Once the patient or athlete has mastered supine and quadruped, it’s time to move on and challenge them in plank and push-up positions. As far as where to start, I feel an elevated push-up position is going to be the easiest for learning purposes and less stress on the shoulders and low back. If the patient is quick on the uptake and quite athletic then I will probably choose exercises from both groups.
Push-Up Stability (45 degrees) –
Push-Up Stability Lateral(45 degrees) –
The emphasis on both of these movements is to teach the patient to maintain a neutral position and brace while holding a more challenging position. The progression would be to work these to the floor. Stairs are a great place to have your patients do these at home to allow them to progress incrementally. Hold time is 10 seconds initially and progressed to 30 seconds.
Progressions, at any level, include alternate lifting the arms, alternate lifting the legs, and finally an opposite arm and leg pattern similar to the Bird Dog.
Push-Up Stability – Alternating Arm Lift
Technique is perfect in picture #1. Watch for the shoulders and pelvis to rotate if the patient loses control (picture #2).
Push -Up Stability – Alternating Hip Extension
The first picture shows proper technique. The most common loss of stability can be seen in picture #2 with lumbar extension plus some scapular winging.
Push-Up Stability – Opposite Arm and Leg
The traditional push-up is a great ‘core stability’ exercise itself, when done correctly. The chest and abdomen should leave the floor simultaneously and the athlete stays rigid throughout the exercise. Place a stick along the spine contacting the head, t-spine, and sacrum, to give the athlete feedback on proper positioning.
Hand position can also be varied to add more of a challenge. Placing one arm forward and one back, both arms slightly forward and one hand on a ball have all been shown to increase recruitment of the abdominals as well as latissimus with only minimal increases in spinal loads (1). Plyometric push-ups, with a clap, show even higher recruitment patterns but that is probably getting too advanced for the clinic. As with all stabilization work, these exercises are not done to fatigue. Perfect form is most important to avoid compensatory strategies.
Plank exercises can be more challenging than the push-up stability exercises now that the elbow, wrist, and hand are out of it. It also limits the ability of the athlete to use the pecs to stabilize. Start with 10 second holds again for the basic front and side planks but do more sets. Initially it is about training the patient or athlete to feel the position and how to stabilize by recruiting the proper muscle groups. If endurance is worked in too quickly, larger muscle groups will start to take over for the small stabilizers.
Progressions from the front plank position include adding hip extension, shoulder flexion, opposite arm and leg lifts, and hip extension plus abduction.
(as you can see, I need some work on this one)
**Notice the “hip hinge” to get into and out of side plank position. This is done to maintain a neutral spine throughout the exercise.
The feet can be stacked during the side plank to make it more challenging but you will see with the transitions why I like to keep the top foot forward.
Progressions from the side plank include adding hip abduction static or dynamic, and hip adduction static or dynamic.
Transitions between front and side planks –
this is as good as it gets right here. All credit goes to Dr. Stuart McGill on this one. Cue the patient to “lock the rib cage to the pelvis” as they roll.
Just a quick note on the side planks as I frequently get comments on how hard they look. Many therapists just can’t believe they can be good for the low back. All I can say is that Dr. McGill swears by them and his research has actually shown relatively low spinal loads during the exercise. He has also demonstrated recruitment of all the abdominal musculature plus the quadratus lumborum and latissimus to add stiffness to the spine. I will admit not everyone is going to make it through all the progressions. Most of the athletes will, but many of my older patients can at least do the side bridge from the knees.
In part III, I will discuss progressions in 1/2 kneeling and standing.
Joe Heiler PT, CSCS
Joe Heiler MSPT is the owner and content manager of SportsRehabExpert.com, a website dedicated to advancing the education of rehab and performance professionals. The site focuses on orthopedic and sports physical therapy topics through webinars, audio interviews, articles, manual therapy and exercise videos, and more.
Joe is also the owner of Elite Physical Therapy and Sports Performance in Traverse City, MI specializing in orthopedics and sports medicine, as well as athletic performance training. He is Graston Technique (GT) Certified as well as a GT Instructor, SFMA and FMS trained, and is passionate about a number of soft tissue and manual techniques including Trigger Point Dry Needling and manipulation.