MUSCLE STRETCHING

IN MANUAL THERAPY
A CLINICAL MANUAL
,
,
The Extremities
--
Volume I
Olaf Evjenth & Jern Hamberg
ALFTA REHAB
Olaf Evjenth & Jern Hamberg
MUSCLE STRETCHING
IN MANUAL THERAPY
A Clinical Manual
Muscle stretching 2000 years ago, Statue from Bangkok.
Volume I The Extremities
ALFTA REHAB
II
/ -
v
MUSCLESTRETCHING IN MANUAL THERAPY, A CLINICAL MANUAL, TWO VOLUMES
by
Olaf Evjenth, M.s.
Lecturer in Manual Therapy,
Hans & OlafInstitute,
Oslo, Norway
and
Jern Hamberg, M.D.
Alfta Rehab Center AB
Alfta, Sweden
Original title: TCijning av Muskier, Varfor och Hur?
Copyright © Alfta Rehab F Ciriag, Alfta, Sweden
No part of this publication may be reproduced, stored in retrieval system, or transmitted in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
without the prior written permission of the publisher.
Translated from Swedish by M. Michael Brady
Photos by BjCim Hamberg
Drawings by Elna Jonsson
5th Edition
Printed by Istiruco Grafico Silvio Basile, Italy, 2002
Distributor: Alfta Rehab Center Promotion AB, Box 94, S-822 22 Alfta, Sweden
ISBN 91-85934-02-X
PREFACE
Today, one patient in four seeking medical aid
does so solely with a locomotor system complaint.
Many of the remaining three-quarters of all
patients seeking medical aid primarily for other
reasons also complain of stiffness, aches, and
painful movement. The muscular-skeletal dis-
orders of patients in these two categories comprise
the greatest single cause of sick leave. The persons
affected dominate the group of those who retire
early on disability pensions. The socio-economic
problems resulting from muscular-skeletal dis-
orders are undoubtedly greater and more wide-
spread than indicated by any single statistic.
Years of research and experience in studying and
treating locomotor system maladies have clearly
proven the effectiveness of treatment through
" relaxation and stretching of shortened muscles and
other related ·structures. The techniques involved
are basically therapeutic, but they may also be
applied in preventative exercise at all levels of
physicallraining programs, for persons of all ages.
Our research has been pragmatically oriented
towards attaining results for a greater number of
patients over longer periods of time. Hence we
have not conducted double-blind tests, but instead
have allowed our patients to function as their own
controls. Prolonged dysfunction, which diminishes
dramatically after relaxation and stretching treat-
ment, is more than ample proof of treatment
effectiveness, both for the therapist and for the
patients involved.
This book is a compendium of therapeutic
techniques that we have used to successfully treat
patients with reduced mobility caused by shor-
tened structures. Treatments for the extremities
and their associated joints are covered in Volume
I. Treatments for the spine and the temporo-
mandibular joint are covered in Volume II.
Although the temporo-mandibular joint is anato-
mically removed from the spine, it is therapeuti-
cally recognized as being closely connected to the
cervical spine and therefore is included in Volume
II. Each of the two Volumes is arranged to be
used as an independent clinical reference.
In this Volume I:
The general principles of manual therapy are
outlined in Part 1, along with a guide to the
organization of the therapy techniques. The
therapy techniques are fully described in Part 2
and Part 3, one to a page. Each description
consists of a drawing showing the muscles in-
volved, two photos showing the starting and final
positions of the technique, and an explicit text
giving positions, grips and procedures.
The Movement Restriction Tables and Index of
Muscles of ParI 4" list the muscles which may
restrict movement and reference them to pages.
The two volumes of this book are intended
primarily to be used as ready-reference clinical
manuals and as texts on muscle stretching in
manual therapy. However , we hope that they will
also provide physiotherapists and medical doctors
with a fresh, comprehensive approach to the
entire subject of muscle stretching in manual
therapy. Our underlying goal has been to contri-
bute to improving the quality of the treatment of
muscular-skeletal disorders, both for patients and
for therapists. We will be pleased if the users of
this manual find it useful in realizing that goal.
Oslo, Norway and Alfta, Sweden
August 1984
Olaf Evjenth and Jern Hamberg
3
CONTENTS
PREFACE
PART 1 GENERAL PRINCIPLES OF RELAXATION AND STRETCHING OF
MUSCLES AND OTHER STRUCTURES
1.1 INTRODUCTION
1.2 INDICATIONS
1.3 CONTRAINDICATIONS
1.4 GUIDELINES FOR THE THERAPIST
1.5 DYSFUNCTION
1.6 MANUAL THERAPY METHODS
1.7 RECOMMENDED THERAPY PROCEDURE
1.8 THERAPY TECHNIQUES - PARTS 2 AND 3
1.9 REFERENCES
PART 2 THERAPY TECHNIQUES FOR THE UPPER EXTREMITY
2 THE SHOULDER
3 THE ELBOW
4 THE WRIST
5 THE FINGERS
PART 3 THERAPY TECHNIQUES FOR THE LOWER EXTREMITY
6 THE HIP
7 THE KNEE
8 THE ANKLE
9 THETOES
PART 4 TABLES AND INDEX
4
10 MOVEMENT RESTRICTION TABLES
11 INDEX OF MUSCLES
7
7
7
7
7
8
8
10
11
12
13
14
49
68
76
89
90
126
133
148
163
164
176
PART 1
GENERAL PRINCIPLES OF RELAXATION AND STRETCHING OF MUSCLES AND
OTHER STRUCTURES
1.1 INTRODUCTION
1.2 INDICATIONS
1.3 CONTRAINDICATIONS
1.4 GUIDELINES FOR THE THERAPIST
1.5 DYSFUNCTION
1.6 MANUAL THERAPY METHODS
1.7 RECOMMENDED THERAPY PROCEDURE
1.8 THERAPY TECHNIQUES - PARTS 2 AND 3
1.9 REFERENCES
5
I. GENERAL PRINCIPLES OF RELAXATION
AND STRETCHING OF MUSCLES AND
OTHER STRUCTURES
1.1. INTRODUCTION
Humans have always been physically active for
reasons other than pure necessity. Nonessential
acti vities, which now classify physiologically as
exercise or stretching, evolved for reasons long
forgotten or never recorded. Although dance and
ritual were obvious progenitors, non-productive
physical activity undoubtedly had utilitari an ori-
gins: Its early practitioners felt better after
stretching. Historical confirmation of the origins
of exercise and stretching is lacking. But there's
ample evidence that stretching, such as that
depicted by the 2000 year old statue shown in the
frontispiece of this book, has been practiced since
the dawn of history.
Stretching now divides into therapeutic stretch-
ing, the topic of this Manual and self-stretching, as
used in exercise , at hl etic training, dance, and
certain ritual exercises. The two categories of
stretching may supplement each other. For inst-
ance , therapists may teach their pati ents sel f-
stretching to speed recovery, and sports teams
may employ therapists to treat athletes. Yet there
is good reason to di fferentiate . Controlled, proper
stretching is beneficial. But uncontroll ed stretch-
ing of muscles and ot her structures may damage ,
such as through causing instability or pathological
hypermobility. In most such cases, self-stretching
is involved.
Unwary athletes and other persons exercising
often self-stretch with great force at long lever
arms, which easil y injures. Some competitive
athletic events, such as gymnastics in general and
women's gymnastics in particular , require extreme
movement and therefore frequentl y injure partici-
pants. Other extreme activities, such as group
exercises to music ("jazzexercise" and "aerobic
dance" are two) also pose high hazard of stretch-
ing damage. Some exercises are faulted, but lack
of knowledge is the leading underlying cause of
self-stretching damage. Most people know littl e of
the normal ranges of movement of the joints of
their bodies. The result is that when they stretch,
normal structures are oft en overstretched, while
shortened structures are seldom adequately
stretched.
An understano;ling of why, when and how
muscles or other structures should be stretched is
prerequisite to stretching to benefit rather than
degrade body function. The role of the therapist in
stretching is then not just to understand and treat ,
but also to guide and teach patients self-stretching
(see references 6 and 7) .
1.2. INDICATIONS
Every pati ent with symptoms involving the loco-
motor system, particularly symptoms of pain
and/or constrained movement, should be ex-
amined to assess joint and muscle functi on. If
examinati on shows joint play to be normal, but
reveals shortened muscles or muscle spasm, then
treatment by stretching is indicated. With a view
towards preventive medicine , all younger children
should be examined and, if necessary, treated for
any disturbed muscle function before symptoms
appear.
1.3. CONTRA INDICATIONS
Any dysfunction and/or pain of suspected patholo<
gical origin contraindicates manual therapy.
Affected patients should be advised to seek
medical diagnosis, and return to therapy if their
doctors negate the suspected pathology and
recommend return.
1.4. GUIDELINES FOR THE THERAPIST
The only reliable way to become proficient in
detecti ng and treating muscle dysfuncti on is
through experience gained by thoroughly examin-
ing every patient. Unfortunately there are no exact
rules for examination. Normal ranges of move-
ment referenced in texts, though typical of large
popul ati ons, are seldom directly applicable in
indi vidual cases and therefore do not always
indicate if muscles and/or other structures need
stretching. So patient examinations should start
with preliminary biomechanical analyses.
If the preliminary analysis identifies shortened
muscles, then a provisional trial treatment is
performed. If the provisional treatment reduces
pain and improves the affected movement pattern,
the preliminary analysis is confirmed, and treat-
ment may proceed. The restoration of the mus-
cles' normal pattern of movement , with freedom
from pain , is the only real measure by which the
treatment may be judged to have been successful.
With experience, examiners can detect particular
shortened muscles that const rain movement in
their surrounding structures. Sometimes move-
ment patterns and/or ranges of movements cannot
be full y restored because of irreversible damage or
changes in locomotive structures. Nonetheless,
stretching can still be valuable in treatment .
The starti ng positions, Fig. a, of the techniques
of Part 3, correspond to positions imposed by
shortening, while the final positions, Fig. b,
correspond to extent of maximum range of
movement.
7
1.5. DYSFUNCTION
1.5.1. Causes and Mechanisms
When functioning normally, a muscle has opti-
mum circulation and innervation, is able to move
freely, is unimpaired in contracting and relaxing,
and has normal elasticity and strength. All
movements should be free of pain. Muscle
function may depart from this norm in many ways,
primarily because muscles are among the most
susceptible of body structures. They must con-
tinually readjust to their use, di suse, or misuse.
Muscle shortening frequently results. Stiff or
shortened muscles are often activated in move-
ments in which they otherwise would not take
part. This overuse in turn leads to injury and/or to
excess inhibition of their antagonists. In general,
the shorter the muscle, the more it may inhibit its
antagonists. Therefore, stimulating and streng-
thening a muscle's antagonists always aids treat-
ment. However, note that the shortened muscle
being treated should always be stretched before its
antagonists are strengthened.
Shortened muscles may cause pain from the
periosteum, tendons, or muscle belly, including
referred pain to other structures or segments. In a
synergistic group, no one muscle should be shorter
than the others of the group. A stiff, shortened
muscle will be subjected to greater stress when
contracted suddenly and forcefully, thus damaging
itself and/or its associated tendon. This can be
prevented by stretching the relevant muscle or
muscle group.
Normal range of movement is determined by
several structures: skin, subcutaneous tissue , mus-
cles, ligaments, joint capsules, joint surfaces, and
intraarticular structures. Changes in any of these
structures alter ranges of movement. Conditions
such as septic or aseptic inflammations may cause
restricted movements when acute, and pathologic-
al instability when chronic. The structures most
affected are the fascia , joint capsules, ligaments ,
and joint cartilages. An example is the develop-
ment of ankylosing spondylarthritis (Morbus
Bechterew). An initial instability becomes hypo-
mobility through degenerative change. Subse-
quent development may further restrict move-
ment ranges , and occasionally lead to ankylosis. If
a reduced range of movement is caused by
shortened muscles, then treatment by stretching
increases and may restore the range of movement
to normal.
1.5.2. Symptoms
Dysfunction due to shortened structures can be
detected by observing one or more of the
following changes it may cause:
1. Pattern of movement,
8
2. Volume and swelling and/or distention of a
muscle,
3. Elasticity of a muscle ,
4. Range of movement at a joint ,
5. Joint play (section 1.6.3, p. 9) ,
6. Quality of the passive stop, end feel (section
1.6.3, p. 9) ; most important.
In addition to these indicators, a patient may
experience fatigue, pain radiating to other muscles
and structures, and a feeling of stiffness in the
shortened muscle(s) . Shortened muscles may also
irritate and damage peripheral nerves and blood
vessels; examples include sports injuries, and the
scalenus, the supinator, the pronator and pirifor-
mis syndromes. Poor physical condition, inadequ-
ate coordination, or unaccustomed movement
often cause altered circulation and faulty muscle
movement patterns. According to Vladimir
Janda(I), this leads to constant micro-traumata,
which, in turn, subsequently effects alterations in
patterns of movement with chronic muscle spasm,
contractures and pain. In an advanced case, joint
function is altered and degenerative changes at the
joints result. Stretching of the relevant muscle( s)
is one way of preventing this chain of events.
1.6. MANUAL THERAPY METHODS
1.6.1. The Basics of Stretching
All therapy techniques including stretching should
be based on thorough examination. Stretching
techniques differ primarily by the type and degree
of patient involvement in procedures administered
by the therapist. Common to all procedures is a
basic, safest sequence of events based on the
principle that a muscle is most relaxed and
therefore may be maximally stretched immediate-
ly after an isometric contraction. According to
Sherrington(2), the stronger the contraction (with-
out pain) , the greater the subsequent relaxation.
So all procedures start with a static contraction
of the shortened muscle( s). Then the muscles are
relaxed, which makes them more easily stretched
for a period of a fraction of a second up to 10 or 12
seconds in pathological cases. During this period,
the muscles can be safely stretched. Often patients
cannot contract from an extreme position, so
treatment procedure cannot begin there. In these
cases, it is best to move back to a position in the
range of movement where the patient can easily
contract , and begin the procedure there.
Muscles are most amenable to stretching when
they are warmed up in the physiological sense, by
preliminary exercise rather than by the application
of passive, external heat. Thus all treatment
should start with some form of warmup. The best
and most specific warmup exercise is contraction
against resistance. The stronger the contraction,
the greater the warmup effect.
Unwanted external stimuli, such as noise or
discomfort , can impair treatment, particularly
treatments requiring combined efforts of patient
and therapist . So the patient should always be
made as comfortabl e as possible. The treat ment
surroundings should be quiet , and other distract-
ing influences should be eliminated whenever
possible.
1.6.2. Therapy Procedures
In all therapy procedures. the therapist works to
counteract some restriction of movement about a
joint. Three different therapeutic approaches are
possible. depending on whether the patient is
completely passive, participates by offering resist-
ance, or participates both by offering resist ance
and by working with the therapist.
1. Patient passive: This technique is used in
treat ing more serious contractu res to produce
lasting lengthening of shortened tissue. The
patient relaxes while the therapist moves the joint
further in the direction of restriction, and then
holds -the" extreme position as long as necessary,
even up to two minutes or more , to lengthen the
shortened structures.
2. Patient resisls: In this gentle technique . the
therapist appli es moderate force to move a joint as
far as possible in the direction of restriction. The
shortened structures then press the joint surfaces
together. Then the therapist applies traction at the
joint, and thus tri es to separate the joint surfaces
as the patient resists. Thereafter, the patient
relaxes and the therapist maintains traction as long
as necessary, until the joint surfaces are felt to
separate. The procedure is repeated until move-
ment is appreciably improved.
3. Palien( resisls and aids: This is the recom-
mended lechnique of this Manual. It starts as does
the " Pati ent resists" technique above , but differs
thereafter. First, the therapist moves a joint as far
as possible in the direction of restriction. Then the
therapist holds the position and asks the patient to
isometrically resist it. Patient and therapist should
resist each other equally, with the patient con-
tracting one or all of the muscles which are to be
stretched; this ensures negligible joint movement.
The patient then relaxes while the therapist moves
the joint further in the direction of restriction. The
process is repeated until improvement is attained.
In some cases when the therapist moves a joint ,
the patient either feels pain or fears pain to an
extent that blocks relaxation. The therapist can
then apply traction and aid or even offer slight
resistance as the patient actively moves the joint in
the direction of restriction. Thus the patient
controls movement and therefore can relax. In all
cases, the therapist holds the extreme position as
long as necessary, even up to two minutes or
more, to lengthen the shortened structures.
1.6.3. Character of Joint Movement
In treating joints, the therapist should continually
assess the quality and quantit y of joint movement
and the manner in which movement stops . These
evaluations then guide the course of further
therapy. For instance , some joint movement
abnormalities may contraindicate stretching ther-
apy.
1. Joint Play
Joint play is the gliding and/or separati on of joint
surfaces without angular movement about a joint.
All joints have a characteristic joint play, with
whi ch the therapist should be familiar. Normally
joint play is greatest in the maximally loose-
packed position and diminishes to minima at the
extremes of the joint range of movement. The
therapist must always examine a joint for joint
play before usi ng any of the treatment procedures
described above. If joint play is less than normal.
it must be restored to normal before ot her therapy
is begun or continued.
2. End Feel
The therapist must be able to sense the extremes
of the various possible ranges of movements about
body joints, that is, the points at which passive
movement stops (3.4). End feel is the sensation
imparted to the therapist at these points. There
arc several different types of end feel; the
therapist must be able to differentiate between
them:
Normal end feel may be soft, firm or hard:
Sofl: Soft tissue approximation and/or stretch-
ing, such as knee or elbow flexion with normally-
developed muscles.
Firm: Capsule and/or ligament stretching, such
as medial rotation of the humerus or femur.
Hard: Bone-to-bone stop, such as elbow exten-
sion.
Abnormal end feel: Abnormalities may produce
varying end feels; six are differentiated:
Less-elastic: Such as due to scar tissue or
shortened connective tissue.
More-elastic: Such as due to increased muscle
tonus, shortened muscles.
Springy block : Internal derangement where the
rebound is seen and felt , such as due to torn
meniscus.
"Empty": The patient feels severe pain, su.ch as
due to acute bursitis, extraarticular abscess or
neoplasm, and will not permit the movement to go
further; no physical stop felt by the therapist.
Premature: Occurs before normal stop, such as
in rheumatoid arthritis or osteoarthrosis, or
contracted ligaments or capsules.
9
Extended: Occurs after normal stop, such as in
cases of instabili ty or hypermobility.
1. 7. RECOMMENDED THERAPY PROCEDURE
The therapy techniques of Section 3 involve the
patient resisting and aiding, the third of the three
approaches to procedure described in 1.6.2, p. 9.
[n these techniques:
• The therapist moves a patient's joint(s), in the
direction of restriction, to positions progressively
approaching, but never exceeding the normal
range of joint motion, as determined by end feel.
• The patient actively participates in the treat·
ment procedure, alternately resisting or aiding
motion as directed by the therapist.
• Successive sequences of isometric contraction.
relaxation and stretching are used to attain the
desired improvement in joint movement range ,
followed by stimul ation of the antagonists. De-
scriptions of these treatment phases follow.
1. 7.1. Isometric Contraction
First . the therapist moves the joint(s) to a posi tion
in the line of movement to less than that which
might cause pain. It may be possible to start in a
position with the shortened structures relatively
stretched. However . it is often necessary to start
in a position where the patient can easily resist the
movement.
Then. in this position. the pat ient is inst ructed
to resist movement by isometricall y contracting
the shortened muscle(s). In this phase, the
therapist and the patient apply forces that coun-
terbalance so there is no movement in the joint
itself. The therapist's grip and resistance applied
must be comfortable. painless. and secure for the
patient.
If isometric contraction causes the patient no
pain. the therapist can readil y and rapidl y tire the
muscle(s) involved by applying sufficient resist -
ance (relative to the contracting muscular force)
for a few seconds or longer. If the isometric
contraction is painful for the patient. then the
therapist should decrease resistance and increase
the period of force counterbalance. up to 10 to 30
seconds.
1.7.2. Relaxation
When the therapist feels that the patient has
sufficiently contracted the shortened muscle(s) .
the patient is instructed to rel ax. As the patient
relaxes, the therapist releases resistance accor-
dingly, so as not to cause pain or unwanted
movement(s).
1. 7 .3. Stretching to Counteract and Reduce Res-
triction
After the preceding isometric contraction and
relaxation, movement may be improved in four
ways:
10
1. The therapist moves the joint in the direction
of restriction.
2. If this movement is painful or if the patient
fears pain, then the therapist may be more
passive and let the patient actively move at
the joint.
3. Pain experienced often may be lessened
considerably if the therapist applies gentle
traction while the patient actively moves at
the joint.
4. Sometimes pain may be further reduced if,
in addition to applying gentle traction, the
therapist also simultaneously either:
a) aids the patient's movement at the joint,or
b) provides gentle resistance while the patient
moves at the joint.
Once an initial new position is attained, the
sequence of contraction, relaxation' and .stretching
is successively repeated to progressively'attain the
desired improvement in movement range. There-
after. the antagonist(s) should be stimulated.
1.7.4. Stimulation of Antagonists
The antagonists to the muscle(s) treated always
should be stimulated immediately after the sequ-
ence of treatment to increase movement in the
direction of restricti on.
To stimulate the ant agonists. th,e therapist
reverses the direction of force or , resistance
appli ed, and counteracts movement. 'To reverse
the direction of force applied, the therapist may
ei ther retain grip or change grip, depending on the
treat ment technique involved. Once the therapist
is prepared to apply a reverse force, the pati ent is
asked to move in the direction just stretched in the
treat ment , and the therapist opposes that move-
ment to evaluate the ability and the force with
which the antagonists contract.
Inhibition of ant agonists can be reduced
through vigorous stimul ation, such as rapid vibrat-
ing movements. pinching and shaking/stretching
muscles, slapping the skin, or traction or com-
pression (approximation) of the joint(s).
Restricted joint mobility or pain may inhibit
and thus lead to weakening of the antagonists.
Therefore it may be necessary to strengthen these
muscles throughout their full range of movement.
The muscles should be able to control movement
through the full range and should also be able to
lock the joint in any position in that range.
Stimul ation of the ant agonists is always a vital part
of successful treatment.
Neurological dysfunction may block or mask a
patient' s perception of stimuli. In these cases,
stimul at ion must be confined to locali zed areas.
For instance, in sti mulating the finger flexor
muscles (antagonists to the finger extensors). the
therapist should apply pressure only to the volar
sides of the fingers.
1. 7 .5. Stretching of Other Structures
Whenever successive contraction and rel axat ion
treatments fail to increase movement at a joint ,
the joint should be reexamined to ascertain if the
restriction is caused by structures other than
muscle(s), such as by ligaments or joint capsules.
If joint play is noticably diminished or absent, it
may be restored using joint mobilization techni-
ques, such as those described by Kaltenborn(3)
and Stoddard(5). However, if joint glide is normal
but movement is restricted, the following proce-
dure may be used. The therapist stretches the
shortened structures by applying an optimal
intensity force. Intensity is the combination of
force magnitude and duration of application, with
duration being the more important in stretching.
Optimal means as small as possible, yet adequate
for results: a small force for a few seconds to two
minutes or more.
The patient should feel the stretching, possibl y
even as pain, though not to the point of serious
discomfort. Elsewhere the treatment should cause
no pain. If the procedure produces no improve-
ment , the force applied may have been of
insufficient intensity. If so, stretching should be
repeated at greater intensity, preferably for longer
periods of time, and then if necessary, with greater
force.
Physiotherapists or doctors may administer
these therapeutic stretching techniques . However,
therapy is more effective if it is supplemented by
more frequent self stretching, preferabl y daily or
several times a day. Therefore, patients should be
taught self stretching (6,7). In general , the more
frequent the stretching, the more moderate the
intensity. Less frequent stretching, such as t hat
done every ot her day, may be at greater intensity.
1.8 TECHNIQUES-PARTS 2 AND 3
1.8.1 Caveat
In all treatments, the therapist should strive to
avoid compression at joints if possible , and, if not ,
to minimize it as much as treatment permits.
Compression may hinder desired movements at
articulations, can stress nerve tissue , or otherwise
damage joints or their immediate structures.
Therefore , traction should be used in all proce-
dures as a means of counteracting any compress-
ion which may' arise as a result of the movement
the therapist induces.
1.8.2 Key to Therapy Techniques
Detailed descriptions of the techniques used to
stretch restricting st ructures are arranged in eight
sections in Parts 2 and 3: shoulder, elbow, wrist,
fingers , hip, knee, ankle, toes.
Each of these sections starts with a Therapy
Guide containing two tabl es. The first table li sts
the possible restrictions at the joint . the muscles
which may cause each of the restrictions, and the
therapi es for those muscles, indexed by number
and page.
Alternative therapies for any particular rest ric-
ti on are indicated by suffix letters. For instance,
there are two techniques for the pectoralis maj or ,
abdominal part listed in section 2.2.1:
2.2.1.A
Section 2 on the shoulder
Subsection 2.2 on restricted
fl exion
Therapies 2.2.1 for Technique A,
the pectoralis major , bilateral
stretching abdominal part
For uniformity, all technique descripti ons are
si mil ar. In all cases where either the right or left
joint may be treated, the ri ght is shown and
discussed. The therapist then reads ri ght for left
and vice versa in the equivalent therapy on the
patient's left.
Each therapy is illustrated wi th a muscle
drawing and starting and final position photos.
X in illustrations indicates points of stabili zation
by hands, belts etc. Arrows in illustrations
indicate directions of stretching movements and
also patient movement in the ant agonist muscle
stimul ation phase. P in texts denotes the patient ,
T the therapist.
All instructions are for you, the Therapist, and
are divided into four parts: Starting Position,
Grip, Procedure and Stimul ati on of Antagonists.
When needed, Notes clarify or suppl ement these
four parts.
The Starting Position instructions consist of
short statements on how to arrange the patient
and yourself to start treatment. They may easily
be remembered if you view them as brief
descriptions of a scene, or as notes you might take
upon first seeing the technique performed by
another therapists.
The other three instructions, Grip, Procedure
and Stimulation of Antagonists are direct instruc-
tions on how to perform the treatment.
Instructions for the patient also require moni-
toring by the therapist. For instance, some
Procedure instructions require the patient to keep
his/her chin tucked in during treatment. You
should then ask the patient to tuck his/her chin in
11
while preparing for treatment, and you also must
continually watch the patient during treatment to
be sure that the tuck is maintained.
Note that most stretching should be performed
gradually and fully , so the origin and insertion of
the muscles are moved as far apart as possible,
approaching but not going beyond the normal
range of movement.
As in anatomy texts , the descripti ons of muscle
action of this Manual assume starting in the
anatomical position. However , muscle action may
change at an extreme joint position, sometimes to
the opposite of that described. For inst ance, when
starting from the anatomical position, the adduc-
tors of the hip flex at the hip joint , yet they act as
extensors at full hip flexion. This is why full range
of movement sometimes can be att ained only by
stretching from different starting positions. Com-
plete tables of muscles involved in restricting
various movements are given in Part 4.
1.8.4 Terminology
Standard anatomic terminology is used through-
out this Manual. However, whe never two or more
synonymous anat omical terms are in accepted
current use, the terms most pertinent to the
physiotherapy situation are used.
Because manual therapy is concerned with
joints and muscles and related struct ures , all
descriptions of therapy procedures and of muscle
actions are in terms of joint movements. For
instance, the action of the biceps brachii muscle of
the upper arm is described as "flexes at the
elbow," whil e a medical anatomy text author
might prefer "fl exes arm and forearm."
In summary, the terminology of this Manual
may be viewed as chosen to suit an active
si tuation , in which the therapi st promotes, directs,
or elicits motion, as opposed to some surgical or
medical choices of terms , which may be viewed as
more passive , intended primarily for identification
or description.
12
1.8.5 Using the Ready Reference Features
The ready reference features of this Manual can
best be explained by example. Assume an adult
female patient, who complains that she is unable
to manipulate the strap clasp of her brassiere ,
because she cannot reach her mid back with her
ri ght hand. The restricted movements involve
various degrees of exte nsion, adducti on and
medial rotation at the shoulder. First , Section 2 on
the shoulder is found eit her by page number from
the Contents or by flipping through the pages to '
find The Shoulder at the top of the pages
involved. Table 2-1 lists the restricted movement
under subsection 2.8, with eight muscles which
may cause restriction and the corresponding
therapies, listed by number and page number. All
primary and secondary restricting muscles are
li s teed in Table 10-1 of the Muscl e Restriction
Tables on page 165.
1.9,REFERENCES
1. Janda, Vladimir, "Die Bedeutung der musku-
laren Fehlhaltung als pathogenetischer Faktor
vertebrangener Storungen, " Arch. physikal. Ther-
apie, 20 (1968),113-116.
2. Sherrington, C.S., " On plastic tonus and
proprioceptive refl exes," Quart. J. Exp. Physiol.,
2 (1909), 109-156.
3. Kaltenborn , Freddy M. , Manual Therapy for
the Extremity Joints, Oslo, Olaf Norlis Bokhan-
del, 1980.
4. Cyriax, James, Textbook of Orthopedic
Medicine, London, Hutchinson, 1969.
5. Stoddard, Al an, Manual' of Osteopathic
Technique, London, Hutchinson, 1980.
6. Gunnari, Hans, and Evjenth, Olaf, Sequence
Exercise, Oslo, Dreyers Forlag, Norwegian edi-
tion 1983, English edition 1984 (Chapter 7 on
self-stretching)
7. Evjenth, Olaf and Hamberg, Jern, Autostretch-
ing. The Complete Manual of Specific Stretching,
Alfta Rehab Forlag, Alfta, Sweden, 1989.
PART 2
THERAPY TECHNIQUES FOR THE UPPER EXTREMITY
2 THE SHOULDER
3 THEELBOW
4 THE WRIST
5 THE FINGERS
13
2 THE SHOULDER
2.1 THERAPY GUIDE
2.1.1 Indications of Reduced Mobility
Restricted arm movements relative to the body and/or the scapulae may be evident in a variety of ways:
1) The arm may be fully mobile relative to the body, with hypomobility (reduced mobility) between
the scapula and the humerus, such as when the scapula is hypermobile.
2) The arm may be fully mobile relative to the body, with hypermobility (excessive mobility) between
the scapula and the humerus, and reduced mobility between the scapula and the thorax, such as
when the scapula is hypomobile.
3) Arm mobility relative to the body may be reduced, as when mobility is reduced at one or more
joints of the shoulder girdle or at the shoulder joint itself.
4) Arm mobility relative to the body may be reduced, even though mobility is normal between the
scapula and the humerus; this occurs when the latissimus dorsi, pectoralis major, or other muscles
and/or structures are shortened.
2.1.2 Patient POSitioning
In therapy techniques for the shoulder with the patient supine on the couch, he/she should be arranged
so the couch itself does not constrain free arm movement. This may be done in two ways. First, the
patient can be positioned to place the shoulder treated over the edge of the couch. Second, a small, firm
cushion or other support may be placed between the patient's scapulae.
Throughout treatment, the patient should keep his/her chin tucked in to stabilize the neck and thus
protect the cervical spine. So the therapist must instruct the patient to tuck his/her chin in before
starting treatment, and must watch to assure that the tuck is maintained throughout the treatment.
Some therapy techniques with the patient supine require that the hips and the knees be flexed. If
necessary, the foot sector of the couch may be raised to help the patient maintain these flexes.
2.1.3 Restrictions, Muscles and Therapies
The muscles which may restrict movement at the shoulder are listed in Table 2-1, along with the applicable
therapies, indexed by manual section number and page. For the compound movements, some muscles
listed may restrict only one or two components of the movement, but are 'listed as they act in the
movement. Muscle actions are listed in Table 2-2.
In all cases, restriction at the should!;" may be regarded as affecting arm motion relative to the body,
or conversely, body motion in the opposite direction relative to a stable arm. The various restrictions
possible are listed in Movement Restriction Tables 10.1 and 10.2 (pp. 165-166).
14
TABLE 2.1 Restrictions at the shoulder
SECTION MOVEMENT RESTRICTING THERAPY Number Page
RESTRICTED MUSCLE(S)
2.2 Flexion Pectoralis major, abdomnial part 2.2.1A,2.2.1B 18,19
sternocostal part 2.2.2A,2.2.2B 20.21
clavicular part 2.2.3A,2.2.3B 22,23
Latissimus dorsi 2.2.4A,2.2.4B 24,25
Teres major 2.2.5 26
Pectoralis minor 2.2.6 27
Subclavius 2.2.7 28
Deltoid , spinal part 2.3.1 29
Triceps brachii, long head 2.3.6A,2.3.6B 35,36
Levator scapulae 2. 12.2A-C 45-47
Trapezius 2.3.4 32
Teres minor 2.3.2 30
Spinalis group Volume II
2.3 Flexion, abduction Deltoid. spinal part 2.3.1 29
and medial rotation
Teres minor 2.3.2 30
Infraspinatus 2.3.3 31
Trapezius , transverse part 2.3.4 32
Rombodei major and minor 2.3.5A, 2.3.5B 33, 34
Triceps brachii , long head 2.3.6A,2.3.6B 35, 36
2.4 Flexion abduction Pectoralis major 2.2.1-2.2.3 18-23
and lateral rotation
Pectoralis minor 2.2.6 27
Latissimus dorsi 2.2.4 24,25
Teres major 2.2.5 26
Infraspinatus 2.3.3 31
Subscapularis 2.11..3 43
2.5 Flexion, adduction Teres minor 2.3.2 30
and medial rotation Infraspinatus 2.3.3 31
2.6 Flexion, adduction Pectoralis major 2.2.1-2.2.3 18-23
and lateral rotation
Pectoralis minor 2.2.6 27
Latissimus dorsi 2.2.4 24, 25
Teres major 2.2.5 26
Subscapularis 2.11.3 43
Coracobrachialis 2.11.1 41
Biceps brachii, short head 2.11.2 42
Deltoid, clavicular part 2.11.1 41
2.7 Extension Trapezius 2.3.4,2.8.1, 32,37
2.12.1 44
Serratus anterior 2.8.2 38
Deltoid, clavicular part 2.11.1 41
Coracobrachialis 2.11.1 41
Pectoralis major 2.2.1-2.2.3 18-23
Biceps brachii, short head 2.11.2 42
15
2.8 Extension, adduction Pectoralis major 2.2.1-2.2.3 18-23
and medial rotation
Deltoid. clavicular part 2.11. 1 41
Coracobrachialis 2.11.1 41
Biceps brachii. short head 2.11.2 42
Teres minor 2.3.2 30
Infraspinatus 2.3.3 31
Trapezius, ascending part 2.8.1 37
Serratus anterior 2.8.2 38
2.9 Extension. adduction Pectoralis major 2.2.1-2.2.3 18-23
and lateral rotation
Deltoid, clavicular part 2.11.1 41
Deltoid, acromial part 2.9.2 40
Biceps brachii 2.9.1 39
Supraspinatus 2.9.2 40
2.10 Extension, abduction Deltoid, clavicular part 2.11.1 41
and medial rOlotion
Pectoralis major 2.2.1-2.2.3 18-23
Coracobrachialis 2.11.1 41
Biceps brachii. short head 2.11.2 42
Biceps brachii. long head 2.9.1 39
Serratus anterior 2.8.2 38
Teres minor 2.3.2 30
Infraspinatus 2.3.3 31
2.11 Extension, abduction Pectoralis major 2.2.1-2.2.3 18-23
and lateral rotation
Deltoid, clavicular part 2.11. 1 41
Coracobrachialis 2.11.1 41
Subscapularis 2.11.3 42
2.12 Depression of the Trapezius, descending part 2.12.1 44
shoulder girdle
Levator scapulae 2.12.2 42
2.13 Elevation of the Pectoralis major 2.2.1-2.2.3 18-23
shoulder girdle
Pectoralis minor 2.2.6 27
Latissimus dorsi 2.2.4 24, 25
Serratus anterior 2.8.2 38
Subclavius 2.2.7 28
. Trapezius 2.3.4,2.8.1, 32.37
2.12.1 44
16
TABLE 2.2 Actions of muscles which may restrict movements at the shoulder.
MUSCLE ACTION
Muscles of the shoulder
and the shoulder girdle
Pectoralis major
Pectoralis minor
Latissimus dorsi
Teres major
Subclavius
Deltoid, spinal part
acromial part
clavicular part
Teres minor
Infraspinatus
Trapezius, t ransverse
part
ascending part
descending part
Rhomboidei
Serratus anterior
Supraspinatus
Levator scapulae
Subscapularis
Muscles of the upper arm
Adducts and medially rotates at shoulder. Has a short extending action when shoulder is flexed.
Has a short flexing action when shoulder is extended. Adducts arm in a transverse plane in relation
to the body.
Depresses raised shoulder. Pull '. shoulder ventrally and caudally. Assists in elevating upper ribs
when raised shoulder is stable.
Extends , adducts and medially rotates at shoulder. Depresses shoulder girdle.
Extends, adducts and medially rotates arm relati ve to scapula .
Depresses and stabilizes clavicle during movements of shoulder. Lifts first rib when raised shoulder
is stable.
Extends, adducts and laterally rotates at shoulder.
Abducts at shoulder.
Flexes, medially rotates and adducts at shoulder.
Laterally rotates and extends at shoulder.
Laterally rotates. at shoulder.
Pulls scapula medially.
Pulls shoulder girdle caudally. Laterally rotates inferior angle of scapula.
Raises shoulder girdle (when head and neck are stable). Laterally flexes head and neck while
simultaneously rotating head to opposite side (when shoulder is stable). Extends neck when
acting bilaterally.
Pulls scapulae cranially and medially while medially rotating inferior angle of scapula .
Moves scapula laterally and ventrally on rib cage. Rotates scapula so that glenoid cavity points
laterally, ventrally, and slightly cranially in abducting and flexing at shoulder.
Abducts at shoulder - also laterall y or medially rotates (depending on the position of the
shoulder).
Raises shoulder gi rdle (when head and neck are stable). Laterally flexes and rotates neck to same
side (when scapula is stable) . Extends neck when acting bilaterally.
Medi ally rotates at shoulder.
Biceps brachii long head Abducts and medi ally rotates at shoulder. Flexes at elbow. Supinates forearm.
Biceps brachii short Adducts and fl exes at shoulder. Flexes at elbow. Supinates forearm.
head
Coracobrachialis Flexes, medially rotates and adducts at shoulder.
Triceps brachii long Extends at elbow. Adducts and extends at shoulder.
bead
17
2.2.IA. The rapy for the pectoralis major,
abdominal part. Bilateral stretcilillg.
Starting Position: P: Supi nc o n couch: knees anel
hips Ilcxed to stabili ze lumbar a nd tho racic regio ns
a nd to preve nt lumbar spinc lordosis: head of
couch lowered: small. finn cushion Illay be placed
between scapul ae to permit maximum shoulder
movement: thorax stabi lized to cOll ch with a belt:
chi n tucked into protect ce rvica l spi ne. T : Standing
at hcad of couch.
Grip: Usi ng bot h hands. T gr ips Illedial sides of p' s
a rms just above the e lbows and holds the m Il exed
a nd full y lat e rall y rotat ed at the sho ulders. ( \I" P is
ve ry strong. T grips just above P's wrists).
Procedure: Using thi s gr ip. T graduall y and fullv
flexes at p' s s ho ulde rs.
Stimulation of Antagonists: T reverses grip (to
under p' s arms). asks P to Il cx arms. and then
resists the fl exi ng to stimulat e p's  
Notes: Stretch ing sho uld always begi n fro m the
positi on where movement is 1110st restri cted .
p's sho ulde r j o int s a re bell e r protected and
stre tching is most effective if T appl ies tracti on to
P's arms as P flex es the m.
The latissimus dorsi , teres major and pectoralis
minor a re a lso stre tched in thi s procedure.
18
Fi g. 1 a. Starting Posit ion.
Fi g. I b. Final Positi o n.
2. 2. 1 B. The rapy fo r the pectoralis maj or,
abdominal pa rt. Ullilat eral stretchill g.
Starting Position P: Supine: knees and hi ps fl exed
to stabili ze lumbar and thoracic regions and to
prevent lu mba r spine lordos is : small firm cushion
may be placed between scapulae to pe rmit
maximum shoul der movement: support under
head and neck; chi n tucked in to protect ce rvica l
spine; arm fl exed above head . T : St andi ng oblique
to P"s right side . facing P"s head.
Grip: T s left hand grips medial side of p' s uppe r
a rm j ust above the elbow and holds it fl exed a nd
full y lat e rall y rotat ed at t he sho ul dc r. p·s fo rear m
lies along T 's forearm wit h p's right hand on the
media l side o f T s upper arm. T s ri ght ha nd
sta bi li zes p's thorax.
Procedure: Us ing thi s grip . T grad uall y and full y
flexes a t p' s sho ul de r.
Stimulation of Antagonists: T re ve rses grip o n P"s
arm. asks P 10 move fu rt her in the directi on of
  and thell resists that movement to
sti mul ate p's ant agoni sts.
otes: Stabili za ti on of the thorax is easie r if both
sides a rc stre tched simult aneously (sec page 18).
The lati ssimus dorsi, teres major a nd pectora lis
minor arc also s\ret ched in this procedure.
Fig. 2 a. St arting Position.
Fig. 2 b. Final Positi o n.
19
2.2.2A. Therapy for the pectoralis major,
sternocostal part.13ilrllera!srrerchillg.
Starting Position: P: Supine: knees and hips Hexed
to stabili ze lumbar and thoracic regions and to
preve nt lumbar spine lordosis: small. firm cus hi on
may be pl aced betwee n scapulae to pcrmit
max imum shoulde r move ment : thorax stabili zed to
couch with a be lt : support under head and neck :
chin tucked in to protect cervical spine: arms flexed
above head. T: Standing at head or cOll ch.
Grip: Usi ng both hands. T gr ips p' s elbows and
forear ms. T holds P's arms fl exed and full y late rall y
rotat ed in the positi on of greatest restri cti on.
betwee n 9(Y abduction and full flexion. ( If P is very
strong. T can grip p' s lower ar ms j ust above the
wri sts) .
Procedure: Using thi s grip. T graduall y and fully
flexes at P's shoulde rs.
Stimulation of Antagonists: T reverses gr ip (to
under p's arms). T then asks P to move arms
further in the direction of stretching. and res ists
that movement to stimul ate p's antagoni sts.
20
Fig. 3 b. Final Posi ti on.
2.2.2B. The rapy for the pectoralis major,
s ternocostal part. Ullil ateral
stretchill g.
Starting Position: P: Supine; knees and hips flexed
to stabili ze lumbar and thoracic regions and to
prevent lumbar spine lordosis; small , firm cushi on
may be placed between scapul ae to permit
maxi mum shoulde r movement ; support under
head and neck ; chin tucked in to protect cervical
spine; thorax stabi li zed to couch with a belt ; arm
flexed above head. T: Standing with left side
towards ri ght side of P's head .
Grip: T' s le ft hand grips medial side of P's upper
ann j ust above the elbow. T holds p's arm f1exed
and full y laterall y rotat ed in t he position of greatest
rest ricti on. between full fl exion and 90° abduction
at the sho ulde r . p's forearm li es along T' s forea rm
with p' s hand against the medial side of T' s uppe r
arm. T"s ri ght hand presses agai nst p's sternum to
stabili ze the thorax.
Procedure: Usi ng thi s grip . T graduall y and fully
flexes at p' s shoulder.
Stimulation of Antagonists: T reverses le ft -hand
grip (to under p's a nn). T then as ks P to move
furth er in the directi on of stretching, and res ists
that Ill ovement to stimul ate p' s antagonists.
Note: Stabilization of the thorax is easier if bot h
sides arc stretched si multaneously. sec therapy
2.2.2A., p. 20.
Fig. -+ Cl. Starting Position.
Fig. 4 b. Final Pos iti on.
2 1
2.2.3A. The rapy for the pectoralis major.
clavicular part. Biiarerai slreu.·hillg.
Starting Position: P: Supine : knees and hips Il excd
to stabili ze lumbar and thoracic regions and to
prevent lumbar spine lordosis: small. firm cushi on
may be placed between scapulae to pe rmit
maximum shoulde r movement ; thorax stabil ized to
couch with a belt: support under head and neck:
chin tucked in to protect cervical spine: a rms fl exed
above head . T: Standing at head or cOllch.
Grip: Us ing both hands. T gri ps medial sides of p's
upper arms at the elbows. T holds P's arms flexed ,
fully laterally rotated and in approximately 90°
abduction at the shoulders with p's elbows flexed
90°. (If P is very strong, T can grip P's forearms or
hands. 1fT's hands are large enough. he/she may be
able to grip P' s elbows and forearms to maintain
maximal lateral rotation).
Procedure: Using thi s grip . T graduall y and full y
abdllcls at p' s shoulders.
Stimulation of Antagonists: T reve rses grip (to
unde r p' s arms). T then asks P to move furthe r in
the direction of stretching. and res ists that
movement to stimulat e p' s antagoni sts.
Note: The pectoralis major may also be bilat e rall y
st retched with P sitting. p' s back should be
support ed (with a chair . a cushion. T' s knee. etc.)
with hips full y fl exed to stabili ze the pelvis and
prot ect the lumbar spine. T stretches by using the
above technique.
22
Fi g. 5 a. Sta rting Positi on.
Fi g. 5 h. Final Position .
::. 1.3B. Therapy for the pectoralis major,
clavicular part. Unilmeral slrelching.
tarting Position: P: Supine: knees and hi ps Hexed
'0 stabili ze lumbar and tho racic regions and to
... reve nt lumba r spine lordosis; small , firm cushi on
may be pl aced between scapul ae to permit
maximum shoulder movement ; thorax stabili zed to
-ouc h with a belt ; support unde r head and neck;
-h in tucked in to prot ect cervi cal spine; ann l-]exed
.. bove head. T: St anding faci ng p's ri ght shoulder.
Grip: T' s ri ght hand grips medial side of p' s upper
arm just above the e lbow. T holds P's arm fl exed.
fu lly late rall y rot ated and in less than 90° abducti on
III the pos it ion where maximall y stretched. p's
fo rea rm li es a long T' s fo rearm with P's hand
against the medi al side of T's upper arm. T' s left
hand is placed over P' s manubrium ste rnum and
left cl avicl e to stabili ze the thorax.
Procedure: Using thi s grip . T graduall y and full y
abducls at p's shoulder.
Stimulation of Antagonists: T reverses ri ght -hand
grip (t o under P's arm) . T the n asks P to move
further in the directi on of stretching. and resists
that movement to stimulat e P' s ant agoni sts.
Note: Stabili zati on of the thorax is easie r if both
si des a re stretched simultaneously. see therapy
2.2.3A. p. 22.
Fig. 6 a. Starting Position.
Fig. 6 b. Final Positi on.
23
2.2.4A. Therapy for the latissimus dorsi.
Bilaleral stretching.
Starting Position: P: Supine; knees and hips Il cxcd
to stabili zc lumbar and thoracic regions and to
preve nt lumbar spine lordos is; head of couch
lowered and small. fi rm cushi on may be pl aced
between scapulac to permit max imum shoulder
moveme nt : abdomen stabili zed to couch with a
be lt ; chin tucked in to protect ce rvical spinc: arms
fl exed above hcad. T: Standing at head of couch.
Grip: Using both hands. T grips p's uppcr arms
from the mcdi al aspcct at the e lbows. T holds p's
arms fl exed and in full latcral rotati on at thc
shoulde rs. ( If P is very strong. T can grip p's
forearms or ha nds for bellc r leveragc).
Procedure: Using thi s grip. T graduall y and full y
flexes at P's shoulde rs.
Stimulation of Antagonists: T revc rses grip (t o
unde r P's arms) . T then asks P to move furth er in
the directi on of stretching. and resists that
movement to stimul ate P's ant agoni sts.
Notes: P's shoulder joints arc bett er protected and
stretching is most effecti ve if T applies tracti on to
P's arms as they arc fl exed.
The lumbar spine can be beller stabili zed by full y
fl exing P's hips and knees and moving the be lt to
the dorsal aspect of P' s thi ghs.
The pectoralis major and minor and the teres major
are also stretched in thi s procedure.
24
Fi g. 7 b. Final Pos iti on.
2.2.4B. Therapy for the latissimus dorsi.
Ull ilateral si reichillg.
Starting Position: 1' : Supine: knees and hips fl exed
to stabili ze lumbar and thoracic regions and to
prevent lumbar spine lordosi s; small. firm cushi on
ma y be placed between scapul ae to permit
maximum shoulder movement : hips and thorax
stabilized with a belt; suppo rt under head and
neck; chin tucked in to prot ect ce rvical spine : ann
flexed above head . T: Standing at head of couch.
facing oblique to p's ri ght side.
Grip: . T"s left hand grips medial side of p's upper
arm just above the elbow. T holds p's arm Ilcxed
and full y late rall y rotated at the shoulde r. p's
forearm lies along T"s forearm with p' s hand
against the medial side of T"s upper arm. T" s ri ght
hand stabili zes the lower ri ght side of p's thorax . ( If
Pis ve ry strong. T"s left hand can grip p's ri ght hand
while T's right hand grips just above p's elbow).
Procedure: Using thi s grip. T graduall y and full y
flexes and la(erally rOiates at p' s shoulde r and
si multaneously applies traction 10 P"s arm whil e
moving it dorsally.
Stimulation of Antagonists: T reverses left-hand
grip (to under p's arm). T then as ks I' to move
further in the direction of stretching. and resists
that movement 10 stimul ate p's ant agoni sts.
Note: Stabilization of the thorax is easier if both
sides arc stretched simultaneously. see therapy
2.2.4A, p. 24.
Fi g. X il. Starting Positi on.
Fi g. 8 b. Final Position .
25
2.2.5. Therapy for the teres major.
Starting Position: P: Supine; knees and hips f1exed
to stabili ze lumbar and thoracic regions and to
prevent lumbar spine lordos is; small . firm cushi on
may be placed between scapul ae to permit
max imum shoulder movement ; support unde r
head and neck; chin tucked in to protect cervical
spine; arm fl exed above head. T: Standing at head
of couch, facing oblique to P's ri ght side.
Grip: T's left hand grips the medial side of P's upper
arm just above the elbow. T holds P's arm flexed
and laterally rotated at the shoulder. P's forearm
lies along T's forearm with P's right hand against
the medial side of T's upper arm. T stabilizes P's
scapula, using right hand to stabilize the lateral
border.
Procedure: Us ing thi s gr ip. T grad uall y and full y
flexes and larerally rotates at p' s shoulder.
Stimulation of Antagonists: T reverses left-hand
gr ip to under P's arm. T then asks P to move further
in the di rection of stretching, and res ists that
movement to sti mul ate p' s ant agoni sts.
Note: NOI applying traction to P's arm whe n fl ex ing
partl y prevents involvi ng the latissimus dorsi and
the pectoralis major.
26
Fig. 9 a. Starl ing Position.
Fig. 9 b. Final Posit ion.
1.2.6 Thc rapy for the pectoralis minor.
tart ing Position: P: Supinc: scapula ovcr side of
couc h: arm in lat eral rotat ion. adducti on and less
tha n 90
0
fl ex ion at the shoulder: elbow flexed. T:
tanding at p's right side. faci ng p's head.
Grip: Ts left hand grips p' s ri ght shoulde r. Ts right
hand grips proximal to p's wri st with p's forearm
-upport ed agai nst T s chest.
Procedure: Usi ng thi s gri p. T graduall y and
maximall y moves p's shoulder girdle by pressing
crallially and dorsally agai nst p's forearm and
elbow down through the line o f the uppe r ar m.
Stimulation of Antagonists: T retai ns grip. T then
as ks P to move further in the directi o n of
.... tretchi ng. and resists that movement to stimul ate
p's antagoni sts.
Fig. 10 a. Starl ing Posit ion.
Fig. 10 b. Final Positi on.
27
2.2.7. The rapy for the subclavius.
Starting Position: P: Sitting: e lbow Il cxcd with
forearm agai nst thorax: back stabil ized against T's
chest. T: Standi ng be hind P. -
Grip: With arms around P. T uses both hands to
grip p's right elbow and forearm.
Procedure: Using thi s grip. T gradual ly and Fig. II a. Start ing Posit ion.
maximall y moves p's shoulder girdl e cranially by
pulling lip against the elbow.
Stimulation of Antagonists: T moves bot h hands to
p' s shoul de r. T then as ks P to move furth er in the
direction of stretching. and resists that movement
to stimul ate P' s antagoni sts.
Notes: During treatme nt. P shoul d exhale when the
shoulder pu ll ed craniall y; thi s moves the first ri b
caudall y. (See Volume II. The Spi ne and
Temporomandibul ar Joint).
I[ strong enough. T ca n use right hand to grip p's
elbow. and left hand to support p's left shoulder.
The deltoid, acromial part and the supraspinatus
are also stretched in thi s procedure. (To avoid the
stretching of these muscles . p's right a rm should be
abducted during the stretching.)
28
Fig. II b. Final Pos iti on.
2.3.1. Therapy for the deltoid , spinal pa rt.
Starting Position: P: Supine ; knees and hips fl exed;
arm flexed approximately 90
0
at shoulder. T:
Standing at head of couch, facing oblique to P's left
side.
Grip: T"s right hand grips the dorsa l side of p·s
elbow. The dorsal side of p·s fo rearm should li e
along the medial side of T" s fo rearm. T" s left hand
stabili zes the late ral borcler of p·s ri ght scapu la .
Procedure: Us ing thi s gri p. T graduall y and full y
flexes, addl/ Cis (ove r and behind p·s head) and
II/edially ratales at p·s shoulder.
Stimulation of Ant agoni sts: T reverses ri ght-hand
grip to ventral side of elbow. T the n as ks P to move
fu rthe r in the directi on of stretching. and resists
that movement to st imul ate p' s ant agoni sts.
Fig. 12 ,I. Stiil'ting Positi on.
Fig. 12 b. Final Positi on.
29
2.3.2. Therapy for t he teres minor.
Starting Position: P: Sitting; ri ght. upper arm full y
Hexed and adducted at shoul de r; elbow fl exed
approxi mately 90°. T: St anding behind P.
Grip: T' s left hand grips p' s forearm just above the
wri st. T' s ri ght hand grips p's upper ann j ust above
the elbow.
Procedure: Using thi s grip. T graduall y rotatc, p' s
arm until full medial roration is att aincd at thc
shoulde r.
Stimulation of Antagonists: T reve rses lc ft- hand
grip to othcr side of forearm. T thcn asks P to move
furthe r in the d irecti on of st retching. and res ists
that moveme nt to st imul ate p' s ant agoni sts.
Note: The deltoid, spinal part and the infraspinatus
are also stretched in thi s procedurc.
30
Fi g. 13 b. Final Pos iti on.
2.3.3.
The rapy for the infraspinatus.
Starting Position: P: Supine: a rm abduct cd
approximate ly 90
0
a nd c lbow fkxcd   T :
Sta nding at hcad o f couch .
Grip: T' s right hand grips P's fo rearm just above
the wrist. T' s left hand stcadics p' s sho uldc r at the
ve ntral side.
Procedure: Using thi s grip. T graduall y rotates p' s
arm until fu ll medial rOlfltioll is attained at the
shoulde r.
Stimulation of Antagonists: T rcta ins grip. T the n
as ks P to move furthe r in the direct io n of
  and resists that movement to stimul ate
  antagoni sts.
Fi g. l-l a. Starting Position.
Fi g. l-l b. Final Posi tion.
31
2.3.4.
Therapy for the trapezius , transverse
part.
Starting Position: P: Lying o n left side: right
shoul de r fiexed approximate ly 90°. T: Sta ndi ng.
left side against p·s chest and abdomc n.
Grip: T"s left hand gr ips p·s scapul a dorsall y and
along the med ial border. T"s right hand grips p·s
upper arm.
Procedure: Using this grip. T graduall y and
maximall y pushes in a la/era I and I'enlrlll direct ion
against p's scapul a.
Stimulation of Antagonists: T retains ri ght -hand
grip. T then asks P to move further in the directi on
of stretching. and resists that movement to
stimul ate p' s ant agoni sts.
f ig. 15 a. Starti ng Position.
2.3. SA. Therapy for the rhomboidei major
and minor. P prolle.
tarting Position: P: Prone: right ar m hangi ng free
ove r edge of couch. T: Standing at head of couch.
10 p' s left.
Grip: T"s left hand on p's right scapula. its thenar
' mi ne nee along the scapula medi al border. T" s
ri ght hand steadi es p's tho rax from P's left.
Procedure: Us ing thi s grip . T graduall y and
maximall y pushes in a IOl erol. I'el/lrol and calldol
Ji rcction against p's scapul a.
timulation of Antagonists: T moves left -hand gri p
'0 \entral side of P's ri ght shoulder. and uses ri ght
ha nd to stabil ize p's thorax on ri ght side . T t hen
.. , ks P to move furth er in the direct ion of
'!retching. and res ists that movement to stimul ate
p's antagoni sts.
=-ote: The trapezius , transverse part is also
tretched in thi s procedure.
If the prone positi on is inconve ni ent o r uncomfort -
able. P ma y bc trcatedlying on side : sec foll owi ng
'cchn ique. therapy 2.3.5 B. p. 34.
Fig. 16 a. Start ing Posit"ioll .
Fig. 16 b. Final Posi ti on.
33
2.3.58. T he rapy for the rhomboidei major
and minor. P Iyillg all side.
Starting Position: P: Lying o n left side: right
shoul de r fl exed approximately 90°. T: Standing and
half silti ng o n couch. with le ft side agai nst p's
abdomen and chest .
Grip: T" s left hand gri ps p's scapul a dorsa ll y along
the med ial bo rder. T" s ri ght hand grips p's upper
arm at the shoul de r.
Procedure: Using' thi s grip. T graduall y and
maximall y pushes in a la/era I, lIellfral and call dal
direct ion aga inst p's scapul a.
Stimulation of Antagonists: T retains grip . T then
as ks P to move furth er in the directi on of
stretching. and resists that movement to sti mul ate
p's ant agoni sts.
34
2.3.6A. T herapy for the triceps brachii , long
head.
Starting Position: P: Sil1ing; shoulder fu ll y fle xed
and add ucted wit h elbow fl exed. T: Standing faci ng
p's left side. or behi nd P if P's shou lder has
restricted flexion.
Grip: T' s right hand gri ps P's forearm above the
wrist. T' s left hand stabili zes latera l side of p' s
shoulder. (When T stands beh ind P. T's left hand
grips p's forea rm above the wrist. T' s ri ght hand
stabilizes p's upper arm above the e lbow).
Procedure: Using thi s gr ip. T gradually and fully
flexes at P's elbow.
Stimulation of Antagonists: T retains gri p. T then
asks P to move further in the direction of
st retching. and resists that movement to stimulate
p's antagoni sts.
Note: If T has difficult y stabili zing P. procedure
may be performed with P lyi ng on side : sec
fo ll owing technique. therapy 2.3.6B. p. 36.
Fig. 18 a. St arting Position.
Fig. 18 b.
35
2.3.6B. Therapy for the triceps brachii , long
head. P Iyil/g 01/ side.
Starting Positi on: 1' : Lying on ri ght side: shou lder
ful lv flexed: head of couch raised so shoulder is also
fully adducted. T: Standing facing I' from front.
Grip: Ts left hand grips 1" , right forearm just
above the wrist. Ts ri ght hand stabili zes 1'\
shoul de r from behind.
Procedure: Using this grip . T graduall y and fully
flexes at P's e lbow.
Stimulation of Antagonists: T retains grip . T t hen
asks I' to move furth er in the direction of
stretching. ane! resists that movement to stimul ate
p' s ant agoni sts.
36
Fi g. I'J b. Final Pos it ion.
2.8.1. Therapy for the trapezius, ascending
part.
Starting Position: P: Lying on left side; ri ght arm
behind back. T : St anding. obliquely facing P.
Grip: T' s le ft hand grips lateral border and the
inferi or angle o f p' s scapul a. T' s right hand grips
the acromi on, coracoid process and head of
hume rus. T' s chest support s elbow.
Procedure: Using thi s grip . T graduall y and
maximall y moves p' s scapul a in a cranial and
medial directi on. Thi s produces a latera l and
sli ghtl y caudal rotati on of the glenoid cavit y.
Stimulation of Antagonists: T moves left hand to
upper medial angle o f scapula . T the n as ks P to
move furthe r in the directi on of stretching. and
resists that moveme nt with left hand to stimul ate
P's ant agoni sts.
Fi g. 20 a. Starting Position.
Fi g. 20 b. Final Positi on.
37
2.8.2. Therapy for the serratus anterior.
Starting Position: P: Sitting. T: St anding at P's left
side. chest and abdomen stabili zing P' s upper arm
and shoulde r.
Grip: T s ri ght hand grips the lateral/do rsal side of
P's upper arm j ust above the elbow. and holds the
arm medi all y rotated and full y adducted. 1""s left
hand grips the ventral/lateral side of p's shoul der.
Procedure: Using thi s grip . T graduall y and
maximall y moves P's scapula in a crallial . dorsal
and medial direct ion.
Stimulation of Antagonists: T moves right hand.
cupping palm over dorsal-medi al side of P's elbow.
T then asks P to move further in the direction of
stretching, and resists that move ment with ri ght
hand to stimul ate p's ant agoni sts.
Fig. 2 1 a. Starting Position.
2.9. 1. Therapy for the biceps brachii . long
head.
Starting Position: P: Lying on left side: right upper
arm full y extended. add ucted and I,nerall y rotated
at shoul der. so the sulcus in tert ubercul aris turns
late rall y: e lbow fl exed and fo rearm fu lly pronated.
T : Standi ng behind P. bUllocks stabi lizi ng P\
lumbar and thoracic regions.
Grip: T's left hand gri ps p's forearm j ust above the
wri s!. T' s right hand stabili zes p's upper arm j ust
above the elbow.
Procedure: Usi ng thi s grip . T graduall y and full y
exrellds at p's e lbow.
Stimulation of Antagonists: T reta ins grip . T then
as ks P to move funher in thc directi o n of
stretching. and resists that movement with left
hand to sti mul ate p's antagonists.

Fig. 22 a. Starting Posit ion.
39
2.9.2. The rapy for t he supraspinatus.
Starting Position: P: Lyi ng on left side: right upper
a rm sli ghtl y abducted and exte nded. but not
mediall y or lat e rall y rotat ed. T : Standing behind P.
Grip: T s right ha nd grips p' s uppe r ann just above
the e lbow. 1""s left forear m (or. if prefe rred. a fi nn .
round cushi on) is pl aced in p' s axi ll a.
Procedure: Usi ng thi s grip . T pull s aga inst p's upper
a rm whil e pi voting at the axi lla and graduall y a nd
full y addl/Cli ll g the a rm be hind the back.
Stimulation of Antagonists: T re tains grip . T t he n
as ks P to 1110ve furthe r in the direction of
stretching. and resists that move ment to stimul ate
p's antagoni sts.
Note: The deltoid, acromial part is al so stre tched in
thi s procedure.
40
Fig. 23 a. Starting Positi on.
t '---:'
,
2. 11.1. Therapy fo r the delt oid , clavicular
part and the coracobrachialis. l3i-
l{/feral sfrercflillg.
Starting Position: P: Supine : knecs and hips ncxcd
to stabilize lumbar and thoracic regions and to
preve nt lumbar spinc lordosis: small. firm cushi on
may be placed between scapulae to pcrmit
maximulll shoulder movement: support under
head and neck: chin tucked in to protect ce rvical
spine. T: Standing at hcad of couch.
Grip: Us ing both hands . T grips the mcdial sides of
p's elbows. forearms against p' s forearms. p' s arms
are abducted approximatc ly 90° and rotated
laterall y. (Narc: filII abducti on combined wit h filII
lateral rotation produces thc undes irable ··close
packed position·· at p· s shoulde r. )
Procedure: Us ing thi s gr ip. T graduall y and
maximall y movcs p· s arms in a dorsal direction.
Stimulation of Antagonists: T rcverses gr ip to under
p·s arms. T thc n as ks P to move further in the
direct ion of stretching. and resists that move mcnt
to stimulat e p' s antagoni sts.
Notes: Thi s proced urc may also bc performcd with
P sitting.
The pectorali s major and subscapularis are also
stretched in t hi s procedurc.
Fig. 2-+ a. Starting Positi on.
Fig. 24 b. Final Positi on.
41
2.11.2. Therapy for t he biceps brachii , short
head.
Starting Position: P: Supine: thorax stabili zed to
couch with a be lt: upper arm fully late rall y rot ated
and fully extended. but less than 90° abducted:
elbow f1cxed with forearm full y pronated. T :
Sitting or standi ng at head of couch wit h left side
agai nst p's right shoulder.
Grip: T' s ri ght hand grips around dorsal side of p's
forear m just above the wrist. T's left hand grips
dorsal-medial side of p's upper arm just above the
elbow.
Procedure: Using thi s grip. T graduall y and fu ll y
eXfellds at p's elbow.
Stimulation of Antagonists: T retains gri p. T then
asks P to move furthe r in the di recti o n of
stretching. and resists that movement to stimul ate
p's antagonists.
42
Fig. 25 u. Start ing Posit ioll.
Fig. 25 b. Final Positi on.
2.11.3. The rapy for the subscapularis.
Starting Position: P: Supine: uppe r arm on couch
with elbow flexed 90°; thorax may be stabili zed to
couch with a belt. T: Standing obliquely faci ng p's
right side.
Grip: T' s left hand stabil izes p' s upper arm against
the couch. T' s ri ght hand grips medi al side o f p's
fo rearm just above the wri st.
Procedure: Us ing thi s grip. T gradually rotates p's
shoulder until full laferal rotation is attained.
Stimulation of Antagonists: T retains grip. T the n
as ks P to move further in the direction of
stretching. and resists that movement to stimulate
p' s antagoni sts.
Notes: St retching may also be perfor med with P's
upper arm held in va ri ous degrees of abducti on.
A firm cushi on pl aced under p' s right scapu la will
push hi s shoul der gi rdl e ve ntrall y, thus preventing
undue strain on the pectoralis major.
Fi g. 26 <I. Starting Positi on.
Fig. 26 b. Fin al Positi on.
43
2.12.1. Thcrapy for thc trapezius, descend-
ing part.
Starting Position: P: Supine: head and neck in full
vc ntral and left lateral l1exion and right rotat ion:
shoulders at cdgc of hcad of couch. T: Standing at
hcad of couch : left sidc of abdomcn support s ri ght
sidc of p's head.
Grip: T' s left hand grips the dorsa l side of p's ncck.
p' s head and neck arc stabili zed betwcc n T' s left
forcarm and chest. T's ri ght hand on p's ri ght
shoulder.
Procedure: Using this gr ip. T appl ies traction to P's
neck while gradually and maximall y pushing p's
shoulde r in a calldal and dorsal direction.
Stimulation of Antagonists: T moves ri ght hand.
cupping p's right elbow in pal m. T then asks P to
movc further in the directi on of stretching .. and
resists that movement to stimulat e p' s antagoni sts.
Note: Avoid any move mcnt s of p's head and neck
ot hcr than the prescribed tracti on appli ed.
Fi g. 27 b. Fina l Position.
44 (Vi cwed from side)
Fig. 27 a. Starling Posit ion .
Fig. 2H Final Posit ion.
(Vicwed from bclow)
2.12.2A. Therapy for the levator scapulae.
Starting Position: 1' : Supine; head and neck in full
ve ntral and left lat eral flexion and left rotati on;
shoulde rs at edge of head of couch; right arm full y
fl exed above headand abducted towards head;elbow
fl exed approximatel y 90°. T: Standing at head of
couch with chest supporting ri ght side o f p's head .
Grip: T' s left hand grips dorsa l side o f p's neck. p's
head and neck arc sta bili zed betwee n T' s left ann
and thorax. p' s ri ght elbow against T' s abdomen.
T' s ri ght hand grips dorsal -lat eral side of p's upper
arm and sho ulde r .
Procedure: Using thi s gr ip. T appli es tracti on to P"s
neck whil e leaning abdomen against p's elbow. T' s
right hand then moves p's shoulder graduall y and
max imall y in a c({lI r/al and dorsal directi on.
Stimulation of Antagonists: T retains grip . T then
asks I' to move furthe r in the direction of
stretching. and resists that movement with right
ha nd to stimul ate p's ant agoni sts.
Note: Avoid any movement s of p' s head and neck
othe r than the prescribed traction appli ed.
Fi g.     a. Start ing Posi tion.
Fi g. 29 b. Final Positi on.
45
2.12.2B.
The rapy fo r the levator scapulae.
Allematil'e grip for palielllS lI'ilh
good shollider flexion.
Starting Position: P: Supine ; head a nd neck in full
ventral a nd left lat e ral fl exion a nd le ft rotati o n;
sho ulde rs at edge of head of couch ; ri ght arm full y
nexed above head and abduct ed towa rds head;elbow
fl exed a pproxima tel y 90°.
T : Standing a t head of couch wi th chest supporting
ri ght side of p's head .
Grip: T s le ft ha nd grips dorsal side of P'5 neck. 1" $
head a nd neck a re stabili zed be tween T s le ft a rm
a nd tho ra x. T s ri ght hand stabili zes 1" 5 chin .
Procedure: Us ing thi s gr ip. T appl ies tracti o n to P's
neck with both hands. whil e leaning abdome n
aga inst p's el bow a nd moving p' s s ho ulde r
graduall y and max imally in a call dal a nd dorsal
directi on.
Stimulation of Antagonists: T moves ri ght hand to
p's uppe r ri ght a rm. T the n asks P to move ri ght
sho ul de r furthe r in the di recti on of stre tching. and
resists tha t moveme nt wi th ri ght ha nd to sti mul ate
p's ant agoni sts.
Note: Avoi d a ny moveme nts of p's head a nd neck
othe r tha n t he prescri bed tracti on appli ed.
46
Fig. 30 b. Final Pos iti o n.
2.12.2C. Therapy for the levator scapulae.
Whel/ P's shoulder is painflli.
Starting Position: P: Supine; head and neck in full
ve ntral and left lateral nex ion and left rotation; on
couch and not beyond edge; ri ght arm abducted
and full y laterall y rotat ed at shoulder with upper
arm resting o n couch. T: Standing at head of couch.
chest supporting right si de of P's head.
Grip: T's left hand grips dorsal side of P's neck. p's
head and neck are stabili zed be tween T's left a rm
and chest. T's right hand is on the dorsal side of P's
scapula with the thenar eminence against P's
supraspinous fossa.
Procedure: Using this grip , T applies tracti on to p's
neck while graduall y and max imall y pushing P's
scapul a in a calldal and dorsal direction.
Stimulation of Antagonists: T moves ri ght hand to
p' s axill a. T the n asks P to move ri ght shoul de r
further in the direction of stretching. and resists
t hat movement with ri ght hand to stimul ate p's
ant agoni sts.
Notes: This procedure should be used if nexing is
constrained at p' s shoulder and/or if stretching
causes pain at the shoulder.
Avoid any movements of P's head and neck ot her
than the tract ion applied.
Fig. 31 a. Starting Positi on.
Fig. 31 b. Final Position.
47
THE ELBO \
3 THERAP) Gt:IDE
The muscles \\ hleh r nct mo\ement al the elbo\\' are li sled in Table 3-1. along wit h t he applicabl e
lherapies. indexed b\ manual eClion number and page . Muscle aClions are lisled in Table 3-2.
The \arious resl riclions possible are lisled in :'- Iovemenl Resl ricl ion Table 10.3 (p. 167).
TABLE 3. 1 al the elbo\\
SECTION
RESTRI CTED
3. 2 Flexioll
RESTRI CTI NG
MUSCLE(S)
Tri cep", brachii
lOll!.! head
tlll.'diai & i at!.' ral head=,,>
Ancollcu:-o
3.3 ExrcllSioll and sllpil/{/-   brachii
/iol/ prollation of
forea rm
Brachi al is
Brachioradiali ",
Extensor carpi radiali", longus
Extcn:-. or carpi brevis
d i gitofUnl
fin gers
middl e finger indi vidual ly
EXl cmor indicis
Extensor digi ti mini mi
Supinator
Extensor carpi
Flexor carpi ulnar i.,
Flexor carpi
Flexor digitonlll1 supcrficiali s
PronalOr teres. hUJl1e r<l1 head
ulnar head
Pronator q uadrat us
Palmar is longus
THERAPY Number
2. 3.6
3.2. I
3. 2. I
2.9. 1, 2. 11.2
3.3. I
3. 3.2
3. 3. 3
3. 3.4
3.3.5
3.3.7
3. 3.6
3.3.8
3.3.9
3.3. 10
3. 3. II
3. 3. 12
3.3. 13
3. 3. 14
3.3. IS
3.3. 15
Tf'16
Pogc
15. :;6
51
51
39.42
52
53
54
55
56
58
57
59
60
61
62
63
64
65
66
66
67
49
TABLE 3.2 Acti on:, of which may re:,t rict mo' ·cmcnt at the clbow
MUSCLE ACTI ON
Muscl es of the upper ann
Triceps brachii
- long head at elbow. Adducts and at shoulder.
- medial/late ral heach Extend at e lbow.
Bi ce ps brachii Fl exes at el bow. Supinates for ea rm. Long head abduct s and mi.' diall )' rotates at shoulde r : short
head adduct::. and   at shoulde r.
Brachiali", Fl exes at clbo\\'.
Muscles of t he forearm
Anconeus
Bn.tcllioradialis
Extensor carpi radialis
longus
Extensor carpi radiali :,
brevis
Extensor digitorulll
cOlll muni :,
Extensor indi cis
Extensor digiti min imi
Supinator
Ex tensor carpi UillMi s
Fl exor carpi ulna ri ",
Fl exor carpi radialis
Fl exor digitorulll supc r-
fi cialis
Pronator tcre:-.. hume ral
head
ulnar head
Pronator quadratus
Palmar is longus
Ext cnds at elbow. Ti ghtens joint capsule.
Fkxcs at elbow. Supinat cs forear m frolll pronated posi tion. Pronates forea rm from supi nated
position.
Fl exes at elbow. Supinatcs for earm. and rad ial fl exes at wr ist.
Flexes at elbow. Supinates for earm. Dorsal fkxe :-. at wri st.
Extends fi nge rs. OIl elbow. Supinat es forearm. DOI" ",al flexes at wri st.
Extends and ulna r deviates index finger. Supinatcs for earm. Dorsal flexes at wrist.
Extends little finger. Fl exes at elbo\\' . Dorsa l and ulnar flexes at wrist.
for ea rm. Fl exes at elbow.
Dorsal and ulnar at wrist. Flexes at elbow. Supinat es fo rea rm.
Fl exes at elbow. Pronat es for earm. Vola r and ulnar flexe s at wri st.
Flexes at el bow. Pronates for l..'a rm. Vola r and radial fl exes at wr ist.
Flexes (includi ng proximal intt;.'rphalangcal joint s). Fl exes at elbow. Volar
at wri st.
Pronates forearm. Fl exes at el bow.
Pronales fo rearm.
Pronates fo rearm.
Fl exes at e lbow. forearm. Vol ' lT at wrist.
NOTE: descr ibes in lerms 111 0st relevant to manual therapy. Cross-reference to terms often used in anatomy text s:
Ulnar flexion:
Radial fl ex ion:
Volar Il cxion:
Dorsal fl exion :
50
toward:-. uln<l , corresponds to adduction (u!. uall y of hand)
towards radius. cor re!. ponds to abduct ion (us ually of hand)
towa rds pal111 , to fl ex ion of hand
towards back of hand. corresponds to exte nsion of hand
3.2.1. The rapy for the triceps brachii,
medial and lateral heads and the
anconeus.
Starting Position: P: Supine: arm sli ght ly abducted
with elbow Hexed . T: St andi ng. ri ght si de against P.
Grip: T' s left hand grips dorsa l side of p' s fo rearm
j ust above wri st. T' s ri ght hand stabili zes p's upper
arm j ust be low the shoul de r.
Procedure: Using thi s grip. T graduall y and full y
flexes at p' s elbow.
Stimulation of Antagonists: T retains grip . T then
as ks P to move furth er in the directi on of
stretching. and res ists that movement to stimul ate
p's ant agonists.
Fig. 32 a. Starting Position.
Fi g. 32 b. Final Posit ion.
5 1
3.3.1. The rapy for the brachialis.
Starting Position: P: Supine; right arm and forearm
bot h Oexed approxi mately 90° to relax biceps. T:
Standing facing p·s right side.
Grip: T's right hand grips medial side of p·s forearm
j ust above wri st. T' s left hand stabili zes p·s uppcr
arm at dorsal side just above the elbow.
Procedure: Usi ng t hi s grip. T grad uall y and fu ll y
extends at P\ elbow.
Stimul ation of Antagoni sts: T retai ns gri p. T the n
asks P to continue extending forearm, and resists
that extension wit h ri ght ann (T's left hand still
stabili zes p's arm) to st imulate p's antagonists.
52
Fig. 33 a. Starting Positi on.
Fig. 33 b. Final Pos iti on.
3.3.2. Therapy for the brachioradialis.
Starting Position: P: Supine; ri ght arm fl exed
approximately 90° and full y medi all y rotated:
forea rm fl exed and full y pronated. '1': standing
facing p's ri ght side .
Grip: T s ri ght hand grips medial side of p's fo rearm
just above the wri st. T s left hand stabili zes p's
upper a rm at the lateral side just above the e lbow,
Procedure: Using thi s grip. T graduall y and full y
extends at p' s el bow and simult aneously draws the
forearm in the II lnar directi on.
Stimulation of Antagonists: T retains grip . T then
asks P to move furthe r in the directi on of
stretching, and res ists that movement to stimul ate
P's ant agoni sts.
Note: This procedure may also be performed with
P's forearm full y supinated .
Fig. 3-1 a. Sta rt ing Posit ion.
53
3.3.3. Therapy for the extensor carpi
radiali s longus.
Starting Position: P: Supine: arm tl exed approx-
imatel y 90
0
and full y medially rotated: forea rm
Ilexed and full y pronated ; wrist full y volar and
ulnar fl exed. T: Standing facing P's ri ght side .
Grip: T's right hand grips wrist and proximal part of
p's hand from the dorsa l side wh il e stabili zing p' s
wrist in full volar and ulnar fkxioll wi th the forearm
fully pronated. T' s left hand sta bili zes p's upper
arm at the dorsal side just proximal to the elbow.
Procedure: Usi ng thi s gr ip. T gradually and fu ll y
extellds at p's elbow and simultaneously draws the
fo rearm in the II/liar directi on.
Stimulation of Antagonists: T reve rses ri ght -hand
grip. movi ng ri ght hand 10 volar side of p's ri ght
hand . and moving left hand to ve ntral side of p's
elbow. T then asks P to move furth er in the
direction of st retching. and res ists that moveme nt
to stimul ate P's antagoni sts.
Note: This technique and therapy is especially use-
ful in treating epicondylitis.
54
Fig. 35 a. Starti ng Positi on.
Fig. 35 b. Final Posi ti on.
3.3.4. Therapy for the extensor carpi
radiali s brevis.
Starting Position: P: Supine; arm fl exed approx-
imately 900 and full y mediall y rotated: fo rea rm
fl exed and ful ly pronated: hand in full volar fl exion.
T: Standi ng facing p's ri ght side.
Grip: T's ri ght hand grips the proximal part of P's
hand at the dorsal side and stabili zes the hand in
full volar fl exion with the forearm full y pronated.
T' s left hand st abili zes P's upper arm at the dorsal
side just proximal to the elbow.
Procedure: Using thi s grip, T graduall y and full y
extends at P' s elbow and simultaneously draws the
fo rearm in the ulnar direction.
Stimulation of Antagonists: T reverses ri ght-hand
grip, moving ri ght hand to vol ar side of P' s right
hand , and moving left hand to ventral side of
elbow. T then asks P to move further in the
directi on of stretching, and resists that movement
to stimul ate P's ant agoni sts.
Note : Tills t echnique and therapy is especiall y use-
ful in t reat ing epicondylit is.
Fig. 36 a. Start ing Position.
Fig. 36 b. Final Pos ition.
55
3.3.5. Therapy for the extensor digitorum
communis.
Starting Position: P: Supine; arm f1 exed approx-
imately 90° and fu ll y mediall y rotated; forearm
f'l exed and full y pronated ; hand full y volar flexed
and fingers full y fl exed at all joints. T: Standing
facing P's ri ght side.
Grip: T's ri ght hand grips dorsal side of p' s fi nge rs
so that full fl exion is maint ained at all finger joint s.
P's hand is held in full volar flexion. and the
forearm is full y pronated. T's left hand stabili zes
P's upper arm at the dorsa l si de just above the
elbow.
Procedure: Usi ng thi s grip . T graduall y and full y
ex/ends at P's elbow and simult aneously draws the
forearm in the II/liar direction .
Stimulation of Antagonists: T retains ri ght-hand
grip . and reve rses left -hand grip to ve ntra l-medial
side of P's elbow. T the n asks P to move further in
the direction of stretching. and res ists that
movement to stimul ate P' s ant agoni sts.
Note: This technique and therapy is especially use-
ful in treating epicondylitis.
56
Fig. 37 H. Starting Posit ion.
Fig. 37 b.
3.3.6. Therapy for the extensor indicis.
Starting Position: P: Supine: forearm Acxed and
fully pronated; index finge r full y ft exed at all the
joi nt s and in full radial flexion at the Me p joint. T:
Standing at p's ri ght side.
Grip: T' s right hand grips dorsal side of p's incl ex
fi nger so that full flexi on is mai nt ained at all the
joi nts whil e p's forearm is full y pronated. T's left
hand grips just above p's wr ist stabil iz ing p's
forearm.
Procedure: Us ing this gri p. T graduall y and fully
volar flexes at p's wri st.
Stimulation of Antagonists: T retains grip. T then
as ks P to move further in the directi on of
st retching. and resists that movement 10 stimulat e
p's ant agoni sts.
Fi g. 3R (I. Start ing Positi on.
Fig. 38 b. Final Position .
57
3.3.7.
Therapy for the extensor digitorum
communis. (Middle fi ll ger oll ly).
Start ing Position: P: Supine: arm nexed approx-
imately 9()O and fu ll y medi all y rotat ed : forea rm
l1cxed and full y pronated : han d full y volar fl exed
between radi al and ulnar fle xion: middle fin ge r is in
fu ll l1cxion at all joint s. T : Sta nding faci ng p·s left
side.
Grip: T"s left hand grips dorsal side of p·s middle
finger so th at full Aexion is maintained at a ll the
finge r joint s . T"s ri ght hand stabili zes P"s upper arm
just above the elbow.
Procedure: Using thi s grip. T graduall y and full y
extends at p's elbow and simult aneoll sly draws the
forearm in an ulll ar directi on.
Stimulation of Antagonists: T retains grip. T then
asks P to move furth e r in the directi on of
stretching. and resists that movement to stimul ate
p's ant agoni sts.
Note: Thi s technique . and the previous o ne . 3.3.6.
p. 57. arc es peciall y use ful in treating e pi condylitis.
Note: This technique and therapy is especially use-
ful in treating epi condylitis.
S8
Fi g. 39 b. Final Positi on.
3.3.8. The rapy fo r the extensor digiti
minimi.
Starting Position: P: Supine; arm Aexed approx-
imately 90° a nd full y med iall y rotated: forearm
ft cxed ; hand in full vola r a nd radial ft cxion: lilli e
finger full y fl exed at a ll joints. T: Sta nding fac ing
p·s ri ght side.
Grip: T"s right hand grips dorsa l side of p·s lilli e
finger so that fu ll flexion is maint ained at all finger
join ts. T" s left hand stabili zes p· s uppe r arm j ust
above the elbow.
Procedure: Usi ng thi s grip. T graduall y a nd fully
exrellds at p· s elbow and si mult aneously draws the
fo rearm in the II/liar di rect ion.
Stimulation of Antagonists: T retains grip . T t he n
as ks P to move further in t he direct io n of
stretching. a nd resists that move me nt to sti mul ate
p's antagoni sts.
Note: This t echnique and therapy is especiall y use-
ful in treating epicondylitis.
Fig ... H) a. Starting Position.
Fig. -10 b. Final Positi o n.
59
3.3.9.
The rapy for the supinator.
Starting Position: P: Supine; arm Aexed approx-
imat e ly 90
0
and fu ll y medi all y rotated: forearm
nexed a nd fully pronated. T: Standing facing p's
ri ght side.
Grip: T's ri ght ha nd grips dorsal side of p's forearm
just above the wrist. T' s left hand stabi li zes p's
uppe r arm at the do rsa l side just above the elbow.
Procedure: Us ing this grip. T gradually a nd fully
extellds at P's e lbow and simultaneously draws the
forearm in the II/liar direction.
Stimulation of Antagonists: T re tains grip . T the n
asks P to move furth e r in the direct io n of
st retching. and resists that movement to st imul ate
P's antagonists.
60
Fig.   I a. Starting Posit ion.
Fig. 41 b. Final Position .
3.3.10. The rapy for the extensor carpi
ulnaris.
Starting Position: P: Supine : a rm ft exed approx-
imat ely 90° and full y medi all y rotated: forearm
pronated: hand in full volar and radi al fl exion. T:
Standing facing p's ri ght side.
Grip: T s ri ght hand grips wri st and proximal part of
p' s hand from the dorsa l side. T s left hand
stabili zes P's upper arm at the dorsa l side just
above the e lbow.
Procedure: Using thi s grip. T graduall y and fu ll y
extends at p's elbow and simult aneoll sly draws the
forearm in the II /liar di rection.
Stimulation of Antagonists: T re tains grip . T then
as ks P to move furth er in the directi on of
stretching, and resists that movement to stimulat e
P's antagoni sts.
Fi g. ~   a . Starting Posit ion.
Fi g. ~   b. Final Positi on.
6 t
3.3.11. The rapy for the flexor carpi ulnari s.
Starting Position: P: Supine; arm fl exed approx-
imately 90° and full y laterall y rotated; forearm
fl exed and full y supinated; hand in full dorsal and
radi al fl exio n. T: standing facing P's right side.
Grip: Ts ri ght hand grips the proximal pa rt of p's
palm and fingers. holding the fingers fu ll y flexed.
Ts left hand stabili zes p· s e lbow at the dorsal side.
Procedure: Us ing thi s grip . T graduall y and full y
extends at p's elbow and simult aneously pushes the
forearm in the lIinar directi on.
St imul ation of Antagonists: T retains gri p. T then
asks P to move further in the direct ion of
stretching. and resists that movement to st imulat e
P's ant agoni sts.
62
-...... _-.. ""
~  
I

Fig .... U '-1. Starting Positi on.
Fig. 43 b. Final Pos iti on.
3.3.12. Therapy fo r the flexor carpi radialis.
Starting Positi on: P: Supine: ar m flexed approx-
imate ly 900 and fully laterall y rotat ed: forcarm
fl exed and full y s upi nated: hand in full dorsal and
ulnar fl exion. T: Standi ng facing p's right side.
Grip: T s ri ght hand grips the radial-volar side o f
the proximal part of p's hand so Me p joints are
free to fl ex. Ts le ft hand stabili zes p' s uppe r ann at
the dorsal side at the elbow.
Procedure: Usi ng thi s grip. T gradually and fully
eXlel/{/s at p' s elbow and simultaneously pushes on
the forear m in the II/liar di rection.
Stimulation of Antagonists: T retains grip. T then
asks P to move further in t he di rect ion of
stretching. and resists that movement to stimulat e
p' s ant agoni sts.
Fig . ..J-J a. Starti ng Position.

Fig. -14 b. Fi nal Pos iti on.
63
3.3.13.
T he rapy fo r the fl exor digi torum
superficia li s.
Sta rting Positi on: P: Supine: ann abducted and full y
latera ll y rota ted; fo rea rm nexed and full y supin-
at ed; ha nd in full dorsal fl exio n: finge rs fu lly
exte nded a t the PIP a nd Me l' joint s. T: Si tting o n
cOllch. back against p's ri ght side.
Gri p: T"s le ft hand grips p·s pa lm a nd fin ge rs so the
DIP j oin ts a rc free to fl ex. T"s right ha nd stabi li zes
p·s uppe r arm at t he me dial side j ust above the
e lbow.
Procedure: Us ing th is grip. T gradua ll y a nd full y
exrmds at p·s elbow a nd simu lta neously pull s o n
t he fo rea rm in the II/li ar directi o n.
Stimul a ti on of Ant agoni sts: T ret ains grip . T the n
asks P to move furth e r in the directi o n of
stretching. and resists that movement to stimul ate
p's ant agoni sts.
Note: The palma ri s longus is a lso stre tched in this
procedure.
64
Fig . .+:) a. Start ing Position.
3. 3.14. Therapy for the pronator teres,
humeral head.
Starting Position: P: Supine: arm fl exed approx-
imately 90° and full y laterall y rotated: forearm
flexed and full y supi nat ed. T: Sitting on couch.
back agai nst p·s ri ght side.
Grip: 1"s left hand gri ps dorsal side o f p·s forearm
j ust above the wrist. 1"s ri ght hand stabi li zes p·s
uppe r arm at the ve ntral side just above t he elbow.
Procedure: Usi ng thi s grip, T graduall y and full y
extends at P's elbow and simult aneously draws the
fo rearm maximall y in the II /liar directi on.
Stimulation of Antagonists: T retains grip. T then
asks P to move furthe r in the directi on of
stretching. and resists that movement to stimul ate
p's ant agoni sts.
ote: The pronator teres, ulnar head and the
pronator quadratus are also stretched in thi s
procedure.
r
Fig . ..J. 6 a. Starting Position.
Fig. 46 b. Final Pos ition.
65
3.3. 15. Therapy for the pronator teres , ulnar
head and thc pronator quadratus.
Start ing Position: P: Supinc: clbow Il cxcd approx-
imatel y 90°,
T : Sitting on couch. ri ght side against p' s ri ght side.
Grip: 1'"s left hand grips dorsal side of P"s forea rm
just above the wri st. 1'"s right hand sta bili zes p's
uppe r a nn at the mcdi al side j ust above the elbow.
Procedure: Us ing thi s grip. T graduall y and
maximall y sup illates P's forearm.
Stimulation of Ant agonists: T retains grip. T the n
as ks P to move furthe r in the c! irecti on of
stretching. and resists that move ment to stimul ate
p' s antagoni sts.
66
Fi g . .\7 b. Final Positi on.
3. 3. 16. The rapy fo r t he pa lma ri s longus.
Starting Position: 1' : Supi ne: sho ul de r abd uct ed
a nd fully latera ll y rotated : e lbow f1 e xed a nd
fo rearm fUll y supinat ed : wrist in full do rsal f1 exi o n
with MCP joints fUll y ext e nded . T : Sitt ing. back
against P's ri ght side.
Grip: T" s left hand grips the proximal pa rt of p's
ha nd from the ulnar-vola r side down to the MCP
joints. T" s right ha nd stabi li zes p' s uppe r arm at the
media l side j ust above the e lbow.
Procedure: Using t hi s gri p. T gradua ll y a nd fllil y
extends a t p' s e lbow a nd simu lta neously pull s o n
the fo rearm in the IIlnar direction .
Stimulation of Anta goni sts: T re ta ins grip. T the n
as ks I' to move fu rt he r in the directi o n of
stretching. and resists that movement to stimul ate
p' s a nt agonists.
Note: To II/aximally st retch the palmaris longus in
thi s proced ure . it may be necessary to full y exte nd
p's fi ngers.
Fig.   a. Start ing Positi on.

Fig. -1. 8 b. Fi nal Positi on.
67
4 THE WRIST
4.1 THERAPY GUIDE
The muscl es which may restri ct movement at the wri st are li sted in Tabl e 4-1 . along with the appli cable
therapi es. indexed by manual sect ion number and page. Muscl e acti ons arc li sted in Table 4-2.
The vari ous restri cti ons possibl e are li sted in Movement Restri cti on Table 10.4 (p. 168) .
Tabte 4- t. Restrict ions at the wr ist
SECTION MOVEMENT MUSCLES WHICH MAY THERAPY Number Page
RESTRICTED RESTRICT MOTION
n. Volar flexi on Ext ensor digi torum communis 3. 3. 5, 3. 3.7 56. 5H
Ext e nso r pollicis longus 4. 2. t
7()
Exte nsor indicis 3. 3.6 57
Extensor digiti minimi 3. 3.8   ~
Ext e nso r carpi radialis longus 3. 3.3 54
Extensor carpi radial is brevis 3. 3.4 55
Extenso r carpi ul nari s 3.3. to 61
4.3 dorsal fl exion Palma ris lo ngus 3. 3. t6 67
Fl exor carpi ulnaris 3. 3. t t 62
Fl exor digit orum supe rfi cialis 3. 3. t3 64
Flexor di gi toru1l1 prof undus 4. 3. 1 7 1
Flexor poBids longus 4. 3.2 72
4.4 I?adia! flexion Flexor ca rpi ul naris 3. 3. 11 , 4.4. 1 62. 73
Extensor carpi ulnari s 3. 3. to, 4.4. t 6 1. 73
4.5 UIll ar fl exioll Abductor poll icis longus 4. 5. t 74
Ext e nso r po llieis brevis 4. 5. 2 75.
Fle xor ca rpi radiali s 3. 3. to 61
Exte nsor carpi rad ialis longus 3. 3.3 54
68
Table 4-2. Acti ons of muscl es whi ch may rest rict move me nt at the wri st.
MUSCLE ACTION
Ext ensor di gitorum
COJ11mUI11S
Ext ends fin ge rs. Fl exes at elbow. Supinates forea rm. Dorsal fle xes at wrist.
Ext ensor polli cis longus Ext ends thumb. Supinat cs forearm. Dorsal and radi al fl exes at wr ist.
Extensor polli cis brevis Ext ends thumb at CMC- and MCP- joint s (and oft e n IP- joint ) . Radi al fl exes at wrist. Vol ar or
dorsal fl exes at wri st (depending on position of hand ). Supinates for ea rm.
Extensor indi cis Ext ends and ulnar deviat es index fi nge r. Supinates forea rm. Dorsal fl exes at wri st.
Extensor di giti minimi Extends little fin ge r. Fl exes at elbow. Dorsal and uln ar fl exes at wr ist.
Extensor carpi radiali s Fl ex at e lbow. Supinat e for earm. Dorsal a nd radi al fl ex at wri st.
longus and brevis
Ext ensor carpi uln aris Dorsal and ul na r fl exes at wri st. Fl exes at elbow. Supinat es forea rm.
Palmari s longus Flexes at elbow. Pronat es forea rm. Volar fle xes at wri st.
Fl exor carpi ulna ri s Fl exes at el bow. Pronates forea rm. Volar and uln ar fle xes at wri st.
Fl exor carpi radiali s Fl exes at e lbow. Pronates forea rm. Vola r and radi al flexes at wr ist.
Flexor digitoru1l1 super- Fl exes fi nge rs (incl ud ing at PIP joints). Flexes at e lbow. Volar flexes at wrist.
ficiali s
Fl exor digitorum pro- Flexes all fin ge r joint s except thumb. Vol ar fl exes at wri st.
fundus
Flexor polli cis longus Opposes and fl exes thumb. Volar fl exes at wri st. May pronat e for ea rm.
Fl exes at elbow (rarely) .
Abductor pol1ici s longus Ahduct'> thumb. Radial and volar fl exes at wrist. Supinates forearm.
NOTES: 1. Actions described in te rms most relevant to manual therapy. Cross-reference to terms often used in anatomy
text s:
Ulnar flexion (towards ulna) , corresponds to adducti on (us uall y of hand)
Radial flexion (towards radius), corresponds to abduction (usually of hand)
Volar fl exion (towards palm), corresponds to flexion of hand
dorsal flexion (towards back of hand). corresponds to extension of hand
2. Finger joint abbreviations : CCM - Carpo-metacarpal , IP - int erphalangeal, MCP - Metacarpo-phalangeal,
PIP - Proximal - interphalangeal.
69
4.2.1. The rapy for the extensor pollicis
longus.
Starting Position: P: Supine: upper arm and e lbo\\'
rest o n couch: elbo\\' at approximately <)()O fl exion:
forearm fully pronated: wri st ill neutral position
with thumb in full Hexion and opposit io n. T:
Standing facing P's ri ght side .
Grip: T's left ha nd grips radi al side of p's thumb
and stabili zes it in full fkxion and oppositi on
against p' s palm. T's right ha nd stabili zes p's
forearm at the ulnar side.
Procedure: Using this grip. T graduall y and full y
volar and ulnar flexes at p' s wri st whil e
simultaneously pronating p's forearm.
Stimulation of Antagoni sts: T retai ns grip. T the n
asks P to move furthe r in the direction of
st retching. and resists that movement to st imul ate
p's antagoni sts.
Note: The extensor pollicis brevis is also st retched in
th is procedure.
70
Fig.. 4 ~ ll. Starting Positi on .
  ~

Fig. -19 b. Fina l Position.

4.3.1. Therapy for the flexor digitorum
profundus.
Starting Position: P: Supine ; elbow flexed 90° and
forearm fully supinat ed; wrist in neutral position
with all finger joints. including the MCP joints.
fully exte nded. T: Sitting on couch. back against
p' s right side .
Grip: T's left hand grips volar sides of p's fingers
and full y extends a ll joints. including the MCP
joint s. (Note that p' s wri st remains in the neutral
positi on or sli ghtl y volar fl exed). T's right hand
stabilizes p's forearm at the mcdial side just above
thc wrist.
Procedure: Using thi s grip. T gradually and fully
dorsal flexes at p's wrist.
Stimulation of Antagonists: T retains grip . T then
asks P to move further in the direction of
stretching. and resists that movement to st imulate
p' s ant agoni sts.
-.--
--
Fig. 50 a. Starting Positi on.
- --
--
71
Therapy for the flexor pollicis longus.
Starting Position: P: Supine; upper arm and el bow
resting against the co uch or against T's abdomen or
thi gh; e lbow fl exed approximatel y 90° and forea rm
full y supinated; wri st in neutral pos it ion wi th
thumb full y extended.
T: Sta nding with ri ght side against P.
Grip: T s left hand grips p's entire thumb from t he
volar side and exte nds it maximall y. T' s ri ght hand
ho lds P's hand from the ulnar/volar aspecl. index
and mi ddl e fin ger around radi a l side of hane!.
Procedure: Using thi s grip, T graduall y and full y
supinates forearm and dorsal flexes at p' s wrist.
Stimulation of Antagonists: T retains grip. T then
as ks P to move further in the direct ion of
stre tching, and res ists that movement to stimul ate
P's antagoni sts.
Note: In anomalo us cases where the flexor pollicis
longus also ori ginates from the medi al epicondyle
of the humerus. it will be necessary to full y extend
p's e lbow to att ain max imal stretching. Ext ension
of P's thumb is more restri cted than whe n the
elbow is fl exed.
72
Fig. 51 a. Starting Posit ion.
Fi g. 5 1 b. Final Pos iti on.
4.4.1. Therapy for the fl exor carpi ulnaris
and the extensor ca rpi ulnari s.
Starting Position: P: Supi ne or sitti ng; ri ght ann
extended . ulnar side resting on couch; wri st in
nelltral positi on. T : Standing. left side against P.
Grip: T' s ri ght hand gri ps p's hand . palm-t o-palm
(" hands hake" grip) with radi al side of index fi nge r
touching the pi siform bone. T' s left hand stabili zes
P's extended arm against couch.
Procedure: Using thi s grip. T graduall y and full y
radial flexes at P's wri st.
Stimulation of Antagonists: T retains grip. T then
as ks P to move furthe r in the directi on of
stretching, and resists that movement to st imul ate
p's antagoni sts.
Notes: Insufficient ulnar glide may constrain the
treatment 's rad ial fl exing. Therefore, during
treatment T should feel fo r free ulnar gli de. If ulnar
glide is rest ricted, T shoul d mobili ze wri st to
restore uln ar gli de.
Radi al fl ex ion may also be restri cted in combi na-
tion with dorsal or volar fl exion. If so, procedure
should accordingly be fo ll owed with wrist dorsall y
or volar fl exed .
Fi g. 52 a. Starting Position.
Fi g. 52 b. Final Posi ti on.
73
4.5.1. Therapy for the abductor poll ids
longus.
Starting Position: P: Supine o r sitting: clbow Hcxcd
approximately 90°: forearm rull y pronated: wrist in
ncutral pos ition . T: Standing. right side against P.
Grip: T placcs thenar eminence of right hand ovcr
p·s first metacarpal bone (from dorsa l sidc) with hi s
fingers gripping the ulnar border of p·s hand (from
volar side). T"s left hand stabili zes p·s fo rcarm just
above the wri st.
Procedure: Us ing thi s grip. T graduall y and
maximall y II/liar flexes at P"s wrist.
Stimulation of Antagonists: T retai ns grip. T the n
asks P to move furth er in the direction of
stretching. and resists that movement to stimul ate
p·s ant agoni sts.
Note: For maximal stretching of the abductor
pollids longus in thi s procedure . T may simul -
taneously fully dorsall y fl ex at p·s wrist.
74
Fig. :)3 tI . Start ing Positi on.
Fig. 53 b. Final Posi tion.
4.5.2. The rapy for the extensor pollicis
brevis.
Starting Position: P: Supine or sitt ing: elbow a t
a pprox imately YO° fl exion : fo rearm full y prona ted
with wri st in nelltral positi on: thumb against palm.
in full o ppositi on a nd fl exion at all join ts. T:
Standing facing p's ri ght side.
Grip: T s ri ght ha nd grips p·s ha nd and thumb fro m
the vola r side. palm-to- palm. a nd holds p·s thumb
full y opposed and Ikxed in all joint s. T s left ha nd
stabili zes P"s fo rearm j ust above the wri st.
Procedure: Us ing th is grip . T graduall y a nd
maximall y ulllar and dorsal flexes at p's wrist while
full y prona ting p·s fo rearm.
Stimulation of Antagonists: T retains grip . T the n
asks P to move furthe r in the directi o n of
stretching. and resists that movement to stimul ate
p's antagoni sts.
Note: If the positi o n of greatest rest rict io n is
att ained with the wri st in vola r Oexion. the n it is
necessary to treal in that positi on.
....... -- 'V
I
,
Fig.   ~ a. Start ing Position.
Fig. 54 b. Final Pos it ion .
75
5 THE FINGERS
5. 1 THERAPY GUIDE
The muscles whi ch may restri ct movements of the fingers are li sted in Table 5- 1, along wi th the
applicable therapi es, indexed by manual sect ion number and page. Muscle act ions are li sted in Table
5-2.
The vari ous restri cti ons possible are li sted in Movement Restricti on Tables 10.5, 10.6 and 10.7 (pp.
169-171) .
TABLE 5. t Rest rictions at the fingers
SECTION MOVEMENT
5.2
5.3
5,4
5. 5
5. 6
5.7
5. 8
5. 9
RESTRt CTED
Flexion
Extellsion
AbductiOIl of ,hllmb
Adduction of l/Illm/}
OPPOSifioll of ,1111mb
Reposition of II/Umb
Opposition of lillie
f inger
Reposilioll of lillle
fi nger
RESTRI CTI NG
MUSCLE(S)
Ext ensor digitorum    
Ext ensor inel ieis
Ext ensor digit i mi nimi
I nterossci dorsales I
Interossei pal mares
l
Lumbricales·
Flexor pol lieis brevis
Flexor poll ieis longus
Flexor digitorum super ficiali s
Flexor digitorum prof undus
Inte rossei dorsales
2
Int e rosse i pal mares
2
Lumbrical es::!
Fl exor di giti mi nimi brevis
Adductor poll ieis a nd/or Inte ros-
se us pal mari s I
Abductor po ll ieis longus
Abduct or poll ieis brevis
poUi eis longus and bre-
vis. Interosseus palma ri s I and
Abd uctor polli ci s longus.
together
Individuall y
Flexor longus
Flexor polli eis brevis
Oppone ns polli eis andlor
Adductor poll ieis. transve rse
head
Abductor di giti mi nimi
Ext enso r d igiti minimi
Flexor digit i mini mi brevis
Opponens di giti minimi
THERAPY
NOTES: I ; Restricts onl y at DI P and PIP joint s: 2: Rest rict s onl y at Mer joint s.
76
Number
3.3.5. 3.3. 7
3. 3.6
3. 3.8
5.2. 1
5.2.2
5.2.3
5. 3. 1
4. 3.2
3. 3. 13
4. 3. 1
5.2. 1
5.2.2
5. 2.3
5. 2.2
5.4. 1
4.5. 1
5.5. 1
5.6. 1
4.2. 1
4.5.2
5. 2. 3
4.5. 1
4.3.2
5. 3. 1
5.7. 1
5.8. 1
3.3.8
5.2.2
5.9. 1
Page
56.5R
57
59
79
SO
SI
82
72
64
71
79
80
81
SO
83
74
84
85
70
75
80. 83
74
72
82
86
87
59
80
88
TABLE 5.2 Actions of muscles which may restrict movement s at the finge rs
MUSCLE ACTIO
Muscl es of the forearm
EXlensor digitorum Extends fingers. Flexes at elbow. Supinat es forearm.
communis Dorsal flexe s al wrist.
EXlensor indicis Extends and ulnar deviates index finger. Supinates forearm. Dorsal flexes at wr ist.
Extensor digiti minimi Extends littl e finger. Fl exes at el bow. Dorsa l and ulnar fl exes al wri st.
Flexor pollicis longus Opposes and flexes thumb. Volar flexe s at wr ist. May pronate forearm. Fl exes at elbow (rarely).
Flexor digitorurn super· Fl exes finge rs (including at PIP joints). Flexes at elbow. Vol ar flexes at wrist.
ficiali s
Flexor digitorul11 pro- Flexes all finger except thumb. Volar flexes al wrist.
fundus
Abductor poll icis longus Abducts thumb. Radi al and volar flexes at   Supinates forearm.
Extensor pollicis longus Ex te nds thumb. Supi nalcs forearm. Dorsal and radial flexes at wrist.
Extensor pollici s brevb Extcnds thumb at CMC and Mep joinb (and often at I P joinl). Radial flexes at wri st. Volar or
dorsal flexcs at wrist (depending on position of hand). Supinates forearm.
Muscles of the hand
Interossei dorsales
l
Flex a1 ]\'fCP joints. Extend at DIP and PIP joinb. Abduct fingers away from axial line through
middl e finge r.
pallllares
l
Flex at Mep joints. Extend at DIP and PIP joints. Adduct fingers toward axial line through middle
finger.
Lumbri cales
l
Flexor digiti minimi
brevis
Flexor pollicis brevis
Adductor pol li cis
Abductor poll icis brevis
Opponens
Opponens digiti mi nil11i
Abductor digiti min illli
Flex at MCP Extend at DIP and PIP joinl s.
Flexes at MCr joint of lillie finger.
Flexes al MCP joinl and assists opposition of Ihumb.
AdduCh thumb. head al so thumb.
Abducts thumb at MCP and CMC joints.
Opposes <lnd t humb
Fl exes little finger at CMC joi nt: opposes little finger.
Abducts and flexe s al MCr joint of little finger
OTES: 1. The interossei dorsales. interossei pal mares. and/or lumbrica les may restrict fi nger fl exion only at the DIP/a nd
PIP joints. and may restrict finger extension only at the Me p joints.
2. Actions described in terms most relevant to manual therapy. Cross reference to terms often used in anatomy
texts:
Ulnar fl exion : towards ulna, corresponds to adducti on (usually of hand)
Radial fl exion: towards radius. corresponds to abduction (usual ly of hand)
Volar flexi on: towards palm, corresponds to fl exion of hand
Dorsal flexion: towa rds back of hand . corresponds to extension of hand
3. Finger joint abbreviations:
CMCCarpo-metacarpal
IP Int erphalangeal
MCP Metacarpo-phalangeal
PIP Proximal -int e rphalangeal
77
78
5.2.1. Therapy fo r the interossei dorsales.
(St rctching of interosseus dorsalis I
shown)
Starting position: P: Supinc or sitting: e lbow Hexcd
approximatc ly 90° and support ed aga inst thc
couch: wrist in neutral positi on: Me p joint sli ghtl y
fl cxcd and DIP and PIP joint s in full Hcxion. T :
Standi ng faci ng p's ri ght side.
Grip: T grips P's index finger with right hand ,
thumb on dorsal side, and holds the DIP and PIP
joi nt s fully fl exed. T's left hand stabili zes P's wrist
and hand at the dorsal side.
Procedure: Us ing this grip. T graduall y and fu ll y
eXfends and oddllefS (in the ulnar di recti on) at thc
Me p j oint of p· s index finger.
Stimulation of Antagonists: T retains grip. T thc n
asks P to move furth er in the directi on of
st rctching. and rcsists that moveme nt to stimul ate
p's antagoni sts.
Notes: T should apply sli ght traction to ass urc good
glidc at the Me p joint. If dorsa l glide at the Me p
joint is painful <md/or restri cted. T should apply
slight tracti on while assuring dorsal glide.
Same grip and procedure for other three flIlgers.
wit h foll owing exceptions:
Finger Int erosseus
dorsa/is
Middle II
Ring III
Littl e IV
Addifional grip
procedllre
Middl e finge r abducted
in IIlnar directi on
Middl e fi nger adducted
in radial direction
Ring finger add ucted in
radial directi on
Fig. 55 3. St arting Posit ion.
79
5.2.2. The rapy for the interossei palmares.
(Stretching of interosseus palmaris
TV shown.)
Starting Position: P: Supine or sitting; elbow tlexed
approximately 90°; wrist in neutral position: all
joints of little finger fully flexed. T: Standing. left
side against P.
Grip: T's right hand grips P's littl e finger (or all p' s
fingers simultaneously) and holds the DIP. PI P and
Mep joints fully nexed. T's left hand stabili zes p's
wrist.
Procedure: Using this grip. T graduall y and fully
eXfends and abdllcfs (in the ulnar direction) at the
Mep joi nt of P's littl e finger.
Stimulation of Antagonists: T retains grip. T then
asks P to move further in the direction of
st retching, and resists that movement to st imul ate
P' s antagonists. Fi g. 56 a. Starting Position.
Notes: While extending the Mep joints during the
procedure. Tapplies tracti on with dorsal gl iding. If
the joints are painful it is advisable to st retch onl y
one muscle at a time.
The flexor digiti minimi brevis is also st retched in
thi s procedure.
Same grip and procedure for the other three
fingers . with foll owing exceptions.
Finger Inrerossells
palmaris
Thumb I
Index II
Ring III
80
Addifiollal grip
procedllre
Thumb finger abducted
in radial direction
Index finger abducted
in radial direction
Ring finger abducted
in ulnar direktion
5.2.3. The rapy for the lumbricales.
Starting Position: P: Supi ne or sit! ing; elbow Aexed
approximate ly 90°; fo rearm full y supinated ; wri st
in neutral pos iti on; MCP jo int s full y extended; DIP
and PIP joill1s full y fkxed . T: Standing. le ft side
against p's ri ght side.
Grip: T's ri ght hand grips all of p's fi ngers. ho lding
t hem full y extended at the MCP joints and full y
Aexed at the DIP and PI P joill1s. T' s left hand
stabili zes P's forea rm just above the wri st.
Procedure: Usi ng thi s grip . T graduall y and full y
dorsally flexes at P's wri st.
Stimulation of Antagonists: T retai ns gri p. T then
as ks P to move furthe r in the directi on of
stretching, and resists that move ment to stimul ate
p's antagoni sts.
Notes: P's Aexed elbow can be support ed against
the couch with T' s left hand gripping p' s hand at the
volar side. Thi s enables T to usc both hands to
obt ain maximal stretching.
Stretching the lumbricales indi viduall y, one at a
time, is most e ffecti ve.
Fi g. 57 a. Sta rting Posi ti on.
Fi g. 57 b. Final Pos iti on.
8 t
5.3.1. Therapy for the flexor pollicis brevis.
Starti ng Position: P: Supine or sitting: elbow fl exed
approximatel y 90
0
and steadi ed agai nst the couch:
forearm full y supinat ed: wrist in neutral position:
thumb extended. T: Standing facin g P.
Grip: T's left hand grips the proxi mal phalanx of p's
thumb. T' s right hand stabili zes p's hand from the
volar aspect.
Procedure: Using this grip. T grad uall y and full y
extel1ds p's thumb.
Stimul ation of Antagonists: T retains grip. T then
as ks P to move furth er in the directi on of
stretching, and resists that movement to stimulat e
p's antagoni sts.
Notes: During the procedure. it may also be
necessary to 5t retch by fully dorsally flexillg at p' s
wrist when extension is most rest ri cted in thi s
posit ion.
The interosseus palmaris I is also stretched in this
procedure.
82
Fig.. 5X <I. Starting Position.
Fig. 58 b. Final Positi o n.
S.4.I. Therapy for the adductor pollicis and
the interosseus palmaris I.
Starting Position: P: Supine or silt ing: elbow nexed
approxi matel y 900 and steadi ed against the couch:
wrist in nelltral position. T : Standing facing p's
right side.
Grip: T"s ri ght hand grips proximal phalanx of the
thumbandthe base of the first metaca rpal bone of
p' s hane!. 1'"s left hand stabili zes p's hand from the
do rsallradial aspect with 1'"s thumb against p's
palm.
Procedure: Us ing thi s grip. T gradua ll y and fully
abdllcls p' s thumb and si multaneously appli es
traction.
Stimulation of Antagonists: T retains gri p. T then
asks P to move furthe r in the directi on of
stretching. and resists that move ment to stimul ate
p' s ant agoni sts.
Note: For maximal stretching. P' s thumb should
also be mediall y rotated.
Fi g. 5') a. Starting Posit ion.
Fig. 59 b. Final Positi on.
83
5.5.1.
Therapy for the abductor pollicis
brevis.
Starting Position: P: Supinc or sitting; elbow Hcxed
approximatel y 90° and steadicd against the couch:
forearm full y pronated with wrist in full dorsal
fl exion; thumb full y cxtended at Mer j oint. T:
Standing facing P' s ri ght side .
Grip: T' s ri ght hand grips the first metaca rpal bonc
and thc prox imal ph alanx of p' s thumb from thc
volar side. with thenar eminence stabili zing p' s first
metaca rpal bone. T' s left hand stabili zcs p's hand
dorsall y and holds p's wrist full y dorsal and ulnar
tlcxed.
Procedure: Usi ng thi s grip . Tappli es tracti on and
graduall y and fully addl/CiS p's thumb.
Stimulation of Antagonists: T retains grip . T thcn
asks P to movc further in thc direction of
stretching. and resists that movemcnt to stimul ate
p's ant agoni sts.
Note: To attai n maximal stretching, i[ may bc
necessary to position p' s arm with the elbow
extended and the forearm full y supi nated.
84
Fig. 60 a. Starting Posit ion.
5.6.1. Therapy for the extensor pollicis
longus and brevis, the interosseus
palmaris I, and the abductor pollicis
longus.
Starting Position: P: Supine or sitting; ulnar side of
forearm and hand steadi ed against couch; forea rm
full y pronated with wri st in neutral positi on.
T: Standi ng. left side against p's ri ght side.
Grip: T' s le ft hand grips p's thumb with T' s thenar
e minence against the dorsal side of p' s first
metaca rpal bone. T' s ri ght hand stabili zes P's hand
from the ulnar-do rsal side.
Procedure: Using thi s grip , T graduall y and full y
opposes P's thumb whil e simultaneously appl ying
tracti on to the CMC joint orthe thumb.
Stimulation of Antagonists: T retains grip. T then
asks P to move furthe r in the direction of
stretching, and resists that movement to stimul ate
p's antagoni sts.
Fig. 6 1 a. St arting Positi on.
Fi g. 6 1 b. Final Position.
85
5.7.1.
Therapy fo r the opponens pollicis
and the adductor poliicis, transverse
head.
Starting Position: P: Supine o r si tting: e lbow flexed
a pprox imate ly 90° a nd steadied aga inst the couch:
wrist in ne ut ra l position: thumb extended. T:
Standing facing p's ri ght si de.
Grip: T's left hand grips the prox imal phala nx of p' s
thumb a nd fi rst metacarpal bone. T' s ri ght hand
stabili zes p's hand at the vola r-radia l side .
Procedure: Using thi s grip. T grad ua ll y a nd fully
reposes p's thumb a nd simult a neo usly applies
tracti on to the CMC joint of the thumb.
Stimulation of Antagonists: T retains grip. T the n
asks P to move furth e r in the direct ion of
stretching, and resists that movement to sti mul ate
p's a nt agoni sts.
86
Fig. 61 a. Starting Posit ion.
Fig. 62 b. Final Pos iti o n.
5.8.1. Therapy for the abductor digiti
minimi.
Starting Position: 1': Supine o r silling: elbow
extended a nd forearm fully supinated: wri st in full
dorsal and radial fl ex ion: all fin ge rs fully fl exed . T:
Standing. back against P.
Grip: 1"s left hand grips P"s llexed lilli e fin ge r. with
index finger over p' s di stal phalanx and hi s thumb
close to p' s MCP joint on the dorsal side. T"s ri ght
hand stabili zes p' s thumb and the rest of p' s lingers
at the radial side.
Procedure: Using thi s grip. T graduall y and full y
eXlcllds and ([ddllels (in the radi al direction) at the
MCP joint of p' s lilli e finge r. .
Stimulation of Antagonists: T retains grip. T then
asks P to move furthe r in the direction of
stretching. and resists that movement to stimul ate
p's antagoni sts.
Fig. 63 a. Starting Positi on.
Fig. 63 b. Final Positi o n.
87
5.9.1. Therapy for the opponens di giti
minimi.
Starting Position: P: Supi ne or sitting; elbow fl exed
approximately 90°; forearm full y pronated with
wrist fully dorsall y fl exed; finge rs fl exed. T:
Standing, left side against P.
Grip: 1"s ri ght hand grips P' s hypothenar
e minence. thumb over volar side of p's 5t h
metacarpal, tip at the hamate of the carpus. 1"s left
hand grips radial side of P's hand , wit h fingers
stabilizing the 4th metaca rpal bone at t he dorsal
side. 1"s left thumb may support P's triquetral and
hamate bones from the distal /palmar aspect.
Procedure: Us ing this grip. T appli es traction and
graduall y and full y reposes (extends and abducts)
at t he CMC joint of P' s li ttle finger.
Stimulation of Antagonists: T retains grip. T thcn
asks P to move further in the direct ion of
stretching. and resists that moveme nt to sti mul ate
p's ant agoni sts.
Note: The opponens digiti minimi may bc
maximally stretched wit h p's e lbow extended,
forearm full y supinated, and wrist full y dorsall y
and radi all y fle xed. However. thi s technique is
more difficu lt to perform.
88
Fig. 64 a. Starting Positi on.
PART3
THERAPY TECHNIQUES FOR THE LOWER EXTREMITY
6 THE HIP
7 THE K EE
8 THE ANKLE
9 THE TOES
89
6 THE HIP
6.1 THERAPY GUIDE
The muscles which may restrict movement at the hip are listed in Table 6-1, along with the applicable
therapies, indexed by manual section number and page. For the compound movements, some muscles
listed may restrict only one or two components of the movement , but are listed as they act in the move-
ment. Muscle actions are listed in Table 6-2.
In all cases , restriction at the hip may be regarded as affect ing leg motion relative to the body, or
conversely, body motion in the opposite direction relat ive 10 a stable leg. The various restrictions
possible are listed in Movement Restriction Table 10.8 (p.I72).
TABLE 6.1 Restrictions at the hip
SECTION MOVEMENT
RESTRICTED
6.2
6.3
6.4
6.5
6.6
6.7
Flexion wi,h knee extended
Flexion willi knee flexed
Flexion, addllclioll and
medial rotation
Flexion. adduction lind
lateral rotarion
other therapies for:
Flexion, abduction Qnd
mel/ia/ rotmioll
Olher fherapies for:
Flexion, abduction
and lateral roUltion
otlier therapies Jor:
RESTRICTING
MUSCLE(S)
The Hamst rings: Biceps femoris.
Semimembranosus. Semitendinosus
Adductor magnus. Gluteus maximus
and other adductors of hip
Gluteus maximus
The Hamstrings
Piriformis
Ouadratus femoris
Gluteus medius and minimus
Gluteus maximus. The Hamstrings.
The Add uctors
Gluteus maximus
The Hamstrings
AdduclOrs
Gluteus maximus. The Hamstrings.
The Adductors
Gluteus maximus
The Hamstrings
Adductors
Gluteus medius. The Hamst rings.
the Adductors
Gluteus medius
The Hamstrings
Adductors
6.8 ExteflSioll or hyperextension Iliopsoas
90
Rectus fe moris
Pectineus
Adductor longus and brevis
Adductor magnus
THERAPY Number
6.2.t
6.3.1
6.4.t , 6.S.1
6.2.1
6.4.2
6.4.1
6.IO.t
6.5.1
6.4.1
6.2.1
6.8.3, 6.tl.l ,
6.12.t-6.12.10
6.6.1
6.4.1
6.2.1
6.8.3, 6.11.1 ,
6.12.1-6.12.10
6.7.t
Page
94
95
96,98
94
97
96
107
98
96
94
105,109.
110-119
99
96
94
105. 109.
110-119
100
6.10.1 107
6.2.1 94
6.8.3,
6.11.1, 105,109,
6.12.1-6.t2.10 IlO-119
6.8.1 , 6.11.1101-102,
109
6.8.2
6.8.3
6.8.3, 6.11.1
6.8.3
103-1 04
105
105. 109
105
6.9 Extensioni" yper-exrellsioll, Gluteus medius and minimus 6. 10. 1 107
(ldduclio" and medial
r01alioll
Tensor fasciae latae 6. 10.2 108
Iliopsoas 6.8. 1, 6.11.11 0 1-102,
109
SarlOrius 6.9. 1 106
Deep muscles of hip 6.9. 1 106
6.10 Extension/II yper-exll'nsioll. Gl uteus medius and mi nimus 6.10.1 107
adduclion and /meral
rotalioll
Tensor fasciae lalae 6.10.2 108
6.11 Extem'ioll / h yper-exrellsioll, Pect ineus 6.8.3 105
abduction and medial
rotation
Adductor brevis and longus 6. 11 . 1 109
I liopsoas 6. 11 . 1, 6.8. 1 109,
101 -102
6. 12 Ex l eI/ s iOIl/l, y per-ex fellS iOIl , Pectineus. Adductor magnus 6. 12. 1-6. 12. 10 110- 11 9
abduction and lateral
Gracil is. and Adductor brevis
roratioll
other therapies for: Pecti neus 6. 8.3 105
Adductor magnus 6.8.3 105
Adductor brevis 6. 11 . 1 109
6. !3 Medial rOlation All lateral rotators 6. 13. 1 120- 122
6. 14 Lateral rotarion All medi al rotators 6. 14. 1 123-125
NOTE: I. Other muscles listed in Table 10.8 (p. l 72) may also restrict.
91
92
TABLE 6.2 Actions of muscles which may res trict movements at the hip.
MUSCLE ACTIO
Muscles of the buttocks
Glut eus maximus
Glut eus medius
Glut eus minimus
Tensor fasciac lat ae
Piriformi s
Quadrat us femori s
Muscles of the thi gh
The " Hamstrings"
Biceps femor is
Sc III i Ill elll bra
 
Adductor brevi s
Adductor longus
Adductor magnus
Iliopsoas
Rectus femori s
Pectineus
Sartorius
Gracilis
Extends and laterally rotates at hip.
Uppe r part : Abducts at hip.
Lowc r part : Adducts at hi p.
Vent ral pa rt : Flexes. abducts and medi ally rotates at hip.
Middl e part : abducts at hip
Dorsal part: Extends. abducb and lat e rally rotates at hi p.
Ve ntral part: Fl exes, abducts and mediall y rotates at hip.
Middl e part : Abducts al hip
Dorsal part : Ex te nds. abducts and lal e rall y at hi p.
Abducts. and mediall y rot ates a l hip. Extends and laterall y rotates at knee.
Abducts. laterall y rotates and ext ends at hip (to about 600 fl exion).
Laterall y   extends and adducts at hip.
LOll !!. head : Flexes and late rall y rot ates at knee. Extends. laterall y rOtates and aclducts at hip.
head : Flexes and laterall y rotates at knee.
Fl exes and mcdially rotales at knee. Exte nds. adducts and medi all y rotates at hip.
and mediall y rotates at knee. EXle nds. aclducts and medi all y rotates at hip.
Adducts. laterally rot ates and fl exes at hip.
Adducts.latcrally rot ates and flexes at hip.
Extends and ad ducts at hip.
Part wit h origin at ischia l tuberosit y: Adduct s. extends and medially rotates at hip.
Ventral and lateral flexes lumbar spi ne. Fl exes and laterally rotates at hip; abducts or adducts
(depending on which extreme position hip is in).
Flexes at hip. Ext ends at knee .
Flexes, adducts a nd laterally rotates at hip.
Flexes, abducts and lat erally rotates at hip. Flexes and medially rot ales at knee.
Adduct s at hi p. Flexes and laterall y rot ates when hip is extended. Extends and mediall y rotates
when hip is maximall y fl exed. Flexes and medially rotates at knee.
93
6.2. 1. Thcrapy fo r the biceps femoris ,
semimembranosus and semitendino-
sus (The Hamstrings).
Starting Position: P: Supine : hip in full fl ex ion and
thi gh stabili zed with a bclt : knee ex tendcd as much
as short ened muscles all ow. T : Standing at p's ri ght
si dc. facing P"s hcad.
Grip: p·s heel and lowcr leg rest on T"s left
shoulder. T" s left hand gri ps vc ntra l side of p· s
lowe r leg just below the knee. T"s ri ght hand
stabili zes p· s lcft t hi gh ve ntrall y j ust prox imal to
the knee . or left thi gh ma y be stabili zed with a bel t.
Procedure: Us ing th is grip . T graduall y and full y
eXlends at p·s kncc.
Stimulation of Antagonists: T moves lcft hand just
proximal to p·s ri ght ankl e. T thc n asks P to movc
furth er in thc dirccti on of stretching. and resists
that move ment to stimulat e P" s ant agoni sts.
Notes: This technique is eas ier for T and more
comfort able for P than conve nti onal stretching
with extended knec. It may be uscd in all cascs
whc re hi p fl exion is greatcr with thc knec fl exed
than wi th the kncc cxtcnded .
For maximal strctching of thc Hamstrings:
Muscle
Biccps femori s
Semimembranosus and
scm i tcndi nasus
94
Technique
Samc. cxccpt p·s lcg is
medial ly rOI{((ed at both
hip and knce and
addllcledat hip .
Same. cxccpt p·s leg is
lalcrally rowlcd at bot h
hip and knec and
abdllCied at hip.
Fig. 6) a. Starling Posi ti on.
Fig. 65 b. Final Pm,ition.
6.3.1. Therapy for the extensor muscles,
excepr the Ha mstrings.
Starting Position: P: Supine: left leg stabili zed with
a belt across hi s thi gh just above the knee: right hi p
and knee in fl exion . T : Standing at p's ri ght side.
facing p's head .
Grip: T"s left hand gri ps ve ntral side of p's knee. T"s
ri ght hand grips p' s th igh from the dorsal /medial
side just above the knee. (Thi s will also protect the
knee when maxi mal fl exion is painful ).
Procedure: Usi ng t hi s grip. T grad uall y and fu ll y
flexes at p's hi p.
Stimulation of Antagonists: T reverses grip. T then
asks P to move furthe r in the direct ion of
stretching. and resists that move ment with left
hand to sti mul ate p' s antagonists.
Fig. 66 a. Starti ng Position.
Fig. 66 b. Final Posit ion.
95
6.4.1. Therapy for the extensors, abductors
and lateral rotators.
Starting Position: P: Supi ne; left leg extended with
left thigh stabilized by a belt: right hip and knee in
llexion. T: Standing at P's ri ght side . facing p's
head.
Grip: T's left hand grips ventra l side of P's knee. T' s
ri ght hand grips medial side of p' s hee l or lower leg
just above the ankle.
Procedure: Using thi s grip. T graduall y and full y
flexes, addl/cls and medially rotales at p' s hip.
Stimulation of Antagonists: T retains gri p. T then
as ks P to move furth er in the direct ion of
stret ching, and resists that move ment to stimul ate
p' s ant agoni sts.
96
Fig. 67 C1. Starti ng Position.
Fig. 67 b. Final Positi on.
6.4.2. Therapy for the extensors, abductors
and lateral rotators. !-l ip flexed 60".
( Mai nl yslretching the piriformis).
Starting Position: P: Supine : pelvis stabili zed with a
belt: left hi p and knee extended : ri ght hi p and knee
pos iti oned in approximate ly 60' fl ex ion: ri ght foot
steadied against the couch on the late ral side of left
leg. T : St anding at p's right side. facing p's head.
Grip: T"s right hand gri ps ven tral- lateral side of p's
knee. T' s le ft hand and forcarm support and
control p's pelvis.
Procedure: Us ing thi s grip. T gradual! y and full y
addll cls at P's hip.
Stimulation of Antagonists: T retains grip. T the n
asks P to move furth er in the directi on of
stretching, and res ists t hat movement to stimul ate
P's ant agoni sts.
Note: p's left thi gh may limit movement of the ri ght
leg. So to all ainmax imal stretching of the
piriformis, it may be necessary to fl ex p's left knee
and f1c x and abduct the left hip before to furthe r
adducting the right hip .
Fig. 68 a. Starting Position.
97
6.5.1. Therapy for the extensors, abductors
and medial rotators.
Starting Position: P: Supine: left thi gh anel pcl vis
stabili zcd with bclts: right hip and kncc Il excd. T:
St anding at p' s righ t side.lcve l with p's hips.
Grip: T s left hanel grips vc ntral side of p' s kncc. T s
right hand grips p's lower leg just above the an kle.
Procedure: Usi ng thi s grip. T gradually and full y
flexes, addl/CiS and laterally rorates at p' s hip .
Stimulation of Antagonists: T retains grip. T then
asks P to movc furth er in the directi on of
stretching. and resists that movement to st imul ate
p's ant agoni sts.
98
Fi g. 69 <I. Start ing Position.
Fig. 69 b. Final Position.
6. 6. 1. Therapy for the ext ensors, adductors
a nd lateral rota tors.
Starting Position: P: Supinc: lcftthi gh stabi li zcd
\Vith a belt: (a bclt ovcr p's pelvis providcs
addi tional stabi li zat io n): right hi p and knce 11excd .
T: Sta nding a t p's ri ght sidc. level \Vith p's kncc.
Grip: 1"s left ha nd grips medial sidc of p's thigh j ust
abovc thc knec. 1"s ri ght ha nd gr ips p's 10\Ver Icg
j ust abovc t hc a nkle.
Procedure: Using thi s gri p. T graduall y a nd full y
flexes, abdl/Cls andliledia!(" ro{{/ {es at P"s hip.
Stimulat ion of Antagonists: T movcs right ha nd 10
proximal-l ateral side of knec. T t hc n as ks P to
movc furthe r int hc di rect ion of strctching. a nd
resists that moveme nt \Vith both hands to sti mul ate
p's a nt agoni sts.
Fig. 70 a. Starting Positi on.
Fig. 70 b. Final Pos itio n.
99
6.7.1. Therapy for the extensors, adductors
and medial rotators.
Starting Position: P: Su pi nc: I crt thigh stabili zcd
wit h a belt: (a bc lt ovcr P"s pelvis provides
addit ional stabil ization): right hip and kncc fl exed.
T: Standing at p's ri ght side . facing p' s head.
Grip: T"s left hand gr ips vc ntral side of p' s knee. T"5
right hand grips p's lower leg just above the ankle.
Procedure: Us ing thi s grip. T graduall y and fully
flexes, abell/cIs and /{{{erally fOtaleS at P"s hip.
Stimulation of Antagonists: T rctains grip. T thc n
asks P to movc further in the direct ion of
stretching. and resists that movement to sti mulat e
p' s ant agonists.
100
Fig. 71 a. Starting Position.
6.8.IA. Therapy for the iliopsoas. Mliscle
markedly s//O/'Ielled.
Starting Position: P: Prone with hip joint located
sightly fo rwa rd o f couch hinge (so lower end of
couch ma y be elevated); Icftleg ove r side o f couch.
foot on the 11001': to avoid lumbar lordos is (whi ch
also may be painful ). thc foot may be moved
fo rward o n the 11 00 r and stabili zed in position by
Ts left fool. This l1exes hip furthe r, nall e ns the
lordosis a nd prevents P evading the stre tching ; a
cushi o n ma y be placed unde r the abdo me n to
increase ve ntral f1 exion of the lumbar spine (and
therefo re the effect of the stretching); pelvis
stabili zed with a bell. T : Standing fa ci ng p' s left
si de about level with p's ri ght knee.
Grip: T's ri ght hand adj usts the a ngle of the foot
e nd of the couch. T s left hand is pl aced on the
dorsal side o f p's ri ght thi gh just distal to the ischial
tuberosity.
Procedure: Using thi s grip, T s ri ght ha nd slowly
lifts the lower pa rt of the couch. thc reby graduall y
and full y extelldillg at p's hip.
Stimulation of Antagonists: T moves ri ght hand to
dorsa l side of thi gh just proximal to knee . T the n
as ks P to move further in the direction of
stretching, and resists that movement to stimulate
p's antagonists. To increase contraction when
st imul ating, T uses left hand to slap p's right
bUllock.
Note: I f the lower e nd of the couch cannot be
elevated. T can use ri ght hand to suppo rt P's leg
j ust above the knee . and gradually lift the leg to
extend at the hip.
Fi g. 72 a. Starting Position .
Fi g. 72 b. Final Position.
tOt
6.8.1B. The ra py for the iliopsoas. Maxilllal
slre[(;hillg.
Starting Position: P: Prone: t run k in left lateral
flexion: left leg over side o f couch with foot o n
11 00r: to avoid lumbar lo rdos is (whi ch ma y be
painful). foot may be moved fo rward on the li oor
a nd stabili zed in position by 1""s left foot: thi s flexes
hip furth er. il all e ns the lordosi s a nd preve nt s P
evad ing the stretchi ng: left foot posit ion regul ates
lumbar lordosis. important in treating patients wi th
low back pain : a cushi on may be pl aced under the
abdomen to increase ve ntral l1ex io n of the lumba r
spine (and therefore the effect of the st retching):
pelvis stabili zed wit h a belt: ri ght knee llexed with
ri ght hip in full medial rotation. T : Standing
obli q ue. facing p's left side level wit h p's thighs.
Grip: Ts right ha nd grips p's lower leg just above
the ankl e. After raising lower e nd of couch (see
Procedure), Ts le ft hand ca n be used to stabili ze
p's right thi gh at the dorsal side just dista l to the
ischi al tube rosi ty; this increases st retching.
Procedure: Us ing this grip. T uses left hand to
slowly rai se the foot e nd of the couch. thereby
graduall y and full y ex/endillg medially ro/ared hip.
Stimulation of Antagonists: T moves ri ght hand to
do rsal side of thi gh just proximal to knee. T then
asks P to move further in the directi o n of
stre tching. and res ists that movement to sti mul ate
P's ant agonists. To increase contraction when
st imulating, T uses left hand to slap P's ri ght
buttock.
Note: If the belt stabili zat ion fails to hold P's pelvis
in pl ace after the foot e nd of the couch is rai sed. 1""s
le ft hand can be placed over p's right thigh to press
the pelvis ve ntrall y towards the couch.
102
Fig. 73 a. Starti ng Position.
6.8. 2A Therapy for the rectus femoris .
Mllscle II/arkedly shortened.
Starting Position: P: Prone; pelvis (and thus the
origi n of the rectus femoris) stabi li zed to the couch
\\i t h a be lt : left leg over side of couch with foot on
110or: to avoid lulllbar lordos is (whi ch also Ill ay be
painful). foot can be Ill oved fo rwa rd on floor and
stabil ized in posi ti on by Ts left foot: thi s fl exes p's
hip further. fl att ens the lordos is and prevents P
from evading the st retching: a cli shi on may be
placed under p's abdomen to increase ve nt ral
flexion of the IUlllbar spine (a nd therefore t he
effect of the st retchi ng): ri ght knee Hexed. T:
Standing facing p's left side at the lower end of the
couch.
Grip: T s right hand grips ventral side of p's ankle.
T s left hand stabi li zes p's thigh j ust distal to the
ischial tuberosity.
Procedure: Using t hi s grip. T graduall y and full y
flexes at p' s knee unti l the heel reaches the butt ock.
ote: Stimul ati on of the antagoni sts: N01 recolI/ -
mellded,' may C({lIse cramps.
Fig. 7-1 a. Start ing Posi ti on.
Fig. 7-1 b. Final Pos ition.
]03
6.8.2B. Therapy for t he rectus femoris.
Maximal slrelchill g.
Starting Position: P: Prone; pelvis (and thus the
ori gin of the rectus femoris) stabili zed to the couch
with a belt; le ft leg over side of couch with foot on
fl oor ; to avoid lumbar lordos is (which also may be
painful ). foot can be moved forwa rd on fl oor and
stabili zed in positi on by T' s left foot : thi s flexes p's
hip furth er. fl all e ns the lordosis and prevelll s P
from evading the stretching; a cli shi on may be
placed unde r p's abdomen to increase ve ntral
fl exi on of the lumbar spine (and therefore t he
effect of the stretching); right hip he ld in full
hyperextension by raising the foot end of the
couch; ri ght knee fl exed. T: St anding oblique .
facing p's left side at the lower end of the couch.
Grip: T' s ri ght hand grips ve ntral side o f p's ankl e.
T s left hand stabili zes p's th igh j ust di stal to the
ischi al tuberosit y.
Procedure: Using thi s grip . T graduall y and full y
flexes at P's knee until the heel reaches the butt ock.
Notes: Stimul ation of the ant agoni sts: NOI
recommended: /1wy calise cramps.
Once in the fin al positi on. furth er stretching may
be attained by graduall y raising the foot e nd of the
couch hi gher.
104
Fi g. 75 a. Starting Positi on.
Fig. 75 b. Final Pos itio n.
6.8.3. Therapy for the pectineus and
adductor longus, brevis and magnus.
Starting Position: P: Lying on left side; left hip and
knee fully fl exed (or P holding own left knee with
bot h hands), pelvis stabili zed wit h a belt just crani al
to the greater trochanter ; ri ght hip full y extended
and mediall y rotated. T: Standing behind P, level
with P' s thigh.
Grip: T"s ri ght hand grips the medial side of p·s
knee a nd T"s ann supports p·s lower leg. Ts left
hand placed on P"s pe lvis at be lt. just crani al to the
great er trochant er. to stabilize and control p's
pelvis.
Procedure: Us ing t hi s grip. T graduall y and fully
abdll cls at p·s hip.
Stimulation of Antagonists: T moves left hand to
lat eral side of thi gh proximal to the knee. and right
hand to late ral side of leg just proxima l to the
ankl e. T then asks P to move furth er in the
directi on of stretching. and resists that movement
to stimulate P's antagonists.
Notes: Abduction at the hip may be pe rformed in
va rying degrees of fl exion. extension and lateral or
medial rotat ion as needed. However . accordingly it
may be necessary to change both the starting
pos it ion and the grip.
Maximal extension. abducti on. and medial rota-
tion at the hip (when none of the surrounding
tissues arc short ened) produces a close packed
1'0Silioll whi ch blocks furth er moveme nt.
With the knee extended. the short adductors and
the gracilis arc stretched if the hip is also fu ll y
extended . abducted and laterall y rotated. Flexing
the knee excl udes the gracilis from stretc hing.
Fig. 76 a. Starting Positi on.
Fig. 76 b. Final Position.
105
.
6.9.1. Therapy for the deep muscles.
Starting Position: P: Lying on ri ght side; left hi p and
knee both flexed approximately 90° with knee ,
lower leg and foot resting on couch or on cushion;
ri ght hip fully extended with knee flexed
approximately 90°; pelvis stabilized wit h a belt;
cushion may be placed under waist to fu rther sup-
port pelvis and lumbar spine. T: Standing behind P
at the lower end of the couch, about level with P's
thigh.
Grip: T s right hand grips p's right knee and thigh
from the ventra l/lat eral side. Ts left hand gr ips p's
lower leg just (lbovc the ankle.
Procedure: Usi ng t hi s grip. T gradual ly and fully
ex/ellds. addllCls a nd lIledially rora/es at P's hip.
Stimulation of Antagonists: T ret ains gri p. T then
asks P to move furth er in the direction of
st retching. and resists that movement to sti mulat e
p's ant agoni sts.
Fig. 77 a. Starling Position.
Notes: The iliopsoas, glut eus medius and minimus ,,-
and tensor fasciae lat ae are also st retched sli ghtl y in r
proccdure. see t herapies 6.R.IA . B pp. 101 - 102.
The sartorius may be stretched using thi s
technique. if p' s right knee is extended instead of
flexed.
t06
Fig. 77 h. Final Position.
6. 10. 1. Therapy for the gluteus medius and
minimus.
Starting Position: P: Lyi ng on ri ght side: le ft hi p and
knee flexed approx imately 90° wit h knee. lower leg
and foot resting on couch or a pill ow: ri ght hi p ancl
knee exte nded: pe lvis stabili zed wi th a bel t: if
necessa ry. a firm cushi on may be placeu unde r t he
waist to further support the pelvis and lumbar
spi ne. T: Standing behind P at the 10IVer end o f the
couch. leve l wi th p's right knee.
Grip: T"s left hand grips P"s ankl e and the proxi mal
part of the foot at the dorsal- late ral side (or around
p's lower leg j ust above the ankl e). T"s ri ght hand
grips ve ntral-lateral side of p's thi gh j ust above the
knee.
Procedure: Using th is grip. T graduall y and full y
addllcts at p's hip. Fig. 78 a. Starting Positi on.
Stimulation of Antagonists: T moves hands to
medial side of p's thigh and leg. T the n asks P to
move further in the direction of stretching. and
res ists that move ment to stimul ate p's antagoni sts.
Notes: To compl ete ly st retch the gluteus medius
and minimus , the above procedure shou ld be
re peat ed with t he fo ll owing modi fica ti ons:
Specific stretching of parts of the glut eus medius
and minimus:
Vent ral part
Dorsal part
Same grip and procedure. ex-
cept P's hip is also extended and
laterally rotated.
Same grip and procedure, ex-
cept P' s hi p is also sli ghtl y flexed
and medially rotated.
Fig. 78 b. Fi nal Positi on.
107

6.10.2. Therapy for the tensor fasciae latae.
Starting Positi on: P: Lying on ri ght side: left hip and
knee fl exed approx imately 900 wit h knee. lower leg
and foot rest ing on couch or pill ow; right hip
extended and latera ll y rota ted with knee f1 exed
approximately 90°; pe lvis stabi li zed with a belt:
fir m cushi on under waist improves support of pelvis
and lumbar spine. T: Standing behind P. level with
p's upper leg.
Grip: T s le ft hand grips ve ntral- lateral side of p's
knee and thi gh and forearm supports lat eral side of
p's lower leg. T"s ri ght hand stabili zes and controls
p's pelvis.
Procedure: Usi ng th is grip. T gradually and full y
extellds. adduCI.I· and laterally rotates at p' s hip .
Stimulation of Antagonists: T moves ri ght hand to
medi al-dorsal side of thi gh just proximal to the
knee. T the n asks P to move furthe r in the direction
of stretching. ancl resists that movement to
stimu late p's antagoni sts.
Note: Maximal st retching is att ained when p's ri ght
knee is fl exed maximall y.
108
Fig. 79 a. Starti ng Position.
Fi g. 79 b. Final Posit ion.
6.11.1. Therapy for the pectineus, adductor
brevis, adductor longus and ili o-
psoas.
Starting Positi on: P: Prone; if necessary. a cushi on
may be placed under abdomen to stabili ze pelvis
and· lumbar spi ne: pelvis is then stabili zed with a
be lt. T: Standing faci ng p·s ri ght side.
Grip: T"s left hand holds ve ntral-med ial side of p·s
knee and thi gh. and p· s lower leg is stabili zed
between T"s left arm and chest. T"s right hand
stabili zes P's ri ght ilium.
Procedure: Using thi s grip. T graduall y and full y
extends, lIIedially rotates and abduCls at p·s hip.
St imul at ion of Ant agonists: T moves right hand 10
dorsa l side of P' s thigh just proximal to knee ' \ll d
left hand to lateral side of leg just proximal 10 the
ank le. T then asks P to move further in the
direction o f st retching. and resists that movement
to stimulat e P's antagonists.
Notes: For more secure pelvis stabili zation. T
pos iti ons p·s left leg over the edge of t he couch wi th
the sole of the foot on the floor. Thi s also flexes p·s
lumbar spine.
To increase the st retching. the lower part of the
couch may be raised. Howeve r. T must then alter
grip . sec therapy 6.S. 1 A, p. 101.
'.
Fig. 80 a. Starti ng Positi on.
109
6.12. 1. Therapy for the adductor muscles.
Bilateral stretchil1g.
Starting Position: P: Supi ne: hips and knees Il cxed
wi th feet together on couch: to preve nt lo rdosis.
lumbar spi ne shoul d be Hexed either by placing a
cushion under the thorax or by ra ising t he head end
of the couch: pelvis stabili zed wit h a belt. T :
Standi ng obl ique. at the lower end of the couch.
leve l with p' s feet.
Grip: Using both hands. T grips ve ntral-medial
sides of p' s knees. For extra force . 1"s foreann(s)
may be pl aced against P's knee(s). as shown here
for ri ght hand and forearm.
Procedure: Using thi s grip . T graduall y and full y
abdllcts at P's hi ps.
Stimulation of Antagonists: T moves hands to
lateral sides o f knees. T the n asks P to move furthe r
in the directi on of stretching. and resists that
movement to stimul ate p' s ant agoni sts.
11 0
Fig. 8 1 a. Starting Position.
Fi g. 8 1 b. Fi nal Positi on.
6.12.2. The rapy for thc adductors. /l ip
extended.
Starting Position: P: Supinc: right legcxtendcd: left
hip exte nded a nd abductcd: pel vis stabili zcd \Vit h a
bclt : left 10\Vc r Icg ovc r sidc of couch furth e r
st abili zcs pe lvis: to prevent lordos is. lumbar spi nc
sho ul d be fl exed ei the r by a cushi on under thorax
or by rai sing thc head e nd of thc couch. T : Standi ng
at lower end of cOll ch. faci ng p' s right side.
Grip: T s right hand grips p's lower Icg just above
the ankl e. T s Icft ha nd grips medi al-dorsal sidc of
p's thi gh just abovc the knee.
Procedure: Us ing th is grip. T grad uall y a nd fu ll y
abdll cls at p's hip .
Stimulation of Antagonists: T moves le ft ha nd to
lat e ral sidc of p's thi gh proxi mal 10 thc knec. T then
asks P to move furthc r in the directi on of
st retching. and resists that movement to stimul ate
p' s a ntagoni sts.
Note: For lIIaxilllal stretching. T can mcdiall y or
laterall y rotatc (as needed) \Vhile abducting at p' s
hip . p's hip Illust not be f'l excd d uring abduct ion.
1
Fig. ~   a. Starting Posi ti on.
)
Fig. 82 b. Fina l Pos iti o n.
til
6.12.3. Therapy for the adductors. (Mainly
stretching the long adductors, except
the gracilis) . Hip flexed 45°.
Starting Position: P: Supine; right hip Hexed
approximately 45° with foot on couch: left hip
extended and abducted: belt stabili zi ng pc\ vis : left
lower leg ove r side o f couch furth er stabili zes
pel vis: to prevent lordos is. lumbar spine should be
He xed either by a cushi on under the thorax or by
raising the head end o f the couch. T: St andi ng
facing p's ri ght side.
Grip: Ts ri ght hand grips medi a l side of p· s lowe r
leg just above the ankle; ri ght forearm lying along
the medial side of p· s lower leg and knee. T s left
hand stabi li zes and cont rols p·s pelvis on the
opposite side.
Procedure: Using thi s grip . T grad uall y and full y
abdllcls at p·s hip.
Stimulation of Antagonists: T moves ri ght hand to
lateral side of p· s ri ght knee. T the n as ks P to move
furth er in the direction o f stretching. and resists
that movement to stimul ate p' s ant agoni sts.
Note: T can va ry abducti on. as needed. by varying
positi on of p· s foot o n couch.
11 2
Fi g. 83 a. Starling Posi ti on.
Fi g. 83 b. Final Positi on.
6.12.4. Therapy for t he adductors. Hip
fl exed 90".
Starting Position: P: Supine; right knee fl exed: ri ght
hip fl exed approximately 90°: left hip extended and
abducted; belt stabili zing pelvi s: left lower leg may
be over side of couch to further stabili ze pelvis: to
prevent lordos is. lumbar spine should be flexed
eithe r by a cushion uncl er the thorax or by raising
the head end of couch. T: Standi ng at p' s right side .
Grip: 1"s ri ght hand grips p' s foot or lowe r leg j ust
above the ankl e. ri ght forearm lyi ng along t he
medial side of P's lower leg and knee. 1"s left hand
stabili zes and controls P's pelvis on the opposit e
side.
Procedure: Using thi s grip , T graduall y and fully
abducts at P's hip.
Stimulation of Antagonists: T moves ri ght hand to
lateral side of P' s ri ght knee. T then asks P to move
furthe r in the direction of stretching, and resists
that movement to stimul ate P's antagonists.
Notes: T should stretch with P's hip rotated to the
position where abduction is most restri cted.
From hyperextension to approximately 60° fl exion,
the adductors act as flexors and lat erally rot ators
at the hip and are maximally stretched when the
hip is extended, abducted and medially rotated.
From 60° fl exion to full fl exion, the adductors act as
extellsors and medial rotators at the hip and are
maximally stret ched when the hip is fl exed, abduc-
ted and laterally rotated.
Fi g. 8-1 a. St arting Positi on.
Fig. 8-1 b. Final Positi o n.
113
6.12.5. Therapy for the adductors. flip fi lii),
flexed.
Starting Position: P: Supine: right hip full y fl exed:
left hip extended and abducted: belt stabi li zing
pel vis: leftlolVer leg may be positi oned over side of
couch to furth c r stabili ze pel vis: to prevent
lordosis. lumbar spine shoul d be l1cxed either by a
cli shion under the thorax or by raising the head end
orthe couch. T: Standing. left side towards P"s ri ght
side.
Grip: Ts right hand grips p' s 10IVer leg just above
the ankl e. ri ght forearm lying along the med ial side
of p's 10IVe r leg and knee . T s left hand stabili zes
and controls p's pel vis on the opposite side.
Procedure: Us ing this grip. T graduall y and full y
abdl/CiS at p' s hip .
Stimulation of Antagonists: T moves right hand to
lateral side of P' , ri ght knee. T then asks P to move
furth er in the directi on of stretching. and resists
that movement to stimul ate p' s antagoni sts.
Note: For increased st retching effect
abducting. T may latera lly rotate p's hip.
degree needed and possibl e.
114
whil e
to the
Fig. 85 a. Start ing Positi on.
Fig. R5 h. Final Posit ion.
6.12.6.
Therapy for the adductors. (Mainly
stretching the long adductors, except
tlte gracilis). Hip flexed 45°.
Starting Position: P: Prone: hi p flexed approx-
imate ly 45°: knee nexed approxi mat ely 90°. T:
Standi ng facing p·s left side.
Grip: T"s right hand controls degree of rotation at
p·s hi p by gripping p·s lower leg just above the
ankl e and stabili zi ng it aga inst p·s left leg. T"s left
hand is placed over p·s ri ght greater trochanter.
Procedure: Using this grip . T pushes left hand down
to graduall y and full y abdllCl at p·s hip: p·s pelvis
rotat es until the medi al side of the thigh is pressed
agai nst the couch.
Stimulation of Antagonists: T moves right hand to
lateral side of P"s knee and left hand to ve ntral side
of thigh just distal to hip . T then asks P to move
further in the direction of stretching. and res ists
that movement to stimul ate p·s ant agoni sts.
Note: If needed. T may tension a belt at the level of
p· s great er trochant er to draw the thigh down to the
cOll ch. see therapy 6. 12.9 p. j 18.
Fig. 86 a. Starl ing Position.
115
6.12.7. The rapy for the adductors. Hip
flexed 90".
Starting Posit ion: P: Prone; hip and knee fl exed
approx imate ly 90°. T: Standing facin g P's left side .
Grip: T s ri ght hand controls degree of rotat ion at
p's hip by gripping P' s lower leg just proximal to the
ankl e and stabili zing it aga inst the couch. T' s left
hand is placed over p's ri ght greater trochanter.
Procedure: Us ing thi s grip , T pushes left hand down
to graduall y a nd full y abduct at p's hip . P's pelvis
rotates until the medi al side of t he thigh is pressed
against the cOllch.
Stimulation of Ant agoni sts: T moves ri ght hand to
lateral side of p's ri ght knee and left hand to vent ral
side of thigh just distal to hip . T then asks P to move
furth er in the di rection of stretching. and resists
that movement to st imul ate P's ant agoni sts.
Note: I f needed, T may tension a belt at the level of
p' s greater trochant er to draw the t hi gh down to the
couch, see the rapy 6.12.9 p. 11 8.
t 16
Fig. 87 a. St arting Positi on.
6.12.8. Therapy for the adductors. Hip jitf' y
flexed.
Starting Position: P: Prone; hip full y fl exed: knee
flexed approx imately 130°. T: Standing faci ng p's
left side.
Grip: T' s right hand controls degree of rotati on at
p's hip by gripping p's lower leg just above the
ankl e and stabili zing it against the couch. T s left
ha nd is placed over p's right greater trochant er.
Procedure: Using thi s grip . T pushes left hand down
to graduall y and full y abdllcf at P's hip . p's pelvis
rotates until the medial side of the thi gh is pressed
against the couch.
Sti mulation of Antagonists: T moves ri ght hand to
lat e ral side of p's right knee and left hand to ve ntral
side of th igh j ust di stal to the hip. T then asks P to
move further in the direction of stret ching, and
resists that movement to stimul ate p's ant agoni sts.
Note: If needed .T may tension a belt at the level of
p' s greater troc hant er to draw the thi gh down to the
couch. sec thcrapy 6. 12.9 p. 11 8.
Fi g. 88 a. Starting Positi on.
Fig. 88 b. Final Position .
117
6. 12.9. Therapy for the adductors. Belt
tension a/ferll arit'c (0 preceding three
therapies.
Alt ernati ve techn iq ue: If P is large andlor strong
compared 10 T . or T ot herwise fi nds press ing p's
thi gh down to the couch diffic ul t. then belt te nsion
may be used instead o f T s to apply the fo rce
required fo r abducti on in therapies 6. 12.6. 6. 12.7.
and 6.12.8 on the preced ing t hree pages. The
exa mple shown he re is t he alte rnate be lt proced ure
to the hand proced ure of therapy 6.12.6 o n page
11 5.
Starting Position: P: As specified fo r the techni que
in volved . except p·s pelvis is stabili zed to the couch
with a belt having a continuously-adj ustable
buck le. wi th t he free tongue of the be lt lyi ng ovcr
p's left side. towa rds T.
Grip: 1"s left hand grips the buckl e of the belt. 1"s
right hand holds the free tongue of the belt near the
buckl e.
Procedure: T ti ght ens the belt. T asks P to push
upwards against the belt. .
Thi s force adducts the ri ght hi p. T then as ks P 10
re lax slowly. As P relaxes. T further ti ght ens the
belt 10 graduall y abdll ct at p's hi p. p's pelvis the n
rotates so the medial side of the ri ght thigh and hip
arc gradua ll y pressed down against the couch. T
repeats until maximal stretching is attained.
Stimulation of Antagoni sts: Same as for preceding
three techni ques: T moves right hand to late ral side
of p·s ri ght knee and left hand to ve ntral side of
th igh j ust distal to hip . T then asks P 10 move
furth er in the direc ti on of st re tching. and resists
that movement to stimulat e p's ant agoni sts.
11 8
Fig. 89 a. Start ing Position.
6.12.10. Therapy for the adductors (including
the gracilis). P Oll side.
Starting Position: P: Lying on left side; left hip and
knee fully fl exed ; ri ght leg extended; pelvi s
stabi li zed by a belt ; P may hold own left knee with
both hands (thi s helps prevent lordosis). T:
Standing behind P at the lower end of the couch .
Grip: T's ri ght hand grips medial-dorsal si de of P' s
ankl e. T's left hand grips P's thigh from behind just
above the knee and from the medial -ventral side.
Procedure: Using this grip, T graduall y and full y
abducts, medially rotates and extends at P' s hip.
Stimulation of Antagonists: T moves both hands to
lateral sides of leg. T then asks P to move further in
the directi on of stretching, and resists that
movement to stimul ate P's ant agoni sts.
Notes: Flexing the knee excludes the gracili s from
st retching, as in therapy 6.8.3 p. 105. As the exact
function of the adductors depends on hip position
always stretch in positi on of maxi mum rest ricti on.
Fig. 90 a. Starling Positi on.
Fi g. 90 b. Final Position.
119
6.13.1A. Therapy for the latera l rotator
muscles. Knee normal, fl exed 9(J' in
treatmen!.
Starting Position: P: Prone; knee flexed 90°; pe lvis
stabili zed wit h a belt. T: Standing facing p's ri ght
si de .
Grip: T's left hand grips ve ntral-medi al side of P's
knee and thigh; left forearm li es along the medial
side of P's lowe r leg. T's ri ght hand stabili zes and
controls P's ri ght ilium and sacrum.
Procedure: Using thi s grip, T gradually and full y Fig. 9 1 a. Starling Position.
medially rotates at P's hip.
Stimulation of Antagonists: T may change grip or
retain grip and use body to resist moti on. Tasks P
to move further in the direct ion of st retching. and
res ists that move ment to stimul ate P's ant agonist s.
Notes: The above procedure ass umes a normal
knee capable of tolerating stress when fl exed. In
some cases , t he knee may be so painful and/or
unstable that stress shoul d not be appl ied to a
fl exed knee. or, in the ext reme. not be appli ed to
the knee at all. T must then alter grip and
procedure accordingly.
See the foll owing two therapi es, 6. 13. I Band
6. 13. IC, pages 12 1 and 122.
As medial rotat ion improves with treatment. the
hip may successively be abducted more in the
starting position.
120
Fig. 9 1 b. Final Posi tion .
6.13. IB
Therapy for t he lateral rotator
muscles. Allen/alive lechlliqlle, Jor
kllees loleralillg Sl/'ess ollly iJ ex-
lellded.
Starti ng Position: P: Prone; pelvis stabili zed with a
belt. T: Standing between p' s legs at the foot of the
couch. faci ng P's head.
Grip: Ts le ft hand gr ips ve ntral side of p's thigh just
above the knee, and T's right hand gri ps the dorsal
side of p's lower leg just below the knee. T's ri ght
forearm li es along the medial side of p's lower leg,
elbow aga inst the med ial side of p's heel.
Procedure: Using thi s grip, T graduall y and fully
medially rO/{lles at P's hip.
St imul ation of Antagonists: T retains grip, but
moves ri ght forearm to lat eral side of p's ri ght
ankl e. T the n asks P to move furth e r in t he
direction of stretching, and resists that movement
to st imulate P's antagonists.
Notes: The above procedure assumes that the knee
is painful andlor unstable if st ressed when ft exed,
but capable of tolerati ng stress when extended. For
stronge r knees. see the previous technique,
6. 13. IA, p. 120. For knees unable to tolerate any
st ress, see the following technique, 6. 13. 1 C, p. 122.
As medial rotation improves with treatment. the
hip may successively be abducted more in the
starting pos iti on.
Fig. 92 a. Starting Position.
Fig. 92 b. Final Posi ti on.
121
6.13.1 C. Therapy for the lateral rotator
muscles. A/lemalive lech"iqlle II sed.
\ViIen knee call1lOf be stressed.
Starting Position: P: Pro ne: pe lvis stabili zed with a
belt. T : Standing at the ri ght side of the foot of the
couch. faci ng p·s head.
Grip: T" s ri ght hand dorsall y grips p·s right
trochant er. T"s left hand grips the ve ntral-medial
side of p· s t hi gh.
Procedure: Using thi s grip . T graduall y and fu ll y
lIl edially rOWle.\" at p·s hip.
Stimulation of Antagonists: T retains grip . T then
asks P to move further in the directi on of
stretching. and resists that movement to st imul ate
p's ant agoni sts.
Notes: The above proced ure is used when the knee
is so painful. unstable or otherwise debilitat ed that
it ca nnot tol erate external force. For stronger
knees . see the preceding two techniques. 6.13. IA
and 6.13. IB. pages 120 and 12 1.
122
Fi g. 93 H. Starti ng Positi on.
6. 14.IA. Therapy for the medial rotator
muscles. Kllee lIorlllal. flexed 90" ill
treatmellT.
ta rting Position: P: Prone: knee Hexed approx-
imate ly 90°: pelvis stabili zed with a belt. T :
tandi ng facing p's left side.
Grip: 1""s ri ght hand grips ve ntral-late ral side of p's
' nee and thi gh; forea rm li cs a long the late ral side
of p's lowe r leg. 1"" s le ft hand stabili zes and controls
p's sacrum and ri ght ilium.
Procedure: Us ing this grip. T graduall y and full y Fig. 9-1 a. Starting Posit ion.
larerally rolal es at p's hip.
Stimulation of Antagonists: T moves right hand to
medial side of p' s ri ght leg j ust prox imal to the
ankle. T then as ks P to move furt her in the
directi on of st retching. and resists that movement
to stimul ate p's antagoni sts.
Notes: A s lateral rotati on improves wi th sli ccessive
treatments, the abducti on at the hip should be
increased in the start ing pos iti on.
This procedure assumes a normal knee capable of
tole rating stress when Hexed .
In some cases. the knee may be so painful andlo r
unstable that stress should not be appli ed to a
flexed knee, or not at all to the knee . T must then
alter grip and procedure accordingly. See t he
fo ll owing two the rapy techniques . 6. 14. 1 Band
6.1 4. IC, pages 124 and 125.
Fi g. 94 b. Final Pos iti on.
123
6.14.IB. Therapy for the medi al rotator
muscles. Alternati ve techHique, llsed
when knee IOlerales STress Oll/Y Ivhen
extell ded.
Starting Position: P: Prone; pelvis stabili zed wit h a
belt. T: Standing at p's ri ght side facing obliquely
towards P.
Grip: T' 5 ri ght hand grips ve ntral side of p's thi gh
j ust above the knee. and T' s left hand grips dorsal
side of p's lower leg just below the knee. T' s left
forearm lies along the dorsal -lat e ral side of p's
lower leg. elbow against the lateral side of p' s heel.
Procedure: Us ing thi s grip. T grad uall y and full y
laterally rotates at P's hip.
Stimulation of Antagonists: T retains grip, but
moves left forearm to medial side of P's right
ankl e . T the n asks P to move further in the
direction of stretching, and resi sts that movement
to stimul ate P's ant agonists.
Notes: As lat eral rotat ion improves with successive
treatment, abduction at the hip should be increased
in the starting positi on.
This proced ure ass umes that the knee is painful
and/o r unstable if stressed when fl exed. but capable
of tolerat ing stress when extended. For stronger
knees, see the previous technique. 6. 14. I A, p. 123.
For knees unable to tolerate any stress. see the
fo ll owing technique, 6. 14. IC, p. 125.
t24
Fig. 95 a. Starti ng Position.
6.14.1C. Therapy for the medial rotator
muscles. Alternative techll ique used,
whell kllee COllll ot be stressed.
Starting Position: P: Prone; leg sli ghtl y abducted to
permit grip ; pe lvis stabili zed wit h a belt. T:
Standing at the ri ght side of the foot of the couch.
faci ng P's head.
Grip: T"s ri ght hand grips t he ventral -latera l side of
p·s great trochant er. T"s left hand grips the
dorsal-medial side of P's t hi gh just below the ischia l
tuberosit y.
Procedure: Usi ng thi s grip, T graduall y and fully
laterally rot([{es at p·s hip.
Stimulation of Antagonists: T retains grip . T then
as ks P to move further in the di recti on of
st retching. and resists that movement to stimulate
p·s antagoni sts.
Note: As late ral rotat ion improves wi th successive
treatment s. abducti on at the hip should be
increased in the starting pos iti on.
Thi s procedure is used when the knee is so painful .
unstabl e or othe rwise debilitat ed that it cannot
tolerat e external force . For stronger knees. sec the
preceding two techniques. 6. 14. 1 A and 6. 14. 1 B,
pages 123 and 124.
Fi g. 96 C:I. St arting Position.
t25
7 THE KNEE
7. 1 THERAPY GU IDE
The muscles whi ch may rest ri ct moveme nt at the knee arc li sted in Table 7- L along wit h the appli cable
the rapies. indexed by manual secti on numbe r and page. Muscle acti ons arc li sted in Table 7-2.
The various restri cti ons possible arc li sted in Movement Restri ct ion Table 10.9 (r . 173) .
Table 7-1. at the knee
SECTION MOVEMENT
RESTRICTED
7.2
7.3

7.5
7.6
7.7
Flexioll
Flexioll (llId medial
roratio" (11';111 slight
aodllcfioll)
Flexioll and lateral
ro/(uioll (lI'illI sligh!
adducfion)
Ex!ellsioll
Extension and /IIedial I'olalioll
Extension alld hoa(il mUllion
MUSCLES WHI CH MAY
RESTR ICT MOTION
QlI adricl..'p'I I
T f<l'l('iae
1;III::rali'l. and
of the quadri cqh
Ten::.ur fa:-,<."iae lat;lI:
int ermedill :-'. and
of till..' Quadriccp:-.
:-.hort head



Biccp:-, fclllori:-. heil d
long. head '

Scmitendinmu::..
and gracili:-.'
lOTES: I. when hip extended or hypcrcxlended.
THERAPY Number
7.2. 1
7. 2.1
7.3.1
6. 10.2
7.4. 1
7.6. 1
8.5. 1-8.5. 3
8.5. 1
7.7. 1
7.6. 1
6.2. 1
7.7. 1
6.2. 1
Page
12g
lUg
12tJ
lOX
UO
Ul


U2
Ul

132

2. Restricts during ext en::.ion. adduction and 1:ltcral rotation at hip. I f the hl\\er kg. I::' Ill l..'d ially rotall.:'d at tl1l..' klll..'l..'.
thi s   may incrca:-.c.
3. May re:-. tri ct when hip b flexed.
126
Table 7- 2. Act ions of muscles which may restrict movement at the knee .
MUSCLE
Muscles of the buttocks
Te nsor fascia
latae
Muscles of t he thigh
Quadriceps
femoris
Biceps femori s
Gracili s
l
Semite ndinosus I
Semimembranos us I
Muscles of the leg
Popliteus
Plantaris
Gastrocnemi us
ACTION
Extends and laterall y rotates at knee. Abduct s. fl exes and media ll y rotates at hip.
Extends at knee. Rectus femo ris also flexes at hi p.
I
Long head: Flexes and laterall y rotates at knee. Extends, laterall y rotates and addllct s at hip.
Short head: Flexes and late rall y rotates al knee.
Addllcts at hip.
Flexes and laterally rOlales when hip is extended. Extends and medially rotates whe n hip is
maximall y fl exed. Flexes and mediall y rOlates at knee .
Flexes and medially rOlates at knee. Ext ends. addllcls and medially rotates at hip.
Flexes and medially rotates at knee. Ext ends, adduct s and medially rotates at hip.
Flexes and medially rotates at knee.
Flexes at knee. Planta r fl exes at ank le.
Flexes at knee. Pla nt ar fl exes at ank le .
~ O T E   I. Ca n rest ri ct at knee when hip is flexed.
127
7.2. 1. Therapy for the quadriceps (vastus
latera li s, vast us intermedius and
vast us medialis). Muscle markedly
shortened.
Starting Position: P: Sitting; wi th lower legs ove r
end o f couch; thi ghs stabili zed with a belt ; T:
Standing between P's legs, facing the medi al side of
p's ri ght leg.
Grip: T's left hand grips ventral side of p's lower leg
just above the ankle. T's right hand li es on the
vent ra l side of p's thi gh. for stabilit y of fl ex ing. ( If P
is very st rong, the n T may use both hands to grip p's
lower leg just above the ankle).
Procedure: Using thi s grip . T graduall y flexes p's
knee.
Stimulation of Antagonists: T retains grip. T then
asks P to move furt her in the direction of
stretching. and resists that movement to stimulat e
p' s ant agoni sts.
Notes: T should continuo usly check knee joint for
normal gli de during treatment.
This procedure may also include medi al or lateral
rotat ion at the knee . to stretch the quadriceps full y
in the positi on of maximum restricti on.
128
Fig. 97 a. Sta rling Pos ition.
7.3.1. Therapy for the quadriceps (vastus
laterali s, vastus intermedius and
vast us medialis).
Starting Position: P: Supi ne; hip and knee fl exed
approximat ely 90° (or mo re . depending on the
degree of short ening of the quadriceps ). T:
Standing facing p's leg.
Grip: T' s right hand grips the proximal part of p' s
foot and ank le (or around thc ve ntral-medial side
of the lowe r leg. just proximal to the ank le). T' s left
ha nd support s P's knee.
Procedure: Usi ng t hi s grip. T grad uall y and fu ll y
flexes, abdllCls and /II edilllly rOlaies at P's knee .
Stimulat ion of Ant agoni sts: T retains grip . T then
asks P to move furth er in the direction of
st retching. and resists that move ment to stimulate
p's antagonists.
Fig. 98 a. Starting Positi on.
I
Fig. 98 b. Final Positi on.
129
7.4. I.
The rapy for the quadriceps (vastus
medialis , vastus intermedius and
vast us lateralis).
Starting Position: 1' : Supine: hip and knee fl exed
approx ima te ly 90° (or more. depending o n the
degree of sho rt e ning of the quadriceps). T :
Standing facing p's leg.
Grip: T s right hand grips around p's ri ght heel from
the media l side. Ts left ha nd supports p's knee.
Procedure: Us ing th is gri p. T gradua ll y a nd fully
flexes, (lddllcls a nd {(liemlly rolllies at p's knee.
Stimulation of Antagonists: T moves ri ght forearm
to a lo ng lat e ral side of p' s ri ght foo t. gripping
medial s ide of heel. T the n asks I' to move further in
the direct ion of st retching. and resists thilt
move ment to stimul ate p' s antagoni sts.
130
Fig. 99 a. Starting Positi o n.
\
Fig. 99 b. Fin a l Positi o n.
7.6.1. Therapy for the biceps femoris , short
head .
Start ing Position: P: Supine: hi p and knee extended
with knee resting on cushi on full y medi all y rot atcd.
T: St anding facing the late ral side of p's leg.
Grip: T s ri ght hand grips lat eral side of p' s hee l. T s
left hand stabili zes p's thi gh just above the knce.
Procedure: Maint aining thi s grip. T graduall y and
full y medially rOlates and extellds at p's knee.
Stimulation of Antagonists: T retains grip. T the n
asks P to move further in the directi on of
stretching, and resists that movement to stimul ate
P's ant agoni sts.
Fi g. 100 <l . Starting Positi on.
Fig. 100 b. Final Pos iti on.
13 1
7.7.1. Therapy for the popliteus.
Starting Position: P: Supine ; hip and knee extended
with knee resting on cushi on and full y laterall y
rotated. T: Standing facing the lateral side of p's
lower leg.
Grip: T"s ri ght hand grips medial side of p's heel (so
that T"s forearm and wrist li e agai nst the medial
side of p's foot). T" s le ft hand stabili zes p' s thigh
jllst above the knee.
Procedure: Us ing this grip. T grad uall y and fully
laterally rotates and extellds at P"s knee .
Stimulation of Antagonists: T retai ns grip . T thcn
as ks P to move further in the dircction of
stretching, and resists that movement to stimul ate
p's antagoni sts .
132
Fig. 101 a. Starting Position.
8 THE ANKLE
8.1 THERAPY GUIDE
The muscles which may restrict movement at the ankl e are li sted in Table 8- 1, along with the applicable
therapies, indexed by manual secti on number and page. Muscle act ions are li sted in Table 8-2.
The various restri ct ions possible are li sted in Movement Restri ction Table 10. 10 (p. l 74).
Table 8 . 1 Restri ctions at the ankle
SECTION MOVEMENT
RESTRI CTED
8.2
8. 3

85
8. 6
8.7
Pial/tar flexion
Plal/f(Ir flexion (Illd
il/I 'ersion (slIpill(l/iollj
offoo!
P/al/wr flexion and
cl 'crsioll (prollation)
Offoo!
Dorsal flexion
Oorsal flexion and
inversion (supinatioll)
offOO!
Oorsal flexion (llld nersioll
(proll(l(iofl) offoor
RESTRI CTING
MUSCLE(S)
Ti bial is anteri or
Extcmor
Extensor digilOfull1
Pcroneu:\

EXI l:Il-;Or digitorum longu:\
Tibialis anterior
Ex tensor
Gastrocnemi us. plantaris and
salcu:--
Gastrocnemius . lateral head. and
plantaris
medial head . and
plant aris
Sole LI S
Tibiali s posterior
Peroneus longus and brcvi:-,
Flexor longus.:!
Flexor
and
Gastrocnemius. lateral head '
Tibiali s posterior
Gastrocnemi us. medial head
l
NOTE: I. May restrict at ankle with knee extended
2. May restrict at ank le with loes extended
THERAPY Number
8.2.1
8.2.2
8. 2.3
8. 2.4
8.2.4
8. 2.3
8.2. 1
8.2.2
8. 5. 1
8.5.2
8.5.3
8.5.4
8.5.5
8.5.6
9.3.2
9.3.4
8.5.6
8.5. 1. 8.5.2
8.5.5
8.5. 1.8.5. 3
Page
135
136· 137
13X·139
I  

I3X·139
135
136- 137


143



154
156



141.
133
TABLE 8.2 Actions of muscles whi ch may restrict movemenh at the ankl e.
MUSCLE ACT ION
Ti bi ali s ant erior Dorsal fl exes at ank le. Inverts (supinates) foot.
Extensor halluci s longus Dorsal fl exes at ankle. Invert s (supinates) foo t.
Ext ensor digitofUm Dorsal fl exes at ankle. Ext ends at DIP, PIP a nd MTP join ts.
longus
Peroneus le rt ius Dorsal fl exes at an kle. Evert s (pronalcs) foot.
Pe roneus longus and Plant ar fl ex at ankl e. Evert (pronate) fOOL
brevis
Flexor hall uci s longus Planta r fl exes at ankle. Fl exes at IP and MTP joint s of greal toe. Ilwe rt s (Mlpinalcs) foot.
Flexor digitorum longus Plantar fl exes at ank lc. Flexes at MTP. PIP and DIP joinh. Inve rt s fool.
Gastrocnemius Flexes al knee. Pl ant ar flexes al ankl c.
Pl antari s Flexes al knee. Pl antar fl exes al J ll k1c.
Soleus Plant ar fl exes at ankl e.
Tibi ali s poste rior Plantar fl exes at ank le. Invert s (s upinatcs) fool. Adducts foot.
Joint abbreviations:
DIP Distal-interphalangeal
IP Int erphalangea l
MTP Metatarsal -phalangeal
PIP Proximal-int erphalangeal
134
8.2.1. The rapy fo r the tibi ali s ant erior.
Starting Position: P: Supine; ankl e over end of the
couch. ( It is easier to glide the talus agai nst the tibi a
if p' s heel is held agai nst the couch. However . if P
has pain in the hee l or subt ala r join ts. this starti ng
positi on cannot be used): foot fully everted
( pronated). T : Standing facing the lat e ra l side of
p's lower leg.
Grip: T's ri ght hand grips p' s instep. from the
cuneiform bones down through the toes. with
fi nge rs curling around the medial side of the foot
onto the sole. T' s left hand stabilizes p's lower leg
just below t he knee.
Procedure: Using this grip. T graduall y and full y
plantar flexes at p's ankl e.
Stimulation of Antagonists: T retains grip. T then
asks P to move further in the directi on of
stretching. and resists that movement to st imulate
p's ant agoni sts.
Fig. 102 a. Start ing Pos iti on.
Fig. 102 b. Final Positi o n.
135
S.2.2A. Therapy for the extensor hallucis
longus.
Starting Position: P: Supine; ankl e dorsally flexed
and over end of couch: lowe r leg stabilized with a
belt. T: Standing facing the late ral side of p' s foot.
Grip: T' s left hand grips the middle of p' s foot from
the medial side, with fi ngers pl ant ar on foot.
covering the MTP joi nt s. T' s ri ght hand stabili zes
p's great toe by gripping the di stal phalanx and
ho lding the IP and MTP joints full y flexed.
Procedure: Us ing thi s grip , T graduall y and fully
plllll/{lrflexes at p's ankl e whil e everting (pronati ng)
P's foot.
Stimulation of Antagonists: T re tains grip . T then
asks P to move furth er in the direction of
stretching. and resists that movement to sti mul ate
p's ant agoni sts.
Note: Thi s procedure may also be performed with
one hand , see the followin g technique, therapy
8.2.2B. p. 137.
136
Fig. 103 a. Start ing Position .
8.2.2B. Therapy for the extensor hallucis
longus. Allel'llalil'e olle-halld grip.
Starting Position: P: Supine: ankl e dorsall y Hexcd
and held ovcr the cnd of t he couch: lowcr Icg
stabili zed wit h a bclt. T: Standing facing thc lateral
side of p's foot.
Grip: T' s left hand stabili zes p's lower leg. T' s ri ght
ha nd grips around p's great toe ovcr the MTP joint
and full y fl exes at the I P and MTP joi nt s.
Procedure: Using thi s grip, T graduall y and ful ly
plalllarflexes at p' s ankl e whil c evenillg (pronat ing)
p' s foot.
Stimulation of Antagoni sts: T retains grip. T then
asks P to move further in the dircction of
stretching
1
and res ists that movement to st imulate
p' s antagoni sts.
Fig. 1   ~ a. Start ing Position .
Fig. 104 b. Final Position.
137
8.2.3A.
Therapy for the extensor digitorum
longus. Toes silllll/ralleolls/y.
Starting Positi on: P: Supi ne: ankle dorsally flexed
and ove r e nd of couch: lower leg stabilized with a
belt. T: Sta nding faci ng the lat e ra l side of p' s foot.
Grip: Ts left hand grips t he mi dd le of . the
media l/plantar side of p's foot. Ts right hand
sta bi lizes p's 2nd through 5th toes by gripping them
from the dorsa l side a nd holding them fu ll y flexed
at the DIP. PIP and MTP joint s.
Procedure: Using th is grip. T graduall y and fu ll y
p/alllar flexes at p's ankle.
Stimulation of Antagonists: T retains gri p. T then
asks P to move furth er in the directi on of
stretching. and resists that movement to stimul ate
p' s ant agoni sts.
Note: The toes may be treated individ ua ll y. see the
fo ll owing techni que. therapy 8.2.38. p. 139 . •
138
Fig. 105 a. Start ing Positi on.
Fig. 105 b. Final Position .
8. 2.3B. Therapy for the extensor di gitorum
longus. Toes illdividllally.
Starting Position: P: Supine; ankl e dorsally fl exed
and over e nd of couch; lower leg stabilized with a
belt just below the patell a. T: Standing at foot of
couch facing the late ral side of P's foot. .
Grip: Ts left hand grips instep of P's foot. T's ri ght
hand stabili zes one of the lateral toes (2nd shown
here) by full y fl exing it at the DIP, PIP and MTP
join ts.
Procedure: Usi ng t hi s gri p, T graduall y and full y
plalllar flexes at P's ankle.
Stimulation of Antagonists: T reta ins gri p. T t hen
asks P to move furt her in the directi on of
stretching, and resists that movement to sti mul ate
p's antagonists.
Fig. 106 a. Starti ng Pos ition.
'8.2.4.
Therapy for the peroneus tertius.
Starting Position: P: Supine; ank le dorsall y Il exed
and over end of couch ; lower leg is stabili zed with a
belt. T : St anding faci ng thc medial side of p's ri ght
foot.
Grip: T' s left hand grips over instep p's foot.
including the base o f the 5th mctatarsal. and holds
the foot full y inve rt ed (supin ated). T"s ri ght hand
grips P' s lower leg just above the ankl e. stabili zing
it to the couch.
Procedure: Us ing thi s grip . T graduall y and fully
plwllar f lexes at P's ankl e.
Stimulation of Antagonists: T retains grip. T then
asks P to move furth er in the directi on of
stretching. and resists that movement 10 stimul ate
p' s ant agonists.
140
Fig. 107 a. Starting Positi on.
8.5. 1. The rapy for the gastrocnemius, plan-
taris and soleus.
Starting Positi on: P: Standing. leaning forward
agai nst a wall: left leg forward . knee and hip ftcxed:
right leg cxtcndcd rearwa rds. toes and ball o f foot
on floor. T: Standing to the sidc of. and behind. p·s
right leg.
Grip: T"s ri ght hand grips the vent ral side of p·s
knee from the dorsal-medial aspcct. T"s left hand
grips dorsal side of p· s lower leg.
Procedure: Using thi s gri p. T (with p·s he lp)
graduall y presses p· s heel to the floor to dorsally
flex at p·s an kl e.
Stimulation of Antagonists: P rocks back on right
heel, retaini ng ankl e dorsal fl exion so ball of foot
rises from fl oor. T pl aces ri ght hand on dorsal side
of P's foot. T then asks P to move hi s foot further
in the direction of stretching, and T resists that
movement to stimulate P's ant agoni sts.
Note: To furthe r increase dorsal fl exion at ankle ,
move P's foot further back.
Fig. lOR <I. Starting Posit ion.
.' ,
, f
. ;, ..... :i.
....... .
Fig. 108 b. Fina l Posit ion.
141
8.5.2.
The rapy for the gastrocnemius, later-
al head .
Starting Position: P: Standing. Icaning forward
obli quely against a wall : left leg fo rward. knee
sli ghtl y fl exed; right leg extended rearwards. toes
and ball o f foot o n 11 001". heel and instep on wedge
to supinate foot. T: Standing behind P. facing the
medial -dorsa l side of p's leg.
Grip: T's left hand grips the ventral side of P' s knee
from the dorsal-lateral aspect. T's right hand grips
dorsal side of P's lower leg.
Procedure: Usi ng thi s grip . T (with p's help)
graduall y presses p's heel to the 1100r (in the l'arliS
positi on) to dorsally flex at p's ankl e.
Stimulati on of Antagonists: P rocks back on ri ght
heel. retai ning ankle dorsa l tl exioll and supinati on.
T pl aces le ft hand on dorsal-media l side of P·s'foot .
T then as ks P to move furth er in the d irection of
stretching, and resists that movement to stimul ate
P's antagoni sts.
Note: The less t he angle between the rea rward leg
and the 11 00r, the greate r the stretching achieved.
142
Fig. 109 a. Starting Position.
Fig. 109 b. Final Posit ion.
8.S.3. Therapy for t he gastrocnemius, me-
dial head and the plantaris.
Starting Posi tion: P: Standing. leaning forward
obliquely aga inst a wa ll : left leg forward. knee
sl ightly flexed: ri ght leg exte nded rearwards. toes
and ball of foot on floor. heel and late ral side of sole
on wedge to pronat e foot. T: Standing behind P.
facing the lateral-dorsa l side o f p's leg.
Grip: T's ri ght hand grips the ve ntra l side of p's
knee from the dorsal-medial aspect. T' s left hand
grips the do rsa l side of p's lower leg. just below the
knee.
Procedure: Us ing thi s gri p. T (with P's help)
grad uall y presses p's heel to the fl oor (with foot in
the va/gll s positi on) 10 dorsally flex at the ankl e.
Stimulation of Antagonists: P rocks back on right
heel. ret aining ankl e dorsal ncx ion and pronati on.
T places ri ght hand on lat e ral-dorsal side of p's
foot. T then asks P to move further in the direction
of stretching. and res ists that move ment to
stimulate p's antagonists.
Note: T he less the angle between the rearward leg
and the floor. the grea ter the stretching.
Fig. 110 a. Starting Posit ion.
Fig. 11 0 b. Final Position.
t43
8.S.4A.
Therapy for the soleus.
Starting Position: P: Standing, leaning forward
oblique ly against a wall ; left leg forward, knee
sli ghtl y fl exed; ri ght hip and knee extended with
heel stabili zed on the fl oor. T: Standing behind P,
facing the lateral/dorsa l side of P' s leg.
Grip: T's ri ght hand grips the dorsal side o f P' s leg
just di stal to the knee . T' s left hand grips P's heel
and sta bili zes it against the fl oor.
Procedure: Using thi s grip. T (with P's he lp)
gradua ll y flexes P' s ri ght knee whil e keeping the
heel against the fl oor to produce full dorsal flexion
at the ankl e.
Stimulation of Antagonists: P rocks back On ri ght
heel, retaining ankl e dorsal fl ex ion and knee
fl exion. T pl aces ri ght hand on dorsal side of P' s
fool. T then asks P to move further in the di recti on
of stretching, and res ists that movement to
stimulat e P' s ant agoni sts.
Note: If P's foot is small and/or mi ght deform, Or
otherwise P cannot tole rat e e rect pos ition with foot
loaded, treatment may be performed with P prone ,
see therapy 8.5.48 . p. 145.
144
, ,
1,1.'
Fig. III a. Starting Positi on.
Fi g. III b. Final Positi on.
8.5.4B. Therapy for the soleus. A /l efl/ ali ve,
,villi P proll e.
Starting Position: P: Prone; P' s knee fl exed
approximately 90°; T: St anding, facing the lateral
side of P's lower leg.
Grip: T' s left hand stabili zes P's heel, forearm
along the sole of P' s foot. T' s ri ght hand grips instep
from the dorsal-medi al side. To increase stabilit y
and/or force appli ed, P's foot may be support ed
against T' s chest.
Procedure: Using thi s grip, T graduall y and full y
dorsal fl exes at P's ankle .
Stimulation of Antagonists: T ret ains grip. T then
asks P to move further in the directi on of
stretching, and resists t hat movement to stimul ate
P's ant agoni sts .
Fi g. 11 2 a. St arting Positi on.
Fig. 112 b. Final Position.
145
8.5.5.
Therapy for the tibialis posterior.
Starting Position: P: Prone: knee Aexcd approx-
imately 90°. T: Standing facing the latcral side of
p·s lower leg.
Grip: T"s left hand grips the plantar side of p· s foot.
wit h fingers around the med ial side (including the
navicular bone). and holds the foot fully evened
( pronat ed) and abducted. T"s right hand stabili zes
p·s leg by gripping the medial side of the lower leg
just prox imal to the ank le.
Procedure: Usi ng this gri p. T graduall y and fully
dorsal flexes at P"s ankl e.
Stimulation of Antagonists: T moves le ft hand to
lateral-dorsal side o f p· s foot. T t he n as ks P to move
funhe r in the direction of st retching. and resists
that movement to sti mul ate p's antagonists.
Note: Thi s techni que may also be used for trea ting
restri cted dorsal l1 exion at the ankl e alld restricted
eversion of the foot.
146
Fig. 11 3 a. Starting Posit ion.
Fig. 113 b. Fin al Position .
8.5.6. Therapy for the peroneus longus and
brevis.
Starting Position: P: Prone: knee fl exed approx-
imate ly 90°. T : Standing facing the lateral side of
p' s lowe r leg.
Grip: 1""s left hand grips plantar-lat eral side of p's
foot (i ncluding the cuboid bone). 1"" s ri ght hand
stabilizes p' s leg by grippi ng the medial side of the
lower legj ust above the ankl e. T holds p's foot full y
inve rted (supinated). To increase stabilit y. p' s foot
ma y be supported agai nst 1""s abdomen or chest.
Procedure: Using thi s grip, T graduall y and full y
dorsal flexes at P's ankl e.
Stimulation of Antagonists: T moves left hand to
dorsal-medial side of P's fool. T then asks P to move
furthe r in the direction of stretching, and resists
that movement to stimulat e P's antagoni sts.
Fig. 11-1 a. Starting Posi ti on.
Fig. 114 b. Final Position.
147
9 THE TOES
9. 1 THERAPY GUIDE
The muscles which may restri ct moveme nt at the joints of the toes are li sled in Table 9- 1, along wilh the
applicable therapies, indexed by manual secti on numer and page. Muscl e act ions are li sted in Table 9-2.
The vari ous restri ct ions possible are li sted in Movement Rest ricti on Table 10.11 (p. 175).
TABLE 9. 1 Restricti o ns at the joints of t he toes
Section
9. 2
9.3
MOVEMENT
RESTRI CTED
Flexion
Extension
RESTRI CTI NG
MUSCLE(S)
Extensor halluci s brevis
Extensor hallucis longus
Extensor digit orul11 brevis
Ext ensor digitorum longus
Flexor hall ucis brevis
Flexor hall ucis longus
Flexor digitorul11 brevis
Fl exor di gitorum longus
Lumbricales
Interosse i dorsales
Plantares
9. ... Abdll ction ar MTP joillf Adductor hallucis
of great toe
Fl exor hall ucis brevis
9 .5 Adduction (l{ MTP joilll Abductor' hallucis
of grear fOe'
9.6
9.7
Lateral l1I ovemellf of
lateral fOes towards
fibula
Fl exor hall ucis brevis. tibial part
Interossei plant ares and Interos·
seus dorsal es I
Medial movemelll of Int erossei dorsales 11.111 and I V,
THERAPY
la/eraf fOes towards tibia Abductor digiti minimi, and fl exor
digiti minimi brevis
NOTE: 1. Very uncommon
148
Number
9.2. 1
8. 2.2
9.2.2
8. 2.3
9.3. 1
9. 3.2
9.3. 3
9. 3.4
9.3.5
9.6.1
9. 7. 1
9.4. 1
9.3. 1
9.5. 1
9.5. 2
9.6. 1
9.7. 1
Page
ISO
136-137
151-152
138-1 39
153
t54
ISS
156
157
16 t
162
158
153
159
160
161
162
TABLE 9.2 Actions of Illuscl l.!!o. \\h ich may movements at the joint s.
MUSCLE ACTION
Muscles of the leg
Extensor hall ucis longus fiexe s at ankl e. Invert s (s upinates) foot. at IP and MTP joints.
Extensor di gitor ulll at ank le. Extends.lI DIP. PIP a nd MTP joint s.
longus
Fk'xur hallucis longus Fl ex .... s at II' and MTP of great toe. Plantar flexes at ankl e. Invert s (supinates) foot.
Fl exo r digit orll m longus Fl cxl.!s at MTP. PIP and DIP joint s. Plant a r f1 cxe!'> ankl e. Inve rt s (s upinat es) foot.
Muscles of the foot
Extensor brevi s Extend" at MTP joint of greal loe.
Fl exor Fibular/ lateral pa rt adducts and flexe s at MTP joint , tibial/ medial part abducts and flex es at MTP
joinL o f great toe.
Ext cnsor digitorulll

Flexo r di gito r-um brc\·is
Lumbricales
Interosse i plant ares
Interossei dorsa les
Adductor hallucis
Abductor halluci s
Abduct or di gi ti minimi
Fl exor digiti minimi

Extends al PIP and MTP  
at MTP and PI P joinh.
EXll.! llcb at DIP and PIP joi nt s. Fl ex at MTP joint s.
Move Jrd. 4th and 5th toes towa rd., tibia. Flex at MTp joint s. and extend at DIP and PIP joints.
Extend at 0 1 P a nd PI P joinl s. Fl ex at MTP joint.,. I moves 2nd toe medially towards tibia . II . II I
and IV move 2nd . J rd and 4th toes lat erall y towards fibula .
Adduct\ a nd f1 exc ... at MTP joint of great toe.
and f1 cxe!'> at MTp joint of gre,tI toe.
Flexes and abduct ... littl c toe late rally towa rd!'> fibul a.
Flexes "md little toe lateral ly towards fibula .
NOTES: I. Joint abbrcvaiation: DIP - Dbtal- int e rphalangeal. I P - Int e rphal angeal. MTP - Met atarsalphalangcal. PI P-
Proxi mn I-i n tefpha langeal.
2. abduct. adduct. medial and lateral arc somcti mes ambiguous when appl ied to the toes. The refor. fo r
clarit y. te rms tow'.lI"ds the fibula , towards the tibia. fibular and ti bial are used wheneve r other analOmical terms
may mislead.
149
9.2.1. Therapy for the extensor hallucis
brevis.
Starting Position: P: Supine; ankl e dorsall y ft exed.
T: Standing facing the lateral side of p·s fool.
Grip: T" s ri ght hand grips p·s great toe near the
MTP-joi nt. T"s left hand stabili zes p·s forefoot
from the medial/pl ant ar side .
Procedure: Using thi s grip, T appli es tracti on while
graduall y and full y flexing at the MTP-joint of the
great toe .
Stimulation of Antagonists: T ret ains grip . T then
asks P to move furth er in the direction of
stretching, and resists that movement to st imul ate
P' s ant agoni sts.
Note: Continuously check for normal MTP joint
gli de during treatment.
150
Fig. 11 5 a. Starting Positi on.
J
Fig. 115 b. Final Positi on.
9.2.2A. Therapy for the extensor di gitorum
brevis. Toes illdividllally.
Starting Position: P: Supi ne; ankl e dorsall y flexed
to prevent interference from the extensor di gitorum
longus. (If P's gastrocnemius is shortened, the knee
must be flexed to permit full dorsal flexion at the
ankl e). T: Standing at foot of couch facing t he
lateral side of P's right foot.
Grip: T's right hand grips one of lateral toes (2nd
toe illustrated). thumb on dorsal si de wit h index
finger on plantar side, and holds the PI P joint fu ll y
flexed. T's left hand stabilizes P's foot by gripping
instep.
Procedure: Maintaining t hi s grip, T appl ies traction
at the MTP joint while graduall y and full y flexing
p's toe.
Stimulation of Antagonists: T retains grip. T then
asks P to move further in the direction of
stretching, and resists that movement to stimul ate
p's ant agoni sts.
Note: Continuously check for normal MTP joint
glide during treatment.
If all toes are restricted , T may treat toes
simultaneousl y usi ng the following technique ,
therapy 9.2.28, p. 152.
Fig. 11 6 a. Start ing Position.
t 51
9.2.2B. Therapy for the extensor digitorum
brevis. FOllr la/eral lOes sillllll-
/(llleolls/v.
Starting Position: P: Supinc; ankl e dorsally l1cxcd
to prevent int erference from the extensor digitorum
longus . (Ir p·s gastrocnemius is short e ned. the knce
must be Acxed to pcrmit full dorsa l Acxio n at thc
ank le). T: Standing. left side against the lat eral sidc
of p· s leg. facing thc do rsum of p·s foot.
Grip: T's right hand grips p·s lateral tocs ncar thc
PIP joints from the dorsal side. T" s Icft hand
stabili zes P"s foot by gripping the mcdial- plant ar
sidc .
Procedure: Using thi s grip . T appl ics traction at the
PI P and MTP joints whilc grad ull y and full y flexil/g
the toes.
Stimulation of Antagonists: T retai ns grip . T thcn
asks P to move further in the directi on of
stretching. and resists that movement to st imulat e
p' s antagoni sts.
152
Fig. 11 7 a. Starting Posi ti on.
Fi g. 117 b. Final Position.
9.3.1. Therapy for the flexor hallucis brevis.
Starting Position: P: Pro ne; knee fl exed approx-
imately900; ankl e plant ar fl exed to avoid
interference from the flexor hallucis longus. T:
Standing facing the lateral side of p·s foot.
Grip: T's left hand grips p·s great toe ncar the MTP
joi nt. T's ri ght hand stabili zes p·s foot by gripping
the medial-dorsal side near the MTP joint. To
increase stabilit y. P' s foot may be support ed
against T's abdomen or chest .
Procedure: Usi ng thi s grip. Tappl ies traction at the
MTP joint whil e graduall y and fu ll y extell dillg the
great toe.
Stimulation of Antagonists: T retains grip. T the n
asks P to move furth er in the di rect ion of
stretching, and resists that movement to stimul ate
P\ antagonists.
Notes: Continuously check for normal MTP joint
glide during treatme nt.
To specificall y stretch :
Flexor hallucis
brevis, tibial See p. 160.
part
Flexor haUucis
brevis, fibular See p. 15 8.
part
Fig. 118 a. Starting Posi ti on.
-
Fig. 118 b. Final Posi ti on.
153
9.3.2. Therapy for the flexor hallucis
longus.
Starting Position : P: Prone: knee fl exed approx-
imate ly 90°; an k Ie pl ant ar fl exed. T: Standi ng
facing the lateral si de of p's foot.
Grip: Ts left hand stabi li zes p's great toe ncar t he
MTP joint and full y ex tcnds the I P and MTP joi nt s.
T s right hand gri ps p's foot from the plantarmcdial
side. To increase stabili ty and/o r force applied. P's
foot may bc support ed against Ts abdomen or
chest.
Procedure: Using thi s gri p. T graduall y and full y
dorsaillexesat P'sankl c.
Stimulation of Antagonists: T reta ins grip. T then
asks P to move furth er in the direction of
stretching. and resists that movement to stimulate
P's ant agoni sts.
154
Fig. 11 9 a. Sta rt ing Pos iti on.
9.3.3. The rapy for the Hexor digitorum
brevis .
Starting Position: P: Pronc : kncc Il excd approx-
imatc ly 90°: anklc pl antar Il cxed. T : St anding
facing thc lateral side of p's ri ght foot.
Grip: T s left hand gr ips nea r thc MT P jo int of one
of p's lat eral toes (2nd toe illustrated). (To obtain a
fir m gri p on the toc. both the D I I' and thc PI P joi nt s
must be ex tended). T s ri ght hand stabili zes p's foot
by gripping the medial-dorsal sidc. To increase
stabilit y. p' s foot may bc support cd agai nst Ts
abdomen or chcst.
Procedure: Maintaining thi s grip . T appli es tracti on
at p's MTP joint whil e T graduall y and full y e.rrell ds
the toe.
Stimulation of Antagonists: T retains gri p. T thcn
as ks P to move further in the directi on of
st retching. and resists that movcment to stimul ate
P's antagoni sts.
Notes: Continuously check fo r normal MTP joint
glide during treatment.
Thi s technique may be used to treat the toes
indi viduall y (as shown. for 2nd toe) or to treat two,
three or all fo ur lateral toes simult aneously. by
accordingly alt e ring grip .
Fig. 120 a. Starting Pos ition.
Fi g. 120 b. Final Pos iti on.
155
9.3.4. Therapy for the Hexor digitorum
longus.
Starting Position: P: Prone; knee f1exed approx-
imate ly 90°; ank le pl ant ar flexed; foot fully everted
(pronat ed). T: Standing facing the lateral side of
p's foot.
Grip: T's left hand stabili zes one or more of p's toes
by fully extending at the DIP and PIP joints and
full y dorsally flexing at the MTP joints. T's right
hand grips the pl ant ar-medial side of P"s foot. To
increase force applied. p' s foot may be supported
against T's chcst.
Procedure: Us ing thi s grip. T graduall y and full y
dorsal flexes at p's ankle.
Stimulation of Antagonists: T retains grip. T then
as ks I' to move further in the direct ion of
stretching. and res ists that movement to sti mul ate
p's ant agoni sts.
Note: In iti al pos ition of toe(s) relati ve to foot must
be carefull y mai nt ained as ankl e is dorsall y flexed.
156
Fig. 12 1 a. Start ing Positi on.
Fig. 121 b. Fi nal Positi on.
9.3.5. Therapy for the lumbricales .
Starting Position: P: Prone; knee fl exed approx-
imately 90°; ankl e in neutral positi on. T: St anding
facing p·s le ft side.
Grip: T' s ri ght hand stabili zes p·s late ral toes by
full y fl exing at the DIP and PIP joints whi le full y
extending at the MTP joints. T' s left hand grips
around p· s foot from pl ant ar side. To increase force
appli ed. p·s foot may be support ed against T' s
chest .
Procedure: Using thi s grip . T graduall y and full y
dorsally flexes at p· s ankl e.
Stimulation of Antagonists: T retains grip. T thell
asks P to move further in the directi on of
stretching. and resists that movement to stimul ate
p' s antagoni sts.
Fi g. 122 a. Starting Positi on.
Fi g. 122 b. Final Positi on.
157
9.4.1. Therapy for the adductor hallucis
and the fl exor hallucis brevis,
fibul ar part .
Starting Position: P: Supine : ankl e in ne utral
pos ition. T : Standing fac ing the medi al side of p's
foot.
Grip: T' s left hand gri ps P's great toe near the MT P
joint. T' s right hand stabili zes p' s foot at the
medi al-dorsal side ncar t he MT P join t of t he great
toe.
Procedure: Maint aining thi s grip . T appli es tracti on
at t he MTP join t whil e graduall y and full y
abduct ing. extending and lat erall y rotating
the great toe (dorsal aspect of t he great toe moves
in tibial direction).
Stimulation of Antagonists: T retains grip. T then
as ks P to move furth er in the directi on of
stretching, and resists that movement to stimul ate
p's antagoni sts.
Notes: Continuously check for normal MTP joint
gli de during treatment.
Thi s technique may be used for treating hallux
valgus.
t 58
Fig. 123 a. Start ing Position.
Fi g. 123 b. Final Pos iti on.
9.5.1. Therapy for the abductor hallucis
and the flexor hallucis brevis,
tibial part.
Starting Position: P: Supinc: ankl e in ncutral
position.T: Standing facing the late ral side of P's
foot.
Grip: T's ri ght hand grips p' s great toe near the
MTP joint. thumb along the fibular side and fl exed
index finger along the tibial side. Ts left hand
stabili zes p' s foot at the dorsal-medial side ncar the
MTP joint of the great toe.
Procedure: Using thi s grip. T applies traction at the
MTP joint while gradually and fully adducring,
exrending and medially rotating the great toe
(dorsal aspect of the great toe moves in fibular
direction).
Stimulation of Antagonists: T retains grip. T then
as ks P to move further in the direction of
stretching, and resists that movement to stimulat e
P's antagonists.
Fig. 124 a. Starting Position.
Fi g. l2-l b. Final Positi on.
159
9.5.2. Therapy for the flexor hallucis brevis,
tibial part
Starting Position: P: Supi ne; ankl e in neutral
pos iti o n. T: St andi ng fac ing the lateral side of P's
foot.
Grip: T's ri ght hand gri ps the distal phalanx of P' s
great toe, thumb along the dorsal side and fl exed
index fi nger on the pl ant ar side. T's left hand
stabili zes p' s foot from the dorsal-medial side near
the MTP joint of the great toe.
Procedure: Maint aining thi s gri p. T appli es t racti on
at the MTP joi nt of P's great toe whil e graduall y
and full y extending, adducting and mediall y rot at- I
ing the proximal phalanx, (dorsal aspect of the
great toe moves in fi bul ar direction).
Stimulation of Antagonists: T retains grip . T then
as ks P to move further in the directi on of
stretching, and resists that movement to stimul ate
P's ant agoni sts.
Note: Stretching is easier when the entire great toe
is gripped. However , the ankl e must then be
pl antar fl exed, to rel ax the flexor hallucis longus.
160
Fig. 125 a. Sta rting Pos ition.
Fi g. 125 b. Final Positi on.
9.6.1. Therapy for the interossei plantares
and interosseus dorsalis [.
Starting Position: P: Supine; ankl e in neutral
posi tion . T : Standing facing the lateral side of p' s
fool.
Grip: 1""s ri ght hand grips near the MTp joi nt s of p's
lateral toes and fu ll y ftexes them at the 01 P and PI I'
joints. 1""s left hand stabilizes p's foot at the
do rsal-medi al side near the MTI'-j oi nt s.
Procedure: Usi ng this grip. with toes maximall y
fl exed at the DIP and I'll' joint s. Tapplies tracti on
at the MTp joints whil e graduall y and full y dorsal
flexillg at the MTp joints and drawing toes laterally
towards the fibu la.
Stimulation of Antagonists: T retains grip. T the n
asks P to move further in the direct ion o f
st retching, and resists that movement to sti mul ate
p's ant agoni sts.
Fig. 126 a. Starting Posi ti on.
Fig. 126 b. Final Position.
16 1
9.7.1. Therapy for the interossei dorsales II ,
III and IV, abductor digiti minimi
and Hexor digiti minimi brevis.
Starting Position: 1': Supine: foot in neutral
position. T: Standing facing the lat eral side of p· s
foot.
Grip: T s ri ght hand grips ncar the MTp joi nt s of p·s
lateral toes. thumb and thenar emine nce over the
dorsal side and fingers along the plantar side. T s
left hand stabili zes p·s foot at the dorsal-medial
si de near the MTp joints . T s ri ght hand then full y
flexes the four toes at the DIP and I'll' joints .
Procedure: Maintaining thi s grip. with the toes
maximall y He xed at the DIP and I'll' joi nt s. Tthe n
appl ies traction at the MTP joint s whil e simul -
taneously dorsal flexil/g at the MTp joint s and
drawing the rOllr tocs towards the ti bia.
Stimulation of Antagonists: T retains grip. T then
asks I' to move furth er in the direction of
stretching. and res ists that movement to stimulate
p' s antagoni sts.
162
Fig. 127 a. Starting Position.
Fi g. 127 b. Final Positi on.
PART -1
TABLES AND I ' DEX
10 MOVEMENT RESTRI CTION TABLES
10- I SHOULDER AND A RM
10-2 SCAPULA AND CLAVICLE
10-3 ELBOW AND FOREARM
10--1 WRIST
10-5 METACARPO-PHALANGEALJOINTS
10-6 FI NGER I NTERPHALANGEALJOI NTS
10-7 CARPO-METACARPALJOINTS OFTI-J UMB AND LITTLE FI NGER
10-8 HIP
10-9 KNEE
10- 10 ANKLE
10- I I TOES
II I NDEX
163
10 MOVEMENT RESTRI CTION TABLES
The foll owing tables li st the va ri o us movement s
whi ch may be rest ri cted, indexed to the muscles
which . when short ened. cause the restrictions.
The tables may be used diagnost icall y. to
identify the muscles which may be involved in
restricting particular moveme nt. Or they may be
used analyt icall y. to ident ify the movement s whi ch
may be restri cted by the shorteni ng of particular
muscles.
In mos t. but not a ll cases. a shorte ned muscle
causes restrict ion to Ill otion in an opposit e manner
to its main act ion: a shortened extensor will
restrict fl exion; a sho rt e ned adductor will restrict
abducti on, and so on. In some cases act ions andlor
restricting effects may change when Illuscles arc in
extreme posi ti ons. For instance . most of t he
adductors of the hip can restrict exte nsion when
the hip is extended. but they also can restri ct
ll exion when the hi p is fl exed.
The actions of many muscles effect more than
oll e movement . frequentl y at more than one j oint .
Therefore. when one of these muscles is shor-
te ned . the restri ct ion it causes at a joint often
depends on the position of ot her joints at whi ch it
acts. For instance. the l1exor digitorum super-
f1 ciali s of the forearm acts to flex the fi ngers.
164
including at the PI P joint s, volar flexes at the
wri st. and fl exes at the elbow. So the restric1ions it
may cause when shorte ned depend on an int er-
relat ionship of these actions. It may:
- restri ct extension and supinati on of the elbow
and forearm when the finge rs are exte nded,
- restrict dorsal flexion at the wri st when the
fin ge rs are exte nded .
- restrict extension at the MCP joints whe n the
PI P joints are exte nded,
- restrict extension of the IP joints whe n the wri st
is dorsally fl exed. the elbow is extended, and the
forearm is supinated.
Condi ti ons for limit ed rest ri ct ion. such as these
for the l1exor digitorum superfi ciali s. are li sted in
the last column to the ri ght in the tables involved.
When the conditi ons li sted arc not fu lfill ed . the
muscle involved may be cons idered not to rest ri ct.
For insta nce. whe n the fi ngers are fl exed, a
short e ned fl exor digit orum superficiali s will not
restri ct dorsal flexion at the wri st (Table 4.4).
10.1. Tabk of
SII OULDER A:-JD RESTRICTED BY SIIORTENED MUSCLES
•• = • = Secondary rcst rictor
RESTRICTED MOVEMENT
SII ORTENED I Fk\ion Ext cll!'l ioll Adduction Abduction Medial
MUSCLE rotati on rota tion
major
-abdominal part
•• •• •
-clavicul a r part
•• • •
part
•• •• •

•• •• •
lac ... maj or
•• •• ••
biceps brachi i
• • •
-long hl.!<l d
deltoid
-clavicular part
•• • •
-acromial part
••
P;'lrt
• • •
teres minor
• • ••
infraspinat u!'l
• ••
hrachii.
• •
-long head
 
•• • •
coracobrachiali"
• • • •

• • ••
brachii
• • •
-s hort head
minor

( . ) (. )
subclavius
• •
165
10.2. Table of
SCAPULA AND CLAVICL E RESTRICTED BY SII ORTENED MUSCLES
•• = Primary rcstrictor • = SI;'condary
RESTRICTED MOVEMENT
SHORT ENED Ek'\'ation Adduction Abduction Medial Lat e ral
MUSCLE rotation rotation
 
••
pectoral i:-. minor
•• •• ••
anteri or
• •• ••
trapezius
-descending part
•• • ••
-t rans\'cr:.e part

••
part
•• •
••
iI;\'alOr scapula!""
•• • •
rhomboidei
•• •• ••
dorsi
• •
pectoralis major
• •
166
10.3. Table of
ELBOW FOREAR\I RESTRICTED BY SII ORTENED MUSCLES
•• = n.;o-.·tnctor • = Secondary
RESTRI CTED MOVEMENT
SI IORTENED
MUSCLE EXle l1!-.ion Pronat ion Supimlt ion Notes
br<lchii
•• •
-long head
  head
•• •
br<lchiali s
••

•• • •
pronator
• •
pronator

brachii
••
,tllCOne us

!-. upinator

••
Ilcxor ca rpi
• •

Ikxor ca rpi
• •
ulna ri s
longm
• •
ex tensor c<l rpi
• •
radial is
ex tenso r Gnpi
• •
radi,t1i s brevi:-.
ex tensor carpi
• •

flexor d igit or ulll
• •
extended
slIpc rfil'ialis
digi lOrul1l
• •
IIngL'r:-. fl exed
COIll I1lUIlI S
ex te nsor di gi ti

IIngcr Il exed
IllIIlIIllI


Ihum/) flexed
longus
abductor

th umb addul'ted
longus
cx lensor indi cis

finge r Ikxcd
flexor polli cis ( . )
• •
thumb ex te nded

167
10.4. Table of
WRIST MOVEMENTS RESTRI CTED BY SI IORTENED MUSCLES
•• = Primary • = Sl:condary restrictor
RESTRICTED MOVEMENT
SHORTENED Volar Radial Ulnilr Not e:.
MUSCLE fl exion l1ex ion flexion flexion
flexor e<lrpi
•• ••
radialis
flexor carpi
•• ••
ulnari s
palmari s longm.

extensor carpi
•• ••
radiali s longu:-.
cxtCIl:.or carpi
••
rad iali s  
extensor carpi
•• ••
ulnari s
flexor di!!.i to rul11

lingl:r eXh..'lllkd
profundu:-.
flexor digit orum

ling(:r extended

cxtcn:-.o r digitorulll
••
tinga fkxl:d
cOlllll1uni:-.
indi<.' i:-.
• •
finger fleXl:d
extl: n:-.or digiti

fi nger flexed
minimi
extenso r polliei s
• •
thumb flexed
longus
extcmor pollici:-.
• •
thumb fl exed
brevi:-.
abductor polii ci:-.
• •
longus adducted thumb
flexor polliei s

flexed th umb
longu:-.
168
11I.5. Tabl e of
METACARPO-PHALA' GE_.\ L I \I CP) JOI :-JT RESTRI CTED
BY \I L-SCLES
•• = • = Secondary rc!. trictor
RESTRICTED MOVEMENTS
SHORTENED
I
Fk ,, - EXIL'n- Abduc- Adduc- Opposi-
MUSCL E ion :-.ion lion lion lion l ion
flexor digilOrum
••
profLllldus
Ilcxor digi lOTUI11
••
superllciali ..
extensor digi l orulll
••
('oll1J11uni :-.
ex tenso r indi cis
••
Cx lcll:..o r digiti
••
rninimi
Itlillbricali::-,
••
III -I V. I -II
inlero:..:..ci
• ••
  I and II
int ,-' ro:..sci dor-
• ••
III & I V

• •
pal mari :-. I
inlcross\"j
• ••
palrnari" I I - I I I
abductor digit i
• ••
( . )
rninimi
flexor digiti
•• •
minimi
  digiti
••
mlnlllll
extensor pollici !o.
•• ••
longu:-.
extensor pollici!o.
•• ••
brevis
Il exor
•• ••
longus
fl exor pollici:-.
•• ••

Note:..
I P j oinll.'xtl.'nclecl
PI P
I.'xtl.' lldcd
DIP & PIP jl)inh
Ikxl.'d
DIP& PIP joinh
llol.'cI
DIP ,-,\: PIPj oillh
tle"cd
dor ..... 1 Ik'xl.'l..1
wr i,,( 8.: Hl'xt'tI
DIP & PIP joint-.
DIP & PIP joinh
th.'Xl'd
DIP & PIP joinh
flcxl'd
D1P & PIP joint:-
Ilnl'd
DIP 8.: PIP jllin!:-
flexed
\\ ri :-.I \ olar
IkxL' d : DIP & PIP
jll inh Ik' x!..' d
\\ ri:-t \ o[ar <lnd
ulnar !kxed: IP
joint flexed
mainly with
forea rm pronalL'd.
& \\ ri:-. I ulna r
IkXL'd
lllainly with \\' ri :-I
dor:-al Ikxed &
I P joi llt cxtc IH.h . .'d
mainly with \\' ri :-' l
Ilexed
169
10.6. Tabk of
FI NGER ( I I' JOINT) RESTRI CTED BY 511 0 RTE:-1I:D
•• = Prima ry • = Seconda ry
RESTRICTED
SI IORTENED
MUSCLE Fkxioll Note ...
Ocxor digilOrum
••
mainl y with flexed -.\:
profundus for(';\1'111
Ikxor eligitorum
••
mainl\' wilh tl('x-.' d, elbow
l'.'\tcll(kd. and fo rl' arm !'! upinatl'd
digitorulll
••
mainh \\ it h \\ riq \'ol ar tll'Xl'tL elbm\
(' ,'\(-.'mic-d, and forcarm IHOlldtl' d
cxtcll!'!or ineliei ...
••
mainh \\jlh \olar flexed. l'll1o\\
l' ,'\(-.' Ilckd, ;t nd [nrc,trlll prtUlatcd
cxtell!'!Of d igiti
••
mainl\' with \ola r tlexl'd. dbO\\
minimi c,'\(-.' n(h,:'d. and [orcaI'm prOlwtcd

••
main ly wilh \\ dor ... ;tI Il excd :tnd i\ ICP
joi nt;.. l.'.'\ lcnelcc\


mainl y \\illl \ IC I"' joint;., l'Xh::'l\(kd
I and II
   

mainly wilh Me p l'xlelldcLl
111 -1 V


\\ illl \ fC P joint;., l','\\('ndcLl
palmarb I


mainly \\ith \I C P-joi nt ... cxtcllLled
II - III

••
\\ ith forca rm pronat cd . \\ \ ola r &
uln ar tic,xcd, \ ICP joint tlexl'd. a nd thumb

flexo r
••
m<tinly with forearm
dor ... al Ilt.'x('d. i\ ICP joint ext(, nded. and
thumb
170
10.7. Table of
,\ IOVDIE:-:T OF TIfE (-\RPO· \IETACARPA L (CMe) JOINTS OF Til E AND
Ti l E L1TTl [ FI ' C.LR RE TRICTED BY SII ORTE:-.IED selES
•• = Pnm 1') r'-....... tndor
RESTRICTED MOVEMENT
SI-I ORTE:-.IED
I
Abduction Adduction Oppo:-:.ition
extcn,,>or poll ici ...
•• •


••
( .. )

bre\ i ...
abduclOr polli ci,
•• •

flexor
••
long.us
licxor
•• •
hrc\b
opponell:o,
• •
polli cis
ahduclOr polli(·j::,
• ••
brcvis
adductor poll jci:-
• ••
exlCn:-,Qr di giti
•• •
mini mi
abductor digiti
• •• ••
minimi
flexor di giti
•• •
minimi brc\' i\
intcrosscm
• ••
palmaris 1
Repn:-:.ition
  \\ it h
"'ri::-ot ulnar &
Ikxcd)
••

••

••
17 1
10.8. Tabl e of
HI P MOVEMENTS RESTRICTED BY SHORTENED MUSCLES
•• = Primary rcstriclor

= Secondary
RESTRI CTED MOVEME, T
SHORTENED Flcx- Ext en- Abduc- Adduc- Lal cnLl Nott: s
MUSCLE ion sion li o n lion rotat ion rotation

•• •

• • •
rectus fe mori s
••
pectinells
•• •• •
tensor fasciat: lawe
• • ••
gluteus    
••
• • ••
   
• • •• •• •
rninimlls
• • •• • ••
femori s
••
• •
mainl y with
-l ong head knee
semit endinosm
••
• •
mainl y with
knee extended

••
• •
mainl\' with
knee ext cmkd

• •• •
main ly wilh
knee extended
adducwr longus
• •• •
,
adductor brevis

•• •
udductor magnlls
• • ••
• ••
pi riformis
• • ••
quad ratus femo ri s
• • ••
gemell i
• ••
obturator Cx l CrTlllS
• ••
obturator
• ••
,
,


172
--'
10.9. Table of
KNEE MOVEMENTS RESTRICT ED BY SHORTENED MUSCLES
•• = Prima ry reslrictor

Secondary restrictor
RESTRICTED MOVEMENT
SHORTENED Fl exion Extension Medial Lat eral Notes
MUSCLE rotation rot ation
':>c mitc ndino':>us
••
. (. ) mainl y with hip !lexed
semimembranosus
••

mainly with hip l-lexcd
biceps femor is
•• ••
mainl y with hip fl exed
reCl us femori s
••
mainly with hip  
vast us lateral is
•• •
vast LI S int ennedius
••
vastlls medialis
••
(. ) (. )
sart o rius
• •
Illdin ly wit h hip extended
popl i teus
• ••
gastrocne mius

plantaris

te nsor fa sciae
• •
Inlae
gracili s
• •
main ly with hip ext ended
173
10.11I. Table of
ANKLE MOVEMENTS RESTRICTED BY SI IORTENED
•• =   • = Secondary
RESTR.ICTED MOVEMENT
SI IORTENED Plantar Dor:-.al I nn: r:, ion E\ crsian Notc:.
MUSCLE fkxioll Ikxioll (supination) (pronation)
ti biali s ante ri o r
•• ••
extenso r digi·
•• ••
ta rum longus
perone liS tertius
•• ••
extensor hallucis
• •
Illilinl y wit h grea t 10C MTP
longus & I P joillb Ikxed
gastrocnemim
••
mainlywilh knt'L' extl'nded
plaJllari s
• •
mainly wit h knee ('xtl..'ncled
sole li S
••
peroneus longus
• ••
tkxor digitorum
• •
mainly \\ ilh ;"ITP. PIP. and
longus DIP joint:-. extended
flexor halluci s
• •
mainl y with MTP & II'
longus joinb extended
tibialis posterior
• •
peroneus brevi!'>
• ••
174
10. 11 . Table of
TOE ,IO\"E\I E' T RE TRICTED B\ SIIORTE:"ED ,IUSCLES
• = Seconda ry
RESTRICTED MOVEMENT
SII ORTE:"ED
i

R""\.lon
Extt'll,ion Abd uct io n Adduction
cXlc n:-,ordigitorum
••
mainl y \\ illl ankle
longu!lo plantar tlexl..'d
CXh.'tbor halJuci "
I
••
mainl y with ankle
longus plantar tlexed
Ilcxor digitorum
••
mainly \\ illl ankl e
!ongu, Ilexed
Ikxo r halJucis
••
main l) \\i lll ankle
tkxed
abd uctor
••
flexor digitorum
••
bre\
abductor digiti
••
millimi
plantae
••

••
DIP
• MTP
mainl y with ankle dorsal
PIP fk xed and MTP join b
exte nded
flexo r •• i\ IT P
 
adducl or halluci:-,
• ••
flexor digiti
•• •
min imi  
inlero!'!!'!\..'us

II'

,ITP

mainly \\ itlt MTP joinb
I exte nded


DIP
• MTP •
mainl) with MTP joinb
II -IV I' ll' exte nded


DIP

NlTP

mainl y with MTP joints
pl antares I' ll' ex te nded
exlen:-,or
••
digitorum  
cx tCJ1 :-,or ••

brevi!'!
175
INDEX OF MUSCLES
abductor digiti minimi manus 76·77.87. 169. 171
abductor digiti millimi pedi s 148- 149. 162, 175
abductor hatJucis 148-1-1.9. 159. 175
abductor polli cis brevi s 76-77. 8 ..k 171
abductorpollicislongus 68-69,74, 76-77 , 85 ,167, 168 ,171
adductor brevis 90-93.95.99-100. 105. 109-122. 172
adductor hallucis 148- 149. 158. 175
adductor longus 90-93.95.99-100. 105. 109- 122 . 172
adductor magnus 90-93.95.96.99-100.105. 109-119,
123- 125. 172
adductor polli cis 76-77. 83. 86, 17 1
-transverse head 76-77.86. 141
anconeus 49-5 1. 167
biceps brachii 16- 17.39.42 . 165. 167
-short head 15-17.39.42. 165. 167
-long head 16-17.39. 165. 167
biceps femor is 90-93. 94. 96. 98-100. 173
- short head 90-93.94. 126- 127. 131. 173
- long head 90-93.94.96.98- 100. 172. 173
brachialis 49-50. 52. 167
brachioradi ali s 49-50.53. 167
coracobrachiali s 15-17.41. 165
delt oid 15-17.28.29.30.40. 165
- acromial part 16- 17.28 ... HL 165
--clavicular part 15- 17. -H. 165
- pars spinali s 15-17.29.30. 165
ext ensor carpi radiali s brevis 49- 50, 55, 68-69, 167, 168
extensor carpi radi alis longus -1.9-50. 5-t. 167. 168
ext ensor carpi ulnari s 49-50.61, 68·69. 73. 167. 168
extensor digiti minil11i 59. 68-69, 167·1 70
extensor digitorum brevis 1 151·1 52. 175
extensor digitorum communb 56. 58, 68·69, 167- 170
extensor digitorum longus 138-139, 174. 175
ext ensor hallucis brevis   150, 175
ext ensor hallucis longus 133- 134. 136-137 . 148-149. 174
extensor indi eis 49-50.57, 68-69. 167-1 70
extensor polli cis brevi s 68-69.70.75-77.85. 167-171
extensor polli cis longus 68-69.70,76-77.85, 167-1 7 1
nexor ca rpi radiali s 49·50.63,68·69. 167, 168
fl exor carpi ulnari s 49-50.62. 68-69. 73. 167. 168
fl exor digiti minimi brevis manus 76-77. 80, 169 , 171
flexor digiti minimi brevis pedi s 1-1. 8- 1-1.9. 162 . 175
fl exor digitorum brevis 1-1. 8· 1-'9,1 55, 175
flexor digitorum longus 133- 134. 148- 149. 156. 174- 175
nexor di gitorum super fici alis 49-50, 64, 68·69, 167·1 70
nexordigitorum profundus 68-69. 7 1. 76-77, 168- 170
flexor hallucis brevi s 148· 149. 153, 158·1 60,175
- fibular part 148-149,153,158.1 75
- tibial part 148-149, 153, 159- 160, 175
flexor hallucis longus 133-134.148- 149.154.160, 174-1 75
flexor pollici s brevis 76-77.82. 169. 171
fl exor pollicis longus 68-69.72. 76-77, 167-1 7 1
gastrocnemius 133-134.141-143. 173- 174
- lat eral head 133-134.141-143.173- 174
- medial head 133-134.141. 143 . 173-1 74
gemell us inferior 96. 98-99 , 106, 120-122. 172
gemell us superior 96, 98-99, 106, 120-122, 172
glut eus maximus 90.93,95.96.98.99. 120-122. 172
gluteus medius 90-93.96. 98.99- 100. 106.107.120-125. 172
gluteus minimus 90-93.96.98.104. 106. 107. 120-122, 172
gracili s 91-93.105. III. 11 9. 123-125. 172-173
hamstrings 90. 93. 94
iliopsoas 91 -93. 101-102. 106. 109. 120-122. 172
infraspinatus 15·17,30,3 1, 165
int erossei dorsales manus 76·77, 79. 169· 170
int erossei dorsales pedis 14S- I-I.9. 161. 162. 175
palmares 76·77, SO, 169·170
interosse us palmari s I 76-77.82-83.85. 169-171
int erossei plant ares pedis 148- 149. 161. 175
lati ssimus dorsi 15-17, I S·19, 24·26, 165, 166
levator scapulae 15·17. -1.5·47 , 166
lumbricales manus 76-77.81. 169-170
lumbricales pedis 148-149. 157. 175
obturator extern us 96,9S, 106. 120·122, 172
obt urator internus 99-100, 120-122, 172
digiti minimi manus 76·77, 8S. 169
opponens pollicis 76-77. 86. 171
palmaris longus 49-50.64.67-69, 167
pectineus 91-93.95.99-100. 105 . 109-122, 172
pectorali s major 15-17.18-23.24.26.41. 43.165-166
-abdominal part 15- 17. 18-19. 24. 26. 165-166
-clavicular part 15- 17.22-23.24.26. 165-166
- sternocostal part 15-17.20-21. 24. 26. 165-166
pectoralis minor 15-1 7, 18-19, 27, 165·166
peroneus brevis 133-134, 147. 174
peroneus longus 133· 134,147, 174
peroneus tertius 133-134. 140. 174
piriformi s 90-93.96-99, 106, 120-122, 172
plantari s 133-134. 141. 143. 173- 174
popliteus 126- 127. 132. 173
pronator teres 65-66. 167
- humeral head 49·50,65. 167
- ulnar head 49-50.65-66. 167
pronat or quadratus 49-50, 65·66, 167
rect us femoris 90-93. 103- 104. 172- 173
rhomboi dei major 15- 17, 33. 166
rhomboidei minor 15-17.33.34, 166
quadratus femoris 90·93.96.98. 106. 120·122. 172
quadriceps femori s 126·130, 172·173
femori s 90-93, 103·10 ..L 172·173
-vast us intermedius 126-1 27, 12S- 130. 173
- vastus lat eral is 126- 127. 128-130, 173
-vast us mediali s 126-127. 128- 130. 173
quadratus plantae 175
91-93, 106, 172, 173
90·93.94.96. 9S-100. 123· 125 . 172·173
semitendinosus 90-93. 9-l, 96, 98-100, 123-125. 172- 173
ant eri or 15·1 7, 38, 166
,ole us 133-134. 141. 144-145. 174
15·17.28.165.166
subscapula ris 15- 17.41. 43.165
supinator -l 9-50, 60. 167
supraspinatus 16-17, 2S. -l0. 165
tensor fasciae latae 9 1·93, 106. 108. 123-125. 171· 173
teres maj or 15-17. 18-19.24. 26. 165
teres minor 15-17.30.165
tibi al is anteri or 133·134, 135.
tibiali s posteri or 133·1 3-1.. l-l6. l 7-l
trapezius 15·17, 16. 32-33,37, 4-l. 166
-ascending part 15-17.37. 166
- descending part 15·1 7, 44, 166
- transverse part 15·17.32·33. 166
tri ceps brachii 15·1 7,35· 36,49-51. 165. 167
- medial and lateral heads 167
- long head 15-17. 35-36. 165. 167