Effective Treatments for Textbook Lumbar Stenosis | Modern Manual Therapy Blog

Effective Treatments for Textbook Lumbar Stenosis

Here are my go-to treatments for patients who have a textbook presentation of lumbar stenosis.

The ironic thing about stenosis is that patients need to walk forward bent to open up their spinal canal. This leads to a cascade of musculoskeletal changes that enchances their dysfunction and makes it harder for them to walk and perform upright ADLs.

Areas to focus on:
Hip Extension

  • the lack of hip extension creates a larger extension moment at the lumbar spine in WB which typically increases their complaints
  • treatments
    • psoas release
    • QL release, especially for lateral stenosis
    • prone knee bend anterior glide
    • IASTM to ITB, rectus femoris
Hip IR
  • I find many of my older population not only have a lack of hip IR, they often have 0 degrees or less
  • any WB movement would place increased stress on the lumbar spine, especially activities like golfing or tennis
  • treatments
    • IASTM/FR to ITB, lateral hamstring/gluteal junctional area
    • hip long axis distraction, mobilization with movement hip IR with the belt ala Mulligan
Thoracic extension
  • improving thoracic extension = less lumbar extension = less closing moments at the lumbar spine
  • IASTM to the paraspinals, general P/As, nothing special here
  • treating the neural container often increases lumbar and LE mobility
  • start with sciatic tensioners and progress to slump sliders/tensioners if needed
  • femoral nerve tensioners/sliders if there is anterior or anterolateral thigh complaints or significant limits to hip extension
Patient Education
  • educate on how research shows long term outcomes for surgery and injections show no lasting effects for leg complaints or walking tolerance
  • meds and injections normally just mask the complaints vs treating the cause and improving function through improving movement quality and quantity
  • decrease any anxiety by telling them when their lower back or LEs feel fine, their spine still has those "kisses of time" on the MRI
  • graded exercise with progressive longer periods of walking upright
  • general conditioning and exercise certainly does not hurt either
  • give them education on other options if therapy is not working
Patient ther ex
  • M's for repeated hip IR - one of my favorites!
  • self sciatic and femoral tensioners
  • glut strengthening as there is often atrophy of the gluteals from a lack of hip extension
  • bilateral lumbar rotation/gapping rotation with LEs over a theraball
I find the above treatments/education often works well, sometimes to increase function, others to completely abolish pain. This is by no means a cookbook for success on an often difficult caseload, with patients who have never exercised before, have poor body awareness, and just want a fix.

  • if you restore mobility to the affected joints, nervous system and surrounding tissues, and function and/or symptoms do not improve within 6-8 weeks, you are probably beating a dead horse so time to consider other options
It was the most heart breaking patient case ever, when I applied everything I could think of to my own father, who had progressively worsening LE weakness and paraesthesia that really affected his walking. I held it off for a few years, especially if he would visit for longer periods of time. 

He went to the Philippines for a few months and stopped doing his exercises and of course did not bring his home traction unit (which actually helped, one of the only ones I have used on a patient!). When he came back, there was nothing I could do to make the LE complaints stay away, and his walking worsened. The bottom line is, I gave it my best shot and he ended having about 80% improvement in function and Sx reduction with minimally invasive spinal surgery. The only thing I recommended. I have not done enough research on it, but I am glad he listened to me, and did not go with a laminectomy or fusion like most of the surgeons he had seen had suggested. He can now walk, golf, and lift his grandkids! I still do maintenance manual work and neurodynamics on him, because it also always makes him feel better.


  1. Great article Erson.
    I also utilize Williams Flexion exercises within the warm up section and add a few basic stabilization exercises following Paris' advice that if he only had one tool in his box, it will be stab. Thanks for the post. David

  2. Another great post here! Are you from the Philippines by the way? I am learning a lot from your blog and everday I'm just checking if there is something new to learn. I might not be able to do those spinal manipulations but at least I see improvements using your muscle or soft tissue works especially home exercises. Looking forward on learning more great stuff here and I recommend this to my other friends.

    1. My parents are from the Philippines, I was born in the US. Are you a physio in the Philippines? I'm glad you find the blog useful, please share it with your friends and colleagues!

  3. Stanley Paris said that? Odd, we are not taught any stabilization ex in his program.

  4. Could you describe what the M's exercise is for hip IR?

  5. Really informative share Spinal Stenosis
    Erson. Looking forward to get some more blogs from

    Keep posting and helping.