PT on the Net Research

Flexibility Training - Part 2


The stretches in this article are presented in the context of assuming that your client is "apparently healthy" as described by the American College of Sports Medicine. It is also assumed that your client has successfully cleared any and all health history questionnaires, has gotten any necessary medical clearance before you work with them and is appropriately warmed up.

Hamstrings: biceps femoris, semitendinosus, semimembranosus

Besides one of the heads of the bicep femoris, the hamstrings cross the hip and the knee, and these stretches are presented using that reference point. Since they cross two joints, there are several options in both stretching and strengthening this muscle group. Remember that even though we are talking about stretching, we must always think of the entire program. There are many issues that can be discovered or uncovered during an assessment, and in flexibility training. Some of these will be presented today and I will also present an entire article on assessment in the near future.

Straight Leg Hamstring Stretch

With the straight leg hamstring stretch, we are lengthening the muscle fibers behind the knee as much as possible and then lengthening at the hip until a stretch is felt, aka the "endpoint."

Client lies on table with both legs straight. Remember, it is always acceptable to bend the knee that is not being stretched. This puts slack in the hip flexors of the non-stretching leg, easing stress on the low back.

Have the client lie close to the edge of the table from which you are working. This makes it easier on your body. Where, and how you position yourself will depend on the length of the client’s leg, your height, and the height of the table. Adjust the height of the table if possible, so that you don’t have to hold your limbs up high over, or away from your body. These same criteria hold true if you are stretching while your client lies on the floor. You will need to determine whether you should be standing, or kneeling. You should keep your spine in neutral, your abs tight, chest out and keep the client’s limb close to your body. You should think about moving your body instead of your limbs.

Active movement is a valuable tool for the trainer to assess many components, such as range of motion, strength, flexibility, and core stability. Assess your client’s active range of hip flexion by asking them to lift up the right leg as high as possible. Determine pain free movement, assess imbalances between the two sides, and determine the endpoint.

"Normal" passive flexibility for the hamstrings is approximately 85 degrees with the low back flat. It is the responsibility of the trainer to determine how much flexibility the client needs or wants as part of the program design process. These needs and wants must then be weighed against the risk of possible hypermobility at the joint, with muscles that are too flexible.

Determine the endpoint: where the client begins to feel a stretch. Put the client’s right leg on your shoulder, or wherever is comfortable for you. (Fig.1)

Figure 1

Put your left hand above the client’s right knee. Do not put your hand on the kneecap. Cue the client to keep the pelvis still, and the opposite leg still.

Cue the client to keep the right knee straight, and push the straight leg down towards the table with approximately 50% effort, for about 4 seconds. Immediately afterward, you may feel the muscle fibers release, and you are able to move the limb into a new endpoint. Repeat this sequence 3-4 times, always beginning at the new endpoint.

Important Points: Many of our clients (many people in general) have difficulty in keeping the pelvis still while the hamstrings are lengthening. This is a classic example of the relationship between proximal stability and distal mobility. We will address this more in the assessment articles. The bottom line is that if the ischial tuberosities come up off the table (the origin of the hamstrings), the stretch is no longer increased; core and pelvic stability is sacrificed, and most importantly-we lose the opportunity to teach our clients new movement and postural positions which will help them in their daily lives against musculoskeletal imbalances.

Before beginning the next cycle, reaffirm that the low back is okay, and look to make sure that the other leg is still and stable, and the pelvis is on the table and neutral. If the client’s left leg comes up off the table, it may very well be because you are going past the endpoint. If the left thigh is coming off the table, it could be because those hip flexors are tight. You can have the client bend the left knee, put the left foot on the table and continue the stretch. Remember that the range of motion did not increase even though it looks like the stretching leg can go further. It is only because you moved the origin of the muscle further off the table, and can therefore move the leg further.

Outer Hip/Abductors

The gluteus medius and minimus abduct and medially rotate the leg at the hip. The tensor fascia latae also abducts (although in a more flexed position), and the iliotibial band is responsible for stability at the hip and the knee since it inserts below the knee.

To stretch this are, we will cue the client to laterally rotate, and adduct at the hip.

Many clients are tight in the muscles of the outer hip and thigh. Many of the traditional sports in which our clients participate put a load on the lateral side of the body, like running, cycling, in-line skating, etc. It is important to remember, however, that a tight muscle is not always the strong muscle. It is the responsibility of the trainer to ascertain which muscles are tight and/or weak and flexible and/or strong,

Have the client lie supine with both legs straight. Assess active range of motion for adduction (which stretches the abductors). Be sure there is no pain in the low back as the client adducts the leg across the midline. Normal passive flexibility for the abductors is approximately 30-40 degrees past the midline of the body.

Sit, or prop yourself on the table facing the client, on the outside of the left leg. Cue the client to keep the hip-bones still, and laterally rotate the right leg at the hip.

A note on cueing: Many trainers would tell the client to "turn the right foot out." It is important to have the client understand that the movement is happening at the hip in order for them to perform the movement completely and efficiently. You may be able to feel the tightness of the muscles in laterally rotating at the hip. It is this "feel" that is crucial in being a safe and effective stretching technician (see Figure 2).

Figure 2

Assist the client in bringing the right leg across the midline of the body, high enough to cross the left thigh.

If the leg goes too high, the client may feel a stretch in the hamstrings. If the hamstring stretch is inhibiting the stretch of the outer hips/IT band, then you may want to bend the knee slightly to put the hamstrings/gastrocnemius in slack. Remember that you are sacrificing the stretching of the IT band if you bend the knee too much.

Keep the client’s leg close to your body, or support your elbow with your body. Support the client’s right knee on the lateral side. Start the sequence at the endpoint. Ask the client "do you feel a stretch? Can you point to where you feel a stretch?" The client may feel stretching around the greater trochanter of the femur, or along the fibers of the IT band. Cue the client to push against your body with 50 percent effort for four to six seconds. After this isometric contraction, you should feel the muscles "give" or "release," allowing you to move further into a stretched position. Repeat this sequence three to four times.

If the client’s right hip comes up off the table, you can cue them to pull it back down before you start the next cycle of contract-relax. Remember, when they pull the hip back down to the table, they will be increasing the stretch, since they are pulling the origin of the muscles further away, and back to the stable position. You may have to continually cue to keep the leg externally rotated.

A Note on Breathing

Obviously, the most important point is for the client to breathe while stretching. You may want to try having the client inhale as they contract the stretched muscle, and exhale as they "release", and stretch. This is not the same as we cue during strength training, i.e. exhaling during exertion, although it works well with the contract-relax stretching.

Figure 3 (another view of the same position)

Always be certain that the ankle is in a neutral position.

Quadratus Lumborum (QL)

Many times the quadratus lumborum – responsible for lateral flexion of the spine, or "hip hiking" of the hip – is either too weak and/or too tight for the core of the body to work efficiently in either initiating, translating or supporting movement in and around the pelvis, and the whole body. This muscle is extremely important in stability of the lumbopelvic region.

Assess active range of motion to determine pain free movement, compensation, and symmetry. Normal flexibility is approximately 35 degrees. Cue the client to sit on the table, with the left leg straight, and out to the side. The right leg should be off the table. If the left hamstrings are tight, they may inhibit the stretch. If so, have the client bend the left knee to put slack in the hamstrings (see Figure 4).

Figure 4

The client should be instructed to keep the right hip bone still or to pull it toward the table. The client’s left arm can also be used to stabilize by holding onto the table.

The main goal is for the client to remain stable while stretching. If the client is unable to sit in this position without falling over to the side, then have them simply sit up with both legs out in front, and the left arm assisting in the stabilization. The client in Figure 4 could also move his left, letting the left leg hang off of the table. The bottom line is that we must understand which muscle(s) we are trying to stretch, we must be sure that the spine is not compromised, and that we are actually cueing the client to move into a position which will illicit a stretch. If you are stretching on the floor, have the client sit with the left leg straight as in Figure 4. Bend the right knee, keeping it perpendicular to the body, with the foot into the body.

Cue the client to reach up overhead with the right arm, and laterally flex over to the left side. Be certain that there is no discomfort in the low back area. Place your body up on the table, or position yourself so as to help secure a good base of support (Fig. 5).

Figure 5

Cue the client to push against you with 50 percent effort for four to six seconds, after which the client may be able to "fall" into a further stretch. It is important to cue the client to increase the stretch if applicable. As they stop pushing against you, they should feel that they can stretch further.

The client may also feel a stretch in the lattissimus dorsi, or erector spinae. You may need to attempt different angles in order to determine where the client most needs the stretch.

Up to this point, the following muscle groups have been presented: hip flexors, quadriceps, hamstrings (straight leg), abductors (outer hip) and quadratus lumborum.

References:

  1. Adler, S., Beckers, D., & Buck, M. (1993). PNF in Practice. Berlin: Springer-Verlag.
  2. Alter, M. (1988). Science of Stretching. Champagne, IL: Human Kinetic Books.
  3. Brotzman, S.B., (1996). Handbook of Orthopedic Rehabilitation. St. Louis, MI: Mosby-YearBook.
  4. Trew, M., Everett, T. (1997). Human Movement: An Introductory Text. Churchill Livingstone.
  5. Porterfield, J., DeRosa, C. (1998). Mechanical Low Back Pain: Perspectives in Functional Anatomy.