Ankle Sprains: Diagnosis, Treatment and Return to Sport

What are Ankle Sprains?

Ankle sprains are one of the most common injuries that people experience.  These injuries account for one million physician visits each year.  Lateral ankle sprains, also known as inversion sprains, are the most common.  They are particularly common in sports.  Forty percent of all traumatic ankle sprains occur during sports.  However, only 50% seek medical attention. The lack of medical care results in an increased risk for developing chronic ankle stability.  There are 3 different grades of ankle sprains, which progressively worsen with each grade.  Healing times vary from a couple of days to up to 6 months depending on severity.

Grades of lateral ankle sprain

What are Lateral Ankle Sprains?

Lateral ankle sprains occur when the outside of the ankle is stressed .  This usually occurs when the ankle is forcefully turned inward. This can happen when stepping on an uneven surface or landing awkwardly after jumping. The lateral ankle sprain typically occurs with stress to 1 of the 3 ligaments that stabilize the outside of the ankle. Depending on whether the foot is up (dorsiflexed), neutral, or down (plantarflexed) different parts of lateral ankle ligaments can be injured.

Lateral ankle sprains

How does a Physical Therapist Diagnose a Lateral Ankle Sprain?

A physical therapist can use tests and measures to diagnose ankle sprains. Typically this will involve checking ROM (range of motion) and strength of the ankle and lower leg.   Additionally, special tests and joint mobilization testing  can bias the ligaments to determine which are involved.  Movement analysis such as the FMS (functional movement screen), hop testing, and running/agility tests can also be used to help determine some of the impairments that may have contributed to the ankle sprain.  If you are seeing a physical therapist with direct access (seeing a PT first without going to a physician) they will perform other tests and screening procedures to make sure physical therapy is appropriate.  If your physical therapist feels you need different services, he or she will direct you to the best healthcare provider.

How are Ankle Sprains Treated?

Depending where you are at in the recovery phase and your goals, a physical therapist will approach your care differently. Early in treatment crutches or a boot may be used and a physical therapist will focus more on pain, swelling and maintaining motion and strength.   As your recovery progresses, your treatment will progress to more active treatments.  This will include manual therapy to improve ankle motion,  proprioceptive training, training for return to activity and strengthening exercises targeting areas that the therapist has found to be weak.

How do you Know you are Ready to Return to Sports?

Physical therapists have a great deal of experience in determining if you are ready to return to sports, work, and other activities.   A few of the tests a physical therapist can use to determine if you are ready to go back to your sport are the FMS, Y-Balance test, hop testing, tuck jump assessment, and the Landing Error Scoring System.  A physical therapist can also give you recommendations on footwear and proper training tips to help avoid ankle sprains in the future.  Contact your physical therapist to learn more about managing ankles sprains.


  1. Vuurberg G, Hoorntje A, Wink L, van der Doelen B,van den Bekerom M, Dekker R, van Dijk C, Krips, R, Loogman, M, Ridderikhok M, Smithuis F, Stufkens S, Verhagen E, de Bie R, Kerkhoffs G. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.British Journal of Sports Medicine 2018;52:956
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Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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Gluteus Maximus Exercise: Training in Multiple Planes

The gluteus maximus is the most powerful hip extensor.  This is important for functional activities performed in one plane such as walking, running, and climbing stairs.  However, this muscle also has important functions outside of straight ahead planes of movement.  The gluteus maximus also helps control balance and generate power in other planes.  Rotational and lateral movements in everyday life and sport require important contributions from the gluteus maximus.

Training the gluteus maximus should incorporate single-plane hip extension exercises and exercises in multiple planes.  Single-plane exercises such as the squat and hip hinge do not fully develop the glutes.  Training programs should also include exercises with rotation of the trunk or lower body on one leg.  These types of exercises prepare athletes for changes or direction, throwing, and jumping from one leg.   Performance improvements and reduced risk for injury often occur with long-term training in multiple planes.  The five exercises included in this article are only examples.  Many other exercises can be adapted to train the entire body with rotational movements.

Crossover Step Up

The crossover step up helps expose and improve any side to side difference in gluteus maximus strength.  Stand to the side with your left leg next to an elevated step or box.  Cross your right foot in front and step up onto the box.  Keep your hips square throughout the exercise.  Next, cross your right foot behind the left while stepping down to briefly touch the floor on the opposite side.  When descending think about sitting back into the hips.   Reverse the movement in the opposite direction.  Perform the exercise slowly with control.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hands or close to the chest.

1-Leg RDL

The single-leg Romanian dead lift (RDL) is a single-leg exercises which requires stabilization of the trunk on the lower limb in multiple planes.  These exercise begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.  Add load by holding a dumbbell or kettlebell in the hand opposite the lunging leg or against the chest.  This exercise shows high activation of both the gluteus maximus and gluteus medius.

Skater Squat

The skater squat introduces rotation of the trunk on the lower limb.  The exercise begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly rotates and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.  Add load by placing a resistance band around the thighs just above the knees.

Rotational 1-Leg Squat

 The rotational 1-leg squat is a progression of the skater squat.  Both exercises have a rotational component to the squat.  This exercise further challenges the balance and stability of the hip.  Begin by balancing on one leg holding a medicine ball in both hands.  The non-weight bearing knee and hip flex to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Rotate the hands and medicine ball upwards and towards the weight bearing leg as you perform the squat.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.

Glutues Maximus Exercise: Closing Thoughts

Gluteus maximus weakness is common in those with chronic back pain, hip bursitis, hip arthritis, knee arthritis, and runner’s knee (patellofemoral pain).  Training the glutes primary function of hip extension is important but often not enough for most demands of sport and everyday life.  These five exercises are challenging and not for everyone.  If you are unable to maintain balance and stability on one leg try other exercises first (basic gluteus maximus exercises).   If you are still unsure how to start, contact your physical therapist for help.


Power Training in Seniors

Typically training for power is thought of as something that is more for the younger, athletic population. However, today older adults are trying to stay more active with activities such as tennis, golf, hiking, or dancing.  All these activities require some component of power.  Are older adults performing any power-based exercise to help with these activities?

What is Power?

First of all, what is power? Power is simply adding speed to a movement.   Power is a combination of strength and speed.   When exercising, we typically encourage slow and controlled movement, but when you are able to control during the exercise, what’s next? We can add resistance to the movement, or sometimes we can add speed. Why would we add speed? Say you are playing tennis and have to move across the court for a drop shot, how do you move to get the ball? Is it slow and controlled or quick? Does it make sense to only strengthen with slow and controlled motions? Or should we think about adding some speed to the movement you are training?

Muscles change with age and they also change with the demands we put on them. As we get older and stop doing fast movements is it fair to expect the body to continue to move quickly to react to a drop shot, field and ground ball, or even jump to catch a ball when playing with grandchildren?

Adding Power Training to an Exercise Program

Adding power to an exercise routine is simple, and can be fun.  You can simply do a movement or exercise that you can do properly and add some speed to it. Another idea can be bouncing a medicine ball or any ball that can bounce onto the ground or a wall. Mini jump hops are also another way to add speed and dynamic movement.

In Closing

Seniors are continuing to stay active in sports and similar to any athlete, they need to train to play the sport they want to do. A lot of the sports and activities seniors do on a daily basis are not slow and controlled. Power is something to think about with a regular workout routine as we age.  If you are not sure how; give your physical therapist a call.


Gluteus Maximus: 5 Exercises to Get Started

The gluteus maximus is the largest muscle of the hip and buttock.  It functions to maintain an erect standing posture and to extend the hip joint.  The gluteus maximus is regarded as one of the strongest muscles in the body.  Strength of the gluteus maximus is required to walk with an upright posture, stand up from a chair, climb stairs, run, jump, and throw a ball.  Weakness is associated with low back pain, knee pain, hip arthritis, and poor balance.  Gluteus maximus exercises are often prescribed for hip arthritis, hip impingement, iliotobial band syndrome, low back pain, patellofemoral pain, and many other overuse injuries.

Exercises start in non-weight bearing positions such as lying on the back or kneeling.   It is recommended that each of these basic exercises is initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.  The main objective of this strengthening program is to progressively overload the gluteus maximus so muscular control, endurance and strength are developed in a systematic manner.

2-Leg Bridge

The bridge is a great hip extension exercise to start with.  Begin by lying on your back with the hips flexed and the feet lined up with the shoulders.  Perform the bridge by lifting both hips from the floor.  A common mistake is to excessively arch the low back.  Hold the bridge position for 2 seconds then return to the starting position.  Lower the body back down in a slow and controlled manner.

Be sure to achieve the bridge position by extending through the hips.  If you lack mobility in your hip joints or hip flexor muscles this may lead to compensation through the low back.  This can be corrected with manual therapy and mobility exercises.  You can also try bringing your fleet slightly closer together and the knees slightly wider apart.  This will allow you to achieve greater hip extension range of motion.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.   Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  It is important to avoid arching through the low back.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

Prone Plank with Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top hip tires the abducting leg will move forward into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus maximus and medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 gluteus maximus exercises do not need to all be performed during the same session.  Start with 2 to 3 of the exercises.  Exercise selection is based on your preferences and the level of difficulty.  The bridge is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging.   This means it is time for a progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.


Muscle Loss in Older Adults: Prevention and Treatment

Loss of muscle with advancing age is referred to as sarcopenia.  This process begins in the fifth decade of life and proceeds at a rate of almost 1% each year.  Declines in muscle strength usually progress faster than muscle size.  Muscle loss with advancing age is associated with many chronic conditions.  These include diabetes, cancer, reduced mobility, disability, and mortality.   It is estimated that 200 million people worldwide will experience sarcopenia that could affect their health over the next 4 decades.

Muscle loss with aging

Muscle loss is quickly becoming a major public health problem with significant clinical, economic, and social consequences.  Prevention and treatment strategies are challenging due to the growing number of older adults above 65.  Exercise and nutritional strategies are considered the primary treatments for age-related muscle loss.  The rest of this article summarizes findings from research on muscle loss in older adults and offers some practical solutions related to exercise.

Diet, Supplements, and Muscle Loss

Muscle is made of proteins.  Amino acids are the building blocks of proteins.  In younger adults (18-30 years old), eating sufficient protein can stimulate some muscle growth by itself.  This can occur with or without exercise in younger adults.  However, muscle growth does not come so easily in older adults.  Therefore, larger amounts of protein in the diet are needed for older adults to preserve or increase muscle.  Younger adults show increased muscle protein rates with the ingestion of 20 grams of protein during a meal.  Older adults require about twice this amount, or 40 grams, to stimulate muscle growth.

Recent research has investigated the role of protein and amino acid supplements for older adults.  The evidence suggests supplementing with protein or amino acids without engaging in an exercise, does little to preserve muscle mass in older adults.  However, increases in muscle size and strength through exercise can be enhanced by certain foods or supplements.    Diets rich in dairy and fish containing polyunsaturated fats make the muscle more sensitive to exercise.  There is also evidence showing protein supplements and creatine monohydrate is beneficial.  Most importantly, research shows that a specific type of exercise, resistance exercise, has powerful positive effects on muscle in older adults.  Resistance exercise is the key to preserving or increasing muscle size and strength as we age.

Resistance Training

Exercise is a highly effective strategy to offset muscle loss.   Exercising with weights has numerous beneficial effects for older adults.  These include increases in muscle mass, strength, power, mood, energy levels, walking speed, balance, and functional performance.  Other forms of exercise, such as aerobic exercise, do not confer these same benefits.  Aerobic exercise, including regular walking, is not enough to prevent muscle loss in older adults.

Contrary to popular belief, adults older than 75 years old can grow significant muscle through resistance exercise.  Heavy weights are not required.  Lighter weights with higher repetitions can result in significant improvements in muscle size and strength regardless of age.  In all cases, the success of any exercise program depends on adherence and staying committed for the long run.  Therefore, it is important to make exercise as enjoyable as possible.  Choose resistance exercises you prefer.  Exercise with friends.  Choose environments (gyms, classes, or in the home) you are most comfortable with.   If you are unsure about how to start, work with a personal trainer or physical therapist.

Developing an Exercise Program to Fight Muscle Loss

Many individuals are unsure about how to structure an exercise program.  Those without resistance training experience or those recovering from an injury have questions about what is safe and appropriate.  How often?  Which exercises?  How many sets?  High or low repetitions? How long should I rest between sets?  These are all excellent questions.  Below I have outlined a list of recommendations for older adults engaging in resistance exercise.  These recommendations are based on research evidence conducted on healthy older adults.

Length of the program

1 year to optimize results but small improvements are often evident after 6-8 weeks.  Ideally, a lifetime committment is best.

Frequency per week

2-3 sessions preferably with one day of recovery between sessions (i.e., Monday, Wednesday, Friday).

Duration of each session

Approximately 1 hour including rest periods between sets and exercises.

Exercises per session

6-8 exercises involving the major muscle groups of the upper and lower body.

Sets per exercise

2-3 sets have been shown to result in greater improvements than single set routines.


50-80% of a one-repetition maximum which is the most amount of weight you can perform properly for one repetition.  An easier guide is to use the recommendations for repetitions per set below.

Repetitions per set

7-9 repetitions per set have been shown to be optimal for strength and muscle development.  This means you should only be able to perform 1-3 more repetitions beyond this range before fatigue becomes limiting.  If you can perform more than this amount without requiring a rest break you can increase the weight.

Duration of each repetition

6 seconds or slow controlled movements are recommended.  Muscle power development requires faster tempos of movement.

Rest between sets

1-2 minutes is optimal.  If this seems like a long time, perform some aerobic activity, such as brisk walking between sets.

Choosing Which Resistance Exercises to Perform

Contrary to the opinions of some, there are no good or bad exercises.  The selection of exercises should be based on several considerations.  This is where a personal trainer or physical therapist can help you get started.  As mentioned, the most important consideration is to choose exercises you enjoy performing.  Beyond this idea, I’ll provide some general recommendations and a few examples.

First, incorporate exercises performed in standing positions as opposed to seated or lying down.  For example, the body weight squat is preferred over a seated leg press.  Second, choose free weights over machines whenever possible.  All machines are not bad but using free weights requires greater muscle activation, control, and coordination.  Third, exercises using multiple joints are preferred over single-joint movements.  For example, the cable row is preferred over a biceps curl.   Finally, incorporate at least one exercise for the fundamental movement patterns such as the squat, hip hinge, upper body push (presses), and upper body pull (row).

Closing Thoughts

Aging is accompanied by a decline in physical activity and function.  Loss of muscle contributes to these changes and is also a consequence of them.  This creates a viscous cycle characterized by muscle loss, weakness, declining function, and developmennt of chronic conditions. Other negative consequences ensue such as osteoporosis and increased body fat.  Exercise can slow down these processes and even reverse them.  In fact, resistance exercise is one of the most effective means to combat the effects of aging and many chronic diseases.  Some have referred to resistance exercise as the, “Fountain of Youth.”  Dietary strategies and supplements can enhance the effects of exercise.   However, there is no magic pill.  Success requires goals, a plan, positive habits, and a commitment.  If you are not sure how to get started, call your physical therapist today.




Fall Prevention: Strength Training with your Physical Therapist

More than one out of four adults, 65 and older, fall each year.  Falling once doubles your chances of falling again.  One out of five falls causes a serious injury such as a broken bone or head injury.  More than 95% of hip fractures are caused by falling.  One in five hip fracture patients dies within a year of their injury.  Women fall more often than men and are more likely to break a bone.  Over the last 10 years, death from falls has increased by 30% in United States.  It is estimated by 2030, falls will result in one death every seven hours.  Clearly, fall prevention programs are needed.

Falls are associated with extrinsic and intrinsic factors.  The extrinsic causes are related to the home environment such as rugs, stairs, and poor lighting.  The intrinsic causes are related to problems with balance or gait, muscle weakness, poor vision, cognitive deficits, the presence of chronic disease, abnormal blood pressure or medications.  Research shows the most effective interventions for preventing falls are based on balance and strength training.

Fall Prevention: Lower Body Strength Training

Fall prevention exercise programs for older people not only reduce the rates of falls but also prevent injuries resulting from falls when they do occur.  Not only does strength training improve muscle size and strength but it also improves bone density.  Therefore, strength training improves an individual’s protective responses during a fall.  The result is a more resilient older adult who is less likely to sustain a debilitating hip fracture from a fall.

Older adults are advised to perform weight-bearing lower body strength training a minimum of 2 to 3 days per week.  Most research studies show that a minimum duration of 26 weeks is needed to achieve the best results.  Body weight exercises, such as squats, are often performed.  However, research shows better improvements in strength and balance when external resistance, such as weights, is used.  Substantial improvements in strength can be achieved with light, moderate, or heavy loads.  Multiple sets of each exercise produce greater improvements in strength compared to single set routines.  Performing 6 to 12 repetitions per set is a great way to achieve improvements in strength and muscle size.  Perhaps most importantly, all strength training exercises initially focus on proper form and then loads are progressively increased over time.

The most frequent exercise utilized in fall prevention exercise programs is the sit-to-stand exercise.  This exercise involves an activity which older adults perform frequently in their daily lives.  The ability to perform this activity without the assistance of the hands has been linked to fall risk in older adults.  It can be easily performed in the physical therapy clinic, any community exercise studio, or in the home.  The exercise is progressed by lowering the height of the chair or by holding weighted objects such as a medicine ball or kettle bell.  Other lower body exercises commonly prescribed include step-ups, hip, and ankle strengthening exercises.


Fall Prevention: Trunk Muscle Strengthening Exercise

Although an important component of any fall prevention program, performing lower body exercise does not guarantee reduced fall risk.  Improvements in lower body muscular strength may not transfer to improved balance if other factors are at play.  One such factor which can influence fall risk is core or trunk muscle strength.  The trunk muscles are composed of the abdominal, pelvic, hip and low back muscles.   These muscles are responsible for transferring forces from the lower to upper body during whole-body movements such as walking or climbing stairs.   The trunk muscles are highly active during a trip suffered while walking.  These muscles act in order to stabilize the trunk over the feet when loss of balance occurs.  The ability of the trunk muscles to react to unexpected disturbances (i.e., suddenly being thrown off balance) has been shown to be delayed in older adults.  Poor ability to activate the trunk muscles has also been linked to an inability to transfer from a chair to standing unassisted.

Trunk muscle exercise focusing on strength and the appropriate timing of contraction can significantly improve balance in older adults.  Trunk muscle strengthening programs can be individually prescribed and progressed by doctors of physical therapy.  Also, many personal trainers, strength coaches, and Pilates instructors are skilled at instructing older adults in these exercises. Exercise can be performed in various positions such as lying on the back, stomach, side, or in kneeling and standing positions.  Trunk strengthening exercises may also be performed using unstable training devices such as exercise balls or balance pads.  Often, resistance bands, light weights, and medicine balls are incorporated based on the individual’s goals.  The 90/90 leg lower and Pallof press are two examples of trunk strengthening exercises but there are many more.


Closing Thoughts

Research supports the benefits of both lower body and trunk strengthening exercise for reducing falls in older adults.  The importance of the trunk muscles for balance and mobility in older adults has been underestimated and often overlooked.   Fall prevention exercise programs are optimized by including individually prescribed lower body and trunk strengthening exercise.   If you are not sure about how to get started, give your physical therapist a call.

Gluteus Medius Exercise Progressions

The primary role of the gluteus medius is to stabilize and control movement of the pelvis during weight bearing functional activities.  This is required for efficient walking, climbing stairs, running, jumping, and throwing.  All of these activities require at least a brief period of single leg support.  The gluteus medius maintains a level pelvis and prevents the opposite side from dropping.  Without adequate functioning of this muscle, balance, strength, power, and performance will be compromised.  Also, abnormal movement patterns, such as dynamic valgus, occur in the presence of inadequate gluteus medius function.

It is advantageous to progress exercises for the gluteus medius from non-weight bearing to standing positions.  The exercises included in this article are 5 options but there are many others.  The most important aspect of these exercises is that they performed in a slow and controlled manner with appropriate body alignment.   The emphasis should first be on proper technique before adding repetitions or resistance.

Band Hip Abduction

Band hip abduction is performed with an elastic band tied around the ankles standing in an upright position with the feet together.   The feet are then pulled slightly apart.  Stand on one leg while keeping the pelvis level.  Abduct the other leg about 25° while maintaining the trunk in an upright position.  The most common mistake is to abduct too far and tip the body to the other side.  It is also important to keep the toes pointing straight ahead throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Both the supporting and moving side gluteus medius are very active during this exercise but the standing leg receives the greater training effect.

Band Internal & External Rotation (IR/ER)

Band IR/ER is performed with an elastic band tied around thighs (just above the knees) standing in an upright position with the feet together.  Once the band is in place, separate the feet to shoulder width or slightly wider.   During the exercise the knees and hips are flexed about 30°.  The hands are placed on the hips.  Initiate the movement by slowly moving one knee inwards over a 2 second period.  Maintain the position of the opposite knee.  Then slowly pull the knee outwards over a 2 second period.   Perform 8 repetitions in a slow and controlled manner on one side before switching to the other leg.

Lateral Band Walk

The lateral band walk is performed with an elastic band tied around the ankles standing in an upright position with the feet together.  During the exercise the knees and hips are flexed about 30°.   The hands are placed on the hips.   Sidestepping is initiated by leading with one leg over a distance slightly wider than shoulder width.  It is important to keep the toes pointing straight ahead and the knees over the toes throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Three slow steps are performed in one direction followed by 3 steps in the opposite direction.  Each cycle constitutes 1 repetition.  Typically, 6-8 repetitions are performed each set.   To increase the challenge of this exercise, two bands can be used.  A second band can be placed above the knees.

Dynamic Leg Swing

The dynamic leg swing begins by standing on one leg with the opposite knee flexed to 90 degrees.  Initiate the movement by swinging the non-weight bearing leg (with the knee flexed).  Move into hip flexion and extension at a rate of 1 second forward and one second backward.   Move through a smooth range of hip motion and do not allow the trunk to move out of the upright position.  Also, maintain control of the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

1-Leg RDL

The single-leg Romanian dead lift begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Closing Thoughts

These 5 exercises can be used as a standalone program for improving gluteus medius activation and strength.  However, all 5 exercises do not need to be performed.  Choose 2-3 exercises to perform 3 days per week.  These exercises are also ideal for athletes and exercise enthusiasts to incorporate into their warm-up routines.  Specifically, try 2 or 3 of these exercises prior to performing compound lifts such as the squat or dead lift.   Next week we’ll highlight some more advanced progressions to load the gluteus medius.  If you any further questions, give your physical therapist a call.



Self-Management of Pain: Your Physical Therapist as a Guide

Too many medical approaches in today’s society are dependent on others (therapists, doctors, etc) and include passive treatments (medications, injections, etc.).  It can be empowering to take control of your own health and seek active forms of treatment for conditions such as low back pain, arthritis, or even every day sprains and strains.  Self-management allows you to develop a sense of control over your problem and offer you tools to use for a lifetime.  However, many are unsure where to start.

Therapeutic Alliance and Self-Management of Pain

In order to optimize self-management for any painful condition, a meaningful working relationship, or therapeutic alliance, in which the patient and provider work together, should be established.  This begins by developing a patient-preferred approach to treatment.  If you prefer to exercise aerobically then you should not be forced to perform lumbar stabilization exercises for your back pain.  If you enjoy strength training in the gym you should not be prescribed aerobic exercise for your knee pain.  Exercise you enjoy is medicine for the body and mind.  Both forms of exercise have been shown to be beneficial for managing back pain.  Let’s choose together what you prefer.

Developing a positive therapeutic alliance with your physical therapist also allows for the careful monitoring of progress over time.  There are going to ups and downs along the way.  Your physical therapist can help pick you up during challenging times.  Your physical therapist can also progress your plan appropriately when things are going well.  A physical therapist can work as a coach offering constructive feedback and encouragement.   They can help you make periodic adjustments to your self-management program.  With this approach, you are in control of your own health and your therapist acts only as a guide.

The interaction between you and your health care provider has been shown to be one of the strongest predictors of patient satisfaction with physical therapy care, and a key contributor to a successful outcome.  Research shows the amount and quality of the interaction between a patient and their physical therapist has a profound impact for those with persistent back pain.  Taking advantage of these positive interactions will magnify the effects of any exercise program or lifestyle modification. Having the same therapist, will potentially enhance the therapeutic alliance, guide you towards your preferred self-management strategies, and help you achieve the best possible long-term outcome.

What Self-Management Looks Like

Your physical therapist will first seek to understand your beliefs about pain and your condition.  Many people hold negative beliefs which are unhelpful to recovery or they are simply untrue.  For example, many people continue to believe that a herniated disc will never heal.  Your physical therapist will redirect you towards what you can control and strategies to improve self-efficacy.

Often a large amount of active participation over a long time is needed to change unhelpful beliefs and poor lifestyle habits.  Your physical therapist will guide you towards forms of physical activity you prefer and which are appropriate.  It is also important that you fully understand the time it takes for the body to heal itself.  The body’s natural healing mechanisms can be enhanced with the appropriate dose of physical activity.  Start too slow and your recovery will be delayed.  Start too fast and “flare-ups” will kill your motivation. Your physical therapist will help you find the best starting point and teach you how to progress.

Exacerbations of pain are going to occur.  You are going to have “flare-ups” of your back pain, neck pain, or shoulder pain.  This needs to be accepted and expected.  You want to develop resilience for these set ups.  There are always strategies available to help you through these challenging times.  Thinking the worst is never helpful in these situations.  Remaining optimistic is the first step.  Next, identify what is under your control to get you back on track.  This is where your physical therapist can help you focus your efforts.

Closing Thoughts                         

People with persistent painful conditions don’t always need more medical treatment.  They need a coach or guide to show them how to manage on their own with active forms of treatment.  Physical therapists can fill this role.  Developing a positive working relationship, or therapeutic alliance, with your physical therapist will get you set on the right track.  The rest is up to you.

Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.