A new insight on back pain

In the early 20th century the SI joint was thought to be the main source of law back pain and was the focus of many scientific investigations. But recently two newest theories have been developed.

First, the theory of rotational malalignment known today as the Malalignment Syndrome which includes: SI joint upslip/downslip (superior/inferior shear), sacral torsion (hip anterior/posterior rotation), hip outflare/inflare (lateral/medial rotation), (Schamberger, 2002, 2006). Diagnosis of these syndromes is very straight forward, as is the treatment of each is

Second, the past 15 years, a well-known group of PTs, have been developing a newer theory that is known as the Joint-By-Joint Approach. This theory is based on understanding the primary role of the different major joints.

Of course all joints need a combination of mobility and stability, but interestingly, each joint displays a predominant need for either mobility or stability.

Lets start from the bottom which joint require mobility or stability…..

Ankles – mobility

Knees – stability

Hips – mobility

Lumbar Spine – stability

Thoracic Spine – mobility

Scapulae – stability

Shoulders – mobility

Cervical Spine (C7-C3) – stability

Cervical Spine (C2, C1) – mobility

Our CNS chooses mobility over stability depending on when we move. Another prospective , when a joint which predominantly requires mobility, reaches its mobility barrier ( it may be physiological or pathological), the surrounding joint will give up their stability to accomplish the mobility requirement. This is involuntary survival technique that is controlled by CNS.

How this above phenomenon will work with Hip and Spine lets understand.

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Proactivephysiotherapy, hamstring, assesment, lower limb

Hamstring strain due to Glute max late firing : Part 1

What is Synergistic dominance ?


It is a self-serving substitution system that allows us to carry on life even though parts of our structure . It may be slowly breaking down and decompensating.

A typical synergistic pattern often exists in runners with a unilaterally tight/hypertonic iliopsoas that is reciprocally inhibiting the ipsilateral gluteus maximus. The hamstrings and adductor magnus (synergists in hip extension) are over active to help the weakened gluteus maximus in hip extension efforts.

This pattern is one of the primary causes of hamstring pulls and is initiated by the late firing of the weakened gluteals during hip extension, especially during activities that include running.

Arthrokinetic Dysfunction :

Synergistic dominance eventually end up with Arthrokinetic Dysfunction .which is the result of prolonged alterations of

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What can be the different diagnosis?


Guideline for Rotator cuff rehabilitation

There are many school of thoughts for RC rehabilitation, here we try to make you easy understanding how to approach . While assessing the rotator cuff in person .

when patient come to us after rotator cuff repair surgery we need to fully understand his daily activities affecting their ability to their normal life. Here there are few keys that need to be consider…….

Key consideration factors in Rotator Cuff Rehab :

• age of the patient,
• activity level,
• injury to affected shoulder,
• response to previous treatment,
• imaging and what were the findings,
• past medical history,
• joint status (hypermobile or hypomobile),
• what they think is going on in their shoulder,
• most importantly is the ultimate goal of the client.


Plan for treatment……..

what do we do for people presenting some form of shoulder pain? There are many different answers but for the purpose of this, we will keep it simple that will help restore
pain free ROM, strength, and slowly return them back to their functional level.

Control on the shoulder pain :

We want to get the shoulder joint moving through self-ROM activities. We prefered patient to go for foam roll their thoracic spine and Latismus dorsi muscles to achieve overhead shoulder mobility. We will work on external rotation ROM at 45 degrees and 90 degrees of abduction.

Following this exercise we prefer to work on shoulder flexion AAROM in supine position, once gradually ROM restore we’d prefer kinetic chain activation exercise.

For strengthening,we like to begin with isometric activities to help with pain control.


When to start  higher level strengthening programme:

Once you achieve all criteria for advanced training we would like to start strengthening activities, we add isotonic strength training with  theraband  : full can, sidelying external rotation, prone horizontal abduction, prone extension and prone full can. There are Many studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities.

There are  evidance, we like to add program in our routine protocol but will change the weights, sets and reps depending on Patient tolerance during exercise.

We rarely have patients perform 3 sets of 10 repetitions so the goal of the exercise needs to be fully understood in order to prescribe it correctly.

Advanced strengthening :

Once an adequate base of strength is achieved , we will add another level of strengthening programme depending upon patient’s requirement. We also focus on proprioceptive exercise once adequate strength achieved.

For athlete , Plyometric strength training is incorporated to allow the athlete to produce a force and power in his sports activities. which will hopefully help them in their return to their sport. This may include chest press, overhead throws, and rotational throws etc…

Pull ups, push-ups, bench pressing and overhead pressing are also added to make sure the athlete is strong in multiple planes to performing his sports.

Finally,The key is knowing the ultimate goal of the athlete .there are many factors that need to be considered when returning a patient back to their highest functional level when they have a  cuff injury.

This post was my attempt at outlining a very general guideline for an athlete or non athletic poplution with a rotator cuff issue and what my thought process may be.

Remember, listen to their issues…they may just tell you what program is best for them!

Any question!!!!!!!


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Supraspinatus tendonitis : Guide to treatment

The supraspinatus is usually injured because of heavy repeated demands placed on it ,such as carrying a briefcase, laptop computer, purse, or baby carrier. It is often impinged under the acromiom due to tight pectoralis and tight subscapularis muscles.

The supraspinatus has a small superior shear component, but its main function is compression because
of the horizontal orientation of the muscle fi bers, thus, it opposes the upward superior shear action of the deltoid.

The impingement cycle is a continuum that can begin anywhere in the sequence and can cause a vicious succession.

supraspinatus from proximal to distal with forward elevation. The primary point of contact on the bursal side is at  the supraspinatus insertion throughout forward elevation. The subacromialbursa facilitates this motion and contact. It is a unique anatomic arrangement that exposes the soft tissues to wear and degeneration as the arm is elevated and rotated during range of motion of the shoulder. Furthermore, the impingement may be accelerated by any anatomic architectural changes in the acromion or acromioclavicular joint that reduce the volume of the subacromial space.  

The long head of the biceps and tendons of the rotator cuff pass through the subacromial space; these include the supraspinatus, infraspinatus, and teres minor muscles, which insert onto the greater tuberosity of the humerus. The subscapularis muscle inserts onto the lesser tuberosity. The rotator interval is created between the subscapularis and
supraspinatus tendons. All four rotator cuff tendons interlace with each other over the humeral head before inserting. This continuity allows a functional interaction of the rotator cuff.

What should you do ?

The patient will complain of posterosuperior shoulder pain. You do asses the shoulder in the first 20-30˚ of abduction. Movement beyond that is the action of

the middle deltoid, which will be painful to a resisted test above 30˚ of abduction. Also, the fibers of the supraspinatus tendon can be impinged where it runs under the acromiom process, which can cause chronic pain .



Start with the basic shoulder protocol. Concentrate on scapula muscle balance exercise. You do release the pectoralis major and minor, subclavius, upper trapezius, middle deltoid, and subscapularis. Muscular balance is essential in shoulder rehabilitation.

It is necessary to balance and release all of the muscles perticularly the pectoralis minor and subscapularis, to properly treat this condition. The enhancement between upper trapezius and lower trapezius will help to relieve pain. Most of the time while doing retraction ,patient does elevation with retraction. We should observe the movemtn pattern and break it. Concentrate on serratus activity because it is responsible for upward rotation movement.

Next follow the specific protocol for the supraspinatus including myofascial release, trigger point work, and Eccentric exercise for tendon load is also helpful.

Reassess and repeat the protocol until the client is pain-free.

To find out more on supraspinatus ……..