STRETCHING 159

11
CHAPTER

Stretching

DEFINITION from the muscle spindle and Golgi tendon organ.

In this stretch, the muscle is elongated gently
It is the elongation of the pathologically shorte- and maintained for long period without pain.
ned or tightened soft tissues with the help of The Golgi tendon organ protects the muscle
some therapeutic techniques. from the stretch by firing the type Ib fibers.
This Ib fibers further relaxes the muscle by
TYPES efferent impulse. So, the muscle fiber goes for
more relaxation and flexibility. Effective
• Passive stretching duration of the stretch is found out by compa-
• PNF ring the groups stretched for 15, 30 and 60
• Self-stretching. seconds, among that 30 and 60 seconds,
stretched muscle fibers show more flexibility
Passive Stretching than the 15 seconds stretched muscle fibers.
• Manual There is no different seen the 30 and 60
• Mechanical. seconds stretched muscle fibers. Taking the
sensitive muscle as a model the test is
performed.
Manual Stretching
It is done by the therapist or by the physician. Ballistic stretching: It is the bouncing or jerky
The stretching may be given for 15-30 seconds, type of stretching. It is a high velocity and short
sometimes it may be extended up to 60 seconds. duration stretching. It can be done actively.
The stretching duration and the force applied Even though the ballistic stretching increases
may change depending on the condition and the the flexibility, it may cause injury because the
tolerance power of the patients. It is of two types: movements may exceed the limits of extensi-
i. Static stretching bility and it has poor control over the
ii. Ballistic stretching. movements. The ballistic stretch activates the
muscle spindle, which send impulses to the
Static stretching: In this slow and prolonged spinal cord, from there to the CNS. The efferent
stretch is applied to avoid the reflex contraction impulse, i.e. the contracting response enters
 160 TEXTBOOK OF THERAPEUTIC EXERCISES

through the α fibers to the muscle fibers. So, of stretch, duration of stretch and number of
the tension created inside the muscle cause the stretch cycle per minute can be set in the
microtrauma. Thus, the ballistic stretch causes mechanical device itself. Thus, manual and
the microtrauma in the muscle and connective mechanical stretching have different effect. The
tissues, apart from increasing their flexibility mechanical stretching (long duration, cyclic)
earlier. gives more flexibility in a short period than the
Zachazawski was arguing about the stretch- manual method of applying stretching.
ing program for the athletes because most of
the athletes require ballistic type of activities. PNF
So, he derived one stretching program for the According to Knott and Ross, facilitation the
athletes that is called as “Progressive Velocity proprioceptor with help of neuromuscular
Flexibility Program”. This stretching program activities can be used to stretch a particular
is mainly based on the velocity [slow, fast] ROM muscle some main PNF techniques are used
[end range, full]. for the stretching, they are:
Here, the athletes undergo a series of 1. Hold and relax
stretching program. First the athletes are given 2. Contract relax
static stretching. After sometime it is changed 3. Slow reversal.
to slow and controlled stretching with mild
oscillation in the end range called as slow short
Hold and Relax
end range (SSER). Then the athlete is
progressed to perform the full-length muscle Here the therapist keeps the limb in the end
stretch, i.e. slow full range (SFR). Once he is range of ROM. For example, in hamstring
mastered in it, he is progressed to fast stretching, the muscle is kept at the end range
stretching in shortened range called as fast by flexing the hip and extends the knee with
short end range (FSER). Finally, he is made to the patient in supine lying. Then the patient is
perform the fast full range stretch. asked to perform the isometric contraction
against the force applied by the therapist. This
contraction activates the GTO and it sends
Mechanical Stretching impulses to spinal cord, from there to the brain.
Long duration mechanical stretching: The low The brain responds by relaxation impulse
intensity and long duration stretch gives more through Ib fibers. After some relaxation, the
flexibility in the muscle and connective tissue therapist flexes the hip some more and achieves
than the less duration stretch. The stretch, a new position. After reaching the new position,
which is given from 20 minutes to several hours, the above said process may be repeated again.
gives good effect than the stretch applied for
less than 20 minutes. The serial cast, pulleys, Contract and Relax
dynamic splints, tilting table, traction are some
Here the therapist takes the limb to the end
of the mechanical devices made for prolonged
range. For example, in hamstring stretching,
mechanical stretching. The stretch is given by
the knee is extended and hip is flexed with the
external force in low intensity for longer patient in supine lying. After attaining the end
duration with the help of mechanical instru- range, the patient is asked to contract the
ment. opposite muscle to the muscle being stretched,
Cyclic mechanical stretching: The stretching i.e. the hip flexor is asked to contract which
program can be given in cyclic manner with results in maximum stretching of the ham-
the help of mechanical devices. The intensity strings. Normally, in any synergic group,
 STRETCHING 161

contraction of agonist results in reflexive system. The efferent system contains two
relaxation of the antagonist, i.e. hip flexors varieties of neurons, they are:
contraction causes the hamstring relaxation. i. α motor neuron
After the consecutive contraction of the hip ii. γ motor neuron.
flexor, the therapist moves the limb still more Alpha motor neurons are the neurons,
forward, i.e. hip flexion and new position is which supply large muscle fibers and excite too
attained. The same procedure is followed many skeletal muscles, which are collectively
without lowering the legs. called as motor units. Alpha motor neurons
supplies to the extrafusal muscle fibers of the
Slow Reversal muscle spindle. The afferent system, which
contains the (1) muscle spindle, (2) Golgi tendon
Here too the therapist takes the limb to the
organ like receptors to send the impulses to
end range for example, in hamstring stretching,
the afferent neurons (Fig. 11.1).
the knee is extended with hip flexed and end
range is attained. In the end range, the patient
is asked to do the isometric contraction of the
hamstring muscle, by opposing the force given
by the therapist. This isometric contraction
activates the GTO and results in relaxation
impulse as we have seen earlier. Then the
patient is asked to do the isotonic contraction
of the opposite muscle to the muscle being
stretched, i.e. hip flexors, so that more amount
of stretching is achieved.
After the isotonic contraction, the new
position is attained, i.e. the stretch is increased
because, due to the isotonic contraction, the
hamstring muscle gets more flexibility. So, it
can go for maximum stretch, then the patient
is asked to relax for some time. Again the same
procedure is followed without lowering the leg.

Self-stretching
The patient himself does this stretching Fig. 11.1: Stretch reflex
program. This type of exercise showing early
improvement in performing stretching with the
Muscle Spindle
guideline of the therapist improves the neuro-
muscular facilitation and relaxes the muscle. A muscle spindle has two types of muscle fibers;
All the procedures are same as in passive they are intrafusal and extrafusal muscle fibers.
stretching. Intrafusal muscle fibers again divided into two
varieties; 1) nuclear bag fibers, 2) nuclear chain
fiber.
STRETCH REFLEX Nuclear bag fibers contains the nucleus in
The proper muscle function is decided by the the center portion of the receptor and it gives
afferent and efferent impulses from the nervous the bag like structure and the end portion of
 162 TEXTBOOK OF THERAPEUTIC EXERCISES

the fiber is innervated by the gamma efferent spinal cord. Some of the branches of the nerve
neurons. enter into anterior horn cells of the spinal cord
Nuclear chain fibers look like the chain and and make synapse and send the nerve to the
the nucleus concentrate more in the center and same muscle is called as monosynaptic
scatterly present in the receptor part of the pathway. Type II fibers also end in monosynaptic
fiber. The end portion of the fiber also supplied pathway and the more delayed signal to the
by gamma efferent neurons. The nuclear bag anterior motor neurons. Whenever the sudden
fibers are innervated by group Ia afferent fibers stretching of the muscle spindle, the dynamic
in the middle portion and the nuclear chain stretch impulses carried out through the type
fibers are innervated by the group Ia, II fibers. Ia (primary afferent) nerve fibers to the spinal
cord, from there strong contraction reflex
Functions of Gamma Motor Neurons comes to the muscle. After the dynamic reflex
Gamma motor neurons are of two types; they is over the muscle is kept in new stretched
are γ-s and γ-d fibers. γ-d fibers excite the position, so the slow and continuous stretch
nuclear bag fibers and enhance the dynamic reflex goes via the group Ia and group II afferent
responses in the muscle spindle and the γ-s fibers fibers to the spinal cord, and the continuous
excite the nuclear chain fibers and enhance the contraction response originates from the spinal
static response in the muscle spindle. cord.

Static Response Negative Stretch Reflex

When the muscle spindle is stretched, the Whenever the muscle is shortened, the
receptors which is present in that spindle is opposite effect occurs. If the muscle shortens,
activated and it sends impulses to the nervous will elicit both the static and dynamic reflexes.
system through the group Ia and group II fibers.
Whenever the muscle spindle is stretched Golgi Tendon Organ
slowly, the proportion of the impulse transmit
impulses many more minutes is called as static Golgi tendon organs are present in the junction
response of the spindle. It occurs due to the between the muscle and the tendon. From
stretching of the nuclear chain fibers because Golgi tendon organ impulses are transmitted
it supplied by both the group Ia (primary to the type Ib nerve fibers. Muscle spindle reflex
afferent) and group II (secondary afferent) nerve changes the length of the muscle and the GTO
fibers. reflex changes the tension in the muscle. From
the GTO the impulses are carried out by the
type I a fibers to the posterior horn cells and to
Dynamic Response
the anterior gray matter. It has both static and
If the muscle spindle structures stretched dynamic function in it. Normally, the responses
suddenly the nerve ending is stimulated from the spinal cord or from the CNS are mostly
powerfully and it is called dynamic response of relaxation of the muscle.
the spindle. It occurs when the nuclear bag
fibers stretched because it is innervated by type
Ia afferent fibers. STRESS-STRAIN CURVE
The role of the extensibility of the soft tissue,
Stretch Reflex the stress-strain curve gives the perfect
Type Ia fibers arise from the muscle spindle knowledge about the load deformation of the
and enter into the posterior horn cells of the soft tissue. Whenever the external force is
 STRETCHING 163

applied to a soft tissue, it goes for more stress therapists add more force after the fist tissue
and strain. The first phase is “elastic phase”, stop, he may feel again the restriction to stretch
the stretched tissue will go for normal position by some structures is called as second tissue
after removing the external force. The second stop. If we apply force more than the first tissue
is “plastic phase”, the stretched tissue may be stop the tissue will be attaining the plastic range.
remain in the elongated state when the external But if the therapist crosses the second tissue
force is removed. Third phase is “failure point”, stop, the tissue may be separated or teared. So,
the stretched tissue may be teared or separated. the stretching technique should be performed
Normally, stretch techniques are done up to within the second tissue stop.
the limit of the plastic range and sometimes
about to reaching the breaking point but Indications
without causing any tissue damage. If the • Post-traumatic stiffness
breaking point is felt, the treatment should be • Post-immobilization stiffness
terminated (Figs 11.2A and B). • Restrictive mobility
• Congenital or acquired bony deformity
• Joint pathology resulting in soft tissue
stiffness
• Soft tissue pathology leading to relative soft
tissue stiffness
• Healed burn scars
• Fear of pain spasm
• Adhesion formation over soft tissue
• Contracture of the joint and soft tissue
• Any type of muscular spasm
• Spasticity (UMS cause).

Contraindications
• Synovial effusion
• Recent fracture
• Sharp pain while doing stretch
• Inflammation in the tight tissue
• Infection over tight tissue
Figs 11.2: A. Stress-strain curve, B. Tissue • Immediately after dislocation
restriction with the stretch • Edema
• Osteoporosis
• Hemophilic joint
While stretching the tightened joint or • Hemarthrosis
muscle the therapist may feel the restriction by • Malignant tumors
the surrounding structures. Limitations may • Flial joint
be due to capsule, ligaments, muscle, skin, fascia, • After joint arthroplasty
cartilages tightness or adhesions. The limitations • Neuropathic joint
or restrictions to stretch is felt by the therapist • Unhealed scars
is called as first tissue stop. Normally, the passive • Unhealed burns
movement can cross the first tissue stop. If the • Chronic rheumatoid arthritis.
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EFFECTIVE STRETCHING intramuscular temperature. Stretching which

is performed after an active exercise will be
Some of the physical modalities are helpful to more effective.
increase the effect of stretching. The assistive
modality that increases the quality of stretch Joint Mobilization
can be given before the stretching regime.
Some of them are: Before doing the joint stretching, joint mobili-
1. Heat zation is done; it reduces the stiffness of the
2. Massage joint by breaking the adhesion formed and
3. Oscillation makes the joint free. Joint traction breaks the
4. Joint mobilization adhesion and stretches the tightened struc-
5. Active exercise. tures. The pendular and oscillation movement
relaxes and reduces the tightness of the soft
Heat tissue. Sometime 1 lb to 2 lb weight also can be
used in the extremity to perform the pendular
Heat increases the relaxation and lengthens movement of the joint.
the muscle fastly. Normally, heat increases
relaxation, circulation, and nutrition, to tissue Note: The stretching can be given about to
and decreases spasm and tightness. Stretching reaching the second tissue stop without causing
performed after applying heat modality requires the microtrauma. If the microtrauma occurs
less force to stretch. The physiotherapy during stretching the iceing can be done to
modalities like hot water, fomentation, IRR, constricting the blood vessels thereby reducing
wax bath, ultrasound, SWD, produces heat in the local blood circulation thus prevents further
the tissue. So, they can be applied before per- damage. Iceing also reduces the post-stretching
forming the stretching. The heat will activate muscular soreness.
the GTO and results in relaxation response Normally, three varieties of stretching can
from the higher center, which reduces the be performed in body. They are:
tension in the muscle. a. Muscular stretching
b. Joint stretching
Massage c. Skin stretching.
Effective maneuver of massage produces:
i. It increases blood circulation. MUSCULAR STRETCHING
ii. It increases blood nutrition. To stretch one particular muscle, the opposite
iii. It enhances local relaxation. action of that muscle should be performed.
iv. It decreases spasm.
Massage can be done after application of
Tendo-Achilles Stretching
heat therapy, which improves the effect of
massage thereby helpful in stretching. Action—Flexion of knee, plantar flexion of
ankle.

Active Exercise
Passive Stretching (Figs 11.3 and 11.4)
Active exercise produces heat inside the body.
Position of Patient: Supine lying.
Warm tissue can be stretched easily. Active
exercise like walking, jogging, cycling increases Position of therapist: Standing beside the
local blood circulation thereby increases the patient.
 STRETCHING 165

Fig. 11.3: Tendo-Achilles stretching starting stage

Fig.11.5: Soleus self-stretching

Fig. 11.4: Tendo-Achilles stretching end stage

Procedure:
• The therapist holds the lower thigh region
with his left hand and flexing the knee.
• The therapist’s right hand holds the heel in
neutral position.
• Slowly extending the knee with the left hand
and dorsiflexes the heel with the right hand.

Self-stretching
• Standing on slopping surface and falling
forwards (Fig. 11.5).
• Standing on the steps with the ball of the
toes (Fig. 11.6).
Note: For soleus stretching knee extension
should be avoided. Gastrocnemius flexes the Fig. 11.6: Gastrocnemius stretching
 166 TEXTBOOK OF THERAPEUTIC EXERCISES

knee and plantar flexes the ankle but soleus is Position of the therapist: Standing beside the
purely for plantar flexion. patient and looking the stretched part.
Procedure: Patient’s knee is flexed and the
Dorsiflexors of Ankle therapist’s left hand holds the anterior portion
Passive Stretching of the knee, right hand holds the ankle of the
Position of patient: Supine lying. patient while forearm and elbow stabilizing the
patient’s pelvic.
Position of therapist: Standing beside the Lifting the thigh up with the left hand of
patient. the therapist extends patient’s hip.
Procedure: Method – II (Fig. 11.8)
• Therapist’s left hand holds the lower leg
region and right hand holds the foot, plantar Position of the patient: Supine lying with the
flexing (pulling downwards). lower part kept hanging at the end of the couch
(from the hip region).
Self-stretching Position of the therapist: Standing beside the
Sitting on the stool by leg hanging, right foot is leg region of the patient, which is hanging.
placed on the left foot and stretching the
dorsiflexors.

Quadriceps Stretching
Action: Hip flexion and knee extension ( Rectus
femoris—hip flexion and knee extension, vastus
medialis, vastus lateralis, vastus intermedius
—knee extension).

Passive Stretching (Fig. 11.7)

Method-I
Position of the patient: Prone lying.

Fig.11.7: Quadriceps stretching in supine lying Fig.11.8: Quadriceps stretching by lying in bed end
 STRETCHING 167

Procedure:
• Left leg of the patient is kept flexed and
hold by the patient himself.
• Therapist’s right hand holding the lower leg
and pushing towards inside, i.e. flexing the
knee.
• Left hand applies force on the lower part of
the thigh and pushes downwards, i.e. hip
flexion.
Method-III
Position of the patient: Side lying.
Position of the therapist: Standing back to the
patient and seeing the limb.
Procedure:
• Left hand of the therapist stabilizes the Fig.11.9: Quadriceps Self-stretching
pelvic and restrict the movement.
• Right hand of the therapist holds the right
knee flexed position and forearm supporting
the leg.
After maximum flexion of the knee, hip
extension is made by pulling the leg backwards.

Self-stretching (Fig. 11.9)

Patient standing with one-foot support and the
other foot, ankle grasped by the respective side
hand by knee flexion then the hip is extended.

Hamstring Stretching
Action: Flexion of the knee, extension of the
hip.

Passive Stretching (Fig. 11.10A)

Position of the patient: Supine lying.
Fig. 11.10A: Hamstring passive stretching
Position of the therapist: Therapist is kneeling
near the leg region of the patient and the Self-stretching
patient leg is kept over his shoulder.
• Patient standing on one leg and other over
Procedure: With the knee extension therapist an elevated position and stretching the
flexes the hip of the patient. hamstrings by bending the hip and trunk
(Fig. 11.10B).
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Fig. 11.10B: Hamstring self-stretching Fig. 11.11: Iliopsoas passive stretching in supine
position
• Long sitting on the floor—grasping the toes
by the corresponding hand and bending the Method – II (Fig. 11.12)
trunk forwards. Position of patient: Side lying.
Position of therapist: Standing back to the patient.
Iliacus and Psoas Major Stretching
Procedure:
Passive Stretching • Therapist’s left hand stabilizes the pelvis and
Method – I (Fig. 11.11) right hand grapes the lower thigh and knee,
Action: Hip flexion.
Position of the patient: Supine lying with the
lower part of the body hanging at the end of
the couch.
Position of the therapist: Therapist is standing
near to the leg region of the patient.
Procedure:
• Normal side leg is kept flexed and holding
by the patient himself.
• Therapist is grasping the other leg and
performing the hip extension by pushing the Fig. 11.12: Iliopsoas passive stretching in side lying
leg down. position
 STRETCHING 169

with forearm supporting the leg region of

the patient.
• The leg is pulled back with the help of right
hand.

Self-stretching
• Fall out standing posture stretches the
illiopsoas (Fig. 11.13).
• Stretched side hip and knee are extended
and kept backwards, the opposite side hip
and knee are medium flexed and kept
forwards and stretches the iliopsoas. Fig. 11.14: Gluteus maximus passive stretching

Procedure:
• Therapist’s right hand grasping the ankle
while his left hand holds the knee posteriorly.
• The leg is lifted with hip and knee flexed,
towards the cranial side of the patient.

Self-stretching
• Kneel sitting is one way of stretching the
gluteus maximum.
• Patient flexing the hip and knee himself, in
supine with his hand maintains a good
stretch.

Hip Adductor
Passive Stretching (Fig. 11.15)
Position of patient: Crook lying.

Fig. 11.13: Iliopsoas Self-stretching

Gluteus Maximus
Action: Hip extension.

Passive Stretching (Fig. 11.14)

Position of patient: Patient is lying supine.
Position of therapist: Therapist is standing Fig.11.15: Hip adductor passive stretching
beside the patient and facing the limb.
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Position of therapist: Standing or sitting beside

the patient facing the limb.
Procedure: Both the heels are kept together
and then drawn apart.

Self-stretching
• Ride sitting stretches the hip adductor
• Long sitting (Fig. 11.16):
• Knee bending to placing the sole of the
foot together.
• Pressure applied on the knee to touch Fig. 11.17: Iliotibial tract passive stretching
the floor.
• Carrying the child in the hip (Indian style Self-stretching
of carrying the child).
• Patient is standing and feet away from the
wall and leaning forward with one leg placed
front and the other internally rotated, 1 foot
back to the front leg (Fig. 11.18).
• In side lying the patient top leg foot is hooked
over the bed end, the hip is internally rotated,
adducted and knee is extended with support
of the bed end.

Fig.11.16: Hip adductor self-stretching

Iliotibial Tract
Passive Stretching (Fig. 11.17)
Action: Flexion, abduction, external rotation
of hip, flexion of knee.
Position of patient: Side lying.
Position of therapist: Standing back to the
patient and facing the limb.
Procedure:
• Therapist’s left hand stabilizes the pelvic and
right hand grasps the patient knee with the
leg placed over the forearm.
• Hip is extended, adducted and medially
rotated, finally knee extended to stretch the
illioitibial tract. Fig. 11.18: Iliotibial tract self-stretching
 STRETCHING 171

Pectoralis Major
Passive Stretching (Fig. 11.19)
Action: Flexion, adduction, and medial rotation
of the shoulder.

Fig. 11.20: Pectoralis major self-stretching

Biceps Stretching
Action: Flexion of shoulder and elbow,
supination of forearm.

Passive Stretching (Fig. 11.21)

Position of patient: Side lying.
Position of therapist: Therapist is standing back
to the patient and facing the limb to be stretched.
Fig. 11.19: Pectoralis major passive stretching
Position of patient: Supine lying with the upper
limb kept at the end of the couch.
Position of therapist: Therapist is standing beside
the patient and facing the respective upper limb.
Procedure: Therapist’s left hand grasps the
wrist and hand of the patient while the right
hand stabilizes the shoulder then the left hand
performs the reverse action of pectoralis major,
i.e. lateral rotation abduction, extension of
shoulder.

Self-stretching
• Both the hands grasped behind the head and
the patient is asked to relax and drop down
Fig. 11.21: Biceps passive stretching
to touch the support surface (Fig. 11.20).
• The relative hand is placed over the wall by Procedure:
standing 3-4 feet away from the wall and • Therapist’s left hand grasps the wrist and
back facing the wall with the shoulder hand of the patient while right hand
externally rotated, abducted and extended. stabilizes the shoulder.
 172 TEXTBOOK OF THERAPEUTIC EXERCISES

• Left hand performs the shoulder extension, • Therapist’s right hand grasping the elbow
elbow extension and forearm pronation. lifts up to gain shoulder flexion.

Self-stretching
• In high sitting, the patient place the hand
back to body on the surface and stretches
the biceps.
• In standing—holding the rod back side and
stretching (Fig. 11.22).

Fig 11.23: Triceps passive stretching

Self-stretching (Fig. 11.24)

In sitting or standing with the opposite side
hand elbow and shoulder extension is performed
Fig. 11.22: Biceps self-stretching to stretch the triceps.

Triceps
Flexor Compartment Muscles of Forearm
Action: Shoulder extension and elbow exten-
Action: Wrist flexion, elbow flexion, finger
sion.
flexion ( MCP, PIP, DIP).
Passive Stretching (Fig. 11.23)
Passive Stretching (Fig. 11.25)
Position of patient: Supine lying or sitting.
Position of therapist: Therapist is standing beside Position of the patient: Sitting or supine lying,
the patient. side lying.

Procedure: Position of the therapist: Standing beside the

• Left hand of the therapist holding the patient.
patient hand and flexing the elbow after the Procedure:
hand reaches the shoulder. Therapist’s left • Therapist’s left hand grasping the lower arm
hand stabilizes the shoulder also. and preventing the shoulder movement.
 STRETCHING 173

Fig 11.26: Flexor compartment of the forearm

Fig 11.24: Triceps self-stretching self-stretching

Sternomastoid Stretching
Action: Same side flexion and opposite side
rotation of the neck and also forward flexion of
the neck.
Position of the patient: Sitting or supine lying
with the neck placed at the end of the couch.
Position of the therapist: Therapist is standing
behind the patient’s head.
Fig 11.25: Flexor compartment of the forearm Procedure: The therapist holds the patient head
passive stretching with both the hand (one below the occipit other
below the chin) and performs the opposite action
• Therapist’s right hand grasps the hand and of the sternomastoid, i.e. opposite side flexion
the fingers. and same side rotation and extension of the
• Therapist extending the fingers and wrist neck.
after the elbow extension. Here the whole
flexor compartment muscles undergo JOINT STRETCHING
stretching.
Joint stretching means the stretching of the
soft tissue around the joint including the
Self-stretching (Fig. 11.26) muscles. The individual muscles can be
Place the hand on the couch with wrist, fingers stretched as mentioned earlier but we need to
and elbow extended and stretching the flexor stretch the ligaments, bursae, capsule,
compartment of the forearm. cartilage and other soft tissues of the joint
 174 TEXTBOOK OF THERAPEUTIC EXERCISES

which may get tight and make the joint stiff. Restricted Extension Movement (Fig. 11.28)
To prevent the stiffness and to improve the
ROM of the joint, this joint stretching will be Position of the patient: Prone lying.
helpful. To stretch one particular muscle, the Position of the therapist: Therapist is standing
opposite action of the muscle has to be done. beside the patient and facing the limb.
To stretch one joint we have to analyze which
action or movement has been restricted and
same action or movement has to be performed
to stretch the structures, which is stiff.

Shoulder Joint
For Restricted Flexion Movement (Fig. 11.27)

Position of the patient: Supine lying.

Position of the therapist: Therapist is standing
beside the patient and facing the limb.
Procedure: Fig.11.28: Stretching the restricted extension
• Therapist’s left hand grasps the lower arm movement of the shoulder
region and the patient’s forearm resting
over the therapist’s forearm. Procedure:
• Therapist’s right hand apply opposite force • Therapist’s left hand grasps the lower arm
on the scapular region to prevent scapular region and the patient’s forearm resting
movement. over the therapist’s forearm.
• Stretch force is given towards the flexion of • Therapist’s right hand applies opposite force
the shoulder with the therapist’s left hand. on the scapular region to prevent scapular
Stretched parts: Capsule, articular cartilages, movement.
glenoidal labrum, extensor muscles and • Stretch force is given towards the extension
synovial membrane of the shoulder joint. of the shoulder with the therapist’s left hand.
Stretched parts: Capsule, articular cartilages,
glenoidal labrum, flexor muscles, glenohumeral
ligament and synovial membrane of the
shoulder joint.

Restricted Abduction Movement (Fig. 11.29)

Position of the patient: Supine lying.
Position of the therapist: Standing beside the
patient and facing the limb.
Procedure:
• Therapist’s left hand grasps the lower arm
Fig.11.27: Stretching the restricted flexion region and the patient’s forearm resting
movement of the shoulder over the therapist’s forearm.
 STRETCHING 175

Position of the therapist: Therapist is standing

beside the patient and facing the limb.
Procedure:
• Therapist’s left hand grasping the lower arm
of the patient while his right hand grasping
the wrist and applying the stretch force
towards the medial rotation.
Stretched parts: Capsule, articular cartilages,
glenoidal labrum, lateral rotator muscles and
synovial membrane of the shoulder joint.

For Restricted Lateral Rotation (Fig. 11.31)

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing
beside the patient and facing the limb.
Fig.11.29: Stretching the restricted abduction
movement of the shoulder Procedure:
• Therapist’s left hand grasping the lower arm
• Therapist’s right hand applies opposite force of the patient while his right hand grasping
on the scapular region to prevent scapular the wrist of the patient and applying the
movement. stretch force towards the lateral rotation.
• Stretch force is given towards the abduction
of the shoulder with the therapist’s left hand.
Stretched parts: Capsule, articular cartilages,
glenoidal labrum, adductor muscles and syno-
vial membrane of the shoulder joint.

For Restricted Medial Rotation (Fig. 11.30)

Position of the patient: Supine lying.

Fig.11.31: Stretching the restricted lateral rotation

movement of the shoulder

Stretched parts: Capsule, articular cartilages,

glenoidal labrum, medial rotator muscles and
synovial membrane of the shoulder joint.

Elbow Joint
For Restricted Flexion Movement (Fig. 11.32)
Fig.11.30: Stretching the restricted medial rotation Position of the patient: Supine lying.
movement of the shoulder
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Position of the therapist: Therapist is standing

beside the patient and facing the limb.

Fig.11.32: Stretching the restricted flexion

movement of the elbow
Fig.11.33: Stretching the restricted extension
Procedure: movement of the elbow
• Therapist’s left hand grasping the lower arm
of the patient and stabilizing the proximal Stretched parts: Capsule, articular cartilages,
joint. elbow flexor muscles, radial and ulnar collateral
• Therapist’s right hand grasping the wrist of ligament.
the patient.
• Stretch force is applied with the right hand Forearm
of the therapist towards the flexion of the
elbow. For Restricted Supination and
Pronation Movement (Fig. 11.34)
Stretched parts: Capsule, articular cartilages,
elbow extensor muscles, radial and ulnar Position of the patient: Supine lying.
collateral ligament.
Position of the therapist: Therapist is standing
beside the patient and facing the limb.
For Restricted Extension Movement (Fig. 11.33)
Procedure:
Position of the patient: Supine lying.
• Therapist’s left hand stabilizing the anterior
Position of the therapist: Therapist is standing aspect of proximal humerus of the patient.
beside the patient and facing the limb. • Therapist’s right hand grasping the lower
forearm,wrist and hand of the patient and
Procedure:
elbow is in 90° flexed position.
• Therapist’s left hand grasping the lower arm
• Therapist’s right hand supinates and
of the patient and stabilizing the proximal
pronates the forearm and stretches the
joint.
structures.
• Therapist’s right hand grasping the wrist of
the patient. Stretched parts
• Stretch force is applied with the right hand • While performing supination: Annular
of the therapist towards the extension of ligament, ulnar collateral ligament, capsule,
the elbow. articular cartilages and pronator muscles.
 STRETCHING 177

Fig.11.34: Stretching the restricted supination and Fig.11.35: Stretching the restricted flexion and
pronation movement of the forearm extension movement of the wrist

• While performing pronation: Annular liga- Restricted Extension Movement (Fig. 11.35)
ment, radial collateral ligament, capsule, Position of the patient: Patient is sitting on the
articular cartilages and supinator muscles. stool or supine lying.

Wrist Joint Position of the therapist: Therapist is standing

beside the patient and facing his wrist.
Restricted Flexion Movement (Fig. 11.35)
Procedure:
Position of the patient: Patient is sitting on the • Therapist’s left hand grasping the lower
stool or supine lying. forearm of the patient while his right hand
grasp the palm and fingers.
Position of the therapist: Therapist is standing
• The therapist extends the wrist of the patient
beside the patient and facing his wrist.
with his right hand.
Procedure:
Stretched parts: Articular disc, capsule, flexor
• Therapist’s left hand grasping the lower
muscles of the wrist, ulnar and radial ligament,
forearm of the patient while his right hand
flexor retinaculum.
grasp the palm and fingers.
• The therapist flexes the wrist of the patient
with his right hand. Restricted Ulnar Deviation Movement (Fig. 11.36)
Position of the patient: Patient is sitting on the
Stretched parts: Articular disc, capsule, exten-
stool or supine lying.
sor muscles of the wrist, ulnar and radial
ligament, extensor retinaculum. Position of the therapist: Therapist is standing
beside the patient and facing his wrist.
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Stretched parts: Articular disc, capsule, ulnar

deviation muscles of the wrist, ulnar ligament,
ulnar part of extensor and flexor retinaculum.

Hip Joint
Restricted Flexion Movement (Fig. 11.37)
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing
beside the patient and facing the hip joint.

Fig.11.36: Stretching the restricted ulnar and radial

deviation movement of the wrist

Procedure:
• Therapist’s left hand grasping the lower
forearm of the patient while his right hand
Fig. 11.37: Stretching the restricted flexion
grasp the palm and fingers. movement of the hip
• The therapist performs the ulnar deviation
of the wrist of the patient with his right Procedure:
hand. • Right hand of the therapist is grasping the
lower leg region of the patient while left
Stretched parts: Articular disc, capsule, radial hand grasping the patient’s knee.
deviation muscles of the wrist, radial ligament,
• Therapist’s both the hand flexes hip and
radial part of extensor and flexor retinaculum.
knee of the patient.
Restricted Radial Deviation Movement (Fig. 11.36) Stretched parts: Capsule, ischiofemoral liga-
ment, extensors of hip, articular cartilages.
Position of the patient: Patient is sitting on the
stool or supine lying.
Restricted Extension Movement (Fig. 11.38)
Position of the therapist: Therapist is standing Position of the patient: Side lying.
beside the patient and facing his wrist.
Position of the therapist: Therapist is standing
Procedure: beside the patient and facing the hip joint.
• Therapist’s left hand grasping the lower
forearm of the patient while his right hand Procedure:
grasp the palm and fingers. • Therapist’s left hand stabilizing the patient
• The therapist performs the radial deviation pelvis, while his right hand grasping the
of the wrist of the patient with his right upper thigh and the leg is resting on the
hand. forearm of the therapist.
 STRETCHING 179

thigh and the leg is placed on the therapist’s

forearm.
• Leg is pulled apart by the therapist’s right
hand.
Stretched parts: Capsule, transverse ligaments,
articular cartilage, adductor muscles.

Restricted Adduction Movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing
Fig.11.38: Stretching the restricted extension beside the patient and facing the hip joint.
movement of the hip Procedure:
• Therapist’s left hand stabilizing the opposite
• Patient’s thigh is lifted by the therapist’s leg of the patient, while his right hand
right hand and performing the extension grasping the lower thigh.
movement of the hip. • Therapist’s right hand pushes the leg inside.
Stretched parts: Capsule, iliofemoral ligament, Stretched parts: Capsule, abductors of the hip,
pubofemoral ligament and flexors of hip. articular cartilages.

Restricted Abduction Movement (Fig. 11.39) Restricted Medial and Lateral

Rotation Movement (Fig. 11.40)
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing Position of the patient: Supine lying
beside the patient and facing the hip joint. Position of the therapist: Therapist is standing
beside the patient and facing the hip joint.

Fig.11.39: Stretching the restricted abduction

movement of the hip
Procedure:
• Therapist’s left hand stabilizes the opposite Fig.11.40: Stretching the restricted medial and
leg while his right hand grasping the lower lateral rotation movements of the hip
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Procedure: • Therapist’s right hand flexes the knee and

• Therapist’s left hand stabilizing the thigh stretches the tightened structures.
of the patient, while his right hand grasping
Stretched parts: Ligaments, medial and lateral
the lower leg.
meniscus, capsule, bursae and extensor muscles.
• Hip and knee are kept in flexed position of
90°.
• Therapist performing stretching both in Restricted Extension Movement (Fig. 11.42)
medial and lateral rotation directions. Position of the patient: Prone lying.
Stretched parts: Position of the therapist: Therapist is standing
• During medial rotation—Capsule, ischio- beside the patient and facing the knee joint.
femoral ligament, articular cartilage, lateral
rotators.
• During lateral rotation—Capsule, pubo-
femoral ligament, iliofemoral ligament,
transverse ligament, round ligament,
articular cartilages, medial rotators.

Knee Joint
Restricted Flexion Movement (Fig. 11.41)

Position of the patient: Prone lying.

Position of the therapist: Therapist is standing
beside the patient and facing the knee joint. Fig.11.42: Stretching the restricted extension
movement of the knee
Procedure:
• Therapist’s left hand stabilizing the pelvis
of the patient while his right hand grasping
the lower leg region.
• Therapist’s right hand extends the knee and
stretches the tightened structures.
Stretched parts: Ligaments, medial and lateral
meniscus, capsule, bursae and flexor muscles.
Ankle Joint
Restricted Plantar Flexion Movement (Fig. 11.43)
Fig.11.41: Stretching the restricted flexion Position of the patient: Supine lying.
movement of the knee
Position of the therapist: Therapist is standing
beside the patient and facing the ankle joint.
Procedure:
Procedure:
• Therapist’s left hand stabilizing the pelvis • Therapist’s left hand grasping the lower leg
of the patient while his right hand grasping region and his right hand palm holding the
the lower leg region. heel of the patient.
 STRETCHING 181

Fig.11.43: Stretching the restricted plantar and Fig.11.44: Stretching the restricted inversion and
dorsiflexion movement of the ankle eversion movement of the subtalar

• Therapist’s right hand plantar flexes the

ankle and stretches the tightened structures. Procedure:
• Therapist’s left hand grasping the ankle
Stretched parts: Ligaments, capsule and dorsi-
joint of the patient while his right hand
flexors.
grasping the foot region.
• Therapist’s right hand is applying stretch
Restricted Dorsiflexion Movement force towards the inversion and eversion
Position of the patient: Supine lying. movement and stretches the tightened
structures.
Position of the therapist: Therapist is standing
beside the patient and facing the ankle joint. Stretched structures
• During inversion—Ligaments, capsules,
Procedure:
articular cartilages and evertors.
• Therapist’s left hand grasping the lower leg
• During eversion—Ligaments, capsules,
region and his right hand palm holding the
articular cartilages and invertors.
heel of the patient.
• Therapist’s right hand dorsiflexes the ankle
and stretches the tightened structures.
SKIN STRETCHING
Stretched parts: Ligaments, capsule and plantar
flexors. It is also like the joint stretching, the stretching
has to be performed in the side of the movement
Subtalar Joints lacking. This type of stretching mainly
performed for the burns contracture, prolonged
Restricted Inversion Eversion Movement immobilization contracture and traumatic
(Fig. 11.44) contracture. For example, if the skin is tight
in the necks that restrict the extension
Position of the patient: Supine lying.
movement has to undergo for the extension
Position of the therapist: Therapist is standing stretching. The same procedure as said in the
beside the patient and facing the ankle joint. joint stretching has to be followed.