The knee is one of the joints most prone to injury. Its structure and many components put it at risk of many types of injuries, which can result in knee pain or loss of function. Injuries of the muscles and tendons surrounding the knee are caused by acute hyperflexion or hyperextension of the knee or by overuse. These injuries are called strains.

History

The mechanism of violence should be interpreted from the history as most of the injuries of knee joint occur due to indirect injuries. More often, the ligamentous structures fail rather than bony structures. The type of activity, position of the knee at the time of injury and the immediate post-traumatic events should be elicited. Ligamentous injury around the knee joint is commonly seen in footballers and coal miners. The side of impact to the knee should be elicited. In a blow to the lateral side of the knee joint, the medial ligamentous structures are stretched and may result in simple sprain or complete tear. When the leg is fixed to the ground, the femur rotates over the tibial particular surface and may tear the menisci. The time sequence of symptoms should be elicited. The post-traumatic events such as the ability of the person to complete the play, ability to walk on his own, time of appearance of swelling and locking of knee must be asked for. In bony injuries and severe ligamentous injuries, the patient may not be able to complete the play. Injuries of the knee joint are commonly associated with effusion inside it. In major ligamentous injuries and avulsion fractures of tibial spine, there will be immediate swelling of the knee joint. In meniscal tears, the effusion characteristically appears 2-3 hours after the injury. If the swelling appears 2 days later, then it must be due to traumatic synovitis. History of audible snap or pop at the time of injury may be associated with anterior cruciate ligament tears. Locking of knee implies inability of the patient to extend his knee fully. Locking may occur in meniscal injuries, avulsion fractures of tibial spine or loose bodies due to old trauma or degenerative arthritis of knee joint. A severe muscular pull off the quadriceps may fracture the patella.

Examination

Inspection

Examination of the knee joint should be done with both lower limbs in identical position in supine and prone positions.

Attitude: In effusions of the knee joint and fractures of the lower end of femur, the knee joint will be in flexion. Quadriceps wasting is seen in injuries to the knee joint even in relatively small period of immobilization.

Swelling or deformity: Effusions of the knee joint, if large enough may manifest as a horseshoe-shaped swelling around the patella. Localized swelling over the patella may be seen in patellar fractures. In fractures around the knee joint, there will be diffuse swelling with obliteration of bony prominences.

Palpation

Swelling or effusion of knee joint: Effusion of knee joint is confirmed by the presence fluctuation and patellar tap.

Palpation of the joint line

The joint line is palpated by running the thumb upwards along the medial tibial condyle until a gap is felt between tibial and femoral condyle. The exact point of tenderness should be identified as this helps in identifying the structure injured. Bony tenderness should be differentiated from soft tissue tenderness. In injuries to the medial collateral ligament, the usual site of tenderness is at its upper part where it inserts at medial femoral condyle. If the tenderness is exactly at the medial joint line, then the likely structure injured is medial meniscus rather than medial cruciate ligament (MCL). If the tenderness is between the MCL and ligamentum patellae, then the anterior horn is likely to be at fault and if the tenderness is posterior horn may be injured. For detecting injuries of anterior horn of medial meniscus, the knee has to be flexed to 90 degree and the gentle pressure is given with the thumb at the midpoint between ligamentum patellae and MCL.

Palpation of Patella

The borders of patella, poles of the patella and the particular surfaces should be palpated for any irregularity, tenderness and defects. If the tenderness is limited to the superior pole of the patella with the loss of active extension, then it may because of quadriceps tendon rapture. Repeated stress at the extensor expansion may cause pain at the suspensor pole or inferior pole of the patella commonly known as jumper’s knee.

Lower end of femur

The lower end of femur consists of medial and lateral femoral condyle and supracondylar region. The condyle should be palpated for signs of fracture. In supracondylar fractures of the femur, the distal fragment is flexed by the pull of gastronomies muscle and may injure the political vessels.

Upper end of tibia

Medial and lateral tibial condyle and tibial tuberosity should be palpated for signs of fracture. The proximal fibula may be palpated a little posterior than the lateral tibial condyle. Head of fibula is located by palpating along the biceps femoris tendon until we get a bony resistance. Fractures of the upper part of tibia and fibula can also be elicited by springing the lower ends of these bones together.

Muscular compartment

In fractures of the tibia and fibula especially in closed fractures, the hematoma collected inside the muscular compartments may increase the intra- compartmental pressure. When the pressure increases above the capillary perfusion pressure, it causes ischemia to the muscles and nerves causing compartmental syndrome. It is diagnosed by demonstrating stretch pain by passive extension of flexor muscles or passive flexion of extensor muscles.

Movements

Presence of active extension of the knee joint rules out any injury to extensor expansion. If there is resistance to both active and passive extension of the knee joint, it may be due to a mechanical block such as torn medial meniscus or loose body. The knee joint frequently becomes stiff following an injury, due to intra-particular and particular adhesions.

Instability tests

The tests to be performed are: valgus, varus stress tests; Lachman’s test; anterior and posterior drawer tests; Mclntosh or pivot shift test; Apley’s grinding and distraction tests; and McMurray’s test.

Neurovascular examination

In distal femoral fractures, the popliteal artery is frequently injured by the sharp distal fragment which is pulled by the gastrocnemius muscle. The common nerve to be injured is the lateral popliteal nerve manifesting as foot drop.

Clinical Features

The patient usually presents with deformity and pain around the knee joint, most often associated with painful swelling of the knee joint. There will be deformity and tenderness around the knee with shortening of the affected limb. Care must be taken to palpate for the posterior tibial and dorsalis pedis artery pulsation. A spiration of the knee joint may show haemarthrosis.

Physical Therapy is a unique rehabilitation technique and art that utilizes a wide variety of procedures such as restoring original functionality and movement to the body, but not limited to eliminating various kinds of pain including Injuries around knee joint, lower back pain, neck pain (cervical) leg pain (sciatica), and post-operative procedures. Typically after being thoroughly evaluated by your physician they generate a specific diagnosis and prescribe physical therapy.

 The mechanism of injury can be interpreted by asking about the mode of injury such as fall by asking about the mode of injury ,such as fall from height, road traffic accident, position of the limb or body at the time of injury, any rotational force acting on the body and the type of activity done by the time of  injury.

The mechanism of injury, site of injury, pain and disabilities should be interpreted from the history.

Examination

Inspection: The patient should be examined in sitting position with his upper torso and upper limbs exposed upto the waist.

Attitude: The position of the limb on inspection should be noted. In fractures of clavicle and anterior dislocation of shoulder, the patient often supports the injured limbs with the other hand. The arm segment may appear short or long depending on in fracture neck of scapula, there will be lengthing of the arm.

Swelling or deformity: In anterior dislocation of shoulder, the anterior axillary fold may be abnormally prominent due to the presence of head of humerus. A swelling along the line of clavicle, diffuse swelling surrounding the proximal humerus may be seen in fractures of the underlying bones. The lateral end of clavicle may appear to be prominent in acromioclavicular joint injuries. The medial end of clavicle may be seen prominently in sternoclavicular injuries.

Shoulder contour: Normally, the shoulder has a round contour due to prominence of the greater tuberosity beneath the deltoid muscle. The greater tuberosity projects beyond the edge of acromion process giving the normal contour. In dislocation of the shoulder joint, due to loss of projection of greater tuberosity, the normal contour will be lost. This is a valuable sign of dislocation. In deltoid paralysis due to axillary nerve injuries, there may be wasting of the muscle causing apparent loss of contour of the shoulder. The shoulder contour may be masked by diffuse swelling associated with fractures of the proximal humerus.

Bony arch: The bony arch is formed by the clavicle, acromion process and spine of scapula. Any deformity in the bony arch should be noted for.

Palpation

The bony points to be palpated are: clavicle, proximal humerus, acromion process, spine and borders of scapula for signs of fracture.

Clavicle: By standing behind the sitting patient, the examiner places both his hands on the medial end of clavicle and runs his fingers along the shaft of both the clavicles. Any irregularity, gap or crepitus should be looked for. In acromioclavicular joint dislocation, the lateral end of clavicle may be displaced upward. On pressing the lateral end of clavicle, it depresses and bounces back like a piano key.

Proximal humerus: By standing on the side of the patient, the elbow is flexed and the proximal humerus is palpated bimanually by keeping one hand and the medial surface of arm and other on the outer surface of the arm. By standing behind the patient, the examiner slides his fingers down from the acromion process to the arm to palpate the greater tuberosity and proximal humerus. If the head of humerus is in normal position, then there will be a bony resistance to palpation. In dislocations, there will be an empty feeling in the shoulder region. The head may be palpable in either of axillary folds. Diffuse tenderness may be present in fractures of proximal humerus. In an intact humerus, the medial epicondyle will be in the same direction as that of the head of humerus.

Scapula: The acromion process and spine of scapula are palpated for irregularity, bony tenderness and crepitus. The axillary and vertebral borders are palpated for signs of fracture. The coracoids process is situated half an inch below the clavicle at its junction with medial two third and lateral one third. Fracture neck of scapula is diagnosed by axial pressure applied through the arm with the elbow flexed.

Movements

Both active and passive movements of the shoulder should be tested. In anterior dislocation of the shoulder, the patient will not be able to touch the opposite shoulder with his hand of affected extremity. This is called Dugas test.

Tests for detecting anterior dislocation of shoulder:

Hamilton ruler’s test: In normal persons, a straight ruler cannot be placed between the acromion process and lateral epicondyle because of the presence of greater tuberosity in its normal position. In dislocation of the shoulder, a ruler can be placed.

Callaway’s test: The vertical circumference of the axillary is increased in dislocation of shoulder due to the presence of head in the anterior axillary fold.

Measurements

The length of the arm is measured from the angle of acromion process to the lateral epicondyle.

Neurological examination: In fracture of the clavicle, brachial plexus may be injured. In fractures and dislocations of humorous, axillary nerve may get damaged. Axillary nerve damage may manifest as paralysis of deltoid muscle and anesthesia in skin over the lower part of deltoid muscle.

Active physical Therapy providing state-of-the-art physical therapy throughout the state of Maryland having multiple locations located in Laurel MD, Clinton MD, Germantown MD and Frederick MD.We are specialize in evaluation and treatment of acute and chronic conditions of the Upper Extremity.Experienced, Qualified and Skilled Certified therapists and our dynamic clinical staff focus on providing personalized attention, individual care, and a positive friendly environment during your treatment session. You can also make your appointment online to start your treatment within 24 to 48 hours at Active Physical Therapy,For more information just visit our Website:-http://active-physicaltherapy.com/

FACET JOINT STRAIN

Pain often occurs when one of the Facet Joints that the vertebrae in your spinal column is suddenly twisted or jerked. A joint that is damaged in this way may stick or “lock”, making movement difficult as well as painful. Facet joint strain can occur throughout your spine.

CAUSES

Awkward twisting or bending of your neck or back can injure the ligaments, muscles, or the capsule of a facet joint whiplash from a car accident is a good example of this type of injury ,  but it can also result from failure to warm up before exercising or playing sports, or from lifting heavy objects. Even simply turning over in bed or sleeping awkwardly can have the same effect. Your muscles may then go into an uncontrollable spasm, making the joint stiff immobile. Facet joints are more vulnerable to strains from middle age onward, when  osteoarthritis may flare up, the disks in your spine have degenerated significantly and the ligaments that are supporting the joints become more slack.

SYMPTOMS AND DIAGNOSIS

In the early stages,disabling pain in your neck or back is often accompanied by pain in your accompanied by restricted movement.Pain from facet joint strain in your lower back  may also radiate into your buttocks,hips,lower abdomen and thighs.Movement may be limited for only a few weeks however it can last for months and in some cases years . unless you receive appropriate treatment, which usually involves manipulation or in chronic cases, an injection.Facet joint starin in your neck may extend down to your neck may extend down to your shoulders, making it difficult to bend your neck or turn shoulders making it difficult to bend your neck or turn your head.Your doctor or therapists will make a diagnosis by giving you a physical examination.

RISKS AND RECOVERY

There is no serious risk from facet joint strain, but failure to relieve pain or inflammation can lead to permanently stiff joints starin in the middle of your back although the least common, may cause pain to radiate around your chest, making it painful and difficult to breathe, especially if the joints between the ribs and thoracic vertebrae become “locked”.

VERTEBRAL COMPRESSION FRACTURE

Weakening of the bones is fairly common in old age and may also occur in younger people who are in poor health. When this loss of structural strength affects the vertebrae of the spinal column, even a slight increase in pressure on them- perhaps due to a fall or sudden vigorous activity-can cause cracks and fractures, especially in the middle and lower back.

CAUSES

Osteoporosis is the most common cause of bones (including the vertebrae) becoming weaker and more susceptible to injury. The condition causes loss of minerals from the bones, women after menopause due to hormonal changes. but men also develop osteoporosis  to some degree as they age if you  are a heavy smoker or heavy drinker do little exercise or have suffered from an eating disorder(such as anorexia) and  an still underweight and very thin, you have a high risk of developing osteoporosis  . In a few causes, taking steroids for a particular medical condition may weaken your bones, as can certain forms of cancer.

 SYMPTOMS AND DIAGNOSIS

 If you fracture a vertebra you will feel a sudden , servere pain in the area of your back where the injury has occurred .Damaged vertebrae in your lower back may also cause pain around your pelvis, and if any nerves are irritated, numbness and tingling in your legs. In the upper part of your back the pain may radiate around your chest and make breathing difficult. You may find it hard to move around and even lying down can cause pain coughing or sneezing may hurt too. This pain and lack of mobility it surely to take several weeks to subside. Your doctor may arrange for a CT or an MRI scan to assess the extent of the fracture.

RISKS AND RECOVERY

Although compression fracture in the spine usually heal within a matter of weeks without any special treatment the shape of your spine and your posture may be permanently affected while the pain lasts you are likely to find it difficult to perform everyday activities.

SARCROILIAC STRAIN

 Located on either side of your spine at the very bottom of the back’ the sacroiliac joints link your sacrum (the fused bones at the base of your spine) to your hip bones’ forming the rear part of your pelvic girdle. They allow the twisting movements of your legs when you walk or run. Problems arise when they either become “locked”, restricting movement, or too mobile.

CAUSES

Sacroiliac strain is usually the result of a sudden impact, such as a heavy blow or fall, which damages the ligamentssupporting the joint. Sudden, unexpected twisting or bending movements, where your muscles are unprepared is absorbed by the ligaments, can have the same effect. Mechanical charges in these joints may also over a period of time due to an imbalanced used of surrounding muscles, abnormalities (such as a slight difference in leg length), orosteoarthritis. Strained ligaments lead to loosening of the joints, making them more mobile. It is also common for pregnant women. To suffer from hyper mobile sacroiliac joints, because of hormonal changes that soften and slacken the ligaments of the pelvis in preparation for giving birth.

SYMPTOMS AND DIAGNOSIS

You will feel a sharp pain in the upper inner part of your buttock when you put your foot down, making walking or running very uncomfortable. There will also be dull pain radiating deep into your lower buttock; sometimes you will also experience referred pain in your legs. Movement of your leg may be restricted, which will also make walking difficult. Your doctor may use MRI scans or X-rays  to identify any inflammation cause of your symptoms. If inflammation is present, you may be given a blood test to check if this is being caused by an infection.

RISKS AND RECOVERY

If you sit still or lie down for a long time, you may feel stiffness and immobility. Ligaments take longer to heal than fractured bone, and may fail to heal completely

Ankylosing Spondilitis (AS) tends to occur in you adults, and usually effects men more severely than women. A form of spinal arthritis, it leads to inflammation and a classification, or hardening, of the ligaments in the sacroiliac joints and in the intervertebral joints that link the vertebrate together. It is also known as Marie-Strumpell or Bechterev’s disease.

CAUSES

Generally, sufferers of Ankylosing Spondilitis are genetically predisposed toward the disease. Little is known about what causes it, although it is known to be an autoimmune disease, which means that the body’s immune system not only fights invading infections but also attracts the body’s own cells. It is thought that AS may start when an immune response to bacteria or a virus continues once the infection has gone.

SYMPTOMS AND DIAGNOSIS

The onset of the disease usually occurs between and mid-teens and the mid-30s. It affects the sacroiliac joint first, and will cause pain and stiffness in your lower back and buttocks that is worse on waking. You may find it difficult to bend forward and your hips joints will be stiff. It advances gradually over several years into the thoracic and cervical spine, causing pain and the stiffness in the rest of your back and neck. Extreme stiffness can result in you hunching forward, flattening your chest and curving your spine. In some people, the inflammation and calcification may eventually affect the joints between the ribs and the mid-spine so that movement of the rib cage is limited, impairing breathing. Your doctor will make a diagnosis by considering your symptoms and performing tests, including blood tests, X-rays and MRI scan, and ultrasound.

RISK

It is important to identify and treat the condition as early as possible to prevent irreversible deterioration in posture and mobility. People with Ankylosing Spondilitis have an increased risk of osteoporosis in the spine and of heart and circulatory problems, such as stroke.

TREATMENT:

Treatment includes physical therapy, exercise, and medication. Physical therapy shown to be of great benefit to AS patients.  Swimming is also one of the preferred exercises since it involves all muscles and joints in a low-impact. Yoga and Jogging are available to reduce symptoms and pain of Ankylosing Spondilitis.

(Heel Pain) Plantar fasciitis may be your problem.

Heel pain is one of the most familiar situations that a lot of patients complain about. Several factors are responsible for this condition. Plantar fasciitis is the most general cause of pain felt in the heel. “Plantar” means the bottom of the foot, “fascia” is a type of connective tissue, and “itis” means “inflammation” This is also referred to as the heel spur syndrome if there is a presence of spur. This condition may also be caused by arthritis, tendonitis, nerve irritation, and stress fracture.

During Heel pain caused by planter fasciitis, the band of tissue expanding from the heel point to the toe tip becomes swollen. In this condition, the tight tissue forming the curve of the foot is first annoyed and will then result in swelling.

Risk factors for plantar fasciitis are

• excessive running
• high arch
• when one leg is longer than the other
• obesity
• occupations with prolonged standing or walking
• sedentary lifestyle
• Achilles tendon tightness

Treatment can be done according to the phases.  Initial treatment should be tried for a few weeks and then should continue with further phases of treatment. Following are some effective treatments.

Tape can be used to give the face rest without reducing activity.  Athletic tape can be bought at all pharmacies. Tape can be the cure in the severe case which can result a sudden increase in weight. Losing weight, ice, and stretching can also cure chronic  pain.

•  If heel pain persists, then physical therapy, foot orthotics, and night splinting may be needed.

•  Stretching the calf muscles without reinjuring the fascia before getting out of bed in the morning and a few times per day is well-known to be a cure for many patients.

• Ice is a miracle cure for soft-tissue injuries.  Ice is not only great for professional football players with knee or shoulder injuries, but also for desk-jockeys who can’t seem to get rid of their heel pain.  It was ranked the third best treatment by our visitors. Applying ice after activity or injury is crucial.  It may be beneficial to apply it up to 5 times a day.

• Physical therapy exercise is one of the best cures for heel pain. But be sure, exercises should be done under experienced physical therapist. When done properly and consistently, physical therapy can help prevent permanent relief from your pain.

90% of patients will improve with the above techniques.  Pain lasting 6 months despite therapy may require shock wave therapy.

Are you suffering from pain during or after sitting?

Pain in the buttocks commonly emanates from the spine, but can also stem from the sacroiliac joints and ligaments, and the muscles and bursae –fluid –filled sacs-of the hip. Most pain in the tail bone area originates in the coccyx.

Causes For Buttock and Coccyx pain

Lumbar and lower thoracic sources such as facet joist, disks, nerves and even muscles can produce pain in this area. Injuries to the lower thoracic vertebrae such as compression fractures also create pain lower down the back. The sacroiliac joint and ligaments of the pelvis can cause pain more locally-deep into the buttock, sometimes to the side of the hip and groin, and occasionally down the leg. Buttock muscles may develop tension, trigger points and tears and can rub the bursae between layers, leading to bursitis-inflammation of the bursa-in the side of the hip. The gluteus medius muscle can tighten and cause hip and buttock pain. The tail bone or coccyx can be painful long after a fall or blow, while the hip joint and associated structures such as the labrum can cause buttock pain.

Symptoms

Lumbar spine nerve-root irritation can radiate to your buttock, and may cause piriformis syndrome. Sacroiliac pain can cause spontaneous, severe pain in inflammatory conditions. Mechanical pain from the joint and ligaments is common and may rise from a fall, or more progressively from ligament laxity during pregnancy or often childbirth. It causes aching pain with sharp stabs, locking sensations, and a sense of instability and may interfere with walking-see hypermobility. Muscle dysfunction may also arise due to overload from sport, or from asymmetrical back, hips, or legs causing a dull ache that worsen the exercise. If hip is the source, walking or running will cause aching, stiffness and pain at night. Bursitis in the hip causes pain from pressure-lying, walking and sitting; coccydynia is painful mainly when sitting.

RISKS AND COMPLICATIONS

The main risk here is incorrect diagnosis: treatments for inflammatory and mechanical condition are quite different. Cancer from the pelvic organs can spread to the bony structure, so ruling out more serious problems is vital.

Physical Therapy for Buttock and Coccyx pain

Once your doctor has referred you, your therapist will perform a thorough assessment. Depending n the assessment your therapist may:

• Perform manual therapy such as manipulation of the coccyx, massage, and stretching of the ligaments attached to the coccyx.

• Perform electrotherapy or acupuncture.

Your therapist may advise you to:

• Sit only for short periods of time and use a coccyx cushion to take the pressure off your tail bone. If you do not have a cushion, you can roll up a towel or fold a pillow.

• Apply ice packs for the first few days after the pain starts,

• Apply heat packs after the few days, several times a day.

• Take stool-softening medication and increase fiber and water intake in order to reduce the pressure on your coccyx during bowel movements

Once your pain has reduced, you may:

• Start a rehabilitation program.

You therapist may advice you to:

• Perform seated-to-seated chair squats, clams, McKenzie extensions; leg raises side-lying leg raises, one-leg circles, and supine and kneeling pelvic tilts.

You May:

• Start low-impact cardiovascular training on the cross-trainer or in the water in the form of aqua aerobics

• Perform deep breathing and relaxation exercises.

Once you are nearly pain-free you may:

• Increase the impact of cardiovascular training such as jogging or running on the treadmill, cycling and aerobics.

• Continue strengthening your hip with leg raises, side –lying leg raises and adductor lifts.by gradually adding weights to your legs, such as ankle weights.

• Continue stretching your back, hip flexors and extensors with knees-to-chest stretches, McKenzie extenshions, kneeling hip flexors and hamstring flexors.

• Resume sports, gradually increasing the load and duration

Some diseases involve the whole spine or develop suddenly in a specific area for example as a result of an osteoporotic compression fracture. Other conditions develop gradually and cause symptoms in several areas such as postural pain and muscle tension, scoliosis and hypermobility syndrome.

Causes

The causes of a problem that affects the whole spine depend on the specific condition. The spine is a single functioning unit with 25 mobile segments, controlled by muscles that can span nearly its whole length as a result a condition that starts at the bottom can spread upward involving new areas of the spine by a chain reaction. Furthermore, the joints of the spine are made of the same tissues as other joints in the body, so an inflammatory disease can involve several joints. In addition bones lose mineral content with age and progressively weaken as a result.

Symptoms

Symptoms of postural disorders or advanced scoliosis that affects the whole spine will vary from pain and aching due to sustained contraction of muscles, fascia and ligaments being stretched or strained. In inflammatory disorders aching is symmetrical or strained. In inflammatory disorders aching is symmetrical and is usually worse in the morning or after a period of inactivity. In osteoporosis there are no symptoms apart from a gradual change in posture until a trivial fall or knock causes a vertebra to collapse producing intense pain. Hypermobile joints will seem to keep “catching” and clicking and will feel unstable.

Risks and Complications

The risks are related to the condition that is causing your symptoms. Some spinal pains are part of a chronic pain condition called fibromyalgia which involves other regions of the body. A diagnosis of fibromyalgia will prevent you from receiving unnecessary and excessive localized treatment. Some metabolic conditions such as vitamin D deficiency may cause widespread aching and this requires careful medical screening.

Physical Therapy for Whole Spine Conditions

Once your doctor has referred you your therapist will perform a thorough assessment. Depending on the findings of the assessment your therapist may:

• Perform soft-issues massage, passive mobilizations and postural taping.
• Teach you about posture and ergonomics.
• Begin functional retraining.

You may begin:

• Mobilizing exercises such as Mckenzie extensions, seated and lying trunk rotations.
• Strengthening exercises such as four-point supine knee lifts, kneeling supermans and calms.
• Stretching exercises such as knees-to-chest stretches, side glides, levator scapulae stretches, seated back extensions, seated waist extensions and seated twist extensions.

If you have a lot more mobility and less pain and have modified your daily activities to prevent postural strain, your therapist may advice you to:

• Move from moderate core-strengthening exercises to high-level exercises such as curl-ups, Swiss ball twists, side crunches, prone arm and leg lifts planks from knees, single leg bridges and side planks.
• Begin functional training such as squats, stationary lunges, forward lunges, reverse lunges with knee lifts and walking lunges.
• Begin sensorimotor training such as single-led stands.
• Begin cardiovascular training by using a cross-trainer or running on the treadmill or outdoors.

If you now have no pain and a full range of movement in your back, your therapist may advice you to:

• Begin more intense strengthening exercises such as prone breast stroke, Swiss ball side crunches, Swiss ball side crunches with twists and Swiss ball back stretches.
• Begin swimming, tai chi or pilates.