Low Back Pain with Movement Coordination Impairments/Core Stability Deficits

The most important thing to remember when it comes to your low back is that it is a strong and stable structure. When we mention core stability, that does not mean your back is unstable but that it may benefit from getting stronger to complete daily tasks and sports activities.

Core stability training should target all aspects of the "corset" including the front, sides, and back as well as scapular stabilizers and hip musculature. It is important to start the program at the appropriate level - too low and you're wasting your time, too high and you may injure yourself or just compensate. The lowest level will start with basic activation exercises.

The speed and resistance should increase and include coordinated movements in all planes of motion. Planned movements should progress to reactionary in response to external perturbations.

There is a benefit to static holds, though a complete program should include both static and dynamic movements and progress toward activity or sport-specific demands. The athlete should continue a strengthening program for the upper and lower body in a pain-free range which may require reducing weight and/or complexity of their program. Cardio/ conditioning should continue so that they are ready to return as quickly as possible in "game shape." Modifications may include use of a bike or an elliptical in place of running, sprinting, or swimming.

They should complete the activity most similar to sport that they can complete pain-free. The athlete should progress through a return to sport program starting with individual drills then group drills then move to simulated game play and finally back to live action.

Low Back Pain with Mobility Deficits

Manual therapy should be utilized to address flexibility deficits with soft tissue mobilization techniques and manual stretching and to address joint mobility deficits with mobilizations and manipulations. Massage guns and foam rollers may be useful too. This should be followed by an exercise to utilize the newly gained range of motion. Focus should be on the thoracic and lumbar spine in all planes of movement as well as the hips, knees and ankles, with primary muscle groups including lats, paraspinals, QL, hip flexors, glutes, quads, hamstrings and calves.

Manual therapy should be immediately followed by these exercises with a daily routine developed to make consistent gains, reduce low back pain, and improve movement capacity.

Low Back Pain with Radiating Pain/Sciatica

Nerves may be the source of your pain rather than the joints, muscles or tendons in the area. A physical therapist may diagnose this as your cause of pain by ruling out local dysfunction and ruling in nerve irritation with tests such as a straight leg raise or slump test. These tests utilize the concept that muscles/tendons only traverse 1-2 joints whereas nerves can be tensioned all the way from head to toe. This differentiation is important because while muscles may respond well to aggressive stretching, nerves may get flared up by this treatment.

Sciatic nerve tension may be due to entrapment at the level of the spine or anywhere along its path as it can get "trapped" at many interfaces from the hip to the knee and down to the ankle. Depending on the severity and irritability of the nerve, multiple joint or single joint movement may be used to tension or glide the nerve. Nerve glides are less aggressive and involve increasing tension at one joint while decreasing tension at another, with the goal of "flossing" the nerve back and forth. Nerve tensioners, or stretching, should be used with caution and would include tensioning across multiple joints. These are useful in less symptomatic cases with persistent, low-level symptoms.

Other ways to assist in improving neural tension include improving the pliability of the muscles and mobility of the joints at the common entrapment sites, usually starting at the spine, moving to the piriformis and hamstrings, then into the calf and shin. This may be accomplished through manual therapy, self-massage, joint mobility exercises and stretching. Core stability training, lower extremity strengthening, postural and movement retraining as well as activity modifications should also be considered to address other impairments that may be contributing to the overall presentation.

Greater Trochanteric Pain Syndrome/Hip Bursitis

Greater Trochanteric Pain Syndrome (GTPS) is associated with pain on the outside of the hip at its most bony prominence. It includes trochanteric bursitis as well as gluteal tendinopathy and a diagnostic process should be used as treatment will be slightly different for each. It is also important to rule out the lumbar spine and hip osteoarthritis.

Lateral hip pain is typically worse with prolonged sitting, stairs, walking, aggressive physical activity, lying directly on that side or stretching the hip across the body and up to the chest. If pain is due to bursitis, an injection may be beneficial but if it is due to gluteal tendinopathy, progressive load will be required

In the acute phase, the goal is to decrease pain with rest, ice, NSAIDs, soft tissue mobilization and pain-free gentle stretching. Education on positions for sitting/sleeping is helpful: do not sleep on involved side; if sleeping on opposite side, place pillow between knees; do not sit cross-legged; do not sit with knees above the hips in low chairs. PT should also address other impairments including core stability/strength, general LE strength and flexibility deficits and especially hip joint mobility as arthritic-type changes or capsular mobility deficits are also commonly present. It is important to understand that tendinopathy does take time to improve and ups and downs throughout the rehab process are common, though with the right treatment, they have a good prognosis to improve.

Hip Impingement

Femoroacetabular impingement (FAI) syndrome is pain in the anterior hip and groin area caused by extra bone growth. CAM deformity is bony overgrowth on the femoral head and Pincer on the acetabulum. These deformities typically cause pain from bony contact/friction as well as labral tears and breakdown of articular cartilage. Pain is typically exacerbated with prolonged sitting in a flexed position, flexing the hip toward and/or across the chest, weight bearing and high impact activities.

This syndrome may be managed conservatively based on the irritability and extent of symptoms, however, hip specialists/orthopedic surgeons should be consulted early in more severe cases to obtain further examination including imaging such as x-rays and MRis (possibly with contrast to look for a labral tear) to determine if the patient is a surgical candidate. Good PT/surgeon communication is important especially in these cases to assure efficient and safe return to activities.

In acute cases, treatment aims to reduce symptoms with manual therapy (soft tissue and joint mobilizations), gentle stretching, isometric hip exercises, and icing. NSAIDs or possibly a steroid dose pack or injection may be recommended by a physician. It will be important to avoid aggravating the hip flexor musculature as tendinopathy here also contributes to anterior hip pain in many of these cases. Activities should be modified to reduce loads placed on the hip joint.

PT should progress to more challenging core stability and hip strengthening exercises based on impairments found with a thorough examination. This core and hip strength should be built upon with more functional and sport-specific movements to work on neuromuscular control and be progressed to dynamic, multiplanar exercises incorporating the upper and lower body depending on the demands of the activity/sport.

Hip Osteoarthritis

Hip osteoarthritis typically affects those >50 years old as it is associated with the cartilage wearing down. X-rays will show bony spurs, osteophytes and a loss of joint space. Pain typically comes with weight bearing activities and bending motions such as squatting to a toilet seat/low chair and putting socks and shoes on. Pain is typically described in a C-shape at the front of the hip/groin and the patient will have decreased ROM, pain with palpation and oftentimes an antalgic gait or a compensatory Trendelenburg gait due to weakness or to offload the hip. Conservative care may delay the need for a hip replacement, but don't wait until you have a decline in quality of life as the surgery and rehab is very successful.

Weight loss, the use of a cane, NSAIDs and cortisone injections are simple ways to reduce inflammation and decrease pain with activities. Physical therapy should focus on manual therapy with stretching and especially joint mobilizations to improve the mobility of the joint capsule itself. This should be followed by self-stretching and self-mobilizations with bands or belts. Strengthening of the hip muscles and quadriceps are very important to provide stability to the lower extremities and improve function with daily activities. Balance is typically addressed as OA typically comes along with older age and falls risk reduction is beneficial in those who need it.

Knee Osteoarthritis

Knee osteoarthritis is characterized by pain, stiffness and swelling of the knee that worsens with weight bearing activities and movements that load the knee joint such as walking, stairs, hills and transitions from sitting and standing. It tends to be worse in the mornings and after prolonged inactivity due to the stiffness. X-rays typically show bony spurs/ osteophytes and a loss of joint space between the thigh and shin bones. While knee OA may eventually lead to the need for a total knee replacement, there are many conservative treatment options to delay this as long as possible.

The most evidence-based recommendations include physical therapy/guided exercise, weight loss and the use of NSAIDs. Each pound of weight loss may decrease knee joint forces by up to 3-4x that amount. Biking may be used to work on fitness with less load on the knee joint. Physical therapy should include exercises to improve the strength of the entire lower extremity but especially the quadriceps, mobility and range of the knee and kneecap, and flexibility of the quad, hamstring and calf.

Manual therapy may be used to improve flexibility of muscles and mobility of the kneecap with passive stretching to address range of motion. Shoewear/ insoles may provide more cushion to decrease joint forces with walking and standing. Supplements such as fish oil, vit D and glucosamine may be trialed.

Orthopedic doctors may recommend glucocorticoid, hyaluronic acid and/or platelet-rich plasma (PRP) injections in severe cases to delay the need for surgery.

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is common in the young, active population. Pain is behind or around the kneecap primarily with squatting, stairs, running, jumping and prolonged sitting. Other knee conditions, such as patellar tendinopathy, must be ruled out as pain with exercise is more conservative with PFPS compared to the more aggressive pain-monitoring model with tendinopathy.

It is helpful to determine the impairments that lead to each patient's pain complaint to develop an individualized program as it may need to address training errors and/or strength, mobility or neuromuscular control deficits.

Strengthening should include both hip and knee-focused training with open and closed kinetic chain exercises. Foot/ankle strengthening and orthotics may be beneficial if midfoot collapse causes compensations at the knee. Exercises should focus on progressive overload while maintaining proper form and neuromuscular control, especially in the frontal plane, to avoid knee valgus which places undue strain on the joint. Blood flow restriction training should be used in those who cannot strength train without excessive anterior knee pain.

Stretching/mobility work should target hip flexors, quads, IT band, hamstring and calf. Patellar taping may assist in pain reduction. The usefulness may be determined with the step down test assessing pain, range and repetitions pre and post taping. Gait retraining may include cues such as soft, quiet landing and increasing cadence which both reduce peak impact forces upon landing. Running education may also include volume of running and avoiding hilly areas. PFPS may persist if not treated appropriately so education is important on the importance of therapy to address impairments and gradually return to pain-free activity.

Patellar Tendinopathy

Patellar tendinopathy is pain typically at the inferior pole of the patellar tendon and is common in those who participate in running and jumping sports or other activities that create increased demand on the knee extensor musculature. Pain is typically palpable on the tendon and is caused by sports activities but also sitting, squatting, stairs, and walking downhill in more irritable cases. The clinician should rule out patellofemoral pain, or pain under the kneecap, as the rehab approach is slightly different.

As we discussed with the Achilles, the best treatment approach for tendinopathy is a tendon loading program. This helps to strengthen the quad musculature but also stimulates reorganization of collagen in the tendon to make it stronger and begin to return to a more normal structure. This will be done through open-chain exercises such as a knee extension with a machine, ankle weights or a resistance band as well as with closed-chain exercises such as squats, lunges, and step exercises. To increase the load on the tendon, perform squats with the heels elevated, knees over toes is okay and actually beneficial in this condition!

Exercises progress from double to single limb, with higher resistance and with faster speeds with plyometrics and agilities which will challenge the tendon to quickly store and release energy.

Stretching the quad and IT band as well as STM, foam rolling and use of a massage gun may help to decrease tension on the area and may supplement the loading program. Shockwave therapy may be considered in chronic cases that do not respond to conservative care.

Shin Splints

Shin splints, or medial tibial stress syndrome, is pain along the inside of the shin bone that affects the muscles and its attachment along the tibia. It is common in running and jumping athletes. The clinician should rule out stress fractures, chronic exertional compartment syndrome and nerve entrapment injuries when considering the diagnosis.

Immediate steps are the basics of rest, ice, massage and gentle stretching. Arch taping and the use of orthotics or more supportive shoewear will play a role in reducing the strain as well as considering the training environment such as surfaces that the athlete runs and jumps on. Strength training is typically needed for more proximal musculature to improve stability of the lower extremity as well as decrease demand on the lower legs for propulsion.

This may require neuromuscular control and movement retraining to utilize more efficient strategies. Foot intrinsic and ankle/calf strengthening is crucial. Many of these cases come up due to overload from a demanding training schedule or training errors so the most important component in improving this condition is implementing an appropriate training schedule and load management strategies. This should be done in consultation with the athlete and other team members such as parents, coaches, and personal and athletic trainers.

Achilles Tendinopathy

Achilles tendinopathy (opathy=pain) causes pain with the first steps in the morning, with prolonged or dynamic activities, with contraction of the calf muscles for plantarflexion (gas pedal motion) and with stretching into dorsiflexion (toes toward your nose). It is typically an overuse injury or related to a drastic increase in activity or training volume.

Diagnosis can be determined with a clinical exam and confirmed with ultrasound imaging or MRI.

The most important treatment for Achilles tendinopathy is progressive loading through the use of heel raises. Progressions are made by transitioning from double limb to eccentric (up with 2, down with 1) to single limb, from flat on the floor to off the edge of the step, from slow to fast, from low rep ranges to high and eventually to weighted and dynamic movements.

Stretching may provide relief though it also may be irritating if it is an insertional tendinopathy (at the attachment to the heel) rather than a midportion (halfway up the tendon). Heel raises should be completed flat on the floor with insertional. There is some evidence for the use of heel lifts, orthotics, taping, night splints, manual therapy, and laser treatment - the need for these should be evaluated on a case by case basis depending on symptom response. There is emerging evidence for the use of shockwave therapy in chronic, persistent tendinopathy.

For specific details on a clinical progression of exercises to incrementally load the Achilles tendon, go to our channel on YouTube This progression is based on data captured with a team from UPenn and University of Delaware.

Check out the progression on YouTube.

Plantar Fasciitis

Plantar fasciitis is pain on the bottom of the foot and arch where the plantar fascia attaches to the heel bone. It usually comes from a recent increase in weightbearing activity through exercise or weight gain in nonathletic individuals. Pain is the worst after prolonged inactivity, with the first steps in the AM, and with excessive activity.

Diagnosis is typically found with a clinical examination including subjective history, palpation of the area, a positive Windlass test (pain with stretching the fascia) and ruling out other causes such as tarsal tunnel syndrome, heel fat pad syndrome and stress fractures.

Treatment must be comprehensive to treat the condition and all relevant impairments as symptoms tend to be persistent with an extended timecourse.

Self-massage and icing may be completed simultaneously by freezing a water bottle and rolling on the foot. Stretching should target the plantar fascia. Calf stretching and self-mobilizations to the ankle should be performed to reduce stress on the midfoot in the stance phase of gait. Strengthening should include foot intrinsics (small muscles of the foot), ankle and calf musculature. Rathleff suggests heavy, slow resistance training with heel raises with a towel under the toes. Glute muscles help control lower extremity mechanics and support the arch.

Arch support taping should be trialed as well as over-the-counter orthotics, night splints and a change to more supportive shoewear. (Asics, Hoka, etc) Laser treatment may help speed up healing.

With persistent problems, cortisone injection may be discussed with your physician. Activity modification and nutritional and weight loss counseling should be used to decrease the stress on the foot.

Patience is key in this condition as there will be ups and downs as you work to progress your activity levels. It may be a long process but symptoms do resolve so keep your head up!

Posterior Tibialis and Peroneal Tendinopathy

Tendinopathy may occur on the inside of the foot/ankle at the posterior tibial tendon or on the outside at the peroneal tendon. Diagnosis is typically made with palpating along the tendon as it goes around either malleolus to where it inserts at the arch and midfoot. Pain is provoked with plantarflexion (gas pedal) and inversion to the inside (for post tib) or eversion to the outside (for peroneal). The clinician should rule out, among others, anterior ankle impingement, tarsal tunnel syndrome, plantar fasciitis for the inside and sinus tarsi syndrome, peroneal or sural nerve irritation for the outside.

As we've discussed with tendinopathy, progressive loading is the most appropriate treatment, typically completed with a resistance band - plantarflexion with inversion for post tib and with eversion for peroneals. Add a tennis ball between the heels to increase post tib activation with heel raises. Single leg balance is another good way to strengthen these muscle groups, with perturbations to create instability with arm or leg reaches and with changes in the surface or completing the exercise with eyes closed. Both of these tendons are part of the active support system for the midfoot and arch, so reducing stress to this area is important. This is done with intrinsic, calf, and gluteal strengthening as well as with arch support taping, over-the-counter orthotics/insoles and more supportive shoewear.

Laser may be appropriate to speed up healing. In persistent cases, shockwave treatment may be beneficial. If there is severe collapse of the arch, surgical consultation may be warranted. Activity modification and nutritional/weight loss counseling may be helpful.

Lateral Ankle Sprains

Lateral ankle sprains occur when an athlete rolls over the outside of the ankle (plantarflexion and inversion) when landing or changing direction. The primary ligament that gets sprained is the anterior talofibular ligament (ATFL) but may also disrupt the calcaneofibular (CFL) and posterior talofibular ligaments (PTFL) in more severe sprains. The primary concern in more severe injuries is a fracture so the Ottawa ankle rules should be used to determine the need for an x-ray.

The first step is to manage the swelling through the use of NSAIDs (discuss with your doctor), ice, elevation and compression with the use of short-stretch bandages with a horseshoe shaped foam pad to go over the lateral malleolus. A short period of immobilization and non-weightbearing status may be beneficial but should gradually progress out of this to assure the maintenance of range, mobility, and foot and ankle strength.

Early stage rehab should encourage pain-free gait without compensations along with open chain ankle activation and closed chain balance and proprioception exercises. Glute strengthening is important as it helps to provide stability proximally.

Exercises should progress in intensity to bodyweight exercises such as squats and lunges, with balance progressing to eyes closed, with distractions, and or unstable surfaces. Jumping and landing will start with double limb and progress to single limb at faster speeds and eventually simulating sports-specific movements.

Readiness for return to sport should be completed through strength testing with a handheld dynamometer, functional tests such as the Y-balance test or hop tests, and clinical judgment based on performance of sports-specific movement observing both the quality and quantity of movement. An ankle brace may be beneficial in returning to play and in reducing the recurrence of ankle sprains.