Anterior (Front) Hip Pain

Anterior hip pain exercises: (a full write up with explanations later)

Here are some exercises which I would recommend for someone suffering from anterior hip pain related to psoas dysfunction:

Self Psoas release: Prone with a baseball/tennis ball pinning the psoas (or your fist).  Lift your leg up to complete the pin/stretch.

Hip flexor stretch (Hold for 30-60 seconds): Make sure to tuck your pelvis under you, thereby flattening your lower back, to stabilize your spine and provide a base of which to stretch the muscle properly)

Plank 8x20 seconds, progress to 6x30 seconds, progress to 4x45 seconds, progress to 3x60 seconds.  Listen to your body and listen to your physical therapist when to progress your exercises

Elevated bridge dips with a band around the knees. 3sets of 15 repetitions

side lying leg raise: 3 sets of 15 repetitions

side plank with clams: 3 sets of 15 repetitions.

You can perform all three sets of these exercises or you can circuit the exercises (plank-dips-leg raise-clams, plank-dips-leg raise-clam, plank-dips-leg raise-clam)

Exercises for Low Back Pain

Here are some exercises which I would recommend for someone experiencing low back pain. These exercises should not hurt. If these exercises do bother you, I would suggest reviewing the videos to make sure you are doing it properly, and consult a physical therapist or your medical doctor. 

Bridge 2-3x (10x10sec hold) . Try and get your heels as close as you can to your bottom. Start by pulling your belly button in to your spine. Dig your heels into the ground to activate your quadriceps and turn your hamstrings off (especially if your get a hamstring cramp). The motions should be lift your toes up, pull belly button in, lift slowly, and lower slowly. 

HS stretch 2 minute stretch

calf stretch 60 second hold

side lying leg raise 3x15

clams 3x15

Plank 8x20sec. progress to 6x30sec. Progress to 4x45 sec. Progress to 3x1min

Rough Exercises for Supraspinatus

Exercises for Supraspinatus tear

Here are some exercises designed for a general rotator cuff tear. These are somewhat advanced exercises, so be aware, you should NOT have any pain while doing these exercises. If you have any pain with these exericses, avoid the exercise and contact your physical therapist or medical doctor. All rotator cuff exercises must begin with strengthening the scapula. If the scapular muscles are not strong, then the shoulder muscles and namely the rotator cuff will have to work even harder to compensate for the weakness.


Scap Squeezes to be performed throughout the day. 5x10. Either form will work.  If you don't have a band, if you lie down on the floor facing down, you can perform the second version of this exercise.

Rows. A very important exercise to work the scapular stabilizers. Try to squeeze your shoulder blades together first prior to performing the row.  This is called setting the scapula prior to performing the exercise.  3x15

Prone Y. This one may hurt, so be aware that you shouldn't have any pain. The goal with this exercise is to squeeze the shoulder blades together down your back. 3x10

Prone T: Here are two forms. One where you hold the position and one where you lift the arms up and down. For a hold, try to hold the position for 20-30 seconds. For repetitions, try to perform 3x15.
Also, there are two ways to do the exercise and it is recommended that you do both. Once with your thumbs pointed up toward the ceiling as seen in this first video. And once with your thumbs pointed down toward the ground as seen in the third video.

Wall angels. This exercise starts to incorporate range of motion of the shoulder while using scapular stability. Perform this exercise slowly and deliberately. 3x10

 ER at 0. I prefer this to be eccentric in the early stages of treatment, but without showing you how to do this, it could get confusing. So as long as this doesn't cause you any pain, then it can be done this way.  3x10

ER at 90. Again, this should not cause you any pain.  Try 3x10

Exercises for Anterior Shoulder Dislocation

Anterior Shoulder Dislocations

This is the history of a young athlete who fell backward and caught himself by falling onto his elbow. 

He reports having his shoulder pop out of its socket and breaking the major bone in his arm. (We would call it a Left shoulder anterior dislocation compounded with a 3 part Fracture of Left Humerus). 

He reports having some muscle atrophy/wasting and some possible resection of muscles during ORIF Surgery to stabilize fracture.

After the surgery he felt some unstable motions from subtle movements for a few months which he doesn’t feel anymore. Physical therapy gave him a few exercises, which he performed with band and did a lightly weighted pendulum for exercise.  He also included self-stretching. One year later he had an additional surgery to remove the internal fixation (pins, screws, and metal plates that were used to stabilize the area). He says he feels more mobility after the second surgery, which he reports as a good thing. He reports that now, he feels overall 75% better from the time of the accident.  Currently he is not comfortable doing active sports or doing anything to threaten another shoulder dislocation. “I don’t try to exert my arm much. I feel that the motion is pretty normal.  I can sleep on my left side in a modified position without pain.  But wearing a backpack irritates the surgical site and I have not done a push-up or pull-up yet.” He says he can pick up heavy objects, but he doesn’t risk it by trying anything crazy. His goal is to do push-ups and pull-ups and is interested in developing a strengthening program so that he can feel normal again.

When I see a history like this, my first thought goes to the structure of the shoulder itself.  So lets talk about that first.  The shoulder is made up of essentially two bones, the humerus and the scapula (shoulder blade). The shoulder blade is connected to the body primarily with muscles, but does have one bone-bone joint, but that is beyond the purpose of this article.

 

The shoulder blade, where it connects to the shoulder is called the glenoid.  

We all know from experience that the shoulder was built for full range of motion, so that we can reach overhead, behind us, across our body, etc.  Anatomically we can see this by looking at the congruency of the humerus to the glenoid.  The best analogy that I can give for this joint is the humerus is to the glenoid as a golf ball is to a tee. 

There really isn’t much congruency between the two bones, which means that without proper muscle control, the shoulder would literally just fall out.  There is a jelly like structure which surrounds the edge of the glenoid, called the labrum. The labrum increases the congruency of the two bones, and provides some passive stability to the shoulder by acting like glue. Often times when there has been a dislocation, or a fracture and dislocation, there will be some damage to the labrum.  

As I mentioned, the glenoid labrum provides some (albeit minimal) passive stability to the shoulder, so a tear within the labrum, could lead to a person feeling constantly unstable. There are some that say that a labral tear is very painful, and there are others that say that the labrum doesn’t have many nerve endings and therefore isn’t that painful.  But in the case of this patient, there was no mention of a labral tear, and we must assume the doctors would notice if there was one, so we will leave this issue for now. 

I want to repeat (to stress importance) that without proper muscle function, the shoulder would just fall out.  Therefore, I want to take a minute to describe what proper muscle function is, and maybe a little about the anatomy of the shoulder.  The body, when talking about muscles, could be divided into different categorizations.  Stabilizing vs mobilizing/movers. Superficial vs deep. Large vs small. One joint vs two joint. When talking about feeling unstable, we will consider the classification of stabilizers vs movers (Or mobilizers, which sounds way better). The larger muscles of the shoulders, namely the showy ones which you see most body builders working out – 

pecs (pectoralis major)

lats (latissimus dorsi)

  

delts (deltoids), 

biceps, triceps 

are considered the movers or mobilizers of the shoulder.  The smaller, deeper muscles – infraspinatus, supraspinatus, subscapularis, teres minor –

are a part of the rotator cuff and are used for stabilizing the shoulder.

When a shoulder pops out the front of the body, we call it an anterior dislocation. If the shoulder goes back in on it’s own, we don’t call it a dislocation but a subluxation. In order to protect the shoulder from future anterior subluxations or dislocations, we need to strengthen the muscles on the front of the shoulder.  It is more important to target strengthening the stabilizers than strengthening the movers during rehabilitation.  If we use a heavy weight, we will be targeting the movers of the shoulder and not the stabilizers. In fact, if we do strengthen the movers without working on the stabilizers, then the shoulder will be forced to move in too great of motion and would likely cause pain. 
 

Here’s an example of what I mean: Sign your name on a piece of paper.  Now, grip the pen in your fist as if you were going to stab it down onto the table.  Now try to write your name without moving your wrist.  It is much more difficult.  If you successfully wrote your name, congratulations.  Likely though, you struggled quite a bit.  That is because you wrote your name using your movers and not the little stabilizers of the hand and fingers. 

Where am I going with this? When the shoulder dislocates forward as in the case of our patient, the front muscle – the one most congruent with the shoulder and the one most responsible for protecting the shoulder (the subscapularis) - gets rapidly stretched and traumatized.  

This is followed with an inflammatory response within the joint, which causes all the muscles surrounding the joint to go into a state of shock or involuntary contraction.  That is why it is necessary to redevelop complete range of motion within the shoulder prior to really beginning strengthening.  However, with the case of anterior dislocation, we want to make sure that we don’t neglect the strengthening aspect of recovery, so that the muscles can do their job in protecting the shoulder from further dislocations.  Since the muscles are responsible for holding the shoulder together - even more than the joint capsule or few ligaments.

In conclusion, specific strengthening of the rotator cuff and namely the subscapularis is important to protect the shoulder from further dislocation and properly rehabilitate the shoulder. 

Following are some exercises for recurring anterior dislocations of the shoulder. These exercises are general and not specific to any specific person, but rather are exercises that specifically target the subscapularis when performed correctly.  If you try these exercises at home, you should not be experiencing any pain, but in the case that you do, please stop the exercises and consult a professional. 

Reminder: You have many muscles that produce the movement of Internal Rotation so it is important to start with light weight and do many repetitions.  As mentioned before, the muscles in your body can be divided into movers and stabilizers, and we are targeting the stabilizers with these exercises.  Although it is impossible to separate out the stabilizers without using the movers, it is the stabilizers that should be the first to respond.  The movers typically respond more (or may even overcompensate) when the weight is heavier or moved at a rapid speed.  Don’t be ashamed to start light and slow and move up in weight. Recommendation: Only to move up in weight when 60-100 repetitions (it could be 3-5 sets of 20 repetitions) are easy to do.  The number of repetitions per set should be no less than 15. If 15 repetitions are difficult, then the weight is too heavy.

1.     IR at 0 degrees with a TB

2.     IR at 90 degrees with a TB

3.     Supine shoulder press/angels (elbows bent to 90 degrees)

4

      D2 extension with a TB. Thumb back when the arm is overhead, and thumb back when the arm is across the body by the opposite hip.  The elbow should remain relatively straight (but not locked out) or very slightly bent. The TB should be tied to the top of a door behind you.

5.     Flys (again, the tendency would be to go heavy, so start really light for the sake of your stabilizers)

6.     Wall Push ups, progressing to table push ups, progressing to floor push ups

7.     Military push ups (down-dog to up-dog)

8.     Windmill (front plank to side plank)

      Alphabet Laser pointing (to the side): A proprioception exercise to regain brain/shoulder control. Try to keep your elbow straight as you do this activity. It can be done forward or to the side. If you don't have a laser pointer, you can just trace it with your finger. Use a laser pointer and trace a picture like this:

     Turkish get ups (start with only using a phone book or a thick hard back book. Try to balance the book on your fist while keeping your thumb tucked in your fist to avoid cheating. It can be done, I promise.  This is also more of a coordination exercise to work on proprioception and control.  Add weight only when you master balancing a book on your fist.

     Advanced exercise: Wall walks: push up to handstand

    Advanced exercise: push up in a handstand

Of course if you have other problems or issues with your shoulder (for example: from the result of a fall, or fracture, or accident, you should consult your local physiotherapist for the exercises that are best geared for you.)