Can incorporating an exercise program like the Alfredson Protocol help athletes and individuals who have hurt their Achilles tendon find pain relief and healing so they can return to regular physical activities?
Exercise Protocol Achilles Tendonitis
Achilles tendonitis occurs when the tendon at the back of the ankle gets injured. It is common in runners. For individuals who have Achilles tendonitis, walking and running can be painful. You might have to stop engaging in exercise and physical activities like sports. Depending on your job, having the condition may make working harder. Here are a few of the signs and symptoms of the condition:
Pain in the back of the lower leg, just above the heel.
Pain with running, jumping, or pointing the toes.
A small lump on the Achilles tendon just above the heel.
The first line of treatment is to rest and ice the tendon. Anti-inflammatory medications can help reduce pain. (American Academy of Orthopaedic Surgeons, 2022) Physical therapy can include strengthening exercises, ultrasound heat therapy, and deep massage. Exercises stretching the nearby muscles will help gradually increase the stress the tendon can handle, eventually reducing inflammation and swelling. Stretching and flexibility exercises will help an Achilles tendon heal. (University of Michigan, 2023)
The only way to determine if an individual has injured their Achilles tendon is to see a doctor. If the injury is Achilles tendonitis, a physical therapist may be recommended. A physical therapist can train individuals on the Alfredson protocol, an exercise protocol program for those with Achilles tendonitis (tendinopathy) that research has shown is helpful for those with the condition. The therapist will train on how to exercise to strengthen the tendon. The exercises stretch the Achilles tendon to help it handle forces and stress, known as eccentric loading. (Stevens M., & Tan C. W. 2014)
Inflammation
Tendonitis is inflammation of a tendon. However, studies have shown that the tendon might not be inflamed in those with the condition. When an area of the body is inflamed, inflammatory cells are present. Individuals usually feel pain in the inflamed area. For those with Achilles tendonitis, the tendon will present with pain, but not necessarily because the tendon is inflamed. Under a microscope, researchers examined tissue from the tendons of those with Achilles tendonitis. They did not find inflammatory cells in the tissue. (Stevens M., & Tan C. W. 2014) This means that although individuals felt pain, they were not inflamed. If there are no inflammatory cells in the tendon, this could explain why those with Achilles tendonitis often do not find relief from the anti-inflammatory treatment of non-steroidal anti-inflammatory drugs (NSAIDs). Studies have shown that gentle exercise protocols for the tendon are more helpful. However, researchers are not sure why these exercises are so beneficial. (O’Neill S., Watson P. J., & Barry S. 2015)
Eccentric Exercise
A chiropractic physical therapy team can help individuals heal the injury with eccentric loading exercises. Eccentric loading exercises work the muscles and tendons to help them get stronger. Once healing has begun, they can help strengthen the tendon. Individuals start slowly with easy exercises and then work up to harder ones. They will have the patient lengthen or stretch out the muscle. As the patient moves, the muscles and tendons contract or shorten. The Alfredson protocol consists of eccentric loading exercises for the Achilles and the muscles that support it.
Alfredson Protocol
Before exercising, talk to a doctor or physical therapist to know if it’s safe. How to do the Alfredson protocol:
First, stand on a small step or curb.
Stand with the balls of your feet on the edge.
Your heels should hang over the edge.
Hold onto something for balance.
Keep the knees straight.
This will load a muscle part of the Achilles tendon called the gastrocnemius.
Using both feet, lift the heels and rise onto the balls of the feet.
Keep the foot with the painful Achilles tendon on the step.
Lift the non-injured foot off the step.
Slowly lower down using the injured ankle.
The heel should move towards the floor.
The ball of the foot should remain in contact with the edge of the step.
Return the non-injured foot to the step.
Repeat the exercise.
Do three sets of 15 reps with the knees straight. Then, do the Alfredson protocol again with the knees slightly bent. This will work a muscle called the soleus, which connects to the gastrocnemius. Perform three sets of 15 repetitions. Perform both exercises twice a day. This could be in the morning and the evening. The Alfredson protocol is most beneficial when done for about 12 weeks. (Stevens M., & Tan C. W. 2014)
Injury Medical Chiropractic and Functional Medicine Clinic
The Alfredson exercise protocol can be done at home with a step or raised platform to put the feet on safely. Individuals should consider working with a personal trainer to ensure safety and get the most out of the workouts. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.
American Academy of Orthopaedic Surgeons. OrthoInfo. (2022). Achilles Tendinitis. https://orthoinfo.aaos.org/en/diseases–conditions/achilles-tendinitis/
University of Michigan. (2023). Achilles Tendon Injury: Physical Therapy and Rehab. https://www.uofmhealth.org/health-library/tr2261
Stevens, M., & Tan, C. W. (2014). Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy, 44(2), 59–67. https://doi.org/10.2519/jospt.2014.4720
O’Neill, S., Watson, P. J., & Barry, S. (2015). WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY?. International journal of sports physical therapy, 10(4), 552–562.
Can cervical retraction be a good addition to a home exercise program for individuals with neck pain, spinal arthritis, or needing to strengthen their neck muscles?
Cervical Retraction
Cervical retraction is a neck exercise that involves gently sliding the head backward while keeping the chin tucked. It can help with:
Neck pain
Stretching and loosening the muscles at the back of the neck.
Headaches
Tightness
Improve posture
Improve flexibility and mobility
Preparation
Basic steps for performing a cervical retraction exercise:
Sit upright with good posture.
Tuck your chin as far as you can comfortably.
Look up while keeping your chin tucked.
Rotate the neck 1-2 inches to each side.
Return to the starting position.
Stop the exercise if you experience pain.
You want to get good at this without loading the joints while learning the movement. Gently and accurately moving your head in alignment with the neck will help you find the correct head action as it moves. Then, it can be performed as a full exercise. Performing the movement correctly requires focus. This is why cervical retraction is done while sitting in a chair with proper posture. Individuals can also stand, but it is more complicated for the body to coordinate than sitting, but it can be done once the individual has practiced.
Sitting or Standing
Gently tuck your chin down toward your neck.
The focus is alignment.
Keeping your chin where it is, press your head back.
There will be soreness, especially for those with pain symptoms, but the neck should feel better.
Be mindful of any intense or severe pain resulting from cervical retraction.
Individuals with cervical spondylosis (neck arthritis) stop if pain presents. (Cleveland Clinic, 2023)
Other Neck Exercises
Another good neck-strengthening exercise is the isometric neck press. In this exercise, you move your head forward, backward, and to each side while your hand provides resistance. This develops flexibility and is recommended for those with arthritis in this area. (Sadeghi, A. et al., 2022) Other exercises include: (Pain Consultants of West Florida, 2019)
Neck extensions: Backward bending can help relieve nerve compression and ease the strain on the cervical spine.
Side rotation: This exercise can improve neck mobility.
Shoulder rolls: This exercise can help keep the neck and shoulder joints fluid.
Injury Medical Chiropractic and Functional Medicine Clinic
If you have a neck condition or radiculopathy that causes pain or other symptoms going down the arm or are unsure how to do it, check with a healthcare provider or physical therapist before trying the exercise. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.
Neck Injuries
References
North American Spine Society. (2012). Cervical exercise: The Backbone of Spine Treatment. https://www.spine.org/KnowYourBack/Prevention/Exercise/Cervical-Exercise
Cleveland Clinic. (2023). Could your neck pain actually be neck arthritis? https://my.clevelandclinic.org/health/diseases/17685-cervical-spondylosis
Pain Consultants of West Florida. (2019). Chronic Neck Pain: How Core Exercises Can Help. Our Blog. https://pcwfl.com/chronic-neck-pain-how-core-exercises-can-help/
Sadeghi, A., Rostami, M., Ameri, S., Karimi Moghaddam, A., Karimi Moghaddam, Z., & Zeraatchi, A. (2022). Effectiveness of isometric exercises on disability and pain of cervical spondylosis: a randomized controlled trial. BMC sports science, medicine & rehabilitation, 14(1), 108. https://doi.org/10.1186/s13102-022-00500-7
For individuals going through post surgery, injury rehabilitation, illness and/or chronic condition management, can physical therapy isometric exercises help?
Isometric Exercise
Isometric exercises are used in physical therapy to help build muscle endurance, improve range of motion, relieve pain, and reduce blood pressure more effectively than other types of exercise. Because they don’t involve joint movement, they are a solid starting point for rehabilitation and are suitable for individuals with a limited range of motion. They can be performed by pushing against an immovable object, like a wall, or by having a therapist provide resistance. Examples of isometric exercises include:
A physical therapist/PT may have a patient perform isometric exercises after injury or illness. During an isometric contraction, the muscle does not change in length, and there is no motion around the joint surrounding the muscle/s. (Rhyu H. S. et al., 2015)
When To Use
Isometric muscular contractions can be used at any time during physical rehabilitation and strengthening or a home exercise program and are regularly used with the following (Rhyu H. S. et al., 2015)
Post-surgery
When muscles cannot contract forcefully enough to move the joint it surrounds.
To help increase neuromuscular input to a specific muscle/s.
When injury or condition frailty makes other forms of exercise dangerous and not beneficial.
A healthcare provider or physical therapist should be consulted first if isometrics are used in a rehabilitation program.
Benefits
The benefits of using isometric exercise after injury or surgery may include the following:
No special equipment is necessary to perform isometric exercises.
The ability to safely contract a muscle while protecting a surgical incision or scar tissue.
The muscles can be strengthened in a specific range of motion around a joint. (NikolaidouO. et al., 2017)
A physical therapist can help determine whether isometric exercise benefits the specific condition.
Effectiveness
Isometric exercise is very effective after injury or surgery. However, when a muscle is contracted isometrically, it gains strength in a very small area and with a short range of motion. For example, an isometric shoulder external rotation performed with the arm at the side will only strengthen the rotator cuff muscles in the specific position that the arm is in. (NikolaidouO. et al., 2017).
Strength gains are specific to the joint’s position during the exercise.
Individuals who want to strengthen their gluteal muscles in their hip using isometrics would have to contract their glute muscles in one specific position for several reps.
Once several reps of the exercise in one position have been performed, the individual moves their hip joint into a new position and repeats the gluteal contractions in the new position.
This makes the exercise time-consuming, but it is perfect for injury rehabilitation, preventing and avoiding worsening or further injuries.
How to Perform
To perform isometric exercises, all that is needed is something stable to push against. (Rhyu H. S. et al., 2015) For example, to strengthen the shoulder muscles:
Stand next to a wall and try to lift an arm out to the side.
Allow the hand to press against the wall so no motion occurs at the shoulder joint.
Once pressed against the wall, hold the contraction for 5 to 6 seconds and slowly release it.
Perform 6 to 10 repetitions of the exercise.
This could be one set of completed isometric exercises for the shoulder muscles.
Elastic resistance bands or tubing can also be used to perform isometric exercises. Hold the tubing in a specific position and then move the body away from the anchor point instead of moving the joint. The muscles will contract against the increased resistance of the elastic tubing, and no motion will occur at the joint. A physical therapist can show and train on how to perform isometric exercises with the bands.
Neuromuscular Stimulation
Isometric exercise can strengthen muscles and help improve the neuromuscular recruitment of the muscles being trained. This enhances muscle contraction and expedites gains in muscle recruitment while protecting the joint. Isometric exercise can also be used during physical therapy using neuromuscular electrical stimulation (NMES). (Fouré A. et al., 2014) For example, a PT may use NMES to improve muscular function for individuals who have difficulty contracting their quadriceps after knee surgery and may be instructed to perform isometric quad-setting exercises during the session.
Injury Medical Chiropractic and Functional Medicine Clinic
A physical therapist can use isometric exercises to help individuals injured or have had surgery and are experiencing difficulty with normal functional mobility by improving their strength during recovery. The exercises can safely enhance the function and stability of the muscles and return individuals to the previous level of activity and function. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.
Personal Injury Rehabilitation
References
Rhyu, H. S., Park, H. K., Park, J. S., & Park, H. S. (2015). The effects of isometric exercise types on pain and muscle activity in patients with low back pain. Journal of Exercise Rehabilitation, 11(4), 211–214. https://doi.org/10.12965/jer.150224
Nikolaidou, O., Migkou, S., & Karampalis, C. (2017). Rehabilitation after Rotator Cuff Repair. The Open Orthopaedics Journal, 11, 154–162. https://doi.org/10.2174/1874325001711010154
Fouré, A., Nosaka, K., Wegrzyk, J., Duhamel, G., Le Troter, A., Boudinet, H., Mattei, J. P., Vilmen, C., Jubeau, M., Bendahan, D., & Gondin, J. (2014). Time course of central and peripheral alterations after isometric neuromuscular electrical stimulation-induced muscle damage. PloS one, 9(9), e107298. https://doi.org/10.1371/journal.pone.0107298
Individuals with hip bursitis often experience discomfort during physical activity, walking, and pain when lying on the affected side. What treatment options are available to control and manage the condition?
Hip Bursitis
Hip bursitis, also known as trochanteric bursitis, is a common condition that causes pain and discomfort in the hip and upper thigh along the outside of the hip joint. It occurs when one of the hip’s bursae, or fluid-filled sacs cushion joints, becomes inflamed. Treatment for hip bursitis is to control the inflammation caused by this condition.
Causes
Hip bursitis can be caused by injury or overuse of the hip, such as repetitive activities, twisting, or rapid joint movement. It can also be caused by a direct blow or fall to the side of the hip.
Symptoms
Pain from hip bursitis can be sharp at first and may feel dull and achy later.
It may be worse when standing up after sitting, moving, or using the hip.
Individuals may also notice pain when lying on the affected side or sitting for a long time.
Rest
This means a period of not participating in physical, exercise, and sports activities that aggravate symptoms. Any activity that causes hip pain should be avoided as this only contributes to inflammation of the bursa. (American Academy of Orthopaedic Surgeons, 2022) Modifying how particular activities are performed can help alleviate pressure on the inflamed bursa. Working with a physical therapist can also be recommended. They are experts in movement and alignment, and if certain muscles are overused compared to others, this can lead to unhealthy movement patterns, causing bursa irritation.
Anti-Inflammatory Medications
Nonsteroidal anti-inflammatory drugs, such as Motrin, Aleve, Naprosyn, etc., will help control inflammation (American Academy of Orthopaedic Surgeons, 2022). Anti-inflammatory medications can be extremely effective but should be taken cautiously. The instructions on the label need to be followed unless directed otherwise by a healthcare provider. Be aware of side effects and inform the healthcare provider if side effects present.
Cold Therapy
Applying ice to the hip area often helps alleviate the symptoms (National Library of Medicine, 2022). Ice can control inflammation by decreasing blood circulation to the area, especially after physical activity and exercise.
Aspiration
A needle is placed into the bursa to drain the fluid for those with a significant amount of fluid collected within the bursa. (National Library of Medicine, 2022) This is rarely needed in cases of hip bursitis, but when it is done, it can be combined with a cortisone injection.
Cortisone Injections
A cortisone injection may also be given into the bursa to alleviate pain. (American Academy of Orthopaedic Surgeons, 2022) The cortisone injection is helpful because it can be a diagnostic and therapeutic tool. In cases where hip bursitis may be one of several diagnoses being considered, cortisone can be given to see if it helps alleviate symptoms. Cortisone is a powerful anti-inflammatory medication that can be administered directly to the problem area. These injections are well-tolerated, but there can be possible side effects. Once the initial symptoms are under control, physical therapy strengthening and stretching exercises may be recommended.
Stretching
Most find relief by stretching the muscles and tendons over the outside of the hip, specifically the iliotibial band. The goal is for a better-conditioned muscle and tendon to glide more easily and not cause inflammation. Proper stretching techniques and posture are important in re-injury prevention.
Physical Therapy
Working with a physical therapist is an effective adjunct treatment for bursitis (American Academy of Orthopaedic Surgeons, 2022). Physical therapists correct muscle imbalances through stretching and exercise and improve alignment to prevent bursa irritation from reoccurring.
Surgery
Most patients get better with conservative treatment within about six weeks. Surgical treatment for hip bursitis is rarely needed (UCSF Health, 2024). Those who do not rest from their activities until the inflammation subsides often have a return of bursitis symptoms, and those who return too aggressively to activities and do not gradually build up also find that their symptoms return. In cases where surgery is needed, the healthcare provider may recommend an arthroscopic bursectomy. (American Academy of Orthopaedic Surgeons, 2022) The surgery is an outpatient minimally invasive procedure in which the bursa is removed through a small incision. After a short healing period, the individual can return to normal activity. Crutches may be used for a few days. Common complications are anesthetic-related complications and infection.
Injury Medical Chiropractic and Functional Medicine Clinic
As with any treatment program, always talk with your healthcare provider before initiating specific treatments. Fortunately, treatment of hip bursitis is generally accomplished with conservative therapies. Efforts to limit pressure directly on the bursa, alleviate inflammation, and restore normal movement to the hip joint will typically resolve symptoms. At Injury Medical Chiropractic and Functional Medicine Clinic, we focus on what works for you to relieve pain and restore function. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other associated medical professionals to integrate into a treatment plan to improve the body’s flexibility and mobility, resolve musculoskeletal issues, and prevent future pain symptoms from reoccurring.
The Chiropractic Approach for Pain Relief
References
American Academy of Orthopaedic Surgeons. (2022). Hip bursitis. https://orthoinfo.aaos.org/en/diseases–conditions/hip-bursitis
National Library of Medicine. (2022). Bursitis: Learn More – How can bursitis be treated? InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG). https://www.ncbi.nlm.nih.gov/books/NBK525763/
For individuals trying to lose weight or improve their diet, can incorporating more fish help improve overall health?
Fish Nutrition
The American Heart Association recommends eating at least two servings of fish each week (American Heart Association, 2021). The type of fish chosen makes a difference, as fish nutrition and calories vary. Some can have a higher calorie count but contain healthy fat.
Nutrition
Comparing fish calories and nutrition data can be tricky. How it is prepared can significantly change its nutritional makeup, and the exact nutrition also varies depending on the variety. As an example, a half portion of a Wild Alaskan Salmon Fillet contains: (U.S. Department of Agriculture. FoodData Central. 2019)
Serving Size 1/2 fillet – 154 grams
Calories – 280
Calories from Fat – 113
Total Fat – 12.5 grams
Saturated Fat – 1.9 grams
Polyunsaturated Fat – 5 grams
Monounsaturated Fat – 4.2 grams
Cholesterol – 109 milligrams
Sodium – 86 milligrams
Potassium – 967.12 milligrams
Carbohydrates – 0 grams
Dietary Fiber – 0 grams
Sugars – 0 grams
Protein – 39.2 grams
The following guide includes other types of fish based on USDA nutrition data (U.S. Department of Agriculture. FoodData Central). Fish calories and nutrition are listed for a 100-gram or 3.5-ounce serving.
Halibut
Raw with skin
116 calories
3 grams fat
0 grams carbohydrate
20 grams protein
Tuna
Yellowfin, fresh, raw
109 calories
Less than one gram of fat
0 grams carbohydrate
24 grams protein
Cod
Atlantic, raw
82 calories,
0.7 grams fat
0 grams carbohydrate
18 grams protein
Mahimahi
Raw
85 calories
0.7 grams fat
0 grams carbohydrate
18.5 grams protein
Ocean Perch
Atlantic, raw
79 calories
1.4 grams fat
0 grams carbohydrate
15 grams protein
Research suggests that fatty fish is the best for weight loss and improved health. Certain types of fish contain an essential fatty acid called omega-3. This polyunsaturated fat provides the body with various health benefits, like reducing the risk of heart disease. Studies show that individuals who eat seafood at least once per week are less likely to die from heart disease. (National Institutes of Health. National Center for Complementary and Integrative Health, 2024) Researchers also believe that omega-3 fatty acids may help reduce symptoms of rheumatoid arthritis and could even improve brain and eye health. Essential omega-3 fatty acids can be taken as a supplement. However, research has not shown that supplements can provide the same benefits as eating omega-3 foods. (Rizos E. C. et al., 2012)
The way that the fish is prepared can change the calorie count. Baked, grilled, and broiled fish are usually the lowest in calories.
Storage and Safety
Fish experts suggest that individuals buy the freshest available. What questions should you ask when visiting the local market?
When was it caught?
The fresher, the better. Fish may remain edible for five days after being caught but may not taste as fresh.
How was it stored?
How the fish is stored and delivered to the market will impact its taste. Fish should be chilled immediately after catching and kept cold throughout delivery and transport.
How does it look and smell?
If the fish has a bad odor, it is likely not fresh. Fresh fish should smell like seawater. If buying fillets, look for a moist texture with clean-cut edges. If the fish is whole, look for clear eyes and a firm texture.
Where is it from?
Buying local fish from sustainable fisheries is recommended but not always possible, depending on where individuals live. There is a Smart Seafood Buying Guide that advises on buying American fish and provides a list of fish with lower mercury levels for health and safety. (Natural Resources Defense Council, 2024)
What is the best way to prepare this fish?
Sometimes, the fishmonger is the best source for simple and healthy recipes and preparation methods. Use fresh fish within two days, or store in the freezer. When ready to use frozen fish, thaw in the refrigerator and never at room temperature. For individuals who don’t like fish taste, there are a few things to help improve the taste. First, try less fishy types. For example, many report that around 100 calories per serving of red snapper tastes less fishy than heavier fish like salmon. Second, try adding fresh herbs and citrus to manage the taste.
Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop a personalized treatment plan through an integrated approach to treating injuries and chronic pain syndromes, improving flexibility, mobility, and agility programs to relieve pain and help individuals return to optimal function. Our providers use an integrated approach to create personalized care plans for each patient and restore health and function to the body through nutrition and wellness, functional medicine, acupuncture, Electroacupuncture, and sports medicine protocols. If the individual needs other treatment, they will be referred to a clinic or physician best suited for them. Dr. Jimenez has teamed up with top surgeons, clinical specialists, medical researchers, nutritionists, and health coaches to provide the most effective clinical treatments.
Nutrition Fundamentals
References
American Heart Association. (2021). Fish and Omega-3 Fatty Acids. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/fish-and-omega-3-fatty-acids
U.S. Department of Agriculture. FoodData Central. (2019). Fish, salmon, king (chinook), raw (Alaska Native). Retrieved from https://fdc.nal.usda.gov/fdc-app.html#/food-details/168047/nutrients
National Institutes of Health. National Center for Complementary and Integrative Health. (2024). 7 things to know about omega-3 fatty acids. Retrieved from https://www.nccih.nih.gov/health/tips/things-to-know-about-omega-fatty-acids
Rizos, E. C., Ntzani, E. E., Bika, E., Kostapanos, M. S., & Elisaf, M. S. (2012). Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA, 308(10), 1024–1033. https://doi.org/10.1001/2012.jama.11374
Natural Resources Defense Council. (2024). The smart seafood buying guide: five ways to ensure the fish you eat is healthy for you and for the environment. https://www.nrdc.org/stories/smart-seafood-buying-guide
Individuals who have gone through recent low back surgery, like a lumbar laminectomy and discectomy, could they benefit from physical therapy for full recovery? (Johns Hopkins Medicine. 2008)
Rehabilitation Exercise Program
A lumbar laminectomy and discectomy is a surgical procedure performed by an orthopedic or neurologic surgeon to help decrease pain, relieve associated symptoms and sensations, and improve flexibility and mobility. The procedure involves cutting away disc and bone material that presses against, irritates, and damages the spinal nerves. (Johns Hopkins Medicine. 2023)
Post-Surgery
The therapist will work with the individual to develop a rehabilitation exercise program. The objective of a rehabilitation exercise program is to help the individual:
Relax their muscles to prevent muscle tensing and becoming over-cautious
Regain full range of motion
Strengthen their spine
Prevent injuries
A guide on what to expect in physical therapy.
Postural Retraining
After back surgery, individuals have to work to maintain proper posture when sitting and standing. (Johns Hopkins Medicine. 2008)
Postural control is important to learn as it maintains the lower back in the optimal position to protect and expedite the healing of lumbar discs and muscles.
A physical therapist will teach the individual how to sit with proper posture and use lumbar support.
Attaining and maintaining proper posture is one of the most important things to help protect the back and prevent future back problems.
Walking helps to improve cardiovascular health and blood circulation throughout the body.
This helps to provide added oxygen and nutrients to the spinal muscles and tissues as they heal.
It is an upright exercise that puts the spine in a natural position, which helps to protect the discs.
The therapist will help set up a program tailored to the individual’s condition.
Prone Press Up
One of the exercises to protect the back and lumbar discs is prone press-ups. (Johns Hopkins Medicine. 2008) This exercise helps keep the spinal discs situated in the proper position. It also helps to improve the ability to bend back into lumbar extension.
To perform the exercise:
Lie facing down on a yoga/exercise mat and place both hands flat on the floor under the shoulders.
Keep the back and hips relaxed.
Use the arms to press the upper part of the body up while allowing the lower back to remain against the floor.
There should be a slight pressure in the lower back while pressing up.
Hold the press-up position for 2 seconds.
Slowly lower back down to the starting position.
Repeat for 10 to 15 repetitions.
Sciatic Nerve Gliding
Individuals who had leg pain coming from the back prior to surgery may have been diagnosed with sciatica or an irritation of the sciatic nerve. Post-surgery, individuals may notice their leg feels tight whenever straightening it out all the way. This could be a sign of an adhered/trapped sciatic nerve root, a common problem with sciatica.
After lumbar laminectomy and discectomy surgery, a physical therapist will prescribe targeted exercises called sciatic nerve glides to stretch and improve how the nerve moves. (Richard F. Ellis, Wayne A. Hing, Peter J. McNair. 2012)
Nerve glides can help free the stuck nerve root and allow for normal motion.
To perform the exercise:
Lie on the back and bend one knee up.
Grab underneath the knee with the hands.
Straighten the knee while supporting it with the hands.
Once the knee is fully straightened, flex and extend the ankle about 5 times.
Return to the starting position.
Repeat the sciatic nerve glide 10 times.
The exercise can be performed several times to help improve how the nerve moves and glides in the lower back and leg.
Supine Lumbar Flexion
After surgery, gentle back flexion exercises can help safely stretch the low-back muscles and gently stretch the scar tissue from the surgical incision. Supine lumbar flexion is one of the simplest exercises to improve lumbar flexion range of motion.
To perform the exercise:
Lie on the back with the knees bent.
Slowly lift the bent knees towards the chest and grasp the knees with both hands.
Gently pull the knees toward the chest.
Hold the position for 1 or 2 seconds.
Slowly lower the knees back to the starting position.
Perform for 10 repetitions.
Stop the exercise if experiencing an increase in pain in the lower back, buttocks, or legs.
Hip and Core Strengthening
Once cleared, individuals can progress to an abdominal and core strengthening program. This involves performing specific motions for the hips and legs while maintaining a pelvic neutral position. Advanced hip strengthening exercises help generate strength and stability in the muscles that surround the pelvic area and lower back. A physical therapist can help decide which exercises are recommended for the specific condition.
Return-to-Work and Physical Activities
Once individuals have gained an improved lumbar range of motion, hip, and core strength, their doctor and therapist may recommend working on specific activities to help them return to their previous level of work and recreation. Depending on job occupation, individuals may need to:
Work on proper lifting techniques.
Require an ergonomic evaluation if they spend time sitting at a desk or workstation.
Some surgeons may have restrictions on how much an individual can bend, lift, and twist from two to six weeks after surgery.
Low-back surgery can be difficult to rehab properly. Working with a healthcare provider and physical therapist, individuals can be sure to improve their range of motion, strength, and functional mobility to return to their previous level of function quickly and safely.
Ellis, R. F., Hing, W. A., & McNair, P. J. (2012). Comparison of longitudinal sciatic nerve movement with different mobilization exercises: an in vivo study utilizing ultrasound imaging. The Journal of orthopaedic and sports physical therapy, 42(8), 667–675. https://doi.org/10.2519/jospt.2012.3854
A big part of sports is avoiding and preventing injuries, as injury prevention is far better than rehabilitation and recovery. This is where prehabilitation comes in. Prehabilitation is a personalized, constantly evolving, and developing strengthening exercise program. The program aims to provide sports-specific targeted exercises and activities to maintain athletes’ physical abilities and mental preparedness for their sport. The first step is for an athletic trainer, sports chiropractor, and physical therapist to examine the individual.
Prehabilitation
Everybody is different when it comes to developing an effective prehabilitation program. Every individual’s program should be progressive and re-evaluated to adapt and adjust to the athlete’s needs. The first step is learning to prevent injuries and following basic injury prevention protocols. Knowing what to do when the body sustains an injury, like home treatment and when it’s time to see a doctor.
Athletes
Athletes of all levels are recommended to incorporate a prehabilitation program into their training. As athletes engage in their sport, their bodies adjust to the physical demands of practicing, playing, and training. Imbalances can happen naturally with normal activity but become more pronounced with each practice, game, and training session and often are the cause of injury. The repetitive movements and regular stresses can cause neuromusculoskeletal symptoms to present. This includes:
Tightness of muscle groups.
Pain and discomfort symptoms.
Stabilization issues.
Strength imbalances.
Program
A chiropractic therapist will measure the individual’s range of motion and strength, biomechanics, evaluate medical history, and present health status. Individuals with an injury or a condition can also benefit from prehabilitation.
Each program is personalized and will address total body balance, sports-specific needs, and weaknesses.
The exercises will balance strength, coordination, range of motion, and stabilization.
The premise is looking at and comparing movements from left to right, front to back, and upper to lower body.
Activities can be subtle, focused exercises or a complex movement sequence to stabilize or improve a specific skill.
Programs focus on strengthening and stabilizing the core, abdominals, hips, and back.
Instability is common and often presents from a lack of core training, as athletes tend to focus on what parts of the body their specific sport utilizes, leaving the core without a regular training routine.
A prehabilitation program has to be constantly updated to adjust to the individual’s progress.
Tools like foam rollers, balance boards, weights, and exercise balls are used.
Training
Prehabilitation should start before any acute or chronic injury occurs, but often it takes a few injuries for individuals to decide to get into a prehabilitation program. Depending on an athlete’s training cycle, prehabilitation can be incorporated into practice or as an independent workout and become part of an athlete’s training routine. A session can include the following:
Warm-up and cool-down exercises.
Exercises to perform while resting or waiting during practice.
A targeted workout on specific weaknesses.
A complete workout for days off or active rest days.
Mini workouts for when traveling and recovery days.
For athletes, feeling challenged and motivated can be the difference between success and failure. Working with a trainer, sports chiropractor, and therapists who know sports, understand athletic needs, and communicate well, will contribute to a successful prehabilitation program.
Improving Athletic Performance
References
Durrand, James et al. “Prehabilitation.” Clinical medicine (London, England) vol. 19,6 (2019): 458-464. doi:10.7861/clinmed.2019-0257
Giesche, Florian, et al. “Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review.” PloS one vol. 15,10 e0240192. 28 Oct. 2020, doi:10.1371/journal.pone.0240192
Halloway S, Buchholz SW, Wilbur J, Schoeny ME. Prehabilitation Interventions for Older Adults: An Integrative Review. Western Journal of Nursing Research. 2015;37(1):103-123. doi:10.1177/0193945914551006
Smith-Ryan, Abbie E et al. “Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation.” Journal of athletic training vol. 55,9 (2020): 918-930. doi:10.4085/1062-6050-550-19
Vincent, Heather K, and Kevin R Vincent. “Rehabilitation and Prehabilitation for Upper Extremity in Throwing Sports: Emphasis on Lacrosse.” Current sports medicine reports vol. 18,6 (2019): 229-238. doi:10.1249/JSR.0000000000000606
Vincent, Heather K et al. “Injury Prevention, Safe Training Techniques, Rehabilitation, and Return to Sport in Trail Runners.” Arthroscopy, sports medicine, and rehabilitation vol. 4,1 e151-e162. 28 Jan. 2022, doi:10.1016/j.asmr.2021.09.032
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