How should I perform the McKenzie protocol press‑up (prone extension) for a patient with S1 radiculopathy (S1 nerve root radiculopathy) and grade 1 diastolic dysfunction (mild diastolic dysfunction)?

McKenzie Protocol Press-Ups for S1 Radiculopathy with Grade 1 Diastolic Dysfunction

McKenzie prone press-ups are safe and appropriate for this patient, as grade 1 diastolic dysfunction represents delayed myocardial relaxation with normal left atrial pressure at rest and does not contraindicate prone positioning or this specific exercise. 1

Exercise Technique and Execution

Starting Position

• Lie prone (face down) on a firm surface with arms positioned at shoulder level, palms flat on the surface 2
• Keep the pelvis and lower body completely relaxed throughout the movement 2
• Begin with the forehead resting on the surface 2

Movement Execution

• Press through the hands to lift the upper body while keeping the pelvis, hips, and legs completely relaxed on the surface 2
• Perform the movement in a rhythmical manner at a moderate to slow controlled speed 1
• Exhale during the upward pressing phase (exertion) and inhale during the lowering phase to avoid Valsalva maneuver 1
• Extend as far as comfortable, ideally achieving full elbow extension if tolerated 2
• Hold the extended position briefly (1-2 seconds) before lowering 2

Dosing Parameters

• Perform 10-15 repetitions per set 1, 2
• Complete 1 set, 2-3 times per day 1
• The goal is symptom centralization—moving pain from the leg toward the lower back 2

Cardiac Safety Considerations

Why This Exercise Is Safe

• Grade 1 diastolic dysfunction indicates delayed myocardial relaxation with normal left atrial mean pressure at rest, making these patients appropriate candidates for exercise stress testing and physical activity 1
• Patients with grade 1 diastolic dysfunction and preserved e′ velocity do not develop elevated filling pressures with exercise, unlike those with more advanced dysfunction 1
• The prone press-up is a low-intensity resistance exercise that does not significantly elevate cardiac demand compared to aerobic exercise 1

Breathing Precautions

• Avoid breath-holding and straining (Valsalva maneuver) by maintaining continuous breathing throughout the movement 1
• This is particularly important because Valsalva can transiently increase intrathoracic pressure and affect venous return 1

Clinical Application for S1 Radiculopathy

Therapeutic Rationale

• McKenzie press-ups aim to centralize symptoms by reducing posterior disc displacement and nerve root compression 2
• In a documented case of S1 radiculopathy with large L5-S1 disc herniation, press-ups were used as initial treatment to reduce and centralize symptoms 2
• The exercise should produce centralization (symptoms moving proximally toward the spine) rather than peripheralization (symptoms moving distally into the leg) 2

Monitoring Response

• If symptoms peripheralize (increase in leg pain/paresthesia) or worsen during press-ups, discontinue this direction of movement immediately 2
• The patient should experience either symptom reduction or centralization for the exercise to be appropriate 2
• Absent S1 reflex and gastrocnemius weakness may persist even after symptom resolution, as documented in successful conservative management cases 2

Common Pitfalls to Avoid

• Do not perform press-ups if they increase leg symptoms or cause peripheralization—this indicates the exercise is mechanically inappropriate for the patient's disc pathology 2
• Avoid combining press-ups with other exercises initially; assess response to this single intervention first before adding multimodal treatments 2
• Do not use press-ups in isolation for extended periods; they should be part of a progression that includes other interventions as symptoms improve 3, 2
• The cardiac condition does not require exercise restriction, but monitor for excessive dyspnea during the exercise, though this is unlikely with prone press-ups 1