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
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.
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.
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.
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.