While manual therapy and education may play a crucial role in injury rehabilitation, injuries and pain respond the best in the long-term to progressive loading through exercise. In fact, exercise is said to be "the closest thing to a miracle cure" (1), and is widely accepted as the means through which you can attain complete recovery.
Prescribing exercise can be intimidating for some therapists, so I wanted to provide some facts and guidelines that may help make this easier!
Fitting the Diagnosis to the Injury
Attaining an accurate diagnosis CAN be difficult, but is often the first stage to developing a treatment plan, including exercise.
1. Do we know the actual pathology/diagnosis?
An over-reliance on imaging and unreliable ‘special’ tests may mean that the true pathology (AKA reason for the client’s pain) may not fully be understood.
A) Imaging typically looks at the injury site at a specific moment in time. To develop a true understanding of the pathology, this information must be examined along with the patient's subjective history and movement patterns. A common example in knee pain would be that an x-ray finding of moderate osteoarthritis of the patella is an additional finding, when the true reason for the patient's knee pain is trigger points in the quadriceps caused by suboptimal movement control.
B) Many Special Tests are not that special. A special test should look to confirm suspicions of a specific diagnosis - they should not be used initially when developing a diagnosis. We know that many special tests lack sensitivity and specificity, and as a result are not helpful in confirming the diagnosis (even with a proper history and objective exam). Nicklaus Biederwolf, a physiotherapist and researcher, has this to say about special tests specific to the shoulder: "A great lack of consistency with regard to how, when, and what special tests to use in clinical examination for shoulder differential diagnosis is evident" (2).
C) Different health care practitioners may develop different diagnoses that fit the information gathered during their assessment, and their bias. It is important to do a comprehensive assessment (including the client's previous medical history, mechanism of injury, pattern of pain, global movement patterns, and a specific joint/tissue/nervous system/vascular assessment).
2. Without imaging, we depend on clinical patterns to develop an accurate diagnosis, however similar pathologies may behave differently in the clinical setting. For example a partial thickness supraspinatus tear (one of the shoulder's rotator cuff muscles) may behave differently in one client versus other clients - and this may be for a wide variety of reasons:
A) Anatomical variations: The acromion (a protrusion on our shoulder blade, under which the supraspinatus tendon glides) come in all shapes and sizes. The same applies to the rest of our bones, and muscles/tendons in our body - we are not as symmetrical and standardized as you may think!
B) Regional Interdependence: Canadian Physiotherapists are known as 'The Movement Specialists' (3), so keep connecting the dots to determine how one area of the body may be affecting another! The thoracic spine, neck, scapula and all of its connecting muscles and ligaments alter the dynamic control and posture of the shoulder, which ultimately impact the supraspinatus tendon.
C) Variations in nociception (sensing pain): Fewer pain nerve endings near the injury site, previous injury to nerve or blood supply at the area, or differences in central nervous system perception of pain on a global level will affect how a patient feels potentially harmful stimuli.
D) Multiple injuries: A mechanism of injury that may tear the supraspinatus may also injure other tissues in the area. For example, there could also be an injury of the labrum, chondral surface of the humerus, biceps tendon, pec major, or subacromial bursa. It is nearly impossible to identify/distinguish all of these pathologies in the clinic without imaging... BUT does it really matter? Read on!
What To Do.. in a World of Unknowns?
It can all get quite confusing..
The items above paint a muddled picture: It can be quite difficult to come up with the correct diagnosis due to many(!!!) factors. Luckily, despite this fact, there are a few things we can do that will promote successful recovery.
1. It may be more important to focus on movement deficits first.
Our bodies are exceptional at healing themselves. In fact, the best athletes in the world are the ones that recover the quickest (from training, games, or injuries). Most of the time, the injured tissue will heal on their own, but will leave us with tight muscles and poor movement patterns as a result of compensation. This means that pursuing imaging and specialist appointments may just end up being a waste of time, health care dollars, and stress. To start, the patient shoulder obtain a couple of opinions (physician and physiotherapist) to determine whether medical testing may be needed. Following these opinions, it is usually best to focus on improving flexibility and movement control.
2. Zoom out; Broaden your perspective!
Often we warn patients against performing certain exercises, based on the fact that they have a certain pathology (e.g. with an acute partial tear of the supraspinatus tendon, stay away from dips or deep bench press). Take a step back and look at global movement patterns - are there any other restrictions / dysfunctions that you could work on first? In our case example: Do you need to work on thoracic mobility, activating scapular upward rotators, releasing scapular downward rotators, activating deep neck flexors, releasing posterior rotator cuff, releasing adhesions at the interface of pec major / supraspinatus / long head of biceps? Maybe a further step back would even suggest asymmetries in lower body, lower back, or neck strength/mobility.
3. Prescribing the exercise.
Suggesting that the patient does a specific exercise is not enough. Ensure that the correct exercise is performed correctly; Spend time on coaching form and don’t expect that your client knows how to do the exercise properly. Lastly, discuss the importance of correct exercise:
By changing these four variables, we can ultimately train the tissue work for its intended purpose and improve
A) Muscular endurance
B) Muscular power
C) Muscular reactivity (plyometrics)
D) Tendon loading capacity
4. Test, and Re-Test
If you've taught the exercises well, allow adequate time for a beneficial result to occur, and re-test the client's functional deficits.
5. Lastly, a client’s most effective exercises may change overtime due to movement quality, tissue quality, perceived effort/challenge, ability to recover quickly, or the applicability to sport and life specific challenges. Follow up a few weeks or months down the road to provide the best possible care to your client.
(1) Academy of Medical Royal Colleges. Exercise: The miracle cure and the role of the doctor in promoting it. AOMRC.org.uk. 2015 Feb
(2) Biederwolf, Nicklaus E. "A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature." International journal of sports physical therapy 8.4 (2013): 427.
3) Physiotherapy Alberta: About Physiotherapy. Accessed February 1, 2018. https://www.physiotherapyalberta.ca/public_and_patients/about_physiotherapy
The Great Outdoors. It is there for you to enjoy, to push your limits, and develop fortitude. For some people, going outdoors can be synonymous with developing injuries, but there are steps you can take to mitigate future injuries from taking place.
The Right Fitness Level
Greater fitness leads to a better understanding of your limits, as well as the ability to achieve greater feats. A physical assessment by a good therapist or strength and conditioning coach can help you sort through the thousands of exercises out there to know which ones are relevant to your needs.
- Slow, gradual increases in exercise and specific training are necessary (months and/or years). Our bodies adapt well to gradual stresses, but if too much load is placed on it at once, expect failure and injuries. It takes great dedication to yield great results. Most outdoor athletes peak in their 30s and 40s as they build cardiovascular endurance, muscular endurance, and a resistance to injury.
- Outdoor athletes often suffer overuse / over-training. It is important to consider whether you have proper body mechanics during training and outdoor pursuits. Have knowledgeable therapists, coaches and other athletes watch your form and provide suggestions. It is also important to include adequate cross-training, regular body maintenance (physiotherapy, massage, rolling), proper nutrition, and adequate rest.
- As a general rule there are certain joints which must be stable (strong ligamentous and muscular support around the joint, which prevents excess joint motion) and others which must have good mobility (the joint is built to be very flexible, however the muscular support around the joint must be able to control this increased range). As pertaining to lower body exercise, the core must be stable, hips must be mobile, knees must be stable, and the ankles must be mobile (Cook, Burton & Kiesel, 2010).
Try adding the following 20-minute routine into your regular workouts, three days a week. It is a small corrective exercise program built to help the user become more aware of hip / knee / ankle positioning during single leg stance. It is not meant to replace regular strength training. Rather, it should enforce the principles of joint alignment, feeling posterior chain engagement and will allow good transfer to outdoor pursuits.
A) Dynamic stretching. Perform dynamic stretching prior to exercise for 30 seconds per muscle group. A few lower body ideas include front/back and side-to-side leg swings, quick quadriceps stretches, quick piriformis/glute stretches, and hopping.
B) Airplane. At first you may need to hold onto something for balance, but eventually you should be able to progress to no hands. Goal = 10 reps per side.
C) Step-ups. Face a mirror and line up the hips and knees on the working leg to be approximately 90 degrees. Ensure that during the exercise, your knee tracks straight (not allowing it to collapse inwards or outwards). Lean forward, try to feel your glutes and hamstring fire on the upper leg then push through the heel on the working leg as you step up (this will help you to activate the posterior chain). Goal = 10 reps per side, with 2 times the expected weight of your backpack and gear.
D) Single leg star balance. Reach as far in each of the four directions as possible, while bending the stance leg at the hip and knee during the reaching phase (this leg should remain straight in line from the hip to the foot). Goal = 10 reps for each leg. 1 rep = a full cycle of the four directions.
Side note: Work to create symmetry in this test, as evidence suggests that a difference of more than 4 cm between left and right legs in ‘the forward reach’ component can help predict whether an athlete is at risk of injuring the leg (Smith, Chimera & Warren, 2014). Tip: Place masking tape on the ground and mark the distance in centimeters.
E) Piriformis rolling and pigeon stretch. 1 minute rolling, 1 minute stretch per side.
F) Lateral Quadriceps rolling and stretch. 1 minute rolling (focus on the outside of the leg), 1 minute stretch per side.
Start With The Right Intel
- Create specific training goals: How many days/hours, what gear do I need to use, am I familiar with the terrain?
- Become efficient and effective in your skill-set by learning the best decision making skills and techniques via free resources (friends, books, videos), and progressing to courses or hiring a guide.
The Right Gear
- Hiking poles take up to 25% of stress off your knees during descent (Schwameder, et al., 1999) help your legs save energy, and improve your balance on technical terrain.
- Boots that fit well can prevent crushed toes, and rolled ankles.
- Bring microspikes, mountaineering gear and/or avalanche gear if you expect snowy conditions.
Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.
Annual Check Up
Annual Physiotherapy Assessment
Functional Dry Needling