Therapeutic Exercise Lab 1: Muscle Flexibility and Length

If your given movement was restricted, discuss how would you determine which tissue was actually causing the restriction and practice the assessment(s) that would help you make that determination.

A large list of things can limit ROM/movement listed in lecture. We can then perform assessments to determine if this is the actual cause of ROM restriction or not. These assessments may include joint accessory motion, end feels of PROM, muscle length/flexibility tests, neural mobility tests, swelling/girth measurements, and a variety of other assessments.

Agonist Contract

Agonist is muscle opposite the range-limiting targets muscle. The patient concentrically contracts the muscle opposite the range-limiting muscles and then holds the end-range position for at least several seconds.

Hold-Relax with Agonist Contraction

Combines HR and AC. Move the limb to the point that tissue resistance is felt in the range limiting target muscle; then have the patient perform a resisted, prestretch isometric contraction of the range-limiting muscle, followed by voluntary relaxation of that muscle and an immediate concentric contraction of the muscle opposite the range limiting muscle.

Review all of the flexibility & muscle length tests listed

Focus on the stability of the origin during the test and recognize the most likely compensatory movements that the body will attempt to perform in order to not feel the tension/discomfort associated with stretch. If we allow these compensations then the tests will falsely indicate that the muscle is not tight when in actuality it might be.

Elongation of Extrinsic Muscles of the Wrist and Hand: Flexor and Extensor Digitorum Muscles

General Technique and Hand Placement and Procedure: First, move the distal IP joint and stabilize it; then move the proximal IP joint. Hold both these joints at the end of their range; then move the MCP joint to the end of the available range. Stabilize all the finger joints and begin to extend the wrist. When the patient feels discomfort in the forearm, the muscles are fully elongated. Note: Motion is initiated in the distal-most joint of each digit to minimize compression of the small joints. Full joint ROM will not be possible when the extrinsic muscles are elongated.

Elbow Extension Stretch

Hand Placement and Procedure ■ Grasp the distal forearm. ■ With the upper arm at the patient's side supported on the table, stabilize the scapula and anterior aspect of the prox- imal humerus. ■ Extend the elbow just past the point of tissue resistance to lengthen the elbow flexors. NOTE: Be sure to do this with the forearm in supination, pronation, and neutral position to stretch each of the elbow flexors. To increase elbow extension with the shoulder extended, stretch the long head of the biceps. Patient Position, Hand Placement, and Procedure ■ With the patient lying supine close to the side of the table, stabilize the anterior aspect of the shoulder, or with the patient lying prone, stabilize the scapula. ■ Pronate the forearm, extend the elbow, and then extend the shoulder. PRECAUTION: It has been reported that heterotopic ossifi- cation (the appearance of ectopic bone in the soft tissues around a joint) can develop around the elbow after traumatic or burn injuries.48 It is believed that vigorous, forcible passive stretching of the elbow flexors may increase the risk of this condition developing. Passive or assisted stretching should therefore be applied very gently and gradually in the elbow region. Use of active stretching techniques, such as agonist contraction, might also be considered.

Stretching Specific Muscles of the Ankle and Foot

Hand Placement and Procedure ■ Stabilize the distal tibia with your proximal hand. ■ Grasp around the foot with your other hand and align the motion and force opposite the line of pull of the tendons. Apply the stretch force against the bone to which the mus- cle attaches distally. ■ To stretch the tibialis anterior (which inverts and dorsi- flexes the ankle), grasp the dorsal aspect of the foot across the tarsals and metatarsals and plantarflex and abduct the foot. ■ To stretch the tibialis posterior (which plantarflexes and inverts the foot), grasp the plantar surface of the foot around the tarsals and metatarsals and dorsiflex and abduct the foot. ■ To stretch the peroneals (which evert the foot), grasp the lateral aspect of the foot at the tarsals and metatarsals and invert the foot.

PROM for Hip Internal and External Rotation

Hand Placement and Procedure with hip and knee extended: Grasp just proximal to the patient's knee with the top hand and just proximal to the ankle with the bottom hand. Roll the thigh inward and outward. Hand Placement and Procedure with hip and knee flexed: Flex the patient's hip and knee to 90 degrees; support the knee with the top hand. If the knee is unstable, cradle the thigh and support the proximal calf and knee with the bottom hand. Rotate the femur by moving the leg like a pendulum. This hand placement provides some support to the knee but should be used with caution if there is knee instability

PROM for Lumbar Flexion

Hand Placement and Procedure: Bring both of the patient's knees to the chest by lifting under the knees (hip and knee flexion). Flexion of the spine occurs as the hips are flexed full range and the pelvis starts to rotate posteriorly. Greater range of flexion can be obtained by lifting under the patient's sacrum with the lower hand.

Cupping and Flattening the Arch of the Hand at the Carpometacarpal and Intermetacarpal Joints

Hand Placement and Procedure: Face the patient's hand; place the fingers of both of your hands in the palms of the patient's hand and your thenar eminences on the posterior aspect. Roll the metacarpals palmward to increase the arch and dorsalward to flatten it. Alternate Hand Placement: One hand is placed on the posterior aspect of the patient's hand with the fingers and thumb supping the metacarpals. Note: Extension and abduction of the thumb at the CMC joint are important for maintaining the web space for functional movement of the hand. Isolated flexion-extension and abduction-adduction ROM of this joint should be performed by moving the first metacarpal while stabilizing trapezium.

PROM for Wrist Flexion/Extension and Radial/Ulnar Deviation

Hand Placement and Procedure: For all wrist motions, grasp the patient's hand just distal to the joint with one hand and stabilize the forearm with your other hand. Note: The range of the extrinsic muscles to the fingers affects the range at the wrist if tension is placed on the tendons as they cross into the fingers. To obtain full range of the wrist joint, allow the fingers to move freely as you move the wrist.

PROM for Elbow Flexion and Extension

Hand Placement and Procedure: Grasp the distal forearm and support the wrist with one hand. This hand also controls forearm supination and pronation. With the other hand, support the elbow. Flex and extend the elbow with the forearm supinated and also with the forearm pronated. Note: The scapula should not tip forward when the elbow extends, as it disguises the true range.

PROM for Shoulder Flexion and Extension

Hand Placement and Procedure: Grasp the patient's arm under the elbow with your lower hand. With the top hand, cross over and grasp the wrist and palm of the patient's hand. Lift the arm through the available range and return.

PROM for Forearm Pronation and Supination

Hand Placement and Procedure: Perform pronation and supination with the elbow flexed as well as extended. When the elbow is extended, prevent the shoulder from rotating by stabilizing the elbow. Grasp the patient's wrist, supporting the hand with the index finger and placing the thumb and the rest of the fingers on either side of the distal forearm. Stabilize the elbow with the other hand. The motion is a rolling of the radius around the ulna at the distal radius. Alternate Hand Placement: Sandwich the patient's distal forearm between the palms of both hand. Precautions: Do not stress the wrist by twisting the hand; control the pronation and supination motion by moving the radius around the ulna.

Elongation of the Two-Joint Hamstring Muscle Group

Hand Placement and Procedure: Place the lower hand under the patient's heel and the upper hand across the anterior aspect of the patient's knee. Keep the knee in extension as the hip is flexed. If the knee requires support, cradle the patient's leg in your lower arm with your elbow flexed under the calf and your hand across the anterior aspect of the patient's knee. The other hand provides support or stabilization where needed. Note: if the hamstrings are so tight as to limit the knee from going into extension, the available range of the muscle is reached simply by extending the knee as far as the muscle allows and not moving the hip.

PROM for Ankle Dorsiflexion

Hand Placement and Procedure: Stabilize around the malleoli with the top hand. Cup the patient's heel with the bottom hand and place the forearm along the bottom of the foot. Pull the calcaneus distalward with the thumb and fingers while pushing upward with the forearm. Note: if the knee is flexed, full range of the ankle joint can be obtained. if the knee is extended, the lengthened range of the two-joint gastrocnemius muscle can be obtained, but the gastrocnemius limits full range of DF. Apply DF in both positions of the knee to provide range to both the joint and the muscle.

PROM Joints of the Toes: Flexion/Extension and Abduction/Adduction

Hand Placement and Procedure: Stabilize the bone proximal to the joint that is to be moved with one hand, and move the distal bone with the other hand. The technique is the same as for ROM of the fingers. Several joints of the toes can be moved simultaneously if care is taken not to stress any structure.

PROM Transverse Tarsal Joint

Hand Placement and Procedure: Stabilize the patient's talus and calcaneus with one hand. With the other hand, grasp around the navicular and cuboid. Gently rotate the midfoot by lifting and lowering the arch.

PROM for Ankle Plantar Flexion

Hand Placement and Procedure: Support the heel with the bottom hand. Place the top hand on the dorsum of the foot and push it into plantarflexion. Note: in bed-bound patients, the ankle tends to assume a PF position from the weight of the blankets and the pull of gravity, so this motion may not need to be performed.

PROM for Hip Abduction and Adduction

Hand Placement and Procedure: Support the patient's leg with the upper hand under the knee and the lower hand under the ankle. For full range of adduction, the opposite leg needs to be in a partially abducted position. Keep the patient's hip and knee in extension and neutral to rotation as abduction and adduction are performed.

PROM Subtalar Joint Inversion and Eversion

Hand Placement and Procedure: Using the bottom hand, place the thumb medial and the fingers lateral to the joint on either side of the heel. Turn the heel inward and outward. Note: supination of the foot may be combined with inversion, and pronation may be combined with eversion.

Types of PNF Stretching

Hold-Relax (HR) or Contract Relax (CR) Agonist Contract (AC) Hold-Relax with Agonist Contract (HR-AC)

PROM for Shoulder Internal (Medial) and External (Lateral) Rotation

If possible, the arm is abducted to 90 degrees, the elbow is flexed 90 degrees, and the forearm is held in neutral position. Rotation may also be performed with the patient's arm at the side of the thorax, but full internal rotation is not possible in this position Hand Placement Procedure: Grasp the hand and the wrist with your index and finger between the patient's thumb and index finger. Place your thumb and the rest of your fingers on either side of the patient's wrist, thereby stabilizing the wrist. With the other hand, stabilize the elbow. Rotate the humerus by moving the forearm like a spoke on a wheel.

PROM for Cervical Lateral Flexion and Rotation

Maintain the cervical spine neutral to flexion and extension as you direct the head and neck into side bending (approximate the ear toward the shoulder) and rotation (rotate from side to side).

Elongation of the Two-Joint Rectus Femoris Muscle

Position the Patient supine with knee flexed over the edge of the treatment table or position prone. Hand Placement and Procedure: When supine, stabilize the lumbar spine by flexing the hip and knee of the opposite lower extremity and placing the foot on the treatment table (hook-lying). When prone, stabilize the pelvis with the top hand. Flex the patient's knee until tissue resistance is felt in the anterior thigh, which means the full available range is reached.

PROM for Lumbar Rotation

Position the patient in the hook-lying position with hips and knees flexed and feet resting on the table. Hand Placement and Procedure: Push both of the patient's knees laterally in one direction until the pelvis on the opposite side comes off the treatment table. Stabilize the patient's thorax with the top hand on shoulder. Repeat in the opposite direction

PROM for Lumbar Extension

Position the patient prone for full extension (hyperextension). Hand placement and procedure: With hands under the thighs, lift the thighs upward until the pelvis rotates anteriorly and the lumbar spine extends

PROM for Scapula Elevation/Depression, Protraction/Retraction, and Upward/Downward Rotation

Position the patient prone with his or her arm at the side or side-lying facing toward you with the patient's arm draped over your bottom arm. Hand Placement and Procedure: Cup the top hand over the acromion process and place the other hand around the inferior angle of the scapula. For elevation, depression, protraction, and retraction, the clavicle also moves as the scapular motions are directed as the acromion process. For rotation, direct the scapular motions at the inferior angle of the scapula while simultaneously pushing the acromion in the opposite direction to create a force couple turning effect.

Discuss and perform the assessment(s) related to how you would know if the particular movement was restricted or not.

Primarily, we look at side to side comparisons or compare against a 'norm'. This can be done in an isolated fashion such as in goniometric measurements or a functional fashion such as looking at UE behind the back movement or a squat (i.e. SFMA).

PROM for Hip Hyperextension

Prone or side-lying must be used if the patient has near-normal or normal motion. Hand Placement and Procedure: If the patient is prone, lift the thigh with the bottom hand under the patient's knee; stabilize the pelvis with the top hand or arm. If the patient is side-lying, bring the bottom hand under the thigh and place the hand on the anterior surface; stabilize the pelvis with the top hand. For full range of hip extension, do not flex knee full rang , as the two-joint rectus femoris would then restrict the range.

Using all of your available resources, select 2 self-stretching exercises for the muscle that may limit the movement. Perform the exercises and practice teaching them to your partner. Discuss appropriate dosing (i.e. frequency, duration, volume, etc.) as well as whether the stretch is isolated or functional. Additionally, discuss how the exercises would relate to a patient's desired activity and what factors may influence the patient's adherence to performing the stretch independently as a home exercise program

Remember that we use stretches to improve extensibility of either musculotendinous or capsular/ligamentous structures. Make sure you understand how to prescribe the parameters of exercise for each of these different types of tissue. Also, recognize that there are a variety of different modes of stretching a single muscle. Be able to understand why you might choose one mode over anotherfor a given individual. Also, ROM exercises can be used to decrease swelling &/or pain. Additionally, they can be used to maintain gains in motion that we have achieved within a therapy visit. Make sure you know and understand how to prescribe a ROM exercise as well as how to make an exercise easier or more challenging based on the concepts of PROM-AAROM-AROM & gravity assisted-gravity eliminated-gravity restricted

PNF Stretching

Sometimes referred to as active stretching or facilitative stretching. Integrate active muscle contractions into stretching. These techniques are used to inhibit or facilitate muscle activation and to increase the likelihood that the muscle to be lengthened remains as relaxed as possible as it is stretched.

PROM for Cervical Flexion

Stand at the end of the treatment table; securely grasp the patient's head by placing both hands under the occipital region. Procedure: Lift the head as though it were nodding (chin toward larynx) to flex the head on the neck. Once full nodding is complete, continue to flex the cervical spine and lift the head toward the sternum.

PROM for Joints of Thumbs and Fingers: Flexion/Extension and Abduction/Adduction

The joints of the thumbs and fingers include the MCP and IP joints. Hand Placement and Procedure: Depending on the position of the patient, stabilize the forearm and hand on the bed or table or against your body. Move each joint of the patient's hand individually by stabilizing the proximal bone with the index finger and thumb of one hand and moving the distal bone with the index finger and the thumb of the other hand. Alternative Procedure: Several joints can be moved simultaneously if proper stabilization is provided. Example: to move all the MCP joints of digits 2-5, stabilize the metacarpals with one hand and move all the proximal phalanges with the other hand. Note: To accomplish full joint ROM, do not place tension on the extrinsic muscles going to the fingers. Tension on the muscles can be relieved by altering the wrist position as the fingers are moved.

Hold-Relax and Contract Relax

The range limiting target muscle is first lengthened to the point of tissue resistance or to the extent that is comfortable for the patient. Patient actively performs a prestretch, end-range, isometric contraction of the range0limiting target muscle against manual resistance applied by the clinician held for 5 seconds and followed by voluntary relaxation of target muscle. Limb is then moved passively to new end range.

PROM for Cervical Extension

Tip the head backward Note: If the patient is supine, only the head and upper cervical spine can be extended; the head must clear and end of the table to extend the entire cervical spine. The patient may also be prone or sitting.

Elongation of Two-Joint Biceps Brachii Muscle

To extend the shoulder beyond zero, position the patient's shoulder at the edge of the table when supine or position the patient prone lying, sitting, or standing. Hand Placement and Procedure: First, pronate the patient's forearm by grasping the wrist and extend the elbow while supporting it. Then, extend (hyperextend) the shoulder to the point of tissue resistance in the anterior arm region. At this point, full available lengthening of the two-joint muscle is reached.

Shoulder Abduction Stretching

To increase abduction of the shoulder, stretch the adductors. Hand Placement and Procedure: With the elbow flexed to 90 degrees, grasp the distal humerus. Stabilize the axillary border of the scapula. Move the patient into full shoulder abduction to lengthen the adductors of the shoulder.

Hip Adductors stretch

To increase adduction of the hip, stretch the tensor fasciae latae and iliotibial (IT) band (Fig. 4.29). Patient Position Place the patient in a side-lying position with the hip to be stretched uppermost. Flex the bottom hip and knee to stabi- lize the patient. Hand Placement and Procedure ■ Stabilize the pelvis at the iliac crest with your proximal hand. ■ With the knee flexed, extend the patient's hip to neutral or into slight hyperextension, if possible. Moving the hip into a small amount of flexion and abduction prior to extending it may help orient the IT band for the stretch. ■ Let the patient's hip adduct with gravity and apply an addi- tional stretch force with your other hand to the lateral aspect of the distal femur to further adduct the hip. NOTE: If the patient's hip cannot be extended to neutral, the hip flexors must be stretched before the tensor fasciae latae can be stretched.

Shoulder Adduction Stretch

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

Ankle Dorsiflexion Stretch

To increase dorsiflexion of the ankle with the knee extended, stretch the gastrocnemius muscle (Fig. 4.34). Hand Placement and Procedure ■ Grasp the patient's heel (calcaneus) with one hand, main- tain the subtalar joint in a neutral position, and place your forearm along the plantar surface of the foot. ■ Stabilize the anterior aspect of the tibia with your other hand. ■ Dorsiflex the talocrural joint of the ankle by pulling the cal- caneus in an inferior direction with your thumb and fingers while gently applying pressure in a superior direction just proximal to the heads of the metatarsals with your forearm. To increase dorsiflexion of the ankle with the knee flexed, stretch the soleus muscle. The knee must be flexed to elimi- nate the effect of the two-joint gastrocnemius muscle. Hand placement, stabilization, and stretch force are the same as when stretching the gastrocnemius. PRECAUTION: When stretching the gastrocnemius or soleus muscles, avoid placing too much pressure against the heads of the metatarsals and stretching the long arch of the foot. Over- stretching the long arch of the foot can cause a flat foot or a rocker-bottom foot.

Elbow Flexion Stretch

To increase elbow flexion, stretch the one-joint elbow extensors. Hand Placement and Procedure: Grasp the distal forearm just proximal to the wrist. With the arm at the patient's side supported on the table, stabilize the proximal humerus. Flex the patient's elbow just past the point of tissue resistance to lengthen the elbow extensors. To increase the elbow flexion with the shoulder flexed, stretch the long head of the triceps. Hand Placement and Procedure: With the patient sitting or lying supine with the arm at the edge of the table, flex the patient's shoulder as far as possible. While maintaining shoulder flexion, grasp the distal forearm and flex the elbow just pas the point of resistance to lengthen the long head of the triceps.

End-Range knee Extension Stretch

To increase end-range knee extension (Fig. 4.33). Patient Position Patient assumes a supine position. Hand Placement and Procedure ■ Grasp the distal tibia of the knee to be stretched. ■ Stabilize the hip by placing your hand or forearm across the anterior thigh. This prevents hip flexion during stretching. ■ Apply the stretch force to the posterior aspect of the distal tibia and extend the patient's knee.

Hip External Rotators stretchl

To increase external rotation of the hip, stretch the internal rotators (Fig. 4.30) Patient Position Place the patient in a prone position with the hips extended and knee flexed to 90°. Hand Placement and Procedure ■ Grasp the distal tibia of the extremity to be stretched. ■ Stabilize the pelvis by applying pressure with your other hand across the buttocks. ■ Apply pressure to the lateral malleolus or lateral aspect of the tibia and externally rotate the hip as far as possible. Alternate Position and Procedure Sitting at the edge of a table with hips and knees flexed to 90°: ■ Stabilize the pelvis by applying pressure to the iliac crest with one hand. ■ Apply the stretch force to the lateral malleolus or lateral aspect of the lower leg and externally rotate the hip. NOTE: When you apply the stretch force against the lower leg in this manner, thus crossing the knee joint, the knee must be stable and pain-free. If the knee is not stable, it is possible to apply the stretch force by grasping the distal thigh, but the leverage is poor and there is a tendency to twist the skin.

Shoulder External Rotation Stretch

To increase external rotation of the shoulder, stretch the internal rotators. Hand Placement and Procedure: Abduct the shoulder to a comfortable position - initially 30-45 degrees and later to 90 if the GH joint is stable - or place the arm at the patient's side. Flex the elbow to 90 degrees so the forearm can be used as a lever. Grasp the volar surface of the mid-forearm with one hand. Stabilization of the scapula is provided by the table on which the patient is lying. Externally rotate the patient's shoulder by moving the patient's forearm closer to the table. This fully lengthens the internal rotators. Precaution: Because it is necessary to apply the stretch forces across the intermediate elbow joint when elongating the internal and external rotators of the shoulder, be sure the elbow joint is stable and pain-free. In addition, keep the intensity of the stretch force very low, particularly in patients with osteoporosis.

Toe Flexion and Extension

To increase flexion and extension of the toes. It is best to stretch any musculature that limits motion in the toes individually. With one hand, stabilize the bone proximal to the restricted joint, and with the other hand, move the phalanx in the desired direction.

Hip Extension with Knee Extension Stretches

To increase flexion of the hip with the knee extended, stretch the hamstrings (Fig. 4.25 A and B). Hand Placement and Procedure ■ With the patient's knee fully extended, support the patient's lower leg with your arm or shoulder. ■ Stabilize the opposite extremity along the anterior aspect of the thigh with your other hand or a belt or with the assistance of another person. ■ With the knee at 0° extension and the hip in neutral rota- tion, flex the hip as far as possible. NOTE: Externally rotate the hip prior to hip flexion to isolate the stretch force to the medial hamstrings and internally rotate the hip to isolate the stretch force to the lateral hamstrings. Alternative Therapist Position Kneel on the mat and place the patient's heel or distal tibia against your shoulder (see Fig. 4.25 B). Place both of your hands along the anterior aspect of the distal thigh to keep the knee extended. The opposite extremity is stabilized in exten- sion by a belt or towel around the distal thigh and held in place by the therapist's knee.

Hip Flexion stretches

To increase flexion of the hip with the knee flexed, stretch the gluteus maximus. Hand Placement and Procedure ■ Flex the hip and knee simultaneously. ■ Stabilize the opposite femur in extension to prevent poste- rior tilt of the pelvis. ■ Move the patient's hip and knee into full flexion to lengthen the one-joint hip extensor.

Shoulder Flexion Stretching

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

PIP and DIP Stretches

To increase flexion or extension of the proximal and distal interphalangeal (PIP and DIP) joints. Hand Placement and Procedure ■ Grasp the middle or distal phalanx with your thumb and finger. ■ Stabilize the proximal or middle phalanx with your other thumb and finger. ■ Move the PIP or DIP joint in the desired direction for stretch.

MCP Joint Stretches

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

CMC Joint stretches

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

Hip Abductors stretch

To increase hip extension and knee flexion simultaneously, stretch the rectus femoris. Patient Position Use either of the positions previously described for increasing hip extension in the supine or prone positions (see Figs. 4.26 and 4.27). Hand Placement and Procedure ■ With the hip held in full extension on the side to be stretched, move your hand to the distal tibia and gently flex the knee of that extremity as far as possible. ■ Do not allow the hip to abduct or rotate.

Hip Extension with knee Flexion stretch

To increase hip extension and knee flexion simultaneously, stretch the rectus femoris. Patient Position Use either of the positions previously described for increasing hip extension in the supine or prone positions (see Figs. 4.26 and 4.27). Hand Placement and Procedure ■ With the hip held in full extension on the side to be stretched, move your hand to the distal tibia and gently flex the knee of that extremity as far as possible. ■ Do not allow the hip to abduct or rotate.

Hip Extension stretch

To increase hip extension, stretch the iliopsoas (Fig. 4.26). FIGURE 4.26 Hand placement and stabilization of the pelvis to increase extension of the hip (stretch the iliopsoas) with the patient lying supine. Flexing the knee when in this position also elongates the rectus femoris. Patient Position Have the patient positioned close to the edge of the treatment table so the hip being stretched can be extended beyond neu- tral. The opposite hip and knee are flexed toward the patient's chest to stabilize the pelvis and spine. Hand Placement and Procedure ■ Stabilize the opposite leg against the patient's chest with one hand or, if possible, have the patient assist by grasping around the thigh and holding it to the chest to prevent an anterior tilt of the pelvis during stretching. ■ Move the hip to be stretched into extension or hyperextension by placing downward pressure on the anterior aspect of the distal thigh with your other hand. Allow the knee to extend so the two-joint rectus femoris does not restrict the range. Alternate Position Have the patient assume the prone-lying position (Fig. 4.27). Hand Placement and Procedure ■ Support and grasp the anterior aspect of the patient's distal femur. ■ Stabilize the patient's pelvis with a downward force on their buttocks. ■ Extend the patient's hip by lifting the femur off the table.

Shoulder Horizontal Abduction Stretch

To increase horizontal abduction of the shoulder, stretch the pectoralis muscles. Patient Position: To reach full horizontal abduction in the supine position, the patient's shoulder must be at the edge of the table. Begin with the shoulder in 60-90 degrees of abduction. The patient's elbow may also be flexed. Hand Placement and Procedure: Grasp the anterior aspect of the distal humerus. Stabilize the anterior aspect of the shoulder. Move the patient's arm below the edge of the table into full horizontal abduction to stretch the horizontal abductors. Note: The horizontal adductors are usually tight bilaterally. Stretching techniques can be applied bilaterally by the therapist, or a bilateral self-stretch can be done by the patient by using a corner or wand.

Shoulder Hyperextension Stretch

To increase hyperextension of the shoulder, stretch the shoulder flexors. Patient Position: Place the patient in a prone position. Hand Placement and Procedure: Support the forearm and grasp the distal humerus. Stabilize the posterior aspect of the scapula to prevent substitute movements. Move the patient's arm into full hyperextension of the shoulder to elongate the shoulder flexors.

Hip Internal rotators stretch

To increase internal rotation of the hip, stretch the external rotators (Fig. 4.30 B). Patient Position and Stabilization Position the patient the same as when increasing external rotation, described previously. Hand Placement and Procedure Apply pressure to the medial malleolus or medial aspect of the tibia and internally rotate the hip as far as possible.

Shoulder Internal Rotation Stretch

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

Ankle Inversion and Eversion

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

Knee Extension stretch

To increase knee extension in the midrange, stretch the knee flexors (Fig. 4.32). Patient Position Place the patient in a prone position and put a small, rolled towel under the patient's distal femur, just above the patella. Hand Placement and Procedure ■ Grasp the distal tibia with one hand and stabilize the but- tocks to prevent hip flexion with the other hand. ■ Slowly extend the knee to stretch the knee flexors.

Knee Flexion stretch

To increase knee flexion, stretch the knee extensors (Fig. 4.31). Patient Position Have the patient assume a prone position. Hand Placement and Procedure ■ Stabilize the pelvis by applying downward pressure across the buttocks. ■ Grasp the anterior aspect of the distal tibia and flex the patient's knee. PRECAUTION: Place a rolled towel under the thigh just above the knee to prevent compression of the patella against the table during the stretch. Stretching the knee extensors too vigorously in the prone position can traumatize the knee joint and cause swelling. Alternate Position and Procedure ■ Have the patient sit with the thigh supported on the treatment table and leg flexed over the edge as far as possible. ■ Stabilize the anterior aspect of the proximal femur with one hand. ■ Apply the stretch force to the anterior aspect of the distal tibia and flex the patient's knee just past the point of tissue resistance. NOTE: This position is useful when working in the 0° to 100° range of knee flexion. The prone position is best for increasing knee flexion from 90° to 135°.

Ankle Plantar Flexion Stretch

To increase plantarflexion of the ankle. Hand Placement and Procedure ■ Support the posterior aspect of the distal tibia with one hand. ■ Grasp the foot along the tarsal and metatarsal areas. ■ Apply the stretch force to the anterior aspect of the foot and plantarflex the foot.

Radial deviation Stretch

To increase radial deviation. Hand Placement and Procedure ■ Grasp the ulnar aspect of the hand along the fifth metacarpal. ■ Hold the wrist in midposition. ■ Stabilize the forearm. ■ Radially deviate the wrist to lengthen the ulnar deviators of the wrist.

Forearm Supination /pronation Stretch

To increase supination or pronation of the forearm. Hand Placement and Procedure ■ With the patient's humerus supported on the table and the elbow flexed to 90°, grasp the distal forearm. ■ Stabilize the humerus. ■ Supinate or pronate the forearm just beyond the point of tissue resistance. ■ Be sure the stretch force is applied to the radius rotating around the ulna. Do not twist the hand, thereby avoiding stress to the wrist articulations. ■ Repeat the procedure with the elbow extended. Be sure to stabilize the humerus to prevent internal or external rotation of the shoulder.

Ulnar Deviation stretch

To increase ulnar deviation. Hand Placement and Procedure ■ Grasp the radial aspect of the hand along the second metacarpal, not the thumb. ■ Stabilize the forearm. ■ Ulnarly deviate the wrist to lengthen the radial deviators.

Wrist Extension Stretch

To increase wrist extension (Fig. 4.24). Hand Placement and Procedure ■ Pronate the forearm or place it in midposition and grasp the patient at the palmar aspect of the hand. If there is a severe wrist flexion contracture, it may be necessary to place the patient's hand over the edge of the treatment table. ■ Stabilize the forearm against the table. ■ To lengthen the wrist flexors, extend the patient's wrist, allowing the fingers to flex passively.

PROM for Shoulder Hyperextension

To obtain extension past zero, position the patient's shoulder at the edge of the bed when supine or position the patient side-lying, prone, or sitting.

PROM for Shoulder Horizontal Abduction (Extension) and Adduction (Flexion)

To reach full horizontal abduction, position the patient's shoulder at the edge of the table. Begin with the arm either adducted or abducted 90 degrees. Hand Placement and Procedure: Hand placement is the same as with flexion, but turn your body and face the patient's head as you move the patient's arm out to the side and then across body.

PROM for Combined Hip and Knee: Flexion and Extension

To reach full range of hip flexion, the knee must also be flexed to release tension on the hamstring muscle group. To reach full range of knee flexion, the hip must be flexed to release tension on the rectus femoris muscle. Hand Placement and Procedure: Support and lift the patient's leg with the palm and fingers of the top hand under the patient's knee and the lower hand under the heel. As the knee flexes full range, swing the fingers to the side of the thigh.

PROM for Shoulder Abduction and Adduction

Use the same hand placement as with flexion, but more the arm out to the side. The elbow may be flexed for ease in completing the arc of motion.

Wrist Flexion stretch

When stretching the muscles of the wrist and hand, have the patient sit in a chair adjacent to you with the forearm sup- ported on a table to stabilize the forearm effectively. To increase wrist flexion. Hand Placement and Procedure ■ The forearm may be supinated, in midposition, or pronated. ■ Stabilize the forearm against the table and grasp the dorsal aspect of the patient's hand. ■ To elongate the wrist extensors, flex the patient's wrist and allow the fingers to extend passively. ■ To further elongate the wrist extensors, extend the patient's elbow.

Elongation of Two-Joint Long Head of the Triceps Brachii Muscle

When the near-normal range of the triceps brachii muscle is available, the patient must be sitting or standing to reach the full ROM. With marked limitation is muscle range, ROM can be performed in the supine position. Hand Placement and Procedure: First, fully flex the patient's elbow with one hand on the distal forearm. Then, flex the shoulder by lifting up on the humerus with the other hand under the elbow. Full available range is reached when discomfort is experienced in the posterior arm region.