Shoulder anatomy: -

The shoulder joints consist of several bony joints or “articulation” which conne
ct the upper limb to the rest of the skeleton and provide a large range of movem
ent. The three bones which forms the shoulder girdle are clavicle, scapula and t
he humerus.
The three main joints of the shoulder girdle are –
• Glenohumeral joint.
• Acromioclavicular joint.
• Sternoclavicular joint.
It is also important to consider one more joint which is important for functioni
ng of shoulder is:
• Scapulothoracic joint.

The scapula
This bone is quite complex and is an attachment site for numerous muscles which
supports movement and stabilization of the shoulder. It overlies 2nd – 7th rib a
nd is tilted forward by an angle of 30 degree, and is encased by 17 muscles whic
h provides control and stabilization against the thoracic wall (the rib cage). T
his is referred to as the scapulothoracic joint and it is only a functional join
t.
The Clavicle
The clavicle is an S shaped bone and is the main connection between the upper ar
m and rest of the axial skeleton the clavicle is also an important site for musc
le attachment.
Shoulder joint: -
The glenohumeral joint is a multiaxial, ball-and-socket, synovial joint which pr
ovides three degree of movement at shoulder joint.
The glenoid cavity is a shallow socket and is inherently unstable. The additiona
l stability is provided by static constraints – the glenohumeral ligaments, glen
oid labrum and capsule – and dynamic constraints, predominantly the rotator cuf
f and scapular stabilizing muscle.
Ligaments of shoulder joint: -
Muscles of shoulder joints
Tha acromio clavicular joint
This joint is formed by the lateral end of clavicle articulating with the medial
aspect of the acromian. The acromioclavicular joint is important in transmittin
g forces through the upper limb and shoulder to the axial skeleton. This joint h
as minimal mobility due its supporting ligaments.
• Acromioclavicular joint ligament which is composed of strong superior (t
op) and inferior ligaments(bottom), weak anterior (front) and posterior (back) l
igaments restricting anterior- posterior (forward and backwards) movement of the
clavicle on the acromian.
• Coracoclavicular ligament is composed of the conoid and trapezoid ligame
nts. It forms a strong heavy band to prevent vertical movements.
The Sternoclavicular joint
The sternoclavicular Joint occurs end of the clavicle, the cartilage of the firs
t rib, and the upper and lateral parts of the manubrium sterni (the upper part o
f the sternum).
This joint functions in all movements of the upper limbs, and is particularly im
portant in throwing and thrusting movements.
The scapulothoracic joint: -
This joint relies entirely on the surrounding musculature for its control. The m
ain muscles which control this joint are:
• Serratus anterior which holds the medial (inside) angle of the scapula a
gainst the chest wall.
• Trapezius which rotates and elevates the scapula with elevation (lifting
up) of the upper arm.
During the elevation the glenohumeral joint rotates 2degree for every 1 degree o
f scapulothoracic rotation.
Clinical perspective: -
Because there are numerous structures that can cause the shoulder pain which can
be scheduled in following five categories: -
1. rotator cuff musculature
2. instability
3. stiffness
4. AC joint
5. referred pain.
Examination
A complete examination involves
1. observation.
• Front.
• Behind.
• Lateral side.
2. Active movements.
• Arm elevation – watch scapular motion and position.
• External rotation with elbows at side
• External rotation at 90 degree of abduction.
• Internal rotation.
• Horizontal flexion.
3. passive movements.
• As above
• Accessory movements.
4. resisted movements
• shoulder flexion.
• Shoulder extension.
• Abduction and adduction of the shoulder.
• Lateral and medial rotation of the shoulder.
• Flexion of elbow.
• Extension of the elbow.
• Subscapularis lift off test.
• Deltoid.
• Supraspinatus.
• Biceps- Speed’s test.
• Biceps- Yergason’s test
5. Palpation
• Clavicle.
• SC joint.
• AC joint
• Coracoid process.
• Sternum.
• Ribs and costal cartilage.
• Shoulder joint
• Rotator cuff tendon
• Bicipital groove
• Rotator cuff muscle
• Periscapular muscles and anterior coracoid muscle
• Axilla.
• Cervicobrachial muscle.
• Scapula.spine processes of lower cervical and upper thorasic vertebra.
6. special test
• instability test
• impingement test
• scapular stability test.
• Muscle tendon pathology test.
• Thoracic outlet test.
7. A rapid examination.
• Observation from front and back
• Palpation of AC joint and its test.
• Palpation of the bicipital groove.
• Passive external rotation.
• Impingement sign in internal and external rotation and with the scapular
assistance test.
• Power of external rotation and of the supraspinatus.
• Crank test for SLAP lesion – scapula – stabilized glenohumeral internal
rotation deficit.
• Apprehension, augmentation, relocation sign if suspected instability.
8. Joint play movements.
• Backward glide of the humerus
• Forward glide of the humerus
• Lateral distraction of the humerus.
• Long arm traction.
• Backward glide of the humerus in abduction.
• Anteroposterior and cephalocaudal movements of the clavicle at the AC jo
int.
• Anteroposterior and cephalocaudal movements of the clavicle at the SC jo
int.
• General movement of the scapula to determine the mobility.

Common Shoulder Disorders

Thoracic Outlet Syndrome
Thoracic outlet syndrome results when there is compression of the neurovascular
structures that are located in the neck. Symptoms of thoracic outlet syndrome in
clude shoulder or arm pain, tingling or numbness (paresthesias), and varying deg
rees of muscle weakness.
• Frozen Shoulder
Frozen shoulder, or adhesive capsulitis, is a medical condition that involves pr
ogressive pain and loss of motion in the shoulder joint. The exact cause of froz
en shoulder is not known, but it is more common in females than males. Frozen sh
oulder results from a thickening and shortening of the capsule that surrounds th
e shoulder joint.
• Biceps Tendonitis
The biceps muscle in a large muscle in the arm that works to bend the elbow as w
ell as elevate the shoulder. This muscle is connected to the bones above and bel
ow the arm by a thick strong tendon. Biceps tendonitis results in a painful sens
ation at the upper shoulder that occurs with movement of the arm.
• Shoulder Separation
A shoulder separation injury involves a disruption of the acromioclavicular (AC)
joint. The most common cause of shoulder separation, or AC joint disruption, is
a direct fall onto the shoulder. This fall injures the tendons that provide sta
bility to the joint.
• Bicep Tendon Rupture
Rupture of the bicep tendon occurs when the tendon becomes frayed under the shou
lder joint. This results when the tendon is placed under friction during repetit
ive movement of the arm. Symptoms of biceps tendon tears include sudden sharp pa
in, as well as tenderness to touch in the upper shoulder region.
The rotator cuff is comprised of four muscles. These individual muscles combine
at the shoulder to form a thick "cuff" over the joint. The rotator cuff has the
important job of stabilizing the shoulder as well as elevating and rotating the
arm. Due to the location of the muscle tendons under the bony structures of the
shoulder joint, they are at increased risk of injury. Rotator cuff tears make up
the majority of rotator cuff disorders. For partial tears, conservative managem
ent, such as physical therapy, can be utilized. Occasionally the tear is too sev
ere and surgical repair is required.
Rotator Cuff injury
The rotator cuff is a group of muscles which work together to prove the glenohum
eral joint with dynamic stability, helping to the joint during rotation
Four muscles form the rotator cuff. These are the:
• Supraspinatous
• Infraspinatous
• Teres Minor
• Subscapularis
The mnemonic “SITS” is often used to refer to these muscles.
Problems with rotator cuff muscle can be classified in to two categories
1. Tears of the tendons muscles.
2. Inflammation of the structures in the joint
Acute Tear
This tends to happen as a result of sudden, powerful movement. This might includ
e falling over on to an out starched hand at speed. The symptoms will usually in
cludes,
• Sudden tearing feeling in the shoulder, followed by a severe pain throug
h the arm.
• Limited movement of the shoulder due to pain or spasm.
• Severe pain for few days which usually resolves quickly.
• Specific tenderness (“X marks the spot”) over the point of rupture / tea
r.
• If the tear is severe, you will not be able to abduct your arm.

Chronic Tear
• Usually found on the dominant side
• More often an affliction of the 40+ age group
• Pain is worst at night and can affect sleeping
• Gradual worsening of pain, eventually some weakness.
• Eventually unable to abduct arm (lift out to the side) without any assis
tance or do any activities with the arm above the head.
• Some limitation of other movements depending on the tendon affected.
Inflammation
• More common in women aged 35-50
• Characteristic ache in the shoulder which feels like it is coming from “
deep inside”
• Tenderness over particular areas, less specific than a tear
• Usually a gradual onset of pain, which “flares up” if using the arms ove
r the head or out to the side
• Can sometimes lead to a chronic tear if untreated
Seek medical attention if:
• The pain persist for more than 2-3 days
• Unable to perform ADL
• Unable to reach up or the side with the affected arm after 2-3 days
• Unable to move the shoulder and arm at all
Assessment of shoulder for rotator cuff injury
• Empty Can Test
• Drop arm test
• Abrasion sign
• Neer’s sign
• Hawkin’s- kennedy test
Treatment
• Rest the shoulder
• Ice can be used at least three times a day and is useful for first coupl
e of days following an injury. Apply ice for no more than 15-20 minutes.
• Warmth may be used after the first few days to help with the pain
• Medication may be helpful to control the pain.
For acute rotator cuff tear
• Apply ice to reduce swelling
• Control pain with appropriate medication
• Rest the arm- a sling can be useful while working, which can be removed
at night.
• Consider a consulting physiotherapist who can assist for proper rehabili
tation.
Causes:
• Repetitive overhead activities.
• Direct trauma from falling on to the shoulder.
• Lifting of heavy objects.
• The injury is also common among people whose jobs or hobbies place heavy
demands on their shoulders.
• Poor posture, especially forward shoulders, can also contribute to rotat
or cuff injury.
Symptoms:
Signs and symptoms of rotator cuff tears include:
• Recurrent, constant pain, particularly with overhead activities
• Pain at night that prevents you from sleeping on the injured side
• Muscle weakness, especially when attempting to lift the arm
• Catching or cracking sounds when the arm is moved
• Limited shoulder motion
Management:
Treatment of rotator cuff tears include conservative measures, such as physical
therapy to strengthen the muscles. Occasionally, the tear is too extensive and s
urgical intervention is necessary.
Impingement syndrome
Impingement syndrome, which is sometimes called Swimmer’s shoulder or thrower’s
Shoulder, is caused by the tendons of the rotator cuff (supraspinatus, infraspin
atus, teres minor and subscapularis muscle) becoming irritated or inflamed as th
ey pass through a narrow bony space called the Subacromial space.
This can lead to thickened of the tendon which may cause further problembecause
there is very little free space, so as the tendons become larger, they are impin
ged further by the structures of the shoulder joint and the muscles themselves.
Classification:-
1. External impingement, which can be either primary or secondary.
Primary
• Is usually due to bony abnormality in the shape acromial arch.
• Can sometimes due to congenital abnormalities (known as os acromiale), o
r due to degenerative changes, where small spurs of bone grow out from the arch
with age, and impinge on the tendons.
Secondary
• Usually due to poor scapular stabilization which alters the physical pos
ition of the acromian, hence causing impingement on the tendons.
• Is often due to weak stress anterior and tight pectoralis minor muscles.
• Other causes can include weakening of the rotator cuff tendons due to ov
eruse (e.g. throwing and swimming) or muscular imbalance with the deltoid muscle
and rotator cuff muscles.
2. Internal impingement
• Occurs predominantly in athletes where throwing is the main part of the
sport.
• The under side of the rotator cuff tendons are impinged against the glen
oid labrum – this tends to cause pain at the back of shoulder joint as well as s
ometimes at the front.
Symptoms
External impingent symptoms
Primary
• Pain at the front and/or side of the shoulder joint with overhead activi
ties such as throwing and front crawl swimming.
Secondary
• Pain at the front and/or side of the shoulder joint with overhead activi
ties such as throwing and front crawl swimming.
Internal impingement symptoms
• Pain at the back and/or side of the shoulder joint when the arm is held
out to the side (abducted) and turned outwards (external rotation)
Treatment
• Rest.
• Apply ice or cold therapy for 10- 15min for 2 hour period.
• Short term immobilization.
• Prescribe anti inflammatory medicine such as ibuprofen or other NSAIDS
• Advice on rehabilitation programmes.
• Discuss the options of directly injected steroids into the subacromial
space to reduce inflammation in the local area.
• Surgery in case which have failed conservative rehabilitation efforts –u
sually after a period of atleast 6 to 12 months.

Thoracic Outlet Syndrome

Thoracic outlet syndrome results when there is compression of the neurovascular
structures that are located in the neck. These neurovascular structures include
the brachial plexus, subclavian artery, and subclavian vein.
Symptoms: Symptoms of thoracic outlet syndrome include shoulder or arm pain, par
esthesias and varying degrees of muscle weakness. Other symptoms that result fro
m vascular compression include claudication or ischemic tissue loss.
Areas of Compression: Three areas of neurovascular compression in thoracic outle
t syndrome are as follows:
1)Between the middle and anterior scalene muscles
2)Between the clavicle and the first rib
3)Between the pectoralis minor muscle and the rib cage
Frozen Shoulder
Frozen shoulder, or adhesive capsulitis, is a medical condition that involves pr
ogresive pain and loss of motion in the shoulder joint. The exact cause of froze
n shoulder is not known. However, it is more common in females than males. The p
rocess of frozen shoulder results from a thickening and shortening of the capsul
e that surrounds the shoulder joint.
Who does it affect?
Is extremely uncommon amongst young people,aand is almostn always found in the f
orty plus 40 + age group, usually in the 40- 70 age range.
What causes frozen a shoulder?
There are two classification of frozen shoulder syndromes:
• Primary- no significant reason for pain/ stiffness
• Secondary- as a result of an event such as trauma, surgery or illness
It is not known exactly what causes this problem, however it is thought that the
linning of the joint (the capsule) becomes inflamed, which causes scar tissue t
o form. This leaves less room for the humerus to move, hence restricting the mov
ements of the joint.
The increased prevlance is amongst the diabetics.
Hormonal changes may be responsible for thehigher incidence amongst the women.
Poor postures may also lead to frozen shoulder.
Frozen shoulder Symptoms: The hallmark symptoms of frozen shoulder include pain
located along the shoulder joint and restricted motion. Shoulder range of motion
is limited in both the active and passive phases. This condition has been descr
ibed in three phases, so the symptoms will differ depending on the phase of the
condition.

The painful phase Stage One- The Freezing Stage

• Gradual onset of aching shoulder
• Developing widespread pain, often worst at night and when lying on the a
ffected side.
• This phase can anywhere between 2-9 months.
The stiffening phase
• Stiffness start to become a problem
• Pain level usually does not alter
• Difficulty with normal daily tasks such as dressing, preparing food, car
rying bags, working.
• Muscle wastage may be evident due to lack of use.
• This stage can last between 4-12 months
The thawing phase
• Gradual improvement in ROM.
• Gradual decrease in pain, although it may reappear as stiffness eases.
• This stage can last between 5-12 months.
What can the patient do?
• Seek medical advice, as early intervention can prevent severe stiffness.
• Follow advice given by medical professional.
• Try to keep the shoulder moving- even if it is just small pendular movem
ents.
What can the therapist/ physician do?
This condition is usually managed conservatively, with surgery as a last measure
if all other attempts fail
• Arrange a course of physiotherapy.
• Oral steroids and/or anti inflammatory medication to reduce inflammation
• Direct injection of steroid medication into the joint to reduce inflamma
tion
• Never block – a short term pain relief option, which is usually very eff
ective
• Surgery if the above fails
What does surgery involve ?
• Surgery maybe performed in some cases, following failure of conservative
treatment method
• Arthroscopic capsular release is the technique used most ofen
• This involves dividing the thickened shoulder capsule.
• Surgery is followed by an aggressive rehabilitation protocol which must
be adhere too.

What is the likely outcome?

• Most cases will resolve on there own or with physiotherapy over a 1-3 ye
ars period.
• Surgery is advised only to those who have improved with conservative tre
atment.
Supraspinatus Muscle
It runs along the top of the scapula and inserts at the top of the arm or humeru
s. This muscle is used to lift the arm up sideways adduction and is also importa
nt in throwing sports as it is the muscle that holds the arm in the shoulder joi
nt when you release what you are throwing.
There are massive forces involved in slowing the arm down after you have th
rown something but few people bother to train these muscles. A heavy fall onto t
he shoulder can also result in injuring this muscle. Injury can occur to the ten
don as it inserts into the top of the shoulder on the humerus.
Inflammation of the supraspinatus tendon - Rehabilitation, mobility, strengtheni
ng.
What is the supraspinatus tendon?
The supraspinatus muscle runs along the top of the shoulder blade and inserts vi
a the tendon at the top of the arm (humerus bone). This muscle is used to lift t
he arm up sideways and is also important in throwing sports as it is the muscle
that holds the arm in the shoulder when you release what you are throwing. There
are massive forces involved in slowing the arm down after you have thrown somet
hing but few people bother to train these muscles. A heavy fall onto the shoulde
r can also result in injuring this muscle.
Symptoms of an inflammed supraspinatus include:
• Pain and weakness when the arm is lifted up sideways through a 60 degree
arc when rotated outwards.
• Pain when you press in at the inside front of the upper arm.
• If it is the tendon that is injured rather than the bursa you are likely
to get more pain when the arm is lifted sideways against resistance.

Biceps Tendonitis
The biceps muscle splits into two tendons at the shoulder. A long one and a shor
t one. The long tendon runs over the top of the humerus bone (upper arm) and att
aches to the top of the shoulder blade. A rupture of this tendon is rare in youn
g athletes but more common in older ones.
The Biceps muscle. The longer tendon on the right goes over the top of the humer
us.
Symptoms:
• A sudden sharp pain at the front of the upper arm.
• Pain and swelling over the front of the shoulder joint.
• You will be unable to contract the biceps muscle against resistance beca
use of pain (certainly in the first couple of days after injuring it).
• Pain on resisted shoulder flexion with straight arm.
Shoulder Separation
A shoulder separation injury involves a disruption of the acromioclavicular, AC,
joint. This joint is composed of the collar bone, or clavicle, and the highest
portion of the shoulder blade, the acromion of the scapula. These two bones meet
on top of the shoulder and form the acromioclavicular joint as mentioned above.
The most common cause of shoulder separation, or AC joint disruption, is a direc
t fall onto the shoulder. This fall injures the tendons that provide stability t
o the joint. The laxity that results allows a degree of separation between the a
cromion and clavicular bones. The degree of separation can range from mild to se
vere with a noticeable deformity.
Treatment of this condition can vary from conservative management with a period
of immobility followed by gentle shoulder strengthening, to surgery.
The AC joint is short for the acromioclavicular joint. Separation of the two bon
es forming this joint is caused by damage to the ligaments connecting them. It i
s sometimes also referred to as a shoulder separation injury.
The acromioclavicular joint is formed by the outer end of the clavicle (collar b
one) and the acromion process of the scapular (shoulder blade). The acromion is
a bony process which protudes forwards from the upper part of the scapular. This
joint forms the highest part of the shoulder.
Symptoms include:
• Pain at the end of the collar bone
• Pain may feel widespread throughout the shoulder until the initial pain
resolves, following this it is more likely to be a very specific site of pain ov
er the joint itself
• Swelling often occurs
• Depending on the extent of the injury a step-deformity may be visible. T
his is an obvious lump where the joint has been disrupted and is visible on more
severe injuries.
• Pain on moving the shoulder, especially when trying to raise the arms ab
ove shoulder height.
Shoulder dislocation
Shoulder dislocation is a very common traumatic injury across a wide range of sp
orts. In most cases, the head of the humerus (upper arm bone) is forced forwards
when the arm is turned outwards (externally rotated) and held out to the side (
abducted). This causes an anterior dislocation, which make up approximately 95%
of dislocations.
Dislocations can also be posterior, inferior, superior or intra thoracic, althou
gh these are very rare and can cause a number of complications and extensive dam
age to surrounding structures. Posterior are the second most common form of disl
ocation, although still only account for around 3% of shoulder dislocations. The
se can occur during seizures and when falling onto an outstretched hand.
The shoulder joint is particularly prone to dislocations due to its high mobilit
y, which sacrifices stability. It is the most commonly dislocated joint, with el
bow, knee, finger and wrist dislocations occurring far less regularly.
Although some consider this to be a minor injury, most shoulder dislocations cau
se tears to the glenoid labrum – the ring of cartilage which deepens the glenoid
fossa and acts as a cup, in which the humerus rests, forming the Glenohumeral (
or shoulder) joint – which can cause an injury known as a Bankart Lesion, and ma
y even cause a fracture to the attached bone (a Bony Bankart Lesion). There may
also be damage to the surrounding ligaments, tendons, nerves, blood vessels and
fractures to other bones.
Shoulder dislocations commonly become a reoccurring problem, with many people le
arning how to reduce them themselves. This is only the case in those with highly
unstable glenohumeral joints. A thorough rehabilitation program can help most i
ndividuals to prevent the shoulder repeatedly dislocating.
Symptoms of a dislocated shoulder:
• The injury is usually acute, caused by direct or indirect trauma such as
a fall or forced abduction and external rotation.
• There is a sudden onset of severe pain, and often a feeling of the shoul
der popping out .
• The shoulder will often look obviously different to the other side, usua
lly loosing the smooth, rounded contour.
• The patient will usually hold the arm close into their body and resist a
bducting and externally rotating the shoulder.
• If there is any nerve damage there may also be pins and needles or numbn
ess through the arm to the hand.
• There is usually quite severe pain associated with a dislocation.
Post Operative Shoulder Rehabilitation Program
A thorough post operative exercise program is essential for adequate recovery af
ter shoulder surgery. Muscle weakness and stiffness of the shoulder joint result
too often due to delayed initiation of a rehabilitation program. As a result, i
t is essential to incorporate a strengthening and stretching exercise routine as
soon as possible after surgery. Making this a priority will maximize your recov
ery. Below a complete post operative shoulder rehabilitation program is reviewed
. The program should be performed three times a day. However, you should discuss
when it is appropriate to begin rehabbing your shoulder with your physician bef
ore starting any exercise regimen.
Stretching Exercises
• Pendulum Exercise:
1) Bend over at the waist letting the affected arm hang down at your side.
2) Sway your body back and forth using the weight of the arm and gravity to gene
rate small circles at the surgical shoulder.
3) Use this technique to move your arm in clockwise and counter-clockwise circle
s.
• Wand Exercise:
Flexion: Stand upright and hold a stick in both hands, palms down. Stretch your
arms by lifting them over your head, keeping your elbows straight. Hold for 5 se
conds and return to the starting position.
Extension: Stand upright and hold a stick in both hands behind your back. Move t
he stick away from your back. Hold the end position for 5 seconds. Relax and ret
urn to the starting position.
External rotation: Lie on your back and hold a stick in both hands, palms up. Yo
ur upper arms should be resting on the floor, your elbows at your sides and bent
90 degrees. Using your good arm, push your injured arm out away from your body
while keeping the elbow of the injured arm at your side. Hold the stretch for 5
seconds.
Internal rotation: Stand upright holding a stick with both hands behind your bac
k. Place the hand on your uninjured side behind your head grasping the stick, an
d the hand on your injured side behind your back at your waist. Move the stick u
p and down your back by bending your elbows. Hold the bent position for 5 second
s and then return to the starting position.
Shoulder abduction and adduction: Stand upright and hold a stick with both hands
, palms down. Rest the stick against the front of your thighs. While keeping you
r elbows straight, use your good arm to push your injured arm out to the side an
d up as high as possible. Hold for 5 seconds.
Horizontal abduction and adduction: Stand upright and hold a stick in both hands
. Place your arms straight out in front of you at shoulder level. Keep your arms
straight and swing the stick to one side, feel the stretch, and hold for 5 seco
nds. Then swing the stick to the other side, feel the stretch, and hold for 5 se
conds.
Strengthening Exercises
• Rotator Cuff Exercises
Exercise One: Lie on your stomach on a table or a bed. Put one arm out at should
er level with your elbow bent to 90 degrees and your hand down. Keeping your elb
ow bent, slowly raise your hand. Stop when your hand is level with your shoulder
. Lower the hand slowly.
Exercise Two: Lie on your side on a bed or the floor. Place your upper arm at yo
ur side with your elbow bent to 90 degrees, and your forearm resting against you
r chest, palm down. Rotate your shoulder out, raising your forearm until it is l
evel with your shoulder. Lower the hand slowly.
Exercise Three: Stand with your arms slightly behind you with both thumbs down.
Raise your arms up, pretending that you are emptying a can with each hand. Lower
the arms slowly
Performing these exercises three times a day will help improve shoulder strength
and range of motion after undergoing an operative procedure. Remember to apply
ice to the affected shoulder after performing the exercise routine. Stop any exe
rcise if significant pain or discomfort is felt.

1) Bend over at the waist letting the affected arm hang down at your side.
2) Sway your body back and forth using the weight of the arm and gravity to gene
rate small circles at the surgical shoulder.
3) Use this technique to move your arm in clockwise and counter-clockwise circle
s.
Isometric Exercises
When performing isometric exercises, a muscle contraction is sustained without m
ovement of the joint.
1. Stand sideways along a wall with your elbow at a 90 degree angle
2.
Position the outside of your forarm against the wall.
3.
Press into the wall, contracting your muscles. (however, you will not move your
shoulder)
4.
Hold for 5 seconds and repeat X 5
5.
Turn 180 degrees and position the inside of your forearm against the wall
6. Repeat steps 2-5
Passive Range of Motion Exercises
Passive range of motion exercises are performed with someone else actively movin
g the affected shoulder. Assistance from your physical therapist to move the sho
ulder in all motions should be performed.
Resisted Range of Motion Exercises
These exercises are typically not performed until 3 - 4 weeks post arthroscopy.
To perform these exercises the shoulder should be moved through flexion, extensi
on, abduction, and internal/external rotation against resistance provided by ela
stic tubing or light weights. Perform each motion five times.
Shoulder Rehabilitation Exercise Program
A thorough post operative exercise program is essential for adequate recovery af
ter shoulder surgery. Muscle weakness and stiffness of the shoulder joint result
too often due to delayed initiation of a rehabilitation program.
A comprehensive program should include such exercises:
STRETCHING EXERCISES:
STRENGTHENING EXERCISES:
Proper Stretching Techniques
It is essential to practice proper stretching techniques. Doing so will allow yo
u to avoid any unnecessary injury. Incorporate these seven steps in your stretch
ing regimen:
• Warm up first
• Hold each stretch for at least 30 seconds
• Don t bounce
• Focus on a pain-free stretch
• Relax and breathe freely
• Stretch both sides
• Stretch before and after activity
•
Rotator Cuff Strengthening Exercises
The rotator cuff consists of a group of four muscles that help lift your arm and
rotate it away from your body. These muscles also move the head of the shoulder
bone during elevation of your arms.
Unfortunately, the muscles are prone to inflammation and tears during overhead a
ctivities. An important way to reduce tears is by strengthening these muscles. T
he exercises below will show you how to strengthen the muscles of your rotator c
uff.
Exercise One:
• Lie on your stomach on a table or a bed
• Put one arm out at shoulder level with your elbow bent to 90 degrees and
your hand down
• Keeping your elbow bent, slowly raise your hand
• Stop when your hand is level with your shoulder
• Lower the hand slowly
• Repeat 10 times
• Perform with opposite arm

Exercise Two:
• Lie on your side on a bed or the floor
• Place your upper arm at your side with your elbow bent to 90 degrees, an
d your forearm resting against your chest, palm down
• Rotate your shoulder out, raising your forearm until it is level with yo
ur shoulder
• Lower the hand slowly
• Repeat 10 times
• Perform with opposite arm
Exercise Three:
• Stand with your arms slightly behind you with both thumbs down
• Raise your arms up, pretending that you are emptying a can with each han
d
• Lower the arms slowly
• Repeat 10 times
The nice thing about these exercises are that you can do them by yourself and ca
n adjust your rate of progress according to what is most comfortable for you. Th
e series proceeds in small steps. Start by lying on your back, grasping a bar wi
th both hands together. Push the bar straight up toward the ceiling. At the end
of each push, lift your entire shoulder off the bed or floor. When you can do th
is 20 times easily, separate your hands an inch or so when you push the cloth to
ward the ceiling. This places slightly more of the load on the muscles of your w
eaker shoulder. As the exercise gets easier, separate your hands more on the was
hcloth until you can push your hand toward the ceiling without any assistance fr
om the opposite arm. Practice this exercise with nothing in your hand until you
are able to repeat it 20 times. Then take an empty pint container and perform th
e same movement, pushing it toward the ceiling. Add water to increase the resist
ance slowly. When the container is full of water, the weight is about one pound.
Make sure that with each press-up you end by lifting your shoulder blade up off
the bed or floor. Be sure that you can perform the movement comfortably 20 time
s at each stage before advancing to the next stage. When you can press one pound
toward the ceiling 20 times, the next step is to perform the exercise with your
back propped up slightly on pillows or by using a recliner or garden chair. Whe
n 20 comfortable repetitions are possible, increase the degree to which your bac
k is propped up. At each level, push the shoulder all the way up: "press plus".
Continue this process until you are able to push the one pound weight 20 times t
oward the ceiling in a sitting position. Work for smooth, slow, controlled motio
ns. This program optimizes the mechanics of your shoulder and gives you the best
chance of regaining good function. You should add other strengthening exercises
as your shoulder permits.
ARTHROSCOPIC ROTATOR CUFF REPAIR
REHABILITATION PROTOCOL
RANGE OF
MOTION IMMOBILIZER THERAPEUTIC EXERCISE
PHASE I
0 - 4 weeks Passive range only – to tolerance - maintain elbow at or anterio
r to mid-axillary line while supine – limit internal rotation at 90° to 40° and
behind back to T12 Sling with supporting abduction pillow to be worn at all
times except for hygiene and therapeutic exercise Codman s, Pendulum Exerc
ise, elbow/wrist/hand ROM grip strengthening, isometric scapular stabilization
PHASE II
4 - 8 weeks 4-6 weeks: Gentle passive stretch to 140° of forward flexion, 40
° external rotation at side, and abduction to 60- 80° - increase internal rotati
on gently at 90° to 60° and behind back to T7-T8.
6-8 weeks: increase ROM to tolerance None 4-6 weeks: begin gentle active a
ssistive exercises (supine position), begin gentle joint mobilizations (grades I
and II), continue with phase I exercises
6-8 weeks: progress to active exercises with resistance, shoulder flexion with
trunk flexed to 45 degree in upright position, begin deltoid and biceps strength
ening*
RANGE OF
MOTION IMMOBILIZER THERAPEUTIC EXERCISE
PHASE I
0 - 4 weeks Passive range only – to tolerance - maintain elbow at or anterio
r to mid-axillary line while supine – limit internal rotation at 90° to 40° and
behind back to T12 Sling with supporting abduction pillow to be worn at all
times except for hygiene and therapeutic exercise Codman s, Pendulum Exerc
ise, elbow/wrist/hand ROM grip strengthening, isometric scapular stabilization
ARTHROSCOPIC ANTERIOR SHOULDER STABILIZATION REHABILITATION PROTOCOL
Phase I – Immediate Post Surgical Phase (Day 1-21):
Goals:
Protect the surgical repair
Diminish pain and inflammation
Enhance scapular function
Achieve appropriate range of motion (ROM)
 Precautions:
Remain in sling, only removing for showering and elbow/wrist ROM
Patient education regarding avoidance of abduction / external rotation
activity to avoid anterior inferior capsule stress
No Passive Range of Motion (PROM)/Active Range of Motion (AROM) of shoul
der
No lifting of objects with operative shoulder
Keep incisions clean and dry
Weeks 1-3:
Sling at all times except where indicated above
PROM/AROM elbow, wrist and hand only
Normalize scapular position, mobility, and stability
Ball squeezes
Sleep with sling supporting operative shoulder
Shower with arm held at your side
Cryotherapy for pain and inflammation
Patient education: posture, joint protection, positioning, hygiene, etc.
Begin isometrics week 3
Phase II – Protection Phase/PROM (Weeks 4 and 5):
Goals:
Gradually restore PROM of shoulder
Do not overstress healing tissue
Precautions:
Follow surgeon’s specific PROM restrictions- primarily for external rot
ation
No shoulder AROM or lifting

Criteria for progression to the next phase:

Full flexion and internal rotation PROM
PROM 30 degrees of external rotation at the side
Can begin gentle external rotation stretching in the 90/90 position
Weeks 4 - 5
Continue use of sling
PROM (gentle), unless otherwise noted by surgeon
- Full flexion and elevation in the plane of the scapula.
- Full Internal rotation.
- External rotation to 30 degrees at 20 degrees
abduction, to 30 degrees at 90 degrees abduction.
Pendulums
Sub maximal pain free rotator cuff isometrics in neutral
Continue cryotherapy as needed
Continue all precautions and joint protection
Phase III – Intermediate phase/AROM (Weeks 6 and 7):
Goals:
Continue to gradually increase external rotation PROM Full AROM
Independence with ADL’s
Enhance strength and endurance
Precautions:
 Wean from Sling
No aggressive ROM / stretching
No lifting with affected arm
No strengthening activities that place a large amount of stress across
the anterior aspect of the shoulder in an abducted position with external rotati
on (i.e. no pushups, pectoralis flys, etc.)
Weeks 6 – 7
PROM (gentle), unless otherwise noted by surgeon
o External rotation to 30-50 degrees at 20 degrees abduction, to 45 degrees at 9
0 degrees abduction
Begin AROM of shoulder
o Progress to full AROM in gravity resisted positions
Begin implementing more aggressive posterior capsular stretching
o Cross arm stretch
o Side lying internal rotation stretch
o Posterior/inferior gleno-humeral joint mobilization
Enhance pectoralis minor length
Scapular retractor strengthening
Begin gentle isotonic and rhythmic stabilization techniques for rotator
cuff musculature strengthening (open and closed chain)
Continue cryotherapy as necessary
Phase IV - Strengthening Phase (Week 8 – Week 12)
Goals:
Continue to increase external rotation PROM gradually
Maintain full non-painful AROM
Normalize muscular strength, stability and endurance
Gradually progressed activities with ultimate return to full functional
activities
Precautions:
Do not stress the anterior capsule with aggressive overhead strengtheni
ng
Avoid contact sports/activities
Weeks 8- 10
Continue stretching and PROM
o External rotation to 65 degrees at 20 degrees abduction, to 75 degre
es at 90 degrees abduction, unless otherwise noted by surgeon.
Progress above strengthening program.
Weeks 10- 12
Continue stretching and PROM
o All planes to tolerance.
Continue strengthening progression program
Phase V – Return to activity phase (Week 12 - Week 20)
Goals:
Gradual return to strenuous work activities
Gradual return to recreational activities
 Gradual return to sports activities
Precautions:
Do not begin throwing, or overhead athletic moves until 4 months post-o
p
Weight lifting:
Avoid wide grip bench press
No military press or lat pulls behind the head. Be sure to “always see
your elbows”
Weeks 12- 16
Continue progressing stretching and strengthening program
Can begin golf, tennis (no serves until 4 mo.), etc.
Can begin generalized upper extremity weight lifting with low weight, an
d high repetitions, being sure to follow weight lifting precautions as above.
Criteria to return to sports and recreational activities:
Surgeon clearance
Pain free shoulder function without signs of instability
Restoration of adequate ROM for desired activity
Full strength as compared to the non operative shoulder (tested via hand
held dynamometry)

ARTHROSCOPIC ANTERIOR SHOULDER STABILIZATION

REHABILITATION PROTOCOL
RANGE OF MOTION IMMOBILIZER THERAPEUTIC
EXERCISE
PHASE I
0-4 weeks Active/Active-Assistive: stretch to 40 of external rotation, and
140 of forward flexion - internal rotation as
tolerated Worn at all times except for hygiene and therapeutic exercise
Elbow/wrist/hand ROM, grip strengthening, isometric abduction, external/internal
rotation exercises with elbow at side
PHASE II 4 - 6 weeks Increase forward flexion, and internal/external rotation
to full motion as tolerated None Advance isometrics in phase I to use of
a theraband, continue with elbow/wrist/hand ROM and grip strengthening,
begin prone extensions, and scapularstabilizing exercises, gentle joint mob
PHASE III 6 - 12 weeks Progress to full active motion without discomfort
None Advance theraband exercises to use of weights, continue with and progres
s exercises in phase II,
begin upper body ergometer
PHASE IV 12 weeks -6 months Full without discomfort None Advance exercise
s in phase III, begin functional progression to work/sport, return to previous a
ctivity level

POSTERIOR STABILIZATION REHABILITATION PROTOCOL

RANGE OF MOTION IMMOBILIZER THERAPEUTIC EXERCISE
PHASE I
0- 6 weeks 0-3 weeks: None
3-6 weeks: begin passive ROM - limit flexion to 90 , internal rotation to 45 , a
nd abduction to 90 Immobilized at all times (except for exercise) in flexio
n, abduction, and 0 of rotation 0-3 weeks: elbow/wrist ROM, grip strengthening
3-6 weeks: begin passive ROM activities - Codman s, anterior capsule mobilizatio
ns
PHASE II 6 - 12 weeks Begin active/active-assistive ROM - passive ROM
to tolerance - ROM Goals: full external rotation, 135 of flexion, 120 of abducti
on Sling worn for comfort only Continue with exercises in phase I, begi
n active-assistive exercises, deltoid/ rotator cuff isometrics - at 8 weeks: beg
in resistive exercises for scapular stabilizers, biceps, triceps, and rotator cu
ff.
PHASE III
12 - 16 weeks Gradual return to full active ROM None Advance activiti
es in phase II, emphasize external rotation and latissimus eccentrics and glenoh
umeral stabilization, begin muscle endurance
activities (upper body ergometer)
PHASE IV
4 - 6 months Full and pain-free None Aggressive scapular stabilizatio
n and eccentric strengthening, begin
plyometric and throwing/racquet program,
continue with endurance activities,
maintain ROM/flexibility
PHASE V 6 - 7 months Full and pain-free None Progress phase I
V activities, return to
full activity.
Biceps Tenodesis Protocol
Phase I – Passive Range of Motion Phase (starts approximately post op weeks 1- 2
)
Goals:
- Minimize shoulder pain and inflammatory response
- Achieve gradual restoration of passive range of motion (PROM)
- Enhance/ensure adequate scapular function
Precautions/Patient Education:
- No active range of motion (AROM) of the elbow
- No excessive external rotation range of motion (ROM) / stretching.
- Stop when you feel the first end feel.
- Use of a sling to minimize activity of biceps.
Ace wrap upper forearm as needed for swelling control
- No lifting of objects with operative shoulder
- Keep incisions clean and dry
- No friction massage to the proximal biceps tendon / tenodesis site
- Patient education regarding limited use of upper extremity despite th
e potential lack of or minimal pain or other symptoms
Activity:
- Shoulder pendulum hang exercise
- PROM elbow flexion/extension and forearm supination/pronation
- AROM wrist/hand
- Begin shoulder PROM all planes to tolerance /do not force any
painful motion
- Scapular retraction and clock exercises for scapula mobility progress
ed to scapular isometric exercises
- Ball squeezes
- Sleep with sling as needed supporting operative shoulder, place a
towel under the elbow to prevent shoulder hyperextension.
- Frequent cryotherapy for pain and inflammation
- Patient education regarding postural awareness, joint protection,
positioning, hygiene, etc.
- May return to computer based work.
Milestones to progress to phase II:
 • Appropriate healing of the surgical incision
• Full PROM of shoulder and elbow
• Completion of phase I activities without pain or difficulty.
Phase II – Active Range of Motion Phase (starts approximately post op week 4).
Goals:
• Minimize shoulder pain and inflammatory response
• Achieve gradual restoration of AROM
• Begin light waist level functional activities
• Wean out of sling by the end of the 2-3 postoperative week
• Return to light computer work
Precautions:
• No lifting with affected upper extremity
• No friction massage to the proximal biceps tendon / tenodesis site
Activity:
• Begin gentle scar massage and use of scar pad for anterior axillary
incision.
• Progress shoulder PROM to active assisted range of motion (AAROM)
andAROM all planes to tolerance.
• Lawn chair progression for shoulder.
• Active elbow flexion/extension and forearm supination/pronation (No re
sistance).
• Glenohumeral, scapulothoracic, and trunk joint mobilizations as indica
ted (Grade I - IV) when ROM is significantly less than expected.
Begin incorporating posterior capsular stretching as indicated
• Cross body adduction stretch
• Side lying internal rotation stretch (sleeper stretch)
• Continued Cryotherapy for pain and inflammation
• Continued patient education: posture, joint protection, positioning,
hygiene, etc.
Milestones to progress to phase III:
• Restore full AROM of shoulder and elbow
• Appropriate scapular posture at rest and dynamic scapular control with
ROM and functional activities
• Completion of phase II activities without pain or difficulty
Phase III - Strengthening Phase (starts approximately post op week 6-8)
Goals:
• Normalize strength, endurance, neuromuscular control.
• Return to chest level full functional activities.
Precautions:
• Do not perform strengthening or functional activities in a given plane
until the patient has near full ROM and strength in that plane of movement.
• Patient education regarding a gradual increase to shoulder activities
Activity:
• Continue A/PROM of shoulder and elbow as needed/indicated
• Initiate biceps curls with light resistance, progress as tolerated
• Initiate resisted supination/pronation
• Begin rhythmic stabilization drills
• External rotation (ER) / Internal Rotation (IR) in the scapular plane
• Flexion/extension and abduction/adduction at various angles of
elevation
Initiate balanced strengthening program
o Initially in low dynamic positions
o Gain muscular endurance with high repetition of 30-50, low res
istance 1-3 lbs)
o Exercises should be progressive in terms of muscle demand /
 intensity,shoulder elevation, and stress on the anterior joint capsule
o Nearly full elevation in the scapula plane should be achieved
before beginning elevation in other planes
o All activities should be pain free and without compensa
tory/substitution patterns
o Exercises should consist of both open and closed chain activit
ies
o No heavy lifting should be performed at this time
Initiate full can scapular plane raises with good mechanics
Initiate ER strengthening using exercise tubing at 30° of abduction (use
towel roll)
Initiate sidelying ER with towel roll
Initiate manual resistance ER supine in scapular plane (light resistance
)
Initiate prone rowing at 30/45/90 degrees of abduction to neutral arm po
sition
Begin subscapularis strengthening to focus on both upper and lower segme
nts
• Push up plus (wall, counter, knees on the floo
r,)
• Cross body diagonals with resistive tubing
• IR resistive band (0, 45, 90 degrees of abduction
• Forward punch
• Continued cryotherapy for pain and inflammation as needed
Milestones to progress to phase IV:
• Appropriate rotator cuff and scapular muscular performance for
chest level activities.
• Completion of phase III activities without pain or difficulty
Phase IV – Advanced Strengthening Phase (starts approximately post op week 10)
Goals:
• Continue stretching and PROM as needed/indicated
• Maintain full non-painful AROM
• Return to full strenuous work activities
• Return to full recreational activities
Precautions:
• Avoid excessive anterior capsule stress
• With weight lifting, avoid military press and wide grip bench press.
Activity:
• Continue all exercises listed above
o Progress isotonic strengthening if patient demonstrates no compensator
y strategies, is not painful, and has no residual soreness
• Strengthening overhead if ROM and strength below 90 degree elevation i
s good
• Continue shoulder stretching and strengthening at least four times per
week
• Progressive return to upper extremity weight lifting program emphasizi
ng the larger, primary upper extremity muscles (deltoid, latissimus dorsi, pecto
ralis major)
o Start with relatively light weight and high repetitions (15-25
)
• May initiate pre injury level activities/ vigorous sports if appropriate / cle
ared byMD
Milestones to return to overhead work and sport activities:
• Clearance from MD
• No complaints of pain
• Adequate ROM, strength and endurance of rotator cuff and scapular musc
ulature for task completion
• Compliance with continued home exercise program
Lumbar spine
THE VERTEBRAL COLOUMN
The Vertebral coloumn is like a curved rod, Composed of 33 vertrebrae and 23 in
tervertebral disk. Due to its 4 curved structure it has a 10 fold ability to re
sist axial compression in comparison with straight rod.
In the frontal plane, the vertebral column bisects the trunk when viewed from th
e posterior aspect, When viewed from the segittal plane, the curves are 2 primar
y curves ( Kyphotic – Thoracic and Sacral) and 2 secondary curves (Lordotic – Ce
rvical and Lumber).
Now have a look over a typical vertebra. It consist of 2 major parts.-
1. Vertebral body – A cylindrically shaped body, designed for weight bearin
g & increased in size creniocaudally.
2. Neural Arch
a. Pedicles – Portion of neural arch that lies anterior to the articular pr
ocesses. Function is to transmit tension and bending forces from the posterior e
lements to the vertebral bodies & increased in size creniocaudally.
b. Posterior Elements
i. Laminae – Thin vertically oriented piece of bone, that serves as origina
tion points for rest of the posterior elements. They transmit the forces from th
e posterior elements to the pedicles.
ii. Spinous Process – Posterior projections of bone that orginate from the c
entral portion of the laminae, serves as a site for muscle attachment.
iii. Transverse Process – Lateral projection of the bone that originate form
the laminae, serves as a site for muscle attachment.
iv. Articular processes
1. Two superior facets
2. Two Inferior Facets
Intervertebral disk –
A disk is interposed between each vertebrae. The principle function of disk has
– to separate the two vertebral bodies, thereby increasing the available motion
, and to transmit load from one vertebral body to another.
The disks are innervated in the outer one third to one half of the fibers of the
annulus fibrosus. They supplied by vertebral and sinuvertebral nerves.
The disks do not receive blood supply from any major arterial branches. The met
aphyseal arteries form a dense capillary plexus in the base of the end plate car
tilage and the subchondral bone deep to the end plate.
Intervertebral disks are composed of three parts.-
1. Nucleus pulposus – is the gelatinous mass found in the center, it predom
inantly consist type II collegen because its ability to resist compressive loads
.
2. Anulus Fibrosus – is the outer ring that surrounds the nucleus pulposus.
3. Vertebral end plates – are layers of cartilage 0.6 to 1 mm thick that co
ver the region of the vertebral bodies encircled by the ring apopysis on both th
e superior and inferior surfaces.
Articulation –
1. Interbody joints – It is cartilaginous joints of the symphysis type betw
een the vertebral bodies, movements include gliding, distraction and compression
and rotation. i.e. six degrees of freedom.
2. Zygopophyseal Articulations – it is diarthdial and synovial joint. it co
mposed of articulation between right and left superior articulating facets of a
vertebra and right and left inferior facets of the adjacent vertebra.
Ligaments and Capsules –
The ligamentous system exhibits considerable regional variability. Six m
ain ligaments are associated with the intervertebral and zygapophyseal joints.
1. Anterior Longitudinal ligaments
2. Posterior Longitudinal Ligaments
3. Ligamentum flavum
4. Interspinous Ligaments
5. Supraspinous Ligaments
6. Intertransverse Ligaments
Anterior Longitudinal Ligaments.-
Covers anterior & lateral portion of the vertebral bodies. It extends fr
om sacrum to second cervical vertebra. Extension of ligaments from c2 to occiput
are called anterior atlanto-occipital and anterior atlantoaxial ligaments. The
ligaments is well developed in the lordotic sections.and get stretched in extens
ion movements.
Posterior Longitudinal Ligaments –
The PLL runs on the posterior aspect of the vertebral column from C2 to
sacrum and forms ventral surface of the vertebral canal. The ligament becomes th
e tentorial membrane from C2 to the Occiput. In the lumber region ligament becom
e a thin ribbon that provide little support for the interbody joints. The PLL is
stretched in flexion and slack in extension.
Ligamentum Flavum
It is thick elastic ligament that connects lamina to lamina from C2 to S
acrum and forms the smooth posterior surface of the vertebral canal. From C2 to
Occiput the ligaments continue as the posterior atlanto0occipital and atlantoaxi
al membranes. In flexion the ligament is in the highest strain but due to its el
astic nature the ligament will not buckle on itself during movement.
Interspinous Ligaments –
It connects spinous processes of adjacent vertebra. The interspinous ligament al
ong the supraspinous ligament is the first to be damaged with excessive flexion.
The interspinous ligament is innervated by medial branches of the dorsal rami,
and thought to be possible source of low back pain.
Supraspinous Ligament –
It is a string ccordlike structure that connects the tips of the spionous proces
ses from the seventh cervical vertebra to L3 or L4. In the cervical region the l
igament becomes the ligamentum nuchae. The supraspinous ligament contains mechan
oreceptors and deformation of the ligament appears to play a role in the recruit
ment of spinal stabilizers such as the multifidus.
Intertransvers Ligaments-
The paired intertransverse ligaments pass between the transverse processes and a
ttach to the deep muscles of the back. In the lumber region ligament consist of
the broad sheets of connective tissue that resembles as the membrane & form a pa
rt of thoracolumber facia. The ligament alternately stretched and compressed dur
ing lateral flexion.
Zygopophyseal Joint Capsules –
The capsules assist the ligaments in providing limitation to motion and
stability for the verbebral column. The role of joint capsules also vary by regi
on.
1. in the cervical spine the facet joint capsules although lax , provide th
e primary soft tissue restraint to axial rotation and lateral bending, but they
provide little restraint to flexion and extension.
2. The facet joint capsules in the lumber spine, in addition to the annular
 fibers, also provide primary restraint to axial rotation.
3. However in the thoracic spine don not provide primary restraint to axial
rotation.
Basic Principal for spinal motion –
The motions available to the column as a whole are flexion and extensio
n, lateral flexion, and rotation. At the level of individual motion segment, the
se motions are often coupled motion.
Coupling pattern , as well as the types and amounts of motion that are a
vailable , are complex, differ from region to region, and depend on the spinal p
osture, curves, orientation of the articulating faces, fluidity, elasticity, and
thickness of the intervertebral disks and extensibility of the muscles, ligamen
ts and joint capsules.
Motions at the interbody and zygapophyseal joints are interdependent.
1. The amount of motion available is determined primarly by the size of the
disk. It is the ratio between the disk thickness and vertebral body height that
determines the available motion. The greater the ratio, the greater the mobilit
y. The ratio is greatest in the cervical region followed by the lumbar region, a
nd the ration is smallest in the thoracic region.
2. The direction of the motion is determined primarily by the orientation o
f the facets.
a. If the superior and inferior facet surfaces of three adjacent vertebrae
lie in the sagittal plane, the motion of flexion and extension are facilitated.
b. If the facet surfaces are placed in the frontal plane, the predominant m
otion that is allowed is lateral flexion.

STRUCTURE OF THE LUMBAR REGION

Typical Lumbar vertebrae –
Body is massive with a transverse diameter is greater than anterioposter
ior. Pedicals & Laminae are short and broad. Facet joints are either biplaner in
orientation or in Sagittal plane in upper lumber & Frontal Plane in lower lumbe
r. Transverse process is long and slender and extends horizontally. Spinous proc
ess is brad and thick and extends horizontally.
The fifth lumber vertebra is a transitional vertebra, it has a wedge shaped body
where anterior portion of the body is of greater height than the posterior port
ion. Transverse processes are large and directed superiorly and posteriorly.
Lumbosacral Angle –
The sacral segment, which is inclined slightly anteriorly and in
feriorly, forms an angle with the horizontal called the Lumbosacral angle. An in
crease in the angle will leads the increase anterior shear forces.
Intervertebral disks –
The disks are concave posteriorly, collgen fibers of annulus are
arranged in sheets called Lamellae, that enables the annulus to provide restrai
nt to the rotation.
Zygapophyseal Joints –
The anterior aspect of each joint remains in the frontal plane,
and the posterior aspect lie close to or in the sagittal plane. The frontal plan
e orientation provides resistance to anterior shear that naturally is present in
the lordotic region. The sagittal plane orientation allows the great range of f
lexion and extension ROM and provides resistance to rotation.
Ligament and Fascia –
The supraspinous ligament is well developed in the lumber region and ter
minates at L3. The Intertransverse ligaments are not true ligament in lumber reg
ion and replace by illiolumber ligament. The posterior Longitudinal Ligament a
thin ribbon in the region, whereas ligamentum flavum is thick ended here. The an
terior longitudinal ligament is strong and well developed in this region.
The illolumber ligaments consist of a series of bands that extends from
the tips and borders o f the transverse processes of L4 and L5 to attach bilater
ally on the iliac crests of the Pelvis.
 Thoracolumber Facia – consist of the three layers: Posterior, Middle and
the anterior. The posterior layer is large thick and arises from thesponous pro
cesses and supraspinous ligaments of the thoracic, lumbar and sacral spines. It
gives rise to the latissimus dorsi cranially, travels caudally and blend with th
e facia of the contralateral gluteus maximus. Deep fibers are continuous with th
e sacrotuerous ligament and connected to the PSIS, iliac crests, and PLL. The po
sterior layer also travels laterally over the erector spinae muscle and forms th
e lateral raphe at the lateral aspect of the erector spinae. The internal abdomi
nal oblique and the transverses abdominal muscles aeries from the lateral raphe.
The posterior layer becomes the middle layer and travels medially again along t
he anterior surface of the erector spinae and attaches back to the transverse pr
ocesses and intertranseverse ligaments of the lumbar spine. These two layers com
pletely surround the lumbar extensors. The anterior layer of the throacolumbar f
ascia is derived from the fascia of the quadratus lumborum muscle, where it join
s the middle layer, inserts into the transverse processes of the lumber spine, a
nd blends with the intertransverse ligaments.
The posterior layer called the active part of the fascia, is activated b
y a contraction of the transverses abdominis muscle, which tighten the fascia. T
he fascia transmits tension longitudinally to the tips of the spinous processes
of L1/L4 and may help the spinal extensors to resist and applied load.
The gluteus maximus and lattisimus dorsi tensed the superfacial layer a
nd provided a pathway for the mechanical transmission of forces between the pelv
is and the trunk.
Function of the Lumber region-
The lumbar region is capable of movement in flexion, extension, lateral
flexion , and rotation. Flexion of the lumber spine is more limited than extensi
on. Most of the flexion takes place at LS joint. During flexion and extension gr
eatest mobility is occur between L4 and S1.
With lateral flexion, pronounced flexion and slight ipsilateral rotatio
n occurs. With axial rotation, however, substantial lateral flexion in a contra
lateral direction occurs, but only a slight amount of flexion occurs. Lateral fl
exion and rotation are most free in the upper lumbar region and progressively di
minish in the lower region. The largest lateral flexion ROM & Axial rotation is
occurs between L2 and L3.
When the lumber spine is flexed , the ROM in rotation is less than when
the lumbar spine is in the neutral position. The Posterior annulus fibrosus and
the PLL seem to play an important role in limiting axial rotation when the spine
is flexed.
Lumbar-Pelvic Rhythm –
A coordinated, simultaneous activity of lumbar flexion and anterior tilt
ing of the pelvis in the sagittal plane during trunk flexion and extension. The
first parts of the bending forward consist of lumbar flexion, followed next by a
nterior tilting of the pelvis at the hip joints. A return to the erect posture i
s initiated by posterior tilting of the pelvis at the hips, followed by extensio
n of the lumbar spine. The initial pelvic motion delays lumbar extension until t
he trunk is raised far enough to shorten the moment arm of the exterenal load, t
hus reducing the load on the erector spinae.
Weight Bearing –
The increased size of the lumbar vertebral bodies and disks in compariso
n with their counterparts in the other region helps the lumbar structures suppor
t the additional weight. The lumber region must also withstand the tremendous co
mpressive loads produced by muscle contraction. Various tests revealing that int
erbody joints shared 80% of the load, the the facet joints 20%. This percentage
can change with altered mechanics., with increased extension or lordosis, the fa
cet joints will assume more of the compressive load.
Lumbosacral loads in the erect standing posture were in the reagne of 0.
82 to 1.19 times body weight , whereas load during level walking wre in the rang
e of 1.41 to 2.07times body weight.
Applied Anatomy
There are five pairs of facet joint in lumbar spine having diarthrodial variety
having separate capsule. Facet joints are located at the vertrebral arch. Injuri
es may lead to –
• Spondylosis ( degeneration of the intervertebral disc).
• Spondylolysis (a defect in pars interarticularis of the arch).
• Spondylolesthesis (a forward displacement of one vertebra over other)
These facets joints direct the motion in the lumbar spine. The shape of these fa
cets allows minimal rotation in the lumbar spine and is accomplished only by she
aring force. The closed packed position of the facet joint is extension. The res
ting position is midway between flexion and extension. The capsular pattern is s
ide flexion and rotation is equally limited followed by extension. The first sac
ral segment is usually included when one talks about lumbar spine. In some cases
the first sacral segment is mobile and is termed as the lumbarization of S1, re
sulting in a sixth “lumbar” vertebra. The fifth lumbar segment is fused with the
sacrum and ilium, resulting in the sacralization of the lumbar vertebra as a re
sult four mobile lumbar vertebrae.
If there is injury to disc four problems may result these are –
• Protusion.
• Prolapse.
• Extrusion.
• Sequestration.
Within the lumbar spine different postures can increase the pressure on interver
tebral disc: -
• Coughing or straining, 5 to 35%.
• Laughing, 40 to 50%.
• Walking, 15%.
• Side bending, 25%.
• Small jumps, 40 %.
• Bending forward, 150 %.
• Rotation, 20 %.
• Lifting a 20kg weight with the back straight and knee bent, 73%.
• Lifting a 20kg weight with the back bent and knee straight, 169%.
Examination: -
Patient history –
The following information should be determined: -
1. Patient’s usual activity or pastime.
2. What kind of activity originally causes back pain?
3. Where are the sites and boundaries of pain?
4. Is there any radiation of pain?
5. Is the pain deep? Superficial? Shooting? Burning? Aching?
6. Is there any parasthesia or anesthesia?
7. Which activity aggravates the pain?
8. Which activities ease the pain?
9. Is the pain improving? Worsening? Staying the same?
10. What about the patient sleeping position?
11. Does the patient have any difficulty with micturation?
12. Is there any pain with coughing? Sneezing? Deep breathing? Laughing?
13. Are there any posture or actions that specifically increases or decrease
s the pain or cause difficulty?
14. Is the pain altered by changing posture?
15. Which movement hurts? Which movements are stiff?
16. Is the pain worse in morning? Evening?
17. Is the patient receiving any medication?
18. What is the patient’s occupation?
Observation: -
The patient should be observed first standing and then sitting. The examiner sho
uld note the following:
1. Body type- there are three general body type:
• Ectomorphic.
• Mesomorphic.
• Endomorphic.
2. Gait.
3. Attitude.
4. Total spinal posture.
5. Marking.
6. Step deformity.
Examination: -
A complete examination of the lumbar spine and lower limb is to be performed.
Active movements: -
Active movements are performed in standing. The most painful movements are done
at last. Always look for the limitation of movement and its possible cause such
as pain, spasm, stiffness, or blocking. Passive over pressure may also be applie
d- but only if the active movements appears to be full and painfree but with ext
reme care. The greatest motion occurs between L4 and L5and betweenL5 and S1. The
following active movements are carried out in the lumbar spine.
- Forward flexion (40 to 60).
- Extension (20 to 35).
- Lateral flexion {left and right (15 to 20)}
- Rotation {left and right (3 to 18)}
As back injuries rarely occur during a “pure” movements, it has been advocated t
hat combined movements of the spine should be included in the examination. The f
amiliar movements which are to be tested:
- Lateral flexion in flexion.
- Lateral flexion in extension.
- Flexion and rotation.
- Extension and rotation.
Quick test can also be performed with precaution.
Passive movements:
In the lumbar spine, passive movements are very difficult to perform because of
the weight of the body. The normal end feel of the lumbar spine is tissue stretc
h in all movements.
Resisted Isometric Movements
The patient is seated. These tests are the same movements as were done actively:
- Forward flexion.
- Extension.
- Side flexion (left and right).
- Rotation (left and right).
Functional Assessment
Injury to the lumbar spine can greatly affect the patient’s ability to function.
Activities such as standing, walking, bending, lifting, traveling, socializing,
and dressing are affected.
Peripheral joints: -
If the examiner does not perform the quick test for peripheral joint or is unsur
e of the findings, the peripheral joints should be quickly scanned to rule out t
he pathology in the extremity. The following joints are scanned:
- Sacroiliac joints.
- Hip joints.
- Knee joints.
- Foot and ankle joints.
Myotomes: -
In this the examiner assesses the following resisted isometric movements.
1. Hip flexion tests the L2 myotome.
2. Knee extension tests the L3 myotome.
3. Ankle dorsiflexion tests the L4 myotome.
4. Toe extension tests the L5 myotome.
5. Ankle plantar flexion tests the S1 myotome.
6. Ankle eversion test the S1 myotome.
Root
Dermatome Muscle weakness Reflex affected Parasthesias
L1 Back, trochanter, groin None None Groin
L2 Back, front of thigh to knee Psoas, hip Adductors None Front of
thigh
L3 Back, medial lower leg Psoas, quads- thigh wasting KJ slug. PKB +,
painful, SLR Inner thigh, ant. Lower leg.
L4 Inner buttocks, outer thigh, inner leg dorsum foot, big toe Tibialis
Anterior, EHL SLR limited, neck flexion, wk. KJ, Side flexion limited Medial a
spect of calf and ankle.
L5 Buttocks, back and side of thigh, lat. Leg, foot dorsum, inner half of s
ole 1, 2, 3 toes EHL, peroneal, gluteus medius, ankle DF, hams- calf wast
ing. SLR limited, neck flex. Pain, AJ decreased Lateral aspect of leg, m
edial three toes.
S1 Buttock, back of thigh, and lower leg Calf and hams, wasting of glutea
ls, peroneals, PFs SLR Limited Lat. 2 toes, foot, leg to knee, Planter
foot
S2 Same as S1 Same as S1 except peroneals Same as S1 Lateral
leg,
S3 Groin, inner thigh to knee None None None
S4 Perinium, genitals, lower sacrum Bladder, rectum None Saddle a
rea, genitals, anus, impotence.
Special tests
SLR
Prone Knee Bending Test.
Slump test
Femoral Nerve Traction Test.
Bowstring Test.
Quadrant test.
Low Back Pain from Muscle Strain
The majority of episodes of acute lower back pain are caused by damage to the mu
scles and/or ligaments in the low back. Even though a muscle strain doesn’t soun
d like a serious injury, the low back pain can be surprisingly severe and is the
cause of many emergency room visits each year.
• A muscle strain happens when the muscle is over-stretched or torn, resul
ting in damage to the muscle fibers (a pulled muscle).
• A lumbar sprain happens when ligaments are stretched too far or torn. Li
gaments are very tough, fibrous connecting tissues that connect the muscles to t
he bones and joints.
For practical purposes, it doesn’t matter if the ligaments or muscles are the so
urce of the lower back pain, since the treatment for all of them is the same.
When the muscles or ligaments in the low back are strained or torn, the area aro
und the muscles can become inflamed. With inflammation the muscles in the back c
an spasm and cause both severe lower back pain and difficulty moving. Pain is of
ten relieved with rest.
Lower back pain from muscle strain occurs most frequently from lifting a heavy o
bject, lifting while twisting, or a sudden movement or fall. The pain is usually
localized (doesn’t radiate to the leg), and there may be muscle spasms or soren
ess upon touch. The patient usually feels better when resting.
Exercise for Sciatica from a Herniated Disc
By: Ron S. Miller, PT
Fig. 1 (larger view)
Fig. 2 (larger view)
Fig. 3 (larger view)
Fig. 4 (larger view)
Fig. 5 (larger view)
Fig. 6 (larger view)
Fig. 7 (larger view)
Leg pain or sciatica (also known as radiculopathy) from a herniated disc is comm
only caused by disc material protruding backwards and irritating or compressing
a nerve root, which in turn causes pain to radiate along the sciatic nerve.
Specific exercises for sciatic pain from a herniated disc are prescribed accordi
ng to which positions will cause the patient’s symptoms to move up the lower ext
remity and into the low back.
Extension exercises
For many patients, getting the pain to move up from the leg to the low back is a
ccomplished by getting into a backwards bending position, called extension exerc
ises or press-ups.
• The low back is gently placed into extension by lying on the stomach (pr
one position) and propping the upper body up on the elbows, keeping hips on the
floor (Figure 1). This should be started slowly, since some patients cannot tole
rate this position at first.
• Hold the press-up position initially for five seconds, and gradually wor
k up to 30 seconds per repetition. Aim to complete 10 repetitions.
After practicing this exercise, the spine specialist may recommend a more advanc
ed form of the extension:
• From the prone position (lying flat on the stomach), press up on the han
ds while the pelvis remains in contact with the floor (Figure 2). Keep the lower
back and buttocks relaxed for a gentle stretch.
• This position is typically held for 1 second, repeated 10 times.
If the patient is unable to lie flat, a similar exercise can be done standing by
arching backward slowly with hands on hips (Figure 3). However, the prone posit
ion described above is usually preferred.
These extension exercises are done regularly, about every two hours. More import
antly, the spine specialist may recommend that the patient with this condition s
hould avoid getting into a forward flexed (bent over) position. This tends to co
unteract the effects of the extension exercises. The specialist may ask the pati
ent to correct any forward flexed positions immediately by doing an extension ex
ercise.
Advanced sciatica exercises for abdominal muscles and back muscles
As the patient’s pain works out of the lower extremity (leg) and centralizes in
the low back, the exercises typically are advanced to strengthen the low back an
d abdominal muscles to prevent recurrences of sciatic pain caused by a herniated
disc.
Low back muscle strengthening exercises:
• Upper back extension. In the prone position with hands clasped behind th
e lower back, raise the head and chest slightly against gravity (Figure 4) while
looking at the floor (stay low). Begin by holding position for 5 seconds, and g
radually work up to 20 seconds. Aim to complete 8-10 repetitions.
• In the prone position with the head and chest lowered to the floor, ligh
tly raise an arm and opposite leg slowly, with the knee locked, 2-3 inches from
the floor (Figure 5). Begin by holding position for 5 seconds, and complete 8-10
repetitions. As strength builds, aim to hold position for 20 seconds.
Abdominal muscle strengthening exercises:
• Curl-ups. For the upper abdominals, the patient should lie on the back w
ith knees bent, fold arms across the chest, tilt the pelvis to flatten the back,
and curl-up lifting the head and shoulders from the floor (Figure 6). Hold for
two to four seconds, then slowly lower to starting position. As strength builds,
aim to complete two sets of ten curls. Do not attempt to lift too high, and bri
ng the head and chest towards the ceiling. For patients with neck pain, place th
e hands behind the head.
• For the lower abdominals, tighten the lower stomach muscles and slowly r
aise the straight leg 8 to 12 inches from the floor (Figure 7), keeping the low
back held flat against the floor. Hold leg raise for eight to 10 seconds, then s
lowly lower to starting position. As strength builds, aim to complete two sets o
f ten lifts.
• Water exercises are also excellent to strengthen the lower abdominal mus
cles, and even just walking in waist-deep water can be helpful.
Other forms of sciatica exercise
Aerobic conditioning may also be encouraged for general body fitness. In general
, walking is an excellent form of exercise for the low back because it is relati
vely low impact but can provide all the benefits of an aerobic workout. Walking
tends to relieve pain from radiculopathy. If possible, it is best to gradually p
rogress to doing up to three miles of exercise walking at a brisk pace each day.
Exercise for Sciatica from Spinal Stenosis
By: Ron S. Miller, PT
Fig. 8
(larger view)
Fig. 9
(larger view)
Fig. 10
(larger view)

Fig. 11
(larger view)
Fig. 6
(larger view)
Sciatic pain from nerve root irritation or impingement can be caused by spinal s
tenosis, a condition that causes the nerve’s passageway to narrow or constrict.
A typical symptom of spinal stenosis is pain that radiates along the sciatic ner
ve down the leg while walking, and to feel relief of the pain after sitting down
. The study of this leg pain (sciatica) is referred to as radiculopathy. For mor
e information on spinal stenosis, please see Definitive Guide to Lumbar Spinal S
tenosis and Living with spinal stenosis.
Spinal stenosis exercises
When treating sciatica from spinal stenosis, the spine specialist may encourage
flexion exercises (forward bending). Flexing the lower spine (bending forward) i
ncreases the size of these passageways and allows the irritation or impingement
to resolve. This is why people with spinal stenosis often feel better when bendi
ng forward (such as leaning on a cane, walker or shopping cart) than when standi
ng up straight.
Exercise targeted at alleviating the sciatica pain caused by spinal stenosis typ
ically includes a combination of specific stretching and strengthening exercises
that focuses on:
1. Stretching the muscles of the back that hold the spine in extension (bac
kwards bending) and;
2. Strengthening the muscles that bring the spine into flexion (forward ben
ding)
Stretching exercises for sciatica from spinal stenosis
The stretches for the muscles of the low back that hold the spine in a backward
bending position (the low back extensors) are typically held lightly for 30 seco
nds. These exercises include the following:
• Back flexion: Lie on the back and gently pull the knees to the chest unt
il a comfortable stretch is felt (Figure 8). After 30 seconds, slowly return to
starting position. Aim to complete four to six repetitions of this flex.
• Get down on the hands and knees, then sit back on the heels with the che
st down and arms outstretched (Figure 9). After 30 seconds, slowly return to sta
rting position. Aim to complete four to six repetitions of this stretch. Do not
bounce on heels.
Strengthening exercises for sciatic pain from spinal stenosis
Strengthening exercises for spinal stenosis focus on strengthening the lower abd
ominal muscles and include:
• Lie on the back and press the low back into the floor by tightening the
lower stomach muscles, pulling the navel (or belly button) in and up (Figure 10)
, hold for 10 seconds. Aim to complete eight to ten repetitions of this press.
• Hook-lying march. For a more advanced exercise, this position may be hel
d while marching in place in the hook-lying position, slowly raising alternate l
egs 3 to 4 inches from the floor (Figure 11). Aim to ‘march’ for 30 seconds, two
to three repetitions, with 30-second breaks in between repetitions.
• Curl-ups. Another strengthening exercise that may be recommended by spin
e specialists to strengthen the lower abs is called a curl-up (Figure 6). These
are done by folding arms across chest, flattening the back by tightening lower a
bs, then raising the head and shoulders from the floor. Hold for two to four sec
onds, then slowly lower to starting position. As strength builds, aim to complet
e two sets of ten curls.
These exercises alone will not necessarily make the patient with sciatica from s
pinal stenosis “better”, but they will allow the patient to more easily hold a p
osterior pelvic tilt during activities, especially standing and walking. This po
sture will allow the patient to perform more activities with less pain. The pelv
ic tilt is often very difficult for patients to learn and can take a good deal o
f practice with the guidance of a physical therapist before it is used effective
ly to treat sciatica resulting from spinal stenosis.
Exercise for Sciatica from Degenerative Disc Disease
By: Ron S. Miller, PT
Fig. 11
(larger view)
Fig. 12
(larger view)
Fig. 13
(larger view)
Fig. 10
(larger view)
Fig. 14
(larger view)
Fig. 5
(larger view)
Fig. 15
(larger view)
Fig. 16
(larger view)
While degenerative disc disease most often causes low back pain, if a degenerate
d disc impinges on a nerve root in the low back it can also cause a form of scia
tica. For more information about degenerative disc disease, please see Overview
of lumbar degenerative disc disease.
Sciatica exercises for degenerative disc disease
The form of exercise typically recommended for treating disc degeneration and th
e sciatica that results is a dynamic lumbar stabilization program, sometimes usi
ng the exercises included in the McKenzie Method. Alleviating sciatic pain cause
d by degenerative disc disease includes finding the most comfortable position fo
r the lumbar spine and pelvis and training the body to maintain this position du
ring activities. In doing this correctly, one can improve the proprioception (se
nse of movement) of the lumbar spine and reduce the excess motion at the spinal
segments. This will in turn reduce the amount of irritation at these segments, r
elieving pain and protecting the area from further damage.
Lumbar stabilization exercises for sciatica
These dynamic lumbar stabilization exercises often require specific hands-on ins
truction because they offer much less benefit if done incorrectly, and they tend
to be much more difficult than they appear.
This type of exercise program is progressive, starting with the easier exercises
and advancing to the more difficult exercises once the lower level program is m
astered. The most important aspect of using these sciatica exercises is sensing
and controlling motion in the spine. Once learned, the body can eventually take
over and do this without the level of concentration it takes early on.
Examples of the dynamic lumbar stabilizing exercises done while on the back incl
ude:
Degenerative disc disease exercises while lying on the back
• Hook-lying march. While lying on the back on the floor, with knees bent
and arms at sides, tighten the stomach muscles and slowly raise alternate legs 3
to 4 inches from the floor (Figure 11). Aim to ‘march’ for 30 seconds, for two
to three repetitions, with 30-second breaks in between repetitions.
• Hook-lying march combination. Same exercise as described above, but incl
udes raising and lowering the opposite arm over the head (Figure 12).
• Bridging. Start by lying on the back with the knees bent, then slowly ra
ise the buttocks from the floor (Figure 13). Hold bridge for eight to 10 seconds
, then slowly lower to starting position. As strength builds, aim to complete tw
o sets of ten bridges.
These exercises should all be performed with a rigid trunk. The pelvic tilt, tig
htening the lower stomach muscles and buttocks to flatten the back (Figure 10),
can be used to find the most comfortable position for the low back.
Degenerative disc disease exercises while lying on the stomach
This same pelvic position (tightening the lower stomach muscles to flatten the l
ower back) is maintained while performing stabilizing exercises from the prone p
osition (lying flat on the stomach):
• Raise one leg behind with the knee slightly bent and no arch in the back
or neck (Figure 14). Hold for four to six seconds, then slowly lower to startin
g position. As strength builds, aim to complete two sets of ten leg raises.
• Lying face down, with elbows straight and arms stretched above the head,
raise one arm and the opposite leg 2 to 3 inches off the floor (Figure 5). Hold
for four to six seconds, then slowly lower to starting position. As strength bu
ilds, aim to complete two sets of opposite side raises.
Similar stabilizing exercises can be done in the 4-point position (kneeling on h
ands and knees), raising the arms and legs only as high as can be controlled, ma
intaining a stable trunk and avoiding any twisting or sagging:
• Raise one leg behind with the knee slightly bent and no arch in the back
or neck (Figure 15). Hold for four to six seconds, then slowly lower to startin
g position. As strength builds, aim to complete two sets of ten leg raises.
• For a slightly more advanced exercise, raise one leg with the knee sligh
tly bent and no arch in the back or neck and also raise the opposite arm (Figure
16). Hold for four to six seconds, then slowly lower to starting position. As s
trength builds, aim to complete two sets of ten leg raises.
Exercise for Sciatica from Isthmic Spondylolisthesis
By: Ron S. Miller, PT
Fig. 10
(larger view)
Fig. 6
(larger view)
Fig. 11
(larger view)
Fig. 12
(larger view)
Sciatica can be caused by isthmic spondylolisthesis if the condition results in
nerve root irritation or impingement. In most cases, if isthmic spondylolisthesi
s affects or pinches a nerve root it will affect the L5 nerve root. For more inf
ormation on this condition, see Isthmic Spondylolisthesis.
When treating sciatica resulting from isthmic spondylolisthesis with exercise, t
he spine specialist will typically recommend an exercise program that is a hybri
d of:
• Flexion based exercises (as when treating spinal stenosis), and
• Stabilization program (as when treating degenerative disc disease).
The goal of this type of exercise program is to teach the lumbar spine to remain
stable in a flexed position. Therefore, the exercises for sciatica caused by is
thmic spondylolisthesis are a combination of both programs.
Sciatica exercises for isthmic spondylolisthesis
These sciatica exercises often require specific hands-on instruction because the
y offer much less benefit if done incorrectly, and the exercises tend to be much
more difficult to do than they appear.
Three exercises that are commonly prescribed for sciatic pain from isthmic spond
ylolisthesis include:
• Pelvic tilt. Specialists treating patients with sciatica from isthmic sp
ondylolisthesis frequently recommend the pelvic tilt (Figure 10), as it will hol
d the lower spine in the flexed position. This includes lying on the back with k
nees bent and flattening the back by tightening the lower stomach muscles, pulli
ng the navel in and up. Hold this position for 10 to 20 seconds, then relax the
muscles. Aim to complete a set of 10 pelvic tilts to strengthen the lower stomac
h muscles.
• Curl-ups. Strengthening the abdominals with the curl-ups (Figure 6) will
also help maintain a proper lower spine position. Lie on the back with knees be
nt, fold arms across the chest, tilt the pelvis to flatten the back by pulling t
he navel (or belly button) in and up. Then curl-up, lifting the head and shoulde
rs from the floor. Do not attempt to lift too high, and bring the head and chest
towards the ceiling. For patients with neck pain, place the hands behind the he
ad to support the neck. Hold for two to four seconds, then slowly lower to start
ing position. As strength builds, aim to complete two sets of ten curls.
• Hook-lying march. As another form of stabilization exercise, the hook-ly
ing march (Figure 11) and hook-lying combination (Figure 12) are again useful he
re as well. ). Aim to ‘march’ for 30 seconds, two to three repetitions, with 30-
second breaks in between repetitions.
Exercise for Sciatica from Isthmic Spondylolisthesis
By: Ron S. Miller, PT
Fig. 10
(larger view)

Fig. 6
(larger view)
Fig. 11
(larger view)
Fig. 12
(larger view)
Sciatica can be caused by isthmic spondylolisthesis if the condition results in
nerve root irritation or impingement. In most cases, if isthmic spondylolisthesi
s affects or pinches a nerve root it will affect the L5 nerve root. For more inf
ormation on this condition, see Isthmic Spondylolisthesis.
When treating sciatica resulting from isthmic spondylolisthesis with exercise, t
he spine specialist will typically recommend an exercise program that is a hybri
d of:
• Flexion based exercises (as when treating spinal stenosis), and
• Stabilization program (as when treating degenerative disc disease).
The goal of this type of exercise program is to teach the lumbar spine to remain
stable in a flexed position. Therefore, the exercises for sciatica caused by is
thmic spondylolisthesis are a combination of both programs.
Sciatica exercises for isthmic spondylolisthesis
These sciatica exercises often require specific hands-on instruction because the
y offer much less benefit if done incorrectly, and the exercises tend to be much
more difficult to do than they appear.
Three exercises that are commonly prescribed for sciatic pain from isthmic spond
ylolisthesis include:
• Pelvic tilt. Specialists treating patients with sciatica from isthmic sp
ondylolisthesis frequently recommend the pelvic tilt (Figure 10), as it will hol
d the lower spine in the flexed position. This includes lying on the back with k
nees bent and flattening the back by tightening the lower stomach muscles, pulli
ng the navel in and up. Hold this position for 10 to 20 seconds, then relax the
muscles. Aim to complete a set of 10 pelvic tilts to strengthen the lower stomac
h muscles.
• Curl-ups. Strengthening the abdominals with the curl-ups (Figure 6) will
also help maintain a proper lower spine position. Lie on the back with knees be
nt, fold arms across the chest, tilt the pelvis to flatten the back by pulling t
he navel (or belly button) in and up. Then curl-up, lifting the head and shoulde
rs from the floor. Do not attempt to lift too high, and bring the head and chest
towards the ceiling. For patients with neck pain, place the hands behind the he
ad to support the neck. Hold for two to four seconds, then slowly lower to start
ing position. As strength builds, aim to complete two sets of ten curls.
• Hook-lying march. As another form of stabilization exercise, the hook-ly
ing march (Figure 11) and hook-lying combination (Figure 12) are again useful he
re as well. ). Aim to ‘march’ for 30 seconds, two to three repetitions, with 30-
second breaks in between repetitions.
Exercise for Sciatic Pain from Piriformis Syndrome
By: Ron S. Miller, PT
Fig. 17
(larger view)
Fig. 18
(larger view)
Fig. 19
(larger view)
Fig. 20
(larger view)
Differences between piriformis syndrome and sciatica
A common symptom of piriformis syndrome is pain along the sciatica nerve, so it
is often thought that piriformis syndrome causes sciatica. However, piriformis s
yndrome does not involve a radiculopathy - a disc extending beyond its usual loc
ation in the vertebral column that impinges or irritates the nerve root - so it
is technically not sciatica. Instead, with piriformis syndrome, it is the pirifo
rmis muscle itself that irritates the sciatic nerve and causes sciatic pain.
The piriformis is a muscle located deep in the hip that runs in close proximity
to the sciatic nerve. The piriformis syndrome is used to describe when the pirif
ormis muscle becomes tight and/or inflamed; which may cause irritation of the sc
iatic nerve. This irritation leads to sciatica-like pain, tingling and numbness
that run from the lower back, to the rear and sometimes down the leg and into th
e foot. For more information on piriformis syndrome, see Piriformis syndrome—ano
ther irritation to the sciatic nerve.
Stretching exercises for the piriformis syndrome (causing sciatic pain)
Stretching the piriformis muscle is almost always necessary to relieve the pain
along the sciatic nerve and can be done in several different positions. A number
of stretching exercises for the piriformis muscle, hamstring muscles and hip ex
tensor muscles may be used to help decrease the painful symptoms along the sciat
ic nerve and return the patient’s range of motion.
Several of the stretching exercises commonly prescribed to treat sciatica sympto
ms from piriformis muscle problems include:
Supine piriformis stretches:
• Lie on the back with the legs flat. Pull the affected leg up toward the
chest, holding the knee with the hand on the same side of the body and grasping
the ankle with the other hand. Trying to lead with the ankle, pull the knee towa
rds the opposite ankle (Figure 17) until stretch is felt. Do not force ankle or
knee beyond stretch. Hold stretch for 30 seconds, then slowly return to starting
position. Aim to complete a set of three stretches.
• Lie on the floor with the legs flat. Raise the affected leg and place th
at foot on the floor outside the opposite knee. Pull the knee of the bent leg di
rectly across the midline of the body using the opposite hand or a towel, if nee
ded (Figure 18), until stretch is felt. Do not force knee beyond stretch or to t
he floor. Hold stretch for 30 seconds, then slowly return to starting position.
Aim to complete a set of three stretches.
• Lie on the floor with the affected leg crossed over the other leg at the
knees and both legs bent. Gently pull the lower knee up towards the shoulder on
the same side of the body (Figure 19) until stretch is felt. Hold stretch for 3
0 seconds, then slowly return to starting position. Aim to complete a set of thr
ee stretches.
Buttocks stretch for the piriformis muscle:
• Begin on all fours. Place the affected foot across and underneath the tr
unk of the body so that the affected knee is outside the trunk. Extend the non-a
ffected leg straight back behind the trunk and keep the pelvis straight. Keeping
the affected leg in place, scoot the hips backwards towards the floor and lean
forward on the forearms (Figure 20) until deep stretch is felt. Do not force bod
y to floor. Hold stretch for 30 seconds, then slowly return to starting position
. Aim to complete a set of three stretches.
Exercise for Sciatic Pain from Sacroiliac Joint Dysfunction
By: Ron S. Miller, PT
Fig. 21
(larger view)
Fig. 2
(larger view)
Fig. 22
(larger view)
Hamstring Stretching Exercises
By: Ron S. Miller, PT
Fig. 23
(larger view)
As a final note, regardless of the diagnosis, most types of sciatica will benefi
t from a regular routine of hamstring exercise, especially hamstring stretching.
The hamstrings are muscles located in the back of the thigh. They help bend the
knee and extend the hip. Tightness in the hamstrings will place increased stres
s on the low back and often aggravate or even cause some of the conditions that
result in sciatica.
When doing the hamstring stretches, patients should avoid bouncing, which can tr
igger a muscle spasm.
Hamstring stretch while lying on the back
Most patients with back pain will benefit from hamstring stretching exercises do
ne while lying on the back. These are the least stressful types of hamstring str
etch:
• Lie on the back, supporting the thigh behind the knee with the hand or w
ith a towel, slowly straighten the knee until a stretch is felt in the back of t
he thigh, trying to get the bottom of the foot to face the ceiling, one leg at a
time (Figure 23). Hold the position initially for 10 seconds, and gradually wor
k up to 20-30 seconds.
• Another low stress hamstring stretch is to lie back on the floor with th
e buttocks against a wall at a corner or by a door jamb. Keeping one leg on the
floor, place the foot of the alternate leg against the wall and try to gently pu
sh the knee straight so raised leg and the leg on the floor make a 90 degree ang
le. Hold the position for 10 to 20 seconds.
Hamstring stretch while sitting
Although they are less gentle than lying on the back, hamstring stretches can al
so be done in a sitting position, where the degree of stretch can be varied base
d on the placement of the leg:
• While sitting at the edge of a chair, straighten one leg in front of the
body with the heel on the floor. Then, sit up straight and try pushing the nave
l towards the thigh without leaning the trunk of the body forwards. Hold this st
retch for 30 seconds, then repeat 3 times for each leg.
Many people – and especially women – tend to be more flexible and may need to el
evate the foot on a stool or chair to get a deep enough stretch.
Causes of Low Back Pain
Common causes : -
Non osseous injury.
- intervertebral Disk
- Apophyseal joint.
Spondylolysis
Sacroiliac joint injury/ inflammation.
Paravertebral and gluteal trigger point
Hip joint pathology.
Less common Causes: -
Intervertebral disk prolapse.
Spondylolisthesis.
Lumbar instability.
Spinal Canal Stenosis.
Vertebral crush fracture.
fibromyalgia.
Rheumatological.
Gyanecological.
Gastrointestinal.
Genitourinary.
Causes Not to be Missed: -
Malignancy.
Primary.
Metastatic.
Osteoid osteoma.
Multiple Myeloma.
Severe Osteoporosis.
Spinal Stenosis
Spinal stenosis refers to a narrowing of the vertebral canal, intervertbral for
amen, or both due to either osseous or soft tissue encroachment. Arnoldi et al.
classified lumbar spinal stenosis by etiology as either developmental/primary or
degenerative/secondary. Primary stenosis is caused by congenital malformations
or defects in postnatal development and occurs rarely. It can manifest itself in
the 3rd or 4th decade of life. Degenerative lumbar stenosis occurs more frequen
tly and is what is seen typically in the clinical setting. Degenerative lumbar s
tenosis usually manifests itself in the 6th or 7th decade of life, with slight p
reponderance in women1. It results from degenerative osseous or soft tissue chan
ges, spondylolisthesis, postsurgical scarring, intervertebral disc herniation, o
r from combinations of these conditions. Other less frequent causes of secondary
stenosis are fractures, tumors, infection or systemic diseases such as Paget’s
disease. Combinations of primary and secondary stenosis can occur and are termed
as mixed.
Anatomically, lumbar spinal stenosis can be classified as either central or late
ral2. Central stenosis involves narrowing of the spinal canal around the thecal
sac containing the cauda equina, and occurs as a result of the facet joint arthr
osis and hypertrophy, thickening and bulging of the ligamentum flavum, bulging o
f the intervertebral disc, or spondylolisthesis. Stenosis at multiple levels is
more common than strictly segmental stenosis. In approximately 40% of cases, cen
tral stenosis is caused by soft tissue hypertrophy.3 Lateral stenosis causes enc
roachment of the spinal nerve in the lateral recess of the spinal canal or in th
e intervertebral foramen, and results form facet joint hypertrophy, loss of disc
height, intervertebral disc bulging, or spondylolisthesis. Knowledge of the pat
hologic anatomy is important for correlating clinical signs and symptoms with im
aging studies and treatment planning. Bony or soft tissue encroachment of an eme
rging nerve root may occur at any lumbar level. The two lower motion segments (L
3-4 and L4-5) are most commonly affected by degenerative stenosis.
NSAIDS are the medication of choice for decreasing inflammation, soft tissue swe
lling, and neural compression. The use of epidurals is questionable and tends to
be more effective for patients with radicular pain symptoms due to herniated in
tervertebral discs rather than for spinal stenosis alone. If a good response is
achieved, a repeated injection is administered in 3-6 months.456
Computerized tomography, myelography and magnetic resonance imaging are the most
important imaging studies for evaluating and quantifying the degree of forminal
stenosis and making the diagnosis. However, degenerative changes do not closely
correlate with symptoms
PIRIFORMIS SYNDROME
Piriformis syndrome is a rare nerve condition in the hip, causing pain and occa
sionally loss of feeling in the back of the thigh, often to the bottom of the fo
ot. It involves compression of the sciatic nerve at the hip by the piriformis mu
scle. The piriformis muscle rotates the hip, allowing the thigh, foot, and knee
to point outward. The piriformis muscle travels from the pelvis to the outer hip
. The sciatic nerve usually passes the hip between this muscle and other muscles
of the hip. Occasionally (15% to 20% of the time) the nerve travels directly th
rough the muscle, causing pressure on the nerve.
Tightness of the piriformis muscle and hip abductor muscles can also cause deep
buttock pain without the sciatic pain down the leg as well. Oftentimes, healthca
re providers will also refer to this as piriformis syndrome despite the classic
nerve symptoms being present as well.
Signs and Symptoms of this Condition
Tingling, numbness, or burning in the back of the thigh to the knee and occasion
ally the bottom of the foot.
Pain and tenderness in the buttock.
Pain and discomfort (burning, dull ache, or throbbing) in the hip, mid-buttock a
rea, or back of the thigh and sometimes to the knee.
Heaviness or fatigue of the leg.
Pain that is worse with sports activities, such as running, jumping, long walks,
and walking up stairs or hills, and is often felt at night or with prolonged si
tting (especially on a hard surface).

Causes
 Pressure on the sciatic nerve at the hip by anything that may cause the pirifo
rmis muscle to spasm and constrict the nerve can cause this syndrome. This inclu
des strain from a sudden increase in the amount or intensity of activity or over
use of the lower extremity. It may also be due to compensation of other extremit
y injuries.
 Tight piriformis muscle.
 Direct pressure from wallet or sitting on a hard surface.
Spondylosis/ Spondylolisthesis
Spondylolysis refers to a defect in the pars interarticularis without slipage of
the vertrebra.
Spondylolisthesis come from the greek root spndyl( spine or vertebrae) and listh
esis ( to slip) and refer to anterior displacement of one vertebral body on the
vertebral body below.
Grading of spondylolisthesis
Meyerding in 1932 devides the AP dimension of vertebral body into Quarter
Grade 1-25%
Grade 2-50%
Grade 3-75%
Grade 4-100%
In grade 5th spondylolisthesis known as spondyloptosis, the superior body entie
rly forward on the subadjacent body
Sacral inclination: -
Also known as sacral tilt , is the angle of displacement of the
sacrum from the vertical. It is the measurement of the angle between a line draw
n along the posterior margin of the first sacral vertebra and its bisection with
the true vertical. The sacrum is angled anteriorly in normal upright standing p
ostures, but the angle tends to decrease as the listhesis increase.
Types of Spondylolisthesis: -
Type I dysplastic:
Dysplasia of the upper sacrum, particularly nthe facet joint, often lead
s to anterior translation of the fifth lumbar segment on the sacrum.
Type II Isthimic:
The Isthmus refers to the pars interarticularis the point where the pedicles and
lamina meet. Isthmic spondylolisthesis is an acquired deformity, although genet
ic predisposition and familial trens have been identified.
Type III Degenerative spondylolisthesis: -
It appers to be a part of generalized osteoartheritis affect women more commonly
then men female to male ratio is 5:1.
It is caused by degenerative changes in the lumbar intervertebral disk and face
t joints.
Type IV Traumatic spondylolisthesis : -
Results from the direct trauma to the lumbar spine.
Type V Pathological spondylolisthesis:-
Results from local or systemic bone diseases. Tumour infection, osteoid osteoma,
osteoporosis or other processes that affect bone quality.
Type VI Iatrogenic Spondylolisthesis: -
It is aquired at the time of surgery. Removal of excessive amount of posterior e
lements during decompressive procedures leaves the segment susceptible to post o
perative stress fracture and instability which may lead to listhesis.
Diskogenic pain
Structure and function of disk: -
Moving centrally from the neurovascular capsule are fibrous annulus plates often
errorneously called rings. The greater the number of anterior and lateral plate
s (as opposed to posterior) allows the nucleus in the lumbar spine to be placed
somewhat to the near tof the disk space. Between the fibrous outer annulus and
the inner fluids
Disk nutrition: -
Side lying or lying with the legs up and back flat facilitates the nutri
tional pressure changes. Some 80% nutrition within a night’s rest occurs with in
the first hour of the rest.
Therefore, by resting during the lunch hour and again at the end of the
workday as well as at the night in the bed it is possible to double the nutritio
n to the disk.
Disk innervation: -
The recurrent sinuvertebral nerve and a gray ramus commmunicans from the
sympathetic nerve.
The level at which the disk prolapse most commonly occur: -
L4/L5> L5/S1> L3/L4> L2/L3> L1/L2.
Classification of disk herniations:-
Macnab presented the following classification:
Disk protusion (annular fibers intact)
Localised annular bulge (usually laterally).
Diffuse annular bulge (usually posterior and bilaterally).
Disk herniations (annular fibers disrupted)
Prolapsed (nucleus has migrated through the inner layers but is still co
ntained)
Extruded (nucleus has broken through the outer most layer)
Sequestered (nucleus has broken from the disk and is in the spinal or in
tervertebral canals).
Ten Tips for Improving Posture and Ergonomics
Over time, poor posture may be caused by habits from everyday activities such as
sitting in office chairs, looking at the computer, driving, standing for long p
eriods of time, or even sleeping. Poor posture can easily become second nature,
causing or aggravating episodes of back pain and damaging spinal structures. For
tunately, the main factors affecting posture and ergonomics are completely withi
n one’s ability to control and are not difficult to change.
The following guidelines suggest several ways to improve posture and ergonomics,
especially for people who work sitting in an office chair for most of the day.
• Know the warning signs of back pain caused by poor ergonomics and postur
e. Back pain may be the result of poor ergonomics and posture if the back pain i
s worse at certain times of day or week (such as after a long day of sitting in
an office chair in front of a computer, but not during the weekends); pain that
starts in the neck and moves downwards into the upper back, lower back and extre
mities; pain that goes away after switching positions while sitting or standing;
sudden back pain that is experienced with a new job, a new office chair, or a n
ew car; and/or back pain that comes and goes for months.
• Get up and move. As muscles tire, slouching, slumping, and other poor po
stures become more likely; this in turn puts extra pressure on the neck and back
. In order to maintain a relaxed yet supported posture, change positions frequen
tly. One way is to take a break from sitting in an office chair every half hour
for two minutes in order to stretch, stand, or walk.
• Keep the body in alignment while sitting in an office chair and while st
anding. Distribute body weight evenly to the front, back, and sides of the feet
while standing. While sitting in an office chair, take advantage of the chair’s
features. Sit up straight and align the ears, shoulders, and hips in one vertica
l line. Any single position, even a good one, will be tiring. Leaning forward wi
th a straight back can alternate with sitting back, using the back support of th
e office chair to ease the work of back muscles. Also be aware of and avoid unba
lanced postures such as crossing legs unevenly while sitting, leaning to one sid
e, hunching the shoulders forward or tilting the head.
• Use posture-friendly props and ergonomic office chairs when sitting. Sup
portive ergonomic “props” can help to take the strain and load off of the spine.
Ergonomic office chairs or chairs with an adjustable back support can be used a
t work. Footrests, portable lumbar back supports, or even a towel or small pillo
w can be used while sitting in an office chair and while driving. Using purses,
bags, and backpacks that are designed to minimize back strain can also influence
good posture. Proper corrective eyewear, positioning computer screens to your n
atural, resting eye position can also help to avoid leaning or straining the nec
k with the head tilted forward.
• Increase awareness of posture and ergonomics in everyday settings. Being
aware of posture and ergonomics at work, at home, and at play is a vital step t
owards instilling good posture and ergonomic techniques. This includes making co
nscious connections between episodes of back pain and specific situations where
poor posture or ergonomics may be the root cause of the pain.
• Use exercise to help prevent injury and promote good posture. Regular ex
ercise such as walking, swimming, or bicycling will help the body stay aerobical
ly conditioned, while specific strengthening exercises will help the muscles sur
rounding the back to stay strong. These benefits of exercise promote good postur
e, which will, in turn, further help to condition muscles and prevent injury. Th
ere are also specific exercises that will help maintain good posture. In particu
lar, a balance of trunk strength with back muscles about 30% stronger than abdom
inal muscles is essential to help support the upper body and maintain good postu
re.
• Wear supportive footwear when standing. Avoid regularly wearing high-hee
led shoes, which can affect the body’s center of gravity and change the alignmen
t of the entire body, negatively affecting back support and posture. When standi
ng for long periods of time, placing a rubber mat on the floor can improve comfo
rt.
• Remember good posture and ergonomics when in motion. Walking, lifting he
avy materials, holding a telephone, and typing are all moving activities that re
quire attention to ergonomics and posture. It is important to maintain good post
ure even while moving to avoid injury. Back injuries are especially common while
twisting and/or lifting and often occur because of awkward movement and control
of the upper body weight alone.
• Create ergonomic physical environments and workspaces, such as for sitti
ng in an office chair at a computer. It does require a small investment of time
to personalize the workspace, home, and car, but the payoff will be well worth i
t. Undue strain will be placed on the structures of the spine unless the office
chair, desk, keyboard, and computer screen, etc. are correctly positioned.
• Avoid overprotecting posture. Remember that it is important to maintain
an overall relaxed posture to avoid restricting movements by clenching muscles a
nd adopting an unnatural, stiff posture. For individuals who already have some b
ack pain, it is a natural tendency to try to limit movements to avoid the potent
ial pain associated with movement. However, unless there is a fracture or other
serious problem, the structures in the spine are designed for movement and any l
imitation in motion over a long period of time creates more pain and a downward
cycle of less motion and more pain, etc.
Driving with Back Pain - Patients Advice
Suspension can make a difference
Drive a car that has a soft ride. A stiff suspension can have a punishing ride.
Switch driving positions frequently and use cruise control.
Technology to help back pain while driving?
I saw this software that automatically adjusts your car seats, www.comfortmotion
.com, a few days ago. Even though it’s not in any cars yet, it will be interesti
ng to see how this will help with back pain and stiffness while driving.
A small cushion can relieve driving back pain
1) Guys the best thing you can do while driving is to put a small cushion behind
your back. Be careful for the cushion should not be thick.
2) Heated seats really help.
3) Sit straight up and dont slide down.
Keep left leg bent to relieve pressure on the low back
I find that if I bend my left leg while driving that relieves the pain that I ge
t in my lower back and legs.
Spinner helps back pain from driving
I couldn t tell you if it is the best thing to do, but I found that installing a
spinner on my steering wheel helped me a lot.
Low seating and a left-hand drive car helped my sciatica
Guidelines to Improve Posture
As already discussed, for correction of poor posture it is important to determin
e where improvement is needed, such as when sitting in an office chair. Next, pa
tients must work on changing daily habits to correct those areas. This effort wi
ll improve back support and over time help decrease back pain and neck pain. It
will take some effort and perseverance, and will seem a little unnatural at firs
t. It is typical to feel uncomfortable, and even feel a little taller, but over
time the new posture will seem natural and more comfortable.
Following are some guidelines of how to achieve good posture and ergonomics in t
he workplace and other situations.
Sitting posture for office chairs
• Be sure the back is aligned against the back of the office chair. Avoid
slouching or leaning forward, especially when tired from sitting in the office c
hair for long periods
• For long term sitting, such as in an office chair, be sure the chair is
ergonomically designed to properly support the back and that it is a custom fit
• When sitting on an office chair at a desk, arms should be flexed at a 75
to 90 degree angle at the elbows. If this is not the case, the office chair sho
uld be adjusted accordingly
• Knees should be even with the hips, or slightly higher when sitting in t
he office chair
• Keep both feet flat on the floor. If there s a problem with feet reachin
g the floor comfortably, a footrest can be used along with the office chair
• Sit in the office chair with shoulders straight
• Don t sit in one place for too long, even in ergonomic office chairs tha
t have good back support. Get up and walk around and stretch as needed
Standing posture
• Stand with weight mostly on the balls of the feet, not with weight on th
e heels
• Keep feet slightly apart, about shoulder-width
• Let arms hang naturally down the sides of the body
• Avoid locking the knees
• Tuck the chin in a little to keep the head level
• Be sure the head is square on top of the neck and spine, not pushed out
forward
• Stand straight and tall, with shoulders upright
• If standing for a long period of time, shift weight from one foot to the
other, or rock from heels to toes.
• Stand against a wall with shoulders and bottom touching wall. In this po
sition, the back of the head should also touch the wall - if it does not, the he
ad is carried to far forward (anterior head carriage).
Walking posture
• Keep the head up and eyes looking straight ahead
• Avoid pushing the head forward
• Keep shoulders properly aligned with the rest of the body
Driving posture
• Sit with the back firmly against the seat for proper back support
• The seat should be a proper distance from the pedals and steering wheel
to avoid leaning forward or reaching
• The headrest should support the middle of the head to keep it upright. T
ilt the headrest forward if possible to make sure that the head-to-headrest dist
ance is not more than four inches.
Posture and ergonomics while lifting and carrying
• Always bend at the knees, not the waist
• Use the large leg and stomach muscles for lifting, not the lower back
• If necessary, get a supportive belt to help maintain good posture while
lifting
• When carrying what a heavy or large object, keep it close to the chest
• If carrying something with one arm, switch arms frequently
• When carrying a backpack or purse, keep it as light as possible, and bal
ance the weight on both sides as much as possible, or alternate from side to sid
e
• When carrying a backpack, avoid leaning forward or rounding the shoulder
s. If the weight feels like too much, consider using a rolling backpack with whe
els.
Sleeping posture with mattresses and pillows
• A relatively firm mattress is generally best for proper back support, al
though individual preference is very important
• Sleeping on the side or back is usually more comfortable for the back th
an sleeping on the stomach
• Use a pillow to provide proper support and alignment for the head and sh
oulders
• Consider putting a rolled-up towel under the neck and a pillow under the
knees to better support the spine
• If sleeping on the side, a relatively flat pillow placed between the leg
s will help keep the spine aligned and straight.
It is important to note that an overall cause of bad posture is tense muscles, w
hich will pull the body out of alignment. There are a number of specific exercis
es that will help stretch and relax the major back muscles. Some people find tha
t meditation or other forms of mental relaxation are effective in helping relax
the back muscles. And many people find treatments and activities such as massage
therapy, yoga, tai chi or other regular exercise routines, or treatments such a
s chiropractic or osteopathic manipulation, etc. to be helpful with both muscle
relaxation and posture awareness and improvement.

Identifying Incorrect Posture

The first step in improving posture is to identify what needs improvement by exa
mining one’s own posture throughout the day, such as sitting in an office chair,
carrying objects, or standing in line. At regular intervals during the day, tak
e a moment to make a mental note of posture and back support. This should be don
e through the normal course of a day to best identify which times and positions
tend to result in poor posture. Some people find it easier to ask someone else t
o observe their posture and make comments or suggestions.
Examples of bad posture and back support:
The following are examples of common behavior and poor ergonomics that need corr
ection to attain good posture and back support:
• Slouching with the shoulders hunched forward
• Lordosis (also called "swayback"), which is too large of an inward curve
in the lower back
• Carrying something heavy on one side of the body
• Cradling a phone receiver between the neck and shoulder
• Wearing high-heeled shoes or clothes that are too tight
• Keeping the head held too high or looking down too much
• Sleeping with a mattress or pillow that doesn t provide proper back supp
ort, or in a position that compromises posture
Examples of bad posture while sitting in an office chair
The following bad habits are especially common when sitting in an office chair f
or long periods of time.
• Slumping forward while sitting in an office chair
• Not making use of the office chair’s lumbar back support
• Sliding forward on the seat of the office chair
Good Posture Helps Reduce Back Pain
Correct posture is a simple but very important way to keep the many intricate st
ructures in the back and spine healthy. It is much more than cosmetic—good postu
re and back support are critical to reducing the incidence and levels of back pa
in and neck pain. Back support is especially important for patients who spend ma
ny hours sitting in an office chair or standing throughout the day.
Problems caused by poor back support and posture
Not maintaining good posture and adequate back support can add strain to muscles
and put stress on the spine. Over time, the stress of poor posture can change t
he anatomical characteristics of the spine, leading to the possibility of constr
icted blood vessels and nerves, as well as problems with muscles, discs and join
ts. All of these can be major contributors to back and neck pain, as well as hea
daches, fatigue, and possibly even concerns with major organs and breathing.
Identifying good posture
Basically, having correct posture means keeping each part of the body in alignme
nt with the neighboring parts. Proper posture keeps all parts balanced and suppo
rted. With appropriate posture (when standing) it should be possible to draw a s
traight line from the earlobe, through the shoulder, hip, knee, and into the mid
dle of the ankle.
Because people find themselves in several positions throughout the day (sitting,
standing, bending, stooping, and lying down) it s important to learn how to att
ain and keep correct posture in each position for good back support, which will
result in less back pain. When moving from one position to another, the ideal si
tuation is that one’s posture is adjusted smoothly and fluidly. After initial co
rrection of bad posture habits, these movements tend to become automatic and req
uire very little effort to maintain.
Ergonomic office chairs for back support
Office work often results in poor posture and strain to the lower back. Many peo
ple work sitting in an office chair that is not properly fitted to their body an
d does not provide enough lower back support. One strategy is to choose an ergon
omic office chair that often provides better support than a regular chair and ma
y be more comfortable for the patient.