthening interrupts the actin-myosin bonds within the intra usal f bers o the
muscle spindle, thus reducing their sensitivity to stretch.22,27,73
St ret ching Techniques

T e ollowing techniques should be used to increase range o motion, relaxation, and
inhibition.
Cont ract -Relax

Contract-relax is a stretching technique that moves the body part passively into the agonist
pattern. T e patient is instructed to push by contracting the antagonist (muscle that will be
stretched) isotonically against the resistance o the therapist. T e patient then relaxes the
antagonist while the therapist moves the part passively through as much range as possible
to the point where limitation is again elt. T is contract-relax technique is benef cial when
range o motion is limited by muscle tightness.
Hold-Relax
Hold-relax is very similar to the contract-relax technique. It begins with an isometric con-
traction o the antagonist (muscle that will be stretched) against resistance, ollowed by a
concentric contraction o the agonist muscle combined with light pressure rom the ther-
apist to produce maximal stretch o the antagonist. T is technique is appropriate when
there is muscle tension on one side o a joint and may be used with either the agonist or
antagonist.7
Slow-Reversal-Hold-Relax
Slow-reversal-hold-relax technique begins with an isotonic contraction o the agonist, which
o ten limits range o motion in the agonist pattern, ollowed by an isometric contraction
Muscle Energy Techniques 333
o the antagonist (muscle that will be stretched) during
the push phase. During the relax phase, the antagonists
are relaxed while the agonists are contracting, causing
movement in the direction o the agonist pattern and
thus stretching the antagonist. T e technique, like the
contract-relax and hold-relax, is use ul or increasing
range o motion when the primary limiting actor is the
antagonistic muscle group.
Because a goal o rehabilitation with m ost inju-
ries is restoration o strength through a ull, nonre-
stricted range o m otion, several o these techniques
are som etim es com bined in sequen ce to accom plish
this goal.50 Figure 12-33 shows a PNF-stretching tech-
n ique in which the therapist is stretchin g an injured
patient.
Figure 12-33 PNF-stre tching te chnique

Muscle Energy Techniques
Muscle energy is a manual therapy technique, which is a variation o the PNF contract-
relax and hold-relax techniques. Like the PNF techniques, the muscle energy techniques
are based on the same neurophysiologic mechanisms involving the stretch re ex discussed
earlier. Muscle energy techniques involve a voluntary contraction o a muscle in a specif -
cally controlled direction at varied levels o intensity against a distinctly executed counter-
orce applied by the therapist.30,48 T e patient provides the corrective intrinsic orces and
controls the intensity o the muscular contractions while the therapist controls the preci-
sion and localization o the procedure.48 T e amount o patient e ort can vary rom a mini-
mal muscle twitch to a maximal muscle contraction.30
Five components are necessary or muscle energy techniques to be e ective 30:
1. Active muscle contraction by the patient.
2. A muscle contraction oriented in a specif c direction.
3. Some patient control o contraction intensity.
4. T erapist control o joint position.
5. T erapist application o appropriate counter orce.
Clinical Applicat ions

It has been proposed that muscles unction not only as exors, extenders, rotators, and
side-benders o joints, but also as restrictors o joint motion. In situations where the mus-
cle is restricting joint motion, muscle energy techniques use a specif c muscle contraction
to restore physiological movement to a joint.48 Any articulation, whether in the spine or
extremities, that can be moved by active muscle contraction can be treated using muscle
energy techniques.48,57
Muscle energy techniques can be used to accomplish several treatment goals30:
• Lengthening o a shortened, contracted, or spastic muscle.
• Strengthening o a weak muscle or muscle group.
• Reduction o localized edema through muscle pumping.
• Mobilization o an articulation with restricted mobility.
• Stretching o ascia.
Treat ment Techniques

Muscle energy techniques can involve 4 types o muscle contraction: isometric, concentric
isotonic, eccentric isotonic, and isolytic. An isolytic contraction involves a concentric con-
traction by the patient while the therapist applies an external orce in the opposite direc-
tion, overpowering the contraction and lengthening that muscle.48
Isometric and concentric isotonic contractions are most requently used in treatment.66
Isometric contractions are most o ten used in treating hypertonic muscles in the spinal ver-
tebral column, while isotonic contractions are most o ten used in the extremities. With both
types o contraction, the idea is to inhibit antagonistic muscles producing more symmetri-
cal muscle tone and balance.
A concentric contraction can also be used to m obilize a joint against its m otion
barrier i there is m otion restriction. For exam ple, i a strength im balance exists between
the quadriceps and ham strings, with weak quadriceps lim iting knee extension, the
ollowing concentric isotonic muscle energy technique may be used ( Figure 12-34A ):
1. T e patient lies prone on the treatment table.
2. T e therapist stabilizes the patient with one hand and grasps the ankle with the other.
3. T e therapist ully exes the knee.
4. T e patient actively extends the knee, using as much orce as possible.
5. T e therapist provides a resistant counter orce that allows slow knee extension
throughout the available range.
6. Once the patient has completely relaxed, the therapist moves the knee back to ull
exion and the patient repeats the contraction with additional resistance applied
through the ull range o extension. T is is repeated 3 to 5 times with increasing
resistance on each repetition.
A B
Figure 12-34
Positions for muscle energy techniques for improving (A) weak quadriceps that limit knee extension and/or hip flexion
and (B) weak hamstrings that limit knee flexion and/or hip extension.
I a knee has a restriction because o tightness in the hamstrings that is limiting
ull extension, the ollowing isometric muscle energy technique should be used (see
Figure 12-34B):
1. T e patient lies supine on the treatment table.
2. T e therapist stabilizes the knee with one hand and grasps the ankle with the other.
3. T e therapist ully extends the knee until an extension barrier is elt.
4. T e patient actively exes the knee using a minimal sustained orce.
5. T e therapist provides an equal resistant counter orce or 3 to 7 seconds, a ter which
the patient completely relaxes.
6. T e therapist again extends the knee until a new extension barrier is elt.
7. T is is repeated 3 to 5 times.
SUMMARY
1. T e PNF techniques may be used to increase both strength and range o motion and are
based on the neurophysiology o the stretch re ex.
2. T e motor neurons o the spinal cord always receive a combination o inhibitory and
excitatory impulses rom the a erent nerves. Whether these motor neurons will be
excited or inhibited depends on the ratio o the 2 types o incoming impulses.
3. T e PNF techniques emphasize specif c principles that may be superimposed on any
o the specif c techniques.
4. T e PNF-strengthening techniques include repeated contraction, slow-reversal, slow-
reversal-hold, rhythmic stabilization, and rhythmic initiation.
5. T e PNF-stretching techniques include contract-relax, hold-relax, and
slow-reversal-hold-relax.
6. T e techniques o PNF are rotational and diagonal movements in the upper extremity,
lower extremity, upper trunk, and the head and neck.
7. Muscle energy techniques involve a voluntary contraction o a muscle in a specif cally
controlled direction at varied levels o intensity against a distinctly executed
counter orce applied by the therapist.
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adults. J Electrom yogr Kinesiol. 2002;12:391-397. stretch in human skeletal muscle in the absence o EMG
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proprioceptive neuromuscular acilitation stretching Williams & Wilkins; 1993.
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2005;40(2):94. in Hem iplegia . Baltimore, MD: Lippincott, Williams &
45. Markos P. Ipsilateral and contralateral e ects o Wilkins; 1992.
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on hip motion and electromyographic activity. Phys T er. sel -stretch incorporating proprioceptive neuromuscular
1979;59(11)P:66-73. acilitation components and a therapist-applied PNF-
46. McAtee R, Charland J. Facilitated Stretching. 3rd ed. technique on hamstring exibility. Physiotherapy.
Champaign, IL: Human Kinetics; 2007. 2004;90(3):151.
47. McHugh MP, Magnusson SP, Gleim GW, Nicholas JA. 62. Sharman M, Cresswell , Andrew G. Proprioceptive
Viscoelastic stress relaxation in human skeletal muscle. neuromuscular acilitation stretching: Mechanisms and
Med Sci Sports Exerc. 1992;24:1375-1382. clinical implications. Sports Med. 2006;36(11):929.
48. Mitchell F. Elements o muscle energy technique. In: 63. Sherrington C. T e Integrative Action o the Nervous
Basmajian J, Nyberg R, eds. Rational Manual T erapies. System . New Haven, C : Yale University Press; 1947.
Baltimore, MD: Lippincott, Williams & Wilkins; 1993. 64. Shrier I. Does stretching help prevent injuries? In:
49. Mitchell U, Myrer J, Hopkins . Acute stretch perception MacAuley D, Best , eds. Evidence Based Sports Medicine.
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50. Osternig L, Robertson R, roxel R, et al. Di erential o maintained hamstring exibility a ter a one-time,
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and muscle energy techniques. J Neurosci Nurs. stretching on hamstring muscle per ormance. J Orthop
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Joint Mobilization and
Traction Techniques in
Rehabilitation
OBJJECT
T IVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Differentiate between physiologic movements and accessory motions.
Discuss joint arthrokinematics.
Discuss how speci c joint positions can enhance the effectiveness of the treatment technique.
Discuss the basic techniques of joint mobilization.
Identify Maitland’s ve oscillation grades.
Discuss indications and contraindications for mobilization.
Discuss the use of various traction grades in treating pain and joint hypomobility.
Explain why traction and mobilization techniques should be used simultaneously.
Demonstrate speci c techniques of mobilization and traction for various joints.
339
340 Chapte r 13 Joint Mobilization and Traction Techniques in Rehabilitation
Following injury to a joint, there will almost always be some associated loss o motion. T at
loss o movement may be attributed to a number o pathologic actors, including contrac-
ture o inert connective tissue (eg, ligaments and joint capsule), resistance o the contractile
tissue or the musculotendinous unit (eg, muscle, tendon, and ascia) to stretch, or some
combination o the two.7,8 I le t untreated, the joint will become hypomobile and will even-
tually begin to show signs o degeneration.30
Joint mobilization and traction are manual therapy techniques that are slow, passive
movements o articulating sur aces.33 T ey are used to regain normal active joint range o
motion, restore normal passive motions that occur about a joint, reposition or realign a
joint, regain a normal distribution o orces and stresses about a joint, or reduce pain—all o
which collectively improve joint unction.25 Joint mobilization and traction are 2 extremely
ef ective and widely used techniques in injury rehabilitation.3
Relationship Between Physiologic

and Accessory Motions
For the therapist supervising a rehabilitation program, some understanding o the biome-
chanics o joint movement is essential. T ere are basically 2 types o movements that govern
motion about a joint. Perhaps the better known o the 2 types o movements are the physi-
ologic m ovem ents that result rom either concentric or eccentric active muscle contractions
that move a bone or a joint. T is type o motion is re erred to as osteokinem atic m otion.
A bone can move about an axis o rotation, or a joint into exion, extension, abduction,
adduction, and rotation. T e second type o motion is accessory m otion. Accessory motions
re er to the manner in which one articulating joint sur ace moves relative to another. Physi-
ologic movement is voluntary, while accessory movements normally accompany physio-
logic movement.2 T e 2 movements occur simultaneously. Although accessory movements
cannot occur independently, they may be produced by some external orce. Normal acces-
sory component motions must occur or ull-range physiologic movement to take place.11 I
any o the accessory component motions are restricted, normal physiologic cardinal plane
movements will not occur.23,24 A muscle cannot be ully rehabilitated i the joint is not ree
to move and vice versa.30
raditionally in rehabilitation programs, we have tended to concentrate more on pas-
sive physiologic movements without paying much attention to accessory motions. T e
question is always being asked, “How much exion or extension is this patient lacking?”
Rarely will anyone ask “How much is rolling or gliding restricted?”
It is critical or the therapist to closely evaluate the injured joint to determine whether
motion is limited by physiologic movement constraints involving musculotendinous units
or by limitation in accessory motion involving the joint capsule and ligaments.15 I physi-
ologic movement is restricted, the patient should engage in stretching activities designed to
improve exibility. Stretching exercises should be used whenever there is resistance o the
contractile or musculotendinous elements to stretch. Stretching techniques are most ef ec-
tive at the end o physiologic range o movement; they are limited to 1 direction; and they
require some element o discom ort i additional range o motion is to be achieved. Stretch-
ing techniques make use o long-lever arms to apply stretch to a given muscle.14 Stretching
techniques are discussed in Chapters 8 and 12.
I accessory m otion is lim ited by som e restriction o the joint capsule or the liga-
m ents, the therapist should incorporate m obilization techn iques into the treatm ent
program. Mobilization techniques should be used whenever there are tight inert or non-
contractile articular structures; they can be used ef ectively at any point in the range
o m otion; and they can be used in an y direction in which m ovem ent is restricted.26
Joint Arthrokinematics 341
Mobilization techniques use a short-lever arm to stretch ligam ents and joint capsules,
placing less stress on these structures, and, consequently, are som ewhat sa er to use
than stretching techniques.5
Clin ica l Pe a r l
Once a patient has progressed through the acute stage, exercises and active and passive
stretching can be accompanied by joint mobilizations. Mobilization of the knee joint
involves gliding the concave tibia anteriorly on the femur.
Joint Arthrokinematics
Accessory motions are also re erred to as joint arthrokinem atics, which include spin, roll,
and glide (Figure 13-1).1,17,19
Spin occurs around some stationary longitudinal mechanical axis and may be in either
a clockwise or counterclockwise direction. An example o spinning is motion o the radial
head at the humeroradial joint as occurs in orearm pronation/ supination (Figure 13-1A).
Rolling occurs when a series o points on one articulating sur ace come in contact with
a series o points on another articulating sur ace. An analogy would be to picture a rocker
o a rocking chair rolling on the at sur ace o the oor. An anatomic example would be the
rounded emoral condyles rolling over a stationary at tibial plateau (Figure 13-1B).
Gliding occurs when a speci c point on one articulating sur ace comes in contact with
a series o points on another sur ace. Returning to the rocking chair analogy, the rocker
slides across the at sur ace o the oor without any rocking at all. Gliding is sometimes
re erred to as translation. Anatomically, gliding or translation would occur during an ante-
rior drawer test at the knee when the at tibial plateau slides anteriorly relative to the xed
rounded emoral condyles (Figure 13-1C).
S pin Roll Glide
A B C
Figure 13-1 Jo int arthro kine matics
A. Spin. B. Roll. C. Glide.

Ex
te
n s io
n Fe mur
s ta tiona ry
S pin
ll
Ro
S lide
e
id
sl
n d
lla io
n
o n s
R te
Tibia x
S pin E
s ta tiona ry
A B
Figure 13-2 Co nve x-co ncave rule
A. Convex moving on concave. B. Concave moving on convex.
Pure gliding can occur only i the 2 articulating sur aces are congruent, where either
both are at or both are curved. Because virtually all articulating joint sur aces are incon-
gruent, meaning that one is usually at while the other is more curved, it is more likely
that gliding will occur simultaneously with a rolling motion. Rolling does not occur alone
because this would result in compression or perhaps dislocation o the joint.
Although rolling and gliding usually occur together, they are not necessarily in similar
proportion, nor are they always in the same direction. I the articulating sur aces are more
congruent, more gliding will occur; whereas i they are less congruent, more rolling will
occur. Rolling will always occur in the same direction as the physiologic movement. For
example, in the knee joint when the oot is xed on the ground, the emur will always roll in
an anterior direction when moving into knee extension and conversely will roll posteriorly
when moving into exion (Figure 13-2).
T e direction o the gliding component o motion is determined by the shape o the
articulating sur ace that is moving. I you consider the shape o 2 articulating sur aces, 1
joint sur ace can be determined to be convex in shape while the other may be considered
to be concave in shape. In the knee, the emoral condyles would be considered the convex
joint sur ace, while the tibial plateau would be the concave joint sur ace. In the glenohu-
meral joint, the humeral head would be the convex sur ace, while the glenoid ossa would
be the concave sur ace.
Clin ica l Pe a r l
Joint mobilization can be used to break down the scar tissue. If plantar exion is limited,
the talus should be glided anteriorly to stretch the anterior capsule. Ankle instability can be
provided with a brace, taping, and exercises to increase stability. Exercises should also target
the muscles responsible for ankle inversion and eversion.
Joint Positions 343
T is relationship between the shape o articulating joint sur aces and the direction o
gliding is de ned by the convex-concave rule. I the concave joint sur ace is moving on a
stationary convex sur ace, gliding will occur in the same direction as the rolling motion.
Conversely, i the convex sur ace is m oving on a stationary concave sur ace, gliding will
occur in an opposite direction to rolling. Hypomobile joints are treated by using a gliding
technique. T us, it is critical to know the appropriate direction to use or gliding.9
Joint Positions
Each joint in the body has a position in which the joint capsule and the ligaments are most
relaxed, allowing or a maximum amount o joint play.4,19 T is position is called the resting
position. It is essential to know speci cally where the resting position is, because testing or
joint play during an evaluation and treatment o the hypomobile joint using either mobili-
zation or traction are usually per ormed in this position. able 13-1 summarizes the appro-
priate resting positions or many o the major joints.
Placing the joint capsule in the resting position allows the joint to assum e a loose-
packed position in which the articulating joint sur aces are maximally separated. A close-
packed position is one in which there is maximal contact o the articulating sur aces o
bones with the capsule and ligam ents tight or tense. In a loose-packed position, the joint
will exhibit the greatest am ount o joint play, while the close-packed position allows or
no joint play. T us, the loose-packed position is m ost appropriate or m obilization and
traction ( Figure 13-3).
Both m obilization and traction techniques use a translational m ovem ent o 1 joint
sur ace relative to the other. T is translation may be either perpendicular or parallel to the
treatm ent plane. T e treatment plane alls perpendicular to, or at a right angle to, a line
running rom the axis o rotation in the convex sur ace to the center o the concave articu-
lar sur ace (Figure 13-4).17,19 T us, the treatment plane lies within the concave sur ace. I
the convex segment moves, the treatment plane remains xed. However, the treatm ent
plane will move along with the concave segment. Mobilization techniques use glides that
translate one articulating sur ace along a line parallel with the treatment plane. raction
techniques translate one o the articulating sur aces in a perpendicular direction to the
treatment plane. Both techniques use a loose-packed joint position.17
A B
Figure 13-3 Jo int capsule re sting po sitio n
A. Loose-packed position. B. Close-packed position.

Table 13-1 Shape , Re sting Po sitio n, and Tre atme nt Plane s o f Vario us Jo ints
Co nve x Co ncave Re sting Po sitio n (Lo o se Clo se -Packe d

Jo int Surface Surface Packe d) Po sitio n Tre atme nt Plane
Sternoclavicular Clavicle* Sternum* Anatomic position Horizontal In sternum
Acromioclavicular Clavicle Acromion Anatomic position, in Adduction In acromion
horizontal plane at 60
degrees to sagittal plane
Glenohumeral Humerus Glenoid Shoulder abducted 55 Abduction and In glenoid fossa in
degrees, horizontally lateral rotation scapular plane
adducted 30 degrees,
rotated so that forearm is in
horizontal plane
Humeroradial Humerus Radius Elbow extended, forearm Flexion and In radial head
supinated forearm perpendicular to
production long axis of radius
Humeroulnar Humerus Ulna Elbow exed 70 degrees, Full extension In olecranon fossa,
forearm supinated 10 and forearm 45 degrees to long
degrees supination axis of ulna
Radioulnar Radius Ulna Elbow exed 70 degrees, Full extension In radial notch of
(proximal) forearm supinated 35 and forearm ulna, parallel to
degrees supination long axis of ulna
Radioulnar (distal) Ulna Radius Supinated 10 degrees Extension In radius, parallel to
long axis of radius
Radiocarpal Proximal Radius Line through radius and Extension In radius,
carpal third metacarpal perpendicular to
bones long axis of radius
Metacarpo- Metacarpal Proximal Slight exion Full exion In proximal phalanx
phalangeal phalanx
Interphalangeal Proximal Distal phalanx Slight exion Extension In proximal phalanx
phalanx
Hip Femur Acetabulum Hip exed 30 degrees, Extension and In acetabulum
abducted 30 degrees, slight medial rotation
external rotation
Tibiofemoral Femur Tibia Flexed 25 degrees Full extension On surface of tibial
plateau
Patellofemoral Patella Femur Knee in full extension Full exion Along femoral
groove
Talocrural Talus Mortise Plantar exed 10 degrees Dorsi exion In the mortise in
anterior/posterior
direction
Subtalar Calcaneus Talus Subtalar neutral between Supination In talus, parallel to
inversion/eversion foot surface
Intertarsal Proximal Distal Foot relaxed Supination In distal segment
articulating articulating
surface surface
Metatarso- Tarsal bone Proximal Slight extension Full exion In proximal phalanx
phalangeal phalanx
Interphalangeal Proximal Distal phalanx Slight exion Extension In distal phalanx
phalanx
* In the sternoclavicular joint, the clavicle surface is convex in a superior/inferior direction and concave in an anterior/posterior
direction.
Joint Mobilization Techniques 345
Glide
e
n
a
Tra ction
l
p
t
n
e
m
t
a
e
90°
r
T
Figure 13-4
The treatment plane is perpendicular to a line drawn from the axis of
rotation to the center of the articulating surface of the concave segment.
Joint Mobilization Techniques

T e techniques o joint mobilization are used to improve joint mobility or to decrease joint
pain by restoring accessory movements to the joint and thus allowing ull, nonrestricted,
pain- ree range o motion.25,34
Mobilization techniques may be used to attain a variety o either mechanical or neu-
rophysiological treatment goals: reducing pain; decreasing muscle guarding; stretching
or lengthening tissue surrounding a joint, in particular capsular and ligamentous tissue;
re exogenic ef ects that either inhibit or acilitate muscle tone or stretch re ex; and pro-
prioceptive ef ects to improve postural and kinesthetic awareness.1,12,18,24,28,30
Movement throughout a range o motion can be quanti ed with various measure-
ment techniques. Physiologic movement is measured with a goniometer and composes the
major portion o the range. Accessory motion is thought o in millimeters, although precise
measurement is di cult.
Accessory m ovem ents may be hypom obile, norm al, or hyperm obile.6 Each joint has
a range-o -m otion continuum with an anatom ical lim it to m otion that is determ ined by
both bony arrangem ent and surrounding so t tissue ( Figure 13-5). In a hypom obile joint,
m otion stops at som e point re erred to as a pathologic point o lim itation, short o the
anatom ical lim it caused by pain, spasm, or tissue resistance. A hyperm obile joint m oves
beyond its anatom ical lim it because o laxity o the surrounding structures. A hypom o-
bile joint should respond well to techniques o m obilization and traction. A hyperm obile
joint should be treated with strengthening exercises, stability exercises, and i indicated,
taping, splinting, or bracing.29,30
In a hypomobile joint, as mobilization techniques are used in the range-o -motion
restriction, some de ormation o so t-tissue capsular or ligamentous structures occurs. I
a tissue is stretched only into its elastic range, no permanent structural changes will occur.
Gra de III
Gra de IV a t
Gra de I Gra de II limit of ra nge Gra de V
PL
BP (P oint of limita tion) AL
(Be ginning (Ana tomica l
point in ra nge limit)
of motion)
Figure 13-5
Maitland’s five grades of motion. AL, anatomical limit; PL, point of limitation.
However, i that tissue is stretched into its plastic range, permanent structural changes will
occur. T us, mobilization and traction can be used to stretch tissue and break adhesions. I
used inappropriately, they can also damage tissue and cause sprains o the joint.30
reatment techniques designed to improve accessory movement are generally slow,
small-amplitude movements, the amplitude being the distance that the joint is moved pas-
sively within its total range. Mobilization techniques use these small-amplitude oscillating
motions that glide or slide one o the articulating joint sur aces in an appropriate direction
within a speci c part o the range.22
Clin ica l Pe a r l
If a patient is restricted in extension, and lateral rotation because of tightness in the anterior
capsule causing the restriction, then the humeral head should be glided anteriorly on the
glenoid to stretch the restriction.
Maitland has described various grades o oscillation or joint mobilization. T e ampli-

tude o each oscillation grade alls within the range-o -motion continuum between some
beginning point and the anatomical limit.23,24 Figure 13-5 shows the various grades o
oscillation that are used in a joint with some limitation o motion. As the severity o the
movement restriction increases, the point o limitation moves to the le t, away rom the
anatomical limit. However, the relationships that exist among the 5 grades in terms o
their positions within the range o motion remain the same. T e 5 mobilization grades are
de ned as ollows:
Grade I. A small-amplitude movement at the beginning o the range o movement.
Used when pain and spasm limit movement early in the range o motion.37
Grade II. A large-amplitude movement within the midrange o movement. Used when
spasm limits movement sooner with a quick oscillation than with a slow one, or
when slowly increasing pain restricts movement hal way into the range.
Grade III. A large-amplitude movement up to the point o limitation in the range o
movement. Used when pain and resistance rom spasm, inert tissue tension, or
tissue compression limit movement near the end o the range.
Grade IV. A small-amplitude movement at the very end o the range o movement.
Used when resistance limits movement in the absence o pain and spasm.
Joint Mobilization Techniques 347
Grade V. A small-amplitude, quick thrust delivered at the end o the range o
movement, usually accompanied by a popping sound, called a manipulation.
Used when minimal resistance limits the end o the range. Manipulation is most
ef ectively accomplished by the velocity o the thrust rather than by the orce o
the thrust.21 Most authorities agree that manipulation should be used only by
individuals trained speci cally in these techniques, because a great deal o skill
and judgment is necessary or sa e and ef ective treatment.31,32
Clin ica l Pe a r l
Most manipulations performed by a chiropractor are grade V. They take the joint to the
end range of motion and then apply a quick, small-amplitude thrust that forces the joint
just beyond the point of limitation. Grade V manipulations should be performed only by
those speci cally trained in this technique. Laws and practice acts relative to the use of
manipulations vary considerably from state to state.
Joint mobilization uses these oscillating gliding motions o one articulating joint
sur ace in whatever direction is appropriate or the existing restriction. T e appropriate
direction or these oscillating glides is determined by the convex-concave rule, described
previously. When the concave sur ace is stationary and the convex sur ace is mobilized, a
glide o the convex segment should be in the direction opposite to the restriction o joint
movement (Figure 13-6A).17,19,35 I the convex articular sur ace is stationary and the concave
sur ace is mobilized, gliding o the concave segment should be in the same direction as the
restriction o joint movement (Figure 13-6B). For example, the glenohumeral joint would
be considered to be a convex joint with the convex humeral head moving on the concave
glenoid. I shoulder abduction is restricted, the humerus should be glided in an in erior
direction relative to the glenoid to alleviate the motion restriction. When mobilizing the
knee joint, the concave tibia should be glided anteriorly in cases where knee extension is
restricted. I mobilization in the appropriate direction exacerbates complaints o pain or
stif ness, the therapist should apply the technique in the opposite direction until the patient
can tolerate the appropriate direction.35
e
e
d
d
i
i
l
l
G
G
R
e
s
tr
ic
ec
tio
S ta tiona ry
f
S ta tiona ry
n
r
J
u
o
s
in
n
t
io
in
t
ct
su
o
J
ri
rf
st
a
e
c
e
R
A B
Figure 13-6 Gliding mo tio ns
A. Glides of the convex segment should be in the direction opposite to the restriction.
B. Glides of the concave segment should be in the direction of the restriction.
ypical mobilization o a joint may involve a series o 3 to 6 sets o oscillations lasting

between 20 and 60 seconds each, with 1 to 3 oscillations per second.23,24
Clin ica l Pe a r l
Traction applied to the spine increases space in between the vertebrae. The increased space
reduces the pressure and compressive forces on the disk.
Indicat ions for Mobilizat ion

In Maitland’s system, grades I and II are used primarily or treatment o pain and grades III
and IV are used or treating stif ness. Pain must be treated rst and stif ness second.24 Pain-
ul conditions should be treated on a daily basis. T e purpose o the small-amplitude oscil-
lations is to stimulate mechanoreceptors within the joint that can limit the transmission o
pain perception at the spinal cord or brainstem levels.
Joints that are stif or hypomobile and have restricted movement should be treated 3 to
4 times per week on alternating days with active motion exercise. T e therapist must con-
tinuously reevaluate the joint to determine appropriate progression rom one oscillation
grade to another.
Indications or speci c mobilization grades are relatively straight orward. I the patient
complains o pain be ore the therapist can apply any resistance to movement, it is too early,
and all mobilization techniques should be avoided. I pain is elicited when resistance to
motion is applied, mobilization, using grades I, II, and III, is appropriate. I resistance can
be applied be ore pain is elicited, mobilization can be progressed to grade IV. Mobilization
should be done with both the patient and the therapist positioned in a com ortable and
relaxed manner. T e therapist should mobilize 1 joint at a time. T e joint should be stabi-
lized as near 1 articulating sur ace as possible, while moving the other segment with a rm,
con dent grasp.
Cont raindicat ions for Mobilizat ion

echniques o mobilization and manipulation should not be used haphazardly. T ese tech-
niques should generally not be used in cases o in ammatory arthritis, malignancy, bone
disease, neurological involvement, bone racture, congenital bone de ormities, and vas-
cular disorders o the vertebral artery. Again, manipulation should be per ormed only by
those therapist speci cally trained in the procedure, because some special knowledge and
judgment are required or ef ective treatment.24
Joint Traction Techniques

raction re ers to a technique involving pulling on 1 articulating segment to produce some
separation o the 2 joint sur aces. Although mobilization glides are done parallel to the
treatment plane, traction is per ormed perpendicular to the treatment plane (Figure 13-7).
Like mobilization techniques, traction may be used either to decrease pain or to reduce
joint hypomobility.38
Kaltenborn has proposed a system using traction combined with mobilization as a
means o reducing pain or mobilizing hypomobile joints.16 As discussed earlier, all joints
have a certain amount o play or looseness. Kaltenborn re erred to this looseness as slack.
Some degree o slack is necessary or normal joint motion. Kaltenborn’s 3 traction grades
are de ned as ollows (Figure 13-8)17:
Joint Traction Techniques 349
e
d
i
l
G
Tra ction Tra ction
e
d
i
l
S ta tiona ry S ta tiona ry
G
Figure 13-7 Tractio n ve rsus g lide s
Traction is perpendicular to the treatment plane, whereas glides are parallel to the treatment
plane.
Grade I traction (loosen). raction that neutralizes pressure in the joint without actual
separation o the joint sur aces. T e purpose is to produce pain relie by reducing
the compressive orces o articular sur aces during mobilization and is used with
all mobilization grades.
Grade II traction (tighten or “take up the slack”). raction that ef ectively separates the
articulating sur aces and takes up the slack or eliminates play in the joint capsule.
Grade II is used in initial treatment to determine joint sensitivity.
Grade III traction (stretch). raction that involves actual stretching o the so t tissue
surrounding the joint to increase m obility in a hypom obile joint.
Grade I traction should be used in the initial treatment to reduce the chance o a pain-
ul reaction. It is recommended that 10-second intermittent grades I and II traction be used,
distracting the joint sur aces up to a grade III traction and then releasing distraction until
the joint returns to its resting position.16
Kaltenborn emphasizes that grade III traction should be used in conjunction with mobi-
lization glides to treat joint hypomobility (see Figure 13-7).17 Grade III traction stretches the
joint capsule and increases the space between the articulating sur aces, placing the joint
Gra de I
Gra de II Gra de III
BP PL AL
(Be ginning (P oint of (Ana tomica l
point in ra nge limita tion) limit)
of motion)
Figure 13-8
Kaltenborn’s grades of traction. AL, anatomical limit; PL, point of limitation.
Figure 13-9 Tractio n and mo bilizatio n sho uld be use d to g e the r
in a loose-packed position. Applying grades III and IV oscillations within the patient’s pain
limitations should maximally improve joint mobility (Figure 13-9).16
Mobilization and Traction Techniques

Figures 13-10 to 13-73 provide descriptions and illustrations o various mobilization and
traction techniques. T ese gures should be used to determine appropriate hand position-
ing, stabilization (S), and the correct direction or gliding (G), traction ( ), and/ or rota-
tion (R). T e in ormation presented in this chapter should be used as a re erence base or
appropriately incorporating joint mobilization and traction techniques into the rehabilita-
tion program.
Mulligan Joint Mobilization Technique

Brian Mulligan, an Australian therapist, proposed a concept o mobilizations based on
Kaltenborn’s principles. Whereas Kaltenborn’s technique relies on passive accessory mobi-
lization, the Mulligan technique combines passive accessory joint mobilization applied by
a therapist with active physiological movement by the patient or the purpose o correcting
positional aults and returning the patient to normal pain- ree unction.27 It is a noninvasive
and com ortable intervention, and has applications or the spine and the extremities. Mul-
ligan’s concept uses what are re erred to as either m obilizations with m ovem ent or treating
the extremities, or sustained natural apophyseal glides or treating problems in the spine.36
Instead o the therapist using oscillations or thrusting techniques, the patient moves in
a speci c direction as the therapist guides the restricted body part. Mobilizations with
Mulligan Joint Mobilization Technique 351
Figure 13-10 Po ste rio r and supe rio r

clavicular g lide s Figure 13-11 Infe rio r clavicular g lide s
When posterior or superior clavicular glides are done at Inferior clavicular glides at the sternoclavicular joint use
the sternoclavicular joint, use the thumbs to glide the the index fingers to mobilize the clavicle, which increases
clavicle. Posterior glides are used to increase clavicular clavicular elevation.
retraction, and superior glides increase clavicular
retraction and clavicular depression.
Figure 13-12 Po ste rio r clavicular g lide s Figure 13-13 Ante rio r/ po ste rio r
g le no hume ral g lide s
Posterior clavicular glides done at the acromioclavicular
(AC) joint apply posterior pressure on the clavicle while Anterior/posterior glenohumeral glides are done with one
stabilizing the scapula with the opposite hand. They hand stabilizing the scapula and the other gliding the
increase mobility of the AC joint. humeral head. They initiate motion in the painful shoulder.
Figure 13-14 Po ste rio r hume ral g lide s Figure 13-15 Ante rio r hume ral g lide s
Posterior humeral glides use 1 hand to stabilize the humerus In anterior humeral glides the patient is prone. One hand
at the elbow and the other to glide the humeral head. They stabilizes the humerus at the elbow and the other glides the
increase flexion and medial rotation. humeral head. They increase extension and lateral rotation.
Figure 13-16 Po ste rio r hume ral g lide s Figure 13-17 Infe rio r hume ral g lide s
Posterior humeral glides may also be done with the For inferior humeral glides, the patient is in the sitting
shoulder at 90 degrees. With the patient in supine position with the elbow resting on the treatment table. One
position, one hand stabilizes the scapula underneath hand stabilizes the scapula and the other glides the humeral
while the patient’s elbow is secured at the therapist’s head inferiorly. These glides increase shoulder abduction.
shoulder. Glides are directed downward through the
humerus. They increase horizontal adduction.
Figure 13-18 Late ral g le no hume ral jo int Figure 13-19 Me dial and late ral ro tatio n
tractio n o scillatio ns
Lateral glenohumeral joint traction is used for initial Medial and lateral rotation oscillations with the shoulder
testing of joint mobility and for decreasing pain. One hand abducted at 90 degrees can increase medial and lateral
stabilizes the elbow while the other applies lateral traction rotation in a progressive manner according to patient
at the upper humerus. tolerance.
Figure 13-20 Ge ne ral scapular g lide s Figure 13-21 Infe rio r hume ro ulnar g lide s
General scapular glides may be done in all directions, Inferior humeroulnar glides increase elbow flexion and
applying pressure at either the medial, inferior, lateral, or extension. They are performed using the body weight to
superior border of the scapula. Scapular glides increase stabilize proximally with the hand grasping the ulna and
general scapulothoracic mobility. gliding inferiorly.
Figure 13-22 Hume ro radial infe rio r g lide s Figure 13-23 Pro ximal ante rio r/ po ste rio r
radial g lide s
Humeroradial inferior glides increase the joint space and
improve flexion and extension. One hand stabilizes the Proximal anterior/posterior radial glides use the thumbs
humerus above the elbow; the other grasps the distal forearm and index ngers to glide the radial head. Anterior glides
and glides the radius inferiorly. increase exion, while posterior glides increase extension.
Figure 13-24 Me dial and late ral ulnar Figure 13-25 Distal ante rio r/ po ste rio r radial
o scillatio ns g lide s
Medial and lateral ulnar oscillations increase flexion and Distal anterior/posterior radial glides are done with one hand
extension. Valgus and varus forces are used with a short- stabilizing the ulna and the other gliding the radius. These
lever arm. glides increase pronation.
Figure 13-26 Radio carpal jo int ante rio r Figure 13-27 Radio carpal jo int po ste rio r g lide s
g lide s
Radiocarpal joint posterior glides increase wrist flexion.
Radiocarpal joint anterior glides increase wrist extension.
Figure 13-28 Radio carpal jo int ulnar g lide s Figure 13-29 Radio carpal jo int radial g lide s
Radiocarpal joint ulnar glides increase radial deviation. Radiocarpal joint radial glides increase ulnar deviation.
Figure 13-30 Carpo me tacarpal jo int ante rio r/ Figure 13-31 Me tacarpo phalang e al jo int
po ste rio r g lide s ante rio r/ po ste rio r g lide s
Carpometacarpal joint anterior/posterior glides increase mobility In metacarpophalangeal joint anterior or posterior
of the hand. glides, the proximal segment, in this case the
metacarpal, is stabilized and the distal segment is
mobilized. Anterior glides increase flexion of the
metacarpophalangeal joint. Posterior glides increase
extension.
Figure 13-32 Ce rvical ve rte brae ro tatio n Figure 13-33 Ce rvical ve rte brae side be nding
o scillatio ns
Cervical vertebrae sidebending may be used to treat paint or
Cervical vertebrae rotation oscillations are done with one stiffness with resistance when sidebending the neck.
hand supporting the weight of the head and the other
rotating the head in the direction of the restriction. These
oscillations treat pain or stiffness when there is some
resistance in the same direction as the rotation.
Figure 13-34 Unilate ral ce rvical face t ante rio r/ Figure 13-35 Tho racic ve rte bral face t
po ste rio r g lide s ro tatio ns
Unilateral cervical facet anterior/posterior glides are done Thoracic vertebral facet rotations are accomplished with one
using pressure from the thumbs over individual facets. They hand underneath the patient providing stabilization and the
increase rotation or flexion of the neck toward the side weight of the body pressing downward through the rib cage
where the technique is used. to rotate an individual thoracic vertebrae. Rotation of the
thoracic vertebrae is minimal, and most of the movement
with this mobilization involves the rib facet joint.
Figure 13-36 Ante rio r/ po ste rio r lumbar Figure 13-37 Lumbar late ral distractio n
ve rte bral g lide s
Lumbar lateral distraction increases the space between
In the lumbar region, anterior/posterior lumbar vertebral transverse processes and increases the opening of the
glides may be accomplished at individual segments using intervertebral foramen. This position is achieved by lying over a
pressure on the spinous process through the pisiform in the support, exing the patient’s upper knee to a point where there
hand. These decrease pain or increase mobility of individual is gapping in the appropriate spinal segment, then rotating the
lumbar vertebrae. upper trunk to place the segment in a close-packed position.
Then nger and forearm pressure are used to separate individual
spaces. This pressure is used for reducing pain in the lumber
vertebrae associated with some compression of a spinal segment.
Figure 13-38 Lumbar ve rte bral ro tatio ns Figure 13-39 Late ral lumbe r ro tatio ns
Lumbar vertebral rotations decrease pain and increase Lateral lumbar rotations may be done with the patient in
mobility in lumbar vertebrae. These rotations should be supine position. In this position, one hand must stabilize the
done in a side-lying position. upper trunk, while the other produces rotation.
Figure 13-40 Ante rio r sacral g lide s Figure 13-41 Supe rio r/ infe rio r sacral g lide s
Anterior sacral glides decrease pain and reduce muscle Superior/inferior sacral glides decrease pain and reduce
guarding around the sacroiliac joint. muscle guarding around the sacroiliac joint.
Figure 13-42 Ante rio r inno minate ro tatio n Figure 13-43 Ante rio r inno minate ro tatio n
An anterior innominate rotation in a side-lying position is An anterior innominate rotation may also be accomplished
accomplished by extending the leg on the affected side then by extending the hip, applying upward force on the upper
stabilizing with one hand on the front of the thigh while the thigh, and stabilizing over the posterosuperior iliac spine.
other applies pressure anteriorly over the posterosuperior This technique is used to correct a posterior unilateral
iliac spine to produce an anterior rotation. This technique innominate rotation.
will correct a unilateral posterior rotation.
Figure 13-44 Po ste rio r inno minate ro tatio n Figure 13-45 Po ste rio r inno minate ro tatio n
A posterior innominate rotation with the patient in side- Another posterior innominate rotation with the hip flexed at
lying position is done by flexing the hip, stabilizing the 90 degrees stabilizes the knee and rotates the innominate
anterosuperior iliac spine, and applying pressure to the anteriorly through upward pressure on the ischium.
ischium in an anterior direction.
Figure 13-46 Po ste rio r inno minate ro tatio n

se lf-mo bilizatio n (supine )
Posterior innominate rotation may be easily accomplished

using self-mobilization. In a supine position, the patient
grasps behind the flexed knee and gently rocks the
Figure 13-47 Po ste rio r ro tatio n se lf-
mo bilizatio n (standing )
innominate in a posterior direction.
In a standing position, the patient can perform a posterior
rotation self-mobilization by pulling on the knee and
rocking forward.
Figure 13-48 Late ral hip tractio n
Because the hip is a very strong, stable joint, it may be

necessary to use body weight to produce effective joint
mobilization or traction. An example of this would be in Figure 13-49 Fe mo ral tractio n
lateral hip traction. One strap should be used to secure the
patient to the treatment table. A second strap is secured Femoral traction with the hip at 0 degrees reduces pain
around the patient’s thigh and around the therapist’s hips. and increases hip mobility. Inferior femoral glides in this
Lateral traction is applied to the femur by leaning back away position should be used to increase flexion and abduction.
from the patient. This technique is used to reduce pain and
increase hip mobility.
Figure 13-50 Infe rio r fe mo ral g lide s Figure 13-51 Po ste rio r fe mo ral g lide s
Inferior femoral glides at 90 degrees of hip flexion may also With the patient supine, a posterior femoral glide can be
be used to increase abduction and flexion. done by stabilizing underneath the pelvis and using the
body weight applied through the femur to glide posteriorly.
Posterior glides are used to increase hip flexion.
Figure 13-52 Ante rio r fe mo ral g lide s Figure 13-53 Me dial fe mo ral ro tatio ns
Anterior femoral glides increase extension and are Medial femoral rotations may be used for increasing
accomplished by using some support to stabilize under the medial rotation and are done by stabilizing the opposite
pelvis and applying an anterior glide posteriorly on the femur. innominate while internally rotating the hip through the
flexed knee.
Figure 13-54 Late ral fe mo ral ro tatio n Figure 13-55 Ante rio r tibial g lide s
Lateral femoral rotation is done by stabilizing a bent knee Anterior tibial glides are appropriate for the patient lacking
in the figure 4 position and applying rotational force to the full extension. Anterior glides should be done in prone
ischium. This technique increases lateral femoral rotation. position with the femur stabilized. Pressure is applied to
the posterior tibia to glide anteriorly.
Figure 13-56 Po ste rio r fe mo ral g lide s Figure 13-57 Po ste rio r tibial g lide s
Posterior femoral glides are appropriate for the patient Posterior tibial glides increase flexion. With the patient
lacking full extension. Posterior femoral glides should be in supine position, stabilize the femur, and glide the tibia
done in supine position with the tibia stabilized. Pressure is posteriorly.
applied to the anterior femur to glide posteriorly.
Figure 13-58 Pate llar g lide s Figure 13-59 Tibio fe mo ral jo int tractio n
Superior patellar glides increase knee extension. Inferior Tibiofemoral joint traction reduces pain and hypomobility.
glides increase knee flexion. Medial glides stretch the lateral It may be done with the patient prone and the knee flexed
retinaculum. Lateral glides stretch tight medial structures. at 90 degrees. The elbow should stabilize the thigh while
traction is applied through the tibia.
Figure 13-60 Alte rnative te chnique s Figure 13-61 Pro ximal ante rio r and po ste rio r
fo r tibio fe mo ral jo int tractio n g lide s o f the bula
In very large individuals, an alternative technique for Anterior and posterior glides of the fibula may be done
tibiofemoral joint traction uses body weight of the proximally. They increase mobility of the fibular head and
therapist to distract the joint once again for reducing reduce pain. The femur should be stabilized. With the knee
pain and hypomobility. slightly flexed, grasp the head of the femur, and glide it
anteriorly and posteriorly.
Figure 13-62 Distal ante rio r and po ste rio r Figure 13-63 Po ste rio r tibial g lide s
bular g lide s
Posterior tibial glides increase plantarflexion. The foot should
Anterior and posterior glides of the fibula may be done be stabilized, and pressure on the anterior tibia produces a
distally. The tibia should be stabilized, and the fibular posterior glide.
malleolus is mobilized in an anterior or posterior direction.
Figure 13-64 Talo crural jo int tractio n Figure 13-65 Ante rio r talar g lide s
Talocrural joint traction is performed using the patient’s Plantarflexion may also be increased by using an anterior
body weight to stabilize the lower leg and applying traction talar glide. With the patient prone, the tibia is stabilized on
to the midtarsal portion of the foot. Traction reduces pain the table and pressure is applied to the posterior aspect
and increases dorsiflexion and plantarflexion. of the talus to glide it anteriorly.
Figure 13-66 Po ste rio r talar g lide s Figure 13-67 Subtalar jo int tractio n
Posterior talar glides may be used for increasing dorsiflexion. Subtalar joint traction reduces pain and increases inversion
With the patient supine, the tibia is stabilized on the table and eversion. The lower leg is stabilized on the table, and
and pressure is applied to the anterior aspect of the talus traction is applied by grasping the posterior aspect of the
to glide it posteriorly. calcaneus.
Figure 13-68 Subtalar jo int me dial and late ral Figure 13-69 Ante rio r/ po ste rio r
g lide s calcane o cubo id g lide s
Subtalar joint medial and lateral glides increase eversion and Anterior/posterior calcaneocuboid glides may be used for
inversion. The talus must be stabilized while the calcaneus increasing adduction and abduction. The calcaneus should
is mobilized medially to increase inversion and laterally to be stabilized while the cuboid is mobilized.
increase eversion.
Figure 13-70 Ante rio r/ po ste rio r cubo id Figure 13-71 Ante rio r/ po ste rio r
me tatarsal g lide s carpo me tacarpal g lide s
Anterior/posterior cuboid metatarsal glides are done with Anterior/posterior carpometacarpal glides decrease
one hand stabilizing the cuboid and the other gliding the hypomobility of the metacarpals.
base of the fifth metatarsal. They are used for increasing
mobility of the fifth metatarsal.
Figure 13-72 Ante rio r/ po ste rio r talo navicular Figure 13-73 Ante rio r/ po ste rio r
g lide s me tacarpo phalang e al g lide s
Anterior/posterior talonavicular glides also increase adduction With anterior/posterior metacarpophalangeal glides,
and abduction. One hand stabilizes the talus while the other the anterior glides increase extension and posterior
mobilizes the navicular bone. glides increase flexion. Mobilizations are accomplished
by isolating individual segments.
movement and sustained natural apophyseal glides have the potential to quickly restore
unctional movements in joints, even a ter many years o restriction.27
Principles of Treat ment

A basic prem ise o the Mulligan techn ique or an therapist choosing to m ake use o
m obilizations with m ovem ent in the extrem ities or sustained natural apophyseal glides
in the spin e is to never cause pain to the patient.10 During assessm ent, the therapist
should look or speci c signs, which may include a loss o joint m ovem ent, pain associ-
ated with m ovem ent, or pain associated with speci c unctional activities.13 A passive
accessory joint m obilization is applied ollowing the principles o Kaltenborn discussed
earlier in this chapter (ie, parallel or perpen dicular to the joint plane). T e therapist
m ust continuously m onitor the patient’s reaction to ensure that no pain is recreated dur-
ing this m obilization. T e therapist experim ents with various com binations o parallel or
perpendicular glides until the appropriate treatm ent plane and grade o m ovem ent are
discovered, which together signi cantly im prove range o m otion and/ or signi cantly
decrease or, better yet, elim inate altogether the original pain. Failure to im prove range
A B
C D
Figure 13-74 Mullig an te chnique s
A. Technique for increasing dorsiflexion. B. Treating elbow lateral epicondylitis. C. Technique for restricted hip abduction.
D. Treating painful knee flexion.
o m otion or decrease pain indicates that the therapist has not ound the correct con-
tact point, treatm ent plane, grade, or direction o m obilization. T e patient then actively
repeats the restricted and/ or pain ul m otion or activity while the therapist continues
to m aintain the appropriate accessory glide. Further increases in range o m otion or
decreases in pain m ay be expected during a treatm ent session that typically involves
3 sets o 10 repetitions. Additional gains may be realized through the application o pain-
ree, passive overpressure at the end o available range.20
An exam ple o m obilization with m ovem ent m ight be in a patient with restricted
ankle dorsi exion ( Figure 13-74A ). T e patient is standing on a treatm ent table with the
therapist m anually stabilizing the oot. A nonelastic belt passes around both the distal
leg o the patient and the waist o the therapist who applies a sustained anterior glide o
the tibia by leaning backward away rom the patient. T e patient then per orm s a slow
dorsi exion m ovem ent until the rst onset o pain or end o range. Once this end point is
reached, the position is sustained or 10 seconds. T e patient then relaxes and returns to
the standing position ollowed by release o the anteroposterior glide, and then ollowed
by a 20-second rest period.27 Figure 13-74B, C, and D shows several additional Mulligan
techniques.
SUMMARY
1. Mobilization and traction techniques increase joint mobility or decrease pain by restor-
ing accessory movements to the joint.
2. Physiologic movements result rom an active muscle contraction that moves an ex-
tremity through traditional cardinal planes.
3. Accessory motions re er to the manner in which one articulating joint sur ace moves
relative to another.
4. Normal accessory component motions must occur or ull-range physiologic move-
ment to take place.
5. Accessory motions are also re erred to as joint arthrokinematics and include spin, roll,
and glide.
6. T e convex-concave rule states that i the concave joint sur ace is moving on the sta-
tionary convex sur ace, gliding will occur in the same direction as the rolling motion.
Conversely, i the convex sur ace is moving on a stationary concave sur ace, gliding will
occur in an opposite direction to rolling.
7. T e resting position is one in which the joint capsule and the ligaments are most re-
laxed, allowing or a maximum amount o joint play.
8. T e treatment plane alls perpendicular to a line running rom the axis o rotation in the
convex sur ace to the center o the concave articular sur ace.
9. Maitland has proposed a series o 5 graded movements or oscillations in the range o
motion to treat pain and stif ness.
10. Kaltenborn uses 3 grades o traction to reduce pain and stif ness.
11. Kaltenborn emphasizes that traction should be used in conjunction with mobilization
glides to treat joint hypomobility.
12. Mulligan’s technique combines passive accessory movement with active physiological
movement to improve range o motion or to minimize pain.
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Regaining Postural
Stability and Balance
Ke v in M . Gu s k ie w icz
OBJJECT
De ne and explain the roles of the 3 sensory modalities responsible for maintaining balance.
Explain how movement strategies along the closed kinetic chain help maintain the center of
gravity in a safe and stable area.
Differentiate between subjective and objective balance assessment.
Differentiate between static and dynamic balance assessment.
Evaluate the effect that injury to the ankle, knee, and head has on balance and postural
equilibrium.
Identify the goals of each phase of balance training, and how to progress the patient through
each phase.
State the differences among static, semidynamic, and dynamic balance-training exercises.
371
372 Chapte r 14 Regaining Postural Stability and Balance
Although maintaining balance while standing may appear to be a rather simple motor skill
or able-bodied athletes, this eat cannot be taken or granted in a patient with musculoskel-
etal dys unction. Muscular weakness, proprioceptive def cits, and range o motion (ROM)
def cits may challenge a person’s ability to maintain their center o gravity (COG) within
the body’s base o support, or, in other words, cause them to lose their balance. Balance is
the single most important element dictating movement strategies within the closed kinetic
chain. Acquisition o e ective strategies or maintaining balance is there ore essential or
athletic per ormance. Although balance is o ten thought o as a static process, it’s actually a
highly integrative dynamic process involving multiple neurologic pathways. Although bal-
ance is the more commonly used term, postural equilibrium is a broader term that involves
the alignment o joint segments in an e ort to maintain the COG within an optimal range o
the maximum limits o stability (LOS).
Despite o ten being classif ed at the end o the continuum o goals associated with
therapeutic exercise,45 maintenance o balance is a vital component in the rehabilitation
o joint injuries that should not be overlooked. raditionally, orthopedic rehabilitation
has placed the emphasis on isolated joint mechanics, such as improving ROM and ex-
ibility, and increasing muscle strength and endurance, rather than on a erent in ormation
obtained by the joint(s) to be processed by the postural control system. However, research
in the area o proprioception and kinesthesia has emphasized the need to train the joint’s
neural system.46-50 Joint position sense, proprioception, and kinesthesia are vital to all ath-
letic per ormance requiring balance. Current rehabilitation protocols should there ore
ocus on a combination o open- and closed-kinetic-chain exercises. T e necessity or a
combination o open- and closed-kinetic-chain exercises can be seen during gait (walk-
ing or running), as the oot and ankle prepare or heel strike (open chain) and prepare to
control the body’s COG during midstance and toe o (closed chain). T is chapter ocuses
on the postural control system, various balance training techniques, and technologic
advancements that are enabling therapists to assess and treat balance def cits in physically
active people.
Postural Control System

T e therapist must f rst have an understanding o the postural control system and its vari-
ous components. T e postural control system utilizes complex processes involving both
sensory and motor components. Maintenance o postural equilibrium includes sensory
detection o body motions, integration o sensorimotor in ormation within the central ner-
vous system (CNS), and execution o appropriate musculoskeletal responses. Most daily
activities, such as walking, climbing stairs, reaching, or throwing a ball, require static oot
placement with controlled balance shi ts, especially i a avorable outcome is to be attained.
So, balance should be considered both a dynamic and static process. T e success ul accom-
plishment o static and dynamic balance is based on the interaction between body and
environment.44 Figure 14-1 shows the complexity o this dynamic process. From a clinical
perspective, separating the sensory and motor processes o balance means that a person
may have impaired balance or 1 or a combination o 2 reasons: (a) the position o the COG
relative to the base o support is not accurately sensed; and (b) the automatic movements
required to bring the COG to a balanced position are not timely or e ectively coordinated.60
T e position o the body in relation to gravity and its surroundings is sensed by combin-
ing visual, vestibular, and somatosensory inputs. Balance movements also involve motions
o the ankle, knee, and hip joints, which are controlled by the coordinated actions along the
kinetic chain (Figure 14-2). T ese processes are all vital or producing uid sport-related
movements.
Postural Control System 373
De te rmina tion of body pos ition Choice of body move me nt
Compa re , s e le ct, a nd combine s e ns e s Select and adjust muscle contractile pattern
Ankle Thigh Trunk Ne ck

Vis ion Ve s tibula r S oma tos e ns ory
mus cle s mus cle s mus cle s mus cle s
Environme nta l inte ra ction Ge ne ra tion of body move me nt
Figure 14-1 Dynamic e quilibrium
(Adapted from Allison L, Fuller K, Hedenberg R, et al. Contemporary Management of Balance De cits.
Clackamas, OR: NeuroCom International; 1994, with permission.)
P os te rior mus cle Ante rior mus cle
Figure 14-2
Paired relationships between major postural musculatures that execute coordinated
actions along the kinetic chain to control the center of gravity.
Control of Balance
T e human body is a very tall structure balanced on a relatively small base, and its COG
is quite high, being just above the pelvis. Many actors enter into the task o controlling
balance within the base o support. Balance control involves a complex network o neural
connections and centers that are related by peripheral and central eedback mechanisms.34
T e postural control system operates as a eedback control circuit between the brain
and the musculoskeletal system. T e sources o a erent in ormation supplied to the postural
control system collectively come rom visual, vestibular, and somatosensory inputs. T e
CNS’s involvement in maintaining upright posture can be divided into 2 components. T e
f rst component, sensory organization, involves those processes that determine the timing,
direction, and amplitude o corrective postural actions based upon in ormation obtained
rom the vestibular, visual, and somatosensory (proprioceptive) inputs.56 Despite the avail-
ability o multiple sensory inputs, the CNS generally relies on only 1 sense at a time or
orientation in ormation. For healthy adults, the pre erred sense or balance control comes
rom somatosensory in ormation (ie, eet in contact with the support sur ace and detection
o joint movement).37,56 In considering orthopedic injuries, the somatosensory system is o
most importance and is the ocus o this chapter.
T e second component, muscle coordination, is the collection o processes that deter-
mine the temporal sequencing and distribution o contractile activity among the muscles o
the legs and trunk which generate supportive reactions or maintaining balance. Research
suggests that balance def ciencies in people with neurologic problems can result rom inap-
propriate interaction among the three sensory inputs that provide orientation in ormation
to the postural control system. A patient may be inappropriately dependent on 1 sense or
situations presenting intersensory con ict.56,70
From a clinical perspective, stabilization o upright posture requires the integration o
a erent in ormation rom the 3 senses, which work in combination and are all critical to
the execution o coordinated postural corrections. Impairment o 1 component is usually
compensated or by the remaining 2 components. O ten, one o the systems provides aulty
or inadequate in ormation such as di erent sur aces and/ or changes in visual acuity and/ or
peripheral vision. In this case, it is crucial that one o the other senses provides accurate and
adequate in ormation so that balance may be maintained. For example, when somatosen-
sory con ict is present such as a moving plat orm or a compliant oam sur ace, balance is
signif cantly decreased with the eyes closed as compared to eyes open.
Somatosensory inputs provide in ormation concerning the orientation o body parts to
one another and to the support sur ace.21,60 Vision measures the orientation o the eyes and
head in relation to surrounding objects, and plays an important role in the maintenance
o balance. On a stable sur ace, closing the eyes should cause only minimal increases in
postural sway in healthy subjects. However, i somatosensory input is disrupted because
o ligamentous injury, closing the eyes will increase sway signif cantly.12,16,37,38,60 T e ves-
tibular apparatus supplies in ormation that measures gravitational, linear, and angular
accelerations o the head in relation to inertial space. It does not, however, provide orienta-
tion in ormation in relation to external objects, and there ore plays only a minor role in the
maintenance o balance when the visual and somatosensory systems are providing accu-
rate in ormation.60
Somatosensation as It Relates to Balance

T e terms som atosensation, proprioception, kinesthesia, and balance are o ten used to
describe similar phenomena. Somatosensation is a more global term used to describe
the proprioceptive mechanisms related to postural control and can accurately be used
Somatosensation as It Relates to Balance 375
synonymously. Consequently, somatosensation is best def ned as a specialized variation
o the sensory modality o touch that encompasses the sensation o joint movement (kines-
thesia) and joint position (joint position sense).46,50 As previously discussed, balance re ers
to the ability to maintain the body’s COG within the base o support provided by the eet.
Somatosensation and balance work closely, as the postural control system utilizes sen-
sory in ormation related to movement and posture rom peripheral sensory receptors (eg,
muscle spindles, Golgi tendon organs, joint a erents, cutaneous receptors). So the question
remains, how does proprioception in uence postural equilibrium and balance?
Somatosensory input is received rom mechanoreceptors; however, it is unclear as to
whether the tactile senses, muscle spindles, or Golgi tendon organs are most responsible
or controlling balance. Nashner55 concluded a ter using electromyography responses ol-
lowing plat orm perturbations, that other pathways had to be involved in the responses they
recorded because the latencies were longer than those normally associated with a classic
myotatic re ex. T e stretch-related re ex is the earliest mechanism or increasing the acti-
vation level o muscles about a joint ollowing an externally imposed rotation o the joint.
Rotation o the ankles is the most probable stimulus o the myotatic re ex that occurs in
many persons. It appears to be the f rst use ul phase o activity in the leg muscles a ter a
change in erect posture.55 T e myotatic re ex can be seen when perturbations o gait or
posture automatically evoke unctionally directed responses in the leg muscles to compen-
sate or imbalance or increased postural sway.14,55 Muscle spindles sense a stretching o
the agonist, thus sending in ormation along its a erent f bers to the spinal cord. T ere the
in ormation is trans erred to alpha and gamma motor neurons that carry in ormation back
to the muscle f bers and muscle spindle, respectively, and contract the muscle to prevent or
control additional postural sway.14
Postural sway was assessed on a plat orm moving into a “toes-up” and “toes-down”
position, and a stretch re ex was ound in the triceps surae a ter a sudden ramp displace-
ment into the “toes-up” position.13 A medium latency response (103 to 118 milliseconds)
was observed in the stretched muscle, ollowed by a delayed response o the antagonistic
anterior tibialis muscle (108 to 124 milliseconds). T e investigators also blocked a erent
proprioceptive in ormation in an attempt to study the role o proprioceptive in ormation
rom the legs or the maintenance o upright posture. T ese results suggested that proprio-
ceptive in ormation rom pressure and/ or joint receptors o the oot (ischemia applied at
ankle) plays an important role in postural stabilization during low requencies o move-
ment, but is o minor importance or the compensation o rapid displacements. T e experi-
ment also included a “visual” component, as subjects were tested with eyes closed, ollowed
by eyes open. Results suggested that when subjects were tested with eyes open, visual in or-
mation compensated or the loss o proprioceptive input.
Another study14 used compensatory electromyography responses during impulsive dis-
turbance o the limbs during stance on a treadmill to describe the myotatic re ex. Results
revealed that during backward movement o the treadmill, ankle dorsi exion caused the
COG to be shi ted anteriorly, thus evoking a stretch re ex in the gastrocnemius muscle,
ollowed by weak anterior tibialis activation. In another trial, the movement was reversed
(plantar exion), thus shi ting the COG posteriorly and evoking a stretch re ex o the ante-
rior tibialis muscle. Both o these studies suggest that stretch re ex responses help to con-
trol the body’s COG, and that the vestibular system is unlikely to be directly involved in the
generation o the necessary responses.
Elimination o all sensory in ormation rom the eet and ankles revealed that proprio-
ceptors in the leg muscles (gastrocnemius and tibialis anterior) were capable o providing
su cient sensory in ormation or stable standing.20 Researchers speculated that group I or
group II muscle spindle a erents, and group Ib a erents rom Golgi tendon organs were the
probable sources o this proprioceptive in ormation. T e study demonstrated that normal
subjects can stand in a stable manner when receptors in the leg muscles are the only source
o in ormation about postural sway.
Other studies5,38 have examined the role o somatosensory in ormation by altering or

limiting somatosensory input through the use o plat orm sway re erencing or oam plat-
orms. T ese studies reported that subjects still responded with well-coordinated move-
ments but the movements were o ten either ine ective or ine cient or the environmental
context in which they were used.
Balance as It Relates to
the Closed Kinetic Chain
Balance is the process o maintaining the COG within the body’s base o support. Again,
the human body is a very tall structure balanced on a relatively small base, and its COG is
quite high, being just above the pelvis. Many actors enter into the task o controlling bal-
ance within this designated area. One component o ten overlooked is the role balance plays
within the kinetic chain. Ongoing debates as to how the kinetic chain should be def ned
and whether open- or closed-kinetic-chain exercises are best have caused many therapists
to lose sight o what is most important. An understanding o the postural control system as
well as the theory o the kinetic (segmental) chain about the lower extremity helps concep-
tualize the role o the chain in maintaining balance. Within the kinetic chain, each moving
segment transmits orces to every other segment along the chain, and its motions are in u-
enced by orces transmitted rom other segments (see Chapter 11).10 T e act o maintaining
equilibrium or balance is associated with the closed kinetic chain, as the distal segment
( oot) is f xed beneath the base o support.
T e coordination o automatic postural movements during the act o balancing is not
determined solely by the muscles acting directly about the joint. Leg and trunk muscles
exert indirect orces on neighboring joints through the inertial interaction orces among
body segments.57,58 A combination o one or more strategies (ankle, knee, hip) are used to
coordinate movement o the COG back to a stable or balanced position when a person’s
balance is disrupted by an external perturbation. Injury to any one o the joints or corre-
sponding muscles along the kinetic chain can result in a loss o appropriate eedback or
maintaining balance.
Balance Disruption
Let’s say, or example, that a basketball player goes up or a rebound and collides with
another player, causing her to land in an unexpected position, thereby compromising her
normal balance. o prevent a all rom occurring, the body must correct itsel by returning
the COG to a position within sa er LOS. A erent mechanoreceptor input rom the hip, knee,
and ankle joints is responsible or initiating automatic postural responses through the use
o 1 o 3 possible movement strategies.
Select ion of Movement St rat egies

T ree principle joint systems (ankles, knees, and hips) are located between the base o sup-
port and the COG. T is allows or a wide variety o postures that can be assumed, while the
COG is still positioned above the base o support. As described by Nashner,60 motions about
a given joint are controlled by the combined actions o at least 1 pair o muscles working
in opposition. When orces exerted by pairs o opposing muscle about a joint (eg, anterior
tibialis and gastrocnemius/ soleus) are combined, the e ect is to resist rotation o the joint
Balance Disruption 377
relative to a resting position. T e degree to which the joint resists rotation is called joint
stif ness. T e resting position and the sti ness o the joint are each altered independently by
changing the activation levels o 1 or both muscle groups.39,60 Joint resting position and joint
sti ness are by themselves an inadequate basis or controlling postural movements, and it
is theorized that the myotatic stretch re ex is the earliest mechanism or increasing the acti-
vation level o the muscles o a joint ollowing an externally imposed rotation o the joint.60
When a person’s balance is disrupted by an external perturbation, movement strategies
involving joints o the lower extremity coordinate movement o the COG back to a balanced
position. T ree strategies (ankle, hip, stepping) have been identif ed along a continuum.37
In general, the relative e ectiveness o ankle, hip, and stepping strategies in repositioning
the COG over the base o support depends on the conf guration o the base o support, the
COG alignment in relation to the LOS, and the speed o the postural movement.37,38
T e ankle strategy shi ts the COG while maintaining the placement o the eet by rotat-
ing the body as a rigid mass about the ankle joints. T is is achieved by contracting either
the gastrocnemius or anterior tibialis muscles to generate torque about the ankle joints.
Anterior sway o the body is counteracted by gastrocnemius activity, which pulls the body
posteriorly. Conversely, posterior sway o the body is counteracted by contraction o the
tibialis anterior. T us, the importance o these muscles should not be underestimated when
designing the rehabilitation program. T e ankle strategy is most e ective in executing rela-
tively slow COG movements when the base o support is f rm and the COG is well within
the LOS perimeter. T e ankle strategy is also believed to be e ective in maintaining a static
posture with the COG o set rom the center. T e thigh and lower trunk muscles contract,
thereby resisting the destabilization o these proximal joints as a result o the indirect e ects
o the ankle muscles on the proximal joints ( able 14-1).
Under normal sensory conditions, activation o ankle musculature is almost exclusively
selected to maintain equilibrium. However, there are subtle di erences associated with loss
o somatosensation and with vestibular dys unction in terms o postural control strategies.
Persons with somatosensory loss appear to rely on their hip musculature to retain their
COG while experiencing orward or backward perturbation or with di erent support sur-
ace lengths.21
Table 14-1 Functio n and Anato my o f Muscle s Invo lve d in Balance Mo ve me nts
Exte nsio n Fle xio n
Jo int Anato mic Functio n Anato mic Functio n
Hip Paraspinals Paraspinals Abdominal Abdominals

Hamstrings Hamstrings Quadriceps Quadriceps
Tibialis Gastrocnemius
Knee Quadriceps Paraspinals Hamstrings Abdominals

Quadriceps Gastrocnemius Hamstrings
Gastrocnemius Tibialis
Ankle Gastrocnemius Abdominals Tibialis Paraspinals

Quadriceps Hamstrings
Gastrocnemius Tibialis
Source: Adapted from Nashner LM. Physiology of balance. In: Jacobson G, Newman C, Kartush J, eds. Hand-
book of Balance Function and Testing . St. Louis, MO: Mosby; 1993:261-279.
I the ankle strategy is not capable o controlling excessive sway, the hip strategy is avail-
able to help control motion o the COG through the initiation o large and rapid motions at
the hip joints with antiphase rotation o the ankles. It is most e ective when the COG is
located near the LOS perimeter, and when the LOS boundaries are contracted by a nar-
rowed base o support. Finally, when the COG is displaced beyond the LOS, a step or stum-
ble (stepping strategy) is the only strategy which can be used to prevent a all.58,60
It is proposed that LOS and COG alignment are altered in individuals exhibiting a mus-
culoskeletal abnormality such as an ankle or knee sprain. For example, weakness o liga-
ments ollowing acute or chronic sprain about these joints is likely to reduce ROM, thereby
shrinking the LOS and placing the person at greater risk or a all with a relatively smaller
sway envelope.58 Pintsaar et al67 revealed that impaired unction was related to a change rom
ankle synergy toward hip synergy or postural adjustments among patients with unctional
ankle instability. T is f nding, which was consistent with previous results reported by ropp
et al, suggests that sensory proprioceptive unction or the injured patients was a ected.
Assessment of Balance
Several methods o balance assessment have been proposed or clinical use. Many o the
techniques have been criticized or o ering only subjective (“qualitative”) measurement
in ormation regarding balance rather than an objective (“quantitative”) measure.63
Subject ive Assessment

Prior to the mid 1980s, there were very ew methods or systematic and controlled assess-
ment o balance. T e assessment o static balance in athletes has traditionally been per-
ormed through the use o the standing Romberg test. T is test is per ormed standing with
eet together, arms at the side, and eyes closed. Normally a person can stand motionless in
this position, but the tendency to sway or all to one side is considered a positive Romberg
sign, indicating a loss o proprioception.8 T e Romberg test has, however, been criticized or
its lack o sensitivity and objectivity. It is considered to be a rather qualitative assessment o
static balance because a considerable amount o stress is required to make the subject sway
enough or an observer to characterize the sway.42
T e use o a quantif able clinical test battery called the Balance Error Scoring System
(BESS) is recommended over the standard Romberg test.32 T ree di erent stances (double,
single, and tandem) are completed twice, once while on a f rm sur ace and once while on
a piece o medium density oam (balance pad by Airex is recommended) or a total o 6 tri-
als (Figure 14-3). Patients are asked to assume the required stance by placing their hands
on the iliac crests, and upon eye closure, the 20-second test begins. During the single-leg
stances, subjects are asked to maintain the contralateral limb in 20 to 30 degrees o hip ex-
ion and 40 to 50 degrees o knee exion. Additionally, the patient is asked to stand quietly
and as motionless as possible in the stance position, keeping their hands on the iliac crests
and eyes closed. T e single-limb stance tests are per ormed on the nondominant oot. T is
same oot is placed toward the rear on the tandem stances. Subjects are told that upon los-
ing their balance, they are to make any necessary adjustments and return to the testing
position as quickly as possible. Per ormance is scored by adding 1 error point or each error
listed in able 14-2. rials are considered to be incomplete i the patient is unable to sustain
the stance position or longer than 5 seconds during the entire 20-second testing period.
T ese trials are assigned a standard maximum error score o 10. Balance test results during
injury recovery are best used when compared to baseline measurements, and clinicians
working with athletes or patients on a regular basis should attempt to obtain baseline mea-
surements when possible.
Assessment of Balance 379
A B C
D E F
Figure 14-3 Stance po sitio ns fo r Balance Erro r Sco ring Syste m (BESS)
A. Double-leg, firm surface. B. Single-leg, firm surface. C. Tandem, firm surface.

D. Double-leg, foam surface. E. Single-leg, foam surface. F. Tandem, foam surface.
Clin ica l Pe a r l
A preseason baseline score can be obtained on a measure such as the BESS for all athletes,
and then used for a postinjury comparison. Because there is such variability within many of
the balance measures, it is important to make comparisons only to an athlete’s individual
baseline measure and not to a normal score. It is best to determine recovery on a measure
by using the number of standard deviations away from the baseline. For example, scores on
the BESS that are more than 2 standard deviations or 6 total points would be considered
abnormal. Repeated assessments over the course of a rehabilitation progression can be
used to determine the effectiveness of the balance exercises.
Table 14-2 Balance Erro r Sco ring Syste m (BESS) Table 14-3 Hig h-Te chno lo g y Balance
Asse ssme nt Syste ms
Erro rs
Static Syste ms Dynamic Syste ms
Hands lifted off iliac crests
Opening eyes Chattecx Balance System Biodex Stability System
Step, stumble, or fall EquiTest Chattecx Balance System
Moving hip into more than 30 degrees of exion Forceplate EquiTest
or abduction Pro Balance Master EquiTest with EMG
Lifting forefoot or heel Smart Balance Master Forceplate
Remaining out of testing position for more than Kinesthetic Ability Trainer
5 seconds Pro Balance Master
The BESS score is calculated by adding 1 error point for Smart Balance Master
each error or any combination of errors occurring during
1 movement. Error scores from each of the 6 trials are
added for a total BESS score, and higher scores represent
poor balance.
Semidynamic and dynamic balance assessment can be per ormed through unctional-
reach tests; timed agility tests, such as the f gure 8 test,15,19 carioca, or hop test 40; Bass est
or Dynamic Balance; timed “ -Band kicks”; and timed balance beam walking with the eyes
open or closed. T e objective in most o these tests is to decrease the size o the base o sup-
port, in an attempt to determine a patient’s ability to control upright posture while moving.
Many o these tests have been criticized or ailing to quanti y balance adequately, as they
merely report the time that a particular posture is maintained, angular displacement, or the
distance covered a ter walking.6,21,46,60 At any rate, they can o ten provide the therapist with
valuable in ormation about a patient’s unction and/ or return to play capability.
Object ive Assessment

Advancements in technology have provided the medical community with commercially
available balance systems ( able 14-3) or quantitatively assessing and training static and
dynamic balance. T ese systems provide an easy, practical, and cost-e ective method o
quantitatively assessing and training unctional balance through analysis o postural sta-
bility. T us, the potential exists to assess injured patients and (a) identi y possible abnor-
malities that might be associated with injury; (b) isolate various systems that are a ected;
(c) develop recovery curves based on quantitative measures or determining readiness to
return to activity; and (d) train the injured patient.
Most manu acturers use computer-inter aced orceplate technology consisting o a
at, rigid sur ace supported on 3 or more points by independent orce-measuring devices.
As the patient stands on the orceplate sur ace, the position o the center o vertical orces
exerted on the orceplate over time is calculated (Figure 14-4). T e center o vertical orce
movements provide an indirect measure o postural sway activity.59 T e Kistler and, more
recently, Bertec orceplates, are used or much o the work in the area o postural stability
and balance.6,17,27,52,54 NeuroCom International, Inc. (Clackamas, OR) has also developed
systems with expanded diagnostic and training capabilities that make interpretation o
results easier or therapists. T erapists must be aware that the manu acturers o ten use con-
icting terminology to describe various balance parameters, and should consult requently
with the manu acturer to ensure that there is a clear understanding o the measure being
taken. T ese inconsistencies have created con usion in the literature, because what some
Figure 14-4 Patie nt training o n the Balance Figure 14-5 Equite st

Maste r
(Courtesy NeuroCom.)
manu acturers classi y as dynamic balance, others claim as really static balance. Our clas-
sif cation system (see “Balance raining” below) will hope ully clear up some o the con u-
sion and allow or a more consistent labeling o the numerous balance-related exercises.
Force plat orms ideally evaluate 4 aspects o postural control: steadiness, symmetry,
and dynamic stability. Steadiness is the ability to keep the body as motionless as possi-
ble. T is is a measure o postural sway. Symmetry is the ability to distribute weight evenly
between the 2 eet in an upright stance. T is is a measure o center o pressure (COP), center
o balance (COB), or center o orce (COF), depending which testing system you are using.
Although inconsistent with our classif cation system, dynamic stability is o ten labeled as
the ability to trans er the vertical projection o the COG around a stationary supporting
base.27 T is is o ten re erred to as a measure o one’s perception o their “sa e” LOS, as one’s
goal is to lean or reach as ar as possible without losing one’s balance. Some manu acturers
measure dynamic stability by assessing a person’s postural response to external perturba-
tions rom a moving plat orm in 1 o 4 directions: tilting toes up, tilting toes down, shi ting
medial-lateral, and shi ting anterior-posterior. Plat orm perturbation on some systems is
unpredictable and determined by the positioning and sway movement o the subject. In
such cases, a person’s reaction response can be determined (Figure 14-5). Other systems
have a more predictable sinusoidal wave orm that remains constant regardless o subject
positioning.
Many o these orce plat orm system s measure the vertical ground reaction orce and
provide a means o com puting the COP. T e COP represents the center o the distribu-
tion o the total orce applied to the supporting sur ace. T e COP is calculated rom hori-
zontal m om ent and vertical orce data generated by triaxial orce plat orm s. T e center
o vertical orce, on NeuroCom’s Equi est, is the center o the vertical orce exerted by
the eet against the support sur ace. In any case (COP, COB, COF), the total orce applied
Figure 14-6 Balance Maste r w ith 5-fo o t fo rce plate acce sso ry
to the orce plat orm uctuates because it includes both body weight and the inertial
e ects o the slightest m ovem ent o the body which occur even when one attem pts to
stand m otionless. T e m ovem ent o these orce-based re erence points is theorized to
vary according to the m ovement o the body’s COG and the distribution o muscle orces
required to control posture. Ideally, healthy athletes should maintain their COP very near
the anterior-posterior and medial-lateral m idlines.
Once the COP or COF is calculated, several other balance parameters can be attained.
Deviation rom this point in any direction represents a person’s postural sway. Postural sway
can be measured in various ways, depending on which system is being used. Mean displace-
ment, length o sway path, length o sway area, amplitude, requency, and direction with
respect to the COP can be calculated on most systems. An equilibrium score, comparing the
angular di erence between the calculated maximum anterior to posterior COG displacements
to a theoretical maximum displacement, is unique to NeuroCom International’s Equi est.
Forceplate technology allows or quantitative analysis and understanding o a subject’s
postural instability. T ese systems are ully integrated with hardware/ so tware systems or
quickly and quantitatively assessing and rehabilitating balance disorders. Most manu ac-
turers allow or both static and dynamic balance assessment in either double or single leg
stances, with eyes open or eyes closed. NeuroCom’s Equi est System is equipped with a
moving visual surround (wall) that allows or the most sophisticated technology available
or isolating and assessing sensory modality interaction.
Long orceplates have been developed by some manu acturers in an attempt to com-
bat criticism that balance assessment is not unctional. Inclusion o the long orceplate
(Figure 14-6) adds a vast array o dynamic balance exercises or training, such as walking,
step-up-and-over, side and crossover steps, hopping, leaping, and lunging. T ese important
return-to-sport activities can be practiced and per ected through the use o the computer’s
visual eedback.
Figure 14-7 Bio de x Stability Syste m Figure 14-8 PROPRIO® Re active Balance Syste m
(Courtesy Perry Dynamics.)
Biodex Medical Systems (Shirley, NY) manu actures a dynamic multiaxial tilting plat-
orm that o ers computer-generated data similar to that o a orceplate system. T e Bio-
dex Stability System (Figure 14-7) uses a dynamic multiaxial plat orm that allows up to 20
degrees o de ection in any direction. It is theorized that this degree o de ection is su -
f cient to stress joint mechanoreceptors that provide proprioceptive eedback (at end
ranges o motion) necessary or balance control. T erapists can assess def cits in dynamic
muscular control o posture relative to joint pathology. T e patient’s ability to control the
plat orm’s angle o tilt is quantif ed as a variance rom center, as well as degrees o de-
ection over time, at various stability levels. A large variance is indicative o poor muscle
response. Exercises per ormed on a multiaxial unstable system such as the Biodex are
similar to those o the Biomechanical Ankle Plat orm System (BAPS board) and are espe-
cially e ective or regaining proprioception and balance ollowing injury to the ankle joint.
®
A newer system, the PROPRIO Reactive Balance System measures the patient’s cen-
ter o mass movement on a computerized, programmable, multidirectional, multispeed
plat orm or both reactive and anticipatory training to assess, rehabilitate, and train bal-
ance and proprioception (Figure 14-8). Instead o assessing lower-leg postural responses
on a orceplate, this system measures trunk movements by placing a sensor on the lumbo-
®
sacral joint, L5-S1. Using ultrasonic technology, the PROPRIO Reactive Balance System
quantif es trunk movement in 6 degrees o reedom—lateral, up/ down, anterior/ posterior,
rotation, exion/ extension, and lateral exion—and displays real-time eedback during
training. T e plat orm can generate perturbations to provide variable sur ace movement
requiring the patient to maintain the patient’s center o mass over the body’s support area
during movement and changing sensory environments.
Injury and Balance

It has long been theorized that ailure o stretched or damaged ligaments to provide adequate
neural eedback in an injured extremity may contribute to decreased proprioceptive mecha-
nisms necessary or maintenance o proper balance. Research has revealed these impair-
ments in individuals with ankle injury23,31,69 and anterior cruciate ligament (ACL) injury.4,65
T e lack o proprioceptive eedback resulting rom such injuries may allow excessive or inap-
propriate loading o a joint. Furthermore, although the presence o a capsular lesion may
inter ere with the transmission o a erent impulses rom the joint, a more important e ect
may be alteration o the a erent neural code that is conveyed to the CNS. Decreased re ex
excitation o motor neurons may result rom either or both o the ollowing events: (a) a
decrease in proprioceptive input to the CNS; and (b) an increase in the activation o inhibi-
tory interneurons within the spinal cord. All o these actors may lead to progressive degen-
eration o the joint and continued def cits in joint dynamics, balance, and coordination.
Ankle Injuries
Joint proprioceptors are believed to be damaged during injury to the lateral ligaments o
the ankle because joint receptor f bers possess less tensile strength than the ligament f bers.
Damage to the joint receptors is believed to cause joint dea erentation, thereby diminish-
ing the supply o messages rom the injured joint up the a erent pathway and disrupting
proprioceptive unction.24 Freeman et al24 were the f rst to report a decrease in the re-
quency o unctional instability ollowing ankle sprains when coordination exercises were
per ormed as part o rehabilitation. T us the term articular deaf erentation was introduced
to designate the mechanism that they believed to be the cause o unctional instability o the
ankle. T is f nding led to the inclusion o balance training in ankle rehabilitation programs.
Since 1955, Freeman 23 has theorized that i ankle injuries cause partial dea erentation
and unctional instability, a person’s postural sway would be altered because o a proprio-
ception def cit. Although some studies74 have not supported Freeman’s theory, other more
recent studies using high-tech equipment ( orceplate, kinesthesiometer, etc) have revealed
balance def cits in ankles ollowing acute sprains25,31,66 and/ or in ankles with chronic
instabilities.9,22,26,67
Di erences were identif ed between injured and uninjured ankles in 14 ankle-injured
subjects using a computerized strain-gauge orceplate.25 Four o 5 possible postural sway
parameters (standard deviation o the mean COP dispersion, mean sway amplitude, aver-
age speed, and number o sway amplitudes exceeding 5 and 10 mm) taken in the rontal
plane rom a single-leg stance position were reported to discriminate between injured and
noninjured ankles. T e authors reported that the application o an ankle brace eliminated
the di erences between injury status when tested on each parameter, there ore improv-
ing balance per ormance. More importantly, this study suggests that the stabilometry tech-
nique o selectively analyzing postural sway movements in the rontal plane, where the
diameter o the supporting area is smallest, leads to higher sensitivity. Because di culties
o maintaining balance a ter a ligament lesion involve the subtalar axis, it is proposed that
increased sway movements o the di erent body segments would be ound primarily in the
rontal plane. T e authors speculated that this could explain nonsignif cant f ndings o ear-
lier stabilometry studies74 involving injured ankles.
Orthotic intervention and postural sway were studied in 13 subjects with acute inver-
sion ankle sprains and 12 uninjured subjects under 2 treatment conditions (orthotic,
Injury and Balance 385
nonorthotic) and 4 plat orm movements (stable, inversion/ eversion, plantar exion/ dor-
si exion, medial/ lateral perturbations).31 Results revealed that ankle-injured subjects
swayed more than uninjured subjects when assessed in a single-leg test. T e analysis also
revealed that custom-f t orthotics may restrict undesirable motion at the oot and ankle,
and enhance joint mechanoreceptors to detect perturbations and provide structural sup-
port or detecting and controlling postural sway in ankle-injured subjects. A similar study66
reported improvements in static balance or injured subjects while wearing custom-made
orthotics.
Studies involving subjects with chronic ankle instabilities9,22,26,67 indicate that indi-
viduals with a history o inversion ankle sprain are less stable in single-limb stance on the
involved leg as compared to the uninvolved leg and/ or noninjured subjects. Signif cant
di erences between injured and uninjured subjects or sway amplitude but not sway re-
quency using a standard orceplate were revealed.9 T e e ect o stance perturbation on ron-
tal plane postural control was tested in 3 groups o subjects: (a) control (no previous ankle
injury); (b) unctional ankle instability and 8-week training program ; and (c) mechanical
instability without unctional instability (without shoe, with shoe, with brace and shoe).67
T e authors reported a relative change rom ankle to hip synergy at medially directed trans-
lations o the support sur ace on the NeuroCom Equi est. T e impairment was restored
a ter 8 weeks o ankle disk training. T e e ect o a shoe and brace did not exceed the e ect
o the shoe alone. Impaired ankle unction was shown to be related to coordination, as sub-
jects changed rom ankle toward hip strategies or postural adjustments.
Similarly, researchers36 reported that lateral ankle joint anesthesia did not alter postural
sway or passive joint position sense, but did a ect the COB position (similar to COP) during
both static and dynamic testing. T is suggests the presence o an adaptive mechanism to com-
pensate or the loss o a erent stimuli rom the region o the lateral ankle ligaments.36 Subjects
tended to shi t their COB medially during dynamic balance testing and slightly laterally dur-
ing static balance testing. T e authors speculated that COB shi ting may provide additional
proprioceptive input rom cutaneous receptors in the sole o the oot or stretch receptors in
the peroneal muscle tendon unit, which there ore prevents increased postural sway.
Increased postural sway requency and latencies are parameters thought to be indica-
tive o impaired ankle joint proprioception.13,69 Cornwall et al9 and Pintsaar et al,67 however,
ound no di erences between chronically injured subjects and control subjects on these
measures. T is raises the question as to whether postural sway was in act caused by a pro-
prioceptive def cit. Increased postural sway amplitudes in the absence o sway requencies
might suggest that chronically injured subjects recover their ankle joint proprioception over
time. T us, more research is warranted or investigating loss o joint proprioception and
postural sway requency.9
In summary, results o studies involving both chronic and acute ankle sprains suggest
that increased postural sway and/ or balance instability may not be caused by a single ac-
tor but by disruption o both neurologic and biomechanical actors at the ankle joint. Loss
o balance may result rom abnormal or altered biomechanical alignment o the body, thus
a ecting the transmission o somatosensory in ormation rom the ankle joint. It is possi-
ble that observed postural sway amplitudes ollowing injury are a result o joint instability
along the kinetic chain, rather than dea erentation. T us, the orthotic intervention 31,61,62
may have provided more optimal joint alignment.
Knee Injuries
Ligamentous injury to the knee has proven to a ect the ability o subjects to accurately
detect position.2,3,4,46,49,50 T e general consensus among numerous investigators per orming
proprioceptive testing is that a clinical proprioception def cit occurs in most patients a ter
an ACL rupture who have unctional instability and that this def cit seems to persist to some
degree a ter an ACL reconstruction.2 Because o the relationships between proprioception

(somatosensation) and balance, it has been suggested that the patient’s ability to balance
on the ACL-injured leg may also be decreased.4,65
Studies have evaluated the e ects o ACL ruptures on standing balance using orceplate
technology, and while some studies have revealed balance def cits,25,53 others have not.18,35
T us, there appear to be con icting results rom these studies depending on which param-
eters are measured. Mizuta et al53 ound signif cant di erences in postural sway when
measuring COP and sway distance area between 11 unctionally stable and 15 unctionally
unstable subjects who had unilateral ACL-def cient knees. Faculjak et al,18 however, ound
no di erences in postural stability between 8 ACL-def cient subjects and 10 normal sub-
jects when measuring average latency and response strength on an Equi est System.
Several potential reasons or this discrepancy exist. First, it has been suggested that
there might be a link between static balance and isometric strength o the musculature at
the ankle and knee. Isometric muscle strength could there ore compensate or any somato-
sensory def cit present in the involved knee during a closed-chain static balance test. Sec-
ond, many studies ail to discriminate between unctionally unstable ACL-def cient knees
and knees that were not unctionally unstable. T is presents a design aw, especially con-
sidering that unctionally stable knees would most likely provide adequate balance despite
ligamentous pathology. Another suggested reason or not seeing di erences between
injured knees and uninjured knees on static balance measures could be explained by the
role that joint mechanoreceptors play. Neurophysiologic studies28,29,43,46 reveal that joint
mechanoreceptors provide enhanced kinesthetic awareness in the near-terminal ROM or
extremes o motion. T ere ore, it could be speculated that i the maximum LOS are never
reached during a static balance test, damaged mechanoreceptors (muscle or joint) may not
even become a actor. Dynamic balance tests or unctional hop tests that involve dynamic
balance could challenge the postural control system (ankle strategies are taken over by hip
and/ or stepping strategies), requiring more mechanoreceptor input. T ese tests would most
likely discriminate between unctionally unstable ACL-def cient knees and normal knees.
Clin ica l Pe a r l
The therapist should ensure that the patient has the necessary pain-free ROM and muscular
strength to complete the tasks that are being incorporated into the program. Additionally,
for exercises beyond the phase I static exercises, the patient must be beyond the acute
in ammatory phase of tissue response to injury. Once these factors have been considered,
the therapist should focus on developing a protocol that is safe yet challenging, stresses
multiple planes of motion, and incorporates a multisensory approach.
Head Injury
Neurologic status ollowing mild head injury has been assessed using balance as a criterion
variable. T erapists and team physicians have long evaluated head injuries with the Romberg
tests o sensory modality unction to test “balance.” T is is an easy and e ective sideline test;
however, the literature suggests there is more to posture control than just balance and sensory
modality,55,56,61,64,72 especially when assessing people with head injury.30,33 T e postural con-
trol system, which is responsible or linking brain to body communication, is o ten a ected as
a result o mild head injury. Several studies have identif ed postural stability def cits in patients
up to 3 days postinjury by using commercially available balance systems.30,33 It appears this
def cit is related to a sensory interaction problem, whereby the injured patient ails to use their
visual system e ectively. T is research suggests that objective balance assessment can be used
or establishing recovery curves or making return to play decisions in concussed patients.
Rehabilitation o concussed patients using balance techniques has yet to be studied.
Balance Training 387
Balance Training
Developing a rehabilitation program that includes exercises or improving balance and pos-
tural equilibrium is vital or a success ul return to competition rom a lower- extremity injury.
Regardless o whether the patient has sustained a quadriceps strain or an ankle sprain, the
injury has caused a disruption at some point between the body’s COG and base o support.
T is is likely to have caused compensatory weight shi ts and gait changes along the kinetic
chain that have resulted in balance def cits. T ese def cits may be detected through the use
o unctional assessment tests and/ or computerized instrumentation previously discussed
or assessing balance. Having the advanced technology available to quanti y balance def cits
is an amenity, but not a necessity. Imagination and creativity are o ten the best tools avail-
able to therapists with limited resources who are trying to design balance training protocols.
Because virtually all sport activities involve closed-chain lower-extremity unction,
unctional rehabilitation should be per ormed in the closed kinetic chain. However, ROM,
movement speed, and additional resistance may be more easily controlled in the open
chain initially. T ere ore, adequate, sa e unction in an open chain may be the f rst step in
the rehabilitation process, but should not be the ocus o the rehabilitation plan. T e thera-
pist should attempt to progress the patient to unctional closed-chain exercises quickly and
sa ely. Depending on severity o injury, this could be as early as 1 day postinjury.
As previously mentioned, there is a close relationship between somatosensation, kines-
thesia, and balance. T ere ore, many o the exercises proposed or kinesthetic training are
indirectly enhancing balance. Several methods o regaining balance have been proposed in
the literature and are included in the most current rehabilitation protocols or ankle 41,73 and
knee injury.11,40,51,72
A variety o activities can be used to improve balance, but the therapist should f rst con-
sider 5 general rules be ore beginning. T e exercises must:
• Be sa e, yet challenging.
• Stress multiple planes o motion.
• Incorporate a multisensory approach.
• Begin with static, bilateral, and stable sur aces and progress to dynamic, unilateral,
and unstable sur aces.
• Progress toward sport-specif c exercises.
T ere are several ways in which the therapist can meet these goals. Balance exercises
should be per ormed in an open area, where the patient will not be injured in the event o a
all. It is best to per orm exercises with an assistive device within an arm’s reach (eg, chair,
railing, table, wall), especially during the initial phase o rehabilitation. When considering
exercise duration or balance exercises, the therapist can use either sets and repetitions or a
time-based protocol. T e patient can per orm 2 to 3 sets o 15 repetitions and progress to 30
repetitions as tolerated, or per orm 10 o the exercises or a 15-second period and progress
to 30-second periods later in the program.
Clin ica l Pe a r l
It should be explained to the patient, at the outset, that the goal is to challenge the
patient’s motor control system, to the point that the last 2 repetitions of each set of
exercises should be dif cult to perform. When the last 2 repetitions no longer are
challenging to the athlete, the athlete should be progressed to the next exercise. This can
be determined through subjective information reported from the athlete, as well as the
therapists objective observations. It is very important to provide a variety of exercises and
levels of exercises so that the patient maintains a high level of motivation.
Classi cat ion of Balance Exercises

Static balance is when the COG is maintained over a f xed base o support (unilateral or
bilateral) while standing on a stable sur ace. Examples o static exercises are a single-leg,
double-leg, or tandem-stance Romberg task. Semidynamic balance involves 1 o 2 possible
activities: (a) T e person maintains their COG over a f xed base o support while standing
on a moving sur ace (Chattecx Balance System or Equi est) or unstable sur ace (Biodex Sta-
bility System, BAPS, medium density oam or minitramp); or (b) the person trans ers their
COG over a f xed base o support to selected ranges and/ or directions within the LOS while
standing on a stable sur ace (Balance Master’s LOS, unctional reach tests, minisquats, or
-Band kicks). Dynamic balance involves the maintenance o the COG within the LOS over
a moving base o support ( eet), usually while on a stable sur ace. T ese tasks require the
use o a stepping strategy. T e base o support is always changing its position, orcing the
COG to be adjusted with each movement. Examples o dynamic exercises are walking on a
balance beam, step-up-and-over task, or bounding. Functional balance tasks are the same
as dynamic tasks with the inclusion o sport-specif c tasks such as throwing and catching.
Phase I
T e progression o activities during this phase should include nonballistic types o drills.
raining or static balance can be initiated once the patient is able to bear weight on the
extremity. T e patient should f rst be asked to per orm a bilateral 20-second Romberg test
on a variety o sur aces, beginning with a hard/ f rm sur ace (Figure 14-9). Once a com ort
zone is established, the patient should be progressed to per orming unilateral balance tasks
on both the involved and uninvolved extremities on a stable sur ace.
T e therapist should make comparisons rom these tests to determine the patient’s abil-
ity to balance bilaterally and unilaterally. It should be noted that even though this is termed
static balance, the patient does not remain per ectly motionless. o maintain static balance,
A B C
Figure 14-9 Do uble - and sing le -le g balance o n a stable surface
A. Double-leg stance. B. Double-leg tandem stance. C. Single-leg stance.

the patient must make many small corrections at the ankle, hip, trunk, arms, or head as
previously discussed (see “Selection o Movement Strategies” above). I the patient is having
di culties per orming these activities, they should not be progressed to the next sur ace.
Repetitions o modif ed Romberg tests can be per ormed by f rst using the arms as a coun-
terbalance, then attempting the activity without using the arms. Static balance activities
should be used as a precursor to more dynamic activities. T e general progression o these
exercises should be rom bilateral to unilateral, with eyes open to eyes closed. T e exercises
should attempt to eliminate or alter the various sensory in ormation (visual, vestibular, and
somatosensory) so as to challenge the other systems. In most orthopedic rehabilitation situ-
ations, this is going to involve eye closure and changes in the support sur ace so the somato-
sensory system can be overloaded or stressed. T is theory is synonymous with the overload
principle in therapeutic exercise. Research suggests that balance activities, both with and
without visual input, will enhance motor unction at the brainstem level.7,73 However, as the
patient becomes more e cient at per orming activities involving static balance, eye closure
is recommended so that only the somatosensory system is le t to control balance.
As improvement occurs on a f rm sur ace, bilateral static balance drills should progress to
an unstable sur ace such as a remor box, DynaDisc rocker board on hard sur ace, Bosu Bal-
ance rainer ( at side up then bubble side up), BAPS board, or oam sur ace (Figure 14-10).1
T e purpose o the di erent sur aces is to sa ely challenge the injured patient, while keeping
the patient motivated to rehabilitate the injured extremity. Additionally, the therapist can
A C
Figure 14-10 Do uble le g balance o n an unstable surface
A. Tremor Box. B. Bosu Balance Trainer, at surface. C. DynaDiscs.

introduce light shoulder, back, or chest taps in

an attempt to challenge the patient’s ability to
maintain balance (Figure 14-11). Once the con-
trol is demonstrated in a bilateral stance, the
patient can progress to similar activities using
a unilateral stance (Figure 14-12). All o these
exercises increase awareness o the location o
the COG under a challenged condition, thereby
helping to increase ankle strength in the closed
kinetic chain. Such training may also increase
sensitivity o the muscle spindle and thereby
increase proprioceptive input to the spinal
cord, which may provide compensation or
altered joint a erence.46
Although static and semidynamic balance
exercises may not be very unctional or most
sport activities, they are the f rst step toward
D E
regaining proprioceptive awareness, re ex
stabilization, and postural orientation. T e
patient should attempt to assume a unctional
stance while per orming static balance drills.
D. Extreme Balance Board. E. Bosu Balance Trainer, bubble surface. raining in di erent positions places a variety
o demands on the musculotendinous struc-
tures about the ankle, knee, and hip joints. For
example, a gymnast should practice static balance with
the hip in neutral and external rotation, as well as dur-
ing a tandem stance to mimic per ormance on a balance
beam. A basketball player should per orm these drills in
the “ready position” on the balls o the eet with the hips
and knees slightly exed. Patients requiring a signif cant
amount o static balance or per orming their sport include
gymnasts, cheerleaders, and ootball linemen.41
Phase II
T is phase should be considered the transition phase rom
static to more dynamic balance activities. Dynamic bal-
ance will be especially important or patients who per orm
activities such as running, jumping, and cutting, which
encompasses approximately 95% o all athletes. Such
activities require the patient to repetitively lose and gain
balance to per orm their sport without alling or becoming
injured.41 Dynamic balance activities should only be incor-
porated into the rehabilitation program once su cient
healing has occurred and the patient has adequate ROM,
muscle strength, and endurance. T is could be as early as
a ew days postinjury in the case o a grade 1 ankle sprain,
Figure 14-11 or as late as 5 weeks postsurgery in the case o an ACL
reconstruction. Be ore the therapist progresses the patient
A therapist causing perturbations using a shoulder tap is to challenging dynamic and sport-specif c balance drills,
good for transitioning from double-leg balance on an unstable several semidynamic (intermediate) exercises should be
surface to single-leg balance on an unstable surface. introduced.
A B C
D E
Figure 14-12 Sing le -le g balance o n an unstable surface
A. Foam pad. B. Rocker Board. C. BAPS Board. D. Bosu Balance Trainer. E. Plyoback.
A B
Figure 14-13 Do uble -le g dynamic activitie s o n a stable surface
A. Minisquats. B. Sit-to-stand from a stability ball.
T ese semidynamic balance drills involve displacement or perturbation o the COG

away rom the base o support. T e patient is challenged to return and/ or steady the COG
above the base o support throughout several repetitions o the exercise. Some o these
exercises involve a bilateral stance, some involve a unilateral stance, while others involve
trans erring o weight rom one extremity to the other.
T e bilateral-stance balance drills include the minisquat, which is per ormed
with the eet shoulder-width apart and the COG centered over a stable base o support
(Figure 14-13A). T e trunk should be positioned upright over the legs as the patient slowly
exes the hips and knees into a partial squat—approximately 50 degrees o knee exion.
T e patient then returns to the starting position and repeats the task several times. Once
ROM, strength, and stability have improved, the patient can progress to a ull squat, which
approaches 90 degrees knee exion. T ese should be per ormed in ront o a mirror so the
patient can observe the amount o stability on their return to the extended position. A large
stability ball can also be used to per orm sit-to-stand activities (Figure 14-13B). Once the
patient reaches a com ort zone, the patient can per orm more challenging variations o these
exercises, beginning on a stable sur ace (Figure 14-14) and progressing to weight, cable, or
tubing-resisted exercises (Figure 14-15). Rotational maneuvers and weight-shi ting exercises
on unstable sur aces such as the Bosu, DynaDisc, or oam pad are used to assist the patient
in controlling the patient’s COG during semidynamic movements (Figure 14-16). T ese
exercises are important in the rehabilitation o ankle, knee, and hip injuries, as they help
improve weight trans er, COG sway velocity, and le t/ right weight symmetry. T ey can be
per ormed in an attempt to challenge anterior-posterior stability or medial-lateral stability.
T e therapist has a variety o options or unilateral semidynamic balance exercises. In
the progression to more dynamic exercises, the patient should emphasize controlled hip
and knee exion, ollowed by a smooth return to a stabilization position. Step-ups can be
per ormed either in the sagittal plane ( orward step-up) or in the transverse plane (lateral
step-up) (Figure 14-17A and B). T ese drills should begin with the heel o the uninvolved
extremity on the oor. Using a 2 count, the patient should shi t body weight toward the
A B
C D
Figure 14-14 Sing le -le g balance dynamic (multiplane ) mo ve me nts o n an stable surface
A. Windmill. B. Single-leg reach. C. Double-arm reach. D. Romanian deadlift.

C D
Figure 14-15 Sing le -le g balance -re siste d (multiplane ) mo ve me nts o n a stable surface
A. Bicep curls using cable or tubing. B. Dumbbell scaption. C. Dumbbell cobra. D. Squat touchdown to overhead press.
A B
C D
Figure 14-16 Do uble -le g and sing le -le g (multiplane ) dynamic balance activitie s
o n an unstable surface
A. Tandem stance on an Extreme Balance Board. B. Standing rotation on DynaDisc. C. Standing rotation
on Bosu Balance Trainer. D. Partner throw-and-catch using a weighted ball while balancing on a foam pad.
A B
C D
Figure 14-17 Ste pping mo ve me nts to stabilizatio n
A. Lateral step up. B. Forward step-up to single-leg balance. C. Step-up-and-over (alternating lead leg). D. Thera-
Band kicks.
E F
E. Forward lunge to single-leg balance. F. Multiplane lunges (sagittal, frontal, transverse).
involved side and use the involved extremity to slowly raise the body onto the step.73 T e
involved knee should not be “locked” into ull extension. Instead, the knee should be posi-
tioned in approximately 5 degrees o exion, while balancing on the step or 3 seconds.
Following the 3 count, the body weight should be shi ted toward the uninvolved side and
lowered to the heel o the uninvolved side. Step-up-and-over activities are similar to step-
ups, but involve more dynamic trans er o the COG. T ese should be per ormed by having
the patient both ascend and descend using the involved extremity (Figure 14-17C) or ascend
with the involved extremity and descend with the uninvolved extremity orcing the involved
leg to support the body on the descend. T e therapist can also introduce the patient to more
challenging static tasks during this phase. For example, the very popular T era-Band kicks
( -Band kicks or steamboats) are excellent or improving balance. T era-Band kicks are
per ormed with an elastic material (attached to the ankle o the uninvolved leg) serving as a
resistance against a relatively ast kicking motion (Figure 14-17D). T e patient’s balance on
the involved extremity is challenged by perturbations caused by the kicking motion o the
uninvolved leg. Four sets o these exercises should be per ormed, 1 or each o 4 possible
kicking motions: hip exion, hip extension, hip abduction, and hip adduction. -Band kicks
can also be per ormed on oam or a minitramp i additional somatosensory challenges are
desired.72 Single and multiplane lunges can also be used to transition to dynamic activities
(Figure 14-17E and F).
T e Balance Shoes (Orthopedic Physical T erapy Products, Minneapolis, MN) are
another excellent tool or improving the strength o lower extremity musculature and, ulti-
mately, improving balance. T e shoes allow lower-extremity balance and strengthening
exercises to be per ormed in a unctional, closed-kinetic-chain manner. T e shoes consist
o a cork sandal with a rubber sole, and a rubber hemisphere similar in consistency to a
lacrosse ball positioned under the midsole (see Figures 25-28 to 25-35). T e design o the
sandals essentially creates an individualized perturbation device or each limb that can
be utilized in any number o unctional activities, ranging rom static single-leg stance to
dynamic gait activities per ormed in multiple directions ( orward walking, sidestepping,
carioca walking, etc).
Clinical use o the Balance Shoes has resulted in a number o success ul clinical out-
comes rom a subjective standpoint, including treatment o ankle sprains and chronic insta-
bility, anterior tibial compartment syndrome, lower leg ractures, and a number o other
orthopedic problems, as well as or enhancement o core stability. Research reveals that
training in the Balance Shoes results in reduced rear oot motion and improved postural
stability in excessive pronators, and that unctional activities in the Balance Shoes increase
gluteal muscle activity (see Chapter 30).
Phase III
Once the patient can success ully complete the semidynamic exercises presented in Phase
II, the patient should be ready to per orm more dynamic and unctional types o exercises.
T e general progression or activities to develop dynamic balance and control is rom slow-
speed to ast-speed activities, rom low- orce to high- orce activities, and rom controlled to
uncontrolled activities.41 In other words, the patient should be working toward sport-spe-
cif c drills that will allow or a sa e return to their respective sport or activity. T ese exercises
will likely di er depending on which sport the person plays. For example, drills to improve
lateral weight shi ting and sidestepping should be incorporated into a program or a tennis
player, whereas drills to improve jumping and landing are going to be more important or
a track athlete who per orms the long jump. As previously mentioned, the therapist o ten
needs to use the therapist’s imagination to develop the best protocol or the patient.
Bilateral jumping drills are a good place to begin once the patient has reached phase
III. T e patient should begin with jumping or hopping onto a step, or per orming butt kicks
or tuck jumps, and quickly establishing a stabilized position (Figure 14-18A to C). A more
dynamic exercise involves bilateral jumping either over a line or some object either ront to
back or side to side. T e patient should concentrate on landing on each side o the line as
A B
Figure 14-18 Jumping and ho pping to stabilizatio n
A. Forward jump-up to stabilization. B. Butt kicks to stabilization.

C D
E F
C. Tuck jumps to stabilization. D. Bidirectional single-leg hop-overs to stabilization. E. Bilateral double-leg

hop-overs to stabilization. F. Multiplanar hops to stabilizations.
quickly as possible (Figure 14-18D).72,73 Bilateral dynamic balance exercises should prog-
ress to unilateral dynamic balance exercises as quickly as possible during phase III. At this
stage o the rehabilitation, pain and atigue should not be as much o a actor. All jump-
ing drills per ormed bilaterally should now be per ormed unilaterally, by practicing f rst on
the uninvolved extremity. I additional challenges are needed, a vertical component can
be added by having the patient jump over an object such as a box or other suitable object
(Figure 14-18E).
As the patient progresses through these exercises, eye closure can be used to urther
challenge the patient’s somatosensation. A ter mastering these straight plane jumping pat-
terns, the patient can begin diagonal jumping patterns through the use o a cross on the
A B
Figure 14-19 Co ntro lling dynamic balance ag ainst cable o r tubing

re sistance
A. Forward and backwards walking on a balance board. B. Lateral hopping in the frontal
plane.
oor ormed by 2 pieces o tape (Figure 14-18F). T e intersecting lines create 4 quadrants
that can be numbered and used to per orm di erent jumping sequences such as 1, 3, 2, 4
or the f rst set and 1, 4, 2, 3 or the second set.72,73 A larger grid can be designed to allow or
longer sequences and longer jumps, both o which require additional strength, endurance,
and balance control.
Another good exercise to introduce prior to advancing to phase III is a balance
beam walk, which can be per ormed against resistance to urther challenge the patient
(Figure 14-19A). ubing can be added to dynamic unilateral training exercises. T e patient
can per orm stationary running against the tube’s resistance, ollowed by lateral and diago-
nal bounding exercises. Diagonal bounding, which involves jumping rom 1 oot to another,
places greater emphasis on lateral movements. It is recommended that the patient f rst learn
the bounding exercise without tubing, and then attempt the exercise with tubing. A oam roll,
towel, or other obstacle can be used to increase jump height and/ or distance (Figure 14-19B).
T e f nal step in trying to improve dynamic balance should involve the incorporation o
sport-related activities such as throwing and catching a ball. At this stage o the rehabilitation
program, the patient should be able to sa ely concentrate on the unctional activity (catching
and throwing), while subconsciously controlling dynamic balance (Figure 14-19C).
Dual-Task Balance Training and Assessment

Although the a orementioned balance training and assessment techniques are validated
and proven to be use ul in the clinical setting, patients typically unction in a more dynamic
environment with multiple demands placed upon them concurrently. Participation in
sport o ten requires patients to split their attention between cognitive and dynamic balance
tasks. T ere ore, a f nal progression or patients recovering rom musculoskeletal injury or
Dual-Task Balance Training and Assessment 401
neurologic injury (eg, concussion) could be the addition o competing motor/ coordination
and cognitive tasks to assess the patient’s per ormance with these challenges. T ough the
cognitive and balance demands are unique, the 2 are linked in that they rely on an individu-
al’s system o attention. T e attention system should be viewed as independent o the in or-
mation processing centers o the brain and, like other systems, is able to communicate with
multiple systems simultaneously.68 Evidence shows the ability to selectively allocate atten-
tion between cognitive and balance tasks, but there is a priority or balance with increasing
di culty o these tasks.71
Once elite athletes progress through the initial phases o the balance exercises, they
may reach a point where these dual-task balance exercises can be o benef t. Keeping the
patient engaged in the patient’s rehabilitation program is important, and these added chal-
lenges can assist in reproducing the type o demands placed on the patient during more
physical activity or competition. o better recreate these demands, the systems should be
challenged in unison to ully assess the unctional limitations o patient, as well as train or
rehabilitate these injury-related limitations.
Dual-task exercises must be clearly explained to the patient, so the patient understands
the task at hand. T e task can be sport specif c, and should ollow the guidelines previously
outlined in this chapter with respect to advancing the exercises using more challenging
stances and sur aces.
Incorporating a cognitive task with a sport-specif c balance task can be done very easily
using di erent colored balls, and specif c rules or instructions provided to the patient. T e
therapist, standing approximately 15 eet away, tosses di erent colored balls to the patient,
who is standing on either a double leg or single leg, and/ or f rm sur ace, oam sur ace, or
balance board (Figure 14-20). T e patient is told to maintain his balance while catching a
blue ball with his right hand, red ball with his le t hand, and yellow ball with both hands.
Initially, this dual task can be di cult, but the patient should attempt to work through the
increased attention demands while allowing his somatosensory system to subconsciously
aid in the maintenance o balance. T e complexity can be increased by adding additional
rules. For example, the patient can be instructed to toss the yellow ball back head high, blue
ball back waist high, and to roll the yellow ball back.
Figure 14-20 Inco rpo rating a co g nitive task w ith spo rt-spe ci c balance
A B C
Figure 14-21 Spo rt-spe ci c co g nitive tasks
A. The therapist rolls different colored balls to the patient. B and C. Standing on an unstable surface. The patient must
decide where to return the ball while maintaining balance.
T e exercises then can be made more sport specif c. For example, the therapist posi-
tions himsel approximately 25 eet rom the patient and rolls the di erent colored balls to
the patient standing on either a double leg or single leg, and/ or f rm sur ace, oam sur ace,
or balance board (Figure 14-21). A hockey player with a hockey stick is asked to return (aim)
the blue ball to the right side o the target, the yellow ball to the center o the target, and the
blue ball to the le t side o the target.
Clin ica l Pe a r l
Research shows that balance exercises can help improve functional ankle instability. The
therapist should design a program that incorporates challenging unilateral multidirectional
exercises involving a multisensory approach (eyes open and eyes closed). The progression
should include the progression suggested in this chapter, which includes the foam, Bosu
Balance Trainer, DynaDisc, BAPS board, Extreme Balance Board, balance beam, and Balance
Shoes. Lateral and diagonal hopping exercises are also a vital part of this protocol. The goal
should be to help strengthen the dynamic and static stabilizers surrounding the ankle joint.
This should result in rebuilding some of the afferent pathways and ultimately improving
ankle joint stability.
Clinical Value of High-Tech

Training and Assessment
T e benef t o using the commercially available balance systems is that not only can def cits
be detected, but progress can be charted quantitatively through the computer- generated
results. For example, NeuroCom’s Balance Master (with long orceplate) is capable o
assessing a patient’s ability to per orm coordinated movements essential or sport per or-
mance. T e system, equipped with a 5- oot-long orce plat orm, is capable o identi ying
Clinical Value of High-Tech Training and Assessment 403
Name : Doe , J ohn J Diag no s is : ACL Te a r L Kne e File : HBM1.QBM

ID: ATID00001 Ope rato r ID: J odi Bowe r Date : 03/06/97
DOB: 11/22/55 Re fe rre d by: Dr. Tom Me rkle Time : 6:35:06 P M
He ig ht: 5'11" Co mme nts : DOI: 7/4/96; DOS : 7/6/96
S TEP UP/OVER TEXT (8 inc h c urb)
Lift-up inde x
% Body wt % Diffe re nce % Body wt
50 50
40 40 33
46
30 30 (1)
20 20
10 10
0 0
Me a n 50 0 50 Me a n
Coe fficie nt of va ria tion Coe fficie nt of va ria tion
33% 90%
Mo ve me nt time
sec % Diffe re nce sec
5.0 5.0
4.0 4.0
3.0 3.0 2.58
36 (2)
2.0 2.0
1.21
1.0 1.0
0.0 0.0
Me a n 50 0 50 Me a n
15% 53%
Impac t Inde x
% Body wt % Diffe re nce % Body wt
100 100
LEFT S IDE RIGHT S IDE 80 80
49
60 60 (3)
39
40 40
20 20
0 0
Me a n 50 0 50 Me a n
14% 100%
LEFT S IDE LEFT/RIGHT DIFFERENCE RIGHT S IDE
Figure 14-22
Results from a step-up-and-over protocol on the NeuroCom New Balance Master’s long forceplate. (Balance master Version
5.0 and NeuroCom are registered trademarks of NeuroCom International Inc. Copyright © 1989-1997. All Rights Reserved.)
specif c components underlying per ormance o several unctional tasks. Exercises are also
available on the system that then help to improve the def cits.62
Figure 14-22 shows the results o a step-up-and-over test. T e components which are
analyzed in this particular task are: (a) Li t-Up Index—quantif es the maximum li ting (con-
centric) orce exerted by the leading leg and is expressed as a percentage o the person’s
weight; (b) Movement ime—quantif es the number o seconds required to complete the
task, beginning with initial weight shi t to the nonstepping leg and ending with impact o
the lagging leg onto the sur ace; and (c) Impact Index—quantif es the maximum vertical
impact orce (percent o body weight) as the lagging leg lands on the sur ace.62
Research on the clinical applicability o these measures has revealed interesting results.
Preliminary observations rom 2 studies in progress suggest that def cits in impact control
are a common eature o patients with ACL injuries, even when strength and ROM o the
involved knee are within normal limits. Several other per ormance assessments are avail-
able on this system, including sit to stand, walk test, step and quick turn, orward lunge,
weight bearing/ squat, and rhythmic weight shi t.
SUMMARY
1. Although some injuries in the region o the lower leg are acute, most injuries seen in an
athletic population result rom overuse, most o ten rom running.
2. ibial ractures can create long-term problems or the athlete i inappropriately man-
aged. Fibular ractures generally require much shorter periods or immobilization.
reatment o these ractures involves immediate medical re erral and most likely a pe-
riod o immobilization and restricted weight bearing.
3. Stress ractures in the lower leg are usually the result o the bone’s inability to adapt to
the repetitive loading response during training and conditioning o the athlete and are
more likely to occur in the tibia.
4. Chronic compartment syndromes can occur rom acute trauma or repetitive trauma o
overuse. T ey can occur in any o the 4 compartments, but are most likely in the ante-
rior compartment or deep posterior compartment.
5. Rehabilitation o medial tibial stress syndrome must be comprehensive and address
several actors, including musculoskeletal, training, and conditioning, as well as proper
shoes and orthotics intervention.
6. Achilles tendinitis will o ten present with a gradual onset over a period o time and may
be resistant to a quick resolution secondary to the slower healing response o tendinous
tissue.
7. Perhaps the greatest question a ter an Achilles tendon rupture is whether surgical re-
pair or cast immobilization is the best method o treatment. Regardless o treatment
method, the time required or rehabilitation is signif cant.
8. With retrocalcaneal bursitis the athlete will report a gradual onset o pain that may be
associated with Achilles tendinitis. reatment should include rest and activity modif -
cation in order to reduce swelling and in ammation.
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Establishing
Core Stability in
Rehabilitation
Ba r b a r a J. Ho o g e n b o o m ,
Jo le n e L. Be n n e t t , a n d M ik e Cla r k
OBJJEC
C T IVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Describe the functional approach to kinetic chain rehabilitation.
De ne the concept of the core.
Discuss the anatomic relationships between the muscular components of the core.
Explain how the core functions to maintain postural alignment and dynamic postural equilibrium
during functional activities.
Describe procedures for assessing the core.
Discuss the rationale for core stabilization training and relate to ef cient functional performance
of activities.
Identify appropriate exercises for core stabilization training and their progressions.
Discuss the guidelines for core stabilization training.
407
408 Chapte r 15 Establishing Core Stability in Rehabilitation
A dynamic, core stabilization training program should be a hallmark component o all com-
prehensive unctional rehabilitation programs.10,13,22,23,28,31,55 A core stabilization program
improves dynamic postural control, ensures appropriate muscular balance, and af ects
joint arthrokinematics around the lumbo-pelvic-hip complex. A care ully cra ted core sta-
bilization program allows or the expression o dynamic unctional strength and improves
neuromuscular e ciency throughout the entire kinetic chain.1,11,16,28,29,31,51,61,64-66,88,89
What Is the Core?

T e core is de ned as the lumbo-pelvic-hip complex.1,28 T e core is where our center o
gravity is located and where all movement begins.33,34,78,79 T ere are 29 muscles that have
an attachment to the lumbo-pelvic-hip complex.7,8,28,80 An e cient core allows or main-
tenance o the normal length-tension relationship o unctional agonists and antago-
nists, which allows or the maintenance o the normal orce-couple relationships in the
lumbo-pelvic-hip complex. Maintaining the normal length-tension relationships and orce-
couple relationships allows or the maintenance o optimal arthrokinematics in the lumbo-
pelvic-hip complex during unctional kinetic-chain movements.88,89,96 T is provides optimal
neuromuscular e ciency in the entire kinetic chain, allowing or optimal acceleration,
deceleration, and dynamic stabilization o the entire kinetic chain during unctional move-
ments. It also provides proximal stability or e cient lower-extremity and upper-extremity
movements.1,28,33,34,43,55,78,79,88,89
T e core operates as an integrated unctional unit, whereby the entire kinetic chain
works synergistically to produce orce, reduce orce, and dynamically stabilize against
abnormal orce.1 In an e cient state, each structural component distributes weight, absorbs
orce, and trans ers ground reaction orces.1 T is integrated, interdependent system needs
to be trained appropriately to allow it to unction e ciently during dynamic kinetic chain
activities.
Core stabilization exercise programs have been labeled many dif erent terms, some o
which include dynamic lumbar stabilization, neutral spine control, muscular usion, and
lumbopelvic stabilization. We use the terms “butt and gut” to educate our patients, col-
leagues, and health care students. T is catchy phrase illustrates the importance o the entire
abdominal and pelvic region working together to provide unctional stability and e cient
movement.
Core Stabilization Training Concepts

Many individuals develop the unctional strength, power, neuromuscular control, and
muscular endurance in speci c muscles that enable them to per orm unctional activi-
ties.1,28,46,55 However, ew people develop the m uscles required or spinal stabiliza-
tion.43,46,47 T e body’s stabilization system has to be unctioning optimally to ef ectively
use the strength, power, neuromuscular control, and muscular endurance developed in
the prim e m overs. I the extrem ity muscles are strong and the core is weak, then there
will not be enough trunk stabilization created to produce e cient upper-extrem ity and
lower-extremity m ovements. A weak core is a undam ental problem o many ine cient
movem ents that leads to injury.43,46,47,55
T e core musculature is an integral component o the protective mechanism that
relieves the spine o deleterious orces inherent during unctional activities.14 A core sta-
bilization training program is designed to help an individual gain strength, neuromuscu-
lar control, power, and muscle endurance o the lumbo-pelvic-hip complex. T is approach
Review of Functional Anatomy 409
acilitates a balanced muscular unctioning o the entire kinetic chain.1 Greater neuromus-
cular control and stabilization strength will of er a more biomechanically e cient position
or the entire kinetic chain, thereby allowing optimal neuromuscular e ciency throughout
the kinetic chain.
Neuromuscular e ciency is established by the appropriate combination o postural
alignment (static/ dynamic) and stability strength, which allows the body to decelerate grav-
ity, ground reaction orces, and momentum at the right joint, in the right plane, and at the
right time.12,31,54 I the neuromuscular system is not e cient, it will be unable to respond
to the demands placed on it during unctional activities.1 As the e ciency o the neuro-
muscular system decreases, the ability o the kinetic chain to maintain appropriate orces
and dynamic stabilization decreases signi cantly. T is decreased neuromuscular e ciency
leads to compensation and substitution patterns, as well as poor posture during unctional
activities.29,88,89 Such poor posture leads to increased mechanical stress on the contractile
and noncontractile tissue, leading to repetitive microtrauma, abnormal biomechanics, and
injury.16,29,62,63
Clin ica l Pe a r l
Decreased stabilization endurance can occur in individuals with low back pain with
decreased ring of the transversus abdominis, internal oblique, multi dus, and deep erector
spinae.70 Training without proper control of these muscles can lead to improper muscle
imbalances and force transmission. Poor core stability can lead to increased intradiscal
pressure.
Review of Functional Anatomy

o ully understand unctional core stabilization training and rehabilitation, the therapist
must ully understand unctional anatomy, lumbo-pelvic-hip complex stabilization mecha-
nisms, and normal orce-couple relationships.4,7,8,80
A review o the key lumbo-pelvic-hip complex musculature will allow the therapist to
understand unctional anatomy and thereby develop a comprehensive kinetic chain reha-
bilitation program. T e key lumbar spine muscles include the transversospina l group, erec-
tor spinae, quadratus lumborum, and latissimus dorsi (Figure 15-1). T e key abdominal
muscles include the rectus abdominis, external oblique, internal oblique, and transversus
abdominis ( A) (Figure 15-2). T e key hip musculature includes the gluteus maximus, glu-
teus medius, and psoas (Figure 15-3).
T e transversospinalis group includes the rotatores, interspinales, intertransversa-
rii, sem ispinalis, and multi dus. T ese muscles are small and have a poor m echanical
advantage or contributing to m otion.27,80 T ey contain primarily type I muscle bers
and are there ore designed mainly or stabilization.27,80 Researchers 80 have ound that
the transversospinalis muscle group contains 2 to 6 tim es the num ber o muscle spindles
ound in larger muscles. T ere ore, it has been established that this group is primarily
responsible or providing the central nervous system with proprioceptive in ormation.80
T is group is also responsible or inter- or intrasegm ental stabilization and segm ental
eccentric deceleration o exion and rotation o the spinal unit during unctional m ove-
ments.4,80 T e transversospinalis group is constantly put under a variety o com pressive
and tensile orces during unctional m ovem ents; consequently, it needs to be trained
adequately to allow dynamic postural stabilization and optimal neuromuscular e ciency
o the entire kinetic chain.80 T e multi dus is the most important o the transversospinalis
muscles. It has the ability to provide intrasegmental stabilization to the lum bar spine in
S upe rior nucha l line
S e mis pina lis ca pitis

Longis s imus ca pitis
S ple nius ca pitis S e mis pina lis ce rvicis
S e rra tus pos te rior

s upe rior
S ple nius ce rvicis

S e mis pina lis
Ere ctor s pina e : thora cis
Iliocos ta lis
Longis s imus
S pina lis
S e rra tus pos te rior infe rior
Inte rna l a bdomina l Multifidus

oblique Qua dra tus lumborum
Exte rna l a bdomina l
oblique (cut)
Figure 15-1 Spinal muscle s
(Reproduced with permission from Prentice. Principles of Athletic Training . 14th ed. New York, NY:
McGraw-Hill; 2011:738.)
all positions.27,97 Wilke et al97 ound increased segm ental stif ness at L4-L5 with activation
o the multi dus.
Additional key back muscles include the erector spinae, quadratus lumborum, and the
latissimus dorsi. T e erector spinae muscle group unctions to provide dynamic interseg-
mental stabilization and eccentric deceleration o trunk exion and rotation during kinetic
chain activities.80 T e quadratus lumborum muscle unctions primarily as a rontal plane
stabilizer that works synergistically with the gluteus medius and tensor ascia lata. T e latis-
simus dorsi has the largest moment arm o all back muscles and there ore has the great-
est ef ect on the lumbo-pelvic-hip complex. T e latissimus dorsi is the bridge between the
upper extremity and the lumbo-pelvic-hip complex. Any unctional upper-extremity kinetic
Review of Functional Anatomy 411
Pe ctora lis ma jor
La tis s imus dors i
S e rra tus a nte rior

Te ndinous
inte rs e ctions Re ctus s he a th
(cut e dge s )
Re ctus s he a th
Tra ns ve rs e a bdomina l
Umbilicus
Inte rna l a bdomina l
Line a s e miluna ris oblique (cut)
Line a a lba Exte rna l a bdomina l
oblique (cut)
Apone uros is of Re ctus a bdominis
exte rna l a bdomina l
oblique Inguina l liga me nt
Figure 15-2 Abdominal muscle s
(Reproduced with permission from Prentice. Principles of Athletic Training . 14th ed. New York, NY:
McGraw-Hill; 2011:827.)
A B S upe rficia l De e p
Ilia c cre s t
Iliops oa s :
Ilia cus Glute us
P s oa s minimus
ma jor Glute us
P iriformis me dius
S a crum La te ra l rota tors :

P iriformis
Pe ctine us Glute us
ma ximus Ge me llus
Adductor Obtura tor
exte rnus s upe rior
ma gnus
Coccyx Obtura tor
Adductor
inte rnus
brevis
Obtura tor
Adductor exte rnus
longus
Is chia l Ge me llus
tube ros ity infe rior
Qua dra tus
Gra cilis fe moris
Figure 15-3 Hip muscle s

Ins e rtion of
gra cilis on A. Anterior. B. Posterior. (Reproduced with permission from Saladin. Anatomy
tibia
and Physiology. 6th ed. New York, NY: McGraw-Hill; 2012:360-361.)
chain rehabilitation must pay particular attention to the latissimus and its unction on the
lumbo-pelvic-hip complex.80
T e abdominals are comprised o 4 muscles: rectus abdominis, external oblique, inter-
nal oblique, and, most importantly, the A.80 T e abdominals operate as an integrated
unctional unit, which helps maintain optimal spinal kinematics.4,7,8,80 When working e -
ciently, the abdominals of er sagittal, rontal, and transversus plane stabilization by control-
ling orces that reach the lumbo-pelvic-hip complex.80 T e rectus abdominis eccentrically
decelerates trunk extension and lateral exion, as well as providing dynamic stabilization
during unctional movements. T e external obliques work concentrically to produce con-
tralateral rotation and ipsilateral lateral exion, and work eccentrically to decelerate trunk
extension, rotation, and lateral exion during unctional movements.80 T e internal oblique
works concentrically to produce ipsilateral rotation and lateral exion and works eccentri-
cally to decelerate extension, rotation, and lateral exion. T e internal oblique attaches to
the posterior layer o the thoracolumbar ascia. Contraction o the internal oblique creates a
lateral tension orce on the thoracolumbar ascia, which creates intrinsic translational and
rotational stabilization o the spinal unit.34,43 T e A is probably the most important o the
abdominal muscles. T e A unctions to increase intraabdominal pressure (IAP), provide
dynamic stabilization against rotational and translational stress in the lumbar spine, and
provide optimal neuromuscular e ciency to the entire lumbo-pelvic-hip complex.43,46-48,58
Research demonstrates that the A works in a eed orward mechanism.43 Researchers have
demonstrated that contraction o the A precedes the initiation o limb movement and
all other abdominal muscles, regardless o the direction o reactive orces.26,43 Cresswell
et al25,26 demonstrated that like the multi dus, the A is active during all trunk movements,
suggesting that this muscle has an important role in dynamic stabilization.46
Key hip muscles include the psoas, gluteus medius, gluteus maximus, and ham-
strings.7,8,80 T e psoas produces hip exion and external rotation in the open chain position,
and produces hip exion, lumbar extension, lateral exion, and rotation in the closed-chain
position. T e psoas eccentrically decelerates hip extension and internal rotation, as well
as trunk extension, lateral exion, and rotation. T e psoas works synergistically with the
super cial erector spinae and creates an anterior shear orce at L4-L5.80 T e deep erector
spinae, multi dus, and deep abdominal wall (transverses, internal oblique, and external
oblique)80 counteract this orce. It is extremely common or clients to develop tightness in
their psoas. A tight psoas increases the anterior shear orce and compressive orce at the
L4-L5 junction.80 A tight psoas also causes reciprocal inhibition o the gluteus maximus,
multi dus, deep erector spinae, internal oblique, and A. T is leads to extensor mechanism
dys unction during unctional movement patterns.51,61,63,65,66,80,89 Lack o lumbo-pelvic-hip
complex stabilization prevents appropriate movement sequencing and leads to synergis-
tic dominance by the hamstrings and super cial erector spinae during hip extension. T is
complex movement dys unction also decreases the ability o the gluteus maximus to decel-
erate emoral internal rotation during heel strike, which predisposes an individual with a
knee ligament injury to abnormal orces and repetitive microtrauma.14,19,51,65,66
T e gluteus medius unctions as the primary rontal plane stabilizer o the pelvis and
lower extremity during unctional movements.80 During closed-chain movements, the glu-
teus medius decelerates emoral adduction and internal rotation.80 A weak gluteus medius
increases rontal and transversus plane stress at the patello emoral joint and the tibio emo-
ral joint.80 A weak gluteus medius leads to synergistic dominance o the tensor ascia latae
and the quadratus lumborum.19,51,53 T is leads to tightness in the iliotibial band and the
lumbar spine. T is will af ect the normal biomechanics o the lumbo-pelvic-hip complex
and the tibio emoral joint, as well as the patello emoral joint. Research by Beckman and
Buchanan 9 demonstrates decreased electromyogram (EMG) activity o the gluteus medius
ollowing an ankle sprain. T erapists must address the altered hip muscle recruitment pat-
terns or accept this recruitment pattern as an injury-adaptive strategy, and thus accept
Transversus Abdominis and Multi dus Role in Core Stabilization 413
the unknown long-term consequences o premature muscle activation and synergistic
dominance.9,29
T e gluteus maximus unctions concentrically in the open chain to accelerate hip
extension and external rotation. It unctions eccentrically to decelerate hip exion and
emoral internal rotation.80 It also unctions through the iliotibial band to decelerate tibial
internal rotation.80 T e gluteus maximus is a major dynamic stabilizer o the sacroiliac (SI)
joint. It has the greatest capacity to provide compressive orces at the SI joint secondary
to its anatomic attachment at the sacrotuberous ligament.80 It has been demonstrated by
Bullock-Saxton 15,16 that the EMG activity o the gluteus maximus is decreased ollowing
an ankle sprain. Lack o proper gluteus maximus activity during unctional activities leads
to pelvic instability and decreased neuromuscular control. T is can eventually lead to the
development o muscle imbalances, poor movement patterns, and injury.
T e hamstrings work concentrically to ex the knee, extend the hip, and rotate the
tibia. T ey work eccentrically to decelerate knee extension, hip exion, and tibial rota-
tion. T e hamstrings work synergistically with the anterior cruciate ligament.80 All o the
muscles mentioned play an integral role in the kinetic chain by providing dynamic stabili-
zation and optimal neuromuscular control o the entire lumbo-pelvic-hip complex. T ese
muscles have been reviewed so that the therapist realizes that muscles not only produce
orce (concentric contractions) in 1 plane o motion, but also reduce orce (eccentric con-
tractions) and provide dynamic stabilization in all planes o movement during unctional
activities. When isolated, these muscles do not ef ectively achieve stabilization o the
lumbo-pelvic-hip complex. It is the synergistic, interdependent unctioning o the entire
lumbo-pelvic-hip complex that enhances stability and neuromuscular control throughout
the entire kinetic chain.
Transversus Abdominis and

Multi dus Role in Core Stabilization
T e A muscle is the deepest o the abdom inal muscles and plays a primary role in trunk
stability. T e horizontal orientation o its bers has a limited ability to produce torque to
the spine necessary or exion or extension m ovement, although it has been shown to be
an active trunk rotator.81 T e A is a primary trunk stabilizer via m odulation o IAP, ten-
sion through the thoracolum bar ascia, and com pression o the SI joints.25,91 For m any
decades, IAP was believed to be an im portant contributor to spinal control by the pres-
sure within the abdom inal cavity putting orce on the diaphragm superiorly and pelvic
oor in eriorly to extend the trunk.6,35,73 It was hypothesized that IAP would provide an
extensor m om ent and thus reduce the muscular orce required by the trunk extensors
and decrease the com pressive load on the lum bar spine.95 Recent research by Hodges
et al42 applied electrical stimulation to the phrenic nerve o humans to produce an invol-
untary increase in IAP without abdom inal or extensor muscle activity. IAP was increased
by the contraction o the diaphragm, pelvic oor muscles, and the A with no exor
m om ent noted. Research has dem onstrated that IAP may directly increase spinal stif -
ness.45 Hodges et al42 used a tetanic contraction o the diaphragm to produce IAP, which
resulted in increased stif ness in the spine. Bilateral contraction o the A assists in IAP,
thus enhancing spinal stif ness.
T e role o the thoracolumbar ascia in trunk stability has also been discussed in the
literature, and it has been theorized that the contraction o the A could produce an exten-
sor torque via the horizontal pull o the A via its extensive attachm ent into the thora-
colum bar ascia.34 Recently, this theory was tested by esh et al93 by placing tension on
the thoracolumbar ascia o cadavers. No approximation o the spinous processes or trunk
extension m ovem ent was noted although a small am ount o compression on the spine
was noted. T is small amount o compression may play a role in the control o interverte-
bral shear orces. Hodges et al42 electrically stimulated contraction o the A in pigs and
demonstrated that when tension was developed in the thoracolumbar ascia, without an
associated increase in IAP, there was no signi cant ef ect on the intervertebral stif ness. In
the next step o that same research study, the thoracolumbar ascial attachments were cut
and an increase in IAP decreased the spinal stif ness. T is demonstrates that the thoraco-
lumbar ascia and IAP work in concert to enhance trunk stability.42 runk stability is also
dependent on the joints caudal to the lumbar spine. T e SI joint is the connection between
the lumbar spine and the pelvic region, which ultimately connects the trunk to the lower
extremities. T e SI joint is dependent on the compressive orce between the sacrum and
ilia. T e horizontal direction and anterior attachm ent on the ilium o the A produces
the compressive orce necessary or spinal stability. Richardson et al84 used ultrasound to
detect movement o the sacrum and ilium while having subjects voluntarily contract their
transverse abdominals. T ey demonstrated that a voluntary contraction o the A reduced
the laxity o the SI joint. T is study also pointed out that this reduction in joint laxity o the
SI joint was greater than that during a bracing contraction. T e researchers did note that
they were unable to exclude changes in activity in other muscles such as the pelvic oor,
which may have reduced the laxity via counternutation o the sacrum.84 T e a orem en-
tioned research ndings illustrate that the A plays an important role in maintaining trunk
stability by interacting with IAP, thoracolum bar ascia tension, and compressing the SI
joints via muscular attachments.
T e multi di are the most medial o the posterior trunk muscles, and they cover the
lumbar zygapophyseal joints except or the ventral sur aces.81 T e multi di are primary sta-
bilizers when the trunk is moving rom exion to extension. T e multi di contribute only
20% o the total lumbar extensor moment, whereas the lumbar erector spinae contribute
30%, and the thoracic erector spinae unction as the predominant torque generator at 50%
o the extension moment arm.56 T e multi dus, lumbar, and thoracic erector spinae mus-
cles have a high percentage o type I bers and are postural control muscles similar to the
A.56 T e multi dus has been shown to be active during all antigravity activities, including
static tasks, such as standing, and dynamic tasks, such as walking.97
Clinical observation and experimental evidence con rm that when the A contracts,
the multi di are also activated.81 A girdlelike cylinder o muscular support is produced as a
result o the coactivation o the A, multi dus, and the thick thoracolumbar ascial system.
EMG evidence suggests that the A and internal obliques contract in anticipation o move-
ment o the upper and lower extremities, o ten re erred to as the eed- orward mechanism.
T is eed- orward mechanism gives the A and multi dus muscular girdle a unique abil-
ity to stabilize the spine regardless o the direction o limb movements.44,45 As noted previ-
ously, the pelvic oor muscles play an important role in the development o IAP, and thus
enhance trunk stability. It has also been demonstrated that the pelvic oor is active during
repetitive arm movement tasks independent o the direction o movement.49 Saps ord et al90
discovered that maximal contraction o the pelvic oor was associated with activity o all
abdominal muscles and submaximal contraction o the pelvic oor muscles was associ-
ated with a more isolated contraction o the A. In this same study, it also was determined
that the speci city o the response was better when the lumbar spine and pelvis were in a
neutral position.90 Clinically, this in ormation is help ul in guiding the patient in the process
o A contraction by instructing the patient to per orm a submaximal pelvic oor isomet-
ric hold. Another interesting act to note is that men and women with incontinence have
almost double the incidence o low back pain as people without incontinence issues.30 In
summary, the lumbopelvic region may be visualized as a cylinder with the in erior wall
being the pelvic oor, the superior wall being the diaphragm, the posterior wall being
the multi dus, and the A muscles orming the anterior and lateral walls. All walls o the
Muscular Imbalances 415
cylinder must be activated and taut or optimal trunk stabilization to occur with all static
and dynamic activities.
Clin ica l Pe a r l
Core training exercises should be safe and challenging and stress multiple planes that are
functional as they are applied to a functional activity or sport. The exercises should also be
proprioceptively challenging and activity speci c.
Postural Considerations
T e core unctions to maintain postural alignment and dynamic postural equilibrium dur-
ing unctional activities. Optimal alignment o each body part is a cornerstone to a unc-
tional training and rehabilitation program. Optimal posture and alignment will allow or
maximal neuromuscular e ciency because the normal length-tension relationship, orce-
couple relationship, and arthrokinematics will be maintained during unctional movement
patterns.14,28,29,50,51,53,55,58,62,64,88,89 I 1 segment in the kinetic chain is out o alignment, it will
create predictable patterns o dys unction throughout the entire kinetic chain. T ese pre-
dictable patterns o dys unction are re erred to as serial distortion patterns.28 Serial distor-
tion patterns represent the state in which the body’s structural integrity is compromised
because segments in the kinetic chain are out o alignment. T is leads to abnormal distort-
ing orces being placed on the segments in the kinetic chain that are above and below the
dys unctional segment.14,28,29,55 o avoid serial distortion patterns and the chain reaction
that 1 misaligned segment creates, we must emphasize stable positions to maintain the
structural integrity o the entire kinetic chain.16,28,55,65,66,87 A comprehensive core stabiliza-
tion program prevents the development o serial distortion patterns and provides optimal
dynamic postural control during unctional movements.
Muscular Imbalances
An optimally unctioning core helps to prevent the developm ent o muscle im balances
and synergistic dominance. T e human movement system is a well-orchestrated system
o interrelated and interdependent components.16,61 T e unctional interaction o each
component in the human movement system allows or optimal neuromuscular e ciency.
Alterations in joint arthrokinematics, muscular balance, and neuromuscular control af ect
the optimal unctioning o the entire kinetic chain.16,88,89 Dys unction o the kinetic chain is
rarely an isolated event. ypically, a pathology o the kinetic chain is part o a chain reac-
tion involving some key links in the kinetic chain and numerous compensations and adap-
tations that develop.61 T e interplay o many muscles about a joint is responsible or the
coordinated control o movement. I the core is weak, normal arthrokinematics are altered.
Changes in normal length-tension and orce-couple relationships, in turn, af ect neuro-
muscular control. I 1 muscle becomes weak, tight, or changes its degree o activation, then
synergists, stabilizers, and neutralizers have to compensate.16,29,61,64-66,88,89 Muscle tightness
has a signi cant impact on the kinetic chain. Muscle tightness af ects the normal length-
tension relationship.89 T is impacts the normal orce-couple relationship. When 1 muscle
in a orce-couple relationship becomes tight, it changes the normal arthrokinematics o
2 articular partners.14,61,89 Altered arthrokinematics af ect the synergistic unction o the
kinetic chain.14,29,61,89 T is leads to abnormal pressure distribution over articular sur aces
and so t tissues. Muscle tightness also leads to reciprocal inhibition.14,29,50-53,61,92,96 T ere-

ore, i one develops muscle imbalances throughout the lumbo-pelvic-hip complex, it can
af ect the entire kinetic chain. For example, a tight psoas causes reciprocal inhibition o the
gluteus maximus, A, internal oblique, and multi dus.47,51,53,77,80 T is muscle imbalance
pattern may decrease normal lum bo-pelvic-hip stability. Speci c substitution patterns
develop to compensate or the lack o stabilization, including tightness in the iliotibial
band.29 T is muscle imbalance pattern leads to increased rontal and transverse plane
stress at the knee. Dr. Vladam ir Janda proposed a syndrome, named the “crossed pelvis
syndrome,” in which a weak abdominal wall and weak gluteals are counterbalanced with
tight hamstrings and hip exors.51 A strong core with optimal neuromuscular e ciency can
help to prevent the development o muscle imbalances. Consequently, a comprehensive
core stabilization training program should be an integral component o all rehabilitation
programs. A strong, e cient core provides the stable base upon which the extremities can
unction with maximal precision and ef ectiveness. It is important to remember that the
spine, pelvis, and hips must be in proper alignment with proper activation o all muscles
during any core-strengthening exercise. Because no 1 muscle works in isolation, attention
should be paid to the position and activity o all muscles during open- and closed-chain
exercises.
Neuromuscular Considerations
A strong and stable core can optimize neuromuscular e ciency throughout the entire
kinetic chain by helping to improve dynamic postural control.37,43,47,57,83,88,89 A number o
authors have demonstrated kinetic chain imbalances in individuals with altered neuromus-
cular control.9,14-16,43,46-48,50-54,61-66,76,77,83,88 Research demonstrates that people with low back
pain have an abnormal neuromotor response o the trunk stabilizers accompanying limb
movement, signi cantly greater postural sway, and decreased limits o stability.46,47,71,77
Research also demonstrates that approximately 70% o patients suf er rom recurrent epi-
sodes o back pain. Furthermore, it has been demonstrated that individuals have decreased
dynamic postural stability in the proximal stabilizers o the lumbo-pelvic-hip complex ol-
lowing lower-extremity ligamentous injuries,9,14-16 and that joint and ligamentous injury can
lead to decreased muscle activity.29,92,96 Joint and ligament injury can lead to joint ef usion,
which, in turn, leads to muscle inhibition. T is leads to altered neuromuscular control in
other segments o the kinetic chain secondary to altered proprioception and kinesthesia.9,16
T ere ore, when an individual with a knee ligament injury has joint ef usion, all o the
muscles that cross the knee can be inhibited. Several muscles that cross the knee joint are
attached to the lumbo-pelvic-hip complex.80 Consequently, a comprehensive rehabilita-
tion approach should ocus on reestablishing optimal core unction so as to positively af ect
peripheral joints.
Research also demonstrates that muscles can be inhibited rom an arthrokinetic
re ex.14,61,92,96 T is is re erred to as arthrogenic m uscle inhibition . Arthrokinetic re exes
are mediated by joint receptor activity. I an individual has abnormal arthrokinematics,
the muscles that move the joint will be inhibited. For example, i an individual has a sacral
torsion, the multi dus and the gluteus medius can be inhibited.41 T is leads to abnormal
movement in the kinetic chain. T e tensor ascia latae become synergistically dominant
and the primary rontal plane stabilizer.80 T is can lead to tightness in the iliotibial band. It
can also decrease the rontal and transverse plane control at the knee. Furthermore, i the
multi dus is inhibited,41 the erector spinae and the psoas become acilitated. T is urther
inhibits the lower abdominals (internal oblique and A) and the gluteus maximus.43,46 T is
also decreases rontal and transverse plane stability at the knee. As previously mentioned,
an e cient core improves neuromuscular e ciency o the entire kinetic chain by providing
Scienti c Rationale for Core Stabilization Training 417
dynamic stabilization o the lumbo-pelvic-hip complex and improving pelvo emoral bio-
mechanics. T is is yet another reason why all rehabilitation programs should include a
comprehensive core stabilization training program.
Clin ica l Pe a r l
Individuals with poor core strength are likely to develop low back pain as a consequence
of improper muscle stability. 71 The straight-leg lowering test is a good way to assess core
strength.
Scienti c Rationale for Core

Stabilization Training
Most individuals train their core stabilizers inadequately compared to other muscle
groups.1,85,86 Although adequate strength, power, muscle endurance, and neuromuscu-
lar control are important or lumbo-pelvic-hip stabilization, per orming exercises incor-
rectly or that are too advanced is detrimental.60,85,86 Several authors have ound decreased
ring o the A, internal oblique, multi dus, and deep erector spinae in individuals with
chronic low back pain.43,46-48,77,82 Per orming core training with inhibition o these key stabi-
lizers leads to the development o muscle imbalances and ine cient neuromuscular con-
trol in the kinetic chain. It has been demonstrated that abdominal training without proper
pelvic stabilization increases intradiscal pressure and compressive orces in the lumbar
spine.3,5,10,43,46-48,74,75 Furthermore, hyperextension training without proper pelvic stabiliza-
tion can increase intradiscal pressure to dangerous levels, cause buckling o the ligamen-
tum avum, and lead to narrowing o the intervertebral oramen.3,5,10,75
Research also shows decreased stabilization endurance in individuals with chronic
low back pain.10,18,33,34,70 T e core stabilizers are primarily type I slow-twitch muscle
bers.33,34,78,79 T ese muscles respond best to time under tension. ime under tension is a
method o contraction that lasts 6 to 20 seconds and emphasizes hypercontractions at end
ranges o motion. T is method improves intramuscular coordination, which improves static
and dynamic stabilization. o get the appropriate training stimulus, you must prescribe the
appropriate speed o movement or all aspects o exercises.22,23 Core strength endurance
must be trained appropriately to allow an individual to maintain dynamic postural control
or prolonged periods o time.3
Research demonstrates a decreased cross-sectional area o the multi dus in subjects
with low back pain, and that spontaneous recovery o the multi dus ollowing resolution
o symptoms does not occur.41 It has also been demonstrated that the traditional curl-up
increases intradiscal pressure and increases compressive orces at L2-L3.3,5,10,74,75
Additional research demonstrates increased EMG activity and pelvic stabilization
when an abdominal drawing-in maneuver is per ormed prior to initiating core train-
ing.3,10,13,22,36,37,48,72,76,83 Also, maintaining the cervical spine in a neutral position during core
training improves posture, muscle balance, and stabilization. I the head protracts during
movement, then the sternocleidomastoid is pre erentially recruited. T is increases the
compressive orces at the C0-C1 vertebral junction. T is can lead to pelvic instability and
muscle imbalances secondary to the pelvo-occular re ex. T is re ex is important to keep
the eyes level.62,63 I the sternocleidomastoid muscle is hyperactive and extends the upper
cervical spine, then the pelvis will rotate anteriorly to realign the eyes. T is can lead to mus-
cle imbalances and decreased pelvic stabilization.62,63
Clin ica l Pe a r l
Frequently altering a rehabilitation program will help keep a patient interested. Consider
these variables as you plan changes: plane of motion, range of motion, loading
parameter (Physioballs, tubing, medicine balls, Bodyblades, etc.), body position (from
supine to standing), speed of movement, amount of control, duration (sets and reps),
and frequency.
Assessment of the Core

Be ore a comprehensive core stabilization program is implemented, an individual must
undergo a comprehensive assessment to determine muscle imbalances, arthrokinematic
de cits, core strength, core muscle endurance, core neuromuscular control, core power,
and overall unction o the lower-extremity kinetic chain. Assessment tools include activity-
based tests that are per ormed in the clinical setting, EMG with sur ace or indwelling
electrodes, and technologically advanced testing and training techniques using real-time
ultrasound. Rehabilitative ultrasound imaging (RUSI) has been used extensively in research
settings and has been proven to be a reliable tool in evaluating the activation patterns o
various abdominal muscles.38,94 RUSI, although not currently readily available in clinical
settings, is a great asset in the laboratory setting. Perhaps the uture will allow or more use
o RUSI in clinical practice.
It was previously stated that m uscle im balances and arthrokinem atic de cits can
cause abnormal m ovem ent patterns to develop throughout the entire kinetic chain. Con-
sequently, it is extrem ely im portant to thoroughly
assess each individual with a kinetic chain dys unc-
tion or m uscle im balan ces an d arthrokin em atic
de cits. All procedures or assessm ent are beyond
the scope o this chapter, and the interested reader
is re erred to the com prehensive re erences provided
to gain an un derstanding o additional assessm ent
procedures that m ay be used to identi y m uscle
im balances. It is recom m ended that the interested
reader use the ollowing re erences to explain a com -
prehensive muscle im balance assessm ent procedure
thoroughly.1,14,19,22,23,28,48,52,54,55,64,88,89,96
Core strength can be assessed by using the
straight-leg lowering test.3,48,58,76,88,89 T e individual is
placed supine. A pressure bio eedback device called
the Stabilizer (Figure 15-4) is placed under the lumbar
spine at approximately L4-L5. T e cuf pressure is raised
to 40 mm Hg. T e individual’s legs are maintained
in ull extension while exing the hips to 90 degrees
(Figure 15-5). T e individual is instructed to per orm
a drawing-in maneuver (pull belly button to spine)
and then atten the back maximally into the table and
pressure cuf . T e individual is instructed to lower the
legs toward the table while maintaining the back at.
Figure 15-4 Stabilize r pre ssure fe e dback unit T e test is over when the pressure in the cuf decreases.
T e hip angle is then measured with a goniometer to
(Courtesy, Chattanooga, a brand of DJO Global Inc.) determine the angle using a rating scale developed by
Assessment of the Core 419
Fa ir 5
Fa ir + (6)
Good − (7)
°
0
°
9
5
Good (8)
°
0
6
°
5
4
° Good + (9)
30
Figure 15-5
15°
Core strength can be assessed using a straight leg-lowering 0° Norma l (10)

test.
Figure 15-6
Kendall (Figure 15-6).59 T is test provides a basic idea o Key to muscle grading in the straight-leg lowering test.
how strong the lower abdominal muscle groups (rectus (Reproduced with permission from Kendall FP, McCreary EK,
abdominis and external obliques) are. Using the pressure Provance PG, Rodgers MM, Romani WA. Muscles: Testing and
eedback device ensures there is no compensation with Function. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins;
the lumbar extensors or large hip exors to stabilize the 2005.)
long lever arm o the legs.

Neuromuscular control o the deep core muscles, A and multi di, are evaluated with
the quality o movement emphasized rather than quantity o muscular strength or endurance
time. Un ortunately, no objecti able manual muscle test exists or either o these important
muscles/ muscle groups; however, Hides et al40 have developed prone and supine tests to
evaluate the muscular coordination o the A and multi dus. T e rst test or the A is per-
ormed in the prone position with the Stabilizer pressure bio eedback unit placed under the
abdomen with the navel in the center and the distal edge o the pad in line with the right and
le t anterior superior iliac spines (Figure 15-7). T e pressure pad is in ated to 70 mm Hg. It is
important to instruct the patient to relax the patient’s abdomen ully prior to the start o the
test. T e patient is then instructed to take a relaxed breath in and out, and then to draw the
abdomen in toward the spine without taking
a breath. T e patient is asked to hold this
contraction or a minimum o 10 seconds,
with a slow and controlled release. Optimal
per ormance, indicating proper neuromus-
cular control o the A, is a 4- to 10-mm Hg
reduction in the pressure with no pelvic or
spinal movement noted. It is important to
monitor pelvic and lower-extremity posi-
tioning as the patient may compensate by
putting pressure through the patient’s legs
or tilting the patient’s pelvis to elevate the
lower abdomen rather than isolating the A
contraction.
esting or the A is also per ormed
in the supine position and relies on palpa-
tion and visualization o the lower abdomen. Figure 15-7 Pro ne transve rse abdo minis te st
Instructions to the patient remain the same as the prone

test and the therapist palpates or bilateral A contraction
just medially and in eriorly to the anterior superior iliac
spines and lateral to the rectus abdominis (Figure 15-8A).
T e Stabilizer pad may also be placed under the lower
lumbar region to monitor whether compensation occurs
with the pelvis (Figure 15-8B). T e pressure reading
should remain the same throughout the test. A change
in the pressure reading indicates that the patient is tilt-
ing the patient’s pelvis anteriorly (pressure decreases) or
posteriorly (pressure increases) in an attempt to atten the
patient’s lower abdomen. T e patient is asked to hold this
contraction or a minimum o 10 seconds, with a slow and
controlled release. With a correct contraction o the A,
A the therapist eels a slowly developing deep tension in the
lower abdominal wall. Incorrect activation o the A would
be evident when the internal oblique dominates and this is
detected when a rapid development o tension is palpated
or the abdominal wall is pushed out rather than drawn in.
T e neuromuscular control o the multi di is exam-
ined with the patient in the prone position and the
therapist palpating the level o the multi dus or mus-
cular activation (Figure 15-9). T e patient is instructed
to breathe in and out and to hold the breath out while
B swelling out the muscles under the therapist’s ngers.
T e patient is then asked to hold the contraction while
resuming a normal breathing pattern or a minimum o
10 seconds. T e therapist palpates the multi dus or sym-
Figure 15-8 Supine transve rsus abdo minis te st metrical activation and slow development o muscular
activation. T is sequence is repeated at the multiple seg-
ments in the lumbar spine. Compensation patterns may include anterior or posterior pelvic
tilting or elevation o the rib cage in an attempt to swell out the multi dus.
A proper and thorough evaluation o the core muscles will lead the therapist in devel-
oping a proper core stabilization program. It is imperative that neuromuscular control o
the A and multi dus precedes all other stabilization exercises. T ese muscles provide the
oundation rom which all the other core muscles work.
Clin ica l Pe a r l
Rehabilitative ultrasound imaging (RUSI) or diagnostic musculoskeletal ultrasound (MSK)

can be utilized to assess dynamic activity of the TA and multi di. However, this technique
requires equipment and operator training. Use of diagnostic ultrasound for clinical
assessment is increasing.
Core Stabilization Training Program

As previously noted, the training program must progress in a scienti c, systematic pattern
with the ultimate goal o training the trunk stabilizers to be active in all phases o unctional
tasks. T ese tasks may include simple static postures, such as standing or sitting, and prog-
ress to very complex tasks, such as high-intensity athletic skills.67 Patient education is the
Core Stabilization Training Program 421
Figure 15-10 The draw ing -in mane uve r re quire s

a co ntractio n o f the transve rsus abdo minis
Figure 15-9 Palpating the multi di for

muscular activation
key to a success ul exercise program. T e patient must be able to visualize the muscle acti-
vation patterns desired and have a high level o body awareness allowing them to activate
their core muscles with the proper positioning, neuromuscular control, and level o orce
generation needed or each individual task.
Performing t he Drawing-In Maneuver

Muscular activation o the deep core stabilizers ( A and multi dus) coordinated with nor-
mal breathing patterns is the oundation or all core exercises.60 All core stabilization exer-
cises must rst start with the “drawing-in” maneuver (Figure 15-10). Opinions vary69,81 in
the exercise science world about the activation o the abdominal muscles during activities.
McGill69 is a proponent o the abdominal bracing technique where the patient is
advised to stif en or activate both the trunk exors and extensors maximally to prevent spi-
nal movement. He uses the training technique o demonstrating this bracing pattern at the
elbow joint. He asks the patient to stif en his or her elbow joint by simultaneously activating
the elbow exors and extensors and resisting an externally applied orce that attempts to
ex the patient’s elbow. Once the patient has mastered that concept, the same principles
are applied to the trunk.
Richardson et al81 teach the abdominal hollowing technique where the navel is drawn
back toward the spine without spinal movement occurring. T is technique does not ask
patients to do a maximal contraction, but instead, a submaximal, steady development o
muscle activation.
We have used a teaching technique that incorporates submaximal abdom inal hol-
lowing and m oderate bracing o the trunk. While standing in ront o a m irror, patients
are asked to put their hands on their iliac crests so their ngers rest anteriorly on their
transverse abdom inals and internal obliques. A good way to state this to the patient is:
“put your hands on your hips like you are m ad.” Patients are then instructed to draw
their navel back toward their spine without m oving their trunk or body while continu-
ing to breathe normally. A good verbal cue is to “make your waist narrow like you are
putting on a tight pair o jeans, without sucking in your breath.” While in that position,
patients are also instructed to not let anyone “push them around” or push them of bal-
ance. T is helps incorporate the total-body bracing technique and the use o the upper
Table 15-1 Te aching Cue s fo r Activatio n o f Co re Muscle s
Ve rbal Cue s
1. Draw navel back toward spine without moving your spine or tilting your pelvis.
2. Make your waist narrow.
3. Pull your abdomen away from your waistband of your pants.
4. Draw lower abdomen in while simulating zipping up a tight pair of pants.
5. Continue breathing normally while contracting lower abdominals.
6. Tighten pelvic oor.
a. Women: contract pelvic oor so you do not leak urine.
b. Men: draw up scrotum as if you are walking in waist deep cold water.
Physical Cue s
1. Use mirror for visual feedback.

2. Put your hands on your waist like you are mad—draw abdomen away from ngertips
while still breathing normally.
3. Tactile facilitation.
a. Use tape on skin for cutaneous feedback.
b. String tied snugly around waist.
4. EMG biofeedback unit.
5. Electrical muscular stimulation.
6. Isometric contraction and holding of pelvic oor and hip adductors.
and lower extrem ities to acilitate total-body stabilization. T is can be re erred to as “the
power position” or “hom e base,” and these key words may be used when teaching the
progression o all core exercises ( able 15-1 or other teaching cues or proper muscular
activation o core muscles).71,85 It should be em phasized that proper muscular activation
cannot be achieved i the patient is holding their breath.
It should also be noted that the drawing-in maneuver should not be abandoned when
the patient is per orming other exercises such as weightli ting, walking, or other aerobic
tasks such as step aerobics, aqua aerobics, or running.
Speci c Core St abilizat ion Exercises

Once the drawing-in maneuver is per ected, neuro-
muscular control o the A and multi dus is accom-
plished in the prone and supine positions as described
in “Assessment o the Core” above. T en progression o
exercises into other positions can take place. Quadru-
ped is a good starting position or the patient to learn
and enhance their power position (Figure 15-11). T is
acilitates the patient keeping their body steady and
minimizing trunk movement. T e patient is instructed
to keep the trunk straight like a tabletop and then draw
the stomach up toward the spine (activating the A and
multi dus) while maintaining the normal breathing
pattern. T is position is held or a minimum o 10 sec-
onds and progressed in time to up to 30 to 60 seconds,
Figure 15-11 Quadrupe d po sitio n fo r maste ring working on endurance o these trunk muscles.67,70 T e
the “draw ing -in” mane uve r o r po w e r po sitio n patient is advised to release the contraction slowly in an
eccentric manner and no spinal movement should occur during this release phase. When
this position is mastered by the patient and the therapist eels that the patient is ready, the
di culty o the exercise can be progressed, limited only by the capabilities o the patient.
Figures 15-12 through 15-14 illustrate the exercises used in a comprehensive core stabi-
lization training program. Exercises may be broken down into 3 levels in the progressive core
stabilization training program : level 1—stabilization (Figure 15-12); level 2—strengthening
(Figure 15-13); and level 3—power (Figure 15-14). T e patient is started with the exercises
at the highest level at which the patient can maintain stability and optimal neuromuscular
control. T e patient is progressed through the program when the patient achieves mastery
o the exercises in the previous level.l,2,4,10,12,15,17,18,22-25,29,34,39,42-48,55,56,62-64,67,68,73,78,79,90,91
A B
C D
Figure 15-12 Le ve l 1 (stabilizatio n) co re stability e xe rcise s
A. Double-leg bridging. B. Prone cobra. C. Front plank. D. Lunge. E. Side plank.

F G
I
H
J K
F. Squats with Thera-Band. G. Pelvic tilts on stability ball. H. Diagonal crunches. I. Alternating opposite arm-leg.
J. Single-leg lunge with abdominal bracing. K. Sit-to-stand with abdominal bracing.
G F
Figure 15-13 Le ve l 2 (stre ng th) co re stability e xe rcise s
A. Bridge with single-leg extension. B. Front plank with single leg-extension. C. Supine alternating arms and legs
(AKA: Dying bug). D. Pushup to side plank. E. Bridging on stability ball. F. Stability ball diagonal crunches.
G. Push-ups on therapy ball.
H I
N O
H. Stability ball hip-ups. I. Stability ball side plank. J. Stability ball pike-ups. K. Stability ball crunches. L. Stability ball
rotation with weighted ball. M. Stability ball single arm dumbbell press with rotation. N. Stability ball diagonal rotations
with weighted ball. O. Prone hip extension.
P
Q
U V
P. Stability ball wall slides. Q. Stability ball straight-leg raise. R. Stability ball hip extension. S. Half-kneeling rotation.
T. Stability balls two-arm support. U. Stability ball Russian twist. V. Stability ball prone cobra.
W X
W. Weight shifting on stability ball. X. Proprioceptive neuromuscular facilitation Bodyblade™.
A B C D
E F G
Figure 15-14 Le ve l 3 (po w e r) co re stability e xe rcise s
A. Weighted ball single-leg jump. B. Weighted ball Diagonal 2 proprioceptive neuromuscular facilitation pattern.
C. Weighted ball double-leg jump. D. Overhead extension. E. Overhead weighted ball throw. F. Weighted ball
one-arm chest pass with rotation. G. Weighted ball double-arm rotation toss from squat.
Guidelines for Core Stabilization Training 429
H I
H. Weighted ball forward jump from squat. I. Stability ball pullover crunch with weighted ball.
Clin ica l Pe a r l
The ultimate goal with core strengthening is functional strength and dynamic stability. As
the patient progresses, the emphasis should change in these ways: from slow to fast, from
simple to complex, from stable to unstable, from low force to high force, from general to
speci c, and from correct execution to increased intensity. Once the patient has gained
awareness of proper muscle ring, encourage the patient to perform exercises in a more
functional manner. Because most functional activities require multiplane movement, design
the exercises to mimic those requirements.
Guidelines for Core Stabilization Training

A com prehensive core stabilization training program should be system atic, progressive,
an d un ctional. he rehabilitation program should em phasize the entire m uscle con-
traction spectrum, ocusing on orce production (concentric
contraction s), orce reduction (eccentric contraction s), an d Table 15-2 Pro g ram Variatio n
dynam ic stabilization (isom etric contractions). he core sta-
bilization program should begin in the m ost challenging envi-
ronm ent the individual can control. A progressive continuum 1. Plane of motion
o unction should be ollowed to system atically progress the 2. Range of motion
in dividual. he program should be m an ipulated regularly 3. Loading parameter
by changing any o the ollowing variables: plane o m otion, 4. Body position
ran ge o m otion , loadin g param eters (Physioball, m edicin e 5. Speed of movement
ball, Bodyblade, power sports trainer, weight vest, dum bbell, 6. Amount of control
tubin g), body position , am ount o control, speed o execu- 7. Duration
tion , am ount o eedback, duration (sets, reps, tem po, tim e 8. Frequency
under tension), and requency ( able 15-2).
Table 15-3 Exe rcise Se le ctio n Speci c Core St abilizat ion Guidelines
When designing a unctional core stabilization training program,
1. Safe the therapist should create a proprioceptively enriched environ-
2. Challenging ment and select the appropriate exercises to elicit a maximal
3. Stress multiple planes training response. T e exercises must be sa e and challenging,
4. Proprioceptively enriched stress multiple planes, incorporate a multisensory environment,
5. Activity speci c be derived rom undamental movement skills, and be activity
speci c ( able 15-3).
T e therapist should ollow a progressive unctional con-
tinuum to allow optimal adaptations.28,31,36,55 T e ollowing are
Table 15-4 Exe rcise Pro g re ssio n key concepts or proper exercise progression: slow to ast, sim-
ple to complex, known to unknown, low orce to high orce, eyes
open to eyes closed, static to dynamic, and correct execution to
1. Slow to fast 20,21,22,28,31,32,36,55
2. Simple to complex
increased reps/ sets/ intensity ( able 15-4).
3. Stable to unstable T e goal o core stabilization should be to develop opti-
4. Low force to high force mal levels o unctional strength and dynamic stabilization.1,10
5. General to speci c Neural adaptations become the ocus o the program instead
6. Correct execution to increased intensity o striving or absolute strength gains.14,28,52,76 Increasing pro-
prioceptive demand by utilizing a multisensory, multimodal
(tubing, Bodyblade, Physioball, m edicine ball, power sports
trainer, weight vest, cobra belt, dum bbell) environm ent
becom es m ore im portant than increasing the external resistance.20,32 T e concept o
quality be ore quantity is stressed. Core stabilization training is speci cally designed to
improve core stabilization and neuromuscular e ciency. You must be concerned with the
sensory in ormation that is stimulating the patient’s central nervous system. I the patient
trains with poor technique and neuromuscular control, then the patient develops poor
m otor patterns and stabilization.28,55 T e ocus o the program must be on unction. o
determine i the program is unctional, answer the ollowing questions:
• Is it dynamic?
• Is it multiplanar?
• Is it multidimensional?
• Is it proprioceptively challenging?
• Is it systematic?
• Is it progressive?
• Is it based on unctional anatomy and science?
• Is it activity speci c?28,31,55
In summary, the core strengthening program must always start with the drawing-
in maneuver that produces neuromuscular control o the A and multi dus. Abdominal
strength is not the key; rather, it is abdominal endurance within a stabilized trunk that
enhances unction and may prevent or minimize injury. T e trunk must be dynamic and
able to move in multiple directions at various speeds, yet have internal stability that pro-
vides a strong base o support so as to support unctional mobility and extremity unc-
tion. T e therapist is only limited by the therapist’s own imagination in the development
o core stabilization exercises. I the power position is maintained throughout the exercise
sequence and the exercise is individualized to the needs o a patient, then it is an appropri-
ate exercise! T e key is to integrate individual exercises into unctional patterns and simu-
late the demands o simple tasks and progress to the highest level o skill needed by each
individual patient.
SUMMARY
1. Functional kinetic chain rehabilitation must address each link in the kinetic chain and
strive to develop unctional strength and neuromuscular e ciency.
2. A core stabilization program should be an integral component or all individuals par-
ticipating in a closed kinetic-chain rehabilitation program.
3. A core stabilization training program will allow an individual to gain optimal neuro-
muscular control o the lumbo-pelvic-hip complex and allow the individual with a
kinetic chain dys unction to return to activity more quickly and sa ely.
4. T e important core muscles do not unction as prime movers; rather, they unction as
stabilizers.
5. T ere are some clinical methods o measuring the unction o the A and multi dus
unction.
6. Real-time ultrasound is an ef ective research tool or assessment o core stabilizers.
7. T e Stabilizer is a use ul adjunct to examination and training o the core.
8. Many possibilities exist or core training progressions. Progression is achieved by
changing position, lever arms, resistance, and stability o sur aces.
9. runk exion activities such as the curl and sit-up are not only unnecessary, but also
may cause injury.
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Vid e o s a re a va ila b le a t w w w.a cce ssp h ysio t h e ra p y.co m .
Su b scrip t io n is re q u ire d .
Aquatic T erapy
in Rehabilitation
Ba r b a r a J. Ho o g e n b o o m a n d Na n cy E. Lo m a x
OBJJE C TII V E S t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Explain the principles of buoyancy and speci c gravity and the role they have in the aquatic
environment.
Identify and describe the three major resistive forces at work in the aquatic environment.
Apply the principles of buoyancy and resistive forces to exercise prescription and progression.
Contrast the advantages and disadvantages of aquatic therapy in relation to traditional

land-based exercise.
Identify and describe techniques of aquatic therapy for the upper extremity, lower extremity,
and trunk.
Select and utilize various types of equipment for aquatic therapy.
Incorporate functional, work-, and sport-speci c movements and exercises performed in the
aquatic environment into rehabilitation.
Understand and describe the necessity for transition from the aquatic environment to the
land environment.
435
436 Chapte r 16 Aquatic Therapy in Rehabilitation
In re ent years, there has een widespread interest in aquati therapy. It has rapidly e ome
a popular reha ilitation te hnique or treatment o a variety o patient/ lient populations.
T is new ound interest has sparked numerous resear h ef orts to evaluate the ef e tiveness
o aquati therapy as a therapeuti intervention. Current resear h shows aquati therapy to
e ene ial in the treatment o everything rom orthopedi injuries to spinal ord damage,
hroni pain, ere ral palsy, multiple s lerosis, and many other onditions, making it use ul
in a variety o settings.29,38 It is also gaining a eptan e as a preventative maintenan e tool
to a ilitate overall tness, ross-training, and sport-spe i skills or healthy athletes.23,33,34
General onditioning, strength, and a wide variety o movement skills an all e enhan ed
y aquati therapy.19,43,48,54
T e use o water as a part o healing te hniques has een tra ed a k through history
to as early as 2400 bc , ut it was not until the late 19th entury that more traditional types
o aquati therapy ame into existen e.4,24 T e development o the Hu ard style whirl-
pool tank in 1820 sparked the initiation o present-day therapeuti use o water y allowing
aquati therapy to e ondu ted in a highly ontrolled lini al setting.8 Loeman and Roen
took this a step arther in 1824 and stimulated interest in use o an a tual pool or what we
now all aquati therapy. Only re ently, however, has water ome into its own as a thera-
peuti exer ise medium used or a wide variety o diagnoses and dys un tions.41
Aquati therapy is elieved to e ene ial primarily e ause it de reases joint om-
pression or es. T e per eption o weightlessness experien ed in the water assists in
de reasing joint pain and eliminating or drasti ally redu ing the ody’s prote tive mus-
ular spasm and pain that an arry over into the patient’s daily un tional a tivities.54,56
Although many patients per eive greater ease o movement in the aquati environment as
ompared to movement on land, the resear h shows that aquati therapy does not a tually
de rease pain more ef e tively than a tivities on land.25 T e primary goal o aquati ther-
apy is to tea h the patient/ lient how to use water as a modality or improving movement,
strength, and tness.2,54 T us, along with other therapeuti modalities and interventions,
aquati therapy an e ome one link in the patient/ lient’s re overy hain.1
Physical Properties and Resistive Forces

T e therapist must understand several physi al properties o the water e ore designing an
aquati therapy program. Land exer ise annot always e onverted to aquati exer ise,
e ause uoyan y rather than gravity is the major or e governing movement. A thorough
understanding o uoyan y, spe i gravity, the resistive or es o the water, and their rela-
tionships must e the groundwork o any therapeuti aquati program. T e program must
e individualized to the patient/ lient’s parti ular injury/ ondition and a tivity level i it is
to e su ess ul.
Buoyancy
Buoyan y is one o the primary or es involved in aquati therapy. All o je ts, on land
or in the water, are su je ted to the downward pull o the earth’s gravity. In the water,
however, this or e is ountera ted to some degree y the upward uoyant or e. A ord-
ing to Ar himedes’ Prin iple, any o je t su merged or oating in water is uoyed upward
y a ounter or e that helps support the su merged o je t against the downward pull o
gravity. In other words, the uoyant or e assists motion toward the water’s sur a e and
resists motions away rom the sur a e.26,54 Be ause o this uoyant or e, a person entering
the water experien es an apparent loss o weight.15 T e weight loss experien ed is nearly
Physical Properties and Resistive Forces 437
equal to the weight o the liquid that is displa ed when
the o je t enters the water ( Figure 16-1).
For exam ple, a 100-l individual, when alm ost om - Gravity
pletely su m erged, displa es a volum e o water that
weighs nearly 95 l ; there ore, that person eels as though
she/ he weighs less than 5 l . T is sen sation o urs
e ause, when partially su m erged, the individual only
ears the weight o the part o the ody that is a ove the
Buoya ncy
water. With im m ersion to the level o the seventh ervi-
al verte ra, oth males and emales only ear approxi-
mately 6% to 10 % o their total ody weight ( BW). T e
per entages in rease to 25 to 31 BW or em ales and
30 to 37 BW or males at the xiphisternal level, and to Figure 16-1 The buoyant force
40 to 51 BW or emales and 50 to 56 BW or males at
the anterosuperior ilia spine level ( a le 16-1).27 T e
per entages dif er slightly or males and emales e ause o the dif eren es in their en-
ters o gravity. Males arry a higher per entage o their weight in the upper ody, whereas
emales arry a higher per entage o their weight in the lower ody. T e enter o grav-
ity on land orresponds with a enter o uoyan y in the water.41 Variations o uild
and ody type only m inimally ef e t weight earing values. As a result o the de reased
per entage o weight earing of ered y the uoyant or e, ea h joint that is elow the
water is de om pressed or unweighted. T is allows am ulation and vigorous exer ise to
e per orm ed with little im pa t and drasti ally redu ed ri tion etween joint arti ular
sur a es.
Progressing the a tivity rom walking to running in the aquati environment does not
hange the or es on the joints; however, minimal hanges in the joint or es o ur as the
speed o running is in reased. Fontana et al20 report a 34% to 38% de rease in or e while
running at hip level o water and a 44% to 47% de rease or e with running at hest level, as
ompared to running on land. T e relative de rease in weight earing or es during aquati
a tivities need to e onsidered when dealing with athletes with injuries and restri tions o
weight earing, and may allow early running or those with su h onditions and limitations.
T rough are ul use o Ar himedes’ Prin iple, a gradual in rease in the per entage o
weight earing an e undertaken. Initially, the patient/ lient would egin non-weight-
earing exer ises in the deep end o the pool. A wet vest or similar uoyan y devi e might
e used to help the patient/ lient remain a oat or the desired exer ises. T is and other
ommer ial equipment availa le or the use in the aquati environment will e dis ussed
in the up oming se tion “Fa ilities and Equipment.”
Speci c Gravit y able 16-1 We ig htbe aring Pe rce ntag e s

Buoyan y is partially dependent on ody weight. How-
ever, the weight o dif erent parts o the ody is not on-
stant. T ere ore, the uoyant values o dif erent ody Pe rce ntag e o f We ig ht Be aring
parts will vary. Buoyant values an e determined y sev- Bo dy Le ve l Male Fe male
eral a tors. T e ratio o one weight to mus le weight,
C7 8 8
the amount and distri ution o at, and the depth and
expansion o the hest all play a role. ogether, these a - Xiphisternal 28 35
tors determine the spe i gravity o the individual ody
ASIS (anterior 47 54
part. On average, humans have a spe i gravity slightly
superior iliac spine)
less than that o water. Any o je t with a spe i gravity
less than that o water will oat. An o je t with a spe i
gravity greater than that o water will sink. However, as with uoyant values, the spe i grav-
ity o all ody parts is not uni orm. T ere ore, even with a total- ody spe i gravity o less
than the spe i gravity o water, the individual might not oat horizontally in the water.
Additionally, the lungs, when lled with air, an urther de rease the spe i gravity o the
hest area. T is allows the head and hest to oat higher in the water than the heavier, denser
extremities. Many athletes tend to have a low per entage o ody at (spe i gravity greater
than water) and there ore an e thought o as “sinkers.” Consequently, ompensation with
otation devi es at the extremities and trunk might e ne essary or some athletes.5,54
Resist ive Forces

Water has 12 times the resistan e o air.50 T ere ore, when an o je t moves in the water; the
several resistive or es that are at work must e onsidered. For es must e onsidered or
oth their potential ene ts and their pre autions. T ese or es in lude the ohesive or e,
the ow or e, and the drag or e.
Cohesive Force
T ere is a slight ut easily over ome ohesive or e that runs in a parallel dire tion to the
water sur a e. T is resistan e is ormed y the water mole ules loosely inding together,
reating a sur a e tension. Sur a e tension an e seen in still water, e ause the water
remains motionless with the ohesive or e inta t unless distur ed.
Bow Force
A se ond or e is the ow or e, or the or e that is gen-
erated at the ront o the o je t during movement. When
the o je t moves, the ow or e auses an in rease in the
water pressure at the ront o the o je t and a de rease
Force in the water pressure at the rear o the o je t. T is pres-
sure hange auses a movement o water rom the high-
pressure area at the ront to the low-pressure area ehind
the o je t. As the water enters the low-pressure area, it
swirls in to the low-pressure zone and orms eddies, or
Move me nt small whirlpool tur ulen es.14 T ese eddies impede ow
y reating a a kward or e, or drag or e (Figure 16-2).
Figure 16-2 The bow force Drag Force

T is third or e, the uid drag or e, is very important in
aquati therapy. T e ow or e on an o je t (and there-
ore also the drag or e) an e ontrolled y hang-
ing the shape o the o je t or the speed o its movement
(Figure 16-3).
Fri tional resistan e an e de reased y making the
o je t more streamlined. T is hange minimizes the sur-
Force Dra g force
a e area at the ront o the o je t. Less sur a e area auses
less ow or e and less o a hange in pressure etween
the ront and rear o the o je t, resulting in less drag or e.
In a streamlined ow, the resistan e is proportional to the
velo ity o the o je t. When working with a patient/ lient
Move me nt with generalized weakness, onsideration o the aquati
environm ent is ne essary. In reased a tivity o urring
around the patient/ lient and tur ulen e o the water an
Figure 16-3 Drag force make walking a hallenging a tivity (Figure 16-4).
Advantages and Bene ts of Aquatic Rehabilitation 439
On the other hand, i the o je t is not streamlined, a
tur ulent situation (also re erred to as pressure or orm
drag) exists. In a tur ulent situation, drag is a un tion
o the velo ity squared. T us, y in reasing the speed o
movement 2 times, the resistan e the o je t must over- Force
15
ome is in reased 4 times. T is provides a method to
in rease resistan e progressively during aquati reha ili-
tation. Considera le tur ulen e an e generated when
the speed o movement is in reased, ausing mus les
to work harder to keep the movement going. Another Move me nt
method to in rease resistan e is to hange dire tions o
m ovement, reating in reased drag. Finally, y simply
hanging the shape o a lim through the addition o reha-
Figure 16-4 Streamlined movement
ilitation equipment that in reases sur a e area, the ther-
This creates less drag force and less turbulence.
apist an modi y the patient/ lient’s workout intensity to
mat h strength in reases (Figure 16-5).
Drag or e must also e onsidered when portions o
a lim or joint must e prote ted a ter injury or surgery.
For example, when working with a patient/ lient with an
a utely injured medial ollateral or anterior ru iate liga-
ment o the knee, resistan e must not e pla ed distal
to the knee e ause o the in reased torque that o urs
aused y drag or es. Force Turbule nce
Quanti ation o resistive or es that o ur during
aquati exer ise is a hallenge. Pöyhönen et al examined
knee exion and extension in the aquati environment using
an anatomi model in are oot and hydro oot-wearing on-
Move me nt
ditions. T ey ound that the highest drag or es and drag
oe ients o urred during early extension rom a exed
position (150 to 140 degrees o exion) while wearing the Figure 16-5 Turbulent ow
hydro oot (making the oot less streamlined), and that aster
velo ity was asso iated with higher drag or es.47
On e therapy has progressed, the patient/ lient ould e moved to ne k-deep water to
egin light weight earing exer ises. Gradual in reases in the per entage o weight earing
are a omplished y systemati ally moving the patient/ lient to shallower water. Even when
in waist-deep water, oth male and emale patients/ lients are only earing approximately
50% o their BW. By pla ing a sinka le en h or hair in the shallow water, step-ups an e
initiated under partial weight earing onditions long e ore the patient/ lient is apa le o
per orming the same exer ise ull weight earing on land. T us, the advantages o dimin-
ished weight earing exer ises are oupled with the proprio eptive ene ts o losed-kineti -
hain exer ise, making aquati therapy an ex ellent un tional reha ilitation a tivity.
Advantages and Bene ts of

Aquatic Rehabilitation
T e addition o an aquati therapy program an of er many advantages to a patient or
patient/ lient’s therapy ( a le 16-2).22,54 T e uoyan y o the water allows a tive exer ise
while providing a sense o se urity and ausing little dis om ort.51 Utilizing a om ination
o the water’s uoyan y, resistan e, and warmth, the patient/ lient an typi ally a hieve
more in the aquati environment than is possi le on land.34 Early in the reha ilitation
able 16-2 Indicatio ns and Be ne ts o f Aquatic The rapy
Indicatio ns fo r Use o f Aquatic The rapy Illustratio n o f Be ne ts
Swelling/peripheral edema Assist in edema control, decrease pain, increase mobility as edema decreases
Decreased range of motion Earlier initiation of rehabilitation, controlled active movements
Decreased strength Strength progression from assisted to resisted to functional; gradual

increase in exercise intensity
Decreased balance, proprioception, Earlier return to function in supported, forgiving environment, slower
coordination movements
Weightbearing restrictions Can partially or completely unweight the lower extremities; regulate
weightbearing progressions
Cardiovascular deconditioning or potential Gradual increase of exercise intensity, alternative training environment for
deconditioning because of inability to train lower weight bearing
Gait deviations Slower movements, easier assessment, and modi cation of gait
Dif culty or pain with land interventions Increased support, decreased weight bearing, assistance as a result of
buoyancy, more relaxed environment
Source: Reproduced from Irion JM. Aquatic therapy. In: Bandy WD, Sanders B, eds. Therapeutic Exercise: Techniques for Intervention . Baltimore,
MD: Lippincott, Williams & Wilkins; 2001:295-332; Sova R. Aquatic Activities Handbook. Boston, MA: Jones & Bartlett; 1993; and Thein JM, Thein
Brody L. Aquatic-based rehabilitation and training for the elite athlete. Orthop Sports Phys Ther. 1998;27(1):32-41.
pro ess, aquati therapy is use ul in restoring range o motion and exi ility. As normal
un tion is restored, resistan e training and sport-spe i a tivities an e added.
Following an injury, the aquati experien e provides a medium where early motions an
e per ormed in a supportive environment. T e slow motion ef e t o moving through water
provides extra time to ontrol movement, whi h allows the patient/ lient to experien e
multiple movement errors without severe onsequen es.43,49 T is is espe ially help ul in
lower-extremity injuries where alan e and proprio eption are impaired. Geigle et al dem-
onstrated a positive relationship etween use o a supplemental aquati therapy program
and unilateral tests o alan e when treating athletes with inversion ankle sprains.22 T e
in reased amount o time to rea t and orre t movement errors, om ined with a medium
in whi h the ear o alling is removed, assists the patient’s a ility to regain proprio eption
and neuromus ular ontrol. For the lient population that has diagnosis o rheumatoid and/
or osteoarthritis with lower-extremity involvement, approximately 80% demonstrate alan e
di ulties and higher risk or alls.16,17 A study per ormed y Suomi and Ko eja 52 demon-
strated that aquati exer ise helped de rease total sway area and medial/ lateral sway in oth
ull vision and no vision onditions, whi h pla ed them in lower risk or alls. In all ages, the
ear o alling an limit people rom progressing to their highest level o un tion.
ur ulen e un tions as a desta ilizer and as a ta tile sensory stimulus. T e stimula-
tion rom the tur ulen e generated during movement provides eed a k and pertur ation
hallenge that aids in the return o proprio eption and alan e.
Clin ica l Pe a r l
Turbulence created by other individuals moving or exercising in the pool can provide
patients/clients with unexpected perturbations to which they must respond dynamically
during exercise activities.
Advantages and Bene ts of Aquatic Rehabilitation 441
T ere is also an o ten overlooked ene t o edema redu tion that o urs as a onse-
quen e o hydrostati pressure. Edema redu tion ould ene t the patient y assisting in
pain redu tion and allowing or an in rease in range o motion.
By understanding uoyan y and utilizing its prin iples, the aquati environment an
provide a gradual transition rom non-weight earing to ull-weight earing land exer ises.
T is gradual in rease in per entage o weight earing helps provide a gradual return to
smooth, oordinated, and low pain or pain- ree movements. By utilizing the uoyan y or e
to de rease the or es o ody weight and joint ompressive or es, lo omotor a tivities an
egin mu h earlier ollowing an injury to the lower extremity than on land. T is provides an
enormous advantage to the athleti population. T e a ility to work out hard without ear o
reinjury provides a psy hologi al oost to the athlete. T is helps keep motivation high and
an help speed the athlete’s return to normal un tion.34 Psy hologi ally, aquati therapy
in reases on den e, e ause the patient or patient/ lient experien es in reased su ess
at lo omotor, stret hing, or strengthening a tivities while in the water. ension and anxiety
are de reased, and the patient/ lient’s morale in reases, as does postexer ise vigor.14,15,41
Mus ular strengthening and reedu ation an also e a omplished through aquati
therapy.44,54 Progressive resistan e exer ises an e in reased in extremely small in re-
ments y using om inations o dif erent resistive or es. T e intensity o exer ise an
e ontrolled y manipulating the ow o the water (tur ulen e), the ody’s position, or
through the addition o exer ise equipment. T is allows individuals with minimal mus le
ontra tion apa ilities to do work and see improvement. T e aquati environment an
also provide a hallenging resistive workout to an athlete nearing ull re overy.54 Addition-
ally, water serves as an a ommodating resistan e medium. T is allows the mus les to e
maximally stressed through the ull range o motion availa le. One draw a k to this, how-
ever, is that strength gains depend largely on the ef ort exerted y the patient/ lient, whi h
is not easily quanti ed.
In another study, Pöyhönen et al46 studied the iome hani al and hydrodynami har-
a teristi s o the therapeuti exer ise o knee exion and extension using kinemati and
ele tromyographi analyses in owing and still water. T ey ound that the owing proper-
ties o water modi ed the agonist/ antagonist neuromus ular un tion o the quadri eps
and hamstrings in terms o early redu tion o quadri eps a tivity and on urrent in reased
a tivation o the hamstrings. T ey also ound that owing water (tur ulen e) auses addi-
tional resistan e when moving the lim opposite the ow. T ey on luded that when pre-
s ri ing aquati exer ise, the tur ulen e o the water must e onsidered in terms o oth
resistan e and alterations o neuromus ular re ruitment o mus les.
Strength gains through aquati exer ise are a ilitated y the in reased energy needs
o the ody when working in an aquati environment. Studies show that aquati exer ise
requires higher energy expenditure than the same exer ise per ormed on land.10,14,15,54 T e
patient/ lient has to per orm the a tivity as well as maintain a level o uoyan y while over-
oming the resistive or es o the water. For example, the energy ost or water running is
4 times greater than the energy ost or running the same distan e on land.14,15,18,32
A simulated run in either shallow or deep water assisted y a tether or otation devi es
an e an ef e tive means o alternate tness training ( ross-training) or the injured ath-
lete. T e purpose o aquati running is to reprodu e the posture o running and utilize the
same mus le groups in the aquati environment as would e utilized on land. However, it
should e noted that there are dif eren es while eing in the unloaded environment and
resistan e o the water with aqua running hanges the relative ontri utions o the involved
mus le groups.58 It should e noted that a study o shallow-water running (xiphoid level)
and deep-water running (using an aqua jogger), at the same rate o per eived exertion,
ound a signi ant dif eren e o 10 eats per minute in heart rate, with shallow-water run-
ning demonstrating a greater heart rate. T e authors o that study point out that aquati
reha ilitation pro essionals should not pres ri e shallow-water working heart rates rom
heart rates values o tained during deep-water exer ise.48
Hydrostati pressure assists in ardia per orman e

220
y promoting venous return, thus the heart does not have
− a ge to eat as ast to maintain ardia output. Deep-water
Maximal he art rate running at su maximal and maximal speeds demon-
Ma xima l he a rt ra te strates lower heart rates than shallow-water running.
− Re s ting he a rt ra te
Re s e rve he art rate
T e greater the temperature o the water, the higher the
heart rate in response.58 All patients/ lients should e
instru ted in how to a urately monitor their heart rate
while exer ising in water, whether deep or shallow.10
He a rt ra te re s e rve He a rt ra te re s e rve Not only does the patient or patient/ lient ene t
× 0.50 (inte ns ity leve l) × 0.85 (inte ns ity leve l)
+ Re s ting he a rt ra te + Re s ting he a rt ra te rom early intervention, ut aquati exer ise also helps
Minimum wo rking Maximum wo rking prevent ardiorespiratory de onditioning through altera-
he art rate he art rate tions in ardiovas ular dynami s as a result o hydrostati
(la nd-ba s e d exe rcis e ) (la nd-ba s e d exe rcis e )
or es.7,28,53 T e heart a tually un tions more e iently
in the water than on land. Hydrostati pressure enhan es
Minimum working Ma ximum working venous return, leading to a greater stroke volume and a
he a rt ra te he a rt ra te redu tion in the heart rate needed to maintain ardia
(la nd-ba s e d exe rcis e ) (la nd-ba s e d exe rcis e )
output.55 T e orresponding de rease in ventilatory rate
− 17 be a ts pe r minute − 17 be a ts pe r minute
Minimum wo rking Maximum wo rking and in rease in entral lood volume an allow the injured
he art rate fo r aquatic he art rate fo r aquatic athlete to maintain a near-normal maximal aero i apa -
exe rc is e exe rc is e ity with aquati exer ise.22,56 For the lient/ patient who has
omor idities, there is a study that examined the ardio-
vas ular response during aquati interventions in patients
Targ e t wo rk zo ne fo r aquatic e xe rc is e
with osteoarthritis. T e authors ound that the systoli and
diastoli lood pressure in reased with entering and exiting
the aquati environment se ondary to the rapid hanges in
hydrostati pressure.3 For the athlete or the geriatri li-
Figure 16-6 Karvonen formula for w ater exercise ent with ompensations, onsideration must e paid to
monitoring responses. Be ause o the hydrostati ef e ts on
(Adapted from Sova R. Aquatic Activities Handbook. Boston, MA: heart e ien y, it has een suggested that an environment-
Jones & Bartlett; 1993:55.) spe i exer ise pres ription is ne essary.33,39,53,57 Some
resear h suggests the use o per eived exertion as an a epta le method or ontrolling exer-
ise intensity. Other resear h suggests the use o target heart rate values as with land exer ise,
ut ompensates or the hydrostati hanges y setting the target range 10% lower than what
would e expe ted or land exer ise (Figure 16-6).50,54 Regardless o the method used, the keys
to su ess ul use o aquati therapy are supervision and monitoring o the patient or patient/
lient during a tivity and good ommuni ation etween patient/ lient and therapist.
Disadvantages of Aquatic Rehabilitation
Disadvant ages
As with any therapeuti intervention, aquati therapy has its disadvantages. T e ost o
uilding and maintaining a reha ilitation pool, i there is no a ess to an existing a ility,
an e very high. Also, quali ed pool attendants must e present, and the therapist involved
in the treatment must e trained in aquati sa ety and therapy pro edures.12,32
An athlete who requires high levels o sta ilization will e more hallenging to work
with, e ause sta ilization in water is onsidera ly more di ult than on land. T ermo-
regulation issues exist or the patient who exer ises in an aquati environment. Be ause
the patient annot always hoose the temperature o the pool, the ef e ts o water tempera-
ture must e noted or ool, warm, or hot pool temperatures. Water temperatures that are
higher than ody temperature ause an in rease in ore ody temperature greater than that
Facilities and Equipment 443
in a land environment as a result o dif eren es in thermo- able 16-3 Co ntraindicatio ns fo r
regulation. Water temperatures that are lower than ody Aquatic The rapy
temperature de rease ore ody temperature and ause
shivering in athletes aster and to a greater degree than
in the general population e ause o their low ody at.10 Untreated infectious disease (patient has a fever/
Another disadvantage o aquati exer ise used or ross- temperature)
training is that training in water does not allow athletes to Open wounds or unhealed surgical incisions
improve or maintain their toleran e to heat while on land. Contagious skin diseases
Serious cardiac conditions
Seizure disorders (uncontrolled)
Cont raindicat ions and Precaut ions Excessive fear of water
Allergy to pool chemicals
T e presen e o any open wounds or sores on the patient Vital capacity of 1 L
or patient/ lient is a ontraindi ation to aquati therapy, Uncontrolled high or low blood pressure
as are ontagious skin diseases. T is restri tion is o vious Uncontrolled bowel or bladder incontinence
or health reasons to redu e the han e o in e tion o the Menstruation without internal protection
patient/ lient or others who use the pool.13,29,30,38,50 Be ause
o this risk, all surgi al wounds must e ompletely healed or
adequately prote ted using a waterproo arrier e ore the Source: Data from Irion JM. Aquatic therapy. In: Bandy WD, Sanders
B, eds. Therapeutic Exercise Techniques for Intervention . Baltimore,
patient/ lient enters the pool. An ex essive ear o the water MD: Lippincott, Williams & Wilkins; 2001:295-332; Sova R. Aquatic
is also a reason to keep a patient/ lient out o an aquati Activities Handbook. Boston, MA: Jones & Bartlett; 1993; Giesecke
exer ise program. Fever, urinary tra t in e tions, allergies C. In: Ruoti RG, Morris DM, Cole AJ, eds. Aquatic Rehabilitation .
Philadelphia, PA: Lippincott-Raven; 1997; and Thein JM, Thein Brody L.
to the pool hemi als, ardia pro lems, and un ontrolled Aquatic-based rehabilitation and training for the elite athlete. J Orthop
seizures are also ontraindi ations ( a les 16-3 and 16-4). Sports Phys Ther. 1998;27(1):32-41.
Use aution (or waterproo arrier) with medi al equipment
a ess sites su h as an insulin pump, osteomies, suprapu i applian es, and G tu es. Patients/
lients with a tra heotomy need spe ial onsideration; they need to remain in waist to hest
depth o water to exer ise sa ely in an aquati environment.
Clin ica l Pe a r l
It may be helpful for patients/clients who participate in aquatic therapy or aquatic exercise
to invest in specialized water exercise shoes to protect the plantar surfaces of their feet
(in tiled pools) and to provide adequate foot support during weightbearing exercise, even
in the gravity-diminished environment.
able 16-4 Pre cautio ns fo r the Use o f

Facilities and Equipment Aquatic The rapy
When onsidering an existing a ility or when planning

to uild one, ertain hara teristi s o the pool should e Recently healed wound or incision, incisions covered by
taken into onsideration. T e pool should not e smaller moisture-proof barrier
than 10 × 12 t. It an e inground or a oveground as long Altered peripheral sensation
as a ess or the patient/ lient is well planned. Both a Respiratory dysfunction (asthma)
Seizure disorders controlled with medications
shallow area (2.5 t) and a deep area (5+ t) should e pres-
Fear of water
ent to allow standing exer ise and swimming or nonstand-
ing exer ise.7 T e pool ottom should e at and the depth
gradations learly marked. Water temperature will vary Source: Data from Irion JM. Aquatic therapy. In: Bandy WD, Sanders
depending on the patient/ lientele that is served. For the B, eds. Therapeutic Exercise: Techniques for Intervention . Baltimore,
athlete, re ommended pool temperature should e 26°C MD: Lippincott, Williams & Wilkins; 2001:295-332; Sova R. Aquatic
Activities Handbook. Boston, MA: Jones & Bartlett; 1993; and Thein
to 28°C (79°F to 82°F) ut may depend on the availa le JM, Thein Brody L. Aquatic-based rehabilitation and training for the
a ility.45 T e water temperature suggested y the Arthritis elite athlete. Orthop Sports Phys Ther. 1998;27(1):32-41.
Figure 16-7 The Sw imEx pool Figure 16-8 Sw imEx custom pool w ith treadmill
This pool’s even, controllable water flow allows for the

application of individualized prescriptive exercise and
therapeutic programs. As many as 3 patients can be treated
simultaneously.
Foundation or their programs is 29°C to 31°C (85°F to 89°F). raditional hemi als that
have een used or pool treatment are hlorine and romine, ut additional options exist,
in luding saltwater system pools.
Depending on the type o the patient’s ondition, the patient/ lient’s per eption o the
water temperature may dif er.
Some pre a ri ated pools ome with an in-water treadmill or urrent-produ ing devi e
(Figures 16-7 and 16-8). T ese devi es an e ene ial ut are not essential to treatment. An
aquati program will ene t rom a variety o equipment that allows in reasing levels o resis-
tan e and assistan e, and also motivates the patient/ lient. Catalog ompanies and sporting
goods stores are good resour es or o taining equipment. T ere are many styles and varia-
tions o equipment availa le: the therapist needs to sele t equipment depending on the needs
o the program. Creative use o a tual sport equipment
( ase all ats, tennis ra quets, gol lu s, et ; Figures 16-9
to 16-12) is help ul to in orporate sport-spe i a tivities
that hallenge the athlete. Use o mask and snorkel will
allow options or prone a tivities/ swimming (Figures 16-13
and 16-14). Instru tion in the proper use o the mask and
snorkel is essential or the patient/ lient’s om ort and
sa ety. Equipment aids or aquati therapy or so- alled pool
toys are limited in their utilization only y the imagina-
tion o the therapist. What is important is to stimulate the
patient/ lient’s interest in therapy and to keep in mind what
goals are to e a omplished.
T e lothing o the therapist is an important
onsideration. Se ondary to the lose proximity o the
therapist to the patient/ lient with some treatments, wear-
ing swimwear that overs portions o the lower extremities
and upper trunk/ upper extremities is an important aspe t
Figure 16-9 Custom pool e nvironme nt o pro essionalism in the aquati environment. Footwear is
Facilities and Equipment 445
Figure 16-10 Other pool equipment
Underwater step, mask and snorkel, kickboard, tubing, and

various sports equipment.
Figure 16-11 Equipment used for resistance

or oatation
Figure 16-13 Prone kayak movement using

Figure 16-12 Flotation equipment mask and snorkel
Challenges the upper extremities and promotes

stabilization of the trunk.
Figure 16-14 Prone hip abduction/adduction w ith manual

resistance by therapist
Note use of mask and snorkel, allowing athlete to maintain proper trunk and
head/neck position.
another important onsideration or the therapist as well as the patient/ lient. Proper aquati
ootwear provides sta ility, tra tion, prevents injuries, and maintains good oot position.
Water Safety
A num er o patients/ lients re erred or aquati therapy are un om orta le in the water
e ause o minimal experien e in an aquati environment. Swimming a ility is not ne es-
sary to parti ipate in an aquati exer ise program, ut instru tion o water sa ety skills will
allow or a satis ying experien e or the patient/ lient. Patients/ lients may need an exer ise
ar or oatation noodle to assist with alan e during am ulation in water, initially. When
adding supine or prone a tivities into the patient/ lient’s program, it is important to instru t
the individual how to assume that position and return to upright position. T is initial a t
will de rease ear and stress or the patient/ lient and also de rease stress to injured area.
Aquatic echniques
Aquati te hniques and a tivities an e designed to egin as a tive assisted movements
and progress to strengthening, e entri ontrol, and un tionally spe i a tivities. A tivi-
ties are sele ted ased on several a tors:
ype o injury/ surgery/ ondition
reatment proto ols, i appropriate
Results/ mus le im alan es ound in evaluation
Goals/ expe ted return to a tivities as stated y the patient/ lient
Aquatic Techniques 447
Aquati programs are designed similarly to land- ased programs, with the ollowing
omponents:
Warm-up
Mo ility a tivities
Strengthening a tivities
Balan e or neuromus ular response a tivities
Enduran e/ ardiovas ular a tivities, in luding possi ilities or ross-training
Sport or un tionally spe i a tivities
Cool down/ stret hing
With these general onsiderations in mind, the ollowing se tions provide examples
o aquati exer ises or the upper extremity, trunk, and lower extremity in a 3-phase reha-
ilitation progression. What has een omitted rom the 4-phase reha ilitation s heme used
throughout this text ook, in the urrent dis ussion, is the initial pain ontrol phase. It is
assumed that y the time the patient arrives or aquati therapy, the patient has under-
gone previous treatment to manage a ute injuries and pain ul onditions. Su sequently,
the patient is ready to egin phases 2 through 4 o the 4-phase approa h.
Upper Ext remit y

T e goal o reha ilitation is to restore un tion y restoring motion and syn hrony o move-
ment o all joints o the upper extremity. As listed a ove, the evaluation o upper extrem-
ity is important and identi ation o dys un tional movements will assist in designing an
ef e tive program. Aquati therapy may e used or treatment o the shoulder omplex,
el ow, wrist, and hand as one o the interventions to a omplish goals along with a land-
ased program. T e ollowing se tions des ri e a reha ilitation progression or shoulder
omplex dys un tion.
Init ial Level

T e lient an e started at hest-deep water in order to allow or support o the s apulo-
thora i area. Walking orward, a kward, and sideways will allow or warm-up, working
on natural arm swing, and restoration o normal s apulothora i motions, rotation, and
rhythm. Initiation o a tivities to work on glenohumeral motions egins at the wall (patient/
lient with a k against the wall); having the patient/ lient in ne k- or shoulder-deep water
gives the lient physi al ues as to posture and quality o movement. T e primary goal dur-
ing the early phase is or the therapist and patient/ lient to e aware o the amount o move-
ment availa le without ompensatory shoulder elevation ( or example in the presen e o
an injury to the rotator uf ). T e other options or positions during early treatment are
supine and prone. T e lient will need otation equipment or ervi al, lum ar, and lower-
extremity support in order to have good positioning when in supine.
Supine a tivities in lude stret hing, mo ilization, and range o motion. Sta iliz-
ing the s apula with one hand, the therapist an work on glenohumeral motion with the
lient (Figures 16-15 and 16-16). T e lient an initiate gentle a tive movement in shoulder
a du tion and extension.
Clin ica l Pe a r l
The aquatic environment is ideal for rehabilitation after rotator cuff repair because of the
assistive property of buoyancy, and the ability to avoid improper elevation where the deltoid
overpowers the weaker rotator cuff, also known as the “ shrug sign.”
Figure 16-15 Range of motion w ith scapular Figure 16-16 Internal and external rotation in
stabilization supine
Note appropriate floatation support for the athlete.
Prone a tivity an e per ormed depending on the lient’s om ort in water and will-
ingness to use a mask and snorkel. Flotation support around the pelvis allows the lient
to on entrate on movement o the upper extremities without worrying a out otation o
the trunk and legs. T e lient is a le to per orm pendulum-type movements, proprio ep-
tive neuromus ular a ilitation diagonals, and straight-plane movement patterns ( exion/
extension and horizontal a du tion/ addu tion) in their pain- ree range. For the lient not
om orta le with the prone position, an alternative position is the pendulum position in the
standing position with the trunk exed.
Deep-water a tivity an e integrated or onditioning/ enduran e uilding in early
stages o upper-extremity reha ilitation. It is important or the lient to per orm pain- ree
range when per orming enduran e-type a tivities.
Int ermediat e Level

T e program an e progressed to hallenge strength y using equipment to resist motion
through pain- ree range. In reasing the sur a e area o the extremity or in reasing the
length o the lever arm will in rease the di ulty o the a tivity. As the lient progresses
into this phase, the limitations o the standing position e ome apparent. T e athlete an
work to the 90-degree angle ut not overhead without exiting the water. It is important or
the lient to maintain a neutral position o the spine and pelvi area in order to avoid injury
and su stitution patterns when per orming strengthening a tivities while standing.
T e lient will e a le to progress with s apular sta ilization rom standing to supine
and prone positions. Supine and prone positioning an allow or more un tional move-
ment patterns and ore sta ilization y the s apular mus les. Re all that prone a tivities
su h as alternate shoulder exion, the “kayaking” type motion (see Figure 16-13), proprio-
eptive neuromus ular a ilitation diagonal patterns, and horizontal shoulder a du tion/
addu tion an all e per ormed using various types o equipment or manual resistan e pro-
vided y the therapist while in prone. Resistan e to ea h o these motions ould e added
during this phase o reha .
Supine positioning allows or work on shoulder internal and external rotation where
resistan e or speed an e added (see Figure 16-16), as well as shoulder extension against
resistan e (Figure 16-17) in varying degrees o a du tion. Internal and external rotation an
e per ormed against resistan e in standing. T e land- ased program and aquati program
A B
Figure 16-17 Supine shoulder extension at 2 different abduction angles, for scapular stabilization
A. Middle trapezius. B. Lower trapezius.
should e oordinated to ensure ontinued improvement o strength, enduran e, and un -

tion. T e goal o treatment in the intermediate-level a tivities is development o strength
and e entri ontrol throughout in reasing ranges o motion.
Final Level
T e goal o this level o treatment is high-level un tional strengthening and training. Equally
important is the transition rom the aquati environment to the land environment. Utiliz-
ing sport equipment in treatment, i appli a le, will keep an athlete motivated and working
toward the goal o returning to sport (Figure 16-18). In reasing the resistan e y using elasti
or otation atta hments will keep it hallenging (Figure 16-19). As in the intermediate level,
the lient needs to e involved in a strengthening and training program on land.
Figure 16-18 Example of sport-speci c training Figure 16-19 Sport-speci c training using
in the aquatic environment. Useful for upper- buoyancy cuffs around a bat for resistance
extremity, core, and low er-extremity training
Spine Dysfunct ion

T e unloading apa ility o water allows the patient or lient ease o movement and some
potential relie o symptoms. T e patients/ lients will need to e shown how to o tain and
maintain the neutral spine position in the water even i they have een instru ted on land.
T e neutral spine position is the asis o treatment in land and water and will progress in
level o di ulty. A tivities o the trunk, upper extremities, and lower extremities all hal-
lenge trunk sta ility, strength, total- ody alan e, and neuromus ular ontrol. Dire tional
movement pre eren es or relie o symptoms, su h as extension- or exion- iased exer-
ises, an e integrated into program. Pregnant patients and lients that experien e a k
pain o ten ene t rom exer ising in an aquati environment se ondary to the unloading
or es on the lower a k.
Init ial Level

Using orward/ a kward/ sideways walking is ommon or a warm-up a tivity in patients/
lients with spine dys un tion. It is an opportunity or the lient/ patient to e ome aware o pos-
tural dys un tions and pra ti e with hanging alignment. Kim et al31 studied aquati a kward
lo omotion exer ise and reported that a training program emphasizing a kward walking is as
ef e tive as progressive resistive exer ise training program utilizing equipment with in reasing
lum ar extension a ter dis e tomy surgery. Ba kward am ulation has een shown to a tivate
paraspinal mus les, the vastus medialis, and ti ialis anterior more than orward walking.35 Ini-
tially, the lient/ patient an start with a speed and length o stride that does not ause dis om-
ort, and then an progress to normal walking speed so as to allow or return to un tion.
Initial instru tion regarding the neutral spine position is the asis or treatment. T e
patient/ lient stands in a partial squat position with the a k against wall to of er eed a k
and allow them to monitor their response. T ere are a variety o ways to instru t the patient
to ontra t the transversus a dominis mus le. It is important or the patient to have the
awareness o maintaining a light transversus a dominis mus le ontra tion and keeping the
lower-extremity mus les relaxed or “so t” during a tivities. Working on the enduran e and
prolonged hold o a dominal sta ilization without in reasing spinal dis om ort is a goal or
the initial level. Upper- and lower-extremity a tivities an e added so as to progressively
hallenge the lient’s a ility to sta ilize without in reasing symptoms. Initially egin with
a tivities without additional equipment, while manipulating the speed o movement through
ontrolled ranges o motion in order to hallenge the a ility to maintain the desired position.
Use o deep-water a tivities an e initiated early in reha ilitation. T e patient/ lient
should maintain a verti al position while per orming small ontrolled movements o the
upper and lower extremities. T e Burdenko approa h to aquati a tivities utilizes deep-
water a tivities e ore a tivities in shallow water. I dealing with radi ular (s iati a) type
symptoms, a trial o deep-water tra tion an e done. Flotation support o the upper ody
and trunk and pla ement o light weights on the ankles allows or gentle distra tion o the
lum ar spine. T e patient/ lient an hang using the otation devi es pla ed on the upper
ody/ trunk, and per orm small pedaling motions as i i y ling/ walking.36
Working on normalizing the gait pattern and developing the a ility to weight ear equally
on the lower extremities in any depth o water om orta le to the lient is important early
in the therapeuti progression. In orporation o a tivities to help entralize the symptoms
are important, as well as en ouraging the patient to per orm only a tivities that maintain or
diminish symptoms during the session. Gentle stret hing and rotation movements an e
per ormed within the pain- ree motion in order to in rease pelvi and lum ar spine mo ility.

At this level, the patient/ lient is allowed to progress away rom the wall, and the extremi-
ties or equipment is used to hallenge their a ility to sta ilize. Sta ility an e initially
Figure 16-20 Anterior posterior trunk Figure 16-21 Trunk stabilization against
stabilization w ith upper extremity horizontal anterior/posterior forces, split stance
abduction/adduction
Note flexed knees and wide base of support.
hallenged y moving the arms through the water to indu e pertur ation to the trunk
(Figure 16-20). T is an e made more hallenging y in reasing the speed o the upper-
extremity movements or adding something to the hands su h as we ed water gloves or
otation dum ells. A ki k oard an e used to mimi pushing, pulling, and li ting motions
(Figures 16-21 and 16-22). Equipment that resists upper-extremity or lower-extremity
movements in a single-leg stan e or lunge position hallenges the patient/ lient’s alan e,
as well as sta ilization using the a dominal and pelvi mus les (Figure 16-23). T ere is
ene t to having the patient/ lient work on oth ilateral and single-leg a tivities su h as
Figure 16-23 Challenging low er-extremity

neuromuscular control and balance, as w ell as trunk
Figure 16-22 Trunk stabilization against oblique/ control, in single-limb stance utilizing upper-extremity
diagonal forces, split stance resistance
A B
Figure 16-24
A. Tuck-and-roll exercise, pike position. B. Tuck-and-roll exercise, tuck position.
squats/ al raises that translate to some o the un tional a tivities su h as sit to stand and
stair lim ing.
T e lient’s a ility to sta ilize an e urther hallenged using deep-water a tivities
that require maintaining a verti al position while ringing knees to hest and progress-
ing to tu king and rolling type movement (Figure 16-24). A tivities an e reated to work
on diagonal and rotational motions o the spine and trunk, while maintaining the neutral
position.
A tivities in a supine position are ef e tive or in reasing trunk mo ility and then pro-
gressing to work on trunk sta ility using Bad Ragaz te hniques (Figures 16-25 and 16-26).21
A tivities in prone position provide an ex ellent method to hallenge the lients a ility to
maintain the neutral spine position, and the patient/ lient may need otation equipment
A B
Figure 16-25 Bad Ragaz technique for trunk stabilization
A. Note short lever arm with therapist contacting the LE’s above the knee in order to protect the knee joint. B. Contact
below the knees (if indicated) increases the trunk and LE stability demands.
to a omplish that goal. T e use o the mask and
snorkel will allow or proper positioning o the spine
while per orming the a tivities (see Figures 16-13
and 16-14). It is important to monitor and tea h the
lient the neutral spine position with ea h new posi-
tion that is introdu ed in the treatment program.
A tivities an e simpli ed or progressed in di -
ulty a ording to patients/ lients’ level o un tion
or their a ility to maintain the neutral spine position.
Final Level
Depending on the patient/ lient’s needs and un -
tional goals related to return to a desired level
o a tivity, the program ould e m odi ed and
progressed. For the patient/ lient returning to a
demanding o upation, development o a program
o li ting/ pushing/ pulling or other needs des ri ed
y the lient an omplement a work- onditioning Figure 16-26 Bad Ragaz technique for oblique
program. For the patient or lient returning to a trunk stabilization
sport, the therapist and athlete an work together to
develop spe i hallenging a tivities. T e therapist needs to e reative with the use o
aquati equipment and should use equipment spe i to the athlete’s sport in order to hal-
lenge the athlete to a higher level o trunk sta ilization. It is important to integrate move-
ment patterns that are opposite o the ones the athlete normally per orms in the athlete’s
sport in order to hallenge ody symmetry during un tion. For example, i a gymnast or
i e skater predominantly turns or rotates in one dire tion, have them pra ti e turns in the
opposite dire tion. T e aquati environment provides the athlete an alternate environment
in whi h to train, that should e en ouraged or the serious athlete to attempt to avoid over-
use type o onditions that an o ur. Espe ially important in this phase is the reintegration
o the patient/ lient a k into treatment and training on land, as the water environment
does not allow the athlete to prepare or the exa t speeds and or es experien ed on land.
Lower-Ext remit y Injuries

Aquati therapy is a ommon modality or reha ilitation o many injuries o the lower extrem-
ity e ause o the properties o unloading and hydrostati pressure. At an early phase o heal-
ing, the lient may need to use a otation elt, vest, exer ise ars, noodles, and various other
uoyan y devi es to provide support, depending on pain and how long they have een non-
weight earing. T e aquati environment allows or limited weight earing and restoration
o gait y al ulating the per entage o weight earing allowed and weight o patient/ lient
and then pla ing the patient/ lient in an appropriate depth o water, as dis ussed previously.
Clin ica l Pe a r l
The aquatic environment is an excellent place to begin gait retraining in the presence
of weight-bearing restrictions after meniscal repairs, once the surgical sites have healed
suf ciently.
Init ial Level

T e expe ted goals o this phase o reha ilitation are the return o normal motion and early
strengthening o af e ted mus les. T e restoration o normal and un tional gait pattern is
also desired. Per orming a kward and sideways walking

adds a un tional dimension to the program in addition
to traditional orward walking. Range-o -motion a tivities
may involve a tive motions o the hip, knee, and ankle.
Utilizing uf s, noodles, or ki k oards under the oot
will assist with in reasing motion, due to the uoyan y
of ered y su h equipment. Exer ises or strengthening
noninvolved joints su h as the hips or ankles an e per-
ormed with the lient who has had a knee injury. How-
ever, it is important to remem er that resistan e (manual
or with devi es) may need to e pla ed a ove the injured
knee in order to de rease torque pla ed upon the knee.
It is im portant to integrate onditioning and alan e
a tivities within this initial level (Figure 16-27). Stand-
ing a tivities should e per ormed with attention paid to
maintaining the spine in a neutral position, as well as to
Figure 16-27 Supine hip abduction/adduction
hallenging alan e and neuromus ular ontrol o the
involved lower extremity (see Figure 16-23).
Note therapist hand placement above the knee in order to
Deep-water a tivities allow or onditioning and
protect the knee ligaments.
ross-training opportunities (Figure 16-28). T e patient/
lient may initially need assistan e with otation devi es,
ut an progress y de reasing the amount o otation
when a le. For the lient who must e non-weight earing
se ondary to an injury or surgery, the deep water allows or
a workout along with maintaining strength in uninvolved
joints. A tivities an involve running, i y ling, s issor-
ing, or ross- ountry skiing motions, and also in orporate
sport-spe i a tivities o the lower extremities, trunk, and
upper extremities.
T e therapist an also in orporate a tivities per-
ormed in the supine position. T e patients/ lients need to
e supported with otation equipment that allow them to
oat evenly and without great ef ort to stay a oat. T e ther-
apist an sta ilize at the eet and have the patient/ lient
work on a tive hip and knee exion and extension in order
to work on in reasing range o motion at the af e ted joint
(Figure 16-29). Resistan e o hip a du tion and addu tion
an also e per ormed in a supine position. Again, atten-
Figure 16-28 Deep-w ater running tion must e paid to the lo ation o applied or e. Resis-
tan e pla ed upon the uninvolved leg movement will also
allow or strengthening o the injured extremity. It should e noted that the therapist must
tea h the patient how to sa ely return to the standing/ verti al position rom the supine or
prone position espe ially with the use o equipment applied to lower extremities.

Depending on the injury, surgery, or ondition, the lient an e progressed to the inter-
mediate level when appropriate. T e a tivities an e progressed y use o weights or o-
tation uf s to in rease di ulty. As in the initial level, resistan e may need to e pla ed
more proximally in the presen e o knee ligament injuries or surgeries. Per orming ir uits
o straight-plane and diagonal patterns with oth lower extremities an e progressed
y per orming with upper-extremity support on the wall and progressing to no support.
T e involved lower extremity an e hallenged y utilizing spe i motions that mimi
Figure 16-29 Supine alternating hip and knee Figure 16-30 Supported single-low er-extremity
exion and extension, using Bad Ragaz technique running movement
Hand contact by therapist gives the patient/client cues for Note the appropriate support of the patient/client with
movement. buoyancy belts and upper-extremity bell and lower-extremity
bell under the stationary lower extremity. Also challenges
trunk stabilization.
running (Figure 16-30). T e patient/ lient an stand on an uneven sur a e, su h as a noodle

or uf , to hallenge alan e and sta ilization. E entri , losed- hain a tivities an e per-
ormed in the shallow water with the lient standing on a noodle or ki k oard or single-leg
reverse squats, and utilizing a noodle, ki k oard, or ar or ilateral reverse-squat motions
in deep-water (Figure 16-31) and progressing to a single-leg reverse squat. Bilateral lower-
extremity strength, enduran e, and oordination an
e hallenged y ki king with a ki k oard, using a
utter ki k. T is is also ex ellent or developing ore
ontrol and aero i enduran e.
Per orming deep-water tether running or sprint-
ing orward and a kward or in reasing periods o
time will allow or overall onditioning. T e lient an
progress to running in shallower water depending
upon the ondition o injury or surgery (Figure 16-32).
Supine a tivities an e ontinued with empha-
sis on strengthening and sta ilization o the trunk,
pelvis, and lower extremities. Pla ement o the thera-
pist’s resistan e will depend on the lient’s strength,
a ility to sta ilize, and how mu h time has elapsed
sin e surgery or injury. In reasing the num er o rep-
etitions and/ or speed o movement will provide more
resistan e and work on atiguing mus le groups o the
lower extremity. T e prone position provides in reased
hallenges to the lient to per orm hip a du tion and Figure 16-31 Reverse squat, bilateral, using otation
addu tion along with hip and knee exion and exten- dumbell beneath the feet
sion. As mentioned previously, the lient an use mask
and snorkel or otation equipment to help with posi- Can be used for balance and neuromuscular coordination, as well
tioning while in the prone position. as range of motion.
A B
Figure 16-32
Deep water running against tubing resistance, (A) forward and (B) backward.
Sport-spe i a tivities an e integrated into the program or the athlete. While pra -
ti ing movement patterns needed or sport, the patient/ lient an start at hest depth and
progress to shallow water. As with spine reha ilitation, there is ene t rom pra ti ing
opposite movement patterns su h as turns and jumps. T e aquati environment will allow
or early initiation o a stru tured jumping and landing program. Some adaptations and
proper instru tion to the patient/ lient will provide similar positive ef e ts as those seen
in land- ased programs.40 Progression to the land- ased jump/ land program is re om-
mended when appropriate.
Final Level
In the nal level, the patient/ lient is involved with a high-level strengthening and train-
ing program. T e aquati program an and should e used to omplement the land pro-
gram. T e athlete an ontinue to pra ti e sport-spe i a tivities and drills in varying
levels o water. De reasing the use o otation equipment an in rease the di ulty with
deep-water a tivities. Using uoyan y uf s on the ankles without using a otation elt will
hallenge the athlete’s a ility to sta ilize and per orm running in deep water. Enduran e
training in an aquati environment is a good alternative or the healthy athlete’s ondition-
ing programs and may help to prevent injuries. As with the upper extremity, this phase also
requires integration o aquati - and land- ased exer ises so as to su ess ully transition the
athlete to ull parti ipation in sport on land.
Special echniques
Bad Ragaz Ring Met hod

T e Bad Ragaz te hnique originated in the thermal pools o Bad Ragaz, Switzerland, in
the 1930s, and ontinued to evolve throughout the years. As a method, it o uses on mus-
le reedu ation, strengthening, spinal tra tion/ elongation, relaxation, and tone inhi i-
tion.17 T e properties o water—in luding uoyan y, tur ulen e, hydrostati pressure,
and sur a e tension—provide dynami environmental or es during a tivities. T e use o
Special Techniques 457
upper-extremity and lower-extremity proprio eptive neuromus ular a ilitation patterns
add a 3-dimensional aspe t to this method. Movement o the lient’s ody through the water
provides the resistan e.11 T e tur ulent drag produ ed rom movement is in dire t relation
to the lient’s speed o movement. T e therapist provides the movement when the lient
works on isometri (sta ilization) patterns; however, the therapist is in the sta le/ xed
position when the lient is per orming isokineti or isotoni a tivities (see Figures 16-26,
16-27, and 16-29).21 Stret hing and lengthening responses an e o tained with passive or
relaxed response rom lient; the therapist needs to support and sta ilize ody segments in
order to o tain desired response.
Awareness o ody me hani s and prevention o injury are important to the therapist
when per orming resistive Bad Ragaz–type a tivities. T e therapist should stand in waist-
deep water, not deeper than the level o 8- 10,21 and wear aqua shoes or tra tion and
sta ility. T e therapist should stand with 1 oot in ront o the other, with knees slightly ent,
and legs shoulder-width apart, to ompensate or the long lever arm or e o the lient.
Burdenko Met hod

T e Burdenko m ethod utilizes m otion as the prin iple healing intervention. A ord-
ing to Burdenko,6 the om ponents o dynam i healing in lude patterns o m ovem ent,
injury assessm ent, and reha ilitation exer ises that o ur with the lient in a standing
position; the psy hology o the injured lient ene ting rom pain- ree m ovem ent, and
lood ow and neural stimulation eing enhan ed y a tivity.6 Six essential qualities are
ne essary or per e ting and maintaining the art o m ovem ent : alan e, oordination,
exi ility, enduran e, speed, and strength. Burdenko advo ates the presentation o these
qualities in exer ise a tivities in the previously stated order. T e a tivities are designed
to hallenge the enter o uoyan y and enter o gravity. reatm ents/ a tivities are initi-
ated in deep water and in orporate shallow-water a tivities as lient su eeds y dem -
onstrating ontrol o m ovem ent while maintaining neutral verti al position. Integration
o land exer ise along with the aquati a tivity addresses
un tional m ovem ent patterns. For urther in ormation
on this te hnique, see “Suggested Readings” at the end
o the hapter.
Halliwick Met hod

T e Halliwi k m ethod is om m only used to tea h indi-
viduals with physi al disa ilities to swim and to learn
alan e ontrol in water. Developed y Jam es M Mil-
lan, the Halliwi k m ethod or on ept is ased on a “ en
Point Program m e.”9 T is m ethod is requently utilized
with the pediatri population, ut portions o the te h-
nique an e utilized to im prove and restore a patient/
lient’s alan e. Use o tur ulent or es an assist in
developing strategies or m aintaining alan e or hal-
len ge th e patient/ lient to m aintain a sta le posture
during a hange in the dire tion o or e. For exam ple, Figure 16-33 Balance and ne uromuscular
the patient/ lient maintain s a sin gle-leg stan e while control restoration technique for trunk and single
the therapist or another person runs around the patient/ low e r e xtre mity
lient of erin g tur ulent pertur ation s ( Figure 16-33).
More in orm ation on the Halliwi k te hn ique is also This exercise demonstrates the use of the principle of
availa le in the “Suggested Readings” se tion at the end turbulence, generated in the Halliwick technique to
o the hapter. challenge the stability of the patient/client.
Ai Chi
Ai hi is an Eastern- ased treatment approa h om ining ai Chi, Zen Shiatsu, Watsu, and
Qi Gong in the water. Bene ts o this approa h in lude promoting relaxation y the use o
diaphragmati reathing that stimulates the parasympatheti nervous system, ore strength-
ening, and in reased exi ility. Per ormed in shoulder-depth water, it progresses rom deep
reathing to total- ody movements through a hara teristi sequen e o postures.42
Special Populations
T ere are many onditions and diagnoses that may ene t rom treatment in the aquati
environment. Aquati therapy interventions an ene t a patient/ lient’s level o un tion.
T e therapist an e the atalyst or providing an introdu tion to an environment that an
e a temporary reha ilitation tool or li estyle tool or tness. T e ollowing dis ussion o
the treatment o the pediatri and neurologi patient/ lient is ut a rie synopsis and the
interested therapist should seek spe ialized training.
Pediat ric Pat ient s and Client s

T e aquati environment provides a un treatment area or the pediatri patient/ lient.
Examples o ongential pediatri diagnoses that are ef e tively treated in the aquati envi-
ronment in lude ere ral palsy, spina i da, and mus ular dystrophy. A wide range o
additional medi al diagnoses may also e appropriate or treatment in this environment.
T e team o therapists, physi ians, and parents an de ide on whether it is appropriate to
initiate aquati therapy as a part o the treatment plan. A om ination o land and aquati
therapy assists with assessing ef e tiveness o therapeuti interventions and o taining
un tional goals. T e major hallenge or the therapist is evaluating the pediatri lient or
water sa ety. Assessment o the hild’s a ility to a ept water to the a e, toleran e to eing
su merged, and reath ontrol are important a tors or the aquati evaluation. T e mental
adjustment o the hild to the water is a ne essary omponent or su ess ul use o water
as a treatment modality. Parents and aregivers may need to nd a swim instru tor to assist
with de reasing ear and in reasing om ort o water, with variety o movements.
A variety o approa hes, su h as Halliwi k, Bad Ragaz Ring Method, and Watsu, an e
integrated and adapted into treatment program or the pediatri patient/ lient. Watsu is a
passive treatment te hnique des ri ed as Zen Shiatsu in water. It was originally reated as
a wellness te hnique and has expanded or utilization with patients and lients. Patients
treated with this te hnique experien e relaxation and tone-inhi iting vesti ular stimulation.
A treatment program onsists o warm-up and ool-down periods, whi h allow or
a tive stret hing and adjustment to the water. Fun tional motor skills are pra ti ed and
integrated into play a tivities. Water provides onstant postural hallenges to the hild.45 As
with the adult patient or lient, the treatment program should progress toward the goals set
y the therapist and e readjusted a ording to patient responses and assessment o prog-
ress. It is important to work in olla oration with the multidis iplinary team o personnel
who parti ipate in the are o the pediatri lient in order to provide synergisti treatment
that in ludes aquati therapy.
Neurologic Pat ient s and Client s

Bene ts o the aquati environment or the patient/ lient with neurologi involvement
in lude a supportive and sa e environment, ease o movement, and an ex ellent medium in
whi h to pra ti e un tional a tivities. T e water allows or the therapist’s ease o handling
the patient/ lient with signi ant neurologi involvement. Support of ered y the water
Special Populations 459
provides sta ility and assistan e or the therapist who is per orming handling te hniques to
a ilitate movement and inhi it tone.
In a older lient/ patient who may have a more omplex medi al history and re ent
neurologi event, there is usually a distur an e o alan e. T is may lead to in rease risks
o alls and ear or that lient. T e aquati environment allows or the lient/ patient to have
more time to re ruit an appropriate postural response. ur ulen e an e used to assist or
resist patient’s alan e. T e task-type training approa h uses the prin iples o uoyan y,
tur ulen e, and hydrostati pressure to address patients disa ilities y working in un -
tional positions with un tional a tivities.11,43
T ere are a variety o treatment approa hes that are ef e tive in a omplishing un -
tional goals. Utilizing the standing and sitting positions en ourage and promote postural
sta ility. T e rst priority is determining the sa est and most sta le position in whi h the
lient an egin to work in the water. Pra ti ing un tional a tivities as a whole allows or
the patient/ lient to master the a tivity while exer ising ontrol during the a tivity and sta-
ilizing multiple ody segments. As patient/ lient progresses, less assistan e and support is
provided, allowing or in reased independen e.42 Like the pediatri population, spe ialized
training is re ommended or those therapists who desire to use aquati reha ilitation as an
intervention strategy or their patients and lients with neuromus ular diagnoses.
SUMMARY
Aquati reha ilitation is not typi ally the ex lusive intervention option or most patients
and lients. T e aquati environment of ers many positive psy hologi al and physiologi
ef e ts during the early reha ilitation phase o injury.37,54 However, in su sequent phases
o reha ilitation, it is typi al to use om inations o land- and water- ased interventions
to a hieve reha ilitation goals. Be ause humans un tion in a “gravity environment,” the
transition rom water to land is ne essary or ull reha ilitation or most patients/ lients.
Some lients use the aquati environment or ontinued strengthening and onditioning
programs se ondary to a pain ul response to land- ased a tivities. Examples o this in lude
those patients with pain that o urs with ompressive or es at joints (su h as ases o dis
dys un tion, spinal stenosis, and osteoarthritis), as well as hroni neuromus ular ondi-
tions su h as multiple s lerosis.
T is hapter provides in ormation regarding indi ations and ene ts as well as on-
traindi ations and pre autions to use o the aquati environment or reha ilitation. Sug-
gestions and exer ises are of ered to help the therapist to in orporate aquati exer ise into
a reha ilitation program. Utilizing the prin iples provided and the examples o a tivities,
physi al therapists an use their judgment, skill, and espe ially their reativity to develop
an exer ise program to meet their patient/ lient’s goals. T e old English prover says “We
never know the worth o water ‘til the well is dry.” T e worth and value o aquati ther-
apy as an intervention annot e ully understood and appre iated until experien ed and
additional resear h is ompleted.
• T e uoyant or e ountera ts the or e o gravity as it assists motion toward the
water’s sur a e and resists motion away rom the sur a e.
• Be ause o dif eren es in the spe i gravity o the ody, the head and hest tend to
oat higher in the water than the heavier, denser extremities, making ompensation
with oatation devi es ne essary.
• T e 3 or es that oppose movement in the water are the ohesive or e, the ow or e,
and the drag or e.
• Aquati therapy allows or ne gradations o exer ise, in reased ontrol over the
per entage o weight earing, in reased range o motion and strength in weak
patients/ lients, and de reased pain and in reased on den e in un tional

movements.
• Pool size and depth, water temperature, and spe i pool equipment vary depending
on the lientele eing treated and the resour es availa le to the therapist.
• Appli ation o the prin iple o uoyan y allows or progression o exer ises.
• Upper- and lower-extremity a tivities oth require and provide a hallenge to trunk
and ore sta ility.
• T e spe ial te hniques ex lusive to the aquati environment an e used to
omplement traditional land- ased therapeuti interventions.
• Aquati therapy an help stimulate interest, motivation, and exer ise omplian e in
pediatri , geriatri , neurologi al, and athleti patients/ lients.
• T e aquati environment is an ex ellent medium to a ilitate speedy un tional return
to work, a tivities o daily living, and sport.
• It is typi al to use a om ination o land- and water- ased therapeuti exer ise
proto ols to a hieve reha ilitation goals.
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Clin Kinesiol. 1990;44(1):12-13. 56. riggs M. Orthopedi aquati therapy. Clin Manage.
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Brody L , Geigle PR. Aquati T erapy or Reha ilitation and Frangolias DD, Rhodes EC. Maximal and ventilatory threshold
raining. Champaign, IL: Human Kineti s; 2009. responses to treadmill and water immersion running.
Burdenko J, Connors E. T e Ultim ate Power of Resistance. Igor Med Sci Sports Exerc. 1995;27(7):1007-1013.
Pu lishing; 1999 [availa le only through mail order]. Green JH, Ca le N , Elms N. Heart rate and oxygen
Burdenko Water & Sports T erapy Institute. Newton, MA; 1998. onsumption during walking on land and in deep water.
Campion MR. Adult Hydrotherapy: A Practical Approach . J Sports Med Phys Fitness. 1990;30(1):49-52.
Ox ord, UK: Heinemann Medi al; 1990. Martin J. T e Halliwi k method. Physiotherapy. 1981;67:
Cassady SL, Nielsen DH. Cardiorespiratory responses o 288-291.
healthy su je ts to alistheni s per ormed on land versus Sova R. Aquatic Activities Handbook . Boston, MA: Jones &
in water. Phys T er. 1992;72(7):532-538. Bartlett; 1993.
Functional Movement
Assessment
Ba r b a r a J. Ho o g e n b o o m , M ich a e l L. Vo ig h t ,
Gr a y Co o k , a n d Gre g Ro s e
OBJJEC
C IVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Explain the bene ts of a functional, comprehensive movement screening process versus the
traditional impairment-based evaluation approach.
Differentiate between movement, testing, and assessment.
Explain how poor movement patterns and dysfunctional movement strategies can result in injury
or reinjury.
Explain the use and components of the Functional Movement Screen and the Selective
Functional Movement Assessment.
Describe, score, and interpret the movement patterns of the Functional Movement Screen and
the Selective Functional Movement Assessment and how the results from each can have an
impact on clinical interventions.
Articulate the difference between movement screening and speci c functional performance tests.
Apply speci c functional performance test to clinical practice.
463
464 Chapte r 17 Functional Movement Assessment
Introduction
Movement is at the core o the human journey. It is oundational to the human experi-
ence and allows us to interact with our environment in ways dif erent rom other mam-
mals. Movement, which begins in the womb, is the basis o early growth and development.
It proceeds in a highly predictable manner in in ants and young children and is known as
the developmental sequence or traditional motor development. Once an individual reaches
a certain age, ull integration o re exive behavior allows the development o purposive,
highly developed, and unique mature motor programs. We continue to move unctionally
throughout a li etime until the ef ects o aging alter the normalcy o movement.
Mot ion versus Movement

Because movement is complex, it must be dif erentiated rom the simpler construct o
motion. We believe that many pro essionals lack a true understanding o movement; they
err on the side o quantitative assessment o motion and ail to understand the hierarchic
progression rom general, undamental movement patterns to speci c, highly special-
ized movements. T ese highly specialized movements have complex, ne-tuned motor
programs that support their consistency and intricacy. Most rehabilitation and medical
pro essionals have been trained to measure isolated joint motion with goniometers, incli-
nometers, linear measurements, and ligament laxity tests. T ese types o motion assess-
ment are not wrong, but rather only a piece o a much bigger puzzle o “movement” and
the inherent stability and mobility demands that are part o the synchronous, elegant, coor-
dinated activities that make up activities o daily living, work tasks, and sport maneuvers.
Mere motion measurements cannot capture the whole spectrum o human movement, nor
the complexity o human unction.
Syst ems Approach t o Movement

T e premise o this chapter and the chapter that ollows is that impairment-based, highly
specialized motion assessment is ar too limiting, and predisposes practitioners to errors
in pro essional judgment. It is too narrow an approach, which ocuses on small, discrete
pieces o an integrated unctional task or movement. T e alternative o a more unctional,
comprehensive movement screen is vitally important or understanding human unction
and identi ying impairments and dys unctional movement patterns that diminish the qual-
ity o unction. In many cases, weakness or tightness o a muscle or group is o ten identi ed
and then treated with isolated stretching or strengthening activities instead o using a stan-
dard movement pattern that could address several impairments at once. Likewise, many
pro essionals o ten ocus on a speci c region o complaint instead o beginning by identi y-
ing a comprehensive movement pro le and relating the pro le to dys unction.
“Fundament als First ”

Where does one start with the examination and assessment o something as complex as
human unction? Standard, requently used, undamental or general movements would
seem the logical place to start. o prepare an athlete or the wide variety o activities needed
to participate in the demands o sport, analysis o undamental movements should be
incorporated into preparticipation screening. Assessment o undamental movements can
help the rehabilitation pro essional determine who possesses or lacks the ability to per-
orm a wide variety o essential movements. We believe that assessment o undamental or
Introduction 465
composite movements is necessary be ore the assessment o highly speci c or specialized
motions or movements. Consider the ollowing statements in the context o assessment o
an athlete:
• What appears to be muscular weakness may be muscular inhibition.
• Identi able weakness in a prime mover may be the result o a dys unctional stabilizer
or group o muscular stabilizers.
• Diminished unction in an agonist may actually be dys unction o the antagonist.
• What is described as muscular tightness may be protective muscle tone leading to
guarding and inadequate muscle coordination during movement.
• “Bad” technique might be the only option or an individual per orming poorly
selected, “of -target” exercises.
• Diminished general tness may be related to the increased metabolic demand
required by patients who use in erior neuromuscular coordination and
compensations.
It is vital that undamental, essential movements be examined to develop a working
hypothesis regarding the source o the dys unction. T is approach allows the rehabilitation
pro essional to see “the big picture” and attempt to discern the cause o the dys unction
rather than just identi ying and treating speci c, isolated impairments. T is undamental
rst approach, typically used when teaching a motor skill, holds true or assessment and
correction o movement.
The Mobilit y–St abilit y Cont inuum

Movement becomes less than optimal (dys unctional) as a result o “breakdowns” in parts
o the movement system. ypically, such breakdowns are described as mobility or stabil-
ity dys unction. Un ortunately, the terms m obility and stability are not universally de ned
and can imply dif erent things to clinicians with dif erent backgrounds. For this reason it is
important to describe the approach o the authors regarding descriptions o mobility and
stability.
Mobility dys unction can be broken down into 2 unique subcategories:
• issue extensibility dys unction involves tissues that are extraarticular. Examples
include active or passive muscle insu ciency, neural tension, ascial tension, muscle
shortening, scarring, and brosis.
• Joint m obility dys unction involves structures that are articular or intraarticular.
Examples include osteoarthritis, usion, subluxation, adhesive capsulitis, and
intraarticular loose bodies.
Stability dys unction may include an isolated muscular weakness or joint laxity, but it
is requently more complex and re ers to multiple systems that are involved in the complex
construct known as motor control. o account or the complexity o a stability problem,
the term stability m otor control dys unction is used. Stability motor control dys unction is
an encompassing, broad description o problems in movement pattern stability. radition-
ally, stability dys unction is o ten addressed by attempting to concentrically strengthen the
muscle groups identi ed as stabilizers o a region or joint. T is approach neglects the con-
cept that true stabilization is re ex driven and relies on proprioception and timing rather
than isolated, gross muscular strength. By using the term stability motor control dys unc-
tion to distinguish stability problems, the clinician is orced to consider the central nervous
system, peripheral nervous system, motor programs, movement organization, timing, coor-
dination, proprioception, joint and postural alignment, structural instability, and muscular
inhibition, as well as the absolute strength o the stabilizers. T e concepts o mobility and
stability are discussed urther in the context o the Selective Functional Movement Assess-
ment (SFMA) later in this chapter.
T e purpose o this chapter, as part o a sports medicine rehabilitation text, is to pro-
vide the context or and convince the reader o the importance o a timely, accurate, and
reproducible unctional movement assessment. Although a part o examination, isolated
measurements and quantitative assessments are not enough to capture the essence o unc-
tional movement in activities o li e.
Movement Screening, esting, and Assessment

Athletic trainers screen during the preseason. Physical therapists are involved in screen-
ing, prevention, and wellness initiatives. Physicians serve patients by medically or surgically
“ xing problems” but also attempt to prevent repeat injury. T e number 1 risk or injury is
previous injury.1-6 What contributes to this paradigm? Poor screening that does not iden-
ti y athletes at risk or injury? Poor rehabilitation that does not “ nish the job”? “Poor” or
untested surgical or medical interventions that do not get to the “root” o the problem?
Each is a possibility, and all disciplines may be responsible or unsuccess ully preparing
or providing the building blocks or ull return to movement normalcy. It is the “job” o all
health pro essionals to adequately screen, test, assess, and identi y movement dys unction
and of er solutions to restore movement e ciency and normalcy.
At this point it is important to distinguish between screening, testing, and assessment
( able 17-1). T is chapter is written to enhance the reader’s ability to comprehensively
assess the “movement” (recall the previous discussion o movement versus motion) o
patients, athletes, and clients. Many would argue that assessment o movement is impor-
tant be ore embarking on a physical per ormance endeavor because the ability to move
provides the oundation or the ability to per orm physical tness activities, work and
athletic tasks, and basic activities o daily living. It is important to be able to distinguish
dys unctional movement rom “normal” movement during preparticipation or preseason
screening, as well as during postinjury or postoperative rehabilitation. It is also important
to acknowledge that training through or despite “poor” movement patterns rein orces poor
quality o movement and is likely to increase the risk or injury and predispose to greater
able 17-1 Diffe re nce be tw e e n Scre e ning , Te sting , and Asse ssme nt
Te rm De nitio n Me aning
Screening A system for selecting suitable people; To create grouping and

to protect somebody from something classi cation; to check risk
unpleasant or dangerous
Testing A series of questions, problems, or practical To gauge ability

tasks to gauge knowledge, experience, or
ability; measurement with no interpretation
needed
Assessment To examine something; to judge or evaluate To estimate inability

it; to calculate a value based on various
factors
Movement Screening, Testing, and Assessment 467
levels o dys unction.4-6 Even highly skilled athletes may have undamental imper ections
in movement.
We propose that the astute sports medicine pro essional combine the tasks o screen-
ing, testing, and assessment to systematically ascertain the risk, ability, or inability o each
athlete, patient, or client. T e outcome o such a logical and re ned procedure would pro-
vide the caregiver the best possible in ormation to ormulate opinions regarding readiness
or participation or return to activities.
T ere ore, screening might come rst in the assessment process, and the outcome o a
use ul, practical movement screening tool or approach would allow the provider to do the
ollowing:
• Demonstrate movement patterns that produce pain within expected ranges o
movement.
• Identi y individuals with nonpain ul but limited movement patterns who are likely to
demonstrate higher potential risk or injury with exercise and activity.
• Identi y speci c exercises and activities to avoid until competency in the required
movement is achieved.
• Identi y and logically link screening movements to the most ef ective and e cient
corrective exercise path to restore movement competency.
• Build a description o standardized, undamental movement patterns against which
broader movement can be compared.
Sahrmann, Kendall, and Janda have each of ered valuable perspectives regarding
human movement, posture, and unction.7-9 T ey have been instrumental in describing
examination o structural, as well as unctional, symmetry or lack thereo . Rehabilitation
pro essionals have progressed rom examination o isolated muscles and posture 7 to appre-
ciation o the necessity o examining complex movement patterns.9
T ere are numerous ways in which slight subtleties in movement patterns contribute
to speci c muscle weaknesses. T e relationship between altered movement patterns
and speci c muscle weaknesses requires that remediation address the changes to the
movement pattern; the per ormance o strengthening exercises alone will not likely
af ect the timing and manner o recruitment during unctional per ormance.
—Dr. Shirley Sahrmann
T e transition rom analysis o motion to analysis o unctional movement and move-

ment patterns helps rehabilitation providers discern the underlying cause o the dys unc-
tion or imbalance. T is paradigm shi t propels rehabilitation providers toward the big
picture, cause-and-ef ect, and regional interdependence thinking necessary or success in
the 21st century.
Most would agree that it is di cult to qualitatively discern the quality o m ovem ent
unless provided with a ramework or making a judgment. Systematic screening, testing,
and assessment o m ovem ent require not only a ramework, but also benchmarks or cri-
teria that de ne the proper m ethod o per orming a movement. We propose 3 possible
general outcom es o m ovem ent assessment ( able 17-2) as determ ined by comparison
between the m ovem ent per orm ed by the athlete and predeterm ined descriptors o
success.
raining through or despite identi ed “poor” movement patterns rein orces poor qual-
ity and increases the risk or injury, even during low-stress activities, and the possibility o
progression to greater movement dys unction. raining and unctional exercise techniques
and strategies are covered in Chapter 20; however, it is important to note here that that poor
movement patterns must be identi ed and addressed be ore embarking on high-level unc-
tional training.
able 17-2 Outco me s o f Mo ve me nt Asse ssme nt
Outco me De scriptio n
Acceptable Movement is good enough to allow the individual to be cleared for

activity without an increase in risk for injury.
Unacceptable Movements are dysfunctional and the individual may be at risk for injury
unless movement patterns are improved.
Painful Screening movements produce pain. Currently injured regions require

additional, more advanced movement and physical assessment, including
imaging, by a quali ed health care provider.
Movement Related to Injury Potential

and Return from Injury
T e greatest risk or injury is a history o previous injury,1-6 and this act has been demon-
strated in a wide variety o populations and athletes. Yet how might this relate to an unin-
jured athlete or worker? Are there certain “markers” or per ormance measures that could
separate high-quality, proper or correct movement rom low-quality, improper or incorrect
movements? Conceptually, i movement is dys unctional, all activities, including activities o
daily living, work tasks, and athletic per ormance built on that dys unction, may be awed
and predispose the individual to increased risk or the development o even greater dys unc-
tion. T is statement is true even when dys unctional base movements are masked by appar-
ently acceptable, age-appropriate, and even highly skilled per ormance. It is possible to move
poorly and not experience pain, and, conversely, to move well and yet experience pain. Over
time, poor movement patterns and dys unctional movement strategies are likely to produce
pain. An example might be a gymnast with an exaggerated lordosis that is “ unctional” or
her sport but is likely, over time, to result in acet joint compression in the lumbar spine and
decreased exibility o the hip exors. It is important to note that although poor movement
patterns may increase risk or injury with activity, good movement patterns do not guaran-
tee decreased risk or injury. It is the job o the astute health care pro essional to target and
address identi able risk actors, such as tight muscles, weak muscles, or poor balance or coor-
dination, during movement and their biomechanical in uences on movement. Once poor
movement patterns are addressed, proper movement must be enhanced with appropriate
strength, endurance, coordination, and skill development, but proper movement comes f rst!
T e Functional Movement Screen and the

Selective Functional Movement Assessment
T e 2 movement assessment systems described in this chapter work together and use some
common patterns o movement, but each possesses unique aspects. T ey serve to provide
common language and “thinking” between a wide variety o health and tness pro essions.
Both are about the assessment o quality and not so much about the assessment o quan-
tity o movement. Both stress the clinician’s ability to rate per ormance quality, rank and
describe the greatest dys unction, and measure, i necessary, within the context o ounda-
tional, general movements.
The Functional Movement Screen and the Selective Functional Movement Assessment 469
The Funct ional Movement Screen

T e Functional Movement Screen (FMS) is a predictive, but not diagnostic, unctional
screening system. T e FMS is an evaluation or screening tool created or use by pro es-
sionals who work with patients and clients or whom movement is a key part o exercise,
recreation, tness, and athletics. It may also be used or screening within the military, re
service, public sa ety, industrial laborers, and other highly active workers. T is screening
tool lls the void between preparticipation/ preplacement screening and speci c per or-
mance tests by examining individuals in a more general dynamic and unctional capacity.
Research suggests that tests that assess multiple acets o unction such as balance, strength,
range o motion (ROM), and motor control simultaneously may assist pro essionals in iden-
ti ying athletes at risk or injury.10-12
T e FMS, described by Cook et al,13,14 is composed o 7 undamental movement patterns
that require a balance o mobility and stability or success ul completion. T ese unctional
movement patterns were designed to provide observable per ormance tasks that relate to
basic locomotive, manipulative, and stabilizing movements. T e tests use a variety o com-
mon positions and movements appropriate or providing su cient challenge to illuminate
weakness, imbalance, or poor motor control. It has been observed that even individuals
who per orm at high unctional levels during normal activities may be unable to per orm
these simple movements i appropriate mobility or stability is not present.10,11 An important
aspect o this assessment system is its oundation on principles o proprioception and kin-
esthesia. Proprioceptors must unction in each segment o the kinetic chain and associated
neuromuscular control must be present or e cient movement patterns to occur.
T e FMS is not intended or use in individuals displaying pain during basic movement
patterns or in those with documented musculoskeletal injuries. Pain ul movement is cov-
ered subsequently in the section on the SFMA. T e FMS is or healthy, active people and or
healthy, inactive people who want to increase their physical activity. Interrater reliability o
the FMS has been reported by Minick et al15 to be high, which means that the assessment
protocol can be applied and reliable scores obtained by trained individuals when there is
adherence to standard procedures.
T e FMS consists o 7 movement patterns that serve as a comprehensive sample o
unctional movement (Box 17-1). Additionally, 3 clearing tests, each associated with one o
the FMS movement patterns, assess or pain with shoulder rotation motions, trunk exten-
sion, or trunk exion.
A kit or FMS testing is available commercially (www.per ormbetter.com); however,
simple tools such as a dowel, 2 × 6 board, tape, tape measure, a piece o string or rope,
and a measuring stick are enough to complete the testing procedures. When conducting
the screening tests, athletes should not be bombarded with multiple instructions about
how to per orm the tests; rather, they should be positioned in the start position and of ered
simple commands to allow achievement o the test movement while observing their per-
ormance. T e FMS is scored on an ordinal scale, with 4 possible scores ranging rom 0 to 3
( able 17-3). T e clearing tests mentioned earlier consider only pain, which would indicate
a “positive” clearing test and requires a score o 0 or the test with which it is associated.
Box 17-1 Se ve n Mo ve me nt Patte rns o f the Functio nal Mo ve me nt Scre e n

able 17-3 Sco ring Syste m fo r the Functio nal Mo ve me nt Scre e n
A Sco re o f . . . Is Give n if. . .
0 At any time during testing the athlete has pain anywhere in the body.
Note: The clearing tests consider only pain, which would indicate a
“ positive” clearing test and requires a score of 0 for the test with which
it is associated.
1 The person is unable to complete the movement pattern or is unable to

assume the position to perform the movement.
2 The person is able to complete the movement but must compensate in

some way to complete the task.
3 The person performs the movement correctly, without any compensation.
T ree is the highest or best score that can be achieved on any single test, and 21 is the best
total score that can be achieved.
T e majority o the movements test both the right and le t sides, and it is important
that the sides be scored independently. T e lower score o the 2 sides is recorded and used
or the total FMS score, with note made o any imbalances or asymmetry occurring during
per ormance o the task (Figure 17-1). T e creators o the FMS suggest that when in doubt,
the athlete should be scored low.
Seven Movement Pat t erns of t he Funct ional Movement Assessment

T e Deep Squat ( Figure 17-2) T e squat is a movement needed in most athletic events;
it is the “ready position” that is required or many power movements such as jumping and
landing. T e deep squat assesses bilateral, symmetric mobility and stability o the hips,
knees, ankles, and core. T e overhead position o the
arms (holding the dowel) also assesses the mobility
and symmetry o the shoulders and thoracic spine.
FMS ™ Te s t Rig ht Le ft S c o re (for bila te ra l te s ts,
e boos e lowe s t o per orm a deep squat, the athlete starts with the
Ove rhe a d de e p s qua t X X s core to re cord) eet at approximately shoulder width apart in the
Trunk s ta bility pus h-up X X sagittal plane. T e dowel is grasped with both hands,
Hurdle s te p
and the arms are pressed overhead while keep-
(drope d by a mong LE) ing the dowel in line with the trunk and the elbows
In-line lunge extended. T e athlete is instructed to descend slowly
(drope d by forwa rd LE)
and ully into a squat position while keeping the
S houlde r mobility
(drope d by uppe r UE) heels on the ground and the hands above the head.
Active s tra ight le g ra is e
T e Hurdle Step ( Figure 17-3 ) T e hurdle step
Rota ry s ta bility
(drope d by a mong LE) is designed to challenge the ability to stride, bal-
ance, and per orm a single-limb stance during coor-
Tota l S core /21
dinated movement o the lower extremity (LE). T e
athlete assumes the start position by placing the eet
together and aligning the toes just in contact with
Figure 17-1 Functio nal Mo ve me nt Scre e n sco ring
the base o the hurdle or 2 × 6 board. T e height o
she e t
the hurdle or string should be equal to the height o
the tibial tubercle o the athlete. T e dowel is place
LE, Lower extremity; UE, upper extremity across the shoulders below the neck, and the athlete
A B C
Figure 17-2 Ove rhe ad de e p squat mane uve r
Beginning (A) and end (B) of movement, frontal view, and midrange, side view (C).
A B
Figure 17-3 Hurdle ste p mane uve r
Midmotion (A) and end motion (B) before return.

A B
Figure 17-4 In-line lung e
Beginning (A) and end (B) of maneuver.
is asked to step up and over the hurdle, touch the heel to the oor (without accepting
weight) while maintaining the stance leg in an extended position, and return to the start
position. T e leg that is stepping over the hurdle is scored.
In-Line Lunge ( Figure 17-4 ) T e in-line lunge attem pts to challenge the athlete
with a m ovem ent that simulates dynam ic deceleration with balance and lateral chal-
lenge. Lunge length is determ ined by the tester by m easuring the distance to the tibial
tubercle. A piece o tape or a tape measure is placed on the oor at the determined lunge
distance. T e arms are used to grasp the dowel behind the back with the top arm exter-
nally rotated, the bottom arm internally rotated, and the sts in contact with the neck and
low back region. T e hand opposite the ront or lunging oot should be on top. T e dowel
must begin in contact with the thoracic spine, back o the head, and sacrum. T e athlete
is instructed to lunge out and place the heel o the ront/ lunge oot on the tape mark.
T e athlete is then instructed to slowly lower the back knee enough to touch the oor
while keeping the trunk erect and return to the start position. T e ront leg identi es the
side being scored.
Shoulder Mobility ( Figure 17-5 ) T is m obility screen assesses bilateral shoulder

ROM by com bining rotation and abduction/ adduction motions. It also requires normal
scapular and thoracic mobility. Begin by determining the length o the hand o the ath-
lete by measuring rom the distal wrist crease to the tip o the third digit. T is distance is
used during scoring o the test. T e athlete is instructed to make a st with each hand with
the thum b placed inside the st. T e athlete is then asked to place both hands behind
the back in a smooth motion (without walking or creeping them upward)—the upper arm
in an externally rotated, abducted position (with a exed elbow) and the bottom arm in
an internally rotated, extended, adducted position (also with a exed elbow). T e tester
B C
Figure 17-5 Sho ulde r mo bility te st
Hand measurement (A), at end of motion (B), and how motion is related to hand measurement (C).
measures the distance between the 2 sts. T e exed (uppermost) arm

identi es the side being scored.
Shoulder Clearing est ( Figure 17-6 ) A ter the previous test is per-
ormed, the athlete places a hand on the opposite shoulder and attempt
to point the elbow upward and touch the orehead (Yocum test). I pain-
ul, this clearing test is considered positive and the previous test must be
scored as 0.
Active Straight-Leg Raise ( Figure 17-7) T is test assesses the abil-

ity to move the LE separately rom the trunk, as well as tests or exibil-
ity o the hamstring and gastrocnemius. T e athlete begins in a supine
position, arms at the side. T e tester identi es the midpoint between the
anterior superior iliac spine and the middle o the patella and places a
dowel on the ground, held perpendicular to the ground. T e athlete is
instructed to slowly li t the test leg with a dorsi exed ankle and a straight
knee as ar as possible while keeping the opposite leg extended and Figure 17-6
in contact with the ground. Make note to see where the LE ends at its
maximal excursion. I the heel clears the dowel, a score o 3 is given; i Screening test for shoulder, also known as the
the lower part o the leg (between the oot and the knee) lines up with Yocum test. If positive for pain, the athlete
the dowel, a score o 2 is given; and i the patient is only able to have the scores 0 on the shoulder mobility test.
thigh (between the knee and the hip) line up with the dowel,
a score o 1 is given.
runk Stability Pushup ( Figure 17-8 ) T is test assesses

the ability to stabilize the spine in anterior/ posterior and
sagittal planes during a closed-chain upper-body move-
ment. T e athlete assumes a prone position with the eet
together, toes in contact with the oor, and hands placed
shoulder width apart (level determined by gender per crite-
ria described later) ( able 17-4), as though ready to per orm
a pushup rom the ground. T e athlete is instructed to per-
orm a single pushup in this position with the body li ted as
a unit. I the athlete is unable to do this, the hands should
be moved to a less-challenging position per criteria and a
pushup attempted again. T e chest and stomach should
Figure 17-7
come of the oor at the same instance, and no “lag” should
Active straight-leg raise test, end of motion. occur in the lumbar spine.
A clearing examination is per ormed at the end o the
trunk stability pushup test and graded as pass or ail, ailure
occurring when pain is experienced during the test. Spinal
A extension is cleared by using a ull-range prone press-up
maneuver rom the beginning pushup position (Figure 17-9);
i pain is associated with this motion, a score o 0 is given.
Rotary Stability ( Figure 17-10 ) T e rotary stability test

is a complex movement that requires neuromuscular control
o the trunk and extremities and the ability to trans er energy
B between segments o the body. It assesses multiplane stabil-
ity during a combined upper extremity (UE) and LE motion.
T e athlete assumes the staring position o quadruped with
the shoulders and hips at 90 degrees o exion. T e athlete is
instructed to li t a hand of the ground and extend the same-
side shoulder (allowing the elbow to ex) while concurrently
li ting the knee of the ground and exing the hip and knee.
Figure 17-8 Trunk stability pushup te st T e athlete needs to raise the extremities only approximately
6 inches rom the oor while bringing the elbow and knee
Beginning of motion (A) and midmotion (B). Note that together (see Figure 17-10A and B) until they touch and
the hand position is for a score of 3 for females (thumbs then return them to the ground. T e test is repeated on the
at chin); to score a 2, females start with the thumbs at opposite side. T e UE that moves during testing is scored.
clavicular height. In males, a score of 3 is achieved with Completion o this task allows a score o 3. I unable to per-
the thumbs at forehead level and a 2 with the thumbs at orm, the athlete is cued to per orm the same maneuver with
chin level.
able 17-4 Alig nme nt Crite ria fo r a Trunk Stability Pushup by Ge nde r
Po sitio n Le ve l Male Fe male
III Thumbs aligned with the forehead Thumbs aligned with the chin
II Thumbs aligned with the chin Thumbs aligned with the clavicle
The athlete receives a score of 1 if unable to perform a pushup at level II.

the opposite LE and UE (see Figure 17-10C and D), which
allows a score o 2 to be awarded. Inability to per orm a
diagonal (level II) stability results in a score o 1.
A clearing examination is per ormed at the end o this
test and again is scored as positive i pain is reproduced.
From the beginning position or this test, the athlete rocks
back into spinal exion and touches the buttocks to the
heels and the chest to the thighs (Figure 17-11). T e hands
should remain in contact with the ground. Pain on this
clearing test overrides any score or the rotary stability test
and causes the athlete to receive a score o 0.
A total score o 21 is the highest possible score on
the FMS, which im plies excellent and symm etric (in tests
that are per orm ed bilaterally) per ormance o the vari- Figure 17-9 Scre e ning (cle aring ) te st fo r
ety o screening maneuvers. otal FMS scores have been spinal e xte nsio n
investigated in relation to injury in National Football
League ootball players 11 and in emale collegiate soc- If positive for pain, the athlete scores 0 on the trunk
cer, basketball, and volleyball players.10 Kiesel et al11 stability pushup.
A B
C D
Figure 17-10 Ro tary stability te st
Flexed position for a score of 3 (A), extended position for a score of 3 (B), flexed position for a score of 2 (C), and
extended position for a score of 2 (D).
reported a 51% probability o ootball players sustaining

a serious injury over the course o 1 season, and Chorba
et al10 ound a signi cant correlation between low FMS
scores (<14) in emale athletes and injury. Furtherm ore,
a score o 14 or less on the FMS resulted in an 11- old
increase in the chance o sustaining injury in pro es-
sional ootball players and a 4- old increase in the risk or
LE injury in emale collegiate athletes.10,11 Okada et al16
investigated the relationship between the FMS and tests
o core stability and unctional per ormance. Signi cant
Figure 17-11 Scre e ning te st fo r spinal e xio n correlations between som e o the FMS screening tests
and per ormance tests o the upper and lower quarter
If positive for pain, the athlete scores 0 on the rotary were reported, but these correlations were not consistent
stability test. am ong all screening maneuvers. No signi cant correla-
tions were ound between measures o core stability and
FMS variables.
The Select ive Funct ional Movement Assessment

Musculoskeletal pain is the reason that most patients seek medical attention. T e contem-
porary understanding o pain has moved beyond the traditional tissue damage model to
include the cognitive and behavioral acets. Most scientists accept that pain alters motor
unction, although the mechanism o these changes has not been clearly identi ed. T e
central nervous system response to pain ul stimuli is complex, but motor changes have
consistently been dem onstrated and seem to be in uenced by higher centers, consis-
tent with a change in transmission o the motor command. T e human body migrates to
predictable patterns o movement in response to injury and in the presence o weakness,
tightness, or structural abnormality. Richardson et al17 summarized the evidence that pain
alters motor control at higher levels o the central nervous system than previously thought
by stating,
Consistent with the identi cation o changes in motors planning, there is compelling
evidence that pain has strong ef ects at the supraspinal level. Both short- and long-
term changes are thought to occur with pain in the activity o the supraspinal structures
including the cortex. One area that has been consistently ound to be af ected is the
anterior cingulated cortex, which has long thought to be important in motor responses
with its direct projections to motor and supplementary motor areas.17
T e SFMA is a movement-based diagnostic system or clinical use. T is system is used

by pro essionals working with patients experiencing pain on movement. T e goal o the
SFMA is to observe and capture the patterns o posture and unction or comparison against
a baseline. It uses movement to provoke symptoms, demonstrate limitations, and of er
in ormation regarding movement pattern de ciency related to the patient’s primary com-
plaint. T e SFMA uses a series o movements with a speci c organizational method to rank
the quality o unctional movements and, when suboptimal, identi y the source o provoca-
tion o symptoms during movement. T e SFMA has been re ned and expanded to help the
health care pro essional in musculoskeletal examination, diagnosis, and treatment geared
toward choosing the optimal rehabilitative and therapeutic interventions. It helps the clini-
cian identi y the most dys unctional movement patterns, which are then assessed in detail.
By identi ying all acets o dys unction within multiple patterns, speci c targeted therapeu-
tic interventions designed to capture or illuminate tightness, weakness, poor mobility, or
poor stability can be chosen. T us, the acets o movement identi ed to most represent or
de ne the dys unction and thereby af ect movement can be addressed. Manual therapy and
corrective exercises are ocused on movement dys unction, not pain.
T e SFMA is one way o quanti ying the qualitative assessment o unctional movement
and is not a substitute or the traditional examination process. Rather, the SFMA is the rst
step in a unctional orthopedic examination process that serves to ocus and direct choices
made during the remaining portions o the examination that are pertinent to the unctional
needs o the patient. T e approach taken with the SFMA places less emphasis on identi-
ying the source o the symptoms and more on identi ying the cause. An example o this
assessment scheme is illustrated by a runner with low back pain. Frequently, the symptoms
associated with low back pain are not examined in light o other secondary causes such as
hip mobility. Lack o mobility at the hip may be compensated or by increased mobility or
instability o the spine. T e global approach taken by the SFMA would identi y the cause o
the low back dys unction.
We believe it is important to start with a whole-body unctional approach, such as the
SFMA, be ore speci c impairment assessments, to direct the evaluation in a systematic and
constructive manner. Un ortunately, a unctional orthopedic examination o ten involves
provocation o symptoms. Provocation o symptoms may occur during the interplay o pos-
ture tests, movement in transition, and speci c movement tests. Production o these symp-
toms creates the road map that the clinician will ollow to a more speci c diagnosis:
• Once symptoms have been provoked, the clinician should work backwards to a more
speci c breakdown o the component parts o the movement.
• Inconsistencies observed between provocation o symptoms that are not the result o
symptom magni cation may suggest a stability problem.
• Consistent limitations and provocation o symptoms can be indicative o a mobility
problem.
T e unctional assessment process emphasizes analysis o unction to restore
proper movement or speci c physical tasks. Use o movement patterns and the
application o speci c stress and overpressure assist in determining whether
dys unction or pain (or both) are present. T e movement patterns will rea rm
hypotheses or redirect the clinician to the cause o the musculoskeletal problem.
As an example, the SFMA standing rotation test (Figure 17-12) is per ormed with
the patient’s eet planted side-by-side and stationary. T e subject makes a com-
plete rotation with segments o the entire body rst in one direction and then in
the other. When consistent production o pain in the le t thoracic spine is noted
during standing le t rotation, the same maneuver can be repeated in the seated
posture (Figure 17-13). T e 2 motions, although similar in demands or spinal
rotation, have several dif erences; with the hips and lower extremities removed
rom the movement, an entirely dif erent level o postural control may result.
When nearly the same provocation o symptoms and limitations at the same
degree o le t rotation are noted during both standing and seated, the cause
may be an underlying mobility problem somewhere in the spine. Alternatively,
i the seated rotation does not produce a consistent limitation and provocation
o symptoms in the same direction and to the same degree, a stability problem
might be present. T is change in position results in a dif erent degree o postural
alignment, muscle tone, proprioception, muscle activation or inhibition, and
re ex stabilization. T e clinician must investigate the lower body component o
this problem. Once consistency or inconsistency is observed with respect to limi-
tation o movement or provocation o symptoms, the clinician should continue to
look or other instances that support the suspicion.
Maintaining or restoring proper movement o speci c segments is key to Figure 17-12 To tal-bo dy
preventing or correcting musculoskeletal pain. T e SFMA also identi es where ro tatio n te st w hile standing
unctional exercise may be bene cial and provides eedback regarding the
ef ectiveness o such exercise. A unctional approach to exercise uses key
speci c movements that are common to the patient regardless o the speci c
activity or sport. Exercise that uses repeated movement patterns required or
desired unction is not only realistic but also practical and time e cient. Such
unctional exercises are discussed in Chapter 18.
Scoring Syst em for t he Select ive Funct ional

Movement Assessment
T e hallmark o the SFMA is the use o simple, basic movements to reveal natu-
ral reactions and responses by the patient. T ese movements should be viewed
in both loaded and unloaded conditions whenever possible and bilaterally to
examine unctional symmetry. T e SFMA uses seven basic movement patterns
(Box 17-2) to rate and rank the 2 variables o pain and unction. In addition,
4 optional tests can be used to urther re ne movement dys unction.
T e term unctional describes any unlimited or unrestricted movement.
T e term dys unctional describes movements that are limited or restricted in
some way because o lack o mobility, stability, or symmetry within a given
movement pattern. Pain ul denotes a situation in which the selective unc-
tional movement reproduces symptoms, increases symptoms, or brings about
secondary symptoms that need to be noted. T ere ore, by combining the words
Figure 17-13 Spinal ro tatio n unctional, dys unctional, pain ul, and nonpain ul, each pattern o the SFMA
in the sitting , unlo ade d po sitio n must be scored with one o 4 possible outcomes ( able 17-5).
Basic Movement s in t he Select ive Funct ional Movement Assessment

T e 7 basic movements or motions included in the SFMA screen look simple but require
good exibility and control. T ey are re erred to as “top-tier” tests or patterns. A patient
who is (a) unable to per orm a movement correctly, (b) shows a major limitation in 1 or
more o the movement patterns, or (c) demonstrates an obvious dif erence between the
le t and right sides o the body has exposed a signi cant nding that may be the key to cor-
recting the problem. T e 7 basic movements o the SFMA are described in the ollowing
sections.
Cervical Spine Assessment ( Figure 17-14 )

• T e cervical spine is cleared or pain and dys unction by the patient actively
demonstrating three patterns o motion: exion (both upper and lower cervical),
extension, and cervical rotation with side bending.
Box 17-2 Mo ve me nt Patte rns o f the Se le ctive Functio nal Mo ve me nt

Asse ssme nt
Se ve n Basic Mo ve me nts Fo ur Optio nal Mo ve me nts

Cervical spine assessment Plank with a twist
Upper-extremity movement pattern assessment Single-leg squat
Multisegmental exion assessment In-line lunge with lean, press, and lift
Multisegmental extension assessment Single-leg hop for distance
Multisegmental rotation assessment
Single-leg stance (standing knee lift) assessment
Overhead deep squat assessment
able 17-5 Sco ring Syste m fo r the Se le ctive Functio nal Mo ve me nt Asse ssme nt Base d o n Functio n
and Pain Re pro ductio n
Labe l o f Outco me o f
Patte rn Pe rfo rmance De scriptio n o f Outco me
Functional nonpainful (FN) Unlimited, unrestricted movement that is performed without pain or increased symptoms
Functional painful (FP) Unlimited, unrestricted movement that reproduces or increases symptoms or brings on
secondary symptoms
Dysfunctional painful (DP) Movement that is limited or restricted in some way because of lack of mobility, stability,
or symmetry; reproduces or increases symptoms; or brings on secondary symptoms
Dysfunctional nonpainful Movement that is limited or restricted in some way because of lack of mobility, stability,
or symmetry and is performed without pain or increased symptoms
A B
Figure 17-14 Ce rvical spine asse ssme nt
Flexion (A), extension (B), and combined side bending/rotation (C).

A B
Figure 17-15 Sho ulde r mo bility te sts
A. Internal rotation, adduction, and extension. B. External rotation, abduction, and flexion.
Upper Extremity Movement Pattern Assessments

( Figure 17-15 )
• T e UE movement pattern assessments check or
total ROM in the shoulder.
• Pattern 1 assesses internal rotation-extension, and
adduction o the shoulder (Figure 17-15A).
• Pattern 2 assesses external rotation, exion, and
abduction o the shoulder (Figure 17-15B).
Multisegmental Flexion Assessment ( Figure 17-16)

• T e multisegmental exion assessment tests or
normal exion in the hips and spine. T e patient
assumes the starting position by standing erect
with the eet together and the toes pointing
orward. T e patient then bends orward at the
hips and spine and attempts to touch the ends o
the ngers to the tips o the toes without bending
the knees.
Figure 17-16 Multise g me ntal e xio n te st: • Observe or the ollowing criteria to be met:
e nd o f mane uve r ■ Posterior weight shi t
■ ouching the toes
Note the straight legs, posterior weight shift, and ■ Uni orm curve o the lumbar spine
distributed spinal curves. ■ No lateral spinal bending
Multisegmental Extension Assessment ( Figure 17-17)

• T e multisegmental extension assessment tests or normal extension in
the shoulders, hips, and spine. T e patient assumes the starting position
by standing erect with the eet together and the toes pointing orward. T e
patient should raise the arms directly overhead and observe the response.
• T e arms are then lowered back to the starting position while the
examiner looks or synchrony and symmetry o scapular motion.
■ T e ability to move one body part independently o another is called
dissociation. Dissociation problems can be caused by poor stabilizing
patterns that do not allow ull mobility and stability at the same time.
I the patient can maintain stability only by limiting limb or trunk
movement, the patient is unctionally rigid rather than dynamically
stable. T e patient may appear to have a restriction in mobility when
in act the true dys unction is inadequate postural or motor control.
As the patient raises the arms overhead, the clinician observes or
the ability to move only one body part and that bilateral symmetry
is present. T e ideal response is or the patient to raise the arms
180 degrees with the pelvis maintaining a neutral position.
• T e patient raises the arms back up to over the head with the elbows
in line with the ear. T e midhand line should clear the posterior
aspect o the shoulder at the end range o shoulder exion. T e elbows
Figure 17-17 Multise g me ntal
e xte nsio n te st: e nd o f mane uve r
should remain extended and in line with the ears. At this point have
the patient bend backwards as ar as possible while making sure that
Note the anterior shift of the pelvis,
the hips go orward and the arms go back simultaneously. T e spine
extension of the upper extremities, and
o the scapula should move posteriorly enough to clear the heels.
distribution of spinal curves.
Both anterior superior iliac spines should move
anteriorly, past the toes.
• Observe or the ollowing criteria to be met:
A B
■ T e anterior superior iliac spine must clear the
toes. Forward rotation o the pelvis will pull
the lumbar spine out o a neutral position into
extension. T e pelvis slides orward by shi ting
body weight toward the ront o the eet and
again pulls the lumbar spine out o neutral.
■ Symmetric spinal curves should be present and
the spine o the scapula must clear a vertical line
drawn rom the patient’s heels.
■ Arms/ elbows in line with the ears represent
180 degrees o shoulder exion.
Multisegmental Rotation Assessment ( Figure 17-18)

• T e multisegmental rotation assessment examines
the total rotational motion available rom the oot
to the top o the spine. Usually, rotation occurs
as a result o many parts contributing to the total
motion. T is assessment tests rotational mobility
in the trunk, pelvis, hips, knees, and eet. T e Figure 17-18 Multise g me ntal ro tatio n te st
patient assumes a starting position by standing
erect with the eet together, toes pointing orward, Start of maneuver (A) and end of maneuver (B). Note the
and arms relaxed to the sides at about waist height. rotation at the pelvis and trunk and the upright posture.
T e patient then rotates the entire body as ar as possible to the right

while the oot position remains unchanged. T e patient returns to the
starting position and then rotates toward the le t.
■ T ere should be at least 50 degrees o rotation rom the starting
position o the pelvis and lower quarter bilaterally.
■ In addition to the 50 degrees o pelvic rotation, there should also
be at least 50 degrees o rotation rom the thorax bilaterally, or
a combined total o 100 degrees o total-body rotation rom the
starting position.
• Observe or the ollowing criteria to be met:
■ Pelvis rotating greater than 50 degrees
■ runk rotating greater than 50 degrees
■ No loss o body height with the rotation testing
■ Note: Because both sides are tested simultaneously with the eet
together, the externally rotating hip is also extending and can thus
limit motion. Close attention should be paid to each segment o
the body. One area may be hypermobile because o restriction in
an adjacent segment. Rotation should be symmetric on each side
(within 10 degrees).
Figure 17-19 Sing le -limb Single-Leg Stance (Standing Knee Lift) Assessment ( Figure 17-19)
stance , e ye s o pe n • T e single-leg stance assessment evaluates the ability to independently
stabilize on each leg in a static and dynamic posture. T e static
portion o the test looks at the undamental oundation or control o
movement. T e patient assumes the starting position by standing erect
with the eet together, toes pointing orward, and arms raised out to
the side at shoulder height. T e patient should be instructed to stand
tall be ore testing. T e patient should li t the right leg up so that the hip
and knee are both exed to 90 degrees. T e patient should maintain
this posture or 10 seconds. T e test is repeated on the le t leg. T e
examiner should look to see whether the patient maintains a level
pelvis (no rendelenburg position present).
• T e test is repeated again with the eyes closed. T e body has 3
main systems that contribute to balance: visual, vestibular, and
somatosensory. When the eyes are closed and vision is eliminated,
the patient must rely on the other 2 systems to maintain an upright
posture.
■ Foot position should remain unchanged throughout the movement,
and the hands should remain resting on the hips.
■ Look or loss o posture or height when moving rom 2 to 1 leg. Any
o the 3 portions o the test are scored as dys unctional i the patient
loses posture.
Overhead Deep Squat Assessment ( Figure 17-20)

• Same as used in the FMS.
• T e overhead deep squat assessment tests or bilateral mobility o
the hips, knees, and ankles. When combined with the overhead UE
Figure 17-20 Ove rhe ad de e p position, this test also assesses bilateral mobility o the shoulders, as
squat well as extension o the thoracic spine.
• T e patient assumes the starting position by placing the instep o the eet in vertical
alignment with the outside o the shoulders. T e eet should be in the sagittal plane,
with no external rotation o the eet. T e patient then raises the arms overhead, arms
abducted slightly wider than shoulder width and the elbows ully extended. T e
patient slowly descends as deeply as possible into a ull squat position. T e squat
position should be attempted while maintaining the heels on the oor, the head and
chest acing orward, and the hands overhead. T e knees should be aligned over the
eet with no valgus collapse.
■ Hand width should not increase as the patient descends into the squat position.
■ T e UEs and hands should not deviate rom the plane o the tibias as the squat is
per ormed.
■ T e ability to per orm this test requires closed chain dorsi exion o the ankles,
exion o the hips and knees, extension o the thoracic spine, and exion abduction
o the shoulders.
Each movement is graded with a notation o unctional nonpain ul, unctional pain-
ul, dys unctional pain ul, or dys unctional nonpain ul (see able 17-5). All responses other
than unctional nonpain ul are then assessed in greater detail to help re ne the movement
in ormation and direct the clinical testing. Detailed algorithmic SFMA breakouts are avail-
able or each o the movement patterns, but they are beyond the scope o this chapter to
describe in detail.
Opt ional Movement s of t he Select ive Funct ional Movement Assessment

In addition to the SFMA top-tier or base assessments, our optional assessments have
recently been added to urther re ne the movement dys unction. T ey serve to illuminate
movement dys unction in higher- unctioning patients.
Once dys unction, or sym ptom s, or both, have been provoked in a unctional man-
ner, it is necessary to work backwards to m ore speci c assessm ents o the com ponent
parts o the unctional m ovem ent by usin g special tests or ROM com parisons. As the
gross un ctional m ovem ent is broken down into its com pon ent parts, the clin ician
should exam ine or consistencies and inconsistencies, as well as the level o dys unction,
in each test with respect to the optim al m ovem ent pattern. Provocation o sym ptom s, as
well as lim itations in m ovem ent or an inability to maintain stability during m ovem ents,
should be noted.
Furt her Re nement of Movement Dysfunct ion: Using t he Breakout s

Once dys unction is noted, the clinician can use the SFMA to systematically dissect each o
the major pattern dys unctions with breakout algorithms. T e breakouts provide an algo-
rithmic approach to testing all areas potentially involved in the dys unction to isolate limita-
tions or determine dys unction by the process o elimination. T e breakouts include active
and passive movements, weightbearing and non-weightbearing positions, multiple-joint
and single-joint unctional movement assessments, and unilateral and bilateral challenges.
By per orming parts o the test movements in both loaded and unloaded conditions, the
clinician can draw conclusions about the interplay between the patient’s available mobility
and stability. I any o the top-tier movements are restricted when per ormed in the loaded
position (eg, limited or in some way pain ul be ore the end o ROM), a clue is provided
regarding unctional movement. For example, i a movement is per ormed easily (does not
provoke symptoms or have any limitation) in an unloaded situation, it would seem logical
that the appropriate joint ROM and muscle exibility exist and there ore a stability problem
may be the reason why the patient cannot per orm the movement in a loaded position. In
this case, a patient has the requisite available biomechanical ability to go through the nec-
essary ROM to per orm the task, but the neurophysiologic response needed or stabilization
that creates dynamic alignment and postural support is not available when the unctional
movement is per ormed.
I the patient is observed to have limitation, restriction, or pain when unloaded, the
patient displays consistent abnormal biomechanical behavior o one or more joints and
would there ore require speci c clinical assessment o each relevant joint and muscle
complex to identi y the barriers that are restricting movement and may be responsible or
the provocation o pain. Consistent limitation and provocation o symptoms in both the
loaded and unloaded conditions may be indicative o a mobility problem. rue restric-
tions in mobility o ten require appropriate manual therapy in conjunction with corrective
exercise.
T e SFMA breakout testing applies the same categorizations as its top-tier assess-
ment, with isolated ocus on each pattern demonstrating pain or dys unction. T is ocus
helps identi y gross limitations in mobility and stability. Recall that the SFMA uses speci c
descriptors to identi y dys unction in both mobility and stability, as described earlier in this
chapter.
• issue extensibility dys unction involves tissues that are extraarticular. Examples can
include active or passive muscle insu ciency, neural tension, ascial tension, muscle
shortening, scarring, and brosis.
• Joint mobility dys unction involves structures that are articular or intraarticular.
Examples can include osteoarthritis, usion, subluxation, adhesive capsulitis, and
intraarticular loose bodies.
Figure 17-21 provides an exam ple o the overhead deep squat pattern breakout.
As can be seen on the algorithm, the clinician is directed to move rom a weighted to an
unweighted posture, and active and passive movements are used to systematically isolate
all the dif erent variables that could cause dys unction during the overhead deep squat.
How t o Int erpret t he Result s of Select ive Funct ional

Movement Assessment
Once the SFMA has been completed, the clinician should be able to: (a) Identi y the major
sources o dys unction and movements that are af ected. (b) Identi y patterns o movement
that cause pain, with reproduction o pain indicating either mechanical de ormation or an
in ammatory process af ecting nociceptors in the symptomatic structures. T e key ollow-
up question must be, “Which o the unctional movements caused the tissue to become
pain ul?” (c) Once the pattern o dys unction has been identi ed, the problem is classi-
ed as dys unction o either mobility or stability to determine where intervention should
commence.
With the SFMA, treatment is not about alleviating mechanical pain; rather, the SFMA
guides the clinician to begin by choosing interventions designed to improve the dys unc-
tional nonpain ul patterns rst. T is philosophy o intervention does not ignore the source
o pain; instead, it takes the approach o removing the mechanical dys unction that caused
the tissues to become symptomatic in the rst place.
Pain- ree unctional movement is the goal or all. It is requisite or work per ormance,
athletic success, and healthy aging. T e pain- ree unctional movement necessary to allow
participation in activities o daily living, work, and athletics has many components: pos-
ture, ROM, muscle per ormance, and motor control. Impairments in any o these com-
ponents can potentially alter unctional movement. T e authors believe that the SFMA
incorporates the essential elements o many daily, work, and sports activities and provides
a schema or addressing movement-related dys unction. (More in ormation can be ound at
www.Rehabeducation.com.) Appendices A5 to A-7 are examples o score sheets used with
the SFMA.
OVERHEAD DEEP S QUATTING PATTERN BREAKOUTS

Limite d ove rhe a d de e p s qua t
Inte rlocke d finge rs be hind ne ck de e p s qua t
DN, DP , or FP If s qua t is now functiona l a nd

non-pa inful – Go re che ck a ll
exte ns ion bre a kout flowcha rts.
As s is te d s qua t
DN, DP , or FP FN
Core S MCD, plus ma ke s ure

multi-s e gme nta l exte ns ion
bre a kouts a re cle a r.
Ha lf kne e ling dors iflexion
FN, FP , or DP DN
Lowe r pos te rior cha in TED a nd/or

a nkle J MD, plus ma ke s ure MS E
a nd S LS bre a kouts a re cle a r.
S upine kne e s to che s t holding s hins
DN, DP , or FP FN
S upine kne e s to If dors ifle xion wa s FN = we ight be a ring core ,

che s t holding thighs kne e a nd/or hip fle xion S MCD. If dors ifle xion
wa s DN, cons ide r kne e s , hips , a nd core norma l.
If dors ifle xion wa s DP or FP the n cons ide r this
a re d box a nd tre a t dors ifle xion. P lus ma ke s ure
multi-s e gme nta l e xte ns ion bre a kouts a re cle a r.
FN FP or DP DN
Kne e J MD (flexion) a nd/or lowe r a nte rior Hip J MD a nd/or pos te rior cha in TED – P roce e d to
cha in TED, plus ma ke s ure multi-s e gme nta l multi-s e gme nta l flexion for hips, but s till ca n be kne e
exte ns ion brea kouts a re cle a r. J MD – Go to multi-s e gme nta l exte ns ion bre a kout.
Figure 17-21
Overhead deep squat pattern breakout. DN, Dysfunctional nonpainful; DP, dysfunctional
painful; FN, functional nonpainful; FP, functional painful; JMD, joint mobility dysfunction;
MSE, multisegmental extension; SLS, single leg stance; SMCD, stability motor control dysfunction;
TED, tissue extensibility dysfunction.
Movement Screening versus Speci c

Functional Performance ests
T e undamental movement screening tests described in this chapter do not assess the
whole o unction. T ey do not include power tasks, running, jumping, acceleration, or
deceleration, which are important acets o almost all sports and must there ore be exam-
ined be ore return o an athlete to practice or competition. T e ollowing section discusses
the evidence that is available and the current utility o several common speci c unctional
per ormance tests.
Pro essionals involved with athletes per orm a wide variety o unctional per ormance
tests. Objective, quantitative assessment o unctional limitations by the use o unctional
per ormance testing has been described in the literature or more than 20 years.18-24 Func-
tional per ormance assessment may be used in an attempt to describe an athlete’s aptitude,
identi y talent, monitor per ormance, describe asymmetry or dys unction, and determine
readiness to participate in sports. Be ore sports participation athletes are requently timed
in a 40-yard dash, measured or vertical jump abilities, or assessed or per ormance on agil-
ity tests such as the timed -test. T is o ten occurs as part o a preparticipation examination.
A ter progressing through postinjury or postsurgical rehabilitation, patients are assessed
or their ability to per orm unctional tasks such as step-downs, hopping, jumping, landing,
and cutting. Functional tests such as these are requently used to simulate sporting activi-
ties or actions in the context o whole-body dynamic movement to contribute to the deci-
sion regarding whether an athlete is “ t” or physically prepared to begin sport participation
or ready to return to play. It is our assertion that these speci c unctional tests should be
per ormed only a ter movement screening has taken place and success ul mastery o the
undamental movements previously described has been demonstrated.
Functional per ormance testing should examine athletes under conditions that imi-
tate the necessary unctional demands o their sports. Functional per ormance tests use
dynamic skills or tasks to assess multiple components o unction, including muscular
strength, neuromuscular control/ coordination, and joint stability.25,26 T ey can be used or
assessment o patients a ter LE injury, surgery, muscular contusions, overuse conditions
such as tendinopathy or patello emoral dys unction, anterior cruciate ligament reconstruc-
tion (ACLR), and ankle instability.19-21,26,27 Ideally, such tests should be time e cient and
simple, require little or inexpensive equipment, and be able to be per ormed in a clinical
setting.11,21,28 I at all possible, such tests should be able to identi y subjects at risk or injury
or reinjury.28-31 Above all, unctional per ormance tests should be objective, reliable, and
sensitive to change.19,24,27,29,32 T e root requirement or establishing the objectivity and reli-
ability o any unctional test is the use o standardized protocols and instructions.27
T e validity o unctional per ormance tests is di cult to establish. Many tests assess
or examine only a portion o the requirements or the composite per ormance o a com-
plex sporting activity. Single-limb assessments may have advantages in evaluating ath-
letes who rely on unilateral limb per ormance, such as runners,33 or athletes or whom
running accounts or a large part o their sport demands. Single-limb tasks or “hops”
of er considerable in ormation regarding unctional readiness in a wide variety o ath-
letes because many sports entail single-limb weight acceptance, hopping, or landing as
a part o their per ormance. Single-limb assessments of er speci c bene ts in the realm
o objectivity because o their ability to provide within-subject, between-limb compari-
sons, described as a “biologic baseline,” versus having to use population-derived norms.
ests such as the single-limb leg press (Figure 17-22), step-down per ormed either to the
ront or laterally (Figure 17-23),27,34 squat,35 hop or distance, triple hop or distance, cross-
over hop or distance (Figure 17-24),18,20,21 stair hop,29,30 and the 6-meter timed single-
limb hop 20,21 are examples o commonly used single-limb tests that allow establishment
Movement Screening versus Speci c Functional Performance Tests 487
o the limb symmetry index (LSI), which helps identi y
existing or residual postoperative asymmetry between
lim bs.20,21,25,29,30 T e unctional status o the knee has
been categorized as “comprom ised” i the LSI is less
than 85%.18,20,21 Single-limb tasks of er a wide variety o
imposed demands on the LE that can be used at various
times during the rehabilitation process or assessment
o symmetry, recovery, and readiness to resume sports
participation.27,29,30 T e triple hop or distance has been
demonstrated to be a strong predictor o both power (as
measured by vertical jump) and isokinetic strength.22,25,36
Sekir et al26 describe a lateral single-limb hop test that may
be an important acet o unctional assessment or ath-
letes who rely on repetitive lateral movements or sport
pro ciency. Several researchers also advocate assess-
ment o lateral movement during single-limb hop test-
Figure 17-22 Sing le -le g pre ss
ing or the side-cutting maneuver because it may be more
valid or athletes who move and cut laterally.37,38 Several
authors18,20,21,29,30 have related the LSI to unctional status; or example, a lower LSI a ter
ACLR is related to poorer unction, and improvements in raw scores on the single-limb
hop test, as well as the LSI, represent unctional recovery over 52 weeks a ter ACLR. Noyes
et al20,21 suggested that the LSI should be higher than 85% be ore return to sport. Loudon
et al27 suggested that in the case o patello emoral pain syndrome, the LSI should be closer
to 90% to prevent reinjury. Bilateral assessments, including squats, leg presses, and 2-legged
“jumps” such as the drop jump (Figure 17-25) or tuck jump (Figure 17-26), may be more
valid or assessing athletes in whom 2-legged jumping and landing tasks are important.31,33
A B C
Figure 17-23 Ste p-do w n te st
Monitor for LE biomechanics and control. A. Front step down; note the trunk and hands. B. Front step-down close-up;
note the alignment of the stance knee. C. Lateral step-down with same qualitative criteria.
A B C
Figure 17-24 Cro sso ve r ho p fo r distance
Start (A), lateral movement (B), and final lateral movement (C). Note: The athlete must “stick”
or control the landing. The athlete attempts to go as far as possible in the combined 3 hops.
A B C
Figure 17-25 Dro p jump asse ssme nt
Start position (A), midposition (B), and landing (C). Note the deep flexion angle in landing and alignment of the hips
and knees.
A B C
Figure 17-26 Tuck jump asse ssme nt
Beginning of movement (A), midmovement (B), and in air in a tucked position (C). Note that this test must be observed
from the side and the front to analyze performance.
Most athletic skills require a combination o vertical, horizontal, and lateral movement by
1 or both LEs. Probably the most important requirement or success ul sport per ormance
is a series o highly developed motor control strategies to allow speed and agility during
per ormance.33 I an LE reach, jump, hop, or agility test could be used to objectively screen
athletes’ neuromuscular per ormance and suggest intervention be ore either sport partici-
pation or return to sport, that unctional per ormance test would be valuable or preventing
injury or decreasing the likelihood o reinjury.12,21,28,31,37
We know o no single optimal, valid, and reliable test that can determine an athlete’s
readiness or participation or return to sport. Given the wide variation and complexity o
the demands o sport, this is not surprising. Many pro essionals suggest the use o unc-
tional test batteries or a series o unctional tests that are related to the speci c demands
o a speci c sport or that can be related to the probable mechanisms o injury or a speci c
pathology. A combination o 2 or more tests is recommended or relevant, sensitive, respon-
sive unctional assessment.18,20,21,39,40 Bjorklund et al39 proposed a unctional test instrument
(battery) named the est or Athletes with Knee Injuries that they describe as valid, reliable,
and sensitive or use a ter ACLR. T e est or Athletes with Knee Injuries is composed o
8 evaluations, including jogging, running, single-limb squat, rising rom sitting (single leg),
bilateral squat, single-limb hop or distance, single-limb vertical jump (per ormed plyo-
metrically), and the single-limb crossover hop (8 meters). T e authors present suggested
scoring criteria or each test that take into account qualitative assessment o per ormance o
the 8 tests. T is is just one such example o combining several unctional per ormance tests
into a series or examination o a group o patients. Clearly, all unctional per ormance tests
are not relevant or all athletes, and it is the role o the rehabilitation pro essional to select
valid, reliable, sensitive, and relevant unctional per ormance tests.
SUMMARY
Movement Scoring Syst ems
1. One o the most di cult decisions that must be made by rehabilitation providers is
whether an athlete is ready to participate in sports or sa ely return to sport participation.
2. Acceptance plus use o undamental movement screening systems such as the FMS
and the SFMA is sweeping across the country. T ese screens of er valuable in orma-
tion to pro essionals regarding the undamental unctional abilities o an athlete in the
realm o m ovem ent by identi ying compensatory movements or de cits in mobility or
stability.
Funct ional Performance Test s

1. Functional per ormance tests or test batteries can be used to assess athletes o all ages
and skill levels who participate in a wide variety o sports.
2. Frequently, unctional per ormance tests assess a acet or single part the vast de-
mands o any given sport, and there ore the validity o such tests is hard to determine.
Although not providing a complete picture o athletic unction, these tests are essential
tools or the rehabilitation pro essional. It is critical that the rehabilitation pro essional
be amiliar with the use o such screens and tests to discern readiness or participation.
3. Skill ul combinations o movement screening, unctional per ormance testing, and
sport-speci c movement testing of er the best assessment o an athlete’s readiness or
return to sport.
Fut ure Research

1. Although evidence regarding tests and systems that are objective, valid, and reliable is
beginning to mount (Minick, DiMattia, Loudon, and others), many questions regard-
ing the big picture o return to unction exist. Does the FMS relate to core stability?
Does it predict per ormance in athletics or merely identi y potential or injury? Which
unctional per ormance measures are best used or athletes who participate in certain
sports? Normative scores or the FMS and other unctional per ormance tests by age
and gender would be very help ul or comparison between athletes.
2. As the published evidence on unctional testing continues to accumulate, rehabilita-
tion pro essionals will have to keep abreast o changes and adapt their use o screens
and tests accordingly.
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Functional Exercise
Progression and
Functional Testing
in Rehabilitation
Tu r n e r A. Bla ck b u r n , Jr a n d Jo h n A. Gu id o , Jr
De ne functional exercise progression.
De ne the SAID (speci c adaptations to imposed demands) principle.
Outline the need for functional progression and testing.
Describe the continuum of functional progression for low- and high-level patients.
Outline a functional progression program for the lower extremity.
Outline a functional progression program for the upper extremity.
Outline a functional progression program for the spine.
Discuss major functional testing research.
497
498 Chapte r 18 Functional Exercise Progression and Functional Testing in Rehabilitation
T e physical therapist plays an important role in helping individuals return to their prein-
jury level o unction. While working to achieve impairment-based goals, unctional testing
is employed to gauge readiness to move through the rehabilitation program and to return
to activity. A unctional exercise progression can be initiated prior to unctional testing or
ollowing the results o unctional tests. In either case, unctional testing or progression
should not exceed the healing constraints o the injured tissue. By breaking down unc-
tional activities into basic tasks, a sa e and ef ective rehabilitation program can be designed.
T is chapter examines unctional exercise testing and unctional exercise progression, and
provides examples or some common upper- and lower-extremity disorders, as well as a
sample spine program.
What Is Functional Testing and Functional

Exercise Progression?
T e ultimate goal o any rehabilitation program is to return an individual to the preinjury
level o unction as quickly and sa ely as possible. Decreasing pain and swelling—and
restoring normal range o motion (ROM), strength, proprioception, and balance—are only
part o the plan. Functional testing and a unctional exercise progression will complete
the rehabilitation program. Functional testing encompasses measuring various activities
to provide a baseline or determining progress or to provide normative data with which
to compare per ormance. A unctional exercise progression can be de ned as a series o
activities that have been ordered rom basic to complex, simple to di cult, that allows or
the reacquisition o a speci c task. Many o the exercises in the unctional progression may
be used or unctional testing. Functional testing and unctional exercise progression allow
the clinician to bridge the gap between basic rehabilitation and a ull return to activity.
How Is Functional Testing Performed?

Functional testing and unctional exercise progression are used in a variety o physical
therapy settings but in very dif erent capacities. Physical therapists practicing in outpatient
orthopedic settings use these techniques to help their patients return to activities o daily
living (ADL), work, and sports. In neurologic and geriatric rehabilitation settings, unctional
testing and unctional exercise progression take on a dif erent meaning, being geared more
toward ADL, trans ers, and ambulating on level and unlevel sur aces.
Despite these dif erences, the principles that guide unctional testing and exercise
progression are the same regardless o the practice setting and level o the patient. Some
patients will move urther through the program than others, based on their speci c reha-
bilitation goals. T ere is little basic science and research to guide the physical therapist
in designing a unctional exercise progression. Rather, common sense prevails and is
employed along with the in ormation available regarding healing constraints o various
musculoskeletal disorders or the precautions that must be heeded or various medical
conditions.
A complete discussion o collagen healing is beyond the scope o this chapter, but
in general, many o the injuries encountered in the outpatient setting will heal in 3 to
6 weeks.20,21 In the early phases o the rehabilitation program, appropriate stress must be
placed on the healing tissues to ensure proper healing. Our bodies heal according to the
SAID (speci c adaptation to imposed demand) principle.13 T e imposed demand is thera-
peutic exercise in the orm o a unctional progression that stresses the injured tissue so
as to enable it to heal at an adequate length and strength. T is enables the individual to
How Is Functional Testing Performed? 499
handle the demands o return to ull unction without reinjuring the area. I the unctional
progression is employed incorrectly, the stress imparted will cause reinjury and impede
the patient’s progress. Healing constraints may be exceeded or new injuries created during
unctional testing or exercise progression, and the therapist should be acutely aware o the
individual’s response to activity. T e presence or absence o the cardinal signs o in amma-
tion, as well as muscle weakness, loss o motion, and instability o the injured joint, should
alert the clinician to reassess the activity being per ormed. T e culprit may be one activity
that is above the abilities o the patient at that time, or that the overall volume exceeds the
ability o the healing structures to accommodate to the stress.
Early in the rehabilitation program, therapeutic techniques should be employed to
meet the various impairment goals, such as eliminating pain and swelling and restoring
ull ROM, strength, proprioception, balance, and normal ambulation without deviations
or assistive devices. Normal ROM can be assessed with a goniometer by comparing estab-
lished norms or the range o the uninvolved opposite extremity. Swelling can be assessed
via tape measure or circum erential measurements, or with volumetric measures o water
displacement. Pain levels can be determined with a visual analog scale.
Strength testing poses a challenge to the clinician. A 5/ 5 manual muscle test grade may
not show true de cits in strength and endurance o the musculature. Isokinetic testing, i
available, may be a better alternative and has been shown to correlate with unction despite
being per ormed in an open-chain ashion.26 We recommend less than a 30% isokinetic de -
icit in the strength and endurance o the involved versus the uninvolved extremity prior to
initiating unctional testing activities or athletic endeavors. T is orm o testing will not be
available to all clinicians, and not all patients will need to undergo an isokinetic evaluation.
Basic manual muscle testing or the use o a handheld dynamometer to increase objectivity
will su ce in many cases. Proprioception at a given joint can be assessed through basic
joint repositioning tasks, or can be measured using the electrogoniometer on the Biodex
Multi-Joint System. Balance testing can be per ormed with or without high-technology
equipment. At a minimum, per orming a single-leg stance activity or total duration, or
counting the number o touchdowns with the opposite lower extremity, can be assessed
with a second hand on a watch. T ere are several excellent balance screens, such as the Berg
balance scale, the clinical test o sensory interaction or balance, and the unctional reach
test. Plisky et al utilized a modi ed version o the S AR excursion balance test termed the “Y
Excursion balance test.” T e authors noted that this simple screen was able to demonstrate
side-side dys unction and problems with balance and strength. T e subject stands and
reaches with 1 lower extremity as ar as able without losing balance in the orward, postero-
medial, and posterolateral directions. T e limb used or balance is the limb being tested.
T ree trials in each direction are measured and an average reach distance is recorded. T e
authors suggested, via logistic regression analysis, that individuals with an anterior right/
le t reach dif erence greater than 4 cm were 2.5 times more likely to sustain a lower-extrem-
ity injury. T e authors also suggested using a composite score derived by adding the three
reach distances, dividing this by three times the limb length (measured rom the anterior
superior iliac spine to the medial malleolus) and multiplying times 100 in order to give a %
score. T ose individuals with a composite reach distance less than 94% o their limb length
were 6.5 times more likely to have a lower-extremity injury. T ere are also several excellent
testing devices on the market that will give the clinician in ormation regarding the postural
sway envelope and directions o movement, such as the Biodex Stability System and the
NeuroCom Balance System (NeuroCom, Inc., Clackamas, OR). Monitored Rehabilitation
Systems devices can be used or unctional motor control testing and training activities.
When an individual has no pain or swelling, and has reached su cient ROM, strength,
balance, and ambulation without deviations, the clinician can determine i unctional
testing is appropriate. In some cases, unctional testing may be used prior to meeting the
impairment goals, provided the individual is not placed at risk or reinjury based on the
healing constraints o the injured tissue. T e in ormation gained will be valuable to the
clinician and the individual in planning urther treatment.
Speci cs
How Is Funct ion Measured?

Functional testing is a onetime, maximal ef ort that is per ormed to assess per ormance.25
T e key is that the test must recreate the activity that the individual will be per orming,
and must be completed in a controlled environment. T e purpose o unctional testing is to
determine an individual’s readiness to return to the preinjury level o unction. T e in or-
mation gained will allow the clinician to point out de cits that must be overcome, and to
progress the rehabilitation program. Functional testing, like the unctional exercise progres-
sion, must begin with simple tasks and progress to highly coordinated tasks. At the lowest
level, or an individual to per orm a sit-to-stand trans er, the leg press or bilateral minis-
quats can be per ormed or repetitions or a length o time. T is will recreate an individual’s
daily activities, in this case, rising rom a chair, commode, or car seat. esting can be per-
ormed through various ranges o motion to recreate the seat heights the individual will
encounter. T e clinician can also use ambulation itsel as a unctional test. Ambulation or
distance is an important determinant to see i the patient can unction in the community.
Ambulation measured or time will determine i the patient can cross a street sa ely or exit
an elevator be ore the door closes.
As another example, the clinician should examine a patient’s ability to climb stairs.
What unctional test can be used to assess this skill? Front or lateral step-ups or step-downs
can be used to determine an individual’s readiness to complete this task. T is test is also
easily standardized. Step-ups can be per ormed with only the heel o the opposite limb
touching the ground. A step height can be chosen that equals heights that will be encoun-
tered at home, the o ce, or in the community. Repetitions are counted, or the number o
repetitions in a set time can be measured. T e results are compared with the uninvolved
limb or established norms. Rosenthal et al22 reported an intraclass correlation coe cient
o 0.99 or the lateral step-up test. Functional testing can be as simple as per orming minis-
quats, ambulation, or lateral step-ups or repetitions, distance, or time.
At the highest level o unctional testing in the lower extremity, an athlete may have to
complete complex movements such as jump or hop tests, shuttle runs, and agility drills.
T is part o the rehabilitation process is an integral part o the rehabilitation pro essional’s
daily routine in the sports setting and can be easily incorporated to meet patients’ needs
in the clinic. T e results o unctional testing will determine when they can return to play.
Daniel et al5 described the one-leg hop or distance test. One-leg hopping is an example
o an activity that places higher demands on the lower extremity than does walking or jog-
ging.23 Subsequently, many clinicians and researchers have used this test or examining
unction in varied populations, especially in patients who have undergone anterior cruciate
ligament (ACL) reconstructions.23 It is easy to see how important this activity is in terms o a
return to athletic competition. T is is an ideal test to determine the individual’s willingness
to accept weight on the involved leg a ter injury.25 T e one-leg hop or distance and the one-
leg timed hop, predominantly used with athletes, also have shown good reliability.5 A sin-
gle-leg hop does have its limitations, in that it only describes one movement, whereas most
sports require a series o complex maneuvers. T ere ore, many authors have attempted to
create even higher-level tests to determine readiness to play. Lephart et al14 examined 3
unctional testing procedures or the ACL-de cient athlete. T ese included the cocontrac-
tion maneuver (a shu ing maneuver around a semicircle while tethered to surgical tub-
ing), a carioca (crossover stepping), and a shuttle run (an acceleration and deceleration
Speci cs 501
test). Several investigators have attempted to correlate the results o isokinetic testing and
unctional activities. Wilk et al23 ound a positive correlation between isokinetic knee exten-
sion peak torque and 3 unctional hop tests (hop or distance, timed hop, and crossover tri-
ple hop). T e results o this study were urther strengthened by Jarvela et al9 who assessed
muscle per ormance 5 to 9 years a ter ACL reconstruction. T ey also correlated the strength
o the knee extensors and exors at 60 degrees per second isokinetically with the one-legged
hop or distance. Both studies suggest that expensive isokinetic devices may not be required
or determining the unctional status o an athlete.9,26 Many physical therapy clinics utilize a
otal Gym (Engineering Fitness International, Inc., San Diego, CA) or lower-extremity reha-
bilitation. Munich et al18 have created a testing protocol or use on this device. T ey exam-
ined 35 healthy subjects who per ormed a 20-second test or unilateral squat repetitions
and a 50-second squat repetition test or time. T eir ndings indicate acceptable test–retest
reliability or the purpose o evaluating unctional ability during the early stages o rehabili-
tation or lower-extremity conditions. One other consideration during unctional testing is
determining an athlete’s eccentric control, which is extremely important in changing direc-
tions and landing rom a jump. Juris et al11 had asymptomatic and symptomatic individu-
als with knee pain per orm a maximal controlled leap. T is test was per ormed by having
the individual per orm a single-leg hop by taking of on the uninjured limb and landing on
the injured limb, termed orce absorption versus orce production. T e results o this study
demonstrated that individuals with knee pain had di culty managing orce absorption as
opposed to creating orce ( orce production). I a traditional single-leg hop is examined, the
individual does per orm orce absorption, but i they have lower-extremity weakness, they
may not create a large takeof orce ( orce production) and, there ore, not stress the limb
in landing. I the orces are lower during the test than those experienced during sports, the
athletes may be returned to activity be ore they are truly ready.
Mattacola et al16 studied a group o patients who had undergone ACL reconstruction
to determine their per ormance during 2 unctional tests conducted on the Smart Balance
Master (NeuroCom, Inc. Clackamas, OR) as compared to a control group. All o the ACL
reconstruction patients were at least 6 months postoperative. Both groups per ormed the
step-up-and-over test (Figure 18-1) and the orward lunge (Figure 18-2) on a long orce
plate. T e control group produced signi cantly more orce during the initial step o the
step-up-and-over task than did the ACL-reconstructed group. In the same test, the ACL
Figure 18-1 The ste p-up-and-o ve r te st pe r- Figure 18-2 The fo rw ard lung e te st pe r-
fo rme d o n the Smart Balance Maste r fo rme d o n the Smart Balance Maste r
(NeuroCom, Inc., Clackamas, OR.) (NeuroCom, Inc., Clackamas, OR.)

reconstruction patients were signi cantly slower when they led with the involved limb.
During the orward lunge test, there were no dif erences between groups in the lunge dis-
tance or the contact time. However, the impact index (percentage body weight, indicates
eccentric ability o nonstepping leg) and the orce impulse (percentage body weight × the
time the orce is exerted) measurements were signi cantly greater or the uninvolved leg
than the involved leg in the ACL patients. Higher impact and orce indices represent bet-
ter unctional ability. Such tests, per ormed on the Smart Balance Master maybe use ul or
screening or unctional disability that might persist a ter ACL reconstruction and not be
recognized with more general, clinical unctional tests.
In lieu o these tests or sophisticated testing equipment, the physical therapist can
have the patient run through a series o progressively di cult tasks such as running straight
ahead and backpedaling, per orming gure-8 runs, cutting maneuvers, and, nally, sports-
speci c tasks.
In the upper extremity, the clinician needs to be more creative to recreate the unctional
demands an individual may encounter during ADL or sports. Functional testing can include
pushups or an athlete or overhead activities per ormed in a specially designed apparatus
or an electrician or carpenter. Again, at the lowest level, simple reaching tests can recreate
ADL such as removing items rom overhead cabinets. o standardize this, a goniometer can
be used to measure ROM at the glenohumeral joint, or a nger ladder to document reach
height. A tape measure can be used to measure reach distance. At the highest levels, activi-
ties that recreate job tasks, as alluded to, can be per ormed in the clinic. Measures o spe-
ci c skills, duration o overhead activity, or speed o activity provide objective evidence o
unctional ability. For the athlete, both open-chain (throwing activities and racquet sports)
and closed-chain ( ootball, wrestling, gymnastics) activities can be reproduced in the clinic.
T e clinician is only limited by the clinician’s imagination.
Whether testing the upper or lower extremity, begin with bilateral support drills and
progress to more demanding unilateral support drills. Always observe or substitution and
poor technique, which may signi y that the activity is too di cult or the patient at that
time, or that the stress is too great on the healing structures. T rough unctional testing, the
therapist can assess speed, strength, agility, and power, which when combined equal unc-
tion.25 Functional testing can be adapted to meet the needs o every patient with whom we
come into contact. Physical therapists have always per ormed unctional testing with their
patients, although they may not have described these activities as such. In the acute care
or rehabilitation hospital, as well as in the nursing home, most activities have a unctional
component and can be used to document unctional status. Everything rom bed mobility
and trans ers to ambulation on level and unlevel sur aces can be measured airly objec-
tively. wo examples o unctional testing or the geriatric population include the multiple-
sit-to-stand (MS S) eld test and the 6-minute walk test. T e MS S claims to measure leg
strength. Netz et al19 correlated knee extensor isokinetic strength and endurance with the
results o the MS S. T ey concluded that the MS S is not able to predict strength o the knee
extensors, but may predict overall endurance o the lower extremities. T e results o this
study are not surprising since it is well accepted that to measure strength and power, the
patient must per orm an explosive maneuver. T is is obviously not appropriate in an older
patient population. In another test o endurance, Bean et al1 per ormed a 6-minute walk
test to determine aerobic capacity and unction. T ey ound a poor correlation between
indirect measures o aerobic capacity but a strong association with unctional measures.
T e results o these 2 studies provide the clinician with a variety o options or unctional
testing in the geriatric population.
In the outpatient setting, the activities required or unctional testing may be more
dynamic, but the principles and goals o treatment are the same. It is easy to take or granted
the ease with which ADL are per ormed. A unctional test can be used to document limita-
tions in ADL tasks, and a unctional exercise progression can be implemented to meet the
Examples 503
speci c needs o the patient. It is imperative to enable individuals to return to their maxi-
mum level o unction or their preinjury status.
What Now?
Now that the unctional testing procedure has been completed at the appropriate time in
the rehabilitation process, what is the next step? Upon completion o unctional testing, the
clinician must be able to use this in ormation to determine the next step in the rehabilita-
tion process. In one scenario, i the individual completes the tasks adequately, return to
work or ADL without restrictions may be recommended. In another scenario, i the indi-
vidual is not able to complete the tasks, the clinician must determine where the breakdown
occurred. Return to ull unction is restricted until these tasks can be completed and it is
sa e or the individual to return to the preinjury activity level. T is is where the unctional
exercise progression should dominate the rehabilitation program. Up until that point, the
patient may have been working on and achieved the majority o the clinical goals, but rom
the results o the unctional testing, the patient may not be ready to return to all necessary
unctional activities.
I the goal activity is kept in mind, whether it is a return to sports or ADL, the activity
can be broken down into small segments that can be per ormed in the clinic. Once the spe-
ci c activity has been broken down into required undamental movements, the individual’s
injured body part is stressed progressively until unction is adequate or a return to work,
ADL, or sports-speci c demands.25 Removing the “conscious mind” rom the activity will
make the movement pattern more automatic and natural. Some suggestions include throw-
ing a ball or the patient to catch during the activity or having the patient count the ngers
held up on your hand. Functional exercises that meet the speci c needs o the patient can
truly be termed “ unctional.”
T e concept o open- versus closed-chain exercise becomes moot when discussing
unctional exercise progression, because everything we do is a combination o these 2 types
o activity. Walking requires a combination o movements (the swing phase is open chain,
the stance phase is closed chain), as does picking up an object of the oor (the individ-
ual braces the body with the uninvolved extremity on a table, which is closed chain, and
reaches or the object, which is open chain). T e hallmark o closed-chain activities, how-
ever, is that they are more closely related to unction, incorporating movements that mimic
daily activities. Both open- and closed-chain exercise can create concentric, isometric, and
eccentric muscular contractions, which are all used or unctional tasks. T ese exercises can
also include acceleration and deceleration, which are extremely important principles when
discussing unctional tasks. Attempting to cross a busy intersection requires acceleration
to get across sa ely. Descending an inclined walkway requires deceleration to prevent alls.
An advantage that closed-chain exercises have is the addition o appropriate proprioceptive
eedback rom the muscle and joint mechanoreceptors. Discontinuing the rehabilitation
program when the clinic-based rehabilitation goals alone are achieved may be appropri-
ate or some individuals, but this will surely be a disservice to those patients returning
to higher levels o unction. T ese patients will have an increased risk or reinjury when
they attempt to return to their preinjury level o unction without completing a unctional
exercise progression.27
Examples
Assume you are treating a police o cer who has suf ered a sprain o the medial compart-
ment o his right knee. A ter valgus stress testing at 30 degrees o exion and an anterior
drawer test with the tibia in external rotation, you determine that there is a slight opening o
the joint space—in other words, a grade III ligament sprain with 1+ instability. Functional
testing may be appropriate initially in the orm o lateral step-ups or minisquats, provided
these activities do not cause too great a stress on the healing medial compartment. T is will
tell you i the individual can per orm sit-to-stand trans ers rom various heights and climb
stairs, important aspects o ADL. able 18-1 describes lower-extremity criteria needed or
return to various unctional activities. T is particular patient will need to return to high-
level unctional activities such as chasing and apprehending suspects.
Initially, starting the patient on a regimen o knee isometrics, modalities as needed to
control pain and swelling, and exibility training is an appropriate course. In an earlier dis-
cussion, it was stated that adequate collagen healing occurs in 3 to 6 weeks. T e second
phase o the rehabilitation program must employ a unctional exercise progression to pro-
gressively load the injured body part. In relation to the Davis law,8 the medial compartment
will heal along the lines o stress. So, to enable it to heal with appropriate tensile strength
and adequate length, activities that involve a valgus stress must be included. o strengthen
the surrounding musculature, open-chain exercises are incorporated. However, it is di -
cult to apply a controlled valgus stress to the knee in the open chain. T ere ore, closed-
chain exercises are a must. T ese may include the testing activities themselves, minisquats
and lateral step-ups with a valgus stress, the BAPS (biomechanical ankle plat orm sys-
tem) board, Pro tter, and the balance-testing devices. able 18-2 describes sample lower-
extremity unctional exercise progression and testing activities.
Table 18-1 Kne e Functio nal Pro g re ssio n
Crite ria fo r Re turn
Functio nal Activity Stre ng th ROM Othe r
Sit to stand 3/5 MMT quad 90 degrees one knee Sitting balance
3/5 MMT ham
3/5 MMT gastroc 120 degrees hip exion Stand balance
Assistive free gait 5/5 MMT quad Full knee extension No pain
4/5 MMT ham 100 degrees knee exion No swelling
Lift body weight on one leg 10 degrees dorsi exion Nonantalgic gait
with heel lift
Motor control of knee Adequate balance
Ascend/descend
Stairs (step over step) 10 side-step-downs
Running 70% quad/ham uninvolved leg Full exion 30 mins bike

15 degrees dorsi exion 50 side-step-downs
2 miles walking
Sprinting 90% quad/ham uninvolved leg 2 miles running
Agility Successful sprinting
Sports activity Functional progression

of activity
gastroc, gastrocnemius; MMT, manual muscle test.

Examples 505
Table 18-2 Lo w e r-Quarte r Functio nal Pro g re ssio n and Te sting Te mplate
Le ve ls Suppo rt Stability Plane Re spo nse Dire ctio n Example s
1 Bilateral Stable Single Single Vertical Leg press

Shuttle
Minisquat
2 Bilateral Unstable Single Single Vertical DynaDisc

Foam roller
Biodex stability
3 Unilateral Stable Single Single Vertical Leg press

Shuttle
Minisquat
Step-up
4 Unilateral Unstable Single Single Vertical Leg press

Shuttle
Minisquat
Step-up
5 Bilateral nonsupport Stable Single, multiple Single, multiple Vertical, Jumping

horizontal “ 5-Dot drill”
Spin hops
6 Unilateral Stable Single, multiple Single, multiple Vertical, Jumping

nonsupport horizontal “ 5-Dot drill”
Spin hops
7 Acceleration, Stable “ Shuttle Run”

deceleration “ T-drill”
Cocontraction
Lateral power hop
Once the clinic-based goals have been achieved and the patient is able to ambulate
on level and unlevel sur aces without deviation or an assistive device, unctional testing
is again per ormed to determine where the patient stands in relation to return to work.
Because o the high-level demands this patient will encounter upon his return to ull duty
as a police o cer, we need to per orm higher-level unctional testing, beginning with jump
or hop tests. T e jump test is per ormed with the individual standing on both limbs. He
is asked to jump as ar as possible in a horizontal ashion (a standing broad jump) and to
stick to the landing. T e individual should be able to jump a distance equal to his height
(or 1.5 times his height).25 I this task is completed, a single-leg hop can be per ormed as
described by Daniel. Noyes et al20 suggest that 2 types o 1-leg hopping tests— or distance
and or time—be used to rule out the instability caused by ACL rupture. able 18-3 describes
current unctional testing research and conclusions related to unctional activity.
I there is less than a 10% de cit between limbs, higher-level unctional testing can
be per ormed. T is will include jogging and backpedaling in a straight line at 25%, 50%,
75%, and 100% ef ort. T en, gure-8 drills are em ployed. Finally, cutting activities are
per orm ed, and in this case, em phasizing an open cut (sidestep cut or a Z cut) to stress
the medial compartment.27 In the late stages o knee rehabilitation, low-level plyometric
Table 18-3 Functio nal Te st Re se arch
Functio nal Te st Re se arch
Lateral step-up ICC.99 (Rosenthal, 1994)22
One-leg hop for distance ICC.99 (Worrell, 1994)27

ICC.96 (Bolgla, 1997)3
One-leg hop timed ICC.77 (Worrell, 1994)27

ICC.66 (Bolgla, 1997)3
One-leg hop triple ICC.95 (Bolgla, 1997)3
One-leg hop crossover ICC.96 (Bolgla, 1997)3
Four-point run ICC.98 (Bolgla, 1997)3
Lateral power hop ICC.91–92 (Tippett, 1996)25
Decreased one-leg timed hop without ACL Positive correlation (Noyes, 1989)20
Decreased one-leg hop distance without ACL Positive correlation (Noyes, 1990)20
Decreased one-leg hop distance in post-ACL reconstruction Positive correlation (Sekiya, 1998)24
One-leg hop distance and time posterolateral ankle sprain No correlation (Worrell, 1994)27
Objective scoring system with posterolateral ankle reconstruction Positive correlation (Kaikkonen, 1994)12
One-leg hop distance with decreased quad strength without ACL Positive correlation (Zätterström, 2000)28
One-leg hop distance with decreased quad strength without ACL No correlation (Gauf n, 1990)7
One-leg hop distance without ACL with a strengthening and Positive correlation (Zätterström, 2000)28
coordination program
One-leg hop distance in reconstructed ACL and laxity No correlation (Jonsson, 1994)10
Cocontraction test and isokinetic strength and power No correlation (Lephart, 1992)15
Cocontraction test and ACL laxity No correlation (Lephart, 1992)15
activities could be incorporated, such as hopping drills in place, in diagonal patterns,

and lateral hops to stress the medial compartment.27 I these tasks are completed without
signs and symptoms o in ammation or hesitancy on the patient’s part, a recommenda-
tion to return to tactical training and ull duty will ollow. Clinical outcomes can measure
the ef ectiveness o the clinician’s unctional exercise progression. able 18-4 describes
various scoring system s that can be employed with knee injuries to document clinical
outcomes.
In the upper extremity, we may have a patient who has suf ered an anterior gleno-
humeral shoulder dislocation. able 18-5 describes a sample progression o activities
with criteria or advancement. Assume that this individual is an artist and painting is her
medium. Special testing may include an anterior apprehension sign, in this case positive,
along with the standard measures o ROM, strength, pain level, and proprioception in the
orm o joint repositioning. Angular repositioning has been advocated at the glenohumeral
joint to determine the input rom the mechanoreceptors about the shoulder joint.4,6
Examples 507
Table 18-4 Kne e Sco ring Syste ms
Lysholm Scale Developed in 1986 by Lysholm

100-point scale
Assesses support with ambulation, limp, stairs,
squatting, pain, swelling, atrophy, and instability
with walking, running, and jumping
Very speci c to ADL
Cincinnati Scale Developed in 1984 by Noyes

Preinjury/surgery to postinjury/surgery comparison
Assesses walking, stairs, running, jumping, twisting,
sports/work activity level
More speci c to sports
Methodist Hospital Scale Developed in 1986 by Shelbourne

Assesses 1-mile walk, stairs, jogging, heavy work, ADL,
repetitive jumping, recreational and competitive sports
More speci c to sports
International Knee Society Scale Developed in 1986 by the IKDC

Assigns an A to D group grading based upon patient
subjective assessment, pain, swelling, giving way,
ROM, laxity, crepitus, and 1-leg hop
More speci c to ADL
Combined Rating System Developed in 1995 by Karlson

Cincinnati, HSS, Lysholm, IKDC
Assesses pain, swelling, giving way, walk, stairs, squat,
run, jump, twist, decelerate, sports, ADL, locking,
function, limp, activity, brace, crutches
Knee Outcome Survey Scale for disability during ADL

Scale for disability during sports
ADL, activities of daily living; HSS, hospital for special surgery; IKDC, international knee documentation committee.
Functional testing at this early stage may include reaching to a certain height or a spe-
ci c number o repetitions, or holding the upper extremity at a certain angle or a speci c
length o time. Both o these activities will recreate the unctional demands o painting.
In the rst stage o the rehabilitation process, just as or the lower-extremity problem, the
ocus is on decreasing pain and swelling through modalities, increasing ROM as tolerated,
and increasing strength through the use o shoulder isometrics. Functional exercise in this
phase may take the orm o rhythmic stabilization at 90 degrees o exion and at 45 degrees
o abduction. T is technique will increase the stability o the shoulder joint by ring the
dynamic stabilizers.
Also in this phase, total shoulder girdle strengthening, as tolerated, may begin with
emphasis on the scapular stabilizers and rotator cuf musculature. Several electromyogra-
phy studies have documented various exercises or these muscle groups. T e authors use a
combination o exercises recommended by Mosely et al17 or the scapula and by Blackburn
et al2 or the rotator cuf . T e core exercises or the scapula consist o rows, seated press-ups,
scaption, and pushups with a plus (scapula protraction).17 T e core exercises or the rota-
tor cuf include prone extension with external rotation, prone horizontal abduction with
Table 18-5 Sho ulde r Functio nal Pro g re ssio n
Crite ria fo r Advance me nt
Functio nal Activity Stre ng th ROM Othe r
Active/passive ROM after Depends on healing

surgery restraints
Isometric strengthening As tolerated As tolerated Depends on healing

restraints
Elevation of arm after surgery Successful gravity eliminated As tolerated Depends on healing
restraints
Elevation of arm with weights Successful elevation with no weights As tolerated Protect healing tissue
over 3 sets of 10 repetitions as necessary
Motor control: Body blade, Successful elevation with no weights As tolerated Protect healing tissue
Thera-tubing, Plyoballs over 3 sets of 10 repetitions as necessary
Weight machines/full-body Successful elevation with 3 lb, 3 sets As tolerated Isokinetics as tolerated
weight of 10 repetitions
5/5 MMT
Free weights Successful weight machine program As tolerated
Sports activities 5/5 MMT Isokinetic test WNL Enough for sport Suf cient healing time
activity
No pain, swelling with

progressive activity
MMT, manual muscle test; WNL, within normal limits.
external rotation, and prone external rotation at 90 degrees o abduction.2 It is up to the

clinician to determine the appropriate application o these core strengthening exercises.
In the second phase o the unctional exercise progression, increased emphasis is
placed on raising the upper extremity in the plane o the scapula initially to raising the
arm in the sagittal plane. T e patient is questioned regarding the duration o time that she
spends painting, and an estimation can be made as to how many times she must li t her arm
in each session. For other individuals, the application o closed-chain exercises or the gle-
nohumeral joint may be appropriate. Closed-chain exercises can be employed to increase
the proprioceptive input o the joint mechanoreceptors, which will enhance motor control.
Moving a ball on a wall and weight shi ting on a table may be low-level activities that are
easily implemented. A unctional exercise progression may include quadruped activities,
the use o the Pro tter, and even the Stairmaster or higher-level tasks. T e use o the Body
Blade at this stage may also help increase the endurance o the shoulder girdle musculature
while enhancing dynamic stability in the sagittal plane. In the nal stage o the rehabilita-
tion process or this individual, large muscle group strengthening and endurance exercises
are added or the deltoid, pectoralis major, and latissimus dorsi. Final unctional testing can
be per ormed to determine whether the patient has the endurance and strength to hold the
upper extremity at approximately 90 degrees or repetitions or time.
For the majority o patients seen in the outpatient setting with low back dys unction,
unctional testing and a unctional exercise progression can return them to their preinjury
Examples 509
Table 18-6 Lumbar Stabilizatio n Pro g re ssio n
Functio nal Activity Crite ria fo r Advance me nt: Lumbar Stabilizatio n Activitie s
Supine Abdominal bracing

Latissimus dorsi sets
Gluteal sets
Hip extensions sets
“ Marching” (hip exions)
“ Dying bug” (unilateral hip and arm movement)
Pelvic anterior/posterior tilt
Prone Quadruped with arm exion

Quadruped with hip extension
Quadruped with contralateral limb elevation
Prone extensions
Seated Physioball
“ Marching”
“ Dying bug”
Standing Trunk rotation stabilization with surgical tubing

?Horizontal adduction and abduction
?Flexion and extension
Chop/lift progression
Lifting Table to table

Carrying objects
Floor to table
Table to overhead shelf
Kneeling Chop/lift progression
Half kneeling Chop/lift progression
level o unction ( able 18-6). For example, a patient with a bulging disk may present with
pain, decreased ROM, and decreased unctional status. Functional testing may include
li ting tasks or sitting or walking or duration, depending on the individual’s occupation.
A unctional exercise progression in this case would include lumbar stabilization exercises
in the supine, sitting, and, ultimately, standing positions. Please re er to Chapter 15 or an
in-depth discussion o stabilization o the core.
o provide one m ore example, suppose you have a new mother who has suf ered a
sprain/ strain o the lumbar region while picking up her child. T e immediate postinjury
care is dedicated to relieving the pain, in ammation, and muscle spasm, and to restor-
ing ROM. Proper instruction in posture and body m echanics can also begin. T e sec-
ond phase o the program can be initiated quickly, usually within the rst 2 weeks, and
activities are designed around li ting tasks. A unctional exercise program may progress to
minisquats to increase lower-extremity strength and endurance, to li ting tasks rom vari-
ous heights, to carrying objects around the clinic. Functional testing, when appropriate,
is geared toward li ting an object o equal or greater weight than the in ant, rom the oor
to the table and vice versa. Carrying or distances and holding or tim e will mimic eeding
and nurturing tasks.
SUMMARY
1. Functional exercise progression and unctional testing are important components o a

complete rehabilitation program.
2. aking into account the patient’s medical condition, the healing constraints o that con-
dition, and the external environment that must be overcome, tasks can be designed to
re-create the unctional demands o each individual.
3. When the patient is able to per orm the goal activity without physical assistance or ver-
bal cueing rom the therapist, the entire activity is attempted and practiced.
4. T e entire ormal rehabilitation program does not have to be completed prior to per-
orming unctional testing or initiating a unctional exercise progression.
5. Activities that are compatible with the patient’s physical status may be implemented
at any time. T ese techniques are employed by physical therapists regardless o setting
and patient diagnosis.
6. T e use o unctional testing and unctional exercise progression will enable the patient
to return to preinjury level o unction as quickly and sa ely as possible.
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24. Sekiya I, et al. Signi cance o the single-legged hop test 28. Zätterström R, et al. Rehabilitation ollowing acute
to the anterior cruciate ligament-reconstructed knee in anterior cruciate ligament injuries—a 12-month ollow-up
relation to muscle strength and anterior laxity. Am J Sports o a randomized clinical trial. Scand J Med Sci Sports.
Med. 1998;26(3):384-388. 2000;10(3):156-163.
25. ippett SR, Voight ML. Functional Progressions for Sports
Rehabilitation . Champaign, IL: Human Kinetics; 1995.
Functional raining
and Advanced
Rehabilitation
M ich a e l L. Vo ig h t , Ba r b a r a J. Ho o g e n b o o m ,
Gr a y Co o k , a n d Gre g Ro s e
OBJJECT
De ne and discuss the importance of proprioception in the neuromuscular control process.
De ne and discuss the different levels of motor control by the central nervous system and the
neural pathways responsible for transmission of afferent and efferent information at each level.
Apply a systematic functional evaluation designed to provoke symptoms.
Demonstrate consistency between functional and clinical testing information (combinatorial power).
Apply a 3-step model designed to promote the practical systematic thinking required for
effective therapeutic exercise prescription and progression.
De ne and discuss objectives of a functional neuromuscular rehabilitation program.
Develop a rehabilitation program that uses various exercise techniques for development of
neuromuscular control.
513
514 Chapte r 19 Functional Training and Advanced Rehabilitation
Function and Functional Rehabilitation

T e basic goal in rehabilitation is to restore and enhance unction within the environ-
ment and to per orm specif c activities o daily living (ADL). T e entire rehabilitation pro-
cess should be ocused on improving the unctional status o the patient. T e concept o
unctional training is not new, nor is it limited to unction related to sports. By def nition,
unction means having a purpose or duty. T ere ore, unctional can be def ned as per orm-
ing a practical or intended unction or duty. Function should be considered in terms o a
spectrum because ADL encompass many di erent tasks or many di erent people. What
is unctional to one person may not be unctional to another. It is widely accepted that to
per orm a specif c activity better, one must practice that activity. T ere ore, the unctional
exercise progression or return to ADL can best be def ned as breaking the specif c activi-
ties down into a hierarchy and then per orming them in a sequence that allows acquisition
or reacquisition o that skill. It is important to note that although people develop di erent
levels o skill, unction, and motor control, certain undamental tasks are common to nearly
all individuals (barring pathologic conditions and disability). Li estyle, habits, injury, and
other actors can erode the undamental components o movement without obvious altera-
tions in higher-level unction and skill. Ongoing higher-level unction is a testament to the
compensatory power o the neurologic system. Imper ect unction and skill create stress in
other body systems. Fundamental elements can f rst be observed during the developmental
progression o posture and motor control. T e sequence o developmental progression can
also give insight into the original acquisition o skill. T e ability to assess retention or loss o
undamental movement patterns is there ore a way to enhance rehabilitation. T e rehabili-
tation process starts with a 2-part appraisal that creates perspective by viewing both ends o
the unctional spectrum :
• T e current level o unction (ADL, work, and sports/ recreation) relative to the
patient’s needs and goals.
• T e ability to demonstrate the undamental movement patterns that represent the
oundation o unction and basic motor control.
Object ives of Funct ional Rehabilit at ion

T e overall objective o a unctional exercise program is to return patients to their preinjury
level as quickly and as sa ely as possible by resolving or reducing the measurable dys unc-
tion within undamental and unctional movement patterns. Specif c training activities are
designed to restore both dynamic joint stability and ADL skills.1 o accomplish this objec-
tive, a basic tenet o exercise physiology is used. T e SAID (specif c adaptations to imposed
demands) principle states that the body will adapt to the stress and strain placed on it.2
Athletes cannot succeed i they have not been prepared to meet all the demands o their
specif c activity.2 Reactive neuromuscular training (RN ) helps bridge the gap rom tradi-
tional rehabilitation via proprioceptive and balance training to promote a more unctional
return to activity.2 T e SAID principle provides constructive stress, and RN creates oppor-
tunities or input and integration. T e main objective o the RN program is to acilitate
the unconscious process o interpreting and integrating the peripheral sensations received
by the central nervous system (CNS) into appropriate motor responses. T is approach is
enhanced by the unique clinical ocus on pathologic orthopedic and neurologic states and
their unctional representation. T is special ocus orces the clinician to consider evalu-
ation o human movement as a complex multisystem interaction and the logical starting
point or exercise prescription. Sometimes this will require a breakdown o the supporting
mobility and stability within a pattern. Regardless o the specif c nature o the corrective
Function and Functional Rehabilitation 515
needs, all the unctional exercises ollow a simple but very specif c path. First, the unctional
exercise program is driven by a unctional screening or assessment that produces a baseline
o movement. T e process o screening and assessment will rate and rank patterns. It will
provide valuable in ormation about dys unction in movement patterns such as asymmetry,
di culty with movement, and pain. Screening and assessment will there ore identi y aulty
movement patterns that should not be exercised or trained until corrected. Second, the
unctional ramework will assist in making the best possible choices or corrective catego-
ries and exercises. No single exercise is best or a movement problem, but there is an appro-
priate category o corrective exercises to choose rom. T ird, ollowing the initial session o
corrective exercises, the movement pattern should be rechecked or changes against the
original baseline. Fourth, once an obvious change is noted in the key pattern, the screening
or assessment is repeated to survey other changes in movement and identi y the next prior-
ity. By working on the most undamental pattern, it is possible to see other positive changes.
T ere ore, these 4 steps provide the ramework that makes corrective exercise success ul:
• T e screening and assessment direct the clinician to the most undamental movement
dys unction.
• One or 2 o the most practical corrective exercises rom the appropriate category
should be chosen and applied.
• Once the exercise has been taught and is being per ormed correctly, check or
improvement in the dys unctional basic movement pattern as revealed by specif c
tests in the screening or assessment.
T is concept is called the unctional continuum . Most patients seek care because o an
obvious source o pain or dys unction. What is not obvious is the true cause o the pain or
dys unction, ascertainment o which is the purpose o unctional movement assessment
(see Chapter 17). By looking at movement as a whole, all the compensations and conscious
sources o pain and dys unction can be highlighted and addressed. Patients all into one o
our phases on a unctional continuum ( able 19-1).
able 19-1 Fo ur Phase s o f the Functio nal Co ntinuum
Phase De scriptio n
Subconscious This is the initial phase when most patients are rst seen
dysfunction by the clinician. Patients are totally unaware of their true
dysfunction (it is in their subconscious) or are convinced that
the problem lies elsewhere.
Conscious dysfunction This is what happens after a movement assessment is

performed. Patients are now aware of their true dysfunction
(it is in their conscious), and they can start to address the real
cause.
Conscious function This phase is entered once patients can perform the correct
functional pattern, but it is not automatic (it is functional only
with conscious control). They still need conscious effort to
perform a good pattern of movement.
Subconscious function The nal stage occurs when patients can perform a functional
pattern automatically (it is in their subconscious control)
without having to think about the correction.
able 19-2 Thre e Rs o f Tre atme nt Phase s
R De scriptio n
Reset Most problems require resetting of the complete system to break them out
of their dysfunctional phase. By just jumping to exercises, the results can be
less than optimal. Types of treatments that would be considered a “ reset”
include joint mobilization, soft-tissue mobilization, and various soft-tissue
techniques.
Reinforce Once the system has been reset, many dysfunctions will need support
or reinforcement while proper patterns are being introduced. Types of
reinforcement devices include taping, bracing, orthotics, postural devices,
and static and dynamic stretching.
Reload The last phase of treatment is the exercise implementation or reload phase,
in which the new software is loaded into the central nervous system and a
true functional pattern of motion can be reprogrammed.
Exercise prescription choices must continually represent the specialized training o the
clinician through a consistent and centralized ocus on human unction and consideration
o the undamentals that make unction possible. Exercise applied at any given therapeutic
level must ref ne movement, not simply create general exertion in the hope o increased
tolerance o movement.3 Moore and Durstine state, “Un ortunately, exercise training to
optimize unctional capacity has not been well studied in the context o most chronic dis-
eases or disabilities. As a result, many exercise pro essionals have used clinical experience
to develop their own methods or prescribing exercise.”4 Experience, sel -critique, and spe-
cialization produce seasoned clinicians with intuitive evaluation abilities and innovations
in exercise that are sometimes di cult to ollow and even harder to ascertain; however,
common characteristics do exist. Clinical experts use parallel (simultaneous) consideration
o all actors in uencing unctional movement. RN as a treatment philosophy is inclusive
and adaptable and has the ability to address a variety o clinical situations. It should also
be understood that a clinical philosophy is designed to serve, not to be served. T e treat-
ment design demonstrates specif c attention to the parts (clinical measurements and iso-
lated details) with continual consideration o the whole (restoration o unction).3 Moore
and Durstine ollow their previous statement by acknowledging that “Experience is an
acceptable way to guide exercise management, but a systematic approach would be better.”4
We use the 3 “Rs” as a way to understand the type o treatment phases that a patient will
undergo ( able 19-2).
The Three-Phase Model for Prescript ion of Exercise

T is chapter demonstrates a practical model designed to promote the systematic thinking
required or e ective prescription o therapeutic exercise and progression at each phase
o rehabilitation.3 T e approach is a serial (consecutive) step-by-step method that will,
with practice and experience, lead to parallel thinking and multilevel problem solving. T e
intended purpose o this method is to reduce arbitrary trial-and-error attempts at prescrib-
ing e ective exercise and lessen protocol-based thinking. It will give the novice clinician
a ramework that will guide but not conf ne clinical exercise prescription. It will provide
experienced clinicians with a system to observe their particular strengths and weaknesses
in dosage and design o exercise. Inexperienced and experienced clinicians alike will
Function and Functional Rehabilitation 517
Box 19-1 Thre e -Phase Re habilitatio n Mo de l
develop practical insight by applying the model and observing the interaction o the sys-
tems that produce human movement. T e ocus is specif cally geared to orthopedic rehabil-
itation and the clinical problem-solving strategies used to develop an exercise prescription
through an outcome-based goal-setting process. All considerations or therapeutic exer-
cise prescription will give equal importance to conventional orthopedic exercise standards
(biomechanical and physiologic parameters) and neurophysiologic strategies (motor learn-
ing, proprioceptive eedback, and synergistic recruitment principles). T is 3-phase model
(Box 19-1) will create a mechanism that necessitates interaction between orthopedic exer-
cise approaches and optimal neurophysiologic techniques. It includes a 4-principle oun-
dation that demonstrates the hierarchy and interaction o the ounding concepts used in
rehabilitation (both orthopedic and neurologic). For all practical purposes, these 4 catego-
ries help demonstrate the e cient and e ective continuity necessary or ormulation o a
treatment plan and prompt the clinician to maintain an inclusive, open-minded clinical
approach.
T is chapter is written with the clinic-based practitioner in mind. It will help the clini-
cian ormulate an exercise philosophy. Some clinicians will discover reasons or success
that were intuitive and there ore hard to communicate to other pro essionals. Others will
discover a missing step in the therapeutic exercise design process. Much o the con usion
and rustration encountered by rehabilitation specialists is because o the vast variety o
treatment options a orded by ever-improving technology and accessibility to emerging
research evidence. o e ectively use the wealth o current in ormation and what the uture
has yet to bestow, clinicians must adopt an operational ramework or personal philosophy
about therapeutic exercise. I a clinical exercise philosophy is based on technology, equip-
ment, or protocols, the scope o problem solving is strictly conf ned. It would continually
change because no universal standard or gauge exists. However, a philosophy based solely
on the structure and unction o the human body will keep the ocus (Box 19-2) uncorrupted
and centralized. echnologic developments can enhance the e ectiveness o exercise only
as long as the technology, system, or protocol remains true to a holistic unctional stan-
dard. Known unctional standards should serve as governing actors that improve the clini-
cal consistency o the clinician and rehabilitation team or prescription and progression
o training methods. T e 4 principles or exercise prescription are based on human move-
ment and the systems on which it is constructed (Box 19-2). T e intent o these 4 distinct
categories is to break down and reconstruct the actors that in uence unctional movement
and to stimulate inductive reasoning, deductive reasoning, and the critical thinking needed
Box 19-2 Fo ur Principle s fo r Pre scriptio n o f Exe rcise

to develop a therapeutic exercise progression. It is hoped that these actors will serve the
intended purpose o organization and clarity, thereby giving due respect to the many
insight ul clinicians who have provided the oundation and substance or construction o
this practical ramework.3
Proprioception, Receptors,
Success in skilled per ormance depends on how e ectively an individual detects, perceives,
and uses relevant sensory in ormation. Knowing exactly where our limbs are in space and
how much muscular e ort is required to per orm a particular action is critical or success ul
per ormance o all activities requiring intricate coordination o the various body parts. For-
tunately, in ormation about the position and movement o various body parts is available
rom peripheral receptors located in and around articular structures and the surrounding
musculature. A detailed discussion o proprioception and neuromuscular control is also
presented in Chapter 9.
Joint s: Support and Sensory Funct ion

In a normal healthy joint, both static and dynamic stabilizers provide support. T e role o
capsuloligamentous tissues in the dynamic restraint o joints has been well established in
the literature.5-15 Although the primary role o these structures is mechanical in nature by
providing structural support and stabilization to the joint, the capsuloligamentous tissues
also play an important sensory role by detecting joint position and motion.8,16-18 Sensory
a erent eedback rom receptors in the capsuloligamentous structures projects directly to
the re ex and cortical pathways, thereby mediating reactive muscle activity or dynamic
restraint.5,6,8,17,19 T e e erent motor response that ensues rom the sensory in ormation is
called neurom uscular control. Sensory in ormation is sent to the CNS to be processed, and
appropriate motor strategies are executed.
Physiology of Propriocept ion

Sherrington 18 f rst described the term proprioception in the early 1900s when he noted the
presence o receptors in the joint capsular structures that were primarily re exive in nature.
Since that time, mechanoreceptors have been morphohistologically identif ed around
articular structures in both animal and human models. In addition, the well-described
muscle spindle and Golgi tendon organs are power ul mechanoreceptors. Mechanorecep-
tors are specialized end-organs that unction as biologic transducers or conversion o the
mechanical energy o physical de ormation (elongation, compression, and pressure) into
action nerve potentials yielding proprioceptive in ormation.10 Although receptor discharge
varies according to the intensity o the distortion, mechanoreceptors can also be described
in terms o their discharge rates. Quickly adapting receptors cease discharging shortly a ter
the onset o a stimulus, whereas slowly adapting receptors continue to discharge while
the stimulus is present.8,10,20 Around a healthy joint, quickly adapting receptors are respon-
sible or providing conscious and unconscious kinesthetic sensations in response to joint
movement or acceleration, whereas slowly adapting mechanoreceptors provide continuous
eedback and thus proprioceptive in ormation related to joint position 10,20,21 (see Chapter 9
or examples o quickly and slowly adapting receptors).
Once stimulated, m echanoreceptors are able to adapt. With constant stimula-
tion, the requency o the neural impulses decreases. T e unctional implication is that
Central Nervous System: Integration of Motor Control 519
mechanoreceptors detect change and rates o change, as opposed to steady-state condi-
tions.22 T is input is then analyzed in the CNS to determine joint position and movement.23
T e status o the musculoskeletal structures is sent to the CNS so that in ormation about
static versus dynamic conditions, equilibrium versus disequilibrium, or biomechanical
stress and strain relationships can be evaluated.24,25 Once processed and evaluated, this
proprioceptive in ormation becomes capable o in uencing muscle tone, motor execution
programs, and cognitive somatic perceptions or kinesthetic awareness.26 Proprioceptive
in ormation also protects the joint rom damage caused by movement exceeding the nor-
mal physiologic range o motion (ROM) and helps determine the appropriate balance o
synergistic and antagonistic orces. All this in ormation helps in generating a somatosen-
sory image within the CNS. T ere ore, the so t tissues surrounding a joint serve a double
purpose: they provide biomechanical support to the bony partners making up the joint by
keeping them in relative anatomic alignment, and through an extensive a erent neurologic
network, they provide valuable proprioceptive in ormation.
Central Nervous System:

Integration of Motor Control
T e response o the CNS alls into 3 categories or levels o motor control: spinal re exes,
brainstem processing, and cognitive cerebral cortex program planning. T e goal o the
rehabilitation process is to retrain the altered a erent pathways and thereby enhance the
neuromuscular control system. o accomplish this goal, the objective o the rehabilitation
program should be to hyperstimulate the joint and muscle receptors to encourage maximal
a erent discharge to the respective CNS levels.21,27-30
First -Level Response: Muscle

When aced with an unexpected load, the f rst re exive muscle response is a burst o elec-
tromyographic activity that occurs between 30 and 50 m illiseconds. T e a erent f bers
o both the muscle spindle and the Golgi tendon organ m echanoreceptors synapse with
the spinal interneurons and produce a re exive acilitation or inhibition o the m otor
neurons.28,30,31 T e m onosynaptic stretch re ex is one o the m ost rapid re exes under-
lying lim b control. T e stretch re ex occurs at an unconscious level and is not a ected
by extrinsic actors. T ese responses can occur simultaneously to control lim b position
and posture. Because they can occur at the sam e time, are in parallel, are subconscious,
and are not subject to cortical inter erence, they do not require attention and are thus
automatic.
At this level o motor control, activities to encourage short-loop re ex joint stabilization
should dominate.15,21,27,30 T ese activities are characterized by sudden alterations in joint
position that require re ex muscle stabilization. With sudden alterations or perturbations,
both the articular and muscular mechanoreceptors will be stimulated to produce re ex sta-
bilization. Rhythmic stabilization exercises encourage monosynaptic cocontraction o the
musculature, thereby producing dynamic neuromuscular stabilization.32 T ese exercises
serve to build a oundation or dynamic stability.
Second-Level Response: Brainst em

T e secon d level o m otor control interaction is at the level o the brain stem.25,28,33 At
this level, a erent m echanoreceptors interact with the vestibular system and visual
in put rom the eyes to control or acilitate postural stability an d equilibrium o the
body.21,25,27-29 A erent m echanoreceptor in put also works in concert with the m uscle
spindle com plex by inhibiting antagonistic m uscle activity under conditions o rapid
lengthenin g and periarticular distortion, both o which accom pan y postural disrup-
tion.26,30 In conditions o disequilibrium in which sim ultaneous neural input exists, a
neural pattern is generated that a ects the m uscular stabilizers and thereby returns
equilibrium to the body’s center o gravity.28 T ere ore, balance is in uen ced by the
sam e peripheral a erent m echanism that m ediates joint proprioception and is at least
partially dependent on an individual’s inherent ability to integrate joint position sense
with neuromuscular control.34
Clin ica l Pe a r l
Balance activities, both with and without visual input, will enhance motor function at the
brainstem level. 28,33
It is im portant that these activities remain specif c to the types o activities or skills
that will be required o the athlete on return to sport.35 Static balance activities should be
used as a precursor to m ore dynamic skill activity.35 Static balance skills can be initiated
when the individual is able to bear weight on the lower extrem ity. T e general progres-
sion o static balance activities is to m ove rom bilateral to unilateral and rom eyes open
to eyes closed.21,28,35-37 With balance training, it is im portant to rem em ber that the sen-
sory system s respond to environmental manipulation. o stimulate or acilitate the pro-
prioceptive system, vision must be disadvantaged, which can be accom plished in several
ways ( Box 19-3).
Third-Level Response: Cent ral Nervous Syst em/Cognit ive

Appreciation o joint position at the highest or cognitive level needs to be included in an
RN program. T ese types o activities are initiated on the cognitive level and include pro-
gramming motor commands or voluntary movement. Repetitions o these movements will
maximally stimulate the conversion o conscious programming to unconscious program-
ming.21,25,27-29,38 T e term or this type o training is the orced-use paradigm . By making a task
signif cantly more di cult or asking or multiple tasks, the CNS is bombarded with input.
T e CNS attempts to sort and process this overload in ormation by opening additional neu-
ral pathways. When the individual goes back to a basic ADL task, the task becomes easier.
T is in ormation can then be stored as a central command and ultimately be per ormed
without continuous re erence to conscious thought as a triggered response.21,27-29,39 As with
all training, the single greatest obstacle to motor learning is the conscious mind. We must
get the conscious mind out o the act!
Box 19-3 Ways to Disadvantag e Visio n fo r Stimulatio n o f the Pro prio ce ptive
Syste m
Central Nervous System: Integration of Motor Control 521
Closed-Loop, Open-Loop, and Feed-Forward Int egrat ion

Why is a coordinated motor response important? When an unexpected load is placed on a
joint, ligamentous damage occurs in 70 to 90 milliseconds unless an appropriate response
ensues.40-42 T ere ore, reactive muscle activity that provides su cient magnitude in the
40- to 80-millisecond time rame must occur a ter loading begins to protect the capsuloliga-
mentous structures. T e closed-loop system o CNS integration may not be ast enough to
produce a response to increase muscle sti ness. T ere is simply no time or the system to
process the in ormation and provide eedback about the condition. Failure o the dynamic
restraint system to control abnormal orce will expose the static structures to excessive
orce. In this case, the open-loop system o anticipation becomes more important in pro-
ducing the desired response. Preparatory muscle activity in anticipation o joint loading
can in uence the reactive muscle activation patterns. Anticipatory activation increases
the sensitivity o the muscle spindles, thereby allowing the unexpected perturbations to be
detected more quickly.43
Very quick movements are completed be ore eedback can be used to produce an
action to alter the course o movement. T ere ore, i the movement is ast enough, a mecha-
nism such as a motor program would have to be used to control the entire action, with the
movement being carried out without any eedback. Fortunately, the open-loop control sys-
tem allows the motor control system to organize an entire action ahead o time. For this to
occur, previous knowledge needs to be preprogrammed into the primary sensory cortex
(Box 19-4).
In the open-loop system, a program that sets up some kind o neural mechanism or
network that is preprogrammed organizes movement in advance. A classic example o
this occurs in the body as postural adjustments are made be ore the intended movement.
When an arm is raised into orward exion, the f rst muscle groups to f re are not even in
the shoulder girdle region. T e f rst muscles to contract are those in the lower part o the
back and legs (approximately 80 milliseconds pass be ore noticeable activity occurs in the
shoulder) to provide a stable base or movement.44 Because the shoulder muscles are linked
to the rest o the body, their contraction a ects posture. I no preparatory compensations
in posture were made, raising the arm would shi t the center o gravity orward and cause
a slight loss o balance. T e eed- orward motor control system takes care o this potential
problem by preprogramming the appropriate postural modif cation f rst rather than requir-
ing the body to make adjustments a ter the arm begins to move.
Lee 45 demonstrated that these preparatory postural adjustments are not independent
o the arm movement but rather are part o the total motor pattern. When the arm move-
ments are organized, the motor instructions are preprogrammed to adjust posture f rst and
then move the arm. T ere ore, arm movement and postural control are not separate events
but instead are di erent parts o an integrated action that raises the arm while maintain-
ing balance. Lee showed that these electromyographic preparatory postural adjustments
Box 19-4 Pre pro g ramme d Info rmatio n Ne e de d fo r an Ope n-Lo o p Syste m
to Wo rk
disappear when the individual leans against some type o support be ore raising the arm.
T e motor control system recognizes that advance preparation or postural control is not
needed when the body is supported against the wall.
It is important to remember that most motor tasks are a complex blend o both open-
and closed-loop operations. T ere ore, both types o control are o ten at work simultane-
ously. Both eed- orward and eedback neuromuscular control can enhance dynamic
stability i the sensory and motor pathways are requently stimulated.21 Each time a signal
passes through a sequence o synapses, the synapses become more capable o transmitting
the same signal.14,46 When these pathways are “ acilitated” regularly, memory o that signal
is created and can be recalled to program uture movements.14,47
Conclusion: Relat ionship t o Rehabilit at ion

A rehabilitation program that addresses the need or restoring normal joint stability and
proprioception cannot be constructed until one has total appreciation o both the mechani-
cal and sensory unctions o the articular structures.27 Knowledge o the basic physiology
o how these muscular and joint mechanoreceptors work together in the production o
smooth, controlled coordinated motion is critical in developing a rehabilitation training
program. T is is because the role o the joint musculature extends well beyond absolute
strength and the capacity to resist atigue. With simple restoration o mechanical restraints
or strengthening o the associated muscles, the smooth coordinated neuromuscular con-
trolling mechanisms required or joint stability are neglected.27 T e complexity o joint
motion necessitates synergy and synchrony o muscle f ring patterns, thereby permitting
proper joint stabilization, especially during sudden changes in joint position, which is com-
mon in unctional activities. Understanding o these relationships and unctional implica-
tions will allow the clinician greater variability and success in returning patients sa ely back
to their playing environment.
Four Principles for

T erapeutic Exercise Prescription
T e unctional exercise program ollows a linear path rom basic m obility to basic stability
to m ovement patterns. Corrective exercise alls into one o the 3 basic categories: m obil-
ity, stability, and retraining o m ovem ent patterns. Mobility exercises ocus on joint ROM,
tissue length, and muscle exibility. Stability exercises ocus on the basic sequencing o
m ovem ent. T ese exercises target postural control o the starting and ending positions
within each m ovement pattern. Movement pattern retraining incorporates the use o un-
dam ental m obility and stability into specif c m ovem ent patterns to rein orce coordina-
tion and timing.
T e corrective exercise progression always starts with m obility exercises. Because
many poor m ovem ent patterns are associated with abnormalities in m obility, restora-
tion o m ovem ent needs to be addressed f rst. Mobility exercises should be per orm ed
bilaterally to conf rm lim itation and asym m etry o m obility. Clinicians should never
assum e that they know the location or side in which m obility is restricted. Rather, both
sides should always be checked and m obility cleared be ore advancing the exercise pro-
gram. I the assessm ent reveals a lim itation or asym m etry, it should be the primary ocus
o the corrective exercise program. reatm ents that prom ote m obility can involve man-
ual therapy, such as so t-tissue and joint m obilization and manipulation. reatm ents o
m obility m ight also include any m odality that im proves tissue pliability or reedom o
movem ent. I no change in m obility is appreciated, the clinician should not proceed to
Four Principles for Therapeutic Exercise Prescription 523
stability work. Rather, all m obility problems should continue to be worked on until a mea-
surable change is noted. Mobility does not need to becom e ull or normal, but im prove-
m ent must be noted be ore advancing. T e clinician can proceed to a stability exercise
only i the increased mobility allows the patient to get into the appropriate exercise pos-
ture and position. T e stability work should rein orce the new m obility, and the new
mobility makes im proved stabilization possible because the new m obility provides new
sensory in ormation. I there is any question about com promised m obility, each exercise
session should always return to m obility exercises be ore m oving to stability exercises.
T is ensures that proper tissue length and joint alignm ent are available or the stabiliza-
tion exercises.
When no limitation or asymmetry is present during the mobility corrective exercises,
one can move directly to stability corrective exercises. Once mobility has been restored, it
needs to be controlled. Stability exercises demand posture, alignment, balance, and control
o orces within the newly available range and without the support o compensatory sti -
ness or muscle tone. Stability exercises should be considered as challenges to posture and
position, rather than being conventional strength exercises.
We propose 4 principles or therapeutic exercise prescription, which we describe as
the 4 “Ps” in this section. T ese principles serve to guide decisions or selecting, advancing,
and terminating therapeutic exercise interventions. Application o these 4 principles in the
appropriate sequence will allow the clinician to understand the starting point, a consistent
progression, and the end point or each exercise prescription. T is sequence is achieved
by using unctional activities and undamental movement patterns as goals. By proceeding
in this ashion, the clinician will have the ability to evaluate the whole be ore the parts and
then discuss the parts as they apply. able 19-3 lists and describes the principles or thera-
peutic exercise prescription.
able 19-3 Fo ur Principle s fo r The rape utic Exe rcise Pre scriptio n
Principle De scriptio n
Functional evaluation and The evaluation must identify a functional problem or limitation resulting in diagnosis of
assessment in relation to a functional problem. Observation of whole movement patterns tempered by practical
dysfunction (disability) and knowledge of key stress points and common compensatory patterns will improve the
impairment ef ciency of evaluation.
Identi cation and Rehabilitation can be greatly advanced by understanding functional milestones and
management of motor fundamental movements such as those demonstrated during the positions and postures
control paramount to growth and development. These milestones serve as key representations
of functional mobility and control, as well as play a role in the initial setup and design of
the exercise program.
Identi cation and The skills and techniques of orthopedic manual therapy are bene cial in identifying
management of speci c arthrokinematic restrictions that would limit movement or impede the motor-
osteokinematic and learning process. Management of myofascial and capsular structures will improve
arthrokinematic limitations osteokinematic movement, as well as allow balanced muscle tone between the agonist
and antagonist. It will also help the clinician understand the dynamics of the impairment.
Identi cation of current Once restrictions and limitations are managed and gross motion is restored, application
movement patterns of proprioceptive neuromuscular facilitation-type patterning will further improve
followed by facilitation and neuromuscular function and control. Consideration of synergistic movement is the nal
integration of synergistic step in restoration of function by focusing on coordination, timing, and motor learning.
movement patterns
Clin ica l Pe a r l
The true art of rehabilitation is to understand the whole of synergistic functional movement
and the therapeutic techniques that will have the greatest positive effect on that movement
in the least amount of time.
The Four Ps
T e 4 Ps represent the 4 principles or therapeutic exercise: purpose, posture, position, and
pattern ( able 19-4). T ey serve as quick reminders o the hierarchy, interaction, and applica-
tion o each principle. T e questions o what, when, where, and how or unctional movement
assessment and exercise prescription are addressed in the appropriate order ( able 19-4 ).
able 19-4 Me mo ry Cue s and Primary Que stio ns Asso ciate d w ith the Fo ur Principle s fo r Pre scriptio n
o f The rape utic Exe rcise
Principle Me mo ry Cue Me mo ry Cue De nitio n Primary Que stio ns
Functional Purpose Used during both the “ What functional activity is limited?”
evaluation and evaluation process and the “ What does the limitation appear to be—a
assessment exercise prescription process mobility problem or a stability problem?”
to keep the clinician intently “ What is the dysfunction or disability?”
focused on the greatest single “ What fundamental movement is limited?”
factor limiting function “ What is the impairment?”
Identi cation Posture Helps the clinician remember “ When in the development sequence is the
of motor to consider a more holistic impairment obvious?”
control approach to exercise “ When do the substitutions and compensations
prescription occur?”
“ When in the developmental sequence does the
patient demonstrate success?”
“ When in the developmental sequence does the
patient experience dif culty?”
“ When is the best possible starting point
for exercise with respect to posture?”
Identi cation of Position Describes not only the location “ Where is the impairment located?”
osteokinematic of the anatomic structure (joint, “ Where among the structures (myofascial or
and muscle group, ligament, etc) articular) does the impairment have its greatest
arthrokinematic where impairment has been effect?”
limitations identi ed but also the positions “ Where in the range of motion does the
(with respect to movement and impairment affect position the greatest?”
load) in which the greatest and “ Where is the most bene cial position for
least limitations occur the exercise?”
Integration Pattern Cues the clinician to continually “ How is the movement pattern different
of synergistic consider the functional on bilateral comparison?”
movement movements of the human body “ How can synergistic movement, coordination,
patterns that occur in uni ed patterns recruitment and timing be facilitated?”
that occupy 3-dimensional “ How will this affect the limitation
space and cross 3 planes in movement?”
(frontal, sagittal, and transverse) “ How will this affect function?”
Pain able 19-5 Thre e Le ve ls o f Functio nal Evaluatio n

Aristotle said, “We cannot learn without pain,” which
is very wise because pain is usually li e’s most power-
ul teacher. However, pain is simply the brain’s inter- Le ve l Name De scriptio n
pretation o a neurologic signal normally associated I Functional Combined movements common
with trauma, dys unction, and instant and continu- activity to the patient’s lifestyle and
ing damage. Pain a ects motor control and greatly assessment occupation are reproduced. They
reduces the e ectiveness o even the best corrective usually t the de nition of a
exercise technique. general or speci c skill.
II Functional or The clinician takes what is learned

Purpose fundamental through the observation of
movement functional movements and breaks
T e word purpose is sim ply a cue to be used dur- assessment the movements down to the
ing both the evaluation process and the exercise static and transitional postures
prescription process to keep the clinician intently seen in the normal developmental
ocused on the greatest single actor lim iting unc- sequence.
tion. T e primary questions to ask or this principle
III Speci c Clinical measurements are used
appear in able 19-4. It is not uncom m on or clini-
clinical to identify and quantify speci c
cians to attem pt to resolve m ultiple problem s with
measurement problems that contribute to
the initial exercise prescription. However, the prac-
limitations in motion or control.
tice o identi ying the single greatest lim iting actor
will reduce rustration and also not overwhelm the
patient. Other actors may have been identif ed in
the evaluation, but a major lim iting actor or a single
weak link should stand out and be the ocus o the initial therapeutic exercise interven-
tion. Alterations in the lim iting actor may produce positive changes elsewhere, which
can be identif ed and considered be ore the next exercise progression.
T e unctional evaluation process should take on 3 distin ct layers or levels
( able 19-5). Each o the 3 levels should involve qualitative observations ollowed by
quantitative docum entation when possible. Norm ative data are help ul, but bilateral
com parison is also e ective and dem onstrates the unctional problem to the patient at
each level. Many patients think that the problem is sim ply sym ptomatic and structural
in nature and have no example o dys unction outside o pain with m ovem ent. Mo roid
and Zim ny suggest that “Muscle strength o the right and le t sides is m ore similar in the
proximal muscles whereas we accept a 10% to 15% di erence in strength o the distal
muscles. . . . With joint exibility, we accept a 5% di erence between goniom etric m ea-
surem ents o the right and le t sides.”48
T e unctional activity assessment involves a reproduction o combined movements
common to the patient’s li estyle and occupation. T ese movements usually f t the def ni-
tion o a general or specif c skill. T e clinician must have the patient demonstrate a variety
o positions and not just positions that correspond to the reproduction o symptoms.49 Static
postural assessment is included, as well as assessment o dynamic activity. T e quality o
control and movement is assessed. Specif c measurement o bilateral di erences is di cult,
but demonstration and observation are help ul or the patient. T e clinician should note the
positions and activities that provoke symptoms, as well as the activities that illustrate poor
body mechanics, poor alignment, right-le t asymmetries, and inappropriate weight shi ting.
When the clinician has observed gross movement quality, it may be necessary to also quan-
ti y movement per ormance. Repetition o the activity or evaluation o endurance, repro-
duction o symptoms, or demonstration o rapidly declining quality will create a unctional
baseline or bilateral comparison and documentation.
Next is the unctional or undam ental m ovem ent assessm ent. T e clinician must
take what is learned through the observation o unctional movements and break the
movements down into the static and transitional postures seen in the normal develop-
mental sequence. T is breakdown will reduce activities to the many underlying m obi-
lizing and stabilizing actions and reactions that constitute the unctional activity. More
simply stated, the activity is broken down into a sequence o primary movements that can
be observed independently. It must be noted that these movements still involve multiple
joints and muscles.49 Assessment o individual joints and muscle groups will be per ormed
during clinical measurements. Martin notes, “T e developmental sequence has provided
the most consistent base or almost all approaches used by physical therapists.”48 T is is a
power ul statement, and because true qualitative measurements o normal movement in
adult populations are limited, the clinician must look or universal similarities in move-
ment. Changes in undamental movements can e ect signif cant and prompt changes in
unction and must there ore be considered unctional as well. Because the movement pat-
terns o most adults are habitual and specif c and thus are not representative o a ull or
optimal movement spectrum, the clinician must f rst consider the nonspecif c basic move-
ment patterns common to all individuals during growth and development. T e develop-
mental sequence is predictable and universal in the f rst 2 years o li e,50 with individual
di erences seen in the rate and quality o the progression. T e di erences are minimal in
comparison to the variations seen in the adult population with their many habits, occu-
pations, and li estyles. In addition to diverse movement patterns, the adult population
has the consequential complicating actor o a previous medical and injury history. Each
medical problem or injury has had some degree o in uence on activity and movement.
T us, evaluation o unctional activities alone may hide many uneconomical movem ent
patterns, com pensations, and asymm etries that when integrated into unctional activi-
ties, are not readily obvious to the clinician. By using the undamental movements o the
developmental progression, the clinician can view mobility and static and dynamic stabil-
ity problems in a more isolated setting. Although enormous variations in unctional move-
ment quality and quantity are seen in specif c adult patient populations, most individuals
have the developm ental sequence in common.50 T e movements used in normal motor
development are the building blocks o skill and unction.50 Many o these building blocks
can be lost while the skill is maintained or retained at some level (though rarely optimal).
We will re er to these movement building blocks as undam ental m ovem ents and consider
them precursors to higher unction. Bilateral comparison is help ul when the clinician
identif es qualitative di erences between the right and le t sides. T ese movements (like
unctional activities) can be compared quantitatively as well.
Finally, clinical m easurem ents will be used to identi y and quanti y specif c prob-
lem s that are contributing to lim itation o m otion or lim itation o control. Clinical mea-
surem ents will f rst classi y a patient through qualitative assessm ent. T e param eters that
def ne that classif cation must then be quantif ed to reveal impairment. T ese classif ca-
tions are called hypermobility and hypomobility and help create guides or treatm ent that
consider the unctional status, anatom ic structures, and the severity o sym ptom s. T e
clinician should not proceed into exercise prescription without proper identif cation o
one o these general categories. T e success or ailure o a particular exercise treatm ent
regimen probably depends m ore on this classif cation than on the choice o exercise tech-
nique or protocol.
Once the appropriate clinical classif cation is determined, specif c quantitative mea-
surements will def ne the level o involvement within the classif cation and set a baseline
or exercise treatment. Periodic reassessment may identi y a di erent major limiting actor
or a weak link that may require reclassif cation, ollowed by specif c measurement. T e new
problem or limitation would then be inserted as the purpose or a new exercise interven-
tion. A simple diagram (Figure 19-1) will help the clinician separate the di erent levels o
unction so that intervention and purpose will always be at the appropriate level and assist
in the clinical decision making related to exercise prescription.51
Post ure
Posture is a word to help the clinician consider a more
holistic approach to exercise prescription. T e primary
questions to ask or this principle appear in able 19-4.
Janda 52 stated an interesting point when discussing pos-
ture and the muscles responsible or its maintenance.
Most discussions on posture and the musculature respon-
sible or posture generally re er to erect standing. However,
“. . . erect standing position is so well balanced that little or
no activity is necessary to maintain it.”52 T ere ore, “basic
human posture should be derived rom the principal
movement pattern, namely gait. Since we stand on one leg
or most o the time during walking, the stance on one leg
should be considered to be the typical posture in man; the
postural muscles are those which maintain this posture.”
Janda reported the ratio o single-leg to double-leg stance
in gait to be 85% to 15%. “T e muscles which maintain
erect posture in standing on one leg are exactly those
which show a striking tendency to get tight.”53 In ants and
toddlers use tonic holding be ore normal motor develop-
ment and maturation produce the ability to use cocontrac-
tion as a means o e ective support. “ onic holding is the
ability o tonic postural muscles to maintain a contraction
in their shortened range against gravitational or manual
resistance.”54 An adult orthopedic patient may revert to
some level o tonic holding a ter injury or in the presence Figure 19-1 Diffe re nt le ve ls o f functio n
o pain and altered proprioception. Likewise, adults who
have habitual postures and limited activity may adopt
tonic holding or some postures. Just as Janda uses single-leg stance to observe postural
unction with greater specif city than the more conventional double-leg erect standing, the
developmental progression can o er greater understanding by examination o the precur-
sors to single-leg stance.55 As stated earlier, undamental movements are basic representa-
tions o mobility, stability, and dynamic stability and include the transitional postures used
in growth and development. From supine to standing, each progressive posture imposes
greater demands on motor control and balance. Box 19-5 lists the most common postures
used in corrective exercise.
T is approach will help the clinician consider how the mobility or stability problem that
was isolated in the evaluation has been (temporarily) integrated by substitution and com-
pensation by other body parts. T e clinician must remember that motor learning is a sur-
vival mechanism. T e principles that the clinician will use in rehabilitation to produce motor
learning have already been activated by the unctional response to the impairment. Necessity
or a nity, repetition, and rein orcement have been used to avoid pain or produce alternative
movements since onset o the symptoms. T ere ore, a new motor program has been activated
Box 19-5 Mo st Co mmo n Po sture s Use d in Co rre ctive Exe rcise

to manage the impairment and produce some level o unction that is usually viewed as dys-
unction. It should be considered a natural and appropriate response o the body reacting to
limitation or symptoms. T e body will sacrif ce quality o movement to maintain a degree o
quantity o movement. aking this into consideration, 2 distinct needs are presented.
Posture or Protection and Inhibition T e clinician must restrict or inhibit the inap-
propriate motor program. In the case o a control or stability problem, the patient must
have some orm o support, protection, or acilitation. Otherwise, the inappropriate pro-
gram will take over in an attempt to protect and respond to the postural demand. Although
most adult patients unction at the necessary skill level, on evaluation, many qualitative
problems are noted. Inappropriate joint loading and locking, poor tonic responses, or even
tonic holding can be observed with simple activities. Some joint movements are used exces-
sively, whereas others are unconsciously avoided. Many primary stability problems exist
when underlying secondary mobility problems are present. Moreover, in some patients, the
mobility problem precedes the stability problem. T is is a common explanation or micro-
traumatic and overuse injuries. It is also why bilateral comparison and assessment o proxi-
mal and distal structures are mandatory in the evaluative process. With a mobility problem,
a joint is not used appropriately because o weakness or restriction. T e primary mobility
problem may be the result o compromised stability elsewhere. Motor programs have been
created to allow a patient to push on despite the mobility or stability problem. T e prob-
lems can be managed by mechanical consideration o the mobility and stability status o the
patient in the undamental postures.
For primary stability problems, mechanical support or other assistance must be pro-
vided. T is can be done simply by partial or complete reduction o stress, which may
include non–weight bearing or partial weight bearing o the spine and extremities or tem-
porary bracing. I the stability problem is only in a particular range o movement, that move-
ment must be managed. I an underlying mobility problem is present, it must be managed
and temporarily taken out o the initial exercise movement. T e alteration in posture can
e ectively limit complete or partial motion with little need or active control by the patient.
T e patient must be trained to deal with the stability problem independently o the mobil-
ity problem or be at a great mechanical advantage to avoid compensation. T e secondary
mobility problem, once managed, should be reintroduced in a nonstress ul manner so that
the previous compensatory pattern is not activated.
Manual articular and so t-tissue techniques, when appropriate, can be used or the pri-
mary mobility problem, ollowed by movement to integrate any improved range and benef t
rom more appropriate tone. I the limitation in mobility seems to be the result o weakness,
one should make sure that the proximal structures have the requisite amount o stability
be ore strengthening and then proceed with strengthening or endurance activities with a
ocus on recruitment, relaxation, timing, coordination, and reproducibility. Note that the
word resistance was not used initially. Resistance is not synonymous with strengthening
and is only 1 o many techniques used to improve unctional movement in early move-
ment reeducation. However, the later sections on position and pattern address resistance
in greater detail. Posture should be used to mechanically block or restrict substitution o
stronger segments and improve quality at the segment being exercised.
Posture or Recruitment and Facilitation T e clinician must acilitate or stimulate the

correct motor program, coordination, and sequence o movement. Although verbal and
visual eedback is help ul through demonstration and cueing, kinesthetic eedback is para-
mount to motor learning.56 Correct body position or posture will improve eedback. T e
posture and movement that occur early in the developmental sequence require a less com-
plex motor task and activate a more basic motor program. T is creates positive eedback
and rein orcement and marks the point (posture) at which appropriate and inappropriate
actions and reactions meet. From this point, the clini-
cian can manipulate requency, intensity, and duration,
or advance to a more di cult posture in the appropri-
ate sequence.
T e clinician must also consider developmental
biomechanics by dividing movement ability into 2 cat-
egories: internal orces and external orces. Internal
orces include the center o gravity, base o support, and
line o gravity. External orces include gravity, inertia o
the body segment, and ground reaction orces. Accord-
ingly, the clinician should evaluate the patient’s abilities
in the same manner by f rst observing management o
the mass o the body over the particular base provided
by the posture. T e clinician then advances the patient
Figure 19-2 Supine bridg ing mo ve me nt
toward more external stresses such as inertia, gravity,
and ground reaction orces. T is interaction requires
various degrees o acceleration production, deceleration control, anticipatory weight shi t-
ing, and increased proprioception. Resistance and movement can stress static and dynamic
postures, but the clinician should also understand that resistance and movement could be
used to ref ne movement and stimulate appropriate reactions.56 Postures must be chosen
that reduce compensation and allow the patient to exercise below the level at which the
impairment hinders movement or control. T is is easily accomplished by creating “sel -
limited” exercises.3 Such exercises require passive or active “locking” by limiting movement
o the area that the patient will most likely use to substitute or “cheat” with during exercise.
o review, posture identif es the undamental movements used in growth and develop-
ment. T ese movements serve as steps toward the acquisition o skill and are also help ul in
the presence o skill when quality is questionable. Figures 19-2 through 19-5 illustrate a ew
examples o these types o movements.
By ollowing this natural sequence o movement, the clinician can observe the point at
which a mobility or stability problem will f rst limit the quality o a whole movement pat-
tern. T e specif c posture o the body is as important as the movement that is introduced
onto that posture. Clinicians may already know the movement pattern that they want to
train, but they also need to consider the posture o the body as the undamental neuro-
muscular plat orm when making a corrective exercise choice. T e posture is the soil and
the movement is the seed. A chop pattern with the arms can be per ormed while supine,
seated, hal kneeling, tall kneeling, and standing. Each posture will require di erent levels
o stability and motor control.
When stability and motor control are the primary problems, a posture must be selected
to start the corrective exercise process. A patient with a mild knee sprain or even a total knee
replacement may demonstrate segmental rolling to one
side, but “logroll” to the other simply to avoid using a
exion-adduction–medial rotation movement pattern
with the involved lower extremity. T e clinician has now
identif ed where success and ailure meet in the develop-
mental sequence. T e knee problem creates a dynamic
stability problem in the developmental sequence long
be ore partial or ull weight bearing is an issue. Conse-
quently, it must be addressed at that level. T e patient is
provided with an example o how limited knee mobility
can greatly a ect movement patterns (such as rolling)
that seem to require little o the knee. However, by restor-
ing the bilateral segmental rolling unction, measurable Figure 19-3 Ro lling to pro ne
qualitative and quantitative improvements in many gait

problems can be achieved. With use o postural progres-
sion, the earliest level o unctional limitation can easily be
identif ed and incorporated into the exercise program. Lim-
itations can also be placed on the posture and movement
(the sel -limited concept) to control postural compensation
and ocus. I rolling rom prone to supine does not present
a problem, a more complex posture can be assumed. T e
obvious next choice would be to move to quadruped. From
the all- ours position, alternate arms and legs can be li ted
to an extended and exed position. T ey can also be tucked
into a exed and extended position by bringing the alter-
Figure 19-4 Pro ne o n e lbo w s w ith re aching nate knee to the alternate elbow. T is causes a signif cant
motor control load by moving rom 4 points o stability to 2.
T e load becomes even greater as movement o the extrem-
ities causes weight shi ting, which must be managed continuously. I the movements are not
compromised, the next progressive posture would be hal kneeling with a narrow base. I this
narrow-base hal -kneeling posture demonstrates asymmetry and dys unction, this is the pos-
ture or which the corrective exercise will be developed. Slightly widening the base improves
control, and as control is developed, the base can be narrowed to challenge motor control.
Clin ica l Pe a r l
The clinician must de ne postural levels of success and failure to identify the postural
level at which therapeutic exercise intervention should start. Otherwise, the clinician could
potentially prescribe exercise at a postural level at which the patient makes signi cant
amounts of inappropriate compensation and substitution during exercise.
Posit ion
T e word position describes not only the location o the
anatomic structure (eg, joint, muscle group, or ligament)
at which impairment has been identif ed but also the
location (with respect to movement and load) at which
the greatest and least limitations occur. T e limitations
can be either reduced strength and control or restricted
movement. T e primary questions to ask or this principle
appear in able 19-4. Orthopedic manual assessment o
joints and muscles in various unctional positions dem-
onstrates the in uence o the impairment and symptoms
throughout the range o movem ent. T e clinician will
identi y various def cits. Each will be qualif ed or quanti-
f ed through assessment and objective testing, and then
addressed through the appropriate dosage and position-
ing or exercise.
Purpose is the obvious reason or exercise intervention,
whereas posture describes the orientation o the body in
space. Position re ers to the specif c mobilizing or stabiliz-
ing segment. Attention should be paid to positions o body
segments not directly involved in the posture or movement
pattern. For the “single-leg bridge” (Figure 19-6), the hip is
Figure 19-5 Half-kne e ling po sitio n moving toward extension. I ROM were broken down into
thirds, this exercise would involve only the extension
third o movement. T e exion third and middle third o
movement are not needed because no impairment was
identif ed in those respective ranges. Not only was the
hip in extension, but the knee was also in exion. T is is
important because the hamstring muscle will try to assist
hip extension in the end range o movement when gluteal
strength is not optimal. However, the hamstrings cannot
assist hip extension to any signif cant degree because
o “active insu ciency.” Likewise, the lumbar extensors
cannot assist the extension pattern because o the passive
stretch placed on them via maximal passive hip exion.
Hip extension proprioception is now void o any inappro-
priate patterning or compensation rom the hamstrings
or spinal erectors through the positional use o active and
passive insu ciency.57 Figure 19-6 Sing le -le g bridg e
Qualitative measures will provide specif c in orma-
tion about exercise start and f nish position, movement
speed and direction, open- and closed-chain considerations, and the need or cueing and
eedback. Close observation o the osteokinematic and arthrokinematic relationships or
movement and bilateral comparison is the obvious starting point. Specif c identif cation o
the structure and position represents mobility observed by selective tension (active, passive,
and resisted movements), and the end eel o the joint structures would provide specif c
in ormation about the mechanical nature o the limitations and symptoms.58 Assessment o
positional static and dynamic control will reveal limitations in stability and provide a more
specif c starting point or exercise.
Quantitative measures will reveal a degree o def cit, which can be recorded in the orm
o a percentage through bilateral comparison and compared with normative data when
possible. ROM, strength, endurance, and recovery time should be considered, along with
many other (quantitative) clinical parameters, to describe isolated or positional unction.
T is will provide clear communication and specif c documentation or goals, as well as be a
tracking device or the e ectiveness o treatment, in ormation that will help def ne the base-
line or initial exercise considerations. As stated earlier, any limitation in mobility or stabil-
ity requires bilateral comparison, in addition to clearing o the joints above and below. T e
proximal and distal structures must also be compared with their contralateral counterparts.
T is central point o physical examination is o ten overlooked. Cyriax58 noted, “Positive
signs must always be balanced by corroborative negative signs. I a lesion appears to lie at or
near one joint, this region must be examined or signs identi ying its site. It is equally essen-
tial or the adjacent joints and the structures around them to be examined so that, by con-
trast, their normality can be established. T ese negative f ndings then rein orce the positive
f ndings emanating elsewhere; then only can the diagnosis be regarded and established.”
A ter position and movement options are established, a trial exercise session should
be used to observe and quanti y per ormance be ore prescription o exercise. Variables,
including intensity and duration, can be used to establish strength or endurance base-
lines. Bilateral comparison should be used to document a def cit in per ormance, which
is also recorded as a percentage. A maximum repetition test (with or without resistance)
to atigue, onset o symptoms, or loss o exercise quality is a common example. T is will
allow close tracking o home exercise compliance and help to establish a rate o improve-
ment. I all other actors are addressed, the rate o improvement should be quite large. T is
is the benef t o correct dosage in prescription o exercise position and appropriate work-
load. Most o the signif cant improvement is not a result o training volume, tissue metabo-
lism, or muscle hypertrophy, but o the e cient adaptive response o neural actors.59 T ese
actors can include motor recruitment e ciency, improved timing, increased proprio-
ceptive awareness, improved agonist/ antagonist coordination, appropriate phasic/ tonic
response to activity, task amiliarity, and motor learning, as well as psychological actors.
Usually, greater def cits are associated with more drastic improvement. reatments should
be geared to stimulate these changes whenever possible.
Pat t ern
T e primary questions to ask or the pattern principle appear in able 19-4. T e word
pattern serves as a cue to the clinician to continually consider the unctional movements
o the human body occurring in unif ed patterns that occupy 3-dimensional space and
cross 3 planes ( rontal, sagittal, and transverse).3 Sometimes this is not easily ascertained by
observing the design and use o f xed-axis exercise equipment and the movement patterns
suggested in some rehabilitation protocols. T e basic patterns o proprioceptive neuromus-
cular acilitation (PNF), or both the extremities and the spine, are excellent examples o
how the brain groups movement. Muscles o the trunk and extremities are recruited in the
most advantageous sequence (proprioception) to create movement (mobility) or control
(stability) movement. Not only does this provide e cient and economical unction, but
it also e ectively protects the respective joints and muscles rom undue stress and strain.
Voss et al60 clearly and eloquently stated, “T e mass movement patterns o acilitation are
spiral and diagonal in character and closely resemble the movements used in sports and
work activities. T e spiral and diagonal character is in keeping with the spiral rotatory char-
acteristics o the skeletal system o bones and joints and the ligamentous structures. T is
type o motion is also in harmony with the topographical alignment o the muscles rom
origin to insertion and with the structural characteristics o the individual muscles.” When a
structure within the sequence is limited by impairment, the entire pattern is limited in some
way. T e clinician should document the limited pattern, as well as the isolated segment
causing the pattern to be limited. T e isolated segment is usually identif ed in the evalu-
ation process and outlined in the “position” considerations. T e resultant e ect on one or
more movement patterns must also be investigated. A review o the basic PNF patterns can
be benef cial to the rehabilitation specialist. Once a structure is evaluated, one should look
at the basic PNF patterns involving that structure. Multiple patterns can be limited in some
way, but usually one pattern in particular will demonstrate signif cantly reduced unction.
Obviously, poor unction in a muscle group or joint can limit the strength, endurance, and
ROM o an entire PNF pattern to some degree. However, the clinician must not simply view
reduced unction o a PNF pattern as an output problem. It should be equally viewed as an
input problem. When muscle and joint unctions are not optimal, mechanoreceptor and
muscle spindle unctions are not optimal. T is can create an input or proprioceptive prob-
lem and greatly distort joint position and muscle tension in ormation, which distorts the
initial in ormation (be ore movement is initiated), as well as eedback (once movement is
in progress). T ere ore, the clinician cannot consider only unctional output. Altered pro-
prioception, i not properly identif ed and outlined, can unintentionally become part o the
recommended exercises and there ore be rein orced. T e clinician must ocus on synergis-
tic and integrated unction at all levels o rehabilitation. An orthopedic outpatient cannot
a ord to have a problem simply isolated 3 times a week or 30 minutes only to reintegrate
the same problem at a subconscious level during necessary daily activities throughout the
remaining week. PNF-style movement pattern exercise can o ten be taught as easily as an
isolated movement and will produce a signif cantly greater benef t. T erapeutic exercise is
no longer limited by sets as repetitions o the same activity. Successive intervals o increas-
ing di culty (although not physically stress ul) that build on the accomplishment o an ear-
lier task will rein orce one level o unction and continually be a challenge or the next. A
simple movement set ocused on isolation o a problem can quickly be ollowed by a pattern
that will improve integration. T e integration can be ollowed by a amiliar undamental
Reestablishing Proprioception and Neuromuscular Control 533
movement or unctional activity that may reduce the amount o conscious and deliberate
movement and give the clinician a chance to observe subcortical control o mobility and
stability, as well as appropriate use o phasic and tonic responses.
Clin ica l Pe a r l
By continuously considering the pattern options, as well as pattern limitations, the clinician
will be able to re ne the exercise prescription and reduce unnecessary supplemental
movements that could easily be incorporated into pattern-based exercise.
Direction, speed, and amount o resistance (or assistance) will be used to produce
more ref ned patterns. Manual resistance, weighted cable or elastic resistance, weight-
shi ting activities, and even proprioceptive taping can improve recruitment and acilitate
coordination. T e clinician should re rain rom initially discussing specif c structural con-
trol such as “pelvic tilting” or “scapular retraction.” Instead, the clinician should use posture
and position to set the initial movement and design proprioceptive eedback to produce a
more normal pattern whenever possible.
Reestablishing Proprioception
Although the concept and value o proprioceptive mechanoreceptors have been docu-
mented in the literature, treatment techniques ocused on improving their unction have
not generally been incorporated into the overall rehabilitation program. T e neurosensory
unction o the capsuloligamentous structures has taken a back seat to the mechanical
structural role. T is is mainly a result o lack o in ormation about how mechanoreceptors
contribute to the specif c unctional activities and how they can be specif cally activated.61,62
Effect s of Injury on t he Propriocept ive Syst em

A ter injury to the capsuloligamentous structures, it is thought that partial dea erentation
o the joint occurs as the mechanoreceptors become disrupted. T is partial dea erentation
may be caused by either direct or indirect injury. Direct e ects o trauma include disruption
o the joint capsule or ligaments, whereas posttraumatic joint e usion or hemarthrosis19
illustrate indirect e ects.
Whether rom a direct or indirect cause, the resultant partial dea erentation alters the
a erent in ormation received by the CNS and, there ore, the resulting re ex pathways to
the dynamic stabilizing structures. T ese pathways are required by both the eed- orward
and eedback motor control systems to dynamically stabilize the joint. A disruption in the
proprioceptive pathway will result in an alteration in position and kinesthesia.63,64 Barrett 65
showed that there is an increase in the threshold or detection o passive motion in a major-
ity o patients with anterior cruciate ligament (ACL) rupture and unctional instability. Cor-
rigan et al,66 who also ound diminished proprioception a ter ACL rupture, conf rmed this
f nding. Diminished proprioceptive sensitivity has likewise been shown to cause giving way
or episodes o instability in the ACL-def cient knee.67 T ere ore, injury to the capsuloliga-
mentous structures not only reduces the mechanical stability o the joint but also dimin-
ishes the capability o the dynamic neuromuscular restraint system. Consequently, any
aberration in joint motion and position sense will a ect both the eed- orward and eed-
back neuromuscular control systems. Without adequate anticipatory muscle activity, the
static structures may be exposed to insult unless the reactive muscle activity can be initiated
to contribute to dynamic restraint.
Rest orat ion of Propriocept ion and Prevent ion of Reinjury

Although it has been demonstrated that a proprioceptive def cit occurs a ter knee injury,
both kinesthetic awareness and reposition sense can be at least partially restored with sur-
gery and rehabilitation. A number o studies examined proprioception a ter ACL recon-
struction. Barrett 65 measured proprioception a ter autogenous gra t repair and ound that
proprioception was better a ter repair than in an average patient with an ACL def ciency
but still signif cantly worse than in a normal knee. He urther noted that patients’ satis ac-
tion was more closely correlated with their proprioception than with their clinical score.65
Harter et al68 could not demonstrate a signif cant di erence in the reproduction o passive
positioning between the operative and nonoperative knee at an average o 3 years a ter ACL
reconstruction. Kinesthesia has been reported to be restored a ter surgery, as detected by
a threshold or detection o passive motion in the midrange o motion.63 A longer thresh-
old or detection o passive motion was observed in a knee with a reconstructed ACL than
in the contralateral uninvolved knee when tested at the end ROM.63 Lephart et al69 ound
similar results in patients a ter arthroscopically assisted ACL reconstruction with a patellar-
tendon autogra t or allogra t. T e importance o incorporating a proprioceptive element
in any comprehensive rehabilitation program is justif ed rom the results o these studies.
Methods to enhance proprioception a ter injury or surgery could improve unction and
decrease the risk or reinjury. Ihara and Nakayama 70 demonstrated a reduction in neuro-
muscular lag time with dynamic joint control a ter a 3-week training period on an unstable
board. Maintenance o equilibrium and an improvement in reaction to sudden perturba-
tions on the unstable board improved neuromuscular coordination. T is phenomenon was
f rst reported by Freeman and Wyke, in 1967, when they stated that proprioceptive def cits
could be reduced with training on an unstable sur ace.51 T ey ound that proprioceptive
training through stabilometry, or training on an unstable sur ace, signif cantly reduced epi-
sodes o giving way a ter ankle sprains. ropp et al53 conf rmed the work o Freeman and
Wyke by demonstrating that the results o stabilometry could be improved with coordina-
tion training on an unstable board.
Relat ionship of Propriocept ion t o Funct ion

Barrett 65 demonstrated the relationship between proprioception and unction. T eir study
suggested that limb unction relied more on proprioceptive input than on strength dur-
ing activity. Blackburn and Voight33 also ound high correlation between diminished kin-
esthesia and the single-leg hop test. T e single-leg hop test was chosen or its integrative
measure o neuromuscular control because a high degree o proprioceptive sensibility and
unctional ability is required to success ully propel the body orward and land sa ely on the
limb. Giove et al71 reported a higher success rate in returning athletes to competitive sports
with adequate hamstring rehabilitation. ibone et al72 and Ihara and Nakayama 70 ound
that simple hamstring strengthening alone was not adequate; it was necessary to obtain
voluntary or re ex-level control o knee instability or return to unctional activities. Walla et
al73 ound that 95% o patients were able to success ully avoid surgery a ter ACL injury when
they could achieve “re ex-level” hamstring control. Ihara and Nakayama 70 ound that the
re ex arc between stressing the ACL and hamstring contraction could be shortened with
training. With the use o unstable boards, the researchers were able to success ully decrease
the reaction time. Because a erent input is altered a ter joint injury, proprioceptive sen-
sitivity to retrain these altered a erent pathways is critical or shortening the time lag in
muscular reaction to counteract the excessive strain on the passive structures and guard
against injury.
The 3-Phase Rehabilitation Model 535
Rest orat ion of Ef cient Mot or Cont rol

How do we modi y a erent/ e erent characteristics? T e mechanoreceptors in and around
the respective joints o er in ormation about change in position, motion, and loading o
the joint to the CNS, which, in turn, stimulates the muscles around the joint to unction.70
I a time lag exists in the neuromuscular reaction, injury may occur. T e shorter the time
lag, the less stress on the ligaments and other so t tissue structures around the joint. T ere-
ore, the oundation o neuromuscular control is to acilitate the integration o peripheral
sensations related to joint position and then process this in ormation into an e ective e er-
ent motor response. T e main objective o the rehabilitation program or neuromuscular
control is to develop or reestablish the a erent and e erent characteristics around the joint
that are essential or dynamic restraint.21
Several di erent a erent and e erent characteristics contribute to e cient regulation
o motor control. As discussed earlier, these characteristics include the sensitivity o the
mechanoreceptors and acilitation o the a erent neural pathways, enhancement o muscle
sti ness, and production o re ex muscle activation. T e specif c rehabilitation techniques
must also take into consideration the levels o CNS integration. For the rehabilitation pro-
gram to be complete, each o the 3 levels must be addressed to produce dynamic stability.
T e plasticity o the neuromuscular system permits rapid adaptations during the rehabilita-
tion program that enhance preparatory and reactive activity.21,40,46,69,70,74
Clin ica l Pe a r l
Speci c rehabilitation techniques that produce adaptations to enhance the ef ciency of

neuromuscular techniques include balance training, biofeedback training, re ex facilitation
through reactive training, and eccentric and high-repetition/low-load exercises. 21
T e 3-Phase Rehabilitation Model

T e ollowing is a 3-phase m odel designed to progressively retrain the neurom uscular
system or com plex unctions o sports and ADL ( able 19-6). T e m odel phases are suc-
cessively m ore demanding and provide sequential training toward the objective o rees-
tablishm ent o neurom uscular control. T is 3-phase m odel has also been described as
RN . Ideally, the phases should be ollowed in order and should use the 4 rehabilitation
considerations m entioned earlier (the 4 Ps) at each
phase. Application o the 4 Ps at each phase is crucial
to place successive dem an ds on the athlete during able 19-6 Thre e -Phase Re habilitatio n Mo de l
rehabilitation. In addition, progression o exercise is
guided by the 4 × 4 design. T e 4 × 4 m ethod o thera-
Phase De scriptio n Obje ctive
peutic exercise design re ers to the 4 possible exercise
position s com bin ed with the 4 types o resistan ce 1 Restore static Restoration of
used ( able 19-7). stability through proprioception
T e di culty o any exercise can be increased by proprioception and
either changing the position (non-weight bearing being kinesthesia
the easiest and standing being the toughest) or chang- 2 Restore dynamic Encourage preparatory
ing the resistance (unloaded with core activation being stability agonist-antagonist
the easiest and loaded without core activation being the cocontraction
hardest). It is important to remember that exercises that
3 Restore reactive Initiate re ex muscular
present too much di culty will orce the patient to
neuromuscular control stabilization
revert back to a compensation pattern. T ere ore, the
f rst set o exercises ollowing a change in mobility will
able 19-7 Fo ur-by-Fo ur Me tho d fo r De sig n give all the in ormation that one needs to know by
o f The rape utic Exe rcise producing 1 o 3 responses:
• It is too easy. T e patient can per orm the
movement or more than 30 repetitions with
The 4 Po sitio ns The 4 Type s o f Re sistance
good quality.
Non-weight bearing Unloaded with core activation • It is challenging, but possible. T e patient can
(supine or prone) per orm the movement 8 to 15 times with good
Quadruped Unloaded without core activation quality o movement and no signs o stress.
Between 5 and 15 repetitions, however, there is
Kneeling (half kneeling Loaded with core activation a sharp decline in quality as demonstrated by
or tall kneeling)
a limited ability to maintain ull ROM, balance,
Standing (lunge, split, Loaded without core activation stabilization, and coordination, or the patient just
squat, single leg) becomes physically atigued.
• It is too dif cult. T e patient has sloppy, stress ul,
poorly coordinated movement rom the beginning,
and it only gets worse.
Using this as a corrective exercise base, the clinician can observe the response and act
accordingly. I the initial choice o exercise is too di cult, decrease the di culty, observe
the response to the next set, and repeat the process. I the initial exercise is too easy, increase
the di culty, observe the response to the next set, and repeat the process. Increasing di -
f culty rarely means increased resistance. A more advanced posture, a smaller base o sup-
port, or a more complex or involved movement pattern is usually indicated to increase the
di culty. A typical example is some orm o activity with a rolling movement pattern mov-
ing to a quadruped exercise, then going to a hal -kneeling activity, and f nally progressing to
movement with a single-leg stance.
Phase I: Rest ore St at ic St abilit y Through

Propriocept ion and Kinest hesia
Functional neuromuscular rehabilitation activities are designed to both restore unctional
stability about the joint and enhance motor control skills. T e RN program is centered on
stimulation o both the peripheral and central re ex pathways to the skeletal muscles. T e
f rst objective that should be addressed in the RN program is restoration o propriocep-
tion. Reliable kinesthetic and proprioceptive in ormation provides the oundation on which
dynamic stability and motor control is based. It has already been established that altered
a erent in ormation received by the CNS can alter the eed- orward and eedback motor
control systems. T ere ore, the f rst objective o the RN program is to restore the neurosen-
sory properties o the damaged structures while at the same time enhancing the sensitivity
o the secondary peripheral a erents.69
o acilitate appropriate kinesthetic and proprioceptive input into the CNS, joint repo-
sition exercises should be used to provide maximal stimulation o the peripheral mecha-
noreceptors. T e use o closed-kinetic-chain activities creates axial loads that maximally
stimulate the articular mechanoreceptors via the increase in compressive orce.10,55 T e use o
closed-chain exercises not only enhances joint congruency and neurosensory eedback but
also minimizes shearing stress about the joint.75 At the same time, the muscle receptors are
acilitated by the change in both length and tension.10,55 T e objective is to induce unantici-
pated perturbations and thereby stimulate re ex stabilization. Persistent use o these path-
ways will decrease the response time when an unanticipated joint load occurs.76 In addition
to weightbearing exercises, active and passive joint-repositioning exercises can be used to
enhance the conscious appreciation o proprioception. Rhythmic stabilization exercises can
able 19-8 Uppe r-Extre mity Ne uro muscular Exe rcise s
Phase I: Phase II: Phase III:

Pro prio ce ptio n and Kine sthe sia Dynamic Stabilizatio n Re active Ne uro muscular Co ntro l
Go als
Normalize motion Enhance dynamic functional stability Improve reactive neuromuscular abilities
Restore proprioception and kinesthesia Reestablish neuromuscular control Enhance dynamic stability
Establish muscular balance Restore muscular balance Improve power and endurance
Diminish pain and in ammation Maintain normalized motion Gradual return to activities/throwing
Stability Exe rcise s
Joint repositioning PNF D2 Flex/Ext PNF D2 Flex/Ext

Movement awareness Supine RS with T-band
RS Side-lying Perturbation RS
RI Seated Perturbation RS—eyes closed
SRH Standing 90 degree/90 degree
PNF D2 Flex/Ext PNF D2 Flex/Ext at end range ER at end-range RS
PNF D2 Flex/Ext RS, SRH, RI 90 degrees/90 ER at end range ER Conc/Ecc
Side-lying RS, SRH, RI Scapular strengthening ER Conc/Ecc RS
Weight bearing (axial compression) Scapular PNF—RS, SRH ER/IR Conc/Ecc
Weightbearing RS, RI ER/IR at 90 degree abduction—eyes ER/IR Conc/Ecc RS
Standing while leaning on hands closed Eyes closed
Quadruped position PNF D2 Flex/Ext—eyes closed Standing on one leg
Tripod position Balance beam Reactive plyoballs
Biped position PNF D2 Flex/Ext—balance beam Pushups on unstable surface
Axial compression with ball on wall Slide board—side to side UE plyometrics
OTIS Slide board pushups Two-handed overhead throw
Axial compression—side to side Side-to-side overhead throw
Axial compression—unstable surfaces One-handed baseball throw
Plyometrics—two handed (light Endurance
and easy) Wall dribble
Two-handed chest throw Wall baseball throw
Two-handed underhand throw Axial compression circles
Axial compression—side/side
Sports speci c
Underweighted throwing
Overweighted throwing
Oscillating devices
Boing
Body blade
Conc, concentric; Ecc, eccentric; ER, external rotation; Ext, extension; Flex, exion; IR, internal rotation; OTIS, oscillating techniques for isometric
stabilization; PNF, proprioceptive neuromuscular facilitation; RI, reciprocal isometrics; RS, rhythmic stabilization; SRH, slow-reversal-hold; UE, upper
extremity.
be included early in the RN program to enhance neuromuscular coordination in response to

unexpected joint translation. T e intensity o the exercises can be manipulated by increasing
either the weight loaded across the joint or the size o the perturbation ( ables 19-8 and 19-9).
T e addition o a compressive sleeve, wrap, or taping about the joint can also provide addi-
tional proprioceptive in ormation by stimulating the cutaneous mechanoreceptors.21,65,77,78
Figures 19-7 through 19-10 provide examples o exercises that can be begun in this phase.
able 19-9 Lo w e r-Extre mity Ne uro muscular Exe rcise s
Phase I: Phase II: Phase III:

Pro prio ce ptio n and Kine sthe sia Dynamic Stabilizatio n Re active Ne uro muscular Co ntro l
Go als
Normalize motion Enhance dynamic functional Improve reactive neuromuscular abilities
Restore proprioception and kinesthesia stability Enhance dynamic stability
Establish muscular balance Reestablish neuromuscular control Improve power and endurance
Diminish pain and in ammation Restore muscular balance Gradual return to activities, running,
Develop static control and posture Maintain normalized motion jumping, cutting
Stability Exe rcise s
Bilateral to unilateral OTIS Squats
Eyes open to eyes closed AWS Assisted
Stable to unstable surfaces PWS AWS
Level surfaces MWS PWS
Foam pad LWS MWS
Controlled to uncontrolled Chops/lifts LWS
PNF ITIS Chops/lifts
Rhythmic stabilization PACE Lunges (front and lateral)
Rhythmic isometrics PNF AWS
Slow reversal hold Rhythmic stabilization PWS
Rhythmic isometrics MWS
Slow-reversal-hold LWS
Stable to unstable surface Stationary walking with unidirectional WS
Rocker board Stationary running
Wobble board PWS
BAPS MWS
Balance beam LWS
Foam rollers AWS
DynaDisc Mountain climber
CKC side to side
Fitter
Slide board
Plyometrics
Jumps in place
Standing jumps
Bounding
Multiple hops and bounds
Hops with rotation
Bounds with rotation
Resisted lateral bounds
Box jumps
Depth jumps
Multidirectional training
Lunges
Rock wall
Clock drill
Step-tos
Four-square
Agility training
AWS, anterior weight shift; BAPS, biomechanical ankle platform system; CKC, closed-chain kinetic; ITIS, impulse techniques for isometric
stabilization; LWS, lateral weight shift; MWS, medial weight shift; OTIS, oscillating techniques for isometric stabilization; PACE, partial-arc
controlled exercise; PNF, proprioceptive neuromuscular facilitation; PWS, posterior weight shift; WS, weight shift.
Figure 19-7 Rhythmic stabilizatio n Figure 19-8 Quadrupe d po sitio n w ith manual
pe rturbatio ns
Figure 19-9 Single-limb balance on an unstable Figure 19-10 Sing le -limb balance w ith
(foam) base o scillating te chnique s fo r iso me tric stabilizatio n
Box 19-6 Balance Variable s That Can Be Manipulate d in the Dynamic Stability
Phase to Pro duce a Se nso ry Re spo nse
Phase II: Rest ore Dynamic St abilit y

T e second objective o the RN program is to encourage preparatory agonist-antagonist
cocontraction. E cient coactivation o the musculature restores the normal orce couples
that are necessary to balance joint orces, increase joint congruency, and thereby reduce the
loads imparted onto the static structures.21 T e cornerstone o rehabilitation during this phase
is postural stability training. Environmental conditions are manipulated to produce a sensory
response (Box 19-6). T e use o unstable sur aces allows the clinician to use positions o com-
promise to produce maximal a erent input into the spinal cord and thus produce a re ex
response. Dynamic coactivation o the muscles about the joint to produce a stabilizing orce
requires both the eed- orward and eedback motor control systems. o acilitate these path-
ways, the joint must be placed in positions o compromise or the patient to develop reactive
stabilizing strategies. Although it was once believed that the speed o the stretch re exes could
not be directly enhanced, e orts to do so have been success ul in human and animal stud-
ies. T is has signif cant implications or reestablishing the reactive capability o the dynamic
restraint system. Reducing electromechanical delay between joint loading and protective
muscle activation can increase dynamic stability. In the controlled clinical environment, posi-
tions o vulnerability can be used sa ely (see ables 19-8 and 19-9). Figures 19-11 and 19-12
provide examples o exercises that can be implemented in this phase.
Figure 19-11 Plyo back, tw o -hande d Figure 19-12 Lung ing mo ve me nt, fo rw ard
uppe r-e xtre mity che st pass w ith spo rt co rd re sistance
Proprioceptive training or unctionally unstable joints a ter injury has been docu-
m ented in the literature.38,53,70,79 ropp et al53 and Wester et al80 reported that ankle disk
training signif cantly reduced the incidence o ankle sprains. Concerning the m echanism
o the e ects, ropp et al53 suggested that unstable sur ace training reduced the pro-
prioceptive def cit. Sheth et al79 dem onstrated changes in healthy adults in patterns o
contraction o the inversion and eversion musculature be ore and a ter training on an
unstable sur ace. T ey concluded that the changes would be supported by the concept o
reciprocal Ia inhibition via the mechanoreceptors in the muscles. Konradsen and Ravin 81
also suggested rom their work that a erent input rom the cal musculature was responsi-
ble or dynam ic protection against sudden ankle inversion stress. Pinstaar et al82 reported
that postural sway was restored a ter 8 weeks o ankle disk training when per ormed 3 to
5 tim es a week. ropp and Odenrick also showed that postural control im proved a ter
6 weeks o training when per orm ed 15 m inutes per day.39 Bernier and Perrin,54 whose
program consisted o balance exercises progressing rom sim ple to com plex sessions
(3 tim es a week or 10 m inutes each tim e), also ound that postural sway was improved
a ter 6 weeks o training. Although each o these training program s do have som e di er-
ences, postural control im proved a ter 6 to 8 weeks o proprioceptive training in subjects
with unctional instability o the ankle.
Phase III: Rest ore React ive Neuromuscular Cont rol

Dynamic reactive neuromuscular control activities should be initiated into the overall reha-
bilitation program a ter adequate healing and dynamic stability have been achieved. T e
key objective is to initiate re ex muscular stabilization.
Progression o these activities is predicated on the athlete satis actorily completing the
activities that are considered prerequisites or the activity being considered. With this in
mind, progression o activities must be goal oriented and specif c to the tasks that will be
expected o the athlete.
T e general progression o activities to develop dynamic reactive neuromuscular con-
trol is rom slow-speed to ast-speed activities, rom low- orce to high- orce activities, and
rom controlled to uncontrolled activities. Initially, these exercises should evoke a balance
reaction or weight shi t in the lower extremities and ultimately progress to a movement pat-
tern. A sudden alteration in joint position induced by either the clinician or the athlete may
decrease the response time and serve to develop reactive strategies to unexpected events.
T ese reactions can be as simple as static control with little or no visible movement or as
complex as a dynamic plyometric response requiring explosive acceleration, deceleration,
or change in direction. T e exercises will allow the clinician to challenge the patient by using
visual or proprioceptive input, or both, via tubing (oscillating techniques or isometric sta-
bilization) and other devices (eg, medicine balls, oam rolls, or visual obstacles). Although
these exercises will improve physiologic parameters, they are specif cally designed to acili-
tate neuromuscular reactions. T ere ore, the clinician must be concerned with the kines-
thetic input and quality o the movement patterns rather than the particular number o sets
and repetitions. When atigue occurs, motor control becomes poor and all training e ects
are lost. T ere ore, during the exercise progression, all aspects o normal unction should be
observed, including isometric, concentric, and eccentric muscle control; articular loading
and unloading; balance control during weight shi ting and changes in direction; controlled
acceleration and deceleration; and demonstration o both conscious and unconscious con-
trol (see ables 19-7 and 19-8). Figures 19-13 through 19-15 are examples o exercises that
can be implemented in this phase.
When dynam ic stability and re ex stabilization have been achieved, the ocus o the
neuromuscular rehabilitation program is to restore ADL and sport-specif c skills. It is
Figure 19-13 Dynamic training ; Figure 19-14 Dynamic training ;

Bo dy Blade , lo w po sitio n Bo dy Blade , e le vate d po sitio n
essential that the exercise program be specif c to the patient’s

needs. T e m ost im portant actor to consider during reha-
bilitation o patients is that they should be per orm ing unc-
tional activities that simulate their ADL requirem ents. T is
rule applies not only to the specif c joints involved but also
to the speed and amplitude o m ovement required in ADL.
Exercise and training drills that will ref ne the physiologic
param eters required or return to preinjury levels o unc-
tion should be incorporated into the program. T e progres-
sion should be rom straight plane to multiplane movement
patterns. ADL movem ent does not occur along a single joint
or plane o m ovem ent. T ere ore, exercise or the kinetic
chain must involve all 3 planes simultaneously. Em phasis
in the RN program m ust be placed on progression rom
sim ple to com plex neurom otor patterns that are specif c
to the demands placed on the patient during unction. T e
unction progression breaks an activity down into its com -
ponent parts so that they can be per orm ed in a sequence
that allows acquisition or reacquisition o the activity.
Basic conditioning and skill acquisition must be achieved
be ore advanced conditioning and skill acquisition. T e
training program should begin with sim ple activities, such
as walking/ running, and then progress to highly com plex
motor skills requiring ref ned neuromuscular m echanism s,
including proprioceptive and kinesthetic awareness, which
Figure 19-15 Ele vate d w all dribble provides re ex joint stabilization. A signif cant am ount
o “controlled chaos” should be included in the program. Unexpected activities during
ADL are by nature unstable. T e m ore patients rehearse in this type o environm ent, the
better they will react under unrehearsed conditions. T e clinician needs to learn how to
categorize, prioritize, and plan e ectively because corrective exercises will evolve and
equipm ent will change. T e clinician’s pro essional skill must be based in a systematic
approach. Just being great at a technique is not good enough. echnical aspects o exer-
cise will change. T e clinician should not worry. T is system is not based on exercise. It
is based on human m ovem ent, not equipment, techniques, or trends. T e f nal and m ost
im portant consideration o this phase is to make the rehabilitation program un. T e f rst
3 letters o unctional are FUN. I the program is not un, com pliance will su er and so
will the results.
SUMMARY
1. Increased attention has been devoted to the development o balance, proprioception,
and neuromuscular control in the rehabilitation and reconditioning o athletes a ter
injury.
2. It is believed that injury results in altered somatosensory input, which in uences neu-
romuscular control.
3. I static and dynam ic balance and neuromuscular control are not reestablished
a ter injury, the patient will be susceptible to recurrent injury and per ormance may
decline.
4. T e 3-phase model or RN may be an excellent method to assist athletes in regaining
optimal neuromuscular per ormance and high-level unction a ter injury or surgery.
5. T e 3-phase model consists o restoring static stability through proprioception and
kinesthesia, dynamic stability, and reactive neuromuscular control.
6. Current in ormation has been synthesized to produce a new perspective or therapeu-
tic exercise decisions. T is new perspective was specif cally designed to improve treat-
ment e ciency and e ectiveness and have a ocus on unction.
7. T e 4 principles o purpose, posture, position, and pattern assist problem solving by
providing a ramework that categorizes clinical in ormation in a hierarchy.
8. T e 4 principles serve as quick reminders o the hierarchy, interaction, and applica-
tion or each therapeutic exercise prescription principle. T e questions o what, when,
where, and how or unctional movement assessment and exercise prescription are an-
swered in the appropriate order.
a. Functional evaluation and assessment = purpose.
b. Identif cation o motor control = posture.
c. Identif cation o osteokinematic and arthrokinematic limitations = position.
d. Integration o synergistic movement patterns = pattern.
9. T e clinician should always ask whether the program makes sense. I it does not make
sense, it is probably not unctional and there ore not optimally e ective.
10. Clin ical wisdom is th e result o experien ce an d applied kn owledge. Inten se
am iliarity an d practical observation im prove application . o be o ben ef t,
the knowledge available must be organized and tem pered by an objective and inclu-
sive ram ework. It is hoped that this ram ework will provide a starting point to better
organize and apply each clinician’s knowledge and experience o unctional exercise
prescription.
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Rehabilitation of
Shoulder Injuries
Jo s e p h B. M y e r s , Te r r i Jo Ru cin s k i,
Willia m E. Pre n t ice , a n d Ro b Sch n e id e r
OBJJECT
Review the functional anatomy and biomechanics associated with normal function of the
shoulder joint complex.
Differentiate the various rehabilitative strengthening techniques for the shoulder, including both
open- and closed-kinetic-chain isotonic, plyometric, isokinetic, and proprioceptive neuromuscular
facilitation exercises.
Compare the various techniques for regaining range of motion, including stretching exercises
and joint mobilization.
Administer exercises that may be used to reestablish neuromuscular control.
Relate biomechanical principles to the rehabilitation of various shoulder injuries/pathologies.
Discuss criteria for progression of the rehabilitation program for different shoulder injuries/
pathologies.
Describe and explain the rationale for various treatment techniques in the management of
shoulder injuries.
PART 4 Intervention Strategies for Speci c Injuries

548 Chapte r 20 Rehabilitation of Shoulder Injuries
Functional Anatomy and Biomechanics

he anatom y o the shoulder joint com plex allows or trem en dous ran ge o m otion .
his wide range o m otion o the shoulder com plex proxim al perm its precise position -
ing o the hand distally, to allow both gross and skilled m ovem ents. However, the high
degree o m obility requires som e com prom ise in stability, which, in turn , increases the
vulnerability o the shoulder joint to injury, particularly in dynam ic overhead athletic
activities.5
T e shoulder girdle com plex is com posed o 3 bones—the scapula, the clavicle, and
the hum erus—that are connected either to one another or to the axial skeleton or trunk
via the glenohum eral joint, the acrom ioclavicular joint, the sternoclavicular joint, and
the scapulothoracic joint ( Figure 20-1). Dynam ic m ovem ent and stabilization o the
shoulder com plex require integrated unction o all our articulations i normal m otion
is to occur.
St ernoclavicular Joint
he clavicle articulates with the m anubrium o the sternum to orm the sternoclavicular
joint, the only direct skeletal con nection between the upper extrem ity and the trunk.
he sternal articulatin g sur ace is larger than the sternum , causing the clavicle to rise
m uch higher than the sternum. A ibrocartilaginous disk is interposed between the 2
articulatin g sur aces. It un ction s as a shock absorber again st the m edial orces an d
also helps to prevent any displacem ent upward. he articular disk is placed so that the
clavicle m oves on the disk, and the disk, in turn, m oves separately on the sternum. he
clavicle is perm itted to m ove up and down, orward and backward, in com bination, and
in rotation.
T e sternoclavicular joint is extremely weak because o its bony arrangement, but it is
held securely by strong ligaments that tend to pull the sternal end o the clavicle downward
and toward the sternum, in ef ect anchoring it. T e main ligaments are the anterior ster-
noclavicular, which prevents upward displacement o the clavicle; the posterior sternocla-
vicular, which also prevents upward displacement o the clavicle; the interclavicular, which
S te rnoclavicula r joint
Clavicle
Acromioclavicula r joint
Gle nohume ra l joint
Hume ra l he a d
1
Gre a te r tube rcle
Ma nubrium
Le s s er tube rcle
Hume rus Bicipita l 2 S te rnum
groove S ca pula
3 Body
De ltoid tube ros ity
S ca pulothora cic 4
joint
Figure 20-1 Ske le tal anato my o f the sho ulde r co mple x
(Reproduced with permission from Prentice. Principles of Athletic Training. 14th ed.
New York: McGraw-Hill; 2011.)
Functional Anatomy and Biomechanics 549
prevents lateral displacement o the clavicle; and the costoclavicular, which prevents lateral
and upward displacement o the clavicle.3
It should also be noted that or the scapula to abduct and upward rotate throughout
180 degrees o humeral abduction, clavicular movement must occur at both the sternocla-
vicular and acromioclavicular joints. T e clavicle must elevate approximately 40 degrees to
allow upward scapular rotation.93
Acromioclavicular Joint
T e acromioclavicular joint is a gliding articulation o the lateral end o the clavicle with
the acromion process. T is is a rather weak joint. A brocartilaginous disk separates the
2 articulating sur aces. A thin, brous capsule surrounds the joint.
T e acromioclavicular ligament consists o anterior, posterior, superior, and in erior
portions. In addition to the acromioclavicular ligament, the coracoclavicular ligament joins
the coracoid process and the clavicle and helps to maintain the position o the clavicle rela-
tive to the acromion. T e coracoclavicular ligament is urther divided into the trapezoid
ligament, which prevents overriding o the clavicle on the acromion, and the conoid liga-
ment, which limits upward movement o the clavicle on the acromion. As the arm moves
into an elevated position, there is a posterior rotation o the clavicle on its long axis that per-
mits the scapula to continue rotating, thus allowing ull elevation. T e clavicle must rotate
approximately 50 degrees or ull elevation to occur; otherwise elevation would be limited
to approximately 110 degrees.93
Coracoacromial Arch
T e coracoacromial ligament connects the coracoid to the acromion. T is ligament, along
with the acromion and the coracoid, orms the coracoacromial arch over the glenohu-
meral joint. In the subacromial space between the coracoacromial arch superiorly and the
humeral head in eriorly lies the supraspinatus tendon, the long head o the biceps tendon,
and the subacromial bursa. Each o these structures is subject to irritation and in amma-
tion resulting either rom excessive humeral head translation or rom impingement during
repeated overhead activities. In asymptomatic individuals the optimal subacromial space
appears to be about 9 to 10 mm.94
Glenohumeral Joint
T e glenohumeral joint is an enarthrodial, or ball-and-socket, synovial joint in which the
round head o the humerus articulates with the shallow glenoid cavity o the scapula.
T e cavity is deepened slightly by a brocartilaginous rim called the glenoid labrum . T e
humeral head is larger than the glenoid, and at any point during elevation, only 25% to
30% o the humeral head is in contact with the glenoid.47 T e glenohumeral joint is main-
tained by both static and dynamic restraints. Position is maintained statically by the gle-
noid labrum and the capsular ligaments, and dynamically by the deltoid and rotator cuf
muscles.
Surrounding the articulation is a loose, articular capsule that is attached to the labrum.
T is capsule is strongly rein orced by the superior, middle, and in erior glenohumeral liga-
ments and by the tough coracohumeral ligament, which attaches to the coracoid process
and to the greater tuberosity o the humerus.87
T e lon g tendon o the biceps m uscle passes superiorly across the head o the
hum erus and then through the bicipital groove. In the anatom ical position the long head
o the biceps m oves in close relation ship with the hum erus. T e tran sverse hum eral
ligam ent m aintain s the lon g head o the biceps tendon within the bicipital groove by
passing over it rom the lesser and the greater tuberosities, converting the bicipital
groove into a canal.
Scapulot horacic Joint

T e scapulothoracic joint is not a true joint, but the movement o the scapula on the wall o
the thoracic cage is critical to shoulder joint motion.92 T e scapula is capable o 5 degrees o
reedom movement, including 3 rotations (orientations) and 2 translations (positions).54,76
Rotation o the scapula can occur around its 3 orthogonal axes, with upward/ downward
rotation occurring around an anteroposterior axis, internal/ external rotation occurring
around a superoin erior axis, and anterior/ posterior tipping occurring around a mediolat-
eral axis. In addition to rotating, the scapula can translate superoin eriorly (scapular ele-
vation and depression), and anteroposteriorly on the thorax. Because anterior/ posterior
translation is limited by the rib cage, protraction/ retraction results rom the anterior/
posterior translation (Figure 20-2). During humeral elevation ( exion, scaption, or abduc-
tion), the scapula and humerus must move in a synchronous ashion in order to maintain
glenohumeral joint congruency, length–tension relationships or the numerous muscles
attaching on the scapula, and adequate subacromial space clearance. Commonly termed
scapulohum eral rhythm , as the humerus elevates, the scapula synchronously upwardly
rotates, posteriorly tips, externally rotates, elevates, and translates posteriorly (retracts).
Alterations in these scapular m ovement patterns have been identi ed in individuals
with varying degrees o rotator tendinopathy (subacromial impingement and rotator cuf
tears),35,69,71,79,103,122 pathologic internal im pingem ent,61 glenohumeral instability,88 ro-
zen shoulder,37,101 and osteoarthritis,37 as well as highly in uenced by atigue,33,34,108,119
upper-quarter posture and tightness,11,12,13 and even history o participation in overhead
athletics.30,63,83,90
Figure 20-2 Scapular mo tio ns

St abilit y in t he Shoulder Joint

Maintaining stability, while the 4 articulations o the shoulder complex collectively allow
or a high degree o mobility, is critical in normal unction o the shoulder joint. Instability is
very o ten the cause o many o the speci c injuries to the shoulder that are discussed later
in this chapter. In the glenohumeral joint, the rounded humeral head articulates with a rela-
tively at glenoid on the scapula. During movement o the shoulder joint, it is essential to
maintain the positioning o the humeral head relative to the glenoid. Likewise it is also criti-
cal or the glenoid to adjust its position relative to the moving humeral head while simul-
taneously maintaining a stable base. T e glenohumeral joint is inherently unstable, and
stability depends on the coordinated and synchronous unction o both static and dynamic
stabilizers.74
St at ic St abilizers
T e primary static stabilizers o the glenohumeral joint are the glenohumeral ligaments, the
posterior capsule, and the glenoid labrum.
T e glenohumeral ligaments appear to produce a major restraint in shoulder exion,
extension, and rotation. T e anterior glenohumeral ligament is tight when the shoulder is
in extension, abduction, and/ or external rotation. T e posterior glenohumeral ligament
is tight in exion and external rotation. T e in erior glenohumeral ligament is tight when
the shoulder is abducted, extended, and/ or externally rotated. T e middle glenohumeral
ligament is tight when in exion and external rotation. Additionally, the middle glenohu-
meral ligament and the subscapularis tendon limit lateral rotation rom 45 to 75 degrees o
abduction and are important anterior stabilizers o the glenohumeral joint.3 T e in erior
glenohumeral ligament is a primary check against both anterior and posterior dislocation
o the humeral head and is the most important stabilizing structure o the shoulder in the
overhead patient.3
T e tendons o the rotator cuf muscles blend into the glenohumeral joint capsule at
their insertions about the humeral head (Figure 20-3). As these muscles contract, tension
Acromion
Cora coid proce s s
S upra s pina tus
te ndon Cora cohume ra l liga me nt
S ubde ltoid S upe rior gle nohume ra l
burs a liga me nt
Infra s pina tus Bice ps bra chii te ndon
te ndon (long he a d)
Gle noid cavity S ubs ca pula r burs a
(a rticula r ca rtila ge ) S ubs ca pula ris te ndon
Te re s minor
te ndon Middle gle nohume ra l
S ynovia l me mbra ne liga me nt
(cut)
Infe rior gle nohume ra l
liga me nt
Figure 20-3 Ro tato r cuff te ndo ns ble nd into the jo int

capsule , cre ating fo rce co uple s in the fro ntal plane
(Reproduced with permission from Prentice. Principles of Athletic Training.

14th ed. New York: McGraw-Hill; 2011.)
is produced, dynamically tightening the capsule and helping to center the humeral head in
the glenoid ossa. T is creates both static and dynamic control o humeral head movement.
T e posterior capsule is tight when the shoulder is in exion, abduction, internal rota-
tion, or any combination o these. T e superior and middle segment o the posterior cap-
sule has the greatest tension, while the shoulder is internally rotated.
T e bones and articular sur aces within the shoulder are positioned to contribute to
static stability. T e glenoid labrum, which is tightly attached to the bottom hal o the gle-
noid and loosely attached at the top, increases the glenoid depth approximately 2 times,
enhancing glenohumeral stability.66 T e scapula aces 30 degrees anteriorly to the chest
wall and is tilted upward 3 degrees to enable easier movement on the anterior rontal plane
and movements above the shoulder.4 T e glenoid is tilted upward 5 degrees to help control
in erior instability.72
The Dynamic St abilizers of t he Glenohumeral Joint

T e muscles that cross the glenohumeral joint produce motion and unction to establish
dynamic stability to compensate or a bony and ligamentous arrangement that allows or
a great deal o mobility. Movements at the glenohumeral joint include exion, extension,
abduction, adduction, horizontal adduction/ abduction, circum duction, and humeral
rotation.
T e muscles acting on the glenohumeral joint may be classi ed into two groups.
T e rst group consists o muscles that originate on the axial skeleton and attach to the
humerus; these include the latissimus dorsi and the pectoralis major. T e second group
originates on the scapula and attaches to the humerus; these include the deltoid, the teres
major, the coracobrachialis, the subscapularis, the supraspinatus, the in raspinatus, and the
teres minor. T ese muscles constitute the short rotator muscles whose tendons insert into
the articular capsule and serve as rein orcing structures. T e biceps and triceps muscles
attach on the glenoid and af ect elbow motion.
T e muscles o the rotator cuf , the subscapularis, in raspinatus, supraspinatus, and
teres minor along with the long head o the biceps unction to provide dynamic stability to
control the position and prevent excessive displacement or translation o the humeral head
relative to the position o the glenoid.9,70,121
Stabilization o the humeral head occurs through coactivation o the rotator cuf
muscles. T is creates a series o orce couples that act to compress the humeral head into
the glenoid, minimizing humeral head translation. A orce couple involves the action o
2 opposing orces acting in opposite directions to impose rotation about an axis. T ese orce
couples can establish dynamic equilibrium o the glenohumeral joint regardless o the posi-
tion o the humerus. I an imbalance exists between the muscular components that create
these orce couples, abnormal glenohumeral mechanics occur.
In the rontal plane a orce couple exists between the subscapularis anteriorly and the
in raspinatus and teres minor posteriorly (see Figure 20-3). Coactivation o the in raspina-
tus, teres minor, and subscapularis muscles both depresses and compresses the humeral
head during overhead movements.
In the coronal plane, there is a critical orce couple between the deltoid and the in e-
rior rotator cuf muscles (Figure 20-4). With the arm ully adducted, contraction o the
deltoid produces a vertical orce in a superior direction causing an upward translation o
the humeral head relative to the glenoid. Coactivation o the in erior rotator cuf muscles
produces both a compressive orce and a downward translation o the humerus that coun-
terbalances the orce o the deltoid, stabilizing the humeral head. T e supraspinatus com-
presses the humeral head into the glenoid and, along with the deltoid, initiates abduction
on this stable base. Dynamic stability is created by an increase in joint compression orces
rom contraction o the supraspinatus and by humeral head depression rom contraction o
the in erior rotator cuf muscles.9,27,70,121
Acromion
S upra s pina tus te ndon

S ubde ltoid
burs a Ca ps ula r liga me nt
Glenoid labrum
De ltoid
mus cle S ynovia l
me mbra ne
Gle noid cavity

of s ca pula
Gle noid labrum

Hume rus
Figure 20-4 Co ro nal plane fo rce co uple s
(Reproduced with permission from Prentice. Principles of Athletic Training. 14th ed. New York:
McGraw-Hill; 2011.)
T e long head o the biceps tendon also contributes to dynamic stability by limiting
superior translation o the humerus during elbow exion and supination.
Scapular St abilit y and Mobilit y

Like the glenohumeral muscles, the scapular muscles play a critical role in normal unction
o the shoulder. T e scapular muscles produce movement o the scapula on the thorax and
help to dynamically position the glenoid relative to the moving humerus. T ey include the
levator scapula and upper trapezius, which elevate the scapula; the middle trapezius and
rhomboids, which retract the scapula; the lower trapezius, which retracts, upwardly rotates,
and depresses the scapula; the pectoralis minor, which depresses the scapula; and the ser-
ratus anterior, which protracts and upwardly rotates the scapula (in combination with the
upper and lower trapezius). Collectively they unction to maintain a consistent length–
tension relationship with the glenohumeral muscles.58,59,80
T e only attachment o the scapula to the thorax is through these muscles. T e muscle
stabilizers must x the position o the scapula on the thorax, providing a stable base or the
rotator cuf to per orm its intended unction on the humerus. It has been suggested that
the serratus anterior moves the scapula while the other scapular muscles unction to pro-
vide scapular stability.58,59 T e scapular muscles act isometrically, concentrically, or eccen-
trically, depending on the movement desired and whether the movement is speeding up or
slowing down.72
Plane of t he Scapula
T e concept o the plane o the scapula re ers to the angle o the scapula in its resting posi-
tion, usually 35 to 45 degrees anterior to the rontal plane toward the sagittal plane. When
the limb is positioned in the plane o the scapula, the mechanical axis o the glenohumeral
joint is in line with the mechanical axis o the scapula. T e glenohumeral joint capsule
is lax, and the deltoid and supraspinatus muscles are optimally positioned to elevate the
humerus. Movement o the humerus in this plane is less restricted than in the rontal or
sagittal planes because the glenohumeral capsule is not twisted.39 Because the rotator cuf
muscles originate on the scapula and attach to the humerus, repositioning the humerus
into the plane o the scapula optimizes the length o those muscles, improving the length–
tension relationship. T is is likely to increase muscle orce.39 It has been recommended
that many strengthening exercises or the shoulder joint complex be done in the scapular
plane.39,128,129
Rehabilitation Techniques for the Shoulder
St ret ching Exercises
Figure 20-5 Static hang ing Figure 20-6 Co dman’s circumductio n e xe rcise
Hanging from a chinning bar is a good The patient holds a dumbbell in the hand and moves it in a circular pattern,
general stretch for the musculature in the reversing direction periodically. This technique is useful as a general stretch in
shoulder complex. the early stages of rehabilitation when motion above 90 degrees is restricted.
Rehabilitation Techniques for the Shoulder 555
Figure 20-7 Saw ing Figure 20-8 Wall climbing Figure 20-9 Ro pe and
pulle y e xe rcise
The patient moves the arm forward and The patient uses the ngers to “walk” the
backward as if performing a sawing hand up a wall. This technique is useful This exercise may be used as an
motion. This technique is useful as when attempting to regain full-range active-assistive exercise when trying
a general stretch in the early stages elevation. ROM should be restricted to a to regain full overhead motion. ROM
of rehabilitation when motion above pain-free arc. should be restricted to a pain-free arc.
90 degrees is restricted.
Figure 20-10 Wall/ co rne r stre tch
Used to stretch the pectoralis major and minor, anterior deltoid,

and coracobrachialis, and the anterior joint capsule.
Figure 20-11 Sho ulde r e xo rs stre tch standing
Used to stretch the anterior deltoid, coracobrachialis, pectoralis

major, and biceps muscles, and the anterior joint capsule.
Figure 20-12 Sho ulde r e xte nso r stre tch Figure 20-13 Sho ulde r adducto rs stre tch
using an L-bar using an L-bar
Used to stretch the latissimus dorsi, teres major and minor, Used to stretch the latissimus dorsi, teres major and minor,
posterior deltoid, and triceps muscles, and the inferior pectoralis major and minor, posterior deltoid, and triceps
joint capsule. muscles, and the inferior joint capsule.
A
A
B
B
C C
Figure 20-14 Sho ulde r me dial ro tato rs stre tch Figure 20-15 Sho ulde r e xte rnal ro tato rs
using an L-bar stre tch using an L-bar
Used to stretch the subscapularis, pectoralis major, Used to stretch the infraspinatus, teres minor, and posterior
latissimus dorsi, teres major, and anterior deltoid muscles, deltoid muscles, and the posterior joint capsule. This stretch
and the anterior joint capsule. This stretch should be done at should be done at (A) 90 degrees and (B) 135 degrees. C. The
(A) 0 degrees, (B) 90 degrees, and (C) 135 degrees. Sleeper Stretch can also be used to stretch the external rotators.
Figure 20-16 Ho rizo ntal adducto rs stre tch using an

L-bar
Used to stretch the pectoralis major, anterior deltoid, and long head
of the biceps muscles, and the anterior joint capsule.
Figure 20-17 Ho rizo ntal abducto rs stre tch Figure 20-18 Ante rio r capsule stre tch
Used to stretch the posterior deltoid, infraspinatus, teres Self-stretch using the wall.
minor, rhomboids, and middle trapezius muscles, and the
posterior capsule. This position might be uncomfortable for
patients with shoulder impingement syndrome.
A B
Figure 20-19 Infe rio r capsule stre tch
A. Self-stretch done with the arm in the fully elevated overhead position. This position might be uncomfortable for
patients with shoulder impingement syndrome. B. Inferior capsule stretch can also be done using a stability ball.
St rengt hening Techniques
A B
Figure 20-20
A. Isometric medial rotation, and (B) isometric lateral rotation, are useful in the early stages of a shoulder rehabilitation
program when full ROM isotonic exercise is likely to exacerbate a problem.
B C
Figure 20-21 Che st pre ss
Used to strengthen the pectoralis major, anterior deltoid, and triceps, and secondarily the coracobrachialis muscles.
A. Performing this exercise with the feet on the floor helps to isolate these muscles. B. An alternate technique is to
use dumbbells on an unstable surface such as a stability ball. C. May also be done in a standing position using cable
or tubing.
Figure 20-22 Incline be nch pre ss Figure 20-23 De cline be nch pre ss
Used to strengthen the pectoralis major (upper fibers), Used to strengthen the pectoralis major (lower fibers), triceps,
triceps, middle and anterior deltoid, and secondarily, the anterior deltoid, coracobrachialis, and latissimus dorsi muscles.
coracobrachialis, upper trapezius, and levator scapula
muscles.
A B C
Figure 20-24 Military pre ss
Used to strengthen the middle deltoid, upper trapezius, levator scapula, and triceps. A. Performed in a seated position on
a bench. B. In a standing position using dumbbells. C. In a seated position using cable or tubing.
Figure 20-25 Lat pull-do w ns
Used to strengthen primarily the latissimus dorsi, teres major, and pectoralis
minor, and secondarily the biceps muscles. This exercise should be done by pulling
the bar down in front of the head. Pull-ups done on a chinning bar can also be
used as an alternative strengthening technique.
A C
Figure 20-26 Sho ulde r e xio n Figure 20-27 Sho ulde r e xte nsio n
Used to strengthen primarily the anterior Used to strengthen primarily the latissimus dorsi, teres major, and posterior
deltoid and coracobrachialis, and deltoid, and secondarily, the teres minor and the long head of the triceps
secondarily the middle deltoid, pectoralis muscles. Note that the thumb should point downward. May be done
major, and biceps brachii muscles. Note (A) standing using a dumbbell, (B) lying prone using cable or tubing, or
that the thumb should point upward. (C) using dumbbells prone on a stability ball.
Figure 20-28 Sho ulde r abductio n to Figure 20-29 Flys (sho ulde r ho rizo ntal
90 de g re e s adductio n)
Used to strengthen primarily the middle deltoid and Used to strengthen primarily the pectoralis major, and
supraspinatus, and secondarily, the anterior and posterior secondarily, the anterior deltoid. Note that the elbow
deltoid and serratus anterior muscles. may be slightly flexed. May be done in a supine position
or standing with surgical tubing or wall pulleys behind.
B C
Figure 20-30 Re ve rse ys (sho ulde r ho rizo ntal abductio n)
Used to strengthen primarily the posterior deltoid, and secondarily, the infraspinatus, teres minor,
rhomboids, and middle trapezius muscles. A. May be done lying prone using dumbbells. B. Prone on a
stability ball. C. Standing using cables or tubing. Note that with the thumb pointed upward the middle
trapezius is more active, and with the thumb pointed downward the rhomboids are more active.
A A
B
B
C
C
Figure 20-32 Sho ulde r late ral ro tatio n

Figure 20-31 Sho ulde r me dial ro tatio n
Used to strengthen primarily the infraspinatus and teres
minor, and secondarily, the posterior deltoid muscles. This
Used to strengthen primarily the subscapularis, pectoralis
exercise may be done isometrically or isotonically, either
major, latissimus dorsi, and teres major, and secondarily,
lying prone using a dumbbell or standing using tubing.
the anterior deltoid. This exercise may be done isometrically
Strengthening should be done with the arm fully adducted
or isotonically, either lying supine using a dumbbell or
at 0 degrees, and also in 90 degrees and 135 degrees of
standing using tubing. Strengthening should be done with
abduction.
the arm fully adducted at 0 degrees, and also in 90 degrees
and 135 degrees of abduction.
Figure 20-33 Scaptio n
Used to strengthen primarily the supraspinatus in the

plane of the scapula, and secondarily, the anterior
and middle deltoid muscles. This exercise should be
done standing with the arm horizontally adducted to
45 degrees.
Figure 20-35 Sho ulde r shrug s
Used to strengthen primarily the upper trapezius and the

levator scapula, and secondarily, the rhomboids.
Figure 20-34 Alte rnative supraspinatus

e xe rcise
Used to strengthen primarily the supraspinatus, and Figure 20-36 Supe rman
secondarily, the posterior deltoid. In the prone position
with the arm abducted to 100 degrees, the arm is Used to strengthen primarily the inferior trapezius, and
horizontally abducted in extreme lateral rotation. Note secondarily, the middle trapezius. May be done lying prone
that the thumb should point upward. using either dumbbells or tubing.
Figure 20-37 Be nt-o ve r ro w s Figure 20-38 Rho mbo ids e xe rcise
Used to strengthen primarily the middle trapezius and Used to strengthen primarily the rhomboids, and secondarily,
rhomboids. Done standing in a bent-over position with the inferior trapezius. Should be done lying prone with
1 knee supported on a bench. manual resistance applied at the elbow.
B Figure 20-40 Scapular stre ng the ning

using a Bo dy Blade
Figure 20-39 Pushups w ith a plus Holding an oscillating Body Blade with both hands,
the patient moves from a fully adducted position
Used to strengthen the serratus anterior. There are in front of the body to a fully elevated overhead
several variations to this exercise, including (A) regular position.
pushups, and (B) weight-loaded pushups with a plus.
Closed-Kinet ic-Chain Exercises
A C
Figure 20-41 Pushups
May be done with (A) weight supported on feet, or (B) modified to support
weight on the knees. C. Wall pushups. Figure 20-42 Se ate d pushup
Done sitting on the end of a table. Place

hands on the tab le and lift weight upward
off of the table isotonically.
Figure 20-43 Iso kine tic uppe r-e xtre mity clo se d-
chain de vice Figure 20-44 Pushups o n a stability ball
One of the only isokinetic closed-kinetic-chain exercise devices An advanced closed chain strengthening exercise that
currently available. (Photo courtesy Biodex Medical Systems, Inc.) requires substantial upper body strength.
Plyomet ric Exercises
Figure 20-45 Cable o r tubing
To strengthen the medial rotators, use a quick eccentric

stretch of the medial rotators to facilitate a concentric
contraction of those muscles.
A B
Figure 20-46 Plyo back
The patient should catch the ball, decelerate it, then

immediately accelerate in the opposite direction.
A. Single-arm toss. B. Two-arm toss with trunk
rotation. C. Standing single-leg and single-arm
C toss on unstable surface.
Figure 20-47 Se ate d sing le -arm w e ig hte d- Figure 20-48 Pushups w ith a clap
ball thro w
The patient pushes off the ground, claps his hands, and catches
The patient should be seated with the arm abducted his weight as he decelerates.
to 90 degrees and the elbow supported on a table.
The therapist tosses the ball to the hand, creating an
overload in lateral rotation that forces the patient to
dynamically stabilize in that position.
Figure 20-49 Pushups o n bo xe s Figure 20-50 Shuttle 2000-1
When performing a plyometric pushup on boxes, The exercise machine can be used for plyometric exercises in
the patient can stretch the anterior muscles, which either the upper or the lower extremity.
facilitates a concentric contraction.
Figure 20-51 Push into w all
The therapist stands behind the patient and pushes her

toward the wall. The patient decelerates the forces and then
pushes off the wall immediately.
Isokinet ic Exercises
A B C
Figure 20-52
When using an isokinetic device for strengthening the shoulder, the patient should be set up such that strengthening can
be done in a scapular plane. A. Shoulder abduction/adduction, (B) internal and external rotation, and (C) Diagonal 1 PNF
pattern. (Courtesy Biodex Medical Systems.)
Propriocept ive Neuromuscular Facilit at ion

Figure 20-53 Rhythmic co ntractio n Figure 20-54 PNF te chnique fo r scapula
Using either a diagonal 1 (D1) or diagonal 2 (D2) pattern. As the patient moves through either a D1 or a D2 pattern,
The patient uses an isometric cocontraction to maintain the therapist applies resistance at the appropriate
a specific position within the ROM while the therapist scapular border.
repeatedly changes the direction of passive pressure.
Figure 20-56 PNF using bo th manual

re sistance and surg ical tubing
Rhythmic stabilization can be performed as the patient

Figure 20-55 isometrically holds a specific position in the ROM with
surgical tubing and force applied by the therapist.
The patient can use resistance from tubing through a
PNF movement pattern.
A B

PNF using (A) Body Blade or (B) Centrifugal Ring Blade. Surgical tubing may be attached to a tennis racket
as the patient practices an overhead serve technique.
This is useful as a functional progression technique.
Exercises t o Reest ablish Neuromuscular Cont rol
Figure 20-59 Figure 20-60 We ig ht shifting o n a ball
Weight shifting on a stable surface may be done kneeling In a pushup position with weight supported on a ball,
in a 2-point position. The therapist can apply random the patient shifts weight from side to side and/or
directional pressure to which the patient must respond to forward and backwards. Weight shifting on an unstable
maintain a static position. In the 2- and 3-point positions, surface facilitates cocontraction of the muscles involved
the arm that is supported in a closed kinetic chain is using in the force couples that collectively maintain dynamic
shoulder force couples to maintain neuromuscular control. stability.
Figure 20-61 We ig ht shifting o n a Fitte r
In a kneeling position the patient shifts weight front to back using a Fitter.
Weight shifting on an unstable surface facilitates cocontraction of the
muscles involved in the force couples that collectively maintain dynamic
stability. (Courtesy Fitter International, Inc.)
Figure 20-62 We ig ht shifting o n a Figure 20-63 We ig ht shifting o n a stability

bio me chanical ankle platfo rm syste m (BAPS) bo ard ball
In a kneeling position the patient shifts weight from side to With the feet supported on a bench, the patient shifts
side and/or backwards and forward using a BAPS board. Weight weight from side to side and/or backwards and forward
shifting on an unstable surface facilitates cocontraction of the using a stability ball. Weight shifting on an unstable surface
muscles involved in the force couples that collectively maintain facilitates cocontraction of the muscles involved in the
dynamic stability. force couples that collectively maintain dynamic stability.
A B
Figure 20-64 Slide bo ard e xe rcise s
A. Forward and backwards motion. B. Wax-on/wax-off motion. C. Lateral motion. The

patient shifts weight from side to side and/or backwards and forward using a slide board.
Weight shifting on an unstable surface facilitates cocontraction of the muscles involved in
the force couples that collectively maintain dynamic stability.
Figure 20-65 Scapular ne uro muscular co ntro l e xe rcise s
The patient’s hand is placed on the table, creating a closed kinetic chain,
and the therapist applies pressure to the scapula in a random direction.
The patient moves the scapula isotonically into the direction of resistance.
A B
Figure 20-66 Stability ball e xe rcise s
The patient lies in a prone position on the stability ball and maintains a stable position and performs (A) Ys, (B) Ts,
and (C) Ws.
Figure 20-67 Bo dy Blade e xe rcise s
The patient is in a 3-point kneeling position holding an oscillating Body Blade in 1 hand
while working on neuromuscular control in the weightbearing shoulder.
Rehabilitation Techniques for Speci c Injuries
St ernoclavicular Joint Sprains

Pat homechanics
Sternoclavicular (SC) joint sprains are not commonly seen as athletic injuries. Although
they are rare, the joint’s complexity and integral interaction with the other joints o the
shoulder complex warrant discussion. T e SC joint has multiple axis o rotation and articu-
lates with the manubrium with an interposed brocartilaginous disc. Pathology o this joint
can include injury to the brocartilage and sprains o the sternoclavicular ligaments and/ or
the costoclavicular ligaments.49
As stated earlier, the SC joint is extremely weak because o its bony arrangement. It is
held in place by its strong ligaments that tend to pull the sternal end o the clavicle down-
ward and toward the sternum. A sprain o these ligaments o ten results in either a subluxing
SC joint or a dislocated SC joint. T is can be signi cant because the joint plays an inte-
gral role in scapular motion through the clavicle’s articulation with the scapula. Combined
movements at the acromioclavicular and SC joints have been reported to account or up to
60 degrees o upward scapular rotation inherent in glenohumeral abduction.3
When this joint incurs an injury, a resultant in ammatory process occurs. T e in am-
matory process can cause an increase in the joint capsule pressure as well as a stif ening o
the joint due to the collagen tissue being produced or the healing tissues. T e pathogen-
esis o this in ammatory process can cause an altering o the joint mechanics as well as an
increase in pain elt at the joint. T is o ten results adversely on the shoulder complex.106
Injury Mechanism
A ter motor vehicle accidents, the most common source o injuries to the SC joint is sports
participation.89 T e SC joint can be injured by direct or indirect orces, resulting in sprains,
dislocations, or physical injuries.49 Direct orce injuries are usually the result o a blow
to the anteromedial aspect o the clavicle and produce a posterior dislocation.49 Indirect
orce injuries can occur in many dif erent sporting events, usually when the patient alls
and lands with an outstretched arm in either a exed and adducted position or extended
and adducted position o the upper extremity. T e exed position causes an anterior lateral
compression orce to the adducted arm, producing a posterior dislocation. T e extended
position causes a posterior lateral compression orce to the adducted arm, leading to an
anterior dislocation. Lesser orces can also lead to varying degrees o sprains to the SC joint.
Additionally, there have been reports o repetitive microtrauma to this joint in sports such
as gol , gymnastics, and rowing.95,106
In gol , an example o mechanism o injury is during the backswing.74 For a right-
handed gol er, the SC joint is subject to medially directed orces on the le t at the top o the
backswing and on the right at the end o the backswing. When the right arm is abducted
and ully coiled at the end o the backswing and the beginning o the downswing, there is
a posterior retraction o the shoulder complex, resulting in an anterior SC joint stress. As a
result o the repetitive nature o gol , this can cause repetitive microtrauma leading to irrita-
tion o the joint. Over time the joint may become hypermobile relative to its normal stable
condition, allowing or degeneration o the so t tissue and brocartilaginous disc. T is o ten
results in a pain ul syndrome af ecting the mechanics o the joint and muscular control o
the shoulder complex.95 Similar examples are ound in gymnastics and rowing.
Rehabilit at ion Concerns

In addressing the rehabilitation o a patient with a SC joint injury, it is important to address
the unction o the joint on shoulder complex movement. T e SC joint acts as the sole
Rehabilitation Techniques for Speci c Injuries 577
passive attachment o the shoulder complex to the axial skeleton. As noted earlier in the
chapter, the clavicle must elevate approximately 40 degrees to allow upward scapular
rotation.93
In most cases the primary problem reported by the injured patient is discom ort asso-
ciated with end-range movement o the shoulder complex. It is important to identi y the
cause o the pain (ie, ligamentous instability, disc degeneration, or ligamentous trauma).
In cases where there is ligamentous instability as well as disc degeneration, the reha-
bilitation should ocus on strengthening the muscles attached to the clavicle in a range that
does not put urther stress on the joint. Muscles such as the pectoralis minor, sternal bers
o the pectoralis major, and upper trapezius are strengthened to help control the motion o
the clavicle during motion o the shoulder complex. Exercises include incline bench, shoul-
der shrugs, and the seated press-up, in a limited ROM (see Figures 20-22, 20-35, and 20-42).
In addition to addressing the dynamic supports o the SC joint, the therapist should employ
the appropriate modalities necessary to control pain and the in ammatory process. It is
also noteworthy, in cases where dislocation or subluxation has occurred, to consider the
structures in close proximity to the SC joint. In the case o a posterior dislocation, signs o
circulatory vessel compromise nerve tissue impingement, and di culty swallowing may be
seen. It is important to avoid these symptoms and communicate with the patient’s physi-
cian regarding any lasting symptoms.106
When dealing with ligamentous trauma that lacks instability, the therapist should
also address the associated pain with the appropriate modalities and utilize exercises that
strengthen muscle with clavicular attachments. In all o the above scenarios, it is impor-
tant to address the role o the SC joint on shoulder complex movement. A ull evaluation o
the shoulder complex should be per ormed to address issues related to scapular elevation.
Exercises such as Superman, bent-over row, rhomboids, and pushups with a plus should be
included to help control upward rotation o the scapula (see Figures 20-36 through 20-39).
Appropriate progression should be ollowed while addressing the healing stages or the
appropriate tissues.
Rehabilit at ion Progression

In the initial stages o rehabilitation, the primary goal is to minimize pain and in ammation
associated with shoulder complex motion. T e therapist should limit activities to midrange
exercises and incorporate the use o therapeutic modalities along with the use o NSAID
intervention rom the physician. Ultrasound is o ten use ul or increasing blood ow and
acilitating the process o healing. Occasionally a shoulder sling or gure 8 strap can help
minimize stress at the joint. During this phase o the rehabilitation progression, the thera-
pist should identi y the sport-speci c needs o the patient so as to tailor the later phases o
rehabilitation to the patient’s demands. T e patient should also continue to work on exer-
cises that maintain cardiorespiratory tness.
When the pain and in ammation have been controlled, the patient should gradually
engage in a controlled increase o stress to the tissues o the joint. T is is a good time to
begin low-grade joint mobilizations resisted exercises or the muscles attaching to the clav-
icle. Exercises in this phase are best done in the midrange to minimize pain. As the patient’s
tolerance increases, the resistance and ROM can be increased. During this phase it is also
important to address any limitations there might be in the patient’s ROM. Emphasis should
be placed on restoring the normal mechanics o the shoulder complex during shoulder
movements.
As the patient begins to enter the pain- ree stages o the progression, the therapist
should gradually incorporate sport-speci c dem ands into the exercise program. Exam -
ples o this are PNF with rubber tubing or the gol er (see Figures 20-55 and 20-56); Stair
Clim ber with eet on chair or the gym nast (see Figure 20-44); and rowing machine or
the rower.
Crit eria for Ret urning t o Full Act ivit y

T e patient may return to ull activity when (a) the rehabilitation program has been pro-
gressed to the appropriate time and stress or the speci c demands o the patient’s sport;
(b) the patient shows improved strength in the muscles used to protect the SC joint when
compared to the uninjured side; and (c) the patient no longer has associated pain with
movements o the shoulder complex that will inevitably occur with the demands o their
sport.
Acromioclavicular Joint Sprains

Pat homechanics
T e acromioclavicular (AC) joint is composed o a bony articulation between the clavicle
and the scapula. T e so t tissues included in the joint are the hyaline cartilage coating the
ends o the bony articulations, a brocartilaginous disc between the 2 bones, the AC liga-
ments, and the costoclavicular ligaments. T ere have been 2 con icting papers regarding
the motion available at the joint. Codman reported little movement at the joint, whereas
Inman reported exactly the opposite.22,48 Multiple authors have reported degenerative
changes at the AC joint by age 40 years in the average healthy adult.29,102
T e AC joint provides the bridge between the clavicle and the scapula. When an injury
occurs to the joint, all so t tissue should be considered in the rehabilitation process. An
elaborate grading system has been reported to categorize injuries based on the so t tissue
that is involved in the injury ( able 20-1).99 T rough evaluation by X-ray, the patient’s injury
should be categorized so as to provide the therapist with a guideline or rehabilitation.
Injury Mechanism
ype I or type II AC joint sprains are most commonly seen in athletics as a result o a direct
all on the point o the shoulder with the arm at the side in an adducted position or all-
ing on an outstretched arm. T e injury mechanism or type III and type IV sprains usually
involves a direct impact that orces the acromion process downward, backward, and inward
while the clavicle is pushed down against the rib cage. T e impact can produce a num-
ber o injuries: (a) racture o the clavicle; (b) AC joint sprain; (c) AC and coracoclavicular
joint sprain; or (d) a combination o the previous injury with concomitant muscle tearing
o the deltoid and trapezius at their clavicular attachments.3 Another possible mechanism
or injury to the AC joint is repetitive compression o the joint o ten seen in weight li ting.106

Management o AC injuries is dependent on the type o injury.40 Age, level o play, and the
demand on the patient can also actor into the management o this injury. Most physicians
pre er to handle type I and type II injuries conservatively, but some authors suggest that
type I and type II injuries can cause urther problems to the patient later in li e.6,26 T ese
injuries might require surgical excision o the distal 2 cm o the clavicle. T e therapist should
consider when developing a treatment plan (a) the stability o the AC joint; (b) the amount
o time the patient was immobilized; (c) pain, as a guide or the type o exercises being
used; and (d) the so t tissue that was involved in the injury. Rehabilitation o these injuries
should ocus on strengthening the deltoid and trapezius muscles. Additional strengthening
o the clavicular bers o the pectoralis major should also be done. Other muscles that help
restore the proper mechanics to the shoulder complex should also be done.
Type I reatment or the type I injury consists o ice to relieve pain and a sling to sup-
port the extremity or several days. T e amount o time in the sling usually depends on
the patient’s ability to tolerate pain and begin carrying their involved extremity with the
Table 20-1 Acro mio clavicular Sprain Classi catio n
Type I
• Sprain of the AC ligaments
• AC ligament intact
• Coracoclavicular ligament, deltoid and trapezius muscles intact
Type II
• AC joint disrupted with tearing of the AC ligament
• Coracoclavicular ligament sprained
• Deltoid and trapezius muscles intact
Type III
• AC ligament disrupted
• AC joint displaced and the shoulder complex displaced inferiorly
• Coracoclavicular ligament disrupted with a coracoclavicular interspace 25% to 100%
greater than the normal shoulder
• Deltoid and trapezius muscles usually detached from distal end of the clavicle
Type IV
• AC ligaments disrupted with the AC joint displaced and the clavicle anatomically
displaced posteriorly through the trapezius muscle
• Coracoclavicular ligaments disrupted with wider interspace
• Deltoid and trapezius muscles detached
Type V
• AC and coracoclavicular ligaments disrupted
• AC joint dislocated and gross displacement between the clavicle and the scapula
• Deltoid and trapezius muscles detached from distal end of the clavicle
Type VI
• AC and coracoclavicular ligaments disrupted
• Distal clavicle inferior to the acromion or the coracoid process
• Deltoid and trapezius muscles detached from distal end of the clavicle
appropriate posture. T e therapist can have the patient begin active assisted ROM immedi-
ately and then incorporate isometric exercises to the muscles with clavicular attachments.
T is will help restore the appropriate carrying posture or the involved upper extremity.
When the patient is able to remove the sling, the therapist should increase the exercise
program to incorporate PRE exercises or the muscles with clavicular attachments and add
exercises to encourage appropriate scapular motion. T is will help prevent related shoulder
discom ort due to poor glenohumeral mechanics a ter return to activity.
Type II T e treatment or type II injuries is also nonsurgical. Because this type o injury
to the AC joint involves complete disruption o the AC ligaments, immobilization plays a
greater role in the treatment o these patients. T ere is no consensus as to the duration o
immobilization. Some authors recommend 7 to 14 days; others suggest using a sling that
not only supports the upper extremity but depresses the clavicle.1,106 T is debate is ueled
by disagreements regarding the time it takes the body to produce collagen and bridge the
gap le t rom the injury. It has been reported that tissue mobilized too early shows a greater
amount o type III collagen than the stronger type I collagen.53 T e time needed to heal
the so t tissues involved in this injury must be considered prior to beginning exercises that
stress the injury. Heavy li ting and contact sports should be avoided or 8 to 12 weeks.
Type III Many authors recommend a nonoperative approach or this type o injury, most
agreeing that a sling is adequate or allowing the patient to rest com ortably.3 Use o this
nonoperative technique is reported to have limited success. Cox reported improved results
without support o the arm in 62% o his patients, whereas only 25% had relie a ter 3 to
6 weeks o immobilization and a sling.26
Operative management o this type o injury can be summarized with the ollowing
options:
1. Stabilization o clavicle to coracoid with a screw.
2. Resection o distal clavicle.
3. ransarticular AC xation with pins.
4. Use o coracoclavicular ligament as a substitute AC ligament.
a t et al ound superior results with coracoclavicular xation. T ey ound that patients
with AC xation had a higher rate o posttraumatic arthritis than those managed with a
coracoclavicular screw.112
Type IV, V, and VI ypes IV, V, and VI injuries require open reduction and internal xa-
tion. Operative procedures are designed to attempt realignment o the clavicle to the scap-
ula. T e immobilization or this type o injury is longer and there ore the rehabilitation time
is longer. A ter immobilization, the concerns are similar to those previously discussed.

Early in the rehabilitation progression, the therapist should be concerned with application
o cold therapy and pressure or the rst 24 to 48 hours to control local hemorrhage. Fit-
ting the patient or a sling is also important to control the patient’s pain. ime in the sling
depends on the severity o the injury. A ter the patient has been seen by a physician or
dif erential diagnosis, the rehabilitation progression should be tailored to the type o sprain
according to the diagnosis.
ypes I, II, and III sprains should be handled similarly at rst, with the time o pro-
gression accelerated with less-severe sprains. Exercises should begin with encouraging
the patient to use the involved extremity or activities o daily living activities and gentle
range-o -motion exercises. Return o normal ROM in the patient’s shoulder is the rst
objective goal. T e patient can also begin isometric exercises to maintain or restore muscle
unction in the shoulder. T ese exercises can be started while the patient is in the sling.
Once the sling is removed, pendulum exercises can be started to encourage movement.
In type III sprains, the therapist should hold of doing passive ROM exercises in the end
ranges o shoulder elevation or the rst 7 days. T e patient should have ull passive ROM
by 2 to 3 weeks. Once the patient has ull active ROM, a program o progressive resistive
exercises should begin. Strengthening o the deltoid and upper trapezius muscles should
be emphasized. T e therapist should evaluate the patient’s shoulder mechanics to identi y
problems with neuromuscular control and address speci c de ciencies as noted. As the
patient regains strength in the involved extremity, sport-speci c exercises should be incor-
porated into the rehabilitation program. Gradual return to activity should be supervised by
the patient’s coach and therapist.
In the case o types IV, V, and VI AC sprains, a postsurgical progression should be ol-
lowed. T e therapist should design a program that is broken down into 4 phases o rehabili-
tation with the goal o returning the patient to the patient’s activity as quickly as possible.3
Contact with the physician is important to determine the time rame in which each phase
may begin. Common surgeries or this injury include open reduction with pin or screw xa-
tion and/ or acromioplasty.
T e early stage o rehabilitation should be designed with the goal o reestablishing
pain- ree ROM, preventing muscle atrophy, and decreasing pain and in ammation. Range-
o -motion exercises may include Codman’s exercises (see Figure 20-6), rope and pulley
exercises (see Figure 20-9), L-bar exercises (see Figures 20-11 to 20-16), and sel -capsular
stretches (see Figures 20-17 and 20-19). Strengthening exercises in this phase may include
isometrics in all o the cardinal planes and isometrics or medial and lateral rotation o the
glenohumeral joint at 0 degrees o elevation (see Figure 20-20).
As rehabilitation progresses, the therapist has the goal o regaining and improving
muscle strength, normalizing arthrokinematics, and improving neuromuscular control o
the shoulder complex. Prior to advancing to this phase, the patient should have ull ROM,
minimal pain and tenderness, and a 4/ 5 manual muscle test or internal rotation, external
rotation, and exion. Initiation o isotonic PRE exercises should begin. Shoulder medial
and lateral rotation (see Figures 20-31 and 20-32), shoulder exion and abduction to 90
degrees (see Figures 20-26 and 20-28), scaption (see Figure 20-33), bicep curls, and triceps
extensions should be included. Additionally, a program o scapular stabilizing exercises
should begin. Exercises should include Superman exercises (see Figure 20-36), rhomboids
exercises (see Figure 20-38), shoulder shrugs (see Figure 20-35), and seated pushups (see
Figure 20-42). o help normalize arthrokinematics o the shoulder, complex joint mobiliza-
tion techniques should be used or the glenohumeral, AC, SC, and scapulothoracic joints
(see Figures 13-10 to 13-20). o complete this phase the patient should begin neuromuscu-
lar control exercises (see Figures 20-59 to 20-67), trunk exercises, and a low-impact aerobic
exercise program.
During the advanced strengthening phase o rehabilitation, the goals should be to
improve strength, power, and endurance o muscles as well as to improve neuromuscular
control o the shoulder complex, and preparing the patient to return to sport-speci c activi-
ties. Prior to advancing to this phase, the therapist should use the criteria o ull pain- ree
ROM, no pain or tenderness, and strength o 70% compared to the uninvolved shoulder.
T e emphasis in this phase is on high-speed strengthening, eccentric exercises, and multi-
planar motions. T e patient should advance to surgical tubing exercises (see Figure 20-45),
plyometric exercises (see Figures 20-46 to 20-51), PNF diagonal strengthening (see Fig-
ures 20-53 to 20-58), and isokinetic strengthening exercises (see Figure 20-52).
When the patient is ready to return to activity, the therapist should progressively
increase activities that prepare the patient or a ully unctional return. An interval program
o sport-speci c activities should be started. Exercises rom stage III should be continued.
T e patient should progressively increase the time o participation in sport-speci c activi-
ties as tolerated. For contact and collision sport patients, the AC joint should be protected.

Prior to returning to ull activity the patient should have ull ROM and no pain or tenderness.
Isokinetic strength testing should meet the demands o the patient’s sport, and the patient
should have success ully completed the nal phase o the rehabilitation progression.
Clavicle Fract ures

Pat homechanics
Clavicle ractures are one o the most common ractures in sports. T e clavicle acts as a strut
connecting the upper extremity to the trunk o the body.31 Forces acting on the clavicle are
most likely to cause a racture o the bone medial to the attachment o the coracoclavicular
ligaments.4 Intact AC and coracoclavicular ligaments help keep ractures nondisplaced and
stabilized.
Injury Mechanism
In athletics, the mechanism or injury o ten depends on the sport played. T e mechanism
can be direct or indirect. Fractures can result rom a all on an outstretched arm, a all or
blow to the point o the shoulder, or less commonly a direct blow as in stick sports like
lacrosse and hockey.95

Early identi cation o the racture is an important actor in rehabilitation. I stabilization
occurs early, with minimal damage and irritation to the surrounding structures, the likeli-
hood o an uncomplicated return to sports is increased. Other actors in uencing the likeli-
hood o complications are injuries to the AC, coracoclavicular, and SC ligaments. reatment
or clavicle ractures includes approximation o the racture and immobilization or 6 to
8 weeks. Most commonly a gure-8 wrap is used, with the involved arm in a sling.
When designing a rehabilitation program or a patient who has sustained a clavicle
racture, the therapist should consider the unction o the clavicle. T e clavicle acts as a
strut of ering shoulder girdle stability and allowing the upper extremity to move more reely
about the thorax by positioning the extremity away rom the body axis.42 Mobility o the
clavicle is there ore very important to normal shoulder mechanics. Joint mobilization tech-
niques are started immediately a ter the immobilization period in order to restore normal
arthrokinematics. T e clavicle also serves as an insertion point or the deltoid, upper trape-
zius, and pectoralis major muscles, providing stability and aiding in neuromuscular control
o the shoulder complex. It is important to address these muscles with the appropriate exer-
cises in order to restore normal shoulder mechanics.

For the rst 6 to 8 weeks, the patient is immobilized in the gure-8 brace and sling. I good
approximation and healing o the racture is occurring at 6 weeks, the patient may begin
gentle isometric exercises or the upper extremity. Utilization o the involved extremity
below 90 degrees o elevation should be encouraged to prevent muscle atrophy and exces-
sive loss o glenohumeral ROM. A ter the immobilization period, the patient should begin
a program to regain ull active and passive ROM. Joint mobilization techniques are used
to restore normal arthrokinematics (see Figures 13-10 to 13-12). T e patient may continue
to wear the sling or the next 3 to 4 weeks while regaining the ability to carry the arm in an
appropriate posture without the gure-8 brace. T e patient should begin a strengthening
program utilizing progressive resistance as ROM improves. Once ull ROM is achieved, the
patient should begin resisted diagonal PNF exercises and continue to increase the strength
o the shoulder complex muscle, including the periscapular muscles, to enable normal neu-
romuscular control o the shoulder.
Crit eria for Ret urn

T e patient may return to activity when the racture is clinically united, ull active and pas-
sive ROM is achieved, and the patient has the strength and neuromuscular control to meet
the demands o their sport.
Glenohumeral Dislocat ions/Inst abilit ies

(Surgical Versus Nonsurgical Rehabilit at ion)
Pat homechanics
Dislocations o the glenohumeral joint involve the temporary displacement o the humeral
head rom its normal position in the glenoid labral ossa. From a biomechanical perspective,
the resultant orce vector is directed outside the arc o contact in the glenoid ossa, creating
a dislocating moment o the humeral head by pivoting about the labral rim.32
Shoulder dislocations account or up to 50% o all dislocations. T e inherent insta-
bility o the shoulder joint necessary or the extreme mobility o this joint makes the gle-
nohumeral joint susceptible to dislocation. T e most common kind o dislocation is that
occurring anteriorly. Posterior dislocations account or only 1% to 4.3% o all shoulder dis-
locations. In erior dislocations are extremely rare. O dislocations caused by direct trauma,
85% to 90% are recurring.104
In an anterior glenohumeral dislocation, the head o the humerus is orced out o its
anterior capsule in an anterior direction past the glenoid labrum and then downward to
rest under the coracoid process. T e pathology that ensues is extensive, with torn capsu-
lar and ligamentous tissue, possibly tendinous avulsion o the rotator cuf muscles, and
pro use hemorrhage. A tear or detachment o the glenoid labrum might also be present.
Healing is usually slow, and the detached labrum and capsule can produce a permanent
anterior de ect on the glenoid labrum called a Bankart lesion. Another de ect that can occur
with anterior dislocation can be ound on the posterior lateral aspect o the humeral head
called a Hill-Sachs lesion . T is is caused by compressive orces between the humeral head
and the glenoid rim while the humeral head rests in the dislocated position. Additional
complications can arise i the head o the humerus comes into contact with and injures the
brachial nerves and vessels. Rotator cuf tears can also arise as a result o the dislocation.
T e bicipital tendon might also sublux rom its canal as the result o a rupture o the trans-
verse ligament.104
Posterior dislocations can also result in signi cant so t-tissue damage. ears o the pos-
terior glenoid labrum are common in posterior dislocation. A racture o the lesser tubercle
can occur i the subscapularis tendon avulses its attachment.
Glenohumeral dislocations are usually very disabling. T e patient assumes an obvious
disabled posture and the de ormity itsel is obvious. A positive sulcus sign is usually present
at the time o the dislocation, and the de ormity can be easily recognized on an X-ray. As
detailed above, the damage can be extensive to the so t tissue.
Injury Mechanism
When discussing the mechanism o injury or dislocations o the glenohumeral joint, it is
necessary to categorize the injury as traumatic or atraumatic, and anterior or posterior. An
anterior dislocation o the glenohumeral joint can result rom direct impact on the posterior
or posterolateral aspect o the shoulder. T e most common mechanism is orced abduction,
external rotation, and extension that orces the humeral head out o the glenoid cavity.73 An
arm tackle in ootball or rugby or abnormal orces created in executing a throw can produce
a sequence o events resulting in dislocation. T e injury mechanism or a posterior gleno-
humeral dislocation is usually orced adduction and internal rotation o the shoulder or a
all on an extended and internally rotated arm.
T e two mechanisms described or anterior dislocation can be categorized as trau-
matic or atraumatic. T e ollowing acronyms have been described to summarize the two
mechanisms.56
Traumatic Atraumatic
Unidirectional Multidirectional
Bankart lesion Bilateral involvement
Surgery required Rehabilitation ef ective
In erior capsular shi t recommended
T e AMBRI group can be characterized by subluxation or dislocation episodes with-
out trauma, resulting in a stretched capsuloligamentous complex that lacks end-range
stabilizing ability. Several authors report a high rate o recurrence or dislocations, espe-
cially those in the UBS category.100

Managem ent o shoulder dislocation depends on a num ber o actors that need to be
identi ed. Mechanism, chronology, and direction o instability all need to be consid-
ered in the developm ent o a conservatively managed rehabilitation program. No single
rehabilitation program is an absolute solution or success in the treatm ent o a shoul-
der dislocation. T e therapist should thoroughly evaluate the injury and discuss those
objective ndings with the team physician. T e initial concern in rehabilitation ocuses
on maintaining appropriate reduction o the glenohum eral joint. T e patient is im m obi-
lized in a reduced position or a period o tim e, depending on the type o managem ent
used in the reduction (surgical versus nonsurgical). For the purpose o this section, the
discussion will continue with conservative managem ent in mind. T e principles o reha-
bilitation, however, remain constant regardless o whether the physician’s managem ent
is surgical or nonsurgical. Surgical rehabilitation should be based on the healing tim e o
tissue af ected by the surgery. T e lim itations o m otion in the early stages o rehabilita-
tion should also be based on surgical xation. It is extremely im portant that the therapist
and physician com municate prior to the start o rehabilitation. A ter the im m obilization
period, the rehabilitation program should be ocused on restoring the appropriate axis o
rotation or the glenohum eral joint, optim izing the stabilizing muscle’s length–tension
relationship, and restoring proper neuromuscular control to the shoulder com plex. In
the uninjured shoulder com plex with intact capsuloligam entous structures, the glenohu-
meral joint maintains a tight axis o rotation within the glenoid ossa. T is is accomplished
dynam ically with com plex neuromuscular control o the periscapular muscles, rotator
cuf muscles, and intact passive structures o the joint. Because the extent o damage in
this type o injury is variable, the exercises em ployed to restore these normal m echanics
should also vary.99 As the therapist helps the patient regain ull ROM, a sa e zone o posi-
tioning should be ollowed. Starting in the plane o the scapula is sa e because the axis o
rotation or orces acting on the joint all in the center o this plane. T e least-provocative
position is som ewhere between 20 and 55 degrees o scapular plane abduction. Keep-
ing the hum erus below 55 degrees prevents subacrom ial im pingem ent, while avoiding
ull adduction m inim izes excessive tension across the supraspinatus/ coracohum eral
and/ or capsuloligam entous com plex. As ROM im proves, the therapist should progress
the exercise program into positions outside the sa e zone, accom m odating the demands
that the patient will need to m eet. Speci c strengthening should be given to address the
muscles o the shoulder com plex responsible or maintaining the axis o rotation, such
as the supraspinatus and rotator cuf muscles. T e periscapular muscles should also be
addressed in order to provide the rotator cuf muscles with their optimal length–tension
relationship or m ore e cient usage. In the later stages o rehabilitation, neuromuscular
control exercises are incorporated with sport-speci c exercises to prepare the patient or
return to activity.56

T e rst step in a success ul rehabilitation program is the removal o the patient rom activi-
ties that may put the patient at risk or reinjury to the glenohumeral joint. A reasonable time
rame or return to activity is approximately 12 weeks, with unrestricted activity coming
closer to 20 weeks. T is is variable, depending on the extent o so t-tissue damage and the
type o intervention chosen by the patient and physician. Some exercises previously used by
the patient might produce undesired orces on noncontractile tissues and need to be modi-
ed to be per ormed sa ely. Pushups, pull-downs, and the bench press are per ormed with
the hands in close and avoiding the last 10 to 20 degrees o shoulder extension. Pull-downs
Table 20-2 Exe rcise Mo di catio n Pe r Dire ctio n o f Instability
Dire ctio n o f Exe rcise s to Be Mo di e d

Instability Po sitio n to Avo id o r Avo ide d
Anterior Combined position of external Fly, pull-down, pushup, bench press,

rotation and abduction military press
Posterior Combined position of internal Fly, pushup bench press,

rotation, horizontal adduction, weightbearing exercises
and exion
Inferior Full elevation, dependent arm Shrugs, elbow curls, military press
and military presses are per ormed with wide bars and machines are kept in ront rather
than behind the head. Supine y exercises are limited to 30 degrees in the coronal plane
while maintaining glenohumeral internal rotation. able 20-2 provides urther modi ca-
tions dependent on directional instability.3
During phase 1 the patient is immobilized in a sling. T is lasts or up to 3 weeks with
rst-time dislocations. T e goal o this phase is to limit the in ammatory process, decrease
pain, and retard muscle atrophy. Passive ROM exercises can be initiated along with low-
grade joint mobilization techniques to encourage relaxation o the shoulder musculature.
Isometric exercises are also started. T e patient begins with submaximal contractions and
increases to maximal contractions or as long as 8 seconds. T e protective phase is a good
time to initiate a scapulothoracic exercise program, avoiding elevated positions o the upper
extremity that put stability at risk. Patients should begin an aerobic training regime with the
lower extremity, such as stationary biking.
Phase 2 begins a ter the patient has been removed rom the sling. T is phase lasts rom
3 to 8 weeks postinjury and ocuses on ull return o active ROM. T e program begins with
the use o an L-bar per orming active assistive ROM (see Figures 20-11 to 20-16). Manual
therapy techniques can also begin using PNF techniques to help reestablish neuromus-
cular control (see Figures 12-3 to 12-10). Exercises with the hands on the ground can help
begin strengthening the scapular stabilizers more aggressively. T ese exercises should
begin on a stable sur ace like a table, progressing the amount o weight bearing by advanc-
ing rom the table to the ground (see Figure 20-59). Advancing to a less stable sur ace like a
biomechanical ankle plat orm system (BAPS) board (see Figure 20-62) or stability ball (see
Figure 20-63) will also help reestablish neuromuscular control.
At 6 to 12 weeks the therapist should gradually enter phase 3 o the rehabilitation pro-
gression. T e goal o this phase is to restore normal strength and neuromuscular control.
Prophylactic stretching is done, as ull ROM should already be present. Scapular and rota-
tor cuf exercises should ocus on strength and endurance. Weightbearing exercises should
be made more challenging by adding motion to the demands o the stabilization. Scapular
exercises should be per ormed in the weight room with guidance rom the therapist in order
to meet the challenge o the patient’s strength. Weight shi ting on a Fitter (see Figure 20-61)
and closed-kinetic-chain strengthening on a stair climber (see Figure 20-44) or endurance
are started. Strengthening exercises progress rom PRE to plyometric. Rotator cuf exercises
using surgical tubing with emphasis on eccentrics are added.2 Progression to multiangle
exercises and sport-speci c positioning is started. T e Body Blade is a good rehabilitation
tool or this phase (see Figure 20-67), progressing rom static to dynamic stabilization and
single-position to multiplanar dynamic exercises.
Phase 4 is the unctional progression. Patients are gradually returned to their sport with
interval training and progressive activity increasing the demands on endurance and stabil-
ity. T is can last as long as 20 weeks, depending on the patient’s shoulder strength, lack o
pain, and ability to protect the involved shoulder. T e physician should be consulted prior
to ull return to activity.
Crit eria for Ret urn t o Act ivit y

At 20 to 26 weeks, the patient should be ready or return to activity. T is decision should be
based on (a) ull pain- ree ROM; (b) normal shoulder strength ; (c) pain- ree sport-speci c
activities; and (d) ability to protect the patient’s shoulder rom reinjury. Some therapist and
physicians like the patient to use a protective shoulder harness during participation.
Mult idirect ional Inst abilit ies of t he Glenohumeral Joint

Pat homechanics
Multidirectional instabilities are an inherent risk o the glenohumeral joint. T e shoulder
has the greatest ROM o all the joints in the human body. T e bony restraints are minimal,
and the orces that can be generated in overhead motions o throwing and other athletic
activities ar exceed the strength o the static restraints o the joint. Attenuation o orce is
multi actorial, with time, distance, and speed determining orces applied to the joint. T us,
stability o the joint must be evaluated based on the patient’s ability to dynamically con-
trol all o these actors in order to have a stable joint. In cases o multidirectional instabil-
ity, there are 2 categories or pathology: atraumatic and traumatic. T e atraumatic category
includes patients who have congenitally loose joints or who have increased the demands
on their shoulder prior to having developed the muscular maturity to meet these demands.
When orces are generated at the glenohumeral joint that the stabilizing muscles are unable
to handle (this occurs most commonly during the deceleration phase o throwing), the
humeral head tends to translate anteriorly and in eriorly into the capsuloligamentous struc-
tures.123 Over time, repetitive microtrauma causes these structures to stretch. Lephart et al
described the essential importance o tension in the anterior capsule o the glenohumeral
joint as a protective mechanism against excessive strain in these capsuloligamentous struc-
tures.65 T ey theorized that the loss o this protective re ex joint stabilization can increase
the potential or continuing shoulder injury. Proprioceptive de cits have been identi ed in
individuals with multidirectional instability4 and even generalized laxity.10 Increased trans-
lation o the humeral head also increases the demand on the posterior structures o the gle-
nohumeral joint, leading to repetitive microtrauma and breakdown o those so t tissues.123
In this type o instability there will usually be some in erior laxity, leading to a positive sul-
cus sign. Although the anterior glenoid labrum is usually intact during the early stages o
this instability, splitting and partial detachment can develop.3 T e patient usually has some
pain and clicking when the arm is held by the side. Any symptoms and signs associated with
anterior or posterior recurrent instability may be present.
Injury Mechanism
It is generally believed that the cause o multidirectional instability is excessive joint volume
with laxity o the capsuloligamentous complex. In the patient, this laxity might be an inher-
ent condition that becomes more pronounced with the superimposed trauma o sport. T is
type o instability might also occur as a result o extensive capsulolabral trauma in patients
who do not appear to have laxity o other joints.95

T e rehabilitation concerns or multidirectional instability are similar to those already
discussed in relation to shoulder instabilities. T e complexity o this program is increased
because o the addition o in erior instability. T e success o the program is o ten deter-
mined by the patient’s tissue status and compliance.109 Additionally, this program empha-
sizes the anterior and posterior musculature. T ese muscles working together are re erred
to as orce couples and are believed to be essential stabilizers o the joint.16 he rehabilita-
tion program should also address the neuromuscular control o these muscles to promote
dynamic stability.43 Compliance is o ten an extremely important actor in maintaining good
results with this type o instability. T e patient must continue to do the exercise program
even a ter symptoms have subsided. I the patient is not compliant, subluxation usually
recurs. For cases where conservative treatment is not success ul, Neer recommended an
in erior capsular shi t surgical procedure that has proven success ul in restoring joint stabil-
ity when used in conjunction with a rehabilitation program.85
Surgical m anagem ent o m ultidirectional instability rem ains controversial.36
Arthroscopic thermal capsulorrhaphy, when per ormed alone, has allen out o avor
as the surgery o choice as a result o high ailure rates and complications.25,45,96 T e role
that the rotator interval plays with regard to instability has come to the ore ront. Although
the integrity o the rotator interval and its relationship to shoulder stability is agreed
upon,18,25,96 the closure o the rotator interval in unstable shoulders remains an orthope-
dic dilem ma. Although the dilemma is ongoing as to whether this closure is per orm ed
arthroscopically or via an open incision, or in combination with thermal techniques, there
are several actors that can be agreed upon. T e rst is that the redundant capsule needs to
be imbricated, the labrum, reverse Bankart, or reverse bony Bankart need to be repaired,
and the rotator interval needs to be closed.10,12 Wilk et al131 suggest a postoperative reha-
bilitation program that is based on 6 actors: (a) type o instability; (b) patient’s in amma-
tory response to surgery; (c) concomitant surgical procedures; (d) precautions ollowing
surgery; (e) gradual rate o progression; and ( ) team approach to treatm ent. T ese ac-
tors determine the type and aggressiveness o the program. First, it must be determined
whether the instability is congenital or acquired. Congenital instabilities should be treated
m ore conservatively. Second, some patients respond to surgery with excessive scarring
and proli eration o collagen ground tissue. Progression should be adjusted weekly based
on assessing capsular end eel. T e third actor takes into account any other procedures
per ormed at the time o surgery. Precautions should be ollowed based on the tissue heal-
ing time o the other procedures. Surgical precautions also should be communicated to
the therapist based on the tissues involved; passive range o m otion (PROM) a ter sur-
gery should be cautious. T e authors suggest conservative PROM progression or the rst
8 weeks postsurgery. T e gradual progression ( actor 5) contrasts to one that moves aster
and then slows down. T e speed o progression should be based on a weekly scheduled
assessment o capsular end eel and progress. T e sixth actor ensures a success ul reha-
bilitation outcome by open and continuous communication between the patient, surgeon,
and therapist.131

T e rehabilitation program should begin with reestablishing muscle tone and proper
scapulothoracic posture. T is helps provide a steady base with appropriate length–tension
relationships or the anterior and posterior muscles o the shoulder complex acting as orce
couples. Strengthening o the rotator cuf muscles in the plane o the scapula should prog-
ress to higher resistance, starting at 0 degrees o shoulder elevation. As the patient becomes
asymptomatic, the therapist should incorporate an emphasis on neuromuscular control
exercises like PNF, rhythmic stabilization, and weightbearing activity to establish coacti-
vation at the glenohumeral joint.28 Sport-speci c training can then be added, rst in the
rehabilitation setting and then in the competitive setting. For success ul results, the patient
might have to continue a program o maintenance or neuromuscular control or as long as
they wish to be asymptomatic.
Shoulder Impingement
Pat homechanics
Shoulder impingement syndrome was rst identi ed by Dr. Charles Neer,85 who observed
that impingement involves a mechanical compression o the supraspinatus tendon, the
subacromial bursa, and the long head o the biceps tendon, all o which are located under
the coracoacromial arch. T is syndrome has been described as a continuum during which
repetitive compression eventually leads to irritation and in ammation that progresses to
brosis and eventually to rupture o the rotator cuf . Neer has identi ed 3 stages o shoulder
impingement:
Stage I
• Seen in patients younger than 25 years o age with report o repetitive overhead
activity
• Localized hemorrhage and edema with tenderness at supraspinatus insertion and
anterior acromion
• Pain ul arc between 60 and 119 degrees; increased with resistance at 90 degrees
• Muscle tests revealing weakness secondary to pain
• Positive Neer or Hawkins-Kennedy impingement signs (Figures 20-68 and 20-69)
• Normal radiographs, typically
• Reversible; usually resolving with rest, activity modi cation, and rehabilitation
program
Stage II
• Seen in patients 25 to 40 years o age with report o repetitive overhead activity
• Many o the same clinical ndings as in stage I
Figure 20-68 Ne e r imping e me nt te st Figure 20-69 Haw kins-Ke nne dy

imping e me nt te st
• Severity o symptoms worse than stage I, progressing to pain with activity and
night pain
• More so t-tissue crepitus or catching at 100 degrees
• Restriction in passive ROM as a result o brosis
• Possibly radiographs showing osteophytes under acromion, degenerative AC joint
changes
• No longer reversible with rest; possibly helped by a long-term rehabilitation
program
Stage III
• Seen in patients older than 40 years o age with history o chronic tendinitis and
prolonged pain
• Many o the same clinical ndings as stage II
• ear in rotator cuf usually less than 1 cm
• More limitation in active and passive ROM
• Possibly a prominent capsular laxity with multidirectional instability seen on
radiograph
• Atrophy o in raspinatus and supraspinatus caused by disuse
• reatment typically surgical ollowing a ailed conservative approach
Neer’s impingement theory was based primarily on the treatment o older, nonathletic
patients. T e older population will likely exhibit what has been re erred to as “outside” or
“outlet” impingement.8,85 In outside impingement there is contact o the rotator cuf with
the coracoacromial ligament or the acromion with raying, abrasion, in ammation, brosis,
and degeneration o the superior sur ace o the cuf within the subacromial space. T ere
might also be evidence o degenerative processes, including spurring, decreased joint space
due to brotic changes, and decreased vascularity.
Internal or “nonoutlet” impingement is more likely to occur in the younger overhead
patient. With internal impingement, the subacromial space appears relatively normal. With
humeral elevation and internal rotation, the rotator cuf is compressed between the poste-
rior superior glenoid labrum (or glenoid rim) and the humeral head. Although this com-
pression is a normal biomechanical phenomenon, it can become pathologic in overhead
patients because o the repetitive nature o overhead sports. T e result is in ammation on
the undersur ace o the rotator cuf tendon, posterior superior tears in the glenoid labrum,
and lesions in the posterior humeral head (Bankart lesion).
T e mechanical impingement syndrome, as originally proposed by Neer, has been
re erred to as primary impingement. Jobe and Kvnite have proposed that an unstable shoul-
der permits excessive translation o the humeral head in an anterior and superior direction,
resulting in what has been termed secondary impingement.50 Based on the relationship o
shoulder instability to shoulder impingement, Jobe and Kvnite have proposed an alterna-
tive system o classi cation:50
Group IA
• Found in recreational patients older than 35 years o age with pure mechanical
impingement and no instability
• Positive impingement signs
• Lesions on the superior sur ace o the rotator cuf , possibly with subacromial
spurring
• Possibly some arthritic changes in the glenohumeral joint
Group IB
• Found in recreational patients older than 35 years who demonstrate instability with
impingement secondary to mechanical trauma
• Positive impingement signs
• Lesions ound on the undersur ace o the rotator cuf , superior glenoid, and humeral
head
Group II
• Found in young overhead patients (younger than age 35 years) who demonstrate
instability and impingement secondary to repetitive microtrauma
• Positive impingement signs with excessive anterior translation o humeral head
• Lesions on the posterior superior glenoid rim, posterior humeral head, or anterior
in erior capsule
• Lesions on the undersur ace o the rotator cuf
Group III
• Found in young overhead patients (younger than age 35 years)
• Positive impingement signs with atraumatic multidirectional, usually bilateral,
humeral instabilities
• Demonstrated generalized laxity in all joints
• Humeral head lesions as in group II but less severe
Group IV
• Found in young overhead patients (younger than age 35 years) with anterior instability
resulting rom a traumatic event but without impingement
• Posterior de ect in the humeral head
• Damage in the posterior glenoid labrum
It has also been proposed that wear o the rotator cuf is a result o intrinsic tendon
pathology, including tendinopathy and partial or small complete tears with age-related
thinning, degeneration, and weakening. T is permits superior migration o the humeral
head, leading to secondary impingement, thus creating a cycle that can ultimately lead to
ull-thickness tears.120
A “critical zone” o vascular insu ciency has been proposed to exist in the tendon o
the supraspinatus, which is ound at approximately 1 cm proximal to its distal insertion
on the humerus. It has been hypothesized that when the humerus is adducted and inter-
nally rotated, a “wringing out” o the blood supply occurs in this tendon. Should this occur
repetitively, such as in the recovery phase on a swimming stroke, ultimately irritation and
in ammation may lead to partial or complete rotator cuf tears.97
It is likely that some as yet unidenti ed combination o mechanical, traumatic, degen-
erative, and vascular processes collectively lead to pathology in the rotator cuf .
Injury Mechanism
Shoulder impingement syndrome occurs when there is compromise o the subacromial
space under the coracoacromial arch. When the dynamic and static stabilizers o the
shoulder complex or one reason or another ail to maintain this subacromial space, the
so t-tissue structures are compressed, leading to irritation and in ammation.44 In ath-
letes, impingement most o ten occurs in repetitive overhead activities such as throwing,
I II III
Figure 20-70 Acro mio n shape s
Type I, flat; type II, curved; and type III, hooked.
swimming, serving a tennis ball, spiking a volleyball, or during handstands in gymnastics.

T ere is ongoing disagreement regarding the speci c mechanisms that cause shoulder
impingement syndrome. It has been proposed that mechanical impingement can result
rom either structural or unctional causes. Structural causes can be attributed to existing
congenital abnormalities or to degenerative changes under the coracoacromial arch and
might include the ollowing:
• An abnormally shaped acromion (Figure 20-70). Patients with a type III or hook-
shaped acromion are approximately 70% more likely to exhibit signs o impingement
than those with a at or slightly curved acromion.7
• Inherent capsular laxity compromises the ability o the glenohumeral joint capsule to
act as both a static and a dynamic stabilizer.50
• Ongoing or recurring tendinitis or subacromial bursitis causes a loss o space under
the coracoacromial arch, which can potentially lead to irritation o other, unin amed
structures, setting up a vicious degenerative cycle.106
• Laxity in the anterior capsule due to recurrent subluxation or dislocation can allow
an anterior migration o the humeral head, which can cause impingement under the
coracoid process.126
• Postural malalignments, such as a orward head, round shoulders, and an increased
kyphotic curve that cause the scapular glenoid to be positioned such that the space
under the coracoacromial arch is decreased, can also contribute to impingement.
Functional causes include adaptive changes that occur with repetitive overhead activi-
ties, altering the normal biomechanical unction o the shoulder complex. T ese include
the ollowing:
• Failure o the rotator cuf to dynamically stabilize the humeral head relative to the
glenoid, producing excessive translation and instability. T e in erior rotator cuf
muscles (in raspinatus, teres minor, subscapularis) should act collectively to both
depress and compress the humeral head. In the overhead or throwing patient, the
internal rotators must be capable o producing humeral rotation on the order o 7000
degrees per second.117 T e subscapularis tends to be stronger than the in raspinatus
and teres minor, creating a strength imbalance in the existing orce couple in the
transverse plane. T is imbalance produces excessive anterior translation o the
humeral head. Furthermore, weakness in the in erior rotator cuf muscles creates
an imbalance in the existing orce couple with the deltoid in the coronal plane.
Myers et al demonstrated that patients with subacromial impingement demonstrated

decreased in erior cuf muscle coactivation while excessive activation o the middle
deltoid is present.82 T e deltoid potentially produces excessive superior translation
o the humeral head, decreasing subacromial space. Weakness in the supraspinatus,
which normally unctions to compress the humeral head into the glenoid, allows or
excessive superior translation o the humeral head.74
• Because the tendons o the rotator cuf blend into the joint capsule, we rely on
tension created in the capsule by contraction o the rotator cuf to both statically and
dynamically center the humeral head relative to the glenoid. ightness in the posterior
and in erior portions o the glenohumeral joint capsule causes an anterosuperior
migration o the humeral head, again decreasing the subacromial space. In the
overhead patient, ROM in internal rotation is usually limited by tightness o both the
muscles that externally rotate and the posterior capsule. T ere tends to be excessive
external rotation, primarily due to laxity in the anterior joint capsule.14
• T e scapular muscles unction to dynamically position the glenoid relative to the
humeral head, maintaining a normal length–tension relationship with the rotator
cuf . As the humerus moves into elevation, the scapula should also move so that the
glenoid is able to adjust regardless o the position o the elevating humerus. Weakness
in the serratus anterior, which elevates, upward rotates, and abducts the scapula, or
weakness in the levator scapula or upper trapezius, which elevate the scapula, will
compromise positioning o the glenoid during humeral elevation, inter ering with
normal scapulohumeral rhythm.23 Altered scapular movement patterns commonly
identi ed in patients with subacromial impingement includes decreased upward
rotation, external rotation, and posterior tipping, all o which have the potential to
compromise subacromial space height, contributing to impingement.23,35,69,71,122
• It is critical or the scapula to maintain a stable base on which the highly mobile
humerus can move. Weakness in the rhomboids and/ or middle trapezius, which
unction eccentrically to decelerate the scapula in high-velocity throwing motions,
can contribute to scapular hypermobility. Likewise, weakness in the in erior trapezius
creates an imbalance in the orce couple with the upper trapezius and levator scapula,
contributing to scapular hypermobility.23
• An injury that af ects normal arthrokinematic motion at either the SC joint or the AC
joint can also contribute to shoulder impingement. Any limitation in posterior superior
clavicular rotation and/ or clavicular elevation will prevent normal upward rotation o
the scapula during humeral elevation, compromising the subacromial space.

Management o shoulder impingement involves gradually restoring normal biomechanics
to the shoulder joint in an ef ort to maintain space under the coracoacromial arch during
overhead activities.55,114 T e therapist should address the pathomechanics and the adaptive
changes that most o ten occur with overhead activities.
Overhead activities that involve humeral elevation ( ull abduction or orward exion)
or a position o humeral exion, horizontal adduction, and internal rotation are likely to
increase the pain.68 T e patient complains o dif use pain around the acromion or glenohu-
meral joint. Palpation o the subacromial space increases the pain.
Exercises should concentrate on strengthening the dynamic stabilizers, the rotator cuf
muscles that act to both compress and depress the humeral head relative to the glenoid (see
Figures 20-31 and 20-32).51,81,114 T e in erior rotator cuf muscles in particular should be
strengthened to recreate a balance in the orce couple with the deltoid in the coronal plane.
T e supraspinatus should be strengthened to assist in compression o the humeral head
into the glenoid (see Figures 20-33 and 20-34).113 T e external rotators, the in raspinatus
and teres minor, are generally weaker concentrically but stronger eccentrically than the
internal rotators and should be strengthened to recreate a balance in the orce couple with
the subscapularis in the transverse plane.
T e external rotators and the posterior portion o the joint capsule are tight and tend
to limit internal rotation and should be stretched (see Figures 20-15, 20-17, and 20-19).
Both horizontal adduction and sleeper stretches have been demonstrated ef ective to
stretch the posterior shoulder.62,75 T ere is excessive external rotation because o laxity in
the anterior portion o the joint capsule, and stretching should be avoided. T ere might
be some tightness in both the in erior and the posterior portions o the joint capsule; this
can be decreased by using posterior and in erior glenohumeral joint mobilizations (see
Figures 13-13, 13-14, 13-16, and 13-17).
Strengthening o the muscles that abduct, elevate, and upwardly rotate the scapula
(these include the serratus anterior, upper trapezius, and levator scapula) should also be
incorporated (see Figures 20-35, 20-39, and 20-40). T e middle trapezius and rhomboids
should be strengthened eccentrically to help decelerate the scapula during throwing activi-
ties (see Figures 20-37 and 20-38). T e in erior trapezius should also be strengthened to
recreate a balance in the orce couple with the upper trapezius, acilitating scapular upward
rotation and stability (see Figure 20-36).
Anterior, posterior, in erior, and superior joint mobilizations at both the SC and the
AC joint should be done to assure normal arthrokinematic motion at these joints (see
Figures 13-10 to 13-12).
Strengthening o the lower-extremity and trunk muscles to provide core stability is
essential or reducing the stresses and strains placed on the shoulder and arm, and this
is also important or the overhead patient (see Figure 20-40).

In the early stages o a rehabilitation program, the primary goal o the therapist is to mini-
mize the pain associated with the impingement syndrome. T is can be accomplished by
utilizing some combination o activity modi cation, therapeutic modalities, and appropri-
ate use o NSAIDs.
Initially, the therapist should have a coach evaluate the patient’s technique in per orm-
ing the overhead activity, to rule out aulty per ormance techniques. Once existing per-
ormance techniques have been corrected, the therapist must make some decision about
limiting the activity that caused the problem in the rst place. Activity limitation, however,
does not mean immobilization. Instead, a baseline o tolerable activity should be estab-
lished. T e key is to initially control the requency and the level o the load on the rotator
cuf and then to gradually and systematically increase the level and the requency o that
activity. It might be necessary to initially restrict activity, avoiding any exercise that places
the shoulder in the impingement position, to give the in ammation a chance to subside.
During this period o restricted activity, the patient should continue to engage in exercises
to maintain cardiorespiratory tness. Working on an upper-extremity ergometer will help to
improve both cardiorespiratory tness and muscular endurance in the shoulder complex.
T erapeutic modalities such as electrical stimulating currents and/ or heat and cold
therapy may be used to modulate pain. Ultrasound and the diathermies are most use ul or
elevating tissue temperatures, increasing blood ow, and acilitating the process o healing.
NSAIDs prescribed by the team physician are use ul not only as analgesics, but also or their
long-lasting antiin ammatory capabilities.
Once pain and in ammation have been controlled, exercises should concentrate on
strengthening the dynamic stabilizers o the glenohumeral joint, stretching the in erior and
posterior portions o the joint capsule and external rotators, strengthening the scapular
muscles that collectively produce normal scapulohumeral rhythm, and maintaining nor-
mal arthrokinematic motions o the AC and SC joints.
REH A BI LI TATI O N P LA N
ARTHROSCOPIC ANTERIOR CAPSULOLABRAL in a restricted range of motion. Shoulder rotation is done
REPAIR OF THE SHOULDER COMPLEX in 20 degrees of abduction; external rotation (ER) is to
30 degrees and internal rotation (IR) is allowed to 25 or
30 degrees for the rst 3 weeks, advancing to 50 degrees
INJURY SITUATION A 27-year-old male baseball player
by week 6. Passive forward elevation (PFE) is progressed to
returns to the throwing rotation of his baseball club after
90 degrees for the rst 3 weeks, advancing to 135 degrees
having elbow surgery 5 months earlier. Three weeks after
by 6 weeks. Active assisted forward elevation (AFE) can be
returning, he starts complaining of posterior shoulder
progressed between weeks 3 and 6 to 115 degrees. Moist
pain. After 3 months of using ice and nonsteroidal antiin-
heat can be used prior to therapy after 10 days. Passive
ammatory drug (NSAID) therapy, he begins to have dif-
range of motion (ROM) is performed by the therapist and
culty with his velocity and control of his pitches, and is
active-assisted ROM by the patient.
now also having anterior shoulder pain near the bicipital
During this phase, ROM is progressed based on the
groove. The patient is diagnosed by an orthopedist with
end feel the therapist gets when evaluating the patient.
posterior impingement secondary to multidirectional
With a hard end feel, the therapist may choose to be more
instability of the glenohumeral joint. An MRI revealed an
aggressive, making sure not to surpass the ROM guide-
additional lesion of the superior labral attachment, and
lines. A soft end feel dictates a slower progression. Range
some degenerative tearing of the rotator cu .
of motion is not the main focus of this phase; healing of the
SIGNS AND SYMPTOMS The patient complains of pos- repaired tissue is the prime goal. The minimally invasive
terior cu pain whenever he externally rotates. He has 165 nature of arthroscopy leads to less pain and in ammation.
degrees of external rotation and 35 degrees of internal Therefore, it is important to stress to the patient the impor-
rotation. Horizontal adduction of the humerus is only 15 tance of protection. Educating the patient to minimize load
degrees. Tenderness is present along the posterior glenohu- to less than 5 pounds and limiting repetitive activities is
meral joint line. He also has a positive O’Brien test for supe- very important. ROM of the patient’s hips is also addressed
rior labral pathology (SLAP lesion), apprehension sign, and during this phase. Aggressive stretching and core stability
relocation test. The patient is evaluated for other factors that exercises may be started to maintain an increased state of
have stressed the throwing motion. Evaluation revealed an exibility of the pitcher’s total rotational capabilities.
extremely tight hip exibility pattern: bilateral hip exion of Shoulder strengthening begins early in this phase
70 degrees, hip internal rotation of 15 degrees bilaterally, with rhythmic stabilization, scapular stabilizing exercises,
and hip external rotation of 50 degrees bilaterally. isometric exercises for the rotator cu muscles, and pro-
prioceptive neuromuscular facilitation (PNF) control exer-
MANAGEMENT PLAN The patient underwent ar- cises in a restricted range of motion. Although scapular
throscop ic anterior capsulolabral repair of the shoulder to stabilizing exercises are begun, protraction should not
address his instability and was rehabilitated with the goal begin until the end of this phase. Protraction has been
of returning to play in 8 to 12 months. shown to stress the anterior and inferior portions of
the joint capsule. Scapula elevation and retraction are
PHASE ONE Protection Phase allowed.125 By the end of this phase, the patient should
have met all ROM goals set and they should be pain free
GOALS: Allow soft-tissue healing, diminish pain and within these guidelines. Advancement to the second
in ammation, initiate protected motion, retard muscle phase should not occur unless these goals are met.
atrophy.
PHASETWO Intermediate Phase
Estimated Length of Time (ELT): Day 1 to Week 6
For the rst 2 to 3 weeks the patient uses a sling, full time GOALS: Restore full ROM, restore functional ROM,
for 7 to 10 days, sleeping with it for the full 2 weeks, and normalize arthrokinematics, improve dynamic stability,
then gradual weaning of the sling. Exercises include hand improve muscular strength.
and wrist range of motion and active cervical spine range Estimated Length of Time (ELT): Weeks 7 to 12
of motion. During this phase, cryotherapy is used before
and after treatments. Passive and active assisted range of During this phase the patient’s ROM will ultimately be pro-
motion for the glenohumeral joint is cautiously performed gressed to fully functional by 12 weeks: at week 9, PFE to
155 degrees, 75 degrees of ER at 90 degrees of abduction, to 90 degrees in the sagittal and frontal planes, overhead
50 to 65 degrees of ER at 20 degrees of abduction, and 60 dumbbell press, pectoralis major ys, and dead lifts can
to 65 degrees of IR. Active forward elevation should prog- be worked in. Lifting exercises that put the bar behind the
ress to 145 degrees. Aggressive stretching may be used head and dips should still be avoided.
during this phase if the goal is not met by 9 weeks. This At week 16, the therapist will initiate a formal interval-
may include joint mobilization and capsular stretching throwing program. Each step is performed at least 2 times
techniques. From week 9 to week 12, the therapist begins on separate days prior to advancing. Throwing should be
to gradually progress ROM exercises to a position func- performed without pain or any increasing symptoms. If
tional for this pitcher. symptoms appear, the patient will be regressed to the pre-
In this phase, strengthening exercises include pro- vious step and remain there until symptom-free.
gressive resistive exercise (PRE) in all planes of shoul-
der motion and IR- and ER-resisted exercises. Exercises PHASE FOUR Return to Full Activity
begin in the scapular plane and work their way to more
functional planes. Incremental stresses are added to GOALS: Complete elimination of pain and full return to
the anterior capsule working toward the 90/90 posi- activity.
tion. Resistance progresses from isotonic to gentle plyo-
metrics. Gentle plyometrics are de ned as two-handed, Estimated Length of Time (ELT): Weeks 24 to 36
low-load activity like the pushup. Rhythmic stabilization Usually by week 24 the patient will begin throwing o
drills continue to be progressed with increasing di culty. the pitcher’s mound. In this phase, the number of throws,
Aggressive strengthening may be initiated if ROM goals intensity, and type of pitch are progressed gradually
are achieved. Strengthening should emphasize high rep- to increase the stress at the glenohumeral joint. By 6 to
etitions (30 to 50 reps) and low resistance (1 to 3 pounds). 7 months the patient will progress to game-type situa-
Weight room activities, including pushups, dumbbell tions and return to competition. The patient will begin by
press (without allowing the arm to drop below the body), limiting his pitch count and progressing if he can maintain
and latissimus pull-downs in front of body, bicep, and tri- his pain- and symptom-free status. Full return may take as
ceps exercises with arm at the side may begin. Exercises long as 9 to 12 months.
should be performed asymptomatically. If symptoms of
pain or instability occur, a thorough evaluation of the Criteria for Returning to Competitive Pitching
patient should be performed and the program adjusted 1. Full functional ROM
accordingly.
2. No pain or tenderness
PHASE THREE Advanced Activity 3. Satisfactory muscular strength
and Strengthening 4. Satisfactory clinical exam
GOALS: Improve strength, power, and endurance;
enhance neuromuscular control; functional activities. DISCUSSION QUESTIONS
1. What other factors may a ect the pitcher’s ability to
Estimated Length of Time (ELT): Weeks 12 to 24
generate velocity of the baseball when he throws
The criteria for progression to this phase should be: the ball?
Active range of motion (AROM) goals met without pain 2. Can the therapist truly simulate the demands of
or substitution patterns, and appropriate scapular pos- pitching during the rehabilitation process?
ture and dynamic control present during exercises. The
3. Should the patient be allowed to take NSAIDs during
patient should maintain established ROM and should
the rehabilitation progression?
continue stretching exercises. Throwing-speci c exer-
cises are initiated, including throwing a ball into the 4. What muscles generate the greatest amounts of
Plyoback. torque during the patient’s throwing motion?
During this phase, additional lifting exercises are 5. What other areas of the thrower’s body should be
added to begin building power and strength. Full dumb- targeted for strengthening, to ensure that he will
bell incline and bench press are added. Shoulder raises recover his delivery speed and power?
Strengthening exercises are done to establish neuromuscular control o the humerus

and the scapula (see Figures 20-59 through 20-67). Strengthening exercises should prog-
ress rom isometric pain- ree contractions to isotonic ull-range pain- ree contractions.
Humeral control exercises should be used to strengthen the rotator cuf to restrict migra-
tion o the humeral head and to regain voluntary control o the humeral head positioning
through rotator cuf stabilization.127 Scapular control exercises should be used to maintain a
normal relationship between the glenohumeral and scapulothoracic joints.58,59,68
Closed-kinetic-chain exercises or the shoulder should be primarily eccentric. T ey
tend to compress the joint, providing stability, and are perhaps best used or establishing
scapular stability and control.
Gradually, the duration and intensity o the exercise may be progressed within indi-
vidual patient tolerance limitations, using increased pain or stif ness as a guide or progres-
sion, eventually progressing to ull-range overhead activities.

T e patient may return to ull activity when (a) the gradual program used to increase the
duration and intensity o the workout has allowed the patient to complete a normal work-
out without pain; (b) the patient exhibits improved strength in the appropriate rotator cuf
and the scapular muscles; (c) there is no longer a positive impingement sign, drop arm test,
or empty can test; and (d) the patient can discontinue use o antiin ammatory medications
without a return o pain. A ter return to play, or even as a prophylactic measure prior to
injury athletes (especially those who participate in overhead sports) bene t rom partici-
pation in an injury prevention program. Although the literature is currently void o scien-
ti cally validated injury prevention programs or the overhead patient, the literature and
clinical experience do support the inclusion o overhead athletic speci c resistance tubing
exercises,84,110,111 shoulder exibility,62,75 and upper quarter posture exercises60 or purposes
o injury prevention.
Rot at or Cuff Tendinit is and Tears

Pat homechanics
Rotator cuf injury has o ten been described as a continuum starting with impingement o
the tendon that, through repetitive compression, eventually leads to irritation and in am-
mation and eventually brosis o the rotator cuf tendon. T is idea began with the work o
Codman in 1934, when he identi ed a critical zone near the insertion o the supraspina-
tus tendon.78 Since then many researchers in sports medicine have studied this area and
expanded the in ormation base, leading to the identi cation o other causative actors.51,91
Neer is also credited with developing a system o classi cation or rotator cuf disease. T is
system seemed to be appropriate until sports medicine pro essionals began dealing with
overhead patients as a separate entity due to the acceleration o repetitive stresses applied
to the shoulder. Disease in the overhead patient usually results rom ailure rom one or
both o these chronic stresses: repetitive tension or compression o the tissue. We now
regard rotator cuf injury in athletics as an accumulation o microtrauma to both the static
and the dynamic stabilizers o the shoulder complex. Meister and Andrews classi ed these
causative traumas based on the pathophysiology o events leading to rotator cuf ailure.
T eir 5 categories o classi cation or modes o ailure are primary compressive, secondary
compressive, primary tensile overload, secondary tensile overload, and macrotraumatic.78
Injury Mechanism
Rotator cuf tendinopathy is a gradation o tendon ailure, so it is important to identi y the
causative actors. T e ollowing classi cation system helps group injury mechanisms to bet-
ter aid the therapist in developing a rehabilitation plan.
Primary compressive disease results rom direct compression o the cuf tissue. T is
occurs when something inter eres with the gliding o the cuf tendon in the already tight
subacromial space. A predisposing actor in this category is a type III hooked acromion pro-
cess, a common actor seen in younger patients with rotator cuf disease. Other actors in
younger patients include a congenitally thick coracoacromial ligament and the presence o
an os acromiale. In younger patients, a primary impingement without one o these associ-
ated actors is rare. In middle-aged athletes/ patients, degenerative spurring on the under-
sur ace o the acromion process can cause irritation o the tendon and eventually lead to
complete tearing o the tendon. T ese individuals are o ten seen because they experience
pain during such activities as tennis and gol .
Secondary compressive disease is a primary result o glenohumeral instability. T e
high orces generated by the overhead patient can cause chronic repetitive trauma to the
glenoid labrum and capsuloligamentous structures, leading to subtle instability. Patients
with inherent multidirectional instability, such as swimmers, are also at risk. T e addi-
tional volume created in the glenohumeral capsule allows or extraneous movement o the
humeral head, leading to compressive orces in the subacromial space.
Primary tensile overload can also cause tendon irritation and ailure. T e rotator cuf
resists horizontal adduction, internal rotation, and anterior translation o the humeral
head, as well as the distraction orces ound in the deceleration phase o throwing and over-
head sports. T e repetitive high orces generated by eccentric activity in the rotator cuf
while attempting to maintain a central axis o rotation can cause microtrauma to the ten-
don and eventually lead to tendon ailure. T is type o mechanism is not associated with
previous instability o the joint. Causes or this mechanism o ten are ound when evaluating
the patient’s mechanics and taking a complete history during the evaluation. T e thera-
pist might nd that the throwing patient had a history o injury to another area o the body
where the muscles are used in the deceleration phase o overhead motion (eg, the right-
handed pitcher who sprained his le t ankle).
Secondary tensile disease is o ten a result o primary tensile overload. In this case, the
repetitive irritation and weakening o the rotator cuf allows or subtle instability. In con-
trast to secondary compressive disease o the tendon, the rotator cuf tendon experiences
greater distractive and tensile orces because the humeral head is allowed to translate ante-
riorly. Over time, the increased tensile orce causes ailure o the tendon.
Macrotraumatic ailure occurs as a direct result o one distinct traumatic event. T e
mechanism or this is o ten a all on an outstretched arm. T is is rarely seen in patients with
normal, healthy rotator cuf tendons. For this to occur, orces generated by the all must be
greater than the tensile strength o the tendon. Because the tensile strength o bone is less
than that o young healthy tendon, it is rare to see this in a patient. It is more common to see
a longitudinal tear in the tendon with an avulsion o the greater tubercle.

When designing a rehabilitation program or rotator cuf tendinopathy, the basic concerns
remain the same regardless o the extent to which the tendon is damaged. Instead, rehabili-
tation should be based on why and how the tendon has been damaged. Once the cause o
the tendinopathy is identi ed and secondary actors are known, a comprehensive program
can be designed. I a comprehensive rehabilitation program does not relieve the pain ul
shoulder, surgical repair o the tendon and alteration o the glenohumeral joint are per-
ormed. Surgical rehabilitation is similar to the nonsurgical plan, with the time o progres-
sion altered based on tissue healing and tendon histology.
Conservative Management Stage I o the rehabilitation process is ocused on reducing

in ammation and removing the patient rom the activity that caused pain. Pain should not
be a part o the rehabilitation process. T e therapist may employ therapeutic modalities to
aid in patient com ort. A course o NSAIDs is usually ollowed during this stage o rehabili-
tation. ROM exercises begin, avoiding urther irritation o the tendon. Attention is paid to
restoring appropriate arthrokinematics to the shoulder complex. I the injury is a result o
a compressive disease to the tendon, capsular stretching may be done (see Figures 20-17
and 20-19). Active strengthening o the glenohumeral joint should begin, concentrating on
the orce couples acting around the joint. Beginning with isometric exercises or the medial
and lateral rotators o the joint (see Figure 20-20), and progressing to isotonic exercises i
the patient does not experience pain (see Figures 20-31 and 20-32). A towel roll under the
patient’s arm can help initiate coactivation o the shoulder muscles, increasing joint stabil-
ity. Exercises might need to be altered to limit translational orces o the humeral head.
Strengthening o the supraspinatus may begin i 90 degrees o elevation in the scapular
plane is available (see Figures 20-33 and 20-34). Aggressive pain- ree strengthening o the
periscapular muscles should also start, as the restoration o normal scapular control will
be essential to removal o abnormal stresses o the rotator cuf tendon in later stages. T e
therapist might want to begin with manual resistance, progressing to ree-weight exercises
(see Figures 20-35 to 20-39).
In stage II, the healing process progresses and ROM will need to be restored. T e thera-
pist might need to be more aggressive in stretching techniques, addressing capsular tight-
ness as it develops. T e prone-on-elbows position is a good technique or sel -mobilization.
T is position should be avoided i compressive disease was part o the irritation. I pain
continues to be absent, strengthening gets increasingly aggressive. Isokinetic exercises at
speeds greater than 200 degrees per second or shoulder medial and lateral rotation may
begin (see Figure 20-52).41
Aggressive neuromuscular control exercises are started in this stage: quick reversals
during PNF diagonal patterns, starting with manual resistance rom the therapist and
advancing to resistance applied by surgical tubing (see Figures 20-55 and 20-56). A Body
Blade may also be used or rhythmic stabilization (see Figure 20-57). T e exercise program
should now progress to ree weights, and eccentric exercises o the rotator cuf should be
emphasized to meet the demands o the shoulder in overhead activities. Strengthening o
the deltoid and upper trapezius muscles can begin above 90 degrees o elevation. Exer-
cises include the military press (see Figure 20-24), shoulder exion (see Figure 20-26), and
reverse ys (see Figure 20-30). Pushups can also be added. It might be necessary to restrict
ROM so the body does not go below the elbow, to prevent excessive translation o the gleno-
humeral joint. Combining this exercise with serratus anterior strengthening in a modi ed
pushup with a plus is recommended (see Figure 20-39).
In the later part o this stage, exercises should progress to plyometric strengthen-
ing132. Surgical tubing is used to allow the patient to exercise in 90 degrees o elevation
with the elbow bent to 90 degrees (see Figure 20-45). Plyoball exercises are initiated (see
Figures 20-46 and 20-47). T e weight and distance o the exercises can be altered to increase
demands. T e Shuttle 2000-1 is an excellent exercise to increase eccentric strength in a
plyometric ashion (see Figure 20-50).
Stage III o the rehabilitation ocuses on sport-speci c activities. With throwing and
overhead patients, an interval overhead program begins. otal body conditioning, return o
strength, and increased endurance are the emphasis. T e patient should remain pain- ree
as sport-speci c activities are advanced and a gradual return to sport is achieved.
Postsurgical Management I conservative management is insu cient, surgical repair

is o ten indicated. Postsurgical outcomes or patients having had a rotator cuf repair can
be quite good.15,19,21,24,46,77,98,105,116,130 T e type o repair done depends on the classi cation o
the injury. Subacromial decompression has been described by Neer as a method to stim-
ulate tissue healing and increase the subacromial space.85 Additional procedures may be
done as open repairs o the tendon along with a capsular tightening procedure. One example
Figure 20-71 Airplane splint
(Courtesy DonJoy.)
is a modi ed Bankart procedure and capsulolabral reconstruction.49 Surgical repairs can

be done both open or closed. Closed arthroscopic rotator cuf repairs are becoming more
common. T e arthroscopic cuf repair addresses the de ciency o the rotator cuf by repair-
ing the tear through the use o sutures and/ or suture anchors. T e arthroscopic technique
spares the atrophy o the deltoid muscles and limits the presence o adhesions. Patients
tend to show a much more rapid recovery o unction with this repair.38,67,115
Stage I usually begins with some orm o immobilization. T is does not mean complete
lack o movement. Instead it re ers to restricting positions based on the surgical repair. In
open repairs, exion and abduction might be restricted or as long as 4 weeks. When the
repair addresses the capsulolabral complex, the patient might spend up to 2 weeks in an
airplane splint (Figure 20-71). Some surgeons have adopted a delayed start to mobilization
and rehabilitation because o a ew studies that have shown improved healing rates without
associated stif ness.57 During this phase, load across the repaired tendon should be mini-
mized. ROM should be passive and in a sa e range. During weeks 0 to 4 postoperation, the
ROM in orward elevation should be kept below 125 degrees and external rotation should
be at 20 degrees o abduction and less than 45 degrees. During weeks 4 to 6 postoperation,
orward elevation can advance to 145 degrees and ER to 60 degrees. T e patient may also
advance to abduction at 90 degrees to begin external rotation ROM up to 45 degrees.
Pain control and prevention o muscle atrophy are addressed in this stage. Shoulder
shrugs, isometrics, and joint mobilization or pain control can be done. Later in this stage,
active assistive exercises with the L-bar and multiangle isometrics are done in the pain- ree
ROM, usually best done in supine position during this phase.
Stage II collagen and elastin components have begun to stabilize. Healing tissue should
have a decreased level o elastin and an increased level o collagen by now.106,131 Regaining
ull ROM and increasing the stress to healing tissue or better collagen alignment is impor-
tant in this stage. Achieving ull passive ROM during this phase is important. Normalizing
the quality o AROM and beginning to work on strength and endurance are also important
goals. T is phase o ten is de ned by weeks 6 to 10 postoperative.
Active, and active assisted ROM exercises are added, progressing rom no resistance to
resistance with light ree weights. I a primary repair has been done to the tendon, resisted
supraspinatus exercises should be avoided until 10 weeks. Internal rotation and external
rotation stretches are introduced at 70 to 90 degrees o abduction. A ull scapula strength-
ening program should be introduced. T e restoration o normal arthrokinematics and
scapulothoracic rhythm is addressed with exercises emphasizing neuromuscular control.
Postural control and endurance should be addressed. T e patient can use a mirror to judge
progress. T e patient may also begin a core exercise program and cardiovascular exercises
at this time.
Stage III collagen and elastin components are nearing maturation.99,131 By week 14, the
tissue should be considered mature. ypically, this stage is de ned as weeks 10 to 16 postop-
eration. Goals during this stage are ull AROM, maintaining ull PROM, gradual restoration o
strength, power, and endurance, and optimal neuromuscular control. Closed-chain exercise
progression may be progressed. A balanced rotator cuf strengthening program should be ol-
lowed, advancing out o the scapular plane and into the unctional position or the patient.
Stage IV is typically de ned by postoperative weeks 14 to 26 and begins the prepara-
tion or return to sports training. During this stage, strength training will be advanced to
plyometric loading.

Return to ull activity should be based on these criteria: (a) the patient has ull active ROM;
(b) normal mechanics have been restored in the shoulder complex; (c) the patient has at
least 90% strength in the involved shoulder as compared to the uninvolved side; and (d)
there is no pain present during overhead activity.
Adhesive Capsulit is (Frozen Shoulder)

Pat homechanics
Adhesive capsulitis is characterized by the loss o motion at the glenohumeral joint. T e
cause o this arthro brosis is not well de ned. One set o criteria used or diagnosis o a ro-
zen shoulder was described by Jobe et al in 1996, and included: (a) decreased glenohumeral
motion and loss o synchronous shoulder girdle motion; (b) restricted elevation (less than
135 degrees or 90 degrees, depending on the author); (c) external rotation 50% to 60% o nor-
mal; and (d) arthrogram ndings o 5 to 10 mL volume with obliteration o the normal axillary
old.52 Other authors have identi ed histologic changes in dif erent areas surrounding the
glenohumeral joint.106 ravell and Simons explained that a re ex autonomic reaction could
be the underlying cause, because o the presence o subscapularis trigger points.118 T e result
is a chronic in ammation with brosis and rotator cuf muscles that are tight and inelastic.
Injury Mechanism
For the purposes o this chapter, we separate this diagnosis into 2 categories: primary ver-
sus secondary rozen shoulder. Adhesive capsulitis may be considered primary when it
develops spontaneously; it is considered secondary when a known underlying condition
(eg, a ractured humeral head) is present.
Primary rozen shoulder usually has an insidious onset. T e patient o ten describes a
sequence o pain ul restrictions in the patient’s shoulder, ollowed by a gradual stif ness
with less pain. Factors that have been ound to predispose a patient to idiopathic capsulitis
include diabetes, hypothyroidism, and underlying cardiopulmonary involvement.106 T ese
actors were identi ed through epidemiologic studies and might have more to do with char-
acteristic personalities o these patients. It is rare to see this type o rozen shoulder in the
athletic population.
Secondary rozen shoulder is more commonly seen in Table 20-3 Diffe re ntial Diag no sis o f Fro ze n
the athletic population. It is associated with many dif erent Sho ulde r
underlying diagnoses. Rockwood and Matsen listed 8 cate-
gories o conditions that should be considered in the dif er-
ential diagnosis o rozen shoulder: trauma, other so t-tissue Trauma
disorders about the shoulder, joint disorders, bone disorders, Fractures of the shoulder region
cervical spine disorders, intrathoracic disorders, abdominal Fractures anywhere in the upper extremity
disorders, and psychogenic disorder ( able 20-3).99 Misdiagnosed posterior shoulder dislocation
Hemarthrosis of shoulder secondary to trauma
Rehabilit at ion Concerns Othe r So ft-Tissue Diso rde rs abo ut the Sho ulde r
T e primary concern or rehabilitation is proper dif erential Tendinitis of the rotator cuff
diagnosis. Attempting to progress the patient into the strength Tendinitis of the long head of biceps
or unctional activities portion o a rehabilitation program Subacromial bursitis
can lead to exacerbation o the motion restriction. T e single Impingement
best treatment or adhesive capsulitis is prevention. Suprascapular nerve impingement
Depending on the stage o pathology when interven- Thoracic outlet syndrome
tion is started, the rehabilitation program time rame can Jo int Diso rde rs
be shortened. In all cases, the goals o rehabilitation are the Degenerative arthritis of the AC joint
same: rst relieving the pain in the acute stages o the dis- Degenerative arthritis of the glenohumeral joint
order, gradually restoring proper arthrokinematics, gradually Septic arthritis
restoring ROM, and strengthening the muscles o the shoul- Other painful forms of arthritis
der complex. Bo ne Diso rde rs
Avascular necrosis of the humeral head
Rehabilit at ion Progression Metastatic cancer
In the acute phase, Codman’s exercises and low-grade joint Paget disease
mobilization techniques can be used to relieve pain. T is Primary bone tumor
may be accompanied by therapeutic modalities and passive Hyperparathyroidism
stretching o the upper trapezius and levator scapulae mus- Ce rvical Spine Diso rde rs
cles. T e therapist may also want to suggest that the patient Cervical spondylosis
sleep with a pillow under the involved arm to prevent inter- Cervical disc herniation
nal rotation during sleep. Infection
In the subacute phase, ROM is m ore aggressively
Intratho racic Diso rde r
addressed. Incorporating PNF techniques such as hold-
Diaphragmatic irritation
relax can be help ul. Progressive demands should be placed
Pancoast tumor
on the patient with rhythmic stabilization techniques. Wall Myocardial infarction
climbing (see Figure 20-8) and wall/ corner stretches (see
Figure 20-10) are also good additions to the rehabilita- Abdo minal Diso rde r
tion program. As ROM returns, the program should start to Gastric ulcer
address strengthening. Isometric exercises or the shoulder Cholecystitis
Subphrenic abscess
are o ten the best way to begin. Progressive strengthening
will continue in the next phase. Psycho g e nic
T e nal phase o rehabilitation is a progressive strength-
ening o the shoulder complex. Exercises or maintenance
o ROM continue, and a series o strengthening exercises Source: Rockwood CA, Matsen FA. The Shoulder. Philadelphia, PA:
WB Saunders; 1990.
should be added. T e rehabilitation program should be tai-
lored to meet the needs o the patient based on the dif eren-
tial diagnosis.

T e patient may return to the patient’s previous level o activity once the proper physiologic
and arthrokinematic motion has been restored to the glenohumeral joint. How long the
patient went untreated and undiagnosed af ects how long it takes to reach this point.
Thoracic Out let Syndrome

Pat homechanics
T oracic outlet syndrome is the compression o neurovascular structures within the tho-
racic outlet. T e thoracic outlet is a cone-shaped passage, with the greater circum erential
opening proximal to the spine and the narrow end passing into the distal extrem ity. On
the proximal end, the cone is bordered anteriorly by the anterior scalene muscles, and
posteriorly by the m iddle and posterior scalene muscles. Structures traveling through
the thoracic outlet are the brachial plexus, subclavian artery and vein, and axillary ves-
sels. T e neurovascular structures pass distally under the clavicle and subclavius muscle.
Beneath the neurovascular bundle is the rst rib. At the narrow end o the cone, the bun-
dle passes under the coracoid process o the scapula and into the upper extremity through
the axilla. T e distal end is bordered anteriorly by the pectoralis minor and posteriorly by
the scapula.
Based on the anatomy o the thoracic outlet, there are several areas where neurovascu-
lar compression can occur. T ere ore, pathology o the thoracic outlet syndrome is depen-
dent on the structures being compressed.
Injury Mechanism
In 60% o the population af ected by thoracic outlet syndrome, there is no report rom the
patient o an inciting episode.64 Some o the theories presented by authors regarding the
etiology o thoracic outlet syndrome include trauma, postural components, shortening o
the pectoralis minor, shortening o the scalenes, and muscle hypertrophy.
T ere are 4 areas o vulnerability to compressive orces: the superior thoracic outlet,
where the brachial plexus passes over the rst rib; the scalene triangle, at the proximal end
o the thoracic outlet, where there might be overlapping insertions o the anterior and mid-
dle scalenes onto the rst rib; the costoclavicular interval, which is the space between the
rst rib and clavicle where the neurovascular bundle passes (the space can be narrowed by
poor posture, in erior laxity o the glenohumeral joint, or an exostosis rom a racture o the
clavicle); and under the coracoid process where the brachial plexus passes and is bordered
anteriorly by the pectoralis minor.106

As described, thoracic outlet syndrome is an anatomy-based problem involving compres-
sive orces applied to the neurovascular bundle. Conservative management o thoracic
outlet syndrome is moderately success ul, resulting in decreased symptoms 50% to 90%
o the time. As the rst course o treatment, rehabilitation should be based on encourag-
ing the least provocative posture. Lef ert advocated a detailed history and evaluation o
the patient’s activities and li estyle to help identi y where and when postural de ciency is
occurring.64
T rough a detailed history and evaluation o an patient’s activity, the therapist can
identi y the cause o compression in the thoracic outlet. T e rehabilitation program should
be tailored to encourage good posture throughout the patient’s day. T erapeutic exercises
should be used to strengthen postural muscles, such as the rhomboids (see Figure 20-38),
middle trapezius (see Figure 20-37), and upper trapezius (see Figure 20-35). Flexibility exer-
cises are also used to increase the space in the thoracic outlet. Scalene stretches and wall/
corner stretches (see Figure 20-10) are used to decrease the incidence o muscle impinging
on the neurovascular bundle. Proper breathing technique should also be reviewed with the
patient. T e scalene muscles act as accessory breathing muscles, and improper breathing
technique can lead to tightening o these muscles.

T e rehabilitation process begins by detailed evaluation o the patient’s activities and symp-
toms. First, the patient is removed rom activities exacerbating the neurovascular symptoms
until the patient can maintain a symptom- ree posture. During this time an erect posture is
encouraged using stretching and strengthening exercises. Gradually encourage the patient to
return to the patient’s sport, or short periods o time, while maintaining a pain- ree posture.
T e time o participation is increased at regular intervals i the patient remains ree o pain.
T is helps build endurance o the postural muscles. Exercising on an upper-body ergometer,
by pedaling backwards, can help build endurance. As the patient returns to sports, it may be
necessary to alter strength-training methods that place the patient in a exed posture.

I the patient responds to the rehabilitation program and can maintain a pain- ree pos-
ture during the patient’s sport-speci c activity, participation can be resumed. T e patient
should have no muscular weakness, neurovascular symptoms, or pain. I the patient ails to
respond to therapy, and unctionally signi cant pain and weakness persist, surgical inter-
vention might be indicated. Surgical procedure depends on the anatomical basis or the
patient’s symptoms.
Brachial Plexus Injuries (St inger or Burner)

Pat homechanics
T e brachial plexus begins at cervical roots C5 through C8 and thoracic root 1. T e ven-
tral rami o these roots are orm ed rom a dorsal (sensory) and ventral (m otor) root. T e
ventral rami join to orm the brachial plexus. T e ventral rami lie between the anterior and
middle scalene muscles, where they run adjacent to the subclavian artery. T e plexus con-
tinues distally passing over the rst rib. It is deep to the sternocleidomastoid muscle in the
neck.86 Just caudal to the clavicle and subclavius muscle, the 5 ventral ram i unite to orm
the 3 trunks o the plexus: superior, middle, and in erior. T e superior trunk is composed
o the C5 and C6 ventral roots. T e middle trunk is ormed by the C7 root, and the in erior
trunk is ormed by C8 and 1 ventral roots. A ter passing under the clavicle, the 3 trunks
divide into 3 divisions that eventually contribute to the 3 cords o the brachial plexus.
T e typical picture o a brachial plexus injury in sports is that o a traction injury. T is
syndrome is commonly re erred to as burner or stinger syndrom e. T ese injuries usually
involve the C5 to C6 nerve roots. T e patient will complain o a sharp, burning pain in the
shoulder that radiates down the arm into the hand. Weakness in the muscles supplied by
C5 and C6 (deltoid, biceps, supraspinatus, and in raspinatus) accompany the pain. Burning
and pain are o ten transient, but weakness might last a ew minutes or inde nitely.
Clancy et al classi ed brachial plexus injuries into 3 categories.20 A grade I injury results
in a transient loss o motor and sensory unction that usually resolves completely within
minutes. A grade II injury results in signi cant motor weakness and sensory loss that might
last rom 6 weeks to 4 months. Electromyography evaluation a ter 2 weeks will demonstrate
abnormalities. Grade III lesions are characterized by motor and sensory loss or at least
1 year in duration.
Injury Mechanism
T e structure o the brachial plexus is such that it winds its way through the musculoskeletal
anatomy o the upper extremity as described. Clancy et al identi ed neck rotation, neck
lateral exion, shoulder abduction, shoulder external rotation, and simultaneous scapular
and clavicular depression as potential mechanisms o injury.20
During neck rotation and lateral exion to one side, the brachial plexus and the sub-
clavius muscle on the opposite side are put on stretch and the clavicle is slightly elevated
about its anteroposterior axis. I the arm is not elevated, the superior trunk o the plexus will
assume the greatest amount o tension. I the shoulder is abducted and externally rotated,
the brachial plexus migrates superiorly toward the coracoid process and the scapula
retracts, putting the pectoralis minor on stretch. As the shoulder is moved into ull abduc-
tion, a condition similar to a movable pulley is ormed, where the coracoid process o the
scapula acts as the pulley. In ull abduction, most stress alls on the lower cords o the bra-
chial plexus.107 T e addition o clavicular and scapula depression to the above scenarios
would produce a downward orce on the pulley system, bringing the brachial plexus into
contact with the clavicle and the coracoid process. T e portion o the plexus that receives
the greatest amount o tensile stress depends on the position o the upper extremity during
a collision.

Management o brachial plexus injuries begins with the gradual restoration o the patient’s
cervical ROM. Muscle tightness caused by the direct trauma, and by re exive guarding that
occurs because o pain, needs to be addressed. Gentle passive ROM exercises and stretch-
ing or the upper trapezius, levator scapulae, and scalene muscles should be done. T e ther-
apist should be care ul not to cause sensory symptoms.
Butler advocates using an early intervention with gentle mobilization o the neural tis-
sues.17 T e goal o early mobilization is to prevent scarring between the nerve and the bed
or within the connective tissue o the nerve itsel as the nerve heals. He advocates low ten-
sile loads to avoid the possibility o irritating a nerve lesion such as axonotmesis or neu-
rotmesis. More chronic, repetitive injuries may use the neural tension test positions to do
mobilizations with higher grades.
Strengthening o the involved muscles is also addressed in the rehabilitation program.
Supraspinatus strengthening exercises, like scaption (see Figure 20-33) and alternative
supraspinatus exercises (see Figure 20-34), should be done. Other exercises or involved
musculature are shoulder lateral rotation (see Figure 20-32) or the in raspinatus, orward
exion and abduction to 90 degrees (see Figures 20-26 and 20-28) to strengthen the deltoid,
and bicep curls or elbow exion.
T e therapist should also work closely with the patient’s coach to evaluate the patient’s
technique and correct any alteration in orm that might be putting the patient at risk or
burners. Prior to return to activity, the patient’s equipment should be inspected or proper
tting, and a cervical neck roll should be used to decrease the amount o lateral exion that
occurs during impact, as in tackling.

T e patient is removed rom activity immediately a ter the injury. T e rehabilitation pro-
gression should begin with the restoration o both active and PROM ROM at the neck
and shoulder. Neural tissue mobilizations utilizing the upper limb tension testing posi-
tions should begin with the patient in the testing positions (see Figure 8-4A and B).17 For
the median nerve, the testing position consists o shoulder depression, abduction, exter-
nal rotation, and wrist and nger extension. For the radial nerve, the elbow is extended,
the orearm pronated, the glenohumeral joint internally rotated, and the wrist, nger, and
thumb exed. T e position or stretching the ulnar nerve consists o shoulder depression,
wrist and nger extension, supination or pronation o the orearm, and elbow exion.
Mobilizations o distal joints, like the elbow and wrist, in large-grade movements should
initiate the treatment phase. Progression should include grade 4 and grade 5 mobilizations
in later phases o recovery.
As the patient gets return o ROM, strengthening o the neck and shoulder is incor-
porated into the rehabilitation program. Strengthening should progress rom PRE-type
strengthening with ree weights to exercises that emphasize power and endurance. Func-
tional progression begins with teaching proper technique or sport-speci c demands that
mimic the position o injury. T e progressive return and proper technique are important to
the rehabilitation program, as they address the psychological component o preparing the
patient or return to sport.

Patients are allowed to return to play when they have ull, pain- ree ROM, ull strength,
and no prior episodes in that contest.124 Additionally, ootball players should use a cervical
neck roll. T e patient’s psychological readiness should also be considered prior to return to
sport. Patients who are too protective o their neck and shoulder can expose themselves to
urther injury.
Myofascial Trigger Point s

Pat hology
Clinically, a trigger point ( P) is de ned as a hyperirritable oci in muscle or ascia that is
tender to palpation and may, upon compression, result in re erred pain or tenderness in a
characteristic “zone.” T is zone is distinct rom myotomes, dermatomes, sclerotomes, or
peripheral nerve distribution. Ps are identi ed via palpation o taut bands o muscle or
discrete nodules or adhesions. Snapping o a taut band will usually initiate a local twitch
response.106
Physiologically, the de nition o a P is not as clear. Muscles with myo ascial Ps reveal
no diagnostic abnormalities upon electromyographic examination. Routine laboratory tests
show no abnormalities or signi cant changes attributable to Ps. Normal serum enzyme
concentrations have been reported with a shi t in the distribution o lactate dehydrogenase-
isoenzymes. Skin temperature over active Ps might be higher in a 5- to 10-cm diameter.118
ravell and Simons classi y Ps as ollows118:
1. Active Ps. Symptomatic at rest with re erral pain and tenderness upon direct
compression. Associated weakness and contracture are o ten present.
2. Latent Ps. Pain is not present unless direct compression is applied. T ese might show
up on clinical exam as stif ness and/ or weakness in the region o tenderness.
3. Primary Ps. Located in speci c muscles.
4. Associated Ps. Located within the re erral zone o a primary P’s muscle or in a
muscle that is unctionally overloaded in compensation or a primary P.
Pathology o a myo ascial P is identi ed with (a) a history o sudden onset during or
shortly a ter an acute overload stress or chronic overload o the af ected muscle; (b) charac-
teristic patterns o pain in a muscle’s re erral zone; (c) weakness and restriction in the end
ROM o the af ected muscle; (d) a taut, palpable band in the af ected muscle; (e) ocal ten-
derness to direct compression, in the band o taut muscle bers; ( ) a local twitch response
elicited by snapping o the tender spot; and (g) reproduction o the patient’s pain through
pressure on the tender spot.
Injury Mechanism
T e most common mechanism or myo ascial Ps in the shoulder region is acute muscle
strain ( able 20-4). T e damaged muscle tissue causes tearing o the sarcoplasmic reticu-
lum and release o its stored calcium, with loss o the ability o that portion o the muscle
Table 20-4 Trig g e r Po ints o f the Sho ulde r to remove calcium ions. T e chronic stress o sustained
muscle contraction can cause continued muscle dam-
age, repeating the above cycle o damage. T e combined
Po ste rio r Sho ulde r Pain presence o the normal muscle adenosine triphosphate
Deltoid supplies and excessive calcium initiate and maintain
Levator scapulae a sustained muscle band contracture. T is produces a
Supraspinatus region o the muscle with an uncontrolled metabolism,
Subscapularis to which the body responds with local vasoconstriction.
Teres minor T is region o increased metabolism and decreased local
Teres major circulation, with muscle bers passing through that area,
Serratus posterior superior
causes muscle shortening independent o local motor
Triceps
unit action potentials. T is taut band can be palpated in
Trapezius
the muscle.
Ante rio r Sho ulde r Pain
Infraspinatus
Deltoid
Scalene T e principal mechanism o myo ascial Ps is related to
Supraspinatus muscular overload and atigue, so the primary concern
Pectoralis major is identi cation o the incriminating activity. T e thera-
Pectoralis minor pist should take a detailed history o the patient’s daily
Biceps activity demands, as well as the changing demands o the
Coracobrachialis patient’s sport activities.
T e cyclic nature o Ps requires interruption o the
cycle or success ul treatment. Interrupting the shortening
118
Source: Data from Travell and Simons.
o the muscle bers and prevention o urther breakdown
o the muscle tissue components should be attempted
using modi ed hold-relax techniques and postisometric
stretching. ravell and Simons advocate a spray-and-stretch method, where vapocoolant
spray is applied and passive stretching ollows. T eoretically, when the muscle is placed in a
stretched position and the skin receptors are cooled, a re exive inhibition o the contracted
muscle is acilitated, allowing or increased passive stretching.118
A ter a treatm ent session where PROM has been achieved, the muscle m ust be
activated to stimulate normal actin and myosin cross bridging. Gentle AROM exercises
or active assistive exercises with the L-bar m ight be a good activity to use as posttreat-
ment activity. Normal muscle activity and endurance must be encouraged a ter ROM is
restored. A gradual progression o shoulder exercises with an endurance em phasis should
be used.

reatment progression or Ps should begin with temporary removal rom activities that
overload the contracted tissue. T e patient is then treated with myo ascial stretching tech-
niques to increase the length o the contracted tissue. Immediate use o the extended ROM
should be emphasized. Strengthening exercises are added once the patient can maintain
the normal muscle length without initiating the return o the contracted myo ascial band.
As strength and unction o the involved muscles return, the patient may gradually return
to the patient’s sport.

T e patient may return to activity in a relatively short period o time i the patient can dem-
onstrate the ability to unction without reinitiating the myo ascial Ps and associated taut
bands. Early return without meeting this criterion can lead to greater regionalization o the
symptoms.
SUMMARY
1. T e high degree o mobility in the shoulder complex requires some compromise in sta-
bility, which, in turn, increases the vulnerability o the shoulder joint to injury, particu-
larly in dynamic overhead athletic activities.
2. In rehabilitation o the SC joint, ef ort should be directed toward regaining normal
clavicular motion that will allow the scapula to abduct and upward rotate throughout
180 degrees o humeral abduction. T e clavicle must elevate approximately 40 degrees
to allow upward scapular rotation.
3. AC joint sprains are most commonly seen in patients who experienced a direct all on
the point o the shoulder with the arm at the side in an adducted position or alling on
an outstretched arm.
4. Management o AC injuries depends on the type o injury. ypes I and II injuries are
usually handled conservatively, ocusing on strengthening o the deltoid, trapezius,
and the clavicular bers o the pectoralis major. Occasionally AC injuries require surgi-
cal excision o the distal portion o the clavicle.
5. reatment or clavicle ractures includes approximation o the racture and immobili-
zation or 6 to 8 weeks, using a gure-8 wrap with the involved arm in a sling. Because
mobility o the clavicle is important or normal shoulder mechanics, rehabilitation
should ocus on joint mobilization and strengthening o the deltoid, upper trapezius,
and pectoralis major muscles.
6. Following a short immobilization period, rehabilitation or a dislocated shoulder
should ocus on restoring the appropriate axis o rotation or the glenohumeral joint,
optimizing the stabilizing muscle’s length–tension relationship, and restoring proper
neuromuscular control o the shoulder complex. Similar rehabilitation strategies are
applied in cases o multidirectional instabilities, which can occur as a result o recur-
rent dislocation.
7. Management o shoulder impingement involves gradually restoring normal biome-
chanics to the shoulder joint in an ef ort to maintain space under the coracoacromial
arch during overhead activities. echniques include strengthening o the rotator cuf
muscles, strengthening o the muscles that abduct, elevate, and upwardly rotate the
scapula, and stretching both the in erior and the posterior portions o the joint capsule
and posterior rotator cuf musculature.
8. T e basic concerns o a rehabilitation program or rotator cuf tendinopathy are based
on why and how the tendon has been damaged. I a comprehensive rehabilitation pro-
gram does not relieve the pain ul shoulder, surgical repair o the tendon and alteration
o the glenohumeral joint are per ormed. Surgical rehabilitation is similar to the non-
surgical plan, with the time o progression altered, based on tissue healing and tendon
histology.
9. In cases o adhesive capsulitis, the goals o rehabilitation are relieving the pain in the
acute stages o the disorder, gradually restoring proper arthrokinematics, gradual resto-
ration o ROM, and strengthening the muscles o the shoulder complex.
10. Rehabilitation or thoracic outlet syndrome should be directed toward encouraging
the least-provocative posture combined with exercises to strengthen postural muscles
(rhomboids, middle trapezius, upper trapezius) and stretching exercises or the sca-
lenes to increase the space in the thoracic outlet in order to reduce muscle impinge-
ment on the neurovascular bundle.
11. Management o brachial plexus injuries includes the gradual restoration o cervical
ROM, and stretching or the upper trapezius, levator scapulae, and scalene muscles.
12. A ter identi ying the cause o myo ascial Ps, rehabilitation may include a spray- and-
stretch method with passive stretching, gentle active ROM exercises or active assistive
exercises, encouraging normal muscle activity and endurance, and gradual improve-
ment o muscle endurance.
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Rehabilitation
of the Elbow
To d d S. Elle n b e ck e r, Ta d E. Pie czy n s k i,
a n d Da v id Ca r f a g n o
OBJJE CTIVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Discuss the functional anatomy and biomechanics associated with normal function of the elbow.
Identify the various techniques for regaining range of motion including stretching exercises
and joint mobilizations.
Perform speci c clinical tests to identify ligamentous laxity and tendon pathology in the
injured elbow.
Discuss criteria for progression of the rehabilitation program for different elbow injuries.
Demonstrate the various rehabilitative strengthening techniques for the elbow, including open-
and closed-kinetic chain isometric, isotonic, plyometric, isokinetic, and functional exercises.
613
614 Chapte r 21 Rehabilitation of the Elbow
reatment o elbow injuries in active individuals requires an understanding o the mech-

anism o injury and the anatomy and biomechanics o the human elbow and upper-
extremity kinetic chain, as well as a structured and detailed clinical examination to identi y
the structure or structures involved. reatment o the injured elbow o both a younger ado-
lescent patient and an older active patient requires this same approach. T is approach con-
sists o understanding the specif c anatomical vulnerabilities present in the young athletes’
elbow, as well as the e ects o years o repetitive stress and the clinical ramif cations these
stresses produce in the aging elbow joint. An overview o the most common elbow injuries,
as well as a review o the musculoskeletal adaptations o the elbow, will provide a plat orm
or the discussion o examination and most specif cally treatment concepts or patients with
elbow injury. T e important interplay between the elbow and shoulder joints in the upper-
extremity kinetic chain is highlighted throughout this chapter in order to support compre-
hensive examination and intervention strategies, as well as the total-arm strength treatment
concept.

Anatomically, the elbow joint comprises 3 joints. T e humeroulnar joint, humeroradial joint,
and the proximal radioulnar joint are the articulations that make up the elbow complex
(Figure 21-1). T e elbow allows or exion, extension, pronation, and supination movement
patterns about the joint complex. T e bony limitations, ligamentous support, and muscular
stability help to protect it rom vulnerability o overuse and resultant injury.
T e elbow complex comprises 3 bones: the distal humerus, proximal ulna, and prox-
imal radius. T e articulations among these 3 bones dictate elbow movement patterns.125
It is also important to mention that the appropriate strength and unction o the upper
quarter (def ned as the cervical spine to the hand, including the scapulothoracic joint) need
to be addressed when evaluating the elbow specif cally. T e elbow complex has an intricate
mechanical articulation between the 3 separate joints o the upper quarter in order to allow
or unction.
Hume rus Hume rus
S upra condyla r
re gion
Coronoid fos s a
La te ra l Me dia l
Ra dia l e picondyle
e picondyle
he a d Bice ps tube rcle Me dia l condyle
La te ra l condyle (trochle a )
(ca pite llum)
Ra dius
Ulna Coronoid proce s s
Ole cra non
Ra dius Ulna
Figure 21-1 Articulatio ns o f the e lbo w jo int co mple x

S ynovia l
ca ps ule
Ra dia l-hume ra l
burs a
Ole cra non
burs a
Hume rus
A
Ra dia l
colla te ra l Ulna r
liga me nt colla te ra l
liga me nt
Annula r
liga me nt
Ulna
Ra dius
Figure 21-2
A. Elbow joint capsule. B. Medial ulnar collateral ligament complex.
In the elbow, the joint capsule plays an important role. T e capsule is continuous
(Figure 21-2A) among the 3 articulations and highly innervated.87,92 T is is important not
only or support o the elbow joint complex but also or proprioception o the joint. T e
capsule o the elbow unctions as a neurologic link between the shoulder and the hand
within the upper-extremity kinetic chain. T ere ore, unction o the capsule has an e ect on
upper-quarter activity and is an obvious important consideration during the rehabilitation
process, i injury does occur.
Humeroulnar Joint
T e humeroulnar joint is the articulation between the distal humerus medially and the
proximal ulna. T e humerus has distinct eatures distally. T e medial aspect has the
medial epicondyle and an hourglass-shaped trochlea, located anteromedial on the distal
humerus.2,53 T e trochlea extends more distal than the lateral aspect o the humerus. T e
trochlea articulates with the trochlear notch o the proximal ulna.
Because o the more distal projection o the humerus medially, the elbow complex
demonstrates a carrying angle that is essentially an abducted position o the elbow in the
anatomic position. T e normal carrying angle (Figure 21-3) is 10 to 15 degrees in emales
and 5 degrees in males.7
Radiocapit ellar Joint

(Humeroradial Joint )
T e radiocapitellar or hum eroradial joint is the
articulation o th e distal lateral hum erus an d
th e proxim al radius. T e lateral aspect o the
hum erus has the lateral epicondyle and the capi-
tellum, which is located anterolateral on the distal
hum erus. With exion, the radius is in contact with
the radial ossa o the distal hum erus, whereas in
extension, the radius and the hum erus are not in
contact.
Proximal Radioulnar Joint

T e proxim al radioulnar joint is the articulation
between the radial notch o the proxim al lateral
aspect o the ulna, the radial head, and the capitel-
lum o the distal hum erus. T e proximal and distal
radioulnar joints are im portant or supination and
pronation . Proxim ally, the radius articulates with
the ulna by the support o the annular ligam ent,
which attaches to the ulnar n otch anteriorly and
posteriorly. T is ligam ent circles the radial head
and adds support. T e interosseous m em brane is
the con nective tissue that unctions to com plete
the interval between the 2 bon es. When there is
a all on the outstretched arm, the interosseous
m em brane can shi t orces o the radius—the main
Figure 21-3 Carrying ang le o f the human e lbo w
weightbearing bone o the orearm —to the ulna.
T is prevents the radial head rom having orce-
ul contact with the capitellum. Distally, the concave radius articulates with the convex
ulna. With supination and pronation, the radius m oves on the m ore stationary ulna.
Ligament ous St ruct ures

T e stability o the elbow starts with the joint capsule and excellent bony congruity inherent
to the three articulations o the human elbow. T e capsule is loose anteriorly and posteri-
orly to allow or movement in exion and extension.131 T e joint capsule is taut medially
and laterally as a result o the added support o the collateral ligaments.
T e medial (ulnar) collateral ligament (MUCL) is an shaped in nature and has 3 bands
(see Figure 21-2B). T e anterior band o the MUCL is the primary stabilizer o the elbow
against valgus loads when the elbow is near extension.131 T e posterior band o the MUCL
becomes taut a ter 60 degrees o elbow exion and assists in stabilizing against valgus stress
when the elbow is in a exed position. T e oblique band o the MUCL does not technically
cross the elbow joint and this does not provide extensive stabilization to the medial elbow
like the anterior and posterior bands.
T e lateral elbow complex consists o 4 structures. T e radial collateral ligament attach-
ments are rom the lateral epicondyle to the annular ligament. T e lateral ulnar collateral
ligament is the primary lateral stabilizer and passes over the annular ligament into the supi-
nator tubercle. It rein orces the elbow laterally, as well as re-en orcing the humeroradial
joint.103,131 T e accessory lateral collateral ligament passes rom the supinator tubercle into
the annular ligament. T e annular ligament is the main support o the radial head in the
radial notch o the ulna. T e interosseous membrane is a syndesmotic tissue that connects
the ulna and the radius in the orearm.
Dynamic St abilizers of t he Elbow Complex

T e elbow exors are the biceps brachii, brachialis, and brachioradialis muscles
(Figure 21-4). T e biceps brachii originates via 2 heads proximally at the shoulder: the long
head rom the supraglenoid tuberosity o the scapula, and the short head rom the cora-
coid process o the scapula. T e insertion is achieved by a common tendon at the radial
tuberosity and lacertus f brosis to origins o the orearm exors. T e unctions o the biceps
brachii are exion o the elbow and supination the orearm.136 T e brachialis originates
rom the lower two-thirds o the anterior humerus and inserts on the coronoid process and
tuberosity o the ulna. It unctions to ex the elbow. T e brachioradialis, which originates
rom the lower two-thirds o the lateral humerus and attaches to the lateral styloid process
o the distal radius, unctions as an elbow exor as well as a weak pronator and supinator
o the orearm.
T e elbow extensors are the triceps brachii and the anconeus muscles. T e triceps bra-
chii has long, medial, and lateral heads. T e long head originates at the in raglenoid tuber-
osity o the scapula, the lateral and medial heads to the posterior aspect o the humerus.
T e insertion is via the common tendon posteriorly at the olecranon. T rough this insertion
along with the anconeus muscle that assists the triceps, extension o the elbow complex is
accomplished.
Figure 21-4 Valg us stre ss te st to e valuate the me dial ulnar co llate ral
lig ame nt co mple x
Clinical Examination of the Elbow

Although it is beyond the scope o this chapter to describe a complete elbow examination,
several important components necessary in the comprehensive examination o the athletes
elbow are discussed. Structural inspection o the athletes elbow must include a complete
and thorough inspection o the entire upper extremity and trunk, because o the reliance o
the entire upper-extremity kinetic chain on the core or power generation and orce attenu-
ation during unctional activities.37 Adaptive changes are commonly encountered during
clinical examination o the athletic elbow, particularly in the unilaterally dominant upper-
extremity athlete. In these athletes, use o the contralateral extremity as a baseline is par-
ticularly important to determine the degree o actual adaptation that may be a contributing
actor in the patient’s injury presentation.
Anatomical adaptation o the athlete’s elbow can be categorized into 4 main catego-
ries or the purpose o this chapter. T ese include range o motion (ROM), osseous, liga-
mentous, and muscular. Each is presented in the context o the clinical examination o the
patient with elbow dys unction.
Range of Mot ion Adapt at ions

King et al77 initially reported on elbow ROM in pro essional baseball pitchers. Fi ty percent
o the pitchers they examined were ound to have a exion contracture o the dominant
elbow with 30% o subjects demonstrating a cubitus valgus de ormity. Chinn et al21 mea-
sured world-class pro essional adult tennis players and reported signif cant elbow exion
contractures on the dominant arm, but no presence o a cubitus valgus de ormity.
More recently, Ellenbecker et al38 measured elbow extension in a population o 40 healthy
pro essional baseball pitchers and ound exion contractures averaging 5 degrees. Directly
related to elbow unction was wrist exibility, which Ellenbecker et al38 reported as signif -
cantly less in extension on the dominant arm because o tightness o the wrist exor muscula-
ture, with no di erence in wrist exion ROM between extremities. Ellenbecker and Roetert41
measured senior tennis players age 55 years and older and ound exion contractures aver-
aging 10 degrees in the dominant elbow, as well as signif cantly less wrist exion ROM. T e
higher utilization o the wrist extensor musculature is likely the cause o limited wrist exor
ROM among the senior tennis players, as opposed to the reduced wrist extension ROM seen
rom excessive overuse o the wrist exor muscles inherent in baseball pitching.47,112
More proximally, measurement o ROM o humeral rotation in the older overhead
athlete is also recommended. Several studies show consistent alterations o shoulder rota-
tional ROM in the overhead athlete.42,75,114 Ellenbecker et al42 showed statistically greater
dominant-shoulder external rotation and less internal rotation in a sample o pro essional
baseball pitchers. Despite these di erences in internal and external rotation ROM, the total
rotation (internal rotation + external rotation) between extremities remained equal, such
that any increases in external rotation ROM were matched by decreases in internal rota-
tion ROM in this uninjured population. Elite level tennis players had signif cantly less inter-
nal rotation and no signif cant di erence in external rotation on the dominant arm, and an
overall decrease in total rotation ROM on the dominant arm o approximately 10 degrees.
Care ul monitoring o glenohumeral joint ROM is recommended or the athlete with an
elbow injury.
Based on the f ndings o these descriptive prof les, the f nding o an elbow exion con-
tracture and limited wrist exion or extension ROM, as well as reduced glenohumeral joint
internal rotation, can be expected during the examination o the older athlete who per orms
a unilateral upper-extremity sport. Care ul measurement during the clinical examination
is recommended to determine baseline levels o ROM loss in the distal upper extremity.
Clinical Examination of the Elbow 619
T is care ul measurement serves to determine i rehabilitative interventions are needed as
well as to assess progress during rehabilitation.
Osseous Adapt at ion

In a study by Priest et al,108 84 world-ranked tennis players were studied using radiography,
and an average o 6.5 bony changes were ound on the dominant elbow o each player. Addi-
tionally, they reported twice as many bony adaptations, such as spurs, on the medial aspect
o the elbow as compared to the lateral aspect. T e coronoid process o the ulna was the
number 1 site o osseous adaptation or spurring. An average o 44% increase in thickness o
the anterior humeral cortex was ound on the dominant arm o these players, with an 11%
increase in cortical thickness reported in the radius o the dominant tennis playing extremity.
Additionally, in an MRI study, Waslewski et al137 ound osteophytes at the proximal or
distal insertion o the ulnar collateral ligament in 5 o 20 asymptomatic pro essional base-
ball pitchers, as well as posterior osteophytes in 2 o 20 pitchers.
Ligament ous Laxit y

Manual clinical examination o the human elbow to assess medial and lateral laxity can
be challenging, given the presence o humeral rotation and small increases in joint open-
ing that o ten present with ulnar collateral ligament injury. Ellenbecker et al38 measured
medial elbow joint laxity in 40 asymptomatic pro essional baseball pitchers to determine
i bilateral di erences in medial elbow laxity exist in healthy pitchers with a long history o
repetitive overuse to the medial aspect o the elbow. A elos stress radiography device was
used to assess medial elbow joint opening, using a standardized valgus stress o 15 daN
(kPa) with the elbow placed in 25 degrees o elbow exion and the orearm supinated. T e
joint space between the medial epicondyle and coronoid process o the ulna was mea-
sured using anterior-posterior radiographs by a musculoskeletal radiologist and compared
bilaterally, with and without the application o the valgus stress. Results showed signif cant
di erences between extremities with stress application, with the dominant elbow opening
1.20 mm, and the nondominant elbow opening 0.88 mm. T is di erence, although sta-
tistically signif cant, averaged 0.32 mm between the dominant and nondominant elbow
and would be virtually unidentif able with manual assessment. Previous research by Rijke
et al113 using stress radiography identif ed a critical level o 0.5-mm increase in medial
elbow joint opening in elbows with ulnar collateral ligament injury. T us, the results o the
study by Ellenbecker et al38 do support this 0.5-mm critical level, as asymptomatic pro es-
sional pitchers in their study exhibited less than this 0.5 mm o medial elbow joint laxity.
Muscular Adapt at ions

Several methods can be used to measure upper-extremity strength in athletic populations.
T ese can range rom measuring grip strength with a grip strength dynamometer to the use
o isokinetic dynamometers to measure specif c joint motions and muscular parameters.
Increased orearm circum erence was measured on the dominant orearm in world-class
tennis players,21 as well as in the dominant orearm o senior tennis players.80
Isometric grip strength dynamometer measurements in elite adult and senior tennis
players demonstrated unilateral increases in strength. Increases ranging rom 10% to 30%
have been reported using standardized measurement methods.21,34,37,80
Isokinetic dynamometers have been used to measure specif c muscular per ormance
parameters in elite-level tennis players and baseball pitchers.34,37,39,40 Specif c patterns o
unilateral muscular development have been identif ed by reviewing the isokinetic literature
rom di erent populations o overhead athletes. Ellenbecker34 measured isokinetic wrist
and orearm strength in mature adult tennis players who were highly skilled, and ound
10% to 25% greater wrist exion and extension as well as orearm pronation strength on
the dominant extremity as compared to the non-dominant extremity. Additionally, no sig-
nif cant di erence between extremities in orearm supination strength was measured. No
signif cant di erence between extremities was ound in elbow exion strength in elite ten-
nis players, but dominant arm elbow extension strength was signif cantly stronger than the
non–tennis-playing extremity.39
Research on pro essional throwing athletes has identif ed signif cantly greater wrist
exion and orearm pronation strength on the dominant arm by as much as 15% to 35%
when compared to the nondominant extremity,37 with no di erence in wrist extension
strength or orearm supination strength between extremities. Wilk, Arrigo, and Andrews139
reported 10% to 20% greater elbow exion strength in pro essional baseball pitchers on the
dominant arm, as well as 5% to 15% greater elbow extension strength as compared to the
nondominant extremity.
T ese data help to portray the chronic muscular adaptations that can be present in the
senior athlete who may present with elbow injury, as well as help to determine realistic and
accurate discharge strength levels ollowing rehabilitation. Failure to return the dominant
extremity-stabilizing musculature to its preinjury status (10% to as much as 35% greater
than the nondominant) in these athletes may represent an incomplete rehabilitation and
prohibit the return to ull activity.
Clinical Examination Methods

In addition to the examination methods outlined in the previous section, including accurate
measurement o both distal and proximal joint ROM, radiographic screening, and muscular
strength assessment, several other tests should be included in the comprehensive examina-
tion o the elbow o the older active patient. Although it is beyond the scope o this chapter
to completely review all o the necessary tests, several are highlighted based on their overall
importance. T e reader is re erred to Morrey92 and Ellenbecker and Mattalino 37 or more
complete chapters solely on examination o the elbow.
Clinical testing o the joints proximal and distal to the elbow allows the examiner to rule
out re erred symptoms and ensure that elbow pain is rom a local musculoskeletal origin.
Overpressure o the cervical spine in the motions o exion/ extension and lateral exion/
rotation, as well as quadrant or Spurling test combining extension with ipsilateral lateral
exion and rotation, are commonly used to clear the cervical spine and rule out radicular
symptoms.50
Additionally, clearing the glenohumeral joint, and determining whether concomitant
impingement or instability is present, is also highly recommended.37 Use o the sulcus sign 88
to determine the presence o multidirectional instability o the glenohumeral joint, along
with the subluxation/ relocation sign 67 and load and shi t test, can provide valuable insight
into the status o the glenohumeral joint. T e impingement signs o Neer 94 and Hawkins
and Kennedy57 are also help ul to rule out proximal tendon pathology.
In addition to the clearing tests or the glenohumeral joint, ull inspection o the scapu-
lothoracic joint is recommended. Removal o the patient’s shirt or examination o the
patient in a gown with ull exposure o the upper back is highly recommended. Kibler et al76
has recently presented a classif cation system or scapular pathology. Care ul observa-
tion o the patient at rest and with the hands placed upon the hips, as well as during active
overhead movements, is recommended to identi y prominence o particular borders o the
scapula, as well as a lack o close association with the thoracic wall during movement.73,74
Bilateral comparison provides the primary basis or identi ying scapular pathology; how-
ever, in many athletes, bilateral scapular pathology can be observed.
Clinical Examination Methods 621
T e presence o overuse injuries in the elbow occurring with proximal injury to the
shoulder complex or with scapulothoracic dys unction is widely reported,33,37,92,95,96 and
thus a thorough inspection o the proximal joint is extremely important in the comprehen-
sive management o elbow pathology.
Elbow Joint : Special Test s

Several tests specif c or the elbow should be per ormed to assist in the diagnosis o elbow
dys unction. T ese include the inel test, varus and valgus stress tests, the milking test, val-
gus extension overpressure test, bounce home test, and provocation tests. T e inel test
involves tapping o the ulnar nerve in the medial region o the elbow over the cubital tunnel
retinaculum. Reproduction o paresthesia or tingling along the distal course o the ulnar
nerve indicates irritability o the ulnar nerve.92
T e valgus stress test (see Figure 21-4) is used to evaluate the integrity o the ulnar
collateral ligament. T e position used or testing the anterior band o the ulnar collateral
ligament is characterized by 15 to 25 degrees o elbow exion and orearm supination.
T e elbow exion position is used to unlock the olecranon rom the olecranon ossa and
decreases the stability provided by the osseous congruity o the joint. T is places a greater
relative stress on the medial ulnar collateral ligament.93 Reproduction o medial elbow
pain, in addition to unilateral increases in ulnohumeral joint laxity, indicates a positive
test. Grading the test is typically per ormed using the American Academy o Orthopedic
Surgeons guidelines o 0 to 5 mm grade I, 5 to 10 mm grade II, and greater than 10 mm
grade III.38 Per orming the test using a position o greater than 25 degrees o elbow exion
will increase the amount o humeral rotation during per ormance o the valgus stress test
and lead to misleading in ormation to the clinician’s hands. T e test is typically per ormed
with the shoulder in the scapular plane, but can be per ormed with the shoulder in the
coronal plane, to minimize compensatory movements at the shoulder during testing. T e
milking sign is a test the patient per orms on himsel , with the elbow held in approximately
90 degrees o exion. By reaching under the involved elbow with the contralateral extrem-
ity, the patient grasps the thumb o their injured extremity and pulls in a lateral direction,
thus imposing a valgus stress to the exed elbow. Some patients may not have enough ex-
ibility to per orm this maneuver, and a valgus stress can be imparted by the examiner to
mimic this movement, which stresses the posterior band o the ulnar collateral ligament.93
T e varus stress test is per ormed using similar degrees o elbow exion and shoulder
and orearm positioning. T is test assesses the integrity o the lateral ulnar collateral liga-
ment, and should be per ormed along with the valgus stress test, to completely evaluate the
medial/ lateral stability o the ulnohumeral joint.
T e valgus extension overpressure test has been reported by Andrews et al7 to deter-
mine whether posterior elbow pain is caused by a posteromedial osteophyte abutting the
medial margin o the trochlea and the olecranon ossa. T is test is per ormed by passively
extending the elbow while maintaining a valgus stress to it. T is test is meant to simulate
the stresses imparted to the posterior medial part o the elbow during the acceleration
phase o the throwing or serving motion. Reproduction o pain in the posteromedial aspect
o the elbow indicates a positive test.
Finally, the moving valgus test described by O’Driscoll et al101 has been recommended
to provide a stress to the ulnar collateral ligament and identi y ulnar collateral ligament
injury. T is test is per ormed with the patient in a seated position with the shoulder
abducted 90 degrees in the coronal plane to simulate the throwing motion. T e elbow is
then exed to 120 degrees while an external rotation orce is maintained by the examiner.
T is external rotation orce creates a valgus load at the elbow. T e elbow is then moved rom
120 degrees o exion to 70 degrees o elbow exion. A positive test involves recreation o
medial elbow pain in what has been termed the “shear zone” between 120 and 70 degrees.
T is test has resulted in a specif city o 75% and sensitivity o 100% when tested against an
arthroscopic evaluation the MUCL. T is test can used to determine the integrity o the ulnar
collateral ligament in the throwing athlete with medial elbow pain.
T e use o provocation tests can be applied when screening the muscle tendon units o
the elbow. Provocation tests consist o manual muscle tests to determine pain reproduction.
T e specif c tests, used to screen the elbow joint o a patient with suspected elbow pathology,
include wrist and f nger exion and extension as well as orearm pronation and supination.33
T ese tests can be used to provoke the muscle tendon unit at the lateral or medial epicondyle.
esting o the elbow at or near ull extension can o ten recreate localized lateral or medial
elbow pain secondary to tendon degeneration.79 Reproduction o lateral or medial elbow pain
with resistive muscle testing (provocation testing) may indicate concomitant tendon injury at
the elbow and directs the clinician to per orm a more complete elbow examination.

Overuse injuries constitute the majority o elbow injuries sustained by the athletic elbow
patient, with one o the most common being humeral epicondylitis.37,98 Repetitive overuse
is one o the primary etiologic actors evident in the history o most patients with elbow dys-
unction. Epidemiologic research on adult tennis players reports incidences o humeral epi-
condylitis ranging rom 35% to 50%.20,55,71,78,109 T e incidence reported in elite junior players
is signif cantly less (11% to 12%).143
Pat homechanics
Et iology of Humeral Epicondylit is
Reported in the literature as early as 1873 by Runge,117 humeral epicondylitis or “tennis
elbow,” as it is more popularly known, has been studied extensively by many authors.
Cyriax, in 1936, listed 26 causes o tennis elbow,25 while an extensive study o this over-
use disorder by Goldie, in 1964, reported hypervascularization o the extensor aponeurosis
and an increased quantity o ree nerve endings in the subtendinous space.48 More recently,
Leadbetter 84 described humeral epicondylitis as a degenerative condition consisting o a
time-dependent process that includes vascular, chemical, and cellular events that lead to
a ailure o the cell-matrix healing response in human tendon. T is description o tendon
injury di ers rom earlier theories where an in ammatory response was considered as a
primary actor; hence Leadbetter 84 and Nirschl96 used the term “tendinosis” as opposed to
the original term o “tendonitis.”
Nirschl95,96 has def ned humeral epicondylitis as an extraarticular tendinous injury char-
acterized by excessive vascular granulation and an impaired healing response in the tendon,
which he has termed “angiof broblastic hyperplasia.” In the most recent and thorough histo-
pathologic analysis, Nirschl et al79 studied specimens o injured tendon obtained rom areas
o chronic overuse and reported that these specimens did not contain large numbers o lym-
phocytes, macrophages, and neutrophils. Instead, tendinosis appears to be a degenerative
process characterized by large populations o f broblasts, disorganized collagen, and vascu-
lar hyperplasia.79 It is not clear why tendinosis is pain ul, given the lack o in ammatory cells,
and it is also unknown why the collagen does not mature or heal typically.
St ruct ures Involved in Humeral Epicondylit is

Nirschl96 described the primary structure involved in lateral humeral epicondylitis as the ten-
don o the extensor carpi radialis brevis. Approximately one-third o cases involve the tendon
o the extensor digitorum communis.79 Additionally, the extensor carpi radialis longus and
Rehabilitation Progression: Humeral Epicondylitis 623
extensor carpi ulnaris can be involved as well. T e primary site o medial humeral epicondylitis
is the exor carpi radialis, ollowed by the pronator teres, and exor carpi ulnaris tendons.95,96
Recent research describes in detail the anatomy o the lateral epicondylar region.18,51
T e specif c location o the extensor carpi radialis brevis tendon lies in erior to the tendi-
nous origin o the extensor carpi radialis longus, which can be palpated along the anterior
sur ace o the supracondylar ridge just proximal or cephalad to the extensor carpi radialis
brevis tendon on the lateral epicondyle.18 Greenbaum et al51 describe the pyramidal slope
or shape o the lateral epicondyle and explain how both the extensor carpi radialis brevis
and the extensor communis originate rom the entire anterior sur ace o the lateral epi-
condyle. T ese specif c relationships are important or the clinician to bear in mind when
palpating or the region o maximal tenderness during the clinical examination process.
Although detailed recent reports are not present in the literature regarding the medial epi-
condyle, care ul palpation can be used to discriminate between the muscle tendon junc-
tions o the pronator teres and exor carpi radialis. Additionally, palpation o the MUCL,
which originates rom nearly the entire in erior sur ace o the medial epicondyle and inserts
into the anterior medial aspect o the coronoid process o the ulna, should be per ormed.
Understanding the involved structures, as well as a detailed knowledge o the exact loca-
tions where these structures can be palpated, can assist the clinician in better localizing the
pain ul tendon or tendons involved.
Dijs et al30 studied 70 patients with lateral epicondylitis. T ey reported the area o
maximal involvement in these cases: the extensor carpi radialis longus in only 1% and the
extensor carpi radialis brevis in 90%. T e body o the extensor carpi radialis tendon was
implicated in 1% o cases, and 8% were at the muscle tendon junction over the most proxi-
mal part o the muscle o the extensor carpi radialis brevis.
Epidemiology of Humeral Epicondylit is

Nirschl95,96 reports that the incidence o lateral humeral epicondylitis is ar greater than
that o medial epicondylitis in recreational tennis players and in the leading arm o gol ers
(le t arm in a right-handed gol er). Medial humeral epicondylitis is ar more common in elite
tennis players and throwing athletes, as a result o the power ul loading o the exor and
pronator muscle tendon units during the valgus extension overload inherent in the accelera-
tion phase o those overhead movement patterns. Additionally, the trailing arm o the gol er
(right arm in a right-handed gol er) is more likely to have medial symptoms than lateral.
Rehabilitation Progression:
Humeral Epicondylitis
Following the detailed examination, a detailed rehabilitation program can commence.
T ree main stages o rehabilitation can conceptually be applied or the patient: protected
unction, total-arm strength, and the return to activity phase. Each is discussed in greater
detail in this section o the chapter with specif c highlights on the therapeutic exercises uti-
lized during each stage o the rehabilitation process.
Prot ect ed Funct ion Phase

During this f rst phase in the rehabilitation process, care is taken to protect the injured
muscle tendon unit rom stress, but not unction. Nirschl95,96 cautions against the use o
an immobilizer or sling because o urther atrophy o the musculature and negative e ects
on the upper-extremity kinetic chain. Protection o the patient rom o ending activities is
recommended, with cessation o throwing and serving suggested or medial-based humeral

symptoms. Allowing the patient to bat or hit 200 backhands allows or continued activity
while minimizing stress to the injured area. Very o ten however, sport activity must cease
entirely to allow the muscle tendon unit time to heal and to most importantly allow ormal
rehabilitation to progress. Continued work or sport per ormance can severely slow the pro-
gression o resistive exercise and other long-term treatments in physical therapy.
Use o modalities may be help ul during this time period; however, agreement on a
clearly superior modality or sequence o modalities has not been substantiated in the lit-
erature.18,82 A metaanalysis o 185 studies on treatment o humeral epicondylitis showed
glaring def cits in the scientif c quality o the investigations, with no signif cantly superior
treatment approach identif ed. Although many modalities or sequences o modalities have
anecdotally produced superior results, there is a great need or prospective, randomized,
controlled clinical trials in order to identi y optimal methods or intervention. Modalities
such as ultrasound,13,98 electrical stimulation and ice, cortisone injection,71,98 nonsteroidal
antiin ammatory drugs,115 acupuncture,19 transverse riction massage,61 and dimethyl sul -
oxide application 106 have all been reported to provide varying levels o relie in the literature.
Boyer and Hastings,18 in a comprehensive review o the treatment o humeral epicondylitis,
reported no signif cant di erence with the use o low-energy laser, acupuncture, extracor-
poreal shockwave therapy, or steroid injection.
T e use o cortisone injection has been widely reported in the literature during the pain
reduction phase o treatment o this o ten-recalcitrant condition. Dijs et al30 compared the
e ects o traditional physical therapy and cortisone injection in 70 patients diagnosed with
humeral epicondylitis. In their research, 91% o patients who received the cortisone injection
received initial relie , as compared with 47% who reported relie rom undergoing physical
therapy. A ter only 3 months the recurrence rate (o primary symptoms) in their subjects,
however, was 51% in the cortisone injection group, and only 5% in the physical therapy group.
Similar f ndings were reported in a study by Verhaar et al135 comparing physical therapy,
consisting o Mills manipulation and cross- riction massage, with corticosteroid injection
in a prospective, randomized, controlled clinical trial in 106 patients with humeral epicon-
dylitis. At 6 weeks, 22 o 53 subjects reported complete relie rom the cortisone injection,
whereas only 3 subjects had complete relie rom this type o physical therapy treatment. At
1 year, there were no di erences between treatment groups regarding the course o treat-
ment. T ese results show the short-term benef t rom the corticosteroid injection, as well as
the ine ectiveness o physical therapy using manipulation and cross- riction massage.
Several recent studies deserve urther discussion as they also can be used to direct cli-
nicians in the development o appropriate interventions. Nirschl et al97 studied the e ects
o iontophoresis with dexamethasone in 199 patients with humeral epicondylitis. Results
showed that 52% o the subjects in the treatment group reported overall improvement on the
investigators’ improvement index, with only 33% o the placebo group reporting improve-
ment 2 days a ter the series o treatments with iontophoresis. One month ollowing the treat-
ment, there was no statistical di erence in the overall improvement in the patients in the
treatment group versus the control group. One additional f nding rom this study that has
clinical relevance was the presence o greater pain relie in the group that underwent 6 treat-
ments in a 10-day period, as opposed to subjects in the treatment group who underwent
treatment over a longer period o time. Although this study does support the use o ionto-
phoresis with dexamethasone, it does not report substantial benef ts during ollow-up.
Haake et al54 studied the e ects o extracorporeal shock wave therapy in 272 patients
with humeral epicondylitis in a multicenter prospective randomized control study. T ey
reported that extracorporeal shock wave therapy was ine ective in the treatment o
humeral epicondylitis. Similarly, Bas ord et al10 used low-intensity Nd:YAG laser irradiation
at 7 points along the orearm 3 times a week or 4 weeks and reported it to be ine ective in
the treatment o lateral humeral epicondylitis.
Based on this review o the literature, it appears that no standardized modality or modal-
ity sequence has been identif ed that is clearly statistically more e ective than any other
at the present time. Clinical reviews by Nirschl95,96 and Ellenbecker and Mattalino 37 advo-
cate the use o multiple modalities, such as electrical stimulation and ultrasound, as well as
iontophoresis with dexamethasone, in order to assist in pain
reduction and encourage local increases in blood ow. T e
copious use o ice or cryotherapy ollowing increases in daily
activity is also recommended. T e use o therapeutic modali-
ties with cortisone injection, i needed, can only be seen as
one part o the treatment sequence, with increasing evidence
being generated avoring progressive resistive exercise.
Exercise is one o the most power ul modalities used in
rehabilitative medicine. Research shows increases in local
blood ow ollowing isometric contractions at levels as sub-
maximal as 5% to 50% o maximum voluntary contraction
both during the contraction and or periods o up to 1 min-
ute postcontraction.65 wo studies showed superior results
in the treatment o humeral epicondylitis using progressive
resistive exercise as compared with ultrasound.46 In a study
by Svernl and Adol son,127 38 patients with lateral humeral
epicondylitis were randomly assigned to a contract relax
stretching or eccentric exercise treatment group. Result o
this study showed a 71% report o ull recovery in the eccen-
tric exercise group, as compared to the group that per ormed
contract-relax stretching, which only ound 39% o the sub-
jects rating themselves as ully recovered. T ese studies
support the heavy reliance on the success ul application o
progressive resistive exercise, with an eccentric component,
in the treatment o humeral epicondylitis.
Tot al-Arm St rengt h Rehabilit at ion

Early application o resistive exercise or the treatment o
humeral epicondylitis ocuses on the important principle
that states that “proximal stability is needed to promote distal
mobility.”126 T e initial application o resistive exercise actually
consists o specif c exercises to strengthen the upper-extremity
proximal orce couples.62 T e rotator cu (deltoid and rotator
cu musculature) and lower trapezius orce couples are tar-
geted to enhance proximal stabilization using a low-resistance,
high-repetition exercise ormat (ie, 3 sets o 15, <60 repeti-
tion maximum loading). Specif c exercises such as side-lying
external rotation, prone horizontal abduction, and prone
extension, both with externally rotated humeral positions and
prone external rotation, all have been shown to elicit high lev-
els o posterior rotator cu activation during electromyogram
research (Figure 21-5).9,15,130 Additionally, exercises such as the
serratus press (Figure 21-6) and manual scapular protraction
and retraction resistance (Figure 21-7) can be sa ely applied
without stress to the distal aspect o the upper extremity during
this important phase o rehabilitation. T e use o cu weights Figure 21-5 Ro tato r cuff e xe rcise s use d
allows some o the rotator cu and scapular exercises to be during re habilitatio n o f e lbo w injurie s
per ormed with the weight attached proximal to

the elbow, to urther minimize overload to the
elbow and orearm during the earliest phases o
rehabilitation i needed or some patients.
T e initial application o exercise to the dis-
tal aspect o the extremity ollows a pattern that
stresses the injured muscle-tendon unit last. For
example, the initial distal exercise sequence or
the patient with lateral humeral epicondylitis
would include wrist exion and orearm prona-
tion, which provides most o the tensile stress
to the medially inserting tendons which are not
directly involved in lateral humeral epicondylitis
(Figure 21-8). Gradual addition o wrist exten-
sion and orearm supination, as well as radial
and ulnar deviation exercises are added as signs
and symptoms allow. Additional progression is
based on the elbow position utilized during dis-
Figure 21-6 Se rratus pre ss e xe rcise use d to re cruit and tal exercises. Initially, most patients tolerate the
stre ng the n the se rratus ante rio r exercises in a more pain- ree ashion with the
elbow placed in slight exion, with a progres-
sion to more extended and unctional elbow
positions, as signs and symptoms allow. T ese exercises are per ormed with light weights,
o ten as little as 1 lb or 0.5 kg, as well as tan or yellow T era-Band, emphasizing both the con-
centric and eccentric portions o the exercise movement. According to the research by Svernl
and Adol son,127 the eccentric portion o the exercise may actually have a greater benef t than
the concentric portion; however, more research is needed be ore a greater and clearer under-
standing o the role isolated eccentric exercise plays in the rehabilitation o degenerative ten-
don conditions is achieved. Multiple sets o 15 to 20 repetitions are recommended to promote
muscular endurance. Several studies show superior results in the treatment o humeral epi-
condylitis using progressive resistive exercise. 24,82,107,127,132
Once the patient can tolerate the most
basic series o distal exercises (wrist exion/
extension, orearm pronation/ supination, and
wrist radial/ ulnar deviation), exercises are
progressed to include activities that involve
simultaneous contraction o the wrist and
orearm musculature with elbow exion/
extension ROM. T ese include exercises such
as exercise ball dribbling ( Figure 21-9), the
Body Blade (Hymanson, X), the B.O.I.N.G.
arm exerciser device (OP P, Minneapolis,
MN) ( Figures 21-10 and 21-11), T era-Band
(Hygenic Corp, Akron, OH), resistance bar
external oscillations ( Figure 21-12) (which
combine wrist and orearm stabilization with
posterior rotator cu and scapular exercise),
and seated rowing (Figure 21-13). Additionally,
the use o closed-kinetic-chain exercise or the
upper extremity is added to promote cocon-
traction and mimic unctional positions with
Figure 21-7 Manual scapular re tractio n e xe rcise joint approximation (Figures 21-14 to 21-16).35
(B)
(A)
(C)
Figure 21-8
Distal upper extremity isotonic exercise patterns, including wrist flexion and extension, radial and ulnar deviation,
and forearm pronation and supination.
Svernl & Adol son 127 ollowed 38 patients with lateral humeral epicondylitis who were
randomly assigned to a contract-relax stretching or eccentric exercise treatment group.
Results o their study showed that 71% o the eccentric exercise group reported ull recov-
ery, as compared to 39% o the subjects who per ormed contract-relax stretching and
rated themselves as ully recovered. Croisior et al24 compared the e ectiveness o a passive
standardized treatment in patients diagnosed with chronic humeral epicondylitis (nonex-
ercise control) to a program that included eccentric isokinetic exercise. A ter training the
patients in the eccentric exercise group had a signif cant

reduction in pain intensity, an absence o bilateral strength
def cit in the wrist extensors and orearm supinators,
improved tendon imaging and improved disability status
with rating scales.
yler et al132 used an elastic based exible bar
(T era-Band Flexbar, Hygenic Corp, Akron, OH) to pro-
vide an eccentric based overload to the wrist and orearm
musculature in addition to a traditional rehabilitation
program. Results o their research, per orm ed initially
on patients with lateral hum eral epicondylitis using a
twisting type exercise to eccentrically load the exten-
sor musculature in an elbow-extended position, showed
superior results to traditional rehabilitation exercises
alone.132 T e reader is re erred to the yler et al article
or the specif c exercise sequence used or both m edial
and lateral hum eral epicondylitis. T e Flexbar exercise
sequence is described as beginning with preparatory
prelading the wrist and hand musculature (concentri-
cally), ollowed by a slow eccentric release o the same
muscles. T is sequence can be per ormed or either wrist
exion or wrist extension. Multiple sets o 15 repetitions
Figure 21-9 are recommended by the researchers,132 with slight levels
Ball dribbling using an exercise ball to promote rapid contraction

of the musculature in an endurance-oriented fashion.
Figure 21-10 Oscillato ry e xe rcise using the Figure 21-11 Oscillato ry e xe rcise using
B.O.I.N.G. (Bio me chanical Oscillatio n Inte g rate s the Bo dy Blade de vice
Ne uro muscular Gain), de vice
Figure 21-12 Oscillatory exercise using the Figure 21-13 Se ate d ro w ing e xe rcise
Thera-Band e x bar use d fo r pro ximal stabilizatio n and to tal-arm
stre ng th
Oscillations can be performed in a sagittal and frontal
plane direction to target specific muscle group activation.
Figure 21-14 Quadrupe d rhythmic stabilizatio n e xe rcise

Figure 21-15 Clo se d-chain uppe r-e xtre mity e xe rcise using the BOSU
platfo rm
Figure 21-16 Po inte r clo se d-chain uppe r e xtre mity e xe rcise using the
Bo dy Blade to pro mo te instability in the o pe n-chain limb and a me dicine ball
unde r the clo se d-chain limb
o discom ort (Visual Analog Scale [VAS] levels 3 to 4) during the exercise being allowed,
which is similar to other types o eccentric training programs.82 T e addition o this exer-
cise, coupled with eccentric wrist exion exercises with elastic tubing or bands or multiple
sets, is used to provide a controlled overload to the wrist, orearm, and f nger musculature
in this stage o the rehabilitation program. T ese site-specif c exercises are integrated with
total extrem ity ocus as described above, including the scapular stabilizers and rotator
cu , to complete the comprehensive rehabilitation program.
Most recently, Peterson et al107 studied a group o 81 patients with a 3-month history
(mean duration: 107 weeks) o chronic lateral elbow pain. Patients were randomly allo-
cated to an exercise group or a control group or a 3-month period o either concentric and
eccentric exercise (exercise group) or a “wait-and-see” control group. Exercises consisted
o controlled wrist exion and extension starting with a 1 kg (women) or 2 kg (men) water
container that was increased by one-tenth (1 dL o water) into the container with subjects
per orming 45 repetitions (3 sets o 15 repetitions). A ter 3 months o training, subjects in
the exercise group had a greater relie o pain with a maximal muscle test provocation and
elongation provocation test. Specif cally, 72% o the subjects in the exercise group had a
30% diminution in pain during the maximal voluntary muscle provocation test as com-
pared with 44% in the control group. T is study demonstrates the continued support o an
exercise-based approach to elbow tendon pathology.
In addition to the resistive exercise, the use o gentle passive stretching to optimize the
muscle tendon unit length is indicated. Combined stretches with the patient in the supine
position are indicated to elongate the biarticular muscle tendon units o the elbow, orearm
and wrist using a combination o elbow, and wrist and orearm positions (Figure 21-17).
Additionally, stretching the distal aspect o the extremity in varying positions o glenohu-
meral joint elevation is also indicated.37 Mobilization o the ulnohumeral joint can also be
e ective in cases where signif cant exion contractures exist. Use o ulnohumeral distrac-
tion with the elbow near ull extension will selectively tension the anterior joint capsule
(Figure 21-18).17
A B
Figure 21-17 Passive stre tching o f the w rist and fo re arm musculature
A. Wrist flexion and pronation to stretch the wrist extensors, and (B) wrist extension and supination to stretch the flexors
and pronators of the distal upper extremity.
Figure 21-18 Ulno hume ral jo int distractio n Figure 21-19 Iso kine tic w rist e xio n/
mo bilizatio n e xte nsio n e xe rcise o n the Bio de x™ iso kine tic
dynamo me te r
Altering the position of elbow exion and extension selectively
stresses portions of the anterior and posterior capsule.
As the patients tolerate the distal isotonic exercise progression pain- ree at a level o
3 to 5 pounds or m edium -level elastic tubing or bands, as well as dem onstrate a toler-
ance to the oscillatory type exercises in this phase o rehabilitation, they are progressed
to the isokinetic orm o exercise. Advantages o isokinetic exercise are the in herent
accom m odative resistance and utilization o aster, m ore unctional contractile veloci-
ties, in addition to providing isolated patterns to elicit high levels o m uscular activa-
tion. T e initial pattern o exercise used anecdotally has been wrist exion/ extension
( Figure 21-19 ), with orearm pron ation / supin ation
( Figure 21-20) added a ter success ul tolerance o a trial
treatm ent o wrist exion/ extension. Contractile veloci-
ties ranging between 180 an d 300 degrees per secon d,
with 6 to 8 sets o 15 to 20 repetition s, are used to os-
ter local muscular endurance.45 In addition to isokinetic
exercise, plyom etric wrist snaps ( Figure 21-21) and wrist
ips ( Figure 21-22), as well as upper-extrem ity patterns,
are utilized to begin to train the elbow or unctional and
sport specif c demands.
Ret urn t o Act ivit y Phase

O the 3 phases in the rehabilitation process or humeral
epicondylitis, return to activity is the one that is m ost
requently ignored or cut short, resulting in serious
Figure 21-20 Iso kine tic fo re arm pro natio n/ potential or reinjury and the developm ent o a “chronic”
supinatio n e xe rcise o n the Bio de x™ iso kine tic status o this injury. Objective criterion or entry into
dynamo me te r this stage are tolerance o the previously stated resistive
Figure 21-21 Plyo me tric w rist snap use d fo r Figure 21-22 Plyo me tric w rist ip use d fo r
e xplo sive training o f the w rist and ng e r e xo r e xplo sive training o f the w rist and ng e r e xo r
muscle g ro ups muscle g ro ups
exercise series, objectively docum ented strength equal to the contralateral extrem ity with
either manual muscle testing or, pre erably, isokinetic testing distal grip strength m ea-
sured with a dynam om eter, and unctional ROM. It is im portant to note that o ten in the
elite athlete, chronic musculoskeletal adaptations exist that prevent attainm ent o ull
elbow ROM. Recall that this is o ten secondary to the osseous and capsular adaptations
discussed earlier in this chapter.
Characteristics o interval sport return programs include alternate day per ormance,
as well as gradual progressions o intensity and repetitions o sport activities. For exam-
ple, utilizing low-compression tennis balls such as the Pro-Penn Star Ball (Penn Racquet
Sports, Phoenix, AZ) or Wilson Gator Ball (Wilson Sporting Goods, Chicago, IL) during
the initial contact phase o the return to tennis decreases impact stress and increases tol-
erance to the activity. Per orming the interval program under supervision, either during
therapy or with a knowledgeable teaching pro essional or coach, allows or the biome-
chanical evaluation o technique and guards against overzealous intensity levels, which
can be a common mistake in well-intentioned, motivated patients. Using the return pro-
gram on alternate days, with rest between sessions, allows or recovery and decreases the
potential or reinjury.
wo other im portant aspects o the return to sport activity are the continued applica-
tion o resistive exercise and the m odif cation or evaluation o the patient’s equipm ent.
Continuation o the total-arm strength rehabilitation

exercises usin g elastic resistance, m edicine balls, and
isotonic or isokinetic resistance is im portant to continue
to enhance not only strength but also m uscular endur-
ance. Inspection and m odif cation o the patient’s ten-
nis racquet or gol clubs is also im portant. For exam ple,
lowering the strin g tension several poun ds and ensur-
ing that the player uses a m ore resilient or so ter string,
such as a coreless multif lam ent synthetic string or gut,
is widely recom m ended or tennis players with upper-
extrem ity in jury histories.95,96,98 Grip size is also very
im portant with research showing changes in m uscular
activity with alteration o handle or grip size.1 Measure-
m ent o proper grip size has been described by Nirschl
as corresponding to the distance between the distal tip
o the ring f nger along the radial border o the f nger to
the proxim al palm ar crease.95 Nirschl has also recom -
Figure 21-23 Co unte rfo rce brace applie d m ended the use o a counter orce brace ( Figure 21-23)
the e lbo w fo r a patie nt w ith late ral hume ral in order to decrease stress on the insertion o the exor
e pico ndylitis and extensor tendons during work or sport activity.52
Additional Treatments Presently

Used for Tendon Injury
Plat elet -Rich Plasma

Platelet-rich plasma (PRP) is a treatment modality that can be utilized in many orthope-
dic injuries involving tendon and ligament. Such treatment involves localized injections o
PRP at various concentrations into the injured tissues, which has been theorized to improve
healing by delivering a high concentration o platelets to the injured region.8 Research dem-
onstrates that platelets are involved in healing through clot ormation and the release o
growth actors and cytokines, although which specif c actors and how they are regulated is
still not completely understood. Growth actors in the PRP concentrate include, but are not
limited to, trans orming growth actor β 1, platelet-derived growth actor, vascular endothe-
lial growth actor, epithelial growth actor, hepatocyte growth actor, and insulin-like growth
actor 1.44 No classif cation system currently exists to regulate PRP preparation, including
regulation o methods o platelet concentration, activation, and the presence o white blood
cell concentration. As a result, much o the literature that relates to the use o PRP is di cult
to cross-re erence and compare despite, recent attempts to uni y a system.29
T e literature supporting the use o PRP treatment or tendon injuries demonstrates
mixed results with variable success related to the location o the injured tendons and
ligaments. Various cell culture and animal studies demonstrate the e cacy o PRP. In one
animal study, PRP used in posttendon repair not only increased healing strength and load-
to- ailure, it did so without increasing adhesion ormation or in ammation 2 weeks ollow-
ing surgery. Although many o the animal studies are encouraging, the results in human
studies have been limited.120,129 During 1 large, stratif ed, block-randomized, double-blind,
placebo-controlled trial by deVos, it was concluded that PRP injection therapy did not
improve pain and activity when compared to saline injections used with controls. Although
this study was per ormed on patients with chronic Achilles tendinopathy, it illustrates the
equivocal nature o PRP treatment.28
Postoperative Rehabilitation Progression 635
Since the deVos study was released in 2006 there have been num erous other PRP
studies exhibiting variable success which is o ten dependent upon the anatomical area o
administration. One such area in which treatment with PRP has been encouraging and has
almost become an established treatment based on level I data is lateral and medial epicon-
dylar tendinopathies. A 2006 level II cohort study comparing PRP and bupivacaine injec-
tion or elbow epicondylitis resulted in statistically signif cant improvement in patients’
VAS or pain score and Mayo elbow score. O note, the study excluded patients taking
nonsteroidal antiin ammatory drugs, a comm on treatm ent currently utilized or such
diagnoses.91 Further evidence supporting PRP has em erged in a level 1 double-blinded
randomized control trial o patients with lateral epicondylitis. T is study included patients
that had ailed nonsteroidal antiin ammatory drug therapy, physical therapy, bracing,
and other conservative therapies commonly used. Patients were randomized and received
either a PRP injection or corticosteroid injection and were then ollowed or 1 and eventu-
ally 2 years. T e PRP group had better improvement with ewer interventions and opera-
tions, with concurrent reductions in the disabilities o the arm, shoulder, and hand and
VAS scores even a ter 2 years. Furthermore, there were no reported complications with the
PRP treatment.49,105 In a similar randomized control study that included lateral epicon-
dylitis and plantar asciitis, PRP outper ormed corticosteroid injections with signif cant
improvement in unction and pain.104
More recent studies have compared PRP with autologous whole blood in the treatment
o lateral epicondylitis. While the patients receiving PRP consistently per ormed better in
a level 1 randomized, controlled study, only one time point at 6 weeks showed any statisti-
cally signif cant di erence.128 A second study utilizing a similar model demonstrated no di -
erence between the 2 groups at 6 months.23 T ese results, however, are not straight orward
because o con ounding actors o red blood cells and white blood cells possibly playing a
role in the healing process. More research is needed to decipher the appropriate concentra-
tions o PRP and whether other blood components should be included in order to positively
impact healing.
Postoperative Rehabilitation Progression

In a study o more than 3000 cases o humeral epicondylitis, Nirschl96 has reported that 92%
respond to nonoperative treatment. Characteristics o patients who o ten require surgical
correction or this condition are ailure o nonoperative rehabilitation programs, minimal
relie with corticosteroid injection, and intense pain in the injured elbow even at rest. Sur-
gical treatment or lateral humeral epicondylitis, as reported by Nirschl,96 involves a small
incision rom the radial head to 1 inch proximal to the lateral epicondyle. T rough this inci-
sion, Nirschl removes the pathologic tissue he termed angiof broblastic hyperplasia , with-
out disturbing the attachment o the extensor aponeurosis, in order to preserve stability o
the elbow.96 Vascular enhancement is a orded by drilling holes into the cortical bone in the
anterior lateral epicondyle to cancellous bone level. Postoperative immobilization is brie
(48 hours), with early motion o the wrist and f ngers on postoperative day 1, progressing
to elbow active assistive ROM during the f rst 2 to 3 weeks. Resistive exercise is gradually
applied a ter the third postoperative week, with a return to normal daily activities expected
at 8 weeks postoperatively and a return to sport activity several months therea ter.95,96
Rehabilit at ion Following Elbow Art hroscopy

Repetitive stresses to the athletic elbow o ten result in loose body ormation and osteochon-
dral injury, in addition to the more commonly reported tendon injury resulting in humeral
epicondylitis. Andrews and So er 4 report that the most common indications or elbow
arthroscopy are loose body removal and removal o osteophytes. Posteromedial decom-
pression includes the excision o osteophytes, with or without resection o additional pos-
teromedial bone rom the proximal olecranon.3 Early emphasis on regaining ull-extension
ROM is possible because o the minimally invasive arthroscopic procedure. T e senior
author’s postoperative protocol ollowing arthroscopic procedures o the elbow is presented
in Appendix 1. Progressive application o resistive exercise to increase both strength and
local muscle endurance orms the bulk o the rehabilitation protocol. Use o early shoul-
der and scapular stabilization is also recommended in these patients in preparation to the
return to overhead activities and aggressive unctional activity ollowing discharge.
Outcomes ollowing elbow arthroscopy or posteromedial osteophyte and loose body
removal were reported by Oglive-Harris et al,102 where 21 patients were ollowed or an aver-
age o 35 months postoperatively, rendering good and excellent results in 7 and 14 patients,
respectively. O’Driscoll and Morrey100 reported that arthroscopic removal o loose bodies
was o benef t in 75% o all patients; however, when loose bodies were not secondary to
some other intraarticular condition, 100% o patients rated the procedure as benef cial.
Andrews and immerman 5 reviewed the results o 73 cases o arthroscopic elbow surgery
in pro essional baseball pitchers. Eighty percent o players were able to return to ull activ-
ity, returning to pitching at their preinjury level or at least 1 season. Further review o these
patients ound that 25% returned or additional surgery, o ten requiring stabilization and
reconstruction o the ulnar collateral ligament as a result o valgus instability. T is impor-
tant study shows the close association between medial elbow laxity and posterior medial
osteochondral injury and highlights the importance o identi ying subtle instability in the
athletic elbow.
Reddy et al110 retrospectively reviewed a sample o 172 patients who underwent elbow
arthroscopy and had a mean ollow-up o 42 months. Fi ty-six percent o these patients had
an excellent result, which allowed them a ull return to activity, with 36% having a good
result. A 1.6% complication rate was reported, with an overall conclusion that this proce-
dure is both sa e and e cacious or the treatment o osteochondral injury o the elbow.
Ellenbecker and Mattalino 37 measured muscular strength at a mean o 8 weeks post-
operatively in 8 pro essional baseball pitchers ollowing arthroscopic removal o loose
bodies and posteromedial olecranon spur resection. Results showed a complete return o
wrist exion/ extension strength and orearm pronation/ supination strength at 8 weeks ol-
lowing arthroscopy. T is allows or a gradual progression to interval sport return programs
between 8 and 12 weeks postoperatively.
Valgus Extension Overload Injuries

Repeated activities, such as overhead throwing, tennis serving, or throwing the javelin, can
lead to characteristic patterns o osseous and osteochondral injury in both the older active
patient, as well as the adolescent elbow. T ese injuries are commonly re erred to as valgus
extension overload injuries.142
Pat homechanics
As a result o the valgus stress incurred during throwing or the serving motion, traction
placed via the medial aspect o the elbow can create bony spurs or osteophytes at the
medial epicondyle or coronoid process o the elbow.11,60,123 Additionally, the valgus stress
during elbow extension creates impingement, which leads to the development o osteo-
phyte ormation at the posterior and posteromedial aspects o the olecranon tip, causing
Ulnar Collateral Ligament Injury 637
chondromalacia and loose body ormation.142 T e combined motion o valgus pressure
with the power ul extension o the elbow leads to posterior osteophyte ormation, because
o impingement o the posterior medial aspect o the ulna against the trochlea and olecra-
non ossa. Joyce 70 has reported the presence o chondromalacia in the medial groove o the
trochlea, which o ten precedes osteophyte ormation. Erosion to subchondral bone is o ten
witnessed when olecranon osteophytes are initially developing. Injury to the ulnar collat-
eral ligament and medial muscle-tendon units o the exor-pronator group can also occur
with this type o repetitive loading.60,144
During the valgus stress that occurs to the human elbow during the acceleration phase
o both the throwing and serving motions, lateral compressive orces occur in the lateral
aspect o the elbow, specif cally at the radio-capitellar joint. O great concern in the imma-
ture pediatric throwing athlete is osteochondritis dissecans and Panner disease.37,70 Both
o these injuries are covered in Chapter 30. In the older adult elbow, the radiocapitellar
joint can be the site o joint degeneration and osteochondral injury rom the compressive
loading.60 T is lateral compressive loading is increased in the elbow with MUCL laxity or
ligament injury.37
Ulnar Collateral Ligament Injury
Pat homechanics and Mechanism of Injury

Attenuation o the ulnar collateral ligament can produce valgus instability o the elbow,
which can lead to medial joint pain, ulnar nerve compromise, and lateral radiocapitellar
and posterolateral osseous dys unction, which results in severe dys unction in the throwing
or racquet sport athlete. T e repetitive valgus loading that occurs in the elbow during the
acceleration phase o the throwing or serving motion can attenuate this structure. Sprains
and partial thickness tears o the MUCL can occur and progress to complete tears and avul-
sions o the ligament rom its bony attachments.31

Nonoperative rehabilitation o the athlete with an ulnar collateral ligament sprain also
involves the primary stages outlined in the rehabilitation o humeral epicondylitis. Dur-
ing the initial stage o rehabilitation, immobilization o the elbow is o ten a characteristic
part o the process to decrease pain and enhance healing. Either an immobilizer or hinged
brace is used to limit end ranges o elbow extension and exion. Modalities are again used
to assist in the healing process, as are gentle ROM, submaximal isometrics, and manual
resistance o both wrist and orearm midrange movements.

Use o a total-arm strength rehabilitation protocol is indicated to acilitate both muscular
strength and endurance to the elbow, orearm, and wrist. In addition to previously men-
tioned exercises, particular attention is given to eccentric muscle work o the wrist exors
and orearm supinators to attempt to dynamically support the attenuated ulnar collateral
ligament. Because o the intimate association between the exor carpi ulnaris and the ulnar
collateral ligament, early strengthening in the pattern o wrist exion and ulnar deviation
may provoke symptoms; however, later in rehabilitation, the repeated use o exercises to
strengthen the muscles directly overlying the injured ligament to provide dynamic stabiliza-
tion is highly recommended.26
In addition to distal strengthening, signif cant emphasis is placed on strengthening o

the rotator cu and scapular stabilizers o the throwing athlete with ulnar collateral liga-
ment injury. In addition to increasing strength and endurance o the scapular stabilizers
and rotator cu musculature, attention is also directed toward the evaluation o shoulder
ROM and specif cally to the range o rotational ROM. Dines et al31 has identif ed increased
glenohumeral internal rotation ROM def cits in throwing athletes with ulnar collateral liga-
ment injury as compared to cohorts o throwing athletes without medial elbow injury. T is
f nding highlights the importance o evaluation and treatment o the entire upper extremity
kinetic chain in the throwing athlete with ulnar collateral ligament injury. T e application
o specif c interventions directed to stretch the posterior shoulder 64 to improve internal
rotation ROM is recommended based on this new f nding. Wilk et al141 and Shanley et al121
both have shown increases in shoulder injury risk with losses o approximately 12 degrees
o internal rotation or more on the throwing arm, as well as losses o only 5 degrees or more
o total rotation ROM141 in baseball pitchers.
Progression to plyometric exercises, which impart a submaximal, controlled valgus
stress to the medial aspect o the elbow such as a 90/ 90 shoulder and elbow medicine ball
toss in later stages o rehabilitation, attempts to simulate loads placed on the medial elbow
(Figure 21-24). Use o the isokinetic dynamometer or distal strengthening is also recom-
mended, with additional training ocused on the shoulder or internal/ external rotation with
the arm abducted 90 degrees and elbow exed 90 degrees (Figure 21-25). Use o this position
imparts a controlled valgus stress to the elbow in addition to strengthening the rotator cu .36
Figure 21-24 Figure 21-25 Iso kine tic 90/ 90 inte rnal/
e xte rnal ro tatio n training po sitio n o n the
Plyometric 90/90 medicine ball toss to simulate loads placed Bio de x™ iso kine tic dynamo me te r
to the medial elbow in the later stages of rehabilitation only
to prepare the overhead athlete for a return to throwing.
Surgical Technique for Ulnar Collateral Ligament Reconstruction 639
A complete return o ROM and isokinetically documented appropriate elbow, orearm,
and wrist strength are required be ore an interval program is initiated. Reoccurrence o
pain, eelings o instability, or neural irritation with throwing or unctional activity identi y
the patient as a potential candidate or an ulnar collateral ligament repair or reconstruction.
It should be noted that many patients who undergo nonoperative rehabilitation may prog-
ress to the need or operative intervention.
Post operat ive Rehabilit at ion Following

Ulnar Collat eral Ligament Reconst ruct ion
Operative procedures or the athlete with valgus instability o the elbow have ocused
on direct primary repair o the ligament 81 as well as utilization o an autogenous gra t or
reconstruction o the medial elbow. Conway et al,22 Jobe et al,68 and Regan et al111 reported
that the palmaris tendon used as the autogenous gra t, harvested rom the ipsilateral ore-
arm, ails at higher loads (357 N) and is 4 times stronger than the native anterior band o the
ulnar collateral ligament, which ails at 260 N.
In a retrospective study by Conway et al22 o 71 throwing athletes who underwent either
surgical repair or reconstruction o the ulnar collateral ligament, 87% were ound to have
a midsubstance tear o the ulnar collateral ligament, 10% had a distal ulnar avulsion, and
only 3% avulsed rom the medial epicondyle. T irty-nine percent o these elbows had cal-
cif cation and scar ormation in the ulnar collateral ligament with 16% demonstrating an
osteophyte to the posteromedial olecranon most likely rom the increased valgus extension
overload secondary to ulnar collateral ligament attenuation.
T e clinical evaluation o these patients preoperatively resulted in a positive valgus
stress test in 8 o the 14 patients who underwent an ulnar collateral ligament repair, and 33
o 56 patients who underwent autogenous reconstruction. Valgus stress radiographs were
also used in the preoperative evaluation with greater emphasis placed upon the subjective
and clinical evaluation.22 Fi ty percent o these athletes demonstrated a exion contracture
that limited ull elbow extension.
Surgical Technique for Ulnar

Collateral Ligament Reconstruction
T e surgical technique used to reconstruct the ulnar collateral ligament is described exten-
sively by Conway et al,22 Jobe et al,68 and Jobe and Elattrache.66 A 10-cm medial incision
over the medial epicondyle is used to provide exposure with care ul dissection and protec-
tion o the ulnar nerve carried out be ore the ulnar collateral ligament is addressed. I a
primary repair is per ormed, adequate normal-appearing ligamentous tissue is required to
allow or direct repair. I inadequate ligamentous tissue is present, a reconstruction is per-
ormed. Additional exposure is required to per orm the reconstruction, which is obtained
by transection o the exor/ pronator tendinous origin.
T is has important ramif cations with respect to rehabilitation. T e removal o this ten-
dinous origin results in a greater amount o time required or healing, and a longer time
period be ore resistive exercise o the exor/ pronator muscles and orearm supination and
wrist extension ROM can be per ormed.
Calcif cation within the ligament and surrounding so t tissues is also removed with
relocation o the ulnar nerve per ormed by removing it rom the cubital tunnel. T e ulnar
nerve is mobilized rom the level o the arcade o Struthers to the interval between the two
heads o the exor carpi ulnaris. T e attachment sites o the anterior band o the ulnar
collateral ligament are identif ed and tunnels are drilled in the medial epicondyle and
proximal ulna to approximate the anatomical location o the original ligament. T e gra t
taken rom the ipsilateral palmaris longus (i available) is then placed in a f gure-o -8 ash-
ion through the tunnels. T e ulnar nerve is care ully transposed so that no impingement or
tethering occurs. Reattachment o the exor pronator origin is then per ormed. T e elbow
is immobilized in a position o 90 degrees o exion, neutral orearm rotation, with the wrist
le t ree to move.

T e elbow remains immobilized or the f rst 10 days postoperatively, with gentle gripping
exercises allowed in order to prevent urther disuse atrophy. Active and passive ROM o the
elbow, wrist, and shoulder are per ormed at 10 days postoperatively. Close monitoring o the
ulnar nerve distribution in the distal upper extremity is recommended because o the trans-
position o the nerve that requently accompanies surgical reconstruction o the MUCL. As
discussed in the previous section entitled “Surgical echnique or UCL Reconstruction”, care
is taken to protect the gra t by gradually progressing elbow extension ROM to 30 degrees
by week 2 and f nally to terminal ranges by 4 to 6 weeks postoperatively. Protection o the
gra t rom large stresses is recommended, even though loss o extension ROM is an undesir-
able postoperative result. T ere ore, progressive increases in elbow extension ROM and the
use o gentle joint mobilization and contract-relax stretching techniques are warranted to
achieve timely, optimal elbow extension. Because o the reattachment o the exor-pronator
tendinous insertion, limited ROM into wrist extension and orearm supination is per ormed
or the f rst 6 weeks until healing o the exor-pronator insertion takes place.
Rehabilitation o the postoperative elbow should also include activities to restore
proprioceptive unction to the injured joint. Kinesthesia is the perceived sensation o the
position and movement o joints and muscles and an important part in the coordination
o movement patterns in the peripheral joints. Simple use o exercises such as angular rep-
lication and end-range reproduction can be used early in rehabilitation, without visual
assistance, to stimulate mechanoreceptors in the postoperative joint. T ese procedures are
utilized early in the rehabilitation process concomitant with ROM and joint mobilization.
Loss o kinesthetic awareness in the upper extremity ollowing injury has been objectively
identif ed by Smith and Brunolli.124
Rehabilit at ion Progression (Appendix 2)

T e progression o resistive exercise ollows previously discussed exercises, beginning with
multiple-angle isometrics at week 2 and submaximal isotonics during the ourth postopera-
tion week. Utilization o the total-arm strength concept is ollowed, with proximal weight
attachment or glenohumeral exercises to prevent stresses placed across the elbow. No gle-
nohumeral joint, internal or external rotation strengthening, is allowed or at least 6 weeks
to as many as 16 weeks postoperation, because o the valgus stress placed upon the elbow
with this movement pattern. During weeks 8 to 12 ollowing surgery, both concentric and
eccentric exercises are per ormed in the elbow extensors and exors, as well as a contin-
ued total-arm strengthening emphasis, with all distal movement patterns described in non-
operative rehabilitation o humeral epicondylitis being applied. Plyometric exercises, ball
dribbling, and closed-chain exercises are also introduced during this time rame.
Isokinetic training is introduced at 4 months postoperation, with isokinetic testing
applied to identi y areas needing specif c emphasis.139,140 Progression o isokinetic training
patterns by these authors again ollows rom wrist extension/ exion to orearm pronation/
supination, and, f nally, to elbow extension/ exion. T e isokinetic dynamometer is also
Elbow Dislocations 641
used at 4 to 6 months postoperatively or shoulder internal/ external rotation strengthening
with 90 degrees o abduction and 90 degrees o elbow exion to impart a gentle, controlled
valgus stress to the elbow. At 4 months postoperation, throwing athletes begin an interval-
throwing program to prepare the elbow or the stresses o unctional activity.
T e duration o rehabilitation postoperatively is o ten 6 months to a year. A slow
revascularization o the gra t through a sheath o granulation tissue that grows rom the
tissue adjacent to the site o implantation encircles the gra t is the rationale provided by
Jobe et al68 or their time-based rehabilitation program. T ey are convinced that at least
1 year is required or the tendon gra t and its surrounding tissues to develop su cient
strength and endurance to unction as a ligament in the medial elbow.
Out comes Following Ulnar Collat eral

Ligament Reconst ruct ion
In their series o 56 reconstructed elbows, Conway et al22 reported baseball players return to
throwing 15 eet by 4.5 months, with competition at 12.5 months postoperation. T e athlete
with a repaired ulnar collateral ligament per ormed throwing activities o 15 eet at 3 months
and competed at 9 months. Overall, an excellent result was achieved in 64% o the opera-
tive elbows o elite athletes. An excellent result was def ned as achieving a level o activity
equal to or greater than preinjury level. Bennett et al12 reported improved stability in 13 o
14 cases o ulnar collateral ligament reconstruction in an active adult and working popula-
tion, with improved stability reported in all cases o direct repair by Kuroda and Sakamaki.81
A exion contracture was reported in as many as 50% o the athletes at a mean o six years
ollowing an autogenous ulnar collateral ligament reconstruction.22 Conway et al22 did not
eel that this f nding limits per ormance, since elbow ROM during throwing ranges rom
120 degrees to 20 degrees, although conscious e ort during rehabilitation is given to regain
as much extension as possible during the time-based rehabilitation program.
Elbow Dislocations
Failure o the normally stable osseous, ligamentous, capsular, and muscular constraints at
the elbow ultimately can lead to dislocation in response to a macrotrauma.
Pat homechanics
T e elbow is the second most commonly dislocated large joint behind the shoulder in the
adult population and the most commonly dislocated joint in children younger than the
age o 10 years.86 It is reported that 7 o every 100,000 people su er an elbow dislocation.69
Inherent in any elbow dislocation is a degree o instability present at the joint. Rehabilita-
tion and treatment are predicated upon regaining ull unctional mobility while maintain-
ing elbow joint stability.
Mechanism of Injury
Elbow dislocations are typically the result o trauma as the person alls onto an outstretched
arm. wo specif c mechanisms o injury have been reported. Hyperextension along with
an axially directed orce causes the olecranon to act as a ulcrum, levering the trochlea
over the coronoid process.86 A posterolateral rotary-directed orce can produce a rotational
displacement o the ulna on the humerus leading to dislocation.99 A combination o axial
compression, elbow exion, valgus stress, and orearm supination produces this type o dis-
placement. Concomitant injuries associated with elbow dislocations include ractures, so t
tissue tear or rupture o ligaments, muscles, and joint capsule, vascular and neural com-
promise, as well as articular cartilage de ects. Following the dislocation event, the elbow
typically presents with signif cant swelling, severe pain, and structural de ormity with the
orearm appearing shortened upon observation.
Classi cat ion

raditionally, elbow dislocations are classif ed according to the direction o ulnar displace-
ment relative to the humerus. T e overwhelming majority o cases involve a posterior
dislocation versus the rare incidence o both anterior and lateral dislocation. Posterior dis-
locations are urther subdivided into posterior, posteromedial, and posterolateral groups.
Approximately 90% o all elbow dislocations are posterior and posterolateral.6 Other classi-
f cations include simple versus complete dislocations. Simple dislocations involve minimal
disruption o the congruity o bony and so t-tissue restraints, which usually allow or early
initiated motion and rehabilitation. Complete dislocations involve the destruction o the
bony restraints and so t tissue, particularly the ulnar collateral ligament. T e ulnar collat-
eral ligament and bony articulation provide the majority o stability at the elbow absorbing
54% and 33% o the valgus orces at 90 degrees o elbow exion and 31% each at 0 degrees
o elbow exion.93 Complete dislocations generally require a longer immobilization and
recovery period to allow or healing o the primary restraints. Further classif cation is used
to describe posterolateral instability as it progresses to dislocation. T is classif cation is
divided into 3 stages and based upon a circular disruption o bone and so t tissue that starts
laterally and progresses toward the medial side o the elbow.99 Stage 1 involves a partial
or complete rupture o the lateral collateral ligament resulting in subluxation. In stage 2,
the entire lateral collateral ligament is ruptured along with part o the anterior and poste-
rior capsule leading to a perched dislocation. Perched re ers to the position o the coronoid
process as it sits “perched” on the posterior aspect o the trochlea. Stage 3 posterolateral
dislocations are considered complete dislocations. Stage 3A involves all so t tissues around
the elbow including the posterior band o the ulnar collateral ligament with the exception
o the anterior band. In stage 3B, complete disruption o both lateral and ulnar collateral
ligament complexes results in gross multidirectional instability.

Immediate care o elbow dislocations initially involves reduction, evaluation o the neu-
rovascular triad or compromise, and urther assessment o ligamentous stability. Radio-
graphs and MRI are obtained to determine the extent o bony and so t-tissue damage. T e
elbow is typically placed in a posterior splint at 90 degrees exion and immobilized until
cleared to begin ROM activities. Severe damage to bony and so t-tissue restraints may
require surgical intervention.

Elbow rehabilitation guidelines ollowing dislocation comprise 3 distinct phases, as pro-
posed by Harrelson and Leaver-Dunn.56 Phase 1 is the immediate motion phase and gen-
erally starts anywhere rom 1 to 10 days postinjury. Early active ROM (all planes) within
a protected and pain- ree range is initiated to prevent adhesion ormation and exion
contracture, which causes subsequent loss o motion and pain. For simple dislocations,
immediate motion protocols have been shown to produce avorable results including
return o ull motion, early return to athletic and competitive activities, and low incidence
Elbow Fractures 643
o recurrent instability.116,133,134 Passive ROM is not indicated early because o the possibility
o heterotopic ossif cation. Management o pain and in ammation is conducted with ice,
compression, and use o modalities. Strengthening activities can include gripping, shoulder
and wrist isotonics, and gentle multiangle submax-to-max isometrics or both elbow exion
and extension. All exercises should be completed in a pain- ree ROM. Care should be taken
to avoid valgus stresses at the elbow. T e posterior splint is usually discharged; however, a
hinged elbow brace may be utilized to protect ROM within the limits o stability.
Phase 2 consists o the intermediate phase rom days 10 to 14. During this period chie
concern is achieving ull elbow ROM particularly extension. Strength, endurance, and
power exercise are progressed to include elbow isotonics in all planes. Progressive resistive
exercises are to be incorporated or the shoulder, wrist, and elbow. Inclusion o propriocep-
tive activities, rhythmic stabilization, plyometrics, and eccentric isotonics during the lat-
ter parts o this phase helps retrain the dynamic elbow stabilizers. Phase 3 is the advanced
strengthening phase beginning rom week 2 to 6. During this phase preparation is made or
a gradual return to sport or activity. Exercise progression is to include sport specif c activi-
ties and drills along with continued progressive resistive exercise. At this time, an interval-
throwing program may be initiated or those returning to overhand throwing activities.
Wilk and Arrigo 138 also include a return to activity phase as part o a general rehabilitation
protocol. Sport-specif c exercise and tests are conducted to determine appropriate stabil-
ity requirements on the elbow. Upon clinical examination by the physician, ROM should
be ull and no pain present. Medical doctor clearance is ultimately required or return to
activity. Bracing or taping may continue to be used to ensure stability and joint protection.
Elbow Fractures
Pat homechanics and Mechanism of Injury

Fractures that a ect unction at the elbow joint may occur at the distal humerus, capitel-
lum, coronoid, olecranon, radial head and neck, supracondylar region, lateral condyle, and
medial epicondyle. T ese ractures occur in both children and adults as the result o an
acute traumatic injury, such as a direct collision or a all on an outstretched hand. A thor-
ough clinical examination and radiographs are important or obtaining a correct diagno-
sis so that appropriate treatment can be given. Clinical signs and symptoms o a racture
include history o traumatic onset, pain, swelling, tenderness, and ecchymosis. Elbow sta-
bility and neurovascular status should also be assessed immediately ollowing injury. T e
presence o the posterior at pad sign on radiographs has been suggested as a sign o an
intracapsular elbow racture in pediatric patients even i no racture is seen on the radio-
graph. E usion within the elbow joint elevates the posterior at pad, making it visible on
radiographs. In a prospective study, the presence o a posterior at pad on radiographs was
indicative o a racture in 76% o the children evaluated. T ese results suggest that the chil-
dren with an elevated posterior at pad sign should be treated as though a nondisplaced
elbow racture is present, even i the racture is not evident on radiographs.122
Types of Elbow Fract ures

Supracondylar Fract ures
Supracondylar ractures are the most common elbow ractures that occur in children and
account or 60% o all elbow ractures.32,89 T ey o ten occur in children who are around
7 years old.27 T e mechanism o injury is a all on a hyperextended arm with pronation.27,32
Because the supracondylar ridge is only 2 to 3 mm thick in children,32 it has a high risk
or injury with a hyperextension mechanism. T e Gartland classif cation system is used to

divide supracondylar ractures into 3 types.32,89 ype I ractures are nondisplaced and usu-
ally treated with 3 weeks o immobilization. ype II ractures are moderately displaced, but
there is contact between the ragments as the posterior periosteal hinge is intact. A com-
plete displacement is classif ed as type III. Posteromedial displacement is associated with
radial nerve injuries, and posterolateral displacement is associated with brachial artery or
median nerve injury. Reduction and surgical stabilization is required or type III, and pos-
sibly or type II ractures.32,89 T ree to 4 weeks o immobilization is recommended ollow-
ing surgery.27 Complications ollowing supracondylar injury may include cubitus varus,
transient nerve injury, and compartment syndrome.32
Full elbow ROM can be di cult to regain a ter supracondylar ractures and rehabilita-
tion may last several months.27 Loss o ROM will vary based on patient age, injury severity,
and concomitant injuries. Keppler et al72 investigated the e ectiveness o physiotherapy in
regaining elbow ROM a ter uncomplicated, operative treatment supracondylar humeral
ractures without neurovascular injury in children between the ages o 5 and 12 years. At
12 and 18 weeks ollowing surgery, results showed a signif cant improvement in elbow ROM
in those children receiving physiotherapy compared to those not receiving treatment. How-
ever, at a 1-year ollow-up, there was no signif cant di erence between the children who
had received physical therapy and those who did not.
Lat eral Condyle Fract ures

Lateral condyle ractures account or 12% to 20% o elbow ractures in children,14,32,83,89
and are the second m ost com m on elbow racture.83 T ese ractures result rom a all on
an outstretched hand with orearm supination.89,90 A varus orce may cause the extensor
muscles and collateral ligam ent to avulse the lateral condyle.32,90 Lateral condyle rac-
tures are classif ed by the Milch system into 2 types based on the location o the racture
line.32,89,90 Milch type I ractures occur when the racture line is lateral to the trochlear
groove or in the trochlear groove. Milch type II ractures extend m edial to the trochlea,
allowing lateral subluxation o the ulna and elbow instability. Proper classif cation in
children may be di cult to assess because the trochlea is not ossif ed until the child is
approximately 10 years old.90
Lateral condyle ractures with less than a 2-mm displacement may be treated nonop-
eratively with immobilization, i racture healing is monitored.32,83 For ractures displaced
more than 2 mm, surgery is recommended.83,89 Surgical treatment may involve open reduc-
tion and internal f xation 14,89 or intraoperative arthrography ollowed by closed reduction
and percutaneous pinning, with no consensus or the optimal technique in the literature.14
Complications ollowing lateral condyle ractures may include delayed union, nonunion,
avascular necrosis o the lateral condyle, and sti ness.32,89
Medial Epicondyle Fract ures

Medial epicondyle ractures account or 8% to 10% o pediatric elbow ractures89 and are
most common in children between the ages o 9 and 15 years.32 T ey are caused by a all
on an outstretched hand with orced wrist hyperextension and valgus stress at the elbow.89
Associated elbow dislocation occurs in 50% o cases.89 Possible complications to be aware
o a ter medial epicondyle ractures include ulnar nerve irritation, elbow instability, non-
union, and sti ness.
Fractures with displacement up to 2 mm can be treated with immobilization. Surgery
is a consideration or ractures displaced greater than 2 mm.32 Farsetti et al43 per ormed
a long-term ollow-up comparison o medial epicondyle ractures displaced greater than
5 mm treated surgically versus nonsurgically. Subjects were divided into 3 treatment
groups: (a) nonsurgical treatment consisting o immobilization, (b) open reduction and
internal f xation o the ragment, and (c) excision o the osteocartilaginous ragment.
Elbow Fractures 645
Outcome measures included ROM, orearm muscle atrophy, elbow stability, grip
strength, radiographs to assess epicondylar nonunion and posttraumatic arthritis, and elec-
tromyography i symptoms o nerve impairment were present. At an average ollow-up o
34 years (range: 18 to 48 years), results showed patients treated with cast immobilization
and patients treated with open reduction and internal f xation had similar unctional out-
comes, despite a high incidence o nonunion o the medial epicondyle in patients treated
with cast immobilization only. A good unctional outcome was def ned as ull or minimally
restricted pain- ree elbow motion, stable manual valgus stress testing, normal ipsilateral
grip strength, minimal-to-no orearm muscle atrophy, and no radiographic signs o osteo-
arthritis. Good results were ound in 16 o 19 patients in the immobilization group and in
15 o 17 patients ollowing open reduction internal f xation. No good results were ound
in patients treated with excision o the epicondylar ragment. Because o poor long-term
outcomes, surgical excision o the medial epicondyle should be avoided. Nonunion did
not have negative e ects on unction. A study by Lee et al85 also showed good to excellent
results in subjects ages 7 to 17 years who had sustained medial epicondyle ractures (with
greater than 5 mm displacement) that were treated operatively.
Radial Head and Neck Fract ures

Radial head and neck ractures occur secondary to a all on an outstretched hand with
valgus stress.32,89 reatment is determined by the amount o displacement and angulation
between the radial head and sha t. Nondisplaced ractures usually have no residual def cits
despite minimal treatment. It has also been shown that displaced Mason type I radial head
or neck ractures have good long-term outcomes with conservative treatment.58 Sanchez-
Sotelo 119 recommends nonoperative treatment or radial head ractures in adults with less
than 2 mm displacement, less than 30% involvement o the articular sur ace, angulation o
less than 30 degrees, and no instability. An angulation o 30 degrees or greater may be an
indication or surgical consideration.89 When treating displaced or comminuted radial head
ractures, the clinician should be aware o possible associated injuries, including osteo-
chondral and ligamentous injury.63 Following radial ractures, complications may include
malunion, radial head overgrowth, avascular necrosis, and nonunion.89

St rat egies t o Regain Elbow Range of Mot ion Following Immobilizat ion
T e amount and rate o progression o rehabilitation ollowing an elbow racture is deter-
mined by several actors, including severity o injury, length o immobilization, concomi-
tant injuries, age o patient, and level o sport activities. T e primary ocus o rehabilitation
is on optimizing the return o elbow ROM and strength, with progression to unctional daily
and sport activities as needed.
Elbow ROM may not be completely regained ollowing traumatic injury. Decreased
ROM may be because o osseous structures, but is usually a result o the joint capsule or
so t-tissue structures (muscles, tendons, ligaments). T e viscoelastic properties o so t
tissue must be considered during treatment to regain elbow ROM. T ese properties include
strain rate dependency, creep, stress relaxation, elastic de ormation, and plastic de orma-
tion. Strain rate is the dependence o material properties on the rate or speed in which a
load is applied. Rapidly applied orces will cause sti ness and elastic de ormation whereas
gradually applied orces will result in plastic de ormation.
Creep is def ned as the continued de ormation o so t tissue with the application o a
f xed load (eg, traction and dynamic splinting). Stress relaxation is the reduction o orces,
over time, in a material that is stretched and held at a constant length (eg, serial casting and
static splinting). Elastic de ormation is the elongation produced by loading that is recovered
a ter the load is removed. T ere is no long-term e ect on

tissues. Plastic de ormation is the elongation produced
under loading that will remain a ter the removal o a load,
resulting in a permanent increase in length.16
A study by Bonutti et al16 evaluated the e ectiveness
o a patient-directed static progressive stretching program
in the treatment o elbow contractures. Subjects had elbow
contractures or 1 month to 42 years that did not respond
to previous treatment consisting o physical therapy,
dynamic splinting, serial casting, surgery, or a combination
o these treatments. T e orthosis providing a static pro-
gressive stretch was worn or 30 minutes with the patient
increasing the amount o stretch every 5 minutes as toler-
ated. Separate 30-minute sessions were used in patients
requiring exion and extension improvement. Results
showed an average improvement o 17 degrees extension
Figure 21-26 Po ste rio r g lide o f the
and 14 degrees exion. Improved results were seen in 4 to
ulno hume ral jo int
6 weeks, with continued improvement in patients using the
orthotic 3 months or more. T ere was no change in ROM in
patients 1 year a ter discontinuation o the orthosis, suggesting that the plastic de ormation
o so t tissue occurred and the elongation o tissue was maintained over time.
Manual rehabilitation techniques or im proving elbow ROM include passive ROM
and joint m obilizations. Passive range is per orm ed in elbow exion, extension, supi-
nation, and pronation. Care should be taken with passive ROM into extension, as end
range stretching o the exors can potentially contribute to heterotrophic ossif cation, as
discussed previously. Elbow joint mobilizations may be used to restore joint arthrokine-
matics. Joint distraction (see Figure 21-18), posterior glides o the ulna ( Figure 21-26),
m edial and lateral ulna glides ( Figure 21-27), radial distraction (Figure 21-28), and dor-
sal and ventral glides o the proximal radioulnar (Figure 21-29) joint are used to increase
elbow ROM.37 Shoulder passive ROM should also be per ormed early in the rehabilitation
process to prevent glenohumeral capsular hypomobility, especially i the injury required
prolonged immobilization.
A B
Figure 21-27 Late ral and me dial g lide s o f the ulno hume ral jo int
A. Lateral glide. B. Medial glide.

Pediatric Considerations 647
Figure 21-28 Radial distractio n mo bilizatio n Figure 21-29 Do rsal and ve ntral g lide s o f the
pro ximal radio ulnar jo int
Pediatric Considerations
When diagnosing and treating pediatric elbow injuries, consideration must be given to bone
maturation and growth. In young children, the elbow joint is cartilaginous with the appear-
ance o apophyseal ossif cation centers between the ages o 2 and 10 years. It is important
to be aware o the apophyseal ossif cation centers at the elbow so that they are not misinter-
preted as ractures on a radiograph. T e ossif cation centers with the date o appearance in
parentheses include the capitellum (2 years), radial head (4 years), medial epicondyle (5 years),
trochlea (7 years), olecranon (9 years), and lateral epicondyle (10 years).32 Because the so t tis-
sues surrounding the apophyses are stronger than the cartilage present at the apophyses, inju-
rious orces causing a sprain or strain in an adult may cause an avulsion racture in children.
T e most common site or an avulsion racture is the medial epicondyle. Medial epicondyle
avulsion ractures occur in young throwing athletes due to an acute valgus stress and exor-
pronator muscle contraction.59 T ere is an acute onset o medial elbow pain a ter orce ul con-
traction such as during a baseball pitch. T e avulsion commonly occurs during late cocking
or early acceleration phase o throwing. A “pop” may be heard at time o injury. I a medial
epicondyle avulsion racture is suspected, it is important to assess the ulnar nerve, point ten-
derness o the medial epicondyle, swelling, ecchymosis, and valgus instability.
T e Salter-Harris classif cation system 118 is commonly used to describe acute physeal
injuries (Figure 21-30). T ere are 5 types o ractures in this classif cation, with type II rac-
tures being the most common. ype I ractures occur when the epiphysis separates com-
pletely rom the metaphysis. T e mechanism o injury involves shear, torsion, and avulsion
orces. reatment consists o casting with excellent prognosis unless vascular damage is
present. In a type II racture, the racture line extends along the growth plate and into the
metaphysis. T e triangular-shaped metaphyseal ragment is re erred to as the T urston-
Holland sign. ype III ractures are intraarticular and extend rom the joint sur ace to the
weak zone o the growth plate and reaches the periphery o the plate. T ere is good prog-
nosis with proper reduction and intact vascular supply. Surgery may be needed or type III
ractures. ype IV ractures are characterized by the racture extending rom the joint sur-
ace through the epiphysis, across the ull thickness o the growth plate, and through a
portion o the metaphysis. Surgery is required or this type o racture, and there is usually
a poor prognosis unless the growth plate is completely and accurately aligned. A type V
racture is rare and involves crushing o the growth plate, which inhibits urther growth.
A
B
C
D
Figure 21-30 Salte r-Harris fracture classi catio n
A. Type I. B. Type II. C. Type III. D. Type IV. E. Type V.
Similar to elbow ractures in adults, treatment o pediatric elbow ractures varies based
on location and type o racture. Protection o the open growth plates is an important con-
sideration to optimize long-term outcomes. Prolonged immobilization ollowing injury can
be more conservative in children than adults, as children do not develop the amount o
sti ness and so t-tissue contractures as adults. Pediatric injuries may require less rehabili-
tation as a result o decreased ROM restriction when compared to adults.
Appendix 1 649
Appendix 1: Postoperative Protocol for Elbow

Arthroscopy and Removal of Loose Bodies
Acut e Phase
Primary goals
1. Reduce pain and postoperative edema
2. Regain joint ROM and muscle length
3. Initiate submaximal resistive exercise as tolerated
Post operat ive Days 1 and 2

1. Removal o bulky postoperative dressing and replacement with Ace wrap.
2. Electric stimulation and ice to decrease pain/ in ammation.
3. Initiation o ROM exercise or the glenohumeral joint, elbow, orearm, and wrist.
4. Initiation o submaximal strengthening exercises including:
a. putty
b. isometric elbow and wrist exion/ extension
c. isometric orearm pronation/ supination
Post operat ive Days 2 t o 7

1. ROM and joint mobilization to terminal ranges or the elbow, orearm, and wrist
(avoid overaggressive elbow extension passive ROM)
2. Begin progressive resistance exercise program with 0 to 1 lb weight and 3 sets
o 15 repetitions
a. wrist exion curls
b. wrist extension curls
c. radial deviation
d. ulnar deviation
e. orearm pronation
f. orearm supination
3. Upper body ergometer
Int ermediat e Phase

Primary goals
1. Begin total-arm strength-training program
2. Emphasize ull elbow ROM
Post operat ive 1 t o 3 Weeks

1. Continue progressive resistance exercise program adding:
a. elbow extension
b. elbow exion
c. isolated rotator cu program (Jobe exercises)
d. seated row
e. manual and isotonic scapular program
f. closed-chain, upper-extremity program
Advanced/Ret urn t o Act ivit y Phase

Primary goals
1. Advance strengthening progression o distal upper extremity
2. Prepare patient or return to unctional activity with simulation o joint angles
and muscular demands inherent in intended sport activity
Post operat ive 4 t o 8 Weeks

1. Isokinetic exercise introduction using wrist exion/ extension and orearm pronation/
supination movement patterns
2. Upper-extremity plyometrics with medicine balls
3. Isokinetic test to ormally assess distal strength
4. Interval sport return program
a. criterion or advancement:
i. ull, pain- ree ROM
ii. 85% to 100% return o muscle strength
iii. no provocation o pain on clinical exam
5. Upper-extremity strength and exibility maintenance program
Appendix 2: Postoperative Rehabilitation

Following Ulnar Collateral Ligament
Reconstruction Using Autogenous Graft
Post operat ive Week 1

Brace
• Posterior splint applied immediately postoperatively with elbow placed in 90 degrees
o exion. Progression to hinged ROM brace dependent on patient tolerance. ROM
brace to remain locked at 90 degrees or week 1.
Rehab
• Modalities to decrease elbow swelling and control pain.
• ROM orearm pronation/ supination and wrist exion/ extension.
• ROM glenohumeral joint and scapulothoracic joint mobilization.
• Shoulder isometrics (no internal rotation or external rotation as a result o valgus
stress on elbow).
• Gripping exercises with balls or putty.

Brace
• ROM set in hinged elbow brace rom 30-100 degrees.
Appendix 2 651
Rehab
• Continue with above exercises and ROM.
• Initiate isometric muscular work o wrist exion/ extension, radial/ ulnar deviation,
and elbow exion/ extension within ROM available at ulnohumeral joint.
• Initiate closed-chain exercise over Swiss balls (wax-on/ o ) with limited weight
bearing over extremity.
• Begin scapular protraction/ retraction manual resistance in side-lying with the elbow
in 90 degrees o elbow exion.

Brace
• Hinged elbow brace is opened to 15 to 110 degrees. (ROM in brace is gradually
increased 5 degrees in extension and 10 degrees in exion each week unless otherwise
specif ed by physician.)
Rehab
• No changes in exercises during this time period.
Post operat ive Weeks 4 t o 5

Brace
• Hinged elbow brace set at 10 degrees-120 degrees.
Rehab
• Begin submaximal isotonic exercise or wrist exion/ extension, radial/ ulnar
deviation and orearm pronation/ supination with light 1-lb weight or T era tubing
(yellow or red).
• Begin shoulder isotonic exercise program with prone extension, prone horizontal
abduction and standing scaption to 80 degrees elevation as tolerated. Continue
to avoid rotational strengthening patterns, due to valgus stress at ulnohumeral
joint. Weight attachment proximal to elbow with cu weights recommended or
introduction.
• Initiate seated rowing using T era tube or machine/ cables.

Brace*
• Hinged elbow brace set at 0 to 130 degrees.
Rehab
• Begin elbow exion/ extension isotonics using available ranges and avoiding a
“bounce home” type movement at end range extension.
• Initiate shoulder internal rotation and external rotation patterns using both isotonic
machine or cables (submax), T era tube (yellow or red to start), and initiation o
side-lying external rotation pattern.
• Begin ball dribbling o ground using Swiss balls, Body Blade, T era-Band resistance
bar oscillation, and B.O.I.N.G. using patterns o radial/ ulnar deviation and pronation/
supination with varied shoulder positions less than 90 degrees o elevation.
*Discontinuation o hinged elbow brace occurs between 6 and 10 weeks postoperative, as designated by re erring
physician.
Post operat ive Weeks 10 t o 12

Rehab
• Plyometric program initiated using Swiss ball, progressing to medicine ball. Patterns
consisting o initially a 2-hand chest pass and progressing to side throws, wood chops,
and eventually eccentric arm deceleration with contralateral arm throwing.
• Continuation o shoulder, elbow, orearm, and wrist isotonics.
• Rhythmic stabilization techniques using both open- and closed-chain environments.
• Closed-chain step-up progression.

Rehab
• Initiation o isokinetic training using the pattern o wrist exion/ extension at speeds
ranging rom 180 to 300 degrees per second. ROM stops used at 0 to 35 degrees wrist
extension and 0 to 55 degrees wrist exion. Upon success ul completion o wrist
exion/ extension during several trial treatments, isokinetic orearm pronation and
supination is initiated using ROM stops o 0 to 50 degrees o pronation and supination.
• Shoulder isokinetic internal rotation/ external rotation is initiated submaximally
using speeds between 210 degrees and 300 degrees per second in the modif ed base
position.
Post operat ive Week 14 (Ret urn t o Act ivit y Phase)

Rehab
• Initiation o elbow extension/ exion isokinetics using speeds between 180 degrees
and 300 degrees per second and ROM stops at 10 degrees extension and 125 degrees
exion.
• Initiation o interval sport return programs.
• Continuation o upper-extremity strengthening programs and maintenance o
particularly elbow extension ROM.
• A return to competitive levels o throwing or racquet sports is not expected until
at least 6 months ollowing surgery.
SUMMARY
1. T e elbow joint is composed o the humeroulnar joint, humeroradial joint, and the
proximal radioulnar joint. Motions in the elbow complex include exion, extension,
pronation, and supination.
2. Fractures in the elbow may occur rom a direct blow or alling on an outstretched
hand. T ey may be treated by casting or in some cases by surgical reduction
and f xation. Following surgical f xation, the patient may require 12 weeks or
rehabilitation.
3. Valgus extension overload injuries occur during the acceleration phase o the
throwing motion and can result in the development o posterior medical osteophytes
and loose bodies in the athletic elbow. reatment via arthroscopy is ollowed by early
immediate ROM and a progression o strength and unctional training to restore ull
unction to the elbow.
Appendix 2 653
4. T e ulnar collateral ligament is injured as a result o a repetitive valgus orce.
Reconstruction is vital to competitive throwing patients.
5. Elbow dislocations result rom elbow hyperextension rom a all on an extended
arm, with the radius and ulna dislocating posteriorly. T e degree o stability present
determines the course o rehabilitation. I the elbow is stable, a brie period o
immobilization is ollowed by rehabilitation. An unstable dislocation requires surgical
repair and thus a longer period o immobilization.
6. Medial epicondylitis results rom repetitive microtrauma to the common exor and
pronator tendons during pronation and exion o the orearm and wrist.
7. Lateral epicondylitis (tennis elbow) occurs with concentric or eccentric overload o
the wrist extensors and supinators, most commonly the extensor carpi radialis brevis
tendon.
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Krupinski E. MRI Evaluation o the Ulnar Collateral
Rehabilitation of the
Wrist , Hand, and Digits
Je a n in e Be a s le y a n d Dia n n a Lu n s f o rd
OBJJE CTIVES
S t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Discuss key concepts of functional anatomy and biomechanics involved in the normal wrist
and hand.
Relate biomechanics and tissue-healing principles to the rehabilitation of various wrist and
hand conditions.
Discuss criteria for progression of the rehabilitation program for speci c hand and wrist
conditions.
Describe the rationale for speci c orthotic techniques in the management of selected wrist
and hand conditions.
659
660 Chapte r 22 Rehabilitation of the Wrist, Hand, and Digits

T e hand is an intricate balance o muscles, tendons, and joints working in unison. T is bal-
ance combines mobility, stability, and dexterity allowing the hand to per orm a multitude
o activities. Any disruption o this balance as a result o an injury or condition can greatly
alter the ability o the hand to per orm activities o daily living (ADL). At work, the hand is
the most requently injured part o the body.79 Hand conditions can occur as a single injury,
over time as in cumulative trauma, or because o a disease process.
reatment o hand conditions requires a complete history and evaluation. T ese evalu-
ations can include subjective and objective assessments that assist the physician and ther-
apist in determining the specif c hand dys unction. A diagnosis o “hand pain” or “wrist
pain” does the client a disservice and may lend itsel to treatment that is not specif c to the
condition. T e reader is re erred to the text, Rehabilitation of the Hand and Upper Extrem ity
(6th ed.),72 or a complete discussion o evaluations and assessments.
reatment o the hand is based on the phases o wound healing. Initially, the in amma-
tory phase usually lasts 3 to 5 days. It is typically a time o vascular dilation and edema.62,89
T e extremity is o ten immobilized during this phase. For example, ollowing a surgery, a
bulky dressing can provide immobilization during this phase. T is phase can be prolonged
in cases o overactive patients or aggressive therapy. Diabetes or specif c medications can
prolong this and other phases o wound healing. T e second phase is the f broplasia phase,
which typically lasts rom 5 to 21 days.62,89 During this phase, the f broblasts lay down col-
lagen in a random network. Depending on the specif c diagnosis, special protected motion
exercises may be allowed during this phase. An example o this is treatment o a newly
repaired exor tendon, which generally begins with passive range o motion (PROM) in a
protective orthosis during this phase to avoid stress on or rupture o the repair.62
T e third phase is the maturation phase that usually begins at 3 weeks. It continues or
several months. Here the randomly oriented collagen matures and develops strength with
intermolecular crosslinking.62,89 Adhesions also orm during this phase. Some treatment
protocols are o ten progressed during this phase. Care should be taken to use caution dur-
ing the application o stress to the area in order to protect the healing tissues.
The Wrist
T e wrist is the connecting link between the hand and orearm.97 T e wrist joints are com-
prised o 8 carpal bones that are arranged in 2 rows. T e proximal row articulates with
the distal radius and the triangular f brocartilage complex ( FCC) o the ulna proximally.
T e distal row articulates with the metacarpals distally. T ere is an intricate relationship
between the carpal bones. Ligaments interconnect the carpal bones, as well as connect the
carpal bones to the radius and ulna.8,16 During range o motion (ROM) the carpal bones
demonstrate complex kinematics.8 Flexion and extension occur through synchronous
movement o proximal and distal carpal rows. Some authors have debated these kinematic
theories noting that the scaphoid sometimes acts as part o the proximal row and other
times acts as a link between the proximal and distal carpal row.46,49,58 Palmer et al58 demon-
strated that many ADL involve a wrist arc rom radial deviation and wrist extension to ulnar
deviation and wrist exion also called the “dart throwers arc” (Figure 22-1). T e scaphoid
and lunate are stable and have minimal intercarpal movements during the dart throwers
motion as noted during kinematic studies.70 An example o an application o this concept
would be initiating a gentle active motion exercise program or a carpal ligament repair to
the scaphoid and lunate using the “dart throwers arc” in order to protect these repairs.
Functional movement o the wrist, or the amount o wrist movement needed to do
most ADL was ound by Ryu et al69 to be 40 degrees o exion, 40 degrees o extension, and a
A B
Figure 22-1 Dart thro w e rs arc
(A) The scaphoid and lunate are most stable and have minimal intercarpal movements
during the dart throwers motion as noted by kinematic studies.11 This movement involves a
wrist arc from radial deviation and wrist extension to (B) ulnar deviation and wrist flexion.
Palmer et al10 demonstrated that many ADL involve this motion. Initiating a gentle active
motion exercise program for a carpal ligament repair to the scaphoid and lunate may be
best done using the dart throwers arc to protect these repairs.
combined arc o 40 degrees o radial and ulnar deviation. It is important or the therapist to
remember to not sacrif ce joint stability or increase joint pain when attempting to increase
ROM. A pain- ree stable joint with adequate unctional motion, as discussed above, serves
the client’s unctional activities better than a joint with greater ROM, greater pain, and less
stability.
Stability o the ulnar side o the wrist is provided by the FCC.97 T is ligament arises
rom the radius and inserts into the base o the ulnar styloid, the ulnar carpals, and the base
o the f th metacarpal.97 T is ligament complex is the major stabilizer o the distal radioul-
nar joint (DRUJ) and is a load-bearing column between the distal ulna and ulnar carpals.97
Injury to the FCC can result in pain with pronation and supination o the orearm and with
ulnar deviation. Diagnostically, this pain may be reduced when the examiner provides sup-
port to the ulna during pronation and supination (Figure 22-2). reatment or this condi-
tion is discussed in the section entitled “Injuries to the Distal Radioulnar Joint”.
T e exor carpi ulnaris (FCU) with its insertion into the pisi orm, a sesamoid bone, is
unique in that it is the only muscle with a tendinous insertion into the wrist. T e proxim-
ity o this easily palpated bone to the ulnar nerve can sometimes be troublesome in cases
o blows to the area or a pisi orm racture. In cases o ulnar nerve compression, symptoms
should be di erentiated to determine i the problem arises rom the Guyon canal (located
under the pisi orm) or at the cubital tunnel o the elbow. Compression o the ulnar nerve at
the cubital tunnel is a more common condition.
T e dorsal wrist has an extensor retinaculum ( ascia) with 6 extensor compartments
that are separated by septa.68 T e purpose o the retinaculum is to prevent bowstring-
ing or subluxation o the tendons during wrist movement. T e f bro-osseous tunnels or
Ulna
Ra dius
A B
Figure 22-2
A. Injury to the TFCC can result in forearm pain with pronation and supination, as well as with wrist ulnar deviation.
Support to the distal ulna may provide support and decrease pain (see Figure 22-11 for an example of an orthosis to
support the distal ulna). B. This pain may be reduced when the instability of the DRUJ is supported by the examiner. This is
completed by providing compression of the distal ulna dorsally and a counterforce to the distal radius in volar direction.
compartments position and maintain the extensor tendons in their synovial sheaths.68 T e
f rst compartment comprises extensor pollicis brevis and abductor pollicis longus. One
o the most common wrist conditions that a ects the tendons in this f rst compartment is
known as de Quervain disease. T e second compartment contains extensor carpi radialis
longus and extensor carpi radialis brevis. T e third contains extensor pollicis longus. T is
tendon is o ten injured in distal radius ractures. In the ourth compartment lies the exten-
sor digitorum communis and extensor indices proprius. T e f th compartment contains
extensor digiti minimi. In the f nal, sixth compartment is the extensor carpi ulnaris.
Volarly, the long f nger exors, long thumb exor, median nerve, and radial artery pass
through the carpal tunnel. T e carpal tunnel consists o a concave arch o carpal bones.
T e roo o this arch includes the transverse carpal ligament, orearm ascia, and the distal
aponeurosis o the thenar and hypothenar muscles.68 T e carpal tunnel is the site o one
o the most common hand pathologies, carpal tunnel syndrome (C S). Any condition that
increases pressure in the tunnel can lead to compression o the median nerve. T is can
result in pain and paresthesia in the median nerve distribution.
The Hand
T e metacarpophalangeal (MCP) joints allow or several planes o motion, including ex-
ion, extension, abduction, adduction, and a slight degree o pronation and supination. T e
metacarpal head has a convex shape, which f ts with a shallow concave proximal phalanx.
T e stability o the MCP joint is provided by its capsule, collateral ligaments, accessory
collateral ligaments, volar plate, and musculotendinous units. T e collateral ligaments
are laterally positioned and are dorsal to the axis o rotation. In extension, the collateral
ligament is lax; in exion, it is taut.41 I the MCP joint is immobilized in extension, the lax
collateral ligament can shorten. Flexion o the MCP is considered the “sa e position” in
order to prevent tightening o the collateral ligaments; however, care should be taken to
PA
A1
A2
C1 A3
C2 A4
C3 A5
Figure 22-3 The pulle ys o f the e xo r te ndo ns
(Reprinted, with permission, from Strickland JW. Development of exor tendon surgery:
twenty- ve years of progress. J Hand Surg. 2000;25:214-235.)
consider the specif c condition when imm obilizing the

MCP joint. Several tendons cross the MCP joints. On the
exor sur ace, the exor digitorum superf cialis (FDS) and
exor digitorum pro undus (FDP) are held closely to the
bones by pulleys. T e A1 pulley ( Figure 22-3) is the site
o tendon drag or locking in the case o a trigger f nger.
T e FDS exes the proximal interphalangeal (PIP) joint,
and the FDP exes the distal interphalangeal (DIP) joint. 1
Injuries to the exor tendons are categorized by zones
( Figure 22-4). Zone 1 is distal to the insertion o FDS 2
whereas zone 2 is located rom the A1 pulley to the inser-
T1
tion o FDS. Zone 3 includes the distal border o the carpal
tunnel to the A1 pulley. Zone 4 consists o the area cov-
ered by the transverse carpal ligament. Zone 5 spans rom T2
the proximal border o the transverse carpal ligament to 3

the exor musculocutaneous junction ( Figure 22-4). T e T3
interosseous muscles are lateral to the MCP joints and
are responsible or abduction and adduction o the MCP 4
joints. T e lumbrical muscles, volar to the axis o rotation
o the MCP joint, insert into the lateral bands, dorsal to the
PIP and DIP joints. T eir unction is MCP joint exion and 5
interphalangeal (IP) joint extension. (T is is why it is pos-
sible to have active IP extension with radial nerve palsy.)
T e extensor mechanism crosses the MCP joint dorsally.
Sagittal bands hold the extensor digitorum com munis
tendons centrally. Injuries and treatm ent to the exten- Figure 22-4 The e xo r te ndo n zo ne s
sor tendons are also categorized by zones (Figure 22-5).
One way to remem ber this system is to locate the odd- (Reprinted, with permission, from Kleinert HE, Schepel S, Gill T.
numbered zones over the joints. Flexor tendon injuries. Surg Clin North Am. 1981;61:267-286.)
The Fingers
T e IP joints are bicondylar hinge joints that allow exion
and extension. Collateral and accessory collateral ligaments
stabilize the joints on the medial and lateral aspects, respec-
tively. T e collateral ligaments are taut in extension and lax
in exion. On the exor sur ace, the FDS bi urcates proximal
to the PIP joint, allowing the FDP to become more superf cial
1 as it continues to insert on the distal phalanx, providing DIP
2 exion. T e FDS inserts on the middle phalanx or PIP ex-
3 ion. Five annular pulleys and 3 cruciate ligaments between
the MCP and DIP joints prevent bowstringing o the tendons.
4 T1 T ese pulleys and ligaments keep the tendon close to the bone
5 and provide the mechanical advantage or composite digit
T2
exion (see Figure 22-3).
T3
On the extensor sur ace, the common extensor tendons
cross the MCP joints and then divide into 3 slips. T e central
6 slip inserts on the dorsal middle phalanx, allowing or PIP
T4 extension. T e 2 lateral slips, called the lateral bands, receive
attachments rom the lumbricals, travel dorsal and lateral to
the PIP joint, rejoin a ter the PIP joint, and insert as the termi-
7 T5
nal extensor into the DIP joint. T is delicately balanced system
serves to extend the IP joints.
The Thumb
T e thumb is responsible or 40% to 50% o the unction o the
hand.87 T e thumb’s ability to oppose the digits, grasp, and
Figure 22-5 The e xte nsor te ndo n zone s pinch occurs as a consequence o the thumb’s unique ability to
balance mobility with joint stability. T e thumb carpal meta-
(Reprinted, with permission, from Kleinert HE, Schepel
carpal joint is a biconcave saddle joint that allows or ROM in
S, Gill T. Flexor tendon injuries. Surg Clin North Am.
a wide variety o planes. T is necessary motion is controlled
1981;61:267-286.)
with joint stability provided by the strong joint capsule and
supporting ligaments. T ere are 4 extrinsic thumb muscles,
which include extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus,
and exor pollicis longus. T e 5 intrinsic muscles that add to the unique mobility and dex-
terity o the thumb include the abductor pollicis brevis, opponens pollicis, abductor polli-
cis, adductor pollicis, and exor pollicis brevis. T e thumb, like the other digits, has a series
o pulleys or the exor tendons.

and Conditions
Dist al Radius Fract ures

Pat homechanics
Fractures o the distal radius can be described by several classif cation systems. It is impor-
tant that the therapist has an understanding o the type o racture and how di erent types
o ractures need to be treated. Some o the questions the therapist may ask are: Is the rac-
ture intraarticular or extraarticular, displaced or nondisplaced? I displaced, in which direc-
tion? Is the racture simple or comminuted, open or closed? Is the radius shortened? and Is
Rehabilitation Techniques for Speci c Injuries and Conditions 665
the ulna also ractured? Answers to these questions will help the therapist select interven-
tions and determine expected outcomes.
It is important to consider the normal anatomy when evaluating wrist ractures. T e
normal radius is tilted volarly. I in a racture the volar tilt becomes dorsal, motion will be
a ected, which can ultimately lead to midcarpal instability, decreased strength, increased
ulnar loading, and a dys unctional DRUJ.52 Another complicating actor is the length o the
radius. T e normal radius is longer than the ulna. I the radius is shortened in a commi-
nuted racture, there is a high potential or disability.12,34,52 Radial shortening may lead to
DRUJ pain, especially with pronation and supination activities. T is can result in reduced
grip strength because o pain and limited use o the hand. T e DRUJ is discussed in greater
detail later in the section entitled “Injuries to the Distal Radioulnar Joint”.
T e type o racture, size o the ragments, and displacement determine the initial treat-
ment. Stable ractures may require casting; however, more complex ractures may require
internal or external f xation by a surgeon.
Injury Mechanism
As is true o most wrist injuries, many distal radius ractures occur rom a all on an out-
stretched hand (otherwise known as a FOOSH injury). T e presence o this condition in the
middle-aged population may indicate a need or a bone density test to rule out osteoporo-
sis, especially when it occurs with a low-impact event.

Rehabilitation may be initiated while the wrist is immobilized. Rehabilitation ollowing a
distal radius racture is similar regardless o the method o f xation. While immobilized,
ROM and edema control o noninvolved joints is essential, so that when immobilization
is discontinued, rehabilitation can be concentrated on the wrist and orearm. T is should
include shoulder ROM in all planes, elbow exion and extension, and f nger exion and
extension. Finger exercises should include isolated MCP exion, composite exion ( ull
f st), and intrinsic minus f sting (MCP extension with IP exion) (Exercise 22-1). Coban or
an Isotoner glove may be used or edema control i necessary. T is helps prevent muscle
atrophy, aids in muscle pumping to decrease edema, and, most importantly, prevents
edema-related hypomobility. Shoulder slings are not usually recommended as they can
contribute to shoulder and elbow sti ness. Other concerns include complications o C S
or complex regional pain syndrome.42 Both conditions are best managed by early detection
and intervention. Another complication is an extensor pollicis longus rupture.42 It is thought
that this occurs rom the extensor pollicis longus rubbing through bone around the racture
site near the Lister tubercle. In such a condition, the patient would be unable to actively
extend the thumb IP joint, and surgical intervention is required. I the racture is stabilized
with a f xator or i pins are present, pin site care may be per ormed depending on the physi-
cian’s pre erence.

Once immobilization is discontinued per the physician, ROM o the wrist can be initiated.
T is includes active wrist exion, extension, radial and ulnar deviation, and orearm prona-
tion and supination. T e patient should be instructed on wrist extension with ull composite
digital exion (Exercise 22-2). T is isolates the wrist extensors rather than using the exten-
sor digitorum communis so as to prevent extrinsic extensor tendon tightness. T is tight-
ness is most commonly seen with plate f xation or prolonged immobilization. Active ROM
to decrease extrinsic extensor tightness requires simultaneous wrist and digital motion.
Active ROM to decrease exor tendon tightness would include simultaneous wrist and digi-
tal extension. Exercises should also include orearm rotation (supination and pronation).
Instruction should be provided to per orm these exercises with the elbow at
90 degrees and held close to the side o the body to avoid compensation rom
the shoulder (Exercise 22-3).
T e initiation o PROM is dependent upon the stability o the racture. A
lightweight hammer or mallet in the hand during pronation and supination
exercises is a help ul tool to gently stretch and increase this motion (Exer-
cise 22-4). Gentle joint mobilizations to the radius and ulna are also help-
ul in increasing motion. When providing orearm rotation passively, gentle
pressure should be applied at the distal radius, proximal to the wrist, not
at the hand. T is will avoid placing unnecessary torque across the carpals.
Gentle wrist distraction combined with exion and extension may be e ec-
tive in increasing ROM in a pain- ree range. Contract and relax techniques
may also be help ul in obtaining the desired ROM. Orthotics can be e ective
tools in increasing ROM in patients who are not progressing. Wrist extension
limitations can be treated e ectively with a serial night orthosis (Figure 22-6).
T e wrist is held in com ortable maximum extension during the abrication
process. T e night orthosis gently and progressively stretches the wrist into
greater extension. T e orthosis is remolded at each therapy visit as gains in
extension are made. It is very e ective in patients that are having di culty
obtaining a unctional range (40 degrees). Caution should be noted not to
apply undue pressure on the median nerve. A static progressive orthosis can
be also used periodically during the day to increase wrist PROM. Daytime
use o this orthosis may help to achieve greater wrist exion and/ or exten-
sion (Figure 22-7). T e orthosis is usually worn or 20 to 30 minutes, 2 to
3 times daily. T e patient adjusts this orthosis as gains are made. T is type o
Figure 22-6 A w rist o rtho sis
is use d fo r a varie ty o f co nditio ns
With conservative management of

CTS it can be beneficial to keep the
wrist in a neutral position at night.
After a healed wrist fracture, wrist
extension limitations can be treated
effectively with a serial night orthosis.
In the clinic, the orthosis is molded
while the wrist is held in comfortable
maximum extension. The night
orthosis gently stretches the wrist
into progressively more extension. The
orthosis is remolded at each therapy
visit as gains in extension are made.
Figure 22-7
A static progressive orthosis can be utilized periodically during the day to increase
wrist ROM. Daytime static progressive orthosis for wrist exion and/or extension
is usually worn for 20 to 30 minutes, 2 to 3 times daily. The patient adjusts this
orthosis as gains are made. This orthosis demonstrates static progressive extension.
orthosis is also available commercially. Static progressive or dynamic
pronation and supination orthotic management may be utilized 2 to
3 times a day so as to not inter ere with unctional use o the hand
(Figure 22-8).21
Active motion can be progressed to strengthening a ter adequate
ROM is achieved, typically occurring at approximately 8 weeks a ter
injury or surgery, when the racture is healed and stable. Strength-
ening a wrist with limited motion too soon may result in developing
strength in less-than-ideal ROM. All strengthening exercises should
be pain ree and can include light weights, T era-Band, or tubing, and
can be graded or wrist and orearm motions. T is can be in conjunc-
tion with com ortable progressive weightbearing exercises such as
wall pushups that progress to the countertop, stairs, and then to a oor
mat (Exercise 22-5). Weight bearing on a ball and gentle ball rolling
can be the next progression (Exercise 22-6).
Mass grasp or grip strength is o ten decreased a ter wrist racture.
T erapy putty is one tool used to address strengthening o mass grasp.
Putty is available in a variety o grades, rom so t to hard, to provide di -
erent levels o resistance. T e type o putty used or grip strengthen-
ing should be so t enough to provide a pain- ree level o resistance. I
the patients aggravate pain in an attempt to increase strength, the pain
will limit their unction during ADL, and may increase edema. Patient
needs and pre erences with regards to level o strengthening should be
taken into consideration to ensure best practice.
Athletes, particularly those in contact sports, can require addi-
tional protection as they resume athletic activity. Many re erees will
not allow a rigid orthosis or cast to be used as a possible weapon on
the f eld o play. A so t cast or various padding materials may be used. Figure 22-8 A static pro g re ssive
T e best care or both the patient and the other team players should be o rtho sis to incre ase pro natio n and
considered. Families may want their children in high-school sports to supinatio n o f the fo re arm
return to play too quickly. T e patient and amily should be cautioned
to avoid the possibility o additional injury or chronic conditions that It is used when stiffness occurs following a
may result rom premature return to the f eld o play. healed distal radius fracture and worn 2 to 3
times a day for 20 to 30 minutes. This orthosis
is based on a concept by Kay Collelo Abram.21
Scaphoid Fract ure
Pat homechanics
Fractures o the scaphoid account or 60% o all carpal injuries.12,50,90 T e prognosis is
related to the site o the racture, obliquity, displacement, and promptness o diagnosis and
treatment. T e blood supply o the scaphoid occurs distal to proximal. A racture through
the proximal one-third o the scaphoid may result in delayed union or avascular necrosis
secondary to the limited blood supply. It can take 20 weeks or longer or a proximal racture
to heal.50 Surgical intervention is necessary i the racture is displaced or results in a non-
union. Not treating the racture can lead to carpal instability and periscaphoid arthritis.59,88
Injury Mechanism
Scaphoid ractures result rom a all on an outstretched hand (FOOSH injury) placing the
wrist in hyperextension and radial deviation.90 A proper diagnosis is a primary concern.
Diagnosis is o ten di cult and not easily conf rmed with a standard radiograph and many
go undiagnosed or misdiagnosed as wrist sprains. A bone scan and/ or MRI may be needed
or def nitive diagnosis. Patients usually have wrist pain with this racture, especially when
palpated in the anatomic snu box (Figure 22-9).

The asterisk (*) indicates the anatomic snuffbox, which can be A forearm-based thumb spica orthosis includes the
painful to palpation in a scaphoid fracture. thumb and wrist. It is most commonly used for a
scaphoid fracture, thumb metacarpal fracture, or de
Quervain tendonitis.

Nonunions can result in cases that are misdiagnosed as a wrist sprain.24 Greater concern
about nonunion exists when the racture is at the proximal pole because o the limited or
absent blood supply in that region. Scaphoid nonunion may lead to carpal instability or
periscaphoid arthritis. A client who is not progressing in therapy and has persistent com-
plaints o wrist pain may need to be urther evaluated by the physician or a possible scaph-
oid racture.

Once the diagnosis has been made, the initial treatment o the nondisplaced scaphoid
racture is casting. As a result o the limited blood supply, healing is slow to occur. Cast-
ing usually continues or at least 8 to 10 weeks with distal scaphoid ractures ollowed by
abrication o a custom thumb spica orthosis (Figure 22-10) or continued protection. Frac-
tures o the middle portion o the scaphoid require 6 weeks in a long arm cast ollowed by
6 weeks in a short arm cast.24 Fractures o the proximal pole o the scaphoid may require an
additional 3 to 6 months o casting or orthotic wear.50,90 T e initiation o wrist active range o
motion (AROM) is determined by the surgeon, based on evidence o racture healing. T e
“dart throwers arc” may be the pre erred AROM exercise to prevent overstretching o nearby
carpal ligaments (see Figure 22-1).70 T e thumb spica orthosis is worn between exercises
and at night as the patient progresses. Active ROM exercises including wrist exion, exten-
sion (see Exercise 22-2), and radial and ulnar deviation are completed in a pain- ree range.
T umb exion and extension, abduction and adduction, and opposition to each f nger are
also initiated (Exercise 22-7A to C). Some patients may be overly aggressive with their home
exercise programs, possibly as a result o the long period o immobilization. T is aggres-
sion may overstretch the healing carpal ligaments compromising wrist stability. It is typi-
cal to have ligament injuries associated with the scaphoid racture. Progressing wrist PROM
to the point o pain can compromise long-term unction. Grip strength measurements are
o ten diminished in the presence o pain. Strengthening exercises are delayed until healing
is complete, adequate AROM has been achieved, and pain is under control. It is important
to note that joint stability should not be sacrif ced or an increase in ROM. Care should be
taken not to return an athlete to a sport too quickly.
Rehabilitation a ter an open reduction and internal f xation o the scaphoid ollows the
same progression as outlined above. T e period o immobilization may be less because o
the repair o the scaphoid with rigid f xation.24,50,90
Injuries t o t he Dist al Radioulnar Joint

Pat homechanics
T e DRUJ is a complex system (see Figure 22-2A). T e design o the structures at the DRUJ
allows or orearm pronation and supination while providing the necessary stability to the
ulnar side o the wrist. T e FCC at the distal ulna provides support and stability to the
DRUJ. Pain in this area can be caused by ractures o the ulna, arthritis, synovitis, disloca-
tion, DRUJ instability, tendonitis, and/ or tears o the FCC.71 A complete evaluation by an
experienced hand surgeon is o ten needed to make an accurate diagnosis. Some o these
conditions can be evaluated by radiography, but others are di cult to diagnose, largely
because o the so t-tissue involvement. T e distal ulna is more prominent in pronation and
less prominent in supination when palpated. When the DRUJ loses stability as a result o a
disruption o the FCC, the ulna can displace during ROM, making a popping or clicking
noise. Patients can have signif cant pain, limiting ADL. Injuries are o ten overlooked and
patients o ten become rustrated when there is a delay in diagnosis and treatment.
Injury Mechanism
A racture to the distal radius commonly includes an injury to the DRUJ. T is may include a
racture to the ulnar styloid or an injury to the FCC. Arthritis at the DRUJ can result in pain
with pronation and supination. Injuries and tears to the FCC can be a result o excessive
load in wrist ulnar deviation and orearm rotation activities.

Patients with persistent pain at the distal ulna should be tested to determine i depres-
sion and support o the ulna during pronation and supination relieves their symptoms
(see Figure 22-2B). Manually depressing the ulna can reduce pain by providing support
to weakened ligaments. A simple wristband that provides padding at the dorsal ulna and
volar radius can be very help ul in decreasing pain and providing support to the FCC
(Figure 22-11).
Surgical intervention can include arthroscopy, ulnar resection, ulnar shortening,
hemiresection interposition arthroplasty, usion with proximal pseudoarthrodesis, repair to
the FCC, and tethering o the distal ulna.6,23,71,83 Each procedure has an individualized and
specif c period o immobilization with specif c casting and/ or orthotic positioning (speci-
f ed by the surgeon), ollowed by gentle and gradual return o ROM. T e therapist should
contact the surgeon to determine the point at which gentle AROM can be initiated. It is
important to avoid aggressive ROM that can stretch out ligaments that provide the neces-
sary stability to the DRUJ. All ROM should be kept pain ree, as stability was a major area o
concern prior to surgery.

T e key to success ul management o injuries to the DRUJ is gradual progression in a pain-
ree range. Motions that need to be addressed or AROM are exion, extension, radial devia-
tion, ulnar deviation, supination, and pronation. Strengthening exercises are delayed until
healing is complete, adequate ROM has been achieved, and pain is under control. Joint
stability should not be sacrif ced or an increase in ROM. Care should be taken not to return
A B
Figure 22-11
A. A prefabricated wrist wrap orthosis (Count’R-force) with padding at the dorsal ulna and the volar wrist is very helpful
in managing painful pronation and supination caused by disruption of the triangular fibrocartilage. B. The wrist wrap
orthosis allows partial wrist movement while supporting the distal ulna.
this patient to work, sport, or other activities too quickly. T e wristband (see Figure 22-11)
can be help ul in returning a patient to activities by decreasing any persistent pain with
orearm rotation.
Carpal Tunnel Syndrome

Pat homechanics
C S occurs as a result o compression o the median nerve at the level o the wrist. T e car-
pal tunnel is made up o the carpal bones dorsally and transverse carpal ligament volarly.
Located in the carpal tunnel are the FDS and FDP to all digits, exor pollicis longus, median
nerve, and median artery.14 I the space within the carpal tunnel is decreased as a result
o in ammation, cyst, tumor, scar tissue, racture, edema, or other conditions, the median
nerve can be compressed. Research has shown when intratunnel pressure o the wrist was
measured, even a small change in wrist position increased this pressure. Studies by Burke
et al14 and Weiss et al92 ound that the lowest intratunnel pressure is with the wrist in a near-
neutral position. T is in ormation should in uence the night orthosis design. Many pre-
abricated orthoses place the wrist in ar too much wrist extension, potentially aggravating
symptoms. Symptoms o classic C S are numbness and tingling in the median nerve distri-
bution, pain or waking at night, and clumsiness or weakness in the hand. Symptoms may
increase with static positioning (eg, driving or reading a newspaper),2 vibration, activation
o the lumbricals,37 and changes in joint position.92 Diagnosis is made by history, the Phalen
test (Figure 22-12), the inel sign, nerve conduction studies, direct pressure over the carpal
tunnel (Figure 22-13), and electromyography. It is important to note that negative nerve
conduction studies are not always conclusive. A study by Grundberg showed that 11.3% o
the patients with negative tests had positive clinical and surgical f ndings.36
Injury Mechanism
T ere are many conditions and injuries that contribute to m edian nerve compres-
sion caused by elevated carpal pressures. T ese include tenosynovitis, racture, carpal
The Phalen test for CTS is full wrist flexion, which Pressure over the carpal tunnel may produce the symptoms of
increases the pressure in the carpal canal. The test numbness and tingling in the median nerve distribution. Positive
is positive if there is numbness and tingling in the findings should be correlated with other clinical symptoms and
median nerve distribution within 60 seconds. assessments.
dislocation, cysts, tumor, diabetes, alcoholism, pregnancy, menopause, thyroid disorders,

obesity, vibration, external orces, tendon load, and changes in joint position.37,44,91

Research suggests that there are several e ective interventions or conservative man-
agement o C S, including orthotic intervention.55,63 Conservative treatment is the f rst-
line intervention and consists o a night orthosis with the wrist in a neutral position (see
Figure 22-6) and relative rest rom aggravating sources.
Occasionally, physicians will recommend a ull-time
wrist orthosis. Pre abricated orthoses may need to be
adapted as they o ten place the wrist in extension as
opposed to a near-neutral position. In some cases o
C S, it is also necessary to limit movement o digits 2
to 5 because o the action o the lumbricals moving into
the carpal tunnel with digit exion.37 Including the MCP
joints in extension within the splint has been reported to
be e ective in decreasing symptoms (Figure 22-14).3,29
Nerve gliding exercises described by Butler 15 should
only be used with extreme caution so as not to increase
symptoms. It is di cult or many patients to keep nerve
gliding techniques symptom ree. Forced nerve glid-
ing may result in increased in am mation, f brosis,
and edema 82 to the nerve, which will worsen instead
o improve symptoms. Activity analysis to determine Figure 22-14
activities that increase symptoms should be done to see
i changes in technique would help to decrease or avoid In some cases of CTS, it is necessary to limit movement of
symptoms. Grip strengthening, conservatively, has been digits 2 to 5 because of the action of the lumbricals moving
ound to be contraindicated by several authors because into the carpal tunnel with digit flexion.34 Including the MCP
o the action o the lumbricals increasing pressure in the joints in extension within the splint has been reported to be
carpal tunnel.29 effective in decreasing symptoms.40
I conservative treatment ails, a carpal tunnel release may be per ormed. T ere are
2 standard approaches to this release. T e open technique exposes and releases the trans-
verse carpal ligament and the endoscopic technique uses portals to view and then release
the transverse carpal ligam ent. Surgeon pre erence determ ines the type o procedure
selected, with reports o advantages and disadvantages to each procedure.13,19,39,56,86 T e
lack o visualization o the nerve has been a critique o the endoscopic technique, with
the possibility o complications such as an incomplete release 86 or the possibility o injury
to the m edian nerve and other structures.56 Critics o the open technique report longer
return to work time and greater scar tenderness.13,29 Rehabilitation is dictated by the indi-
vidual needs o each patient rather than by the surgical technique utilized. Rehabilita-
tion ollowing release consists o wound care, scar managem ent, and ROM exercises.29
endon gliding exercises are used to im prove ROM, prevent adhesions, and decrease
edema. endon glides begin with ull f nger extension, and then hook f st to maxim ize
FDP pull-through in relation to FDS. T e digits are also placed into a straight f st to maxi-
mize FDS pull-through, as well as a composite ( ull) f st to use all o the f nger exors. Full
extension should be per orm ed between each position and should be kept pain ree (see
Exercise 22-1). T e FDS is also isolated by holding all but 1 digit in MCP extension and
exing each digit at the PIP joint individually (Exercise 22-8). Wrist AROM should also be
per ormed in a pain- ree range.

T e postoperative progression a ter carpal tunnel release
involves a gradual return to normal use. Grip strengthening
and repetitive activities should be initiated gradually in order
to prevent in ammation and aggravation o the preoperative
symptoms.29 Returning to work will require an evaluation o the
conditions that may have aggravated the symptoms. Padded
work gloves can be help ul in decreasing vibration and protect-
ing sensitive incision sites (Figure 22-15). Workstation evaluation
and adaptations may be needed to avoid awkward and repetitive
movements whenever possible.
Boxer’s Fract ure

Pat homechanics
A boxer’s racture is a racture o the f th metacarpal neck, which
is the most commonly ractured metacarpal.39 On impact with
a solid object, the metacarpal will requently shorten and angu-
late. Because o the large degree o mobility o the f th metacar-
pal, less-than-per ect anatomic reduction is acceptable, allowing
adequate hand unction.7
Injury Mechanism
T is injury occurs most requently rom contact against an object
with a closed f st. It can also be the result o a all. Many patients
Figure 22-15 who sustain this racture because o a hostile encounter are
reluctant to admit the true cause o the injury.
Patients that have persistent pain may benefit from
padded bicycle gloves as they return to their sports. Rehabilit at ion Concerns
This glove protects the sensitive area while allowing I the injury is open, the risk o in ection is serious. T is is espe-
a gradual return to such activities as golf or tennis. cially true when a closed f st has struck another’s mouth and
come in contact with the opponent’s teeth and/ or saliva. I the
injury is closed, treatment consists o proper immobilization,
edema control, and ROM o noninvolved joints. Proximal IP joint
extension can be problematic especially o the f th digit. In some
cases, open reduction and internal f xation is required. Postoper-
atively, proper orthotic management, edema control, and AROM
o uninvolved joints are important.26,39
reatment is immobilization in a plaster gutter support, or
in a thermoplastic orthosis (Figure 22-16). T e latter is o ten pre-
erred, as it allows removal o the orthosis or ROM o the wrist
and digits, as well as skin hygiene. T e orthosis immobilizes the
ring and small f nger metacarpals and MCP joints. T e MCP
joints are placed in com ortable exion and the wrist is usually
le t ree. T e orthosis should be adjusted and remolded as edema
decreases. Immobilization with the orthosis is continued or
approximately 4 to 6 weeks. I there is an open wound present,
it should be monitored or in ection and the physician should be
contacted immediately. T e physician may place the patient on a
course o antibiotics when an open wound is present.

During the tim e o im mobilization, AROM to noninvolved
joints is maintained. T e surgeon, based on the stability o the
racture or surgical f xation, should determine the initiation o
MCP AROM to the involved digits. At approximately 6 weeks, Figure 22-16
the orthosis is o ten discontinued i there is evidence o radio-
graphic healing, but may be used as needed or protection during A boxer’s fracture orthosis often protects the ring and
heavier activities. A buddy tape (Figure 22-17) may be used when small nger proximal phalanxes and the MCP joint.
MCP AROM is allowed to promote proper digital
alignment. A patient may gradually resume normal
activity without the orthosis when there is evidence
o radiographic healing. Gentle grip strengthening
exercises with putty can be initiated with a healed
racture usually at 6 to 8 weeks a ter injury or surgi-
cal intervention.
de Quervain Tenosynovit is
Pat homechanics
de Quervain tenosynovitis is an in ammation in the
f rst dorsal compartment a ecting abductor pollicis
longus and extensor pollicis brevis.4,48 T e Finkel-
stein test,33 which involves thumb exion into the
palm with passive wrist ulnar deviation, can assist
with making the diagnosis ( Figure 22-18). It may
be help ul to compare the level o pain elicited to the
noninjured side. T is test alone cannot conf rm the Figure 22-17
diagnosis, as it can be uncom ortable in the normal
population. T e results o the Finkelstein test must Buddy taping may be utilized to encourage or maintain proper
be considered in conjunction with other clinical digit alignment when adequate healing allows MCP AROM
f ndings. following a boxer’s fracture.
Injury Mechanism
Repeated wrist movements may cause de Quervain teno-
synovitis. Less- requent causes include a direct blow to
the radial styloid, acute strain as in li ting, or a ganglion
cyst in the f rst dorsal compartment.4,48

Initial treatment is rest rom aggravating activities. Modali-
ties or edema reduction and pain control such as ultra-
sound and ice are widely utilized by clinicians or this
condition. Ice is used or its ability to manage in amma-
tion and pain.4,31 Michlovitz54 reports that ultrasound
at lower intensities most likely produces its therapeutic
Figure 22-18 The Finke lste in te st w ill be e ects by the phenomenon known as m icrostream ing. T is
po sitive fo r pain in de Que rvain te no syno vitis
is reported to cause changes in cell permeability and may
help to promote healing. Michlovitz54 discusses that low-
Passive flexion of the thumb with wrist ulnar deviation is the
dose pulsed ultrasound may be e ective in acute and sub-
provocative position.51,52 Always compare to the noninvolved
acute rehabilitation o tendonitis, but stresses that urther
side, as this test can be uncomfortable with a normal hand.
study is needed. In addition, an analysis o activities should
be per ormed to determine aggravating activities. T ese
activities should then be avoided or adapted as necessary.
Orthotic managem ent or de Quervain tenosynovitis includes im m obilization
o the thumb at the MCP and carpometacarpal (CMC) joints as well as the wrist (see
Figure 22-10).96 Immobilization is usually ull time with removal o the orthosis or hygiene
or the f rst 4 to 6 weeks. Many patients need to be reminded not to “f ght” their orthosis,
but to relax and let it support them. Resisting the orthosis can aggravate symptoms. Some
patients may have a combined condition that includes irritation to the radial sensory nerve.
T is nerve irritation can include hypersensitivity that makes the area pain ul to touch.
T ese patients may also be unable to tolerate ice. Clinical use o a transcutaneous electri-
cal nerve stimulation may be e ective or pain control or these patients until the nerve
symptoms subside. As the pain rom the tendon is reduced a ter 4 to 6 weeks, the patient
slowly decreases the wear time o the orthosis. Activity is resumed gradually, while avoiding
irritating activities. I pain is persistent, immobilization is continued. Patients who do not
respond to conservative management may be candidates or surgical intervention o the
f rst dorsal compartment.
Various surgical techniques are used to treat this condition. Some surgeons hope to
prevent the complication o a tendon subluxation with an internal tendon sling to help
stabilize the release. T is surgery will require a thumb spica orthosis or approximately
6 weeks postoperatively, with the initiation o gentle thumb and wrist AROM usually at
the 4-week point.4,48 AROM consists o gentle thumb opposition, exion, and extension
(see Exercise 22-7), as well as wrist exion and extension (see Exercise 22-2). I the release
to the f rst dorsal compartment does not include an internal sling, then gentle AROM as
described above can begin a ter the sutures are removed. T is is usually 10 to 14 days a ter
surgery. A ter a simple release (no internal sling), some physicians pre er a thumb spica
orthosis or a ew weeks. T e patient gradually resumes normal activity around the sixth
week a ter surgery.48 It is important that the therapist consult with the physician to imple-
ment the pre erred postoperative protocol.
Complications rom surgery include hypersensitivity, complex regional pain syndrome,
incomplete release, tendon subluxation, and injury to the radial sensory nerve.48 A radial
sensory nerve injury will present itsel as a very di erent type o pain than the patient had
be ore surgery. T e patient may complain o numbness, or pain that is burning, shooting,
or electrical in nature. Care should be taken to avoid any
pressure rom the orthosis in the area o the radial sensory
nerve at the wrist during the preoperative or postoperative
programs.

Early strengthening exercises should be avoided or symp-
toms could be exacerbated. Increased symptoms are likely
to limit return to normal activity. Patients should have
pain- ree ROM in the a ected area as the primary goal.
Aggravating activities should be addressed and adapted as
appropriate. Some patients may benef t rom the support
and protection o a so t neoprene orthosis as they return
to activities (Figure 22-19).5 T is so t orthosis allows ROM,
but provides gentle support and padding to an area that can
be hypersensitive. It also allows more activity because it is
more exible than a custom thermoplastic/ ridged orthosis
and the hand is protected during ADL. Figure 22-19
Some patients, who have difficulty returning to activities
Trigger Finger because of nerve pain, appreciate the support and
Pat homechanics protection of a soft neoprene orthosis. This Comfort
Cool soft orthosis allows good ROM, but provides
rigger f nger or stenosing exor tenosynovitis can be
gentle support and padding to an area that can be
described as a discrepancy between the exor tendon and
hypersensitive. This orthosis will then allow more activity
the A1 pulley, which is located at the level o the metacarpal
as the patient is not fearful of bumping or hitting the
head. T is disproportionate size does not allow or smooth
hand accidentally during daily living activities.56 (Photo and
gliding o the exor tendon within the sheath. T is may
splint courtesy of North Coast Medical, Inc., Gilroy, CA.)
cause pain, “catching,” or even locking o the digit in exion.
Occasionally pain is identif ed by the patient to be in the
dorsal PIP joint, the DIP joint, or the entire f nger. T is pain,
is, however, re erred pain 18 rom the exor tendon and/ or
the A1 pulley. In addition, a nodule may also be present and
may be palpated. Patel and Bassini described 6 stages o
trigger f nger ( able 22-1).60
Table 22-1 Pate l and Bassini’s Stag e s o f
Injury Mechanism Ste no sing Te no syno vitis 58
riggering may be the result o exor tendon in ammation
or thickening o the tissues or a variety o reasons. T is may
Stag e s De scriptio n
be caused by overuse o the exors, thereby causing a larger
in amed or even bulbous tendon. Also, diseases such as 1 Normal
arthritis and diabetes can cause changes in the so t tissues. 2 Uneven
Because use o the regular use o the hand or daily tasks, a
perpetual cycle may occur causing a constant irritation o 3 Triggering = Clicking = Catching
the tendon, limiting a smooth glide. 4 Locking of nger in exion on extension,
unlocked by active nger motion
5 Locking of nger in exion on extension,
O ten, patients are not re erred immediately rom the physi- unlocked by passive nger motion
cian or therapeutic intervention. In many cases, a patient
is provided with a cortisone injection to the exor tendon 6 Locked nger in exion or extension
at the site o the A1 pulley. T is has been reported to have
A B C
Figure 22-20
A. The literature notes many types of orthosis that effectively limit the amount of tendon glide excursion in the treatment of
trigger finger. This orthosis limits MCP flexion. B. This orthosis limits PIP flexion. C. This orthosis limits DIP flexion.
varying levels o success.61 A patient may be re erred to a therapist or an orthosis, modali-

ties, and possible PROM.30 Modalities may provide some benef t to the in amed tendons
and or pain control.
Orthotic use in all stages, with the exception o the last stage, has been e ective or
many patients.20,30,80,81,85,95 T e literature discusses the many types o orthoses that are rec-
ommended to limit the amount o tendon glide/ excursion (Figure 22-20). T is immobili-
zation may decrease pain and in ammation as well as decrease the active “catching” o
the thumb or digit. Immobilization with an orthosis is done ull-time or 3 to 6 weeks, with
removal o the orthotic or hygiene purposes, avoiding active motion.20 Patients who do not
respond to immobilization may require a surgical release o the A1 pulley.
T erapy considerations or a postsurgical trigger-f nger release include active motion
as early as the same day. T e ocus o therapy includes wound care as needed, ROM, edema
control techniques, and eventual scar management.

Patients are usually seen in therapy or only a ew postoperative visits. Many patients are
discharged prior to beginning a strengthening program. Strengthening can be initiated,
i needed, at approximately 3 weeks postsurgery. T is can be done with T eraputty and
should be gradual without irritation or pain. Occasionally, hypersensitivity o the scar is
noted and will need to be addressed with desensitization techniques. I overuse was a pri-
mary cause o the initial trigger f nger, patient education should be provided. T is would
include avoiding sustained gross grasp and repetitive digital exion activities. Analysis o
activities with modif cations and adaptations to the environment should be per ormed and
provided as needed.
Ost eoart hrit is of t he Carpomet acarpal Joint

Pat homechanics
Osteoarthritis (OA) can a ect all o the joints o the thumb. A swan-neck de ormity is com-
mon, involving 21% o patients with OA.95 T is de ormity is o ten characterized by meta-
carpal adduction, CMC subluxation rom the trapezium, MCP joint hyperextension, and IP
joint exion (Figure 22-21A). Pinch is o ten pain ul because the CMC subluxation becomes
more pronounced during heavy pinch activities. T e thumb IP joint sometimes assumes a
A B
Figure 22-21
A. OA can affect all of the joints of the thumb. A swan-neck deformity is often characterized by metacarpal adduction,
CMC subluxation from the trapezium, MCP joint hyperextension, and IP joint exion. B. Designing and fabricating a thumb
orthosis for the OA CMC joint requires careful positioning during fabrication to immobilize the CMC appropriately. A gentle
correction of the swan-neck deformity would place the thumb (opposite of the deformity) in metacarpal abduction, align
the metacarpal on the trapezium, ex the MCP joint, and extend the IP joint in joints that are passively correctable.
exed position. T e Eaton classif cation has been widely used to def ne severity and guide
treatment o this de ormity through radiographs.28 When evaluating the thumb, determine
the specif c pattern o de ormity so that treatment can be more specif c in terms o orthotic
support and therapeutic management.
Injury Mechanism
Osteoarthritis is o ten called the wear-and-tear disease, but research demonstrates that the
breakdown in the articular cartilage is caused by both mechanical and chemical actors.9
Complex biomechanical actors appear to activate the chondrocytes to produce degrada-
tive enzymes.40,96 Mechanical actors, such as abnormal loading o the joint rom trauma,
heavy labor, joint instability, aging, and obesity, can increase the risk o OA.40 A ected per-
sons have a genetic susceptibility, and OA occurs more requently in women older than age
50 years than in men o the same age.47,96

General principles o exercise include avoiding pain ul AROM and PROM by working
within the client’s com ort level. General AROM exercises or the hand include wrist ex-
ion and extension, gentle digit exion and extension, and thumb opposition. Encouraging
CMC motion in exion and abduction with the thumb MCP and IP joints exed can assist
the patient in relearning CMC movement instead o overusing the MCP and IP joints during
ADL (see Exercise 22-7D and E). T ere is moderate evidence to support hand exercises in
OA or increasing grip strength, improving unction, improving ROM, and pain reduction.84
Combining joint protection and pain ree hand home exercises were ound to be an e ec-
tive means to increase hand unction, as measured by grip strength and sel -reported global
unctioning in persons with hand OA.27 Exercise programs that utilize AROM as opposed to
pinch strengthening66,76,84 were ound to be more e ective. Even light putty-pinching exer-
cises impart large orces22 to an unstable CMC joint and may aggravate a potential de or-
mity. Stability must not be sacrif ced or a possible increase in strength. A stable pain- ree
thumb provides a post against which the digits can grip and pinch e ectively. Stretching
and massaging the f rst web space at the adductor pollicis brevis may help reduce muscle
tightness that can promote the adduction contracture and subsequent MCP hyperexten-
sion de ormity.1 T umb web space stretching or widening can be done by having the client
grasp a 1-inch wooden dowel11 (Exercise 22-9A) as part o the home program, as well as
techniques to relax the adductor pollicis. Anatomically, strengthening the f rst dorsal inter-
osseous (Exercise 22-9B) may help provide stability to the base o the CMC as it originates
at the base o the f rst metacarpal.1
Designing and abricating a thumb orthosis or the OA CMC joint requires care ul posi-
tioning during abrication to immobilize the CMC appropriately. A gentle correction o the
swan-neck de ormity would place the thumb (opposite o the de ormity) in metacarpal abduc-
tion, align the metacarpal on the trapezium, ex the MCP joint, and extend the IP joint.11 Sta-
bilizing the CMC joint with an appropriate orthosis can decrease pain and increase unction in
patients that are passively correctable (see Figure 22-21B).84,93 Research indicates that specif c
orthoses were pre erred by patients. Weiss et al93,94 ound that a hand-based thumb orthosis
and a short, exible, neoprene orthosis were pre erred. Night CMC orthoses were ound to
decrease pain and disability a ter 12 months o wear.94 Use o an orthosis also is e ective in
reducing the need or surgery. One study reported a ter wearing the orthoses or 7 months,
only 30% o the patients reported wanting to have surgery.65 A systematic review published by
Valdes and Marik84 ound that orthotic provision had a positive impact on decreasing hand
pain and increasing hand strength and unction in patients with OA. T e therapist has several
choices when selecting the proper orthosis or the client. T e orthosis can be custom abri-
cated o lightweight thermoplastics, or in some cases a so t material (eg, Neoprene) can be
used i the strapping is applied properly, to counteract the de orming orces. T ere are also
several pre abricated options available. T e authors o this chapter have had good patient
acceptance and reported pain reduction with both the neoprene Com ort Cool T umb CMC
Restriction Splint (see Figure 22-19) (available rom North Coast Medical) and T e Push
MetaGrip (Figure 22-22) (available rom HandLab). T is client acceptance is attributable to
decreased pain and increased joint stability when using the
properly f t orthoses during pinching activities. Clients o ten
misinterpret this as an increase in strength. A stable, pain-
ree thumb is important to hand unction and provides a
post that the digits can grip and pinch e ectively.

OA is a chronic condition with remissions and exacer-
bations. T e principles above will continue as the client
progresses through the disease process. It is important to
avoid pain during daily activities and during treatment so
as to avoid joint de ormities. CMC surgery may be indi-
cated as the disease progresses.
Figure 22-22 Ulnar Collat eral Ligament Sprain

(Gamekeeper’s or Skier’s Thumb)
The Push MetaGrip is a prefabricated option that has high
patient acceptance. This acceptance is often attributable to Pat homechanics
decreased pain and increased joint stability when using the Injury to the ulnar collateral ligament (UCL) o the
properly fitted orthoses during pinching activities. thumb MCP joint is one o the most common ligament
injuries.10,17,38,51,73,78 T e injury is classif ed as grade I when there is pain but minimal dam-
age to the ligament; grade II is a partial tear with some joint instability; and grade III is a
complete disruption o the UCL with more than 30 degrees o lateral instability. It is most
o ten the distal attachment o the ligament where the rupture occurs.38,51
T e patient will complain o pain or tenderness on the ulnar side o the MCP joint, as
well as in ammation, in all classif cations. I the ligament is completely torn, one must
also be concerned about a Stener lesion. A Stener lesion is where the torn UCL protrudes
beneath the adductor aponeurosis. T is places the aponeurosis between the ligament and
its insertion. I this occurs, reattachment will not occur and surgery is needed.78
Injury Mechanism
UCL injuries occur when a torsional load is applied to the thumb.16 It requently occurs
in pole sports as a result o a all on an outstretched hand when landing with a pole on
an abducted thumb.10,17,38,51,73,78 T is injury is re erred to as gamekeeper’s injury as well as
skier’s thumb. Gamekeeper’s injury occurs most requently rom chronic repeated stress on
the UCL78 whereas skier’s thumb occurs most commonly as an acute injury.38 Football play-
ers also may sustain this injury while abducting the thumb be ore making a tackle.51

Early diagnosis and treatment are important. An unstable thumb MCP joint or a Stener
lesion, i not treated, can become chronically pain ul and unstable possibly resulting in
arthritic changes and reduced pinch strength.10,17,78 reatment or incomplete (grade I or II)
tears and some grade III avulsions is o ten immobilization in a thumb spica cast or orthosis
(Figure 22-23). T is is o ten utilized or 6 to 8 weeks, depending on the pre erences o the
physician. Care should be taken to avoid MCP radial deviation during the immobilization
phase so as to prevent stretching o the healing UCL. T ere is some support or using an
orthosis rather than a cast or immobilization.32,43 In addition to treatment with an orthosis,
there is some support or early initiation o AROM.43,45 T ere has also been some support or
utilization o a hinged orthosis. T is orthosis allows or motion in exion and extension but
prevents MCP ulnar and radial deviation.35,53,74
reatm ent or Stener lesions or displaced
bony avulsion injuries is a surgical repair. Early
operative intervention is recommended because
delayed reconstruction is less success ul.17 Post-
operatively, a thumb spica orthosis is usually
worn or 6 to 8 weeks with initiation o thumb
AROM based on physician pre erences.

Some patients, as they return to sports or specif c
activities, pre er to continue to wear a thin hand-
based thum b spica orthosis (see Figure 22-23)
or protection. T is orthosis can be abricated
with light (1/ 16 in) orthotic materials that can f t
under a ski or other sport’s glove. A simple Vel-
cro thumb sling described by Fillon may be pre-
erred by patients who require a so ter option.35 Figure 22-23
T e orthosis secures the thum b to the index
digit avoiding ulnar deviation. T ese patients A hand-based thumb spica orthosis is utilized for protection of the
will gradually wean rom the orthosis as they UCL. This condition is often referred to as gamekeeper’s thumb or
progress. skier’s thumb.
Mallet Finger
Pat homechanics
A mallet f nger is the avulsion o the terminal exten-
sor tendon, which is responsible or extension o the
DIP joint.70 T e patient will be unable to extend the
DIP joint actively upon examination (Figure 22-24).
It may occur with or without racture o bone. I there
is a large racture ragment where the racture rag-
ment is displaced greater than 2 mm, or the DIP joint
has volar subluxation on radiograph, the injury will
require open reduction and internal f xation.
Injury Mechanism
T e injury mechanism is orced exion o the DIP
joint while it is held in ull extension.77 It requently
happens when a ball or some other object strikes the
Figure 22-24 A malle t ng e r de fo rmity w ith DIP ully extended digit. It also may occur when tucking
e xio n in bedding or when the tendon is weakened by the
arthritic process.

Rehabilitation o the mallet f nger requires excellent orthotic/ casting skills and good patient
compliance. T ere is a tendency to minimize this condition and many patients are non-
compliant. reatment includes an orthosis that places the DIP joint in slight hyperextension
(Figure 22-25) or 6 to 8 weeks with no exion o the DIP joint.25,57,77 I the DIP joint is exed
even once during the immobilization period, the 6-week immobilization period begins
again at that time. An orthosis or cast should be custom made,64 com ortable to the patient,
and designed not to cause skin breakdown. I the splint is removable, the patient should be
able to reapply it with the DIP held in hyperextension. Skin integrity needs to be monitored
A B
Figure 22-25
A. A mallet nger orthosis must hold the DIP in slight hyperextension. Skin integrity needs to be monitored with the orthosis
being modi ed or redesigned if irritation occurs. B. Waterproof QuickCast II material allows full-time wear even while bathing.
and the orthosis be modif ed or redesigned i irritation occurs. Because o this challenge,
many clinicians utilize a waterproo QuickCast II material that allows ull-time wear even
while bathing. T e QuickCast II material is heated with a hair dryer and quickly applied to
the digit held in slight DIP hyperextension (Figure 22-26A–E). Patients return weekly or cast
changes. I the cast becomes loose between cast changes, it can be held snug by an overwrap
o Coban. Range o motion o noninvolved f ngers and joints should be maintained. Athletes
may require cast changes with each game or practice as a consequence o perspiration. T e
therapist can instruct the team’s athletic trainer in the QuickCast II technique so as to reduce
the number o visits the athlete has to make to the clinic.
A B
C D
E F
Figure 22-26
A. The QuickCast II material can be heated up with a hair dryer. B. The digit held in slight
DIP hyperextension at all times. C and D. The cast is quickly applied and the position of
slight hyperextension maintained as the orthosis cools. Patients return weekly for cast
changes. E. If the cast becomes loose between cast changes, it can be held snug by an
overwrap of Coban. ROM of noninvolved fingers and joints should be maintained. PIP
flexion with the DIP cast will not put tension on the injury and should be encouraged.
F. The cast is removed with a special short scissors.
A B
Figure 22-27
A. Once the tendon is healed, often at approximately 6 to 8 weeks,94 orthotic weaning is initiated with a schedule
of 2 hours on, 2 hours off, and at least 1 month of night orthotic wear.96 An adjusted Oval 8 orthosis facilitates easy
donning and doffing during this phase. The Oval 8 is heated up at this junction and the orthosis gently placed in slight
hyperextension. B. The Oval 8 holding the digit in place and in slight hyperextension.

Once the tendon is healed, o ten at approximately 6 to 8 weeks,57 orthotic weaning is ini-
tiated. I an extensor lag is present, use o the orthosis either continues or the physician
evaluates or the possibility o surgery. Orthotic weaning is initiated
with a schedule o 2 hours on, 2 hours o , and at least 1 month o
night splinting.57 I no extension lag develops, then the time out o
the orthosis is gradually increased. An adjusted Oval 8 orthosis acili-
tates easy donning and do ng during this phase ( Figure 22-27).
Gentle DIP joint AROM consists o initiating light use o the hand. No
attempt should be made to passively ex the DIP joint or to stretch
out the tendon with DIP joint blocking (Exercise 22-10). Full ROM is
usually gained through regular unctional hand use. Athletes should
wear a DIP joint orthosis or no less than 8 weeks.
Bout onnière Deformit y

Pat homechanics
T e posture o a f nger with a boutonnière de ormity is PIP joint
exion and DIP joint hyperextension (Figure 22-28). It is caused by
interruption o the central slip. Normally, the central slip will initi-
ate extension o exed PIP joints. When the central slip is disrupted,
the extensor muscle displaces proximally and shi ts the lateral bands
shi t volarly. T e FDS is then unopposed without an intact central
slip and will ex the PIP joint. T e lateral bands displace volarly and
may become f xed as the de ormity progresses. T is then makes pas-
Figure 22-28 sive correction very di cult. T e DIP joint hyperextends because all
the orce to extend the PIP is transmitted to the DIP joint.68
A boutonnière deformity may start as a Once a f xed de ormity is present, treatment can be challenging.
PIP contracture. It can in time result in reatment within 6 weeks o the initial injury is associated with better
hyperextension of the DIP joint. outcomes.75 Many patients do not seek immediate medical attention,
mistakenly eeling that the f nger was “just jammed” and that it will resolve quickly. reat-
ment or the acute injury is uninterrupted immobilization, with an orthosis or QuickCast II,
o the PIP joint in ull extension or 6 to 8 weeks67 (Figure 22-29). T e DIP joint is le t ree
or blocked in slight exion without strapping to encourage DIP exion. T is will synergisti-
cally relax the extrinsic and intrinsic extensor tendon muscles and exercises the oblique
retinacular ligament.49
Injury Mechanism
Injury occurs when the extended f nger is orcibly exed, such as when being hit by a ball or
because o a all when striking the f nger on another object.67,73 rauma to the dorsal aspect
o the PIP joint can also be a mechanism o injury.67

O primary concern is early and proper diagnosis and treatment. Radiographs can help to
rule out a racture or a PIP joint dislocation. It is also very important to immobilize the PIP
in ull extension. As edema decreases, requent orthotic modif cations are needed to assure
ull PIP joint extension. I diagnosis is made late and there is a f xed PIP exion contrac-
ture, serial casting may be the best conservative measure to restore extension. Serial casting
with QuickCast II is pre erred by many patients as it is waterproo and more easily tolerated.
Following return o ull extension (usually a ter 6 to 8 weeks), the digit is then placed in a
removable orthosis or the weaning program (see Figure 22-27A). Weaning occurs gradually
with a return to the immobilization orthosis i an extension lag develops at the PIP joint.

Weaning rom the orthosis a ter 6 to 8 weeks may be initiated with a 2 hours on and 2 hours
o daytime schedule and with night immobilization continuing or several weeks. Gentle
A B
Figure 22-29
A. Treatment for the acute boutonnière injury is uninterrupted immobilization of the PIP joint in full extension for
6 to 8 weeks. The DIP joint is left free or blocked in slight flexion without strapping to encourage DIP flexion. This
will synergistically relax the extrinsic and intrinsic extensor tendon muscles and exercise the oblique retinacular
ligament.13 B. Chronic injures usually require serial casting to gradually obtain full PIP extension.
PIP joint AROM begins gradually, observing or the development o PIP joint extension lag.
I an extension lag develops, the patient is returned to the orthosis. I the extension lag is
persistent, the patient should be re erred to the surgeon or evaluation. Orthosis weaning
programs that progress without an extension lag can gradually return to using the hand or
light activities. Night immobilization may continue or 12 weeks and beyond.
Protocols
de Quervain Tendonit is Conservat ive Management Prot ocol

Acut e Phase
T e initial treatment is rest rom aggravating activities. T is includes ull-time wear o the
orthosis or 4 to 6 weeks (see Figure 22-10) with removal o the orthosis or bathing and
skin care. T e orearm-based orthosis includes the wrist, thumb (CMC), and MCP joints.
Modalities to decrease in ammation may be utilized by the clinician during this phase as
well. Goals or the acute phase include the ollowing:
1. T e patient will report reduced pain while wearing the orthosis.
2. T e patient will be independent with the orthotic program.

A ter wearing the orthosis or 4 to 6 weeks, weaning o the orthosis is initiated i the patient
reports a decrease in pain (with a pain analog scale). T is begins with a schedule o 2 hours
on and 2 hours o during the day. Pain ul activities are avoided, and night immobilization
continues. T e time out o the orthosis gradually increases, as dictated by reduced pain lev-
els. I the symptoms return during the weaning program, the physician should be contacted
to determine i ull-time immobilization with the orthosis should be resumed, or i surgery
is an option. T e goals o the intermediate phase are to wean rom the orthosis during the
day and to gradually return to ADL without an increase in pain.
Advanced Phase
T e patient gradually weans rom the night orthosis. Some activities including work activi-
ties may need to be avoided, modif ed or adapted as necessary to prevent recurrence o the
condition. T e goal o the advanced phase is to gradually wean rom the night orthosis and
return to ull participation in ADL without an increase in pain.
Ret urn t o Funct ion

Strengthening exercises should be avoided to prevent irritation to the involved tendons.
Once the patient returns to pain- ree ADL, ormal strengthening programs are usually not
needed. Work as well as all activities should be care ully analyzed and adapted as possible
to avoid recurrence o pain ul symptoms. T e goal o the return-to- unction phase is to
return to ADL and work activities without a recurrence o symptoms.
Mallet Finger Conservat ive Management Prot ocol

Acut e Phase
Rehabilitation or a mallet f nger requires precise abrication o an orthosis or a cast. T e
orthosis or QuickCast II must be applied in slight DIP hyperextension and worn ull-time or
6 to 8 weeks. T e hyperextension position must be maintained at each weekly orthosis/ cast
change or the immobilization period must be initiated again rom the beginning. When
Protocols 685
patients are wearing an orthosis, the patient should per orm skin care checks and hygiene
at least once a day. It is important that the patient is independent with the home orthosis/
casting program including proper use and duration o wear, and avoids any unsupported
DIP motion when removed or short time periods during skin care. I the patient is wear-
ing a QuickCast II, it will need to be changed by the therapist at least once a week. Many
patients are unable to obtain the position o slight DIP hyperextension at the initial therapy
visit. T is requires serial casting or a serial extension orthosis until the position is obtained
(see Figure 22-26). T e goals o the acute phase include achieving slight DIP hyperexten-
sion. Once this is obtained, a 6- to 8-week immobilization period begins. I the cast or
orthosis becomes loose, Coban or tape should be used to secure it. T e patient should be
able to complete PIP AROM exercises in the DIP orthosis/ cast.

T e cast/ orthotic program continues or 6 to 8 weeks until ull active DIP extension is
achieved.95,97 At the 6-week point, the DIP active extension position is care ully tested by
having the digit supported in hyperextension by the examiner. T e support is then brie y
removed by the examiner to observe or ull active DIP extension. I ull active DIP extension
is achieved, the patient moves on to the intermediate phase. I the DIP exes slightly, support
is immediately reapplied by the examiner and the orthosis/ cast is reapplied. At this point,
the immobilization may continue or the patient may consult with the physician regarding
surgical intervention. T e goal o the intermediate phase is ull active DIP extension.
Advanced Phase
A ter ull active DIP extension has been achieved by means o the continuous DIP orthosis/
cast extension program, weaning rom the orthosis is initiated. Weaning proceeds by gradu-
ally decreasing the amount o time in the orthosis and observing or DIP extension lags. T is
weaning usually involves a change in the wearing schedule to include 2 hours on and 2 hours
o with continued night wear. An easily removable orthosis or this weaning period is the
Oval 8 orthosis rom 3-point products (see Figure 22-27). T is orthosis is adjusted to place
the DIP in slight hyperextension. T e ease o donning and removal o this “ring style” ortho-
sis may improve patient compliance. A ter 3 to 4 days, i ull DIP extension is maintained, the
wearing schedule or time out o the orthosis is increased to 4 hours on and 4 hours o and
continues at night. T is weaning procedure continues until the daytime orthosis is gradually
discontinued, but wearing a night orthosis continues or at least 1 month.96
I at any point during the weaning program, the DIP demonstrates an extension lag,
the orthosis is reapplied and the physician contacted. T e patient may be a candidate or
surgery i the orthosis program has been unsuccess ul. Some physicians and/ or patients
may pre er another trial month o the ull-time orthosis program as opposed to surgery.
T e goal o the advanced phase is success ully weaning rom the orthosis during the day
while maintaining ull active DIP extension o the involved digit. It is important to note that
i the patient has an extension lag, it will only increase a ter the orthosis is discontinued.95,97
Ret urn t o Funct ion

T e advanced phase ends with success ul weaning rom the daytime DIP orthosis. Dur-
ing the return-to- unction phase the patient gradually weans rom the night orthosis. One
option is to wear the night orthosis every other night and gradually increase the number
o nights out o the orthosis. T is continues until night orthotic wear is eliminated and ull
active DIP extension is maintained. Blocking (Exercise 22-10) to the DIP, as well as PROM,
are prohibited to avoid stress to the newly healed tendon. T e patient gradually returns to
using the digit or progressively more involved ADL. Once again (as stated previously), any
return o the DIP extension lag is reported to the surgeon.
Exercises
A B C D E
Exercise 22-1
Tendon gliding exercises allow for maximum gliding of the FDS and FDP. A. Start with full composite finger extension. B. Move
to MCP flexion with IP extension activating the intrinsics and then return to extension. C. Move to hook fisting, which gives
maximum differential tendon gliding between FDS and FDP and return to extension. D. Move to long fisting with MCP and PIP
flexion and DIP extension for maximum FDS tendon glide and return to extension. E. Finally, move to composite flexion with
full fisting, which gives the maximum glide of the FDP tendon.
A B
Exercise 22-2
A. Wrist extension encourages exercise of the common wrist extensor tendons (extensor carpi radialis longus, extensor
carpi radialis brevis, and extensor carpi ulnaris). Digit flexion should be maintained to eliminate extensor digitorum
communis contribution and to isolate the wrist musculature. B. Wrist flexion encourages exercise of the common
wrist flexors (flexor carpi ulnaris, flexor carpi radialis). Digit extension should be maintained to avoid FDS and FDP
contributions and to isolate the wrist musculature.
Protocols 687
A B
Exercise 22-3
A. Active supination exercises the supinator and the biceps. It should be done with elbow at
90 degrees of flexion with the humerus by the side. This eliminates shoulder rotation. B. Active
pronation exercises should also be done in the same position.
A B
Exercise 22-4
A. Passive supination can be done with a hammer. The lever action of the hammer assists with the passive motion.
B. Passive pronation is also done with the hammer.
A B
Exercise 22-5
A. Wall pushups encourage wrist motion and general upper-body strengthening. They also encourage weight bearing
and closed-chain activities. B. Pushups can be progressed from the wall to a table or countertop. This encourages gradual
progression of increased weight bearing to the extremity.
Exercise 22-6
Pushups on a ball encourage upper-extremity control.
Protocols 689
A B C
D E F
Exercise 22-7
Some of the more common AROM exercises to the thumb include (A) opposition, (B) flexion, (C) extension, and
(D) palmar abduction. (E) Carpometacarpal (CMC) flexion with MCP and IP flexion is used in cases of CMC osteoarthritis.
This encourages the patient to relearn how to move the CMC instead of over using the MCP and IP joints during ADL.
(F) CMC abduction with MCP and IP flexion.
Exercise 22-8
To isolate active movement of the FDS, the noninvolved
ngers are held in full extension, allowing only the
involved nger to ex.
A B
Exercise 22-9
A. Stretching and massaging the first web space to a tight adductor pollicis brevis may help prevent the adduction
contracture and subsequent MCP hyperextension deformity.76 Thumb web space stretching or widening can be done by
having the client grasp a 1-inch wooden dowel as part of the home program, as well as techniques to relax the adductor
pollicis (AP).76,77 B. Anatomically, strengthening the first dorsal interossius may help provide stability to the base of the
CMC as it originates at the base of the first metacarpal.76
A B
Exercise 22-10
A. Blocked DIP exercises encourage FDP pull-through. Stabilizing the middle phalanx allows the flexion force to
concentrate at the DIP joint. B. Blocked PIP exercises encourage FDS pull-through. Stabilizing the proximal phalanx then
allows the flexion force to act at the PIP joint.
Protocols 691
SUMMARY
1. Scaphoid ractures may not be obvious on an initial radiograph. Some scaphoid rac-
tures are misdiagnosed as wrist sprains. Proper immobilization is important in the
long-term outcome.
2. C S is usually treated by rest and with a night orthoses that place the wrist in a neutral
wrist position.
3. Orthotic provision in patients with CMC OA has been demonstrated to decrease hand
pain and increase hand strength and unction. T e therapist has several choices when
selecting the proper orthosis or the client.
4. Boxer’s ractures with an open wound have a high incidence o in ection.
5. de Quervain tenosynovitis should be immobilized or 4 to 6 weeks in a thumb spica
orthosis.
6. rigger f nger may be managed conservatively with the use o several types o orthoses
or a minimum o 3 to 6 weeks o immobilization.
7. T e goal in the treatment o UCL injuries (gamekeeper’s thumb and skier’s thumb)
is stability o the MCP joint. Care should be taken to avoid any thumb MCP radial
deviation.
8. Conservative management o a mallet f nger requires a cooperative compliant pa-
tient. DIP exion is not allowed at any time during the 6- to 8-week orthotic or casting
program.
9. Early treatment o the boutonnière de ormity is essential, as is a proper orthotic po-
sition. T e PIP joint should be ully extended with the DIP joint ree or in slight ex-
ion. Serial casting can be e ective in increasing extension in chronic boutonnière
de ormities.
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Groin, Hip, and T igh
Tim o t h y F. Ty le r, St e p h a n ie M . Sq u it ie r i,
a n d Gre g o r y C. Th o m a s
OBJJECT
T I VES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Discuss the functional anatomy and biomechanics of the groin, hip, and thigh.
Discuss injuries to the groin, hip, and thigh and describe the biomechanical changes that
occur during and after injury.
Discuss and describe the functional injury evaluation of the groin, thigh, and hip.
Articulate the role previous injury may play in subsequent injuries in the athlete.
Describe the at-risk populations and the mechanism of injury for muscle strains, muscle
contusions, and acetabular labral injuries.
Demonstrate application of various intervention strategies for a wide variety of hip pathologies
including muscle strains and contusions and acetabular labral injuries.
Apply principles of prevention and wellness using screening for imbalances and preseason-
strengthening programs for susceptible populations.
Apply principles of stretching, strengthening, open- and closed kinetic-chain exercises,

plyometrics, isokinetics, and proprioceptive neuromuscular facilitation exercises to the hip
complex as a part of comprehensive rehabilitation.
695
696 Chapte r 23 Rehabilitation of the Groin, Hip, and Thigh
T e occurrence o injuries to the hip, pelvis, and thigh are relatively small when compared
to the other lower-extremity regions.1-5 Although statistically less prevalent, a hip pathology
can cause immediate gait abnormalities, lead to chronic pain, and give rise to premature
degeneration in the hip joint itsel . T ese injuries can vary signif cantly depending on the
specif c sporting activity involved.6 Contact sports will have a high incidence o traumatic
injuries, such as ractures, contusions, and dislocations, whereas endurance sports, like
running, swimming, and biking, can lead to stress and overuse injuries. No matter what the
injury, proper diagnosis and intervention is key to returning the athlete back to the athlete’s
sport(s) o choice. T is chapter identif es common hip pathologies and directs an appropri-
ate and concise rehabilitation program to optimize a patient’s recovery time.
Anatomy and Biomechanics

T e primary unction o the hip joint is to support the weight o the head, arm, and trunk,
while also serving as the connection between the lower extremities and the pelvic girdle.
T e anatomical design o the hip is well suited to handle this task as well as the increased
loads that can be transmitted during athletic competition.7 Joint impact orces such as run-
ning produces loads up to 3 to 5 times body weight.
T e joint itsel is the articulation between the acetabulum o the pelvis and the head
o the emur. T ese 2 segments orm a diarthrodial ball-and-socket joint with 3 degrees o
reedom : exion/ extension in the sagittal plane, abduction/ adduction in the rontal plane,
and medial/ lateral rotation in the transverse plane.
T e cuplike concavity o the acetabulum is ormed by the usion o 3 bones: ilium,
ischium, and pubis. T ese bones typically unite by the late teenage years.8 T e resulting
socket is located on the lateral aspect o the pelvic bone and has an angular orientation
o in erior and anterior. T e emoral component o the joint has an angular orientation o
superior and anterior. T ese orientations represent the angles o inclination and torsion
respect ully. T e angle o inclination is measured in the rontal plane between the axis o
the head/ neck and the axis o the sha t. Normal angles range between 125 and 135 degrees.
A pathological increase in inclination is called coxa valga , and a decrease is re erred to as
coxa vara . T e angle o torsion is measured in the transverse plane between the axis o the
head/ neck o the emur and the axis through the emoral condyles. It can best be viewed
by looking down the length o the emur rom top to bottom. Normal angles o torsion are
between 10 and 15 degrees with an increase termed anteversion and a decrease called
retroversion .7 Both normal and abnormal angles are properties o the emur and indepen-
dent o the hip joint.
T e emoral and acetabular sur aces correspond well to each other, but given the
increased need or stability at this joint, an accessory structure is needed. T e entire
periphery o the acetabulum is rim med by a ring o wedge-shaped f brocartilage called
the acetabular labrum . T is labrum not only deepens the socket but also increases the
concavity o the socket through its triangular shape. T is structural stability is rein orced
by the hip joint capsule and its ligaments.
T e capsule is attached proximally to the entire periphery o the acetabulum beyond
the labrum. T e distal end covers the head and neck like a sleeve and attaches to the base
o the emoral neck. T is capsule is considered to have 3 rein orcing ligaments: 2 anteriorly
and 1 posteriorly. T e 2 anterior ligaments are the ilio emoral ligament and pubo emoral
ligament. T ese are o ten re erred to as the Y ligam ent of Bigelow . T e ischio emoral liga-
ment is the posterior capsular ligament.7 Femoroacetabular anomalies may occur at the
hip joint. T ese morphological variances include an abnormal emoral head interacting
with a normal acetabulum, or, conversely, a normal emoral head acting on an abnormally
ormed acetabulum.9
Anatomy and Biomechanics 697
Movements at the hip joint consist o arthrokinematic and osteokinematic actions.
T e arthrokinematics that occur within the joint can best be visualized as the movement
o the convex head o the emur within the concavity o the acetabulum. T us the convex
on concave rule states that arthrokinematic motions are opposite o the osteokinematic
movements. Hip exion created by primary movers such as the iliopsoas, rectus emoris,
tensor ascia lata, and sartorius occurs in the anterior direction around the coronal axis.
During hip exion there is a posterior glide o the humeral head. Full range through exion
is approximately 125 degrees.
T e hip extensors are made up o the gluteus maximus and hamstrings, which consist
o the biceps emoris, semimembranosus, and semitendinosus. Extension occurs posteri-
orly around the coronal axis causing an anterior glide o the emoral head. Normal range or
extension is 10 degrees.
Abduction o the hip is brought about by the primary actions o the gluteus medius
and gluteus minimus. T is movement occurs away rom the midsagittal plane in the lat-
eral direction. Normal range is approximately 45 degrees, with in erior movement o the
humeral head.
T e gracilis, adductor magnus, longus, and brevis produce osteokinematic adduction
toward the midsagittal plane. T is results in a superior arthrokinematic emoral head glide
within the acetabulum. Adduction range on average is 10 degrees.7,10,11
T e f nal m otion o the hip is hip rotation that occurs in the transverse plane o
m otion and is o ten overlooked. More im portance has been given to the patients’ abil-
ity to control hip rotation during unction m ovem ents. In patients with patello em oral
pain syndrom e, it has been suggested that a theoretical m echanism or pathology may
be weak em oral external rotators that allow the emur to be in relative internal rota-
tion and in uence patellar alignm ent and kinematics. In act, the role o the hip rota-
tor muscles is requently overlooked when addressing prevention and rehabilitation o
lum bar spine injuries. Weak and/ or shortened hip rotators may contribute to abnormal
lum bopelvic posture and cause com pensatory m otion in the lum bar spine during daily
activities. T e detrim ental e ects o inadequately conditioned and prepared hip rotators
may predispose the athlete to lum bar spine injuries. T e small external rotators o the hip
(piri ormis, obturator internus, obturator externus, gem ellus superior, gemellus in erior,
and quadratus em oris) sometimes get atigued or overpowered by the large internal rota-
tors o the hip (gluteus maximus, gluteus m edius, and gluteus m inimus) creating muscle
im balance.
Hip Muscular St rains

A muscle strain, also called a pull or tear, is a common injury, particularly among people
who participate in sports. T e thigh has 3 sets o strong muscles: the hamstring muscles
posteriorly, the quadriceps muscles anteriorly, and the adductor muscles medially. T e
hamstring and quadriceps muscle groups are particularly at risk or muscle strains because
they cross both the hip and knee joints. T ey are also used or high-speed activities, such as
track and f eld events, ootball, basketball, ice hockey, and soccer.
Most commonly, the mechanism o injury or muscle strains in the hip area is when a
stretched muscle is orced to contract suddenly. A all or direct blow to the muscle, over-
stretching, and overuse can tear muscle f bers resulting in a strain. T e risk o muscle strain
increases i the patient had a prior injury in the area, per orms inadequate warm-up be ore
exercising or attem pts to do too much too quickly. Strains may be mild, m oderate, or
severe depending on the extent o the injury. Signs and symptoms may include pain over
the injured muscle (the most common symptom o a hip strain), increased pain level with
muscular contraction, swelling and discoloration (depending on the severity o the strain),
and a loss o strength in the muscle.
Evaluation o hip muscle strains can be challenging when overlapping conditions

exist. A muscle that is pain ul on contraction and pain ul when stretched may be strained.
Certain exercises or stretches in specif c ways, which stress the involved muscle, can help
determine which muscle is injured. A radiograph or other diagnostic test may be used to
rule out the possibility o a stress racture o the hip, which has similar symptoms, including
pain in the groin area, with weight bearing. In most cases, no additional tests are needed to
conf rm the diagnosis.
In general, interventions are chosen and rehabilitation programs designed to relieve pain,
restore range o motion (ROM), and restore strength, in that order. Rest, ice, compression, and
elevation is standard protocol or mild-to-moderate muscle strains. Gently massaging the area
with ice may also help decrease swelling. Nonsteroidal anti-in ammatory drugs (NSAIDs)
can be taken to reduce swelling and ease pain. Compression shorts/ sleeve or a compression
bandage may also be help ul to decrease swelling and provide support. I walking causes pain,
consider limiting weight bearing and using crutches or the f rst day or two a ter the injury.
Adduct or Muscle St rains

Adductor muscle strains can result in missed playing time or athletes in many sports.
Adductor muscle strains are encountered most requently in ice hockey and soccer.12-14
T ese sports require a strong eccentric contraction o the adductor musculature during
competition.15,16 Recently, adductor muscle strength has been linked to the incidence o
adductor muscle strains. Specif cally, the strength ratio o the adduction–abduction muscles
groups has been identif ed as a risk actor in pro essional ice hockey players.17 Intervention
programs can lower the incidence o adductor muscle strains, but cannot avoid them
altogether. T ere ore, proper injury treatment and rehabilitation must be implemented to
limit the amount o missed playing time and avoid surgical intervention.18
Adduct or Musculat ure

T e group o muscles along the inner thigh is re erred to as the adductor muscle group.
T is group o 6 muscles includes the pectineus, adductor longus, adductor brevis, adductor
magnus, gracilis, and obturator externus. All o the adductor muscles are innervated by the
obturator nerve except or the pectineus, which gets its motor intervention rom the emoral
nerve. T ese muscles originate in the inguinal region at various points on the pubis. T ey
travel in erior to insert along the medial emur. T e main action o this muscle group is to
adduct the thigh in the open kinetic chain and stabilize the lower extremity to perturbations
in the closed kinetic chain. Each individual muscle can also provide assistance in emoral
exion and rotation.8,19 T e adductor longus is thought to be the most requently injured
adductor muscle.20 Its lack o mechanical advantage may make it more susceptible to strain.
Adduct or Muscle Injury

A groin strain is def ned as pain on palpation o the adductor tendons or the insertion on the
pubic bone, or both, and groin pain during adduction against resistance.18,21,22 Groin strains
and muscle strains in general are graded as a f rst-degree strain i there is pain but minimal
loss o strength and minimal restriction o motion. A second-degree strain is def ned as tis-
sue damage that compromises the strength o the muscle, but not including complete loss
o strength and unction. A third-degree strain denotes complete disruption o the mus-
cle tendon unit. It includes complete loss o unction o the muscle.23 A thorough history
and a physical examination is needed to di erentiate groin strains rom athletic pubalgia,
osteitis pubis, hernia, hip-joint osteoarthrosis, rectal or testicular re erred pain, piri ormis
syndrome, or presence o a coexisting racture o the pelvis or the lower extremities.20-23
Imaging studies can sometimes be use ul to rule out other possible causes o inguinal pain.24
Adduct or Muscle St rain Incidence

T e exact incidence o adductor muscle strains in sport is unknown. T is is partly a result
o athletes playing through minor groin pain and the injury going unreported. In addi-
tion, overlapping diagnosis can also skew the exact incidence. Groin strains are among the
most common injuries seen in ice hockey players.25-27 It has been documented that groin
strains accounted or 10% o all injuries in elite Swedish ice hockey players.28 Furthermore,
Molsa 29 reported that groin strains accounted or 43% o all muscles strains in elite Finish
ice hockey players. yler et al17 published the incidence o groin strains in a single National
Hockey League (NHL) team o 3.2 strains per 1000 player-game exposures. In a larger study
o 26 NHL teams, Emery et al13 reported, the incidence o adductor strains in the NHL has
increased over the last 6 years. T e rate o injury was greatest during the preseason compared
to regular and postseason play. Prospective soccer studies in Scandinavia report a groin
strain incidence between 10 and 18 injuries per 100 soccer players.30 Ekstrand and Gillquist14
documented 32 groin strains in 180 male soccer players representing 13% o all injuries over
the course o 1 year. Adductor muscle strains, certainly, are not isolated to these 2 sports.
Risk Fact ors

Previous studies have shown an association between strength and/ or exibility and muscu-
loskeletal strains in various athletic populations.14,31,32 Ekstrand and Gillquist 14 ound that
preseason hip abduction ROM was decreased in soccer players who subsequently sustained
groin strains compared with uninjured players. T is is in contrast to the data published on
pro essional ice hockey players that ound no relationship between passive or active abduc-
tion ROM (adductor exibility) and adductor muscle strains.17,33
Adductor muscle strength has been associated with a subsequent muscle strain. yler
et al17 ound that preseason hip adduction strength was 18% lower in NHL players who sub-
sequently sustained groin strains, as compared to those who remained uninjured. T e hip
adduction to abduction strength ratio was also signif cantly di erent between the 2 groups.
Adduction strength was 95% o abduction strength in the uninjured players but only 78%
o abduction strength in the injured players. Additionally, in the players who sustained a
groin strain, preseason adduction to abduction strength ratio was lower on the side that sub-
sequently sustained a groin strain compared with the uninjured side. Adduction strength
was 86% o abduction strength on the uninjured side, but only 70% o abduction strength
on the injured side. Conversely, another study on adductor strains on ice hockey players
ound no relationship between peak isometric adductor torque and the incidence o adduc-
tor strains.33 Unlike the previous study this study had multiple testers using a handheld
dynamometer, which would increase the variability and decrease the likelihood o f nding
strength di erences. However, the results o Emery et al33 did demonstrate that players who
practiced during the o season were less likely to sustain a groin injury as were rookies in
the NHL. T e f nal risk actor was the presence o a previous adductor strain. yler et al17
also linked preexisting injury as a risk actor, as in their study, 4 o the 9 groin strains (44%)
were recurrent injuries. T is is consistent with the results o Seward et al34 who reported a
32% recurrence rate or groin strains in athletes participating in Australian Rules Football.
Prevent ion
Now that researchers have identif ed players at risk or a uture adductor strain, the next
step is to design an intervention program to address all risk actors. yler et al25 were able
to demonstrate that a therapeutic intervention o strengthening the adductor muscle group
could be an e ective method or preventing adductor strains in pro essional ice hockey
players. Prior to the 2000 and 2001 seasons, pro essional ice hockey players were strength
tested. T irty-three o these 58 players were classif ed as being “at risk,” which was def ned
as having an adduction–abduction strength ratio o less than 80%, and placed on an inter-
vention program. T e intervention program consisted o strengthening and unctional
exercises aimed at increasing adductor strength ( able 23-1). T e injuries were tracked
over the course o the 2 seasons. In the present study, there were 3 adductor strains, which
all occurred in game situations. T is gives an incidence o 0.71 adductor strains per 1000
player-game exposures. Adductor strains accounted or approximately 2% o all injuries. In
contrast, there were 11 adductor strains and an incidence o 3.2 adductor strains per 1000
player-game exposures in the 2 seasons prior to the intervention. In those prior 2 seasons,
adductor strains accounted or approximately 8% o all injuries. T is was also signif cantly
lower than the incidence reported by Lorentzon et al28 who ound adductor strains to be
10% o all injuries. O the 3 players who sustained adductor strains, none o the players had
sustained a previous adductor strain on the same side. One player had bilateral adductor
strains at di erent times during the f rst season. T is study demonstrated that a therapeutic
intervention o strengthening the adductor muscle group can be an e ective method or
preventing adductor strains in pro essional ice hockey players.
Rehabilit at ion
Despite the identif cation o risk actors and strengthening intervention or ice hockey
players, adductor strains continue to occur in all sports.24 T e high incidence o recurrent
strains could be a result o incomplete rehabilitation or inadequate time or complete tissue
repair. Hömlich et al18 demonstrated that a passive physical therapy program o massage,
able 23-1 Adducto r Strain Injury Pre ve ntio n Pro g ram
Warm-up Bike
Adductor stretching
Sumo squats
Side lunges
Kneeling pelvic tilts
Strengthening program Ball squeezes (legs bent to legs straight)

Different ball sizes
Concentric adduction with weight against gravity
Adduction in standing on cable column or elastic resistance
Seated adduction machine
Standing with involved foot on sliding board moving in
sagittal plane
Bilateral adduction on sliding board moving in frontal plane
(ie, bilateral adduction simultaneously)
Unilateral lunges with reciprocal arm movements
Sports-speci c training On ice, kneeling, adductor pulls together

Standing resisted stride lengths on cable column to
simulate skating
Slide skating
Cable column crossover pulls
Clinical goal Adduction strength at least 80% of the abduction strength

stretching, and modalities were ine ective in treating chronic groin strains. By contrast, an
8- to 12-week active strengthening program consisting o progressive resistive adduction
and abduction exercises, balance training, abdominal strengthening, and skating move-
ments on a slide board proved more e ective in treating chronic groin strains. An increased
emphasis on strengthening exercises may reduce the recurrence rate o groin strains. An
adductor muscle strain injury program progressing the athlete through the phases o heal-
ing was developed by yler et al25 and anecdotally seems to be e ective ( able 23-2). T is
able 23-2 Adducto r Strain Po stinjury Pro g ram
Phase I (acute) RICE for rst approximately 48 hours after injury

NSAIDs
Massage
Transcutaneous electrical nerve stimulation (TENS)
Ultrasound
Submaximal isometric adduction with knees bent→with knees straight progressing
to maximal isometric adduction, pain-free hip PROM in pain-free range
Non-weightbearing hip progressive resistive exercises without weight in antigravity
position (all except abduction), pain-free, low-load, high-repetition exercise
Upper body and trunk strengthening
Contralateral lower extremity (LE) strengthening
Flexibility program for noninvolved muscles
Bilateral balance board
Clinical milestone Concentric adduction against gravity without pain
Phase II (subacute) Bicycling/swimming

Sumo squats
Single-limb stance
Concentric adduction with weight against gravity
Standing with involved foot on sliding board moving in frontal plane
Adduction in standing on cable column or Thera-Band
Bilateral adduction on sliding board moving in frontal plane (ie, bilateral adduction
simultaneously)
Unilateral lunges (sagittal) with reciprocal arm movements
Multiplane trunk tilting
Balance board squats with throwbacks
General exibility program
Clinical milestone Involved lower-extremity PROM equal to that of the uninvolved side and involved
adductor strength at least 75% that of the ipsilateral abductors
Phase III (sports-speci c training) Phase II exercises with increase in load, intensity, speed, and volume
Standing resisted stride lengths on cable column to simulate skating
Slide board
On ice, kneeling, adductor pulls together
Lunges (in all planes)
Correct or modify ice-skating technique
Clinical milestone Adduction strength at least 90% to 100% of the abduction strength and involved
muscle strength equal to that of the contralateral side
PROM, passive range of motion; RICE, rest, ice, compression, elevation.

Figure 23-1 Ball sque e ze Figure 23-2 Side -lying hip adductio n
type o treatment regime combines modalities and passive treatment immediately, ol-
lowed by an active training program emphasizing eccentric resistive exercise. T is method
o rehabilitation program has been supported throughout the literature.22,24 Exercises or
this injury are shown in Figures 23-1 to 23-4. An adductor stretch is shown in Figure 23-5.
Hamst ring Musculat ure

T e Hamstrings actually comprise 3 separate muscles: the biceps emoris, semitendinosus,
and semimembranosus. T ese muscles originate just underneath the gluteus maximus on
the pelvic bone and attach on the tibia and f bula. T e hamstrings are primarily ast-twitch
muscles, responding to low repetitions and power ul movements. T e primary unctions o
the hamstrings are knee exion and hip extension.
Figure 23-3 Sumo squats Figure 23-4 Slide bo ard

Hamst ring Muscle Injury

Hamstring muscle strains commonly result rom a wide variety
o sporting activities, particularly those requiring rapid accelera-
tion and deceleration. An eccentric load to the muscle causes the
majority o these injuries. Garrett et al23,35 demonstrated that, in
young athletes, hamstring muscle strains typically involve myo-
tendinous disruption o the proximal biceps emoris muscle.
Other authors also have shown experimentally that the weak link
o the muscle complex is the myotendinous junction.23,36 Although
apophyseal ractures o the ischial tuberosity have been reported
in young athletes, the majority o hamstring muscle strains are
f rst- and second-degree strains.37
Hamst ring Muscle St rain Incidence

Hamstring muscle strains are among the most common injuries
in sports involving high-speed movement and physical contact.
T ey can account or 12% to 16% o all injuries in athletes,38-42 with
a recurrence rate as high as 22% to 34%.42-44 Hamstring strains are
by ar the most commonly seen muscle strains in Australian Rules
Football, with an incidence o 8.05 injuries per 1000 player-game- Figure 23-5 Adducto r stre tch
hours. Soccer players are also susceptible to hamstring strains
with an incidence o 3.0 per 1000 player-game-hours or hamstring
strains. Overall, any athlete who sprints as part o their sport may
contribute to the incidence o hamstring strains.
Risk Fact ors

Factors causing hamstring muscle injury have been studied or many years. It has been sug-
gested that, strength def cits,32 lack o exibility,45-46 muscle atigue,47 poor core stability,48
inadequate proper warm-up,49 poor lumbar posture,50 and prior hamstring injury51-53 may
predispose an athlete to a hamstring strain.
Croisier et al54 suggest that the persistence o muscle weakness and imbalance may
give rise to recurrent hamstring muscle injuries and pain. T ese authors believe that when
there is insu cient eccentric braking capacity o the hamstring muscles compared with the
concentric motor action o the quadriceps muscles, the muscle may be at risk or injury.
Ekstrand and Gillquist 55 prospectively studied male Swedish soccer players and ound
hamstrings to be the muscle group most o ten injured. T ey noted that minor injuries
increased the risk o having a more severe injury within 2 months. Likewise, Engebretsen
et al examined more than 500 amateur soccer players and ound that among all the risk
actors, a previous hamstring strain was the greatest risk actor or a recurrent strain.51
Others have noted a recurrence rate o 25% or hamstring injuries in intercollegiate ootball
players.56
Prevent ion
It has been well established in the literature that eccentric training works in preventing
hamstring strains.1,32,57,58 Arnason et al57 prospectively studied elite soccer teams in Iceland
and Norway and ound eccentric training combined with warm up stretching appeared to
reduce the risk o hamstring strains; although no e ect was ound rom exibility training
alone. Peterson et al58 ound that the addition o eccentric hamstring training decreased the
rate o overall, new and recurrent acute hamstring injuries.
Rehabilit at ion
T ere is no consensus or rehabilitation o the ham string mus-
cles a ter strain. However, a rehabilitation program consist-
ing o progressive agility and trunk stabilization exercises has
been shown to be m ore e ective than a program em phasizing
isolated ham string stretching and strengthening in prom oting
return to sports and preventing injury recurrence in athletes
su ering an acute ham string strain.48 T e aim o the physical
therapy is to restore ull pain- ree ROM and strength throughout
the ROM. In addition, as a com plem ent to the usual restoration
o unction, we em phasize restoring eccentric muscle strength
and correction o agonist–antagonist im balances in the reha-
bilitation process. We recom m end the inclusion o eccentric
exercises at a lengthened state o the ham string m uscles, sub-
maximally, as soon as the patient can tolerate it. Our rationale is
based on basic science animal research 59 and imaging studies o
human muscle tissue 23 that have indicated incom plete healing
ollowing muscle strains. Fibrosis at the injury site is thought to
be related to the risk o reinjury. Based on these observations,
interventions aim ed at rem odeling the m uscle tissue m ay be
e ective in reducing the risk associated with having had a prior
muscle strain. Eccentric muscle contractions have been shown
Figure 23-6 Se ate d multiang le to result in m uscle–tendon junction rem odeling in an anim al
iso me trics at 30, 60, 90 de g re e s o f
m odel,60 and m ore recently have been shown to cause intramus-
kne e e xio n
cular collagen rem odeling in humans.61 Brockett et al62 exam -
ined the angle torque curves o previously injured ham string
subjects and com pared them to the noninvolved side, and unin-
jured controls. T e authors ound that peak ham string torque occurred at a signif cantly
shorter muscle length in the injured ham string when com pared to controls, im plying a
possible shi t in the length–tension curve. It is possible that when an athlete sustains a
ham string strain the athlete may return to play with weakness at longer muscle lengths
which can predispose them or another strain. It is our belie that training specif cally
in the lengthened state will allow the ham string to achieve optimal strength at a longer
operating length. Schm itt et al63 developed a protocol or rehabilitating ham string strains
with an em phasis on lengthened state eccentric training in the latter stages. Rehabilita-
tion during the acute stage would start with relative rest and protection o the injured
muscle lasting rom 1 to 3 days. Returning to exercise in this stage can lead to reinjury and
disruption o the healing tissue. Multiangle isom etrics, as shown in Figure 23-6, should
be initiated to properly align the regenerating muscle f bers and lim it the extent o con-
nective tissue f brosis. Static stretching is not recom mended particularly during this stage
because you want to prevent disruption o the healing f bers. Rest, ice, com pression, and
elevation, along with anti-in am matory m edication, are help ul during the im m ediate
stages o treatm ent. Heat, ice, electrical stimulation, laser and ultrasound are m odalities
that can also be used in conjunction with each other during the rehabilitation program to
acilitate a return to com petition. T e goals o this stage are to normalize gait, and obtain
knee exion strength at greater than 50% o the uninjured length upon manual muscle
testing at 90 degrees o knee exion.63
During the second phase o rehabilitation, an e ective strengthening program should
ocus on concentric and eccentric contractions. T e goals o this second phase are to pro-
gressively increase strength throughout the ROM and to improve neuromuscular control.63
During this phase, end range lengthening should be avoided i pain ul. However, eccentric
exercises can be achieved using an isokinetic dynamometer, i available, or by per orming
Figure 23-7 Sing le -le g w indmills Figure 23-8 Stiff-le g g e d de adlift
exercises such as straight-leg deadli t, single-leg windmills, and Nordic hamstring exer-
cise.63 Exercises are shown in Figures 23-7 to 23-9. Prior to athletic competition, a general
warm-up (jogging, cycling) to increase tissue temperature ollowed by dynamic stretching
that includes sports-specif c movements is recommended. Examples o dynamic stretches
or the legs include orward or backward lunges, high-knee marching, and straight-leg kicks
(Figure 23-10). In order to complete this phase and progress to the next phase, there should
Figure 23-9 No rdic hamstring e xe rcise Figure 23-10 Straig ht-le g kicks
be ull strength (5/ 5 on manual muscle test) or be within 20% o

the uninjured leg in the zero to 90-degree range when measured
with hand held dynamometer.63
During the third phase o rehabilitation, the ocus is on
unctional movements and eccentric strengthening in a length-
ened state. It is in this phase that plyometrics and sports spe-
cif c activity may be initiated. Lengthened-state eccentrics can
be per ormed using an isokinetic dynamometer (Biodex). T e
patient should be in hip exion and then passively extends and
exes the knee into end ROM. T e patient is told to resist passive
motion as the knee extends. It is important to assure the hip is
exed as the knee extends to ensure the hamstring is truly at a
lengthened state (Figure 23-11). An alternative to using the dyna-
mometer or lengthened state eccentric training is by using a
T era-Band, cable column, or manual resistance, which is shown
in Figure 23-12. able 23-3 provides a hamstring protocol in an
eccentric lengthened state.
Quadriceps St rain
T e quadriceps is a group o 4 muscles that sit on the anterior
aspect o the thigh. T ey are the vastus medialis, intermedius,
Figure 23-11 Le ng the ne d-state lateralis, and, f nally, the rectus emoris. T e quadriceps attach to
e cce ntrics o n iso kine tic dynamo me te r the ront o the tibia via the patella tendon and originate at the top
o the emur. T e exception is the rectus emoris, which actually
crosses the hip joint and originates on the pelvis. T e unction o
the quadriceps as a whole is to extend the knee. T e rectus emoris not only unctions to
extend the knee, but also acts as a hip exor because it crosses the hip joint. Any o these
muscles can strain (or tear) but probably the most common is the rectus emoris. T e grad-
ing system is the same as the adductor strains. A grade III tear is elt as an abrupt, sudden,
acute pain that occurs during activity (o ten while sprinting). It may be accompanied by
swelling or bruises on the thigh. T e rehabilitation o quadriceps strains ollows the same
A B
Figure 23-12
A, B. Lengthened-state eccentric training on cable column.
able 23-3 Hamstring Strain Pro to co l in an Ecce ntric Le ng the ne d State
Phase I (acute) RICE (rest, ice, compression, elevation) for rst approximately 48 hours after injury
NSAIDs
Soft-tissue mobilization (STM)/instrument-assisted soft-tissue mobilization (IASTM)
Transcutaneous electrical nerve stimulation (TENS)
Ultrasound
Submaximal multiangle isometrics performed at 30, 60, and 90 degrees of knee exion
(see Figure 23-7)
Progressive hip strengthening
Stationary bicycle
Single-leg balance
Pain-free isotonic knee exion (see Figure 23-9 )
Bilateral balance board
Clinical milestone Pain-free isometric contraction against submaximal (50% to 75% ) resistance during
prone knee exion manual muscle test
Avoid excessive active or passive lengthening of the hamstrings
Phase II (subacute) Bicycling

Treadmill at moderate to high intensity
Isokinetic eccentrics in a nonlengthened state
Single-leg windmills (see Figure 23-8 )
Single-leg stance with perturbation (ball toss/reaches)
Supine hamstring hurls on Swiss ball
STM/IASTM
Nordic hamstring exercise (see Figure 23-10 )
Shuttle jumps
Prone leg drops
Lateral/retro band walks
Clinical milestone Full strength 5/5 without pain during prone knee exion, pain-free forward and backward
jogging, pain-free max eccentric contraction in a nonlengthened state, strength de cits less
than 20% compared to the noninjured limb
Phase III (lengthened Treadmill moderate to high intensity as tolerated

state training) Hamstring dynamic stretching
Isokinetic eccentric training at a lengthened state (Figures 23-14 to 23-16 )
STM/IASTM
Plyometric training
Sport-speci c drills
Clinical milestone Full strength without pain in the lengthened state, full ROM without pain, bilateral symmetry
in knee exion angle of peak torque, sport-speci c movements without pain or symptoms
principles as the rehabilitation process o adductors and hamstring strains. Exercises or

this type o injury initially are shown in Figures 23-13 and 23-14. Advanced exercises can
be as given in Figures 23-15 and 23-16. Stretches are shown in Figures 23-17 through 23-19.
Avulsion Fract ures

Avulsion ractures are the result o a sudden, orce ul, eccentric or unbalanced contrac-
tion o a musculotendinous unit at its attachment at an apophysis. raction epiphyses, or
Figure 23-13 Straig ht-le g raise s Figure 23-14 Sho rt arc quads
Figure 23-15 Balance Figure 23-16 Ste p up Figure 23-17 Kne e ling hip e xo r
bo ard squats stre tch
Figure 23-18 Standing Figure 23-19 Tho mas stre tch

hip e xo r/ quad stre tch
apophyses, are bony projections o orming bone
that do not contribute to longitudinal growth o the
bone. T ese epiphyseal plates are weaker than their
associated ligaments; or this reason, injuries that
would result in torn ligaments or tendons in adults
may produce traumatic separation o the apophyses
in adolescents. T ese injuries account or up to 15%
o children’s ractures.64
T e ischial apophysis is the site o hamstring
and adductor magnus origin and is the last apoph-
ysis to unite.65 An avulsion here is the result o a
violent or orce ul hip exion while the knee is
extended. T is injury is commonly seen in hurdlers,
sprinters, cheerleaders, and dancers.
T e athlete will give a history report o a trau-
Figure 23-20 Bridg e s
matic event that caused an acute onset o pain. T ey
present with tenderness over the ischial tuberosity
and pain with a straight-leg raise. An antalgic gait may be evident as well as statem ents o
pain with sitting. Def nitive diagnosis is per ormed radiographically. In older adults with
no history o traumatic incident, a system ic or pathologic cause needs to be reviewed.66
reatment or this injury begins with rest along with pain- ree active range o motion
(AROM) and passive ROM and protected weight bearing with crutches i needed.67 With a
reduction o pain, initiation o light strengthening and gentle stretching can be prescribed.
Exercises shown in Figures 23-2 and 23-20 to 23-22 illustrate such interventions. Normaliza-
tion o gait cycle is progressed throughout healing time. Progressive resistant exercises are
introduced with return o ROM and cessation o pain. A steady advancement to sport-spe-
cif c activities should concentrate on strengthening, proprioceptive training, and, f nally,
plyometrics (exercises shown in Figures 23-3, 23-15, 23-16, 23-27, and 23-30). Patients
should not return to competition until ull ROM and strength is restored.24
Another avulsion racture in the pelvis involves the anterior in erior iliac spine. T is
injury cost commonly occurs in kicking sports. T e anterior in erior iliac spine is the origin
o the re ected head o rectus emoris. T e tension load occurs in the kicking mechanics
with a sudden contraction o the rectus while the hip is extended and the knee is exed.
Examination may reveal an antalgic gait pattern along with local tenderness and pain with
resisted hip exion.
Avulsion o the anterior superior iliac spine involves the same mechanics o hip exten-
sion with exed knee, but involves a orce ul contraction o the sartorius muscle. T is is
Figure 23-21 Ring sque e ze s Figure 23-22 Pro ne hip e xte nsio n
ound in sprinters during high-speed hip extension.

T e athlete will present with palpable tenderness over
the anatomical landmark.
Both in juries respon d well to con servative
treatm ent that involves initial rest and cessation o
injuring activity. Rehabilitation is sim ilar to that o
the ischial avulsion racture with em phasis on pain-
ree progression (exercises shown in Figures 23-13,
23-14, and 23-22 to 23-24).
Hip Point er
Figure 23-23 Hip abductio n stre tch A hip pointer occurs rom a traumatic blow or all
to the iliac crest. It is also re erred to as a contusion
o the iliac crest. T e impact causes bleeding rom ruptured capillaries and inf ltration o
blood into muscles, tendons, and other so t tissues; that is, subperiosteal and subcutaneous
regions.8 T e iliac crest has a minimal amount o overlying atty or muscular tissue, which
makes it more susceptible to injury than other more protected areas o the body. Hip point-
ers occur most commonly in contact sports such as ootball, rugby, and hockey, but also
occur in noncontact sports, such as volleyball, as a result o a all or dig onto the hip or side.
T e signs and symptoms include a sudden onset o pain a ter a traumatic hit or all
onto that side. Pain is o ten localized (point tender) and may present with swelling and
ecchymosis at the injury site. T e athlete may present physically with guarding, decreased
strength, pain with resistance, and gait abnormalities.68
T ree grades o contusion can be distinguished based on physi-
cal f ndings. A grade I hip pointer presents with a normal gait and
posture, but with complaints o pain, palpable tenderness, and
minimal swelling. Grade II injuries are more pain ul with noticeable
swelling and abnormal gait patterns. ROM is limited and trunk move-
ment is pain ul. T e posture may be exed to the injured side. Finally,
a grade III presents with severe pain, increased swelling, ecchymosis,
limited ROM, and a slow and shortened stride length during gait.
Initial rehabilitation should consist o ice, com pression,
NSAIDs, and rest in a position o com ort. An assistive device may
be utilized i gait is too pain ul. As pain decreases, interventions
should ocus on return o ull ROM and stretching o all adjacent
musculature (see Figures 23-17, 23-18, 23-25, and 23-26). Modali-
ties may be utilized as needed to aid in pain reduction and tissue
healing.69,70 Progression to strength and aerobic training should be
implemented with emphasis on pain- ree activity. As pain contin-
ues to subside, activities should be increased with a transition to
sport-specif c training. With a return to sports, a protective pad will
be worn to prevent reinjury to the area.
Quadriceps Cont usion

Pat homechanics
Because the quadriceps muscle is in the ront o the thigh, a direct
blow to the area that causes the muscle to compress against the
emur can be very disabling.1,31 A direct blow to the anterior por-
Figure 23-24 Se ate d hip e xio n tion o the muscle is usually more serious and disabling than a
Figure 23-25 Mo di e d pirifo rmis stre tch Figure 23-26 Supine ITB stre tch w ith strap
direct blow to the lateral quadriceps area because o the di erences in muscle mass present
in the 2 areas. Blood vessels that break cause bleeding in the area where muscle tissue has
been damaged.3 I not treated correctly, or i treated too aggressively, a quadriceps contu-
sion can lead to the ormation o myositis ossif cans (see “Myositis Ossif cans” below). Ice
hockey players are especially susceptible to this injury because o the velocity o the puck
and players causing high impact.
At the time o injury, the patient may develop pain, loss o unction to the quadriceps
mechanism, and loss o knee exion ROM. How orce ul the blow was at the time o injury
determines the grade o injury.
Injury Mechanism
A patient with a grade I contusion may present a normal gait cycle, negative swelling, and
only mild discom ort on palpation. T e patient’s active knee exion ROM while lying prone
should be within normal limits. Resistive knee extension while sitting and lying supine with
the knee bent over the end o a table may not cause discom ort.
A patient with a grade II contusion may have a normal gait cycle. Attempting to con-
tinue activity will likely cause the injury to become progressively disabling. I the gait cycle
is abnormal, the patient will splint the knee in extension and avoid knee exion while bear-
ing weight because the knee eels like it will give out. T is patient may also externally rotate
the extremity to use the hip adductors to pull the leg through during the swing-through
phase. T is move may be accompanied by hiking the hip at push-o , which causes tilting o
the pelvis in the rontal plane. Swelling may be moderate to severe, with a noticeable de ect
and pain on palpation. While the patient is lying prone, AROM in the knee may be limited,
with possibly only 90 degrees o motion. Resistive knee extension while sitting and lying
supine with the knee bent over the end o a table may be pain ul, and a noticeable weakness
in the quadriceps mechanism may be evident.
A patient with a grade III contusion may herniate the muscle through the ascia to cause
a marked de ect, severe bleeding, and disability. T e patient may not be able to ambulate
without crutches. Pain, severe swelling, and a bulge o muscle tissue may be present on pal-
pation. When the patient is lying prone, knee exion AROM may be severely limited. Active
resistive knee extension while the patient is sitting and lying supine with the knee bent over
the end o a table may not be tolerated, and severe weakness may be present. I a grade III
quadriceps contusion is diagnosed, a possible racture should be ruled out.71
Rehabilit at ion Concerns and Progression

A patient with a grade I quadriceps contusion should begin ice and 24-hour com pres-
sion im m ediately. wenty- our–hour com pression should be continued until all signs
and symptom s are absent. Gentle, pain- ree quadriceps exercises, such as quad sets, may
be per orm ed on the f rst day. Progressive resistive strengthening exercises may also be
per orm ed as soon as possible, usually on the second day, as long as they are pain- ree
(see exercises in Figures 23-13, 23-14, and 23-24) T is patient’s AROM should be care ully
m onitored. A patient with a grade I quadriceps contusion may try to continue normal
activities, but com pression and protective padding should be worn until the patient is
symptom ree.
A patient with a grade II contusion should be treated very conservatively. Crutches
should be used until a normal gait can be accomplished ree o pain. Ice, 24-hour com-
pression, and electrical muscle stimulation modalities may be started im m ediately to
decrease swelling, in ammation, pain, and to promote ROM.29 Compression should be
applied at all times to minimize bleeding into the area. Pain- ree quadriceps isom etric
exercises may be per ormed as soon as possible, usually within the f rst 3 days. Between
days 3 and 5, ice is continued with pain- ree AROM while the patient is sitting and lying
prone. AROM lying supine with the knee bent over the end o a table can be added. Passive
stretching is contraindicated at this time and not used until the later phases o rehabilita-
tion. Massage and heat modalities are also contraindicated in the early phases because o
the possibility o promoting bleeding and eventually myositis ossif cans. At approximately
day 5, the patient may per orm straight-leg raises without weights and then progress to
weights, pain ree (see exercise in Figure 23-13). As AROM increases and approaches 95 to
100 degrees o knee exion, swimming, aquatic therapy, and biking may be per ormed, i
the seat height is adjusted to the patient’s available ROM. Between days 7 and 10, heat in
the orm o hot packs, ultrasound, or whirlpool, may be used, as long as swelling is absent
and the patient is approaching ull AROM while lying prone. Pain- ree quadriceps progres-
sive resistive strengthening exercises may be per ormed in the order given (see exercises
in Figures 23-13 and 23-14), exion with knee both extended and exed (see exercises in
Figures 23-3, 23-15, and 23-16), and isokinetics may be added. Ice or heat modalities,
with AROM, should be continued be ore all exercises as a warm-up. Pain- ree quadriceps
stretching exercises should not be rushed and can be started between 10 and 14 days as
needed (see exercises in Figure 23-18). A patient with a grade II quadriceps contusion may
require 3 to 21 days or rehabilitation, depending upon the severity o the injury. Jogging,
slide board (see exercise in Figure 23-4), plyometrics, and unctional activities may be
used a ter the ourteenth day. Compression and protective padding should be worn dur-
ing physical activity until the patient is symptom ree.
A patient with a grade III quadriceps contusion should use crutches, rest, ice,
24-hour com pression , an d electrical m uscle stim ulation m odalities im m ediately to
decrease pain, bleeding, and swelling and to counteract atrophy.29 T e patient may begin
pain- ree isom etric quadriceps exercises between days 5 and 7. Ice and 24-hour com -
pression should be continued rom the very f rst day through day 7, with pain- ree AROM
exercises, while the patient is sitting and lying prone, added about day 7. AROM lying
supine with the knee bent over the end o a table can also be added. At approximately
day 10, the patient may per orm straight-leg raises without weights and then progress
to weights by day 14 (see exercise in Figure 23-13). Electrical muscle stimulation m ay
be very help ul in this phase to counteract m uscle atrophy and reeducate m uscle con-
traction. Again, as AROM increases and approaches 95 to 100 degrees o knee exion,
swim m ing, aquatic therapy, and biking may be per orm ed i the seat height is adjusted
to the patient’s available ROM. A ter day 14, the patient may use heat in the orm o hot
packs or whirlpool, as long as the swelling has decreased and the patient has gained
AROM. At approximately the third week o rehabilitation, pain- ree quadriceps progres-
sive resistive strengthening exercises may be per orm ed in the order presented (see exer-
cises in Figures 23-13 to 23-16), and isokinetics. Pain- ree quadriceps stretching m ay
also be per orm ed (see exercises in Figures 23-17 and 23-18) i the patient is care ul not
Hip Dislocation 713
to overstretch the quadriceps muscles. A patient with a grade III quadriceps contusion
may require 3 weeks to 3 m onths or rehabilitation. In general, at approximately week 3,
the patient may begin jogging, slide board, plyom etrics, and unctional activities. Again,
com pression and protective padding should be worn during all com petition until the
patient is sym ptom ree.72
Myosit is Ossi cans

Pat homechanics and Injury Mechanism
With a severe direct blow or repetitive direct blows to the quadriceps muscles that cause
muscle tissue damage, bleeding, and injury to the periosteum o the emur, ectopic bone
production may occur.1,21 In 3 to 6 weeks, calcium ormation may be seen on X-ray f lms. I
the trauma was to the quadriceps muscles only, and not to the emur, a smaller bony mass
may be seen on radiographs.1
I quadriceps contusion and strain are properly treated and rehabilitated, myositis ossi-
f cans can be prevented. Myositis ossif cans can be caused by trying to “play through” a
grade II or III quadriceps contusion or strain and by early use o stretching exercises into
pain, ultrasound, and other heat modalities.73

A ter 1 year, surgical removal o the bony mass may be help ul. I the bony mass is removed
too early, the trauma caused by the surgery may actually enhance the condition.
A ter radiographic diagnosis, intervention should ollow that or a grade II or III quad-
riceps contusion or quadriceps strain (see treatment and rehabilitation or grade II and
III quadriceps contusions and strains).72 T e bony mass usually stabilizes a ter the sixth
month.18 I the mass does not cause disability, the patient should be closely monitored and
ollow the treatment and rehabilitation programs outlined in grade II and III quadriceps
contusions and strains. It has also been recommended that myositis can be treated using
acetic acid with iontophoresis.53
Hip Dislocation
T e capsule and ligaments o the hip joint permit little or no distraction even upon strong
traction orces. T e joint is also very di cult to traumatically dislocate (unlike the gleno-
humeral joint). Under circumstances where the joint sur aces are neither maximally con-
gruent nor in a closed-pack position, the hip joint is at risk or traumatic dislocation. T is
position o particular vulnerability occurs when the hip joint is exed, internally rotated
and adducted.7 In this position, a strong orce up the emoral sha t toward the joint may
push the emoral head out o the acetabulum. T is is ound predominantly in motor vehicle
accidents as a consequence o the seated position o an individual within the car. Upon a
head on collision the dashboard provides the load down the emoral sha t dislocating the
hip joint.
Although rare in athletes, 2 general categories o hip dislocation exist: anterior and
posterior.74 Anterior dislocations compose only 10% o cases and occur in contact sports
as a result o a violent orce that send the hip into extension, abduction, and lateral rota-
tion.24,75 T e more prevalent posterior dislocation occurs with excessive loads applied to
a exed, adducted, and internally rotated joint. T is mechanism is ound also in contact
sports where the athlete has a high-speed uncontrolled all onto a exed knee such as in
a gang tackle.
When a posterior dislocation is sustained, the athlete presents with severe pain in the
hip region with inability to walk or move the involved leg. T e a ected limb will appear
shortened, exed, adducted, and internally rotated. O great concern with this injury is the
compromise o hip vascularity and the close relationship o the sciatic nerve. T ese 2 com-
ponents make hip dislocations a medical emergency. T e dislocated hip can occlude the
lateral circum ex artery, which is the primary provider o circulation to the emoral head.
T is reduced ow can lead to avascular necrosis o the emoral head. Adults whose hips are
reduced within 8 hours rom the time o injury have a low incidence o avascular necrosis.
T ose whose reduction occurred more than 8 hours earlier have up to approximately a 40%
chance o this complication.64 Stretching or compression o the sciatic nerve as a result o
this injury may lead to paralysis o hamstrings and muscularity distal to the knee that is
innervated by the nerve.76
Medical treatm ent includes rapid reduction and hospitalization along with pos-
sible traction or imm obilization in a hip spica cast until the joint is pain ree, which is
approximately 1 to 3 weeks. Following this initial time line, rehabilitation will begin with
simple assisted ROM to maintain normal exibility. Pain- ree use o isometrics or muscu-
lar stimulation can be utilized to prevent excessive atrophy and aid in muscular reeduca-
tion acutely 69,70 Crutch ambulation with progressive weight bearing is implemented with
advancement to gait normalization. Progressive resistance exercises can begin with return
o painless ROM and concentration ocused on proximal hip musculature (see exercises
in Figures 23-2, 23-13, and 23-22 to 23-24). Advancement o exercise can progress as toler-
ated and with pain- ree motions.
Labral Tears
T e acetabular labrum is a f brocartilage ring around the rim o the acetabulum, located in
the socket o the hip joint. It has the job o increasing the congruency o the hip joint, acting
as a shock absorber during weight bearing.77 T e acetabular labrum can be torn i there is
a twisting movement while the hip joint is bearing weight, and it requently occurs during
soccer activity. Gol ers and ice hockey players are also susceptible to labral tears that can
result in arthritis i not treated, according to a study reported at the annual meeting o the
Radiological Society o North America in Chicago.
T e onset o pain is immediate and usually located at the ront o the hip joint. As with
all hip problems, the pain may become di use and di cult to pinpoint. I the ront o the
hip joint is a ected, there may be a pinching sensation when the patient exes the hip by
bringing the knee up to the chest. A mechanical catching or giving way sensation in the hip
may also occur. Symptoms usually occur when the hip is changing position. T e pain may
be reproduced in sport during activities that require concomitant weight bearing and twist-
ing; or example, driving a gol ball.78
Labrum tears can be the result o an underlying anatom ic abnormality o the hip.
Because a torn labrum not only causes pain and instability but also disturbs the mechani-
cal unction o the hip in its own right and predisposes to arthritis, a sym ptomatic labral
tear is an indication or treatm ent both to prevent arthritis and im prove sym ptom s. Non-
operative treatm ent o labral tears can be success ul i the tear is small and stable. I non-
operative m eans are not success ul, the results o hip arthroscopy have to be reported
to be good.79 A return to sports is usually possible between 2 and 3 m onths a ter the
operation.
Although hip arthroscopy usually can allow symptom-relieving trimming o the torn
labrum in a minimally invasive way, i the torn labrum occurred because o an underlying
anatomic abnormality in the hip, it is usually advisable to correct the underlying anatomic
hip abnormality f rst.80
Hip Dislocation 715

An em erging surgical trend hip arthroscopy is becom ing m ore com m on, especially
am ong athletes. T e application o this m inimally invasive technique, com bined with
advances in MRI, is considered a signif cant advancem ent in treating many orm s o
chronic hip injuries. Although the surgery is new and em erging, the rehabilitation pro-
gression should take into consideration the basic science principles o so t-tissue healing
( able 23-4).
Following surgery, the patient is instructed to use bilateral crutches with partial weight
bearing as tolerated or the f rst 2 weeks. T en, they are progressed to one crutch or 1 week,
until they regain normal gait. Gait training to restore normal gait is paramount at this point
in the rehabilitation. Some surgeons utilize a hip brace to restrict hip exion ROM. During
the second week, the patient may also begin some easy pool walking and stationary biking
without resistance.
able 23-4 Arthro sco pic Hip Labral Re pair Re habilitatio n Guide line s
Weightbearing (WB) status Foot at with 20 lb of pressure

Duration 2 to 4 weeks
Continuous passive motion Start 30 to 70 degrees

(CPM) Increase as tolerated 0 to 90 degrees
Duration 2 weeks
Sleeping Ace wrap feet when sleeping for 2 weeks
Brace Daytime use

Set at 0 to 90 degrees of hip exion
Stationary bicycle Immediate postoperatively

1 to 2 times/day × 15 to 20 minutes
Avoid pinching in front of hip by setting seat high
Pool exercises Begin postoperative day 14 or as soon as sutures are removed and wound is healed
Range of motion Examine stool internal rotation—day 3 (may push early internal rotation within pain limits)
Examine stool external rotation—day 7 (limit to 30 degrees internal rotation)
2 to 3 sets × 12 to 15 repetitions
Quadriceps rocking—day 7
AROM—within limits of brace or as tolerated if no brace is worn
PROM (passive range of motion)—within available pain-free limits after brace is removed
Strength Quad sets/ankle pumps—day 1

Isometrics in neutral day 7 (within painful limits)
Bridges—days 7 to 10
Isotonic weight equipment day 14
Except for leg press begin at 6 weeks
Shuttle/Pilates begin at 3 to 4 weeks dependent on WB
Trunk strength
Transverse abdominis
Side supports
Trunk and low-back stabilization as tolerated
(continued )
able 23-4 Arthro sco pic Hip Labral Re pair Re habilitatio n Guide line s (Continued )
Function No straight-leg raises for 4 weeks

May begin pool walking in chest-high water
Avoid antalgic gait
Be aware of weakness of gluteus medius, side supports, and transverse abdominis
strength in sagittal, coronal, and transverse planes
Balance As soon as WB is permitted begin working on both double- and single-leg balance with
eyes open and eyes closed
10 repetitions × 5 seconds is a good place to start
General considerations
• Typically requires 3 months of supervised therapy
• Mo nth 1: tissue he aling phase (1 to 2 × pe r w e e k)
Goals: Pain control

Decrease tissue in ammation
Decrease swelling
Maintenance of motion ( exion 0 to 90 degrees internal rotation as tolerated; internal
rotation 0 to 30 degrees)
• Mo nth 2: e arly functio nal re co ve ry (2 to 3 × pe r w e e k)
Goals: Full PROM

Progress to full AROM
Early strength gains
Avoid exor tendonitis and abductor tendonitis
• Mo nth 3: late functio nal re co ve ry (2 to 3 × pe r w e e k)
Goals: Advance strength gains—focus on abductor and hip exor strength

Balance and proprioception
Continue to monitor for development of tendonitis
Progress to sport-speci c activity in months 3 and 4 depending on strength
Do not progress to running until abductor strength is equal to contralateral side
Progression to sport-speci c activities requires full strength return and muscle coordination
Precautions • Avoid anything that causes either anterior or lateral impingement

• Be aware of low-back sacroiliac joint dysfunction
• Pay close attention for the onset of exor tendonitis and abductor tendonitis
• Patients with preoperative weakness in proximal hip musculature are at increased risk
for postoperative tendonitis
• Modi cation of activity with focus on decreasing in ammation takes precedent if
tendonitis occurs
Independent ambulation is encouraged at the 3-week mark. Aerobic activity is

increased to 30 minutes along with the activation o active assistive hip ROM exercises. Any
explosive movements or rotational hip torque could potentially damage the hip capsule
and labrum and are there ore to be avoided. During the f rst 4 to 6 weeks, pain- ree exercise
is recommended to avoid a synovitis, tendonitis, or overstretching.
At 2 weeks postoperation, light hip isotonics and more weightbearing exercises such
as bridges and single-leg bridges are initiated (see exercises in Figures 23-1 and 23-20).
Strengthening o the hip extensors, abductors, and external rotators are emphasized, along
with light stretching or hamstrings, hip exors, quadriceps, and the iliotibial band (I B).
Insidious Injuries 717
T e straight-leg exercise is avoided until the ourth week ollowing sur-
gery, because o the potential or high compressive loading. ROM is
pushed or internal rotation, but progressed more slowly or external
rotation. runk strengthening is begun at this time with emphasis on
the transverse abdominals and the back extensors.
At 6 weeks, the patient begins light internal-external hip-rotation
stretching, which marks the f rst time stretches are introduced to the
postoperative hip beyond the AROM. Eight weeks ollowing surgery,
lower-extremity strength work, which includes squats, Romanian dead
li ts, our-way hip exercises, lunges, and lateral step work, is initiated
(see exercises in Figures 23-8, 23-15, 23-16, 23-27, 23-28, and 23-30).
T e li ting program emphasizes lighter weights and higher repetitions
and is designed to build endurance and avoid positions that could
potentially aggravate the hip. Avoid anything that causes either anterior
or lateral impingement. T e physical therapist should be aware o over-
lapping condition such as low-back pain and sacroiliac dys unction.
In addition, monitoring or the onset o exor tendonitis and abductor
tendonitis can help prevent ailures. Keep in mind that patients with
preoperative weakness in proximal hip musculature are at increased
risk or postoperative tendonitis.80
Following hip arthroscopy, patients should avoid weightbearing
twists and turns on the hip or up to 3 months a ter surgery. Although
not evidence based, sim ilar to a healing m eniscus, this compression
with rotation is likely not benef cial to a healing labrum o patients in
all age groups and o all occupations. It is recommended that patients Figure 23-27 Late ral w alks
attempt to keep their movements within the midline, certainly or a
6-week period. T ey can then gradually introduce rotational move-
ments to the hip, but such movements must be under their own control. Rotational thera-
peutic exercises should start with non-weightbearing exercises and progress cautiously
to ull weight bearing. At the 3- to 4-month point, assum ing no setbacks, patients are
allowed to return to unprotected, ull activities provided ull strength and coordination
have returned.
Insidious Injuries
Bursit is
Bursae are lined with synovium and are synovial
uid f lled sacs that exist normally at sites o riction
between tendons and bone as well as between these
structures and the overlying skin.64 It is analogous
to f lling a balloon with oil and rubbing it between
your f ngers. T e purpose o the bursae is to dissi-
pate riction caused by 2 or more structures moving
against one another.8 T e development o a bursi-
tis is the product o 1 o 2 mechanisms, the most
common being in ammation secondary to exces-
sive riction or shear orces as a result o overuse.
Posttraumatic bursitis is the other mechanism, and
stems rom direct blows and contusions that cause
bleeding in the bursae with resultant in ammation. Figure 23-28 Clam she lls
T e 3 major bursae around the hip joint that are suscep-

tible to bursitis are the iliopsoas bursa, ischial bursa, and
the greater trochanteric bursa.
Trochant eric Bursit is

T e greater trochanteric bursa lies between the gluteus
maximus, tensor asciae latae, and the sur ace o the
greater trochanter. Its location on the lateral aspect o the
hip exposes it to contact injuries in sports such as ootball,
soccer, and ice hockey. More commonly though, it is seen
in the clinic as an overuse injury ound in runners, bik-
ers, and cross-country skiers. It may also be ound in indi-
viduals with an increased Q angle, prominent trochanters,
or a leg-length discrepancy. It is the repetitive motion o
hip exion and extension on an excessively compressed
Figure 23-29 Passive Obe r’s stre tch bursa that gives rise to irritation and in ammation. T is
can occur with tightness in tissues around the hip, or
example, the I B pulling across the hip, or hip adductors
bringing the thigh into a more midline position. Poor running mechanics or continuous
running on banked sur aces that brings the lower extremity into an increased adducted
position can also cause undue strain at the hip.
Signs and symptoms o trochanteric bursitis include warmth and reported pain at the
greater trochanter region o the hip. Pain with hip abduction resistance, palpable tender-
ness at lateral hip, pain with gait and possible swelling or ecchymosis at the sur ace o the
greater trochanter, as well as pain with lying on a ected side may be present.81,82
Intervention begins by taking a thorough history rom the patient to determine activity
level, length o onset, or mechanism o possible traumatic incident. Examination is then
per ormed to check or ROM, tenderness, tightness, and weakness
in surrounding so t-tissue structures. It is necessary to analyze gait
and stair patterns as well as possibly analyzing running mechanics
i subjective complaints warrant.
Initial home rehabilitation or the individual will consist o
rest, ice, and nonsteroidal antiin ammatories. Clinical treatment
emphasizes modalities or in ammation, or example, ultrasound,
stretching o appropriate structures such as the I B and adductors
(see exercises in Figures 23-25, 23-26, and 23-29), as well as slow
integration into progressive resistive exercises or encompassing hip
musculature (see exercises in Figures 23-2, 23-13, 23-22 to 23-24,
and 23-28).70,83 I the underlying cause is a leg-length discrepancy,
it should be corrected with the appropriate device. Upon normal-
ization o ROM and exibility, a gradual return to sport-specif c
activities should be implemented. Full return to sports should
emphasize prevention with a regular stretching program or appro-
priate padding or traumatic injuries.
Ischial Bursit is
Although uncommon, ischial bursitis may occur as a complication
o an injury to the hamstring insertion into the ischial tuberosity or
as a direct trauma to a all or hit. T e symptoms include pain while
sitting and localized tenderness. It is important to distinguish this
bursitis rom a hamstring tear at the origin. Initial treatment con-
Figure 23-30 Co ne to uche s sists o rest, ice, and NSAIDs. Sitting cushion may be utilized as
Insidious Injuries 719
needed. General stretching o the hamstrings and progressive resistant exercises are imple-
mented as pain subsides (see stretching in Figures 23-25 and 23-26, as well as exercises in
Figures 23-2, 23-22 to 23-24, and 23-28).
Iliopsoas (Iliopect ineal) Bursit is

Iliopsoas (iliopectineal) bursitis is most o ten caused by excessive activity. It is thought to be
irritated by the iliopsoas muscle passing over the iliopectineal eminence. T is rubbing may
also be associated with a snapping hip. Pain is reported in the inguinal area and can radi-
ate into emoral triangle. Associated palpable tenderness can be present by placing the hip
in exion and external rotation. T is position can also help relieve symptoms. reatment
includes the rest, NSAIDs, and stretching o the iliopsoas (see stretches in Figures 23-17
and 23-18). Strengthening o any muscle imbalances can be initiated in pain- ree arcs (see
exercises in Figures 23-2, 23-13, and 23-22 to 23-24).
Snapping Hip Syndrome

Snapping hip syndrome (coxa saltans) can arise rom 2 di erent sources: intraarticular
and extraarticular. Intraarticular causes include loose bodies, osteocartilaginous exostosis,
labral tears, synovial chondromatosis, and subluxation o the hip. More common, though,
is the extraarticular causes o a “snapping hip.” T is occurs primarily, but not exclusively,
when the I B snapping is over the greater trochanter during hip exion and extension. Hip
adduction and knee extension will tighten the I B and accentuate the snapping sensation.
T is continuous pathomechanical movement can lead directly to trochanteric bursitis. A
second extraarticular source comes rom the iliopsoas tendon as it passes just in ront o
the hip joint. T is tendon can catch on the pelvic brim (iliopectineal eminence) and cause
a snap when the hip is exed.84
T is syndrome is common in ballet dancers where 44% o reported hip pain involved a
snapping or clicking. Most complaints concerned the sensation, with only one-third report-
ing pain.85 T e condition can present itsel with specif c exion movements o the thigh
such as situps. Both have signs and symptoms o an audible snap or click either laterally or
anterior deep in the groin which may or may not be pain ul. T ey may also present with an
associated bursitis.
reatment or a patient with snapping hip syndrome begins with a thorough exam-
ination. During the subjective evaluation, the clinician must question the patient to
determine which actions exacerbate symptom s during daily activities and athletics. T e
objective examination is designed to determine the severity o pathology and to per orm
a biomechanical assessment. T e in ormation gathered in this portion o the examina-
tion can be used to guide specif c elem ents o the treatment program. Muscle-tendon
length and strength, joint m obility testing, and palpation o the injured area are key to
a proper exam ination. Biom echanical assessm ent o the patient includes both static
(posture) and dynam ic (gait/ unctional m ovem ent) elem ents. Per orm static inspec-
tion o the entire lower extremity. Particular areas o attention during this portion o the
examination include observation o genu recurvatum, knee exion contracture, biome-
chanical abnormalities o the oot, hip exion contracture, and the amount o internal or
external rotation present in the lower extremity during static stance. Also take note o leg
length. Gait analysis allows the clinician to conf rm the f ndings o static examination and
observe i a movement dys unction is present. Functional movements (eg, squatting, stair
accent/ descent) may urther dem onstrate to the clinician the severity o the m ovem ent
dys unction.85
Once identif cation o contributing actors has been completed, treatment can be
directed toward those actors. Intervention during the acute phase consists o stan-
dard antiin ammatory care and the elimination o activities that exacerbate symptoms.
Physical therapy modalities (eg, ice, ultrasound, electrical stimulation, iontophoresis) may
be used during this time.69,70 Activity modif cation depends on the severity o the pathology.
Crutches may be used in severe cases, while simply decreasing the time and intensity o the
aggravating activity is commonly used in less severe cases. Muscle weakness and/ or tight-
ness in the thigh or pelvis is addressed with a strengthening and stretching program (see
exercises in Figures 23-2, 23-13, 23-22 to 23-24, and 23-28, and stretches in Figures 23-25,
23-26, and 23-29). Biomechanical abnormalities o the oot may require an orthotic to
assist with oot stabilization or control (re er to Chapter 26). Leg-length de ormities com-
monly require a li t in the shoe to assist with balancing the entire lower extremity. For those
patients with a symptomatic snapping hip and trochanteric bursitis unresponsive to con-
servative therapy, a surgical procedure has been described as an e ective method o treat-
ment in this specif c population.86
Osteitis Pubis
T e anterior connection between the 2 pubic bones o the pelvis creates the pubic sym-
physis. T is along with the sacroiliac joint completes the closure o the pelvic ring. Gen-
erally, there is little motion at this joint. Excessive orces, however, may occur to produce
injury or dislocation. Osteitis pubis is the result o in ammation at the pubic symphysis.
It is most o ten encountered in postoperative patient who have undergone invasive proce-
dures around the pelvic region. In athletes, this pathology may present as a type o overuse
injury or stress racture. It is seen mainly in distance runners, soccer players, and in other
sports requiring pivoting and kicking. T e constant repetitive orce at the symphysis can be
the cause o in ammation and pain. T e stress may also be caused by traction on muscles
whose origins arise rom the pubis symphysis region.24
Patients report pain in the groin region that may radiate down the medial thigh and is
exacerbated with sporting activities. T ere is palpable tenderness over the pubic symphysis
and statements o clicking or popping with various movements. Pain may also be present dur-
ing normal gait, stair climbing, or lying on one’s side. T e examination should ocus on subjec-
tive and objective f ndings as well as the e ects that occur on other activities of daily living.87
Early treatment involves rest and the use o NSAIDs.88 As pain subsides, intervention
should concentrate on the def cits ound and pelvic stabilization. Closed-chain exercises
may be started or stabilization prior to moving to open-chain motions (see exercises in
Figures 23-1, 23-15, 23-20, 23-28, and 23-31). Because the in ammation may be caused by
traction at muscular origins, exercises should be modif ed based o subjective complaints
o discom ort. Corticosteroid injection may be used i symptoms do not resolve with non-
invasive treatment.89
Apophysitis
Apophysitis is an in ammatory response to overuse and chronic traction at an apophysis in
athletic children (see “Avulsion Fractures” above). T e injury is characterized with an insid-
ious onset and palpable tenderness at the bony landmark. T ere may or may not be accom-
panying swelling present. reatment consists o relative rest rom high-intensity activity
with management o in ammation and pain. Graded progression o exibility with open-
and closed-chain strengthening activities implemented (see exercises in Figures 23-2,
23-13, 23-20, 23-22 to 23-24, 23-27, and 23-28). With a cessation o pain, a return to sports
program begins. raining is tailored or specif c sports and monitored or the return o pain
and irritation. I this is encountered, training is reduced to pain- ree levels.
Femoral Neck Stress Fracture 721
Figure 23-31
A, B. Standing hip abduction with Thera-Band at 2 angles.
Femoral Neck Stress Fracture

Bone is a specialized type o connective tissue that is capable o only a limited num ber
o reactions to a large number o abnormal conditions. T e basic nature o these reac-
tions is best considered at a microscopic or cellular level. T ere are just 4 basic ways in
which bone can react to abnormal conditions: (a) local death, (b) an alteration in bone
deposition, (c) alteration in bone reabsorption, and (d) mechanical ailure ( racture). T e
Wol law states that intermittent stresses applied to bone result in architectural remodel-
ing to allow adaptation to the new mechanical environment.51 T us bone is in a constant
state o change with bone deposition being com pleted by osteoblasts while at the sam e
time allowing or bone reabsorption by osteoclasts. T is dynamic remodeling is based on
applied stresses that occur in response to weight bearing and muscle contractions. T us
maintenance o healthy bone mass and structure relies on a balance between osteoclastic
and osteoblastic activity.90
A stress racture is a metabolic event in which an overuse repetitive injury exceeds
the intrinsic ability o the bone to repair itsel .91,92 It is this stage where osteoclastic activity
exceeds osteoblastic activity and leads to a stress racture.93-95 Although emoral neck stress
ractures are rare, representing only 5% o all stress ractures, they do commonly occur in
endurance athletes.96,97 It is o ten associated with participation in sports involving running,
jumping, or other lower-extremity repetitive stress.
wo types o stress ractures can occur in the emoral neck. T ey are described as trans-
verse, which presents on the tension side o the neck, or compression ractures, which
occur on the medial side o the emoral neck.98 T e tension ractures have a poor prognosis
able 23-5 Pro to co l fo r Re turn to Running Afte r a Hip o r Pe lvis Injury
Running Time
Misse d (We e k) Mo di catio n o f Running Pro g ram
<1 No modi cation of preinjury training
1 to 2 Decrease 25% from preinjury mileage
2 to 3 Decrease 50% from preinjury mileage rst week, 25% second week
≥4 Week 1: Walk 1 to 2 miles, alternating 1 minute fast and 1 minute

normal pace
Week 2: Walk 2 to 3 miles, alternating a 1.5-minute jog with

a 1.5-minute walk
Week 3: If no pain occurs, substitute a 10-minute jog every other day

for walk/jog; incorporate rest days as needed
Week 4: Same as week 3, but increase jog to 15 minutes every other

day in lieu of walk/jog
Week 5: Jog 15 minutes and alternate with 25 minutes every other day;
incorporate rest days as needed
Week 9: Resume training at preinjury level if training errors have been

corrected
Data from James SL. Running injuries of the knee. Instr Course Lect. 1998;47:407-417.
and are treated aggressively with open reduction and internal f xation. T e ractures on the
compression side heal well and respond avorably to noninvasive treatment.98
T is section discusses rehabilitation o compression emoral neck stress ractures. An
athlete with a possible stress racture will present with reports o pain in groin and thigh,
which is exacerbated with activities. It is important to obtain a detailed history to pinpoint
any increased training regimes or changes in gear or equipment used in the training pro-
gram. T e patient may have an antalgic gait pattern or possible lurch and a decrease in
available ROM secondary to pain. able 23-5 is a protocol or return to running a ter a hip
or pelvis injury.
Initial treatment o a diagnosed racture includes rest, ice, NSAIDs, and cessation
o pain ul activity. ROM and progressive resistant exercises are carried out within pain-
ree limits (see exercises in Figures 23-2, 23-13, and 23-22 to 23-24). Crutches with non–
weightbearing ambulation can be prescribed until relie o pain in gait cycle. As pain
reduces, a gradual increase rom non-weightbearing to touchdown weight bearing to
partial weight bearing to discontinuation o crutches is implemented. Utilization o cross
training, or active rest, can be accomplished by activities such as water running, stationary
bike riding, and upper-body ergometer training. Activity resumption requires recovery
periods that allow or tissue healing and adaptation (see exercise in Figures 23-15, 23-16,
and 23-27). A return to running should be initiated and m onitored toward the end o
rehabilitation. raining and rest days are key components in returning the athlete based
o this injury etiology. See able 28-4 or a return-to-running protocol. Increasing training
volume by no more than 10% per week allows adaptation to mechanical stress as speed and
intensity are gradually reintroduced.24
SUMMARY
1. So t-tissue injuries to the hip, thigh, and groin can be extremely disabling and o ten
require a substantial amount o time or ull rehabilitation.
2. Early return a ter so t-tissue injury to the thigh o ten exacerbates the problem.
3. Previous injury to the so t tissues about the hip and thigh predispose athletes to
additional injury, especially i not rehabilitated ully.
4. Pathologies o the acetabular labrum are more common than once thought and o ten
treated with arthroscopic surgery and subsequent rehabilitation.
5. Snapping or clicking hip syndrome occurs most commonly when the I B snaps over
the greater trochanter causing trochanteric bursitis.
6. Hip dislocations are rare, but require care ul rehabilitation in order to return the
patient/ client to ull unction.
7. T e emur is subject to stress ractures (uncommon) and avulsion ractures.
8. Di erent patterns o injury exist in the skeletally mature (adult) patient than in the
skeletally immature patient (children and adolescents).
9. Protection a ter so t-tissue injury is important to prevent urther injury (padding,
wrapping, compression shorts/ sleeves).
REFERENCES
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Rehabilitation
of the Knee
Ro b e r t C. M a n s k e , B.J. Le h e ck a ,
M a r k De Ca r lo , a n d Ry a n M cDiv it t
OBJJECTIVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Understand the functional biomechanics associated with normal function of the knee.
Utilize a general rehabilitation progression when treating knee injuries.
Integrate a comprehensive understanding of pathomechanics and mechanism of injury into the

rehabilitation of ligamentous and meniscal injuries.
Integrate a comprehensive understanding of pathomechanics and mechanism of injury into the

rehabilitation of patellofemoral and extensor mechanism injuries.
Justify the use of external supports to augment the rehabilitation process.
Implement a functional progression to ensure safe return to activity.
727
728 Chapte r 24 Rehabilitation of the Knee
Functional Biomechanics of the Knee

T e study o biomechanics, along with unctional anatomy, is a cornerstone to knee reha-
bilitation. A complete understanding o joint articulations, arthrokinematics, and the struc-
tures responsible or controlling movement is essential or the clinician to make sound
decisions in the diagnosis and treatment o musculoskeletal disorders. Despite the rela-
tive simplicity o a hinge-type joint, the knee provides an interesting biomechanical study
because o the intricacies required to maintain stability without good bony support along
with attenuating orces greater than 4 times the weight o the body. T e patello emoral joint
and the pain syndromes o ten associated with the knee also present an interesting study.
A solid knowledge o the supporting structures and stress placed on the patello emoral joint
provides the ramework or rehabilitation program design.
Tibiofemoral Joint
Tibiofemoral Art iculat ion: Menisci-Femoral Condyles
T e condyles o the distal emur articulate with the shallow, concave tibial plateau, resulting
in signif cant tibio emoral joint incongruence. ibio emoral stability would be insu cient
i le t solely to the skeletal structure. T e medial and lateral menisci provide additional con-
gruency to the joint through their semicircular shape and peripheral thickness, thus orm-
ing a wedge surrounding the emoral condyles.
T e contact area o the menisci varies signif cantly during knee range o motion
(ROM). In weight bearing, the total contact area o the menisci decreases with knee ex-
ion. Although mean sur ace area increases in non-weightbearing conditions, total menisci
contact area also decreases during knee exion. Following a meniscectomy, sur ace contact
area decreases, resulting in a greater amount o stress upon the contact sur ace.
Axial Forces
T e ability o the tibio emoral joint to withstand orces imposed by the superincumbent
weight o the body combined with the ground reaction orce transmitted through the dis-
tal extremity requires interaction o multiple structural actors. T e longitudinal axis o the
emur extends laterally to medially to the tibio emoral articulation, resulting in an oblique
angle ormed 5 to 10 degrees away rom vertical. It would seem that this alignment would
produce a greater load on the lateral emoral condyle; however, a close look at the mechani-
cal axis that connects the head o the emur with the superior sur ace o the talus contra-
dicts this. T e mechanical axis, which is the true line o weight bearing and determines the
angle o orce distribution, produces approximately equal weight bearing on the lateral and
medial compartments o the tibio emoral joints during bilateral stance.
Art hrokinemat ics

Arthrokinematics is a description o the accessory motion that occurs between articulating
sur aces. T e accessory motions o rolling and gliding o the joint sur aces occur in combi-
nation during the osteokinematic motion at the knee. T is combination allows the articu-
lating sur aces to stay in contact and permit maximal osteokinematic motion.
Arthrokinematic motion plays a prominent role in sagittal plane movements o the tib-
io emoral joint. During knee exion in the closed kinetic chain (CKC), the convex emur
moves on a f xed, concave tibia. When a convex sur ace is moving on a concave sur ace, roll-
ing and gliding occur in opposite directions. Because o this relationship, the emur must
glide anteriorly to counteract the posteriorly directed roll that is occurring (Figure 24-1).
Functional Biomechanics of the Knee 729
B C
Figure 24-1 Arthro kine matic mo tio n
A. Anterior gliding of the femur on the tibia. B. Posterior rolling of the femur on the tibia. C. Both gliding and rolling.
(Reproduced from Scott WN. The Knee . St. Louis, MO: Mosby; 1994:77, with permission from Elsevier.)
Without the anterior glide o the emur, tibio emoral exion would be limited, as the emur
would roll o the posterior tibia. During CKC knee extension, the emur rolls anteriorly and
glides posteriorly. In the open kinetic chain (OKC), the concave tibia moves on the convex
emur as rolling and gliding occur anteriorly with extension and posteriorly with exion.
Although rolling and gliding must both occur to keep the tibia and emur in contact,
the rolling and gliding do not happen simultaneously as the knee exes. At the initiation o
exion, pure rolling occurs between the joint sur aces, with gliding becoming more promi-
nent to terminal exion. Once the gliding starts in early exion, the ratio between rolling
and gliding is 1:2, progressing to a 1:4 ratio at terminal exion.
Screw-Home Mechanism
Near terminal knee extension, arthrokinematic motion occurs in the transverse plane.
Because the medial emoral condyle is 1 to 2 cm longer than the lateral emoral condyle, the
lateral emoral condyle completes all o its motion when the knee is at 30 degrees o exion
in a weight-bearing position. As the knee continues to extend and glide on the medial emo-
ral condyle, it pivots on the f xed lateral emoral condyle, thus producing medial emoral
rotation on the f xed tibia.
Rotation at terminal extension, called the screw-hom e m echanism (Figure 24-2), is an
involuntary motion that occurs because o bony geometry. T e screw-home mechanism is
crucial or knee stability, locking the tibio emoral joint into a close-packed position. As the
emur internally rotates on the f xed tibia, the emoral condyles become closely united and
congruent with the menisci, the tibial tubercles becomes lodged in the intercondylar notch,
and the ligaments become taut. For the tibio emoral joint to ex rom terminal extension,
the joint must f rst unlock. While this is also an automatic motion caused by the bony struc-
ture o the emoral condyles, the popliteus can initiate the lateral rotation o the emur on a
f xed tibia to begin the unlocking o the tibio emoral joint.
Kinemat ic Mot ion of t he Tibiofemoral Joint

Flexion/ext ension
ibio emoral motion occurs in the 3 cardinal planes (Figure 24-3). Flexion/ extension,
occurring in the sagittal plane, is the largest motion. Sagittal plane ROM varies among
patients. De Carlo and Sell32 reported that emales average 6 degrees o recurvatum to
P roxima l/
Dis ta l
Inte rna l/
Exte rna l
Me dia l/ Flexion/
La te ra l Exte ns ion
Va rus / Ante rior/

Va lgus Pos te rior
Exte ns ion Flexion
Figure 24-2 The tibia e xte rnally ro tate s as Figure 24-3 Kne e mo tio n in e ach plane o ccurs
the kne e mo ve s into te rminal e xte nsio n, cre ating aro und an axis
a “scre w -ho me ” me chanism
(Reproduced from Scott WN. The Knee . St. Louis, MO: Mosby; 1994:17,
with permission from Elsevier.)
(Reproduced from Scott WN. The Knee . St. Louis, MO: Mosby;
1994:22, with permission from Elsevier.)
143 degrees o exion, whereas males average 5 degrees o recur-
vatum to 140 degrees o exion. During sagittal plane motion,
the instantaneous axis o rotation o the knee also varies. A study
o a series o roentgenograms illustrated that the instantaneous
axis o rotation orms a semicircle (Figure 24-4).85 An abnormal
instantaneous axis o rotation can result rom internal derange-
ment in the tibio emoral joint, causing a compensatory attenu-
ation o static supporting structures o the knee. T ese abnormal Ins ta nt
ce nte r
stresses on the articulating sur aces can result in early degenera- pa thway
tive changes.
Rot at ion
Motion in the transverse plane is in uenced by the position o
the knee in the sagittal plane. In the close-packed position (ter-
minal extension), motion in the transverse plane cannot occur.
Rotation is greatest at 90 degrees o knee exion. In this position,
lateral rotation averages 45 degrees and medial rotation averages
30 degrees.85 T e axis or tibio emoral rotation runs longitudi-
nally through the medial tibial intercondylar tubercle.
Figure 24-4 No rmal instantane o us axis
o f ro tatio n fo rms a se micircle
Abduct ion/Adduct ion
Only a small am ount o tibio em oral m otion occurs in the ron- (Reproduced from Scott WN. The Knee . St. Louis, MO: Mosby;
tal plane. Sim ilar to rotation, this m otion is dictated by the posi- 1994:76, with permission from Elsevier.)
tion o the knee in the sagittal plane. Abduction and adduction,

primarily lim ited by ligaments, reach a maximum at 30 degrees
o knee exion. T e muscles do not contribute m otion to the
rontal plane.
Knee St abilit y
Stability o the tibio emoral joint is o primary concern in the orthopedic setting. Although
the bony structures o the knee contribute to stability in terminal extension, the knee must
rely on so t tissues or stability during most o the degrees o movement. Injury to these
structures (the menisci, muscles, and ligaments) o ten results in debilitating instability.
A review o the literature related to knee stability reveals varied and o ten contradic-
tory in ormation on the roles o di erent support structures.68 T e di erences in results
are because studies o ten test knee stability in a static scenario and in varied positions.
Although describing the stabilizers individually provides a “clean and neat” presentation,
one must remember that most o the structures work together to provide knee stability in
all motions.
Menisci
T e menisci contribute mainly to orce distribution and dissipation, although they can
provide a degree o stability to the tibio emoral joint. Johnson et al77 have made clinical
observations that joint laxity can result a ter meniscectomy. T e belie that the medial and
lateral menisci act as anterior and posterior wedges to prevent anteroposterior movement
is supported by several studies that ound that resection o the medial meniscus resulted in
more instability than resection o the lateral meniscus.90,91,92,150 T e studies o ten ound that
resection o the anterior cruciate ligament (ACL) exposed a greater reliance on the menisci
or stability, but that the medial supporting structures must be intact or more e ective
stability.
Muscular Cont ribut ions

As the tibio emoral joint becomes loaded, stability can be gained rom multiple dynamic
structures. T e main muscular contributors to anteroposterior stabilization are the quad-
riceps, hamstring, gastrocnemius, and popliteus muscles. T e quadriceps complex resists
posteriorly directed orces on the tibia, while the hamstrings, gastrocnemius, and poplit-
eus resist anterior displacement o the tibia. T e popliteus and the semimembranosus, as a
result o their multiple connections, are particularly crucial in the stability o the posterior
tibio emoral joint.
T e muscles that contribute to medial stability as the knee exes are part o the pes
anserine complex (Figure 24-5). T e iliotibial tract, popliteus, and biceps emoris provide
lateral stability (Figure 24-6), but the popliteus is the main contributor, particularly in the
posterolateral direction. It is uncertain what e ect the dynamic structures have on rota-
tional stabilization, but the position and action o the popliteus and hamstring muscles
would suggest a minor contribution to rotational stability.
Ligament s and St abilit y

T e role o ligaments in knee stability has been widely substantiated in the scientif c litera-
ture as well as by practical clinical observations o ligament disruption. Ligaments enhance
Adductor tube rcle
Pa te llofe mora l
liga me nt S e mime mbra nos us
Ante rior joint
ca ps ule Pos te rior oblique
S upe rficia l me dia l

colla te ra l liga me nt S e mite ndinos us
Gra cilis S a rtorius (cut)
Figure 24-5 Me dial static and dynamic stabilize rs o f the kne e

Va s tus la te ra lis
La te ra l pa te lla r
re tina culum
Bice ps fe moris
Iliotibia l ba nd
Pa te lla r liga me nt
Common
pe rone a l ne rve
Ga s trocne mius,
la te ra l he a d
Tibia lis a nte rior

S ole us
Pe rone us longus Exte ns or digitorum

longus
Figure 24-6 Late ral dynamic stabilize rs o f the kne e

knee stability by their ability to restrict tensile orces along the orientation o their f bers.
Knee stability is reliant on multiple ligamentous, meniscal, muscular, or bony structures.
T is is an important actor to consider when studying the biomechanics o ligaments,
because no ligament acts alone in limiting knee motion, nor does 1 ligament limit 1 plane
o movement.
T e medial collateral ligament (MCL) is the primary stabilizer against valgus stress.
Studies in which the superf cial f bers o the MCL were disrupted showed an increase in
knee valgus ollowing an externally directed orce. T e superf cial f bers also limited exter-
nal rotation o the tibia, whereas sectioning the deeper f bers o the MCL did not signif -
cantly increase valgus movement or external rotation.60 Secondary restraints include the
ACL, posterior cruciate ligament (PCL) (especially at terminal extension), and the lateral
compartment because o the increased compressive orces.139
T e lateral collateral ligament (LCL) is the primary restraint to varus orces. T e restrain-
ing e ect o the LCL increases as the knee exes. T e LCL’s maximal contribution in limit-
ing lateral joint opening is 69% at 25 degrees o knee exion. T e ACL and PCL contribute
as secondary stabilizers and provide maximal protection against varus orces at 8 degrees
o exion, but then decrease as the knee exes. T e lateral joint capsule, particularly the
posterior portion, contributes to stability, but this e ect also decreases with increased knee
exion.55 Other secondary restraints include the medial compartment through compres-
sion and the popliteus, iliotibial band (I B), and biceps emoris.
It is well established that the ACL is the primary restraint to anterior translation o
the tibia. T e anteromedial and posterolateral bundles allow the ACL to be taut during all
ranges o knee motion. At 90 degrees o exion, the ACL contributes 85% o the restraining
orce and this orce increases up to 30 degrees o exion. Clinically, this property is dem-
onstrated by the classic Lachman test that examines ACL integrity by placing an anteriorly
directed orce to the tibia with the knee in 20 to 30 degrees o exion.21 T e MCL and LCL
provide minimal secondary ligamentous support, with other contributions rom the poste-
rior capsule, I B, and hamstrings.
T e PCL is responsible or restricting the majority (94%) or posterior tibial transla-
tion. I the PCL is not present, the popliteus and posterolateral capsule provide most o the
support, with minor contributions o the MCL, LCL, posteromedial capsule, and medial
capsule.
As noted previously, ligaments limit movement in the direction o the f bers. Because
there is not a ligament aligned in the transverse plane, it is evident that a combination o
ligaments and other structures must work to restrict tibio emoral rotation. T e ACL has
been shown to be the primary restraint o tibial internal rotation, with secondary restraint
provided by the posteromedial capsule and the LCL.93 T e posterolateral capsule and the
MCL are the primary restraints or external tibial rotation.
Pat ellofemoral Joint

Funct ions of t he Pat ella
T e patella possesses very unique characteristics that are required or normal unction
o the knee. T e patella unctions to increase the distance (lever arm) rom the joint axis,
increase leverage o the quadriceps through gliding in the trochlear, provide a smooth artic-
ular sur ace, and provide a bony shield to the trochlea and condyles o the distal emur dur-
ing knee exion.79
T e length o the lever arm changes rom knee exion to extension, m odulating the
orce production that the patella provides. In ull exion, there is little anterior displace-
m ent o the quadriceps tendon. T us, the patella contributes only 10% to the length o the
lever arm in this position. As the knee extends, the patella m igrates superiorly and ante-
riorly in the trochlear groove, leading to a greater m echanical advantage. T e m echanical
advantage reaches its peak at 45 degrees o knee exion, where the patella contributes
30% to the lever arm. As the knee nears term inal extension, the e ect o the patella on
quadriceps orce (Fq) decreases to the point where the quadriceps muscles must gen-
erate 60% m ore orce to per orm the last 15 degrees o knee extension. T e inability o
weakened quadriceps to per orm this m otion is dem onstrated by a quadriceps lag during
a straight-leg raise.
Pat ellofemoral Cont act Areas

As the knee goes through a ROM, various portions o the patella articulate with the trochlea
(Figure 24-7). Good ellow et al56 described the contact sur aces o the patello emoral joint at
di erent points o knee exion during weightbearing conditions. At terminal extension, the
patella lies slightly lateral and proximal to the trochlea without contact. T e patella engages
with the bony groove between 10 to 20 degrees o exion. T e area o contact is initiated
at the in erior pole o the patella and moves superiorly on the retropatellar sur ace until
90 degrees o exion, where the major contact point is on the superior pole. T e contact o
the patella rom lateral to medial also varies with
knee motion. During the f rst 90 degrees o exion, Me dia n
ridge
the contact is exclusively lateral. A ter 90 degrees,
the contact moves medially to the odd acet. Odd fa ce t
90° 135°
135°
Pat ellofemoral Joint React ion Force La te ra l 45°
Me dia l
and Joint St ress 20°
T e amount o orce that the posterior sur ace o
the patella encounters with various activities is well
documented. Clinically, understanding the ROM
and load optimal or patello emoral joint contact Figure 24-7 Pate llo fe mo ral co ntact are as during
orces is very use ul in treating patello emoral dis- varying de g re e s o f e xio n
orders that result rom abnormal orce on the pos-
(Reproduced from Scott WN. The Knee . St. Louis, MO: Mosby; 1994:22, with
terior sur ace o the patella. Patello emoral joint permission from Elsevier.)
reaction orce 149 (Fp ) is determined by the ollow-
ing equation:
Fpf = kXFq
At a specif c point o knee ROM, the amount o Fq multiplied by the angle o knee ex-
ion (X) equals Fpf, or Fp = kXFq, where k is a constant that is predetermined or each angle
o knee exion.
T e amount o orce that the patella encounters does not ully reveal the amount o
stress placed on the patella. Joint surface stress is determined by the amount o orce placed
on a given area o joint sur ace. T is relationship is expressed by the equation orce/ area =
stress. T us, the less area to which a orce is applied, the greater amount o stress is applied
to the joint. T e amount o stress that is on a given point o the patella has important clinical
implications. It is the amount o stress, not simply the joint reaction orce, that can in ict
abnormal wear or pain on the posterior sur ace o the patella.59
OKC Joint Reaction Force During OKC unction, Fp increases as the knee extends rom
90 degrees o knee exion. At 90 degrees o exion, the patellar tendon and quadriceps
muscles are perpendicular to each other and Fq tends to result in a low Fp . As the knee
extends rom 90 to 60 degrees o knee exion, Fq must increase, resulting in increased Fp .
A ter 60 degrees o knee exion, Fq levels o and Fp is relatively unchanged to end range.
OKC Joint Stress As a result o decreased joint sur ace area contact during knee
extension, joint stress increases rom 90 degrees o exion to approximately 20 degrees
o extension. ypically, there is little to no patellar contact area past 20 degrees o exion
to terminal extension; thus, joint stress o ten does not occur during this range. For the
patients who do maintain some contact in this ROM, joint stress will be very high owing to
the small contact area.
CKC Joint Reaction Force Investigation o joint reaction orce in the CKC shows that
in contrast to the OKC, Fp decreases as the knee extends. T is decrease in orce is greatest
between 30 and 90 degrees o exion. Fp decreases at a lesser rate past 30 degrees o ex-
ion, particularly because there is relatively no contact between the articulating sur aces o
the patello emoral joint past 20 degrees.149
CKC Joint Stress As in the OKC, joint sur ace contact area increases as the knee extends
rom 90 degrees o exion. However, the Fq required or knee extension decreases aster
than the contact area decreases, resulting in a decrease o joint stress. Realizing when the
patello emoral joint is subjected to stress is crucial or exercise prescription to minimize the
amount o injury to patello emoral articular cartilage.
Funct ional Implicat ions of Joint React ion Force and St ress
Understanding the amount o Fp and joint stress that are encountered with daily tasks can
be use ul in educating patients who have anterior knee pain. As a result o the elastic pull
o the proximal and distal tendon units, there is a substantial amount o orce present dur-
ing sitting.69 T is increased stress accounts or a patient’s subjective complaint o anterior
knee pain during prolonged sitting. Although sitting can impose a low load with long dura-
tion pressure on the patello emoral joint, dynamic movements requently cause abnormal
stress and injury. During gait, the joint reaction orce is typically 50% o the body weight as
the knee exes to 10 to 15 degrees during initial contact.69 Stair ambulation, which requires
increased Fq and knee exion, can produce ar greater Fp . As the knee reaches 60 degrees
o exion during stair ambulation, joint reaction orce can be as much as 3.3 times the body
weight.30,69 As the knee approaches 130 degrees o exion in deep-squatting activities, joint
reaction orce may reach 7.8 times the body weight.30,69
Force Dissipat ion

T e patello emoral joint is subjected to varying extremes o joint reaction orce over small
areas. Fortunately, the trochlea and articulating sur ace o the patella possess multiple
properties responsible or dissipating patello emoral joint stress. When compressed, articu-
lar cartilage allows uid to ow reely within the matrix and permits the cartilage to expand
laterally. T e patella benef ts rom thickened articular cartilage that easily expands laterally
during compression. As knee exion increases, the patella will seat more deeply into the
trochlea and contact more sur ace area, which reduces the stress at a given point. T is prop-
erty also contributes to greater patello emoral joint stability. Because o the large amount
o permeability and compressibility o the articular cartilage, there is greater stress on the
matrix that composes the cartilage. Un ortunately, chronic wear to the matrix can lead to
degeneration and eventual patellar lesions.
Pat ellar St abilit y

Static Stabilization T e articulation o the patella with the trochlea represents the great-
est contribution to patellar stability. T e trochlea acts as a trough or the patella to glide
within. T ere is a greater degree o dynamic muscle pull rom the proximal–lateral direc-
tion, necessitating increased support to prevent excessive lateral movement. T is support
is provided in part by the large anterior extension o the lateral emoral condyle. A lack o
lateral emoral condyle height can contribute to chronic patella subluxation or dislocation.
T e lack o bony contact between the patella and trochlea rom 20 degrees o exion
to terminal extension results in a dependence on so t-tissue restraints. Investigators have
described the medial and lateral extensor retinacula as the primary restraints to excessive
patellar movement in the rontal plane.156 T e added support o medial and lateral patel-
lo emoral ligaments present in a portion o the population will rein orce the retinacula.30,125
Dynamic Stabilization T e dynamic musculotendinous stabilizers are oriented in a

longitudinal ashion proximal and distal to the patella. T e single distal stabilizer, the patel-
lar tendon, contains the patella in eriorly. Proximally, the quadriceps generate a superior
pull through the quadriceps tendon.30,48 T e combination o these longitudinal orces pro-
vides stability during knee exion by seating the patella into the trochlear groove. However,
the longitudinal pull may decrease stability by pulling the patella out o the trochlear groove
during knee hyperextension.
Based on the pull o the quadriceps muscle, an imbalance o the vastus lateralis and
vastus medialis oblique can result in abnormal tracking o the patello emoral joint and
disrupt stability as the knee approaches terminal extension. T ere is controversy in recent
literature regarding the role o this mechanism in aiding the stability o the patello emoral
joint and decreasing anterior knee pain, as well as optimal treatment techniques.14,96,148
Overview of General Rehabilitation Progression Following Knee Injury 737
In uence of Proximal and Distal Joint Position

on the Patellofemoral Joint
Hip and Femur Changes in the position o the emur at the hip joint can alter
the orientation o the trochlea. T e osteokinematics o the emur in the rontal
and transverse planes can a ect the directional orce o the quadriceps on the
patella. Clinically, the most common abnormal movement pattern is hip adduc-
tion and internal rotation, causing an inward collapse o the knee and medial
displacement o the trochlea. T e insertion o the quadriceps at the tibial tuber-
cle remains f xed, resulting in a more laterally aligned patella.
Kendall et al80 cited dominance o the hip internal rotators and adductors as
possible sources o this aulty movement pattern. In addition, positional weak-
ness or increased length o the hip abductors and external rotators, particularly
the posterior f bers o the gluteus medius, contributes to the inward collapse knee.
Tibia and Foot Rotation o the tibia can also in uence the alignment o the
patello emoral joint. As the tibia rotates either medially or laterally against a
f xed emur, the patella can either glide or rotate in the direction o the tibial
tubercle. Whether glide or rotation occurs depends upon the proximal f xation
o the patella.
Rotation o the tibia has several in uences. T e proximal tibia will laterally
rotate with a dominance o muscle action o the biceps emoris or tensor asciae Q
latae–I B. Medial rotation can be caused by the predominance o the semitendi-
nosus and semimembranosus. Distally, tibial rotation is in uenced by the posi-
tion o the subtalar joint. Pronation will lead to medial rotation o the tibia, thus
positioning the patella medially relative to the trochlea.
Quadriceps Angle
T e quadriceps angle (Q angle) is the angle ormed between a line connect-
ing the anterior superior iliac spine to the midpoint o the patella and a line
that connects the tibial tubercle with the midpoint o the patella (Figure 24-8).
A 15-degree angle between these 2 lines is considered normal.2,30 A Q angle
greater than 20 degrees can contribute to pathology in the patello emoral
joint. A large Q angle can cause displacement o the patella laterally, resulting
in a bowstringing e ect against the lateral emoral condyle during quadriceps
contraction.73,89
T ere are several concerns when using the Q angle as a diagnostic
tool. A large Q angle has not been shown to predispose a knee to patello emoral
pain, nor do all patients with patello emoral pain have a large Q angle. Also, the
measure assumes that the patella is centered in the trochlea; however, a laterally
subluxed patella can result in a alse-positive f nding.57
Overview of General Rehabilitation Figure 24-8 The Q ang le
Progression Following Knee Injury

When treating knee injuries, the clinician should utilize a progression that considers the
physiologic e ects o the rehabilitation. T is general progression should be understood
so that guidelines and principles can be used to develop protocols or more specif c knee
pathologies or or surgical procedures.102 When ollowing any rehabilitation progres-
sion there are several general principles that should be considered: (a) awareness o joint
in ammation or joint irritability; (b) the amount o motor control and muscular strength
o the knee and lower extremity; (c) the ROM available at the joint; (d) the progression o
weight bearing; and (e) the patients’ present unctional status compared to their ultimate
desired outcome.163
Pain and in ammatory control, ROM, gait training, strengthening exercises, agility
drills, and sport-specif c exercises must all be implemented in a sequence that adheres to a
criterion-based rehabilitation protocol. I the rehabilitation deviates rom a criterion-based
approach, the body will respond with adverse e ects such as in ammation, swelling, pain,
and urther injury.
For purposes o this section, the general treatment plan has been divided into 4 phases.
Many rehabilitation protocols set a time line to determine when it is appropriate to advance
to the next phase. However, movement between phases should be criterion-based, requir-
ing the patient to meet the goals outlined in each phase and not on a prespecif ed period
o time. Advancing a patient into a later stage without ull ROM or controlled swelling has
a high probability o delaying the entire rehabilitation process. A skilled clinician knows
when to advance a patient, delay a patient who has plateaued or regressed, or provide some
overlap between phases.
Phase I
In the past, the majority o acute injuries requiring surgery
were o ten repaired within days o the initial insult. As a
result, patients were undergoing surgery with acute swell-
ing and in ammation, ROM def cits, antalgic gait patterns,
and muscular weakness. Immediate surgery ollowing an
ACL tear o ten led to a severe arthrof brosis.144 As with
most injuries that require surgery, delaying surgery until
the knee has passed the acute in ammatory stage and
regained near-normal ROM and strength can contribute
to a more optimal outcome.
Preoperative rehabilitation involves both mental and
physical preparation. T e patient must be given time to
experience the psychological responses to injury as well
as become emotionally prepared or the challenges o
surgery and postoperative rehabilitation. Patient educa-
tion about the surgical and rehabilitative procedures is
o utmost importance. Using anatomical models or other
resources, the clinician should explain the injury as well
as the surgical technique. Detailed understanding o the
postoperative rehabilitation program and goals is help-
ul. T e patient must exhibit a positive attitude and have
a sense o control over his/ her situation. T e clinician
should also establish a good rapport with the patient dur-
ing this time.
A ter acute injury rom either trauma or surgery the
initial ocus is placed on the elimination o pain and swell-
ing, and restoration o ROM. In the early stages o reha-
bilitation, a knee Cryo Cu (Aircast Inc., Summit, NJ) is
an easy and e ective way to control pain and swelling by
means o cold and compression (Figure 24-9). Compres-
sion garments and ice bags can also be used. T ese early
Figure 24-9 Cryo Cuff applicatio n pro vide s orms o treatment may minimize strength and motion
co ld and co mpre ssio n losses ollowing injury. Pain is o ten the main deterrent
to motion and can lead to muscular and neurogenic inhi-
bition, weakness and atrophy, and altered neuromuscu-
lar patterns. As the knee is acutely irritated at this time,
care should be taken to not urther irritate the tissues by
rushing weightbearing status, progressing exercises too
quickly, or orcing ROM.
Early controlled kn ee ROM exercises are im por-
tant to prevent joint f brosis, and provide nutrition to
the articular cartilage o the joint sur aces.95 Motion
exercises will help align collagen f bers providin g a
m ore exible, strong scar that will help prom ote the
ull return o norm al joint m echanics.62 ROM exercises
should begin alm ost im m ediately a ter the injury, with a Figure 24-10 Quadrice ps se tting is iso me tric
greater em phasis placed on regaining extension. Am ong quadrice ps co ntractio n pe rfo rme d in full e xte nsio n
the m an y exercises to im prove passive exten sion are fo r e arly stre ng the ning and re cruitme nt
heel props and prone han gs. ypically, exion can be
im proved through exercises such as heel slides. How-
ever, because an active contraction o the rectus em oris is needed to per orm a supine
heel slide, a wall slide m ay be m ore use ul early in rehabilitation. Alternatively, use o a
towel under the oot to pull into exion may also allow relaxation o the anterior mus-
culature enough or the exercise to be tolerated. ROM should be the ocus o treatm ent
until both legs are sym m etrical. Once the knee has achieved near 110 degrees o exion,
using a stationary bike with m inimal tension can be an adjunct to gaining urther exion
ROM. It has been shown that returning ull ROM prior to surgery decreases postopera-
tive com plications.135,143
Once ull ROM is restored and swelling and pain are minimal, basic level strengthen-
ing can begin. A resistive exercise continuum should be utilized, beginning with low-level
isometric strengthening. Isometric quadriceps contraction rom a long-sitting position,
or quad sets, is an exercise o ten employed a ter a major knee injury (Figure 24-10). As
strength and weightbearing improve, the patient can begin selective CKC exercises, such
as minisquats, step-downs, and cal raises. Gait training can also begin during this period.
As weight bearing becomes tolerable, gait should be practiced in a normal heel-to-toe pat-
tern, with emphasis on obtaining ull extension at heel strike and knee exion at the swing
through phase. Low-impact aerobics, such as stationary bicycle and stair machines, are also
appropriate at this time.
T e preoperative phase also includes measurement and testing o both extremities.
Strength testing is achieved typically through an isokinetic strength assessment. Single-
leg hop test is another unctional measure that can be utilized. Other measurements that
should be taken include ligament arthrometry, ROM, and subjective knee questionnaire.
Phase II
Phase II ollows many o the same principles o the preoperative phase but also includes
those patients whose injuries do not require surgery or who choose a nonoperative treat-
ment. Immediate postinjury status is o ten thought o as the protection phase. Phase II is
characterized by pain modulation, restoration o normal ROM, basic strengthening, and
restoration o normal gait.
Pain modulation can take place through a number o modalities. Ice, compression, and
elevation are staples during this period to control pain and swelling. Limiting ROM and
weightbearing status through an immobilizer, brace, or crutches can appropriately protect
and rest the joint, depending on the type o injury. T e e ects o pain and swelling and the
e ectiveness o a Cryo Cu were discussed earlier in the preoperative section.
T e importance o early ROM, when indicated, cannot

be overstated. Motion is o ten the key to recovery. O ten
a ter surgery, a continuous passive motion (CPM) device
is applied to the knee to begin early motion through a
small arc (Figure 24-11). Especially with surgical patients
with knee injuries an immediate emphasis is placed on
regaining terminal knee extension. erminal knee exten-
sion acilitates a normal gait pattern and also prevents scar
tissue rom orming in the emoral notch becoming a per-
manent block to knee extension.51 Lack o ull extension
has been linked to quadriceps weakness, anterior knee
pain, and crepitus.136 T is has led to a market o exten-
sion boards and devices aimed at achieving the motion
(Figure 24-12). Exercise instruction or gaining knee exten-
sion includes prone hangs and heel props. Prone hangs
allow passive knee extension with the involved knee and
lower leg o the end o the table (Figure 24-13). Gravity-
Figure 24-11 CPM de vice pe rmits e arly assistance rom the prone position allows the weight o the
mo tio n extremity in gaining extension. An ankle cu weight can
be added or additional assistance. Heel props are per-
ormed in supine with the heel o the extremity propped
onto a bolster, li ting the gastrocnemius and distal thigh
rom the table (Figure 24-14). T is position allows the knee
to relax into ull extension with gravity assistance also. A
weight or strap can be a xed superior to the patella or an
increase in assistance.
Although not as urgent a concern, obtaining knee
exion is also im portant. Knee exion can be im proved
through heel slides, wall slides, an d active-assistive
knee exion in sitting. Heel slides are per orm ed rom
a long-sitting position with knees starting in a position
o extension then m oving into knee exion. Heel slides
Figure 24-12 Exte nsio n bo ard use d to g ain
are typically more com ortable and tolerated better when
full hype re xte nsio n
done passively. T e patient can grasp the lower leg and
passively pulls it into urther exion ( Figure 24-15). T is
can also be per orm ed with a towel either under the oot
or wrapped around the ankle. Wall slides involve the
patient in a supine position with legs extended up a wall.
T e injured leg slowly slides down the wall with the assis-
tance o gravity and the uninjured leg ( Figure 24-16). I
needed, an additional outside orce rom the patient’s
uninvolved leg, can be used to push the knee into deeper
exion. Active-assistive knee exion is per orm ed in a
short-sitting position. From this position, the noninjured
leg can pull the injured leg into even m ore exion. A sta-
tionary bicycle also can be used as a m echanical means
o attaining exion. With both eet strapped into the ped-
als, the patient can use the contralateral leg to propel the
knee into exion. T e clinician should adjust the seat to
a position that is challenging to the patient. As this posi-
Figure 24-13 The prone hang is performed w ith tion becom es easy, the seat can be lowered, increasing
the patient’s distal thighs at the edge of the table the am ount o exion required at the knee to com plete
a revolution. I a ull revolution cannot be com pleted,
a rocking strategy can be em ployed. An alternating or-
ward and backward pedaling m otion is used until the
knee gets “over the top” o the f rst revolution. A f nal
strategy or increasing knee exion is the use o the total
gym (Engineering Fitness International, San Diego, CA).
T e am ount o exion and orce used to gain it will be
determ ined via the angle o the equipm ent and the use o
the range-limiting protection strap.
Along with ROM, a ew associated concepts to con-
sider are exibility and joint m obility. Im proving exibil-
ity m eans increasing the ability o so t-tissue structures
to elongate through a range o joint m otion. A lack o Figure 24-14 The he e l pro p is an e arly
so t-tissue elongation may or may not be a result o the e xte nsio n e xe rcise
injury; however, balancing the available ROM is critical
or norm al biom echanics to occur at the knee. Mobili-
zation o the patello em oral and tibio em oral joints may
also be n ecessary or restoration o accessory m otion,
especially a ter a period o im m obilization. Grades I and
II m obilizations are oscillations applied at less-than-
ull joint m obility and can be use ul in pain control and
preventing restrictions o joint m otion during the early
phases o rehabilitation. Grades III and IV m obilizations
are taken to the end o physiologic joint m otion an d
are used to correct restrictions to joint m otion. In erior
glides o the patello em oral joint along with posterior
glides o the tibio em oral joint will help aid in increas-
in g physiologic knee exion . Superior patello em oral
glides and anterior tibio em oral glides will help achieve Figure 24-15 He e l slide s are an e ffe ctive
ull physiologic knee extension. T e im portance o the me ans o f o btaining kne e e xio n
screw-home mechanism in knee extension should not be
orgotten. In the patient struggling to achieve ull exten-
sion, passive joint m otion to external tibial rotation may
need to be evaluated and m obilizations to external tibial
passive m obility m ay need to be instituted. I present,
90 degrees o knee exion is the best position to assess
or this m otion restriction.
Basic strengthening to regain leg control and improve
quadriceps tone is also important during the early reha-
bilitation period. Exercises to improve leg control include
quad sets, straight-leg raises, and active knee exion and
extension. Straight-leg raises are per orm ed with the
patient in a long-sitting position and the knee in ull exten-
sion. T e patient contracts the quadriceps muscle, much
like per orming a quad set, and then raises the leg 6 to 12
inches o the table (Figure 24-17). T e straight-leg raise
should be per ormed slowly in a controlled manner. Partial
to ull knee extension and exion exercises are to be com-
pleted during this time, with ROM depending on the status
o the articular cartilage and menisci. Sitting knee exten-
sions are per ormed in a pain- ree ROM o the edge o the Figure 24-16 Wall slide s are pe rfo rme d
table. With both exion and extension, active assistance by slo w ly sliding the fo o t do w n the w all
can be provided rom the contralateral extremity. Addi-

tional resistance or these exercises should not be added
until the patient is able to obtain ull knee motion and at
appropriate time rames dependent upon pathology.
Gait restoration is critical in a ecting many aspects
o early rehabilitation . Early postin jury the patient
should am bulate with crutches until gait is n orm al-
ized. Facilitation o quadriceps unction is encouraged
through ull knee extension at heel strike and ull weight
bearin g as tolerated durin g the stan ce phase o gait.
Backward walkin g can be a m ean s o obtaining active
kn ee extension in those having di culty obtain ing ull
Figure 24-17 Straig ht-le g raise pe rfo rme d extension at heel strike. Early weight bearing also allows
by initiating a quad se t and maintaining kne e or joint com pression an d physiologic m otion at the
e xte nsio n w hile raising the le g o ff the table . This knee joint, which are con ducive to cartilage nutrition
sho uld pro g re ss fro m active -assiste d to active an d norm al physiologic stresses to osseous an d so t-
tissue structures about the knee.
oward the en d o phase I, the patient should be
encouraged to progress to ull weight bearing without crutches. Practicing in ront o
a m irror m ay enhance the patient’s ability to am bulate norm ally. Stance phase during
norm al am bulation is one o the m ost basic orm s o CKC quadriceps strengthening. By
achieving ull independent weight bearing, the patient is able to regain good quadriceps
tone and leg control, m aking it possible to im plem ent m ore challenging strengthening
exercises. Bilateral m inisquats are per orm ed with the eet shoulder-width apart and
toes pointing orward. T e patient slowly bends the hip and knees to one-quarter o a
typical ull squat, maintaining the knees in a position posterior to the toes ( Figure 24-18).
T is m in isquattin g activity can be per orm ed n ear a
stable object at arm level or balance. T e bilateral leg
press is sim ilar to the bilateral one-quarter knee bend in
muscular activity. Bilateral cal raises are appropriate or
strengthening the triceps surae musculature. T e patient
can begin this exercise rom a at sur ace and advance
to standing on a stable object with heels hanging o the
edge or a greater ROM. T e patient should elevate as
high as possible, contracting tightly at the top. Unilateral
stance o the involved extrem ity, i tolerable, can be used
to begin im proving balance and proprioception.
Working toward leg control and normal gait is aimed at
improving the patient’s unction. Depending on the injury,
a knee brace or taping o the patella may be appropriate to
assist in returning unction to the patient. Cross-training
activities, such as swimming, biking, or stair machine, may
be appropriate to initiate muscular endurance and aerobic
capacity. Swimming is contraindicated in surgical patients
with unhealed wounds.
Phase III
Once goals o phase II are achieved, the patient can move
orward to phase III. I ull terminal knee extension or
Figure 24-18 Bilate ral o ne -quarte r squats exion are still lacking, ROM must be placed at a priority.
pe rmit e arly CKC stre ng the ning o f the quadrice ps Full ROM must be achieved prior to m ore strenuous
strengthening activities. I this criterion is not ollowed, the body may respond adversely.
T e main ocus o phase III is advanced strengthening.
Strengthening activities o phase II are continued with either increased repetitions and
or resistance. T e patient should be encouraged to place more resistance on the involved
side as tolerated, in a progression toward unilateral strengthening. Once the patient has
su cient leg control to per orm a unilateral knee bend without di culty, weight room
activities may comm ence. A combination o both OKC and CKC activities, as well as con-
centric and eccentric muscular strengthening, should be utilized with most knee condi-
tions. Chapter 11 provides an introductory discussion o OKC and CKC exercises.
OKC exercises or the knee are an excellent way to acilitate isolated quadriceps muscle
strengthening. However, caution must be exercised, as patello emoral compressive orces
are distributed over a smaller contact area with progressive knee extension.131 For patients
with patello emoral compressive issues a range o knee extension rom 90 to 50 degrees
may be tolerated more avorably. OKC extension exercises also produce an anterior shear
orce that signif cantly loads the ACL, particularly in the last 30 degrees o extension. T us, a
sa er ROM or postoperative ACL patients may be between approximately 45 and 90 degrees
o exion. In any patient respective o pathology, per ormance o ull terminal extension
should be per ormed only i there is su cient quadriceps strength and proper alignment to
complete the exercise without pain.
CKC exercise is thought by some to be pre erred or a more unctional rehabilitation
o the lower extremity. During CKC exercises, patello emoral compressive orces become
larger as exion increases.131 However, CKC exercises produce reduced shear orces across
the tibio emoral joint through cocontraction and axial loading.12 T us, a sa e general range
or patients to begin CKC exercise is rom 0 degrees to approximately 45 degrees. A more
advanced patient may go beyond 45 to 90 degrees o knee exion i the exercise can be
completed without pain.
Frequently, em phasis in rehabilitation is placed solely on concentric activity. How-
ever, eccentric activity is dom inant in m ost athletic activities such as running, tennis,
and throwing. Eccentric lower-extrem ity control is needed when landing rom a jum p
in activities such as basketball, track and f eld, volleyball, and gym nastics. Additionally,
eccentric control is recogn ized as im portant or e cient gait. In act, m any activities
o daily living require eccentric activity, such as bending over to pick up an object or
descending stairs.
T e potential orce o eccentric muscle activity can be described as part o the stretch-
shortening cycle.24 Muscle eccentric stretching loads potential energy into elastic elements
that is trans erred into kinetic energy during the concentric phase o a muscle contraction,
thereby raising the peak potential orce.24 T is is the premise behind plyometric activity.
For example, consider a standing vertical leap. During the knee and hip exion phase,
stored potential energy occurs as the muscles lengthen eccentrically. T is allows the ath-
lete to jum p higher than i jum p rom a static position o knee and hip exion without
eccentric loading.
Advanced strengthening in phase III should emphasize unilateral exercises, including
leg press, step-downs, cal raises, and leg extensions. When starting unilateral extremity
exercises a patient can per orming leg press and leg extensions by using the uninvolved
leg through the concentric phase ollowed by only the involved in the eccentric portion o
the li t. Step-downs are per ormed by having the patient stand on a step with the a ected
extremity. T e patient slowly lowers the contralateral leg to the oor while maintaining
good biomechanical alignment o the lower extremity, then returning to the starting posi-
tion (Figure 24-19). Initially, the height o the step should be small (2 to 4 in) and should
increase as the exercise becomes easier. Di culty o the exercise can be increased by per-
orming the step-down to the ront or back o the step. At this time more advanced exer-
cises, such as light squats and lunges, can commence.
Aerobic exercise is always important and can be initi-

ated with a stair machine, elliptical runner, or stationary
bicycle. I aerobic exercise is already being done it can
be progressed to greater intensity levels. I wounds have
healed, the patient can also begin swimming and per orm-
ing other hydrotherapy activity.
oward the end o phase III, early agility drills can
begin. Jumping rope, straight-ahead jogging, or easy posi-
tion drills or athletes are appropriate. During this period,
ROM should be maintained, pain and swelling should not
occur, and a normal gait pattern should be achieved.
Phase IV
A unctional return to prior activity status is the goal o the
f nal phase. T e patient can progress, once meeting the
goals o phase III and maintaining the objectives, rom
the previous phase. Phase IV is characterized by a unc-
tional progression that includes activity- or sport-specif c
exercises, agility drills, and balance and proprioceptive
training.
T e patient con tinues advan ced stren gthen in g
throughout the entire phase. Once 65% to 70% strength
is attained in the involved leg (usually tested with an iso-
kinetic strength assessm ent), agility activities and sports
specif c drills can be advanced sa ely. Weight-room activ-
ities and hom e strengthening exercises should progress
rom high repetition/ low weight to low repetition/ high
weight. Moderate speed strengthening and cardiovascu-
lar conditioning should be continued during this period.
Activities and exercises during this phase should be
unctional, specif c, and progressive. Whether a mail car-
rier or a ootball linebacker, the rehabilitation needs to
Figure 24-19 Ste p-do w ns can be made mo re ocus on tasks required or that individual to return to his/
challe ng ing by incre asing the he ig ht o f the ste p her prior activity status. A mail carrier may be required
to li t moderately heavy objects and walk long distances,
while a linebacker requires explosive power and high-
speed change o direction. Solo sport activities, such as shooting a basketball or hitting a
tennis ball, are appropriate during this time.
Advanced agility drills can include lateral shu es, cariocas, crossover drills, and back-
ward running. By ocusing on agility activities rather than on jogging, the patient is more
apt to improve areas o conf dence, moderate speed strength, quickness, and sport-specif c
skills. By avoiding the repetition and redundancy o jogging and making the activity pur-
pose ul and specif c, the patient is o ten able to better absorb joint compressive orces and
become more engaged in rehabilitation sessions.
As the patient progresses, agility training becom es more vigorous. Figure-o -eights
and hal -to- ull-speed running should be included at this time. ypically, a unctional
progression will ollow a scheme that gradually increases speed increments rom hal to
three-quarter, to ull-speed activity. Chapter 18 provides additional suggestions or unc-
tional progressions. Making certain activities are per ormed with proper technique is para-
mount. o begin, jumping movements should be per ormed straight up and down with no
lateral moments at the knee. T e patient should maintain the trunk over knees and knees
Speci c Rehabilitation Techniques for Ligamentous and Meniscal Injury 745
over eet while keeping the hips, knees, and ankles in a straight line. Landing on the balls
o the eet instead o at- ooted and assuming a position o slight exion in the hips and
knees is help ul.
Durin g return to activity, the clin ician should challen ge the patient’s balan ce
through perturbation activities per orm ed on a wobble board, oam, or tram polin e.
Per orm ing the exercise unilaterally or with eyes closed increases the di culty. T ese
exercises im prove joint stabilization patterns through cocontractions o the quadriceps
and ham strings. T e patient also im proves body awareness through an en hancem ent
in proprioceptive in orm ation . Chapter 9 provides additional in orm ation regarding
neuromuscular training.
Be ore a ull return to prior activity level, the patient’s involved extremity should be
reevaluated. ROM, isokinetic strength assessment, ligament arthrometry, and a combina-
tion o subjective knee questionnaire and unctional tests should all be compared to preop-
erative or preinjury status. T e patient should have ull ROM, acceptable ligament stability,
and 80% strength bilaterally be ore returning to competitive athletic or recreational activi-
ties. T e patient should complete a sport- or occupation-specif c unctional progression
prior to ull return.
Speci c Rehabilitation Techniques for

Ligamentous and Meniscal Injury
Medial Collat eral Ligament Sprain

Pat homechanics
Although current research on knee ligament injuries appears to ocus more on ACL inju-
ries, the MCL remains the most commonly injured ligament o the knee.173 In young, active
patients, approximately 90% o all knee ligament injuries are to ACL, MCL, or a combina-
tion o the two.112 Success ul management o MCL injuries o ten depends on establishing
the existence o an isolated lesion, with no associated damage to other knee structures,
particularly the ACL. Isolated MCL injuries can heal spontaneously, without the need or
surgical correction, even in complete ligament ruptures when the ragmented ends o the
damaged tissue are not in close approximation.174
A clear understanding o the anatomy o the m edial knee is im portant in under-
standing injury biom echanics and developing a treatm ent strategy. Warren and Marshall
used the three-layer concept to describe the m edial structures o the knee.162 T e f rst,
m ost superf cial layer is com posed o the ascia surrounding the sartorius muscle. T e
interm ediate second layer contains the superf cial MCL, the m edial patello em oral liga-
m ent, and the ligam ents o the posterom edial corner o the knee. T e third and deep-
est layer o knee structures includes the capsule and the deep MCL. T e MCL can tear
m idsubstance or at either the em oral or tibial attachm ent sites. Approximately 65% o
MCL sprains occur at the proximal insertion site on the emur. On the basis o location
o the injury, rehabilitation can vary substantially. MCL injuries occurring m idsubstance
or near em oral origin tend to develop m ore sti ness and readily incur ROM loss.52 Res-
toration o ull m otion should be m onitored closely within the f rst ew weeks ollowing
injury. In contrast, injuries at the tibial attachm ent tend to heal with residual laxity and
thus have easier return o ROM. As a result, additional protection m ay be required to
allow the MCL to heal.
T e grade o ligam ent injury is determ ined by the am ount o joint laxity. A grade I
MCL sprain presents with tenderness caused by m icrotears, no increased laxity, and a
f rm end point. A grade II sprain involves an incom plete tear with som e increased laxity
with valgus stress at 30 degrees o exion and m inim al laxity in ull extension, and a f rm
end point. T ere is tenderness to palpation, hem orrhage, and pain on valgus stress test.
A grade III sprain is a com plete tear with signif cant laxity on valgus stress in ull exten-
sion. No end point is evident, and as a result o not having opposing ends, pain is less
than that experienced with grade I or II sprains. Signif cant laxity with valgus stress test-
ing in ull extension likely indicates injury to the m edial joint capsule and the cruciate
ligam ents.
Mechanism of Injury
Injury to the MCL occurs as a result o valgus stress to the knee rom a contact or noncon-
tact orce. T e most common mechanism o injury or an isolated MCL injury is by a direct
lateral contact, which is requent during contact sports such as ootball. A direct orce to the
outside o the knee can result in a valgus stress to the medial aspect o the knee that exceeds
the strength o the ligament. T e patient will usually explain that the knee was hit on the
lateral side with the oot planted and that there was immediate pain on the medial side o
the knee that elt more like a “pulling” or “tearing” than a “pop.” A true “popping” sensation
may be more indicative o an MCL sprain with concomitant ACL rupture.
Less commonly, the MCL is injured through a noncontact mechanism that occurs
when the oot is planted and an indirect rotational orce is coupled with an increased valgus
stress at the knee. T is mechanism is common in sports that involve cutting maneuvers
such as soccer, basketball, and ootball. T is mechanism may be more likely to incur dam-
age to other anatomical structures such as meniscus and ACL.

Historically, the standard o care or MCL injuries was surgical management.118-121 Since
the early 1980s, the treatment o MCL sprains has changed considerably.71 T e current
approach is nonsurgical and includes limited immobilization with early ROM and strength-
ening exercises. Shelbourne and Patel142 ound the best approach or management o a
combined MCL–ACL injury is achieved by treating the MCL injury nonsurgically and per-
orming a delayed reconstruction o the ACL.
Patient advancem ent varies according to the location o the tear, degree o ligam en-
tous in stability, con com itant injuries involved, age, an d activity dem ands. A patient
with a grade III tear at the em oral attachm ent site typically will have m ore di culty
restoring m otion, whereas patients with tears at the tibial insertion tend to have m ore
instability.
Grade I injuries may be progressed as tolerated with or without the use o a hinged
knee brace. Grade II injuries can be progressed as tolerated, depending on the patient’s
signs and sym ptom s. T ese injuries will display increased valgus laxity but retain a f rm
en d point. A hin ged knee brace can be used early in the rehabilitation, although an
im m obilizer m ay be used or patient com ort. Grade III injuries m ay be progressed as
tolerated with a hinged brace or m ay be im m obilized in 30 degrees o exion or 1 to 3
weeks i a m ore conservative approach is used. T is protection provides a stable envi-
ron m ent or proper healin g and tightenin g o the injured ligam entous com plex. T e
physician and clinician should collaborate on patient progression at each clinical visit,
as overlapping o the 3 phases is very com m on and has been built into this progres-
sion. T ere are several instances when operative managem ent may be warranted: (a) a
large bony avulsion exists; (b) there is a concom itant tibial plateau racture; (c) there is
a concom itant ACL injury; and (d) there is intraarticular entrapm ent o the end o the
torn MCL. Surgery can be per orm ed using prim ary reconstruction or via surgical repair.
Kovachevich et al recently reported that no studies have com pared the 2 orm s o surgi-
cal treatm ent.84 T ere ore, at this tim e, no clear evidence-based recom m endations can
be made or either procedure.

Phase I: 0 to 3 Weeks Phase I is characterized by pro-
tection, early healing, and restoring ROM. T e clinical
goals are to minimize pain and swelling and to attain ull-
weightbearing and normal gait with or without a brace or
immobilizer.
A Cryo Cu is to be used as tolerated throughout the
day or control o pain and swelling. A stockinette can
be worn to assist in swelling control. Antiin ammatory
medications can be taken as prescribed by the physician.
Immobilization is dependent on the patient’s instability
and pain. For patients with a grade I MCL injury, brac-
ing is used as needed. Patients with a grade II injury use
Figure 24-20 Stre ss shie lding the MCL
by applying a varus fo rce to the kne e w hile
a brace and possibly an immobilizer. Grade III injuries
pe rfo rming passive kne e e xio n rang e o f mo tio n
are managed with a hinged brace, cast, or immobilizer.
Immobilization times will vary depending on the severity
o instability and physician’s pre erence.
T e patient may be allowed to weight bear as tolerated with or without protective
devices, depending on pain status. ROM exercises are per ormed 3 times daily (prone
hangs, heel props, wall slides, and heel slides). I an immobilization period is required,
ROM exercise may be delayed.
Phase II: 1 to 5 Weeks Phase II rehabilitation ocuses on restoring ull ROM and begin-
ning a strengthening program that utilizes both OKC and CKC exercises. Clinical goals
include no swelling, ull ROM, normal gait, pain- ree activities o daily living, and initiation
o strengthening and proprioception activities. ROM exercises are continued during this
period. During attempts to gain passive exion ROM the clinician can stress shield the heal-
ing MCL by applying a varus orce (Figure 24-20) T e patient should begin to exhibit a nor-
mal gait pattern without assistance rom a hinged brace, or assistive devices. A brace can be
worn as needed or com ort. Strengthening exercises begin bilaterally and are progressed to
a unilateral exercise. T e regimen consists o minisquats, step-downs, toe raises, leg presses,
and leg extensions. Proprioceptive activities and nonimpact aerobic training, such as sta-
tionary bicycle, stair machine, and elliptical trainers, are initiated at this time.
By the end o phase II, the patient should possess ull ROM, including terminal exten-
sion. Stockinette use can be discontinued at the end o this phase i no swelling is present.
Use o the Cryo Cu a ter exercise and or pain control can be continued as needed.
Phase III: 2 to 8 Weeks T e f nal phase consists o a progressive return to unctional

activities. T e goals o phase III include pain- ree activities o daily living without a brace,
weight-room strengthening, completing a unctional progression with a brace, and return
to sport or work with a brace. T e clinician administers the unctional progression and
isokinetic strength assessment. For a return to ull competitive activity, the patient should
meet the ollowing criteria:
1. Minimal to no pain
2. Full ROM
3. Quadriceps and hamstring strength equal to 90% o the uninvolved limb
4. Completion o a running progression program.
T e average time or return to play varies with sport and injury extent. A grade I injury
requires approximately 10 days or return to ull activity, a grade II injury takes approxi-
mately 20 days. A grade III injury requires anywhere rom 3 to 6 weeks.
Strengthening should be per ormed unilaterally, continuing the exercises rom phase II.
Most phase III activities are per ormed in the weight room and include unilateral leg press
to 90 degrees, step-downs rom a 2- to 4-inch step height, unilateral leg extensions, squats to
90 degrees per ormed in a squat rack, lunges, and stair machine.
Easy agility drills are initiated at this time and should be completed with a hinged knee
brace. Activities should include jump rope, backward running, lateral slides, cariocas, cut-
ting movements, and a jogging to sprinting progression.
Success ul completion o a unctional progression constitutes the end o this phase.
At this time, the patient can return to ull activity. A unctional knee brace is used depend-
ing on the demands o the individual’s activity or sport and degree o injury. T e patient
needs to continue a regular strengthening program even a ter ull return to activity.
Lat eral Collat eral Ligament Sprain

Pat homechanics
Fortunately, the lateral aspect o the knee is well supported by secondary stabilizers, and iso-
lated injury to the LCL is rare. When it does occur, the clinician must rule out other ligamen-
tous injuries. Isolated sprain o the LCL is the least common o all knee ligament sprains.112
LCL sprains result in disruption at the f bular head either with or without an avulsion in
approximately 75% o the cases, with 20% occurring at the emur, and only 5% as midsubstance
tears.156 It is not uncommon to see associated injuries o the peroneal nerve because the nerve
courses around the head o the f bula. A complete disruption o the LCL o ten involves injury
to the posterolateral joint capsule, as well as the PCL, and occasionally the ACL.
T e am ount o laxity evident on a varus stress test determ ines the severity o injury
to the LCL. Grading the extent o LCL laxity ollows the sam e I to III grading scale as
the MCL.
Mechanism of Injury
An isolated LCL injury is almost always the result o a varus stress applied to the medial
aspect o the knee. Occasionally, a varus stress may occur during weight bearing when
weight is shi ted away rom the side o injury, creating stress on the lateral structures.
Patients report hearing or eeling a pop and immediate lateral pain. Swelling is immediate
and extraarticular, with no intraarticular joint e usion unless there is an associated menis-
cus or capsular injury.

Grade I injuries may be progressed as tolerated with or without the use o a hinged knee
brace. Grade II injuries can be progressed as tolerated, depending on the patient’s signs
and symptoms. T ese injuries display increased varus laxity but retain a f rm end point. A
hinged knee brace can be used early in the rehabilitation, although an immobilizer may
be used or patient com ort. Grade III injuries may be managed nonoperatively with brac-
ing or 4 to 6 weeks, limited to 0 to 90 degrees o motion; however, grade III LCL tears with
associated ligamentous injuries that result in rotational instabilities are usually managed by
surgical repair or reconstruction. T is is certainly the case i the patient has chronic varus
laxity and intends to continue participation in athletics, or i there is a displaced avulsion.

T e rehabilitation progression ollowing LCL sprains should ollow the same course as was
previously described or MCL sprains. In the case o a grade III LCL sprain that involves
multiple ligamentous injury with associated instability that is surgically repaired or recon-
structed, the patient should be placed in a postoperative brace, with partial weight bear-
ing or 4 to 6 weeks. At 6 weeks, a rehabilitation program involving a care ully monitored
gradual sport-specif c unctional progression should begin. In general, the patient may
return to ull activity at about 6 months.
Ant erior Cruciat e Ligament Sprain

Pat homechanics
T e healing potential o a torn ACL is very poor.47 Healing potential or a partially torn ACL
can be avorable when certain conditions exist, but only 15% o all ACL injuries are partial
tears.39 Because o the poor healing conditions, the torn ACL o ten leads to anterior laxity,
rotary instability, and meniscal tears when le t untreated. Furthermore, untreated ACL inju-
ries lead to unctional def cits,54,66,105 and an increased risk o second ACL injury.123 Very ew
athletes can participate at a high level with a non unctional ACL.64 Giving-way episodes are
o ten the result, damaging the meniscus and articular cartilage within the joint.
Convincing evidence suggests that an active individual with a torn ACL is susceptible
to meniscal injury.22 Results o ACL reconstruction 9 years a ter surgery strongly correlated
with the status o the meniscus and articular cartilage.140 Patients who undergo ACL recon-
struction without meniscal tears requiring or removal o articular cartilage damage had sig-
nif cantly better long-term results compared to patients who had surgery with meniscus
removal or severe articular cartilage damage. Patients with normal meniscus and articular
cartilage at the time o surgery had subjective scores equal to a normal control group with-
out knee injuries.
T e temporary stability o a nonoperated ACL tear is o ten re erred to as the “honey-
moon period.” When treated nonoperatively, an active individual will likely become symp-
tomatic. T e present laxity will lead to instability, causing giving-way episodes with ensuing
swelling and pain. Damage to the meniscus and articular cartilage is highly probable ol-
lowing such episodes. Meniscal damage is associated with hal o acute cases and 90% o
chronic ACL def ciencies o greater than 10 years’ duration.39 T irty percent o acute ACL
injuries and 70% o ACL-def cient knees at 10 years postinjury display articular cartilage
lesions.39 T e relationship o long-term joint arthrosis to ACL def ciency is not ully under-
stood. However, the alteration o knee biomechanics can lead to areas o overload, causing
articular cartilage breakdown. Depending on the length o ollow-up, detectable osteoar-
thritis in ACL injuries ranges rom 15 to 65%.31,44
As with MCL and LCL sprains, the severity o the injury is indicated by the degree o
laxity or instability. Rotational instability is present i indicated by a positive pivot shi t.
Patients most o ten report eeling and hearing a pop and a eeling that the knee “gave out.”
T ere is also signif cant pain, and hemarthrosis occurs within 1 to 2 hours.
Mechanism of Injury
T e most common injury mechanism to the ACL involves a noncontact valgus and external
rotation stress to the knee as the oot is planted on the ground. T e classic example o this
mechanism happens in ootball when a running back plants the oot to make a cut and
avoid being tackled. Occasionally, the mechanism o injury involves deceleration, valgus
stress, and internal rotation. Knee hyperextension combined with internal rotation can also
produce a tear o the ACL.
External contact orces to the tibio emoral joint can result in a combined knee injury
o which an ACL rupture is a com ponent. ypically, this injury is a result o lateral or
hyperextension orce to the knee, which requently results in complete rupture o both the
ACL and MCL, plus a longitudinal tear o the lateral meniscus, all o which require surgi-
cal reconstruction. Another common mechanism occurs when an athlete is unexpectedly
bumped right be ore landing rom a jump, causing a premature contraction o the quadri-
ceps and landing upon an anteriorly translated tibia. Chapter 31 discusses ACL injuries in
athletic emales.

Although success ul treatment options exist ollowing ACL injury, an appropriate evidence-
based plan o care is still under debate. For the sedentary individual, a more conserva-
tive approach may be considered in which the acute phase o the injury is allowed to pass
ollowed by a vigorous rehabilitation program. I normal unction does not return and the
knee remains unstable, then reconstructive surgery is considered.
Most active and athletic patients pre er a more aggressive approach. T e ideal patient is
a young, motivated, and skilled athlete who is willing to make the personal sacrif ces neces-
sary to success ully complete the rehabilitation process. T us, success ul outcomes ollowing
surgical repair and reconstruction are dependent to a large extent upon patient selection.
In the case o a partially torn ligament, the medical community is split on treatment
approach. Some eel that a partially damaged ACL is incompetent and should be viewed
as i the ligament were completely gone. Others pre er a prolonged initial period o immo-
bilization and limited motion, hoping that the ligament will heal and remain unctional.
Decisions or nonoperative treatment should be based on the individual’s preinjury status
and a willingness o the patient to engage only in activities such as jogging, swimming, or
cycling that will not place the knee at high risk. T is is clearly a case where the patient may
seek several opinions be ore choosing the treatment course.
Surgical technique is crucial to a success ul outcome. T e improper placement o the
tendon gra t can prevent the return o normal motion. T e type o gra t chosen also a ects
postoperative rehabilitation in terms o tensile strength, harvest site comorbidity, and
revascularization.
raditional rehabilitation ollowing ACL reconstruction is based on the work o
Paulos et al124 in which phases o rehabilitation correspond to healing tim e ram es o
animal m odels. T e traditional m odel em phasized limited ROM and weight bearing, as
well as delayed strengthening and return to activity. Return to sports typically occurred
within 6 to 12 months. In 1990, Shelbourne and Nitz141 reported positive outcomes with an
accelerated rehabilitation program that emphasized im mediate ROM and ull extension,
imm ediate weight bearing as tolerated, early CKC strengthening, and return to sporting
activities by 2 m onths and to ull competition within 4 to 6 months.
T e ollowing rehabilitation progression is based on the accelerated program.

( able 24-1 outlines the ollowing discussion)
Phase I: Preoperative T e preoperative phase objectives ocus on physically preparing
the knee or surgery and mentally preparing the patient to deal with the surgery and postop-
erative rehabilitation. Restoration o ull ROM and normal strength prior to reconstruction
are key components o this phase, with emphasis on obtaining ull ROM be ore strength-
ening. o achieve ull ROM, swelling must also be reduced. T e clinician can educate the
patient on the basic principles o rehabilitation, including maintenance o ull hyperexten-
sion and ull exion, early weight bearing, and OKC and CKC strengthening.101,104
Preoperative testing provides a baseline or objective comparison in later phases. Bilat-
eral ROM, including ull terminal knee extension, a K -1000 ligament arthrometer and an
isokinetic strength evaluation, isometric leg press, and single-leg hop test on the nonin-
volved leg are all per ormed prior to surgery.
Gaining ull ROM is the f rst goal during this period. Extension exercises include heel
props, towel stretches, and prone hangs. An extension board or other extension device can
be used i gaining ull extension is di cult. Exercises aimed at gaining exion include heel
slides, wall slides, and supine exion hangs. In conjunction with ROM exercises, activities
to develop quadriceps control are initiated. Active heel li ts and standing knee lockouts pro-
duce quadriceps strength and develop early extension habits. Once ull ROM with minimal
Table 24-1 Po sto pe rative Re habilitatio n Afte r ACL Re co nstructio n
Phase Days – Weeks Go als Re strictio ns Tre atme nt Clinical Mile sto ne s
Phase I: PO Restore ROM WBAT with RICE Surgical reconstruction

Preoperative both active bilateral Electrical stimulation Full knee extension
and passive axillary Extension ROM Restoration of strength
Quadriceps crutches Passive exion ROM Minimal effusion
activation Brace locked at Glute/Quad/Ham sets No increased pain
Decreased 0 degrees Hip abduction/
effusion adduction
Pain reduction Leg presses
Minisquats
Step-downs
Phase II: PO Wks 0 to 2 WBAT bilateral Full WBAT brace Patellar mobilization Previous milestones
Immediate axillary locked in full Scar tissue mobilization Clean incisions
PO Phase crutches locked extension × 1 PROM exion and Good quadriceps
in extension week extension recruitment
Full knee After week 1 PROM exion SLR with minimal lag
extension PROM exion progressed to Normalized patellar
Quadriceps can be started 110 degrees week 1 mobility
control Brace still locked 130 degrees week 2 Weight bearing
Pain reduction in extension Quadriceps sets progressed without
Normal patellar for weight Straight leg raises × 4 symptoms
mobility bearing until Ankle pumps Minimal pain and
SLR with no CPM effusion
extensor lag Weight shifts
Cryotherapy
Phase III: PO Wks 2 to 4 Normalized Braced unlocked Progression of previous Previous milestones
Intermediate quadriceps for weight Isometric quad sets Satisfactory clinical
PO Phase recruitment bearing as at 0, 60, and exam
Normal patellar tolerated 90 degrees ROM 0 to 130 degrees
mobility Crutches Squats and leg press Improved stability with
No pain or discontinued at 0 to 60 degrees unilateral stance
effusion approximately Stationary bike No pain
Restoration 2 weeks Step-downs Normal gait
of motion Calf raises
Maintain full Minisquats
weight bearing Balance drills
Improve balance Band exercises
Phase IV: PO Wks 4 to 12 Full bilateral ROM None Previous strengthening Previous milestones
Strengthening Increase strength Progress bilateral Full motion: 0 to
Phase and endurance loading to single limb 130 degrees
No pain loading exercises Single leg stance ×
No swelling Lunges 0 to 60 degrees 30 sec
Preparation for Advanced balance Squat 60 degrees
activities activities with equal weight
Hip extension bearing
progressing to No pain or effusion
isolated hamstring
exercises in 12 weeks
(continued )
Table 24-1 Po sto pe rative Re habilitatio n Afte r ACL Re co nstructio n (Continued )
Phase Days – We e ks Go als Re strictio ns Tre atme nt Clinical Mile sto ne s
Phase V: PO Wks 12+ Restoration of None Previous strengthening Previous milestones

Return to full motion Unilateral calf raises Full motion
Activity Phase No swelling Progress CKC exercises Full con dence
No pain Advance hamstring in knee
Return of full exercises Functional testing
activities Agility drills >90% of
Advanced balance uninvolved
drills Isokinetic testing
Sports speci c drills >90% of
uninvolved
CKC, closed kinetic chain; CPM, continuous passive motion; PO, postoperative; RICE, rest, ice, compression, elevation; ROM, range of motion;
SLR, straight-leg raise; WBAT, weight bearing as tolerated; Wks, weeks.
swelling is obtained, CKC strengthening can begin. T e

patient can per orm leg press, minisquat, step-down, sta-
tionary bike, and stair machine activities.
Phase II: Days 1 to 14 Phase II begins im m ediately

a ter surgery to 2 weeks postoperatively. For those who
may be likely to have m otion problem s, a CPM machine
is utilized the day o surgery and is set rom 0 to 30
degrees exion (see Figure 24-11). A Cryo Cu is donned
im m ediately a ter surgery to control pain and swelling.
During these f rst ew weeks the patient is encouraged
to ully weight bear as tolerated, with crutches i needed.
T e patient generally begins ormal therapy near
the third postoperative day. Initially, extension exercises
are per ormed 6 times daily. T e knee is allowed to ully
extend into terminal extension or 10 minutes during each
bout with a heel prop. owel stretches are also used to
help gain extension. Knee exion exercises are per ormed
through a ROM o 110 degrees, completed 6 times daily.
T e patient can urther increase exion by pulling the leg
toward the buttocks and holding or 3 minutes. Leg con-
trol is initiated with exercises that emphasize active quad-
riceps contractions such as quad sets, straight-leg raises,
and active heel height.
Exercise progression or knee extension ROM
becomes a critical actor during this time. T e patient
continues to push toward ull hyperextension equal to the
opposite leg by means o towel stretches, heel props, and
prone hangs. A standing knee lock-out is per ormed by
standing with the weight shi ted to the reconstructed leg
while ully locking the knee into extension by contracting
Figure 24-21 Standing kne e lo cko ut the quadriceps ( Figure 24-21). Obtaining ull extension
facilitate s e xte nsio n in w e ig ht be aring and normal gait early in the rehabilitation process enables
the patient to regain quadriceps tone and leg control, set-
ting the pace or the entire rehabilitation program. Once
ull knee extension and normal ambulation are obtained,
more challenging leg control exercises such as minisquats
and knee extensions are implemented. Knee exion con-
tinues to progress through heel slides, wall slides, and
supine exion hangs.
Criteria or progression to phase III consist o ull ter-
minal extension, exion to 130 degrees, minimal pain and
swelling, so t-tissue healing, normalized gait, and the abil-
ity to lock the operated knee into ull extension compared
bilaterally.
Phase III: Weeks 2 to 4 Clinical goals or phase III are

ull ROM, including terminal knee extension, and contin- Figure 24-22 Sitting back o n o ne ’s he e ls to
ued strengthening. T e patient should work toward being achie ve te rminal kne e e xio n and asse ss e xio n
able to sit back onto the heels. Again, ROM should be mea- ROM
sured and documented at the end o this phase.
I ull passive terminal extension or ull exion is not
yet attained, other therapeutic methods should be taken
to meet these goals. Because o the importance o attain-
ing ull ROM, especially extension, additional clinic visits
may need to be scheduled. An extension board or other
extension device can be used at home and during clinic
visits to restore ull extension. Supine exion hangs are the
most common method o regaining terminal exion. T e
patient can gauge proximity to ull terminal exion by sit-
ting back onto the heels (Figure 24-22).
Leg control through quadriceps strength is targeted
with the addition o a progression o double leg squats
to step-down exercises. Squats can begin bilaterally on a
level sur ace progressing to a labile sur ace (Figure 24-23).
High requency and high repetitions are used to stimulate
the patellar tendon gra t harvest site. Progression to uni-
lateral step-downs is determined by maintaining ull ROM Figure 24-23 Incre ase quadrice ps stre ng th
and minimal swelling. by pe rfo rming bilate ral squats on a labile surface ,
Progression to phase IV is achieved through equal w hich cause s an incre ase in proprio ce ptive de mand
motion bilaterally, a normal gait without assistive device,
ability to stand on the surgical leg without assistance, and minimal pain and swelling. I
these goals are not yet achieved, the athlete remains at phase III until the goals are met.
Phase IV: Weeks 4 to 12 Phase IV is characterized by improved strength and the initia-
tion o unctional activities. Full ROM including terminal extension should be maintained
throughout this phase. Quadriceps tone should continue to improve with visible quadri-
ceps def nition returning. Once 70% quadriceps strength has been demonstrated, a pro-
prioceptive and agility program can begin. A sport-specif c unctional progression can be
set up toward the end o this phase.
Postoperative testing at 4 weeks includes a subjective knee questionnaire, bilateral
ROM, and K -1000 arthrometry. An isometric leg press test can also per ormed at this time.
Near the 12-week postoperative date an isokinetic evaluation is per ormed at speeds o 60
degrees, 180 degrees, and 300 degrees per second.
During this period, strengthening exercises progress rom bilateral to unilateral in an
e ort to emphasize strength o the quadriceps and patellar tendon gra t site. T e exercise
regimen consists o unilateral leg presses, unilateral knee

extensions, unilateral step-downs, and lunges on stable and
unstable sur aces (Figure 24-24). Stair machines, stationary
bicycles, and elliptical trainers can be used or aerobic con-
ditioning and moderate speed strengthening.
Controlled agility training activities are initiated based
upon the patient’s subjective knee rating and strength-
testing scores. Agility training and limited sports partici-
pation not only help the patient to regain quickness and
unctional movement patterns but also restore conf dence
in returning to previous unctional status. Agility drills may
include orm running in shortened distances, backward
running, lateral slides, crossovers, and single-leg hopping.
Individual athletic drills should be sport specif c, such as
shooting a basketball or dribbling a soccer ball. For spe-
cif cs on current jump training programs advocated or
emale athletes, re er to Chapter 31. T is component o
rehabilitation is not only or athletes, but should also be
tailored to meet the demands each patient will ace upon
return to prior activity level.
Phase V: Week 12 and On Return to ull activity is the

ocus o the f nal phase. T e goals or the patient are to
maintain ull ROM, continue quadriceps strengthening,
and increase activities as appropriate. esting at this time
includes a subjective knee questionnaire, bilateral ROM,
K -1000 arthrometry, isokinetic strength test, and isomet-
ric leg press. T e single-leg hop test should be initiated
now or a unctional comparison o the legs. T e single-
leg hop is per ormed or distance with takeo and landing
Figure 24-24 Incre ase quadrice ps stre ng th by rom the same leg.
pe rfo rming unilate ral lunge s o n a labile surface ,
Exercises to maintain ull ROM and continuous
w hich cause s an incre ase in proprio ce ptive de mand
strength and conditioning are adjusted according to the
patient’s needs. A unctional progression is integrated to
meet the unique needs o each patient. T e patient, amily, coach, and athletic trainer need
to be educated when and how to modi y activity based upon subjective and objective knee
f ndings. Return to ull, nonrestricted activities is the ultimate goal o the patient and clini-
cian in pursuit o a success ul outcome. T e patient will periodically ollow up in the clinic
or reassessment, strength testing, and research purposes.
Post erior Cruciat e Ligament Sprain

Pat homechanics
Knowledge o anatomy and biomechanics o the PCL have been greatly expanded over
the past 15 years. T is increased understanding has led to a greater scientif c basis or the
design o rehabilitation approaches to this complicated ligament. Isolated injuries or tears
o the PCL are uncommon and usually the result o a combined ligament injury. Most PCL
tears occur on the tibia (70%), whereas 15% occur on the emur and 15% are midsubstance
tears.109 In the PCL-def cient knee, there is an increased likelihood o medial side meniscus
lesions and chondral de ects.53
As with other ligament sprains the severity o the injury is indicated by the degree o lax-
ity. In a grade I injury, there will be 0 to 5 mm o posterior tibial translation but the tibial
plateau will maintain its position anterior to the medial emoral condyle. A grade II sprain will
have 5 to 10 mm o posterior translation o the tibial while the medial tibial plateau rests ush
with the medial emoral condyle. A grade III sprain will demonstrate greater than 10 mm o
posterior translation and the medial tibial plateau will all posterior to the medial emoral
condyle. Additionally with grades II and III sprains there will be increased laxity with the pos-
terior drawer, posterior sag, and reverse pivot shi t tests when compared to the opposite knee.
Increased laxity is typically associated with combined ligament injuries and meniscus tears.
Mechanism of Injury
In athletics, the most common mechanism o injury to the PCL is with the knee in a position
o orced hyper exion with the oot plantar exed. T e PCL may also be injured when the
tibia is orced posteriorly on the f xed emur or the emur is orced anteriorly on the f xed
tibia. It is also possible to injure the PCL when the knee is hyper exed and a downward
orce is applied to the thigh. Forced hyperextension and combined rotational orces will
usually result in injury to both the PCL and ACL. I an anteromedial orce is applied to a
hyperextended knee, the posterolateral joint capsule may also be injured. I enough valgus
or varus orce is applied to the ully extended knee to rupture either collateral ligament, it is
possible that the PCL may also be torn. When torn the ligament normally ails at its midsub-
stance, however, avulsions o the tibial or emoral attachments can occur. An isolated tear
will occur during athletics, while combined injuries are more likely a ter traumatic high-
energy trauma such as dislocations.
A ter PCL injury, the patients will likely indicate that they heard a pop. Unlike ACL inju-
ries, patients sustaining injury to the PCL will o ten eel that the injury was minor and that
they can return to activity immediately. T ere will be mild-to-moderate swelling occurring
within 2 to 6 hours.

Perhaps the greatest concern in rehabilitating a patient with an injured PCL is altered
joint arthrokinematics, which may eventually lead to degeneration o both the medial
compartment and the patello emoral joint. Van de Velde et al ound that in patients with
PCL-def cient knees there is a shi t o tibio emoral contact location and increased medial
compartment cartilage de ormation beyond 75 degrees o knee exion.157 Logan et al ound
that a ruptured PCL leads to an increase in passive sagittal laxity in the medial compart-
ment, resulting in a persistent posterior subluxation o the medial tibia so that the emoral
condyle rides up the anterior upslope o the medial tibial plateau.94 Interestingly the kine-
matics o the lateral compartment are not altered by PCL rupture.
T e treatment o PCL injuries remains unclear because o the uncertainty about the
natural history and because o the lack o consistent and reproducible surgical results.
Patients sustaining grade I or II PCL injuries should initially undergo nonoperative treat-
ment as most athletes return to unctional activity independent o degree o laxity. In addi-
tion, nonoperative treatment results are o ten similar to those or operative treatment.
Many patients with an isolated PCL tear do not seem to exhibit any unctional per ormance
limitations and can continue to compete athletically, whereas others occasionally are lim-
ited in per orming normal daily activities.53 Parolie and Bergf eld 122 reported a success rate
o greater than 80% with nonoperative treatment and that knee stability was not related to
return to sport or patient satis action.
Nonoperative treatment o PCL should ollow a course o rehabilitation similar to that
o the general progression presented earlier. For grades I and II injuries a more rapid pro-
gression with minimal immobilization can be undertaken. Rehabilitation ollowing a grade
III injury may be more reserved with a slower progression. In the early phase o grades I
and II injuries, hamstring exercises should be avoided and knee extension should be per-
ormed in an arc o 0 to 60 degrees to prevent increased tibio emoral shear orces. Bracing
may be use ul to prevent subtle subluxation in patients who report pain during rehabilita-
tion, but is generally not recommended. For patients with a signif cant sag sign, it may be
necessary to splint the knee in extension in order to promote healing in a shortened posi-
tion. O ten, there is minimal unctional limitation and the patient may progress rapidly
through the rehabilitative process with minimal pain and swelling. Because outcomes ol-
lowing nonoperative treatment o grade III injuries are less predictable, a more conserva-
tive approach is recommended. With these injuries a short course o immobilization with
passive rather than active motion early may be required.
Operative treatment o acute or chronic grade II or III isolated PCL tears remains con-
troversial. Furthermore, there are typically associated ligamentous injuries with increased
posterior laxity. T ere ore, PCL reconstructions are most o ten per ormed secondary to
combined ligamentous instability, making the rate o per orming isolated PCL reconstruc-
tion minimal. T e decision to undergo operative treatment should be based on the unc-
tional participation status o the individual and associated risk actors that may produce
arthritic changes.
Post erior Cruciat e Ligament Rehabilit at ion Progression

able 24-2 outlines the ollowing discussion.
Phase I: Preoperative Phase I includes preoperative rehabilitation and objective

testing. T e goals o this phase include restoring ull ROM and quadriceps strength,
m inim izing swelling and pain, and educating the patient in the basic principles o PCL
Table 24-2 Po sto pe rative Re habilitatio n Afte r PCL Re co nstructio n
Clinical
Phase Days – Weeks Go als Re strictio ns Tre atme nt Mile sto ne s
Phase I: PO Restore ROM WBAT with bilateral RICE Surgical

Preoperative both active axillary crutches Electrical stimulation reconstruction
and passive Brace locked at Extension ROM Full knee extension
Quadriceps 0 degrees Passive exion ROM Restoration of
activation No isolated to 60 degrees strength
Decreased hamstring Glute sets Minimal effusion
effusion exercises Quad sets No increased pain
Pain reduction Hip abduction/
adduction
Phase II: PO Wks 0 to 2 WBAT bilateral Full WBAT brace Patellar mobilization Previous milestones
Immediate axillary locked in full Scar tissue Clean incisions
PO Phase crutches extension × 1 week mobilization Good quadriceps
locked in After week 1 PROM PROM exion and recruitment
extension exion can be extension SLR with minimal lag
Full knee started PROM exion Normalized patellar
extension Brace still locked progressed to mobility
Quadriceps in extension for 60 degrees Weight bearing
control weight bearing × Quadriceps sets progressed
Pain reduction 4 weeks Straight leg raises × 4 without symptoms
Normal patellar No isolated hamstring Ankle pumps Minimal pain and
mobility exercises effusion
(continued )
Table 24-2 Po sto pe rative Re habilitatio n Afte r PCL Re co nstructio n (Continued )
Clinical
Phase III: PO Wks 2 to 6 Normalized Braced unlocked for Progression of Previous milestones
Intermediate quadriceps weight bearing at previous Satisfactory
PO Phase recruitment 4 weeks PROM exion clinical exam
Normal patellar Brace allowed open progressed to ROM 0 to
mobility to 100 degrees 100 degrees 120 degrees
No pain or Crutches Isometric quad sets Improved stability
effusion discontinued at at 0, 60, and with unilateral
Restoration 6 weeks 90 degrees stance
of motion No isolated Squats and leg press No pain
Maintain full hamstring 0 to 60 degrees Normal gait
weight exercises Stationary bike
bearing Step-downs
Improve Calf raises
balance Balance drills
Phase IV: PO Wks 6 to 12 Increase No isolated Previous strengthening Previous milestones

Strengthening strength and hamstring Progress bilateral Full motion: 0 to
Phase endurance exercises loading to single 135 degrees
No pain limb loading Single-leg stance ×
Preparation for exercises 30 sec
activities Lunges 0 to Squat 60 degrees
60 degrees with equal
Advanced balance weight bearing
activities No pain or effusion
Hip extension
progressing to
isolated hamstring
exercises in
12 weeks
Phase V: PO Wks 12+ Restoration of Isolated hamstring Previous strengthening Previous milestones
Return to full motion exercises can begin Unilateral calf raises Full motion
Activity Phase No swelling at 12 weeks Progress CKC Full con dence
No pain exercises in knee
Return of full Advance hamstring Functional
activities exercises testing >90%
Agility drills of uninvolved
Advanced Isokinetic
balance drills testing >90%
Sports speci c drills of uninvolved
CKC, closed kinetic chain; PO, postoperative; PROM, passive range of motion; RICE, rest, ice, compression, elevation; ROM, range of motion;
SLR, single-leg raise; WBAT, weight bearing as tolerated; wks, weeks.
rehabilitation. Unlike patients with ACL injury, m ost patients with an isolated PCL injury
do not have preoperative ROM lim itations, quadriceps atrophy and weakness, or sig-
nif cant e usion. A unctional PCL brace may be worn to assist in preventing posterior
tibio em oral shear orces. Strengthening exercises can progress as in the general progres-
sion with caution against ham string dominated exercises and active knee exion beyond
60 degrees. Preoperative testing consists o bilateral ROM, ligam ent arthrom etry, and iso-
kinetic strength evaluation.
Phase II: Days 1 to 14 T e goals o phase II include controlling swelling and pain
through the use o cryotherapy, improving gait quality, improving quadriceps control, and
gradually returning exion ROM.
T e patient wears a Cryo Cu and compression garment immediately postoperative
through the f rst week. Cryotherapy can be weaned to 6 to 8 times per day a ter the f rst week
o surgery. T e patient will ambulate with crutches and a brace locked into extension, pro-
gressing rom weight bearing as tolerated to ull-weightbearing throughout the f rst 2 weeks.
T e brace should be unlocked several times per day or ROM but should remain locked
in extension or 4 weeks. Extension ROM is maintained by laying the leg at or 10 min-
utes, 3 to 4 times per day. T e patient can work on passive exion rom 0 to 60 degrees, 3 to
4 times per day. Strengthening exercises to acilitate the early return o quadriceps control
include quad sets, straight-leg raises, and knee extensions rom 0 to 60 degrees o knee ex-
ion. T e patient is seen in the clinic 1 week postoperation to evaluate and modi y the reha-
bilitation program as needed.
Phase III: Weeks 2 to 6 T e goals o phase III include attaining symmetrical hyperex-
tension, increasing exion to 90 degrees, improving quadriceps strength, restoring patellar
mobility, and restoring normal gait.
Cryotherapy is continued 4 to 6 tim es per day and a com pression garm ent is worn in
order to m inim ize residual swelling and pain. o avoid stretching the gra t, the patient
gradually begins to increase knee exion passively up to 90 degrees, which can be done
in a sitting position by placing a sm all bolster in the popliteal crease an d gently pull-
ing the distal tibia back. T is technique ensures anterior placem ent o the tibia during
exion. Heel props or prone hangs can begin approxim ately 3 tim es per day in order to
obtain sym m etrical hyperextension. At the 4-week tim e ram e, the brace can be opened
up to 100 degrees or am bulation and ROM exercises. Patellar m obilization is also initi-
ated in order to restore norm al patellar glide and prevent contracture. Restoration o
normal hyperextension and superior patellar glide is essential or proper patello em oral
biom echanics.
T e patient may begin CKC strengthening that includes minisquats, cal raises, step-
ups/ -downs, and leg presses in addition to the strengthening exercises o phase II. T e goals
o strength training in this phase include muscle reeducation and protection o healing tis-
sue. Active knee exion and hamstring strengthening or activation must be avoided in this
phase. Gait quality is assessed and progressed rom ull-weightbearing with a unctional
PCL brace locked at 100 degrees o exion a ter 4 weeks.
Neuromuscular control drills at this time can be started to improve balance and coordi-
nation. Early exercises, such as weight-shi ting to the involved leg progressing to unilateral
stand on a stable sur ace, can be initiated in phase III.
Phase IV: Weeks 6 to 12 Goals o phase IV include gradual return o ull exion and
aggressive strengthening. Cryotherapy is continued as needed. T e exion block on the
PCL brace may be removed at this time. Full symmetrical ROM should be obtained by the
end o weeks 10 to 12. Extension ROM is maintained by per orming heel props, while ull
exion is obtained by using the popliteal bolster and per orming heel slides. T e bolster
may be rem oved once 120 degrees o exion is achieved. T e intensity o the current
OKC and CKC strengthening exercises may be increased, and isolated hamstring strength-
ening can be initiated at the end o this phase i needed. Start hamstring strengthening
by OKC hip extension progressing to isolated ham string maneuvers ( Figure 24-25). Step
machine may be initiated using the PCL brace, and swimming may also begin ollowing
adequate healing o the incision. Exercises include squats, unilateral step-ups, and leg
presses. ROM is m easured during each clinical visit,
and knee ligam ent arthrom etry is conducted at the
sixth postoperative week.
Neuromuscular control drills can progress in this
phase to include unilateral balance activities on an
unstable sur ace such as oam or balance board. Between
weeks 6 and 12 perturbations can be added to the bal-
ance board, as well as sport-specif c activities, such as
catching a ball or swinging a racket, while balancing.
Phase V: Week 12 and On Phase V consists o weeks

12 through the f rst postoperative year. T e goals o
phase V include restoration o normal exibility and a
Figure 24-25 Initiatio n o f hamstring e xe rcise s
by co mbining w ith g lute us maximus during OKC hip
gradual return to sports, emphasizing return o power
e xte nsio n
and endurance. ypically, the patient will experience a
gradual return to ull activity between 6 and 12 months
postoperation.
Once ull ROM is obtained, a comprehensive exibility program is begun on a daily
basis. T e unctional PCL brace may be removed and the a orementioned CKC strengthen-
ing exercises are per ormed with increased intensity, three times per week. Isotonic ham-
string strengthening may be begun i rendered appropriated by the clinician. T e principle
o specif city is very important or preparing the athlete or the high-speed movements,
jumping, and rapid changes in direction required by individual sports. Proprioceptive train-
ing needs to be addressed to improve static and dynamic balance def ciencies. raining or
proprioception should be progressed rom slow to ast speeds, low to high stress, and con-
trolled to uncontrolled activities. Because real-li e sport situations require response to rapid
unknown or anticipated destabilizing loads to the knee, exercises that incorporate protective
responses rapidly are help ul. T is may require that quick, unanticipated, random destabili-
zation loads be imparted to the patient’s knee during rehabilitation drills.
Jogging and running are initiated once the patient has a strength o at least 75% com-
pared to the uninvolved side. T is usually does not occur until approximately 6 months
a ter surgery. Running can begin in a pool, with progression to a treadmill and then to regu-
lar, level sur ace, dry land running.
Functional strength def cits need to be addressed i they are encountered in this phase,
once the patient has achieved 80% o quadriceps strength compared to the uninvolved
side. Agility drills are introduced in the 6- to 9-month postoperative time rame. T ese drills
include change o direction, orward and backward running, lateral slides, shuttle drills,
cutting, spinning, and carioca drills. T e patient must sa ely pass a unctional progression
be ore a return to sports is allowed.
During periodic therapy visits at 6 months and 1 year, a subjective knee question-
naire, ROM, ligament arthrometry, isometric strength evaluation, and once strength is
appropriate single-leg hop tests are per ormed at each o these visits. T ese tests are use ul
to make an in ormed decision regarding the sa e return o the athlete to physical activity.
Meniscal Injury
Pat homechanics
T e medial meniscus has a much higher incidence o injury than the lateral meniscus, which
may be attributed to the coronary ligaments that attach the meniscus peripherally to the tibia
and also to the capsular ligament. T e lateral meniscus does not attach to the capsular liga-
ment and is more mobile during knee movement. Because o the attachment to the medial
structures, the medial meniscus is prone to disruption rom valgus and torsional orces.
A meniscus tear o ten results in immediate joint-line pain with an e usion developing
gradually over 48 to 72 hours. Initially, pain is described as a “giving-way” eeling. T e torn
meniscus may become displaced and wedge itsel between the articulating sur aces o the
tibia and emur, thus imposing a chronic locking or “catching” o the joint. A knee that is
locked at 10 to 30 degrees o exion may indicate a tear o the medial meniscus, whereas a
knee that is locked at 70 degrees or more may indicate a tear o the posterior portion o the
lateral meniscus. A positive McMurray test usually indicates a tear in the posterior horn o
the meniscus.
Chronic meniscal lesions may also display recurrent swelling and obvious muscle atro-
phy around the knee. T e patient may complain o an inability to per orm a ull squat or
to change direction quickly without pain when running, a sense o the knee collapsing, or
a “popping” sensation. Displaced meniscal tears can eventually lead to serious articular
degeneration with major impairment and disability. Such symptoms and signs usually war-
rant surgical intervention.
Mechanism of Injury
Acute meniscus injuries are most o ten caused by coupled compression and rotation. As
a result o these orces, the meniscus becomes pinched within the tibio emoral joint and
tears. Noncontact mechanisms include a plant and cut maneuver or jumping, common in
sporting activities. A contact mechanism is usually the result o a direct blow or orce to
the knee that causes a valgus, varus, or hyperextension orce combined with rotation while
the knee is in a weightbearing position. Additional mechanisms during routine activities o
daily living include squatting and pivoting in and out o a car.
Meniscal lesions can be longitudinal, oblique, or transverse. Stretching o the anterior
and posterior horns o the meniscus can produce a vertical–longitudinal or “bucket-handle”
tear. A longitudinal tear may also occur by orce ully extending the knee rom a exed posi-
tion, while the emur is internally rotated. During extension, the medial meniscus is suddenly
pulled back, causing the tear. In contrast, the lateral meniscus can sustain an oblique tear by
a orce ul knee extension with the emur externally rotated.

T ree surgical treatment choices are possible or the patient with a damaged meniscus:
partial meniscectomy, meniscal repair, or meniscal transplantation. Historically, it was an
accepted surgical treatment or a torn meniscus to involve total removal o the damaged
meniscus. However, total meniscectomy has been shown to cause premature degenerative
arthritis. With the advent o arthroscopic surgery, the need or total meniscectomy has been
virtually eliminated. Surgical management o meniscal tears should include every e ort to
minimize loss o any portion o the meniscus.
T e location o the meniscal tear o ten dictates whether surgical treatment will involve
a partial meniscectomy or a meniscal repair. ears that occur within the avascular inner
one-third o the meniscus will have to be resected because they are unlikely to heal, even
with surgical repair. Because o adequate vascular supply, tears in the middle one-third
o the meniscus, and particularly in the outer one-third, may heal well ollowing surgical
repair. Partial meniscectomy is much more common than meniscal repair.
Meniscus Repair Rehabilit at ion Progression

As a result o so t-tissue healing restraint time rames, rehabilitation ollowing menis-
cus repair techniques are usually di erent than that o meniscectomy. Stresses, such as
loaded unrestricted weight bearing and knee exion, that may be tolerable in a patient with
meniscectomy, may be intolerable in a meniscus repair patient.
Table 24-3 Po sto pe rative Re habilitatio n Afte r Me niscus Re pair
Phase Days – We eks Go als Re strictio ns Tre atme nt Clinical Mile sto ne s
Phase I: PO Wks Quadriceps activation WBAT with RICE Full knee extension
Immediate 0 to 4 Decreased effusion bilateral axillary Electrical stimulation ROM 0 to
PO Phase Wound healing crutches Glute sets 60 degrees knee
Pain reduction Brace locked at Quad sets exion
Begin proximal 0 degrees AAROM exion to Minimal effusion
strengthening ROM 0 to 60 degrees No increased pain
60 degrees Hip abduction/ Single limb stance
exion × 4 wks adduction
Phase II: PO Wks WBAT bilateral axillary Full WBAT brace Exercises as previous Previous milestones
Intermediate 4 to 6 crutches opened to 0 to Patellar mobilization Good quadriceps
PO Phase Quadriceps control 90 degrees Scar tissue recruitment
Pain reduction Discontinue mobilization Normalized patellar
Normal patellar crutches as AROM progressed mobility
mobility tolerated to 90 degrees Full weight
Progress to CKC Heel raises bearing without
exercises Minisquats symptoms
Step-ups Normal gait
Flexibility exercises
Balance and
proprioception
Phase III: PO Wks Increase strength, Knee exion Progression of Previous milestones
Advanced 6 to 10 power and motion not previous Satisfactory clinical
Strengthening endurance greater than Advanced balance exam
Phase Normalized quadriceps 130 degrees training Full ROM
recruitment No pivoting Leg presses Improved stability
Normal patellar Endurance exercises with unilateral
mobility Swimming and stance
No pain or effusion cycling No pain
Preparation for Equal hip strength
advanced activities bilaterally
Phase IV: PO Wks Increase power Avoidance of Previous Previous milestones

Return to 11 to 16+ and endurance loaded full strengthening Full con dence
Activity Phase Return to sports hyper exion Endurance drills in knee
and ADLs Agility drills Functional testing
Return to unrestricted Plyometrics >90% of
activities Initiation of running uninvolved
progression Isokinetic testing
Sports speci c drills >90% of
uninvolved
ADLs, activities of daily living; AAROM, active assistive range of motion; CKC, closed kinetic chain; PO, postoperative; RICE, rest, ice, compression,
elevation; ROM, Range of motion; WBAT, weight bearing as tolerated; Wks, weeks.
Phase I: Weeks 0 to 4 T e goals o phase I include increasing quadriceps activation,

decreasing e usion and pain and to begin proximal strengthening or ull lower-extremity
control. During the initial 4 weeks, weight bearing is allowed as tolerated as long as the
brace is locked in ull extension. Weightbearing orces may be benef cial to the repaired
meniscus as it applies “hoop stress” to the meniscus, which actually pushes the meniscus
peripherally, approximating the injured healing tissue. ROM during this time is limited to
0 to 60 degrees o exion. It is thought that this is the sa e range that does not allow undue
shear stress to the healing tissue. Although exion ROM is limited initially, extension is
allowed to be ull and expected to be equal to the uninvolved side.
Exercises that are tolerated at this time include quadriceps setting, gluteal sets, active
assistive range o motion rom 0 to 60 degrees exion, ankle pumps, and straight-leg raises
in all planes as tolerated. Modalities can be used judiciously or decreasing postoperative
pain and swelling.
Criteria to progress to phase II include obtaining ull knee extension equal to unin-
volved side, ROM 0 to 60 degrees o exion, minimal joint e usion and pain, and ability to
stand on single leg without compensation or pain.
Phase II: Weeks 4 to 6 T e goals o phase II are to gain better quadriceps control, restore
normal patellar mobility, and progress closed kinetic exercises as tolerated. At 4 weeks, the
brace can be opened to 0 to 90 degrees or activities and crutches can be discontinued i
they are still used. Patellar mobility should be assessed and use o mobilizations is allowed
to ensure ull patellar motion is regained. Additionally at this time, incisions or portal sites
should receive scar mobilization as needed to return ull so t-tissue excursion.
In addition to previous exercises, CKC exercises can be initiated, including heel raises,
minisquats, and step-ups. I CKC exercises cannot be per ormed in ull weight bearing with
proper orm, they can be initially done on a total gym or leg press machine to o oad some
o the weight. Balance and proprioception exercises can also be started, including use o
tilt boards. Balance exercises should always be started easy, with bilateral weight shi ts pro-
gressing to harder exercises in a gradual, sa e progression.
Criteria to move to phase III include previous milestones and good quadriceps recruit-
ment, normal patellar mobility, ability to ully bear weight without pain or increased symp-
toms, and a normalized gait pattern without limp or antalgia.
Phase III: Weeks 6 to 10 Phase III goals are to begin working on strength, power and
endurance. I Fq is not normalized by this time, it should be symmetrical to the uninvolved
be ore this phase is over. T is phase is to allow the patient to prepare or advanced activities
o their sport or vocation.
At 6 weeks postoperation, i above criteria are met, the brace is allowed to be opened to
130 degrees. However, complete unrestricted hyper exion and pivoting are not yet allowed.
Advanced balance training drills are allowed. T ese include single-leg perturbation-type
exercises with eyes open ollowed by eyes closed, i tolerated. Loaded leg presses, lunges,
and squats are also allowed now. Swimming and cycling are started as tolerated, with grad-
ual progressions o intensity and distance.
Criteria or phase IV include ull motion and improved stability with unilateral stance.
T ere should be no knee pain or swelling and proximal strength should also be equal bilat-
erally to allow orces that will be applied in the return to activity phase.
Phase IV: Weeks 11 to 16+ Phase IV goals are to continue to work on strength, power,
and endurance, and to return the patient to sports or unrestricted activities o daily living.
T e limitation o no pivoting is li ted at this time, but ull loaded hyper exion is limited until
6 months.
Exercises include advancement o endurance drills and initiation o sport-specif c or
work-specif c drills. Agility drills are advanced per patient needs. Plyometric activities can
commence, as can a gradual running progression.
Be ore returning to sports or work, the patient should have ull sel -conf dence in knee,
have strength tests demonstrating 90% o uninvolved, and unctional tests demonstrating
90% o uninvolved or age-matched normal.
Rehabilitation ollowing m eniscal repair com mands restricted joint motion through
6 weeks to allow or so t-tissue healing. An upper body ergometer can be used to main-
tain cardiorespiratory endurance during this period. During this period, weight bearing is
either limited, or allowed as tolerated with the knee locked in ull extension, as per physi-
cian recommendations. Early strengthening can include quad sets and OKC hip exercises.
Early, restricted, weightbearing exercise can be accomplished in an aquatic environment,
when incisional healing allows. Chapter 16 has more details on aquatic rehabilitation.
ROM exercises should ocus on attaining exion and extension within the restrictions. Par-
tial weight bearing on crutches should progress to ull weight bearing a ter 6 weeks. Once
the brace can be removed, rehabilitation progresses similar to the general progression to
regain ull ROM and normal muscle strength. Generally, the patient can return to ull activ-
ity around 3 months.
Not all meniscus tears require surgery. Some m eniscus tears may heal or become
asymptomatic without surgical intervention. When a tear remains symptomatic, sur-
gery is recommended. Rehabilitation varies depending on the course o treatm ent and
type o meniscal injury. Nonoperative rehabilitation aims to reduce swelling, restore ull
ROM, and normalize gait be ore returning to normal activities. T e specif c rehabilitation
exercises or nonoperative rehabilitation are similar to those prescribed here or partial
meniscectomy.
Part ial Meniscect omy Rehabilit at ion Progression

Table 24-4 outlines the ollowing discussion.
Phase I: Days 1 to 7 Clinical goals o phase I are to control swelling and in ammation,
increase ROM, normalize gait, and improve quadriceps control. T e clinician will test bilat-
eral ROM during this phase.
A Cryo Cu or other orm o cryotherapy is applied 6 to 8 times per day to control pain
and swelling. Cold application is particularly important ollowing exercise. Use o a compres-
sion garment during the f rst postoperative week will help control swelling. However, with
a partial meniscectomy a postoperative splint or motion control brace is not needed. T e
patient should keep the leg elevated as much as possible the f rst ew days ollowing surgery.
Regaining ull extension is a critical actor in this phase. T e patient is encouraged to
push extension and regain ull exion through towel extensions, prone hangs, and heel
slides. Extension can be assisted through a standing knee lockout with weight shi ted to the
operated leg.
T e patient should begin partial to ull weight bearing with bilateral axillary crutches.
Use o crutches can be discontinued once gait is normalized. In most instances, the patient
will be ull weight bearing by 2 weeks. T e patient may be non-weightbearing or a period o
time i an osteochondral lesion is present on a weightbearing sur ace.
Quadriceps strengthening exercises are initiated to acilitate early return to normal
strength. Strengthening should include straight-leg raises, knee extensions, and cal raises.
Phase II: Weeks 1 to 3 Phase II goals include attaining ull ROM, normal gait, no swell-
ing, and an early return to agility and sport-specif c activities as tolerated. T e clinician
again measures ROM.
Cryotherapy should be continued 3 to 4 times per day and always a ter exercise. I the
patient does not have ull extension or exion, ROM exercises are continued. Exercises
should include unilateral one-quarter squats, unilateral step-downs, unilateral cal raises,
and lunges. T ese exercises should not be per ormed i pain or crepitus exists.
Bicycle and stair machine workouts can begin in this phase. Initial workouts should
be 10 to 15 minutes in length and progress to 30 minutes with moderate to high resistance.
oward the end o this phase, the patient can per orm short sprints in 5-minute intervals.
Table 24-4 Po sto pe rative Re habilitatio n Afte r Partial Me nisce cto my
Phase Days – We eks Go als Re strictio ns Tre atme nt Clinical Mile sto ne s
Phase I: PO Week 1 Independent WBAT with RICE Full extension

Immediate ambulation bilateral Glute sets No limp
PO Phase Quadriceps axillary Quad sets No increased effusion
activation crutches as AAROM exion to No increased pain
Decreased needed 60 degrees
effusion
Wound healing
Pain reduction
Phase II: PO Weeks Quadriceps Full WBAT Exercises as previous Previous milestones
Intermediate 1 to 3 control Discontinue Patellar mobilization Full ROM
PO Phase Pain reduction crutches as Scar tissue mobilization Good quadriceps
Normal patellar tolerated Minisquats recruitment
mobility Step-ups Normalized patellar
Increased ROM Flexibility exercises mobility
Begin proximal Balance and Full passive knee
strengthening proprioception extension
Full weight bearing
without symptoms
Phase III: PO Weeks Normalized None at this time Progression of previous Previous milestones
Advanced 3 to 6 quadriceps Advanced balance Satisfactory clinical
Strengthening recruitment training exam
Phase Normal patellar Leg presses Improved stability with
mobility Endurance exercises unilateral stance
Full active ROM No pain
No pain Equal hip strength
No effusion bilaterally
Phase IV: PO Weeks Return to sports None at this time Previous strengthening Previous milestones
Return to 6 to 8+ and ADLs Endurance drills Functional testing
Activity Phase Agility drills >90% of uninvolved
Plyometrics Isokinetic testing
Initiation of running >90% of uninvolved
progression
Sport-speci c drills
ADLs, activities of daily living; AAROM, active assistive range of motion; PO, postoperative; RICE, rest, ice, compression, elevation; ROM, range of
motion; WBAT, weight bearing as tolerated.
Freestyle and utter kick swimming can be per ormed as well, but breaststroke is not
encouraged. A jogging-to-sprinting progression can be per ormed in chest-deep water.
Proprioceptive and balance exercises to help improve neuromuscular control can
begin in phase II and usually is advanced rapidly. Balance exercises can begin bilateral on
a balance board progressing to unilateral as the patient is able to tolerate ollowing the gen-
eral principles o simple be ore complex exercises.
Once ull ROM is regained and the patient has su cient leg control, weight-room
activities can be initiated. Exercises include unilateral leg presses, unilateral knee exten-
sions, cal raises, and hamstring curls. Once tolerable, agility and sport-specif c activities
can commence toward the end o this phase.
Phase III: Weeks 3 to 6+ T e ocus o phase III is on a unctional return to prior activity
level. T e patient is to maintain ull ROM and no swelling. I weakness is noted, strength-
ening should continue to address the specif c def cit. T e clinician tests bilateral ROM and
isokinetic strength i a specif c athletic goal is desired. Implementation o a sport-specif c
unctional progression is appropriate at this time.
Art icular Cart ilage

Articular cartilage covers the en ds o bon es o synovial joints. Water is the prim ary
com pon ent (65% to 80%) o articular cartilage an d provides or load de orm ation
properties and gives cartilage its ability to absorb stress and com pressive orces.76 T e
rem inder o articular cartilage com ponents includes proteoglycans and noncollagenous
proteins (10% to 15%) and collagen (10% to 15%). Articular cartilage provides a wear-
resistant, accom m odative sur ace that can withstand high com pressive and shear loads
during physical activities and m ovem ent. Because o synovial uid and the properties o
articular cartilage, a low coe cient o riction allows ease o m ovem ent between joint
sur aces.
Pat homechanics
Hunter, in 1743, described articular cartilage as “a troublesom e thing and once destroyed,
it is n ot repaired.”70 Because o the prevalence o articular cartilage in the hum an body,
injuries incurred to articular cartilage resulted in an estim ated 385,000 procedures to
repair articular cartilage de ect in the United States in the year 1995 with num bers con-
tinuing to increase. A retrospective review assessing m ore than 25,000 knee arthrosco-
pies ound that 63% involved articular chondral lesions, with the m ost com m on location
being the patellar articular sur ace (36%), with the m edial em oral condyle a very close
second (34%).166
Mechanism of Injury
Articular cartilage can be injured in multiple ways. Injury can be incurred during trauma or
sports activities through direct blunt trauma to the knee such as landing on the ground or
other hard sur ace or rom a contusion between knee and helmet during a tackle in ootball.
An indirect injury to the bone and overlying articular cartilage can occur during a twist-
ing or torsional maneuver, such as occurs when making a plant-and-cut pattern to ake an
opponent in soccer or basketball, that ultimately injures the ACL. Lastly, prolonged immo-
bilization o a joint creates a loss o joint movement and synovial uid production, and the
uid becomes stagnant and the nutrients in the synovial uid depleted. Without this move-
ment and constant ow o resh synovial uid necrosis o the articular cartilage occurs.98-100
T e signif cance o articular cartilage atrophy and degeneration is related to the magnitude
and duration o joint immobilization. Joint contact sur aces su er greater degenerative
changes than noncontact areas o articular cartilage.98-100

A primary problem with articular cartilage injuries to the knee is that the injuries most
commonly occur in the area o the patella or emoral condyle that makes contact between
30 and 70 degrees o knee exion.134 T is commonly a ected ROM is used or almost all
activities o daily living, including normal gait, ascending and descending stairs, and sitting
and rising rom chairs.
An injury to vascularized tissue incites a cascade o events characterized by hemor-
rhage, in ammation, and f brin clot ormation. T is reaction is almost nonexistent as artic-
ular cartilage is a nonhomogeneous and avascular tissue that lacks the ability to stimulate,
regulate, or organize intrinsic repair.3 Furthermore, mechanisms that hamper cartilage

repair include both cell apoptosis and the presence o catabolic enzymes. T ese mecha-
nisms impede the ability o di erentiated chondrocytes to multiply su ciently in tissue
or to reach the site o injury by migration in extracellular matrix.97,146 Without a vascular
response, articular cartilage cannot orm a f brin sca old or mobilize cells to repair the
de ect. Chondrocytes are trapped within the dense extracellular matrix and are incapable
o mobilizing the damage site via vascular access channels.100
Surgical Procedures
In general, there are 2 broad orms o surgical treatm ent or articular cartilage injury. T e
f rst are marrow-stimulating techniques involving utilizing one’s own body’s pluripotent
marrow stem cells to create reparative tissue consisting o f brocartilage, which consists
o primarily type 1 collagen.113 T ese techniques include procedures such as m icro rac-
ture, abrasion chondroplasty, and subchondral drilling to allow marrow stem cells to
repopulate the area devoid o articular cartilage. T ese procedures are still com m only
used because they can be done arthroscopically, cost very little, and are thought to relieve
sym ptom s. T e drawback seems to be that the cartilage that returns is usually f brocarti-
lage, the repair tissue that does not have the robust wear characteristics o the original
hyaline type tissue.
T e second group o procedures aims to restore the injured area with normal or near-
normal articular cartilage. T ese procedures are called cartilage replacem ent techniques
and include those such as osteochondral autogra ts and autologous chondrocyte implan-
tation procedures. T e main goals o these techniques are to restore normal articular
cartilage contour o the joint and provide a superior wear sur ace more like the original
articular cartilage that is being replaced. T ese procedures are, however, more demand-
ing and incur not only increased cost, but longer rehabilitation and potentially m ore
complications.
Rehabilitation ollowing articular cartilage procedures is still in its in ancy. Little is
known regarding optimal treatment. Although like other knee postoperative rehabilitation
early motion and progression to closed chain activity is needed, the optimal time rame or
progression is not yet standardized due to varied procedures and surgeon own rehabilita-
tion philosophy. Until specif c guidelines are determined to be optimal, it is crucial that the
surgeon and therapist have excellent communication regarding extent o damage, dura-
bility o the surgical procedure, size o de ect, location o lesion, and specif c restrictions
placed upon the patient.106
Art icular Cart ilage Rehabilit at ion Progression

Table 24-5 outlines the ollowing discussion.
Phase I: Weeks 1 to 6 T e f rst phase o rehabilitation ollowing articular cartilage pro-

cedures is the Proliferation Phase in which healing constraints are placed upon the patient
to protect the repair.16,17,169 Although advances allow some early weight bearing in isolated
cases, usually there is some orm o controlled partial weight bearing initially. T ere ore, it
is important to gradually increase passive motion, increase weight bearing, and decrease
swelling and enhance motor control o the quadriceps muscles.
Because o the movement o synovial uid in the knee joint, passive ROM is per ormed
to create di usion o the synovial uid and provide stimulation or reparative cells to be
produced.19,20,161 Passive ROM exercises can be done via CPM device or with a physical ther-
apist. T is passive movement o the knee is started immediately a ter surgery to help nour-
ish healing articular cartilage and prevent intraarticular scar adhesions rom orming. Some
have recommended the use o CPM or 8 hours per day or up to 6 to 8 weeks.132 I a CPM
device is not available, the judicious use o active assisted or passive ROM is recommended
or the reasons listed above. In addition to knee joint, passive ROM emphases should be
Table 24-5 Po sto pe rative Re habilitatio n afte r Micro fracture and ACI
Phase We e ks Go als Re strictio ns Tre atme nt Clinical Mile sto ne s
Phase I: PO 0 to 6 Independent NWB or TTWB RICE Full extension

Early PO ambulation with bilateral Glute sets Independent use of
Phase Quadriceps axillary Quad sets in ROM that does ambulatory device
activation crutches not engage lesion No increased effusion
Decreased effusion PROM and AAROM in range No increased pain
Wound healing restriction that does not
Pain reduction engage lesion site per
surgeon orders
Full extension × 1 week
Full exion × 6 weeks
OKC exercises light resistance
in ROM that does not
engage lesion × 4 weeks
Patellar mobilization
Scar tissue mobilization
No CKC exercises
Phase II: PO 6 to 12 Quadriceps control DC crutches Exercises as previous Previous milestones

Intermediate Pain reduction gradually as Begin CKC exercises Full ROM extension
PO Phase Normal patellar tolerated at Restrict range that does not and exion
mobility 8 weeks engage lesion Good quadriceps
Increased ROM May use Minisquats recruitment
Begin CKC pool or Step-ups Normalized patellar
exercises unweighting Flexibility exercises mobility
Begin proximal devices to Balance and proprioception Full passive knee
strengthening transition to extension
Increased balance full weight Full weight bearing
bearing without symptoms
Phase III: PO 12+ Normalized Continue to Progression of previous Previous milestones

Return to quadriceps increase Advanced balance training Satisfactory clinical
Activity recruitment tolerance to Leg presses exam
Phase Normal patellar OKC, CKC Endurance exercises Improved stability with
mobility exercises as Agility and sports speci c unilateral stance
Full active ROM tolerated exercises should begin at No pain
No pain limiting 50% effort progressing to Equal hip strength
No effusion to ranges full as tolerated bilaterally
that do not Running delayed until Quadriceps and
engage 6 months hamstring strength
lesion to within 90%
or cause bilaterally
symptoms
ADLs, activities of daily living; AAROM, active assistive range of motion; CKC, closed kinetic chain; NWB, non-weightbearing; OKC, open kinetic chain;
PO, postoperative; PROM, passive range of motion; RICE, rest, ice, compression, elevation; ROM, range of motion; TTWB, touch-toe weightbearing.
placed on per ormance o patellar mobilization and passive movement, as a loss o motion
across the extensor mechanism could be deleterious to normal knee unction.
Because weight bearing is limited initially in the proli erative phase, early strength-
ening exercises are directed toward quadriceps volitional neuromuscular motor control
rather than strict muscle strengthening. Because o weightbearing limitations, exercises
are limited to those o an open-chain nature, including quadriceps setting and straight-leg
raises in all planes. Any quadriceps exercise can be supplemented with electrical stimula-
tion i there is a lack o neuromuscular control during active contraction. In some limited
instances, depending on the location o the lesion, partial weight bearing may be allowed
with the use o a rehabilitation brace locked in ull extension.43 T e surgeon should include
on the physical therapy re erral orm the type o surgical procedure, the location o the
lesion, and any restrictions in ROM and weight bearing. A diagram o the lesion site is also
help ul, as it enables the therapist to adhere to the ROM limitations and ensure that the
lesion is not engaged during exercise.43
Phase II: Weeks 6 to 12 Weeks 6 to 12 are known as the ransition Phase.16,17,169 Usu-
ally by 6 weeks the lesion has begun to f ll in with im mature cartilage tissue and is able
to tolerate an increased progression o weight bearing and therapeutic exercises. It is at
this tim e that the patient progresses rom partial weight bearing to ull weight bearing.
Progression o weight bearing has been called into question lately as it is elt by som e
that although an “excessive” approach to weight bearing m ay risk gra t delam ination,
whereas a too “conservative” approach may not provide adequate biom echanical gra t
stimulus.35,36 T e physical therapist should watch or signs o regression i the therapist
sees an increase in patient pain or knee joint e usion with weightbearin g increases.
I this occurs, it may be an indication that the articular lesion is being harm ed and both
ROM an d progression o weight bearin g m ay n eed to be decreased until sym ptom s
have subsided. It is usually during the 6- to 12-week tim e ram e that patients believe they
can begin to return to norm al activities o daily living without the substantial restric-
tion s that were im posed by weightbearing lim itation s an d m otion restriction in the
previous phase.
wo ways in which exercise progression can be graded during this phase o increased
weight bearing and stress are to begin using cardinal planes o movement be ore multiple
planes and using bilateral exercise prior to unilateral loading exercises. Weightbearing exer-
cises, such as squats, lunges, and weight shi ting, should begin in cardinal planes, moving
either in anterior-posterior or medial-lateral directions be ore using multiple plane-type
movements, such as diagonals and rotation movements. Additionally, these exercises
should always be done with 2 legs prior to progressing to a single leg. Utilization o this
simple-to-complex progression o exercises ensures a gradual progression o applied loads
and stress so as not to overload or damage healing cartilage tissue.
Phase III: Months 3 to 6 Postoperative months 3 to 6 are called the Rem odeling
Phase.16,17,169 It is thought that during this phase there is an ongoing remodeling o the
cartilage tissue that allows it to gain strength and durability. In this phase, activities can
be increased to allow light unctional activities. Patients without symptoms in this phase
should continue all previous exercises rom the prior stage but can begin more unctional
loading activities also. Low-to-moderate impact activities, including recreational walking
on level ground, bicycle riding, and golf ng, may begin as tolerated. High-impact activi-
ties are still not advisable at this point; however, with select patients and surgeon approval,
adapted high-impact activities, such as jogging in a pool or use o an Alter G Antigravity
readmill (Fremont, CA), may be permitted.
Phase IV: Months 6 to 18 T e f nal phase, called the Maturation Phase, runs rom
6 months to approximately 18 months postsurgery.16,17,169 Full maturation o the articular
cartilage de ect depends on multiple actors, including health o patient, age o patient, size
o de ect, location o de ect, and surgical procedure per ormed. Just like previous phases,
impact loading should be done slowly and gradually, in a progressively gradient manner.
T ese activities should be always patient specif c based on their presentation and varied
needs or requirements.
General Rehabilitation Progression for Patellofemoral Pathology 769
General Rehabilitation Progression

for Patellofemoral Pathology
A patient with patello emoral pain should initially be treated with a tailored conser-
vative rehabilitation program. An e ective rehabilitation program takes into consideration
the anatomy o the joints, the stage o healing, and the patient’s response to treatment.
Chapter 31 presents additional discussion o patello emoral considerations in athletic
Table 24-6 Ge ne ral Re habilitatio n fo r Pate llo fe mo ral Patho lo g y
Phase We e ks Go als Pre cautio ns Tre atme nt Clinical Mile sto ne s
Phase I: 1 Independent ambulation Avoid kneeling, Relative rest Full ROM

Acute Phase Decreased effusion deep squatting, Cryotherapy, Normalized gait
Pain and in ammation prolonged antiin ammatory Minimal effusion
reduction positioning, and modalities Minimal pain
other aggravating LE stretching
activities Grade I and II
mobilizations
Phase II: 2 to 6 Pain reduction Avoid kneeling, Continued cryotherapy >80% LE strength,
Intermediate Normal patellar mobility deep squatting, and modalities as balance, and
Phase Normal LE exibility exed-posture indicated proprioception
LE strengthening, cycling, Patellar glides and tilts Normalized patellar
including thigh, hip, running LE stretching mobility and LE
and calf musculature (especially IT band, quadriceps, exibility
Maintenance of hills), and other hamstrings, calf
cardiovascular aggravating LE and core progressive
conditioning activities strengthening
Quadriceps, hip
abduction, hip ER,
and hip extension
strengthening
OKC exercises 60 to
90 degrees
CKC exercises 0 to
45 degrees
Orthotic needs evaluation
Proprioceptive and
cardiovascular training
Phase III: 6+ Return to pain-free ADL Avoid hill running Advanced strength and No pain during ADL
Advanced Full LE strength, and aggravating balance training Equal LE strength,
Phase balance, and activities Continued exibility balance, and
proprioception exercises proprioception
Tolerance for return- Endurance exercises bilaterally
to-sport progression Bracing or taping as Return to sport
initiation indicated
ADL, activities of daily living; CKC, closed kinetic chain; ER, external rotation; IT, iliotibial; LE, lower extremity; OKC, open kinetic chain; ROM, range
of motion.
emales. A general 3-phase rehabilitation program or patello emoral injury is presented,

with specif c techniques or def ned patello emoral conditions to ollow. T e time rames
o each phase varies, depending on pathology severity and patient activities, such as voca-
tional necessities.
Phase I: Days 0 t o 7
Phase I goals are to control pain and in ammation o the involved so t-tissue structures,
restore normal ROM and gait, and educate the patient about the rehabilitation progres-
sion and sa ety considerations. Controlling pain and in ammation allows the patient to
progress com ortably through the rehabilitation process. Full knee ROM and normal gait
mechanics are essential to return to typical daily activities and initiate unctional reha-
bilitation exercises.
Cryotherapy in the orm o ice bags or ice massage, 3 to 4 times per day, is e ective
in reducing pain and controlling in ammation. Other physical modalities including ultra-
sound, iontophoresis, and electrical stimulation may also help control patello emoral
symptoms. Physician-prescribed nonsteroidal antiin ammatory medication can be use-
ul as well. Active and active-assistive ROM exercise, a partial to ull weightbearing pro-
gression, and the use o assistive devices as needed will aid restoration o knee ROM and
normal ambulation. T e patient should be educated to modi y or avoid activities that exac-
erbate patello emoral pain (such as kneeling, deep squatting, or prolonged positioning),
and encouraged to manage symptoms with modalities or rest as they occur.
Phase II: Weeks 2 t o 6

T e emphasis o phase II is exibility, advanced strengthening, proprioception, and car-
diovascular conditioning. Exercise intensity and stress on the patello emoral joint should
be kept low in an e ort to progress through rehabilitation without increasing symptoms.
T e clinician should conduct a dynamic biomechanical evaluation once ROM and gait are
normal to determine the underlying cause o dys unction. By the end o phase II, the patient
should have improved exibility o tightened structures, improved lower-extremity strength
and proprioception, and maintained level o cardiovascular conditioning. In addition, the
patient’s biomechanical abnormalities should be addressed.
Flexibilit y
Flexibility exercises addressing def cits in the quadriceps, hamstrings, I B, and
gastrocnemius–soleus complex must be initiated. Evidence demonstrates abnormal joint
stress i these tissues lack exibility.110,164 T e requency and duration o such stretching is
controversial. Studies o individuals with limited hamstring exibility (a 30-degree loss
o knee extension at 90 degrees o hip exion) have examined the di erences o 30- and
60-second duration stretches.10,11 T e studies were in agreement that no increase in exibility
occurred when the duration o stretching was increased rom 30 to 60 seconds; however, the
average age o these subjects was 26 years. Research on stretching duration in elderly people
has revealed that optimal stretching protocols may be age dependent. A study by Feland et
al indicated that 60-second stretches were more e ective than 15- or 30-second stretches or
groups o elderly subjects with tight hamstrings during a 6-week stretching routine.40 None-
theless, lower-extremity tissue exibility must be optimized to reduce abnormal loading o
the patello emoral joint.
In addition to muscular exibility, patellar mobility should be incorporated to address
imbalances in the passive so t tissue stabilizers. T e patient can be instructed in sel -
m obilization techniques to correct an abnormal patellar glide or tilt ( Figure 24-26).
A B
Figure 24-26 Mo bilizatio n fo r the pate lla
A. To mobilize the patella for a restricted medial glide, instruct the patient to long sit with knees straight and quadriceps
relaxed. B. To mobilize the patella for a restricted lateral tilt (tight deep medial retinacular bers), push laterally and
anteriorly on the undersurface of the medial edge of the patella with the thumbs and push posteriorly on the lateral
edge of the patella with the ngertips, titling laterally.
OKC and CKC St rengt hening

Strengthening exercises or patients with patello emoral dys unction have shi ted rom
non-weightbearing OKC exercises to more unctional CKC exercises. T is change is a result
o reports that CKC exercise causes less patello emoral joint stress and may, there ore, be
more tolerable or patients with patello emoral dys unction.
A study by Steinkamp et al126 demonstrated that patello emoral joint stresses or leg
press and leg extension exercises intersect at 48 degrees o knee exion. Patello emoral
stress at 0 and 30 degrees o knee exion was signif cantly less during the CKC leg press
exercise than OKC leg extension exercise. Conversely, at 60 and 90 degrees o knee exion,
patello emoral stress was signif cantly greater during the leg press exercise than during the
leg extension exercise.
Similarly, Escamilla et al38 showed that patello emoral stress during the leg press exer-
cise progressively increases as the knee exion angle increases. During OKC knee exten-
sion, the results revealed progressively increasing patello emoral stress until approximately
60 degrees o knee exion, at which point patello emoral stress was inversely related to knee
exion angles as the knee continued to ex. Escamilla et al recommended CKC exercise in
between 0 and 50 degrees o knee exion, and OKC exercise at lower (0 to 30 degrees) or
higher (75 to 90 degrees) knee exion angles.
In 2000, Witvrouw et al172 per ormed the f rst prospective, randomized study compar-
ing the e cacy o OKC versus CKC exercises in the management o patello emoral pain.
T e group using a CKC protocol had signif cant improvements in pain and unction com-
pared to the OKC group. However, both protocols showed increased quadriceps strength
and unction, and decreased pain. As a result, Witvrouw et al suggest using both OKC and
CKC strengthening in the treatment o patello emoral pain.
An evidence-based approach to OKC and CKC exercises or the patient with patello-
emoral pain will include both interventions. OKC exercises, such as leg extensions, appear
produce less stress between 60 and 90 degrees o knee exion, and CKC exercises appear
to produce less joint stress between 0 and 45 degrees o knee exion (Figure 24-27). T e
sa est ROM will undoubtedly be di erent or each patient. T e patient and clinician should
be conscious o pain, crepitus, and the location o patel-

lar articular sur ace lesions during exercise. An optimal
progression includes increases in repetitions, external
loads, and ROM per patient’s tolerance. Activities may also
be advanced by transitioning rom bilateral to unilateral
stance, with or without perturbation or labile sur aces.
Role of t he Vast us Medialis Obliquus

Clinicians have long attempted to isolate the vastus media-
lis obliquus (VMO) in an e ort to counteract the pull o the
vastus lateralis and subsequently improve dynamic patellar
tracking. Mirzabeigi et al111 studied the electromyographic
(EMG) activity o the separate quadriceps muscles during
Figure 24-27 CKC e xe rcise s, such as the le g 9 sets o exercises thought to target VMO recruitment. T e
pre ss, pro duce le ss pate llo fe mo ral jo int stre ss results showed that EMG activity o the VMO was not sig-
be tw e e n 0 and 45 de g re e s o f kne e e xio n than nif cantly greater than the other muscles tested, suggesting
g re ate r de g re e s o f e xio n that the VMO cannot be signif cantly isolated during these
exercises. Some studies have, however, shown that high
levels o VMO EMG activity relative to vastus lateralis can be produced during leg press,
lateral step-up, terminal knee extension, quad set, and hip adduction exercises.28,75,145,168
A review o the evidence shows that altering lower-limb joint orientation or adding a
cocontraction does not pre erentially enhance VMO activity over the vastus lateralis, but
more well-designed studies are required.147 Regardless, recruitment and strengthening o
the VMO occurs in conjunction with general strengthening o the entire quadriceps, and
is essential or rehabilitation o the patient with patello emoral pathology.111 T e benef t o
quadriceps strengthening has been emphasized in several studies o patients with patello-
emoral pain.15,78,127 Cowen et al27 reported delayed onset o VMO EMG activity during stair
climbing in patients with patello emoral pain compared to controls. Chiu et al25 reported that
lower-limb strength training 3 times per week or 8 weeks, including knee extension exer-
cises, signif cantly increased patello emoral joint contact area in patients with patello emoral
pain syndrome, e ectively reducing mechanical stress to the joint. Additionally, Natri et al115
per ormed a 7-year prospective ollow-up study o patients with chronic patello emoral pain
that ound extension strength to be a signif cant predictor o success ul outcomes.
Dist al Fact ors

T e role o oot mechanics in patello emoral joint dys unction has been theorized or quite
some time. Buchbinder et al18 proposed that prolonged pronation would internally rotate
the lower extremity, producing a medially displaced patella. iberio 155 similarly contended
that excessive subtalar joint pronation produces excessive internal rotation o the emur,
causing increased lateral patello emoral joint contact orces.
As a result, clinicians have attempted to limit the amount o tibial internal rotation and
coupled emoral internal rotation in an e ort to decrease the Q angle and resultant lateral
patello emoral joint contact orces. Klingman et al82 reported that a medial wedge orthosis
was capable o producing a mean medial displacement o the patella relative to the emo-
ral trochlear groove o 1.08 mm. Sutlive et al152 ound that the best predictors o improve-
ment in patients with patello emoral pain using an o -the-shel oot orthosis and modif ed
activity were ore oot valgus alignment o 2 degrees or more, passive great toe extension o
78 degrees or less, or navicular drop o 3 mm or less. A more recent study suggests that age
older than 25 years, height less than 65 inches, and maximum pain level on a visual analog
scale o less than 53.25 mm are also strongly predictive o benef t rom oot orthoses.159
A complete lower-extremity biomechanical examination in weightbearing and non-
weightbearing positions is important. Literature supports an association between excessive
pronation, lower-extremity internal rotation, and altered
patello emoral mechanics. Patients demonstrating exces-
sive oot pronation or excessive lower-extremity internal
rotation may benef t rom a oot orthosis as part o a com-
prehensive rehabilitation program. Chapter 26 discusses
examination and prescription o oot orthotics.
Proximal Fact ors

Patients with patello emoral pain who demonstrate a lack
o adduction and internal rotation control during weight-
bearing activities are candidates or hip strengthening
(Figure 24-28). Internal rotation o the emur causes the
trochlear groove to rotate underneath the patella, gen-
erating increased lateral patello emoral joint stress as a
result o the relative lateral position o the patella.87
Several studies demonstrate that patients with patel- Figure 24-28 Fe mo ral adductio n and inte rnal
lo emoral pain have hip strength def cits including abduc- ro tatio n co llapse during w e ig htbe aring activitie s
tion, external rotation, and extension.108 Ireland et al74
reported that subjects with patello emoral pain were 26% weaker in hip abduction and 36%
weaker in hip external rotation compared to a control group. Moreover, several studies have
shown signif cant decreases in pain and increases in unction ollowing hip abductor and
external rotator strengthening in patients with patello emoral pain.49,81,114
Assessm ent o the hip and pelvis must be a priority in patients with suspected prox-
imal weakness or lack o dynam ic pelvic control, but the exibility o proximal tissues
m ust also be exam ined. Iliotibial band tightness is especially correlated with patel-
lo em oral pathology; there ore, stretches to optim ize the tissue’s exibility should be
im plem ented.65,67,171
Propriocept ion and Cardiovascular Condit ioning

T e pain and abnormal tissue stresses present in patello emoral dys unction may lead
to proprioception def cits. Baker et al8 ound that joint position sense was signif cantly
decreased in knees with patello emoral pain compared to the control group, decreased
between the symptomatic and asymptomatic knees in the test group, and decreased
between the asymptomatic knees in the test group compared to the control group. Whether
or not proprioception def cits precede or result rom patello emoral pain, proprioception
must be addressed during rehabilitation.
Maintaining cardiovascular conditioning is another im portant objective when treat-
ing a patient with patello em oral pain. T e clinician should strive to provide the patient
with alternative training m ethods that allow pain- ree knee ROM and m inim ize patel-
lo em oral stress or return to prior activity level. Depending on the cause o patello em o-
ral pain and involved tissues, options or cardiovascular conditioning include jogging,
swim m ing, bicycling on raised seats, and upper body ergom etry or other orm s o endur-
ance exercise equipm ent. A recent study by Roos et al dem onstrates that backward run-
ning produces 25% less patello em oral joint com pression orces com pared to orward
run ning; there ore, it m ay be pre erred as a unique way to m aintain cardiovascular
conditioning.133
Phase III: Week 7 and On

T e goal o phase III is to return the patient to the prior level o activity. A maintenance
program o cryotherapy, lower-extremity exibility, and lower-extremity strengthening
should be continued 3 times per week to maintain the gains o phase II. Prior to ull return
A B
Figure 24-29 Exte rnal suppo rts
A. Patellar sleeve with lateral J buttress and straps for patellar subluxation or lateral
patellar alignment. B. Infrapatellar band for patellar tendinitis and traction apophysitis.
to activity, an activity-specif c unctional progression should be per ormed with the use o
external support as needed. T e importance o abdominal stability is also applicable during
this phase, especially or athletes and active individuals. Suboptimal core muscle unction
has been correlated with knee pathomechanics in multiple studies.1,175
Bracing and Taping

Many external supports (Figure 24-29) have been designed to augment the return to pain-
ree activity through helping to maintain patellar alignment or decrease so t-tissue stresses.
Patellar braces are typically made o an elastic wrap or neoprene sleeve with various cutouts
and pads to help control patellar positioning and tracking. An in rapatellar strap placed
around the patellar tendon has been advocated or patellar tendinitis or traction apophy-
sitis, and an I B strap placed around the distal I B or I B riction syndrome. T ese straps
apply compression near the site o irritation and act as a “counter orce” to decrease stress
at the tendinous insertion. Although research on patellar straps is scant, similar braces have
been shown to increase pain threshold and a ect proprioception in patients with lateral
epicondylitis.116
Although wearing a brace appears to be e ective in reducing pain, radiographic stud-
ies show that decreases in pain are not the result o improvement in patellar alignment.128
Powers et al125 ound a signif cant reduction in pain immediately upon application o
patellar bracing and a signif cant increase in total patello emoral joint contact area, as
well as small but signif cant changes in lateral patellar displacement. T eir results sug-
gest that increases in patello emoral joint contact area may decrease patello emoral pain
by decreasing joint stress. Powers et al130 again supported
this theory with a study that showed bracing signif cantly
decreased patello emoral stress during ree and ast walking
when compared to the nonbraced condition.
Bracing appears to provide some patients with a decrease
in pain, improved patello emoral joint contact, and the allow-
ance o an adequate quadriceps strengthening and exercise
progression.129 T e pain reduction secondary to wearing a
brace may be the edge a patient needs to continue with reha-
bilitation exercises and return to sport activity. However,
a brace should not be a substitution or a comprehensive
rehabilitation program. A recent review reports moderate
evidence or no additive e ectiveness o knee braces to exer-
cise therapy on pain and con icting evidence on unction.153 A
A popular adjunct to treating patello emoral pain is taping
(Figure 24-30). In 1986, McConnell107 published the taping
methods or the treatment o patellar chondromalacia. T e
theory behind the McConnell taping technique is a passive
correction o the abnormal glide, tilt, and rotational compo-
nents o patellar maltracking to allow pain- ree rehabilitation
and acilitate VMO recruitment.
Much like bracin g, num erous studies support that
taping provides pain relie . However, alteration in patel-
lar align m ent or acilitation o the VMO has also been dis-
puted. P ei er et al126 showed that McConnell m edial glide
tapin g resulted in signif cant m edial glide o the patel-
lo em oral joint be ore, but not a ter, a running and agility
task. Ng an d Chen g117 reported a sign if cant decrease in
B
pain with patellar taping, but also reported a decrease in
the relative activity o the VMO. A random ized controlled
trial by Wittingham et al165 ound that the com bination o
tapin g and exercise was superior to placebo taping and
exercise and exercise alone in treating patients with patel-
lo em oral pain. A multicenter study by Wilson et al170 ound
that patellar tapin g provided an im m ediate decrease in
pain regardless o how the taping was applied, supporting
that it is unlikely that taping works by altering patellar posi-
tion. Cowan et al29 ound that individuals receiving thera-
peutic patellar taping im proved in both EMG onset o vasti
muscle contraction and pain in a stair-stepping task when
com pared with placebo taping and no tape. In conclusion,
a review o therapeutic taping on patello em oral pain syn-
drom e suggests that, although patellar taping appears to C
decrease pain an d im prove unction durin g activities o
daily living and rehabilitation exercise, strong evidence to
identi y the underlying m echanism s rem ains unavailable.5 Figure 24-30 Pate llo fe mo ral taping
Clinically, taping and bracing o er signif cant pain
relie in treating patients with patello emoral pain despite A. McConnell technique gliding the patella medially
the unknown mechanism by which either works. Whether for an abnormal lateral glide. B. McConnell technique
or not changes occur in vasti muscle recruitment is debat- tilting the patella medially for an abnormal lateral tilt.
able, but less muscle inhibition is expected with reduced C. McConnell technique internally rotating the patella
pain. Evidence shows that the benef ts rom external patellar for an abnormal external rotation.
supports probably do not occur rom changes in patellar tracking or alignment. Changes in
proprioception, increases in patello emoral joint compression that decrease peak stresses,
and shi ting contact rom sensitive to less irritated areas are more plausible explanations.
Regardless o the mechanism by which patients experience relie through these applica-
tions, the use o external patellar supports can be a use ul adjunct to quadriceps strength-
ening and exercise progression.
Speci c Rehabilitation Techniques

for Patellofemoral Injuries
Classi cat ion of Pat ellofemoral

and Ext ensor Mechanism Injuries
Complaints o pain and disability associated with the patello emoral joint and extensor
mechanism are exceedingly common. T e terminology used to describe this anterior knee
pain has been a source o some con usion and requires clarif cation.
Several authors have proposed classif cation system s or patello em oral disor-
ders.41,50,58,72,85,109,167 We choose to use the classif cation proposed by Wilk et al167 because
o its comprehensive and clearly def ned diagnostic categories. T e classif cation system
divides patello emoral disorders into the ollowing: (a) patellar compression syndrome
(PCS), (b) patellar instability, (c) biomechanical dys unction, (d) direct patellar trauma,
(e) so t-tissue lesions, ( ) overuse syndromes, (g) osteochondritis diseases, and (h) neuro-
logic disorders. However, the scope o this chapter does not eature management or direct
patellar trauma, osteochondritis diseases, or neurologic disorders.
In general, the majority o patello emoral injuries can ollow the general patello emo-
ral rehabilitation progression. However, rehabilitation techniques and concerns unique to
each disorder exist and are presented with the corresponding phases. T e general progres-
sion should be re erenced i a particular phase is not described.
Pat ellar Compression Syndromes

Pat homechanics
PCS is characterized by a patella overconstrained by the surrounding so t tissue, caus-
ing grossly restricting patellar m obility.167 ypically, PCS occurs on the lateral side, but
it can also occur globally, in which case patellar m obility is restricted both m edially and
laterally. PCS sign s an d sym ptom s o ten in clude peripatellar pain and crepitus with
squatting or stair clim bing, synovial irritation, decreased patellar m obility (laterally or
globally), patellar m alalignm ent or m altracking, and strength def cits or im balan ce.154
I le t untreated, the abnormal pressure will have a deleterious e ect on patello em oral
articular cartilage.

Phase I Pain modulation and in ammatory control must begin immediately. Cryother-
apy and activity modif cation should be used to manage these symptoms. Grades I and II
patellar mobilizations can be used or pain control via large f ber input, and may be pre-
ceded by the use o a moist hot pack or patient com ort. In the case o severe lateral com-
pression, patellar taping can be applied to unload the lateral patello emoral articulation
by providing a low-load, long-duration stretch. Patient education is critical to modi y and
avoid pain ul activities and manage symptoms.
Speci c Rehabilitation Techniques for Patellofemoral Injuries 777
Phase II T e primary ocus o phase II is the stretching o tightened lateral structures.
T is can be accomplished through patellar mobilization, prolonged tape application, and
I B stretching. In exibility o the hamstrings, quadriceps, and gastrocnemius should also
be addressed. With global PCS, usually secondary to trauma or immobilization, normal
patellar mobility and ull knee ROM must be restored be ore initiating urther therapy.
Grades III and IV patellar mobilizations should be used to address specif c limitations.
Moreover, both patellar tilts and glides should be implemented to ensure adequate exibil-
ity o both deep and superf cial retinacular f bers, respectively. T e most restricted motion
should be addressed f rst, and retinacular stretching may be per ormed between 1 and
10 minutes at a time.173 An emphasis on medial patellar tilts and deep retinacular f bers
should be given to the patient with lateral compressive symptoms.
Quadriceps strengthening should be pain- ree and may be augmented by patellar tap-
ing. T e clinician must determine appropriate resistance and ROM with which to per orm
exercises to maintain pain- ree strengthening. T e ocus o strengthening should not be on
eliciting activation o the VMO, but rather the quadriceps as a whole. Once normal patellar
mobility is restored, the patient can advance to an increased activity progression. Again,
care should be taken to restore normal mobility be ore any aggressive exercises to prevent
advancement o articular cartilage degeneration.
Pat ellar Inst abilit y

Pat homechanics
Patellar instability is the partial or complete lateral displacement o the patella, and is o ten
associated with injury to medial so t-tissue structures. Patello emoral joint stability depends
on the architecture o the trochlea and patella, limb alignment, surrounding muscle unc-
tion, and the integrity o so t-tissue constraints. In ull extension, the patella has minimal
contact with the emur. Upon knee exion, the patella f nds increasing stability within the
trochlear groove. rochlear dysplasia (abnormal shape and depth o the trochlear groove)
and patella alta (an abnormally high-riding patella) encourage patellar instability. Higher
Q angles create larger lateral vectors and increased the risk o lateral dislocation as well.
Persistent lateral patellar deviation, also caused by VMO weakness, causes lateral structures
such as the I B to contract, resulting in urther deviation and greater lateral subluxation. It
was recently noted that the primary pathoanatomy associated with lateral patellar disloca-
tion is injury to the medial patello emoral ligament (MPFL).37,137
T e MPFL is the primary static so t-tissue restraint to lateral patellar displacement.26
T e ligament originates near the medial epicondyle and adductor tubercle, coursing medi-
ally to attach to the upper one-hal or two-thirds o the medial patella, as well as the deep
ascia o the VMO tendon.9 T e MPFL resists lateral patellar displacement greatest in ull
knee extension, losing tension upon knee exion as the trochlea and VMO take over sta-
bilization o the patella within the trochlear groove.6 It has been shown to provide 50% to
60% o restraint to lateral patellar translation during 0 to 20 degrees o knee exion.33 In a
recent study o nearly 200 patients with lateral patellar dislocation, rupture o the MPFL at
the patella attachment site occurred in 47% o knees, at the emoral attachment in 26%, and
at both sites in 13%.61 Attenuation o the MPFL without rupture occurred in 13% o knees.
Mechanism of Injury
In the absence o extensive medial-sided injury, nonoperative treatment is o ten recom-
mended or primary patellar dislocations. However, a high percentage o associated pathol-
ogy, other than injury to the MPFL, accompanies lateral patellar dislocation, including
loose bodies (13%), meniscus tears (21%), patella ractures (7%), MCL sprains/ tears (21%),
and osteochondral lesions (49%).61
T e classic noncontact mechanism involves a plant and cut maneuver during which
the thigh internally rotates, promoting knee valgus. A simultaneous contraction o the
quadriceps pulls the patella superiorly and creating a orce to displace the patella. As a
rule, displacement occurs laterally with the patella shi ting over the lateral emoral condyle.
Pain, swelling, and subsequent restriction o ROM are likely to occur in addition to palpable
tenderness at the attachment site o medial retinaculum near the adductor tubercle.
T e patella can also dislocate with contact, orcing the patella laterally. T e patient
reports a pain ul giving-way episode. T e patient experiences a complete loss o knee unc-
tion, pain, and swelling, with the patella remaining in an abnormal lateral position. I vol-
untary relocation does not occur, a physician should immediately reduce the dislocation
by applying mild pressure on the patella with the knee extended as much as possible T e
rate o recurrent dislocation a ter primary dislocation and nonoperative treatment is 15%
to 44%.63 T e rate o recurrent dislocation increases a ter a second dislocation to 50%.42
Chronically subluxing patellae will place abnormal stress on the patello emoral joint and
medial restraints.

Phase I T e goals o phase I are to control pain and in ammation and to restore ull
ROM and normal gait. Acutely ollowing patellar dislocation, the knee may be braced
or immobilized in extension or 3 to 6 weeks. T e patient will require use o crutches or
ambulation until ull ROM and normal gait are attained. reatment o chronic instabil-
ity or subluxation requires less drastic e orts to manage pain, in ammation, and e usion
Table 24-7 Po sto pe rative Re habilitatio n Afte r MPFL Re co nstructio n
Clinical
Phase Days – We eks Go als Re strictio ns Tre atme nt Mile sto ne s
Phase I: Day 1 to Wk 6 Protect the surgical Brace locked in Total leg strengthening, Full knee
Protective repair full extension including hip extension
Phase Decrease pain and weeks 0 to 2; strengthening (in No pain
in ammation weight bearing all planes), foot and No effusion
Prevent the as tolerated in ankle, trunk and core 4/5 quadriceps,
negative effects locked brace strengthening hamstring,
of immobilization Discontinue Patellofemoral joint and hip
Restore brace at night mobilization in all planes strength
normal knee at week 4 Cryotherapy and
arthrokinematics Discontinue brace modalities as needed for
Prevent primary/ at 6 weeks pain control
secondary (per physician Obtain full knee extension
hypomobility approval) if immediately
Promote dynamic straight-leg Progress knee motion 0 to
stability raise can be 90 degrees by week 4
Prevent re ex performed (full ROM by week 10)
inhibition and without Advance to mini squats,
secondary extensor lag mini lunges, hamstring
muscle atrophy curls, step downs, and
supine core/hip exercises
in weeks 5 to 6
(continued )
Table 24-7 Po sto pe rative Re habilitatio n Afte r MPFL Re co nstructio n (Continued )
Clinical
Phase II: PO Wks Progressively Discontinue brace Continue to progress Full knee exion
Moderate 7 to 12 restore ROM (full at 6 weeks AROM/PROM (full by and extension
Protection by week 10) (per physician week 10) (by week 10)
Phase Maintain repair approval) Progress previous No pain
Progressively if straight-leg LE strengthening No swelling
restore motion, raise can be exercises by altering 5/5 quadriceps,
strength, and performed intensity, speed, and/or hamstring and
balance without proprioception hip strength
extensor lag Bosu/dynadisc lunges
Avoid activities Bosu/box stepovers
that provoke
pain
Phase III: PO Wks Full non painful Avoid activities Maintain full ROM Full symmetrical
Minimum 13 to 16 AROM/PROM that provoke pain Increase intensity and AROM/PROM
Protection Restoration of decrease repetitions No pain
Phase/ muscle strength, of standard exercises No swelling
Advanced power and Double-leg jumping Full balance and
Strengthening endurance in place proprioception
Phase No pain or Double-leg jumping 5/5 isometric
tenderness multiple planes knee manual
Full balance and Single-leg hopping in place muscle test
proprioception Initiation of light functional/ 5/5 isometric hip
Gradual initiation plyometric activities: manual muscle
of functional double-legs progressing test
activities to single (ie, ladder drills)
Phase IV: PO Wks Maintain muscle None Continue previous Return to activity
Return to Full 17 to 20+ strength, power exercises and/or sport
Activity Phase and endurance Initiate more advanced
Maintain knee single-leg plyometric
motion training
Maintain Advanced sport-speci c
balance and training
proprioception Progress interval sports
Progress functional programs
activities
Return to
unrestricted
sports activity
AROM, active range of motion; LE, lower extremity; PO, postoperative; PROM, passive range of motion; ROM, range of motion; Wks, weeks.
compared to acute instability. Nonetheless, irritation can be controlled by icing and avoid-
ance o aggravating activities.
Phase II T e emphasis o phase II is dynamic patellar stabilization through lower-

extremity strengthening and stretching. I lateral tracking o the patella is involved in the
instability, correction o lower-extremity alignment or tightened lateral structures such
as the I B must be addressed. Also, i lateral tracking is the result o abnormal adduction
and internal rotation o the thigh, gluteus maximus and medius strengthening must be
addressed. Maintaining cardiorespiratory endurance o the lower-extremity musculature is
also important. As the condition o the knee improves, activities can be gradually advanced.
Care should still be taken to minimize swelling during this stage, as it has a detrimental
e ect on quadriceps activity.
Phase III With advanced exercise and a unctional progression, the use o a patellar sta-
bilization brace may be used to encourage patellar stability and patient conf dence. Quad-
riceps and gluteal strengthening should be advanced. Agility and sport-specif c drills can
also be introduced as appropriate. Athletes should practice cutting and jumping with bio-
mechanical cues be ore returning to sport, including a ocus on exed knees upon landing
or planting without emoral internal rotation or knee valgus.
I conservative treatments ail to return patients to their desired level o activity with-
out continued symptoms o giving way, surgical treatment is an option. MPFL reconstruc-
tion rehabilitation should ollow a structured guideline to ensure that excessive stress is not
placed on gra t tissue.103
Biomechanical Dysfunct ion

Pat homechanics
Biomechanical dys unction is an alteration in the normal biomechanics o the lower
extremity. T e alteration is o ten subtle but can have a pro ound e ect via repetition or
intense activity. Individuals who develop patello emoral pathology have been shown to
be signif cantly weaker on measures o hip abduction, knee exion, and knee extension
strength, and commonly display greater navicular drop.13 Leg length discrepancies, lower-
extremity exibility def cits, and weakness o the hip, core, ankle, and oot are also common
causes o biomechanical dys unction. Proximal and distal actors a ecting patello emoral
biomechanics were previously discussed.

Phase I reatment o biomechanical dys unction o the lower extremity rarely involves
a ocus on the source o pain. Excessive subtalar joint pronation or other intrinsic imbal-
ances o the oot that result in altered patello emoral articulation should be addressed
with strengthening, ootwear, or orthotics. A true or unctional limb length discrepancy
can cause pronation and other gait deviations; there ore, a shoe li t or manual correction
may be indicated. Flexibility def ciencies can also lead to pronation, increased stress on
the extensor mechanism, changes in gait, and lateral displacement o the patella. T e clini-
cian should restore any loss o exibility in the gastrocnemius–soleus complex, quadriceps,
hamstrings, I B, and hip rotators. In addition, weakened gluteal muscles that result in an
unstable pelvis and uncontrolled hip adduction and internal rotation during dynamic activ-
ities must be unctionally strengthened. One study o hip and core muscle EMG activity
during exercise suggests side-bridging and unilateral supine bridging are largely e ective
or activation o the gluteus medius and maximus, respectively, in addition to core muscu-
lature (Figures 24-31 and 24-32).34
Soft -Tissue Lesions

Pat homechanics
A so t-tissue lesion involves pain and in ammation o the numerous so t-tissue structures
that surround the knee. Commonly involved tissues include bursa, plica, in rapatellar at
pad, distal I B, and MPFL. So t-tissue lesions may be the result o direct trauma, repeated
activity, or biomechanical abnormality.
Figure 24-31 Side -bridg ing targ e ts the Figure 24-32 Unilateral supine bridging targe ts
g lute us me dius in additio n to co re musculature the glute us maximus in addition to core musculature
Bursitis in the knee can be acute, chronic, or recurrent, and is usually the result o a
direct trauma. Although any o the knee bursae can become in amed, the prepatellar, deep
in rapatellar, and suprapatellar bursae have the highest incidence o irritation in sports and
among blue collar workers with heavy workloads and requent kneeling.88 Swelling is local-
ized to the location o injury.
T e medial patellar plica is also subject to injury. T is bandlike tissue can bowstring
across the anterior aspect o the medial emoral condyle, impinging between the articular
cartilage and the medial patellar acet during knee exion. Consequently, it has been seen
to play a mechanical role in the development o medial emoral chondropathy, which con-
f rms that excision o a plica is an appropriate prophylactic procedure during knee arthros-
copy.23 T e patient may eel or hear a snap and report pain ul pseudolocking, although an
intermittent dull pain is the most common symptom.4 In ammation o the plica, at times
induced by acute trauma, leads to f brosis and thickening with a loss o extensibility. When
present, the majority o plicae are pliable and asymptomatic.
T e distal I B is injured while repetitively crossing the lateral emoral condyle during
exion and extension o the knee. Several studies suggest this pathology is especially preva-
lent among athletes.45,151,171 Pain will radiate laterally toward the proximal tibia, becoming
increasingly severe with continued activity. Increased tension o the I B may be the result
o hip weakness; leg length discrepancy; tightness in the tensor asciae latae, hamstrings,
and quadriceps; genu varum ; excessive pronation; internal tibial torsion; or restricted
dorsi exion.

Phase I During phase I o the rehabilitation process, iontophoresis, phonophoresis,
and ice massage can be used to control pain and in ammation or numerous so t-tissue
lesions. None o these modalities will be e ective, however, unless the patient is educated
and complies with appropriate activity modif cation. Also emphasized are a nonantalgic
gait and ull ROM. In the case o chronic bursitis, a compression wrap should be worn con-
tinuously. Medial plica syndrome requires ample stretching o the quadriceps, hamstrings,
and gastrocnemius.4 With chronic I B syndrome, transverse riction massage administered
by a therapist o via the use o a oam roller can be use ul to create localized in ammation
and promote collagen realignment. Isolated stretches, including contract–relax techniques,
should precede muscle strengthening and reeducation. For athletes with I B syndrome,
both running and cycling should be avoided during the acute phase.46 Swimming with a
pool buoy between the legs is an alternative or aerobic conditioning.
Phase II Strengthening can begin once in ammation and pain are resolved. In patients
with I B riction syndrome, caution must be taken with exercise near terminal knee exten-
sion where the I B passes over the lateral emoral condyle. T ese patients should avoid
exercising on stairclimbers and running hills (especially downhill), in one direction on a
track, or on sloped roads.46 Moreover, patients should only begin a return-to-running pro-
gression once they can per orm all strengthening exercises with proper orm and without
pain. Patients with plica syndrome should avoid exercise with ull knee exion, such as
deep squatting, which can compress an in amed plica. I the lesion is the result o a biome-
chanical dys unction, alignment o the lower-extremity must be addressed.
Overuse Syndromes
Pat homechanics
Overuse syndromes are the result o excessive activity or stress to the extensor mechanism
and include patellar tendinitis and traction apophysitis. endinitis o the extensor mecha-
nism can occur at the superior patellar pole (quadriceps tendinitis), the tibial tubercle,
or, most commonly, at the distal pole o the patella. Patellar tendinitis usually develops in
patients involved in activities that require repetitive jumping and is requently given the
name “jumper’s knee.” Point tenderness on the posterior aspect o the in erior pole o the
patella is the hallmark symptom. T is condition is typically related
to the eccentric shock-absorbing unction that the quadriceps pro-
vides upon landing rom a jump.
raction apophysitis is a common adolescent condition that
results rom repeated stress o the patellar tendon at the apophysis
o either the tibial tubercle or in erior patellar pole. T e condition
is characterized by pain and swelling that increases with activity
and decreases with rest. Osgood-Schlatter disease occurs over the
tibial tuberosity while Larsen-Johansson disease, although much
less common, occurs at the in erior pole o the patella.

Phase I Ice massage and iontophoresis can be used to con-
trol pain and in am mation during this stage o rehabilitation.
Avoidance o jum ping, kicking, running, and sudden decelera-
tion that can cause undue stress on the extensor m echanism is
warranted. ransverse riction massage can be used to acili-
tate the healing process o patellar tendinitis, but should not be
per orm ed in conjunction with antiin am matory m odalities.
Ultrasound can reasonably be excluded as treatment or patellar
tendinopathy.86
Phase II T erapeutic exercise, especially eccentric strength-

ening, is strongly supported by evidence as e ective treatment
or patellar tendinopathy.86 Exercises can be progressed rom
low velocity to high velocity, and bilaterally to unilaterally. Sev-
eral studies suggest standing on a 25-degree decline board while
Figure 24-33 Ecce ntric quadrice ps per orming eccentric training o the quadriceps (Figure 24-33).160
training o n a 25-de g re e de cline bo ard Evidence suggest patellar tendon strain is signif cantly greater,
stop angles o the ankle and hip joints are signif cantly smaller, and EMG amplitudes o the
knee extensor muscles are signif cantly greater during exercise on the decline board com-
pared with standard squats.83 Moderate evidence exists or more conservative, heavy, slow
resistance training o the quadriceps.86 Reducing body weight, increasing upper-leg exibil-
ity, and the use o orthotics may also be benef cial treatment options or the intermediate
phase o rehabilitation.158
Phase III Using a patellar strap can be benef cial in controlling pain when returning to
intense activity. Controlled sports-specif c exercise usually begins in this advanced stage
o rehabilitation, although several studies report benef t rom eccentric exercise rehabilita-
tion programs targeting tendinopathy while continuing sports participation.138 Activities or
patients with traction apophysitis, an o ten sel -limiting condition, can be progressed i the
patient remains pain- ree.
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Rehabilitation of
Lower-Leg Injuries
Ch r is t o p h e r J. Hir t h
OBJJEC
Discuss the functional anatomy and biomechanics of the lower leg during open-chain and
weightbearing activities such as walking and running.
Identify the various techniques for regaining range of motion, including stretching exercises and
joint mobilizations.
Discuss the various rehabilitative strengthening techniques, including open- and closed-chain
isotonic exercise, balance/proprioceptive exercises, and isokinetic exercise for dysfunction of the
lower leg.
Identify common causes of various lower-leg injuries and provide a rationale for treatment of
these injuries.
Discuss criteria for progression of the rehabilitation program for various lower-leg injuries.
Describe and explain the rationale for various treatment techniques in the management of
lower-leg injuries.
789
790 Chapte r 25 Rehabilitation of Lower-Leg Injuries

T e lower leg consists o the tibia and f bula and 4 muscular compartments that either origi-
nate on or traverse various points along these bones. Distally the tibia and f bula articulate
with the talus to orm the talocrural joint. Because o the close approximation o the talus
within the mortise, movement o the leg will be dictated by the oot, especially upon ground
contact. T is becomes important when examining the e ects o repetitive stresses placed
upon the leg with excessive compensatory pronation secondary to various structural lower-
extremity malalignments.78,79 Proximally the tibia articulates with the emur to orm the tib-
io emoral joint, as well as serving as an attachment site or the patellar tendon, the distal
so t-tissue component o the extensor mechanism. T e lower leg serves to transmit ground
reaction orces to the knee as well as rotatory orces proximally along the lower extremity
that may be a source o pain, especially with athletic activities.56
Compart ment s of t he Lower Leg

All muscles work in a unctionally integrated ashion in which they eccentrically deceler-
ate, isometrically stabilize, and concentrically accelerate during movement.50 T e muscular
components o the lower leg are divided anatomically into 4 compartments. In an open-
kinetic-chain position, these muscle groups are responsible or movements o the oot, pri-
marily in a single plane. When the oot is in contact with the ground, these muscle–tendon
units work both concentrically and eccentrically to absorb ground reaction orces, control
excessive movements o the oot and ankle to adapt to the terrain, and, ideally, provide a
stable base to propel the limb orward during walking and running.
T e anterior compartment is primarily responsible or dorsi exion o the oot in an
open-kinetic-chain position. Functionally these muscles are active in early and m id-
stance phase o gait, with increased eccentric muscle activity directly a ter heel strike to
control plantar exion o the oot and pronation o the ore oot.21 Electromyographic stud-
ies have noted that the tibialis anterior is active in m ore than 85% o the gait cycle during
running.54
T e deep posterior compartment is made up o the tibialis posterior and the long toe
exors and is responsible or inversion o the oot and ankle in an open kinetic chain. T ese
muscles help control pronation at the subtalar joint and internal rotation o the lower
leg.21,54 Along with the soleus, the tibialis posterior will help decelerate the orward momen-
tum o the tibia during midstance phase o gait.
T e lateral com partment is made up o the peroneus longus and brevis, which are
responsible or eversion o the oot in an open kinetic chain. Functionally, the peroneus
longus plantar exes the f rst ray at heel o , while the peroneus brevis counteracts the
supinating orces o the tibialis posterior to provide osseous stability o the subtalar and
midtarsal joints during the propulsive phase o gait. T is is a prime example o muscles
working synergistically to isometrically stabilize during movement. Electromyographic
studies o running report an increase in peroneus brevis activity when the pace o running
is increased.54
T e superf cial posterior compartment is made up o the gastrocnemius and soleus
muscles, which in open-kinetic-chain position are responsible primarily or plantar exion
o the oot. Functionally these muscles are responsible or acting eccentrically, controlling
pronation o the subtalar joint and internal rotation o the leg in the midstance phase o gait
and acting concentrically during the push-o phase o gait.21,54
Rehabilitation Techniques for the Lower Leg 791
Rehabilitation Techniques for the Lower Leg
Figure 25-1 Active rang e o f mo tio n ankle

plantar e xio n Figure 25-2 Active rang e o f mo tio n ankle
do rsi e xio n
Used to activate the primary and secondary ankle
plantarflexor muscle-tendon units after a period of Used to activate the tibialis anterior, extensor hallucis
immobilization or disuse. This exercise can be performed longus, and extensor digitorum longus muscle-tendon units
in a supportive medium such as a whirlpool. after a period of immobilization or disuse.
Isot onic Open-Kinet ic-Chain Exercises
Figure 25-3 Active rang e o f mo tio n ankle Figure 25-4 Active rang e o f mo tio n ankle
inve rsio n e ve rsio n
Used to activate the tibialis posterior, flexor hallucis longus, Used to activate the peroneus longus and brevis
and flexor digitorum longus muscle-tendon units after a muscle–tendon units after a period of immobilization
period of immobilization or disuse. or disuse.
Figure 25-5 Re sistive rang e o f mo tio n ankle Figure 25-6 Re sistive rang e o f mo tio n ankle
plantar e xio n w ith rubbe r tubing do rsi e xio n w ith rubbe r tubing
Used to strengthen the gastrocnemius, soleus, and secondary Used to isolate and strengthen the ankle dorsiflexors,
ankle plantar exors, including the peroneals, exor hallucis including the tibialis anterior, extensor hallucis longus, and
longus, exor digitorum longus, and tibialis posterior, in extensor digitorum longus, in an open chain.
an open chain. This exercise will also place a controlled
concentric and eccentric load on the Achilles tendon.
Figure 25-8 Re sistive rang e o f mo tio n ankle

Figure 25-7 Re sistive rang e o f mo tio n ankle e ve rsio n w ith rubbe r tubing
inve rsio n w ith rubbe r tubing
Used to isolate and strengthen the ankle everters, including
Used to isolate and strengthen the ankle inverters, including the peroneus longus and peroneus brevis, in an open
the tibialis posterior, flexor hallucis longus, and flexor chain.
digitorum longus, in an open chain.
Figure 25-9 Active rang e o f mo tio n to e e xio n/ e xte nsio n
Used to activate the long toe flexors, extensors, and foot intrinsic
musculature. This exercise will also help to improve the tendon-gliding ability
of the extensor hallucis longus, extensor digitorum longus, flexor hallucis
longus, and flexor digitorum longus tendons after a period of immobilization.
Closed-Kinet ic-Chain St rengt hening Exercises
Figure 25-10 To w e l-g athe ring e xe rcise
Used to strengthen the foot intrinsics and long toe exor and
extensor muscle-tendon units. A weight can be placed on
Figure 25-11 He e l raise s
the end of the towel to require more force production by the
Used to strengthen the gastrocnemius musculature and
muscle-tendon unit as range of motion and strength improve.
will directly load the Achilles tendon.
Figure 25-12 Tw o -le g g e d he e l raise
Used to strengthen the gastrocnemius when the knee is

extended and the soleus when the knees are flexed. The
flexor hallucis longus, flexor digitorum longus, tibialis Figure 25-13 One -le g g e d he e l raise
posterior, and peroneals will also be activated during this
activity. The patient can modify concentric and eccentric Used to strengthen the gastrocnemius and soleus muscles
activity depending on the type and severity of the condition. when the knee is extended and flexed, respectively. This can
For example, if an eccentric load is not desired on the be used as a progression from the two-legged heel raise.
involved side, the patient can raise up on both feet and
lower down on the uninvolved side until eccentric loading
is tolerated on the involved side.
Figure 25-14 Se ate d clo se d-chain ankle Figure 25-15 Se ate d clo se d-chain ankle
do rsi e xio n/ plantar e xio n active ROM inve rsio n/ e ve rsio n active ROM
Used to activate the ankle dorsiflexor/plantarflexor Used to activate the ankle inverter/everter musculature in a
musculature in a closed-chain position. closed-chain position.
Figure 25-16 Statio nary cycle
Used to reduce impact of weightbearing forces on the

lower extremity while also maintaining cardiovascular
fitness levels.
Figure 25-17 Stair-ste pping machine
Used to progressively load the lower extremity in a closed-

chain as well as maintain and improve cardiovascular tness.
A B
Figure 25-18 Ankle plantar e xo rs to w e l stre tch
A. Used to stretch the gastrocnemius when the knee is extended and (B) the soleus when the knee is flexed. The
Achilles tendon will be stretched with both positions. The patient can hold the stretch for 20 to 30 seconds.
A B
Figure 25-19
A. Standing gastrocnemius stretch. Used to stretch the gastrocnemius muscle. The Achilles tendon will also be
stretched. B. Standing soleus stretch. Used to stretch the soleus muscle. The Achilles tendon will also be stretched.
Figure 25-20 Standing ankle do rsi e xo r stre tch
Used to stretch the extensor hallucis longus, extensor digitorum

longus, tibialis anterior, and anterior ankle capsule.
Figure 25-23 Standing sing le -

le g balance bo ard activity
Figure 25-21 Kne e ling ankle do rsi e xo r stre tch
Used to activate the lower-leg musculature
Used to stretch the extensor hallucis longus, extensor digitorum and improve balance and proprioception in
longus, tibialis anterior, and anterior ankle capsule. This is the involved extremity.
an aggressive stretch that can be used in the later stages of
rehabilitation to gain endrange-of-motion ankle dorsiflexion.
Figure 25-24 Static sing le -le g

standing balance pro g re ssio n
Used to improve balance and proprioception of

the lower extremity. This activity can be made
Figure 25-22 Standing do uble -le g balance o n more dif cult with the following progression:
BOSU Balance Traine r (a) single-leg stand, eyes open; (b) single-leg
stand, eyes closed; (c) single-leg stand, eyes
Used to activate the lower-leg musculature and improve balance open, toes extended so only the heel and
and proprioception in the lower extremity. metatarsal heads are in contact with the ground;
(d) single-leg stand, eyes closed, toes extended.
A
B
C D
Figure 25-25 Sing le -le g standing rubbe r-tubing kicks
Used to improve muscle activation of the lower leg to maintain single-leg standing on the involved extremity while
kicking against the resistance of the rubber tubing. A. Extension. B. Flexion. C. Adduction. D. Abduction.
Exercises t o Improve Cardiorespirat ory Endurance
Figure 25-27 Uppe r-bo dy e rg o me te r
Used to maintain cardiovascular fitness when lower-extremity

ergometer is contraindicated or too difficult for the patient to use.
Figure 25-26 Po o l running w ith
o tatio n de vice
Used to reduce impact weightbearing forces

on the lower extremity while maintaining
cardiovascular fitness level and running form.
Figure 25-29 Exe rcise sandal

fo rw ard and backw ards w alking
Figure 25-28 Exe rcise sandals (OPTP, Minne apo lis, MN)
Used to enhance balance and proprioception and
increase muscle activity in the foot intrinsics,
Wooden sandals with a rubber hemisphere located centrally on the
lower-leg musculature, and gluteals. The patient
plantar surface.
takes small steps forward and backwards.
Figure 25-30 Exe rcise sandals side ste pping Figure 25-31 Exe rcise sandals butt kicks
Used to enhance balance and proprioception in the frontal Used to promote balance and proprioception along with
plane. Increases muscle activity of the lower-leg musculature increased muscle activity of the foot intrinsics, lower-leg
and foot intrinsics. The patient moves directly to the left or musculature, and gluteals. This exercise enhances single-leg
right along a straight line with the toes pointed forward. stance in the exercise sandals.
Figure 25-32 Exe rcise sandals hig h kne e s
Used to enhance balance and proprioception and muscle

activity of the foot intrinsics, lower-leg musculature, and
especially the gluteals. The patient should maintain an
Figure 25-33 Exe rcise sandals single -le g stance
upright posture and avoid trunk flexion with hip flexion.
Used to enhance balance, proprioception, and muscle
This exercise promotes single-leg stance progression for a
activity in the entire lower extremity. This exercise is the
short period of time.
most demanding in the exercise sandal progression.
Figure 25-34 Exe rcise sandal ball catch Figure 25-35 Achille s te ndo n e cce ntric muscle
lo ading
Used to enhance balance, proprioception, and lower-
leg muscle activity. The patient focuses on catching and Used to enhance gastrocnemius (knee straight) and soleus
throwing the ball to the therapist while moving laterally to (knee bent) strength and Achilles tendon tensile strength.
the left or right. The patient uses the uninvolved side to elevate onto the
patient’s toes and then places all weight on toes of the
involved side to eccentrically lower. Initially, the patient
lowers to the step and then progresses below the level of
the step. Extra weight can be added via a backpack.
A B
Figure 25-36 Sho rt fo o t co nce pt
Used to enhance and strengthen the foot intrinsic muscles. The patient is instructed to shorten the foot from front to
back while keeping the toes straight. The metatarsal heads should stay in contact with the ground. The therapist can
palpate the foot intrinsics and will notice a raised longitudinal arch with a flexible foot type. The shortened foot should
be maintained at all times while in the exercise sandals.
Tibial and Fibular Fract ures

Pat homechanics
T e tibia and f bula constitute the bony components o the lower leg and are primarily
responsible or weight bearing and muscle attachment. T e tibia is the most commonly
ractured long bone in the body, and ractures are usually the result o either direct trauma
to the area or indirect trauma such as a combination rotatory/ compressive orce. Fractures
o the f bula are usually seen in combination with a tibial racture or as a result o direct
trauma to the area. ibial ractures will present with immediate pain, swelling, and pos-
sible de ormity and can be open or closed in nature. Fibular ractures alone are usually
closed and present with pain on palpation and with ambulation. T ese ractures should
be treated with immediate medical re erral and most likely a period o immobilization
and restricted weight bearing or weeks to possibly months, depending on the severity and
involvement o the injury. Surgery such as open reduction with internal f xation o the bone,
usually o the tibia, is common.
Injury Mechanism
T e 2 mechanisms o a traumatic lower-leg racture are either a direct insult to the bone or
indirectly through a combined rotatory/ compressive orce. Direct impact to the long bone,
such as rom a projectile object or the top o a ski boot, can produce enough damaging orce to
racture a bone. Indirect trauma rom a combination o rotatory and compressive orces can be
mani ested in sports when an athlete’s oot is planted and the proximal segments are rotated
with a large compressive orce. An example o this could be a ootball running back attempting
to gain more yardage while an opposing player is trying to tackle him rom above the waist and
applying a superincumbent compressive load. I the patient’s oot is planted and immovable
and the lower extremity is rotated, the superincumbent weight o the de ender may be enough
to cause a racture in the tibia. A f bular racture may accompany the tibial racture.

ibial and f bular ractures are usually immobilized and placed on a restricted weightbear-
ing status or a period o time to acilitate racture healing. Immobilization and restricted
weight bearing o a bone, its proximal and distal joints, and surrounding musculature will
lead to unctional def cits once the racture is healed. Depending on the severity o the
racture, there also may be postsurgical considerations such as an incision and hardware
within the bone. Complications ollowing immobilization include joint sti ness o any
joints immobilized, muscle atrophy o the lower leg and possibly the proximal thigh and hip
musculature, as well as an abnormal gait pattern. Bullock-Saxton demonstrated changes in
gluteus maximus electromyographic muscle activation a ter a severe ankle sprain.13 Proxi-
mal hip muscle weakness is magnif ed by the immobility and non-weightbearing action
that accompanies lower-leg ractures. It is important that the therapist per orm a compre-
hensive evaluation o the patient to determine all potential rehabilitation problems, includ-
ing range o motion, joint mobility, muscle exibility, strength and endurance o the entire
involved lower extremity, balance, proprioception, and gait. T e therapist must also deter-
mine the unctional demands that will be placed on the patient upon return to competition
and set up short- and long-term goals accordingly. Upon cast removal it is important to
address range-o -motion (ROM) def cits. T is can be managed with passive, then active,
ROM exercises in a supportive medium such as a warm whirlpool (Figures 25-1 to 25-4,
25-9, 25-14, 25-15, 25-16, and 25-17). Joint sti ness can be addressed via joint mobilization
to any joint that was immobilized (see Figures 13-61 to 13-68). It is possible to have post-
traumatic edema in the oot and ankle a ter cast removal that can be reduced with mas-
sage. Strengthening exercises can help acilitate muscle f ring, strength, and endurance
(Figures 25-5 to 25-8 and 25-10 to 25-17). Balance and proprioception can be improved
with single-leg standing activities and balance board activities (Figures 25-22 to 25-25). Car-
diovascular endurance can be addressed with pool activities including swimming and pool
running with a otation device, stationary cycling, and the use o an upper-body ergom-
eter (see Figures 25-16, 25-26 and 25-27). A stair stepper is also an excellent way to address
cardiovascular needs as well as lower-extremity strength, endurance, and weight bearing
(Figure 25-17).
Once the patient demonstrates prof ciency in static balance activities on various bal-
ance modalities, m ore dynamic neuromuscular control activities can be introduced.
Exercise sandals (OP P, Minneapolis, MN) can be incorporated into rehabilitation as a
closed-kinetic-chain unctional exercise that places increased proprioceptive demands on
the patient. T e exercise sandals are wooden sandals with a rubber hemisphere located
centrally on the plantar sur ace (Figure 25-28). T e patient can be progressed into the exer-
cise sandals once they demonstrate prof ciency in bare oot single-leg stance. Prior to using
the exercise sandals the patient is instructed in the short- oot concept—a shortening o the
oot in an anteroposterior direction while the long toe exors are relaxed, thus activating
the short toe exors and oot the intrinsics (see Figure 25-36).37 Clinically, the short oot
appears to enhance the longitudinal and transverse arches o the oot. Once the patient can
per orm the short- oot concept in the sandals, the patient is progressed to walking in place
and orward walking with short steps (Figure 25-29). T e patient is instructed to assume a
good upright posture while training in the sandals. Initially, the patient may be limited to 30
to 60 seconds while acclimating to the proprioceptive demands. Once the patient appears
sa e with walking in place and small-step orward walking, the patient can ollow a rehabili-
tation progression ( able 25-1 and Figures 25-30 to 25-34).
T e exercise sandals o er an excellent means o acilitating lower-extremity muscula-
ture that can be a ected by tibial and f bular ractures. Bullock-Saxton et al noted increased
gluteal muscle activity with exercise sandal training a ter 1 week.14 Myers et al also dem-
onstrated increased gluteal activity, especially with high-knees marching in the exercise
sandals.48 Blackburn et al have shown increased activity in the lower-leg musculature, spe-
cif cally the tibialis anterior and peroneus longus, while per orming the exercise sandal pro-
gression activities.11 T e lower-leg musculature is usually weakened and atrophied, rom
being so close to the trauma. T e exercise sandals o er an excellent means o increasing
muscle activation o the lower-leg musculature in a unctional weightbearing manner.
Table 25-1 Exe rcise Sandal Pro g re ssio n
1. Walking in place
2. Forward/backward walking—small steps
3. Sidestepping
4. Butt kicks
5. High knees
6. Single-leg stance—10 to 15 seconds
7. Ball catch—sidestepping
8. Sport-speci c activity
• Each activity can be performed for 30 to 60 seconds with rest between each activity.
• All exercises should be performed with short-foot and good standing posture except
where sport-speci c activity dictates otherwise.

Management o a postimmobilization racture requires good communication with the phy-
sician to determine progression o weightbearing status, any assistive devices to be used
during the rehabilitation process, such as a walker boot, and any other pertinent in orma-
tion that can in uence the rehabilitation process. It is important to address ROM def cits
immediately with active range o motion (AROM), passive stretching, and skilled joint
mobilization. Isometric strengthening can be initiated and progressed to isotonic exercises
once ROM has been normalized. A ter weightbearing status is determined, gait training
to normalize walking should be initiated. Assistive devices should be utilized as needed.
Strengthening o the involved lower extremity can be incorporated into the rehabilitation
process, especially or the hip and thigh musculature. It is important or the therapist to
identi y and address this hip muscular weakness early on in rehabilitation through open-
and closed-chain strengthening. Balance and proprioceptive exercises can begin once
there is ull pain- ree weightbearing on the involved lower extremity.
As ROM, strength, and walking gait are normalized, the patient can be progressed to a
walking/ jogging progression and a sport-related unctional progression. It must be realized
that the rate o rehabilitation progression will depend on the severity o the racture, any
surgical involvement, and length o immobilization. T e average healing time or uncom-
plicated nondisplaced tibial ractures is 10 to 13 weeks; or displaced, open, or comminuted
tibial racture, it is 16 to 26 weeks.67
Fibular ractures may be immobilized or 4 to 6 weeks. Again, an open line o commu-
nication with the physician is required to acilitate a sa e rehabilitation progression or the
patient.
Crit eria for Full Ret urn

T e ollowing criteria should be met prior to the return to ull activity: (a) ull ROM and
strength, compared to the uninvolved side; (b) normalized walking, jogging, and running
gait; (c) ability to hop or endurance and 90% hop or distance as compared to the unin-
volved side, without complaints o pain or observable compensation; and (d) success ul
completion o a sport-specif c unctional test.
Tibial and Fibular St ress Fract ures

Pat homechanics
Stress ractures o the tibia and f bula are common in sports. Studies indicate that stress
ractures o the tibia occur at a higher rate than those o the f bula.7,8,45 Stress ractures in
the lower leg are usually the result o the bone’s inability to adapt to the repetitive loading
response during training and conditioning o the athlete. T e bone attempts to adapt to the
applied loads initially through osteoclastic activity, which breaks down the bone. Osteo-
blastic activity, or the laying down o new bone, will soon ollow.53,77 I the applied loads
are not reduced during this process, structural irregularities will develop within the bone,
which will urther reduce the bone’s ability to absorb stress and will eventually lead to a
stress racture.8,27
Repetitive loading o the lower leg with a weightbearing activity such as running is usu-
ally the cause o tibial and f bular stress ractures. Romani reports that repetitive mechani-
cal loading seen with the initiation o a stress ul activity may cause an ischemia to the
a ected bone.58 He reports that repetitive loading may lead to temporary oxygen debt o the
bone, which signals the remodeling process to begin.58 Also, microdamage to the capillaries
urther restricts blood ow, leading to more ischemia, which again triggers the remodeling
process—leading to a weakened bone and a setup or a stress racture.58
Stress ractures in the tibial sha t mainly occur in the mid anterior aspect and the pos-
teromedial aspect.7,45,55,77 Anterior tibial stress ractures usually present in patients involved
in repetitive jumping activities with localized pain directly over the mid anterior tibia. T e
patient will complain o pain with activity that is relieved with rest. T e pain can a ect activ-
ities o daily living (ADL) i activity is not modif ed. Vibration testing using a tuning ork will
reproduce the symptoms, as will hopping on the involved extremity. A triple-phase techne-
tium-99 bone scan can conf rm the diagnosis aster than an X-ray, as it can take a minimum
o 3 weeks to demonstrate radiographic changes.53,55,77 Posteromedial tibial pain usually
occurs over the distal one-third o the bone with a gradual onset o symptoms.
Focal point tenderness on the bone will help di erentiate a stress racture rom medial
tibial stress syndrome (M SS), which is located in the same area but is more di use upon
palpation. T e procedures listed above will be positive and will implicate the stress racture
as the source o pain. Fibular stress ractures usually occur in the distal one-third o the
bone with the same symptomatology as or tibial stress ractures. Although less common,
stress ractures o the proximal f bula are noted in the literature.45,73,88
Injury Mechanism
Anterior tibial stress ractures are prevalent in patients involved with jumping. Several
authors have noted that the tibia will bow anteriorly with the convexity on the anterior
aspect.18,53,56,77 T is places the anterior aspect o the tibia under tension that is less than ideal
or bone healing, which pre ers compressive orces. Repetitive jumping will place greater
tension on this area, which has minimal musculotendinous support and blood supply.
Other biomechanical actors may be involved, including excessive compensatory pronation
at the subtalar joint to accommodate lower-extremity structural alignments such as ore oot
varus, tibial varum, and emoral anteversion. T is excessive pronation might not a ect the
leg during ADL or with moderate activity, but might become a actor with increases in train-
ing intensity, duration, and requency, even with su cient recovery time.30,77 Increased
training may a ect the surrounding muscle–tendon unit’s ability to absorb the impact o
each applied load, which places more stress on the bone. Stress ractures o the distal pos-
teromedial tibia will also arise rom the same problems as listed above, with the exception
o repetitive jumping. Excessive compensatory pronation may play a greater role with this
type o injury. T is hyperpronation can be accentuated when running on a crowned road;
such is the case o the uphill leg.60 Also, running on a track with a small radius and tight
curves will tend to increase pronatory stresses on the leg that is closer to the inside o the
track.60 Excessive pronation may also play a role with f bular stress ractures. T e repeated
activity o the ankle everters and cal musculature pulling on the bone may be a source o
this type o stress racture.53 raining errors o increased duration and intensity along with
wornout shoes will only accentuate these problems.60 Other actors, including menstrual
irregularities, diet, bone density, increased hip external rotation, tibial width, and cal girth,
also have been identif ed as contributing to stress ractures.8,29

Immediate elimination o the o ending activity is most important. T e patient must be
educated on the importance o this to prevent urther damage to the bone. Many patients
will express concerns about f tness level with loss o activity. Stationary cycling and run-
ning in the deep end o the pool with a otation device can help maintain cardiovascular
f tness (see Figures 25-16 and 25-26). Eyestone et al demonstrated a small, but statistically
signif cant, decrease in maximal aerobic capacity when water running was substituted or
regular running.23 T is was also true with using a stationary bike.23 T ese authors recom-
mend that intensity, duration, and requency be equivalent to regular training. Wilder
et al note that water provides a resistance that is proportional to the e ort exerted.84 T ese
authors ound that cadence, via a metronome, gave a quantitative external cue that with
increased rate showed high correlation with heart rate.84 Nonimpact activity in the pool or
on the bike will help maintain f tness and allow proper bone healing. Proper ootwear that
matches the needs o the oot is also important. For example, a high arched or pes cavus
oot type will require a shoe with good shock-absorbing qualities. A pes planus oot type
or more pronated oot will require a shoe with good motion control characteristics. Recent
evidence-based reviews indicate that shock-absorbing insoles can have a preventative
e ect with tibial stress ractures.65 A detailed biomechanical exam o the lower extremity,
both statically and dynamically, may reveal problems that require the use o a custom oot
orthotic. Stretching and strengthening exercises can be incorporated in the rehabilitation
process. T e use o ice and electrical stimulation to control pain is also recommended. T e
utilization o an Aircast with patients who have diagnosed stress ractures has produced
positive results.20 Dickson and Kichline speculate that the Aircast unloads the tibia and
f bula enough to allow healing o the stress racture with continued participation.20 Swen-
son et al reported that patients with tibial stress ractures who used an Aircast returned
to ull unrestricted activity in 21 ± 2 days; patients who used traditional regimen returned
in 77 ± 7 days.76 Fibular and posterior medial tibial stress ractures will usually heal with-
out residual problems i the above-mentioned concerns are addressed. Stress ractures o
the mid anterior tibia can take much longer, and residual problems might exist months to
years a ter the initial diagnosis, with attempts at increased activity.18,22,55,56 Initial treatment
may include a short leg cast and non–weight bearing or 6 to 8 weeks. Batt et al noted that
use o a pneumatic brace in those individuals allowed or return to unrestricted activity, an
average o 12 months rom presentation.4 T e proposed hypothesis or use o a pneumatic
brace is that elevated osseous hydrostatic and venous blood pressure produces a positive
piezoelectric e ect that stimulates osteoblastic activity and acilitates racture healing.87
Rettig et al used rest rom the o ending activity as well as electrical stimulation in the orm
o a pulsed electromagnetic f eld or a period o 10 to 12 hours per day. T e authors noted
an average o 12.7 months rom the onset o symptoms to return to ull activity with this
regimen.56 T ey recommended using this program or 3 to 6 months be ore considering
surgical intervention.56 Chang and Harris noted good to excellent results with a surgical
procedure involving intramedullary nailing o the tibia with individuals with delayed union
o this type o stress racture.18 Surgical procedures involving bone gra ting have also been
recommended to improve healing o this type o stress racture.

A ter diagnosis o the stress racture, the patient may be placed on crutches, depending
on the amount o discom ort with ambulation. Ice and electrical stimulation can be used
to reduce local in ammation and pain. T e patient can immediately begin deep-water
running with the same training parameters as their regular regimen i they are pain- ree.
Stretching exercises or the gastrocnemius–soleus musculature can be per ormed 2 to
3 times per day (Figure 25-19). Isotonic strengthening exercises with rubber tubing can
begin as soon as tolerated on an every-other-day basis, with an increase in repetitions and
sets as the therapist sees f t (see Figures 25-5 to 25-8). Strengthening o the gastrocnemius
can be done initially in an open chain and eventually be progressed to a closed chain (see
Figures 25-5, 25-12, and 25-13). T e patient should wear supportive shoes during the day
and avoid shoes with a heel, which can cause adaptive shortening o the gastrocnemius–
soleus complex and increase strain on the healing bone. Custom oot orthotics can be ab-
ricated or motion control in order to prevent excessive pronation or those patients who
need it. Foot orthotics can also be abricated or a high-arched oot to increase stress dis-
tribution throughout the plantar aspect o the whole oot versus the heel and the metatar-
sal heads. Shock-absorbing materials can augment these orthotics to help reduce ground
reaction orces. T e exercise sandal progression can also be introduced to help acilitate
lower-leg muscle activity and strength (see Figures 25-29 to 25-34 and 25-36). As the symp-
toms subside over a period o 3 to 4 weeks and X-rays conf rm that good callus ormation
is occurring, the patient may be progressed to a walking/ jogging progression on a sur ace
suitable to that patient’s needs. T e patient must demonstrate pain- ree ambulation prior
to initiating a walk/ jog program. A quality track or grass sur ace may be the best choice
to begin this progression. T e patient may be instructed to jog or 1 minute, then walk or
30 seconds or 10 to 15 repetitions. T is can be per ormed on an every-other-day basis with
high-intensity/ long-duration cardiovascular training occurring daily in the pool or on the
bike. T e patient should be reminded that the purpose o the walk/ jog progression is to pro-
vide a gradual increase in stress to the healing bone in a controlled manner. I tolerated, the
jogging time can be increased by 30 seconds every 2 to 3 training sessions until the patient is
running 5 minutes without walking. T e above progression is a guideline and can be modi-
f ed based on individual needs.
Romani has developed a 3-phase plan or stress racture management.58 Phase 1
ocuses on decreasing pain and stress to the injured bone while also preventing decon-
ditioning. Phase 2 ocuses on increasing strength, balance, and conditioning, and normal-
izing unction, without an increase in pain. A ter 2 weeks o pain- ree exercise in phase 2,
running and unctional activities o phase 3 are introduced. Phase 3 has unctional phases
and rest phases. During the unctional phase, weeks 1 and 2, running is progressed; in the
third week, or rest phase, running is decreased. T is is done to mimic the cyclic ashion o
bone growth. During the f rst 2 weeks, as bone is resorbed, running will promote the or-
mation o trabecular channels; in the third week, while the osteocytes and periosteum are
maturing, the impact loading o running is removed.58 T is cyclic progression is continued
over several weeks as the patient becomes able to per orm sport-specif c activities without
pain.58

T e patient can return to ull activity when: (a) there is no tenderness to palpation o the
a ected bone and no pain o the a ected area with repeated hopping; (b) plain f lms dem-
onstrate good bone healing; (c) there has been success ul progression o a graded return to
running with no increase in symptoms; (d) gastrocnemius–soleus exibility is within nor-
mal limits; (e) hyperpronation has been corrected or shock-absorption problems have been
decreased with proper shoes and oot orthotics i indicated; and ( ) all muscle strength and
muscle length issues o the involved lower extremity have been addressed.
Compart ment Syndromes

Compartment syndrome is a condition in which increased pressure within a f xed osseo as-
cial compartment causes compression o muscular and neurovascular structures within the
compartment. As compartment pressures increase, the venous out ow o uid decreases
and eventually stops, causing urther uid leakage rom the capillaries into the compart-
ment. Eventually arterial blood in ow also ceases secondary to rising intracompartmental
pressures.82 Compartment syndrome can be divided into 3 categories: acute compartment
syndrome, acute exertional compartment syndrome, and chronic compartment syndrome.
Acute compartment syndrome occurs secondary to direct trauma to the area and is a medi-
cal emergency.38,74,82 T e patient will complain o a deep-seated aching pain, tightness, and
swelling o the involved compartment. Reproduction o the pain will occur with passive
stretching o the involved muscles. Reduction in pedal pulses and sensory changes o the
involved nerve can be present, but are not reliable signs.82,86 Intracompartmental pressure
measurements will conf rm the diagnosis. Emergency asciotomy is the def nitive treatment.
Acute exertional compartment syndrome occurs without any precipitating trauma. Cases
have been cited in the literature in which acute compartment syndrome has evolved with
minimal to moderate activity. I not diagnosed and treated properly, it can lead to poor
unctional outcomes or the patient.24,86 Again, intracompartmental pressures will conf rm
the diagnosis, with emergency asciotomy being the treatment o choice. Chronic compart-
ment syndrome (CCS) is activity-related in that the symptoms arise rather consistently at
a certain point in the activity. T e patient complains o a sensation o pain, tightness, and
swelling o the a ected compartment that resolves upon stopping the activity. Studies indi-
cate that the anterior and deep posterior compartments are usually involved.6,57,64,75,85 Upon
presentation o these symptoms, intracompartmental pressure measurements will urther
def ne the severity o the condition. Pedowitz et al developed modif ed criteria using a slit-
catheter measurement o the intracompartmental pressures. T ese authors consider 1 or
more o the ollowing intramuscular pressure criteria as diagnostic o CCS: (a) preexercise
pressure greater than 15 mm Hg; (b) a 1-minute postexercise pressure o 30 mm Hg; (c) a
5-minute postexercise pressure greater than 20 mm Hg.51

Management o CCS is initially conservative with activity modif cation, icing, and stretch-
ing o the anterior compartment and gastrocnemius–soleus complex (see Figures 25-21 to
25-23). A lower-quarter structural exam along with gait analysis might reveal a structural
variation that is causing excessive compensatory pronation and might benef t rom the use
o oot orthotics and proper ootwear. However, these measures will not address the issue
o increased compartment pressures with activity. Cycling has been shown to be an accept-
able alternative in preventing increased anterior compartment pressures when compared
to running and can be utilized to maintain cardiovascular f tness.2 I conservative measures
ail, asciotomy o the a ected compartments has produced avorable results in a return to
higher level o activity.57,61,82,85
T e patient should be counseled regarding the outcome expectations a ter asciotomy
or CCS. Howard reported a clinically signif cant improvement in 81% o the anterior/ lateral
releases and a 50% improvement in deep posterior compartment releases with CCS.36 Slim-
mon et al noted that 58% o the subjects responding to a long-term ollow-up study or CCS
asciotomy reported exercising at a lower level than be ore the injury.68 Micheli et al noted
that emale patients may be more prone to this condition and that or reasons unclear, they
did not respond to the asciotomy as well as their male counterparts.46

Following asciotomy or CCS, the immediate goals are to decrease postsurgical pain, swell-
ing with RICE (rest, ice, compression, elevation), and assisted ambulation with the use o
crutches. A ter suture removal and so t-tissue healing o the incision has progressed, AROM
and exibility exercises should be initiated (see Figures 25-1 to 25-4, 25-18 to 25-21). Weight
bearing will be progressed as ROM improves. Gait training should be incorporated to pre-
vent abnormal movements in the gait pattern secondary to joint and so t-tissue sti ness or
muscle guarding. AROM exercises should be progressed to open-chain exercises with rub-
ber tubing (see Figures 25-5 to 25-8). Closed-kinetic-chain activities can also be initiated to
incorporate strength, balance, and proprioception that may have been a ected by the surgi-
cal procedure (see Figures 25-11 to 25-15 and 25-22 to 25-25). Lower-extremity structural
variations that lead to excessive compensatory pronation during gait should be addressed
with oot orthotics and proper ootwear a ter walking gait has been normalized. T ese mea-
sures should help control excessive movements at the subtalar joint/ lower leg and thus the-
oretically decrease muscular activity o the deep posterior compartment, which is highly
active in controlling pronation during running.54 Cardiovascular f tness can be maintained
and improved with stationary cycling and running in the deep end o a pool with a otation
device (see Figures 25-16 and 25-26). When ROM, strength, and walking gait have normal-
ized, a walking/ jogging progression can be initiated.

T e patient may return to ull activity when: (a) there is normalized ROM and strength o the
involved lower leg; (b) there are no gait deviations with walking, jogging, and running; and
(c) the patient has completed a progressive jogging/ running program with no complaints
o CCS symptoms. It should be noted that patients undergoing anterior compartment asci-
otomy may not return to ull activity or 8 to 12 weeks a ter surgery, and patients undergoing
deep posterior compartment asciotomy may not return until 3 to 4 months postsurgery.40,61
Muscle St rains
Pat homechanics
T e majority o muscle strains in the lower leg occur in the medial head o the gastroc-
nemius at the musculotendinous junction.28 T e injury is more common in middle-aged
patients and occurs in activities requiring ballistic movement, such as tennis and basket-
ball. T e patient may eel or hear a pop as i being kicked in the back o the leg. Depend-
ing on the severity o the strain, the athlete may be unable to walk secondary to decreased
ankle dorsi exion in a closed kinetic chain, which passively stretches the injured muscle
and causes pain during the push-o phase o gait. Palpation will elicit tenderness at the site
o the strain, and a palpable divot may be present, depending on the severity o the injury
and how soon it is evaluated.
Injury Mechanism
Strains o the medial head o the gastrocnemius usually occur during sudden ballistic move-
ments. A common scenario is the patient lunging with the knee extended and the ankle
dorsi exed. T e ankle plantar exes, in this case the medial head o the gastrocnemius, are
activated to assist in push-o o the oot. T e muscle is placed in an elongated position and
activated in a very short period o time. T is places the musculotendinous junction o the
gastrocnemius under excessive tensile stress. T e muscle–tendon junction, a transition area
o one homogeneous tissue to another, is not able to endure the tensile loads nearly as well
as the homogeneous tissue itsel , and tearing o the tissue at the junction occurs.

T e initial management o a gastrocnemius strain is ice, compression, and elevation. It is
important or the patient to pay special attention to compression and elevation o the lower
extremity to avoid edema in the oot and ankle that can urther limit ROM and prolong the
rehabilitation process. Gentle stretching o the muscle–tendon unit should be initiated early
in the rehabilitation process (see Figure 25-18). Ankle plantar exor strengthening with rub-
ber tubing can also be initiated when tolerated (see Figure 25-5). Weight bearing may be
limited to an as-tolerated status with crutches. T e oot/ ankle will pre er a plantar exed
position, and closed-kinetic-chain dorsi exion o the oot and ankle, which is required dur-
ing walking, will stress the muscle and cause pain. Pulsed ultrasound can be utilized early in
the rehabilitation process and eventually progressed to continuous ultrasound or its ther-
mal e ects. A stationary cycle can be used or an active warm-up as well as cardiovascular
f tness. A heel li t may be placed in each shoe to gradually increase dorsi exion o the oot
and ankle as the patient is progressed o crutches. Standing, stretching, and strengthen-
ing can be added as so t-tissue healing occurs and ROM and strength improve. Eventually
the patient can be progressed to a walking/ jogging program and sport-specif c activity. It is
important that the patient warm up and stretch properly be ore activity, to prevent reinjury.

Early management o a medial head gastrocnemius strain ocuses on reduction o pain and
swelling with ice, compression, and elevationand modif ed weight bearing. T e patient is
encouraged to per orm gentle towel stretching or the a ected muscle group several times
per day (see Figure 25-18). AROM o the oot and ankle in all planes will also acilitate move-
ment and act to stretch the muscle (see Figures 25-1 to 25-4). With mild muscle strains,
the patient may be o crutches and per orming standing cal stretches and strengthening
exercises by about 7 to 10 days with a normal gait pattern (see Figures 25-12, 25-13, and 25-
19). Moderate to severe strains may take 2 to 4 weeks be ore normalization o ROM and gait
occur. T is is usually because o the excessive edema in the oot and ankle. Strengthening can
be progressed rom open- to closed-chain activity as so t-tissue healing occurs (see Figures
25-14, 25-15, and 25-22 to 25-25). As walking gait is normalized, the patient is encouraged to
begin a graduated jogging program in which distance and speed are modulated throughout
the progression. Most so t-tissue injuries demonstrate good healing by 14 to 21 days postin-
jury. In the case o mild muscle strain, as the patient becomes more com ortable with jogging
and running, plyometric activities can be added to the rehabilitation process. Plyometric
activities should be introduced in a controlled ashion with at least 1 to 2 days o rest between
activities to allow or muscle soreness to diminish. As the patient adapts to the plyometric
exercises, sport-specif c training should be added. Care should be taken to save sudden, bal-
listic activities or when the patient is warmed up and the gastrocnemius is well stretched.

T e patient may return to ull activity when the ollowing criteria have been met: (a) ull
ROM o the oot and ankle; (b) gastrocnemius strength and endurance are equal to the
uninvolved side; (c) ability to walk, jog, run, and hop on the involved extremity without
any compensation; and (d) success ul completion o a sport-specif c unctional progression
with no residual cal symptoms.
Medial Tibial St ress Syndrome

Pat homechanics
M SS is a condition that involves increasing pain about the distal two-thirds o the poste-
rior medial aspect o the tibia.27,70 T e soleus and tibialis posterior have been implicated as
muscular orces that can stress the ascia and periosteum o the distal tibia during running
activities.2,26,64 In a cadaveric dissection study, Beck and Osternig implicated the soleus,
and not the tibialis posterior, as the major contributor to M SS.5 Magnusson et al noted
reduced bone mineral density at the site o M SS, but could not ascertain whether this was
the cause or the result.42 Bhatt reported abnormal histologic appearance o bone and peri-
osteum in longstanding M SS.10 Pain is usually di use about the distal medial tibia and the
surrounding so t tissues and can arise secondary to a combination o training errors, exces-
sive pronation, improper ootwear, and poor conditioning level.16,66 Initially, the area is di -
usely tender and might hurt only a ter an intense workout. As the condition worsens, daily
ambulation may be pain ul and morning pain and sti ness may be present. T ere is limited
evidence in the literature that interventions used in rehabilitation are e ective at preventing
M SS.19,88 Rehabilitation o this condition must be comprehensive or each individual and
address several actors, including musculoskeletal, training, and conditioning, as well as
proper ootwear and orthotics intervention.
Injury Mechanism
Many sources have linked excessive compensatory pronation as a primary cause o
M SS.16,26,64,70,80 Bennett et al reported that a pronatory oot type was related to M SS. T e
authors noted that the combination o a patient’s gender and navicular drop test measures
provided an accurate prediction or the development o M SS in high school runners.9 Sub-
talar joint pronation serves to dissipate ground reaction orces upon oot strike in order to
reduce the impact to proximal structures. I pronation is excessive, or occurs too quickly,
or at the wrong time in the stance phase o gait, greater tensile loads will be placed on the
muscle–tendon units that assist in controlling this complex triplanar movement.31,78 Lower-
extremity structural variations, such as a rear oot and ore oot varus, can cause the subta-
lar joint to pronate excessively in order to get the medial aspect o the ore oot in contact
with the ground or push-o .70 T e magnitude o these orces will increase during running,
especially with a rear oot striker. Sprinters may present with similar symptoms but with a
di erent cause, that being overuse o the plantar exors secondary to being on their toes
during their event. raining sur aces including embankments and crowned roads can place
increased tensile loads on the distal medial tibia, and modif cations should be made when-
ever possible.

Management o this condition should include physician re erral to rule out the possibility
o stress racture via the use o bone scan and plain f lms. Activity modif cation along with
measures to maintain cardiovascular f tness should be set in place immediately.
Correction o abnormal pronation during walking and running can be addressed with
antipronation taping and temporary orthotics to determine their e ectiveness. Vicenzino
et al reported that these measures were help ul in controlling excessive pronation.83 I the
above measures are help ul, a custom oot orthotic can be abricated. Masse’ Genova and
Gross noted that oot orthotics signif cantly reduced maximum calcaneal eversion and cal-
caneal eversion at heel rise with abnormal pronators during treadmill walking.44 Proper
ootwear, especially running shoes with motion-control eatures, can also be very help ul
in dealing with M SS. Although the above-mentioned measures provide passive support
to address abnormal pronation, exercise sandals may provide a dynamic approach to man-
aging excessive pronation issues. Michell et al noted a trend in reduced rear oot eversion
angles in 2-dimensional rear oot kinematics during bare oot treadmill walking with abnor-
mal pronators in subjects who trained in the exercise sandals or 8 weeks.47 T e subjects also
demonstrated improved balance in a single-leg stance and subjectively noted improved
oot unction.47 T ese improvements might be a result o increased muscle activity o the
oot intrinsics via the short- oot concept and increased activity o the lower-leg musculature
that may assist in controlling pronation. Also, the exercise sandals appear to place the oot
in a more supinated position, which may enhance the cuboid pulley mechanism and its
e ects on the unction o the f rst ray during the push-o phase o gait.35 Ice massage to the
a ected area may help reduce localized pain and in ammation. A exibility program or
the gastrocnemius–soleus musculature should be initiated.

Running and jumping activities may need to be completely eliminated or the f rst 7 to
10 days a ter diagnosis. Pool workouts with a otation device will help maintain cardiovas-
cular f tness during the healing process. Gastrocnemius–soleus exibility is improved with
static stretching (see Figure 25-19). Ice and electrical stimulation can be used to reduce
in ammation and modulate pain in the early stages. As the condition improves, general
strengthening o the ankle musculature with rubber tubing can be per ormed along with
cal muscle strengthening (see Figures 25-5 to 25-8, 25-12, and 25-13). T ese exercises may
cause muscle atigue but should not increase the patient’s symptoms. T e exercise sandal
progression can be introduced to enhance dynamic pronation control at the oot and ankle
(see able 25-1; Figures 25-29 to 25-34, and 25-36). An isokinetic strengthening program o
the ankle inverters and everters can be utilized to improve strength and has been shown
to reduce pronation during treadmill running (see Figure 25-24).25 As mentioned previ-
ously, it is imperative that all structural deviations that cause pronation be addressed with
a oot orthotic or at least proper motion-control shoes. As pain to palpation o the distal
tibia resolves, the patient should be progressed to a jogging/ running program on grass
with proper ootwear. T is may involve beginning with a 10- to 15-minute run and pro-
gressing by 10% every week. In the case o track athletes, a pool or bike workout can be
implemented or 20 to 30 minutes a ter the run to produce a more demanding workout.
T e patient needs to be compliant with a gradual progression and should be educated to
avoid doing too much, too soon, which could lead to a recurrence o the condition or pos-
sibly a stress racture.

T e patient may return to ull activity when: (a) there is minimal to no pain to palpation
o the a ected area; (b) all causes o excessive pronation have been addressed with an
orthotic and proper ootwear; (c) there is su cient gastrocnemius–soleus musculature ex-
ibility; and (d) the patient has success ully completed a gradual running progression and a
sport-specif c unctional progression without an increase in symptoms.
Achilles Tendinit is
Pat homechanics
Achilles tendinitis is an in ammatory condition that involves the Achilles tendon and/ or
its tendon sheath, the paratenon. O ten there is excessive tensile stress placed on the ten-
don repetitively, as with running or jumping activities, that overloads the tendon, espe-
cially on its medial aspect.49,63 T is condition can be divided into Achilles paratenonitis
or peritendinitis, which is an in ammation o the paratenon or tissue that surrounds the
tendon, and tendinosis, in which areas o the tendon consist o mucinoid or atty degen-
eration with disorganized collagen.63 T e patient o ten complains o generalized pain and
sti ness about the Achilles tendon region that when localized is usually 2- to 6-cm proxi-
mal to the calcaneal insertion. Uphill running or hill workouts and interval training will
usually aggravate the condition. T ere may be reduced gastrocnemius and soleus muscle
exibility in general that may worsen as the condition progresses and adaptive shortening
occurs. Muscle testing o the above muscles may be within normal limits, but pain ul, and
a true def cit may be observed when per orming toe raises to atigue as compared to the
uninvolved extremity.
Injury Mechanism
Achilles tendinitis will o ten present with a gradual onset over a period o time. Initially the
patient might ignore the symptoms, which might present at the beginning o activity and
resolve as the activity progresses. Symptoms may progress to morning sti ness and discom-
ort with walking a ter periods o prolonged sitting. Repetitive weightbearing activities, such
as running, or early season conditioning in which the duration and intensity are increased
too quickly with insu cient recovery time, will worsen the condition. Excessive compensa-
tory pronation o the subtalar joint with concomitant internal rotation o the lower leg sec-
ondary to a ore oot varus, tibial varum, or emoral anteversion will increase the tensile load
about the medial aspect o the Achilles tendon.32,63 Decreased gastrocnemius–soleus com-
plex exibility can also increase subtalar joint pronation to compensate or the decreased
closed-kinetic-chain dorsi exion needed during early and midstance phase o running. I
the patient continues to train, the tendon will become urther in amed and the gastroc-
nemius–soleus musculature will become less e cient secondary to pain inhibition. T e
tendon may be warm and pain ul to palpation, as well as thickened, which may indicate the
chronicity o the condition. Crepitans may be palpated with AROM plantar and dorsi exion
and pain will be elicited with passive dorsi exion.

Achilles tendinitis can be resistant to a quick resolution secondary to the slower healing
response o tendinous tissue. It has also been noted that an area o hypovascularity exists
within the tendon that may urther impede the healing response. It is im portant to create
a proper healing environment by reducing the o ending activity and replacing it with an
activity that will reduce strain on the tendon. Studies have shown that the Achilles ten-
don orce during running approaches 6 to 8 tim es body weight.63 Addressing structural
aults that may lead to excessive pronation or supination should be done through proper
ootwear and oot orthotics, as well as exibility exercises or the gastrocnemius–soleus
complex. So t-tissue manipulation o the gastrocnem ius–soleus with a oam roller can be
help ul prior to stretching. Modalities such as ice can help reduce pain and in am ma-
tion early on, and ultrasound can acilitate an increased blood ow to the tendon in the
later stages o rehabilitation. Cross- riction massage may be used to break down adhe-
sions that may have ormed during the healing response and urther improve the gliding
ability o the paratenon. Strengthening o the gastrocnem ius–soleus musculature must be
progressed care ully so as not to cause a recurrence o the symptoms. Lastly a gradual pro-
gression must be made or a sa e return to activity to avoid having the condition becoming
chronic.

Activity modif cation is necessary to allow the Achilles tendon to begin the healing pro-
cess. Swim m ing, pool running with a otation device, stationary cycling, and use o an
upper-body ergom eter are all possible alternative activities or cardiovascular m ain-
tenance (see Figures 25-16, 25-26, and 25-27). It is im portant to reduce stresses on the
Achilles tendon that may occur with daily ambulation. Proper ootwear with a slight heel
li t, such as a good running shoe, can reduce stress on the tendon during gait. Struc-
tural biom echanical abnormalities that mani est with excessive pronation or supination
should be addressed with a custom oot orthotic. Placing a heel li t in the shoe or build-
ing it into the orthotic can reduce stress on the Achilles tendon initially, but should be
gradually reduced so as not to cause an adaptive shortening o the muscle-tendon unit.
Gentle pain- ree stretching can be per orm ed several tim es per day and can be done
a ter an active or passive warm -up with exercise or m odalities such as superf cial heat or
ultrasound (see Figures 25-18 and 25-19). Open-kinetic-chain strengthening with rubber
tubing can begin early in the rehabilitation process and should be progressed to closed-
kinetic-chain strengthening in a concentric and eccentric ashion utilizing the patient’s
body weight with m odif cation o sets, repetitions, and speed o exercise to intensi y the
rehabilitation session (see Figures 25-5, 25-12, and 25-13). Recent studies report excellent
results with the use o eccentric training o the gastrocnemius–soleus musculature with
chronic Achilles tendinosis over a 12-week period.1,52,59 T e patient should be progressed
to a regim en o isolated eccentric loading o the Achilles tendon using body weight ( Fig-
ure 25-35). A walking–jogging progression on a f rm but orgiving sur ace can be initi-
ated when the sym ptom s have resolved and ROM, strength, endurance, and exibility
have been normalized to the uninvolved extrem ity. T e patient must be rem inded that
this progression is designed to improve the a ected tendon’s ability to tolerate stress in
a controlled ashion and not to im prove f tness level. Studies show that cardiovascular
f tness can be maintained with biking and swimm ing.23 Finally, it is im portant to educate
the patient on the nature o the condition in order to set realistic expectations or a sa e
return without recurrence o the condition.
REH A B I LI TATIO N P LA N
ACHILLES TENDINITIS MANAGEMENT PLAN The goal is to decrease pain,
address the issues of abnormal pronation, and provide a
INJURY SITUATION A 17-year-old male lacrosse player protected environment for the tendon to heal. Eventually
presents with pain in his right Achilles. He notes that the address ROM and strength de cits that are preventing the
pain has been present for the past week, secondary to athlete from functioning at his expected level.
an increase in preseason conditioning that has included
long runs on asphalt, hill running, and interval training PHASE ONE Acute In ammatory Stage
on the track. He currently has morning sti ness and pain
with walking, especially up hills and going down stairs. GOALS: Modulate pain, address abnormal pronation,
The patient is concerned that the pain will a ect his and begin appropriate therapeutic exercise.
conditioning for the lacrosse season, which will start in
3 weeks. Estimated Length of Time (ELT): Day 1 to Day 4
Use ice and electrical stimulation to decrease pain. Non-
SIGNS AND SYMPTOMS The patient stands in moder- steroidal antiin ammatory drugs could help reduce
ate subtalar joint pronation with mild tibial varum. His in ammation. A foot orthotic could be fabricated to
single-leg stance balance is poor, with an increase in sub- address the excessive pronation, which may be placing
talar joint pronation and internal rotation of the entire increased tensile stress on the medial aspect of the Achil-
lower extremity. Observation of the tendon reveals slight les tendon. A heel lift could be built into the foot orthotic.
thickening. Palpation reveals mild crepitus with pain 4 cm It might be recommended that the patient wear a motion-
proximal to the calcaneal insertion on the medial side of control running shoe to address pronation and provide a
the tendon. ROM testing reveals tightness in both the gas- heel lift. The patient could begin gentle, pain-free towel
trocnemius and soleus musculature versus the uninvolved stretching for the gastrocnemius and soleus musculature
side. A 6-inch lateral step-down demonstrates restricted several times per day. Conditioning could be done in a
closed-kinetic-chain ankle dorsi exion that is painful, with pool or on a bike.
compensation at the hip to get the opposite heel to touch
the ground. The patient is able to perform 10 heel raises PHASETWO Fibroblastic Repair Stage
on the right with pain and 20 on the left without pain.
Walking gait reveals increased pronation during the entire GOALS: Increase gastrocnemius–soleus exibility, gain
stance phase of gait. A 12-degree forefoot varus is noted strength, and improve single -leg stance (SLS) balance
on the right with the athlete in a prone subtalar joint neu- and single -leg stance closed-kinetic-chain functional
tral position. activity.

T e patient may return to ull activity when: (a) there has been ull resolution o symptoms
with ADL and minimal or no symptoms with sport-related activity; (b) ROM, strength, ex-
ibility, and endurance are equal to the opposite uninvolved extremity; and (c) all contribut-
ing biomechanical aults have been corrected during walking and running gait analysis with
proper ootwear and/ or custom oot orthotics.
Achilles Tendon Rupt ure

Pat homechanics
T e Achilles tendon is the largest tendon in the human body. It serves to transmit orce rom
the gastrocnemius and soleus musculature to the calcaneus. ension through the Achilles
tendon at the end o stance phase is estimated at 250% o body weight.63 Rupture o the Achil-
les tendon usually occurs in an area 2 to 6 cm proximal to the calcaneal insertion, which has
been im plicated as an avascular site prone to degenerative changes.17,34,39 T e injury pres-
ents a ter a sudden plantar exion o the ankle, as in jumping or accelerating with a sprint.
T e patient will o ten eel or hear a pop and note a sensation o being kicked in the back
o the leg. Plantar exion o the ankle will be pain ul and lim ited but still possible with the
Estimated Length of Time (ELT): Days 5 to 14 be sport-speci c and initially should be done every other
day to allow the tendon to recover. A sport-speci c func-
As signs of in ammation decrease, the use of ultrasound
tional program could also begin when straight running
could be introduced, rst at a pulsed level and then at a
and sprinting are tolerated by the patient. Other forms of
continuous level. Stretching could be progressed to stand-
conditioning could also be continued to maintain tness
ing on a at surface. Strengthening could be started with
levels. Achilles taping may be of bene t when the athlete
isometrics and progressed to open-kinetic-chain isoton-
returns to training on a daily basis to reduce excess load to
ics with rubber tubing. As the patient improves, stand-
the tendon over the next several weeks.
ing double-leg heel raises can be introduced. Single-leg
stance activity could be added, focusing on control of the Criteria for Returning to Competitive Lacrosse
lower extremity, especially foot pronation and lower-leg
1. No pain with walking, ADL, and running.
internal rotation. Conditioning at the end of this stage
could be upgraded to weightbearing activity, such as the 2. Gastrocnemius–soleus exibility and strength are
elliptical trainer with the foot at on the pedal, avoiding equal to the uninvolved extremity.
ankle plantar exion. 3. Improved single-leg stance balance, closed-kinetic-
chain function (step-down, squat, lunge).
PHASETHREE Maturation Remodeling Stage
GOALS: Complete elimination of pain and full return to DISCUSSION QUESTIONS

activity.
1. Why would an orthotic be helpful in this case?
Estimated Length of Time (ELT): Week 3 to Full Return 2. Why would closed-kinetic-chain activities such as
a single-leg stance and reach and a step-down be
As ROM and strength improve, the athlete could be pro- painful and limited with this condition?
gressed to gastrocnemius–soleus stretching on a slant
3. Explain what training errors may have caused this
board and single-leg heel raises, with an increased focus
condition to arise with this patient.
on eccentric loading of the involved side. Dynamic mus-
cle loading via double-leg hopping on a yielding surface 4. Explain what intrinsic factors may have
such as jumping rope for short periods of time could be contributed to this condition occurring with
added. A running program on a at, yielding surface such this patient.
as grass or track could be initiated with good running 5. Explain why an Achilles tendon taping would
shoes and the foot orthotic in place. The program should bene t this patient during his sporting activity.
assistance o the tibialis posterior and the peroneals. A palpable de ect will be noted along
the length o the tendon, and the T ompson test will be positive. T e patient will require
the use o crutches to continue ambulation without an obvious limp.
Injury Mechanism
Achilles tendon rupture is usually caused by a sudden orce ul plantar exion o the ankle.
It has been theorized that the area o rupture has undergone degenerative changes and
is more prone to rupture when placed under higher levels o tensile loading.34,49,62,63 T e
degenerative changes may be a result o excessive compensatory pronation at the subta-
lar joint to accommodate or structural deviations o the ore oot, rear oot, and lower leg
during walking and running. T is pronation can place an increased tensile stress on the
medial aspect o the Achilles tendon. Also, a chronically in exible gastrocnemius–soleus
complex will reduce the available amount o dorsi exion at the ankle joint, and excessive
subtalar joint pronation will assist in accommodating this loss. T e above mechanisms
may result in tendinitis symptoms that precede the tendon rupture, but this is not always
the case. Fatigue o the deconditioned patient or weekend warrior may also contribute to
tendon rupture, as well as improper warm-up prior to ballistic activities such as basketball
or racquet sports.33

A ter an Achilles tendon rupture, the question o surgical repair versus cast immobilization
will arise. Cetti et al report that surgical repair o the tendon is recommended to allow the
patient to return to previous levels o activity.17 Surgical repair o the Achilles tendon may
require a period o immobilization or 6 to 8 weeks to allow or proper tendon healing.15,34,43
T e deleterious e ects o this lengthy immobilization include muscle atrophy, joint sti ness
including intra-articular adhesions and capsular sti ness o the involved joints, disorga-
nization o the ligament substance, and possible disuse osteoporosis o the bone.15 Iso-
kinetic strength def cits or the ankle plantar exors, especially at lower speeds, have been
documented with periods o cast immobilization or 6 weeks.41 Steele et al noted signif -
cant def cits isokinetically o ankle plantar exor strength a ter 8 weeks o immobilization.68
Some eel that the primary limiting actor that in uences unctional outcome might be the
duration o postsurgical immobilization.72 Several studies have been done using early con-
trolled ankle motion and progressive weight bearing without immobilization.3,15,34,43,63,69,71,81
It is important not only to regain ull ROM without harming the repair, but also to regain
normal muscle unction through controlled progressive strengthening. T is can be per-
ormed through a variety o exercises, including isometrics, isotonics, and isokinetics (see
Figures 25-1 to 25-13). Open- and closed-kinetic-chain activities can be incorporated into
the progression to gradually increase weightbearing stress on the tendon repair, as well as
to improve proprioception (see Figures 25-11, 25-14, 25-15, and 25-22 to 25-25). Cardiovas-
cular endurance can be maintained with stationary biking and pool running with a otation
device. Gait normalization or walking and running can be per ormed using a treadmill.

It is important or the therapist to have an open line o communication with the physi-
cian in charge o the surgical repair. Decisions about length and type o immobilization,
weightbearing progression, allowable ROM, and progressive strengthening should be thor-
oughly discussed with the physician. Excellent results have been reported with early and
controlled mobilization with the use o a splint that allows early plantar exion ROM and
that slowly increases ankle dorsi exion to neutral and ull dorsi exion over a 6- to 8-week
period o time.15,34 More recent studies have noted excellent unctional results with early
weight bearing and ROM. Aoki et al reported a ull return to sports activity in 13.1 weeks.3
Controlled progressive weight bearing based on percentages o the patient’s body weight
can be done over 6 to 8 weeks postoperatively, with ull weight bearing by the end o this
time rame. During the early stages o rehabilitation, ice, compression, and elevation are
used to decrease swelling. A variety o ROM exercises are done to increase ankle ROM in
all planes as well as initiate activation o the surrounding muscles (see Figures 25-1 to 25-4,
25-9, 25-10, 25-14, 25-15, 25-18, and 25-20). By 4 to 6 weeks postoperatively, strengthening
exercises with rubber tubing can be progressed to closed-chain exercises utilizing a per-
centage o the patient’s body weight with heel raises on a otal Gym apparatus (see Figures
25-5, 25-8, and 25-11). It is important to do more concentric than eccentric loading initially,
so as not to place excessive stress on the repair. Gradual increases in eccentric loading can
occur rom 10 to 12 weeks postoperatively. Also at this time, isokinetic exercise can be intro-
duced with submaximal high-speed exercise and be progressed to lower concentric speeds
gradually over time (see Figures 24-24 and 24-25). By 3 months, ull-weightbearing heel
raises can be per ormed (see Figures 25-12 and 25-13). At the same time a walking/ jogging
program can be initiated. Isokinetic strength testing can be done between 3 and 4 months to
determine i any def cits in ankle plantar exor strength exist. T e number o single-leg heel
raises per ormed in a specif ed amount o time as compared to the uninvolved extremity
can also be utilized to determine unctional plantar exor strength and endurance. Sport-
related unctional activities can be initiated at 3 months along with a progressive jogging
program. A ull return to unrestricted athletic activity can begin a ter 6 months, once the
patient success ully meets all predetermined goals.

T e patient can return to ull activity a ter the ollowing criteria have been met: (a) ull
AROM o the involved ankle as compared to the uninvolved side; (b) isokinetic strength
o the ankle plantar exors at 90% to 95% o the uninvolved side; (3) 90% to 95% o the
number o heel raises throughout the ull ROM in a 30-second period as compared to the
uninvolved side; and (4) the ability to walk, jog, and run without an observable limp and
success ul completion o a sport-related unctional progression without any Achilles ten-
don irritation.
Ret rocalcaneal Bursit is

Pat homechanics
T e retrocalcaneal bursae is a disc-shaped object that lies between the Achilles tendon
and the superior tuberosity o the calcaneus.12,63 T e patient will report a gradual onset
o pain that may be associated with Achilles tendinitis. Care ul palpation anterior to the
Achilles tendon will rule out involvement o the tendon. Pain is increased with AROM/
passive ROM ankle dorsi exion and relieved with plantar exion. Depending on the sever-
ity and swelling associated, it may be pain ul to walk, especially when attempting to attain
ull closed-kinetic-chain ankle dorsi exion during the midstance phase o gait.
Injury Mechanism
Loading the oot and ankle in repeated dorsi exion, as in uphill running, can be a cause o
this condition. When the oot is dorsi exed, the distance between the posterior/ superior
calcaneus and the Achilles tendon will be reduced, resulting in a repeated mechanical com-
pression o the retrocalcaneal bursae. Also, structural abnormalities o the oot may lead to
excessive compensatory movements at the subtalar joint, which may cause riction o the
Achilles tendon on the bursae with running.

Because o the close proximity o other structures, it is important to rule out involvement
o the calcaneus and Achilles tendon with care ul palpation o the area. Rest and activity
modif cation in order to reduce swelling and in ammation is necessary. I walking is pain-
ul, crutches with weight bearing as tolerated is recommended or a brie period. Gentle
but progressive stretching and strengthening should be added as tolerated, with care being
taken not to increase pain with gastrocnemius–soleus stretching (see Figures 25-5, 25-12,
25-13, 25-18, and 25-19). I excessive compensatory pronation is noted during gait analy-
sis, recommendations on proper ootwear should be made, especially in regard to the heel
counter, and oot orthotics should be considered.

T e early management o this condition requires all measures to reduce pain and in am-
mation, including ice, rest rom o ending activity, proper ootwear, and modif ed weight
bearing with crutches i necessary. Cardiovascular f tness can be maintained with pool
running with a otation device. Gentle stretching o the gastrocnemius–soleus needs to
be introduced slowly because this will tend to increase compression o the retrocalcaneal
bursae. As pain resolves and ROM and walking gait are normalized, the patient may begin
a progressive walking/ jogging program. T e patient can progress back to activity as the
condition allows. Heel li ts in both shoes may be necessary in the early return to activity,
with gradual weaning away rom them as AROM/ passive ROM dorsi exion improves. T e
condition may allow ull return in 10 days to 2 weeks i treated early enough. I the condition
persists, 6 to 8 weeks o rest, activity modif cation, and treatment may be needed be ore a
success ul result is attained with conservative care.
Crit eria for Ret urn t o Full Act ivit y

T e ollowing criteria need to met be ore return to ull activity: (a) no observable swelling
and minimal to no pain with palpation o the area at rest or a ter daily activity; (b) ull ankle
dorsi exion AROM and normal pain- ree strength o the gastrocnemius and soleus muscu-
lature; and (c) normal and pain- ree walking and running gait.
SUMMARY
1. Although some injuries in the region o the lower leg are acute, most injuries seen in an
athletic population result rom overuse, most o ten rom running.
2. ibial ractures can create long-term problems or the patient i inappropriately man-
aged. Fibular ractures generally require much shorter periods or immobilization.
reatment o these ractures involves immediate medical re erral and most likely a pe-
riod o immobilization and restricted weight bearing.
3. Stress ractures in the lower leg are usually the result o the bone’s inability to adapt to
the repetitive loading response during training and conditioning o the patient and are
more likely to occur in the tibia.
4. CSSs can occur rom acute trauma or repetitive trauma o overuse. T ey can occur in
any o the 4 compartments, but are most likely in the anterior compartment or deep
posterior compartment.
5. Rehabilitation o M SS must be comprehensive and address several actors, including
musculoskeletal, training, and conditioning, as well as proper ootwear and orthotics
intervention.
6. Achilles tendinitis o ten presents with a gradual onset over a period o time and may be
resistant to a quick resolution secondary to the slower healing response o tendinous
tissue.
7. Perhaps the greatest question a ter an Achilles tendon rupture is whether surgical re-
pair or cast immobilization is the best method o treatment. Regardless o treatment
method, the time required or rehabilitation is signif cant.
8. With retrocalcaneal bursitis the athlete will report a gradual onset o pain that may be
associated with Achilles tendinitis. reatment should include rest and activity modif -
cation in order to reduce swelling and in ammation.
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Ankle and Foot
Sco t t M ille r, St u a r t L. (Sk ip ) Hu n t e r,
a n d Willia m E. Pre n t ice
OBJJEC
Discuss the biomechanics and functional anatomy of the foot and ankle.
Discuss the various injuries that occur at the ankle and foot.
Discuss the various treatment options for rehabilitating the ankle and foot.
Discuss the various functional exercises and appropriate progressions.
Discuss the effect of rst ray position, forefoot varus, forefoot valgus, and calcaneal varus
on the foot and lower extremity.
Describe a biomechanical examination of the foot.
Describe techniques for orthosis fabrication.
Discuss appropriate running footwear options.
Identify speci c pathomechanics and/or pathology associated with the foot and ankle and the
appropriate treatment options.
823
824 Chapte r 26 Rehabilitation of the Ankle and Foot
Talocrural Joint
T e ankle or talocrural joint is a hinge joint ormed by articular acets on the distal tibia,
the medial malleolus, and the lateral malleolus, which articulate with the talus. T e talus is
the second largest tarsal bone and main weightbearing bone o the articulation linking the
lower leg to the oot. T e relatively square shape o the talus allows the ankle only 2 move-
ments about the transverse axis: plantarf exion and dorsif exion. Because the talus is wider
on the anterior aspect than posteriorly, the most stable position o the ankle is dorsif ex-
ion as the talus ts tighter between the malleoli. In contrast, as the ankle moves into plan-
tarf exion, the wider portion o the tibia is brought into contact with the narrower posterior
aspect o the talus, creating a less-stable position than dorsif exion.5
T e lateral malleolus o the bula extends urther distally so that the bony stability o
the lateral aspect o the ankle is more stable than the medial. Motion at the talocrural joint
ranges rom 20 degrees o dorsif exion to 50 degrees o plantarf exion, depending on the
patient. An individual requires 20 degrees o plantarf exion and 10 degrees o dorsif exion
or walking, and up to 25 degrees o plantarf exion or running or normal gait.2,3
Talocrural Joint Ligament s

T e ligamentous support o the ankle consists o the articular capsule, 3 lateral liga-
ments, 2 ligaments that connect the tibia and bula, and the medial or deltoid ligament
(Figure 26-1). T e 3 lateral ligaments include the anterior talo bular, posterior talo bular,
and calcaneo bular ligaments. T e anterior and posterior tibio bular ligaments bridge the
tibia and bula and orm the distal portion o the interosseous membrane. T e thick deltoid
ligament provides primary resistance to oot eversion. A thin articular capsule encases the
ankle joint.
Talocrural Joint Muscles

T e muscles passing posterior to the lateral malleolus will produce ankle plantarf exion
along with toe f exion. Anterior muscles serve to dorsif ex the ankle and to produce toe
extension. T e anterior muscles include the extensor hallucis longus, the extensor digito-
rum longus, the peroneus tertius, and the tibialis anterior. T e posterior muscle group alls
Ante rior
tibiofibula r
Ante rior
ta lofibula r
La te ra l P os te rior
tibiofibula r De ltoid
ta loca lca ne a l
P os te rior
P os te rior ta lotibia l
ta lofibula r P os te rior
Ca lca ne ofibula r ta loca lca ne a l
A B
Figure 26-1 Lig ame nts o f the talo crural jo int
A. Lateral aspect. B. Medial aspect.

Tibia
Tibia
Fibula
Ta lus Fibula
Ta lus
Na vicula r Na vicula r
Cune iforms Cune iforms
S e s a moid P ha la nge s
Ca lca ne us Ca lca ne us
A Me ta ta rs a ls P ha la nge s
B Me ta ta rs a ls Cuboid
Figure 26-2 Bo ne s o f the fo o t
A. Medial aspect. B. Lateral aspect.
into 3 layers: at the super cial layer is the gastrocnemius; the middle layer includes the
soleus and the plantaris; and the deep layer contains the tibialis posterior, f exor digitorum
longus, and f exor hallucis longus.5
Subt alar Joint

T e subtalar joint (S J) consists o the articulation between the talus and the calcaneus
( Figure 26-2).97 Supination and pronation are normal m ovements that occur at the S J.
T ese movem ents are triplanar movements, that is, movem ents that occur in all 3 planes
sim ultaneously.28,73,84 In non–weight bearing, pronation is the com posite m otion o
abduction, dorsif exion, and calcaneal eversion. Supination is the com posite m otion o
adduction, plantarf exion, and calcaneal inversion.2,28,73,110,118
In weight bearing, the S J also acts as a torque convertor to translate the pronation
or supination into leg rotation.2,110,118 S J pronation creates tibial internal rotation when
the knee f exes (unlocks), whereas supination acilitates tibial external rotation when the
knee extends. T e movements o the talus during pronation and supination have pro ound
e ects on the lower extremity, both proximally and distally.
Effect s of Rearfoot and Forefoot Alignment

and Mobilit y on STJ Posit ion
T e evaluation o rear oot and ore oot alignment and mobility to determine i there are
primary abnormalities o the oot is essential in the treatment o any lower-extremity over-
use injury. T is assessment is per ormed in a subtalar joint neutral (S JN) position, most
commonly with the patient in a prone position. Once S JN is attained, the evaluator looks
or deviations rom intrinsic normalcy, which can be described as the bisection o the cal-
caneus (posteriorly) being parallel with the bisection o the lower third o the lower leg
between the tibia and bula. Next, the posterior bisection o the calcaneus is perpendic-
ular to the line bisecting the second through th metatarsal heads. Finally, metatarsal’s
2 through 5 should be in the same plane as the rst metatarsal.2,3
When alignment abnormalities are present in the ore oot or rear oot, compensation
or these alignment aults occur. Compensation can be de ned as the movement o one
body part in order to neutralize the e ects o a movement or alignment o another body
part. Normal compensation allows or normal unction o the oot and ankle. However,
excessive compensation occurs when the

motion o the oot and ankle surpasses the
tolerance o the supportive tissues, which
can result in so t-tissue damage.
Compensation can take place at either
the rear oot or the ore oot. Rear oot com-
pensation occurs when the S J pronates
or supinates to get the plantar sur ace o
the calcaneus f at on the ground. Fore oot
compensation occurs when the S J and
midtarsal joint (M J) pronate or supi-
nate to get the metatarsal heads f at on
the ground. A oot is described as uncom-
pensated when the rear oot or ore oot
does not reach f at contact to the ground,
usually because o lack o S J motion or
Figure 26-3 Co mpe nsate d subtalar o r calcane al varus extreme abnormal alignment in the lower
extremity.2,3
Comparing non–weightbearing neutral to weightbearing resting position. Com pensated subtalar (calcaneal)
(Figure used with permission of Brian Hoke, American Physical Rehabilitation varus is present when the calcaneus is
Network.) inverted and the ore oot is in neutral in
a non–weightbearing position. In weight
bearing, compensation is then noted with
increased S J pronation bringing the plantar sur ace o the calcaneus f at to the ground
(Figure 26-3). Uncompensated subtalar (calcaneal) varus is evident when there is insu -
cient motion o the S J to compensate or the de ormity and the calcaneus remains inverted
(Figure 26-4).2,3
Compensated ore oot varus is present when the calcaneus is neutral and the ore oot
is in a varus position ( rst metatarsal more cephalad as compared to the th) in a non–
weightbearing position. In weight bearing, compensation occurs secondary to increased
S J pronation bringing the ore oot into
contact with the ground ( Figure 26-5).
ypically, this com pensation involves
excessive ore oot m obility and the S J
rem ains pronated throughout stance
phase. Uncom pensated ore oot varus is
evident when there is insu cient motion
at the S J, M J, or rst ray to bring the
ore oot into contact with the ground
(Figure 26-6).2,3
Compensated ore oot valgus is pres-
ent when the calcaneus is neutral and the
ore oot is in a valgus position ( rst meta-
tarsal more caudal as compared to the
th) in a non–weightbearing position.
In weight bearing, compensation occurs
when the calcaneus moves into an inverted
Figure 26-4 Unco mpe nsate d subtalar o r calcane al varus position (Figure 26-7). In this condition,
there is o ten decreased mobility o the rst
Comparing non–weightbearing neutral to weightbearing resting position. ray and the S J resupinates be ore the oot
(Figure used with permission of Brian Hoke, American Physical Rehabilitation f at phase o stance due to the premature
Network.) loading o the medial ore oot.2,3
It is less typical, but not uncommon to
have combinations o subtalar varus with
either a ore oot varus or valgus. Mobility
o the rear oot, ore oot, and rst ray play a
key role in whether compensation is noted
or not.
Midt arsal Joint

T e M J consists o 2 distinct joints with
2 di erent axes that unction simultane-
ously: the calcaneocuboid joint later-
ally and the talocalcaneonavicular joint
medially.2,3 T e M J depends primarily
on ligam entous and muscular tension
to maintain position and integrity. T e
midtarsal region comprises 2 joint axes: Figure 26-5 Co mpe nsate d fo re fo o t varus
an oblique and a longitudinal. T e axes
can undergo independent m otion in a Comparing non–weightbearing neutral to weightbearing resting position.
non–weightbearing position; however, the (Figure used with permission of Brian Hoke, American Physical Rehabilitation Network.)
movements o the axes in a weightbearing
position are controlled by the S J. T is is
considered a constrained system and the stability o the M J is directly related to the posi-
tion o the S J. Furthermore, as the M J becomes more or less mobile, it has an overall
direct e ect on the distal portion o the oot as a result o the articulations at the tarsometa-
tarsal joint.78
Effect s of Midt arsal Joint Posit ion During Pronat ion

During pronation, the talus adducts and plantar f exes and makes the joint articulations o
the M J more congruous. T e planes o the oblique and longitudinal axes o the talocal-
caneonavicular and calcaneocuboid joints become more parallel, thus allowing increased
mobility so the oot becom es more
supple. T e resulting oot is in a loose
pack position and o ten re erred to as
a “loose bag o bones.”28,97 T is normal
unction o the M J allows the oot to
accommodate both even and uneven
sur aces.
As more motion occurs at the M J,
the lesser tarsal bones, particularly the
rst metatarsal and rst cunei orm,
becom e m ore m obile. T ese bones
comprise a unctional unit known as
the rst ray. With pronation o the M J,
the rst ray is more mobile because o
its articulations with that joint. One o
the original descriptions was Morton’s
paper describing the now classic Mor-
ton toe.79 T e rst ray is also stabilized Figure 26-6 Unco mpe nsate d fo re fo o t varus
by the attachment o the long peroneal
tendon, which attaches to the base o Comparing non–weightbearing neutral to weightbearing resting position.
the rst metatarsal. T e long peroneal (Figure used with permission of Brian Hoke, American Physical Rehabilitation Network.)
tendon passes posteriorly around the

base o the lateral malleolus and then
through a notch in the cuboid to cross
the oot to the rst m etatarsal. T e
cuboid unctions as a pulley to increase
the mechanical advantage o the pero-
neal tendon. Stability o the cuboid is
essential in this process. In the pro-
nated position, the cuboid loses much
o its mechanical advantage as a pulley;
there ore the peroneal tendon no longer
stabilizes the rst ray e ectively. T is
condition creates hypermobility o the
rst ray and increases pressure on the
other metatarsals.
Figure 26-7 Co mpe nsate d fo re fo o t valg us Effect s of Midt arsal Joint

Posit ion During Supinat ion
Comparing non–weightbearing neutral to weightbearing resting position.
During supination, the talus abducts and
(Figure used with permission of Brian Hoke, American Physical Rehabilitation Network.)
dorsi f exes, which raises the level o the
talonavicular joint superior to that o the
calcaneocuboid joint and allows less congruency o both joint articulations.95 T e planes o
the oblique and longitudinal axes o the joints become more oblique or nonparallel. T is
position o the axes causes increased stability o the oot, making the oot more rigid and sta-
ble. Because less movement occurs at the calcaneocuboid joint, the cuboid becomes hypo-
mobile. T e long peroneal tendon has a greater amount o tension because the cuboid has
less mobility and thus will not allow hypermobility o the rst ray. In this case the majority
o the weight is borne by the rst and th metatarsals. T is normal e ect o the M J allows
the oot to become a more rigid lever or more e cient push o during late stance phase.
Tarsomet at arsal Joint

T e tarsometatarsal joint comprises the 4 proximal tarsal bones o the rst, second, and
third cunei orms, and the cuboid articulating distally with the bases o the 5 metatarsal
bones. T e articulating bones o the tarsometatarsal joint allow or accommodation o
rotational orces introduced to the mid oot and ore oot region when the oot is engaged in
weightbearing activities. T e tarsometatarsal joints move as a unit and work in unison with
the midtarsal and S Js, and it is o ten di cult to distinguish the individual contributions to
the overall movement pattern o the oot.72 Also known as the Lis ranc joint, the tarsometa-
tarsal joint provides a locking mechanism that also aids in oot stability.
Met at arsal Joint s

ogether with subtalar, talonavicular, and tarsometatarsal interrelationships, oot stabiliza-
tion depends on the interaction between the metatarsal joints. T e rst ray moves indepen-
dently rom the other metatarsal bones. As a main unctional weightbearing unit, the rst
ray is necessary or body propulsion. Stabilization depends on the peroneus longus muscle,
which attaches on the medial aspect o the rst ray. As with the other segments o the oot,
stability o the rst metatarsal bone depends on the relative position o the subtalar and
talonavicular joints. Control o the rst ray with orthotic therapy has shown to be e ective
in the management o lower-extremity overuse injuries.2
T e th metatarsal bone, like the rst metatarsal bone, moves independently. With
plantarf exion, the rst metatarsal moves into abduction and eversion while the th moves
into adduction and inversion. Conversely, with dorsif exion, the rst metatarsal moves into
adduction and inversion while the th moves into abduction and eversion.2,49
T e second ray is the most stable o the 5 rays because o the secure connection with
the tarsals. T e second ray unctions as the pivot point, as the other rays undergo a torsional
twist during the motions o oot pronation and supination.72
Biomechanics of Normal Gait

T e unctions o the oot during the gait cycle are adaptation, shock absorption, rigid sup-
port or leverage, and torque conversion. T e action o the lower extremity during walking
gait can be divided into 2 basic phases (Figure 26-8A). T e rst is the stance, or support
phase, which starts with the initial contact at heel strike and ends at toe-o . Stance phase
can be subdivided into 3 de ned events: contact, midstance, and propulsion. T e second
is the swing or recovery phase, which can also be subdivided into 3 de ned events: early
swing, mid swing, and late swing. T is represents the time immediately a ter toe-o in
which the leg is moved rom behind the body to a position in ront o the body in prepara-
tion or heel strike.2,3
T e action o the lower extremity during running gait can also be divided into 2 basic
phases (see Figure 26-8B). T e rst is the support phase, which starts with the initial
contact and ends at takeo . Support phase can be subdivided into 3 di erent events: oot
contact, mid support, and toe-o . T e second is swing phase, which can be subdivided into
3 de ned events: ollow through, orward swing, and oot descent.
T ere are distinct di erences in the gait cycle o an individual who is walking, jogging,
or running. T ese di erences include speed, vertical ground reaction orce (GRF), stance
time and oot contact. Speed o gait can be de ned or various orms o gait, including
S tanc e S wing
Conta ct Mid s ta nce P ropuls ion Ea rly swing Mid swing La te swing
S uppo rt S wing
Foot conta ct Mid s upport Toe off Follow through Forwa rd swing Foot de s ce nt
Figure 26-8 Gait cycle
A. Walking. B. Running. (Adapted from American Physical Rehabilitation Network, 2000.)

walking at a pace o 15 to 30 minutes per mile (2 to

4 mph), jogging at a pace o 7 to 14 minutes per mile
(5 to 9 mph), and running at a pace o 6 minutes per
mile or aster (10+ mph).3
T ere is variability in GRF data between the le t
and right oot o an individual, as well as between
individuals. Generally speaking, with walking, peak
GRF at initial contact is less than body weight (BW)
and exceeds BW near the end o contact. Peak GRF
Figure 26-9 Ce nte r o f w e ig htbe aring fo rce s then diminishes at midstance but exceeds BW to
the highest peak value during propulsion. During
(Adapted from American Physical Rehabilitation Network, 2000.) jogging, peak GRF at initial contact is 1.5 to 2 times
BW, which increases to approximately 2 to 3 times
BW during propulsion. With running, there is no
peak GRF at initial contact, but a single peak o 2 to 3 times BW occurs during propulsion,
which is actually less than jogging (Figure 26-9).3
T e time an individual spends in each phase depends on whether the individual is
walking, jogging, or running. One complete gait cycle is de ned as initial contact o le t oot
through the initial contact o the le t oot again. T e duration o the gait cycle is approxi-
mately 1.0 second or walking, 0.7 seconds or jogging, and 0.6 seconds or running. T e
start o the gait cycle is described by heel strike during walking, and either heel, mid oot,
or ore oot strike with jogging or running. T e part o the oot that strikes during jogging or
running depends on the speed and cadence o the activity. With walking, there is a period
o time, called the double-lim b support phase, in which there is an overlap between stance
phase o one limb and stance phase o the opposite limb. T is phase constitutes the rst
12% and the last 12% o each stance phase. During jogging and running, there is no dou-
ble-limb support phase. T ere is actually a nonsupportive or f oat phase with running and
jogging. T e duration o stance is also reduced as an individual progresses rom walking
to running, with walking stance duration approximately 0.6 seconds, jogging 0.23 seconds,
and running 0.17 seconds. When comparing walking to running, the ratio o stance to swing
changes with the percentage o stance phase diminishing and the percentage o swing
phase increasing.3
Cadence is de ned as the number times (step requency) both eet hit the ground
in a 60-second period o time. More speci c to running, the “ideal” cadence is 180 steps
per minute. T is number is based on elite runners and is used more as a guide than an
absolute. Cadence manipulation is one technique to acilitate the transition to a ore oot
strike pattern with running rom a heel strike pattern.46,47 Several studies have looked at
the higher incidence o running injuries with the presence o an impact peak in the vertical
GRF.12,25,27,64,76,105 An impact peak is more prevalent with a heel strike pattern as compared
to a ore oot strike pattern. Heiderscheit et al concluded that runners who increased their
step requency by 5% demonstrated a decreased in vertical excursion o the center o mass
(COM) and decrease in braking impulse. A 10% increased increase in step requency dem-
onstrated a decrease in GRF at the hip and knees.46,47 Even though this particular study did
not address the e ect o GRF speci cally to the ankle and oot, assumptions can be made to
the bene t o cadence manipulation on the entire kinetic chain.
T e oot’s unction during the support phase o running is two old. At initial contact,
the oot acts as a shock absorber to the impact orces and then adapts to the uneven sur-
aces. At push-o , the oot unctions as a rigid lever to transmit the explosive orce rom the
lower extremity to the running sur ace.
Despite the noted di erences observed in walking versus running, there are a number
o similarities in the gait cycle. In a heel-strike pattern with walking or running gait, ini-
tial contact o the oot is on the lateral aspect o the calcaneus with the S J in supination.8
Associated with this supination o the S J is an obligatory external rotation o the tibia. As
the oot is loaded, the S J moves into a pronated position until the ore oot is in contact
with the ground. T e change in subtalar motion occurs between initial heel strike and 20%
into the support or stance phase. As pronation occurs at the S J, there is obligatory inter-
nal rotation o the tibia. ransverse plane rotation occurs at the knee joint because o this
tibial rotation.8 Pronation o the oot unlocks the M J and allows the oot to assist in shock
absorption and to adapt to uneven sur aces. It is important during initial impact to reduce
the GRFs and to distribute the load evenly on many di erent anatomic structures through-
out the oot and leg. Pronation is normal and allows or this distribution o orces to as many
structures as possible to avoid excessive loading on just a ew structures. T e S J remains
in a pronated position until 55% to 85% o the support phase with maximum pronation is
concurrent with the body’s center o gravity passing over the base o support.5 Maximal pro-
nation is approximately 6 to 8 degrees or walking and 9 to 12 degrees or running.3
T e oot begins to resupinate and will approach the neutral subtalar position at 70% to
90% o the support phase. In supination, the M Js are locked and the oot becomes stable
and rigid to prepare or push-o . T is rigid position allows the oot to exert a great amount
o orce rom the lower extremity to the walking or running sur ace.55
Pat homechanics of Gait Associat ed wit h Running Form

Although bare oot running isn’t a new concept, there has been a great deal o public-
ity since the book Born to Run was released in 2008, and the push toward a more “natural
or minimalistic” running style. In conjunction with the rise in interest within the running
community, there is an increase in evidence to support the potential bene ts to transition-
ing to a mid oot style running approach as compared to the more traditional heel strike
pattern.12,25,27,64,76,96,105 Moving away rom shod (or traditional shoe) running toward bare-
oot and/ or the use o minimalistic ootwear is one “tool” to promote this type o running
approach. As a note or clari cation, this shi t toward a mid oot strike pattern pertains more
directly to the distance running athlete, as compared to a sprinting athlete whose running
is per ormed predominately by striking on the ore oot.
o brief y summarize the research, the ollowing have been described as potential
bene ts to bare oot running12,25,27,64,76,96,105:
• Less contact time ( oot moves o o the ground aster)
• Lower f ight time (correlates with higher cadence)
• Lower passive vertical peak impact orces
• Increased preactivation o triceps surae (stored elastic energy)
• Increased vertical sti ness (results in less COM displacement)
• Bare oot runners exhibit more ore oot and mid oot striking patterns
• Shod running is associated with signi cantly increased peak torque orces at the hip,
knee, and ankle joints
Another concept that also needs to be taken into consideration when discussing mid-
oot versus heel-strike patterns is the oot position relative to the runners COM. Dicharry
showed that runners who per ormed a mid oot landing pattern, but out in ront o their
COM, had signi cantly higher vertical loading rate and impact peaks as compared to those
who per ormed a heel-strike pattern with the oot position near their COM.26
Despite the proposed bene ts to bare oot/ ore oot running, care needs to be taken in
the implementation, utilization, and progression o bare oot running, use o minimalistic
ootwear, or cadence manipulation. It should be noted that despite the studied di erences
in bare oot/ minimalistic ootwear/ mid oot landing style, calcaneal and tibial movement
patterns do not substantially di er when compared to shod/ heel-strike landing style.106

However, excessive or dys unctional movement patterns at the calcaneus or tibia are com-
mon biomechanical actors in overuse injuries in all runners.
Anecdotally, one author has seen a signi cant rise in lower-extremity injures in runners
who present to the clinic since 2008. Speci c to the oot and ankle, Achilles tendinopathy,
plantar asciitis, and lateral metatarsal stress ractures seem to be the most common inju-
ries associated with runners who have changed their running orm or undergone modi ca-
tion/ removal o traditional ootwear.42,75 It is theorized that the increased demand on the
so t tissue and preactivation levels o the triceps surae may be one reason or the rise in
injuries. Another reason or the increase in overuse injuries is related to the rapid increase
in either the rate or volume o running training.
It should be noted that some runners may not be candidates or bare oot/ minimalistic
techniques or use o the mid oot landing pattern. Numerous anatomical actors should be
considered, including the presence o a cavus (high-arch) oot, leg-length discrepancies,
and muscle weakness, which may preclude someone rom success ul bare oot running or
the use o minimalistic ootwear.15,60,81,96,111 Furthermore, i a runner is experiencing any o
the previously noted injuries commonly seen with bare oot or mid oot landing style, allow-
ing the runner to continue with a heel-strike pattern may be advantageous during the run-
ner’s rehabilitation process.
A review o the running literature published (o papers in English rom 1980 to 2011)
by Lorenz and Pontillo 65 indicated that while minimal data exist that de nitively support
bare oot running, there are data to support the argument that runners should use a ore-
oot (mid oot) strike versus heel-strike pattern. Whether there is a positive or negative e ect
on injury rate is yet to be determined. Unquestionably, more research is de nitely needed
to assist in the development o an evidence-based approach to reduce the requency o
running-related injuries. However, there is agreement in the literature that a ew common
actors exist in reducing the risk or injury, including: slow progression using minimalistic
ootwear or bare oot training techniques; consideration o oot intrinsic strength ; adequate
proximal stability o hip abductors and f exors; and a thorough lower extremity assessment
with a gait biomechanical evaluation.31,81,94,96
Pat homechanics of Gait Associat ed wit h Primary

Abnormalit ies of t he Foot
S J motion can be analyzed throughout all phases o gait
with signi cant di erences noted between the previously
described abnormalities o the ore oot and rear oot, most
S UP
4
e ectively through slow motion video analysis. Having an
understanding o these di erences will assist in proper
treatment and management o lower-extremity overuse
0
injuries. S J is evaluated during the contact, midstance,
and propulsion stages o stance phase.
4
P RO With intrinsic normalcy (Figure 26-10), during con-
tact the S J is slightly supinated at heel strike (HS) and
pronates to 3 to 5 degrees o pronation by oot f at (FF).
HS FF HR TO
During midstance, the S J resupinates to neutral or slight
supination by heel rise (HR). During propulsion, the S J
Figure 26-10 Subtalar jo int mo tio n analysis continues to supinate to toe-o ( O).2,3
With com pensated subtalar varus ( Figure 26-11),
Intrinsic normalcy. (Figure used with permission from Brian Hoke, during contact the calcaneus is inverted more than nor-
American Physical Rehabilitation Network.) mal at initial HS, thus the S J must excessively pronate to
S UP S UP
4 4
0 0
4 4
P RO P RO
HS FF HR TO HS FF HR TO
Figure 26-11 Subtalar jo int mo tio n analysis Figure 26-12 Subtalar jo int mo tio n analysis
Compensated subtalar or calcaneal varus. (Figure used with Uncompensated subtalar or calcaneal varus. (Figure used
permission from Brian Hoke, American Physical Rehabilitation with permission from Brian Hoke, American Physical Rehabilitation
Network.) Network.)
compensate or this abnormality. During midstance, the S J will resupinate as the weight
shi ts rom the heel; however, there is a lag as compared to normal as HR approaches.
Because o this lag, there is associated delayed tibial external rotation. During propulsion,
the S J continues to O.2,3
With uncompensated subtalar varus (Figure 26-12), during contact the calcaneus is
again inverted more than normal at heel strike; however, in this situation the S J motion is
insu cient to compensate or the de ormity. T e calcaneus remains inverted throughout
midstance and propulsion toward O. Weight bearing is more lateral than normal during
midstance, but will shi t medially as the heel rises.2,3
With compensated ore oot varus (Figure 26-13), during contact the S J reacts the
same as in intrinsic normalcy. However, during midstance, the S J continues to pronate to
compensate or the ore oot alignment. Because o the continued pronation, this mecha-
nism unlocks the M J creating excessive ore oot mobility at HR. During propulsion, the
S J remains pronated throughout the remainder o stance. T is is described as either late
pronation or delayed resupination, and typically there is associated excessive tibial internal
rotation.2,3
With uncompensated ore oot varus (Figure 26-14),
during contact the S J is slightly supinated at heel strike;
however, it usually pronates less than the normal 3 to
S UP
5 degrees. During midstance, the S J motion is insu - 4
cient to compensate or the ore oot alignment and weight
bearing stays on the lateral ore oot. During propulsion,
0
there is a small amount o continued pronation at the S J
and no resupination as the oot approaches O. T ese
4
individuals are classi ed as neither an overpronator nor P RO
supinator, just lacking su cient motion at the S J.2,3
Finally, with com pensated ore oot valgus ( Fig-
HS FF HR TO
ure 26-15), during contact the S J pronates, but this
motion may be limited to premature loading o the rst
ray. As a result, during midstance, the S J rapidly resu- Figure 26-13 Subtalar jo int mo tio n analysis
pinates as a result o the inf uence o the normal or rigid
rst ray. During propulsion, when the heel begins to rise, Compensated forefoot varus. (Figure used with permission from
potential S J pronation occurs to achieve the necessary Brian Hoke, American Physical Rehabilitation Network.)
S UP S UP
4 4
0 0
4 4
P RO P RO
HS FF HR TO HS FF HR TO
Figure 26-14 Subtalar jo int mo tio n analysis Figure 26-15 Subtalar jo int mo tio n analysis
Uncompensated forefoot varus. (Figure used with permission Compensated forefoot valgus. (Figure used with permission
from Brian Hoke, American Physical Rehabilitation Network.) from Brian Hoke, American Physical Rehabilitation Network.)
weight shi t rom the lateral aspect o the stance oot to the contralateral limb. T is is typi-
cally observed when the oot snaps back into pronation late in the stance phase.2,3
Ankle Sprains
Ankle sprains are among the more common musculoskeletal injuries.10,21,23,120 Injuries to
the ligaments o the ankle may be classi ed either according to their location or by the
mechanism o injury.
Inversion Sprains An inversion ankle sprain is the most common and o ten results in
injury to the lateral ligaments. T e anterior talo bular ligament is the weakest o the 3 lat-
eral ligaments. Its major unction is to stop orward subluxation o the talus. It is injured
in an inverted, plantar f exed, and internally rotated position.57,113 T e calcaneo bular and
posterior talo bular ligaments are also likely to be injured in inversion sprains as the orce
o inversion is increased. Increased inversion orce is needed to tear the calcaneo bular
ligament. Because the posterior talo bular ligament prevents posterior subluxation o the
talus, injuries to it only occur with severe trauma, such as complete dislocations.11 T e del-
toid ligament may also be contused in inversion sprains due to impingement between the
bular malleolus and the calcaneus.
Eversion Sprains T e eversion ankle sprain is less common than the inversion ankle
sprain, largely because o the bony and ligamentous anatomy. As mentioned previously,
the bular malleolus extends urther in eriorly than does the tibial malleolus. T is, com-
bined with the strength o the thick deltoid ligament, prevents excessive eversion. More
o ten, eversion injuries may involve an avulsion racture o the tibia be ore the deltoid liga-
ment tears.18 Despite the act that eversion sprains are less common, the severity is such
that these sprains may take longer to heal than inversion sprains.86
Syndesmotic Sprains Isolated injuries to the distal tibio emoral joint are re erred to as
syndesmotic sprains. T e anterior and posterior tibio bular ligaments are ound between
the distal tibia and bula and extend up the lower leg as the interosseous ligament or syn-
desmotic ligament. Sprains o the ligaments are more common than has been realized in the
past. T ese ligaments are torn with increased external rotational or orced dorsif exion and
are o ten injured in conjunction with a severe sprain o the medial and lateral ligament com-
plexes.112 Initial rupture o the ligaments occurs distally at the tibio bular ligament above
the ankle mortise. As the orce o disruption is increased, the interosseous ligament is torn
more proximally. Sprains o the syndesmotic ligaments are extremely hard to treat and o ten
take months to heal. reatments or this problem are essentially the same as or medial or
lateral sprains, with the di erence being an extended period o immobilization. Rehabilita-
tion will likely require a longer period o time than or the inversion or eversion sprains.
Severity of the Sprain T ere are several actors involved with the severity o an ankle
sprain, including previous history, intrinsic and extrinsic abnormalities, velocity, and
mechanism o injury. In a grade I sprain, there is some stretching or perhaps minimal
tearing o some o the ligamentous bers, with little or no joint instability. Mild pain, little
swelling, and joint sti ness may be apparent. With a grade II sprain, there is some tearing
and separation o the ligamentous bers and moderate instability o the joint. Moderate-to-
severe pain, swelling, and joint sti ness should be expected.
Grade III sprains involve total rupture o the ligament, mani ested primarily by gross
instability o the joint. Severe pain may be present initially, ollowed by little or no pain
caused by total disruption o nerve bers. Swelling may be pro use, and thus the joint tends
to become very sti some hours a ter the injury. A grade III sprain with marked instability
usually requires some orm o immobilization lasting several weeks. Frequently, the orce
producing the ligament injury is so great that other ligaments or structures surrounding the
joint may also be injured. With cases in which there is injury to multiple ligaments, surgical
repair or reconstruction may be necessary to correct instability.

During the initial phase o ankle rehabilitation, the major goals are reduction o postinjury
swelling, bleeding, and pain, and protection o the already healing ligament. As is the case
in all acute musculoskeletal injuries, initial treatment e orts should be directed toward lim-
iting the amount o swelling.89 T is is perhaps more true in the case o ankle sprains than
with any other injury. Controlling initial swelling is the single most important treatment
measure that can be taken during the entire rehabilitation process. Limiting the amount o
acute swelling can signi cantly reduce the time required or rehabilitation. Initial manage-
ment includes compression, ice, elevation, rest, and protection.
Compression Immediately ollowing injury and evaluation, a compression wrap should

be applied to the sprained ankle. An elastic bandage should be rmly and evenly applied,
wrapping distal to proximal. It is also recommended that the elastic bandage be wet in
order to acilitate the passage o cold. o add more compression, a horseshoe-shaped elt
pad may be inserted under the wrap over the area o maximum swelling.
Following initial treatment, open Gibney taping may be applied under an elastic wrap
to provide additional compression and support. Care should be taken not to compartmen-
talize this treatment by placing tape across the top and bottom o the open area o the open
Gibney (Figure 26-16). Uneven pressure or uncovered areas over any part o the extremity
may allow the swelling to accumulate.
Other devices are available that apply external compression to the ankle to control or
reduce swelling. External compression should be used both initially and throughout the
rehabilitative process. Most o these devices use either air or cold water within an enclosed
bag to provide pressure to reduce swelling. One commonly used device is the intermittent
compression unit, such as a Jobst, or other pneumatic pump, or the Cryo Cu (Figure 26-17).
Ice T e use o ice on acute injuries has been well

documented in the literature. Initially, ice and com-
pression should be used together, because this treat-
ment regimen is more e ective than ice alone.104 T e
initial use o ice is indicated or constricting super -
cial blood f ow to prevent hemorrhage as well as in
reducing the hypoxic response to injury by decreas-
ing cellular metabolism. Long-term bene ts may be
rom reduction o pain and guarding.5 Garrick sug-
gests the use o ice or a minimum o 20 minutes once
every 4 waking hours.36 Ice should not be used longer
than 30 minutes, especially over super cial nerves
such as the peroneal and ulnar nerves. Prolonged
use o ice in such areas may produce transient nerve
palsy.30
Current literature suggests that ice can be used
during all phases o rehabilitation,61 but is most
Figure 26-16 Clo se d baske t w e ave taping e ective i used immediately a ter injury.89 Ice can
certainly do no harm i used properly, but heat, i
applied too soon a ter injury, may lead to increased swelling. O ten the switch rom ice to
heat cannot be made or days or weeks, i necessary at all.
Elevation Elevation is an essential part o edema control. Pressure in any vessel below
the level o the heart is increased, which may lead to increased edema accumulation.19
Elevation allows gravity to work with the lymphatic system rather than against it. Elevation
decreases hydrostatic pressure to decrease f uid loss and also assists venous and lymphatic
return through gravity.89 Patients should be encouraged to maintain an elevated position
as o ten as possible, particularly during the rst 24 to 48 hours ollowing injury. An attempt
should be made to treat in the elevated position rather than the gravity-dependent position.
Any treatment per ormed in the dependent position will allow edema to increase.89,102
A B
Figure 26-17
A. Jobst intermittent air compression device. B. Cryo Cuff.
Rest It is important to allow the inf am matory process
to run its course during the rst 24 to 48 hours be ore
incorporating aggressive exercise techniques. However,
rest does not m ean that the injured patient does noth-
ing. Contralateral exercises may be per ormed to obtain
cross-trans er e ects on the m uscles o the injured
side.59 Isom etric exercises may be per orm ed very early
in dorsif exion, plantarf exion, inversion, and eversion
(see Exercises 26-1 to 26-4). T ese types o exercises
may be per orm ed to prevent atrophy without ear o
urther injury to the ligam ent. Active plantarf exion and
dorsif exion may be initiated early because they also do
not endanger the healing ligam ent as long as they are
done in a pain- ree range. Active plantarf exion and dor-
sif exion can be done while the patient is iced and ele-
vated. Inversion and eversion are to be avoided, because
they m ight initiate bleeding and urther traumatize Figure 26-18 Co mme rcially available Aircast
ligam ents. ankle stirrup
Protection Several appliances are available to accomplish this early protected motion.
Quillen 90 recommends the ankle stirrup, which allows motion in the sagittal plane while
limiting movement o the rontal plane and thus avoids stressing the injured ligaments
through inversion and eversion ( Figure 26-18). Several commercially available braces
accomplish this goal and also apply cushioned pressure to help with edema.107 When a
commercially available product is not easible, a similar protective device may be ashioned
rom thermoplastic materials such as Hexalite or Orthoplast (Figure 26-19).
T e open Gibney taping technique also provides early medial and lateral protection
while allowing plantarf exion and dorsif exion, in addition to being an excellent mecha-
nism o edema control (see Figure 26-16).
Gross et al compared the e ectiveness o a number o commercial ankle orthoses and
taping in restricting eversion and inversion. All o these support methods signi cantly
reduced inversion and eversion immediately a ter initial application and ollowing an exer-
cise bout when compared to preapplication measures. O the support systems tested, tap-
ing provided the least amount o support a ter exercise.45 Early application o these devices
allows or early ambulation.

In the early phase o rehabilitation, vigorous exercise is
discouraged. T e injured ligament must be maintained
in a stable position so that healing can occur.82 T us, dur-
ing the period o maximum protection ollowing injury,
the patient should be either non–weight bearing or per-
haps partial weight bearing on crutches.
Partial weight bearing with crutches helps con-
trol several com plications to healing. Muscle atro-
phy, proprioceptive loss, and circulatory stasis are all
reduced when even limited weight bearing is allowed.
Weight bearing also inhibits contracture o the tendons,
which may lead to tendinitis. For these reasons, early
ambulation, even i only touchdown weight bearing, is
essential.68 Figure 26-19 Mo lde d He xalite ankle stirrup
It has been clearly demonstrated that a healing ligament needs a certain amount o
stress to heal properly. T e literature suggests that early limited stress ollowing the ini-
tial period o inf ammation may promote aster and stronger healing.11,82 T ese studies
ound that protected motion acilitated proper collagen reorientation and thus increased
the strength o the healing ligament. Once swelling and pain decrease, indicating that
ligaments have healed enough to tolerate limited stress, rehabilitation can become more
aggressive.
Range of Motion In the early stages o the rehabilitation, inversion and eversion should
be minimized. Light joint mobilization concentrating on dorsif exion and plantarf exion
should be initiated rst.67 Range o motion (ROM) can be improved by manual joint mobi-
lization techniques. It can also be improved through exercises such as towel stretching or
the plantarf exors (see Exercise 26-27) and standing or kneeling stretches or the dorsif ex-
ors (see Exercise 26-29). Patients are encouraged to do these exercises slowly, without pain,
and to use high repetitions (2 to 3 sets o 30 to 40 repetitions).
As tenderness over the ligament decreases, inversion-eversion exercises may be initi-
ated in conjunction with plantarf exion and dorsif exion exercises. Early exercises include
pulling a towel rom one side to the other by alternatively inverting and everting the oot
and alphabet drawing in an ice bath, which should be done in capital letters to ensure that
ull range is used.
Exercises per ormed on a BAPS (biomechanical ankle plat orm system) (Board Spec-
trum T erapy Products, Inc.) board, Fitter Rocker board, Fitter Wobble board, or the BOB
may be bene cial or ROM as well as a beginning exercise or regaining neuromuscular
control.114 T ese exercises typically should rst be per ormed in a seated position, progress-
ing to partial and then ull weight bearing.
Initially, the patient should start in the seated position with Fitter Rocker board
in the plantarf exion-dorsif exion direction. As pain decreases and ligam ent healing
progresses, the board m ay be turned in the inversion -eversion direction (see Exer-
cises 26-25A and B). As the patient per orm s these m ovem ents easily, the patient could
start weight bearing active-assisted ROM in the plantarf exion -dorsif exion direction
with the BOB (see Exercise 26-11). A seated BAPS board or Fitter Wobble board m ay be
used or ull ROM exercises, including clockwise and counter clockwise direction s (see
Exercise 26-33A ). When seated exercises are per orm ed with ease, progression to partial
weightbearing exercises should be initiated, utilizing a leg-press m achine or otal Gym.
Finally, progression to ull weightbearing exercises is initiated, ocusing on ROM an d
balance retraining (see Exercises 26-33B and C).
Vigorous pain- ree heel cord stretching or the gastrocnemius and soleus should be ini-
tiated as soon as possible, utilizing either static or dynamic multiplanar techniques (see
Exercises 26-26, 26-28, and 26-11). McCluskey et al70 ound that the heel cord acts as a bow-
string when tight and may increase the chance o ankle sprains.
Strengthening Isom etrics m ay be done in the 4 m ajor ankle m otion planes, rontal
and sagittal (see Exercises 26-1 to 26-4). T ey may be accom panied early in the rehabili-
tative phase by plantarf exion and dorsif exion isotonic exercises, which do not endan-
ger the healing ligam ents (see Exercises 26-7, 26-8, and 26-10). As the ligam ents heal
and ROM increases, strengthening exercises may be initiated in all planes o m otion (see
Exercises 26-5 and 26-6). Care must be taken when exercising the ankle in inversion and
eversion to avoid tibial rotation as a substitute m ovem ent.
During the early stages o rehabilitation, oot intrinsic strengthening exercises are rec-
ommended, including towel curls (see Exercise 26-12) and arch raises (see Exercise 26-13).
Pain should be the basic guideline or deciding when to start inversion-eversion iso-
tonic exercises. Light resistance with high repetitions has ewer detrimental e ects on
the ligaments (2 to 4 sets o 15 to 25 repetitions). Resistive tubing exercises, ankle weights
around the oot, and a multidirectional Elgin ankle exerciser (see Exercise 26-9) are excel-
lent methods o strengthening inversion and eversion. ubing has advantages in that it may
be used both eccentrically and concentrically.
Isokinetics have advantages in that more unctional speeds may be obtained (see Exer-
cises 26-19 and 26-20). Proprioceptive neuromuscular acilitation strengthening exercises,
which isolate the desired motions at the talocrural joint, can also be used (see Exercises 26-21
to 26-24).
Proprioception and Neuromuscular Control T e role o proprioception in repeated

ankle trauma has been questioned.17,32,35,80 T e literature suggests that proprioception is
certainly a actor in recurrent ankle sprains. Rebman 92 reported that 83% o patients expe-
rienced a reduction in chronic ankle sprains a ter a program o proprioceptive exercises.
Glencross and T ornton 43 ound that the greater the ligamentous disruption, the greater the
proprioceptive loss.
Early weightbearing has previously been m entioned as a m ethod o reducing pro-
prioceptive loss. During the early rehabilitation phase, standing on both eet with side-
to-side and heel-to-toes weight shi ting is recom m ended, as well as double-lim b stance
with eyes closed. Next progression would be single-leg stance on a stable sur ace starting
with eyes open working toward eyes closed including per orm ing this with additional
weight shi ting toward the heel (see Exercises 26-31). T is exercise series can be pro-
gressed to single-lim b stance on unstable sur aces, which should be done initially with
support rom the hands, using such com m ercial devices as oam rollers, Fitter Wobble
board, Fitter Rocker board, DynaDisc (Exertools), BOSU (DW Fitness, LLC) Balance
rainer, or KA system. Once the patient dem onstrates good control on a speci c device,
the patient can progress to ree standing and controlling the board through all ranges
(see Exercise 26-32). o urther challenge the patient’s neuromuscular control and incor-
porate m ore unctional activities, perturbations can be introduced via the upper extrem i-
ties using tubing, m edicine balls, or the Body Blade while in a single-limb stance position
(see Exercise 26-34).
Other closed kinetic chain exercises may be unctionally bene cial. T e leg press
(see Exercise 26-36), m ini orm squats (see Exercise 26-38A), or m inilunges (see Exer-
cise 26-39) are each examples o closed kinetic chain exercises. Initially, start any o the
closed kinetic chain exercises in double-limb stance and progress to single limb (see Exer-
cise 26-37) or to unstable sur aces (see Exercise 26-38B). Single-leg standing kicks using
abduction, adduction, extension, and f exion o the uninvolved side, while weight bearing
on the a ected side, will increase both strength and proprioception. T is may be accom-
plished either by ree standing (see Exercise 26-35) or while having the patient stand on
an unstable sur ace.
Additional in ormation on impaired neuromuscular control and reactive neuromuscular
training can be re erenced in Chapter 9.
Proximal Stability T is chapter ocuses on the oot and ankle. However, it is essen-
tial that when managing a patient with oot and ankle pathology or pathomechanics, that
proximal stability is addressed, speci cally that o the knee, hip, and trunk musculature. As
already discussed, ROM, strength, f exibility, and neuromuscular control are all key compo-
nents. More detailed in ormation is available in several previous chapters, including those
on the core, hip, and knee.
o urther expand on strengthening exercises, when a patient has weightbearing
restrictions, initiating mat table exercises or proximal trunk and hip stability early in the
rehabilitation process are recommended. For example, exercises or gluteus medius, hip
lateral rotators, trunk extensors, and gluteus maximus can be initiated against gravity,
against resistance or using an exercise ball. Once weight bearing is progressed to ull and
pain- ree, then a more unctional program can be implemented.
Finally, it is important when managing a patient with a proximal movement-related

dys unction or diagnosis, to examine the oot and ankle. It is well accepted that when the
oot comes into contact with the ground, there is a biomechanical inf uence up the kinetic
chain.2,3 T us, the assumption can be made that overuse injuries involving knees, hips, or
back could be related to oot or ankle pathomechanics.
Cardiorespiratory Endurance Cardiorespiratory conditioning should be maintained

during the entire rehabilitation process. A stationary bike, NuStep (NuStep Inc.), or ellipti-
cal trainer are all appropriate orms o no impact, partial to ull-weightbearing activities
as long as pain- ree motion is achieved (see Exercises 26-42 to 26-44). An upper-extremity
ergometer or Air-Dyne (Schwinn Fitness) bike with the hands (see Exercise 26-41) provides
excellent cardiovascular exercise without placing stress on the lower extremities. Pool activ-
ities such as running using a f oat vest or swimming are also good cardiovascular exercises
(see Exercise 26-40). Further in ormation on aquatic therapy in rehabilitation is available in
Chapter 16.
Functional Progressions Functional progressions may be as complex or simple as

needed. T e more severe the injury, the greater the need or a detailed unctional pro-
gression. T e typical progression begins early in the rehabilitation process as the patient
becomes partial weight bearing. Full weightbearing activities should be started when
ambulation can be per ormed without a limp. Running may be initiated as soon as ambula-
tion is pain- ree. Pain- ree hopping on the a ected side may also be a guideline to deter-
mine when running is appropriate.
Exercising in a pool allows or early running. T e patient is placed in the pool in a
swim vest that supports the body in water. T e patient then runs in place without touching
the bottom o the pool. Proper running orm should be stressed. Eventually the patient is
moved into shallow water so that more weight is placed on the ankle. More detail on varied
aquatic exercises is ound in Chapter 16.
Progression is then to running on a smooth, f at sur ace, ideally a track. Initially, the
patient should jog straight and walk the curves, and then progress to jogging the entire
track. Initially, a time-based progression is easier or the patient to ollow as the patient may
start as low as 5 minutes o running or the rst time. For the rst 4 weeks, the patient may
increase the running time a ter two success ul runs at the allowed time. It is also important
during the rst 4 weeks to run every other day with a rest day in between. Rest does not
necessarily mean doing nothing. It is recommended that cross-training take place on the
o days as previously described in the “Cardiorespiratory Endurance” section above. A ter
4 weeks o pain- ree running, the patient is then allowed to start running 2 days in a row with
a day o in between. General guidelines or return to running include 10% to 15% increase
in total mileage or time per week. Once a pain- ree running base has been reestablished,
speed may be increased to a sprint in a straight line.
Movement in directions other than straight planes is necessary or return to sport. T e
cutting sequence should begin with circles o diminishing diameter. Cones may be set up
or the patient to run gure-8s as the next cutting progression. T e crossover or side step is
next.4 T e patient sprints to a predesignated spot and cuts or sidesteps abruptly. When this
progression is accomplished, the cut should be done without warning on the command o
another person. Jumping and hopping exercises should be started on both legs simultane-
ously, and gradually reduced to only the injured side.
T e patient may per orm at di erent levels or each o these unctional sequences.
One unctional sequence may be done at hal speed while another is done at ull speed.
An example o this is the patient who is running ull speed on straights o the track while
doing gure-8s at only hal speed. Once the upper levels o all the sequences are reached,
the patient may return to limited practice, which may include early teaching and unda-
mental drills.
It has been estimated that 30% to 40% o all inversion injuries result in reinjury.32,52,53,69,99
In the past, patients were simply allowed to return to their normal activities once the pain
was low enough to tolerate the activity. T e contemporary rehabilitative process should
include a gradual progression o unctional activities that slowly increase the stress on the
ligaments.58
It is common practice that some type o ankle support be worn initially. It appears that
ankle taping does have a stabilizing e ect on unstable ankles37,115 without inter ering with
motor per ormance.33,70 McCluskey et al69 suggest taping the ankle and also taping the shoe
onto the oot to make the shoe and ankle unction as a single unctional unit. High-topped
ootwear may urther stabilize the ankle.48 An Aircast or some other supportive ankle brace
can also be worn or support as a substitute or taping (see Figure 26-18).
Subluxat ion and Dislocat ion of t he Peroneal Tendons

Pat homechanics
T e peroneus brevis and longus tendons pass posterior to the bula in the peroneal groove
under the superior peroneal retinaculum. Peroneal tendon dislocation may occur because
o rupture o the superior retinaculum or because the retinaculum strips the periosteum
away rom the lateral malleolus, creating laxity in the retinaculum. It appears that there is
no anatomic correlation between peroneal groove size or shape and instability o the pero-
neal tendons.56 An avulsion racture o the lateral ridge o the distal bula may also occur
with a subluxation or dislocation o the peroneal tendons.
Injury Mechanism
Subluxation o peroneal tendons can occur rom any mechanism causing sudden and orce-
ul contraction o the peroneal muscles that involves dorsif exion and eversion o the oot.56
T is orces the tendons anteriorly, rupturing the retinaculum
and potentially causing an avulsion racture o the lateral mal-
leolus. T e patient will o ten hear or eel a “pop.” In di erentiat-
ing peroneal subluxation rom a lateral ligament sprain or tear,
there will be tenderness over the peroneal tendons and swelling
and ecchymosis in the retromalleolar area. During active ever-
sion, the subluxation o the peroneal tendons may be observed
and palpated. T is is easier to observe when acute symptoms
have subsided. T e patient will typically complain o chronic
“giving way” or “popping.” I the tendon is dislocated on initial
evaluation, it should be reduced using gentle inversion and
plantarf exion with pressure on the peroneal tendon.56

Following reduction, the patient should be initially placed in a
compression dressing with a elt pad cut in the shape o a key-
hole strapped over the lateral malleolus, placing gentle pressure
on the peroneal tendons. Once the acute symptoms abate, the
patient should be placed in a short leg cast in slight plantarf ex-
ion and non–weight bearing or 5 to 6 weeks (Figure 26-20).
Aggressive ankle rehabilitation, as previously described, is initi-
ated a ter cast removal.
In the case o an avulsion injury, or when this becomes a
chronic problem, conservative treatment is unlikely to be suc-
cess ul and surgery is needed to prevent the problem rom Figure 26-20 Sho rt-le g w alking cast
recurring. A number o surgical procedures have been recommended, including repair

or reconstruction o the superior peroneal retinaculum, deepening o the peroneal
groove, or rerouting the tendon. Following surgery, the patient should be placed in a non–
weightbearing short-leg cast or approximately 4 weeks. T e course o rehabilitation is simi-
lar to that described or ankle ractures with increased emphasis on strengthening o the
peroneal tendons in eversion.56 T e patient may require approximately 10–12 weeks or
rehabilitation.
Tendinopat hy
Inf ammation o the tendons surrounding the ankle joint is common. T e tendons most
comm only involved are the posterior tibialis tendon behind the m edial malleolus, the
anterior tibialis under the extensor retinaculum on the dorsal sur ace o the ankle,
and the peroneal tendons both behind the lateral malleolus and at the base o the th
metatarsal.112
endinitis or tendinopathy o these tendons may result rom one speci c cause or rom
a variety o mechanisms, including aulty oot mechanics (discussed later in the section enti-
tled Excessive Pronation and Supination); inappropriate or poor ootwear that can create
aulty oot mechanics; acute trauma to the tendon; tightness in the plantarf exor complex;
or training errors in the athletic population. raining errors include training at too great o
an intensity, training too requently, changing training sur aces, and changes in activities
within the training program.112 Patients who develop a tendinopathy are likely to complain
o pain both with active movement and passive stretching; swelling around the area o the
tendon because o inf ammation o the tendon and the tendon sheath ; crepitus on move-
ment; and sti ness and pain ollowing periods o inactivity, but particularly in the morning.

In the early stages o rehabilitation, exercises are used to produce increased circulation and
thus increased lymphatic f ow. T is will not only acilitate removal o f uid and the by-prod-
ucts o the inf ammatory process, but will also increase nutrition to the healing tendon. In
addition, exercise should also be used to limit atrophy, which may occur with disuse, and to
minimize loss o strength, proprioception, and neuromuscular control.
echniques should be incorporated into rehabilitation that act to reduce or eliminate
inf ammation, including rest, using therapeutic modalities (ice or iontophoresis), and use
o antiinf ammatory medications as prescribed by a physician.
I aulty oot mechanics are a cause o tendinitis, it may be help ul to construct an
appropriate orthotic device to correct the oot and ankle biomechanics. aping o the oot
may also be help ul in temporarily reducing stress on the tendons.
In many instances, i the mechanism causing the irritation and inf ammation o the
tendon is removed, and the inf ammatory process runs its normal course, the tendinopathy
will o ten resolve within 10 days to 2 weeks. T is is particularly true i rest and treatment are
begun as soon as the symptoms begin. Un ortunately, as is most o ten the case, i treatment
does not begin until the symptoms have been present or several weeks or even months, the
tendinopathy will take much longer to resolve. T is is because o longstanding inf amma-
tion, during which the tendon thickens, making the period o time required or that tendon
to remodel signi cantly greater.
In our experience, it is better to allow the patient to rest or a su cient period o time
so that tendon healing can take place. With tendinopathy, an aggressive approach that
does not allow the tendon to rst eliminate the inf ammatory response and then begin
tissue realignment and remodeling will not allow the tendon to heal. T is may potentially
exacerbate the existing inf ammation and lead to chronic inf ammation. T us, the rehabili-
tation progression must be slow and controlled, with ull return when the patient is ree o
tendon pain.
Ankle Fract ures and Dislocat ion

When dealing with ractures o the ankle or tibial and bular malleoli, the therapist must
always be cautious about suspecting an ankle sprain when a racture actually exists. A rac-
ture o the malleoli will generally result in immediate swelling. Ankle ractures can occur
rom several mechanisms that are similar to those seen or ankle sprains. In an inversion
injury, medial malleolar ractures are o ten accompanied by a sprain o the lateral liga-
ments o the ankle. A racture o the lateral malleolus is o ten more likely to occur than
a sprain i an eversion orce is applied to the ankle. T is is because the lateral malleolus
extends as ar as the distal aspect o the talus. With a racture o the lateral malleolus, how-
ever, there may also be a sprain o the deltoid ligament. Fractures result rom either avulsion
or compression orces. With avulsion injuries, it is o ten the injured ligaments that prolong
the rehabilitation period.44
Osteochondral ractures are sometimes seen in the talus. T ese ractures may also be
re erred to as dome ractures o the talus. Generally, they will be either nondisplaced or
compression ractures.44
Although sprains and ractures are very common, dislocations in the ankle and oot are
rare. T ey most o ten occur in conjunction with ractures and require open reduction and
internal xation.98

Generally, nondisplaced ankle ractures should be managed with rest and protection until
the racture has healed, whereas displaced ractures are treated with open reduction and
internal xation. Nondisplaced ractures are treated by casting the limb in a short-leg walk-
ing cast or 6 weeks with early weight bearing. T e course o rehabilitation ollowing this
period o immobilization is generally the same as or ankle sprains. Following surgery or
displaced or unstable ractures, the patient may be placed in a removable walking cast;
however, it is essential to closely monitor the rehabilitation process to make certain that the
patient is compliant.44
I an osteochondral racture is displaced and there is a ragment, surgery is required to
remove the ragment. In other cases, i the ragment has not healed within a year, surgery
may be considered to remove the ragment.44

Following open reduction and internal xation, a posterior splint with the ankle in neu-
tral should be applied, and the patient should be non–weight bearing or approximately
2 weeks. During this period e orts should be directed at controlling swelling and wound
management.
At 2 to 3 weeks, the patient may be placed in a short-leg walking brace (see Figure 26-20),
which allows or partial weight bearing, or 6 weeks. Active ROM plantarf exion and dor-
sif exion exercises can begin and should be done 2 or 3 times a day, along with general
strengthening exercises or the rest o the lower extremity.
At 6 weeks, the patient can be weight bearing in the walking brace and this should
continue or 2 to 4 weeks m ore. Isom etric exercises (see Exercises 26-1 to 26-4) can be
per ormed initially without the brace, progressing to isotonic strengthening exercises (see
Exercises 26-5 to 26-8 and 26-10), which concentrate on eccentrics. Stretching exercises
can also be incorporated (see Exercises 26-11 and

26-25 to 26-29). I there are speci c joint restrictions
at the ankle and oot, mobilization techniques by a
therapist may be used to reduce capsular tightness.
Exercises to regain proprioception and neu-
romuscular control, as previously described in the
“Ankle Sprains” section, can be progress rom sitting
to standing and rom stable to unstable sur aces as
tolerated (see Exercises 26-25 and 26-31 to 26-35).
As strength and neuromuscular control continue
to increase, more unctional, closed kinetic chain-
strengthening activities can begin (see Exercises
Ne utra l We ightbe a ring 26-14 to 26-18 and 26-36 to 26-39).
Figure 26-21 Subtalar o r calcane al varus Excessive Pronat ion and Supinat ion
Comparing weightbearing neutral and resting positions. O ten when we hear the terms pronation or supina-
tion , we automatically think o some pathological
condition related to gait. It must be reemphasized that pronation and supination o the oot
and S J are normal movements that occur during the support phase o gait. However, i
pronation or supination is excessive, delayed, or prolonged, overuse injuries may develop.
Excessive or prolonged supination or pronation at the S J is likely to result rom some struc-
tural or unctional de ormity in the oot or leg. T e structural de ormity orces the S J to
compensate in a manner that will allow the weightbearing sur aces o the oot to make stable
contact with the ground and get into a weightbearing position. T us, excessive pronation or
supination is a compensation or an existing structural de ormity. T ree o the most com-
mon structural de ormities o the oot as previously described are subtalar or calcaneal varus
(Figure 26-21), ore oot varus (Figure 26-22), and ore oot valgus (Figure 26-23).
Structural calcaneal varus and ore oot varus de ormities are usually associated with
excessive pronation. A structural ore oot valgus usually causes excessive supination. T e
de ormities usually exist in 1 plane, but the triplane S J will inter ere with the normal unc-
tions o the oot and make it more di cult to act as a shock absorber, adapt to uneven
sur aces, and act as a rigid lever or push o . T e
compensation rather than the de ormity itsel usu-
ally causes overuse injuries.
Excessive, delayed, or prolonged pronation
o the S J during the support phase o running is a
major cause o stress injuries. Overload o speci c
structures results when excessive pronation is pro-
duced in the support phase or when pronation is
prolonged into the propulsive phase o running.
Excessive pronation during the support phase
will cause compensatory S J motion such that the
M J remains unlocked, resulting in an excessively
loose oot. T ere is also an increase in tibial rotation,
which orces the knee joint to absorb more trans-
Ne utra l We ightbe a ring
verse rotation motion. Delayed or late pronation
o the S J is when the motion initially is not exces-
Figure 26-22 Fo re fo o t varus sive, but because o the continued pronation during
stance phase, a similar result exists as with excessive
Comparing weightbearing neutral and resting positions. pronation. Prolonged pronation o the S J will not
allow the oot to resupinate in time to provide a rigid lever
or push o , resulting in a less power ul and e cient orce.
T us, various oot and leg problems will occur with exces-
sive, delayed, or prolonged pronation during the support
phase, including callus ormation under the second meta-
tarsal, stress ractures o the second metatarsal, bunions
because o hypermobility o the rst ray, plantar asciitis,
posterior tibial tendinitis, Achilles tendinitis, tibial stress
syndrome, iliotibial band riction syndrome, or medial
knee pain.
Several extrinsic keys may be observed that indicate
disproportionate pronation,97 including excessive eversion
o the calcaneus during the stance phase (Figure 26-24) Ne utra l We ightbe a ring
and excessive or prolonged internal rotation o the tibia.
T is internal rotation may cause increased symptoms in
the shin or knee.24 A lowering o the medial arch accompa- Figure 26-23 Fo re fo o t valg us
nies pronation. It may be measured as the navicular di er-
Comparing weightbearing neutral and resting positions.
ential71—the di erence between the height o the navicular
tuberosity rom the f oor in a non–weightbearing position
versus a weightbearing position (Figure 26-25). As previously discussed, the talus plantar
f exes and adducts with pronation. T is may present as a visually discernible medial bulging
o the talar head (Figure 26-26). T is same talar adduction causes increased concavity below
the lateral malleolus in a posterior view while the calcaneus everts (Figure 26-27).73
Prolonged or excessive supination at heel strike and the resultant compensatory move-
ment at the S J will not allow the M J to unlock, causing the oot to remain excessively
rigid. T us, the oot cannot absorb the GRFs e ciently. Excessive supination limits tibial
internal rotation. Injuries typically associated with excessive supination include th meta-
tarsal stress ractures, Achilles tendinopathy, inversion ankle sprains, tibial stress syndrome,
peroneal tendinitis, iliotibial band riction syndrome, or trochanteric bursitis.
Structural de ormities originating outside the oot also require compensation by the
oot or a proper weightbearing position to be attained. ibial varum is the common bow-
leg de ormity.73 T e distal tibia is medial to the proximal tibia (Figure 26-28).28 T is mea-
surement is taken weight bearing with the oot in neutral position.50 T e angle o deviation
Figure 26-24 Eve rsio n o f the calcane us, Figure 26-25 Me asure me nt o f the navicular
indicating pro natio n diffe re ntial
P rona tion Ne utra l S upina tion
Figure 26-27 Co ncavity be lo w the late ral

malle o lus, indicating pro natio n. Co ncavity be lo w
Figure 26-26 Me dial bulg e o f the talar the me dial malle o lus, indicating supinatio n
he ad o f the le ft fo o t, indicating pro natio n
o the distal tibia rom a perpendicular line rom the calcaneal midline is considered tibial
varum.39 ibial varum increases pronation to allow proper oot unction.13 At heel strike, the
calcaneus must evert to attain a perpendicular position.110
Ankle joint equinus is another extrinsic de ormity that may require abnormal compen-
sation. It may be considered an extrinsic or intrinsic problem, but is typically a result o loss
o talocrural joint ROM into dorsif exion. T e key compensator is the oblique M J. I the
M J is hypermobile or unstable, there will be increased dorsif exion and ore oot abduc-
tion at the M J. I the M J is hypomobile or stable, there will
be early heel rise during propulsion with continued orced
pronation.
During normal gait, the tibia must m ove anterior to
the talar dom e. Approximately 10 degrees o dorsif exion
or walking and 15 to 20 degrees or running are required
(Figure 26-29).73 Lack o dorsif exion may cause compensatory
pronation o the oot with resultant oot and lower-extremity
pain. O ten, this lack o dorsif exion results rom tightness
o the posterior leg muscles. Fore oot equinus, in which the
plane o the ore oot is below the plane o the rear oot, is
another cause.73 It occurs in many high-arched eet. T is
de ormity requires more ankle dorsif exion. When enough
dorsif exion is not available at the ankle, the additional move-
ment is required at other sites, such as dorsif exion o the M J
and rotation o the leg.

In individuals who excessively pronate or supinate, the goal
o treatment is quite simply to correct the aulty biomechan-
ics that occur as a result o the existing structural de ormity.
An accurate biomechanical analysis o the oot and lower
extrem ity should identi y those de orm ities that require
abnormal compensatory m ovem ents. In the majority o
Figure 26-28 Tibial varum o r bo w -le g cases, aulty biomechanics can be corrected by constructing
de fo rmity an appropriate orthotic device.
Figure 26-29 Do rsi e xio n o f 10 de g re e s is Figure 26-30 Examinatio n po sitio n fo r STJN

ne ce ssary fo r no rmal w alking g ait po sitio n
Despite arguments in the literature, the authors have ound orthotic therapy to be o
tremendous value in the treatment o many lower-extremity problems. T is view is sup-
ported in the literature by several clinical studies. Donatelli28 ound that 96% o patients
reported pain relie rom orthotics and 52% would not leave home without the devices in
their shoes. McPoil et al ound that orthotics were an important treatment or valgus ore-
oot de ormities only.72 Riegler reported that 80% o patients experienced at least a 50%
improvement with orthotics.93 T is same study reported improvements in sports per or-
mance with orthotics. Hunt reported decreased muscular activity with orthotics.50
T e process or evaluating the oot biomechanically, constructing an orthotic device,
and selecting the appropriate ootwear is given in detail in next section.
Examination T e rst step in the evaluation process is to establish a position o S JN.

T e patient should be prone with the distal third o the leg hanging o the end o the table
(Figure 26-30). A line should be drawn bisecting the posterior lower leg and posterior calca-
neus (Figure 26-31).112 With the patient still prone and the le t oot as the example, the ther-
apist palpates the talus with the right hand while the ore oot is inverted or everted using
the le t hand. One nger should palpate the talus near the anterior aspect o the bula and
the thumb near the anterior portion o the medial malleolus (Figure 26-32). T e position at
which the talus is equally prominent on both sides is considered neutral subtalar position.54
Root et al97 describe this as the position o the S J where it is neither pronated or supinated.
It is the standard position in which the oot should be placed to examine de ormities.84 In
this position, the lines on the lower leg and calcaneus should orm a straight line. Any vari-
ance is considered to be a rear oot valgus or varus de ormity. T e most common de ormity
o the oot is a rear oot varus de ormity.77 A varus deviation o 2 to 3 degrees is normal.117
Another m ethod o determ ining S JN position involves using the lines that were
drawn on the leg and back o the heel in a di erent manner. With the patient prone, the
calcaneus is moved into ull eversion and inversion, with angle measurements taken at the
end range o each position. Neutral position is then considered to be two-thirds o the total
S J ROM away rom maximum inversion or one-third o the total S J motion away rom
maximum eversion. For example, rom a neutral position, i the oot inverts 27 degrees and
everts 3 degrees, the total S J ROM equals 30 degrees. T us, the position at which this oot
is neither pronated nor supinated is that point at which the calcaneus is inverted 7 degrees,
A B
Figure 26-31
A. Line bisecting the posterior leg and calcaneus. B. Comparing non–weightbearing neutral to weightbearing
resting position. (Figure used with permission from Brian Hoke, American Physical Rehabilitation Network.)
which is calculated by subtracting 20 degrees (two-thirds o 30 degrees) rom maximal

inversion (27 degrees). T e normal oot pronates 6 to 8 degrees rom neutral.97
Once the S J is placed in a neutral position, mild dorsif exion should be applied to
the ore oot at the th metatarsophalangeal joint while observing the metatarsal heads
(speci cally second to th) in relation to the plantar sur ace o the calcaneus. First meta-
tarsal position is evaluated independently o the other metatarsals. Fore oot varus is an
osseous de ormity in which the medial metatarsal heads are inverted in relation to the
plane o the calcaneus (see Figure 26-22). Fore oot varus is the most common cause o
excessive pronation, according to Subotnick.108 Fore oot valgus is a position in which the
lateral metatarsals are everted in relation to the rear oot (see Figure 26-23). T ese ore oot
de ormities benign in a non–weightbearing position, but in stance the oot or metatarsal
heads must somehow get to the f oor to bear weight.
T is compensated movement is accomplished by the
talus rolling down and in and the calcaneus everting or
a ore oot varus. For the ore oot valgus, the calcaneus
inverts and the talus abducts and dorsif exes. McPoil et
al73 report that ore oot valgus is the most common ore-
oot de ormity in their sample group.
In a calcaneal varus de ormity, when the oot is in
S JN position non–weight bearing, the calcaneus is
in an inverted position; however, the metatarsals are still
in a relative perpendicular position to the calcaneus.
o get to oot f at in weight bearing, the S J must pro-
nate (see Figure 26-21). Minimal osseous de ormities o
the ore oot have little e ect on the unction o the oot.
When either ore oot varus or valgus is too large, the oot
compensates through abnormal movements to bear
weight.
Figure 26-32 Palpatio n o f the talus to Further consideration or the position and mobility
de te rmine STJN po sitio n o the rst ray is necessary. T e rst ray in relationship to
the remainder o the metatarsals can either be dorsif exed,
neutral, or plantarf exed. Clinically, a neutral or plan-
tarf exed rst ray is most commonly seen. Mobility o the
rst ray is an important predictor in pathomechanics and
injury mechanism.2,3 For example, a rigid plantarf exed
rst ray will respond di erently in weight bearing than a
mobile plantarf exed rst ray. T is distinction in mobility
is important when making recommendations or orthosis
abrication in regard to ore oot correction. With a f exible
rst ray, a medial post may be used directly under the rst
ray only. With a more rigid rst ray, medial posting mate-
rial will extend more laterally to encompass additional
metatarsals ( Figure 26-33). T ere is urther discussion
on speci c orthotic construction in the section entitled
Orthosis Materials and Fabrication.
A. Fle xible 1s t ra y B. Rigid 1s t ra y

corre ction corre ction
St ress Fract ures in t he Foot
T e most common stress ractures in the oot involve the
Figure 26-33 First ray co rre ctio n fo r a fo o t
o rtho sis
navicular, second metatarsal (March racture), and diaph-
ysis o the th metatarsal (Jones racture). Navicular and
second metatarsal stress ractures are likely to occur with excessive oot pronation, whereas
th metatarsal stress ractures tend to occur in a more rigid pes cavus oot.
Navicular Stress Fractures Individuals who excessively pronate during running gait
are likely to develop a stress racture o the navicular. T is is attributed most commonly
to individuals with either a compensated calcaneal and/ or ore oot varus. Because o the
compensatory movement and increased stress at the talonavicular joint o the tarsal bones,
it is most likely to have a stress racture.
Second Metatarsal Stress Fractures Second metatarsal stress ractures occur most
o ten in running and jumping sports. As is the case with other injuries in the oot associ-
ated with overuse, the most common causes include calcaneal varus and/ or ore oot varus
structural de ormities in the oot that result in excessive pronation, f exible rst ray, training
errors, changes in training sur aces, and wearing inappropriate shoes. T e base o the sec-
ond metatarsal extends proximally into the distal row o tarsal bones and is held rigid and
stable by the bony architecture and ligament support. In addition, the second metatarsal is
particularly subjected to increased stress with excessive pronation, which causes a hyper-
mobile oot. In addition, i the second metatarsal is longer than the rst, as seen with a
Morton toe, it is theoretically subjected to greater bone stress during running. A bone scan,
as opposed to a standard radiograph, is requently necessary or diagnosis.
Fifth Metatarsal Stress Fractures Fi th m etatarsal stress ractures can occur rom
overuse, acute inversion, or high-velocity rotational orces. A Jones racture occurs at the
diaphysis o the th metatarsal most o ten as a sequela o a stress racture.98 T e patient
will complain o a sharp pain on the lateral border o the oot and will usually report hear-
ing a “pop.” Because o documented poor blood supply and a history o delayed healing,
a Jones racture may result in nonunion, requiring an extended period o rehabilitation. A
common oot type seen with this injury is more o a supinatory oot, or those patients with
a ore oot valgus or a rigid plantarf exed rst ray. T e patient spends more time laterally,
thus increasing stresses to the th metatarsal. As previously mentioned, this injury has
been cited in the literature as a possible result o transitioning to bare oot or minimalistic
ootwear too quickly.42,75

Rehabilitation e orts or stress ractures should ocus on determ ining the precipitating
cause or causes and alleviating them. Second metatarsal stress ractures tend to do well
with m odi ed rest and non–weightbearing exercises, such as pool running (see Exercise
26-40), upper-body ergom eter (see Exercise 26-41), stationary bike (see Exercise 26-42),
or NuStep (see Exercise 26-43) to maintain the patient’s cardiorespiratory tness or 2 to
4 weeks. An elliptical trainer may be utilized to transition the patient rom non–weight-
bearing activity to nonim pact weightbearing exercise. T is is ollowed by a progressive
return to ull-im pact activities o running and jum ping unctional activities over a 2- to
3-week period, potentially using appropriately constructed orthoses and m odi ed oot-
wear. Stress ractures o both the navicular o the proximal sha t o the th m etatarsal
usually require m ore aggressive treatm ent; requiring non–weightbearing short-leg casts
or 6 to 8 weeks or nondisplaced ractures. With cases o delayed union, nonunion, or
especially displaced ractures, both the Jones and navicular ractures require internal
xation, with or without bone gra ting. In the highly active patient, im m ediate internal
xation should be recomm ended.
Plant ar Fasciit is/Fasciosis

Pat homechanics
Heel pain is a very common problem that may be attributed to several etiologies, includ-
ing heel spurs, plantar ascia irritation (acute or chronic), and bursitis. Plantar asciitis is
a “catch-all term” that is commonly used to describe pain in the proximal arch and heel.
However, when truly de ning whether someone has plantar asciitis, it is important to con-
sider the absence or presence o inf ammation. I histologic ndings indicate the presence
o inf ammation, the diagnosis o plantar asciitis is appropriate and subsequent treatment
appropriate or acute inf ammation should be considered.21 However, i ndings include
myxoid degeneration with ragmentation and degeneration o the plantar ascia, as well as
bone marrow vascular ectasia, the diagnosis can be made o degenerative asciosis without
inf ammation, not asciitis.63 T us, treatment intervention should be varied when treating
chronic versus acute conditions.
T e plantar ascia (plantar aponeurosis) runs the length o the sole o the oot. It is a
broad band o dense connective tissue that is attached proximally to the medial sur ace o
the calcaneus. It ans out distally, with bers and their various small branches attaching
to the metatarsophalangeal articulations and merging into the capsular ligaments. Other
bers, arising rom well within the aponeurosis, pass between the intrinsic muscles o the
oot and the long f exor tendons o the sole and attach themselves to the deep ascia below
the bones. T e unction o the plantar aponeurosis is to assist in maintaining the stability o
the oot and in securing or bracing the longitudinal arch.112
ension develops in the plantar ascia both during extension o the toes and depression
o the longitudinal arch as the result o weight bearing. When the weight is principally on
the heel, as in ordinary standing, the tension exerted on the ascia is negligible. However,
when the weight is shi ted to the ball o the oot (on the heads o the metatarsals), ascial
tension is increased. In running, because the push-o phase involves both a orce ul exten-
sion o the toes and a power ul push-o thrust o the metatarsal heads, ascial tension is
increased to approximately twice the BW.
Patients who have a mild pes cavus oot type are particularly prone to ascial strain.
Modern street shoes, by nature o their design, take on the characteristics o splints and
tend to restrict oot action to such an extent that the arch may become somewhat rigid. T is
occurs because o shortening o the ligaments and other mild abnormalities. T e patient,
when changing rom dress shoes to so ter, more f exible athletic shoes, o ten develops irrita-
tion o the plantar ascia. rauma may also result rom poor running technique or improper
running ootwear. Excessive lumbar lordosis—a condition in which an increased orward
tilt o the pelvis produces an un avorable angle o oot strike when there is considerable
orce exerted on the ball o the oot—can also contribute to this problem.
Injury Mechanism
A number o anatomic and biomechanical conditions have been studied as possible causes
o plantar asciitis. T ey include leg-length discrepancy, excessive pronation o the S J,
inf exibility o the longitudinal arch, and tightness o the gastrocnemius–soleus unit. Wear-
ing shoes without su cient arch support, an overlengthened stride during running, transi-
tion to mid oot or ore oot landing pattern too quickly, and running on so t sur aces are also
potential causes o plantar asciitis.
T e patient complains o pain in the anteromedial aspect o the heel, usually at the
attachment o the plantar ascia to the calcaneus, which eventually moves more centrally
into the central portion o the plantar ascia. T is pain is particularly troublesome upon
arising in the morning or upon bearing weight a ter sitting or a prolonged period o time.
However, the pain typically decreases a ter a ew steps. Pain also will be intensi ed when
the toes and ore oot are orcibly dorsif exed, particularly with terminal stance phase in
weight bearing.

With respect to the treatment o heel pain or plantar asciitis/ asciosis, research has not
indicated any consensus on a speci c treatment regimen that has proven to resolve heel
pain with any statistical signi cance. However, Gill41 states that there is agreement that
nonsurgical treatment is ultimately e ective in approximately 90% o patients. Despite
the uncertainty in the literature regarding a speci c treatment, there are several di erent
interventions that have proven to be bene cial in the acute and chronic management o
heel pain.
Orthotic therapy is very use ul in the treatment o this problem. T e authors have ound
that semif exible orthoses addressing the patient’s speci c biomechanical and structural
concerns, in combination with exercises, can signi cantly reduce the pain level o these
patients (Figure 26-34).
A semif exible orthosis tends to be more e ective than a rigid orthotic device, par-
ticularly in a more active patient or athlete, because it allows or ore oot and rear oot cor-
rection or decreasing pathomechanical compensation
with appropriate shock absorption. An extra-deep heel
cup could also be built into the orthosis to provide
im proved calcaneal and subsequent S J control. T e
orthosis should be worn at all times, especially upon
arising rom bed in the morning. T e patient should
be encouraged to wear a supportive shoe with the pre-
scribed orthosis, rather than ambulating bare ooted.14
When so t orthoses are not easible, longitudinal arch
taping may reduce the sym ptoms. A simple arch tap-
ing or alternative taping technique o ten allows pain-
ree am bulation.120 For those patients who have a
distended calcaneal at pad, the use o a heel cup will
help to reapproximate the lateral margins o the at pad
under the calcaneus, reestablishing the natural cush- Figure 26-34 Se mi e xible full-le ng th custo m
ion under the area o irritation. o rtho sis
A B C
Figure 26-35
A. Low-dye arch taping. B. Leukotape P taping technique. C. Kinesiotape technique.
T e use o low-dye longitudinal arch taping121 (Figure 26-35A) or Leukotape P technique

(Figure 26-35B) has been shown to unload the plantar aponeurosis in weightbearing situ-
ations. Kinesio EX can be utilized or pain management (Figure 26-35C) as described by
the Kinesio aping Method. In more chronic or severe cases, it may be necessary to use a
night splint to maintain a position o static stretch while sleeping or a short-leg walking cast
during the day or 4 to 6 weeks.
Pain- ree heel cord stretching should be used, along with an exercise to stretch the
plantar ascia in the arch (see Exercises 26-30B and C) i these tissues are tight. During
the acute phase, or i there is pain with passive stretching o heel cords or plantar ascia,
dynamic stretching can be done (see Exercises 26-28). Exercises or manual therapy tech-
niques that help to increase dorsif exion o the great toe also may be o bene t to this prob-
lem (see Exercises 26-26 and 26-30A). Passive stretching should be per ormed using the
principle o a low load, prolonged stretch and per ormed at least 3 times a day.100 E ective
stretching is most e ective with “consistency versus intensity.”
As or the use o antiinf ammatory intervention, it is important to consider the stage o
healing (acute versus chronic). In the acute phase, nonsteroidal antiinf ammatory medica-
tions may be bene cial. Steroidal injection may be warranted at some point i symptoms ail
to resolve, although review o the literature is inconclusive as to the e cacy o injections or
long-term bene ts.1,34,38,62,63,74,85,86,88,101 Concerns regarding the use o steroid injection or
management o heel pain or plantar asciitis or asciosis include the potential or calcaneal
at pad deterioration, plantar ascia rupture, decreased plantar ascia tension, reduced arch
height, ine ectiveness o subsequent extracorporeal shock wave therapy, and the potential
development o several other oot problems.1,62,85,86 Lemont 63 suggests that treatment regi-
mens, such as corticosteroid injections into the plantar ascia, should be reevaluated in the
absence o inf ammation.
Other possible interventions include ultrasound, iontophoresis with acetic acid or
dexamethasone, extracorporeal shock wave therapy, or surgery. Preliminary research in the
literature has shown that extracorporeal shock wave therapy has been success ul in manag-
ing plantar asciosis.74,86,91
Management o plantar asciitis generally requires an extended period o treatment. It
is not uncommon or symptoms to persist or as long as 8 to 12 weeks. Persistence on the
part o the patient in doing the recommended stretching and oot intrinsic strengthening
exercises is critical, along with addressing any biomechanical or structural concerns. As
with many o the oot and ankle injuries cited in this chapter, orthotic therapy, activity
modi cation, appropriate ootwear, and addressing any proximal neuromusculoskeletal
concerns are also keys to success ully managing plantar asciitis or asciosis.
Cuboid Subluxat ion

A condition that o ten mimics plantar asciitis is cuboid subluxation. Pronation and trauma
have been reported to be prominent causes o this syndrome.119 Displacement o the cuboid
causes pain along the ourth and th metatarsals, as well as directly over the cuboid. T e
primary reason or pain is the stress placed on the long peroneal muscle when the oot is
in pronation. In this position, the long peroneal muscle allows the cuboid bone to move
downward and medially. T is problem o ten re ers pain to the heel area as well. Many times
this pain is increased upon arising a ter a prolonged non–weightbearing period.
Rehabilit at ion Considerat ions

Dramatic treatm ent results may be obtained by manipulation technique to restore
the cuboid to its natural position. T e manipulation is done with the patient prone
(Figure 26-36A). T e plantar aspect o the ore oot is grasped by the thumbs with the ngers
supporting the dorsum o the oot. T e thumbs should be over the cuboid. T e manipula-
tion should be a thrust downward to move the cuboid into its more dorsal position. O ten a
pop is elt as the cuboid moves back into place. Once the cuboid is manipulated, an orthosis
or taping technique is required to support it in its proper position (Figure 26-36B).
I manipulation is success ul, quite o ten the patient can return to normal unction
immediately with little or no pain. It should be recommended that the patient wears an
appropriately constructed orthosis to reduce the chances o recurrence, along with speci c
oot intrinsic strengthening exercises (see Exercise 26-13).
Figure 26-36
A. Prone position for cuboid manipulation.
B. Corrective cuboid taping technique.
Peelen describes an alternate way o manipulating a sub-

luxated cuboid using a speci c sequence or mobilizing the
other bones o the oot rst in order to e ectively remobilize the
cuboid. He states that it is rare that only 1 or 2 bones o the oot
are dys unctional in isolation. By rst mobilizing the talus, cal-
caneus, navicular, cunei orms, and metatarsals, the necessary
space to reduce the cuboid under the distal lip o the calcaneus
is achieved.87
Hallux Valgus Deformit y (Bunions)

A bunion is a de ormity o the head o the rst metatarsal in
which the large toe assumes a valgus position (Figure 26-37). A
bunion is commonly associated with a structural ore oot varus
or f exible rst ray. T e result o the outward splaying o the
rst ray is an increased pressure on the rst metatarsal head.
T e bursa over the rst metatarsophalangeal joint becomes
inf amed and eventually thickens. T e joint becomes enlarged
and the great toe becomes malaligned, moving laterally toward
the second toe, sometimes to such an extent that it eventually
overlaps the second toe. T is type o bunion may also be asso-
Figure 26-37 Hallux valg us de fo rmity ciated with a depressed or f attened transverse arch. O ten the
w ith a bunio n bunion occurs rom wearing shoes that are pointed, too narrow,
too short, or have high heels.
A bunion is one o the most requent pain ul de ormities o the great toe. As the bunion
is developing, there is typically associated tenderness, swelling, and enlargement with cal-
ci cation o the head o the rst metatarsal. Shoes that t poorly can increase the irritation
and pain o the bunion.

Prevention is the key; however i the condition progresses, a custom orthosis is recom-
mended to help normalize oot mechanics. O ten an orthotic designed to correct a struc-
tural ore- oot varus or f exible rst ray can help increase stability and signi cantly reduce
the symptoms and progression o a bunion. Shoe selection may also play an important role
in the treatment o bunions. Shoes o the proper width cause less mechanical irritation to
the bunion. Local therapy, including moist heat, soaks, iontophoresis, or ultrasound, may
alleviate some o the acute symptoms o a bunion. Protective devices, such as wedges, pads,
and tape, can also be used. Surgery to correct the hallux valgus de ormity is very common
during the later stages o this condition, but the potential o postoperative sti ness or loss
o motion is a concern.
Mort on Neuroma
A neuroma is a mass occurring about the nerve sheath o the common plantar nerve while
it divides into the 2 digital branches to adjacent toes. It occurs most commonly between the
metatarsal heads and is the most common nerve problem o the lower extremity. A Morton
neuroma is located between the third and ourth metatarsal heads where the nerve is the
thickest, receiving both branches rom the medial and lateral plantar nerves. T e patient
complains o severe intermittent pain radiating rom the distal metatarsal heads to the tips
o the toes and is o ten relieved when non–weight bearing. Irritation increases with the col-
lapse o the transverse arch o the oot, putting the transverse metatarsal ligaments under
stretch and thus compressing the common digital nerve and vessels. Excessive oot prona-
tion can also be a predisposing actor, with more metatarsal shearing orces occurring with
the prolonged ore oot abduction.
T e patient complains o a burning paresthesia in the ore oot that is o ten localized
to the third web space and radiating to the toes.110 Hyperextension o the toes on weight-
bearing—as in squatting, stair climbing, or running—can increase the symptoms. Wearing
shoes with a narrow toe box or high heels can increase the symptoms. I there is prolonged
nerve irritation, the pain can become constant. A bone scan is o ten necessary to rule out a
metatarsal stress racture.

Orthotic therapy is essential to reduce the shearing movements o the metatarsal heads. o
reduce this shearing e ect, o ten either a metatarsal bar is placed just proximal to the meta-
tarsal heads or a teardrop-shaped pad is placed between the heads o the third and ourth
metatarsals in an attempt to have these splay apart with weightbearing (Figure 26-38). T e
goal o the orthosis with placement o additional pads such as these is to decrease pressure
on the a ected area.
T erapeutic modalities such as ultrasound or iontophoresis can be used to help reduce
inf ammation. Shoe selection also plays an important role in treatment o neuromas. Nar-
row shoes, particularly women’s shoes that are pointed in the toe area and certain men’s
boots, may squeeze the metatarsal heads together and exacerbate the problem. A shoe
that is wide in the toe-box area should be selected. A straight-laced shoe o ten provides
increased space in the toe box.103 Firm-soled, inf exible shoes (such as clogs) can assist in
managing this problem by inhibiting hyperextension o the toes during gait. O ten, appro-
priate so t orthotic padding or a gel pad will markedly reduce pain. On a rare occasion sur-
gical excision may be required.
A B
Figure 26-38
A. Metatarsal bar. B. Teardrop pad.
Turf Toe
ur toe is a hyperextension injury that usually occurs in the
athletic population and results in a sprain o the metatarso-
phalangeal joint o the great toe, either rom repetitive over-
use or trauma.116 ypically, this injury occurs on unyielding
synthetic tur , although it can occur on grass or hard court
sur aces as well. Many o these injuries occur because arti -
cial tur shoes o ten are more f exible and allow more dorsi-
f exion o the great toe.

Some shoe companies have addressed this problem by add-
ing steel or other materials to the ore oot o their tur shoes
Figure 26-39 Turf to e taping to sti en them. Flat insoles that have thin sheets o steel
under the ore oot are also available. When commercially
made products are not available, a thin, f at piece o Ortho-
plast may be placed under the shoe insole or may be molded to the oot.116 aping the toe to
prevent dorsif exion may be done separately or with one o the shoe-sti ening suggestions
(Figure 26-39).
Modalities o choice include ice, iontophoresis, and ultrasound. One key component
or the acute management or tur toe is rest and protection.
In less-severe cases, patient can continue normal activities with the addition o a rigid
insole. With more severe sprains, 3 to 4 weeks may be required or pain to reduce to the
point where the patient can push o on the great toe.
Tarsal Tunnel Syndrome

T e tarsal tunnel is a loosely de ned area about the m edial malleolus that is bordered
by the retinaculum, which binds the tibial nerve.40 Overpronation, overuse conditions,
and trauma may cause neurovascular problem s in the ankle and oot. Sym ptom s may
vary with pain, num bness, and paresthesia reported along the m edial ankle and into the
sole o the oot.9 enderness may be present over the tibial nerve area behind the m edial
malleolus.

Neutral oot control with a custom orthosis may alleviate symptoms in less involved cases.
Surgery is o ten per ormed i symptoms do not respond to conservative treatment or i
weakness occurs in the f exors o the toes.9
Rehabilit at ion Techniques Summary

T e ankle and oot can be a complicated and con using region to manage with success.
T us, with any ankle or oot injury, it is important to “treat what you nd,” and evaluate
“above and below” the joint. Furthermore, address any imbalances in strength, f exibility,
mobility, or neuromuscular control both proximally and distally, as well as biomechani-
cal and gait considerations. Finally, help the patient to help themselves with the skills and
knowledge available to reach their unctional goals.
Orthosis and Footwear Recommendations 857
Orthosis and Footwear Recommendations
Philosophy of Ort hot ic Therapy

Almost all problems o the lower extremity have been treated using orthotic therapy. T e use
o an orthosis (commonly re erred to as “orthotic”) or control o oot de ormities has been
recommended by various health care pro essionals or many years.7,20,22,29,40,54,95,108,110,118
T e normal oot unctions most e ciently when no de ormities are present that predispose
it to injury or exacerbation o existing injuries. Orthoses are used to control abnormal com-
pensatory movements o the oot by “bringing the f oor to the oot.”51
T e oot unctions most e ciently in an S JN position. By providing support so that
the oot does not have to move abnormally, an orthosis should help prevent compensatory
problems.
For problems that have already occurred, the orthosis provides a plat orm o support
so that so t tissues can heal properly without undue stress. In summary, the goal is to create
a biomechanically balanced kinetic chain by using a device capable o controlling motion
pathology in the oot and leg by maintaining the oot in or close to S JN position. Basically,
there are 2 types o orthoses:
• Biomechanical orthosis—a hard device (Figure 26-40) or semif exible device (see
Figures 26-34 and 26-41) capable o controlling movement-related pathology by
attempting to guide the oot into unctioning at or near S JN. T is device consists o a
shell (or module) that is either rigid or f exible with noncompressible posting (wedges)
angled in degrees that will address both ore oot and rear oot de ormities (Figure 26-42).
T e rigid style shell is abricated rom carbon graphite, acrylic Rohadur, or (polyethylene)
hard plastic. T e control acquired is high, while shock absorption is sacri ced
somewhat. T e f exible shell is abricated rom thermoplastic, rubber, or leather and is
the pre erred device or the more active or sports-speci c patient. T e semirigid device
takes advantage o various types o materials that provide both shock absorption and
motion control under increased loading while retaining their original shape. T e rigid
devices take the opposite approach and are designed to rmly restrain oot motion
and alter its position with nonyielding materials. Both the rigid and f exible shells are
molded rom a neutral cast and allow control or most overuse symptoms.2,3,51,66,110
• Accommodative orthosis—a device that does
not attempt to establish oot unction around the
S JN but instead allows the oot to compensate.
T ese devices are designed or patients who are
deemed to be poor candidates or biomechanical
control because o congenital mal ormations,
restricted motions at oot or leg, neuromuscular
dys un ctions, insensitive eet, illness, or
physiologic old age. T e materials used to abricate
the shell are so ter that will yield to oot orces
rather than resist them. Compressible wedges are
used to bias the oot.2,3
Although not considered a true orthosis, o tentimes
pads and so t, f exible elt or gel supports (Figure 26-43)
can be readily abricated or situations when shoe space
is compromised (eg, running spikes) or when shoes are
not worn (eg, ballet dancing). T is type o oot correc-
tion is advocated or mild overuse syndromes. Figure 26-40 Hard o rtho sis
Figure 26-41 Se mi e xible thre e -quarte r– Figure 26-42 Fo o t o rtho sis se mi e xible she ll
le ng th custo m o rtho sis w ith noncompre ssible posting attache d unde rne ath
Figure 26-43 Fe lt pads
A. Metatarsal pads. B. Metatarsal bars. C. Metatarsal cookies. D. Longitudinal metatarsal

pads. E. Scaphoid pads. F. Horseshoe heel cushions. G. Dancer pads.
A B
Figure 26-44 Fo am-bo x impre ssio n
A. Impression taken in the seated position. B. Foam impressions used for construction of the orthosis.
Negat ive Foot Impression

Some therapists will make a negative impression o the patient’s oot using a oam box or
slipper casting using plaster strips or a commercial casting product. T is negative impres-
sion is mailed to an orthotic laboratory, where it is abricated utilizing therapist recommen-
dations or laboratory discretion. Others like to complete the entire orthosis rom start to
nish, which requires a much more skilled evaluator and technician, as well as the neces-
sary equipment and supplies. T ere are obvious cost advantages and disadvantages to in-
o ce abrication.
No matter which method is chosen, the rst step is the abrication o the negative
impression, which is done with the patient in a S JN. I using the oam-box impression
method, the patient is placed in a seated position with the knee directly over the oot. T e
patient’s oot is gently placed on the oam box. T e therapist will then place the oot in an
S JN position. While maintaining this semi-weightbearing alignment, the therapist will
apply a downward orce through the knee and the ore oot toward the f oor until the heel
is seated in the oam. Finally, the toes are seated into the oam avoiding overcompression
o the oam. T e oot is care ully removed rom the oam box by li ting the heel rst. T is is
then repeated on the contralateral side (Figure 26-44).
T e other method o developing the negative mold is using the slipper cast technique.
Once S JN is ound in a non–weightbearing position, 3 layers o plaster splints are applied
to the plantar sur ace and sides o the oot. S JN position is maintained as pressure is
applied on the th metatarsal area in a dorsif exion direction until the M J is locked. T is
position is held until the plaster dries. At this point the plaster cast may be sent out to have
the orthosis abricated by the lab or ready or the next step by the therapist. I it is mailed
out, the appropriate measurements o ore oot and rear oot positions should be sent, along
with any extrinsic measurements.
T e next step is making the positive mold by pouring plaster o Paris into the cast or
oam-box impression. When working with the cast molds, the inside o the plaster should
be liberally lined with talc or powder.
No special preparation is required when using the oam-box impressions.
Ort hosis Mat erials and Fabricat ion

Many di erent materials may be used in the abrication o a custom orthosis, including the
shell (or module), top covers, posting materials, or any type o additional padding or inserts
(eg, gel heel insert). T e speci c type o materials used by a therapist or orthotist depends
on the pre erence o that individual. Considerations should include long-term goal o the
device, what material has proven to be success ul, availability o the material, and ease o
working with the material. Other considerations include color, sti ness (durometer), dura-
bility, and shock absorption.
One author uses one-eigth-inch Aliplast covering (Alimed Inc., Boston) with a one-
quarter-inch Plastazote underneath. A rectangular piece o each material large enough to
completely encompass the lower third o the mold is cut. T ese 2 pieces are placed in a con-
vection oven at approximately 275°F. At this temperature, the 2 materials bond together and
become moldable in approximately 5 to 7 minutes. At this time, the materials are removed
rom the oven and placed on the positive mold. Ideally, a orm or vacuum press should be
used to orm the orthosis to the mold.51
I the patient is present and once cooled, the uncut orthosis is placed under the oot
while the patient sits in a chair. Excess material is then trimmed rom the sides o the orthosis
with scissors. Any material that can be seen protruding rom either side o the oot should be
trimmed to provide the proper width o the orthosis. T e length should be trimmed so that the
end o the orthosis bisects the metatarsal heads. T is style is slightly longer than traditional
sulcus length orthosis, but one author has ound that this length provides better com ort.51
Next, a third layer o medial Plastazote may be glued to the arch to ll that area to the
f oor. Grinding begins with the sides o the orthosis, which should be ground so that the
sides are slightly beveled inward to allow better shoe t. T e bottom o the orthosis is leveled
so that the sur ace is perpendicular to the bisection o the calcaneus. Grinding is contin-
ued until very little Plastazote remains under the Aliplast at the heel. T e ore oot is posted
by selectively attaching and/ or grinding Plastazote just proximal to the metatarsal heads.
Fore oot varus is posted by grinding more laterally than medially. Fore oot valgus requires
grinding more medially than laterally. With the metatarsal length orthosis, the nal step is
to grind the distal portion o the orthosis so that only a very thin piece o Aliplast is under the
area where the orthosis ends. T is prevents discom ort under the ore oot where the ortho-
sis stops. I the patient eels that this area is a problem and the metatarsal length device has
already been abricated, a ull insole o Spenco or other material may be used to cover the
orthosis to the end o the shoe to eliminate the dropo sometimes elt as the orthosis ends.
Another author has developed a measurement system in conjunction with an orthotic
laboratory (Biocorrect Custom Foot Orthotics Laboratory, Kentwood, MI) to determine the
amount o ore oot and rear oot posting required or the needed biomechanical corrections.
Having already per ormed the lower leg and calcaneal bisection and the non–weightbear-
ing assessment, weightbearing measurements are taken using an inclinometer in an S JN
position, resting position, and end-range dorsif exed position o 25 degrees (Figure 26-45A
and B). T e end-range measurements are then used to prescribe the recommended rear-
oot posting (0 to 3 degrees maximum) and ore oot posting (0 to 6 degrees maximum).
When making recommendations to an orthotics laboratory, other considerations need to
be made including materials used or shells, posting, top covers, length o orthosis, cutouts,
deep heel cups, gel heel inserts, metatarsal pads or bars, or external f anges. T e length
o an orthosis can be described as a ull, sulcus, or metatarsal device. A ull-length device
starts at the calcaneus and extends past the distal phalanges. A metatarsal length device
extends distal to the metatarsal phalangeal joints, whereas the sulcus length device stops
just proximal to the metatarsal phalangeal joints. An external f ange, not routinely used, is
an extension o the shell and rear oot posting to provide additional motion or position con-
trol. Finally, the thickness o the orthosis needs to be considered depending on its use and
the ootwear into which the device is going to be placed.
A B
Figure 26-45
A. End-range dorsiflexion (25 degrees). B. Rear foot measurement with inclinometer.
In the majority o cases, a ull-length orthosis that allows or ore oot and rst ray cor-
rection along with the standard rear oot correction is suggested. Exact corrections will be
determined depending on the patient’s biomechanical issues.
Biocorrect Custom Foot Orthotics Laboratory recommends a high-density (1 to 3 mm)
polyethylene shell, which is lightweight and high-impact resilient (JMS Plastics Supply
Inc., Neptune, NJ). Various top covers (ACOR Inc., Cleveland, OH) are available using one-
eighth-inch Vinair, leather, or Neosponge in combination with one-sixteenth-inch to three-
sixteenths-inch P-Cell or Micro-cell Pu ethylene vinyl acetate (EVA) material or additional
shock absorption (Figure 26-46). A rmer EVA (45 to 50 durometers) material (JMS Plastics
Supply Inc.) is used or the extrinsic ore oot/ rear oot posting and arch support.
T e process is essentially the same as previously
described, except the patient does not need to be
present to determine the necessary ore oot, rear oot,
or rst ray corrections. T ese prescribed corrections D
have already been established during the evaluation C
process. Once all o the speci c materials have been
attached or glued to the shell, the necessary grinding
B
will take place to complete the nished orthosis.
ime must be allowed or proper break-in. T e
patient should wear the orthosis or 3 to 4 hours the
rst day, 6 to 8 hours the next day, and then all day
on the third day. Physical activities should be started
with the orthosis only a ter it has been worn all day or A
several days.49
Sometimes corrections or adjustments are nec-
essary to the orthosis. Orthotic therapy is “an art and
a science,” so it is important to be able to make cor-
rections or adjustments quickly and easily. T is may Figure 26-46 Vario us to p co ve r mate rials
inf uence a clinician as to whether they choose an out-
o -state versus a local laboratory, or make the invest- A. Leather top cover. B. Microcell Puff top cover. C. Neosponge
ment o having a ull or partial in-house laboratory. top cover. D. Vinair top cover.
Shoe Select ion

Shoes are one o the biggest considerations in treating a oot problem success ully.109 Even a
properly made orthosis is less e ective i placed in a poorly constructed or an inappropriate
shoe or the patient. It is critical that the shoe–orthosis inter ace matches the anatomical
alignment and biomechanics o each individual. In many cases related to walking or run-
ning, improper shoe and/ or orthotic can be a primary cause o lower extremity overuse
injuries, ranging rom the hip to the oot.
As noted, pronation is usually a problem o hypermobility. T us, pronatory oot types
need stability and rmness to reduce excess movement. Research indicates that ore oot
compression o the outer sole o the shoe may actually increase pronation versus a bare oot
condition.6 T e ideal shoe or a pronated oot is less f exible with good rear oot control.
Conversely, supinated eet are usually more rigid. Shoes with adequate cushion and f ex-
ibility bene t this type o oot.
Several construction actors may inf uence the rmness and stability o a shoe. T e
basic orm upon which a shoe is built is called the last ( Figure 26-47).3,6 T e upper is t-
ted onto a last in several ways. Each method has its own f exibility and control charac-
teristics. A central slip-lasted shoe is sewn together like a m occasin and is very f exible.
A peripheral (Strobel or Cali ornia) lasted shoe has similar characteristics as the central
slip, except the stitching is along the outside o the shoe. Board-lasting provides a piece o
berboard upon which the upper is attached, which provides a very rm, inf exible base
or the shoe. A combination-lasted shoe is boarded in the back hal o the shoe and slip-
lasted in the ront, which provides rear- oot stability with ore oot mobility. T e shape o
the last may also be used to assist with shoe selection. T e 3 di erent types o shapes are
straight lasted, curved lasted, and semicurved lasted and are usually consistent with the
construction o a shoe. T e shape and the construction o the last are typically consistent
Boa rdla s te d Ce ntra l s lipla s te d
P e riphe ra l la s te d
(S trobe l or Ca lifornia ) Combina tion la s t
S lipla s te d
Boa rdla s te d
Figure 26-47 Sho e last co nstructio n

with one another. Most patients with excessive pronation
per orm better in a straight-lasted shoe,3,6 that is, a shoe
in which the ore oot does not curve inward in relation to
the rear- oot.
In comparing all o the dress and athletic shoes avail-
able to the consum er, running shoes have the greatest
investm ent in money and resources by the manu actures
or research and developm ent with respect to controlling
the m otion o the oot. T us, when it com es to providing
a patient with speci c ootwear recom m endations or
running or walking, running shoes have the largest selec-
tion o options to choose rom. T ere are several di er-
ent categories o running shoes available with a speci c
purpose in m ind. Som e are designed m ore or training,
while others geared or per ormance. Since 2008, there
has been a resurgence o shoes developed to prom ote the
Figure 26-48 Minimalistic/ Spe cialty sho e
m inimalistic or bare oot trend in running. Within each
(Vibram Five Fing e r)
category, there are several di erent brands with their own
unique cushioning and control system s. T e general cat-
egories can be de ned as: Motion Control, Stability, Guidance, Straight-lasted Cushion,
Neutral Cushion, Minimalistic/ Per ormance, Minimalistic/ Specialty ( Figures 26-48 and
26-49), Spikes, and rail Runner.
Midsole design plays the biggest role in the amount o cushion or stability inherently
built into the shoe. T ere are several eatures o the midsole that de ne each shoe, includ-
ing EVA density, stability system s, last shape and drop. T e m idsole is what separates
the upper portion o the shoe rom the outsole (bottom o the shoe).3,16 EVA is one o the
m ost com m only used materials in the m idsole.3,86 T e higher the density o the EVA is
(measured by Durometer scale), the m ore sti the midsole o a shoe will be. In the Guid-
ance, Stability, and Motion Control categories, a dual-density EVA is o ten times utilized.
A higher density EVA, o ten tim es colored di erently to show that it is denser, is placed
under within the less dense EVA material along the m edial aspect o the midsole to assist
with pronation control. Also, in an e ort to control rear oot m ovement, many shoe manu-
acturers have rein orced the heel counter both internally and externally, o ten in the orm
o extra plastic along the outside o the heel counter.3,71
Each manu acturer has a unique, patented stability sys-
tem to promote m ore pronation control (eg, Brooks Pro-
gressive Diagonal Rollbar ound in their Adrenaline 12).
A straighter-lasted shoe will be inherently m ore stable
than a semi- or curve lasted shoe just be the geometry o
the m idsole. Finally, the drop o the shoe (m easured in
m illim eters rom the heel to the toe) plays a role in per-
ormance o the shoe. It is theorized that a smaller drop
rom heel to toe will encourage a m ore m id- oot strike
pattern as com pared to a heel-strike pattern. T e newer
line o Minimalistic category range rom a zero, 4- or
8-mm drop shoe, whereas the more traditional ootwear
(Neutral Cushion through Motion Control) range rom 8-
to 12-m m drop shoes.
Other actors that may a ect the per ormance o a
shoe are the outsole contour and composition, lacing
systems, and ore oot wedges ( or speci c details, re er to Figure 26-49 Minimalistic/ Spe cialty sho e
able 26-1). (Ultra Ze ro Dro p)
Table 26-1 Ge ne ral Classi catio n and Characte ristics o f Running Sho e Type s
Mo tio n Co ntro l Sho e

• Indications: Severe overpronator
• Straighter last shape
• Board or combination last construction a
• Midsole materials (EVA or Polyeurethane (PU)) depend on BW
• Firmer dual-density medial midsole or stabilization device and typically runs from heel counter up into forefoot
• Reinforced and/or extended heel counter
• Will sometimes use higher medial side versus lateral side (wedge) for increased early motion control
Stability Sho e
• Indications: Moderate over-pronator
• Semicurved last shape
• Combination or peripheral last construction
• Midsole materials (EVA or PU) dependent on BW
• Firmness of dual-density medial midsole or stabilization device dependent of range of stability shoe and typically
runs from the heel counter up past the arch
• Firm heel counter
Guidance Sho e
• Indications: mild overpronator
• Semicurved last shape
• Combination or peripheral last construction
• Midsole materials usually a lighter weight EVA
• Firmness of dual-density medial midsole or stabilization device dependent of range of stability shoe that typically
runs under the arch
• Firm heel counter
Straig ht-Laste d Cushio n Sho e
• Indication: Neutral to supinatory foot that is unstable
• Newer transition shoe that bridges the gap between cushion and stability mostly with the geometry of the shoe
• Straighter last shoe
• Midsole materials (EVA or PU) dependent on BW, but usually lean to lighter-weight EVA
• Single density midsole
• May utilize stability pillars (eg, Brooks Dyad series)
• Firmer heel counter
Ne utral Cushio n Sho e
• Indication: Neutral to supinatory foot
• Typically more curve last shape
• Central or peripheral slip last construction
• Single density midsole
• Midsole cushioning units (rearfoot and forefoot)
Minimalistic/ Pe rfo rmance Sho e
• Indication: neutral to supinatory foot
• Recommended use: short distance training or racing
• Typically more curve last shape
• Central or peripheral slip last construction
• Single density midsole with minimal to zero drop from heel to toe
• Midsole cushioning units (rearfoot and forefoot)
a
Board last combination primarily used with older running shoes and basketball shoes. Combination last primarily used with newer running shoes.
Source: Rob Lillie, General Manager at Gazelle Sports, Kalamazoo, Michigan.
Shoe Wear Evaluat ion

Shoe wear patterns can som etimes give the therapist help ul in ormation about the
patient’s biom echanical considerations and potential movement dys unctions. Patients
with excessive pronation o ten wear out the ront o the running shoe under the second
metatarsal (Figure 26-50). Shoe wear patterns are commonly misinterpreted by patients
who think they must be pronators because they wear out the back outside edges o their
heels. Actually, most people who wear out the back outside edges o their shoes are con-
sistent with lateral heel strike at initial contact. Just be ore heel strike, the anterior tibial
muscle res to prevent the oot rom slapping orward. T e anterior tibialis muscle not only
dorsif exes the oot but also slightly inverts it, hence the wear pattern on the back edge o
the shoe. For those runners who are mid oot to ore oot strikers, typically less lateral heel
wear is evident. T e key to inspection o wear patterns on shoes is observation o the heel
counter and the ore oot.
T ere are 3 sim ple tests that can be utilized to determ ine the structural integrity o
a running shoe. T e rst test is used to determ ine i the individual is placing an excep-
tional amount o torsional torque on the shoe, speci cally through the mid oot region. By
simply placing the shoe on a f at sur ace, and pushing down on the ront o the toe box in
the center, observe the natural m ovement pattern o the shoe. I the shoe veers m edially
or laterally, this is indicative o increased torsion on the shoe. T is may indicate that a
more stable shoe is required to counteract the orce, or an orthosis is necessary to cre-
ate improved balance throughout stance phase. T e second test is to determine excessive
wear o the shoe. I it is possible to bend the toe o the shoe in hal to touch the heel collar
o the shoe, the shoe no longer has the necessary structural integrity to unction properly.
In m ost cases, the shoe’s cushioning properties have been
broken down to a point where the shoe would be more likely
to cause injury than to prevent injury. T e third test is also
utilized to determ ine i the shoe’s structural stability is solid
enough to support the runner. Simply, bend the shoe in a “ g-
ure 8” pattern. In this test, i you can twist the shoe around the
central axis, the structural integrity is broken down enough to
increase the possibility o injury.
Fin ally, run n in g sh oes are curren tly bein g design ed
with the prim ary goal o having the lightest weight shoe pos-
sible. Newer m aterials are bein g used to decrease weight
while attem ptin g to m aintain som e stability and cushioning
properties. he result o this tren d is that the li e expectancy
o shoes drastically decreases. Run n ers, or the m ost part,
should be lookin g at changing their running shoes a ter 300
total m iles o run n in g, rather than the old adage o 450 to
500 m iles.
Another evaluation technique or ootwear is to determine
i the patient is placing an exceptional amount o torsional
torque on the shoe, speci cally through the mid oot region. By
simply placing the shoe on a f at sur ace, and pushing down on
the ront o the toe box in the center, observe the natural move-
ment pattern o the shoe. I the shoe veers medially or later-
ally, this is indicative o increased torsion on the shoe. T is may
indicate that a more stable shoe is required to counteract the Figure 26-50 Fro nt fo re fo o t o f a running
orce, or an orthosis is necessary to create improved balance sho e sho w ing the typical w e ar patte rn o f a
throughout stance phase. pro nato r
Exercises
Rehabilitation Techniques
St rengt hening Exercises

Isomet ric St rengt hening Exercises
Exercise 26-1 Exercise 26-2

Isometric inversion against a stable object. Used to Isometric eversion against a stable object. Used to strengthen
strengthen the posterior tibialis, flexor digitorum longus, the peroneus longus, brevis, tertius, and extensor digitorum
and flexor hallucis longus. longus.
Isometric plantarflexion against a stable object. Used to Isometric dorsiflexion against a stable object. Used to
strengthen the gastrocnemius, soleus, posterior tibialis, strengthen the anterior tibialis and peroneus tertius.
flexor digitorum longus, flexor hallucis longus, and plantaris.
Rehabilitation Techniques 867
Isot onic Open-Chain St rengt hening Exercises
A B
Exercise 26-5
Inversion exercise. A. Using a weight cuff. B. Using resistive
tubing. Used to strengthen the posterior tibialis, flexor
digitorum longus, and flexor hallucis longus.
A B
Exercise 26-6
Eversion exercise. A. Using a weight cuff. B. Using resistive tubing. Used to strengthen the peroneus longus, brevis, tertius, and
extensor digitorum longus.
A B
Exercise 26-7
Dorsiflexion exercise. A. Using a weight cuff. B. Using resistive tubing. Used to strengthen the anterior tibialis and
peroneus tertius.
A B
C D
Exercise 26-8
Plantar exion exercise. A. Concentric against
gravity. B. Using surgical tubing. C. Eccentric-
Stage 1. D. Eccentric-Stage 2. Used to strengthen
the gastrocnemius, soleus, posterior tibialis, exor
digitorum longus, exor hallucis longus, and plantaris.
Exercise 26-9
Multidirectional Elgin ankle exerciser.
Closed-Chain St rengt hening Exercises
A B
Exercise 26-10
Isolated toe raises. A. Toe
raises with extended knee
strengthens the gastrocnemius.
B. Toe raises with flexed knee
strengthens the soleus.
A B
Exercise 26-11
Active-assisted plantarflexion using the
BOB (Caledonia, MI). A. Starting position.
B. Finishing position. Can also use as a static
stretch by holding end range positions.
Exercise 26-12
Towel gathering exercise. Toe flexion. Used to strengthen the flexor
digitorum longus and brevis, lumbricales, and flexor hallucis longus.
A B
Exercise 26-13
Foot intrinsic strengthening. A. Starting position, relaxed foot. B. End position, with actively drawn up arch.
Exercise 26-15
Slide board exercises.
Exercise 26-14
Lateral step-ups.
Exercise 26-17
Forward step-up with alternate arm raise using
a dumbbell. Used for cross-over strengthening
Exercise 26-16 of gluteus maximus and balance/neuromuscular
control as well as contralateral dorsal musculature
Shuttle exercise machine. associated with thoracolumbar fascia.
A B
Exercise 26-18
Hip hiking. A. Starting position. B. Finishing position. Used to strengthen gluteus medius. Can also
be used as a neuromuscular retraining exercise having the patient stop when pelvis is level or in
conjunction with a biofeedback unit over gluteus medius for proper recruitment.
Isokinet ic St rengt hening Exercises
Exercise 26-19
Isokinetic inversion/eversion exercise.
Used to improve the strength and
endurance of the ankle inverters and
everters in an open chain. Also can
provide an objective measurement of
muscular torque production.
Exercise 26-20
Isokinetic plantarflexion/dorsiflexion
exercise. Used to improve the strength
and endurance of the ankle dorsiflexors
and plantarflexors in an open chain.
Also can provide an objective
measurement of torque production.
Propriocept ive Neuromuscular Facilit at ion St rengt hening Exercises
A B
Exercise 26-21
Diagonal 1 (D1) pattern moving into flexion. A. Starting position: ankle plantar flexed, foot everted, toes flexed. B. Terminal
position: ankle dorsiflexed, foot inverted, toes extended.
A B
Exercise 26-22
Diagonal 1 (D1) pattern moving into extension. A. Starting position: ankle dorsiflexed, foot inverted, toes
extended. B. Terminal position: ankle plantar flexed, foot everted, toes flexed.
A
A
B B

Diagonal 2 (D2) pattern moving into flexion. Diagonal 2 (D2) pattern moving into extension.
A. Starting position: ankle plantar flexed, foot inverted, A. Starting position: ankle dorsiflexed, foot everted,
toes flexed. B. Terminal position: ankle dorsiflexed, foot toes extended. B. Terminal position: ankle plantar
everted, toes extended. flexed, foot inverted, toes flexed.
A B
Exercise 26-25
Fitter Rocker board exercises are an active range of motion exercise, useful in regaining normal ankle motion and
early neuromuscular retraining. A. Seated plantarflexion—dorsiflexion. B. Seated inversion—eversion. Both can be
progressed to standing, in partial or full weight bearing conditions.
A B C
Exercise 26-26
Standing heel cord stretch. A. Gastrocnemius. B. Soleus. C. Gastrocnemius stretch using a slant board.
A B
Exercise 26-27
Seated heel cord stretch using a towel. A. Gastrocnemius. B. Soleus.
A B C
Exercise 26-28
Dynamic heel cord stretch. A. Position 1. B. Position 2. C. Position 3. Varied positions offer different dynamic challenges to the
ankle and foot musculature, in addition to stretching the heel cord.
A B
Exercise 26-29
Ankle plantarflexion stretch for the anterior tibialis.
A. Standing. B. Kneeling.
A B
Exercise 26-30
Plantar fascia stretches. A. Manual. B. Floor stretch.
C. Prostretch.
Exercise 26-31
Static single-leg standing balance progression. Used to improve balance
and proprioception of the lower extremity. This activity can be made more
difficult with the following progression: (a) single-leg standing with eyes
open; (b) single-leg standing with eyes closed; (c) single-leg standing with
eyes open and toes extended so only the heel and metatarsal heads are in
contact with the ground; and (d) single-leg standing with eyes closed and
toes extended.
A B C
Exercise 26-32
Standing single-leg balance activities of increasing dif culty. Used to activate the lower-leg musculature and
improve balance and proprioception of the involved extremity. A. Wedge board. B. BAPS board. C. BOSU ball.
Exercise 26-32 (Co n t in u e d )

D
D. Biodex Stability System™.
A B
Exercise 26-33
Fine motor-control activity in multiple planes using the Fitter
wobble board for weightbearing progressions. A. Seated.
B. Total Gym. C. Standing.
A B
C D
Exercise 26-34
Single-leg stance on an unstable surface while performing functional activities.
A. Single-limb stance on BAPS™ board with medicine ball toss. B. Single-limb
stance on BOSU™ ball with Body Blade™. C. Single-limb stance on Airex™ foam
pad with Plyoback medicine ball toss. D. Single-limb stance on DynaDisc™ with
tubing self-perturbations (forward).
A B
C D
Exercise 26-35
Single-limb stance tubing kicks. Resisted kicks with the tubing around the uninvolved side while weight bearing on the
involved side will challenge neuromuscular control. Four directions: A. Flexion. B. Extension. C. Adduction. D. Abduction.
Exercise 26-36
Double-leg press.
Exercise 26-37
Single-leg press on Total Gym using a DynaDisc.
A B
Exercise 26-38
A. Mini form squats. B. Mini form squats on BOSU™ ball with medicine ball lift to increase difficulty
as a result of perturbation offered by the upper-extremity movement and weighted medicine ball.
Exercise 26-39
Mini-lunge to unstable surface (BOSU™ ball).
Exercises t o Improve Cardiorespirat ory Endurance
Exercise 26-41
Exercise 26-40 Upper body ergometer used to maintain cardiovascular
fitness when LE exercise is too painful or too difficult.
Pool running with flotation device. Used to
Note: This brand of upper extremity ergometer also has
reduce the impact of weightbearing forces
LE pedals for alternate use.
on the lower extremity while maintaining
cardiovascular fitness level and running form.
Exercise 26-42
AirDyne stationary exercise bicycle. Used to maintain cardiovascular
fitness when lower-extremity weight bearing is difficult.
Exercise 26-43
Recumbant bicycle.
Exercise 26-44
Elliptical trainer. Used to maintain cardiovascular fitness
when weight bearing, no impact activity is recommended.
SUMMARY
1. T e movements that take place at the talocrural joint are ankle plantarf exion and dor-
sif exion. Inversion and eversion occur at the S J.
2. T e position o the S J determines whether the M Js will be hypermobile or hypomobile.
Dys unction at either joint may have a pro ound e ect on the oot and lower extremity.
3. Ankle sprains are very common. Inversion sprains usually involve the lateral ligaments
o the ankle, and eversion sprains requently involve the medial ligaments o the ankle.
Rotational injuries o ten involve the tibio bular and syndesmotic ligaments and may
be very severe.
4. T e early phase o treatment o ankle sprains includes use o ice, compression, eleva-
tion, rest, and protection, all o which are critical components in preventing swelling.
5. Early weight bearing ollowing ankle sprain is bene cial to the healing process. Re-
habilitation may become more aggressive ollowing the acute inf ammatory response
phase o healing.
6. Nondisplaced ankle ractures should be managed with rest and protection until the
racture has healed, whereas displaced ractures are treated with open reduction and
internal xation.
7. Subluxation o peroneal tendons can occur rom any mechanism causing sudden and
orce ul contraction o the peroneal muscles that involves dorsif exion and eversion o
the oot. In the case o an avulsion injury or when this becomes a chronic problem,
conservative treatment is unlikely to be success ul and surgery is needed to prevent the
problem rom recurring.
8. endinitis in the posterior tibialis, anterior tibialis, and the peroneal tendons may result
rom one speci c cause or rom a collection o mechanisms. echniques should be in-
corporated into rehabilitation that acts to reduce or eliminate inf ammation, including
rest, using therapeutic modalities (ice, ultrasound, iontophoresis), and using antiin-
f ammatory medications as prescribed by a physician.
9. Excessive or prolonged supination or pronation at the S J is likely to result rom some
structural or unctional de ormity, including ore oot varus, a ore oot valgus, or a rear-
oot varus, which orces the S J to compensate in a manner that will allow the weight-
bearing sur aces o the oot to make stable contact with the ground and get into a
weightbearing position.
10. Orthotics are used to control abnormal compensatory movements o the oot by “bring-
ing the f oor to the oot.” By providing support so that the oot does not have to move
abnormally, an orthotic should help prevent compensatory problems.
11. Shoe selection is an important parameter in the treatment o oot problems. T e type o
oot will dictate speci c shoe eatures.
12. T e most common stress ractures in the oot involve the navicular, second metatar-
sal (March racture), and diaphysis o the th metatarsal (Jones racture). Navicular
and second metatarsal stress ractures are likely to occur with excessive oot pronation,
whereas th metatarsal stress ractures tend to occur in a more rigid pes cavus oot.
13. A number o anatomic and biomechanical conditions have been studied as possible
causes o plantar asciitis. T ere is pain in the anterior medial heel, usually at the at-
tachment o the plantar ascia to the calcaneus. Orthotics in combination with stretch-
ing exercises can signi cantly reduce pain.
14. Subluxation o the cuboid will create symptoms similar to plantar asciitis and can be
corrected with manipulation.
15. A bunion is a de ormity o the head o the rst metatarsal in which the large toe as-
sumes a valgus position that is commonly associated with a structural ore oot varus in
which the rst ray tends to splay outward, putting pressure on the rst metatarsal head.
16. In treating a Morton neuroma, a metatarsal bar is placed just proximal to the metatarsal
heads or a teardrop-shaped pad is placed between the heads o the third and ourth
metatarsals in an attempt to have these splay apart with weight bearing.
17. ur toe is a hyperextension injury resulting in a sprain o the metatarsophalangeal
joint o the great toe.
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Rehabilitation Protocols
Achilles Tendon Repair Program *

• Surgical indications: Rupture o the Achilles tendon rom the insertion on the calcaneus.
• Surgical interventions: Surgical xation o the Achilles tendon to the anatomical
insertion on the calcaneus.
Acut e Phase
Beginning of Week 3 Postoperatively
1. Weightbearing status: Non–weight bearing
2. Patient education in protection o surgical site
3. ROM exercises:
a. Out-o -splint active ROM (AROM)
b. Plantarf exion and/ or dorsif exion (2 sets o 5 repetitions 3 times per day)
4. Strengthening:
a. Initiate non–weightbearing proximal strengthening activities or lower extremities
and core stabilizers (3 sets o 15 repetitions)
5. Proprioceptive/ neuromuscular reeducation exercises:
a. Seated rocker board or plantarf exion and dorsif exion (Exercise 26-25A)
Week 4 Postoperatively
1. Weightbearing status: Non–weight bearing
2. ROM exercises:
a. Out-o -splint AROM
b. Plantarf exion and/ or dorsif exion (2 sets o 20 repetitions)
c. Inversion and/ or eversion (2 sets o 20 repetitions)
d. Circumduction in both directions (2 sets o 20 repetitions)
3. Strengthening exercises:
a. Isometric inversion and/ or eversion in neutral (2 sets o 20 repetitions)
(Exercises 26-1 and 26-2)
b. oe curls with towel and weight (Exercise 26-12)
*T e Achilles endon Repair Program modi ed and used with permission rom Orthopaedic Associates o Grand
Rapids, PC, Grand Rapids, MI.
c. Continue with non-weightbearing proximal strengthening or lower extremities
and core stabilizers (3 sets o 15 repetitions)
4. Proprioceptive/ neuromuscular re-education exercises:
a. Seated rocker board or plantarf exion-dorsif exion and inversion-eversion
(Exercises 26-25A and B)
b. Seated wobble board or clockwise and counterclockwise circumduction
(Exercise 26-33A)
5. Physical therapy adjuncts:
a. Gentle manual mobilization o scar tissue
b. Cryotherapy with caution o any open areas
Week 5 Postoperatively
1. Weightbearing status: Progressive partial-weight bearing in walker splint
2. ROM exercises:
a. Previous AROM exercises continued
b. Begin gentle passive stretching into dorsif exion with towel
(Exercise 26-27A)
a. Isometric inversion and/ or eversion (2 sets o 20 repetitions)
(Exercises 26-1 and 26-2)
b. Isometric plantarf exion (initially 2 sets o 10 repetitions, progressing to 2 sets
o 20 repetitions over the course o the week) (Exercise 26-3)
c. T era-Band inversion and/ or eversion (2 sets o 10 repetitions)
(Exercises 26-5B and 26-6B)
d. T era-Band plantarf exion and/ or dorsif exion (2 sets o 10 repetitions)
(Exercises 26-7B and 26-8B)
e. Continue with proximal strengthening or lower extremity and core stabilizers
in non- or partial-weight bearing in walker splint (3 sets o 15 repetitions)
a. Standing rocker board or plantarf exion-dorsif exion and inversion-eversion
maintaining weightbearing restrictions (Exercises 25A and B, progressed to PWB in
standing)
b. Standing wobble board or clockwise and counterclockwise circumduction
maintaining weightbearing restrictions (Exercise 26-33C)
5. Conditioning activities:
a. Stationary bicycling begins, 7 to 12 minutes, minimal resistance
(Exercise 26-42)
b. Water therapy can begin under total buoyant conditions with use o a f oatation
device (Aqua-jogger vest) (Exercise 26-40)
c. In the water, ankle ROM and running/ walking activities can be initiated
a. Manual mobilization o scar and cryotherapy continues
b. Manual mobilization o ankle and oot joints (i necessary)
c. Gentle passive manual stretching (unless patient already has 10 degrees o
dorsif exion)

Weeks 6 to 8 Postoperatively
1. Weightbearing status: Progressive partial- to ull-weight bearing by week 7 or 8
2. ROM exercises:
a. Previous ROM exercises decreased to one set o 10 repetitions each
direction
b. Passive stretching continues into dorsif exion with progressively greater e orts
(knee in ull extension and f exed to 35 to 40 degrees) (Exercises 26-27A and B)
c. Begin standing cal stretch with ull extension and f exed at week 7
(Exercises 26-26A and B)
a. Decrease isometrics to 1 set o 10 repetitions or inversion and/ or eversion and
plantarf exion
b. Progress T era-Band resistance or inversion, eversion, plantarf exion, and
dorsif exion (3 sets o 20 repetitions)
c. Continue with proximal lower-extremity and core-stability exercises progressing to
ull-weight bearing a ter week 7 (Exercises 26-18A and B)
4. Conditioning exercises:
a. Stationary bicycling to 20 minutes with minimal resistance
(Exercise 26-42)
b. Water therapy exercises continue in totally buoyant state
a. Continue with previous wobble board and rocker board exercises
b. Once ull-weight bearing achieved , can initiate single-leg balance activities on stable
sur aces
a. Gentle cross- ber massage to Achilles tendon to release adhesions between tendon
and peritendon so t-tissue structures
b. Continue with previous manual therapy techniques i needed
c. Cryotherapy continues; ultrasound and electrical stimulation may be added or
chronic swelling or excessive scar ormation
Advanced Phase
1. Weightbearing status: Full-weight bearing with heel li t (high top shoes)
2. ROM exercises:
a. Further progressed with standing cal stretch
b. Add dynamic heel cord stretching in multiple planes (Exercises 26-28A to C)
a. Discontinue isometric exercises
b. Continue with progressive resistance T era-Band ankle strengthening in all
directions
c. Begin double-leg heel raises (plantarf exion) with BW as tolerated
(Exercises 26-8C and 26-11A and B)
d. Continue with proximal lower-extremity and core-stability exercises in ull-weight
bearing (Exercises 26-35A to D)
a. Initiate single-leg balance activities on unstable sur aces, including rocker board,
wobble board, oam rollers, DynaDisc, BOSU Balance rainer, or KA system as
tolerated (Exercises 26-32A to D)
b. Progress single-leg balance activities on unstable sur aces with perturbations by
therapist or using medicine balls, dumb bell weights, T eratubing, or Body Blade
(Exercises 26-34A to D)
a. Stationary cycling
b. readmill walking
c. StairMaster
d. Elliptical trainer (Exercise 26-44)
e. NuStep (Exercise 26-43)
f. Water therapy exercises in chest-deep water
6. T erapy adjunct:
a. Previously described i needed
Ret urn t o Funct ion Phase

Weeks 14 and Beyond Postoperatively
a. Heel raises should progress to use additional weight at least as great as BW, and in
the case o athletes, up to 1.5 times BW
b. Initiate single-leg heel raises as tolerated, possibly eccentric rst, the progressing to
concentric (Exercises 26-8A and D)
c. Progress unctional strengthening exercises speci c to athletic activity as patient
tolerates (Exercises 26-15 and 26-39)
a. Progress to jogging on trampoline and then to treadmill running via a walk-run
program
b. Eventually per orm steady-state outdoor running up to 20 minutes be ore adding
gure-8 or cutting drills
c. Water therapy exercises per ormed in shallow (waist deep) water
d. In the water, begin to include hopping, bounding, and jumping drills
3. Goals:
a. T e completely rehabilitated Achilles tendon repair allows 15 to 20 degrees o
dorsif exion and the ankle. T is must be maintained with regular stretching o
the gastrocnemius-soleus group. Caution must be considered not to overstretch
the Achilles tendon. Do not want to continue manual or passive stretching once
20 degrees o dorsif exion is achieved
b. Strength and endurance are developed to preinjury levels, and continued strength
and f exibility work is advised
c. Once return to sporting activities allowed, patient can complete unctional sports-
speci c drills without pain or compensation
Modi ed Brost rom Ankle Rehabilit at ion Program †

• Surgical indications: Chronic lateral ankle instability.
• Surgical interventions: A lateral incision is made to the ankle region, at which time
the capsule and lateral ligament structures, including the anterior talo bular and
calcaneo bular ligaments are tightened. Surgery may also include os calcis osteotomy.
Acut e Phase
Prior to Start o Physical T erapy
1. Weightbearing status: Non–weight bearing progressing to ull-weight bearing
(depends on the physician orders)
2. Patient education in protection o surgical site

1. Weightbearing status: Full-weight bearing
2. ROM exercises: Protect inversion. Do not stretch out repair
a. Out-o -splint AROM
b. Plantarf exion and/ or dorsif exion (2 sets o 20 repetitions)
c. Eversion and limited inversion (2 sets o 20 repetitions)
d. Circumduction in both directions (2 sets o 20 repetitions)
a. Ankle isometrics in all directions or light manual resistance (2 sets o 20 repetitions)
(Exercises 26-1 to 26-4)
b. Initiate proximal lower-extremity strengthening activities or lower extremity and
core stabilizers (3 sets o 15 repetitions) (Exercises 26-35A to D)
4. Stretching exercises:
a. Pain- ree gastrocnemius-soleus stretching (30 second hold × 3 sets)
(Exercise 26-27)
a. Seated rocker board or plantarf exion and dorsif exion (Exercise 26-25A)
b. Seated rocker board or eversion and limited inversion (Exercise 26-25B)
c. Seated wobble board or clockwise and counterclockwise circumduction
(Exercise 26-33A)
Single-leg balance activities on stable sur ace progressing to perturbations
by therapist or using medicine balls, dumb bell weights, T eratubing, or Body
Blade (Exercises 26-32A to D and 26-34A to D)
a. Gentle manual mobilization o scar tissue
b. Manual therapy or joint mobility protecting surgical site (i needed)
c. Modalities or pain and swelling control
d. Gait training
†T
e Modi ed Brostrom Ankle Rehabilitation Program modi ed and used with permission rom Orthopaedic
Associates o Grand Rapids, PC, Grand Rapids, MI.
7. Conditioning exercises:
a. Stationary bicycling to 20 minutes, minimal resistance
b. Water therapy can begin under total buoyant conditions with use o a f oatation
device (Aqua-jogger vest) (Exercise 26-40)
c. In the water, ankle ROM and running/ walking activities can be initiated
Advanced Phase
1. Weightbearing status: Full-weight bearing
2. ROM exercises:
a. As needed. Do not stretch out repair
a. Concentric/ eccentric strengthening in both open and closed kinetic chain
positions
b. Discontinue isometric exercises
c. Initiate isokinetic strengthening (50% maximum e ort) (Exercises 26-19 and 26-20)
d. Continue with proximal lower-extremity and core-stability exercises in ull-weight
bearing
a. Initiate single-leg balance activities on unstable sur aces, including rocker board,
wobble board, oam rollers, DynaDisc, BOSU Balance rainer, or KA system as
tolerated (Exercises 26-32A to D)
b. Progress single-leg balance activities on unstable sur aces with perturbations by
therapist or using medicine balls, dumb bell weights, T eratubing, or Body Blade
(Exercises 26-34A to D)
a. Stationary cycling
b. readmill walking
c. Straight-line running progression program
d. StairMaster
e. Elliptical trainer
f. NuStep
g. Water therapy exercises in chest-deep water
6. T erapy adjunct:
a. Previously described i needed
Ret urn t o Funct ion Phase

Weeks 14 and Beyond Postoperatively
a. Progress unctional strengthening exercises speci c to athletic activity as patient
tolerates
a. Progress straight line running program to 20 minutes be ore adding gure 8 or
cutting drills
b. Water therapy exercises per ormed in shallow (waist deep) water

c. In the water, begin to include hopping, bounding, and jumping drills
3. Goals:
a. T e completely rehabilitated Modi ed Brostrom procedure allows or ull ankle
ROM maintaining protection into inversion not to overstretch the repair.
b. Strength and endurance are developed to preinjury levels, and continued strength
and f exibility work is advised
c. Return to sporting activities allowed once patient cancomplete unctional sports
speci c drills without pain or compensation
Cervical and
T oracic Spine
Te r r y L. Gr in d s t a ff a n d Er ic M . M a g r u m
OBJJEC IVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Discuss the functional anatomy and biomechanics of the cervical and thoracic spine.
Compare and contrast the regional differences between the cervical and thoracic spine.
Discuss the rehabilitation approach to conditions of the cervical spine.
Discuss the rehabilitation approach to conditions of the thoracic spine.
Explain the rationale for why therapeutic exercise programs for the cervical and thoracic spine
would include neuromuscular control of the scapulothoracic joint or the lumbopelvic region.
Describe why a comprehensive history and examination are necessary to develop a rehabilitation
program for cervical and thoracic spine pathology.
Compare and contrast common clinical presentations for cervical or thoracic spine pathologies.
Explain the components of a comprehensive rehabilitation approach for the management of

cervical or thoracic spine pathology.
Incorporate the rehabilitation approach to speci c conditions affecting the cervical or thoracic spine.
897
898 Chapte r 27 Cervical and Thoracic Spine

T e cervical and thoracic spine are comprised o 19 vertebrae (7 cervical and 12 thoracic).
ypically, components o the vertebrae include the body, pedicle, lamina, transverse pro-
cesses and spinous process (Figures 27-1 and 27-2). T e posterior aspect o the vertebral
body, lamina, transverse processes and spinous process orm the vertebral oramen. T e
spinal cord passes through the vertebral oramen with nerve roots that pass through the
intervertebral oramen. T e size o the vertebral oramen progressively decreases in a caudal
direction as the spinal cord tapers in size. T e intervertebral oramen are larger at the cervical
and lumbar levels to accommodate the larger nerve roots at each level which are responsible
or innervation o the limbs. T e cervical nerve roots (C1-7) exit through the intervertebral
oramen above the associated vertebral segment, while the other nerve roots exit below their
associated vertebral segment (eg, C8 nerve root exits below C7, 1 nerve root exits below 1).
T ere are 2 major joints or each vertebral segment: the intervertebral and zygapophy-
seal ( acet) joints. T e intervertebral joint is a symphysis joint consisting o 2 vertebral bod-
ies connected by an intervertebral disc. T e zygapophyseal joint (right and le t side) is a
diarthrodial synovial joint with articulations between the in erior acet o a vertebral seg-
ment and the superior acet o the caudal segment.
T e intervertebral disc transmits loads between segments and provides spacing between
segments allowing motion to occur. T ere is a progressive increase in disc size rom the cer-
vical to the lumbar region. T e anterior portion o the disc is wider and relatively stronger
than the thinner posterior aspect o the disc. Each vertebral segment is separated by an inter-
vertebral disc, with the exception o the atlantooccipital and atlantoaxial joints. T e disc is
comprised o 3 major structural components: nucleus pulposus, annulus f brosus, and the
vertebral end plate. T e primary composition o these structures are water, collagen, and pro-
teoglycans. T e nucleus pulposus is the innermost aspect o the disc and has a higher water
and proteoglycan content and lower collagen content relative to the annulus f brosus and the
vertebral end plate, which provides the ability to resist compressive loads between the seg-
ments. T e supportive structure o the disc is provided by the annulus f brosus and the ver-
tebral end plate which have a higher collagen content than nucleus pulposus. T e vertebral
end plate serves as a cartilaginous attachment or the
disc to the vertebral body and provides structure to the
superior and in erior aspects o the nucleus pulposus.
T e annulus f brosus also contains elastin, surround-
ing the periphery o the nucleus pulposus and attach-
ing to the vertebral end plates. T e anterior portion o
the annulus f brosus is stronger as a result o higher col-
lagen content than the weaker posterior aspect o the
annulus f brosus. T e higher collagen content and the
presence o elastin provide circum erential support to
the nucleus pulposus and is able to resist tensile orces.
Nutrition and hydration o the intervertebral disc is
primarily dependent on di usion, which results rom
movement and compression o the vertebral segments.
T e outer third o the annulus f brosus has a neuro-
vascular supply and is innervated by the sinuvertebral
nerve.1 T is indicates that the area can be a pain gen-
erator, as well as having the capability or tissue heal-
ing. Because the posterior aspect o the disc is in close
Figure 27-1 Ce rvical and tho racic ve rte brae proximity to the spinal cord and nerve roots, there is
anato my the potential or the disc to encroach on these tissues.
A B
Figure 27-2 Ce rvical and tho racic ve rte brae anato my
Clin ica l Pe a r l
Discogenic referral pattern from the mid cervical region is to the medial border of the scapula.
Active motion is produced by coordinated interaction contractile tissues while acces-

sory motion is in uenced by contractile and noncontractile tissues. Available physiologic
motion at the spine occurs in the 3 cardinal planes and includes exion and extension, lat-
eral exion (side bending), and rotation. T ree additional arthrokinematic motions occur at
the spine and include lateral translation, compression/ distraction, and anterior/ posterior
translation. T ese motions do not occur in isolation, but are a result o coupled segmental
motion and contributions o adjacent vertebral segments.
Consistent with available motions at the spine, the cervical and thoracic spine are sub-
ject to orces including compression/ tension, bending, torsion, and shear. Compression
and tension produce an axial orce through the vertebral body, intervertebral disc, and
zygapophyseal joints. Bending orces cause compression and tension depending on i the
tissues are approximated or separated. orsion is caused during rotation with the interver-
tebral disc distributing the load. Shearing is caused by anterior/ posterior translation o the
vertebral segment with the load distributed by the intervertebral disc with minimal contri-
bution rom the surrounding musculature.
Regional Considerat ions

Although there are common structural and unctional characteristics o the spinal regions,
as described previously, there are also key structural and unctional di erences between the
cervical and thoracic spine. T ere is a cephalocaudal increase in vertebral body size as each
segment is responsible or greater weightbearing loads than the caudal segment. T e cervical
able 27-1 Ce rvical Spine Rang e o f Mo tio n spine bears less weight than the thoracic spinal segments and
has greater mobility, while the thoracic spine has greater sta-
bility (less mobility) as a result o articulations with the ribs.
• Flexion 45 degrees Although there are di erences between the cervical and tho-
• Extension 45 degrees racic spinal regions, the lower cervical vertebrae and the upper
• Rotation 80 to 90 degrees thoracic vertebrae, also known as the cervicothoracic region,
• Side bending 45 degrees share characteristics o both regions. Additionally, the lower
thoracic and upper lumbar segments or the thoracolumbar
region also share common characteristics.
Cervical Spine
T e cervical spine is characterized by as being mobile ( able 27-1), providing control o
the head, while protecting the spinal cord and vertebral arteries. A variety o techniques
exist to quanti y cervical range o motion (Figure 27-3).2,3 T ere are 7 vertebrae (C1-7), sep-
arated into an upper, craniovertebral region (C1-2), and a lower region (C3-7). T e atlas
(C1) and axis (C2) serve as a junction between the cervical spine and occiput. T e atlan-
tooccipital joint is the articulation between the occiput and atlas with exion and exten-
sion as the primary motion (approximately 10 to 30 degrees). T e atlantoaxial joint is the
articulation between the C1 and C2 vertebral segments with rotation as the primary motion
(approximately 45 degrees in each direction). A key di erence at the cervical spine is that
an intervertebral disc is not present between the atlantooccipital joint or the atlantoaxial
joint. T e ratio o intervertebral disc height to vertebral body height is greater in the cervi-
cal spine relative to the thoracic spine. T e greater proportional disc height in the cervical
spine allows or greater motion, as well as the ability to accom-
modate the larger cervical nerve roots.
T e zygapophyseal joints are oriented in the rontal plane
(prom otes exion/ extension) and have a larger joint cap-
sule, which provides a greater availability o motion. Greater
amounts o exion and extension occur at the lower segments
relative to the upper segm ents with maximum exion and
extension motion occurring at the C5-6 segment.4 Lateral ex-
ion (side bending) and rotation are coupled motions that occur
in an ipsilateral manner (eg, le t lateral exion occurs in con-
junction with le t rotation). Forces across the cervical spine are
dependent on position o the head and neck. T e line o gravity
alls anterior to the cervical spine, creating an external exion
moment and anterior shear. T e vertebral body and interverte-
bral disc bear approximally two-thirds o the compressive load
with the other one-third distributed across the zygapophyseal
joints. Loads are highest at end ranges o motion.
T e primary unctions o muscles in the cervical spine
region are to control the head and scapula, as well as to provide
stability to the cervical spine. Because o the higher mobility o
the cervical spine (as compared to other regions in the spine)
and the relatively low contribution o noncontractile supportive
structures (ligament, bony structures comprise approximately
20% o the mechanical stability), the surrounding musculature
provides a considerable amount o stability.5 Flexion o the cer-
vical spine is produced primarily by the bilateral contraction
o the sternocleidomastoid muscles and the scalene muscle
Figure 27-3 Ce rvical spine rang e o f group (anterior, middle, and posterior) on the anterior aspect
mo tio n asse ssme nt w ith inclino me te r o the neck (Figure 27-4). Smaller muscles, such as the longus
S upe rficia l De e p
Dig as tric :
Ante rior be lly
P os te rior be lly
S upra hyoid
group
S tylo hyo id
Mylo hyo id Hyoid bone
Common ca rotid a rte ry
Le va tor s ca pula e Inte rna l jugula r ve in
Thyro hyo id
S te rno hyo id Infra hyoid
Infra hyoid Omo hyo id: S te rno thyro id group
group S upe rior be lly
Infe rior be lly
S te rnocle idoma s toid Cla vicle
A Ante rio r vie w
S tylo hyo id
Dig as tric (pos te rior be lly)
Hyoglos s us
S ple nius ca pitis
Mylo hyo id
Dig as tric Infe rior pha rynge a l cons trictor
(a nte rior be lly)
S te rnocle idoma s toid
Hyoid bone
Tra pe zius
Thyro hyo id
Le va tor s ca pula e
Omo hyo id
(s upe rior be lly) S ca le ne s
S te rno thyro id Omo hyo id (infe rior be lly)
S te rno hyo id
B Late ral vie w
Figure 27-4 Ante rio r ce rvical spine musculature

capitis and longus colli, also contribute to spinal exion, but have more o a stabilizing role
by providing compression. Extension is produced by the upper trapezius, levator scapula,
splenius capitis, splenius cervicis, erector spinae, and semispinalis muscles (Figure 27-5).
Because the upper trapezius and levator scapula also provide motion to the scapula, cervi-
cal spine motion via these muscles is urther in uenced by movement o the scapula and
upper extremity. Although smaller in cross-sectional area, the suboccipital muscles are
responsible or extension o the occiput and have a proprioceptive role. Lateral exion and
rotation occur when a muscle contracts unilaterally. Bilateral contraction o muscle pairs

S ple nius ca pitis S e mis pina lis ce rvicis

s upe rior
S ple nius ce rvicis

S e mis pina lis
Ere ctor s pina e : thora cis
Iliocos ta lis
Longis s imus
S pina lis
S e rra tus pos te rior infe rior
Inte rna l a bdomina l Multifidus

oblique Qua dra tus lumborum
oblique (cut)
Figure 27-5 A. Po ste rio r ce rvical spine musculature


Longis s imus ce rvicis
Tra pe zius
Figure 27-5 B. Po ste rio r ce rvical musculature in anato mic disse ctio n (Co n t in u e d )
produces either exion (ie, sternocleidomastoid) or extension (ie, upper trapezius). Ipsilat-
eral lateral exion (side bending) is produced by the scalenes, sternocleidomastoid, upper
trapezius, levator scapula, and suboccipital muscles. Ipsilateral rotation is produced by the
levator scapula, splenius capitis, splenius cervicis, erector spinae, semispinalis, and suboc-
cipital muscles. Contralateral rotation is produced by the scalenes, sternocleidomastoid,
and upper trapezius muscles.
Clin ica l Pe a r l
The upper trapezius and levator scapulae tend to get tight because they are countering the
anterior shear forces of the head, created by the line of gravity. Tightness of these muscles
is accentuated by a forward head posture.
able 27-2 Tho racic Spine Rang e o f Mo tio n

Thoracic Spine
T e degree o available motion ( able 27-2) at the thoracic
spine is less than the cervical spine and primarily as a result • Flexion 20 to 45 degrees
o articulations with the ribs. A variety o techniques exist • Extension 20 to 45 degrees
to quanti y thoracic spine range o motion ( Figures 27-6 • Rotation 35 to 50 degrees
• Side bending 20 to 40 degrees
and 27-7).6,7 T e vertebral bodies are more wedge shaped,
with a larger posterior height relative to the anterior portion.
T is wedge shape contributes to the kyphotic curve o the thoracic spine. T e thoracic
intervertebral disc height to vertebral body height is less than the cervical spine and pro-
vides greater stability (less m obility). T ere are 2 ribs associated with each thoracic spine
vertebrae. T e thoracic vertebral body has demi acets that serve as an articulation with
the head o the ribs known as the costovertebral joint . T e transverse process also artic-
ulates with the ribs at the costotransverse joint. Structure and unction o the thoracic
spine are coupled with the ribs. Ribs 1 to 7 have a direct attachm ent to the sternum (true
ribs), whereas ribs 8 to 10 have an indirect attachm ent with the sternum via costochon-
dral cartilage, and ribs 11 and 12 are considered f oating ribs and have no attachment to
the sternum (see Figures 27-5 and 27-6). T e upper thoracic segm ents are similar to lower
cervical segm ents, and the lower thoracic segm ents are sim ilar to the lum bar region. T is
overlap indicates that pathology o the cervical or lum bar spine can in uence the tho-
racic region.
Clin ica l Pe a r l
Less mobility is available in the upper thoracic region as a result of direct attachment of
the ribs to the sternum.
T e joint capsule o the zygapophyseal joints is smaller and more taut than the cervi-
cal spine. T e slightly lateral orientation o the upper thoracic ( 1-6) acet joints rom the
rontal plane provides more lateral exion and rotation relative to exion and extension.
Flexion o the thoracic spine is limited by tension o the posterior longitudinal ligament
while extension is limited because o the wedge shape o the vertebral body and the larger
spinous processes. T is limitation is most pronounced in the
upper thoracic segments ( 1-6). T oracic spine rotation and
lateral bending are limited by articulations with the ribs. T e
line o gravity alls anterior to the thoracic spine, creating an
external exion moment, which is counteracted by posterior
ligaments and musculature. T e thoracic spine is also subject
to increased compressive loads caused by the support o the
head, neck, and upper extremities.
Muscles within the thoracic spine region have a number
o unctions including respiration, movement o the thorax,
movement o the upper extremity, and coupling with the cer-
vical and lumbar spine. It is important to note that motion in
the thoracic spine does not occur independently rom other
regions. Flexion o the thoracic spine is produced by grav-
ity, the anterior abdominal musculature (rectus abdominis,
obliques) and the psoas (Figure 27-8). Extension is produced
by the erector spinae, semispinalis thoracis, multif dus, and
quadratus lumborum ( Figure 27-9). Similar to the cervical
spine rotation, lateral exion and rotation occur as a result
o the unilateral action o the exor and extensor muscula-
ture. Lateral exion is produced by the external and internal
obliques, quadratus lumborum, erector spinae, rhomboids,
and serratus anterior. Rotation is produced by ipsilateral con-
traction o erector spinae, multif dus, splenius thoracis and
Figure 27-6 Tho racic spine rang e o f external oblique and contralateral contraction o the inter-
mo tio n asse ssme nt w ith inclino me te r nal oblique muscle. T e intercostal muscles (external and
Importance and Purpose of Examination 905
internal) play a substantial role with breathing. T e
external intercostal muscles are responsible or rib ele-
vation, while the internal intercostals are responsible
or rib depression. Additionally, the scalene muscles
have an attachment on the f rst (anterior and middle)
and second (posterior) ribs. T e scalenes assist with
elevation o the sternum and ribs during breathing.
During episodes o increased ventilatory demand the
sternocleidomastoid, pectoralis major, subclavius, can
all in uence rib motion.
Motion o the ribs is coupled with motion o the
thoracic spine segment. Flexion o the thoracic spine is
coupled with posterior rib elevation and internal tor-
sion while extension o the thoracic spine is coupled
with posterior rib depression and external torsion.8
T oracic rotation causes the ipsilateral rib to rotate Figure 27-7 Tho racic spine rang e o f mo tio n
posteriorly (external torsion) and the contralateral rib asse ssme nt w ith g o nio me te r
to rotate anteriorly (internal torsion).8 Lateral exion
(side bending) causes approximation o the ipsilateral
ribs and separation o the contralateral ribs.8
Importance and Purpose of Examination

In many instances, medical re erral or rehabilitation does not include specif c in orma-
tion regarding the underlying pathology (ie, neck pain). Although a specif c diagnosis can
provide the clinician with a better understanding o the underlying pathology, the clinician
must still obtain a thorough history and per orm a comprehensive examination. A system-
atic history and examination should be able to determine aggravating and easing actors,
identi y impairments which contribute to unctional limitations and pain, establish base-
line objective and subjective measures to monitor progress, and establish patient rapport,
decrease anxiety, and increase patient compliance with the rehabilitation program. T e
clinician should also look at sites adjacent to the cervical and thoracic spine (eg, shoulder,
lumbar spine) or potential contributing actors. Because o the proximity o vital organs
(heart, lungs) and overlap with common areas o re erred pain, it is important or the clini-
cian to determine the source o pain (musculoskeletal vs. nonmusculoskeletal). Nonmus-
culoskeletal pain, such as cardiac, pulmonary, or visceral pain, should be re erred to the
appropriate health care provider.
Clin ica l Pe a r l
Visceral referral is common in the thoracic region. Poorly localized pain occurs secondary to
projection to various parts of the central nervous system from this region.
Although exam ination techniques are n ot within the context o this chapter, inter-
ventions that are speci ic to addressin g the underlying pathology are critical com po-
n ents o the rehabilitation plan an d should be selected based on exam ination indings.
herapeutic exercise, m anual therapy (joint m obilization , m assage) and physical
agents/ m odalities m ay be used to address patient im pairm ents, unctional lim itations,
and pain. he selection o interventions should have a speci ic purpose with appropriate
P e ctora lis ma jor
La tis s imus dors i
Te ndinous
inte rs e ctions
Re ctus s he a th (cut e dge s )
Re ctus s he a th
Tra ns ve rs e a bdomina l
Umbilicus
Inte rna l a bdomina l
Line a s e miluna ris
oblique (cut)
Line a a lba
oblique (cut)
Apone uros is of Re ctus a bdominis
e xte rna l a bdomina l
oblique Inguina l liga me nt
A S upe rfic ial
S ubcla vius
P e ctora lis minor (cut)
P e ctora lis minor

Inte rna l inte rcos ta ls
Exte rna l inte rcos ta ls

Re ctus a bdominis (cut)
Re ctus s he a th

oblique (cut)
Inte rna l a bdomina l Inte rna l a bdomina l

oblique oblique (cut)
P os te rior wa ll of re ctus s he a th
(re ctus a bdominis re move d)
Inguina l liga me nt
Tra ns ve rs e a bdomina l (cut)
B De e p
Figure 27-8 Ante rio r tho racic spine musculature

Importance and Purpose of Examination 907
S upe rficia l De e p

S ple nius ca pitis
Tra pe zius
Le va tor s ca pula e
Rhomboide us minor
Rhomboide us ma jor
S upra s pina tus
Infra s pina tus
De ltoid
Te re s minor
Te re s ma jor
Ere ctor s pina e S e rra tus a nte rior

infe rior

La tis s imus
oblique
dors i
Exte rna l a bdomina l Inte rna l a bdomina l

oblique oblique
Thora columba r
fa s cia
Glute us me dius Glute us minimus
Glute us ma ximus
La te ra l rota tors
Figure 27-9 Po ste rio r tho racic spine musculature
rationale and consideration o evidence-based practice. he clinician should con sis-

tently m onitor patient progress and alter the program as needed. Although interven-
tions listed within this chapter are speci ic to the cervical and thoracic spine, clinicians
should appreciate that interventions ocused on this region o ten have overlapped with
therapeutic exercise program s or shoulder an d lum bar spine pathology. Exam ples
included interventions to im prove n eurom uscular control o the scapulothoracic joint
or the lum bopelvic region.
Rehabilitation Considerations for

the Cervical and T oracic Spine
T e joints o the cervical and thoracic spine are similar to other joints in the body in that they
can become pain ul, have the potential or bony and cartilage changes, and can increase
or decrease motion. T e potential or degenerative bony, cartilage, and intervertebral disc
changes increases with age,9-12 and is thought to be accelerated with repetitive motions and
spinal loading and commonly occurring during occupation 13 or sporting activities.14 Smok-
ing is also thought to accelerate degenerative changes.10 T e close proximity o the spinal
cord and nerve roots as well as the presence o the intervertebral disc adds additional so t
tissues, which may contribute to pathology. Musculature surrounding this area is also sub-
ject to strains and overuse injuries.
Clin ica l Pe a r l
A thorough history and comprehensive examination will help guide the intervention approach.
Identif cation o a specif c pathoanatom ical cause o cervical spine or thoracic

spine pain is not always possible.15- 17 T us, the clinician should ocus on treating
causative actors, such as im pairm ents and unctional lim itations, which are contribut-
ing to the pathology. T is approach is not new or unique, but has been better def ned
with treatm ent-based classif cation system s that have been proposed. T e purpose o
treatm ent-based classif cation system s is to identi y comm on patterns in the history and
physical exam ination with the intent o better individualizing treatm ent program s to
im prove outcom es.18 T is system is not a cookie cutter approach, but does provide a ex-
ible evidence-based ramework or clinicians to derive intervention program s. Although a
treatment-based classif cation system has been proposed or the cervical spine, it has not
been developed or the thoracic spine but the principles o rehabilitation managem ent
are consistent. Knowledge o sym ptom duration (acute, chronic) and tissue irritability, as
well as joint and so t-tissue mobility (hypermobile, normal, hypom obile), can provide the
clinician with valuable in ormation, which is then prioritized to determ ine the direction
o the intervention program.
Although a num ber o pathologies m ay be present within the cervical or thoracic
spine regions, there are considerable sim ilarities am ong the intervention approaches
(Appen dix 1). T e oun dation o the rehabilitation program is therapeutic exercise
com plem ented with other specif c interventions, such as manual therapies or physical
agents/ m odalities, which address m otion, pain, and radicular sym ptom s,19,20 and patient
education regarding contributing actors 19,20 and m echanism s o pain.21 Acute condi-
tions or conditions with highly irritable sym ptom s (pain) can be managed with relative
rest, range o m otion, physical agents/ m odalities, and lower intensity manual therapies.
Conditions involving hyperm obility or decreased neurom uscular control benef t rom
exercise interventions which im prove stability and neurom uscular control. Hypom obil-
ity may be addressed with m anual therapies such as joint m obilization and stretching.
Radicular sym ptom s can be addressed with interventions that decrease m echanical or
chem ical stim uli that irritate nervous tissue and prom ote centralization o sym ptom s.
Finally, headaches that have a m usculoskeletal com pon ent m ay also be managed via
im pairm ent-based interventions directed at the cervical and thoracic region. Rehabilita-
tion progression is based on resolution o sym ptom s and changes in im pairm ents and
unction.
Cervical Spine 909
Clin ica l Pe a r l
Best available evidence for treatment of most musculoskeletal pathology: education,

manual therapy, and exercise prescription.
Cervical Spine
Neck pain has an annual incidence rate o 15% with a recurrence rate o nearly 25%.22,23 As
previously stated, it is not always possible to identi y a specif c underlying pathoanatomi-
cal cause.15-17 Females and individuals with high psychological stress are more at risk or
neck pain.15,24 Prolonged sitting, o ten associated with o ce or computer work, is also con-
sidered to be a risk actor, particularly when coupled with poor posture.24 Participation in
general f tness programs appear to decrease the risk o neck pain.15
T e cervical spine is highly dependent on surrounding musculature or mechanical
stability.5 Following injury there is atrophy and decreased unction o surrounding mus-
culature, particularly the deeper stabilizing musculature.25 T ese changes occur within a
relatively short time period (<1 month) and also result in decreased joint position sense.26
Individuals with neck pain tend to utilize the larger superf cial muscles to a greater extent
than the deeper cervical stabilizing muscles (longus capitis and longus colli),27,28 which is
evidenced by decreased per ormance o the craniocervical exion test.29 T is muscle dys-
unction is thought to persist despite symptom resolution 26 and is the rationale or inclu-
sion o postural exercises, with low loads, targeting deep cervical neck exors in therapeutic
exercise programs.20,30 Def cits o the deeper stabilizing musculature can be determined
clinically using the craniocervical exion test (Figure 27-10).31
In dividuals with cervical spin e pathology o ten present with characteristic his-
tory an d physical exam ination in dings that can help determ ine pre erred treatm ent
options ( able 27-3). hese pro iles are o ten part o a treatm ent-based classi ication
system,18 which identi ies com m on pattern s in the history an d physical exam ination
with the intent o better in dividualizin g treatm ent program s to im prove outcom es.18
his provides a lexible evidence-based ram ework or clinicians to derive intervention
program s.
T e oundation o the rehabilitation program or
cervical spine pathology is therapeutic exercise com-
plemented with manual therapy or physical agents/
m odalities to address m otion, pain, and radicu-
lar sym ptom s, and patient education to address
potential causative actors (posture)19,20 and mecha-
nisms o pain.21 Acute conditions or conditions with
highly irritable sym ptoms (pain) can be managed
with relative rest, range o motion, physical agents/
m odalities, and lower-intensity manual therapies.
Conditions involving hyperm obility or decreased
neuromuscular control benef t rom exercise inter-
ventions that improve stability and neuromuscular
control. Manual therapies are indicated when there
is a restriction in so t-tissue or joint mobility. Hypo-
mobility may be addressed with manual therapies
such as joint mobilization and stretching. Radicular
symptoms can be addressed with interventions that Figure 27-10 Cranio ce rvical e xio n te st
able 27-3 Tre atme nt Base d Classi catio ns decrease m echanical or chem ical stimuli that irritate ner-
fo r Ce rvical Spine Patho lo g y vous tissue and promote centralization o symptoms. Finally,
headaches that have a musculoskeletal component may also
be managed via im pairm ent-based interventions directed
Therapeutic exercise at the cervical and thoracic region. Rehabilitation program
Mobility and exercise progression is based on resolution o symptoms and changes
Centralization (nerve root compression) in im pairm ents and unction. Clinicians are encouraged
Acute neck pain as a result of trauma (whiplash) to reevaluate the patient and attempt to urther identi y the
Cervicogenic headache underlying cause o symptom s or cases that do not resolve
with typical conservative management.
Degenerat ive Disc/Joint Disease, Spondylosis, and St enosis

Degenerative changes broadly include degenerative disc/ joint disease, spondylosis, and
stenosis. T e typical patient with degenerative changes in cervical spine structures with or
without radiculopathy is 30 to 50 years o age. Individuals older than 50 years o age are
more likely to have stenosis (central or lateral). T e progressive loss o intervertebral disc
height is thought to place greater demands on articular sur aces, acilitating degenerative
changes and contributing to ligamentous laxity. Degenerative changes and intervertebral
disc pathology tend to occur more o ten between the C5 and C7 segments.32

Exercise intervention is a consistent com ponent or the managem ent o m ost cervi-
cal spine pathologies.19,20 It is not clear whether a specif c approach targeting cervical
stabilizing muscles or a generalized approach to strengthen neck and upper extrem -
ity is m ore e cacious or sym ptom managem ent.20,33,34 It is suggested that exercises be
selected to address specif c im pairm ents and unctional lim itations with regard to the
stage o rehabilitation. Generally a specif c approach targeting deeper cervical stabiliz-
ing muscles is used initially ( Figures 27-11 to 27-15), then transitioned to a generalized
approach as sym ptom s dim inish and neuromuscular control im proves ( Figures 27-26
to 27-29). Lower-load exercises are also m ore likely to be tolerated during acute stages
when structures are highly irritable (pain) than higher-load strengthening approaches.
Figure 27-11 Chin tuck—supine w ith stabilize r Figure 27-12 Chin tuck—supine w ith arm
mo ve me nt
Cervical Spine 911
Figure 27-13 Chin tuck—pro ne Figure 27-14 Chin tuck—pro ne o n e lbo w s
Lower-load exercises are also thought to better target deeper stabilizing musculature 35
and have been shown to decrease pain sensitivity.36 Positional progression is usually rom
a supine ( Figures 27-11 and 27-12), to a prone or 4-point kneeling position ( Figures 27-13
and 27-14), to sitting or standing ( Figures 27-16 to 27-18). Initial exercises ocus on estab-
lishing neuromuscular control o the cervical spine in static positions ( Figures 27-11,
27-13, and 27-16) and progress to incorporating surrounding musculature (eg, arm move-
m ent with cervical stabilization) ( Figures 27-12, 27-18, and 27-23). Progression should
also incorporate education o posture ( Figure 27-33) and exercises that develop endur-
ance ( Figure 27-25) while incorporating tasks o daily living or m im icking recreational
activities ( Figures 27-28 and 27-30).
Cent ralizat ion (Nerve Root Compression)

Disc herniation and stenosis are the most common causes o cervical nerve root compres-
sion, with males a ected more than emales.32 T e incidence o radiculopathy is 83 per
Figure 27-15 Chin tuck—se ate d Figure 27-16 Iso me tric ce rvical spine
e xte nsio n w ith The ra-Band
Figure 27-18 Ho rizo ntal abductio n—pro ne ro w
Figure 27-17 Se ate d tho racic

e xte nsio n w ith chin tuck
Figure 27-19 Pro ne sho ulde r Figure 27-20 Y o n stability ball—

ho rizo ntal abductio n o n stability ball sho ulde r e xio n pro ne 135 de g re e s
Figure 27-21 T o n stability Figure 27-22 W o n stability ball

ball—ho rizo ntal abductio n
Cervical Spine 913
100,000 people with individuals older than 50 years o age the most commonly a ected.32
Cervical nerve root compression causes radicular symptoms, specif cally arm pain, and
sensory and motor def cits. Individuals with nerve root compression and radiculopathy
are more likely to demonstrate radicular symptoms with cervical spine motion, especially
extension. Degenerative changes and intervertebral disc pathology tend to occur more
o ten between the C5-7 segments.32 Individuals with neurologic signs and symptoms indic-
ative o cervical myelopathy (gait abnormality, positive Ho mann or Babinski tests, abnor-
mal re exes) should be re erred to a physician.37
Clin ica l Pe a r l
Clinical prediction rule for discogenic pathology: (+) Spurling test, (+) upper limb tension test,
cervical rotation less than 60 degrees, (+) distraction test: positive likelihood ratio of 30.3 .

Radicular symptoms can be addressed with interventions which decrease mechanical or
chemical stimuli which are irritating nervous tissue and promote centralization o symp-
toms.38 Centralization describes the migration distal symptoms toward the spine in response
to movement or intervention. Peripheralization describes symptoms which become more
distal with movement or provoking activities. T e most common interventions are thera-
peutic exercise, traction (manual or mechanical), manual therapy, and patient education
regarding posture.20,39-42 Un ortunately, individuals with nerve root compression have a
less- avorable prognosis compared to other cervical spine pathologies.16 Individuals who
meet at least 3 o the ollowing 4 predictive criteria are thought to have the most avorable
outcomes: participation in a comprehensive rehabilitation program, younger than 54 years
o age, dominant arm not involved, and cervical exion does not increase symptoms.43
Cases that are not responsive to conservative management, involve a decline in quality o
li e, or have neurologic def cits (sensory/ motor) may be considered or surgical interven-
tion. It is estimated that approximally 25% o
individuals with radiculopathy require surgi-
cal intervention.32
Initial management o nerve root com-
pression should ocus on centralization o
symptom s. Interventions include traction
(manual or mechanical) (Figures 27-34 and
27-35) and cervical retraction (Figures 27-36
and 27-37). Once pain decreases and symp-
toms begin to centralize, exercises that ocus
on neuromuscular control o the neck can be
initiated in static positions (see Figures 27-11,
27-13, and 27-16) and progressed to incorpo-
rate surrounding musculature (eg, arm move-
ment with cervical stabilization) (see Figures
27-12, 27-18, 27-23, and 27-38).20,30 Def cits
o the deeper stabilizing musculature can be
determined clinically using the craniocervical
exion test (see Figure 27-10).31 Because pos-
ture can contribute to neck pain, the patient Figure 27-23 Sho ulde r e xte rnal ro tatio n w ith
should be educated on proper posture (see tubing —bilate ral
Figure 27-33) and made aware o patterns that

may contribute to dys unction (eg, head orward,
slum ped, rounded shoulders). Exercises that
involve the upper extremity can then be incorpo-
rated while maintaining a stable cervical spine (see
Figures 27-12, 27-18, and 27-23). Examples include
interventions to improve neuromuscular control
o the scapulothoracic joint (see Figures 27-18 to
27-23, 27-28 to 27-32, and 27-55 to 27-66). Stretch-
ing exercises may also be incorporated to address
muscular tightness identif ed during the exami-
nation ( Figures 27-39 to 27-41). Progression
should also incorporate education o posture (see
Figure 27-33), and exercises that develop endur-
ance (see Figure 27-25) while incorporating tasks o
daily living or mimicking recreational activities (see
Figure 27-24 Scapular pro prioce ptive ne uromuscular
Figures 27-28 and 27-30).
facilitation (PNF) patte rn
Acut e Joint Pat hology

T e person with acute cervical spine joint injury and intervertebral disc pathology tends to
be a younger individual, 20 to 35 years o age. T e Canadian C-Spine Rules can be used to
determine i cervical spine imaging is necessary ollowing neck injury.44 Brie y, individu-
als who do not meet high- or low-risk criteria and can actively rotate the neck 45 degrees
Figure 27-25 Uppe r bo dy e rg o me te r w ith pro pe r po sture

Cervical Spine 915
Figure 27-26 Ne ck ro tatio n—re siste d Figure 27-27 Ne ck side be nding —re siste d
bilaterally are less likely to have a cervical spine racture. As in any case, i there are suspi-
cions o racture, spinal cord involvement, or dislocation, the patient should be re erred
immediately to an emergency department. A cervical sprain usually results rom a trau-
matic event (motor vehicle collision, collision sports). Muscles may also be strained with
the traumatic event. T ere may be palpable tenderness over the transverse and spinous
processes that serve as sites o attachment or the ligaments.45
Alternatively, acute joint pathology may have an insidious onset and is o ten f rst
noticed a ter waking in the morning. T is is typically isolated to a single vertebral seg-
ment and mani ests as hypomobility and pain. Interventions may include physical agents/
modalities to decrease pain and muscle spasm and be complemented with manual thera-
pies to address joint hypomobility.
Figure 27-28 Sho ulde r e xte rnal ro tatio n w ith tubing —standing
Figure 27-29 Lat pulldo w n Figure 27-30 Pro prio ce ptive

ne uro muscular facilitatio n (PNF)
patte rn w ith tubing

T erapeutic exercise and manual therapy tend to benef t a younger individual who presents
with an acute onset o symptoms that are not radicular.46-48 Individuals with more acute
symptoms tend to have a better prognosis than individuals with chronic pathology.16,22,49
Manual therapies directed at the cervical spine (see Figures 27-34 to 27-37 and 27-42
Figure 27-31 Pushup w ith ce rvical stabilizatio n Figure 27-32 Sho ulde r pre ss
Cervical Spine 917
to 27-47) have been shown to improve unction 50 and range o motion,51,52
and to decrease pain sensitivity.53 T ese changes are thought to comple-
ment the hypoalgesia associated with therapeutic exercise.36 Regarding
the benef ts o mobilization versus a manipulation approach, it does not
appear that manipulation augments e ects to a greater degree than mobi-
lization.54 Improvements in unction, range o motion, and decreased pain
can also be accomplished via manual therapy interventions directed at the
thoracic spine (Figures 27-67 to 27-70) or individuals with cervical spine
pathology.55,56 Interventions directed at the thoracic spine may help to min-
imize some o the risks (craniocervical arterial dissection) associated with
cervical spine manipulation,57,58 but may not be as e ective as interventions
directed at the cervical spine.59
T e use o therapeutic exercise in conjunction with manual ther-
apy is thought to provide the greatest im provem ent in pain and unc-
tion.19,20,39,47,50 It is important to note that the com prehensive approach
is thought to yield better outcom es than either therapeutic exercise or
manual therapy per ormed in isolation.20,50 Manual or mechanical traction
(see Figures 27-34 and 27-35) may also be used to relieve pain and muscle
guarding. I hyperm obility is present, which is com m on ollowing joint Figure 27-33 Pro pe r sitting
sprain, strengthening and stabilization exercises should be incorporated po sture
Figure 27-34 Manual tractio n Figure 27-35 Me chanical tractio n
Figure 27-36 Ce rvical re tractio n mo bilizatio n Figure 27-37 Supine ce rvical re tractio n
into the rehabilitation program.45 Initial exercises should ocus on neuromuscular control
o the neck (see Figures 27-11 to 27-18). T e deeper cervical stabilizing muscles (longus
capitis and longus colli) are targeted using low loads and ocusing on endurance.20,30 Def -
cits o the deeper stabilizing musculature can be determined clinically using the cranio-
cervical exion test (see Figure 27-10).31 T e exercise progression includes exercises to
improve neuromuscular control o the scapulothoracic joint (see Figures 27-18 to 27-23,
27-28 to 27-32, and 27-55 to 27-66) with emphasis placed on maintaining control o the
cervical spine. Progression should also incorporate tasks o daily living or mimic recre-
ational activities (see Figures 27-28 and 27-30).
Traumat ic Neck Pain (Whiplash)

Acute neck injuries are m ost com m only attributed to whiplash, which has both physi-
cal and em otional/ psychological com ponents. Whiplash is o ten the result o a m otor
vehicle collision 60 and has an incidence between 70 and 329 per 100,000 people.49,50
Approximately 50% o individuals ollowing acute whiplash injury develop chronic symp-
toms lasting at least 1 year.61 T us it is imperative to identi y individuals at risk or pro-
longed symptoms and disability. T e strongest predictors o prolonged pain (>6 m onths)
include neck pain greater than 5.5/ 10 and a score on the Neck Disability Index greater
than 14.5/ 50.62
Clin ica l Pe a r l
Impairments related to the aftereffects of whiplash can vary widely between individuals.
A variety o sym ptom s may be associated with whiplash, including n eck pain,
decreased range o m otion, headache, dizziness, visual disturbances, radicular sym p-
tom s, and cognitive im pairm ent.63 A num ber o structures included the intervertebral
disc, zygapophyseal joints, ligam ents, and musculature may be damaged,64 but specif c
pain-generating structures may not always be identif ed.17 As a result o the num ber o
potential structures involved, as well as the em otional/ psychological com ponents, it is
evident that whiplash is not a hom ogeneous pathology. Care ul consideration o exam i-
nation f ndings and clinical presentation should be used to determ ine the structure o
the rehabilitation program. Com m on im pairm ents associated with whiplash are pain, a
loss o cervical spine range o m otion, and decreased proprioception.65 Sim ilar to general
neck pain,22,23 individuals with whiplash tend to utilize the larger superf cial muscles to
a greater extent than the deeper cervical stabilizing m uscles.66 T e m otor system dys-
unction is thought to persist despite initial sym ptom resolution, potentially contribut-
ing to recurrent sym ptom s.26 T ese persistent muscles im balances provide the rationale
or using low-load postural exercises targeting deep cervical neck exors.20,30 Def cits o
the deeper stabilizing musculature can be determ ined clinically using the craniocervical
exion test.31
Clin ica l Pe a r l
Diminished or absent pain is not indicative of the resolution of motor impairments in

patients who has sustained a whiplash injury. Additional interventions are required for
a full return to function.
Cervical Spine 919

Following acute trauma, the recommendation is or
the rehabilitation program to emphasize active range
o motion through exercise and manual therapy67 and
improve neuromuscular control and proprioception
with gaze stabilization and a cervical proprioceptive
training progression.68 T e rehabilitation program
should also minimize disability through patient edu-
cation 67 and avoid imm obilization via the use o a
so t cervical collar.67,69,70 T e use o a so t collar (see
Figure 27-47), although thought to acilitate heal-
ing, may actually prolong recovery. T e use o physi-
cal agents/ modalities may complement the exercise
rehabilitation program to minim ize pain and acili-
tate m otion. Exercises that ocus on neuromuscular
control o the neck can be initiated in static positions Figure 27-38 Ce rvical active rang e o f mo tio n w ith
(see Figures 27-11, 27-13, and 27-16) and progressed supine w e dg e
to incorporating surrounding musculature (eg, arm
movement with cervical stabilization) (see Figures 27-12, 27-18, 27-23, and 27-38).20,30 Def -
cits o the deeper stabilizing musculature can be determined clinically using the craniocer-
vical exion test (see Figure 27-10).31 Sensorimotor training exercises to improve eye–neck
coordination and gaze stability are also incorporated.68 T ese exercises are initiated with the
neck in a static position (stationary) and moving the eyes between 2 f xed targets. Progression
involves eye movement to a f xed target ollowed by moving the head toward a f xed target.
Clin ica l Pe a r l
In patients with chronic whiplash-associated disorder, proprioceptive/sensorimotor training

is commonly needed for a full return to function.
A ter acute symptoms begin to subside (usually 3 to 6 weeks), individuals should con-
tinue with a ocused therapeutic exercise program.71 Exercises that incorporate upper-
extremity movement and require neuromuscular control o the neck and scapulothoracic
joints (see Figures 27-18 to 27-23, 27-28 to 27-32, and 27-55 to 27-66) may be added as
motor control improves. It is important to note that because patients may still experience
symptoms, aggressive intervention programs may be counterproductive.71 Exercises should
continue to ocus on neuromuscular control o the neck, as well as improving kinesthetic
awareness o head position.72 Advanced sensorimotor training exercises to improve neu-
romuscular control, eye–neck coordination, and gaze stability include per orming coor-
dinated eye and head movements during walking or while maintaining balance on an
unstable sur ace.68 Cases that progress to chronic symptoms may still derive short-term
benef ts rom exercise and manual therapy, but the long-term e cacy is questionable.73
Cervicogenic Headache
Cervicogenic headache has a prevalence o 1% to 4% and is thought to account or approxi-
mately 20% o all headaches.74,75 Women have a greater prevalence than men.76,77 Head-
ache that originates rom the cervical spine is known as cervicogenic.78 T e headache is
characteristically unilateral, with a “ram horn” presentation, and is provoked by cervical
spine motion.79 Pain typically originates in the neck and then extends to the head. T e
upper cervical segments (C1-3), including acets and discs are thought to contribute to
this pathology.80,81 T ere is also tightness o the superf cial neck musculature, tenderness
o the upper cervical joints and surrounding musculature, decreased range o motion, and
decreased neck strength and endurance.80,82 Cervicogenic headache can be distinguished
rom other headaches with a comprehensive examination. T e presence o restricted
motion, hypomobility o the upper segments, and def cits o the deeper stabilizing mus-
culature determined using the craniocervical exion test were indicative o cervicogenic
headache.83 T e signs and symptoms that indicate conservative management o cervico-
genic headache include therapeutic exercise and manual therapy.34
Clin ica l Pe a r l
Convergence of the trigeminal nerve and the upper 3 cervical nerve roots in the
trigeminocervical nucleus is likely to be a contributor to cervicogenic headaches.

Cervicogenic headaches are responsive to intervention programs that target cervical spine
stabilizing muscles, improve strength o upper extremity musculature, and address hypo-
mobility o the cervical or thoracic spine with manual therapy.34,84,85 Cryotherapy is also
thought to demonstrate benef t.77 Initial management includes manual therapy interven-
tions to decrease tenderness and acilitate motion in the upper cervical segments (see Fig-
ures 27-36, 27-37, and 27-42 to 27-44). Next, exercises that ocus on neuromuscular control
o the neck can be initiated. T e deeper cervical stabilizing muscles (longus capitis and
longus colli) are targeted using low loads and ocusing on endurance (see Figures 27-11
to 27-15).20,30 Def cits o the deeper stabilizing musculature can be determined clinically
using the craniocervical exion test (see Figure 27-10).31 Exercises that involve the upper
extremity can then be incorporated while maintaining a stable cervical spine (see Figures
27-12, 27-18, and 27-23). T ese exercises are then progressed to more challenging posi-
tions and are similar to exercises to improve neuromuscular control o the scapulothoracic
joint (see Figures 27-18 to 27-23, 27-28 to 27-32, and 27-55 to 27-66). Progression should
also incorporate tasks o daily living or mimic recreational activities (see Figures 27-28 and
27-30). Stretching exercises may also be incorporated to address muscular tightness identi-
f ed during the examination (see Figures 27-39 to 27-41).
Figure 27-39 Syno vial cho ndro mato sis Figure 27-40 Scale ne stre tch
(SCM) stre tch
Cervical Spine 921
Figure 27-41 Le vato r scapulae stre tch Figure 27-42 Mo bilizatio n pro ne ce rvical
po ste ro ante rio r (PA)
Figure 27-43 Mobilization ce rvical late ral glide Figure 27-44 Mo bilizatio n ce rvical ro tatio n
Figure 27-45 Ne ural mo bilizatio n o r the Figure 27-46 Ce rvical se lf-mo bilizatio n w ith
uppe r limb te nsio n te st (ULTT). ng e rs
T oracic Spine
T oracic spine injuries occur at a lower incidence rate than injuries to the cervical spine
(10% in 1 year).86 Similar to cervical spine injury, emales and individuals with psychosocial
variables (eg, stress, poor mental status) are more at risk or thoracic spine injury.86 Addi-
tionally activities that place loads across the thoracic spine, such as sports or occupational
activities, also increase the risk o thoracic spine injury. Additionally individuals with con-
current musculoskeletal pain (cervical spine, lumbar spine) also have a higher incidence o
thoracic spine pain than do individuals without concurrent musculoskeletal pain.86
T e thoracic spine region is characterized as being more stable than the adjacent cervical
spine. T e stability o the thoracic spine is provided by articulations with the ribs and ster-
num, lower thoracic intervertebral disc height to vertebral body height, and smaller, more taut
zygapophyseal joints. T oracic spine pathology can involve a number o structures and covers
a much greater region than the cervical spine. Complexity is added as a result o the ribs and
underlying structures o the thoracic cavity (heart, lungs). Pain in this region is o ten vague
and may not include a specif c mechanism o injury.87 T us it is important or the clinician
to di erentiate between musculoskeletal and nonmusculoskeletal (eg, cardiac, pulmonary)
causes o thoracic spine pain. Acute (traumatic) injury o ten presents with a specif c mecha-
nism, such as contact with another individual or object resulting in racture, contusion, or
muscle strain. Most thoracic spine injures are nontraumatic and have an insidious onset rom
overuse a ecting the surrounding bones, joints, muscles, and intervertebral disc.
Similar to the cervical spine, it is possible to determine treatment options based on
injury mechanism, tissue involvement, and location o pain. Although acute injury ( rac-
ture, intercostal muscle strain) can occur at any segment, overuse injuries are o ten char-
acterized by region. Additionally the thoracic spine may also be subjected to pathologies
that are not the result o an injury, such as scoliosis or Scheuermann kyphosis, but may still
have an impact on daily unction and recreational activities. T e f rst rib is o ten implicated
in dys unctional breathing and injuries involving the cervical spine and upper extrem-
ity, because it is an attachment site or muscles which have origins in the cervical spine
(scalenes, subclavius). T e midthoracic region ( 2-8) is susceptible to costochondritis and
rib stress racture. Pain localized to the costochondral or costosternal joints may be associ-
ated with a costochondritis or ietze syndrome. Both conditions are similar, except ietze
syndrome includes the presence o swelling, heat, or erythema.88 Stress ractures o the ribs
commonly occur in individuals who per orm repetitive rotational activities that place loads
across the ribs and thoracic spine.88,89 T ese commonly occur in throwing sports (baseball,
javelin), gol , and rowing. First rib stress ractures are thought to be caused by attachment
o the scalenes, subclavius, and serratus anterior, whereas stress ractures o the other ribs
are o ten associated with serratus anterior and external oblique involvement.88-90 Additional
contributing mechanisms include hypomobility o posterior spinal structures.89,91,92 T e
lower thoracic segment ( 8-12) is susceptible to intervertebral disc pathology.93
Managem ent o most thoracic spine injuries involves relative rest rom aggravating
activities and interventions that acilitate the return to activity. Symptoms may persist or
m onths94 or become recurrent,95 but are thought to resolve within a year.96,97 Most condi-
tions are thought to be sel -limiting,87,88 indicating that individuals may continue activity
as symptoms allow. Conservative managem ent is usually symptomatic87-89 and includes
reassurance.88 T e use o m odalities,87,98 analgesics,88 or local injections 94,95 may be nec-
essary to manage pain ul conditions. Initially loads and stress across the upper thoracic
spine and ribs may be minimized with the use o an arm sling or cervical so t collar (see
Figure 27-47), whereas loads across the lower segments can be m inim ized with the use o
a rib/ lum bar spine support belt (Figure 27-77). Relative rest is o ten 3 to 6 weeks in dura-
tion with a gradual progression back to activity.87,88,90,99,100 Relative rest rom aggravating
Thoracic Spine 923
actors can also minimize loads across the a ected area. Exercise
intervention is a consistent com ponent or the managem ent o
thoracic spine pathology and o ten shares sim ilarities between
exercise programs that ocus on scapula and lumbar stabilization.
Many o the muscles with attachments in the thoracic spine have
origins or insertions in the cervical, shoulder, or lum bar regions,
thus sim ilarities between program s are apparent. Manual thera-
pies are indicated when there is a restriction in so t tissue or joint
mobility. Program progression is based on resolution o symptoms
and changes in impairments and unction. Clinicians are encour-
aged to reevaluate the patient and attempt to urther identi y the
underlying cause o symptom s or cases that do not resolve with
typical conservative management.
Int ercost al Muscle St rain

Muscle strain is usually a result o heavy li ting or athletic events
that involve the upper extremity (rowing, wrestling). Muscle strain
may also be the result o recent illness that involves coughing or
vomiting. Pain is usually isolated to the muscle belly, between the
ribs, and is worse with movement. Muscle strains o ten have symp-
tom s that overlap with rib injury. Intercostal muscle spasm can
o ten accompany rib injury to immobilize the a ect area. Figure 27-47 Ce rvical self-mobilization
w ith strap
Management typically involves relative rest, splinting i necessary,
and avoidance o aggravating activities. Interventions to address dis-
com ort such as cryotherapy or electrical stimulation can be used as
needed. A cardiovascular conditioning program should be imple-
mented to maintain physical f tness during the rehabilitative process.
Because breathing can aggravate a costovertebral joint sprain, car-
diovascular conditioning may need to be modif ed to avoid urther
injury aggravation. Acute management o intercostal muscle strain
may include immobilization o the lower ribs with the use o a rib/
lumbar spine support belt (see Figure 27-77) or with rib taping. Pro-
gression back to activity is o ten based on symptomatic criteria. As
symptoms begin to subside range o motion exercises may be added
to the rehabilitation program (Figures 27-73 to 27-75). I impairments
in strength or neuromuscular control are present exercise interven-
tions to address these impairments should be included as part o
the rehabilitation program. T e progression o exercises is similar
shoulder and lumbar spine injuries. Exercises are f rst per ormed
with trunk support and single plane movements (see Figures 27-18
to 27-23, 27-28 to 27-30, and 27-55). Exercise loads may be increased
and urther advanced using more challenging upper body exercises
(see Figures 27-31, 27-32, 27-57, and 27-61) and incorporating kneel-
ing and standing positions (see Figures 27-56, 27-58, and 27-60).
Exercises, including upper extremity weight bearing using unstable
sur aces, may require the greatest amount o scapulothoracic and Figure 27-48 Arm sling and ce rvical
lumbopelvic neuromuscular control (see Figures 27-59 to 27-66). co llar
Cost overt ebral Art hralgia or Joint Sprain

Injury to the costovertebral joints is o ten the result o repetitive stress placed through the
joint. T e costotransverse joint may also be involved as a result o the close proximity and
unction o these joints. Activities involving repetitive motion with upper-extremity loading,
such as swimming and rowing, are thought to cause costovertebral joint sprain.101 Pain may
be reproduced with movement, breathing, coughing, or lying in a supine position. Pain in
the supine position is urther exacerbated with movement such as a sit up or bench press.
Pain is usually localized to the costovertebral joint, but may radiate along the associated rib
to the lateral or anterior chest wall. Costovertebral joint sprain typically involves a rib seg-
ment between 4-8, with ribs 6 to 7 the most commonly a ected. enderness with palpa-
tion o the costovertebral joint or with a rib spring test is a hallmark sign.
Hypomobility o the a ected segment may also be evident and determined with joint
mobility testing. T e associated hypomobility o the segment is likely why this injury may
also be re erred to as a costovertebral joint subluxation. Costovertebral joint sprain is o ten
associated with decreased neuromuscular control o the lumbopelvic and scapulothoracic
regions. It is possible that weakness or decreased neuromuscular control in these adjacent
regions may place greater loads and demands on the costovertebral joint. Un ortunately,
the def nitive causes o costovertebral joint sprain and relationship with surrounding
regions are not well understood. T e signs and symptoms o ten mimic rib stress racture
and may precipitate rib stress racture.

Rehabilitation should initially ocus on symptom management and attempting to address
underlying impairments which contributed to the injury. Relative rest rom aggravating
actors can also minimize loads across the a ected area. Physical agents/ modalities and
oral analgesics may help diminish symptoms. T e intervention program should include
therapeutic exercise and manual therapies to address impairments. Hypomobile segments
are addressed with manual therapy interventions such as joint mobilization/ manipulation
(see Figures 27-67 to 27-70), and sel -mobilization (Figures 27-71 to 27-75). A cardiovas-
cular conditioning program should be implemented to maintain physical f tness during
the rehabilitative process. Because breathing can aggravate a costovertebral joint sprain,
cardiovascular conditioning may need to be modif ed to avoid urther injury aggrava-
tion. Interventions to improve strength and neuromuscular control o the scapulothoracic
(see Figures 27-18 to 27-23, 27-28 to 27-32, and 27-55 to 27-66) and lumbopelvic regions
(Figures 27-49 to 27-53) may begin as symptoms allow. T is progression is similar to exer-
cises or shoulder and lumbar spine injuries. Exercises are f rst per ormed with trunk sup-
port and single-plane movements (see Figures 27-18 to 27-23, 27-28 to 27-30, and 27-55).
Exercise loads may be increased and urther advanced using more challenging upper-body
exercises (see Figures 27-31, 27-32, 27-57, and 27-61) and incorporating kneeling and stand-
ing positions (see Figures 27-56, 27-58, and 27-60). Exercises, including upper-extremity
weight bearing using unstable sur aces, may require the greatest amount o scapulotho-
racic and lumbopelvic neuromuscular control (see Figures 27-59 to 27-66). Although rela-
tive rest and rehabilitation can diminish symptoms, the clinician should attempt to identi y
contributing actors to the initial injury in attempt to prevent urther reoccurrence.
Cost ochondrit is and Tiet ze’s Syndrome

Costochondritis and ietze syndrome are localized to the costochondral or costosternal
joints with a diagnosis based on clinical symptoms and examination f ndings.88 T ese
Thoracic Spine 925
Figure 27-49 Bridg e stability ball Figure 27-50 Alte rnating arm/ le g e xte nsio n
conditions tend to a ect emales more than males.102 Symptoms tend to be

localized to the anterior chest, lateral to the sternum ( 2-5) at the costo-
chondral joints. T e conditions are relatively similar, except ietze syndrome
includes the presence o swelling, heat, or erythema.88 Imaging studies o er
little value in the diagnosis o costochondritis or ietze syndrome.103 Symp-
toms may be recurrent95 and persist or months,94 but are thought to typically
resolve within 1 year.96,97 T e mechanism o injury may be a result o contrac-
tion o adjacent musculature,89 repetitive arm adduction,89 and hypomobility
o posterior spinal structures and ribs.89,91,92 Pain can be provoked palpation
o the costochondral joint, rib springing, and with arm movement, especially
shoulder horizontal adduction.88 Identif cation o the underlying cause o cos-
tochondritis is necessary or appropriate management. Costochondritis and
ietze syndrome are thought to be sel -limiting conditions,88 allowing individ-
uals to continue activity participation as symptoms allow.

Rehabilitative management usually ocuses on symptom resolution 87-89 and
addressing contributing impairments. Because the condition is sel -limiting,
Figure 27-51 Hip
programs also typically include reassurance.88 Interventions usually address
abductio n—standing
Figure 27-52 Hip abductio n—side lying Figure 27-53 Side bridg e
Figure 27-54 Hip e xo r stre tch Figure 27-55 Bilate ral scapular re tractio n
(se ate d o r standing )
tightness o anterior chest musculature and pro-

mote extension o the thoracic spine and ribs (see
Figures 27-67 to 27-73). Addressing anterior muscle
tightness and thoracic spine hypomobility is thought
to decrease loads placed on the joints o the anterior
chest (costosternal joint).98 Initial therapeutic exercises
include postural correction (see Figure 27-33), cervical
stabilization (see Figures 27-11 to 27-13), and scapu-
lar stabilization exercises (see Figures 27-18 to 27-23).
Initial exercises can usually be advanced quickly as
symptom s allow. Exercise loads may be increased
and urther advanced using more challenging upper-
body exercises (see Figures 27-31, 27-32, 27-57, and
27-61) and incorporating kneeling and standing
positions (see Figures 27-56, 27-58, and 27-60). Exer-
cises, including upper-extremity weight bearing using
unstable sur aces, may require the greatest amount o
scapulothoracic and lumbopelvic neuromuscular con-
trol (see Figures 27-59 to 27-66). Once symptoms begin
to subside, individuals can begin to reintegrate into
recreational activities. Cases where symptoms do not
dissipate with typical conservative management can
present challenges or the patient and clinician. T e
use o oral analgesics may also help diminish symp-
toms,88 and aggressive management may also include
a localized corticosteroid injection.94,95
Rib St ress Fract ure

Stress ractures o the ribs commonly occur in indi-
Figure 27-56 Standing ro w w ith cable / tubing — viduals who per orm repetitive overhead or rotational
split stance activities which place loads across the ribs and thoracic
Thoracic Spine 927
spine. T ese comm only occur in throwing sports
(baseball, javelin), gol , and rowing. First rib stress rac-
tures occur more o ten in overhead athletics (baseball,
tennis) 99,100 are thought to be caused by attachment
o the scalenes, subclavius, and serratus anterior. Stress
ractures o the other ribs are o ten associated with ser-
ratus anterior and external oblique involvement,88 and
typically occur at ribs 4 to 8.104 Females are thought to
be at greater risk than males because o lower bone
mineral density.104 Stress ractures are usually precipi-
tated by an increase in training volume and may also
be a result o technique or changes in equipment. Pain
may be specif c to one area or may be vague, possibly
radiating into the shoulder or upper back. Pain can be
reproduced with palpation o the a ected area and
with breathing (worse with high rates or deep inspira- Figure 27-57 Pushup w ith plus
tion). Rib springing can reproduce pain and a bony cal-
lus may be palpable.
Decreased upper-extremity strength relative to lower-extremity strength and decreased
neuromuscular control o the lumbopelvic region also may be risk actors or rib stress rac-
ture.105 It is possible that weakness or decreased neuromuscular control in these adjacent
regions may place greater loads and demands on the thoracic spine and ribs. Un ortunately,
the def nitive causes o rib stress racture and relationship with surrounding regions is not
well understood. Similar to costovertebral joint sprain and costochondritis, there also may
be hypomobility o posterior spinal structures and ribs.89,91,92 It is hypothesized that this
hypomobility results in a concurrent hypermobility o the rib, which usually occurs along
the lateral rib margin.

Management o rib stress racture is also guided by symptom resolution.87-89 Initially, loads
across the f rst rib may be minimized with the use o an arm sling or cervical so t collar (see
Figure 27-48).88 Lower ribs can be immobilized with the use o a rib/ lumbar spine support
A B C D
Figure 27-58 “Cho p and lift w ith cable o r The ra-Band (kne e ling , tall kne e ling , half kne e ling )”
Figure 27-59 Pre ss up TRX® Figure 27-60 Sing le -le g Ro manian de adlift
Suspe nsio n Training ,
San Francisco , CA.
A B
C D
Figure 27-61 Ro lling diag o nals (uppe r e xtre mity/ lo w e r e xtre mity and e xio n/ e xte nsio n)
Thoracic Spine 929
belt (see Figure 27-77) or with rib taping.106 Relative rest rom aggravating actors can also
minimize loads across the a ected area. Relative rest is o ten 3 to 8 weeks in duration with
a gradual progression back to activity.87,88,99,100 Physical agents/ modalities and oral analge-
sics may help diminish symptoms.88 T e intervention program should include therapeutic
exercise and manual therapies to address impairments, as well as a cardiovascular condi-
tioning program to maintain physical f tness during the rehabilitative process.104 Hypomo-
bile segments are address with manual therapy interventions such as joint mobilization/
manipulation (see Figures 27-67 to 27-70) and sel -mobilization (see Figures 27-71 to
27-75). Exercises are f rst per ormed with trunk support and single-plane movements (see
Figures 27-18 to 27-23, 27-28 to 27-30, and 27-55). Exercise loads may be increased and
urther advanced using more challenging upper-body exercises (see Figures 27-31, 27-32,
27-57, and 27-61) and incorporating kneeling and standing positions (see Figures 27-56,
27-58, and 27-60). Exercises, including upper-extremity weight bearing using unstable sur-
aces, may require the greatest amount o scapulothoracic and lumbopelvic neuromuscular
control (see Figures 27-59 to 27-66). It should be noted that because breathing can aggra-
vate a rib stress racture, cardiovascular conditioning may need to be modif ed to avoid ur-
ther injury aggravation. A ter pain subsides, a gradual progression back to activity over the
course o 1 to 2 weeks is advised.
Clin ica l Pe a r l
Stress fractures that are caused by technique (eg, golf, rowing) often reoccur if technical
modi cations are not part of the rehabilitation program.
Int ervert ebral Disc Pat hology

Although thoracic disc herniations are not as common as cervical or lumbar disc hernia-
tions, they can still have debilitating e ects.107 Most disc herniations are central or posterior
lateral.108 Posterolateral disc pathology mani ests with pain localized to the paravertebral
region, whereas anterior tears produce visceral pain. Pain may be reproduced or provoked
with activities that increase intradiscal pressure (straining, sneezing) or place tension on
neural structures (slump test, neck exion). Disc pathology is determined using imaging
such as MRI. Because o the kyphotic curvature o the thoracic spine, the spinal cord and
nerve roots are in closer proximity to the intervertebral disc than the cervical and lumbar
regions. T ere ore, even small herniations may irritate or compress these neural structures
highlighting the importance o a comprehensive neurological examination o the distal seg-
ments. Individuals with neurologic def cits such as bowel/ bladder impairment or upper
motor neuron signs, should be re erred to a physician or urther examination. Lower tho-
racic regions ( 8-L1) are more likely to demonstrate disc pathology as this region has larger
discs, bearing greater loads, with more mobile vertebral segments relative to the upper tho-
racic region.109,110 T e segm ents 11-12 and 12-L1 are the m ost com m on for interverte-
bral disc pathology.110 Most individuals with thoracic spine intervertebral disc pathology
will have avorable outcomes with conservative management.108 It is also possible that the
intervertebral disc herniation can be reabsorbed over time.111
Clin ica l Pe a r l
Thoracic intervertebral disc pathology is more common in lower thoracic segments than in
the upper segments.
Figure 27-62 Scapular re tractio n TRX® Figure 27-63 Supine ro w TRX® Suspe nsio n
Suspe nsio n Training , San Francisco , CA. Training , San Francisco , CA.
Figure 27-64 Pushup plus TRX® Suspe nsio n Figure 27-65 Sho ulde r pro tractio n TRX®
Training , San Francisco , CA. Suspe nsio n Training , San Francisco , CA.
Figure 27-66 Sho ulde r e xte nsio n TRX® Figure 27-67 Mo bilizatio n pro ne tho racic
Suspe nsio n Training , San Francisco , CA. po ste ro ante rio r (PA)
Thoracic Spine 931
Figure 27-68 Mo bilizatio n pro ne midtho racic Figure 27-69 Mo bilizatio n se ate d midtho racic
Figure 27-70 Mo bilizatio n supine uppe r o r Figure 27-71 Tho racic se lf-mo bilizatio n w ith
midtho racic to w e l ro ll
Figure 27-72 Tho racic se lf-mo bilizatio n w ith Figure 27-73 Tho racic se lf-mo bilizatio n w ith
te nnis balls fo am ro lle r

reatment is similar to disc pathology o the cervical
or lumbar spine. Initial management o acute injury
and pain should ocus on activity modif cation and
interventions which help decrease pain (analge-
sics, cryotherapy, physical agents). As initial acute
sym ptom s decrease, the rehabilitation program
should consist o therapeutic exercise and manual
therapy, and o ten includes a traction component to
address the more narrow intervertebral space rela-
tive to the cervical or thoracic spine. Interventions
should progress to active interventions and include
active range o motion (see Figures 27-71 to 27-75),
stretching (Figure 27-76), and exercises to improve
endurance and strength (see Figures 27-18 to
Figure 27-74 Tho racic side -lying ro tatio n 27-23, 27-28 to 27-30, and 27-55). Manual therapies
se lf-mo bilizatio n should be utilized to promote thoracic extension
(see Figures 27-67 to 27-75). Exercise loads may be
increased and urther advanced using more chal-
lenging upper-body exercises (see Figures 27-31, 27-32, 27-57,
and 27-61) and incorporating kneeling and standing positions
(see Figures 27-56, 27-58, and 27-60). Exercises, including
upper-extremity weight bearing using unstable sur aces, may
require the greatest amount o scapulothoracic and lumbopel-
vic neuromuscular control (see Figures 27-59 to 27-66). Cases
that do not respond to conservative management may require
more invasive interventions, such as injection or surgery, and
warrant re erral to a physician.
Scoliosis
A scoliosis is an abnormal curve (>10 degrees) that occurs
in the coronal or rontal plane in the thoracic spine or in the
lum bar spine, or in both regions simultaneously. Scoliosis
may be classif ed into 3 categories: congenital, neuromuscu-
lar, and idiopathic. Congenital and neuromuscular are less
common and are the result o underlying bony mal ormation
(congenital) or neuromuscular pathology, such as cerebral
palsy. Idiopathic scoliosis is m ore com m on with unknown
contributing actors. Idiopathic scoliosis may be urther sub-
divided into early onset (prior to 10 years o age) and late onset
or adolescent. Adolescent scoliosis is thought to a ect 1% to
3% o the general population, with emales more a ected than
males.112,113 Sports that involve unilateral rotation (ie, throw-
ing) are thought to contribute to a higher risk o scoliosis.114
T e majority o individuals with scoliosis are asymptomatic,
but seek care because o asymmetrical abnormalities. As the
Figure 27-75 Tho racic kne e ling ro tatio n curvature progresses, back pain can develop, but is not thought
se lf-mo bilizatio n to be at a greater rate than that o the general population.115
Thoracic Spine 933
Figure 27-76 Pe cto ralis mino r stre tch Figure 27-77 Rib/ lumbar spine suppo rt be lt
Cardiopulmonary unction can be compromised i the chest is de ormed as a consequence

o the scoliosis (typically curves >50 degrees).115

Conservative management o scoliosis includes bracing, therapeutic exercise, and electri-
cal stimulation to minimize curve progression. Bracing is usually considered with curves
between 25 and 40 degrees, particularly i the patient is skeletally immature and the curve is
likely to progress.116 Bracing can minimize curve progression, but has limited high-quality
evidence.117 T erapeutic exercise and manual therapy can also reduce curvature progres-
sion, reduce brace wear, and improve strength and mobility,118-120 but also has limited high
quality evidence.118,121,122 Aerobic training can improve cardiovascular unction.123 A com-
mon limitation o current studies is patient compliance.
Cases that are not responsive to conservative care are considered or surgical interven-
tion. T e most common reason or surgery is pain relie and to mitigate pulmonary com-
plications. Surgery is typically recommended or curves greater than 50 degrees, especially
in individuals who are skeletally immature. As surgical options are employed to minimize
curvature progression, this usually involves multiple surgical procedures. Although surgi-
cal intervention has inherent risk, these risks are thought to be outweighed by the benef ts
gained in lung unction and reduced de ormity.115
A well-designed rehabilitation program can provide pain relie and improve unction
in many patients. Rehabilitation programs or scoliosis typically include therapeutic exer-
cise, manual therapy, and postural education with visual and tactile bio eedback. Acute
pain can be managed with activity modif cation and interventions that help decrease pain
(analgesics, cryotherapy, physical agents). T e rehabilitation program should also consist
o therapeutic exercises (see Figures 27-50, 27-53 to 27-58, and 27-61) and manual thera-
pies (see Figures 27-67 to 27-75) that target specif c impairments identif ed in the exam-
ination and attempt to establish a normalized spinal curvature. Postural education and
exercises should ocus on sitting and standing postures (see Figure 27-33). Emphasis is
placed on the posture o the shoulder and pelvic girdle and positions which unload the
curve pattern. T erapeutic exercise is then per ormed in the corrected postural pattern to
increase muscular endurance (see Figure 27-25) and to help rein orce the pattern. Cases
that do not respond to conservative management may require more invasive interventions
such as surgery.
SUMMARY
Identif cation o a specif c pathoanatomical cause o cervical spine or thoracic spine pain
is not always possible. T e clinician must obtain a thorough history and per orm a compre-
hensive examination to identi y the causative actors such as impairments and unctional
limitations that are contributing to the pathology. Although a number o pathologies may
be present within the cervical or thoracic spine regions, there are considerable similarities
among the intervention approaches.
Interventions should address specif c impairments and unctional limitations with
consideration o the available evidence, clinician experience, and patient values. T e oun-
dation o the rehabilitation program is therapeutic exercise complemented with other spe-
cif c interventions that address motion, pain, and radicular symptoms. T e clinician should
consistently monitor patient progress and alter the program as needed. Rehabilitation pro-
gression is based on resolution o symptoms and changes in impairments and unction.19,20
Sample Cases
Cervical Case 1: Cervical Radiculopat hy

Background
T e patient is a 35-year-old male attorney and recreational triathlete with a 2-week onset
o right moderate (3/ 10), lateral, midcervical pain and severe (7/ 10), sharp, shooting pain
in his lateral orearm with intermittent thumb/ index f nger paresthesia. Symptoms began
ollowing painting rooms, including ceilings, in his new house or 2 weeks a ter work and
on weekends. Symptoms are aggravated in the AM/ f rst rising; when sitting/ driving or
longer than 30 minutes; when looking up; and with right rotation. Symptoms are relieved
with supine lying in exion (2 pillows), arm resting on top o head, and nonsteroidal
antiin ammatory drugs (NSAIDs). Neck Disability Index: 16/ 50. Objective f ndings: Limited
cervical range o motion (ROM)—right rotation, right side bending, extension. (+) upper
limb tension test (UL ) 1 right; pain with Spurling test; reduction in symptoms with
cervical distraction. His lateral cervical paraspinals are tender to palpation, with muscle
spasm and guarding right > le t. Normal myotomal strength, sensation to pin prick and light
touch, muscle stretch re exes.
Treat ment 42,43,124

Phase I: (acute—cervical + radicular pain mid ROM cervical sidebending (SB)/ rotation/
extension)
Manual T erapy: Cervical manual distraction in neutral, slight exion
(see Figures 27-34, and 27-36)
T oracic extension mobilization/ manipulation (see Figures 27-68 to 27-70)
So t tissue mobilization—upper trapezius, scaleni, suboccipitals
Neural mobilization – ULL 1 (gentle, pain ree) (see Figure 27-45)
Exercise: Deep neck exor training (supine) (see Figures 27-11 and 27-12)
Mid ROM (pain ree) cervical rotation (see Figure 27-38)
Postural correction—sitting (see Figures 27-17, 27-25, and 27-33)
Bilateral scapular retraction and external rotation (ER) (see Figure 27-55)
Education: Sitting posture—work station modif cations/ ergonomics (see Figure 27-33)
Thoracic Spine 935
Phase II: (subacute—cervical rotation/ SB/ extension with radicular pain at end ROM)
Manual T erapy: Continue manual cervical distraction (see Figures 27-34
and 27-36)
So t-tissue mobilization to cervical paraspinals
Cervical side glide mobilizations right C5-6 (see Figure 27-43)
Cervical rotational/ opening mobilizations right C5-6 (see Figure 27-44)
T oracic manipulation (see Figures 27-68 to 27-70)
Exercise: Prone cervical stabilization (deep neck exors)—sagittal plane

(see Figure 27-13)
Seated cervical stabilization—scapular stabilization (pulleys or tubing)
(see Figure 27-23)
Prone scapular stabilization (see Figures 27-18 and 27-19)
Neural mobilizations—sel (see Figure 27-45)
Phase III: (nonradicular signs and symptoms)
Manual T erapy: Cervical manual distraction (see Figures 27-34 and 27-36)
Cervical opening mobilizations/ manipulation (see Figures 27-43 and 27-44)
So t-tissue mobilization—cervical paraspinals
Exercise: Cervical stabilization (general cervical strengthening)—multiplanar/
multipositional (see Figures 27-26 and 27-27)
Scapular stabilization—prone stability ball (see Figures 27-19 to 27-22)
Phase IV: (symptom ree, ull active range o motion [AROM])
Exercise: Sport-specif c cervical/ scapular stabilization (see Figures 27-62 to 27-66)
Bike f t/ postural assessment
Swimming stroke mechanic training
Return to gym exercises—review postural correction with progressive increase in
resistance training (see Figures 27-29 and 27-32)
Cervical Case 2: Ant erior Cervical Decompression/Fusion

(ACDF) Post operat ive Rehabilit at ion
Background
T e patient is a 58-year-old emale administrative assistant and recreational tennis
player who presented with chronic neck pain and progressive myelopathy and who ailed
12 weeks’ o conservative management, including physical therapy, pharmacologic man-
agement, and epidural steroid injections × 3. She had a 2-level cervical decompression and
anterior cervical instrumented usion at C5-6.
Treat ment /Post operat ive Management 125-127

Phase I (Postoperative weeks 4 to 8): ollowing 4 weeks o cervical collar + progressive
walking program (15 minutes 1×/ day, progressing up to 30 minutes 2×/ day)
Manual T erapy: So t-tissue mobilization to cervical paraspinals, including anterior
incision
Gentle cervical AROM exercises (supine) (see Figure 27-38)
Exercise: Upper body ergometry (postural correction) (see Figure 27-25)

Sensorimotor training: deep neck exor activation (see Figures 27-11 and 27-12)
Scapular retraction exercise (prone—head supported) (see Figure 27-18)
Education: Posture (see Figure 27-33)

Relaxation/ stress management/ breathing
Pain physiology
Sel -management/ coping strategies
Sel -e cacy
Phase II (Postoperative weeks 8 to 12):
Manual T erapy: Progression o cervical active ROM exercises to ull
Passive range o motion (PROM)—progress cervical ROM to ull
Grades II/ III cervical side bend/ side glide mobilizations (above/ below C5/ 6)
(see Figures 27-43 and 27-44)
T oracic mobilizations (see Figures 27-67 to 27-70)
Exercise: Cervical stabilization exercises (seated) (see Figures 27-15 to 27-17)

Upper-extremity rowing, proprioceptive neuromuscular acilitation (PNF)
diagonals (see Figures 27-24, 27-29, 27-30, 27-55, and 27-56)
Cervical motor control exercises through progressing ROM (supported to
unsupported) (see Figures 27-13 to 27-17)
Education: Sel -e cacy

Ergonomics—workstation design (see Figure 27-33)
Phase III (Postoperative weeks 12 to 16):
Exercise: Progress endurance o cervical stabilizers (deep neck exors)
General strengthening—upper quarter with cervical stabilization/ postural
correction (see Figures 27-29 and 27-32)
Functional training: Scapular stabilization with standing sport-specif c (tennis)
movement patterns (see Figures 27-28 and 27-30)
Education: Postural correction with return to prior level o activity
Thoracic Case 1: Rib St ress Fract ure

Background
Patient is an 18-year-old emale collegiate-club-level rower (single sculler) with a 3-week his-
tory o anterior lateral lower rib cage pain that worsens with increased training/ practice in
the boat. Symptoms are aggravated by breathing, cough/ sneeze; overhead upper-extremity
use— exion worse than abduction; trunk extension > exion; transitional movements,
especially sit-to-supine in bed; unable to row secondary to sharp pain. Symptoms are eased
with rest, analgesics, ice. Bone scan (+) lateral seventh rib stress injury.
Treat ment 104,105,128

Phase I: Education: Rest × 3 weeks rom all rowing
Thoracic Spine 937
Analgesics (not NSAIDs)
Ice or pain management
Diet/ caloric intake consultation/ re erral
Manual T erapy: So t-tissue mobilization to regional myo ascia-abdominals,
obliques, intercostals, serratus
Grades II/ III mobilizations to thoracic spine (see Figures 27-67 to 27-70)
Hip/ lumbar exion mobilization/ stretching
Exercise: Lower-body cardiovascular training: cycling (upright posture)
runk/ core stability (avoiding excessive abdominal loading/ contraction)
(see Figures 27-49, 27-50, and 27-53)
Lower quarter/ hip strengthening (gluteals) (see Figures 27-51 and 27-52)
Stretching or lumbar/ hip especially exion (see Figure 27-54)
Phase II: Education: Gradual progressive return to rowing (on land/ ergo meter)
Assess rowing mechanics—cuing to correct, especially simultaneous leg drive
Manual T erapy: Regional so t-tissue mobilization
T oracic mobilization (grades II/ III) to improve costovertebral, costotransverse,
thoracic mobility (see Figures 27-67 to 27-75)
Exercise: Gradual progression o upper quarter cardiovascular training, including
ergometry/ rowing
Progress trunk/ core stability using unstable sur aces and unilateral exercises
(see Figures 27-49, 27-50, and 27-53)
Lower quarter strengthening, especially hip/ knee extension, including squats and
single-leg Romanian deadli t (see Figure 27-60)
Scapular stabilization—mid/ lower trap strengthening, light resistance—serratus
strengthening (see Figures 27-19 to 27-22, 27-55, and 27-56)
Phase III: Education: Continue progressive return to rowing—progress to boat
Rowing biomechanical assessment—cueing
Manual T erapy: Continue regional so t-tissue mobilization
Joint mobilizations: T oracic, costotransverse, costovertebral joint mobilizations
(grades III/ IV) (see Figures 27-67 to 27-75)
Exercise: Progress scapular stabilization especially serratus anterior
Progress to eccentric serratus strengthening, including weightbearing exercises
(see Figures 27-57 to 27-60)
Phase IV: Education: Continue to progress toward ull practice load
Communicate with coaches to rein orce mechanics/ technique recommendations
Manual T erapy: So t-tissue mobilizations
Joint mobilizations as needed (see Figures 27-67 to 27-75)
Exercise: Continue to strengthen scapular stabilizers, especially eccentric serratus
(see Figures 27-63 to 27-67)
Incorporate endurance training with emphasis on proper technique
Progress core/ trunk stability incorporating more specif c abdominal
cocontraction into rowing specif c strengthening and technique drills.
Single-leg squats and single-leg Romanian deadli t (see Figure 27-60). Can
incorporate unstable sur aces
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Appendix 1
Phys ic al
ag e nts /
mo dalitie s Manual
the rapie s Co ntro lle d
Advanc e d
mo bility and
Manual mus c le -s pe c ific
dynamic
the rapie s and g e ne ral
Patie nt s tability
e xe rc is e
e duc atio n e xe rc is e
Lo w-lo ad
mus c le -s pe c ific
e xe rc is e
Ac ute pain and Mo tio n and

ne uro mus c ular c o ntro l ne uro mus c ular c o ntro l Func tio nal tas ks
Example s Example s Example s

• Chin tuck—S upine with s ta bilize r • Chin tuck—S upine with a rm move me nt • S houlde r e xte rna l rota tion
(Figure 27-11) (Figure 27-12) with tubing —S ta nding
• Mobiliza tion ce rvica l la te ra l glide • P rone s houlde r horizonta l a bduction on (Figure 27-28)
s ta bility ba ll (Figure 27-19) • P NF pa tte rn with tubing
(Figure 27-43) a nd rota tion
• Ne ck rota tion re s is te d (Figure 27-16) (Figure 27-30)
(Figure 27-44)
• S ta nding row with ca ble /tubing —S plit
• Mobiliza tion prone midthora cic s ta nce (Figure 27-56)
(Figure 27-68) • P us h up with plus (Figure 27-57)
• Horizonta l a bduction—P rone row
(Figure 27-18)
Rehabilitation of
Injuries to the Lumbar
and Sacral Spine
Da n ie l N. Ho o k e r a n d Willia m E. Pre n t ice
OBJJEC
Discuss the functional anatomy and biomechanics of the spine.
Describe the difference between spinal segmental stabilization and core stabilization.
Explain the rationale for using the different positioning exercises for treating pain in the spine.
Conduct a thorough evaluation of the back before developing a rehabilitation plan.
Compare and contrast the importance of using either joint mobilization or core stabilization
exercises for treating spine patients.
Differentiate between the acute versus reinjury versus chronic stage models for treating low
back pain.
Explain the eclectic approach for rehabilitation of back pain in the athletic population.
Describe basic- and advanced-level training in the reinjury stage of treatment.
Incorporate the rehabilitation approach to speci c conditions affecting the low back.
943
944 Chapte r 28 Rehabilitation of Injuries to the Lumbar and Sacral Spine

From a biomechanical perspective, the spine is one o the most complex regions o the
body, with numerous bones, joints, ligaments, and muscles, all o which are collectively
involved in spinal movement. T e proximity to and relationship o the spinal cord, the
nerve roots, and the peripheral nerves to the vertebral column add to the complexity o this
region. Injury to the cervical spine has potentially li e-threatening implications, and low
back pain is one o the most common ailments known to humans.
T e 33 vertebrae o the spine are divided into 5 regions: cervical, thoracic, lumbar,
sacral, and coccygeal. Between each o the cervical, thoracic, and lumbar vertebrae lie
f brocartilaginous intervertebral disks that act as important shock absorbers or the spine.
T e design o the spine allows a high degree o exibility orward and laterally, and
limited mobility backward. T e movements o the vertebral column are exion and exten-
sion, right and le t lateral exion, and rotation to the le t and right. T e degree o movement
di ers in the various regions o the vertebral column. T e cervical and lumbar regions allow
extension, exion, and rotation around a central axis. Although the thoracic vertebrae have
minimal movement, their combined movement between the f rst and twel th thoracic ver-
tebrae can account or 20 to 30 degrees o exion and extension.
As the spinal vertebrae progress downward rom the cervical region, they grow increas-
ingly larger to accommodate the upright posture o the body, as well as to contribute to
weight bearing. T e shape o the vertebrae is irregular, but the vertebrae possess certain
characteristics that are common to all. Each vertebra consists o a neural arch through
which the spinal cord passes, and several projecting processes that serve as attachments
or muscles and ligaments. Each neural arch has 2 pedicles and 2 laminae. T e pedicles are
bony processes that project backward rom the body o the vertebrae and connect with the
laminae. T e laminae are at bony processes occurring on either side o the neural arch that
project backward and inward rom the pedicles. With the exception o the f rst and second
cervical vertebrae, each vertebra has a spinous and transverse process or muscular and
ligamentous attachments, and all vertebrae have multiple articular processes.
Intervertebral articulations are between vertebral bodies and vertebral arches. Articula-
tion between the bodies is o the symphysial type. Besides motion at articulations between
the bodies o the vertebrae, movement takes place at our articular processes that derive rom
the pedicles and laminae. T e direction o movement o each vertebra is somewhat depen-
dent on the direction in which the articular acets ace. T e sacrum articulates with the ilium
to orm the sacroiliac joint, which has a synovium and is lubricated by synovial uid.
Ligament s
T e major ligam ents that join the various vertebral parts are the anterior longitudinal, the
posterior longitudinal, and the supraspinous. T e anterior longitudinal ligament is a wide,
strong band that extends the ull length o the anterior sur ace o the vertebral bodies.
T e posterior longitudinal ligament is contained within the vertebral canal and extends
the ull length o the posterior aspect o the bodies o the vertebrae. Ligaments connect one
lamina to another. T e interspinous, supraspinous, and intertransverse ligaments stabilize
the transverse and spinous processes, extending between adjacent vertebrae. T e sacroiliac
joint is maintained by the extremely strong dorsal sacral ligaments. T e sacrotuberous and
the sacrospinous ligaments attach the sacrum to the ischium.
Muscle Act ions

T e muscles that extend the spine and rotate the vertebral column can be classif ed as either
superf cial or deep. T e superf cial muscles extend rom the vertebrae to ribs. T e erector
spinae is a group o superf cial paired muscles that is made up o 3 columns or bands, the
longissimus group, the iliocostalis group, and the spinalis group. Each o these groups is
urther divided into regions, the cervicis region in the neck, the thoracis region in the mid-
dle back, and the lumborum region in the low back. Generally, the erector spinae muscles
extend the spine. T e deep muscles attach one vertebra to another and unction to extend
and rotate the spine. T e deep muscles include the interspinales, multif dus, rotators, tho-
racis, and the semispinalis cervicis.
Flexion o the cervical region is produced primarily by the sternocleidomastoid mus-
cles and the scalene muscle group on the anterior aspect o the neck. T e scalenes ex the
head and stabilize the cervical spine as the sternocleidomastoids ex the neck. T e upper
trapezius, semispinalis capitis, splenius capitis, and splenius cervicis muscles extend the
neck. Lateral exion o the neck is accomplished by all o the muscles on one side o the
vertebral column contracting unilaterally. Rotation is produced when the sternocleidomas-
toid, the scalenes, the semispinalis cervicis, and the upper trapezius on the side opposite to
the direction o rotation contract in addition to a contraction o the splenius capitis, sple-
nius cervicis, and longissimus capitis on the same side o the direction o rotation.
Flexion o the trunk primarily involves lengthening o the deep and superf cial back mus-
cles and contraction o the abdominal muscles (rectus abdominis, internal oblique, external
oblique) and hip exors (rectus emoris, iliopsoas, tensor asciae lata, sartorius). Seventy-f ve
percent o exion occurs at the lumbosacral junction (L5-S1), whereas 15% to 70% occurs
between L4 and L5. T e rest o the lumbar vertebrae execute 5% to 10% o exion.12 Extension
involves lengthening o the abdominal muscles and contraction o the erector spinae and the
gluteus maximus, which extends the hip. runk rotation is produced by the external obliques
and the internal obliques. Lateral exion is produced primarily by the quadratus lumborum
muscle, along with the obliques, latissimus dorsi, iliopsoas, and the
rectus abdominis on the side o the direction o movement.
Spinal segm ent stability is produced by the deep muscles o
the spine (m ultif di, m edial quadratus lum borum , iliocostalis
lum borum, interspinales, intertransversarii) working in concert
with the transversus abdom inis and internal abdom inal oblique
( Figure 28-1). T eir location is close to the center o rotation o the
spinal segm ent and their short muscle lengths are ideal or con-
trolling each spinal segm ent. T e transversus abdom inis, because
o its pull on the thoracolum bar ascia, and its ability to create
increased intraabdom inal pressure as it narrows the abdom inal
cavity, is a major partner in spinal segm ent stability ( Figure 28-2).
T is com bination creates a rigid cylinder and in concert with the
deep spinal muscles provides signif cant segm ental stability to the
lum bar spine and pelvis.20,33-35,58-60,62,67-69
Spinal Cord
T e spinal cord is that portion o the central nervous system that is
contained within the vertebral canal o the spinal column. T irty-
one pairs o spinal nerves extend rom the sides o the spinal cord,
coursing downward and outward through the intervertebral ora-
men passing near the articular acets o the vertebrae. Any abnor-
mal movement o these acets, such as in a dislocation or a racture,
may expose the spinal nerves to injury. Injuries that occur below the
third lumbar vertebra usually result in nerve root damage but do not
cause spinal cord damage. Figure 28-1 Muscle s o f the lo w back
T e spinal nerve roots combine to orm a network o nerves,
or a plexus. T ere are 5 nerve plexuses: cervical, brachial, lumbar, The multi dus and the quadratus lumborum muscles.
sacral, and coccygeal.
Figure 28-2 The transve rse abdo minis and

e xte rnal o blique muscle s
The Importance of Evaluation

in Treating Back Pain
In many instances a ter re erral or medical evaluation, the patient returns to the therapist
with a diagnosis o low back pain. Even though this is a correct diagnosis, it does not o er
the specif city needed to help direct the treatment planning. T e therapist planning the
treatment would be better served with a more specif c diagnosis, such as spondylolysis, disk
herniation, quadratus lumborum strain, piri ormis syndrome, or sacroiliac ligament sprain.
Regardless o the diagnosis or the specif city o the diagnosis, the importance o a
thorough evaluation o the patient’s back pain is critical to good care. T e therapist should
become an expert on this individual patient’s back. aking the time to per orm a compre-
hensive evaluation will pay great rewards in the success o treatment and rehabilitation. T e
evaluation has 6 major purposes:
1. o clearly locate areas and tissues that might be part o the problem. T e therapist
should use this in ormation to direct treatments and exercises.31,34,50
2. o establish the baseline measurements used to assess progress and guide
the treatment progression and help the therapist make specif c judgments on
the progression o or changes in specif c exercises. T e improvement in these
measurements also guides the return-to-activity decision and provides 1 measure o
the success o the rehabilitation plan.37,46,70
3. o provide some provocative guidance to help the patients probe the limits o their
condition, help them better understand their problem, present limitations, and
understand the management o their injury problem.37,46,70
4. o establish conf dence in the therapist. T is increases the placebo e ect o the
therapist patient interaction.86,87
The Importance of Evaluation in Treating Back Pain 947
5. o decrease the anxiety o the patient. T is increases the patient’s com ort, which
will increase the patient’s compliance with the rehabilitation plan; a more positive
environment is created, and the therapist and patient avoid the “no one knows what is
wrong with me” trap.17,53
6. o provide in ormation or making judgments on pads, braces, and corsets.
able 28-1 provides a detailed scheme or evaluation o back pain.
Table 28-1 Lumbar and Sacro iliac Jo int Obje ctive Examinatio n
1. Standing position
a. Posture—alignment
b. Gait
i. Patient’s trunk frequently bent laterally or hips shifted to one side
ii. Walks with dif culty or limps
c. Alignment and symmetry
iii. Trochanteric levels
iv. Posterior superior iliac spine (PSIS) and anterior superior iliac spine (ASIS) levels
v. Levels of iliac crests
Recent studies have raised the concern that these clinical assessments of alignment are not valid because of
the small movements available at the sacroiliac joints. These tests should be used as a small part of the overall
evaluation and not as standalone tests. In sacroiliac dysfunction, the ASIS, PSIS, and iliac crests may not appear to
be in the same horizontal plane
d. Lumbar spine active movements
i. With sacroiliac dysfunction, the patient will experience exacerbation of pain with side bending toward the
painful side
ii. Often a lumbar lesion is present along with a sacroiliac dysfunction
e . Single-leg standing with backwards bending is a provocation test and can provoke pain in cases of spondylolysis
or spondylolisthesis
2. Sitting position
a. Lumbar spine rotation range of motion
b. Passive hip internal rotation and external rotation range of motion
i. Piriformis muscle irritation would be provoked by internal rotation and could be present from sacroiliac joint
dysfunctions or myofascial pain from overuse of this muscle
ii. Limited range of motion of the hip can be a red ag for hip problems
c. Sitting knee extension produces some stretch to the long neutral structures
d. Slump sit is used to evaluate lumbar exibility and neutral tension
3. Supine position
a. Hip external rotation in a resting position may indicate piriformis muscle tightness
b. Palpation of the transversus abdominis, as the patient is directed to contract, can help in the assessment of spinal
segment control. Can the patient isolate this contraction from the other abdominal muscles?
c. Palpation of the symphysis pubis for tenderness. Some sacroiliac problems create pain and tenderness in this
area. Sometimes the presenting subjective symptoms mimic adductor or groin strain but the objective evaluation
does not show pain or weakness on muscle contraction or muscle tenderness that would support this assessment
d. Straight-leg raise (passive)
i. Interpretation of straight-leg raise: pain provoked before
• 30 degrees—hip problem or very in amed nerve
• 30 to 60 degrees—sciatic nerve involvement
• 70 to 90 degrees—sacroiliac joint involvement
• Neck exion—exacerbates symptoms—disk or root irritation
• Ankle dorsi exion or Lasègue sign—exacerbated symptoms usually indicate sciatic nerve or root irritation
(continued )
Table 28-1 Lumbar and Sacro iliac Jo int Obje ctive Examinatio n (Continued )
e . Sacroiliac loading test (compression, distraction, posterior shear or P4 Test, Gaenslen Scissor Stretch)—
pain provoked by physical stress through the sacroiliac joints can be helpful in assessing for sacroiliac joint
dysfunction
f. FABER ( exion, abduction, external rotation), also known as the Patrick test—at end range assesses irritability of
the sacroiliac joint; hip muscle tightness can also be assessed using this test
g . FADIR ( exion, adduction, internal rotation) produces some stretch on the iliolumbar ligament
h. Bilateral knees to chest—will usually exacerbate lumbar spine symptoms as the sacroiliac joints move with the
sacrum in this maneuver
i. Single knee to armpit can provoke pain from a variety of sources from sacroiliac joint to lumbar spine muscles
and ligaments; make the patients be speci c about their pain location and quality
4. Side-lying position
a. Iliotibial band length—sacroiliac (SI) joint problems sometimes create tightness of the iliotibial band and
stress to the iliotibial band will provoke pain in the SI joint area
b. Quadratus lumborum stretch and palpation
c. Hip abduction and piriformis muscle test
Pain provocation in muscular locations with either of these tests indicates primary myofascial pain problems
or secondary tightness, weakness, and pain from muscle guarding associated with different pathologies. Pain
provocation in the SI joint area would help con rm an SI joint dysfunction
5. Prone position
a. Palpation
i. Well-localized tenderness medial to or around the PSIS indicates SI dysfunction
ii. Tenderness lateral and superior to the PSIS indicates gluteus medius irritation or myofascial trigger
point
iii. Gluteus maximus area—sacrotuberous and sacrospinous ligaments are in this area, as well as piriformis
muscle and sciatic nerve. Changes in tension and tenderness can help make the evaluation more
speci c
iv. Tenderness around spinous processes or postural alignment faults from S-1 to T-10 could implicate some
lumbar problems
b. Anterior—posterior or rotational provocational stresses can be applied to the spinous processes
c. Sacral provocation stress test—pain from anterior–posterior pressure at the center of the sacral base and/or
on each side of the sacrum just medial to the PSIS may be indicative of SI joint dysfunction
d. Hip extension—knee exion stretch will provoke the L3 nerve root and create a nerve quality pain down the
anterolateral thigh
e . Anterior rotation stress to the sacroiliac joint can be delivered by using passive hip extension and PSIS pressure;
pain in the SI joint area on either side would be indicative of SI dysfunction
6. Manual muscle test

If the lumbar spine or posterior hip musculature is strained, active movement against gravity and/or
resistance should provoke a pain complaint similar to patients’ subjective description of their
problem
a. Hip extension
b. Hip internal rotation
c. Hip external rotation
d. Hip exion
e . Hip adduction
f. Trunk extension—arm and shoulder extension
g . Trunk extension—arm, shoulder, and neck extension
h. Trunk extension—resisted
i. Multi dus activation and control
j. Spinal segment coactivation of transversus abdominis and multi di29,44,52,69,70
Spinal Segment Control Exercise 949
Rehabilitation Techniques for the Low Back
Posit ioning and Pain-Relieving Exercises

Most patients with back pain have some uctuation o their symptoms in response to cer-
tain postures and activities. T e therapist logically treats this patient by rein orcing pain-
reducing postures and motions and by starting specif c exercises aimed at specif c muscle
groups or specif c ranges o motion. A general rule to ollow in making these decisions is
as ollows: Any m ovem ent that causes the back pain to radiate or spread over a larger area
should not be included during this early phase of treatm ent. Movements that centralize or
diminish the pain are correct movements to include at this time.50 Including some exercise
during initial pain management generally has a positive e ect on the patient. T e exercise
encourages them to be active in the rehabilitation plan and helps them to regain lumbar
movement.29,87
When a patient relieves pain through exercise and attention to proper postural control,
the patient is much more likely to adopt these procedures into a daily routine. A patient
whose pain is relieved via some other passive procedure, and then is taught exercises, will
not be able to readily see the connection between relie and exercise.20,36,58,69
T e types o exercises that may be included in initial pain management include the
ollowing:
• Spinal segment control, transverse abdominis, and multif dus coactivation
• Lateral shi t corrections
• Extension exercises—stretching and mobilization
• Flexion exercises—stretching and mobilization
• Postural traction positions
• Gentle rhythmic movements in exion, extension, rotation, and sidebending
• Spinal manipulation
Spinal Segment Control Exercise

In devising exercise plans to address the di erent clinical problems o the lumbo-pelvic-hip
complex, the use of core-stabilizing exercises is a m ust for every problem for recovery, m ain-
tenance, and prevention of reinjury. Clinically, the core stabilization rehabilitation exercise
sequence begins with relearning the muscle activation patterns necessary or segmental
spinal stabilization. T is beginning exercise plan is based on the work o Richardson, Jull,
Hodges, and Hides.33-36,60,68,69
T e f rst step in segmental spinal stabilization is to reestablish separate control o the
transversus abdominis and the lumbar multif di (see Figures 28-1 and 28-2). T e control
and activation o these deep muscles should be separated rom the control and activation o
the global or superf cial muscles o the core. Once the patients have mastered the behavior
o coactivation o the transversus abdominis and multif di to create and maintain a corset-
like control and stabilization o the spinal segments, they may then progress to using the
global muscles in the core stabilization sequence and more unctional activities. Segmental
spinal stabilization is the basic building block o core stabilization exercises and should be
an automatic behavior to be used in every subsequent exercise and activity.2,33,34,36,44,58,59
T e basic exercise that the patient must master is coactivation o the transversus
abdominis and multif di, isolating them rom the global trunk muscles. T is contraction
should be o su cient magnitude to create a small increase in the intraabdominal pressure.
T is is a simple concept, but these muscle contractions are normally under subconscious
automatic control; and in patients with low back pain, the subconscious control o timing
and f ring patterns become disturbed and the patient loses spinal segmental control.34 o
regain this vital skill and return the subconscious timing and f ring patterns o these mus-
cles, the patient will need individual instruction and testing to prove that the patient has
mastered the conscious control o each muscle individually and in a coactivation pattern.
T e next step is to incorporate this coactivation pattern into unctional exercise and other
activities. T e success o this exercise is dependent upon this muscular coactivation becom-
ing a habitual postural control movement under both conscious and subconscious control.
A muscle contraction o 10% to 15% o the maximum voluntary contraction o the
multif dus and the transversus abdominis is all that is necessary to create segmental spinal
stability. Contraction levels greater than 20% o maximum voluntary contraction will cause
over ow o activity to the more global muscles and negate the exercise’s intent o isolating
control o the transversus abdom inis and multif di.36 Precision o contraction and con-
trol is the intent o these exercises; the ultimate goal is a change in the patient’s behavior.
As this behavior is incorporated into more daily activities and exercise, the strength and
endurance o these muscle groups will also improve, and the core system will work more
e ectively and e ciently.28,37,38,43,46,47
Transversus Abdominis Behavior Exercise Plan

1. est the patient’s ability to consciously contract and control the transversus
abdominis in isolation rom the other abdominal muscles. T e therapist can assess
the contraction through observation and palpation. T e patient is positioned in a
com ortable relaxed posture: stomach-lying, back-lying, side-lying, or hand-knee
position. T e best palpation location is medial to the anterior superior iliac spine
(ASIS) approximately 1.5 inches (Figure 28-3). T e internal abdominal oblique has
more vertical f bers and is closest to the ASIS, whereas the transversus f bers run
horizontal rom ilia to ilia. T e therapist monitors the muscle with light palpation
Figure 28-3
Palpation location to feel for isolated transversus abdominis contraction.
A B
Figure 28-4
The quadrupeds position can be used to demonstrate and practice the isolated transversus abdominis contraction. The
patient is instructed to (A) let the belly sag, and then (B) slowly and gently contract the pelvic floor muscles and practice
holding this position for 10 seconds.
and instructs the patient to contract the muscle, eeling or the transversus drawing
together across the abdomen. As the contraction increases, the internal oblique
f bers and external oblique f bers will start to f re. I the patients cannot separate the
f ring o the transversus rom the other groups and/ or cannot maintain the separate
contraction or 5 to 10 seconds, they will need individual instruction with various
orms o eedback to regain control o this muscle behavior. In patients with low
back pain, transversus contraction usually becomes more phasic and f res only in
combination with the obliques or rectus.36,69
2. T e patients are positioned in a com ortable pain- ree position and instructed to
breathe in and out gently, stop the breathing, and slowly, gently contract and hold the
contraction o their transversus—and then resume normal light breathing while trying
to maintain the contraction. Changes in body position (positions o choice are prone,
side-lying, supine, or quadruped), verbal cues, and visual and tactile eedback will
speed and enhance the learning process (Figure 28-4). T e use o imaging ultrasound
as visual bio eedback to visualize the contractions o these muscles provides
visualization o the tendon movement and can help in isolating and bringing these
muscle contractions under cognitive control.36,69
3. T e lumbar multif di contractions are taught with tactile pressure over the muscle
bellies next to the spinous processes (Figure 28-5). T e patient is asked to contract
the muscle so that the muscle swells up directly under the f nger pressure. T e eeling
should be a deep tension. A rapid superf cial contraction or a contraction that brings
in the global muscles is not acceptable, and continued trial and error with eedback is
used until the desired contraction and control are achieved.36,69
4. As soon as cognitive control o the transversus and multif di is achieved, more
unctional positions and exercises aimed at coactivation o both muscles are begun.
T e therapist should attempt to have the patient use the transversus and multif di
coactivation in a com ortable neutral lumbopelvic position with restoration o a
normal lordotic curve so that the muscle coactivation strategies can start to be
incorporated into the patient’s daily li e (Figure 28-6). Repetition improves the
e ectiveness o this contraction, and as it is used more, the cognitive control becomes
less and the subconscious pattern o segmental spinal stabilization returns to
normal.36,69

Palpation location to feel for isolated lumbar Palpation location to feel contractions, to give the
multifidi contractions. patient feedback on the patient’s ability to perform a
coactivation segmental spinal stabilization contraction.
5. Incorporating the coactivation contraction back into activities is the next step and is
accomplished by graduating the exercises to include increases in stress and control.
Supine-lying with simple leg and arm movements is a good starting point. Using a
pressure bio eedback unit or this phase will help the patients measure their ability to
use the coactivation contraction e ectively during increased exercise. T e Stabilizer
pressure bio eedback unit is in ated to a pressure o approximately 40 mm Hg. As
the patient coactivates the transversus abdominis and multif di, the pressure reading
should stay the same or decrease slightly and remain at that level throughout the
increased movement exercises (Figure 28-7). T is is an indirect measure o the spinal
A B
Figure 28-7
The stabilizer pressure biofeedback unit can be used as an indirect method of measuring correct activation of the spinal
segment stabilization coactivation contraction. The stabilizer is inflated to 40 mm Hg pressure and placed under the
patient’s (A) abdomen or (B) back. The patient should be instructed to contract the transversus in a way that does not
make the pressure in the cuff start to rise or fall.
segment stabilization, but gives the patients an
outside eedback source to keep them more ocused A B
on the exercise.36,69
6. T is can be ollowed with trunk inclination
exercises in which the patients maintain a neutral
lumbopelvic position and incline their trunk in
di erent positions away rom the vertical alignment
and hold in positions o orward-lean to side-lean
or specif c time periods (Figures 28-8 and 28-9).
T is is f rst done in the sitting position. As control,
strength, and endurance increase, the positions can
become more exaggerated and the holding times
longer.
7. Return the patient to a structured progressive
resistive core exercise program (see
Chapter 15). T e incorporation o the segmental
spinal stabilization coactivation contraction as the
precursor to each exercise is the goal at this point in
returning the patient to unctional activity.
8. T e therapist should teach this technique both as
an exercise and as a behavior. T e exercises should
be taught and monitored in an individual session Figure 28-8 Trunk inclinatio n e xe rcise
with opportunity or eedback and correction. T e
patients must also use this skill in the unctional The patient finds a comfortable neutral spine position and
things they do every day. T e patients are asked coactivates the transversus abdominis and lumbar multifidi to
to trigger this spinal segment control skill in provide the segmental spinal stabilization.
response to daily tasks, postures, pains, and certain
movements (Figure 28-10A and B). As their pain is controlled, the coactivation
contraction should be incorporated into activities o daily living.
A B
Figure 28-9
The patient challenges his or her spinal segment control by leaning away from the vertical
position while holding the neutral spine position for 10 seconds.
A B
Figure 28-10
The patient is instructed to become posture savvy by frequently using the coactivation
contraction throughout the patient’s day. The coactivation thereby becomes a subconscious
movement pattern the patient incorporates into all the patient does.
Segmental spinal stabilization is complementary or all orms o treatment and di er-

ent pathologies. T is exercise program can be incorporated and started at the same time as
other therapies. T e di erent orms o therapy summate, and the patient improves more
quickly and maintains the gains in range and strength achieved with other therapies. Spinal
segment control may also decrease pain and give the patient a measure o control to use in
minimizing pain ul stress through the injured tissues.
Lat eral Shift Correct ions

Lateral shi t corrections and extension exercises probably should be discussed together
because the indications or use are similar, and extension exercises will immediately ollow
the lateral shi t corrections.
T e indications or the use o lateral shi t corrections are as ollows:82
• Subjectively, the patient complains o unilateral pain re erence in the lumbar or hip
area.
• T e typical posture is scoliotic with a hip shi t and reduced lumbar lordosis.
• Walking and movements are very guarded and robotic.
• Forward bending is extremely limited and increases the pain.
• Backwards bending is limited.
• Side bending toward the pain ul side is minimal to impossible.
• Side bending away rom the pain ul side is usually reasonable to normal.
• A test correction o the hip shi t either reduces the pain or causes the pain to
centralize.
• T e neurologic examination may or may not elicit the ollowing positive f ndings:
■ Straight-leg raising may be limited and pain ul, or it could be una ected.
■ Sensation may be dull, anesthetic, or una ected.
■ Manual muscle test may indicate unilateral weakness o specif c
movements, or the movements may be strong and painless.
■ Re exes may be diminished or una ected.50
T e patient will be assisted by the therapist with the initial lateral shi t
correction. T e patient is then instructed in the techniques o sel -correction.
T e lateral shi t correction is designed to guide the patient back to a more
symmetrical posture. T e therapist’s pressure should be f rm and steady and
more guiding than orcing. T e use o a mirror to provide visual eedback is
recommended or both the therapist-assisted and sel -corrected maneuvers.
T e specif c technique guide or therapist-assisted lateral shi t correction is
as ollows (Figure 28-11):
1. Prepare the patient by explaining the correction maneuver and the roles
o the patient and the therapist.
a. T e patient is to keep the shoulders level and avoid the urge to side
bend.
b. T e patient should allow the hips to move under the trunk and
should not resist the pressure rom the therapist but allow the hips
to shi t with the pressure.
c. T e patient should keep the therapist in ormed about the behavior
o the back pain. Figure 28-11 Late ral shift
d. T e patient should keep the eet stationary and not move a ter co rre ctio n e xe rcise
the hip shi t correction until the standing extension part o the
correction is completed. Emphasis is on pulling the hips, not on
e. T e patient should practice the standing extension exercise as part pushing the ribs.
o this initial explanation.
2. T e therapist should stand on the patient’s side that is opposite the
patient’s hip shi t. T e patient’s eet should be a com ortable distance apart, and the
therapist should have a com ortable stride stance aligned slightly behind the patient.
3. Padding should be placed around the patient’s elbow, on the side next to the therapist
to provide com ortable contact between the patient and the therapist.
4. T e therapist should contact the patient’s elbow with the shoulder and chest, with the
head aligned along the patient’s back. T e therapist’s arms should reach around the
patient’s waist and apply pressure between the iliac crest and the greater trochanter
(see Figure 28-11).
5. T e therapist should gradually guide the patient’s hips toward the therapist. I the pain
increases, the therapist should ease the pressure and maintain a more com ortable
posture or 10 to 20 seconds, and then again pull gently. I the pain increases again, the
therapist should again lessen the pull and allow com ort. T en the therapist should
instruct the patient to actively extend gently, pushing the back into and matching the
resistance supplied by the therapist. T e goal or this maneuver is an overcorrection o
the scoliosis, reversing its direction.
6. Once the corrected or overcorrected posture is achieved, the therapist should
maintain this posture or 1 to 2 minutes. T is procedure may take 2 to 3 minutes to
complete, and the f rst attempt may be less than a total success. Repeated e orts 3
to 4 minutes apart should be attempted during the f rst treatment e ort be ore the
therapist stops the treatment or that episode.
7. T e therapist gradually releases pressure on the hip while the patient does a standing
extension movement (Figure 28-16). T e patient should complete approximately 6
repetitions o the standing extension movement, holding each or 15 to 20 seconds.
8. Once the patient moves the eet and walks even a short distance, the
lateral hip shi t usually will recur, but to a lesser degree. T e patient
then should be taught the sel -correction maneuver (Figure 28-12). T e
patient should stand in ront o a mirror and place one hand on the hip
where the therapist’s hands were and the other hand on the lower ribs
where the therapist’s shoulder was.
9. T e patient then guides the hip under the trunk, watching the
mirror to keep the shoulders level and trying to achieve a corrected
or overcorrected posture. He/ she should hold this posture or
30 to 45 seconds and then ollow with several standing extension
movements as described in step 7 (see Figure 28-16).50
Ext ension Exercises

T e indications or the use o extension exercise are as ollows:
• Subjectively, back pain is diminished with lying down and is increased
with sitting. T e location o the pain may be unilateral, bilateral, or
central, and there may or may not be pain radiating into either or both
legs.
• Forward bending is extremely limited and increases the pain, or the pain
re erence location enlarges as the patient bends orward.
Figure 28-12 Hip shift se lf- • Backwards bending can be limited, but the movement centralizes or
co rre ctio n diminishes the pain.1
• T e neurologic examination is the same as outlined or lateral shi t
The patient can use a mirror for visual correction.50,51
feedback as they apply the gentle guiding
T e e cacy o extension exercise is theorized to be rom 1 or a combina-
force to correct their hip shift posture.
tion o the ollowing e ects:
The patient uses one hand to stabilize
themselves at the rib level and uses the • A reduction in the neural tension.
other hand to guide the hips across to • A reduction o the load on the disk, which, in turn, decreases disk
correct their alignment. This position is pressure.
held for 30 to 45 seconds, and then the • Increases in the strength and endurance o the extensor muscles.
patient is instructed to go into the standing
• Proprioceptive inter erence with pain perception as the exercises allow
extension position for 5 to 6 repetitions,
sel -mobilization o the spinal joints.
holding the position for 20 to 30 seconds.
Hip shi t posture has previously been theoretically correlated to the ana-
tomical location o the disk bulge or nucleus pulposus herniation. Creating
a centralizing movement o the nucleus pulposus has been the theoretical
emphasis o hip shi t correction and extension exercise. T is theory has good logic, but
research on this phenomenon has not been supportive.63 However, in explaining the exer-
cises to the patient, the use o this theory may help increase the patient’s motivation and
compliance with the exercise plan.
End-range hyperextension exercise should be used cautiously when the patient has
acet joint degeneration or impingement o the vertebral oramen borders on neural struc-
tures. Also, spondylolysis and spondylolisthesis problems should be approached cautiously
with any end-range movement exercise using either exion or hyperextension.
Figures 28-13 to 28-20 are examples o extension exercises. T ese examples are not
exhaustive but are representative o most o the exercises used clinically.
T e order in which exercises are presented is not signif cant. Instead, each therapist
should base the starting exercises on the evaluative f ndings. Jackson, in a review o back
Figure 28-13 Pro ne e xte nsio n o n e lbo w s Figure 28-14 Prone extension on hands
Figure 28-15 Alternate arm and leg extension
Figure 28-16 Standing e xte nsio n
Figure 28-17 Supine hip exte nsion—butt lift

or bridge
A. Double-leg support. B. Single-leg support.

A B
Figure 28-18 Pro ne sing le -le g hip e xte nsio n
A. Knee flexed. B. Knee extended.
A B
Figure 28-19 Pro ne do uble -le g hip e xte nsio n
A. Knees flexed. B. Knees extended.
A B
Figure 28-20 Trunk e xte nsio n—pro ne
A. Hands near head. B. Arms extended—superman position.

exercise, stated, “no support was ound or the use o a preprogrammed exion regimen that
includes exercises o little value or potential harm and is not specif c to the current needs
o the patient, as determined by a thorough back evaluation.” T e review also included a
report o Kendall and Jenkin’s study, which stated that one-third o the patients or whom
hyperextension exercises had been prescribed worsened.31
Flexion Exercises
T e indications or the use o exion exercises are as ollows:
• Subjectively, back pain is diminished with sitting and is increased with lying down or
standing. Pain is also increased with walking.
• Repeated or sustained orward bending eases the pain.
• T e patients’ lordotic curve does not reverse as they orward bend.
• T e end range o sustained backwards bending is pain ul or increases the pain.
• Abdominal tone and strength are poor.
In his approach, Saal elaborates on the thought that “No one should continue with
one particular type o exercise regimen during the entire treatment program.”73 We concur
with this and believe that starting with one type o exercise should not preclude rapidly
adding other exercises as the patient’s pain resolves and other movements become more
com ortable.
T e e cacy o exion exercise is theorized to derive rom 1 or a combination o the ol-
lowing e ects:
• A reduction in the articular stresses on the acet joints.
• Stretching to the thoracolumbar ascia and musculature.
• Opening o the intervertebral oramen.
• Relie o the stenosis o the spinal canal.
• Improvement o the stabilizing e ect o the abdominal musculature.
• Increasing the intraabdominal pressure because o increased abdominal muscle
strength and tone.
• Proprioceptive inter erence with pain perception as the exercises allow sel -
mobilization o the spinal joints.39
Flexion exercises should be used cautiously or avoided in most cases o acute disk
prolapse and when a laterally shi ted posture is present. In patients recovering rom disk-
related back pain, exion exercise should not be commenced immediately a ter a at-lying
rest interval longer than 30 minutes. T e disk can become more hydrated in this amount
o time, and the patient would be more susceptible to pain with postures that increase disk
pressures. Other, less stress ul exercises should be initiated f rst and exion exercise done
later in the exercise program.50
Figures 28-21 to 28-31 show examples o exion exercises. Again these examples are
not exhaustive, but are representative o the exercises used clinically.
Joint Mobilizat ions

T e indications or the use o joint mobilizations are as ollows:
• Subjectively, the patient’s pain is centered around a specif c joint area and increases
with activity and decreases with rest.
• T e accessory motion available at individual spinal segments is diminished.
Figure 28-21 Sing le kne e to che st Figure 28-22 Do uble kne e to che st
Stretch holding 15 to 20 seconds. Alternate legs. A. Stretching—holding posture 15 to 20 seconds.

B. Mobilizing—using a rhythmic rocking motion
within a pain-free range of motion.
• Passive range o motion is diminished.

• Active range o motion is diminished.
• T ere may be muscular tightness or increased ascial tension in the area o the pain.
• Back movements are asymmetrical when comparing right and le t rotation or side
bending.
• Forward and backward bending may steer away rom the midline.
T e e cacy o mobilization is theorized to be rom 1 or a combination o the ollowing
e ects:
• ight structures can be stretched to increase the range o motion.
• T e joint involved is stimulated by the movement to more normal mechanics, and
irritation is reduced because o better nutrient–waste exchange.
• Proprioceptive inter erence occurs with pain perception as the joint movement
stimulates normal neural f ring whose perception supersedes nociceptive perception.
Mobilization techniques are multidimensional and are easily adapted to any back pain
problem. T e mobilizations can be active or passive or assisted by the therapist. All ranges
( exion, extension, side bending, rotation, and accessory) can be incorporated within the
Figure 28-23 Po ste rio r pe lvic tilt Figure 28-24 Partial sit-up
Figure 28-25 Ro tatio n partial sit-up
Figure 28-26 Slump sit stre tch po sitio n
Figure 28-27 Flat-fo o te d squat stre tch
Figure 28-28 Hamstring stre tch
Figure 28-29 Hip e xo r stre tch Figure 28-30 Kne e ro cking side to side
Figure 28-31 Kne es tow ard chest rock Figure 28-32 Supine hip lift-bridg e -ro ck
exercise plan. T e mobilizations can be carried out according to Maitland’s grades o oscil-
lation, as discussed in Chapter 13. T e magnitude o the orces applied can range rom
grade 1 to grade 4, depending on levels o pain. T e theory, technique, and application
o the therapist-assisted mobilizations and manipulation are best gained through guided
study with an expert practitioner.46
Figures 28-30 to 28-38 show the various sel -mobilization exercises.
Figures 13-36 to 13-45 show joint mobilizations that can be used by the therapist.
Spinal Joint Manipulat ion

T e research rom the mid-1990s through 2000 has clarif ed the role o spinal mobilization
and manipulation in the overall scheme o back and neck rehabilitation. reatment algo-
rithms have evolved and the role o mobilization and manipulation techniques is better
understood and is taking its right ul place in rehabilitation plans. T e literature supports
manipulation or the short-term benef ts o pain relie and quicker return to unctional
activities.26 Long-term results show no detriment to this approach when compared to other
specif c treatment plans. T e reverse, however, is true. When manipulation is not included
A B
Figure 28-33 Pe lvic tilt o r pe lvic ro ck
A. Swayback horse. B. Scared cat.

Figure 28-34 Kne e ling —do g -tail w ag s Figure 28-35 Sitting Figure 28-36 Sitting
or standing rotation o r standing side be nding
A B
Figure 28-37 Standing hip-shift Figure 28-38 Standing pe lvic ro ck

side to side
A. Butt out. B. Tail tuck.
in a population that would benef t, the pain and loss-

o - unction symptoms last longer and can worsen.10
T is makes the case or including greater use o spinal
manipulation in rehabilitation plans than might have
previously been used by therapists.10,14,22,24,26
T e techniques used are shared among osteo-
pathic, physical therapy, chiropractic, and athletic
training disciplines, with theoretical rationales or use
and matching certain techniques to certain evaluative
f ndings varying between groups. T e basic technique
is simple and can be learned and used by any thera-
pist rom the undergraduate student to the most expe-
rienced practitioner. Figures 28-39, 28-58, and 28-59
show the basic positioning or the therapist and the
patient. Once the positioning is set, the therapist deliv-
Figure 28-39 ers a high velocity, low-amplitude thrust mobilization
to the lumbar spine or innominate that creates a sud-
Various side-lying and back-lying positions can be used to both den perturbation o the general lumbar and sacroiliac
stretch and mobilize specific joints in the lumbar area. region. Although there is o ten an associated popping
sound attributed to a cavitation o 1 or more o the
acet joints, the success o the treatment and pain relie
mechanisms are not attributed to this sound. T e pain relie e ect o the manipulation is
poorly understood but the action mechanism will likely be multimodal and will include the
a erent input to the central nervous system and its e ect on the endogenous pain control
systems.4,5,15,16,25,40,65,66,71 T e increased use o a technique adds to increased skill in per or-
mance and security with that particular technique.
T e indications or joint manipulation in the lumbar spine and pelvis are as ollows:26
• Subjectively, the patient’s pain is limited to the low back and hip area and does not
radiate below the knee.
• T e symptoms have a recent onset, less than 16 days since onset.
• One lumbar segment is thought to be hypomobile.
• One hip has limited internal rotation.
• T e patient will score low on a ear and avoidance to physical activity and work
questionnaire.87
A B C
Figure 28-40
Weight shifting and stabilization exercises should progress from (A) quadrupeds, to (B) triped, to (C) biped.
Figure 28-41 Back-lying —hip-hike shifting
Figure 28-42 Standing hip hike
Figure 28-43 Back-lying —hip-hike re siste d
Figure 28-44 Pro ne -lying hip inte rnal Figure 28-45 Hip-lift bridg e s
ro tatio n w ith e lastic re sistance
T e athletic population should have a high proportion o low back pain patients that
meets this clinical prediction rule. Manipulation should def nitely be included in their
rehabilitation plan.
T erapists are usually entry-level caregivers or patients with low back pain and are
well positioned to use manipulation in the f rst treatments aimed at reducing back pain and
increasing unction.14,21,22,23 I the patient has only 3 o the above f ndings, the treatment
results might not be as good, but including manipulation would still be worth the e ort and
would not be contraindicated.
T e side e ects and potential adverse events are requently used as contraindication
to lumbar spinal manipulation but in act are unproven and in most studies the complaints
are musculoskeletal in nature and consist o mild pain, sti ness, and guarding o move-
ments. T ese changes are usually sel -limiting and do not a ect the long-term outcome o
the patient. T e risk or serious complications (disk herniation, cauda equina syndrome) is
very low.8,9,23,72
Rehabilitation Techniques for Low Back Pain
Low Back Pain

Pat homechanics
In most cases, low back pain does not have serious or long-lasting pathology. It is generally
accepted that the so t tissues (ligament, ascia, and muscle) can be the initial pain source.
T e patient’s response to the injury and to the provocative stresses o evaluation is usually
proportional to the time since the injury and the magnitude o the physical trauma o the
injury. T e so t tissues o the lumbar region should react according to the biologic process
o healing, and the time lines or healing should be like those or other body parts. T ere
is little substantiation that injury to the low back should cause a pain syndrome that lasts
longer than 6 to 8 weeks. Pain avoidance and ear mechanisms are issues that also play a big
role in return to activity and require some inclusion in the rehabilitation plan.17,70,73
Injury Mechanism
Back pain can result rom 1 or a combination o the ollowing problems: muscle strain, piri-
ormis muscle or quadratus lumborum myo ascial pain or strain, myo ascial trigger points,
lumbar acet joint sprains, hypermobility syndromes, disk-related back problems, or sacro-
iliac joint dys unction.6

Acute Versus Chronic Low Back Pain T e low back pain that most o ten occurs is an
acute, pain ul experience rarely lasting longer than 3 weeks. As with many injuries, thera-
pists o ten go through exercise or treatment ads in trying to rehabilitate the patient with
low back pain. T e latest ad might involve exion exercise, extension exercise, joint mobi-
lization, dynamic muscular stabilization, abdominal bracing, myo ascial release, electrical
stimulation protocols, and so on.3 o keep perspective, as therapists select exercises and
modalities, they should keep in mind that 90% o people with back pain get resolution o the
symptoms in 6 weeks, regardless o the care administered.73,87
T ere are patients who have pain persisting beyond 6 weeks. T is group o patients will
generally have a history o reinjury or exacerbation o previous injury. T ey describe a low
back pain that is similar to their previous back pain experience.
T ese patients are experiencing an exacerbation or reinjury o previously injured tis-
sues by continuing to apply stresses that may have created their original injury. T is group
o patients needs a more specif c and ormal treatment and rehabilitation program.17,73
Rehabilitation Techniques for Low Back Pain 967
T ere are also people who have chronic low back pain. T is is a very small percentage
o the population that su ers rom low back pain. T e di erence between the patient with
an acute injury or reinjury and a person with chronic pain has been def ned by Waddell. He
states, “Chronic pain becomes a completely di erent clinical syndrome rom acute pain.”87
Acute and chronic pain not only are di erent in time scale, but are undamentally di er-
ent in kind. Acute and experimental pains bear a relatively straight orward relationship to
peripheral stimulus, nociception, and tissue damage.41
T ere may be some understandable anxiety about the meaning and consequences o
the pain, but acute pain, disability, and illness behavior are generally proportionate to the
physical f ndings. Pharmacologic, physical, and even surgical treatments directed to the
underlying physical disorder are generally highly e ective in relieving acute pain. Chronic
pain, disability, and illness behavior, in contrast, become increasingly dissociated rom
their original physical basis, and there may be little objective evidence o any remaining
nociceptive stimulus. Instead, chronic pain and disability become increasingly associated
with emotional distress, depression, ailed treatment, and adoption o a sick role. Chronic
pain progressively becomes a sel -sustaining condition that is resistant to traditional medi-
cal management. Physical treatment directed to a supposed but unidentif ed and possi-
bly nonexistent nociceptive source is not only understandably unsuccess ul, but may also
cause additional physical damage. Failed treatment may both rein orce and aggravate pain,
distress, disability, and illness behavior.54-57

A discussion o the rehabilitation progression or the patient with low back pain can be much
more specif c and meaning ul i treatment plans are lumped into 2 stages. Stage I (acute
stage) treatment consists mainly o the modality treatment and pain-relieving exercises.
Stage II treatment involves treating patients with a reinjury or exacerbation o a previous
problem. T e treatment plan in stage II goes beyond pain relie , strengthening, stretching,
and mobilization to include trunk stabilization and movement training sequences and to
provide a specif c, guided program to return the patient to unctional activity.73,74
Stage I (Acute Stage) Treatment Modulating pain should be the initial ocus o the
therapist. Progressing rapidly rom pain management to specif c rehabilitation should be a
primary goal o the acute stage o the rehabilitation plan. T e most common treatment or
pain relie in the acute stage is to use ice or analgesia. Rest, but not total bed rest, is used to
allow the injured tissues to begin the healing process without the stresses that created the
injury.18 I the patient f ts the clinical prediction rules or spinal manipulation, this should
be initiated as soon as the patient can tolerate the positioning.23
Along with rest, during the initial treatment stage, the patient should be taught to
increase com ort by using the appropriate body positioning techniques described previ-
ously, which may involve (a) lateral shi t corrections (see Figure 28-11); (b) extension
exercises (see Figures 28-13 to 28-20); (c) exion exercises (see Figures 28-21 to 28-31); (d)
sel -mobilization exercises (see Figures 13-46 and 13-47); or (e) spinal manipulation (see
Figure 28-39 and Figure 28-58). Segmental spinal stabilization exercise should be initiated
concurrently with these other exercises. Outside support, in the orm o corsets and the use
o props or pillows to enhance com ortable positions, also needs to be included in the initial
pain-management phase o treatment.73,87 T e patient should also be taught to avoid posi-
tions and movements that increase any sharp, pain ul episodes. T e limits o these move-
ments and positions that provide com ort should be the initial ocus o any exercise.
T e patient should be encouraged to move through this stage quickly and return to
activity as soon as range, strength, and com ort will allow. T e addition o a supportive
corset during this stage should be based mostly on patient com ort. We suggest using an
eclectic approach to the selection o the exercises, mixing the various protocols described
according to the f ndings o the patient’s evaluation. Rarely will a patient present with clas-
sic signs and symptoms that will dictate using one variety o exercise.
Stage II (Reinjury Stage) Treatment In the reinjury or chronic stage o back rehabilita-
tion, the goals o the treatment and training should again be based on a thorough evalua-
tion o the patient. Identi ying the causes o the patients’ back problems and recurrences is
very important in the management o their rehabilitation and prevention o reinjury. A goal
or this stage o care is to make the patients responsible or the management o their back
problem. T e therapist should identi y specif c problems and corrections that will help the
patients better understand the mechanisms and management o their problem.73
Specif c goals and exercises should be identif ed about the ollowing:
• Which structures to stretch.
• Which structures to strengthen.
• Incorporating segmental spinal stabilization and abdominal bracing into the patient’s
daily li e and exercise routine.
• Progression o core stabilization exercises.
• Which movements need a motor learning approach to control aulty mechanics.73
Stretching T e therapist and the patient need to plan specif c exercises to stretch
restricted groups, maintain exibility in normal muscle groups, and identi y hypermobility
that may be a part o the problem. In planning, instructing, and monitoring each exercise,
adequate thought and good instruction must be used to ensure that the intended struc-
tures get stretched and areas o hypermobility are protected rom overstretching.36 Inad-
equate stabilization will lead to exercise movements that are so general that the exercise
will encourage hyper exibility at already hypermobile areas. Lack o proper stabilization
during stretching may help perpetuate a structural problem that will continue to add to the
patient’s back pain.
In the therapist’s evaluation o the patient with back pain, the ollowing muscle groups
should be assessed or exibility.37
• Hip exors
• Hamstrings
• Low back extensors
• Lumbar rotators
• Lumbar lateral exors
• Hip adductors
• Hip abductors
• Hip rotators
Strengthening T ere are numerous techniques or strengthening the muscles o the

trunk and hip. Muscles are perhaps best strengthened by using techniques o progressive
overload to achieve specif c adaptation to imposed demands (the SAID principle). T e
overload can take the orm o increased weight load, increased holding time, increased
repetition load, or increased stretch load to accomplish physiologic changes in muscle
strength, muscle endurance, or exibility o a body part.19
T e treatment plan should call or an exercise that the patient can easily accomplish
success ully. Rapidly but gradually, the overload should push the patient to challenge the
muscle group needing strengthening. T e therapist and the patient should monitor con-
tinuously or increases in the patient’s pain or recurrences o previous symptoms. I those
changes occur, the exercises should be modif ed, delayed, or eliminated rom the rehabili-
tation plan.39,73
Core Stabilization Core stabilization training, dynamic abdominal bracing, and f nd-
ing neutral position all describe a technique used to increase the stability o the trunk (see
Chapter 15). T is increased stability will enable the patient to maintain the spine and pelvis
in the most com ortable and acceptable mechanical position that will control the orces o
repetitive microtrauma and protect the structures o the back rom urther damage. Core
muscular control is 1 key to giving the patients the ability to stabilize their trunk and con-
trol their posture. Abdominal strengthening routines are rigorous, and the patient must
complete them with vigor. However, in their unctional activities, the patients need to take
advantage o their abdominal strength to stabilize the trunk and protect the back.31,47,75
Richardson et al ocus attention on m otor control o the transversus abdom inis and
lum bar multif di in various positions.34,73 Once this control is established, di erent posi-
tions and m ovem ents are added. As the vigor o the exercise is progressively increased,
the patient will incorporate the m ore global muscles in stabilizing the patient’s core (see
Chapter 15). T en the patient m oves into the unctional exercise progression with the
spinal segm ent stabilization as the base m ovem ent in core stabilization, which is needed
to per orm unctionally.73 T e concept o increasing trunk stability with muscle contrac-
tions that support and limit the extrem es o spinal m ovem ent is im portant.
Basic Functional Training T e patients must be constantly committed to improving

body mechanics and trunk control in all postures in their activities o daily living. T e thera-
pist needs to evaluate the patients’ daily patterns and give them instruction, practice, and
monitoring on the best and least stress ul body mechanics in as many activities as possible.
T e basic program ollows the developmental sequence o posture control, starting
with supine and prone extremity movement while actively stabilizing the trunk. T e patient
is then progressed to all ours, kneeling, and standing (Figure 28-40).
Emphasis on trunk control and stability is maintained as the patient works through this
exercise sequence.31,49,73
T e most critical aspect or developing motor control is repetition o exercise. However,
variability in positioning, speed o movement, and changes in movement patterns must
also be incorporated. T e variability o the exercise will allow the patients to generalize their
newly learned trunk control to the constant changes necessary in their movements. T e
basic exercise, transversus abdominis and lumbar multif di coactivation, is the key. Incor-
porating this stabilization contraction into various activities helps rein orce trunk stabiliza-
tion and returns trunk control to a subconscious automatic response.
T e use o augmented eedback (electromyography, palpation, ultrasound imagery,
pressure gauges) o the transversus abdominis and lumbar multif di contractions may be
needed early in the exercise plan to help maximize the results o each exercise session
supervised by the therapist. T e therapist should have the patient internalize this eedback
as quickly as possible to make the patient apparatus- ree and more unctional. With aug-
mented eedback, it is recommended that the patient be rapidly and progressively weaned
rom dependency on external eedback.
Advanced Functional Training Each activity that the patient is involved in becomes
part o the advanced exercise rehabilitation plan. T e usual place to start is with the
patient’s strength and conditioning program. Each step o the program is monitored, and
emphasis is placed on spinal segmental stabilization or even the simple task o putting
the weights on a bar or getting on and o exercise equipment. Each exercise in its strength
and conditioning program should be retaught, and the patients be made aware o its best
mechanical position and the proper stabilizing muscular contraction. T e strength program
is patient-specif c, attempting to strengthen weak areas and improve strength in muscle
groups needed or better unction.73
T e patients should be taught to start their stabilizing contractions be ore starting any
movement. T is presets their posture and stabilization awareness be ore their movement
takes place. As the movement occurs, they will become less aware o the stabilization con-
traction as they attempt to complete an exercise.
T ey might revert to old postures and habits, so eedback is important.
Each patient is di erent, not only with the individual back problem but also with the
abilities to gain motor skill and to overcome the ear and avoidance associated with chronic
back pain.87 Patients di er in degree o control and in the speed at which they acquire these
new skills o core stabilization.
Reducing stress to the back by using braces, orthotics, shoes, or com ortable supportive
urniture (beds, desks, or chairs) is essential to help the patients minimize chronic or over-
load stresses to their back. T e stabilization exercise should also be incorporated into their
activities o daily living.59 Use o a low back corset or brace may also make the patient more
com ortable (Figure 28-56).

For most low back problems the stage I treatment and exercise programs will get the patients
back into their activities quickly. I the pain or dys unction is pronounced or the problem
becomes recurrent, an in-depth evaluation and treatment using stage I and stage II exercise
protocols will be necessary. T e team approach, with patient, doctor, and therapist working
together, will provide the comprehensive approach needed to manage the patient’s back
problem. Close attention to and emphasis on the patient’s progress will provide both the
patient and the therapist with the encouragement to continue this program.
Muscular St rains
Injury Mechanism
Evaluative f ndings include a history o sudden or chronic stress that initiates pain in a mus-
cular area during the workout. T ere are 3 points on the physical examination that must be
positive to indicate the muscle as the primary problem. T ere will be tenderness to palpa-
tion in the muscular area and the muscular pain will be provoked with contraction and with
stretch o the involved muscle.

T e treatment should include the standard protection, ice, and compression. Ice may be
applied in the orm o ice massage or ice bags, depending on the area involved. An elas-
tic wrap or corset would protect and compress the back musculature. Additional modali-
ties include pulsed ultrasound or a biostimulative e ect and electrical stimulation or
pain relie and muscle reeducation. T e exercises used in rehabilitation should make the
involved muscle contract and stretch, starting with very mild exercise and progressively
increasing the intensity and repetition loads. In general this would include active extension
exercises such as hip li ts (see Figures 28-17 to 28-19), alternate arm and leg, hip extension
(see Figure 28-15), trunk extension (see Figure 28-20), and quadratus hip shi t exercises
(Figures 28-41 to 28-43). A good series o abdominal spinal segmental stabilization and core
stabilization exercises would also be help ul (see Figures 28-23 and 28-24). Stretching exer-
cises might include the ollowing: knee to chest (see Figures 28-21 and 28-22), side-lying leg
hang to stretch the hip exors (see Figure 28-29), slump sitting (see Figure 28-26), and knee
rocking side to side (see Figure 28-30).

Initially, the patients may wish to continue to use a brace or corset, but they should be
encouraged to do away with the corset as their back strengthens and their per ormance
returns to normal.19,39
Piriformis Muscle St rain

Pat homechanics
Piri ormis syndrome was discussed in detail in Chapter 23.
T e piri ormis muscle re ers pain to the posterior sacro-
iliac region, to the buttocks, and sometimes down the pos-
terior or posterolateral thigh. T e pain is usually described
as a deep ache that can get more intense with exercise
and with sitting with the hips exed, adducted, and medi-
ally rotated. T e pain gets sharper and more intense with
activities that require decelerating medial hip and leg rota-
tion during weight bearing.7
enderness to palpation has a characteristic pat-
tern, with tenderness medial and proximal to the greater
trochanter and just lateral to the posterior superior iliac
spine (PSIS). Isometric abduction in the sitting position
produces pain in the posterior hip buttock area, and the
Figure 28-46 Hand-kne e po sitio n— re
movement will be weak or hesitant. Passive hip internal
hydrant e xe rcise
rotation in the sitting position will also bring on posterior
hip and buttock pain.61

Rehabilitation exercises should include both strength-
ening and stretching.7,61 Strengthening exercises should
include prone lying hip internal rotation with elastic
resistance (Figure 28-44), hip-li t bridges (Figure 28-45),
hand-knee position f re hydrant exercise (Figure 28-46),
side-lying hip abduction straight-leg raises (Figure 28-47),
and prone hip extension exercise (Figure 28-48).
Stretching exercises or the piri ormis include back-
lying legs-crossed hip adduction stretch ( Figure 28-49),
back-lying with the involved leg crossed over the unin-
volved leg, ankle to knee position, pulling the uninvolved
knee toward the chest to create the stretch (Figure 28-50),
contract-relax-stretch with elbow pressure to the muscle
Figure 28-47 Side -lying hip abductio n
insertion during the relaxation phase (Figure 28-51).42,78,81
straig ht-le g raise s
T is can also be done in the sitting position with the same
mechanics, but the patient leans over at the waist and
brings the chest toward the knee.
Quadrat us Lumborum St rain

Pat homechanics
Pain rom the quadratus lumborum muscle is described
as an aching, sharp pain located in the ank, in the lat-
eral back area, and near the posterior sacroiliac region
and upper buttocks. T e patient usually describes pain
on moving rom sitting to standing, standing or long peri-
ods, coughing, sneezing, and walking. Activities requir-
ing trunk rotation or side bending aggravate the pain. T e
muscle is tender to palpation near the origin along the
lower ribs and along the insertion on the iliac crest. Pain Figure 28-48 Pro ne hip e xte nsio n e xe rcise
Figure 28-49 Back-lying le g s-cro sse d hip Figure 28-50 Se lf pirifo rmis stre tch
adductio n stre tch
will be aggravated on side bending, and the pain will usually be localized to one side. For
example, with a right quadratus problem, side bending right and le t would provoke only
right-side pain. Supine hip-hiking movements would also provoke the pain.

Rehabilitation strengthening exercise should include back-lying hip-hike shi ting ( Fig-
ure 28-54), standing with 1 leg on elevated sur ace and the other ree to move below that
level, hip-hike on the ree side (Figure 28-55), and back-lying hip-hike resisted by pulling on
the involved leg (see Figure 28-43).
Stretching exercises should include side-lying over a pillow roll leg-hand stretch (Fig-
ure 28-52), supine sel -stretch with legs crossed (Figure 28-53), hip-hike exercise with hand
A B
Figure 28-51 Pirifo rmis stre tch using e lbo w pre ssure
A. Start-contract. B. Relaxation-stretch.
Figure 28-52 Side -lying stre tch o ve r pillo w ro ll Figure 28-53 Supine se lf-stre tch—le gs cro sse d
pressure to increase stretch (see Figure 28-54), and standing one leg on a small book stretch
(see Figure 28-55).89
Myofascial Pain and Trigger Point s

T e above examples o muscle-oriented back pain in both the piri ormis and quadratus
lumborum could also have a myo ascial origin. T e major component in success ully
changing myo ascial pain is stretching the muscle back to a normal resting length. T e mus-
cle irritation and congestion that create the trigger points are relieved and normal blood
ow resumes, urther reducing the irritants in the area. Stretching through a pain ul trigger
point is di cult.
Figure 28-54 Hip-hike e xe rcise w ith hand pre ssure Figure 28-55 Standing
1-le g -up stre tch
A variety o com ort and counterirritant modalities can be used preliminarily to, dur-
ing and a ter the stretching, enhance the e ect o the exercise. Some o the methods used
success ully are dry needling, local anesthetic injection, ice massage, riction massage, acu-
pressure massage, ultrasound electrical stimulation, extracorporeal shock wave therapy,
and cold sprays.38
T e indications or treating low back pain with myo ascial stretching and treatment
techniques are as ollows38:
1. Subjectively, muscle soreness and atigue rom repetitive m otions are common
antecedent mechanisms. Patients are also susceptible as atigue and stress overload
specif c muscle groups. T ere may be a history o sudden onset during or shortly
a ter an acute overload stress, or there may be a gradual onset with repetitive
or postural overload o the a ected muscle. T e pain may be an incapacitating
event in the case o acute onset, but it may also be a nagging, aggravating type
o pain with an intensity that varies rom an awareness o discom ort to a severe
unrelenting type o pain. T e pain location is usually a re erred pain area remote
rom the actual myo ascial trigger point. T ese trigger points can be present but
quiescent until they are activated by overload, atigue, trauma, or chilling. T ese
points are called latent trigger points. T is deep, aching pain can be specif cally
localized, but the patient is not sensitive to palpation in these areas. T is pain can
o ten be reproduced by maintaining pressure on a hypersensitive myo ascial trigger
point.
2. Passive or active stretching o the a ected myo ascial structure increases pain.
3. T e stretch range o muscle is restricted.
4. T e pain is increased when the muscle is contracted against a f xed resistance or the
muscle is allowed to contract into an extremely shortened range. T e pain in this case
is described as a muscle cramping pain.
5. T e muscle may be slightly weak.
6. rigger points may be located within a taut band o the muscle. I taut bands are ound
during palpation, explore them or local hypersensitive areas.
7. Pressure on the hypersensitive area will o ten cause a “jump sign”; as the therapist
strums the sensitive area, the patient’s muscle involuntarily jumps in response.
8. T e primary muscle groups that create low back pain in patients are the quadratus
lumborum and the piri ormis muscles.42,78,79,81
Simons and ravell devoted 2 volumes to the causes and treatment o various myo as-
cial pains.78,79 T ey have done a very thorough job o describing the symptoms and signs o
each area o the body, and they give very specif c guidance on exercises and positioning in
their treatment protocols.
Rehabilit at ion Technique

Myo ascial trigger points may be treated using the ollowing steps:
1. Position the patient com ortably but in a position that will lead the patient to
stretching the involved muscle group.
2. Caution the patient to use mild progressive stretches rather than sudden, sharp, hard
stretches.
3. Hot pack the area or 10 minutes, and ollow with an ultrasound and electrical
stimulation treatment over the a ected muscle.
4. Use an ice cup, and use 2 to 3 slow strokes starting at the trigger point and moving in
1 direction toward the pain re erence area and over the ull length o the muscle.
5. Begin stretching well within the patient’s com ort. A stretch should be maintained
or a minimum o 15 seconds. T e stretch should be released until the patient is
com ortable again. T e next stretch repetition should then be progressively more
intense i tolerated, and the position o the stretch should also be varied slightly.
Repeat the stretch 4 to 6 times.
6. Hot pack the area, and have the patient go through some active stretches o the
muscle.
7. Re er to Simons and ravell’s manual or specif c re erences on other muscle
groups.42,78,79
8. So t-tissue mobilization and positional release techniques are used to treat and
resolve trigger points (see Chapter 8). T erapeutic eccentric active massage has
shown some clinical success. In this technique, the muscle or ascia associated with
the identif ed trigger point is actively contracted to its shortest possible length. Using
a small amount o lubricant, the active trigger point is compressed with a f rm steady
pressure. T e therapist provides resistance to the shortened muscle, and the patient
is instructed to continue to resist, but also allow the eccentric lengthening o the
muscle to occur in a smooth, controlled manner. As the muscle lengthens under the
compressive massage, the trigger point is compressed and the irritants in the area are
dispersed over a greater area. T is helps the pain decrease, and the muscle begins to
unction more normally.
T e f rst repetition is usually uncom ortable or the patient. Subsequent repetitions are
more com ortable and the patient can control the contraction better. Six to 8 repetitions are
used or each trigger point treated. T is technique is empirically based, and research stud-
ies are needed to establish their validity.
Lumbar Facet Joint Sprains

Sprains may occur in any o the ligaments in the lumbar spine. However, the most com-
mon sprain involves lumbar acet joints. Facet joint sprain typically occurs when bending
orward and twisting while li ting or moving some object. T e patients will report a sudden
acute episode that caused the problem, or they will give a history o a chronic repetitive
stress that caused the gradual onset o a pain that got progressively worse with continuing
activity. T e pain is local to the structure that has been injured, and the patient can clearly
localize the area. T e pain is described as a sore pain that gets sharper in response to certain
movements or postures. T e pain is located centrally or just lateral to the spinous process
areas and is deep.
Local symptoms will occur in response to movements, and the patient will usually limit
the movement in those ranges that are pain ul. When the vertebra is moved passively with
a posterior–anterior or rotational pressure through the spinous process, the pain may be
provoked.

T e treatment should include the standard protection, ice, and compression as mentioned
previously. Both pulsed ultrasound and electrical stimulation could also be used similarly
to the treatment o muscle strains but localized to the specif c joint area.
Joint mobilization using posterior–anterior glides (see Figure 13-36) and rotational
glides (see Figures 13-38 and 13-39) should help reduce pain and increase joint nutrition.
T e patient should be instructed in segmental spinal stabilization exercises using transversus
abdominis and lumbar multif di coactivation and good postural control (see Figures 28-3
to 28-10). Strengthening exercises or abdominals (see Figures 28-23 to 28-25) and back
extensors (see Figures 28-17 to 28-20) should initially be limited to a pain- ree range. Stretch-
ing in all ranges should start well within a com ort range and gradually increase until trunk
movements reach normal ranges. Patients should be supported with a corset or range-limit-
ing brace, which should be used only temporarily until normal strength, muscle control, and
pain- ree range are achieved.19,45,46,83,84 It is important to guard against the development o
postural changes that might occur in response to pain.
Hypermobilit y Syndromes (Spondylolysis/Spondylolist hesis)

Pat homechanics
Hypermobility o the low back may be attributed to spondylolysis or spondylolisthesis.
Spondylolysis involves a degeneration o the vertebrae and, more commonly, a de ect in
the pars interarticularis o the articular processes o the vertebrae.52 T is condition is o ten
attributed to a congenital weakness, with the de ect occurring as a stress racture. Spon-
dylolysis might produce no symptoms unless a disk herniation occurs or there is sudden
trauma such as hyperextension. Commonly spondylolysis begins unilaterally. However,
i it extends bilaterally, there may be some slipping o one vertebra on the one below it.
A spondylolisthesis is considered to be a complication o spondylolysis o ten resulting in
hypermobility o a vertebral segment.21 Spondylolisthesis has the highest incidence with L5
slipping on S1.52
Injury Mechanism
Movements that characteristically hyperextend the spine are most likely to cause this
condition.52

he patients usually have a relatively long history o eelin g “som ething go” in their
back. T ey complain o a low back pain described as a persistent ache across the back
(belt type). T is pain does not usually inter ere with their workout per ormance, but is usu-
ally worse when atigued or a ter sitting in a slumped posture or an extended time. T e
patients may also complain o a tired eeling in the low back. T ey describe the need to
move requently and get temporary relie o pain through sel -manipulation. T ey o ten
describe sel -manipulative behavior more than 10 times a day. T eir pain is relieved by rest,
and they do not usually eel the pain during exercise. On physical examination, the patient
usually will have ull and painless trunk movements, but there may be a wiggle or hesita-
tion in orward bending at the midrange. On backwards bending, movement may appear to
hinge at 1 spinal segment. When extremes o range are maintained or 15 to 30 seconds, the
patient eels a lumbosacral ache. On return rom orward bending, the patient will use thigh
climbing to regain the neutral position. On palpation there may be tenderness localized to
1 spinal segment.52,64

Patients with this problem will all into the reinjury stage o back pain and may require
extensive treatment to regain stability o the trunk. T e patient’s pain should be treated
symptomatically. Initially, bracing and occasionally bed rest or 1 to 3 days will help reduce
pain. T e major ocus in rehabilitation should be on segmental spinal stabilization exer-
cises that control or stabilize the hypermobile segment (see Figures 28-3 to 28-10). Pro-
gressive trunk-strengthening exercises, especially through the m idrange, should be
incorporated. Core stabilization exercises that concentrate on transversus abdominis
behavior and endurance should also be used (see Chapter 15).33,34,36,48,60,62,67-69 T e patient
should avoid manipulation and sel -manipulation as well as
stretching and exibility exercises. Corsets and braces are ben-
ef cial i the patient uses them only or support during higher-
level activities and or short (1- to 2-hour) periods to help with
pain relie and atigue (see Figure 28-56).31,73 Hypermobility o
a lumbar vertebrae may make the patient more susceptible to
lumbar muscle strains and ligament sprains. T us it may be nec-
essary or the patient to avoid vigorous activity. T e use o a low
back corset or brace might also make the patient more com ort-
able (see Figure 28-56).32
Disk-Relat ed Back Pain

Pat homechanics
T e lumbar disks are subject to constant abnormal stresses stem-
ming rom aulty body mechanics, trauma, or both, which, over
a period o time, can cause degeneration, tears, and cracks in the
annulus f brosus.13 T e disk, most o ten injured, lies between
the L4 and L5 vertebrae. T e L5-S1 disk is the second most com-
monly a ected.80
Injury Mechanism Figure 28-56 A lo w e r-lumbar co rse t o r

brace
T e mechanism o a disk injury is the same as that or the lum-
bosacral sprain— orward bending and twisting that places
abnormal strain on the lumbar region.77 T e movement that produces herniation or bulging
o the nucleus pulposus may be minimal, and associated pain may be signif cant. Besides
injuring so t tissues, such a stress may herniate an already degenerated disk by causing the
nucleus pulposus to protrude into or through the annulus f brosis. As the disk progressively
degenerates, a prolapsed disk may develop in which the nucleus moves completely through
the annulus. I the nucleus moves into the spinal canal and comes in contact with a nerve
root, this is re erred to as an extruded disk. T is protrusion o the nucleus pulposus may
place pressure on the spinal cord or spinal nerves, causing radiating pains similar to those
o sciatica, as occurs in piri ormis syndrome. I the material o the nucleus separates rom
the disk and begins to migrate, a sequestrated disk exists.80

Patients will report a centrally located pain that radiates unilaterally or spreads across the
back. T ey may describe a sudden or gradual onset that becomes particularly severe a ter
they have rested and then tried to resume their activities. T ey may complain o tingling or
numb eelings in a dermatomal pattern or sciatic radiation.76 Forward bending and sitting
postures increase their pain. Patients’ symptoms are usually worse in the morning on f rst
arising and get better through the day. Coughing and sneezing may increase their pain.80
On physical examination, the patient will have a hip-shi ted, orward-bent posture.
On active movements, side bending toward the hip shi t is pain ul and limited. Side bend-
ing away rom the shi t is more mobile and does not provoke the pain. Forward bending is
very limited and pain ul, and guarding is very apparent. On palpation, there may be ten-
derness around the pain ul area. Posterior–anterior pressure over the involved segment
increases the pain. Passive straight-leg raising will increase the back or leg pain during
the f rst 30 degrees o hip exion. Bilateral knee-to-chest movement will increase the back
pain. Neurologic testing (strength, sensory re ex) may be positive or di erences between
right and le t.80
TREATMENT OF DISK-RELATED BACK PAIN check demonstrated normal feeling over both lower
extremities. On palpation, she was nontender over all
INJURY SITUATION A 31-year-old mother was attempt- major structures.
ing to put her 2-year-old daughter in the child restraint
seat of her minivan. After picking the child up, she bent PHASE ONE Acute Phase
forward and twisted to get the child into the seat and felt
immediate intense pain in her low back and down the GOALS: Decrease pain, encourage rest, maintain spinal
back of her right leg. Her right leg gave way and she col- segment stability, and create safe, pain-free movement
lapsed to the oor with back and right-leg pain. She was behaviors that minimize the stress on the disk complex.
referred to a therapist for evaluation and treatment by a
family practice physician. Estimated Length of Time (ELT): Days 1 to 3
Functionally she was very guarded and sti look- The patient was treated with 3 days of relative bed rest.
ing. On forward bending, she was very guarded and used She was encouraged to work on spinal segment stability
compensating movement patterns to move from sit to exercises, knees toward chest, and knee-rocking mobili-
stand or standing to lying down. Lumbar spine forward zations while in a at-lying position (supine, side-lying, or
bending and right straight-leg raising provoked central prone). Multiple bouts of the 90/90 position and prone-
back pain that radiated into her right posterior thigh. on-elbows position were used for their positional traction
Backwards bending provoked central pain and was bene t. Activities of daily living were kept to a necessary
restricted at 50% of normal range. Sitting knee exten- level—remain at home, avoid sitting posture. Standing
sion movement with the right leg provoked central pain and walking for brief periods (less than 10 minutes) were
and posterior thigh pain when the knee exion angle allowed. The physician prescribed analgesic and antiin-
reached 60 degrees. Dorsi exion at the ankle and chin to ammatory medications.
chest movement increased this pain. Posterior–anterior
mobilizations to the sacrum and the L5 spinous process PHASETWO Intermediate Phase
increased central back pain and caused some shooting
pain down the right leg. On manual muscle test, trunk GOALS: Decrease pain, encourage motion. Encour-
extension was strong and painless. Left hip extension age rest positions that enhance centralization of the disk
and left hip internal rotation and external rotation were nucleus and provide optimum nourishment for the disk
strong but provoked right posterior leg pain. A sensory complex.

T e patient should be treated initially with pain-reducing modalities (ice, electrical stimu-
lation, rest). T e therapist should then use the lateral shi t correction (see Figure 28-11), ol-
lowed by a gentle extension exercise (see Figure 28-16). T e patient is then sent home with
the ollowing rest and home-exercise program.
T e patient must commit to resting in a at-lying position three to our times a day or 20
to 30 minutes. During that time the patient can use some prone press-up extension exercises,
holding the stretched position or 15 to 20 seconds or each repetition (see Figures 28-13 and
28-14). Another recommended pain-relieving position is the 90/ 90 position—90 degrees o
hip exion and 90 degrees o knee exion (Figure 28-57). Both o these exercises provide very
mild traction to the lumbar spine that enhances the centralization and nourishment e ect
o the at-lying position on the disk, which, in turn, leads to decreased pain and increased
unction. Segmental spinal stabilization exercises can also be incorporated into the rest posi-
tions and may be used concurrently with other modalities (see Figures 28-3 to 28-10).85
T e goal is to reduce the disk protrusion and restore normal posture. When posture,
pain, and segmental spinal control return to normal, the core stabilization exercises should
be emphasized and progressed. T e patient may recover easily rom the f rst episode, but i
repeated episodes occur, the patient should start on the reinjury stage o back rehabilitation.
When the patient changes positions—sit to stand or lying to stand—the patient should
do a lateral shi t sel -correction (see Figures 28-12 and 28-16), ollowed by a segmental
Estimated Length of Time (ELT): Day 4 to Week 4 Estimated Length of Time (ELT): Week 5 to 6 Months
After 3 days, the patient was encouraged to come to the The patient was reevaluated, and speci c exibility and
physical therapy clinic for treatment, once a day. The strengthening problems were identi ed. Tight muscle
above activities were preceded with the comfort modali- groups were stretched 3 or 4 times a day, weak muscle
ties of hot packs and electrical stimulation. Spinal seg- groups were isolated and progressively strengthened.
ment stabilization was reassessed, and the patient started Spinal segment stability and core stability were stressed
on the beginning-level core stability exercises. The patient with more challenging exercises. Normal strength and
was instructed to be at-lying for 20 to 30 minutes 4 times conditioning exercises were encouraged, but technique
daily and to continue to minimize time spent in sitting was monitored closely and the patient was encouraged to
postures. At 1 week, the patient was encouraged to walk use spinal segment stability coactivation patterns in every
for conditioning and movement purposes, starting with exercise. Functional activities of daily living drills were
10 minutes and working up to 30 minutes. The walking begun, with the patient being encouraged to incorporate
was followed by at-lying and positional traction peri- spinal segment coactivation patterns into her motor plan-
ods of 20 to 30 minutes. The core stability exercises were ning for each drill.
gradually progressed to continue to challenge strength
and endurance as the pain became more manageable. At Criteria for Return to Function
3 weeks, more functional exercises were included. Squats, 1. The patient demonstrates good spinal segment
balance activities, and light weight lifting (no axial load- control in the physical therapy clinic.
ing) were begun. Flat-lying postures, 4 times daily, were 2. The patient has normal exibility and strength in her
encouraged. At 4 weeks, the patient was instructed to lower extremities.
gradually increase sitting times, guided by comfort.
3. Functional performance test scores are at least 90%
of previous baseline scores.
PHASETHREE Advanced Phase
4. The patient tolerates 1 to 1.5 hours of exercise with
GOALS: Maximize core stability strength and endur- no symptoms.
ance, retrain functional movement patterns to include 5. The patient demonstrates in exercises that she
spinal segment and core stability, return normal exibility can perform the activities of daily living with no
and strength to lower extremities, and encourage good noticeable compensatory movement patterns.
mechanics in activities of daily living.
spinal coactivation contraction (see Figures 28-8 to 28-10).

Some gentle exion exercises, low back corsets, and heat
wraps may make the patient more com ortable.
I the disk is extruded or sequestrated, about the only
thing that can be done is to modulate pain with electrical
stimulation. Flexion exercises and lying supine in a exed
position may help with com ort. T e use o a low back cor-
set or brace may also make the patient more com ortable
(see Figure 28-56). Sometimes the symptoms will resolve
with time, but i there are signs o nerve damage, surgery
may be necessary.85
Sacroiliac Joint Dysfunct ion

A sprain o the sacroiliac joint may result rom twisting Figure 28-57 The 90-90 po sitio n
with both eet on the ground, stumbling orward, alling
backwards, stepping too ar down and landing heavily on The patient is positioned back-lying with hips flexed to
one leg, or orward bending with the knees locked during 90 degrees and knees supported at 90 degrees by stool
li ting.45 Activities involving unilateral orce ul movements or pillows.
are the usual activities associated with the onset o pain. Any o these mechanisms can pro-
duce stretching and irritation o the sacroiliac, sacrotuberous, or sacrospinous ligaments.48

T e patient will report a dull, achy back pain near or medial to the PSIS, with some associ-
ated muscle guarding. T e pain may radiate into the buttocks or posterior lateral thigh. T e
patient may describe a heaviness, dullness, or deadness in the leg or re erred pain to the
groin, adductor, or hamstring on the same side. T e pain may be more noticeable during
the stance phase o walking, on stair climbing, and rolling in bed.89
Side bending toward the pain ul side will increase the pain. Straight-leg raising will
increase pain in the sacroiliac joint area a ter 45 degrees o hip motion. On palpation, there
may be tenderness over the PSIS, medial to the PSIS, in the muscles o the buttocks, and
anteriorly over the pubic symphysis. T e back musculature will have increased tone on
1 side. 27,37,70
I a sacroiliac joint is stressed and reaches an end-range position in rotation, the joint
can become dys unctional as pain, mechanical orm-closure locking, and/ or muscle guard-
ing create hypomobility at the joint. T is hypomobility is usually temporary, and o ten
spontaneous repositioning will occur. T is allows the pain to go away and muscle guarding
to disappear. With the joint back to normal alignment, unction returns to normal.37,70
When normal alignment does not spontaneously return, treatment e orts should ini-
tially mobilize or manipulate the joints and then work on spinal segment stabilization to
maintain and improve sacroiliac joint stability. T ese exercises, along with core stability
training are the key to preventing recurrences. T e therapist should consider sacroiliac dys-
unction as a problem with pelvic stability rather than mobility.37,68

Recent studies o sacroiliac joint testing cast severe doubt on our ability to recognize the
postural asymmetries that have been associated with directionally specif c techniques.27,37,70
T e treatment o sacroiliac dys unction has been grounded in the empiricism o doing tech-
niques that reduce pain. Postural asymmetries have given the therapist a starting point or
directionally specif c techniques, but the instruction in deciding on appropriate technique
is to try one and, i the outcome is not satis actory, move on to the next technique, which
may be biomechanically opposite to the f rst technique.19,48 Empirically, these mobiliza-
tions have been used or many years and have demonstrated a good e ect on sacroiliac
dys unctions with an asymmetry o the pelvis and pain. Each technique has about the same
e ect on the pelvis and sacroiliac joints because the joints are part o an arch, and orces at
any point in the arch can be translated throughout the structure to the a ected part o the
arch. T ese stretches should be used only at the beginning stage o treatment to ree the
joint rom the initial hypomobility.89
A posterior innominate rotation may be used to treat sacroiliac dys unction (see
Figure 28-58). T e patient is positioned with legs and trunk moved toward the side o the low
ASIS. T is locks the lumbar spine so that the mobilization e ect will be primarily at the sac-
roiliac joint. T e therapist stands on the side away rom the low ASIS and rotates the patient’s
trunk toward the therapist. T e patient is instructed to breathe and relax as the therapist
overpressures the rotation to take up the slack. T e lower hand contacts the low ASIS and
mobilizes or manipulates the innominate into posterior rotation.64
T e therapist should also mobilize the sacroiliac joint using stretching positions 1 and
2 or the anterior–posterior sacroiliac joint rotation stretch to correct the postural asymme-
try (Figures 28-59 and 28-60).11-13,30,88 T e stretch exercise should be done in 2 or 3 bouts
a day, 3 or 4 repetitions each time, holding the stretch position or 20 to 30 seconds. Spi-
nal segment stability exercises are utilized a ter each stretching bout (see Figures 28-4
to 28-10).68 T ese stretches should not be continued longer than 2 or 3 days. T e spinal
A B
Figure 28-58 Po ste rio r inno minate ro tatio n
A. Starting position. B. Mobilization position.
A B C
Figure 28-59 Sacro iliac stre tch, po sitio n 1
A. Starting position. B. Position for isometric resistance. C. Stretch position.
A B C
Figure 28-60 Sacro iliac stre tch, po sitio n 2
A. Starting position. B. Position for isometric resistance. C. Stretch position.

TREATMENT PROTOCOL TO CORRECT SACROILIAC stretching and the strengthening exercises 3 times a day.
DYSFUNCTION He was also given analgesic medicine to make him more
comfortable.
On day 2, stretching was continued and the stretch-
INJURY SITUATION A 47-year-old male was crossing an
ing exercise load was increased by adding repetitions.
intersection when he stepped o the curb onto his left
A stretching program was begun for the hip abductors,
foot and misjudged the height. He felt immediate sharp
hip internal rotators, hip exors, and hamstrings. His
pain in his low back. He was referred to physical therapy
usual weight-lifting session was modi ed to a non-
for evaluation and treatment. The patient complained of
weightbearing program. His conditioning workout was
mild pain and a sti -tight feeling in his left groin area, with
done on the exercise bike and in the pool. Hot packs
hip exion and adduction, increasing his discomfort. His
were applied to the adductor area preliminary to the
previous medical history was unremarkable for hip, sacro-
exercise and stretching programs. The sacroiliac area was
iliac, or muscle problems, and he was in excellent physical
treated with ice and electrical stimulation at a moderate
condition with no other injuries at this time.
sensory intensity.
Functionally, the patient walked with a reduced stride
On day 3, stretching was discontinued. Strengthening
length on the left, which produced a mild limp. Walking
was increased with the addition of elastic resistance to hip
produced some mild left groin pain, and stair climbing
abduction and adduction. Functional exercises were initi-
increased this pain in his left groin. Range of motion was
ated, including line walking, minisquats, and side shu e
assessed. Lumbar spine range was full in all ranges, but
with tubing resistance. Modalities remained the same.
side-bending left and backward bending created pain in
the left sacroiliac region. Holding the backward bent posi- PHASETWO Intermediate Phase
tion created some left groin pain similar in nature to the
pain that occurred initially. Passive hip range of motion GOALS: Increase spinal segment awareness, core stabi-
was full in all ranges, with mild groin pain provoked on the lization strength, return to functional exercises, and return
end range of exion, abduction, and internal rotation. On to practice and play status.
manual muscle test, hip exion and abduction were strong
but produced pain in the left groin similar in nature to Estimated Length of Time (ELT): Days 4 to 7
the presenting pain. Right and left straight-leg raise tests
Pain modalities were continued. Stretching exercises
were positive for left groin pain. Bilateral knees-to-chest
to the left hip abductors, exors, and internal rotators
test was full-range and painless, as were the stress test of
were continued. Strengthening exercises continued with
iliac approximation, iliac rotation, and posterior–anterior
increased repetitions, resistance, and di culty. Hot packs
spring test. On palpation, there was mild tenderness along
and electrical stimulation were continued, as were the spi-
the left sacroiliac joint and over the left gluteus medius
nal segment and core stabilization exercises.
just lateral to the PSIS (posterior superior iliac spine). The
hip abductors, hip exors, and hamstring muscles were PHASETHREE Advanced Phase
nontender but had increased tone.
GOALS: Maintain spinal segment strength, increase
PHASE ONE Acute Phase core strength, and return to normal exercise routines.
GOALS: Modulate the pain, stretch, and strengthen Estimated Length of Time (ELT): Day 8 to 6 Weeks
the sacroiliac joint to return them to a more symmetric Postinjury
position.
Pain modalities should be used if needed. Tight muscle
Estimated Length of Time (ELT): Days 1 to 3 groups should continue to be stretched two or three times
a day. Strengthening routines should become more chal-
The patient was treated with stretching to bring his sac- lenging but not more time-consuming.
roiliac joints into symmetric positions. Spinal segment
stabilization was initiated along with beginning core sta- Criteria for Return to Function
bilization exercises (hip-lift bridges, isometric hip adduc- The patient demonstrates that he can perform functional
tion ball squeezes). The left groin and sacroiliac area were activities and activities of daily living with no noticeable
treated with ice. The patient was instructed to repeat compensatory movements.
segmental stabilization exercises are continued to try to instructed to relax the hip and leg and allow the leg to
create the behaviors that stabilize the sacroiliac joints and drop toward the oor. As the patient relaxes, the thera-
strengthen the muscles that support the joint. T e exer- pist applies a gentle overpressure to the oot and takes
cises should be progressed to include more core stabiliza- up the slack as the patient allows the hip and leg to drop
tion and unctional training, leading to return to sports. urther to the oor.
Corsets and pelvic stabilizing belts are also help ul during In the position 2 stretch (see Figure 28-60), the patient
higher-level activities and/ or i the patient is having prob- is positioned on either the right or le t side. T e patient is
lems with recurrences (see Figure 28-56).64 side-lying with the trunk rotated so that the lower arm is
Sacroiliac stretch positions 1 and 2 that will help behind the hip and the upper arm is able to reach o the
realign the patients’ pelvis when they are having sac- table toward the oor. Both knees and hips are exed to
roiliac dys unction. Position 1 (see Figure 28-59) and approximately 90 degrees. T e patient’s knees are sup-
position 2 (see Figure 28-60) stretches can be done in ported on the therapist’s thigh. T e therapist also sup-
both right side-lying and le t side-lying positions. T e ports the eet in this stage o the stretch.
starting position o the position-1 stretch is side-lying Be ore beginning the stretch component o the posi-
with the upper hip exed 70 to 80 degrees and the knee tion 2 stretches, the therapist provides isometric resis-
exed approxim ately 90 degrees (see Figure 28-59). tance to li ting both legs toward the ceiling, holding the
T e patient’s trunk is then rotated toward the upper contraction or 5 seconds. T e patient is instructed to
side as ar as is com ortable. T e patient is instructed exhale while relaxing the legs and allowing them to drop
to li t the top leg into hip abduction and internal rota- toward the oor. T e therapist adds a light pressure to the
tion, and resist the therapist or 5 seconds. T e patient eet and shoulder blade area to guide the stretch and take
is instructed to breathe and exhale as the therapist gen- up slack. T e therapist holds the patient in a com ortable
tly overpressures the trunk rotation. T e patient is then maximum stretch or 20 to 30 seconds.
SUMMARY
1. T e low back pain that patients most o ten experience is an acute, pain ul experience
o relatively short duration that seldom causes signif cant time loss rom practice or
competition.
2. Regardless o the diagnosis or the specif city o the diagnosis, a thorough evaluation o
the patient’s back pain is critical to good care.
3. Back rehabilitation may be classif ed as a 2-stage approach. Stage I (acute stage) treat-
ment consists mainly o the modality treatment and pain-relieving exercises. Stage II
treatment involves treating patients with a reinjury or exacerbation o a previous prob-
lem. In patients meeting the clinical prediction rule or being included in a manipula-
tion treatment group, spinal manipulation should be initiated early in stage I.
4. Segmental spinal stabilization and core exercise should be included in the exercise
plan o every patient with back pain.
5. T e types o exercises that may be included in the initial pain management phase in-
clude the ollowing: lateral shi t corrections, extension exercises, exion exercises, mo-
bilization exercises, and myo ascial stretching exercises.
6. It is suggested that the therapist use an eclectic approach to the selection o exercises, mix-
ing the various protocols described according to the f ndings o the patient’s evaluation.
7. Specif c goals and exercises included in stage II should address which structures to
stretch, which structures to strengthen, incorporating segmental spinal stabilization
into the patient’s daily li e and exercise routine, and which movements need a motor
learning approach to control aulty mechanics.
8. T e rehabilitation program should include unctional training that may be divided into
basic and advanced phases.
9. Back pain can result rom 1 or a combination o the ollowing problems: muscle strain,
piri ormis muscle or quadratus lumborum myo ascial pain or strain, myo ascial trigger
points, lumbar acet joint sprains, hypermobility syndromes, disk-related back prob-
lems, or sacroiliac joint dys unction.
10. Cervical pain can result rom muscle strains, acute cervical joint lock, ligament sprains,
and various other problems.
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Rehabilitation
Considerations for
the Older Adult
Jo le n e L. Be n n e t t a n d M ich a e l J. Sh o e m a k e r
O BJJEC
C T IVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Describe the facets of the normal aging process in terms of successful aging.
Identify and apply common principles for managing older patients/clients with orthopedic
disorders.
Describe system changes that occur predictably with aging, inactivity and disease.
Describe musculoskeletal injuries common to the geriatric population and the related treatment
principles.
Discuss and describe key elements of the history and physical examination for the rehabilitation
of the older patient/client that may differ from younger patient/client populations.
Understand the importance of rehabilitation for targeted functional outcomes and maintenance
of functional independence in the geriatric population.
PART 5 Special Consideration for Speci c Patient Populations

988 Chapte r 29 Rehabilitation Considerations for the Older Adult
Rehabilitative care o older adults has evolved into a specialty area o practice or many
clinicians. Geriatrics, or the care o the older adult, is based on the recognition that the
aging process causes the body to respond dif erently to injury, disease, and medical care
than when it was younger. T e eld o geriatrics continues to gain attention as a result o the
rapid growth o this segment o the population and its predicted socioeconomic impact in
the present century.
raditionally, demographers have used the age o 65 years to delineate an individual
reaching “old age.” Reasons or this delineation include established social practices, such as
retirement rom work, and eligibility or bene ts such as Social Security and Medicare. T is
segment o the population is growing steadily, both in absolute numbers and in propor-
tion to the total population. A tremendous increase in the number o individuals reaching
“old age” is projected to occur during the next 40 to 50 years. In 1900, there were 3 million
persons aged 65 years and older in the United States, representing 4% o the total popula-
tion. In 1988, the number o persons age 65 years and older grew to 31.6 million or 12.7% o
the total population.76 It is estimated that in 2030, more than 70 million individuals will be
older than the age o 65 years, representing nearly 20% o the population.81 T is dramatic
growth is a result o the large cohorts born during the post-World War II “baby boom” that
will be reaching old age, and the improved survivorship in all age cohorts, especially those
regarded as the oldest-old at 85+ years. T e number o older adults age 85 years or older is
predicted to triple in number by 2014.14 Since the mid-19th century, li e expectancy in the
United States has nearly doubled, rom 40 years to almost 80 years,73 because o both medi-
cal and scienti c breakthroughs and improved health habits. However, or the rst time in
history, li e expectancy at birth has the potential to decline as a result o the ef ects o wide-
spread, chronic diseases associated with obesity.65 T us, the United States may be aced
with a large number o older adults with a greater amount o comorbidity.
T e ability to move is a prerequisite to unctional independence, and unctional inde-
pendence is considered to be a large contributor to quality o li e with aging. Pain and mus-
culoskeletal impairments can lead to disability among older Americans, and at least 39% o
Medicare enrollees have at least 1 health-related activities o daily living (ADL) disability17
and 47% report a di culty with walking.75 Given the projected increase in the number o
older adults, the greater severity o comorbidity, and the expected prevalence o movement
dys unction, physical therapists have a critical role in helping older adults age success ully.
Orthopedic care o older adults requires the clinician to utilize a unique perspective
that is dif erent rom that used when caring or younger adults. T e impact o pain and mus-
culoskeletal impairment on unction is o ten underreported and incorrectly attributed to
normal aging, and multiple comorbidities require care ul consideration or providing sa e
and ef ective care. T is chapter provides a perspective rom which to view the older adult
patient/ client, in addition to speci c considerations or the orthopedic rehabilitation o
older adults.
Key Components of Geriatric Assessment

T e ollowing key components o geriatric assessment represent concepts unique to the
older adult that should be considered when examining and developing an intervention
plan or the older adult. Pain and impairments associated with musculoskeletal conditions
such as osteoarthritis can have signi cant ef ects on unctional status, quality o li e, and
the ability to continue to live independently in the community i the presenting clinical
problem is not comprehensively addressed by the physical therapist. able 29-1 presents
the respective historical and examination data that should be considered or each key
assessment component.
Key Components of Geriatric Assessment 989
Table 29-1 Histo ry and Examinatio n Strate g ie s to Addre ss Ke y Co mpo ne nts

o f the Asse ssme nt o f Olde r Adults
Asse ssme nt Co mpo ne nt Histo ry o r Examinatio n Strate g y
Physiologic reserve capacity Utilize impairment- and performance-based measures

and preclinical decline with normative values
• Timed Up and Go
• Timed chair rise
• Stair-climbing test
• Six-minute walk test
Ask about task modi cation: time to complete,
compensatory strategy, or decreased frequency
Frailty In the history and examination, consider:

• Gait speed
• Grip strength
• Changes in activity level
• Self-reported exhaustion/fatigue
• Weight loss
Differentiating between the Consider the impairments noted during the examination
effects of aging vs. disuse vs. in light of the patient/client’s clinical course and medical
disease history
Polypharmacy Review the medication list and be alert to common side

effects and signs/symptoms not consistent with the
known medical history
System-speci c considerations: Screen for risk factors of cardiovascular disease

Cardiovascular Measurement of vital signs at rest and during exercise
Assess for symptoms of vascular claudication
Consider risk of thromboembolic disease
Pulmonary Assess for appropriate respiratory response to exercise
Sensory Assess sensory function and organization (sensory testing,

vision screening, balance performance with con icting
sensory information)
Ask about fall history and ability to rise from the oor
Neuropsychological Screen for dementia (MMSE or SLUMS)

Screen for depression (GDS)
Musculoskeletal Screen for risk factors of osteoporosis
GDS, Geriatric Depression Scale; MMSE, Mini-Mental State Examination; SLUMS, St. Louis University Mental Status
Examination.
Physiologic Reserve Capacit y

Nearly all body systems demonstrate age-related changes, resulting in a reduced physi-
ologic reserve and reduced capacity to respond to stress. T us, older persons may require
greater time to recover rom exercise or acute medical illness, or they may be more suscep-
tible to a decline in unctional status. As physiologic reserve decreases, there is a threshold
below which a decline in unction becomes evident.18 For example, combined quadriceps
strength o approximately 300 N is required to per orm a sit-to-stand without the use o
the upper extremities.31 Strength below this threshold results in impaired unctional per or-
mance in sit-to-stand activities such as toileting. Another example can be ound with peak
oxygen consumption. Lower aerobic reserve capacity is associated with a reduced ability to
complete ADL’s such as housework, and an aerobic capacity o less than 20 mL kg−1 min −1
is associated with a decline in community ambulation.25
Exam ination o the older adult should consider per ormance on unctional-based
tests compared to established age-related norm s in order to identi y clinically relevant
reductions in physiologic reserve, and interventions should be provided as appropriate
( able 29-2).
T e timed up-and-go test measures the time it takes to stand rom a standard arm-
chair, walk 3 meters, return to the chair, and sit. T resholds that distinguish between levels
o independence with ADL include: independence (<20 seconds), assistance with ADL
(>30 seconds), and varying levels o independence (20 to 29 seconds).68 T e timed up-and-
go test has also been used to assess all risk, but has not consistently been demonstrated to
be sensitive in detecting those patients who are predisposed to alling.
T e timed chair rise is a measure o unctional mobility and lower-body strength.
Several versions o the test have been studied, including the time required to per orm 5 sit-
to-stand repetitions (17-inch high armless chair, no use o the upper extremities), or how
many repetitions can be per ormed in 30 seconds.45,46
T e 6-minute walk test has been used as a measure o exercise tolerance and endur-
ance across a wide variety o musculoskeletal, neuromuscular, and cardiopulmonary
conditions. T e patient/ client is instructed to walk as ar as possible in 6 minutes, and vital
sign response is typically monitored or heart rate, blood pressure, oxygen saturation, and
perceived exertion.4
Com ortable gait speed is a measure o walking ability and balance. Gait speeds o less
than 0.56 m/ s in rail older adults have been associated with an increased risk o recur-
rent alls,82 and speeds less than 0.6 m/ s are strongly associated with poorer health status.77
Com ortable gait speed can be measured over a 10-meter distance with 5 additional meters
be ore and a ter the 10-meter course to allow or acceleration and deceleration.
Although grip strength is not a per ormance-based unctional test, well-established,
age-related normative data exist.28,41,42,60,85 Additionally, grip strength is closely associ-
ated with other unctional measures, development o disability, and mortality,11,12 and also
serves as a key measure or identi ying railty as discussed below.
Preclinical Disabilit y
Given that a marked loss o physiologic reserve in one system can result in unctional loss,
partial loss o physiologic reserve in multiple systems may result in a change in unctional
status, and may be evident be ore a person presents to a clinician with a complaint o
unctional limitation or disability.20 Preclinical disability is a clinically detectable decline
in physical unction, characterized by increased time to complete a task, modi cation o
a task, or a decreased requency o task per ormance.35,37 Consequently, a patient/ client
may report that she only goes shopping once every 2 weeks because it is too atiguing, or
that she occasionally must use the powered cart. T is patient/ client may not recognize
these subtle changes in task per ormance as being important enough to report to a health
care provider, however, she might demonstrate a decline in gait speed and timed up-and-
go per ormance that indicates the potential or continued decline in unction over time. It
is, there ore, important to make determinations about risk o incipient unctional decline
based on objective measurement(s) rather than based on patient/ client sel -report,9,13,84
and to initiate interventions as early as possible to prevent urther decline.
Key Components of Geriatric Assessment 991
Table 29-2 Ag e -Re late d No rmative Value s fo r Functio nal Pe rfo rmance
Me asure s
Ag e Me an (Std De v) [Std Erro r]
60-69 70-79 80-89
Time d up and g o (se c)
Male a 8 (2) 9 (3) 10 (1)
Female a 8 (2) 9 (2) 11 (3)
Combined b 7.24 [.17] 8.54 [.17]
30-Se co nd time d chair rise (re ps)
Male c 15.8 (4.4) 14.3 (4.2) 11.8 (4.3)
Female c 14 (3.75) 12.7 (3.7) 10.8 (4.1)
Combined d 14 (2.4) 12.9 (3.0) 11.9 (3.6)
5-Re pe titio n time d chair rise (se co nds)
Male e 12.7 [.24] 13.4 [.29] 14.7 [.25]
Female e 13.2 [.22] 14.2 [.29] 16.58 [.30]
6-Minute w alk te st (me te rs)
Male a 572 (92) 527 (85) 417 (73)
Female b 538 (92) 471 (75) 392 (85)
Male c 597 (90) 534 (104) 457 (120)
Female c 536 (85) 483 (97) 406 (113)
Co mfo rtable g ait spe e d (m/ s)
Male a 1.59 (.24) 1.38 (.23) 1.21 (.18)
Female a 1.44 (.25) 1.33 (.22) 1.15 (.21)
a Steffen
TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly
people: six-minute walk test, berg balance scale, timed up and go, and gait speeds. Phys Ther. 2002;82:128-137.
b Isles RC, Low Choy NL, Steer M, Nitz JC. Normal values of balance tests in women aged 20-80. J Am Geriatr Soc.
2004;52:1367-1372.
cRikli RE, Jones CJ. Functional tness normative scores for community-residing older adults, aged 60-94. J Aging
Phys Act. 1999;7:162-181.

d Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing
older adults. Res Q Exerc Sport. 1999;70:113-117.

e Ostechega Y, Harris TB, Hirsch R, et al. Reliability and prevalence of physical performance examination assessing
mobility and balance in older persons in the US: data from the Third National Health and Nutrition Examination
Survey. J Am Geriatr Soc. 2000;48:1136-1141.
Frailt y
In contrast to preclinical disability, it is also important to identi y patients/ clients who are
rail, as these individuals are at high risk or a variety o adverse health outcomes, including
imminent nursing home placement, surgical complications, hospitalization, and death.50
T e de nition o railty is currently under debate, although a commonly accepted de nition
is the presence o any 3 o the ollowing 5 characteristics: slow gait speed, impaired grip
strength, sel -reported decline in activity level, sel -reported exhaustion or generalized
atigue, and unintentional weight loss.36,50 Physical therapists are uniquely positioned to
identi y most o these characteristics, provide appropriate rehabilitative interventions, and
make appropriate medical re errals.
Different iat ion Bet ween t he Effect s

of Aging, Inact ivit y, and Disease
T e diagnostic process used by physical therapists includes con rming or re uting hypoth-
eses that attempt to explain why a particular patient/ client presents with movement
dys unction. In the older adult, the history and physical examination must dif erentiate
between the ef ects o aging, inactivity, and disease and the underlying impairments and
unctional limitations that result in movement dys unction. Mild impairments in range o
motion (ROM) may be a result o increased stif ness associated with aging that occurs in
the tendinous or ligamentous structures around a joint. T ey may also be a result o chronic
inactivity and reduced demand on a particular joint or ull ROM. It is also possible that
an acute immobilization contributed to the disuse o a particular joint. Additionally, ROM
impairments may be caused by a pathologic process within the joint or periarticular tissues.
In the older adult, pronounced ef ects o aging, increased likelihood o multiple disease
states, and greater susceptibility to the ef ects o inactivity all require care ul dif erentiation
during the examination.
Polypharmacy
Older persons are more likely to have a num ber o medical problem s and are likely tak-
ing many medications. An excessive number o prescribed m edications is known as poly-
pharm acy. Additionally, it should be noted that older patients/ clients o ten take dif erent
medications prescribed by dif erent physicians, which may contribute to polypharmacy.
It has been reported that 87% o older patients/ clients are taking at least 1 prescrip-
tion m edication and 3 over-the-counter drugs each day.63 T ere is a linear relationship
between the num ber o drugs taken and the increased potential or adverse drug reac-
tions.40 Approximately 19% o hospital adm issions o older persons are attributable to
drug reactions.40 Increased sensitivity to drug ef ects can be a consequence o changes in
drug absorption with age, the number o drugs taken simultaneously, or ailure o health
care providers to take into account the proper way to prescribe and adm inister drugs to
geriatric patients/ clients.
Although there are many potential adverse outcomes o polypharmacy, some are o
particular interest to those who treat geriatric patients and clients. T e ef ects o drugs—
particularly benzodiazepines, barbiturates, and antidepressants—are am ong the risk ac-
tors associated with alls.54 Even i the individual does not suf er a serious all, the threat
o a all is o ten enough to cause one to lim it activity, which results in deconditioning
and unctional decline. Delirium, a tem porary change in attention and consciousness,
may be m istaken or dem entia (a permanent loss o intellectual abilities), when in act it
may be attributable to drug sensitivity. Con usion is especially com mon when drug reac-
tions occur in someone with pre-existing mild dementia. A person suf ering rom a mild
adverse drug reaction that goes undetected or months may experience a gradual reduc-
tion in sel -care skills and independence. Patients/ clients experiencing musculoskel-
etal com plaints o ten are chronic users o nonsteroidal antiin am matory drugs, which
can cause gastric bleeding. Narcotics may result in oversedation and loss o unctional
ability.56
System Changes with Aging, Inactivity, and Disease 993
T e primary care physician should regularly monitor all medications taken by older
adults. T e physician needs to know what drugs the patient/ client is taking so that the
physician can eliminate duplications and generally be aware o and avoid adverse ef ects
o drug interactions. A thorough history o the older adult seeking rehabilitation services
should include a list o current medications. One should consider adverse reactions when
evaluating acute changes in unctional ability and mentation. Patients/ clients and amilies
should be instructed to keep all medications in the original containers, never mix several
drugs in one bottle, and throw away what is no longer in use.
System Changes with

Aging, Inactivity, and Disease
Cardiovascular Syst em
With age, there is a decrease in maximal heart rate, a mild decrease in stroke volume, and
reduced arteriovenous O2 dif erence that contribute to a reduction in maximal oxygen con-
sumption (VO2max) by approximately 5% to 15% per decade a ter age 25.69 Activity level,
however, can either mitigate or exacerbate this loss. Older adult subjects have demon-
strated gains in VO2max comparable to younger subjects when placed on an exercise or train-
ing program. Acute inactivity, such as that which occurs with hospitalization, can account
or drastic reductions in VO2max. Increased blood viscosity ( rom uid loss and subsequent
increase in hematocrit) and venous stasis increase the risk o thromboembolic disease. Car-
diac diseases, such as coronary artery disease and the sequelae o myocardial in arction
and cardiomyopathy, will greatly reduce VO2max. Peripheral arterial vascular disease can
substantially reduce walking tolerance through muscle ischemia and claudication pain.69
T e impact o these changes on unction is o great concern. First, with a reduction in
activity tolerance, there is a tendency in older adults or urther activity curtailment, result-
ing in urther deconditioning and exacerbation o disease. Following hospitalization, older
patients/ clients may sustain a signi cant decline in unction. Up to 35% o older patients/
clients admitted to acute care demonstrated a decline in ADL
by discharge.23 T ose patients/ clients with cardiovascular dis-
ease and a history o inactivity are at a much greater risk o an
Table 29-3 Risk Facto rs fo r Cardio vascular
Dise ase
adverse event during exercise; there ore, care ul consideration,
screening, and monitoring must occur to ensure sa ety during a
rehabilitation program.
Modi able Risk Factors
In a direct access setting, physical therapists must be able Age >55 years for males, >65 years for females
to screen or risk actors o cardiovascular disease, per orm Stress
and interpret a cardiovascular history, and sa ely account or Smoking
cardiac disease by modi ying exercise programs and making Hypertension
appropriate re errals to other practitioners. Because o the high Hyperlipidemia
prevalence o cardiovascular disease in older adults, it is essen- Physical inactivity
tial that physical therapists in orthopedic practice screen or
Nonmodi able Risk Factors
and assess cardiovascular comorbidities in each patient/ client Age
encounter. able 29-3 highlights modi able and non-modi - Family history
able risk actors or cardiovascular disease. T e American Heart Male gender
Association (adapted by Brooks)15,33 has guidelines or risk clas-
si cation and vital sign monitoring during exercise, and should Other Risk Factors
Diabetes Mellitus
be strongly considered when initiating or progressing exercise
Obesity
in an older adult with known risk actors or cardiovascular dis-
ease ( able 29-4).
Table 29-4 Risk Classi catio n fo r Exe rcise Training and Vital Sig n Mo nito ring
Ame rican He art Stre ss Te st

Asso ciatio n Risk o r Physician
Classi catio n Cle arance Vital Sig n Mo nito ring
A1 No At rest during initial exam.
A2 Yes At rest and during exercise on initial exam only.
A3 Yes At rest and during exercise on initial exam;

consider periodic monitoring.
B Yes At rest and during exercise until safety established,

and whenever intensity is increased.
C Yes At rest and during exercise throughout the

episode of care.
D Yes Exercise for conditioning purposes not

recommended. Monitor vital signs at rest and
during changes in functional activity level.
Class A1: Nonelderly with no symptoms or risk factors.

A2: Elderly patients with less than 2 cardiovascular risk factors.
A3: Elderly patients with more than 2 risk factors.
Class B: Known cardiovascular disease but stable and without resting ischemia or angina.
History of mild heart failure; compensated, stable.
Appropriate vital sign response with activity.
Only mild dyspnea, fatigue, or palpitations with normal, higher level activities (New York Heart Classes I and II).
Class C: Inappropriate vital sign response to activity/exercise.
Moderate to signi cant dyspnea, fatigue, or palpitations with low levels of activity (New York Heart Classes III
and IV).
Known ischemia during exercise testing.
Class D: Unstable ischemia/angina at rest.
Severe valvular stenosis or regurgitation.
Heart failure that is not compensated.
Uncontrolled arrhythmias.
Deep vein thrombosis is another potentially atal cardiovascular disease that requires
consideration by the orthopedic physical therapist. Patients/ clients undergoing orthopedic
surgery with subsequent immobilization o a limb are at particularly high risk or deep vein
thrombosis. T e popular Homan sign is o little clinical value, as it has been demonstrated
to have sensitivity o less than 50%. Wells et al71,83 developed clinical decision rules that
can be particularly use ul in assessing likelihood o the presence o deep vein thrombosis
( able 29-5).
Pulmonary Syst em
Age-related changes in the pulmonary system include reduced chest wall compliance,
decreased lung elasticity, and increased peripheral chemoreceptor sensitivity to respond
to respiratory acidosis.69 T ese changes, however, do not account or limitations in exercise
tolerance. T ere ore, dyspnea not explained by previous medical history, especially in the
absence o a recent cardiac work-up, requires physician re erral.
System Changes with Aging, Inactivity, and Disease 995
Table 29-5 Clinical De cisio n Rule De ve lo pe d by We lls and Co lle ag ue s

to Pre dict Like liho o d o f Pe riphe ral De e p Ve in Thro mbo sis
Active cancer (within 6 months of diagnosis or palliative care) 1
Paralysis, paresis, or recent plaster immobilization of lower extremity 1
Recently bedridden ≥3 days or major surgery within 4 weeks of application 1

of clinical decision rule
Localized tenderness along distribution of the deep venous system a 1
Entire lower-extremity swelling 1
Calf swelling ≥3 cm compared with asymptomatic lower extremityb 1
Pitting edema (greater in the symptomatic lower extremity) 1
Collateral super cial veins (nonvaricose) 1
Alternative diagnosis as likely or greater than that of deep vein thrombosisc 2
Score interpretation:
0: probability of proximal lower-extremity deep vein thrombosis (PDVT) of 3% [95% con dence
interval (CI) 1.7% to 5.9% ]
1 or 2: probability of PDVT of 17% (95% CI 12% to 23% )
3: probability of PDVT of 75% (95% CI 63% to 84% )
a
Tenderness along the deep venous system is assessed by rm palpation in the center of the posterior calf,
the popliteal space, and along the area of the femoral vein in the anterior thigh and groin.
b
Measured 10 cm below tibial tuberosity.
c
Most common alternative diagnoses are cellulitis, calf strain, and postoperative swelling.
Inactivity, especially bed rest, can have signi cant impact on pulmonary unction, pri-
marily as a result o mismatches in ventilation and per usion, reduced alveolar ventilation,
and increased susceptibility to airway closure and secretion retention.
Pulmonary diseases are most responsible or ventilatory limitations that af ect exer-
cise tolerance in the older adult. Diseases such as emphysema and chronic bronchitis com-
prise the diagnoses known as chronic obstructive pulmonary diseases. Restrictive diseases,
including pulmonary brosis, may also account or dyspnea and limited exercise tolerance
in the older adult.69
T e impact o these age-, inactivity-, and disease-related changes in the pulmonary
system on unction o ten results in the downward spiral o activity-curtailment and urther
deconditioning because o dyspnea. T ese patients/ clients may also have complaints about
atigue. Patients with pulmonary disease are also more susceptible to recurrent in ections
and disease exacerbation, leading to requent hospitalization and associated unctional
decline.
Because cardiac disease is requently present as a com orbidity in patients/ clients
with lung disease, the a orem ention ed discussion regarding risk actors and m on itor-
ing is applicable. Additionally, positioning during physical therapy intervention s is a
consideration, as the supine position without an elevated head can result in dyspnea.
Because o a signi cant reduction in exercise tolerance, requent rest breaks, as well
as cueing to increase respiratory depth and decrease respiratory rate, may be needed.
Breath holding should be avoided, and coordination o breathing with m ovem ent should
be encouraged.
Sensory Syst ems

Maintaining an upright posture requires adequate sensory input regarding the body’s posi-
tion in space. Somatosensory, visual, and vestibular in ormation comprise the 3 main sen-
sory systems involved in balance and postural control. Because alls pose such a signi cant
concern or the older adult, o ten resulting in orthopedic injuries, having an understanding
o how age and disease can impact these sensory systems is important or physical thera-
pists managing older patients/ clients with orthopedic dys unction.
Age-related changes in somatosensation include diminished touch, vibration, and
proprioception senses.24 Age-related changes in vision include decreased visual acuity,
contrast sensitivity, dark adaptation, and depth perception.24 Age-related changes in the
vestibular system include reduced sensory hair cells and neurons, which reduces sensitivity
to movement and position.24 Any o these changes alone should not account or clinically
signi cant declines in per ormance. However, when combined with either signi cant age-
related change in multiple systems or disease in 1 or more o the sensory systems, these
changes can contribute to impaired balance and increased all risk.
Somatosensory diseases such as peripheral polyneuropathy associated with diabetes
can contribute to increased all risk and decreased stability, especially on nonlevel sur-
aces and when walking in dark or low-light conditions. Common diseases af ecting vision
include macular degeneration, cataracts, and glaucoma. I the treatment room has win-
dows, make sure the sunlight is not directly in the patient/ client’s eyes. T e patient/ client
should sit with his or her back to the window and the clinician should have the daylight
shining on the clinician’s ace to enhance the visual contrast or the patient/ client. Reduced
visual unction results in di culty maintaining balance on un-level sur aces, and can mark-
edly impair the ability to maintain balance in the presence o vestibular disease. Vestibular
diseases such as vestibular neuritis, Ménière disease, and perilymphatic stula will greatly
reduce the ability to maintain balance and stability in low-light conditions, nonlevel sur-
aces, or in the presence o impaired vision or somatosensation.
Screening or sensory impairment contributions to impaired balance is necessary to
develop optimal compensatory strategies, designing an appropriate balance retraining pro-
gram, or to acilitate re erral to a specialized balance center or other appropriate practi-
tioner. Furthermore, obtaining a patient/ client’s all history is an essential element to the
geriatric history, especially or those orthopedic problems that are the result o a all or
that may contribute to impaired balance and gait disturbances. Orthopedic oot problems,
lower-extremity weakness, and gait disturbances are consistently ound to increase all risk.
Persons with 1 or more alls in the preceding 6 months are at an elevated risk or uture
alls.72,74 Asking about ability to rise rom the oor without assistance is not only an indica-
tor about general mobility; need or instruction in oor trans ers can be determined as well.
Auditory changes with age include high requency hearing loss, reduced speech dis-
crimination, and reduced ltering o background noise.24 A variety o disease processes can
urther reduce conductive and/ or sensorineural hearing unction. Clinicians need to make
an extra ef ort to speak directly to the patient/ client, enunciate clearly, vary the volume o
speech as necessary, reduce background noise, and utilize visual and tactile cues to aug-
ment communication.
Dementia and Depression
Dement ia
Age-related declines in cognitive unction are relatively minimal compared to changes
that occur due to pathology such as Alzheimer disease and vascular dementia, and the
Dementia and Depression 997
Table 29-6 Strate g ie s fo r Pro viding Inte rve ntio n to Co g nitive ly

Impaire d Elde rly
• Simplify instructions, cues (verbal, visual, and tactile), programs, environment.

• Explain in simple terms, in a consistent manner, with frequent repetition.
• Slow down speech, pace of session.
• Avoid change —maintain consistency of therapist, environment, program.
• Accept the patient’s reality—in patients with severe dementia, to the extent practicable,
do not correct the patient’s perception of time, location, and purpose.
• Educate and support the family—include family, if willing, in education on treatment
plan, and home exercise programs. Also be ready to confront denial in the patient
and family about the patient’s cognitive impairments. Encourage seeking out support
groups, respite care, etc.
dementia that occurs with increasing age. Acute changes in cognitive unction (delirium)
do have an element o reversibility, but can o ten contribute to additional, persistent
changes.56
T e unctional impact o cognitive decline is great, and leads to increasing dependence
on others in order to remain in the community, and is highly associated with nursing home
placement. Additionally, cognitive-related ADL changes and loss o unction are diagnostic
eatures o dementia.26
Detection o cognitive decline and initiation o re erral or urther work-up is impor-
tant so that reversible causes can be ruled out, patient/ caregiver education can begin, and
re erral to appropriate resources can be made to minimize the impact on unction. O par-
ticular concern to the orthopedic physical therapist is to ensure that instruction in precau-
tions and home exercise programs be presented simply in order to ensure retention and
ollow-through.56 able 29-6 provides strategies to help with this.
Screening or dementia can be accomplished using the Mini-Mental State Examina-
tion 34 or the St. Louis University Mental Status Examination.78 Both instruments provide
thresholds that can help determine severity o impairment and need or medical re erral.
Depression
Up to 18% o older adults experience depression, and depression is closely associated with
physical disability, chronic pain, and cognitive decline.39 It is essential that symptoms o
depression be recognized and that appropriate re errals be made, especially given the mul-
tiple treatment options that are available, including medication, psychotherapy, and am-
ily therapy. In the older adult, depression is primarily mani ested via physical rather than
emotional symptoms.64 T is places the physical therapist in a key position to help with early
detection o symptoms o depression and the subsequent need or re erral.
T e impact o depression on unction cannot be overstated. T ose with persistent
symptoms o depression have been shown to have up to a 5- old increase in unctional dis-
ability over time, and depression has been shown to negatively impact rehabilitation gains
and unctional status during inpatient rehabilitation.55,83 Depression can also impact cogni-
tive unctioning, and is considered to be a cause o reversible dementia.
Physical therapists may suspect depression in patients/ clients with overt or preclini-
cal unctional decline, especially in the absence o any change in medical status. Symp-
toms o depression also may be suspected in patients/ clients who are having trouble with
concentration, retention o home exercise programs, or other signs o cognitive decline.
Additionally, probing questions about stressors, changes, or losses may help with deter-
mining whether depressive symptoms are contributing to the observed cognitive and unc-
tional decline.
T e Geriatric Depression Scale is available in both 30- and 15-item ormats.2,87 T resh-
olds or both ormats are available to indicate the possible presence o depression that can
guide medical re erral.
Musculoskeletal System
T e biologic and mechanical behaviors o all o the musculoskeletal so t tissues—including
skeletal muscle, articular cartilage, intervertebral disks, tendons, ligaments, and joint
capsules—are altered with age.
Skelet al Muscle
Loss o skeletal muscle mass with age is well documented. Muscle size decreases an aver-
age o 30% to 40% over a li etime and af ects the lower extremities more than the upper
extremities.38 T is decrease in muscle mass is a direct result o a reduction in both muscle
ber size and number that occurs with advancing age and is largely attributed to progres-
sive inactivity and sedentary li estyles.38 Fiber loss appears to be more accelerated in type
II muscle bers, which decrease rom an average o 60% in sedentary young men to below
30% a ter the age o 80 years.53 ype II bers have approximately twice the intrinsic strength
per unit area, and twice the velocity o contraction, o type I bers, and are used primarily
in activities requiring power such as sprinting or strength training and are not stimulated
by normal ADL.
St rengt h Changes
With reduced muscle mass comes a reduction in muscle orce production, strength, and
aerobic tness— requently hallmarks o advancing age. Strength loss may begin slowly
around the age o 50 years and becomes more rapid with advancing age. Strength loss cor-
relates with mass loss until advanced age, at which time ber atrophy may not account
ully or the observed strength loss, suggesting a possible neural in uence. Loss o muscle
strength with age is attributed to muscle ber loss, muscle ber atrophy, and denervation
o muscle bers.67
St rengt h Training
Exercise intensity has been shown to be the most important variable or improving strength
and unction in the older adult.16 High-intensity strength training (60% to 80% o one’s
1-repetition maximum) has been shown to be sa e and result in signi cant gains in muscle
strength, size, and unctional mobility even in the most rail older adult.16 Improvements
in lower-extremity strength positively impacts mobility and independence with ADL.
Sedentary individuals should begin exercise programs at lower initial levels and progressively
increase intensity as tolerance allows. Individuals with arthritic joints may not tolerate large
compressive orces across the joints and will require modi cations in exercise position and
intensity. It is also important to incorporate exercises that work on retraining the easily
atrophied type II bers. Exercises incorporating quicker, more explosive actions are also
necessary to prepare the older adult patient or real li e situations such as tripping on an
obstacle and losing their balance. T ese explosive and reactive type o exercises must be
Bone 999
modi ed or each patient/ client’s level o unction and progress as tolerated, taking sa ety
into consideration with each task.
Articular Cartilage
Morphologic changes in articular cartilage with age include a reduced number o chondro-
cytes, decreased rates o collagen and elastin synthesis, altered composition o bril types,
and reduced water content. Dehydrated cartilage may have a reduced ability to dissipate
orces across the joint, leading to increased susceptibility to mechanical ailure.1 With aging
and increased wear and tear, cartilage may break down, beginning with brillation and
eventually leading to sclerosis o subchondral bone and continued cartilage degeneration.
Some degree o mechanical breakdown seems to be part o the normal aging process, but
severe destruction o cartilage and subchondral bone involvement leads to osteoarthritis
(OA), which is the most common orm o joint disease in the United States. OA can lead to
signi cant impairments in joint unction and marked disability, leading to eventual joint
replacement. Rehabilitation ef orts should include reduction o pain, elimination o joint
stress, maintenance o joint ROM, maintenance o strength and endurance, and improve-
ment in unctional independence.66
Tendon, Ligament and Joint Capsule

T e most prevalent symptom o changes in periarticular connective tissue is loss o exten-
sibility, which results in subsequent reduction in joint motion. Changes in structure and
unction may occur as a result o normal aging and rom disuse and inactivity. In addition,
the tensile properties o some ligament–bone complexes show a decline in tensile stif ness
and ultimate load to ailure with increasing age.86 Degenerative changes in dense brous
tissues may result in spontaneous or low-energy-level ruptures o the rotator cuf o the
shoulder, the long head o the biceps, the posterior tibial tendon, patellar ligament, and
Achilles tendon; they also may lead to sprains o joint capsules and ligaments, including
those o the spine. Care should be taken with explosive, high-energy activities and loading
o joints in the older individual, especially when initiating an exercise program in a previ-
ously sedentary person.
Bone
Bone mineral density is de ned as bone mineral content relative to the area or volume
o bone in the site o measurement and is expressed as g/ cm 2, with 2 g/ cm 2 considered a
normal value. Strength o bone and ability to withstand compressive and tensile orces is
related to bone mineral density. Bone mineral density reductions are known to occur with
age and disuse, as are the strength properties o bone. T roughout li e, women may lose as
much as 35% to 40% o cortical bone and 50% to 60% o trabecular bone.27 Men lose slightly
less bone with age. Reduction o bone mineral density below 1 g/ cm 2 is considered below
the racture threshold and increases the risk o osteoporotic-related ractures.
Ost eoporosis
Osteoporosis is a generalized disease o bone in which there is a marked decrease in the
amount o bone. T e World Health Organization de nes osteoporosis as a decrease in bone
mineral density o more than 2.5 standard deviations below the mean as compared to young
Table 29-7 Risk Facto rs fo r normals. Postmenopausal osteoporosis is caused by a decrease in

De ve lo ping Oste o po ro sis estrogen and results in rapid bone loss 5 to 7 years ollowing the
onset o menopause. Women in this group have a high incidence
o vertebral body ractures with subsequent postural changes, loss
• Age (over 50 years) o body height, and persistent pain and loss o unction. Advanc-
• Genetic factors ing age is among the risk actors or developing osteoporosis
Sex (women > men) ( able 29-7). Age-related osteoporosis occurs equally in men and
Race (white > black) women ages 70 years and greater, and mani ests mainly in hip and
Family history vertebral ractures. Fractures o the proximal humerus, proximal
Body type (small frame > large frame) tibia, pelvis, and metatarsal bones are also common. It may be pru-
• Postmenopause
dent to assume that even asymptomatic older adults may have a
• Nutritional factors
reduction in bone mineral density, as reduced bone mineral den-
Low body weight
sity o as much as 30% may be present be ore being evident on plain
Low dietary intake of calcium
High alcohol consumption radiographs. Exercise and mechanical stress to the bone, along
Eating disorders with estrogen replacement and increased calcium consumption,
High caffeine consumption have been well documented as preventative or the development
• Lifestyle factors and progression o osteoporosis.52 Weightbearing and strength-
Immobilization/inactivity ening exercises have been shown to maintain bone density and
Cigarette smoking reduce the incidence o osteoporosis-related ractures.52 A consis-
• Medical factors tent program o walking may be adequate or the lower extremities
Early menopause and spine, but upper-extremity resistance exercises should also
Medication use: corticosteroids, antacids, be per ormed. For the older individual, sa ety and all prevention
anticoagulants
during exercise are important concerns. T e therapist should be
Menstrual cycle disorders
creative in designing exercises that stress the skeletal system while
ensuring sa ety o the patient/ client.
Many patients/ clients who receive physical therapy have
medical conditions that require long-term corticosteroid use. Corticosteroids assist in the
management o in ammatory and autoimmune illnesses. Un ortunately, long-term corti-
costeroid use results in a signi cant decrease in bone density. Bone density or patients/
clients treated with corticosteroids or periods o 5 years is 20% to 40% less than density or
nontreated control subjects.70 Clinicians need to be aware o their patients/ clients’ use o
corticosteroids because exercise and activity protocols or these patients/ clients may need
to be modi ed in order to prevent ractures rom occurring.
Aging Spine
As noted above, the bone density changes o the spine are signi cant and a normal part
o aging. Other structures that undergo signi cant aging changes within the spine include
the ligaments o the spine, the intervertebral discs, and the zygapophyseal joints. As noted
above, the aging ligaments o the spine are no dif erent than other ligaments in the body,
and they also diminish in tensile strength. T is loss in tensile strength combined with loss o
trunk musculature strength may lead into spinal instability. T e ligamentum avum thick-
ens with aging and it has been demonstrated that there is a 50% increase in thickness in
persons older than 60 years o age.80 T e thickened ligamentum avum occupies valuable
space within the spinal canal and with extension o the spine this ligament can cause spinal
cord compression because it causes narrowing o the canal. T is spinal canal narrowing is
also exacerbated in the older adult patient/ client by the usual aging process o osteophyte
development. Lumbar stenosis is a common diagnosis among the older adult.
T e intervertebral disc also undergoes signi cant changes with aging. T e greatest
changes occur at the nucleus pulposus and the transitional region between the nucleus
pulposus and the annulus brosis. Dehydration o the nucleus pulposus starts to occur by
Fractures in the Older Adult 1001
the age o 40 years and the gelatinous nucleus pulposus becomes rm. T e disc becomes
stif er and this stif ness plays a role in the decreased overall spinal ROM noted in the older
adult. With aging, ssures and cracks begin to appear in the disc and disc herniation may
progress with increased exion loads to the spine while per orming ADL with poor body
mechanics and sustained sitting postures that are common in the older patient/ client. T e
aging discs’ ability to distribute orce is also altered with these physiologic changes, and
thus greater load is placed on the vertebral bodies, zygapophyseal joints, and spinal liga-
ments. T e zygapophyseal joints undergo a degenerative process that is typical o synovial
joints and degeneration o the articular cartilage is noted particularly in the cervical and
lumbar spines.58 Spinal disorders may progress into decreased mobility because o pain and
lower-extremity weakness, and with decreased mobility comes the other unctional de cits
noted in previous sections. It is important or the physical therapist to thoroughly evaluate
the aging client to determine i the pain is musculoskeletal, neurogenic, vascular, or sys-
temic in origin. T e aging process causes dys unction in all o these systems and any one
o these systems may be the cause o spine pain. T e treatment program must look at the
total body and include lower-extremity strengthening and exibility exercise to provide a
oundation that allows the aging client to per orm proper body mechanics. runk stabiliza-
tion exercises must also be incorporated, but the clinician may need to alter the position o
treatment to accommodate areas o weakness or stif ness in the older adult patient/ client.
Fractures in the Older Adult

Fractures are a common occurrence in older adults and are o both medical and socioeco-
nomic importance. Approximately 250,000 individuals older than the age o 65 years experi-
ence a hip racture in the United States each year.79 Hip ractures alone have an associated
mortality rate as high as 50%. Other common racture sites include the proximal humerus,
distal radius, and the vertebral bodies. T ere are many reasons or the increased incidence
o ractures in the older adult, but the 2 primary risk actors are osteoporosis and alls. T ere-
ore, interventions or ractures in the older adult should also include measures to prevent
osteoporosis and reduce the risk or alls. Once a racture has occurred, the clinician must
work toward the restoration o preinjury levels o unction, mobility, and sel -care.
Fract ures of t he Proximal Humerus

Fractures o the proximal humerus account or approximately 4% to 5% o all ractures.10
T eir incidence rises dramatically beyond the th decade o li e and occurs more requently
among women than among men. Existing osteoporosis is a major risk actor or proximal
humeral ractures in the senior population. T e most common mechanism o injury is a all
on an outstretched hand rom standing height or lower. Fractures o the proximal humerus
sustained in this manner are usually through the surgical neck and are nondisplaced or
minimally displaced. When the mechanism involves a direct blow to the shoulder (as in
a all to the side without a protective response), the racture pattern is usually much more
complex.
Classi cat ion

Approximately 85% o ractures at the proximal humerus are nondisplaced or minimally
displaced.21 T e remaining 15% exhibit various racture patterns. Neer developed the most
commonly used classi cation system or these ractures ( able 29-8). T e Neer system clas-
si es ractures according to the number o parts or racture ragments and the degree o
angulation (or malalignment) o the parts. o be classi ed as displaced or angulated, the
Table 29-8 Ne e r Classi catio n Syste m fo r Hume rus Fracture s
Cate g o ry De scriptio n
1-Part Nondisplaced or minimally displaced
2-Part 1 Part displaced > 1 cm or angulated > 45°
3-Part 2 Parts displaced and/or angulated from each other, and from the
remaining part
4-Part 4 Parts displaced and/or angulated from each other
Fracture dislocation Displacement of the humeral head from the joint space with fracture
part must be displaced at least 1 cm or angulated at least 45 degrees.22 T e 4 important

parts that may be displaced or angulated are the head (at the level o the surgical neck or
anatomic neck), the greater and lesser tuberosities, and the sha t. With racture o either o
the tuberosities, the pull o the attached muscles likely will cause displacement o the rac-
ture ragments. Fractures at the level o the anatomic neck requently cause interruption o
blood supply to the humeral head and may result in avascular osteonecrosis.
Treat ment
Many methods o treatment o proximal humeral ractures have been proposed through the
years. T e disability that results rom proximal humeral racture is usually the result o lost
ROM and the development o a rozen shoulder. Shoulder ROM can be lost by angular de or-
mity o the proximal humerus, injury to the rotator cuf , or the development o arthro bro-
sis secondary to prolonged immobilization.22 T e treatment goal or patients/ clients with a
proximal humeral racture is a united racture with pain- ree unction. o achieve this goal,
reasonable restoration o the normal anatomy and early rehabilitation are needed. Fortu-
nately, the majority o proximal humeral ractures are nondisplaced or minimally displaced
and can be satis actorily treated with conservative measures. T e arm is immobilized with
a sling until pain and discom ort decrease. Active exercises or the elbow, wrist, and ngers
should begin immediately to avoid stif ness and disability in these noninjured joints. Initial
immobilization and early motion has been continually described as having a high degree
o success because most proximal humeral ractures are minimally displaced. Because
adhesive capsulitis is a requent complication a ter ractures o the proximal humerus, early
motion exercises should begin as soon as tolerated. ypically, active-assisted exercises can
begin about 1 week a ter the injury. T e patient/ client should wear the sling during periods
o activity (such as walking) or when sleeping until the so t callus has stabilized the rac-
ture ragments (usually 3 to 4 weeks a ter injury). T e patient/ client may remove the sling
while exercising or when inactive (such as resting in a chair). Attention should also be given
to scapular stabilization exercises. T e unction o these muscles is important or normal
scapulohumeral rhythm. As the racture healing approaches a clinical union, strengthening
exercise with external resistance should be added to the overall program ( able 29-9).
Displaced Humeral Fract ures

Displaced ractures are di cult to treat by closed reduction. Even i closed reduction o the
“2-part” and more severe racture is success ul, the rehabilitation program may need to be
scaled back to avoid redisplacement. T is is especially important i the pull o the muscle
Table 29-9 Exe rcise Guide line s fo r Pro ximal Hume rus Fracture s
Pro ble m Exe rcise Time Line
Maintain or Assisted ROM (wand, wall End of in ammatory stage

improve ROM climbs, pendulum) (usually 1 week)
Passive Overhead stretching
(overhead pulley)
Restore strength Submaximal isometrics No risk of fragment displacement,

usually immediate
Full active ROM against gravity X-ray evidence of union, usually
6 weeks
External resistance/isotonics Ability to perform full active ROM
against gravity, X-ray evidence
of union, usually 6 weeks
Maximize Touch top of head, back of Assisted—evidence of callus

function neck, low back Unassisted—X-ray evidence
of union, usually 6 weeks
attachments displaced one o the tuberosities. Fractures classi ed as 2-part and above have
a greater likelihood o operative reduction and internal xation to achieve stable xation.21
For patients/ clients who are undergoing open reduction with internal xation, the
postoperative goals remain the same as with non-displaced ractures: early return to unc-
tion and avoiding the development o adhesive capsulitis. Because o the numerous types
o racture patterns and dif erent surgical xations, exercise guidelines must be individual-
ized and modi ed as needed. In some cases, the surgeon will be con dent that the internal
xation is stable and the patient/ client may progress through the exercise program more
rapidly. In other cases, pace o the rehabilitation program will be slower secondary to com-
minution, osteoporosis, or damage to the vascular supply. Each o these may compromise
stability and/ or delay healing.
Fract ures of t he Dist al Radius

Fractures o the distal radius are one o the most common ractures encountered in ortho-
pedics. T ese ractures constitute 15% o all ractures that result in emergency room visits.30
T e older adult has an increased number o distal radius ractures or 2 reasons. T e rst
is related to the ragility o the bone secondary to postmenopausal osteoporosis. T e sec-
ond is related to the increased incidence o alls in the older adult as compared to younger
individuals. As with proximal humeral ractures in older persons, the usual mechanism o
injury is a all on an outstretched arm.
Classi cat ion

No universally accepted classi cation o distal radius ractures has been developed to date.
o be considered a distal radius racture, the racture must have occurred within 3 cm o the
radiocarpal joint.59 T e Colles racture is the most common type o distal radius racture and
is by de nition a dorsally angulated and displaced racture o the radial metaphysis within
2 cm o the articular sur ace.30 Comminution o the racture is most common in the older
adult. Because o the racture ragment displacement, the majority o these ractures require
some type o reduction to ensure anatomic alignment. Most Colles ractures are managed
by closed reduction and cast xation. Open reduction with internal xation, external x-
ators, or percutaneous pins and plaster may be used or severe cases with displacement.
A Smith racture, conversely, is a volar angulated and displaced metaphyseal racture that
may be intraarticular, extraarticular, or part o a racture dislocation.30 T is type o racture
usually occurs rom a all onto the dorsum o the hand. A Smith racture is o ten very unsta-
ble and may result in signi cant disability a ter it has healed. Carpal tunnel syndrome and
re ex sympathetic dystrophy are potential complications o Smith racture.
Treat ment
General principles or exercise and treatment are similar or both types o distal radial rac-
ture. Nondisplaced ractures are treated nonoperatively. A short arm cast is usually applied
and the racture immobilized or 3 to 4 weeks. I at that time there is radiographic evidence o
healing and the racture site is minimally tender, a removable splint is applied until the area
is nontender. Overall, the most important rehabilitation consideration is early ROM. Full
active ROM exercises or all nonimmobilized joints o the upper extremity should begin as
soon as the racture has been stabilized. T is is most important or the glenohumeral joint in
order to prevent the development o adhesive capsulitis. Although the cast should end at the
proximal palmar crease to allow motion o the metacarpal phalangeal joints, sometimes the
cast limits motion, nonetheless. T ere ore, it is important to move the metacarpal phalangeal
joints as much as the cast will allow. T e patient/ client should also per orm active exercises
o the remaining thumb and nger joints. Strict compliance with active ROM exercises sev-
eral times a day will minimize loss o unction during the immobilization period.
ypically, all immobilization is removed at about 6 weeks postinjury and ROM and
strengthening exercises or the immobilized joints are initiated at this time. Emphasis
should be on restoring motion in wrist extension, orearm supination, thumb opposition,
and nger metacarpal phalangeal joint exion. Restoring wrist extensor and grip strength
exercises is very important to restore unction o the hand and wrist.
With displaced ractures, surgical xation is usually required.30 ypes o surgical xa-
tion include pins in plaster, percutaneous pinning, external xation, and open reduction
with internal xation. Postreduction care will parallel that o nondisplaced ractures.
Fract ures of t he Proximal Femur

Fractures o the proximal emur are common problems or the older population and are
one o the most potentially devastating injuries in the older adult. T e incidence o hip rac-
ture increases a ter the age o 50 years and then doubles or each decade beyond 50 years o
age.48 More than 200,000 hip ractures occur in the United States each year, and the current
mortality rate 1 year a ter hip racture in older adult patients/ clients ranges rom 12% to
36%.48 Mortality is higher than or age-matched individuals without hip ractures, with the
highest mortality rates occurring in institutionalized patients/ clients. A ter 1 year, mortality
rates return to that o age- and sex-matched controls.48
Osteoporosis is a common predisposing actor or hip ractures. As many as 7% o hip
ractures may occur spontaneously.48 T e most common mechanism or injury is a all pro-
ducing a direct blow over the greater trochanter. Following racture, disability and unc-
tional dependence are common. T ere ore, the overall goal o the treatment is to return the
patient/ client to the preinjury level o unction.
Classi cat ion

T e 3 common classi cations o emoral neck ractures are those based on (a) anatomic
location o the racture, (b) direction o the racture angle, and (c) displacement o the rac-
ture ragments. With regard to anatomic location, surgeons divide ractures o the proximal
emur into 3 groups. Femoral neck ractures are located rom just below the articular sur-
ace to just superior to the intertrochanteric area. Intertrochanteric ractures are located
between the greater and lesser trochanters. Subtrochanteric ractures occur in the proximal
sha t below the level o the lesser trochanters. For patients/ clients older than the age o 65
years, 95% o hip ractures are in the emoral neck or the intertrochanteric regions.48
Treat ment
It is generally accepted that surgical management, ollowed by early mobilization, is the
treatment o choice or hip ractures in the older adult.48 Historically, nonoperative manage-
ment resulted in an excessive rate o medical morbidity and mortality as well as malunion
and nonunion in displaced ractures. T e overall goal o treatment or racture o the proxi-
mal emur is to return the patient/ client to the preinjury level o unction as quickly and as
sa ely as possible. Age, cognitive impairment, and coexisting morbidities may impact the
level o independence the patient/ client is able to achieve. T e therapist should develop the
postoperative care on an individual basis in consultation with the physician. Because o the
high degree o variability in racture patterns and postoperative racture stability, ongoing
communication is essential to developing a sa e and ef ective rehabilitation program.
Physical therapy should begin on the rst postoperative day. Patients/ clients who
receive more than 1 physical therapy treatment session per day are more likely to regain
unctional independence and return home.43 T e treatment program should include ROM
and strengthening exercises, training in trans ers and gait with an assistive device, and
training in unctional activities such as ADL. T e exercise program should increase in inten-
sity and di culty until the day o discharge. Some surgeons have recommended restricted
weight bearing until the racture has healed, whereas others have shown that unrestricted
weight bearing can be started immediately without detrimental ef ects in the presence o
stable internal xation. Biomechanical data have shown that non-weightbearing ambula-
tion places signi cant stresses across the hip as a result o muscular contraction at the hip
and knee.48 Gait training with an assistive device should begin on the rst postoperative day.
Distance should be advanced and stair training introduced over the next couple o days.
Ideally, the patient/ client should be able to ambulate well enough to negotiate the indoor
home environment by the time o discharge. Weight bearing as tolerated with a walker is
appropriate or the majority o emoral neck and intertrochanteric racture patients/ clients
treated with operative reduction and internal xation or prosthetic replacement.
Cemented xation o prosthetic replacements allows immediate ull weight bearing,
whereas biologic growth xation may delay ull weight bearing or 6 to 12 weeks. Biologic
growth xation is thought to have a lower xation ailure rate than cemented xation and
is pre erable in younger, more active individuals. For older individuals who are at risk or
greater morbidity and mortality a ter racture, the early weightbearing status af orded by
cemented xation may be desirable. Because there is a greater likelihood o instability and
healing complications with subtrochanteric ractures, patients/ clients with this type o rac-
ture may require a longer period o protected weight bearing. T e patient/ client should
advance to a cane and eventually eliminate the assistive devices when racture healing and
sa ety considerations permit.
During the rst ew weeks o racture healing, emphasis should ocus on active or
active-assistive ROM exercises with gravity eliminated, progressing to ull active motion
exercises against gravity as soon as allowed by adequate racture healing. It is important
that the patient/ client begin the exercise program as tolerated on the rst postoperative
day. T e exercise program should be designed to help prepare the patient/ client or unc-
tional activities. Patients/ clients should per orm the exercises in the supine, sitting, and
standing positions. It is important or the patient/ client to be able to move the operated
limb through a ull ROM against gravity in order to per orm simple ADL, such as bed mobil-
ity and trans ers. In most cases ollowing operative reduction and internal xation, there is
no restriction o the ROM activities. In contrast, patients/ clients who undergo prosthetic
replacement o the emoral head will likely be restricted in the amounts o hip exion (less
than 90 degrees), adduction (0 degrees), and internal rotation (0 degrees) allowed in the
early postoperative period because o hip dislocation risk. Exercises should progress in
intensity each day until the patient/ client can move and control the limb independently.
A ter some healing has occurred (3 to 4 weeks), external resistance may be added, provided
the patient/ client’s strength is good enough to achieve ull ROM against gravity without
assistance. Pain during resistance exercise may indicate that the exercise is too intensive
and should be monitored by the therapist. Restoring hip-abductor and knee-extensor
strength are critical or ambulatory unction a ter hip racture and should receive particular
attention.
Total Joint Arthroplasty

Hip, knee, and shoulder arthroplasty are increasingly common procedures. Replacement
o damaged cartilage sur aces with arti cial weightbearing materials has enabled surgeons
to dramatically improve unction and relieve pain in many patients/ clients. OA is the pre-
cursor to most total joint replacements and it is estimated that the prevalence o OA in the
United States will increase rom 43 million in 1997 to 60 million in 2020.19 Medical advances
have allowed total joint replacements o the hip and knee to become much less invasive in
the last ew years and depending on the type o xation immediate weight bearing o some
degree is possible. T e large volume o in ormation on this topic does not allow or an in-
depth discussion on this topic to occur in this chapter.
Consensus in the research does indicate that therapeutic exercise is the treatment
modality o choice or preoperative and the postoperative care ollowing total joint arthro-
plasties.66 Regarding the initial evaluation either a be ore and a ter elective surgery situation,
it is important to determine the presurgical unctional status o the patient/ client. Items
that are key to know include the patient/ client’s ambulation status, ROM o the involved
joint, unctional tasks such as walking tolerance, the need or upper extremity assist o an
arm chair to stand rom sitting, and the ability to navigate stairs and outdoor items such as
curbs. During this interview process with the patient/ client, it is essential to determine the
personal goals o the patient/ client and what constitutes success in the patient/ client’s eyes.
T e patient/ client struggling with OA has learned how to compensate to accomplish walk-
ing and other ADL, and these patterns o movement have become natural to the patient/ cli-
ent. It is important during the rehabilitation process to identi y these compensation patterns
and work with the patient/ client to modi y these movement patterns to promote a return to
normal and e cient movement. Astenphen et al6 evaluated patients/ clients with mild knee
OA and patients/ clients with severe knee OA and compared their gait with asymptomatic
individuals and determined that both OA groups demonstrated increased midstance knee
adduction moments, decreased peak knee exion moments, decreased peak hip adduction
moments and decreased peak hip extension moments as compared to the control group.
T e severe OA group also demonstrated signi cant kinematic dif erences at the hip knee
and ankle joints. Many other studies have also demonstrated that knee OA patients/ clients
reduce the knee extension moments and decrease their walking speed and stride length
to accommodate to the pain.8,44,47,51 It is important during the later stages o rehabilitation
a ter a total knee or hip replacement that these kinematic de cits be addressed, and exer-
cises should ocus on minimizing knee adductor moments and work on hip extension and
knee extension during the stance to toe of phases o gait. T is may be hard to normalize
because the patient/ client has been so used to compensating or the pain and ROM restric-
tions, but it needs to be addressed to regain the ull higher-level unction that the patient/
client desires. Another biomechanical component that is requently present is a leg-length
Intervention Considerations for Older Adults 1007
asymmetry that may be structural or unctional. Correcting this may involve building a tem-
porary or permanent heel li t or shoe insert to accommodate the asymmetry.
When dealing with hip and knee replacements, ROM is always a key component o the
rehabilitation process. It is essential to regain as much ROM as possible to accommodate
unctional tasks. Patients/ clients undergoing hip replacements will have ROM restrictions
initially and regaining hip ROM seems to be less o a challenge than the patients/ clients
undergoing knee replacement. It is essential to regain ull active knee extension ollowing
surgery and su cient knee exion to accommodate unctional tasks. T e usual expectation
or active knee exion ollowing surgery would range rom 110 to 120 degrees.62 Overall
lower-extremity strength is another essential component o ull recovery rom joint replace-
ment surgery. Many studies demonstrate that quadriceps strength is lowest in the patients/
clients with knee OA who score the highest on the Western Ontario and McMaster Universi-
ties Arthritis Index (WOMAC), which demonstrates the most severe symptoms. Research
also illustrates that the quadriceps strength decreases by 50% to 60% o the preoperative
status just 1 month postsurgery.7,61 I the overall quadriceps strength is de cient prior to
surgery and then decreases even more a ter surgery, it is imperative that the rehabilitation
program include many exercises and other modalities to increase quadriceps strength in
the closed-chain position. Strengthening the other lower-extremity muscle groups, includ-
ing the gluteals and hip abductors, cal muscle group, and hamstrings, is also important in
order to complete the ull rehabilitation program. Each o these muscle groups are needed
to allow proper gait patterns, trans er rom sit to stand and into and out o a car, ascend and
descend stairs, and per orm unctional activities such as squatting; all o which are needed
or e cient movement. All unctional tasks require balance and proper proprioception/
neuromuscular control in order to ensure e cient movements. Concepts regarding balance
retraining interventions are discussed in the ollowing section, and need to be adapted as
appropriate or an individual’s weightbearing status and weightbearing tolerance.
Intervention Considerations for Older Adults

Interventions or most musculoskeletal conditions in the older adult are similar to those
utilized in a younger adult; however, there are several important considerations when pro-
viding interventions or older adults.
Pat ient /Client -Relat ed Inst ruct ion

Patient/ client-related instruction must account or the a orementioned sensory system
impairments with regard to vision (eg, larger print or education materials) and hearing (eg,
slower, well-articulated speech), as well as increased repetition and inclusion o a caregiver
or those with cognitive impairment. T e key to success ul treatment o any dys unction
is the ability and desire o the patient/ client to ollow through with the prescribed exer-
cise program provided by the treating clinician. T rough years o experience in treating the
older adult patient/ client, we have ound that using an analogy o a car and comparing it
to the aging process o the human body is an excellent way to improve adherence, espe-
cially with regard to prevention-related interventions. We all desire to drive a luxury auto-
mobile that is power ul, smooth, e cient, quiet, and reliable. T is can also be said about
our human body. As we age, individual systems o the body, not unlike the systems o the
automobile, can become de cient and af ect the overall per ormance o the entire car. An
example o this may be when the strength and exibility o the lower extremities are dimin-
ished (eg, worn shocks and suspension system o the car), the articular sur aces o the joints
may be more susceptible to degeneration and damage (wear and tear on the tires). Similar
examples can be ound using this human body and car analogy ( able 29-10).
Table 29-10 Similar Example s to the Car Analo gy Using the Human Body
Car Syste m Bo dy Syste m
Shock and suspension system Muscle strength and exibility
Tires Articular cartilage and joints
Engine Cardiovascular and muscular endurance
Air lter and exhaust system Pulmonary system
Car frame Skeletal system
Fluids (gas, oil, coolant, etc.) Hydration and nutrition
Therapeut ic Exercise
T e deleterious ef ects o immobility are well documented. Because o the summative
ef ects o aging on multiple systems, atigue, reduction in sensory in ormation, ear o all-
ing, and ef ects o accumulated disease processes, many older adults experience a gradual
reduction in activity level over time. T is decreased activity sets up a vicious cycle o disuse
and loss o unction. Loss o muscle mass, demineralization o bone, diminished cardiopul-
monary unction, and loss o neuromuscular control have been directly related to lack o
physical activity. Disuse exacerbates the aging process and negatively impacts physiologic
reserve in the ace o disease and injury. Participation in a regular exercise program has
proven to be an ef ective intervention/ modality to reduce or prevent unctional declines
associated with aging. Regular exercise can also provide a number o psychological bene ts
related to preserved cognitive unction, alleviation o depression symptoms, and behavior
and an improved concept o personal control and sel -e cacy.
Participation in a regular exercise program is an ef ective intervention/ modality to
reduce/ prevent a number o unctional declines associated with aging. Older individuals, who
are well into the eighth and ninth decades o li e, respond to both endurance and strength
training. Regular exercise and physical activity contribute to a healthier, independent li e-
style with associated improved unctional capacity and quality o li e. Rehabilitation ollow-
ing injury or illness should include education regarding the bene ts o physical activity and
instruction or the implementation o and sa e participation in a li elong exercise program.
Endurance Training
Endurance training in the older adult is not dif erent than in the younger adult, although
there are some special considerations. First, it is important to appropriately screen the older
adult or risk actors related to cardiovascular disease and adverse cardiovascular events
during exercise as previously outlined. T is is critical to selecting which patient/ client/
client is appropriate or endurance training, determining whether lower intensities are
required, determining whether physician re erral and clearance is needed, and determining
whether closer vital sign monitoring is needed. However, in the absence o increased risk or
signi cant comorbidity, the healthy older adult is able to per orm aerobic training at simi-
lar intensities as younger adults (Figure 29-1). raining intensities up to 80% o maximum
heart rate can be sa ely tolerated in appropriately selected individuals.3 It should be noted
that individuals on beta blocker medications or high blood pressure and/ or cardiovascular
disease will have a blunted heart rate response to exercise, and exercise training intensity
Intervention Considerations for Older Adults 1009
should dictated based upon rating o perceived exertion ( able 29-11)
(Figure 29-2).
St rengt h Training
Similar to endurance training, strength training in the appropriately
selected older adult is not dif erent than in younger adults (Figures 29-3A
and B). An appropriate screening process, as previously outlined, is
critical, and in those individuals without signi cant contraindications,
higher training intensities may be utilized. In act, strength training
results in a dose–response dependent manner as younger individuals,
with the greatest strength gains occurring with high (>80% o 1 repeti-
tion maximum) intensity training.32,57 T e sa ety and e cacy o strength
training in the older adult is well-established.57 With regard to speci c-
ity o training, attention should be given to the speci c mode o exercise
that most closely resembles the unctional de cit or which the strength
training is being used 57 to ensure that strength gains translate into
improved unction (Figure 29-4).
Additionally, unctional training such as inclusion o variable
speed, repeated unctional tasks like sit-to-stand, multidirectional step-
Figure 29-1 The e lliptical training
ping and walking, squatting, and reaching may result in similar strength
machine , an e xce lle nt cho ice fo r
gains as a usual strength training group, but with the additional bene t
ae ro bic e xe rcise in the g e riatric
po pulatio n be cause it is w e ig ht-
be aring , but lo w impact
Table 29-11 Rating o f Pe rce ive d Exe rtio n
This is a scale for effort, exertion, leg fatigue, or breathlessness (whichever symptom is
the most limiting for you). The number 0 represents no effort, exertion, leg fatigue, or
breathlessness. The number 10 represents the strongest or greatest effort, exertion, leg
fatigue, or breathlessness that you have ever experienced. Select a number that represents
your perceived level of effort, exertion, leg fatigue, or breathlessness.
0 Nothing at all
0.5 very, very slight (just noticeable)
1 very slight
2 slight (light)
3 moderate
4 somewhat severe
5 severe (heavy)
7 very severe
10 very, very severe (almost max)
Adapted from: Borg GAV. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377-381.
o greater changes in gait, balance, and coordina-

tion (Figure 29-5).29,49
Balance Ret raining

Requisite to unctional mobility is maintenance
o the center o gravity over the base o support,
which is accomplished through multiple af erent,
central processing, and ef erent pathways. T e pri-
mary af erent pathways include the visual system,
the vestibular system and proprioception. Central
processing pathways generate a variety o strategies
or maintaining and recovering balance depend-
ing on the context and the disturbance and the
environmental and task demands; the motor and
musculoskeletal responses must be activated to
main upright balance. T ese motor responses are
Figure 29-2 classi ed as the ankle strategy, hip strategy, and
stepping strategy. I the disturbance in balance is
Stationary bicycling, an alternative low impact choice for aerobic small, then the ankle strategy is the primary protec-
exercise in the geriatric population. The bicycle is also good for tive response, where the eet remain planted on the
range of motion in the hips and knees. ground and the body moves above the ankle joints.
T e exor muscles at the eet begin the ankle strat-
egy response, progressing upward using sequentially more proximal movers. I larger orces
disturb the center o gravity, the hip strategy is used to maintain balance; where the eet
remain planted but the hips ex and then quickly extend back to neutral to regain balance.
T e muscles activated rst during the hip strategy are the abdominals and quadriceps and
then muscles are recruited caudally. I the balance perturbation is larger than the ankle and
A B
Figure 29-3
A. A senior performing seated resistance training of the upper extremities and postural stabilizers in a seated position.
Caution must be used to ensure proper trunk stability and posture during this exercise. B. A senior performing seated
resistance training of the upper extremities. Caution must be used to avoid postural compensations or the use of
momentum during this exercise.
Case Example 1011

A senior performing closed chain, partial weight-bearing A senior performing standing resistance training for the
strengthening of the lower extremities, important for upper extremities. Caution must be used to promote proper
maintaining functional independence in sit to stand and technique, and avoid substitution or postural compensations
other ADLs. during this exercise.
hip strategies can “manage” then the motor response is a corrective step, stumble, or hop
in order to regain the center o gravity over the base o support. All o these strategies can
be anticipatory or reactive in nature, and both depend on adequate musculoskeletal unc-
tion to prevent a all. T ese motor responses can be improved with many dif erent exercises
and these exercises should be a part o every exercise program involving the older orthope-
dically involved patient/ client. Additionally, balance exercises should include unctional
tasks such as backwards and side-stepping, stepping up to a curb, stepping around and over
obstacles, walking on uneven terrain, and changing gaze and head position during walking.
Case Example
T e ollowing is an example o the principles discussed in this chapter applied to the treat-
ment o an older individual with comorbidities and a typical orthopedic condition. A 75-year-
old male presents to an outpatient orthopedic clinic with a diagnosis o adhesive capsulitis o
the shoulder. T e patient/ client reports the mechanism o injury was when he stumbled on
a throw rug at home and ell onto the oor with the orce directly on his shoulder. T is injury
occurred approximately 4 weeks prior and now his shoulder is stif , pain ul, and weak. T e
patient/ client’s primary complaint is that he cannot move his arm enough to put on his shirt
without help rom his wi e, reach his back pocket, or put on his seatbelt. T e patient/ client
reports he had a contusion in the deltoid region that has now resolved and he had X-rays
and a MRI that ruled out any ractures or rotator cuf tears. His medical history includes an
11-year history o Parkinson disease with no other remarkable comorbidities noted. His age,
gender, and history o hypertension were noted as risk actors or cardiovascular disease.
Based on the history, the physical therapist has 2 dif erent issues that must be con-
sidered. T e patient/ client has the orthopedic injury that started as a hematoma and has
developed into a so t-tissue restriction as a result o patient/ client-induced immobilization
secondary to pain and ear o hurting his shoulder more with activity. Another issue the clini-
cian must consider is the ef ect o Parkinson disease on the patient/ client’s balance and gait,
which may have been the underlying cause o the all. T e examination process must evalu-
ate both the movement dys unction o the shoulder and also the balance and dynamic gait
de cits that are present because o the 11-year history o Parkinson disease. Comprehensive
treatment o this patient/ client includes treating the shoulder dys unction and developing
an exercise program and patient/ client education plan that consider the neurologic issues
associated with Parkinson disease, which can include cognitive de cits, his risk actors or
cardiovascular disease, and his gait and balance de cits. Other issues to consider while treat-
ing this patient/ client are the postural changes that have occurred with this long history o
Parkinson disease and its ef ect on various treatment positions, such as supine, side-lying,
and prone. T e orward head and thoracic kyphosis that typically accompany this neurologic
condition must be accommodated with pillows so as to acilitate a com ortable treatment
posture when lying on the treatment table. It is also important to monitor when the patient/
client takes his medication (eg, levodopa) to control his Parkinson tremors and rigidity. It
would be advantageous to per orm the joint and so t-tissue mobilizations along with the
active exercises during the time rame when the body is at its most relaxed state. T e clinician
will have di culty making therapeutic gains and could put the patient/ client at risk o injury
i the clinician per orms manual therapy techniques to the shoulder when the rigidity o the
muscles is at its highest. T e patient/ client should be able to tell the clinician at which time in
the medication cycle he eels his muscles are the most relaxed, which is the desirable time or
treatment. Gait and balance training should be included, and vital sign monitoring during
the initial exercise session and during increases in exercise intensity should be considered.
T e above example illustrates the challenges present when treating the older adult
patient/ client in an orthopedic setting. T e older adult patient/ client will requently pres-
ent with a “simple” orthopedic injury that is compounded with other comorbidities. T e
physical therapist must consider the big picture and evaluate multiple systems to deter-
mine what unctional de cits are present at the orthopedic injury site (such as shoulder in
above example) and how the aging process and comorbidity af ect the overall unctional
status o the patient/ client. reatment plans must incorporate exercises or both local and
global de cits detected in the evaluation process.
SUMMARY
1. T e eld o geriatrics will continue to grow as the population ages. As li e expectancy
increases, rehabilitation o the physically disabled older adult will become an increas-
ingly essential component o overall geriatric care.
2. T e aging process af ects multiple systems in the body and has a direct impact on the
rehabilitation o acute and chronic musculoskeletal conditions common in the older
adult.
3. Orthopedic conditions are commonly experienced by the older population. Fractures
commonly occur and are o ten the result o osteoporosis and alls. When articular car-
tilage damage is severe or there is chronic joint pain, hip, knee, and shoulder arthro-
plasty are increasingly common procedures speci cally designed to provide patients/
clients with dramatically improved li estyle and unction.
4. Examination and evaluation o older adults must ocus on determining the relative
contributions rom aging, inactivity, and disease on reduced physical unctioning.
5. Emphasis in the rehabilitation program should be placed upon the importance o phys-
ical activity in preventing injury and minimizing unctional decline. Rehabilitation pro-
viders must be aware o the special needs that this population has in order to acilitate
the development o ef ective rehabilitation interventions.
Case Example 1013
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Considerations for the
Pediatric Patient
St e v e n R. Tip p e t t
O B JE CTIVES t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Describe common macrotraumatic and microtraumatic musculoskeletal injuries occurring in the

skeletally immature patient.
Describe selected congenital, acquired, and musculoskeletal pathologies seen in active skeletally
immature patients.
Apply basic rehabilitation principles governing the care and prevention of macrotraumatic and
microtraumatic musculoskeletal injuries in the skeletally immature patient.
Differentiate between categories of growth plate fractures.
Describe physiologic considerations unique to the active skeletally immature patient.
Describe special psychological considerations for the skeletally immature athlete.
Describe participation guidelines for the skeletally immature athlete.
1017
1018 Chapte r 30 Considerations for the Pediatric Patient
Growing musculoskeletal tissue is innately predisposed to specif c injuries that vary

greatly rom the injuries sustained by their skeletally mature counterparts, yet more and
more youngsters are sustaining injuries that years ago primarily occurred in the skeletally
mature athlete.1,19,39 Many injuries that occur in youth sports today can be attributed to the
increased volume o participation by youngsters in a variety o competitions that are sched-
uled by adults.18
T is chapter brie y describes common macrotraumatic and microtraumatic injuries
sustained by the young patient, along with basic principles that govern the treatment o
these injuries. Macrotraumatic injuries occur as a result o a single, supramaximal load-
ing o bone, ligament, muscle, or tendon. Common youth macrotraumatic injuries that are
discussed include epiphyseal and avulsion ractures. Microtraumatic injuries, on the other
hand, result rom submaximal loading that occurs in a cyclic and repetitive ashion. Com-
mon microtraumatic injuries that occur in the immature musculoskeletal system that are
presented include osteochondroses and traction apophysites. Special concerns unique to
the immature musculoskeletal system that do not all neatly into the macrotraumatic or
microtraumatic categories also are presented. Finally, physiologic and psychological issues
unique to the youth patient also are presented.
Macrotraumatic Musculoskeletal Injuries
Epiphyseal Fract ures

Growing bone is the weak musculoskeletal link in the young athlete. Physical demands
resulting in muscle strain or ligament sprain in the skeletally mature patient may result in
epiphyseal plate injury in the young patient. T e epiphyseal plate or growth plate is divided
into zones di erentiated rom one another by their structure and unction. Beginning at
the growth area o long bone and progressing in the direction o mature long bone, the
4 regions o the growth plate are the reserve zone, proli erative zone, hypertrophic zone,
and bony metaphysis. T e reserve zone produces and stores matrix; the proli erative zone
also produces matrix and is the site or longitudinal bone cell growth. T e hypertrophic
zone is subdivided into the maturation zone, degenerative zone, and zone o provisional
calcif cation. It is within the hypertrophic zone that matrix is prepared or calcif cation, and
it is here that the matrix is ultimately calcif ed.48
Injury to the growth plate can occur when stress or tensile loads placed upon bone
exceed mechanical strength o the growth plate–metaphysis complex. wo actors that
impact epiphyseal plate injury are (a) the ability o the growth plate to resist ailure and
(b) the orces applied to bone or the stresses induced in the growth plate. Based upon
results rom animal studies, it has been determined that the weakest region o the growth
plate is the hypertrophic zone. T e hypertrophic zone is susceptible to injury because o the
low volume o bone matrix and high amount o developing immature cells in this region.48
T e majority o epiphyseal ractures are caused by high-velocity injuries. Although
growth plate ractures certainly result rom youth sporting activities, a detailed description
o all epiphyseal plate ractures is beyond the scope o this chapter. A brie description o the
Salter-Harris classif cation o growth plate ractures, along with some o the more common
epiphyseal plate ractures in sports, however, is warranted.
T e Salter-Harris classif cation o growth plate racture consists o 5 types o ractures
and is based upon the relationship o the racture line to the growing cells o the epiphyseal
plate as well as the mechanism o injury (Figure 30-1). ype I ractures are caused by shear-
ing orces in which there is complete separation o the epiphysis without racture through
bone. T ese ractures are most commonly seen in very young people when the epiphyseal
plate is relatively thick. ype II ractures are the most common type o growth plate ractures
Macrotraumatic Musculoskeletal Injuries 1019
and result rom shearing and bending
orces. In the type II racture, the line
o separation traverses a variable dis-
tance along the epiphyseal plate and
then makes its way through a segment
o the bony metaphysis that results in
a triangular-shaped metaphyseal rag-
ment. ype II ractures usually occur in Type I—S e pa ra tion Type II—Fra cture –s e pa ra tion Type III—Fra cture –pa rt
an older child who has a thin epiphy- of the phys is of growth pla te a nd s ma ll of phys is
pa rt of me ta phys is
seal plate. ype III ractures usually
result rom shearing orces and result
in intraarticular ractures rom the joint
sur ace to the deep zone o the growth
plate and then along the growth plate
to its periphery. ype IV ractures are
intraarticular and also result rom shear-
ing orces. T ese ractures extend rom Type IV—Fra cture –phys is Type V—Crus hing of phys is with
the joint sur ace through the epiphysis a nd me ta phys is no dis pla ce me nt–may ca us e
pre ma ture clos ure
across the entire thickness o the growth
plate and then through a segment o the
bony metaphysis. ype V ractures are Figure 30-1 Gro w th plate fracture s acco rding to the
caused by a crushing mechanism and Salte r-Harris classi catio n
31
are relatively uncommon.
Salter-Harris type III ractures war- A. Type I. B. Type II. C. Type III. D. Type IV. E. Type V.
rant special m ention. T ese ractures
are typically limited to the distal tibial
epiphysis.48 Injury to the proximal tibial epiphysis or distal emoral epiphysis may result
rom valgus loading o the knee, which is requently encountered in contact and collision
sports. T e clinician cannot rely solely on radiographic examination to conf rm this type o
injury. In a series o 6 high school athletes (5 playing ootball, 1 playing soccer), all injured
by a valgus load, routine anterior-posterior and lateral radiographs did not demonstrate
Salter-Harris type III ractures o the distal emoral epiphysis. Oblique radiographs with
emoral rotation, crosstable lateral views demonstrating at in the joint, or aspiration o a
hemarthrosis with at in the aspirate help to conf rm growth plate racture with an intraar-
ticular component.62 A thorough ligamentous examination with care ul palpation skills is
required to help di erentiate joint line opening rom epiphyseal plate opening.
Other common epiphyseal ractures seen in children involve the medial epicondyle and
the bones o the hand. T e medial epicondyle epiphyseal racture is the most common elbow
racture seen in the young patient. From a macrotraumatic standpoint, epiphyseal racture o
the medial epicondyle is requently the childhood counterpart o elbow dislocation in the adult
and is typically caused by hyperextension and valgus loading.1 Epiphyseal plate ractures o
the medial epicondyle are typically Salter-Harris type I or II, although types III and IV injuries
have also been reported. Medial epicondyle ractures typically result in the epicondyle being
displaced in eriorly and possibly trapped in the elbow joint.45 As the medial epicondyle serves
as the attachment o the elbow and wrist exors, avulsion ractures o the medial epicondyle
also occur and are discussed later in the chapter in the section entitled “Avulsion Fractures”.
Epiphyseal ractures in children are more common in the hand than in other long bones
o the upper extremity.53 As a result, care must be taken by the parent, coach, or health care
pro essional not to simply disregard f nger injuries as simply a “jammed f nger.” Growth
plate ractures in the hand usually involve the proximal and middle phalanges o the bor-
der digits. T e most common epiphyseal plate racture in the skeletally immature hand is a
Salter-Harris type II at the base o the proximal phalanx o the little f nger.54
T e term Little League shoulder is used to describe an epiphyseal racture o the proximal
humeral epiphysis that typically occurs in the young baseball pitcher.13 Although this injury
can be macrotraumatic in nature, as distraction orces across the physis can approach
one-hal the athlete’s body weight,20 the condition is thought to be a consequence o repeti-
tive microtrauma. Fractures o the proximal humeral epiphysis are usually Salter-Harris
type I or II. Radiographs demonstrate widening o the proximal humeral physis, and to a
lesser degree may demonstrate lateral metaphyseal ragmentation, along with deminer-
alization or sclerosis o the proximal humeral metaphysis. It should be noted that as the
humerus adapts with increased retroversion, the majority o these youngsters remain
asymptomatic as the condition evolves.34,37 Avoiding all throwing until the patient is asymp-
tomatic is vital in the treatment o this condition. Most patients are able to sa ely return to
throwing with symptoms despite abnormal radiographs.14
Avulsion Fract ures

As is the case with growing bone, much o the in ormation regarding growing muscle is
also based on animal studies. Although the physiology o the growth plate allows or bone
growth, muscle does not inherently possess a specif c structural site to allow or adaptation.
It is clear that muscle adaptation does occur in order to accommodate or skeletal growth
or as a response to therapeutic stretching exercise ollowing periods o immobilization
with muscle tissue in a shortened position. Based upon animal studies, it appears that a
change in muscle length results rom changes within the actual muscle belly itsel and/ or
an increase in tendon length. In the skeletally immature animal model, change in muscle
length occurs via changes in the length o both muscle and tendon. Research involving
mature animals, on the other hand, indicates an increase in muscle length that occurs pri-
marily through elongation o the muscle belly.21
When changes in muscle length do not match the changes in long-bone growth, tensile
loads placed within the muscle predispose the youngster to injury. Contractile unit injury rom
voluntary contraction or passive stretch can be exacerbated as a result o inadequate muscle
length. Injuries can range rom various degrees o muscle strain to situations where the bony
attachment o the muscle ails prior to muscle damage. Common sites o avulsion racture in the
lower extremity include the anterosuperior iliac spine (ASIS), anteroin erior iliac spine (AIIS),
ischial tuberosity, and the base o the f th metatarsal. As orces across the joints o the lower
extremity rom running, jumping, and kicking exceed most orces across the upper extremity,
avulsion ractures o the lower extremity outnumber avulsion ractures o the upper extremity.
Stresses across the shoulder and elbow o the young throwing athlete, however, are su cient
enough to result in avulsion o the medial humeral epicondyle and proximal humerus.
Lower Extremity
Ant erosuperior Iliac Spine

Avulsion o the ASIS is caused by a contraction or stretch o the sartorius. T e sartorius is the
longest muscle in the body and crosses the anterior hip and proximal medial knee joints.
T e growth center at the ASIS appears between the ages o 13 and 15 years and uses to the
pelvis between the ages o 21 and 25 years ( ables 30-1 and 30-2).43 Excessive orce rom
the pulling o the sartorius with the hip in extension and knee in exion may result in an
avulsion o the ASIS. Positions o hip extension combined with knee exion seen in the trail
leg during sprinting and hurdling can predispose these athletes to ASIS avulsion racture.
When the growth center does avulse rom the bony origin on the pelvis, displacement o the
avulsed ragment is uncommon.53
Lower Extremity 1021
Table 30-1 Maturatio n o f Bo ne s o f the Arm and Sho ulde r
Bo ne Maturatio n Time table
Clavicle, sternal epiphysis Closure years 18 to 24
Acromion Closure years 18 to 19
Coracoid Closure years 18 to 21
Subcoracoid Closure years 18 to 21
Scapula, vertebral margin, Closure years 20 to 21

and inferior angle
Glenoid cavity Closure year 19
Humerus, head, center, and Fuse together years 4 to 6; fuse to shaft at years 19 to
lesser tuberosities 21 in males, years 18 to 20 in females
Humerus, capitulum, lateral Fuse together at puberty; fuse to shaft at year 17 in males,
epicondyle, and trochlea year 14 in females
Olecranon Closure years 15 to 17 in males, years 14 to 15 in females
Radius, head Closure years 13 to 17 in males, years 14 to 15 in females
Radial tuberosity Closure years 14 to 18
Ulna, distal epiphysis Closure year 19 in males, year 17 in females
Styloid of ulna Closure years 18 to 20
Radius, distal epiphysis Closure year 19 in males, year 17 in females
Styloid process, radius Closure variable
Lunate Appears year 4
Navicular Appears year 6
Pisiform Appears year 12
Triquetrum Appears years 1 to 2
Hamate Appears month 6
Capitate Appears month 6
Trapezoid Appears year 4
Trapezium Closure year 5
Metacarpal I, epiphysis Closure years 14 to 21
Metacarpals II to IV, epiphysis Closure years 14 to 21
Proximal phalanx I, epiphysis Closure years 14 to 21
Distal phalanx I, epiphysis Closure years 14 to 21

Table 30-2 Maturatio n o f Bo ne s o f the Le g and Hip
Bo ne Maturatio n Time table
Pelvic bones Fuse at puberty
Iliac crest Closure year 20
Femur, head Closure years 17 to 18 in males, years 16 to 17 in females
Greater trochanter Closure years 16 to 17
Lesser trochanter Closure years 16 to 17
Femur, distal epiphysis Closure years 18 to 19 in males, year 17 in females
Proximal epiphysis Closure years 18 to 19 in males, years 16 to 17 in females
Tibial tuberosity Closure year 19
Fibula, proximal epiphysis Closure years 18 to 20 in males, years 16 to 18 in females
Fibular malleolus Closure years 17 to 18
Distal epiphysis Closure years 17 to 18
Calcaneus, epiphysis Closure years 12 to 22
Tarsus Completion variable
Metatarsals I to V, epiphysis Closure year 18 in males, year 16 in females
Metatarsals, heads Closure years 14 to 21
Proximal phalanges I to V, Closure year 18

epiphysis
Middle phalanges II to V, Closure year 18

epiphysis
Distal phalanges Closure year 18, beginning proximally
Ant eroinferior Iliac Spine

Avulsion o the AIIS is caused by a stretch or contraction o the rectus emoris. T e AIIS
serves as the site o the direct (anterior, or straight) head o the rectus emoris. As is the case
with ASIS avulsions, activities involving hyperextension o the hip com bined with knee
exion can also result in AIIS avulsion. T e growth center at the AIIS appears between
the ages o 13 and 15 years and uses at approximately 16 to 18 years.43 As a result o earlier
ossif cation, avulsion ractures at the AIIS are less requent than avulsion ractures involving
the ASIS. Athletes involved in running, jumping, and kicking sports usually sustain AIIS
avulsion ractures.29 When avulsion occurs, displacement o the bony muscle origin is rare
because the tensor ascia lata, inguinal ligament, and an intact re ected (posterior) head
o the rectus emoris (which originates at the superior rim o the acetabulum) all serve to
prevent signif cant AIIS displacement.53
With both ASIS and AIIS avulsion ractures, the youngster is typically able to rem em -
ber a specif c event and usually unable to continue participation.7 T e patient dem -
onstrates weakness o the involved m uscle as evidenced by resisted hip exion. In the
avulsed ASIS, resisted hip exion with the external rotation may be use ul in the physical
assessm ent. Point tenderness o the ASIS or AIIS is virtually always present. Swelling, i
present, may be m inimal, and there is m inimal i any ecchym osis noted. rans ers rom
sit to supine are usually guarded and may require assistance rom the patient’s upper
extrem ities or the contralateral lower extrem ity. Assum ing a prone position m ay be
uncom ortable. Passive stretch into com plete knee exion may or may not produce pain.
Passive stretch o the hip into extension with sim ultaneous knee exion m ay increase
symptom s. Gait is typically antalgic with increased trunk exion during stance, decreased
hip exion during swing-through, and decreased hip extension during late stance.60
Peroneals
Inversion ankle sprains are sustained requently by patients o all ages in a wide variety o
sport- and nonsport-related activities. As the patient inverts the ankle, stresses can be placed
through the evertor muscle group, either by passive stretch or by active contraction to pull
the oot back into eversion or by both. Excessive orces generated by the peroneus brevis
may result in avulsion o its insertion at the base o the f th metatarsal. Avulsion racture o
the base o the f th metatarsal typically results in point tenderness along with weakness o
resisted ankle eversion, especially when resisted at the athlete’s available end-range inver-
sion. Resisted eversion may or may not cause pain. Passive inversion o the ankle typically
increases pain at the bony insertion. Swelling may be present, but occurs distal to the tra-
ditional location o swelling seen in ankle sprains. Ecchymosis, i present, typically does not
arise until a ew days ollowing injury.60
Ischial Tuberosit y
Avulsion o the hamstring origin at the ischial apophysis was f rst described in the mid-
1850s, and it occurs with greater requency than avulsions on the anterior aspect o the
pelvis.53 Growth centers in this region appear between the ages o 15 and 17 years and use
to the ilia between the ages o 19 and 25 years.42,53 Athletes with an avulsion racture o the
ischial tuberosity typically demonstrate discom ort with prolonged sitting. Assessment o
hamstring length at 90 degrees o hip exion will o ten show inadequate exibility bilater-
ally, with more limitation on the involved side that is usually accompanied by pain. T ere
may or may not be weakness with resisted knee exion, but there is usually weakness noted
with resisted or nonresisted prone active hip extension. T ere is typically minimal, i any,
ecchymosis in the area, and swelling is usually not apparent.60
Ant erior Cruciat e Ligament Injury in t he Young At hlet e

Although the diagnosis and management principles governing injuries to the anterior
cruciate ligament are ound in Chapters 24 and 31, a ew thoughts specif c to this injury
in the skeletally immature athlete is warranted. As is the case with many lower-extremity
macrotraumatic injuries, sprains o the anterior cruciate ligament in young athletes is the
norm rather than the exception. Although young athletes may avulse the anterior cruci-
ate rom the bony insertion, many still tear the ligament in the midsubstance and require
reconstruction.
Reconstruction o the anterior cruciate ligament in the skeletally immature knee does
pose problems not encountered when the distal emoral epiphysis has closed.
Standard practice involves transepiphyseal reconstruction with hamstring allogra t
versus extraarticular reconstruction.2,25 Prompt surgical intervention (within 12 weeks) to
the anterior cruciate ligament-def cient young athlete is paramount, as evidence demon-
strates a delay in reconstruction can result in increased meniscal injuries and intraarticu-
lar chondral injury.33 A success ul return to sports a ter reconstruction can be expected,
and many young athletes continue their careers into college.52 Many studies have evaluated
the impact o a variety o programs intended to “prevent” anterior cruciate injuries, but the
success o these varied programs is mixed, and ew programs specif cally ocus on skeletally
immature athletes.17,40
Upper Ext remit y

A m edial epicondyle epiphyseal racture is the m ost com m on elbow racture seen in the
young patient (Figure 30-2).3 As discussed previously, this injury m ay occur as a result
Clavicle s te rna l Acromion

e piphys is
S ca pula
Hume ra l he a d
Hume rus proxima l
e piphys is
Me dia l e picondyle
Hume rus dis ta l
e piphys is
La te ra l e picondyle
Ole cra non
Ra dius proxima l
Ulna proxima l e piphys is
e piphys is
Ra dius dis ta l e piphys is

Ulna dis ta l
e piphys is Ca rpa l bone s
Me ta ca rpa l bone s
P ha la nge s
Figure 30-2 Lo catio n o f uppe r e xtre mity e piphyse s
A. Upper-extremity ossification and epiphyseal plate closure.

B. Lower-extremity ossification and epiphyseal plate closure.
Ilia c cre s t
Pe lvic bone s
Fe mora l he a d
Gre a te r trocha nte r

Le s s e r trocha nte r
Fe mur dis ta l e piphys is
Tibia
Fibula r proxima l e piphys is proxima l e piphys is
Tibia l tube ros ity
Fibula r dis ta l e piphys is

Tibia dis ta l e piphys is
Ta rs a l bone s
Me ta ta rs a l bone s Me ta ta rs a l e piphys is
P ha la nge s
o a m acrotraumatic hyperextension or valgus injury. T e m edial epicondyle serves as

the attachm ent site o the orearm exor/ pronator group, and as such can also be a loca-
tion or avulsion racture. T is type o injury is typically caused by valgus loading during
the acceleration phase o the throwing m echanism. Avulsion o the triceps attachm ent
at the olecranon has also been reported. T is condition has been observed to result in
separated ossif cation centers that persist into adulthood with subsequent olecranon
nonunion.26
Treat ment Principles

Conservative treatment o all avulsion ractures mimics that o a severe muscle strain. In
ractures involving the lower extremity, assisted gait is a must until weightbearing activi-
ties are pain ree and without substitution. Compression o the area in the orm o elastic
wraps or neoprene sleeves may provide warmth and minimize discom ort experienced with
activities o daily living and early rehabilitation e orts. Modalities to minimize pain and
acilitate healing are indicated early in the treatment regimen. Once in ammation rom
the initial injury has subsided, gentle single-joint stretching exercises can begin. wo-joint
stretching exercises should begin only a ter 1-joint stretches are pain ree. Submaximal
single-joint strengthening exercises can begin when pain ree. Strengthening e orts should
be preceded by warm-up activities, and strengthening exercises should also be ollowed
by stretching o the involved muscle. When isolated 2-joint strengthening e orts are toler-
ated without di culty, the young athlete can be allowed to return to a unctional progres-
sion program.60 Avulsion injuries o the upper extremity must be treated with rest until the
youngster is asymptomatic. A gradual return to throwing sports through a supervised unc-
tional progression program is vital.
Microtraumatic Injuries
Apophysit is
T e apophysis o growing bone di ers rom the epiphysis o skeletally im mature bone.
T e apophysis is an independent center o ossif cation that does not contribute to the lon-
gitudinal length o a long bone. An apophysis, however, does contribute to the structure
and orm o mature long bone by serving as a site o tendinous or ligamentous attachment.
It is the role o the apophysis as the site or tendinous attachment that enters the picture o
overuse injuries seen in the growing patient. At skeletal maturity, the apophysis uses to its
site o attachment to its respective long bone. Prior to skeletal maturity, however, traction
placed upon an apophysis rom an in exible musculotendinous unit may result in apophy-
seal in ammation and delayed usion to the long bone. raction apophysitis commonly
occurs at the tibial tubercle, calcaneus, and iliac crest.
Lower Ext remit y

Repetitive loading activities o the lower extremities in combination with muscle-tendon
length insu ciency can yield traction orces through apophyseal centers that result in
in ammation o the apophysis. Young patients involved in running, jumping, and kicking
activities are inherently predisposed to large traction orces through apophyseal centers,
especially during a growth spurt. T ese traction apophysites are typically sel -limiting, but
cases that do not respond to traditional conservative measures may require short-term
immobilization to assist in eliminating pain and in ammation.
Calcaneal Apophysitis (Sever Disease) Sever disease is a traction apophysitis o the

growth center o the calcaneus. Sever disease typically a ects youngsters 8 to 13 years o age,
with the peak incidence occurring at age 11 years in young emales and at age 12 years in
young males.32,49 Sever disease requently a ects youngsters involved in outdoor all sports
ollowing a dry summer that results in dry, hard ground. Soccer, ootball, and even band
participants, especially early in the season, are commonly diagnosed with Sever disease.60
Young soccer players who routinely participate on artif cial sur aces may also experience
symptoms consistent with Sever disease.32 Spikes or other shoes lacking in adequate shock
absorption and ore oot support, or shoes with broken-down heel counters, contribute to
the incidence o Sever disease.
Microtraumatic Injuries 1027
A B
Figure 30-3
A. Front knee should be flexed for soleus stretching, back knee should be straight for
gastrocnemius stretching, and heels should remain on the floor. B. Standing on a slantboard
(see also Figure 30-4) at the point of a discernable stretch for 10 minutes can be incorporated
into a home stretching program.
Sever disease is characterized by pain and point tenderness at the posterior calcaneus
near the insertion o the Achilles tendon. Local signs o in ammation may be present in
acute cases. Swelling at the calcaneal apophysis also may be present, but this is an excep-
tion rather than the rule. Patients with tight calves, internal tibial torsion, ore oot varus,
a dorsally mobile f rst ray, weak dorsi exors, and genu varus may be more susceptible to
Sever disease.
reatment o Sever disease should ocus on establishing normal exibility o the gastroc-
nemius-soleus muscle group (Figures 30-3 and 30-4). Cal stretching should include exercises
with the knee extended and the knee exed. Just as importantly, stretching in a weightbear-
ing position should be per ormed with the correction o any rear oot-to-lower-leg or ore oot-
to-rear oot abnormality. Orthotic intervention may be a consideration in the treatment o
Sever disease and may range rom temporary heel li ts or heel cups to more sophisticated
custom-f t orthotics to correct biomechanical abnormalities. Dorsi exion strengthening
exercises along with oot intrinsic strengthening may also help manage symptoms.60
Tibial Tubercle Apophysitis (Osgood-Schlatter Disease) Initially described in 1903,

Osgood-Schlatter disease (OSD) is commonly seen in active and nonactive youngsters
alike.29 Like all traction apophysitises, the condition is usually sel -limiting, but because o
its prevalence and the ominous name, parents and young patients may mistakenly expect a
poor prognosis. T is is not to downplay the potential longstanding problems that can arise
when the condition is not adequately diagnosed and treated.
Development o the tibial apophysis begins as a cartilaginous outgrowth. Secondary
ossif cation centers appear with subsequent progression to an epiphyseal phase when
Us e ¾ ″ plywood
5¼ 18
2 ends 5¼ × 12
12 13½
1 top 13½ × 18 16½
1 front 5¼ × 16½ 5¼
c h
in
18
h
c
n
i
6
12
in c
h
Figure 30-4 Dire ctio ns fo r fabricating a slantbo ard to facilitate

g astro cne mius-so le us stre tching
the proximal tibial physis closes and the tibial apophysis uses to the tibia.23 Calcif cation
o the apophysis begins distally at the average age o 9 years in emales and 11 years in
males. Fusion o the apophysis to the tibia can take place via several ossif cation centers
and occurs, on average, at age 12 years in emales and 13 years in males.29 T ere is a nor-
mal transition rom distal f brocartilage to proximal f brous tissue at the tibial apophysis.
Fibrous tissue is more readily able to withstand the high tensile loads involved with athletic
activities than the weaker cartilage o the secondary ossif cation center. Microavulsions can
occur through the area o bone and cartilage at the secondary ossif cation center, resulting
in the potential or the development o separate ossicles, which can be a source o pro-
longed pain or reinjury.29 Complications o OSD are ew, but in addition to the ormation o
an accessory ossicle, patellar subluxation (secondary to patella alta), patella baja, nonunion
o the tibial tubercle, and genu recurvatum have been reported.27,31,66
T e diagnosis o OSD is not a clinical challenge. Sym ptom s are typically unilateral,
although up to 25% o cases can be bilateral in nature.23 T ere m ay or may not be a his-
tory o injury. raditional literature reveals that OSD a ects m ore young m ales than
emales; however, recent evidence suggests no signif cant di erence between m ale and
em ale involvem ent.60 T e youn gster typically com plains o achin g around the tibial
tubercle that is increased during or ollowing jum pin g, clim bin g, or kn eelin g activi-
ties. T e tibial tubercle may be reddened, raised, or tender to palpation. Sym ptom s are
usually conf ned to the tibial tubercle and typically not present at the superior or in e-
rior patellar poles or the patellar tendon; however, patello em oral tenderness m ay be
present.53 enderness at the cartilaginous junction o the patella and patellar tendon at
the in erior patellar pole is indicative o Sinding-Larsen-Johansson disease.55,56 Findings
on radiography (especially i only per orm ed unilaterally) are o ten m isleading, as it is
di cult to di erentiate between abnorm al ragm entation rom normal centers o ossif -
cation. Radiographs, however, m ay reveal so t-tissue swelling. Som e athletes with OSD
also have patella alta, an d som e authors have n oted a link between patients with
OSD and Sever disease.29
reatment o OSD should emphasize a judicious stretching program. Inadequate quad-
riceps exibility is virtually always present. T e shortened muscle group combined with
the ballistic nature o quadriceps activity in jumping sports are at the heart o OSD. Over-
zealous stretching o the quadriceps, however, may increase the pull on the tibial tubercle
and only serve to increase symptoms. Stretching o the quadriceps should begin prone,
stressing an increase in quadriceps length at the knee joint only. A bolster under the hips
may be required to place the muscle on slack at the hip joint. All stretching must be accom-
panied by a pull within the quadriceps muscle belly, not at the tibial tubercle. wo-joint
stretching exercises should be instituted when adequate muscle length is established at the
knee without an increase in tibial tubercle tenderness (Figure 30-5). Quadriceps weakness
is requently not a major concern in this patient population; many o these youngsters have
excellent quadriceps recruitment with no atrophy. Chronic cases, however, will result in
quadriceps atrophy. Pain- ree isometrics or low-load and high-repetition knee extension
A B
Figure 30-5 Quadrice ps stre tching
A. Proper technique. B. Improper technique with excessive trunk flexion.

A B
Figure 30-6 Lo ng -sitting hamstring stre tching
A. Proper technique. B. Improper technique with excessive thoracolumbar flexion.
exercise may be incorporated i quadriceps atrophy is noted. Progressive resistive exer-

cises o the quadriceps must be used judiciously, as they may only serve to increase pain
at the tibial tubercle. As tight hamstrings require increased quadriceps orce to overcome
the tight posterior structures, hamstring exercises must be included in the comprehensive
program to manage OSD ( Figures 30-6 and 30-7). I competing in a contact or collision
sport, young athletes with OSD should be f tted with a
protective pad to minimize the risks o blunt trauma to
the area. When the tibial tubercle area is in amed, even
when the athlete is not participating, protective padding
should also be considered to minimize the incidence o
the inadvertent blunt trauma encountered in activities o
daily living.60
Iliac Apophysitis
Iliac apophysitis is a condition typically seen in the older
youngster involved in running sports. Active patients
between the ages o 14 and 16 years are usually the prime
candidates or iliac apophysitis.15 T e ossif cation center
o the iliac crest appears anterolaterally and advances
posteriorly until it reaches the posterior iliac spine. T e
average age o closure is 16 years in boys and 14 years
in girls, but closure may be delayed up to 4 additional
years.28 T e gluteus medius originates on the ilium just
in erior to the iliac crest and is another muscle that may
contribute to iliac apophysitis. T e gluteus medius helps
to maintain pelvic symmetry or single-leg stance activi-
ties during running and hopping. In ammation o the
Figure 30-7 Wall stre tch hamstring stre tching iliac apophysis is thought to be rom a repetitive pull o
the abdominal musculature at its insertion on the iliac
The youngster should maintain full knee extension and keep crest.43 During physical activities, the abdominal muscles
the buttocks on the floor. As hamstring flexibility improves, serve as trunk stabilizers and accessory muscles o res-
the youngster should ultimately be able to place the heels, piration. Although most commonly seen as an overuse
backs of the knees, and buttocks against the wall. apophysitis, incomplete avulsion ractures o the iliac
apophysis have been reported rom sudden contraction o the abdominals with a quick
change in direction while running.
Patients who experience iliac apophysitis usually demonstrate exquisite point ten-
derness along the iliac crest, which is typically unilateral and located along the anterior
one-hal o the iliac crest. Seated or standing lateral trunk exion away rom the side o
involvement is usually uncom ortable. Weakness or
pain with resisted hip abduction, oblique abdominal
muscular activity, and pain or compensation with hop-
A
ping on the involved leg may also be present. A com-
plete lower-extremity biomechanical examination may
be indicated to determine structural or compensa-
tory leg length inequality that may contribute to iliac
apophysitis.
reatment o iliac apophysitis should center on
regaining normal exibility o the iliotibial band, the
abdominals, and gluteus medius. T e patient at the
outset o a exibility program typically tolerates 2-joint
stretching o the iliotibial band with the knee extended
(Figure 30-8). T e traditional Ober test position, along
with variations, is e cient stretching activity, but o ten
accompanied by substitution o excessive hip exion,
trunk exion, or rotation. Seated lateral exion away
rom the side o involvement, progressed to standing
lateral exion, which is then progressed to standing
lateral exion with arms extended overhead, is a good
stretching progression. Prone press-ups with rotation
and lateral exion may also be incorporated into the
stretching program.60
Fifth Metatarsal Apophysitis (Iselin Disease) Out

o many traction apophysites that a ect the young
patient, Iselin disease is the most rarely encountered.
T e insertion o the peroneus brevis may be irritated B
by activities requiring f ne oot control as in the case o
dancers and gymnasts. Patients with abnormal relation-
ships between the ore oot and rear oot may be predis-
posed to Iselin disease. A tight gastrocnemius-soleus
complex or weak dorsi exors may also contribute to
apophysitis at the base o the f th metatarsal.51
Upper Ext remit y

As previously noted, the elbow is subjected to large
orces during the throwing mechanism. T ese orces are
especially problematic in baseball pitchers and catch- Figure 30-8
ers, as well as young tennis players.30 In the skeletally
immature patient, these orces may result in shoulder A. Standing iliotibial band stretching. The uninvolved leg is
and/ or elbow injury. Much has been done to explore crossed over in front of the involved leg and the youngster
the reasons or shoulder and elbow injury in the throw- leans the hips toward the wall. B. Side-lying iliotibial band
ing youngster. In regards to the youth baseball pitcher, stretching. Lying on the involved side with feet, hips, and
the previously held notion that throwing the curve ball shoulders in a straight alignment, the athlete pushes up onto
at an early age was the primary cause in developing extended elbows.
elbow problems. Recent work, however, demonstrates that the velocity o throwing and
the number o pitches contribute to a much greater extent than the type o pitch.47 T e
American Orthopaedic Society or Sports Medicine does recommend age-appropriate
introduction to a variety o pitches with the astball only rom age 8 years ollowed by the
introduction o a changeup at age 10 years, the curve at age 14 years, and other o speed
pitches ollowing a ter that.30 o minimize the risk o overuse injury, various organiza-
tions have proposed guidelines to limit throwing in the developing arm. T e American
Academy o Orthopaedic Surgeons recommends limiting pitching to no more than 4 to 10
innings per week and 60 to 100 pitches per game.30 Little League Baseball recommends
age-specif c pitch counts, as well as suggested rest periods between throwing.5 Knowledge
o and adherence to the pitch count recommendations are inconsistent.18,35 Measures to
consider regarding the prevention o overuse injuries in children include preparticipation
exams, ensuring appropriate parental supervision and coaching, recognizing sport readi-
ness, avoiding training errors, delaying single-sport specialization, allowing or adequate
rest and recovery, and avoiding overscheduling.16,36
Although these guidelines are an important step in preventing upper-extremity overuse
injury, they are only part o the story. Many youngsters participate in organized baseball
programs that are not o cially a liated with Little League. T ese youngsters may not have
guidelines to regulate how much an individual can pitch. T ese guidelines also do not apply
to batting practice and o ten are not considered when youngsters pitch in tournament play.
Finally, the number o innings may not be the best indicator to use, as an inning in base-
ball played by 9- to 12-year-olds ranges rom 4 to 50 pitches per inning, and the number o
pitches per pitching outing ranges rom 4 to 100.4
Spine
Most spine injuries involve the muscles, ligaments, and intervertebral disks. T ese inju-
ries are usually sel -limiting and rarely result in signif cant neurologic com promise.59 wo
conditions o the osseous structures o the spine, however, do involve the young patient:
spondylolysis and spondylolisthesis. Spondylolysis is a bony de ect in the pars interar-
ticularis, a portion o the neural arch located between the superior and in erior articular
acets. Physical orces encountered by youngsters involved in physical activities play a sig-
nif cant role in the development o spondylolysis. Activities that involve repetitive loading,
especially with the lum bar spine in extension/ hyperextension, such as ballet, gymnastics,
diving, ootball, weight li ting, and wrestling, have been implicated in spondylolysis. Spon-
dylolysis originates in children between the ages o 5 and 10 years, and m ost requently
occurs at the f th lumbar vertebra, with the ourth lumbar vertebra being involved sec-
ond most requently.42 Many youngsters with spondylolysis remain asymptomatic or long
periods o tim e and are not diagnosed until later in their skeletal development. Radio-
graphs rom the lateral and oblique views are required in order to visualize the racture in
its entirety along the longitudinal plane. Positive radiograph f ndings include asymmetry
o the neural arch, in erior apophyseal joint, and posterior elements with rotation o the
spinous process away rom a unilateral spondylolytic lesion. C scan and bone scan with
single-photon em ission computed tomography can aid in the radiologic diagnosis and
staging o spondylolysis.41 A comm on f nding in patients with spondylolysis (symptomatic
or asymptomatic) is hamstring spasm.58 T e etiology o this ham string spasm is thought
to be caused by either a postural re ex to stabilize the L5-S1 segm ent or to nerve root
irritation.27,41,42,58
Spondylolisthesis is a condition in which a vertebra slips anterior to the vertebra imme-
diately below it. Spondylolisthesis most requently takes place between the f th lumbar and
f rst sacral vertebrae, although the condition can occur at more than one spinal segment.
T e superior border o the in erior vertebra is divided into quarters, and the slip is described
Special Considerations 1033
in terms o the width that the superior vertebra slips anteriorly in relation to the vertebra
below it. A grade 1 spondylolisthesis is an anterior slip o 25% or less o the vertebral width ;
a grade 2 slip is up to 50% o the vertebral width ; a grade 3 spondylolisthesis is a slip up to
75% o the vertebral width ; and a grade 4 is a complete anterior slip. Spondylolisthesis is
classif ed as degenerative, traumatic, pathologic, or isthmic. It is the isthmic classif cation
that typically involves the young patient. In the isthmic category o spondylolisthesis, it is
debatable whether a bilateral spondylolysis is a precursor or slippage and resultant insta-
bility o a spinal segment.
reatment o spondylolysis and spondylolisthesis centers on healing o the bony de ect
and decreasing the patient’s symptoms. reatment depends upon the physician’s personal
pre erence and ranges rom relative rest without a brace to 23 hours o bracing. When brac-
ing is used, the brace is typically a rigid custom-f t lumbar spinal orthosis designed to keep
the youngster out o extension. In addition to activity modif cation, hamstring stretching is
an integral part o the treatment program.
Special Considerations
Musculoskelet al Considerat ions

Some conditions involving the young patient may actually be congenital in nature, but do
not cause symptoms until the youngster becomes physically active in youth sports or physi-
cal education classes. Conditions such as these have unknown etiologies; some clearly have
genetic predispositions, whereas others may be traced to excessive activity. Musculoskel-
etal conditions that are discussed here include tarsal coalition, Legg-Calvé-Perthes disease
(LCPD), slipped capital emoral epiphysis (SCFE), osteochondroses, and patello emoral
pain syndrome.
Tarsal Coalit ion

Persistent ankle and oot pain in the young patient in conjunction with recurrent ankle
sprains could possibly be a result o an underlying tarsal coalition. A tarsal coalition is an
abnormal usion between tarsal bones in the rear oot or mid oot caused by a ailure o bony
segmentation. T e most common tarsal coalitions occur between the calcaneus and navic-
ular, the talus and the navicular, or the talus and calcaneus. Most tarsal coalitions present
clinically in patients between the ages o 8 and 16 years, with anywhere rom 50% to 60%
o tarsal coalitions occurring bilaterally. T ere is amilial predisposition in some cases o
tarsal coalition.51 As coalitions can be f brous, cartilaginous, or osseous, radiographs o the
oot are many times interpreted as being unremarkable. Bone scan and C scan may be o
benef t in those cases where radiographs ail to demonstrate pathologic f ndings. Stretch-
ing and strengthening o extrinsic and intrinsic ankle musculature may help to minimize
motion and strength losses. A custom-made or o -the-shel orthosis may also help to mini-
mize symptoms.36
Legg-Calvé-Pert hes Disease

LCPD is an avascular necrosis o the emoral head thought to be caused by an occlusion o
the blood supply to the emoral head rom excessive uid pressure resulting rom an in am-
matory or traumatic synovial e usion o the hip joint. LCPD typically involves active young-
sters between the ages o 3 and 11 years and is ound 4 times more requently in young boys
than in young girls. LCPD is usually unilateral, although 15% o youngsters have bilateral
involvement.49 Youngsters diagnosed with LCPD may or may not be able to recall a history
o trauma, but LCPD should be ruled out in any male athlete younger than 12 years o age
with longstanding groin or knee pain worsened by a weightbearing position. Young patients
usually will present with a limp and a compensated or uncompensated gluteus medius gait.
It should be noted that it is not unusual or the youngster to have no complaints o hip pain.
Pain, when present, is usually in the groin and very requently re erred to the knee. In act,
LCPD can be misdiagnosed as patello emoral pain.61
Slipped Capit al Femoral Epiphysis

SCFE, although rare, is a condition that may not mani est itsel until a youngster becomes
involved in sports activities. SCFE involves boys twice as o ten as girls and typically occurs
between 10 and 15 years o age during a period o rapid growth.53,64 A suspected causative
actor is a potential hormonal imbalance; consequently, SCFE should be suspected in
youngsters who are tall and thin or short and obese who complain o longstanding thigh,
groin, or knee pain. Progressive cases o SCFE may result in a varus de ormity with con-
comitant external rotation.
T ere are also other conditions that may result in groin pain or pain around the pelvis
that may be mani ested a ter a macrotraumatic event. Musculoskeletal conditions include
hernia, avulsion racture o the lesser trochanter, iliopectineal bursitis/ tendinitis (snapping
hip), abdominal muscle strain, congenital dislocation o the hip, septic arthritis, and toxic
synovitis. Nonmusculoskeletal di erential diagnoses as a source o acute or persistent hip
pain include leukemia and neuroblastoma.48 Other potential causes o hip pain are bone
tumor, appendicitis, pelvic in ammatory disease, hemophilia, arterial insu ciency, and
sickle cell anemia.22
Ost eochondroses
Osteochondrosis and osteochondritis are 2 distinctly di erent pathologic entities. Osteo-
chondrosis is typically a sel -limiting disorder that involves a secondary epiphyseal center
or pressure epiphysis at the end o a long bone or a primary epiphyseal center o a small
bone.57 Osteochondrosis involves degeneration or avascular necrosis with resultant regen-
eration or recalcif cation and typically does not demonstrate bony ragmentation.8,57 Osteo-
chondritis, on the other hand, is an in ammation o the subchondral bone and articular
cartilage. Osteochondritis dissecans involves resultant ragmentation o articular carti-
lage within the joint. Many o the osteochondroses have their origins in chronic, repetitive
trauma. T e pathology and subsequent prognosis o osteochondrosis and osteochondritis
o immature bone di er rom that o mature bone.
Juvenile osteochondritis dissecans (JOCD) o the knee can be a devastating condition i
not diagnosed and treated early. Although ischemia, genetic predisposition, and abnormal
ossif cation are theoretical causes o JOCD,24 growing evidence suggests that microtrauma
to the immature knee over the course o months and years is the primary cause o JOCD.9,10
T e majority o JOCD lesions involve the medial emoral condyle, and most lesions occur
on the weightbearing sur ace. T e site o JOCD pathology is subchondral bone, not articular
cartilage.11 Many lesions go undiagnosed or misdiagnosed. In a series o 192 patients, 80%
had symptoms or more than 15 months and 90% had symptoms or longer than 8 months.9
Symptoms center around an insidious onset o knee pain, with or without e usion, and
knee pain that is increased with weightbearing activities and typically reduced with rest.
Youngsters with JOCD are usually involved in year-round physical activity, or participate in
more than 1 sport with little, i any rest, between sporting seasons. Success ul treatment is
based upon accurate diagnosis, staging o the activity o the lesion, the ability o the lesion to
heal, and subsequent nonoperative or operative intervention. Conservative treatment cen-
ters around minimizing weightbearing and shear orces, activity modif cation, stretching o
in exible hamstrings and calves that serve to increase joint reaction orces, and appropriate
quadriceps strengthening exercises initiated and progressed on an individual basis.
Another common site o osteochondrosis involves the elbow o a growing patient.
Osteochondrosis o the capitellum o the elbow is called Panner disease. Panner disease
is typically seen in young throwing athletes who complain o chronic dull aching in the
elbow joint. Point tenderness at the lateral elbow is common, as is a subtle loss o elbow
extension.8 As the condition progresses, the loss o extension can be more pronounced and
accompanied by a loss o pronation and supination. Initially, rest and activity modif cation
is important and should be ollowed by a range o motion and strengthening program along
with a supervised unctional progression program to return to throwing.
Pat ellofemoral Pain

Patello emoral pain is requently encountered in many physical therapy clinics. Symp-
toms in youngsters are comparable to their adult counterparts. Dull peripatellar aching,
pain with stairs or prolonged sitting, giving way o the knee, and pseudolocking episodes
in extension are classic signs o patello emoral involvement. reatment is symptomatic
and should include pain- ree quadriceps strengthening; hamstring, cal , and iliotibial band
stretching; correction o biomechanical abnormalities; activity modif cation; bracing; and
screening or signs o hyperelasticity that may indicate patello emoral joint instability.
Growing Pains
Prior to closing out the description o various microtaumatic concerns in the youngster, the
clinician should also be made aware o the signif cance o the diagnosis o growing pains.
It is not uncommon or the physical therapist to receive a re erral to address various mus-
culoskeletal issues in a growing child with the chie complaint o pain. T e re erring practi-
tioner may lack su cient knowledge in musculoskeletal examination principles to provide
an adequate clinical impression. Because the presenting chie complaint in an active child
can be pain, a clinical diagnosis o growing pains is made. Growing pains is a misnomer as
the process o growing should not be pain ul and the majority o children who truly have
growing pains do not experience symptoms during growth spurts. T e diagnosis o growing
pains should never be taken at ace value by the therapist.
When present, growing pains are typically seen in younger children. Pain is usually in
the thighs, calves, or shins and is bilateral. It is usually present during the evening or at
night, and there is usually no morning sti ness. T e youngster does not typically limp on
the involved lower extremity. In cases where pain is located in areas other than the lower
extremities, when pain is accompanied by morning sti ness, a limp, malaise, recurrent
ever, and/ or night sweats, urther examination is indicated as opposed to accepting the
clinical impression o growing pains at ace value.
Physiologic Considerat ions

T e youngster’s cardiovascular response to exercise is related to the size o the youngster.65
Children demonstrate a double sigmoid growth pattern rom birth to adulthood. T ere is a
rapid gain in growth in in ancy and early childhood that slows down during middle child-
hood. T e second rapid increase in growth occurs during adolescence. T e peak height
velocity is def ned as the maximum rate o growth in stature and occurs in girls rom 10.5 to
13 years, but may start as early as 9 years or as late as 15 years. Peak height velocity o boys
occurs rom 12.5 to 15 years, but may start as early as 10 years or as late as 16 years.48
As the youngster’s heart is smaller than that o the mature adult, its capacity as a reservoir
or blood is also smaller. Children, there ore, have a lower stroke volume at all levels o exer-
cise.65 T e exercising youngster compensates or this lower stroke volume with an increased
heart rate. As is seen in the adult, the youngster’s systolic blood pressure rises during exercise,
but the child’s elevation in systolic blood pressure is less than that seen in the adult.65 T e red
blood cell count or young boys and girls are similar with comparable abilities to carry oxygen
to exercising organs. A ter menarche, however, emales demonstrate lower blood volume and
ewer red blood cells, with a resultant decreased oxygen-carrying capacity. T us, young girls
typically demonstrate a mean blood pressure lower than that seen in young boys.50
As the child’s thoracic cavity is smaller than that o the mature adult, the child demon-
strates a smaller vital capacity than the adult and also shows an elevated respiration rate as
compared to the mature adult.6,65 As the child matures, the ability to per orm work (both
aerobic and anaerobic) increases.4,6,49,65 A ter menarche, girls have a slightly lower oxy-
gen uptake per kilogram o body weight but are similar to boys per kilogram o lean body
weight.21,28 T e maximum oxygen uptake is similar in young boys and girls until approxi-
mately 12 years o age. Males continue to demonstrate an increase until 16 to 18 years o
age, with emales ailing to show signif cant gains a ter 12 to 14 years o age.5,63 Young boys
and girls have similar proportions o slow-twitch and ast-twitch muscle f ber. Strength di -
erences between the genders are minimal when strength is expressed relative to at- ree
weight. Both young boys and young girls have been shown to be able to sa ely participate in
strength-training programs.8,10,26,38
Independent o gender, the young athlete typically does not tolerate prolonged periods
o heat exposure; there ore, care must be taken when the youngster participates in sports
in a hot and humid environment. A child has a greater sur ace area-to-mass ratio than
does the typical adult, resulting in a greater trans er o heat into their young bodies. T e
child also has a higher production o metabolic heat per kilogram o body weight as com-
pared to adult counterparts, which serves to urther challenge the young thermoregulatory
system.4,6,49,65
Psychological Considerat ions

o this point, the chapter has presented many physical and physiologic characteristics
that constitute the unique challenges to evaluating and treating youth injuries. Be ore con-
cluding this chapter, however, another vital area
Table 30-3 Be ne ts o f Physical Activity in Childre n must also be discussed—the unique psychological
demands placed upon young athletes, especially
those involved in intense competition and training.
Physical
T ere are many benef ts to physical activity in
Increased maximal aerobic power and general stamina 12
Control of body mass and fat reduction
the youngster ( able 30-3 ). T ere are many di -
Increased muscle strength and endurance erences, however, between ree- owing play and
Increased range of motion organized sports. Organized sports, ortunately or
Decreased blood lipid levels un ortunately, carry the obligatory win or lose con-
Improved ventilatory ef ciency notations o competition and also involve adults
Increased oxygen consumption who coach and train the youngster as well as adults
who interpret and en orce the rules that govern com-
Psycho lo g ical
petition. T e adverse e ect o adult in uences upon
Feelings of competency and mastery
Personal self-esteem the young athlete is but one potential negative psy-
Engaging in enjoyable behavior chological aspect o youth sport participation.
Achieving desired goals Participation in organized sport can be taken to
Gaining admiration of others an extreme. Intensive participation can be described
Safe training in risk-taking behavior in terms o requency and/ or intensity. Examples
Satisfaction in achievement o intensive participation include the ice skater or
Feeling of working toward a goal gymnast who trains daily or hours and competes all
Peer group interaction year round or years on end. Other examples include
Awareness of, and adherence to, rules the multisport athlete who trains and competes on
Personal role de nition
a daily basis all year round. T is intensive partici-
pation places signif cant physical demands on the
Table 30-4 Po te ntial Ne g ative Aspe cts o f Inte nsive Yo uth Spo rt Participatio n
• Children are not permitted to be children.

• Children are denied important social contacts and experiences.
• Children are victims of a disrupted family life.
• Children may experience impaired intellectual development.
• Children are exposed to excessive psychological/physiologic stress.
• Children may become so involved with sport that they become detached from society.
• Children may face a type of abandonment upon completion of their athletic career.
body, demands that may result in serious overuse or stress- ailure injury. Just as the young
body grows to accept greater physical demands, so does the young mind. Intensive par-
ticipation places many demands on the youngster, some o which may be unrealistic. As
this relates to intense competition, research demonstrates that a child’s cognitive ability to
develop a mature understanding o the competition process does not occur until the age o
12 years. It is not until between the ages o 10 and 12 years that children develop the capac-
ity to comprehend more than just one other viewpoint. Finally, a ter the age o 12 years, the
youngster can readily adopt a team perspective.30,44
able 30-4 identif es the negative psychological aspects o intense youth sport par-
ticipation. Psychological issues may also enter the picture when rehabilitating youth sport
participants involved in intense competition and training. Risk actors or psychological
complications in the injured child include stress in the amily, high-achieving siblings, over-
or underinvolved parent(s), a paradoxical lack o leisure in athletic activity, sel -esteem that
is reliant on athletic prowess, and a narrow range o interests beyond athletics.32,46
T is chapter provided an overview o the unique physical and psychological issues that
a ect youth sport participants. T e rehabilitation pro essional evaluating and treating the
young athlete must be cognizant o these unique eatures. Evaluation and treatment prin-
ciples must re ect the special circumstances that present in the youth athlete.
SUMMARY
1. Pediatric patients are not miniature adults and should not be treated as such.
2. T ere are many proposed benef ts o strength training in children and adolescents,
including increased strength, power, endurance, and neuromuscular skill.
3. Current evidence indicates that there are no contraindications to strength-based
exercises in young patients.
4. Children and adolescents should not be allowed to exercise to exhaustion or train
without supervision.
5. A high index o suspicion or epiphyseal injury should be used when examining young
patients a ter traumatic injuries. Immature bone is susceptible to damage at the growth
plates.
6. Apophyseal injuries occur uniquely in the growing child or adolescent, and are due
to traction placed on the bony apophysis by the musculotendinous unit that inserts
there.
7. T ere are many excellent physical and psychosocial benef ts to sport participation in
children and adolescents.
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Considerations for the
Physically Active Female
Ba r b a r a J. Ho o g e n b o o m , Te re s a L. Sch u e m a n n ,
a n d Ro b y n K. Sm it h
O BJJEC
C TII V E S t h e r a p is t s h o u ld b e a b le t o d o t h e f o llo w in g :
Recognize/identify the general anatomic, physiologic, and neuromuscular differences that exist
between genders.
Develop an understanding of common gender differences that predispose the female athlete to
development of patellofemoral dysfunction.
Identify characteristics that may contribute to increased susceptibility of the female to anterior
cruciate ligament (ACL) injury, including mechanism of injury, intrinsic factors, extrinsic factors,
and combined factors.
Identify typical muscular activation and timing patterns, as well as the kinematics and joint
position of the lower extremity during performance of physical tasks by females.
Educate physically active females, coaches, and other sports medicine personnel regarding
prevention of ACL injuries, including proper cutting and jumping techniques and neuromuscular
reeducation/strengthening of the lower extremity.
Prescribe a lower-extremity reactive neuromuscular training exercise program for the physically
active female to aid in ACL injury prevention.
Identify possible sequelae to ACL injury and rehabilitation.

(continued )
1041
1042 Chapte r 31 Considerations for the Physically Active Female
OBJECTIVES (continued )
Utilize the concept of “ envelope of function” to minimize adverse effects of musculoskeletal

injury and subsequent rehabilitation.
Understand the importance of incorporating core strengthening into an exercise program of the
physically active female.
Identify the potential stresses and risks that occur in the shoulder joint complex as a
consequence of softball windmill pitching.
Prescribe an exercise program speci c to the windmill softball pitcher.
Understand the potential stresses to the shoulder complex during freestyle swimming and
identify which musculature is at greatest risk for fatigue and subsequent impingement.
Develop a comprehensive rehabilitation program for the swimmer with a shoulder injury.
Develop a general understanding of most common injuries sustained by female gymnasts and
identify potential risks involved in the excessive training at an early age common among female
gymnasts.
Acknowledge the implications that excessive, early training may have on hormonal and growth
processes in the young female athlete.
Describe the components of the female triad to enable prevention, identi cation, and treatment
of these components as a member of a multidisciplinary medical team.
Educate physically active females in proper exercise guidelines when planning for, during, and
after pregnancy with a thorough knowledge of the physiologic changes that occur during this
unique time.
T e visibility o the athletic emale, which has grown dramatically over the past century, is
now established throughout the world. At the beginning o the century, in 1902, the m od-
ern Olym pic Games were ounded, but women were excluded rom participation. At that
time, women’s sports were considered to be “against the laws o nature.”212 In 1972, itle IX
o the Educational Assistance Act was passed. T is was a pivotal point in the history o the
United States regarding emale participation in sports and exercise. itle IX states that “no
person in the U.S. shall, on the basis o sex, be excluded rom participation in, be denied
the benef ts o , or be subject to discrim ination under any educational program o action
receiving ederal f nancial assistance” 212, p. 841 A ter itle IX, a 600% increase was seen in
all levels o women’s athletic participation.211 Wom en and girls o all ages and abilities are
participating in sports in record high numbers. In act, 43.2% o collegiate athletes5 and
approximately 46% o Olympic athletes3 were emale as o publication o this text.
Participation in sports by girls and women continues to grow. T e National Federa-
tion o State High School Associations has collected data on sports participation across the
United States since 1971.6 In its most recent school year report, the National Federation
o State High School Associations reports 7,692,520 scholastic (high school aged partici-
pants) (both male and emale), the greatest number o participants ever. Likewise, the total
Gender Differences 1043
number o emales participating set an all time high with 3,207,533 participants.6 Basketball
remains the most popular high school sport or girls in the United States, with almost 18,000
participants, ollowed by track and f eld/ cross country, volleyball, so tball, and soccer.6
Studies by the National Collegiate Athletic Association (NCAA) describe a 10% increase
in participation across athletic programs or women rom 1989 to 1993.24 T e greatest single
rise in emale participants o 21.18% occurred during the 1982-1983 school year, as com-
pared to a 5.85% increase in male participants.6 T e NCAA reports that more than 100,000
women participate in intercollegiate sports each year; in act, this number is ast approach-
ing 200,000.5 T e most recently available participation report indicates that 195,657 women
participated in collegiate sports (43.2% o all participants), with the greatest number par-
ticipating in soccer, ollowed by track and f eld, so tball, and basketball. Currently, women
play in a wide variety o sports, play at many levels, are o ered the opportunity not only to
participate but also to gain monetary reimbursement (scholarship and pro essional sala-
ries) and media acclaim. As participation and notoriety has increased, so has the need to
understand the injuries being sustained by emale athletes.
With the increase in women’s participation in sport came an increased injury incidence
among emale athletes.43 It was common, even 15 years ago, or a emale athlete to receive
di erent treatment than a male with an identical injury. For example, women runners who
complained o tendonitis were o ten told to stop running, whereas men were given a spe-
cif c treatment protocol that combined rest with activity. T is is no longer commonplace.
No longer are male athletes predominant recipients o rehabilitation. Active emales are
being rehabilitated as requently as active males. T ere has been some suggestion that
emales are more susceptible to athletic injury than males176; however, current literature
indicates that injury patterns are more sport-specif c than gender-specif c.212,249 Nonethe-
less, there are several types o injuries, which seem to be more prevalent in the emale ath-
lete. Such injuries are o increasing concern to the sports medicine specialist.
One heavily researched area in the sports medicine arena is the increased rate o
anterior cruciate ligament (ACL) injury among emales when compared to males.212,237,270
Female athletes have a 4 to 6 times higher incidence o ACL injuries compared to their male
counterparts.133,206 Other injuries ound to be requent among emale athletes include patel-
lo emoral pain syndrome, spondylosis and spondylolithesis, stress ractures, bunions, and
shoulder pain.16,32,43,80,85,158,229,252 T e reasons or the high requencies o these types o inju-
ries in emales remain elusive but have been receiving more attention in the last decade.
T e media, medical, and rehabilitation communities have brought emale ACL injuries and
the emale athlete triad to the ore ront o attention (see later section “T e Female Athlete
riad”). A discussion regarding basic gender di erences serves as a basis or urther discus-
sion o injuries common to representative, individual sports, as well as other considerations
regarding the active emale.
Gender Di erences
Physiologic St rengt h Differences

Gender di erences between emales and males are evident in strength, aerobic capacity,
and endurance. T ese di erences become pronounced a ter puberty. Prepubertal boys
and girls have similar strength, and when corrected or lean body mass, and their V̇O 2
max is also similar.250,256 Endurance per ormance is just slightly better in boys than in girls
be ore puberty. However, these di erences may be a result o social rather than biologic
constraints, including the possibility o ewer role models or girls, less opportunities, and
di erent training programs.212,256 At puberty, these gender-related discrepancies are exag-
gerated because o both anatomical and physiologic di erences. T is time period seems to
be a time when emale athletes are particularly at risk, as a result o the hormonal, biome-
chanical, and unctional per ormance changes that occur.109,252
Skeletal muscle physiology in men and women does not di er signif cantly.251
estosterone and androstenedione are the androgenic hormones that are most important
in muscle f ber development. T ere is a variance in resting testosterone levels, but the aver-
age or emales is between one-tenth and one-hal the blood levels o males. Consequently,
men have greater potential or strength and power development related to testosterone
levels alone. When considering estrogen levels, women have higher levels than men, and
this hormone inter eres with muscular development as a result o its role in increasing body
at stores. A ter puberty, women typically have less lean body mass than men, especially
in the lower body, because o increased estrogen levels, and subsequent at body mass
increases.88 Average body at or a sedentary college-age woman is 23% to 27%, whereas
or a college-age man it is 15% to 18%. It is typical or some athletes (especially runners,
gymnasts, and ballet dancers) to demonstrate lower body at percentages because o the
per ormance and appearance demands o their sports. T ese two physiologic hormonal
di erences (body at and blood hormone levels) help to explain why muscle mass is
predictably lower in women than in men.88,275
Strength can be examined in 2 di erent ways. Absolute strength is the maximum
amount o weight one can li t (e.g. 50 lb). Relative strength relates this maximal amount to
an individual’s muscle mass (e.g. 80 lb o muscle mass can li t 50 lb).141 Men appear to dem-
onstrate larger absolute strength gains as a consequence o larger cross-sectional muscle
f ber size. However, the actual number o muscle f bers is similar between genders. When
examining relative gains in strength, studies show that women and men achieve similar
results while undergoing identical weight-training programs.141,196 “Because muscle cross-
sectional area (muscle f ber size multiplied by the number o muscle f bers) is directly
related to the ability to produce orce, individuals who have larger muscles are able to li t
more weight.”196, p. 4 able 31-1 provides examples o this conclusion.
When comparing strength to lean body mass (body weight without at) or cross-sectional
area, women are about equal to men and are equally capable o developing strength relative
to total muscle mass.196 Gender is irrelevant in the ability o a muscle to produce orce.196
Holloway and Baechle 141 were unable to show signif cant gender di erences in adapta-
tions to resistance training, except or the amount o muscle hypertrophy. Absolute strength
gains are a result o the combination o muscle hypertrophy and neuromuscular recruit-
ment. When diet is unchanged during a resistance training program, the average woman
responds with a decrease in intramuscular and subcutaneous at stores, and little change in
limb circum erence (less hypertrophy than males) mostly owing to lower testosterone levels
and smaller muscle f ber size.141,196,212 rue muscle hypertrophy is less visible in emales, but
improved muscular def nition is evident.196
able 31-1 Re lative Ve rsus Absolute Stre ngth in Fe male Ve rsus Male Athle te s
Female soccer player 125 lb With 15% body fat = 106 lb lean body mass
Absolute strength = 150 lb squat
Relative strength = 150/106 = 1.4
Male soccer player 155 lb With 12% body fat = 136.5 lb lean body mass
Absolute strength = 185 lb squat
Relative strength = 185/136.5 = 1.4
Note: Equal relative strength but greater absolute strength in demonstrated by the male soccer player.
Dore et al88 ound that males and emales exhibited sim ilar cycling peak power
until age 14 years. At age 14 years, loosely considered to be the transition to puberty,
males dem onstrated higher cycling peak power. Males had higher lean leg volume than
emales. As age increased, where there were similar lean leg volumes, males still showed
greater cycling peak power. Conclusions were two old: (a) the sex-related di erence can
be explained by the di erence in body composition, specif cally there is a lower limb at
increase in girls, whereas there is an increased lean body mass in boys; and (b) the ques-
tion o the possibility that di erences in neuromuscular activation exist, which could play
a role in peak muscle per ormance.88 Neuromuscular di erences are exam ined more
thoroughly later in this chapter, in the section entitled “Neuromuscular Di erences”.
So ar, no evidence exists to suggest that women should undergo strength training any
di erently than men. “Assuming equal nutrition, the rate and degree o improvement in
strength should be equal between genders. Signif cant gains in muscle strength and endur-
ance can be achieved by use o a training program 3 to 4 days a week.”196, p. 5 Once either gen-
der has reached a high level o competitiveness and muscularity, changes in muscle mass
and f ber content is minimal.17 However, women do show lower proportions o their total
lean body mass in their upper body, contributing to gender strength di erences that are
greater in the upper body than in the lower body. Nevertheless, hypertrophy and absolute
strength di erences evident between genders occur as a result o the physiologic changes
that occur at puberty.196
Anat omical Differences

Anatomical di erences are also a reason or variance in strength. Men and women’s bod-
ies respond di erently to similar weight training programs as a result o anatomical di er-
ences. T ese di erences include women are 3 to 4 inches shorter; are 25 to 30 lb lighter;
have 10 to 15 lb (8% to 10%) more body at; have 40 to 45 ewer pounds o at- ree weight
(bone, muscle, organs); have less muscle mass supported by narrower shoulders; and have
shorter extremities.196 “All these actors combined give men a mechanical advantage over
women, which enables them to handle more weight and generate more power.”196, p. 3 Broader
shoulders tend to benef t males in developing muscular strength in the upper body,
whereas wider pelvises seem to benef t emales in developing lower body strength. Men
with broader shoulders have a higher center o gravity than women with wider pelvises, giv-
ing men a superior mechanical advantage or gaining upper-body mass.196 T us, as previ-
ously stated, the largest di erence in absolute strength in emales versus males is ound in
the upper body as compared to the lower body.141
Structural di eren ces have been n oted between genders in both the upper and
lower extrem ities. In the upper body, structural di erences include narrower shoulders,
shorter arm lengths, decreased muscle f ber, and total m uscle cross-sectional area, and
according to som e authors, increased carrying angle o the orearm.196,250 When exam in-
ing structural di erences o the lower extrem ity between genders, multiple actors a ect
alignm ent. Wom en have greater am ounts o static external knee rotation, greater active
internal hip rotation, greater interacetablular distance, and increased hip width when
normalized to em oral length than m en.65 T ese actors contribute to greater knee valgus
(genu valgum ) angles in wom en. T e structural com bination o increased hip adduc-
tion and rotation, em oral anteversion, and genu valgum m ay explain the larger quadri-
ceps (Q) angle and rotational positioning o the lower extrem ity in wom en than in m en
( Figures 31-1 and 31-2). T e average Q angle or m en is 13 degrees and or wom en it is
18 degrees,61 but m easurem ent o the Q angle is exam iner dependent and can be erratic.
Lower-extrem ity structural di erences m ay play a actor in lower-extrem ity injuries in
the active emale.65 Structural di erences related to ACL injury are discussed in greater
detail later in this chapter, in section entitled “Intrinsic Factors”.
Pat ellofemoral Dysfunct ion

As previously m entioned, the larger Q angle ound in emales has been identif ed as a
predisposing actor to patello emoral dys unction, which plagues many active emales
regardless o sport or age. Anterior knee pain is one o the most com mon sources o com-
plaint am ong emale athletes.41 Most patello emoral dys unction can be categorized as
mechanical or in ammatory, with the rare exceptions o tum ors, regional pain syndrom e,
and re erred pain patterns.147 For the active emale, patello emoral dys unction should be
thoroughly evaluated to determine whether instability, malalignment, tracking abnormal-
ities (either o the patella itsel or the emur underneath it), compression orces, or m otor
control issues contribute to the anterior knee discom ort. Appropriate patellar mobility
should include su cient superior glide with active quadriceps contraction, as well as
equal medial and lateral glide.235 Increased patellar lateral glide indicates abnormal laxity
and instability when correlated with a positive apprehension test that simulates instances
o patellar subluxation or dislocation.147,235 Patellar instability is a mechanical cause o
anterior knee pain and occurs more requently in emales than in males.147 T e active
emale is more susceptible to patellar instability secondary to the anatomical alignment
and muscular strength di erences already described. However, contem porary thinking
supports m ore a biom echanical and m otor control approach to both the genesis and
treatm ent o patello em oral syndrom es and anterior knee pain.54 reatm ent o patellar
instability and other patello emoral diagnoses have been discussed in much greater detail
in Chapter 24.
Alignm ent observation should include not only Q-angle measurem ents but also
determination o tibial torsion, oot position, and leg-length discrepancies. Malalignment
may include superior or in erior position o the patella, medial or lateral patellar glide,
rotation, or tilt. Abnormal positions o the patella may include 1 or a combination o these
actors.190 Common patellar malalignment patterns include “grasshopper” or “squinting”
patella. A complete evaluation o muscular balance, including both exibility and strength
o the hip, pelvis, and thigh musculature, directs treatment to m inim ize these subopti-
mal patterns.190 McConnell patellar taping191 or the use o kinesiotape applications29 may
provide proprioceptive input to a ect patellar tracking and muscular recruitment. T ese
interventions provide symptomatic relie in many patients, which allows or a conservative
rehabilitation program to be completed.191
A static Q-angle m easurem ent is not as help ul as the sam e m easurem ent be ore
and during an activity such as a m inisquat to determ ine i the Q angle increases, dem on-
strating lack o optim al m otor control.147 Patellar tracking should be assessed to ensure
normal position o the patella within the trochlear groove throughout knee m otion. An
exam ple o abnormal patellar tracking is a J sign, when the exam iner observes the patella
jum p laterally (at approximately 30 degrees o exion) as the knee m oves rom exion
into extension and is associated with patello em oral sym ptom s.178,235 Conservative man-
agem ent o patellar tracking abnormalities, especially in the adolescent emale athlete,
should be the rule 147 and should be addressed systematically a ter a thorough evaluation
o the muscle im balance or exibility and strength. Neuromuscular training to address
recruitm ent patterns o both proxim al and thigh musculature, core stability, and bal-
ance def cits are elaborated upon later in this chapter. echniques to be discussed have
applicability with the rehabilitation program or m ost biom echanical causes o anterior
knee pain.
T is discussion o patello emoral dys unction illustrates the increased predisposition
to this injury complaint o the physically active emale based on the gender di erences in
anatomy and strength. A subsequent review o the neuromuscular di erences precedes
the discussion o another widespread knee injury that is more common in emale than in
male athletes.
Neuromuscular Differences
When comparing genders, research supports di erences in dynamic neuromuscular con-
trol o lower limb biomechanics.129,130,133,218,295 Neuromuscular control is a combination o
proprioception and the muscular systems’ response to the proprioceptive input. Imbal-
ances in quadriceps-to-hamstring ratios, di erences in jump-landing positions, weakness
in proximal hip musculature, higher landing orces, and lower gluteus maximus electro-
myographic (EMG) activity during landing are all reported in emales when compared to
males.132,145,295 Noyes et al218 conducted research using the drop-jump test with both male
and emale athletes that measured the distance between the hips, knees, and ankles in the
coronal plane during landing. Findings revealed no signif cant di erence between male
and emale subjects in mean knee and ankle separation distance during the landing and
takeo phases. Signif cant di erences between male and emale athletes were shown in
knee and ankle separation during the prelanding phase only (the 3 phases include takeo ,
prelanding, and landing). However, a ter a 6-week Sportsmetrics neuromuscular training
program 128 (Appendix A), emale athletes had statistically greater knee and ankle separa-
tion distances than those o males in all 3 phases o the jump-land sequence.207
Hewett et al130 went beyond the coronal plane and measured a drop jump-landing task in
emales with 3-dimensional motion analysis. Data were gathered on athletes prior to sports
participation. Athletes who had injured their ACL demonstrated signif cantly higher knee
abduction angles (knee valgus) at initial contact and increased maximal limb displacement
than did those who were uninjured. Peak vertical ground reaction orce corresponded with
knee abduction angle. T e greater the abduction angle, the greater the ground reaction orce
in ACL-injured athletes but not in uninjured athletes. Athletes who sustained ACL injuries
“demonstrated signif cant increases in dynamic lower extremity valgus and knee abduction
loading be ore sustaining their injuries compared to uninjured controls.”130, p. 497 Maximum
knee exion angle at landing was 10.5 degrees less in injured than in noninjured athletes.
T ese di erences suggest decreased neuromuscular control or alternative strategies or unc-
tion in the lower extremity o emales as evidenced by biomechanical di erences observed.12,30
Coactivation o the quadriceps and hamstrings is an important protective mecha-
nism at the knee joint or protection against not only excessive anterior shear orces but
also knee abduction and dynamic lower-extremity valgus orces.34 Female athletes have
lower hamstring-to-quadriceps-strength ratios than males during isokinetic testing at
300 degrees per second.129 When the hamstrings are underrecruited, relative overrecruit-
ment o the quadriceps may result. T is recruitment strategy used by emales may directly
limit the potential or balanced muscular cocontraction, which aids in protecting liga-
ments.130 It has also been postulated that males may use a protective mechanism involv-
ing the hamstrings, considered to resist anterior tibial translation, to counteract high-peak
landing orces. Females tend to contract their quadriceps f rst in response to an anterior
tibial translation, which provides additional anterior translation, whereas males responded
by contracting their hamstrings f rst, thereby limiting the anterior translation. With these
f ndings, it is suggested that emales tend to be “ligament-dominant” in their joint strate-
gies, whereas males demonstrate more “muscle-dominant” joint strategies.133
Greater knee abduction angles during jump-stop unanticipated cutting activity were
also described by Ford et al.105 Females demonstrated greater knee abduction angles (knee
valgus) at initial contact than their male counterparts. Greater knee abduction angles sup-
port the concept o ligament dominance rather than muscular control to absorb the ground
reaction orce during sporting maneuvers. In such a movement strategy, the athlete is allow-
ing the ground reaction orce to control the direction o motion o the knee joint, which, in
turn, causes the ligaments to take up a disproportionate amount o orce.105
Proximal hip musculature activation is also ound to di er between genders. Zazulak
et al295 reported that emale athletes demonstrated less activity o the gluteus maximus
compared to males during the landing phase o a single-leg drop jump. Decreased activa-
tion o proximal hip stabilizers may contribute to the valgus landing position observed in
emale athletes. Greater rectus emoris activity was also observed in emales compared to
males during the precontact period o the jump. T is is postulated to place an increased
anterior sheer orce on the tibia during landing. T e authors concluded that these 2 f ndings
together may contribute to altered kinetic energy absorption during landing, as well as caus-
ing increased ground reaction orces and high valgus torques contributing to knee injury.295
Female sex hormones may also have signif cant e ects on neuromuscular control.
Estrogen has both direct and indirect e ects on the neuromuscular system. During the
ovulatory phase, there is a slowing o muscle relaxation. T roughout the menstrual cycle,
estrogen levels uctuate radically. Fluctuating hormone status has pro ound e ects on
muscle unction,253 tendon and ligament strength, and the central nervous system.133
Hormonal in uences on neuromuscular control is discussed urther in the ACL section o
this chapter. Clearly, neuromuscular patterning and per ormance is a ected by many actors.
Anterior Cruciate Ligament Injuries

With higher participation rates o emales at all levels, increased sport-related injuries
were expected; however, what was unexpected was the disproportionate number o knee
ligament injuries that occur. T e most serious injury that has risen to the ore ront o
attention is injury to the ACL o emales. A pattern o disproportionately high ACL injury
rates in emales, compared to their male athlete counterparts, was identif ed. For example,
during the 1989-1990 intercollegiate basketball season, the NCAA Injury Surveillance
System data showed that emale athletes injured their ACLs 7.8 times more o ten than
males,228 and this trend continues. Sports that appear to have high risk, at all levels o
play, involve jumping, rapid deceleration, and cutting maneuvers. Sports such as soccer,
basketball, volleyball, team handball, and gymnastics have been identif ed as high-risk
sports or the emale athlete.24,25,44,63,71,87,103,115,127,132,171,180,195,222,247,261,296,298 In act, more than
30,000 serious knee injuries in emale athletes at the high school and intercollegiate levels
are projected to occur yearly in the United States.125
T e costs o ACL injuries are dramatic, not only f nancially (medical and rehabilitation
services) but also in terms o long-term consequences, such as concurrent injury (such as
articular cartilage or meniscus), lost playing time, lost scholarships, and increased potential
or long-term posttraumatic osteochondral degeneration and disability.112,119,289 According
to Ireland,148,150 even in the era where prevention has been deemed important, emales con-
tinue to experience a higher rate o injury to the ACL than their male counterparts. What
is especially troubling is that even as years have passed and emale athletes begin sports
play earlier, train harder, and receive improved training and coaching, their injury rate has
not declined.150 T ere ore, the present ocus remains less on reporting injury statistics and
hypothesizing about potential causes and continues in the era o prevention. Prevention o
ACL injuries in the emale athlete has become a priority or the sports medicine, rehabilita-
tion, and research communities.
Mechanisms of Injury
As more women and girls participate in sports, much attention has been given to under-
standing the mechanisms o ACL injuries. Many authors have described 2 mechanisms o
injury: contact and noncontact.24,25,146,218 Approximately 30% o all ACL injuries are classi-
f ed as contact injuries, and the remaining 70% are not related to direct contact and clas-
sif ed as noncontact.119 Some authors have reported that as many as 75% o sports-related
Anterior Cruciate Ligament Injuries 1049
injuries to the ACL are via noncontact mechanisms.219 Contact injuries are easily discerned
rom the clinical history surrounding the injury and typically occur during contact sports
like ootball and rugby. In contrast, the mechanisms and activities that are involved in non-
contact ACL injuries are less apparent and vary between sports. Sports that are at high risk
or, and incur, many noncontact ACL injuries are those classif ed as noncontact or collision
sports such as basketball, soccer, volleyball, gymnastics, and team handball.23,25,31,111,150,283
Early writing by Henning in the late 1980s in uenced much o the current thinking
about the mechanisms o noncontact ACL injuries.119 A ter studying injuries incurred by
emale basketball players over a 10-year time span, Henning concluded that the 3 most
common mechanisms o injury were 119:
• Planting and cutting (29% o all injuries)
• Straight-knee landings (28% o all injuries)
• One-step stop with the knee hyperextended (26% o all injuries)
Henning concluded that prevention and skill development (especially in the emale
athlete) must incorporate the opposite o the previously mentioned motor behaviors,
including:
• T e accelerated rounded turn, per ormed o a exed knee
• Bent knee landings
• T e 3-step stop
T ese motor behaviors are addressed more thoroughly later in the chapter in the sec-
tion on prevention and training.
Subsequently, many mechanisms have been described or contributing to noncontact
injuries, including sudden orce ul twisting motions with the oot planted,194 planting/ side-
stepping/ cutting maneuvers,77 “out o control play,”119, p. 142 landing,49,103 and deceleration
maneuvers.119 Video analysis o ACL injuries that occurred during the play o basketball
and soccer demonstrated that women were injured most commonly when landing rom a
jump and when they suddenly stopped running.119 It is very interesting to note that women
and girls have been shown to per orm landing and cutting activities with more erect posture
than men, and there ore place themselves at greater risk or ACL injury.119 Video analysis o
actual ACL injuries demonstrated that the position o the lower limb at the time o injury is
o ten knee exion less than 30 degrees, a position o knee valgus, and external rotation o
the oot relative to the knee (Figure 31-3).49,119,128
Postural and positional variations in motor skills, when combined with greater valgus
alignment and increased quadriceps activation, may urther increase the possibility o injury
or the emale athlete.132 otal positional control o the lower extremity is important, both
in terms o exion/ extension and varus/ valgus. Low exion angles (commonly described as
less than 45 degrees exion) increase the anterior strain on the ACL when active quadriceps
contractions occur. T e quads act as the ACL antagonist and add to the anterior/ posterior
straight plane load sustained by the ACL. Likewise, increased varus/ valgus positioning o the
lower extremity adds torque to the knee that challenges the ACL in its derotational unction.
Factors to explain the position o the lower extremities o emales during landing may include
def cits in proximal muscle strength and endurance as well as neuromuscular skill actors.
Finally, related to im pact during landing, current research suggests that strategies
di er in emales as com pared to m ales. T is m ay be a result o biom echanical actors,
poorer m uscle stren gth an d/ or n eurom uscular control, or insu cient strategies or
shock absorption, as previously discussed.169 Du ek and Bates 94 exam ined the relation-
ship between lan ding orces an d in jury stating that m any injuries that occur durin g
jum ping sports occur during landing. Male athletes appear to em ploy di erent m ech-
anism s to com pen sate or high landin g orces than do em ales.129,132 Markol et al186
dem onstrated that m uscular contraction can decrease both the varus and valgus laxity
o the knee when landing. Jum ping and landing are addressed in greater detail in a later
section entitled “Knee Kinematics and Landing Characteristics”.
In summary, although women do sustain contact mechanism ACL injuries, the vast
majority appears to occur by noncontact mechanisms. According to the Hunt Valley Con-
sensus con erence,119 “T e common at-risk situation or noncontact ACL injuries appears
to be deceleration, which occurs when the athlete cuts, changes direction, or lands rom a
jump.”119, p. 149
Although many studies o er strong support or noncontact mechanisms o injury as
prevalent in the emale athlete,25,118,180,207,208,279 Ireland maintains that the “true incidence o
noncontact ACL injuries and the actual numbers o athletes a ected are di cult to deter-
mine.”150, p. 150 T e discrepancy between ACL injury rates by sex and mechanism o injury,
at all levels o sport participation, remains a hot topic in sports medicine. Fortunately, neu-
romuscular control, balance, and motor skill training all appear to be critical modif able
actors associated with injury prevention.
Fact ors Relat ed t o Ant erior Cruciat e Ligament

Injury in t he Female At hlet e
Why women continue to sustain 2 to 8 times more ACL injuries than their male counter-
parts continues to be an unanswered question or researchers in many disciplines. Clearly,
injuries to the ACL occur as a result o complex interactions o anatomical, biomechani-
cal, neuromuscular, hormonal, and environmental actors. Various actors have been sug-
gested to explain these di erences and are categorized by many authors as intrinsic ( actors
that are not controllable) and extrinsic ( actors that are controllable).22,24,118,124,146,150 More
recently, a third category o actors, described as “both” or partially controllable has been
described by Ireland ( able 31-2).150
Int rinsic Fact ors

Intrinsic or noncontrollable actors have been described as hormonal e ects o estrogen,
inherent ligamentous laxity present in emales, and other anthropometric di erences in
men and women, such as lower-extremity alignment, notch width, and ACL size.
able 31-2 Summary o f Facto rs Sug g e ste d to Co ntribute to ACL Injury

in Fe male Athle te s
Intrinsic Facto rs Extrinsic Facto rs Co mbine d Facto rs
Lower-extremity alignment Strength Proprioception

• Q angle/pelvic width • Balance
Endurance
• Varus/valgus of the knee • Position sense
Shoes/footwear
(see Figures 31-2 and 31-10) Neuromuscular control
• Foot alignment Motivation
Muscular ring order
Hyperextension Kinematics of movement
(See Figures 31-4, 31-5, 31-8,
Physiologic rotatory laxity
and 31-10A, B)
ACL size
Notch size and shape Acquired skills
• Sport-speci c motor programs
Hormonal in uences
Inherited skills/coordination
Na rrowe r
pe lvis
Wide r pe lvis
Fe mora l
a nte ve rs ion
Incre a s e d fle xibility/

hype re xte ns ion Le s s fle xibility
Ge nu va lgum Ge nu va rum
Exte rna l tibia l Inte rna l or
tors ion ne utra l tibia l
tors ion
Figure 31-1 Structural diffe re nce s be tw e e n me n and w o me n
Women (left ) typically exhibit a wider pelvis, femoral anteversion greater tibial external
rotation, and genu valgum. (Reproduced from Grif n LY. Rehabilitation of the Injured Knee .
St. Louis, MO: Mosby-Year Book; 1995, with permission from Elsevier.)
Ante rior s upe rior

ilia c s pine
Incre a s e d fe mora l
Q a nte ve rs ion
Q
Exce s s ive Q-a ngle
P a te lla Exce s s ive la te ra l
force s
Tibia l tube rcle
P a te lla s ubluxa tion
Exte rna l tibia l

tors ion
Foot prona tion
Figure 31-2 Ge nde r diffe re nce s in Q ang le
Women (right ) exhibit a greater Q angle, increased external tibial torsion, and femoral
anteversion. (Reproduced from Grif n LY. Rehabilitation of the Injured Knee . St. Louis,
MO: Mosby-Year Book; 1995, with permission from Elsevier.)
Investigation regarding notch width and ACL size has demonstrated

emales to have smaller notches and smaller ACLs than males22,144,269,279; how-
ever, the evidence correlating this with injury is contradictory.133 Regardless,
there is little or no opportunity or reasonable intervention, and these areas
have been researched less in the last several years. Likewise, although laxity
is greater in emales than in males,248 there is con icting evidence regarding
the relationship o laxity to injury. Exercise-induced laxity that occurs a ter
30 minutes o athletic activity may play a role in ligament injury and relate to
neuromuscular protective training.272 Finally, investigations o Q angle in rela-
tionship to injury demonstrate that injury rate di erences between males and
emales could not be accounted or by the di erences in anatomy.118
Research e orts have been dedicated to understanding the interaction
between emale sex hormones and ACL injuries. Because the emale sex hor-
mones estrogen, progesterone, and relaxin are cyclical and a ect ligaments,
they may play a role in uctuation in both strength and laxity o the ACL.133,289
Con icting research evidence exists as to what portion o the menstrual cycle
is the most “risky,”25,26,288,289 and whether the e ects o hormones (estrogen,
especially) may be greater than just on the ligament itsel and may extend to
changes in motor skill.133,236 Originally, the ovulatory phase was described as
the time during which most injuries occurred.289 More recently, Slauterbeck
and Hardy263 ound that many injuries occurred around menses. In their most
recent work, Wojtys et al288 described that more ACL injuries than expected
Figure 31-3 Typical po sitio n (43%) occurred during the ovulatory phase (in all emales) and ewer injuries
o f ACL injury than expected occurred during the luteal phase (34%). T e distribution o
injury by phases was di erent or those women who were taking oral contra-
Note that knee valgus, foot external ceptives, with only a trend toward more injuries in the ovulatory phase (29%),
rotation, and knee exion are less than and ewer injuries than expected during the ollicular phase (14%), demon-
30 degrees. strating the potential or some protection o ered by use o oral contraceptives.
Möller-Neilson and Hammer 199 also reported decreased injury rates in women
who used oral contraceptives.
T e e ects o hormones may extend beyond their e ect on the ACL itsel . Evidence sug-
gests that the neuromuscular system may be signif cantly a ected by the uctuating milieu
o emale sex hormones.133,166 Estrogen may have e ects on neuromuscular patterning and
per ormance throughout the menstrual cycle, but seems to decrease motor skills in the pre-
menstrual phase.175,236
Clearly, the relationship between emale horm ones and ACL injuries remains con-
troversial, not only in term s o susceptibility o ligam ents to injury but also in term s o
m echanism and location o action. It is not clear whether horm ones in uence muscle
unction and motor skills,236 the neuromuscular system,133,175,230 or cerebral/ central ner-
vous system unction.165,236,288 Interestingly, over the last several decades, suggestions or
control o intrinsic actors have been given, such as notchplasty and hormonal manipula-
tion or protection o the ACL in emales. T ese examples were not received with much
zeal by the m edical com munity and were never accepted as reasonable interventions.
Most in sports medicine agree that to reduce the number o ACL injuries sustained by the
emale athlete, attention must be paid to actors that are modif able,150 such as extrinsic
or combination actors.
Ext rinsic Fact ors

Extrinsic or controllable actors are parameters such as leg strength (both total absolute
strength and hamstrings/ quadriceps ratios), muscle recruitment order, muscle reaction
tim e, playing style, training/ preparation, coaching/ conditioning, skill acquisition, and
sur aces o play.146,150,290
Generation o muscular orce is a key element in providing dynamic stability about
joints. T e inability to control external orces may result in injury to the static structures
providing stability to that joint. T e inherent physiologic di erences in muscle mass and
hormonal levels o testosterone between males and emales make it predictable that males
will always be stronger than emales. I body mass is accounted or and subjects o similar
activity levels are compared, does this inequality still exist?
Huston and Wojtys 145 tested this hypothesis using isokinetic testing and concluded
that athletic emales and a control group o em ales were both statistically weaker in
quadriceps and ham strings muscle strength at 60 degrees per second, as com pared to
their male counterparts. Other researchers have also docum ented that wom en have less
muscle strength in the quadriceps and ham strings than men, even when normalized or
body weight.122 Anderson et al22 also tested the quadriceps and ham strings isokinetically
at 60 and 240 degrees per second and ound sim ilar results. With corrections or body
mass, the male athletes generated greater peak torque, greater work, and average power
outputs than the emale athletes or both quadriceps and ham strings ( p < 0.05).22 Knapik
et al158 determ ined that emale athletes with a ham string muscle group m ore than 15%
weaker than the other side were 2.5 tim es m ore likely to sustain a lower-extrem ity injury.
T ey also reported that this side-to-side im balance in ham string strength existed in 20%
to 30% o emale athletes.
Previous research illustrates the importance o hamstring strength and endurance in
acting as an agonist to the ACL or dynamic knee joint stability.22,90,145,247 T e hamstring
muscles have been shown to be protective o the ACL because o their ability to shield the
ACL rom excessive anterior shear and strain. I the hamstrings are to e ectively counter-
act the torque produced by the quadriceps, they must demonstrate a certain percentage
o strength as compared to the quadriceps they are opposing. Knapik157 also reported that
athletes with a hamstring-to-quadriceps ratio o less than 0.75 were 1.6 times more likely to
be injured. Isokinetic testing by Moore and Wade 200 revealed that hamstring-to-quadriceps
ratios in emales were signif cantly lower than those in males at 60, 180, and 300 degrees
per second. Huston also determined that emales had hamstring-to-quadriceps ratios in
the 0.40 range.145 Eccentric hamstrings-to-quadriceps ratio was also signif cantly weaker in
emale athletes as compared to male athletes.202 It has been hypothesized that hamstring-
to-quadriceps ratios lower than 0.60 may predispose an athlete to ACL injury.131
As indicated previously, strength def cits in the emale athlete are evident and may play
a role in predisposing the emale to an ACL injury. I strength may play a role, how does
the endurance mode o these muscles play a role in knee stability and injury vulnerability?
A study conducted by Rozzi et al247 demonstrated that both males and emales had a
decrease in the ability to detect joint motion moving into the direction o extension, an
increase in the onset time o contraction or the medial hamstring and lateral gastrocne-
mius muscles in response to landing a jump, and an increase in the electromyogram o
the f rst contraction o the vastus medialis and lateralis muscles while landing a jump
when atigued.234 Research by Zhou et al297 has shown electromechanical delay o the knee
extensors to increase by 147% a ter muscular atigue. Nyland et al220 looked at the e ects
o eccentric work-induced hamstring atigue on sagittal and transverse plane knee and
ankle biodynamics and kinetics during a running, crossover cut, or directional change.
T ey determined that hamstring atigue created decreased dynamic transverse plane knee
control demonstrated by increased knee internal rotation during heel strike. Peak ankle
plantar exion moment and decreased knee internal rotation magnitude during the propul-
sion phase o the cutting maneuver when atigued is believed to represent a compensatory
attempt or knee dynamic stability rom the gastrocnemius and soleus.220 Wojtys et al290 also
demonstrated the e ect o atigue on knee joint stability. When the quadriceps and ham-
strings were exercised to a point o atigue, there was resultant increase in tibial movement,
causing increased vulnerability to ACL injury.290
Combined Fact ors

More recently, combined or partially controllable actors have been suggested as those that
have contributions inherent to the individual (intrinsic actors) combined with those that
are more extrinsic in nature and, there ore, able to be modif ed.145 Examples o combined
actors are proprioception and neuromuscular control. Both o these actors are a ected by
an individual’s genetic makeup, but can be taught, to some extent, by structured programs
to address their areas o def ciency.119,129,131,132
Proprioception has been def ned as the culmination o all neural inputs originating
rom joints, tendons, muscles, and associated deep-tissue proprioceptors. T ese inputs into
the central nervous system result in the regulation o re exes and motor control.131 T e body
receives proprioceptive in ormation by three separate systems. T ey include the visual sys-
tem, the vestibular system, and the peripheral mechanoreceptors. When discussing injuries
to the ACL, the role o the mechanoreceptors has been the primary ocus in the literature.
Researchers agree that the ACL does contain mechanoreceptors, but i the central nervous
system has a decreased sensory eedback rom the knee, there is a decreased ability to stabi-
lize the knee joint dynamically. T is places the knee at risk or injury, either microtrauma or
macrotrauma.140 Following injury to the capsuloligamentous structures, it is thought that a
partial dea erentation o the joint occurs as the mechanoreceptors become disrupted. T is
partial dea erentation, which is secondary to injury, may be related to either direct or indi-
rect injury. Direct trauma e ects would include disruption o the joint capsule or ligaments,
whereas posttraumatic joint e usion or hemarthrosis154 can illustrate indirect e ects.
Whether a direct or indirect cause, the resultant partial dea erentation alters the a erent
in ormation into the central nervous system and, there ore, the resulting re ex pathways to
the dynamic stabilizing structures. T ese pathways are required by both the eed- orward
and eedback motor control systems to dynamically stabilize the joint. A disruption in
the proprioceptive pathway will result in an alteration o position and kinesthesia.36,262
Barrett38 showed an increase in the threshold to detection o passive motion in a majority o
patients with ACL rupture and unctional instability. Corrigan,73 who also ound diminished
proprioception a ter ACL rupture, conf rmed this f nding. Diminished proprioceptive
sensitivity has also been shown to cause giving way or episodes o instability in the ACL-
def cient knee.51 Rozzi et al248 tested proprioception by measuring knee-joint kinesthesia
as the threshold to detection o passive motion while moving either the direction o knee
exion or extension. T e study determined that emales took signif cantly longer than the
males to detect joint motion moving in the direction o knee-joint extension implicating
the hamstrings as def cient in proprioception. Injury to the capsuloligamentous structures
not only reduces the joint’s mechanical stability but also diminishes the capability o the
dynamic neuromuscular restraint system. T ere ore, any aberration in joint motion and
position sense will impact both the eed- orward and eedback neuromuscular control
systems. Without adequate anticipatory muscle activity, the static structures may be
exposed to insult unless the reactive muscle activity can be initiated to contribute to
dynamic restraint.
T e reader is re erred to the previous section on gender di erences to review the vari-
ous neuromuscular control actors that vary rom emale to male. In re erence to the emale
athlete and ACL injuries, the ollowing specif c variables will be examined: the muscle f ring
patterns o the lower extremity with physical tasks, the timing o those muscular responses,
and the kinematics and joint position o the lower extremity during activity.
Muscular Act ivat ion and Timing Pat t erns

In a study conducted by Huston and Wojtys,145 di erent muscular f ring patterns were
illustrated between emales (control and athlete group) and males (control and athlete
group). T ey tested m uscular respon se to anterior translation o the tibia usin g EMG
recordin gs during a relaxed response to m ovem ent and a voluntary m uscle contrac-
tion response to m ovem ent. All 4 groups recruited the gastrocnem ius m uscle f rst in the
relaxed response to anterior translation o the tibia. T e spinal level o muscle f ring pat-
tern was gastrocnem ius-ham string-quadriceps or all groups, but as the translation o
the tibia continued in the relaxed response phase o the testing, em ale athletes relied
m ore on quadriceps activity than on ham strin gs to stabilize their kn ee. T e predom -
inant m uscle recruitm ent order o the m ale athletes an d both control groups was the
ham string-quadriceps-gastrocn em ius muscle pattern. In contrast, the em ale athletes
recruitm ent pattern was quadriceps-ham strin g-gastrocnem ius. During the voluntary
muscle contraction response, the emale athletes dem onstrated the sam e response as
the emale controls and both m ale groups. T is pattern was ham string-quadriceps-gas-
trocnem ius. T ese results support the concept o “quadriceps dom inance” in emale ath-
letes in term s o m uscular recruitm ent.
With respect to the muscle reaction tim e in this study, no signif cant di erences
were ound at the spinal cord level or the quadriceps and hamstrings; however, the male
and emale athletes produced signif cantly aster gastrocnem ius muscle responses com -
pared to the two control groups. In the interm ediate phase o the relaxed response test-
ing and the voluntary response to tibial translation, there was no signif cant di erence
or all muscles between all 4 groups. When testing muscular strength and time to reach
this peak orce utilizing isokinetic testing, Huston and Wojyts 145 ound no di erences in
time-to-peak torque or knee extension at 60 and 240 degrees per second or all groups.
Signif cant di erences did exist between male and emale athletes or ham string tim e-
to-peak torque at 60 and 240 degrees per second. T e emale athletes were statistically
signif cantly slower than the male athletes and m inimally slower than the emale con-
trol group, although this di erence was not statistically signif cant.145 Contrary to Huston
and Wojyts, Rozzi et al248 did not f nd sex di erences in the tim e-to-peak torque tested
isokinetically or either ham strings or quadriceps. T is same study did f nd signif cantly
greater EMG peak am plitude o the lateral hamstrings or the emale athletes when land-
ing rom a jum p on 1 leg. T e authors stated that this f nding may be related to the idea
that emale athletes possess inherent joint laxity and the ham strings must activate at a
higher level to provide stability to the joint.248
T e latency period between sensory eedback and dynamic movement is known as
electromechanical delay and has been shown to be shorter in males compared to emales,
thus allowing superior e ciency o dynamic stabilization in males.170
DeMont et al86 studied the muscular activity be ore oot strike in various unctional
activities or ACL-def cient subjects, ACL-reconstructed subjects, and a control group, and
compared involved to uninvolved legs o each subject. All subjects were emale. T e tasks
consisted o downhill walking, running, hopping, and landing rom a step. Di erent bilat-
eral activation o vastus medialis obliques occurred with downhill walking and running
activities or the ACL-def cient group. T e ACL-def cient group also showed a signif cant
increase in vastus lateralis activation during running and landing when compared bilater-
ally and also when compared to ACL reconstructed and control group subjects. Activation
o the lateral gastrocnemius was lower in downhill walking and higher in the landing task
in the ACL-def cient group also. T e ACL-reconstructed group showed signif cant di er-
ences between the involved and uninvolved limb in the lateral gastrocnemius or the hop.
T ese side-to-side di erences or the ACL-def cient and ACL-reconstructed groups, and
group di erences between ACL-def cient and control groups, suggest that the emales with
an ACL-def cient knee use unique strategies involving the vastus medialis obliques, vastus
lateralis, and lateral gastrocnemius, and these muscles need to be addressed in the reha-
bilitation process. A similar study per ormed by Swanik et al274 demonstrated ACL-def cient
subjects to exhibit greater peak activity (as measured by isometric electromyography) in the
medial hamstring in comparison with the ACL-reconstructed group and greater peak activ-
ity in the lateral hamstring than the control group during running. During landing rom a
step, the ACL-def cient group demonstrated signif cantly less isometric EMG activity in the
vastus lateralis when compared to the control group. T ese f ndings suggest the importance
o the hamstrings in controlling anterior tibial translation and rotation, as well as their pos-
sible role in inhibition o the quadriceps in an e ort to dynamically stabilize the knee in the
ACL-def cient knee.
For dynamic stabilization to occur at the knee, many muscles are involved that directly
pass around the joint as well as other muscles that are distally and proximally positioned
but play a role in controlling the orces at the knee. Baratta et al34 investigated muscular
coactivation patterns at the knee. Subjects consisted o nonathletes, recreational athletes,
and highly competitive athletes, and EMG data were collected during an isokinetic strength
test. High-per ormance athletes with hypertrophied quadriceps had inhibitory e ects on
the coactivation o the hamstrings compared to the recreational athletes. T ey also deter-
mined that athletes who routinely exercised their hamstrings demonstrated inhibited quad-
riceps and had coactivation patterns similar to those o the nonathletes. Muscular balance
is key to e cient dynamic joint stabilization.
Muscle sti ness is important to stability o the knee and demonstrated when muscles
surrounding the knee contract, o ering the joint increased contact orce and decreased joint
mobility. Markol et al186 reported that nonathletes could increase varus and valgus knee
sti ness 2 to 4 times with isometric contraction o the hamstrings and quadriceps. Athletes
in the same study were able to increase their joint sti ness by a actor o 10 with the same
isometric contraction. Bryant and Cooke 56 demonstrated gender di erences in knee sti -
ness in a study in 1988. When testing varus and valgus sti ness, emales rotated at the tibia
66% more than the males and were 35% less sti . Another study that looked at gender di -
erences in the anterior-posterior plane o motion determined a signif cant di erence in
emales, and males, ability to sti en the knee joint. Men were able to increase their joint
sti ness by 4 times, whereas the emales were only able to sti en their joint by 2 times.146 T e
exact mechanism o knee sti ness is not completely understood, although a study by Such
et al determined that lower-extremity muscle mass had the largest in uence on the sti ness
properties o the knee.273
Knee Kinemat ics and Landing Charact erist ics

As noted in the previous section on the mechanisms o injury, it is well documented in
the literature that most o the ACL injuries occur when landing rom a jump or during
deceleration and pivoting. It has been documented that the quadriceps exerts its maximum
anterior sheer orce when the knee exion angles are the smallest (20 to 25 degrees exion),
which places a measurable strain on the ACL.260 Eccentric activation o the quadriceps at
high velocities present during athletic movements may produce too much orce or the
static and dynamic stabilizers o the knee to resist, thus allowing injury to occur. EMG
studies demonstrate eccentric quadriceps muscle activation during such activities as
running, cutting, and landing rom a jump to be more than 2 times greater than maximum
voluntary contraction.119 It has also been docum ented in the literature that there is a
signif cant di erence in how males and emales per orm the previously noted movement
patterns.
Malinzak et al179 were one o the f rst research groups to investigate these kinematic
gender di erences. EMG and 3-dimensional kinematic analyses o cutting and running
were obtained rom male and emale athletes. Females demonstrated signif cantly less knee
exion, increased knee valgus, and decreased hip exion than males during both o these
movement patterns. Females also had greater quadriceps and lower hamstring activation
levels especially at heel strike.144 Colby et al72 investigated 4 di erent cutting maneuvers
in males and emales using 2-dimensional video analyses and electromyography and had
similar results as Malinzak et al.179 T e average knee exion angle was 22 degrees or each
cutting maneuver. Quadriceps activity was 161% o the maximum voluntary isometric con-
traction as compared to 14% o the maximum voluntary isometric contraction or ham-
string activity.72 T is urther demonstrates the “quadriceps/ -dominant” state and how weak
hamstrings or hamstring/ quadriceps muscular imbalances present in emale athletes could
contribute to their susceptibility or ACL injuries.
Lephart et al170 also investigated strength and lower-extremity kinematics during land-
ing. Single-leg landing and orward hop tasks were studied using electromyography and
orce plates with emale basketball, volleyball, and soccer players, and matched male sub-
jects. T is study also tested strength o the quadriceps and hamstrings via isokinetic test-
ing. T e ollowing results were all signif cant at the level o p < 0.05. For single-leg landing,
emales had greater hip internal rotation, less knee exion, and less lower-leg internal rota-
tion. T e emales also had signif cantly less time to maximum angular displacement o knee
exion. During the orward hop task, emales had less knee exion, less lower-leg internal
rotation, and more time to maximum angular displacement or hip internal rotation and
less time to maximum angular displacement or knee exion. T ere were no signif cant di -
erence or vertical ground reaction orce variable or both landing and hopping tasks. Iso-
kinetic testing revealed signif cant lower peak torque to body weight or knee extension and
exion (p < 0.05). Overall, the emales landed in a more valgus position and with less knee
exion, thus less time or absorption o the impact orces. T e weakness demonstrated in
the quadriceps and hamstrings may also play a role in the landing kinematics.170
In a ollow-up study to Malinzak, Chappel et al64 hypothesized that emale recreational
athletes would have increased proximal anterior tibial shear orce, knee extension moment,
and knee valgus moment while per orming orward, backward, and vertical stop-jumps.
T e results o this study are similar to those o previous studies. Women exhibited greater
proximal tibia anterior shear orce than did men during the landing phase o all jumps. All
subjects exhibited greater proximal tibia anterior shear orce during the landing phase o
the backward stop-jump task than during the other 2 stop-jumps. Women also exhibited
greater valgus and extensor moments than did the males or all 3 stop-jumps.
Ground reaction orce di erences during landing are an interesting kinematic vari-
able to examine between males and emales. Du ek and Bates94 examined landing orces
and pointed out that higher landing orces had a positive relationship with injury occur-
rence. Hewett et al132 examined the results o a neuromuscular training program and deter-
mined that the training program resulted in signif cant decreases in peak landing orces
and decreases in valgus-varus moments at the knee. T ey indicated that the valgus-varus
moments at the knee served as signif cant predictors o peak landing orces. T is same
study demonstrated that the males’ landing orces were an average o 2 bodyweights greater
than the emales, yet they have lower rate o serious injury. It has been hypothesized that
high landing orces by the males are dissipated through increased knee exor activity at the
instant o landing and greater angular knee exion at landing. Both o these strategies may
allow males to dissipate ground reaction orces more e ciently.
T e previously mentioned studies have all looked intimately at the knee joint. But what
e ects do the trunk, hip, and ankle have on the kinematics o the knee joint? Bobbert and
van Zandwijk48 described, in their research, the knee being “slaved” to the moment pro-
duced at the hip. It has been theorized that, because most emales have weak hip extensors,
they use the iliopsoas or trunk control over their hips and land in a more erect posture
and have greater extensor moments at the knee. Decreased trunk exion also decreases
maximal quadriceps and hamstrings activation, thus decreasing dynamic stabilization
directly at the knee joint. Observation o videotapes o ACL injuries has demonstrated that
two-thirds o the injuries occurred when the center o gravity appeared behind the knee.
Another theory regarding this variable is that during upright landings, the rectus emoris
may act as a hip stabilizer and pull the trunk orward. T is power ul contraction by the
rectus emoris may also produce a large tibia anterior shear orce. More research needs to
be per ormed to prove or disprove these theories, but trunk and hip control appear essen-
tial to e cient athlete maneuvers and should be part o all prevention and rehabilitation
programs.
In summary o the extrinsic and combined actors that may predispose the emale ath-
lete or higher incidence o ACL injuries, the ollowing items were revealed:
1. Females are weaker in their quadriceps and hamstrings as compared to males.
2. Females have a lower hamstring-to-quadriceps ratio as compared to males.
3. When both men and women are atigued, the stability o the knee joint is
compromised.
4. ACL-def cient subjects have decreased proprioception.
5. Females are slower to detect proprioception as measured by detection o passive
movement in the direction o knee extension as compared to males.
6. Females use more o a quadriceps-hamstring-gastrocnemius muscle f ring pattern
in response to anterior tibia translation and males use more hamstring-quadriceps-
gastrocnemius pattern.
7. Females are slower to reach peak torque or the hamstring group as compared to
males.
8. Females have a longer electromechanical delay between stimulus and action as
compared to males.
9. Females demonstrate a decrease in muscle sti ness and thus decreased ability to
stabilize knee joint as compared to males.
10. Females demonstrate the ollowing patterns when landing rom a jump or
decelerating
a. Decrease in knee exion
b. Increase in knee valgus (see Figure 31-3)
c. Increase in hip internal rotation (see Figure 31-3)
d. Decrease in trunk and hip exion
Assessment and Screening

As noted previously, many research studies have ocused on determining the exact cause o
the higher requency o ACL injuries in emales as compared to males. Although much time
has been spent on this subject, no def nitive intrinsic, extrinsic, or combined actors have
been identif ed as strong predictors o ACL injuries. A study by Arendt et al,25 published in
1999, set out to determine potential patterns that cause ACL injuries by using the NCAA
Injury Surveillance System. T e conclusions o this study stated that common noncontact
ACL injuries mechanism were pivoting or landing rom a jump. T ey ound no comorbidity
or illness patterns. T e injured athletes were experienced, with many years o sports partici-
pation be ore and during high school. Hyperextension was the only physical examination
eature that could possibly be linked to ACL injuries. Females were more likely to be injured
just prior to or just a ter their menses and not midcycle.25 Because o the multi actorial pre-
sentation o this injury, the sample size or such a study must be quite large to be predictive.
T ese authors stated that their project was to be viewed as a pilot study and hoped it would
stimulate more research in this area. Subsequently, many researchers have attempted to
ormulate skill-related tasks and unctional assessments that could accurately predict the
risk o ACL injury.
Prevention and Exercise Considerations 1059
Based on this in ormation, should the clinician working with these athletes conduct a
screening process in an attempt to identi y those athletes at risk and thereby institute pre-
vention programs to minimize the incidence o ACL injuries among their athletic teams?
Current research and practical knowledge do not o er a single valid and reliable screening
tool, although some evidence exists that a examining a set o variables (body mass, tibial
length, knee valgus, knee exion during landing, and hamstring-to-quadriceps ratio) may
assist in the prediction o athletes prone to high loads during landing.206 Most clinicians do
not have access to the technology and equipment necessary to examine balance, proprio-
ception, kinesthesia, neuromuscular patterns, or kinematic analysis o orces and angles.
T is does not mean the clinician cannot look at the athlete with simple unctional testing.
Strength and muscular endurance can be examined either isokinetically or with one repeti-
tion maximum testing. Functional tests, such as single-leg and tandem stance balancing,
can screen or basic proprioception def cits, and single-leg hop tests, vertical jump, and the
tuck jump assessment can assist in grossly examining explosive power o the lower extrem-
ity and dynamic stability at the hips and knees. Observing joint positions and landing char-
acteristics rom a jump, both visually and with simple video analysis, is an easy thing or
the clinician to do. Incorrect technique or motor per ormance def cits that can be identi-
f ed can then be corrected to enhance physical per ormance and possibly lower injury risk,
especially or the emale athlete.
Injury prevention programs have been developed and tested based on the previ-
ous in ormation with the goal o enhancing physical per ormance and decreasing injury
occurrence among emale athletes. T e authors o this chapter believe that addressing the
previously stated def cits common to emale athletes can only enhance their physical per-
ormance and as a result may decrease the risk o ACL injury. Both high-tech screening
and low-tech (clinical) screening procedures are important. When a def cit is identif ed, it
should be addressed, and only good things can come rom any education or improvement
that occurs.
Prevention and Exercise Considerations

As noted previously, the research indicates some possible areas where emales and males
di er in their muscle physiology, biomechanics, hormonal levels, joint stability, joint kine-
matics, proprioception, and skill level in athletics. Which o these actors are controllable
and what has the research determined as the best approach or injury prevention? T at
is the question we all ask ourselves. Although this topic o injury prevention or ACLs has
received much attention lately, it is not a new topic. Henning was investigating this idea in
the early 1980s, and a ter a 10-year study o ACL injuries in emale basketball players, he
ormulated a prevention program based on altering the “quad-cruciate interaction.”119 As
previously mentioned, Henning concluded that the most common mechanisms o injury
to the ACL were planting and cutting, straight-leg landing, and 1-step stop with the knee
hyperextended.119 His prevention program consisted o activities to eliminate or minimize
these mechanisms. Henning proposed using an accelerated rounded turn o a bent knee
instead o the pivot-and-cut movement pattern. He also emphasized drills that worked on
landing on a bent knee and a 3-step stop with the knee bent. T e common thread in all the
drills was the bent knee position. It has also been illustrated in research studies discussed
in the previous sections o this chapter that emales do land rom jumps with a straight-leg
position and have excessive valgus knee position with landing and cutting movements dur-
ing sports (see Figures 31-3 and 31-7B). Both o these positions put the emales at risk or
an ACL injury. Henning’s prevention program did show some success in decreasing ACL
injuries (89% decrease). Although his program did have its limitations, it was an admirable
start in addressing this problem and provided impetus or modern prevention programs.
Proprioception def cits in ACL-injured and ACL-reconstructed patients is well docu-

mented. So, it only seems natural to look at this component and incorporate it into a pre-
vention program. Cara a et al60 did just this in developing their 5-phase proprioceptive
program that progressed the athlete through increasingly di cult skills using di erent bal-
ance boards. T e study showed a statistically signif cant decrease in ACL injuries in semi-
pro essional and amateur soccer players or the exercise program versus the control group
o skill-matched soccer players. T e study received criticism or not being randomized and
or aws in program standardization, but it can be looked at as a pilot study and a plausible
approach to developing a prevention program incorporating proprioception training.
In the mid-1990s, Hewett et al132 conducted a seminal study to determine the e ect
o jump training on landing mechanics and lower-extremity strength in 11 emale athletes
involved in jumping sports. Vertical jump height, isokinetic muscle strength, and orce anal-
ysis testing were per ormed prior to and a ter the training program or the emale athletes
and a group o male athletes. T e jump program was per ormed over a 6-week period and
was per ormed on alternate days, 3 days a week. During the jumping program, 4 basic tech-
niques were emphasized:
1. Correct posture with spine erect, shoulders back, and body alignment o shoulders
over knees throughout the jump. Control o the trunk over the body is important.
2. Jumping straight up with no excessive side-to-side or orward-backward movement.
3. So t landings, including toe-to-heel rocking and bent knees.
4. Instant muscular recoil or preparation or the next jump.
See Appendix A or details o the Jum p- raining Program .132

T e results o the training program or the emale group revealed peak landing orces
decreased 22%, knee varus-valgus moments decreased approximately 50%, and hamstring-
to-quadriceps peak torque ratios increased 26% on the nondominant side and 13% on the
dominant side. Hamstring power increased by 44% with training on the dominant side and
21% on the nondominant side. Mean vertical jump height also increased by 10%. Multiple
regression analysis revealed that varus-valgus moments were signif cant predictors o peak
landing orces.132
T e results o this study led the researchers to continue with a ollow-up project with
this jump-training program. Hewett et al129 developed a prospective research study to
determine the e ect o this same jump-training program on the incidence o knee injury in
emale athletes. T ey monitored 2 groups o emale athletes; 1 group per ormed the jump-
training program and 1 group did not. A group o untrained male athletes were also used
or comparison. T e groups were monitored throughout the high school soccer, volleyball,
and basketball seasons. Results o this study revealed that the untrained emale athletes
had a 3.6 times higher incidence o knee injury than trained emale athletes ( p < 0.05)
and 4.8 times higher incidence than male athletes (p < 0.03). T e incidence o knee injury
in trained emale athletes was not signif cantly di erent rom that in the untrained male
athletes.129 T e results o this early, innovative study indicated that a plyometric training
program may have a positive e ect in reducing incidence o emale ACL injuries. T e
authors o this study acknowledged several limitations to their study. It was not a random-
ized, double-blind study, and there were not equal numbers o each type o sports par-
ticipant in each group. Conclusions rom this study indicate that the plyometric training
program decreased the magnitude o varus-valgus moments at the knee and improvement
in hamstring-to-quadriceps strength ratio. As noted previously, many researchers believe
that these 2 lower-extremity variables, as well as trunk motion, play a strong role in ACL
injury in emale athletes.106,132,216 However, it should be noted that the results rom contem-
porary research suggest that a prevention program must train roughly 89 emale athletes in
order to prevent 1 ACL injury when applied generally to a group.206
Prevention and Exercise Considerations 1061
An interesting act to note about many o these prevention programs is the component
o educating the athlete about how to correctly per orm landing or cutting tasks. Henning
developed a teaching tape consisting o examples o noncontact ACL injuries ollowed by
illustrations o the recommended drills done in the gym as well as on the playing f eld.
He stated that young athletes are more receptive to technique modif cation and called it
“improved player technique skills.”119 Ettlinger et al101 stated that ACL injuries in alpine ski-
ers could be reduced as much as 60% by using standardized training programs be ore the
ski season. T e subjects were trained to avoid high-risk behavior, recognize potentially dan-
gerous situations, and to respond quickly whenever these conditions were encountered.
Hewett et al132 used verbal cueing to encourage proper jumping and landing techniques.
Such phrases as “on your toes,” “straight as an arrow,” “light as a eather,” “shock absorber,”
and “recoil like a spring” were all used to illustrate proper technique. Similarly, Myer et al
used the tuck jump assessment task and both verbal and visual eedback during the task
to f ne-tune and attempt to correct jumping and landing strategies.205 T e authors o this
chapter also use 3 words beginning with the letter L to instruct athletes in correct per or-
mance o all motor skills: Low, Light, and (in) Line. T ese cues re er to low, exed knee
landings and transitions; so tness and quietness during landings; and parallel thighs during
activity, respectively. T is pneumonic is also re erred to as L3.
Another important study by Onate et al224 reported the importance o eedback and
educating the athletes in proper technique per ormance. T ey looked at the e ects o aug-
mented eedback versus sensory eedback on the reduction o jump-landing orces. T e
augmented eedback group received in ormation on how to land so ter via video and verbal
analysis, the sensory eedback group was asked to use the experience with their baseline
jumps to land so ter, and the control groups were given no extraneous eedback on how to
land so ter. T e subjects in the augmented eedback had signif cantly reduced peak vertical
ground reaction orce as compared to the sensory eedback and control groups.224 All clini-
cians and researchers must remember that even though you may have the per ect preven-
tion program, i your subjects do not understand the movement pattern and technique you
are asking them to per orm, it is all or naught.
Myer et al204 examined a comprehensive neuromuscular training program to study
the e ects on lower-extremity biomechanics and improved per ormance in the emale
athlete’s vertical jump, single-leg hop, speed, bench press, and squat. As previously dis-
cussed, multiple research studies have been carried out examining the positive e ects o a
plyometric or jump-training program ; however, this study combined plyometrics with core
strengthening, balance training, interval speed training, and resistance training.204 Fi ty-
three emale athletes involved in basketball, volleyball, or soccer participated. Forty-one
subjects were assigned to the training group and 12 to the control group. Pretesting was
conducted 1 week be ore the training program and posttesting 4 days a ter the f nal train-
ing session. T e athletes received eedback on biomechanical analysis and correct tech-
nique be ore and a ter training sessions. T e 90-minute training sessions were held 3 days
a week ( uesday, T ursday, and Saturday). able 31-3 provides a breakdown o the training
sessions. Subjects trained or 6 weeks, while control subjects did not change their normal
exercise program. Results demonstrated statistically signif cant improvements compared
to their pretrained values in vertical jump height, single-leg hop distance, sprint speed,
bench press maximum, and squat maximum or the trained group. Knee exion range o
motion (ROM) during landing rom a box jump was signif cantly increased. Varus and val-
gus torques were signif cantly lower or the right knee and showed a trend toward decrease
valgus torque in the le t knee. T e control group showed no increase in any o the previously
measured parameters over a 6-week period.204 T is study supports the benef ts o a compre-
hensive exercise approach when treating the emale athlete. A combination o plyometrics,
core strengthening, balance training, upper- and lower-body strengthening, speed training,
and, very importantly, education on technique proves to be valuable in improving athletic
able 31-3 Ne uro muscular Training Pro g ram Sche dule
Tue sday Thursday Saturday
• 30-minute plyometric • 30-minute plyometric • 45-minute speed station

station station • 45-minute strength
• 30-minute strength station • 30-minute speed station station
• 30-minute core- • 30-minute strengthening
strengthening and balance and balance station
station
Developed by Myer et al.204
per ormance, as well as in decreasing potentially dangerous variables in knee biomechan-

ics when running and jumping.106
Mandelbaum et al182 per ormed a recent prospective study similar to the previous stud-
ies to examine prevention o ACL tears in the emale athlete. T e authors developed a com-
munity-based program named the “Prevent Injury and Enhance Per ormance Program,”
which was created specif cally or emale soccer players between the ages o 14 and 18 years.
T is program consists o basic warm-up activities, stretching techniques or the trunk and
lower extremities, strengthening exercises, plyometric activities, and soccer-specif c agility
drills. T e program also places heavy emphasis on proper landing technique. T is train-
ing program was implemented to address the eed- orward mechanism as described previ-
ously. T e specif c goal was to improve the athlete’s ability to anticipate external orces or
loads to stabilize the knee joint, protecting the inherent structures.182
Results o this study using the “Prevent Injury and Enhance Per ormance Program”
were impressive in reducing ACL injury in soccer players. Analysis o data rom the f rst year
o the study revealed an 88% overall reduction in ACL injury compared to the control group
ollowed by a 74% reduction o ACL injury during the second year o the study. T e authors
concluded that prophylactic training ocusing on developing neuromuscular control o the
lower extremity through strengthening exercises, plyometrics, and sports-specif c agilities
drills “may address the proprioceptive and biomechanical def cits that are demonstrated in
the high-risk emale athletic population.”182, p. 1008 T ese researchers and others continue to
study the “Prevent Injury and Enhance Per ormance Program” with a variety o populations.
Exercise Considerations
When designing an exercise program or any athlete, and especially the emale athlete,
the authors o this chapter like to use the lower-extremity reactive neuromuscular training
sequence described in able 31-4. T e basic premise o the exercise sequence is to begin
with a stable base o support in a closed-chain position. T en, progress with resistance and
perturbations rom resistance or trunk and upper-extremity movements. When the athlete
becomes prof cient with the exercises per ormed with a stable base, the base is then nar-
rowed and an environment o instability is created.
T e progression repeats with an unstable base o support. Sport-specif c training
is added next with the goal o neuromuscular control becoming a natural, noncognitive,
adaptation to the movement patterns required by the sport. T e ollowing are some ideas
we have developed based on our clinical experience, as well as being creative with the exer-
cise progression.
Exercise Considerations 1063
able 31-4 Lo w e r-Extre mity Re active Ne uro muscular Training , Fro m Le ss to Mo re Dif cult
(To p—Le ss Dif cult, Bo tto m—Mo st Dif cult)
De scriptio n o f Activity Example s Fig ure De mo nstrating a
Stable base, bilateral lower extremities Partial squats, step down and hold None
Unstable base, bilateral lower extremities Wobble boards, foam rollers None
Stable base, unilateral lower extremity Single-limb stance, unilateral squats Figures 31-5 and 31-6A
star diagram, contralateral LE tubing and B
(“ steamboats” )
Unstable base, unilateral lower extremity Wobble boards, foam rollers, minitramp Figure 31-7A and B
Stable base, with added UE/trunk challenges Squat positions with ball throws, None
perturbations
Unstable base, with added UE/trunk Wobble boards, foam rollers, DynaDiscs, Figures 31-8 and 31-9
challenges with ball throws, perturbations
Jump/landing sequence from stable base Jump/land on gym oor, Jump/land from None
minimal elevation (stair, mat)
Jump/landing sequence from unstable base Jump/land from mini-tramp Figure 31-10A and B
Jump/landing sequence with distractions Jump/land with twists, external None

resistance, passing balls
LE, lower extremity; UE, upper extremity.

a See
Figures 31-6 to 31-10.
Based on the previous descriptive in ormation about emale neuromuscular and unc-
tional strategies, how does the rehabilitation pro essional gets the emales to bend their
knees, avoid the valgus knee position, and get their gluteal region down with the trunk
exed to minimize the potential risk o knee injury? We propose that you make the athlete’s
exercise program ocus on these exact positions (see Figure 31-11).
Strengthening the quadriceps and hamstrings in the exed trunk and knee position can
be per ormed with simple wall sits, step-down position with a static hold (see Figures 31-4
and 31-5) and progress into closed-chain squats in a protected position using the Smith
Squat Rack. T e key part o this squat is to note that the athlete never ully extends knee
and works in a range o 30 to 90 degrees o knee exion and uses the bench as her spot-
ter. T is is the position we want her to assume when per orming sports, so we must train
her muscles in this position. What about powerli ting techniques or emales, such as the
power clean or snatch? T e purpose o these powerli ting movements should not be or
brute strength but rather or quick ootwork and bent knee position with trunk stabiliza-
tion. Female athletes o ten do not do the simple squat technique per ormed by most males
in all levels o sports. Proper technique or ree-weight li ting is the key, and lighter-weight
body bars are optimal or learning, rather than the heavy 45-lb standard weightli ting bars.
T e Smith squat machine is also use ul or early control o the bar during squats and other
upper extremity li ts. readmill retro uphill walking in a knee- exed position is also e ec-
tive or working the quadriceps in an optimal position. I the hamstrings are to be active
when the trunk is exed, then they also need to be strengthened in a exed trunk posi-
tion such as seated open-chain resisted knee exion. Another way to work the gluteals and
Figure 31-4 Example o f a Figure 31-5 Be tte r stance

unilate ral stable base e xe rcise lo w e r-e xtre mity po sitio n
Note the incorrect valgus and internal Subjects must be corrected and coached
rotation. Training must be done with the to work in excellent lower-extremity
lower extremity in proper alignment. alignment. Note that this can also be
done in mirror for visual feedback and
corrections.
A B
Figure 31-6
Single limb stance hip abduction/adduction with elastic resistance to offer
perturbation. AKA “Steamboats” (A) Start position (B) Finish position.
Exercise Considerations 1065
A B

A. Unstable surface (1Ž2 foam roll) balance activity. B. Same activity with use of Subject, on DynaDisc/unstable base
mirror for visual feedback on lower extremity positioning during the task. on DynaDisc (unstable base, 1 lower
extremity) throwing a ball to/from another
person for distraction/balance perturbation.
A B
Figure 31-9 Figure 31-10 Dynamic jump/ land training
Unstable base, unilateral lower extremity Subject shown airborne after jumping off minitramp (A). Subject landing from
exercise, with distraction/perturbation jump (B). During exercise training, stress correct lower extremity position and
technique of ball throw/catch. “soft landing.”
hamstrings in a closed-chain trunk exed position is to do a semi-

squat uphill walking lunge on a treadmill. T is is the reversal o the
retro uphill squat walk.
Another possibility is to com bine strengthening and neuro-
m uscular retraining. In Figure 31-12, the athlete is per orm ing
a unilateral, closed-kinetic chain partial squat on the otal Gym,
using a DynaDisc under her oot, thereby per orm ing both types o
exercise concurrently. T is is an exam ple o an unstable base used
during a unilateral strengthening activity.
Muscular atigue slows electrom echanical delay, decreases
knee stability, and com prom ises proprioception.220,247 Muscu-
lar atigue will happen to all athletes i they compete at an intense
level, so the athlete must be trained to have a stable knee even
when atigued. Fatiguing the athlete and then carefully working on
proprioception, cutting and deceleration maneuvers, and proper
landing position rom a jump are possible techniques or training,
although controversial.
When the big picture o total-body positioning is examined,
attention must be paid to the joints distal and proximal to the knee
joint. O ten the ankle and its role as the f rst link o the chain to
absorb the orces and then stabilize the base o support are orgot-
Figure 31-11 ten. Adequate motion o the talocrural and the subtalar joints must
be present or normal landings to occur. T e gastrocnemius and
Single limb plantar flexion, training the plantar soleus have a role in posterior stabilization o the knee joint and
flexors in the “down low” position. need to be strengthened in the position in which they must excel:
knee and trunk exion (see Figure 31-11). In the study by Huston
and Wojtys,145 the gastrocnemius was the f rst muscle to respond to
tibia anterior translation in the relaxed posi-
tion. An intriguing thought is that maybe the
oot and cal muscles are the key to knee sta-
bility, as they are the f rst line o de ense or all
closed-chain activities. T e trunk and hips are
the joints proximal to the knee, and they pos-
sess the most muscular mass and thus the most
potential or e cient body control. We call
this concept “T e Butt and Gut” and believe
f rmly in its role in prof cient movement pat-
terns or all joints o the body. Females are
usually weaker in their gluteal muscles and
lack some trunk control with high-level sports
movements. Emphasis on hip rotators, hip
extensors, transverse abdominals, and hip
adductors strength and endurance should be
part o every athlete’s f tness program. With
strong hip and trunk muscles, the landing
and running characteristics o genu valgus,
Figure 31-12 Use o f DynaDisc o n To tal Gym fo r stre ng th hip internal rotation, straight knee position at
training oot impact, and erect trunk position should be
minimized and possibly eliminated.105,130,133
Single-leg partial squats with an unstable surface. Close attention is paid Educating your athletes in proper move-
to the position and alignment of the lower extremity. Foot position shown ment patterns is the key to success or injury
could be improved. prevention. As noted previously, research
Sequelae from Anterior Cruciate Ligament Injury 1067
shows that visual and verbal cueing enhances the per ormance o proper technique in the
quest or optimal position o the body or injury prevention and e cient, power ul sports
movements. Simple video can be used to record an athlete during a movement or task,
allow the athlete to see what they look like per orming the task, and identi y what improve-
ments could be made and what the goal is regarding proper technique.
Excellent clinicians requently review the literature and then think o bold, creative
ways to exercise their patients based on the positions that make the emale athlete vulner-
able to ACL injury. Although ACL reconstructive surgery provides excellent, predictable
outcomes in most cases, and rehabilitation a ter ACL reconstruction has become standard
physical therapy practice, no reconstructed knee is as good as an uninjured knee. In the
world o ACL injuries in emale athletes, the mother’s old quote “an ounce o prevention is
worth a pound o cure” rings true.
Sequelae from Anterior Cruciate

Ligament Injury
We re er the reader to Chapter 24 or a com plete analysis o the in ormation regarding
evaluation and treatm ent o the emale athlete (or any athlete) su ering an ACL injury.
Prevention o this debilitating injury cannot be m ore em phasized with the growing
concerns that have been raised am ong the sports m edicine com m unity regarding
the early degenerative changes a ter a knee injury and specif cally ollowing an ACL
injury.81,82,98,114,244,246 Curl et al reviewed m ore than 30,000 knee arthroscopies with a
variety o patient ages and reported chondral injuries in 63% o these patients, with an
average o 2.7 articular cartilage injuries per knee.79 Bone bruises, most comm on in the
lateral compartment, are observed in 80% o MRI studies ollowing ACL tear.198 At the time
o surgery, 9% o all ACL injured patients have documented acute cartilage de ects. T is
sam e population dem onstrates a 19% incidence o articular cartilage de ects at 9-year
ollow-up.246 T is signif cant increase in cartilage de ects demonstrates that stabilization
o the knee through ACL reconstruction does not elim inate the risk o degenerative
changes in the articular cartilage.13,14 In act, many current studies indicate that despite
reconstruction o the injured ACL, patients will develop osteoarthritis within 5 years a ter
surgery. In a systematic review conducted by Oiestad et al, the authors reported that up
to 13% o those with isolated ACL injuries and 24% to 48% o those with ACL plus other
concom itant knee injuries experienced dem onstrable osteoarthritis within 10 years,
lower than some o the reports in the literature.223 Whether this is a result o subclinical or
unrecognized osteochondral or m eniscal injury concomitant with the ACL injury or the
reconstructive surgery is unknown.
Numerous studies show good-to-excellent results ollowing ACL reconstructive sur-
gery with re erence to stability, normal knee mobility, normalized strength, and return to
previous level o activity.10,28,81,82,143,153,185,221,258,266 Work completed by Daniels et al was the
f rst to document concern regarding early degenerative changes in knees that had stability
restored with an ACL reconstruction in 5-year 80 and 10-year ollow-up studies.81 At 5- to
20-year ollow-up, patients post-ACL reconstruction demonstrate up to a 50% increase in
radiographic changes associated with arthritis compared to the contralateral, uninjured
knee.229 Concern regarding such degenerative changes was expressed by Gilquist who wrote
that these surgeries resulted in “giving the patient enough security to go back to strenuous
sports and then [ruin] the knee.”114 T is concern is valid, but one must consider the concept
o joint unction and def ne “ ull” unction.
Dye describes the knee joint as a mechanical engineering model with a complex, meta-
bolically active system or transmission o orces among the emur, tibia, f bula, and patella,
with cruciate ligam ents acting as linkages, articular

cartilage and menisci as weightbearing entities and
orce absorbers, and muscles as orce generators and
absorbers.98 In our view, the concept o musculoskel-
Zone of
s tructura l fa ilure
etal unction includes the capacity not only to generate,
transmit, absorb and dissipate loads but also to main-
Zone of tain tissue homeostasis while doing so.97
s upra phys iologica l T is statem ent beauti ully illustrates our belie
ove rloa d Enve lope of
d
that joint un ction is n ot truly attained unless the
a
o
function
L
system can escape rom tissue destruction or degen-
Zone of
home os ta s is
eration while com pleting a desired level o unctional
activity. Dye presents the con cept o “envelope o
Zone of un ction,”96 which is the sa e zone o loading that a
s ubphys iologica l unde rloa d system can m aintain n orm al hom eostasis as illus-
trated in a load distribution curve (see Figure 31-13).
Fre que ncy Below this sa e zon e is the subphysiologic loadin g
zone, causing loss o tissue hom eostasis secondary to
decreased loadin g, which results in such injuries as
Figure 31-13 Enve lo pe o f functio n osteopenia and m uscular atrophy. Above the “enve-
lope o unction” is a zone o structural ailure with
loads great or requent enough to cause actual ailure
o an elem ent o the system, such as a m eniscal or ACL tear. T e zone that is im m ediately
above the envelope o unction, the zone o supraphysiologic load, represents loads at a
orce or requency that cause a disruption o the tissue hom eostasis be ore ailure, that
is, stress ractures or articular cartilage degeneration.
T is concept o “envelope o unction” correlates nicely with the Wol law that states
cyclical loadin g o the cartilage and bon e results in increased strength an d durabil-
ity o these structures and ultim ately the m usculoskeletal system. However, excessive
loading results in degradation o the cartilage m icrostructure and arthritic changes.181
Maintaining activity within the “envelope o unction” results in m aintenance o tissue
hom eostasis and the ability to strengthen the m usculoskeletal system, while exceed-
ing this physiologic loading and m oving into the “supraphysiologic loading zone” with
increased intensity, duration, or requency o activity results in degradation o the sys-
tem an d disruption o tissue hom eostasis. Sports m edicine personnel involved in the
orthopedic m edical care o a emale athlete should adhere to the principle o remaining
in the zone o hom eostasis as def ned by the current status o the joint involved. Def n-
ing this zone is a di cult task a ter com pleting the rehabilitation ollowing an orthope-
dic injury such as an ACL tear and surgical reconstruction. T e challenge o attaining a
level o activity (loading) o the injured joint to allow tissue building, such as muscular
hypertrophy, without entrance into the zone o supraphysiologic loading (overloading)
that could a ect articular cartilage degeneration or m eniscal irritation, requires extrem e
care in planning with respect to activity intensity, duration, and requency. Determ ining
such a zone also requires excellent com munication between the surgeon and the reha-
bilitation pro essional regarding any preexisting conditions and surgical f ndings. Astute
observation o the sports m edicine specialist or signs o in am mation with a prescribed
rehabilitation program and allowed unctional/ sporting activities is necessary to ensure
proper physiologic loading.
T e physically active emale m ay be at greater risk than her m ale counterparts or
articular cartilage degeneration and concerns. Gender di erence in the knee joint size
and greater valgus alignm ent m ay result in a greater stress concentration in the lateral
and patello em oral com partm ents o the emale’s knee. MRI studies o the human knee
dem onstrate that em ales have signif cantly less cartilage thickness and volum e than
Core Stabilization for the Female Athlete 1069
age-matched m ales.68 Articular cartilage has a com plicated organization o hyaline car-
tilage with an extracellular matrix com posed principally o type II collagen and sparsely
distributed chondrocytes. Anim al studies also docum ent lower levels o proteoglycan
and collagen in the cartilage o em ale rats. Considering the increased incidence o ACL
in jury in emales versus m ales and the emale articular cartilage basic science, chondral
injury concerns are well ounded.
Core Stabilization for the Female Athlete

T e common prerequisite or participation and success in all types o sports is a strong and
stable core o the human body. Control o balance in upright posture and stability o the seg-
ments o the spine are required not only or activities o daily living but also or high-level
sports activity.100 T is stability enables athletes to transmit orces rom the earth through
the kinetic chain o the body and ultimately propel the body or an object using the limbs.74
T e concept o core stabilization o the trunk and pelvis as a prerequisite or movements o
the extremities was described biomechanically in 1991.52 Subsequently, core stabilization
has become a major trend, both in treatment o injuries and in training regimes used to
enhance athletic per ormance and prevent injury.
Many terms and rehabilitation programs
are associated with the concept o core stability,
including lumbar stabilization, dynamic stabi-
lization, motor control (neuromuscular) train-
ing, neutral spine control, muscular usion, and
trunk stabilization.12 T e core has been concep-
tually described as either a box or a cylinder 241
because o its anatomical and structural com-
position. T e abdominals create the anterior
and lateral walls; the paraspinals and gluteals
orm the posterior wall, while the diaphragm
and pelvic oor create the top and bottom o
the cylinder, respectively (Figure 31-14). Addi-
tionally, hip girdle musculature rein orces and
supports the bottom o the cylinder. Envision-
ing this cylindrical system helps to understand
its unction as that o a dynamic muscular sup-
port system, described by some authors as the
powerhouse, engine, or a “muscular corset that
works as a unit to stabilize the body and spine,
with and without limb movement.”12, p. S86
Proximal stability or distal mobility is a
com m only understood principle o human
movement. It was originally described by Knott Figure 31-14 Anato mic cylinde r o f trunk
and Voss159 and applied in the concepts asso-
ciated with proprioceptive neurom uscular The muscle contraction of “drawing in” of the abdominal wall with an
acilitation. Nowhere is the concept o dynamic isometric contraction of the lumbar multifidus. The interrelationship
proximal stability m ore im portant than in and the interaction between these 2 muscles and the fascial system
sports. Without proximal control o the core, can be appreciated, and the figure illustrates how they can work
athletes could not use the lower extremities together to give spinal support. (Reproduced, with permission, from
to propel the body in running and jumping or Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal
use the upper extremities to support or propel Segmental Stabilization in Low Back Pain: Scienti c Basis and Clinical Approach .
the body (in activities such as gymnastics and Edinburgh, UK: Churchill Livingstone; 1999.)
able 31-5 Example s o f Co re De mands, Kine tic Chain Re latio nships, and Outco me s o f Spe ci c
Spo rting Tasks
Spo rting Activity Co re De mands Kine tic Chain Re latio nships Outco me
Windmill softball Rotational and exion/ Transmission of forces from Velocity, location, rotation of
pitch extension stability, ground to LEs through trunk pitched ball (55 to 70 mph);
acceleration, and to UE to ball delivery of various types of pitches
deceleration of trunk (drop, rise, breaking ball, etc)
Gymnastics: vault Rotational and exion/ Transmission of forces from Conversion of horizontal energy
event extension stability; power horse to UEs through trunk to vertical; speed, position, and
with punch from horse to propel body in airborne trajectory of body through space
positions
Tennis serve Rotational and exion/ Transmission of forces from Velocity, location, spin of served
extension stability; ground to LEs through trunk ball (80 to 120 mph); delivery of
acceleration and to UE through racquet to ball various types of serves
deceleration of trunk
Swimming: butter y Flexion/extension stability Transmission of forces from Ef cient propulsion of body
stroke UEs to trunk to LEs to team through water, avoid excess
with butter y kick trunk exion and extension
Volleyball serve Rotational and exion/ Transmission of forces from Velocity, location, rotation of
extension stability; ground to LEs through trunk served ball; various types of spins
acceleration and to UE to ball and serves ( oater, topspin)
deceleration of trunk
LE, lower extremity; UE, upper extremity.
swimming), or to manipulate, use, and throw objects (such as throwing a shot put or so t-
ball, or using a tennis racquet). T e core is in the middle o the human kinetic chain and
serves a link between the upper and lower extremities. T is allows or trans er o energy
rom the lower to the upper extremities and vice versa.
Strength and coordination o the core musculature is vital to per ormance and genera-
tion o power in many sports. When the core is unctioning optimally, muscles elsewhere in
the kinetic chain also unction optimally allowing the athlete to produce strong, unctional
movements o the extremities ( able 31-5).65,156 Even small alterations in the kinetic chain
have serious repercussions throughout other portions o the kinetic chain and thus on skills
that are based upon e cient utilization o the entire chain.156 T ere ore, without proper sta-
bilization and dynamic concentric and eccentric control o the trunk during athletic tasks,
the extremities or “transition zones” between the core and extremities can be overstressed
(ie, hip and rotator cu ).
A wide variety o movements are associated with sport per ormance; there ore, athletes
must possess su cient strength and dynamic motor control o the core in all 3 planes o
movement (transverse, rontal, sagittal).167 Core stability is vital to athletic per ormance and
especially important or the emale athlete. In a study o male and emale runners, emales
were ound to have greater hip adduction, hip internal rotation, and tibial external rota-
tion movements during the stance phase o running. Ferber et al102 believe that gender di -
erences in lower-extremity kinematics place greater demands on the core musculature o
emale athletes. Additionally, core stability may even be more vital or the emale athlete as
Core Stabilization for the Female Athlete 1071
a result o her overall decreased total extremity strength as compared to her age-matched
male participant.65 Documented di erences in proximal strength measures in emale ath-
letes suggest that emales may have a less-stable base upon which torque and orce can be
generated or resisted. T is “lack o core stability” is a possible contributor to lower-extrem-
ity injury.119,149 Although important energy has been devoted to prevention o ACL and
other knee injuries in the emale athlete, the sports physical therapist must broaden his/ her
ocus to the body as a whole and include core strengthening activities as a part o prepara-
tory training or all emale athletes.
Reviewing and considering the anatomy o the core allows the sports physical ther-
apist to best understand principles o injury and rehabilitation (re er to Chapter 15).
Stability o the core requires both passive (o ered by bony and ligamentous structures)
and dynam ic sti ness (o ered by coordinated muscular contractions). A spine without
the contributions o the muscular system is unable to bear essential com pressive loads
and remain stable.187 Anatom ists have known or decades that a compressive load o as
little as 2 kg causes buckling o the lum bar spine in the absence o muscular contrac-
tions.201 Likewise, signif cant m icrotrauma o the lum bar spine occurs with as little as
2 degrees o rotation, dem onstrating the vital stabilizing unction o the muscles o the
lumbar spine.110,116 Core stabilization is important not only or protection o the lum bar
spine but also to resist the reactive orces produced by m oving lim bs that are transmitted
to the spine and other muscles o the core.193
Contem porary research has illum inated the roles o two im portant local m uscle
groups: the transversus abdominis ( A)75,136,137,139 and the multif dus.134,287 T e A—deepest
o the abdom inal muscles—uses its horizontal f ber alignm ent and attachment to the tho-
racolum bar ascia to increase intraabdom inal pressure, thereby making the core cylinder
as a whole m ore stable. Although increased intraabdom inal pressure is associated with
the control o spinal exion orces and a decrease in load on the extensor muscles,278 it is
probable that the A is m ost im portant in its ability to assist in intersegm ental control240
by o ering “hooplike” cylindrical stresses to enhance sti ness and limit both translational
and rotational movem ent o the spine.100,192 Bilateral contraction o the A per orm s the
m ovement o “drawing in o the abdom inal wall”258 and does not produce spinal m ove-
m ent. T e A is active throughout the m ovem ents o both trunk exion and extension,
suggesting a unique stabilizing role during dynamic movem ent, di erent rom the other
abdominal muscles.75,76,193 Also, EMG evidence suggests that the m ore internal muscles
o the trunk ( A and internal obliques) behave in an anticipatory or eed- orward manner
to provide proactive control o spinal stability during m ovem ents o the upper extrem i-
ties,137,138 regardless o the direction o limb m ovem ents.138 T is is im portant to rem em ber
when treating the athlete whose sport is heavily reliant on the upper extrem ity such as
so tball, swim ming, gym nastics, and volleyball.
Mechanisms of Injury t o t he Core

Many potential mechanisms o injury exist or the athlete. Cholewicki et al66 suggest that a
common actor or injury to athletes may be the inability to generate su cient core stability
to resist external orces imposed upon the body during high-speed events. Other authors
suggest a def cient endurance o the trunk stabilizing musculature that predisposes the
athlete to traumatic orces over time,241 and motor control def cits and imbalances o the
local muscles ( A and multif dus) and the global musculature (rectus abdominis and erec-
tor spinae) that occur during per ormance o unctional activities. A weak core could result
in ine cient movements, altered postures, and an increased potential or both macro- and
microtraumatic injury.65
wo exam ples o m icrotraum atic in juries that occur in the em ale athlete are
spon dylolysis and spondylolisthesis. T e athletic population is m ore prone to these
conditions and m ore likely to be sym ptom atic rom

these in juries. Spon dylolytic m icro racture o the
pars is believed to happen as a result o shear orces
occurrin g during repetitive exion and extension.275
Athletes with high rates o this type o m icrotrau-
m atic in jury include gym nasts,99 divers, f gure skat-
ers, swim m ers who per orm the butter y stroke,275
and volleyball players,99 as a result o extrem e exten-
sion / exion reversals in trun k posture dem an ded
by these sports. In act, gym nasts youn ger than age
24 years have 4 tim es greater incidence o spondyloly-
sis than the general emale population.275 Microtrau-
m atic injuries m ay occur rom m uscular im balances
or uncontrolled shear orces acting on the spine,123,275
or because o lack o m uscular control and stabiliza-
tion o ered by the core stabilizers. Sports, such as
Figure 31-15 Example o f side -bridg ing gol , diving, and so tball, have the potential or m icro-
traum atic injury to the core to be induced sim ilarly,
but related to extrem es o rotation, o ten in com bina-
tion with extension. Care ul assessm ent o m otor strategies and subsequent corrective
m ovem ent retraining by the sports physical therapist may be a key to prevention o many
m icrotraum atic injuries.
Leetun et al167 ound that male athletes had statistically greater core stability scores
on tests o hip abduction, hip external rotation, and the side bridge when com pared to
em ale athletes ( Figure 31-15).167 Athletes who experienced injury to the core (spine/
hip/ thigh), knee or ankle, and oot during an athletic season dem onstrated lower core
stability m easures than those who did not.167 Again, this leads the sports physical thera-
pist to consider core strength, endurance, and m otor per ormance training as a possible
intervention or prevention o injury, especially or the em ale athlete.
Rehabilit at ion and Treat ing t he Core

Simple, reliable, and objective clinical test procedures or dynamic motor control o the
core are not readily available. Clinically, therapists utilize manual muscle tests that examine
isometric holding o muscles, some positional holding tests (the plank or side plank) or
endurance in isometric positions, and pressure bio eedback to assess the ability o a patient
to hold the core stable during some dynamic tasks. A clinical test or the multif dus was
devised that involves the activation o the multif dus at various segments under the pal-
pating f nger o a therapist.241 T is is per ormed in the prone position using the command
“gently swell out your muscles under my f ngers without using your spine or pelvis. Hold the
contraction while breathing normally,” 241, p. 116 including side-to-side comparison to assess
or segmental activation or inhibition. For many excellent examples o core strengthening
exercises, re er to Chapter 15. o make these exercises more specif c to your emale ath-
lete, incorporate these concepts while per orming training programs or other regions. For
example, or a swimmer, the therapist may have the athlete lie prone on a swiss ball while
per orming T era-Band movements mimicking the pull-through phase. T e ball introduces
an unstable base to challenge the core muscles.
Knowledge and application o core stabilization will benef t emale athletes in all sports
at all levels by improving per ormance, increasing athleticism, and decreasing the poten-
tial or injury to the spine and extremities. o provide an optimal, comprehensive exercise
program or all emale athletes, unctional core exercises should be implemented into the
emale athlete’s sports-specif c program.
Special Considerations Concerning the Shoulder in the Active Female 1073
Special Considerations Concerning the

Shoulder in the Active Female
Shoulder Laxit y
Are women more prone to shoulder injuries? T is question does not have ample research
to be answered conclusively. Most studies do not separate shoulder injuries by gender or
separate general injuries rom specif c ones. In 2001, Sallis et al249 compared sports inju-
ries in men and women and ailed to show a signif cant di erence in overall injury rate.
However, these authors reported that in all sports, women reported a higher rate o hip and
shoulder injuries. A signif cant di erence was ound with a higher rate o shoulder inju-
ries in emale swimmers compared to their male counterparts. Yet, the training or emale
and male swimmers di ered greatly, so it is di cult to draw any specif c conclusion.249 T e
training regimen, their structural build, and/ or presence o laxity may have predisposed
the athletes to overuse injuries. Conclusions are unable to be drawn, until more controlled,
specif c research is carried out.
Other studies have described di erences in various injuries between genders. Kroner
and Lind 162 ound no di erence in shoulder dislocations between genders. All shoulder
dislocations were recorded over a 5-year period in an area within a population o 253,753
athletes. O this population, 53.3% o shoulder dislocations occurred in males and 46.7%
occurred in emales. However, a notable di erence occurred between the age group where
the peak incidence occurred. Males were 21 to 30 years old, and emales were 61 to 80 years
old. T e injury in the older age group was typically caused by a all on an outstretched arm.162
A high incidence o shoulder impingement is reported in emale so tball players286 and
both genders o volleyball players.32,53 T e shoulder was also the most commonly injured
upper-extremity joint in both genders during alpine skiing.254
Clinical experience might suggest that women in general are more exible and dem-
onstrate increased laxity o their joints when compared to men. Are women more at risk or
shoulder injuries because o laxity? First, it is important to describe the di erence between
laxity and instability. Laxity is not synonymous with instability. Laxity is the physiologic
motion that allows or normal ROM. Instability is the abnormal sym ptom atic motion that
results in pain, subluxation, or dislocation.55
T ere are many general joint laxity tests in literature, the m ost well known are those
by Carter an d Wilkinson ,62 which have been m odif ed by Beighton 42 ( able 31-6 and
able 31-6 Ge ne ralize d Jo int Laxity Te sts
Carte r and Wilkinso n Be ig hto n e t al
1. Passive thumb apposition to forearm 1. Passive hyperextension of small nger

2. Passive nger hyperextension so nger >90
parallel to forearm 2. Passive thumb apposition to forearm
3. Elbow hyperextension >10 degrees 3. Elbow hyperextension >10 degrees
4. Knee hyperextension >10 degrees 4. Knee hyperextension >10 degrees
5. Excessive ankle dorsi exion and foot 5. Trunk exion, knee extension, and
eversion palms at on oor
Source: Adapted from Brown GA, Tan JL, Kirkley A. The lax shoulder in females. Issues, answers, but many more
questions. Clin Orthop Relat Res. 2000;372:110-122.
Figure 31-16
Hypermobility screening maneuvers, as developed by Carter and Wilkinson
and modified by Beighton et al.
Figure 31-16). T ese tests exam ine ROM at the trunk (single test) and knees, f ngers,
thum bs, and elbows bilaterally and assigns a point system (0 to 9; a score greater than
5 = diagnosed as hyperm obile). Other hyperm obility tests have not been proven reli-
able and valid. Consequently, m any studies ound in literature regarding general laxity
di erences between genders are not valid. O the studies in literature, only 1 utilized
the 0 to 9 Beighton scale exam ining generalized m obility in adolescents.83 T e authors
reported that o 264 adolescent athletes, 22% o all em ales and 6% o all males tested
were generally “hyperm obile.” However, it would be in correct to con clude rom this
study that generalized laxity correlates with shoulder laxity. T e astute clinician can and
should recall the structural and physiologic di erences between the genders and take
into account clinical experience in order to rehabilitate the em ale athlete’s shoulder in
a m ulti aceted way.
So tball, swimming, and gymnastics are 3 sports that emerge when considering the
emale athlete. T ere is a high incidence o injury in both genders when considering so t-
ball/ baseball, swimming, and gymnastics. So tball is discussed separately because o the
di erence in the pitching delivery and the di erences in rules regarding number o allow-
able pitches. Swimming is discussed separately because o the extreme high numbers
o shoulder injuries that occur in emale swimmers. Finally, the sport o gymnastics is
described in relationship to its injury potential in emales.
Shoulder Injuries in t he Windmill Soft ball Player

Little research has ocused on so tball pitching biom echanics or injury rates sustained
by pitchers. Yet, so tball was the team sport with the greatest participation in the United
States in 1995. In 1996, Plum m er 234 reported so tball as one o the astest growing sports
or wom en at the college and high school levels. In act, in the m ost recent school year
data, so tball was the high school sport with the ourth greatest emale participation rate,
ollowing only basketball, outdoor track and f eld, and volleyball.6 When com paring the
sport o so tball to baseball, it is very sim ilar in m any demands and unctional tasks.
Although the so tball playing f eld is sm aller, the reaction tim e or a batter is directly
com parable to baseball. T e biggest di erence between baseball and so tball exists in
pitching. T e so tball m ound is at instead o elevated as in baseball. T e distance rom
hom e plate to the pitching rubber is 40 t or youth so tball and 60 t 6 in or baseball.
A baseball weighs 5 oz in com parison to a so tball that weighs 6¼ to 7 oz.37 T e delivery
o the pitch also di ers signif cantly between the windm ill pitch in ast-pitch so tball and
the overhand release in baseball or general overhead throwing. Sim ilar m usculature is
used, but in a very di erent order and with di erent m echanics (see Figure 31-17),286
with the biceps being m ore active in the so tball pitching m otion (38% maximum volun-
tary isom etric contraction) than the overhead throwing m otion (19% m aximum volun-
tary isom etric contraction).243,259
In a review o the existing literature, only 4 studies have addressed emale so tball
injury incidence and prevalence. Results suggested that 63% to 80% o all injuries were
in the upper extremity and 37% to 50% o the pitchers studied had a time-loss injury in
1 season.135,257,274,286 Furthermore, there were 5.6 injuries per 1000 athlete exposures in so t-
ball compared to 4.0 injuries per 1000 athlete exposures in baseball, 63% o which involved
the shoulder. Marshall et al described overuse o the shoulder as among the most common
injury in emale collegiate so tball players.188 Based upon these statistics and clinical experi-
ence, it would seem prudent to investigate injury prevention strategies.286
Likewise, there are only 2 published studies on windmill pitching biomechanics, as
compared to numerous studies on baseball pitching biomechanics. In these studies, it is
reported that shoulder distraction orces are similar to those ound in overhand pitching.
Barrentine et al37 reported that maximum distraction stresses at the shoulder (98% body
weight) were reached at 77% o the delivery phase and maximum compressive orce at the
elbow (70% body weight) occurred at the end o the delivery phase. T e di erence between
baseball and so tball pitching is the phase o pitching during which the distraction orces
occur, and the position o the humerus during the pitch. In windmill pitching, maximum
distraction orces at the shoulder occur during acceleration, whereas maximum shoul-
der distraction orces or baseball occur during windmill pitching. Shoulder distraction
orces occur when the humerus is in a slightly exed position while controlling internal
rotation and elbow extension during acceleration, be ore ball release. Notably, centri ugal
Kne e up Foot conta ct Ma x e xte rna l Re le a s e Ma x inte rna l

rota tion rota tion
Phas e s Wind-up S tride Arm Arm Arm Follow-through

cocking a cce le ra tion de ce le ra tion
A
B TOB S FC REL
Figure 31-17 Six phase s of pitching a base ball (A) and thre e name d phase s of pitching a softball (B)
REL, ball release; SFC, stride foot contact; TOB, top of the backswing. (A. Reproduced, with permission, from Fleisig GS,
Andrews JR, Dillman CJ, Escamilla RF. Kinematic and kinetic comparison between baseball pitching and football passing. J Appl Biomech.
1996;12:207-224; and B. Reproduced, with permission, from Werner SL, Guido JA, McNiece RP, Richardson JL, Delude NA, Stewart GW.
Biomechanics of youth windmill softball pitching. Am J Sports Med. 2005;33(4):553. )
distraction orce on the glenohumeral joint is accentuated because the elbow remains in
ull extension during most o the circumduction motion. For overhand pitching, maximum
shoulder distraction orces occur when the humerus is rotated internally and horizontally
adducted while maintaining a position o abduction during deceleration a ter ball release.
T e biceps labrum complex and the rotator cu are both at risk or overuse injury at these
phases. Conversely, medial elbow injuries are reported less requently in so tball pitching
compared to baseball, likely because o the small amount o varus torque produced during
the windmill motion.37
It is interesting that a so tball pitcher may pitch any number o consecutive innings
and games, while baseball pitchers are care ully monitored and o ten restricted in number
o pitches and innings they are allowed to throw. So tball pitchers can throw 1200 to 1500
pitches in a 3-day period as compared to 100 to 150 or baseball. A reason or this seems
related to the traditional belie that so tball windmill pitching orces were much less in the
shoulder and elbow than that o the baseball pitch.286 T is is may be true or the amount o
varus torque at the elbow, but not or the distraction orces at the shoulder.
Werner et al286 studied the biomechanics o 53 emale windmill pitchers, ages ranging
rom 11 to 19 years. Statistically signif cant di erent ranges o motion were ound, includ-
ing greater shoulder external rotation and decreased internal rotation in the dominant
arm. What remains unknown is whether these ROM di erences are a result o the windmill
biomechanics or the concurrent demands o overhand throwing, which is also a big part
o so tball. Elbow-carrying angle and hyperextension were ound to be similar bilaterally.
Maximum elbow and shoulder distraction orces were 46% body weight and 94% body
weight, respectively.
T is study along with the study conducted by Barrentine et al37 show that the com-
pressive orces at the elbow and the distraction orces at the shoulder are similar to base-
ball pitchers. T us, allowing so tball pitchers to throw an unlimited number o pitches is
subjecting them to potential orces o su cient amplitude to cause overuse injuries. With
such high magnitude o shoulder distraction stress and rapid deceleration o the humerus
near ball release, the posterior rotator cu is at high risk or injury, as is the biceps labrum
complex, because o the combination o shoulder distraction stress and elbow extension
torque.286 With overuse, eccentric muscle loading o the posterior muscle girdle can cause
stretching o these muscles allowing dynamic anterior instability o the humeral head.41
When rehabilitating so tball pitchers, it is important or the clinician to understand the
stresses and orces present during pitching. Educating coaches and athletic trainers regard-
ing these f ndings is also necessary or injury prevention. An important implementation or
windmill pitching injury prevention may be to establish a pitch count as is traditional in
baseball.
Rehabilit at ion and Ret urn t o Play

It is important to know the demands o the sport o so tball or e cient rehabilitation. T e
game requires the same demands o baseball or the overhead throw, hitting, running, cut-
ting, quick bursts o acceleration and deceleration, sliding, and catching. T e di erence in
rehabilitation occurs with the di erences in the demands o pitching compared to base-
ball pitching. In the windmill pitch, the pectoralis major is an important contributor to
the power o the pitch and also acts as a stabilizer against anterior orces. T e subscapu-
laris helps the pectoralis major in its role as a stabilizer. T e serratus anterior is a scapulo-
humeral synchronizer.177 T e teres minor is also ound to be very active in decelerating the
humerus. T ese muscles should be highlighted in the rehabilitation program along with the
standard return-to-throwing rehabilitation.
Core strengthening is also a key actor in return to play or the so tball player. T e
demands on the core during throwing and hitting cannot be ignored. T e trans er o energy
rom the ground through the limbs to core must provide a stable base or the upper extremi-
ties to unction properly.142
Consequently, rehabilitation and return to play or the windmill so tball pitcher may
include some variations to the typical so tball or baseball rehabilitation program that does
not require the windmill motion in the athlete’s return to playing. As with any overhead ath-
lete, it will be important to restore a balance o stability and mobility in the shoulder, with
a strong, stable core. It is also important to strengthen scapular stabilizers as one would
in any overhead athlete rehabilitation program. For the windmill pitcher, it may be more
e ective to include specif c unctional activities highlighting the demands o the pitch when
acute pain and in ammation have subsided. Functional exercises that the authors o this
chapter like to use are summarized in able 31-7 with Figures 31-18 to 31-33 to demonstrate
the techniques. T ese exercises are unctional and windmill-pitch specif c.
T e trunk rotation with a bicep curl (see Figure 31-18) mimics the motion required
in the trunk and arm near and at ball release. T e T era-Band provides resistance or
trunk acilitation/ control while the weight in the hand provides concentric and eccentric
strengthening or the shoulder extensors/ exors and biceps.
T e step-up with ipsilateral arm raise and contralateral hip extension (see Figure 31-20)
synchronously f res the latissimus dorsi and hip extensors. At the beginning o the pitch
delivery, the dominant leg remains in a closed chain, neutral hip position. T e hip then
travels into extension, which is mimicked in the step up. During the f rst 25% o the pitch
delivery phase, the latissimus dorsi is very active.
able 31-7 Sample Functio nal Exe rcise s fo r Re turn-to -Windmill Pitching
Exe rcise Muscle s Affe cte d Targ e te d Pitching Phase Cycle
Trunk rotation with biceps curl Trunk and hip rotators Biceps End of SFC to REL
(see Figure 31-18 )
Lawn mower with external rotation Scapular retractors Teres minor SFC to REL
(see Figure 31-19 )
Step up/arm lift/hip extension Hip extensors First 25% of pitch delivery (up to TOB)
(see Figure 31-20 ) Latissimus dorsi
Chest press on swiss ball with serratus Core stabilizers Pectoralis major is a key muscle
punches (see Figure 31-21 ) Pectoralis major in power of entire pitch cycle and
Serratus anterior stabilizes against anterior sheer forces
Step up with hip ER/IR Hip extensors Beginning of windup to TOB (with ER
(see Figure 31-22 ) Hip internal rotators movement of the exercise)
Hip external rotators At REL (with IR movement of the
Quadriceps and hamstrings exercise)
“ Full can” in tall kneeling on DynaDisc Core stabilizers SFC → REL

or BOSU ball (see Figure 31-23 ) Shoulder ER
Physioball deceleration throw with Concentric and eccentric training Just after SFC → REL
therapist (see Figure 31-24 ) of biceps
Shoulder exors/extensors Trunk/
hip rotators
Lunging with military press LE—Quadriceps, hamstrings, hip No speci c phase

(see Figure 31-25 ) extensors, and rotators
UE—Shoulder external rotators,
deltoids, latissimus dorsi
Core stabilizers
Push-up plus progression Pectoralis major Pectoralis and serratus active through
(see Figure 31-26 ) Serratus anterior Triceps entire cycle
Shoulder IR with Thera-Band sitting Shoulder internal rotators Beginning → SFC

on swiss ball (see Figure 31-27 ) (subscapularis)
Core stabilizers
ER, external rotation; IR, internal rotation; LE, lower extremity; REL, ball release; SCF, stride food contrast; TOB, top of backswing;
UE, upper extremity.
T e chest press on a Physioball with serratus punch (see Figure 31-21) challenges the
core, as it has to stabilize the trunk on the ball while strengthening the pectoralis major,
which is a key muscle in the power o the pitch and a major stabilizer against anterior sheer
orces. Although not positionally correct or the so tball pitch, this exercise incorporates the
serratus anterior, which is important to strengthen as the scapula must provide a strong,
stable base.
T e step-up with closed-chain hip external and internal rotation (see Figure 31-22)
trains the hip and core in the similar motions the hip passes through rom beginning o
wind up (step-up phase), be ore and during stride oot contact (hip external rotation), and
at delivery phase when the pelvis is closing and the hip goes into internal rotation.
A B
Figure 31-18 Trunk ro tatio n w ith bice ps curl
A. Start in stride stance facing sideways, front foot pointing forward, back foot pointing
sideways with Thera tubing wrapped around waist and secured at shoulder (to resist rotation).
B. Weight in dominant/pitching hand. Perform a bicep curl while rotating trunk forward.
A B
Figure 31-19 Law n Mo w e r w ith e xte rnal ro tatio n
A. Stance, forward flexion at waist with weight in hand. B. Retract scapula like a rowing motion,
adding external rotation at the end.
In Figure 31-23, the athlete is strengthening the shoulder

elevators ( ull can position) while challenging the core at the
same time. T is is important to provide excellent humeral steer-
ing, balance the strong internal rotators, and also it is impor-
tant in the overhead throw, as the pitcher must also participate
in de ensive plays. T us, the lunge with military press (see
Figure 31-25) can also assist in trunk/ lower extremity control
while overhead shoulder stability is maintained, and double as
the top o backswing movement.
Plyoball deceleration throw (see Figure 31-24) helps to
strengthen the shoulder concentrically and eccentrically mim-
icking the last portion o the pitching cycle. T e push-up “with
a plus” exercise (see Figure 31-26) is important as the pectora-
lis and the serratus anterior are muscles active throughout the
entire pitching cycle.
Return to pitching should be gradual with a progression o
percent e ort as well as number o pitches. Re er to Appendix B
or a return-to-windmill pitching program. A return-to-throw-
ing program is also included in Appendix C. T e return-to-
throwing guidelines should be modif ed to the specif c athlete.
Is she an exclusive pitcher who only needs to make shorter over-
hand throws to the bases? Or does she also play another posi-
tion when not pitching, that is, outf eld or inf eld? T is should
Figure 31-20 Ste p up/ arm lift/ hip be a actor in the decision making regarding the f nal distance
e xte nsio n at which the so tball player per orms the throwing program. For
example, an exclusive pitcher is not going to need to spend time
Step onto step with dominant leg (right for right-handed at the 120 t and 150 t stage; more time would be ocused on
pitcher) and lift ipsilateral arm into exion with weight specif c windmill exercises and shorter overhand throwing.
while left leg raises into hip extension.
A B
Figure 31-21 Che st pre ss o n Physio ball w ith se rratus punch
A. Lie on back over ball, feet shoulder width apart, dumbbells in both hands. Start with elbows bent, weights at chest.
B. Straighten elbows pressing weights together, at the end of the motion add scapular protection.
A B
Figure 31-22 Ste p up w ith clo se d chain e xte rnal ro tatio n/ inte rnal ro tatio n
Step up onto step with dominant leg, keep other leg in slight hip exion with knee exion (A). Slowly
rotate into internal rotation and external rotation on dominant leg. (B, external rotation shown.)
More research is needed in the area o windm ill pitching

as well as educating coaches and players in the potential risk o
injury with overuse. Clearly, current research is showing orces
at the shoulder to be much higher than once believed. T e active
emale can perhaps decrease the risk o su ering rom an over-
use shoulder injury by ollowing pitch guidelines closer to that o
a baseball pitcher and per orm ing a windm ill-specif c exercise
routine.
Shoulder Injuries in Female Swimmers

T ere is insu cient research to conclusively report that emale
swimmers actually sustain shoulder injuries at a higher rate than
male swimmers. Most studies are not gender specif c when injuries
to the upper extremity are reported.15,231,285,291,292 It is evident, how-
ever, that di erences exist between males and emales in anatomy,
upper-body strength, and laxity, as previously discussed. T ere ore,
with high numbers o shoulder injuries reported in swimming,285 it
is important or the sports medicine personnel to understand the Figure 31-23 Full can, tall kne e ling
demands and risks that the sport imposes. o n DynaDisc o r BOSU ball
Swimming has become a very popular recreational and com-
petitive athletic activity. riathlons are becom ing increasingly Start in tall kneeling position on balance challenging
popular as well, and swimming is 1 o the 3 components. Ninety surface. Raise weight at 45-degree angle with
percent o complaints by swimmers that are signif cant enough to thumbs up, within comfort range. Emphasize good
seek m edical attention pertain to the shoulder.285 Sport-specif c trunk alignment throughout exercise.
A B C
Figure 31-24 Plyo ball de ce le ratio n thro w w ith the rapist
Standing in stride stance facing sideways, horizontally abduct the shoulder and extend the elbow. Therapist tosses
Plyoball; athlete catches (A) while simultaneously rotating pelvis forward and bringing ball through (B), flexing the
shoulder and elbow (mimicking delivery and follow through) (C); then reverse the same motion and athlete tosses back
to therapist with shoulder and elbow extended (ie, reverse sequence from C→B→A). Focuses on concentric and eccentric
training. Have athlete mimic her delivery as much as possible.
A B
Figure 31-25 Lung ing w ith military pre ss
A. Start with legs straight, elbows bent, hands shoulder height. Raise arms overhead, extending
elbows; as arms raise overhead, perform lunge. B. Return to starting position.
A B
Figure 31-26 Wall push-up “plus”
A. Hands shoulder width apart, flex elbows as lower down to wall. B. Extend elbows and at
end of exercise add an extra push (plus) into scapular protraction. Progression: at wall, at
table, on floor, hands on wobble board or BOSU ball, feet on Physioball, hands on floor. Note
poor trunk positioning on left.
A B
Figure 31-27 The ra-Band sho ulde r inte rnal ro tatio n o n Physio ball
While sitting on Physioball and facing away from door, grasp Thera-Band at shoulder
height. In the 90/90 position (A), pull band forward into internal rotation (B). May also
train external rotators by facing wall and pulling opposite direction.
D La te
Ea rly re cove ry
re cove ry
C
Ea rly
pull-through
Ea rly
pull-through B
Figure 31-28 The S-shape d curve in Figure 31-29 Phase s o f the fre e style sw imming
pull-thro ug h stro ke cycle
(Adapted from Pink M, Perry J, Browne A, Scovazzo ML, (Adapted from Pink M, Perry J, Browne A, Scovazzo ML, Kerrigan J.
Kerrigan J. The normal shoulder during freestyle swimming. The normal shoulder during freestyle swimming. An electromyographic
An electromyographic and cinematographic analysis of and cinematographic analysis of twelve muscles. Am J Sports Med.
twelve muscles. Am J Sports Med. 1991;19:574.) 1991;19:569-576.)
demands o swim ming include increased shoulder internal rotation and adduction
strength, increased shoulder ROM, and endurance o the shoulder complex. During the
reestyle stroke, most o the orward propulsion is produced by the upper body, the legs
help minimally (Figures 31-34 and 31-35). Specif cally, the shoulder adductors and exten-
sors (pectoralis major and latissimus dorsi) should be assessed. T ese same muscles pro-
duce internal rotation. Increases in adduction and internal rotation can lead to muscle
A B C
Figure 31-30 Pro ne sw imming e xe rcise o n ball
A. Start position. B. Internal rotation or during pull through. C. Finish position. Note: performing this exercise prone on the
ball increases sport position specificity and demands on the core musculature.
imbalances, which can reduce glenohumeral stability and provide
optimal conditions or impingement. Freestyle is used 80% o the time
during the swimmer’s training, regardless o what stroke the athlete
uses competitively.15 T ere ore, impingement poses a potential prob-
lem to all swimmers.
As m entioned previously, swim ming requires shoulder ROM
greater than that o nonswimmers in order to excel. T is increased
motion allows or longer stroke length, which directly correlates to a
swimmer’s speed. Although the increased ROM is benef cial to per-
ormance, it can be detrimental to glenohumeral stability. Excessive
ROM produces capsuloligamentous laxity, which decreases the orce
produced by the rotator cu muscles to provide stability.285
T e third specif c demand includes the incredible endurance
necessary o the rotator cu and scapular stabilizers. T e teres m inor,
in raspinatus, and subscapularis are rotator cu muscles that f re
continuously through the swim m ing cycle. T e scapular stabilizer
that also f res continuously is the serratus anterior. T ese muscles are
at risk or atigue with resultant possibilities o impingement or insta-
bility/ subluxation o the shoulder. T e repetitive nature o swim ming
predisposes the participant to overuse injury rom m icrotrauma and
mechanical primary im pingem ent. T is can ultimately lead to insta- Figure 31-31
bility, rotator cu atigue, and resultant secondary im pingem ent.15
Swim m ers average 8000 to 20,000 m o training per day and may Typical gymnast pose before/after routines and
practice twice a day, with no rest days in between. T is subjects the landing jumps/tumbling moves. Note excessive
shoulder com plex to an incredibly high num ber o stroke repetitions. lumbar lordosis.
An average com petitive swim m er may swim 10,000 m per day. T us,
an athlete who swim s 20 cycles per 50 m (estimated or the average
swim m er), com pletes 4000 repetitions per shoulder, every day.15
Unpublished data rom Centinela Hospital Medical Center Bio-
mechanics Laboratory report that swimmers exhibited a higher incidence o positive
Hawkins test than positive Neer tests or shoulder impingement.232 T e Hawkins test ana-
lyzes compression o the rotator cu tendons under the acromion, whereas the Neer test
analyzes the pinching o the rotator cu undersur ace on the anterosuperior glenoid rim.
T is may indicate that swimmers tend to display more problems with compression o the
cu tendons under the acromion rather than undersur ace tears. EMG studies reveal swim-
mers with pain ul shoulders have altered muscle-f ring patterns when compared to swim-
mers with no shoulder pain. T e serratus anterior has decreased muscle activity and the
rhomboids have increased activity rom the nonpain ul shoulders, during mid pull through.
I the serratus anterior is not unctioning properly to aid in scapular upward rotation and
protraction, then the acromion would also lack upward rotation placing the swimmer at
risk or compression o the cu tendons under the acromion.
Interestingly, the rhomboids are an antagonist muscle to the serratus anterior. When
the serratus anterior atigues, there is no other muscle that can help produce the same
action. T e antagonist muscle is called upon to help stabilize the scapula creating a distur-
bance in the synchrony o normal scapular rotation during propulsion.
As previously noted, the serratus anterior and subscapularis f re continuously through-
out the reestyle stroke. T e serratus anterior is f ring continuously to provide a stable base
or the humerus, and the subscapularis is f ring caused by the humerus being in predomi-
nately internal rotation throughout the stroke. T ese 2 muscles are susceptible to injury
because o atigue.232
In a similar example, the same research documented that the subscapularis (an inter-
nal rotator) had decreased muscle activity and the in raspinatus (an external rotator) is
ound to have increased muscle activity compared to normal at mid recovery in pain ul
shoulders. Again, the antagonist muscle is called upon when atigue has occurred in the
agonist causing potential imbalances and asynchronous movement. Another method to
encourage the subscapularis to diminish its activity could be to avoid the extreme ranges o
internal rotation motion avoiding impingement.232
T ree-dim ensional videography was used by Yanai and Hay292 to determ ine when,
during the swim m ing m otion, the shoulder experienced im pingem ent. During the ront
crawl in swim m ing, on average, im pingem ent occurred during 24.8% o the stroke tim e.
However, each subject m onitored experienced im pingem ent in some cycles and not oth-
ers. T is suggests that stroke technique m ay play a actor in susceptibility to im pinge-
m ent.292 Som e studies show that between 50% and 70% o the tim e, shoulder pain was
reported during pull through ;78,242 others, however, report im pin gem ent occurs m ore
o ten during the recovery stage.291,292 During early pull-through, the pectoralis major and
the teres m inor are highly active, with their activity peaking at m id pull-through. T e
teres m inor is the prim e contributor to maintaining hum eral head congruency in the
glenoid because o its insertion closer to the axis o rotation than the pectoralis. In pain-
ul shoulders, the m ost notable di erence during pull-thorough was decreased m uscle
activity o the serratus anterior.232
T e hand entry position during reestyle stroke is also reported to be a requent point o
pain in swimmers.291 During hand entry and orward reach, the upper trapezius, rhomboids,
and serratus anterior are all active to orm a orce couple to properly position the glenoid
ossa. T e supraspinatus and the anterior and middle deltoid are also active to abduct and ex
the humerus as the hand reaches orward in the water. Without the supraspinatus, the deltoid
proper f ring o predisposes the humeral head to excessive movement within glenoid ossa.232
Rehabilit at ion and Ret urn t o Swimming

Shoulder rehabilitation or these emale swimmers should be multi aceted. Great empha-
sis should be placed on restoring normal ROM, strength, and endurance based on the
evaluative f ndings. able 31-8 lists the typical signs and symptoms o possible causes o
able 31-8 Typical Sig ns and Sympto ms and Po ssible Cause s o f Sw imme r’s
Sho ulde r
Sig ns and Sympto ms Po ssible Cause
Postural deformities of rounded Tightness of the pectoralis minor

shoulders and thoracic kyphosis
Weakness of the posterior cuff Weakness can be a result of strength imbalances

muscles and scapular stabilizers between the anterior and posterior muscles
secondary to the demands of the sport and to
stretch weakness
Limited internal rotation and Tightness of the posterior capsule or posterior cuff
excessive external rotation ROM muscles which causes a shift in the available ROM
Decay of normal scapulothoracic Tightness of the anterior chest musculature and

rhythm weakness of the scapular stabilizers
Source: Adapted from Allegrucci M, Whitney SL, Irrgang JJ. Clinical implications of secondary impingement of
the shoulder in freestyle swimmers. J Orthop Sports Phys Ther. 1994;20(6):313.
swimmer’s shoulder. Exercises should incorporate trunk and hip movements along with
both scapular and glenohumeral neuromuscular retraining. Core stability should also be
emphasized in the shoulder rehabilitation program as it needs to provide a stable base or
the athlete to propel their body orward.
Range of Mot ion

Flexibility and m obilization techniques should re ect the f ndings rom the evaluation.
Im portance should be given to restore normal ROM without com prom ising stability. T e
m ost typical restrictions are ound in the posterior portion o the glen ohum eral joint
capsule or tightness o the posterior rotator cu muscles.285 Swim m ers, in general, tend
to spend m ore tim e stretching their anterior capsule. T is results in loss o internal rota-
tion and horizontal adduction. Horizontal adduction may be im proved by stabilizing the
scapula on the thorax while crossing the arm over the chest. T is can be per orm ed at
90 degrees o shoulder exion and above to address all portions o the cu . Posterior
capsule exibility is im proved by exin g the shoulder to 90 degrees and providing a
downward orce on the exed elbow.
Internal rotation ROM, rather than external rotation, at the end range o abduc-
tion proves to be important or swimmers. T is motion is most important during the late
recovery stage o the reestyle stroke. Internal rotation should be stretched at 90 degrees,
135 degrees, and at end-range abduction in stretches assisted by the therapist or utilizing
sel -stretches such as the “sleeper stretch.” External rotation stretching should still be car-
ried out i it is lacking. Other important muscles to check or normal exibility include the
pectoralis major and minor, upper trapezius, levator scapulae, biceps, triceps, and serratus
anterior. Swimming strokes do not happen in a straight cardinal plane o motion; during
the arm cycle, there are multiple combinations o movements taking place.15 A exibility
program can be creatively structured with this in mind.
St rengt h and Endurance Training

Developm ent o a strength and endurance training program should ocus on restoring
normal balance to the anterior and posterior shoulder musculature. It also should ocus
on restoring equilibrium between scapular and hum eral m ovem ents. It is im portant to
rem em ber that increased adduction and internal rotation strength is unavoidable in
swimm ers. o avoid muscular im balance, em phasis on rotator cu exercises with im por-
tance on external rotation strength is benef cial.285 T e 3 primary considerations in a
strengthening program are (a) isolate the rotator cu and scapular muscles, (b) im ple-
m ent endurance-based exercises, and (c) include sports-specif c unctional exercises.15
able 31-9 provides primary considerations and rationale or developing a strengthening
program or swim mers.
Female swimmers appear to be highly susceptible to secondary impingement as a con-
sequence o exibility, strength, and muscular endurance actors discussed earlier. Please
re er to Chapter 20 or details on primary and secondary impingement. able 31-10 provides
basic guidelines or progression o treatment or swimmer’s shoulders with 2-degree
impingement. T e initial goal in the rehabilitation program is to establish a stable scapular
base and strengthen the rotator cu muscles in a neutral position.255 Phase II introduces
exercises up to 90 degrees. In Phase III, overhead exercises can be initiated with unctional
training. Phase IV is gradual return to athletic activity, progressing in speed and distance.15
Most swimming programs emphasize only upper-extremity strengthening and unction.
Challenging core stability during some upper-extremity exercises is benef cial to the athlete.
Swimming is a chain o events involving the arms, trunk, and legs together. Focusing solely
on the shoulder complex ails to address all areas o the kinetic chain vital to swimming
e ciency and per ormance.
able 31-9 Co nside ratio ns and Ratio nale in a Stre ng the ning Pro g ram
fo r Sw imme rs
Primary Co nside ratio ns Ratio nale
Isolation of the rotator cuff and EMG studies demonstrate cuff muscles
scapulohumeral muscles (correctly train act independent of each other during the
prime movers/stabilizers, not antagonists) stroke cycle
Muscular endurance, high repetitions of Swimming involves excessive repetition

speci c exercises (sprint, middle-distance, and muscular endurance; 3 sets of 10
or long-distance swimmer—should re ect repetitions are inadequate
in number of repetitions given)
Sports-speci c function Exercises speci c to the swimmers stroke

and body postures help return to sport as
ef ciently and quickly as possible
able 31-10 Basic Guide line s fo r Pro g re ssio n o f Tre atme nt fo r Sw imme r’s
Sho ulde rs w ith a 2-De g re e Imping e me nt
Phase I
Modalities PRN for pain control
Address ROM losses
Rotator cuff strengthening at 0 degrees abduction, with towel support
• Side lying ER
• Thera-Band ER/IR
• Thera-Band ER/IR isometric “ step-always”
Scapulothoracic muscle in neutral
• Shrugs
• Prone arm raise at 0 degree abduction
• Scapular retraction (row)
• Prone ball roll (for lower trap)
• Prone ball stabilization on oor
Aerobic conditioning
• Bike
• Kicking in water
Phase II (0 to 90)
Rotator cuff strengthening
• Prone ER
• Thera-Band ER
• Prone arm raise with ER at 90 degrees abduction, progress to 120 degrees abduction
• Elevation in scapular plane (full can)
Scapulothoracic exercises
• Scapular protraction (supine on ball progress to standing using Thera-Band with
shoulder at 90 degrees, and in a weightbearing position on one-half foam roller)
• Stabilization exercises
■ Bilateral → unilateral
■ Add dynamic resistance
■ Progress to stabilizing on a ball
able 31-10 Basic Guide line s fo r Pro g re ssio n o f Tre atme nt fo r Sw imme r’s
Sho ulde rs w ith a 2-De g re e Imping e me nt (Continued )
• Push-up “ plus” progression

■ Wall → table → modi ed (on knees) → regular
Axial humeral muscles
• Flexion
• Abduction in the plane of the scapula (challenge core on BOSU ball in tall kneeling)
• Lat pull-down
• Chest press (challenge core stability by laying supine on ball)
• Bench press
Proprioception
• Active and passive matching
Aerobic conditioning
• Upper body ergometer
• Rower
• Kicking in water
Phase III—Functio nal training

Full range exion and abduction strengthening
Combined movement patterns
• Proprioceptive neuromuscular facilitation D1 and D2 (Thera-Band, Bodyblade, manual,
Plyoball)
Stroke-speci c exercise
• Simulation of pull-through and reverse pull-through with Thera-Band (prone on swiss
ball to challenge core at same time) (see Figure 31-30 )
• Simulation of recovery:
1. Prone horizontal abduction with ER
2. Prone horizontal adduction with IR at 160 degrees abduction
3. Thera-Band-resisted ER at 30 degrees of abduction progressing to 90 degrees of
abduction
Plyometric exercises
Swim bench (if available)
ER, external rotation; IR, Internal rotation.

Source: Adapted and modi ed from Allegrucci M, Whitney SL, Irrgang JJ. Clinical implications of secondary
impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther. 1994;20(6):316.
Propriocept ion and Funct ional Training

Retraining joint proprioception in reestyle swimmers, and all athletes, is important. Are
di erences seen in swimming stroke patterns with pain ul shoulders intentional changes to
avoid pain, or caused by inadequate eedback rom joint receptors rom capsular damage?
Multiple studies have shown proprioceptive def cits in subjects with glenohumeral joint
multidirectional instability.35,47,89 However, no studies specif c to symptomatic swimming
athletes are available. Proprioception is derived rom both conscious and unconscious
components, as was previously described in detail in other chapters. Making the athlete
consciously aware o humeral and scapular position during strength training and swim-
ming may help to improve conscious proprioception. However, only conscious training is
not enough, unconscious neuromuscular output is also vital to athletic per ormance. rain-
ing unconscious proprioceptive awareness can be carried out with plyometric training.15
Plyometric training is used to not only enhance power and explosiveness but may also
help improve “synchrony o movement that is needed or the swimming stroke.” 15, p. 315
Progression o an upper-extremity plyometric training program or swimmers should

include progressing the degree o shoulder abduction (starting in more neutral positions
increasing to overhead); progressing the weight o the medicine ball; and increasing speed,
repetitions, and di culty.
Closed-chain exercises can be use ul in rehabilitation o the swimmer because they
mimic how the body is pulled over the arms during pull through, while engaging the trunk
and core muscles or stabilization.15 For example, in Phase III, a T era-Band can be used
to provide resistance mimicking the pull through phase while the athlete is prone over a
Physioball (see Figure 31-30). T is orces the core muscles to stabilize the athlete’s body as
her arm is going through a specif c motion. During this exercise, it is important to keep the
shoulder at 90 degrees o abduction to ensure proper mechanics and avoid impingement.
Internal obliques are also important muscles to strengthen because o the rotation required
at the trunk or the swimmer to body roll during reestyle. I core muscles are weak or lack
endurance, they will not provide a stable base or the upper extremities. As discussed in
several contexts, but especially important in the swimmer, a weak core can be a contribut-
ing actor in a shoulder injury.119,149
T roughout the rehabilitation program, it is easible or the athlete to continue swim-
ming with use o swimming aids (ie, kickboard held under the body), modif cation o yard-
age, and altered rest time. T is active rest concept is dependent on the severity and nature
o shoulder injury and should be athlete and injury specif c. For example, an impingement
injury caused by atigue o the posterior cu muscles may still respond positively to treat-
ment in conjunction with a signif cant decrease in yardage and increase in rest time be ore
swimming again to avoid atigue. It is vital to educate both the coach and swimmer that at
the f rst sign o shoulder pain the athlete is to stop swimming.15
In conclusion, reestyle swimmers can present with signs and symptoms o either insta-
bility or impingement, or a combination o both. T e rotator cu provides stability at the
glenohumeral joint and can there ore be a source o pain or disability when instability or
impingement occurs. It is essential to provide the optimum environment or the rotator cu to
work e ectively by balancing adequate stability with the appropriate mobility in the shoulder
complex. Accordingly, or an e cient and e ective rehabilitation program, clinicians must
have knowledge o the sport-specif c skills that are required. Finally, creativity in designing
the rehabilitation program to incorporate the core with upper-extremity activities and meet
the swimmers’ demands (sprinter, middle, or long-distance swimmer) is essential as well.15
Considerations in the Female Gymnast

T e f nal sport or special consideration in regard to the emale athlete is gymnastics. Gym-
nastics is important to consider because o its high potential or micro- and macrotraumatic
injuries, as well as the vulnerability o its athletes to body image issues that are elaborated
upon in the emale athlete triad section. Certainly, similar considerations may exist in
sports not mentioned; however, it is beyond the scope o this chapter to attempt to cover all
sports in which women participate.
Multiple injuries occur in gymnasts o all ages and ability levels, whether recreational
or competitive. Women’s gymnastics involves 4 apparatuses: beam, oor exercise, vault,
and uneven bars. Men’s gymnastics involves 6 apparatuses: oor exercise, rings, parallel
bars, pommel horse, vault, and high bar. T e demands o this sport include the need or
great exibility, incredible strength, balance, and explosive power. Competitive gymnastics
requires intensive training with a large time commitment, usually beginning at a young
age. T e average junior elite gymnast (age 10 to 14 years) spends more than 5 days per week
training, or a total o approximately 25 hours a week.57 Such demand on a young body
is not without penalty. T e period o rapid growth, which occurs in adolescence, causes
Considerations in the Female Gymnast 1091
the young gymnast to be more susceptible to injury than the postpubescent gymnast.57
Questions also arise in regards to the possibility o stunted or inhibited growth during these
vital years o development and maturation.58,277,284
Recently, a Gymnastics Functional Measurement ool was developed and studied by
Sleeper et al.264 T is f eld-based assessment tool was ound to correlate with United States
Gymnastics competitive level o the athletes and allows sports practitioners to reliably
examine and score per ormance in 10 important physical tasks necessary or participation
in gymnastics. Such a sport-specif c test battery may assist the clinician to determine readi-
ness or participation in gymnastics and risk or potential injury.
Gymnasts sustain a large variety o injuries. Caine et al57 ollowed 50 competitive gym-
nasts over a 1-year period tracking injuries. T e most commonly injured regions in the body
by order o requency were (a) the lower extremity (63.7%), particularly the ankle and knee;
(b) the upper extremity (20.4%), particularly the wrist; (c) and the spine and trunk (15.2%),
particularly the lower back. T ese f ndings are consistent with other multiple studies con-
ducted.33,57,172,252,271 Gymnasts were most likely to injure themselves on the oor exercise
(35.4%), ollowed by the balance beam (23.1%), the uneven bars (20%), and, lastly, the vault
(13.8%). T e remaining 7.7% o injuries were placed under “other,” pertaining to possible
warm-up or conditioning periods. T e distribution between sudden onset and gradual
onset o injury was 44.2% and 55.8%, respectively. Clearly traumatic as well as overuse inju-
ries occur in this sport.
Female gymnasts o today are shorter, lighter, and mature later than their predecessors
30 years earlier. Increased magnitude and intensity o training at an early age has become
standard. T e question arises whether these external characteristics are a result o sel -
selection or gymnastics or a result o inadequate nutrition or the level o activity during
this crucial period o development.58 Studies suggest that the shorter emoral leg length
seen in emale gymnasts may be a result o the repetitive compressive stress causing pre-
mature closure o emoral and tibial epiphyses.58,59,183,276 A short-term longitudinal study by
Mansf eld and Emans183 reported that gymnasts advance through puberty without a normal
pubertal growth spurt. Catchup growth does occur once the gymnast retires rom the sport
or signif cantly reduces training58; however, it is questionable whether adequate growth and
normal height are eventually achieved. Longitudinal studies o 1 set o triplets and 2 sets
o twins (one gymnast, other one(s) not) reveal signif cantly later onset o menarche when
compared to their nongymnast sibling. In the set o triplets, energy expenditure exceeded
energy intake by 600 kcal and the gymnast had lower body weight and percent body at
compared to her siblings.58
Lower levels o hormones and decreased serum growth actors have also been identi-
f ed in gymnasts. Serum leptin is involved in the regulation o energy intake and energy
expenditure. Leptin is secreted by adipocytes and binds to an appetite-stimulating neu-
ropeptide, which produces neurons in the hypothalamus. Leptin levels increase with ood
intake and decrease during periods o starvation. Low body at levels have been linked to
low levels o leptin. A decline in leptin levels has an e ect on the secretion o gonadotropins
and sex steroids, which may be a actor in delayed menarche and amenorrhea leading to
the emale athlete triad, which is discussed in detail later in this chapter.284
Some additional noteworthy considerations in the sport o gymnastics include (a)
gymnasts do not wear any type o supportive shoe while training and competing, making it
di cult to correct aulty biomechanics at the oot with any type o orthosis; (b) the typical
postural salute to judges, and landing o jumps and dismounts, is a hyperlordotic position o
the lumbar spine, potentially contributing to trunk instability problems (see Figure 31-31);
(c) gymnastics, unlike many sports, has a signif cant amount o skills and activities per-
ormed with the upper extremities in a closed-chain position; and (d) gymnasts jump and
land rom various heights with twisting and rotational components. With these actors in
mind, ocus should be placed on balancing strength and exibility to help correct aulty
biomechanics or structural aults; emphasis placed on core strength and stability and edu-
cation o gymnasts should occur regarding ideal trunk posturing at the beginning and end
o routines. Likewise, education on proper jumping and landing must be an integral part o
training and rehabilitation. Re er to the section “Anterior Cruciate Ligament Injuries” ear-
lier in this chapter or more detail on jumping and landing.
O additional concern are the body image requirements and subsequent disorders
common in the sport o gymnastics potentially leading to inadequate caloric intake.58,59,277
Educating the coaches, gymnast, and rehabilitation sta in regard to the emale athlete triad
potential risks o osteoporosis and stress ractures, as well as stunted growth patterns, is
important.
T e Female Athlete riad
Hist orical Perspect ive and Evolut ion

T e emale athlete triad ( riad) was f rst described by Rosemary Agostini, MD, Bar-
bara Drinkwater, PhD, Aurelia Nattiv, MD, and Kimberly Yeager, MD, MPH, in the early
1990s.1,50,96,213, 214 T e riad (see Figure 31-32) was used to describe the connection between
3 independent clinical disorders: eating disorders, amenorrhea, and osteoporosis. Contin-
ued research and discussion among sports medicine pro essionals in varied disciplines led
to the American College o Sports Medicine publishing the f rst Fem ale Athlete riad Posi-
tion Statem ent in 1997.96 T e purpose o the position statement was to provide direction
or identif cation, prevention, and treatment o these individual, yet connected, medical
disorders in this specialty population.8,19,213, 215
Evolution o this original concept has continued. Classif cation o eating disorders
such as anorexia nervosa (AN),209 bulim ia nervosa (BN), and eating disorders not other-
wise specif ed (EDNOS) were the severe orm s o nutritional def cit that were observed.
Because a m inority o em ale athletes f t the diagnostic criteria or any o these diseases,
Dis orde re d
e a ting
De cre a s e d
Me ns trua l
bone mine ra l
irre gula ritie s
de ns ity
Figure 31-32 The fe male athle te triad, as rst de scribe d in 1997

The Female Athlete Triad 1093
the term eating disorders has been expanded to include the concept o disordered eating
patterns that encom passes a wide range o harm ul nutritional strategies associated with
the other actors o the riad.21,215 Osteoporosis (identif ed in the original riad descrip-
tion) has been m odif ed to include osteopenia and the less-severe orm s o bone loss
m ore com m on ly seen in em ales screened and diagnosed with the riad. Discussion
also ensued regarding the expansion o am enorrhea to include m enstrual irregularities
and other reproductive dys unctions that are associated with but independent o am en-
orrhea. T ese other dys unctions are interm ittently seen in association with other com -
ponents o the riad, and include oligom enorrhea, anovulation, and altered luteal phase
len gth.213, 215 T e revised and updated riad describes the interaction and coexistence
o eating disorders/ disordered eating behavior, m enstrual irregularities, and decreased
BMD. 215
Further evolution has established a spectrum concept or each o the independent yet
interrelated components. T e current concept o the riad re ers to the interrelationship
between energy availability, menstrual unction, and BMD. Each o these components is
described and illustrated as a spectrum in the publication o the revised position statement
by the American College o Sports Medicine in 2007. 215 Each spectrum ranges rom the
healthiest state to the unhealthiest state o a emale athlete in each o these components
(see Figure 31-33).
Component s
Energy Availabilit y
T ere is a very important relationship between the amount o calories consumed and the
amount o calories expended or any athlete. T e spectrum o energy availability ranges
rom low energy availability with or without an eating disorder to optimal energy availabil-
ity. Optimal energy availability def ned as the appropriate balance o calories; or simply
stated: calories taken in versus calories expended. Energy availability is critical or optimal
Optimal e ne rg y
availability
Re duce d e ne rgy ava ila bility

with or without
dis orde re d e a ting
Low e ne rg y availability
Eume no rrhe a Optimal bo ne
with o r witho ut
an e ating dis o rde r he alth
S ubclinica l
me ns trua l
dis orde rs
Low
BMD
Func tio nal

hypo thalamic
ame no rrhe a Os te o po ro s is
Figure 31-33 The fe male athle te triad, as de scribe d in 2007
Note the spectra between “optimal health” and “poor health” in the 3 components of the
triad.
per ormance, maintenance o body composition, and prevention o health problems.23 For
the emale athlete, the prevention o health problems includes:
• establishing and maintaining normal menstruation 39,215
• preservation o a strong immune system 213
• building and repairing muscle tissue and bone 23,39
A “negative energy balance” resulting rom a sustained negative calorie balance (intake
less than output) can be a result o many actors, ranging in decreasing severity rom a clini-
cally diagnosed eating disorder to the elimination o a ood group, or example, dairy or
meat rom the diet, to inadvertently not eating enough to keep up with a sudden or unex-
pected increase in a training schedule. T e internal and external pressures to achieve ath-
letic success, attain a body composition o unreasonably low body at percentage, and/ or
achieve or maintain unrealistically low body weight o ten lead to disordered eating patterns
and occasionally to clinical eating disorders.11,18-21,39,40
Clinical eating disorders include AN, BN, and EDNOS.39 Each o these disorders have
specif c diagnostic criteria that are established ( ables 31-11 to 31-13). AN represents the
extreme o voluntary starvation with severe caloric restriction and an altered sel -image,
viewing onesel as overweight when in reality being as much as 15% below o ideal body
weight. T e prevalence o AN is 0.5% to 1% in adolescent and young adult women as com-
pared to 2% to 4% with BN.23 BN is characterized by a “binge and purge” eating behavior.
Binging occurs as a result o physiologic hunger ollowed by purging to eliminate the caloric
intake.23 T e purging behavior takes a multitude o orms including vomiting, laxative use,
diuretic use, enemas, and excessive exercise.11,19,21,39,40,117,126,152 Physiologic and psychologi-
cal problems resulting rom this purging behavior include uid and electrolyte imbalances,
dehydration, acid-base imbalances, cardiac arrhythmia, the enlargement o the parotid
glands, erosion o tooth enamel, gastrointestinal disorders, low sel -esteem, anxiety, depres-
sion, and reported cases o suicide.19,21,39,40,45,50
able 31-11 Diag no stic Crite ria fo r Ano re xia Ne rvo sa (AN)
A. Refusal to maintain body weight at or above a minimally normal weight for age and
height. Weight loss leading to maintenance of body weight <85% of that expected;
or failure to make expressed weight gain during period of growth, leading to body
weight <85% of that expected.
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced; undue
in uence of body weight or shape on self-evaluation; or denial of the seriousness of
the current low body weight.
D. In postmenarchal females, amenorrhea, i.e., the absence of at least 3 consecutive
menstrual cycles. A female is considered to have amenorrhea if her periods occur only
following hormone administration.
Sp e cify t yp e :
Re stricting type : During the episode of anorexia nervosa, the person does not regularly
engage in binge eating or purging behavior, i.e., self-induced vomiting or misuse of
laxatives or diuretics.
Bing e e ating / purg ing type : During the episode of anorexia nervosa, the person regularly
engages in binge eating or purging behavior, i.e., self-induced vomiting or misuse of
Data from DSM-IV, American Psychiatric Association, 1994.

able 31-12 Diag no stic Crite ria fo r Eating Diso rde r No t Othe rw ise
Spe ci e d (EDNOS)
A. For females, all of the criteria for AN are met, except the individual has regular menses.
B. All criteria for AN are met except that, despite signi cant weight loss, the person’s
current weight is in the normal range.
C. All criteria for BN are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than 2 per week for a duration
of less than 3 months.
D. Regular use of inappropriate compensatory behavior by an individual of normal body
weight after eating small amounts of food (self-induced vomiting after consumption
of 2 cookies).
E. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
F. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular
use of inappropriate compensatory behaviors characteristic of BN.
Data from DSM- IV, American Psychiatric Association, 1994.
T e EDNOS diagnosis includes those individuals who meet every other criteria or AN
except amenorrhea/ oligomenorrhea or decreased body weight or those individuals who
demonstrate all other criteria or BN with a decreased requency or duration o the purging
behavior. T is additional category, EDNOS may lead to better detection and treatment o
those emale athletes who exhibit the criteria or AN but paradoxically maintain “normal”
able 31-13 Diag no stic Crite ria fo r Bulimia Ne rvo sa (BN)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following:
1. Eating, in a discrete period of time, e.g., within any 2-hour period, an amount of
food that is de nitely larger than most people would eat during a similar period
of time and under similar circumstances, and
2. A sense of lack of control over eating during the episode, e.g., a feeling that one
cannot stop eating or control what or how much one is eating.
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting;
or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average,
at least twice a week for 3 months.
D. Self-evaluation is unduly in uenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Sp e cify t yp e :
Purg ing type : The person regularly engages in self-induced vomiting or the misuse of
No n-purg ing type : The person uses other inappropriate compensatory behaviors, such
as fasting or excessive exercise, but does not regularly engage in self-induced vomiting
or the misuse of laxatives or diuretics.
Data from DSM- IV, American Psychiatric Association, 1994.

body weight because o the increased lean body mass.19,21,40 Despite the many strides that
have been made in the classif cation o disordered eating, there are a plethora o unhealthy
eating behaviors that elude the AN, BN, or EDNOS diagnoses and result in a negative energy
balance.
It is di cult to estim ate the num ber o em ale athletes who dem onstrate disor-
dered eating or unhealthy eating habits. Several di erent surveys have been developed
in an attem pt to identi y collegiate em ale athletes with disordered eatin g behav-
iors. T e prevalence o eating disorders ranged rom 6% to 60%, dependin g upon the
tool used, how the tool was adm in istered, the athletic population , and the def n in g
criteria.11,21,39,40,45,50,213,215,226 T ere are many reasons or this wide range o those classi-
f ed as disordered eaters. Many athletes consider disordered eating patterns normal and
harm less. Others den y disordered eating patterns on standard questionnaires. Man y
studies re erenced to assess the prevalence o eating disorders use questionnaires that
assess sym ptom s o eating disorders without an assessm ent by a trained clinician or a
screening tool that conf rm s def ned disordered eating patterns.152 In 2004, the National
Eating Disorder Screening program screened m ore than 16,000 students and 59% scored
positive or sym ptom s o an eating disorder.50 Reinking et al239 determ in ed that disor-
dered eating patterns were not signif cantly di erent in athletes versus nonathletes in
a collegiate setting. However, there was a greater disposition o disordered eating pat-
terns in lean versus nonlean athletes.239 At least 1 con ounding actor o this study was
that there was a requirem ent at this university that all athletes take a nutrition class.
Although som e authors have shown that nutritional knowledge does change eating pat-
terns in athletes,293,294 other studies question whether knowledge is easily translated into
action in em ale athletes.238 Such studies rem ain valuable, but lead to a wide range o
prevalence in research reports, as well as lack o consensus about the role o education
on a ecting eating behaviors.
T ere are several theories as to why disordered eating patterns occur, including incor-
rect popular perceptions, biologic actors, and psychological reasons. Many attribute the
evolution o these unhealthy eating patterns to the overwhelming desire to be thin.9,11,19,21,245
Specif cally with athletes, this desire is o ten held in conjunction with the desire to win at all
costs.50 Many emale athletes think and are told that “thinner is better.” T ere is a percep-
tion among athletes, coaches, and the media that thinner athletes are aster, stronger, and
more power ul. Biologic imbalances in neurotransmitters (serotonin, norepinephrine, and
melatonin) have been suggested as an etiology or eating disorders.39,40 Psychological con-
tributing actors include poor coping skills leading to poor stress management, insu cient
amily support, sexual and/ or physical abuse, and low sel -esteem.40 Struggling with many
changes in their bodies, adolescent emale athletes are particularly at risk or development
o disordered eating patterns that may be the stepping stone or the other components o
the riad. Early detection with knowledge o the warning signs o eating disorders is key
(see able 31-14).
Menst rual Funct ion

T e spectrum o menstrual unction is another component o the riad and ranges rom
unctional hypothalamic amenorrhea to eumenorrhea. Eumenorrhea is def ned as regular
menstrual cycles at intervals near the median interval or young adult women.213 In young
adult women, menstrual cycles recur at a median interval o 28 days, which varies with
a standard deviation o 7 days.213 Menstrual irregularities include primary amenorrhea,
secondary amenorrhea, oligomenorrhea, and suppressed luteal phase (luteal phase def -
ciency) and anovulation.91,174 Amenorrhea is def ned as the absence o menstrual bleeding
and is classif ed as either primary or secondary. Primary amenorrhea re ers to absence o
menstrual bleeding by the age o 16 years even though other emale sex characteristics are
apparent or by age 14 years in the absence o sexual development. Secondary amenorrhea
able 31-14 Warning Sig ns o f Eating Diso rde rs 11,17,21
Ane ro xia Ne rvo sa (AN) Bulimia Ne rvo sa (BN)
Ph ysica l sig n s Ph ysica l sig n s

• Signi cant weight loss unrelated • Swollen parotid glands
to medical illness • Face and extremity edema
• Fat and muscle atrophy • Sore throat and chest pain
• Amenorrhea • Fatigue
• Dry hair and skin • Bloating, abdominal pain
• Cold, discolored hands and feet • Diarrhea or constipation
• Decreased body temperature • Menstrual irregularities
• Cold intolerance • Callous formation or scars on knuckles
• Lightheadedness (Russell’s sign)
• Decreased ability to concentrate • Erosion of dental enamel
• Bradycardia
• Lanugo ( ne, baby hair)
Be h a vio rs Be h a vio rs
• Severe reduction in food intake • Exhibits much concern about weight
• Excessive denial of hunger • Eating patterns that alternate between
• Compulsive and/or excessive exercising purging and fasting
without signs of fatigue or weakness • Depression, guilt, and/or shame
• Peculiar, ritualistic patterns of food especially following a binge
handling
• Intense fear of weight gain
is def ned as the cessation o the menstrual cycle or at least 3 months a ter the initiation o
menstruation.50 Amenorrhea, as def ned by the International Olympic Committee, means
ewer than 2 menstrual cycles per year.3 T e main di erence between primary and second-
ary amenorrhea is that in the latter at least 1 menstrual cycle did occur, indicating that the
reproductive chain, including the hypothalamus, pituitary gland, ovaries, and uterus, suc-
cess ully completed at least 1 cycle.91,107,213 With secondary amenorrhea, this chain became
disrupted and is not unctioning normally.
T e n orm al physiology o m en struation is a com plex, coordinated interaction
o horm onal and organ involvem ent occurring in a cyclical m an ner.11,50,109,121,251 T e
m enstruation cycle is divided into 3 phases: the ollicular phase, during which the egg
m atures; the ovulatory phase, during which the egg is released; and the luteal phase,
in which the uterin e lin in g prepares or the im plantation o the ertilized ovum. I
im plantation does not occur, then the uterine lining is sloughed and m enstrual bleed-
ing begins.109,121 T e hypothalamus produces and secretes gonadotropin-releasing hor-
m one (Gn RH) regularly. T is stim ulates the intact an d un ctioning pituitary glan d to
produce luteinizing horm one and ollicle-stim ulating horm one. Lutein izin g horm on e
and ollicle-stim ulating horm one stim ulate the ovaries or m aturation and release o
oocytes (eggs). T e ovaries cyclically produce estrogen and progesterone that stim ulate
the endom etrium (uterine lining) to develop and the cyclical withdrawal o estrogen and
progesteron e result in m enstrual shedding o the uterine linin g. T is ultim ately leads
to m enstrual bleeding rom a norm al uterus with an unobstructed tract to the external
genetalia.109,121 T is well-coordinated, yet com plicated, cycle o events may be disrupted
anywhere along this process, dem onstrating that there are many reasons or the onset
able 31-15 Cause s o f Ame no rrhe a 28,73 o am en orrhea.109,121 Pregnan cy an d hypothalam ic am en or-
rhea are the 2 m ost com m on reasons or the cessation o m en-
strual cycles. One subset o hypothalam ic am enorrhea has been
Pregnancy described as “exercise-related” or “athletic” am en orrhea.50,265
Abnormalities of the reproductive tract Determ in in g the diagn osis o athletic am en orrhea is on e o
Ovarian failure exclusion o all the other possible causes, requiring an extensive
Pituitary tumors evaluation by a physician with experience an d expertise with
athletic wom en. It should be noted that cessation o m enstru-
Hypothalamic amenorrhea
Chronic anovulation ation is not a n orm al con sequence o athletic participation or
Polycystic ovarian disease training or sport (see able 31-15).174
Exercise-associated amenorrhea T e loss o menstrual cycling coincident with exercise has long
been recognized by pro essional dancers, athletes, coaches, and
the medical pro ession.11,50 T e etiology, prevalence, and treatment
o athletic amenorrhea are not completely known and agreed upon
to date. In the early 1970s, it was proposed that low body at and weight were the cause o this
cessation o menstrual bleeding. T is hypothesis has since been re uted and other actors
have been postulated and are currently under investigation. T ese actors include the physi-
cal stress o exercise, increased endogenous opioids rom exercise, and overall energy avail-
ability based on the “energy balance” discussed previously.40,50,84,174,213 All o these actors
are postulated to directly a ect the production and release o GnRH rom the hypothalamus.
T e prevalence o amenorrhea again is di cult to accurately assess because some
emale athletes and coaches welcome the cessation o menstrual bleeding. T is condi-
tion indicates to these athletes and coaches that su cient training rather than a problem
is occurring, so medical workup is not even considered. It is reported that 10% to 20% o
vigorously exercising women are amenorrheic as compared to 5% o the general population
when pregnant women are excluded.187 T e prevalence o amenorrheic elite runners and
pro essional ballet dancers rises as high as 40% to 50%.50,92,93,161,164,187,216 T e dangers o pro-
longed amenorrhea include reversible loss o reproductive capacity and possibly irrevers-
ible bone loss. T e long-term consequences o adolescent amenorrhea are yet to be ully
understood and determined.
Oligomenorrhea is def ned as menstrual cycles greater than 36 days or having less than
8 menses per year.95,213 T is may result rom anovulation, which results rom low levels o
both estrogen and progesterone or normal estrogen production but low levels o proges-
terone.213 Female athletes with luteal suppression o ten present with irregular menses.
T is component o the riad still emphasizes amenorrhea, but an expanded view o the
riad includes all o these menstrual irregularities. Detection o menstrual irregularities are
o ten attempted by interview or via a completed sel -questionnaire by the emale athlete.
T e preparticipation screening process is an ideal time to assess or these irregularities and
appropriately re er to a medical expert such as a physician with experience and expertise
with athletic women or a thorough evaluation.
Bone Mineral Densit y

T e f nal component o the riad is the BMD spectrum, ranging rom osteoporosis to opti-
mal bone health. Osteoporosis is currently the most common bone disease in the United
States, a ecting more than 25 million Americans to date.7,108,163,210 T e def nition per the
Consensus Development Con erence on Osteoporosis is a disease characterized by low
bone mass, microarchitectural deterioration o bone tissue leading to enhanced skeletal
ragility, and an increased risk or racture.210 Measures o BMD with dual-energy X-ray
absorptiometry (DEXA)26 are used to diagnose osteoporosis and osteopenia with diagnos-
tic criteria that have been established or postmenopausal women.34 Figure 31-34 is a DEXA
scan o a emale athlete. Un ortunately, there are no similar diagnostic criteria that have
been established or premenopausal women to date.155,210,215,225
Tota l body bone de ns ity
Re fe re nce : Tota l
1.37 3
1.29 2
1.21 1
)
2
Y
m
1.13 0
A
c
T
/
1.05 −1
-
g
S
(
c
D
0.97 −2
o
M
r
e
B
0.89 −3
0.81 −4
0.73 −5
20 30 40 50 60 70 80 90 100
Age (ye a rs )
1 2 3
BMD Yo ung -adult Ag e -matche d
Re g io n (g /c m 2 ) (%) T-s c o re (%) Z-s c o re
He a d 2.351 - - - -
Arms 1.177 - - - -
Le gs 1.386 - - - -
Trunk 1.003 - - - -
Ribs 0.703 - - - -
Pe lvis 1.252 - - - -
S pine 1.178 - - - -
Tota l 1.295 115 2.1 119 2.6
Figure 31-34 DEXA Scan fo r individual w ith no rmal bo ne de nsity
T ere are 2 types o bones: cortical bone, which is tightly com pacted plates o bone,
and trabecular or spongy bone, which is made up o bone spicules separated by spaces
in a honeycom b ashion.70,93,95 T e peripheral skeleton (long bones) is com prised pre-
dominantly o cortical bone. T is bone is less susceptible to changes in reproductive hor-
mones than the trabecular bone. T e axial skeleton (pelvis, vertebral colum n, and ends
o the long bones) is com prised m ostly o trabecular bone. T ese aspects o our skeleton
are m ore susceptible to changes in reproductive horm ones re ecting the predom inant
location o bony changes that occur with both m enopause and exercise-induced am en-
orrhea.70,215 BMD is determ ined by the ratio o osteoclastic (resorption) and osteoblas-
tic (rem odeling) activity. Weightbearing activities directly stimulate osteoblastic activity
according to the Wol law. Sex horm ones, estrogen and testosterone, also avor osteo-
blastic activity with peak bone growth noted during puberty. T e opposite e ect o rapid
bone loss is seen at menopause with the loss o estrogen. Estrogen also plays a role by lim-
iting osteoclastic activity, thus im proving the absorption o calcium at the gastrointestinal
level and decreasing elim ination o calcium at the renal level.70,95 Other actors a ecting
BMD include genetics, sm oking, alcohol consum ption, cortisol levels, and nutrition.34,36
Calcium and vitam in D consum ption is critical or proper bone health. Calcium is nec-
essary or bone rem odeling, but the amount o calcium absorbed is dependent upon an
adequate am ount o vitamin D.23,104,108,217
Abnormalities in bone homeostasis have been documented in emale athletes with
both premature osteoporosis,72,108 scoliosis,45,108,282 and ractures, including premature
osteoporotic84,91 and stress ractures o various locations 91,92,108,151 All athletes have cyclic
stresses creating an increased rate o osteoclastic activity ollowed by osteoblastic activity.

I adequate rest or time is not given, an imbalance preventing adequate new bone to be laid
down occurs, resulting in a progressive weakening and racture o the involved bone.108 T is
phenomenon occurs more requently in emale athletes, resulting in stress injuries to the
bone. In a retrospective review o medical records o a Division I college institution over a
10-year period, Arendt et al23 demonstrated that emale distance runners su ered the most
stress injuries to bone (6.4%). Across all sports, emale athletes were 2 times as likely to
su er stress injuries to bone as male athletes. T e authors attributed this increased rate
not only to sex-related actors but also BMD, menstrual history, and diet.113 Another study
demonstrated that athletes with stress ractures had a lower bone density.203 Other studies
have reported a higher incidence o stress ractures among amenorrheic and oligomenor-
rheic athletes than eumenorrheic athletes.23,189,216 Menstrual irregularities and decreased
BMD certainly are not seen in every case o stress injury to bone, but both may place the
athlete at higher risk.92
In addition to being at higher risk or stress injuries to bone, athletes with menstrual di -
culties are unlikely to reach their total BMD potential resulting in an overall lower peak BMD
and a decreased ability to maintain BMD over a li etime because o lower levels o estrogen.
Outcomes o studies regarding bone loss are pessimistic regarding the ability to reverse the
lower BMD with treatment.93,113,189 T ere are studies that report an increase in serial BMD
results with amenorrheic counterparts resuming menses, but the levels remain below their
eumenorrheic-matched counterpart. Amenorrheic runners using hormone replacement
therapy have demonstrated maintenance o BMD, but no gains.165 T ese studies collectively
demonstrate the necessity to educate young emale athletes in the importance o adequate
nutrition, including calories, calcium and vitamin D intake, regular menses, and appropriate
training levels, including weightbearing activities or their maturity level.
Interaction Between the Components

of the Female riad
T e 3 components o the riad have been presented and described as independent medi-
cal conditions, and now the link between them is detailed. T e possible theories behind
athletic amenorrhea were mentioned previously. T e observations that both amenorrheic
athletes had decreased body at and individuals with AN had low body at led to the hypoth-
esis that altered body composition was not only correlated but causative. Loucks et al com-
pleted research matching amenorrheic and eumenorrheic (normal menstruation) athletes
or body at and ound that menstruation status was independent o this variable.173 Another
study concluded that the only di erence between the groups (amenorrheic vs. eumenor-
rheic) with such matched athletes was the negative energy balance that occurred with train-
ing in the amenorrheic group.197 T ese studies indicate that it is the negative energy balance
o caloric intake versus expenditure rather than body at stores that is linked to the condi-
tion o amenorrhea.
Another theory to explain exercise-induced amenorrhea was that the physical stress o
the exercise increased the levels o cortisol that were capable o disrupting the menstrual
cycle. Again, both amenorrheic athletes and individuals diagnosed with AN demonstrated
elevated cortisol levels with corresponding decreased levels o GnRH. As discussed pre-
viously in the section on amenorrhea, decreased levels o GnRH can result in exercise-
induced amenorrhea. Cortisol has another role in the body as well with the regulation
o plasma glucose and is released not only in response to physical stress o exercise but
also with decreased levels o plasma glucose. T e di culty lies in separating these roles
and determining whether high levels o cortisol disrupts the normal hormonal cascade by
Interaction Between the Components of the Female Triad 1101
suppressing GnRH levels resulting in amenorrhea because o the physical stress o exercise
or the decreased plasma levels o glucose. Loucks et al demonstrated that the hormonal
cascade changes seen in luteinizing hormone could be normalized in emales receiving
dietary supplementation, highlighting once again the important role o nutrition (positive
energy balance) with intense exercise.174
“Negative energy balance” as the cause o exercise-induced amenorrhea has been
supported in the research.11,84,120 wo studies demonstrate that a combination o exercise
training and caloric restriction in animals and humans results in amenorrhea with rever-
sal upon an increase in caloric intake.174,197 T is urther supports the existence o a direct
relationship between daily energy availability and the hormonal cascade controlling the
menstrual cycle.1,2,173,174,197 T ese articles may explain why emale athletes with similar
body composition and training intensity have varied menstrual status including amenor-
rhea, oligomenorrhea, and eumenorrhea (normal menstrual cycling). It is not directly the
exercise intensity that causes the change in the hormonal cascade controlling menstrua-
tion, but rather, the sustained negative energy balance in those emale athletes not taking
in enough calories or the energy expended during training. Interventions subsequently
should include increased caloric intake in order to attain a positive energy balance in com-
bination with other interventions to target restoration o normal bone metabolism. More
specif c intervention strategies will be discussed later in this chapter.
T e interactions o the disordered eating patterns resulting in the negative energy
balance and osteopenia should also be elaborated on. Unhealthy eating behaviors with
diagnosed clinical eating disorders (AN, BN, EDNOS) and subclinical eating disorders
can rapidly cause an inadequate intake o calcium, vitamin D, and vitamin K, resulting in
decreased building blocks or osteoblastic activity to increase overall BMD and allow or
normal bone homeostasis during sports participation. As discussed previously, the window
o opportunity to reach peak bone mass occurs prior to the third decade o li e and is most
important in adolescence. T ese correspond with the same time that disordered eating pat-
terns are most prevalent and the time that many emale athletes are competing at high lev-
els, with high training intensities, durations, and requency. Failure to reach optimum BMD
during this time secondary to inadequate nutrition may not be reversible.213
Additional interactions between menstrual irregularities and osteopenia are also
evident. Some o these interactions with the multi actorial role o estrogen with normal
bone metabolism and the ability to achieve peak BMD as it is related to secondary amen-
orrhea have already been discussed. T e condition known as hypoestrogenemia lacks
well-designed studies specif cally addressing the e ect o delaying menarche as a result o
premenarchal training. Premenarchal training in a number o sports has been correlated
with delayed menarche, but this does not imply causation.107,161 A retrospective study with
college gymnasts suggests that delayed menarche is associated with increased risk o sco-
liosis, stress ractures, and low peak BMD.184 T ese patterns start to demonstrate the serious
and long-term implications o triad interactions and the synergistic nature o the compo-
nent spectrums. Each o the components o the riad exist on a continuum o severity, thus
the interactions between the components alls in a spectrum o severity as well. Early detec-
tion o the components greatly assists with the treatment o each component, as well as the
interactions that may be present.
Screening
Preparticipation screenings provide an excellent opportunity to identi y the components o
the riad. Appendices D and E are examples o screening questionnaires or in ormation
gathering regarding eating habits, menstrual history, and bone health. More extensive ques-
tionnaires and surveys regarding eating habits and menstrual history can be included should
preliminary screening indicate a need. Additional resources can be ound in Appendix F.
Menstrual history is o ten used or predicting bone density.91,165 In addition, Drinkwater has
demonstrated a linear relationship between the degree o bone loss and the degree o men-
strual dys unction.91,92 Any abnormalities with menstrual cycle detected in the medical his-
tory section should be noted and discussed with the primary care or team physician in order
to acilitate urther studies to conf rm bone density. It has been recommended that any
emale athlete with history o clinical eating disorders, amenorrhea, or oligomenorrhea or
more than 3 months have urther study to determine bone density. Similarly, documented
history o stress ractures may indicate urther study. History o stress ractures, especially o
the emoral neck, sacrum, or pelvis (cancellous bone), is increasingly concerning secondary
to a recent study that ound that emale athletes with a stress racture in cancellous bone are
more likely to have osteopenia than athletes who sustain a stress racture in cortical bone
such as the tibia or metatarsal.164 Increasing access, ease, and a ordability o DEXA scans
have acilitated the ability to conf rm a suspicion o bone density problems.
Logistically, implementing these screening tools works nicely in sports preparticipa-
tion screening. It is the experience o the authors and documented by other medical pro-
essionals that in ormation regarding eating habits and belie s, sel -image, and menstrual
history is more accurately gathered when there is a trained medical pro essional interview-
ing the emale athlete rather than the use o tools that require sel -administration.39,40,126
Many athletes with problems in these areas su er guilt and shame regarding their behav-
iors and are skilled at hiding their actions, but most will provide honest and accurate
answers to direct and nonjudgmental questioning. It is important to make clear that the
in ormation gathered will be held in conf dence and will be used or the athlete’s benef t.
Questionnaires such as ound in Appendix D or a combination o established question-
naires (see Appendix E) may also be used outside the preparticipation screening environ-
ment or any emale athlete suspected o having the riad.
A recent study indicated that there is a lack o conf dence in members o the sports
medicine team regarding screening and success ully identi ying athletes with eating disor-
ders.94 One hundred and seventy-one athletic trainers who worked at NCAA Divisions IA
and IAA institutions completed a survey that examined college athletic trainers’ conf dence
in helping emale athletes who have eating disorders. Less than 33% elt conf dent in asking
an athlete i she had an eating disorder and only 25% elt conf dent identi ying a emale ath-
lete with an eating disorder, although virtually all o them (91%) had dealt with a emale ath-
lete with an eating disorder and (93%) thought that increased attention to preventing eating
disorders among collegiate emale athletes was necessary. Less than hal worked at an insti-
tution that provided training or education on eating disorders to them. T e authors o that
study recommended that athletic programs develop and implement eating disorder poli-
cies, as well as provide education on prevention o eating disorders, to increase conf dence
o athletic trainers in identi ying and supporting a emale athlete with an eating disorder.94
It is sometimes di cult to be conf dent in our skill at screening athletes or the com-
ponents o the riad because o the di culty in di erentiating healthy and unhealthy ded-
ication to excellence in sport. Distinguishing between healthy and unhealthy eating and
exercising behaviors is one challenge or the sports medicine team. In addition to keeping
in mind the set criteria or the 3 types o clinical eating disorders, there are other charac-
teristics that have been outlined to distinguish between women developing components
o the riad and athletic women. Athletes remain goal-directed in training with good and
improving exercise tolerance and e cient body metabolism. Athletes have well-developed
muscles, a body composition with normal at store levels, and an unimpaired body image.
Athletes with or developing components o the riad have poor to decreasing exercise toler-
ance and a distorted body image. Body metabolism has dropped resulting in signs such as
dry skin, cold intolerance, and decreasing muscle size and development.11,120 Consideration
o these additional actors may assist in improving the conf dent detection o athletes with
components o the triad and acilitate re erral or early intervention.
Prevention and Treatment 1103
Prevention and reatment

T e ongoing concern about the onset o each o these conditions and the interrelated
nature o these conditions with emale athletes has led to education and legislative e orts
to decelerate the growth o this entity. In 1993, the Eating Disorders In ormation and Edu-
cation Act was incorporated into the Women’s Health Equity Act.11,45,152 From this act, the
National Eating Disorder screening program was activated on college campuses throughout
the United States, not only to enhance the screening and treatment or the riad but also to
accelerate the prevention programs or each o these components.40,50,70,152 As the American
College o Sports Medicine’s position statement stated a call to action and medical pro-
essionals began to intervene in the screening, prevention, and treatment o this growing
entity, e orts have continued and have signif cantly accelerated with the establishment
o this act and program. One study compared 149 emale varsity athletes with 209 emale
controls (nonathletes) rom 2 NCAA Division I universities to assess eating habits and
behaviors, as well as alcohol consumption and drinking behaviors. T e results showed that
problem eating and drinking behaviors existed in both groups but not at di erent rates as
previously demonstrated. T e authors concluded, “this f nding may be the result o coach,
athletic trainer, and peer-group counseling at these 2 schools or a general trend or lower
rates o unhealthy behaviors among emale athletes.”120 Sundgot-Borgen ound that educa-
tion to coaches and athletes had a positive e ect on the prevention o disordered eating pat-
terns.267 In 2002, the ormation o the Female Athlete riad Coalition, a nonprof t 501(c)(3)
organization, represents key medical, nursing, athletic, and sports medicine groups, as well
as concerned individuals who come together to promote optimal health and well-being or
emale athletes and active girls and women. Ongoing educational e orts or all concerned
parties to prevent the riad and promote optimal health and well-being or emale athletes
and active girls and women.1,8
Nevertheless, we are ar rom attaining the goal o maximal prevention o this entity.
Other studies have addressed the conf dence o medical pro essionals in screening, pre-
venting, and helping emale athletes with nutrition, disordered eating, and menstrual dys-
unction.40,45,126 Beals surveyed NCAA Division I athletic programs and ound that education
about menstrual dys unction and eating disorders was made available to athletes in 73% o
the participating programs; only 61% o these schools made this education available to the
coaches, and less than 41% o schools made this education a requirement o either the ath-
letes or coaching sta s. O the respondents, only 35% believed that the menstrual dys unc-
tion screening and 26% that the eating disorders screening was success ul.39 When emale
collegiate cross-country runners were screened about nutritional knowledge, several spe-
cif c areas o def cient nutritional knowledge were identif ed. T ese areas o def cient nutri-
tional knowledge included vitamin supplementation, the necessity or at in the body and
diet, the necessity o a calcium source in the diet, the recommended amount o calcium,
and appropriate sources o it. T e authors noted that those athletes that completed a nutri-
tion course in college scored signif cantly higher overall, indicating appropriate nutritional
knowledge might lead to better nutritional choices.294
Providing accurate in ormation regarding sports nutrition is essential or athletes.
Good nutritional in ormation is o ten addressed in the context o avoiding poor health
im plications, which o ten will not m otivate an athlete to make the necessary dietary
improvements. Optimizing per ormance with appropriate body composition and aiding
recovery ollowing increased training or injury may serve as better motivators.215 Proper
nutrition is a signif cant determ inant o athletic per ormance. Hawley et al reports, “no
single actor plays a greater role in optim izing per ormance than diet.”126 A good place
to start in the provision o sound nutritional advice is the revised Food Pyram id (see
Figure 31-35) developed by the United States Departm ent o Agriculture.280 Ongoing
Gra ins Ve ge ta ble s Fruits Da iry Me a ts

S e rving s ize 5 oz 2 cups 1 1/2 cups 3 cups 5 oz
Unite d S ta te s De pa rtme nt of Agriculture (public doma in)
Figure 31-35 MyPyramid—update d ve rsio n o f the Fo o d Guide Pyramid 4
research has led to its development and continued revision. Modif cations and additions
to the original pyramid illustration have been completed to include a reorganization o the
essential ood groups, size, and portion in ormation or each o these groups, the neces-
sity o hydration and exercise or a healthy li estyle, and the ability to urther tailor the
recom mendations depending on your sex, age, and activity level.152.280 T e pyramid can
provide the basics or nutrition. Additionally, the U.S. government has provided a simple
graphic called “MyPlate” that is help ul regarding the general com position o a healthy
diet displayed on a plate (Figure 31-36). o build on these basics, urther guidance regard-
ing appropriate body composition, iron intake, calcium intake,217 at consum ption, and
possible supplementation is necessary.
Other strategies to be implemented or prevention o the riad include education o
athletes, parents, and coaches on sound training techniques including limitations o total
training hours or adolescents and elimination o weight determinations and body at
level standards by coaches. Education o these same individuals about the riad, includ-
ing predisposing actors, warning signs, and implications, can be completed. Other edu-
cational goals should include the elimination o myths such as amenorrhea is normal, rest
is not needed, and that ood is the enemy. Promotion o healthy attitudes, such as ood is
the uel that provides the nutrients necessary to optimize per ormance, as well as healthy
body images o emale athletes, will continue to assist in the prevention o the triad. T ese
strategies and others can be explored to assist emale athletes to realize that thinner is
not better, her chosen sport does not have an ideal weight that must be attained, and a
Pregnancy in the Physically Active Female 1105
healthy balance o calories consumed must be maintained
with the energy expended in order to optimize athletic
per ormance.1,11,18,21,45
reatm ent o the com ponents o the riad should be
in the hands o a multidisciplinary team including but not Da iry
lim ited to team physicians, sports physical therapists,227 Fruits
Gra ins
281
certif ed athletic trainers, sports dieticians, sports psy-
chologists, and coaches. reatm ent o disordered eating
Ve ge ta ble s
patterns needs to resolve the psychosocial actors, stabi-
lize medical conditions, and establish healthy eating pat- P rote in
terns. Sundgot-Borgon ound that cognitive behavioral
therapy, in addition to nutritional counseling, was more
benef cial in the treatm ent o emale athletes with disor-
dered eating patterns than nutritional therapy alone.268
Nutritional counseling should include the necessity o Choos e MyPlate .gov
balancing caloric intake with the caloric expenditure o
training to attain a positive energy balance.11,21,39,70 T e
attainm ent o a positive energy balance is also key to
treating menstrual irregularities.213,215 A ter identif cation Figure 31-36 MyPlate g raphic
o the underlying cause o m enstrual irregularities, the
ocus will be to treat this and establish normal m enstrual This graphic simply illustrates excellent eating related to
unction .213,215 Optim izing calcium and other m icro- meal composition on a plate.
nutrient and macronutrient intake as well as m odif ca-
tion o a training regim e to ensure this positive energy
balance is the f rst step.70,117,215 Continued m edical supervision to observe the e ect
o these changes is necessary and possible intervention with horm one replacem ent is
decided upon an individual basis.57 Once again, attaining a positive energy balance with
adequate calcium intake and resumption o normal m enstruation is im portant to treat-
ing a emale athlete with bone density loss.163 Exercise modif cation may be necessary to
establish a bone hom eostasis avorable to osteoclastic activity with exercise prescription
or appropriate weight bearing and resistive exercise. T ese recom m endations, as well as
pharmacologic treatment, are based on the individual’s data and risk prof le. T e National
Osteoporosis Foundation has established guidelines 210 or pharmacologic treatm ent o
postm enopausal wom en, but these guidelines cannot be readily utilized or the younger
emale athlete. Further study and research is needed in this area. T e multidisciplinary
team led by a qualif ed m edical pro essional should coordinate e orts or treatm ent o
the individual components o the riad, subsequently ending the cascade into the inter-
dependent relationship between these com ponents with the root o this treatm ent being
the establishm ent o a “positive energy balance” or each athlete. Appendix F provides
additional sources o in ormation regarding the riad.
Pregnancy in the Physically Active Female

T e physically active emale enjoys many benef ts rom the exercise she regularly com-
pletes. Pregnancy does not change these benef ts but does present special challenges or
the emale athlete as she plans and manages her pregnancy ( able 31-16). T e main chal-
lenge is exercising at a level that sa eguards the health o both the mother and etus.27 T ere
are physiologic changes to the cardiovascular, respiratory, and musculoskeletal system that
need to be understood and considered in order to decide a sa e level o exercise through-
out the pregnancy. Knowledge o these physiologic changes and the consequences o exer-
cise and training on the course o pregnancy, labor, and delivery should provide guidance
able 31-16 Exe rcise Be ne ts during Pre g nancy or the medical provider o the physically active emale
to establish guidelines that ensure her and the etus’s
sa ety throughout gestation.
• Increase or maintain aerobic tness More physicians are encouraging emales to
• Increase cardiac reserve remain active during their pregnancies. Adopting a new
• Increased tolerance for physical work exercise routine or signif cantly increasing the intensity
• Improve sleep o the present exercise routine is not recommended at
• Positive effect on psychological state this time o considerable physiologic change.28 Known
• Decrease risk of gestational diabetes physiologic changes to the cardiovascular system
• Decreases in total mood disturbance include substantial increases in blood volume up to
• Decreased labor time
50% by the end o pregnancy. T is increase occurs f rst
• Decreased maternal pain perception
in the plasma volume causing a dilutional anemia in the
• Decreased rate of medical intervention such as pitocin,
f rst and second trimester. T e blood volume increase
forceps delivery, and caesarean section
• Promote faster recovery from labor continues in the third trimester with the red cell mass
69
• Promote good posture during and after pregnancy increasing so the anemia is partially corrected. T is
• Prevent or minimize low back pain blood volume expansion results in greater oxygen-
• Prevent excessive “ fat” weight gain carrying capacity, but concurrently increases cardiac
• Prevention of gestational diabetes work. In highly conditioned athletes, this blood volume
increase is greater than in sedentary emales.67 Addi-
tional cardiovascular changes include increased stroke
volume, cardiac output, and resting pulse by 10 to 15 beats per minute. T ese increases
may help to ensure adequate blood ow to the uterus during exercise, as well as dissipa-
tion o heat.67 Blood pressure usually alls during pregnancy reaching its lowest levels in
midpregnancy. Increased circulation to the uterus, kidneys, skin, and breasts occurs and is
accompanied by a reduction in venous tone. With this reduction and the increasing size o
the uterus decreasing venous return to the heart especially in the supine position, supine
hypotension can occur.67 T is is the basis or the recommendation to avoid supine exercise
a ter the f rst trimester.18
When exercising, the emale athlete has increases in pulse rate, cardiac output, and
blood pressure.18 T e pregnant athlete experiences these same increases to a lesser degree.
With these increases, the increased blood ow goes primarily to the working muscles and
results in some shunting o blood rom the uterus and developing etus.67 T is observation
has raised concern o risk to the etus with intense and/ or prolonged exercise, but evidence
or such concern is lacking.28,67 Respiratory system changes may help to alleviate the ulti-
mate result o the blood shunting that occurs.
Respiratory system chan ges occurrin g durin g pregnan cy in clude in creased
tidal volum e, m inute ventilation, and oxygen consum ption, as well as decreased resid-
ual volum e and unctional residual capacity. T e ultimate result is an unchanged overall
vital capacity; however, the pregnant woman may experience shortness o breath because
o an increased sensitivity to carbon dioxide driving increased ventilation and lower blood
levels o carbon dioxide and slightly m ore alkaline pH.233 T ese biochem ical changes
have a sa eguarding e ect or the etus by increasing placental gas exchange and prevent-
ing etal acidosis.67 Pregnant wom en are just as e cient in achieving increased levels o
oxygen consum ption during exercise as nonpregnant wom en,67 but changes in mater-
nal oxygenation are am plif ed in the etus. Because anaerobic exercise results in relative
maternal hypoxia and acidosis, it is recom mended that prolonged anaerobic exercise be
avoided. On the other hand, aerobic exercise in pregnant subjects has been shown to
result in greater increases in m inute ventilation than nonpregnant wom en. T is hyper-
ventilation helps protect the etus rom hypoxia or changes in pH with aerobic exercise.67
Changes in the musculoskeletal system o the pregnant, active emale result in signif -
cant postural, gait, and balance changes. T e pregnant emale’s center o gravity moves or-
ward, o ten driving an increased lumbar lordosis with a resultant stretch weakness o the
core stabilizers.67 Ligamentous laxity increasing the mobility o all joints especially the pel-
vis resulting in maternal “waddling” in late pregnancy and a requent complaint o low back
pain as the weight increases with resultant increased orces on the vertebral column. Pelvic
or abdominal support devices made especially or the pregnant emale can help support
the growing abdominal weight as well as stabilization o the pelvis as relaxin becomes more
prevalent prior to delivery. Secondary to these musculoskeletal concerns o ligamentous
laxity causing increased propensity to alling and increased torque on already lax ligaments,
a pregnant women may want to consider swimming, stationary cycling, stair-climbing appa-
ratus, or a treadmill to minimize the risk o alling and to decrease orces on taxed joints.67
T e e ects o exercise on pregnancy outcomes have been studied with re erence to etal
development, etal growth, metabolic status o the etus, and labor. It is known that high
maternal core temperature is associated with etal development problems, such as neural
tube de ects, early in gestation. Many o the physiologic changes during pregnancy help
to keep maternal temperature lower with or without exercise, but additional precautions
especially in the f rst trimester should be taken to ensure a near normal maternal tem-
perature during exercise sessions.18,28,67 Historically, it has been a concern that exercising
during pregnancy would cause decreased etal growth and low birth weight. It has been
ound that women who begin pregnancy underweight have a greater risk o delivering an
underweight or preterm newborn. Because emale athletes may be underweight at the start
o a pregnancy, this f nding would include this population. I there is attention and care
given to nutrition and appropriate weight gain be ore or at the initiation o the pregnancy,
this concern can be minimized.66 T ere is also evidence to demonstrate that i moderate
exercise continues throughout pregnancy and does not exceed prepregnancy levels, there
is no compromise o etal growth.18,67 However, it has been shown that pregnant women
who exercise intensely deliver approximately 1 week earlier than those who are sedentary
or exercise moderately. T is early delivery subsequently causes a relatively low birth rate
because o the average 100-g di erence in birth weight and decreased body at deposition
in the earlier-delivered baby as compared to ull-term babies. Recent reports conf rm that
exercise during pregnancy has little e ect on the acute status o the etus when mother and
unborn baby are healthy.28,65,67 Fetal heart rate and oxygenation remain normal with intense
exercise during the third trimester up to labor.18,67 Actual labor and delivery are improved
by regular exercise throughout pregnancy with less necessary medical intervention, less
orceps delivery, cesarean sections, shorter labor with aster dilation, 50% less transition
time, and less pushing time to delivery.67
Based on the current research, the Am erican Academy o Obstetricians and Gyne-
cologists published the most recent guidelines or exercise in pregnancy and postpartum,
recognizing the sa ety and benef ts o exercise throughout pregnancy.18 T ese guidelines
encourage the physically active emale to continue exercising throughout pregnancy, with
special attention given to adequate weight gain, preventing hypertherm ia, and avoid-
ing injury. T e guidelines give specif c recom mendations regarding adequate nutrition,
highlighting that pregnancy requires an additional 300 kcal per day in order to maintain
m etabolic hom eostasis, cautioning exercising pregnant wom en to ensure an adequate
caloric intake. Additional instructions encourage strict adherence to contraindications to
exercise, such as pregnancy-induced hypertension, preterm rupture o m embranes, pre-
term labor during the prior or current pregnancy, incompetent cervix/ cerclage, persistent
second- or third-trim ester bleeding, and intrauterine growth retardation.16 T ese recom -
mendations suggest, or the f rst tim e, a possible role or exercise in the prevention o
gestational diabetes. Furthermore, the recommendations promote exercise or sedentary
women and those with medical or obstetric complications, but only a ter medical evalua-
tion and clearance. In summary, the physically active emale can sa ely continue athletic
pursuits and/ or exercise throughout her pregnancy with som e considerations regarding
intensity and contact.
SUMMARY
1. For more than a decade, emale athlete participation has signif cantly risen at all lev-
els including high school, collegiate, and Olympics.3,5,6 T e benef ts or the emale to
remain physically active continue to outweigh the costs.19,46,160,168 An awareness o the
gender di erences enables the sports medicine specialist to develop prevention, train-
ing, and rehabilitation programs that will e ectively minimize the cost o remaining
physically active throughout the emale’s li e span in a variety o sport endeavors.
• Anatomical, strength, and neuromuscular di erences exist between emale and
male athletes. T ese di erences should be understood and acknowledged during
examination and treatment o emale athletes.
• ACL injuries continue to be prevalent among emale athletes.
• ACL injuries in emale athletes are multi actorial. Some actors can be modif ed,
while others cannot. Contemporary prevention and rehabilitation ocus on
neuromuscular strategies or movement.
• Core stability is vital or athletic per ormance by all athletes. Female athletes should
address the core during rehabilitation a ter injury as well as during per ormance
training.
• T e athletically active emale has many unique issues including laxity, sport-specif c
potential or injury (so tball pitching, swimming, gymnastics), and the riad.
• Specif c protocols are included or rehabilitation o the athletic emale who
participates in so tball and swimming.
• Progressive reactive neuromuscular training or lower extrem ity and core
stabilization is important. A sample progression is included.
• T e riad is an important condition about which the sports medicine provider must
be knowledgeable in order to provide screening, education, and appropriate re erral.
• T e physically active emale can sa ely participate in activity during pregnancy,
ollowing the medical guidelines such as those prescribed by American College o
Obstetricians and Gynecologists.
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Appendix A: Jump- raining Program

T is program was developed by Cincinnati Sports Medicine and is reprinted, with permis-
sion, rom Hewett E, Stroupe AL, Nance A, Noyes FR. Plyometric training in emale athletes:
Decreased impact orces increased hamstring torques. Am J Sports Med . 1996;24:765-773.
Re pe titio ns o r
Exe rcise Time Inte rvals
Phase I: Te chnique We e k 1 We e k 2
1. Wall jumps 20 seconds 25 seconds
2. Tuck jumpsa 20 seconds 25 seconds
3. Broad jumps, stick landing 5 repetitions 10 repetitions
4. Squat jumpsa 10 seconds 15 seconds
5. Double-leg cone jumpsa 30 seconds/30 seconds 30 seconds/30 seconds
6. 180-Degree jumps 20 seconds 25 seconds
7. Bounding in place 20 seconds 25 seconds
Phase II: Fundame ntal We e k 3 We e k 4
2. Tuck jumpsa 30 seconds 30 seconds
3. Jump, jump, jump, vertical jump 5 repetitions 8 repetitions
5. Bounding for distance 1 run 2 runs
6. Double-leg cone jumpsa 30 seconds/30 seconds 30 seconds/30 seconds
7. Scissors jump 30 seconds 30 seconds
8. Hop, hop, stick landing a 5 repetitions/leg 5 repetitions
Phase III: Pe rfo rmance We e k 5 We e k 6
2. Step, jump up, down, vertical 5 repetitions 10 repetitions
3. Mattress jumps 30 seconds/30 seconds 30 seconds/30 seconds
4. Single-legged jumps for distance a 5 repetitions/leg 5 repetitions/leg
6. Jumping into bounding a 3 runs 4 runs
7. Single-legged hop, hop, stick landing 5 repetitions/leg 5 repetitions/leg
a Jumps
to be performed on mat-type surface. This program is set up to run for 6 weeks. Jump training should be
performed 3 times per week. Stretching and warm-up should be done before any jumping exercises. Stretching
should also follow all jump training sessions. A 30-second rest period should follow each jump-training exercise.
Appendix B: Interval Windmill Pitching Program 1119
Descript ion of Jump Training Exercises

1. Wall jumps: With knees slightly bent and arms raised overhead, bounce up and down
o toes.
2. uck jumps: From standing position, jump and bring both knees up to chest as high
as possible. Repeat quickly.
3. Broad jumps stick landing: wo- ooted jump as ar as possible. Hold landing or
5 seconds.
4. Squat jumps: Standing jump raising both arms overhead. Land in squatting position
touching both hands to oor.
5. Double-leg cone jumps: Double-leg jump with eet together. Jump side to side
over cones quickly. Cones approximately 8 in high. Repeat orward and
backward.
6. 180-Degree jumps: wo- ooted jump. Rotate 180 degrees in midair. Hold landing
2 seconds, then repeat in reverse direction.
7. Bounding in place: Jump rom one leg to the other leg straight up and down,
progressively increasing rhythm and height.
8. Jump, jump, jump, vertical jump: T ree broad jumps with vertical jump immediately
a ter landing the third broad jump.
9. Bounding or distance: Start bounding in place and slowly increase distance with
each step, keeping knees high.
10. Scissors kicks: Start in stride position with one oot well in ront o other. Jump up,
alternating oot positions in midair.
11. Hop, hop, stick the landing: Single-legged hop. Stick landing or 5 seconds. Increase
distance o hop as technique improves.
12. Step, jump up, down, vertical: wo- ooted jump onto 6- to 8-in step. Jump o step
with 2 t, then vertical jump.
13. Mattress jumps: wo- ooted jump on mattress, tramp, or other easily compressed
device. Per orm side-to-side/ back-to- ront.
14. Single-legged jumps or distance: One-legged hop or distance. Hold landing
(knees bent) or 5 seconds.
15. Jump into bounding: wo- ooted broad jump. Land on single leg, then progress into
bounding or distance.
Appendix B: Interval Windmill

Pitching Program
T is program is reprinted, with permission, rom Werner SL, Guido JA, McNeice RL,
Richardson JL, Delude NA, Stewart GW. Biomechanics o youth windmill so tball pitching.
Am J Sports Med. 2005;33(4):552-560.
A warm-up period, stretching, and overhand throwing should precede all steps in the
program.
Warm-up
Jogging, jumping rope, etc to increase blood ow to the muscles; once a light sweat is devel-
oped, move to stretching.
St ret ching
Full body stretching is important or reducing the chance o injury and or increasing
mobility o all parts o the body (which allows the whole body to be used to throw, rather
than just the arm).
Throwing
Overhand throwing is important to loosen the throwing arm be ore pitching. T row rom
30 to 60 t until the throwing arm eels ready to pitch.
Pit ching
Progress to the next step o the program once current step is accomplished is completely ree
o pain. Allow at least 24 hours to pass between successive steps. Each athlete progresses
at a di erent rate. T ere is no optimal length o this program. Once step 14 is completed
success ully, the athlete is ready to return to unrestricted windmill pitching.
Phase I
Step 1 15 pitches at 50% e ort Step 5 30 pitches at 75% e ort

Step 2 30 pitches at 50% e ort Step 6 30 at 75%, 45 at 50%
Step 3 45 pitches at 50% e ort Step 7 45 at 75%, 15 at 50%
Step 4 60 pitches at 50% e ort Step 8 60 pitches at 75%
Phase II
Step 9 45 at 75%, 15 at 100% Step 11 45 at 75%, 45 at 100%

Step 10 45 at 75%, 30 at 100%
Phase III
Step 12 30 pitches at 75% as a warm-up, 15 change ups at 100%, 50 astballs at 100%

Step 13 30 pitches at 75% as a warm-up, 30 change ups at 100%, 30 astballs at 100%
Step 14 30 pitches at 75% as a warm-up, 75 pitches at 100%, mix in change ups
Appendix C: Interval Softball

T rowing Program
T is program is reprinted, with permission, rom Werner SL, Guido JA, McNeice RL,
Richardson JL, Delude NA, Stewart GW. Biomechanics o youth windmill so tball pitching.
Am J Sports Med. 2005;33(4):552-560.
Warm-up
Jogging, jumping rope, etc to increase blood ow to the muscles; once a light sweat is
developed, move to stretching.
St ret ching
Full body stretching is important or reducing the chance o injury and or increasing
mobility o all parts o the body (which allows the whole body to be used to throw, rather
than just the arm).
Appendix C: Interval Softball Throwing Program 1121
Throwing Mechanics
A crow-hop technique should be used in all phases o the interval-throwing program. T is
technique places the arm in a mechanically sound position or throwing.
Throwing
Warm-up throws should take place rom 30 to 45 t and progress to the distance indicated
or the ollowing successive phases. Progress to the next step o the program once current
step is accomplished completely ree o pain. Allow at least 24 hours to pass between suc-
cessive steps. Each athlete progresses at [a] di erent rates [sic]. T ere is no optimal length
o this program. Once step 11 is completed success ully, the athlete is ready to return to
unrestricted overhand throwing.
45 Phase
Step 1 10 to 15 warm-up throws

25 throws at 45 t
Rest 15 minutes
10 to 15 warm-up throws
25 throws at 45 t

25 throws at 45 t
Rest 10 minutes
25 throws at 45 t.
Rest 10 minutes
25 throws at 45 t
60 Phase

25 throws at 60 t
Rest 15 minutes
25 throws at 60 t
25 throws at 60 t
Rest 10 minutes
25 throws at 60 t
Rest 10 minutes
25 throws at 60 t
90 Phase

25 throws at 90 t
Rest 15 minutes
25 throws at 90 t

25 throws at 90 t
Rest 10 minutes
25 throws at 90 t
Rest 10 minutes
25 throws at 90 t
120 Phase

25 throws at 120 t
Rest 15 minutes
25 throws at 120 t
25 throws at 120 t
Rest 10 minutes
25 throws at 120 t
Rest 10 minutes
25 throws at 120 t
150 Phase

25 throws at 150 t
Rest 15 minutes
25 throws at 150 t
25 throws at 150 t
Rest 10 minutes
25 throws at 150 t
Rest 10 minutes
25 throws at 150 t
25 throws at 150 t
Rest 10 minutes
25 throws at 150 t
Rest 10 minutes
50 throws at 150 t
Appendix E: Female Athlete Triad In-Depth Questionnaire1 1123
Appendix D: Female riad Screening

Questionnaire 1
1. Do you worry about your weight or body composition? Yes/ No
2. Do you limit or care ully control the oods that you eat? Yes/ No
3. Do you try to lose weight to meet weight or image/ appearance requirements in
your sport? Yes/ No
4. Does your weight a ect the way you eel about yoursel ? Yes/ No
5. Do you worry that you have lost control over how much you eat? Yes/ No
6. Do you make yoursel vomit, use diuretics or laxatives a ter you eat? Yes/ No
7. Do you currently or have you ever su ered rom an eating disorder? Yes/ No
8. Do you ever eat in secret? Yes/ No
9. What age was your f rst menstrual period? Yes/ No
10. Do you have monthly menstrual cycles? Yes/ No
11. How many menstrual cycles have you had in the last year? Yes/ No
12. Have you ever had a stress racture? Yes/ No
Appendix E: Female Athlete riad

In-Depth Questionnaire 1
Please circle the response that best matches your situation.
Never = 1, Rarely = 2, Occasionally = 3, More o ten than not = 4, Regularly = 5, Always = 6
1. Do you want to weigh more or less than you do? 1 2 3 4 5 6
2. Do you lose weight regularly to meet weight requirements or your sport? 1 2 3 4 5 6
How do you do it?_______________________________________________
3. Is weight/ body composition an issue or you? 1 2 3 4 5 6
4. Are you satisf ed with your eating habits? 1 2 3 4 5 6
5. Do you think your per ormance is directly a ected by your weight? 1 2 3 4 5 6
I so how?______________________________________________________
6. Do you have orbidden oods? 1 2 3 4 5 6
7. Are you a vegetarian? 1 2 3 4 5 6
Since what age?_________________________________________________
8. Do you miss meals? 1 2 3 4 5 6
I so, how o ten?_______________ For what reason?__________________
9. Do you have rapid increases o decreases in your body weight? 1 2 3 4 5 6
10. What do you consider your ideal competitive weight? 1 2 3 4 5 6
11. Has anyone ever suggested you lose weight or change your eating habits? 1 2 3 4 5 6
12. Has a coach, judge, or amily member ever called you at? 1 2 3 4 5 6
13. What do you do to control your weight? 1 2 3 4 5 6
14. Do you worry i you have missed a workout? 1 2 3 4 5 6
15. Do you exercise or are you physically active as well as training

or your sport? 1 2 3 4 5 6
16. Do you have stress in your li e outside o sport? 1 2 3 4 5 6
What are these stresses?_________________________________________
17. Are you able to cope with stress? 1 2 3 4 5 6
How?__________________________________________________________
18. What is your amily structure?____________________________________
19. Do you use or have you use(d) these ways to lose weight?
a. Laxatives 1 2 3 4 5 6
b. Diuretics 1 2 3 4 5 6
c. Vomiting 1 2 3 4 5 6
d. Diet pills 1 2 3 4 5 6
e. Saunas 1 2 3 4 5 6
f. Plastic bags or wrap during training 1 2 3 4 5 6
g. Other methods (please state)__________________________________ 1 2 3 4 5 6
Review o systems: (headaches/ visual problems, galactorrhea/ acne/ male pattern hair
distribution)
Complete history o injuries.
Nutritional analysis assessing energy balance and nutrient balance.
Appendix F: Other Sources and Screening

ools to Assess Eating Disorders and Other
Components of Female riad
1. www.alltrue.net/ site/ adadweb.htm—National Association o Anorexia Nervosa
and Associated Disorders.
2. www. emaleathletetriad.org—T e Female Athlete riad Coalition
3. www.mentalhealthscreening.org—website o National Eating Disorder Screening
Program
4. www.ncaa.org—website o the National Collegiate Athletic Association
5. www.no .org—website or National Osteoporosis Foundation
6. www.hedc.org—Harvard Eating Disorders Center (HEDC)
7. www.womanhealth.gov—website o O ce on Women’s Health, U.S. Department
o Health and Human Services
Developed Screening ools or Female riad components21,34,40
1. Female Athlete Screening ool (FAS )
2. Eating Disorder Inventory (EDI)
3. Eating Disorder Inventory-2 (EDI-2)
4. Eating Disorder Exam 12.0D
5. Eating Attitudes est (EA )
6. Bulemia est (BULI )
7. Bulemia est–Revised (BULI -Rev)
Appendix F: Other Sources and Screening Tools to Assess Eating Disorders and Other Components of Female Triad 1125
8. Setting Conditions or Anorexia Nervosa Scale (SCANS)
9. Restrained Eating Questionnaire
10. Physiologic Screening est
11. Diagnostic Criteria or Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders
not otherwise specif ed (Diagnostic and Statistical Manual of Mental Disorders,
4th Edition [DSM-IV])
Index
Page numbers ollowed by f and t denote f gures and tables, respectively.
A Adductor muscle strains, rehabilitation Ankle- oot injuries, rehabilitation o , 856

Abdominal bracing technique, 421 o , 698 cardiorespiratory endurance,
Abdominal strengthening routines, 969 incidence, 699–702 884–885
Abnormal orces, 583 muscle injury, 698–699 unctional anatomy/ biomechanics,
Abnormal neuromotor, 416 musculature, 698 824–834
Accessory motion, 340, 345 postinjury program, 701t injury mechanism, 834–856
Accommodation phenomenon, 122 prevention, 699–700, 700t orthosis/ ootwear recommendations,
Accommodative orthosis, 857 rehabilitation, 700–702 857–865
Acetaminophen, 57 risk actors, 699 proprioceptive neuromuscular
advantage o , 58 stretch, 703f acilitation strengthening,
Achilles tendinitis, 814 Adenosine triphosphate (A P), 181, 182 873–874
injury mechanism, 812–813 Adhesive capsulitis. See Frozen shoulder reestablish neuromuscular control,
pathomechanics, 812 Aerobic metabolism, 183 878–883
rehabilitation concerns, 813 A erent f bers, types o , 124 rehabilitation techniques, 866–885
rehabilitation progression, 813 A erent mechanoreceptor, 376, 520 strengthening exercises
Achilles tendon, 793, 817 A erent nerve f bers, 123 closed-chain, 869–872
eccentric muscle loading, 801f Aggressive neuromuscular control isokinetic, 872–873
repair program, 890–893 exercises, 598 isometric, 866
tensile strength, 801 Aging, 992 isotonic open-chain, 867–869
Achilles tendon rupture, 815, 816 spine, 1000–1001 stretching exercises, 875–877
ull return criteria, 817 Agonistic pattern, 330 Ankle ractures and dislocation, 843
injury mechanism, 815 Ai chi, 458 injury mechanism, 843
pathomechanics, 814–815 Aircast ankle stirrup, 837f pathomechanics, 843
rehabilitation concerns, 816 AirDyne stationary exercise bicycle, 884f rehabilitation concerns, 843
rehabilitation progression, 816–817 Airplane splint, 599f rehabilitation progression, 843–844
Acromioclavicular joint sprains, 578–581 Algorithms, 14–18 Ankle inversion, 791f
classif cation, 579t components, shapes and descriptions resistive range, 792f
criteria or returning to ull activity, 581 o , 19t Ankle inverter/ everter musculature
injury mechanism, 578 construction o , 19–20 closed-chain position, 794
management o , 578 evaluation scheme, 20f Ankle joint. See also alocrural joint
pathomechanics, 578 muscular strength, power, and equinus, 846
rehabilitation concerns, 578–580 endurance, 24f Ankle plantar exion, 791f, 809
rehabilitation progression, 580–581 neuromuscular e ciency/ unctional stretch or anterior tibialis, 877f
Acromion shapes, 591f return, 25f Ankle plantar exors
Action potential, 96 range o motion (ROM), 23f musculature, closed-chain
Active-assisted plantar exion, 869f Aliplast covering, 860 position, 794
Active-assistive knee exion, 740 Alpha–gamma coactivation, 235 towel stretch, 795f
Active range o motion (AROM), 804 Alzheimer disease, 996 Ankle sprains, rehabilitation
Active release technique, 214–215 Amenorrhea, 1097 techniques, 844
Activities o daily living (ADL), 498, 514, 660 causes o , 1098t pathomechanics/ injury
def nition o , 224 American College o Sports Medicine mechanism, 834
disability, 988 (ACSM), 184, 186 compression, 835–836
Activity pattern indicators pain prof le, 118 Analgesics, use o , 58 elevation, 836
Acupressure, 217 Angiof broblastic hyperplasia, 635 eversion sprains, 834
Acute joint pathology Ankle dorsi exion, 368, 791f inversion sprains, 834
pathomechanics and injury Ankle dorsi exors, 792 protection, 837
mechanism, 914–915 closed-chain position, 794 rest, 837
rehabilitation concerns and Ankle eversion, 791f sprain severity, 835
progression, 916–918 resistive range, 792f syndesmotic sprains, 834–835
1127
1128 Index
Ankle sprains, rehabilitation techniques spine dys unction pathomechanics, 765

(Cont’d.) f nal level, 453 rehabilitation concerns, 765–766
progression, 837 initial level, 450 rehabilitation progression
cardiorespiratory endurance, 840 intermediate level, 450–453 phase I, 766–768
unctional progressions, 840–841 upper extremity, 447–449 phase II, 768
motion, range o , 838 f nal level, 449–450 phase III, 768
neuromuscular control, 839 initial level, 447–448 phase IV, 768
proprioception, 839 intermediate level, 448–449 postoperative rehabilitation a ter
proximal stability, 839–840 Aquatic therapy, in rehabilitation micro racture, 767t
strengthening, 838–839 advantages and benef ts in, 439–442 structures
Ankle strategy, 377 Ai chi, 458 damage, physiology o , 40–41
Anorexia nervosa (AN), 1092 anterior posterior trunk stabilization injuries to, 37–41
diagnostic criteria, 1094t with, 451f ligament sprains, 37–39
Antagonist pattern, 330 aquatic techniques, 446–456 actors a ecting, 39
Anterior cruciate ligament (ACL) injuries, Bad Ragaz ring method, 452f–453f, in knee joint, 38f
292, 384, 731, 745 455f, 456–457 physiology o , 38–39
def cient knees, 238 balance and neuromuscular control synovial joint, anatomy o , 37f
in emale athletes, 1050, 1058 restoration technique, 457f surgical procedures, 766
combined actors, 1054 buoyancy, 436–437, 437f Articular receptors, 226
extrinsic/ controllable actors, Burdenko method, 457 Aspirin, or healing process, 57t
1052–1053 contraindications or, 443t Atrophy, 151
intrinsic actors, 1050–1052 custom pool environment, 444f asymmetrical, 141
knee kinematics/ landing deep-water running, 454f Autogenic inhibition, 199
characteristics, 1056–1058 disadvantages in, 442–443 de nition o , 329
muscular activation, timing patterns, equipment used or resistance/ Automatic postural movements
1054–1056 oatation, 445f coordination o , 376
healing potential o , 749 acilities and equipment, 443–446 Avulsion ractures, 42, 707–710,
hyperextension, 1058 otation equipment, 445f 708f–709f, 1020
injury, 1043, 1044 Halliwick method, 457 mimics, conservative treatment o , 1026
mechanisms o , 1048–1050 indications and benef ts o , 440t Axial orces, 728
reconstruction o , 486, 487, 489, internal and external rotation in
500, 501 supine, 448f B
rupture, 533 neurologic patients and clients, 458–459 Babinski re ex, 100
sex hormones, 1052 pediatric patients and clients, 458 Back-lying
sprain, 749–754 physical properties and resistive orces hip-hike shi ting, 965f
mechanism o injury, 749 in, 436–439 legs-crossed hip adduction
pathomechanics, 749 pool equipment, 445f stretch, 972f
reconstruction, postoperative precautions or, 443t Back pain. See Low back pain,
rehabilitation, 751t–752t prone hip abduction/ adduction, 446f rehabilitation techniques
rehabilitation concerns, 750 prone kayak movement using mask disk-related back pain (See Disk-related
rehabilitation progression and snorkel, 445f back pain)
phase I, 750–752 range o motion with scapular treatment o , 946–948
phase II, 752–753, 752f stabilization, 448f Bad Ragaz ring method, 452f–453f, 455f,
phase III, 753, 753f resistive orces, 438–439 456–457
phase IV, 753–754, 754f special populations, 458–459 Balance activities, 237, 238
phase V, 754 special techniques, 456–458 Balance Error Scoring System (BESS), 378
video analysis, 1049, 1057 specif c gravity, 437–438 Balance Shoes, 397, 398
Anterior muscles, 824 sport-specif c training, 449f Balance techniques, 386
Anterior superior iliac spine streamlined movement, 439f Balance training, 236
(ASIS), 950 supine hip abduction/ adduction, 454f Ball squeeze, 702f
Anterior tibial stress ractures, 805 supine shoulder extension, 449f BAPS board, 298, 298f
Anteroin erior iliac spine (AIIS), 1020 SwimEx pool, 444f Bare oot/ minimalistic ootwear/ mid oot
Anterosuperior iliac spine (ASIS), 1020 turbulent ow, 439f landing style, 841
Apophysitis, 720 water exercise, Karvonen ormula Bench press exercise machine, 160f
Aquatic techniques, 446–456 or, 442f Berger adjustment technique, 164t
activities, 446–447 water sa ety, 446 Beta blocker, 78
components, 447 weightbearing percentages, 437t Bilateral dynamic balance exercises, 399
lower-extremity injuries Arthrogenic muscle inhibition, 416 Bilateral jumping drills, 398
f nal level, 456 Articular cartilage, 765–768, 999 Bilateral-stance balance drills, 392
initial level, 453–454 mechanism o injury, 765 Biodex Medical Systems, 383
intermediate level, 454–456 morphologic changes in, 999 Biodex Multi-Joint System, 499
Index 1129
Biodex Stability System, 499, 879f Bursitis, 52, 718–719, 781 Cartilages, 39
Biomechanical ankle plat orm system iliopsoas ( iliopectineal ) bursitis, 719 f brillates, 40
(BAPS), 504, 585, 838 ischial bursitis, 718–719 replacement techniques, 766
boards, 294 trochanteric bursitis, 718 Celecoxib, or healing process, 57t
Biomechanical dys unction Cell apoptosis, 766
pathomechanics, 780 C Cellular processes, pathology, 3
rehabilitation progression, 780, 781f Cadence, 830 Center o balance (COB), 381
Biomechanical model, 291 Calcaneal apophysitis, 1026 Center o orce (COF), 381
Biomechanical orthosis, 857 Calcaneal varus, 826f Center o gravity (COG), 372, 375
Bleeding, 36 Calcaneof bular ligament, 79 Center o mass (COM), 830
Body positioning techniques, 967 Calcaneus Center o pressure (COP), 381
Bone eversion o , 845f Centralization. See Nerve root
arm/ shoulder, maturation, 1021t line bisecting, 848f compression
density, 1000 Cal stretching, 1027 Central nervous system (CNS), 96, 100,
ractures, 41–44, 42f Calisthenic strengthening exercises, 224, 372, 514
gross structure o , 41f 167, 167f closed-loop system o , 521
growing, 1018 Canadian C-Spine Rules, 914 motor control integration, 232–240
injuries to, 41–44 Car analogy, using human body, 1008t f rst level o , 232–235
leg/ hip, maturation, 1022t Cardiorespiratory conditioning, 840 second level o , 235–239
material, types o , 41 Cardiorespiratory endurance, 799–801 integration o balance training,
osteoporosis, 999–1000 Cardiorespiratory endurance techniques, 236–239
physiology o healing, 43–44, 43f 181, 183–186, 840 third level o , 239–240
spurs, 40 continuous training, 183–186 Central re ex pathways, 536
types o , 1099 requency o training, 184 Cervical region exion, 945
Bone mineral density (BMD), 999 intensity o training, 184 Cervical spine, 909–921, 918–919
Bony structure, 196 monitoring heart rate, 184–185 acute joint pathology, 914–918
BOSU balance trainer perceived exertion, rating o , 185 cases o , 934–936
standing double-leg balance, 797f time (duration), 186 centralization (nerve root
Bounding exercise, 257 type o exercise, 185–186 compression), 911–914
Boutonnière de ormity, 682–684, 682f def nition o , 176 cervical retraction mobilization, 917f
injury mechanism, 683 interval training, 186 cervicogenic headache, 919–922
pathomechanics, 682–683 Cardiorespiratory system craniocervical exion test, 909f
rehabilitation concerns, 683 adaptation o heart to exercise, 176–178 degenerative disc/ joint disease,
rehabilitation progression, 683–684 cardiac output, 177–178 spondylosis, and stenosis,
treatment or, 683f heart rate, 176–177 910–911
Bow orce, 438, 438f stroke volume, 177 unctional anatomy and biomechanics,
Boxer’s racture, 672–673 training e ect, 178–180 898–905, 898f–899f
injury mechanism, 672 adaptation in blood ow, 178–179 importance and purpose o , 905–907
orthosis, 673f adaptation o lungs, 180 musculature, 901f–903f
pathomechanics, 672 adaptations in blood, 180 pathoanatomical cause o , 908
rehabilitation concerns, 672–673 blood pressure, 179 range o motion, 900t, 919f
rehabilitation progression, 673 training e ects on, 176–180 assessment with inclinometer, 900t
Brachial plexus injuries (stinger or Cardiovascular disease rehabilitation considerations or, 908
burner) risk actors or, 993t sel -mobilization with strap, 923f
criteria or return to activity, 605 Cardiovascular f tness, 808, 817 stabilizer, 910f
injury mechanism, 603–604 Cardiovascular system traumatic neck pain (whiplash), 918–919
pathomechanics, 603 age-, inactivity-, and disease-related treatment based classif cations, 910t
rehabilitation concerns, 604 changes, 993–994 Cervicogenic headache
rehabilitation progression, 604–605 Carpal tunnel syndrome (C S), 78, 139, injury mechanism, 919–920
Brostrom ankle rehabilitation program, 662, 670–672, 671f, 1004 pathomechanics, 919–920
894–896 cases o , 671f rehabilitation concerns, 920–922
Buddy taping, 673f injury mechanism, 670–671 rehabilitation progression, 920–922
Built-in system, 68 pathomechanics, 670 Chemical mediators, 31–33
Bulbous enlargements, 51 Phalen test or, 671f Chest
Bulimia nervosa (BN), 1092 rehabilitation concerns, 671–672 double knee, 960f
diagnostic criteria, 1095t rehabilitation progression, 672 single knee, 960f
Bullock-Saxton demonstrated Carpometacarpal joint, osteoarthritis o , Chondroblast cells, 44
changes, 802 676–678 Chondromalacia, 40
Buoyancy, 436–437, 437f injury mechanism, 677 Chopping, 318
Burdenko method, 457 pathomechanics, 676–677 Chronic compartment syndrome
Burner syndrome, 603 rehabilitation concerns, 677–678 (CCS), 808
1130 Index
Chronic muscular adaptations, 620 Compartment syndromes, rehabilitation unctional anatomy, review o , 409–413
Clavicle ractures techniques guidelines or, 429–431
criteria or return, 582 emergency asciotomy, 807 exercise progression, 430t
injury mechanism, 582 pathomechanics/ injury mechanism, exercise selection, 430t
pathomechanics, 581 807–808 program variation, 429t
rehabilitation concerns, 582 rehabilitation concerns, 808 multif dus, role o , 413–415
rehabilitation progression, 582 rehabilitation progression, 808–809 muscular imbalances, 415–416
Clearing tests, 65, 94–95, 469 returning to ull activity, 809 neuromuscular considerations, 416–417
Clients, def nition o , 5 Compensated ore oot valgus, postural considerations, 415
Clinical decision-making process, 826, 828f, 833 scientif c rationale or, 417–418
6, 12–14 Compensated ore oot varus, 827f specif c stabilization exercises, 422–429
Clinical reasoning process, 9–12, 10, 11 Compensated subtalar, 826f strengthening program, 168, 430
dialectical model o , 12 Competent decision makers, 12 training program, 420–429
Clinical trials, 13 Comprehensive core stabilization transversus abdominus ( A) muscles,
Closed-chain exercises, 245 training program, 418, 423, 429 role o , 413–415
Closed kinetic chain (CKC) exercise, goal o , 430 Core strengthening, 1077
596, 728 Comprehensive exibility program, 759 Corrective exercise progression, 522
BAPS board and minitramp, 298, 298f Comprehensive unctional rehabilitation Corticosteroids, use o , 36
leg press, 295–296, 295f programs, 408 Cortisone injection, use o , 624
lunges, 294–295, 295f Computer-inter aced orceplate Costochondritis, 924–926
minisquats, 294–295, 294f technology, 380 pathomechanics and injury
to regain neuromuscular control, Concave radius articulates, 616 mechanism, 924–925
290–291 Concentric contractions rehabilitation concerns and
or rehabilitation o lower-extremity vs. eccentric contractions, 159 progression, 925–926
injuries, 293–299 Concurrent shi t, 289 Costovertebral arthralgia, 924
slide boards and f tter, 298–299, 299f contractions, 294 pathomechanics and injury
stair-climbing machines, 296 Cone touches, 718f mechanism, 924
stationary bicycle, 297–298, 298f Con usion, 992 rehabilitation concerns and
stepping machine, 296f Connective tissue, 195 progression, 924
step-ups, 296, 297f components o , 53 Coughing, 977
strengthening exercises, 793–795 massage, 217 Creep, def nition o , 645
terminal knee extensions using surgical Consensus, therapeutic exercise, 1006 Crepitus, 48
tubing, 297, 297f Continuous passive motion (CPM) Crossover hop, or distance, 488f
vs. open-kinetic-chain exercise, device, 740 Cryo Cu , 747, 834f, 835, 836f
287–306 Continuous training, 183–186 Cryotherapy, 55, 758, 770
biomechanics o activities in lower requency o training, 184 Cuboid subluxation
extremity, 291–293 intensity o training, 184 pathomechanics/ injury mechanism, 853
biomechanics o activities in upper monitoring heart rate, 184–185 rehabilitation considerations, 853–854
extremity, 299–305 perceived exertion, rating o , 185 Cutaneous receptor, analgesic response
elbow, 301 time (duration), 186 to, 127
oot and ankle, 291 type o exercise, 185–186 Cytokines, 32, 33
knee joint, 291–293 Contraction, types o , 150
patello emoral joint, 293 Contract–relax techniques, 781 D
pushups, pushups with a plus, Contralateral rotation, 903 Daily Adjusted Progressive Resistive
press-ups, step-ups, 304 Contusion, 53–54 Exercise (DAPRE) program, 164
shoulder complex joint, 300–301 Convex-concave rule, 343 adjusted working weight, 164t
slide board, 305 Coracobrachialis, 552 Dart throwers arc, 661f
o upper-extremity injuries, 301–305 Coracoid process, 91 Davis law, 504
weight-shi ting exercises, 302–303 Core, def nition o , 408 Decision-making process, 6, 9–12. See also
wall slides, 294–295, 294f Core muscles, teaching cues or Clinical decision-making process
Closed-loop system, o eedback motor activation o , 422t Deep core muscles
control, 231 Core stabilization exercise programs, 408 neuromuscular control o , 419
Coactivation contraction, 954f level 1, 423f–424f Deep somatic pain, 117
Codman’s exercises, 601 level 2, 425f–428f Deep vein thrombosis, 994
Cognitively impaired elderly level 3, 428f–429f clinical decision rule, 995t
interventional strategies, 997 Core stabilization training, in Deep-water activities, 450, 454
Cohesive orce, 438 rehabilitation, 300, 969 Degenerative disc/ joint disease, 910–911
Collagen, 35, 199 assessment o core, 418–420 pathomechanics and injury
Collagen f bers, 38, 47 concept o , 408–409 mechanism, 910
Colles ractures, 1003 drawing-in maneuver per orminance, rehabilitation concerns and
Comminuted racture, 42, 42f 421–422 progression, 910–911, 910f–912f
Index 1131
Degenerative diseases, 36 Dual-energy X-ray absorptiometry rehabilitation concerns, 645–646
Dehydrated cartilage, 999 (DEXA), 1098 types o , 643–645
Dehydration, 1000 with normal bone density, 1099f isokinetic orearm pronation/
Delayed-onset muscle soreness (DOMS), Dual-task exercises, 401 supination exercise, 632f
cause o , 53 Durometer scale, 863 isokinetic 90/ 90 internal/ external
Delirium, 992 DynaDisc/ BOSU ball, 1081f rotation training position, 638f
DeLorme program, 163t DynaDisc on otal Gym, 1066f isokinetic wrist exion/ extension
Dementia, 996–997 DynaDisc/ unstable, 1065f exercise, 632f
Depressed re exes, 97–98 Dynamic balance tests, 385 joint complex
Depression, 997–998 Dynamic exibility, 196 articulations o , 614f–615f
De Quervain’s tenosynovitis, 673–675 Dynamic heel cord stretch, 876f distal humerus, 614
injury mechanism, 674 Dynamic jump/ land training, 1065f dynamic stabilizers o , 617
pathomechanics, 673 Dynamic musculotendinous proximal radius, 614
rehabilitation concerns, 674–675 stabilizers, 736 proximal ulna, 614
De Quervain tendonitis conservative Dynamic restraint system, 241 role o , 615
management protocol Dynamic stabilizers, 224 lateral complex, structures, 616
acute phase, 684 Dynorphin, 130 manual scapular retraction
advanced phase, 684 in pain control, 128–130 exercise, 626f
intermediate phase, 684 oscillatory exercise, 628f–629f
return to unction, 684 E passive stretching, 631f
Diagnostic reasoning process, 19 Eating disorders pediatric considerations, 647–648
Diagonal bounding exercises, 400 warning signs o , 1097t plyometric wrist, 633f
Diclo enac, or healing process, 57t Eating disorders not otherwise specif ed pointer closed-chain upper extremity
Diencephalon, 228 (EDNOS), 1092 exercise, 630f
Di unasil, or healing process, 57t diagnostic criteria, 1095t postoperative protocol or elbow
Digitorum muscles, 143 Eccentric load, 280 arthroscopy, 649–650
Disability, 3 Eccentric wrist exion exercises, 631 acute phase, 649
Disablement model, 3–4, 4f Econcentric contraction, 150 advanced/ return to activity
risk actors, 3 Edema reduction phase, 650
Disk-related back pain benef t o , 441 intermediate phase, 649–650
injury mechanism, 977 E erent f bers, 123 prone extension, 957f
pathomechanics, 977 Elastic cartilage, 39 quadruped rhythmic stabilization
rehabilitation concerns, 977 Elastic sti ness, 332 exercise, 629f
rehabilitation progression, 978–979 Elbow, 301 rehabilitation o
treatment o , 978 arthroscopy or posteromedial elbow arthroscopy, 635–636
Dislocations, 52 osteophyte, 636 unctional anatomy and
Displacing orces, 236 ball dribbling exercise, 628f biomechanics, 614–617
Dissociation, 481 carrying angle o , 616f guidelines, 642
Distal interphalangeal (DIP) joint, 663 clinical examination o , 618–620 humeral epicondylitis, 622–623
Distal mobility, proximal stability ligamentous laxity, 619 humeroulnar joint, 615
or, 1069 methods o , 620–622 ligamentous structures,
Distal radioulnar joint (DRUJ) injuries, muscular adaptations, 619–620 616–617
661, 669–670 osseous adaptation, 619 pathomechanics, 622–623
pathomechanics, 669 range o motion adaptations, progression o , 623–634
rehabilitation concerns, 669 618–619 protected unction phase,
rehabilitation progression, 669–670 closed-chain upper-extremity 623–625
Distal radius ractures, 664–667, 1003 exercise, 630f proximal radioulnar joint, 616
injury mechanism, 665 counter orce brace, 634f radiocapitellar/ humeroradial joint,
pathomechanics, 664–665 dislocations in 616
rehabilitation concerns, 665 classif cation o , 642 return to activity phase, 632–634
rehabilitation progression, 665–667 mechanism o injury, 641–642 techniques or specif c injuries,
Dorsi exion, 837, 846, 847f pathomechanics, 641 622–623
Double-leg press, 882f rehabilitation concerns, 642 total-arm strength rehabilitation,
Double-limb support phase, 830 rehabilitation progression, 642–643 627–632
Drag orce, 438–439, 438f distal upper extremity isotonic ulnar collateral ligament injury,
Drawing-in maneuver exercise, 627f 637–639
contraction o transversus extensors o , 617 valgus extension overload injuries,
abdominis, 421f exors o , 617 636–637
per ormance, 421–422 ractures in rotator cu exercises, 625f
quadruped position or, 422f pathomechanics and mechanism o seated rowing exercise, 629f
Drop jump assessment, 488f injury, 643 serratus press exercise, 626f
1132 Index
Elbow (Cont’d.) Excessive pronation kinetic chain relationships, 1070t

tendon injury, treatments used or, pathomechanics/ injury mechanism, menstrual unction, 1096–1098
634–635 844–846 pregnancy, in physically active emale,
platelet-rich plasma, 634–635 rehabilitation concerns, 846–849 1105–1107
ulnohumeral joint distraction examination, 847–849 prevention/ treatment, 1103–1105
mobilization, 632f Exercise machines, 160 screening, 1101–1102
valgus stress test, 617f disadvantage, 161 sport-specif c training, 1062
Electromyography (EMG), 291, 772 vs. ree weights, 159–161 vs male athletes, 1044t
interpretation, 230 Exercise program/ progression, 246–258 Female gymnast, 1090–1092
Elevated re exes, 98–99 phase I, static stabilization, 247–250, Female sex hormones, 1048
Elgin ankle exerciser, 247f–250f Female swimmers
multidirectional, 869f multiplanar exercise, 249–250 signs and symptoms, 1087
Elliptical training machine, 885f, 1009f technique modif cation, 250 Female triad screening
Endogenous opioids, 124 uniplanar exercise, 248–249 questionnaire, 1123
β−Endorphin, in pain control, phase II, transitional stabilization, Femoral neck stress racture, 721–723
128–130 250–254, 251f, 253f Fenopro en, or healing process, 57t
Endorphins, 128 unctional testing, 254 Fibrocartilaginous disk, 548
End-range dorsi exion, 861f lunge, 252–254 Fibrosis, 34
Endurance, impaired, 175–192 squat, 251–252 Fibrotic adhesions, 214
caloric thresholds and targets, 187 technique modif cation, 254 Fibular ractures, 804
cardiac output limits, 178f, 179f phase III, dynamic stabilization, 254– Fi th metatarsal stress ractures, 849
cardiorespiratory endurance 258, 256f Fine motor-control activity, 879f
techniques, 183–186 multidirectional drills, 257–258 Finger exors, 662
cardiorespiratory system, training resisted bounding, 257 Finger injuries, rehabilitation o
e ects on, 176–180 resisted hopping, 255 boutonnière de ormity, 682–684
combining continuous and interval resisted running, 255–257 boxer’s racture, 672–673
training, 187 resisted walking, 255 carpal tunnel syndrome, 670–672
detraining, 187–188 Exercise sandals, 799f carpometacarpal joint, osteoarthritis
exercise, producing energy or ball catch, 801f o , 676–678
anaerobic vs. aerobic metabolism, butt kicks, 800f De Quervain’s tenosynovitis, 673–675
182–183 orward/ backwards walking, 799f distal radioulnar joint injuries, 669–670
excess postexercise oxygen high knees, 800f distal radius ractures, 664–667
consumption, 183 progression, 803t unctional anatomy and
heart rate sidestepping, 800f biomechanics, 664
maximum, 177f single-leg stance, 800f mallet f nger, 680–682
plateau, 177f Exercise training variables, 156t protocols, 684–690
maximal aerobic capacity, 180–182, Expert vs. novice decision making, 12 scaphoid ractures, 667–669
180f, 181f Extension exercises, 956–959 trigger f nger, 675–676
cardiorespiratory endurance and Extensors ulnar collateral ligament (UCL) sprain,
work ability, 181–182 o elbow, 617 678–679
ast-twitch vs. slow-twitch muscle tendon zones, 664f Finkelstein test, 674f
f bers, 181 External oblique muscles, 946f Fitter Rocker board exercises, 875f
oxygen consumption, rate o , Flat- ooted squat stretch, 961f
180–181 F Flexibility
perceived exertion, rating o , 185t Fabrication, 860–861 def nition o , 194
stroke volume plateaus, 178f Fascia, 210 exercise program, 273
Endurance training, in older adult, 1008 Fast kicking motion, 397 Flexion, 704f
Energy-generating systems, 182 Fast-twitch f bers, 153 exercises, 959
Enkephalin, 123 Fat, 196 90-90 position, 979f
interneurons, 127 Feed- orward motor control, 231 moment, 293
Epiphyseal ractures, 1018–1020 Feel contractions, palpation location, 952 Flexor carpi ulnaris (FCU), 661
Ethnicity, 77 Feet, exor muscles, 1010 Flexor digitorum pro undus (FDP), 663
Etudolac, or healing process, 57t Felt pads, 858f Flexor digitorum superf cialis (FDS), 663
Eumenorrhea. See Normal Female athlete triad, 1092, 1092f, 1093f isolate active movement o , 689f
menstrual cycling bone mineral density, 1098–1100 Flexors
Evaluation process, 117 eating disorders, 1124–1125 o elbow, 617
Evaluation scheme algorithm, 20f energy availability, 1093–1096 tendons pulleys o , 663f
Evidence-based practice, 14 envelope o unction, 1068f tendons zones, 663f
def nition o , 13 historical perspective/ evolution, Flotation equipment, 445f
levels o , 13t 1092–1093 Fluid process, 82, 83
use, 12–14 in-depth questionnaire, 1123–1124 Flurbipro en, or healing process, 57t
Index 1133
Foam-box impression, 859f Frontal plane postural control, 385 Functional per ormance testing, 486
Food guide pyramid Frozen shoulder Functional progressions, 840
MyPyramid-updated version o , 1104f criteria or return to activity, 601 Functional rehabilitation, 514–518
Foot di erential diagnosis o , 601t objectives o , 514–516
bones o , 825f injury mechanism, 600–601 phases o , 515t
impression, negative, 859 pathomechanics, 600 prescription o exercise
intrinsic strengthening, 870f rehabilitation concerns, 601 principles or, 517t
primary abnormalities o rehabilitation progression, 601 three-phase model or, 516–518
gait, pathomechanics, 832–834 Functional assessment process, 477 Rs o treatment phases, 516t
stress ractures, pathomechanics/ Functional continuum, 515 three-phase rehabilitation model, 517t
injury mechanism, 849 Functional evaluation process, 525 Functional strengthening exercises, 157f
stress ractures, rehabilitation Functional exercise program, 509 Functional strength training, 155–156
concerns, 850 Functional exercise progression, 508 Functional testing
f th metatarsal stress ractures, concept o , 498 concept o , 498
849–850 examples, 503–509 examples, 503–509
navicular stress ractures, 849 knee unctional progression, 504t knee scoring systems, 507t
second metatarsal stress ractures, 849 lower-quarter unctional progression per orming, 498–500
talar head, 846f and testing template, 505t research in, 506t
Foraminal encroachment test. See lumbar stabilization progression, 509t smart balance master
Spurling test shoulder unctional progression, 508t orward lunge test, 501f
Force–couple relationships, 157 specif cs in, 500–503 step-up-and-over test, 501f
Force couples, 300 Functional movement, assessment o specif cs in, 500–503
Forced-use paradigm, 240, 520 based thinking, 26 Functional training
Forceplate technology, 382 undamentals, 464–465 balance variables, 540t
Force plat orms, 381 injury potential and return rom central nervous system, 519–522
Forearm-based thumb, 668f injury, 468 closed-loop, open-loop, and eed-
Fore oot equinus, 846 mobility–stability continuum, 465–466 orward integration, 521–522
Fore oot valgus, 845f model o , 5 f rst-level response, 519
Fore oot varus, 844f motion vs. movement, 464 second-level response, 519–520
Forward head posture (FHP), 137, 138, 145 outcomes o , 468t third-level response, 520
Fractures screen, 469–476 corrective exercise, postures used
in ankle, 843 screening and testing, 466–468, 466t in, 527t
anterior tibial stress, 805 screening vs. specif c unctional dynamic training, 542f
avulsion, 42 per ormance tests, 486–489 elevated wall dribble, 542f
bone, 41–44, 42f crossover hop or distance, 488f unctional evaluation, three levels
clavicle, 581–582 drop jump assessment, 488f o , 525t
Colles, 1003 single-leg press, 487f unction and unctional rehabilitation,
distal radius, 664–667 step-down test, 487f 514–518
in elbow tuck jump assessment, 489f hal -kneeling position, 530f
pathomechanics and mechanism o selective unctional movement lunging movement, 540f
injury, 643 assessment, 476–485 neuromuscular control, 518–519,
rehabilitation concerns, 645–646 systems approach to movement, 464 533–535
types o , 643–645 Functional movement screen (FMS), e cient motor control restoration
epiphyseal, 1018–1020 469–476 o , 535
f bular, 804 movement patterns o proprioception restoration and
f th metatarsal stress, 849 active straight-leg raise, 473–474, 474f prevention o reinjury, 534
in hip, 1001 deep squat, 470, 471f proprioceptive system, e ects o
lateral condyle, in elbows, 644 hurdle step, 470–472, 471f injury, 533–534
medial epicondyle, in elbows, 644–645 in-line lunge, 472, 472f relationship o proprioception to
nondisplaced, 843 rotary stability, 474–476, 475f unction, 534
radial head and neck, 645 shoulder clearing test, 473, 473f neuromuscular exercises
scaphoid, 667–669 shoulder mobility, 472–473, 473f lower-extremity, 538t
stress, 804 spinal extension, screening upper-extremity, 537t
subtrochanteric, 1005 (clearing) test or, 475f open-loop system, 521t
supracondylar, 643–644 spinal exion, screening test or, 476f pattern, 532–533
varieties o , 41 trunk stability pushup, 474, 474f, 474t 3-phase rehabilitation model,
Frailty, 991–992 scores, 475 535–543, 535t
Freestyle swimming stroke cycle, 1084f scoring sheet, 470f phase I, 536–540
Free weights scoring system or, 470t phase II, 540–541
advantages and disadvantages, 160 Functional per ormance measures phase III, 541–543
Friction massage, 217 age-related normative values or, 991t plyoback, 540f
1134 Index
Functional training (Cont’d.) injury mechanism, 583–584 protocol in eccentric lengthened

position, 530–532 pathomechanics, 582–583 state, 707t
proprioception, 518–519, 533–535 rehabilitation concerns, 584 rehabilitation, 704–706
e cient motor control restoration rehabilitation progression, 584–586 risk actors, 703
o , 535 Glenohumeral joint, multidirectional Hand
proprioception restoration and instabilities o based thumb spica orthosis, 679f
prevention o reinjury, 534 criteria or returning to ull activity, 596 knee position-f re hydrant exercise,
proprioceptive system, e ects o exercises, 301 971f
injury, 533–534 injury mechanism, 586, 590–592 prone extension, 957f
relationship o proprioception to pathomechanics, 586, 588–590 rehabilitation o
unction, 534 rehabilitation concerns, 586–587, boutonnière de ormity, 682–684
proprioceptive system, disadvantage 592–593 boxer’s racture, 672–673
vision, 520t rehabilitation progression, 587, carpal tunnel syndrome, 670–672
quadruped position with manual 593–596 carpometacarpal joint, osteoarthritis
perturbations, 539f Glenoid labrum, 549 o , 676–678
receptors, 518–519 Gliding, component o motion, 342 De Quervain’s tenosynovitis,
rhythmic stabilization, 539f Gluteus medius 673–675
rolling to prone, 529f electromyogram (EMG) activity o , 412 distal radioulnar joint injuries,
single-limb balance, 539f Glycogen, 182 669–670
supine bridging movement, 529f Glycosaminoglycans, 34 distal radius ractures, 664–667
support and sensory unction, 518 Goldberg points, 84 unctional anatomy and
therapeutic exercise Golgi tendon organ (G O), 199, 201, 226, biomechanics, 662
our-by- our method or design 227–228, 269, 329, 331, 375 protocols, 684–690
o , 536t desensitization o , 251 scaphoid ractures, 667–669
our Ps, 524–533 intra usal f bers, 228 ulnar collateral ligament (UCL)
memory cues and primary sensitivity o , 227 sprain, 678–679
questions, 524t Gonadotropin-releasing hormone Hard orthosis, 857f
pain, 525 (GnRH), 1097 Hawkins-Kennedy impingement test, 588f
pattern, 532–533 Goniometer, 197 Healing process, understanding and
position, 530–532 Granulation tissue, 34 managing o , 162
posture, 527–530 Graston technique, 215–216, 216f articular structures, injuries to, 37–41
prescription, our principles or, Groin, rehabilitation o atrophy, 36
522–533 anatomy and biomechanics, 696–713 bone, injuries to, 41–44
purpose, 525–527 Ground reaction orce (GRF), 829 corticosteroids, 36
body weight (BW), 830 edema, 36
G Growth plate racture extent o injury, 36
Gait Salter-Harris classif cation o , 1018 f broblastic repair phase, 34–35
cycle, 829 Growth plate–metaphysis complex, 1018 collagen, importance o , 34–35
restoration, 742 T e Guide to Physical T erapist Practice, health, age, and nutrition, 37
running orm 2–3, 66 hemorrhage, 36
pathomechanics o , 831–832 digital version o , 2 humidity, climate, and oxygen
training, 255 impact o , 9 tension, 37
Gastrocnemius, 792, 875f interventions in, 19 in ection, 37
Gastrocnemius-soleus complex, 808 musculoskeletal practice patterns, 8–9 in ammatory response phase, 31–34
exibility, 811 overview o , 5–9 antiin ammatory medications, use
musculature, 813 scope o , 4f o , 33–34
stretching, 1028f Gymnastics, 1090, 1091 chronic in ammation, 33
Gate control theory clot ormation, 33
in pain, 127–128, 127f H vascular reaction, 31–33
Gentle pain- ree stretching, 813 Halliwick method, 457 injury and in ammatory response
Gentle stretching Hallux valgus de ormity phase o , 32f
muscle–tendon unit, 809 pathomechanics/ injury keloids and hypertrophic scars, 37
Geriatric assessment mechanism, 854 maturation remodeling phase, 35
key components, 988–993 rehabilitation concerns, 854 progressive controlled mobility, role
Geriatric Depression Scale, 998 Hamstring muscles o , 35
Gering’s disease, 99 cocontraction o , 292 medications or, 56–58
Gibney taping technique, 835, 837 strains in NSAIDs or, 57t
Glenohumeral dislocations/ hamstring musculature, 702 muscle spasm, 36
instabilities, 583 incidence, 703–706 musculoskeletal injuries, 52–54
criteria or return to activity, 586 injury, 703 musculotendinous structures, injuries
exercise modif cation per direction, 585t prevention, 703 to, 44–49
Index 1135
nerve tissue, injuries to, 49–52, 50f role in unction, 137–138 throwing mechanics, 1121
poor vascular supply, 36 role in pathology, 138–140 warm-up, 1120
primary injuries, 31 thirty-point postural assessment, 141t Interval training, 186
rehabilitation in, 29–59 upper lateral gluteus maximus Interval windmill pitching program
rehabilitation philosophy, 58–59 atrophy, 141f pitching, 1120
separation o tissue, 36 Humeral epicondylitis, 622 stretching, 1120
sport-related injury, cycle o , 30f epidemiology o , 623 throwing, 1120
therapeutic exercise to, 54–56 etiology o , 622 warm-up, 1119–1120
Healing techniques, 436 structures involved in, 622–623 Intervention techniques, 13
Health care provider, 105 treatment o , 624 choice o , 7
Hear rate reserve (HRR), 184 Hyaline cartilage, 37, 39 components to, 6
Heart rate, 177 Hydrostatic pressure, 441 physical therapists, 6
Heating modality, type o , 56 Hyperextension, 855 Intervertebral articulations, 944
Heel pain, 850 Hypermobility screening maneuvers, Intervertebral disc pathology
Heel raises, 793f 1074, 1074f pathomechanics and injury
Hemoglobin, 180 Hypermobility syndromes mechanism, 929–931
Henning’s prevention program, 1059 injury mechanism, 976 rehabilitation concerns and
Hernia, 1034 pathomechanics, 976 progression, 932
Hill-Sachs lesion, 583 rehabilitation concerns, 976 Intraabdominal pressure (IAP), 412
Hip-hike exercise, 872f, 972 rehabilitation progression, 976–977 Intra usal f bers, 226
with hand pressure, 973f Hyperplasia, 153 Inversion ankle sprains, 1023
Hip muscles, 411f Hypertension, 77 Ipsilateral thoracolumbar hypertrophy, 141
abduction, 925f Hypertrophy, 151 Isokinetic devices, 165, 165f
abduction stretch, 710f, 721f Hypomobile joint, 345 disadvantage o , 166
dislocation in, 713–717 Hypothesis-oriented algorithm or Isokinetic dynamometer
labral tears, 714–717 clinicians (HOAC), 14 lengthened-state eccentrics on, 706f
risk o , 1006 HOAC II, 15f–18f Isokinetic exercises, 164–166, 570
extension in, 1006 parts o , 14 as conditioning tool, 165–166
exion, 710f Hypothetic-deductive process, 12 in rehabilitation, 166
exors, 945 Isokinetic atigue protocol, 244
stretch, 926f, 961f I Isokinetic inversion/ eversion exercise, 872f
ractures in, 1001 Ibupro en, 57 Isokinetic plantar exion/ dorsi exion
internal rotators, 737 or healing process, 57t exercise, 872f
li t bridges, 965f Iliac apophysitis, 1030 Isokinetic training, 640
pointer, 710 treatment, 1031 Isolated lumbar multif dicontractions
protocol or return to running a ter Iliotibial band (I B), 734 palpation location, 952
injury, 722t Iliotibial band (I B) riction Isolated toe raises, 869f
shi t posture, 956 syndrome, 774 Isolation-type exercises, 290
shi t sel correction, 956, 956f Impairment, 3 Isometric exercise, 157–158, 158f
strains in, 697–698 Impulse technique or isometric disadvantage o , 158
arthroscopic labral repair stabilization (I IS), 250 use o , 158
rehabilitation guidelines, Inactivity, 992 Isometric grip strength dynamometer, 619
715t–716t Indomethacin, or healing process, 57t Isometric muscle energy technique, 335
strategies, 1011 In ammation Isotonic contraction
Ho a massage, 217 chronic, 33 slow reversal, 315
Ho man sign, 100 def nition o , 31 Isotonic equipment, 160f
Homan sign, 994 Insidious injuries
Hoop stress, 762 snapping hip syndrome, 719–720 J
Hopping exercises, 840 Intensity, def nition o , 274 Jobst intermittent air compression
Human posture and unction, patterns o , Intercostal muscle strain device, 836f
135–145 pathomechanics and injury Joint capsule, 999
assessment o , 140–145 mechanism, 923 Joint compressive orces, 289
anterior view, 143–144 rehabilitation concerns and Joint hypomobility, 349
lateral view, 144–145 progression, 923 Joint mechanoreceptors, 228
posterior view, 140–143 International Classif cation o Joint mobility dys unction, 484
gastrocnemius muscle, 142f Functioning, Disability, and Joint mobilization techniques, 345–348,
muscle imbalance, vicious cycle Health (ICF) model, 2 959–962
o , 139f Interphalangeal (IP) joint extension, 663 contraindications or, 348
one-joint adductor tightness, 142f Interval so tball throwing program grades, 346–347
proprioception role in, 136–137 stretching, 1120 indications or, 348
protracted in erior ribs, 144f throwing, 1121–1122 using posterior–anterior glides, 975
1136 Index
Joint motions talonavicular glides, 366f meniscal injury, 759–765

active ranges o , 198t thoracic vertebral acet rotations, 357f overview o progression ollowing
Joint proprioception, assessment o , tibial glides, 362f, 364f injury, 737–745
229–230 tibio emoral joint traction, 363f phase I, 738–739
Joint proprioceptors, 384 traction and mobilization, 350f phase II, 739–742
Joint-repositioning exercises, 536 traction vs. glides, 349f phase III, 742–744
Joints, 339–368 ulnar oscillations, 354f phase IV, 744–745
calcaneocuboid glides, 365f unilateral cervical acet anterior/ patello emoral injuries techniques,
carpometacarpal glides, 356f, 366f posterior glides, 357f 776–783
cervical vertebrae rotation Joint sprain, 924 posterior cruciate ligament sprain,
oscillations, 356f pathomechanics and injury 754–759
cervical vertebrae sidebending, 356f mechanism, 924 progression or patello emoral
clavicular glides, 351f rehabilitation concerns and pathology, 769–776
convex-concave rule, 342f progression, 924 screw-home mechanism, 730, 730f
cuboid metatarsal glides, 366f Joint sti ness, 377, 802 stability, 731–734
emoral glides, 361f, 362f Joint sur ace stress, 735 ligaments and stability, 732–734
emoral rotation, 362f Joint systems, 376 Menisci, 731
emoral rotations, 361f Joint traction techniques, 348–350 muscular contributions,
emoral traction, 360f grades, 349 732, 732f, 733f
f bula glides, 363f Jones racture, 849 tibio emoral joint, 728
f bular glides, 364f Jumping exercises, 258, 840 kinematic motion o , 730–731
glenohumeral glides, 351f Jumping sequences, 400 Knee injury, progression o , 737–745
glenohumeral joint traction, 353f Jump-training program, 1118 phase I, 738–739, 738f, 739f
gliding motions, 347f description o , 1119 phase II, 739–742, 740f–742f
hip traction, 360f Juvenile osteochondritis dissecans phase III, 742–744, 744f
humeral glides, 352f (JOCD), 1034 phase IV, 744–745
humeroradial in erior glides, 354f Kneeling, 963f
humeroulnar glides, 353f K ankle dorsi exor stretch, 797f
innominate rotation, 359f, 360f Karvonen equation, 185 Knight’s DAPRE program, 164t
joint arthrokinematics, 341–343, 341f Kendall’s structural approach
joint capsule resting position, 343f to postural assessment, 136 L
joint mobilization techniques, 345–348 Keterolac, or healing process, 57t Labral tears, 714–717
contraindications or, 348 Ketopro en, or healing process, 57t pathomechanics and injury
indications or, 348 Kinesiotape technique, 852f mechanism, 714
joint positions, 343–345, 345f Kinetic chain concept, 156, 288–289 rehabilitation concerns and
joint traction techniques, 348–350 concurrent shi t in, 289 progression, 715–717
Kaltenborn’s grades o traction, 349f muscle actions in, 288 Lachman test, 734
lumbar lateral distraction, 357f Knee Lateral bands, 664
lumbar vertebral glides, 357f abduction angles, 1047 Lateral collateral ligament (LCL), 733, 748
lumbar vertebral rotations, 358f arthrokinematics, 728–730, 729f sprain in, 748–749
lumber rotations, 358f axial orces, 728 mechanism o injury, 748
Maitland’s f ve grades o motion, 346f Cryo Cu , 738 pathomechanics, 748
metacarpophalangeal glides, 356f, 366f extension, 1006 rehabilitation concerns, 748
Mulligan joint mobilization technique, exion, 378, 704f rehabilitation progression, 748–749
350–368, 367f joint, 291–293 Lateral condyle ractures
principles o treatment, 367–368 kinematics/ landing characteristics, in elbows, 644
patellar glides, 363f 1056–1058 Lateral shi t corrections, 954–956,
radial glides, 354f pain, anterior, 1046 955, 955f
radiocarpal joint, 355f patello emoral joint, 734–737 Lateral step-ups, 871f
relationship between physiologic and range o motion (ROM), 728 Lawn Mower with external rotation, 1079f
accessory motions, 340–341 rehabilitation o Laxity tests, 1073, 1073t
rotation oscillations, 353f anterior cruciate ligament sprain, Leg extension, 957f
sacral glides, 358f 749–754 Legg-Calvé-Perthes disease (LCPD), 1033
scapular glides, 353f articular cartilage, 765–768 Leg-lowering test, 419f
shape, resting position, and treatment unctional biomechanics o , 728–737 Leg press, 295–296, 295f
planes o , 344t lateral collateral ligament sprain, Length–tension curve, 87
subtalar joint glides, 365f 748–749 Lesser trochanter, avulsion racture o , 1034
subtalar joint traction, 365f ligamentous and meniscal injury Leukotape P taping technique, 852f
superior/ in erior sacral glides, 358f techniques, 745–768 Levator scapulae stretch, 921f
talar glides, 364f, 365f medial collateral ligament sprain, Levodopa, 1012
talocrural joint traction, 364f 745–748 Li ting, 318
Index 1137
Ligament, 999 M Medial-lateral loading, 279, 279f
Ligamentous injury, 385 Macrotraumatic musculoskeletal dynamic distance drills, 279
techniques or, 745–768 injuries, 31 in-place activities, 279
Ligamentous laxity, 1107 avulsion ractures, 1020 Medial patello emoral ligament
Ligamentous sprain epiphyseal ractures, 1018–1020 (MPFL), 777
grade 1, 38 Maitland’s system, 348 postoperative rehabilitation a ter
grade 2, 38 Mallet f nger, 680–682 reconstruction, 778t–779t
grade 3, 38 de ormity, 680f Medial tibial stress syndrome (M SS),
Ligamentous trauma, 577 injury mechanism, 680 805, 810
Ligaments, 944 pathomechanics, 680 injury mechanism, 810–811
Limb symmetry index (LSI), 487 rehabilitation concerns, 680–682 pathomechanics, 810
Limits o stability (LOS), 372 rehabilitation progression, 682 rehabilitation concerns, 811
Linear racture, 42, 42f Mallet f nger conservative management rehabilitation progression, 811–812
Link system, 288, 288f protocol returning criteria, to ull activity, 812
Long-sitting hamstring stretching, 1030f acute phase, 684–685 Me enamic acid, or healing process, 57t
Low back pain, rehabilitation techniques advanced phase, 685 Meloxicam, or healing process, 57t
acute vs. chronic, 966–967 intermediate phase, 685 Meniscal injury, 759–765
injury mechanism, 966 return to unction, 685 mechanism o injury, 760
muscles o , 945f Manual muscle test, 86 partial meniscectomy rehabilitation
pathomechanics, 966 Manual therapy techniques, 340. See also progression, 764t
positioning/ pain-relieving Muscle energy techniques phase I, 763
exercises, 949 active release technique, 214–215 phase II, 763–764
rehabilitation progression Graston technique, 215–216, 216f phase III, 765
advanced unctional training, massage, 216–217, 216f pathomechanics, 759–760
969–970 or mobility increment, 210–217 postoperative rehabilitation, 761t
basic unctional training, 969 myo ascial release, 210–212, 213f rehabilitation concerns, 760
core stabilization, 969 positional release therapy, 214, 214f rehabilitation progression
return criteria, 970 strain-counterstrain technique, phase I, 761–762
stage II (reinjury stage) 212–213, 214f phase II, 762
treatment, 968 March racture, 849 phase III, 762
stage I (acute stage) treatment, Massage, 216–217, 216f phase IV, 762–763
967–968 acupressure, 217 techniques or, 745–768
strengthening, 968 connective tissue massage, 217 Meniscal tears, surgical management
stretching, 968 riction massage, 217 o , 760
Low-dye arch taping, 852f ho a massage, 217 Meniscus, 37
Lower-extremity reactive neuromuscular myo ascial release, 217 Metabolic equivalents (ME s), 180, 187
training, 1063t re exive/ mechanical, 217 Metacarpophalangeal (MCP) joints, 662
Lower leg rolf ng, 217 Metatarsal bar, 855f
compartments o , 790 trager, 217 Metatarsal bone, 829
rehabilitation techniques Maximal aerobic capacity, 180f Metatarsal joints, 828–829
isotonic open-kinetic-chain limiting actors o , 181 Micro-cell Pu ethylene vinyl acetate
exercises, 791–793 Maximal heart rate (MHR), 177 (EVA) material, 861
strengthening techniques, 791 Maximum repetition test, 531 Microtraumatic injuries, 31, 1018
Lumbar acet joint sprains McConnell technique, 775f Midsole design, 863
pathomechanics/ injury mechanism, 975 McGill pain questionnaire, 118, 119f Midtarsal joint (M J)
rehabilitation progression, 975–976 McMurray test, 760 ore oot mobility at HR, 833
Lumbar joint objective examination, McQueen technique, 163, 163t position during pronation, 827–828
947t–948t Mechanoreceptors, 225, 244, 246, 375, 541 position during supination, 828
Lumbar lordosis, 144 Medial collateral ligament (MCL), 733, 745 Mini-lunge, to unstable sur ace, 883f
Lumbar multif dicontractions, 951 rehabilitation progression Minimalistic/ Specialty shoe, 863
Lumbar spine phase I, 747 Minisquats, 294–295, 294f
joint manipulation, 964 phase II, 747, 747f Minitramp, 298, 298f
Lumbar stenosis, 1000 phase III, 747–748 Mobility, impaired, 193–218
Lumbo-pelvic-hip complex, 408, 409, sprain in, 745–748 active and passive range o motion,
412, 413 mechanism o injury, 746 196–197
Lunges, 252–253, 294–295, 295f pathomechanics, 745–746 active knee joint exion, 197
assisted technique, 252 rehabilitation concerns, 746 anatomic actors that limit exibility,
orward lunge, 253 Medial (ulnar) collateral ligament 195–196
lateral and medial weight shi t, 253–254 (MUCL), 616 excessive joint motion, 196f
lateral weight shi t, 252 Medial epicondyle ractures extreme exibility, 195f
Lunging with military press, 1082f in elbows, 644–645 exibility importance to patient, 194
1138 Index
Mobility, impaired (Cont’d.) Muscle strains, 46–48, 48f tendinitis/ tendinosis, 48–49
manual therapy techniques or, 210–217 classif cation o , 46–47 tendon, structure o , 47f
stretching criteria or ull return, 810 tenosynovitis
e ects on kinetic chain, 200 injury mechanism, 809 physiology o , 49
e ects on physical and mechanical muscle healing, physiology o , 47–48 Myo ascial pain
properties o muscle, 199–200 pathomechanics, 809 pathomechanics/ injury mechanism,
exercises (See Stretching exercises) rehabilitation concerns, 809 973–974
importance o increasing muscle rehabilitation progression, 810 rehabilitation technique, 974–975
temperature prior to, 201 Muscle stretch re exes (MSRs), 96, 97 Myo ascial release, 210–212, 213f, 217
to improve mobility, 197–198 Muscle–tendon junction, 809 Myo ascial stretching, 974
neurophysiologic basis o , 199 Muscular activation Myo ascial trigger points, 606t
techniques (See Stretching palpating multif di or, 421f criteria or return to activity, 606
techniques) timing patterns, 1054–1056 injury mechanism, 605–606
Mobility dys unction Muscular endurance pathology, 605
joint mobility dys unction, 465 def nition o , 150 rehabilitation concerns, 606
tissue extensibility dys unction, 465 actor levels o , 150–153 rehabilitation progression, 606
Mobilization prone cervical Muscular atigue, 1066 Myof laments
posteroanterior (PA), 921f Muscular orce, 152 actin, 154
Molded hexalite ankle stirrup, 837f Muscular power myosin, 154
Monitored Rehabilitation Systems actor levels o , 150–153 Myosin myof laments, 152
devices, 499 Muscular strains Myositis ossif cans, 54
Morton neuroma criteria or return, 970 pathomechanics and injury
pathomechanics/ injury mechanism, injury mechanism, 970 mechanism, 713
854–855 rehabilitation progression, 970 rehabilitation concerns and
rehabilitation concerns, 855 Muscular strength progression, 713
Morton’s paper, 827 def nition o , 150 MyPlate graphic, 1105f
Morton toe, 849 actor levels o , 150–153
Motor control system, 241 age, 152 N
Motor nerve impulses biomechanical considerations, Nabumatone, or healing process, 57t
requency o , 329 151–152 Nagi model, 4
Movement assessment systems, 468 length–tension relationship, Naproxen, or healing process, 57t
Movements 152, 152f Narcotics, 992
types o , 340 neuromuscular e ciency, 151 Navicular di erential, measurement, 845f
Mulligan joint mobilization technique, number o muscle f bers, 151 Neck
350–368, 367f overtraining, 152 lateral exion, 945
principles o treatment, 367–368 position o tendon attachment, rotation, 915f
Mulligan’s concept, 349 151–152, 151f sidebending, 915f
Multidirectional drills, 257–258 size o muscle, 150–151 Neer impingement test, 588f
Multiple sit-to-stand (MS S) f eld test, 502 ast-twitch vs. slow-twitch f bers, 153 Neer system, 1001
Muscle actions, 944–945 muscles contraction, 154f or humerus ractures, 1002t
Muscle energy techniques, 333–335 ratio in muscle, 153 Negative energy balance, 1101
clinical applications, 333 vs. muscular endurance Nerve f ber, 121
components o , 333 training or, 169 Nerve injuries, 50
positions or, 334f Muscular strengthening, 441 Nerve root compression
treatment techniques, 334–335 Muscular tension, 138 pathomechanics and injury
Muscle f ber Musculoskeletal injuries, 52–54, 54f mechanism, 911–913
type o , 268 acute, 835 rehabilitation concerns and
Muscles bursitis, 52 progression, 913–914
contractions, 950 contusion, 53–54 Nerve tissue
hypertrophy, 155, 531, 1044 dislocations and subluxations, 52 injuries to, 49–52, 50f
imbalances, 417 muscle soreness, 53 nerve cell, structural eatures o , 49f
in primary unctions, 900 Musculoskeletal system neuron regeneration, 50f
reaction time, 1055 skeletal muscle, 998 physiology o , 50–52
receptors strength changes, 998 Neural pathways, 228–229
anatomy o , 227f strength training, 998–999 Neural tension stretches, 202f
soreness, 53 Musculotendinous, 46 Neural tissue, 196
spindles, 199, 226–227 Musculotendinous structures NeuroCom Balance System, 499
role in, 234 injuries to, 44–49 NeuroCom’s Balance Master, 402
sti ness, 1056 muscle, parts o , 45f–46f NeuroCom’s Equi est, 381
tendon, 45 muscle strains, 46–48, 48f Neurologic impulses, 268
types o , 44 muscle healing, physiology o , 47–48 Neuroma, 854
Index 1139
Neuromuscular control, in rehabilitation records, 83–84 One-legged heel raise, 794f
process, 223–258, 230, 518 signs and symptoms, 98t Open kinetic chain (OKC) exercise, 729
Biodex dynamometer, 230f spinal nerve with re ex arc, 97f kinetic chain concept, 288–289
Biodex stability trainer, unstable spurling test, 66f strengthening, 813
sur ace training on, 239f steps or, 67–82 vs. closed-kinetic-chain exercise, 168,
body blade exercises, 575f straight-leg raising test, 93f 287–306, 293f
central nervous system motor control thoracic outlet test, 94f biomechanics o activities in lower
integration, 232–240 thoughts or, 109–110 extremity, 291–293
exercise program/ progression, 246–258 vertebral artery test position, 95f biomechanics o activities in upper
exercises to reestablish, 572–575 yellow and red ags, 73t extremity, 299–305
importantance o , 224 Neuromuscular training program elbow, 301
integration, CNS levels o , 233f schedule, 1062t oot and ankle, 291
joint proprioception, assessment o , Neuromusculoskeletal disorders, 80 knee joint, 291–293
229–230 Neuromusculoskeletal system, 92 link system, 288f
muscle receptors, anatomy o , 227f Neurotransmitters, 123 patello emoral joint, 293
muscle response coordination with Neutral spine position, 953f pushups, pushups with a plus, press-
unexpected loads, 240 Nociceptors, 122 ups, step-ups, 304, 304f, 305f
muscle spindle, excitation o , 234f Nondisplaced ractures, 843 resistive orces, 292f
objectives o , 245–246 Nonmusculoskeletal di erential scapular muscles, rhythmic
proprioception diagnoses, 1034 stabilization or, 303f
and motor control, 230–231 Nonsteroidal antiin ammatory drugs shear and compressive orce vectors,
physiology o , 225–229 (NSAIDs), 33, 55, 56, 934 mathematical model, 292f
reestablishment o , 242–245 course o , 598 shoulder complex joint, 300–301
a erent/ e erent characteristics, inhibiting prostaglandin synthesis, 58 slide board, 305, 305f
244–245 use o , 34, 58, 577, 593 o upper-extremity injuries, 301–305
muscle atigue, 244 Nordic hamstring exercise, 705f weight-shi ting exercises, 302–303,
re ex muscle f ring, EMG assessment Norepinephrine, 124 302f, 303f
o , 230f Normal gait, biomechanics o , 829–831 Orthopedic care, 988
response time, 241–242 Normal menstrual cycling, 1101 Orthopedic injuries, 374
scapular neuromuscular control Numeric pain scale, 118, 120f Orthopedic manual assessment, 530
exercises, 574f Numeric rating scale (NRS), 120f Orthosis
sensory organization, 238f Nutritional in ormation, 1103 materials, 860–861
slide board exercises, 574f types o , 676f
stability ball exercises, 575f O Orthotic intervention, 384
terminology, 224–225 Oblique racture, 42, 42f Orthotic therapy, 851, 861
weight shi ting Older adults philosophy o , 857–859
on ball, 572f age-related normative values, or Oscillating technique or isometric
on biomechanical ankle plat orm unctional per ormance stabilization (O IS), 248
system (BAPS) board, 573f measures, 991t Osgood-Schlatter disease (OSD), 1027
on f tter, 573f case example, 1011–1012 Osteitis pubis, 720
Neuromuscular di erences, 1047–1048 displaced humeral ractures, 1002–1003 Osteoarthritis (OA), 999
Neuromuscular re ex pathways, 242 distal radius Osteoarthrosis, 39
Neuromuscular rehabilitation program, 541 classif cation, 1003–1004 Osteochondral ractures, 843
Neuromuscular scan examination, 63–110 history and examination strategies, 989t Osteochondrosis, 1034
assessment, 85f, 101–103 intervention considerations Osteokinematic motion, 340
basic elements o , 84–101 balance retraining, 1010–1011 Osteopathic mobilization technique, 214
bottom line, 82 endurance training, 1008–1009 Osteoporosis, 1004, 1093
caveats with, 65–66, 101, 107–109 patient/ client-related instruction, risk actors, 1000t
unctional test, 88f 1007–1008 Overload principle, 155
goal, 103–105 strength training, 1009–1010 Over-the-counter nonnarcotic
iliac crest height, observation o , 85f therapeutic exercise, 1008 analgesics, 56
manual muscle test, 86f–88f orthopedic care, 988 Overuse syndromes
muscle stretch re exes, 100t proximal emur, 1004 pathomechanics, 782
objective/ physical examination, 82–101 classif cations o , 1004–1005 rehabilitation progression
“O” sign, 87f treatment, 1005–1006 phase I, 782
overview o , 67 proximal humerus, 1001 phase II, 782–783, 782f
plan, 105–109 classif cation, 1001–1002 phase III, 783
purpose o , 64–67 treatment, 1002 Oxaprosin, or healing process, 57t
questionnaire rehabilitative care, 988 Ox ord technique, 163t
abridged version, 74–82, 75t treatment, 1004 Oxygen demand, 183
preevaluation, 69t–71t Oligomenorrhea, 1098 Oxygen tension, 36
1140 Index
P phase II, 779–780 physiologic considerations, 1035–1036

Pain, 92, 115–132 phase III, 780 psychological considerations, 1036–1037
a erent neurons, classif cation o , 124t Patello emoral dys unction, 1046 Peelen, 854
AM/ PM pattern o , 79–81 Patello emoral injuries Pelvic rock, 962f
assessment o classif cation o , 776 Pelvic tilt, 962f
documentation, 120 techniques or, 776–783 Pelvo-occular re ex, 417
scales, 117–120 Patello emoral joint, 293, 734–737 Perceived exertion, rating, 1009t
cause o , 120 orce dissipation, 736 Perception, 120–123
chart, 118f in uence o proximal and distal joint cognitive in uences, 122–123
def nition o , 116 position on, 737 sensory receptors, 121, 121t
interneuron unctions, 130f patella, unctions o , 734 Periaqueductal gray (PAG), 128
management, 130–132 patellar stability Peripheral cartilage, 40
goals in, 120 dynamic stabilization, 736 Peripheral deep vein thrombosis
nature o , 81 static stabilization, 736 age-, inactivity-, and disease-related
neural a erent transmission, 123f patello emoral contact areas, changes, 995t
neural transmission, 123–126 734–735, 735f Peripheral pain receptor, 124
acilitators and synaptic quadriceps angle, 737, 737f Peripheral receptors, 312
transmission inhibitors, 123–124 reaction orce and joint stress, 735 Peripheral stretch receptors, 312
nociception, 124–126 unctional implications, 736 Peroneal tendons, subluxation/
neurophysiologic explanations o OKC joint reaction orce, 735 dislocation o , 841
control, 127–130 OKC joint stress, 735 injury mechanism, 841
descending pain control, 128, 129f Patello emoral pathology pathomechanics, 841
β−endorphin and dynorphin in pain patella, mobilization, 771f rehabilitation concerns/ progression,
control, 128–130, 131f progression or, 769–776, 769t 841–842
gate control theory, 127–128, 127f bracing and taping, 774–776, Peroneus tertius, 824
pain control mechanisms, summary 774f, 775f Persistent ankle, 1033
o , 130 CKC exercises, 772f Physically active emale, 1042
numeric rating scale (NRS), 120f distal actors, 772–773 anterior cruciate ligament (ACL)
perception, 120–123 exibility exercises, 770–771 injury, 1043
cognitive in uences, 122–123 OKC and CKC strengthening, assessment and screening, 1058–1059
sensory receptors, 121, 121t 771–772 exercise considerations, 1062–1067
point o , 91 phase I, 770 emale athlete, core stabilization,
synaptic transmission, 125f phase II, 770–773 1069–1072
types o phase III, 773–776 gender di erences
acute vs. chronic, 116 proprioception and cardiovascular anatomical di erences, 1045
deep somatic, 117 conditioning, 773 neuromuscular di erences,
radiating, 116 proximal actors, 773, 773f 1047–1048
re erred, 116 vastus medialis obliquus, role o , 772 patello emoral dys unction, 1046
visual analog scales, 117f Pathologic re exes, 100 physiologic strength di erences,
Pain charts, 117, 118f Patient/ client management model, 4, 7f 1043–1045
Pain control mechanisms Patient/ client-related instruction, 1007 injury mechanisms to core, 1071–1072
summary, 130 Patient-directed static progressive kinetic chain relationships, 1070t
Pain control strategies, 130 stretching program, 646 National Collegiate Athletic
Pain- ree unctional movement, 484 Patient management models, 5 Association (NCAA), 1043
Pain- ree hopping, 840 Patients prevention/ exercise considerations,
Palpation, 90, 91 def nition o , 5 1059–1062
Panner disease, 1035 sel -management strategies or, 19 rehabilitation and treating, 1072
Parkinson disease, 1011, 1012 Pectoralis minor stretch, 933f rehabilitation/ return, 1077–1081
Partial sit-up exercises, 960f Pediatric patient rehabilitation/ return to swimming,
Passive Ober’s stretch, 718f epiphyseal ractures, 1019 1086–1090
Passive range o motion (PROM), 587 lower extremity proprioception and unctional
Patellar compression syndromes anterosuperior iliac spine, 1020–1026 training, 1089–1090
pathomechanics, 776 macrotraumatic musculoskeletal range o motion, 1087
rehabilitation progression injuries, 1018 strength and endurance
phase I, 776 avulsion ractures, 1020 training, 1087
phase II, 777 epiphyseal ractures, 1018–1020 sequelae rom, 1067–1069
Patellar instability, 1046 microtraumatic injuries shoulder injuries, in emale swimmers,
mechanism o injury, 777–778 apophysitis, 1026–1033 1081–1086
pathomechanics, 777 musculoskeletal considerations, shoulder injuries, windmill so tball
rehabilitation progression 1033–1035 player, 1075–1077
phase I, 778–779 musculoskeletal tissue, growing, 1018 shoulder laxity, 1073–1075
Index 1141
Physical therapists, 466 three-component model, 267f balance training, 387–400
and evaluation, 6 upper-extremity plyometric drills, 276t balance exercises, classif cation
intervention, 6 Plyometric prerequisites, 270–273 o , 388
medical diagnosis, 102 biomechanical examination, 270–271 phase I, 388–390
or pain control strategies, 130–132 dynamic movement testing, 272–273 phase II, 390–398
in primary care, 6 exibility, 273 phase III, 398–400
role in, 2, 498 stability testing, 271–272 biodex stability system, 383f
Physical therapy, 6, 20, 101 Plyometric programs cognitive task with sport-specif c
ine ectiveness o , 624 design, 273–277 balance, 401f
limitations, 102 direction o body movement, 273 controlling dynamic balance against
system, 10 external load, 274 cable/ tubing resistance, 400f
Physioball, with serratus punch, 1080f requency, 274 control o balance, 374
Physiologic reserve capacity, 989–990 intensity, 274 double-leg and single-leg (multiplane)
Physiologic strength di erences, recovery, 275–277 dynamic balance activities on
1043–1045 speed o execution, 274 unstable sur ace, 395f
Pilates method, 206–209 training age, 274–275 double-leg balance on unstable
Piri ormis muscle strain volume, 274 sur ace, 389f–390f
pathomechanics, 971 weight o patient, 273 double-leg dynamic activities on stable
rehabilitation progression, 971 guidelines or, 278 sur ace, 392f
Piri ormis stretch, 711f Plyometrics, 166, 266 double/ single-leg balance on stable
using elbow pressure, 972f Plyometric training sur ace, 388f
Piroxicam, or healing process, 57t goal o , 267 dual-task balance training and
Plantar aponeurosis, 850 Polypharmacy, 992–993 assessment, 400–402
Plantar ascia stretches, 877f Pool running dynamic equilibrium, 373f
Plantar asciitis/ asciosis with otation device, 799f, 884f equitest, 381f
injury mechanism, 851 Positional release therapy, 214, 214f high-technology balance assessment
pathomechanics, 850–851 Posterior–anterior pressure, 977 systems, 380t
rehabilitation concerns, 851–853 Posterior cruciate ligament (PCL), 733 high-tech training and assessment,
Plantar exion, 837 sprain in, 754–759 clinical value o , 402–404
Plantar exion exercise, 868f mechanism o injury, 755 injury and balance, 384–386
Plastazote, 860 pathomechanics, 754–755 ankle injuries, 384–385
Plastazote underneath, 860 reconstruction, postoperative head injury, 386
Platelet-rich plasma (PRP), 634–635 rehabilitation, 756t–757t knee injuries, 385–386
Platelets, 33 rehabilitation concerns, 755–756 jumping and hopping to stabilization,
Plyoball deceleration, 1080, 1082f rehabilitation progression 398f–399f
Plyometric drills, 279 phase I, 756–758 patient training on balance master, 381f
Plyometric exercises, 167f, 638 phase II, 758 postural control system, 372–373
biomechanical and physiologic phase III, 758 PROPRIO® reactive balance
principles, 267–270 phase IV, 758–759, 759f system, 383f
mechanical characteristics o , phase V, 759 single-leg balance on unstable
267–268 treatment o , 755 sur ace, 391f
neuromuscular coordination, 270 Posterior innominate rotation, 981f single-leg balance-resisted
neurophysiologic mechanisms, Posterior longitudinal ligament, 944 (multiplane) activities on stable
268–269 Posterior pelvic tilt exercises, 960f sur ace, 394f
Chu’s plyometric categories, 274t Postural assessment, 136 single-leg dynamic activities on stable
orms o , 267 Postural control system, 385 sur ace, 393f
integrating plyometrics into Postural equilibrium, maintenance o somatosensation as, 374–376
rehabilitation program, 279–283 balance, assessment o , 378–384 sport-specif c cognitive tasks, 402f
medial-lateral loading, 279–280, 279f objective assessment, 380–384 stepping movements to stabilization,
rotational loading, 280 subjective assessment, 378–380 396f–397f
shock absorption (deceleration balance disruption, 376–378 step-up-and-over test, 403f
loading), 280–283 movement strategies, selection o , Postural stability, 137
lower-extremity plyometric drills, 277t 376–378 Postural sway, 236, 237
plyometric programs balance error scoring system (BESS), Preclinical disability, 990–991
design, 273–277 stance positions or, 379f, 380t Pregnancy
guidelines or, 273 balance master with 5- oot orceplate exercise benef ts, 1106t
program development, 270–273 accessory, 382f in physically active emale, 1105–1107
plyometric prerequisites, 270–273 balance movements Prevent Injury and Enhance Per ormance
in rehabilitation, 166–167, 266–284 unction and anatomy o Program, 1062
seated chest pass test, 272t muscles, 377t Primary care concept
situp-and-throw test, 273t balance to closed kinetic chain, 376 physical therapists in, 6
1142 Index
Problems rhythmic stabilization, 315–316 Quadriceps/ hamstrings, coactivation

HOAC II def nitions o , 11t slow reversal, 315 o , 1047
neuromusculoskeletal assessment, 10 slow-reversal-hold, 315 Quadriceps muscle, 736
solving, 12–14 slow reversal-hold-relax, 204 Quadriceps strain, 706–707
Problem-solving model, 12 strengthening exercises, 839 Quadriceps strengthening exercises,
Progressive resistive exercise, 159 strengthening techniques, 571–572 763, 777
program, 165 rhythmic contraction, 571f Quadriceps stretching, 1029f
techniques, 158–164, 162 or scapula, 571f Quadriceps weakness, 1029
Progressive velocity exibility program, 203 stretching or improving range o Questioning process, 72
Prone hip extension exercise, 971f motion, 329–333
Prone-lying hip internal rotation stretching technique, 333f R
with elastic resistance, 965f stretch re ex, diagrammatic Radial distraction mobilization, 647f
Prone single-leg hip extension, 958f representation o , 330f Radial head and neck ractures
Prone swimming exercise on ball, 1084f therapeutic techniques, 312 in elbows, 645
Proprioception, 136, 518 treating specif c problems with, 316 Radiating pain, 116
def nition o , 225 upper-trunk movement patterns, Range-o -motion (ROM), 21, 85–86, 372,
Golgi tendon organ (G O), 227–228 325f–326f, 325t 469, 498, 499, 519, 618, 660, 838
methods to improve, 243 Proprioceptive stretch re ex, 268 active, 23
muscle spindle, 226–227 Proprioceptors, 122, 469 active-assisted, 23
neural pathways, 228–229 PROPRIO reactive balance system, 383 algorithm, 23f
physiology o , 225–229 Prosthetic replacements, cemented def cits, 802
Proprioceptive mechanoreceptors, f xation o , 1005 exercises, 600
242, 533 Protection, Restricted activity, Ice, passive, 23
Proprioceptive neuromuscular Compression, and Elevation resistance exercises, 158
acilitation (PNF) techniques, (PRICE) technique, 54 standard measures o , 506
201, 311–335, 532 principles o , 21 Reactive neuromuscular training (RN ),
basic strengthening techniques, Proteoglycans, 34, 765 224, 245–246, 514, 537, 540, 542
314–316 Provocation tests objectives o , 245
contract-relax, 204 use o , 622 phases o , 248
D1 lower-extremity movement Provocative tests, 92, 93, 94 Reciprocal inhibition, 330
patterns, 322t, 323f Proximal hip musculature activation, 1047 Reconditioning
D2 lower-extremity movement Proximal humerus ractures principle, 155
patterns, 322t, 324f exercise guidelines, 1003t Recumbant bicycle, 885f
D1 upper-extremity movement Proximal interphalangeal (PIP) joint, 663 Reestablish neuromuscular control,
patterns, 319t, 320f Proximal radioulnar joint 797–798
D2 upper-extremity movement dorsal and ventral glides o , 647f Re erred pain, 116
patterns, 319t, 321f Pseudohernia, 143, 143f Re exive/ mechanical massage, 217
hold-relax, 204 Pulmonary diseases, 995 Re exive mechanisms, 137
or improving strength and enhancing Pulmonary system Re ex sympathetic dystrophy, 1004
neuromuscular control, 312–313 age-, inactivity-, and disease-related Rehabilitation, 20–26
acilitation and inhibition changes, 994–995 acute phase, 20–22, 21f
concepts, 312 Pumping mechanism, 176 interventions application to provide
rationale or use, 312–313 Push MetaGrip, 678f early motion, 22
lower trunk movement patterns, Pushups, 688f pain and in ammation, control o ,
326t, 327f with a plus, press-ups, step-ups, 304, 20–21, 21f
muscle energy techniques, 333–335 304f, 305f promote and progress tissue
clinical applications, 333 healing, 22
treatment techniques, 334–335 Q advanced phase, 23–25, 24f
muscle energy techniques, positions Q-angle intermediate phase, 22–23, 23f
or, 334f gender di erences, 1051f return to unction phase, 25–26, 25f
neck extension and rotation, 328f measurements, alignment Rehabilitation programs, 282, 340
neck exion and rotation, 328f observation, 1046 Rehabilitation protocols, 30
patterns, 317–328, 916f Quadratus lumborum strain Rehabilitation strengthening
component movements, 317 pathomechanics, 971–972 protocols, 288
o lower extremity, 318f rehabilitation progression, 972–973 Rehabilitative care, 988
o upper extremity, 317f Quadriceps contusion, 710–713 Rehabilitative ultrasound imaging
principles o , 313–316 injury mechanism, 711 (RUSI), 418
reciprocal inhibition, diagrammatic pathomechanics, 710–711 Remodeling process, 44
representation o , 331f rehabilitation concerns and Resistance training programs, 151, 154, 162
repeated contraction, 315 progression, 711–713 in adolescent, 170
rhythmic initiation technique, 315 Quadriceps orce, 734 circuit training, 163
Index 1143
di erences in males and emales, Rhythmic initiation technique, 315, 316 Scapulohumeral rhythm, 550
169–170 Rhythmic stabilization, 315–316 Schwann cells, 50, 51, 52
pyramids, 163 Rib stress racture Sclerotomic pain, 117
specif c resistive exercises used in management o , 927 Scoliosis, 84
rehabilitation, 170 pathomechanics and injury pathomechanics and injury
split routine, 163 mechanism, 926–927 mechanism, 932–933
stages o , 169 rehabilitation concerns and rehabilitation concerns and
supersets, 163 progression, 927–929 progression, 933
Resistance training techniques Rolf ng, 217 Seated heel cord stretch, 876f
bench press exercise machine, 160f Rolling Secondary compressive disease, 597
Berger adjustment technique, 164t diagonals, 928f Secondary hyperalgesia, 124
calisthenic strengthening exercises, Romberg tests, 389 Second metatarsal stress ractures, 849
167, 167f Rotational loading Segmental spinal stabilization, 949, 954
concentric vs. eccentric contractions, 159 dynamic distance drills, 280 Selective unctional movement
DAPRE adjusted working weight, 164t in-place activities, 280 assessment, 476–485
DeLorme program, 163t Rotation partial sit-up, 961f basic movements in
exercise training variables, 156t Rotator cu cervical spine assessment, 478, 479f
ree weights vs. exercise machines, muscles tendons o , 551 movement patterns o , 478t
159–161 tendinitis and tears multisegmental extension assessment,
unctional strengthening exercises, 157f criteria or return to activity, 600 481, 481f
unctional strength training, 155–156 injury mechanism, 596–597 multisegmental exion assessment,
isokinetic device, 165f pathomechanics, 596 480, 480f
isokinetic exercise, 164–166 rehabilitation concerns, 597–600 multisegmental rotation assessment,
as conditioning tool, 165–166 Rotator tendinopathy, 550 481–482, 481f
in rehabilitation, 166 Running shoe types optional movements o , 483
isometric exercise, 157–158, 158f classif cation and characteristics, 864t overhead deep squat assessment,
isotonic equipment, 160f ront ore oot, 865f 482–483, 482f
Knight’s DAPRE program, 164t overhead deep squat pattern breakout,
McQueen technique, 163t S 484, 485f
overload principle, 155 Sacroiliac joint dys unction results o , 484
Ox ord technique, 163t pathomechanics/ injury mechanism, scoring system or, 479t
plyometric exercises, 167f 979–980 single-leg stance (standing knee li t)
in rehabilitation, 166–167 rehabilitation concerns, 980 assessment, 482, 482f
progressive resistive exercise rehabilitation progression, 980–983 spinal rotation in sitting, 478f
techniques, 158–164, 162 treatment protocol, 982 total-body rotation test, 477f
recommended techniques, 162–163 Sacroiliac joint objective examination, upper extremity movement pattern
Sanders program, 163t 947t–948t assessments, 480, 480f
strengthening exercises, 161f Sacroiliac ligament sprain, 946 Selective Functional Movement
surgical tubing or thera-band, 161 Sacroiliac stretch, positions, 981f Assessment (SFMA), 466, 476
used in rehabilitation, 163–164 Salter-Harris classif cation system, standing rotation test, 477, 477f
variable resistance, 161–162 647, 648f Sel -management strategies
Resisted kicks, 881f growth plate ractures, 1018, 1019f or patients, 19
Resistive exercises type I ractures, 1018 Sel piri ormis stretch, 972f
application o , 625 type II ractures, 1019 Semidynamic balance exercises, 390
progression o , 24 type III ractures, 1019 Semi exible ull-length custom
Resistive orces, 292f, 438–439 type IV ractures, 1019 orthosis, 851f
bow orce, 438, 438f Sanders program, 163, 163t Semi exible three-quarter–length custom
cohesive orce, 438 Scan examination model orthosis, 858f
drag orce, 438–439, 438f basic elements o , 67 Sensory mechanoreceptors, 228
quantif cation o , 439 Scaphoid ractures, 667–669 Sensory modality unction, 386
Respiratory system, 1106 injury mechanism, 667 Sensory receptors
Rest, ice, compression, elevation pathomechanics, 667 types o , 121
(RICE), 808 rehabilitation concerns, 668 Sensory stimulation concept, 128
Retrocalcaneal bursitis rehabilitation progression, 668–669 Sensory systems
ull return criteria, 818 Scapula age-, inactivity-, and disease-related
injury mechanism, 817 plane o , 553 changes, 996
pathomechanics, 817 Scapular muscles, 553 Sensory testing, 90
rehabilitation concerns, 817 rhythmic stabilization or, 303f Serial distortion patterns, 415
rehabilitation progression, 817–818 Scapular proprioceptive neuromuscular Series elastic component (SEC), 267, 268
Return-to-windmill pitching acilitation (PNF) pattern, 914f Sever disease. See Calcaneal apophysitis
sample unctional exercises, 1078t Scapular stabilization, 448 Sex hormones, 1099
1144 Index
Sexual/ physical abuse, 1096 scapulothoracic joint, 550 Somatic dys unction, 80
Shear orce vectors shoulder adductors stretch, 556f def nition o , 80
compressive orce vectors, shoulder complex, skeletal anatomy Somatosensory diseases, 996
mathematical model, 292f o , 548f Somatosensory system, 389
Shock absorption (deceleration loading), shoulder extensor stretch, 556f Specif c adaptations to imposed demands
280–283, 829 shoulder external rotators stretch, 557f (SAID), 514
depth jumping preparation, 280 shoulder exors stretch standing, 556f principle, 224, 498
in-place activities, 280 shoulder joint, stability in, 551–554 Specif c gravity, 437–438
specif c plyometric exercises, 280–283, shoulder medial rotators stretch, 557f Spinal cord, 123, 945–946
281f–283f static hanging, 554f central nervous system, 945
Shoe last construction, 862f sternoclavicular joint, 548–549 Spinal disorders, 1001
Shoe selection, 855, 862–864 sternoclavicular joint sprains, 576–578 Spinal extension, screening (clearing) test
Shoe wear evaluation, 865 strengthening techniques, 559–570 or, 475f
Short oot concept, 801f stretching exercises, 554–559 Spinal exion, screening test or, 476f
Short-leg walking cast, 841 techniques or, 554–575 Spinal joint manipulation, 962–966
Shoulder thoracic outlet syndrome, 602–603 Spinal mobilization, 962
external rotation, 913f, 915f wall climbing, 555f Spinal muscles, 410f
Shoulder clearing test, 473, 473f wall/ corner stretch, 555f Spinal nerve
Shoulder complex Shoulder joint, stability in with re ex arc, 97f
arthroscopic anterior capsulolabral dynamic stability to, 552–553 Spinal segment control exercise
repair o , 594–595 plane o scapula, 553–554 extension exercises, 956–959
girdle complex, 548 scapular stability and mobility, 553 exion exercises, 959
joint complex, 300–301, 554 static stabilizers, 551–553 joint mobilizations, 959–962
anatomy o , 548 Shoulder mobility, 472–473, 473f lateral shi t corrections, 954–956
Shoulder impingement Shuttle exercise machine, 871f muscle contractions, 950
management o , 592 Side-lying hip abduction straight-leg segmental spinal stabilization, 949
stages o , 588–590 raises, 971f spinal joint manipulation, 962–966
Shoulder injuries, rehabilitation o Side-lying hip adduction, 702f transversus abdominis behavior
acromioclavicular joint, 549 Side-lying stretch over pillow roll, 973f exercise plan, 950–954
acromioclavicular joint sprains, Single-leg hopping., 754 Spinal segment stability, 945
578–581 Single-leg hop test, 534 Spinal vertebrae progress, 944
adhesive capsulitis ( rozen shoulder), Single-leg press, 487f Spiral racture, 42, 42f
600–601 Single-leg standing rubber-tubing Spondylolisthesis, 1032, 1071. See also
anterior capsule stretch, 558f kicks, 798f Hypermobility syndromes
biomechanics, 548–554 Single-leg windmills, 705f treatment o , 1033
brachial plexus injuries (stinger or Single-limb stance, 880f Spondylolysis, 1071
burner), 603–605 tubing kicks, 881f Spondylosis, 910–911
clavicle ractures, 581–582 Situp-and-throw test, 272 pathomechanics and injury
Codman’s circumduction exercise, 554f Skeletal muscles, 44 mechanism, 910
coracoacromial ligament, 549 characteristics, 45 rehabilitation concerns and
coronal plane orce couples, 553f contraction progression, 910–911
exercises to reestablish neuromuscular types o , 150 Sport-specif c training, 449f
control, 572–575 portions o , 44 Sprains, 835
unctional anatomy, 548–554 Skilled gol er approaches, 82 severity o , 835
glenohumeral dislocations/ Skin, 196 Spurling test, 65, 95
instabilities, 582–586 Slide boards, 305, 305f, 702f Squat, 251–252
glenohumeral joint, 549–550 exercises, 871f anterior weight shi t, 252
glenohumeral joint, multidirectional and f tter, 298–299, 299f assisted technique, 251–252
instabilities, 586–596 Slipped capital emoral epiphysis (SCFE), lateral weight shi t, 252
horizontal adductors stretch, 558f 77, 1033 medial weight shi t, 252
in erior capsule stretch, 559f Slow-oxidative f bers, 153 posterior weight shi t, 252
isokinetic exercises, 570 Slump sit stretch position, 961f Stability exercises, 523
myo ascial trigger points, 605–606 Smith racture, 1004 Stability motor control dys unction, 465
proprioceptive neuromuscular Sneezing, 977 Stabilizers, 420
acilitation strengthening So t-tissue lesions core, 417
techniques, 571–572 pathomechanics, 780–781 pressure bio eedback, 952, 952f
rope and pulley exercise, 555f rehabilitation progression pressure eedback unit, 418f
rotator cu tendinitis and tears, 596–600 phase I, 781–782 Stair-climbing machines, 296
rotator cu tendons blend, 551f phase II, 782 Stair-stepping machine, 795f
sawing, 555f So t-tissue mobilization technique, 215f Standing ankle dorsi exor stretch, 796f
scapular motions, 550f So t-tissue techniques, 528 Standing extension, 957f
Index 1145
Standing gastrocnemius stretch, 796f pushups with clap, 569f rear oot/ ore oot alignment, e ects o ,
Standing heel cord stretch, 875f reverse ys, 563f 825–827
Standing hip hike, 965f rhomboids exercise, 566f supination o , 831
Standing pelvic rock, 963f scaption, 565f toe-o ( O), 832
Standing posture, 140 scapular strengthening, 566f Subtalar joint motion analysis,
Standing single-leg seated pushup, 567f 833, 833f, 834f
balance activities, 878f seated single-arm weightedball Subtrochanteric ractures, 1005
balance board activity, 797f throw, 569f Sulindac, or healing process, 57t
Static exibility, 196 shoulder abduction, 563f Sumo squats, 702f
Static progressive orthosis, 666f, 667f shoulder extension, 562f Supination exercises, 687f
Static single-leg standing balance shoulder exion, 562f Supine hip
progression, 797f, 878f shoulder lateral rotation, 564f abduction/ adduction, 454f
Static stability testing, 271 shoulder medial rotation, 564f extension, 957f
Stationary bicycle, 297–298, 298f shoulder shrugs, 565f li t-bridge-rock, 962f
Stationary cycle, 795f shuttle 2000-1, 569f Supine I B stretch, 711f
Stenosing tenosynovitis superman, 565f Supine sel -stretch—legs crossed, 973f
Patel and Bassini’s stages o , 675t Strength-to-bodyweight ratio, 169 Supine shoulder extension, 449f
Stenosis, 910–911 Strength-training programs, 150, 271s Supplemental exercise program, 22
pathomechanics and injury Strength-training techniques, 155, 156 Supracondylar ractures
mechanism, 910 Stress in elbows, 643–644
rehabilitation concerns and ractures, 804, 805, 926 Surgical tubing, 161
progression, 910–911 reducing, 970 SwimEx pool, 444f
Step-down test, 487f relaxation, 332 Swimmer’s shoulder
Stepping machine, 296f Stretching exercises, 205, 554–559, guidelines or progression o treatment,
Stepping strategy, 237 795–796, 971, 972 1088t–1089t
Step-ups, 296, 297f examples o , 206f signs and symptoms, 1086t
Sternoclavicular joint sprains, 576–578 Stretching techniques, 201–205, 333f strengthening program, 1088t
criteria or returning to ull activity, 578 agonist versus antagonist muscles, Synaptic transmission
injury mechanism, 576 201–203 in pain, 125f
pathomechanics, 576 alternative techniques, 206–210 Synergistic dominance, 200
rehabilitation concerns, 576–577 comparing stretching techniques, Synergistic muscle groups, 202
rehabilitation progression, 577–578 204–205 Synovial chondromatosis (SCM)
Sternocleidomastoid (SCM), 144, 145 dynamic stretching, 203 stretch, 920f
Sti -legged deadli t, 705f pilates oor exercises, 209f Systolic pressure, 179
Stinger syndrome, 603 pilates method, 208f
Straight-leg kicks, 705f proprioceptive neuromuscular T
Strain-counterstrain technique, acilitation stretching alocrural joint, 824
212–213, 214f techniques, 204 ligaments o , 824, 824f
Streamlined movement, 439f sound stretching program, guidelines muscles, 824–825
Strength development physiology and precautions or, 208t arsal tunnel syndrome
muscle hypertrophy, 153–155 static stretching, 203–204, 207f pathomechanics and injury
reversibility, 154 stretching neural structures, 205 mechanism, 856
physiologic adaptations to resistance yoga, 209–210, 211f rehabilitation concerns, 856
exercise, 155 Stretch re ex, 269, 329 arsometatarsal joint, 828
Strengthening exercises, 161f diagrammatic representation o , 330f eardrop pad, 855f
Strengthening techniques Stretch-shortening cycles, 254, 266 endinitis, 48–49
alternative supraspinatus exercise, 565f components, 267 endinopathy
bent-over rows, 566f Stroke volume, 177 pathomechanics/ injury
cable or tubing, 568f Structural di erences mechanism, 842
chest press, 559–570, 560f men and women, 1051f rehabilitation concerns/ progression,
decline bench press, 561f Subjective, objective, assessment, and 842–843
ys, 563f plan (SOAP), 67, 103 endinosis, 48–49
incline bench press, 561f Subluxations, 52 endon, 999
isokinetic upper-extremity closedchain Substantia gelatinosa, 124 gliding exercises, 686f
device, 567f Subtalar joint (S J), 825 structure o , 47f
lat pull-downs, 562f compensated subtalar (calcaneal) enosynovitis, 49
military press, 561f varus, 826f physiology o , 49
plyoback, 568f heel rise (HR), 832 erminal knee extensions
push into wall, 570f heel strike (HS), 832 using surgical tubing, 297, 297f
pushups, 567f neutral position, 837 estosterone, 169
pushups with a plus, 566f talus, palpation o , 848f T alamus, 228
1146 Index
T era-Band, 927f T oracolumbar ascia otal joint arthroplasty

kicks, 397 role o , 413 hip, knee, and shoulder
movements, 1072 T romboplastin, 33 arthroplasty, 1006
T erapeutic exercise T umb Western Ontario and McMaster
acute injury phase, 54–55 AROM exercises, 689f Universities Arthritis Index
design process, 517 rehabilitation o (WOMAC), 1007
principles or, 517 boutonnière de ormity, otal peripheral resistance ( PR), 179
to healing process, 54–56 682–684 owel-gathering exercise, 793f
presurgical exercise phase, 54 boxer’s racture, 672–673 rager, 217
remodeling phase, 55–56 carpal tunnel syndrome, raining errors, 81
repair phase, 55 670–672 raining techniques
use o , 917 carpometacarpal joint, osteoarthritis principles o , 183
T erapeutic interventions, 1–27 o , 676–678 ranscutaneous electrical nerve
algorithms, 14–18 De Quervain’s tenosynovitis, stimulators ( ENS), 128
construction o , 19–20 673–675 ranslation, 341
clinical decision making, 12–14 distal radioulnar joint injuries, ransverse ractures, 42, 42f
clinical reasoning, 9–12 669–670 ransversus abdominis ( A), 409
decision making, 9–12 distal radius ractures, 664–667 behavior exercise plan, 950–954
disablement model, 3–4 unctional anatomy and contraction, 950, 951
evidence-based practice use, 12–14 biomechanics, 664 role in maintaining trunk
expert vs. novice decision making, 12 protocols, 684–690 stability, 414
unctional movement-based scaphoid ractures, 667–669 testing or, 419
thinking, 26 ulnar collateral ligament (UCL) ransversus abdominis test, 946f
T e Guide to Physical T erapist sprain, 678–679 prone, 419f
Practice, 2–3 ibial/ f bular stress ractures, supine, 420f
overview o , 5–9 rehabilitation techniques rapezius orce couples, 625
patient management models, 5 ull return, criteria, 807 rauma, 43
problem solving, 12–14 ull return criteria, 804 raumatic lower-leg racture, 802
rehabilitation, 4-phase approach to, injury mechanism, 802, 805 raumatic neck pain (whiplash)
20–26 pathomechanics, 802, 804–805 pathomechanics and injury
T erapeutic techniques, 312 rehabilitation concerns, 802–803, mechanism, 918
T erapist monitors, 212 805–806 rehabilitation concerns and
T oracic kyphosis, 139 rehabilitation progression, 804, progression, 919
T oracic outlet syndrome 806–807 reatment plane, 343
criteria or return to activity, 603 ibial ractures, 802 riangular f brocartilage complex
injury mechanism, 602 ibial tubercle apophysitis. See Osgood- ( FCC), 660
pathomechanics, 602 Schlatter disease (OSD) ricyclic drugs
rehabilitation concerns, 602 ibial varum/ bow-leg de ormity, 846 serotonin depletion inhibit, 122
rehabilitation progression, 603 ibio emoral joint riggered reactions, 240
T oracic spine abduction/ adduction, 731 rigger f nger, 675–676
cases o , 936–937 exion/ extension, 730–731 injury mechanism, 675
costochondritis, 924–926 rotation, 731, 731f pathomechanics, 675
costovertebral arthralgia or joint tibio emoral articulation, menisci- rehabilitation concerns, 675–676
sprain, 924 emoral condyles, 728 rehabilitation progression, 676
unctional anatomy and biomechanics, kinematic motion o , rigger point ( P), 116
898–905, 898f–899f 730–731 def nition o , 605
importance and purpose o , 905–907 ietze’s syndrome pathomechanics/ injury mechanism,
intercostal muscle strain, 923 pathomechanics and injury 973–974
intervertebral disc pathology, mechanism, 924–925 principal mechanism, 606
929–932 rehabilitation concerns and rehabilitation technique, 974–975
musculature, 906f–907f progression, 925–926 treatment progression or, 606
pathoanatomical cause o , 908 issue extensibility dys unction, 484 rochlear groove, 79
range o motion, 903t oe extension runk
assessment with goniometer, 905f active range, 793f anatomic cylinder o , 1069f
assessment with inclinometer, 904f oe exion, 870f extension—prone, 958f
rehabilitation considerations or, 908 active range, 793f inclination exercise, 953f
rib stress racture, 926–929 olmetin, or healing process, 57t rotation with biceps curl, 1079f
scoliosis, 932–933 onic receptors, 122 stability, 414
thoracic side-lying rotation sel - “ op-tier” tests, 478 stability pushup, 474, 474f, 474t
mobilization, 932f otal body weight ( BW), 437 uck jump assessment, 489f
ietze’s syndrome, 924–926 otal Gym, single-leg press, 882f urbulent ow, 439f
Index 1147
ur toe medial weight shi t, 249 Weightbearing orces, center, 830f
hyperextension injury, 856 posterior weight shi t, 249 Weight cu , 867f, 868f
pathomechanics/ injury mechanism, 856 Upper-body ergometer, 799f, 884f Weight-shi ting exercises, 302–303, 302f,
rehabilitation concerns, 856 Upper extremity epiphyses 303f, 964f
taping, 856f location o , 1024f, 1025f Western Ontario and McMaster
wo-legged heel raise, 794f Upper limb tension test (UL ), Universities Arthritis Index
921f, 934 (WOMAC), 1007
U Upper-quarter scan examination, 88 Wol law, 35
Ulnar collateral ligament (UCL) injury, Wrist
637–639 V extension encourages exercise, 686f
pathomechanics and mechanism o Valgus extension overload injuries, unctional movement o , 660
injury, 637 636–637 orthosis, 666f
postoperative rehabilitation ollowing pathomechanics, 636–637 rehabilitation o
reconstruction, 650–652 Valgus extension overpressure test, 621 boutonnière de ormity, 682–684
reconstruction, 639 Valgus stress, 636, 637 boxer’s racture, 672–673
rehabilitation concerns, 640 tests, 621 carpal tunnel syndrome, 670–672
rehabilitation progression, 640–641 Variable resistance, 161–162 carpometacarpal joint, osteoarthritis
surgical technique or, 639–643 Various top cover materials, 861 o , 676–678
rehabilitation concerns, 637 Varus stress test, 621 De Quervain’s tenosynovitis,
rehabilitation progression, 637–639 Vasoconstriction, 31 673–675
sprain in, 678–679 Vastus medialis obliquus (VMO), 772 distal radioulnar joint injuries,
injury mechanism, 679 Ventroposterolateral area, 228 669–670
pathomechanics, 678–679 Vibram f ve f nger, 863f distal radius ractures, 664–667
rehabilitation concerns, 679 Vigorous pain- ree heel cord, 838 unctional anatomy and
rehabilitation progression, 679 Visual analog scales, 117, 117f biomechanics, 660–662
Ulnohumeral distraction Vital sign monitoring protocols, 684–690
use o , 631 exercise training, risk classif cation scaphoid ractures, 667–669
Ulnohumeral joint or, 994t ulnar collateral ligament (UCL)
lateral and medial glides o , 646f sprain, 678–679
posterior glide o , 646f W wrap orthosis, 670f
Uncompensated ore oot varus, 827f Wall push-up plus, 1083f
Uncompensated subtalar, 826f Wall slides, 294–295, 294f Y
Unilateral stable base exercise, 1064f Wall stretch hamstring stretching, 1030f Yoga, 209–210
Uniplanar exercise, 248–249 Water exercise, Karvonen ormula or, 442f
anterior weight shi t, 248 Water sa ety, 446 Z
lateral weight shi t, 248–249 Wedge board, 878f Zygapophyseal joints, 1001

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Musculoskeletal

Barbara J. Ho o g e nbo o m, EdD, PT, SCS, ATC

Michae l L. Vo ig ht, DHSc, PT, OCS, SCS, ATC, CSCS, FAPTA

William E. Pre ntice , PhD, PT, ATC, FNATA

New York Chicago San Francisco Athens London Madrid

eBook conversion by codeMantra

Contributors vii 9 Impaired Neuromuscular Control: Reactive

PAR 1 Foundations of the PAR 3 T e ools of Rehabilitation

5 Impaired Posture and Function 135 15 Establishing Core Stability in

7 Impaired Endurance: Maintaining Aerobic 18 Functional Exercise Progression and Functional

8 Impaired Mobility: Restoring Range of Motion 19 Functional Training and Advanced

PAR 4 Intervention Strategies 27 Cervical and Thoracic Spine 897

20 Rehabilitation of Shoulder Injuries 547 28 Rehabilitation of Injuries to the Lumbar

21 Rehabilitation of the Elbow 613

25 Rehabilitation of Lower-Leg Injuries 789 Index 1127

26 Rehabilitation of the Ankle and Foot 823

David Carfagno, DO Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM

B.J. Lehecka, DPT Tad E. Pieczynski, PT, MS, CSCS

Updat ed, Evidence-based Int ervent ion St rat egies

Inst ruct or Resources

Identify the components of the examination process as de ned by The Guide.

PAR 1 Foundations of the Rehabilitation Process

Relate evidence-based practice to clinical reasoning.

Describe the algorithmic approach to clinical reasoning for intervention selection.

Articulate a movement-based philosophy upon which to construct plans for intervention

T e Guide t o Physical T erapist Pract ice

P a thology/ Impa irme nt Functiona l Dis a bility

Ca rdiopulmona ry P hys ica l

Biologica l fa ctors De mogra phic fa ctors

P hys ica l a nd s ocia l e nvironme nt

Me dica l ca re Me dica tions /The ra pie s Re ha bilita tion

Other Models of Patient Management

Overview of T e Guide: Part 1

T e chapter continues with a general discussion o the scope o practice or physical

Figure 1-3 The patie nt/ clie nt manag e me nt mo de l

• Multisite or multisystem involvement

Overview of T e Guide: Part 2

Musculoskelet al Pract ice Pat t erns 1-3

4A. Primary prevention/ risk reduction or skeletal demineralization

Overview of T e Guide: Parts 3 and 4

Clinical Reasoning and Decision Making

Effective decision-making about evaluation, diagnosis, and prognosis requires approaching

able 1-1 HOAC II De nitio ns o f Pro ble ms

Type o f Pro ble m De nitio n Example s

PIPs Impairments, functional Pain, loss of ROM about

NPIPs Problems identi ed by someone Postural impairments,

Anticipated Problems that do not exist at the Secondary shortening of

Expert Versus Novice Decision Making

Problem Solving, Clinical Decision Making,

able 1-2 Le ve ls o f Evide nce fo r Re se arch

Level • High-quality randomized controlled trials

Level II • Prospective cohort studies

Level III • Case-control studies

Level IV • Case series (no, or historical, control group)

Level V • Expert opinion

Data from the J Bone Joint Surg, instructions for Authors.

Hypo the s is -Orie nte d Alg o rithm fo r Clinic ians II

Co lle c t Initial Data

Ge ne rate Patie nt-Ide ntifie d Pro ble ms (PIPs ) Lis t

Fo rmulate Examinatio n S trate g y

Co nduc t the Examinatio n, Analyze Data, Re fine Hypo the s e s ,

For Ea ch Exis ting For Ea ch Anticipa te d

Cons ulta tion Cons ulta tion