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Picture

Extension Rotation Syndrome Part II: Treatment

9/12/2014

3 Comments

 
Picture
A few weeks back, I wrote a post about assessing for Lumbar Extension Rotation Syndrome (ERS) in low back pain patients. Since then I have received several comments from people wanting information regarding treatment options for this condition.

Overview
A typical patient presentation includes age >55 years old, chronic low back pain, and may be involved in a rotational sport (golf, tennis, etc). On physical examination, you will observe an exaggerated lumbar lordosis, paraspinal muscle asymmetry, excessive pelvic rotation during gait, and hinging during cardinal plane extension testing. They will often complain of unilateral lumbar pain that increases with extension and is relieved with non-weight bearing lumbar flexion. Generally a patient with ERS hyperextends their low back, which does not allow the gluts to fire properly.   


Treatment
For the purposes of this post, I want to focus on core stability and lumbopelvic disassociation. I find that pure hip strengthening is not appropriate early on because the patient cannot adequately engage their gluteals without lumbar compensation. Since the patient has excessive lumbar lordosis and hinging during functional movements, addressing core stability is essential. Additionally, strengthening and motor control of the hip extensors and external rotators is important once the core has sufficient control. Manual therapy is performed on a patient-to-patient basis depending on individual impairments found during the physical examination. Since the patient is generally hypermobile at the hinging segment, they are hypomobilie cranially or caudally. Thoracic and lumbar mobilizations and manipulations are appropriate for the appropriate patient.  

Core Stability
Assuming the patient has low irritability levels and good body awareness, I will usually begin TherEx by retraining the transversus abdominus (TrA) in supine. After the patient can maintain a neutral low back position, I will incorporate the bent knee fall out exercise using a blood pressure cuff for additional cueing. Many progressions of the blood pressure cuff are appropriate until the patient demonstrates good isolation of the TrA in supine. As the patient progresses, I take them through a progression of exercises in quadruped to ensure the patient can maintain a neutral low back posture in a gravity independent position. The progression includes isolated TrA contraction, TrA hand heel rocks (see below), and removing limbs from the table (alternating shoulder flexion, alternating hip extension, then birddog exercises). When the patient can demonstrate good control in quadruped, I address core control in spinal weight bearing. In standing, I have found using the wall as an external cue helps the patient 'find' their TrA. When appropriate, begin functional training in standing by incorporating mini-squats, lunges, and other upper and lower extremity disassociation exercises. 

Below is a progression of 3 common exercises I prescribe for ERS from supine to standing.    

Supine BKFO
Quadruped Hand Heel Rock
Standing Hip Extension
Please let me know if you have any questions  or would like more information regarding treatment options of extension rotation syndrome.

-Jim 
3 Comments
Michael Carnell
1/17/2017 01:19:40 pm

What happens when you have tried everything? core, dry needling, chiro, pt, injections

Reply
Chris link
1/17/2017 07:43:18 pm

Hi Michael,

That is a difficult question to answer, because each intervention you listed means different things to each practitioner. I've seen horrible "core stabilization" exercises and there are different techniques of dry needling. There are good practitioners and bad practitioners. Hypothetically, if all the above were done correctly with a compliant patient and the patient did not progress, I would say they likely would require a shift towards pain science education and treatment. The hypothetical individual sounds like a patient with chronic pain. Hope this helps!

Reply
Alec
9/4/2019 09:44:59 pm

Where can I get more information on the exercise protocol. I am dealing with this issue for quiet some time.

Reply



Leave a Reply.

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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
    • Research Articles
    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test