Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomized clinical trial

Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS


Patellar tendinopathy (PT) is a common chronic tendon injury that not only effects a high percentage of the athletic population, but also a number of people that participate in physically demanding work. Currently, there is no known direct cause of PT, making it difficult to determine first-line treatment as not all people respond the same way to the same treatments. Eccentric exercise therapy (EET) is one line of treatment that has strong evidence supporting its effectiveness for PT, however, EET can be pain-provoking. Additionally, the onset of pain with this mode of treatment makes its use debatable during the competitive season for athletes as they are less likely to adhere to treatment. Recent research proposes the utilization of progressive tendon-loading exercises (PTLE) within the limits of “acceptable” pain, however, there is no current comparison between EET and PTLE. This study compares the effectiveness of PTLE with EET in patients with PT.


This study looked at 76 recreational, competitive, and professional athletes with clinically diagnoses and ultrasound-confirmed PT that were randomly assigned to receive either EET (control group) or PTLE (intervention group) for 24 weeks. Most participants (82%) had previously underwent treatment for PT but failed to recover fully. PTLE consisted of 4 stages: 1. daily isometric exercises, 2. isometric and isotonic exercises, 3. plyometric loading and running exercises, and 4. sport-specific exercises. Progression through these stages was determined by individual progression criteria based on pain provocation during a single-leg squat. EET consisted of 2 stages: eccentric exercises performed 2x/day for 12 weeks followed by sport-specific exercises for 12 weeks if the participant was compliant to stage 1. Both groups received exercises targeting risk factors for PT such as flexibility exercises and hip strengthening exercises.

Outcome measures:

The primary outcome was the VISA-P questionnaire. Secondary outcomes were return to sport rate, subjective patient satisfaction, and exercise adherence.


The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 points vs. 18 points).
There was a trend towards a higher return to sports rate in the PTLE group (43% vs. 27%).
The percentage of patients with an excellent satisfaction was significantly higher in the PTLE group (38%) than in the EET group (10%).
There was no significant difference between subjective patient satisfaction and exercise adherence between the PTLE and EET groups after 24 weeks.


This study demonstrated improved performance in the PTLE group compared to the EET group that was both important and clinically relevant. Additionally, as this study included participants who had received prior treatment for PT but did not improve, the findings of this study also indicate that PTLE is still beneficial to this population. Other findings from the PTLE group are that there was a higher return to sports rate compared to the EET group and participants in the PTLE group reported that the exercises were significantly less painful to perform. However, it should be noted that in the PTLE group, less than half of the patients returned to sports at a preinjury level after performing PTLE for 24 weeks. This indicates the need for further improvements on the PTLE program. Both groups demonstrated improvements in pain, function, and ability to play sports, suggesting the importance of exercise therapy in general as a form of conservative management for patients with PT.

Take Home Messages:

Patellar tendinopathy is a chronic condition that affects a large number of people, however there is constant research being conducted to investigate what forms of conservative treatment are the best to trial prior to more invasive procedures. At the time this study was conducted, eccentric exercise training, or training done where the muscle is loaded during the phase where its length is increasing, had strong evidence supporting the effectiveness in PT. The difficult part regarding EET is that it is pain-provoking and its beneficial use during a competitive season for an athlete was uncertain. Another challenge of PT is that one treatment doesn’t work for all patients diagnosed with PT, resulting in several patients having gone through an unsuccessful bout of physical therapy, which only adds to the frustration surrounding the rehabilitation process. This study demonstrated that progressive tendon loading not only worked the same, if not better, than EET and was less pain-provoking, but also was successful in participants who had gone through unsuccessful bouts of treatment for their PT. For clinicians, this means that utilization of progressive tendon loading should be trialed in patients with longer-standing PT or previously failed bouts of treatment. For patients, this means progressive tendon loading is worth trialing, regardless of chronicity or history of treatment, as a form of treatment for PT.

Article Reference:

Breda, S. J., Oei, E., Zwerver, J., Visser, E., Waarsing, E., Krestin, G. P., & de Vos, R. J. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine55(9), 501–509. https://doi.org/10.1136/bjsports-2020-103403

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy

Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS


Eccentric exercise is the most commonly prescribed exercise for the treatment of tendinopathy, however, is often too painful to complete. In the competitive season, athletes are less likely to adhere to an eccentric loading program due to increased pain and experiencing either no benefit or worse outcomes, however they may be more compliant with pain reduction strategies that enable ongoing sports participation. Few interventions reduce patellar tendinopathy (PT) pain in the short term. Isotonic exercise has been shown to be as effective as eccentric loading in PT, however there is little to no current research demonstrating this form of exercise’s effect on pain. Isometric exercise has been shown to reduce pressure pain thresholds in normal populations but has not been studied in PT. This study compared the effect of a short bout of isometric and isotonic quadriceps loading on PT pain, maximum contraction strength of the quadriceps, and the neurophysiology of the two exercises.   


This study looked at six male volleyball players with PT pain. Three players had unilateral pain and the other three had bilateral pain. Immediate and 45-minute effects following a bout of isometric and isotonic muscle contractions were compared. Complete inclusion and exclusion criteria can be found in the original article. Below are the loading protocols utilized in the study.

Outcome measures:

PT pain during the single leg decline squat (SLDS), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition.


Isometric contractions reduced pain with SLDS from 7.0­­±2.04 to 0.17±0.41 and isotonic contractions reduced pain with SLDS from 6.33±2.80 to 3.75±3.28.
Isometric contractions released cortical inhibition from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition.
Condition by time analysis showed pain reduction was sustained by 45 minutes post-isometric but not isotonic condition.
The mean reduction in pain scores post-isometric was 6.8/10 compared to 2.6/10 post-isotonic
MVIC increased significantly following the isometric condition by 18.7%±7.8, and was significantly higher than baseline and isotonic condition, and at 45 minutes post-intervention.


Isometric exercise immediately reduced patellar tendon pain with the effect sustained for 45 minutes while isotonic exercise had a smaller magnitude immediate effect on patellar tendon pain that was not sustained. There were also no non-responders to isometric exercise regardless of pain severity or length of time of symptoms while there was variable pain reduction experienced following isotonic exercise that was no sustained. Individuals with PT have higher amounts of cortical muscle inhibition for their quadriceps and heavy isometric exercise reduced this inhibition, which may be a factor in the mechanism of pain reduction. The clinic implication of this is isometric exercise may be an important option for clinicians to offer in tendons that are difficult to load without aggravating symptoms. This study had multiple limitations, one of which was the small sample size that was comprised of men, which makes it difficult to determine if the results are generalizable to all patellar tendon pain. Another limitation of the study was participants were diagnosed with patellar tendinopathy so it is difficult to determine if the same effects would be observed in other cases of anterior knee pain. This study also lacked a control group, or group where no intervention was performed, which would further qualify observed results of the study.

Take Home Message:

One of the most well-known interventions for tendinopathy in the world of physical therapy is to eccentrically load the tendon to an individual’s pain tolerance, however what interventions are you left with when the patient is unable to participate because of high levels of pain? The findings from this study give clinicians an alternative intervention for their patients that have more painful tendons by reducing the patient’s pain in the short-term, which would then allow them to tolerate other interventions that may have previously been too painful. As stated in the article, the use of isometric exercise for pain reduction in patellar tendinopathy is a great option for in-season athletes who may not want to stop participating because of their pain but would still benefit from short-term pain reduction. This study had a handful of limitations, such as a small sample size, however this shouldn’t deter clinicians from utilizing isometric exercise as a tool for pain management for PT pain.

Article Reference:

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386

Mariano Rocabado’s Approach to Tempormandibular Joint Evaluation and Treatment

by John Baur, PT, DPT, OCS, FAAOMPT

The material for this article consists of a compilation of the evaluation and treatment techniques learned from Mariano Rocabado, PT, DPT while attending Basic Cranio-Facial (CF1), Intermediate Cranio-Facial (CF2) and Advanced Cranio-Facial (CF3) courses through the University of St Augustine and from peer reviewed journals.  Dr. Rocabado is recognized internationally as an expert in the field of temporomandibular joint dysfunction (TMD).  This article contains an overview of diagnostic radiographic imaging and manual therapy treatment techniques for TMD patients.

A common focus in TMD treatment involves the position of the cranium and the mandible relative to the cranium.  The term craniovertebral centric relation refers to the stability of Atlas and Axis and how Atlas is stabilized on Axis, and how the Axis is stabilized on C3.

In physical therapy the term craniovertebral centric relation refers to a three dimensional articular ligamentous position of the cranium over the upper cervical spine.  The condyles of the occiput adopts a stable position over the first cervical vertebra (Atlas), which maintains a stable anteroposterior and lateral position with the odontoid process in a horizontal alignment over the shoulders of the Axis (C2).  This relationship allows the occiput, Atlas and Axis to perform 50% of the function of the craniocervical unit.  The Atlas, Axis (two atypical vertebrae) and C3 form the upper cervical spine and they perform 50% of the function of the neck.

The craniovertebral centric relation should not be confused with centric occlusion which is the relationship between the maxilla and mandible.  The physical therapist treatment should focus on accomplishing a craniovertebral centric relation and congruency in the craniovertebral joints.

It is also important to understand the concept of the synovial joints of the TMJ and the idea that the temporal component of the joint has to be horizontal.  The position of the temporal portion of the temporomandibular joint is related to the position of the cranium which is dependent on how the occiput relates to the craniovertebral joints.  If the occiput is level horizontally in the sagittal plane and the patient has a functional craniovertebral angulation with adequate space between occiput and Atlas, than the TMJ disc is going to be related to the temporal bone in a horizontal position. Once the position of the disc is identified in the fossa, than the physical therapist should know where the condyle should be relative to the disc and the condyle and disc will be in the center of the fossa.

Normal Condyle-Disc-Temporal Relation (Westesson)

The condyle is related in the fossa once the temporal bone is horizontal, and once the temporomandibular disc is stable on the fossa.  Once the occiput is in a horizontal position in the sagittal plane the horizontal position of the temporal bone must be determined.  Next the physical therapist sketches a vertical line passing through the center of the fossa in the 12 o’clock position and a horizontal line in the 3 o’clock position.  This disc should be anteriorly and in between the vertical and horizontal lines.  Next to determine the position of a stable relationship between the condyle, the disc, and the fossa the physical therapist should understand the principle of centric relation.

Westesson angle – first determine the horizontal position of the temporal bone which is determined by the horizontal position of the occiput.  Next trace a horizontal line tangent to the inferior border of the eminence.  A perpendicular line can be drawn crossing the deep portion of the fossa.  Both lines determine the position of the disc in the posterior wall of the eminence.

The active joint surface of the condyle it is convex and the active joint surface of the temporal component is convex.  Thus, active joint surfaces of the active TMJ structures are both convex.  When two convex surfaces gliding in opposite directions occurs in joint it produces “wear-and-tear” and degeneration.  To change this relationship the disc provides a concave joint surface.

In the temporomandibular joint, there is a convex surface of the condyle that produces an inferior independent synovial joint. The convex surface of the temporal bone produces a superior independent synovial joint.  This results in a convex on a concave inferior synovial joint and a concave on convex superior synovial joint.

The concave disc is needed for congruency and stability since the temporomandibular joint has two convex surfaces that face each other and it is inherently an unstable joint.  Fifty percent of the TMJ function comes from the inferior synovium, and 50% function comes from the superior synovium.  It is important that the two convex surfaces remain very tight together with the concave disc, where the convex and concave surfaces meet, in order for the joint to remain stable.

Craniovertebral Angle and Cervical Lordosis

The second cervical vertebra (C2) is the most important vertebrae to exam at this level since it is the vertebrae that supports the weight of the cranium and distributes forces to the rest of the cervical spine.  The position of C2 will determine the curvature of the lower cervical spine.  A functional craniverbral angle should fall between 96 and 106 degrees and achieving this measurement should be one aim of physical therapy treatment.  The physical therapist will want to accomplish centric relations and congruency in the craniovertebal joints and the dentist will want objective reasoning and measurements, and this can be accomplished by measuring the craniovertebral angle.

Cranioverbral Angle / McGregor’s Plane

The loss of cervical lordosis will increase the compressive forces and load through the cervical spine and can lead to cervical joint degeneration.  So it is important to recognize the loss of cervical lordosis in developing children in order to prevent postural abnormalities that may cause degenerative joint changes and orofacial pain.

The craniovertebral angle, the angle between the cranium (basi occiput) and C2, plays a major role in establishing the cervical lordosis. It is also noting that the craniovertebral angle is important because of its impact on the sub-cranial space.  Rocabado teaches the concept of the functional craniovertebral unit, the concept of the craniovertebral angle and the importance of adequate functional sub-cranial spaces. Also how the sub-cranial angle determines the curvature of the lower cervical spine.

The below cephalometric radiographs demonstrate the association between the craniovertebral angle and lordosis in the mid/lower cervical spine. The radiograph on the right demonstrates sub-cranial backward bending, as seen by the narrowed space between occiput and the spinous process of C2. The cervical lordosis is consequently decreased or reversed.

The cephalometric radiographs on the left demonstrates normal position of the head and cervical spine and on the right a flattened cervical lordosis with sub-cranial backward bending.

The sub-cranial angle can be assessed on a radiograph. The below image demonstrates the sub-cranial angle, formed by the McGregor’s line and the odontoid plane (blue arrow). The McGregor’s line is drawn from the posterior hard palate to the basi occiput and the odontoid plane from the anterior-inferior margin of the body of C2 to the tip of the odontoid. Where these two lines intersect there should be a 96-106 degree angle posteriorly (see radiograph below).

Cephalometric radiograph. Please note the position of the hyoid bone (yellow arrow) in line with the C3/4 interspace. Notice also the posterior arch of atlas in a mid-position between basi occiput and C2 spinous process, dividing the sub-cranial space in half.

Skeletal Midline

Skeletal midline is an important component in establishing cranioverbral symmetry in the coronial plane.  The Axis (C2) plays an important part in establishing skeletal midline because it is used as a reference point for creating the vertical vector through the dens and vertebral body.  When C2 is in skeletal midline the spinous process should be vertically in line with the  center of the dens.  Dentist would determine skeletal midline when the patient swallows and bites the point at which the central line of the maxillary (upper) central incisor will coincide with the center of the mandibular (lower) central incisor.  The center of the maxilla should coincide with the center of the mandible.

The skeletal midline of the craniomandibular joints is determined by a vertical line that crosses through the middle of the dens and the spinous process of C2.  The second cervical vertebra acts as the base for the cranium and the Atlas is in between as a stabilizer.  The cranium is also attached ligamentous with C2.

In this position, Atlas (C1) should be proportionally related on the left and right to the dens of the Axis.  The inferior joint surfaces of Atlas will symmetrically on top of the shoulders of Axis in a horizontal position to allow Atlas to rotate.  The Atlas is going to be sitting horizontally on top of Axis, perpendicularly.  In order for the cranium to be horizontal in the coronal plane, C2 must be on a skeletal midline, with a craniovertebral angle between 96 and 106 degrees.

The midline of the maxilla and the mandible should be on a skeletal midline that corresponds to the skeletal midline of the craniovertebral joints.  There should essentially be one skeletal midline that crosses the center of the cranium, through the center of the mandible and the middle of the cervical vertebrae.  The dentist will try to get the mandible to the maxilla on a skeletal midline.  Whereas the physical therapist has to coincide that skeletal midline with the midline of the craniovertebral joints in order achieve congruency and stability in centric relation.

If a patient can side bends to the right and not to the left than C2 is likely rotated to the right. The patient can side bend towards the problem, but not away.  The spinous process will move in the opposite direction of the head.  This is a good test for the stability of the craniovertebral joint mobility.

If the Atlas is not sitting on top of Axis in skeletal midline then the patient will not have normal function of the craniovertebral joints.  If the patient does not have a cranium that is horizontally related in the sagittal plane or the coronal plane they cannot have a stable occlusion.

The occlusive contacts change depending on the position of the cranium.  Different cranial positions will create different mechanics.  The cervical joints need to have centric relations for normal patterns of growth and development.

Principles of Occlusion:

Everything is relative to how the mandible moves to the cranium.  Physical therapists use to believe that all cranio-facial problems were caused by muscles. This belief was accepted for about 10 years. Then there was 10 years that were focused on occlusion or how teeth related to each other.

The front teeth help to guide the mandible forward until they are approximate.  When the front teeth are edge-to-edge, the back molars should not touch and the mandible moves forward and down.  The separation of the back teeth helps protect them.  Canine guidance and incisive guidance are mutually protected system to decrease wear-and-tear of the teeth.  The canines provide lateral guidance and the right canine protects the left and vice versa. The front teeth help provide anterior guidance.

The back molars are more powerful when biting than the front teeth and the canines are not as strong as back molars.  A centric occlusion is when the joint surfaces are maximally congruent.  When the TMJ cannot accomplish any further movement in a given direction it is in a close pack position.

In-occlusion means no contact between teeth and the TMJ is in a loose pack position.  Occlusion means to close and this is when the TMJ is in a closed pack position.

The contraction of the muscles of mastication increases when the teeth are touching.  The temporomandibular joints should not spend more than 15 minutes of a 24 hour period in a closed pack position and the teeth should not be in occlusion for more than 15 minutes a day.  Thus, the teeth should be in a loose pack position for the majority of time.  The amount of time that teeth are touching equals the amount of time that the muscles are contracting.  The more time the TMJ is in closed pack position, the more time the TMJ is exposed to an isometric muscle contraction which can lead to para-function.  It is important to keep your mandible at resting position in order to preserve or rebuild anterior guidance and to preserve or rebuild canine guidance for protection and muscle relaxation and to avoid premature degeneration.

The importance of sub-cranial spaces

A disturbance of the cranio-vertebral angle implies postural aberration and might indicate that physical therapy intervention is needed. Therefore it is important that we teach the orthodontists that we work with to measure the craniovertebral angle and palpation of the suboccipital triangle. The dentist will then have an objective way of knowing if the cranium is anteriorly or posteriorly rotated and if functional space is adequate, and can then decide whether to refer the patient to physical therapy. This assessment can be done easily.

Atlanto-occipital backward bending demonstrated on a model

The space between the basi occiput and C2 should not be less than 20 mm and the physical therapist should be able to place a minimum of a two fingers in this space.  So in the absence of a radiograph a clinician should be able to evaluate through palpation the loss of functional sub-cranial space.

Functionally there needs to be a space between the occiput and Atlas, and their needs to be a space between Atlas and Axis.  These spaces are supposed to be proportional, 6.5mm +/- 2.5mm and the spaces can vary between 4 and 9mm (Rocabado, CF2, CF3 2013).

The spaces between occiput and Atlas and the spaces between Atlas and Axis can decrease.  If C2 shifts, it can go into a state of immobilization and the spaces can cause a mechanical entrapment of the neuro-vascular structures which can cause headaches and facial pain (Rocabado, CF2, CF3, 2013).

The landmarks of the suboccipital triangle include the basi occiput superiorly, spinous process of C2 inferiorly and transverse process of C1 laterally.  Three muscles of the border the triangle include: Rectus Capitis Posterior Major (above and medially), Obliquus capitis superior (above and laterally) and Obliquus capitis inferior (below and laterally).  The floor is formed by the posterior occipito-atlantal membrane, and the posterior arch of the atlas.  Palpation in the suboccipital triangle can help us determine the functional sub-cranial spaces and serving as a provocation test for the soft tissue in this area.

                                                                                 The suboccipital Triangle (yellow triangle) – provocation test.

The effect of occlusal changes on the sub-cranial angle

Lowering of the mandible leads to a temporary increase in cranial backward bending. The posture of the head has been found to change immediately following an “opening of the bite” – with an increase in vertical dimension anteriorly (a.k.a. lowering of the mandible).  Using an inter-occlusal appliance, normal individuals were subjected to an opening of the bite, ranging from 0.3-9º. Within one hour a posterior rotation of the head was found in 90% of the subjects.  Physical therapists must be aware that wearing an appliance will have this effect and this may lead to symptoms in some of our patients. Patients with an ample sub-cranial functional space are going to tolerate this change in the sub-cranial angle, but for someone who already has a narrow craniovertebral angle (<96º) this might lead to symptoms.

A physiological cervical lordosis is seen with a craniovertebral angle between 96ᵒ-106ᵒ.  Non-physiological cervical postures are seen with craniovertebral angles <96ᵒ (posterior cranial rotation, lower cervical spine moves into flexion/inverted cervical lordosis) and >106ᵒ result in anterior cranial rotation.

Trigeminal cervical nucleus

The trigeminal cervical nucleus is located in the center of the upper cervical spinal cord and it has three branches: V1, V2, and V3.  The first cervical vertebral (C1) corresponds with V1 branch of trigeminal cervical nucleus which innervates supraorbital area of the face.  The second cervical vertebral (C2) corresponds with V2 branch of the trigeminal cervical nucleus which innervates infraorbital area of the face.  The third cervical vertebral (C3) corresponds with V3 branch of the trigeminal cervical nucleus which innervates the mandibular area of the face.  Understanding the anatomical relationship between the upper cervical spine and the trigeminal cervical nucleus will help the physical therapist identify segmental dysfunction based on pain patterns of the face and head.  Also, it is important to know that the position of C2 will influence the functional spaces of the cervical spine posteriorly which can contribute to headaches and facial pain of a cervical origin.

The cervicogenic headaches are pain  that refers to the head from a source in the cervical spine.  Unlike other types of headaches, cervicogenic headaches has attracted interest from disciplines outside of neurology.  Orthopaedic manual physical therapist, dentist in the area of craniofacial and oral pain, and interventional pain specialist (anesthesiologist) have developed an interest this headache treatment (The Lancet, 2009).  Cervicogenic headache are the best understood of the common headaches.  The mechanism is known, and these headaches have been induced experimentally in healthy volunteers.  In some patients, cervicogenic headaches can be treated temporarily by diagnostic blocks to the cervical joints and nerves (International Headache Society, 2004).

The convergence of cervical and trigeminal afferents on second-order neurons in the trigeminocervical nucleus may refer pain from the upper cervical spine into the head and face.  Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain neck symptoms of trigeminal origin (EG, Migraine) (Dreyfus, 1994).

Every time there is a loss of space in the craniovertebral angle you lose the distance between the spinous process of C2 and occiput. When the distance or space between occiput and C2 is lost it will cause the Atlas to try to find a way to maintain a functional space and the Atlas will no longer have any functional space.  Physical therapy treatment should focus on increasing or opening up the space between occiput and C2 to allow the atlas to have space between occiput and C2.

If there is a loss space between occiput and atlas or Atlas and Axis, or both, the patient could also have a loss of space in the craniovertebral angle.  If the position of C2 changes, the spaces will change and the cranial nerves and vascular structures can become entrapped.  C2 becomes the most important vertebrae to treat in this condition of trying to find a horizontal position for the cranial and for a stable craniovertebral system.

X-Rays will show if the space between occiput and C2 or occiput and atlas have decreased.  If those spaces have decreased, they form an entrapment for the ligaments and others tissues in that area and that can lead to headaches.  A physical therapist must manually open up those spaces.  The space between occiput and C2 should be at least 20 mm.

To manually assess this space you should palpate the spinous process of C2 and then  side bend the head to the left and right to feel C2 rotate. The physical therapist should be able to feel the space between occiput and C2 and the movement of C2.  Fifty percent (50%) of the rotation of the head takes place at Atlas and Axis with the occiput on top.  The occiput and Atlas uses the dens as an Axis of rotation and it allows the head to rotate right or left.  If the patient turns their head to the right the patients head should go from the sternum to the most prominent portion of the shoulder laterally.

The patient should have 50% rotation to the right, and 50% rotation to the left.  The flexion-rotation test is one of the best ways to prove craniofacial pain or headaches of cervical origin.

Atlas can be related to the wings on a plane. When the plane needs to turn right, the right wing drops down and goes back while the left wing goes up and forward. When the plane needs to turn left, the left wing goes down and back while the right wing goes up and forward.   If the transfer process of Atlas is more prominent on the left side, it means that it rotated to the right. If the transfer process of Atlas is more prominent of the right side, it means that it rotated to the left.

Manual Therapy Treatment to Increase Subocciptal Spaces

So the physical therapist will need to change the position of C2, and by doing so you will open up or increase the space between occiput and C2 and this will help atlas to restore functional space with occiput and axis.

When treating TMD it is important to note that:

  • Some problems can be caused by the neck, in which case it is important to stabilize the cervical spine.
  • When dentists look at teeth, they should find at least one contact that is wrong.
  • The physical therapist should continue to stabilize cervical spine.
  • Have an objective concept with your patient’s dentist. Relay evaluation measurements and findings.
  • Accomplish a state of rest for TMJ and cervical joints.
  • Occlusion contacts will continue to change with treatment. It will be important for the patient to follow up her/his dentist throughout treatment.
  • Breathing patterns may be evaluated in patients who have sleep apnea.
  • You want the muscles to relax in order to find a stable position.

Manual Therapy Treatment Technique (in sitting) to Increase Subocciptal Spaces

  • Place patient is a seated position with the malar bone over the sternum.
  • Palpate the subocciptal triangle. Assess for provocation of pain or symptoms.
  • Alar ligament test – Side bend (or laterally rotate the cranium) C2 should rotate in the same direction. Assesses the stability of the Alar ligament on the opposite side of the side bending.
  • Determine the position of C2-C3 by evaluating sidebending and look for right and left motion restriction and asymmetry.
  • Evaluate Atlas rotation by fully flexing (anteriorly rotating) the cervical spine and assess the cervical spine rotation left and right.
  • Long axis traction/distraction of C2-C0 in sitting.
    1. 6 times with 6 second holds
    2. The purpose of the distraction force is to lubricate the joints
    3. With inspiration the head moves up as the curvature of the spine straightens and with exhalation the head moves down as the spine returns to a resting curvature. This movement produces the force for distraction.
    4. When the patient breaths in, the head moves up and the physical therapist supports the head with one hand and the exhalation produces a nature distraction. The muscles also relax with exhalation and the weight of the body produces a distraction force with the body moving away from the head.
    5. The fingers of the mobilizing hand should be placed over the mastoid process, hand / thumb over the malar bone and the thumb in front of the ear.
    6. To produce a specific distraction the physical therapist uses the opposite hand to stabilize C2 laterally over the transverse processes. The stabilizing hand should be not aggressively hold down C2.

Figure 1: Long Axis Traction/Distraction

  • Long axis traction/distraction of C2-C0 with cranium side bending (lateral rotation of the cranium) in the direction of the restriction. Once side bending (lateral rotation) movement improves rotation to the opposite direction can be added.
    1. Follow the same steps noted above and then add gently side-bend/mobilize head towards the motion restriction while the distraction force in maintained.
    2. The goal is to lubricate the cervical joints and to improve side bending (lateral rotation) mobility in the direction of the restriction.
    3. The physical therapist stands on the opposite side of the side bending.
    4. The amount of side bending (lateral rotation) and rotation is approximately 11 mm (less than .5 inch) in each direction.
    5. Eventually side bending and rotation movements can be combined.
    6. When performing right side bending (of the cranium) mobilization with left rotation the C2 is being mobilized on C3 and the right C0 on mobilized on C1.

Figure 2: Long Axis Distraction with Right Lateral Rotation


Figure 3: Long Axis Distraction with Right Lateral Rotation with Opposite Rotation

  • Occiput “Lift”
    1. Cross hands around the malar bone in order to have good control of the head and face. Take the neck to end range rotation in the direction of the restriction.
    2. While in end range rotation, have the patient inhale and then exhale to produce a quick distraction force/”occiput lift”. The mobilization occurs at the end of the exhalative breath.

Figure 4: Occiput “Lift”

The objective of this sequence of techniques is to initially identify upper cervical spine mobility restrictions.  Then treat the hypomobile joints by first lubricating the joints through gentle long axis distraction and then progress the treatment to mobilizing the joint in the direction of the hypomobilty/restriction.  Rocabado progresses the treatment from long axis distraction, to long axis distraction with side bending (lateral rotation), and then long axis distraction with side bending (lateral cranium rotation) with horizontal rotation.  Finally, Rocabado does a distraction mobilize (approximately a grade IV-V) of the CO/C1 joint while at end range horizontal rotation.

Rocabado describes the Atlas (C1) as being “like a disc” functioning between C0 and C2.  This treatment sequence mobilizes the inferior joint surface of C1 by mobilizing C2 (rotation of C2 on C1) and mobilizing the condyles of the occiput on Atlas.  The Atlas receives a maximum amount of mobilization without moving the Atlas itself.


This project was intended to provide an overview of knowledge attained while studying with Mariono Rocabado and not his complete and comprehensive craniovertebral evaluation / treatment approach.  The foundation of Rocabado’s evaluation approach lays in assessing the upper cervical stability, in particular the sagittal and coronal planes, and this was outlined in this capstone project.  In addition, Rocabado stresses the importance of preparing joints for treatment in a gradual progressive manner.  A sample treatment was outlined so the reader could appreciate Rocabado’s principle of a progressive treatment approach.


  • Dreyfus P; Michaelson M, Fletcher D, Atlanto Coppipital and Lateral Atllanto Axial Joint Pain Patterns. Spine 1994; 1: 1125-31.
  • International Headache Society. The International Classification of Headache Disorders. 2nd. Edition Cephalalgia 2004; 24 (SUPPL. 1) 115-116.
  • Mariano Rocabado. January 2013. Basic Cranio-Facial (CF1). University of St. Augustine. Online course.
  • Mariano Rocabado. February 2013. Intermediate Cranio-Facial (CF2). University of St. Augustine. Chicago, IL.
  • Mariano Rocabado. February 2013. CF3 – Advanced Cranio-Facial (CF3) University of St. Augustine. Chicago, IL.
  • thelancet.com/neurology Vol. 8, October 2009

Orthopaedic Treatment for Benign Calf Amyotrophy

by Ray Moore, PT, DPT, OCS

The purpose of this capstone project was to describe the case of a patient who presented to the clinic with an uncommon motor neuron disease including the treatment plan and discussion of orthopaedic manual therapy principles.  Benign calf amyotrophy is a sub category of lower motor neuron diseases often called benign focal amyotrophy.  This condition was originally reported by Hirayama et al. (Cintas 2017) and focused on Asian male youth with distal upper extremity muscle atrophy and weakness.  Lower extremity involvement was later reported as Wasted Leg Syndrome by Prabhakar et al. in 1981.  Since, several forms and presentations of benign focal amyotrophy have been studied and reported on yet there remains a gap between empirical studies and clinical treatment.  Relative to other motor neuron disorders such as ALS and myopathies, little is known of the etiology, cause and treatment of benign focal amyotrophy.  Some reports indicate that fewer than one hundred cases involving the lower extremity have been diagnosed, with most in the eastern hemisphere, particularly India.  Consequently, this author was unable to locate significant research pertaining to physical therapy or other treatment of benign calf amyotrophy (Cintas 2017).

There are two proposed origins leading to benign focal amyotrophy: repetitive trauma and idiopathic cause.  The available literature notes that males are considerably more affected, up to 10:1 male to female ratio, and most patients are under the age of 30 at diagnosis (Cintas 2017).  There is some variability of age range in different parts of the world which has led some to believe that benign focal amyotrophy is a diverse condition with varying types of presentations.  The earlier upper extremity variant described by Hirayama was believed to be caused by repetitive cervical spine flexion trauma or microtrauma causing flattening of the cord. 

However, MRI of the lumbar spine of patients with lower extremity involvement are typically normal with no cord or nerve root abnormalities detected (Cintas 2017).  However, MRI showed “marked atrophy and increased signal intensity were found mainly in gastrocnemius and soleus muscles” in one study (Hamano 1999).  EMG is one of the most helpful diagnostic tools and findings include “fibrillations, positive sharp waves and fasciculations” (Cintas 2017).  Nerve conduction velocity can be normal or slowed. 

(Stain of normal gastrocnemius cells vs. muscle cells in BCA, Felice et al. 2003)

Other signs indicative of lower motor neuron involvement can be present including hyporeflexia, absent Babinski sign, visible atrophy, calf muscle fasciculations, and fatigable weakness.  Surrounding musculature is typically spared such as foot intrinsics however Hamano et al. reported involvement of some quadriceps and hamstring muscles in one patient (Hamano 1999).  To date, there is no clear explanation for the predominant involvement of the gastroc-soleus muscles.

A key difference between benign focal amyotrophy and other motor neuron diseases is the lack of progression and self-limiting nature.  Patients with benign calf amyotrophy experience lower leg weakness over a period of months to years which can last for a variable period.  Most reports suggest that lower leg weakness and atrophy slowly worsens then stabilizes.  Due to the lack of long term studies, it is unclear whether patient experience a full return of muscle strength, girth and function once the progression has ceased.  Treatment for severe upper extremity cases can include avoidance of cervical spine flexion, cervical collar use, and cervical spine surgery with duroplasty (Cintas 2017).  A search for treatment of lower extremity or benign calf amyotrophy revealed no empirical studies other than a brief mention of physical and occupational therapy.  Given the lack of findings on lumbar MRI versus cervical and upper extremity involvement, novel functional treatment approaches must be discovered.

Case Presentation

The patient, referred to as Robert, presented to our clinic and was referred by a neurologist with a special interest in neuromuscular disorders and EMG.  He is a 28 year old male of Greek origin who began experiencing gradual right calf weakness about one year prior to this evaluation.  Robert reported no trauma or known change in activity level prior to symptom onset.  He also experienced right lateral foot numbness which did not progress.  Prior to this evaluation, Robert reported some left lateral foot numbness but states that this fully resolved.  Robert’s right calf weakness progressed over several months and six months later he began seeing his neurologist.  At this point, Robert reported visible right calf atrophy compared to the left.  His neurologist ordered lumbar spine MRI with and without contrast which was unremarkable and EMG/NCV testing.  Robert’s NCV testing was normal bilateral but needle EMG showed fibrillation potentials and positive sharp waves in the right medial gastrocnemius muscle and to a lesser degree in the tibialis posterior.  There were no motor unit action potentials of the right gastrocnemius and reduced recruitment of the tibialis posterior.  Additionally, Robert’s serum creatine kinase was elevated at 596 U/L. 

On examination, Robert is a tall and physically fit individual who was previously an avid runner.  Robert is a school teacher and waited six months after seeing his neurologist to schedule a PT appointment due to his schedule.  Upon PT evaluation, the primary diagnosis was a suspected S1 nerve root lesion and benign calf amyotrophy was not mentioned on his PT prescription.  He reported no history of pain and Robert demonstrated abbreviated stance on right lower extremity during gait with limited toe push off in end stance phase. 

Robert’s right mid-calf muscle girth measured two cm less than the left and his right Achilles deep tendon reflex was absent while all other lower extremity reflexes were within normal limits.  Sensation to light touch was normal except diminished over right lateral 5th metatarsal.  Lumbar and lower extremity range of motion was normal, straight leg raise and slump tests negative, and Babinski/clonus were absent.  Small, infrequent fasciculations were detected in the right gastrocnemius and ankle plantarflexion was measured at 3+/5 compared to 5/5 on the left.  All other lower extremity MMT was 4+/5 to 5-/5 and normal for his age. 
Of note, there was minimal palpable contraction of the right gastroc-soleus during resisted plantarflexion.  No significant lumbar or other orthopaedic abnormalities were found during the examination.  Robert was instructed in some lower extremity therapeutic exercises and we attempted to finish the session with Russian muscle stimulation to the right gastroc.  Interestingly, Russian stimulation was unable to evoke muscle activation or twitch response from Robert’s gastroc-soleus, though he did feel increasing tingling sensation, a finding I had not previously seen in eight years of experience. 

At a subsequent follow up visit, Robert reported that he had seen his neurologist to review findings and she suspected he had benign calf amyotrophy, which is often a diagnosis of exclusion once other neuromuscular pathologies are ruled out.  Since I was not previously aware of this rare condition, I researched the topic thoroughly to best provide a treatment plan for my patient and quickly found a lack of evidence or even non-empirical discussion.  While benign focal amyotrophy is a self-limiting lower motor neuron disease, it is still possible to positively affect a patient’s outcome and quality of life with orthopaedic manual therapy and other physical therapy interventions.

Treatment and Research

Erl Pettman discusses the facilitated segment and its impact on extremity strength (NAIOMT 2005).  In this article, Pettman details how acute or repetitive injuries leading to segmental stiffness can cause additional unexpected outcomes.  Facet hypomobility at a segment can cause an adjacent or nearby hypermobility.  For example, limited left hip spin can lead to lack of left hip extension and/or rotation.  For normal gait to occur, this individual will have to hyperextend a segment in the lumbar spine or sacroiliac joint to allow upright gait.  Similarly, an L3 hypomobility into extension may lead to an extension hypermobility at L4 or L5 to promote full normal lumbar extension during functional movement.  When this issue becomes sub-acute to chronic, abnormal segmental input to the segment occurs which can present with both changes locally and in the extremities (Pettman 2005).
Segmental facilitation can cause muscle tenderness, hypo or hyperreflexia, altered skin and muscle sensitivity, muscle hypertonicity, inhibition of antagonist muscle groups, and muscle weakness that it typically not fatigable.  Pettman discusses common segmental facilitation at C2/3, C5/6 and L4/5, though it can occur at any spinal segment.  “It is proposed that the constant afferent barrage ultimately leads to a state of ‘central segmental excitation’ that, in turn, lowers the synaptic resistance and facilitates neuronal transmission” (Pettman 2005).  Furthermore, as discussed throughout the lab courses in the Fellowship program, manual therapy treatment to the axial spine can be beneficial in improving peripheral signs and symptoms.

One of the hallmark examples discussed by Pettman is the treatment of C5/6 for tennis elbow caused in part by segmental facilitation (Pettman 2005).  Manipulations, mobilizations, proprioceptive mobilizations, muscle energy techniques, and proprioceptive neuromuscular facilitation can improve the afferent barrage that this segment is receiving and reduce the peripheral consequences of that segment.  One such benefit of these treatments is the increase of peripheral myotomal muscle strength.

In a randomized controlled trial, Chilibeck et al. tested the effects of spinal manipulation on imbalances in lower extremity strength (Chilibeck 2011).  These authors performed segment specific chiropractic manipulations on subjects found to have a 15% or higher strength discrepancy between lower extremities.  Chilibeck et al. performed manipulations and placebo treatment to the spinal level associated with the muscle that they found weakness.  For example, subjects with hip flexor weakness received treatment to the corresponding L2-3 level.  This study found that lumbar spine manipulation can lead to a statistically significant increase in strength in knee and hip flexion for individuals with 15% or greater difference in pre-treatment strength.  The authors discuss possible explanations for increased lower extremity strength following spinal manipulation including “reduced nerve impingement, altered discharge from muscle spindles, Golgi tendon organs, mechanoreceptors and nocioceptors, altered sensory processing in the spinal cord, and altered skeletal muscle reflexes….to cause an increase in motor neuron excitability” (Chilibeck 2011).  This can lead to improved motor unit firing and increased strength in the associated myotome.

Robert’s mechanical lumbar exam did not show any significant instabilities, hypomobility, or considerable tenderness.  Robert was limited in thoracic-lumbar junction right rotation and demonstrated hypermobility into right extension at L5-S1 as measured by PPIVM, PAIVM and H/I testing.  Robert’s end-range was excessive but pain free.  For this reason, a thoraco-lumbar junction manipulation was performed followed by neuro-muscular re-training to this level.  Robert’s right rotation immediately improved but hypermobility was still noted at L5-S1.  While it was understood that the cause of Robert’s right calf weakness was clearly not restricted to the musculoskeletal system (given his negative lumbar MRI and other findings), it was hypothesized that some deficits may be caused by segmental facilitation at L5-S1, or that the minor mechanical lesions in the lumbar spine were a result of altered gait pattern due to neuropathic gastroc-soleus weakness.

Following the thoracic-lumbar junction manipulation, proprioceptive wobble PA mobilizations were performed at L5/S1 to improve afferent inputs with the possibility of increasing some gastroc-soleus strength that was limited by potential segmental facilitation versus motor neuron pathology.  Given the self-limiting nature of the patient’s diagnosis, it was explained that any additional safe method to increase his lower extremity strength would be worth a trial.  After two treatment sessions, the patient reported about 10% improvement in his right lower extremity strength with weight bearing activities and he began to demonstrate a slight observable and palpable contraction of his gastroc-soleus muscle upon voluntary contraction.

An early indication that Robert’s condition was not limited to the musculoskeletal system was his response to Russian current muscle electric stimulation.  Following his initial evaluation, I and a colleague attempted to apply muscle stimulation to Robert’s gastroc-soleus.  Using multiple currents and variations of parameters, we were unable to elicit a single twitch response.  The patient was able to feel the current sensation but no muscle contraction.  After reviewing Michelle Cameron’s Physical Agents in Rehabilitation, I found that “denervated muscles do not contract in response to the pulses of electricity that produce contractions in innervated muscles” since the “current causes depolarization of their motor nerves” (Cameron 2003).  At this time, I hypothesized that this patient was experiencing a condition related to pathologic denervation.  Cameron mentions that denervated muscles can be stimulated by “long pulses of electricity, lasting for 10 ms or longer.”  The typical treatment for denervated muscle is direct current stimulation however research has shown that any effect may be related to placebo and DC stimulation could hinder nerve regeneration (Cameron 2003).  Therefore, I did not continue with muscle electric stimulation.  However, in retrospect, I may have considered Russian muscle stimulation to the lumbar multifidus for the same reasoning as mobilization/manipulation for segmental facilitation.

Much of this patient’s treatment consisted of therapeutic exercise as well as a home exercise program.  Initially, Robert performed de-weighted calf raises in the seated position, single leg stance to tolerance with one hand assist, and theraband exercise for tibialis posterior strengthening.  Robert performed 3-4 sets of 20 repetitions for endurance training or he performed exercises to fatigue.  Robert was instructed to allow additional rest between sets for 45-60 seconds due to the fatigability of his lower extremity muscles.

Since Robert was an avid runner and weightlifter prior to this condition, his exercise routine included functional activities with modifications made as necessary.  Robert was unable to perform standing de-weighted bilateral heel raises, but after two sessions, he was able to complete sets of heel raises on the leg press on the lowest resistance.  Robert also performed bilateral leg press until he was able to complete weight bearing squats without excessive left trunk lean.  Resistance for the leg press was set based on Robert’s subjective ability to perform repetitions without heavily relying on the left lower extremity.  Robert also performed stool scoots early with right leg for activation of neighboring musculature.

Emphasized throughout the Fellowship didactic and lab work is the role of the individual spinal segmental stabilizers, like the multifidus, and their role in global stabilization and mobility.  Much like a train, if each car is not properly connected and stabilized, the entire train will not move.  If the multifidus and other segmental stabilizers do not properly stabilize a segment, such as L5-S1, then the entire mechanics of the spine can be affected and locomotion and functional mobility is not optimal.  For this reason, specific activation of the L4-S1 multifidus, as well as transverse abdominis and kegel exercises were implemented.  Robert was instructed on multifidus step-down activation with tactile cues.  Transverse abdominis and kegel muscle activation was added and more advanced exercises were built from this foundation.  Robert was encouraged to include segmental stabilizer activation in all static and dynamic activities of his daily routine.

After two sessions, Robert was able to progress to balance and higher level strengthening activities such as single leg dead lift with one hand assist, balance activities on soft surface, and hopping on trampoline on right leg.  Advanced balance and strengthening exercises such as plantarflexion and dorsiflexion on foam board and double leg squats on bosu ball were added at subsequent visits.  On the fourth visit, I saw Robert in the evening and he complained of lower leg swelling.  He stated that it was improving but he still experienced swelling in the evening.  Due to lack of function of the muscle pump, I provided Robert with a lower leg sleeve to be worn on days that he would be in the dependent position.  Additionally, since Robert is a teacher, I suggested that Robert take seated or supine rest breaks whenever possible and perform ankle pumps.  These modifications helped to reduce Robert’s complaints of lower leg swelling in the evening.

By his sixth visit, Robert reported about 25% improvement in right lower leg strength and 50% or more improvement in overall functional improvement since initial evaluation.  He was demonstrating a palpable and observable contraction of his gastroc-soleus and had progressed to exercises like right SLS on trampoline with soccer ball kick and the slide board for agility.  While Robert was unable to return to running, he was much more confident in his gait and did not experience tripping over his right foot.  Robert then had a follow up visit with his neurologist and left the country for a two week vacation.

When he returned three weeks later, Robert reported that he was being referred to another hospital for work up and treatment for benign calf amyotrophy.  He reported that while on vacation, he did not get to perform his home exercise program or other exercise much and stated that his right lower leg strength improvements had diminished.  However, functionally, Robert felt that he had made considerable improvements in physical therapy and reported improved confidence following treatment.  Robert was resuming teaching the following week and stated that he would have to self-discharge due to time restrictions.  Robert had a follow up EMG study that showed “some firing” compared with little to no activity prior.  He was able to voluntarily contract his gastroc-soleus with visible contraction during exercises.  Robert still complained of mild sensory deficit over the lateral foot but stated that it had improved since beginning physical therapy.  Robert’s right calf girth increased by one centimeter in a six week period.  Robert reported that he had experienced the most progress in over a year while he participated in physical therapy.  Robert was discharged with the recommendation that he follow up as his schedule allowed to continue to improve any remaining functional deficits.


          As expert clinicians, we are expected to be able to treat both simple and complex cases, perform detailed yet directed evaluations, demonstrate pattern recognitions, and have a wealth of knowledge of conditions to perform differential diagnosis.  However, the knowledge and preparation an expert clinician should possess cannot be limited or contained in a box.  Often, clinicians are forced to adapt to new information on unforeseen exposure.  In this case, a patient with a motor neuron disease that is so uncommon that very few in the physical therapy field are aware of it, came to my clinic with an atypical presentation.  Having performed the lumbar and lower extremity scan many times, I was quickly able to recognize that this patient did not show the normal signs and symptoms of radiculopathy or lumbar pathology. 

          Furthermore, I determined that this patient probably did not exhibit an atypical presentation of a common condition.  For example, while receiving mentoring during this Fellowship, my mentor and I evaluated a patient with lateral thigh pain.  While I hastily suspected the lumbar spine, I learned about a potential entrapment point for the lateral femoral cutaneous nerve just above the iliac crest.  Like much of the valuable knowledge and experience I had gained during mentorship, I was previously unaware of this entrapment site.  Still, I was able to recognize that this patient could have an atypical presentation of a common condition.  This Fellowship Program also furthered my ability to recognize patients that require attention outside of the scope of physical therapy practice.  Had Robert come to our clinic as a direct access patient, I would have immediately referred him to a physician. 

          Since Robert was under a physician’s care and he presented with functional impairments from an undiagnosed condition, I used my training to develop an individualized treatment plan for Robert both before and after his diagnosis was confirmed.  The expert clinician may be occasionally challenged by an unfamiliar diagnosis or presentation.  Fellowship and other training can assist in making that clinician adaptable to apply previously learned material and experiences to the creation of a treatment plan for a new diagnosis. 

          The particular difficulty that this case provided was a lack of clinical or empirical evidence for treatment of benign focal amyotrophy.  Several searches uncovered some literature that mentions the words physical and occupational therapy, but little other treatment was specified.  One might assume that since self-limiting, individuals with benign focal amyotrophy do not require physical therapy.  However, physical therapy is a critical component in the recovery of people diagnosed with Guillaine-Barre Syndrome and other self-limiting diseases.  Physical therapy is not limited to conditions that it is the primary treatment of choice such as whiplash or tennis elbow.


          This capstone project involves the application of skills and knowledge possessed by a Fellow in training to a topic not previously highlighted in physical therapy literature.  Limitations included the lack of considerable literature, especially pertaining to treatment, and a sample size of one patient.  While preparing for this capstone project, one intervention I would have implemented was muscle stimulation to the lumbar multifidus.  Still, it was a very valuable experience to treat a patient with such a rare condition and assist in his progress and regaining of functional mobility.  It is often difficulty for a young and active patient to understand their condition and why they can’t perform at the level they were accustomed.  As a physical therapist, part of our job is to help return that function to the best of our ability and provide understanding and education for the patient.  Both before and after confirmed diagnosis, Robert appreciated the education he was provided and he fully bought into his treatment plan.  He showed some progress which was uncertain given his diagnosis.  Fortunately for me, Robert presented to my clinic after I have performed much of the requirements for Fellowship training, including mentoring hours.  While my mentor did not specifically prepare me to treat someone with benign calf amyotrophy, I was prepared to adapt and care for a patient with a condition that I could not reasonably be trained for, which I believe is one of the chief purposes of Fellowship training.


  • Cintas, P. (2017). Motor neuron diseases: Benign focal amyotrophy. Revue Neurologique, 173(Motor neuron diseases), 338-344. doi:10.1016/j.neurol.2017.03.016
  • Felice K, Whitaker C, Grunnet M. Benign calf amyotrophy: clinicopathologic study of 8 patients. Archives Of Neurology [serial online]. October 2003;60(10):1415-1420.
  • Hamano T, Mutoh T, Kuriyama M, et al. MRI findings of benign monomelic amyotrophy of lower limb. Journal Of The Neurological Sciences [serial online]. June 1, 1999;165(2):184-187.
  • Chilibeck P, Cornish S, Schulte A, et al. The effect of spinal manipulation on imbalances in leg strength. The Journal of the Canadian Chiropractic Association.  September, 2011; 55(3): 183-192.
  • Pettman, E. The Facilitated segment.  The North American Institute of Orthopaedic Manual Therapy. October, 2005; Volume IX, Issue 5.
  • Cameron, M. Physical Agents in Rehabilitation: From Research to Practice (Second Edition).  Saunders.

Plantar Fasciitis: Stretching vs Strengthening and Stretching only a 2-study comparison

Reviewed by Mark Boyland PT, DPT, CSCS

Plantar fasciitis is a common diagnosis with symptoms including pain at the heel, difficulty walking, and increased foot pain usually for the first few steps in the morning or when walking after a period of immobility.  While there are many treatment options available we will review two studies which examined primarily exercise interventions on the treatment of plantar fasciitis pain. Effects of Strengthening and Stretching Exercises on the Temporaspatial Gait Patterns in Patients with Plantar Fascitis: A Randomized Control Trial and Effect of a home-based stretching exercises on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis. Both study participants were educated by a Physical Therapist on proper execution of these exercises and received a written home exercise program with instructions on how to perform and progress exercises.

The study which compared strengthening vs stretching group had 84 participants, a sizeable group, whereas the stretching only study had only 20 participants.  Participants were selected if they had only plantar fascial pain without other systemic conditions or other forms of lower extremity pain.  The strengthening vs stretching group was monitored for 12 weeks whereas the stretching only group was monitored for just over 3 weeks.

Interestingly enough the general pain, time of the worst pain, gait parameters, and muscle strength improved regardless of stretching only or strengthening only in either study.  However, there was limited changes on multisegmental mobility of the foot before and after interventions and there were no significant between group differences in any of the noted parameters.  However, both studies had significant decreases in pain from baseline to the first 2 weeks with progressively improving symptoms in following weeks, though not as significant.

Both studies provided the exercise protocols including sets, reps, progressions, and approximate time to complete assigned exercises.  The PMCID will be provided for free article access to review both protocols via Pubmed. The strengthening vs stretching study was a more traditional protocol including 3 sets of 10-15 repetitions of 4 strengthening exercises or 3 repetitions of 30 seconds with 10 seconds rest for the stretches. Patients were instructed to complete these exercises 3 times per day. The stretching vs strengthening study exercises took between 6-10 minutes to complete per session. The stretching only study had 3 stretching exercises which were performed for 20-30 seconds with 10 seconds rest for 10 sets 5 days a week over 3 weeks, the stretching only study took about 20 minutes to complete their exercises.

For Therapists:  Recent research has been guiding us to introduce a progressive loading program to help manage and improve our patient’s symptoms.  These two studies provide a framework on how to provide this progressive loading to your patients and that you have 3 options to provide your patients, pending their compliance/preference for exercise.  There seems to be no agreement between these two papers as to what a minimal/maximal dose of exercise intervention at this time, however 20-30 minutes of dedicated exercise seems to be a good start.

For Patients:  Plantar Fasciitis can be a difficult condition to recover from and that pain improvements can continue for up to 12 weeks after beginning an exercise program.  Your therapist can provide you with a stretching and/or a strengthening program to help manage/improve your symptoms depending on what you feel that you prefer.  This condition can be self-managed at home for the most part and your Therapist should be progressing you on a weekly to bi weekly basis pending your overall symptoms.  However, before you begin self-treating, a Physical Therapy Evaluation is critical to rule out other diagnoses or pathologies


Effects of Strengthening and Stretching Exercises on the Temporospatial Gait Parameters in Patients with Plantar Fasciitis:  A Randomized Control Trial.  PMCID PMC6960082

Effect of a home-based stretching exercise on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis.    PMCID: PMC7493445