Peripheral Nerve Tensioner videos for that irritated nervous system

Below are Tensioner videos for your irritated and sensitive peripheral nerves. Warning: please only do this if your knowledgeable health care provider has taught these and specifically said that you should do these exercises.

Gentler "Slider" movements can be seen at a previous post here: Slider Videos

Median Nerve Tensioner

http://youtu.be/dimiK2GzE6o

Radial Nerve Tensioner

http://youtu.be/uR4BzP61Jvk

Ulnar Nerve Tensioner

http://youtu.be/DE5YwKxIrOY

Sciatic nerve slump tensioner

http://youtu.be/Xy1Lv3FK2Dk

Sciatic nerve long sitting tensioner

http://youtu.be/Wrn0gqDjl5U

 

Persistent pain resources can be found here: Pain resources

Hamstring Tendinopathy: Sample Rehabilitation Program Videos

Audience: Therapists and Patients Purpose: This post is video overview of the sample exercise progression I might advocate for patients (primarily runners) who present with persistent longstanding high hamstring pain.

Background

Runners, particularly faster runners, will often present with high hamstring tendon pain.  The pain is typically felt where the muscles insert into the bottom bone of the hip (the ischial tuberosity).  In addition to the hamstrings the adductor magnus can often be involved.

Patients will feel pain with running (particularly at speed), pain when pulling their shoe off with the foot, often pain with sitting and even some pain getting out of a chair.  When I see these patients they have often had this condition for months or years.

When the pain has been around for months you may want to consider this dysfunction a failed healing response.  Throw the ideas about inflammation out the window.  These patients have rested their leg and even done some remedial exercises but to no avail.

 

The exercise approach is simple – TISSUE RESPONDS TO LOAD.  Injury treatment is the judicious application of stress – applying this stress to an injured tissue is stimulus for adaptation.  This application of stress to the  non-responding tissue (i.e. your hamstrings) can be complimented with all other treatment techniques and assessments.  In addition to applying stress we also want to try the find the cause of the initial hamstring overload (Good luck).  Some possibilities being:

1. Weak glutes

2.  Poor trunk strength/endurance/control

3. Restricted joints anywhere (feet, fibular head, SI joints, Thoracolumbar junction)

4. Excessive anterior tilt while running (motor control or tight passive/active tissues?)

5. Overstriding

6. Understriding and “hanging” on to your hamstrings when running (rare)

7.  The big daddy – too much, too soon, for you at that point in time.

8. Poor tissue quality (sometimes our muscles and tendons just need a little rubbin’ lovin’  e.g. ART, myofascial, Gua Sha, Acupuncture, general massage)

OK, enough lecturing, you are still in pain

My clinical take is that many athletes get issues 1-8 somewhat taken care with usual care. (This assumes it is not crappy run of the mill care where someone sticks ultrasound and a TENS machine on you and then tells you to stretch). After the usual care (which is the non-horrible kind) patients are then given remedial exercises for the hamstrings (stretching, bridges, curls) but they still aren’t responding.

With these recalcitrant cases we often then need to stress the tissue harder (or find the other key link in the dysfunction).  Inspired by the painful eccentric loading protocol’s variable success in tendon pain (a nice review here and here) I choose to ignore some of the eccentric loading exercises alone and also add heavy resistance training.  For my patients, eccentric loading means that you just work a muscle as it gets longer not as it gets shorter.  It is like lowering a weight but never picking it up again.  It never made sense that concentric exercises would negate the benefits of eccentric exercises and why would daily loading be necessary? (Update: I should listened to  Jill Cooke's podcasts (search on itunes if you care), she is an amazing tendon researcher and has been saying this for a long time).  I had good success with heavy resistance training  but did not have any research to support it.  Fortunately, I found some (click here on a comparison of heavy resistance training versus painful eccentric loading), so I can go back in time and support my previous views and say I was evidenced-based(this is definitely some confirmation bias on how I select the papers that I read).

 

Here are some exercises that I often recommend for runners

A warning, don’t do these willy nilly.  Have your therapist or strength and conditioning coach guide you through these exercises and create the appropriate parameters (how much, how often etc).  Not all of these exercises are meant to be done on the same day.  Work with a professional to create a program.  You can also be doing a lot of other exercises for your core or upper body.

If you are my patient and aren’t sure, email me.

Stage One (2 weeks)

Rationale: Train the glutes, get the  hamstrings ready for more load, train the trunk, say hello to the external hip rotators

Bridge Series (Front to Side)

http://youtu.be/nOw87GtKgFY

 

Back Bridge

http://youtu.be/rjNLyGcfV8E

 

Bird Dog

http://youtu.be/xGHusEEYj6U

ClamShell

http://youtu.be/2aVy6sDVa4c

 

Squats with External Rotation

http://youtu.be/Js0JFw7N4QY

 

Perform the squat as seen in the video below but have tubing around both knees.  When squatting down attempt to press the outside of your knees against the tubing.

The squat in the video is not ideal.  You DO NOT want the knees to start the motion.  The first motion is the butt going backwards with the weight through the heels and the balls of the feet.  The squat starts with a bow or a “hip hinge”.

Hip Flexion Drives

http://youtu.be/HfZnPU1-XhI

Put a cable or tubing around your knee.  Drive your knee forward training your hip flexors.  If you can do 15 easily then add more weight.  Try to not let your spine bend forwards or backwards.

Cabled Hip Extensions

http://youtu.be/knovP_bSv4s

This exercise attempts to mimic the function of the hamstrings during running.  The hamstrings and glutes work to pull the swinging leg backwards toward the ground and support your weight during foot strike.  Hamstring strains occur during this phase.  Click on this link for a post about hamstring function during running (click here).

With this exercise you want a cable or tuning tied around your ankle.  You then pull your leg backwards with your butt and hamstring and slowly return your leg back to the start.  Try not to arch your back during this exercise.  Focus on feeling tension in your hamstrings and glutes.  You will also feel this in the leg that is standing on the ground.  For balance it is OK to grab onto something while doing this exercise (it will also take the strain off the leg that is on the ground).

Stage Two Learning Phase(weeks 2-6)

Repetitions: 8 to 12 (2-3 repetitions shy of muscle failure or form breakdown)

Sets: 1-2

 

Bridge Series (Front and Side)

 

Back Bridge Walkouts

http://youtu.be/TsjQOLHupCE

 

Deadlift Learn (light weights)

http://youtu.be/Mp_XwsEGQ-4

 

One Leg Deadlift

http://youtu.be/F8XBCWHJ3FA

 

Hip Airplane

http://youtu.be/0okjZoaSRLA

 

Cabled Hip Extensions

Cabled Hip Flexion

Stage 3 (weeks 6 to 12)

Repetitions: 4 to 8 (1-2 repetitions shy of muscle failure or form breakdown)

Sets: 2-3

Nordic Hamstring Curls

http://youtu.be/BgLDQ83jh7I

 

Bridge Series (Front and Side)

Single Leg Bridge Eccentric Slide Outs

http://youtu.be/8pw-Ek5AxWM

Deadlift

One Leg Deadlift

Hip Airplane

Cabled Hip Extensions

Cabled Hip Flexion

Runner Strength: Basic Exercise Videos for runners

Audience: Patients Purpose: Exercise videos for patients wishing to train their trunk and hips

 

This article is just a video series for runners to do some basic strength work.  Stop worrying about the core.  Just get strong during all movements.  We try to build capacity to withstand load.  We might also improve running efficiency with strength work.  There could probably be thirty different exercises below.  This is not a program just a few suggestions for what can be easily done.  You will notice that there are no exercises that are specifically "core" exercises.  With these exercises you the benefits to training the core can be gleaned from the appropriate choice of compound exercises.

Squat

http://youtu.be/Js0JFw7N4QY

 

One Leg squat

http://youtu.be/ysi8xVcWMcQ

 

Clam Shell

http://youtu.be/M0Hkr7gdqCg

 

Hip Airplane

http://youtu.be/0okjZoaSRLA

 

Deadlift

http://youtu.be/Mp_XwsEGQ-4

One Leg deadlift

http://youtu.be/F8XBCWHJ3FA

 

Hip Flexion against a cable

http://youtu.be/HfZnPU1-XhI

 

Hip Extension Cable Drives

http://youtu.be/knovP_bSv4s

 

 

 

 

Basic Shoulder Movement Videos

Audience: Patients Purpose: Exercise videos for those doing shoulder rehabilitation

Preamble

The same exercises or movements can be used with different intentions and to achieve a different goal.  Some possible intentions being:

1. Motion is Lotion - we are moving your shoulder in a manner just to calm down nerves, decrease pain and get that pissed off shoulder happy with moving again.  The amount of weight or resistance is not that important

2. Stress loading - for whatever reason we want to stress your shoulder and shoulder girdle musculature.  You might have some weakness (e.g. prolonged immobility, post surgical) or we wish to increase the capacity of your joint and muscles to withstand load.  Appropriate weight selection, speed of movement and technique is important

3. Motor control - certainly there is some overlap with the previous two intentions mentioned.  But with this intention we might look at trying to change how your muscles work together.  An example, is training both the internal and external rotator cuff during alternating movements.  We are trying to get the cuff to pull the humeral head away from the scapula or just get the muscles happy working together again.  Load or stress is important but so is learning the movement.

Here we go.  A bunch of videos.

Sidelying External Rotation (for training the rotator cuff and the lower trapezius)

http://youtu.be/2aVy6sDVa4c

Scaption (for training the supraspinatus and the posterior cuff during arm elevation)

http://youtu.be/3fRcgp2-nmM

Unilateral "Y" Exercise on Stomach

http://youtu.be/45tT5CsY7ws

 

Unilateral "T" Exercise

http://youtu.be/0ptjYqn0vbE

 

Unilateral External Rotation

http://youtu.be/N7KkQwL51cY

 

Standing External Rotation with tubing (care of www.mikereinold.com)

http://youtu.be/_G0feLqXA0E

 

 

 

Patellofemoral Pain Syndrome - 2 day exercise program

Audience: Patients Contents: Attached is a pdf of a two day (6 day a week) basic exercise program for someone with patellofemoral pain syndrome.

For therapists, this would obviously be modified for the specific needs of your patients/clients.

 

Program One here: pfps bodymechanic sheet

Program Two Here - hip and knee dysfunction two day program for le dysfunction

Have fun,

Greg Lehman

Your Toronto Physiotherapist

Side Bridge Variation Exercise Sheet - training inside and out.

Purpose: Exercise Sheet handout Attached is a handout for four variations on the sidebridge.  If you do not know what you are doing please speak with a professional before incorporating these into  your strength and conditioning program.

HERE IS THE FULL SHEET IN PDF: side bridge variations sheet

Shoulder Impingement Rehabilitation: Part One

Audience: Health Professionals and Patients Source of Information: Paula Ludewig, Ben Kibler, Ann Cools, Rafael Escamilla, Mike Reinold, Kevin Wilks

Disclaimer: The information below really just scratches the surface.  References at the end of post are excellent.  The point of this post is to get people to think more about culprits of dysfunction when it comes to the shoulder rather than just labeling shoulders with victim diagnoses (e.g. bursitis, tears, "tendinitis" - I hate that word - a future post will address my disdain).

Shoulder Impingement is not a diagnosis.  It is a finding and can be both a cause and the result of dysfunction.  Impingement is pretty much what it sounds like - something is getting pinched.  Ever reach into your back seat or reach to put your coat on and feel a sharp pain somewhere around your shoulder (and often down to your elbow).  That is impingement.  Some structure under the shoulder blade is getting pinched and does not like it.  Who likes to get pinched?

I crudely categorize  shoulder impingement into two categories (although they can be split to a greater extent as well) - 1. Internal impingement and 2. External Impingement.

Internal Impingement - what is pinching?

  • rotator cuff muscles (Supraspinatus and Infraspinatus) get pinched against the upper-back (and even the upper front) portion of the Glenoid/Labral complex during shoulder abduction and external rotation.  This is essentially the position of throwing or reaching to put your coat on.
  • less commonly, the subscapularis muscles (an internal rotator cuff muscle) can get pinched between the corocoid process and the lesser tuberosity of the humerus

External Impingement - what is pinching?

  • pinching of the rotator cuff tendons or long head of the biceps brachii on any part of the coracoacromial arch (i.e. the underside of the front of the shoulder blade).  This arch consists of the coracoacromial ligament, the acromial undersurface and the undersurface of the AC joint.

The aim of treatment - Stop the pinching stupid.

The end goal of treatment is simple.  Get the surfaces that are pinching each other out of each other's way.  When my 3 year old pushes over my 10 month old I don't leave them beside each other.   With impingement treatment we are trying to make space -   Space can be made in two ways:

1. Get the arm bone out of the way (some will call this joint centration) by optimizing rotator cuff function.

2. Get the shoulder blade out of the way.  We will try to put the shoulder blade in an optimal position.

How do we make space?

I typically use a lot of manual therapy.  An extensive amount of my modified Active Release Technique, gentle trigger point holds, contract-relax, PIR, spine manipulation, A-P mobilizations etc.  I tend to treat any structure that can influence the shoulder and less scientifically, "feels not normal".  Because that is a lot of the  magic of manual therapy - we do a subjective evaluation of tissue texture, "vitality", robustness, springiness, ropeyness, "adhesions" etc and work those areas.  I will treat all "faulty" tissue that attaches to the shoulder, the neck and the back.  Ultimately, I believe that I am influencing the nervous system to modulate pain and change muscle recruitment.

One caveat, I tend to avoid stretching the front of the shoulder.  I kept seeing weight lifters (i.e. bench pressers) with internal impingement but they thought they were protected because of stretching the crap out of the front their shoulder and then busting out a deep bench press.  Avoid this please.  This may cause anterior laxity which then allows the the humeral head to translate into a pinching position.

But Manual Therapy is just the start:

In order to make long lasting change we need to change how the shoulder complex functions.  It is through rehabilitation exercises (both supervised/corrected and at  home) that we can essentially teach the shoulder and spine musculature to again work like the good team that they are and stop the pinching.  Because it is often the loss of teamwork that is the problem.  A shoulder might have an incredible amount of strength but certain positions or movements cause an equally incredible amount of pain.  Lots of strength does not equal a healthy shoulder.  What is mostly likely happening is that something is wrong with how the body moves and optimal body movement is a result of good teamwork by the muscles.

Below is a quick overview of some components of the rehabilitation regime.  Part two of the post will delve a great deal into the science and research behind appropriate exercise prescription.

Overview of elements that might be incorporated (if needed)

1. Check and train spine stability - people should be doing lower spine exercises so why not introduce McGill's big three or some other program for the spine that you like.

2. Stretch pectoralis minor (this might lead to decreases in anterior tilting of scapula to make more space underneath and has been shown to be associated with improvements in pain)

3. Check and treat deep neck flexor inhibition (perhaps the patient is using the superficial neck muscles excessively which then anteriorly rotates the scapula or inhibits movement of the clavicular - again this can decrease space.  **Please note, I don' t think there is any research (despite the almost universal acceptance of the upper crossed syndrome) on this but it is not unreasonable to  think that alterations in how the neck moves can negatively affect how the shoulder blade moves.

4. Teach the external and internal rotator cuff muscles to "play catch" with one another.  One theory on dysfunction is that the rotator cuff no longer works as a team and then no longer centres the arm bone under the shoulder blade.  Working the arm in external and then internal ranges can facilitate these muscles.  Follow this with...

5. External rotator cuff strengthening at neutral first and then all ranges of elevation.

6. Posterior capsule stretching (e.g. sleeper stretch, cross body adduction).

7. Serratus anterior strengthening

8. Scapular positioning exercises (learning how to move the scapula into different positions - up, down, back, forward)

9. Teach diaphragmatic breathing (Why not, everything is connected)

A future post will explore in much greater detail shoulder rehabilitation exercises.  This next post will focus much on the work of Ann Cools, Mike Reinold (www.mikereinold.com), Paula Ludewig and Rafael Escamilla.  I take no ownership of the research - I am just an early adopter and respect the science and thought behind their exercise prescriptions.

UPDATE: As goes with the internet there is a tonne of redundancy.  Please see the following link from Mike Reinold who made a great post on impingement way back last year and way before me.  Dr Reinold is also involved in the research attempting to understand shoulder pathology so it is nice and prudent to go to a primary source. http://www.mikereinold.com/2010/11/shoulder-impingement-3-keys-to.html

References

1. Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther. 2011 Feb;16(1):33-9.

2. Cools AM, Cambier D, Witvrouw EE.Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J Sports Med. 2008 Aug;42(8):628-35. Epub 2008 Jun 3. Review

3. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Review.

4. Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A.Scapular Summit 2009: introduction. July 16, 2009, Lexington, Kentucky. J Orthop Sports Phys Ther. 2009 Nov;39(11):A1-A13. Review.

5. Escamilla RF, Yamashiro K, Paulos L, Andrews JR.Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Med. 2009;39(8):663-85. Review.