Examples of functional exercise progressions
Programs and exercises to help an athlete return to their specific sport.
Once the athlete has been clinically assessed for functional deficits, it is time to progress to the functional movements necessary to return the athlete to his or her sport. At this point, full range of motion, a normal gait pattern, symmetrical flexibility, strength, proprioception, and balance should be close to their preoperative levels. As previously discussed, the clinician should be cognizant of the basic injury mechanisms and biomechanics while moving the athlete through the functional progression. Athletes should not experience pain or altered gait mechanics as they attempt each movement. Supervision by the clinician or coach is imperative to ensure that each movement is mechanically correct. Braces or tape can be worn if needed during the functional progression.
1. Jumping on both legs: 5 times
2. Jumping on injured leg: 5 times
3. Jogging laps: both directions
4. Jogging figure eights (half, three quarter, full speed): 10 yards (10 m)
5. Cariocas (crossovers): both directions
6. Circling: both directions
7. Stand-up sequence from down position: 5 times
8. Spin drills, partner in down position (wrestler uses hands for balance, chest on opponent's back), both directions: 5 times
9. Shooting from standing position, with opponent progressively increasing speeds
10. Circling, with tying-up opponent
11. Shoot and sprawl: wrestler balances on injured leg while working against unanticipated maneuvers of opponent
12. Down position sequence: opponent applies resistance as injured wrestler attempts to get up
13. Live wrestling
1. Heel raises, injured leg: 10 times
2. Walking at fast pace: 50 yards (50 m)
3. Jumping on both legs: 10 times
4. Jumping on injured leg: 10 times
5. Jogging straight: full court
6. Jogging straight and curves: 2 laps
7. Sprinting (half, three quarter, full speed): full court
8. Running figure eights (half, three quarter, full speed): baseline to quarter court
9. Triangle drills: sprint baseline to half court, backward run back to baseline, defensive slides along baseline; repeat in opposite direction
10. Cariocas (crossovers): half, three quarter, full speed
11. Cutting: half, three quarter, full speed
12. Position drills
1. Heel raises, injured leg: 10 times
2. Walking at fast pace: first base
3. Jumping on both legs: 10 times
4. Jumping on injured leg: 10 times
5. Jogging straight: first base
6. Jogging straight and curves: 2 laps around bases
7. Sprinting (half, three quarter, full speed): first base
8. Sprinting (half, three quarter, full speed): rounding first base
9. Running figure eights: home plate to pitcher's mound
10. Backward running: simulate fielding fly ball
11. Throwing: short toss to long toss
12. Hitting: tee to batting cage to live
13. Position drills
1. Heel raises, injured leg: 10 times
2. Walking at fast pace: 50 yards (50 m)
3. Jumping on both legs: 10 times
4. Jumping on injured leg: 10 times
5. Jogging straight: 50 yards (50 m)
6. Jogging straight and curves: 2 laps
7. Sprinting (half, three quarter, full speed): 40 yards (40 m)
8. Running figure eights (half, three quarter, full speed): 15 yards (15 m)
9. Cariocas (crossovers), both directions: 40 yards (40 m)
10. Backward running: 40 yards (40 m)
11. Cutting (half, three quarter, full speed)
12. Position drills
When an athlete is able to begin running again, it is necessary to return to previous mileage gradually. Provide the following guidelines to help ensure a safe return to the road.
- Make sure you stretch before and after running.
- Keep the running surface as soft, smooth, and level as possible.
- Emphasize form.
- Ice the involved area until numb after running.
- Follow these mileage guidelines. Do not progress to the next step if the previous one caused pain.
Previously Running 20-30 Miles per Week | | Day | |
| Week | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total Miles |
| 1 | 1 | 0 | 1 | 0 | 1 | 0 | 2 | 5 |
| 2 | 0 | 2 | 0 | 2 | 0 | 3 | 0 | 7 |
| 3 | 3 | 2 | 0 | 3 | 2 | 0 | 3 | 13 |
| 4 | 3 | 0 | 4 | 3 | 0 | 4 | 4 | 18 |
| 5 | 0 | 5 | 4 | 0 | 5 | 5 | 5 | 24 |
Previously Running 30-40 Miles per Week
| | Day | |
| Week | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total Miles |
| 1 | 2 | 0 | 2 | 0 | 2 | 0 | 3 | 9 |
| 2 | 0 | 3 | 0 | 3 | 0 | 4 | 3 | 13 |
| 3 | 0 | 4 | 4 | 0 | 5 | 4 | 0 | 17 |
| 4 | 5 | 4 | 0 | 5 | 5 | 0 | 6 | 25 |
| 5 | 5 | 0 | 6 | 5 | 5 | 0 | 6 | 27 |
When an athlete is able to begin running again, it is necessary to return to previous mileage gradually. Provide the following guidelines to help ensure a safe return to the road.
- Make sure you stretch before and after running.
- Keep the running surface as soft, smooth, and level as possible.
- Emphasize form.
- Ice the involved area until numb after running.
- Follow these mileage guidelines. Do not progress to the next step if the previous one caused pain
Previously Running 30 to 45 Minutes per Day | Day | |
| Week | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total Minutes |
| 1 | 10 | 0 | 10 | 0 | 12 | 0 | 14 | 46 |
| 2 | 0 | 16 | 0 | 18 | 0 | 20 | 0 | 54 |
| 3 | 25 | 20 | 0 | 25 | 25 | 0 | 30 | 125 |
| 4 | 30 | 0 | 30 | 35 | 0 | 35 | 40 | 170 |
| 5 | 0 | 40 | 35 | 0 | 45 | 40 | 45 | 205 |
Previously Running 45 Minutes per Day
| | Day | |
| Week | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total Minutes |
| 1 | 10 | 0 | 12 | 0 | 15 | 0 | 17 | 54 |
| 2 | 0 | 20 | 0 | 20 | 0 | 22 | 0 | 62 |
| 3 | 25 | 20 | 0 | 30 | 25 | 0 | 35 | 135 |
| 4 | 30 | 0 | 35 | 35 | 0 | 40 | 35 | 175 |
| 5 | 0 | 40 | 40 | 35 | 0 | 45 | 40 | 200 |
| 6 | 40 | 0 | 45 | 45 | 40 | 0 | 50 | 220 |
| 7 | 45 | 45 | 50 | 0 | 55 | 50 | 50 | 295 |
This is an excerpt from Effective Functional Progressions in Sport Rehabilitation.
Introduction to the key components of functional progression programs
Programs should be designed for a specific person.
Many key components are inherent in a successful functional progression program. Since the program above all else has to be designed for a specific person, following one preset guideline or functional progression cannot be recommended. Therefore, it is important in this chapter to briefly review some of the key components in the rehabilitation process and the process of using and applying functional exercise progressions, and then introduce in the following chapters a detailed series of functional progressions, with supportive evidence and background information in anatomy and biomechanics, to empower the reader to develop his or her own progression for successful applications.
The continued monitoring of the signs and symptoms of the patient during the functional progression is of critical importance for the success of any progression. This forms the basis for the rate and frequency of the progression of the program. Some of the key signs and symptoms are introduced in chapter 1 but are so important that they warrant repeating. For example, the presence of intra-articular swelling is one factor of critical importance in virtually all rehabilitation and functional progressions. Although it may be somewhat joint specific, intra-articular swelling can be palpated and measured or clinically observed in several key joints throughout the body. Swelling about the knee and ankle, for example, is easily monitored and in lower extremity progressions can be an extremely valuable marker for clinical progression. In other joints such as the glenohumeral and coxofemoral joints, swelling is much less noticeable and does not play a major role in the screening process. Progressing exercise and activities in the presence of joint swelling is contraindicated and clearly not recommended.
Other signs and symptoms that often occur with or without swelling are joint pain, significant muscular fatigue or loss of control, and decreased joint motion. The presence of any of these in isolation or combination slows down the functional progression. Using visual analog scales (VAS) or simply asking the person to rate his level of pain, fatigue, or improvement using a scale of 0 to 10 can help put an objective slant on otherwise subjective perceptions of the person's function and feelings during the progression.
The concept of continuous progression is apparent to most, but it is often not adhered to in many suboptimal programs. It is difficult and often encumbering to initially design the functional progression program. Continuing to adjust and progress the program, however, is required to successfully progress the person to optimize gains in strength, motion, and function. Frequent and periodic reevaluations of function as well as consistent monitoring of performance are required to allow continuous progression of the program once initiated. Each of the subsequent chapters on the upper and lower extremities and the trunk will outline specific progressions, complete with information about the methods commonly used and recommended for progressing the program. These form the basic elemental aspects of a functional progression program and can include increases in volume, frequency, duration, and of course exercise intensity.
This key concept highlights the need to balance specific training with the required basic progressions to ensure that optimal baseline strength, coordination, and other important factors remain present throughout the progression. To best illustrate this concept, here is a specific example. When a throwing athlete returns to pitching after rotator cuff tendinitis, baseball-specific progressions are used, including throwing drills that progressively increase the intensity and distance of the throwing motion as well as progress from throwing on flat ground to off the mound. Although this sounds like a very sound progression for a baseball pitcher (and from a throwing perspective, it is), failure to address rotator cuff and scapular strengthening—which for all intents and purposes may appear to be too basic—will likely result in inadequate emphasis on those important muscle groups and lead to muscular imbalance and suboptimal recovery. Additionally, ignoring core stability training and hip strengthening progressions during this return program would also be remiss because these programs (rotator cuff and scapular program, core stability, and hip strengthening) form the basis on which the functionally specific program can progress.
This example highlights the importance of combining sport- or activity-specific programs with more-basic programs to ensure strength development and muscular balance. Other examples include the continued emphasis on quadriceps strength development in the patient while cutting and running drills are concomitantly being progressed to ensure that this important muscle group is continuing to develop during the sport-specific progression. The basic progressions supplied in this book for key muscle groups, and concepts such as core stability, scapular stabilization, and rotator cuff strength, cannot be forgotten or deemphasized once the other sport-specific functional progressions are initiated.
Another key factor to consider with respect to functional progression is the integration and use of objective tests and functional tests to guide the progression of the program. The final three chapters of this book list key tests and measures that can help guide the clinician during the progression of a functional program. An example of the application of this type of testing helps support this concept. Frequently, a one-leg stability test or one-leg squat test is used during rehabilitation or preseason physical evaluation of an athlete. For this test, the athlete performs a one-leg squat while the clinician observes the quality of the motion. Often during this movement, the contralateral hip drops downward (termed a positive Trendelenburg sign) as the knee of the stance limb bends (figure 2.1). The presence of this finding indicates weakness of the stance limb's gluteus medius, as it is unable to properly stabilize the pelvis in a level orientation during the descent of the one-leg squat maneuver (Hardcastle and Nade 1985; Kibler, Press, and Sciascia 2006, Chimielewski et al. 2007).
More-detailed interpretation of functional testing has been reported by Piva et al. (2006) for a lower extremity step-down test. Compensatory movements of the arm, dropping of the pelvis, and inward (valgus) angulation of the knee while performing the step-down test can be objectively evaluated and provide key insight into the readiness of a person to return to lower extremity functional activities. The presence of a positive hip drop or Trendelenburg finding in a patient after knee injury indicates the need for more-specific and basic exercise progressions to increase core and gluteus medius strength before introducing more-advanced progressions. This test, then, can become a key part of the reevaluation process to ensure that adequate hip and core stability and pelvic control have been restored before moving on to more-functional and sport-specific programs.
A similar example in the upper extremity is the use and application of clinical tests such as impingement tests (Ellenbecker 2004) and the subluxation relocation test (Hamner, Pink, and Jobe 2000) coupled with isokinetic strength testing to determine readiness of a patient with rotator cuff tendinitis to return to more-advanced throwing progressions. In this example, progressing a patient who has pain in the position of 90° of abduction and 90° of external rotation to a throwing program would be inadvisable based on the findings of that objective test. Similarly, extensive weakness or an imbalance in the rotator cuff musculature identified with an isokinetic shoulder internal and external rotation test is another contraindication for progression. Frequent testing and retesting to gauge improvement not only ensures proper rates of progression in the functional programs but also empowers the person or athlete by demonstrating the effectiveness of the programs being applied to improve baseline function. Functional tests and objective measures of strength, range of motion, and anthropometric girth can form the basis for the thoughtful and educated progression of the programs contained in this book.
The final section of this chapter deals with the importance of evaluating the person's technique as he progresses in the functional program. One of the key concepts in the evaluation of technique involves the kinetic link principle. Clinicians often focus so closely on the injured joint or segment during evaluation that other links and compensations in the kinetic chain are missed and not properly addressed in either the rehabilitation or functional progression program. Many methods can be used to evaluate technique, including simple clinical observation, expert consultation, and video analysis. All three of these methods can prove useful; it is difficult to always rely solely on clinical observation because of the high inherent speeds of human performance. Additionally, the varied sport performance background of the people being worked with often requires expertise beyond the specialty of the primary clinician. Outside exerts with established competence in the sport or activity in question can often offer critically important information relative to the development and implementation of the functional progression program.
Finally, the readily accessible use of digital video recorders and computer software, which allows for manipulation of those images to improve analysis as well as provide feedback to the athlete or person, is exceptionally important in this process. A discussion of the role the kinetic link plays in human performance closes this chapter and prepares the reader for the specific information contained in the second part of this book.
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Examples of muscular strength tests for the upper extremity
Objective assessment of muscular strength in the upper extremity is indicated to determine the presence of muscular strength deficiencies as well as to monitor progress during exercise progression.
Objective assessment of muscular strength in the upper extremity is indicated to determine the presence of muscular strength deficiencies as well as to monitor progress during exercise progression. Although not always feasible, the use of a handheld dynamometer or isokinetic dynamometer is recommended to provide the highest degree of accuracy and represent muscular strength relationships (e.g., bilateral comparisons and unilateral strength ratios). Specific test positions have been described by Daniels and Worthingham (1980) and Kelly, Kadrmas, and Speer (1996) for testing the rotator cuff and scapular musculature. Of key importance is the close monitoring of external and internal rotation strength in the neutral position as well as in 90° of glenohumeral joint abduction. These can be tested bilaterally and compared. Close monitoring of the medial scapular border is also necessary, specifically during external rotation testing. If the evaluator notes significant movement of the medial border of the scapula away from the thorax during testing of external rotation with the arm in neutral abduction or adduction at the side, this constitutes a “flip sign.” This indicates a lack of scapular stabilization and points the evaluator to include scapular stabilization exercise progressions in the person's exercise programming.
Additionally, the empty can test has been used to test for supraspinatus strength and can also be used as a provocation test to evaluate rotator cuff pathology (Itoi et al. 1999). Although all muscles of the upper extremity can be tested manually, the rotator cuff and scapular muscles are perhaps of greatest importance during functional screening. Distal strength testing using a hand-grip dynamometer should reveal significantly greater dominant-arm strength in baseball pitchers and tennis players (Ellenbecker and Mattalino 1997b).
Isokinetic testing performed at 90° of glenohumeral joint abduction is recommended for screening overhead athletes. This joint position more-specifically addresses muscular function required for overhead activities (Bassett, Browne, and Morrey 1994). Descriptive data profiles for throwing athletes (Wilk et al. 1993; Ellenbecker and Mattalino 1997b) as well as for elite junior tennis players (Ellenbecker and Roetert 2003) are listed in tables 3.1 through 3.5. These data provide objective information regarding the normal torque-to-body-weight ratios as well as external rotation and internal rotation (ER/IR) ratios used in the interpretation of instrumented upper extremity strength testing.
Table 3.1 Isokinetic Peak Torque-to-Body-Weight and Work-to-Body-Weight Ratios for 147 Professional Baseball Pitchers
| | INTERNAL ROTATION | EXTERNAL ROTATION |
| Speed | Dominant Arm | Nondominant Arm | Dominant Arm | Nondominant Arm |
| 210º/sec | | | | |
| Torque | 21% | 19% | 13% | 14% |
| Work | 41% | 38% | 25% | 25% |
| 300º/sec | | | | |
| Torque | 20% | 18% | 13% | 13% |
| Work | 37% | 33% | 23% | 23% |
Data were obtained on a Cybex 350 concentric isokinetic dynamometer.
Data from T.S. Ellenbecker and A.J. Mattalino, 1997, “Concentric isokinetic shoulder internal and external rotation strength in professional baseball pitchers,” Journal of Orthopaedic Sports Physical Therapy 25: 323-328.
Table 3.2 Isokinetic Peak Torque-to-Body-Weight Ratios for 150 Professional Baseball Pitchers
| | INTERNAL ROTATION | EXTERNAL ROTATION |
| Speed | Dominant Arm | Nondominant Arm | Dominant Arm | Nondominant Arm |
| 180º/sec | 27% | 17% | 18% | 19% |
| 300º/sec | 25% | 24% | 15% | 15% |
Data were obtained on a Biodex isokinetic dynamometer.
Data from K.E. Wilk et al., 1993, “The strength characteristics of internal and external rotator muscles in professional baseball pitchers,” American Journal of Sports Medicine 21: 61-66.
Table 3.3 Isokinetic Peak Torque-to-Body-Weight Ratios and Single Repetition Work-to-Body-Weight-Ratios in Elite Junior Tennis Players
| | DOMINANT ARM | NONDOMINANT ARM |
| | Peak Torque (%) | Work (%) | Peak Torque (%) | Work (%) |
| External rotation (ER) | | |
| Male, 210º/sec | 12 | 20 | 11 | 19 |
| Male, 300º/sec | 10 | 18 | 10 | 17 |
| Female, 210º/sec | 8 | 14 | 8 | 15 |
| Female, 300º/sec | 8 | 11 | 7 | 12 |
| |
| Internal rotation (IR) | | |
| Male, 210º/sec | 17 | 32 | 14 | 27 |
| Male, 300º/sec | 15 | 28 | 13 | 23 |
| Female, 210º/sec | 12 | 23 | 11 | 19 |
| Female, 300º/sec | 11 | 15 | 10 | 13 |
A Cybex 6000 series isokinetic dynamometer and 90° of glenohumeral joint abduction were used. Data are expressed in foot-pounds per unit of body weight for ER and IR.
Data from T.S. Ellenbecker and E.P Roetert, 2003, “Age specific isokinetic glenohumeral internal and external rotation strength in elite junior tennis players,” Journal of Science and Medicine in Sport 6(1): 63-70.
Table 3.4 Unilateral External Rotation and Internal Rotation Ratios in Professional Baseball Pitchers
| | Dominant Arm | Nondominant Arm |
| 210º/seca | | |
| Torque | 64 | 74 |
| Work | 61 | 66 |
| 300º/seca | | |
| Torque | 65 | 72 |
| Work | 62 | 70 |
| 180º/secb | | |
| Torque | 65 | 64 |
| 300º/secb | | |
| Torque | 61 | 70 |
aData from, T.S. Ellenbecker and A.J. Mattalino, 1997, “Concentric isokinetic shoulder internal and external rotation strength in professional baseball pitchers,” Journal of Orthopaedic Sports Physical Therapy 25: 323-328. bData from W.E. Wilk et al., 1993, “The strength characteristics of internal and external rotator muscles in professional baseball pitchers,” American Journal of Sports Medicine 21: 61-66.
Table 3.5 Isokinetic External Rotation/Internal Rotation Ratios in Elite Junior Tennis Players
| | DOMINANT ARM | NONDOMINANT ARM |
| ER/IR ratio | Peak torque (%) | Work (%) | Peak torque (%) | Work (%) |
| Male, 210º/sec | 69 | 64 | 81 | 81 |
| Male, 300º/sec | 69 | 65 | 82 | 83 |
| Female, 210º/sec | 69 | 63 | 81 | 82 |
| Female, 300º/sec | 67 | 61 | 81 | 77 |
A Cybex 6000 series isokinetic dynamometer and 90º of glenohumeral joint abduction were used. Data are expressed as ER/IR ratios representing the relative muscular balance between the external and internal rotators.
Data from T.S. Ellenbecker and E.P. Roetert, 2003, “Age specific isokinetic glenohumeral internal and external rotation strength in elite junior tennis players,” Journal of Science and Medicine in Sport 6(1): 63-70.
Muscular imbalances caused by repetitive and forceful internal rotation during the acceleration of the throwing motion, tennis serve, and forehand can lead to unilateral muscular imbalances on the dominant arm between the external and internal rotators and jeopardize optimal muscular stabilization. Careful monitoring of the external and internal rotation unilateral strength ratio is an integral measure of musculoskeletal testing programs for return to sport as well as injury prevention and assists in the determination of optimal application of exercise programs for the overhead athlete.
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Employ a progressive rehab program for tennis players
The following interval return program provides functional progressions based on the demands and activities required by tennis.
The following interval return programs provide sport-specific functional progressions for returning to golf, tennis, and baseball. Each has specific instructions for returning based on the demands and activities required for successful performance in that sport. Reviewing the stages, and in many instances working with the person as he or she progress through the stages, is recommended to ensure an optimal result or return to participation. The programs listed here are designed to be given to the injured athlete and provide an overview of the progression of activity that is recommended for this functional return.
Of critical importance is the continued use of functional tests and objective measures to determine proper strength and range of motion before initiating the interval return program. Integration of continued functional exercise progression during the execution of the return programs is also recommended. Each of the programs in this section of the text provides step-by-step progressions of the key aspects of functional performance in these sports. Evaluation of proper sport biomechanics or technique is also of critical importance to decrease loading and ensure optimal progression in these functional return programs.
Frequency: Alternate-day performance
Supervision: Emphasis on proper stroke mechanics
Stroke progression: Groundstrokes → volleys → serves → overheads → match play
Impact progression: Low pre-impact ball velocity to higher pre-impact ball velocity
Ball progression: Low compression (foam) to regulation tennis ball
Sequencing: Proper warm-up, interval tennis program, cool-down and cryotherapy
Timing: Supplemental rotator cuff and scapular exercises performed either on rest day after interval tennis program or after execution of interval tennis program on the same day to minimize the effects of overtraining and overload
- Begin at the stage indicated by your therapist or doctor.
- Do not progress or continue the program if joint pain is present.
- Always stretch your shoulder, elbow, and wrist before and after the interval program, and perform a whole-body dynamic warm-up before performing the interval tennis program.
- Play on alternate days, giving your body a recovery day between sessions.
- Do not use a wallboard or backboard as it leads to exaggerated muscle contraction without rest between strokes.
- Ice your injured arm after each stage of the interval tennis program.
- It is highly recommended to have your stroke mechanics formally evaluated by a USPTA teaching professional.
- Do not attempt to impart heavy topspin or underspin to your groundstrokes until the later stages of the interval program.
- Contact your therapist or doctor if you have questions about or problems with the interval program.
- Do not continue to play if you encounter localized joint pain.
Start with foam-ball impacts, beginning with ball feeds from a partner. Perform 20 to 25 forehands and backhands, assessing initial tolerance to groundstrokes only. Presence of pain or abnormal movement patterns in this stage indicates you are not ready to progress to the actual interval tennis program. Continued rehabilitation would be emphasized.
Perform each stage ________ times before progressing to the next stage. Do not progress to the next stage if you had pain or excessive fatigue in your previous outing—remain at the previous level until you can perform that part of the program without fatigue or pain.
Stage 1
a. Have a partner feed 20 forehand groundstrokes to you from the net. (Partner must use a slow, looping feed that results in a waist-high ball bounce.)
b. Have a partner feed 20 backhand groundstrokes as in 1a.
c. Rest 5 minutes.
d. Repeat 20 forehand and backhand feeds.
Stage 2
a. Begin as in Stage 1, with a partner feeding 10 forehands and 10 backhands from the net.
b. Rally with a partner from the baseline, hitting controlled groundstrokes until you have hit 50 to 60 strokes. (Alternate between forehand and backhand, allowing 20 to 30 seconds rest after every two or three rallies.)
c. Rest 5 minutes.
d. Repeat 2b.
Stage 3
a. Rally groundstrokes from the baseline for 15 minutes.
b. Rest 5 minutes.
c. Hit 10 forehand and 10 backhand volleys, emphasizing a contact point in front of the body.
d. Rally groundstrokes for 15 minutes from the baseline.
e. Hit 10 forehand and 10 backhand volleys as in 3c.
Pre-Serve Interval
Perform these tasks before Stage 4. Note: This interval can be performed off court and is meant solely to determine readiness for progression into Stage 4 of the interval tennis program.
a. After stretching, with racket in hand, perform serving motion for 10 to 15 repetitions without a ball.
b. Using a foam ball, hit 10 to 15 serves without concern for performance result (focusing only on form, contact point, and the presence or absence of symptoms).
Stage 4
a. Hit 20 minutes of groundstrokes, mixing in volleys using a format of 70% groundstrokes and 30% volleys.
b. Perform 5 to 10 simulated serves without a ball.
c. Perform 5 to 10 serves using a foam ball.
d. Perform 10 to 15 serves using a standard tennis ball at approximately 75% effort.
e. Finish with 5 to 10 minutes of groundstrokes.
Stage 5
a. Hit 30 minutes of groundstrokes, mixing in volleys using a format of 70% groundstrokes and 30% volleys.
b. Perform 5 to 10 serves using a foam ball.
c. Perform 10 to 15 serves using a standard tennis ball at approximately 75% effort.
d. Rest 5 minutes.
e. Perform 10 to 15 additional serves as in 5c.
f. Finish with 15 to 20 minutes of groundstrokes.
Stage 6
a. Repeat Stage 5, increasing the number of serves to 20 to 25 instead of 10 to 15.
b. Before resting between serving sessions, have a partner feed easy, short lobs to attempt a controlled overhead smash.
Stage 7
Before attempting match play, complete steps 1 to 6 without pain or excess fatigue in the upper extremity. Continue to progress the amount of time rallying with groundstrokes and volleys in addition to increasing the number of serves per workout until you can perform 60 to 80 overall serves interspersed throughout a workout. Remember that an average of up to 120 serves can be performed in a tennis match; therefore, be prepared to gradually increase the number of serves in the interval program before engaging in full competitive play.
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Muscular stabilization exercises for the knee
The musculoskeletal system provides joint stabilization and allows force production to facilitate locomotion in the lower extremity.
The musculoskeletal system provides joint stabilization and allows force production to facilitate locomotion in the lower extremity. The amount of force production is dependent upon the torque generated through the moment arm (Best and Kirkendall 2003).
The muscular anatomy that provides dynamic stability to the knee is most easily divided into quadrants corresponding to their locations of anterior, posterior, lateral, or medial. These structures enable joint motion to occur and also provide dynamic protection to supporting structures of the tibiofemoral joint, including ligaments and menisci.
Anterior Compartment
The quadriceps muscle group makes up the largest portion of the anterior compartment of the knee and consists of four muscles: rectus femoris, vastus medialis, vastus lateralis, and vastus intermedialis (see figure 4.7). These muscles form a common patellar tendon innervated by the femoral nerve.
The most anterior of the quadriceps muscles is the rectus femoris, originating from the anterior inferior iliac spine and the superior rim of the acetabulum (Cox and Cooper 1994). The three other heads border the rectus femoris distally. The rectus femoris, as a two-joint muscle, performs both hip flexion and knee extension. Lack of flexibility of the rectus femoris can contribute to abnormal patellar tracking.
The vastus lateralis, the largest head of the quadriceps muscles, originates on the anterior inferior greater trochanter, the intertrochanteric line, the lateral lip of the linea aspera, and the intermuscular septum. The fibers run in a 12 to 15º lateral direction to the femur, with a portion of the distal attachment terminating into the lateral retinaculum (Gray 1973; Lieb and Perry 1968). Dominance of the vastus lateralis along with tightness in the lateral retinaculum can result in excessive lateral displacement of the patella.
The vastus medialis originates at the lower end of the anterior intertrochanteric line. The vastus medialis also originates from the linear aspera and intermuscular septum, with a division that originates from the medial supracondylar line and adductor longus and adductor magnus tendon. The distal portion of the vastus medialis, the vastus medialis oblique (VMO), has fibers that run in a 60 to 65° medial direction to the femur (Gray 1973; Lieb and Perry 1968). Together with the vastus medialis longus, which has a fiber direction 15 to 18° medial to the femur, its primary function is to maintain dynamic patellar alignment. Swelling and pain can occur at the VMO because of its oblique fiber direction, which opposes the Q-angle alignment.
The vastus intermedialis originates on the anterior mediolateral surface of the femoral diaphysis. Its fibers run almost entirely in a vertical direction and contribute to extension of the knee.
The four quadriceps muscles converge into the superior pole of the patella and form the quadriceps tendon. Continuing distally, the patellar tendon extends from the inferior patellar pole to the tibial tuberosity. The tendon is widest at the apex of the patella and tapers slightly as it attaches into the tibial tuberosity. On average, the patellar tendon is 5 to 6 cm (2 to 2.4 in.) long and 7 mm thick (Cox and Cooper 1994; Fulkerson and Hungerford 1990a). However, patellar tendon length is actually a function of the height of the patella itself. The patellar tendon morphology may have ramifications for use as a graft source for ACL reconstruction.
The quadriceps function antagonistically to the hamstrings in an eccentric mode to control knee flexion. In this mode of muscular contraction, the quadriceps absorb compressive forces and decelerate the weighted extremity. The fiber direction of the vastus medialis oblique (VMO) serves to control patellar tracking through varying degrees of knee motion. It is critical to maintain dynamic balance of the quadriceps to limit the dominance of lateral structures.
Posterior Compartment
The hamstrings make up the posterior muscles of the knee. These include the semimembranosus, semitendinosus, and biceps femoris (figure 4.8). All these muscles, with the exception of the short head of the biceps femoris, originate from the ischial tuberosity and extend below the knee. The semimembranosus attaches on the anterior medial aspect of the medial tibia, and the semitendinosus attaches on the proximal medial tibia. The semimembranosus performs flexion and internal rotation of the knee and extension and internal rotation of the hip. It resists excessive hip abduction and external rotation of the tibia as well as provides dynamic support to the posterior capsule. During knee flexion, the semimembranosus, through its attachment to the posterior horn of the medial meniscus, assists with retraction of the medial meniscus. This prevents impingement by the medial femoral condyle and subsequent injury to the medial meniscus during flexion of the knee (Aglietti, Insall, and Cerulli 1983; Wallace, Mangine, and Malone 1997).
The semimembranosus and semitendinosus are innervated by the tibial division of the sciatic nerve. The semimembranosus also shares a branch of the nerve with the posterior section of the adductor magnus muscle.
The semitendinosus arises farther posteriorly from the ischial tuberosity. It inserts inferior to the gracilis and sartorius and with these two muscles forms the pes anserinus. The pes anserine bursa lies directly under these tendons and can be a source of irritation. The semitendinosus provides additional valgus stability to the knee and assists with flexion and internal rotation of the knee and extension of the hip.
The biceps femoris lies opposite to the semimembranosus and semitendinosus on the lateral side. The long head arises from the ischial tuberosity, while the short head originates from the posterior lateral lip of the linea aspera. The tendon of insertion runs distally and anteriorly and splits at the inferior portion of the lateral collateral ligament (LCL). The biceps femoris tendon consists of three layers: (1) a lateral layer that lies superficial to the LCL, (2) a middle layer that splits around the LCL, and (3) a deep layer that lies medial to the ligament. The superficial layer inserts anteriorly on the crural fascia and Gerdy's tubercle. The middle layer surrounds the LCL to conjoin at the fibular head. The deep layer divides to insert on Gerdy's tubercle anteriorly and the fibular head posteriorly (Terry and LaPrade 1996).
The biceps femoris is an important dynamic stabilizer of the posterolateral compartment of the knee. The multilayered tendon checks rotatory and anteroposterior stresses through its insertion into the posterolateral capsule (Andrews et al. 1994). The long head receives innervation from the tibial branch of the sciatic nerve (L5,S2-S3), while the short head receives a branch from the peroneal division (L5, S2). The biceps femoris prevents excessive adduction of the tibia and excessive anteroposterior displacement of the lateral tibial condyle. It provides dynamic support to the posterolateral knee.
Gastrocnemius
The gastrocnemius has a medial and lateral head that originate from the posterior aspect of the medial and lateral femoral condyle and adjacent femur and joint capsule (figure 4.9). The common tendon of insertion anchors into the posterior calcaneus. Although the gastrocnemius is primarily viewed as an ankle plantar flexor, it also functions as a knee flexor. This muscle plays a vital role in providing dynamic support to the knee during the midstance phase of gait. The gastrocnemius is innervated either by separate branches of the tibial nerve to each head or by a common stem of the nerve.
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Example of scapular stabilization progressions
This exercise provides a training stimulus for the important trapezius–serratus anterior force couple components and provide dynamic stabilization of the scapula.
These exercises provide a training stimulus for the important trapezius-serratus anterior force couple components and provide dynamic stabilization of the scapula. These exercises help provide the proximal platform of strength for the upper extremity and are the first stage in the scapular progression series.
Starting position: Stand with your arms in front of your body, elbows flexed 90° and a piece of elastic band or tubing placed across the hands in the palm-up position. Shoulders are in neutral rotation such that the hands are directly in front of you.
Exercise action: With light tension in the band, externally rotate both shoulders by moving the hands apart about 3 to 6 inches (8 to 15 cm) against the resistance of the band. While holding this position, maximally retract and depress (squeeze shoulder blades together and downward), holding this end position for 1 to 2 seconds. Return to the starting position by relaxing the shoulder blades and moving the hands back toward each other.
Primary muscle groups: Scapular stabilizers, rotator cuff
Indications: Excellent exercise to recruit the lower trapezius with little activation of the upper trapezius
Contraindications: Shoulder pain
Pearls of performance: Ensuring that the patient maximally retracts the scapulae is an important guide in this exercise. Giving feedback by palpating the scapular medial border is recommended during skill acquisition of this exercise.
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