Active Trunk Rotation

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Stretch the Left Iliopsoas

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Manual Therapy, Manual Stretching, Self Stretch, Supine Heel slide

Stretch the Left Iliopsoas

To Stretch the Left Iliopsoas:

  • The patient starts in half kneeling with the left knee placed on a towel or pillow on the floor with the hip internally rotated and the right hip and knee flexed to 90º. Their right hand may be placed on a chair or against the wall for support.
  • Have them place their left hand on their left buttocks. They are instructed to tighten the left buttocks muscle and tuck the hips under (12:00). They draw the belly button in and keep the shoulders centered over the hips so that they don’t arch the back.
  • Instruct the patient to use their right leg to pull the pelvis forward leading with the front of the left hip. They should feel a stretch in the front of the left leg/thigh. Further stretch can be obtained by maintaining this stretch position and side bending the trunk away (toward the right).
  • They are instructed to hold the stretch for 30 seconds 2-3 times or perform a series of isometric contractions attempting to pull the left hip forward for 5-7 seconds then relaxing and stretching further.
  • Then have the patient switch sides and repeat with the right leg.

Rolling Through the Legs

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, All Upper Quarter, Functional Integration, Hip EXT Firing Pattern

Rolling Through the Legs

  • Patient is lying supine with the arms separated overhead and legs apart, at the 10 and 2 and 8 and 4 o’clock positions.
  • Ask the patient to roll over to the prone position starting and moving by using the right leg only.
  • The patient should lead with right hip flexion followed by adduction of the extended leg.
  • The upper body should not contribute to the roll, but follow segmentally the movement of the right leg and pelvis. Watch for any breath holding or substitution by pushing off the left foot.
  • If the patient has difficulty you can use verbal cues and manual contacts thru the pelvis to assist. Asking the patient to elongate along the axis of movement can be helpful. In the illustrated example above the patient would attempt to elongate thru the right arm and/or left leg as they roll to the left.
  • You can also provide compression through the bottom of the left foot or through the right arm to encourage elongation through the axis of movement.
  • Once prone you instruct the patient to roll back to supine initiating the movement through the right leg by extending the hip, adducting the hip and segmentally extending back through the spine without substituting by pushing off with either hand or the left foot. The same manual contacts can be applied to the left foot and/or right arm to assist the patient as needed.
  • Ask the patient to repeat the movement 5 to 6 times as tolerated to both sides.

Trunk Rotation Over a Swiss Ball

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, Functional Integration, Hip EXT Firing Pattern, Rolling

Trunk Rotation Over a Swiss Ball

  • The patient begins this exercise by lying on their back with both legs supported over a swiss ball and with the arms abducted to 90 degrees and both palms facing the ceiling. The ball should be right up against the thighs. If the front of the ball were a clock the left leg is positioned at 10 o’clock and the right leg at 2 o’clock to begin this exercise.
  • Instruct the patient to take a deep breath as they slowly lower their legs to the left side, only lowering as far as they can while keeping the right shoulder blade on the ground. Ideally the outside of the left leg should touch the floor.
  • To complete the entire pattern ask the patient to look to the right as they externally rotate the right arm and internally rotate the left arm so that the left palm is now facing the ground.
  • Instruct the patient to exhale and use their abdominals to bring the legs back to the midline.
  • Have them repeat the rotation to the right side ideally touching the outside of the right leg to the floor.
  • The patient is instructed to work slowly back and forth 3 to 5 times initially, coordinating the arm rotations with the lower trunk rotation.
  • The patient increases the number of repetitions as their strength and control improves.

Trunk Rotation

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, Functional Integration, Hip EXT Firing Pattern, Rolling

Trunk Rotation

  • The patient begins this exercise by lying on their back with both knees bent and feet flat on the floor with the arms abducted to 90 degrees and both palms facing the ceiling.
  • Place a small ball between the patient’s knees and ask them to hold the ball between the knees as they flex the hips up to 90 degrees.
  • Ask the patient to find a neutral lumbar spine with the hips flexed by rotating the pelvis to 6 and 12 o’clock and finding the midpoint.
  • Instruct the patient to take a deep breath as they slowly lower their legs to the left side, only lowering as far as they can while keeping the right shoulder blade on the ground.
  • To complete the entire pattern ask the patient to turn their head to the right, and externally rotate the right arm and internally rotate the left arm so that the left palm is now facing the ground.
  • Instruct the patient to exhale and use their abdominals to bring the legs back to the midline.
  • Have them repeat the rotation to the right side, working slowly back and forth 3 to 5 times coordinating the head and arm rotations with the lower trunk rotation.
  • The patient increases the number of repetitions as their strength and control improves.

Abdominal Oblique Retraining Exercise

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, Retraining

Abdominal Oblique Retraining Exercise

  • The patient is lying on their back with the knees and hips flexed and feet flat on the floor.
  • They are instructed to slowly drop their knees to the right approximately half way to the floor.
  • Ask the patient to slowly bring the knees back to the midline by flattening their back working from above down segmentally without engaging their hips, ie., T12, L1 then L2, etc. (Tell the patient to think about moving the pelvis towards 1 and 2 o’clock).
  • Once they’ve returned to the midline have the patient drop their knees slowly to the left, about half way to the floor.
  • Ask the patient to slowly bring the knees back to the midline by flattening their back working from above down segmentally without engaging their hips (Tell the patient to think about moving the pelvis towards 10 and 11 o’clock).
  • The patient repeats these movements alternating back and forth 3-5 times initially, gradually working up to 10 reps as their control/strength improves.
  • Make sure that the patient does not initiate the return to midline movement through the hips, but rather through the spine.

Dysfunctional Trunk Rotation Test

in 2 Movement Tests Lower Quarter, Active Trunk Rotation, All Lower Quarter

Dysfunctional Trunk Rotation Test

Anatomy and Biomechanics:

Active trunk rotation occurs by the combined activation of the abdominal obliques, multifidi and the erector spinae muscles. This functional movement test also requires that the patient has normal and symmetrical facet joint mobility for flexion and rotation in the lower thoracic and lumbar spines. Restricted spinal rotation, secondary to non-neutral segmental dysfunctions, especially an ERS dysfunction from T6 to L2 that limits segmental flexion and rotation, can interfere with the performance of this test. Consequently ERS dysfunctions found from T6 to L2 need to be addressed as described in module #3. before attempting to retrain this dysfunctional movement pattern with the following exercise.

Abdominal Obliques: Key Global Mobilizers for rotation of the thoracic and lumbar spine and pelvis.

External Obliques – Anterior fibers attach from ribs 5 thru 8 and interdigitate with the serratus anterior. They insert into the linea alba through a broad flat aponeurosis. The lateral fibers attach from ribs 9 thru 12 and interdigitate with the latissimus dorsi. They form the inguinal ligament running from the ASIS to the pubic tubercle. Acting bilaterally they flex the lumbar spine and posteriorly tilt the pelvis. Acting unilaterally they laterally flex the spine to the same side and rotate away, similar to the action of the SCMs.

Innervation – T5 to T12 intercostal nerves

Internal Obliques – Anterior fibers attach along the lateral two-thirds of the inguinal ligament and iliac crest and insert into the crest of the pubis and linea alba. The lateral fibers attach to the middle third of the iliac crest and thoracolumbar fascia and insert to the inferior borders of ribs 10-12. Acting bilaterally they flex and posteriorly rotate the pelvis. Acting unilaterally with the anterior fibers of the external obliques on the opposite side they rotate the thorax forward, when the pelvis is fixed, or rotate the pelvis backward when the thorax is fixed.

Innervation – T7-12 intercostal nerves, iliohypogastric and ilioinguinal nerves

The oblique abdominals also have a vertical component to their orientation meaning that when they contract they also cause simultaneous flexion of the trunk and therefore the lumbar spine. The role of the multifidus in rotation is to oppose this flexion effect and not by themselves do they produce rotation of the spine (Bogduk and Twomey, 1991).

Substitution Patterns to watch out for during retraining:

Patients will often substitute by using the hip external rotators to bring the legs and pelvis back to the table rather than using the obliques when performing this test. Therefore the therapist should instruct the patient to initiate and perform this movement from the trunk and not from the hips. We propose that hypertonicity and chronic tightness of the hip external rotators, especially the piriformis, may be due to this dysfunctional motor control substitution pattern.

Patients will often substitute by overutilization not only of the hip external rotators, but also by using the quadratus lumborum or the lateral fibers of the obliques resulting in frontal plane side bending. They may also substitute for the multifidus by using the erector spinae muscles resulting in excessive segmental extension to compensate for the lack of control in the transverse plane. Therefore the therapist should watch for any trunk side bending or spinal extension that may occur when retraining the patient in the performance of the following exercise. Not only can these substitution patterns be palpated with your fingers placed alongside the spinous processes as demonstrated in module #2, but an astute therapist can often observe these substitution patterns as they occur by asking the patient to slowly and repeatedly rotate the legs and pelvis back and forth from side to side.

Supine Quadratus Lumborum Self Stretch

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, All Upper Quarter, Hip ABD Firing Pattern, Rolling, Self Stretch, Self-mobilization, Shoulder Circle

Supine Quadratus Lumborum Self Stretch

To Stretch the Left Quadratus Lumborum

  • The patient is lying supine and crosses the right leg over the left.
  • Instruct the patient to drop both legs to the right.
  • Have the patient push their knees together for 5 to 7 seconds and then relax. Upon relaxation the right leg pulls the left leg further over to the right to increase the stretch.
  • Repeat 3-4 times progressively.
  • Goal – try to touch the inside of the left knee to the floor without raising the left shoulder off the floor.
  • Repeat on the opposite side.

Quadratus Lumborum Hands and Knees Self Stretch

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Lower Quarter, Hip ABD Firing Pattern, Self Stretch

Quadratus Lumborum Hands and Knees Self Stretch

To Stretch the Right Quadratus Lumborum:

  • Have the patient reach forward with the right hand and grasp a solid object. From this position instruct the patient to sit back diagonally towards the right hip, elongating (stretching) the right side of the back.
  • The right arm may be internally rotated (thumb down) or externally rotated (thumb up). Since the latissimus dorsi is an internal rotator of the shoulder internal rotation of the arm places more stretch selectively on the quadratus muscle.
  • Have the patient hold the stretch position for 30 seconds and repeat 2-3 times alternating sides.

Piriformis Stretch Above 90 Degrees of Hip Flexion

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, Active Trunk Rotation, All Lower Quarter, All Manual Therapy, Manual Stretching, Muscle Energy, Rolling

Piriformis Stretch Above 90 Degrees of Hip Flexion

  • Therapist externally rotates the leg, then adducts the leg towards the opposite shoulder
  • Patient is instructed to push out with both the knee and ankle; if external rotation is more limited, push out with the ankle only
  • Upon relaxation the therapist adds further adduction and/or ER to the new barrier
  • Repeat 3 to 4 times
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