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Rehab and Sports; A Winning Combination

That’s the theme for our 18th Annual Rehab Symposium scheduled to take place on March 31st – April 2nd, 2017 at the Wyndham Disney Springs Resort in Lake Buena Vista. The speakers are all under contract, the Wyndham is booked and our Rehab Council website is now ready to accept registrations at: It’s time for all of us to make plans to attend. The Spring weather is delightful in Orlando and we’re working with the local Central Florida weatherman to assure plenty of sunshine.

Here’s the rundown. We will be offering 18 CEUs of (pending) credit through Palmer College of Chiropractic. And there is a possibility that we might even add two more CEUs of credit during a 2 hour breakout session on Sunday. The Symposium starts on Friday, March 31st, at 1:00 pm with Dr. David Seaman giving a 3 hour presentation on “How Low-grade Inflammation can disrupt Rehab”. After a half hour vendor break Drs. Alf Garbutt and Jerrold Simon will follow up at 4:30 pm with “Rehab of Military, MVA and Sports Concussions” which ends at 7:30 pm. The evening’s festivities are capped by a vendor and member social hour in Salon 1-2 at the Wyndham Hotel.

Saturday, April 1st, features four different speakers all speaking for 2 hours each and covering everything from postural restoration to low-level laser therapy. It all begins at 8:00 with Stephen Perle, DC, MS teaching “Spinal Rehabilitation Exercise Therapy”. At 10:30 am Dr. Skip George will instruct on how to utilize “Postural Restoration for Rehab and Performance.” After the Rehab and ACRB Board Meetings lunch will be served and will feature a luncheon speaker who will be named in the next few months. Just before lunch the 2017 Rehab Chiropractor of the Year will be announced. Any ideas who it may be? The afternoon will conclude with Jerome True, DC FIACN explaining the effectiveness of “Laser Therapy Treatment for Radiculopathy” followed by Perry Nickelston, DC, NKT demonstrating “Kinesiology Taping for Rehab and Sports.” As you can already tell, the Symposium is peppered with Rehab and Sports related subject matter.

Now don’t forget Sunday, April 2nd. Starting at 8:00 am, Ted Forcum, DACBSP will demonstrate the “Use of Instrument Assisted Soft Tissue Mobilization” and then Jonathan Puleio, M.Sc., CPE will conclude our Symposium at 10:30 am – 12:30 pm with the “Fundamentals of Office Ergonomics” for DCs. In addition, there will be vendor door prizes be given out during the 10:00 am vendor break. During all of our vendor breaks, snacks such as granola bars & fruit as well as juices, water and coffee with be available for any registered attendees who care to indulge.

Remember, registration is just a click away. Please log on to: Looking forward to seeing everyone in Lake Buena Vista this coming Spring 2017.
Best regards,

Jerrold Simon, DC, DACRB President, ACA Rehab Council

Post Surgical Knee Rehab Study

Results and Analysis of Pilot Studies

conducted on the ROM3® Rehab System

About the ROM3 Rehab System

It has been observed that after a knee trauma, including injury or surgery, patients who undergo earlier movement, more movement, and more active movement of the joint tend to enjoy greater range of motion and better overall outcome than patients who perform less movement, delayed movement, or only passive movement of the joint.


The ROM3 Rehab System is an application of the above datum. A patented technology, it was designed to facilitate earlier movement and active movement of the affected joint, as well as more comfortable movement, consequently allowing and inviting more motion.

More information about the ROM3 technology, shown here, can be found at

Purpose of the Pilot Studies

Pilot studies are generally performed to assess the effectiveness of the materials, apparatus and procedures that will be used in larger-scale studies. The results gained from pilot studies help researchers determine the feasibility of engaging in additional work in the area and also helps researchers determine the most appropriate strategies to assess the data.

The information gained from pilot studies can also help to determine the value of continuing to explore the effectiveness of an invention, which is one of the primary purposes of the two pilot studies described below.

The two pilot results presented in this document concern the results from inpatient and outpatient rehabilitation protocols. Combined, the results strongly indicate that the ROM3 is usable immediately after surgery and is highly effective in assisting recovery after knee surgery by achieving more rapid Range of Motion.

The pilot studies were also useful in that the data collection protocols suggested that the instrument should be modified and streamlined so that the physical therapists will all be using the same metric and will not find the instrument to be cumbersome or burdensome. The results of the pilot studies have provided useful data and areas for modification so that imminent large- scale studies will yield the most informative data.

Inpatient Rehabilitation Pilot Study

Goals of the Study

Inpatient Rehabilitation Pilot Study

The three main goals of the study were:

  1. To explore the usability and safety of use of the ROM3 Rehab System immediately after TKA.
  2. To determine if use of the ROM3 Rehab System immediately after TKA has a significant effect on patients’ range of motion and speed of recovery.
  3. To determine if use of the ROM3 Rehab System immediately after TKA has a significant effect on lengths of stay and cost.

Description of Sample

The inpatient rehabilitation pilot study was conducted at Labette County Medical Center in Parsons, Kansas. The study consisted of 107 cases—13 cases in the ROM3 group (five male, eight female) and 94 in the comparison group.

Patients of both the ROM3 group and the comparison group were representative of all three surgeons at Labette County Medical Center. Twelve of the patients in the ROM3 group had a single total knee arthroplasty (TKA, i.e., total knee replacement) while one patient had TKA in both knees. Therefore, the total data set included 14 TKAs.

After surgery, each patient received standardized therapy per current rehabilitation protocols at Labette County Medical Center, where the data was collected.

Patients in the ROM3 group used the ROM3 Cycle in addition to the usual therapy protocol for a period of 7-15 minutes per day on each of post-op days #1-#4. All other therapy was kept the same for both groups.

Results & Analysis, Inpatient Rehabilitation Study

  1. Ability to safely use the ROM3 Cycle. The most important datum from the pilot study is that patients were able to safely use the ROM3 Cycle one day after surgery (1 day post-op).In actual fact, all of the cases in the ROM3 group were able to use the ROM3 Cycle for at least 8 minutes on each of the 4 days of the study.Twelve of the 13 cases in the ROM3 group were able to use the ROM3 Cycle immediately. One patient did not initially use it due to being admitted into the Intensive Care Unit (ICU) following surgery, and instead used the device later.Therefore, for those patients who were medically stable, 100% were able to use the device. There were no complications, worsened conditions, or cases in which a patient was medically stable but couldn’t use the ROM3 Cycle because its use extended beyond the patient’s ability—even post-op day #1.This is, itself, a very important finding since usability and safety by all patients is vital. It is commonly observed that a substantial percentage of TKA patients have severely limited range of motion after surgery. A device for the purpose of helping patients who have limited range of motion to recovery more quickly would be of little value if their limited range of motion prevented them from using it, or if its use worsened their condition.

    The findings indicate that the ROM3 Cycle may be used in the fashion that was intended, that is, immediately following surgery.

  2. Effect of the ROM3 Rehab System on range of motion and speed of recovery.It has been observed that 90° range of motion is an important milestone in recovery, since below 90° ROM, patients tend to struggle and experience discomfort and lack of functional mobility; above 90° ROM, patients demonstrate a greater level of functional independence and can better assume their own burden of care—a major goal of post-op therapy. Therefore 90° ROM was chosen as a key benchmark for this inpatient pilot study.All cases in the ROM3 group reached 90° range of motion in 4 days or less, except one patient (a patient with bilateral TKAs who reached 90o in only one knee within 4 days).There were three patients in the ROM3 group who reached 90° ROM on the first day after surgery. Each of these individuals continued to improve, and each reached an additional 4° – 5° or more using the ROM3 Cycle.Of the 94 patients in the comparison group, only 40.5% reached the critical 90° ROM benchmark within 4 days. Of the other 59.5%, most achieved 90° ROM in 5 to 10 days; and several with very stiff knees took longer than 10 days.

    Thus 100% of the ROM3 group reached the important milestone of 90° ROM between 1 and 6 days faster than the majority (59.5%) of the comparison group.

  3. Effect of the ROM3 Rehab System on length of stay and cost.Within the comparison group, the 40.5% that reached 90° ROM by post-op day #4 were discharged from the hospital in similar timeframes as the ROM3 group.For the 59.5% of the comparison group that took longer than 4 days to reach 90° ROM, hospital stays averaged 1.6 days longer than the ROM3 group.These additional 1.6 days of care, though relatively small, were quite expensive for the hospital, costing an average of $3,252.08 more per patient than the average cost per patient in the ROM3 group.Additionally, the maximum total cost for a longer stay patient in the comparison group was $10,211.19 more than the average cost per patient in the ROM3 group.

    Since hospitals receive flat rate reimbursements based on the diagnosis, regardless of the actual length of stay, the additional days of care are at the hospital’s expense—hospitals are not typically reimbursed for additional days of care. Thus hospitals have direct economic benefit from discharging patients as quickly as possible.

    Had the ROM3 technology and resultant savings been applied to the entire comparison group (assuming the results from the pilot study hold true across a larger scale), the savings would have been even more substantial:

    94 patients x 59.5% = 56 patients (whose hospital stay and cost could have been reduced)
    56 patients x $3,252.08 average extra cost = $182,116.48 (potential savings on 94 patients)

    From this projection, it can be extrapolated that use of the ROM3 Rehab System with TKA patients for just 4 days immediately after surgery would generate an average cost savings of $1,907.41 per patient due to earlier discharge.

    It is noted that a large and growing number of joint replacement surgeries today are performed on an outpatient basis in surgery centers. These outpatient centers typically discharge patients the same day; therapy still generally begins on day #0 or day #1 post-op but at home or in another venue.

    The location and setting of the patient and therapy equipment is not considered the key element of this inpatient pilot study. Rather, the key element was the timing of the delivery of the ROM3 therapy—i.e. in the days immediately following TKA.

    With this in view, it is expected that the savings generated by use of the ROM3 Rehab System immediately post-TKA will naturally accrue to whatever entity is responsible for the cost of therapy within the respective healthcare model, regardless of the location or setting. Under a fee-per-service model, payors may reap the benefit in the form of a reduced reimbursement. In a bundled payment model, the organization responsible for reducing the number of therapy sessions will be rewarded. Cash patients will pocket the savings themselves.

Outpatient Rehabilitation Pilot Study

Goals of the Study

The three main goals of the study were:

  1. To determine if the ROM3 Rehab System is usable by TKA patients with joint pain and limited range of motion in outpatient therapy.
  2. To determine if use of the ROM3 Rehab System in outpatient therapy beginning 3-5 weeks after TKA has a significant effect on patients’ range of motion.
  3. To determine if use of the ROM3 Rehab System in outpatient therapy affects speed of recovery and/or number of therapy visits needed to reach full recovery.

Description of Sample

The pilot study consisted of 29 outpatient therapy cases—15 in the ROM3 group (eight male, seven female) and 14 in the comparison group (four males and ten females). All of the patients had single TKAs performed at Kansas City Orthopaedic Institute, a leading orthopaedic hospital.

After surgery and prior to the pilot data collection, each patient in both groups had received therapy during their inpatient stay in the hospital, followed by 2-4 weeks of in-home therapy.

Next, beginning 3-5 weeks after surgery, each patient received outpatient physical therapy per current rehabilitation protocols at Kansas City Orthopaedic Institute, when the pilot data was collected. For patients in the ROM3 group, use of the ROM3 Cycle for a period of 8-15 minutes was substituted for the usual therapy protocol. All other procedures were kept the same for both groups.

All patients in both groups received therapy from the same therapist only, and all outcome measurements for both groups were conducted by a single therapist, minimizing variables and ensuring uniformity of measurement technique.

Results & Analysis, Outpatient Rehabilitation Study

  1. Ability to use the ROM3 Cycle. 100% of the patients in the ROM3 group were able to use the ROM3 during their initial visit and in all subsequent visits.

    All patients from both groups had continuing joint pain and indicated that excessive flexion or extension of the affected joint increased pain exponentially. Nevertheless, patients from the ROM3 group indicated they could comfortably use the ROM3 Cycle without prohibitive pain.

    Several from the ROM3 group had very limited range of motion at the beginning of therapy—too limited to perform a single revolution on a stationary bike—but were still able to use the ROM3 Cycle. One patient had severely limited range of motion, with only 47° of knee flexion at initial visit. This patient was likewise able to pedal the ROM3 Cycle on the first visit and on all subsequent visits, and showed significant improvement in range of motion.

    Once again, this is a very important finding since usability by all patients is vital. It is commonly observed that a substantial percentage of TKA patients continue to have limited range of motion for weeks post-op—including some at 4-6 weeks post-op. A device for the purpose of assisting patients with limited range of motion would be of little value if their limited range of motion prevented them from using it.

    These results indicate that the ROM3 Rehab System is usable in one of its primary intended uses—enabling therapeutic, productive motion for virtually any medically stable TKA patient at several weeks post-op.

  2. Effect on Range of Motion. The data from the two groups were compared examining the active range of motion (AROM) from initial exam to discharge. The two groups were compared on the gain in AROM.

    The mean AROM gain for the ROM3 group was 25.67° versus 17.79° for the comparison group. (See Figure 1.)


    The ROM3 group’s results included superior gains in both knee flexion and extension. All but two ROM3 group patients reached 0° extension, while in the comparison group, 9 out of 14 did not achieve 0° by discharge.

  3. Speed of Recovery, Number of Visits. The ROM3 group had significantly fewer visits until discharge compared to the comparison group, t(27) = 2.16, p < .039. The ROM3 group required an average of 9.54 visits until discharge, while the comparison group required an average of 15.71 visits.

    This is impressive by itself as the ROM3 patients not only achieved a greater average range of motion, but did so in 40% fewer visits. (See Figure 2.)


    Due to faster recoveries, patients in the ROM3 group saw a reduction in necessary therapy visits by an average of 6.17 fewer visits per patient. Assuming an average charge of $100 per visit, this implies a $617 average savings per patient, and with better outcomes.


The results of the pilot studies provide preliminary indications that the ROM3 is an effective apparatus for use with patients who completed TKAs. In summary, the major results of the pilot study indicate that:

  1. Patients, including those with joint pain and severely limited range of motion, are able to comfortably and safely use the ROM3 after TKA surgery, including as early as the day of surgery and the day after surgery.
  2. TKA patients who use the ROM3 Rehab System, whether immediately after surgery or several weeks later, either inpatient or outpatient, reach greater levels of range of motion faster and recover earlier.
  3. TKA patients who use the ROM3 Rehab System immediately after surgery have shorter hospital stays (or fewer therapy sessions, depending on healthcare model). This alone can save an average of more than $1,900 per patient in cost of care.
  4. Patients who use the ROM3 Rehab System during outpatient physical therapy required an average of 6.17 fewer visits than those in the comparison group, a 40% reduction in therapy visits, and an additional cost savings of $617 per patient.
  5. The tremendous gains seen in the pilot work indicate considerable improvement over the current state-of-the-art TKA rehabilitation treatment.

The results of the two pilot studies provide a very useful examination of the potential of using the ROM3 for TKA rehabilitation. Patients find the device usable immediately after surgery, their progress is more rapid, and their lengths of stay and/or number of visits for rehabilitation are significantly fewer.

Large-scale data with more evaluation points are expected to provide even stronger and clearer results. Pilot data, being smaller in size, generally provide encouraging, but statistically insignificant results1.

The results from both the Inpatient and Outpatient Pilot Studies indicate that the ROM3 is not only an effective device in the rehabilitation of total knee replacement, but is also quite useful in reducing the cost of such rehabilitation.

When one factors in these results with the fact that more than one million patients undergo TKAs annually2, the difference in savings by using the ROM3 Rehab System both immediately after surgery and later in outpatient therapy could be in excess of $2.5 billion dollars per year.

The volume of TKAs is forecasted to reach 3.5 million per year within 14 years3, suggesting this savings could reach more than $8.8 billion dollars annually.

Pressure to reduce healthcare costs is extremely high and rising. It is safe to assume that both providers and payors will be interested in such a savings.

Increased Use

As stated, these studies examined data from patients who each had less than a dozen uses of the ROM3 Cycle, either for just 4 days immediately after surgery, or not beginning until 3-5 weeks post-op. The question arises as to whether an increased use of the ROM3 Cycle, such as on a daily basis throughout the recovery process, might produce even faster recoveries, better outcomes, and greater cost savings.

Certain healthcare providers have begun combining both inpatient and outpatient use of the ROM3 Rehab System, and added home use of the ROM3 Cycle between discharge and outpatient therapy. Under this structure, patients use the ROM3 Rehab System regularly from date of surgery through 5-10 weeks after—some 35-75+ uses. Tracking and analysis of outcome data from this thorough rehabilitation protocol is imminent; it appears to offer even quicker recoveries, fewer visits required, and greater cost savings.

It will require randomized controlled trial studies with larger sample sizes before the ROM3 will be argued to be the next generation of accepted protocol for total knee replacement rehabilitation. However, the pilot data and results presented in this paper provide a glimpse of the power of the results that the ROM3 Rehab System produces.


1 A Note on Small Sample Sizes and Statistical Significance:

Statistical significance when examining two or more groups involves an estimate of variability due to between group differences and an estimate of variability due to within group differences. Between group differences occur as a function of differences between groups. The ROM3 Rehab System produces significantly shorter time in rehabilitation, for example. The means for the ROM3 are smaller in terms of the number of rehab visits or length of stay in an inpatient unit. However, there are going to be individual differences within each group. Some people are going to respond to rehab faster than others. This is why it is important to randomly assign individuals to groups as the researcher will not know these individual characteristics of patients prior to treatment. To generate significant results, the ratio of between-groups and within-groups variability is determined. If the differences between groups, between-group variability, is larger than the variability between patients, within-group variability, the result will be statistically significant.

The between-group variability between the treatment and comparison groups must be much larger than the variability that naturally exists between individuals within a group. When this occurs, the ratio of between- group versus within-group variability becomes larger, suggesting that there are real and important differences between the groups.

The larger the sample size the greater the probability that significant results will occur when there are real differences. Conversely, the smaller the sample size the less probable that significant results will occur, due to the lack of power to find real differences, even if they exist.

The fact that the differences between the ROM3 and comparison groups were so robust that significant results were found in the pilot studies suggests two things: 1. that using the ROM3 Rehab System produces clinically significant results that can be seen even in small samples, and 2. that it is more probable that those differences are real differences. As a result, it is expected that the results from large-sample-size studies will be even more convincing.

Larger sample sizes generally produce less within group variability as the samples become better estimates of the populations they are representing. Thus the ratio becomes increasingly larger. It is anticipated that the results from further research with larger sample sizes will produce more impressive results. Such studies are now commencing.

2 Gittins M(1), Doucette D. Total joint arthroplasty: tips for improving efficiency. Am J Orthop (Belle Mead NJ). 2014 Mar;43(3 Suppl):S1-4. PubMed PMID: 24911640.

3 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. PubMed PMID: 17403800.

Warrior Mace

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Incidence of Diastasis Recti Abdominis During the Childbearing Year

Jill Schiff Boissonnault, Mary Jo Blaschak
Published July 1988


This study was conducted to determine 1) the incidence of diastasis recti abdominis among women during the childbearing year and 2) the location of the condition along the linea alba. Clinicians have long noted its presence, prenatally and postnatally, but the magnitude of the problem is currently unknown. A cross-sectional design was used to test 71 primiparous women placed in one of five groups, based on placement within the childbearing year. A commonly accepted test for diastasis recti abdominis was performed. Palpation for diastasis recti abdominis at the linea alba was performed 4.5 cm above, 4.5 cm below, and at the umbilicus. Diastases were observed at all three places, but most often at the umbilicus. A significant relationship (p < .05) was found between a woman’s placement in her childbearing year and the presence or absence of the condition. Diastasis recti abdominis was observed initially in the women in the second trimester group. Its incidence peaked in the third trimester group; remained high in the women in the immediate postpartum group; and declined, but did not disappear, in the later postpartum group. These findings demonstrate the importance of testing for diastasis recti abdominis above, below, and at the umbilicus throughout and after the childbearing year

Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review

Read the full article



Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy, and has been related to lumbopelvic instability and pelvic floor weakness. Women with DRAM are commonly referred to physiotherapists for conservative management, but little is known about the effectiveness of such strategies.


To determine if non-surgical interventions (such as exercise) prevent or reduce DRAM.

Data sources

EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro were searched.

Study selection/eligibility

Studies of all designs that included any non-surgical interventions to manage DRAM during the ante- and postnatal periods were included.

Study appraisal and synthesis methods

Methodological quality was assessed using a modified Downs and Black checklist. Meta-analysis was performed using a fixed effects model to calculate risk ratios (RR) and 95% confidence intervals (CI) where appropriate.


Eight studies totalling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomised controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.


The papers reviewed were of poor quality as there is very little high-quality literature on the subject.

Conclusion and implications

Based on the available evidence and quality of this evidence, non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.

The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women

Chiarello, Cynthia M. PT, PhD1; Falzone, Laura A. PT, MS2; McCaslin, Kristin E. PT, MS3; Patel, Mita N. PT, MS4; Ulery, Kristen R. PT, MS5


Ms Falzone, Ms McCaslin, Ms Patel, and Ms Ulery were enrolled the the Master of Science Degree in Physical Therapy at Columbia University at the time data was collected for this study.

This research was presented at Combined Sections Meeting of the APTA, Boston, MA, 2002 and received the 2002 Research Award from the Section on Women’s Health.

Approvals: This project was reviewed and approved by the Columbia University and Columbia Presbyterian Institutional Review Board, #9906.

Background: Diastasis Recti Abdominis (DRA), a separation of the 2 bellies of the rectus abdominis at the linea alba, may occur in more than half of all pregnancies. Due to hormonal changes and a growing uterus, the abdominal muscles become over‐stretched and weak, compromising posture, trunk stability, respiration, trunk motion, and vaginal delivery. Exercise to strengthen the abdominal musculature during pregnancy may affect the presence and size of DRA, however, no research has specifically examined this relationship.

Purpose: The purpose of this project was to determine the effect of an abdominal strengthening exercise program on the presence and size of DRA in pregnant women.

Study Design: A 2 group, between subjects, quasi‐experimental post‐test design.

Methods: Subjects were comprised of 8 pregnant women participating in an abdominal exercise program and 10 non‐exercising pregnant women. Diastis recti abdominis was measured using a digital caliper at 3 marked sites along the midline of each subject’s abdomen: 4.5 cm above the umbilicus, at the umbilicus, and 4.5 cm below the umbilicus. Two measurements were taken at each site, and the average was used for statistical analyses. Descriptive statistics were generated, and independent t‐tests were performed on each subject characteristic. An analysis of covariance was computed with the number of previous pregnancies as the covariate to control for the difference between the subject groups.

Results: Ninety percent of non‐exercising pregnant women exhibited DRA while only 12.5% of exercising women had the condition. The mean DRA located 4.5 cm above the umbilicus was 9.6 mm (± 6.6) for the exercise group and 38.9 mm (± 17.8) for the non‐exercise group. The mean DRA located at the umbilicus was 11.4 mm (± 3.82) for the exercise group and 59.5 mm (± 23.6) for the non‐exercise group. The mean DRA located 4.5 cm below the umbilicus was 8.2 mm (± 7.4) for the exercise group and 60.4 (± 29.0) for the non‐exercise group.

Conclusions: The occurrence and size of DRA is much greater in non‐exercising pregnant women than in exercising pregnant women. Because of the integral role the abdominal muscles play in functional activities we recommend examining pregnant and postpartum women for the presence of DRA.

The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period

Authors: Patrícia Mota, PT, PhD1, Augusto Gil Pascoal, PT, PhD1, Ana Isabel Carita, PhD1, Kari Bø, PT, PhD2

1Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal.
2Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.

The study was approved by the Review Board of the University of Lisbon, Faculty of Human Kinetics. This study is part of the research project “Effects of Biomechanical Loading on the Musculoskeletal System in Women During Pregnancy and the Postpartum Period” (PTDC/DES/102058/2008), supported by the Portuguese Foundation for Science and Technology. This study was also supported by the International Society of Biomechanics Dissertation Grant. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.

Address correspondence to Dr Patrícia Mota, Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, Cruz Quebrada 1495-688 Lisboa, Portugal. E-mail:
Published: Journal of Orthopaedic & Sports Physical Therapy, 2015 Volume:45 Issue:10 Pages:781–788 DOI: 10.2519/jospt.2015.5459

Journal of Women’s Health Physical Therapy:
Spring 2005 – Volume 29 – Issue 1 – p 11–16
Research Study

Post Surgery: Knee Rehabilitation


Effects on Athletic Performance with Three Seperate Injuries and Three Surgeries Over a 16 Year Period

By: Robert Pruni, D.C.,
3035 Five Forks Trickum Road
Lilburn, GA 30047
Phone: 404-831-1400

Case Study

A blow out of the knee is what is referred to as an unhappy triad, terrible triad, horrible triangle or O’Donoghue’s triad. It is an injury to the anterior cruciate ligament, medial collateral and medial meniscus. Originally, O’Donoghue’s triad did not include the lateral meniscus, which is an oddity among athletes as there is always an associated tear to the lateral meniscus with a me- dial meniscus tear. Tears to the lateral meniscus are far more common than the medial meniscus with sprains to the ACL. The skeletal com- ponents in the unhappy triad are the patella, femur and bia. There are no muscles directly involved in this injury; however, muscular atrophy takes place quickly in the quadriceps, and is a necessary component in rehabilitation as well as addressing the neurological components of proper motor coordinated patterns and the effect of Neurological Crossover. 2) The unhappy triad we are discussing, which you will see in this case study as well as many other cases, is very rare and typically caused by a compression with torsion. The injuries damage both femurobial compartments as well as the ACL and the PCL. Therefore, it has been suggested by Friden T, Zatterstrom R, Lindstrand A, Moritz U (1995) that this entity should be replaced by the “unhappy compression injury.” The medial collateral ligament, lateral collateral ligament, the posterior cruciate ligament and the anterior cruciate ligament are the four primary ligaments of the knee.

Symptoms associated with the unhappy triad are pain in the affected knee with an inability to move the knee through its full range of motion.

The affected knee has soreness and swelling.

The affected knee will also catch or lock. There is a sensation of the knee “giving out” and instability with twisting or side to side movements. Often, there is a swelling behind the knee of the popliteal bursa or a Baker’s cyst. This is not a true cyst as communication with the synovial sac is often maintained.


Patient is a 34 year old male, high level athlete: Various sports, Body Building, Competive obstacle running and rugby.

This case study is about my own knee, and the initial damage that occurred as well as the effects on high level athletic performance 16 years following the first ACL reconstruction to the right knee. The injury occurred while jumping a bike in motocross. The bike was approximately 15’ in the air. The bike pulled back too far and I let go of the bike; I fell from the 15’ height landing with my body moving forward. Meanwhile, my leg hit the ground hyper-extending the leg in a Coxa varus genu valgus posi on with 100 degrees of counterclockwise rotation. I was on my stomach with my lower leg almost perpendicular to my femur. I rolled to my back and pulled my lower leg back into an in line position. I had no motor use of the lower leg. I noticed the effusion in the calf which was the size of a football. This is an “unhappy compression injury”.

Clinical Presentation

An ACL reconstruction was performed following an MRI, which showed the complete tear of the ACl, MCL and LCL with significant tears to the medial and lateral meniscus anterior and posterior. The post-surgical care goal, was to improve the ROM. This care started immediately following surgery in the hospital attempting to bend the leg 5-10 degrees. The Quality of pain following the surgery was different from the injury, because the symptoms resulting from the injury occurred with any movement and produced a sharp pain that was nauseating. The pain following the surgery was throbbing, deep and constant; it radiated with deep achiness into the calf. Stiffness was constant and was relieved temporarily with ice. Percocets were prescribed which were discontinued after the first day due to nausea. The Timing of the symptoms was constant with deep achiness and stiffness due to the reconstruction, which required extreme effort to move.


Significant atrophy of the right calf and right quadriceps in particular the Vastus Medialis Oblique following surgery. Edema noted from the medial femoral condyle across to the lateral femoral condyle. The patella not as clearly defined as patella of the non-injured left knee. 3.) Palpation of the medial posterior aspect of the knee is the tendons of the sartoruis, gracilis and semitendinosus. Inflammation is noted in the common insertion of these muscles and localized inflammation of the pes anserine bursa.


Edema and sponginess noted in the quadriceps insertion medial and lateral. Edema also palpated in the synovial bursa between the medial head of the gastrocnemius and the semi-membranosus.


Chiropractic Analysis: Limited knee internal and external rotation and flexion and extension due to post surgical edema. Overactive piri-formis, Inhibited Quadriceps, right gluteal and right hamstring. There is a weakness in the right hip flexor with difficulty performing a one leg straight leg raiser. The patient was able to perform with great effort to 60 degrees.

Muscle Testing: The primary extensors showed weakness. The quadriceps were affected. Nerve Femoral L2, L3, L4. Muscle testing was a 2 and could not perform full ROM. The primary flexor group, the hamstrings, were also affected. Semi-membranousus tibial portion of the sciatica nerve L5, Semitendinousus tibial portion of the sciatic nerve, L5 and biceps femoris bial portion of the sciatic nerve S1.

Orthopedic evaluation

Only ROM testing was performed. Orthopedic testing to the knee was not performed due to post-surgical edema.

Height 5’ 11” Weight 202 lbs BP 122/78 Respiration 12 Pulse 64


Short term goals: Reduce pain, edema and improve ROM
Intermediate goals: Improve pain free ROM, increase flexibility, Incorporate evidenced based rehabilitation protocols concurrently with CPM and isometric and eventually isokinetic rehab.
Long term goals: Improve not only the extremity ROM with full strength and a one range explosiveness, but also to repair damaged motor coordinated patterns for complex high level athletic activity.


The post-surgical care was designed in several phases. The initial phase of treatment was designed to accelerate the post-surgical healing process while maintaining/restoring mobility as much as possible. The second phase was to restore joint stability, and finally to improve the functional strength of the injured leg to pre-injury levels. For twelve days following surgery, my treatment consisted of a cryocuff immobilizer, which I removed three times a day to perform flexion/extension exercises with a continuous passive motion machine. The first day goal was to passively move the knee joint through a 15 ̊ arc. Each day, the range motion goal was increased 10 ̊ until 115 ̊ of motion could be accomplished passively. By day 12, with daily treatment, most of the edema and inflammation were under control and the incision was closed.

The next step in my functional recovery was to begin phase one of rehabilitation. Instead of returning to my own rehabilitation clinic, I decided to obtain treatment at a physical therapy sports medicine cen- ter to see if I could pick up a few physical therapy tricks as well as introduce them to my FlexBuild- ing program; the mission was accomplished on both accounts.

The experience was a good one. In the begging of phase one, rehabilitation goals were to improve flexibility and proprioception. During the first week, in addition to my Gonstead chiropractic care to my lower back addressing chronic L4 and sacral subluxations with an accessory joint and spatulated transverse process of L5 to the ileum, this stage of care I utilized interferential prior to passive rehabilitation because of the deeper penetration and decreased skin resistance. The joint was still stiff; therefore, 30-50Hz was utilized. We followed up with multiple angle isometrics submaximal and maximal. Concurrently, I did reflex inhibition at the mid range of motion with antagonistic contractions to the quadriceps and hamstrings.

During the second and third weeks, I commenced short arc isokinetics submaximal and maximal and a modified FlexBuildingTM program, which was mid to 75% R.O.M. against gravity to light concentric modified FlexBuildingTM. In comparison to other proprioception neuromuscularfacilitation (PNF) types of stretching and rehab, the difference is that instead of the usual “stretch-relax-stretch” or “stretch-isometric contraction- stretch further” method of improving range of motion and proprioception, FlexBuildingTM disarms the splinting guarding mechanism by sending sensory afferent-stimuli to the thalamus and processing motor efferent with the immediate agonistic contraction. This full R.O.M. stretch with a full R.O.M. contraction results in improved flexibility, tone, and stabilization throughout the entire length of the muscle.

As I entered my fourth week of phase one rehab, I was already at 160 ̊ straight leg hip flexion. I was able to resist from 100 ̊ hip flexion pushing through extension to zero ̊ with partial resistance and minimal discomfort.

Other types of rehab added to the program included: balancing on the wobble board, eyes open and closed, once for 30 seconds, which could be achieved with the eyes open. I was also doing light leg press, one leg and then two starting with 8-12 reps for three sets. The sets required me to use one leg with 20lbs and two legs with 50lbs. A continual increase in weight and reps was progressed to train muscular en- durance.

The Zinovie technique commenced first because of the initial fatigue. As endurance increased, the Pyramid method was utilized to increase strength and move forward toward returning to athletic activity. Movements utilized were leg press, seated leg curl, leg extension and squats. Step ups were added concurrently which were not as difficult as a step down, backward striking the heel of the left leg. Into the fourth week of rehab, this increased functional strength the most. Strength was better with the body weight movement of stepping up and down, forward and backward with a backward step down to the heel rather than when the strength was tested immediately following with 50-80lbs high rep with 3 sets of 50 reps Leg Press. As the weeks progressed, the high rep endurance was added at the end of the Pyramid with super sets of pistol squats.

One interesting observation I made, is that I did not work during my rehabilitation process and had access to four chiropractors in my office. I had forced myself to go into my office to get adjusted following PT as I was fatigued and simply could not do it. My knee ROM therapy was always better on Lumbar L4 and sacral adjustment days. No clinical data was obtained and it was merely an observation.

4.) The core was also addressed. Weakness or lack of sufficient coordination in core musculature can lead to less efficient movements, compensatory movement patterns, strain, overuse, and injury or re-injury.

5.) Phase III, Advanced rehabilitation: Characterized by restoring normal joint kinematics, ROM, and continued improvement of muscle performance. The primary goals to be addressed during this phase are restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/ balance/proprioception. Criteria for progression to phase IV include: strength > 70-80% of non-involved (NI) side and demonstration of initial agility drills with proper form (e.g. avoidance of medial collapse3 5 of bilateral lower extremities, coordinated and symmetrical movement of all extremities, controlled movement of entire body).

Progression was better than anticipated. However, there was one problem. The plan that we designed failed to consider neurologic crossover.

Neurologic crossover can produce positive or negative effects. Feeding information to the side opposite the injured side, will gain benefit to the injured side by neurologic crossover. Rehabilitating opposite the injured side is important during not only phase one of rehab, but also phase one of initial healing to decrease reflex inhibition. Since positive information can be programmed through rehab therapy, conversely, negative information can also be programmed (Order).

To put this into practical context, I began to note the diminished functional capacity, motor coordination and range of motion in my non-injured leg.

To understand this effect, we must recognize that during an injury and recovery, if a non-injured area opposite the injured area is not trained, an engram resulting from neurological-crossover can develop, mimicking the injured area. “All motion, pathological or functional, can be represented by a neurological organization of a pre-programmed pattern of muscular activity devised for a specific purpose called an “engram.” The law of facilitation states that once an impulse has passed through a certain pathway to the exclusion of another, it will tend to take the same course in the future. Resistance in the path diminishes each time the impulse traverses this path. This is how basic motor learning or neural habits are formed. By nature, once an engram is developed, each additional excitation causes exactly the same activity through facilitation.

This concept can apply not only to the agonist/active muscle, but also to the facilitation of inhibition to antagonistic muscle groups. Once that pathway has been established, the transmission and end resulting motion or action becomes easier to perform and maintain. (Petruska) “Therefore, because of neurologic crossover, an engram developed in the non-injured leg. We discovered this developed in the non-injured leg almost eight weeks post-surgery.”

At this point, we were addressing the injured leg with an adequate warm-up. After which we proceeded with knee FlexBuildingTM (therapists resisted leg extension/leg curl) as well as hip abductor, adductor, and hamstring FlexBuildingTM. My straight leg hamstring FlexBuildingTM had improved to 170 ̊ after rehab. Since my goal was to return to serious weight training, I also wanted to start stimulating the “good leg.”

After a few warm-ups, I was shocked to discover that I could only straight leg raise my non-injured leg to 100 ̊ before the stiffness began to tilt my pelvis. There was no pain, but my “good side” had diminished performance capacity in comparison to the injured or “bad” side. It would appear that a negative engram had developed as a result of neurological crossover after only eight weeks. Looking back, this could have been easily avoided with minimal rehabilitation effort and focus on the non-injured side during my recovery. If this had been done, a positive engram could have just as easily been programmed, which may have diminished my recovery time. Instead, by neglecting the non-injured side for eight weeks, a negative engram resulted requiring some additional rehab to the non-injured side and a more prolonged recovery time for the injured side.

Based on these findings, remember to rehab both sides physiologically. (FlexBuilding Healthy Exercising Guide Book, Robert Pruni, Doc Talk pgs. 7-9)

At eight months post-surgical rehabilitation, there was still an 1 1⁄2″ of atrophy in the calf as well as 2” of atrophy in the quad measuring 3” above the knee. Despite the atrophy, the 40 yard dash returned to 4.9 seconds which was the pre injury time and a full squat below parallel of 405lbs and 3⁄4 squat of 595 lbs. 40” box jump both feet returned as well as a 20” box jump single leg either side was the same with no dysfunction noted. A Single leg squat to the surgical right leg and non-injured left leg were within normal limits.

It was about this time that a second injury to the ACL occurred during a skateboarding accident while doing an eight foot ramp drop in. A second surgery was performed and the rehabilitation process started again. Following this rehabilitation, the results were about the same. Athletic performance returned to the same high level. Some permanent atrophy was noted to the leg following two ACL reconstructions, but in the 15 years following there were no functional deficits noted. Athletic performance ironically and gradually continued to improve over the next 15 years. Placements in obstacle racing went from the top 15% in the athletes 20’s and 30’s, to the top 1⁄2% racing in the elite heats in the late 40’s following two ACL reconstructions.

A third injury to the same knee required a third surgery at age 48, with a crush injury to the femoral condyles, which included tearing of the medial and lateral meniscus, and tears to the ACL, PCL, medial and lateral collateral ligaments. The orthopedist described the meniscal tears as shredded.

Surgery was performed in late November and rehabilitation commenced immediately. Similar protocols were followed, and the patient competed in the qualifiers for American Ninja Warrior in May, five and one half months post-surgery.

Post rehabilitation results

All athletic performance activity, utilizing both legs, showed no functional deficit. During the rehabilitation and training process, a single leg squat could not be performed. A single leg box jump as well, could not be performed at six month post-surgery despite competing at ANW and another OCR and placing first. Training continued for another 4+ months trying to improve on the single leg strength. Almost one year post third surgery at age 49: Full squat below parallel 405lbs. A heavier 2/3 squat was not performed. The patient with continued high intensity training, still cannot perform a single leg squat. The non-injured left leg has the same 20” single leg box jump as 16 years ago. At one year post-surgical the right leg has only a single leg box jump of 7” with great effort.


The Neurological Crossover appears to have positive and negative engrams that can result. After 15 years, no adverse functional deficits were noted from two prior knee surgeries. Following a third surgery to the same knee, at almost one year post-surgery, it appears age and degenerative arthritic changes have little effect on the athletic performance when utilizing the entire body(two leg squat and box jumps the same as 16 years ago.) It appears that the continued decreased single leg function, is a result of disrupted motor patterns when the continually damaged side has to perform without the aid of the normal motor patterns of the opposite side. This will be a fascinating ongoing case to see, if the single leg function can return to normal with a continual rehab to both sides.


1.)Shelbourne K, Nitz P (1991). “The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears”. Am J Sports Med 19 (5): 474–7
2.) Friden T, Zatterstrom R, Lindstrand A, Moritz U (1995) “Compression or distraction of the anterior cruciate injured knee. Variations in injury pattern in contact sports and downhill skiing” Knee Surg Sports Traumatol Arthrosc 3 (3): 144-7
3.) Hoppen eld, Stanley, Physical Examina on of the Spine and Extremi es, Appleton- Century-Cro s pp 181-182
4.) Michael Fredericson, MDa, *Tammara Moore, PTb, Muscular Balance, Core Sta- bility, and Injury Preven on for Middle and Long Distance Runners

Tarlov Cysts


Dr. Gary Tennant, Chiropractic Physician
Case Study Submission for the American Chiropractic Rehabilitation Board

Subject: Patient: RG is a 79-year-old female that has had Tarlov Cysts confirmed on her MRI.

Her presenting chief complaints in 2015 being numbness in her hip and legs. On her intake form she listed the symptoms as such:

  1. Sciatica Tingling, burning sensation in the left and right leg and feet were rated as an 8/10 on left and a 6/10 on the right
  2. Numbness in the leg that radiates down to the outer toes is rated as an 8/10 on the left and 6/10 on the right
  3. Pain in lower back 2-3/10
  4. Leg /Foot/ Toe Cramps 9/10 when they occur but have almost gone with away with this patient placing a bar of soap in the bed
  5. Bladder and bowel prolapses eight and six years respectively both of which have been treated conservatively by specialists
  6. Excruciating eye pain rated as a 10/10 sometimes. She has been treated by an ophthalmologist with limited success.

HPI (history of present illness)


Provocative/palliative – precipitating/relieving- This patient’s pain is aggravated by walking. She also states that although she does have discomfort, her main complaints are the numbness and loss of balance.

Quality/quantity – character. Numbness and pain. Primarily into the hip on the left but also feels it on the right.

Region – location/radiation. Both hips and posterior thighs. The symptoms are worse on the left. Both feet feel numbness again with the left being worse.

Severity – constant/intermittent. The symptoms are rated an 8/10 on the right and 6/10 on the left. They are described as intermittent depending on in which activity she is engaged.

Timing – onset/frequency/duration. They are described as intermittent depending on in which activity she is engaged. She first started having symptoms twelve years ago, she thought is was sciatica.

I saw Ruth originally ten years ago. X-rays showed some degeneration and spondylolisthesis. Ruth over the years has had flexion- distraction manipulation, spinal decompression and instrument adjustments. She has also had a variety of therapies like interferential current, hot moist packs and ultrasound. These treatments sometimes seemed help but other times not very much. Nonetheless, her symptoms have not progressed dramatically. I have seen case studies where this can be the case. Sometimes a condition not getting worse is a success, albeit not the most fulfilling from a patient or practitioner’s viewpoint. I ordered an MRI which came back with the diagnosis of Tarlov cysts.

At the time I was unfamiliar with this disease. As I researched it I found out that Tarlov cysts were a fairly common finding. The quoted statistics are between 5-8% of the general population has these cysts. However, most are asymptomatic. If a practitioner like myself does some quick math, undoubtedly we have had hundreds of patients that have these cysts to one degree or another. I have had 12,000 patients over my 30-year career in chiropractic. If 5% of them have had Tarlov cysts, then the math works out to about 600 of them having this condition. I am only aware of two of my patients having the diagnosis. Unfortunately, this means that about 598 have had these and I was unaware.

Referral to a neurosurgeon: After the MRI results showed these cysts and the radiologist wrote the diagnosis, I immediately referred Ruth to a local neurosurgeon. I asked all parties if I could have permission to attend the consultation between Ruth and the neurosurgeon. I accompanied Ruth and her husband when she consulted with Dr. Martin Leukin. Dr. Leukin stated that there was no treatment for Ruth’s condition. Apparently when these cysts are operated on they refill with fluid. So he recommended conservative treatment, so the treatment fell back on me.

Anatomy and physiology: Tarlov cysts are also known as perineural or sacral nerve root cysts. They are dilations of the nerve root sheaths and are abnormal sacs filled with cerebrospinal fluid that can cause a progressively painful radiculopathy (nerve pain). They are located most prevalently at the S2, S3 level of the sacrum. They are best viewed in an MRI image or CT scan. Plain films do not pick demonstrate this abnormality due the fact that water is penetrated by the radiation of regular cathode x-rays. In that by definition water is incompressible it means that when there is fluid inside the nerve sheath, either the nerve is going to compress or the sheath will expand. This is the essence of the pathophysiology associated with Tarlov cysts.

With that mechanism known the clinical question becomes what nerves are involved and to what extent. The sacral nerve roots S2, S3 and S4 have a distribution with a dermatomal pattern into the posterior thigh and pudendal region. The viscera affected are the bladder, bowels and reproductive areas. Ruth actually has had both a prolapsed uterus and bowel, consistent with the viscera innervated by the S2-4 nerve roots.

Usually Tarlov cysts cause no symptoms and are found incidentally on magnetic resonance imaging (MRI) studies done for other reasons.

However, in some cases, the cysts expand, putting pressure on the affected nerve root. The resulting compression and nerve pressure may include sharp, burning pain in the hip and down the back of the thigh, possibly with weakness and reduced sensation all along the affected leg and foot. Tarlov cysts sometimes enlarge enough to cause erosion of the surrounding bone, which is another way they may cause back pain or sacral pain.

Tarlov cysts are a fairly common finding in the general population. According to radiopaedia the incidence is 5% of the population. However, in an informal survey of some of my colleagues, very few have ever heard of this disorder much less attempted to treat it. I called Dr. John Aikenhead who is a chiropractic radiologist who reads films for several MRI centers, he stated that he sees two or three films per day in which the patients’ have these cysts. This informally confirms that they are not rare and perhaps should be better understood by modern chiropractors. The treatment options listed on the Mayo Clinic website as well as the Tarlov Cyst Disease Foundation list potential treatment options from TENS Units to alkaline diet to surgery. However, none of them list rehabilitation as a treatment choice nor do they say anything against rehabilitation or exercises.

Tarlov felt that hemorrhage into the subarachnoid space caused accumulations of red cells which impeded the drainage of the veins in the perineurium and epineurium, leading to rupture with subsequent cyst formation. Four out of the seven patients in Tarlov’s 1970 article had a history of trauma. Because many of the patients with perineural cyst in their series did not have histories of trauma, Fortuna et al. believed that the perineural cysts were congenital, caused by arachnoidal proliferations within the root sleeve.

Tenderness on firm pressure over the sacrum may be present. Commonly, the symptomatology is intermittent at its onset and is most frequently exacerbated by standing, walking and coughing. Bed rest alleviates the discomfort.

1. Tarlov IM. Perineural cysts of the spinal nerve roots. Arch Neural Psychiatry. 1938;40:1067–74

Interestingly, Tarlov cysts are not mention in the radiology textbook authored by Terry Yochum.

Another resource is the National Institute of Neurological Disorders and Stroke; they have the following information:

What are Tarlov Cysts?
Tarlov cysts are sacs filled with cerebrospinal fluid that most often affect nerve roots in the sacrum, the group of bones at the base of the spine. These cysts (also known as meningeal or perineural cysts) can compress nerve roots, causing lower back pain, sciatica (shock-like or burning pain in the lower back, buttocks, and down one leg to below the knee), urinary incontinence, headaches (due to changes in cerebrospinal fluid pressure), constipation, sexual dysfunction, and some loss of feeling or control of movement in the leg and/or foot. Pressure on the nerves next to the cysts can also cause pain and deterioration of surrounding bone. Tarlov cysts can be diagnosed using magnetic resonance imaging (MRI); however, it is estimated that the majority of the cysts observed by MRI cause no symptoms. Tarlov cysts may become symptomatic following shock, trauma, or exertion that causes the buildup of cerebrospinal fluid. Women are at much higher risk of developing these cysts than are men.
(Comment: Ruth has been treated for eye pain. She has not had an MRI of other body parts, in theory they can occur anywhere. It is hypothesized that Tarlov cysts might negatively affect cerebral spinal pressure. This could cause a myriad of eye symptoms.
Is there any treatment?

Tarlov cysts may be drained and shunted to relieve pressure and pain, but relief is often only temporary and fluid build-up in the cysts will recur. Corticosteroid injections may also temporarily relieve pain. Other drugs may be prescribed to treat chronic pain and depression. Injecting the cysts with fibrin glue (a combination of naturally occurring substances based on the clotting factor in blood) may provide temporary relief of pain. Some scientists believe the herpes simplex virus, which thrives in an alkaline environment, can cause Tarlov cysts to become symptomatic. Making the body less alkaline, through diet or supplements, may lessen symptoms. Microsurgical removal of the cyst may be an option in select individuals who do not respond to conservative treatments and who continue to experience pain or progressive neurological damage.

What is the prognosis?

In some instances, Tarlov cysts can cause nerve pain and other pain, weakness, or nerve root compression. Acute and chronic pain may require changes in lifestyle. If left untreated, nerve root compression can cause permanent neurological damage.
National Institute of Neurological Disorders and Stroke

In that I was unfamiliar with how patients with Tarlov cysts generally present I searched f for other case studies to see if the symptoms were similar.

Another patient (not Ruth):

This 47-year-old woman presented with a 1-year history of progressive, intractable sacrococcygeal pain and numbness as well as dysesthesias of both feet. At the time, she was becoming increasingly incapacitated, although she was still able to work as a flight attendant. She rated her pain as 6 of 10 possible points on a visual analog scale. Her symptoms were aggravated by standing, walking, lifting, and climbing stairs as well as by coughing. Pain was rapidly relieved by recumbency. She had a history of renal calculi. She had no bowel or bladder dysfunction, and sensation for urination and defecation was normal.


Anatomy and Physiology:

Structure.—Each typical spinal nerve contains fibers belonging to two systems, viz., the somatic, and the sympathetic or splanchnic, as well as fibers connecting these systems with each other16

1. The somatic fibers are efferent and afferent. The efferent fibers originate in the cells of the anterior column of the medulla spinalis, and run outward through the anterior nerve roots to the spinal nerve. They convey impulses to the voluntary muscles, and are continuous from their origin to their peripheral distribution. The afferent fibers convey impressions inward from the skin, etc., and originate in the unipolar nerve cells of the spinal ganglia. The single processes of these cells divide into peripheral and central fibers, and the latter enter the medulla spinalis through the posterior nerve roots.17

2. The sympathetic fibers are also efferent and afferent. The efferent fibers, preganglionic fibers, originate in the lateral column of the medulla spinalis, and are conveyed through the anterior nerve root and the white ramus communicans to the corresponding ganglion of the sympathetic trunk; here they may end by forming synapses around its cells, or may run through the ganglion to end in another of the ganglia of the sympathetic trunk, or in a more distally placed ganglion in one of the sympathetic plexuses. In all cases they end by forming synapses around other nerve cells. From the cells of the ganglia of the sympathetic trunk other fibers, postganglionic fibers, take origin; some of these run through the gray rami communicantes to join the spinal nerves, along which they are carried to the blood vessels of the trunk and limbs, while others pass to the viscera, either directly or after interruption in one of the distal ganglia. The afferent fibers are derived partly from the unipolar cells and partly from the multipolar cells of the spinal ganglia.18

The mid and lower sacral nerve root distribution is more in the posterior portion of the thighs and medially. There are branches that also innervate the pudendal region. Visceral innervation includes the reproductive organs, bladder and lower intestines. Tarlov cysts are a definite potential source of nerve root compression. However, in that they affect the sacral nerve roots there is a pattern of symptoms that differs from more common radiculopathies found in S1 nerve root lesion or L5 nerve root pathologies.

Although originally believed by Tarlov to be asymptomatic lesions, these cysts, when present in the sacral neural canal and foramina, have since been found to cause a variety of symptoms, including radicular pain, paresthesias, and urinary or bowel dysfunction.

Dermatomal distribution of the lower extremities
Dermatomal distribution of the lower extremities
Visceral Innervation from S2-4
Visceral Innervation from S2-4


Notice the swollen sacral nerve root, this photo was taken during a surgery to drain the cysts. This method generally has not offered good long term results.
Notice the swollen sacral nerve root, this photo was taken during a surgery to drain the cysts. This method generally has not offered good long term results.

General physical considerations

Ruth is a 79-year-old active female. She is 5’ 6” and weights 124 lbs. Her BMI is calculated at 20.0. Her blood pressure was measured in a seated position at 128/68 with a pulse rate of 74 and a respiration rate of 16. She is still working twenty hours a week. Her most strenuous activity is golf occasionally in the summer and she walks frequently. She is very active with her grandchild and travels frequently with her husband who is 85 years old.

Physical Examination (Pre rehabilitation):

Individual Position Examination– (Format AMA Guidelines to Impairment 5th Edition page 375)
Standing Posture
Scoliosis – Slight lean to the left
Lordosis – Slightly flattened lumbar curve
Kyphosis – None
Muscles- Paraspinal muscles were non tender and symmetrical
Tenderness – there was slight tenderness to deep posterior to anterior pressure at the mid to lower sacral region. The coccyx was non tender
Gait – this patient has a normal gait. Her speed of gait is very good for her age.
Range of Motion – see table below
Muscle Strength
Heel-toe. The patient was able to raise up on her toes but needed to hold onto a rail for balance. Heel walking was normal.
Recumbent Supine Neurological
Sensory testing showed a numbness over L4, L5 and S1 dermatomes on both side with the left feeling more numbness than the right
Patellar – 2+ bilaterally, Achilles – 2+ bilaterally, Medial Hamstring – 2+ bilaterally
Strength was graded as 4/5 for the tibialis anterior, quadriceps, and hamstrings.
SLR – Normal with 80 degrees
Recumbent Prone Nerve Tension
Femoral Nerve Stretch was normal.
Individual Position (Post Rehab Program) Examination was essentially the same as the previous exam
Standing Posture
Scoliosis – Slight lean to the left
Lordosis – Slightly flattened lumbar curve
Kyphosis – None
Muscles- Paraspinal muscles were non tender and symmetrical
Tenderness – there was slight tenderness to deep posterior to anterior pressure at the mid to lower sacral region. The coccyx was non tender
Gait – this patient has a normal gait. Her speed of gait is very good for her age.
Range of Motion – pre and post ROMs are shown in the table below
Muscle Strength
Recumbent Supine Neurological
Sensory testing showed a numbness over L4, L5 and S1 dermatomes on both side with the left feeling more numbness than the right
Patellar – 2+ bilaterally, Achilles – 2+ bilaterally, Medial Hamstring – 2+ bilaterally
Strength was graded as 4/5 for the tibialis anterior, quadriceps, and hamstrings.
SLR – Normal with 82 degrees. This is a slight improvement.
Recumbent Prone Nerve Tension
Femoral Nerve Stretch was normal.

Range of Motion Testing:

Motion Tested Measured ROM
Normal ROM Reference Percent of Normal Deficit ROM
Percent of Normal
LUMBAR SPINE: We used a dual inclinometer method for measuring the range of motion of the lumbar spine as outlined in the AMA Guides to Impairment:
Flexion 35⁰ 60⁰ 58% 42% 37⁰ 62%
Extension 6⁰ 25⁰ 24% 76% 12⁰ 50%
Right Lateral Bending 19⁰ 25⁰ 76% 24% 23⁰ 92%
Left Lateral Bending 21⁰ 25⁰ 84% 16% 22⁰ 88%
Lumbar Impairment 11% If this patient was to be given an impairment according to the AMA Guides to Impairment Range of Motion Method (5th Edition) 9%

Motion palpation: There was a hypermobility in the posterior to anterior direction on L4 on L5. There were slight areas of hypomobility in both sacroiliac joints, although her age of 79 might attribute greatly to this finding. Her hip range of motion in the Fabere’s position was graded as slightly restricted. This is of significance because a lack of motion in the hips can create and hypermobility on the lumbar spine as a type of compensation pattern.

Overhead squat assessment was evaluated and was essential normal. Therefore, Ruth was started on a program that mostly addressed the other functional tests (like endurance and balance as outlined below).

X-rays and MRI imaging:
Tarlov cysts may also cause diffuse poorly localized sacral pain due to pressure on adjacent periosteum and joint capsules and can also result in sacral insufficiency fractures from erosion of the sacrum. Thoracic Tarlov cysts have even been noted to cause angina-like symptoms
Initial plain radiographic examination may reveal Tarlov cysts causing erosion of the sacrum, bone scalloping, or a rounded paravertebral shadow

Below is an AP view of the lumbar spine. The first image is considered a normal or ideal film; the second one is a film of this patient.
AP view of the lumbar spine. The first image is considered a normal or ideal film; the second one is a film of this patient.
X-rays of the LUMBAR SPINE 09/03/2015
X-rays of the LUMBAR SPINE 09/03/2015

Findings: Seven views of the lumbar spine were obtained, including flexion and extension views. There is a Grade 1 Anterolisthesis of L4 on L5. This is slightly increased on flexion views. It is similar in appearance on extension views. Vertebral body heights are maintained. Alignment is otherwise normal. Narrowing of the L5-S1 intervertebral disc space. Moderate facet joint arthropathy of the lower lumbar spine.

Radiologist Report

There is significant translation forward at some of the segments listed above. Perhaps with extension stabilization there would be less and that might cause less nerve root traction and help minimize the myriad of symptoms that are related to the spine. Analysis performed by Gary Tennant, D.C. using Posture Ray Software
There is significant translation forward at some of the segments listed above. Perhaps with extension stabilization there would be less and that might cause less nerve root traction and help minimize the myriad of symptoms that are related to the spine. Analysis performed by Gary Tennant, D.C. using Posture Ray Software
Flexion Extension (Lateral) Views:
Flexion Extension (Lateral) Views

(Analysis performed by Gary Tennant, D.C. using Posture Ray software)

There are angulation abnormalities as well as translation abnormalities. These would be ratable impairments according the AMA Guide to the Evaluation of Permanent Impairment (5th Edition).
There are angulation abnormalities as well as translation abnormalities. These would be ratable impairments according the AMA Guide to the Evaluation of Permanent Impairment (5th Edition).
MRI report stated: Grade I anterolisthesis L4-L5 with approximately 3 mm of slippage. There is a moderate sized right and two smaller left sacral Tarlov’s cyst. There is also a small pernineural cyst in the left L5-S1. (Interestingly Ruth symptoms are more pronounced on the left than the right even though the cyst on the right is larger)
Lateral View of the Magnetic Resonance Image. Note the huge white spot which is the fluids inside these cysts.

MRI report stated: Grade I anterolisthesis L4-L5 with approximately 3 mm of slippage. There is a moderate sized right and two smaller left sacral Tarlov’s cyst. There is also a small pernineural cyst in the left L5-S1.<br />
(Interestingly Ruth symptoms are more pronounced on the left than the right even though the cyst on the right is larger)

Physical Performance and Functional Evaluations:

Shear Test was positive
The shear test has the patient prone with upper body supported on the table and feet on the ground. Posterior to anterior pressure is applied to the spinous processes. Then the patient lifts their legs up (toward the ceiling) while pressure is reapplied. If pain lessens then that means that there is instability and extension rehab is warranted

Side Bridge Endurance Test was tested at 32 seconds on the left and 36 seconds on the right (I used Liebenson’s Guide that less than 45 seconds was considered dysfunctional.
Rehabilitation program to use stabilization training using side bridge exercises. She was also performed stretches of her hip flexors.

Trunk Extensor Endurance Test was measured at 42 seconds (less than 60 is considered dysfunctional
Rehabilitation program to facilitate / strengthen the trunk extensors, gluteus maximus and hamstrings

Trunk Flexor Endurance was tested at 35 seconds (less than 50 seconds is considered dysfunctional).

The 2 Minute Step in Place test is part of the Senior Fitness Test Protocol used to test aerobic endurance, and is designed to test the functional fitness of seniors. This test is performed as an alternative to the 6 minute walk test for people who use orthopedic devices when walking, as well as in the case of people who have difficulty balancing.

Equipment required: tape for marking the wall, stopwatch, wall.
Procedure: The subject stands up straight next to the wall while the level corresponding to midway between the patella (knee cap) and iliac crest (top of the hip bone). The subject then marches in place for two minutes, lifting the knees to the height of the tape. Resting is allowed, and holding onto the wall or a stable chair is allowed. Stop after two minutes.

Scoring: Record the total number of times the right knee reaches the tape level in two minutes. Below is a table showing the recommended ranges for this test based on age groups (from Jones & Rikli, 2002).

Step up test scoring:


Ruth scored 82 (normal for this age group is 68-100), Ruth’s score is within the normal limits but certainly could be improved.

Endurance Training: The goals for Ruth was to improve core stability and endurance and to increase her stability on one legged stance

Lab Tests:

I did not order any outside lab tests in that the MRI is considered the definitive diagnostic procedure to use with Tarlov cysts. However, I did do a urine pH test to see if her body perhaps was acidic. Her morning urine pH was measured at 6.5. Alkaline diets are surprisingly a recommendation for treating Tarlov cysts as listed on the Tarlov website. However, I did not instruct Ruth to start on an alkaline diet but will once this study is completed.

Differential Diagnosis

First, Tarlov cysts have a potential, but not an actual, communication with the spinal subarachnoid space and thus may exhibit delayed filling or lack of filling on myelographic examination. Meningeal diverticula, on the other hand, are in free communication with the spinal subarachnoid space and thus usually fill initially during myelography. Second, Tarlov cysts occur at or distal to the junction of the posterior nerve root and the DRG, usually in the sacral region. In comparison, meningeal diverticula occur proximal to the DRG and develop throughout the vertebral column, most often at thoracic levels. Last, Tarlov cysts occur in the perineurial space and have at least part of their wall composed of nerve fibers or ganglion cells. Conversely, meningeal diverticula have a wall lined with arachnoid mater, with or without a dural covering, and do not contain nerve fibers. Moreover, Tarlov noted that perineurial cysts, although often asymptomatic, were capable of producing clinical symptoms. whereas meningeal diverticula were more often asymptomatic. Tarlov also distinguished perineurial cysts from “unusually long arachnoidal prolongations over nerve roots,” which he asserted were of no pathological significance.

But probably the focus for a chiropractor is to use Tarlov cysts as a differential diagnosis for unrelenting sacral pain with nerve root symptoms. Less likely would be to consider these perineural cysts in the event that cauda equinae is presented in a patient.

Patient Management

The following Outcome Assessment and Functional Tests to evaluate the results of treatment:

  1. Bournemouth Questionnaire: The 7 items of the Bournemouth score includes (1) pain intensity, (2) effect of work on pain, (3) effect of pain on social activity, (4) anxiety, (5) depression, (6) ability to carry out normal activity, (7) and ability to control pain.
  2. Lower Extremity Questionnaire
  3. Spinal Stenosis Questionnaire
  4. AMA Guide to Impairment Range of Motion Method
  5. The Shear Test
  6. Standing Balance Test
  7. Step Up Test
  8. Back Extension Endurance
  9. Trunk (Core) Flexion Endurance
  10. Side Bridge Endurance

Both the single leg standing balance ability and the trunk extensor have been shown to predict future back pain according to Biering-Sorenson as described in Spine Journal 1984;9:106-119 and Hides in Spine Journal 1996;21:2763-2769.

Rehabilitation and Exercises:

Exercise Purpose Functional Deficiency Test
Sitting on Exercise Ball Neurological Activation and proprioception of the core group Balance Test (Single leg stand
Ball Curl Up Activation, proprioception, strengthening and increasing endurance of abdominals Abdominal Curl Up endurance
Dead Bugs (Same as above) Back Extension Endurance
Quadraped (Bird Dogs) (Same as above) Back Extension Endurance
Back Extension Activation, proprioception, strengthening and increasing endurance of the back extensors Back Extension Endurance
Clams Part of a four exercise glut max/ med routine Single leg stance and Step up test
Side Lying leg raise (Same as above) Single leg stance and Step up test
Glute Activation Exercises (Same as above) Single leg stance and Step up test
Glute Bridges (Same as above) Single leg stance and Step up test
Side Bridges Proprioception, strengthening and increasing endurance of abdominal and back muscles, particularly the transversus abdominis, rectus abdominis, obliques and QL. Side Bridge Endurance Test
All of the above exercises were done 2 sets of 12 repetitions. Done twice a week for 4 weeks and then a reevaluation was performed
Step ups onto 10” step Increase CV endurance, balance training and to strengthen the glut max, hamstrings and calves Single leg stance and Step up test

Ruth was started on an exercise and rehabilitation protocol for strengthening extensors due to the positive Shear Test. We added some balance exercises due to the diminished time with the one leg balance test. And we added steps up to increase endurance. All of these were measured and considered with her age of 79 being kept in mind. She underwent the rehab program described below twice and week for four weeks for a total of eight rehabilitation sessions.

Cardiovascular training with concentration on strengthening the gluteus maximus– step ups for 10 minutes. She was instructed to step up onto a 10” step and had a rail available for stability.

Nutritional considerations:
In that Tarlov cysts are a fluid swelling, it was considered to prescribe a Curcumin plus other white willow bark and boswelia supplement. The effects of curcumin (turmeric) are said to be anti-inflammatory.
However, this patient has been placed on aspirin therapy to alleviate intense eye pain possibly associated with Tarlov cysts. This eye pain is thought to be due to an increase in cerebrospinal fluid pressure. It certainly is an unusual symptom to be associated with a lower back condition. With this particular patient, it actually became a concern because when she performed extension maneuvers one of the limiting factors was eye pain and pressure.

Patient education/ home care
One legged standing three times a day for two minutes. She was encouraged to continue walking and if possible to walk inclined or declined terrain.

Rationale and considerations for rehabilitation:

There were three reasons why I decided to attempt to get gains through rehabilitation

  1. Ruth was deficient in some standardized test like the one leg standing balance and endurance for back extension
  2. She also has some underlying spondylolisthesis that has some additional slippage as demonstrated on the flexion/ extension films.
  3. In any patient over 50 years old increasing balance and endurance decreases the risk of injuries and falls. Ruth has some balance issues on occasion due to the paresthesia’s in her legs.

Outcome of Care

Assessment /Test Beginning Results Ending Results Changes and comments
Bournemouth Questionnaire 36% 33%
Lower Extremity Questionnaire 16% 16% Unchanged
Spinal Stenosis Questionnaire 46% 44% 5% improvement, not significant
AMA Guide to Impairment Range of Motion Method of the Lumbar spine 11% 9% 2% improvement in an Impairment score
The Shear Test Positive Positive No change
Standing Balance Test Eyes open 8 s 10 s Normal for 70-79 years is 14.2 s There was a gain of 25% which is significant, Ruth will continue to work on this in that balance issue are a huge risk and one her main deficiencies.
Step Up Test 82 86 8% improvement
Back Extension Endurance 42 s 49s There was a significant 17% improvement in this patient’s back extension endurance.
Trunk (Core) Flexion Endurance 35 s 38 s This represents a 9% improvement in core endurance
Side Bridge Endurance
Left side
Right side
32 s
36 s
35 s
38 s
There were asymmetries in the prerehab times of 13% and post rehab of 9%. Both are still considered abnormal in that they are less than 45 and also there is a greater side-side difference of 5%

Conclusion: Mrs. G completed 8 rehabilitation sessions as outlined above. We reexamined her, had her complete the Outcome Assessments and Functional tests. Based on those criteria, we concluded that Mrs. G did not receive significant benefit in what is said to be an “untreatable condition.” She seemed to report less pain on occasion and slight increased functionality as measured by the Bouehemouth. She improved the functional tests such as the one leg balance by the following amounts 2 seconds. The examination showed minimal improvements.

Based on this one case study other practitioners might offer a clinical trial of specific rehabilitation to ascertain the possibility of offering some relief for these type of patients.


There were two benefits that were seen in using a specific rehabilitation protocol with this patient with Tarlov cysts. She improved in her balance and her endurance. In that she has balance and numbness complaints, she would most probably have decreased her risk of falling to some decrease. She also improved her back extension endurance. That improvement might help her to avoid progression of her back pain. However, her main complaints of leg pain and numbness did not change significantly from the beginning of the program to the end.

Dr. Gary Tennant
Chiropractic Physician
386 Forest Blvd.
Park Forest, IL 60466


(I am certain that the reader of this case study are familiar with the exercises that I chose for Ruth’s rehabilitation. I decided as I relooked at each exercise to reference a good source. I kept them in the paper only as an addendum. But I plan on using the following the help teach my staff about these exercises and progression. Gary Tennant, D.C.)

Stuart McGill, professor of spinal biomechanics at the University of Waterloo, Ontario, is one of the world’s leading experts on lumbar research. McGill has identified three exercises referred to as the Big 3 that focus on stabilization. The exercises are often used in clinical populations by those in chronic pain. They put minimal load on the back and focus on endurance. The benefit from any exercise is only as good as the technique applied to the exercise. McGill suggests some very specific techniques to accomplish core stability

Ball Exercises – the patient was told to sit on a ball and move in the different directions to increase core activation and proprioception of the lumbar spine and pelvis.

Ball Curl Up

The curl up varies from a standard crunch. There should be no movement through the lumbar spine. Hands are placed in the small of the back to monitor movement. Elbows are down to begin and elevated as a progression. Maintain the entire spine in neutral, including the neck; lift only the head and shoulders. Compared to a crunch, the curl-up involves very little curl and the upper body and neck stay elongated. There is minimal range of motion. Other progressions involve prebracing the abdominals and deep breathing during the exercise.

Dead Bugs for strengthening of the core (2 sets of 12)

Dead Bug How To

  1. Lie on your back with your arms extended in front of your shoulders.
  2. Bend your hips and knees to a 90-degree angle.
  3. Tighten your abs and press your lower back into the floor.
  4. Take a deep breath in.
  5. As you exhale, slowly extend your left leg toward the floor and bring your right arm overhead. Keep your abs tight and don’t let your lower back arch.
  6. Slowly return your arm and leg to the starting position.
  7. Repeat with your opposite arm and leg. Continue alternating

Bird Dog 2 sets of 12

From a quadruped position, one leg is lifted and then returned, followed by lifting the opposite extended arm. To progress, both the leg and opposite arm are lifted. Making a fist can increase the tension in the extended arm. Further progressions involve drawing a square with both the foot and hand simultaneously. The exercise is performed on alternating sides

Back Extensions 2 sets of 12

Gluteus Medius / Maximus Routine

The progression above utilizes an 8″ mini-band to resist the gluteus medius isolated activation, gluteus maximus isolated activation, bridges and potentially a side-stepping circuit for a quick succession of exercises that progress the client from isolated activation to core integration to reactive integration for the glute complex.

Clams -Side lying with a band 2 sets of 12

The clam exercises produced EMG activity between 34-40% for both muscles.  While this is low in comparison to other exercises, the authors did not use resistance during testing.  I would still use this, especially with a resistance band around the thighs, as am early-stage or activation exercise. The authors also compared clams at 30 degrees and 60 degrees of knee flexion and showed no different in gluteus medius activity

DiStefano, L. (2009). Gluteal Muscle Activation During Common Therapeutic Exercises Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2796

Side Lying Leg Raise-Leg abduction with hip in extension for activation of the gluteus maxami and medii.

Side-Lying Hip Abduction should be used in all people needing glut medius strengthening.  EMG activity was almost 20% higher than the next exercise

DiStefano, L. (2009). Gluteal Muscle Activation During Common Therapeutic Exercises Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2796

(Prone): Glute Max Activation with band 2 sets of 12

Glute Max Activation:

(Supine): Glute Bridges 2 sets of 12

How to Perform the Glute Bridge with a band Properly
How to Perform the Glute Bridge with a band Properly

Start by having the patient lying face up on the floor with arms to the side, knees bent, and heels on the ground.  Have them lift the hips off the ground until knees, hips, and shoulders are in a straight line making sure to squeeze the glutes as they reach the top of the movement. All of the weight should be balanced between your shoulders and your feet. The patients knee should flare out to activate the gluteus medius concurrently, after holding for 2-3 seconds, have the slowly lower their hips back to the ground and allow the buttocks and back to slightly touch the ground before completing another rep.

Side Bridges

The side bridge, or plank can be performed from the knees if you have limited strength or ability to engage the abdominal wall. Begin by lying on the right side supported by the right elbow, hip and knee. Using support of the left hand, press up through the hips until you are supporting your body between your elbow and your knees.

Training times begin at 10 second intervals. Build up endurance for stabilization with repeated short bouts, rather than increasing duration. According to McGill, once these are tolerated, progression to a more difficult version of the exercise or other exercises is justified. Bracing, rather than hollowing, during exercise enhances stabilization. To brace, avoid drawing in the navel and instead tighten the entire core, as if you were about to be thrown a punch.

I acknowledge McGill’s work on endurance times for extension, flexion and side bridge. But the standard deviations appear very wide which means there is a wide variety of data points. Expectations have to be modified in the elderly.
I acknowledge McGill’s work on endurance times for extension, flexion and side bridge. But the standard deviations appear very wide which means there is a wide variety of data points. Expectations have to be modified in the elderly.

Kan, S., Jeon, H., Kwon, O., Cynn, H., Choi, B. (2013). Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Manual Therapy 18, 303-307

Shoulder Instability


SUBJECT:  Shoulder instability.

I. Review of Anatomy and Physiology

The shoulder complex consists of four joints that function in a precise, coordinated, synchronous manner. Position changes of the arm involve movements of the clavicle, scapula, and humerus. These movements are the result of the combined work of the sternoclavicular, acromioclavicular, and glenohumeral joints and the scapulothoracic gliding mechanism (1).

The ligamentous and periarticular structures of the shoulder complex combine in maintaining the joint relationships, withstanding the forces applied to the joint surfaces, and stabilizing the dependent limb (1).

Due to poor osseous congruency and capsular laxity, the glenohumeral joint is very unstable, which makes it the most frequently dislocated joint in the human body. It relies on dynamic stabilizers and the neuromuscular system for its stability. (5, 6, 7)



The glenohumeral joint is a multiaxial ball-and-socket synovial joint. The articular surfaces, the head of the humerus and the glenoid fossa of the scapula, although reciprocally curved, are oval and are not sections of true spheres. The head of the humerus is larger than the glenoid fossa. The articular surfaces are not congruent, and the joint is loose packed. Full congruence and the close-packed position are obtained when the humerus is abducted and rotated laterally (1).

The glenoid labrum is a rim of fibrocartilaginous tissue attached around the margin of the glenoid fossa. Some theories state that the labrum deepens the articular cavity, protects the edges of the bone, and assists in lubrication of the joint. The shape of the labrum adapts to accommodate rotation of the humeral head, adding flexibility to the edges of the glenoid fossa. The tendons of the long head of the biceps brachii and triceps brachii muscles contribute to the structure and reinforcement of the labrum.
The labrum seems to represent a fold of the capsule, however, and its major function may be to serve as an attachment for the glenohumeral ligaments (1).

The capsule surrounds the joint and is attached medially to the margin of the glenoid fossa beyond the labrum. Laterally, it is attached to the circumference of the anatomical neck, and the attachment descends about a half-inch onto the shaft of the humerus. The capsule is loose fitting to the extent that the joint surfaces can be separated 2 to 3 mm by a distractive force. The capsule is relatively thin and, by itself, would contribute little to the stability of the joint. The integrity of the capsule and the maintenance of the normal glenohumeral relationship depend on the reinforcement of the capsule by ligaments and the attachment of the muscle tendons of the rotator cuff mechanism.
Anteriorly, the capsule is strengthened by the glenohumeral ligaments and the attachment of the subscapularis tendon. The latter is a major dynamic stabilizer of the anterior aspect of the shoulder. Posteriorly, the capsule is strengthened by the attachment of the teres minor and infraspinatus tendons (1).

Rotator Cuff
The rotator cuff is the musculotendinous complex formed by the attachment to the capsule of the supraspinatus muscle superiorly, the subscapularis muscle anteriorly, and the teres minor and infraspinatus muscles posteriorly. All of their tendons blend intricately with the fibrous capsule. They provide active support to the joint and can be considered true dynamic ligaments (1).



A number of related factors influence the stability of the glenohumeral joint.
A shallow glenoid fossa, one third of the articular surface of the humerus, creates a potential for instability. Instability in the glenohumeral joint is mostly anterior, to a lesser extent inferior, and least of all posterior (1).

According to Panjabi, there are three subsystems that works together to promote spinal stability: central nervous subsystem (control); osteoligamentous subsystem (passive); and muscle subsystem (active) (9). Hess adapted Panjabi’s model proposed for spinal segmental stability for the glenohumeral joint, which states that joint stability is based on the interaction between the active, passive and neural control subsystems, with the rotator cuff muscles, activating at different positions, compressing the convex humeral head into the concave glenoid, thus resisting the shear force experienced by the humeral head (14).

Passive stability

The passive system is composed of the glenohumeral joint, the ligaments: glenohumeral ligament and coracohumeral ligament (2).

Dynamic stability

Dynamic stability of the glenohumeral joint is assisted by the sensorimotor system, due to the presence of mechanoreceptors within the joint which influence the patterns of muscle recruitment, reflex activity and joint stiffness. Receptors within the joint capsule contribute to a reflex arc, which will cause activation of the muscles, the rotator cuff and the long head of the biceps brachialis, which overlie the joint capsule (2,15,16).
The short rotator muscles exerting a force in a downward and medial direction in abduction are critical in controlling the position of the humeral head. The posterior tilt of the glenoid fossa, together with the posteriorly tilting humeral head, provides a relationship that also counteracts the tendency toward anterior instability (1).
A glenohumeral joint with a lax capsule and ligaments might be stabilized dynamically in the end-range of motion if the glenoid concavity is maintained and the function of the external and internal rotators, which are efficient stabilizers in this position, is enhanced. (8)

Movement of the shoulder

In order to move the shoulder, first we need to extend the thoracic spine, then stabilize the scapula and the move the humerus in the glenoid fossa (18). The sequence of muscle activation during shoulder abduction begins with the stabilization of the scapula. This provides a stable base upon the glenohumeral joint abductors can ground themselves and act on the humerus. Stabilization of the scapula relies on isometric contraction of the upward scapula rotators (upper and lower trapezius and serratus anterior). With the scapula stabilized the supraspinatus activates first providing pure abduction without elevation in a linear effect directed into the glenoid fossa. Then deltoid activates pulling the humerus in abduction and elevating the arm in abduction (17).

After a luxation, active and passive stabilization systems are damaged, biomechanical alteration occurs and it leads to articular instability. A proper muscular rehabilitation should be performed in order to achieve stabilizers efficiency and avoid future instability (2).

Motor development

Development of human motor function in early childhood is genetically pre-determined and follows a predictable pattern. These motor patterns or programs are formed as the central nervous system matures, enabling the infant to control posture, achieve erect posture against gravity, and to move purposefully via muscular activity (11). In the normal motor development, the shoulder first develops mobility, the ability to move the upper extremity in space. This is referred as open chain movement. After mobility is achieved, the shoulder starts to develop stability with close chain activities (prone position on elbows and forearms, and then on hands). In these positions the shoulder is performing a weight bearing function described as the stability aspect of motor behavior. Once the infant has achieved a stable close chain position the next phase of development of stability of the shoulder is to move one arm in open chain while the other is in contact with the ground or another surface, in close chain. This is weight shifting in various weight bearing postures of the upper extremities. This is critical to develop equilibrium and tilting response. Like in the prone position, progression in shoulder stability in the supine position starts when the infant is pulled to sitting the rotator cuff muscles, cervical, trunk and hip flexors muscles exhibit active antigravity control (4).

II. History
Case presentation.
Objectives: The purpose of this paper is to report the case of a patient with chronic pain and instability on her right shoulder who was treated with chiropractic and rehabilitation care.
Subject: Patient was a 25 year old female aerial dancer with pain and instability on right shoulder, the onset was 3 months ago, falling in a rehearsal. History of trauma: while performing an exercise having the shoulder at 90° of abduction the patient fell and hyper extended the right shoulder. When she fell she felt the shoulder “went out” and she pulled back in. She noted referred pain and instability since as well as lack of strength and inability to perform her activity.

III. Physical Evaluations
Examination revealed:
Neurological testing: reflexes, myotomes and dermatomes were unremarkable; Posture: forward head posture, increased thoracic kyphosis, protracted shoulders, winging of right scapula, pelvis postures was neutral; Gait: Normal;
Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited and painful, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Palpation: tightness in right upper trapezius, tenderness and pain over the greater tubercle of the right humerus; Orthopedic testing: Anterior drawer and posterior drawer of shoulder shows instability without pain. Sitting apprehension test was positive with pain. Empty can test was positive for supraspinatus. Infraspinatus test was positive; In Janda´s abduction test when performing in right shoulder abduction the right upper trapezius was the first muscle to fire, compensating the action of right supraspinatus and right deltoid.

VI. Chiropractic Assessments
VI.I Structural analysis:
Tight right upper trapezius and levator scapulae. Tight pectoralis major. Underactive middle and lower trapezius.
VI.II Static and motion palpation:
Static palpation: C2 fixed in right rotation and right lateral flexion; T4, T5 and T6 fixed posteriorly.
Motion palpation: Hypomobility in right cervical rotation; Hypomobility of mid-thoracic spine.

VII. Differential Diagnosis
SLAP lesion, Subacromial bursitis, Rotator cuff tear.

VIII. Patient Management

VIII.I Treatment
Chiropractic technique: Cervical spine: Diversified Index contact to pillar-sitting (10); Thoracic spine: Diversified Bilateral knife-edge contact to transvers processes. Patient was adjusted in every visit.
Rehabilitation: Thoracic spine mobility exercises, Shoulder stability exercises. Thoracic spine mobility exercises were performed to achieve extension; Then progressing to a Rib roll T-spine rotation. Shoulder stability exercises: Patient was first taught to hold a quadruped position. Then from four point support in a quadruped to three-point support (extending one hip, and then the other), then progress to upper limb (flexing one shoulder and then the other), and then progress to a birddog (two points support position), holding each position for 10 seconds performing 4 sets. The patient was progress then to a bear crawl position (first 4 points support and then 3 points support and then crawling forward and backward). Then the patient was started in static shoulder pulling exercises first with a double arm double leg kettlebell deadlift and then she was progressed to a single arm single leg kettlebell deadlift. And finally to chops and lifts with bands, to integrate mobility and stability exercises for the shoulder (4,11,12,13).
VIII.II Frequency: The patient was treated once a week over an 8-week time period.
VIII.III Patient education and home care: Patient was instructed in preforming the exercises daily at home. Patient was taught the exercises in the office and in each visit previous exercises were reviewed, to make sure she was doing them correctly.

VIII.IV Rehabilitative considerations: Incorporating the motor development model of the shoulder to a rehabilitation protocol: the patient was started first with thoracic spine mobility exercises (extension and rotation), then patient was progressed from static stability close chain exercises, four point support, for shoulder and scapula stabilizers, to one arm moving (open chain mobility exercise) while the other is in contact with the ground (close chain stability exercise) three point support, and then to a moving cross crawling pattern, then to a pulling movement (holding weight) and finally in a push-pull dynamic exercises (chops and lifts) to Integrate mobility and stability of the shoulder.

IX. Outcome of Care

Patient was reassessed in every visit.

Week one: Posture: forward head posture, normal thoracic kyphosis, protracted shoulders, winging of right scapula; Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited and painful, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was positive for supraspinatus, infraspinatus test was positive.
Week two: Posture: forward head posture, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited with no pain, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was negative, infraspinatus test was negative.
Week three: Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine with no pain, full range of motion of shoulder with no pain; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was negative, infraspinatus test was negative.
Week four: Patient was asymptomatic, Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine with no pain, full range of motion of shoulder with no pain; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week five: (Same as week four) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week six: (patient was asymptomatic and shoulder was stable) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative. Patient was instructed to return to physical activities (aerial dancing).
Week seven: (Same as week six) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week eight: Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative (patient was discharged).
Follow-up: In a 2 month after discharged telephone follow-up, the patient revealed that the pain had not returned and the shoulder was stable during physical activities and daily living activities.

X. Discussion:

The classic rehabilitation of shoulder instability has consisted of: immobilization of the affected shoulder, flexibility exercises (passive range of motion, assisted flexion and abduction arm raises, pendulum exercises, cross over arm stretch, passive internal and external rotation, etc.) and strength exercises for rotator cuff (isometric and isotonic) (7,19,20,21,22). In the classic rehabilitation protocol, the muscles of the rotator cuff are treated as prime movers. We know now that the rotator cuff muscles work as shoulder stabilizers and they should be treated as so (2,9,14,15,16). Thus the rehabilitation of shoulder instability should incorporate exercises that address: mobility of thoracic spine, stability of scapulae, and mobility and stability of the glenohumeral joint all of these performed in a natural progression according to the development of human motor function.

XI. Reference

• Functional Anatomy of the Shoulder Complex. Malcolm Peat. PHYS THER. 1986; 66:1855-1865.
• Estudio de las luxaciones de hombro. Protocolos y valoración de la contingencia. Enrique Céster Balletbó.
• Essentials of Orthopedics & Applied Physiotherapy. Jayant Joshi. Elsiver
• Physical Therapy Jan S Tecklin. fourth ed. Development. Motor development in the normal child.
• Magnetic Resonance Imaging in Orthopedics and Sports Medicine, Volume II, David W. Stoller, 2007, p 1329-1338
• Current concepts in the treatment of anterior shoulder dislocations, D. Y. Wen, ‘, American Journal of Emergency Medicine, Volume 17, Number 4, 1999, p 401-407 (Level of Evidence 2A)
• ‘Non-operative Rehabilitation for traumatic and atraumatic glenohumeral instability’, K E. Wilk, L. C. Macrina, M. Reinold, North American Journal of Sports Physical Therapy, 2006, p 16-31 (Level of Evidence 1A)
• Dynamic Glenohumeral Stability Provided by the Rotator Cuff Muscles in the Mid-Range and End-Range of Motion a Study in Cadaver. Seok-Beom Lee, M.D., Ph.D.; Kyu-Jung Kim, Ph. D; Shawn W. O’Driscoll, M.D., Ph.D.‡; Bernard. Morrey, M.D; Kai-Nan an, Ph.D. J Bone Joint Surg Am, 2000 Jun; 82 (6): 849 -849.
• Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation and enhancement. J Spinal Disorders 1992; 5:383-389.
• Thomas Bergmann. Chiropractic Technique Principles and Procedures. First edition.
• Clinical Commentary Dynamic Neuromuscular stabilization & sports rehabilitation. Clare Frank, DPT, OCS, FAAOMPT, Alena Kobesova, MD, PhD , Pavel Kolar, PT, PhD The International Journal of Sports Physical Therapy | Volume 8, Number 1 | February 2013 | Page 62
• The Rib-Roll Stretch for Thoracic Spine Mobility. Perry Nickelston, DC, FMS, SFMA. Dynamic Chiropractic.
• The Chop and Lift Reconsidered: Integrating Neuromuscular Principles into Orthopedic and Sports Rehabilitation. Michael L Voight, PT, DHSc, OCS, SCS, ATC, CSCS Barbara J Hoogenboom, PT, EdD, SCS, ATCb Gray Cook, MSPT, OCS, CSCS North American Journal of Sports Physical Therapy august 2008 volume 3, number 3
• Functional stability of the glenohumeral joint. Hess, S. Manual Therapy, 5, 63–71.
• The synergistic action of the capsule and the shoulder muscles. Guanche, C., Knatt, T., Solomonow, M. et al. American Journal of Sports Medicine, 23, 301–306
• Sports Rehabilitation and Injury Prevention. Paul Comfort, Earle Abrahamson. Wiley-Blackwell
• Kinesiology Movement in the Context of Activity, second edition. David Paul Greene, Susan L Roberts. Elsivier Mosby. 2005
• Movement, Functional Movement Systems: Screening, Assessment and Corrective Strategies. Gray Cook. On target publications.
• Rotator Cuff and Shoulder Conditioning Program. American Academy of Orthopaedic Surgeons.
• Shoulder Instability: Management and Rehabilitation. Kimberley Hayes, PT1 Mary Callanan, MD2, Judie Walton, PhD3 Anastasios Paxinos, MD4 George A. C. Murrell, MD, PhD5
• Diagnóstico y Tratamiento del Síndrome de Manguito Rotador, Guía Rápida. Instituto Mexicano del Seguro Social.
• Tratamiento Quirúrgico de la Inestabilidad Anterior de Hombro (articulación gleno-humeral), Guía de Referencia Rápida. Instituto Mexicano del Seguro Social.

Conscious Core Stability For Low Back Pain Occurring Under Spinal Load: Queuing the Patient

Joseph W. Piwoszkin DC
Darien, IL

Review of Anatomy and Physiology

The low back, or lumbar spine, consists of five lumbar vertebrae aptly referred to as L1, L2, L3, L4, and L5. The most inferior aspect of the lumbar spine, L5, connects to the sacrum; a large spade-shaped bone that connects the spine to the iliac bones of the hip.

The cervical spine and lumbar spine both consist of a lordotic curve with no supporting osseous structures. Unlike the thoracic spine, where each vertebra has a set of ribs attached (creating a supportive thoracic cage) the cervical spine and lumbar spine rely more heavily on muscular stability.

Due to the “upright” nature of mankind, axial loading of the spinal osseous structures is common. The job of the surrounding musculature is to resist buckling of the spine under the loads of activity. Anterior/abdominal muscles used for lumbar spine stability include the internal oblique, external oblique, transverse abdominus, and the rectus abdominus muscles. Posterior/back muscles used for lumbar spine stability include the multifidus, quadratus lumborum, lumbar erector spinae, and the thoracic erector spinae muscles. For the sake of this case study, these are the muscles being referenced when referring to core musculature (1).

Background Information

Low back pain patients requiring core rehabilitation can be defined in one of several groups: the deconditioned, imbalanced muscle development ratio, or the inability to maintain co-contraction (2). All have one common aspect to their rehabilitative care; they require education in creating a co-contraction of the core musculature. Currently, there are no outlined methods of checking for this stability pattern in patients during functional activities. Therefore, a high amount of responsibility is given to the patient’s kinesthetic awareness of functional bracing patterns. The responsibility of educating the patient in these patterns occurs during baseline rehabilitative care. When instructing the lay person on proper form and firing patterns with rehabilitative exercise, communication is key. Patients with low kinesthetic awareness at baseline (i.e. difficulty producing willful abdominal wall muscle contraction laying supine with knees at 45 degrees) should not progress to more active and functional exercise until this is mastered. If the practitioner cannot evoke abdominal wall musculature contraction in the patient, progression may be limited.

These are individuals who struggle with conscious core stability. Eliciting co-contraction in these individuals will rely heavily on the skill of the practitioner and their ability to kinesthetically educate or “queue” the patient into creating the desired outcome. A common difficulty with the aforementioned patient base is activating the abdominal wall muscles: especially internal/external oblique and transverse abdominus.

When performing an exercise used to target abdominal wall musculature, without proper queuing it is possible to continue to use poor firing patterns to execute the movements (overusing hip flexors, spinal erectors, quadratus lumborum). In the subacute or chronic patient, these “abdominal” exercises performed without proper abdominal wall contraction may continue to cause pain, but in the same patient with proper queuing, may not cause pain. Granata and Marras showed that co-contraction of the core musculature increases spinal stability by 36% to 64% (3). It may be considered that this considerable change in stability may affect whether or not the patient feels pain with rehabilitation, as well as activities involving spinal load.

Psoas major, part of the hip flexor group iliopsoas, originates at the lumbar spine. A compensatory pattern of overusing the hip flexors without dispersing force into the abdominal wall during stabilization may cause difficulty in maintaining a neutral spine. A lumbar hyperextension pattern is seen in hip flexor/erector spinae dominant stabilization patterns during exercise. According to McGill, a neutral lordosis in the lumbar spine during loaded activity has been shown to minimize risk of low back injury (4). Good queuing to correct these movement patterns in early rehabilitation may have a direct effect on outcomes.


Ruth, a 52-year-old female, presented to clinic for examination of low back pain. She rated the intensity of her pain on a scale of zero to ten, with zero being complete absence of symptoms and ten being very severe or unbearable pain, a seven. Pain was described with the following qualifiers: dull, sharp, deep, and stiffness. Upon questioning, Ruth stated her symptoms were aggravated by activities involving sitting, sleeping and bending. She stated that some relief was obtained when standing. Denied having, or ever having, any radicular symptoms into either legs. Ruth reported that about one and a half years ago she had a cyst removed from her right ovary. Roughly 6 weeks after surgery she woke up in the morning with extreme pain. The pain was located in the right lateral hip region. Reported pain was worse in the morning but decreased to “tolerable” levels after about 2 hours. Patient received a corticosteroid injection into the right hip that helped the pain, but since that time the pain has migrated to the low back. She reports still having occasional lateral hip pain if she moves incorrectly. Ruth has had x-rays and an arthrogram of the right hip. She reports having no known trauma in either the hip or low back areas. Previous relevant surgeries included two cesarean sections, a hysterectomy, and removal of the right ovary. Ruth also reports having undergone about one month of physical therapy, thirteen visits total, immediately previous to this examination. Ruth had another corticosteroid injection scheduled six days from our initial examination. Ruth works as a secretary. No red flags were found during the initial history.

Ruth’s previous rehabilitation did not involve any core stabilizing education. She stated that she did exercises for “her back muscles” and “leg exercises” as well. During her thirteen previous physical therapy visits at another institute she reported that her pain would decrease mildly followed by severe “flare-ups” of pain. This cycle continued throughout the thirteen visits.

Physical Evaluation

Active Lumbar Spine Range of Motion
Patient showed moderate-severe restriction in standing flexion, and moderate standing extension restriction. Both standing flexion and extension produced pain. Mild-moderate restrictions in left/right lateral flexion and left/right rotation without pain, but patient was hesitant to push these boundaries.

With the patient prone, pain was noted with palpation over the posterior superior iliac spines bilaterally. Quadratus lumborum palpation revealed trigger points in the medial fibers near the origin along the upper lumbar spine with pain elicited. Gluteus maximus muscle origins on the right were hypertonic and tender. Middle and lower thoracic erector spinae musculature was overdeveloped comparatively with noted hypertonicity.

Motion palpation of the spine revealed restricted movement in the lower thoracic and upper lumbar spine. Counter nutation restriction of the sacrum.

Neurological Examination
Lower extremity muscle strength, pain/touch sensation, and reflexes were all within normal limits. No pathological reflexes were present.

Orthopedic Examination
Negative tests include: Straight leg raise, Bragard’s, Patrick-Fabere, and Kemp’s.
Positive Yoeman’s test bilaterally with pain in the respective sacroiliac areas and low back. Hibb’s positive on the right for pain in the right sacroiliac joint, negative on the left. Milgram’s positive for severe low back pain with the inability to hold the position for any amount of time.

Functional Examination
Squat test – Patient was asked to perform a squat with no previous queuing. While attempting to squat the patient used almost exclusively knee flexion with no hip hinging/flexion. Patient described having fear avoidance in “bending forward” because of back pain. Patient was placed supine with knees at 45 degrees and the examiner attempted to provoke an abdominal wall contraction from the patient. The patient showed complete inability to willingly produce any type of muscle contraction. When placed in a dead bug position (patient unable to raise her legs on her own due to pain) the patient described moderate low back pain, and light perturbation to the raised legs produced severe low back pain.

X-ray and MRI arthrogram reports of the right hip were requested. X-rays were performed four months prior and the MRI arthrogram three months prior to the presenting examination. X-ray impressions stated “no evidence of acute bony abnormality” and the MRI arthrogram impressions were slight fraying of the acetabular labrum, strain of the gluteus medius at its insertion upon the greater trochanter with trochanteric bursitis, associated gluteus minimus insertional tendinosis, and no bony lesions demonstrated in the pelvis.

Differential Diagnosis
Acquired Sacroiliac and Lumbar Spine Instability and/or Sacroiliitis with Lumbar Spine Facet Syndrome.
Discogenic Pain of the Lumbar Spine

Rationale for the above diagnosis is severe pain and resulting fear avoidance behavior combined with the lack of ability to engage abdominal wall musculature. Correlation with tissue and spinal palpation, positive orthopedic tests, and functional testing support these diagnoses. Consideration of the multiple abdominal wall traumas from surgical intervention were made, however, good core stability patterns may not have been present prior to these interventions.

A compilation of information put together by Bogduk and Aprill supports the aforementioned structures as being valid sources of pain (5).

Patient Management/Intervention

These guidelines are not designed as a specific practice model. They may or may not be used, as deemed necessary by the practitioner, to help elicit abdominal wall muscle firing patterns. The “language” used is intended to be easily understood by the lay person.

Screening & Queuing Co-contraction
Patient began lying supine with knees flexed at 45 degrees, feet flat.
Explain that you will be testing their ability to contract their “stomach muscles”
An example of what a muscle contraction feels like can be easily made using the biceps muscle. Most patients will understand that when “flexing” the biceps the muscle should feel firm.
“We want the same response in your stomach muscles”
Press the pads of your second, third, and fourth fingers 2’ to 4” lateral of the umbilicus. Have the patient do the same with their own hand on the other side. Your pressure while pressing against their abdomen should be similar to the deep palpation pressure you would use during an abdominal exam.
Ask the patient to “push your fingers away using their stomach”
It is important at this point to correct any excessive lumbar extension in their attempt to contract the abdominal musculature. You may queue the patient by putting your other hand under their lumbar spine and telling them to either lightly press against it or to not let their back raise away from your bottom hand when attempting to contract.
If the patient is able to achieve this, have them place both hands around their abdomen (level with the umbilicus) with their thumbs wrapping posteriorly and fingers anteriorly.
Explain that when contracting, they should feel their hands being “pushed away in all directions” as if expanding their stomach 360 degrees.
When the patient is able to achieve co-contraction at this level, progress them appropriately into your rehabilitative program. Explain that this is their foundation, and the importance of being able to consciously stabilize their core/spine.
When performing core stability exercises (i.e. Dead/Dying Bugs or Plank/Bridge positions), make sure the patient is not falling back into lumbar hyperextension and a hip flexor/erector spinae dominant bracing pattern. Otherwise, you are continuing to train a dysfunctional pattern.
If the patient is unable to comply with the above method, you may try the following:
Remain in the above mentioned position with your hand and the patient’s hand on the abdomen. Ask the patient to give you a “fake cough” or a short fast exhale. You should note their abdomen pressing out against your hand during this. Ask the patient if they felt it as well. Make sure the patient is applying the appropriate amount of pressure onto their own abdomen.
It may help to explain the muscles you are trying to contract attach the bottom of the ribs to the front of the pelvis, and that they should feel their ribs “being pulled down” or “dropping” when they cough or forcibly exhale.
Another option is to press down on the bottom of the patient’s rib cage using the thumb and forefinger of one hand, pressing lightly into the intercostal spaces roughly even with the midclavicular line on each side. Have the patient continue with the above methods as you hold this position.
Have the patient try to hold the contraction once they achieve it using the previous method. The patient may need to use this method multiple times. If so, allow the patient time to rest with a few normal cycles of respiration between multiple attempts.
If the patient can maintain an abdominal wall brace with a normal breathing cycle pattern continue with number 5 listed above.
Once the patient can consciously contract and hold their abdominal wall it is important to address an abdominal breathing pattern. If the patient cannot breathe during a held co-contraction, they should not be progressed into exercise involving core stability.

Patient Outcomes

Two visits were required before Ruth was able to create and maintain a co-contraction of core musculature while lying supine. By Ruth’s third visit she was able to progress to positioning herself and holding the dead bug position for 30 seconds without pain. Ruth presented on her fifth visit with a “flare-up” of pain. However, the pain was less than previous flare-ups and she was able to resume her previous level of rehabilitation on the next visit two days later. Ruth has continued to progress into exercises like straight leg raises, leg abductions, glute raises with feet on a BOSU, bridges/side bridges, prone hip extensions, dying bugs, standing chops, monster and crab walks. She performed the previously mentioned exercises without additional pain. By Ruth’s ninth visit she was having no morning pain, no pain with her current activities of daily living, and only “mild discomfort” while sitting in a car. Ruth also made a personal decision not to have the cortisone injection which was scheduled for six days after her presenting examination.


Ruth was a superb example of having absolutely no conscious ability to stabilize and she required special attention to attain this firing pattern. Many patients can pick up this pattern quickly but are simply weak while others naturally create this pattern with no queuing at all.

The author would state that the importance of educating the patient of the dynamics of core exercise is equal to the ability to prescribe the appropriate rehabilitative program. It should be considered that exercise directed at the anterior abdominal wall can be ineffective if the patient is unable to use the correct muscle firing co-contraction patterns. When performing rehabilitative core exercise without first addressing how to properly stabilize the core, the risk of provoking the spine under a less than ideal stability pattern increases.


Liebenson, Craig. The Role of Muscles, Joints, and Nervous System in Painful Conditions of the Spine. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 2: 31-47.
Osborne N, Cook J. Global Muscle Stabilization Training – Isotonic Protocols. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 27: 682-685.
Granata KP, Marras WS. Cost-benefit of muscle cocontraction in protecting against spinal instability. Spine 2000;25: 1398 – 1404.
McGill, Stuart M. Lumbar Spine Stability: Mechanism of Injury and Restabilization. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 5: 94-95.
Bogduk N, Aprill C. The Sources of Back Pain. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 6: 113-119.

Journal Abstracts by Scott Michael Schreiber, D.C., D.A.C.R.B

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines.

Read Full Article

Global Rating of Change Scales: A Review of Strengths and Weaknesses and Considerations for Design

Most clinicians ask their patients to rate whether their health condition has improved or deteriorated over time and then use this information to guide management decisions. Many studies also use patient-rated change as an outcome measure to determine the efficacy of a particular treatment. Global rating of change (GRC) scales provide a method of obtaining this information in a manner that is quick, flexible, and efficient. As with any outcome measure, however, meaningful interpretation of results can only be undertaken with due consideration of the clinimetric properties, strengths, and weaknesses of the instrument.

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Effect of workplace- versus home-based physical exercise on musculoskeletal pain among healthcare workers: a cluster randomized controlled trial

The prevalence and consequences of musculoskeletal pain is considerable among healthcare workers, allegedly due to high physical work demands of healthcare work. Previous investigations have shown promising results of physical exercise for relieving pain among different occupational groups, but the question remains whether such physical exercise should be performed at the workplace or conducted as home-based exercise. Performing physical exercise at the workplace together with colleagues may be more motivating for some employees and thus increase adherence. On the other hand, physical exercise performed during working hours at the workplace may be costly for the employers in terms of time spend. Thus, it seems relevant to compare the efficacy of workplace- versus home-based training on musculoskeletal pain. This study is intended to investigate the effect of workplace-based versus home-based physical exercise on musculoskeletal pain among healthcare workers.

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Effects of vitamin D supplementation and exercise training on physical performance in Chilean vitamin D deficient elderly subjects.

The aim was to assess the effects of resistance training and vitamin D supplementation on physical performance of healthy elderly subjects. Ninety-six subjects, aged 70 years or more with 25 OH vitamin D levels of 16 ng/ml or less, were randomized to a resistance training or control group. Trained and control groups were further randomized to receive in a double blind fashion, vitamin D 400 IU plus 800 mg of calcium per day or calcium alone. Subjects were followed for nine months.

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2016 Trends To Be Aware of

The American College of Sports Medicine (ACSM) published its annual fitness trend forecast. (November/December issue of ACSM’s Health & Fitness Journal®) ). The survey was completed by more than 2,800 health and fitness professionals worldwide, and was designed to reveal trends in various fitness environments. Read more

Acupuncture in a Multidisciplinary Setting

The purpose of this paper is to describe how acupuncture can be implemented in a multidisciplinary setting. Acupuncture can be implemented in any practice, however, this specific paper will specifically apply to how I am implementing it in my current practice. It will include a brief description of what is acupuncture, how does acupuncture work, how it applies to a multidisciplinary practice, diseases or disorders to be treated, cost structure of equipment to be used, billing and coding, safety precautions, clean needle technique, and forms to be used. Read more

A Tribute to the Prague School of Rehab


Yes, you read that right. The theme for our 2016 Joint Rehab & Pediatrics Council Symposium which takes place at the New York-New York Casino/Hotel in Las Vegas on March 4th – 6th, 2016 is “A Tribute to the Prague School of Rehab”. And we have great speakers who are trained in the Prague School of Rehab as well as Dynamic Neuromuscular Stabilization (DNS). Speakers such as Drs. Craig Morris, Pamela Tunnell and Maria Perri will elaborate on the historical origins of the Prague School and DNS, clinical pearls gleaned from the research and publications of Vladimir Janda, Pavel Kolar, Karel Lewit and Frantisek Vele. Janda’s postural assessment will be discussed as well as clinical highlights from the Prague School including a neuromusculoskeletal and palpatory examination of the abdomen for the lower back pain patient, the difference between reflex vs. mechanical soft tissue techniques and the pathophysiological soft tissue barrier.

In addition, an optional Friday (3/4/16) 2 hour CEU program will focus on post (minimally invasive) surgical spine rehabilitation. Drs. Jerrold Simon. Anthony Gross and George Petruska will be examining the many therapies, both surgical and non-surgical, developed to combat back and neck pain. In particular, Dr. Gross will delineate common minimally invasive spine surgical procedures such as MISS-endoscopic (non-fusion) laminotomy, foraminotomy, discectomy and laser DTA as well as MISS-fusion procedures such as XLIF, TLIF, PLIF and Anterior Cervical Discectomy Fusion (ACDF). During the second hour, Drs. Jerrold Simon and George Petruska will discuss how to go about medically clearing the post-surgical patient for spinal rehabilitation. Common categorical drugs and their cardiovascular, pulmonary or hypertensive side effects will be enumerated. Finally, the post minimally invasive functional capacity exam for both the thoraco-lumbar as well as the cervico-dorsal surgical patient will be demonstrated with focus on how to then subsequently generate proper post-surgical rehab protocols.

On Sunday, March 6th, doctor attendees will be able to choose between a Rehab track vs. a Pediatrics track. During the first two hours of the Rehab track, Dr. William Morgan will discuss modic vertebral endplate changes as documented by MRI. This will included orientation and sequencing of the MRI images as well as defining modic changes while detailing their clinical significance. During the second two hours of the Rehab track Dr. Philip Palmer will then expound upon assessing symmetry of gait, power and dynamic stability using computer models. He will also cover gait and balance training for concussed patients using the vestibular-ocular reflex, smooth pursuit pathway and the visual vestibular system. In addition on Sunday, March 6th, the Pediatrics track will feature Dr. Michelle Stafford who will lecture on the ramifications, remedies and results of pediatric tongue tie therapies. She will define and classify oral labial and lingual frenulum and expound upon the benefits of early tongue tie therapy as well as the long-term effects of untreated tongue tie. Finally, during the last two hours of the Pediatrics track, Pediatrics Council President Dr. Elise Hewitt will discuss craniosacral therapy for infants. Instruction will include demonstration on a model of an infant as well as video footage of actual patient sessions.

As you can see, our first ever Joint Rehab and Pediatrics Symposium is shaping up to be a real winner. It’s easy to be a part of this event. Simply register online by clicking on:

See you in Las Vegas,

Jerrold J. Simon, DC, DACRB
President, ACA Rehab Council

Republish of Postpartum Osteitis Pubis Treated Successfully with Shockwave Therapy: A Case Report

The purpose of this case study was to demonstrate that Extracorporeal Shockwave Therapy (ESWT) could be an adjunctive therapy for patients with postpartum osteitis pubis. Osteitis pubis is a painful, inflammatory condition that is difficult to handle without a comprehensive treatment method. A 26-year-old female patient with a notable condition of postpartum osteitis pubis participated in this case study. The treatment involved ESWT as a therapy for the patient’s groin and pubic pain due to osteitis pubis. Read more

US Chiropractors’ Attitudes, Skills and Use of Evidence-Based Practice: A Cross-Sectional National Survey

Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession. Read more

The Effectiveness of Exercise for the Management of Musculoskeletal Disorders and Injuries of the Elbow, Forearm, Wrist, and Hand: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. Read more

Functional Movement Screeen Normative Values and Validity In High School Athletes: Can the FMS™ Be Used as a Predictor of Injury?

Limited information exists regarding injury risk factors for high school athletes. The Functional Movement Screen (FMS™) has been used to identify functional movement impairments and asymmetries, making it a potential predictor of injury. Read more

An appraisal of the Functional Movement Screen™ grading criteria – Is the composite score sensitive to risky movement behavior?

To examine the relationship between the composite Functional Movement Screen (FMS) score and performers’ spine and frontal plane knee motion. Read more

Review Article of Consecutive Loops Theraband and Demonstration Videos

There are tremendous benefits to patients doing band work. For years we have had tubing, tubing with handles, Thera-bands, loops, the Stretch strap, and now the Consecutive Loop (CLX) Theraband. In my office patients are being introduced to the CLX along with bodyweight exercises before using free weights or Kettlebells. Read more

Aquatic Therapy Use in Management of Musculosketetal Dysfunction

Aquatic physical therapy is one of the fastest growing areas of physical therapy and rehabilitation. The benefits have been recognized since ancient times when whirlpools and hot springs were used to promote healing and manage medical aliments. Read more

Tongue Tie: Ramifications, Remedies and Results

Speaker: Michelle P. Stafford, DDS
Board Certified Pediatric Dentist
2 hours of lecture presentation given for:
ACA Pediatrics Council – ACA Rehab Council 2016 Joint Symposium
March 6, 2016


This workshop will teach the doctor of chiropractic a basic understanding of ankyloglossia (tongue tie) and upper lip tie. Information and current research will be discussed including diagnosis, treatment modalities, and benefits of frenulum revision. Utilizing various before and after photographs and videos, Dr. Stafford will demonstrate the frenectomy procedure. Emphasis will be on the diagnosis and treatment of infants to positively impact breastfeeding. Dr. Stafford will also review potential long term speech pathology, orthodontic malocclusion, and craniosacral consequences that ankyloglossia may contribute to in children, teenagers, and even into adulthood.

Course Objectives

  1. Understanding the mechanics of breastfeeding
  2. Looking at the impact of oral frenulum (both upper lip and tongue) on breastfeeding
  3. Diagnosing ankyloglossia (tongue tie) and upper lip tie
  4. Recommending treatment for ankyloglossia and upper lip tie and finding appropriate providers along with necessary follow up care

Hourly Outline

Hour One

Hour Two

Dynamic Neuromuscular Stabilization and the Prague School of Rehabilitation

The following gives details about the Thursday (3/3/16) and Friday (3/4/16) pre-2016 ACA Rehab Council Symposium 12 hour coursework covering “Dynamic Neuromuscular Stabilization and the Prague School of Rehabilitation”. This 12 hour Pre-Annual Rehab Symposium Seminar is also going to held at the New York-New York Casino / Hotel in Las Vegas on the Thursday and Friday just prior to the 2016 Annual ACA Rehab Symposium.

View the complete course details here:

The doctors can also find full registration details on our website:—exercise-sports-course-1.html

Course Hours:

Thursday, March 3: 9am – 5pm (1 hour lunch break)
Friday, March 4: 9am – 5pm (1 hour lunch break)

Early Bird Registration:

June 17, 2015 – August 19, 2015 $400.00
August 20, 2015 – October 28, 2015 $500.00
October 29, 2015 – December 30, 2015 $600.00
December 31, 2015 – March 2, 2016 $700.00
At the door: $750.00

Instructor: Brett Winchester, DC

Brett Winchester received his Doctor of Chiropractic degree from Logan College of Chiropractic.

Brett is currently a member of the Logan College of Chiropractic faculty, developing and instructing Logan’s advanced biomechanics course. He also lectures across the globe on various manual medicine topics, including manipulation, mobilization and rehabilitation. Brett’s lectures have been well received by chiropractors, physical therapists and osteopaths. His instruction centers on integrating manual treatment with active self-care.

Brett’s private practice, Winchester Spine and Joint Center is located outside St. Louis, Missouri, established its reputation on evidence-based care for diverse patient populations including professional athletes, occupational athletes, pediatrics and geriatrics.

DNS has played an integral role in Dr. Winchester’s practice and treatment approach.

Here is the description of the course:

PART I: 2 day course

•Demonstrate an understanding of the basic principles of developmental kinesiology.
•Describe the relationship between development during the first year of life and dysfunction of the locomotor system in adulthood.
•Discuss and demonstrate the basis of human movement: support, stepping forward, the biomechanics of motor function, the verticalization process & functional joint centration in postural development.
•Evaluate and correct poor respiratory patterns.
•Assess the integrated stabilizing system of the spine both visually and utilizing dynamic functional tests.
•Integrate corrective exercises based on the DNS functional tests and developmental positions in supine, prone, low kneeling, oblique sit, and quadruped global movements.
•Demonstrate how DNS corrective exercises can be integrated with other exercise strategies.

ACA Sports Council

The ACA Sports Council is holding their 2015 Annual Symposium at the Embassy Suites Hotel in Denver, CO on October 23rd – 24th. Please click on the following link for more information and to register:

Major Study Reveals ADHD Drugs Have Never Been Proven Safe or Effective

A recent study lead by researchers from Boston Children’s Hospital, the Department of Pediatrics at Harvard Medical School and several other institutions, concludes that the clinical trials for drugs approved as “treatment” for ADHD were not designed to assess adverse events or long-term safety and efficacy.

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Dynamic Warm-Up In The Workplace May Increase Workplace Productivity, Safety: A Call to Research Based On Results Of Implementation In The Athletic Community

Introduction: Virtually every company is looking for ways to make their employees safer, more effective, and protected from injury. The United States Bureau of Labor Statistics reports that hundreds of thousands of non-fatal injuries involving sprains, strains, tears, and back injuries affect the American workforce annually. While a push for pre-work stretching and designing of an ergonomic workstation have helped, an even greater decrease in work-related injuries could result from replacing static stretch routines with a dynamic warm-up, involving various, tailored exercises and proprioceptive tasks for employees to perform prior to the start of their work day. Read more

Familial Predisposition in Cervicogenic Disequilibrium, as it Relates to Functional Disturbances and Somatotype – A Case Study

Abstract: Dizziness is a nonspecific term that means various things to various people. It falls under a greater category of vertigo, but for our purposes we will concentrate on the subcategory of disequilibrium. This paper will review the origins, testing procedures and common disturbances of the physiologic and neurologic systems that affect balance and contribute to disequilibrium. This study will further concentrate on the familial link between structure and function of the cervical spine and the pathogenesis of cervical disequilibrium in a mother and daughter case study. Read more

Dr. Greg Rose Named Keynote Speaker for 2015 Rehab Symposium

Dr. Greg Rose, co-founder of the Titleist Performance Institute (TPI), is the keynote speaker for our 2015 Rehab Symposium scheduled for March 20th – 22nd, 2015 at the Disney Swan Hotel in Orlando, FL. Greg is a chiropractic physician and an engineer.

The Titleist Performance Institute ( is the world’s leading educational organization and research facility dedicated to the study of how the human body functions in relation to the golf swing.

His topic title will be “The Body-Swing Connection – making the link between the body and the swing.”

To register for our Spring 2015 Rehab Symposium, click

Video of a Quick Review of Various Manual Therapies for the Forearm by Dr. Alf Garbutt

Part of what I am going to cover today has to do with the distal part of the upper extremity. It is common to have wrist extensor problems with musicians and typists, causing pain that radiates to the hand witch get mis-diagnosed as carpal-tunnel. Read more

Functional Taping and Muscle Dysfunction

Kinesiology taping is a commonly used method to treat various conditions and aid in rehabilitation. Many research studies to date analyze the effects of kinesiology taping around the ankle joint. Kinesiology taping is proposed to: normalize muscular tone1; increase range of motion2; increase endurance3; and improve functional movement4. Read more