Corrective Exercise

CORRECTIVEEXERCISEA Practical Approach

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Hodder ArnoldA MEMBER OF THE HODDER HEADLINE GROUP

Kesh Patel

CORRECTIVEEXERCISEA Practical Approach

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British Library Cataloguing in Publication DataA catalogue record for this title is available from the British Library

ISBN-10: 0 340 88932 2ISBN-13: 978 0 340 88932 9

First Published 2005

Impression number 10 9 8 7 6 5 4 3 2 1Year 2009 2008 2007 2006 2005

Copyright © 2005 Kesh Patel

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Cover photograph by Corbis. Artwork by Barking Dog Art. Internal photographs by James Newell. Internal artwork by Apple Agency.Typeset by Phoenix Photosetting, Chatham, Kent.Printed in Great Britain for Hodder Arnold, an imprint of Hodder Education, a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH by Arrowsmith, Bristol.

www.hoddereducation.co.uk

To my wife, Suzanne, and my daughter, Maya India, who continue to enlighten me, and havetaught me to live in the moment and enjoy the sanctuary of unconditional love.


CONTENTS

Acknowledgements xList of figures xiList of tables xviPreface xvii

Part 1An Introduction to Corrective Exercise 11 A practical approach to corrective exercise 2

Evaluation 2Programme design 3The body as an integrated system 4

2 Principles of postural assessment 5Introduction 5Muscle recruitment in standing posture 5Ideal alignment 6Observation of posture 6Interpretation and correction of faulty posture 7

3 Principles of movement 11Introduction 11Complex movement 11Variables of movement 13

4 Principles of manual muscle testing 19Introduction 19Causes of muscle weakness 20Practical considerations in muscle testing 21Altered dominance in muscle recruitment patterns 23

5 Principles of programme design 26Introduction 26Phases of exercise progression 26Acute exercise variables 31

Part 2 The Shoulder 356 Functional shoulder anatomy 36

Overview of shoulder anatomy 36Structure and function of the shoulder girdle 37Structure and function of the shoulder joint 38Muscles of the shoulder 39

7 Evaluation of the shoulder 44Alignment analysis 44Movement analysis 46Muscle length 47Muscle strength 51

8 Corrective exercise for the shoulder 58Corrective exercise progression 58Corrective exercises for the shoulder 59

Part 3The Trunk and Spine 1059 Functional trunk and spine anatomy 107

Overview of spine anatomy 107Structure and function of the spine 107Muscles of the trunk 110

10 Evaluation of the trunk 115Alignment analysis 115Movement analysis 117Muscle length 118Muscle strength 121

11 Corrective exercise for the trunk 130Corrective exercise progression 130Corrective exercises for the trunk 131

Part 4The Pelvis, Hip and Knee 16712 Functional pelvis, hip and knee anatomy 168

Overview of pelvis, hip and knee anatomy 168Structure and function of the pelvis, hip and knee 169

viii Contents

Muscles of the pelvis 174Muscles of the hip joint 175Muscles of the hip and knee joint 177Muscles of the knee 178

13 Evaluation of the pelvis, hip and knee 182Alignment analysis 182Common alignment problems 184Movement analysis 188Muscle length 190Muscle strength 196

14 Corrective exercise for the pelvis, hip and knee 204Corrective exercise progression 205Corrective exercises for the hip 205

Glossary 255Index 261

ixContents

ACKNOWLEDGEMENTS

It’s impossible to adequately acknowledgeand thank the many people who contributedto the development of this book.

I am especially indebted to Suzanne Patel,having been the lucky beneficiary of her wiseeditorial comments and relentless motivationin maintaining the books momentum.

A special acknowledgment goes to theteam at Hodder Education, and in particular,Matthew Smith, for his guidance and supportthroughout the development of this book.

I would like to thank all the osteopaths,chiropractors, physiotherapists, sportstherapists, personal trainers and massagetherapists, that I have worked with, and whocontinue to keep me on my toes. To all thestudents I have taught over the years - the olddog has learned a few of your new tricks.

My heartfelt appreciation goes to all thewonderful clients that I have worked with

over the years, who have opened up myunderstanding of the many facets of health.They have taught me that when you’reheaded in the right direction, you’ll know it’sright, because you’re sure enough to beunsure, but never unsure enough to not doit.

I am especially thankful for the knowledgeand wisdom of the many innovative healtheducators involved in the field of integratedhealth; in particular, the extraordinary PaulChek whose work and philosophy continuesto inspire me.

Finally, I would like to acknowledge thecreative and inspiring work of RichardBandler and the late Moshe Feldenkrais –who have taught me that in order to changethe way we move, think and feel, we mustfirst change the image of ourselves that wecarry within us.

LIST OF FIGURES

Figure 1.1 A systematic and practical approach to corrective exercise . . . . . . . . . . . . . . . .Figure 1.2 The kinetic chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 2.1 Ideal plumb alignment – lateral view . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 6.1 Skeletal anatomy of the shoulder complex – (a) anterior, (b) posterior views .Figure 6.2 Movements of the scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 6.3 Movements of the shoulder joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 6.4 Muscles of the shoulder – (a) anterior, (b) posterior views . . . . . . . . . . . . . . . .Figure 7.1 Normal scapula alignment – posterior view . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.2 Test for length of pectoralis major – (a) normal length of lower fibres,

(b) normal length of upper fibres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.3 Test for length of pectoralis minor – left, normal length; right, short . . . . . . . .Figure 7.4 Test for length of teres major, latissimus dorsi, rhomboids – (a) start position,

(b) end position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.5 Test for length of medial rotators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.6 Test for length of lateral rotators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.7 Test for length of medial and lateral rotators . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.8 Anterior deltoid strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.9 Posterior deltoid strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.10 Middle deltoid strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.11 Pectoralis major/latissimus dorsi strength test . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.12 Internal rotator strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.13 External rotator strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.14 Upper trapezius/levator scapulae strength test . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.15 Rhomboid strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.16 Serratus anterior strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.17 Teres major strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 7.18 Latissimus dorsi strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.1 Scapulohumeral muscle stretch – (a) pectoralis major upper fibres,

(b) pectoralis major lower fibres, (c) latissimus dorsi/teres major/teres minorFigure 8.2 Medial rotation – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.3 Lateral rotation – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.4 Side-lying circumduction and thoracic integration – (a) before, (b) after . . . .Figure 8.5 Trapezius activation – (a) level 1, (b) level 2, (c) level 3 . . . . . . . . . . . . . . . . . .Figure 8.6 Prone serratus pull – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 8.7 Standing shoulder flexion – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.8 Standing shoulder abduction – (a) start position, (b) upper trapezius

activation, (c) lower trapezius activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.9 Wall climbing – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.10 Standing circumduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.11 Assisted shoulder flexor/abductor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.12 Assisted pectoralis minor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.13 Assisted medial/lateral rotator stretch – (a) start position, (b) medial rotator

stretch, (c) lateral rotator stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.14 Four-point kneeling cross-crawl – (a) before, (b) after . . . . . . . . . . . . . . . . . . .Figure 8.15 Ball circumduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.16 Closed-chain weight shifts – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.17 Prone iso-abdominals – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.18 Side-lying iso-abdominals – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.19 Wall push-up – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.20 Seated push-up – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.21 Medial/lateral rotation – (a) lateral rotation end position, (b) medial rotation

end position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.22 Shoulder PNF patterns: ‘Reaching for seatbelt’ – (a) start, (b) end positions;

‘Putting on seatbelt’ – (c) start, (d) end positions; ‘Drawing the sword’ – (e)start, (f) end positions; ‘Replacing the sword’ – (g) start, (h) end positions . . .

Figure 8.23 Scaption – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.24 Standing push pattern (cable) – (a) before, (b) after . . . . . . . . . . . . . . . . . . . .Figure 8.25 Standing pull pattern (cable) – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . .Figure 8.26 Shoulder press – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.27 Pull-down – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.28 Upright row – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.29 Dips – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.30 Pull-over – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.31 High-low wood-chop – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.32 Medicine ball chest pass – (a) before, (b) during, (c) after . . . . . . . . . . . . . . . .Figure 8.33 Squat raise – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 8.34 Barbell clean and press – (a) before, (b) during, (c) after . . . . . . . . . . . . . . . .Figure 9.1 Skeletal anatomy of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 9.2 A motion segment of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 9.3 Movements of the spine – (a) flexion, (b) extension, (c) lateral flexion,

(d) rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 9.4 Muscles of the trunk – (a) anterior, (b) posterior . . . . . . . . . . . . . . . . . . . . . . .Figure 10.1 Normal alignment of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 10.2 Forward-bending test for length of posterior back musculature . . . . . . . . . . . .Figure 10.3 Range of motion in trunk flexion (without hip flexion) . . . . . . . . . . . . . . . . . .Figure 10.4 Range of motion in trunk extension (without hip extension) . . . . . . . . . . . . . .Figure 10.5 Transversus abdominis strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 10.6 Back extensor strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xii List of figures

Figure 10.7 Lateral trunk flexor strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 10.8 Lower abdominal strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 10.9 Upper abdominal strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 10.10 Trunk rotator strength test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.1 Curled forward bending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.2 Side bending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.3 Spine rotation – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.4 Seated low back stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.5 Nerve flossing – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.6 Cat-camel – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.7 Abdominal hollowing – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.8 Abdominal bracing – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.9 Floor bridge – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.10 Four-point arm/leg reach – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.11 Curl-up – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.12 Lower abdominal curl – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.13 Supine hip extension: torso on ball – (a) before, (b) after . . . . . . . . . . . . . . . .Figure 11.14 Supine hip extension: feet on ball – (a) before, (b) after . . . . . . . . . . . . . . . . .Figure 11.15 Stability ball abdominal curl – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . .Figure 11.16 Stability ball back extension – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . .Figure 11.17 Russian twist: feet on stability ball – (a) before, (b) after . . . . . . . . . . . . . . . . . .Figure 11.18 Iso-abdominals: prone – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.19 Iso-abdominals: side-lying – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.20 Forward ball roll – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.21 Supine lateral ball roll – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.22 Squat – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.23 Dead lift – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.24 High-low wood-chop – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.25 Power crunch – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.26 Russian power twist: body on ball – (a) before, (b) after . . . . . . . . . . . . . . . . . .Figure 11.27 Oblique medicine ball toss – (a) before, (b) during, (c) after . . . . . . . . . . . . . .Figure 11.28 (a) Vertical oscillations with a Bodyblade®; (b) Horizontal oscillations with a

Bodyblade® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 11.29 Barbell clean and press – (a) before, (b) during, (c) after . . . . . . . . . . . . . . . .Figure 12.1 Skeletal anatomy of the pelvis, hip and knee – (a) anterior, (b) posterior . . . .Figure 12.2 Movements of the pelvis – (a) neutral, (b) anterior tilt, (c) posterior tilt,

(d) lateral tilt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 12.3 Movements of the hip joint – (a) flexion and extension, (b) adduction and

abduction, (c) medial and lateral rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 12.4 Movements of the knee joint – (a) flexion and extension, (b) medial and

lateral rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 12.5 Muscles of the pelvis – (a) anterior, (b) posterior . . . . . . . . . . . . . . . . . . . . . . .Figure 12.6 Muscles of the hip joint – (a) anterior, (b) posterior . . . . . . . . . . . . . . . . . . . . .Figure 12.7 Muscles of the hip and knee joint – (a) anterior, (b) posterior . . . . . . . . . . . . .

xiiiList of figures

Figure 12.8 Muscles of the knee joint – (a) anterior, (b) posterior . . . . . . . . . . . . . . . . . . .Figure 13.1 Ideal plumb alignment of the pelvis, hip and knee . . . . . . . . . . . . . . . . . . . . . .Figure 13.2 Angle of declination of the femoral neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.3 Angle of inclination of the femoral neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.4 Hip extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.5 Hip flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.6 Hip joint lateral asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.7 Hip antetorsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.8 Hip retrotorsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.9 Bow legs and knock knees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.10 The Craig test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.11 Test for length of hip flexor muscles – (a) normal length, (b) shortness in

the iliopsoas, (c) shortness in the rectus femoris, (d) shortness in the sartorius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 13.12 Test for length of hamstring muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.13 Test for length of tensor fasciae latae and iliotibial band – modified Ober testFigure 13.14 Test for strength of hip flexors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.15 Test for strength of medial rotators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.16 Test for strength of lateral rotators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.17 Test for strength of tensor fasciae latae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.18 Test for strength of posterior gluteus medius . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.19 Test for strength of hip adductors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.20 Test for strength of gluteus maximus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.21 Test for strength of quadriceps femoris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 13.22 Test for strength of hamstrings – (a) medial hamstrings, lateral hamstrings . . .Figure 14.1 Hip flexor stretch – (a) floor, (b) couch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.2 Standing abductor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.3 Assisted abductor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.4 Standing adductor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.5 Assisted adductor stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.6 Piriformis stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.7 Iliotibial band stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.8 Prone hip rotation – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.9 Side-lying adductor roll-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.10 Four-point rocking – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.11 Standing quadriceps stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.12 Prone quadriceps stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.13 Standing hamstring stretch (spiral) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.14 Supine hamstring stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.15 Seated hamstring stretch with stability ball . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.16 Supine calf stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.17 Forward bending – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.18 Supine leg raise – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.19 Supine leg drop – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xiv List of figures

Figure 14.20 Supine leg slide – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.21 Side-lying hip abduction – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.22 Side-lying hip adduction – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.23 Prone hip extension – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.24 Seated knee extension – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.25 Band shuffle – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.26 Standing balance – (a) single leg, (b) rocker-board (intermediate),

(c) Vew-Do™ board (advanced) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.27 Wall slide – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.28 Supine isometric bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.29 Supine bridge lateral roll – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.30 Standing hip flexion/glute contraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.31 Four-point reach – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.32 Supine floor bridge – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.33 Supine hip extension: feet on ball – (a) before, (b) after . . . . . . . . . . . . . . . . .Figure 14.34 Supine hip extension: torso on ball – (a) before, (b) after . . . . . . . . . . . . . . . .Figure 14.35 Squat – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.36 Lunge – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.37 Dead lift – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.38 Squat push – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.39 Clean and press – (a) before, (b) during, (c) after . . . . . . . . . . . . . . . . . . . . . .Figure 14.40 Box jumps – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.41 Multi-planar hops – (a) start, (b) sagittal plane hop, (c) frontal plane hop,

(d) transverse plane hop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 14.42 High-low wood chop – (a) before, (b) after . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xvList of figures

LIST OF TABLES

Table 2.1 Ideal standing alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 2.2 Corrective exercise for common postural problems . . . . . . . . . . . . . . . . . . . . . .Table 3.1 Seven biomotor skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 5.1 Manipulation of acute exercise variables for muscular endurance/stabilisation,

strength, muscle hypertrophy and power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 6.1 Summary of muscles involved in shoulder movements . . . . . . . . . . . . . . . . . . .Table 7.1 Muscles whose adequate length is important for full shoulder movement . . . .Table 9.1 Summary of the major muscles involved in trunk movements (thoracic

and lumbar spine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 12.1 Summary of muscles involved in pelvis, hip and knee movements . . . . . . . . . .Table 13.1 Common deviations observed during squatting and walking . . . . . . . . . . . . . . .

PREFACEA HISTORY OF CORRECTIVEEXERCISE

The concept of using exercise as atherapeutic tool is by no means a new one.As far back as the early nineteenth century,structured exercise was being used for thetreatment of sedentary lifestyles, in the formof group gymnastics. By the turn of thetwentieth century, the forward-thinking workof Eustace Miles and Eugene Sandowinspired many prominent physiologists andphysicians to become interested in the use ofexercise as a therapeutic modality. Theextensive use of anthropometricmeasurements at the time introducedevaluation protocol into the exercise arena.

As the mid-twentieth century approached,the growing acceptance of the psychologicalbenefits of exercise led to the introduction ofmind-body exercise systems. The work ofprominent physical educators, such asFrederick Mathias Alexander, MosheFeldenkrais, Joseph Pilates and MiltonTrager, was instrumental in thisdevelopment. Largely provoked by their ownpersonal experience of major illness ormusculoskeletal impairment, they recognisedthe intimate relationship between physical

fitness and pathology. Fundamental to theirapproach was an explicit understanding ofhuman movement and how it relates toefficient functioning of the body. Theseconcepts were further supported by the workof Rudolf Laban and Irmgard Bartenieff.Exercise was becoming recognised as atherapeutic tool within the context ofphysical rehabilitation and the foundationsfor the field of corrective exercise were beinglaid.

Today’s modern and often sedentarylifestyle has reduced the need forspontaneous and functional movement,resulting in a multitude of musculoskeletaldysfunctions. The increased popularity anduse of gyms has motivated many back intothe exercise arena. Combined with thegrowing responsibility that individuals aretaking for their own health, this hasstimulated increased interest in exercise as atherapeutic tool. As a result there has been amerging of knowledge from the disciplines ofrehabilitation and exercise. The field ofcorrective exercise bridges the gap betweenpure rehabilitation and exercise science.


1An Introductionto CorrectiveExercise

1A PRACTICAL APPROACH TOCORRECTIVE EXERCISE

One of the most challenging areas ofmusculoskeletal rehabilitation is theidentification of the weakest link: successfultreatment of this link can have a wide-reaching effect throughout the whole body.The concept of using exercise as atherapeutic tool is by no means a new one.Musculoskeletal dysfunction is commonlycaused by biomechanical weakness. With thisin mind, the use of exercise to correctdysfunction is an interesting approach to

rehabilitation. When exercise training isstructured and integrated correctly, using amultifaceted approach, it can help the clientto achieve, maintain and enhance theirrehabilitative goals, often without the needfor other intervention. A well-devisedcorrective exercise programme can enhancemuscle performance, decrease the severity ofinjury, decrease the risk of re-injury andaccelerate recovery and return to activity.Long-term solutions should focus not only oncorrecting the root cause of the problem, butalso on teaching optimal movement patterns,for lifelong health and function.

Evaluation and programme design are atthe heart of successful corrective exercise.This book presents a practical approach tocorrective exercise in a systematic order, asillustrated in Figure 1.1.

EvaluationThe evaluation procedure seeks to uncoverthe root cause of dysfunction. This processrequires an understanding of posture,movement and muscle testing, as well as adegree of therapeutic skill. Identifying themechanical cause of musculoskeletaldysfunction is an important objective incorrecting a problem and alleviating pain.

Failure to identify faulty posturalalignment and muscle imbalance patternsoften slows progression of an otherwise well-planned corrective exercise programme.

Musculoskeletal dysfunction

Posturalassessment

Movementanalysis

Muscletesting

Acu

te e

xerc

ise v

ariable

s

Evaluation

ProgrammeDesign

Phase 1Muscle balance

Phase 2Stabilisation

Phase 3Functional strength

Phase 4Functional power

Figure 1.1. A systematic and practical approach tocorrective exercise

Although evaluation procedures may beperformed in isolation, the fullbiomechanical status of an individual will bebest determined by collation andinterpretation of all data, while taking intoaccount the unique individuality of theclient.

Evaluation of the kinetic chain starts withan examination of static posture, with theaim of identifying any underlying muscleimbalances. This is a practical starting pointfor evaluation as it gives an overall idea ofmuscle function. The principles of overallpostural assessment are outlined in Chapter2, with more specific details of correct andfaulty alignment being explored in therelevant sections.

The second step in evaluation involvesmovement analysis. This can offer thetherapist a significant quantity of informationrelating to muscle recruitment and thepresence of compensatory movementpatterns. Knowledge of the building blocks offunctional movement is crucial tointerpreting the results of these tests andsubsequent exercise prescription. Chapter 3discusses the principles of movement andhow these can be used to assess a client’slifestyle. Combining this knowledge withspecific movement tests given later in thebook will help to build a bespoke exerciseprogramme.

Testing muscle function is the final step inthe evaluation and adds to previous findings.The principles of muscle testing, as well aspractical considerations, are outlined inChapter 4. Specific tests for muscle lengthand strength are outlined in the relevantchapters.

Programme designThe importance of programme designcannot be overstated. Not all exercises can be

recommended for everyone, and specificexercises are performed in different ways bydifferent people. Exercises should always beadapted to the client’s needs and performedcorrectly under good initial supervision.

It is necessary to design programmes thatare flexible and progressive. An approachshould be developed that will address theneeds of the individual, yet also take intoaccount the results of the evaluation.Exercise should also be functional to theclient – that is, particular to the uniquedemands of their occupational, recreationalor sporting environment.

Corrective exercise training should focusprimarily on restoring muscle balance: ifoptimal balance is not achieved, any existingmuscle imbalance may be increased furtherby exercise. Stability, functional strength andpower development can then progress inaccordance with the client’s rehabilitationobjectives.

The basis for exercise progression in thisbook focuses on the attainment of fourspecific objectives:

1 muscle balance

2 stability

3 functional strength

4 functional power.

These objectives are based on anunderstanding of exercise periodisationprinciples. As such, they will allow individualsof any ability to meet the objectives ofrehabilitation and performance. Details ofeach of these phases are discussed inChapter 5.

Successful exercise prescription isdependent on the manipulation of a numberof acute exercise variables. It is necessary toselect exercises that will be most beneficial tothe client with regard to their needs anddevelop these exercises through effective

3A practical approach to corrective exercise

management of load, repetitions, timing andrecovery. This process should take placewithin a structured framework that involvessystematic progression. As well as introducingthe principles of programme design, Chapter5 also discusses how exercise variables can besuccessfully managed to allow progression.

The body as anintegrated systemThe body is made up of a number of movingparts, or links, which are often referred tocollectively as the kinetic chain. The kineticchain is made up of three systems (see Figure1.2):

1 the active (or muscular) system

2 the passive (or articular) system

3 the control (or neural) system.

The optimal function of the kinetic chain isdependent on the integration of thesemechanisms into an infinite number ofreactions that produce movement. Duringmovement there is distinct separation of thekinetic chain into three structural systems:

1 the shoulders

2 the trunk

3 the pelvis, hips and knees.

Dysfunction in any part of these structurescan manifest as neuromuscular ormusculoskeletal problems. Understandingthe functional anatomy and biomechanics of

these body systems is important. Parts 2, 3and 4 provide an overview that will lay afoundation for effective exerciseprescription.

Corrective Exercise: A Practical Approachoffers all sports therapists, personal trainersand bodywork specialists a chance to buildon and integrate their own knowledge andbackground into the context of correctiveexercise, with the objective of achievingoptimal neuromuscular and musculoskeletalhealth and performance. This book providesa unique perspective on the role of correctiveexercise as an effective and practicaltherapeutic modality.

4 Corrective Exercise: A Practical Approach

PASSIVE(articular)

KINETICCHAIN

CONTROL(neural)

ACTIVE(muscular)

Figure 1.2. The kinetic chain

2PRINCIPLES OF POSTURALASSESSMENT

IntroductionOptimal posture is part of habitual well-being, involving sound skeletal structure,soft-tissue integrity and properneuromuscular control. The unique uprightstance exhibited by humans creates specificfunctional demands on the musculoskeletalsystem during all daily activities. Even thoughthe human body assumes many postures, itdoes not hold any of them for a significantamount of time, although certain characteristic and habitual posturalpatterns may become evident over a periodof time.

Standing posture creates a closed kineticchain, involving the body’s three mainsupport structures: the neck and shoulders;the trunk; and the pelvis, hips and knees.Forces are transmitted between the links ofthis chain in such a way that problems arisingin one system can (and invariably do) affectother systems. With gravitational force beinga significant factor in influencing humanposture, any weight-bearing position insitting, standing and gait can contribute tocontinuous stress and strain on thesupporting structures. Changes in the lengthof muscles and/or connective tissue maysubsequently result in diminished motioncontrol, leading to faulty postural alignmentand movement patterns. When this occurs,corrective exercise can be a useful tool inrestoring muscle balance, via specific

stretching and strengthening of theappropriate muscles.

Muscle recruitment instanding postureClinical evaluation of static posture requiresthe body to be in a standing, weight-bearingposition. In optimal alignment the musculareffort required to hold this position isminimal, with most of the support comingfrom the body’s ligamentous structures. Theactive muscles are generally anti-gravitymuscles, which control postural sway in thesagittal and frontal planes within the threesupport systems. These are described below.

Neck and shouldersThere is slight activity in the neck flexors andextensors, depending on the degree ofposterior and anterior postural sway,respectively. The upper trapezius, serratusanterior and supraspinatus also show someactivity in supporting the shoulder girdle.

TrunkDuring anterior postural sway, there isincreased activity of the paraspinal muscles;during posterior sway, there is slight activityin the abdominals. Lateral sway may also

produce some activity in the lateral trunkflexors.

Pelvis, hips and kneesThe iliopsoas is continually active in standingposture to maintain pelvic and hipalignment. Postural sway produces phasicbursts of activity in the gluteus medius andtensor fasciae latae, as well as activity in thequadriceps and hamstrings. In the leg, thegastrocnemius and tibialis anterior areresponsible for the control of sagittal planepostural sway.

Ideal alignmentIdeal skeletal alignment is a position in whichthere is minimal stress and strain on thebody’s support systems, and which isconducive to optimal movement andefficiency of the body. In reality, thisalignment is represented by an erect andwell-balanced head position, normal spinalcurvatures, a neutral position of the pelvisand alignment of the lower extremities forweight bearing. It is important to note thatoptimal balance of the spine’s normal curves contributes significantly to healthyposture.

Observation of postureThe common and most effective way toobserve posture is from a lateral view. Figure2.1 shows ideal alignment from a lateral view.When viewing posture laterally, the line ofreference is located in the mid-frontal plane.Since the only fixed point in standingposture is where the feet make contact withthe floor, the line of reference begins here,at a position slightly anterior to the lateralmalleolus. There are a number of useful

surface and anatomical landmarks thatcoincide with the plumb line in the lateralview to assist in postural observation.

Posture should also be observed from ananterior and posterior view, with a plumbline being used as a fixed line of reference.When viewing posture anteriorly orposteriorly, the plumb line is positioned inthe mid-sagittal plane, beginning midwaybetween the heels and continuing throughthe middle of the pelvis, spine and skull.Table 2.1 gives details of optimal alignmentof major landmarks in the sagittal and frontalplanes.


Figure 2.1. Ideal plumb alignment – lateral view

Interpretation andcorrection of faultypostureThe purpose of any postural correction is torestore muscle balance and normalise rangeof joint motion. It is also important that anypatterns of faulty posture alignment be

confirmed by muscle testing (length andstrength); details of these tests for theshoulder, trunk, hip and knee are outlined inthe appropriate chapters of this text.

Correction of faulty posture can involveseveral modalities, depending on the extentand aetiology of the dysfunction. Althoughcorrection may require use of specialtherapeutic techniques, such as soft-tissuemanipulation and orthotic correction,

7Principles of postural assessment

Table 2.1. Ideal standing alignment

Landmark(s) Optimal alignment in standing

Feet The longitudinal arch is dome-shaped and is not low or flat; thefeet are toed out slightly (approximately 10°); in heeled shoes,the feet are parallel; weight should be central over arches andborne evenly between left and right feet.

Knees and legs Legs are straight (not knock-kneed or bow-legged); forward-facing patella; laterally, the knees are not flexed orhyperextended.

Hips, pelvis and spine Left and right posterior superior iliac spine are level (and (posterior view) anterior superior iliac spine, anteriorly); spine does not curve to

the left or right; the hips are not rotated; shoulders are level(although the right shoulder may be slightly low and right hipslightly high in right-handed individuals, and vice versa for left-handed).

Hips, pelvis and spine The buttocks are not prominent; abdomen should be flat in (lateral view) adults; the four natural curves of the spine should be evident

(lordosis in the cervical and lumbar regions and kyphosis in thethoracic and sacral regions); there should not be any excessivecurvatures present.

Chest, shoulders and Chest should be positioned slightly upwards and forwards arms (halfway between full inspiration and full expiration); arms

hanging relaxed by sides, with palms facing the body; elbowsslightly bent with forearms facing forwards; shoulders are leveland not in rotation; shoulder blades should lie flat againstribcage, with separation of about 4 inches.

Head Head is in a position of optimal balance and is neither too farforwards nor too far back; cheekbones should be positioned inthe same vertical line as the clavicles.

corrective exercise can provide a long-termsolution when combined with posturetraining. Posture training should be part of apreventative care programme and shouldbecome a habitual part of the client’slifestyle. Special attention should always bepaid to observation and reinforcement ofposture during execution of all exercises.

At times, there may be discrepanciesbetween the results of postural assessmentand muscle testing. In these instances, thedifferences may be due to a number offactors, such as the effects of an old injury,recent illness or specific ‘guarding’ patternsthat have become habitual. Theseobservations may require further historicalinvestigation. When attempting to correctposture, the therapist must be realistic andaccept the limits imposed by possible long-term structural variations.

In standing, faulty alignment will occurwhen a muscle fails to provide adequatesupport for weight bearing. If the fault hasbeen long-standing, then furthercompensations may also be present furtherup or down the kinetic chain. Accurateassessment and observation of standingposture can thus provide valuableinformation on muscle balance to assist incorrective exercise prescription.

The following table outlines guidelines forpostural correction, including exercise andovercoming habitual patterns. Details ofspecific alignment problems relating to theshoulder, trunk and hip, and correctiveexercise, can be found in the relevantchapters.


Table 2.2. Corrective exercise for common postural problems

Postural fault Short muscles Long muscles Corrective exercise

Forward head Cervical extensors Cervical flexors carriage

Upper trapezius; levator scapulae

Thoracic kyphosis Shoulder adductors; Thoracic extensorspectoralis minor; intercostals Middle and lower

trapeziusInternal oblique (upper lateral fibres)

Medially rotated Upper trapezius; Middle and lower shoulders serratus anterior; trapezius

pectoralis minor

Stretch cervical extensors,if tight; strengthen cervicalflexors; strengthenthoracic extensors; deep-breathing exercises, witharms overhead to stretchintercostals and upperabdominals; stretchpectoralis minor, shoulderadductors and internalrotators, if tight;strengthen middle andlower trapezius

9Principles of postural assessment

Table 2.2. Corrective exercise for common postural problems (continued)


Excessive lumbar Lumbar erectors Abdominals Stretch low back, if tight; lordosis (external oblique) strengthen abdominals

Hip flexors using posterior pelvic tilt Hip extensors exercises; stretch hip

flexors, if short; strengthenhip extensors, if weak;educate proper posturalalignment

Flat-back Anterior abdominals Lumbar erectors Strengthen low back muscles, if weak;

Hip extensors One-joint hip strengthen hip flexors to flexors aid in restoring anterior

pelvic tilt; stretchhamstrings, if tight;educate proper posturalalignment

Sway-back Upper anterior Lower anterior Strengthen external abdominals (rectus abdominals oblique; stretch upper abdominis and (external oblique) abdominals and internal oblique) intercostals by placing

One-joint hip arms overhead and doing Hip extensors flexors deep breathing (wall

standing/sitting exercise);stretch hamstrings, if tight;strengthen hip flexors, ifweak (standing hip flexionexercise or supine legraise); educate properpostural alignment

High left hip Left lateral trunk Right lateral Stretch left lateral trunk (opposite for muscles trunk muscles and thigh muscles high right hip) (including fascia);

Right hip abductors; Left hip abductors strengthen right lateral right tensor fasciae (gluteus medius); trunk muscles; strengthen latae; left hip right hip adductors left gluteus medius if adductors weakness is pronounced;

educate proper posturalalignment


Table 2.2. Corrective exercise for common postural problems (continued)


Knee flexion Hamstrings; Quadriceps; soleus Stretch hamstrings and hip popliteus flexors, if tight; educate

proper postural alignment

Knee Quadriceps; soleus Hamstrings; Stretch quadriceps, if tight; hyperextension popliteus educate proper postural

alignment, with emphasison avoidinghyperextension

Medially rotated Hip medial rotators Hip lateral rotators It is important to ascertain femur whether the rotation is

acquired or structural;stretch medial rotators;strengthen lateral rotators;educate proper posturalalignment

Knock knees Iliotibial band; Medial knee It is important to ascertain lateral knee muscles muscles whether the problem is

acquired or structural;stretch iliotibial band;educate proper posturalalignment

Pronation Peroneals Tibialis posterior Walking re-educationexercises; educate properpostural alignment

Supination Tibialis posterior Peroneals Walking re-educationexercises; educate properpostural alignment

3PRINCIPLES OF MOVEMENT

IntroductionAll movement patterns can be consideredfunctional if they fulfil the desired objectiveof movement. A number of differentmovements are possible for a given task,producing a number of desired outcomes.However, an outcome that is kinetic-chain-efficient, and thus biomechanically safe, is animportant objective for the client. Foreffective corrective exercise prescription it isimportant to have an understanding of thebasic building blocks of movement and howthey fit together to create complexmovement patterns. This information is avaluable tool that can be used to analysefaulty movements and correct them usingexercise. Whereas postural assessment canhelp to identify underlying muscleimbalances, movement analysis will uncoverhow these imbalances contribute tomovement impairment.

The prescription of exercise based on thebuilding blocks of movement is known asfunctional training. In the framework ofcorrective exercise, the term suggests anapproach to exercise that is centred on aclient’s occupational, recreational andsporting activities. For this reason, theconcepts of functional training apply across abroad scope of exercises, involving differentmethodologies and rehabilitation tools.

This chapter aims to examine the buildingblocks of movement, and how this

information can be used to support previousfindings of muscle imbalance. The variablesof human movement and their relevance tocorrective exercise is also discussed.

Complex movement

The building blocks ofmovementAll complex movement can be broken downinto basic building blocks; these basepatterns are made up of six isolated jointactions in the sagittal, frontal and transverseplanes: flexion and extension movements in thesagittal plane; abduction, adduction and lateralflexion movements in the frontal plane; androtational movements in the transverse plane.

Primary movements consist ofsimultaneous joint actions to produce fourimportant movement patterns: lifting(including squatting and lunging), pulling,pushing and trunk rotation. These patterns areuseful in producing movement, generally in astraight line. This is the most advantageousmethod of overcoming external forces orobjects, and when accuracy is needed inmovement. Primary movements can beeffectively trained with specific exercises andcombined with other primary patterns toproduce useful movement sequences. It isimportant to note that the coordinatedsequencing of lifting, trunk rotation and

pushing or pulling contributes significantlyto the development of power during manyactivities of daily living. With this in mind it isimportant for the therapist to have a fullunderstanding of the biomechanics of thesefour important patterns.

Complex or integrated movements consistof the sequential use of primary (and base)patterns to generate maximum force at theend of a movement. The precise sequencingof body parts occurs so that subsequentsegments are accelerated with theappropriate timing, creating a speed that isfunctional to the movement. Many of thesemovements involve trunk rotation to assist inspeed production. Although integratedmovements are commonly seen in sportsperformance, such as a golf swing or kicking,there are many examples that occur inactivities of daily living. These includeswinging the legs out of bed in the morning,getting in and out of a car, or knocking in afence post with a mallet.

Movement observation incorrective exerciseWhen a client demonstrates a faultymovement pattern, for example, an inabilityto squat correctly, the therapist must beginby breaking down that particular movementsequence into simple observable parts. Thiswill help to identify dysfunction and can helpto target corrective exercise. If the therapistunderstands the correct biomechanicalsequence of the primary movement pattern,each individual part of the faulty movementcan be observed in terms of joint and muscleaction. If specific muscles are unable toperform their desired action, the overallmovement will show decreased efficiency.Although pain may not always be present as aresult of faulty movement, the faulty

movement should not be overlooked as afuture source of pain. Any identified muscledysfunctions should be confirmed via muscletesting, before exercise prescription begins.Failure to identify specific muscledysfunction may lead to unnecessary exerciseprescription.

The results of movement analysis shouldbe used to build a programme that focuseson training movements, rather than muscles.If the objectives of rehabilitation include


Clinical perspectiveBreaking down complex movements andre-educating the primary patterns mayallow for correct execution of movementsin an isolated way that is conducive tolearning. Each individual pattern can thenbe built up progressively with theappropriate temporal and spatial control,to reproduce the complex pattern.

A performance-related example of thisprocess is seen in the re-education of aforehand movement in tennis. Themovement can be broken down into amodified squat (primary pattern), with hipmedial/lateral rotation (base pattern) anda trunk rotation (primary pattern).Teaching proper squat mechanics (partialrange of motion only) and integrating thismovement with hip medial/lateral rotationwill begin the facilitation of transfer ofground reaction forces through thelumbo-pelvic-hip complex.

The upper and lower body patterns canthen be integrated, using cables or tubing,followed by medicine balls. The final stepmay include sports-specific drills, wherethe enhanced movement pattern isintegrated into a coaching session, thusmaking the transition from the clinical tothe performance environment.

performance-related goals, the programmecan be developed further to includecombinations of primary patterns with speeddevelopment (power-based exercise).

Variables of movementEvery movement has a set of six variables indiffering proportions which make thatparticular movement unique. Understandingthese variables is required so that they can bemanaged effectively during exercise tocorrect and enhance faulty movements.These six variables of movement are:

1 integration of muscle action

2 combination of biomotor skills

3 planes of motion

4 maintenance of centre of gravity over baseof support

5 acceleration, deceleration and stabilisation

6 open and closed chain contribution.

This information is useful to the therapistbecause it will enable a client’s daily activitiesto be profiled. Daily activities that combineall these variables to a high degree areconsidered to be complex or highlydemanding movements; activities that usethese to a lesser degree are simple or lessdemanding.

Assessment of movement in this way allowsthe therapist to select appropriate exercisesthat have the same profile as the client’s dailyactivities. The resulting exercises will betailor-made to the client’s functionaldemands. Further manipulation of thesevariables in a corrective exercise programmewill consequently lead to improvedperformance. The six variables of movementare summarised below.

1. Integration of muscle actionMovement begins with muscle recruitment,following the propagation of nerve impulses,in order to produce segmental motion ofjoints. Recruitment patterns involve theintegration of a number of muscle actionssequentially or simultaneously: very rarely domuscles act in isolation. For a movement tobe biomechanically correct and safe, thereneeds to be minimal joint stress, withmaximal neuromuscular efficiency. For thisto occur, muscle recruitment must involvethe correct force couples and exhibit thecorrect firing sequence. The nervous systemis organised in such a way as to optimise theselection of muscle synergies, rather than theselection of the individual muscles. In thisway the nervous system ‘thinks’ in terms ofmovement patterns and not isolated musclefunction. Training individual muscles overprolonged periods of time can createartificial feedback mechanisms, disruptedforce couples and aberrant forcesthroughout the kinetic chain.

An understanding of agonistic/antagonistic and synergistic muscle actionduring movement enables the therapist toprescribe individual exercises thatdemonstrate similar, if not identical,recruitment patterns. For example, whenbending down to pick up a heavy object fromthe floor, the ascent should be initiated by aposterior pelvic tilt. This action isprecipitated by contraction of the gluteals, amuscle group that is commonly weak. In thepresence of gluteal weakness, the lumbarerectors will preferentially recruit, producinglarge and potentially damaging amounts ofshear force through the lumbar vertebrae.Instructing clients in basic lifting patterns willfacilitate optimal learning; if the client isparticularly weak or shows signs of atrophy inthe gluteals, isolation exercises could be

13Principles of movement

prescribed to stimulate strength andhypertrophy as quickly as possible. However,once the goals of isolation have beenattained, integration of the gluteals back intothe lifting pattern should be prioritised.

2. Combination of biomotorskillsBiomotor skills can be described as thevarious abilities that are required to performany given movement. All movement is madeup of these skills in various amounts; theexact proportions will depend on thedemands of a given task. The biomotor skillsof a corrective exercise programme shouldclosely match the abilities of the client andthe demands of their lifestyle. The sevenbiomotor skills and their application incorrective exercise are shown in Table 3.1.

When injury or impairment occurs, one ormore biomotor skills may be affected,resulting in a deficit. Because biomotor


Clinical perspectiveWhen addressing biomotor deficits withina corrective exercise programme, it mayseem beneficial to include exercises thattrain several skills at once within a trainingsession. However, this may actually inhibitthe development of specific skills at theexpense of others. The exception to thisrule is where time is limited, in which casethis type of ‘condensed’ exercise may beproductive. In this instance, single ‘hybrid’exercises may be performed which addressmultiple biomotor skills, whilesimultaneously training a number offunctional movement patterns. Examplesof such exercises include the squat, thewood-chop and the supine lateral ball roll.

The subsequent restoration and furtherenhancement of biomotor skills can vastlyimprove and accelerate the therapeuticprocess, providing a range of challengingand interesting exercises.

Table 3.1. Seven biomotor skills

Biomotor skill Application in corrective exercise

Strength – the ability Adding resistance to the body during exercise can develop to apply force strength and should be relevant to occupational or recreational

demands. Care should be taken because loads that are too highcan create a breakdown in neuromuscular stabilisation and causethe client to be susceptible to further injury or premature fatigue.

Power – force times Power can be increased by increasing the load (force) or velocity increasing the speed (velocity) with which the load is moved.

Power training provides the client with the ability to condition andrestore movement patterns in a biomechanically correct mannerand at a more functionally appropriate speed.

Muscular endurance Repetitive dynamic contraction allows for endurance gains that are – the ability of the based on high-repetition muscle contractions (usually 20 muscles repeatedly to repetitions or more), while continuous tension produces

abilities tend to exhibit codependency, adeficit in one can significantly influenceanother (for example, a loss of strength willaffect an individual’s ability to generatepower and speed). Any biomotor deficits thathave occurred as a result of injury should becorrected. Once restored, biomotor skills canbe further improved for the purpose of

performance enhancement, or as apreventative measure against further injury.

When qualifying the biomotor skills of aclient, it is important to understand that thegoal is to determine where to directrehabilitative efforts: the primary objective isto restore deficits, rather than reinforcingcompetencies.


Table 3.1. Seven biomotor skills (continued)

Biomotor skill Application in corrective exercise

perform a sub- endurance gains based on sustained isometric muscle contractions. maximal task without Muscular endurance is more important than strength development fatigue in certain rehabilitation protocols.

Coordination – the Corrective exercises that involve multiple joint actions can be used control over a series to improve coordination and can train clients to recruit muscles in of muscular the correct sequence. The development of coordination ranks contractions, so as to high on the list of skills that can be acquired through classical create a desired movement-based systems such as Pilates and the Feldenkrais motion method.

Flexibility – the range Most leisure or recreational activities require only normal amounts of motion possible of flexibility, and functional range of movement may be more around a specific important for long-term injury prevention. Flexibility may be joint or series of improved via a number of different techniques, such as static, articulations; specific active and PNF (proprioceptive neuromuscular facilitation) to a given joint or stretching; as well as through a number of popular flexibility-based movement disciplines, such as yoga or martial arts.

Balance – the ability Balance can be improved effectively by constantly stressing an to maintain a centre individual’s limits of stability in a proprioceptive and multi-planar of gravity over a fixed environment, using balance-boards, stability balls, foam rollers and base of support single-leg stances. The design and implementation of balance into

a corrective exercise programme is critical for developing andimproving the sequencing of muscle recruitment patterns requiredfor joint stabilisation and optimal muscular control.

Agility – the ability to Many daily activities require a basic level of agility (e.g. walking); change direction of high levels of agility are generally reserved for high occupational movement quickly demands or sports performance. Agility may be developed through

the use of stability balls, wobble-boards or simple plyometricexercises, such as multi-planar hops.

3. Planes of motionAlmost all activities of daily living involvemovement in three planes of motion –sagittal, frontal and transverse planes. Thischaracteristic is not exclusive just to complexmovement patterns; for example, less complexactivities, such as walking, involve sagittalplane movement, with smaller movements inthe frontal and transverse planes. Walking alsorequires a large amount of stabilisation in allthree planes for optimal movement.

Weakness in one plane during walking isexemplified in a client who has a weakgluteus medius. As the gluteus medius is oneof the major frontal plane stabilisers of thehip joint, weakness can result in an alteredgait pattern (Trendelenburg sign) that ischaracterised by a side-to-side ‘wag’ in thehips. Restoring strength to the gluteusmedius is part of an overall correctiveexercise programme that may also focus ongait re-education.

Multi-planar activities are best performedusing free weights, body weight, cablemachines, stability balls, balance-boards andplyometric training. Many traditionalresistance machines work by placing theindividual into a fixed plane of motion,thereby locking rotary joints into linearpaths. This isolation significantly reduces theneed for stabilisation in other planes, thusincreasing the risk of wear and tear on jointsand decreasing the functional carry-over intodaily activities. For example, many exercisesare often sagittal plane dominant. Whileflexion and extension are necessary todevelop functional movement, there may becompromised stability of the frontal andtransverse planes. If the client’s occupationalor recreational requirements arepredominantly sagittal plane, there will stillbe an increased risk of injury due to the lackof stability in the other planes.


Clinical perspectiveIntegrated movements are essential tooptimal physical function. These patternsare made up of multi-planar movementsequences, involving acceleration,deceleration and stabilisation mechanics,and the maintenance of balance over abase of support. Consideration of this playsan important part in equipment andexercise choice. The use of cables andpulleys has been shown to have greaterfunctional carry-over to daily activitiesbecause of the greater freedom and varietyof joint movement that they allow. Inaddition, the use of free weights ormedicine balls may also provide similarfunctional joint and muscle loading. Theoverall effect of this type of training is toenhance significantly the ability to stabilisevarious joints, especially the spine, thuscontributing to overall musculoskeletalhealth.

Many training machines found in gymsand health clubs offer only isolation ofjoint action in fixed planes of motion. Forrehabilitation purposes, these types ofmotor patterns may not be sufficientlyeffective in meeting day-to-day demands.When an injured or painful body partneeds to be less active, machines may beuseful in isolating these parts, whilesimultaneously training other body parts.For example, when a client has low backpain, they can use machines that offerlumbar support, while still training theupper or lower extremities. Machines mayalso be used to regress an exercise if theclient has muscle weakness. In thisinstance, the weak muscle can bestrengthened in a machine prior tointroducing more integrated exercises.

4. Maintenance of centre ofgravity over base of supportEssentially, most functional movements occurfrom the standing position. From thisposition the body must overcome the effectsof gravity while at the same time producingthe desired movements. During thesemovements, muscle systems work to stabilisethe upright posture in all three planes ofmotion.

This maintenance of upright posturerelies heavily on the activation of righting andequilibrium reflexes to maintain balance.Righting reflexes tend to be dominant whenan individual moves across stable surfaces,such as the pavement. They work byconstantly adjusting body parts in relation tothe head, and vice versa. Equilibrium reflexesare more dominant when moving acrosslabile surfaces, such as sand and soft grass, orwhen the supportive surface is moving, suchas on a bike or a train. In reality, manyactivities use a mixture of both reflexreactions, although one may dominate.

For general improvements in thesereflexes the introduction of labile surfaces toa corrective exercise programme is sufficient.Exercise programmes that are based aroundfixed machines can be limiting, as the kineticchain is being stimulated under an assistedpattern of stabilisation, thereby reducing theextent of muscle recruitment and balancerequirement.

5. Acceleration, decelerationand stabilisationAlmost all movement occurs at varyingspeeds, involving acceleration anddeceleration of intrinsic (body weight) andextrinsic (additional) loads. During thesemovements isometric muscle contraction

must occur to stabilise the loads. Forexample, lifting a weight from the floorinvolves acceleration of hip extension as aresult of gluteal and hamstring contraction,followed by eccentric contraction of theabdominals and hip flexors to decelerate themovement. Isometric contraction must alsooccur in the trunk flexors and extensors, aswell as the deeper abdominal muscles, tostabilise the spine, and in the knee extensorsto stabilise the knee.


Clinical perspectiveThe demands placed on the kinetic chainduring daily activities are numerous andoften challenging. These includestabilisation during static postures;premeditated dynamic and ballisticmovement; unpredictable loading; andmaintenance of the centre of gravity overthe base of support. For this reason, manytherapists and trainers have beenmotivated to recommend exercise trainingon labile surfaces such as wobble-boardsand stability balls. Although these devicescan certainly challenge the motor systemto meet the demands of particularlydynamic tasks, they may not be beneficialfor some individuals in the first instance.

Regardless of injury status and trainingexperience, all corrective exerciseprogrammes should begin on stablesurfaces to establish a positive slope ofimprovement. When there is sufficientqualification of static and dynamic stability,labile surfaces may be introduced slowlyand progressively, until the specific goal ofexercise is reached. Unnecessary use ofthis type of training may significantlydevelop certain biomotor skills at theexpense of more important ones.

Movement at fixed speeds is rare, exceptin cases of heavy lifting that require optimalcontrol and coordination. In the absence ofadequate neuromuscular control, the bodywill move only within a range of speed thatthe nervous system has been programmed to allow, no matter how strong the musclesare.

When designing a corrective exerciseprogramme it is important to account for thevariations in performance speed that occurwith daily tasks, as well as the significance ofthese speeds on the forces acting on thebody. For example, lifting a 5 kg weightquickly may require more force generationthan lifting a 10 kg weight slowly. Theimplications of this are often seen in clientswho experience back pain while bendingquickly to pick up light objects. Using avariety of lifting speeds and tempos, ratherthan fixed speeds, will enhance thedevelopment of functional movement.

6. Open- and closed-chaincontributionThe kinetic chain refers to the link system ofthe body, in which the links are made up of aseries of joints that connect bones to oneanother, with articulation of the jointsprovided by muscle action. The term open-

chain movement is commonly applied toactions in which the distal end of a limb isfree to move in space, whereas closed-chainmovement refers to any exercise where thedistal end of a limb meets with externalresistance that prohibits or restrains its freemotion. It is important to note that themuscle actions during open-chainmovements are reversed during closed-chainmovements. In reality, human movement iscomposed of a variety of open- and closed-chain movements. For example, picking up ashopping bag is a closed-chain movementwith respect to the legs and an open-chainmovement with respect to the trunk andupper body.

When designing a corrective exerciseprogramme, it is important to prescribecompatible chain exercises, where possible.This will enhance the degree of functionalcarry-over to daily life. In some cases,compatible exercises may not be possible.For example, in the presence of closed-chaindysfunction, closed-chain exercise may resultin compensatory muscle recruitment thatmay further hinder normal muscle activity. Inthis situation, the use of open-chain exercisesthat isolate specific joint movements mayimprove strength and range of motionsignificantly, prior to the reintroduction ofclosed-chain movements.


4PRINCIPLES OF MANUALMUSCLE TESTING

IntroductionMuscle weakness is a common characteristicof muscle performance, even in individualswho participate in regular physical activity. Itis a misconception that participation inregular exercise or sport places adequatedemands on all muscle groups, and precisemuscle testing will often identify a number ofweak muscles.

Muscle strength testing is used todetermine the ability of muscles to providestability and support as well as their capabilityto function during movement. Muscle lengthtesting is used to determine whether musclelength is limited (too short to allow normalrange of motion) or excessive (too long,allowing a larger range of motion).

Manual muscle testing is an integral partof the physical evaluation of a client. Itprovides the therapist with an importantdiagnostic tool for objective assessment ofmuscular weakness. Many neuromuscularand musculoskeletal impairments arecharacterised by muscle weakness, resultingin imbalance. Muscle weakness will result inloss of movement if the muscle cannotcontract sufficiently to move the body partthrough a partial or complete range ofmotion; weakness allows a position ofmisalignment. It is important to understandthat muscle shortness will also result in lossof motion if the muscle cannot be elongatedthrough its full range of motion; shortness

causes a position of misalignment. A state ofmuscle imbalance exists when a muscle isweak and its antagonist is strong; the strongmuscle tends to shorten and the weak muscletends to lengthen.

Although shortness of muscles iscommonplace, in many cases this is correctedmost effectively by stretching the muscle andstrengthening the antagonist. Wherestretching is indicated, short muscles shouldbe stretched in such a way as to preventinjury, with the end goal of permittingoptimal joint function. The only exception isa restriction of motion for the sake ofstability.

Imbalances may be the result ofoccupational or recreational activities inwhich there is repeated use of certainmuscles, without adequate exercise of theopposing muscles. In any instance, imbalancemay be symmetrical or asymmetrical, asrevealed by accurate muscle testing. Muscleimbalances can also distort body alignmentand are responsible for a number of faultypostures (see Chapter 2). These imbalancescan contribute to unnecessary stress andstrain on joints, ligaments and muscles.Manual testing of muscle strength and lengthis the therapist’s tool of choice to determinethe extent of an imbalance prior tocorrective exercise prescription.

Identifying the changes that occur inmuscle and the causes of these changes is thekey to restoring optimal neuromuscular and

musculoskeletal function. Changes in muscleare not limited to those who do exercise orhave physically demanding jobs; even themost sedentary lifestyles are associated withrepeated movements or postures that maycause functional changes in muscle. If thesemovements and postures are maintained infaulty alignment, there may be changes inmuscle strength and length. Also, the role ofthe nervous system as a contributing factor tomusculoskeletal pain is oftenunderemphasised in rehabilitation. Ascommonly observed, many individuals withstrong muscles develop pain syndromes.Often these syndromes need to be addressedby instructing the individual to controlmovements by conscious effort rather than byincreasing muscle size.

Before designing an effective correctiveexercise programme, it is important tounderstand that changes in recruitmentpatterns, as well as muscle length and musclestrength, are concurrent. The most effectiveapproach should address all three issues:strength or stretching exercises alone areunlikely to affect muscle recruitment duringfunctional activities. Because the maximalstrength a muscle can develop is directlyrelated to the initial length of its fibres,muscle strength and length testing providesthe therapist with important informationregarding muscle function. Knowledge ofsynergistic muscle action during functionalmovement, combined with accurate muscletesting, will give the therapist a valuablediagnostic tool when designing correctiveexercise programmes.

Causes of muscleweaknessMany factors contribute to muscle weakness,including atrophy, stretch weakness and

strain, often causing pain and fatigue as wellas changes in muscle recruitment, such assubstitution and altered (synergistic)dominance. Weakness should be addressedin accordance with the root cause – if due todisuse (atrophy), then corrective exercises; ifdue to overwork (strain), then rest; if due tooverstretch (stretch weakness), then relief ofthe stretch.

Weakness resulting frommuscle atrophyMuscle weakness resulting from muscleatrophy is not normally associated with painon contraction, but with an inability to holdthe relevant limb in the test position or atany point against resistance in the test range.This type of weakness can affect both theactive and passive tension of a muscle,subsequently influencing the static anddynamic stability of the joint it crosses: theresult is a significantly reduced ability of themuscle to develop force, less stability of thejoint and potentially faulty joint alignment.The decreased number of sarcomeres andconnective tissue resulting from muscleatrophy means that muscle size anddefinition are often reduced.

The reversal of muscle atrophy is bestachieved via corrective strengtheningexercises that focus on specific muscles,particularly if there is an imbalance ofsynergists (as opposed to general atrophy).Exercises that emphasise major musclegroups may not necessarily correct atrophy ofonly one of the muscles within the group,but may contribute further to it.

Weakness resulting frommuscle strainMuscle weakness can also occur in the formof strain, resulting from excessive short-term


stretching or excessive eccentric loading ofmuscle. Muscle strain is almost invariablyassociated with pain on contraction andpalpation, and, as with atrophy, the muscle isunable to hold the limb in any positionagainst resistance. Strained muscles shouldbe rested at their ideal length to preventfurther stretching.

Any exercise prescription should berelatively pain-free; once the muscle is nolonger painful, any underlying weaknessshould be treated in the same way as atrophy.

Weakness due to overstretchMuscles that are subject to prolonged periodsof stretch may become weak and maintain alengthened position. Characteristics that helpto identify overstretch weakness are:

1 The muscle tests weak throughout itsrange of motion.

2 Postural alignment evaluation indicates anincreased resting muscle length (forexample, depressed shoulders or hipadduction/medial rotation).

Overstretch weakness may be reversedeffectively via an exercise programme thatstrengthens the muscle and alleviates thestretch; concurrently, the client may alsoneed to be instructed in correct posturalhabits, particularly during periods ofinactivity (such as prolonged sitting orsleeping).

Overstretch can often progress to painfulmuscle strain if not corrected soon after theonset of the length change.

Practical considerationsin muscle testingMuscle testing requires a detailed knowledgeof the agonistic and antagonistic actions of

muscles, as well as their role in stabilisationand substitution. The relationship betweenmuscle imbalance and faulty movementoffers a unique approach for treatment viacorrective exercise. Specific exercises that are

21Principles of manual muscle testing

Clinical perspectiveIt is important for the therapist todetermine the cause of identified muscleweakness and be aware that weakness canresult from all repeated movements orpostures, even when asleep.

Three important examples exist ofoverstretch weakness during sleeping. Thefirst is the development of elongateddorsiflexors (and shortened plantarflexors) in the supine position, caused bythe downward force of the duvet on thefeet.

Second, in the side-lying position,where the upper leg is in adduction,flexion and medial rotation, there will beprolonged stretching of the posteriorgluteus medius. This condition is moreprevalent in individuals who have a broadpelvis and is therefore more common inwomen. During manual muscle testing,these individuals will be unable tomaintain the hip in abduction, extensionand lateral rotation against resistance. Thisoverstretch weakness can produce hipadduction or an apparent leg lengthdiscrepancy when standing.

Third, the side-lying position can alsocause abduction and forward tilt of thelowermost scapula, particularly if theshoulder is pushed forwards duringsleeping; this may result in overstretch ofthe lower trapezius and rhomboids. Thetop shoulder may also be subject tooverstretch, via forward pull of the armacross the body.

based on the results of the muscle tests offerthe most effective treatment.

The order in which muscles are tested isgenerally a matter of preference; however,the tests should be ordered to avoid frequentand unnecessary changes in position for theclient. Muscles that are closely related inaction or position should be tested insequence.

Length testingMuscle length testing involves movementsthat increase the distance between theinsertion and origin of a muscle, thereforeelongating it in a direction opposite to themuscle action.

For muscles that pass over one joint only(for example, the iliopsoas), the range ofjoint motion and the range of muscle lengthwill be the same. For muscles that pass overtwo or more joints, the range of musclelength will be less than the total range ofmotion of the joints over which the musclepasses. When measuring the range of motionof a two-joint muscle, it is necessary to allowthe muscle to be slack over one joint in orderto measure the range of motion in the otherjoint.

Precise testing requires that the bone ofthe origin of the muscle be in a fixedposition, while the insertion moves in thedirection of muscle elongation. Althoughmostly passive, length testing can involveactive assisted movements on the client’spart.

Strength testingMuscle strength testing involves placing abody part in a position against gravity (whereappropriate) and applying pressure directlyopposite the line of pull of the muscle beingtested; the body part proximal to the tested

area is stabilised or fixated (if necessary) toensure specificity of testing.

The placement, direction and amount ofpressure applied to the body part areimportant (yet subjective) factors whentesting for strength. As a general rule,pressure is applied gradually in order to


Clinical perspectiveLimited joint range of motion caused byshort muscles is an important contributorto musculoskeletal pain and is oftentreated by muscle stretching. Althoughvigorous passive stretching can yieldsignificant improvements in joint range ofmotion within short time periods (10–20minutes), these methods can disruptmuscle fibre alignment and damage themuscle. Stretching a markedly shortmuscle may be more effectively achievedby prolonged stretching at low loads overlarger timescales, to produce morepermanent structural changes in muscle.

Emphasis is often placed on stretchingmuscles that have shortened and not oncorrecting muscles that have lengthened.It is important to be aware that alengthened muscle does not automaticallyshorten when its antagonist is stretched.The most effective treatment is to stretchthe shortened muscle while simultaneouslycontracting the lengthened muscle. Thisapproach is very successful as it addressesthe length changes of all muscles involvedand is particularly important in caseswhere the short muscle causescompensatory movement at a joint (orjoints). For example, if short hamstringscause compensatory lumbar flexion, theback extensors as well as the kneeextensors should be contracted whilestretching the hamstrings.

determine the degree of muscle strength.Sudden applied pressure can break the pullof an apparently ‘strong’ muscle.

When a muscle or muscle group attemptsto compensate for a lack of function of aweak muscle, the result is a substitutionmovement. For accurate strength testing,substitution should be avoided bymaintaining the correct test position and viaassisted fixation. For example, during pronehip extension the lumbar erectors may causeanterior pelvic tilt (substitution), due to aweak gluteus maximus. This can be avoidedby correct cuing of the movement by thetherapist or by stabilisation of the pelvis.

In strength testing, grading is based onthe ability of the client to hold the body partin a given position against gravity: in thisinstance, strength is graded as ‘fair’, becausethe pull of gravity is a constant factor. Gradesabove and below ‘fair’ involve a subjectiveevaluation based on the pressure applied.

Finally, it is important to note that musclestrength is not constant throughout therange of motion, and in testing it is notadvisable to grade strength at various pointsin the range. The point in the range ofmotion that is used for grading is determinedon the basis of whether the muscle is a one-joint or multi-joint muscle. The position for aone-joint muscle is at completion of range ofjoint motion; for a two-joint muscle, it iswithin the mid-range of the overall length ofthe muscle.

Altered dominance inmuscle recruitmentpatternsOne of the most common contributors tomuscle imbalance is reciprocal inhibition. Anunderstanding of this concept, and therelated phenomenon, synergistic dominance, is

important during all stages of the evaluationprocess.

Reciprocal inhibition occurs when a tightmuscle causes decreased neural input to itsfunctional antagonist. When the neural driveof a muscle is reduced, it will no longerproduce the same amount of force withproper timing. In order to maintain the sameproductivity of a given movement pattern,the synergists must take over the role ofprime movers. The nervous system willrespond by increasing the neural activity tothe synergists: a concept known as synergisticdominance. Synergistic dominance producesa movement that occurs with alteredneurological and mechanical control.

Reciprocal inhibition and synergisticdominance can lead to a decrease in theactivity of the prime mover and caneventually result in atrophy and alteredappearance of the muscle, and,consequently, pain and injury.

Alterations in the recruitment of synergiststhat can be clinically observed includerepeated recruitment of only one muscle of aforce couple or of one muscle ofcounterbalancing synergists. The result is amovement that is in the direction of thedominant synergist. With this in mind, anymovement pattern repeated often enoughhas the potential to create imbalance withinthe tissues creating that movement.

The following examples highlight some ofthe more commonly observed synergisticdominance patterns that may be useful whenconsidering corrective exercise prescription.

Dominance of the uppertrapezius over the lowertrapeziusBalance of the upper and lower trapezii isfundamental to optimal control of the


scapular. Whereas the lower trapeziusdepresses the scapula, the upper portionelevates it and is often dominant. Thiscommonly observed pattern of excessiveelevation is generally a result of learnedbehaviour rather than an issue of musclestrength, and, as such, lower trapeziusstrengthening exercises alone may not beadequate; instruction in properscapulohumeral rhythm has a greaterlikelihood of restoring balance and strength.

Dominance of the hamstringsover the abdominalsThe hamstrings and abdominals combine toform a force couple for posterior pelvic tilt:the abdominals exert an upward pull on thepelvis, while the hamstrings exert adownward pull. When the abdominal musclesweaken, the hamstrings become thedominant driving force on posterior pelvictilt, a pattern that becomes reinforcedthereafter. The result is an imbalance instrength, with the abdominals testing weakand the hamstrings testing strong.

An observation of this imbalance can bemade during straight leg-raising in a supineposition. If the abdominals are weak, thecontralateral hamstrings will stabilise theanterior pelvic tilt to a greater extent thanthe abdominals. Instruction in reducing theamount of hip extension via the hamstringswill help to increase activity of the abdominalmuscles and restore optimal synergy betweenthe two groups of muscles.

Dominance of the hamstringsover the gluteus maximusThe hamstrings and gluteus maximus alsocombine to form a force couple for hipextension. Where the gluteus maximus is the

dominant muscle of hip extension, itsattachments to the proximal and distal (viathe ITB) femur reinforce the position of thefemoral head in the acetabulum during hipextension, providing stability. Disruption ofthis synergy is commonly seen in sway-backpostures, in which the hamstrings aredominant. During a prone hip extensionmovement, an individual with sway-backposture often recruits the hamstrings beforethe gluteus maximus; muscle testing of thegluteus maximus usually confirms weakness.

This hamstring dominance can predisposethe individual to an overuse syndrome, suchas muscle strain, and is a commonoccurrence in distance runners. Because thehamstrings (with the exception of the shorthead) do not attach on the femur, they donot offer precise control of the femoral headduring hip extension; therefore, dominantactivity of the hamstrings can also contributeto hip joint stress. This may be exacerbatedfurther by the presence of weak hip flexors.

Dominance of the pectoralismajor over the subscapularisDuring the action of humeral medialrotation, the pectoralis major is oftendominant over the subscapularis. Accurateobservation and palpation of humeralmovement during medial rotation will oftensupport these findings in the first instance. Ifthe pectoralis major is dominant, thehumeral head will glide excessively in ananterior direction, unable to becounterbalanced by the action of thesubscapularis (posterior glide of the humeralhead). When the subscapularis is tested inthe prone position, it usually tests weak,caused by excessive length.


Dominance of the rectusabdominis over the externalobliquesThe rectus abdominis and external obliquecombine to form a force couple producingposterior pelvic tilt. Commonly, the rectusabdominis may be the more dominantmuscle for this action, and is also visually

observed by a depression of the chest. Wheninstructed to perform lower abdominalexercises, the individual will have difficultyrecruiting the external obliques, as indicatedby palpation, instead preferring to engagethe rectus abdominis. Assessment of themovement will reveal associated trunk flexionor chest depression.


5PRINCIPLES OF PROGRAMMEDESIGN

IntroductionHuman movement is made up of integratedmuscular performance, with musclesperforming actions in a multi-planarenvironment, often at different speeds. Forthis reason the exercises presented in thisbook support an integrated approach torehabilitation that can benefit manyindividuals. Approaches that focus solely onmuscle strength at the expense of developingfunctional movement patterns are generallyless effective.

Corrective exercise programmes should bedesigned in a structured yet purposefulmanner. This concept is known asperiodisation and is based on the correctmanipulation of exercise variables over time,to ensure safe and effective progression.

The exercises presented in this book areordered into four systematic and progressivephases, with each phase acting as aprerequisite to that which follows. The fourphases are:

1 restoring muscle balance

2 restoring stabilisation

3 restoring functional strength

4 restoring functional power.

This chapter aims to discuss the rationalebehind these progressions and highlight theadaptations that can be made during eachphase. This is followed by a discussion of

which exercise variables are needed for eachspecific adaptation, and how to manipulatethese variables safely to achieve and maintaina positive slope of improvement for theclient.

Phases of exerciseprogressionUndoubtedly, the most important outcomeof any rehabilitation programme isimprovement, as defined by the client’sgoals. Exercise progression is essential toachieve this outcome. Once a slope ofimprovement has been established, exercisesmay be progressed to increase functionalperformance, as well as general motivation.

The phases of exercise in this book aredesigned to follow a hierarchal structure inrelation to the development of seven relevantbiomotor skills: flexibility, balance, muscularendurance, strength, coordination, agility andpower/speed. As the client moves through eachphase, biomotor skill acquisition increases.

The therapist should aim to progress theclient through the phases in the orderdescribed; however, all phases may not benecessary to restore optimal function. Forexample, the occupational and recreationaldemands of a specific client may be metthrough the exercises in phases 1 and 2 only.

Effective and appropriate periodisation oftimescales is also important, and is

dependent on the client’s goals and theirtraining experience/age. It is recommendedthat 4–6 weeks is spent in each phase beforeprogression to the next phase; a frequency ofexercise matching three times a week will besufficient in achieving the required goals. Iftraining experience and training age arehigh, the client may progress through eachphase at a faster rate. However, it is the roleof the therapist to determine accuratelywhether the client is ready for progression,by objective feedback (re-evaluation) andsubjective feedback (observation andperceived exertion). Ultimately, the progressand success of any corrective exerciseprogramme will be subject to individualcompliance and the development of apractical home exercise programme.

The list of exercises contained in the laterchapters are by no means exhaustive,although they do provide the therapist with abasic library from which to start prescription.Where possible, this library should be builtupon in accordance with the four phases ofprogression to increase the number ofoptions available.

ContraindicationsAny contraindications to exercise should befully understood by both therapist and client.If a particular movement pattern cannot beperformed by the client, the therapist shouldexplore variations of that movement beforeremoving the exercise from the programme.In many cases, a good understanding ofbiomechanical principles will allow thetherapist to reposition a client or regress anexercise to make it safer and eliminate risk ofinjury altogether.

Where the treatment of pain orimpairment is beyond the level ofcompetence of the therapist, referral may benecessary.

Phase 1 – Restoring musclebalanceRelevant biomotor development – flexibility,strengthThe aim of phase 1 is to restore normalmuscle length, in particular, of the musclesresponsible for gross movement. This beginswith a number of flexibility and strengthexercises designed to restore range of motionand introduce postural awareness. Theexercises should be based on functionalmovement patterns where possible –establishing familiarity of movement at anearly stage will result in greater potential forapplication of movement post-rehabilitation.Range of motion should be developed inaccordance with optimal joint and musclefunction that is specific to the client. The

27Principles of programme design

Clinical perspectiveThe use of soft-tissue treatment can oftenbe combined with corrective exercise toassist progression in clients who presentwith local muscle ischaemia and abnormalmuscle texture.

Ischaemia is often caused by musclespasms, trigger points, poor posture orpsychological stress, resulting indysfunctions of agonist–antagonistrelationships and/or imbalanced forcecouples. These dysfunctions may delayrecovery as well as progression throughexercise, unless alleviated at the outset.For this reason, appropriately qualifiedtherapists can use a variety of soft-tissuetreatments to remove muscle spasm andrelease the tissues that may otherwiseimpede normal muscular and jointfunction during exercise.

client should be encouraged to play an activerole in their treatment.

This phase is an essential first step incorrecting any muscle imbalances, asidentified by muscle testing. Beforebeginning this or any other phase, it isessential that acute pain and inflammationhave been treated appropriately. Flexibilityand mobility may also be enhanced throughthe use of additional approaches such asmuscle energy technique (MET), activeisolated stretching (AIS) or somaticeducation methods, such as the Feldenkraismethod.

Phase 2 – RestoringstabilisationRelevant biomotor development – flexibility,strength, muscular endurance, balanceThe aim of phase 2 is to restore and enhancethe joint stabilisation role of muscles by

retraining co-contraction force couples. Thiscan be achieved using static, dynamic andreactive stabilisation exercises. Staticstabilisation exercises activateagonist–antagonist force couples, withminimal joint movement, while dynamicstabilisation does so during a partial or fullrange of motion activities. Reactivestabilisation exercises focus on stimulatingproprioceptive pathways that are the basis ofmore complex movements, and also help tocondition balance and spatial awareness. Allthree mechanisms are essential forenhancing muscle activation awareness.

Exercises in this phase becomeprogressively more complex by addingcomponents of muscular endurance andbalance (as well as continuing strengthdevelopment). The range of stabilisationdemands imposed on the body by theactivities of daily living also requires trainingin a number of body positions in both open-and closed-chain settings. Muscularendurance is best conditioned through theuse of positional holding patterns (up to 8seconds) or higher repetition of movement;balance can be improved effectively via theintroduction of the client to labile surfaces,such as a stability ball or balance-board, or bysimply reducing the base of support, such asa single-leg stance.

The higher-repetition routines used in thisphase help to increase vascularisation oftissues for better recovery, and prepareconnective tissues for the higher demands ofstrength and power training in phases 3 and4. Reactive movement patterns are selectedwhere possible to increase the proprioceptivedemands placed on the body: by performingexercises on labile surfaces (to a level that aclient can control), the nervous system isforced to adapt by enhancing its centralstabilisation mechanisms. This form oftraining can be extremely effective for


Clinical perspectiveWhen muscles exhibit excessive length,stretching should be avoided, as well aspostural positions that may furtherlengthen the already stretched muscles.For example, a low back that is excessivelyflexible will be stretched further duringprolonged periods of slumped sitting. Theobjective in this situation is to correctposture during sitting. Althoughstrengthening exercises can be used, formany active individuals strength willimprove simply by avoiding overstretching.

Stretching exercises are encouragedwhere muscles are short. Exercises must beprescribed and administered correctly toavoid unnecessary stretching in other partsof the body.

increasing neuromuscular coordination andefficiency, and is an essential prerequisite foraction-specific strength adaptations.

Selection of functional exercises will offerthe client significantly more carry-over intodaily life. These exercises are used asbuilding blocks for the more advanced andcomplex movement patterns outlined inphases 3 and 4. Lack of the skills from thisphase may result in deficits in movementpattern and movement response.

Phase 3 – Restoring functionalstrengthRelevant biomotor development – flexibility,strength, muscular endurance, balance,coordinationThe aim of phase 3 is to restore functionalstrength and further develop coordination ofmovement, usually in a functional uprightstance. This is achieved using combinationsof primary movement patterns.

Strength training allows for increases involume, intensity and force production toenhance the preparation of a client for thehigher force demands of their daily orsporting activities. During exercise,concentric, eccentric and isometric muscleactions are emphasised, with progressingspeeds of contraction to maximise betterforce production. Hypertrophy is often anadaptation in this phase of training.

Functional strength exercises are usuallyperformed using resistance in the form ofexercise bands or tubing, or free weights,although in many instances body weight isjust as effective, particularly if the client isunaccustomed to resistance training. Many ofthese exercises can be modified to meet therequirements of functional activities, simplyby manipulating body position or range ofmotion.

Strength training can also be modifiedeffectively to increase ‘stabilisation-endurance’, essential for optimal jointstabilisation. This form of training entails theuse of ‘super-set’ techniques, where a stableexercise, such as a floor bridge, isimmediately followed with a stabilisationexercise that has a similar biomechanicalmotion, such as a supine hip extension (feeton a stability ball). High amounts of volumeper unit time can be generated in this way.

The outcomes of this phase include


Clinical perspectiveThe use of visualisation and kinaestheticawareness is an important teaching aidduring the development of muscle balanceand stabilisation in phases 1 and 2. This isparticularly important when instructing onspinal alignment and muscle activationawareness.

The constituent movements of anexercise may be visualised in a slow-motionsequence prior to performance. Thisstrategy is particularly useful for teachingintegrated movement patterns, such assquatting or rotation. Sometimes use of amirror can be beneficial in this process.

Alternatively, the practice of simplekinaesthetic techniques, such asprogressive muscle relaxation (PMR), canhelp to establish control of joint stiffness.Instructing a client in self-palpation duringmuscle contraction may also help them tofocus on the specific muscle or musclesinvolved.

Further information on thedevelopment of awareness for exercise canbe gained from the work of MosheFeldenkrais, F. Mathias Alexander andThomas Hanna.

increased functional strength in both open-and closed-chain environments, as well asimproved link-sequencing and forcegeneration through the kinetic chain.

Phase 4 – Restoring functionalpowerRelevant biomotor development – flexibility,strength, muscular endurance, balance,coordination, speed, agilityThe aim of phase 4 is to introduce speed ofmovement that has functional carry-over fordaily living: a concept known as functionalpower. Movements in daily life are rarelyperformed at fixed speeds, but involveacceleration and deceleration, combinedwith stabilisation. For this reason, exercisesthat are performed with quick, powerful andexplosive movements are used to improvefunctional power.

Many functional power exercises closelymimic common everyday movements andusually involve integration of the entirekinetic chain. Activities in the occupationaland recreational environment do nottypically require significant loading ofmuscles and joints; therefore exercisesshould focus on the control and stabilisationof movement under speed, rather thanunnecessary amounts of resistance.Additional resistance may be applied wherethe functional demands of occupation orsport dictate.

Functional power training is achieved byeither increasing the load (force), as inprogressive strength training, or increasingthe speed (velocity) with which the load ismoved. Power training increases the rate offorce production by increasing the numberof motor units activated, the synchronybetween them and the speed at which theyare excited. By using either heavier weights

(approximately 60 to 90 per cent, 1-repetition maximum) with explosivemovement or low resistance with a highvelocity, power output is significantlyincreased.

For power movements to occur safely,range of motion, stabilisation and functionalstrength must all be optimal. Particularemphasis should also be placed on optimalshoulder, trunk and hip integration, toensure smooth coordination of groundreaction forces up through the body. Thiswill result in coordination and control ofmovement, providing a high degree offunctional carry-over into occupation,recreation and sport.


Clinical perspectivePlyometric training, originally known asjump training, is a form of power trainingthat combines speed of movement withstrength. The purpose of plyometrics is toheighten the excitability of the nervoussystem to help improve the reactive abilityof the neuromuscular system.

Any movement that uses the stretchreflex to increase force production isplyometric in nature. During plyometricexercise, the eccentric pre-stretch ofmuscle places additional stress on themusculo-tendinous junction. This stretch-shortening cycle may be beneficial in themanagement of tendonitis, by increasingthe tensile strength of the tendon.

Through a gradual and progressiveeccentric-loading programme, thetherapist can use plyometric exerciseeffectively to facilitate joint awareness,strengthen soft tissue during healing andincrease functional strength and power inall three planes of movement.

Acute exercise variablesProgression through a corrective exerciseprogramme requires the consideration andmanipulation of specific acute exercisevariables. These include:

❑ exercise selection

❑ number of exercises

❑ exercise sequence

❑ repetitions performed

❑ number of sets

❑ tempo of movement

❑ rest or recovery time

❑ load applied.

Manipulation of variables should be based onthe current level of functional capacity of theclient (that is, the volume and intensity ofexercise they can currently tolerate). As theclient improves during the exerciseprogramme (observed or reported),functional capacity will increase. This positiveslope of improvement can be maintained byfurther manipulation and management ofacute exercise variables.

Exercise selectionTherapists and exercise professionals face theconstant challenge of meeting a wide rangeof rehabilitation and performance objectives.No set of exercises is ideal for everyone andall corrective exercise programmes shouldconsider the client’s objectives, as well astheir exercise history.

Exercise selection should be synonymouswith the objective of achieving optimalmovement capability for the client’sdemands. As such, the criteria for functionalmovement should be used as a guideline.Once exercises have been chosen, thetherapist should consider how to progress as

well as regress an exercise, while still trainingthe required movement pattern. This is easilyachieved by identifying the base and primarymovements that the exercise is made of, andincreasing the demands of those movements:for example, adding another plane of motion or challenging a particular biomotorability.

Exercise selection should always besupported by the results of posturalassessment, movement analysis and muscletesting. Given the individual nature andcircumstances of each client, choosing theappropriate exercises should take intoaccount the goals of the client, as well asother factors, including existing or pastinjury, training history and occupation.

Injury historyThe effects of past injury often affect theindividual’s ability to perform exercisescorrectly, and the extent of this should beassessed carefully during the evaluationstages. Depending on the type of injury,exercises can be selected that work towardsthe goals of rehabilitation, while treating theinjury itself.

Training historyTraining history relates to training age andtraining experience. Training age signifiesthe amount of time spent doing exercise,whereas training experience is determined bybiomotor development. Greater training ageand experience allow for more advancedexercise selection.

Occupational historyKnowledge of the demands placed upon aclient by their working environment is anessential requirement in successful exerciseprescription, for two main reasons. First,occupational demands will determine thecurrent level of functional capacity of the


client (that is, the volume and intensity ofexercise they can currently tolerate). Second,an understanding of the client’s movementpatterns in the workplace may suggest themechanical cause of impairment or injury,which can then be corrected throughexercise.

Number of exercisesThe number of exercises selected forinclusion in a programme can mean thedifference between success and continuedimprovement, or failure and non-adherence.If too many exercises are prescribed, the riskof injury increases, as the body can onlyrecover from a certain level of physical stress.This is an important factor in clients withinjury, as a significant number of resourceswill already be involved in combating pain orinflammation present.

Specificity is also reduced when too manyexercises are used as the body has limitedcapacity to adapt to multiple stimuli.

Exercise sequenceThe order in which exercises are performedis often overlooked, but it is an importantfactor that can contribute significantly to thesuccess of an exercise programme. Thefollowing should all be considered whensequencing an exercise programme:

1 Highly integrated exercises should beperformed before isolation exercises, toavoid fatigue of stabiliser muscles. Injurymay result if stabiliser or smallersynergistic muscles are exercised inisolation first, and they may destabiliseassociated joints during the laterexecution of complex movement patterns.

2 Training should progress from the mostimportant to the least important exercises,

in relation to the objectives of exercise.This will prioritise specific skill andmovement acquisition over those that arenot as important.

3 Exercise should move from the most tothe least neurologically demanding. Theuse of proprioceptive aids, such as stabilityballs and balance-boards, will significantlyincrease neural drive to muscles viafurther activation of righting and tiltingreflexes. If placed at the start of aprogramme, these exercises willsignificantly challenge the client withouttoo much risk of nervous fatigue.


Clinical perspectiveConsideration of the spine is important inthe sequencing of exercises within a singlesession. Prior activities and positions canaffect the mechanics of the spine inensuing activities. For example, theligamentous and disc creep that occursafter prolonged sitting can result inligament laxity and subsequent risk ofinjury. Although disc volume appears toredistribute evenly on standing, this cantake time, sometimes up to half an hour.With this in mind, exercises involvingloading under flexion should be avoidedinitially, before being sequencedalternately with exercises involvingextension.

In order to reduce viscous frictionwithin the spine, specific movementpatterns should be performed as part of awarm-up. The most effective are thoseperformed in a slow, continuous mannerthat emphasise precision and control ofmovement, for example, the cat-camelexercise or a sequence of Feldenkraismovements.

RepetitionsCorrective exercise programmes shouldgenerally begin with a 12–15 repetition rangeas this allows for a safe lifting load prior toprogression. Further progression will then bedependent on the following factors:

1 Whether the client’s rehabilitationobjectives are power, strength,hypertrophy or muscularendurance/stabilisation

2 Biomotor ability – if the client does nothave adequate biomotor skill to perform aprescribed exercise with good technique,a reduction in repetitions may benecessary to enhance motor development,before increasing repetitions

3 Available time – repetitions can bedecreased if time is a factor.

SetsThe number of sets performed will dependon training experience and age, occupationaland recreational demands and timeavailability. Performing more sets will greatlyincrease the volume and overall intensity ofan exercise programme, thereby increasingrecovery needs.

TempoTempo refers to the speed at whichrepetitions are performed and is described interms of concentric, isometric and eccentricmovements. Therefore a ‘2-1-2’ tempo woulddescribe a movement which involves 2seconds of concentric and eccentricmovement, with a 1-second isometric pause(or hold) in the middle. Of the acuteexercise variables, tempo is usually given theleast consideration, but has an important

role in rehabilitation. In the early phases ofcorrective exercise, where the developmentof new movement patterns is important,tempo should be slower and controlled tofacilitate optimal muscle recruitment.Medicine balls and other plyometricexercises are favoured for task-specific high-speed movements.

Manipulation of the isometric componentcan produce holding patterns which can beused to improve muscular endurance. Thesepatterns are integral to daily living where anumber of isometric holds may be required,for example, gardening. To ensure optimalrecovery of muscle, this duration should notexceed 8 seconds. When 8 seconds ofisometric contraction can be achieved, anincrease of repetitions and load should beprescribed. Corrective exercise programmesfor endurance/stabilisation developmentshould include both higher-repetitionroutines and holding patterns for optimalfunctional adaptation.

RestThis refers to the rest period between sets ofrepetitions and is a crucial element in theclient’s recovery and consequentperformance of an exercise. Too little restmay not provide adequate musculoskeletaland neuromuscular recovery, increasing therisk of immediate injury. Too much rest mayreduce the overall intensity of exercise andmay slow down or even prevent the desiredadaptive response.

LoadThe chosen load will be concurrent withrepetitions performed and the expectedadaptation. It is usually described as apercentage of the client’s 1-repetition


maximum, as determined objectively usingresistance, or subjectively via perceivedexertion.

A guide for how to manipulate sets,repetitions, load, tempo and rest for differentobjectives is given in Table 5.1.


Table 5.1. Manipulation of acute exercise variables for muscularendurance/stabilisation, strength, muscle hypertrophy and power

Adaptation Sets Repetitions Load Tempo Rest

Muscular endurance 1–3 15–20 40–60% 1-2-4 0–60 seconds1-8-4

Strength 2–4 4–6 80–90% 2-0-2 60–90 seconds

Hypertrophy 3–5 6–12 75–85% 1-2-3 30–60 seconds

Power 3–5 1–5 85–100% Explosive 2–4 minutes 8–10 30–45% Explosive

2 The Shoulder

The shoulder is most appropriately referredto as the ‘shoulder complex’ and comprises aunique arrangement of bones, joints andmuscles that allows the arm an incrediblylarge range of motion. It is considered one ofthe most complex musculoskeletal systems ofthe human body and serves as the functionallink between the upper limb and the trunk.Consequently, the shoulder complex mustprovide mobility, combined with a stable baseof support for the arm. While the absence ofbony constraints offers this range of motion,stability is sacrificed, being provided bymuscles and ligaments. Therefore, normalmuscle balance and integration are essentialfor normal shoulder function, whether foreveryday activities or for sport.

Movement of the shoulder and armoccurs through articulation of the shouldergirdle, consisting of the sternoclavicular andacromioclavicular joints, and the shoulderjoint, also known as the glenohumeral joint.The dynamic and integrated movement ofthese joints is known as scapulohumeralrhythm, a phenomenon that requires thecoordinated activity of up to 16 muscles. Thisintimate relationship between the scapulaand the humerus results in greater mobilitythan any other single articulation in thebody. Although, occasionally, movement ofthe scapula is deliberately restricted (as insome postural-based exercises), in all naturaland functional movement, articulation of thescapula and the humerus is continuous.

Given the complexity of the shoulder, it iseasy to see how a small imbalance in muscleaction can lead to functional problems withinthe shoulder joint; in activities of daily livingthese often manifest as changes inscapulohumeral rhythm. These changes maycause, or be caused by, poor posture, muscleweakness and imbalance or altered musclerecruitment patterns, resulting in pain, injuryand abnormal biomechanics of the shoulder.Effective treatment of these issues involves anunderstanding of normal shouldermovement, and the therapist must be able toassess correct alignment and movement ofthe shoulder girdle and shoulder joint, aswell as muscle length and strength. Followingthis, corrective exercise can serve to addressthese biomechanical deficiencies and restoreoptimal function.

This section aims to discuss the functionalanatomy and biomechanics of the shouldercomplex and to relate these biomechanicalprinciples to the accurate prescription ofcorrective exercise. A functional approach toclinical evaluation of the shoulder will also bepresented, laying down an essentialfoundation to the understanding of exerciseprescription. The final chapter provides thetherapist with a number of correctiveexercises for the shoulder within the contextof an overall framework for functionalprogression. These exercises are designed torehabilitate effectively and enhance theperformance of the shoulder complex.

6FUNCTIONAL SHOULDERANATOMY

Overview of shoulderanatomyThe skeletal anatomy of the shoulder jointcomplex is shown in Figure 6.1. The large

range of motion of the shoulder is achievedthrough the interaction of acromioclavicularand sternoclavicular joints of the shouldergirdle and the shoulder joint itself. Thismeans that all scapula movement is

Figure 6.1. Skeletal anatomy of the shoulder complex – (a) anterior, (b) posterior views

(a) (b)

Coracoid process

Acromion

Clavicle

Superior angle

Scapula

Medialborder

Inferior angleGlenoid cavity

Humerus

Clavicle

Superior angle

Humerus

Glenoidcavity

Inferior angle

Medialborder

Scapula

Acromion

Coracoid process

Spine

accompanied by movement of the shoulderjoint.

Structure and functionof the shoulder girdleThe shoulder girdle is made up of theclavicles and the scapulae. The claviclearticulates at two points: laterally with theacromion, forming the acromioclavicularjoint, and medially with the sternum,forming the sternoclavicular joint. Thesternoclavicular joint provides the only pointof articulation with the axial skeleton.

The sternoclavicular joint allows motion ofthe clavicle in all three planes of motion,producing the following observedmovements:

❑ elevation and depression of the shoulder

❑ forward and backward movement of theshoulder

❑ circumduction of the shoulder, with theclavicle revolving forwards anddownwards, or backwards and upwards.

Movement at the acromioclavicular joint islimited and involves a gliding motion of theclavicle on the sternum and rotation of thescapula. Movements at the sternoclavicularjoint combine with movement at theacromioclavicular joint to produce the largerange of movement observed with thescapula (see Figure 6.2).

The seven basic movements of the scapulaare:

1 elevation – a movement in which thescapula moves in a superior or upwarddirection, such as that found in shruggingof the shoulders

2 depression – a movement in which thescapula moves in an inferior or downward

direction, normally as a return fromelevation or anterior tilt

3 abduction – a movement in which thescapula moves away from the vertebralcolumn, following the line of the ribs

4 adduction – a movement in which thescapula moves towards the vertebralcolumn

5 upward rotation – a movement in whichthe inferior angle of the scapula moveslaterally and the glenoid cavity movesupwards

6 downward rotation – a movement inwhich the inferior angle of the scapulamoves medially and the glenoid cavitymoves downwards

7 anterior tilt – movement in which thecoracoid process moves downwards andanteriorly, while the inferior angle movesupwards and posteriorly.

37Functional shoulder anatomy

Figure 6.2. Movements of the scapula

Depression

Adduction

Elevation

Abduction

Downwardrotation

Upwardrotation

Anterior tilt

During functional activities of daily livingand sport, these individual scapulamovements do not occur in isolation, andnormally a degree of rotation or tiltaccompanies abduction/adduction andelevation/depression.

Structure and functionof the shoulder jointThe shoulder joint, also known as theglenohumeral joint, is a ball-and-socket jointformed by the articulation of the sphericalhumeral head with the glenoid fossa. The sixbasic movements of the shoulder joint are:

1 flexion – an anterior movement of thehumerus in the sagittal plane, which maystart from a position of 45° extension andends in an overhead position of 180°. It isimportant to note that full flexion capabilityof the shoulder is the result of an integratedaction of the shoulder girdle and shoulderjoint, known as scapulohumeral rhythm; thefirst 120° of flexion from a neutral positionare provided by the glenohumeral joint,with the remaining 60° of flexion occurringas a result of scapula abduction and upwardrotation.

2 extension – a posterior movement of thehumerus in the sagittal plane, which maystart from a position of full flexion (180°)and end in a position of 45° extension (armextended backwards). In the presence ofelbow flexion, the range of motion forextension will be increased, due to adecrease in the pull of the biceps brachii.

3 abduction – a lateral movement of thehumerus in the frontal plane, startingfrom a neutral position (arm by the sideof body) and ending in a position of 180°vertically overhead. This end position isthe same as that attained in flexion and is


Figure 6.3. Movements of the shoulder joint

Extension

Flexion

Abduction

Adduction

Lateralrotation

Medialrotation

the result of coordinated shoulder girdleand shoulder joint movements(scapulohumeral rhythm).

4 adduction – a medial movement of thehumerus in the frontal plane, often as areturn to the neutral position (arm by theside of body) from full abduction (180°).Adduction also accounts for up to 10° ofmotion in a direction that is obliquelyupwards and in front of the body.

5 lateral rotation – a movement in which thehumerus turns about its longitudinal axis,resulting in the anterior surface of thehumerus facing away from the mid-sagittalplane (arm turned outwards). The startingpoint is where the shoulder is in 90°abduction and the elbow flexed to 90°; theend position is where the forearm isparallel to the head at 90° lateral rotation.

6 medial rotation – a movement in whichthe humerus turns about its longitudinalaxis, resulting in the anterior surface ofthe humerus facing towards the mid-sagittal plane (arm turned inwards). Thestarting point is where the shoulder is in90° abduction and the elbow flexed to 90°;the end position is 70° medial rotation, ifno shoulder girdle movement is allowed.

Three additional functional movements ofthe shoulder joint occur as a combination ofthe above motions:

1 horizontal adduction – a forward movementof the flexed arm in the horizontal plane

2 horizontal abduction – a backwardmovement of the flexed arm in thehorizontal plane

3 circumduction – a sequential combinationof flexion, abduction, extension andadduction of an extended arm, so that thearm draws a cone shape with its apex atthe glenohumeral joint.

Muscles of the shoulderDuring movement of the shoulder complexthe synergistic action of up to 16 muscles actsto mobilise and stabilise the scapula andshoulder joint (see Figure 6.4). Thesemuscles have attachments on the scapula, thethorax, the vertebral column and thehumerus. The majority are obliquelyoriented to provide rotatory as well as linearmotion of the shoulder complex.

Understanding how these muscles worktogether to provide stability and movementwill enable the therapist to prescribecorrective exercise, restoring muscle balance,range of motion and functional strength.

Pectoralis majorA large fan-shaped muscle consisting of anupper (clavicular) and a lower (sternal)portion. The clavicular portion primarilyadducts the arm horizontally and is also


Clinical perspectiveShoulder pain is commonly associated withmedial rotation, which can make theshoulders appear rounded forwards at rest.This will prevent the arm being lifted to afull overhead position (that is, the abilityto achieve full flexion or abduction).

When lifting the arm to a full overheadposition, a degree of lateral rotation isneeded. Medial rotation of the shoulder atrest prevents the natural lateral rotation ofthe arm as it is lifted. This results in areduced ability to lift the arm overheadwithout compensatory movement or pain.

Therefore, a primary objective incorrective exercise would be to restore afunctional degree of lateral rotation.

responsible for medial (inward) rotation.Above the horizontal plane the clavicularportion aids further abduction. The sternalportion has an opposite action and producesa downward and forward movement of thearm.

The pectoralis major works synergisticallywith the serratus anterior and is important inall pushing, throwing and punchingmovement patterns in the sagittal plane.

Pectoralis minorA small muscle lying beneath the pectoralismajor, involved in anterior tilt of the scapulaas well as in downward rotation, depression,abduction and lateral tilt.

When the scapula is stabilised by themiddle trapezius and rhomboids, such asduring pulling or rowing actions, thepectoralis minor exerts an upward pull onribs three to five, thus contributing to good

thoracic posture. In this way it is regarded asan important postural muscle.

SubclaviusA thin muscle that depresses the clavical,draws the shoulder forwards and downwardsand helps to stabilise the sternoclavicularjoint during all shoulder movements.

CoracobrachialisA muscle that acts to adduct the arm weaklyand stabilise the humerus during shouldermovement. During adduction it workssynergistically with the clavicular portion ofthe pectoralis major; during stabilisation itworks with the middle deltoid and the longhead of the triceps.

During multi-planar movement itcontributes to global stabilisation of theglenohumeral joint.


Figure 6.4. Muscles of the shoulder – (a) posterior, (b) anterior views

(a) (b)

Trapezius

Deltoid

Levator scapulae

Supraspinatus

Infraspinatus

Teres minor

Teres major

Triceps brachii(long head)

Trapezius

Deltoid

Pectoralis major

Serratusanterior

Biceps brachi

TrapeziusA large scapula muscle consisting of threeparts (upper, middle and lower fibres),involved in four major movement patterns ofthe scapula: elevation, upward rotation,adduction and depression.

The upper fibres elevate the scapuladuring movement and stabilise the scapuladuring load-bearing activities. The middlefibres adduct the scapula (with therhomboids) and the lower fibres depress thescapula (along with the pectoralis minor).The upper and lower fibres combine to forma force couple, producing upward rotation ofthe scapula.

Latissimus dorsiA broad sheet of muscle that extends,adducts and medially rotates the arm. It alsodraws the shoulder downwards andbackwards. Through its attachment to theinferior angle of the scapula it keeps thescapula positioned against the thoracic wall.

Levator scapulaeA muscle that elevates the medial border ofthe scapula in conjunction with the upperportion of the trapezius. With the rhomboidsand pectoralis minor it acts to produce adownward rotation of the scapula.

Rhomboids (major and minor)From a functional perspective, therhomboids act as a single muscle. Theirprimary action is to adduct and stabilise thescapula in conjunction with the middle fibresof the trapezius. This force couple isimportant in both static and dynamicshoulder posture.

The secondary action of the rhomboids isdownward rotation of the scapula.

Serratus anteriorThis muscle works to abduct the scapula, anaction that is antagonistic to the action of therhomboids. It also combines with the uppertrapezius to form a force couple that rotatesthe scapula during abduction and flexion ofthe arm.

DeltoidA large muscle of the shoulder consisting ofthree parts: anterior, middle and posteriorportions. The anterior portion acts to flexand medially rotate the arm and is activeduring all forward movements, such asthrowing and punching. The middle portionacts to abduct the arm and the posteriorportion extends and laterally rotates the arm.

The rotator cuff groupAs a group the rotator cuff muscles act todraw the humerus towards the glenoid fossaand subsequently prevent the larger musclesfrom dislocating the humerus duringmovement.

SupraspinatusAids the deltoid in abduction of the arm aswell as weakly flexing the arm.

InfraspinatusThe main action of this muscle is to rotatelaterally and abduct the arm. In particular,this muscle prevents posterior dislocation ofthe arm during crawling movements.

Teres minorThis muscle contributes to a force couplewith the infraspinatus, producing lateral


rotation of the arm. It also weakly adductsthe arm.

SubscapularisThis muscle’s main action is medially torotate the arm. It specifically contributes toanterior stabilisation of the glenohumeraljoint.

Teres majorA small muscle that medially rotates, adductsand extends the arm. During these actions itworks with the latissimus dorsi.

Biceps brachiiA large muscle of the arm, which crosses theshoulder joint to flex weakly and adduct thearm.

Triceps brachii (long head)This muscle aids in extension of the arm aswell as adduction of the arm from anabducted position.


Clinical perspective –Comparative anatomy of theshoulder and hip jointThe shoulder girdle and joint aredependent upon functional stability of thewhole kinetic chain; shoulder instabilitymay be a common manifestation ofinstability within the hip.

Many approaches to rehabilitation andconditioning of the shoulder and hipjoints have been derived from the study ofprimary reflexes that emerge shortly afterbirth, such as cross-crawl patterns, wherethere is smooth integration of theshoulder and hip complexes. Cross-crawlmovements, such as four-point kneelingexercises, have been successful in manytherapeutic settings. These are based on anumber of biomechanical principles, forexample, the glenohumeral joint becomesmore stable under load, in a closed-chainenvironment.

Interestingly, there are a number ofstructural similarities between the shoulderand hip joints. Both joints exhibit a highdegree of mobility as ball-and-socket joints,and serve as foundations for the moreflexible spinal segments of the cervical andlumbar spine, respectively.


Table 6.1. Summary of muscles involved in shoulder movements

Movement Prime mover Synergist

Scapula elevation Upper trapezius RhomboidsLevator scapulae Serratus anterior (upper

fibres)

Scapula depression Pectoralis minor Pectoralis majorLatissimus dorsi Lower trapezius

Scapula adduction Rhomboids Latissimus dorsiTrapezius (middle/lower)

Scapula abduction Serratus anterior Pectoralis minor

Upward rotation of scapula Trapezius (upper/lower) Serratus anterior (lowerfibres)

Downward rotation of Rhomboids Latissimus dorsiscapula Pectoralis minor Pectoralis major

Levator scapulae

Flexion Anterior deltoid Pectoralis major (clavicular Coracobrachialis portion)

Extension Latissimus dorsi Teres minorTeres major Triceps brachii (long head)Posterior deltoid

Abduction Middle deltoid Anterior/posterior deltoidSupraspinatus Serratus anterior

Adduction Pectoralis major Teres majorLatissimus dorsi Anterior deltoid

Medial rotation Subscapularis Anterior deltoidPectoralis majorLatissimus dorsiTeres major

Lateral rotation Infraspinatus Posterior deltoidTeres minor

7EVALUATION OF THESHOULDER

Shoulder evaluation is an importantprerequisite to corrective exerciseprescription as it helps to identify muscle andmovement imbalances of the shouldercomplex. This is done using evaluationtechniques that draw on an understanding ofthe functional anatomy of the shoulder inthe context of static and dynamic shoulderposture.

This section outlines evaluation ofshoulder alignment, scapulohumeral rhythmand muscle length and strength. Combiningthe results of these assessments will helpbuild a progressive corrective exerciseprogramme.

Alignment analysisOverall shoulder alignment is a goodindicator of changes in muscle length and ofjoint alignment that may need to becorrected to allow for optimal motion,during exercise or daily activities. Observedmuscle tightness or weakness can then bedetermined by testing for length andstrength. Deviations in alignment are thosethat differ from the ideal postural standard.

Normal scapula alignmentIn ideal postural alignment, the scapulae lieparallel to one another against the thorax,with the medial border of each positionedabout two inches from the thoracic spine;

superiorly and inferiorly, the scapulae arepositioned between ribs two and seven (seeFigure 7.1). The scapulae are tiltedapproximately 30° anterior to the frontalplane.

Common alignment problemsCommon scapula misalignments to look forwhen assessing static shoulder postureinclude the following.

Figure 7.1. Normal scapula alignment – posterior view

Scapula elevationElevation of the scapula causes the shouldersto appear closer to the ears, making the neckappear short.

Elevation of the entire scapula suggestsshortness of the upper trapezius; if scapulaadduction is also observed, rhomboid andlevator scapulae shortness may also bepresent.

Elevation of the superior angle suggestsshortness of the levator scapulae.

Excessive scapula depressionDepression of scapulae causes the clavicles toappear horizontal; in excessive depression,the acromioclavicular joint is lower than thesternoclavicular joint.

Depression suggests upper trapeziusweakness, and the pectoralis major andlatissimus dorsi may be short. Duringflexion/abduction, this can result inexcessive stress at the acromioclavicular andglenohumeral joints.

Scapula adductionAdduction is observed when the medialborder of the scapula is less than 2 inchesfrom the spine; the rhomboid and middletrapezius may be short, while the serratusanterior is weak.

Scapula abductionAbduction is observed when the medialborder is more than 3 inches away from thespine and the scapula is positioned morethan 30° anterior to the frontal plane. In thiscase, the glenoid is positioned furtherforwards and the humerus will appearmedially rotated. Exercise prescriptionshould focus on corrective scapula adductionas, more often than not, adduction of thescapula will also correct the apparentrotation in the humerus.

The short muscles in abduction-rotationare the serratus anterior and pectoralismajor.

Anterior tiltingAnterior tilting causes the inferior angle ofthe scapula to protrude away from thethorax. This is often associated with shortnessof the pectoralis minor and/or shortness ofthe biceps brachii and anterior deltoid. If thebiceps brachii is short, correct scapularepositioning will cause the elbow to flex.

Downward rotationDownward rotation occurs when the inferiorangle of the scapula is closer to the spine andthe medial border is not parallel. In mostcases, the rhomboids and levator scapulaeare short, and the upper trapezius andserratus anterior are weak. This is a commondeviation in those with shoulder pain.

Scapular wingingWinging of the scapula is observed when themedial border protrudes away from thethorax and is associated with weakness of theserratus anterior. Winged scapulae may also

45Evaluation of the shoulder

Clinical perspectiveClients with scoliosis often have kyphosisand rotation of the spine, which forms arib ‘hump’, resulting in misalignment ofthe scapula on one side of the body. If therib ‘hump’ causes the scapula to wing, theclient should not be encouraged to correctthe alignment by contraction of thescapula adductors. Shortness of thesemuscles restricts abduction and upwardrotation of the scapula, leading to possiblerotator cuff tears, impingement and neckpain, caused by excessive tension in theupper trapezius.

be due to a flat thoracic spine, a roundedback or even scoliosis.

In clients who perform chin-ups orclimbing activities, there may be hypertrophyof the subscapularis, which gives rise to theappearance of winged scapula; in this case,the scapulae are no longer flat on the thorax.

Movement analysisOverall shoulder movement is best observedby looking at the integrated relationship ofthe shoulder girdle and shoulder joint – aphenomenon known as scapulohumeral rhythm.For every 3° of shoulder movement, theglenohumeral joint contributes 2° ofmovement and the scapula contributes 1° ofmovement. This timing is considered to bethe normal standard for shoulder movement.

Scapulohumeral rhythm is seen in allmovements of the shoulder, especially duringthe later stages of flexion and abduction.Assessment of these movements can be madeby visual means and can be assisted usingpalpation of the inferior angle of the scapuladuring movement. It is important to notethat if the scapula and humerus are notcorrectly aligned at the start of movement,compensation will occur during movement,giving rise to potential joint and musclestress.

By instructing the client to performflexion and abduction (and rotation)movements (as outlined below), the therapistcan identify deviations in scapulohumeraltiming and subsequent muscle imbalances.

Upward rotationDuring full flexion, the scapula will stopmoving when the shoulder is flexed to 140°,with the remaining movement occurring atthe glenohumeral joint. At 180° of flexion,the inferior angle should be close to the

midline of the thorax in the frontal plane,and the medial border should be upwardlyrotated to 60°. At this point, the scapulashould slightly depress, posterior tilt andadduct. Excessive kyphosis and/or a shortpectoralis minor can inhibit this end rangemovement.

Movement of the inferior angle beyondthe midline indicates excessive scapulaabduction, suggesting rhomboid weakness.This test can be administered in bothstanding and supine positions.

Scapula wingingThe scapula should not wing duringflexion/abduction movements or during thereturn. Winging indicates weakness of theserratus anterior muscle.

Scapula elevationThere should be some elevation (shrugging)of the shoulder during flexion/abduction,especially during the later stages (greaterthan 90°).

If there is excessive depression at rest,elevation of the scapula during thesemovements must be restored, usually bystrengthening the upper trapezius.

Position of the humerusThe head of the humerus should stay centredthroughout flexion/abduction. For this tooccur, the rotator cuff musculature mustoffset the upward pull of the deltoid bylaterally rotating the humerus, to preventimpingement at the acromion.

In clients with rotator cuff weakness, thepectoralis major and latissimus dorsi may actinstead to force the humeral head into theglenoid fossa. Because both these musclesmedially rotate the humerus,


flexion/abduction movements will alter theposition of the humeral head in the glenoid,causing impingement and pain.

SpineThere should be minimal movement of thespine during full flexion/abductionmovements. A thoracic kyphosis will cause ananterior tilt of the scapula, thereby limitingfull flexion capability. This is a movementimpairment commonly seen in those whoseoccupations involve prolonged seatedpostures.

Scapula adductionWhen the elbow is flexed to 90°, lateralrotation of the shoulder should not causescapula adduction during the first 35°motion. Adduction of the scapula is a sign ofrhomboid dominance and/or poor controlof shoulder rotation.

If there is an accompanied posteriormovement of the humeral head, this mayindicate dominance of the posterior deltoidover the teres minor and infraspinatus.

Muscle lengthMuscle length testing will determine whetherthe range of muscle length is normal, limitedor excessive. For full range of motion in the

shoulder there are a number of muscles thatmust have adequate length. Musclesimportant in scapulohumeral movementduring flexion or abduction and lateral andmedial rotation that should be tested arelisted in Table 7.1.

The lengths of these muscles can beassessed using the tests outlined below. Toeliminate trunk movement during testing,these tests should be administered with theclient supine, knees bent and low back flaton the couch.


Table 7.1. Muscles whose adequatelength is important for full shouldermovement

Movement Muscles

Scapulohumeral Pectorales major flexion or abduction and minor

Latissimus dorsiTeres majorSubscapularisRhomboids

Lateral rotation Pectoralis majorLatissimus dorsiTeres majorSubscapularis

Medial rotation Teres minorInfraspinatusPosterior deltoid

Muscle(s): Pectoralis major.Starting position: Client is supine, with kneesbent, low back flat, arms by sides.Test: Clavicular portion – the shoulder islaterally rotated (palm up) and arm isabducted to 90°; sternal portion (lowerfibres) – as above, except that the arm isabducted to 135°.

Normal length: The arm rests at table level,with low back remaining flat.Shortness: Shortness is observed when thearm does not drop down to the level of thetable.Excessive length: The arm drops below thelevel of the table if the client is positioned atthe edge of the couch.


Figure 7.2. Test for length of pectoralis major – (a) normal length of lower fibres, (b) normal length of upperfibres

(a) (b)

Muscle(s): Pectoralis minor.Starting position: Client is supine, with kneesbent, low back flat, arms by sides.Test: Therapist looks down at the client’sshoulders from the head of the couch.Normal length: The back of the shoulder isin contact with the couch.Shortness: The shoulder is raised above thelevel of the couch.

Muscle(s): Teres major, latissimus dorsi,rhomboids.Starting position: Client is supine, with kneesbent, low back flat, arms by sides.Test: Client raises both arms in flexionoverhead, keeping arms close to the head.Normal length: Arms are brought down totable level, while maintaining a flat low back.Shortness: Inability to get arms to table level.If the client has tightness of the upperabdominals, this will give a false test readingin favour of shortness.


Figure 7.3. Test for length of pectoralis minor – left,normal length; right, short

Figure 7.4. Test for length of teres major, latissimusdorsi, rhomboids – (a) start position, (b) end position

(a)

(b)

Muscle(s): Medial rotators.Starting position: Client is supine, with kneesbent, low back flat. The arm is abducted to90° and the elbow is flexed to 90°, with theforearm perpendicular to the table.Test: Lateral rotation of shoulder, bringingforearm down towards the table, parallel withhead.Normal length: Forearm flat on table (90°),with low back flat.

Muscle(s): Lateral rotators.Starting position: Client is supine, with kneesbent, low back flat. The arm is abducted to90° and the elbow is flexed to 90°, with theforearm perpendicular to the table.Test: Medial rotation of shoulder, bringingforearm down towards the table (palmdown), while therapist holds the shoulderdown. This will prevent compensatorymovement of the shoulder girdle.Normal length: Forearm almost flat on table(70° of motion).


Figure 7.5. Test for length of medial rotators Figure 7.6. Test for length of lateral rotators

Muscle(s): Medial and lateral rotators.Starting position: Client is standing, witharms by sides.

Test: Client reaches one hand behind backto touch the inferior angle of the oppositescapula (medial rotation), and reaches theother hand over the shoulder on the sameside to touch the superior angle of thescapula (lateral rotation).Normal length: No excessive movementsubstitution by the shoulder girdle.Shortness: Substitution of the shoulder girdlewhen reaching behind the back indicatesfunctional shortness of the lateral rotators.Substitution of the shoulder girdle whenreaching over the shoulder indicatesfunctional shortness of the medial rotators.Excessive substitution of the shoulder girdlemay result in overdevelopment of thepectoralis minor.

Muscle strengthMuscle strength testing in the shoulder willdetermine the ability of muscles to providestability and movement. As shoulder muscleweakness can be caused by disuse as well asoveruse, it is essential for the therapist tocollate these results with those of alignmentand movement analysis and muscle lengthtesting.

The major shoulder muscles thatcontribute to movement and stability whichshould be tested are outlined below.


Figure 7.7. Test for length of medial and lateralrotators

Muscle(s)/movement: Anteriordeltoid/flexion.Starting position: Sitting with elbow flexed to90°.Test: Place palm down on acromion tostabilise scapula and palpate anterior deltoid.Client resists posterior palmar pressureapplied on the anterior arm around lowerbicep.Weakness: Decreased ability to push armforwards-upwards.Shortness: Decreased range of motion inextension.

Muscle(s)/movement: Posteriordeltoid/extension.Starting position: Sitting with elbow flexed to90°.Test: Place palm down on acromion tostabilise scapula and palpate long head oftriceps with thumb, and posterior deltoidwith palm. Pressure is now applied with otherhand on the distal humerus in an anteriordirection.Weakness: Decreased ability to push armbackwards-upwards.Shortness: Decreased range of motion inflexion.


Figure 7.8. Anterior deltoid strength test Figure 7.9. Posterior deltoid strength test

Muscle(s)/movement: Middledeltoid/abduction.Starting position: Sitting with elbow flexed to90°.Test: Stabilise the acromion with palm onmiddle deltoid. Other palm applies pressureon lateral epicondyle of humerus, as clientabducts arm.Weakness: Decreased ability to lift arm inabduction; downward translation of humeralhead.Shortness: Decreased range of motion inadduction.

Muscle(s)/movement: Pectoralismajor/adduction.Starting position: Sitting with elbow flexed to90°.Test: Stabilise acromion with palm on middledeltoid. Other palm applies pressure onmedial epicondyle of humerus, as clientadducts arm. Palpate pectoralis major duringmovement.Weakness: Decreased ability to adduct arm.Shortness: Decreased range of movement inabduction.


Figure 7.10. Middle deltoid strength test Figure 7.11. Pectoralis major/latissimus dorsi strengthtest

Muscle(s)/movement: Subscapularis,pectoralis major/internal rotation.Starting position: Sitting with elbow flexed to90°.Test: Stabilise humerus by holding elbowjoint by waist. Place other hand on wrist andinstruct client to rotate arm inwards againstresistance.Weakness: Decreased ability medially torotate humerus; humerus assumes position oflateral rotation.Shortness: Range of motion limited in lateralrotation and overhead flexion.

Muscle(s)/movement: Infraspinatus, teresminor/external rotation.Starting position: Sitting with elbow flexed to90°.Test: Stabilise humerus by holding elbowjoint by waist. Place other hand on wrist andinstruct client to rotate arm outwards.Weakness: Decreased ability laterally to rotatehumerus; humerus assumes position ofmedial rotation.Shortness: Range of motion limited inmedial rotation.


Figure 7.12. Internal rotator strength test Figure 7.13. External rotator strength test

Muscle(s)/movement: Upper trapezius,levator scapulae/scapula elevation.Starting position: Standing with arms at sides.Test: Place each palm on acromion, usingthumbs to palpate upper trapezius. Applydownward pressure as client shrugsshoulders.Weakness: Decreased ability to elevatescapulae and extend cervical spine; thepresence of scapula abduction as rhomboidstabilisation is lost; medial rotation.Shortness: Scapula starts movement from aposition of adduction and elevation;shortness accompanies serratus weakness(rhomboid dominance).

Muscle(s)/movement: Rhomboid/scapularetraction.Starting position: Prone, lying with test armheld away from table in medial rotation and90° abduction. The scapula should be slightlyelevated.Test: One hand is placed on the oppositescapula to fixate it. Pressure is appliedagainst the forearm in a downward direction,and client resists.Weakness: Decreased ability to retractscapulae; abduction of scapula and forwardshoulder position in static posture.Shortness: Scapula starts movement from aposition of adduction and elevation; weakserratus.


Figure 7.14. Upper trapezius/levator scapulae strengthtest

Figure 7.15. Rhomboid strength test

Muscle(s)/movement: Serratusanterior/scapula protraction.Starting position: Standing with arm flexedto 90° and elbow flexed to approximately90°.Test: Stand behind client and place palm onthoracic spine to stabilise trunk. Cup theother hand around the flexed elbow andapply resistance posteriorly. Client to resistmotion by pushing the elbow forwards.Weakness: Winging of scapula; difficulty inflexing arm.Shortness: Abduction of scapula during staticalignment, often accompanied by weakrhomboids; forward shoulder position.

Muscle(s)/movement: Teresmajor/extension, adduction.Starting position: Prone, lying with arm inextension and adduction; elbow is flexed toallow hand to rest on lower back.Test: Pressure is applied against arm, justabove elbow, in the direction of abductionand flexion.Weakness: Decreased ability to holdextension/abduction.Shortness: Full range of motion limited inlateral rotation and abduction; scapula willbegin to rotate simultaneously withflexion/abduction.


Figure 7.16. Serratus anterior strength test

Figure 7.17. Teres major strength test

Muscle(s)/movement: Latissimus dorsi.Starting position: Prone, lying with armstraight by the sides, in medial rotation.Test: Pressure against forearm in direction ofabduction and slight flexion. Client tries toadduct and extend arm.Weakness: Inability to adduct arm towardsbody. Lateral trunk flexion is reduced.Shortness: Limitation in flexion/abduction.Depression of shoulder girdle downwards.Seen in long-term crutch-walking patients.


Figure 7.18. Latissimus dorsi strength test

8CORRECTIVE EXERCISE FORTHE SHOULDER

Corrective exerciseprogressionThe goals of corrective exercise for theshoulder are twofold: to re-establish musclebalance and neuromuscular control and toprovide adequate functional progression forreintegration into activities of daily livingand/or sport.

Stability of both the scapula and shoulderjoint is desirable before functional strengthcan be introduced; but at the same time, thecomplex mobility that the shoulder affordsmust not be overlooked. Therefore, aneffective rehabilitation programme shouldinclude stability and mobility exercises.

The client may then progress tofunctional strength exercises that conditionthe shoulder complex for load-bearing andload-transferring activities once mobility andstability have been restored. Many of thesemovement patterns fall into the three maincategories of pushing, pulling and rotation.During each of these movements, theshoulder is intimate with the back andcontralateral hip musculature.

With this in mind, the final stages ofcorrective exercise should focus on whole-body power movements that enable the lowerextremities to coordinate and transferground reaction forces through the torsoand up to the shoulder, for example, duringlifting, throwing and chopping actions.

The following exercises are divided intofour progressive phases.

Phase 1 – Muscle balanceThese exercises are aimed at restoringnormal muscle length, in particular, themuscles responsible for gross shouldermovement. Many of the exercises can bestarted during the acute stages of injury andprogressed by adding resistance, eithermanually by the therapist or with weights. Asa result, pain-free and compensation-freerange of motion will be re-established withinthe shoulder joint and shoulder girdle.

Phase 2 – Static, dynamic andreactive stabilisationThese exercises aim to match the functionalstabilisation demands of the shoulder, byemphasising co-contraction force couples atthe shoulder girdle and shoulder joint. Staticstabilisation exercises activate the rotator cuffmusculature, with minimal joint movement,while dynamic stabilisation requiresactivation of agonist–antagonist force couplesduring range-of-motion activities. Reactivestabilisation exercises focus on stimulatingproprioceptive pathways that exist infunctional shoulder movements and help tocondition feedback and feed-forwardmechanisms.

These exercises will re-establish scapularcontrol and rotator cuff strength in bothopen- and closed-chain settings.

Phase 3 – Functional strengthThe goal during this phase is to reintegrateshoulder stabilisation into activities of dailyliving and/or sports performance; in order toprescribe exercise accurately, it is importantfor the therapist to understand thefunctional demands of the patient, includingoccupational, recreational and sportingfactors. These movements can then berestored to integrate pain-free shoulderstrength and function. Before reintegration itis important to address deficiencieselsewhere in the kinetic chain.

The outcomes of this phase includeincreased functional strength in both open-and closed-chain environments, as well asimproved link-sequencing and forcegeneration from the lower extremitiesthrough to the shoulder complex.

Phase 4 – Functional powerThese exercises address the specific demandsimposed on the shoulder by activities seen inboth occupation and sport. Almost allshoulder joint and shoulder girdlemovements involve acceleration anddeceleration mechanics, and are rarelyperformed at fixed speeds, for example,picking up a child from the floor or pushinga car door shut.

The preferred method of conditioningduring this phase is plyometric exercise,requiring quick, powerful and explosivemovements of the shoulder, often inconjunction with the entire kinetic chain. Forthis to occur safely, range of motion,stabilisation and functional strength must all

be optimal. Particular emphasis should alsobe placed on optimal hip and trunk rotation,to ensure smooth coordination of groundreaction forces up through the body.

This will result in coordination andcontrol of movement, providing a highdegree of functional carry-over intooccupation, recreation and sport.

Corrective exercises forthe shoulder

Phase 1 exercises – Restoringmuscle balance and flexibilityScapulohumeral muscle stretchMuscle group(s): Latissimus dorsi, teresmajor/minor, pectoralis majorPhase/modality: Flexibility, muscle balanceEquipment: None

Purpose❑ To stretch the latissimus dorsi, pectoralis

major and teres major/minor.

❑ To increase range of motion of shoulderflexion.

❑ To decrease upper back curve.

❑ To increase performance of abdominalmuscles.

Prerequisites❑ Pain-free range of motion in shoulder

flexion.

❑ Adequate pelvic control to maintain flatlumbar spine.

❑ Clients with kyphosis may need to place apillow under thoracic spine and head.

59Corrective exercise for the shoulder

Starting positionClient is supine, with hips and knees flexed,low back flat, arms at sides.

Correct performance❑ To stretch the pectoralis major, the client

keeps elbows extended and abducts thearms to 90°. In this position, they areinstructed to pull back the scapula withthe middle trapezii to stretch thepectoralis major. Stretch is held for 5–10seconds before resting and repeating for atotal of 10 repetitions. To stretch thelower fibres of the pectoralis major, thestretch is performed in a position of 130°


Figure 8.1. Scapulohumeral muscle stretch – (a)pectoralis major upper fibres, (b) pectoralis majorlower fibres, (c) latissimus dorsi/teres major/teresminor

(a)

(b)

(c)

abduction. Here, the client is instructed todepress the scapula using the lowertrapezius.

❑ To stretch the latissimus dorsi, the clientkeeps the elbows extended while flexingboth shoulders. Arms should be kept closeto ears and the shoulder should bemaintained in lateral rotation. The lowerback must remain flat against thetable/floor. The client holds the endrange for 5–10 seconds and then returnsarms to the sides, performing 10repetitions.

❑ To stretch the teres major/minor, theclient performs the above, except thatonce shoulder flexion reaches 90°, theclient uses the opposite hand to hold theinferior angle of the scapula against thechest wall and completes the movement.The client holds the end range for 5–10seconds, alternating arms after 10repetitions.

Medial rotationMuscle group(s): Lateral rotatorsPhase/modality: Flexibility, mobility, strengthEquipment: None

Purpose❑ To stretch lateral rotators of shoulder.

❑ To eliminate anterior tilt of scapula withrotation.

❑ To eliminate anterior glide of humeralhead during medial rotation.

❑ To improve performance of lateralrotators.

Prerequisites❑ Pain-free range of motion in abduction.

❑ If range of motion is limited in rotation, asmall weight can be added to assist thestretch. The weight should be heavyenough to exert a rotational effect, but notso heavy as to stimulate lateral rotation.

❑ Optimal flexibility of scapular motion.


Figure 8.2. Medial rotation – (a) before, (b) after

(a) (b)

Starting positionClient is supine, with hips and knees flexed,shoulder abducted to 90° (neutral rotation),elbow flexed to 90°. A small towel may beplaced under the arm to align humerus inthe scapula plane. The client holds down theshoulder with the opposite hand to preventanterior motion of the humeral head oranterior tilt of the scapula.

Correct performance❑ The client medially rotates the humerus,

allowing the forearm to drop to the table,without lifting the shoulder girdle.

❑ The arm is returned and the movement isrepeated slowly and continuously 5–10times until full range of motion isachieved, without compensation or pain.

❑ The exercise is repeated with the otherarm.

ProgressionsAfter client is able to perform the movementcorrectly, the addition of weights can be usedto strengthen the lateral rotators.

Lateral rotationMuscle group(s): Medial rotatorsPhase/modality: Flexibility, mobility, strengthEquipment: None

Purpose❑ To stretch shoulder medial rotators.

❑ To train the humerus to moveindependently of the scapula.

❑ To improve performance of medialrotators.

Prerequisites❑ Pain-free range of motion in abduction. If

pain is present at 90° abduction, thedegree of abduction should be reduced,by supporting arm on a towel to position

shoulder in mild flexion (plane ofscapula).

❑ Optimal flexibility of scapular motion.


Figure 8.3. Lateral rotation – (a) before, (b) after

(b)

(a)

Starting positionClient is supine, with hips and knees flexed,shoulder abducted to 90° (neutral rotation)and elbow flexed to 90°, as in the previousexercise.

Correct performance❑ Client laterally rotates humerus while

maintaining a constant position of thescapula and no humeral head movement.

❑ The arm is returned and the movement isrepeated slowly and continuously 5–10times until full range of motion isachieved, without compensation or pain.

❑ The exercise is repeated with the otherarm.

ProgressionsAfter client is able to perform the movementcorrectly, the addition of weights can be usedto strengthen the medial rotators.

Side-lying circumduction and thoracicintegrationMuscle group(s): Shoulder, arm, chest back

Phase/modality: Flexibility, mobility, strengthEquipment: None

Purpose❑ To enhance awareness and performance

of scapulohumeral rhythm.

❑ To integrate range of motion of theshoulder/arm into gentle thoracic andtrunk movements.

Prerequisites❑ Pain-free range of motion at the shoulder

and elbow.

❑ A good degree of flexibility in the trunkrotators.

Starting positionClient is side-lying, with hip and knee flexionto approximately 90°. The spine should be ina neutral position, with the head restingcomfortably on the straight flexed arm. Thetopmost arm should be positioned in 90°abduction and 90° elbow flexion, and inhorizontal adduction, so that the palm restson the floor, about 12 inches in front of theclient’s chest. The elbow should bepositioned above the wrist.


Figure 8.4. Side-lying circumduction and thoracic integration – (a) before, (b) after

(a) (b)

Correct performance❑ Keeping the palm in position (some

movement at the wrist is allowed), theclient begins to move the elbow in acircular motion, moving it forwards, down,back and up, as if drawing a circle.

❑ To integrate the movement with the trunk,the client is instructed to allow the headand trunk to rotate inwards as the elbowmoves away from the body – as if they areabout to kiss the floor; as the elbow movesdown towards the feet, the client shouldmove the trunk back to the centre andgently depress the scapula; as the elbowmoves towards the body, the client shouldgently retract the scapula while rotatingthe torso outwards; and finally, when theelbow moves upwards, the client shouldelevate the scapula (shrugging).

❑ The movement should be continuedsmoothly for 5–10 repetitions, beforechanging direction. The exercise isrepeated on the other side.

❑ Particular awareness should be placed onsmooth integration of the scapulohumeralrhythm with torso rotation.

ProgressionsSurgical tubing may be tied around theclient’s arm, just above the elbow, to providegentle multidirectional resistance.

Trapezius activationMuscle group(s): Middle and lower trapeziusPhase/modality: Muscle balance, flexibility,endurance, stabilisationEquipment: None

Purpose❑ To improve performance of the middle

and lower trapezius muscles.

❑ To integrate trapezius action into lateralrotation of the shoulder.


Figure 8.5. Trapezius activation – (a) level 1, (b) level2, (c) level 3

(a)

(b)

(c)

Prerequisites❑ Optimal scapular control and flexibility.

❑ Optimal range of motion in shoulderlateral rotation.

❑ Ability to maintain a neutral lumbarcurvature, with adequate abdominalstrength.

Starting positionClient is lying prone, with legs straight.Shoulders and elbows are flexed, with fingersinterlaced behind head. Towels may beplaced under each shoulder to correct anyanterior tilt of the scapulae.

Correct performance❑ LEVEL 1 – the client lifts the arms by

adducting the scapulae. The client shouldvisualise a diagonal downward movementof the scapulae and should not allow theshoulders to shrug – this would suggestupper trapezius and rhomboid action.The position should be held for up to 8seconds, before relaxing and repeating5–10 times. (Special attention should bepaid to depressing the shoulder girdleusing the lower trapezius, rather than thelatissimus dorsi.)

❑ LEVEL 2 – the client assumes the sameposition as above, except that the handsare now resting by the sides of the headon the ulnar borders (thumbs pointingupwards). The client adducts the scapulaas before, by bringing the shoulder bladestowards and down the spine. The clientshould lift the arm and hand whilecontracting the trapezius. The handshould remain slightly higher than theelbow to emphasise lateral rotation. Thisposition is held for up to 8 seconds,before relaxing and repeating 5–10 times.

❑ LEVEL 3 – the client is positioned as

above, except that the elbows are nowextended with the shoulders in 120°abduction. The client adducts the scapulaas before, by bringing the shoulder bladestowards and down the spine, lifting thearms 1–2 inches off the table/floor. Thisposition is held for up to 8 seconds,before relaxing and repeating 5–10 times.

Progressions❑ This exercise may be performed using

alternate arms, with an opposite glutecontraction to re-educate a cross-crawlpattern.

❑ Small weights may be added to each hand.

Prone serratus pullMuscle group(s): Serratus anterior,shoulder/armPhase/modality: Muscle balance, strengthEquipment: None

Purpose❑ To re-establish neuromuscular control of

the scapula protractors.

❑ To restore balance between the scapularetractors and protractors.

❑ To improve performance of the serratusanterior muscle.

Prerequisites❑ Pain-free extension of lumbar spine. If the

client has an excessive lumbar lordosis,this exercise should not be used.

❑ Optimal scapular control.

Starting positionThe client is prone, lying with the upperbody supported on both elbows. The elbowsshould be positioned under the shouldersand the scapulae should assume a neutralposition of retraction/protraction.


Correct performance❑ The client begins by allowing the thorax

to drop down towards the floor, bycontrolling scapula retraction undergravity. Using equal pressure appliedthrough both elbows, the client thenpushes the thorax upwards (as if trying topush the floor away from the body). Thisaction will contract the serratus anterior.

❑ The client should aim to increaseawareness of the movement, as well asscapula control, through protraction.

ProgressionsThe therapist may apply pressure to theupper back to increase strength of theserratus anterior.

Standing shoulder flexionMuscle group(s): Shoulder flexors, serratusanterior, rotator cuffPhase/modality: Flexibility, muscle balance,strength, stabilisationEquipment: None

Purpose❑ To increase range of shoulder flexion.

❑ To improve performance of serratusanterior and shoulder flexors.

❑ To reduce compensatory elevation ofshoulder girdle during flexion.

❑ To encourage depression of the humeralhead during flexion.

Prerequisites❑ Some pain-free range of motion in

flexion.

❑ Adequate abdominal control to stabiliselumbar spine.

Starting positionClient stands close to and facing the wall,with feet comfortably apart. The shouldersand elbows are flexed to 90°, with the ulnarsurface of the forearms and hands resting onthe wall. The client should exert somepressure against the wall, to create adepression force of the humeral heads.

Correct performance❑ The client flexes the shoulders by sliding

the hands up the wall. The humerusshould not medially rotate during flexion.


Figure 8.6. Prone serratus pull – (a) before, (b) after

(a) (b)

The movement is stopped when the clientreaches a comfortable range of flexion orwhen pain occurs in the region of theacromion.

❑ The end position is held for up to 8seconds, before returning to the start andrepeating 5–10 times.

❑ If the rotator cuff is particularly weak, theclient can use one hand to assist shoulderflexion.

❑ The therapist can also assist in scapulaupward rotation, particularly if therhomboids are dominant.

Progressions❑ If complete range of motion can be

achieved, the client can lift the handsaway from the wall at end range and hold,

before allowing the arms to slide backdown to the start position.

❑ To enhance performance of this exercise,the client should be instructed to thinkabout scapula abduction and upwardrotation.

Standing shoulder abductionMuscle group(s): Shoulder abductors,trapeziusPhase/modality: Flexibility, muscle balance,strength, stabilisationEquipment: None

Purpose❑ To improve performance of the trapezius.

❑ To increase range of scapula upwardrotation.


Figure 8.7. Standing shoulder flexion – (a) before, (b) after

(a) (b)

❑ To improve control of humeral lateralrotation.


abduction (up to 140°).

❑ Adequate abdominal control to stabiliselumbar spine.

Starting positionClient stands close to and facing the wall,with feet comfortably apart. The elbows are


Figure 8.8. Standing shoulder abduction – (a) startposition, (b) upper trapezius activation, (c) lowertrapezius activation

(a) (b)

(c)

flexed, with the arms at the sides of the body,in slight abduction, and the ulnar surface ofthe forearms and hands resting on the wall –this position requires lateral rotation of thehumerus and adduction of the scapulae. Theclient should exert some pressure against thewall, to create a depression force of thehumeral heads.

Correct performance

❑ UPPER TRAPEZIUS – the client isinstructed to abduct the shoulders bysliding the forearms up the wall, in adiagonal pattern. When abduction reaches90°, the client should shrug the shoulderswhile continuing abduction/elevation.This will activate the upper trapezius. Atcompletion of motion, the client shouldlift the arms away from the wall byadducting the scapula and hold thisposition for up to 8 seconds.

❑ LOWER TRAPEZIUS – the client shouldabduct the shoulders as before,continuing to end range. At completion,

they are instructed to lift the arms awayfrom the wall by adducting and depressingthe scapula. This position is held for up to8 seconds, before reversing the motionback to the start position.

❑ The therapist should ensure that theclient is adducting the scapula and notjust moving the glenohumeral joint ordepressing the scapula using the latissimusdorsi.

ProgressionsHolding times should be increasedprogressively, up to 8 seconds.

Wall climbingMuscle group(s): Shoulder flexors, shoulderabductorsPhase/modality: FlexibilityEquipment: None

PurposeTo restore active full range of motion inflexion and abduction.


Figure 8.9. Wall climbing – (a) before, (b) after

(a) (b)

PrerequisitesPain-free active range of motion.

Starting positionClient stands close to and facing wall, withelbow flexed, shoulder in slight extensionand palm on wall.

Correct performance❑ Client begins by slowly walking the hand

up the wall, into shoulder flexion,extending the elbow as the hand getshigher. Range of motion should berestricted to a pain-free arc.

❑ The client should be instructed to beaware of scapulohumeral rhythm duringthe movement.

❑ The hand is walked back down and themovement repeated 5–10 times, beforechanging hands.

ProgressionsThe exercise can also be performed as anabduction movement, with the clientstanding side-on to the wall.

Wall corner stretchMuscle group(s): Pectoralis major, pectoralisminor, anterior deltoidPhase/modality: FlexibilityEquipment: None

Purpose❑ To stretch the anterior musculature of the

shoulder.

❑ To stretch the anterior joint capsule.

PrerequisitesPain-free range of motion in shoulderabduction (90°) and extension.

Starting positionClient is standing, facing the corner of thewall, with arms abducted to approximately90°, elbows flexed to 90° and palms on bothwalls.

Correct performance❑ Client begins by gently leaning their body

weight forwards to stretch the anteriorshoulder musculature.

❑ The stretch is held for 10–15 seconds,before resting and repeating 5 times.

Standing circumductionMuscle group(s): Posterior shoulder


Figure 8.10. Standing circumduction

Phase/modality: FlexibilityEquipment: Couch

Purpose❑ To stretch the posterior shoulder

musculature, particularly when flexionabduction is restricted in the early stagesof rehabilitation.

❑ To stretch the posterior joint capsule.

PrerequisitesPain-free range of motion.

Starting positionClient is standing and leaning over atable/couch, with one hand supportingupper body. The other hand is allowed todrop down towards the floor.

Correct performance❑ The client begins by allowing the arm to

move in a circular pattern, as if drawing acircle with the hand.

❑ The movement is repeated for 5–10circles, before changing direction. Theexercise is repeated with the other arm.

Progressions❑ Increase size of circle.

❑ Addition of weight, by holding a dumb-bell, to increase the stretch.

Assisted shoulder flexor/abductor stretchMuscle group(s): Latissimus dorsi, teresmajorPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the latissimus dorsi and teresmajor.

PrerequisitesPain-free range of motion inflexion/abduction.

Starting position❑ Client is lying supine, with knees bent and

low back flat.

❑ The shoulder to be stretched is in amaximum flexion/abduction position andin slight medial rotation.


Figure 8.11. Assisted shoulder flexor/abductor stretch

Correct performance❑ The therapist holds the arm just above the

elbow and applies traction in an overheaddirection, while gently pulling the armdown towards the couch. The other handis used to stabilise the scapula, to preventexcessive abduction.

❑ The stretch is held for up to 20 seconds.

❑ Muscle energy techniques may be used ifthe muscle is particularly tight.

Assisted pectoralis minor stretchMuscle group(s): Pectoralis minorPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the pectoralis minor.

PrerequisitesPain-free range of motion of the scapula.

Starting positionClient is seated, with arms by sides.


Figure 8.12. Assisted pectoralis minor stretchFigure 8.13. Assisted medial/lateral rotator stretch –(a) start position, (b) medial rotator stretch, (c) lateralrotator stretch

(a)

Correct performance❑ Therapist stands behind patient and pulls

the shoulders back and down, holding forup to 20 seconds.

❑ If the pectoralis minor is particularly tight,muscle energy techniques may be used.

❑ This stretch may also be performed withthe client supine.

Assisted medial/lateral rotator stretchMuscle group(s): Rotator cuff, pectoralismajor, latissimus dorsi, deltoidPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the medial and lateral rotators ofthe shoulder.

PrerequisitesPain-free range of motion inabduction/rotation.

Starting position❑ Client is supine, with knees bent and low

back flat.

❑ The shoulder to be stretched is in 90°abduction, with elbow flexed to 90°.


(b) medial rotator stretch (c) lateral rotator stretch

Correct performance❑ MEDIAL ROTATOR STRETCH – the

therapist holds the arm just above theelbow and applies traction to theglenohumeral joint. The humerus isgently rotated in the direction of lateralrotation towards the couch (90°).

❑ LATERAL ROTATOR STRETCH – asabove, but rotation is taken in a medialdirection towards the couch (90°). In thisstretch, the client applies downwardpressure to the shoulder with their otherhand, to prevent anterior translation.

Phase 2 exercises – Restoringstatic, dynamic and reactivestabilisation

Four-point kneeling cross-crawlMuscle group(s): Shoulders, back,abdominalsPhase/modality: Stabilisation – static,dynamic, reactive; strengthEquipment: None

Purpose❑ To integrate scapulohumeral movement

and stability with opposite hip movement.

❑ To strengthen the shoulderflexors/abductors.

❑ To condition the spinal rotators.

Prerequisites❑ The client must be able to hold and

maintain a neutral spine, prior to themovement.

❑ The client must be able to stabilise thespine through abdominal bracing.

Starting positionClient begins on all fours with a neutral spinealignment.

Correct performance❑ Client slowly raises one arm (thumb up)

to shoulder height, holding for 3 seconds


Figure 8.14. Four-point kneeling cross-crawl – (a)before, (b) after

(a)

(b)

before returning, maintaining optimalalignment. Repeat for the other side.

❑ Perform 6 repetitions, alternating eachside.

❑ As a variation, perform the movementlaterally, by taking the arm out to the side.This will place more emphasis onshoulder abductors/extensors.

Progressions❑ Once good control and alignment are

achieved, the client can progress to raisingalternate arm and alternate leg. As the legis raised to hip height, ensure that the toeis pointed away (triple extension).Particular attention should be focused onsmooth coordination of the arm and leg,ensuring that optimal stability andalignment are maintained throughout.

❑ The duration of the hold can also beincreased to a maximum of 8 seconds.

❑ Increase repetitions to a maximum of 15each side.

❑ Perform with eyes closed.

❑ For increased strength through theshoulder musculature, the client can holda small dumb-bell. Alternatively, thetherapist can apply gentle pressure alongthe arm, thereby changing the perceivedresistance.

❑ Perform the exercise unilaterally holdingan oscillating Bodyblade®, beforerepeating on the other side.

Ball circumductionMuscle group(s): Shoulders, rotator cuff,abdominalsPhase/modality: Stabilisation – static,dynamic, reactive; strengthEquipment: Stability ball, small medicine ball

Purpose❑ Strengthens rotator cuff group.

❑ Increases proprioception within theglenohumeral joint.

❑ Increases upper body strength.

Prerequisites❑ Adequate functional flexibility in the

anterior shoulder musculature.

❑ If client has an upper-crossed posture, thestretching of the pectorales major andminor, latissimus dorsi, upper trapezii andlevator scapulae must precede loading ofthe glenohumeral joint, to ensure optimalscapular retraction and depression.

Starting positionClient begins by placing a stability ballagainst the wall at shoulder height. Clientstands in front of it, with arm fully extended,palm in the centre of the ball. Maintain goodposture, with neutral spine and someabdominal bracing.

Correct performance❑ Client performs circumduction at the

glenohumeral joint so that the ball rollsround in a circular pattern.

❑ Complete 10 circles before changingdirection. Repeat with the other arm.

❑ Focus on the scapulohumeral rhythmduring the entire movement.

Progressions❑ Increase the size of the circle.

❑ Put more body weight into the movementby standing further back from the ball.Ensure that optimal alignment is stillmaintained.

❑ The exercise may be performed kneelingupright, with one hand on the ball,


progressively putting more body weightinto the ball. This position will engage theabdominal musculature to a greaterdegree.

❑ The exercise can be progressed finally to afour-point kneeling position, with onehand on a small medicine ball. In thisposition, there will be a largerinvolvement of the rotator cuff, as there ismore body weight through theshoulder/arm complex.

Closed-chain weight shiftsMuscle group(s): Shoulders, rotator cuff,chest, abdominalsPhase/modality: Stabilisation – static,reactive; strength

Equipment: Rocker-board, balance-board,Vew-Do™ board

Purpose❑ Lateral rhythmic stabilisation during

flexion.

❑ Strengthens rotator cuff group.


❑ Increases upper body strength.

Prerequisites❑ Adequate functional flexibility in the

anterior shoulder musculature.

❑ Optimal scapular control.


Figure 8.15. Ball circumduction

❑ Good control of neutral spine alignment.

Starting positionClient begins in a four-point kneelingposition, with neutral spine.

Correct performance❑ While holding neutral alignment, client

starts shifting weight from left to righthand, in a rocking motion, graduallyincreasing range of motion.

❑ Repeat up to 10 times each side.

Progressions❑ Place both hands on a rocker-board,

positioned for frontal plane movement(rocking side to side).

❑ Place both hands on a balance-board andtry to maintain a pure frontal planemovement, from side to side.

❑ Place both hands on a Vew-Do™ board

and try to keep the board horizontal whileshifting it side to side.

Prone iso-abdominalsMuscle group(s): Shoulders, chest, back,abdominalsPhase/modality: Stabilisation – static,dynamic; strengthEquipment: None

Purpose❑ Strengthens rotator cuff group in flexion.


❑ Increases upper body strength and corestabilisation.

❑ Functionally integrates upper and lowerbody stability.

Prerequisites❑ Client must be instructed in

diaphragmatic breathing.


Figure 8.16. Closed-chain weight shifts – (a) before, (b) after

(a) (b)

❑ Adequate abdominal bracing.

❑ Neutral spine alignment.

Starting positionClient assumes a prone position, with elbowsand shoulders flexed to 90°. The elbowsshould be positioned under the shoulders.

Correct performance❑ Client begins by bracing the abdominals

and lifting the body up onto the forearms.

❑ Hold body position and optimal spinalalignment for 3 seconds, before returningand resting.

❑ Repeat up to 10 times, keeping neutralspine alignment from cervical through tolumbar spine.

❑ Focus on quality, NOT duration.

Progressions❑ Increase holding time to a maximum of 8

seconds.

❑ Perform weight shifts from left to rightarm (rocking) for additional shoulderstability.

❑ Raise alternate legs, for additional corestabilisation.

Side-lying iso-abdominalsMuscle group(s): Shoulders, chest, back,abdominalsPhase/modality: Stabilisation – static,dynamic; strengthEquipment: None

Purpose❑ Strengthens rotator cuff group in

abduction.


❑ Increases upper body strength and corestabilisation.

❑ Functionally integrates upper and lowerbody stability.

❑ Conditions the oblique musculature.




❑ Neutral spine alignment.

❑ Functional flexibility in the lumbo-pelvic-hip complex.


(a)

Figure 8.17. Prone iso-abdominals – (a) before, (b)after

(b)

Starting positionClient is lying on the right side with legsbent. Optimal postural alignment must bemaintained throughout movement. Placeright elbow directly under right shoulder.


and lifting body up onto right forearm.

❑ Hold body position and optimal spinalalignment for 3 seconds, before returningand resting.

❑ Repeat up to 10 times, keeping neutralspine alignment from cervical through tolumbar spine. Repeat on the left side.


ProgressionsIncrease holding time to a maximum of 8seconds.

Wall push-upMuscle group(s): Anterior shoulder, rotatorcuff, serratus anteriorPhase/modality: Stabilisation – dynamic,reactive; strengthEquipment: None

PurposeTo strengthen the anterior shouldermusculature in a close chain.

❑ To strengthen the rotator cuff inflexion/abduction.

❑ To increase proprioception in theglenohumeral joint.

❑ To activate the scapula protractionmechanism.

Prerequisites❑ Optimal scapular control.

❑ Pain-free range of motion in flexion andabduction.

❑ Good control of neutral alignment andabdominal brace.

Starting positionClient stands facing a wall, with elbowsextended, both palms on the wall, aboutshoulder-width apart.

Correct performance❑ Client performs a push-up against the

wall, by flexing elbows and allowingscapula to retract.


(a)

Figure 8.18. Side-lying iso-abdominals – (a) before, (b)after

(b)

❑ Pushing body away from wall, client allowsthe scapula to protract fully as end rangeof elbow extension approaches. This willengage the serratus anterior.

❑ Repeat 10 times, maintaining good spinalalignment throughout the movement.

Progressions❑ The therapist may increase resistance by

applying pressure to the upper back.

❑ For additional multi-planar stabilisation,the push-up may be performed against astability ball on the wall. Ensure that themovement is performed with minimal ballwobble.

❑ The client may progress to performing abox push-up (four-point kneel position).This position will provide furtherintegration of the abdominal musculature.

❑ The box push-up can be progressedfurther by placing the hands on a rocker-board or Vew-Do™ board. This will serveto enhance proprioception within theglenohumeral joint.

❑ Full push-up.

❑ Push-up with legs on stability ball.

Seated push-upMuscle group(s): Shoulder/armPhase/modality: Stabilisation – static,dynamic; strengthEquipment: Bench/couch

Purpose❑ To strengthen shoulder musculature in a

closed chain.

❑ To strengthen the rotator cuff.

❑ To strengthen the scapular depressors andadductors.

Prerequisites❑ Optimal scapular control.

❑ Pain-free range of motion in elevation,depression and extension.

❑ Good control of neutral alignment.

Starting positionClient is seated at the end of a bench orcouch, with hands gripping the edges, feeton floor.


(a)

Figure 8.19. Wall push-up – (a) before, (b) after

(b)

Correct performance❑ Client begins the movement by bracing

the abdominals and lifting body weight offthe bench. The body should rise no morethan 4 inches (depending on arm length).

❑ Slowly return and repeat up to 10 times.

❑ The client should be instructed to focuson depressing and adducting the scapula(visualise a diagonal movementdownwards), while simultaneously liftingthe sternum vertically upwards.

Progressions❑ Seated on a stability ball. This will add a

multi-planar dimension to the exercise, aswell as providing a key progression from aclosed-chain to an open-chainenvironment.

❑ Feet off the floor. This progressionrequires the client to lift the whole body.

❑ Full dip movement, where the body isallowed to drop further to the floor,before pushing upwards. This progressionactivates the triceps to a greater degree.


(a) (b)

Figure 8.20. Seated push-up – (a) before, (b) after

Medial/lateral rotationMuscle group(s): Rotator cuff, shouldersPhase/modality: Dynamic stabilisation,strengthEquipment: Cable, exercise band, dumb-bell

Purpose❑ To strengthen rotator cuff complex in

internal and external rotation, beforeintegration into kinetic chain movement.

❑ To increase the stability of theglenohumeral joint in an open chain (inpreparation for throwing activities).

Prerequisites❑ Functional flexibility in shoulder rotation.

❑ If the client has an upper-crossed posture,this must be corrected prior to loading(stretch pectorales major and minor,

latissimus dorsi, upper trapezius, levatorscapulae).

Starting position❑ Client is standing with a square stance,

side-on to the line of resistance (cable orexercise band). The elbow is flexed to 90°and the client is holding the band orcable handle. The elbow is held close tothe side of the body.

❑ For medial rotation, the hand nearest thecable should be holding the handle. Forlateral rotation, the opposite hand shouldbe holding the handle.

Correct performance❑ MEDIAL ROTATION – standing in good

alignment, with abdominals braced, clientslowly rotates the forearm inwards,keeping the elbow by the side of the body.


Figure 8.21. Medial/lateral rotation – (a) lateral rotation end position, (b) medial rotation end position

(a) (b)

❑ It is important that the upper arm doesnot move during the rotation (exceptaround a vertical axis). Repeat 10 timesbefore changing arms.

❑ LATERAL ROTATION – client slowlyrotates the forearm outwards. Repeat 10times before changing arms.

❑ Emphasise movement from theglenohumeral joint.

❑ As a variation, lateral rotation may beperformed in a side-lying position, using adumb-bell. As above, the client keeps theelbow close to the body and rotates theforearm outwards (or upwards, in thiscase).

Progressions❑ Increase the resistance of the band or use

a heavier dumb-bell.

❑ Perform the exercise with a dumb-bell in asupine position, with arm abducted to 90°.This progression allows for medial andlateral rotation within the same exerciseand is particularly useful for rotator cuffstrength during throwing actions.

Shoulder PNF patternsMuscle group(s): Shoulder/arm, rotator cuff,abdominals, backPhase/modality: Dynamic stabilisation,strengthEquipment: Cable, band, dumb-bell

Purpose❑ To condition the shoulder/arm complex

through the common ‘chopping’ and‘lifting’ diagonal movement patterns, seenin daily living and sport.

❑ To integrate the rotator cuff back into‘chopping’ and ‘lifting’ patterns.

Prerequisites❑ Pain-free functional range of motion in

abduction.

❑ Optimal rotator cuff function.

Starting position❑ Client is standing side-on to an adjustable

cable/band system (high and lowsettings).

❑ ‘REACHING FOR SEATBELT’ – clientholds a low cable next to the body.

❑ ‘PUTTING ON SEATBELT’ – client holdsa high cable across the body.

❑ ‘DRAWING THE SWORD’ – client holds alow cable across the body.

❑ ‘REPLACING THE SWORD’ – clientholds a high cable next to the body.

❑ Hold good postural alignment, withabdominals braced.

Correct performance❑ ‘REACHING FOR SEATBELT’ – client

moves the arm from a low position next tothe body to a high position on theopposite side of the body. The elbowshould start in extension and move toflexion at the end of the movement. Theshoulder starts in neutral and movesthrough flexion-horizontal adduction-medial rotation. The hand starts by theside of the body and ends in a positionover the opposite shoulder. Repeat slowly10 times.

❑ ‘PUTTING ON SEATBELT’ – clientmoves the arm from a high position onthe opposite side of the body to a lowposition on the same side of the body.The elbow should start in flexion andmove to extension at the end of themovement. The shoulder starts in flexion-horizontal adduction-medial rotation and



(c) (d)

(a) (b)

Figure 8.22. Shoulder PNF patterns: ‘Reaching for seatbelt’ – (a) start, (b) end positions; ‘Putting on seatbelt’ –(c) start, (d) end positions;


(g) (h)

(e) (f)

Figure 8.22. (contd) ‘Drawing the sword’ – (e) start, (f) end positions; ‘Replacing the sword’ – (g) start, (h) endpositions.

ends in neutral. The hand starts in aposition over the opposite shoulder and ends at the side of the body. Theclient should be instructed to visualiseputting on a seatbelt. Repeat slowly 10 times.

❑ ‘DRAWING THE SWORD’ – client movesthe arm from a low position on theopposite side of the body to a highposition on the same side of the body.The elbow should start in slight flexionand move to full extension at the end ofthe movement. The shoulder starts inslight flexion-horizontal adduction-medialrotation and ends in 110–130° abduction.The hand starts in a position over theopposite hip and ends in a position justabove the head. The client should beinstructed to visualise drawing a sword.Repeat slowly 10 times.

❑ ‘REPLACING THE SWORD’ – clientmoves the arm from a high position onthe same side of the body to a low positionon the opposite side of the body. Theelbow should start in full extension andmove to slight flexion at the end of themovement. The shoulder starts in110–130° abduction and ends in slightflexion-horizontal adduction-medialrotation. The hand starts in a position justabove the head and ends in a positionover the opposite hip. Repeat slowly 10times.

❑ Particular attention should be focused onscapulohumeral rhythm throughout themovement, as well as maintaining neutralspinal alignment.

❑ There should be no rotation in the torsoduring the movement.

❑ The flexion patterns may be performedwith a dumb-bell for variation.

Progressions❑ Increase weight or resistance of band.

❑ Perform the exercise in a single-leg stance.

❑ These patterns may be performed usingan oscillating Bodyblade®.

❑ This exercise can be progressed furtherinto a full ‘wood-chop’ movement, byslowly introducing torso rotation and,finally, a lateral weight shift. For furtherdetails of the wood-chop exercise, pleaserefer to phase 3.

ScaptionMuscle group(s): Shoulders, rotator cuffPhase/modality: Dynamic stabilisation,strengthEquipment: Dumb-bell, exercise band

Purpose❑ To strengthen the shoulder

abductors/flexors.

❑ To maximise stability of the glenohumeraljoint.

❑ To increase scapular control.

Prerequisites❑ Pain-free range of motion in abduction.

❑ Functional rotator cuff.

❑ Optimal core strength.

Starting positionClient is standing in good posturalalignment, with dumb-bells in each hand, inslight medial rotation.

Correct performance❑ Brace the abdominals and raise arms,

keeping thumbs at 45° angle. The armsshould be raised at an angle of 30° forwardsof the frontal plane (the plane of the scapula).


❑ Do not allow the head to jut forwards(sternocleidomastoid activation).

❑ Lower and repeat 10 times.

Progressions❑ Increase weight.

❑ Alternate arms.

❑ Single-leg stance.

Phase 3 exercises – Restoringfunctional strength

Standing push pattern (cable)Muscle group(s): Shoulder/arm, chest,abdominalsPhase/modality: Strength, stabilisation,balanceEquipment: Cable, exercise bands

Purpose❑ To integrate the shoulder musculature

into the ‘push’ movement pattern.


(a) (b)

Figure 8.23. Scaption – (a) before, (b) after

❑ To strengthen the pectoralis major andtriceps brachii.

❑ To increase force generation through theentire kinetic chain.

Prerequisites❑ Functional flexibility and range of motion

of the shoulder/arm complex.

❑ Good level of core strength.

❑ Upper extremity muscle balance. Clientswith upper-crossed posture shouldundergo a flexibility programme beforeattempting these movement patterns.


facing away from the cable machine.

Handles are held, with elbows flexed to90° and arms abducted to 90°, in aposition where the elbows are in line withthe shoulders.

❑ Abdominals should be braced prior tomovement.

❑ It is important that the arms do not startfrom a position of horizontal abduction(elbows behind shoulders). This will avoidunnecessary stress on the anterior jointcapsule.

❑ Ensure that weight distribution is evenbetween both feet and central from heelto toe. Allow the knees to bend slightlyand do not lean into the movement. Inthis position, the core musculature willactivate to keep the body upright.


(a) (b)

Figure 8.24. Standing push pattern (cable) – (a) before, (b) after

Correct performance❑ While holding good postural alignment

and a strong abdominal brace, slowly pushthe handles out in front of the body.

❑ During the movement, allow a smallamount of horizontal adduction at bothshoulders, so that the handles meet in thecentre, in front of the body.

❑ Slowly return both arms to the startposition, before completing 10repetitions.

❑ It is important to avoid ‘swaying’ duringthe movement. This can be minimised bychoosing a light enough weight andactivating an abdominal brace just beforethe movement begins.

Progressions❑ Increase weight (gradually).

❑ Alternate arms – increases core activation.

❑ Split stance – this position will increasethe stabilisation requirement in thefrontal plane, thereby recruiting the torsorotators to a greater degree.

❑ Single-leg stance – increases the reactivecomponent, as well as the multi-planarstabilisation requirement.

❑ Sitting on a stability ball (with bothfeet/one foot in contact with floor) –conditions and trains reactive stabilisation(especially within the core musculature).

❑ Kneeling on a stability ball.

❑ Standing on a balance-board/rocker-board.

VariationsThere are two main open- and closed-chainvariations within the ‘push’ pattern that canbe used as exercises within their own right, as

progressions to the above or simply to addvariety to an existing rehabilitationprogramme. These include the following:

❑ PUSH-UP (closed chain) – please refer tophase 2 for a complete description of thisexercise and progressions.

❑ BENCH PRESS (open chain) – thisexercise involves lying on a bench and‘pushing’ a barbell or dumb-bells abovethe body in the same motion as describedabove. The limiting factor of this exerciseis that when lying on a bench, thescapulae are somewhat restricted inadduction, thereby putting excessive stressthrough the anterior joint capsule of theglenohumeral joint. This can be overcomeby performing the exercise supine on astability ball, using dumb-bells rather thana barbell. This position will allow thescapula to retract freely around thecurvature of the ball. This exercise willincrease the reactive stabilisationrequirement of the core, as well asincreasing proprioceptive input to theshoulder musculature.

Standing pull pattern (cable)Muscle group(s): Shoulder/arm, back,abdominalsPhase/modality: Strength, stabilisation,balanceEquipment: Cable, exercise bands


into the ‘pull’ movement pattern.

❑ To strengthen the upper backmusculature and the biceps brachii.

❑ To increase force generation through theentire kinetic chain.


Prerequisites❑ Functional flexibility and range of motion

of the shoulder/arm complex.


❑ Upper extremity muscle balance. Clientswith upper-crossed posture shouldundergo a flexibility programme beforeattempting these movement patterns.


facing the cable machine. Handles areheld, with elbows extended and armsflexed to 90°.

❑ Abdominals should be braced prior tomovement.

❑ Ensure that weight distribution is evenbetween both feet and central from heel

to toe. Allow the knees to bend slightlyand do not lean backwards. In thisposition, the core musculature will activateto keep the body upright.

Correct performance❑ While holding good postural alignment

and a strong abdominal brace, slowly pullthe handles towards the body, maintainingelbows at shoulder level.

❑ The handles should be pulled inwardsuntil the elbows line up with theshoulders.

❑ Slowly return both arms to the startposition, before completing 10repetitions.

❑ It is important to avoid ‘swaying’ duringthe movement. This can be minimised bychoosing a light enough weight and


(a) (b)

Figure 8.25. Standing pull pattern (cable) – (a) before, (b) after

activating an abdominal brace just beforethe movement begins.

Progressions❑ Increase weight (gradually).

❑ Alternate arms – increases core activation.

❑ Split stance – this position will increasethe stabilisation requirement in thefrontal plane, thereby recruiting the torsorotators to a greater degree.

❑ Single-leg stance – increases the reactivecomponent, as well as the multi-planarstabilisation requirement.

❑ Sitting on a stability ball (with bothfeet/one foot in contact with floor) –conditions and trains reactive stabilisation(especially within the core musculature).

❑ Kneeling on a stability ball.

❑ Standing on a balance-board/rocker-board.

Variations❑ There is a useful functional variation of

the pull pattern that is worth mentioninghere. It is called the bent-over row and is acommon movement pattern found inmany gyms and rehabilitation centresworldwide.

❑ In this exercise, the client picks up abarbell or a pair of dumb-bells andassumes a square stance. From here theyshould bend the knees slightly and flexthe hips to approximately 60°, so that thehands are positioned just above the knees.The spine should remain in neutralthroughout the movement; therefore,good levels of torso stability are requiredfor this exercise.

❑ The client then begins to ‘row’ (pull) thebar towards the lower chest region, beforelowering.

❑ This exercise can be progressed by addingmore weight.

Shoulder pressMuscle group(s): Shoulder/arm, trapezius,abdominalsPhase/modality: Strength, stabilisation,balanceEquipment: Barbell, dumb-bells, exerciseband

Purpose❑ To strengthen the shoulder musculature

(deltoid, upper trapezius).

❑ To integrate the kinetic chain intooverhead movements of daily living andsport.

Prerequisites❑ Pain-free range of motion in

flexion/abduction.

❑ Adequate levels of core strength.

❑ Optimal postural control and alignment.

Starting position❑ Client is standing holding a barbell

(slightly wider than shoulder-width grip)in front of the body. Alternatively, a pairof dumb-bells can be held by the sides ofthe body.


Clinical perspectiveThe human body is regularly subjected tothe push/pull pattern in both open- andclosed-chain daily activities, for example,opening/closing doors, pushing a child ina buggy, pushing a lawnmower, sawingwood; it is also a vital movement pattern inmany sports, including boxing, rowing andwindsurfing.

❑ The barbell is lifted into a position justbelow the chin (start position). In thisposition the elbows are fully flexed.

❑ The abdominals are braced and the bodyand spine are in good alignment.

Correct performance❑ Push the barbell (or dumb-bells) upwards,

extending the elbows, until arms aremaximally abducted. Maintain optimalbody alignment and do not allow thespine to overextend. This can be achievedby holding an abdominal bracethroughout the movement.

❑ Slowly return the bar to the start positionand repeat 10 times.

❑ Aim to use equal force through bothshoulders and arms to push the barupwards.


❑ Single-arm dumb-bell shoulderpress/alternate dumb-bell shoulder press– this exercise will increase activation ofthe core musculature (especially thecontralateral obliques); in an attempt tostabilise the body, integrate the frontalplane.

❑ Sitting on a stability ball.

❑ Standing on a rocker-board.


(a) (b)

Figure 8.26. Shoulder press – (a) before, (b) after

Pull-downMuscle group(s): Scapulardepressors/adductors, back, bicepsPhase/modality: Strength, stabilisationEquipment: Cable, exercise band

Purpose❑ To strengthen the latissimus dorsi and

lower trapezius.

❑ To aid balance between the scapulaelevators and depressors, for injuryprevention.


adduction/abduction.



Starting position❑ Client is seated in front of a cable

machine, holding the handles, with elbowsextended and hands wider than shoulder-width apart. The arms are in almost fullabduction, forming a V-shape. Palms arefacing towards each other (neutral grip).

❑ The spine should be held in neutralalignment and the abdominals braced,ready for movement. In this position, thescapulae should be elevated, under thepull of the cables.

Correct performance❑ The movement consists of two parts,

which take place in the frontal plane andshould be integrated together to producea smooth continuous motion: (1) theelbows are flexed, as they are brought


(a) (b)

Figure 8.27. Pull-down – (a) before, (b) after

down towards the side of the hips; (2) thescapulae are depressed and adducted.

❑ Return to the start position, by extendingthe elbows and allowing the scapulae toelevate, against the upward pull of thecable. Do not allow the arms to ‘jerk’back.

❑ Perform 10 repetitions.

Progressions❑ Increase the weight – it is important not to

compromise weight for good technique inthis exercise. If the weight is too heavy,the latissimus dorsi may end up doing allthe work, because it has a largermechanical advantage, and it may bedifficult to depress the scapulae; in thissituation, the scapula adduction/elevationmechanism will take over, resulting in thefacilitation of the rhomboid/uppertrapezius force couple.

❑ Seated on a stability ball. This may beprogressed further by balancing on onefoot.

❑ Kneeling position – this will recruit thecore stabilisation mechanism to a greaterextent.

Upright rowMuscle group(s): Shoulders, upper trapezius,bicepsPhase/modality: Strength, stabilisationEquipment: Cable, band, barbell, dumb-bells

Purpose❑ To strengthen the shoulder and upper

back musculature.

❑ To integrate the kinetic chain in anupward ‘pull’ pattern.


adduction/abduction.


Figure 8.28. Upright row – (a) before, (b) after

(a)

(b)



Starting position❑ Client is standing in front of a low cable

machine, holding the handles in front ofthe body. Alternatively, a barbell can beheld. The hands should be no wider thanshoulder-width apart, with a pronatedgrip. The elbows are extended (armsstraight).

❑ The spine should be held in neutralalignment and the abdominals braced,ready for movement.

Correct performance❑ Begin the movement by flexing the elbows

and abducting the arms in a smooth,continuous manner, so that the handles(or barbell) are ‘rowed’ upwards towardsthe chin.

❑ The movement is completed at 90° ofhumeral abduction and slight horizontalabduction (elbows pulled slightlyposteriorly – this activates the scapulaadduction mechanism).

❑ Slowly return to the start position andperform 10 repetitions.


❑ Standing on a balance-board.

❑ Where possible, practise this exerciseusing all available equipment, includingcables, bands, barbells and dumb-bells.Using free weights will condition the bodyin a more functional way.

DipsMuscle group(s): Shoulders/arms, scapuladepressorsPhase/modality: Strength, stabilisation

Equipment: Bench, chair


(a)

Figure 8.29. Dips – (a) before, (b) after

(b)

Purpose❑ To increase strength of the chest and

triceps.

❑ To enhance shoulder stabilisation.

Prerequisites❑ The client should have a functional need

for loading the shoulder in this position.

❑ The client must have 45° or more ofactive, compensation-free shoulderextension to perform this exercise safely.

❑ This exercise is not vital for developingmaximal strength of the arms or chest.

Starting position❑ Client has hands placed on the edge of a

bench or heavy chair, so that the shoulderis in comfortable extension. Glutes mustbe kept as close to the bench as possible.Feet should be together and knees slightlybent.

❑ Hands should be close to the sides of thebody, with arms straight and scapulaeretracted.

Correct performance❑ Bending the arms, slowly lower the body

down until the shoulders are just aboveelbow height (elbows flexed to 90°).

❑ Straighten the arms to return the body tothe starting position.

❑ Maintain good form and alignment andperform 10 repetitions.

❑ Only lower the body to a comfortablepoint.

Pull-overMuscle group(s): Latissimus dorsi, pectoralismajor, triceps brachiiPhase/modality: Strength, stabilisationEquipment: Dumb-bell, medicine ball,exercise band

Purpose❑ To strengthen latissimus dorsi, pectoralis

major and triceps brachii, in a functionalmovement pattern.


Figure 8.30. Pull-over – (a) before, (b) after

(a)

(b)

❑ This pattern may be particularly useful forthose involved in overhead activities thatinvolve double extension, for example,painting/decorating or throwing actions.

PrerequisitesThe client must demonstrate good functionalflexibility (specifically the latissimus dorsiand pectorales major and minor) throughoutthe shoulder girdle to perform this exercisewithout compensation in the spine.

Starting positionClient is lying supine on a bench, or the endof a couch, holding a medicine ball/dumb-bell vertically overhead, with elbowsextended.

Correct performance❑ Lower the weight backwards slowly, while

flexing the elbows and shoulders, so thatthe elbows end up slightly higher than theshoulders and the elbows are flexed to90°.

❑ Brace the abdominals and extend theshoulders and elbows to bring the weightback to the start position (arms straight).

❑ Range of motion should be limited to thatspecified by assessment.

Progressions❑ Lying supine on a stability ball.

❑ This exercise can be progressed to afunctional power movement by slowlylowering the weight and then acceleratingthrough the upward movement, in asmooth manner. Alternatively, the armscan be kept straight throughout themovement, effectively lengthening thelever arm and making the exercise harder.Adding speed in this way requires a highlevel of core strength and stabilisation,

combined with perfect movementtechnique, and is only suitable for high-performance conditioning programmes(sport-specific throwing actions).

High-low wood-chopMuscle group(s): Shoulders, arms, torsorotators, total bodyPhase/modality: Strength, stabilisation,balanceEquipment: Cable, exercise band


into a total body movement that requirescore stabilisation.

❑ To re-educate the torso rotationmechanism and strengthen the obliquemusculature.

Prerequisites❑ Functional flexibility of the shoulder/arm,

without compensation in the spine.

❑ Adequate strength and flexibility in theoblique musculature and lumbar spine.

❑ Adequate leg strength.

Starting position❑ Client is standing in a shoulder-width

stance, facing away from the cablemachine, holding the handle with bothhands above the right shoulder. In thisposition, the left hand should grip thehandle first, with the right hand over thetop of the left hand.

❑ Good spinal alignment should bemaintained, with a strong abdominalbrace, prior to the movement.

Correct performance❑ Starting from optimal posture, initiate a

rotational movement, from the trunk


outwards, towards the left. Do not pullwith the shoulders or arms. Pull the cablehandle downwards and across the body.

❑ Use a slow tempo to start with. Avoidbeginning the movement from a forwardflexed position.

❑ Do not push so quickly that the shouldersround forwards; generate movement fromthe core instead of the arms.

❑ Allow the torso and arms to move back tothe start position and repeat up to 10times.

Progressions❑ As stability is developed, progress to

lateral weight shifting (moving weightfrom right to left leg and vice versa), sothat the movement resembles a wood-chopping motion.

❑ The wood-chop may also be progressed by

performing the exercise seated on astability ball. This will increase awarenessof the obliques to a greater extent,providing the ball is kept still throughoutthe movement.

❑ LOW-HIGH WOOD-CHOP – cable isadjusted so that the line of resistancestarts low and moves high.

❑ LATERAL WOOD-CHOP – cable isadjusted so that the line of resistance ishorizontal.

❑ This exercise can also be progressed to afunctional power movement byaccelerating through the chop downwardsand slowly returning to the start. Addingspeed in this way requires a high level ofcore strength and stabilisation, combinedwith perfect movement technique, and isonly suitable for high-performanceconditioning programmes (sport-specific).


(a) (b)

Figure 8.31. High-low wood-chop – (a) before, (b) after

Phase 4 exercises – Restoringfunctional powerMedicine ball chest passMuscle group(s): Chest, shoulders, corePhase/modality: Power, stabilisationEquipment: Medicine ball

Purpose❑ Improves concentric acceleration,

dynamic stabilisation and eccentricdeceleration of the shoulder joint andgirdle.

❑ Enhances the body’s ability to transferforce along the kinetic chain.

Prerequisites❑ If a lower- or upper-crossed posture is

noted, a proper stretching programmemust be completed before attempting thisexercise to ensure ideal lumbar alignmentand stability.


Clinical perspectiveThe wood-chop movement patternsprovide a foundation to many rotationalactivities, both occupational and sport-specific, and are based on PNF(proprioceptive neuromuscularfacilitation) flexion/extension patterns.When progressed to involve weightshifting, the movement presents a moreefficient way of generating force from theground up and transferring these groundforces across the lumbo-pelvic-hip complexand out through the shoulder and arm. Inthis way, the shoulder/arm musculaturewill not compensate and overwork at theexpense of the spine and lowerextremities.

The movement can be modified verysuccessfully to rehabilitate, condition andenhance many occupational and sportingactions, including manual labouring,tennis and golf.

All of the above movement patterns arefunctional in nature, requiring static,dynamic and reactive stabilisation in open-and closed-chain situations; the exercisesresemble many occupational, recreationaland sporting actions. Muscles do not workin isolation, but combine to formimportant force couples, which thenintegrate with parts (or the whole) of thekinetic chain, resulting in forcegeneration. With this in mind, it is crucialto train the movement, not the muscle; thismeans strengthening and stabilising theshoulder girdle and shoulder jointthroughout ranges of motion that arefunctional for that person. In order toachieve this goal, it is important for thetherapist to assess the load-bearingcapabilities of the shoulder in a functionalsetting. This will involve knowing what the

functional demands of the client’sjob/sport are, and testing the client withloads that are relevant to the activities theyperform. For example, a mother who has atwo-year-old child would benefit from ashoulder conditioning programme thatprogresses her towards handling around10 kg (approximate weight of a two-year-old child), in various lifting and carryingactivities – for example, squatting to pickup a child, lifting a child to a carryingposition, and so on. By considering thedaily routine of the mother, the number ofload-bearing activities she performs andthe different positions she puts her bodyinto, the therapist can begin to puttogether a well-structured rehabilitationand conditioning programme, tailored toher needs.

❑ The client must exhibit good corestrength and stabilisation.

Starting position❑ Ensure that the client completes a

thorough neuromuscular warm-up, toengage the nervous system prior to theexercise.

❑ The client should stand in optimalalignment, holding a medicine ball infront of the chest, with feet pointingstraight ahead.

❑ Abdominals should be braced, inpreparation for the movement.

Correct performance❑ Start by standing tall, with shoulder blades

depressed and retracted. Hold medicineball close to chest.

❑ Movement is the summation of theshoulder protraction, elbow extension andwrist flexion as the ball is acceleratedhorizontally away from the body.

❑ Therapist catches the ball and throws itback. The client should try to catch theball, decelerating through theshoulder/arm complex, bringing the ballback into the chest.

❑ Maintain a solid foundation through the


(a) (b)

Figure 8.32. Medicine ball chest pass – (a) before, (b) during

lower extremities by maintaining anabdominal brace throughout themovement.

❑ Repeat continuously until power begins todiminish (that is, throwing speed slowsdown) or when 12 repetitions have beencompleted.

❑ The therapist should look for anycompensations through the kinetic chain.

Progressions❑ Standing on a balance-board.

❑ Standing on one leg.

❑ A rotational component can be added tothis exercise to increase power in thetransverse plane. The client starts in thesame position as above, but instead ofpassing the ball in front of the body, theycan rotate the torso 45° and then pass theball. It is important to ensure that theforce generation begins with a slightweight shift to one leg; this is followed byactivation of the oblique musculature torotate the body in the same direction;finally, the shoulder/chest musculature isengaged to pass the ball away at a 45°angle. The ball is thrown back and theclient has to decelerate the kinetic chainand return to the start. This variationrequires a high degree of coordinationand is only suitable when the client is ableto demonstrate good link sequencingfrom the ground up.

Squat raiseMuscle group(s): Legs, back, shoulders, arms,corePhase/modality: Power, stabilisation, balanceEquipment: Medicine ball, dumb-bell


dynamic stabilisation and eccentricdeceleration of the entire kinetic chain.

❑ Enhances the body’s ability to transferforce along the kinetic chain, duringextension and flexion.

❑ Particularly useful for activities and sports where force is generated from theground up, towards the upper extremities(for example, tennis, basketball, golf,boxing).

Prerequisites❑ Client must demonstrate a good squat/lift

pattern.


Figure 8.32. (contd) Medicine ball chest pass – (c) after

(c)

❑ Pain-free range of motion in shoulderflexion.

❑ If a lower- or upper-crossed posture isnoted, a proper stretching programmemust be completed before attempting thisexercise to ensure ideal lumbar alignmentand stability.


Starting positionClient is standing in a square stance, holdingthe weight with both hands in front of thebody. The arms are straight and the handsare positioned at waist/hip level (slightshoulder flexion).

Correct performance❑ Begin the movement by squatting down to

a point where the weight is just above thefloor. Brace the abdominals, ready foracceleration.

❑ Accelerate the weight upwards by focusingon the smooth integration of ankledorsiflexion, knee and hip extension andshoulder flexion. The end position iswhere the arms are extended overheadand the body is in optimal posturalalignment.

❑ Slowly return to the bottom position andrepeat until the speed cannot bemaintained or when 12 repetitions havebeen completed.


(a) (b)

Figure 8.33. Squat raise – (a) before, (b) after

❑ It is important to brace the abdominalsjust before the point of acceleration, toprotect from spine from overextension atthe top of the movement.

ProgressionsIncrease the weight.

Barbell clean and pressMuscle group(s): Shoulders, total body, corePhase/modality: Power, stabilisation, balanceEquipment: Barbell

Purpose❑ Increases total body strength and power. It

is important to remember that thestrength and power developed here arecompletely relative to the posture of theclient during the exercise and the rangeof motion the client moves through.



(b) (c)

Figure 8.34. Barbell clean and press – (a) before, (b) during, (c) after

(a)

Prerequisites❑ The client must exhibit good

lifting/squatting technique and be able toperform the upright row and shoulderpress exercises.

❑ If a lower- or upper-crossed posture isnoted, a proper stretching programmemust be completed before attempting thisexercise, to ensure ideal lumbaralignment and stability.


❑ The client must be properly progressedthrough stability and strength phases, inorder to ensure that there is adequateflexibility, core strength and time foradaptation, thereby reducing chance ofinjury.

❑ The therapist must have a justifiablereason and system of programmeprogression to implement this advancedexercise. This exercise is useful inactivities where there are distinct stages of link sequencing/power transfer – forexample, lifting a child and placing theminto a high chair, or during a tennis serve.

Starting position❑ Begin with feet shoulder-width apart and

toes pointing forwards.

❑ Bend the knees slightly and bend at thewaist, grasping the barbell with bothhands slightly wider than shoulder-widthapart (palms facing body).

❑ Brace the abdominals.

Correct performance❑ Perform an explosive triple extension

movement in the lower extremities –

ankle, knee and hip extension, and drivethe elbows high. Make sure the barbelltravels in a vertical, linear fashion (closeto body).

❑ As bar reaches shoulder height, externallyrotate the arms and ‘catch’ the weight infront of the shoulders, simultaneouslydropping into a half-squat position, to getunder the weight. From here, contract theglutes to stand into a full upright position,with bar resting on your chest.

❑ Brace the abdominals, sink into a half-squat position to pre-stretch the glutesand quickly follow this with anotherexplosive movement, pushing the barbellup into a shoulder press. This movementshould start from a glute contraction, as ifpushing the floor away and, at the sametime, pushing the bar upwards. Stand tallat the top, with good posture and a strongabdominal brace.

❑ Carefully lower the barbell back to theground. Reset posture and perform 6–8repetitions.

Progressions❑ Increase the weight gradually, while

maintaining good technique.

❑ This advanced exercise should beperformed in ‘chunks’ before attemptingthe whole sequence. The client should becompetent in performing a dead lift,upright row and shoulder press; thesemovements can then be combinedsuccessively. For example, once the deadlift can be performed, the client canattempt a dead lift with the upright row(also known as the ‘clean’); once thisdouble sequence is perfected, the finalpressing movement can be added, tocomplete the entire motion.


3 The Trunk andSpine

The human spine is a remarkable structureof mobility and stability, characterised by aninherent S-shaped curvature. The integrity ispreserved by the unique and functionalarrangement of the anterior and posteriortrunk musculature. The balance betweenmobility and stability is under the closecontrol of the central nervous system; thelarge muscles of the trunk provide mobility,with the smaller, deeper muscles controllingstability. The dynamic interaction of theanterior and posterior trunk musclesprovides specific co-contraction patterns,designed to stabilise and mobilise the spineduring activities of daily living. Because thestructure of the spine is inherently unstable,activation of the trunk musculature isessential for the maintenance of trunkposition and control during static anddynamic postures.

As the functional link between theshoulder and pelvis, the spine is able toaccommodate the many movement patternsseen in daily activities. These movements arealmost always continuous with movement atthe shoulder or pelvis: the thoracic spinerotates with the shoulders and the lumbarspine rotates with the pelvis. The trunkmusculature plays a crucial role in theefficient transfer of ground reaction forcesfrom the lower body through to the upper

body, which in turn creates movement at theupper limbs; with optimal force transfercomes optimal power, which is necessary forall human movement.

The specific functional loads andcomplexity of movement patterns imposedon the trunk musculature by almost all dailyactivities often predispose the spine toaberrant forces, which, if left unchecked, maylead to acute and chronic spine dysfunction.Poor posture, muscle weakness or imbalanceand faulty muscle recruitment may becontributing factors to spinal problems andmay result in a lack of spinal stability and/orcontrol, loss of coordinated movement,asymmetry of weight distribution and backpain. Effective treatment of these problemsinvolves an understanding of spinebiomechanics, and the therapist must be ableto assess correct posture and movement ofthe spine as well as trunk muscle function.Following this, corrective exercise can serveto address any biomechanical deficienciesand restore optimal function.

This section aims to discuss the functionalanatomy and biomechanics of the spine andtrunk, with particular emphasis on the role ofthe trunk musculature in producingmovement. A functional approach to clinicalevaluation of the spine and trunk is discussedto provide an essential foundation for the

understanding of exercise prescription. Thefinal chapter provides the therapist with anumber of corrective exercises for the trunkwithin the context of an overall framework

for functional progression. These exercisesare designed to rebalance the trunkmusculature effectively to function optimallywithin everyday activities.


9FUNCTIONAL TRUNK AND SPINEANATOMY

Overview of spineanatomyThe spinal column forms the basic structureof the trunk and plays an important role inthe maintenance of both static and dynamicposture. It allows individual as well asintegrated movement of the head, neck andtrunk. Structurally, it is able to do this via itsdivision into the cervical, thoracic andlumbar regions, each giving rise to a distinctset of vertebral movements; functionally, asystem of local and global muscles acts tomobilise and stabilise the spine. The skeletalanatomy of the spine is shown in Figure 9.1.

Structure and functionof the spineThe spine, also known as the vertebralcolumn, consists of 33 vertebrae. There are 7cervical (neck) vertebrae, named C1–7; 12thoracic (chest and rib) vertebrae, namedT1–12; and 5 lumbar vertebrae, named L1–5.The sacrum is made up of 5 fused vertebrae(S1–5) and the coccyx, or tailbone, consistsof 4 small fused vertebrae. The unique‘wedge’ shape of the sacrum allows iteffectively to absorb ground reaction forcesfrom the lower extremities, as well as bodyweight forces from above.

Each vertebra consists of an anterior andposterior part, linked to one another viaintervertebral discs. When two vertebrae arejoined together by a disc, along withligamentous support, this functional unit isknown as a ‘motion segment’ (see Figure 9.2).

Figure 9.1. Skeletal anatomy of the spine

Cervicalvertebrae

Thoracicvertebrae

Lumbarvertebrae

Sacrum

Coccyx {

C1

C7

T1

T12

L1

L5

S1–5

�

��

�

The intervertebral disc comprises a fibrousouter layer (annulus fibrosus) and a soft,jelly-like nucleus (nucleus pulposus). Theannulus fibrosus consists of concentricallyarranged rings of collagen fibres, as well asfibrocartilage; this structure helps to keepthe nucleus pulposus under tension, thuscontributing to shock absorption andmaintaining the shape of the disc.

The range of motion of the spine as anintegrated column is considerable; themovements allowed are flexion, extension,lateral flexion and rotation (see Figure 9.3).


(a) (b)Figure 9.3. Movements of the spine – (a) flexion, (b) extension, (c) lateral flexion, (d) rotation

Figure 9.2. A motion segment of the spine

Vertebral body

Intervertebral disc

Transverseprocess

Spinousprocess

Vertebral body

Transverseprocess

Intervertebraldisc

Spinousprocess

FlexionForward bending in the sagittal plane, withgreatest movement occurring at thelumbosacral junction. This results incompression of the anterior portion of theintervertebral discs, causing a posterior (andlateral) migration of the annulus.

ExtensionThe return from flexion, with greatestmovement in the cervical and lumbar spine.Hyperextension is backward bending in thesagittal plane from a neutral position. Thethoracic spine has limited extension

capabilities due to the overlapping of thespinous processes.

Lateral flexionSide bending in the frontal plane. Greatestmotion occurs in the cervical and lumbarspine, but is limited in the thoracic spine, asthe ribs act as splints for the vertebrae.

If lateral flexion in the lumbar spineoccurs to the right, there is rotation of thelumbar vertebrae to the left. When lateralflexion occurs in a forward flexed position,the opposite occurs: the vertebrae turn right,with most of this coupled movement takingplace in the thoracic spine.

109Functional trunk and spine anatomy

(c) (d)

Figure 9.3. (contd) Movements of the spine

RotationRotary movement of the spine in thetransverse plane. Rotation is classifiedaccording to movement of the upper spine inreference to the lower spine. Greatestmovement occurs in the cervical spine,becoming increasingly limited towards thelumbar spine. As posture becomes morehyperextended, rotation occurs further downthe spine. In forward flexion, rotation occurshigher up the spine.

Whenever rotation occurs in the spine, itis accompanied by a slight degree of lateralflexion to the same side.

Muscles of the trunkThe trunk is made up of several groups ofmuscles that extend, laterally flex, rotate andflex the trunk (see Figure 9.4). All these


Clinical perspectiveDuring functional activities of daily livingand sport, these individual movements ofthe spine may not necessarily occur inisolation, but as combined movements, forexample, flexion accompanied by slightrotation during asymmetrical bending(picking up a shopping bag). When thesecombined movements occur, there may beaberrant forces exerted on the spine thatcan result in acute and chronic pain. It istherefore important for the therapist to beaware of the specific functionalmovements performed by each client, inorder to condition the trunk musclesappropriately for the level of demandrequired.

Figure 9.4. Muscles of the trunk – (a) anterior, (b) posterior

(a)

Superficial layer

Externaloblique

Internaloblique

Linea alba

Rectusabdominis

Rectusabdominis

Transversusabdominis

Transversusabdominis(cut away)

Deep layer

muscles play an important role in stabilisingthe trunk, but under the influence of gravity,it is the back extensors that contributesignificantly to this cause.

This section focuses on some of theimportant back extensor muscles, as well ason the deep and superficial abdominalmusculature, both of which are effective

movers and stabilisers of the spine.Understanding the roles of these muscles inmovement of the trunk is a prerequisite toeffective corrective exercise prescription.

Obliquus externus abdominis(external oblique)A large, flat muscle, the fibres of whichoriginate on the lower 8 ribs and rundiagonally downwards and inwards, to insertlaterally on the anterior iliac crest andmedially on the rectus sheath.

When the external obliques act bilaterally,their action is to flex the lumbar andthoracic spine against resistance. Unilateralcontraction in conjunction with otherposterior-lateral muscles results in lateralflexion of the spine to the same side;however, unilateral contraction with theopposite internal oblique (and other spinalrotators) produces rotation to the opposite


Clinical perspectiveWeakness of the back extensors results in adistinct loss of spinal stability; however,functional weakness of these muscles israre and is a common misdiagnosis in lowback pain. In fact, one of the underlyingreasons for this feeling of weakness isfaulty postural alignment – something thatis commonplace in low back pain patientsand often caused by weakness of theabdominal musculature.

Figure 9.4. (contd)

(b)

Deep layerSuperficial layer

ErectorSpinae

Iliocostalis(pulled away)

Iliocostalis

Longissimus

Spinalis

Multifidi

Quadratuslumborum

Multifidus (cut)

�

side. The external oblique shows greatestactivity during trunk flexion activities from asupine position.

Obliquus internus abdominis(internal oblique)A smaller, fan-shaped muscle that liesbeneath the external oblique. Its fibresoriginate from the iliac crest andthoracolumbar fascia, running diagonallyupwards to insert on the cartilage of thelower four ribs, and medially to the rectussheath.

Bilateral contraction of the internaloblique causes flexion of the lumbar andthoracic spine; unilaterally, it acts to flexlaterally and rotate the spine to the sameside.

The internal oblique shows greatestactivity during trunk rotation and hip flexionand extension movements.

Rectus abdominisA long, flat muscle originating on the pubiccrest, with fibres extending upwards to inserton the xiphoid process and ribs 5–7. Therectus is normally divided into three or fourbellies of tendinous bands. Each part of therectus is enclosed within a sheath ofconnective tissue (rectus sheath) that iscontinuous with the lateral abdominals andthoracolumbar fascia. These fibres meetcentrally to form the linea alba.

Bilateral contraction of the rectusabdominis causes flexion of the lumbar andthoracic spine, and unilateral contractioncauses lateral flexion.

The upper portion of the rectus showsgreatest activity during spine flexion activitiesinitiated from the upper body. The lowerportion shows greater activity during

movements that decrease pelvic tilt(flattening the low back). The lower portionof the rectus abdominis is an importantpostural muscle and often needsconditioning to restore muscle balance andnormal lumbar curvature.

Transversus abdominisA broad sheet of muscle whose fibres runhorizontally from the thoracolumbar fasciaand lower 6 ribs to the linea alba.

Its main action is to compress theabdominal viscera by ‘narrowing’ the waist,and, as such, is a muscle used in forcedexhalation. Unlike the other abdominalmuscles, it is not a mover of the spine, butaids in stabilising the trunk, especially whenintegrated with the entire abdominal wall.

Erector spinaeA complex group of muscles consisting ofthree longitudinal columns: iliocostalis,longissimus and spinalis. The erector spinaeforms the largest muscle mass of the back. Itcontributes little to the maintenance ofupright posture and engages most duringactions of extension, hyperextension andlateral flexion, when performed againstgravity or resistance.

The iliocostalis muscle runs from the iliaccrest to the ribs. The iliocostalis is the mostlateral of the three parts of the erectorspinae. In concert with the other erectorspinae muscles, its unilateral action is to flexthe spine laterally; bilaterally, it extends thespine.

The longissimus is the longest of the threegroups and runs between the transverseprocesses of the vertebrae. In concert withthe other erector spinae muscles, itsunilateral action is to flex the spine laterally;bilaterally, it extends the spine.


The spinalis is the least prominent andmost medial of the three groups. Togetherwith the other erector spinae muscles, itsunilateral action is to flex the spine laterally;bilaterally, it extends the spine.

Multifidus (deep posteriorspine)As part of the deep posterior spinal muscles(and the transversospinalis group), thisgroup of small muscles originates from thetransverse process of one vertebra, runningobliquely and medially upwards and insertingon the vertebra above, or often onto thesecond or third vertebra above. Collectively,the multifidi are thought to be responsiblefor localised movements, contributing tosegmental stability of the spine.

Psoas majorA long muscle that is located at the back ofthe abdominal wall, the fibres of whichoriginate from the bodies of the twelfththoracic and all lumbar vertebrae, and insertonto the lesser trochanter. As a muscle of thelower spine, it acts to flex the vertebralcolumn; as a muscle of the pelvis, it flexesthe thigh.

Quadratus lumborumA flat muscle extending from the iliac crestto the lowest rib and upper four lumbarvertebrae. It causes lateral flexion of the

lumbar spine when acting unilaterally, andstabilises the pelvis and lumbar spinebilaterally.


Clinical perspectiveThe functional division of the abdominalmuscles necessitates a truly integratedapproach to rehabilitation andconditioning, often employing exercisesthat incorporate larger movement patternsunder load.

It is important to understand that theredoes not appear to be a functionalseparation of the upper and lower rectusabdominis, although the upper and lowerportions can be emphasised preferentiallyin certain activities. However, any exercisethat recruits the rectus abdominis will stillactivate upper and lower portions, asduring a trunk curl exercise, for example.

On the other hand, the upper andlower portions of the obliques can berecruited separately to produce the manymovements of torso twisting and sidebending, as seen in many daily activitiesand sport. Due to their criss-crossing fibrealignment, the obliques also play a crucialrole in enhancing spine stability.

One of the main roles of the transversusabdominis during movement is in themaintenance of intra-abdominal pressure,especially during heavy load bearing. Dueto a similar fibre orientation, it almostalways co-contracts with the internaloblique to contribute to spinal stability.


Table 9.1. Summary of the major muscles involved in trunk movements (thoracicand lumbar spine)


Flexion Rectus abdominis Quadratus lumborum (towards end Internal oblique range of flexion)External oblique

Extension Erector spinae Trapezius (lower fibres)Quadratus lumborum Internal obliqueMultifidus

Lateral flexion Quadratus lumborum PsoasRectus abdominis MultifidusErector spinaeInternal obliqueExternal oblique

Rotation Internal oblique PsoasExternal oblique Erector spinaeMultifidus Rectus abdominis

Quadratus lumborum

10EVALUATION OF THE TRUNK

Evaluation of the flexors, extensors androtators of the trunk holds the key tosuccessful exercise prescription, for bothprevention and alleviation of spinaldysfunction.

This chapter outlines evaluation of thetrunk in relation to alignment of the spine,movement and muscular strength. Withregard to the spine, particular attention willbe paid to the thoracic and lumbar regions,as it is these areas that rely heavily on thebalanced support and control provided bythe trunk muscles. Combining the results ofthese assessments will help to build aprogressive corrective exercise programme.

Alignment analysisOptimal alignment of the spine and pelvis isconducive to good alignment of the trunk, aswell as alignment of the upper and lowerextremities. This position minimises jointstresses during weight bearing in almost alldaily activities.

For the purpose of gaining informationabout trunk muscle balance, spinalalignment is best observed in the standinglateral view. The client stands with feet apartin a comfortable and normal posture, and islined up with a suspended plumb line. Thefixed point of reference is slightly anterior tothe lateral malleolus, a base point whichrepresents the mid-frontal plane in idealalignment. Deviations from the ideal

standard are noted by the therapist. Plumb-line testing in the anterior and posteriorviews can also be employed to provideinformation regarding lateral curvatures ofthe spine.

Normal lateral alignment ofthe spineThe normal curves of the spine are labelledaccording to their direction of convexity inthe sagittal plane: anterior in the cervicalregion (lordosis), posterior in the thoracicregion (kyphosis) and anterior in the lumbarregion (lordosis). In the same way, lateralcurvature is also named in the direction ofconvexity, such as that present in scoliosis.

In ideal lateral alignment, the plumb lineshould run through the following points ofreference, as outlined in Figure 10.1:

❑ mastoid process

❑ bodies of cervical vertebrae

❑ axis of shoulder joint

❑ approximately midway through trunk

❑ bodies of lumbar vertebrae.

Deviations of the points of reference fromthe ideal plumb line highlight the degree offaulty alignment. It is useful to describe thesedeviations as slight, moderate or severe,rather than by quantitative means.Restoration of trunk muscle balance is a key

factor in re-establishing optimal alignment ofthe spine.

Common alignment problemsAcquired misalignments occur when weaktrunk muscles cannot provide adequatesupport for the spine. In contrast, shorttrunk muscles may limit range of motion ofthe spine, thus contributing to overall muscleimbalance. It is important to note that ifcorrection of spinal alignment causesundesirable changes in the alignment ofother joints, then the impairment is probablystructural, not acquired.

Common misalignments to look for whenassessing static spinal alignment include thefollowing, and are often associated with lowback pain.

Lumbar lordosisLumbar lordosis is observed ashyperextension of the lumbar spine, with thepelvis in anterior tilt. A degree of hip flexionwill also be observed.

Lordosis suggests weakness of theabdominals, in particular, the externaloblique, and also the hip extensors, namelythe gluteus maximus. The muscles that areshort are the lumbar erectors and the hipflexors.

Flat-back postureCharacteristics of a flat-back posture includelumbar spine flexion (flattened low back),posterior pelvic tilt and hip extension. It isthe opposite observation of lordosis.

This posture suggests weakness of thelumbar erectors and one-joint hip flexors.The muscles that are short include theanterior abdominals and the hip extensors.

Sway-back postureSway-back posture is characterised by aforward-displaced pelvis and a backward-displaced upper trunk. As a result, the pelvisis posteriorly tilted, with a degree of hipextension.

Weak muscles include the lowerabdominals (especially the external oblique)and one-joint hip flexors. Short musclesinclude the upper portion of the rectusabdominis and internal oblique, as well asthe hip extensors.

ScoliosisScoliosis is characterised by a lateralcurvature of the spine. Since the vertebralcolumn cannot bend laterally withoutrotating, scoliosis involves both lateral flexionand rotation. The cause of scoliosis can be


Figure 10.1. Normal alignment of the spine

acquired (functional), often relating toneuromuscular problems affecting themuscles of the trunk, or structural(idiopathic), involving changes in the bonystructure of the spine or unilateral extremityimpairment.

In both functional and idiopathicscoliosis, muscle weakness and tightness stillexist and unilateral corrective exercise canprovide significant benefits in many patients.Common weak muscles often include theabdominals (rectus abdominis and internaloblique) and paraspinal muscles on the sideof convexity, as well as the external obliqueon the side of the concavity. Muscle testingshould also include: back extensors; lateraltrunk; hipadductors/abductors/flexors/extensors;middle and lower trapezius; latissimus dorsi;and iliotibial band/tensor fasciae latae.

Movement analysisMany tests exist for observing movements ofthe trunk in a number of positions. However,those performed in the standing position willprovide an adequate foundation from whichthe therapist can build.

The results of these tests are notnecessarily intended for end range of motionassessment, but rather to observe importantfunctional movements that highlight musclerecruitment patterns and subsequentimbalance.

From a standing position, the client isasked to perform four standard movements:

❑ forward bending (flexion)

❑ backward bending (extension)

❑ side bending (lateral flexion)

❑ rotation.

The therapist observes the shape of the spine

and trunk during movement; any deviationsshould be noted as excessive movement,limited movement or timing impairments.

Forward bending: FlexionFlexion is the most commonly usedmovement of daily living and variesaccording to the region of the spine. Inforward bending, the movement comes fromboth the lumbar spine and pelvis. The pelvistilts anteriorly and moves posteriorly tomaintain the centre of gravity over the baseof support. This integrated movement of thelumbar spine and pelvis is known as lumbar-pelvic rhythm, with more movement comingfrom the hips than the spine.

Maximum lumbar flexion isapproximately 30–50°, based on the lumbarspine starting in a position of 20–30°extension. Full flexion is observed when thelumbar curve has flattened, but normallydoes not progress to the point where thespine curves convexly backwards. At thispoint, the lumbar erectors are inactive andmost of the stress is on the passive supportstructures. Any further forward movementfollowing full lumbar flexion is generatedthrough hip flexion.

During the return from forward flexion,the movement should begin with hipextension, followed by a combined extensionmotion from both the hips and the spine.When observing flexion, it is important tounderstand that all spinal segments shouldcontribute to the movement in a smooth andcontinuous manner.

Return from flexion should not beinitiated from the lumbar region. This isoften a contributing factor to back painthrough increased compressive forces on thespine. Another observed deviation is forwardhip-sway during return from flexion. Thisaction reduces the load on the hip and is

117Evaluation of the trunk

common in patients with weak hip extensors(sway-back posture).

A full flexion position that is greater than50° is considered excessive. Also, if 50 percent or more lumbar flexion occurs withouthip flexion, this is considered a timingimpairment of lumbar-pelvic rhythm. Asimilar timing problem can occur when thelumbar spine flexes more than the hips, asituation which is affected by hamstringlength. Typically, females tend to flex morereadily in the hips, and males in the lumbarspine.

Backward bending: ExtensionFunctional activities do not demand largeranges of motion in extension, and, as such,maximum lumbar extension is approximately25°.

Many of the problems that arise in lumbarextension are due to extension stress causedby excessive tightness of the hip flexors andlumbar erectors, rather than limited range ofmotion. Coupled with weak, taut abdominalmuscles, most of the extension movementoccurs at the lower lumbar vertebrae, ratherthan evenly through the entire lumbar spine.During functional and sport-specificmovement, the action of repeatedhyperextension is a contributing factor to lowback pain.

Side bending: Lateral flexionNormal lumbar lateral flexion from astanding position will enable the fingertips toreach the level of the knee, allowing forapproximately 25° of motion. Thoraciclateral flexion generally allows for up to 70°of movement due to a greater number ofvertebrae. The magnitude of the lateral curvein the thoracic spine depends on the numberof vertebrae involved.

As range of motion is not a reliableindicator of lateral flexion motion, it is moreuseful to observe the shape of the curveduring side bending. During optimal lateralflexion, the lumbar vertebrae bend and forma smooth curve that is continuous with thethoracic spine.

Deviations in lateral flexion are inevitablyaccompanied by rotation, as one movementaffects the other. Impairment of lateralflexion commonly occurs in patients whoexhibit marked hypertrophy of the lumbarerector spinae. In this instance, the stiffnessof the muscles limits their movement,showing up as a straighter movement of thelumbar spine, rather than a curve.

RotationRotational range of motion in the lumbarspine is limited to no more than 15°, with thegreatest rotational range occurring at thelumbosacral junction. The greatest amountof trunk rotation occurs in the thoracic spine(35–50°). During movement, it is importantto observe which regions of the spine areinvolved in the motion and to what extent.

Rotational restrictions are often the resultof muscle imbalances within the abdominals.Shortness of the external oblique on one sideand internal oblique on the other side canlimit range of motion during trunk rotation.This can easily be seen in asymmetry of thelumbar paraspinal muscles, with greater bulkon one side.

Muscle lengthThe spine is a multi-joint structure, and, assuch, the muscles that support it must belong enough to allow normal mobility, yetshort enough to contribute to optimal jointstabilisation. Although length testing alonecan offer some insight into trunk flexibility,


the following tests should be performed inconjunction with movement analysis toobtain a full evaluation of trunk flexibility,both statically and dynamically.

The tests shown below focus on length ofthe posterior trunk muscles only, as well asthe important observation of the contourand shape of the back during forwardbending. The length of the anteriorabdominals is not usually tested, asinformation regarding theirshortness/weakness can be determined fromcomprehensive strength testing.

Muscle(s): Posterior back musculature,hamstrings.Starting position: Client is in the long-sittingposition (legs extended, feet at right angles).Test: Instruct client to reach forwards and tryto touch toes, as comfortably as possible. Thetherapist observes the contour of the back, inparticular, the lumbar and thoracic regions.

Normal length: Normal flexion of the lumbarspine allows the spine to flatten in thisregion. Normal flexion of the thoracic spineallows an increase in the convexity in thisregion. The overall contour of the back, fromlumbar through to thoracic regions, shouldbe smooth and continuous (especially in thethoracic spine).

Normal length of the hamstrings allowsadequate hip flexion so that the anglebetween the sacrum and couch isapproximately 80°.Shortness: Shortness in the lumbar muscles(erector spinae) normally presents asexcessive thoracic flexion, as the thoracicspine compensates for lack of lumbarmovement. Note that the client may still beable to touch their toes. In extreme cases,there may still be a lumbar lordosis presentduring forward bending.

Shortness in the hamstrings may prevent


Figure 10.2. Forward-bending test for length of posterior back musculature

the client from touching their toes, and inthese situations the contour of the back mustbe carefully observed to determine whetherthere is shortness in the back musculature.Excessive length: The client is able to reachbeyond the toes in forward bending.Excessive length may be present in one or allof the following muscles: hamstrings, lowback and upper back.

Muscle(s): Posterior back musculature(without hip flexion).Starting position: Client is supine, resting onforearms, with legs straight. The elbow isflexed to 90° and the arms are close to thebody.Test: The client is instructed to flex thespine, keeping the pelvis flat on the couch(no hip flexion).Normal length: The client can flex the spine,while maintaining a flat pelvis.


Figure 10.3. Range of motion in trunk flexion (without hip flexion)

Muscle(s): Posterior back musculature,anterior abdominals (without hip extension).Starting position: Client is prone, resting onforearms. The elbows are flexed to 90°, withthe arms close to the body.Test: The client is instructed to propthemselves up on their forearms, keeping thepelvis flat on the couch (no hip extension).Normal length: The client can extend thespine, while maintaining a flat pelvis.Note: If the serratus anterior is weak, theremay be winging of the scapula during thistest, which will interfere with back extension.

Muscle strengthStrength testing for the trunk should focuson the deep and superficial abdominalmuscles, and to a lesser extent on the lowback muscles (extensors), as these are rarelyweak. Careful assessment of these muscles

will allow the therapist accurately to prescribestretching or strengthening exercises as partof a corrective exercise programme.

The following trunk muscles should betested:

❑ deep abdominal muscles – transversusabdominis

❑ back extensors

❑ lateral trunk flexors

❑ trunk flexors (upper and lowerabdominals)

❑ trunk rotators (obliques).

The back extensors are tested in the proneposition, and should be tested only if theclient is able to assume this position withoutpain. Extension tests should not beperformed routinely if the client has a historyof lumbar compression.

The lateral trunk flexors are tested with


Figure 10.4. Range of motion in trunk extension (without hip extension)

the client in a side-lying position, and thetrunk flexors (anterior abdominals) aretested in the supine position.

The trunk rotators (obliques) are tested ina supine position. Care and attention mustbe administered when conducting trunkrotation tests, as they present more of ademand on the client.

Muscle(s): Transversus abdominis.Pre-test: The client may need to beinstructed on how to contract the transversusabdominis without moving the trunk orpelvis. This is best done in a four-pointkneeling position. For further details of thismanoeuvre, please refer to phase 2 ofcorrective exercises for the trunk in Chapter11 (p. 136).Starting position: The client is lying prone,with legs straight. A pressure biofeedbackpad (or blood pressure cuff) is placed underthe patient’s belly button, inflated to

70 mmHg and allowed to stabilise. If thispressure is uncomfortable for the patient, asmaller inflation may be required. It isimportant for the therapist to identify anaverage point where the needle fluctuatesdue to respiration.Test: The client is asked to breathe in andout and, while holding the breath, instructedto draw in the navel towards the spine, sothat the belly button lifts off the couch.During the manoeuvre, the client should tryto keep a steady spinal and pelvic position,and should not engage any other muscles,such as the glutes or the superficialabdominals.

The therapist should observe the needlemovement. Once full contraction is achieved,the client can resume normal breathing. Thetest can be repeated if necessary to obtain aconsistent result.Normal strength: A reduction in pressure by6–10 mmHg indicates sufficient shortness of


Figure 10.5. Transversus abdominis strength test

the transversus abdominis, independent ofother abdominal muscles.Weakness: Inability to reduce the pressure bymore than 2 mmHg indicates that thetransversus abdominis is unable to shortenindependently of other abdominal muscles.Note: Failure to drop the pressure is notalways indicative of a weak transversusabdominis, but may point to excessiveactivation of other global muscles that serveto flatten the low back. These may includethe glutes, hamstrings and lower abdominals.Special attention must be paid to observingthe movements of the pelvis during the test.

A rise in pressure is normally indicative ofcontraction of the rectus abdominis orexternal obliques. As they contract, they willpush on the pressure pad, causing a rise inpressure. This may not necessarily point toweakness of the transversus abdominis, butrather to overactivity of the rectus abdominisor external obliques.

Muscle(s): Back extensors.Starting position: Client is prone, with handsclasped behind head. Therapist stabilises thelegs on the couch, to avoid lifting.Test: The client performs a trunk extensionto their full range of motion, and holds.Normal: Client can raise the trunk inextension through their range of motion,without excessive lordosis.Weakness: Bilateral weakness of the backextensors results in a lumbar kyphosis(flattening of low back) and increasedthoracic kyphosis. Unilateral weakness resultsin a lateral curvature of the lumbar spine,with convexity towards the weak side.Shortness: Bilateral shortness results in anincrease in lumbar lordosis. Unilateralshortness results in lateral curvature, with aconcavity towards the short side. Shortnessmay also be caused by weak gluteus maximus(see next test).


Figure 10.6. Back extensor strength test

Muscle(s): Gluteus maximus (during backextension).Starting position: Client is prone, with handsclasped behind head.Test: Client performs a back extensionmovement. Therapist observes low backposture.Normal strength: The moment that backextension is initiated, the client exhibits anormal anterior curve in low back.Weakness: The moment that back extensionis initiated, the client exhibits an increasedlordosis in low back. Full range of motioncannot be accomplished. Holding the pelvisdown in the direction of posterior tilt willenable full range of motion.

Muscle(s): Lateral trunk flexors – obliques,quadratus lumborum, latissimus dorsi, rectusabdominis.Pre-test: Test for hip abductor strength, aslateral trunk flexion in side-lying is a

combination of trunk flexion and hipabduction. Adequate strength in hipabduction will stabilise the pelvis duringmovement.Starting position: Client is side-lying straight,with a support between the legs. The top armis extended down the topmost thigh, and thelower arm is across the chest, holding theopposite shoulder. The legs are held down tocounterbalance the weight of the trunk.Test: Client raises trunk directly sideways.Normal strength: Client can raise trunksideways to a point of maximum lateralflexion, with lowermost shoulder rising up atleast 4–6 inches from the couch.Weakness: Client cannot raise the trunk orminimally raise the lowermost shoulder offthe couch.Note: If the back hyperextends duringmovement, the quadratus lumborum andlatissimus dorsi are short, indicatingweakness of the anterior abdominals.


Figure 10.7. Lateral trunk flexor strength test

The presence of trunk rotation duringlateral flexion can be indicative of animbalance between the internal and externalobliques. If the trunk rotates forwards duringlateral flexion, this indicates a greater pull bythe external oblique on that side. If the trunkrotates backwards, this indicates a greater pullby the internal oblique on that side. Thisimbalance may also be seen by performinglateral flexion over a stability ball.

Muscle(s): Lower abdominals.Starting position: Client is lying supine, withlegs straight and arms folded across chest.Test: The therapist assists the client in raisingboth legs to a vertical position (legs straight –tightness of the hamstrings will affect this).Client then tilts the pelvis posteriorly toflatten the low back. This is achieved bycontracting the abdominals. The client isasked to hold this tilt while slowly loweringthe legs, without moving the head or

shoulders. The therapist should observe theposition of the low back and pelvis duringlowering. The moment the pelvis starts to tiltanteriorly and the low back arches, the anglebetween the legs and the table is noted. Thiscan be assisted by placing a hand under thepatient’s lower back.Normal strength: If the client can lower thelegs to the table (zero angle) withoutanterior tilt of the pelvis, then normalstrength is present in the lower abdominalmuscles.

If the angle between the legs and the tableis 15–45°, strength is considered as being‘good’ (a).

If the angle between the legs and the tableis 45–75°, strength is considered as being‘fair’ (b).Weakness: If the angle between the legs andthe table is 75–90°, strength is considered asbeing ‘poor’ (c) and there is markedweakness of the lower abdominal muscles.


Figure 10.8. Lower abdominal strength test

(a) good


(c) poor

(b) fair

Figure 10.8. (contd) Lower abdominal strength test

Note: This test may not be suitable if theclient has low back pain, or is known to haveweak abdominal musculature. In thisinstance, the test may be modified using asingle bent leg, rather than straight legs.

Muscle(s): Upper abdominals.Pre-test: Back flexibility should be testedprior to this test, so that restricted range ofmotion is not misconstrued as muscleweakness.Starting position: Client is lying supine, withlegs slightly bent (knee angle ofapproximately 15°) and toes resting on thehands of the therapist, which are positionedabout 6 inches above the level of the couch.Toes should be pointed (ankle plantarflexion). The arms are positioned alongsidethe body.Test: The client performs a slow trunk curlby lifting the head and shoulders, while

maintaining the same pressure on thetherapist’s hands with their toes. Thetherapist observes whether the client’s toesare able to maintain constant pressure ontheir hands. Strength is graded according toperformance of this movement with the armsin three different positions.Normal strength: Client can perform thetrunk curl with the arms by the sides of thehead (fingers by ears), while maintaining thesame pressure on the therapist’s hands.

Strength is considered ‘fair/good’ if theclient can perform the trunk curl with thearms across the chest, while maintaining thesame pressure on the therapist’s hands.

Strength is considered ‘average/fair’ if theclient can perform the trunk curl only withthe arms by the sides, while maintaining thesame pressure on the therapist’s hands.Weakness: Weakness of the upper abdominalmuscles is present if the client cannot


Figure 10.9. Upper abdominal strength test

perform a trunk curl with the arms by thesides, without lifting the toes. This mayindicate the presence of facilitated hip flexormuscles.

Muscle(s): Trunk rotators – rectusabdominis, obliques.Starting position: Client is supine, with legsstraight, which are stabilised by the therapist.Test: Level 1 – client holds arms by sides andflexes and rotates the trunk to the right andholds for 5 seconds. The movement isrepeated to the left.

Level 2 – client extends arms forwards andflexes and rotates the trunk to the right andholds for 5 seconds. The movement isrepeated to the left.

Level 3 – client holds arms across chest

and flexes and rotates the trunk to the rightand holds for 5 seconds. The movement isrepeated to the left.

Level 4 – client holds hands by ears andflexes and rotates the trunk to the right andholds for 5 seconds. The movement isrepeated to the left.Normal strength: Client can complete testingat level 4.Weakness: Client cannot holdflexion/rotation and the trunk begins to de-rotate and extend. Completion of levels 1–3indicates strength grades of ‘average’,‘moderate’ and ‘good’, respectively.Note: Imbalance can exist between theinternal and external obliques, and is presentwhen there is rotation during side-lyinglateral flexion (see earlier test on p. 123).


Figure 10.10. Trunk rotator strength test


Clinical perspectiveMany popular training programmes forthe trunk tend to emphasise abdominaland low back strength. However, one ofthe most important functions of theabdominal muscles is to stabilise the spine,a function often neglected, especially insport. It is important to condition themajor stabilisers of the trunk – the internaloblique and transversus abdominis – theonly two muscles which pass from theanterior to the posterior parts of thetrunk.

For optimal stabilisation, strength aloneis insufficient: it is the speed with whichthe muscles contract in reaction to a force,as well as their endurance, which isimportant. Additionally, the ability of aclient to differentiate deep abdominalfunction (internal oblique and transversusabdominis) from superficial abdominalfunction (external oblique and rectusabdominis) is also vital. In the context ofcorrective exercise, once the function ofthe deep abdominal wall has been isolated,it should then be effectively reintegratedinto a number of trunk exercises andmovements that are functional to theclient.

11CORRECTIVE EXERCISE FORTHE TRUNK

Corrective exerciseprogressionThere is considerable evidence to suggestthat imbalance and lack of muscle controlwithin the trunk are important features inpatients with low back pain. Thereforecorrective exercise programmes must bespecific to correct these deficits.

In the majority of cases of low back pain,biomechanical modification is initiallyrequired in the form of postural correction.Daily activities should be adapted to reduceposition-related stresses to the lumbar spine;at the same time, it is important to addressthe issues of muscle weakness, tightness andcontrol.

The long-term success of any correctiveexercise programme lies in the ability tointegrate strength and neuromuscularcontrol into the functional activities of dailyliving and sport.

The four progressive phases of correctiveexercise in relation to the trunk aredescribed below.

Phase 1 – Muscle balanceThese exercises are aimed at restoringnormal length within the superficial trunkmuscles, in particular the low back. This isbest achieved through a combination ofstretching and static postural correction. As

almost all patients will be active bothoccupationally and recreationally, it is alsoimportant to incorporate postural correctionduring light functional activities, such asbending, lifting and reaching; with this inmind, emphasis should be directed towardsmuscle recruitment patterns, lumbar-pelvicrhythm and neutral spine alignment.

Phase 2 – Static, dynamic andreactive stabilisationThe exercises aim to improve stabilisation ofthe lumbar spine by restoring endurance ofthe deep abdominal wall and low backmuscles (inner unit), as a prerequisite toconditioning the superficial layers of theabdominal wall and low back (outer unit). Byre-educating all three layers of the abdominalwall, integration between the inner and outerunits can take place during functionalactivities, enhancing spine stability. Much ofthis work is achieved through abdominal wallco-contraction in a variety of static anddynamic postures that challenge neutralspine alignment.

Phase 3 – Functional strengthThe goal during this phase is to ensure thatthe stabilisation capabilities of the trunkmuscles are sufficient to control the lumbarspine under increasing load. Preliminary

exercises should aim to apply rotatory load tothe trunk through unilateral movement ofthe arms or legs in a variety of positions.From here, progression can be made byusing external resistance and larger extremityjoint movement. The final stages shouldinclude functional exercises that are relevantto the patient’s occupational andrecreational environment. As all movementpatterns require smooth integration of theinner and outer units, both functionalstrength and control of the trunkmusculature in open- and closed-chainenvironments should be the final outcome.

Phase 4 – Functional powerThis phase will further improve coordinationand control of movement, to provide a highdegree of functional carry-over intooccupation, recreation and sport.

The preferred method of conditioningduring this phase is plyometric exercise,demanding a high stabilisation requirementfrom the inner unit, simultaneously withquick, powerful torque production from theouter unit and extremity muscles. The resultis enhanced link-sequencing and forcegeneration from the lower extremities,through the trunk and out to the upperextremities.

For this to occur safely, muscle balance,stabilisation and functional strength must allbe at optimal levels, and particular emphasisshould be placed on optimal hip and trunkrotation, to ensure smooth coordination ofground reaction forces up through the body.

Corrective exercises forthe trunk

Phase 1 exercises – Restoringmuscle balance and flexibilityPelvic tiltsMuscle group(s): Low back, abdominal wallPhase/modality: Flexibility, mobilityEquipment: None

Purpose❑ To improve mobility of the lumbar

spine.

❑ To increase awareness of the lumbo-pelvic-hip complex.

Starting positionClient is lying supine, with knees bent, feetflat on floor and the spine in a natural curve(neutral alignment).

Correct performance❑ Client gently flattens the low back and

then arches, tilting the pelvis posteriorlyand anteriorly. This movement isperformed slowly and deliberately, andthe pelvis is tilted only within a pain-freerange of motion.

❑ The movement is continued for up to 2minutes or until the movement becomesfluid and controlled.

Variations❑ PELVIC CLOCKS – The tilting may also

be performed in a circular motion. Here,begin with a posterior tilt and then slowlymove the pelvis round in a clockwisedirection, towards an anterior tilt. Themovement is completed by continuingclockwise back to the start. The motion is

131Corrective exercise for the trunk

repeated in an anticlockwise direction andthe exercise is repeated as above.

❑ The pelvic clocks may be performed on astability ball to enhance proprioception.Start by sitting upright on a ball in goodpostural alignment. Circular pelvic tiltingis performed as above, using the ball as apivot.

Curled forward bendingMuscle group(s): Lumbar and thoracicerectors, glutesPhase/modality: Flexibility, mobilityEquipment: None

Purpose❑ To increase lumbar and thoracic flexibility

(do not prescribe in the presence ofthoracic kyphosis or osteoporosis).

❑ To increase range of motion in hipflexion.

❑ To encourage use of hip extensors,particularly in the presence of an anteriorpelvic tilt.

Starting positionClient stands with feet positioned about hip-width apart.

Correct performance❑ Client slowly reaches towards the floor,

allowing the neck, trunk and hips to flexuntil a comfortable range of motion isreached.

❑ Client returns to an upright position bycontracting the glutes and extending thehips. The movement should not beinitiated by extending the spine.

Side bendingMuscle group(s): Abdominals, paraspinalmusclesPhase/modality: Flexibility, mobilityEquipment: None

Purpose❑ To increase flexibility of the paraspinal

and abdominal muscles.

❑ To encourage thoracolumbar, rather thanlumbosacral, movement.

Starting positionClient is standing, with feet positioned abouthip-width apart.

Correct performance❑ Client places hands just above the iliac

crests, at the lowest level of the ribs, andslowly bends to one side by tilting theshoulders rather than moving at the waist.


Figure 11.1. Curled forward bending

❑ The therapist observes the movement andencourages movement of the thoracicspine, if necessary. The movement shouldbe pain-free.

❑ Motion is repeated to the other side andcontinued until the movement becomescoordinated.

Spine rotationMuscle group(s): Spinal rotatorsPhase/modality: Flexibility, mobilityEquipment: None

Purpose❑ To increase range of motion in spinal

rotation.

❑ To encourage use of the thoracic spine inrotation.

Starting positionClient is lying supine, with knees bent andfeet flat on floor, holding each elbow withthe opposite hand (‘Cossack’ position). Theelbows are pointing towards the ceiling.

Correct performance❑ The client begins by slowly rotating the

thoracic spine, side to side, allowing theelbows to reach towards the opposite sideof the floor.


Figure 11.2. Side bending

(a)

(b)

Figure 11.3. Spine rotation – (a) before, (b) after

❑ Client allows the head to turn naturallywith the movement.

❑ The movement is continued until fullpain-free range of motion is achieved.

❑ The legs should remain still throughoutthe movement, and the client isencouraged to keep the ribcage ‘soft’, toensure full rotation from the thoracicspine.

VariationsThis exercise may be performed in astanding or sitting position, against a wall orseated on a stability ball.

Seated low back stretchMuscle group(s): Low backPhase/modality: FlexibilityEquipment: Pillow

PurposeTo stretch tight low back muscles,particularly in those with excessive hamstringlength.

Starting positionClient is seated on a chair, with feet restingon the floor and a rolled-up pillow on thelap.

Correct performanceClient bends forwards over the pillow tostretch the low back, holding for up to 20seconds.

Variations❑ This stretch may be performed in a supine

position by tilting the pelvis to flatten thelow back on the floor, or by bending andbringing both knees towards the chest andholding for up to 20 seconds.

❑ To perform the stretch in a proneposition, a rolled-up pillow is placedunder the abdomen and a rolled-up towelunder the ankles.

Nerve flossingMuscle group(s): Paraspinal muscles,hamstrings, sciatic nervePhase/modality: MobilityEquipment: None

PurposeTo increase mobility of the sciatic nervethrough the intervertebral foramen.

Starting positionClient is seated upright at the end of acouch, with legs hanging freely.

Correct performance❑ Client begins by gently flexing the cervical

spine, then extends the cervical spine withsimultaneous knee extension of one leg.

❑ As the knee is flexed, the cervical spine isflexed and the movement is then repeatedusing the other leg.


Figure 11.4. Seated low back stretch

❑ The exercise is continued slowly anddeliberately for up to 1 minute or until anincrease in mobility is achieved.

Note: If there is excessive tension in thesciatic nerve, this exercise may exacerbatesymptoms. If the client reports a reduction insymptoms the next day, then frequency offlossing can be increased.

Posterior pelvic tilt (external oblique)Muscle group(s): External oblique,transversus abdominisPhase/modality: Muscle balance, strengthEquipment: None

Purpose❑ To strengthen the external oblique.

❑ To encourage use of the external obliquerather than the glutes or rectusabdominis, during posterior pelvic tilt.

Starting positionClient is lying supine, with knees bent, feetflat on floor and hands beside the head.

Correct performance❑ The transversus abdominis is activated by

pulling the lower abdomen up and in, andthe pelvis is tilted posteriorly to flatten thelow back by action of the external oblique.

❑ Client holds the position for up to 8seconds, while breathing easily. Theexercise is repeated 6 times.

❑ The therapist should observecompensatory use of the rectus abdominisor glutes to tilt the pelvis posteriorly.

Note: The client should be encouraged tocarry over the awareness of holding the lowerabdomen in and up, when standing. Thisexercise may also be performedincorporating a leg slide, using alternate legswhile holding the contraction.


(a)

(b)

Figure 11.5. Nerve flossing – (a) before, (b) after

Cat-camelMuscle group(s): Paraspinal musclesPhase/modality: MobilityEquipment: None

PurposeTo increase mobility of the spine by reducingviscous stresses.

Starting positionClient assumes a four-point kneelingposition, with hands below the shoulders andknees below the hips. Spinal alignment isneutral.

Correct performance❑ Client flexes the spine by allowing the

head and tailbone to drop downwards,and then extends the spine by lifting thehead and tailbone upwards (arched back).The movement is performed slowly anddeliberately.

❑ Emphasis should be placed on motion ofthe spine rather than end range flexibility.

❑ Perform 6 cycles.

Phase 2 exercises – Restoringstatic, dynamic and reactivestabilisationAbdominal hollowingMuscle group(s): Transversus abdominis,internal oblique, pelvic floorPhase/modality: Static stabilisation, strength,enduranceEquipment: None

PurposeTo increase awareness, strength andendurance of the deep abdominal muscles.

Starting positionClient is lying supine, in neutral spinealignment, with knees bent and feet flat onfloor.

Correct performance❑ Client draws lower abdomen upwards and

inwards, to narrow the waist. This positionis held for a few seconds before releasingand repeating.

❑ The therapist should observe for anycompensatory movement, such as loss ofneutral alignment, contraction of therectus abdominis or glutes, or any otherupper or lower extremity movement. Ifany of these occur, the therapist should


Figure 11.6. Cat-camel – (a) before, (b) after

(b)

(a)

correct the faulty movement by instructingthe patient.

❑ At this stage, emphasis should be placedon isolation of the deep abdominalmuscles.

ProgressionsProgression can occur in a number of stages:

❑ GRADING THE CONTRACTION – theclient is taught to contract the deepabdominal muscles to different intensitiesof contraction (100 per cent, 90 per cent,down to 10 per cent). This serves toincrease proprioception within the deepabdominal wall.

❑ INCREASING CONTRACTION TIME –once ability to contract is achieved, theclient can then increase holding times upto 8 seconds maximum. Endurance can befurther enhanced by increasing thenumber of repetitions. It is important thatthe client is instructed in the properbreathing technique while holdingcontractions.

❑ POSITIONAL CONTRACTIONS – theclient is instructed to maintaincontractions in a number of bodypositions, including prone lying, side-lying, four-point kneeling, two-pointkneeling, sitting (stability ball) andstanding.

❑ EXTREMITY MOVEMENT – the finalstage of progression is to maintain theabdominal contraction while performingupper and lower extremity movement.These movements are usually performedin a number of positions (as above) andinvolve moving arms and legs incontrolled and precise movementpatterns. The aims at this stage aresignificantly to challenge lumbar stabilityand spine position using body weight. Thisprovides a useful foundation for furtherfunctional and load-bearing movements.This approach forms the basis of a body-conditioning system known as Pilates.


(a)

(b)

Figure 11.7. Abdominal hollowing – (a) before, (b)after

Abdominal bracingMuscle group(s): Entire abdominal wallPhase/modality: Static stabilisation, strength,enduranceEquipment: None

Purpose❑ To increase awareness, strength and

endurance of the entire abdominal wall.

❑ To provide a primary stabilisationmechanism for the lumbar spine.

Starting positionClient is lying supine, in neutral spinealignment, with knees bent and feet flat onfloor.

Correct performance❑ Client braces or ‘stiffens’ the muscles of

the trunk and holds for a few seconds,before releasing.

❑ The therapist should be aware of the useof mental imagery to aid the patient. Thismay include instructions about tighteningother muscles in the body and applyingthe same technique to the torso; askingthe client to imagine they are about to behit in the torso; asking the client to coughand notice the stiffness that it produces inthe torso.

❑ Careful observation should be made toensure the client is maintaining neutralspine alignment throughout the exercise.

ProgressionsProgression can occur in a number of stages:

❑ GRADING THE CONTRACTION – theclient is taught to brace the abdominalmuscles to different intensities ofcontraction (100 per cent, 90 per cent,down to 10 per cent). This teaches theclient to use the correct intensity of bracewhen required.

❑ INCREASING CONTRACTION TIME –once ability to contract is achieved, theclient can then increase holding times upto 8 seconds maximum. Endurance can befurther enhanced by increasing thenumber of repetitions. It is important thatthe client is instructed in the properbreathing technique while holdingcontractions.

❑ POSITIONAL CONTRACTIONS – theclient is instructed to maintaincontractions in a number of bodypositions, including prone lying, side-lying, four-point kneeling, two-pointkneeling, sitting (stability ball) andstanding.


(a)

(b)

Figure 11.8. Abdominal bracing – (a) before, (b) after

❑ EXTREMITY MOVEMENT – the finalstage of progression is to maintain theabdominal brace while performing upperand lower extremity movement. Thesemovements are usually performed in anumber of positions (as above) andinvolve moving arms and legs incontrolled and precise movementpatterns. The aims at this stage aresignificantly to challenge lumbar stabilityand spine position using body weight. Thisprovides a useful foundation for furtherfunctional and load-bearing movements.

Oblique slingMuscle group(s): ObliquesPhase/modality: Static stabilisation, strengthEquipment: None

Purpose❑ To enhance awareness of the internal and

external oblique force couple, as used intrunk rotation.

❑ To improve the functioning of theobliques, particularly in patients withunilateral rotational dysfunction.

❑ To increase the strength of the obliques.

Starting positionClient is lying supine, in neutral spinealignment, with knees bent and feet flat onfloor. One hand should be placed over theright external oblique and the other handover the left internal oblique.

Correct performance❑ Client begins to draw the hands closer to

one another by focusing on co-contractingthe opposite internal and externaloblique. To aid this process initially, asmall compensatory movement of theshoulder and the opposite hip is allowed.


Clinical perspectiveThere is an important difference betweenabdominal hollowing and abdominalbracing and their contribution to spinalstability. While abdominal hollowing is animportant exercise for motor re-educationin low back pain patients, the act ofhollowing does not ensure optimal stabilityfor the spine.

Abdominal bracing is more effective atenhancing spine stability as it activates allthree layers of the abdominal wall. This isachieved through two mechanisms. First,during bracing, the criss-cross structure ofthe obliques is fully utilised to providestiffness for the trunk; second, theabdominal muscles are more effectivestabilisers of the trunk when they have awider base, that is, when the abdomen isnot hollowed. In this way, an abdominalbrace provides maximal lumbar stabilitythrough co-contraction of all theabdominal muscles. This can prove to bemore energy-efficient, as high levels of co-contraction in bracing are rarely requiredduring daily functional activities.

In practice, individuals rarely havecomplete inactivity of the deep abdominal,except in some cases of abdominalsurgery, chronic sedentary lifestyles andpathological muscle weakness/wasting.Many low back pain patients exhibit someability to contract the deep abdominals,and, with this in mind, corrective exerciseshould be progressive. Once deepabdominal contraction has been restored,the bracing mechanism should be taughtas the primary means of spinal stabilisationand implemented further in all functionalactivities.

❑ The position is held for a few secondsbefore releasing. It is then repeatedseveral times before changing sides.

ProgressionsOBLIQUE CURL – Once the client hasgained awareness of the obliques, they canthen proceed to adding rotational spinemovements. In this exercise the fingertips areplaced by the sides of the head and the clientcurls the trunk diagonally towards theopposite hip, before returning and repeatingto the other side. To facilitate integrated useof the internal and external oblique, theclient should be instructed to lift theshoulder rather than the elbow, with asimultaneous lift from the opposite hip.

Note: If the client has rotational dysfunction,such as that present in scoliosis, it may benecessary to perform the oblique sling orcurl unilaterally, as part of an overallcorrective exercise programme. In thisinstance, muscle strength testing is aprerequisite.

Floor bridgeMuscle group(s): Low back, abdominals, hipextensorsPhase/modality: Dynamic stabilisation,strengthEquipment: None

Purpose❑ To challenge and enhance lumbar stability

during hip extension.

❑ To strengthen the hip extensors.

Prerequisites❑ Pain-free range of motion in hip

extension.

❑ Ability to perform an abdominal brace.

Starting positionClient is lying supine, with knees bent andfeet flat on floor. Arms are held by the sidesof the body.

Correct performance❑ Client begins by lifting the hips up

towards the ceiling until there is a straightline between the knees and the shoulders.The movement should be initiated with anabdominal brace and a contraction of theglutes. Return to the start position.

❑ The movement is performed 6–10 times,before resting.


Figure 11.9. Floor bridge – (a) before, (b) after

(b)

(a)

Progressions❑ Arms across chest.

❑ Single leg.

❑ Feet on a stability ball.

Note: If the client experiences cramp in thehamstrings during the movement, thetherapist should check that pelvic alignmentis optimal, and correct if necessary. If theproblem persists, the quadriceps should bestretched.

Four-point arm/leg reachMuscle group(s): Low back, abdominals, hipextensors, shouldersPhase/modality: Dynamic stabilisation,strengthEquipment: None

Purpose❑ To challenge and enhance lumbar stability

during hip extension.

❑ To strengthen the hip extensors.

❑ To condition the cross-crawl movementpattern.


extension.

❑ Ability to perform an abdominal brace.

❑ Adequate rotator cuff strength.

Starting positionClient assumes a four-point kneelingposition, with hands below shoulders andknees below hips. Body weight should becentral, midway between shoulders and hips.

Correct performance❑ Client braces the abdominals and reaches

forwards with one arm and backwards withthe opposite leg. Neutral spine alignment

should be maintained throughout. Themovement is repeated for the other side,for a total of 6 repetitions each side.

❑ The arm and leg reach should not gohigher than horizontal or body level.Initially, the client may only be able to


(a)

(b)

Figure 11.10. Four-point arm/leg reach – (a) before,(b) after

achieve a small reach, beforecompromising spine position and bracingability. The reaching distance may have tobe increased slowly as the client becomesstronger.

❑ The therapist should also observe any side-to-side movement of the hips and correctthis by instructing the client to braceharder or decrease the distance reached.If movement still occurs, the exercise canbe regressed to just moving the arms orlegs alone, until adequate strength andcontrol are achieved.

Progressions❑ Lateral reach – the arms and legs are

taken out to the sides.

❑ ‘Crawling’ – the client is instructed tocrawl forwards and backwards whilemaintaining lumbar stability.

Curl-upMuscle group(s): Abdominals (upper)Phase/modality: Dynamic stabilisation,strengthEquipment: None

Purpose❑ To strengthen the abdominals while

minimising stresses to the lumbar spine.

❑ To challenge and enhance lumbar stabilityduring flexion.

PrerequisitesPain-free range of motion in flexion.

Starting positionClient is lying supine, with one leg straightand the other bent. Hands are positionedunder the lumbar spine for support andfeedback. It is essential that the lumbar spineis held in a neutral position throughout themovement.

Correct performance❑ Client braces the abdominals and lifts the

head and shoulders a short distance offthe floor. The elbows remain on the floor.The end position is held for 1 secondbefore returning.

❑ Particular emphasis should be placed onflexing the thoracic spine, NOT thelumbar or cervical regions. The aim is toactivate the rectus abdominis and not toproduce spine motion.

❑ Perform up to 10 repetitions with goodtechnique.


(a)

(b)

Figure 11.11. Curl-up – (a) before, (b) after

Progressions❑ The elbows can be lifted during the

movement.

❑ The end position of flexion can be heldfor up to 8 seconds, before returning.

Note: If the client experiences neck pain,they should be instructed to place theirtongue on the roof of their mouth behindthe front teeth, to encourage neckstabilisation patterns. If the problem persists,isometric neck exercises may be prescribed.

Lower abdominal curlMuscle group(s): Abdominals (lower)Phase/modality: Dynamic stabilisation,strengthEquipment: None

PurposeTo strengthen the lower abdominals.

PrerequisitesPain-free range of motion in flexion.

Starting positionThe client is lying supine, with knees bentand feet flat on floor. The therapist placestheir hand under the client’s lumbar spine.The client is instructed to flatten their backinto the therapist’s hand, by engaging the(lower) abdominals.

Correct performance❑ While maintaining the abdominal

contraction, the client raises and lowersthe flexed knee, bringing the knee abovethe hip and then back down. Themovement is performed 8 times, beforerepeating with the other leg.

❑ The therapist observes whether the back iskept flat throughout the entire exercise. Ifthe back starts to arch, the movement

must be stopped and resumed oncecorrected.

Progressions❑ The first stage of progression involves

gradually straightening the leg to producea longer lever arm, until the client canperform the exercise, holding the lowback flat with one leg straight.

❑ The final stage of progression involvesraising and lowering both legs. In thisinstance, the client should begin withboth legs fully bent, before progressing tostraighter legs. Please note that the use ofboth legs is an advanced exercise.


(a)

(b)

Figure 11.12. Lower abdominal curl – (a) before, (b)after

Note: If a flat back cannot be maintainedduring the movement, the posterior lateralfibres of the external oblique may not bestrong enough to assist the rectus abdominisin flattening the back. Muscle strengthtesting will be necessary to establish this.

Phase 3 exercises – Restoringfunctional strengthSupine hip extension: torso on ballMuscle group(s): Hip extensors, abdominalwallPhase/modality: Strength, stabilisation,balanceEquipment: Stability ball

Purpose❑ To increase the strength of the hip

extensors.

❑ To improve neuromuscular control of thelateral abdominal muscles, in preparationfor larger kinetic chain movements.

❑ To improve whole body balance.

Prerequisites❑ Good level of core strength.

❑ Optimal scapula control to ensureretraction and depression.

Starting position❑ Client sits on the stability ball and rolls

down, while comfortably placing the head,neck and shoulder blades on the ball, withboth feet positioned straight ahead.

❑ The hips are lifted until they are in linewith knees; hands are placed across thechest. The hips should remain levelthroughout the exercise. The scapulae areslightly retracted and depressed and theabdominals are braced.

Correct performance❑ Client begins to perform hip flexion by

lowering the hips towards the ball,followed with extension, by pushingthrough the heel of the planted foot. Themovement should be done slowly andextension must be initiated throughabdominal bracing and glute contraction.

❑ The therapist should observe the hips andshoulders to ensure they are levelthroughout the entire movement and thatproper spinal position is maintainedthroughout.


(a)

(b)

Figure 11.13. Supine hip extension: torso on ball – (a)before, (b) after

Progressions❑ Eyes closed.

❑ Holding a weight on the legs.

Supine hip extension: feet on ballMuscle group(s): Hip extensors, abdominalwallPhase/modality: Strength, stabilisation,balanceEquipment: Stability ball


extensors.




❑ Optimal scapula control to ensureretraction and depression.

❑ Normal hamstring length.

Starting positionClient is lying supine, with legs straight andheels resting on a stability ball, hip-widthapart. Part of the ball should be restingagainst the calf muscles. Arms are resting onthe floor beside the body.

Correct performance❑ Client braces the abdominals and

performs hip extension by lifting the hipsup, until a straight line is formed from theknees to the shoulders. The movement


Figure 11.14. Supine hip extension: feet on ball – (a) before, (b) after

(a) (b)

should be initiated by contracting theglutes.

❑ Return to the start position and perform atotal of 8–10 repetitions.

❑ The therapist should observe the hips andspine for any faulty movements andcorrect if necessary. Excessive wobblingshould be controlled through appropriatelevels of abdominal bracing and mayindicate weakness in the lateralabdominals.

Progressions❑ Eyes closed.

❑ Feet closer together on ball.

❑ Hands across chest.

❑ Adding knee flexion – as hip extension isperformed, there is simultaneous kneeflexion, by ‘pulling’ the ball in towards theglutes using the heels. Knee flexionshould end in a position where the ball isclose to the glutes (approximately 100°knee flexion). This is an advancedexercise.

Stability ball abdominal curlMuscle group(s): AbdominalsPhase/modality: Strength, balanceEquipment: Stability ball

Purpose❑ To increase strength of abdominals.


Prerequisites❑ Adequate thoracic flexion.


❑ Pain-free range of motion in extension.

Starting positionFrom a seated position on the ball, clientrolls down to allow the whole spine to rest onthe ball, with the back comfortably archedover the ball. The head should be tiltedbackwards slightly, but not excessively. Thehands are placed across the chest and thefeet are positioned approximately shoulder-width apart. The abdominals areappropriately braced.


(a)

(b)

Figure 11.15. Stability ball abdominal curl – (a) before,(b) after

Correct performance❑ Client begins curling the trunk by lifting

the head and shoulders off the ball andbringing the lower ribs towards the iliaccrest. This position is held for 1 secondbefore returning to the start. Themovement is repeated 8–10 times.

❑ The movement should be initiated bycurling the head first (chin to chest),followed by flexing the thoracic spine tolift the shoulders. The end position isachieved when the client can no longer

curl the trunk and full abdominalcontraction is felt.

Progressions❑ The fingertips may be placed on the sides

of the forehead.

❑ Brace the abdominals to a greaterintensity during the movement.

Stability ball back extensionMuscle group(s): Back extensors, abdominalsPhase/modality: Strength, enduranceEquipment: Stability ball


Clinical perspectiveThe abdominal curl over a stability ball hasa different and distinct place in correctiveexercise compared to the traditional floorcurl-up, for three reasons:

❑ Being positioned over a stability ballallows the trunk to be curled through amuch larger range of flexion and istherefore functional to daily activities.

❑ Performing exercise on a stability ballwill challenge the neuromuscularsystem to a greater degree, conditioningimportant righting and tilting reflexpathways.

❑ A curl-up on the stability ball causesalmost double the amount of co-contraction of the abdominalmusculature. Correspondingly, thespine load also increases.

Use of the stability ball for the curl-upexercise can be an effective way tochallenge and enhance lumbar stability. Inpractice, it is essential that the clientestablishes adequate spine stability andload-bearing capacity on a stable surface,before attempting to tolerate additionalspinal compression.

(a)

(b)

Figure 11.16. Stability ball back extension – (a) before,(b) after

Purpose❑ To increase the strength and endurance

of the back extensors.

❑ To enhance lumbar stability in extensionmovements.


❑ Pain-free range of motion in extension.Although the exercise does not require anend range extension position, it doesproduce significantly higher extensorforces, which may be contraindicated insome patients.

Starting positionClient is lying prone over a stability ball, withknees slightly bent to provide balance andstability. The hands are placed by the sides ofthe head (not touching) and the abdominalsare braced to an appropriate level.

Correct performance❑ Client begins by slightly flexing and then

extending the spine, continuing for up to15 repetitions.

❑ The movement should be performedslowly and deliberately, ensuring that thespine does not extend past neutralalignment.

❑ The aim of this exercise is to focus onmaximum recruitment of the backextensor muscles, rather than full range ofmotion. The use of mental imagery mayassist the client in this task.

Progressions❑ Moving the ball further towards the pelvis.

❑ Holding a small weight in one hand willsignificantly increase the challenge ofstabilisation, consequently recruiting moremotor units.

Russian twist: feet on stability ballMuscle group(s): ObliquesPhase/modality: Strength, stabilisation,balance, coordinationEquipment: Stability ball

Purpose❑ To strengthen the obliques.

❑ To integrate the abdominal wall intorotational actions.

Prerequisites❑ Good awareness of the oblique sling.

❑ Adequate hip flexor flexibility.

Starting positionClient is lying supine, with knees flexed to90° and heels resting on the ball,approximately hip-width apart. Hands are bythe sides of the body and the abdominals arelightly braced.

Correct performance❑ Client slowly allows the ball to rotate to

the left, just a few inches. From here,client activates the right external obliqueand left internal oblique to draw the ballback to the centre (oblique sling) andrepeats on the other side, using theopposite obliques, performing 6–8repetitions each side.

❑ The shoulders should remain on the floorthroughout the movement.

❑ If the therapist observes unstablemovement, the distance rotated should bedecreased to improve control. If theproblem persists, the client should beinstructed to practise the ‘oblique sling’exercise, until good coordination andstrength of the obliques is achieved.


Progressions❑ Increase distance rotated.

❑ Faster activation of the oblique sling.

❑ Hands across chest (advanced).

VariationsRussian twist: body on ball. If the client canhold a bridge position on the stability ball for1 minute and exhibit good technique withthe basic Russian twist exercise, they can trythis variation.

❑ The client assumes a bridge position, withhands clasped together, pointing towardsthe ceiling. The arms remainperpendicular to the trunk throughout

the movement. The abdominals arebraced.

❑ Maintaining a stable pelvis, the trunk isslowly rotated to each side. As strengthdevelops, range of motion and speed canbe increased.

❑ It is important to maintain proper spinalalignment. Hips should not drop whilerotating.

Iso-abdominals: proneMuscle group(s): Abdominals, glutes,shouldersPhase/modality: Strength, static stabilisationEquipment: None


(a) (b)

Figure 11.17. Russian twist: feet on stability ball – (a) before, (b) after

Purpose❑ To increase isometric strength of the

abdominals.

❑ To enhance integration of the entireabdominal wall.

Prerequisites❑ Adequate core and glute activation.

❑ Diaphragmatic breathing while bracing.

Starting positionClient assumes a prone position, with elbowsand shoulders flexed to 90°. The elbowsshould be positioned under the shoulders.

Correct performance❑ Client begins by bracing the abdominals,

tightening the glutes and lifting the bodyup onto the forearms.

❑ Client holds body position and optimalspinal alignment for 3 seconds, beforereturning and resting.

❑ Repeat up to 10 times, keeping neutralspine alignment from cervical through tolumbar spine.


Progressions❑ Increase holding time to a maximum of

8 seconds.

❑ Perform weight shifts from left to rightarm (rocking) for additional shoulderstability.

❑ Raise alternate legs for additional corestabilisation.

Iso-abdominals: side-lyingMuscle group(s): Abdominals, shouldersPhase/modality: Strength, static stabilisationEquipment: None

PurposeTo increase the isometric strength of theobliques.




Starting positionClient is lying on the right side, with kneesbent. Optimal postural alignment must be


Figure 11.18. Iso-abdominals: prone – (a) before, (b) after

(a) (b)

maintained throughout movement. Clientplaces right elbow directly under rightshoulder.


and lifting body up onto right forearm.

❑ Client holds body position and optimalspinal alignment for 3 seconds, beforereturning and resting.

❑ Repeat up to 10 times, keeping neutralspine alignment from cervical through tolumbar spine. Repeat on the left side.


ProgressionsIncrease holding time to a maximum of 8seconds.

Forward ball rollMuscle group(s): Abdominals, shoulders,armsPhase/modality: Strength, stabilisationEquipment: Stability ball

Purpose❑ To integrate isometric abdominal strength

into upper and lower extremitymovements.

❑ To improve multi-planar lumbar stability.

Prerequisites❑ Adequate rotator cuff strength.

❑ Instruction in diaphragmatic breathing.


Starting positionClient assumes a kneeling position in front of the ball and places clasped hands at thecentre of the ball, ensuring neutral spinealignment and bracing abdominals.

Correct performance❑ Client begins to roll forwards slowly,

keeping the spine in good alignment. The forward movement comes from thesimultaneous action of knee extensionand shoulder flexion. The hips shouldremain the same distance away from theball at all times.

❑ The therapist should observe for archingin the low back, which may indicate a lackof stability. In this instance, a tighter bracemay be the solution. If the problempersists, instruct the client to perform ashorter movement.


Figure 11.19. Iso-abdominals: side-lying – (a) before,(b) after

(b)

(a)

ProgressionsIncrease the distance moved.

Supine lateral ball rollMuscle group(s): Abdominals, total bodyPhase/modality: Strength, stabilisation,balance, coordinationEquipment: Stability ball

Purpose❑ To strengthen the abdominals and low

back in all three planes of motion.

❑ To improve static stabilisation of themuscles of the trunk.

PrerequisitesThis is an advanced exercise and the clientmust possess good flexibility and strength inthe lumbo-pelvic-hip complex.

Starting positionFrom a seated position on the ball, clientrolls down into a bridge position, allowingthe head and shoulders to rest on the ball.Arms are straight and out to the sides and awooden dowel is held across the chest. Theabdominals are braced.

Correct performance❑ Client slowly rolls the whole body along

the ball to the right, until the rightshoulder begins to come off the ball,ensuring that the hips and shoulders arelevel throughout the movement. Thisposition is held for 2–3 seconds, beforerolling over to the other side andrepeating. Perform 3–4 repetitions eachside, before resting.


(a)

Figure 11.20. Forward ball roll – (a) before, (b) after

(b)

❑ It is important that the abdominals arebraced throughout the movement andthat the whole body rolls as one unit.

❑ The therapist can observe the woodendowel to ensure it remains horizontalthroughout and that the spine is nottwisting in any way.

Progressions❑ Increase the holding time to up to 8

seconds.

❑ Increase the distance moved. This willplace increasing stresses on the trunkmusculature to stabilise the entire body.

Note: This is an advanced exercise thatshould be placed towards the end of thefunctional phase. It is designed to train anumber of skills, including strength,endurance, agility, balance, coordination andflexibility – with this in mind, careful

attention should be paid to technique andexecution.

SquatMuscle group(s): Abdominals, low back, legsPhase/modality: Strength, stabilisationEquipment: None

Purpose❑ To improve lumbar stabilisation during

functional movements.

❑ To enhance the body’s ability to transferforce along the kinetic chain, duringextension and flexion. Particularly usefulfor activities and sports where force isgenerated from the ground up.


flexion.


(a) (b)

Figure 11.21. Supine lateral ball roll – (a) before, (b) after


❑ Good flexibility in the calf muscles.


Starting positionIn a standing position, client places the feetshoulder-width apart, places arms acrosschest and assumes good postural alignment.The spine should remain in neutral

alignment throughout the movement. Theabdominals should be lightly braced.

Correct performance❑ Client performs triple flexion of the hip,

knee and ankle, and squats down to aposition where the thighs are parallel withthe floor. In this position, the kneesshould not overshoot the toes and shouldbe tracking over the second toe of eachfoot (not bowing inwards or outwards).The spine is still in neutral alignment andthe hips are pushed backwards tomaintain balance over the feet.


Figure 11.22. Squat – (a) before, (b) after

(a) (b)

❑ From this position, client braces theabdominals further and contracts theglutes, while performing triple extensionof the ankle, knee and hip, to return tothe start position. Perform 10–12repetitions.

❑ It is important to contract the glutes at thebeginning of the upward push, as this willallow the pelvis to initiate the movement,prior to the spine.

❑ The therapist should observe spinalalignment, knee position and thecoordination of triple extension/flexion.There should be particular emphasis onthe sequencing of abdominal and glutecontraction at the start of the upwardphase.

❑ If there is muscle weakness in the legs, thesquat can be modified into a half- orquarter-squat, where the client onlycompletes the range of motion availableto them. Tightness in the calves mayprevent full range of motion and thesemuscles should be stretched prior toattempting this exercise.

Progressions❑ Slower tempo.

❑ Use of a weighted barbell. Thisprogression involves holding a barbellacross the upper back and requiresadequate strength in shoulder abduction,along with good scapula control.

Dead liftMuscle group(s): Abdominals, low back, legsPhase/modality: Strength, stabilisationEquipment: Dumb-bells

Purpose❑ To improve lumbar stabilisation during

functional movements.



noted, a proper stretching programmemust be completed before attempting thisexercise, to ensure ideal lumbaralignment and stability.

❑ Good flexibility in the calf muscles.


Starting positionIn a standing position, client places the feetshoulder-width apart, holding a pair of lightdumb-bells. The spine should remain inneutral throughout the movement. Clientlightly braces the abdominals.


knee and ankle, and bends down to aposition where the thighs are almostparallel with the floor, as if to place thedumb-bells beside the body. In thisposition, the knees should not overshootthe toes and should be tracking over thesecond toe of each foot (not bowinginwards or outwards). The spine is still inneutral alignment and the hips arepushed backwards to maintain balanceover the feet.

❑ From this position, client braces theabdominals further and contracts theglutes, while performing triple extensionof the ankle, knee and hip, to return tothe start position. Perform 10–12repetitions.




❑ If there is muscle weakness in the legs, thedead lift can be modified into a half- or

quarter-lift, where the client onlycompletes the range of motion availableto them. Tightness in the calves mayprevent full range of motion and thesemuscles should be stretched prior toattempting this exercise.

Progressions❑ Use of heavier dumb-bells.

❑ Use of a barbell.

Note: The dead-lift pattern is almost identicalto the squat, except that the weight islowered to the floor. This exercise (and the


(a)

Figure 11.23. Dead lift – (a) before, (b) after

(b)

squat) is extremely functional for patientswho exhibit faulty lifting and bendingmovement patterns and can be adapted toincorporate load bearing where necessary.

High-low wood-chopMuscle group(s): Abdominals, total bodyPhase/modality: Strength, stabilisation,balanceEquipment: Cable, exercise band

Purpose❑ To enhance lumbar stabilisation through

functional whole body movement.




❑ Adequate strength and flexibility in theanterior and lateral abdominals and in thelumbar spine.

❑ Adequate leg strength.

Starting position❑ Client starts in a standing position, with a

shoulder-width stance, facing away fromthe cable machine and holding thehandle with both hands above the rightshoulder. In this position, the left handshould grip the handle first, with the righthand over the top of the left hand.


Correct performance❑ Starting from optimal posture, client

initiates a rotational movement from thetrunk outwards, towards the left. Clientshould not pull with the shoulders orarms. The cable handle is pulleddownwards and across the body.

❑ Use a slow tempo to start with. Avoidbeginning the movement from a forwardflexed position.


Clinical perspectiveThe squat and dead lift are functionalmovement patterns and are performed byalmost everyone on a daily basis. They areused in activities such as rising up from achair and lifting heavy bags off the floor,as well as a large number of sport-specificmovements. As many of these activities arerepeated many times throughout the day,rehabilitation and conditioningprogrammes should be tailored to theindividual’s demands.

By focusing on strength-endurance thesquat/dead-lift pattern can be used as aneffective corrective exercise tool. Forexample, a mother who has a two-year-oldchild may bend down to lift her childapproximately 30 times a day. Along with anumber of other bending/lifting activities,this may amount to a total of about 50movements. To increase her functionalcapacity to squat/dead-lift safely, withgood lumbar stabilisation, a correctiveexercise programme can be prescribedthat includes squatting or lifting,progressively, up to 50 repetitions daily.The use of an appropriately weightedmedicine ball (estimated weight of thechild) may be used to improve functionalstrength.

For patients who regularly lift unevenloads with both hands, for example,shopping bags, the dead-lift pattern can besuitably modified using medicine balls ofdifferent weights, or an unevenly weightedbarbell.

❑ Do not push so quickly that the shouldersround forwards; movement should begenerated from the core instead of thearms.


Progressions❑ As stability is developed, progress to

lateral weight shifting (moving weightfrom right to left leg and vice versa), sothat the movement resembles a ‘wood-chopping’ motion.

❑ The wood-chop may also be progressed byperforming the exercise seated on astability ball. This will increase awareness

of the obliques, providing the ball is keptstill throughout the movement.



❑ This exercise can also be progressed to afunctional power movement, byaccelerating through the chop downwardsand slowly returning to the start. Addingspeed in this way requires a high level ofcore strength and stabilisation, combinedwith perfect movement technique, and isonly suitable for high-performanceconditioning programmes (sport-specific).


(a) (b)


Phase 4 exercises – Restoringfunctional power (all power movements require athorough cardiovascular andneuromuscular warm-up prior toperformance)

Power crunchMuscle group(s): AbdominalsPhase/modality: Power, strength,stabilisationEquipment: Stability ball, dumb-bell,medicine ball

PurposeTo increase strength and power of the trunkflexors.

Prerequisites❑ Ability to perform a stability ball crunch

with good form.

❑ Good abdominal strength.

Starting position❑ As with the basic stability ball crunch,

except that a medicine ball or dumb-bellis held firmly on the chest.

❑ The therapist should kneel behind theball to stabilise, if necessary.

Correct performance❑ The crunch is performed as normal,

except that the concentric movementshould be more explosive, building up thespeed over 10–12 repetitions. The exerciseshould stop when there is a noticeable loss


Figure 11.25. Power crunch – (a) before, (b) after

(a) (b)

of speed or when 12 repetitions have beenachieved.

❑ It is essential that momentum is not usedto perform this movement (that is, nobouncing on the stability ball).

❑ Focus on perfect technique rather thanthe number of repetitions.

Note: This is a very advanced exercise andshould only be performed if deemednecessary, both from a functional and musclebalance perspective.

Russian power twist: body on ballMuscle group(s): ObliquesPhase/modality: Power, strength,stabilisation, balanceEquipment: Stability ball, medicine ball

PurposeTo develop power in rotational movement.

Prerequisites❑ Good level of strength in the lateral

abdominal musculature.

❑ Ability to perform the Russian twist usingown body weight.

Starting positionClient begins in a bridge position on the ball,holding a small medicine ball in both handsvertically above chest. Client bracesabdominals and should aim to keep the spinein good alignment throughout the exercise.


Figure 11.26. Russian power twist: body on ball – (a) before, (b) after

(a) (b)

Correct performanceThe performance is the same as the bodyweight Russian twist, except rotation speed isincreased as the repetitions increase.Perform 10–12 repetitions, or as many aspossible before the speed begins to decrease.

ProgressionsIncrease weight.

Note: This is an advanced exercise and thetherapist should watch carefully for goodtechnique and alignment throughout themovement.

Oblique medicine ball tossMuscle group(s): Obliques, total bodyPhase/modality: Power, strength,coordinationEquipment: Medicine ball

Purpose❑ To increase functional power and strength

in the obliques.

❑ To condition task-specific accelerationand deceleration in rotational movements.

Prerequisites❑ Good level of strength in the lateral and

anterior abdominal musculature.

❑ Ability to perform the wood-chop and/orRussian twist.

Starting positionStanding upright, with knees slightly bent, ingood postural alignment, client holds themedicine ball with both hands and braces theabdominals.

Correct performance❑ With a partner standing about 6–8 feet

away, to one side, client passes the ball justin front of partner. When throwing the

ball, aim to rotate the body using asmooth integrated movement from thelegs, hips, torso and shoulders/arms.When catching the ball, allow the body todecelerate by absorbing the weightthrough the shoulders/arms, torso, hipsand legs, before accelerating again andthrowing it back.

❑ Perform 10 passes before repeating on theother side.

Progressions❑ Increase the weight of the medicine ball.

❑ Increase the throwing distance.


(a)

Figure 11.27. Oblique medicine ball toss – (a) before

Vertical/horizontal oscillations with aBodyblade®Muscle group(s): Abdominals, total bodyPhase/modality: Power, strength,stabilisation, balanceEquipment: Bodyblade®

PurposeTo condition the entire kinetic chain inpower, strength and reactive stabilisation.

Prerequisites❑ Good core strength and frontal plane

stability.

❑ Adequate flexibility in the shouldercomplex.

Starting positionIn a standing position, feet shoulder-widthapart, client assumes good posturalalignment, with scapulae slightly adducted


(b) (c)Figure 11.27. (contd) Oblique medicine ball toss – (b) during, (c) after

and depressed. Client holds the Bodyblade®with arms straight and both hands in thecentre, using an interlocking grip. The flatsurface of the Bodyblade® should be facinglaterally. The abdominals are braced.

Correct performanceClient begins to oscillate the Bodyblade®side to side at a steady rate, using quick handaction. As a steady oscillation is achieved, thehand movement is increased to increase the

amount of flexing in the blade. Increase to amaximum speed and hold this oscillation foras long the body can be stabilised.Note: The therapist should observe the clientfor any position changes of the blade whichmay result in a redirection of forces to thebody.

VariationsThe Bodyblade® may be held horizontally, asshown (see Figure 11.31b). A number of


Figure 11.28. (a) Vertical oscillations with a Bodyblade®; (b) Horizontal oscillations with a Bodyblade®

(a) (b)

other body and limb positions can be used tocondition a number of upper body muscles.All variations will require significantstabilisation from the superficial and deepabdominal muscles.

Barbell clean and pressMuscle group(s): Abdominals, shoulders,total bodyPhase/modality: Power, strength,stabilisation, balanceEquipment: Barbell

Purpose❑ Enhances lumbar stability during power

movements.

❑ Increases total body strength and power. Itis important to remember that thestrength and power developed here arecompletely relative to the posture of theclient during the exercise, and the rangeof motion that the client moves through.






❑ The client must be properly progressedthrough stability and strength phases, inorder to ensure that there is adequateflexibility, core strength and time for

adaptation, thereby reducing chance ofinjury.

❑ The therapist must have a justifiablereason and system of programmeprogression to implement this advancedexercise. This exercise is useful inactivities where there are distinct stages oflink sequencing/power transfer – forexample, lifting up a child and placingthem into a high chair, or during a tennisserve.

Starting position❑ Client begins with feet shoulder-width

apart and toes pointing forwards.

❑ Client bends the knees slightly and bendsat the waist, grasping the barbell with bothhands slightly wider than shoulder-widthapart (palms facing body).

❑ Abdominals are braced.

Correct performance❑ Client performs an explosive triple

extension movement in the lowerextremities – ankle, knee and hipextension – and drives the elbows high.The barbell must travel in a vertical, linearfashion (close to body).

❑ As bar reaches shoulder height, clientexternally rotates the arms and ‘catches’the weight in front of the shoulders,simultaneously dropping into a half-squatposition, to get under the weight. Fromhere, the glutes are contracted to standinto a full upright position, with barresting on the chest.

❑ Bracing the abdominals, client sinks into ahalf-squat position to pre-stretch the glutesand quickly follows this with anotherexplosive movement, pushing the barbellup into a shoulder press. This movement



Figure 11.29. Barbell clean and press – (a) before, (b) during, (c) after

(a)

(b)

(c)

should start from a glute contraction, as ifpushing the floor away, and at the sametime pushing the bar upwards. Stand tallat the top with good posture and a strongabdominal brace.

❑ The barbell is carefully lowered to theground. Reset posture and perform 6–8repetitions.

Progressions❑ Increase the weight gradually, while


❑ This advanced exercise should beperformed in ‘chunks’ before attemptingthe whole sequence. The client should becompetent in performing a dead lift,upright row and shoulder press; thesemovements can then be combinedsuccessively. For example, once the deadlift can be performed, the client canattempt a dead lift with the upright row(also known as the ‘clean’); once thisdouble sequence is perfected, the finalpressing movement can be added, tocomplete the entire motion.


4 The Pelvis, Hipand Knee

The pelvis or the ‘pelvic girdle’ is made up ofthe two hip bones, the sacrum and thecoccyx, and forms the essential functionallink between the trunk and the lowerextremity. Movement of the pelvic girdle islargely dependent on movement of thespine. In contrast to the shoulder girdle, thepelvic girdle offers more strength thanmovement and is assisted by some of themost powerful muscles of the body.

The sockets of the pelvic girdle(acetabula) articulate with the femur to formthe hip joint, producing movement of thelower extremity. The larger depth of the hipjoint socket limits large ranges of movement,allowing for weight bearing instead:therefore, flexibility in the hip joint issacrificed for stability.

The distal end of the femur articulateswith the tibia at the knee joint, the largestjoint in the human body. The knee jointfunctions in both weight bearing andlocomotion and is subject to enormousstresses in all planes of motion; to meet thesedemands it has a complex yet strongligamentous system, combined with afunctional muscular system.

Understanding the mechanics of thepelvis, hip and knee is of particularimportance in corrective exercise, as almostall movements involving the lower extremityinvolve the integrated action of the pelvis,hip joints and knee joints. While these jointswork together to produce movement, theymust also contribute to stability of the entirekinetic chain. With this in mind, correctiveexercise should be tailored towards function,rather than isolation of individual muscles.

Mechanical dysfunction of the pelvis, hipand knee commonly presents ascombinations of muscle imbalance andmovement impairment, all of which candevelop into chronic degenerative conditionsand predictable pain patterns. These can behelped with corrective exercise.

This section aims to review the functionalanatomy of the pelvic girdle and knee jointand discusses a number of evaluationstrategies. The final chapter outlinescorrective exercise to facilitate and enhancemuscular control of hip and thighmovement.

12FUNCTIONAL PELVIS, HIP ANDKNEE ANATOMY

Overview of pelvis, hipand knee anatomyThe pelvis, hip and knee (and ankle) formthe basic structures involved in lowerextremity mobility and stability. Theconsiderable range of motion of the thighand leg is achieved through the dynamicrelationship between the pelvic girdle and

hip joint and the knee joint. Structurally,movement is brought about by articulation ofthe pelvis and femur at the hip joint, andarticulation of the femur and tibia at theknee joint. Functionally, movement isachieved via a multitude of one- and two-jointmuscles that mobilise and stabilise thesejoints. The skeletal anatomy of the pelvis, hipand knee is shown in figure 12.1.

Figure 12.1. Skeletal anatomy of the pelvis, hip and knee – (a) anterior, (b) posterior views

(a) (b)

Anterior superioriliac spine

Patella

Pubic symphysis

Femur

Tibia

Posterior superioriliac spine

Femur

Tibia

Structure and functionof the pelvis, hip andkneeThe pelvic girdle consists of two hip bones(innominate bones) and provides a strongand stable support for the lower extremities.Each hip bone is composed of three separatebones at birth: the ilium, pubis and ischium.These bones eventually fuse at a depressioncalled the acetabulum, which forms thesocket for the hip joint.

The hip joint is formed by the articulationof the head of the femur with theacetabulum. The deep, cup-shaped

acetabulum is reinforced with strongligamentous and cartilaginous support,designed to protect it against the impact ofthe femoral head during forceful movement,as well as preventing excessive hip jointmovement.

The femur, or thigh bone, is the largest,heaviest and strongest bone of the body. Itarticulates proximally with the hip anddistally with the tibia, forming the knee joint.The patella, or kneecap, is located anteriorto the knee joint. It is held in place by thequadriceps tendon above and the patellarligament below. It functions to increase theleverage of the quadriceps tendon, tomaintain the position of the tendon when

169Functional pelvis, hip and knee anatomy

Figure 12.2. Movements of the pelvis – (a) neutral, (b) anterior tilt, (c) posterior tilt, (d) lateral tilt

(a) (b)

the knee is bent and to protect the kneejoint.

Movements of the pelvisMovement of the pelvis is a product oflumbar spine and hip joint motion, allowingthe pelvis to tilt forwards, backwards andsideways (see Figure 12.2).

Anterior tilt (forward tilt)A position of the pelvis in which the anteriorsuperior iliac spine (ASIS) is anterior to thesymphysis pubis in the vertical plane.Anterior tilt may also be observed as anincrease in the angle from the horizontal

between the posterior superior iliac spine(PSIS) and ASIS, resulting in a downwardmovement of the symphysis pubis and anupward movement of the posterior surface ofthe sacrum.

In standing posture, anterior tilting isassociated with increased lumbar lordosisand hip flexion.

Posterior tilt (backward tilt)A position of the pelvis in which the ASIS isposterior to the symphysis pubis in thevertical plane. Anterior tilt may also beobserved as a decrease in the angle from thehorizontal between the PSIS and ASIS,resulting in an upward movement of the


(c) (d)

Figure 12.2. (contd) Movements of the pelvis

symphysis pubis and a downward movementof the posterior surface of the sacrum.

In standing posture, posterior tilting isassociated with a flattening of the lumbarcurve and hip extension.

Lateral tiltA position of the pelvis where one ASIS ishigher than the other. In standing posture, alateral tilt is associated with lumbar lateralflexion and adduction of the hip joint on theside of the high ASIS; the opposite hip jointwill be in abduction.

RotationA rotation of the pelvis in the horizontalplane around a longitudinal axis.

Movements of the hip jointMovements at the hip joint are generallydescribed as movements of the femur (whenthe pelvis is fixed) or movements of thepelvis (when the femur is fixed). Thisincludes flexion and extension; abductionand adduction; lateral and medial rotation;and circumduction (see Figure 12.3).


Figure 12.3. Movements of the hip joint – (a) flexion and extension, (b) adduction and abduction, (c) medial andlateral rotation

(a) (b)

Flexion Extension

Abduction

Adduction

FlexionA movement of the femur in an anteriordirection when the pelvis is fixed; or bringingthe pelvis towards the fixed thighs, such asbending from a standing position.

The range of hip joint flexion is 0–125°and may be restricted by the tension of thehamstring muscles. The hamstrings aretherefore placed in a shortened positionwhen testing range of motion in flexion.

ExtensionA movement of the femur in a posteriordirection when the pelvis is fixed; or

movement of the pelvis and trunk in aposterior direction when the legs are fixed.

The range of hip joint extension is 0–10°and may be restricted by the rectus femoris.The rectus femoris is therefore placed in ashortened position when testing range ofmotion in extension.

Hyperextension involving excessiveposterior movement of the femur is onlypossible when the femur is laterally rotated.This movement may be restricted in somepeople.

AbductionA lateral movement of the femur away fromthe mid-sagittal plane when the pelvis andtrunk are fixed; or movement of the trunk sothat the pelvis moves laterally downwardstowards a fixed thigh.

The range of motion in abduction isapproximately 45°, with greater range ofmotion being possible when coupled withlateral rotation of the femur. Abduction islimited by the adductor muscles.

AdductionA medial movement of the femur towards themid-sagittal plane when the pelvis and trunkare fixed; or movement of the trunk so thatthe pelvis moves laterally upwards, away fromthe fixed thigh.

The range of motion in adduction isapproximately 10° and can be limited by theabductor muscles.

Lateral rotationA movement in which the anterior surface ofthe thigh moves away from the mid-sagittalplane, resulting in an outwardly turned knee.Rotation may also occur from counter-rotation of the pelvis on the femur. Lateralrotation is usually restricted to approximately45°.


(c)

Figure 12.3. (contd) Movements of the hip joint

Medial rotation

Lateralrotation

Medial rotationA movement in which the anterior surface ofthe thigh moves towards the mid-sagittalplane, resulting in an inwardly turned knee.Rotation may also occur from counter-rotation of the pelvis on the femur. Medialrotation is usually restricted to approximately45°.

CircumductionA combination of flexion, abduction,extension and adduction, performed insequence.

Movements of the knee jointThe primary movements that occur at theknee joint are flexion and extension, with alimited degree of rotation (see Figure 12.4).

FlexionA movement of the tibia in a posteriordirection in the sagittal plane, resulting in

approximation of the posterior surfaces ofthe calf and thigh. The range of flexion isapproximately 0–140°. During early flexion,the tibia also rotates medially on the femur(non-weight bearing). Stability of the kneejoint in flexion is provided by the anteriorcruciate ligament, as well as femoral anteriorglide.

ExtensionA movement of the tibia in an anteriordirection in the sagittal plane, to a positionof straight alignment (0°). The final phase ofextension is accompanied by a slight outwardrotation of the tibia (non-weight bearing).Stability of the knee joint in extension isprovided by the posterior cruciate ligament,as well as femoral posterior glide.

Hyperextension is an abnormal movementbeyond the zero position of extension;however, in many occupational andrecreational postures, there may be a fewdegrees of ‘normal’ extension beyond zero.


Figure 12.4. Movements of the knee joint – (a) flexion and extension, (b) medial and lateral rotation

(a) (b)

Medial rotationLateralrotation

Flexion

Extension

RotationMedial rotation is rotation of the anteriorsurface of the tibia towards the mid-sagittalplane. Movement away from the mid-sagittalplane is lateral rotation.

This slight amount of rotation can onlytake place when the knee is flexed in non-weight bearing. In this position, theligamentous support becomes slack. Whenthe knee is extended (zero position), forexample, in weight bearing, the jointbecomes ‘locked’, preventing rotation.

Muscles of the pelvisMuscles involved in movement of the pelvisare shown in Figure 12.5. As pelvicmovement is dependent on lumbar spinemovement (as well as hip joint movement), anumber of important trunk muscles have asignificant action on the pelvis, particularly

when the lower extremity is fixed. Their rolein pelvic movement is described below.

External obliqueA large, flat muscle, with obliquely orientedfibres, that tilts the pelvis posteriorly whenacting bilaterally. Unilaterally, the lateralfibres act to move the iliac crest in a superiordirection (upwards). The external obliquealso combines with the contralateral internaloblique to form a force couple for rotation ofthe trunk or pelvis.

Adequate performance of this importantpostural muscle is significant in controllingrotation and for lumbar support, and specifictraining is often necessary. Weakness of theexternal oblique is more common in femalesand can be associated with an increase in theinfrasternal angle, causing the ribs to flareoutwards.


(a) (b)

Figure 12.5. Muscles of the pelvis – (a) anterior, (b) posterior

Quadratuslumborum

Psoas

Externaloblique

Internaloblique

Quadratuslumborum

Psoas

Internal obliqueA fan-shaped muscle with obliquely orientedfibres that tilts the pelvis posteriorly andflexes the thorax, when acting bilaterally.Unilaterally, the internal oblique tilts thesame side of the pelvis, moving it in asuperior direction (upwards).

Rectus abdominisA large, beaded muscle that flexes the thoraxand tilts the pelvis posteriorly. This muscle isoften more dominant than the internal andexternal oblique, affecting the control ofpelvic and trunk rotation.

IliopsoasA long muscle that flexes the hip or tilts thepelvis anteriorly when the legs are fixed.

Erector spinae (lumbar)A long muscle that is divided into threegroups, which, when acting bilaterally, causeanterior pelvic tilt. Unilateral action causeslateral pelvic tilt.

Quadratus lumborumA muscle with obliquely oriented fibres,which laterally tilts the pelvis when actingunilaterally, with the trunk fixed. If the pelvisis fixed, it acts to flex the trunk laterally.

Muscles of the hip jointThe following muscles (see Figure 12.6) allhave an action at the hip joint, contributingto movement or stabilisation of the thigh.Although these muscles have attachments onthe pelvis, their main action on the pelvis isregarded as one of stability, rather thanmobility.

IliopsoasAs a muscle affecting the hip joint as well asthe pelvis, the iliopsoas flexes the hip andweakly rotates it laterally. It may also serve asa stabiliser for the hip joint in a standingposition.

Tensor fasciae latae (TFL) andiliotibial band (ITB)The TFL flexes, medially rotates and abductsthe hip, as well as tensing the ITB. Actingtogether as a unit, the TFL-ITB and gluteusmaximus act to stabilise the pelvis and kneein weight bearing.

TFL shortness is commonly mistaken foriliopsoas shortness, and in the non-weight-bearing leg can contribute to lateral tibialtorsion. When the TFL is short, the iliopsoasand posterior gluteus medius are often weak.In this instance, if the lower extremity isfixed, TFL shortness can result in rotation ofthe pelvis and lumbar spine.

Gluteus maximusThe largest and most superficial of the threebuttock muscles, the gluteus maximusextends and laterally rotates the hip. Theupper fibres contribute to hip abduction andthe lower fibres contribute to hip adduction.Over 75 per cent of the fibres insert into theITB. Shortness of the muscle may contributeto lumbar flexion during sitting postures.

Weakness of the gluteus maximus (alongwith the other posterior hip muscles) maycompromise control of the femur at the hipjoint, particularly during the stance phase ofwalking, and is a common observation insway-back postures.

As well as extending the hip when thetrunk is fixed, the gluteus maximus is alsovery active during triple extension of the


ankle, knee and hip, such as during heavylifting. In this instance, the gluteus maximusis most active during the mid to end range ofthe movement.

Gluteus mediusThe second largest of the three buttockmuscles, the gluteus medius is divided intoanterior and posterior portions, according tofunction. The posterior gluteus medius(PGM) acts to extend, abduct and laterallyrotate the hip, and is prone to weakness andlengthening. The weakened muscle is usuallyassociated with pain in the muscle belly, withthe source of pain being faulty alignment ofthe femoral head in the acetabulum. Thepain can occur during contraction orpalpation and with hip joint movement.

The anterior fibres of the gluteus mediusabduct, medially rotate and weakly flex thehip, and this portion of the muscle is usuallystrong.

The gluteus medius is an importantstabiliser of the hip in standing posture andgait. When weight is shifted to one leg, thegluteus medius (and other abductors)contracts to stabilise the hip and prevent adrop of the pelvis on the other side(Trendelenburg’s sign).

Gluteus minimusThe smallest of the three buttock muscles,the gluteus minimus abducts, mediallyrotates and weakly flexes the hip. Thismuscle works in conjunction with the gluteusmedius: whereas the medius is primarily anabductor, then a medial rotator, the minimusis primarily a medial rotator, then anabductor.

PiriformisA small muscle that is one of a group of sixdeep lateral rotators of the hip. Thepiriformis laterally rotates, extends andabducts the hip when the hip is flexed.Shortness of this muscle can contribute tosciatic pain. The piriformis and other lateralrotators are secondary to the gluteusmaximus in their mechanical advantage inlateral rotation; therefore, in the presence ofa weak gluteus maximus, the piriformis maybecome short and facilitated, therebycontributing to piriformis syndrome.

PectineusA short, thick muscle that adducts, mediallyrotates and weakly flexes the hip.

Adductors (brevis, longus andmagnus)The adductor brevis and longus both adductand flex the hip and are also active duringmedial rotation. The adductor magnus alsoadducts the hip, with the anterior fibresflexing the hip and the posterior fibresextending the hip. This muscle is also activeduring medial and lateral rotation.

Muscles of the hip andknee jointThe muscles of the hip joint include severalmuscles that act equally or more effectively atthe knee joint (see Figure 12.6). These areknown as two-joint muscles.


Rectus femorisAs part of the quadriceps femoris group, therectus femoris is a two-joint muscle thatflexes the hip and extends the knee. Thismuscle is also active during abduction andlateral rotation.

SartoriusA long, slim, two-joint muscle that crosses thethigh obliquely in a lateral to medialdirection. It flexes, laterally rotates andabducts the hip; and in a non-weight-bearingposition, it acts to flex and rotate the kneemedially.

GracilisA long, thin muscle that adducts the hip andflexes the knee. When the knee is flexed in

non-weight bearing, this muscle also assists inmedial rotation of the tibia.

HamstringsThe hamstring group consists of threemuscles: biceps femoris, semimembranosusand semitendinosus.

The biceps femoris (also known as thelateral hamstrings) extends and laterallyrotates the hip, and also flexes and laterallyrotates the knee in non-weight bearing. Thesemimembranosus and semitendinosusmuscles (also known as the medialhamstrings) extend and medially rotate thehip, as well as flexing and rotating the kneemedially.

Imbalances between the medial versus thelateral hamstrings may result in faultyrecruitment patterns of the lower extremity.


Figure 12.6. Muscles of the hip and knee joint – (a) anterior, (b) posterior

(a) (b)

Psoas

Tensor fasciaelatoe

Iliotibial band

Gracilis

Sartorius

Rectus femoris

Gluteusmaximus

Adductors

Biceps femoris(long head)

Semitendinosus

Semimembranosus

Biceps femoris(short head)

Gluteusmedius

Gluteusmaximus(cut away)

Gluteusminimus

Piriformis

Adductors

This is commonly seen in cyclists, who havemedially rotated hips as the medialhamstrings are used more than the lateralhamstrings when cycling.

If the lateral hamstrings becomedominant, they may reduce the activity of thedeep hip lateral rotators.

Muscles of the kneeThe true knee joint muscles are the vastusintermedius, vastus lateralis, vastus medialisand popliteus (see Figure 12.7). Althoughthe tibialis anterior, peroneus longus andsoleus do not contribute to knee joint action,they are listed here for their contribution tolower extremity movement patterns.


(a) (b)

Figure 12.7. Muscles of the knee joint – (a) anterior, (b) posterior

Vastus lateralis Vastus medialis

Tibialisanterior

PopliteusPeroneus longus

Soleus

Gastrocnemius(cut away)

Clinical perspectiveThe multiple functions of the hamstringsat the hip and lower extremity oftenpredispose these muscles to strain, whichmay be due to overuse when synergisticmuscles are underused. For example,hamstring strain is often seen in runnerswho exhibit sway-back posture. Theposterior pelvic tilt and associated hipextension seen in this posture, alongsideatrophy and weakness of the gluteusmaximus, may result in strain.

Dominant hamstring muscles may alsosubstitute for quadriceps function, byproducing knee extension (as a result ofhip extension) when the foot is fixed onthe floor.

Vastus intermedius, lateralisand medialisAs part of the quadriceps femoris group, thevasti muscles arise from a common origin onthe greater trochanter and attach to the tibia.Because they are one-joint muscles, they arepowerful extensors of the knee, regardless ofhip joint position. Their greatest activity isduring the last phase of knee extension. Thevastus medialis is an important stabiliser ofthe knee in weight bearing through its rolein medial glide of the patella, thuspreventing lateral dislocation.

PopliteusA small muscle, located behind the kneejoint, which flexes the knee and mediallyrotates the tibia. Its primary function is tostabilise and protect the knee joint fromanterior dislocation of the femur.

Gastrocnemius and soleusThe gastrocnemius muscle is a two-jointmuscle that flexes the knee and plantar-flexes the ankle. The soleus is a one-jointmuscle that plantar-flexes the foot at theankle joint.

Tibialis anteriorA long muscle than runs the entire length ofthe tibia and dorsiflexes the ankle andinverts the foot. This muscle is antagonisticto the peroneus longus.

Peroneus longusA long muscle that is situated on the lateralaspect of the leg, which plantar-flexes theankle and everts the foot. Shortness of themuscle is present in clients with pronated feet.


Clinical perspectiveWhen the gastrocnemius-soleus complex isweak, the client is unable to plantar-flexthe ankle fully against resistance. In orderto complete plantar flexion, the client maysubstitute by using the other plantarflexors, such as the peroneus longus ortibialis posterior. In turn, these maybecome short. Correction of thiscompensation can be made byencouraging the client to ‘lift the heels’when plantar-flexing, rather than ‘goingup onto the toes’.

Clinical perspectiveThe tibialis anterior may be particularlyprone to overuse in running patternswhere the individual has a posterior-displaced centre of gravity. In thisinstance, there is prolonged dorsiflexion,with minimal plantar flexion, resulting inoveruse of the tibialis and potentialanterior shin splints.


Table 12.1. Summary of muscles involved in pelvis, hip and knee movements


Pelvis

Anterior tilt Iliopsoas Tensor fasciae lataeErector spinae SartoriusRectus femoris Pectineus

Posterior tilt Rectus abdominis External obliqueInternal oblique Hamstrings

Lateral tilt Erector spinae IliopsoasQuadratus lumborum Gracilisadductors Pectineus

Rotation External oblique Erector spinaeInternal oblique Rectus abdominisGlutealsLateral rotators

Hip

Flexion Iliopsoas SartoriusRectus femoris Adductors (longus, brevis)Tensor fasciae latae Pectineus

Anterior gluteus mediusGluteus minimus

Extension Gluteus maximus Adductor magnus (superior fibres)Posterior gluteus medius PiriformisSemimembranosusSemitendinosusBiceps femoris (long head)

Abduction Gluteus medius Tensor fasciae lataeGluteus minimus Sartorius

Piriformis

Adduction Adductors PectineusGracilisGluteus maximus (lower fibres)

Medial rotation Anterior gluteus medius PectineusGluteus minimus Adductors (brevis, longus)Tensor fasciae lataeSemimembranosusSemitendinosus


Table 12.1. Summary of muscles involved in pelvis, hip and knee movements(continued)


Hip

Lateral rotation Gluteus maximus IliopsoasLateral rotators PiriformisBiceps femoris Sartorius

Posterior gluteus medius

Knee

Flexion Hamstrings GracilisSartoriusPopliteusGastrocnemius

Extension Quadriceps femoris Tensor fasciae latae

Medial rotation Popliteus SartoriusSemimembranosus GracilisSemitendinosus

Lateral rotation Biceps femoris Tensor fasciae latae

13EVALUATION OF THE PELVIS,HIP AND KNEE

Evaluation of the pelvis, hip and knee willenable the therapist to identify movementimpairment and muscle dysfunction, and puttogether a systematic approach to correctiveexercise. Knowledge of the biomechanics ofthe lower extremity will allow the therapist toindividualise the client’s rehabilitation andhelp to prevent injury or impairment.

This chapter outlines assessment of thelower extremity in relation to alignment ofthe pelvis, hip and knee, as well as musclelength and strength. Combining the results of these assessments will help to build a progressive corrective exerciseprogramme.

Alignment analysisEvaluation of static alignment of the pelvis,hip joint and knee as part of lower extremitypostural assessment should examine theclient anteriorly, posteriorly and laterally(plumb line). The plumb line can offer anaccurate visual line of reference to assessdeviations from the ideal alignment in thesagittal plane (see Figure 13.1), and anterioror posterior horizontal lines of reference canprovide insight into pelvic asymmetry in thefrontal plane.

Basic alignment of the pelvis, hip jointand knee joint is outlined below.

Normal alignment of the pelvisIdeal, or ‘neutral’, alignment of the pelvis ispresent when the anterior superior iliacspine (ASIS) is in the same vertical plane asthe symphysis pubis, producing a pelvic tilt ofup to 10° between the ASIS and posteriorsuperior iliac spine (PSIS).

In practice, structural variations in pelvicFigure 13.1. Ideal plumb alignment of the pelvis, hipand knee

tilt exist, especially between males andfemales, and the therapist should not expectany one angle to be an indication of normalalignment.

When a pelvic tilt is present, there mayalso be changes in the alignment of thespine, hip joint and knee. If correction of atilt causes unwanted changes in alignment ofthe spine, hip joint and knee, theimpairment is probably structural.

Misalignment may also occur around thevertical axis, resulting in pelvic rotation ortorsion, and may be determined by observingdeviations from the frontal plane betweenthe left and right ASIS.

Normal alignment of the hipjointIdeal alignment of the hip joint is presentwhen the side-view line of reference passesslightly posterior to the centre of the hipjoint (see Figure 13.2). Deviations either side

183Evaluation of the pelvis, hip and knee

Figure 13.2. Angle of declination of the femoral neck Figure 13.3. Angle of inclination of the femoral neck

Antetorsion

Normal

Retrotorsion

Normal

0°

Normal125°

Valgum145°

Varum110°

of this reference may indicate hip flexion orextension, both of which may haveimplications on the pelvis and knee joint.

Structural variations of the hip jointshould be assessed carefully to ensure thatcorrective exercise prescription is applicableto the client’s available range of motion. Thetwo main structural variations that arecommonly seen are deviations from thenormal angle of declination and inclination.

The angle of declination, also known asthe angle of torsion, is the angle between theneck of the femur and the transverse axis ofthe femoral condyle. The normal angle isapproximately 15° anterior.

The angle of inclination is the angleformed between the neck of the femur andthe longitudinal axis of the femoral shaft.The normal angle is approximately 125°.

Normal alignment of the kneejointIn the sagittal plane, ideal alignment of theknee joint is present when the side-view lineof reference passes slightly anterior to theaxis of the knee joint (see Figure 13.1). Inthis position, the femur lies in the sameplane as the tibia. Structural variations ofknee flexion and hyperextension can occur,with the latter being more common.

In the frontal plane, ideal alignment ofthe knee joint is present when the knee islocated vertically over the second toe.Structural and acquired variations from theideal alignment can result in knock knees(genu valgum) or bow legs (genu varum).

Common alignmentproblemsMany muscles of the pelvis and hip joint arealso common to the knee joint; therefore

postural alignment problems frequentlyinvolve all three structures. Commonproblems to look for when assessing staticalignment of the pelvis, hip and knee includethe following.

Hip extensionHip joint extension is an alignment fault inclients with posterior pelvic tilt andhyperextended knees. It is common in sway-back postures and particularly in activitiessuch as distance running and contemporarydance. The result of prolonged hiphyperextension (greater than 10°) isweakening of the anterior joint capsule and


Figure 13.4. Hip extension

iliopsoas, as well as the development offemoral anterior glide syndrome.

Hip flexionHip flexion is a common postural fault inclients with increased lumbar lordosis andexcessive anterior pelvic tilt. The presence ofhip flexion in standing can be the result ofweakness in the rectus abdominis or externaloblique and glutes, as well as shortness in thehip flexors.

Hip joint lateral asymmetry(apparent leg lengthdiscrepancy)In this common postural fault, one iliac crestis higher than the other (more than half aninch), resulting in a lateral pelvic tilt andlateral lumbar flexion (and rotation). Thehip on the side of the high iliac crest is inadduction and the other hip is in abduction.This alignment is often associated with lowback, hip and, sometimes, ankle pain.

Weak muscles include the hip abductors,and when the adducted hip is placed intoslight abduction, the iliac crests oftenbecome level.


Figure 13.5. Hip flexion Figure 13.6. Hip joint lateral asymmetry

Hip antetorsionIn this structural misalignment, the angle ofthe head and neck of the femur is rotatedanteriorly beyond the normal alignment of15°. Excessive hip medial rotation and genuvalgum (knock knees) may also appear to bepresent in the client with antetorsion. If theclient sits with the hip in maximum medialor lateral rotation, hip pain can develop.With correct alignment of the femurs in thehip joints, the feet appear pigeon-toed.However, many clients will habitually positionthe feet forwards in standing and walking,thus rotating the hip laterally and causingthe head of the femur to point anteriorly.This may result in pain.

Hip retrotorsionIn this structural condition the angle of thehead and neck of the femur is rotatedposteriorly with respect to the femoral shaft.The range of medial rotation is limited andlateral rotation is excessive. If a client withretrotorsion crosses their legs in prolongedsitting, the excessive medial rotation canresult in hip pain, due to irritation of theanterior capsule. There will also be anaccompanied stretch-weakening of the hipabductors and lateral rotators. With correctalignment of the femurs in the hip joints, thefeet appear turned out.


Figure 13.7. Hip antetorsion Figure 13.8. Hip retrotorsion

Knee hyperextensionKnee hyperextension is a common structuralor acquired fault and is present when thefemur is positioned anterior to the tibia. Inthis position, the posterior joint capsule isstretched with slackness in the anteriorcruciate ligament. Knee hyperextension may

also be associated with bowing of the tibia inthe sagittal plane, although bowing can oftenoccur independently. The condition isnormally accompanied by hip extension anda sway-back posture.

Genu valgum (knock knees)and genu varum (bow legs)Genu valgum is an acquired or structuralvariation in the angle of the femur, resultingin knock knees (see Figure 13.9). In thestructural condition, the feet are likely to beneutral or supinated, indicating the presenceof antetorsion. Acquired misalignment isusually caused by hip medial rotation, withthe feet pronated. In this instance, the hiplateral rotators may be weak.

Genu varum is an acquired or structuralvariation in the angle of the tibia or femur,resulting in bow legs (see Figure 13.9). Theclient with genu varum will often walk withan abnormal gait. Excessive genu varum canbe an indicator of degenerative knee jointdisease. Hip medial rotation with kneehyperextension can give rise to acquiredgenu varum. In this instance, the feet areoften laterally rotated and pronated.Correction of the hip rotation ofteneliminates genu varum and foot pronation.

Tibial torsionTibial torsion is a rotation of the shaft of thetibia, often in a lateral direction, and isalmost always associated with shortness of theiliotibial band.


Clinical perspectiveStructural variations of the femur resultingin hip torsion are common. Knowledge ofthese variations is necessary for accurateprescription of corrective exercise asvariation can contribute to back, hip andknee pain.

In exercise and sport, the presence ofhip antetorsion and retrotorsion can causea number of compensatory movementpatterns. In activities where hip lateralrotation is required, such as ballet, thepresence of antetorsion can often result incompensatory lateral tibial rotation, whichmay cause knee pain.

In activities and sports that requirerotation while the feet are fixed, such astennis and golf, the presence ofretrotorsion may cause compensatorylumbar rotation and facet jointcompression, as the hip reaches the limitof medial rotation. In this instance, theindividual should be instructed to placethe feet in an appropriate lateral positionto allow for optimal hip medial range ofmotion.

Movement analysisThere are a number of tests that are usefulwhen evaluating movement of the pelvis, hipand knee. The results of these tests are notnecessarily intended for end range of motionassessment, but rather to observe importantfunctional movements that highlight musclerecruitment patterns and imbalance. Usingmovement for diagnosis of muscledysfunction places emphasis on correctingthe pattern of muscular recruitment and notonly on palliative treatment of the painfulmuscle. As structural variations are commonwithin the hip and knee, these should betaken into account when interpretingmovement capability and prescribingexercise.

Active range of motion testsThe following tests outline some of theimportant movements that can be used togain a basic understanding of the client’srange of motion.

Hip abductionFrom a standing position, ask the client tospread legs as wide as possible. Good rangeof motion is indicated by an ability to abducteach leg to at least 45° from the midline.

Hip adductionFrom a standing position, ask the client tobring their legs together and alternately crossone in the front of the other. Good range ofmotion is indicated by an ability to achieve atleast 10° of adduction.


Figure 13.9. Bow legs and knock knees

Normal Bow legs Knock-knees

Hip flexionFrom a standing or supine position, ask theclient to bring each knee towards the chest,without flattening the low back or usingassistance. Good range of motion in flexionis indicated by an ability to flex the hip toapproximately 120°.

Hip extensionFrom a seated position on a chair, ask theclient to fold their arms across their chestand stand up. Good functional extensorstrength and ability to return from flexion isindicated by an ability to stand up whilekeeping the back straight, without the needfor assistance from the arms.

Hip flexion and adductionFrom a seated position on a chair, ask theclient to cross one thigh over the other.Good functional range of motion in hipflexion and adduction is indicated by anability to cross thighs comfortably.

Hip flexion, abduction and externalrotationFrom a seated position on a chair, ask theclient to place the outside of one foot on theopposite knee. Good functional range of

motion in the combined movement offlexion, abduction and external rotation isindicated by an ability to perform themovement comfortably.

Hip medial/lateral rotationFrom a prone lying position, with one kneein 90° flexion, ask the client to drop the kneeoutwards. Good range of motion in medialrotation is indicated by an ability to rotatethe hip to approximately 30° from thevertical. If the knee is dropped inwards, goodrange of motion in lateral rotation isindicated by an ability to rotate the hip to atleast 40° from the vertical.

The results of the active range of motionfor medial and lateral rotation can be used aspreliminary measurements for the presenceof hip antetorsion: if medial rotation seemsexcessive (greater than 50°) and lateralrotation is limited (less than 15° fromvertical), antetorsion is suggested. The Craigtest can be used to gain further informationregarding the degree of antetorsion.Assessment of the angle of torsion at the hipjoint is important in prescribing hipabduction exercises to ensure that the rangeof motion is appropriate for the client’sfemoral alignment.


Test: Craig test.Starting position: The client is lying prone,with one knee flexed to 90°. The therapistmoves the hip through the full ranges ofmedial and lateral rotation, while palpatingthe greater trochanter.Outcome: The position in the range ofrotation at which the trochanter is mostprominent is the position in which thefemoral head is optimally situated in theacetabulum. If this angle is greater than 15°from the vertical in the direction of hipmedial rotation, the femur is considered tobe in antetorsion.

Functional movement testsSquat and gait analysis are two importantfunctional movements that can be used togain an understanding of lower extremitymuscle balance. The following tests outlinethe basic procedures for evaluating the squatpattern and walking gait. Deviationscommonly seen during squatting andwalking, and the subsequent muscleimbalances, are summarised in Table 13.1.The results of these tests should becorrelated with those of muscle testingbefore prescribing corrective exercise.Test: Squat.Starting position: Client is standing, with feetplaced shoulder-width apart and arms acrosschest.Movement: Instruct the client to squat down,under control, to a position that iscomfortable. If they are unsure of how tosquat, an analogy of sitting on a chair may beuseful. The client should perform as manyrepetitions as are necessary to observe themovement from all angles (anterior,posterior and lateral views). If the client isweak, ensure adequate rest is taken betweenrepetitions. Specific observations are made ofthe pelvis, hips, knees and feet.Test: Walking gait.Starting position: Client is standing.Movement: Instruct the client to walk up anddown the room at a moderate pace (or on atreadmill, if available). They should beinstructed to walk without trying to correctthemselves in any way. Specific observationsare made of the pelvis, hips, knees and feet.

Muscle lengthAdequate length of the hip flexors and hipextensors is required for optimal function ofthe hip and knee, as well as the managementand prevention of some cases of low back


Figure 13.10. The Craig test

pain. Changes in the length of these musclesmay produce compensatory changes instability and movement at the knee, as well asin the thoracic and lumbar spine. Thefollowing muscle tests will determine whetherthe range of motion at the hip and kneejoint is normal, limited or excessive. Theseresults can then be used to determine thedegree of muscle imbalance.

Muscle(s): Hip flexors – iliopsoas, rectusfemoris, tensor fasciae latae, sartorius.Starting position: Client begins by sitting atthe end of a couch, with thighs half off theedge. The therapist places one hand behindthe subject’s back and another behind oneknee, as the client rolls back into a supineposition. The client holds the knee close tothe chest, just enough to allow the lumbar

curve to flatten, without excessive posteriorpelvic tilting.Notes: If testing for excessive length of thehip flexors, the hip joint should be at theedge of the couch, with the thigh completelyoff the end.Test: The other thigh is allowed to dropdown towards the couch, with the kneenaturally flexing over the edge.Normal length: All four hip flexor musclesare normal length if the posterior thightouches the couch and the knee flexes toapproximately 80° (while the low back andsacrum are flat on the couch). The kneeflexion indicates that the rectus femoris andsartorius are normal in length.Note: As there are four muscles involved inthis length test, the variations observed arediscussed individually below.


Table 13.1. Common deviations observed during squatting and walking

Observation Weak muscles Short muscles

Feet flatten Gluteus medius, anterior Gastrocnemius, peronealstibialis, posterior tibialis

Feet externally rotate Gluteus medius Soleus, biceps femoris,piriformis

Knees turn inwards Gluteus medius, gluteus Adductors, iliotibial bandmaximus

Knees turn outwards Adductors Biceps femoris, iliopsoas,piriformis

Low back arches Gluteus maximus, gluteus Iliopsoas, rectus femoris, medius, core musculature erector spinae, latissimus

dorsi

Low back rounds Core musculature, gluteus External oblique, rectus maximus abdominis, hamstrings

Asymmetrical weight shift Gluteus medius, gluteus Gastrocnemius-soleus, biceps maximus, transversus femoris, iliotibial band, abdominis, multifidi iliopsoas, piriformis

Iliopsoas (one-joint hip flexor)Normal length: The posterior thigh touchesthe couch, with the low back and sacrum flat.Shortness: The posterior thigh does nottouch the couch (see Figure 13.11 (b)), withthe low back and sacrum flat.Excessive length: When the hip joint ispositioned at the end of the couch, the thighdrops below couch level.

Rectus femoris (two-joint hipflexor)Normal length: The knee flexes to 80° in thetest position.Shortness: Knee flexion is less than 80° inthe test position. If the client is placed in akneeling position, shortness of the rectusfemoris will pull the pelvis into an anteriortilt, resulting in an increase in lumbarlordosis (compared to standing) (see Figure13.11 (c)).

Tensor fasciae lataeShortness: Abduction of the hip as it extends;lateral deviation of the patella, in thepresence or absence of hip abduction;compensatory extension of the knee, if thehip is not allowed to abduct; medial rotationof the hip; lateral rotation of the tibia.Although this indicates shortness of thetensor fasciae latae, the modified Ober testshould be used specifically to test the lengthof this muscle (see p. 195).

SartoriusShortness: A combination of at least three ofthe following indicates shortness: hipabduction, flexion and external rotation;knee flexion (see Figure 13.11 (d)).

Muscle(s): Hamstrings – biceps femoris(short head), semimembranosus,semitendinosus, biceps femoris (long head).Starting position: Client is supine, with kneesextended and low back and sacrum flat oncouch. If low back does not flatten due to hipflexor shortness, a small pillow may be placedunder the knees to flex the hips just enoughto allow the back to flatten.Test: The therapist stabilises one leg andraises the other, with knee extended and footrelaxed. The client may assist in raising theleg.Normal length: With the low back andsacrum flat, an angle of 80° is achievedbetween the couch and the leg.Shortness: The angle between the couch andthe leg is less than 80°. (If the clientperforms a seated forward bend, the anglebetween the sacrum and the table is less than80°, indicating limited flexion of the pelvistowards the thigh; in this instance, there maybe compensatory movement of the thoracicspine to achieve forward bending.)Excessive length: An angle greater than 90° isachieved.Note: Excessive posterior tilting of the pelvisduring the test will give a false indication ofthe length of the hamstrings, with theapparent length being greater than actuallength. Anterior tilt of the pelvis during



(a)

(b)

Figure 13.11. Test for length of hip flexor muscles – (a) normal length, (b) shortness in the iliopsoas

testing will make the hamstrings appearshorter than the actual length.

Muscle(s): Tensor fasciae latae and iliotibialband.Starting position: The client is side-lying, withthe lower leg flexed at the hip and knee toflatten the low back. The top leg is straight,and the therapist places one hand just belowthe topmost iliac crest, applying slightpressure upwards to stabilise the pelvis andkeep the trunk in contact with the table.Test: The therapist raises the top leg into aposition of abduction and slight extension(without rotation). The leg is held in anextended position and allowed to drop intoadduction towards the couch.Normal length: The leg drops approximately10° below horizontal, with the knee extendedand the pelvis in neutral.Shortness: The extended leg remains abovehorizontal, indicating shortness of the tensorfasciae latae and iliotibial band.


(c)

(d)

Figure 13.11. (contd) Test for length of hip flexormuscles – (c) shortness in the rectus femoris, (d)shortness in the sartorius


Figure 13.12. Test for length of hamstring muscles

Figure 13.13. Test for length of tensor fasciae latae and iliotibial band – modified Ober test

Muscle strengthMuscle strength testing of the lowerextremity will determine the ability of thepelvic, hip and knee muscles to providestability and movement. Weakness orshortness of these muscles can contribute toa number of common postural faults and/orlow back pain.

Muscle(s): Hip flexors.Starting position: Client is sitting, with kneesbent over the side of the couch.Test: Client flexes hip (with a flexed knee) afew inches off the couch, against resistanceon the anterior thigh. To test the iliopsoas,full hip flexion should be performed andheld.Weakness: A decreased ability to flex the hipagainst resistance, resulting in lumbarkyphosis or sway-back posture in standing.Unilateral weakness may result in lumbarscoliosis.Shortness: Increased lumbar lordosis withanterior pelvic tilt during tests. This will alsobe seen in upright posture.Note: When resisted hip flexion isaccompanied by lateral rotation andabduction, the sartorius may be short or thetensor fasciae latae weak. Medial rotationmay be evidence of a stronger tensor fascialata over the sartorius.

If the client has weak trunk muscles andcannot stabilise the pelvis, the test may be

performed in the supine position, with legsstraight. In this case, pressure is applied (inthe direction of extension) to a slightlyabducted and laterally rotated hip.


Figure 13.14. Test for strength of hip flexors

Muscle(s): Medial rotators.Starting position: Client is sitting on a couch,with knees bent over the side, holding on tothe edge.Test: The thigh is medially rotated. Counter-pressure is applied to the medial side of thelower thigh, as well as to the lateral aspect ofthe lower leg.Weakness: Inability to maintain medialrotation against resistance, resulting in adominance of lateral rotation of the lowerextremity in standing and walking.Shortness: Inability to rotate the hip laterallyin the test position. This can also be observedin weight bearing, with a subsequenttendency towards knock knees. There willalso be an inability to sit cross-legged.

Muscle(s): Lateral rotators.Starting position: Client is sitting on a couch,with knees bent over the side, holding on tothe edge.Test: The thigh is laterally rotated. Counter-pressure is applied to the lateral side of thelower thigh, as well as to the medial aspect ofthe lower leg.Shortness: Excessive range of lateral rotation,with limited medial rotation. In standingthere may be an outward turning of the feet.Weakness: Inability to hold the test position,with a tendency towards knock knees instanding posture.


Figure 13.15. Test for strength of medial rotators Figure 13.16. Test for strength of lateral rotators

Muscle(s): Tensor fasciae latae.Starting position: Client is supine, with legsstraight.Test: The hip is abducted, flexed andmedially rotated, while keeping the kneeextended. Pressure is applied against thelower leg in the direction of extension andadduction.Weakness: Inability to maintain the medial

rotation against pressure. In the standingposition, this may cause a tendency towards abow-leg position and lateral rotation of thehip.Shortness: In standing, shortness of thismuscle can be observed as anterior pelvic tilt,hip flexion and a tendency towards knockknees.


Figure 13.17. Test for strength of tensor fasciae latae

Muscle(s): Posterior gluteus medius.Starting position: Client is side-lying, withlower leg flexed and pelvis slightly rotatedforwards. The uppermost iliac crest isstabilised by the therapist.Test: The hip is abducted, with slightextension and lateral rotation, with the kneein extension. Pressure is applied to thelateral aspect of the lower leg in the directionof adduction and flexion.Weakness: An inability to hold the testposition, with a tendency for the gluteus

medius to cramp. During walking, weakabductors in the stance leg will cause the hipjoint to adduct, rather than abduct.Consequently, the opposite side of the pelvisdrops downwards. This is known as theTrendelenburg sign.Shortness: In standing, there may be a lateralpelvic tilt, low on the side of tightness.Note: The hip abductors may test normal asa group, whereas a test of the gluteus mediusmay uncover weakness.


Figure 13.18. Test for strength of posterior gluteus medius

Muscle(s): Hip adductors.Starting position: Client is side-lying, withlegs straight. The therapist is standingbehind, holding the upper leg in 15–20°abduction. The client may hold on to theside of the couch.Test: The lower leg is adducted away fromthe table (no hip rotation, flexion orextension), against pressure applied on themedial aspect of the thigh.

Weakness: Marked weakness occurs when theclient is unable to maintain the pressure andthe thigh drops down.Shortness: In standing, the pelvis will be highon the side of tightness, so much so thatplantar flexion may be required to maintainbalance.


Figure 13.19. Test for strength of hip adductors

Muscle(s): Gluteus maximus.Starting position: Client is prone, with theknee flexed to 90°. The therapist stabilisesthe sacrum.Test: The hip is extended, maintaining kneeflexion, while pressure is applied against theposterior thigh in the direction of hipflexion.Weakness: Inability to hold the test positionagainst pressure. In standing, the client may

find walking difficult, with weight beingdisplaced more posteriorly. In the forward-bend position, there may be difficulty inraising the trunk back to an upright position,without the use of the arms.Note: It is important to test the gluteusmaximus for strength as a prerequisite forback extensor testing.


Figure 13.20. Test for strength of gluteus maximus

Muscle(s): Quadriceps femoris.Starting position: Client is sitting, with kneesover the side of the couch.Test: The knee is extended against pressureapplied on the anterior leg, just above theankle.Weakness: An inability to extend the kneefully shows marked weakness and mayinterfere with squatting and stair climbing. Inthe standing position, the weakness results inhyperextension of the knee, which mayrequire the client to ‘snap’ or ‘lock’ the kneeback during walking.Shortness: Shortness of the rectus femoris, inparticular, will result in restriction of kneeflexion during hip extension movements, orrestriction of hip extension when the knee is

flexed. This may impact activities such asrunning or sprinting.Note: Dominance of the rectus femoris willresult in the client leaning backwards duringthe test, in order to obtain the greatestmechanical advantage. Dominance of thetensor fasciae latae will cause medial rotationof the hip during testing.

Muscle(s): Hamstrings (medial and lateral).Starting position: Client is prone, with theknee flexed to 50°. The therapist stabilisesthe posterior thigh.Test: To test the medial hamstrings, the kneeis flexed 50–70°, with the hip and knee inmedial rotation. To test the lateralhamstrings, the knee is flexed 50–70°, withthe hip and knee in lateral rotation. In bothcases, pressure is applied to the posterior leg,just above the ankle, in the direction of kneeextension. No pressure should be exertedagainst the rotation.Weakness: Inability to maintain rotationindicates weakness of medial or lateralhamstrings. In the standing position,weakness of the medial and lateralhamstrings allows hyperextension of theknee. There may be anterior pelvic tilting ifthe weakness is bilateral, and pelvic rotationif unilateral weakness exists. Lateralhamstring weakness can result in a tendencytowards bow legs, and medial hamstringweakness allows for knock knees, with lateraltibial rotation.Shortness: Shortness may result in a knee-flexion posture in standing that isaccompanied by posterior pelvic tilting andflattening of the lumbar curve.Note: If the rectus femoris is very short, therewill be limited knee flexion during testing. Inthis instance, there may be compensatory hipflexion, as observed by anterior pelvic tiltingand excessive lumbar lordosis.


Figure 13.21. Test for strength of quadriceps femoris


(a)

(b)

Figure 13.22. Test for strength of hamstrings – (a) medial hamstrings, (b) lateral hamstrings

14CORRECTIVE EXERCISE FORTHE PELVIS, HIP AND KNEE

Corrective exerciseprogressionThe objectives of corrective exerciseprescription for the pelvis, hip and knee aremultifaceted. Because the hip region andlower extremity provide the first step in thetransference of ground reaction forcesthrough the kinetic chain, it becomesimportant to condition these structures in anintegrated way, once balance and alignmenthave been restored.

The vast majority of daily activities utilisethe pelvis, hip and knee, including sitting,standing, bending and walking. Thereforeany impairment of these basic movementpatterns must be identified and corrected,using optimal exercises that provideadequate functional progression.

Muscle balance and stability should berestored to the pelvis, hip and knee as a firststep in corrective exercise. Following this, theclient is then ready to progress ontofunctional strength exercises that conditionthese structures for load-bearing and load-transferring activities. Many of thesemovement patterns fall into the two maincategories of squatting and lifting. It isimportant to note that during these activitiesmovement of the pelvis, hip and knee isintegrated with the trunk and shoulder. Withthis in mind, continual attention to

alignment and body mechanics is required bytherapist and client.

The final stages of corrective exercisefocus on whole body movements that enablethe pelvis, hip and knee to coordinate andtransfer ground reaction forces through thetorso and up to the shoulder, in a controlledmanner.

The following exercises are divided intofour progressive phases.

Phase 1 – Muscle balanceThese exercises are aimed at restoringnormal length of the pelvic, hip and thighmuscles, through a combination of passiveand active stretching techniques, with theintention of re-establishing optimal range ofmotion. When joint mobility is within normallimits, subsequent movement can continue tobe normal and pain patterns will bealleviated.

Phase 2 – Static, dynamic andreactive stabilisationThe aim of these exercises is to improvestabilisation of the hip and knee joint, byimproving the neuromuscular control ofspecific movement patterns. Many of theseexercises involve minimal joint movements ina multi-planar environment, allowing the

client to build control and confidence ofmovement. The use of stability balls androcker-boards is strongly encouraged duringthis phase.

Phase 3 – Functional strengthThe goal during this phase is to ensure thatthe stabilisation capabilities of the hip andknee muscles are sufficient to control the legunder increasing load. These exercisesgenerally involve simple movement patterns,but with a larger range of motion that fullyutilises the client’s own body weight, oradded resistance, in both open- and closed-chain situations. From here, a number ofimportant functional variations can beperformed that may be specific to the client’soccupational and recreational environment.

Phase 4 – Functional powerThe aim of this phase is further to improvecoordination and control of movement, toprovide a high degree of functional carry-over into occupation, recreation and sport.These exercises involve the addition of speedto the movement, often using plyometricexercise. The result is enhanced link-sequencing and force generation from thelower extremities, through the trunk and outto the shoulders and arms.

For this to occur safely, muscle balance,stabilisation and functional strength must allbe at optimal levels and particular emphasisshould be placed on optimal hip and trunkrotation, to ensure smooth coordination ofground reaction forces up through the body.

Corrective exercises forthe hip

Phase 1 exercises – Restoringmuscle balance and flexibilityHip flexor stretchMuscle group(s): Hip flexors – iliopsoas,tensor fasciae latae, rectus femoris, sartoriusPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the hip flexors (one-joint and two-joint).

Starting position❑ FLOOR STRETCH (one-joint) – Client is

lying supine, with knees bent, both feetflat on the floor. The low back is flat.

❑ COUCH STRETCH (two-joint) – Client islying supine on the couch, holding bothknees towards the chest, and far enoughup the couch to allow the thigh to dropdown and the lower leg to hang off theedge. The low back is flat.

Correct performance❑ FLOOR STRETCH – the client brings one

leg up towards the chest and holds it,while keeping the low back flat to thefloor. The other leg is extended straightout, and the gluteals on that side arecontracted, while the back of the leg ispushed into the floor. This position isheld for 8–10 seconds and repeated 6times, before swapping legs.

❑ COUCH STRETCH – from the startposition, the client allows one leg to lowertowards the couch and holds for 20–30seconds, while keeping the low back flat.

205Corrective exercise for the pelvis, hip and knee

Variations❑ During the couch stretch, if lowered thigh

begins to abduct, it should be pulled intowards the midline. The abduction mayrepresent shortness of the tensor fascialata. This action may also be performed bya therapist.

❑ If the knee extends, this indicatesshortness of the rectus femoris. In thisinstance, the lower leg may be activelypulled inwards to a point where the ankleis positioned under the knee to providean appropriate stretch. This action mayalso be performed by a therapist.


(a) (b)

Figure 14.1. Hip flexor stretch – (a) floor, (b) couch

Standing abductor stretchMuscle group(s): AbductorsPhase/modality: FlexibilityEquipment: None

PurposeTo increase range of motion of the lateralhip muscles.

Starting positionClient is standing, with the leg to bestretched crossed in behind.

Correct performance❑ The client laterally flexes away from the

stretching leg until a stretch is felt.

❑ This position is held for 20–30 seconds,repeating 2–3 times and swapping legs ifnecessary.


Figure 14.2. Standing abductor stretch

Assisted abductor stretchMuscle group(s): AbductorsPhase/modality: FlexibilityEquipment: None

PurposeTo increase range of motion of the lateralhip muscles.

Starting positionClient is supine, with the leg to be stretchedin hip flexion and knee extension, as shown(see Figure 14.3). The therapist holds thelower leg with one hand and stabilises thehip with the other.

Correct performance❑ The therapist gently adducts the leg and

stops when a resistance barrier is felt. Thisposition is held for 20–30 seconds, beforerelaxing and repeating 2–3 times.

❑ The stretch is repeated on the other leg.

VariationsThis stretch may also be performed usingPNF.


Figure 14.3. Assisted abductor stretch

Standing adductor stretchMuscle group(s): AdductorsPhase/modality: FlexibilityEquipment: None

PurposeTo increase range of motion of the hipadductors.

Starting positionThe client is standing, with one leg straightand the opposite leg bent, with both feetfacing forwards, as shown (see Figure 14.4).

Correct performance❑ The client moves sideways towards the

bent leg until a stretch is felt in the innerthigh of the straight leg.

❑ The stretch is held for 20–30 seconds andrepeated 2–3 times before swapping legs.


Figure 14.4. Standing adductor stretch

Assisted adductor stretchMuscle group(s): AdductorsPhase/modality: FlexibilityEquipment: None

PurposeTo increase range of motion of the hipadductors.

Starting positionClient is lying supine, with both legs straight.

Correct performance❑ The therapist stabilises the contralateral

hip with one hand and gently abducts theleg to be stretched by pulling, just belowthe knee, until a stretch is felt.

❑ The position is held for 20–30 secondsand repeated 2–3 times before swappingsides.



Figure 14.5. Assisted adductor stretch

Piriformis stretchMuscle group(s): Piriformis, hip lateralrotatorsPhase/modality: FlexibilityEquipment: None

Purpose❑ To stretch the piriformis.

❑ To increase range of motion and functionof the hip joint.

Starting positionClient is lying supine, with the left legstraight and the right knee flexed. The rightfoot is positioned on the lateral aspect of theleft thigh, just above the knee, as shown (seeFigure 14.6).

Correct performance❑ The client gently pulls the right knee

towards the left hip until a stretch is feltdeep in the right gluteals.

❑ This position is held for 20–30 secondsbefore repeating 2–3 times on each side.

ITB stretchMuscle group(s): Tensor fasciae latae-iliotibial bandPhase/modality: FlexibilityEquipment: None

Purpose❑ To improve the performance of the hip

abductor muscles.

❑ To stretch the tensor fasciae latae-iliotibialband.

❑ To improve isometric strength of thelateral abdominal musculature.

Starting positionClient is side-lying, with lower hip and kneebent, and the pelvis slightly rotated forwards.The top leg is straight and positionedforwards, with the knee turned up slightly.


Figure 14.6. Piriformis stretch Figure 14.7. Iliotibial band stretch

Correct performance❑ The top leg is abducted and then

extended, so it is positioned slightlybehind the body. The leg is then droppedtowards the floor and allowed to hang for15–20 seconds.

❑ The pelvis should not move and the lowback should not be allowed to arch duringthe movement.

Prone hip rotationMuscle group(s): Hip rotatorsPhase/modality: FlexibilityEquipment: None

Purpose❑ To stretch the hip rotators.

❑ To decrease compensatory motion of thepelvis during hip movement.

Starting positionThe client is lying prone, with foreheadresting on hands, as shown (see Figure 14.8).The lower abdominals are upwards andinwards to stabilise the spine and pelvis. Oneknee is flexed to 90°.

Correct performance❑ The client rotates the hip by allowing the

foot to move in towards the opposite legand then away.

❑ The movement is repeated 10 times ineach direction, before swapping legs.


(a) (b)

Figure 14.8. Prone hip rotation – (a) before, (b) after

Side-lying adductor roll-upMuscle group(s): Adductors, medial rotatorsPhase/modality: FlexibilityEquipment: None

PurposeTo increase range of motion in adductionand medial rotation.

Starting positionThe client is side-lying, with top leg bent atthe hip and knee and positioned over thelower leg, as shown (see Figure 14.9). Thelower leg is straight and neutral spinealignment is maintained throughout themovement.

Correct performance❑ The client internally rotates the lower leg,

allowing the toes to point upwards. All themotion should be generated from the hip,while keeping the leg completely straight.

❑ The movement is repeated 8–10 timesbefore swapping legs.


Figure 14.9. Side-lying adductor roll-up

Four-point rockingMuscle group(s): Low back, glutealsPhase/modality: FlexibilityEquipment: None

Purpose❑ To stretch the gluteals and low back

muscles.

❑ To decrease compressive forces acting onthe spine.

❑ To improve hip-bending motion.

Starting positionThe client is in a four-point kneeling stance,as shown (see Figure 14.10), with the spine

in neutral alignment. The hips are centredover the knees, and the shoulders over thewrists.

Correct performance❑ Client rocks gently backwards, aiming the

buttocks towards the ceiling, allowing thelow back to remain in neutral. Do not letthe low back arch upwards. Themovement should be aided by pushingback with the hands.

❑ Return to the start position by initiatingthe movement back, using the glutealsand bracing the abdominals.

❑ Repeat slowly 8 times.


(a) (b)

Figure 14.10. Four-point rocking – (a) before, (b) after

Standing quadriceps stretchMuscle group(s): Quadriceps femorisPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the quadriceps and hip flexors.

Starting positionThe client is standing in optimal alignment,holding one ankle. A wall may be used tolean against for balance.

Correct performance❑ The client is instructed to perform a

posterior pelvic tilt, while squeezing thegluteals of the stretching leg.

❑ This position is held for 20–30 secondsand repeated 2–3 times before swappinglegs.

Prone quadriceps stretchMuscle group(s): Quadriceps femorisPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the quadriceps and hip flexors.

Starting positionClient is lying prone, with forehead restingon one hand and the other hand holding theankle of the stretching leg.


Figure 14.11. Standing quadriceps stretch Figure 14.12. Prone quadriceps stretch

Correct performance❑ The client is instructed to perform a

posterior pelvic tilt, while squeezing thegluteals of the stretching leg.

❑ This position is held for 20–30 secondsand repeated 2–3 times before swappinglegs.

VariationsThis stretch can be performed using PNF.Note: This stretch may be contraindicated inthose with existing low back pain.

Standing hamstring stretch (spiral)Muscle group(s): Hamstrings (medial andlateral)Phase/modality: FlexibilityEquipment: Couch

PurposeTo increase functional flexibility of thehamstrings.

Starting positionClient is standing in optimal alignment, withone leg resting straight on couch. Thetherapist should ensure that the couch is setat the appropriate height for the client to beable to stand in neutral spinal alignment.The foot of the support leg should be facingforwards and the hips should be square tothe stretching leg.

Correct performance❑ The client performs an anterior tilt of the

pelvis to stretch the hamstrings. If this is

insufficient to induce a stretch, the levelof the couch should be set higher.

❑ The stretching leg is then slowly rotatedfrom the hip, alternating left to right,while maintaining good spine alignment.

❑ The movement is repeated 8 times in eachdirection, before swapping legs.


Figure 14.13. Standing hamstring stretch (spiral)

Supine hamstring stretchMuscle group(s): HamstringsPhase/modality: FlexibilityEquipment: None

PurposeTo increase flexibility of the hamstrings.

Starting positionThe client is lying supine, in neutralalignment, with one leg straight. The otherleg is slightly bent at the knee, held by onehand below the back of the knee and onehand above the knee, on the posterior thigh.

Correct performance❑ The leg to be stretched is gently pulled

towards the chest, until a stretch is felt inthe hamstrings. It is important that thelumbar spine remains in neutral

alignment and the knee remains slightlyflexed – do not allow the knee to bendfurther.

❑ This position is held for 20–30 seconds,before repeating 2–3 times and swappinglegs.

Seated hamstring stretchMuscle group(s): HamstringsPhase/modality: FlexibilityEquipment: Stability ball

PurposeTo stretch the hamstrings.


Figure 14.14. Supine hamstring stretch

Figure 14.15. Seated hamstring stretch with stabilityball

Starting positionClient is seated on a stability ball, in optimalspinal alignment, with both legs straight outin front. The lower abdominals are drawnupwards and inwards to stabilise the spine,and the ankles are dorsiflexed.

Correct performance❑ An anterior pelvic tilt is performed while

maintaining a straight-leg position, andthe client then slowly leans forwards fromthe hips until a stretch is felt in thehamstrings.

❑ This position is held for 20–30 secondsand repeated 2–3 times.

VariationsThis stretch may be performed using one legat a time.Note: Some individuals will not need to leanforwards. The anterior pelvic tilt alone willcreate a hamstring stretch. Maintenance ofthe anterior pelvic tilt is an important part ofthis stretch – leaning too far forwards shouldnot be encouraged, as compensatorystretching may occur at the lumbar orthoracic spine.

Standing calf stretchMuscle group(s): Gastrocnemius, soleusPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the gastrocnemius and soleusmuscles.

Starting positionThe client is facing a wall, with armsstretched out for support. One leg is broughtforwards, and the leg to be stretched isplaced further back. The toes of the rear leg

should be facing forwards, with the foot flaton the floor.

Correct performanceGently shift weight forwards onto front leg,while maintaining a straight back leg, until astretch is felt in the calf. This position is heldfor 20–30 seconds and repeated 2–3 timesbefore changing legs.

VariationsThe rear leg may be slightly bent to stretchthe soleus muscle.

Supine calf stretchMuscle group(s): GastrocnemiusPhase/modality: FlexibilityEquipment: None

PurposeTo stretch the gastrocnemius.

Starting positionThe client is lying supine, with a straight legover the therapist’s knee. The therapistplaces one hand on the anterior thigh, justabove the knee, and the other hand on thesole of the foot.

Correct performance❑ The therapist applies resistance in the

direction of dorsiflexion, until acomfortable stretch is felt. The kneeshould be kept straight throughout. Thisposition is held for 20–30 seconds andrepeated 2–3 times before changing legs.

❑ The client may assist the stretch by activelydorsiflexing the ankle.




Figure 14.16. Supine calf stretch

Phase 2 exercises – Restoringstatic, dynamic and reactivestabilisationForward bending from standingMuscle group(s): Gluteals, low backPhase/modality: Stabilisation – static,dynamic; strengthEquipment: None

Purpose❑ To increase hip joint flexibility.

❑ To improve performance of the gluteals.

❑ To improve the lumbar stabilisationmechanism.

Starting positionClient is standing in good alignment, withfeet placed comfortably apart. Hands mayrest on a table or on thighs if the client isweak.

Correct performance❑ Begin the movement by slowly bending at

the hip joints, while keeping the spine inneutral alignment. Bend as far as possible.


(a) (b)

Figure 14.17. Forward bending – (a) before, (b) after

Return to standing by tightening thegluteals and abdominals, while moving thehips back inwards.

❑ If short hamstrings limit the movement,allow the knees to bend slightly.

Supine leg raiseMuscle group(s): Hip flexors, abdominalsPhase/modality: Stabilisation – static,dynamicEquipment: None

PurposeTo improve the performance of theabdominals in controlling pelvic motion.

Starting positionClient is lying supine, with knees and hipsflexed, feet flat on floor.

Correct performance❑ The client contracts the deep abdominal

muscles by pulling the navel upwards andinwards, and lifts one foot off the flooruntil the knee and hip are flexed to 90°(tabletop position).

❑ Maintaining the abdominal contraction,the leg is returned to the floor and themovement performed for a total of 10repetitions, before changing legs.

VariationsThe hands may be lifted a few inches abovethe floor to increase the performance of theabdominal muscles.


(a) (b)

Figure 14.18. Supine leg raise – (a) before, (b) after

Supine leg dropMuscle group(s): Hip flexors, abdominals,hip adductorsPhase/modality: Stabilisation – static,dynamicEquipment: None

Purpose❑ To improve the performance of the

abdominals in controlling pelvic motion.

❑ To strengthen the hip adductors.

Starting positionClient is lying supine, with both knees andhips flexed. One leg is raised off the floor,with the knee positioned above the hip andflexed to 90° (tabletop position).


muscles by pulling the navel upwards andinwards. Maintaining the leg in thetabletop position, the hip is horizontallyabducted, allowing the leg to droptowards the floor. The pelvis and lumbarspine must remain in neutral throughoutthe movement.

❑ The abdominal contraction is maintainedas the leg is returned to the start position.The movement is performed for a total of10 repetitions, before changing legs.



(a) (b)Figure 14.19. Supine leg drop – (a) before, (b) after

Supine leg slideMuscle group(s): Hip flexors, abdominalsPhase/modality: Stabilisation – static,dynamicEquipment: None

PurposeTo improve the performance of theabdominals in controlling pelvic motion.

Starting positionClient is lying supine, with legs straight.


muscles by pulling the navel upwards and

inwards, and slides one foot along thefloor until the hip and knee are flexedand the foot is resting flat on the floor.

❑ Maintaining the abdominal contraction,slide the foot down and return to the startposition.

❑ The movement is alternated from side toside, for a total of 20 repetitions each side.



(a) (b)

Figure 14.20. Supine leg slide – (a) before, (b) after

Side-lying hip abductionMuscle group(s): Hip abductors, abdominalsPhase/modality: Stabilisation – static,dynamicEquipment: None

Purpose❑ To improve performance of hip

abductors.

❑ To improve performance of the lateralabdominal musculature.

Starting positionClient is side-lying, with lower leg bent andtop leg straight.

Correct performance❑ The top leg is lifted upwards, towards the

ceiling. The pelvis remains in neutral andthe low back does not arch or flattenduring the movement.

❑ The leg is lowered and the movementrepeated for a total of 10 repetitions,before changing legs.

VariationsThis exercise may be regressed by allowingthe top leg to bend slightly before startingthe movement.


(a) (b)

Figure 14.21. Side-lying hip abduction – (a) before, (b) after

Side-lying hip adductionMuscle group(s): Hip adductors, abdominalsPhase/modality: Stabilisation – static,dynamicEquipment: None

Purpose❑ To improve performance of hip adductor

muscles.

❑ To stretch hip abductors.

Starting positionThe client is side-lying, with the leg to beexercised lowermost. The hip and knee arestraightened and the pelvis is held in neutral

alignment. The top leg is rotated at the hipand the knee is bent, with the foot flat on thefloor in front of the lower leg. The top handcan be placed on the floor to stabilise thetrunk.

Correct performance❑ The client contracts the abdominals by

pulling the navel upwards and inwards,and lifts the lower leg up towards the topleg.

❑ The leg is returned and the movementrepeated for a total of 10 repetitions,before changing legs.


(a) (b)

Figure 14.22. Side-lying hip adduction – (a) before, (b) after

Isometric glutesMuscle group(s): Gluteus maximusPhase/modality: Static stabilisationEquipment: None

PurposeTo improve performance of the gluteusmaximus.

Starting positionThe client is lying prone, with legs straight.

Correct performanceThe client tightens the buttock muscles whilethinking about ‘turning the legs outwards’.This position is held for up to 8 seconds,before relaxing and repeating 10 times.

Prone hip extensionMuscle group(s): Gluteus maximus,hamstrings, absPhase/modality: Stabilisation – static,dynamicEquipment: None

Purpose❑ To improve performance of the gluteus

maximus and hamstrings.

❑ To stretch the hip flexor muscles.

❑ To improve performance of the backextensor and abdominal muscles.

Starting positionThe client is lying prone, with legs straight.


pulling the navel upwards and inwards.One leg is lifted off the floor by tighteningthe gluteus maximus. The leg is lifted onlyhigh enough to maintain a stable pelvis –do not allow the pelvis to rock.

❑ This position is held for up to 8 secondsbefore relaxing, and the movement isperformed for 10 repetitions on each leg.

VariationsThis exercise can be performed by firstflexing the knee to 90°. This positionshortens the hamstrings and allows for


(a) (b)

Figure 14.23. Prone hip extension – (a) before, (b) after

increased performance by the gluteusmaximus and back extensors.

Seated knee extensionMuscle group(s): Quadriceps femoris, hipflexorsPhase/modality: Stabilisation – static,dynamicEquipment: None

Purpose❑ To improve control of the anterior thigh

and back extensor muscles.

❑ To control hip rotation during kneemovement.

❑ To stretch the hamstring and calf muscles.

Starting positionClient is seated, with neutral spinealignment. Hips and knees should be flexedto approximately 90°. The hands can beplaced on the low back to monitor neutralalignment during the movement.

Correct performance❑ Client slowly extends one knee as far as

possible, while maintaining a neutralspine, keeping the abdominals contractedthroughout.

❑ This position is held for up to 8 secondsbefore returning. Perform the movement10 times on each leg.


(a) (b)

Figure 14.24. Seated knee extension – (a) before, (b) after

Band shuffleMuscle group(s): Hip abductors, hip flexors,abdominalsPhase/modality: Stabilisation – static,dynamic; balanceEquipment: Exercise band

Purpose❑ To improve functional performance of the

hip abductors.

❑ To improve performance of theabdominals during hip abduction.

PrerequisitesGood postural and abdominal control.

Starting positionClient is standing, with an exercise bandplaced around the mid-lower leg. Feet arepositioned shoulder-width apart, toespointing forwards and knees slightly bent.


pulling the navel upwards and inwards,and performs a slow, controlled lateralmovement, side to side and forwards.


(a) (b)

Figure 14.25. Band shuffle – (a) before, (b) after

❑ The client should be encouraged togenerate strength from the trunkmusculature. The knees should alwaysremain over the second toes and not beallowed to fall inwards or outwards.

❑ The movement should be performed for2–3 minutes.

Standing balanceMuscle group(s): Trunk, hip and legsPhase/modality: Stabilisation, balance,strengthEquipment: Rocker-board, Vew-Do™ board

Purpose❑ To improve performance of total body

stabilisation and strength.

❑ To improve the functional strength of thelower extremity.

❑ To improve postural control duringbalance (sport-specific).

Prerequisites❑ Good postural and abdominal control.

❑ Good ability to stabilise statically in anupright position.


(a) (b)

Figure 14.26. Standing balance – (a) single leg, (b) rocker-board (intermediate)

Starting positionClient is standing, with good spinalalignment and abdominals contracted.

Correct performance❑ SINGLE-LEG BALANCE – while

maintaining good posture, the client liftsone leg off the floor and holds thisposition for up to 8 seconds, beforeswapping legs. The movement isalternated between legs for a total of 8repetitions each side. The knee should bepositioned over the second toethroughout the movement.

❑ ROCKER-BOARD – the client is instructedto maintain balance on the rocker-board,without the edges touching the floor.Good postural alignment should be keptthroughout the movement.

❑ VEW-DO™ BOARD – in this advancedexercise, the client maintains balancewhile standing on a Vew-Do™ board.

VariationsIncrease the balance time.


(c)

Figure 14.26. (contd) Standing balance – (c) Vew-Do™board (advanced)

Wall slideMuscle group(s): Anterior/posterior thigh,abdominalsPhase/modality: Stabilisation, strength,balanceEquipment: Stability ball

PurposeTo improve performance, strength andcoordination of the trunk and lowerextremity.

Starting positionClient is standing, with the stability ballplaced in the low back against a wall. Feet arepositioned shoulder-width apart, with kneesover the second toes.


pulling the navel upwards and inwards,and slowly lowers the hips byapproximately 6 inches. Neutral spinealignment is maintained throughout themovement. The return is initiated bycontracting the buttocks and tighteningthe abdominals further.

❑ The knees are positioned over the toesthroughout the movement.

❑ The movement is repeated 10 times,before resting, and the exercise may berepeated 2–3 times in total.

VariationsAs the client gets stronger, the hips may belowered further, until maximum range ofmotion is achieved (hips reach knee height).


(a) (b)

Figure 14.27. Wall slide – (a) before, (b) after

Supine isometric bridgeMuscle group(s): Hip extensors, abdominalwallPhase/modality: Stabilisation, strength,balanceEquipment: Stability ball


extensors.




❑ Optimal scapula control.

Starting positionSit on the stability ball and roll down, whilecomfortably placing the head, neck andshoulder blades on the ball, with both feetpositioned straight ahead.

Correct performance❑ The hips are lifted until they are in line

with knees, and hands are placed acrossthe chest. The scapulae are slightlyretracted and depressed and theabdominals are braced.

❑ This position is held for up to 8 seconds,before resting momentarily. Up to 10repetitions are performed in total.

❑ The therapist should observe the hips andshoulders to ensure they are levelthroughout the entire movement, andthat proper spinal position is maintainedthroughout.

Variations❑ Eyes closed.

❑ This exercise may be regressed to a floorisometric bridge.


Figure 14.28. Supine isometric bridge

Supine bridge lateral rollMuscle group(s): Legs, total bodyPhase/modality: Stabilisation, strength,balanceEquipment: Stability ball

Purpose❑ To strengthen the entire kinetic chain in

all three planes of motion.

❑ To improve static stabilisation of themuscles of the pelvis, hip and knee.

PrerequisitesThis is an advanced exercise and the clientmust possess good flexibility and strength inthe lumbo-pelvic-hip complex.

Starting positionFrom a seated position on the ball, the clientrolls down into a bridge position, allowingthe head and shoulders to rest on the ball.Arms are straight and out to the sides, and a

wooden dowel can be held across the chestto maintain alignment. The abdominals arebraced.

Correct performance❑ The client slowly rolls the whole body

along the ball to the right, until the rightshoulder begins to come off the ball,ensuring that hips and shoulders are levelthroughout the movement. This positionis held for 2–3 seconds, before rollingover to the other side and repeating.Perform 3–4 repetitions each side, beforeresting.

❑ It is important that the abdominals arebraced throughout the movement andthat the whole body rolls as one unit.

❑ The therapist can observe the woodendowel to ensure it remains horizontalthroughout and that the spine is nottwisting in any way.


(a) (b)

Figure 14.29. Supine bridge lateral roll – (a) before, (b) after

Variations❑ Increase the holding time to up to 8

seconds.

❑ Increase the distance moved. This willplace increasing stresses on the trunkmusculature to stabilise the entire body.

Note: This is an advanced exercise that isdesigned to train a number of skills,including strength, endurance, agility,balance, coordination and flexibility – withthis in mind, careful attention should be paidto technique and execution.

Walking re-educationMuscle group(s): Legs, abdominalsPhase/modality: Stabilisation, balance,coordinationEquipment: None

Purpose❑ To prevent excessive rotation of pelvis and

lumbar spine during walking gait.

❑ To improve control of the pelvis and spinevia the abdominal muscles.

❑ To improve awareness of knee positionduring walking gait.

❑ To improve performance of the plantarflexors and gluteals during walking gait.

Starting positionClient is standing and contracts theabdominals by pulling the navel upwards andinwards.

Correct performance❑ LIMITING PELVIC ROTATION – client

places hands on pelvis and practises

walking while trying to prevent pelvicrotation. It may be necessary to takesmaller steps initially, particularly if theabdominals are weak or if the hip flexorsare tight.

❑ LIMITING HIP MEDIALROTATION/HIP ADDUCTION – at heelstrike, the client is instructed to contractthe gluteals to prevent excessive hipmedial rotation.

❑ LIMITING KNEE HYPEREXTENSION –at heel strike, the client is instructed notto allow the knee to hyperextend. Thereshould be good use of the plantar flexorsduring this movement (see below,FACILITATING ANKLE PLANTARFLEXION).

❑ LIMITING KNEE ROTATION – the clientsteps forwards with the foot turned slightlyoutwards. On heel strike, the gluteals arecontracted to maintain this medialrotation at the knee, and the knee shouldbe in slight flexion, ready for the weightshift. There should be good use of theplantar flexors during this movement (seebelow, FACILITATING ANKLE PLANTARFLEXION). Hip antetorsion maycontribute to excessive medial rotationand should not be considered adysfunction.

❑ FACILITATING ANKLE PLANTARFLEXION – on heel strike, the clientshould think about pushing back on thefloor to control the forward movement ofthe knee. As the foot approaches toe-off,the client pushes the ball of the foot intothe floor and lifts the heel.


Phase 3 exercises – Restoringfunctional strengthStanding hip flexion/glute contractionMuscle group(s): Hip flexors, gluteals,abdominalsPhase/modality: StrengthEquipment: None

Purpose❑ To improve performance of gluteal

muscles.

❑ To improve isometric control by theabdominal muscles.

PrerequisitesPain-free range of motion in standing hipflexion.

Starting positionClient is standing, with feet close together.

Correct performance❑ Client begins by shifting weight to the

stance leg and tightening the buttockmuscles on this side. Client contracts theabdominals, by pulling the navel upwardsand inwards, and flexes the opposite hipand knee, lifting the leg off the floor. Thisposition is held for up to 8 seconds,maintaining full contraction of thegluteals and abdominals.

❑ Keep the pelvis and shoulders level anddo not allow the knee to rotate mediallyor the ankle to pronate.

❑ Perform 8–10 repetitions before changinglegs.


Figure 14.30. Standing hip flexion/glute contraction

Four-point reachMuscle group(s): Hip and knee extensors,back extensors, abdominals, shouldersPhase/modality: Strength, balance,endurance, coordinationEquipment: None

Purpose❑ To improve performance of the lumbo-

pelvic-hip complex.

❑ To improve balance control.

❑ To improve performance of theabdominal muscles.

❑ To enhance the cross-crawl movementpattern.

Starting positionClient is in a four-point kneeling stance, withhands positioned below the shoulders, andknees below the hips. The spine is in neutralalignment, with the head in line with thebody. The client contracts the abdominals bypulling the navel upwards and inwards.


extension.

❑ Ability to perform an abdominal hollowand brace.

❑ Adequate rotator cuff strength.

Correct performance❑ Client braces the abdominals and reaches

forwards with one arm and backwards withthe opposite leg. Neutral spine alignmentshould be maintained throughout. Themovement is repeated for the other side,for a total of 6–8 repetitions each side.

❑ The arm and leg reach should not gohigher than horizontal, or body level.Initially, the client may only be able toachieve a small reach, beforecompromising spine position and bracingability. The reaching distance may have tobe increased slowly as the client becomesstronger.


Figure 14.31. Four-point reach – (a) before, (b) after

(a) (b)

❑ The therapist should also observe any side-to-side movement of the hips and correctthis by instructing the client either tobrace harder or to decrease the distancereached. If movement still occurs, theexercise can be regressed to moving thearms or legs alone, until adequatestrength and control is achieved.

Variations❑ Lateral reach – the arms and legs are

taken out to the sides.

❑ ‘Crawling’ – the client is instructed tocrawl forwards and backwards, whilemaintaining lumbar stability.

❑ Hold the end position for longer(maximum of 8 seconds).

Supine floor bridgeMuscle group(s): Hip extensors, backextensors, abdominalsPhase/modality: Strength, balance,enduranceEquipment: None

Purpose❑ To improve performance of gluteals and

low back.

❑ To improve control of abdominal muscles.

❑ To challenge and enhance lumbar stabilityduring hip extension.


extension.

❑ Ability to perform an abdominal hollowand brace.

Starting positionThe client lies supine, with knees bent andfeet flat on floor. Arms are held by the sidesof the body. The client contracts theabdominals by pulling the navel upwards andinwards.

Correct performance❑ Begin by lifting the hips up towards the

ceiling until there is a straight linethrough the knees, hips and shoulders.The movement should be initiated with anabdominal brace and a contraction of thegluteals. Return to the start position.

❑ The movement is performed 6–10 times,before resting.


(a) (b)

Figure 14.32. Supine floor bridge – (a) before, (b) after

Variations❑ Arms across chest.

❑ Single leg.

❑ Feet on a stability ball.

❑ The end position may be held for up to 8seconds.

Note: If the client experiences cramp in thehamstrings during the movement, thetherapist should check that pelvic alignmentis optimal, and correct if necessary. If theproblem persists, the quadriceps should bestretched and more emphasis should beplaced on initiating the movement with thegluteals and abdominals.

Supine hip extension: feet on ballMuscle group(s): Hip extensors, abdominalsPhase/modality: Strength, balance,enduranceEquipment: Stability ball


extensors.




(a) (b)

Figure 14.33. Supine hip extension: feet on ball – (a) before, (b) after


❑ Optimal scapula control, to ensureretraction and depression.

❑ Normal hamstring length.

Starting positionThe client lies supine, with legs straight andheels resting on a stability ball, hip-widthapart. Part of the ball should be restingagainst the calf muscles. Arms are resting onthe floor, beside the body. The clientcontracts the abdominals by pulling the navelupwards and inwards in preparation for themovement.

Correct performance❑ Client braces the abdominals and

performs hip extension by lifting the hipsup, until a straight line is formed from theknees to the shoulders. The movementshould be initiated by contracting theglutes.

❑ Return to the start position and perform atotal of 8–10 repetitions.

❑ The therapist should observe the hips andspine for any faulty movements andcorrect if necessary. Excessive wobblingshould be controlled through appropriatelevels of abdominal bracing, and mayindicate weakness in the lateralabdominals.

Variations❑ The end position may be held for up to 8

seconds, to improve muscular enduranceof the hip and back extensors.

❑ Eyes closed.

❑ Feet closer together on ball.

❑ Hands across chest.

❑ Adding knee flexion – as hip extension isperformed, there is simultaneous kneeflexion, by ‘pulling’ the ball in towards theglutes using the heels. Knee flexionshould end in a position where the ball isclose to the glutes (approximately 100°knee flexion). This is an advancedexercise.


Supine hip extension: torso on ballMuscle group(s): Hip and back extensors,abdominalsPhase/modality: Strength, balance,enduranceEquipment: Stability ball


extensors.




❑ Optimal scapula control, to ensureretraction and depression.

Starting position❑ The client sits on the stability ball and rolls

down, while comfortably placing the head,neck and shoulder blades on the ball, withboth feet positioned straight ahead.

❑ The hips are lifted until they are in linewith knees, and hands are placed across

the chest. The hips should remain level(horizontally) throughout the exercise.The scapulae are slightly retracted anddepressed and the abdominals are braced.The client contracts the abdominals bypulling the navel upwards and inwards inpreparation for movement.

Correct performance❑ Client begins to perform hip flexion by

lowering the hips towards the ball, movingonly as far as is comfortable. Thismovement is followed with hip extension,by pushing through the heels of the feet,to return to the start position. Themovement should be done slowly andextension must be initiated throughabdominal bracing and glute contraction.

❑ The therapist should observe the hips andshoulders to ensure they are levelthroughout the entire movement, andthat proper spinal position is maintainedthroughout.

Variations❑ Holding the end position, following

extension, for up to 8 seconds, to improvemuscular endurance.


(a) (b)

Figure 14.34. Supine hip extension: torso on ball – (a) before, (b) after

❑ Eyes closed.

❑ Holding a weight on the legs.

SquatMuscle group(s): Legs, abdominals, low back,shouldersPhase/modality: Strength, balance,coordinationEquipment: None

Purpose❑ To strengthen the legs and lumbo-pelvic-

hip musculature.

❑ To improve lumbar stabilisation duringfunctional movements.





Figure 14.35. Squat – (a) before, (b) after

(a) (b)

❑ Good flexibility in the posterior thigh andleg muscles.

❑ Good core strength and stabilisation.

Starting positionIn a standing position, client places the feetshoulder-width apart, with arms across chestand good postural alignment. The spineshould remain in neutral alignmentthroughout the movement. The abdominalsshould be contracted by pulling the navelupwards and inwards, or by performing anabdominal brace.


knee and ankle, and squats down to aposition where the thighs are parallel withthe floor. In this position, the kneesshould not overshoot the toes and shouldbe tracking over the second toe of eachfoot (not bowing inwards or outwards).The spine is still in neutral alignment andthe hips are pushed backwards tomaintain balance over the feet.

❑ From this position, brace the abdominalsfurther and contract the glutes, whileperforming triple extension of the ankle,knee and hip, to return to the startposition. Perform 10–12 repetitions.



❑ If there is muscle weakness in the legs, thesquat can be modified into a half- orquarter-squat, where the client completesonly the range of motion available tothem. Tightness in the calves may preventfull range of motion and these musclesshould be stretched prior to attemptingthis exercise.

Variations❑ If the client does not possess the

coordination, balance or strength toperform the squat, this exercise may beregressed to the wall slide (see Phase 2,above, p. 231).

❑ Slower tempo.

❑ Use of a weighted barbell. Thisprogression involves holding a barbellacross the upper back, and requiresadequate strength in shoulder abduction,along with good scapula control.

❑ Single-leg squat.

❑ Standing on a rocker-board/balance-board.

LungeMuscle group(s): Legs, abdominals, low backPhase/modality: Strength, balance,coordinationEquipment: None


hip musculature.




❑ To improve overall balance andcoordination.





Starting positionIn a standing position, client places the feetshoulder-width apart, allowing the arms tohang by the sides of the body and assuminggood postural alignment. The spine shouldremain in neutral alignment throughout themovement. The abdominals should becontracted by pulling the navel upwards andinwards, or by performing an abdominalbrace.

Correct performance❑ Maintaining good spinal alignment, the

client begins by stepping forwards and


(a) (b)

Figure 14.36. Lunge – (a) before, (b) after

slightly laterally, allowing the hip to dropdownwards and slightly forwards, until thethigh is almost parallel to the floor.

❑ From this position, the client contracts theabdominals and glutes and performs tripleextension of the ankle, knee and hip, toreturn to an upright stance. Neutral spinealignment must be maintainedthroughout the movement.

❑ The movement is repeated on alternatelegs, for a total of 8 repetitions each side.

Variations❑ If the client does not possess the balance

or coordination to perform this exercise,it can be regressed to a static lunge. In thisexercise, the client maintains the forwardposition and lunges on the spot. Handsmay be placed on a wall for extra support.

❑ Use of dumbbells.

❑ Walking lunge – the client lungesforwards, followed by a stepping throughto the upright stance, followed by anotherlunge with the opposite leg. Themovement is continued as a series ofwalking lunges.

❑ Balance-board lunge (advanced) – onefoot may be placed on a balance-board, toperform static lunges.

❑ Backward lunge (advanced) – from anupright position, the client stepsbackwards, followed by a lunge back to thestart position. The movement is alternatedbetween legs.

Dead liftMuscle group(s): Legs, abdominals, low back,shouldersPhase/modality: Strength, balance,coordinationEquipment: Barbell


(a)

(b)

Figure 14.37. Dead lift – (a) before, (b) after


hip musculature.



❑ To improve overall balance andcoordination.





Starting positionIn a standing position, client places the feetshoulder-width apart, holding a barbell. Thespine should remain in neutral throughoutthe movement. The client contracts theabdominals by pulling the navel upwards andinwards.


knee and ankle, and bends down to aposition where the thighs are almostparallel with the floor, as if to place thebarbell on the floor. In this position, theknees should not overshoot the toes andshould be tracking over the second toe ofeach foot (not bowing inwards or

outwards). The spine is still in neutralalignment and the hips are pushedbackwards to maintain balance over thefeet.

❑ From this position, client braces theabdominals further and contracts theglutes while performing triple extensionof the ankle, knee and hip, to return tothe start position. Perform 10–12repetitions.

❑ It is important to contract the glutes at thebeginning of the upward push, as this willallow the pelvis to initiate the movementprior to the spine.


❑ If there is muscle weakness in the legs, thedead lift can be modified into a half- orquarter-lift, where the client completesonly the range of motion available tothem. Tightness in the calves may preventfull range of motion and these musclesshould be stretched prior to attemptingthis exercise.

Variations❑ Use of heavier weight.

❑ Use of unevenly weighted barbell.

Note: The dead-lift pattern is almost identicalto the squat, except that the weight islowered to the floor. This exercise (and thesquat) is extremely functional for patientswho exhibit faulty lifting and bendingmovement patterns, and can be adapted toincorporate load bearing where necessary.


Phase 4 exercises – Restoringfunctional powerSquat pushMuscle group(s): Total bodyPhase/modality: Power, stabilisation,balance, coordinationEquipment: Medicine ball, dumb-bell


dynamic stabilisation and eccentricdeceleration of the entire kinetic chain.

❑ Enhances the body’s ability to transferforce along the kinetic chain, duringextension and flexion.

❑ Particularly useful for activities and sportswhere force is generated from the groundup, towards the upper extremities (forexample, tennis, basketball, golf, boxing).

Prerequisites❑ Client must demonstrate a good squat,

dead-lift and shoulder-press pattern.

❑ Pain-free range of motion in shoulderflexion.




Figure 14.38. Squat push – (a) before, (b) after

(a) (b)

Starting positionClient is standing, with feet positioned aboutshoulder-width apart, holding the weightwith both hands on the chest. The clientcontracts the abdominals by pulling the navelupwards and inwards, in preparation for themovement.

Correct performance❑ Client begins the movement by squatting

down to a point where the thighs areparallel to the floor. The abdominals arebraced, ready for acceleration.

❑ Client accelerates the weight upwards, byfocusing on the smooth integration ofankle dorsiflexion, knee and hipextension and shoulder flexion. The endposition is where the arms are extendedoverhead and the body is in optimalpostural alignment.

❑ Slowly return to the bottom position andrepeat until the speed cannot bemaintained, or when 12 repetitions havebeen completed.

❑ It is important to brace the abdominalsjust before the point of acceleration, toprotect the spine from overextension atthe top of the movement.

Variations❑ Increase the weight.

❑ Perform a squat raise (see Chapter 8,Phase 4, p. 101).

Clean and pressMuscle group(s): Total bodyPhase/modality: Power, strength,stabilisation, balance, coordinationEquipment: Barbell

Purpose❑ Increases total body strength and power. It

is important to remember that thestrength and power developed here arecompletely relative to the posture of theclient during the exercise and the rangeof motion that the client moves through.








❑ The therapist must have a justifiablereason and system of programmeprogression to implement this advanced

exercise. This exercise is useful inactivities where there are distinct stages oflink sequencing/power transfer – forexample, lifting up a child and placingthem into a high chair or during a tennisserve.

Starting position❑ Client begins with feet shoulder-width

apart and toes pointing forwards.

❑ Client flexes the knees and hips andbends down, grasping the barbell withboth hands slightly wider than shoulder-width apart (palms facing body).

❑ The abdominals are braced in preparationfor the movement.


Figure 14.39. Clean and press – (a) before, (b) during, (c) after(b) (c)

(a)

Correct performance❑ Client performs an explosive triple

extension movement in the lowerextremities – ankle, knee and hipextension – and drives the elbows high,making sure the barbell travels in avertical, linear fashion (close to body).

❑ As bar reaches shoulder height, clientshould externally rotate the arms and‘catch’ the weight in front of theshoulders, simultaneously dropping into ahalf-squat position, to get under theweight. From here, the glutes arecontracted to stand into a full uprightposition, with bar resting on the chest.

❑ The abdominals are braced again, sinkinginto a half-squat position to pre-stretch theglutes, and quickly following with anotherexplosive movement, pushing the barbellup into a shoulder press. This movementshould start from a glute contraction, as ifpushing the floor away, and at the sametime pushing the bar upwards. Stand tallat the top, with good posture and a strongabdominal brace.

❑ Carefully lower the barbell back to theground. Reset posture and perform 6–8repetitions.

Variations❑ Increase the weight gradually, while


❑ This advanced exercise should beperformed in ‘chunks’ before attemptingthe whole sequence. The client should becompetent in performing a dead lift,upright row and shoulder press; thesemovements can then be combinedsuccessively. For example, once the deadlift can be performed, the client canattempt a dead lift with the upright row(also known as the ‘clean’); once this

double sequence is perfected, the finalpressing movement can be added, tocomplete the entire motion.

Box jumpsMuscle group(s): Total bodyPhase/modality: Power, strength, balance,coordinationEquipment: Box

Purpose❑ To increase total body strength and

power, and to enhance the body’s abilityto transfer force along the kinetic chain.

❑ To improve acceleration and decelerationmechanics.

❑ To enhance static, dynamic and reactivestabilisation.

Prerequisites❑ The client should exhibit good

squatting/lifting technique.

❑ A proper stretching programme must becompleted before attempting thisexercise, to ensure ideal lumbaralignment and stability.



Starting positionFollowing a thorough dynamic warm-up, theclient stands in front of the box, with feetplaced shoulder-width apart. The abdominalsare contracted by pulling the navel upwardsand inwards.


Correct performance❑ Client braces the abdominals, flexes the

hips and knees slightly and, with both feet,jumps upwards and forwards onto thebox, landing with feet parallel andshoulder-width apart. The landing shouldbe flat-footed, with the force absorbedthrough the knee and hip. Once the forcehas been absorbed, the client shouldstand upright, in good postural alignment,looking straight ahead.

❑ The movement is repeated 8–10 timesbefore resting.

Variations❑ A jump-down can be performed, forwards

or backwards. Jumps may also beperformed sideways, to improve frontalplane power and stabilisation.

❑ Two-legged jump to one-legged landing;one-legged jump to two-legged landing; orone-legged jump to one-legged landing.

Multi-planar hopsMuscle group(s): Total bodyPhase/modality: Power, strength,stabilisation, balanceEquipment: None


(a) (b)

Figure 14.40. Box jumps – (a) before, (b) after


(a) (b)

(c) (d)

Figure 14.41. Multi-planar hops – (a) start, (b) sagittal plane hop, (c) frontal plane hop, (d) transverse plane hop

Purpose❑ To increase multi-planar neuromuscular

stability.

❑ To increase total body strength andpower, and to enhance the body’s abilityto transfer force along the kinetic chain.

❑ To improve acceleration and decelerationmechanics.

Prerequisites❑ The client must be able to perform a two-

legged static or box jump and a single-legbalance, with optimum posture.

❑ A proper stretching programme must becompleted before attempting thisexercise, to ensure ideal lumbaralignment and stability.



Starting positionThe client contracts the abdominals, bypulling the navel upwards and inwards, andstands on one leg in preparation for themovement.

Correct performance❑ The client flexes the hip and knee slightly,

followed by an explosive extension of thehip and knee to jump forwards and landon the opposite leg. Optimal posture mustbe maintained throughout the movement.

❑ The landing is stabilised for 3–4 seconds,while assuming an upright stance. Theclient then flexes the hip and knee again

and performs another explosiveextension, returning to the start position.The movement is performed 6–8 timesbefore swapping legs.

❑ The above format is used to perform side-to-side hops (frontal plane) and turninghops (transverse plane), where a 90° turnis performed.

VariationsIf the client does not possess enoughstrength or balance, this exercise may beregressed to a multi-planar jump, using twolegs.

High-low wood-chopMuscle group(s): Total bodyPhase/modality: Power, strength,stabilisation, balanceEquipment: Cable, exercise band

Purpose❑ To integrate the lower extremity into

rotational movement patterns.

❑ To enhance lumbar stabilisation throughfunctional whole body movement.




❑ Adequate strength and flexibility in theanterior and lateral abdominals, andlumbar spine.

❑ Adequate leg strength and flexibility.

Starting position❑ Client starts in a standing position, with a

shoulder-width stance, facing away from


the cable machine and holding thehandle with both hands above the rightshoulder. In this position, the left handshould grip the handle first, with the righthand over the top of the left hand.


Correct performance❑ Starting from optimal posture, client

initiates a rotational movement, from thetrunk outwards, towards the left. Do notpull with the shoulders or arms. Clientpulls the cable handle downwards andacross the body.

❑ Use a slow tempo to start with. Avoid

beginning the movement from a forwardflexed position.

❑ Do not push so quickly that the shouldersround forwards; generate movement fromthe core instead of the arms.


❑ This exercise should be progressed to afunctional power movement, byaccelerating through the chop downwardsand slowly returning to the start. Addingspeed in this way requires a high level ofcore strength and stabilisation, combinedwith perfect movement technique, and issuitable only for high-performanceconditioning programmes (sport-specific).


(a) (b)


Variations❑ As stability is developed, progress to

lateral weight shifting (moving weightfrom right to left leg and vice versa), sothat the movement resembles a ‘wood-chopping’ motion.

❑ The wood-chop may also be progressed byperforming the exercise seated on astability ball. This will increase awareness

of the obliques to a greater extent,providing the ball is kept still throughoutthe movement.




GLOSSARY

Abduction Movement away from the midline of the body.

Adduction Movement towards the midline of the body.

Agonist A muscle whose action is opposed by another muscle (antagonist).

Antagonist A muscle that works in opposition to another muscle (agonist).

Anterior Towards the front of the body.

Atrophy A decrease in muscle size due to inactivity.

Biomechanics The mechanics of biological movement, involving forces that arisefrom or outside of a body.

Bow legs Outward bowing of legs. Structural bow legs involves actual bowing ofthe bones; postural bow legs is an apparent bowing resulting from acombination of pronation of the feet, hyperextension of the knees andmedial rotation of the hips.

Centre of gravity The point at which the three midplanes of the body intersect. In idealpostural alignment, it is considered to be slightly anterior to thefirst/second sacral segment.

Circumduction Circular movement of a joint about 360 degrees.

Contraction An increase in muscle tension, with or without change in overallmuscle length.

Contralateral The opposite side of the body.

Distal Away from the centre of the body or reference point.

Dorsal Towards the back of the body.

Dorsiflexion Ankle joint extension.

Dysfunction Inability to function properly; functional impairment.

Eversion Turning of the foot outwards away from the body; a combination ofpronation and forefoot abduction.

Extension An increase in the angle on the joint; return from flexion.

Fascia A fibrous membrane that covers, supports and separates muscles.

Fixation The application of stabilisation, support or counter-pressure.

Flexion A reduction in the angle of the joint.

Force-couple Action of two forces in opposite directions to produce rotation arounda joint.

Frontal plane A vertical plane extending from side to side, dividing the body into ananterior and a posterior portion.

Functional exercise Exercises designed to prepare an individual for a specific task.

Genu valgum Knock knees.

Genu varum Bow legs.

Hyperextension Movement beyond the normal range of joint motion in extension.

Inferior Towards the bottom of the body or a position below a reference point.

Inversion Turning of the foot inwards towards the body: a combination ofsupination and forefoot adduction.

Ipsilateral On the same side of the body.

Isometric exercise An exercise in which a muscle contracts against resistance, but doesnot change in length.

Knock knees Knees touch with feet apart.

Kyphosis An excessive posterior curve, normally found in the thoracic region ofthe spine.

Lateral Positioned towards the outside of the body or away from the midline ofthe body.

Lateral flexion Side bending.

Lordosis An excessive anterior curve, usually found in the lumbar region of thespine.

Medial Towards the centre or closer to the midline of the body.

Mobility Ability to move freely; often regarded as a combination of flexibilityand coordination.

Muscle balance A balance of strength of opposing muscles acting on a joint, providingideal alignment for stabilisation and movement.

Muscle imbalance Unequal strength of opposing muscles, leading to faulty alignment andmovement.

256 Glossary

Muscular endurance The ability to perform repetitive muscular contractions againstresistance for an extended period of time.

Muscular strength The ability of a muscle to generate force against resistance.

Neuromuscular The interactions of the nervous and muscular systems to create control coordinated movement.

Neutral spine A position or range of movement somewhere between full flexion andfull extension of the spine, as defined by the client; it is dependent onexisting symptoms, pathology and musculoskeletal restrictions.

Overstretch Weakness in a multi-joint muscle resulting from repetitive movements weakness or habitual postures that elongate a muscle beyond its normal length.

Pelvic tilt An anterior (forward), posterior (backward) or lateral (sideways) tilt ofthe pelvis from a neutral position.

Peripheral Towards the surface of the body.

Plantar flexion Ankle joint flexion.

Plumb line A vertical line of reference that represents the line of gravity; used inpostural assessment.

Posterior Towards the back of the body.

Power Ability to generate large amounts of force against resistance in a shortperiod of time.

Progression A gradual increase in the level and intensity of exercise.

Pronation Rotation of the arm to position the palm downwards; rotation of thefoot to position the sole laterally.

Prone Lying face downwards.

Proprioception The ability to determine the position of a joint in space.

Proximal Towards or near the centre of the body or reference point.

Range of motion The range through which a joint can move.

Resistance A force that hinders motion.

Rotation Movement around a longitudinal axis in the transverse plane.

Sagittal plane A vertical plane extending from front to back, dividing the body intoright and left halves.

Scapulohumeral The movement of the scapula relative to the movement of the rhythm humerus throughout a full range of flexion/abduction.

Scoliosis Lateral curvature of the spine; may be C-shaped or S-shaped.

257Glossary

Shortness Tightness; a slight to moderate decrease in muscle length.

Stability The capacity to provide support.

Strain The extent of deformation of a tissue under loading.

Stress Any force that tends to distort a body.

Stretch To elongate or increase in length.

Subjective Perceived by the individual; not evident to the examiner.

Superior Towards the top of the body or a position above a reference point.

Supination Rotation of the arm to position the palm upwards; rotation of the footto position the sole medially.

Supine Lying face upwards.

Sway-back A faulty postural alignment in which there is posterior displacement ofthe upper trunk and anterior displacement of the pelvis.

Tension The effective force generated by a muscle.

Transverse plane A horizontal plane dividing the body into upper and lower portions.

258 Glossary

SUGGESTED READING

Behnke, R.S., 2001. Kinetic Anatomy, Champaign, IL: Human Kinetics.

Brooks, Douglas S., 1998. Program Design for Personal Trainers. Bridging Theory into Application.Human Kinetics, Champaign, IL.

Brukner, Peter and Khan, Karim, 2002. Clinical Sports Medicine, revised 2nd edn. McGraw-Hill.

Chaitow, Leon and DeLany, Judith Walker, 2002. Clinical Application of NeuromuscularTechniques: The Lower Body, London: Churchill Livingstone, vol. 2.

Chek, P., 2000. Movement that Matters, Encinitas, CA: The C.H.E.K. Institute.

Corning-Creager, Caroline, 1996. Therapeutic Exercises using Foam Rollers, Executive PhysicalTherapy, Inc.

Dick, Frank W., 1997. Sports Training Principles, 3rd edn, London: A & C Black.

Feldenkrais, Moshe, 1996. Mindful Spontaneity: Lessons in the Feldenkrais Method, North AtlanticBooks.

Hamilton, Nancy and Luttgens, Kathryn, 2002. Kinesiology. Scientific Basis of Human Movement,international edn, McGraw-Hill.

Hanna, Thomas, 1988. Somatics: Reawakening the Mind’s Control of Movement, Flexibility andHealth, Cambridge, MA: Perseus.

Hoppenfeld, Stanley, 1976. Physical Examination of the Spine and Extremities, Upper SaddleRiver, NJ: Prentice Hall.

Hanna, Thomas, 1993. The Body of Life – creating new pathways for sensory awareness and fluidmovement, Healing Arts Press.

Kendall, Florence, McCreary, Elizabeth and Provance, Patricia, 1993. Muscles Testing andFunction: 4th edn Posture and Pain, Philadelphia, PA: Lippincott Williams and Wilkins.

Kingston, Bernard, 2000. Understanding Joints: A Practical Guide to Their Structure and Function,Cheltenham, UK: Nelson Thornes.

McGill, Stuart, 2002. Low Back Disorders. Evidence-Based Prevention and Rehabilitation,Champaign, IL: Human Kinetics.

Norris, Christopher M., 2000. Back Stability, Champaign, IL: Human Kinetics.

Posner-Mayer, J., 1995. Swiss Ball Applications for Orthopedic and Sports Medicine, Denver, CO:Ball Dynamics International Inc.

Prentice, William, 1999. Rehabilitation Techniques, 3rd edn, McGraw-Hill.

Richardson, Carolyn et al., 2000. Therapeutic Exercise for Spinal Segmental Stabilization in the LowBack. Scientific Basis and Clinical Approach, London: Churchill Livingstone.

Sahramann, Shirley, 2002. Diagnosis and Treatment of Movement Impairment Syndromes, St Louis,MO. Mosby Inc.

Whittle, Michael, 2001. Gait Analysis, an introduction, 3rd edn, Oxford: ButterworthHeinemann.

260 Suggested reading

INDEX

abdominal bracing 138–9abdominal curl see curlabdominal hollowing 136–7,

139abdominal muscles 111–12

balance/flexibility exercises132–3

clinical perspectives 113, 129,139, 147

dominance over hamstrings 24function 129length tests (anterior

abdominals) 121in pelvic movements 174–5in pelvic/hip stabilisation

exercises 221–5, 226–7,228, 231, 234

in pelvic/hip strengtheningexercises 235–45

in shoulder stabilisationexercises 74–7, 77–8,78–9, 83–6

in shoulder strengtheningexercises 87–92

in spinal stabilisationexercises 136–44

strength tests 122–3, 124–9strengthening exercises

144–58see also back, muscles;

iso-abdominals; trunkmuscles and specificmuscles

abduction 11, 255hip joint 171, 172, 181

assessment 188exercises 224

shoulderexercises 67–70

middle deltoid strength testduring 53

movement analysis during46, 47

scapula 37, 43, 45shoulder joint 38, 39, 43

abduction/externalrotation/flexion (hipjoint), assessment 189

abductorship 176

exercises 207–8, 224, 228–9shoulder, exercises 67–70, 71–2

acceleration 17–18acetabulum 169acromioclavicular joint 36, 37

movements 37adduction 11, 255

hip joint 171, 172, 181assessment 188exercises involving 213,

225limiting, in walking

re-education 234adduction, shoulder

scapula 37, 43, 45analysis 47

shoulder joint 39, 43horizontal 39

strength tests duringlatissimus dorsi 54pectoralis major 53, 54teres major 56

adduction/flexion (hip joint),assessment 188

adductorship 177

exercises 208–9, 213, 222,225

strength tests 200shoulder

exercises 93–4shortness 45

agility 15in restoring of power 30

alignment, skeletalideal 6, 7, 182–3, 183–4, 184knee and hip joint/pelvis see

hip joint; knee; pelvisshoulder 7

evaluation 44–6spine and trunk 7

analysis 115–17problems 116–17

angle of declination andinclination of femoral neck183, 184

ankle plantar flexion in walkingre-education 234

anterior view of posture 6antetorsion, femur in 186, 187,

190arm(s)

alignment in standing, ideal7

muscles, exercises usingshoulder balance-restoring

63–4, 65–6shoulder power-restoring

101–3shoulder stabilisation 80–1,

83–6shoulder strengthening

87–92, 95–6, 97–8trunk strengthening 151–2

arm/leg reach, four-point141–2, 236–7

atrophy, muscle 20

Note: Bold figures indicate definition of terms in glossary.

backmuscles 8, 9, 112–13

extensors see extensorslength tests 119–21in shoulder

balance-restoringexercises 63–4

in shoulder power-restoringexercises 101–3

in shoulder stabilisationexercises 74–5, 77–8,83–6

in shoulder strengtheningexercises 89–91

strength test 123stretch (low back) 134, 214structure and function

112–13in trunk and hip

strengtheningexercises, low 94–5,153–7, 241–5

in trunk stabilisationexercises, low 140–2,220–1

see also paraspinal muscleexercises

postural abnormalities 116–17corrective exercises 8, 9

see also spine; trunkbackward bending 118backward lunge 244balance (muscle) 15, 256

reflexes maintaining 17restoration exercises 27–8

pelvis/hip/knee 204shoulder 58, 59–74trunk 130, 131–6

in restoration of power 30in restoration of stabilisation

28–9in restoration of strength

29–30standing 229–30see also imbalance

balance-board 76–7, 229–30,244

ball (types used) see medicineball; stability ball

ball circumduction 75–6ball roll

forward 151–2

supine lateral 152–3band see exercise bandbarbell, exercises with

power-restoringhip 247–9shoulder 103–4

strengthening 242hip 242shoulder 91–2, 94–5trunk 164–6

bench press 89bending see curl; flexion;

forward bending; lateralflexion

biceps brachii 42in pull-down 93–4strengthening 89–90, 93–4

biceps femoris 178length test 192

biomotor skills 14–15, 26development 14–15, 27–30repetitions and 33see also specific skills

Bodyblade®,vertical/horizontaloscillations 162–4

bow legs 187, 255buttock muscles see gluteal

muscles; gluteus maximus;gluteus medius; gluteusminimus

cable, exercises usingpelvic/hip strengthening

252–4shoulder stabilisation 82–6shoulder strengthening


calf stretch 218–19, 227cat-camel 136centre of gravity see gravitycervical lordosis 115chest

alignment in standing, ideal7

muscles, exercises usingshoulder balance-restoring

63–4shoulder power-restoring

99–101shoulder stabilisation 77–9

shoulder strengthening87–9

chest pass, medicine ball 99–101circumduction 255

hip joint 173shoulder joint 39

ball 75–6side-lying 63–4standing 70–1

clean and press, barbell 103–5,164–6, 247–9

closed-chain movements 18shoulder 76–7

contraction 255gluteal muscles 235–6

coordination 15in restoring power 30in restoring strength 29–30

coracobrachialis 40couch stretch 205, 206Craig test 189, 190curl (abdominal)

curl-up 142–3, 147curled forward bending 132lower abdominal curl 143–4oblique curl 140stability ball 146–7

dead lift 155–7barbell 244–5dumb-bells 155–7

deceleration 17–18declination (of femoral neck),

angle of 183, 184deltoids 41

anatomy 41strength tests 52–3strengthening 91–2stretch 70, 73

depression, scapula 37, 43depressors, scapular, exercises

93–4, 95–6dips 95–6dorsiflexors, elongated 21dumb-bells, exercises with

pelvic/hip power-restoring246–7

shoulder power-restoring101–3

shoulder stabilisation 82–7shoulder strengthening 91–2,

94–5, 96–7

262 Index

trunk power-restoring 159–60trunk strengthening 155–7

dynamic stabilisation exercises 28pelvis/hip/knee 204–5shoulder 58, 74–87spine 130, 136–44

elevation, scapula 37, 43analysis 46strength test during 55

endurance (muscle) 14–15, 257exercises/training

manipulation of acutevariables 34

restoring power 30restoring stabilisation 28–9restoring strength 29–30

equilibrium reflex 17erector spinae

exercises 132in pelvic movement 175structure and function

112–13eversion, foot 255exercise(s)

contraindications 27number of 32number of repetitions 33, 34number of sets 33, 34objectives 3pelvis/hip/knee 204–54programme design 3–4,

26–34progression 257

phases 26–30selection 31–2sequence of 32shoulder 58–106specific acute variables 31–4trunk 130–66, 229–30

exercise band usehip stabilisation 228–9hip strengthening 252–4shoulder stabilisation 82–7shoulder strengthening


extension 11, 256hip joint 171, 172, 180

assessment 189exercises 144–6, 226–7,

238–40

malalignment in 184–5knee joint 173

exercises 227shoulder joint 38

anterior deltoid strengthtest during 52

strength test during 56spine/trunk 108, 109, 114

analysis 118exercises 147–8gluteus maximus strength

test during 124see also hyperextension

extensorsback

strength test 121, 123strengthening exercises

237, 240–1weakness 111, 123

hiplength 190–1in spinal stabilisation

exercises 140–2strengthening exercises

144–6, 232, 236–41knee, in strengthening

exercises 236–7external oblique see oblique

abdominal musclesexternal rotation, hip joint,

assessment of flexion andabduction and 189

external rotator strength tests54

feet see footfemur 169

movements 171–3medial rotation see medial

rotationneck, angle of declination

and inclination 183, 184structural variation resulting

in hip torsion 187flat-back 116

corrective exercises 9flexibility 15

exercises 15pelvic/hip/knee 205–20restoring balance 27–8restoring power 30restoring stabilisation 28–9

restoring strength 29–30shoulder 59–74trunk 131–6

flexion 11, 256ankle joint see plantar flexionhip joint 171, 172, 180

assessment 189exercises employing 236–7malalignment in 185

knee 173, 181correction 10exercise employing hip

extension plus 146,239

lateral see lateral flexionshoulder joint 38

anterior deltoid strengthtest during 52

exercise 66–7, 69–70movement analysis during

46–7, 47spine/trunk 108, 109, 114

analysis 117–18range of motion in 120,

121see also forward bending

flexion/abduction/externalrotation (hip joint),assessment 189

flexion/adduction, hip joint,assessment 189

flexorship

exercises 215, 221–3, 227length 190–1length tests 191–2, 193–4strength tests 196

shoulder, exercises 69–70,71–2

stretch 205–6trunk

lateral, strength test 124–5strength and

power-restoringexercises 159–60

strength test 121–2floor bridge 140–1

supine 237–8floor stretch 205, 206foot (feet)

on ball 145–6, 148–9, 238–9eversion 255

263Index

foot (feet) – continuedideal alignment in standing 7inversion 256pronation 10, 258supination 10, 258

forward ball roll 151–2forward bending (from

standing) 117–18exercise 132

four-point kneelingarm/leg reach 141–2, 236–7cross-crawl 74–5rocking 214

frontal plane 256motion in 11, 16

hops 251, 252

gait analysis 190, 191gastrocnemius 179

stretch 218–19weakness 179

genu valgum see knock kneesgenu varum (bow legs) 187,

256glenohumeral joint see shoulder

jointgluteal muscles (in general)

176balance/flexibility exercises

132contraction 235–6stabilisation exercises 220–1strengthening exercises

149–50, 235–6stretch 214

gluteus maximus 175exercises 226–7strength test 124, 201weakness 124, 176, 177, 201

gluteus medius 176posterior

overstretching in sleep 21strength test 199weakness 21, 176, 199

gluteus minimus 175gracilis 177gravity, centre of 255

maintenance 17

hamstrings 177dominance of abdominals

over 24

dominant, substituting forquadriceps function 178

exercises 134–5, 226–7stretch 216–18, 227

length tests 119–21, 192, 195lengthened 120, 192shortened 119–20, 192, 202strain 178strength tests 202, 203weakness 202

headalignment in standing, ideal

7forward carriage, correction 8

hip, anatomy 167, 168, 169hip bones 169hip joint 169

alignment 183–4alignment problems 184–7

lateral asymmetry (high leftor right hip) 9, 185

exercises 204–54movements 167, 171–3,

180–1analysis 188–90limiting various, in walking

re-education 234supine extension 144–6,

238–40muscles 175–7

acting also at knee joint177–8

extensors see extensorslength tests 119–21, 190–5postural problems relating

to 9–10recruitment in standing 6strength tests 21, 196–203

shoulder joint and,comparative anatomy 42

history, client 31–2hops, multiplanar 250–2horizontal plane see transverse

planehumerus, position during

shoulder movement 46hyperextension 256

hip joint 172knee joint 173, 187, 202

correction 10limiting, in walking

re-education 234

hypertrophy (muscle)manipulation of acute

exercise variables 34subscapularis 46

iliocostalis muscle 112iliopsoas 175, 176

exercises 205–6length test 191, 192shortness 176, 192, 193see also psoas major

iliotibial band 176length test 194, 195shortness 194stretch 211–12

ilium 169spines

and pelvic alignment183–4

and pelvic movements170–1

imbalance (muscle) 19causes 19correction see balance,

restorationinternal and external obliques

125, 128inclination (of femoral neck),

angle of 183, 184infraspinatus 41

strength test 54injury history 31innominate bones 169internal oblique muscle see

oblique abdominal musclesinternal rotator strength tests

54intervertebral discs 109inversion, foot 256ischium 169iso-abdominals

prone 77–8, 149–50side-lying 78–9, 150–1

isometric bridge, supine 232isometric glutes 226

joint movements see movement;range of motion and specificmovements

jump training see plyometrictraining

jumping on/off box 249–50

264 Index

kinaesthetic awareness 29kinetic chain 4

closed-chain movements seeclosed-chain movements

in daily activities, demands on17

evaluation 3open-chain movements 18separation into 3 structural

systems 4knee(s) (and knee joint)

alignment 184ideal and normal 7,

184problems 184–7

anatomy 167, 168, 169–70functions 167knock see knock kneesmovements 173–4, 181

analysis 188–90flexion see flexionhyperextension see

hyperextensionrotation see rotation

muscles 177–80acting also at hip joint

176–7extensors, in strengthening

exercises 236–7recruitment in standing 6

kneeling see four-point kneelingknock knees (genu valgum) 10,

187, 256correction 10

kyphosis 45, 256thoracic 47, 115

correction 8

lateral ball roll, supine 152–3lateral flexion (side bending)

11, 118, 256exercises 132–3, 220–1spine/trunk 108, 109, 114

analysis 118lateral flexors of trunk, strength

test 124–5lateral pelvic tilt 171, 180lateral rotation

hip joint 172, 181assessment 189

knee joint 173, 174, 181shoulder joint 39, 43, 47

performance exercises62–3, 82–3

restoration 39testing 50, 51

lateral rotatorship, strength tests 197length test 50, 51stretch 61–2, 73–4

lateral view of posture 6, 7lateral wood-chop 98, 158, 254latissimus dorsi 41

length test 49strength test 56, 124–5strengthening 93, 96–7stretch 59–61, 71–2, 73–4

legsalignment in standing, ideal

7bow 187, 255drop, supine 222length discrepancy, apparent

(=high left or right hip)9, 185

muscles, exercises usinghip stabilisation 229–30,

233–4shoulder power-restoring

101–3trunk/hip strengthening

153–7, 241–5raise, supine 143–4, 221single-leg balance 230slide, supine 222see also arm/leg reach

lengthbalance-restoring exercises

aimed at restoring seebalance, restorationexercises

leg, apparent discrepancy(=high left or right hip)9, 185

testing 19, 22shoulder 47–51trunk 118–21

see also lengthened muscle;shortened muscle

lengthened muscle 8–10, 19avoiding stretching 28back muscles 120correction 27, 28hamstrings 120, 192

in postural problems 8–10levator scapulae 41

strength test 55lifting 11

see also dead liftload 33–4long muscles see lengthened

musclelongissimus dorsi 112lordosis 256

cervical 115lumbar see lumbar spine

lumbar spineerector exercises 132lordosis 115, 116

excessive, correctiveexercises 9

movements, and associatedproblems 117–18

lumbarpelvic rhythm 117lunge 242lying down see prone; side-lying;

supine

medial rotationhip joint/femur 171, 173, 181

assessment 189correction 8increasing range of motion

in 213limiting, in walking

re-education 234knee joint 173, 174, 181shoulder 39, 43, 47

correction 8, 39pain associated with 39performance exercises

61–2, 82–3strength test during 57testing 50, 51

medial rotatorship

exercises 213strength tests 197

shoulderexercises 62–3, 73–4length tests 50, 51

medicine ball, exercises withpelvic/hip power-restoring

246–7in shoulder power-restoring

99–103

265Index

medicine ball, exercises with –continued

shoulder stabilisation 75–6shoulder strengthening 96–7trunk power-restoring 159–61

motion see movementmotion segment (spine) 107motor skills see biomotor skillsmovement/motion 11–18

analysis/observation (ingeneral) 3, 12–13

building blocks 11–12complex 11–13hip joint see hip jointknee joint see kneepelvic see pelvisplanes of 11, 16principles 11–18shoulder 37–9, 43

analysis 46–7spine/trunk 108–10

analysis 117–18during shoulder

movements 47substitution 23variable of 13–18see also kinetic chain; range of

motion and specificmovements

multifidus muscle 113muscle(s)

action, integration 13–14atrophy 20contraction see contractioncoordination see coordinationendurance see endurancehip joint see hip jointhypertrophy see hypertrophyknee see kneelength see lengthlong and short see lengthened

muscle; shortenedmuscle

pelvic see pelvispower see powerrecruitment

altered dominance inpatterns of 23–5

in standing posture 5–6shoulder see shoulderstrain see strainstrength see strength

stretching see overstretch;stretching

testing (manual testing offunction) 3, 19–25

hip/thigh 119–21, 190–203practical considerations

21–3shoulder 47–51trunk 118–28

trunk see abdominal muscles;back, muscles; trunk

weakness see weaknesssee also specific muscles

neck, muscle recruitment instanding 5

nerve (sciatic) flossing 134–5nervous system and

musculoskeletal pain 20

Ober test, modified 192, 195oblique abdominal muscles

111–12, 113external 111–12

balance and strengthexercises 135, 148–9

dominance of rectusabdominis over 25

overactivity 123in pelvic movement 174spinal stabilisation exercises

139–40structure and function

111–12weakness 174

imbalance between 125, 128internal 112

in pelvic movement 175spinal stabilisation exercises

136–7, 139–40spinal stabilisation function

129strength tests 124–5, 128strengthening exercises 160–1

oblique curl 140occupation history 31–2open-chain movements 18overstretch weakness 21, 257

in sleeping 21

pain (musculoskeletal)nervous system and 20

shoulder, associated withmedial rotation 39

paraspinal muscle exercises132–3, 134–5, 136

patella 169–70pectineus 177pectoralis major 39–40

length test 48strength test 53, 54strengthening 87–9, 96–7stretch 59–61, 70, 73–4

pectoralis minor 40length test 49stretch 70, 72–3

pelvic clocks 131–2pelvic floor muscles, in spinal

stabilisation exercise 136–7pelvic tilts 131–2, 257

alignment with 183anterior 170, 180in exercises 131–2, 135lateral 171, 180posterior 135, 170–1, 180

pelvis (pelvic girdle) 167alignment (in standing)

182–3ideal 7, 182normal 182–3problems 184–7

anatomy 167, 168, 169lumbar spine, integrated

movement 117movements 167, 169, 170–1,

180analysis 188–90in walking re-education 234

muscles 174–5recruitment in standing 6

spine as functional linkbetween shoulder and105

peroneus longus 179Pilates 137piriformis 176

stretch 211planes of motion 11, 16plantar flexion 257

in walking re-education 234plyometric (jump) training 30

pelvic/hip/knee muscles249–52

trunk muscles 131

266 Index

popliteus 179posterior view of posture 6, 7posture 5–10

assessment 3, 5–10views 6

faultyback see backinterpretation and

correction 7–10standing, muscle recruitment

in 5–6power 14, 257

restoring 30manipulation of acute

variables 34pelvic/hip/knee muscles

205, 242–54shoulder muscles 59, 99–104trunk muscles 159–66

trunk muscles 131power crunch 159–60power twist, Russian 160–1press

bench 89shoulder 91–2

programme design 3–4, 26–34pronation 257

foot 10prone exercises

hip extension 226–7hip rotation 212iso-abdominals 77–8, 149–50quadriceps stretch 215–16

proprioception 257proprioceptive neuromuscular

facilitation (PNF) patterns,shoulder 83–6

wood-chop movement and 99protraction, scapula, strength

test during 55psoas major 113

see also iliopsoaspubis 169pull-down 93–4pull-over 96–7pull pattern, standing

in daily activities 91exercise 89–91

pulling 11push pattern, standing

in daily activities 91exercise 87–9

push-upseated 80–1, 89wall 79–80

pushing 11

quadratus lumborumin pelvic movement 175strength test 124–5structure and function 113

quadriceps femoris group 202dominant hamstrings

substituting functionallyfor 178

exercises 215–16, 227strength tests 202see also rectus femoris; vastus

intermedius/lateralis/medialis

range of motion 257hip joint 172

increasing 213tests 188–90

limited, treatment 22measurement 22spine 108

in trunk flexion 120, 121reactive stabilisation exercises

28pelvis/hip/knee 204–5shoulder 58, 74–87spine 130, 136–44

reciprocal inhibition 23rectus abdominis 112

dominance of 202over external obliques 25

exercises involving 113overactivity 123in pelvic movement 175strength tests 124–5, 128structure and function 112

rectus femoris 177exercises 205–6length test 191, 192shortness 194, 202, 206

reflexes maintaining balance 17repetitions, number of 33, 34rest periods 33, 34retraction, scapula, strength test

during 55retrotorsion, hip 186, 187rhomboids 41

length test 49overstretch (from sleeping

position) 21strength test 55

righting reflex 17rocker-board 76–7, 229–30rotation 11, 257

hip joint 212external, assessment of

flexion and abductionand 189

lateral see lateral rotationmedial see medial rotationprone (exercise) 212

knee jointlateral 173, 174, 181limiting, in walking

re-education 234medial 173, 174, 181

pelvis 171, 180limiting, in walking

re-education 234scapula, downward 37, 41,

43, 45–6scapula, upward 37, 43

evaluation 46shoulder

external 54internal 54lateral see lateral rotationmedial see medial rotation

spine 108, 110trunk/spine 11, 12, 108, 110,

114analysis 118exercises 97–8, 133–4

rotator(s)hip 176, 177

exercises 211, 212shoulder see external rotator;

internal rotator; lateralrotator; medial rotator

trunk/torsoexercises involving 97–8,

133–4strength tests 122, 128

rotator cuff muscles 41–2exercises using

balance-restoring 66–7, 73–4stabilisation 75–7, 79–80,

82–7weakness 46

267Index

row, upright 94Russian twist

body on ball 149, 160–1feet on ball 148–9

sagittal plane 257motion in 11, 16

hops 251sartorius 177

exercises 205–6length test 191, 192shortness 192, 194

scaption 86–7scapula 37

alignment 44–6analysis 44–6faulty 44–6normal 44

depressor exercises 93–4,95–6

movements 37–8, 43analysis 46–7strength test during 55–6

winging 45–6, 46scapulohumeral muscle stretch

59–61scapulohumeral rhythm 38, 46,

47, 257sciatic nerve flossing 134–5scoliosis 45, 116–17, 257‘seatbelt, reaching for and

putting on’ 83, 83–6seated exercises see sitting downsemimembranosus 178

length test 192semitendinosus 178serratus anterior 41

exercises 65–7, 79–80strength test 56

sets, number of 33, 34shortened muscle (shortness)

8–10, 19, 258back muscles 119, 123correction 8–10, 19, 28hip/thigh muscles 191

adductors 200flexors 196gluteus medius (posterior)

199hamstrings 119–20, 192,

202iliopsoas 176, 192, 193

iliotibial band 194lateral rotators 197medial rotators 197quadriceps femoris (incl.

rectus femoris) 194,202, 206

sartorius 192, 194tensor fasciae latae 176,

192, 194, 198, 206in postural problems 8–10scapula adductors 45

shoulder 35–104alignment see alignmentanatomy 36–43exercises 58–106medial rotation see medial

rotationmovement see shouldermuscles 39–43

length tests 47–51postural problems relating

to 8–9recruitment in standing 5strength test 51–7in trunk and hip

strengtheningexercises 149–52,164–6, 236, 241–2,244–5

in trunk stabilisationexercises 141–2

spine as functional linkbetween pelvis and 105

shoulder girdle 37–8movements 37–8, 43

analysis 46–7coordinated with shoulder

joint movement(=scapulohumeralrhythm) 38, 46, 47,257

in power-restoring exercises99–101

structure 37shoulder joint (glenohumeral)

hip joint and, comparativeanatomy 42

movement 38–9, 43analysis 46–7coordinated with shoulder

girdle movement(=scapulohumeral

rhythm) 38, 46, 47,257

in power-restoring exercises99–101

see also scapulohumeralrhythm

shoulder press 91–2side bending see lateral flexionside-lying exercises

hip abduction 224hip adduction 213, 225hip adductor roll-up 213iso-abdominals 78–9, 150–1

single-leg balance 230sitting down

hamstring stretch 217–18knee extension 227low back stretch 134push-up 80–1, 89

skeletal alignment see alignmentsleeping, overstretch weakness

21soft-tissue treatment 27soleus 179

stretch 218weakness 179

speedmovement and 17–18in restoring of power 30

spinalis muscle 113spine (vertebral column)

alignment see alignmentanatomy 107–8corrective exercises 8–9

sequence of 32function 105movements see movementstabilisation

abdominal muscleinvolvement 129

exercises 130–1, 136–44,220–1

see also backsquat (exercise) 153–5, 157,

241–2dead lift and, comparisons

245squat (test), functional

movement analysis 190,191

squat raise/push 101–3, 246–7stabilisation 17–18, 28–9

268 Index

abdominal muscleinvolvement in spinalstabilisation 129

exercises 28–9pelvis/hip/knee 204–5,

220–34shoulder 58–9, 74–87spine 130–1, 136–44, 220–1

stability ball, exercises withbalance and

flexibility-restoring,pelvis/hip/knee 217–18,231–4

power-restoring, trunk 159–61strengthening

pelvis/hip/knee 238–41trunk 144–9, 151–3

standing (upright position)balance 229–30forward bending from see

forward bendingmuscle recruitment 5–6pelvic/hip/knee exercises

229–30abductor stretch 207adductor stretch 209calf stretch 218hamstring stretch 216quadriceps stretch 215

shoulder exercisesabduction 67–9circumduction 70–1flexion 66–7pull pattern 89–91push pattern 87–9row 94–5

static stabilisation exercises 28pelvis/hip/knee 204–5shoulder 58–9, 74–87spine 130, 136–44

sternoclavicular joint 36, 37movements 37

strain (muscle) 258hamstrings 178weakness due to 20–1

strength (muscle) 14, 257exercises/training 14, 29–30

avoidance with excessivelength 28

back muscles 94–5manipulation of acute

variables 34

pelvic/hip/knee muscles205, 235–46

in restoring of balance27–8

in restoring of stabilisation28–9

shoulder muscles 59,87–99

trunk muscles 130–1,144–58

testing 19, 22–3hip muscles 21, 196–203shoulder muscles 51–7trunk muscles 121–8

stretching 19, 28back muscles (lower) 134,

214hip/thigh muscles 205–12,

214–19, 227lateral rotators 59–61, 73–4in range of motion limitation

22shoulder muscles

lateral rotators 61–2latissimus dorsi 59–61,

71–2, 73–4medial rotators 62–3, 73–4pectoralis major 59–61, 70,

73–4pectoralis minor 70, 72–3teres major 59–61, 71–2teres minor 59–61

see also overstretchsubclavius 40subscapularis 42

hypertrophy 46strength test 54

substitution movement 23supination 258

foot 10, 258supine exercises

bridge lateral roll 233–4calf-stretch 218–19floor bridge 237–8hip extension 144–6, 238–40isometric bridge 232leg drop 222leg raise 143–4, 221leg slide 223trunk muscles 136–41, 142–4,

145–6, 149–50, 152–3,238–9

supraspinatus 41sway-back 116, 258

corrective exercises 9‘sword, drawing and replacing

the’ 83, 84, 86synergistic dominance 23–5

tempo 33, 34tensor fasciae latae 176

dominance 202exercises 205–6length test 191, 192, 194, 195shortness 176, 192, 194, 198,

206strength test 198stretch 211–12weakness 198

teres major 42length test 49strength test 56stretch 59–61, 71–2

teres minor 41–2strength test 54stretch 59–61

thigh muscleslength restoration 204in stabilisation exercises 231

thoracic spineerector exercises 132kyphosis see kyphosisshoulder/arm movements

integrated withmovements of 63–4

tibial torsion 187tibialis anterior 179–80tilts

pelvic see pelvic tiltscapular, anterior 37, 45

torsionhip joint/femoral neck 186,

187angle of (=angle of

declination) 183, 184tibial 187

torso see trunktraining history 31training machines (gyms/health

clubs) 16transverse (horizontal) plane

258motion in 11, 16

hops 251, 252

269Index

transverse abdominisin balance-restoring exercises

135in spinal stabilisation

exercises 136–7strength test 122–3structure and function 112,

113, 129trapezius 41

lower 41, 64–5dominance of upper over

23–4exercises 64–5, 93–4overstretch (from sleeping

position) 21middle 41, 64–5

exercises 64–5, 67–9upper 41

exercises 67–9, 91–2strength test 55

Trendelenburg sign 199triceps brachii 42

strengthening 87–9, 95–7trunk (torso) 105–66

alignment see alignmenton ball 144, 240–1exercises 130–66, 229–30movement see movementmuscles 110–14

length tests 118–21in pelvic movements 174–5

postural problems relatingto 9

recruitment in standing5–6

strength test 121–8see also abdominal muscles;

back, musclesrotation see rotationsee also back; spine

upright positions see standing

vastusintermedius/lateralis/medialis 179

vertebrae 107vertebral column see spineVew-Do™ board 76–7, 229–30visualisation 29

walkinggait analysis 190, 191lunge 244re-education 234

wall climbing 69–70wall corner stretch 70wall push-up 79–80wall slide 231warm-up before power

movements 159weakness 19

causes 20–1gastrocnemius—soleus

complex 179hip/thigh muscles 191

adductors 200flexors 196gluteus maximus 124, 176,

177, 201gluteus medius (posterior)

21, 176, 199hamstrings 202lateral rotators 197medial rotators 197quadriceps femoris 202tensor fasciae latae 198

rotator cuff 46trunk muscles (incl.

abdominals) 128anterior abdominals 124back extensors 111, 123external oblique 174lower abdominals 125transversus abdominis 123upper abdominals 127

weight-shifts, closed-chain,shoulder 76–7

wood-chophigh-low 97–9, 157–8, 252–4lateral 98, 158, 254low-high 98, 158, 254

270 Index

Documents

Corrective Exercise