Research

Behaviourofthemuscletendonunitduringstatic stretchingfollowingunloading
Hiroshi Kanazawa, Yukio Urabe, Taizan Shirakawa Aims: To determine the amount of displacement in the muscle-tendon unit of the medial head of the human gastrocnemius muscle during static stretching, after a period of non-weight-bearing following injury. Methods: Twenty female patients with a unilateral lower leg injury participated in this study (N= 13 following ankle fracture-dislocation; N= 7 following fracture of the tibiofibula). The difference in displacement of the junction of the fascicle and the deep aponeurosis junction (DA) at ¼ proximal height of the lower leg and that of the myotendinous junction (MTJ) between the injured and uninjured leg was measured using ultrasonograms and analyzed by two way analysis of variance for repeated measures and paired t-tests. Findings: Initially, DA displacement was larger, and MTJ displacement was smaller, in the injured compared with the uninjured leg. After treatment, DA and MTJ displacements in the injured leg approached levels of the uninjured leg. At all time points, DA and MTJ displaced distally during the first three minutes of stretching in both legs (P < 0.01). Conclusions: Following a non-weight-bearing period, fascicles and tendon may be excessively extended. Recovery of the muscle tendon complex might be accelerated by applying exercises aimed at attaining increased extensibility of the aponeurotic tissue.
Keywords:n muscle-tendonunitnrehabilitationn stretchingn unloading
Submitted 7 August 2009, sent back for revisions 1 October 2009; accepted for publication following double-blind peer review

Hiroshi Kanazawa is Senior Physiotherapist, Director of Department of Rehabilitation, Department of Rehabilitation, Matterhorn Rehabilitation Hospital, and Doctorate Student, Graduate School of Health Sciences, Hiroshima University, Hiroshima; Yukio Urabe is Professor, Graduate School of Health Sciences, Hiroshima University, Hiroshima; and Taizan Shirakawa is Senior Orthopedic Surgeon, President of Matterhorn Rehabilitation Hospital, Matterhorn Rehabilitation Hospital, Hiroshima, Japan Correspondence to: H Kanazawa E-mail: kanah@mbe. ocn.ne.jp

3 December 2009

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tretching exercises are commonly undertaken in sports and rehabilitation settings. Among the benefits of stretching of human musculoskeletal structures are injury prevention, and improved performance by regaining joint range of motion (Hortobagyi et al, 1985; Taylor et al, 1990; Wilson et al, 1991; Witvrouw et al, 2004). Similarly, in physical therapy, stretching is one of the most effective techniques used for lengthening shortened muscles, and improvement of joint range of motion (Ylinen, 2008). To determine the most effective stretching method and optimal stretching time, an understanding of the response to stretching of the muscle-tendon unit in various states is required. The reaction of a healthy muscle-tendon unit to stretching has been previously examined in healthy adults (Herbert et al, 2002; Kubo et al, 2005; Morse et al, 2008). Herbert et al (2002) measured changes in length of muscle fascicles in relaxed human gastrocnemius muscle during passively imposed changes in joint angle. They

reported that in gastrocnemius, which has relatively long tendons, only 27% of the total change in muscle-tendon length was transmitted to the muscle fascicles. Kubo et al (2005) showed that while the muscle fascicles, tendon and aponeurosis stretched during passive dorsiflexion of the ankle joint, the elongation of the tendon was significantly greater than that of the aponeurosis. Morse et al (2008) reported that the muscletendon unit length increased by 21.9 mm during stretching. However, the reaction to stretching of an unhealthy muscle-tendon unit, such as in muscle injuries including muscle strain, muscle tendon atrophy, or unloading, is largely unknown. The aims of the present study were to investigate the reaction of the muscle-tendon unit to stretching after a period of non-weight-bearing, compared with that of a healthy muscle-tendon unit, and to quantify, using ultrasonograms, the displacement of the fascicle-deep aponeurosis junction (DA) and the myotendinous junction (MTJ) during stretching of the medial head of the gastrocnemius muscle.

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InternationalJournalofTherapyandRehabilitation,March2010,Vol17,No3

Thirteen patients were diagnosed with a fracture-dislocation of the ankle... A given coordinate point was precisely reproduced by using records of four squares of the probe fixation frame.2 years. The amount of distal displacement of each of the markers reflects the reaction of the muscle-tendon unit to stretching. The right image shows the myotendinous junction (MTJ). The stretching board with a freely adjustable angle.Vol17. and the level metre. maximal ankle dorsiflexion angle of the injured leg. Japan) with an 8MHz linear scanning probe (PLM-805AT. The markers were the junction of the fascicle and the DA at ¼ proximal height of the lower leg and at the MTJ (Figure 1). proximal distal proximal distal Figure 1. ultrasonograms were recorded every minute using an ultrasonic apparatus (Power Vision 6000 SSA-370A. or to the Achilles tendon. During stretching. Equal distribution of load between both legs was ensured at the beginning of stretching by asking the patient to apply half their body weight to each of two independent scales. The left image shows the fascicle-deep aponeurosis junction (DA). using a freely adjustable angle and an attached incline level meter (Niigata Seiki Co. Japan. A photograph of an representative ultrasonographic measurement is shown in Figure 3. Toshiba Medical Systems Co.4 cm. Ultrasonographic measurements Ultrasonographic measurements were performed after medical approval was given for the patient to begin weight-bearing of more than half of their body weight on the injured limb. In a standing position. Determination of the markers. but none had received direct injury to the gastrocnemius muscle or soleus muscles. the amount of displacement of two markers in the DA and MTJ during stretching on a stretching board was measured in both the injured and uninjured legs of each patient.3 ± 4. Markers were determined on ultrasonogram (arrows). 133 InternationalJournalofTherapyandRehabilitation. All patients were non-weight-bearing on one leg following a unilateral lower leg injury. USA). All patients had undergone surgical repair. Patients then stood for 10 minutes on the stretching board. Anonymity and confidentiality of the patients were assured. In each experimental session. Participants Twenty female patients (age 52.6 ± 6.No3 . or the angle just before the patients bent their knee.Methods design The study was an observational clinical study design. Procedures Determining markers in the medial head of the gastrocnemius muscle Two markers were identified in the gastrocnemius muscle by ultrasonogram performed in a standing position. Toshiba Medical Systems Co. Using an ultrasonogram. All participants provided written informed consent following study approval by the Institutional Review Board of the authors’ hospital. DA was determined with high brightness and a clearly depicted point in the junction of fascicle and deep aponeurosis at 1/4 proximal height of the lower leg. height. which was set to the predetermined Figure 2. Figure 2). Pelvis and trunk orientation during stretching was monitored by visual observation. weight 57. 154. (mean±SD)) were examined. the maximal ankle dorsiflexion angle was determined as the angle of tolerable submaximal stretching pain.March2010. The amount of distal displacement of each of the markers in the recorded images was measured using ImageJ image analysis software (NIH. These markers were carefully chosen and confirmed to show clear echoes. and seven with tibiofibular fractures.). A probe fixation frame made from an ethylene-vinyl acetate sponge was used during ultrasonographic measurements to help maintain the position of the probe.6 kg. in accordance with the principles of the Declaration of Helsinki. the maximal ankle dorsiflexion angle of the patients’ injured leg was quickly measured on a stretching board.6 ± 12.

0011). paired t-tests were performed to compare the difference between the uninjured and injured legs. uninjured leg and time) was used to compare the difference in the amount of displacement of DA and MTJ between the uninjured and injured legs for every 1 minute (a = 0. (a) The arrow shows a DA position in the standing position. statistical analyses All statistical tests were performed in GraphPad Prism 5.00 (GraphPad Software.005. Two-way analysis of variance for repeated measures (factors: injured leg. Upon detection of a significant main effect. A case of shift of the markers before and after stretching. (d) The white arrow is a MTJ position after stretching for 10 minutes. CA). Bonferroni correction for multiple comparisons was applied. Calf circumference Calf circumference was measured using a fibreglass tape measure at the point of maximum calf girth. (c) The arrow shows a MTJ position in the standing position. proximal distal proximal distal 134 InternationalJournalofTherapyandRehabilitation. La Jolla. Ultrasonographic measurements were repeated every week. A probe fixation frame was used to facilitate the depiction of the markers.05). (b) The white arrow is a DA position after stretching for 10 minutes.Vol17.05). Figure 3. Paired t-tests were used to detect significant differences in maximal ankle dorsiflexion angle and circumferences of the calf between the first and final measurements (a=0. Paired t-tests were used to assess the difference in the amount of displacement of DA and MTJ for every 1 minute a=0.No3 . Ultrasonographic measurement.Research of the study measured the displacement of the markers in the ultrasonograms. One physical therapist blinded to the purpose and methods Figure 4.March2010. and the level of significance was set at 0. and were concluded when there was no statistical laterality in the amount of displacement of both markers after stretching. One physical therapist blinded to the purpose and methods of the study measured the calf circumference. Data are presented as means ± 1SD.

1±1. maximal calf circumference was 1.4 weeks. The DA and the MTJ were identified by the deep aponeurosis-fascicle junction and the myotendinous junction. Nikolaou et al.8° at the beginning of measurements to 18.2 -1. As such.Vol17. P = 0. A typical case of DA and MTJ displacements measured by ultrasonogram are shown in Figure 4a. during the three minutes prior to the final measurement (P < 0. detailed observations revealed a deep aponeurosis-fascicle junction and/or superficial aponeurosis-fascicle junction in injured regions (Hughes et al.2 15. Change of the circumference of the calf Circumference of the calf (cm) First measurement Uninjured leg (a) Injured leg (b) Laterality (a)-(b) 32.7±2.9 9.7 cm lower in the injured leg than in the uninjured leg (P = 0.4±3. the distal displacement of DA on the injured side gradually decreased towards the final measurements (Figure 5b. Noonan et al.6±1. These regions are easily injured and are affected by changes in the state of the muscletendinous tissue.7±0. the distal displacement of MTJ on the injured side gradually increased towards the final measurements (Figure 6b. Subsequently.5±3.6 Final measurement 5.3±0.2 * * Note:*P<0.01).0 MTJ (mm) First measurement Final measurement 15.8±1. calf circumference was 1.3 ± 0. Table 2. At the MTJ.8 -1.1 16. 1994).01).9 ± 2. Amount of displacement of the DA and MTJ during 10 minutes stretching DA (mm) First measurement Uninjured Injured 5. the distal displacement of MTJ became increasingly similar to that of the uninjured side (Figure 6d). No significant interactions between factors were found for uninjured and injured legs.73). Previous histological studies have demonstrated a high incidence of damage to the myotendinous junction in muscle strain injuries (Garrett et al.8 ± 4. MTJ displaced significantly until three minutes before the final measurement on both the injured and uninjured sides (P < 0. The amount of the displacement of DA and MTJ did not differ significantly after four minutes. The amount of displacement of the DA and MTJ at the first and final measurements is shown in Table 2. During the entire measurement period. at which time the maximal angle of ankle dorsiflexion in the injured leg improved from 4.05).9 5. c). the authors considered that these regions may be particularly responsive to muscle stretching. At the final measurement.March2010.Results The average postoperative period before approval for partial weight-bearing (50% body weight) was 6. and there was a significant difference in the amount of displacement of MTJ between uninjured legs and injured legs for every one minute. There was a significant main effect between uninjured and injured legs at the DA (P < 0. The average MTJ displacement is shown in Figure 6.6cm smaller in the injured leg than in the uninjured leg (P = 0. The distal displacement of MTJ on the injured side was smaller than that on the uninjured side in the first measurement (Figure 6a).035) indicating muscle atrophy (Table 1).1° vs 24. 1995).8±0.2 30. 1987.5 ± 4. Furthermore. There was no significant change in the maximal ankle dorsiflexion angle in the uninjured leg (23. c).2±2.05). b and Figure 4c.05:significantdifferencebetweenfiguresjoinedbylines utes before the final measurement. d. on both the injured and uninjured sides (P < 0. the distal displacement of DA became more similar to that of the uninjured side (Figure 5d).8±2.6° at the final measurement (P < 0. The overall average of DA displacement is shown in Figure 5. In the final measurement.7 * * Note:*P<0. discussion Ultrasonograms of the gastrocnemius muscle in humans with a unilateral lower leg injury were used to examine the reaction to static stretching in the present study.2±3.No3 135 .4 4. DA displaced significantly until three min- Table 1. a significant main effect between uninjured legs and injured legs was found (P < 0.4±0. During the entire measurement period.3 ± 3.1±1. respectively. 1993.6 Final measurement 32. Significant differences in the amount of displacement of DA for every 1 minute between the uninjured and injured legs were found during the three minutes before the final measurement (P < 0. Taylor et al. respectively.8 ± 0.05). In the final measurement. At the beginning of measurements.05:significantdifferencebetweenfiguresjoinedbylines InternationalJournalofTherapyandRehabilitation.1 31. Subsequently. The distal displacement of DA on the injured side was larger than that on the uninjured side in first measurement (Figure 5a).8 ± 3.01).01).023).9°. 1987.

March2010. which has been observed in disuse and ageing (Reeves et al. following 10 minutes of stretching.No3 .4 weeks Ankle dorsiflexion angle: 7.8° Stretchingtime(min) b) Post-operation 8.1 ± 2. Following longer periods of recovery. 1987. d). Eliasson et al (2007) found that the mechanical properties most affected by unloading in the rat were hysteresis and creep. Fukashiro et al.7 ± 1. 1988). 1986. Suspended rat tendons had lower values for maximal stress and tangent 136 modulus than tendons of control rats (AlmeidaSilveira et al.0 weeks (final measurement) Ankle dorsiflexion angle: 18. at the time of first measurement.6° Figure 5.4 weeks (first measurement) Ankle dorsiflexion angle: 4. a) In the first measurement. Over the whole of the measurement period.01 Stretchingtime(min) a) Post-operation 6. 1995) has been reported. Narici. tendon hysteresis and Young’s modulus (Shorten. In addition. injured MTJ displacement was smaller than that in uninjured legs at this time.8 ± 4. Hubbard and Soutas-Little. showing a reversed reaction to that seen in the uninjured leg (Figure 7). decreased stiffness of the suspended rat soleus muscle (Canon and Goubel. b) In the postoperation 8. 1984. In contrast. where the distal displacement of DA became similar to that of the uninjured side. These factors could explain the mechanical changes in the passive part of series elasticity (Almeida-Silveira et al. In this study. 1981. DA displaced significantly (P < 00.1) until three minutes on both the injured and uninjured sides. Unloading can affect these properties. 2001.0° ** Distaldisplacement(mm) Distaldisplacement(mm) ** ** ** ** ** ** ** ** ** ** ** Stretchingtime(min) c) Post-operation 10. as shown in animal models. and both decreased with disuse compared with the control rat. Achilles tendon suspension resulted in smaller surface area of collagen fibres (Nakagawa et al. on the injured side. However. Maganaris and Paul.Vol17. These mechanical characteristic changes would influence the results of this study.2 weeks Ankle dorsiflexion angle: 13. the authors were not able to identify a specific factor to explain the change observed in the patients.1 weeks and c) postoperation 10.7 ± 2.8 ± 3.3° Stretchingtime(min) d) Post-operation 12. InternationalJournalofTherapyandRehabilitation. 1994.Research ** ** ** Distaldisplacement(mm) Distaldisplacement(mm) ** ** ** ** ** ** ** ** ** **P<0. the distal displacement of the DA was larger than the uninjured side. to the final measurements. injured DA displacement was greater than that in uninjured legs. the distal displacement of DA on the injured side were gradually decreased.8 ± 3. 1989) and lower concentration of collagen (Vailas et al.6 ± 4. Pollock and Shadwick.7 weeks measurements. 2005. These findings may relate to changes in the mechanical characteristics of the muscle–tendon complex. Bennet et al. 2002). 2000) and increased tendon compliance.9 ± 2. 2005). Mechanical properties of human muscle and tendon reported in the literature include tendon stiffness. the reaction of the injured leg became closer to that of the uninjured leg. Total average of the distal displacement of the deep aponeurosis junction (DA). Ker. 2000).

and greater lengthening of the muscle belly in the injured leg may have been caused by decreased tensile strength of the muscle. 2002. on the injured side.0 weeks (final measurement) Ankle dorsiflexion angle: 18. 2006).No3 . Winiarski et al. 1987) and plaster cast fixation (Cooper. 1994) occurred in the atrophic muscle. Desplanches et al. (a) In the first measurement.7 weeks measurements. Those studies suggested that shortening of the crosssectional area and minimization of the muscular fibre (Desplanches et al. (b) In the postoperation 8. at the time of the first measurements. the 5. MTJ displaced significantly until three minutes (P < 0. 1990). to the final measurements d). Ultrasonographic measurements in the present study showed that both markers were distally displaced in both legs in the spontaneous standing 137 InternationalJournalofTherapyandRehabilitation. Thus.1 ± 2. 1979). 1978.Vol17.8 ± 3. 1972. the distal displacement of MTJ was smaller than uninjured side.March2010.8 ± 3. However. Many authors consider that a muscle electromyogram (EMG) level must be lower than 1% of that during maximal voluntary contraction before considering that muscular contraction is negligible (McNair et al. 1979.4 weeks (first measurement) Ankle dorsiflexion angle: 4. Herbison et al. 1987. Morey. Laterality of injured calf circumference was observed. 1978). 1987.0° ** ** ** Distaldisplacement(mm) ** ** ** **P<0.6° Figure 6. Skeletal muscle atrophy due to inactivity has been investigated using experimental animal models of hind limb suspension (Morey.01 ** Stretchingtime(min) c) Post-operation 10. suggests the presence of muscle atrophy.** ** ** Distaldisplacement(mm) Distaldisplacement(mm) ** ** ** ** ** ** ** ** ** Stretchingtime(min) a) Post-operation 6. Hauschka et al. In addition.1 weeks. the distal displacement of MTJ became increasingly similar to that of the uninjured side. The authors did not measure the EMG of the gastrocnemius muscle at the period of unloading in the present study.3° Stretchingtime(min) d) Post-operation 12. Over the whole of the measurement period.9 ± 2. Herbison et al (1979) observed injury to muscle cells following six weeks of a plaster cast fixed to the hind leg of a rat. respectively (Herbison et al.7 ± 1. and decreased tensile strength during muscle contraction (McDonald et al. Total average of the distal displacement of the myotendinous junction (MTJ). irregularity of the muscular fibre sequence (Winiarski et al.8 ± 4.7 ± 2. the distal displacement of MTJ on the injured side were gradually increased. Hind limb suspension and plaster cast fixation resulted in 40% and 42% weight reduction in the rat gastrocnemius and soleus muscles.2 weeks Ankle dorsiflexion angle: 13. the laterality of calf muscle circumference in this study may reflect muscle atrophy.6 ± 4.8° ** ** ** Distaldisplacement(mm) ** ** Stretchingtime(min) b) Post-operation 8. Gajdosik.01) on both the injured and uninjured sides. 1987).4 weeks Ankle dorsiflexion angle: 7. and (c) in the postoperation 10.6% decrease in the circumference of the calf in the injured leg compared with that in the uninjured leg.

position.0 weeks after surgery. rehabilitation during this period should be performed carefully. and the outer-tendon length then gradually returned and reached a plateau. Thus. We suggest that extensibility of the deep aponeurosis. and aponeurosis were stretched by 21. and 5. The bold arrow shows DA and MTJ. Thus. As distal displacement of the DA occurred at the same time. 22. Schematic diagram showing the distal displacement of the deep aponeurosis (DA) and of the myotendinous junction (MTJ). Ultrasonograms have been used previously to examine extension of the muscle-tendon unit. the increase in length of the muscle was entirely accounted for by the change in length of the muscle fascicles. We suggest that large distal displacement of the DA mainly relates to muscle fascicle elongation. More recently. After this period. much of the increase in muscle-tendon length during stretching occurred in the tendon. it was possible to determine internal changes by displacement of DA and MTJ. For instance. c) The distal displacement of the DA and the MTJ in the injured leg. The authors also observed that the outer-tendon was extended rapidly by stretching.7 ± 2. a muscle fascicle may have been more extended. tendon.No3 . Elongation of the muscle fascicle and superficial aponeurosis located proximal of the DA may lead to simultaneous distal displacement of the DA. Kubo et al (2005) demonstrated that although the muscle fascicle. In the injured leg. Herbert et al (2002) demonstrated that the gastrocnemius muscle fascicles lengthened one138 conclusions The results of the present study indicate that an injured leg exhibits an opposite reaction to an uninjured leg with respect to DA and MTJ displacement during eight weeks of postoperative InternationalJournalofTherapyandRehabilitation. In resting muscles. there was no difference between elongations of the muscle fascicle and tendon. while the small distal displacement of the MTJ relates to outer-tendon elongation. The arrow shows an approximate distal displacement. Future studies are required to investigate an effective method for treatment of damaged muscles and tendons.Research quarter of the lengthening of their muscle-tendon unit during stretching. MTJ a) DA b) c) Figure 7. and/or massotherapy may be effective treatments. The authors have previously observed only minor displacement of the superficial aponeurosis during the stretching to the gastrocnemius muscle in the knee extended position (Kanazawa et al. In the present study.9 ± 3. muscle tissues were extended rapidly by stretching. Furthermore. while the muscle fascicles appeared to contribute little to the total changes in muscle-tendon length. However.8 ± 2. Thus. and that the muscle fascicles changed length in a very similar manner to the change in MTJ. Morse et al (2008) reported that the muscle-tendon unit length increased by 21.9 mm. Thus.March2010. the distal displacement of the MTJ observed after one minute indicated shortening of the outer-tendon. and as such. b) The distal displacement of the DA and MTJ in the uninjured leg. the authors did not measure the actual muscle length or calculate the values for the tendon and muscle fascicles. respectively. the deep aponeurosis located between MTJ and DA appears to stretch less in the injured leg than the uninjured leg suggesting a change in the mechanical characteristics of the deep aponeurosis.5 mm.Vol17. and displacement of the MTJ was smaller. than those in the uninjured leg.0 mm.2 ± 2. 2007). distal displacement of the DA was larger. On the other hand. further extended up to three minutes and then muscle fascicle length reached a plateau. the distal displacement of the DA in the present study may be caused by muscle fascicle elongation. in that study. thermotherapy. during passive dorsiflexion. and they concluded that pre-conditioning of the muscle-tendon unit extension occurs nearly equally by the tendon and muscle fascicles. Similarly.9 mm during stretching. a) A location of DA and MTJ in the spontaneous standing position. The distal displacement of the MTJ at 0–1 minute of standing may be caused by the outer-tendon elongation due to movement distal to the calcaneus bone at the insertion of the Achilles tendon. concentrated rehabilitation can be performed effectively. The present study showed that the laterality of the DA and MTJ did not resolve until 12. the reaction of the muscle-tendon unit to stretching returns to normal.

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J Appl Physiol 62(6): 2338–47 Herbert RD. hot water immersion on the mechanical properties of human muscle and tendon in vivo. Urabe Y. Pflugers Arch 429(3):332–7 Cooper RR (1972) Alterations during immobilization and regeneration of skeletal muscle in cats. J Appl Physiol 63(2): 558–63 Desplanches D. J Exp Biol 93: 283–302 Kubo K. Roy RR. J Physiol 539(Pt 2): 637–45 Herbison GJ. Hirota K (1989) Effects of disuse on the ultrastructure of the Achilles tendon in rats. Eur J Appl Physiol 59(3): 239–42 Narici MV (2005) Myotendinous alterations and effects of resistive loading in old age. Macdonald BL. Almeida-Silveira MI. while the small distal displacement of the MTJ suggests outer-tendon elongation. Garrett WE (1990) Viscoelastic properties of muscle-tendon units. Shibayama A (2001) In vivo determination of muscle viscoelasticity in the human leg. Moseley AM. Am J Sports Med 21(2): 190–4 Vailas AC.

Vol17. irregularity of the muscular fibresequence(Winiarskietal. ThedistaldisplacementofMTJ on the injured side gradually increased towards the final measurements and lastly.thereactionofthe muscle-tendon unit to stretching returns to normal. the distal displacement of MTJ became increasingly similar to that of the uninjured side. Kayar SR. the elongation of the tendon was significantly greater than that oftheaponeurosis. Herbertetal(2002)measured changesinthelengthofmuscle fascicles in a relaxed human gastrocnemius muscle during passively imposed changes in joint angle. suggesting a change in the mechanical characteristics ofthedeepaponeurosis.as there may be muscle atrophy.March2010. Earlierstudiessuggestedthat shorteningofthecross-sectionalareaandminimizationofthe muscular fibre (Desplanches et al.stretchingisoneofthe mosteffectivetechniquesused forlengtheningshortenedmuscles. Fitts RH (1994) Force-Velocity and power characteristics of rat soleus muscle fibers after hindlimb suspension.orunloading. Degens H. Clin Biomech 20(3): 291–300 McDonald KS.asignificantmaineffect between uninjured legs and injuredlegswasalsofound. Butler JE. after postoperative recovery from a leg injury. The authors of this study suggest future studies are required to investigateaneffectivemethod fortreatmentofdamagedmusclesandtendons. In the injured leg.1990). More recently. with equal distributionatthebeginningof stretchingensuredbyaskingthe patienttoapplyhalftheirbody weight to each of two independentscales. the authors wereabletodetermineinternal changesbydisplacementofDA andMTJ. J Physiol 539(Pt 2): 637–45 Kubo K. Seynnes OR. while the small distal displacementoftheMTJrelates to outer-tendon elongation. Mayet MH. J Appl Physiol 77(4): 1609–16 McNair PJ.thermotherapy. the deep aponeurosis located between MTJ and DA appears to stretch less in the injured leg than the uninjured leg.1987. Jones DA (2008) The acute effect of stretching on the passive stiffness of the human gastrocnemius muscle tendon unit. Normalization of the muscle tendoncomplexmightacceleratebyattainingincreasedextensibilityoftheaponeurotictissue during the treatment period. Earlierliteraturerevealsthata muscle electromyogram (EMG) levelmustbelowerthan1%of that during maximal voluntary contraction before considering that muscular contraction as negligible (McNair et al. J Physiol 586(1): 97–106 Winiarski AM. J Appl Physiol 62(6): 2338–47 Herbert RD. Stanley SN (2002) Stiffness and passive peak force changes at the ankle joint: the effect of different joint angular velocities. something of great importancetothepatient. Corresponding distal displacementmeasurementswere carried out using the image  analysissoftware. The authorssuggestextensibilityof thedeepaponeurosis. usinganultrasonicimagingsystem. Hoppeler H (1990) Rat soleus muscle ultrastructure after hindlimb suspension. an understanding of optimal stretching time  isessential. 1994) occurs in the atrophic muscle. These findings may relate to changes in the mechanical characteristics of themuscle–tendoncomplex. 2002. Kanehisa H.Inthistypeof clinical setting.1987). Inthisstudy. The displacement in the muscle-tendon unit of the human gastrocnemius muscleduringstaticstretching.ultrasonographic measurements of equal distributionofloadbetweenboth legs were made. such as in muscle injuries.in 140 InternationalJournalofTherapyandRehabilitation. Thus. The procedural findings of the present study would help in postoperativecareduringrehabilitation. Alford EK.Hauschkaetal. than those in the uninjured leg. J Appl Physiol 69(2): 504–08 Gajdosik RL (2006) Influence of a low-level contractile response from the soleus. Exp Neurol 96(3): 650–60 Manjunatha Mahadevappa.anddisplacementofthe MTJ was smaller. and/or massotherapy as effective treatments. Thus. There is 5. and that the muscle fascicles changed length in a very similar manner to the change in MTJ.6% decrease in the circumferences of the calf in the injured leg compared with thatintheuninjuredlegatthe timeofthefirstmeasurements – suggesting the presence of muscleatrophy. after a period of non-weightbearing following injury. The results of the present study indicate that an injured leg. PhD Assistant Professor.Research COMMENTARIES Stretching exercises are commonly undertaken for sports and rehabilitation procedures after injury. muscle tendonatrophy. Indian Institute of Technology Kharagpur. Edgerton VR (1987) Size and metabolic properties of single muscle fibers in rat soleus after hindlimb suspension. India mmaha2@smst.iitkgp. Hence. Fukunaga T (2005) Effect of clod and hot water immersion on the mechanical properties of human muscle and tendon in vivo. Morse et al (2008) reported that the muscle-tendon unit length increased by 21.No3 . Moseley AM. It was suggested that large distal displacement of the DA mainly relates to muscle fascicle elongation. Chiang PC.No significantinteractionsbetween factors were found for uninjuredandinjuredlegs. and decreased tensile strength during muscle contraction (McDonald et al. exhibits an opposite reaction to an uninjured leg with respect to DA and MTJ displacement. the distal displacement of DA became more similar to that of the uninjured side. In physical therapy. Sempore B. Eur J Appl Physiol 96(4): 379–88 Hauschka EO.Meanwhile. gastrocnemius and tibialis anterior muscles on viscoelastic stress-relaxation of aged human calf muscle-tendon units. Desplanches D. Dombroski E.ernet. The findings from the ultrasonic imaging quantitative study included a significant maineffectbetweenuninjured and injured legs at the deep aponeurosisjunction(DA). Sempore B.9mm during stretching. including muscle strain. Blaser CA. In this study. distal displacement of the DA was larger. the distal displacementofDAontheinjuredside gradually decreased towards the final measurements and finally.is of high clinical significance but  largelyunknown. Flandrois R. rehabilitation during this period should be performed very carefully. Roy RR. At the myotendinous junction (MTJ).and significant differences in the amountofdisplacementofDA. School of Medical Science and Technology. Roy RR. 1987. Gajdosik. Kubo et al (2005) showed that while the muscle fascicles. After thisperiod.Theauthorsin thisstudydidnotmeasurethe EMGofthemuscleattheperiodofunloading. Further. the stretching reaction of an unhealthy muscle-tendon unit. Edgerton VR (1987) Mechanical properties of rat skeletal muscle after hind limb suspension. J Appl Physiol 63(2): 558–63 Desplanches D. Maganaris CN.Itisproposed that further study should look attheEMGinthesemuscles. Gandevia SC (2002) Change in length of relaxed muscle fascicles and tendons with knee and ankle movement in humans.2006). the final outcome after treatment was DA and MTJ displacements in the injured leg approached levels of the uninjured leg. Hewson DJ. Flandrois R (1987) Structural and functional responses to prolonged hindlimb suspension in rat muscle.Desplanchesetal.tendonandaponeurosisstretchedduringpassivedorsiflexion of the ankle joint.Ultrasonograms were recorded every minute. is of importance in both sports and and stroke injuries. and improvement of joint rangeofmotion. Clin Biomech 17(7): 536–40 Morse CI.

 Furthermore. For instance. Costa AL. Sports Med 37(3): 213–24 Ryan ED. Rubini et al. 2004. Costa PB.March2010. Jones DA (2008) The acute effect of stretching on the passive stiffness of the human gastrocnemius muscle tendon unit. Int J Sports Med 30(1): 60–5 Malliaropoulos N. However.2004. Thedifferencebetweenthese two responses may be due to the duration of the stretching protocol.however. Furthermore. Harvey LA (2010) Regular stretch does not increase muscle extensibility: a randomized controlled trial. Defreitas JM. However. additional research is needed to delineate thetype.2004).Therefore. Herda TJ. an increaseinstretchtolerancecan alsobeapositiveoutcomefrom stretchingconsideringthatthere is a plausible analgesic effect which reflects less pain during stretching (Malliaropoulos etal. Oklahoma. Gomes PS (2007) The effects of stretching on strength performance. small stretching-induced strength deficits maynotbeclinicallyrelevant. Asshowninthisstudy. University of Oklahoma. Papalexandris S.regarding theacuteviscoelasticchangesvs stretch tolerance increases. Cramer Assistant Professor.Thepresent study examined the range of motion of the injured vs noninjured limbs as outcome measures to assess the effectiveness oftherehabilitationstretching. as the rehabilitation programme progresses. although acute stretching has been consistently shown to decreasestrength(Shrier. Acute stretching-induced force deficits (Shrier. For example. particularly when strength testing may also occur during the samesession. Much less is known about the applicationofstretchinginrehabilitation settings. Costa Doctoral Research Assistant.andfrequencyhaveyet tobeestablished. These findings are consistent with those of previous studies (Morse et al. Ryan ED. Department of Health and Exercise Science. Beck TW. Rubinietal.whichisstructurally andphysiologicallysimilartothe aponeuroses described in the presentstudy.Vol17. Previous studies from our laboratory have indicated that anacuteboutofstretchingmay affecttheH:Qratio(Costaetal.andthesemay influenceordeterminetheeffectivenessofstretchingasarehabilitationtool(Malliaropouloset al. 2007) must also beacknowledgedashavingthe potential to transiently weaken the stretched muscles – even duringrehabilitation.differences between the injured and non-injured side only resolved after nearly 13 weeks of treatment. when there is a clear benefitofregainingafunctional range of motion. the authors suggested that the improved range of motion may be related to an increased extensibilityoftheaponeuroses.2007).2005). Defreitas JM. Scand J Med Sci Sports 20(1): 136–44 Costa PB. it is the viscoelastic alterations and decreases in musculotendinous stiffnessthataredesirableeffects ofstretchingsoastoelicitprogressive increases in range of motion and perhaps (although this is debatable) decrease the risk of injury. Cramer JT (2009) Determining the minimum number of passive stretches necessary to alter musculotendinous stiffness. Cramer JT. Thus. Seynnes OR. rather than the contractile elements of the musculotendinousunit. Marek et al (2005) suggested thatintheearlystagesofrehabilitation. Maganaris CN. Conversely. Fincher AL et al (2005) Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output. We previously suggestedthatcliniciansshould use caution when interpreting the H:Q ratio if this test was performed immediately after stretching (Costa et al.thesefindings needtobeplacedinthecontext of a comprehensive rehabilitation programme. specific rehabilitation guidelines concerning the type of stretching regimen. track rehabilitationprogress.Finally. The majority of research related to stretching is most often focused on performance and mechanistic approaches. Papacostas E (2004) The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Thus. Stout J. J Sports Sci 27(9): 957–61 Shrier I (2004) Does stretching improve performance? A systematic and critical review of the literature.anddecidewhen athletescanreturntoplayisthe hamstrings-to-quadriceps (H:Q) ratio.No3 141 . J Sports Med Phys Fitness 49(4): 401–09 Costa PB. Ben M. 2008.not necessarily muscle extensibility (BenandHarvey. Degens H. The authors should be commended fortheireffortstoinvestigatethe pragmaticuseofstaticstretching forthepurposesofrehabilitation. stretching may just cause a transient increaseinstretchtolerance. 2009) which is usually causedbychangesinviscoelastic propertiesofthemusculotendinous unit.weagreewith the authors that extreme care mustbetakenduringtheperiod whereinjury-relatedbilateraldifferencesarestillsignificant. For example.andintensity of stretching necessary to elicit changes in musculotendinous stiffnessandviscoelasticchangesasopposedtomereincreases instretchtolerance. attention must be given astowhenthestretchingprotocolisperformedduringarehabilitation session.edu InternationalJournalofTherapyandRehabilitation. Collectively. Beck TW. Presumably. Biophysics Laboratory.This article represents a unique andinterestingstudythatexamined the muscle-tendon unit’s responses to static stretching using an ultrasound imaging device in the injured and uninjured legs of 20 women. Beck TW. Ryan et al. 2009a. Joel T. Clin J Sport Med 14(5): 267–73 Pablo B.furtherstudies are needed in clinical populations to help answer these  fundamentalquestions. DeFreitas JM.particularly if the results of these testsaretobeusedformaking decisionsregardingrehabilitation progressorthereturntoplayfor athletes(Mareketal. J Athl Train 40(2): 94–103 Morse CI. USA pcosta@ou. Herda TJ. the present study supports the hypothesis that stretching an injured limb can improve the range of motion to that demonstrated by the uninjured limb. Herda TJ. Cramer JT (2009a) Effects of static stretching on the hamstrings-toquadriceps ratio and electromyographic amplitude in men.Thus.2009).evidenceisbuilding to suggest that stretching mayindeedbeanecessaryrehabilitation component for recovery following a musculoskeletal injury. 2008.whichfurtherimpliesthat stretching is an important part of the postoperative rehabilitation programme. stretching may influence the noncontractile. J Orthop Sports Phys Ther 38: 632–9 Ryan ED. 2009b). stretch volume. 2009)thathavesuggestedthat the elongation of the musculotendinousunitmaybeexplained by viscoelastic changes in the perimysium. 2009a). Ryan ED. Med Sci Sports Exerc 36(5): 756–59 Marek SM. Therefore. as long as precautions are taken regarding when the stretching protocol takes place within a rehabilitation session. a common assessment used to assess the risk of thigh muscle strain injuries. Future well-controlled studies should focus on the chronic effectsofstaticstretchingduring a rehabilitation programme on injuredlimbsinordertoprovide further support for the recommendation of stretching during post-injuryrehabilitation. Cramer JT (2009b) Effects of stretching on peak torque and the H:Q ratio. J Physiol 586(1): 97–106 Rubini EC. strength assessments are also frequently conducted in order to assess muscle imbalances and the progress of the rehabilitation programme. care must be taken and clinicians should be aware of these stretching-inducedstrengthdeficits when conducting strength assessments immediately after stretchingontheirpatients. The fundamental question stillremains. duration. stretching has been shown to decrease musculotendinous stiffness (Ryan et al. Nevertheless. Conversely. Herda TJ et al (2008) The time course of musculotendinous stiffness responses following different durations of passive stretching. Papalada A.2004).duration. Beck TW.

 As well-described by many investigators. paperback. when prescribing stretch exercises to our patients. complex and fragile. Themyotendinousunitplays animportantroleinforcetransmission from myofibrils across the muscle cell membrane.e. and‘howmuchistoomuch?’. £19.andconsequentlythetendon) change. and c) there is enlargement of the rough sarcoplasmic reticulum.So. Previous studies have indicated that during passive stretching of the gastrocnemius muscle. Dr Eli Carmeli Professor. two questions that frequently come up and we struggle with are: ‘should we stretch by any means?’. b) there is anincreaseinbasementmembranes in the myo side.uk 142 InternationalJournalofTherapyandRehabilitation.99 AL SPECI Only £14. andmustbesolvedinorderto choose the best intervention programmeforpatients.characterized by intensive membrane renewal and recycling. The basement membrane is modified by the presence of caveolae and vacuoles. Stanley Steyer School of Health Professions. Yet.duration:how longshouldthestretchbeheld (slowandprolongedupto20 seconds).No3 . Applyingstretchingisalways controversial among practioners. a) the quiescent/inactive fibrocytes in the myo-tendon region are replaced by activated fibroblasts.Themagnitude of the force transmitted from muscle to tendon is directly influenced by the unique..bothanatomically and biomechanically.Since thefirstroleingoodpracticeis ‘do not harm’.isfundamentalandcentralforphysiotherapypractice. some believe that recovery of the muscle tendon complex mightbeacceleratedbyapplyingstretching.thefasciclelengthens.9F9ER O F FF 25% O and quote code: QBJA Fundamental Aspects of Nursing series 01722 716 935 Offer expires 30 April 2010 To claim your discount call To find out more about Quay books titles visit www.Research The challenge of soft tissue stretching to alleviate pain.Onemayask:‘whybother with stretching?’. and these small changes are not maintained minutes after the intervention ceases. Israel elie@post. to increase range of motion. 176 pages. As long as a definite and explicit answer does not exist.Vol17.March2010.inalongrunwemay losemorethanwegain. Themuscletendonregionisa complexunit. Sackler Faculty of Medicine. publication January 2007. 234 x 156 mm. and to decrease the stiffness and the thixotropic properties of the whole unit following injury. and one mustalwaysabolishthepotential for further muscle-tendon injuriesduringastretch. in terms of the extent of myotendon complex loose. it lacks ‘scientific humility’ and some degreeofprudence.co. Eventhoughtheconclusionof thisarticlewasconvincinglyin support of stretching.tau. the collagen bundles are disrupted. These apparently adaptive changes to stretching are a non-inflammatory reaction of themyo-tendonregion. On the other hand. and at the tendon side. Tel Aviv University. These should consider several factors: intensity: how intense should the stretch be –isitpain-free.il Karina McGann Fundamental Aspects of Pain Assessment and Management Karina McGann Text takes a holistic approach to the assessment and management of pain and its multi-dimensional nature Includes pharmacological and non-pharmacological approaches Patient-centred and evidence based essential text on the management of pain ISBN-13: 978-1-85642-292-5.quaybooks. and frequency: how often should one perform the stretch(5–6timesperweek). it is important to use cautious steps. from the mechanical point of view this local response might permanently weaken the myotendon resistance to stretch. during stretching. only a small percentage (less than 25%) of the overall length(i. structureofthisunit. resulting in the formation of disorientedfibres.ac. and thantothetendon. Physical Therapy Department. and result in interference or obstruction of the electromechanical delay. to the extracellular matrix.