Orthopedic Conditions and
Corrective Exercises
Back and Spinal Cord
• The biggest musculoskeletal issue you will face
as a trainer
• Most of your clients will currently have, or have
had, back pain
• Why:
– People are overweight and out of shape
– People sit on their butts all day
– No Core Strength
– Limited Flexibility
– Poor Posture
– Bad Biomechanics
Low Back Pain (LBP)
• One of the leading causes of pain and disability
• Low back pain is a generalized term involving
several different diagnoses, including but not
limited to:
– Disc dysfunction
– Muscle strain
– Spondylolisthesis
– Spondylolysis
– Spinal stenosis
– Sciatica
Intervertebral Disk Anatomy
• Soft “cushion like” structure that separate each
vertebrae
• Purpose
– Act as shock absorbers between the vertebrae
– Function as ligaments by holding the vertebrae
together
– Act as joints allowing the spine mobility in all three
planes
• The disc is comprised of two primary elements
– Nucleus Pulposus
– Anulus Fibrosus
• Jelly doughnut
Intervertebral Disk Anatomy
• Nucleus Pulposus
– A soft, gel-like inner
substance contained
within the anulus
fibrosus
– Consistency of
toothpaste
• Anulus Fibrosus
– Tough, outer ring that
surrounds and contains
the nucleus pulposus
Intervertebral Disk Video
• http://www.youtube.com/watch?v=kcwaOT
put_o&feature=related
Bad Biomechanics
• Disc pressure increases
–33% while sitting
–33% while standing when slightly bent
forward
–45% while sitting when slightly bent
forward
–52% while standing when bent far
forward
–63% while sitting when bent well forward
Movement Effects
• During Flexion
– Anterior portion of annulus fibrosis is
compressed
– Annulus fibrosis bulges anteriorly
– Posterior portion is stretched
• i.e., rubber ball between wood blocks
• Under Compression
– Nucleus pulposus distributes pressure in all
directions to annulus fibrosis
– Pressure is transmitted to the vertebral bodies
– Under high compressive forces DISK WILL
RUPTURE!
Herniated Disk
• Also called protruding, bulging, ruptured,
prolapsed, slipped, or degenerated discs
• Part of the nucleus pulposus makes its way
through the outer anulus fibrosus, resulting
in inflammation; this inflammation irritates
the spinal nerve roots
• Symptoms
– Back and neck pain, tingling or numbness in
the glutes, legs or feet, muscle weakness
• When a client has a herniated disc, he or
she should seek medical treatment
Back Rehabilitation
• Surgical Treatments
– Laminectomy
– Artificial Disk Replacement
• Non-Surgical Treatments
– Rehabilitation Exercises
– Injections
• Cortisone may help reduce swelling and
inflammation of the nerve roots, allowing
for increased mobility. These injections
are referred to as epidurals or nerve
blocks.
Lumbar Laminectomy Video
• http://www.youtube.com/watch?v=EvQPZx
Xr3Rs
Artificial Disk Replacement Video
• http://www.youtube.com/watch?v=dLhUJl8
guA8&NR=1
Preventing Disk Herniations
• Proper lifting techniques when picking
objects from the floor
• Maintaining a healthy weight
• Practicing good posture when walking,
sitting, standing, and sleeping
• Sitting with your feet flat on the floor (not
crossed)
• Sleeping on a firm mattress
• Avoid wearing high-heeled shoes
Preventing Disk Herniations
• Physical activity is key
• Consistent and rational exercise
• Core stability and strength
• Flexibility
• Accident prevention – is your body
prepared for the activity you are
about to do?
Herniated Disk Exercise Guidelines
• Movement Contraindications
– Lumbar flexion
• Avoid lumbar flexion to prevent the
posterior protrusion of the disc material
– Lumbar rotation
• Exercise Contraindications
– Sit-up’s, barbell back squats, stiff-leg deadlifts,
bent-over rows, supine leg lifts, trunk rotations
(i.e., chops), knee-to-chest stretch, stiff-leg toe
touch, superman’s, good morning’s, bicycle
riding and Spinning due to possible increased
flexion with forward lean
Herniated Disk Exercise Guidelines
• Obtain medical clearance
• Begin with one set of 10–15 repetitions, and progress
to 3 sets of 15–20
• Exercise Indications
– Drawing-in, chin tucks, posterior pelvic tilts, supine
bridge on floor or SB, quadruped opposite-armopposite-leg, kneeling hip flexor stretch, SB against
the wall squat, walking, aquatics
– SB stabilization
• Draw-in with 90 degree angle at both the hip and
knee and thighs should be parallel with the floor
when seated on the ball
• Raise and lower one foot at a time
• Alternating heel raises
Back Strain
• Strains to the muscles of the lumbosacral spine
are common, and may have a variety of causes
including direct trauma and overuse
• Retraining muscles to function in their
designed manner will enable the muscle to
work more efficiently
• Movement and exercise restriction is highly
dependent on the muscle that has been strained
• For example: If erector spinae muscles have been
strained, lumbar extension exercises and
exercises requiring isometric contraction (bentover DB row) should be avoided during the early
phases of tissue healing
Back Strain Exercise Guidelines
• Movement Contraindication
–Passive Lumbar Flexion (during inflammatory phase)
–Active lumbar extension (during inflammatory phase)
•Exercise Contraindication
–Barbell back squat, stiff-leg deadlift, knee-to-chest
stretch, supine leg lifts, bent-over rows
•Exercise Indication
–None during inflammatory phase, progressing to
gentle flexion stretching, followed by extension
strengthening
–Posterior pelvic tilts, quadruped opposite-armopposite leg, supine bridge on floor or SB
Spondylolisthesis
• Spondylo means vertebrae
• Listhesis means forward slippage
• Spondylolisthesis is a forward slippage of one
vertebra on another
Spondylolysis
• A spondylolysis occurs when there is a fracture,
found in a region of the vertebrae called the
pars interarticularis
• The pars interarticularis connects the vertebral
body in front with the vertebral joints behind
Spondylolisthesis and Spondylosysis
Exercise Guidelines
• Obtain medical clearance
• Strengthen the muscles that insert on the spine
• Spinal stabilization to achieve ‘‘core stability’’ is
a key component
• Avoid exercises involving lumbar extension
(stiff-leg deadlifts and barbell back squats)
– Places stress on pars interarticularis and may
worsen condition
• Most abdominal crunches are appropriate
Spondylolisthesis and Spondylosysis
Exercise Guidelines
• Movement Contraindication
– Lumbar extension
• Exercise Contraindications
– Barbell back squat, deadlift, stiff-leg deadlift,
standing DB or BB shoulder press, bent-over
rows, trunk extensions (superman)
• Exercise Indications
– Begin with one set of 10–15 repetitions, and
progress to 3 sets of 15–20
Spondylolisthesis and Spondylosysis
Exercise Guidelines
• Exercise Indications
– Kneeling hip flexor stretch-very important to
maintain neutral pelvic spine in order to eliminate
hyperextension of the spine
– Supine hamstrings stretch using a towel
– Prone quadriceps stretch- place a rolled towel can
under the distal thigh to create an increased stretch
– Iliotibial band stretch
– Posterior pelvic tilts
– SB crunch
– Quadruped drawing-in
Spinal Stenosis
• Stenosis means narrowing
• Spinal stenosis is a narrowing of the spinal canal,
which places pressure on the spinal cord
• Symptoms are pain, weakness, or numbness in the
legs, calves or buttocks
• Individuals should seek Physical Therapy to help
stabilize the spine, build endurance and increase
flexibility
Sciatica
• Inflammation of the sciatic nerve
• Sciatic nerve originates in the lumbar spine and
travels into the thigh. Provides motor innervation to the
hamstrings and all of the muscles in the leg and the
foot.
• Causes
– Herniated disk (most common), pregnancy, spinal
stenosis, spondylolisthesis, piriformis syndrome
• Symptoms
– Cramping of the thigh, shooting pain from the glutes
down the leg, tingling, or pins-and-needles
sensation in the legs and thighs, a burning
sensation in the thigh
Sciatica Exercise Guidelines
• Obtain medical clearance
• Most physical therapy programs will be
tailored to address the underlying cause of
the person’s sciatic pain, such as a
herniated disc or piriformis syndrome
• Doing the wrong type of exercise can
worsen the sciatic pain, so it is important
to get an accurate diagnosis prior to
starting an exercise program
Shoulder
• The shoulder has
the greatest range
of motion of all
joints in the body
–Higher injury risk
• Relationship
between the
scapula and
humerus is key
Shoulder Impingement Syndrome
• Also known as rotator cuff tendonitis or bursitis
• It is the pinching of the supraspinatus, the long head
of the biceps tendon or subacromial bursa under the
acromial arch
• What not to do:
– Anything overhead
– Most “pressing” exercises
– Anything heavy
– Be wary of “pulling” exercises
• What to do:
– Focus on the specific scapular and rotator cuff
muscles to re-establish shoulder stability
– Gradually move back into general exercise program
once pain subsides
Shoulder Impingement Exercise Guidelines
• Movement Contraindication
– Overhead with internally rotated shoulder
• Exercise Contraindications
–Overhead DB or BB shoulder press in the
frontal plane, lateral raise in the frontal
plane, upright row, incline BB bench press,
BB bench press, doorway pec stretch
(abducted shoulders and 90 degrees of
elbow flexion), dips, behind-the neck
exercises, DB pull-overs
Shoulder Impingement Exercise Guidelines
• Exercise Indications
– 1-3 sets of 10-15 repetitions
– Light weight 0-5 pounds
• Scapular stabilizing exercises
– Tubing rows, push-up plus, DB shoulder
shrugs, tubing shoulder extensions
(swimmers)
• Rotator cuff exercises
– External and internal rotation with tubing, DB
scaption
Hip Replacement
• Also known as hip arthroplasty
• Total hip arthroplasty movement restrictions
include the following for 10-12 weeks after
surgery
– No hip flexion greater than 90 degrees
– No hip adduction past neutral
– No twisting or pivoting the hip medially or
laterally
– No kneeling
– Do NOT cross legs at the knees or ankles
when sitting, standing, or lying down
• Avoid high impact activities-running and jumping
Hip Replacement Exercise Guidelines
• Exercise Contraindications
–Hip adduction machine, cable chops,
piriformis stretch, hip abductor stretch
•Exercise Indications
–SB against-the-wall squats, calf raises,
dorsiflexion (heel raises), swimming,
walking, Elliptical trainer, heel slides, quad
sets, glute sets (isometrically contracting
glutes), recumbent bike
Hip Replacement Exercise Guidelines
Heel slide
• Sit on a firm surface with your legs straight in front of
you.
• Slowly slide the heel of your affected leg toward your
buttock by pulling your knee to your chest as you
slide.
• Return to the starting position.
• 3 sets of 10 repetitions
Quadriceps isometrics (Quad Set)
• Sit on the floor with your affected leg straight and your
other leg bent
• Press the back of your knee into the floor by tightening
the muscles on the top of your thigh.
• Hold this position 10 seconds
• 3 sets of 10 repetitions
Anterior Cruciate Ligament
Reconstruction
• Exercises following ACL reconstruction
are an extremely important part of a
person’s rehabilitation
• The function of the ACL is to control knee
motion and provide proprioceptive
feedback
• The ACL limits anterior tibial translation
and rotation relative to the femur
ACL Reconstruction Exercise Guidelines
• Movement Contraindication
– Open knee movements less than 45 degrees of
knee flexion
• Exercise Contraindications
– Leg extension performed from greater than 90
degrees of knee flexion to greater than 45 degrees
of knee extension
• Exercise Indications
–SB Leg curls, step-up’s, SB squats against the wall,
quad sets, heel slides, wall squat with ball squeeze
(hip adduction), step-up’s, lunges, single-leg balance