mosby's stretching pocket guide, 2014

Writer and Consultant

Sandra K. Anderson, BA, LMT, ABT

MOSBY’S

STRETCHING POCKET GUIDE

3251 Riverport LaneSt. Louis, Missouri 63043

MOSBY’S STRETCHING POCKET GUIDE

ISBN: 978-0-323-22640-0

Copyright © 2014 by Mosby, Inc., an affiliate of Elsevier Inc.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowl-edge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

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ISBN: 978-0-323-22640-0

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iii

Stretching techniques give massage therapists additional useful techniques they can use to enhance the health and well-being of their clients. This pocket guide discusses the therapeutic tool of stretching, which is a manual bodywork method that lengthens and elongates soft tissues, including muscles, tendons, ligaments, joint capsules, and fascia. Stretching is for soft tissues that have increased tension and are shortened and contracted. These tissues resist lengthening and limit mobility of the joint they cross. Stretching helps increase flexibility and remove adhesions and allows the body to move more fluidly.

The material in this stretching pocket guide is compiled from leading textbooks and resources for massage therapy and includes newly developed content. Topics include principles behind stretch-ing, basic stretching techniques, a basic static stretching atlas, ad-vanced stretching techniques, and stretching for self-care. Massage therapists can use stretching for self-care to educate their clients as well as to increase their own flexibility, a crucial component of career longevity.

This book is designed as a practice quick-reference to assist the mas-sage therapist in practicing safe and beneficial stretching techniques. It consolidates key information into one convenient, well-organized source for fast and easy reference.

Introduction

iv Acknowledgments

AcknowledgmentsThank you to Sandy Fritz for use of information in Fundamentals of Therapeutic Massage, 5th edition and Sports and Exercise Massage, 2nd edition; Joseph E. Muscolino for use of information in Kinesiology, 2nd edition, Know the Body, and The Muscle and Bone Palpation Manual, 1st edition; Jeffrey Simancek for use of information in Deep Tissue Massage Treatment, 2nd edition; and Susan Salvo for use of information in Massage Therapy: Principles and Practice, 4th edition.

v

Contents

1 Principles behind Stretching, 1

Definition of Terms, 1Factors Affecting Flexibility, 5Stretching, 6

Benefits and Cautions of Stretching, 7Cautions, 8Benefits of Stretching on Soft Tissue, 10

Properties of Soft Tissue, 12Connective Tissue, Muscles, and Stretching, 12Compensation, 13

Physiology behind Stretching, 14Joints, 14Muscle Tissue, 15Proprioceptors, 21

Major Categories of Stretching, 22Static Stretching, 23Dynamic Stretching, 24Ballistic Stretching, 28

2 Basic Stretching Techniques, 29

Guidelines for Successful Stretching, 29Muscle Relaxation, 29Warming the Tissues, 29Duration, 31

vi Contents

Safe and Effective Stretching Methods, 32Stretching Procedures, 32Overstretching, 33

Reasoning and Application, 33

How Stretches Can Be Reasoned Out Instead of Memorized, 34Multiplane Stretching, 35Isolating a Stretch to One Target Muscle, 40Stretching Other Target Tissues, 41

Direct Tissue Stretching, 41Longitudinal Stretching, 44Cross-Directional Stretching, 47

Basic Static Stretching Techniques, 48

3 Basic Static Stretching Atlas, 49

Neck, 49Neck Circles, 50Neck Lateral Flexion, 50Neck Lateral Flexion with Rotation, 50Neck Forward Flexion, 50

Wrist and Hand, 50Flip Wrist, 50Interlace Fingers and Mobilize Wrist, 50Metacarpal Scissors, 54Pull and Circumduct Fingers, 55

Arm and Shoulder, 55Arm Pull, 56Shoulder Circles, 58

Spine, 58Spinal Twist I, 58Spinal Twist II, 59Spinal Twist III, 60Spinal Twist IV, 60

Hip and Knee, 62Leg Pull, 62Leg Rock, 63

viiContents

Hip Clock Stretch, 63Hip Circles, 63Hip Flexion, 65Groin Stretch, 65Heel to Hip, 65Hip Hyperextension, 68

Ankle and Foot, 68Plantar Flexion, 69Dorsiflexion, 69Metatarsal Scissors, 69Pull and Circumduct Toes, 69

4 Advanced Stretching Techniques, 71

Pin and Stretch, 71

Proprioceptive Neuromuscular Facilitation, 74

Contract Relax, 74

Antagonist Contract, 75

Contract Relax Antagonist Contract, 81

Active Isolated Stretching, 81

Muscle Energy Techniques, 81Principles of Muscle Energy Techniques, 83Breathing and Eye Movement, 85Methods, 86Pulsed Muscle Energy Procedures, 95

Examples of Stretching, 97

5 Stretching for Self-Care, 105

Principles of Stretching for Self-Care, 106

Stretches, 107

Glossary, 141

Index, 147

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1

Human beings are designed to move. Therefore, all humans need to have at least some level of mobility and strength. Movement occurs at joints, and muscles provide the movement. Muscles must be strong enough to create the desired movement, and joints need to be both mobile and stable enough to cope with the movement. Along with muscular strength, the soft tissues of the body need to be pliable. For example, healthy muscles are supple and have a plentiful blood supply. They receive sufficient nutrients and oxygen and have wastes removed efficiently. Healthy muscles do not remain in a state of chronic contraction, a state that requires a great deal of energy, decreases mobility of body parts, and can lead to injury.

Definition of TermsBecause tight muscles, joints, and other soft tissues can be painful, decrease movement, and possibly lead to injury, clients can benefit from stretching techniques that improve function, restore mobility, and increase joint movements. These techniques provide additional treatment options and can be performed easily before, during, or after a massage treatment, or they may be used as the primary technique.

The terms “stretched,” “elongated,” “loose,” and “lengthened” all are used to describe the quality of soft tissues when they are pliant or pliable. Flexibility is the ability of soft tissues to yield to tension forces without tissue damage during joint range of motion (ROM).1 Flexibility refers to mobility of a joint and how muscles, ligaments, tendons, or other soft tissues affect it. A more complete description of flexibility is the ability to move joints through their full, intended ROM. ROM is the range, usually expressed in degrees of a circle,

1Chapter

Principles behind Stretching

2 Chapter 1 Principles behind Stretching

through which bones of a joint can move or be moved. Each specific joint has a normal ROM that is expressed in degrees, as shown in Table 1-1.

When performing a stretch on a client, the term target tissue is used to describe the tissue that will be stretched; target muscle is used when stretching a specific muscle or muscle group.

Entire Spine

Flexion 135 degrees Extension 120 degreesRight lateral flexion 90 degrees Left lateral flexion 90 degreesRight rotation 120 degrees Left rotation 120 degrees

Head at Atlantooccipital Joint


Atlas at Atlantoaxial Joint

Flexion 5 degrees Extension 10 degreesRight lateral flexion Negligible Left lateral flexion NegligibleRight rotation 40 degrees Left rotation 40 degrees

Lower Cervical Spine


Entire Cervical Spine


Entire Cervicocranial Region and Head at Atlantooccipital Joint


Thoracic Spine


Average Ranges of Motion from Anatomic Position

Table 1-1

3Chapter 1 Principles behind Stretching

Lumbar Spine


Thoracolumbar Spine


Pelvis at Hip and Lumbosacral Joints*

Anterior tilt 30 degrees Posterior tilt 15 degreesRight depression 30 degrees Left depression 30 degreesRight rotation 15 degrees Left rotation 15 degrees

Thigh at Hip Joint

Flexion 90 degrees Extension 20 degreesAbduction 40 degrees Adduction 20 degreesMedial rotation 40 degrees Lateral

rotation50 degrees

Leg at Tibiofemoral Joint

Flexion 140 degrees (Hyper)extension 5 degreesMedial rotation 15 degrees Lateral

rotation30 degrees

Foot at Talocrural Joint

Dorsiflexion 20 degrees Plantar flexion 50 degrees

Foot at Subtalar Joint

Pronation-eversion 10 degrees Supination- inversion

20 degrees

Pronation- dorsiflexion

2.5 degrees Supination– plantar flexion

5 degrees

Pronation–lateral rotation (abduction)

10 degrees Supination– medial rotation (adduction)

20 degrees

Toes 2-5 at MTP Joints

Extension 60 degrees Flexion 40 degrees

Big Toe at MTP Joints

Extension 80 degrees Flexion 40 degrees

Average Ranges of Motion from Anatomic Position—cont’d

Table 1-1

Continued


Entire Shoulder Joint Complex

Flexion 180 degrees Extension 150 degreesAbduction 180 degrees Adduction 0 degreesLateral rotation 90 degrees Medial rotation 90 degrees

Arm at Glenohumeral Joint

Flexion 100 degrees Extension 40 degreesAbduction 120 degrees Adduction 0 degreesLateral rotation 50 degrees Medial rotation 90 degrees

Scapula at Scapulocostal Joint

Upward rotation 60 degrees Downward rotation

0 degrees

Clavicle at Sternoclavicular Joint

Elevation 45 degrees Depression 10 degreesProtraction 30 degrees Retraction 30 degreesUpward rotation 45 degrees Downward rotation 0 degrees

Scapula at Acromioclavicular Joint

Upward rotation 30 degrees Downward rotation 0 degrees

Forearm at Elbow Joint

Flexion 145 degrees Extension 0 degrees

Forearm at Radioulnar Joints

Pronation 160 degrees Supination 0 degrees

Hand at Wrist Joint

Flexion 80 degrees Extension 70 degreesRadial deviation 15 degrees Ulnar deviation 30 degrees

Fifth CMC Joint


Fourth CMC Joint


Third CMC Joint


Second CMC Joint

Flexion 0-2 degrees Extension 0 degrees


Table 1-1


Thumb at Saddle Joint

Abduction 60 degrees Adduction 10 degreesFlexion 40 degrees Extension 10 degreesMedial rotation 45 degrees Lateral rotation 0 degrees

Proximal Phalanx of Fingers 2-5 at MCP Joint

Flexion 90-110 degrees Extension 0-20 degreesAbduction 20 degrees Adduction 20 degrees

Proximal Phalanx of Thumb at First MCP Joint


Fingers at Proximal Interphalangeal Joints


Fingers at Distal Interphalangeal Joints


Interphalangeal Joint of Thumb


CMC, Carpometacarpal; MCP, metacarpophalangeal; MTP, metatarsophalangeal.*With the client seated and the thighs flexed 90 degrees at the hip joint. Numbers would be different if the client were standing and based on whether the knee joint was flexed or extended.Data from Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.


Table 1-1

Shortened and contracted soft tissues resist lengthening and limit mobility of the joint they cross. Flexible joints move more efficiently because their ROM is greater than in tight joints. Move-ment takes less effort and less energy. These joints are also less prone to injury because they have more freedom of movement, and they are better able to adapt to stresses placed on them. An example is a person with an extremely tight shoulder who slips on ice or trips while going upstairs. When this person reaches out the arm with the tight shoulder to stop the fall, the shortened tissues are unlikely to be able to absorb the shock of impact the way looser and softer tissues can. Tearing of the soft tissues can result.

Factors Affecting FlexibilityAs with all types of movement, the ability to increase flexibility depends to a certain extent on genetics. Younger people are


generally more flexible than older people, and women are usually more flexible than men. Flexibility is affected by past injuries, bone length, childhood nutrition, level of strength, body core temperature, time of day (flexibility decreases during cooler times of the day and increases during warmer times of the day), mood, and stress levels.

On a physical level, flexibility is most often limited by the following:• The structure and shape of the joint.• Ligaments and tendons that cross the joint.• Adhesions from past injuries or surgeries.• Amount of muscle tissue surrounding the joint.• Amount of adipose tissue surrounding the joint.• Muscles that are highly toned but shortened.• Fascial binding. Bind means a resistance barrier.• Shortened muscles due to inactivity.• Muscle imbalance. If one of a group of synergistic muscles is

much stronger than the others, or if an agonist is much stronger than the antagonist for a particular joint action, the result can be reduced flexibility.

• Overuse of a muscle without maintaining a complete ROM. An example of this is a person who wears high heels much of the time. Because the ankles are in plantar flexion, calf muscles tend to become chronically shortened.

• Aging. With aging, the soft tissues decrease in elasticity, and muscles tend to atrophy.

• Periods of rapid growth such as occurs during puberty. If the body is growing quickly, flexibility may be hindered because the body has not adjusted to the changing ROM at the joints. Along with that, soft tissues have not had time to adapt to the rapid growth.

• Paralysis, neurologic disease, injury, or joint immobilization. These are injuries or pathologies that affect how tissues and joints function.2

Contrary to popular belief, muscle length is not the primary limiting factor in developing flexibility. Normal, healthy muscle tissue can be stretched to about twice its resting length.

StretchingStretching is a mechanical method that introduces various forces that extend, expand, lengthen, and elongate soft tissues.


Lengthening is a neurologic response that allows the muscles to stop contracting and relax. The difference between elongation and lengthening is that elongation refers to extending the length of the soft tissue. The soft tissues may be muscles, fascia, and associated tendons and ligaments (collectively called myofascial units); joint capsules; or other fascial planes.

Benefits and Cautions of StretchingStretching is crucial to the overall health of the body. Stretching helps increase flexibility and remove adhesions and allows the body to move more fluidly. Stretching can also help correct muscle imbalances (e.g., if a muscle is disproportionally stronger than its antagonist or if one side of the body is stronger than the other), relieve abnormal joint stress, maintain normal functional length of muscles, and improve neuromuscular efficiency. Neuromuscular efficiency is the ability of the neuromuscular system to allow ago-nists, antagonists, and stabilizers to work synergistically to produce, reduce, and stabilize the entire kinetic chain. The kinetic chain is an integrated functional unit made up of myofascial systems (muscles, ligaments, tendons, and fascia), articular systems (bones and their joints), and the nervous system. These systems work together for structural integrity and efficient movement.3

Repetitive, limited ROM activities performed over a prolonged period can create muscles that are chronically shortened or, con-versely, muscles that are in a lengthened position but are tight because they have developed excessive tone, known as hypertonicity. For example, hip flexors such as rectus femoris, psoas, and iliacus can become shortened secondary to long periods of sitting or bending at the waist. The hip flexors contract repeatedly but with a reduced ROM creating the shortening. Similarly, trunk extensors such as the erector spinae can become lengthened and hypertonic secondary to long periods of bending over. Weight-training exercises, if habitually performed with limited ROM, such as without full extension, flexion, or rotation, can also lead to muscles that are chronically shortened or lengthened and tight.

Chronically shortened or lengthened muscles can be the first step in a series of events leading to injury. Over time, shortened hip flexors can lead to a reduction of the normal lordotic curve of the lumbar spine, which can impair the spine’s load-bearing and shock-absorption capacity. Overly tight hamstrings have the same effect on the lumbar spine. When the spine cannot function normally, a wide


range of injuries, from acute to chronic, are possible. Optimally, stretching helps prevent and alleviate acute or chronic injuries.

Overall, the therapeutic effects and uses of stretching include the following:• Help maintain or increase ROM and improve joint function.• Increase flexibility. A flexible joint requires less energy to move; a

lengthened muscle requires less energy, whereas a tight and con-tracted muscle wastes energy.

• Relieve muscle and joint stiffness associated with the aging process.

• Stimulate production of synovial fluid.• Increase joint health by decreasing the viscosity (thickness) of

synovial fluid so that it can lubricate the joint better. This also increases nutrition to the joint.

• Reduce pain.• Increase blood and lymph flow within the tissues because of

the mechanical pumping effect produced as tissues are alternately squeezed and released. This allows for greater elasticity and reduction in muscle soreness.

• Assist in assessing tissues.• Decrease risk of injury by preventing joint sprains, muscle strains

or tears, and reinjury to previous joint and muscle trauma.• Increase mobility, which can potentially increase physical perfor-

mance and efficiency.• Increase kinesthetic awareness.• Aid in rehabilitation.• Possibly improve body alignment and posture.• Improve muscular balance.• Increase neuromuscular coordination.• Increase muscular relaxation, which decreases stress.4,5

CautionsDuring stretching methods, the client should experience a pulling sensation in the short soft tissue but never pain or strain in the joint or in other parts of the body that are not being stretched.

Anatomic barriers are determined by the shape and fit of the bones at the joint. To prevent serious joint injury, no jointed area should be stretched beyond anatomic barriers. Physiologic barriers are caused by the limits of the ROM imposed by nerve and sensory function. When the physiologic barrier is reached, the sensation at the barrier is soft and pliable. An adaptation in a physiologic barrier


to limit movement protectively is called a pathologic barrier. Pathologic barriers often manifest as stiffness, pain, or a “catch.” The pulling sensation into the area being stretched acts as a protective mechanism, signaling not to move into anatomic limits that could potentially result in injury.

There are two types of pathologic barriers:• Pain and stiffness occur when the joint movement assessment

identifies reduced ROM or hypomobility. Stretching may be indicated.

• A lack of resistance is experienced when normal ROM is reached during assessment, indicating hypermobility (an unusu-ally large ROM). Stretching should not be done; strengthening is required.

HypermobilityIt is possible for a joint to become too flexible. Excessive flexibility can be just as detrimental as not enough flexibility because both increase the risk of injury. Joint hypermobility can cause the following symptoms:• Joint pain.• Back pain.• Joint dislocation (the joint comes out of its correct position).• Soft tissue injuries, such as tenosynovitis (inflammation of the

protective sheath around a tendon).Excessive joint ROM affects women more than men because

female hormones increase flexibility. Joint hypermobility is treated with an exercise program to improve fitness and muscle strength resulting in increased stability. Because of the risk of injury and pos-sibly joint dislocation, hypermobile joints should not be stretched.

Contraindications and Other CautionsIf clients report any of the following, they need to consult with their health care provider before the massage therapist performs any stretches.• Lack of joint integrity. The integrity of the joints should be

maintained throughout the entire stretch. This means that joints should be stretched in alignment with their movements and that awkward positions should not be used. Otherwise, there is a great risk of injury.

• Joint inflammation. Any type of joint inflammation is a contrain-dication. Stretching and ROM techniques are likely to increase


inflammation, create pain, and cause further damage to the affected joints.

• Neuropathy. Neuropathy is a contraindication for stretching and ROM techniques. It interferes with the body’s ability to detect sensations, which means the client will not have accurate sensa-tions about the length and intensity of the stretch. The risk of injury is increased.

• Bone disease. Diseases such as osteoporosis are a contraindication for stretching and ROM techniques. They increase the risk of injury.

• Prolonged use of steroids. Steroid use can cause brittle bones and fragile skin, so caution is warranted when performing stretches.

• Untreated hypertension. Untreated hypertension is a contraindi-cation for stretching. Because of the demands placed on blood vessels during stretches, there is a danger of increasing blood pressure.

• Nerve root damage or radiating pain. These are contraindications for stretching. Stretching can cause further damage and pain along the nerve pathways.

• Pregnancy. Pregnancy is a caution for stretching. The hormone relaxin, which is secreted during pregnancy, causes tendons and ligaments to loosen; this prepares the pelvis to widen for birth of the baby. As a result, all joints and associated connective tissue structures become more pliable, increasing the risk of displace-ment during stretching and ROM techniques.

Benefits of Stretching on Soft TissueShortened and contracted soft tissues generally resist lengthening and limit mobility in the joint they cross. This tension in a tissue is its resistance to stretch. The limited joint motion is the motion that is in the opposite direction from the location of the tight tissues.

If the tight tissue is located on the posterior side of the joint, anterior motion of a body part at that joint will be limited, and if the tight tissue is located on the anterior side of the joint, posterior motion of a body part at that joint will be limited. Figure 1-1, A, shows decreased flexion of the thigh at the hip joint because of taut tissue and tight hamstrings on the posterior side of the hip joint. Similarly, tight hamstrings would also limit anterior tilt of the pelvis at the hip joint. If anterior hip joint tissues, especially hip joint flexor muscles such as the tensor fasciae latae seen in Figure 1-1, B, are


tight, a decrease in ROM in extension of the thigh at the hip joint occurs. Similarly, tight anterior hip joint tissues limit posterior tilt of the pelvis at the hip joint.

As stated, shortened, contracted tissue can be described as having greater tension. There are two types of tissue tension—passive tension and active tension. All soft tissues can exhibit increased passive tension. Passive tension results from factors affecting the natural elasticity of a tissue, such as fascial adhesions that build up over time in soft tissues. Active tension occurs when contractile elements of the muscle (actin and myosin filaments) contract via the sliding filament mechanism, creating a pulling force toward the center of the muscle. Whether a soft tissue has increased passive or

A

BFIGURE 1-1 A,Tighthipextensors (hamstrings) limit flexionof the thighatthehipjoint.B,Tighthipflexors(tensorfasciaelatae) limitextensionofthethighatthehipjoint.(FromMuscolinoJE:Kinesiology,ed2,St.Louis,2011,Mosby.)


active tension, this increased tension makes the tissue more resistant to lengthening. Stretching is done to lengthen and elongate these tissues, with the goal of restoring full ROM and flexibility to the body.

Muscles have traditionally been considered to be the only tis-sues that exhibit active tension. However, more recent research shows that fibrous connective tissues often contain cells called myofibroblasts, evolving from fibroblasts normally found in con-nective tissue. Myofibroblasts, also found in muscle tissue, contain contractile proteins that can actively contract. Although not present in the same numbers as in muscle tissue, connective tissue myofibroblasts may be present in sufficient numbers to be biome-chanically significant and must be considered when assessing the active tension of that connective tissue.6

Properties of Soft TissueWhen a joint has limited ROM, the joint does not move fully or easily. The loss of flexibility can be a predisposing factor for pain, balance disorders, and injury. Motion may be limited by a mechanical issue within the joint, swelling of tissue around the joint, stiffness of soft tissues, pain, spasticity of associated muscles, or disease. Diseases that prevent a joint from fully extending over time may produce contractures causing permanent inability to extend the joint beyond a certain fixed position.

Connective Tissue, Muscles, and StretchingWhen joint movement assessment shows ROM to be limited, stretching may be indicated to increase flexibility. Stretching should be directed at the muscle tissue and myofascia. Myofascial tissue has the most elastic tissue. Ligaments and tendons have less elastic tissue and are not intended to stretch. Overstretching ligaments may weaken the joint’s integrity and cause destabili-zation, increasing the risk of injury. Once the fascia associated with the muscle has reached its maximum length, attempting to stretch further serves only to stretch the ligaments and puts undue stress on the tendons. Myofascia can be safely elongated through proper stretching techniques. This elongation is beneficial because the fascial network allows muscles, bones, and blood vessels to communicate down to a cellular level, continuously coordinating and restoring the body’s physiologic functions.


Stretching introduces forces of bend, torsion, and tension that mechanically affect connective tissue. The connective tissue fibers are elongated past their bind so that they can enter the plastic range. Plastic range is the range of movement of connective tissue that is beyond its elastic limit. In this range, the tissue perma-nently deforms and cannot return to its original state. Either the fibers unravel, or there is a local therapeutic inflammatory response that signals for change in the fibers. Stretching also affects the ground substance, warming and softening it, which increases its pliability.

Because fascial sheaths provide structural support, it is impor-tant to work with an understanding of the three-dimensional nature of the body. Shifts in structure have more than a localized effect. The body supports stability before mobility, and compensa-tion patterns occur throughout the body. Changes in structure must be balanced with either lengthening or strengthening activities that allow the body to maintain a sense of balance. If stability and mobility are not taken into account, the body tends to react to changes in structure, such as the effects of stretching, with increased muscle spasms and acute pain. This results in a decreased ability to respond to stretching, making it ineffective.

Additionally, before stretching, the muscles usually must be lengthened or the muscles in the area may develop protective spasms. These protective spasms develop because stretching often moves into pathologic barriers formed by connective tissue changes. The connective tissue component cannot be accessed until the muscle has been lengthened. Without stretching, any lengthening may be restricted by shortened connective tissue. Although length-ening without stretching is possible and often desirable, lengthening must always be done before stretching. During stretching, the two methods work together.7

CompensationDirection of ease is the way the body allows for postural changes, muscle shortening, and weakening compensation patterns, depend-ing on its balance in gravity. Although compensation patterns may be inefficient, the patterns developed serve a purpose and need to be respected. It may seem logical to locate a shortened muscle group or a rotated movement pattern and use direct methods to reverse the pattern. However, this approach may not be the best one.


Protective sensory receptors prevent any forced stretching of tissues to move out of a compensation pattern. Instead, with pattern of compensation respected, the body position should be exaggerated and then coaxed into a more efficient position.

Because stretching requires adaptation on the part of the body’s soft tissues, it is important to determine if:• The current condition is resourceful compensation that is produc-

tive and should not be changed.• The client’s tissues are adaptable and have enough time to respond

to the change.• The change positively affects how the client’s body moves

and feels.7

Physiology behind StretchingTo understand flexibility and how stretching works, it is important to understand the anatomy and physiology of all the structures involved. These structures include the joints, muscle tissue, and proprioceptors.

JointsThe types of joints that provide the greatest amount of movement in the body are synovial joints or diarthroses. They have a space between the bones called a synovial cavity. This gap allows free movement at the joint. Joints without this gap allow little or no movement. Figure 1-2 shows the basic structure of a synovial joint. The bones in the joint are joined by an articular capsule made of dense irregular connective tissue, and they often have accessory ligaments surrounding them for support. Figure 1-3, A, shows the hip joint with its ligaments, and Figure 1-3, B, shows the knee joint with its ligaments and associated structures, such as muscles and bursae. As seen in these figures, synovial joints are quite complicated because of the need to be both mobile and stable.

Ligaments are thick, tough, fibrous tissue. Most of the collagen fibers in ligaments are arranged in parallel bundles, giving them the greatest amount of tensile strength. Tensile means the ability to withstand longitudinal stress. However, there are also fibers within the ligament that are oriented in other ways. These fibers give pliability, strength, and a certain amount of stretch to the ligament as the joint moves in various directions. Stretching improves the flexibility and health of ligaments. Also, even though ligaments


can stretch only minimally, stretching the surrounding soft tissues improves the joint’s flexibility. Therefore, the ROM of a joint can be increased and maintained.

Muscle TissueEach skeletal muscle is a separate organ composed of thousands of muscle cells called muscle fibers because of their elongated shape. A typical muscle fiber is about 4 inches long. Skeletal muscles also have fascia surrounding muscle fibers as well as the entire muscle. Three layers of connective tissue extend from the fascia to protect

Bone

Blood vessel

Nerve

Periosteum

Joint capsule

Joint cavity(contains

synovial fluid)

Articular cartilage

Synovial membrane

FIGURE 1-2 Basic structure of a synovial joint. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


and strengthen muscle tissue. The outermost layer is epimysium, surrounding the entire muscle. The perimysium surrounds groups of 10 to 100 or more muscle fibers and groups them into bundles called fascicles. Within each fascicle, the endomysium surrounds individual muscle fibers. All three connective tissue layers extend beyond the muscle fibers to form a tendon, which attaches

Lessertrochanter

Anterior view

Pubofemoralligament

Pubicbone

A

AIIS

Posterior view

Zonaorbicularis

Ischialtuberosity

Ischiofemoralligament

Greatertrochanter

of femur

Iliofemoralligament

Exposedheadof femur

Iliofemoralligament

Ischiofemoralligament

Greater trochanterof femur

FIGURE 1-3 A,Hipjoint.(FromMuscolinoJE:Kinesiology,ed2,St.Louis,2011,Mosby.)


to bone. Muscle tissue also has a rich blood and nerve supply. Figure 1-4 shows skeletal muscle tissue and its connective tissue coverings.

The plasma membrane of a skeletal muscle fiber is called the sarcolemma. The sarcolemma has thousands of inward folds called transverse (T) tubules that tunnel toward the center of each muscle fiber. T tubules open to the outside of the fiber and are filled with interstitial fluid. Nerve impulses travel along the sarcolemma and through the T tubules, quickly spreading throughout the muscle fiber. This is how a nerve impulse excites all parts of the muscle fiber at once.

Within the muscle fibers are tiny, threadlike structures called myofibrils. These are the contractile organelles of skeletal muscle extending the entire length of the muscle fiber. Within myofibrils are even smaller structures called thin filaments, made of a protein

S

P

I

A

Hamstringmuscles

Poplitealartery

and vein

Quadricepstendon

Fat

Femur

Suprapatellarbursa

Gastroc-nemius

Meniscus

Capsule

Patella

Popliteus

Tibia

Patellarligament

Patellarligament

Infrapatellarfat

B

FIGURE 1-3, cont’d. B,Kneejoint.(FromGoslingJ,etal:Human anatomy,ed4,Philadelphia,2002,Saunders.)


called actin, and thick filaments, made of a protein called myosin. They do not extend the entire length of a muscle fiber. Instead, they are arranged in compartments called sarcomeres, which are the basic functional units of a myofibril. Figure 1-5 shows the micro-scopic structures of skeletal muscle tissue.

Muscles can change length because of the overlapping thin and thick filaments; this is referred to as the sliding filament mechanism. The edges of the sarcomere are called Z disks, to which the thin filaments are attached. In the center of the sarcomere are the thick strands, which, during contraction, pull the Z disks closer together by attaching to the thin filaments with specialized links called cross bridges. These cross bridges function similar to boat oars as they reach out and attach and pull on the thin filaments, causing the Z disks to move toward one another. The Z disks pull on neighboring sarcomeres, and the whole muscle fiber shortens. The result is an overall shortening or contraction of the muscle in response to a nerve impulse. The sliding filament mechanism is shown in Figure 1-6. When the nerve impulse stops, the filaments slide back to their habitual resting positions.

Muscle

Bone

EndomysiumPerimysium

Epimysium

FIGURE 1-4 Skeletal muscle tissue and its connective coverings. (FromMuscolinoJE:Kinesiology,ed2,St.Louis,2011,Mosby.)


BoneTendon

Fascia

Muscle

Fascicle

Muscle fiber(muscle cell)

MyofibrilT tubule

Sarcoplasmicreticulum

Z disk

Sarcomere

Thick filament Thin filament

Z disk

EpimysiumPerimysiumEndomysium

FIGURE 1-5 A-D,Microscopicstructuresofskeletalmuscle. (FromPattonK,ThibodeauG:Anatomy and physiology,ed7,St.Louis,2010,Mosby.)


Microscopic Effect of Stretching a MuscleWhen muscle fibers are stretched, they elongate as each sarcomere extends to the point where no overlap between the thick and thin filaments exists at all. At this point, the tension of the stretch is taken up by the sarcolemma and endomysium (Fig. 1-7). If the stretch tension goes beyond this point, microscopic tears can develop both in the connective tissue and within the sarcomere itself. These microtraumatic injuries eventually heal, but there may be minute scarring and microadhesions that leave the muscle fiber less capable of contraction and lengthening.

Each sarcomere has a habitual resting length. Correct stretching lengthens the muscle by causing the thin and thick filaments to

H zone I band A band

Thick filaments

Thin filamentsZ diskZ disk

Sarcomere

RELAXED

INTERMEDIATE CONTRACTING STAGE

FULLY CONTRACTED

FIGURE 1-6 Sliding filament mechanism. (From Patton K, Thibodeau G:Anatomy and physiology,ed7,St.Louis,2010,Mosby.)


adopt a new habitual resting position, lengthening the sarcomere. Regular stretching causes myofibrils to grow longer by growing new sarcomere segments. These new sarcomere segments increase the ROM of the muscle and increase the power the muscle can generate. Therefore, stretching not only increases the muscle’s pliability, it also increases its strength.

ProprioceptorsThe neuromuscular system has built-in protection against severe muscular injury. This protection is in the form of proprioceptors that sense changes in muscle tension and muscle length. Proprioceptors are embedded in muscles, especially postural muscles and tendons, and they provide the nervous system with information about the degree to which muscles are contracted and the amount of tension on tendons as well as pressure on the joint, the positions of joints, and acceleration and deceleration of joints during movement.

The proprioceptors involved in stretch reflexes are muscle spindles found in the bellies of muscles (Fig. 1-8). Muscle spindles monitor changes in length of skeletal muscle fibers. When a muscle has stretched far enough during a particular movement, the muscle is stimulated to contract, relieving the stretching. It prevents injury by preventing overstretching and possible tearing of muscle tissue. Resetting the muscle spindle is the mechanism of proprio-ceptive neuromuscular facilitation and contract-relax stretching methods discussed in Chapter 4.

The stretch reflex is activated when a muscle is stretched for too long, when a muscle is stretched to the point of pain, or if a muscle is not flexible enough to tolerate the stretch. In the last case, the muscle has a rebound contraction to prevent injury. The way to prevent this is always to begin stretches slowly and within the

Z disk Z diskThick

filamentsThin

filaments

H zone I band A band

FIGURE 1-7 Sarcomereduringastretch.


tolerance of the muscle tissue. This approach can be thought of as meeting the tissue where it is and encouraging it to stretch a bit further. Forcing a stretch not only results in rebound contraction, but it also can cause injury.

The proprioceptors involved in tendon reflexes are tendon organs, which are found in the musculotendinous junction (Fig. 1-9). Tendon organs measure tension applied to tendons from muscle contraction. The tendon reflex protects tendons and associ-ated muscles from damage by causing muscle relaxation in response to excessive tension on tendons by muscle contraction.

Joint kinesthetic receptors are found in and around the articular capsules of synovial joints. They respond to pressure and acceleration and deceleration of joints. Articular ligaments contain receptors similar to tendon organs that cause adjacent muscles to relax when excessive strain is placed on the joint.

Major Categories of StretchingThe two primary variations of stretching techniques are passive and active. Passive stretching occurs when a second person (the massage

Extrafusalmuscle

Intrafusalmuscle

Receptor(sensorynerve)

Motornerve

Motornerve

Intrafusalmuscle

Extrafusalmuscle

MUSCLE SPINDLE

FIGURE 1-8 Musclespindle.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


therapist) applies the force to stretch the tissue. Passive stretching is one of the most controlled forms of stretching. This form of stretching usually involves the massage therapist controlling the stretch through a specific motion. The client relaxes to the point of the elongation, and the massage therapist can progress the movement throughout its ROM. Active stretching is when clients stretch themselves. The three major categories of stretching are static, dynamic, and ballistic.

Static StretchingStatic stretching is a slow and progressive elongation of the target muscle accomplished by holding the stretch for 15 to 30 seconds. It is considered passive. After 15 to 30 seconds, the massage therapist can progress the stretch further, if it is comfortable for the client, and hold again, then release. Three repetitions of stretching and

Sensory nerve

Golgi tendonorgan

Tendon

FIGURE 1-9 Tendonorgan.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


releasing are usually recommended. Static stretches are performed so that the joints are placed in the outer limits of the available ROM and held. Static stretches are safe and effective. Most people are familiar with these stretches and often perform them at home (Fig. 1-10).

Static stretching can activate the stretch reflex if the stretch is continued beyond comfort or the stretch is not held for at least 15 seconds. A possible rebound contraction can occur before that time, creating a tug-of-war between the desire to stretch and the target muscle resisting overstretching to avoid injury. This rebound contraction is why it is important to maintain focus while stretch-ing and pay attention to signals the client’s body is giving.3

Dynamic StretchingDynamic stretching is considered active. It involves moving the joints of the body through ranges of motion instead of holding the body in a static position of stretch. The idea is that whenever a joint

FIGURE 1-10 A clientperformsa static stretchof the left armandscapularregion.(FromMuscolinoJE:Kinesiology,ed2,St.Louis,2011,Mosby.)


is moved in a certain direction, the tissues on the other side of the joint are stretched. If the hip joint is flexed, the anterior muscles are contracting, and the tissues on the other side of the joint, the hip joint extensor muscles and other posterior soft tissues, are stretched. Similarly, if the hip joint is extended, the hip joint flexor muscles and other anterior tissues are stretched.

When doing dynamic stretching, the joint motions need to be performed in a careful, prudent, and graded manner, gradually increasing the intensity of the motions. For this reason, dynamic stretching begins with small ranges of motion, which gradually build up to full ranges of motion. If dynamic stretching is done before a physical workout, the ranges of motion that are performed should be the same ranges of motion that will be asked of the body during the physical workout. If the exercise entails some form of added resistance, the resistance of the exercise should be added gradually to the dynamic stretching after the full ranges of motion of the joints are accomplished.

For example, before playing tennis, the client would go through the motions of forehand, backhand, and serving strokes without a racquet in hand, beginning with small swings and building up to full ROM swings. Then the same order of motions would be repeated with the added resistance of having the tennis racquet in hand (but not actually hitting a ball), starting with small swings and gradually working up to full ROM swings. Finally, the client adds the full resistance of hitting the tennis ball while playing on the court, starting with gentle, short swings and gradually building up to full ROM and powerful swings (Fig. 1-11).

Dynamic stretching can be recommended to clients as an exer-cise warm-up in addition to a way to stretch tissues. It increases local circulation, warms the tissues, lubricates the joints and brings them through their ROM, and engages the neural pathways that will be used during the exercise routine.

As explained earlier, static stretching is beneficial if the tissues are warmed up first. Static stretching can be very effective after an exercise routine is done (or if the tissues are first warmed up by applying moist heat). However, some sources are recommending that even static stretching should be performed in more of a move-ment-oriented “dynamic” manner. It was classically recommended to hold a stretch 15 to 30 seconds, whereas many sources now advocate that the stretch should be held for only 2 to 3 seconds. Approximately 8 to 10 repetitions can be done instead of the


A

B

FIGURE 1-11 A,Ashortforehandswingisdonewithoutholdingaracquet.B,AfullROMswingisdonewithouttheracquet.


C

D

FIGURE 1-11, cont’d. C,Theclientusesaracquettoprovidegreaterresis-tance,firstwithashortswing.D,TheclientusesafullROMswing.(FromMuscolinoJE:Kinesiology,ed2,St.Louis,2011,Mosby.)


References 1. Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby. 2. Run the Planet: Factors limiting flexibility. 2010. www.runtheplanet.com/

trainingracing/stretching/chap2-limitingfactors.asp. Accessed May 21, 2013. 3. Freeman JE, Anderson SK: Career longevity, the practitioner’s guide to

wellness and body mechanics, Philadelphia, 2013, Davis. 4. Andersen JC: Stretching before and after exercise: effect on muscle

soreness and injury risk, J Athl Train 40:218–220, 2005. 5. Mayo Clinic: Stretching: focus on flexibility. 2009. http://www.mayoclinic.

com/health/stretching/HQ01447. Accessed May 25, 2013. 6. Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby. 7. Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St. Louis, 2013,

Mosby. 8. Simancek J: Deep tissue massage treatment, ed 2, St. Louis, 2013, Mosby.

previously recommended 3 repetitions. As the method of static stretching is changed from a few long statically held stretches to more repetitions with the stretch being held for less time, static stretching increasingly resembles dynamic stretching.6

Ballistic StretchingBallistic stretching, although popular, can be detrimental to the body. This type of stretching is active and is often referred to as a type of dynamic stretching. It was practiced by athletes for years. Ballistic stretches use the momentum of a moving body or a limb in an attempt to force it beyond its normal end point. These stretches are of high force and short duration. This type of stretching is not considered safe and can lead to injury by aggravating muscle and connective tissue. Ballistic stretching involves rapid bouncing motions to force the target muscle to elongate. The stretched target muscles are used like springs to pull the individual out of the stretched position. It does not allow the muscles to adjust to and relax into the stretched position. Instead, it may cause them to tighten up by repeatedly activating the stretch reflex, often producing small muscle tears that result in scar tissue.8

29

Joints, muscles, and other soft tissues that benefit from massage also benefit from stretching techniques for improved function, re-stored mobility, and increased range of motion (ROM). These techniques are additional treatment options and can be performed easily before, during, or after a massage treatment, or as the primary technique.

Guidelines for Successful StretchingTo stretch the client’s tissues successfully, there are several guide-lines to follow to assist the stretching process and enhance results. These guidelines involve muscle relaxation, warming the tissues, minimum force, breath, and duration.

Muscle RelaxationMuscle relaxation means the lengthening of inactive, or noncon-tracting, muscle fibers or muscles. Relaxation is the opposite of tension; tension occurs in contracted muscles and results in stiffness, insufficient oxygen and nutrient supply secondary to decreased local circulation, and fatigue.

Relaxation is crucial to increased flexibility. If a client’s muscle is contracted at the time of stretching, the thin and thick filaments cannot slide to a longer resting position. The filaments are asked to do opposing actions at the same time, causing strain on the muscle’s tendons. A stretching technique can cause a muscle to remain elongated after being stretched only if the muscle is relaxed while it is being stretched.

Warming the TissuesStretching should be done when the target tissues are most receptive to being stretched, which is when they are already warm. Warming

2Chapter

Basic Stretching Techniques

30 Chapter 2 Basic Stretching Techniques

soft tissue facilitates stretching because heat soothes the central nervous system, helping muscles relax. Also, because of its proper-ties, myofascial tissue is more easily stretched when warm. Cold tissues resist stretching and are more likely to be injured.

Massage therapists can warm the target tissues by applying moist heat. The client can take a hot shower, hot bath, or use a whirlpool before the massage treatment, if these facilities are avail-able. Alternatively, the massage therapist can place a moist heating pad or hydrocollator pack on the target tissues.1

Minimum ForceStretching should never be painful. After stretching is complete, it should feel rejuvenating. Soreness after a stretching session is a sign that the stretching has been too vigorous.

Every client has varying tolerances to discomfort and pain. It is recommended to stretch the client’s tissues only to the point of mild to moderate discomfort if the goal is to improve ROM. The massage therapist should stretch up to that point, then decrease the stretch until the muscle relaxes, then stretch again. Using too much force during the stretch may cause injury to the area.

The comfort barrier is the first point of resistance before the client perceives any discomfort at either the physiologic or the pathologic barrier. If stretching causes pain, it is likely that the tar-get muscles or muscles will tighten in response to the pain. Also, if the target muscle is stretched either too quickly or too forcefully, the stretch reflex may be stimulated, resulting in muscle tightening, which is the opposite of the desired outcome.

Stretching should always be done slowly, rhythmically, with the minimal force needed, and within the client’s tolerance. A stretch can be performed as intensely as needed but should always be without client pain. When in doubt, it is best to be conservative regarding the speed and forcefulness of a stretch. Gently and slowly stretching a client over many sessions is a safer way to loosen target tissues. It may take more sessions, but a positive outcome is essen-tially guaranteed. Stretching too quickly and forcefully not only may set back the progress of the client’s treatment program but also may cause tissue damage that is difficult to reverse (Box 2-1).

BreathProper breath is important for successful stretching. There are many different schools of thought about client breathing patterns during

31Chapter 2 Basic Stretching Techniques

stretching. However, the most effective method is for the client to breathe normally with efficient breaths and to visualize the muscles, tendons, and ligaments lengthening during the stretch. The client should avoid holding the breath because this increases blood pressure and general muscular tension. Breathing efficiently should also enhance relaxation while being stretched.

The client should breathe in the following manner during stretches:• Inhale before the stretch.• Exhale into the stretch.• Breathe normally during the stretch.• Inhale while being returned to the start position.

DurationStretching duration can vary, depending on numerous factors. Foremost is the type of stretching being performed. Dynamic stretching involves several “swings” or gross motor movements of the extremities that last only a few seconds. Static stretching methods involve longer periods, sometimes up to 1 minute.

Short, agonizing stretching sessions are not more effective (and may result in scar tissue formation) than longer sessions of lesser intensities. Major muscles can stretch in a relaxed state to about 50% longer than their usual resting length if patience is used. Fascia is given time to relax as well. Fascia generally is slow to relax because of the postural stressors placed on the body. Just as

Clients often describe a stretch as being painful but go on to say that the pain feels good. For this reason, a distinction should be made between what is often described by the client as good pain and true pain (or what might be called bad pain). Good pain is often the way that a client describes the sensation of the stretch; causing good pain as a result of a stretch is fine. However, if a stretch causes true pain—in other words, the client winces and resists or fights the stretch—the intensity of the stretch must be lessened. Otherwise, not only will the stretch be ineffective, but also the client is likely to be injured. A stretch should never be forced.

Spotlight BOX 2-1

(From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)


stressors did not cause fascia to be in a shortened state overnight, fascia does not relax and become more elastic instantly. Refer to the section on “Connective Tissue, Muscles, and Stretching” in Chapter 1.

Safe and Effective Stretching MethodsMost joint mobilization and stretching techniques are best admin-istered on unlubricated skin; any excess lubricant may need to be wiped off if massage was previously administered on that area. If the entire session is devoted to joint mobilization and stretching, the client may remain clothed; the routine is best performed with the client wearing flexible clothing such as sweatshirts and pants, tights, or leggings.

The massage therapist should tell the client beforehand about the movements that will be performed. The movements may need to be demonstrated, especially if they require active participation by the client. Also, it is essential to use proper body mechanics when applying these movements because they can be physically demand-ing on the massage therapist, particularly if the client has a large body size.

Stretching ProceduresHave the client actively demonstrate a baseline ROM before stretching; this helps to evaluate the effectiveness of the technique.• Stretch tissues only when they are warm and pliable. After warm-

ing through a hot shower or heat pack application, use jostling, rocking, or superficial friction to prepare the area.

• Stabilize the body so that only the target area is isolated during stretching.

• Move the area to the pathologic barrier and back off a bit.• Instruct the client to inhale right before the stretch and then

exhale slowly as the stretch is performed.• Stretching should always be done within the comfortable limits

of the range of motion of the client.• Stretching should be controlled and performed at a slow pace.• A stretch can be performed in sets of 10 repetitions with a 15- to

30-second rest in between each stretch.• An increase of 10% in ROM is sufficient during a massage

session. Do not attempt to increase the ROM more than 25% during a massage session.2


OverstretchingIf stretching is done properly, the client should not feel soreness the next day. The opposite should be true—the client should feel good. If the client has soreness, it may be an indication of overstretching, and the intensity and duration of future stretches should be reduced.

Overstretching increases the time it takes to gain greater flexi-bility because overstretching damages tissues; they need to repair themselves to have the same extensibility as before they were injured. One of the easiest ways to overstretch is to stretch without warming the tissue. Just because a muscle can be moved to its limit without warming up does not mean it is ready for the strain that stretching could place on it.

The sensations felt as the extreme ranges of a stretch are reached include localized warmth of the stretched muscles, followed by a burning or spasmlike feeling, and then sharp pain. The localized warming usually occurs at the attachments of the stretched muscles. If the client feels these sensations, the intensity of the stretch needs to be decreased.

If the warming sensation is ignored, or perhaps the client did not feel it, and the stretch is continued until a definite burning sensation is felt in the stretched muscles, the stretch should be discontinued immediately. If the stretch is continued to the point that the client feels a sharp pain, it is likely that the stretch has already resulted in tissue damage, which may cause immediate pain and soreness that persists for several days.3

Reasoning and ApplicationJoint movement and palpation are the assessments for determining if stretching can be used to alleviate areas of tissue shortening that are involved in a lack of flexibility. During the massage treatment, each joint should be moved actively or passively, or both, to deter-mine the available ROM.

It is important not to confuse joint movement with stretching. Joint movement assesses the limits of movement as indicated by the palpation of bind. The sensation of bind comes from tissue being restrained from motion. Stretching begins at the bind and then moves into it to increase the amount of available movement.

When moving a joint during assessment, one should stay within the normal physiologic barriers. If limits of ROM are identified, the massage therapist should gently and slowly encourage the joint to increase the ROM only if hypomobility exists. It may take multiple


massage sessions, with client self-stretching in between the sessions, to see long-lasting results. Flexibility generally increases gradually.2

How Stretches Can Be Reasoned Out Instead of MemorizedTo create a stretch, the client’s body is moved into a position that creates a line of tension that pulls on the target tissues (Fig. 2-1). If the stretch is effective, the tissues are lengthened.

FIGURE 2-1 Hatch marks indicate the line of stretch when the client’s upper extremity is stretched. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)


If the target tissue to be stretched is a muscle or muscles, the massage therapist can identify the position the client’s body must be moved into to achieve an effective stretch. The massage therapist recalls the joint movements for the target muscle and moves the client’s body part opposite of one or more of these actions. Examples are as follows:• If a muscle flexes a joint, stretching would involve extension of

that joint.• If the muscle abducts a joint, stretching would involve adduction

of that joint.• If a muscle medially rotates a joint, stretching would involve

lateral rotation of that joint.• If a muscle has more than one action, the optimal stretch would

involve the opposite of all its actions.If the target muscle to be stretched is the right upper trapezius,

its actions are extension, right lateral flexion, and left rotation of the neck and head. Stretching the right upper trapezius would require flexion, left lateral flexion, or right rotation of the head and neck.1

Multiplane StretchingBecause space is three-dimensional, mapping space and describing movements that occur within the three dimensions involves the use of planes. A plane is a flat surface that cuts through space. The three major, or cardinal, planes are sagittal, frontal (coronal), and transverse (horizontal). A sagittal plane divides the body into left and right portions. The midsagittal plane divides the body into equal right and left halves. The frontal plane divides the body into anterior and posterior portions. The transverse plane divides the body into superior/proximal and inferior/distal portions. An addi-tional plane is any that is not purely sagittal, frontal, or transverse; it is called an oblique plane. The planes are shown in Figure 2-2.

Figure 2-3, A, shows examples of motion within the sagittal plane. The head and neck are flexing at the spinal joints, and the forearm is flexing at the elbow joint. Figure 2-3, B, shows examples of motion of a body part within the frontal plane. The head and neck are left laterally flexing at the spinal joints, and the left arm is abducting at the shoulder joint. Figure 2-3, C, shows examples of motion of a body part within the transverse plane. The head and neck are rotating to the right at the spinal joints, and the left arm is medially rotating at the shoulder joint. Figure 2-3, D,


FIGURE 2-2 Four types of planes: A, Sagittal. B, Frontal. C, Transverse. D, Oblique. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)

C D

A B


A

BFIGURE 2-3 A, Motions of body parts within a sagittal plane. B, Motions of body parts within a frontal plane.


D

C

FIGURE 2-3, cont’d C, Motions of body parts within a transverse plane. D, Motions of body parts within an oblique plane. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)


shows examples of motion of a body part within an oblique plane. The head and neck are doing a combination of extension in the sagittal plane, left lateral flexion in the frontal plane, and right rotation in the transverse plane. The right arm is doing a combi-nation of flexion in the sagittal plane, adduction in the frontal plane, and medial rotation in the transverse plane. Stretching a muscle across more than one cardinal plane is called multiplane stretching.

When a muscle has many actions, it is not always necessary to do the opposite of all of them, although it might be desired or needed at certain times. If the right upper trapezius is tight enough, simply doing flexion in the sagittal plane might be enough to stretch it. However, if further stretch is needed, left lateral flexion in the frontal plane or right rotation in the transverse plane, or both, could be added as shown in Figure 2-4.

FIGURE 2-4 The right upper trapezius is stretched in all three planes. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)


Even if not every plane of action is used for the stretch, it is still important to be aware of all the muscle’s actions, or a mistake might be made with the stretch. If the right upper trapezius is being stretched by flexing and left laterally flexing the client’s head and neck, it is important not to let the client’s head and neck rotate to the left because this would allow the right upper trapezius to be slackened, and the tension of the stretch would be lost. Given that the right upper trapezius also elevates the right scapula, it is important to ensure that the right scapula is depressed or at least not allowed to elevate during the stretch, or the tension of the stretch will also be lost.1

Isolating a Stretch to One Target MuscleIt is sometimes challenging to isolate one target muscle for stretch-ing. Usually an entire functional group of muscles is stretched at the same time (Box 2-2). Figuring out exactly how to isolate a target muscle depends on knowing the joint actions of the muscles involved. This knowledge eliminates the need to memorize a large number of stretches. Critical thinking can be used to reason through the steps necessary to figure out which stretches are needed for a client-centered treatment.

For example, if a client’s thigh is stretched into extension in the sagittal plane, the entire functional group of sagittal plane hip flexors is stretched (tensor fasciae latae, anterior gluteus medius and minimus, sartorius, rectus femoris, iliopsoas, pectineus, adductor longus, gracilis, and adductor brevis). To isolate just one of the hip flexors requires modifying the stretch to achieve the desired result. If the stretch involves extension in the sagittal plane and adduction in the frontal plane, all hip flexor muscles that are also frontal plane adductors will be slackened, and the hip flexor muscles that are also

Whenever a stretch affects a functional group of muscles—in other words, many muscles—the tightest muscle within the line of tension of the stretch is usually the limiting factor of how forcefully the stretch can be done. The problem is that if a different muscle is the target muscle to be stretched, it will not be successfully stretched because the stretch was limited by the tighter muscle.

Spotlight BOX 2-2



abductors, such as tensor fasciae latae, sartorius, and anterior gluteus medius and minimus, will be stretched.

If medial rotation of the thigh in the transverse plane is also added to the stretch so that the thigh is now being extended in the sagittal plane, adducted in the frontal plane, and medially rotated in the transverse plane, all hip joint flexors and abductors that are also transverse plane medial rotators will be slackened, but the stretch on muscles that perform flexion, abduction, and lateral rotation of the thigh at the hip joint will be increased. In this case, sartorius is the target muscle stretched because it is the only hip joint flexor and abductor muscle that also laterally rotates the thigh at the hip joint. (Iliopsoas would also be stretched because it is a hip flexor and lateral rotator, and some sources state that it can also abduct.) Because sartorius also flexes the knee, the knee joint should be extended during the stretch.

Whenever a client’s body part is moved into a stretch in one direction (in one plane), the entire functional group of muscles located on the other side of the joint is stretched. To isolate the stretch to one or only a few of the muscles in this functional group requires modifying the stretch. The modification could be adding movements in other planes to the stretch or adding a stretch to another joint if the target muscle crosses more than one joint.1

Stretching Other Target TissuesIf the target tissue to be stretched is not a muscle but a ligament, a joint capsule, or some other soft tissue, the stretch can still be reasoned out instead of memorized. One way to do this is to think of this tissue as though it were a muscle. Figure out what its action would be if it were a muscle, and then perform the action that is antagonistic to that action. For example, if the target tissue is a ligament located on the anterior hip joint, the massage therapist would move the client’s thigh posteriorly (or posteriorly tilt the pelvis at the hip joint) to stretch it.

Direct Tissue StretchingDirect tissue stretching targets tissues in a local area that have been assessed as shortened and have binding (Fig. 2-5, A and B). If only a small section of muscle needs to be stretched, if the muscle cannot be stretched using joint movement, or if the joints are so flexible that not enough pull is put on the tissues for an effective stretch, direct tissue stretching may be an option (Box 2-3). This type of


A

B

FIGURE 2-5 A, Beginning of direct tissue stretch. B, End of direct tissue stretch.


C

DD

C

FIGURE 2-5, cont’d. C, Beginning of longitudinal stretch. D, End of longitudinal stretch. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St. Louis, 2013, Mosby.)


stretching does not involve joint movement as part of the technique. However, palpation or joint movements are used as the assessments to identify areas of shortened tissue, and the tissue is directly stretched using various mechanical forces. The two types of direct tissue stretching are longitudinal and cross-directional.

Longitudinal StretchingLongitudinal stretching pulls connective tissue in the direction of the fibers. It is performed along with movement at the joint and gliding applied with drag in the direction of the force (Fig. 2-5, C and D). If longitudinal stretching is inadvisable, if it is ineffective because a joint is hypermobile, or if the area to be stretched is not effectively stretched longitudinally, cross-directional stretching, discussed in the next section, is a better choice. Cross-directional stretching focuses on

Some muscle tissues are extremely difficult to stretch by using active or passive joint movement. This difficulty is related to the size, shape, and direction of the tissue fibers. Muscle tissues that are small and short, square or rectangular, or oriented transversely in the body re-spond better to direct tissue stretching. Following is a list of some muscles that are better addressed by direct methods:SuboccipitalsSupraspinatusPectoralis minorSerratus posterior superiorSerratus posterior inferiorSupinatorAnconeusLongissimusIliocostalisSemispinalisMultifidusRotatoresQuadratus lumborumQuadricepsPopliteusTibialis anterior

Spotlight BOX 2-3

(From Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.)


the tissue itself and does not depend on joint movement. Four meth-ods of longitudinal stretching include basic longitudinal stretching, separating the ends of tissue to lengthen it, active assisted longitudinal stretching, and using compression with longitudinal stretching.

Basic Longitudinal StretchingThe procedure for basic longitudinal stretching is as follows: 1. Position the target muscle in the direction of ease. Stabilize and

isolate the muscle group. 2. Use gliding, compression, and kneading to warm and relax the

target muscle. 3. Have the client inhale. As the client exhales, stretch the muscle

to its physiologic or pathologic barrier or to wherever is toler-able for the client; this is the point of bind. Release the stretch slightly to prevent muscle spasm. Make sure the stretch stays in line with the muscle fibers.

4. Have the client breathe normally while holding the stretch position for at least 10 seconds; this is the lengthening phase. Feel for a small amount of muscle release.

5. Take up slack by lengthening the muscle further for up to 20 seconds to create longitudinal pull on the connective tissue; this allows for changes in the connective tissue component of the muscle.

6. Release the stretch.

Separating the Ends of Tissue to Lengthen ItLongitudinal tissue stretching can also involve separating the ends of the tissue to lengthen it. This technique is useful if only a small section of muscle needs to be stretched, if the muscle does not lend itself to stretching with joint movement, or if the joints are so flexible that not enough pull can be applied to the muscle to achieve an effective stretch to the tissues.

The procedure is as follows (Fig. 2-6): 1. Locate the tissues to be stretched. 2. Place the hands, fingers, or forearms directly over the area to be

stretched. 3. Separate the fingers, hands, or forearms to apply tension force to

stretch the tissue. Alternatively, lift the tissue with enough pres-sure to stretch the tissue; this applies bending or torsion force.

4. Take up all slack from lengthening, and then increase the force of the stretch for up to 20 seconds.


5. Repeat two or three more times. 6. Release the stretch.

Active Assisted Longitudinal StretchingThe following procedure is used for active assisted longitudinal stretching: 1. Isolate the target muscle. Make sure it will not be working

against gravity in the stretching position. 2. Lengthen the muscle to its physiologic or pathologic barrier.

Increase the stretch slightly beyond this point, and gently hold for 1 to 2 seconds.

3. Release the muscle to its starting position. Repeat this action in a rhythmic fashion for 5 to 20 repetitions.

4. To increase the effectiveness of the stretch, have the client contract the antagonist while the target muscle is lengthened and stretched.

Using Compression with Longitudinal StretchingTo use compression with longitudinal stretching, do the following: 1. Isolate the target tissue. 2. Apply compression into the shortened tissue and hold it in a

fixed position.

FIGURE 2-6 Separating the ends of tissue to lengthen it. (From Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.)


3. Have the client move the adjacent joint to lengthen the tissue. This is also called active release.

4. Alternatively, the massage practitioner can compress the shortened tissue, and use his or her other hand to move tissue or the joint into a stretched position. This is also called pin and stretch, which is discussed in Chapter 4.4

Cross-Directional StretchingCross-directional stretching pulls the connective tissue against the fiber direction. This technique involves pulling and twisting, which are torsion and bend forces. The procedure for cross-directional stretching is as follows (Fig. 2-7): 1. Isolate the target tissue. 2. To stretch the area, use compression and move against the fiber

direction. 3. Lift the tissue slightly and hold for 30 to 60 seconds until the

tissue feels warmer or releases.For skin and superficial connective tissue, do the following:

1. Isolate the target tissue. 2. Lift and pull the tissue, first moving into the restriction and

then pulling and twisting out of it, keeping a constant tension

FIGURE 2-7 Cross-directional tissue stretch. (From Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.)


on the tissue; this is similar to pulling taffy. Proceed slowly. Take up slack until the tissue feels warmer or releases.4

Basic Static Stretching TechniquesBasic static stretching techniques that can be easily incorporated into massage treatments are presented in Chapter 3.

References 1. Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby. 2. Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby. 3. Freeman JE, Anderson SK: Career longevity, the practitioner’s guide to wellness

and body mechanics, Philadelphia, 2013, Davis. 4. Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St. Louis, 2013,

Mosby.

49

The techniques presented in this atlas are passive movements involving static stretches.* These techniques can be performed before, during, or after a massage treatment. A brief description of the technique is presented along with a photo. The techniques should be performed on both sides of the client’s body when applicable.

As mentioned in Chapter 2, the massage therapist should have the client actively demonstrate a baseline range of motion before stretching; this will help to evaluate the effectiveness of the technique. As discussed in Chapter 2, the client should inhale before the stretch, exhale into the stretch, breathe normally during the stretch, and inhale while being returned to the start position. The stretch should be held for 20 to 30 seconds, depending on the client’s tolerance and when the massage therapist feels the tissue release.

Massage therapists should check their state’s definition of scope of practice for the inclusion or exclusion of these techniques. Additional stretches to supplement the ones presented here are described in Chapters 4 and 5.

NeckJoint mobilizations and stretches of the neck are performed while the client is in the supine position. They include neck circles, neck lateral flexion with and without rotation, and neck forward flexion. Movements of the neck include flexion, extension, lateral flexion, and rotation.

3Chapter

Basic Static Stretching Atlas

*From Salvo SG: Massage therapy principles and practice, ed 4, pp 162-170, St. Louis, 2012, Mosby.

50 Chapter 3 Basic Static Stretching Atlas

Neck CirclesPlace one hand on the client’s forehead, rocking the head side to side while your other hand intermittently compresses the tissue in the lamina groove on the opposite side up and toward you (Fig. 3-1). If done correctly, it will feel as if your hands are pushing and pulling alternately.

Neck Lateral FlexionWith one hand, pull the client’s head toward the near shoulder while your hand stabilizes the client’s far shoulder (Fig. 3-2). Do not lift the head while pulling.

Neck Lateral Flexion with RotationWith one hand, pull the client’s rotated head toward the near shoulder; the client’s head is rotated away from you or toward the far shoulder. Use your other hand to stabilize the client’s far shoulder (Fig. 3-3). Do not lift the head while pulling. Repeat on the opposite side.

Neck Forward FlexionSupport the base of the skull with one or both hands or forearm while you lift the head toward the chest (Fig. 3-4). If both forearms are used, they can be crisscrossed at the base of the client’s skull before the lift.

Wrist and HandJoint mobilizations and stretches of the wrist and hand are flip wrist, interlace fingers and mobilize wrist, metacarpal scissors, and pull and circumduct fingers. The massage therapist should not apply excessive force while moving the wrist and hand. The four move-ments of the wrist are abduction, adduction, flexion, and extension.

Flip WristLightly pincer-grip just above the wrist with your thumbs and index fingers of both hands. Use your remaining fingers to flip the client’s hand up and down while you stabilize the wrist (Fig. 3-5). This action moves the wrist into flexion and extension.

Interlace Fingers and Mobilize WristHolding the client’s forearm vertically, interlace your fingers with the client’s fingers. Move the wrist into flexion, extension, abduction, and adduction as your other hand stabilizes the client’s forearm just above the wrist (Fig. 3-6).

51Chapter 3 Basic Static Stretching Atlas

A

B

C

FIGURE 3-1 A, Begin by moving the head away from you. B, Move theheadtothecenter.C,Movetheheadtowardyou.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-2 Necklateralflexion.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-3 Neck lateral flexion with rotation. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-4 Neckforwardflexion.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-5 Flip wrist. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


Metacarpal ScissorsLightly pincer-grip two of the metacarpal bones with your thumbs and index fingers of both hands. Alternately move them up and down; move to the next pair of bones and repeat (Fig. 3-7). Mobilize the tissues between each pair of metacarpals.

FIGURE 3-6 Interlace the fingers before moving wrist. (From Salvo SG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

1

1

22

FIGURE 3-7 Metacarpalscissors.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-8 Pull andcircumduct finger. (FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

Pull and Circumduct FingersSupport the client’s wrist with one of your hands while you pull and circumduct each finger with the other hand (Fig. 3-8). Move in both directions (i.e., clockwise and counterclockwise).

Arm and ShoulderJoint mobilizations and stretches of the arm and shoulder are arm pulls and shoulder circles. These movements are best applied while the client is supine but can be adapted for use in the prone or side-lying position. The movements of the shoulder are flexion, extension, adduction, abduction, rotation, and circumduction. The elbow permits flexion, extension, and rotation (the latter movement permits pronation and supination of the forearm).


FIGURE 3-9 Pulling the arm down. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

Arm PullThis technique has four parts: 1. While standing tableside near your client’s hip, grasp just above

the wrist. Pull and release the arm several times (Fig. 3-9). The arm can be tapped or gently bounced on the massage table while you pull or traction it.

2. Grasp just above the wrist and stand several feet away from the table’s side. The shoulder will be abducted 90 degrees. Pull and release the arm several times (Fig. 3-10).

3. Adduct the client’s shoulder by draping his or her arm across the chest. Push the arm horizontally across the table using one hand over the shoulder and the other hand over or under the elbow (Fig. 3-11).


FIGURE 3-10 Pullingthearmtotheside.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-11 Pulling the arm across the chest. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


4. Grasp just above the wrist and position yourself several feet away from the top of the table. Pull and release the arm several times (Fig. 3-12).

Shoulder CirclesBeginning with the client’s arm at his or her side, create an arc by pulling the arm up toward the ceiling until it is vertical; continue pulling the arm until it is over the client’s head (Fig. 3-13, A). With your other hand, bend the client’s elbow and bring the arm laterally to the client’s side (Fig. 3-13, B). Maintain traction during the entire movement sequence. Repeat three times.

SpineThe umbrella term “spinal twist” is used for techniques for the spine that employ a lengthening and rotational motion on a supine-lying client. These movements are repeated on each side of the client.

Spinal Twist IAnchor the client’s far hip with your lower hand while you pull the far shoulder up and toward you with your upper hand. The

FIGURE 3-12 Pulling the arm overhead. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


client’s arms can be relaxed or placed with hands behind the head (Fig. 3-14).

Spinal Twist IIWith the client’s near leg bent and the foot placed on the lateral side of the far knee, push the bent knee away from you while pulling the far shoulder up and toward you (Fig. 3-15).

A

B

FIGURE 3-13 A,Pullthearmovertheclient’shead.B,Pullarmdowntotheclient’sside.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


Spinal Twist IIIAnchor the client’s far shoulder while you pull the bent far knee toward you and down (Fig. 3-16).

Spinal Twist IVAnchor the client’s near shoulder while you push the bent near knee away from you (Fig. 3-17).

A

B

FIGURE 3-14 A, Client’s arms relaxed. B, Client’s hands behind the head.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-15 SpinaltwistII.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-16 Spinal twist III. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-17 Spinal twist IV. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

Hip and KneeJoint mobilizations and stretches of the hip and knee areas are leg pull, leg rock, hip clock stretch, hip circles, hip flexion, groin stretch, heel to hip, and hip hyperextension. Hip move-ments are flexion, extension, adduction, abduction, rotation, and circumduction. Knee movements are essentially flexion and extension.

Leg PullWhile standing at the foot of the table, grasp just above the client’s ankle. Pull and release several times (Fig. 3-18). The leg can be tapped or gently bounced on the massage table while you are pulling or applying traction.


Leg RockWhile standing tableside, place your hands above and below the client’s knee. Rock the leg back and forth to rotate the hip (Fig. 3-19).

Hip Clock StretchFlex the client’s hip and knee while supporting both the knee and the heel; while imagining that the client’s leg is the hour hand of a clock, push and stretch the hip in a 10 o’clock, 12 o’clock, and 2 o’clock stretch (Fig. 3-20). Repeat in the opposite direction.

Hip CirclesAfter performing the hip clock stretch, move the client’s flexed hip and knee in a circle three times (Fig. 3-21). Reverse the direction and repeat.

FIGURE 3-18 Leg pull. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-19 Leg rock. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

2

12

10

FIGURE 3-20 Hipclockstretch.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


Hip FlexionFlex the client’s hip by placing one hand just above and behind the ankle and raise the leg. Place your other hand above the knee to maintain knee extension during the movement (Fig. 3-22). To stretch the calf after hip flexion, dorsiflex the ankle (Fig. 3-23).

Groin StretchFlex and laterally rotate the client’s near hip, and flex the near knee. Place the near foot by the far knee. Stretch the hip adductors by gently pressing down on the iliac crest of the far hip with one hand and just above the near flexed knee with the other hand (Fig. 3-24).

Heel to HipFlex the client’s near knee by moving the heel toward the near hip (Fig. 3-25). A dorsiflexion of the ankle can be added during the stretch (Fig. 3-26).

FIGURE 3-21 Hip circles. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-22 Hip flexion. (FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-23 Hipflexionwithankledorsiflexion.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-24 Groin stretch. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-25 Heel to hip. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)


FIGURE 3-26 Heeltohipwiththeadditionalankledorsiflexion.(FromSalvoSG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-27 Hip hyperextension. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

Hip HyperextensionFlex the client’s knee and lift the thigh until the hip is hyperex-tended. The hand lifting the thigh should be above the flexed knee while the other hand anchors the sacrum (Fig. 3-27). Release and repeat two more times.

Ankle and FootJoint mobilizations and stretches of the ankle and foot are plantar flexion and dorsiflexion, metatarsal scissors, and pull and circumduct


BA

FIGURE 3-28 Plantar flexion (A) and dorsiflexion (B). (From Salvo SG:Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

toes. The ankle and foot movements, which include dorsiflexion, plantar flexion, inversion, and eversion, can be applied while the client is prone or supine.

Plantar FlexionWhile holding the client’s heel with one hand, push down on the top of the foot with the other hand to move the ankle into plantar flexion (Fig. 3-28, A).

DorsiflexionHold the client’s heel with one hand while pushing the ball of the foot toward the knee with the other hand to move the ankle into dorsiflexion (see Fig. 3-28, B).

Metatarsal ScissorsLightly pincer-grip two of the metatarsal bones with your thumbs and index fingers of both hands. Alternately move them up and down, then move to the next pair of bones and repeat (Fig. 3-29). Mobilize the tissues between each pair of metatarsals.

Pull and Circumduct ToesSupport the client’s foot with one hand while you pull and circumduct each toe with the other hand (Fig. 3-30). Move in both directions (i.e., clockwise and counterclockwise).


1

12

2

FIGURE 3-29 Metatarsal scissors. (FromSalvoSG:Massage therapy princi-ples and practice,ed4,St.Louis,2012,Mosby.)

FIGURE 3-30 Pull and circumduct the toes. (From Salvo SG: Massage therapy principles and practice,ed4,St.Louis,2012,Mosby.)

71

There are several types of advanced stretching techniques massage therapists can use to address soft tissues that do not release with basic stretching techniques. These techniques make use of neurologic mechanisms such as the tendon and stretch reflexes. The techniques presented in this chapter are pin and stretch, proprioceptor neuro-muscular facilitation (PNF), contract relax (CR), antagonist contract (AC), contract relax antagonist contract (CRAC), active isolated stretching (AIS), and muscle energy techniques (MET).

Pin and StretchPin and stretch is a stretching technique in which the massage therapist pins (stabilizes), usually through compression, one part of the client’s body and then stretches the tissues up to that pinned spot through either active or passive movement. The purpose of the pin and stretch is to stretch a more specific region of the client’s body. As discussed in Chapter 2, when a body part is moved to cre-ate a stretch, a line of tension is created. Everything along the line of tension will be stretched. However, if only a certain area of soft tissue along that line of tension needs to be stretched, then the pin and stretch technique can be used to localize to that specific region.

For example, if a side-lying stretch is performed on a client as shown in Figure 4-1, A, the entire lateral side of the client’s body from the client’s distal thigh to the upper trunk will be stretched. While the stretch over this line of tension may be effective, it is not targeted to a specific muscle. Spread over such a large region of the client’s body, focus of the stretch is diluted. Also, if one region of soft tissue of the client’s body within that line of tension is tight, it might stop the stretch from continuing into another area of the line of tension that is specifically targeted to stretch.

4Chapter

Advanced Stretching Techniques

72 Chapter 4 Advanced Stretching Techniques

B

A

FIGURE 4-1 A,Side-lyingstretchofaclient.B,Pinningtheclient’slowerribcage.

73Chapter 4 Advanced Stretching Techniques

If the massage therapist pins the client’s lower rib cage, as seen in Figure 4-1, B, the stretch will no longer occur in the client’s lateral thoracic region. Instead it will be directed to the client’s lateral pelvis and lateral lumbar region. If the massage therapist instead pins the client’s iliac crest, as seen in Figure 4-1, C, the stretch will no longer occur in the client’s lateral lumbar region. It will now be directed to only the lateral muscles and other soft tissues of the client’s thigh. Therefore, the pin and stretch technique pins and stabilizes a part of the client’s body, focusing and directing the stretch along the line of tension to the target tissues.

Continuing with this example, if the target tissues are gluteus medius and quadratus lumborum (as well as other muscles of the lateral pelvis and lateral lumbar region), pinning the client at the lower rib cage, as seen in Figure 4-1, B, would be the ideal approach. If the target tissue is limited to gluteus medius (and other muscles or soft tissues of the lateral pelvis), the ideal location to pin the client during this side-lying stretch is at the iliac crest, as seen in Figure 4-1, C. As can be seen, pin and stretch is a powerful technique that allows for much greater specificity when stretching a client.1

C

C, Pinning the client’s iliac crest. (From Muscolino J:Kinesiology,ed2,St.Louis,2011,Mosby.)FIGURE 4-1, cont’d


Proprioceptive Neuromuscular FacilitationProprioceptive neuromuscular facilitation (PNF) is a common passive technique that uses neuromuscular reflexes—the tendon reflex and the stretch reflex, to increase range of motion (ROM) and to reeducate the body. Common techniques used in PNF are the CR and AC techniques, and a combination of both, known as the contract relax antagonist contract technique (CRAC).

PNF follows the normal use patterns of the body, is a good option to use for rehabilitation and strengthening, and is more effective than static stretching. However, a regular daily regimen of training is required to maintain flexibility gained from PNF. PNF stretching is not recommended for children or adolescents whose bones are still growing.

Contract RelaxThe name contract relax (CR) is used because the target muscle is first contracted, and then it is relaxed. CR involves the use of postisometric relaxation. Immediately following this contraction, there is a period during which all neural impulses are inhibited to that muscle, allowing it to relax; this is postisometric relaxation.

Usually, the agonist (target) muscle is isometrically contracted using just a little strength for a short duration (7 to 10 seconds). This isometric contraction stimulates the tendon organs located in the tendon of the target muscle. As discussed in Chapter 1, tendon organs measure tension applied to tendons from muscle contraction. The tendon reflex protects tendons and associated muscles from damage by causing muscle relaxation in response to excessive ten-sion by muscle contraction. However, in the case of postisometric relaxation, excessive tension is not being placed on the tendons. Instead, minimal isometric contraction of the muscle is just enough to stimulate the tendon organs.

Although the contraction of a CR stretch is usually isometric, it can also be done concentrically. In other words, when the client contracts against the resistance of the massage therapist, the client can be allowed to shorten the muscle and move the joint success-fully. Whether the contraction is isometric or concentric, the tendon reflex is still initiated, adding to the effectiveness of the stretch.

Generally, the client is asked to inhale and then hold the breath while isometrically contracting against resistance and then exhale and relax while the target muscle is being stretched (Box 4-1). CR stretch-ing is performed by first having the client isometrically contract the


target muscle with mild to moderate force against resistance provided by the massage therapist. The massage therapist then stretches the target muscle by lengthening it immediately afterward. The isometric contraction is usually held for approximately 5 to 10 seconds (although some sources recommend holding the isometric contrac-tion for 30 seconds). This procedure is usually repeated three to four times.1

Each repetition of a CR stretch begins where the previous rep-etition ended. However, it is possible, and sometimes needed, to ease off the stretch before beginning the next repetition. The reason is that the mechanism of CR stretching is the tendon reflex. The client needs to be able to generate a forceful enough contraction to stimu-late this reflex. Sometimes this is impossible if the client is trying to contract the target muscle when it is stretched extremely long.

The procedure for CR is as follows (Fig. 4-2): 1. Lengthen the target muscle to the comfort barrier, and then

ease off slightly. 2. Have the client tense the target muscle for 7 to 10 seconds. 3. Have the client stop the contraction, and lengthen the target

muscle again. 4. Repeat steps 1 through 3 until the desired resting length is

obtained.2

Antagonist ContractSimilar to CR stretching, antagonist contract (AC) stretching also uses a neurologic reflex to “facilitate” the stretch of the target muscle. However, instead of the tendon reflex, AC uses reciprocal inhibition.

Therearetwochoicesfortheclient’sbreathingprotocolwhendoingaCRstretch.Theclientcanholdinthebreathwhencontractingthetargetmuscleagainsttheresistanceofthemassagetherapist,ortheclientcanexhalewhencontractingthetargetmuscle(thinkexertiononexhale)againstthemassagetherapist’sresistance.Althoughcon-tractingwhenexhalingisprobablyslightlypreferred,ifCRstretchingwillbecombinedwithACstretchingtoperformCRACstretching,itisnecessary for theclient tohold in thebreathwhencontracting thetargetmuscle.

Spotlight BOX4-1



A

Contract

Target

Lengthen

Target

B

FIGURE 4-2 A, Isolate targetmuscles (hamstringsandgastrocnemius)andhave the client contract by pushing calf down. B, Lengthen target muscle.


D

Target

C

C, Isolatetargetmuscles(latissimusdorsiandpectoralismajor),andhaveclientcontractbypushingarmsdowntowardchest.D,Relaxandlengthen.(FromFritzS:Mosby’s fundamentals of therapeutic massage,ed5,St.Louis,2013,Mosby.)

FIGURE 4-2, cont’d

Reciprocal inhibition is a neurologic reflex that creates a more effi-cient joint action by preventing two muscles that have an agonist-antagonist relationship from contracting at the same time. When a muscle contracts, antagonists are inhibited from contracting; they are relaxed. Neurologically inhibited muscles are more easily stretched.


If brachialis contracts to flex the forearm at the elbow joint, reciprocal inhibition inhibits triceps brachii from contracting and extending the elbow joint. Using reciprocal inhibition, the client contracts the antagonist muscle to create a stretch in the agonist muscle.

The procedure for using reciprocal inhibition when stretching a client is as follows (Fig. 4-3): 1. Have the client perform a joint action that is antagonistic to the

joint action of the target muscle. This action inhibits the target muscle, allowing for a greater stretch to be done at the end of this active movement. Ask the client to inhale before the movement and then exhale during the movement.

2. At the end of the client’s ROM, stretch the client further and hold the position 1 to 3 seconds, and then release.

3. Repeat the procedure approximately 10 times.1The following is the procedure for contract antagonist and

stretch (Fig. 4-4): 1. Lengthen the target tissues to the client’s comfort barrier, and

then ease off slightly. 2. Have the client contract the antagonist muscles. 3. Have the client stop the contraction, and slowly bring the target

tissues into a lengthened state, stopping at resistance. 4. Repeat steps 1 through 3 three or four times. The goal is 10%

to 25% improvement or ideal resting length of the client’s muscle.2

Confusion can occur between reciprocal inhibition and AC. AC is reciprocal inhibition but with beginning lengthened positioning of the target muscle and the massage therapist providing resistance against contraction of the antagonist muscle group. The difference between CR and AC stretching is that in CR stretching, the client actively isometrically contracts the target muscle, and then the mas-sage therapist stretches it immediately afterward. With AC stretch-ing, the client actively moves his or her body into the stretch of the target muscle, and then the massage therapist stretches the target muscle further immediately afterward.

Put another way, with CR stretching, the client contracts the target muscle to stimulate the tendon reflex to relax it, whereas with AC stretching, the client contracts the antagonist of the target muscle so that the agonist is reciprocally inhibited and relaxed and then taken into a stretch.


A

B

FIGURE 4-3 A,Theclientactivelyleftlaterally flexes the neck, whichstretches the right lateral neck flexormuscles and results in reciprocalinhibition of the right lateral flexors.B,AttheendoftheROMofleftlateralflexion, the massage therapiststretches the client’s neck further,continuing the stretch of the rightlateral neck flexor muscles. (FromMuscolinoJ:Kinesiology,ed2,St.Louis,2011,Mosby.)


B

Targettissue

Target tissue

A

Resistanceforce

Resistanceforce

Directionof push

Directionof push

Target

Target

FIGURE 4-4 A, Lengthen the target tissues to the client’s comfort barrier.Apply counterforce on the antagonist muscles, and instruct client to pushgentlyintothehands.B,Theclientstopscontracting;themassagetherapiststretchesthetissues,stoppingatresistance.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


Contract Relax Antagonist ContractCR and AC can be combined to enhance the lengthening effects. This combined approach is called contract relax antagonist contract (CRAC).

The procedure for CRAC is as follows (Fig. 4-5): 1. Position the target tissues at the client’s comfort barrier, and

then ease off slightly. 2. Have the client contract the target muscle for 7 to 10 seconds,

and then relax. 3. Have the client contract the antagonist muscles. 4. Have the client stop the contraction, and slowly bring the target

tissues into a lengthened state, stopping at resistance. 5. Repeat steps 3 and 4 three or four times. The goal is 10% to 24%

improvement or ideal resting length of the client’s muscle.2

Active Isolated StretchingActive isolated stretching (AIS) was developed by Mattes. AIS involves contracting muscles opposite of the target muscles, using reciprocal inhibition. The target muscles are identified and isolated by using precise, localized movements.

The procedure for AIS is as follows (Fig. 4-6): 1. Identify the target muscles to be stretched. 2. Have the client stretch the target muscles by actively, but gently,

contracting the antagonists. 3. At the end of the client’s ROM, the massage therapist increases

the intensity of the stretch by adding a moderate force that stretches the target muscles further. The added stretch should be gentle so that the stretch reflex is not triggered. Note: Steps 2 and 3 are called the stretch phase; the entire duration of the stretch phase should be no more than 2 seconds.

4. The massage therapist supports the client’s body and guides it back to the starting position. This step is called the recovery phase. The client should always be brought back to the original starting position at the end of each repetition.

5. Steps 2 through 4 are repeated approximately 8 to 10 times. Each successive repetition usually allows an incremental gain of a few degrees of motion of the stretch.3

Muscle Energy TechniquesMuscle energy techniques (MET) are active because they involve a voluntary contraction of the client’s muscles in a specific and controlled


B

Target

Target

Resistance

Resistance

Directionof push

Directionof push

A

Target

Target

Resistance

Resistance

Directionof push

Directionof push

FIGURE 4-5 CRAC,andthenstretchshoulderadductors.A,Contracttar-gettissueagainstappliedcounterforce.B,Movehandstoantagonistmuscles,andinstructclienttopushintotheappliedcounterforce,con-tractingtheantagonistmuscles.


C

C,Instructtheclienttostoppushing,andthenstretchthetargettissues.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


direction, at varying levels of intensity, against a specific counterforce applied by the massage therapist. The amount of effort may vary from a small muscle twitch to a maximal muscle contraction. The duration may be a fraction of a second to several seconds. All contractions begin and end slowly, gradually building to the desired strength. MET have various applications but are focused primarily on dysfunctional move-ment patterns involving hypomobility.

MET and PNF are similar in that both involve the client con-tracting muscles isometrically and the massage therapist performing passive stretches. However, PNF also includes active movements by the client.

Research indicates that PNF and MET stretching is more efficient than static passive stretching. Understanding how MET is beneficial has changed over the past few years, most notably that postisometric and reciprocal inhibition effects do not account for the ability to increase the tissue length. Instead, it is believed to be due to an increased tolerance to stretch resulting from MET application.4

Principles of Muscle Energy TechniquesCounterpressure is the force applied to an area that either exactly or partially matches the effort the client is exerting. The effort the client is exerting is through an isometric or isotonic muscle contraction.


B

A

FIGURE 4-6 AssistedAISofthemedialrotatorsoftherightarm.A,Theclientisintheneutralstartingposition.B,Theclientactivelymovestherightarmintolateralrotation,beginningthestretchofthemedialrotators.Themas-sage therapist adds a gentle force that moves the right arm into furtherlateral rotation, continuing the stretch of the medial rotators. (Photos byYanikChauvin.FromStillermanE:Modalities for massage and bodywork,St.Louis,2009,Mosby.)


Three types of muscle contractions are used in MET: isometric, eccentric isotonic, and concentric isotonic. In an isometric muscle contraction, the distance between the proximal and distal (origin and insertion) attachments of the target muscle is maintained at a constant length. A fixed tension develops in the target muscle as the client contracts the muscle against an equal counterpressure applied by the massage therapist, preventing shortening of the muscle. In this contraction, the effort of the muscle, or group of muscles, is matched exactly by a counterpressure so that no movement occurs, only increased effort on the part of the client.

An isotonic contraction is one in which the muscle changes length. The effort of the target muscle or muscles is not matched by the counterpressure of the massage therapist, allowing a degree of resisted movement to occur. With a concentric isotonic contraction, the muscle shortens. The massage therapist applies a counterforce but allows the client to move the proximal and distal (origin and insertion) attachment of the target muscle together against the pres-sure. In an eccentric isotonic contraction, the muscle lengthens. The massage therapist applies a counterforce but allows the client to move the jointed area so that the proximal and distal (origin and insertion) attachment of the target muscle separate as the muscle lengthens against the pressure. Multiple isotonic contractions require the client to move the joint through a full ROM against partial resistance applied by the massage practitioner.

MET usually do not use the full contraction strength of the client. With most isometric work, the contraction should start at about 25% of muscle strength. Subsequent contractions can involve progressively greater degrees of effort but never more than 50% of the available strength. Sometimes only about 10% of the available strength in muscles is used in this way, and there is an increase in effectiveness by using longer periods of contraction. Pulsed con-tractions (a rapid series of repetitions) using minimal strength are also effective.

Breathing and Eye MovementThe use of coordinated breathing to enhance particular directions of muscular effort can be beneficial. During MET, all muscular effort is enhanced by inhaling as the effort is made and exhaling on the lengthening phase.

Eye position is also effective owing to reflex muscle contraction in response to voluntary eye movement. Looking toward the direction of


the contraction causes or facilitates the target muscles to contract. Looking away from the direction of contraction inhibits the target muscles. Use of eye movement can be helpful with clients who are prone to cramping or are having difficulty using only a small contrac-tion force. The eye movement replaces the contraction of the target muscles, or it can enhance the contraction being used with MET. It is recommended that eye movement be used first before active target muscle contraction.

Almost all flexor patterns—trunk, hip, knee, ankle, shoulder, arm, and wrist—are increased in tension (facilitated) when the client looks toward the abdomen and are inhibited when the eyes roll up. Extensor patterns—trunk, hip, knee, and ankle—are facilitated when the client looks up and are inhibited when the client rolls eyes down. When in doubt about the position, the massage therapist can just instruct clients to roll the eyes in big circles slowly and deliberately. The result is a CRAC pattern.

Following are common examples of use of eye movement (Fig. 4-7):• To increase tension in neck flexors (tense and then relax), have the

client look toward the belly, rolling eyes down.• To decrease tension in neck flexion, have the client look up over

the head, rolling eyes up.• To increase tension in left neck rotation or lateral flexors, have the

client look left.• To decrease tension in left neck rotators or lateral flexors, have

client look right.• Reverse for right rotation or lateral flexor patterns.

A successful application is to lengthen the target tissue to bind and then hold. The client begins the eye movement (usually big circles) as the facilitation and inhibition (contraction and relaxation) occur. The lengthening force on the target muscles is slowly increased until a more normal resting length is achieved (Fig. 4-8).2

MethodsEnergy methods for MET can be used together or in sequence to enhance their effects. Muscle tension in one area of the body often indicates imbalance and compensation patterns in other areas of the body. Tension patterns can be self-perpetuating. Often, using an integrated approach introduces the type of information the nervous system needs to self-correct.

To perform MET effectively, the massage therapist positions muscles so that their attachments are either close together or


A

B

FIGURE 4-7 A,Eyeslookingdown—facilitatesflexors,adductors,andinternalrotators;inhibitsextensors,abductors,andexternalrotators.B,Eyeslookingup—facilitatesextensors,abductors,andexternalrotators;inhibitsflexors,ad-ductors,andinternalrotators.


C

D

C,Eyeslookingleft—facilitatesallmusclemovementtotheleft;inhibitsallmusclemovementtotheright.D,Eyeslookingright—facilitatesallmusclemovementtotheright;inhibitsallmusclemovementtotheleft.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


lengthened with the attachments separated. The target muscle or muscles should be isolated whether the client is in a supine, prone, side-lying, or seated position.

The procedure for an integrated approach follows. The position from Option A, steps 1 and 2, or Option B, steps 1 and 2, is used as the starting point for the rest of the process that begins at step 3 (Fig. 4-9).


B

A

FIGURE 4-8 A,Instructclienttolookdown.Applygentlepressure.Flexorsmaintaincontraction.B,Instructclienttomoveeyesup.Applygentlepressure.Flexorsinhibit,relax,andaremoretoleranttostretching.


C

D

Stretch

Contract

C,Eyeslookright.Musclesontherightsideofthebodycontract.D,Instructclienttolooklefttoincreasetolerancetostretch-ingoftherightneckflexors.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)



A

B

FIGURE 4-9 A,Part1.Locatetargetarea.OptionA:Identifythepatternofdistortion.B,Increasedistortionineaseposition.


C

D

C,Part1.Locatetargetarea.OptionB:Usetenderpointandmovebodyintoeaseuntilthepointlessensinpain.D,Part2.Treatment.Stabilizeclientinexaggerateddistortionorpositionofease.Instructclienttomoveoutofthepatternintoneutralposition.



E

F

E,Asclientismoving,provideresistancefortheclienttopushorpullagainstforabout10seconds.F,Attheendofthemovement,gentlyincreasethelengtheningtoperformthestretch.



G

G,IflocatingatenderpointwasusedinPart1,palpatethetenderpointagainandrefinethestretchpositionasnecessarytoensurethetissuescontainingthetenderpointarestretched.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


Option A 1. Identify the most obvious of the postural distortion symptoms. 2. Exaggerate the pattern by increasing the distortion, moving the

client’s body into ease. This position isolates the various muscles and associated tissues to be addressed in the next part of the procedure. Continue with step 3.

Option B 1. Identify a painful point on the client’s body. 2. Move the client’s body into ease until the point is substantially

less tender to pressure. The position of ease isolates the various muscles and associated tissues to be addressed in the next part of the procedure. Continue with step 3.

After choosing from Option A or Option B, continue the pro-cedure as follows: 3. Stabilize the client in as many different directions as possible.

The result should be the client is in the position of exaggerated distortion or position of ease.


4. Instruct the client to move out of the pattern into neutral posi-tion. Be as vague as possible and do not guide the client because it is important for the client to identify the resistance pattern.

5. As the client is moving, provide resistance for the client to push or pull against for about 10 seconds.

6. Modify the resistance angle as necessary to achieve the most solid resistance pattern for the client.

7. Notice when the client’s breathing changes. While still provid-ing modified resistance, allow the client to move through the pattern slowly.

8. When the client has achieved as much extension as possible, recognize that the client has achieved the lengthening pattern.

9. Gently increase the lengthening to perform the stretch. 10. Pay attention to what body areas become involved besides the

one addressed. This is the guide to the next position.

Pulsed Muscle Energy ProceduresPulsed muscle energy procedures involve engaging the com-fort barrier and using small, resisted contractions (usually 20 in 10 seconds). This method can be used to increase stretch toler-ance in chronically shortened tissues or stimulate weakened elongated tissue to increase tone.

The procedure for pulsed muscle energy is as follows (Fig. 4-10): 1. Isolate the target muscle by placing the attachments as close

together as possible. 2. Apply counterpressure for the contraction. 3. Instruct the client to contract the target tissues rapidly in small

movements for about 20 repetitions. Go to step 4, or maintain the position, but switch the counterpressure location to the opposite side and have the client contract the antagonist mus-cles for 20 repetitions. Rapid eye movement can replace the pulses or enhance the action.

4. Slowly lengthen the target tissues. Repeat steps 2 to 4 until there is 10% to 25% improvement or a more ideal resting length of the client’s muscle is obtained.

Using pulsed muscle energy to stimulate weak inhibited muscles, do the following (Fig. 4-11): 1. Isolate the target muscle by placing the attachments as close

together as possible. 2. Apply counterpressure for the contraction.


A

Resistance

Resistance

Target

BTarget tissue

FIGURE 4-10 A, Isolate target muscle and apply counterpressure for thecontraction.Havetheclientpulsethemusclebackandforthusingtiny,con-trolled movements. B, Tell the client to stop movement, and stretch theshortenedtissues.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


Targethip abductors

Resistance

FIGURE 4-11 Exampleofpulsedmuscleenergytostimulateweak,inhibitedhipabductormuscles.Isolatetargetarea,andinstructtheclienttopulseintoresistance force 20 times. Return the area to normal position and do notstretch.Repeatifnecessary.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)

3. Instruct the client to contract the target tissues rapidly in small movements for about 20 repetitions. Rapid eye movement can replace the pulses or enhance the action.

4. Slowly return the area to normal position. Do not stretch.Note: All contracting and resisting efforts should start and finish

gently.2

Examples of Stretching 1. Lateral neck stretch (Fig. 4-12, A). Position the head at end

range of movement (tissue bind) and stabilize with one hand. This is point of resistance for MET. With the other hand, gen-tly push the shoulder down and away toward the client’s feet to provide force to stretch the target tissues.

2. Pectoralis major stretch (Fig. 4-12, B). Use one hand or forearm to apply compressive force for pulling the tissue into bind. With the other hand, begin to press the upper arm down. When resistance (tissue bind) is felt, it is appropriate to intro-duce MET methods.


B

A

FIGURE 4-12 A-J,Examplesofstretching.(FromFritzS:Sports and exercise massage,ed2,St.Louis,2013,Mosby.)


D

C

FIGURE 4-12, cont’d.

3. Lateral torso stretch (Fig. 4-12, C). With the client in side-lying position, hold the client’s arm over the head with one hand, and place the other hand on the lateral torso just inferior to the axilla. Gently move the arm downward. When resistance (tissue bind) is felt, apply compressive force on the lateral torso to stretch the target tissues.

4. Stretch to increase external rotation of the shoulder joint (Fig. 4-12, D). Abduct the shoulder 90% while leaving the arm on the massage table. With one hand, stabilize just me-dial to the glenohumoral joint. With the other hand, move the client’s arm in external rotation with or without client assistance. Stop at bind to stretch the tissues.


F

E


5. Stretch to increase supination and pronation of the forearm (Fig. 4-12, E). Position the elbow just short of full extension and stabilize with one hand. With the other hand, turn the client’s palm up to stretch until resistance (tissue bind) is felt. Various applications of MET can be used to increase tolerance to the stretch.

6. Hip flexor stretch (Fig. 4-12, F). The hip flexors are more easily stretched with the client in side-lying position. With one hand or forearm, stabilize at the gluteus muscles on the top leg while using the other hand to grasp above the knee on the leg on the table. Slide the bottom leg along the massage table until resis-tance (tissue bind) is felt to stretch the tissues.


H

G


7. Hip abductor stretch (Fig. 4-12, G). Cross one of the client’s legs over the other, slightly internally rotate it, and use one hand to stabilize it at the knee. Place the other hand on the lateral side of the thigh about midway between hip and knee, and place the forearm firmly along the client’s lateral thigh to mid-calf. Pull the entire lower leg medially until resistance (tissue bind) is felt to stretch the tissues.

8. Quadriceps femoris stretch (Fig. 4-12, H). With the client prone, stabilize the client’s midposterior thigh with one hand. With the other hand, flex the client’s knee to 90 degrees. Con-tinue flexing until resistance (tissue bind) is felt to stretch the tissues. However, do not flex more than an additional 45 degrees (do not attempt to bring heel to gluteal muscles).


J

I


9. Stretching the sole of the foot (Fig. 4-12, I). With the client prone or in side-lying position, use one hand to stabilize the heel by pushing it down toward the massage table. Use the palm of the other hand to extend toes until resistance (tissue bind) is felt to stretch the tissues.

10. Trunk torque stretch (Fig. 4-12, J). With the client in side-lying position, stand behind the client. As the client flexes the top hip to 45 degrees, use one hand to push the client’s knee down to the massage table while stabilizing the lateral thigh with the forearm. Place the other forearm across the chest, just under the clavicle, and roll the client back until resistance (tissue bind) is felt to stretch the tissues.


References 1. Muscolino JE. Kinesiology, ed 2, St. Louis, 2011, Mosby. 2. Fritz S. Sports and exercise massage, ed 2, St. Louis, 2013, Mosby. 3. Stillerman E. Modalities for massage and bodywork, St. Louis, 2013,

Mosby. 4. Fryer G. MET—efficacy and research. In Chaitow L, editor: Muscle

energy techniques, ed 3, Philadelphia, 2006, Churchill Livingstone.

105

Clients can experience decreased flexibility and tightness in various parts of their bodies depending on their levels of activity, the type of work they do, how they use their bodies for activities of daily living, and what they prefer to do for recreation. A classic example is a client who spends many hours a day sitting and working at a computer; this can lead to stiffness in the back and neck, tight shoulders, and hip joints that are locked tight. A client who has a small child may have postural dis-tortion from carrying the child on one hip, leading to chronic shorten-ing in the opposite quadratus lumborum. A client who plays tennis may have shoulder tightness, and a client who bicycles may have tightness in gastrocnemius, soleus, and tibialis anterior. Clients who have mini-mal levels of activity may have tightness in almost every joint.

Using efficient body mechanics greatly decreases susceptibility of massage therapists to strain and chronically shorten soft tissues. However, because of the physical nature of bodywork, massage thera-pists are prone to tension and dysfunction. If an aligned spine is not maintained, the result could be stiffness and pain in the neck and back. If the shoulders are not relaxed, stiffness and pain in the shoul-ders, arms, and forearms could develop. If the knees are kept locked, stiffness and pain in the hips, thighs, knees, and lower leg could occur.

An aspect of self-care that is beneficial for both clients and massage therapists is stretching they can perform for themselves. For clients, this stretching helps continue the effects of the massage between sessions and contributes to the client’s overall health and sense of well-being. For massage therapists, performing stretches as part of a regular fitness routine as well as between treatment sessions is a way to increase flex-ibility and reduce the chance of injury. The stretches included in this chapter can be used by clients and massage therapists. These stretches can also supplement the techniques presented in Chapter 2.

5Chapter

Stretching for Self-Care

106 Chapter 5 Stretching for Self-Care

In certain municipalities, recommending stretches may be out of the scope of practice for massage therapy. Massage therapists should check with their local or state regulations to see whether recom-mending stretches for self-care is allowable.

Principles of Stretching for Self-CareFlexibility can be developed at any age as long as stretches are performed in the appropriate manner. The section “Guidelines for Successful Stretching” in Chapter 2 also applies to stretching for self-care. Additionally, the following principles are essential to increasing flexibility:• Stretching in one area of the body does not increase flexibility in

another area. For example, stretching the shoulder muscles does not improve flexibility in the hips.

• All joints do not need to be targeted for self-care stretching. Stretches can be performed on the joints and muscles that need them the most. This way, if their time to spend stretching is lim-ited, clients and massage therapists can maximize their efforts.

• To be effective, stretching exercises must be similar in form and speed to the technique or skill needing improvement. Slow, static stretching does not improve fast movements, such as those in-volved in running or performing percussion or vibration, nearly as well as dynamic stretching movements. Dynamic stretching methods have limited ability to improve a static skill, such as the slow pace involved in lifting items or techniques such as myofas-cial release or trigger point work in massage therapy. It is ideal to do both slow, static stretching and dynamic stretching.

Efficient and effective resistance training programs can also have a beneficial effect on flexibility levels. Whatever level of flexibility a person has, the primary concern should be to have adequate strength throughout the full range of motion of any given joint. Two key points are to perform resistance exercises through the involved joint’s full range of motion and to work antagonistic pairs of muscles equally. Massage therapists can consider recommending to clients to engage in a resistance training program (if it is within the scope of practice for the region in which they practice) along with a stretching routine. Massage therapists may also want to consider resistance training themselves if they do not already engage in this training.

The following section includes stretches for each region of the body. They can be performed in the sequence presented or performed individually, depending on the needs of the client or massage therapist.

107Chapter 5 Stretching for Self-Care

StretchesAll of the following stretches (Figs. 5-1 through 5-58) are static stretches.* They should be held for 20 to 30 seconds, depending on tolerance and when the tissue releases. The techniques should be performed on both sides of the client’s body when applicable.

FIGURE 5-1 A-C, Trapezius. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

A

B C

*From Muscolino J: Know the body, St. Louis, 2012, Mosby.


FIGURE 5-2 Rhomboids. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-3 Levator scapulae. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-4 Posterior deltoid. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-5 Infraspinatus and teres minor. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-6 Teres major and latis-simus dorsi. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-7 Supraspinatus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-8 Anterior deltoid and pectoralis major. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-9 Subscapularis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-10 Serratus anterior. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-11 Pectoralis minor. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-12 Subclavius. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-13 Sternocleidomastoid. The client left laterally flexes and right rotates the head and neck and then extends the lower neck while tucking the chin in. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-15 Longus colli. The client’s head and neck are extended and laterally flexed to the opposite side. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-14 Scalene group. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-16 Splenius capitis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-17 Semispinalis capitis. Note: Flexion is the most important component of this stretch. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


B

A

FIGURE 5-18 A and B, Suboccipitals. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-19 Temporalis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-20 Deltoid. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-21 Biceps brachii. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-22 Brachialis. The client’s elbow joint is fully extended with the forearm in position halfway between full supination and full pronation. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-23 Triceps brachii. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-24 Brachioradialis. The client’s forearm is fully extended at the elbow joint. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-26 Wrist flexor group. If ulnar deviation is added to the extension, the stretch of the flexor carpi radialis is enhanced. If radial deviation is added to the extension, the stretch of the flexor carpi ulnaris is enhanced. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-25 Pronator teres. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-28 Supinator. Note: It is easy to confuse pronation of the forearm at the radioulnar joints with medial rotation of the arm at the glenohumeral joint. Be sure that the forearm is being pronated. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-27 Radial group. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-29 Thenar group. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

A

B

FIGURE 5-30 A and B, Hypothenar group. A, Abductor digiti minimi manus. B, Flexor digiti minimi manus and opponens digiti minimi. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-31 Adductor pollicis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-32 Latissimus dorsi. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-33 Erector spinae group. Note: When returning to the seated posi-tion, it is best for the client to place the forearms on the thighs, using them to push himself or herself back up. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-34 Transversospinales group. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-35 Quadratus lumborum. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-36 Intercostals. Isolating the bending to the thoracic region as much as possible is important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-37 Rectus abdominis. The stretch of one side muscle can be en-hanced by adding some lateral flexion to the opposite side. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


A

B

FIGURE 5-38 A and B, Abdominal obliques. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-39 Diaphragm. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-40 Iliopsoas. Note: Keeping the trunk straight or slightly extended is important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-41 Gluteus maximus. Note: If the client experiences a pinching sensation in the groin with this stretch, it is helpful either to stretch the hip flexors (especially sartorius and iliopsoas) first before performing this stretch or to laterally rotate and abduct the thigh at the hip joint first to untwist and slacken the hip joint capsule. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-43 Piriformis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-42 Gluteus medius and tensor fasciae latae. Note: It is important to avoid placing too much weight on the ankle joint of the foot in back. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-44 Quadratus femoris. Note: If the client experiences a pinching sensation in the groin with this stretch, it is helpful first to stretch the hip flexors (especially sartorius and iliopsoas) before performing this stretch or to laterally rotate and abduct the thigh at the hip joint first to untwist and slacken the hip joint capsule. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-45 Hamstring group. Note: The spine does not need to bend in this stretch. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-46 Sartorius. Note: Not allowing the pelvis to fall into an anterior tilt and ensuring that excessive weight is not placed on the ankle joint of the foot in the back are important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-47 Quadriceps femoris. Note: When performing this stretch, en-suring that the knee joint is not rotated is important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-48 Pectineus and gracilis. Note: Not allowing the pelvis to fall into an anterior tilt and ensuring that excessive weight is not placed on the ankle joint of the foot in the back are important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-49 Adductor longus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-50 Adductor magnus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-51 Tibialis anterior. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-52 Extensor digitorum longus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-53 Extensor hallucis longus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-54 Fibularis longus and fibularis brevis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-55 Gastrocnemius. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

FIGURE 5-56 Soleus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


A

BFIGURE 5-57 A, Extensor digitorum brevis. B, Extensor hallucis brevis. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)


FIGURE 5-58 A, Tibialis posterior. B, Flexor digitorum longus. C, Flexor hal-lucis longus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)

A

B

C

141

Actin Thin protein filaments within myofibrils.Active isolated stretching (AIS) Involves contracting muscles opposite

of the target muscles, using reciprocal inhibition. The target muscles are identified and isolated by using precise, localized movements. Developed by Aaron Mattes.

Active stretching Occurs when the person stretches himself or herself.Active tension Occurs when a muscle’s contractile elements (actin and

myosin filaments) contract via the sliding filament mechanism, creating a pulling force toward the center of the muscle.

Anatomic barriers Barriers to joint movement determined by the shape and fit of the bones.

Antagonist contract (AC) Technique in which the antagonist muscle is contracted, causing the agonist (the target muscle that is to be stretched) to relax; this occurs through reciprocal inhibition.

Articular systems Bones and their joints and the nervous system.Ballistic stretching A type of dynamic stretching using the momen-

tum of a moving body or a limb in an attempt to force it beyond its normal end point. These stretches are of high force and short duration.

Bind Limits of movement as indicated by the palpation of a resistance barrier.

Cardinal plane Major plane. The cardinal planes are sagittal, frontal (coronal), and transverse (horizontal).

Comfort barrier The first point of resistance before the client perceives any discomfort at either the physiologic or the pathologic barrier.

Concentric isotonic contraction Contraction in which the muscle shortens.

Contract relax (CR) Stretching technique in which the target muscle is first contracted and then relaxed; the postisometric relaxation (PIR) period is ideal for progressing further into the stretch.

Contract relax antagonist contract (CRAC) Combination of contract relax (CR) and antagonist contract (AC) techniques. CRAC stretching begins with the client contracting the target muscle. Next, the client actively contracts the antagonist muscles. When

Glossary

142 Glossary

the client relaxes the antagonist muscles, the massage therapist stretches the target muscle. Combining CR with AC stretching can create an even greater stretch for the target muscles.

Coronal plane Divides the body into anterior and posterior portions; also called frontal plane.

Counterpressure Force applied to an area that either exactly or partially matches the effort the client is exerting. The effort the client is exerting is through an isometric or isotonic muscle contraction.

Cross bridges Links between the thin (actin) and thick (myosin) filaments within a sarcomere. Cross bridges function similar to boat oars as they reach out, attach, and pull on the thin filaments, causing the Z disks to move toward one another. The Z disks pull on neighboring sarcomeres, and the whole muscle fiber shortens. The result is an overall shortening or contraction of the muscle in response to a nerve impulse.

Cross-directional stretching Pulls the connective tissue against the fiber direction. Involves pulling and twisting, which are torsion and bend forces.

Diarthroses Joints that provide the greatest amount of movement; also called synovial joints. They have a space between the bones called a synovial cavity. This gap allows much movement at the joint. Joints without this gap provide little or no movement.

Direct tissue stretching Targets tissues in a local area that have been as-sessed as shortened and have binding. The two types of direct tissue stretching are longitudinal and cross-directional. Direct tissue stretching is used if only a small section of muscle needs to be stretched, if the muscle does not lend itself to stretching with joint movement, or if the joints are so flexible that not enough pull is put on the structures to achieve an effective stretch.

Direction of ease The way the body allows for postural changes and muscle shortening or weakening compensation patterns, depending on its balance in gravity.

Dynamic stretching Involves moving the joints of the body through ranges of motion instead of holding the body in a static position of stretch. The idea is that whenever a joint is moved in a certain direction, the tissues on the other side of the joint are stretched; considered active.

Eccentric isotonic contraction Contraction in which the muscle lengthens.

Elongation Extending the length of soft tissue.

143Glossary

Endomysium Connective tissue that surrounds individual muscle fibers.

Epimysium Connective tissue that surrounds the entire muscle.Fascicle Muscle fibers numbering 10 to 100 grouped into a bundle

and surrounded by perimysium.Flexibility The ability of soft tissues to yield to tension forces without

tissue damage during joint range of motion. Flexibility refers to a joint’s mobility and how muscles, ligaments, tendons, or other soft tissues affect it.

Frontal plane Divides the body into anterior and posterior portions; also called coronal plane.

Horizontal plane Divides the body into superior/proximal and inferior/distal portions; also called transverse plane.

Hypermobility An unusually large range of joint movement.Hypertonicity Excessive muscle tone.Hypomobility Reduced range of joint movement.Isometric muscle contraction Contraction in which the distance be-

tween the proximal and distal (origin and insertion) attachments of the target muscle is maintained at a constant length.

Isotonic contraction Contraction in which the muscle changes in length.

Kinetic chain An integrated functional unit made up of myofascial systems (muscles, ligaments, tendons, and fascia), articular systems (bones and their joints), and the nervous system.

Lengthening A neurologic response that allows the muscles to stop contracting and relax.

Line of tension Pulls on the target tissues, placing a stretch on them.Longitudinal stretching Pulls connective tissue in the direction of the

fiber configuration. Performed along with movement at the joint and gliding applied with drag in the direction of the force.

Midsagittal plane Divides the body into equal right and left halves.Multiplane stretching Stretching a muscle across more than one

cardinal plane.Muscle energy techniques (MET) Involve a voluntary contraction of

the client’s muscles in a specific and controlled direction, at vary-ing levels of intensity, against a specific counterforce applied by the massage therapist.

Muscle fiber Muscle cell; so named because of its elongated shape.Muscle spindle Proprioceptor found in the bellies of muscles; in-

volved in stretch reflex. Muscle spindles monitor changes in length of skeletal muscle fibers. When a muscle has stretched far

144 Glossary

enough during a particular movement, the muscle is stimulated to contract, relieving the stretching. It prevents injury by pre-venting overstretching, and possible tearing, of muscle tissue.

Myofascial systems Muscles, ligaments, tendons, and fascia.Myofascial units Muscles, fascia, and associated tendons and

ligaments.Myofibrils Threadlike structures within muscle fibers. These are the

contractile organelles of skeletal muscle, and they extend the entire length of the muscle fiber.

Myofibroblasts Contain contractile proteins that can actively con-tract; found in muscle tissue and fibrous connective tissue.

Myosin Thick protein filaments within myofibrils.Neuromuscular efficiency Ability of the neuromuscular system to

allow agonists, antagonists, and stabilizers to work synergistically to produce, reduce, and stabilize the entire kinetic chain.

Oblique plane A plane that is not purely sagittal, frontal, or transverse.Passive stretching Occurs when a second person (the massage

therapist) applies the force to stretch the tissue.Passive tension Results from factors affecting the natural elasticity

of a tissue, such as fascial adhesions that build up over time in soft tissues.

Pathologic barrier An adaptation in a physiologic barrier to joint movement; stiffness, pain, or a “catch” that acts as a protective mechanism, signaling not to move into anatomic limits, which could potentially result in injury.

Perimysium Connective tissue that surrounds groups of 10 to 100 or more muscle fibers and groups them into bundles called fascicles.

Physiologic barriers Barriers to joint movement caused by the limits imposed by nerve and sensory function.

Pin and stretch Stretching technique in which the massage therapist pins (stabilizes) one part of the client’s body and then stretches the tissues up to that pinned spot.

Plane A flat surface that cuts through space.Plastic range Range of movement of connective tissue that is taken

beyond the elastic limits. The tissue permanently deforms in this range and cannot return to its original state.

Postisometric relaxation Period after an isometric contraction during which all neural impulses are inhibited to that muscle, allowing it to relax.

Proprioceptive neuromuscular facilitation (PNF) Uses neuromuscu-lar reflexes (tendon reflex and stretch reflex) to increase range

145Glossary

of motion and to reeducate the body. Common techniques used in PNF are contract relax and antagonist contraction and a combination of both known as contract relax antagonist contraction.

Proprioceptors Sensory receptors embedded in muscles, especially pos-tural muscles, and tendons. They provide the nervous system with information about the degree to which muscles are contracted and the amount of tension on tendons as well as pressure on the joints, the positions of joints, and acceleration and deceleration of joints during movement.

Pulsed muscle energy procedures Involve engaging the comfort barrier and using small, resisted contractions (usually 20 in 10 seconds). This method can be used both to increase stretch tolerance in short tissues and to stimulate weak long tissue to increase tone.

Range of motion (ROM) The range, usually expressed in degrees of a circle, through which bones of a joint can move or be moved.

Reciprocal inhibition Neurologic reflex that creates a more efficient joint action by preventing two muscles that have an agonist-antagonistic relationship from contracting at the same time. When a muscle is contracted, muscles that have antagonistic actions are inhibited from contracting; they are relaxed.

Relaxation The lengthening of inactive, or noncontracting, muscle fibers or muscles.

Sagittal plane Divides the body into left and right portions.Sarcolemma Plasma membrane of a skeletal muscle fiber.Sarcomeres Compartments that are the basic functional units of a

myofibril.Sliding filament mechanism Method in which muscles change

length, owing to overlapping thin (actin) and thick (myosin) filaments. The edges of the sarcomere, to which the thin fila-ments are attached, are called Z disks. In the center of the sarcomere are the thick strands which, during contraction, pull the Z disks closer together by attaching to the thin fila-ments with specialized links called cross bridges. These cross bridges function similar to boat oars as they reach out, attach, and pull on the thin filaments, causing the Z disks to move toward one another. The Z disks pull on neighboring sarco-meres, and the whole muscle fiber shortens. The result is an overall shortening or contraction of the muscle in response to a nerve impulse.

146 Glossary

Static stretching Slow and progressive elongation of the target muscle by holding the stretch for 20 to 30 seconds; considered passive.

Stretch reflex Muscle spindles, which are found in the bellies of muscles, monitor changes in length of skeletal muscle fibers. When a muscle has stretched far enough during a particular movement, the muscle is stimulated to contract, relieving the stretching. The stretch reflex prevents injury by preventing over-stretching and possible tearing of muscle tissue.

Stretching A mechanical method that introduces various forces that extend, expand, lengthen, and elongate soft tissues.

Synovial cavity Space between bones in synovial joints (diarthroses). This gap allows much movement at the joint. Joints without this gap provide little or no movement.

Synovial joints Joints that provide the most amount of movement; also called diarthroses. They have a space between the bones called a synovial cavity. This gap allows much movement at the joint. Joints without this gap provide little or no movement.

Target muscle Specific muscle or muscle group being stretched.Target tissue The tissue being stretched.Tendon organs Proprioceptors found in the musculotendinous junc-

tion; involved in tendon reflex. Tendon organs measure tension applied to tendons from muscle contraction. The tendon reflex protects tendons and associated muscles from damage by causing muscle relaxation in response to excessive tension on tendons by muscle contraction.

Tendon reflexes Tendon organs, which are found in the musculotendi-nous junction, measure tension applied to tendons from muscle contraction. The tendon reflex protects tendons and associated muscles from damage by causing muscle relaxation in response to excessive tension on tendons by muscle contraction.

Tenosynovitis Inflammation of the protective sheath around a tendon.Tensile Ability to withstand longitudinal stress.Transverse plane Divides the body into superior/proximal and inferior/

distal portions; also called horizontal plane.Z disks Edges of a sarcomere.

147

Body mechanics, 105Bone disease, 10Brachialis, 119fBrachioradialis, 120fBreath, 30–31Breathing, and eye movement, 85–86

CCardinal planes, 35Carpometacarpal (CMC) joint, range

of motion of, 2–5tCervical spine, range of motion of, 2–5tCervicocranial region, range of motion

of, 2–5tChronic contraction, 1Comfort barrier, 30Compensation, 13–14Concentric isotonic contraction, 85Connective tissue, 12–13Contract relax antagonist contract

(CRAC), 81, 82–83fContract relax (CR), 74–75, 75b

procedure for, 75, 76–77fContractures, 12Counterpressure, 83, 95, 96fCross bridges, 18Cross-directional tissue stretching,

47–48, 47f

DDeltoid, 118f

anterior, 111fposterior, 109f

Destabilization, 12Diaphragm, 129fDirect tissue stretching, 41–48, 42–43f

cross-directional, 47–48longitudinal, 44–47muscles addressed by, 44b

Direction of ease, 13–14Dislocation, of joint, 9Distal interphalangeal joints, range of

motion of, 2–5tDistortion, 91–94fDorsiflexion, 69, 69f

with heel to hip, 68fwith hip flexion, 66f

AAbdominal obliques, 128fAbductor digiti minimi manus, 123fAcromioclavicular joint, range of

motion of, 2–5tActin, 17–18Active isolated stretching (AIS), 81, 84fActive release, 47Active stretching, 22–23Active tension, 11–12Adductor longus, 134fAdductor magnus, 135fAdductor pollicis, 124fAging, 6Agonist muscle, 74Anatomic barriers, 8–9Anatomic position, average ranges of

motion from, 2–5tAnconeus, 44bAnkle and foot, 68–69

dorsiflexion, 69, 69fmetatarsal scissors, 69, 70fplantar flexion, 69, 69fpull and circumduct toes, 69, 70f

Antagonist contract (AC), 75–78procedure for, 78, 80f

Anterior deltoid, 111fArm and shoulder, 55–58

arm pull, 56–58pulling the arm across the

chest, 57fpulling the arm down, 56fpulling the arm overhead, 58fpulling the arm to the side, 57f

shoulder circles, 58, 59fArticular capsule, 14Articular ligaments, 22Articular systems, 7Atlantoaxial joint, range of motion of,

2–5tAtlantooccipital joint, range of motion

of, 2–5t

BBad pain, 31bBallistic stretching, 28Biceps brachii, 119fBind, 6

Index

148 Index

Hip and knee, 62–68groin stretch, 65, 67fheel to hip, 65, 67f

with ankle dorsiflexion, 68fhip circles, 63, 65fhip clock stretch, 63, 64fhip flexion, 65, 66f

with ankle dorsiflexion, 66fhip hyperextension, 68, 68fleg pull, 62, 63fleg rock, 63, 64f

Hip flexors, 130f, 132fstretch, 98f, 100

Hip joint, range of motion of, 2–5tHip joint capsule, 130f, 132fHypermobility, 9Hypertension, untreated, 10Hypertonicity, 7Hypomobility, 9Hypothenar, 123f

IIliac crest, 72–73fIliocostalis, 44bIliopsoas, 129f, 130f, 132fInfraspinatus, 109fIntegrated approach procedure, 88,

91–94fIntercostals, 127fInterphalangeal joint, range of motion

of, 2–5tIsometric contraction, 74, 85Isotonic contraction, 85

JJoint inflammation, 9–10Joint kinesthetic receptors, 22Joint movement, 33Joints, 14–15, 16–17f

elbow, 119fsynovial, 14

KKinetic chain, 7

LLateral flexion

of neck, 50, 52fof neck, with rotation, 50, 52f

Lateral neck stretch, 97, 98fLateral torso stretch, 98f, 99Latissimus dorsi, 76–77f, 110f, 124fLengthening, 6–7

Duration, stretching, 31–32Dynamic stretching, 24–28, 26–27f,

31, 106

EEccentric isotonic contraction, 85Elbow joint, 119f

range of motion of, 2–5tElongation, 6–7Endomysium, 15–17, 20Epimysium, 15–17Erector spinae, 125fExtensor digitorum brevis, 139fExtensor digitorum longus, 136fExtensor hallucis brevis, 139fExtensor hallucis longus, 137fEye movement, and breathing,

85–86

FFascial sheaths, 13Fascicles, 15–17Fibularis brevis, 137fFibularis longus, 137fFilaments, 17–18Flexibility, 1–2

factors affecting, 5–6Flexion, 116fFlexor carpi radialis, 121fFlexor carpi ulnaris, 121fFlexor digiti minimi manus, 123fFlexor digitorum longus, 140fFlexor hallucis longus, 140fFoot sole, stretching of, 98f, 102Forearm stretching, 100Frontal plane, 35, 36f

motions of body parts within, 37–38f

GGastrocnemius, 76–77f, 105, 138fGlenohumeral joint, 122f

range of motion of, 2–5tGluteus maximus, 130fGluteus medius, 131fGood pain, 31bGracilis, 134f

HHamstring, 76–77f, 132fHeel to hip, 67f

with ankle dorsiflexion, 68fHip abductor stretch, 98f, 101

149Index

Levator scapulae, 108fLigaments, 14–15Line of tension, 34, 34fLongissimus, 44bLongitudinal stretching, 44–47

active assisted, 46basic, 45separating ends of tissue, 45–46, 46fusing compression with, 46–47

Longus colli, 115fLumbar spine, range of motion of,

2–5tLumbosacral joints, pelvis at hip and,

range of motion of, 2–5t

MMetatarsophalangeal joints, range of

motion of, 2–5tMidsagittal plane, 35Minimum force, 30, 31bMultifidus, 44bMultiplane stretching, 35–40Muscle energy techniques (MET),

81–97breathing and eye movement, 85–86,

87–88f, 89–90fmethods for, 86–95, 91–94fprinciples of, 83–85

Muscle fibers, 15–17Muscle imbalance, 6Muscle relaxation, 29Muscle spindle, 21, 22fMuscle stretching, 20–21

microscopic effect of, 20–21Muscle tension, 29Muscle tissue, 15–21Muscles, 12–13Myofascia, 12Myofascial systems, 7Myofascial units, 6–7Myofibrils, 17–18Myofibroblasts, 12Myosin, 17–18

NNeck, 49–50

forward flexion, 50, 53flateral flexion, 50, 52flateral flexion with rotation,

50, 52fneck circles, 50, 51f

Nerve root damage, 10Neuromuscular efficiency, 7Neuropathy, 10

OOblique plane, 35, 36f

motions of body parts within, 37–38f

Opponens digiti minimi, 123fOverstretching, 33

PPain, 105Palpation, 33Passive stretching, 22–23Passive tension, 11–12Pathologic barriers, 8–9Pectineus, 134fPectoralis major, 76–77f, 111f

stretch of, 97, 98fPectoralis minor, 44b, 113fPelvis, range of motion of, 2–5tPerimysium, 15–17Physiologic barriers, 8–9Pin and stretch, 47, 71–73Piriformis, 131fPlane, 35Plastic range, 13Popliteus, 44bPosterior deltoid, 109fPostisometric relaxation, 74Postural distortion symptoms, 94Pregnancy, 10Pronation, 119f

forearm, 122fPronator teres, 121fProprioceptive neuromuscular

facilitation (PNF), 74Proprioceptors, 21–22Proximal interphalangeal joints, range

of motion of, 2–5tProximal phalanx of MCP, range of

motion of, 2–5tPulse muscle energy procedure, 95–97,

96f, 97f

QQuadratus femoris, 132fQuadratus lumborum, 44b, 105, 126fQuadriceps, 44bQuadriceps femoris, 133f

stretch, 98f, 101

RRadial deviation, 121fRadial group, 122fRadiating pain, 10

150 Index

Radioulnar joints, 122frange of motion of, 2–5t

Range of motion (ROM), 1–2, 20–21average, from anatomic position, 2–5t

Reciprocal inhibition, 75–78procedure for, 78, 79f

Rectus abdominis, 127fResistance training, 106Rhomboids, 108fROM see Range of motion (ROM)Rotation, and neck lateral flexion, 50,

52fRotatores, 44b

SSaddle joint, range of motion of, 2–5tSagittal plane, 35, 36f

motions of body parts within, 37–38fSarcolemma, 17, 20Sarcomeres, 17–18

during stretch, 21fSartorius, 130f, 132f, 133fScalene muscles, 115fSelf-care, 105–140Semispinalis, 44bSemispinalis capitis, 116fSerratus anterior, 112fSerratus posterior inferior, 44bSerratus posterior superior, 44bShoulder circles, 59fShoulder joint

range of motion of, 2–5tstretching, 98f, 99

Side-lying stretch, 71, 72–73fSkeletal muscles, 15–17

connective tissues and, 18fstructures of, 19f

Sliding filament mechanism, 11–12, 18, 20f

Soft tissuebenefits of stretching on, 10–12, 11fproperties of, 12–14

Soleus, 105, 138fSoreness, 30, 33Spine, 58–60

range of motion of, 2–5tspinal twist, 58

I, 58–59, 60fII, 59, 61fIII, 60, 61fIV, 60, 62f

Splenius capitis, 116fStatic stretching, 23–24, 24f, 31, 106, 107

basic atlas of, 49–70basic techniques, 48

Sternoclavicular joint, range of motion of, 2–5t

Sternocleidomastoid, 114fSteroids, prolonged use of, 10Stiffness, 105Stretch reflex, 21Stretching, 107

advanced techniques, 71–104active isolated stretching, 81antagonist contract, 75–78contract relax, 74–75contract relax antagonist

contract, 81examples of, 97–102, 98fmuscle energy techniques, 81–97pin and stretch, 71–73proprioceptive neuromuscular

facilitation, 74basic techniques, 29–48

direct tissue stretching, 41–48guidelines for successful stretching,

29–32reasoned out instead of

memorized, 34–41reasoning and application, 33–34safe and effective stretching

methods, 32–33benefits and cautions of, 7–12connective tissue, muscles and, 12–13contraindications and other cautions,

9–10definition of terms, 1–7major categories of, 22–28other target tissues, 41physiology of, 14–22principles of, 1–7, 106for self-care, 105–140static, 49–70target muscle, 40–41, 40b

Subclavius, 114fSuboccipitals, 44b, 117fSubscapularis, 112fSubtalar joints, range of motion of, 2–5tSupination, 119fSupinator, 44b, 122fSupraspinatus, 44b, 110fSynovial cavity, 14Synovial joints, 14

basic structure of, 15f

TTalocrural joints, range of motion of,

2–5tTarget muscle, 2Target tissue, 2

151Index

Temporalis, 118fTendon organs, 22, 23fTendon reflex, 22, 74Tenosynovitis, 9Tensile, 14–15Tension, 11–12

active, 11–12passive, 11–12

Tensor fasciae latae, 131fTeres major, 110fTeres minor, 109fThenar group, 123fThoracic region, 127fThoracic spine, range of motion of, 2–5tThoracolumbar spine, range of motion

of, 2–5tTibialis anterior, 44b, 105, 135fTibialis posterior, 140fTibiofemoral joints, range of motion of,

2–5tTightness, 105Transverse plane, 35, 36f

motions of body parts within, 37–38fTransversospinales, 125f

Trapezius, 107fTriceps brachii, 120fTrue pain, 31bTrunk torque stretch, 98f, 102

UUlnar deviation, 121fUpper trapezius, right, stretching of,

35, 39f

WWarming tissues, 29–31Wrist and hand, 50–55

flip wrist, 50, 53finterlace fingers and mobilization of,

50, 54fmetacarpal scissors, 54, 54fpull and circumduct fingers, 55

Wrist flexor, 121f

ZZ disks, 18

mosby's stretching pocket guide, 2014

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