Musculoskeletal Physiotherapy

Summary of Conditions
Brittany MacLeod

ABSTRACT
Condition overviews, initial assessment + treatment principles
Table of Contents
Checklist of Practical Skills for OSCEs....................................................................................................3
MSK Patient Interview.......................................................................................................4
The Lower Limb..................................................................................................................4
Hip.........................................................................................................................................................4
Practical Skills........................................................................................................................................6
Knee......................................................................................................................................................6
Practical Skills........................................................................................................................................8
Ankle.....................................................................................................................................................9
Practical Skills......................................................................................................................................10
The Upper Limb................................................................................................................11
Shoulder..............................................................................................................................................11
Practical Skills......................................................................................................................................11
Elbow...................................................................................................................................................11
Practical Skills......................................................................................................................................11
The Lumbar Spine.............................................................................................................13
Specific Conditions..............................................................................................................................13
Lumbar Radiculopathy.........................................................................................................................13
NSLBP..................................................................................................................................................13
Mechanical SIJ pain.............................................................................................................................14
Acute Mechanical LBP.........................................................................................................................14
Spondylisis...........................................................................................................................................15
Chronic/Persistent LBP....................................................................................................................16
Practical skills......................................................................................................................................17
Generalised Treatment Approaches....................................................................................................18
The Cervical and Thoracic Spine.......................................................................................19
Common Conditions............................................................................................................................19
Practical Skills......................................................................................................................................19
Post-Orthopaedic Management.......................................................................................20
Checklist of Practical Skills for OSCEs
Hip
 Joint vs lateral hip conditions DD (hip OA vs labral tear vs gluteal tendinopathy)
 ROM and Major Special Tests
 Glute Med/pelvic stabilisers
 Education and self management
Knee
 DD acute (ligament vs meniscus vs dislocation)
 ROM and major special tests
 PFJ TDT
 Manual therapy
 Exercise management
Ankle
 DD
 ROM, KTW, special tests
 Basic MT
 Ankle exercises
Shoulder
 Ax scapulohumeral rhythm
 Impingement tests
 Scapula assistance TDT
 Basic MT
 Isometric, RC loading and scap retraining
 Self-management
Elbow
 DD – articular vs tendon vs nerve
 ROM and special tests
 TDT
 Ax scapulohumeral rhuthm
 Basic MT
 Exercise and self management
Lumbar
 Basic DD
 Neurological
 Neurodynamic
 ROM/ PAIVMS
 Basic A+E
 MT
Cervical
 Neurological
 Neurodynamic
 ROM/PAIVMS/PPIVMS
 Scap assessment
 DNF assessment
Cases covered in MSK OSCE Week: knee pain, acute LBP, ankle fracture, neck
pain/headache, insidious onset shoulder pain, insidious onset elbow pain

Healing time frames

 Bone - ~4-6 weeks
 Soft tissue ~8-12 weeks
 Post-operative – see post-op management section

MSK Patient Interview

 Introduce yourself, explain what physiotherapy is/ what you will do
 What is your main concern?
Ask about:
 Pain (severity using VAS), P+N, numbness, weakness, clicking, grinding, locking,
swelling (speed and amount), bruising
 Mechanism of injury (contact/non-contact/amount of force)/ time of pain onset
 Duration of pain
 Insidious onset: duration of training, changes in training, environmental and
equipment factors
 Pain referral/clear adjacent joints
 24 hr pattern – is it worse in the morning, or evening
 Aggravating and Relieving factors
 Current level of function (use of outcome measures)
Past MHx
 Previous injuries
 THREADS
Social History
 Support at home, living environment
 Hobbies
 Work/ level of function needed to return
Goals

MSK Physical Examination

Need to identify source of impairment, and impact of impairment associated with:
 Muscle strength
 Muscle length
 ROM deficit – need to determine if due to pain restriction or capsular/bony
restriction
 Motor control
 Balance
The Lower Limb
Hip
1. Muscle Tear
Signs and Symptoms – pain on palpation of muscle belly, normally can point to a specific
sore spot rather than just generalised muscle soreness; inability to perform desired function
Ax
MMT of affected muscle; palpation; MLT of affected muscle
Rx
Relative rest; gradual isometric – eccentric- concentric strengthening program; sports
taping over point of injury for pain relief (allows continuation of game play)
2. Labral Tear
The labrum is a vulnerable structure due to compressive, shear and tensile forces, with
larger forces placed on the tissue with reduced bony support of an anteverted femur.

Signs and Symptoms – Pt reports locking, clicking, grinding, giving way, deep pain, anterior
or posteriorly, mostly traumatic or degenerative, ER hip F most aggravating
Ax
Pain on palpation; gait observation; FABER/FADIR (test for intra-articular pathology),
Thomas Test, MMT and ROM, distraction glide , TDT with MWM
Rx
Manual therapy initially for pain relief
Exercises for neuromotor, sensorimotor and generalised strengthening
Surgical management via arthroscopy

3. Gluteal Tendinopathy
Signs and Symptoms – Pt reports lateral hip pain, around greater trochanter, pain sitting
knees togther or legs crossed, pain on side lying (affected up), pain in hip adduction, SLS
Ax
Observe gait, Ober’s test, derotation test, SLS stance, palpation, ITB MLT
Rx
Isometrics for abduction and adduction, bridging and squatting double to single leg
progression

4. Hip OA
Signs and Symptoms – pain on squat, hip F and E (Active), decreased IR passive ROM
Ax
Squat, FADIR, Hip ROM, MMT, Scour test, balance, SLS
Rx
Glides for pain relief, gradual strengthening program, sensorimotor exercises

5. Perthe’s Disease

Signs and Symptoms – anterior hip pain with limp, low grade pain in anterior thigh which
may radiate to the knee, age 4-10, male,
Ax
Palpation, ROM
 Rx
Rest from aggravating activities, may require time out of sport, Exercises for hip
abduction and IR
Severe cases may require surgical intervention

6. Groin pain
 Adductor
Signs and Symptoms - pain with kicking, twisting, side to side movements, pain at adductor
longus tendon, pain on resisted adduction
Ax
Abduction ROM, Adduction MMT, adductor squeeze test
Rx
Soft tissue therapy, gradual strengthening of abd/add, stretches
 Illiopsoas
Signs and Symptoms – pain during straight line running, proximal anterior thigh pain, pain
on resisted him flexion and hip flexor stretch
Ax
Hip flexion ROM, MMT, Hip Ext ROM
Rx
Stabilising pelvis exercises, hip strength exercises
 Inguinal
Signs and Symptoms – pain during sit ups, coughing, pain on inguinal palpation, pain on
valsavalva
Ax
Abdominal MMT, palpation
Rx
Abdominal and LL strength, focus on abd/add muscles

 Pubic
Signs and Symptoms – local tenderness over pubic symphysis
Ax – palpation of pubic symphysis (there are no particular diagnostic/resistance tests to
identify pubic groin pain); potential +ve adductor squeeze test
Rx
Initial deloading period/break from sport; gradual increaaase in loading over a 3 month
period (dependent on progress) move from less WB to more e.g. stationary bike, stepper
then running
Return to training when 30mins pain free running tolerated (guide only)

Practical Skills
 Special Tests:  Movement Ax
 FABER  AP, PA, lateral and distraction
 FADIR accessory glides
 De-rotation test  AROM + PROM – flexion, extension,
 SLS for pain abd/add, IR, ER
 Adductor squeeze test  Ober’s test
 Retroversion-anteversion Ax  Thomas Test
 Beighton scale  MWM AP, lateral glide hip flexion
Knee
1. Meniscal Injury
Signs and symptoms – pain getting in and out of a chair, difficulty standing,
locking/clunking/catching, deep pain
P/I – twisting mechanism, tearing sensation, morning stiffness, pain increases with use – no
night pain
Ax
Palpation (joint line tenderness), reduced ROM, difficulty WB, SLS, Special tests: Thessaly,
McMurrays, Apley’s,
Rx
Gentle ROM, AP/PA MT
A+E – pain management strategies, avoid agg positions, send for scan, explain condition
Quads and hamstring strength and length, SL balance for neuroMSK control, JPS training
Knee MRI is the GOLD standard of diagnosis
2. MCL Injury
Signs and symptoms – pain on medial knee
P/I – pain on WB, popping sound at time of injury, feeling of instability, pain at joint line
P/E
Ax
Palpation; Special tests: Valgus stress test
Rx
Valgus instability tape, glides, LL strength for stability, balance/proprioception
A+E
Pain management, immobilise, gentle ROM/isometric holds
Strength and ROM training
Proprioceptive/sensory training
3. LCL Injury
Signs and symptoms – pain on lateral joint line, instability near extension, difficulty with
stairs/uneven terrain, antalgic gait
Ax
Special tests: Varus stress test, posterolateral instability test
Rx
Varus instability tape, glides, LL strength for stability, TFL specific strenghtneing,
balance/proprioception

4. PCL Injury
Signs and symptoms – mild swelling, pain, feeling of instability, pain with kneeling
Ax
Special tests: sag sign, posterior draw test, posterolateral instability/dial test,
Rx
Passive glides, LL strength for stability, balance/proprioception, progress to reaction time
drills

5. ACL Partial tear/ Rupture

Signs and symptoms – flexion/ER/Valgus force MOI, pain, associated feeling of giving way,
may report pop
Ax
AROM, joint line palpation, Special tests: Lachman test, Anterior draw test, lateral pivot shift
test
Rx
LL strength for stability, balance/proprioception  end stage progress to perturbation
training
MRI is GOLD standard for identification of severity
Pre-hab for surgical management + post-op recovery; or follows conservative management
program

6. Patella fracture/dislocation
Signs and symtpoms – pain on medial patella, instability, the feeling of something popping
out and then back in, pain free in resting extension
Ax
Palpation of medial patella border; Special tests: patellar apprehension test, pain on quads
contraction
Rx
Lateral Retinaculum stretch/MT; isometric quads, VMO activation, gait re-education and
address apprehension
7. PFP
Signs and symptoms – gradual onset pain, tender patella facets, creptitus, stiffness; pain on
prolonged sitting, climbing stairs, squatting, kneeling, hiking, running, hopping and jumping.

Ax
Knee valgus, quad patellar tracking, increased pronation, hip abductor weakness, adductor
muscle tightness, dynamic foot control, anteversion/retroversion, reproduced poor motor
control on functional tests
Special tests: Patellar apprehension test, TDT – patella taping with squat/other activity; anti-
pronation tape with activity
Rx
MT – patellofemoral glides, stretching of lateral retinaculum, patella taping/orthoses; VMO
activation and quads retraining, posterior chain strengthening/correction of hip alignment,
retrain functional tasks
8. Fat Pad impingement
Signs and symptoms – pain distal to patella, pain on impact (jumping/landing), worse by
hyperextension or prolonged standing/squatting, pain increases with activity
Ax
Pain on single leg hop, pain on palpation pain on active+passive knee extension, and passive
knee flexion, pain on inferior glide
Special tests: TDT – patella deload tape
Rx
Quads retraining/ address LL strength imbalance to fix hyperextension
Deload tape if indicated
A+E

9. Knee OA
Signs and symptoms – increasing pain with activity, worse in morning, stiffening/crepitus,
pain at night which may disturb sleep
Ax
AROM and passive ROM (Decrease), reduced quads and hamstring MMT, SL balance, JPS,
palpation
Special tests: McMurrays, valgus/varus stress test may recreate grinding sensation;
Rx
Tibiofemoral rotations or AP/PA  3 or 4 if glide is not changing pain levels - Could apply as
MWM  extension move into flexion; Goniometer  assess range; check on stairs;
Improve knee flexion without a glide – quads massage, contract relax and hold relax, passive
stretch (do not need load)

10. ITB friction syndrome

Signs and symptoms - Achey pain on lateral aspect of knee, Aggravated by running cycling,
Pain developing at same time during activity, Downhill activities are aggravating
Ax
Repeated knee F/ext, palpation of lateral femoral epicondyle, Special tests: Ober’s
Rx
Strengthening of IR/ER/ABD/ADD, soft tissue therapy of gluteus maximus and ITB, stretching
of gluteals and ITB

11. Quadriceps tendinopathy

REVIEW GENERAL TENDINOPATHY MANAGEMENT

12. Patellar tendinopathy

Signs and symptoms – front knee pain, made worse by jumping, squatting, changing
direction and decelerating, palpable thickened tendon, worse in morning
Ax
Palpation, Squat, SL hop, decline squat **, kinetic chain MMT (generalised weakness), MLT
of quads and hamstrings
Rx
Trigger point/deep tissue massage; kinetic chain strengthening specific to calves, glutes and
hamstrings; isometric holds for pain, in off season need to completely re-build strength
baseline

Practical Skills
 Special Tests:
 Varus Stress test (LCL)
 Valgus stress test (MCL)
 Sag sign + posterior draw test, dial test (PCL)
 Lachman test, Anterior drawer test, Lateral pivot shift test (ACL)
 Thessaly test
 McMurrays
 Apley’s
 Joint effusion
 Patellar apprehension
 AP, PA, lateral and medial tibio-femoral joint glides; joint distraction, medial/lateral
rotation
 AP, PA, superior and inferior tibio-fibular joint glides
 Superior/inferior/medial/lateral PFJ glides
 AROM + PROM – flexion, extension, abd/add, IR, ER
 Lateral retinaculum mobilisation
 Patella taping

Ankle
1. Lateral ligament injury
Signs and symptoms – pain under and around lateral malleolus, swelling, inability to WB,
MOI – inversion and PF
Ax
Palpation, anterior draw test, talar tilt inversion test, ROM DF via KTW
Rx
Active strengthening exercises, balance exercises, lunge stretches, taping for support/return
to sport
2. Medial/deltoid ligament injury

Signs and symptoms – pain under and around medial malleolus, swelling, inability to WB,
MOI – forced eversion
Ax
Palpation, talar tilt eversion test, ROM PF
Rx
Active strengthening exercises, balance exercises, taping for support/return to sport

3. High Ankle sprain – AITFL/Syndesmosis

Signs and symptoms – pain and swelling on the anterior ankle, inability to WB, MOI – ER
with load
Ax
Palpation, fibular squeeze test, passive external rotation, PF ROM,
Rx
Immobilisation in boot/crutches or surgery required. Post-acute phase: Active strengthening
exercises, balance exercises, taping for support/return to sport
4. Chronic ankle Instability (CAI)
Signs and Symptoms – swelling, discomfort +tenderness, repeated ankle sprains
Ax
Special tests: anterior drawer, inversion/eversion tilt tests, medial subtalar glides, balance
Ax
Rx
Calf stretch, Lower leg muscle strengthening, balance and proprioception exercises
5. Malleolar #
Signs and symptoms – pain on palpation of malleolar zone, swelling, inability to WB, rapid
onset swelling, may have heard sound at MOI
Ax
Palpation, tapping proximal tibia/fibula to fracture site may elicit pain
Rx
Initial period immobilisation, Active strengthening exercises, balance exercises, stretching to
regain ROM,

6. Avulsion # of the 5th MT

Signs and symptoms – pain on the head of the 5th MT, swelling in the foot, difficulty WB, MOI
– inversion
Ax
Palpation, painful inversion and decreased inversion ROM
Rx
After immobilisation, active strengthening exercises, balance exercises, glides of foot joints
for stiffness

7. Achilles tendinopathy
Signs and Symptoms – gradual onset pain at Achilles, pain on heel raises or hopping,
reduced range, pain and stiffness morning after activity
Ax
Observation of muscle atrophy, reduce DF ROM, palpation
Rx
Calf soft tissue massage, isometric  endurance/concentric  energy storage exercises e.g.
slow skipping, fast stair climb  energy storage and release (more speed elements)
8. Ankle impingement syndrome
Posterior
Signs and symptoms – insidious onset pain posterior ankle, secondary to PF injury
Ax
Special test: posterior impingement test, TDT –AP glide MWM for pain; palpation, functional
activity ax, passive/active PF,
Rx
MT of talocrual and subtalar joint; LL and foot intrinsic strengthening, biomechanic
correction
Anterior
Signs and symptoms – vague discomfort progressing to pain in front of ankle, worse with
activity, stiffness, loss of speed
Ax
Palpation, abnormal gait, DF ROM, Special test: ankle impingement test
Rx
AP talocrural glides, ROM and strength maintenance exercises
9. Medial tibial stress syndrome
Signs and Symptoms – bad in morning, worse at beginning of exercise,
Ax
Palpation of posteromedial border, hopping, MLT and MMT of calves, DF and PF AROM
Rx
Low dye taping, soft tissue massage, strength and stretch exercises
 10. Plantar Fasciopathy
Signs and Symptoms – inferior medial heel pain, worse in the morning and decreases with
activity,
Ax
Observation of foot biomechanics, palpation, MLT calves, MMT posterior chain, special test:
windlass mechanism
Rx
Soft tissue therapy, self massage with golf ball or trigger point ball, Calf stretch,
strengthening hip abductors/adductors
11. Tibialis Posterior Tendinopathy
Signs and Symptoms – medial foot and top of foot pain (navicular), after change in training,
over pronated foot
Ax
Palpation, inversion MMT, heel raise, DF/PF ROM
Rx
Deep tissue massage of muscle belly, progressive concentric-eccentric loading post acute
inflammatory phase

Other Conditions
 Peroneal tendinopathy
 Tibialis anterior tendinopathy
 FHL tendinopathy
 Calcaneal fat pad injury
 Sinus tarsi syndrome
 Tarsal tunnel syndrome

Practical Skills
 Special Tests:
 Anterior Drawer Test
 Talar tilt inversion stress test
 Talar tilt eversion stress test
 Supination stress test
 Passive external rotation
 KTW test
 Simmonds Thompson Calf squeeze
 Squeeze test (syndesmosis or fracture)
 Subluxing peroneal tendons
 Lunge test
 Posterior ankle impingement
 Tinel’s
 Windlass (MTP joint)
 AP, PA talocrural joint (MWM)
 Lateral/medial subtalar joint glide
 Joint distraction
The Upper Limb
Shoulder
Common Conditions
1. Instability of GHJ
2. Shoulder impingement
3. RC Tendinopathy
4. Adhesive Capsulitis
5. SLAP pathology
6. GIRD
7. ACJ sprain

Practical Skills
 Passive glides – GHJ AP, PA, inferior and lateral glides, ACJ AP, PA glides, SCJ AP,
inferior and superior glides
 Special tests
 Instability – Sulcus sign, load and shift test, apprehension test
 Labral – O’Brien’s Active Compression test, biceps load test, Crank test,
 Capsular restriction – Anterior capsule length test, Posterior capsule length
test
 Impingement – Neer’s, Hawkins Kennedy
 RC tests – Empty can, Gerber’s lift off
 LHB – Speeds test, Yergason’s test
 ACJ – horizontal adduction, shoulder shrug
 MMT – lower trapezius, SA
 Motor control – HOH positioning
 Joint distraction GHJ
 MWMs
 ROM – passive, self assisted and active assisted
 Resistance exercises for RC, lower trapezius, upper trapezius, SA,
 ACJ tape, HOH tape

Elbow
Common Conditions
1. Extensor Tendinopathy (lateral elbow tendiopathy/tennis elbow)
2. Flexor/pronator tendinopathy
3. MCL sprain
4. Bursitis
5. Triceps tendinopathy
6. Posterior impingement

Practical Skills
 Passive combined movements + AROM
 Passive glides – humeroulnar AP, longitudinal, radioulnar AP and PA, medial and
lateral elbow glides,
 Special tests
 LCL/Varus stress test
  MCL/Valgus stress test
 Grip strength test
 TDT – MWM lateral glide with gripping, MWM PA of radius with gripping
 AP/PA glide of superior radio-ulnar
 Self-glides – lateral, PA
 Deloading tape, lateral glide tape, valgus/varus instability taping
The Lumbar Spine

Specific Conditions
Lumbar Radiculopathy
Brief run done of Ax plan  As the patient has neurological symptoms it is important to
establish a baseline and also determine the degree of severity, therefore a neurological
exam must be conducted.
Physical Examination
Priority 1: Neurological/Neurodynamic Examination
Priority 2: Lateral Shift correction
Functional
Brief run down of Tx plan 
Management
Treatment 1: Neural slider
o Supine knee bend – extend knee and PF, flex knee and DF
Treatment 2: Reverse lateral flexion – manual therapy technique
o Grade 3 – progress to grade 4
o Reassess pain and ROM
Treatment 3: A +E
o Neurological symptoms explained – irritation of nerve root due to sensitivity
o Evidence on return to work and how it is very important in level of functionality,
reduction of pain and best prognosis  those who go back to work sooner have
better outcomes
o 80% have favourable outcomes and in most cases symptoms are gone within 4-6
weeks
o Exercise is favourable – level of exercise will increase over time, whilst symptoms are
still quite irritable it is important to stay within boundaries of limited pain, and avoid
exercises that make leg pain worse
o In the long term – maintenance of gym will be extremely helpful in preventing
recurrence of LBP
o If the neurological symptoms get worse with exercises, please stop and come back
and see me
o Pain medication

NSLBP
Physical Examination
Priority 1: Motor control assessment
o Forward lean test in sitting and standing
o Motor control assessment of functional tasks
Priority 2: Functional assessment (or manual examination???)
o Observation of squat and deadlift – observe and correct motor control
Management
Treatment 1: A+E
 o Highly likely that pain is associated with irritation in his back due to poor motor
control – with correction of some technique and increasing awareness of how his
back is positioned, can continue at the gym and reduce pain, prevent it from
occurring again
o Some of the pain may be due to central sensitisation – over time the danger signals
sent to the brain build up meaning that less perceived threat is required to cause
pain
o There is nothing dramatically wrong with the back, the pain is not due to damaged
structures and can be easily monitored with motor control exercises
o Motor control exercises will increase your awareness of back in space and help you
to understand when you might be going into a position that is aggravating for your
back.
o Prolonged positions are also aggravating to you, adapting the position and finding a
neutral position so your back is not constantly bent over may decrease the pain
o We know that exercise is very much beneficial in reducing pain in LBP
Treatment 2: Motor control Prescription
o Squat – bodyweight only – (regress to mini squat; progress to adding weight)
o Deadlift movement – bodyweight only (regress to forward lean in standing; progress
to adding minimal weight)
o Pelvic tilt in squat against wall – maintain flat spine on wall
o Lumbopelvic dissociation in sitting
o 3x10 reps as tolerated (pain/fatigue)

Treatment 3: Manual therapy – reverse lateral flexion

o Grade 3/4
Alternative: Hamstring/hip extensor stretch

Mechanical SIJ pain

Physical Examination
Priority 1: Lumbar AROM and OP to rule out the lumbar spine (would also do gillet’s and
stork test in standing)
Priority 2: SIJ provocation tests
Alternative: functional assessment
Management
Treatment 1: A+E
o Advice and education – postural positioning, explain diagnosis, position for holding
baby Using belt
o Work modifications – sit and stand alternating
o Exercise – walking, swimming, cycling
Treatment 2: Exercise Prescription
o Crab walks
o Glute bridges
o Weight transfer in standing
Treatment 3: Manual Therapy – WB anterior rotation (MWM)
o 8 reps on L leg lifting R leg; reassess with stairs/ single leg stance task
o Repeat once or twice more if effective
Acute Mechanical LBP
Physical Examination
Priority 1: AROM/repeated movement examination
Priority 2: palpation/PAIVM – in prone if can get into prone, or side lying
Alternative: functional
Management
Treatment 1: A+E
o You haven’t sustained a serious injury back and have been doing the right things up
to this point; 50% will recover within 1-2 weeks and severity of your symptoms
should continue to decrease exponentially
o Can rule out anything sinister – recovery should be good as a result of this
o From when I was pressing on your back, we can tell that you have sustained a mild
sprain to that segment in your back. This is very common and mild injury and there
are a lot of factors that contribute to this pain. You have said that you have quite
high levels of pain and it get aggravates quite easily. It doesn’t mean you are doing
any harm or injury to you back at the moment it just means that your back is quite
sensitive.
o Pain messages sent to the pain centres in your brain which can be amplified by lack
of sleep, prolonged position, stress about work or home, lack of activity and negative
attitude. Alternatively number of factors that we know help dull down the pain
messages sent.
o Temporary changes to help with recovery – pain medication, work adaptations
o Encourage return to work but maybe the ability to work from home to avoid that
prolonged position just for the next few days
o Activities – walking, swimming,
o Support temporarily at home and work
o 50% close to full recovery 1-2/52
Treatment 2: Exercise prescription towards directional preference
Directional preference to extension
o Repeated extension in standing x10 2-3 times a day
o Cat camel exercise
o Prone on elbows
Treatment 3: Rotation MT and HVT
o Evidence for HVT in acute LBP
o Contraindications for HVT – osteoporosis, structural deformity, structural instability,
inflammatory conditions, vascular deficits, worsening neurological signs/symptoms,
cord compression, red flags, non-mechanical symptoms

Spondylisis
Brief run down of Ax plan  Prioritising active range of movement assessment in order to
determine what movements bring on pain and clarify if there is a specific side that is more
painful than others. In this case, if the patient can tolerate it is important to assess the
extension quadrant as this mimics many movements she may have to perform in
gymnastics. After this, it is important to perform a manual examination for identification of
the painful segment and any muscle wasting as well as review functional tasks in order to
provide direction to management and exercise prescription.
Physical Examination
Priority 1: AROM and Combined movements (if pain free on AROM and overpressure)
o Flexion/Extension
o Extension quadrant
Priority 2: Manual examination for identification of segment
o Palpation + PAIVM
Functional
Brief run down of Tx plan  Begin with advice and education. Whilst there is no need to use
overly pathoanatomical or threatening language, it is important that the patient
understands she has a serious injury and that there is a necessity for some time off sport to
allow for proper bone healing. Educate on other ways to maintain fitness that will not be
provoking or aggravating to her injury. Address motor control exercises, what they are and
why they are important. Outline prognosis and timeline for return to sport. Teach motor
control exercises to begin increasing awareness of back positioning in space for reduction of
pain and also as a preventative measure for recurrence. Teach other exercises for gluteus
medius strengthening to address maladaptive positions i.e. trendelenburg and provide more
stability and strength to the lower spine.
Management
Treatment 1: A+E
o Necessity for immediate time off sport in order to allowed healing of bone; however
understand that it is important to you that you maintain physical fitness. Can still do
some stabilised upper/lower body bodyweight workouts. For cardiovascular fitness,
swimming or cycling are good alternatives.
o It is important that you are pain free before sport specific exercise or more intensive
exercise begins as you are at risk of worsening the injury.
o Motor control exercises are in order to retrain positioning and increase the
awareness of your back so you can learn to prevent overly going into extension
which will significantly improve your pain and provide you with the ability to prevent
this exercise from happening again.
o You mentioned earlier that NSAIDs have been helping with the pain, this is great.
However, I would recommend you speak to a pharmacist about some alternative
pain medication, as we know that it is better for bone healing to avoid the use of
NSAIDs in the early stages.
o Timeline for return to sport depends on the extent of the fracture but normally
ranges from 8-12 weeks.
Treatment 2: Motor Control Prescription
o Hip Ext in prone with TA contraction (regress range of hip ext; progress to standing?)
o 4 point kneel – arm and leg lift (regress – just arm/just leg; progress to lift arm leg,
hold leg out whilst moving arm in and out for 10 reps)
o Single leg squat
o Squat against wall – correct anterior tilt by maintaining back in contact with the wall
in order to force neutral spine
Treatment 3: Exercise prescription – Gluteus medius strength
o Side lying abduction
o Standing isometric hold
o Lateral squat walk with band
Chronic/Persistent LBP
Physical Examination
Priority 1: Neurological/Neurodynamic
Priority 2: functional – need to see hyper vigilant behaviours; assess and correct – sit to
stand, other tasks they have been having difficulty with
Management
Treatment 1: A+E ***
o Reconceptualise problematic pain beliefs, reassurance, importance of self-
management.
o Might provide an analogy about the problem with being upright and bracing all the
time
o Providing normative information regarding MRI findings *table
o Specifically discuss workplace strategies - regular breaks, using back of chair for
support
o Ensure the patient understands the role and efficacy of exercise management –
especially the exercises and strategies around relaxing the back and moving it more
o Provide links/handouts to expand knowledge and concerns re pain
o Address patient concerns and misunderstandings, unhelpful belief; educating pain
does not equal harm; reduce fear avoidance
o Movement encouragement, and demonstration of how; reincorporating functional
tasks
o Address centralisation
Treatment 2: Exercise prescription
o Cat Camel
o Forward lean in sitting
o Knees to chest in supine
o Anterior posterior pelvic tilt in sitting with hands on pelvis
o Okay to begin cycling – may find it actually improves pain (cycling and walking one to
two times a day), may be better to avoid gym classes for this week whilst pain calms
down. Then slowly re-incorporate gym classes when capable of modifying exercises
her.
Treatment 3: MWM PAIVM into flexion
o In sitting – 8 reps; reassess ROM and VAS; if effective (more than 2 point change on
VAS scale) then repeat two more times

Practical skills
 Observation – pelvic alignment, muscle bulk, shoulder girdle, knee H/E,
lordosis/kyphosis, ability to correct to optimal posture
 Active AROM
 AROM with OP
 Combined movements
 Repeated movement Ax
 MT – PAIVM, Unilateral PAIVM, Flexion PPIVM, Segmental rotation, manipulation,
reverse lateral flexion
 Box taping
 MMT (Glutes, abdominals, extensors, QL)
 MLT – Thomas test, hamstring length
  Neurological – sensation, MMT (power), reflexes
 Neurodynamic – PNF (for severe/irritable cases), SLR, PKB (femoral nerve and rec
fem), slump test
 Sitting lumbopelvic dissociation
 Forward lean test
 4 point kneel – neutral spine and lumbopelvic dissociation
 Hip extension in prone
 TA and Multifidus activation
 SIJ Provocation tests – thigh thrust, distraction, compression, PA sacrum, Gaenslens
 SIJ movement tests – Gillet test, stork test
 SIJ ASLR
 MT – anterior/posterior rotation in supine or MWM in standing, MWM in
sitting/standing for Flexion

Generalised Treatment Approaches

Lumbar spine MT
 PA/ unilateral PA – aid saggital movements, specifically ext, for pain and ROM
 Flexion PPIVM – acute pain, flexion related
 Reverse Lateral flexion – neural symptoms / acute LBP
 Segmental Rotation – Acute LBP
 Manipulation – Acute if tolerated
 Massage – pain/ROM
 MWM Prone into ext – increase extension ROM/ reduce pain
 MWM 4 point kneel into flexion – increase flexion ROM/ reduce pain
 MWM flexion sitting – increase flexion ROM/ reduce pain
 MWM flexion standing – increase flexion ROM/ reduce pain
Pelvis MT
 Anterior rotation – increase ROM/ for pain
 Posterior rotation– increase ROM/ for pain
 AP ASIS– increase ROM/ for pain
 Massage– increase ROM/ for pain, in position of stretch if tolerated
 PA sacrum – more mild symptoms
Neurodynamic exercises
 Supine – head and foot slider  acute and irritable
 Supine – DF and knee F slider  less acute
 Supine – DF tensioner  less acute
 Sitting – Knee F/Ext + DF/PF slider  less severe if pt can tolerate sitting
 Sitting – DF/PF + cervical Ext/F slider  very mild/ distal symptoms (normally
progressed from above)
 Sitting – DF/PF tensioner  very mild/ distal symptoms (normally progressed from
above)
General exercises
 Active ROM – reduce pain and tension, use during acute episodes or to reduce
spasm
 Extension specific exercises - directional preference = extension
 Flexion specific exercises – directional preference = flexion
  Anterior/posterior pelvic tilting – increase lower lumbar range, reduce pain, increase
motor control/positional awareness
Motor control exercises
 Breathing exercises – reduce tension, increase awareness of bracing
 4 pt kneel
 Lumbopelvic dissociation – improve coordination and awareness
 Sit to heels – flexion control issue (maintain neutral), in flexed position to improve
flexion ROM and for flexion directional preference
 Lumbopelvic dissociation – improve postural awareness
 Hip extension in prone – extension control issue
 Birddog – ext/flex control issue
 Squat – ext/flex control issue
 Forward lean in sitting – flexion control issue
 Forward lean in standing – flexion control issue
 Static TA - TDT
 Static Multifidus – reduced ability to isolate segmental movements
 Bridge – endurance + extension control
 Plank - endurance
 Roll down wall – extension control issue, practice relaxing lumbar spine
Add complex movements once above is done with ease
Stretch/release exercise
 Hip Flexor – increase flexibility, may be needed if contributing to excessive lumbar
extension
 Hamstrings – increased flexibility, may be needed if contributing to excessive lumbar
flexion
 Piriformis – reduce pelvic/LBP, indicated with neural symptoms
 QL – increase side flexion ROM
 Lat Dorsi – indicated for pelvic and LB pain

The Cervical and Thoracic Spine

Common Conditions
1. Acute Mechanical Cx disorder
2. Chronic Mechanical Cx disorder
3. Nerve root compression
4. Neural mechanosensitivity
5. Chronic Whiplash Associated disorder
6. Cervicogenic Headache
7. Cervicogenic Headache w/ dizziness
8. TMJ pain
9. Thoracic intervertebral joint dysfunction
10. Costo transverse joint disorder

Practical Skills
 Scapular observation
 Cervical AROM – flexion, extension, LF, rotation, upper CF, upper CE
  Combined movements
 VBI test + Vestibular check
 Cervical MT – PAIVM central, Unilateral PAIVM, LF PPIVM, first rib AP, rotation
PPIVM, lateral glide, traction,
 Prone scapular hold test
 CCFT
 Craniocervical Extensors and rotators in 4 point/prone
 Neurological – sensation, power and reflexes (triceps, biceps, brachioradialis,
Babinski and clonus)
 Neurodynamic – median nerve
 Sliders
 Scapular retraining – sidelying using pillows, functional, SA training,
 SNAG – AP + rotation
 Thoracic AROM – flexion, extension, LF, rotation
 Thoracic MT – rotation PPIVM, costosternal/costochondral glides, Central and
unilateral PAIVM, manipulation, MWM extension, rotation MWM
 JPE
 Movement sense
 Smooth pursuit neck torsion
 TMJ – inferior, lateral, medial, PA glides
 TMJ ROM

Post-Orthopaedic Management
Use of crutches
Education on graduated WB out of crutches – NWB  PWB  FWB/WBAT
Basic gait observation and retraining
Exercise for modified strengthening
Active assisted exercises post-surgery/sling
Graduated strengthening per body region