Costovertebral Joint Mobilization with Long Sitting Slump Stretch

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Costovertebral Joint Mobilization with Long Sitting Slump Stretch

Treatment for Regional Pain Syndrome involving the Right Leg (Adapted from Cleland and McRae, 2002).:

Patient is long sitting with a belt wrapped around the balls of the feet.
The patient attempts to straighten the knees as much as possible and pull the toes up using the belt.
The patient flexes forward as far as possible and drops the head down.
The therapist side bends and rotates the patient to the left and holds the patient in this position.
The therapist then applies a PA grade III or IV mobilization to ribs 8 through 12 to mobilize the costovertebral joints from T8-12 on the right side.
Patient reports on any relief or change in symptoms in the R leg.

Slump Sitting Mobilization

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Slump Sitting Mobilization

Patient sitting at the edge of the table with the neck and trunk flexed, arms behind the back.
Therapist stabilizes the head and neck in flexion and passively straightens the leg to the barrier.
The therapist then immediately releases the tension by bending the knee.
Therapist repeatedly straightens and bends the knee 8-10 times.
Patient is then instructed to sit up tall and rock the pelvis forward (6:00) and backward (12:00) to release any tension in the low back.
Repeat this sequence with the other leg and then with both legs.
Further mobilization can be done by holding dorsiflexion of the ankle while straightening of the knee.

Counter Stretch with Manual Pressure at L5 or L4

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Counter Stretch with Manual Pressure at L5 or L4

Patient stands with the feet approximately hip width apart and places both hands on top of a counter or table top with the hands shoulder width apart. Patient pushes their hands against the table to assist in extending the thoracic spine.
Patient instructed to bend their knees but keep the heels flat on the floor, lift their sit bones up and back, towards the ceiling to achieve a neutral spine.
Actively the patient straightens the elbows and attempts to elongate the spine, dropping the chest towards the floor.
Finally, have the patient straighten the knees while maintaining a neutral lumbar spine, keeping the sit bones lifting towards the ceiling.
Patient notes where they feel pain
Therapist then applies strong PA pressure on the spinous process of L5 and the patient attempts to straighten the knees again and reports any change/improvement in pain behind the knees or down the leg.
If there is no change in symptoms therapist applies unilateral PA pressure on the lamina of L5, first on one side then the other and patient reports any change in symptoms
If no change is reported with manual pressure at L5 the process is repeated at L4
The goal is for the patient to report an improvement in their symptoms (less pain behind the knee or leg) when the therapist maintains a PA glide at L4 or L5

Supine Piriformis Self Stretch Above 90 Degrees

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Supine Piriformis Self Stretch Above 90 Degrees

To Stretch the Left Piriformis:

Have the patient reach under the left leg and grasp underneath the ankle with their right hand and under their left knee with the left hand.
Instruct the patient to draw the left and ankle towards their right shoulder using both hands.
A stretch should be felt in the left buttocks.
Then have the patient push their left knee and ankle into both hands for 5-7 seconds, when the patient relaxes have them draw their left leg further up towards the right shoulder.
Have them repeat 3-4 times progressively drawing the left leg further up towards the right shoulder upon each relaxation.
Then have them repeat this exercise on the right side.

Piriformis Self Stretch Above 90 Degrees

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Piriformis Self Stretch Above 90 Degrees

To Stretch the Left Piriformis:

Starting from the hands and knees position, the patient places the left foot across and underneath the trunk so that the arch of the foot is facing the ceiling with the left knee remaining outside of the trunk.
Have the patient stretch out the right leg straight behind them while keeping the pelvis straight.
Instruct the patient to gradually sink down until they feel a stretch in the left buttocks. You can have the patient either stay up with their elbows extended or have them come down to rest on their forearms.
Ask the patient to press their left leg straight down into the table or floor for 5-7 seconds, then relax and stretch further by sliding the right leg further back making sure that they keep the pelvis level.
Repeat a series of contract/relax efforts 3-4 times.
No pain should be felt in the left knee or low back during this exercise.

Piriformis Self Stretch Below 90 Degrees

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Piriformis Self Stretch Below 90 Degrees

To Stretch the Left Piriformis:

Have the patient place their left foot outside of their right knee and flat on the table.
The patient places their left hand over the left pelvis to stabilize and places the right hand over the lower left thigh, a towel or belt wrapped around the lower left thigh will also work.
Have the patient maintain an active contraction of the right leg to keep it straight.
Instruct the patient to slowly pull the left leg across until a stretch is felt in the left posterior hip area.
From this position a series of contract/relax efforts can be made for 5-7 seconds, progressively stretching into further adduction or the stretch can be maintained for 30 seconds and repeated 2-3 times.

Piriformis Stretch Above 90 Degrees of Hip Flexion

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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

Piriformis Stretch Below 90 Degrees of Hip Flexion

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Piriformis Stretch Below 90 Degrees of Hip Flexion

Therapist stands on the opposite side of the table and places the left hand on the L ASIS to stabilize
Patient’s left foot is placed outside of the right knee
Therapist adducts the leg to the barrier
Patient attempts to abduct the leg for 5 -7 seconds then relaxes
Repeat 3 to 4 times

Soft Tissue Mobilization of the Posterior Hip Capsule

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Soft Tissue Mobilization of the Posterior Hip Capsule

Patient is positioned with the right hip off the table, but the PSIS is still on the table.
The therapist uses both arms to laterally distract the hip.
A strap can also be placed around the hip to apply lateral distraction.
Therapist slightly adducts and IR the hip then applies a posterior glide thru the femur.
If painful in the groin or SI, abduct the hip slightly.

Soft Tissue Mobilization of the Posterior Hip Capsule

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Soft Tissue Mobilization of the Posterior Hip Capsule

Patient is side lying with the treatment side up. The therapist uses the elbow to scour around the posterior aspect of the hip capsule feeling for areas of tension. The therapist can also work from the posterior aspect of the greater trochanter back across the gluteal area to the sacrum and address any tension in the external rotators of the hip with deep friction massage.

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