Three-Dimensional Scapular Mobilization (Side Lying)

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Three-Dimensional Scapular Mobilization (Side Lying)

To Stretch the Right Rhomboids:

Patient is lying on their L side and the therapist is standing behind.
The therapist reaches underneath the patient’s R arm and places their hand on top of the patient’s R scapula.
The therapist’s L fingers reach under the superior medial border of the scapula.
Using both hands the therapist draws the scapula inferiorly while upwardly rotating and abducting the scapula to stretch the rhomboids.
The therapist maintains the stretch for 30 seconds and repeats 2 to 3 times.

Shoulder Circles

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Shoulder Circles

How to Perform

The patient is side lying with the hips and knees flexed to approximately 60 degrees and the arms straight out in front.
The top arm is taken around in a circle overhead keeping the elbow straight and the hand in contact with the floor.
The patient is instructed to keep the knees together, but is encouraged to rotate through the thoracic spine and rib cage.

Interpretation and the most common dysfunctional patterns seen
Normally the patient should be able to keep the hand in contact with the floor with the elbow straight as they circle the hand around a full 360 degrees.

Notice in the patient above, the restriction for the left versus the right shoulder circle. This restriction is indicative of a loss of thoracic and rib cage mobility for left rotation and limits ER of the left shoulder.

Note: This patient presents with a loss of IR of the R shoulder and ER of the left shoulder secondary to a loss of left rotation of the thoracic spine and rib cage!

Prone Planks with Alternating Hip Extension

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Prone Planks with Alternating Hip Extension

The patient starts in prone lying resting on their elbows that are positioned under the shoulders.
Instruct the patient to rise up on their toes and forearms until they feel that their spine is straight. Observe their spinal position and provide feedback as indicated to make sure they are able to achieve and hold a neutral lumbar spine for 10 seconds.
Once the patient can perform 10 repetitions holding each one for 10 seconds they can increase the level of difficulty by lifting and holding one foot off the table for 10 seconds, then they reverse and lift the other foot off the table for 10 seconds before lowering back down to the floor.
An EMG analysis of 18 exercises designed to strengthen the gluteal muscles found that the prone plank with hip extension with the knee flexed had the highest % of MVIC of any of the exercises tested (Boren et al., 2011.) Caution is therefore advised when prescribing this exercise especially early on in the rehabilitation of a patient.

Prone Planks

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Prone Planks

The patient starts in prone lying resting on their elbows that are positioned under the shoulders.
Instruct the patient to rise up on their toes and forearms until they feel that their spine is straight. Observe their spinal position and provide feedback as indicated to make sure they are able to achieve and hold a neutral lumbar spine for 10 seconds.
They work up to 10 repetitions, holding each one for 10 seconds.

Heel Sitting to Kneeling

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Heel Sitting to Kneeling

The patient starts by sitting on their heels with the trunk erect.
Ask the patient to find a neutral lumbar spine by rotating the pelvis toward 12:00 then 6:00 and find the midpoint.
Instruct the patient to draw the belly in and hold a neutral lumbar spine.
From this position and while maintaining a neutral lumbar spine, instruct the patient to rise up to a kneeling position by extending through their hips and not through the lumbar spine.
Once in the kneeling position the patient slowly reverses back to heel sitting, again by moving through the hips and not through the back.
Instruct the patient to repeat 3-5 times and increase the reps as their strength improves.
This exercise helps to improve a patient’s standing tolerance and strengthen the quadriceps.
Make sure that the patient’s lumbar spine stays neutral throughout the exercise.

Single-Limb Deadlift with Straight Knee

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Single-Limb Deadlift with Straight Knee

To strengthen the Right Gluteus Maximus:

The patient is standing with their hands at their sides.
Ask the patient to reach down with their left hand towards the outside of their right foot while keeping their right leg as straight as possible.
The patient should bend forward from the waist and trunk and avoid bending the right knee as much as possible.
Instruct the patient to try to touch their left fingers to the outside of their right foot.
They then return to upright standing and repeat 3 to 5 times initially, working up to 10 repetitions on each leg.
This exercise requires good extensibility of the hamstrings which should be stretched prior to doing this exercise.
Single-limb deadlift with a straight knee was reported to produce the highest % of MVIC for the gluteus maximus out of 12 exercises that are commonly prescribed for gluteal strengthening (DiStefano et al. 2009).

Single-Limb Deadlift with Bent Knee

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Single-Limb Deadlift with Bent Knee

To strengthen the Right Gluteus Maximus:

The patient is standing with their hands at their sides.
Ask the patient to reach down with their left hand towards the outside of their right foot while keeping their right leg as straight as possible.
The patient should bend forward from the waist and trunk and avoid bending their right knee as much as possible.
Instruct the patient to try to touch their left fingers to the outside of their right foot.
They then return to upright standing and repeat 3 to 5 times initially, working up to 10 repetitions on each leg.
This exercise requires good flexibility of the hamstrings so the patient is allowed to bend the right knee if the hamstrings are tight.

Single Leg Bridge

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Single Leg Bridge

To strengthen the L gluteus maximus:

The patient is lying on their back with both knees bent up and feet resting flat on the floor.
Ask the patient to bring their right knee up to the chest and hold with their hands.
Instruct the patient to draw the toes of the L foot up and gently push the left heel away to inhibit the left hamstrings.
Now ask the patient to bridge up on their L foot as high as they can while they hold their R knee to chest.
Have the patient hold for 10 seconds then slowly lower their L hip back down to the table.
Have them repeat for 3 to 5 reps initially working up to 10 reps on each leg.

Supine Bridging – Bilateral and Unilateral

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Supine Bridging – Bilateral and Unilateral

To activate and strengthen the gluteus maximus:

The patient is lying on their back with knees bent and feet hip width apart.
Instruct the patient to find a neutral lumbar spine, midway between the end range of 12:00 and 6:00 then draw the belly in towards the spine.
Ask the patient to lift the toes up and push the heels away to tighten the quadriceps, then lift the hips up off the table while maintaining a neutral spine.
Instruct the patient to tighten the buttocks muscles as they bridge up.
Don’t let the patient lift up so high that they arch the lower back and lose the neutral position.
Have the patient hold for 10 seconds and repeat initially 3-5 times.
As the patient become stronger, they can attempt to straighten one knee while in the bridge position. They hold for 10 seconds and alternate with the opposite leg before lowering to the table. Make sure the pelvis doesn’t drop and the hamstrings do not cramp. Cramping of the hamstrings is an indication that the gluteus maximus is not engaged enough and that this exercise is too advanced for the patient.
Pushing away with the heels activates the quadriceps to inhibit the hamstrings from working to hard.

Prone Hip Extension Off the Table

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Prone Hip Extension Off the Table

The patient is lying on their stomach on a table top, positioned with their knees bent and feet flat on the floor.
Instruct the patient to find a neutral lumbar spine by rocking the pelvis towards 12:00 then 6:00, finding the midpoint in between. The therapist monitors the PSISs to insure that they are level in the frontal plane.
The patient is instructed to hold this position by drawing the belly button in towards the spine.
Ask the patient to extend one leg at a time, maintaining flexion of the knee and keeping a neutral lumbar spine. Make sure that the patient does not abduct or externally rotate the leg during hip extension and that the PSISs remain level.
The patient should feel their buttocks tighten during the movement. The therapist should also be able to palpate tone in the gluteus maximus during this exercise.
Make sure that the movement occurs in the hip joint, avoiding extension of the spine.
It may be helpful to instruct the patient to try and elongate the leg by reaching away with their knee as the hip is extended.
Have the patient hold for 10 seconds and initially repeat only 3-5 times. Alternate legs.

Retraining