REHAB PROTOCOLS

Camila Maria Cenci

2024

HEAD & NECK PROTOCOLS

 NECK PAIN

1. General (non-specific) neck pain

 Description: In most cases, a specific nociceptive source of pain (disc, muscle, joint, etc.)
cannot be determined. An obvious source cannot be linked to a person’s symptoms.

 Signs and Symptoms: Dull, achy pain along the sides or back of the neck or in the shoulder
or upper back region, but the location varies. Symptoms may become sharp with certain
movements and limit ROM.

 Aggravating Factors: it is often unrelated to injuries (strains, disc herniation, etc.) It may be
influenced by other factors, such as stress, sleep and general physical activity level. Pay
attention not only to movements and positions that make the pain worse, but also to the
less obvious factors that can influence pain.

 Prognosis: Most general neck pain cases resolve within 4 to 6 weeks after starting rehab.

 Treatment Strategy: it combines soft tissue mobilisations and joint mobilisation, mobility
exercises, sensorimotor control and resistance training exercises.

Phase 1: Soft tissue mobilisations to reduce pain and tension in the cervical extensors, upper
trapezius, levator scapulae, rhomboids and thoracic spine.

Phase 2: Start stretching levator scapulae, upper trapezius and pectoral muscles. Cervical
mobility drills in flexion, extension, lateral flexion and rotation. Lastly, cervical isometrics to
gradually improve stress tolerance and capacity.

Phase3: Focus on sensorimotor control and resistance training exercises to build neck
control and strength in all planes of motion. Other resistance training exercises focus on the
scapular muscles since loading these muscles can reduce neck tightness and pain.

2. Neck Strains and Sprains (Whiplash)

 Description: Neck strains and sprains involve the muscles that run along the posterior
and/or anterior of the neck and the facet joints. Both are typically associated with traumatic
injuries (car accidents and contact sports…)

 Signs and Symptoms: Dull, achy pain along the side or back of the neck, in the shoulders or
in the upper back region. It can become sharp with certain neck or shoulder movements.
The patient may also feel pain in the front of the neck or limited ROM, especially when
turning the head to one side.

 Aggravating Factors: For STRAIN, stretching or contracting the muscles along the side or
back of the neck cause pain. If the strain is on the right side for example, it will hurt to
stretch tilting the head to the left or contract by tilting the head to the right. If there is a
SPRAIN, compressing the tissues to end range by rotating the head, tilting the head toward
the injured side or looking up, typically reproduces de symptoms.

 Prognosis: Most strains and sprains resolve within 4 to 6 weeks.

 Treatment Strategy: Soft tissue mobilisations + mobility exercises + resistance training

Phase 1: Reduce pain and improve mobility (just be careful not to make the symptoms
worse). Mobilise the thoracic spine (especially thoracic extension) and surrounding soft
tissues to reduce neck pain.

Phase 2: Start stretching levator scapulae, upper trapezius and pectoral muscles. Cervical
mobility drills in flexion, extension, lateral flexion and rotation. Finally, implement cervical
isometrics, adding load gradually.

Phase3: Focus on resistance training to help make the neck and surrounding muscles more
resilient.

3. Cervical Spondylosis (Arthritis)

 Description: Spondylosis or Arthritis of the neck is common as people age and often
produces no pain.

 Signs and Symptoms: Pain or stiffness when checking your blind spot, looking up at the
ceiling or performing any activity that requires the neck to move through the full ROMs. It
typically produces dull, achy pain and stiffness. In some cases clicking and popping may
occur when turning the head from side to side, or it will hut at the ends of the ROM, when
trying to turn your head all the way to one side.

 Aggravating Factors: Looking all the way up or to the side, holding the head in one position
for long periods (driving, reading, computer…)

 Prognosis: improves in 4 to 6 weeks

 Treatment Strategy: soft tissue massage, stretching and mobility exercises, and resistance
training.

Phase 1: To reduce pain and tension, and improve neck mobility, focus on soft tissue
mobilisation techniques that address the neck and scapular muscles and the thoracic region.

Phase 2: Stretch the neck + scapular muscles and add cervical mobility exercises. End phase
2 with cervical isometrics to rebuild neck muscle strength.

Phase3: Focus on resistance training exercises to improve neck strength.

 NERVE PAIN (RADICULOPATHY)

1. Disc Herniation (disc bulge) and Stenosis

 Description: Nerve pain that radiates down the arm often originates in the neck. It often
results from nerve inflammation, disc herniation, stenosis and prolonged postural positions
that compromise nerve health. A lot of people have nerve pain not because a disc bulge is
touching the nearby nerve but because inflammation has irritated and sensitised it.

 Signs and Symptoms: From sharp pain, like a lightning bolt, to numbness and tingling
sensations. Symptoms travel along the path of the nerve.

 Aggravating Factors: Rotating the head toward the painful side or looking up typically causes
nerve discomfort.

 Prognosis: if you eliminate or modify the aggravating activities and follow a rehab program,
in 8 to 12 weeks it is resolved.

 Treatment Strategy: Pain medications and muscle relaxants may be helpful in the early
stages of rehab.

Phase 1: To reduce pain and tension, soft tissue mobilisations of cervical extensors, levator
scapulae, pectoral muscles and mid-back region.

Phase 2: Focus on spine and peripheral nerve mobility. Thoracic rotation stretches and
cervical mobility help improve spinal mobility and reduce pain. Stretch pectoral muscles and
nerve slider exercises to mobilise the peripheral nerves individually.

Phase3: Introduce more intense nerve mobilisations called tensioners. Finally, once the pain
has resolved and the mobility improves, add phase 3 of the Neck Pain protocol to strengthen
the muscles.

2. Thoracic Outlet Syndrome

 Description: TOS is a condition where the nerves and/or blood vessels that run from the
neck to the arm become irritated, injured or compressed in the space between the first rib
and collarbone. It often results from sports that involve repetitive shoulder movements
(golf, swimming…), postures that stress the nerves and blood vessels and traumatic
accidents (whiplash).

 Signs and Symptoms: Pain in the neck, arm, or hand, often accompanied by numbness or
tingling in the arm and hand. In severe cases, hand weakness can occur.

 Aggravating Factors: Repetitive shoulder or arm movements such as carrying heavy items.

 Prognosis: Symptoms generally improve within 4 to 6 weeks of the rehab.

 Treatment Strategy: Stretch the muscles of the neck and shoulders, teach postural
modification to reduce nerve stress. Pain medications and muscle relaxants may also be
helpful in the early stages.

Phase 1: To reduce pain and tension, soft tissue mobilisation techniques that target the
neck, shoulder complex, and thoracic spine.

Phase 2: Focus on spine and peripheral nerve mobility. Introduce stretches and nerve
mobilisation techniques. They will improve nerve health, reduce pain, and improve neck and
shoulder mobility.

Phase3: Introduce tensioner nerve mobilisations. Once the pain has resolved and mobility
improves, add the Phase 3 exercises for Neck Pain to strengthen the muscles.

 HEADACHE PAIN
1. Cervicogenic Headache

 Description: they originate from the upper cervical spine (muscles, joints, discs) and cause
referred pain in regions of the head and/or face. It generally comes from activities that
create tension in the neck such as stress, holding certain static positions (looking at the
computer), sleep difficulties, neck position while sleeping, etc.

 Signs and Symptoms: Steady, non-throbbing pain on one side of the neck near the base of
the skull that can refer down the neck into the shoulder blade or up to the forehead. For
most people, the pain radiates from the upper neck, over the head, and into one eye socket
or the forehead. Neck stiffness and pain when sneezing or coughing can also occur.

 Aggravating Factors: it typically involves lower cervical flexion with upper cervical extension.

 Prognosis: After correcting the triggering positions, the pain improves after a few weeks.

 Treatment Strategy: Physiotherapy, massage and behaviour modification.

Phase 1: Focus on mobilising the suboccipital muscles at the base of the skull. Mobilise the
levator scapulae and upper trapezius muscles.

Phase 2: Stretch the suboccipital muscles. Wall chin tuck exercises. Neck flexor isometric
hold to build neck strength in a neutral position.

Phase3: Add isometric contractions to continue building strength in all planes of motion.
Once the pain has resolved, implement Phase 3 of the Neck Pain protocol to strengthen the
neck and surrounding muscles.

 JAW PAIN
1. Temporomandibular disorder (TMD)

 Description: TMD can result from a direct injury, inflammation, of the joints, and/or overuse
of the region. Sleep issues related to the jaw (grinding, clenching…) and neck sprains and
strains can also contribute to TMD.

 Signs and Symptoms: aching pain near the joint or in the ear and may cause difficulty
chewing. The patient may also experience locking or catching while moving the jaw.

 Aggravating Factors: Grinding teeth, clenching jaw muscles, and chewing hard or chewy
foods.

 Prognosis: it can persist for months or even years if the true cause is not identified. It is
crucial to see a dental provider to ensure dental problems are not related.

 Treatment Strategy: physiotherapy (soft tissue mobilisation and mobility exercises for the
jaw and upper neck) and dental intervention (use of a bite plate or splint)

Phase 1: Mobilise the masseter and temporalis muscles. Also suboccipital mobilisation.

Phase 2: Incorporate active mobility exercises that capture the primary jaw movements.

Phase3: Implement jaw-specific strengthening exercises for the opening and closing
movements. Once the pain has improved, complete the Phase 3 Neck Pain exercises.

SHOULDER PROTOCOLS
  SHOULDER PAIN

1.Rotator Cuff Injury (tear/tendinopathy)

 Description: The rotator cuff includes 4 muscles that stabilize and rotate the shoulder joint:
SUPRASPINATUS + INFRASPINATUS + SUBSCAPULARIS + TERES MINOR. These muscles and
tendons are susceptible to tendinopathies (mainly the supraspinatus). Rotator cuff injuries
happen generally as a result of trauma from an impact, fall or overuse (such as high-volume
throwing). Degenerative tears are common as people age and almost always affect the
supraspinatus.

 Signs and Symptoms: Pain at the top or side of the shoulder and it may refer down the side
of the upper arm. The pain is close to the surface and can be triggered by sleeping on the
painful side, reaching above the level of the shoulder, or playing sports that involve
overhead motions. If you injure one of the other rotator cuff muscles, you may experience
pain on the back of the shoulder (infraspinatus and/or teres minor) or the front of the
shoulder and/or armpit (subscapularis). Pain is typically dull and achy but becomes sharp
when the muscles are active.

 Aggravating Factors: Reaching overhead and/or away from the body. Sleeping on the painful
side, and lifting objects with an extended arm.

 Prognosis: It depends on the severity. Tendinopathy usually resolves within 4 -12 weeks.

 Treatment Strategy: Tendinopathy and small tears are treated with mobility and strengthening
exercises. Large tears are usually treated surgically.

Phase 1: Soft tissue mobilisation techniques that target the posterior rotator cuff (infraspinatus +
teres minor), levator scapulae, rhomboids, upper trapezius, pectoral muscles and thoracic spine. Next,
add shoulder isometrics to start building strength in a LOW-LOAD manner. Lastly, work on shoulder
mobility with PROM drills. You should begin passive mobility early to avoid joint contracture, frozen
shoulder etc.

Phase 2: Add thoracic flexion-extension + scapular protraction-retraction mobility exercises. Add the
angel and end phase 2 with the strengthening exercise prone T.

Phase3: Focus on building rotator cuff and scapular muscle strength with resistance training
exercises. Strengthens the scapular retractors and rotator cuff focusing on external rotation exercises.
Strengthens the subscapularis (only muscle that internally rotates the shoulder). Next, train the
deltoid and rotator cuff (specially supraspinatus) adding the shoulder raise options. Next are the
pressing exercises to work the pectoral and serratus anterior muscles. Push-ups for the serratus
anterior and supinated curl to strengthen the biceps brachii muscle.

2. Shoulder Impingement (now -> Subacromial Pain Syndrome)

 Description: The structures underneath the acromion (supraspinatus + biceps long head
tendon + subacromial bursa) become sensitive. The pain typically occurs when reaching
away from the body with an extended arm, especially when reaching above the shoulder or
sleeping on the painful side. SPS is not usually caused by a traumatic injury and does not
always mean anything is torn. Inflammation and irritation also cause pain when you use
those structures. Another possibility is a bone spur due to genetics or overuse injuries.

 Signs and Symptoms: Dull and achy pain at rest, becoming sharp when stressing the
structures in the subacromial space. Pain is experienced on the top, side or front of the
shoulder and may refer down the side of the upper arm. Painful arc from 60 to 120 degrees
of abduction.

 Aggravating Factors: Reaching overhead, sleeping on the painful side and lifting objects with
an extended arm. It is common to irritate the area with repetitive overuse injury. In the
worst-case scenario, the person might have a small tear, but for most people it’s just
inflammation.

 Prognosis: It typically takes 4-12 weeks to return to normal.

 Treatment Strategy: Shoulder mobility and rotator cuff strengthening are the most common
treatments. For a bone spur or a large tear, the patient may be referred to surgery. SPS
protocol is similar to the rotator cuff injury.

Phase 1: Soft tissue mobilisation techniques that target the posterior rotator cuff
(infraspinatus + teres minor), levator scapulae, rhomboids, upper trapezius, pectoral muscles
and thoracic spine. Next, add shoulder isometrics to start building strength in a LOW-LOAD
manner. Lastly, work on shoulder mobility with PROM drills. You should begin passive
mobility early to avoid joint contracture, frozen shoulder etc.

Phase 2: Add thoracic flexion-extension + scapular protraction-retraction mobility exercises.

Add the angel and end phase 2 with the strengthening exercise prone T.

Phase3: Focus on building rotator cuff and scapular muscle strength with resistance training
exercises. Strengthens the scapular retractors and rotator cuff focusing on external rotation
exercises. Strengthens the subscapularis (only muscle that internally rotates the shoulder).
Next, train the deltoid and rotator cuff (specially supraspinatus) adding the shoulder raise
options. Next are the pressing exercises to work the pectoral and serratus anterior muscles.
Push-ups for the serratus anterior and supinated curl to strengthen the biceps brachii
muscle.

 SHOULDER INSTABILITY
1. Labral tears and dislocations/subluxations

 Description: Labral tears (SLAP and Bankart lesions) are injuries to the fibrocartilaginous rim
of the shoulder. They can result in shoulder instability which often leads to dislocations
and/or subluxations. A common injury type is ANTERIOR dislocation (often with the arm out
and externally rotated). It is common to refer a sensation of sharp pain or that the shoulder
is going to dislocate when putting the arm through the hole of the clothes. It often causes
apprehension with certain movements away from the body. A previous injury makes people
more susceptible to labral tears and dislocations. Those with hypermobile joints are also
more susceptible to labral tears and dislocations.

 Signs and Symptoms: it often causes sharp, catching pain with movements such as rotating
the shoulder externally, reaching overhead and moving the arm out/across the body. A deep
aching sensation for several hours after the provocative movement is commonly
experienced. The pain feels as if it’s coming from deep inside the joint. the shoulder might
also pop, click or grind. The patient may feel weakness, looseness or instability.

 Aggravating Factors: Overhead motions like lifting, throwing, reaching up, out or across the
body combined with rotation.

 Prognosis: 8-12 weeks. But some recurrent dislocation often require surgical repair of the
labrum.

 Treatment Strategy: Rehab focus on improving shoulder stability and strength.

Phase 1: Soft tissue mobilisation targeting the rotator cuff, rhomboids and pectorals. AROM
drills for the shoulder complex (lifting the arm here generally causes less pain the rotator
cuff tears, for this reason, the patient can skip the PROM). End phase 1 with shoulder
isometrics to increase joint stability.

Phase 2: Lower Load Resistance Training (LLRT) to focus on building motor control and
strength. Don’t do any stretching because the joint is already hypermobile.

Phase3: Add more advanced resistance training exercises to continue building stability and
strength. Strengthen the biceps brachii to protect against future dislocations (especially
anterior ones). Exercises of closed-chain help stabilise the ball of the humerus in the
shoulder socket. Leave the “shoulder press” exercise to the end of phase 3.

 FROZEN SHOULDER (ADHESIVE CAPSULITIS)

 Description: Progressive condition where the shoulder joint capsule tightens, leading to
progressive stiffness, pain, functional limitations and mobility restrictions. More common
between the ages of 40-65. Diseases that lead to systemic inflammation (diabetes, thyroid
disease) also increase the risk of developing frozen shoulder and rotator cuff or labral tears.
If the patient have shoulder pain and start to lose ROM, they should start rehab!

PHASES:

1. FREEZING – It hurts and getting tight (2-9 months).

2. FROZEN – ROM is stuck. Pain is not so bad but the arm won’t move. (4-12 months).
3. THAWING – it slowing starts to loosen up spontaneously (12-24 months).

 Signs and Symptoms: Mobility restrictions + pain. The ROM is lost in a particular order:
EXTERNAL ROTATION  ABDUCTION  FLEXION.
Pain (deep and vague, affecting the whole joint) may be the first thing the patient notice, but
then the arm stops turning outward. Always compare to the healthy side.

 Aggravating Factors: Pain and mobility restrictions, especially into external rotation,
abduction and flexion.

 Prognosis: It improves within 6 months, when treated early with physio + cortisone
injections.

 Treatment Strategy: Combination of Physiotherapy + Anti-inflammatory medication +

Steroid injections. Rehab focuses on improving ROM (joint mobilisations and stretching).
Don’t spend time on soft tissue mobilisations (only if there is much pain and tension), your
focus is regaining shoulder mobility + function.

Phase 1: PROM. The key is to push the affected shoulder to the point where the patient feel
a moderate stretch but not severe pain. End phase 1 with shoulder isometrics, one the
shoulder muscle can atrophy.

Phase 2: Add Low-Load, Long-Duration (LLLD) stretches holding the positions longer (up to 5
min) to challenge the mobility without causing pain or discomfort. End phase 2 with
shoulder flexion eccentrics.

Phase3: Focus on rebuilding shoulder strength once mobility started to improve. Add phase
3 exercises as soon as the patient have mobility to complete the exercises or the muscles
may become deconditioned and atrophied.

 BICEPS TENDINOPATHY
 Description: The LHB tendon often develops tendinopathy and pain at the front of the
shoulder, and the region is typically irritated by activities that involve repetitive shoulder
stress (racquet sports, golf, swimming and throwing). Pain comes on either gradually or
suddenly from these activities as overuse. A tendon tear is usually caused by long-standing
wear and tear, or a high-acceleration movement.

 Signs and Symptoms: Dull, achy pain typically affects the front of the shoulder and can
become sharp with aggravating movements or activities.

 Aggravating Factors: Reaching, lifting or pulling overhead; sleeping on the painful side and
moving your arm behind your body.

 Prognosis: With rehab 6-12 weeks if you modify provocative activities.

 Treatment Strategy: Allow the tendon to calm down and implement progressive
strengthening program targeting the shoulder and scapula muscles. Most people (not
athletes) can tear their biceps, not have surgery and be fine (unless it doesn’t improve after
12-16 weeks).

Phase 1: Soft tissue mobilisation of the elbow flexors, pectorals and levator scapulae
muscles. End phase 1 with shoulder isometrics (biceps + rotator cuff).

Phase 2: implement AROM and early biceps + rotator cuff resistance exercises. Resistance
training has the best scientific evidence for resolving tendon issues.

Phase3: Build shoulder strength targeting the biceps muscle and shoulder blade muscles.

ELBOW PROTOCOLS
 TENNIS ELBOW (Lateral Epicondylalgia)

 Description: Typically involves the irritation of the tendon of the extensor carpi radialis
brevis (ECRB) muscle. It becomes irritated when you overuse the finger and wrist extensor
muscles with grip-intense activities (gardening, typing, cooking, tennis…). It often happens
following repeated eccentric contractions. It can also occur when the tendon is used with
high force or at a high volume, as well as a result from repetitive overuse if the finger
extensors are constantly opening the hand.

 Signs and Symptoms: Pain on the outside of the elbow that worsens when extending the
fingers and/or wrist or performing activities that activate these muscles. Dull and achy pain
at rest, becoming sharp during specific tasks. Weakness in the hand and forearm is also
common. Pain is reproduced by palpating or pressing the area.

 Aggravating Factors: Any activity that causes the finger and wrist extensor muscles to
contract repetitively or for long periods.

 Prognosis: Resolves within 2 to 12 weeks.

 Treatment Strategy: Focus on building wrist extensor muscle and tendon strength.
Cortisone injections can significantly reduce inflammation, but must be used with caution, as
steroids are known to weaken connective tissue, including tendons. Braces can also be used
to reduce pain, but only temporarily.

Phase 1: Focus on soft tissue mobilisations that target the wrist and finger extensor muscles.
Also add pectoral mobilisation and nerve slider which also help reduce pain and improve
mobility.

Phase 2: Start by stretching the pectoral and wrist and finger extensor muscles to further
reduce pain and improve mobility. After that, you can start loading the affected tendons
with isometric wrist extensor contraction. Finish phase 2 with a wrist flexion and extension
active mobility exercise.

Phase3: Focus on strengthening the forearm muscles (resistance training has the best
evidence for healing tendinopathy). Add grip training to train the extensors isometrically.

 GOLFER’S ELBOW (Medial Epicondylalgia)

 Description: Wrist and finger flexor muscles become irritated at their attachment site on the
medial side of the elbow. Pain is usually associated with activities that require repetitive,
forceful use of flexor muscles (climbing, golf, or racquet sports, gripping tools for gardening
or carpentry). It affects the squeezing part of the movement instead of the opening of the
hand. It is less common than teeing elbow, because the flexors are twice as strong as the
extensors and thus, less prone to overuse issues. It is not exclusive to those who play golf,
overhead throwers may also experience this condition.

 Signs and Symptoms: Dull, achy pain that becomes sharp with certain tasks. It is also noticed
reduced grip strength. Pain is reproduced with palpation on the inside of the elbow. Wrist
flexion with resistance may also hurt.

 Aggravating Factors: Activities that work the wrist and finger flexor muscles – flexing and
extending the wrist and performing grip-related tasks.

 Prognosis: Resolves within 2 to 12 weeks.

 Treatment Strategy: Focus on gradually improving wrist and finger flexor strength. Elbow
braces can reduce pain but should be used temporarily.

Phase 1: Focus on mobilising the wrist and finger flexor muscles to reduce pain and tension.
Mobilise the elbow flexor muscles which share fascial connections and assist in the
movements of the wrist flexors. Mobilise pectoral muscles and median and ulnar nerves to
improve nerve health and mobility and reduce pain.

Phase 2: Stretch the pectoral muscles and wrist and finger flexor muscles. Begin to load the
tendons with isometric contractions and active mobility exercises.

Phase3: Focus on strengthening the forearm muscles and finally grip training exercises.

 TRICEPS TENDINOPATHY
 Description: Irritation of the triceps tendon occur when training demand surpasses the
tendon’s capacity (overuse or repetitive stress injuries), for example: too many burpees,
which are particularly problematic because the triceps act as a brake to slow the body as you
drop to the ground. All pressing motions that involve extending the elbow under force or
load can create a triceps tendon flare-up. Too many push-ups, heavy bench presses, dips or
overhead movements like military presses and handstands.

 Signs and Symptoms: Dull, achy pain at rest and sharp pain on the back of the elbow with
those specific activities.

 Aggravating Factors: Activities that require extending the elbow or contracting the triceps
muscles forcefully or rapidly.

 Prognosis: 2 to 12 weeks

 Treatment Strategy: Eliminate the aggravating factors and focus on gradually strengthening
the triceps tendon. Slowly load the tendon, first isometrically and then eccentrically.

Phase 1: Start mobilising the triceps muscles to reduce tension and pain in the area.
Mobilise and stretch latissimus dorsi muscle because of how closely it attaches to the upper
triceps besides being a synergist with the triceps. Finish phase 1 with triceps isometric
exercise (isometric contractions reduce tendon pain).

Phase 2: It begins focusing on resistance training exercises.

Phase3: Focus on making the tendon stronger and more resilient. Focus on concentric an
eccentric contraction exercises of the injured side exclusively, without the assistance of the
uninjured arm before performing the other exercises that incorporate the triceps.

WRIST & HAND PROTOCOLS

  WRIST PAIN

1 . Wrist Sprain

 Description: Typically result from a blunt force trauma such as a fall. It often occur alongside
wrist fractures, generally at the end of the radius or in one of the carpal bones. Sprains and
fractures both hurt a lot.

 Signs and Symptoms: Sharp pain, swelling and weakness.

 Aggravating Factors: Moving the wrist (flexing, extending and twisting); picking up or
squeezing objects.

 Prognosis: First, rule out a fracture. Most wrist sprains heal within 2 to 12 weeks.

 Treatment Strategy: Combination of temporary bracing (in severe cases), gradual mobility
and strengthening exercises.

Phase 1: Focus on reducing tension and pain in the wrist flexor and extensor muscles and
regaining joint mobility in all planes of motion. Apply soft tissue mobilisations to reduce pain
and tension as well as active mobility exercises in order not to lose ROM.

Phase 2: Perform stretches for the wrist flexor and extensor muscles. Implement gradual
strengthening work with wrist flexor + extensor isometrics and finger flexor + extensor
exercises

Phase3: Focus on regaining wrist muscle and tendon strength and making the entire wrist
and hand region more resilient.

2 . De Quervain’s tenosynovitis (thumb tendon pain)

 Description: It happens when the sheath that surround the tendons (specifically abductor
and extensor ones) become irritated, causing pain on the side of the wrist near the base of
the thumb. Texting and typing without regular breaks can cause flare-ups.

 Signs and Symptoms: Dull, achy pain on the side of the wrist near the base of the thumb. It
can become sharp with provocative movements and positions of the wrist and hand (such as
bending the wrist to one side).

 Aggravating Factors: Excessive use of the thumb abductor and extensor muscles, such as
picking up your child, video gaming, texting, gardening, and racquet sports.

 Prognosis: It resolves within 4 to 6 weeks with rehab + avoiding the aggravating factors.

 Treatment Strategy: Avoid the aggravating activities, and performing rehab. In severe cases,
an injection with steroid medication or anesthetic can reduce pain.

Phase 1: Start with soft tissue mobilisations for the wrist flexors and extensors + wrist
mobility exercises.

Phase 2: Stretch the finger flexor and extensor muscles + wrist and finger strengthening
exercises.

Phase3: Focus on strengthening exercises for all available wrist movements. Also, continue
the mobility exercises from phase2.

 CARPAL TUNNEL SYNDROME

 Description: Stress on the median nerve on the anterior side of the wrist. Recent research
observes edema or selling inside the nerve. The median nerve runs through a narrow space
(carpal tunnel) which can become inflamed. The carpal tunnel also houses eight tendons. If
the patient is flexing the fingers a lot (typing, writing…), the tendons slide and create friction
in the tunnel, causing inflammation and putting pressure on the median nerve. If the
pressure exists for too long or it’s too intense, it is as if the nerve is slowly choking. Nerves
have their own microcirculation, so when you choke a nerve, you stop blood flow to it.

 Signs and Symptoms: Pain, numbness and tingling in the thumb, index finger, middle finger
and thumb-side half of the ring finger. Hand weakness and difficulty with fine motor tasks
may also occur as the condition worsens.

 Aggravating Factors: Forceful gripping, holding an object for prolonged periods, or keeping
the wrists bent forward or backward (typing, driving, or reading a book).

 Prognosis: 8 to 12 weeks with rehab.

 Treatment Strategy: Wrist splints to keep the joint in a neutral position and reduce nerve
irritation), nerve glide exercises, steroid injections and changing sleep and work habits.

Phase 1: Start by mobilising the pectoral and wrist/finger flexor muscles. After that, add
median nerve mobilisation techniques to improve nerve mobility and blood flow.

Phase 2: Stretch pectorals and wrist flexors. The goal is to loosen these muscles so that the
median nerve can move more freely. Next, add wrist flexion and extension mobility exercise
to mobilise the median nerve at the carpal tunnel space. Finish phase 2 with 2 neck exercises
because the median nerve originates in the neck (C5-T1).

Phase3: Focus on strengthening the affected wrist and finger muscles. Also, strengthens the
muscles that allow maintain an upright neutral neck posture, which can reduce stress on the
cervical nerve roots.

BACK & SPINE PROTOCOLS

  BACK PAIN

1 . Non-specific LBP (acute and chronic)

 Description: it accounts for 90 – 95% of back pain cases. It is a type of pain where a specific
nociceptive source for a person’s symptoms (disc, muscle, joint, etc.) cannot be determined.
It is a general pain that exists when an obvious source cannot be linked to the person’s pain.
When the MRI is inconclusive, people feel like they won’t get better because they don’t
know what is going on in their body. However, while pain and injury often occur together,
they are different and can occur independently. LBP is the premier example of this, since
most cases do not involve injury. Pay attention to other contributing factors such as stress,
sleep, nutrition etc.

 Signs and Symptoms: Dull, achy pain along one or both sides of the low back. In some cases,
pain radiates into the buttock. Symptoms can become sharp with certain movements and
can limit ROM and the ability to perform functional tasks. However, the location and type of
symptoms can vary quite a bit from one person to the next.

 Aggravating Factors: Non-specific pain is usually less mechanical than a straightforward back
injury (sprain, strain, etc.), and is often influenced by factors such as stress, sleep, and
general physical activity. So, pay attention not only to physical factors that worsen the
patient’s pain, but also to factors that may not be on your radar.

 Prognosis: from 4 to 6 weeks with rehab.

 Treatment Strategy: Rehab for non-specific low back pain combines manual therapy (massage, joint
mobilisation) and mobility, sensorimotor control, and resistance training exercises. If symptoms become
chronic, psychological and emotional interventions may be added to the treatment plan. Don’t let the
patients’ fear and anxiety stop them from moving and exercising. Respect the symptoms while confronting
the pain with gradual doses of movement so that they don’t lose mobility, strength, or functional capacity.
In the protocol, pay attention to the body and adjust the sets, reps, and exercise variations to match the
symptoms. Consistent training should desensitise the system and improve the patient’s mobility, strength,
and function.

Phase 1: Start with spine and hip (lumbar extensors + QL + glutes + piriformis + hamstrings) soft tissue
mobilisation to reduce pain and muscle tension. Add stretches targeting the hip flexors (which attach either
to the pelvis or to the spine) that can effectively combat LBP. End phase 1 introducing Low-Load active
mobility (quadruped flexion and extension).

Phase 2: Use more advanced mobility and stretching drills that take the spine deeper into available ROM.
Add a series of gluteal activation and strengthening exercises (bridge, side-lying hip abduction, lateral squat
walk…). Finally, the first resistance exercise targeting the abdominal and back muscles (Pallof press), to
start rebuild muscle strength.

Phase3: Focus on building hip (specially gluteal) and trunk/core strength and control. Strengthening these
muscles will prepare the patient to resume the activities of daily living.

2 . Muscle Strain
  Description: Muscle strains in the low back are common and typically happen when lifting or
catching something heavy unexpectedly. The muscles surrounding the LB must generate
force rapidly and are more likely to be strained if they do not have the strength to handle
the external load. Strains can also happen with slower movements if you are heavily loaded
or with lower loads if your back is rounded or twisted. They can even happen with simple
daily movements such as bending over to pick something or standing up from a chair. It is
common to complete a movement when your tissues are not warm and end up with a
muscle strain.

 Signs and Symptoms: It typically produces pain when the muscle is contracting, being
stretched, or being palpated. The patient often experience pain when they return to
standing after bending over (when the muscle must contract to return to the upright
position). Pain is sharp when the tissue is stressed. A strain can happen on both sides, but
generally is generally is felt on one side or the other. The pain typically remains in the back
and does not radiate down the leg. The muscle may ache and feel tight at rest.

 Aggravating Factors: Contracting or stretching the low back make the pain worse – bending
at the waist, lifting an object from the floor or even carrying from an upright position.

 Prognosis: It depends on the severity of the strain (I-III). But as the back muscle tissue has a
good blood supply, from 3 to 6 weeks.

 Treatment Strategy: Muscle relaxants may help with severe pain. Rehab exercises can
improve muscle strength, which helps the injury heal and prevent the likelihood of reinjury
by strengthening the extensors and surrounding tissues.

Phase 1: Focus on alleviating pain using soft tissue mobilisation and stretching exercises, but
be careful with techniques that target the healing tissues! Applying too much pressure in the
region of the sprain could aggravate the symptoms and delay healing. If the techniques
create more than mild pain, remove them!

Phase 2: Gradually work on spinal mobility as the pain decreases to avoid the area becoming
stiff. Move as far as the body can tolerate. Focus on regaining full spine ROM.

Phase3: The pain must be minimal or absent, so start adding more resistance. Implement
strengthening exercises that target the gluteal and spinal muscles to increase the capacity to
handle force without damage, maximizing tissue integrity and reduce the likelihood of future
strains.

3 . Facet Joint Sprain

  Description: Facet joint sprain can happen when the spine is injured by being jarred
(accident, sports-related trauma), or forced to move beyond its normal mobility.

 Signs and Symptoms: They typically happen in the low back and produce unilateral pain that
is reproduced with twisting, extending or bending the low back. Pain is often sharp in these
provocative positions and then achy at rest, especially in the acute phase.

 Aggravating Factors: Bending forward, or bending or twisting to one side.

 Prognosis: From 4 to 6 weeks

 Treatment Strategy: Reduce pain and restore spinal ROM and strength. A muscle relaxant
may be helpful for severe pain. The protocol is similar to the muscle strain but with the goal
of regaining full spinal mobility.

Phase 1: Starts with soft tissue mobilisations and stretches to reduce muscle pain, tension or
spasm caused by the surrounding low back and hip muscles tightness.

Phase 2: Once the pain decreases, start working on spinal mobility. Ask the patient to move
as far as the body can tolerate. As the facet joints heal, they regain spinal mobility.

Phase3: Once the mobility is back to normal and the pain is gone, focus on building hip and
low back muscle strength. Muscles act like shock absorbers, so optimal function means less
force is transferred to the joints.

 What is the difference between a muscle strain and a facet joint sprain? The pain is similar
but the mechanism of injury is different. A strain typically occurs when force is applied to the
muscle, such as when performing a deadlift. Sprains generally happen when the joints are in
an end-range position and then twisted or jarred.

4 . Spondylolysis and Spondylolisthesis

  Description: Common causes of LBP, especially in children and adolescents who participate
in sports that apply repetitive force to the spine (gymnastics, football, weightlifting…). It
happens due to a stress fracture in the vertebrae. The bone becomes weakened to the point
that it begins to shift out of position either backward (retrolisthesis) or forward
(anterolisthesis). It is graded I to IV based on how far the bone has moved from its original
position. The signs, symptoms, aggravating factors, prognosis and treatment are the same
for both of them.

 Signs and Symptoms: In most cases, people experience only a general LBP, and the cause is
usually not identified unless an X-ray is ordered. Symptoms may include pain that radiates to
the buttock, back stiffness, back muscle spasm and hamstring tightness. A higher grade
spondylolosthesis that affects a nerve in the low back, numbness, tingling and weakness in
the legs may occur.

 Aggravating Factors: Arching or extending the spine beyond neutral and under force.

 Prognosis: From 6 to 12 weeks

 Treatment Strategy: Behaviour modification and physiotherapy stretches and exercises are
the preferred treatments. A low back brace may be recommended to take stress off the
healing bones. If symptoms are not improving and the vertebral slippage is worsening, a
surgery may be recommended. The stretches in phase 1 (particularly the hip flexors and
hamstrings) often reduce back pain associated with spondylolisthesis. At the beginning of
phase 2 BE CAUTIOUS with the lumbar extension mobility drills as many cases of
spondylolisthesis are related to repeated lumbar extension. So, perform only partial ROM or
skip them. In phase 3, when the patient performs the dead bug and abdominal rollout, avoid
letting the low back extend. If any other exercises cause back pain or radiating nerve pain,
omit them.

5 . Sacroiliac Joint Pain (SIJ)

 Description: Injury to the SIJ typically comes from an abnormal one-side trauma (falling on
your tailbone or stepping off a curb without realising it and jarring the leg to one side of the
 pelvis). It is also common in pregnancy. The SIJ moves little and are thought to account for
just 15 - 30% of back pain cases. It is easy to mistake LBP in L4-L5 and L5-S1 for SIJ pain.
Perform the special tests to identify the source of the pain. Also, the SIJ and LBP protocols
are very similar.

 Signs and Symptoms: Pain is usually located on one side of the low back and may radiate
into the buttock or back of the thigh. Low back stiffness is often reported, and some people
feel a sense of instability, as if their back is going to give out or buckle. SIJ pain does not
cause pain that radiates into the lower leg and foot. So, if the patient is experiencing this,
refer to the Nerve Pain protocol.

 Aggravating Factors: Placing pressure on the joint, such as when climbing stairs, running or
jogging, standing on one leg, or lying on one side, often brings SIJ pain.

 Prognosis: From 4 to 6 weeks once you modify the aggravating activities.

 Treatment Strategy: The first step is to modify the aggravating activities and perform the
rehab exercises that target the hip and low back muscles. An injection can be administered
to reduce inflammation and pain – injections can also serve as a diagnostic tool; if the pain
goes away, it was truly coming from the SIJ. For pregnant or hypermobile people, SIJ stability
belts might provide some benefit and pain relief when performing the stability exercises.
Most people with SIJ pain find relief with gluteal mobilisations and stretches and exercises
that activate and strengthen these muscles. Work through the protocol and check with the
patient which movements are most effective for him/her. If something causes pain, take it
out and try adding it again later.

 NERVE PAIN
1 . Sciatica (from the low back)

 Description: Irritation of the sciatic nerve or its branches that originate in the low back. This
irritation can be caused by prolonged pressure on the nerve (sitting on a hard surface or for
too long), a low back injury that causes inflammation around the nerves, and low back
stenosis (narrowing the passageway of the nerve). The cause of sciatica could be a disc
herniation that is touching the nerve roots or resulting in inflammation that is irritating the
nerve roots. Sometimes sciatica comes from the glute region (deep gluteal pain syndrome),
in this case, check the hip protocols.

 Signs and Symptoms: Sharp pain and burning, numbness, and/or tingling sensations that
radiate into the buttock and back of the thigh. Increased nerve irritation can make pain
travel into the calf, shin, and foot and cause muscle weakness in the legs.

 Aggravating Factors: Pain typically happens by bending the back into flexion or extension,
stretching the sciatic nerve, prolonged sitting or driving, or lifting objects. Most people feel
radiating nerve pain (especially in the low back), when the spine is in flexion.

 Keep in mind the concept of CENTRALISATION: ask the patient to identify the activities or
tasks that make the pain from sciatica radiate farther down the leg (peripheralisation). It
means that the activity is aggravating the nerve, so they should temporarily modify or
eliminate it. Even in the rehab protocol, if an exercise makes the pain travel farther down
the leg, take it out. Instead, find activities and exercises that create CENTRALISATION –
where the pain moves toward the spine. Such movements can serve as a test and a
treatment exercise.

 Prognosis: from 4 to 6 weeks if the activities or positons that aggravate the nerve are
modified.
  Treatment Strategy: Managed with physical therapy exercises that improve nerve health
and blood flow. If the symptoms do not improve after 6 weeks and there is leg weakness,
refer to the orthopaedic doctor for spinal MRI, as an injection or low back surgery may be
necessary. Besides the exercises, many people find relief with low back traction, applying ice
or heat and taking anti-inflammatory medication.

Phase 1: Focus on soft tissue mobilisations to reduce back and nerve pain, as they target the
nerve running through the buttock, down the hamstring region and into the calf. BE
CAUTIOUS with the glute/piriformis and hamstring mobilisations – too much pressure can
aggravate the sciatic nerve. The quad mobilisations target the path of the femoral nerve, so
focus on these areas for nerve pain on the front of the thigh.

Phase 2: Start with stretching exercises focusing the hamstrings. Ask the patient not to pull
the leg too high, which can aggravate the sciatic nerve. Pull to the point where a mild stretch
is felt and start there. Add mobility exercises such as lumbar flexion-extension. Avoid
movement that make the patient’s nerve pain to peripheralise, focus on those that make the
pain CENTRALISE – leave the leg. Test the movements and see how the body responds. Ask
the patient to be careful when performing the sciatic nerve mobilisation at the end of phase
2. The key is to find the position where the nerve begins to tighten without flaring up the
symptoms.

Phase3: Include a more aggressive sciatic nerve mobilisation (slump) and a femoral nerve
mobilisation depending on the nerve pain areas. If slump causes more pain, stick with sciatic
nerve mobilisation with strap from phase 2. The resistance exercises at the end of phase 33
target the gluteal muscles and often help with low back pain and sciatica.

 Why do people keep getting sciatica, and what to do about it? Musculoskeletal pain is
usually cyclical, and with time and movement, it will resolve. People can do rehab and still
have flare-ups. Stick to the protocol and avoid or modify the aggravating factors, listen to
the body! It is also important to remember that, pain and injury are not only influenced by
the activities/exercises, but they can also be exacerbated by poor diet, lack of sleep, high
stress, sitting or being static for long periods, and so on. Look at all the potential cause and
take a multifactorial approach to alleviating and preventing the issue.

2 . Disc Herniation
  Description: Disc herniation is more commonly observed in the last two segments of the low
back (L4-L5 and L5 –S1). It produces pain, numbness, and tingling that radiate into the leg
(radiculopathy). However, disc herniation occur in a large number of the asymptomatic
population, and having a herniation does not mean the person will feel pain. In fact, disc
herniation account for only 1 – 3% of back pain cases! Disc herniations most often occur
when the low back is loaded in a flexed and rotated position, such as when bending over to
pick up something from the ground.

 Signs and Symptoms: Those that produce pain, it is typically in the low back and down the
back of one leg, like sciatica. Pain can range from an ache in the back to sharp lightning-bolt
pains, along with numbness, tingling and weakness in the affected leg.

 Aggravating Factors: In most cases, pain is triggered when the spine is flexed or rounded, or
when sitting/driving, but it can also occur with prolonged standing.

 Prognosis: If aggravating activities are modified, pain resolves within several weeks to 3 - 4
months

 Treatment Strategy: Anti-inflammatory medication, ice or heat and traction units can ease
the pain. But physical therapy is the best defence and the path to regain full function. If the
pain has not improved after 3 to 4 months or if there is muscle weakness in the legs, refer to
the orthopaedic doctor for possible injections or surgery. Tell the patient not to rush into
surgery, but be mindful of nerve and muscle function.
The goal here is to get out of pain and return to full function. The injury could be permanent
and always show up on imaging. Tell the patient to focus on how he/she feels and move, and
modify the behaviour to accelerate healing.
Most symptomatic disc herniations cause sciatica, so approach this injury in a similar
fashion. Symptoms match the nerve that exits at the affected level of the spine.

 L1 – L3  pain on the front of the thigh.

 L4, L5, S1  pain on the back of the thigh and glutes.

 Do disc herniations heal? Research shows that around 66% do reabsorb and heal! Even if the herniation is not
reabsorbed, pain typically goes away and function returns to normal. Again, having a disc herniation does not
necessarily mean the person will have pain or functional limitation. Many cases are asymptomatic. It is part of
aging, and how the disc changes over time! Pay more attention to function and pain than a purely based diagnose
on MRI.
 When to consider surgery? If the patient has pain for mover 6 months, have tried physiotherapy and nothing has
improved, if there is radiating nerve pain and progressive loss of strength in the leg (can’t do a calf raise, elevate
the leg, lift the leg outward), or suddenly has a muscle that is not working, refer to a doctor and consider a
surgical intervention.

3 . Lumbar Stenosis
 Description: A condition in which the pathway for the nerves in the low back narrows,
leading to pain in the low back and legs. Stenosis can occur anywhere in the spine but is
most common in the low back. It can happen due to an herniated disc, arthritis in a facet
joint, a or a bone spur. It is common and not something to worry about unless there is
numbness, tingling or weakness. Most middle-aged people who get imaging have stenosis
but not pain.

 Signs and Symptoms: Pain and/or pressure in the low back, and tingling and numbness that
radiate into one or both legs. Weakness may also be present in the legs and people may
have difficulty walking long distances. With more severe nerve compromise, foot drop can
occur.

 Aggravating Factors: Extending or arching the low back (standing up straight, being upright
for too long, or walking) increases the pain and neurological symptoms.

 Prognosis: from 4 to 6 weeks by modifying the aggravating activities (reducing time standing
and walking, maintaining a neutral spinal position) and implement rehab exercises.

 Treatment Strategy: Focus on improving low back and hip mobility, strength, and endurance
is the primary method of treatment.
When progressing through the protocol, be careful with the lumbar extension mobility
exercises! Which tend to worsen stenosis-related nerve symptoms.
Also, be careful when mobilising the nerves! Only stretch to the point where the symptoms
begin. If pushed too far, the nerve can flare up and increase pain.

 MID-BACK AND RIB CAGE PAIN

1 . Thoracic Disc Bulge

 Description: The thoracic spine is naturally more stable and less mobile than the lumbar and
cervical spine due to the connection to the ribs. For this reason, issues like disc bulges and
herniations are less common in the thoracic region. Moreover, many degenerative changes
associated with the thoracic discs do not produce pain and occur unnoticed. An injury to a
spinal disc in this region is generally the result of a trauma like a car crash or a sudden force
in the thoracic spine – maybe the person lift something heavy, cough or sneeze in a way that
puts pressure on the thoracic cage. Injury can also occur when there is a heavy asymmetric
load on the shoulders – a firefighter carrying a heavy ladder, for example.

 Signs and Symptoms: Sharp pain in the upper or mid-back, depending on the level in the
spine. If a nerve root is affected, pain may radiate around the side of the trunk in line with a
rib – the thoracic spine is unique in that the nerves do not go into the arms or legs, they only
wrap around the ribs.

 Aggravating Factors: Activities that move the thoracic spine suddenly, such as sneezing or
coughing can exacerbate pain. Bending to lift something or rotating to look over one
shoulder might also hurt.

 Prognosis: In most cases, it resolves in 6 to 8 weeks with rest, general movement and
physiotherapy to improve thoracic mobility.

 Treatment Strategy: Start with mobilisation, stretching and mobility exercises (phase 1 and
2), which help reduce the pain. Rhomboid and pectoral mobilisations loosen up the major
muscles attached to the thoracic region. Thoracic extension mobilisation and mobility
exercises improve joint and soft tissue mobility.
The thoracic rotation and extension stretches in phase 2 improve thoracic mobility and
reduce mid-back-related pain. Stretching the pectoral muscles helps with pulling the
shoulder blades back so that the shoulders are less rounded, taking stress off the mid-back
muscles.
Once the pain has decreased, add resistance exercises at the end of phase 2 and in phase 3
to boost strength and control in the muscles on the anterior and posterior aspects of the
thoracic cage.

2 . Rib Injuries
 Description: The first 7 pairs (true ribs), attach directly to the sternum. The next 3 pairs are
“false” ribs because they attach to the seventh rib via cartilage. Ribs 11 and 12 float and do
not attach to the sternum either. All ribs attach to the spine via the costovertebral joints.

General rib pain  It does not involve trauma. Pain is reported after twisting to reach
something or pick something up. This pain is usually associated with spasming of the
surrounding muscles and not damage to the rib joints.
Slipped rib syndrome  It happens when a rib “pops out”. Common in sports like jiu-jitsu
that involve rotating against a resisting opponent. It feels like the rib tears away from the
cartilage.
Costochondritis  It is a common diagnosis for pain along the sternum, which causes
inflammation that spreads and covers the entire sternum region.

 Signs and Symptoms: Costovertebral rib joints are associated with sharp, nagging pain in the
interscapular region. On the front side, rib pain can be sharp with breathing, coughing, and
sneezing, and it is typically experienced along the edge on the breastbone where the ribs
attach.

 Aggravating Factors: Most rib pain is exacerbated with movement of the rib cage, such as
turning to look over the shoulder. Pain is also experienced when you apply pressure to the
injured rib, chest, or back or use the muscles that attach to the rib.

 Prognosis: It depends on the severity but typically 3 to 6 weeks for sprains and 6 to 12
weeks for fractures.

 Treatment Strategy: Most rib injuries are treated by eliminating or modifying activities that
would delay healing and implementing techniques that reduce muscle spasm and improve
the mobility the mobility of the rib cage and thoracic spine.

Phase 1: Start with soft tissue mobilisations to reduce pain and tension in the pectoral,
rhomboid and portions of the trapezius muscles. Loosen them can help regain mobility. Add
mobility exercises involving the thoracic spine and ribs, and the shoulder blades.

Phase 2 and Phase3: Implement more challenging stretches for the thoracic spine and rib
cage. Don’t push too hard if the patient has suffered a severe rib injury. Add resistance
exercises at the end of phase 2 and in phase 3 to make the thoracic spine and rib cage more
resistant to injury, stronger and more stable.

HIP PROTOCOLS
  HIP PAIN

1 . Hip Impingement

 Description: Also known as FAI, it is a condition in which premature contact between the
ball of the femur and the roof of the acetabulum occurs. It is divided into 2 categories:
1) Cam Deformities – changes in the shape of the femoral head neck junction
2) Pincer Deformities – bony overgrowths on the acetabular rim

In both cases, there are pain on the front or inside of the groin or hip when the hip is in an
end range flexion position (at the bottom of a squat for example). Some patients also report
clicking, locking, catching, stiffness, or feeling like their hip might give way.

With a true hip impingement, the bone is shaped differently. There is a little bump on the
femur, in the socket, or both, and those bumps are hitting each other. This can happen due
to stress on the tissue, anteversion or retroversion for example. Another theory is that the
condition may be present at birth.

 Signs and Symptoms: Pain in the groin but it can also present pain on the outside of the hip.
hip stiffness and limping is common. Sharp pain when the hip is forced into deep flexion
and/or end-range adduction or internal rotation. The hallmark is a pinch in the front of the
hip and groin when in deep hip flexion.

 Aggravating Factors: end-range flexion and internal rotation positions.

 Prognosis: Rehab + behaviour modification

 Treatment Strategy: Physiotherapy + anti-inflammatory medication first. If conservative

treatment is unsuccessful, arthroscopy surgery may be recommended. Physio focuses on
strengthening the hip in a multiplanar fashion, core strengthening, stretch and mobility
exercises.

Phase 1: Relieving pain and improving mobility. Start with stretches targeting the glutes,
hamstrings and hip flexors. Add mobility exercises with AROM including hip external and
internal rotation, abduction and flexion.

Phase 2: Focus on strengthening the hip muscles in multiple planes of movement with an
emphasis on the hip abductors (gluteus medius and minimus).

Phase3: Continue strengthening the hips, glutes and legs.

2 . Labral Tear
  Description: It is more likely to happen to those who practice activities that take the hips
into end-range positions (dance, hockey, martial arts, golf…). Labral tears in the hip
experience less instability than the shoulder, due to the deep socket. It’s usually just pain in
the groin or front hip area. Hip pains can mimic one another, so sometimes it might be tricky
to identify them. Labral tear is usually best diagnosed using an MRI with contrast. However,
imaging is just one piece of the puzzle. Research has shown that up to 54% of asymptomatic
people have labral tears.

 Signs and Symptoms: sharp pain in the anterior hip and groin regions that is provoked by
moving the hip into a combination of flexion + adduction + internal rotation.

 Aggravating Factors: prolonged sitting, deep hip flexion, squats and lunges.

 Prognosis: It improves from 6 to 8 weeks when aggravating activities are modified and rehab
is implemented.

 Treatment Strategy: Ease pain by resting and modifying movements that require deep hip
flexion (adopting a wider, externally rotated stance for squats and deadlifts). Anti-
inflammatory medication may be helpful in the acute phase. Labral tears are treated with
rehab exercises that improve hip strength and stability. If the pain persist after completing
the rehab protocol, the patient may need arthroscopic surgery. The protocol is basically the
same as the hip impingement, as they produce similar pain and limitations.

Phase 1: Start with stretch and mobility exercises. Because the hip joint is deep, soft tissue
mobilisations tend not to help much.

Phase 2 and Phase3: Focus on multiplanar hip and core strengthening. For the exercises that
require hip flexion (squats, hip thrust...) ask the patient to go as deep as he/she can without
pain.

3 . Hip Osteoarthritis
  Description: OA is the most cause of hip pain in adults over 50. A hip replacement may be
recommended if the pain is severe enough to limit the functional activities. OA usually
results from either an injury to the joint or factors that impair the joint’s ability to heal.
Sedentary and/or overweight people or repeatedly stressing the tissue beyond the capacity
can injure the cartilage, or make it unable to repair itself effectively. Besides, arthritis is
inflammatory and so, many things can affect inflammation such as nutrition, sleep hygiene,
stress levels, etc.

 Signs and Symptoms: OA hurts mainly in the groin but it can also hurt on the side of the hip.
OA individuals typically experience morning joint stiffness that improve within an hour of
awakening. Limited mobility in at least two of the six hip movements.

 Aggravating Factors: Pain typically occurs during weight-bearing tasks such as walking, stair
climbing, squatting, twisting, and deep bending of the hip.

 Prognosis: Rehab exercises will not correct osteoarthritis but can help slow the development
by strengthening the surrounding muscles.

 Treatment Strategy: It is primarily treated with physical therapy and exercise.

Phase 1: Includes stretches for muscles that tend to be tight in the presence of OA. Mobility
exercises is also important as OA typically limits joint mobility.

Phase 2 and Phase3: Focus on resistance training to improve hip strength as well as function
with daily tasks. If the patient feel joint pain, stop and modify the movement. It is OK to
perform partial ROM with these exercises.

4 . Gluteal tendinopathy and Trochanteric bursitis

 Description: Previously, pain on the outside of the hip, right on top of the bone, was always
diagnosed as trochanteric bursitis. However, the glute tendons also go over that bursa and
attach to the bone. Many tendons do that. Now we know that pain on the outside of the hip
is most often due to gluteal tendinopathy.
Gluteal tendinopathy is associated with dysfunction of the gluteus medius and minimus and
their respective tendons as they attach on the greater trochanter. Either the tendons were
stressed suddenly in a new way, or the volume of an existing activity was increased too
rapidly (lots of running, walking, stair climbing or hiking. Regardless if its bursitis or
tendinopathy, the treatment strategy is the same.

 Signs and Symptoms: both gluteal tendinopathy and bursitis produce pain on the lateral hip
over the greater trochanter that can range from a dull ache at rest to sharp pain. It can be
reproduced by touching around the greater trochanter.

 Aggravating Factors: Pain typically occurs when applying pressure to the irritated tendons or
bursa (sleeping on that side for example) or moving the hip into adduction. Running,
walking, deep flexion movements and positions such as deep squats or sitting in a low chair.

 Prognosis: From 4 to 12 weeks once the patient modify or eliminate aggravating positions
and activities, and implement resistance training program.

 Treatment Strategy: Both gluteal tendinopathy and bursitis require a modification or

elimination of aggravating activities and positions. Performing rehab exercises designed to
strengthen the gluteal muscles and tendons. Applying heat to the side of the hip and
sleeping on the non-painful side with a pillow between the legs can relieve pain. When
performing squats and single-leg movements ask the patient to consider limiting dynamic
valgus by controlling the alignment of the leg.

Phase 1: Focus on relieving pain and improving hip mobility. Start with stretches and
mobility exercises.

Phase 2 and Phase3: Focus on strengthening the hip muscles in multiple planes of
movement with an emphasis on the hip abductors (gluteus medius and minimus). Research
shows that strengthening these muscles and their respective tendons usually relieves pain
associated with gluteal tendinopathy.

 NERVE PAIN
1 . Piriformis Syndrome (Deep Gluteal Pain Syndrome)

 Description: Piriformis syndrome creates discomfort in the buttock, hip and leg. It can be
subdivided into 2 categories:
1. Primary piriformis syndrome – is believed to result from anatomical variations of the
sciatic nerve or the piriformis muscle. Little evidence exists to support this type and it is
considered much less prevalent than was once thought.
2. Secondary piriformis syndrome – results from a direct insult to the region, including
trauma or issues that reduce blood flow, such as falls, hip-related surgery, pain-induced
muscle spasm, and prolonged mechanical compression, like sitting on a wallet. Extreme
hip extensor or hip rotator exercises (too many loaded squats and lunges) and
overstretching the nerve (too much yoga or stretching) also can lead to this condition.

Piriformis syndrome is starting to be phased out an a diagnosis because the pain associated
with this condition can be related to numerous muscles (glutes, P-GO-GO-Q, and hamstrings)
not just the piriformis.

 Signs and Symptoms: it typically produces symptoms that are similar to sciatica – pain in the
buttock, possibly with radiating nerve pain into the back of the thigh, calf and foot. The
patient will feel the pain deep in the hip socket or back pocket area. Some people just have a
deep ache in the buttock, while others have numbness and tingling down their leg.

 Aggravating Factors: putting pressure on the piriformis muscle and underlying sciatic nerve,
such as with prolonged sitting or sitting on hard surfaces, typically aggravates symptoms.
Often, symptoms are triggered by a big workout, or hard run followed by a long flight, or car
ride. Basically, any prolonged seated position where you can’t get up and move frequently.
When this syndrome flares up, contracting the gluteal muscles may be painful.

 Prognosis: from 4 to 6 weeks if modified or eliminated the aggravating factors.

 Treatment Strategy: it is primarily treated by applying heat to the buttock, stretching nearby muscles,
taking muscle relaxants or anti-inflammatories, and doing rehab exercises. In severe cases,
corticosteroid injection can help.

Phase 1: start with myofascial release and other techniques to reduce pain. Glute/piriformis and
hamstring mobilisations. Add hip extensor stretches and mobility exercises from the hip to the low
back. End phase 1 with sciatic nerve mobilisation.

Phase 2: Progress from sciatic nerve mobilisation to the slump mobilisation. Progress stretches from
phase 1 challenging mobility and flexibility further. End phase 2 with resistance exercises to start
strengthening the glutes and deep hip rotators in a low-load fashion.

Phase3: Focus on more challenging resistance training exercises to strengthen the glutes, deep hip
rotators and low back muscles (core). It’s important to strengthen the core and low back because the
sciatic nerve originates in the low back.
 HIP FLEXOR PAIN
1 . Hip Flexor Strains and Tendinopathy

 Description: The iliopsas muscle (psoas major, psoas minor and iliacus) is a major hip flexor.
They blend together into one tendon and attach to the lesser trochanter. Pain in this area is
usually associated with hip flexion, such as in high volume walking, running, hiking or stair
climbing. Any activity that involves a repetitious marching motion can affect the iliopsoas or
hip flexor tendon. Strains are also common.

 Signs and Symptoms: sharp pain in the front of the hip and groin region with activities that
contract the muscles. Dull ache in the area following activities that irritate the tendon.

 Aggravating Factors: activities with hip flexion contractions, such as running and fast
walking. Deep squats, lunges, sitting in a low seat can compress the tendon and provoke
symptoms.

 Prognosis: from 6 to 12 weeks once the aggravating activities are modified or eliminated and
a rehab program is implemented.

 Treatment Strategy: Primarily treated with physiotherapy, anti-inflammatory medication

and steroid injection may be used to reduce acute pain.

Phase 1: start by mobilising the quadriceps muscle (rectus femoris is also a hip flexor). Add
hip flexor stretch (careful with strains). Because the psoas muscle attaches to the low back,
lumbar rotation stretch can reduce hip flexor-related pain. End phase 1 with hip flexion
mobility exercise and hip flexor isometric to start strengthening these muscles.

Phase 2 and Phase3: focus on resistance training with exercises targeting the hip flexors and
hip external rotators (hip flexors assist with external rotation). In phase 3 make the exercises
from phase 2 more challenging.

 HAMSTRING PAIN
1 . Hamstring Strain

 Description: hamstring strains commonly occur when the muscles are contracting forcefully
while lengthening (eccentric contraction). It can occur in the upper or lower part of the
muscle, and in either case the treatment strategy is similar.

 Signs and Symptoms: pain is typically located on the back of the thigh somewhere between
where the hamstrings attach to the pelvis or knee. Sharp pain is felt when contracting the
muscles. The patient may hear or feel a pop, which is the muscle fibres tearing.

 Aggravating Factors: running and hip hinging movements like deadlifting and hamstring
stretches can cause flare-ups and pain.

 Prognosis: healing times vary based on the grade of the strain (I-III) and location of the
injury. A strain in the muscle takes around 3 to 6 weeks to heal. An injury of the
musculotendinous region takes longer, from 4 to 8 weeks. Injuries of the tendon are the
slowest and can heal up to 4 months.

 Treatment Strategy: hamstring strains require strengthening exercises that gradually load
the injured muscle and/or tendon. In case of a complete hamstring tear (extreme bruising,
feeling a gap and significant strength loss), surgery may be indicated.

Phase 1: the protocol aims to progressively challenge the hamstring muscles. Start with
hamstring slide, toe-elevated bridge, standing hamstring curl.

Phase 2 and Phase3: progressively increase the challenge on the hamstring muscles, so do
only the exercises that create mild or no pain. As the hamstrings are hip extensors and knee
flexors, include exercises using one or both of these movements. The Nordic exercise is
powerful for not only rehab, but also reducing the odds of a second strain.

2 . Proximal Hamstring Tendinopathy

 Description: This is a relatively new diagnosis that describes pain where the hamstring
tendon attaches to the ischial tuberosity. It is usually associated with repeatedly
compressing against the ischial tuberosity (sitting on a hard surface or doing a hamstring
stretch).

 Signs and Symptoms: PHT produce pain at the sit bone and is reproduced when the hip is in
flexion and the hamstrings are contracting or being stretched. Pain is typically sharp with
activities that stress the tendon and the region aches at rest.

 Aggravating Factors: stretching the hamstrings, hip hinging movements, running uphill,
sprinting, and similar activities often provoke the issue. The patient may need to temporarily
stop stretching and limit prolonged sitting to desensitise the tendon and allow it to heal.

 Prognosis: from 6 to 12 weeks when modifying aggravating activities and strengthen the
tendon.

 Treatment Strategy: it is predominantly treated with physical therapy integrating resistance

training exercises that gradually increase the strength and capacity of the hamstring tendon.
Stretching is not included in the program as it would aggravate it in the acute stage. It
instead focuses on loading and strengthening the tendon and muscles gradually.

Phase 1, 2 and 3: start the protocol with lower-load exercises that do not allow the hip to
move into much flexion, such as toe-elevated bridge, standing hamstring curl, ball hamstring
curl and step-up. As you progress through the phases, add exercises like split squat, elevated
hamstring bridge, skater squat, deadlift and Nordic. The protocol limits hip flexion early on
because this position compresses the upper hamstring tendon against the ischial tuberosity.

 GROIN STRAIN
 Description: Of the major groin muscles, adductor longus is thought to be the most
commonly strained, but any of the adductors could be involved. The most common site of
injury is the musculotendinous junction, as the tissue in this region is thought to be less
elastic. Injuries to the adductor group are often associated with movements such as kicking,
pivoting, skating, and sprinting and with sports such as hockey, gymnastics, soccer, martial
arts, football, and track and field.

 Signs and Symptoms: it causes pain on the inside of the thigh that is usually felt closer to the
groin rather than farther down the thigh. Pain is sharp when the muscles contract, a dull
ache may be felt when not using the muscles.

 Aggravating Factors: because the groin muscles help in hip extension and leg stabilisation,
pain is typically experienced with activities that require high degrees of hip stability (surfing,
ice skating, running, hopping, etc.) along with stair climbing, standing from a seated position,
and getting in and out of a car (especially a low one).

 Prognosis: healing times vary based on the severity (I – III) and location of injury. Muscle
strain = 3-6 weeks. Musculotendinous region = 4-8 weeks. Tendon = up to 4 months.

 Treatment Strategy: Adductor strains are treated with gradual strengthening exercises.
Research shows that resistance training restores tissue integrity, reduces strain frequency,
and helps prevent reinjury.

Phase 1: Focus on reducing acute pain and includes basic hip mobility exercises (flexion,
abduction and adduction) and a bridge with an isometric adductor squeeze. Isometrics begin
strengthening the injured muscles while adding force in a controlled fashion.

Phase 2: the resistance training exercises in this phase gradually increase the demand on the
adductor muscles. Add side-lying adduction with the weight of the leg if it’s not too painful.
The single-leg bridge and chair squat focus on extension, which is important to address
because some adductors assist the glutes with hip extension.

Phase3: this phase demands more of the adductors. The wider stance of the sumo squat
recruits the groin muscles. The split squat is harder than the chair squat. The lateral lunge
and lateral step-up also work on hip extension, but the abduction requires the adductors to
contract to stabilise the hip joint and pull the body over the stance leg. The adductor plank is
the most challenging groin exercise but one of the best to strengthen these muscles.

KNEE PROTOCOLS
  KNEE PAIN

1 .Patellofemoral Joint Pain

 Description: Mechanical issues like poor patellar tracking can contribute to pain in some cases,
however, patellofemoral pain is more complicated and can be influenced by non-mechanical variables
like the psychological and emotional states. Patellofemoral joint pain syndrome (PFPS) is a common
condition that produces pain behind the kneecap.
Similar to patellar tendinopathy, PFPS pain is typically brought on by activities that involve a lot of
running (especially heel strikers, who place more load on their quads and knees), jumping and
squatting. Movements that require the knees to move forward over the toes (lunges, front squats,
high-bar back squats, hiking downhill, walking down stairs, etc.) might amplify the condition because
they compress the patellofemoral joint, placing extra stress on the area. For most people, PFPS is a
temporary irritation caused by overuse and inflammation. However, it can be associated with a
gradual deterioration of cartilage  CONDROMALACIA PATELLAE) on the back of the kneecap. This is
considered an arthritic condition. Still, the protocol for both conditions is the same. The best way to
prevent arthritis and the pain associated with PFPS is to address aggravating factors, increase hip and
knee strength and avoid activities that place more load or volume on the joint than it is conditioned to
handle.

 Signs and Symptoms: Pain located behind the kneecap and it is typically sharp. Touching the soft
tissue in the region usually does not reproduce symptoms.

 Aggravating Factors: Activities that compress and place increased stress on the joint (squatting,
walking up and down stairs, sitting for long periods, running and cycling.

 Prognosis: It typically improves within 4 to 6 weeks when modifying aggravating factors and rehab is
implemented.

 Treatment Strategy: It is exclusively treated with physiotherapy which focuses on strengthening the
kinetic chain and improving neuromuscular control with aggravating activities (running, squatting…).
The temporary use of orthotics for individuals with increased foot pronation and patellofemoral joint
taping can be helpful. Applying ice, taking anti-inflammatory medication, and refraining from
aggravating activities all tend to reduce pain.

Phase 1: start with soft tissue mobilisations (quads + calf) and stretches (quads + calf) to reduce pain.

Phase 2 and 3: Follow phase 2 with sensorimotor control and strengthening exercises. One of the best
strengthening exercises to combat patellofemoral pain is to strengthen the gluteal muscles, especially
abductors and external rotators. Poor hip control can increase stress on knee structures. After
focusing on the hip, add exercises that strengthen the knee muscles, especially the quads. However,
high-volume and heavy quad training is associated with patellofemoral pain! so, start with exercises
that limit the compressive loads on the joint  lateral step-up, reverse lunge, split squat, and skater
squat. Careful with knees-over-toes exercises, as they make patellofemoral joint pain worse!

2 . Iliotibial (IT) Band Syndrome

 Description: The IT band is a dense, fibrous band of connective tissue that runs along the lateral thigh
from the hip to the knee. It is one of the primary causes of lateral knee pain in runners. Although
several factors can contribute to IT band syndrome (anatomy, exercise volume, mechanics…), it is
believed that repetitive compression of the fat pad and/or bursa under the IT band leads to
inflammation and pain. High volume loading (e.g high-mileage running) or loading that is unfamiliar (a
new sport or activity) can spark an inflammatory response. The situation can be further amplified
when a runner’s foot lands with a valgus or varus deviation from neutral. In order to treat this
condition, it’s important to look at three potential causes: mechanics (neuromuscular control), hip
and knee strength, and training volume. The best strategies for preventing and treating most
connective tissue conditions are strength training and program design (managing training volume). IT
band syndrome is a connective tissue disorder, which means pain is usually caused by overuse.
Because this condition mainly affects runners, it’s important to address the mileage the patient is
putting on his/her body. Remember to tell the patient to increase the volume gradually and give the
tissues time to adapt. Combine intelligent program design with rehab exercises.

 Signs and Symptoms: It typically produces sharp pain on the outside of the knee during activities like
running. Some people also experience a popping or snapping sensation. IT band syndrome can
sometimes hurt higher, such as at the hip, but it is most common in the knee.

 Aggravating Factors: High volume running, running downhill or on uneven terrain, starting a new
running program, and squatting are commonly associated with this type of pain.

 Prognosis: In most cases, it improves within 4 to 6 weeks when modifying the aggravating activities
and implementing rehab exercises.

 Treatment Strategy: Treat IT band syndrome by managing the stress on the tissue, which means
reducing running volume, temporarily running on flat surfaces, and potentially trying running shoes or
orthotics that limit foot pronation and promote a more neutral knee alignment. It is also important to
strengthen the gluteus medius and minimus and knee muscles and address neutral knee alignment
mechanics during functional tasks.

Phase 1: Addressing IT band syndrome is similar to addressing patellofemoral joint pain. This phase
focus on mobilising and stretching the quads and calf, which can reduce pain by temporarily altering
the stresses applied to the lateral knee.

Phases 2 and 3: Once the pain is under control, improve hip and knee strength and movement
control. The hip strengthening exercises include side-lying abduction, lateral squat walk, and fire
hydrant, target the abductors (gluteus medius and minimus) and external rotators. These muscles
help control the hip joint and femur, and consequently, a better knee control. The lateral step-up,
split squat, skater squat, reverse lunge, and other strengthening exercises combine quadriceps and
gluteal movements, building capacity and control.
Focus on the movements and do not allow the knee to move in or out, which is associated with the
development of IT band syndrome.

 KNEE INSTABILITY
1 . Meniscus Tear

 Description: The meniscus are the knee’s primary shock absorbers. They also stabilise the joint
together with the ligaments ACL and PCL. Meniscus tears can be degenerative or traumatic and
typically involve twisting on a leg that is planted. Degenerative tears can occur with simple activities
that impart lower forces on the tissue, like twisting awkwardly or playing some recreational sport.
Many people have degenerative meniscus tears but don’t experience pain or disruptions in functional
ability. In other cases, the symptoms are cyclical, like arthritis, which is why they are often associated
with osteoarthritis of the knee.

 Signs and Symptoms: Meniscus tears typically produce joint swelling and sharp or aching pain when
bending, straightening, or twisting. In more severe cases, people experience limited knee ROM with
catching/locking and instability or a feeling that the knee will give way or buckle. Many patients also
report hearing or feeling a pop when the meniscus tears.

 Aggravating Factors: Standing on the affected leg and twisting or trying to move the knee through its
full ROM, such as when squatting. Prolonged sitting and standing may increase pain and swelling in
the joint.

 Prognosis: Healing and recovery depends somewhat on the symptoms, the severity and the location
of the tear. The periphery of the meniscus has a better blood supply and has better chance of healing.
The central two-thirds of the meniscus is not as well vascularised and may not heal well due to poor
circulation. If the periphery is torn and there is instability or locking, symptoms often improve
significantly within 2 – 3 months. If the tear is in the central part, rehab can improve pain and
function, but there is a higher likelihood of needing surgical intervention.

 Treatment Strategy: Research suggests that most meniscus tears (especially degenerative and less
severe tears) should be addressed with rehab first. In most cases, symptoms improve after 6 -12
weeks of rehab when modifying or eliminating aggravating factors. The protocol does not include soft
tissue mobilisation or stretching because the focus here is restoring joint ROM and then boosting
strength and stability of the knee. Numerous exercises target the quads because they are very
important for knee joint stability. Besides, the glutes are important for controlling the femur, which
makes up one half of the hip and knee joints. The hamstrings also help stabilise the knee joint and for
this reason, exercises targeting this muscle group is also included in the protocol. Standing exercises
focus on sensorimotor control, maximising neuromuscular function and helping recovery.

Phase 1: Start with heel slide, quad isometrics, short arc quad, supine straight-leg raise, side lying hip
abduction.

Phases 2 and 3: Add banded squat, knee extension, single-leg bridge, ball hamstring curl, split squat,
step-up. The last phase starts with standing banded hydrant, Bulgarian split squat, single-leg deadlift,
lateral step-down, clock, skater squat, single-leg hamstring curl, tiptoe walk and finally, bilateral jump
to unilateral landing (only if the knee stability is very high and there is the need to perform jumping in
the daily life).

2 . Ligament Tear (ACL, PCL, MCL, LCL)

  Description: The ligaments help hold the femur to the tibia and fibula and play a key role in
maintaining joint stability. The ACL controls rotation and forward motion of the tibia. The
PCL controls backward movement of the tibia. The MCL provides stability in valgus motion.
The LCL provides stability by resisting extreme varus motion. The ligaments are usually torn
in extreme sideways, oblique, and/or rotational motions. ACL and MCL tears tend to result
from dynamic valgus knee movements. LCL tears usually happen due to varus stress
although is less common. PCL is commonly injured when there is a fall on a bent knee.

 Signs and Symptoms: knee ligament injuries typically produce joint swelling, pain, and, in
many cases, a feeling of instability where the joint gives way or slips when weight is put on
the leg. Patients usually report a popping sound at the time of injury and have difficulty
moving the knee through its full ROM. With MCL and LCL touching the area reproduces pain.
with ACL and PCL tears, pain often occurs on the back of the knee but can be diffuse and
deep, making the injury difficult to pinpoint.
Felling like you do not have control (unstable, as if the leg is going to give out when you put
weight on it) is a sign that is specific to ligament tears.

 Aggravating Factors: activities like standing on one leg (especially when twisting or pivoting),
squatting, lunging, climbing stairs, running, and jumping are typically associated with pain
and feelings of joint instability.

 Prognosis: some ligament ruptures can be treated successfully with rehab that focuses on
building muscle strength and improving neuromuscular control. There should be significant
changes within 3 to 4 months. Surgical reconstruction may be necessary if the patient
continue to experience pain and episodes of instability.

 Treatment Strategy: Both ligament and meniscus tears create pain and instability in the
knee joint and affect passive subsystems (ligaments and cartilage), so rehab has many of the
same objectives.

Phase 1: In the beginning of rehab, you should focus on reducing any swelling that is
present and restoring knee joint ROM. The pain and swelling can be relieved by elevating the
leg, applying a compression sleeve, and using ice and anti-inflammatory medication.

Phases 2 and 3: After pain and swelling are under control and joint mobility is full, the
attention shifts to maximizing muscle strength and joint stability via neuromuscular control
exercises. Such as the squat, leg extension, step-up, lateral step-down, ball curl, and skater
squat. *When a passive subsystem element like a ligament is damaged, you must make up
for this loss of stability with the active subsystem (muscles and nerves) through specific
movements and exercises. Always focus on neuromuscular control!

3 .Kneecap Dislocation
 Description: Certain injuries can force the kneecap out of the groove. Kneecap dislocations
are fairly uncommon (2-3% of the population). They are more often seen in adolescent
female athletes, and typically associated with trauma or planting the foot, and then
suddenly changing direction, pivoting, or landing hard on one leg. In most cases, the medial
patellofemoral ligament is disrupted, allowing the patella to shift laterally.

 Signs and Symptoms: It typically produces an audible pop followed by intense, sharp pain.
the knee swells, and bearing weight is usually difficult.

 Aggravating Factors: movements such as pivoting, jumping, squatting and running.

 Prognosis: the patient should feel better after 6 to 8 weeks of rehab focusing in glute and
quadriceps strengthening.

 Treatment Strategy: first-time dislocations should be managed with physical therapy, but re-
dislocation rates following conservative treatment range from 14 to 44%. When dislocations
recur many times, surgical intervention is often required to re-stabilise the joint.

Phases 1,2 and 3: In rehab, the knee is immobilised for 6 weeks with a cast or ROM brace.
Following the period of immobilisation, start with exercises too restore ROM, improve motor
control, increase quad, hamstring, and hip strength. As patellofemoral dislocations create
joint instability, you can apply the same protocol as the meniscus and ligament tears.
The protocol first focus on regaining knee mobility and motor control in phase 1. Then it
shifts to more challenging exercises in phases 2 and 3 that help build strength and
neuromuscular control.

 PATELLAR TENDINOPATHY
 Description: Also known as ‘’jumper’s knee’’ because it usually happens due to a lot of
jumping. As with most tendinopathies, pain manifests when the tissues are not conditioned
to handle the load or volume of movement. Although jumping is a common cause of patellar
tendinopathy, any activity that causes the quads to contract repeatedly (squatting, hiking
downhill, walking downstairs), can irritate the tendon, leading to an overuse or repetitive
stress injury.

 Signs and Symptoms: Pain is typically sharp, and the knee may ache and throb at rest
following aggravating activities. The tendon pain usually occurs between the bottom point of
the kneecap and the tibial tuberosity, but can also be present above the kneecap.

 Aggravating Factors: Activities that require forceful contractions of the quads, like the ones
previously mentioned.

 Prognosis: most cases resolve within 8 to 12 weeks when eliminating aggravating activities
and following the rehab protocol.

 Treatment Strategy: treat patellar tendinopathy with exercises that improve tendon
strength an capacity. First, ask the patient to modify the volume and intensity of aggravating
activities to give the tendon the opportunity to recover. The patient may use patellar tendon
strap (it should be a very temporary strategy, as chronic use can lead to tendon
deconditioning). A corticosteroid injection may reduce pain, but because these medications
weaken tendons, it’s better to avoid them if possible.

Phase 1: Start with soft tissue mobilisation of the quadriceps. Heel slide is used as a general
pain reducer. Knee extension isometric can reduce tendon pain when help for 30 to 45
seconds and begin to rebuild tendon strength and capacity. Finish phase 1 with several
hip/gluteal exercises to improve hip strength and promote knee health.

Phases 2 and 3: Focus on hip and graded quadriceps/patellar tendon loading. Phase 2
includes lower-load quad exercises such as the isometric wall sit, front plank reach, tiptoe
walk, and eccentric bench squat. Once isometric contractions have calmed tendon pain,
start eccentric contractions.
Phase 3 combines single-leg exercises that target the hip, hamstrings, and quads. The
‘’decline squat’’ is one of the best for targeting the quads and patellar tendon. Phase 3
finishes with hopping movements, which help with the tendon’s energy storage and release
capacities (non-athletes can omit these).

 KNEE OSTEOARTHRITIS
 Description: In OA, the cartilage breaks down and over time, it can deteriorate creating
bone-on-bone friction. At this stage, OA becomes a severe condition that limits the patient’s
ability to complete daily tasks and a knee replacement is recommended.
Knee pain that increases in frequency and severity could be an early sign of arthritis. It is
important to remember that the cartilage breaks down faster in people who are either very
sedentary or very active, whereas moderate-dose activity protects it.
In addition, arthritis is an inflammatory condition that can accelerate the breakdown of the
cartilage, so, remember the behaviour modifications to reduce inflammation and slow the
process such as getting more sleep, reduce stress, improve the diet, etc.

 Signs and Symptoms: It typically produces pain in the joint, swelling, joint stiffness, limited
ROM (flexion and extension), and difficulty with functional tasks such as standing, squatting,
walking, and running.

 Aggravating Factors: Activities that require increased ROM, such as squatting or getting in
and out of a chair. Pain may increase when the joint is loaded, such as standing for extended
periods, or after long walks.

 Prognosis: While rehab will not revert arthritic changes, improving ROM and strengthening
the muscles surrounding the knee joint can improve cartilage health and slow the
progression.

 Treatment Strategy: Rehab focuses on building knee and hip strength and implementing
mobility exercises to maintain joint ROM needed for daily activities. Rest, anti-inflammatory
medication, ice, and heat can reduce pain temporarily.

Phase 1: is all about pain relief. Implement soft tissue mobilisations and stretches targeting
the calf muscles, quadriceps, and hamstrings.

Phases 2: As many people with knee OA have limited knee flexion, extension, or both, phase
2 begins with passive and active mobility exercises. Heel slide, and then active mobility drills
such as standing hamstring curl and knee extension teach the neuromuscular system to
utilise the ROM gained from heel slide. End phase 2 strengthening the glute and calf
muscles, which absorb shock and support the knee.

Phase 3: in this phase, the strength exercises targeting the hamstrings, quads, calf and glutes
are more challenging- ball hamstring curl, bridge, split squat, goblet squat, step-up, single-
leg calf raise.
As the muscles become STRONGER, they can accept more load, which means LESS FORCE is
transferred to sensitive joint structures.

ANKLE & FOOT PROTOCOLS

 CALF AND ACHILLES PAIN

1. Achilles Tendinopathy/Tear
 Description: It happens when the tendon becomes irritated, resulting in pain, ankle stiffness, and
difficulty plantar-flexing. Achilles tendinopathy generally stems from overuse but can come rapidly if
the person is not warmed up or has not built up the tissue to handle a high volume of jumping,
sprinting, or running uphill. When the Achilles is in a weakened state, it is much more likely to
rupture, and a full or partial tear often requires surgery. *The Achilles tendon is the strongest and
thickest tendon in the body, yet it is the one most commonly ruptured. To identify if the tendon has
been ruptured, apply the Thompson’s test!

 Signs and Symptoms: Achilles tendinopathy is divided into 2 categories based on the location of
symptoms:
1. Mid-substance tendinopathy – causes pain several centimetres (approximately 2-7cm) from the
calcaneal insertion of the tendon
2. Insertional tendinopathy – causes pain on the back of the calcaneus where the tendon attaches.

Pain can be sharp with activities that stress the tendon, and the area often aches at rest or after
activity.

 Aggravating Factors: Walking, running, sprinting, jumping, climbing stairs, and any activity that
involves lifting and lowering the heel.

 Prognosis: It typically resolves within 2 to 12 weeks, depending on the problem and whether it is
chronic, when the patient temporarily modify or stop aggravating activities and implement a tendon
load program.

 Treatment Strategy: Firstly, the patient must modify behaviours to allow the tendon to heal and
gradually loading the tendon and calf muscles with resistance training exercises. The patient may also
be put in a boot that locks the ankle at 90 degrees to allow the tendon to heal (generally for 6 weeks).
*There is NO STRETCHING is this protocol because you should not stretch an Achilles tendinopathy. A calf stretch
might make the pain worse!

Phase 1: Focus on reducing pain. Calf and plantar mobilisations reduce muscle tension and tightness.
The calf isometrics typically reduce Achilles tendon pain. Knee straight calf raise and knee bent
version target different muscle groups such as gastrocnemius and soleus respectively. * If the pain is
acute and the patient cannot perform calf raises, stick to the mobilisations and isometrics.

Phases 2: Continue building calf and Achilles tendon strength with calf eccentrics. Add band inversion
to target the tibialis posterior, which assist the calf muscles. End phase 2 with the split squat and ball
hamstring curl to target muscles farther up the kinetic chain that support the calf and Achilles tendon.

Phase 3: Provide more challenging resistance exercises. Complete the calf raises on one leg (at least
20-25 raises). Skater squat and forward lunge support the calf complex. End this phase with tiptoe
walk targeting the calf muscles and ankle stabilisers, especially the soleus muscle.
2. Calf Strain
 Description: It usually happens when the muscle fibres are damaged due to a sudden stress
with a forceful load.

 Signs and Symptoms: Strains typically produce sharp pain in the calf muscle region (not the
Achilles tendon) when the muscles are in use and a dull ache at rest, especially in the early
phases. For most people, pain occurs in the musculotendinous junction.

 Aggravating Factors: Walking, running, jumping, or standing on tiptoe.

 Prognosis: Healing times vary depending on the severity of the strain, but most of them heal
within 3 to 6 weeks with rehab.

 Treatment Strategy: Calf strains are treated almost exclusively with physiotherapy that
gradually increase muscle strength and integrity. Whether the patient has a calf strain or
Achilles tendinopathy, the protocol is nearly the same.

Phase 1: is all about reducing pain. With a strain, skip the calf mobilisation, which could
create more discomfort and delay healing. In order to reduce muscle tension and tightness
implement plantar mobilisation. Calf isometrics begin to build strength and knee-straight
calf raise target the gastrocnemius while knee-bent calf raise target the soleus. *If the
patient cannot do the double leg raises, stick with the isometrics while the injury heals more.

Phases 2 and 3: mirror the approach for Achilles tendinopathy (opposite).

 PLANTAR FASCIOPATHY (FASCIITIS)

 Description: It is the most common cause of heel pain and occurs in both active and sedentary
people. The pain typically occurs at the front of the heel on the sole of the foot where the plantar
fascia attaches to the calcaneus. Plantar fasciopathy or fasciitis is more common in runners and
overweight individuals and can be associated with arch height, lower body strength, and ankle and
foot mobility.
The fascia also maintains the arch of the foot along with muscles and other ligaments. Repeatedly
straining the plantar fascia – from too much standing, walking, or running – can lead to plantar
fasciitis, which is classified as a repetitive stress or overuse injury.

 Signs and Symptoms: Pain is often sharp, especially upon standing first thing in the morning,
returning to standing after being seated for long periods, or prolonged standing in place. It can also be
a dull ache, usually around the front or inner side of the heel, or feel like a tender bruise on the
bottom of the foot.

 Aggravating Factors: Standing or walking for long periods (especially barefoot or on hard surfaces),
running, jumping, and adjusting to a new pair of shoes can worsen the problem.

 Prognosis: Most cases resolve within 2 to 12 weeks when eliminating or modifying aggravating factors
and implementing rehab.

 Treatment Strategy: Most cases are treated with physiotherapy, massage of the foot and lower leg,
anti-inflammatory medication, night splints, and orthotics. * Different shoes or orthotics often help
not because they reposition the arch of the foot, but because they change the load on the tissue,
varying the source of stress. For more resistant or chronic cases, steroids injections can be used.
Many people believe that changing the walking and running mechanics can prevent or alleviate pain.
However, most likely, the cause of pain is not the low arches because the body has adapted to them.
Training variables such as VOLUME and INTENSITY are what mainly contribute to the issue. If pain is a
recurring problem, the patient need to address the speed, distance, and/or duration of training,
making sure to give enough time for the body to heal.

Phase 1: The rehab protocol aims to reduce pain with calf and plantar soft tissue mobilisations. Then,
implement straight and bent-knee plantar fascia calf stretches to eliminate pain and improve stretch
tolerance. Also, hamstring stretches to improve posterior chain flexibility. Stretching hamstrings also
stretches the sciatic nerve, helping reduce pain. The last exercise is the towel curl, to activate and
strengthen the 4 layers of deep intrinsic muscles in the arc of the foot.

Phases 2: Start with straight and bent-knee calf raises. Add band inversion for the tibialis posterior,
which helps in arch position and control. The last exercise in phase 2 is kettlebell deadlift to
strengthens the hamstrings, glutes and low back muscles and helps improve posterior chain flexibility.

Phase 3: Focus on increasing the load tolerance of the plantar fascia with knee-straight and knee-bent
plantar fascia calf raises using the Fasciitis Fighter or a rolled-up towel. The last 3 exercises target the
glutes, hamstrings, and quads, which are major stabilisers of the upper kinetic chain. *Improving
strength and control at the hip and knee takes stress off the ankle and foot.

 ANKLE SPRAIN
 Description: Ankle sprains are common injuries and can lead to long-term impairments,
including pain, stiffness, and gait abnormalities in as many as 72% of individuals. Besides,
nearly 80% of those who suffer a sprain are likely to experience re-injury!
Sprains can happen with inversion (3/4 of cases) or eversion. The ankle usually turns inward
because the ligament on the inside is so strong that it’s harder to turn out. The individual
may tear one or all of the 4 ligaments (grade I - III). The patient typically feels a pop followed
by sharp stabbing pain. Despite the pain, the person should be able to bear some weight on
the injured foot and take at least 4 steps immediately after the injury. If the person cannot
put any weight on it, it is likely to have a fracture, and an x-ray should be taken.

 Signs and Symptoms: Sprains typically cause sharp pain and throbbing or aching at rest.
Swelling and discoloration of the surrounding tissues can occur with more severe sprains.

 Aggravating Factors: Turning the foot in or out, walking, running on uneven surfaces, and
other movements that stress the ligaments.

 Prognosis: It typically heal within 4 to 16 weeks, depending on the severity and how quickly
the rehab program is implemented.

 Treatment Strategy: Most sprains require a rehab program that focuses on regaining joint
stability, strength, and neuromuscular control. Resting and elevating the leg, and wearing
compression garment, can reduce swelling and pain. If ligament damage is significant and the
ankle feels unstable, surgical reconstruction may be necessary.
The treatment varies based on the grade of the sprain. For a substantial sprain with swelling and
bruising up the leg, 3 to 7 days of rest will allow the patient to protect the area, elevate the limb,
and apply compression. After a couple of days, the patient may be able to do ankle pumps, which
can help with blood flow and mobility during early recovery. The key here is to let the injury calm
down before starting phase 1.

Phase 1: Focus on reducing pain and improving active mobility via the calf mobilisation and ankle
mobility plantarflexion-dorsiflexion exercise. Limited ankle dorsiflexion is common after ankle
sprains, so the standing dorsiflexion stretch comes next. Add band exercises to build strength in
the sagittal plane of motion. *Don’t move into the frontal plane (inversion-eversion) early on!

Phases 2: Add ankle inversion and eversion with a band, kneeling dorsiflexion stretch, double-leg
calf raise to help control and stabilise the joint. Standing banded hydrant and lateral step-down
to strengthen the quads and glutes to help stabilise the hip and knee as well.

Phase 3: Progress to Knee-straight and knee-bent single-leg calf raises. Add the clock exercise to
improve dynamic balance and proprioception. Tiptoe walk targets the calf muscles (especially
the soleus), but performing it correctly requires ankle stability. End phase 3 with single-leg hops
and skater jumps to control the ankle in a more challenging fashion.
 SHIN SPLINTS (MEDIAL TIBIAL STRESS SYNDROME)
 Description: MTSS, or shin splints, is a repetitive stress injury of the anteromedial shin region. The
most common running-related musculoskeletal injury, MTSS typically involves excessive loading of the
tissues from which the body is unable to heal. In most cases, it is due to an increase in training
intensity, distance, or duration, but they can involve other variables, such as running on hard surfaces,
wearing shoes with poor shock absorption, or engaging in a new activity – like going for a long walk on
the beach.
A lot of issues with the bone or tendon create symptoms in similar areas, so they all get lumped
together under the umbrella term MTSS. The patient can have shin splints on the inside, back, or front
of the shin bone. There can also be anterior or posterior shin splints, which affect different muscular
compartments.
 Anterior shin splints – are more related to the ankle dorsiflexor muscles, especially tibialis
anterior. They are more common in runners who heel-strike, and also happen in people who do a
lot of downhill hiking.
 Posterior shin splints occur more often on the back side of the bone, in the posterior
compartment with the calf and tibialis posterior. This type of shin splint is more common in
forefoot strikers. Striking the ground with the ball of the foot makes the tibialis posterior and calf
muscles work much harder to absorb shock.

 Signs and Symptoms: Pain is typically felt in the front and inside of the shin region. It is provoked
when the are is stressed, such as during running or walking downhill. Touching the shinbone
reproduces the pain. Symptoms may be sharp during activity, and the area may ache or throb
afterward.

 Aggravating Factors: walking, running, and jumping.

 Prognosis: they usually resolve with rest and rehab. But the timeframe can vary based on the severity
and activity levels. Most people recover within 6 to 8 weeks.

 Treatment Strategy: It is treated with physiotherapy and training program modifications. The rehab
focus on reducing pain, building strength and gradually increasing running or jumping volume. *If the
symptoms do not improve after 6 to 8 weeks, the patient may consult with a doctor to rule out a
stress fracture.

Phase 1: Focus on reducing pain and relieving tension in the anterior and posterior muscle
compartments. For the posterior shin splint start with the calf and tibialis posterior mobilisations, and
tibialis anterior mobilisation for anterior shin splints. However, it doesn’t hurt to work all these
muscle groups. Add calf stretches (straight and bent-knee) and tibialis anterior stretching.

Phases 2: Use banded movements to start strengthening the muscles and tendons. Band inversion
exercise targets the tibialis posterior and band dorsiflexion the tibialis anterior. Add calf raises
(straight and bent-knee), skater squat to strengthen the glutes and quads.

Phase 3: Continue strengthening the muscles located proximally in the kinetic chain. Also, add tiptoe
walk to improve lower leg strength. Single-leg hops at the end of this phase place more stress on the
tissues, so, implement this exercise only when the patient can hop and land with little or no pain.