Stretching

STRETCHING
USHA PANIHAR
Sports Physio

DEFINITION
• Stretching is a general term used to describe
any therapeutic maneuver designed to
increase the extensibility of soft tissues,
thereby improving flexibility by elongating
(lengthening) structures that have adaptively
shortened and have become hypomobile over
time

MECHANISM- STRETCH REFLEX
• When a stretch force is applied to a muscle-tendon unit
either quickly or over a prolonged period of time,
• The primary and secondary afferents of intrafusal
muscle fibers sense the length changes and activate
extrafusal muscle fibers via alpha motor neurons in the
spinal cord,
• Thus activating the stretch reflex and increasing
(facilitating) tension in the muscle being stretched.
• The increased tension causes resistance to lengthening
and, in turn, is thought to compromise the
effectiveness of the stretching procedure.

Stretch Reflex
http://www.apsubiology.org/anatomy/2010/2010_Exam_Reviews/Exam_4_Review/CH_13_Proprioception_and_Types_of_Reflexes.htm

Reciprocal Inhibition
• When the stretch reflex is activated in a muscle
being lengthened, decreased activity (inhibition)
in the muscle on the opposite side of the joint,
referred to as reciprocal inhibition
• To minimize activation of the stretch reflex and
the subsequent increase in muscle tension and
reflexive resistance to muscle lengthening during
stretching procedures, a slowly applied, low-
intensity, prolonged stretch is considered
prefereable to a quickly applied, short-duration
stretch.

Autogenic Inhibition
• In contrast, the GTO, as it monitors tension in the muscle
fibers being stretched, has an inhibitory impact on the level
of muscle tension in the muscle-tendon unit in which it lies,
particularly if the stretch force is prolonged. This effect is
called autogenic inhibition.
• Inhibition of the contractile components of muscle by the
GTO contributes to reflexive muscle relaxation during a
stretching maneuver, enabling a muscle to be elongated
against less muscle tension.
• It is thought that if a low-intensity, slow stretch force is
applied to muscle, the stretch reflex is less likely to be
activated as the GTO fires and inhibits tension in the
muscle, allowing the parallel elastic component (the
sarcomeres) of the muscle to remain relaxed and to
lengthen.

Indications for Use of Stretching
• ROM is limited because soft tissues have lost their
extensibility as the result of adhesions, contractures,
and scar tissue formation, causing functional
limitations or disabilities.
• Restricted motion may lead to structural deformities
that are otherwise preventable.
• There is muscle weakness and shortening of opposing
tissue.
• May be used as part of a total fitness program
designed to prevent musculoskeletal injuries.
• May be used prior to and after vigorous exercise
potentially to minimize post exercise muscle soreness.

Contraindications to Stretching
• A bony block limits joint motion.
• There was a recent fracture, and bony union is incomplete.
• There is evidence of an acute inflammatory or infectious
process (heat and swelling) or soft tissue healing could be
disrupted in the tight tissues and surrounding region.
• There is sharp, acute pain with joint movement or muscle
elongation.
• A hematoma or other indication of tissue trauma is
observed.
• Hypermobility already exists.
• Shortened soft tissues provide necessary joint stability in
lieu of normal structural stability or neuromuscular control.
• Shortened soft tissues enable a patient with paralysis or
severe muscle weakness to perform specific functional
skills otherwise not possible.

Determinents of stretching tech.
• Alignment: positioning a limb or the body
such that the stretch force is directed to the
appropriate muscle group
• Stabilization: fixation of one site of
attachment of the muscle as the stretch force
is applied to the other bony attachment
• Intensity of stretch: magnitude of the stretch
force applied
• Duration of stretch: period of time a stretch
force is applied and shortened tissues are held
in a lengthened position

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• Speed of stretch: speed of initial application
of the stretch force
• Frequency of stretch: number of stretching
sessions per day or per week
• Mode of stretch: form or manner in which the
stretch force is applied (static, ballistic, cyclic);
degree of patient participation (passive,
assisted, active); or the source of the stretch
force (manual, mechanical, self)

Alignment
• Proper alignment or positioning of the patient and the
specific muscles and joints to be stretched is necessary for
patient comfort and stability during stretching.
• Alignment influences the amount of tension present in soft
tissue and consequently affects the ROM available in joints.
• Alignment of the muscles and joint to be stretched as well
as the alignment of the trunk and adjacent joints must all
be considered.
For example,
• To stretch the rectus femoris ( crosses two joints)
effectively, as the knee is flexed and the hip extended, the
lumbar spine and pelvis should be aligned in a neutral
position. The pelvis should not tilt anteriorly nor should the
low back hyperextend; the hip should not abduct or remain
flexed.
• When a patient is self-stretching to increase shoulder
flexion, the trunk should be erect, not slumped

E.g.- (A) Correct alignment when stretching the rectus femoris: the lumbar spine,
pelvis, and hip are held in a neutral position as the knee is flexed.
(B) Incorrect position of the hip in flexion. In addition, avoid anterior pelvic tilt,
hyperextension of the lumbar spine, and abduction of the hip.

(A) Correct alignment when stretching to increase shoulder
flexion: the cervical and thoracic spine is erect.
(B) Incorrect alignment: forward head and rounded spine.

Stabilization
• To achieve an effective stretch of a specific muscle or
muscle group and associated periarticular structures, it
is necessory to stabilize (fixate) either the proximal or
distal attachment site of the muscle-tendon unit being
elongated.
• Either site may be stabilized, but for manual stretching
it is common for a therapist to stabilize the proximal
attachment and move the distal segment.
• For self-stretching procedures, a stationary object, such
as a chair or a doorframe, or active muscle
contractions by the patient may provide stabilization of
one segment as the other segment moves.
• During self-stretching, it is often the distal attachment
that is stabilized as the proximal segment moves

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• Stabilization of multiple segments of a patient’s
body also helps maintain the proper alignment
necessary for an effective stretch.
For example,
• when stretching the iliopsoas, the pelvis and
lumbar spine must maintain a neutral position as
the hip is extended to avoid stress to the low
back region.
• Sources of stabilization include manual contacts,
body weight, or a firm surface such as a table,
wall, or floor.

(A) The proximal attachment (femur and pelvis) of the muscle
being stretched (the quadriceps) is stabilized as the distal
segment is moved to increase knee flexion.

(B) During this self-stretch of the quadriceps, the distal
segment (tibia) is stabilized through the foot as the patient
moves the proximal segment (femur) by lunging forward.

Intensity of Stretch
• The intensity (magnitude) of a stretch force is
determined by the load placed on soft tissue to
elongate it. There is general agreement among
clinicians and researchers that stretching should be
applied at a low intensity by means of a low load.
• Low-intensity stretching in comparison to high-
intensity stretching makes the stretching maneuver
more comfortable for the patient and minimizes
voluntary or involuntary muscle guarding so a patient
can either remain relaxed or assist with the stretching
maneuver.

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• Low-intensity stretching (coupled with a long
duration of stretch) results in optimal rates of
improvement in ROM without exposing tissues,
possibly weakened by immobilization, to
excessive loads and potential injury.
• Low-intensity stretching has also been shown to
elongate dense connective tissue, a significant
component of chronic contractures, more
effectively and with less soft tissue damage and
post-exercise soreness than a high-intensity
stretch.2

Duration of Stretch
• One of the most important decisions a therapist must
make when selecting and implementing a stretching
intervention (stretching exercises or use of a
mechanical stretching device) is to determine the
duration of stretch that is expected to be safe,
effective, practical, and efficient for each situation.
• If more than one repetition of stretch (stretch cycle) is
carried out during a treatment session (which is most
often the case), the cumulative time of all the stretch
cycles is also considered an aspect of duration.

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• In general, the shorter the duration of a single stretch cycle,
the greater the number of repetitions applied during a
stretching session.
• Many number of combinations have been studied. For
example,
• In a study by Cipriani et al., two repetitions of 30-second
hamstring stretches were found to be equally effective
compared to six repetitions of 10-second stretches.
• However, Roberts and Wilson found that over the course of
a 5-week period three 15-second hamstring stretches each
day yielded significantly greater stretch-induced gains in
ROM than nine daily 5-second stretches.

Intensity, Duration, Frequency, and Mode of Stretch—
Interrelationships and Impact on Stretching Outcomes
• Inverse relationship between intensity and duration as
well as between intensity and frequency of stretch.
– The lower the intensity of stretch, the longer the time the
patient will tolerate stretching and the soft tissues can be
held in a lengthened position.
– The higher the intensity, the less frequently the stretching
intervention can be applied to allow time for tissue healing
and resolution of residual muscle soreness.
• A low-load (low-intensity), long-duration stretch is
considered the safest form of stretch and yields the
most significant, elastic deformation and long-term,
plastic changes in soft tissues.

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• Manual stretching and self-stretching in
hypomobile but healthy subjects and prolonged
mechanical stretching in patients with chronic
contractures yield significant stretch-induced
gains in ROM.
• In the well elderly, stretch cycles of 15, 30, and 60
seconds applied to the hamstrings for four
repetitions have all been shown to produce
significant gains in ROM with the greatest and
longest-lasting improvements occurring with the
use of 60-second stretch cycles.

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• In healthy young and/or middle-age adults -
– Stretch durations of 15, 30, 45, or 60 seconds or 2 minutes to
lower extremity musculature produced significant gains in ROM.
– Stretch cycles of 30- and 60-second duration applied to the
hamstrings for one repetition daily are both more effective than
one repetition daily of a 15-second stretch cycle but are equally
effective when compared to each other.
– Two repetitions daily of a 30-second static stretch of the
hamstrings yield significant gains in hamstring flexibility similar
to those seen with six repetitions of 10-second static stretches
daily.
– Static stretches of the hip adductors for 15 seconds or 2 minutes
produce equal improvements in ROM.
– There seems to be no additional benefit to holding each stretch
cycle beyond 60 seconds.
– Three cycles of 30-second and 1-minute stretches are no more
effective for improving ROM than one cycle of each duration of
stretch.

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• When the total duration of stretch is equal, cyclic stretching is
equally effective and possibly more comfortable than static
stretching.
• In patients with chronic, fibrotic contractures:
– Common durations of manual stretching or self stretching may not be
effective.
– Use of prolonged static stretch with splints or casts is more effective.
• Frequency of stretching needs to occur a minimum of two times per
week for healthy hypomobile individuals, but more frequent
stretching is necessary for patients with soft tissue pathology to
achieve gains in ROM.
• Although stretch-induced gains in ROM often persist for several
weeks to a month in healthy adults after cessation of a stretching
program, permanent improvement in mobility can be achieved only
by use of the newly gained ROM in functional activities and/or with
a maintenance stretching program.

Types of stretching
• Static stretching
• Cyclic/intermittent stretching
• Ballistic stretching
• Proprioceptive neuromuscular facilitation
stretching procedures (PNF stretching)
• Manual stretching
• Mechanical stretching
• Self-stretching
• Passive stretching
• Active stretching

Cyclic/Intermittent Stretching

Manual or Mechanical/Passive or
Assisted Stretching
• A sustained or intermittent external, end-range
stretch force, applied with overpressure and by
manual contact or a mechanical device, elongates
a shortened muscle tendon unit and periarticular
connective tissues by moving a restricted joint
just past the available ROM.
• If the patient is as relaxed as possible, it is called
passive stretching. If the patient assists in moving
the joint through a greater range, it is called
assisted stretching.

Manual Stretching
• During manual stretching a therapist applies an external
force to move the involved body segment slightly beyond
the point of tissue resistance and available ROM.
• The therapist manually controls the site of stabilization as
well as the direction, speed, intensity, and duration of
stretch.
• Manual stretching can be performed passively, with
assistance from the patient, or even independently by the
patient.
• Manual stretching usually employs a controlled, end range,
static, progressive stretch applied at an intensity consistent
with the patient’s comfort level, held for 15 to 60 seconds
and repeated for at least several repetitions

Points to consider in use of manual stretching.
• May be most appropriate in the early stages of a
stretching program to determine how a patient
responds to varying intensities or durations of
stretch and when optimal stabilization is most
critical.
• Performed passively if a patient cannot perform
self-stretching owing to a lack of neuromuscular
control of the body segment to be stretched
• If a patient has control of the body segment to be
stretched, it is often helpful to ask the patient to
assist the therapist with the manual stretching
maneuver, particularly if the patient is
apprehensive and is having difficulty relaxing.

Self-Stretching
• Self-stretching (also referred to as flexibility exercises
or active stretching) is a type of stretching procedure a
patient carries out independently after careful
instruction and supervised practice.
• Self-stretching enables a patient to maintain or
increase the ROM gained as the result of direct
intervention by a therapist.
• This is an integral component of a home exercise
program and is necessary for long-term self-
management of many musculoskeletal and
neuromuscular disorders

• Teaching a patient, self-stretching procedures
correctly and safely is fundamental for preventing
re-injury or future dysfunction.
• Proper alignment of the body or body segments
is critical for effective self-stretching.
• Sufficient stabilization of either the proximal or
distal attachment of a shortened muscle is
necessary.
• Static stretching with a 30- to 60-second duration
per repetition is considered the safest type of
stretching

Mechanical Stretching
• Mechanical stretching devices apply a very low
intensity stretch force (low load) over a prolonged
period of time to create relatively permanent
lengthening of soft tissues, presumably due to plastic
deformation.
• The equipment can be as simple as a cuff weight or
weight-pulley system or as sophisticated as some
adjustable orthoses or automated stretching machines.
• These mechanical stretching devices provide either a
constant load with variable displacement or constant
displacement with variable loads.

Low-load mechanical stretch with a cuff weight and self
stabilization of the proximal humerus to stretch the elbow
flexors and increase end-range elbow extension.

Duration of Mechanical Stretch
• Mechanical stretching involves a substantially longer overall
duration of stretch than is practical with manual stretching
or self-stretching exercises.
• The duration of mechanical stretch reported is ranges from
15 to 30 minutes to as long as 8 to 10 hours at a time or
continuous throughout the day except for time out of the
device for hygiene and exercise.
• Serial casts are worn for days or weeks at a time before
being removed and then reapplied.
• The time frame is dependent on the type of device
employed, the cause and severity of impairment, and
patient tolerance.
• The longer durations of stretch are required for patients
with chronic contractures as the result of neurological or
musculoskeletal disorders than for healthy subjects with
only mild hypomobility

Mechanical device (JAS Orthosis) applying a static
progressive stretch to elbow flexors
http://archive.constantcontact.com/fs001/1101756418198/archive/1104206462442.html

Proprioceptive Neuromuscular
Facilitation Stretching Techniques
• PNF stretching also referred to as active stretching or
facilitative stretching, integrate active muscle
contractions into stretching maneuvers to facilitate or
inhibit muscle activation and to increase the likelihood
that the muscle to be lengthened remains as relaxed as
posssible as it is stretched.
• when muscle fibers are reflexively inhibited through
autogenic or reciprocal inhibition, there is less
resistance to elongation by the contractile elements of
the muscle.
• Inhibition techniques are designed to relax only the
contractile structures of muscle, not the connective
tissue in and around shortened muscles.

Types of PNF Stretching
• There are several types of PNF stretching
procedures. They include:
– Hold–relax (HR) or contract–relax (CR)
– Agonist contraction (AC)
– Hold–relax with agonist contraction (HR-AC).

Hold–Relax and Contract–Relax
• With the hold–relax (HR) range limiting muscle is first
lengthened to the point of limitation or to the extent
that is comfortable for the patient.
• The patient then performs a prestretch, end-range,
isometric contraction (for 5 to 10 seconds) followed by
voluntary relaxation of the tight muscle.
• The limb is then passively moved into the new range as
the range-limiting muscle is elongated.
• A sequence for using the HR technique to stretch
shortened pectoralis major muscles bilaterally and
increase horizontal abduction of the shoulders.

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• In the clinical and athletic training settings the HR and CR
techniques appear to make passive elongation of muscles more
comfortable for a patient than manual passive stretching.
PRECAUTION:
• It is not necessary for the patient to perform a maximal isometric
contraction of the tight muscle prior to stretch.
• Multiple repetitions of maximal prestretch isometric contractions
have been shown to result in an acute increase in arterial blood
pressure, most notably after the third repetition.
• To minimize the adverse effects of the Valsalva maneuver (elevation
in blood pressure), have the patient breathe regularly while
performing submaximal (low-intensity) isometric contractions held
for 5 to 10 seconds with each repetition of the stretchimg
procedure.
• A submaximal contraction is also easier for the therapist to control
if the patient is strong.

Hold–relax (HR) procedure to stretch the pectoralis
major muscles bilaterally.
The therapist horizontally abducts the
shoulders bilaterally to a comfortable
position. The patient isometrically contracts
the pectoralis major muscles against the
therapist’s resistance for 5 to 10 seconds
The patient relaxes, and the therapist passively
lengthens the pectoralis major muscles by
horizontally abducting the shoulders into the newly
gained range. After a 10-second rest with the muscle
maintained in a comfortably lengthened position, the
entire sequence is repeated.
R

Agonist Contraction
• The “agonist” refers to the muscle opposite the range-
limiting muscle. “Antagonist,” therefore, refers to the
range-limiting muscle.
• The short muscle (the antagonist) preventing the full
movement of the prime mover (the agonist).
• Dynamic range of motion (DROM) and active stretching
are terms that have been used to describe the AC
procedure.
• the patient concentrically contracts (shortens) the
muscle opposite the rangelimiting muscle and then
holds the end-range position for at least several
seconds

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• The movement of the limb is independently controlled by
the patient and is deliberate and slow, not ballistic. In most
instances the shortening contraction is performed without
the addition of resistance.
• For example, if the hip flexors are tight, the patient can
perform end-rage, prone leg lifts by contracting the hip
extensors concentrically; the end-range contraction is held
for a number of seconds. After a brief rest period, the
patent repeats the procedure.
• It has been suggested that when the agonist is activated
and contracts concentrically, the antagonist (the range-
limiting muscle) is reciprocally inhibited, allowing it to relax
and lengthen more easily.
• However, the theoretical mechanism of receiprocal
inhibition has been substantiated only in animal studies,
not in studies of humans.

• The AC technique seems to be especially effective when significant
muscle guarding restricts muscle lengthening and joint movement
and is less effective in reducing chronic contractures.
• This technique is also useful when a patient cannot generate a
strong, pain-free contraction of the range-limiting muscle, which
must be done during the HR procedure.
• This technique is also useful for initiating neuromuscular control in
the newly gained range to re-establish dynamic flexibility. The AC
technique is least effective if a patient has close to normal
flexibility.
PRECAUTIONS:
• Avoid full-range, balllistic movements when performing concentric
contractions of the agonist muscle group. Rest after each repetition
to avoid muscle cramping when the agonist is contracting in the
very shortened portion of its range.

Hold–Relax with Agonist Contraction
• The HR-AC stretching technique combines the HR and
AC procedures.
• The HR-AC technique is also referred to as the slow
reversal hold–relax technique.
• To perform the HR-AC procedure, move the limb to the
point that tissue resistance is felt in the tight (range-
limiting) muscle; then have the patient perform a
resisted, prestretch isometric contraction of the range-
limiting muscle followed by relaxation of that muscle
and an immediate concentric contraction of the muscle
opposite the tight muscle.

• For example, to stretch knee flexors, extend
the patient’s knee to a comfortable position
and then have the patient perform an
isometric contraction of the knee flexors
against resistance for 5 to 10 seconds. Tell the
patient to relax the knee flexors and then
actively extend the knee as far as possible,
holding the newly gained range for several
seconds.

PRECAUTIONS FOR STRETCHING
General Precautions
• Do not passively force a joint beyond its normal ROM.
Remember, normal (typical) ROM varies among
individuals. In adults, flexibility is greater in women
than in men.When treating older adults, be aware of
agerelated changes in flexibility.
• Use extra caution in patients with known or suspected
osteoporosis due to disease, prolonged bed rest, age,
or prolonged use of steroids.
• Protect newly united fractures; be certain there is
appropriate stabilization between the fracture site and
the joint in which the motion takes place.

• Avoid vigorous stretching of muscles and connective tissues
that have been immobilized for an extended period of time.
Connective tissues, such as tendons and ligaments, lose
their tensile strength after prolonged immobilization. High-
intensity short-duration stretching procedures tend to
cause more trauma and resulting weakness of soft tissues
than low-intensity, long-duration stretch.
• Progress the dosage (intensity, duration, and frequency) of
stretching interventions gradually to minimize soft tissue
trauma and postexercise muscle soreness. If a patient
experiences joint pain or muscle soreness lasting more than
24 hours after stretching, too much force has been used
during stretching, causing an an inflammatory response.
This, in turn, causes increased scar tissue formation.
Patients should experience no more residual discomfort
than a transitory feeling of tenderness.

• Avoid stretching edematous tissue, as it is
more susceptible to injury than normal tissue.
Continued irritation of edematous tissue
usually causes increased pain and edema.
• Avoid overstretching weak muscles,
particularly those that support body
structures in relation to gravity.

Stretching Procedures
According to Anatomical Planes
UPPER LIMB STRETCHING

Flexion of the Shoulder
• To increase flexion of the shoulder (to stretch the
shoulder extensors)
• Hand Placement and Procedure
• Grasp the posterior aspect of the distal humerus, just
above the elbow.
• Stabilize the axillary border of the scapula to stretch
the teres major, or stabilize the lateral aspect of the
thorax and superior aspect of the pelvis to stretch the
latissimus dorsi.
• Move the patient’s arm into full shoulder flexion to
elongate the shoulder extensors

Hand placement and stabilization
of the pelvis to stretch the
Latissimus dorsi and increase
shoulder flexion.
Hand placement and stabilization
of the scapula to stretch the
Teres major and increase
shoulder flexion

Hand placement and
stabilization of the scapula
for the stretching procedure
to increase shoulder
abduction
Abduction of the Shoulder
To increase abduction of
the shoulder (to stretch the
adductors)
Hand Placement and
Procedure
With the elbow flexed to
90, grasp the distal
humerus. Stabilize the
axillary border of the
scapula. Move the patient
into full shoulder abduction
to lengthen the adductors
of the shoulder.

Hyperextension of the Shoulder
• To increase hyperextension of
the shoulder (to stretch the
• shoulder flexors)
• Patient Position
• Place the patient in a prone
position.
• Hand Placement and
Procedure
• Support the forearm and
grasp the distal humerus.
• Stabilize the posterior aspect
of the scapula to prevent
substitute movements.
• Move the patient’s arm into
full hyperextension of the
shoulder to elongate the
shoulder flexors
Hand placement and
stabilization of the scapula
to increase extension of the
shoulder beyond neutral.

Adduction of the Shoulder
• To increase adduction of the shoulder (to stretch
the abductors).
• It is rare when a patient is unable to adduct the
shoulder fully to 0 (so the upper arm is at the
patient’s side).
• Even if a patient has worn an abduction splint
after a soft tissue or joint injury of the shoulder,
when he or she is upright the constant pull of
gravity elongates the shoulder abductors so the
patient can adduct to a neutral position.

External Rotation of the Shoulder
• To increase external rotation of the
shoulder (stretch the internal
rotators)
• Abduct the shoulder to a
comfortable position—initially 30 or
45 and later to 90 if the
glenohumoral (GH)
• joint is stable—or place the arm at
the patient’s side.
• Flex the elbow to 90 so the forearm
can be used as a lever.
• Grasp the volar surface of the mid-
forearm with one hand.
• Stabilization of the scapula is
provided by the table on which the
patient is lying.
• Externally rotate the patient’s
shoulder by moving the patient’s
forearm closer to the table. This fully
lengthens the internal rotators.
Shoulder position (slightly
abducted and flexed) and hand
placement at the mid to
proximal forearm to increase
external rotation of the
shoulder. A folded towel is
placed under the distal humerus
to maintain the shoulder in
slight flexion. The table stabilizes
the scapula

Internal Rotation of the Shoulder
•To increase internal rotation of the
shoulder (stretch the external
rotators)
•Hand Placement and Procedure
•Abduct the shoulder to a
comfortable position that allows
internal rotation to occur without
the thorax blocking the motion
(initially to 45 and eventually to 90).
•Flex the elbow to 90 so the forearm
can be used as a lever.
•Grasp the dorsal surface of the
midforearm with one hand, and
stabilize the anterior aspect of the
shoulder and support the elbow with
your other forearm and hand.
•Move the patient’s arm into internal
rotation to lengthen the external
rotators of the shoulder.
Hand placement and
stabilization of the shoulder to
increase internal rotation of the
shoulder.

Hand placement and
stabilization of the anterior
aspect of the shoulder and
chest to increase horizontal
abduction of the shoulder
past neutral (to stretch the
pectoralis major).
Horizontal Abduction of the
Shoulder
•To increase horizontal abduction
of the shoulder (stretch the
pectoralis muscles)
•Patient Position
To reach full horizontal abduction
in the supine position, the
patient’s shoulder must be at the
edge of the table. Begin with the
shoulder in 60 to 90 of abduction.
The
patient’s elbow may also be
flexed.
•Hand Placement and Procedure
•Grasp the anterior aspect of the
distal humerus. Stabilize the
anterior aspect of the shoulder.
•Move the patient’s arm below
the edge of the table into full
horizontal abduction to stretch
the horizontal adductors.

The Elbow and Forearm: Special
Considerations
• Several muscles that cross the elbow, such as
the biceps brachii and brachioradialis, also
influence supination and pronation of the
forearm.
• Therefore, when stretching the elbow flexors
and extensors, the techniques should be
performed with the forearm pronated as well
as supinated.

Elbow Extension
• To increase elbow
extension (to stretch the
elbow flexors )
Procedure
• Grasp the distal forearm.
• With the upper arm at
the patient’s side
supported on the table.
stabilize the scapula and
anterior aspect of the
proximal humerus.
• Extend the elbow just
past the point of tissue
resistance to lengthen
the elbow flexors
Hand placement and
stabilization of the scapula and
proximal humerus for
stretching procedures to
increase elbow extension.

Elbow Flexion
• To increase elbow flexion (stretch
the one-joint elbow extensors).
• Grasp the distal forearm just
proximal to the wrist. With the
arm at the patient’s side
supported on the table, stabilize
the proximal humerus.
• Flex the patient’s elbow just past
the point of tissue resistance to
lengthen the elbow extensors.
• To increase elbow flexion with the
shoulder flexed (stretch the long
head of the triceps)

Wrist Extension
• To increase wrist extension
• Pronate the forearm or place it in
midposition, and grasp
• the patient at the palmar aspect
of the hand. If there is a severe
wrist flexion contracture, it may
be necessary to place the
patient’s hand over the edge of
the treatment table.
• Stabilize the forearm against the
table.
• To lengthen the wrist flexors,
extend the patient’s wrist,
allowing the fingers to flex
passively.
Hand placement and stabilization of the
forearm for stretching procedure to
increase extension of the wrist.

• Radial Deviation
• To increase radial deviation.
• Grasp the ulnar aspect of the hand along the fifth
• metacarpal.
• Hold the wrist in midposition.
• Stabilize the forearm.
• Radially deviate the wrist to lengthen the ulnar deviators of the
wrist.
• Ulnar Deviation
• To increase ulnar deviation.
• Grasp the radial aspect of the hand along the second metacarpal,
not the thumb.
• Stabilize the forearm.
• Deviate the wrist ulnarly to lengthen the radial deviators.

• The Digits: Special Considerations
• The complexity of the relationships among the joint
structures and the intrinsic and multijoint extrinsic muscles
of the digits requires careful examination and evaluation of
the factors that contribute to loss of function in the hand
because of limitation of motion. The therapist must
determine if a limitation is from restriction of joints,
decreased muscle flexibility, or adhesions of tendons or
ligaments.
• The digits should always be stretched individually, not
simultaneously. If an extrinsic muscle limits motion,
lengthen it over one joint while stabilizing the other joints.
• Then hold the lengthened position and stretch it over the
second joint, and so forth, until normal length is obtained.
• As noted in Chapter 3, begin the motion with the most
distal joint to minimize shearing and compressive stresses
to the surfaces of the small joints of the digits. Specific
methods of intervention for dealing with adhesions of
tendons are described in Chapter 19.

• CMC Joint of the Thumb
• To increase flexion, extension, abduction, or
adduction of the carpometacarpal (CMC) joint of
the thumb.
• Stabilize the trapezium with your thumb and
index finger.
• Grasp the first metacarpal (not the first phalanx)
with your other thumb and index finger.
• Move the first metacarpal in the desired direction
to increase CMC flexion, extension, abduction,
and adduction.

MCP Joints of the Digits
• To increase flexion, extension, abduction, or adduction of
the MCP joints of the digits.
• Stabilize the metacarpal with your thumb and index finger.
• Grasp the proximal phalanx with your other thumb and
index finger.
• Keep the wrist in midposition.
• Move the MCP joint in the desired direction for stretch.
Allow the interphalangeal (IP) joints to flex or extend
passively.

PIP and DIP Joints
• To increase flexion or extension of the proximal (PIP) and distal (DIP)
interphalangeal joints.
• Grasp the middle or distal phalanx with your thumb and finger.
• Stabilize the proximal or middle phalanx with your other thumb and
finger.
• Move the PIP or DIP joint in the desired direction for stretch.
Stretching Specific Extrinsic and Intrinsic Muscles of the Fingers
• Elongation of extrinsic and intrinsic muscles of the hand is
described in Chapter 3.
• To stretch these muscles beyond their available range, the same
hand placement and stabilization are used as with passive ROM.
The only difference in technique is that the therapist moves each
segment into the stretch range.

Lower limb stretching
The Hip: Special Considerations
• Because muscles of the hip attach to the
pelvis or lumbar spine, the pelvis must always
be stabilized when lengthening muscles about
the hip. If the pelvis is not stabilized, the
stretch force is transferred to the lumbar
spine, in which unwanted compensatory
motion then occurs.

Flexion of the Hip
• To increase flexion of the hip with the knee flexed
(stretch the gluteus maximus).
• Flex the hip and knee simultaneously.
• Stabilize the opposite femur in extension to
prevent posterior tilt of the pelvis.
• Move the patient’s hip and knee into full flexion
to lengthen the one-joint hip extensor.

Flexion of the Hip with Knee Extension
• To increase flexion of the hip with the knee extended (stretch the
hamstrings)
• With the patient’s knee fully extended, support the patient’s lower
leg with your arm or shoulder.
• Stabilize the opposite extremity along the anterior aspect of the
thigh with your other hand or a belt or with the assistance of
another person.
• With the knee at 0 extension, and the hip in neutral rotation, flex
the hip as far as possible.
• N O T E : Externally rotate the hip prior to hip flexion to isolate the
stretch force to the medial hamstrings and internally rotate the hip
to isolate the stretch force to the lateral hamstrings.
• Alternate Therapist Position
• Kneel on the mat and place the patient’s heel or distal tibia against
your shoulder. Place both of your hands along the anterior aspect of
the distal thigh to keep the knee extended.
• The opposite extremity is stabilized in extension by a belt or towel
around the distal thigh and held in place by the therapist’s knee.

Hand placement and stabilization of the opposite femur to stabilize the
pelvis and low back for stretching procedures to increase hip flexion with
knee extension (stretch the hamstrings) with the therapist standing by the
side of the table or kneeling on the table.

Extension of the Hip
• To increase hip extension (to stretch
the iliopsoas)
• Have the patient close to the edge
of the treatment table so the hip
being stretched can be extended
beyond neutral. The opposite hip
and knee are flexed toward the
patient’s chest to stabilize the pelvis
and spine.
• Stabilize the opposite leg against the
patient’s chest with one hand, or if
possible have the patient assist by
grasping around the thigh and
holding it to the chest to prevent an
anterior tilt of the pelvis during
stretching.
• Move the hip to be stretched into
extension or hyperextension by
placing downward pressure on the
anterior aspect of the distal thigh
with your other hand. Allow the
knee to extend so the two-joint
rectus femoris does not restrict the
range
pelvis to increase extension of the hip
(stretch the iliopsoas) with the patient lying
supine. Flexing the knee when in this
position also elongates the rectus femoris.

Alternate Position
• The patient can lie prone
• Support and grasp the anterior
aspect of the patient’s distal
femur.
• Stabilize the patient’s buttocks to
prevent movement of the pelvis.
• Extend the patient’s hip by lifting
the femur off the table.
• Note: To increase hip extension
and knee flexion simultaneously
(stretch the rectus femoris).
Hand placement and stabilization to
increase hyperextension of the hip with the
patient lying prone.

Abduction of the Hip
• To increase abduction of the hip
(stretch the adductors)
• Support the distal thigh with your
arm and forearm.
• Stabilize the pelvis by placing
pressure on the opposite anterior
iliac crest or by maintaining the
opposite lower extremity in slight
abduction.
• Abduct the hip as far as possible
to stretch the adductors.
• N O T E : You may apply your
stretch force cautiously at the
medial malleolus only if the knee
is stable and pain-free. This
creates a great deal of stress to
the medial supporting structures
of the knee and is generally not
recommended by authors.
opposite extremity (or pelvis) for the
stretching procedure to increase
abduction of the hip.

Patient positioned side-lying. Hand
placement and procedure to stretch
the tensor fasciae latae and IT band.
Adduction of the Hip
• To increase adduction of the hip [stretch
the tensor fasciae latae and iliotibial (IT)
band]
• Place the patient in a side-lying position
with the hip to be stretched uppermost.
Flex the bottom hip and knee to stabilize
the patient.
• Stabilize the pelvis at the iliac crest with
your proximal hand. Flex the knee and
extend the patient’s hip to neutral or into
slight hyperextension, if possible. Let the
patient’s hip adduct with gravity and apply
an additional stretch force with your other
hand to the lateral aspect of the distal
femur to further adduct the hip.
• N O T E : If the patient’s hip cannot be
extended to neutral, the hip flexors must be
stretched before the tensor fasciae latae
can be stretched.

External Rotation of the Hip
• To increase external rotation of
the hip (stretch the internal
rotators)
position, hips extended and knee
flexed to 90.
• Grasp the distal tibia of the
extremity to be stretched.
• Stabilize the pelvis by applying
pressure with your other hand
across the buttocks.
• Apply pressure to the lateral
malleolus or lateral aspect of the
tibia, and externally rotate the
hip as far as possible.
(A) Hand placement and stabilization of
the pelvis to increase external rotation
of the hip.

Alternate Position and Procedure
• Sitting at the edge of a table with hips and knees flexed
to 90.
• Stabilize the pelvis by applying pressure to the iliac
crest with one hand.
• Apply the stretch force to the lateral malleolus or
lateral aspect of the lower leg, and externally rotate
the hip.
• N O T E : When you apply the stretch force against the
lower leg in this manner, thus crossing the knee joint,
the knee must be stable and pain-free. If the knee is
not stable, it is possible to apply the stretch force by
grasping the distal thigh, but the leverage is poor and
there is a tendency to twist the skin.

Internal Rotation of the Hip
• To increase internal rotation of
the hip (stretch the external
rotators)
• Patient Position and
Stabilization
• Position the patient the same as
when increasing external
rotation, described previously.
• Apply pressure to the medial
malleolus or medial aspect of
the tibia, and internally rotate
the hip as far as possible.

The Knee: Special Considerations
• The position of the hip during stretching
influences the flexibility of the flexors and
extensors of the knee.
• The flexibility of the hamstrings and the rectus
femoris must be examined and evaluated
separately from the one-joint muscles that
affect knee motion.

Knee Flexion
• To increase knee flexion (stretch
the knee extensors)
• Have the patient assume a prone
position.
• Stabilize the pelvis by applying
downward pressure across the
buttocks. Grasp the anterior aspect of
the distal tibia, and flex the patient’s
knee.
• PRECAUTION: Place a rolled towel
under the thigh just above the knee to
prevent compression of the patella
against the table during the stretch.
Stretching the knee extensors too
vigorously in the prone position can
traumatize the knee joint and cause
swelling
increase knee flexion (stretch the
rectus femoris and quadriceps) with the
patient lying prone.

Knee Extension
• To increase knee extension in
the midrange (stretch the knee
flexors)
position and put a small, rolled
towel under the patient’s
distal femur, just above the
patella.
Procedure
• Grasp the distal tibia with one
hand and stabilize the
buttocks to prevent hip flexion
with the other hand.
• Slowly extend the knee to
stretch the knee flexors.
increase mid-range knee extension with
the patient lying prone.

The Ankle and Foot: Special
Considerations
• The ankle and foot are composed of multiple
joints. Consider the mobility of these joints as
well as the multi joint muscles that cross these
joints when increasing ROM of the ankle and
foot.

Hand placement and procedure to increase
dorsiflexion of the ankle with the knee
extended (stretching the gastrocnemius)
Dorsiflexion of the Ankle
• To increase dorsiflexion of the
ankle with the knee extended
(stretch the gastrocnemius
muscle)
• Grasp the patient’s heel
(calcaneus) with one hand,
maintain the subtalar joint in a
neutral position, and place your
forearm along the plantar surface
of the foot.
• Stabilize the anterior aspect of
the tibia with your other hand.
• Dorsiflex the talocrural joint of
the ankle by pulling the calcaneus
in an inferior direction with your
thumb and fingers while gently
applying pressure in a superior
direction just proximal to the
heads of the metatarsals
• with your forearm

Plantarflexion of the Ankle
• To increase plantarflexion of the ankle.
• Support the posterior aspect of the distal tibia
with one hand.
• Grasp the foot along the tarsal and metatarsal
areas. Apply the stretch force to the anterior
aspect of the foot, and plantarflex the foot as far
as possible.

Inversion and Eversion of the Ankle
• To increase inversion and eversion of the ankle.
• Inversion and eversion of the ankle occur at the
subtalar joint as a component of pronation and
supination. Mobility of the subtalar joint (with
appropriate strength) is particularly important for
walking on uneven surfaces.
• Stabilize the talus by grasping just distal to the malleoli
with one hand.
• Grasp the calcaneus with your other hand, and move it
medially and laterally at the subtalar joint.

Stretching

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