Stretching Poker Guide

MOSBY’S
STRETCHING
POCKET GUIDE
Writer and Consultant

Sandra K. Anderson, BA, LMT, ABT
3251 Riverport Lane
St. Louis, Missouri 63043

MOSBY’S STRETCHING ISBN: 978-0-323-22640-0
POCKET GUIDE
Copyright © 2014 by Mosby, Inc., an affiliate of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrange-
ments with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowl-
edge in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of
their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-323-22640-0
Vice President and Publisher: Linda Duncan

Executive Content Strategist: Kellie White
Content Manager: Rebecca Leenhouts
Publishing Services Manager: Julie Eddy
Senior Project Manager: Richard Barber
Design Direction: Amy Buxton
Printed in the United States
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Introduction
Stretching techniques give massage therapists additional useful

techniques they can use to enhance the health and well-being of
their clients. This pocket guide discusses the therapeutic tool of
stretching, which is a manual bodywork method that lengthens and
elongates soft tissues, including muscles, tendons, ligaments, joint
capsules, and fascia. Stretching is for soft tissues that have increased
tension and are shortened and contracted. These tissues resist
lengthening and limit mobility of the joint they cross. Stretching
helps increase flexibility and remove adhesions and allows the body
to move more fluidly.
The material in this stretching pocket guide is compiled from
leading textbooks and resources for massage therapy and includes
newly developed content. Topics include principles behind stretch-
ing, basic stretching techniques, a basic static stretching atlas, ad-
vanced stretching techniques, and stretching for self-care. Massage
therapists can use stretching for self-care to educate their clients as
well as to increase their own flexibility, a crucial component of career
longevity.
This book is designed as a practice quick-reference to assist the mas-
sage therapist in practicing safe and beneficial stretching techniques.
It consolidates key information into one convenient, well-organized
source for fast and easy reference.
iii
iv Acknowledgments
Acknowledgments
Thank you to Sandy Fritz for use of information in Fundamentals
of Therapeutic Massage, 5th edition and Sports and Exercise
Massage, 2nd edition; Joseph E. Muscolino for use of information
in Kinesiology, 2nd edition, Know the Body, and The Muscle and
Bone Palpation Manual, 1st edition; Jeffrey Simancek for use of
information in Deep Tissue Massage Treatment, 2nd edition; and
Susan Salvo for use of information in Massage Therapy: Principles
and Practice, 4th edition.
Contents
1 Principles behind Stretching, 1

Definition of Terms, 1
Factors Affecting Flexibility, 5
Stretching, 6
Benefits and Cautions of Stretching, 7

Cautions, 8
Benefits of Stretching on Soft Tissue, 10
Properties of Soft Tissue, 12

Connective Tissue, Muscles, and Stretching, 12
Compensation, 13
Physiology behind Stretching, 14

Joints, 14
Muscle Tissue, 15
Proprioceptors, 21
Major Categories of Stretching, 22

Static Stretching, 23
Dynamic Stretching, 24
Ballistic Stretching, 28
2 Basic Stretching Techniques, 29

Guidelines for Successful Stretching, 29
Muscle Relaxation, 29
Warming the Tissues, 29
Duration, 31
v
vi Contents
Safe and Effective Stretching Methods, 32

Stretching Procedures, 32
Overstretching, 33
Reasoning and Application, 33

How Stretches Can Be Reasoned Out Instead
of Memorized, 34
Multiplane Stretching, 35
Isolating a Stretch to One Target Muscle, 40
Stretching Other Target Tissues, 41
Direct Tissue Stretching, 41

Longitudinal Stretching, 44
Cross-Directional Stretching, 47
Basic Static Stretching Techniques, 48
3 Basic Static Stretching Atlas, 49

Neck, 49
Neck Circles, 50
Neck Lateral Flexion, 50
Neck Lateral Flexion with Rotation, 50
Neck Forward Flexion, 50
Wrist and Hand, 50

Flip Wrist, 50
Interlace Fingers and Mobilize Wrist, 50
Metacarpal Scissors, 54
Pull and Circumduct Fingers, 55
Arm and Shoulder, 55

Arm Pull, 56
Shoulder Circles, 58
Spine, 58
Spinal Twist I, 58
Spinal Twist II, 59
Spinal Twist III, 60
Spinal Twist IV, 60
Hip and Knee, 62

Leg Pull, 62
Leg Rock, 63
Contents vii
Hip Clock Stretch, 63

Hip Circles, 63
Hip Flexion, 65
Groin Stretch, 65
Heel to Hip, 65
Hip Hyperextension, 68
Ankle and Foot, 68

Plantar Flexion, 69
Dorsiflexion, 69
Metatarsal Scissors, 69
Pull and Circumduct Toes, 69
4 Advanced Stretching Techniques, 71

Pin and Stretch, 71
Proprioceptive Neuromuscular Facilitation, 74
Contract Relax, 74
Antagonist Contract, 75
Contract Relax Antagonist Contract, 81
Active Isolated Stretching, 81
Muscle Energy Techniques, 81
Principles of Muscle Energy Techniques, 83
Breathing and Eye Movement, 85
Methods, 86
Pulsed Muscle Energy Procedures, 95
Examples of Stretching, 97
5 Stretching for Self-Care, 105

Principles of Stretching for Self-Care, 106
Stretches, 107
lossary, 141
G
I ndex, 147
This page intentionally left blank
Principles behind
Chapter
1
Stretching
Human beings are designed to move. Therefore, all humans need to
have at least some level of mobility and strength. Movement occurs
at joints, and muscles provide the movement. Muscles must be
strong enough to create the desired movement, and joints need to
be both mobile and stable enough to cope with the movement.
Along with muscular strength, the soft tissues of the body need to
be pliable. For example, healthy muscles are supple and have a
plentiful blood supply. They receive sufficient nutrients and oxygen
and have wastes removed efficiently. Healthy muscles do not
remain in a state of chronic contraction, a state that requires a
great deal of energy, decreases mobility of body parts, and can lead
to injury.
Definition of Terms
Because tight muscles, joints, and other soft tissues can be painful,
decrease movement, and possibly lead to injury, clients can benefit
from stretching techniques that improve function, restore mobility,
and increase joint movements. These techniques provide additional
treatment options and can be performed easily before, during,
or after a massage treatment, or they may be used as the primary
technique.
The terms “stretched,” “elongated,” “loose,” and “lengthened” all
are used to describe the quality of soft tissues when they are pliant
or pliable. Flexibility is the ability of soft tissues to yield to tension
forces without tissue damage during joint range of motion (ROM).1
Flexibility refers to mobility of a joint and how muscles, ligaments,
tendons, or other soft tissues affect it. A more complete description
of flexibility is the ability to move joints through their full, intended
ROM. ROM is the range, usually expressed in degrees of a circle,
1
2 Chapter 1 Principles behind Stretching
through which bones of a joint can move or be moved. Each specific

joint has a normal ROM that is expressed in degrees, as shown in
Table 1-1.
When performing a stretch on a client, the term target tissue
is used to describe the tissue that will be stretched; target muscle is
used when stretching a specific muscle or muscle group.
Table 1-1 A
verage Ranges of Motion from Anatomic
Position
Entire Spine
Flexion 135 degrees Extension 120 degrees
Right lateral flexion 90 degrees Left lateral flexion 90 degrees
Right rotation 120 degrees Left rotation 120 degrees
Head at Atlantooccipital Joint
Atlas at Atlantoaxial Joint
Right lateral flexion Negligible Left lateral flexion Negligible
Lower Cervical Spine
Entire Cervical Spine
Entire Cervicocranial Region and Head at Atlantooccipital Joint
Thoracic Spine
Chapter 1 Principles behind Stretching 3
Table 1-1 A
Position—cont’d
Lumbar Spine
Thoracolumbar Spine
Pelvis at Hip and Lumbosacral Joints*
Anterior tilt 30 degrees Posterior tilt 15 degrees
Right depression 30 degrees Left depression 30 degrees
Thigh at Hip Joint
Abduction 40 degrees Adduction 20 degrees
Medial rotation 40 degrees Lateral 50 degrees
rotation
Leg at Tibiofemoral Joint
Flexion 140 degrees (Hyper)extension 5 degrees
Medial rotation 15 degrees Lateral 30 degrees
rotation
Foot at Talocrural Joint
Dorsiflexion 20 degrees Plantar flexion 50 degrees
Foot at Subtalar Joint
Pronation-eversion 10 degrees Supination- 20 degrees
inversion
Pronation- 2.5 degrees Supination– 5 degrees
dorsiflexion plantar flexion
Pronation–lateral 10 degrees Supination– 20 degrees
rotation medial rotation
(abduction) (adduction)
Toes 2-5 at MTP Joints
Extension 60 degrees Flexion 40 degrees
Big Toe at MTP Joints
Extension 80 degrees Flexion 40 degrees
Continued
Table 1-1 A
Position—cont’d
Entire Shoulder Joint Complex
Lateral rotation 90 degrees Medial rotation 90 degrees
Arm at Glenohumeral Joint
Lateral rotation 50 degrees Medial rotation 90 degrees
Scapula at Scapulocostal Joint
Upward rotation 60 degrees Downward 0 degrees
rotation
Clavicle at Sternoclavicular Joint
Elevation 45 degrees Depression 10 degrees
Protraction 30 degrees Retraction 30 degrees
Upward rotation 45 degrees Downward rotation 0 degrees
Scapula at Acromioclavicular Joint
Upward rotation 30 degrees Downward rotation 0 degrees
Forearm at Elbow Joint
Forearm at Radioulnar Joints
Pronation 160 degrees Supination 0 degrees
Hand at Wrist Joint
Radial deviation 15 degrees Ulnar deviation 30 degrees
Fifth CMC Joint
Fourth CMC Joint
Third CMC Joint
Second CMC Joint
Flexion 0-2 degrees Extension 0 degrees
Table 1-1 A
Position—cont’d
Thumb at Saddle Joint

Medial rotation 45 degrees Lateral rotation 0 degrees
Proximal Phalanx of Fingers 2-5 at MCP Joint
Flexion 90-110 degrees Extension 0-20 degrees
Proximal Phalanx of Thumb at First MCP Joint
Fingers at Proximal Interphalangeal Joints
Fingers at Distal Interphalangeal Joints
Interphalangeal Joint of Thumb
CMC, Carpometacarpal; MCP, metacarpophalangeal; MTP, metatarsophalangeal.

*With the client seated and the thighs flexed 90 degrees at the hip joint. Numbers
would be different if the client were standing and based on whether the knee joint
was flexed or extended.
Data from Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.
Shortened and contracted soft tissues resist lengthening and

limit mobility of the joint they cross. Flexible joints move more
efficiently because their ROM is greater than in tight joints. Move-
ment takes less effort and less energy. These joints are also less prone
to injury because they have more freedom of movement, and they
are better able to adapt to stresses placed on them. An example is a
person with an extremely tight shoulder who slips on ice or trips
while going upstairs. When this person reaches out the arm with
the tight shoulder to stop the fall, the shortened tissues are unlikely
to be able to absorb the shock of impact the way looser and softer
tissues can. Tearing of the soft tissues can result.
Factors Affecting Flexibility

As with all types of movement, the ability to increase flexibility
depends to a certain extent on genetics. Younger people are
generally more flexible than older people, and women are usually
more flexible than men. Flexibility is affected by past injuries,
bone length, childhood nutrition, level of strength, body core
temperature, time of day (flexibility decreases during cooler times of
the day and increases during warmer times of the day), mood, and
stress levels.
On a physical level, flexibility is most often limited by the
following:
• The structure and shape of the joint.
• Ligaments and tendons that cross the joint.
• Adhesions from past injuries or surgeries.
• Amount of muscle tissue surrounding the joint.
• Amount of adipose tissue surrounding the joint.
• Muscles that are highly toned but shortened.
• Fascial binding. Bind means a resistance barrier.
• Shortened muscles due to inactivity.
• Muscle imbalance. If one of a group of synergistic muscles is
much stronger than the others, or if an agonist is much stronger
than the antagonist for a particular joint action, the result can be
reduced flexibility.
• Overuse of a muscle without maintaining a complete ROM. An
example of this is a person who wears high heels much of the
time. Because the ankles are in plantar flexion, calf muscles tend
to become chronically shortened.
• Aging. With aging, the soft tissues decrease in elasticity, and
muscles tend to atrophy.
• Periods of rapid growth such as occurs during puberty. If the
body is growing quickly, flexibility may be hindered because the
body has not adjusted to the changing ROM at the joints. Along
with that, soft tissues have not had time to adapt to the rapid
growth.
• Paralysis, neurologic disease, injury, or joint immobilization.
These are injuries or pathologies that affect how tissues and joints
function.2
Contrary to popular belief, muscle length is not the primary
limiting factor in developing flexibility. Normal, healthy muscle
tissue can be stretched to about twice its resting length.
Stretching
Stretching is a mechanical method that introduces various
forces that extend, expand, lengthen, and elongate soft tissues.
Lengthening is a neurologic response that allows the muscles to

stop contracting and relax. The difference between elongation and
lengthening is that elongation refers to extending the length of the
soft tissue. The soft tissues may be muscles, fascia, and associated
tendons and ligaments (collectively called myofascial units); joint
capsules; or other fascial planes.
Benefits and Cautions of Stretching

Stretching is crucial to the overall health of the body. Stretching
helps increase flexibility and remove adhesions and allows the
body to move more fluidly. Stretching can also help correct muscle
imbalances (e.g., if a muscle is disproportionally stronger than its
antagonist or if one side of the body is stronger than the other),
relieve abnormal joint stress, maintain normal functional length
of muscles, and improve neuromuscular efficiency. Neuromuscular
efficiency is the ability of the neuromuscular system to allow ago-
nists, antagonists, and stabilizers to work synergistically to produce,
reduce, and stabilize the entire kinetic chain. The kinetic chain is an
integrated functional unit made up of myofascial systems (muscles,
ligaments, tendons, and fascia), articular systems (bones and their
joints), and the nervous system. These systems work together for
structural integrity and efficient movement.3
Repetitive, limited ROM activities performed over a prolonged
period can create muscles that are chronically shortened or, con-
versely, muscles that are in a lengthened position but are tight
because they have developed excessive tone, known as hypertonicity.
For example, hip flexors such as rectus femoris, psoas, and iliacus can
become shortened secondary to long periods of sitting or bending at
the waist. The hip flexors contract repeatedly but with a reduced
ROM creating the shortening. Similarly, trunk extensors such as the
erector spinae can become lengthened and hypertonic secondary to
long periods of bending over. Weight-training exercises, if habitually
performed with limited ROM, such as without full extension,
flexion, or rotation, can also lead to muscles that are chronically
shortened or lengthened and tight.
Chronically shortened or lengthened muscles can be the first
step in a series of events leading to injury. Over time, shortened hip
flexors can lead to a reduction of the normal lordotic curve of the
lumbar spine, which can impair the spine’s load-bearing and shock-
absorption capacity. Overly tight hamstrings have the same effect on
the lumbar spine. When the spine cannot function normally, a wide
range of injuries, from acute to chronic, are possible. Optimally,

stretching helps prevent and alleviate acute or chronic injuries.
Overall, the therapeutic effects and uses of stretching include the
following:
• Help maintain or increase ROM and improve joint function.
• Increase flexibility. A flexible joint requires less energy to move; a
lengthened muscle requires less energy, whereas a tight and con-
tracted muscle wastes energy.
• Relieve muscle and joint stiffness associated with the aging
process.
• Stimulate production of synovial fluid.
• Increase joint health by decreasing the viscosity (thickness) of
synovial fluid so that it can lubricate the joint better. This also
increases nutrition to the joint.
• Reduce pain.
• Increase blood and lymph flow within the tissues because of
the mechanical pumping effect produced as tissues are alternately
squeezed and released. This allows for greater elasticity and
reduction in muscle soreness.
• Assist in assessing tissues.
• Decrease risk of injury by preventing joint sprains, muscle strains
or tears, and reinjury to previous joint and muscle trauma.
• Increase mobility, which can potentially increase physical perfor-
mance and efficiency.
• Increase kinesthetic awareness.
• Aid in rehabilitation.
• Possibly improve body alignment and posture.
• Improve muscular balance.
• Increase neuromuscular coordination.
• Increase muscular relaxation, which decreases stress.4,5
Cautions
During stretching methods, the client should experience a pulling
sensation in the short soft tissue but never pain or strain in the joint
or in other parts of the body that are not being stretched.
Anatomic barriers are determined by the shape and fit of the
bones at the joint. To prevent serious joint injury, no jointed area
should be stretched beyond anatomic barriers. Physiologic barriers
are caused by the limits of the ROM imposed by nerve and sensory
function. When the physiologic barrier is reached, the sensation at
the barrier is soft and pliable. An adaptation in a physiologic barrier
to limit movement protectively is called a pathologic barrier.

Pathologic barriers often manifest as stiffness, pain, or a “catch.” The
pulling sensation into the area being stretched acts as a protective
mechanism, signaling not to move into anatomic limits that could
potentially result in injury.
There are two types of pathologic barriers:
• Pain and stiffness occur when the joint movement assessment
identifies reduced ROM or hypomobility. Stretching may be
indicated.
• A lack of resistance is experienced when normal ROM is
reached during assessment, indicating hypermobility (an unusu-
ally large ROM). Stretching should not be done; strengthening is
required.
Hypermobility
It is possible for a joint to become too flexible. Excessive flexibility
can be just as detrimental as not enough flexibility because
both increase the risk of injury. Joint hypermobility can cause the
following symptoms:
• Joint pain.
• Back pain.
• Joint dislocation (the joint comes out of its correct position).
• Soft tissue injuries, such as tenosynovitis (inflammation of the
protective sheath around a tendon).
Excessive joint ROM affects women more than men because
female hormones increase flexibility. Joint hypermobility is treated
with an exercise program to improve fitness and muscle strength
resulting in increased stability. Because of the risk of injury and pos-
sibly joint dislocation, hypermobile joints should not be stretched.
Contraindications and Other Cautions

If clients report any of the following, they need to consult with their
health care provider before the massage therapist performs any
stretches.
• Lack of joint integrity. The integrity of the joints should be
maintained throughout the entire stretch. This means that joints
should be stretched in alignment with their movements and that
awkward positions should not be used. Otherwise, there is a great
risk of injury.
• Joint inflammation. Any type of joint inflammation is a contrain-
dication. Stretching and ROM techniques are likely to increase
inflammation, create pain, and cause further damage to the

affected joints.
• Neuropathy. Neuropathy is a contraindication for stretching and
ROM techniques. It interferes with the body’s ability to detect
sensations, which means the client will not have accurate sensa-
tions about the length and intensity of the stretch. The risk of
injury is increased.
• Bone disease. Diseases such as osteoporosis are a contraindication
for stretching and ROM techniques. They increase the risk of
injury.
• Prolonged use of steroids. Steroid use can cause brittle bones and
fragile skin, so caution is warranted when performing stretches.
• Untreated hypertension. Untreated hypertension is a contraindi-
cation for stretching. Because of the demands placed on blood
vessels during stretches, there is a danger of increasing blood
pressure.
• Nerve root damage or radiating pain. These are contraindications
for stretching. Stretching can cause further damage and pain
along the nerve pathways.
• Pregnancy. Pregnancy is a caution for stretching. The hormone
relaxin, which is secreted during pregnancy, causes tendons and
ligaments to loosen; this prepares the pelvis to widen for birth of
the baby. As a result, all joints and associated connective tissue
structures become more pliable, increasing the risk of displace-
ment during stretching and ROM techniques.
Benefits of Stretching on Soft Tissue

Shortened and contracted soft tissues generally resist lengthening
and limit mobility in the joint they cross. This tension in a tissue
is its resistance to stretch. The limited joint motion is the motion
that is in the opposite direction from the location of the tight
tissues.
If the tight tissue is located on the posterior side of the joint,
anterior motion of a body part at that joint will be limited, and if
the tight tissue is located on the anterior side of the joint, posterior
motion of a body part at that joint will be limited. Figure 1-1, A,
shows decreased flexion of the thigh at the hip joint because of taut
tissue and tight hamstrings on the posterior side of the hip joint.
Similarly, tight hamstrings would also limit anterior tilt of the pelvis
at the hip joint. If anterior hip joint tissues, especially hip joint flexor
muscles such as the tensor fasciae latae seen in Figure 1-1, B, are
B
FIGURE 1-1 A, Tight hip extensors (hamstrings) limit flexion of the thigh at
the hip joint. B, Tight hip flexors (tensor fasciae latae) limit extension of the
thigh at the hip joint. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011,
Mosby.)
tight, a decrease in ROM in extension of the thigh at the hip joint

occurs. Similarly, tight anterior hip joint tissues limit posterior tilt
of the pelvis at the hip joint.
As stated, shortened, contracted tissue can be described as
having greater tension. There are two types of tissue tension—passive
tension and active tension. All soft tissues can exhibit increased
passive tension. Passive tension results from factors affecting the
natural elasticity of a tissue, such as fascial adhesions that build
up over time in soft tissues. Active tension occurs when contractile
elements of the muscle (actin and myosin filaments) contract via
the sliding filament mechanism, creating a pulling force toward the
center of the muscle. Whether a soft tissue has increased passive or
active tension, this increased tension makes the tissue more

resistant to lengthening. Stretching is done to lengthen and
elongate these tissues, with the goal of restoring full ROM and
flexibility to the body.
Muscles have traditionally been considered to be the only tis-
sues that exhibit active tension. However, more recent research
shows that fibrous connective tissues often contain cells called
myofibroblasts, evolving from fibroblasts normally found in con-
nective tissue. Myofibroblasts, also found in muscle tissue, contain
contractile proteins that can actively contract. Although not
present in the same numbers as in muscle tissue, connective tissue
myofibroblasts may be present in sufficient numbers to be biome-
chanically significant and must be considered when assessing the
active tension of that connective tissue.6
Properties of Soft Tissue

When a joint has limited ROM, the joint does not move fully
or easily. The loss of flexibility can be a predisposing factor for
pain, balance disorders, and injury. Motion may be limited by a
mechanical issue within the joint, swelling of tissue around the joint,
stiffness of soft tissues, pain, spasticity of associated muscles, or
disease. Diseases that prevent a joint from fully extending over time
may produce contractures causing permanent inability to extend the
joint beyond a certain fixed position.
Connective Tissue, Muscles, and Stretching

When joint movement assessment shows ROM to be limited,
stretching may be indicated to increase flexibility. Stretching
should be directed at the muscle tissue and myofascia. Myofascial
tissue has the most elastic tissue. Ligaments and tendons have
less elastic tissue and are not intended to stretch. Overstretching
ligaments may weaken the joint’s integrity and cause destabili-
zation, increasing the risk of injury. Once the fascia associated
with the muscle has reached its maximum length, attempting
to stretch further serves only to stretch the ligaments and
puts undue stress on the tendons. Myofascia can be safely
elongated through proper stretching techniques. This elongation
is beneficial because the fascial network allows muscles, bones,
and blood vessels to communicate down to a cellular level,
continuously coordinating and restoring the body’s physiologic
functions.
Stretching introduces forces of bend, torsion, and tension that

mechanically affect connective tissue. The connective tissue fibers
are elongated past their bind so that they can enter the
plastic range. Plastic range is the range of movement of connective
tissue that is beyond its elastic limit. In this range, the tissue perma-
nently deforms and cannot return to its original state. Either the
fibers unravel, or there is a local therapeutic inflammatory response
that signals for change in the fibers. Stretching also affects the
ground substance, warming and softening it, which increases its
pliability.
Because fascial sheaths provide structural support, it is impor-
tant to work with an understanding of the three-dimensional
nature of the body. Shifts in structure have more than a localized
effect. The body supports stability before mobility, and compensa-
tion patterns occur throughout the body. Changes in structure
must be balanced with either lengthening or strengthening
activities that allow the body to maintain a sense of balance.
If stability and mobility are not taken into account, the body
tends to react to changes in structure, such as the effects of
stretching, with increased muscle spasms and acute pain. This
results in a decreased ability to respond to stretching, making it
ineffective.
Additionally, before stretching, the muscles usually must be
lengthened or the muscles in the area may develop protective
spasms. These protective spasms develop because stretching often
moves into pathologic barriers formed by connective tissue changes.
The connective tissue component cannot be accessed until the
muscle has been lengthened. Without stretching, any lengthening
may be restricted by shortened connective tissue. Although length-
ening without stretching is possible and often desirable, lengthening
must always be done before stretching. During stretching, the two
methods work together.7
Compensation
Direction of ease is the way the body allows for postural changes,
muscle shortening, and weakening compensation patterns, depend-
ing on its balance in gravity. Although compensation patterns
may be inefficient, the patterns developed serve a purpose and need
to be respected. It may seem logical to locate a shortened muscle
group or a rotated movement pattern and use direct methods to
reverse the pattern. However, this approach may not be the best one.
Protective sensory receptors prevent any forced stretching of tissues

to move out of a compensation pattern. Instead, with pattern of
compensation respected, the body position should be exaggerated
and then coaxed into a more efficient position.
Because stretching requires adaptation on the part of the body’s
soft tissues, it is important to determine if:
• The current condition is resourceful compensation that is produc-
tive and should not be changed.
• The client’s tissues are adaptable and have enough time to respond
to the change.
• The change positively affects how the client’s body moves
and feels.7
Physiology behind Stretching

To understand flexibility and how stretching works, it is important
to understand the anatomy and physiology of all the structures
involved. These structures include the joints, muscle tissue, and
proprioceptors.
Joints
The types of joints that provide the greatest amount of movement
in the body are synovial joints or diarthroses. They have a space
between the bones called a synovial cavity. This gap allows free
movement at the joint. Joints without this gap allow little or no
movement. Figure 1-2 shows the basic structure of a synovial
joint. The bones in the joint are joined by an articular capsule
made of dense irregular connective tissue, and they often have
accessory ligaments surrounding them for support. Figure 1-3, A,
shows the hip joint with its ligaments, and Figure 1-3, B, shows
the knee joint with its ligaments and associated structures, such
as muscles and bursae. As seen in these figures, synovial joints are
quite complicated because of the need to be both mobile and
stable.
Ligaments are thick, tough, fibrous tissue. Most of the collagen
fibers in ligaments are arranged in parallel bundles, giving them the
greatest amount of tensile strength. Tensile means the ability to
withstand longitudinal stress. However, there are also fibers within
the ligament that are oriented in other ways. These fibers give
pliability, strength, and a certain amount of stretch to the ligament
as the joint moves in various directions. Stretching improves the
flexibility and health of ligaments. Also, even though ligaments
Periosteum
Bone
Blood vessel
Nerve
Joint capsule
Joint cavity
(contains
synovial fluid)
Articular cartilage
Synovial membrane
FIGURE 1-2 Basic structure of a synovial joint. (From Salvo SG: Massage
therapy principles and practice, ed 4, St. Louis, 2012, Mosby.)
can stretch only minimally, stretching the surrounding soft tissues

improves the joint’s flexibility. Therefore, the ROM of a joint can be
increased and maintained.
Muscle Tissue
Each skeletal muscle is a separate organ composed of thousands of
muscle cells called muscle fibers because of their elongated shape.
A typical muscle fiber is about 4 inches long. Skeletal muscles also
have fascia surrounding muscle fibers as well as the entire muscle.
Three layers of connective tissue extend from the fascia to protect
and strengthen muscle tissue. The outermost layer is epimysium,

surrounding the entire muscle. The perimysium surrounds groups
of 10 to 100 or more muscle fibers and groups them into bundles
called fascicles. Within each fascicle, the endomysium surrounds
individual muscle fibers. All three connective tissue layers
extend beyond the muscle fibers to form a tendon, which attaches
AIIS
Exposedhead
Ischiofemoral of femur
ligament
Pubic
Greater bone
trochanter
of femur
Iliofemoral Pubofemoral
ligament Lesser ligament
trochanter
Anterior view
Iliofemoral
ligament
Ischiofemoral
ligament
Greater
trochanter
of femur
Ischial Zona
tuberosity orbicularis
A Posterior view
FIGURE 1-3 A, Hip joint. (From Muscolino JE: Kinesiology, ed 2, St. Louis,
2011, Mosby.)
Popliteal
artery
and vein
Quadriceps Hamstring
tendon muscles
Suprapatellar
bursa
Fat
Patellar
ligament Femur
Patella Gastroc-
nemius
Infrapatellar
fat Capsule
Patellar Meniscus
ligament
Tibia
Popliteus
S
A P
B
I
FIGURE 1-3, cont’d. B, Knee joint. (From Gosling J, et al: Human
anatomy, ed 4, Philadelphia, 2002, Saunders.)
to bone. Muscle tissue also has a rich blood and nerve supply.
Figure 1-4 shows skeletal muscle tissue and its connective tissue
coverings.
The plasma membrane of a skeletal muscle fiber is called the
sarcolemma. The sarcolemma has thousands of inward folds called
transverse (T) tubules that tunnel toward the center of each muscle
fiber. T tubules open to the outside of the fiber and are filled with
interstitial fluid. Nerve impulses travel along the sarcolemma and
through the T tubules, quickly spreading throughout the muscle
fiber. This is how a nerve impulse excites all parts of the muscle fiber
at once.
Within the muscle fibers are tiny, threadlike structures called
myofibrils. These are the contractile organelles of skeletal muscle
extending the entire length of the muscle fiber. Within myofibrils
are even smaller structures called thin filaments, made of a protein
Muscle
Bone
Epimysium
Perimysium
Endomysium
FIGURE 1-4 Skeletal muscle tissue and its connective coverings. (From
Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)
called actin, and thick filaments, made of a protein called myosin.

They do not extend the entire length of a muscle fiber. Instead, they
are arranged in compartments called sarcomeres, which are the
basic functional units of a myofibril. Figure 1-5 shows the micro-
scopic structures of skeletal muscle tissue.
Muscles can change length because of the overlapping thin
and thick filaments; this is referred to as the sliding filament
mechanism. The edges of the sarcomere are called Z disks, to which
the thin filaments are attached. In the center of the sarcomere are
the thick strands, which, during contraction, pull the Z disks closer
together by attaching to the thin filaments with specialized links
called cross bridges. These cross bridges function similar to boat
oars as they reach out and attach and pull on the thin filaments,
causing the Z disks to move toward one another. The Z disks pull
on neighboring sarcomeres, and the whole muscle fiber shortens.
The result is an overall shortening or contraction of the muscle in
response to a nerve impulse. The sliding filament mechanism is
shown in Figure 1-6. When the nerve impulse stops, the filaments
slide back to their habitual resting positions.
Tendon
Bone
Fascia
Muscle
Epimysium
Perimysium
Endomysium
Fascicle
T tubule Myofibril
Muscle fiber
Sarcoplasmic
(muscle cell)
reticulum
Sarcomere
Z disk
Thick filament Thin filament
Z disk
FIGURE 1-5 A-D, Microscopic structures of skeletal muscle. (From Patton K,

Thibodeau G: Anatomy and physiology, ed 7, St. Louis, 2010, Mosby.)
RELAXED
H zone I band A band
Thick Thin
Z disk Z disk filaments filaments
INTERMEDIATE CONTRACTING STAGE
FULLY CONTRACTED
Sarcomere
FIGURE 1-6 Sliding filament mechanism. (From Patton K, Thibodeau G:
Anatomy and physiology, ed 7, St. Louis, 2010, Mosby.)
Microscopic Effect of Stretching a Muscle

When muscle fibers are stretched, they elongate as each sarcomere
extends to the point where no overlap between the thick and thin
filaments exists at all. At this point, the tension of the stretch is
taken up by the sarcolemma and endomysium (Fig. 1-7). If
the stretch tension goes beyond this point, microscopic tears can
develop both in the connective tissue and within the sarcomere
itself. These microtraumatic injuries eventually heal, but there may
be minute scarring and microadhesions that leave the muscle fiber
less capable of contraction and lengthening.
Each sarcomere has a habitual resting length. Correct stretching
lengthens the muscle by causing the thin and thick filaments to
H zone I band A band
Thick Thin
Z disk Z disk filaments filaments
FIGURE 1-7 Sarcomere during a stretch.
adopt a new habitual resting position, lengthening the sarcomere.

Regular stretching causes myofibrils to grow longer by growing
new sarcomere segments. These new sarcomere segments increase
the ROM of the muscle and increase the power the muscle can
generate. Therefore, stretching not only increases the muscle’s
pliability, it also increases its strength.
Proprioceptors
The neuromuscular system has built-in protection against severe
muscular injury. This protection is in the form of proprioceptors that
sense changes in muscle tension and muscle length. Proprioceptors
are embedded in muscles, especially postural muscles and tendons,
and they provide the nervous system with information about the
degree to which muscles are contracted and the amount of tension
on tendons as well as pressure on the joint, the positions of joints,
and acceleration and deceleration of joints during movement.
The proprioceptors involved in stretch reflexes are muscle
spindles found in the bellies of muscles (Fig. 1-8). Muscle spindles
monitor changes in length of skeletal muscle fibers. When a
muscle has stretched far enough during a particular movement, the
muscle is stimulated to contract, relieving the stretching. It prevents
injury by preventing overstretching and possible tearing of muscle
tissue. Resetting the muscle spindle is the mechanism of proprio-
ceptive neuromuscular facilitation and contract-relax stretching
methods discussed in Chapter 4.
The stretch reflex is activated when a muscle is stretched for too
long, when a muscle is stretched to the point of pain, or if a muscle
is not flexible enough to tolerate the stretch. In the last case, the
muscle has a rebound contraction to prevent injury. The way to
prevent this is always to begin stretches slowly and within the
MUSCLE SPINDLE
Intrafusal
muscle Motor
nerve
Receptor
(sensory
nerve)
Motor
nerve
Extrafusal
muscle Intrafusal
muscle
Extrafusal
muscle
FIGURE 1-8 Muscle spindle. (From Salvo SG: Massage therapy principles and
practice, ed 4, St. Louis, 2012, Mosby.)
tolerance of the muscle tissue. This approach can be thought of as

meeting the tissue where it is and encouraging it to stretch a bit
further. Forcing a stretch not only results in rebound contraction,
but it also can cause injury.
The proprioceptors involved in tendon reflexes are tendon
organs, which are found in the musculotendinous junction
(Fig. 1-9). Tendon organs measure tension applied to tendons from
muscle contraction. The tendon reflex protects tendons and associ-
ated muscles from damage by causing muscle relaxation in response
to excessive tension on tendons by muscle contraction.
Joint kinesthetic receptors are found in and around the articular
capsules of synovial joints. They respond to pressure and acceleration
and deceleration of joints. Articular ligaments contain receptors
similar to tendon organs that cause adjacent muscles to relax when
excessive strain is placed on the joint.
Major Categories of Stretching

The two primary variations of stretching techniques are passive and
active. Passive stretching occurs when a second person (the massage
Sensory
nerve
Golgi tendon
organ
Tendon
FIGURE 1-9 Tendon organ. (From Salvo SG: Massage therapy principles and
therapist) applies the force to stretch the tissue. Passive stretching

is one of the most controlled forms of stretching. This form of
stretching usually involves the massage therapist controlling the
stretch through a specific motion. The client relaxes to the point
of the elongation, and the massage therapist can progress the
movement throughout its ROM. Active stretching is when clients
stretch themselves. The three major categories of stretching are
static, dynamic, and ballistic.
Static Stretching
Static stretching is a slow and progressive elongation of the target
muscle accomplished by holding the stretch for 15 to 30 seconds. It
is considered passive. After 15 to 30 seconds, the massage therapist
can progress the stretch further, if it is comfortable for the client,
and hold again, then release. Three repetitions of stretching and
releasing are usually recommended. Static stretches are performed

so that the joints are placed in the outer limits of the available
ROM and held. Static stretches are safe and effective. Most people
are familiar with these stretches and often perform them at home
(Fig. 1-10).
Static stretching can activate the stretch reflex if the stretch is
continued beyond comfort or the stretch is not held for at least
15 seconds. A possible rebound contraction can occur before that
time, creating a tug-of-war between the desire to stretch and the
target muscle resisting overstretching to avoid injury. This rebound
contraction is why it is important to maintain focus while stretch-
ing and pay attention to signals the client’s body is giving.3
Dynamic Stretching
Dynamic stretching is considered active. It involves moving the
joints of the body through ranges of motion instead of holding the
body in a static position of stretch. The idea is that whenever a joint
FIGURE 1-10 A client performs a static stretch of the left arm and scapular
region. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)
is moved in a certain direction, the tissues on the other side of the

joint are stretched. If the hip joint is flexed, the anterior muscles are
contracting, and the tissues on the other side of the joint, the hip
joint extensor muscles and other posterior soft tissues, are stretched.
Similarly, if the hip joint is extended, the hip joint flexor muscles
and other anterior tissues are stretched.
When doing dynamic stretching, the joint motions need to be
performed in a careful, prudent, and graded manner, gradually
increasing the intensity of the motions. For this reason, dynamic
stretching begins with small ranges of motion, which gradually
build up to full ranges of motion. If dynamic stretching is done
before a physical workout, the ranges of motion that are performed
should be the same ranges of motion that will be asked of the body
during the physical workout. If the exercise entails some form of
added resistance, the resistance of the exercise should be added
gradually to the dynamic stretching after the full ranges of motion
of the joints are accomplished.
For example, before playing tennis, the client would go through
the motions of forehand, backhand, and serving strokes without a
racquet in hand, beginning with small swings and building up to full
ROM swings. Then the same order of motions would be repeated
with the added resistance of having the tennis racquet in hand
(but not actually hitting a ball), starting with small swings and
gradually working up to full ROM swings. Finally, the client adds
the full resistance of hitting the tennis ball while playing on the
court, starting with gentle, short swings and gradually building up
to full ROM and powerful swings (Fig. 1-11).
Dynamic stretching can be recommended to clients as an exer-
cise warm-up in addition to a way to stretch tissues. It increases
local circulation, warms the tissues, lubricates the joints and brings
them through their ROM, and engages the neural pathways that
will be used during the exercise routine.
As explained earlier, static stretching is beneficial if the tissues
are warmed up first. Static stretching can be very effective after
an exercise routine is done (or if the tissues are first warmed up
by applying moist heat). However, some sources are recommending
that even static stretching should be performed in more of a move-
ment-oriented “dynamic” manner. It was classically recommended
to hold a stretch 15 to 30 seconds, whereas many sources now
advocate that the stretch should be held for only 2 to 3 seconds.
Approximately 8 to 10 repetitions can be done instead of the
B
FIGURE 1-11 A, A short forehand swing is done without holding a racquet.
B, A full ROM swing is done without the racquet.
D
FIGURE 1-11, cont’d. C, The client uses a racquet to provide greater resis-
tance, first with a short swing. D, The client uses a full ROM swing. (From
previously recommended 3 repetitions. As the method of static

stretching is changed from a few long statically held stretches to
more repetitions with the stretch being held for less time, static
stretching increasingly resembles dynamic stretching.6
Ballistic Stretching
Ballistic stretching, although popular, can be detrimental to the
body. This type of stretching is active and is often referred to as a
type of dynamic stretching. It was practiced by athletes for years.
Ballistic stretches use the momentum of a moving body or a limb in
an attempt to force it beyond its normal end point. These stretches
are of high force and short duration. This type of stretching is
not considered safe and can lead to injury by aggravating muscle
and connective tissue. Ballistic stretching involves rapid bouncing
motions to force the target muscle to elongate. The stretched target
muscles are used like springs to pull the individual out of the
stretched position. It does not allow the muscles to adjust to and
relax into the stretched position. Instead, it may cause them
to tighten up by repeatedly activating the stretch reflex, often
producing small muscle tears that result in scar tissue.8
References
1 . Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.
2. Run the Planet: Factors limiting flexibility. 2010. www.runtheplanet.com/
trainingracing/stretching/chap2-limitingfactors.asp. Accessed May 21, 2013.
3. Freeman JE, Anderson SK: Career longevity, the practitioner’s guide to
wellness and body mechanics, Philadelphia, 2013, Davis.
4. Andersen JC: Stretching before and after exercise: effect on muscle
soreness and injury risk, J Athl Train 40:218–220, 2005.
5. Mayo Clinic: Stretching: focus on flexibility. 2009. http://www.mayoclinic.
com/health/stretching/HQ01447. Accessed May 25, 2013.
6. Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.
7. Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St. Louis, 2013,
Mosby.
8. Simancek J: Deep tissue massage treatment, ed 2, St. Louis, 2013, Mosby.
Basic Stretching
Chapter
2
Techniques
Joints, muscles, and other soft tissues that benefit from massage
also benefit from stretching techniques for improved function, re-
stored mobility, and increased range of motion (ROM). These
techniques are additional treatment options and can be performed
easily before, during, or after a massage treatment, or as the primary
technique.
Guidelines for Successful Stretching

To stretch the client’s tissues successfully, there are several guide-
lines to follow to assist the stretching process and enhance results.
These guidelines involve muscle relaxation, warming the tissues,
minimum force, breath, and duration.
Muscle Relaxation
Muscle relaxation means the lengthening of inactive, or noncon-
tracting, muscle fibers or muscles. Relaxation is the opposite of
tension; tension occurs in contracted muscles and results in stiffness,
insufficient oxygen and nutrient supply secondary to decreased local
circulation, and fatigue.
Relaxation is crucial to increased flexibility. If a client’s muscle is
contracted at the time of stretching, the thin and thick filaments cannot
slide to a longer resting position. The filaments are asked to do opposing
actions at the same time, causing strain on the muscle’s tendons.
A stretching technique can cause a muscle to remain elongated after
being stretched only if the muscle is relaxed while it is being stretched.
Warming the Tissues

Stretching should be done when the target tissues are most receptive
to being stretched, which is when they are already warm. Warming
29
30 Chapter 2 Basic Stretching Techniques
soft tissue facilitates stretching because heat soothes the central

nervous system, helping muscles relax. Also, because of its proper-
ties, myofascial tissue is more easily stretched when warm.
Cold tissues resist stretching and are more likely to be injured.
Massage therapists can warm the target tissues by applying
moist heat. The client can take a hot shower, hot bath, or use a
whirlpool before the massage treatment, if these facilities are avail-
able. Alternatively, the massage therapist can place a moist heating
pad or hydrocollator pack on the target tissues.1
Minimum Force
Stretching should never be painful. After stretching is complete, it
should feel rejuvenating. Soreness after a stretching session is a sign
that the stretching has been too vigorous.
Every client has varying tolerances to discomfort and pain. It is
recommended to stretch the client’s tissues only to the point of
mild to moderate discomfort if the goal is to improve ROM. The
massage therapist should stretch up to that point, then decrease the
stretch until the muscle relaxes, then stretch again. Using too much
force during the stretch may cause injury to the area.
The comfort barrier is the first point of resistance before the
client perceives any discomfort at either the physiologic or the
pathologic barrier. If stretching causes pain, it is likely that the tar-
get muscles or muscles will tighten in response to the pain. Also, if
the target muscle is stretched either too quickly or too forcefully, the
stretch reflex may be stimulated, resulting in muscle tightening,
which is the opposite of the desired outcome.
Stretching should always be done slowly, rhythmically, with the
minimal force needed, and within the client’s tolerance. A stretch
can be performed as intensely as needed but should always be
without client pain. When in doubt, it is best to be conservative
regarding the speed and forcefulness of a stretch. Gently and slowly
stretching a client over many sessions is a safer way to loosen target
tissues. It may take more sessions, but a positive outcome is essen-
tially guaranteed. Stretching too quickly and forcefully not only
may set back the progress of the client’s treatment program but also
may cause tissue damage that is difficult to reverse (Box 2-1).
Breath
Proper breath is important for successful stretching. There are many
different schools of thought about client breathing patterns during
Chapter 2 Basic Stretching Techniques 31
Spotlight BOX 2-1

Clients often describe a stretch as being painful but go on to say that
the pain feels good. For this reason, a distinction should be made
between what is often described by the client as good pain and true
pain (or what might be called bad pain). Good pain is often the way
that a client describes the sensation of the stretch; causing good
pain as a result of a stretch is fine. However, if a stretch causes true
pain—in other words, the client winces and resists or fights the
stretch—the intensity of the stretch must be lessened. Otherwise,
not only will the stretch be ineffective, but also the client is likely
to be injured. A stretch should never be forced.
(From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)
stretching. However, the most effective method is for the client to

breathe normally with efficient breaths and to visualize the muscles,
tendons, and ligaments lengthening during the stretch. The
client should avoid holding the breath because this increases blood
pressure and general muscular tension. Breathing efficiently should
also enhance relaxation while being stretched.
The client should breathe in the following manner during
stretches:
• Inhale before the stretch.
• Exhale into the stretch.
• Breathe normally during the stretch.
• Inhale while being returned to the start position.
Duration
Stretching duration can vary, depending on numerous factors.
Foremost is the type of stretching being performed. Dynamic
stretching involves several “swings” or gross motor movements
of the extremities that last only a few seconds. Static stretching
methods involve longer periods, sometimes up to 1 minute.
Short, agonizing stretching sessions are not more effective (and
may result in scar tissue formation) than longer sessions of lesser
intensities. Major muscles can stretch in a relaxed state to about
50% longer than their usual resting length if patience is used.
Fascia is given time to relax as well. Fascia generally is slow to
relax because of the postural stressors placed on the body. Just as
stressors did not cause fascia to be in a shortened state overnight,

fascia does not relax and become more elastic instantly. Refer to
the section on “Connective Tissue, Muscles, and Stretching” in
Chapter 1.
Safe and Effective Stretching Methods

Most joint mobilization and stretching techniques are best admin-
istered on unlubricated skin; any excess lubricant may need to be
wiped off if massage was previously administered on that area. If the
entire session is devoted to joint mobilization and stretching,
the client may remain clothed; the routine is best performed
with the client wearing flexible clothing such as sweatshirts and
pants, tights, or leggings.
The massage therapist should tell the client beforehand about
the movements that will be performed. The movements may need
to be demonstrated, especially if they require active participation
by the client. Also, it is essential to use proper body mechanics when
applying these movements because they can be physically demand-
ing on the massage therapist, particularly if the client has a large
body size.
Stretching Procedures
Have the client actively demonstrate a baseline ROM before
stretching; this helps to evaluate the effectiveness of the
technique.
• Stretch tissues only when they are warm and pliable. After warm-
ing through a hot shower or heat pack application, use jostling,
rocking, or superficial friction to prepare the area.
• Stabilize the body so that only the target area is isolated during
stretching.
• Move the area to the pathologic barrier and back off a bit.
• Instruct the client to inhale right before the stretch and then
exhale slowly as the stretch is performed.
• Stretching should always be done within the comfortable limits
of the range of motion of the client.
• Stretching should be controlled and performed at a slow pace.
• A stretch can be performed in sets of 10 repetitions with a 15- to
30-second rest in between each stretch.
• An increase of 10% in ROM is sufficient during a massage
session. Do not attempt to increase the ROM more than 25%
during a massage session.2
Overstretching
If stretching is done properly, the client should not feel soreness the
next day. The opposite should be true—the client should feel good.
If the client has soreness, it may be an indication of overstretching,
and the intensity and duration of future stretches should be reduced.
Overstretching increases the time it takes to gain greater flexi-
bility because overstretching damages tissues; they need to repair
themselves to have the same extensibility as before they were
injured. One of the easiest ways to overstretch is to stretch without
warming the tissue. Just because a muscle can be moved to its limit
without warming up does not mean it is ready for the strain that
stretching could place on it.
The sensations felt as the extreme ranges of a stretch are reached
include localized warmth of the stretched muscles, followed by a
burning or spasmlike feeling, and then sharp pain. The localized
warming usually occurs at the attachments of the stretched muscles.
If the client feels these sensations, the intensity of the stretch needs
to be decreased.
If the warming sensation is ignored, or perhaps the client did not
feel it, and the stretch is continued until a definite burning sensation
is felt in the stretched muscles, the stretch should be discontinued
immediately. If the stretch is continued to the point that the client
feels a sharp pain, it is likely that the stretch has already resulted in
tissue damage, which may cause immediate pain and soreness that
persists for several days.3
Reasoning and Application

Joint movement and palpation are the assessments for determining
if stretching can be used to alleviate areas of tissue shortening that
are involved in a lack of flexibility. During the massage treatment,
each joint should be moved actively or passively, or both, to deter-
mine the available ROM.
It is important not to confuse joint movement with stretching.
Joint movement assesses the limits of movement as indicated by the
palpation of bind. The sensation of bind comes from tissue being
restrained from motion. Stretching begins at the bind and then
moves into it to increase the amount of available movement.
When moving a joint during assessment, one should stay within
the normal physiologic barriers. If limits of ROM are identified, the
massage therapist should gently and slowly encourage the joint to
increase the ROM only if hypomobility exists. It may take multiple
massage sessions, with client self-stretching in between the sessions,

to see long-lasting results. Flexibility generally increases gradually.2
How Stretches Can Be Reasoned Out Instead

of Memorized
To create a stretch, the client’s body is moved into a position that
creates a line of tension that pulls on the target tissues (Fig. 2-1).
If the stretch is effective, the tissues are lengthened.
FIGURE 2-1 Hatch marks indicate the line of stretch when the client’s
upper extremity is stretched. (From Muscolino JE: Kinesiology, ed 2, St. Louis,
2011, Mosby.)
If the target tissue to be stretched is a muscle or muscles, the

massage therapist can identify the position the client’s body must
be moved into to achieve an effective stretch. The massage therapist
recalls the joint movements for the target muscle and moves
the client’s body part opposite of one or more of these actions.
Examples are as follows:
• If a muscle flexes a joint, stretching would involve extension of
that joint.
• If the muscle abducts a joint, stretching would involve adduction
of that joint.
• If a muscle medially rotates a joint, stretching would involve
lateral rotation of that joint.
• If a muscle has more than one action, the optimal stretch would
involve the opposite of all its actions.
If the target muscle to be stretched is the right upper trapezius,
its actions are extension, right lateral flexion, and left rotation of
the neck and head. Stretching the right upper trapezius would
require flexion, left lateral flexion, or right rotation of the head
and neck.1
Multiplane Stretching
Because space is three-dimensional, mapping space and describing
movements that occur within the three dimensions involves the use
of planes. A plane is a flat surface that cuts through space. The three
major, or cardinal, planes are sagittal, frontal (coronal), and
transverse (horizontal). A sagittal plane divides the body into left
and right portions. The midsagittal plane divides the body into
equal right and left halves. The frontal plane divides the body into
anterior and posterior portions. The transverse plane divides the
body into superior/proximal and inferior/distal portions. An addi-
tional plane is any that is not purely sagittal, frontal, or transverse; it
is called an oblique plane. The planes are shown in Figure 2-2.
Figure 2-3, A, shows examples of motion within the sagittal
plane. The head and neck are flexing at the spinal joints, and the
forearm is flexing at the elbow joint. Figure 2-3, B, shows examples
of motion of a body part within the frontal plane. The head and
neck are left laterally flexing at the spinal joints, and the left arm
is abducting at the shoulder joint. Figure 2-3, C, shows examples
of motion of a body part within the transverse plane. The head
and neck are rotating to the right at the spinal joints, and the
left arm is medially rotating at the shoulder joint. Figure 2-3, D,
A B
C D
FIGURE 2-2 Four types of planes: A, Sagittal. B, Frontal. C, Transverse.
D, Oblique. (From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)
B
FIGURE 2-3 A, Motions of body parts within a sagittal plane. B, Motions of
body parts within a frontal plane.
D
FIGURE 2-3, cont’d C, Motions of body parts within a transverse plane.
D, Motions of body parts within an oblique plane. (From Muscolino JE:
Kinesiology, ed 2, St. Louis, 2011, Mosby.)
shows examples of motion of a body part within an oblique plane.

The head and neck are doing a combination of extension in the
sagittal plane, left lateral flexion in the frontal plane, and right
rotation in the transverse plane. The right arm is doing a combi-
nation of flexion in the sagittal plane, adduction in the frontal
plane, and medial rotation in the transverse plane. Stretching a
muscle across more than one cardinal plane is called multiplane
stretching.
When a muscle has many actions, it is not always necessary to
do the opposite of all of them, although it might be desired or
needed at certain times. If the right upper trapezius is tight enough,
simply doing flexion in the sagittal plane might be enough to stretch
it. However, if further stretch is needed, left lateral flexion in the
frontal plane or right rotation in the transverse plane, or both, could
be added as shown in Figure 2-4.
FIGURE 2-4 The right upper trapezius is stretched in all three planes. (From
Even if not every plane of action is used for the stretch, it is still
important to be aware of all the muscle’s actions, or a mistake might
be made with the stretch. If the right upper trapezius is being
stretched by flexing and left laterally flexing the client’s head and
neck, it is important not to let the client’s head and neck rotate to
the left because this would allow the right upper trapezius to be
slackened, and the tension of the stretch would be lost. Given
that the right upper trapezius also elevates the right scapula, it is
important to ensure that the right scapula is depressed or at least not
allowed to elevate during the stretch, or the tension of the stretch
will also be lost.1
Isolating a Stretch to One Target Muscle

It is sometimes challenging to isolate one target muscle for stretch-
ing. Usually an entire functional group of muscles is stretched at
the same time (Box 2-2). Figuring out exactly how to isolate a
target muscle depends on knowing the joint actions of the muscles
involved. This knowledge eliminates the need to memorize a large
number of stretches. Critical thinking can be used to reason
through the steps necessary to figure out which stretches are
needed for a client-centered treatment.
For example, if a client’s thigh is stretched into extension in
the sagittal plane, the entire functional group of sagittal plane hip
flexors is stretched (tensor fasciae latae, anterior gluteus medius and
minimus, sartorius, rectus femoris, iliopsoas, pectineus, adductor
longus, gracilis, and adductor brevis). To isolate just one of the hip
flexors requires modifying the stretch to achieve the desired result.
If the stretch involves extension in the sagittal plane and adduction
in the frontal plane, all hip flexor muscles that are also frontal plane
adductors will be slackened, and the hip flexor muscles that are also
Spotlight BOX 2-2

Whenever a stretch affects a functional group of muscles—in other
words, many muscles—the tightest muscle within the line of tension
of the stretch is usually the limiting factor of how forcefully the stretch
can be done. The problem is that if a different muscle is the target
muscle to be stretched, it will not be successfully stretched because
the stretch was limited by the tighter muscle.

abductors, such as tensor fasciae latae, sartorius, and anterior gluteus

medius and minimus, will be stretched.
If medial rotation of the thigh in the transverse plane is also
added to the stretch so that the thigh is now being extended in the
sagittal plane, adducted in the frontal plane, and medially rotated in
the transverse plane, all hip joint flexors and abductors that are also
transverse plane medial rotators will be slackened, but the stretch
on muscles that perform flexion, abduction, and lateral rotation of
the thigh at the hip joint will be increased. In this case, sartorius is
the target muscle stretched because it is the only hip joint flexor and
abductor muscle that also laterally rotates the thigh at the hip joint.
(Iliopsoas would also be stretched because it is a hip flexor and
lateral rotator, and some sources state that it can also abduct.)
Because sartorius also flexes the knee, the knee joint should be
extended during the stretch.
Whenever a client’s body part is moved into a stretch in
one direction (in one plane), the entire functional group of muscles
located on the other side of the joint is stretched. To isolate the
stretch to one or only a few of the muscles in this functional group
requires modifying the stretch. The modification could be adding
movements in other planes to the stretch or adding a stretch to
another joint if the target muscle crosses more than one joint.1
Stretching Other Target Tissues

If the target tissue to be stretched is not a muscle but a ligament, a
joint capsule, or some other soft tissue, the stretch can still be
reasoned out instead of memorized. One way to do this is to think
of this tissue as though it were a muscle. Figure out what its action
would be if it were a muscle, and then perform the action that
is antagonistic to that action. For example, if the target tissue is a
ligament located on the anterior hip joint, the massage therapist
would move the client’s thigh posteriorly (or posteriorly tilt the
pelvis at the hip joint) to stretch it.
Direct Tissue Stretching

Direct tissue stretching targets tissues in a local area that have been
assessed as shortened and have binding (Fig. 2-5, A and B). If only
a small section of muscle needs to be stretched, if the muscle cannot
be stretched using joint movement, or if the joints are so flexible
that not enough pull is put on the tissues for an effective stretch,
direct tissue stretching may be an option (Box 2-3). This type of
B
FIGURE 2-5 A, Beginning of direct tissue stretch. B, End of direct tissue
stretch.
D
FIGURE 2-5, cont’d. C, Beginning of longitudinal stretch. D, End of
longitudinal stretch. (From Fritz S: Mosby’s fundamentals of therapeutic
massage, ed 5, St. Louis, 2013, Mosby.)
Spotlight BOX 2-3

Some muscle tissues are extremely difficult to stretch by using active
or passive joint movement. This difficulty is related to the size, shape,
and direction of the tissue fibers. Muscle tissues that are small and
short, square or rectangular, or oriented transversely in the body re-
spond better to direct tissue stretching. Following is a list of some
muscles that are better addressed by direct methods:
Suboccipitals
Supraspinatus
Pectoralis minor
Serratus posterior superior
Serratus posterior inferior
Supinator
Anconeus
Longissimus
Iliocostalis
Semispinalis
Multifidus
Rotatores
Quadratus lumborum
Quadriceps
Popliteus
Tibialis anterior
(From Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.)
stretching does not involve joint movement as part of the technique.

However, palpation or joint movements are used as the assessments
to identify areas of shortened tissue, and the tissue is directly
stretched using various mechanical forces. The two types of direct
tissue stretching are longitudinal and cross-directional.
Longitudinal Stretching
Longitudinal stretching pulls connective tissue in the direction of the
fibers. It is performed along with movement at the joint and gliding
applied with drag in the direction of the force (Fig. 2-5, C and D).
If longitudinal stretching is inadvisable, if it is ineffective because a
joint is hypermobile, or if the area to be stretched is not effectively
stretched longitudinally, cross-directional stretching, discussed in the
next section, is a better choice. Cross-directional stretching focuses on
the tissue itself and does not depend on joint movement. Four meth-
ods of longitudinal stretching include basic longitudinal stretching,
separating the ends of tissue to lengthen it, active assisted longitudinal
stretching, and using compression with longitudinal stretching.
Basic Longitudinal Stretching

The procedure for basic longitudinal stretching is as follows:
1. Position the target muscle in the direction of ease. Stabilize and
isolate the muscle group.
2. Use gliding, compression, and kneading to warm and relax the
target muscle.
3. Have the client inhale. As the client exhales, stretch the muscle
to its physiologic or pathologic barrier or to wherever is toler-
able for the client; this is the point of bind. Release the stretch
slightly to prevent muscle spasm. Make sure the stretch stays in
line with the muscle fibers.
4. Have the client breathe normally while holding the stretch
position for at least 10 seconds; this is the lengthening phase.
Feel for a small amount of muscle release.
5. Take up slack by lengthening the muscle further for up to
20 seconds to create longitudinal pull on the connective tissue;
this allows for changes in the connective tissue component of
the muscle.
6. Release the stretch.
Separating the Ends of Tissue to Lengthen It

Longitudinal tissue stretching can also involve separating the ends
of the tissue to lengthen it. This technique is useful if only a small
section of muscle needs to be stretched, if the muscle does not
lend itself to stretching with joint movement, or if the joints are so
flexible that not enough pull can be applied to the muscle to achieve
an effective stretch to the tissues.
The procedure is as follows (Fig. 2-6):
1. Locate the tissues to be stretched.
2. Place the hands, fingers, or forearms directly over the area to be
stretched.
3. Separate the fingers, hands, or forearms to apply tension force to
stretch the tissue. Alternatively, lift the tissue with enough pres-
sure to stretch the tissue; this applies bending or torsion force.
4. Take up all slack from lengthening, and then increase the force
of the stretch for up to 20 seconds.
FIGURE 2-6 Separating the ends of tissue to lengthen it. (From Fritz S: Sports
and exercise massage, ed 2, St. Louis, 2013, Mosby.)
5. Repeat two or three more times.

6. Release the stretch.
Active Assisted Longitudinal Stretching

The following procedure is used for active assisted longitudinal
stretching:
1. Isolate the target muscle. Make sure it will not be working
against gravity in the stretching position.
2. Lengthen the muscle to its physiologic or pathologic barrier.
Increase the stretch slightly beyond this point, and gently hold
for 1 to 2 seconds.
3. Release the muscle to its starting position. Repeat this action in
a rhythmic fashion for 5 to 20 repetitions.
4. To increase the effectiveness of the stretch, have the client
contract the antagonist while the target muscle is lengthened
and stretched.
Using Compression with Longitudinal Stretching

To use compression with longitudinal stretching, do the following:
1. Isolate the target tissue.
2. Apply compression into the shortened tissue and hold it in a
fixed position.
3. Have the client move the adjacent joint to lengthen the tissue.
This is also called active release.
4. Alternatively, the massage practitioner can compress the
shortened tissue, and use his or her other hand to move tissue
or the joint into a stretched position. This is also called pin and
stretch, which is discussed in Chapter 4.4
Cross-Directional Stretching
Cross-directional stretching pulls the connective tissue against the
fiber direction. This technique involves pulling and twisting, which
are torsion and bend forces. The procedure for cross-directional
stretching is as follows (Fig. 2-7):
2. To stretch the area, use compression and move against the fiber
direction.
3. Lift the tissue slightly and hold for 30 to 60 seconds until the
tissue feels warmer or releases.
For skin and superficial connective tissue, do the following:
2. Lift and pull the tissue, first moving into the restriction and
then pulling and twisting out of it, keeping a constant tension
FIGURE 2-7 Cross-directional tissue stretch. (From Fritz S: Sports and exercise
on the tissue; this is similar to pulling taffy. Proceed slowly. Take

up slack until the tissue feels warmer or releases.4
Basic Static Stretching Techniques

Basic static stretching techniques that can be easily incorporated
into massage treatments are presented in Chapter 3.
References
1. Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.
2. Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.
3. Freeman JE, Anderson SK: Career longevity, the practitioner’s guide to wellness
and body mechanics, Philadelphia, 2013, Davis.
4. Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St. Louis, 2013,
Mosby.
Basic Static
Chapter
3
Stretching Atlas
The techniques presented in this atlas are passive movements
involving static stretches.* These techniques can be performed
before, during, or after a massage treatment. A brief description of
the technique is presented along with a photo. The techniques
should be performed on both sides of the client’s body when
applicable.
As mentioned in Chapter 2, the massage therapist should have
the client actively demonstrate a baseline range of motion
before stretching; this will help to evaluate the effectiveness of the
technique. As discussed in Chapter 2, the client should inhale
before the stretch, exhale into the stretch, breathe normally during
the stretch, and inhale while being returned to the start position.
The stretch should be held for 20 to 30 seconds, depending on the
client’s tolerance and when the massage therapist feels the tissue
release.
Massage therapists should check their state’s definition of scope
of practice for the inclusion or exclusion of these techniques.
Additional stretches to supplement the ones presented here are
described in Chapters 4 and 5.
Neck
Joint mobilizations and stretches of the neck are performed while
the client is in the supine position. They include neck circles, neck
lateral flexion with and without rotation, and neck forward flexion.
Movements of the neck include flexion, extension, lateral flexion,
and rotation.
*From Salvo SG: Massage therapy principles and practice, ed 4, pp 162-170,

St. Louis, 2012, Mosby.
49
50 Chapter 3 Basic Static Stretching Atlas
Neck Circles
Place one hand on the client’s forehead, rocking the head side to
side while your other hand intermittently compresses the tissue in
the lamina groove on the opposite side up and toward you (Fig. 3-1).
If done correctly, it will feel as if your hands are pushing and pulling
alternately.
Neck Lateral Flexion

With one hand, pull the client’s head toward the near shoulder
while your hand stabilizes the client’s far shoulder (Fig. 3-2). Do not
lift the head while pulling.
Neck Lateral Flexion with Rotation

With one hand, pull the client’s rotated head toward the near shoulder;
the client’s head is rotated away from you or toward the far shoulder.
Use your other hand to stabilize the client’s far shoulder (Fig. 3-3). Do
not lift the head while pulling. Repeat on the opposite side.
Neck Forward Flexion

Support the base of the skull with one or both hands or forearm
while you lift the head toward the chest (Fig. 3-4). If both forearms
are used, they can be crisscrossed at the base of the client’s skull
before the lift.
Wrist and Hand

Joint mobilizations and stretches of the wrist and hand are flip wrist,
interlace fingers and mobilize wrist, metacarpal scissors, and pull
and circumduct fingers. The massage therapist should not apply
excessive force while moving the wrist and hand. The four move-
ments of the wrist are abduction, adduction, flexion, and extension.
Flip Wrist
Lightly pincer-grip just above the wrist with your thumbs and index
fingers of both hands. Use your remaining fingers to flip the client’s
hand up and down while you stabilize the wrist (Fig. 3-5). This
action moves the wrist into flexion and extension.
Interlace Fingers and Mobilize Wrist

Holding the client’s forearm vertically, interlace your fingers
with the client’s fingers. Move the wrist into flexion, extension,
abduction, and adduction as your other hand stabilizes the client’s
forearm just above the wrist (Fig. 3-6).
Chapter 3 Basic Static Stretching Atlas 51
C
FIGURE 3-1 A, Begin by moving the head away from you. B, Move the
head to the center. C, Move the head toward you. (From Salvo SG: Massage
FIGURE 3-2 Neck lateral flexion. (From Salvo SG: Massage therapy principles
and practice, ed 4, St. Louis, 2012, Mosby.)
FIGURE 3-3 Neck lateral flexion with rotation. (From Salvo SG: Massage
FIGURE 3-4 Neck forward flexion. (From Salvo SG: Massage therapy principles
FIGURE 3-5 Flip wrist. (From Salvo SG: Massage therapy principles and
FIGURE 3-6 Interlace the fingers before moving wrist. (From Salvo SG:
Massage therapy principles and practice, ed 4, St. Louis, 2012, Mosby.)
2 2
FIGURE 3-7 Metacarpal scissors. (From Salvo SG: Massage therapy principles
Metacarpal Scissors
Lightly pincer-grip two of the metacarpal bones with your thumbs
and index fingers of both hands. Alternately move them up and
down; move to the next pair of bones and repeat (Fig. 3-7). Mobilize
the tissues between each pair of metacarpals.
FIGURE 3-8 Pull and circumduct finger. (From Salvo SG: Massage therapy
principles and practice, ed 4, St. Louis, 2012, Mosby.)
Pull and Circumduct Fingers

Support the client’s wrist with one of your hands while you pull and
circumduct each finger with the other hand (Fig. 3-8). Move in both
directions (i.e., clockwise and counterclockwise).
Arm and Shoulder

Joint mobilizations and stretches of the arm and shoulder are arm
pulls and shoulder circles. These movements are best applied while
the client is supine but can be adapted for use in the prone or
side-lying position. The movements of the shoulder are flexion,
extension, adduction, abduction, rotation, and circumduction. The
elbow permits flexion, extension, and rotation (the latter movement
permits pronation and supination of the forearm).
Arm Pull
This technique has four parts:
1. While standing tableside near your client’s hip, grasp just above
the wrist. Pull and release the arm several times (Fig. 3-9). The
arm can be tapped or gently bounced on the massage table
while you pull or traction it.
2. Grasp just above the wrist and stand several feet away from the
table’s side. The shoulder will be abducted 90 degrees. Pull and
release the arm several times (Fig. 3-10).
3. Adduct the client’s shoulder by draping his or her arm across
the chest. Push the arm horizontally across the table using one
hand over the shoulder and the other hand over or under the
elbow (Fig. 3-11).
FIGURE 3-9 Pulling the arm down. (From Salvo SG: Massage therapy
FIGURE 3-10 Pulling the arm to the side. (From Salvo SG: Massage therapy
FIGURE 3-11 Pulling the arm across the chest. (From Salvo SG: Massage
4. Grasp just above the wrist and position yourself several feet
away from the top of the table. Pull and release the arm several
times (Fig. 3-12).
Shoulder Circles
Beginning with the client’s arm at his or her side, create an arc by
pulling the arm up toward the ceiling until it is vertical; continue
pulling the arm until it is over the client’s head (Fig. 3-13, A). With
your other hand, bend the client’s elbow and bring the arm laterally
to the client’s side (Fig. 3-13, B). Maintain traction during the entire
movement sequence. Repeat three times.
Spine
The umbrella term “spinal twist” is used for techniques for the
spine that employ a lengthening and rotational motion on a
supine-lying client. These movements are repeated on each side
of the client.
Spinal Twist I
Anchor the client’s far hip with your lower hand while you pull
the far shoulder up and toward you with your upper hand. The
FIGURE 3-12 Pulling the arm overhead. (From Salvo SG: Massage therapy
B
FIGURE 3-13 A, Pull the arm over the client’s head. B, Pull arm down to the
client’s side. (From Salvo SG: Massage therapy principles and practice, ed 4,
St. Louis, 2012, Mosby.)
client’s arms can be relaxed or placed with hands behind the head
(Fig. 3-14).
Spinal Twist II
With the client’s near leg bent and the foot placed on the lateral
side of the far knee, push the bent knee away from you while
pulling the far shoulder up and toward you (Fig. 3-15).
B
FIGURE 3-14 A, Client’s arms relaxed. B, Client’s hands behind the head.
(From Salvo SG: Massage therapy principles and practice, ed 4, St. Louis, 2012,
Mosby.)
Spinal Twist III

Anchor the client’s far shoulder while you pull the bent far knee
toward you and down (Fig. 3-16).
Spinal Twist IV
Anchor the client’s near shoulder while you push the bent near knee
away from you (Fig. 3-17).
FIGURE 3-15 Spinal twist II. (From Salvo SG: Massage therapy principles and
FIGURE 3-16 Spinal twist III. (From Salvo SG: Massage therapy principles
FIGURE 3-17 Spinal twist IV. (From Salvo SG: Massage therapy principles
Hip and Knee

Joint mobilizations and stretches of the hip and knee areas
are leg pull, leg rock, hip clock stretch, hip circles, hip flexion,
groin stretch, heel to hip, and hip hyperextension. Hip move
ments are flexion, extension, adduction, abduction, rotation, and
circumduction. Knee movements are essentially flexion and
extension.
Leg Pull
While standing at the foot of the table, grasp just above the client’s
ankle. Pull and release several times (Fig. 3-18). The leg can be
tapped or gently bounced on the massage table while you are pulling
or applying traction.
FIGURE 3-18 Leg pull. (From Salvo SG: Massage therapy principles and
Leg Rock
While standing tableside, place your hands above and below
the client’s knee. Rock the leg back and forth to rotate the hip
(Fig. 3-19).
Hip Clock Stretch

Flex the client’s hip and knee while supporting both the knee and
the heel; while imagining that the client’s leg is the hour hand of
a clock, push and stretch the hip in a 10 o’clock, 12 o’clock, and
2 o’clock stretch (Fig. 3-20). Repeat in the opposite direction.
Hip Circles
After performing the hip clock stretch, move the client’s flexed hip
and knee in a circle three times (Fig. 3-21). Reverse the direction
and repeat.
FIGURE 3-19 Leg rock. (From Salvo SG: Massage therapy principles and
2
10
12
FIGURE 3-20 Hip clock stretch. (From Salvo SG: Massage therapy principles
FIGURE 3-21 Hip circles. (From Salvo SG: Massage therapy principles and
Hip Flexion
Flex the client’s hip by placing one hand just above and behind
the ankle and raise the leg. Place your other hand above the knee
to maintain knee extension during the movement (Fig. 3-22). To
stretch the calf after hip flexion, dorsiflex the ankle (Fig. 3-23).
Groin Stretch
Flex and laterally rotate the client’s near hip, and flex the near knee.
Place the near foot by the far knee. Stretch the hip adductors by
gently pressing down on the iliac crest of the far hip with one hand
and just above the near flexed knee with the other hand (Fig. 3-24).
Heel to Hip
Flex the client’s near knee by moving the heel toward the near hip
(Fig. 3-25). A dorsiflexion of the ankle can be added during the
stretch (Fig. 3-26).
FIGURE 3-22 Hip flexion. (From Salvo SG: Massage therapy principles and
FIGURE 3-23 Hip flexion with ankle dorsiflexion. (From Salvo SG: Massage
FIGURE 3-24 Groin stretch. (From Salvo SG: Massage therapy principles
FIGURE 3-25 Heel to hip. (From Salvo SG: Massage therapy principles
FIGURE 3-26 Heel to hip with the additional ankle dorsiflexion. (From Salvo
SG: Massage therapy principles and practice, ed 4, St. Louis, 2012, Mosby.)
FIGURE 3-27 Hip hyperextension. (From Salvo SG: Massage therapy

Hip Hyperextension
Flex the client’s knee and lift the thigh until the hip is hyperex-
tended. The hand lifting the thigh should be above the flexed knee
while the other hand anchors the sacrum (Fig. 3-27). Release and
repeat two more times.
Ankle and Foot

Joint mobilizations and stretches of the ankle and foot are plantar
flexion and dorsiflexion, metatarsal scissors, and pull and circumduct
toes. The ankle and foot movements, which include dorsiflexion,

plantar flexion, inversion, and eversion, can be applied while the
client is prone or supine.
Plantar Flexion
While holding the client’s heel with one hand, push down on the
top of the foot with the other hand to move the ankle into plantar
flexion (Fig. 3-28, A).
Dorsiflexion
Hold the client’s heel with one hand while pushing the ball of the
foot toward the knee with the other hand to move the ankle into
dorsiflexion (see Fig. 3-28, B).
Metatarsal Scissors
Lightly pincer-grip two of the metatarsal bones with your thumbs
and index fingers of both hands. Alternately move them up and
down, then move to the next pair of bones and repeat (Fig. 3-29).
Mobilize the tissues between each pair of metatarsals.
Pull and Circumduct Toes

Support the client’s foot with one hand while you pull and
circumduct each toe with the other hand (Fig. 3-30). Move in
both directions (i.e., clockwise and counterclockwise).
A B
FIGURE 3-28 Plantar flexion (A) and dorsiflexion (B). (From Salvo SG:
Massage therapy principles and practice, ed 4, St. Louis, 2012, Mosby.)
1 2
2 1
FIGURE 3-29 Metatarsal scissors. (From Salvo SG: Massage therapy princi-
ples and practice, ed 4, St. Louis, 2012, Mosby.)
FIGURE 3-30 Pull and circumduct the toes. (From Salvo SG: Massage
Advanced Stretching
Chapter
4
Techniques
There are several types of advanced stretching techniques massage
therapists can use to address soft tissues that do not release with
basic stretching techniques. These techniques make use of neurologic
mechanisms such as the tendon and stretch reflexes. The techniques
presented in this chapter are pin and stretch, proprioceptor neuro-
muscular facilitation (PNF), contract relax (CR), antagonist contract
(AC), contract relax antagonist contract (CRAC), active isolated
stretching (AIS), and muscle energy techniques (MET).
Pin and Stretch

Pin and stretch is a stretching technique in which the massage
therapist pins (stabilizes), usually through compression, one part of
the client’s body and then stretches the tissues up to that pinned
spot through either active or passive movement. The purpose of the
pin and stretch is to stretch a more specific region of the client’s
body. As discussed in Chapter 2, when a body part is moved to cre-
ate a stretch, a line of tension is created. Everything along the line
of tension will be stretched. However, if only a certain area of soft
tissue along that line of tension needs to be stretched, then the pin
and stretch technique can be used to localize to that specific region.
For example, if a side-lying stretch is performed on a client as
shown in Figure 4-1, A, the entire lateral side of the client’s body
from the client’s distal thigh to the upper trunk will be stretched.
While the stretch over this line of tension may be effective, it is not
targeted to a specific muscle. Spread over such a large region of the
client’s body, focus of the stretch is diluted. Also, if one region of
soft tissue of the client’s body within that line of tension is tight, it
might stop the stretch from continuing into another area of the line
of tension that is specifically targeted to stretch.
71
72 Chapter 4 Advanced Stretching Techniques
B
FIGURE 4-1 A, Side-lying stretch of a client. B, Pinning the client’s lower rib cage.
Chapter 4 Advanced Stretching Techniques 73
C
FIGURE 4-1, cont’d C, Pinning the client’s iliac crest. (From Muscolino J:
Kinesiology, ed 2, St. Louis, 2011, Mosby.)
If the massage therapist pins the client’s lower rib cage, as seen in
Figure 4-1, B, the stretch will no longer occur in the client’s lateral
thoracic region. Instead it will be directed to the client’s lateral pelvis
and lateral lumbar region. If the massage therapist instead pins the
client’s iliac crest, as seen in Figure 4-1, C, the stretch will no longer
occur in the client’s lateral lumbar region. It will now be directed to
only the lateral muscles and other soft tissues of the client’s thigh.
Therefore, the pin and stretch technique pins and stabilizes a part of
the client’s body, focusing and directing the stretch along the line of
tension to the target tissues.
Continuing with this example, if the target tissues are gluteus
medius and quadratus lumborum (as well as other muscles of the
lateral pelvis and lateral lumbar region), pinning the client at the
lower rib cage, as seen in Figure 4-1, B, would be the ideal approach.
If the target tissue is limited to gluteus medius (and other muscles or
soft tissues of the lateral pelvis), the ideal location to pin the client
during this side-lying stretch is at the iliac crest, as seen in Figure
4-1, C. As can be seen, pin and stretch is a powerful technique that
allows for much greater specificity when stretching a client.1
Proprioceptive Neuromuscular Facilitation

Proprioceptive neuromuscular facilitation (PNF) is a common
passive technique that uses neuromuscular reflexes—the tendon
reflex and the stretch reflex, to increase range of motion (ROM) and
to reeducate the body. Common techniques used in PNF are the
CR and AC techniques, and a combination of both, known as the
contract relax antagonist contract technique (CRAC).
PNF follows the normal use patterns of the body, is a good
option to use for rehabilitation and strengthening, and is more
effective than static stretching. However, a regular daily regimen of
training is required to maintain flexibility gained from PNF. PNF
stretching is not recommended for children or adolescents whose
bones are still growing.
Contract Relax
The name contract relax (CR) is used because the target muscle is first
contracted, and then it is relaxed. CR involves the use of postisometric
relaxation. Immediately following this contraction, there is a period
during which all neural impulses are inhibited to that muscle, allowing
it to relax; this is postisometric relaxation.
Usually, the agonist (target) muscle is isometrically contracted
using just a little strength for a short duration (7 to 10 seconds). This
isometric contraction stimulates the tendon organs located in the
tendon of the target muscle. As discussed in Chapter 1, tendon
organs measure tension applied to tendons from muscle contraction.
The tendon reflex protects tendons and associated muscles from
damage by causing muscle relaxation in response to excessive ten-
sion by muscle contraction. However, in the case of postisometric
relaxation, excessive tension is not being placed on the tendons.
Instead, minimal isometric contraction of the muscle is just enough
to stimulate the tendon organs.
Although the contraction of a CR stretch is usually isometric, it
can also be done concentrically. In other words, when the client
contracts against the resistance of the massage therapist, the client
can be allowed to shorten the muscle and move the joint success-
fully. Whether the contraction is isometric or concentric, the tendon
reflex is still initiated, adding to the effectiveness of the stretch.
Generally, the client is asked to inhale and then hold the breath
while isometrically contracting against resistance and then exhale and
relax while the target muscle is being stretched (Box 4-1). CR stretch-
ing is performed by first having the client isometrically contract the
Spotlight BOX 4-1

There are two choices for the client’s breathing protocol when doing
a CR stretch. The client can hold in the breath when contracting the
target muscle against the resistance of the massage therapist, or the
client can exhale when contracting the target muscle (think exertion
on exhale) against the massage therapist’s resistance. Although con-
tracting when exhaling is probably slightly preferred, if CR stretching
will be combined with AC stretching to perform CRAC stretching, it is
necessary for the client to hold in the breath when contracting the
target muscle.
target muscle with mild to moderate force against resistance provided

by the massage therapist. The massage therapist then stretches the
target muscle by lengthening it immediately afterward. The isometric
contraction is usually held for approximately 5 to 10 seconds
(although some sources recommend holding the isometric contrac-
tion for 30 seconds). This procedure is usually repeated three to four
times.1
Each repetition of a CR stretch begins where the previous rep-
etition ended. However, it is possible, and sometimes needed, to ease
off the stretch before beginning the next repetition. The reason is
that the mechanism of CR stretching is the tendon reflex. The client
needs to be able to generate a forceful enough contraction to stimu-
late this reflex. Sometimes this is impossible if the client is trying to
contract the target muscle when it is stretched extremely long.
The procedure for CR is as follows (Fig. 4-2):
1. Lengthen the target muscle to the comfort barrier, and then
ease off slightly.
2. Have the client tense the target muscle for 7 to 10 seconds.
3. Have the client stop the contraction, and lengthen the target
muscle again.
4. Repeat steps 1 through 3 until the desired resting length is
obtained.2
Antagonist Contract
Similar to CR stretching, antagonist contract (AC) stretching also
uses a neurologic reflex to “facilitate” the stretch of the target muscle.
However, instead of the tendon reflex, AC uses reciprocal inhibition.
Contract
Target
Lengthen
Target
B
FIGURE 4-2 A, Isolate target muscles (hamstrings and gastrocnemius) and
have the client contract by pushing calf down. B, Lengthen target muscle.
Target
D
FIGURE 4-2, cont’d C, Isolate target muscles (latissimus dorsi and pectoralis
major), and have client contract by pushing arms down toward chest. D, Relax
and lengthen. (From Fritz S: Mosby’s fundamentals of therapeutic massage,
ed 5, St. Louis, 2013, Mosby.)
Reciprocal inhibition is a neurologic reflex that creates a more effi-

cient joint action by preventing two muscles that have an agonist-
antagonist relationship from contracting at the same time. When a
muscle contracts, antagonists are inhibited from contracting; they are
relaxed. Neurologically inhibited muscles are more easily stretched.
If brachialis contracts to flex the forearm at the elbow joint, reciprocal

inhibition inhibits triceps brachii from contracting and extending the
elbow joint. Using reciprocal inhibition, the client contracts the
antagonist muscle to create a stretch in the agonist muscle.
The procedure for using reciprocal inhibition when stretching a
client is as follows (Fig. 4-3):
1. Have the client perform a joint action that is antagonistic to the
joint action of the target muscle. This action inhibits the target
muscle, allowing for a greater stretch to be done at the end of this
active movement. Ask the client to inhale before the movement
and then exhale during the movement.
2. At the end of the client’s ROM, stretch the client further and
hold the position 1 to 3 seconds, and then release.
3. Repeat the procedure approximately 10 times.1
The following is the procedure for contract antagonist and
stretch (Fig. 4-4):
1. Lengthen the target tissues to the client’s comfort barrier, and
then ease off slightly.
2. Have the client contract the antagonist muscles.
3. Have the client stop the contraction, and slowly bring the target
tissues into a lengthened state, stopping at resistance.
4. Repeat steps 1 through 3 three or four times. The goal is 10%
to 25% improvement or ideal resting length of the client’s
muscle.2
Confusion can occur between reciprocal inhibition and AC. AC
is reciprocal inhibition but with beginning lengthened positioning
of the target muscle and the massage therapist providing resistance
against contraction of the antagonist muscle group. The difference
between CR and AC stretching is that in CR stretching, the client
actively isometrically contracts the target muscle, and then the mas-
sage therapist stretches it immediately afterward. With AC stretch-
ing, the client actively moves his or her body into the stretch of the
target muscle, and then the massage therapist stretches the target
muscle further immediately afterward.
Put another way, with CR stretching, the client contracts the
target muscle to stimulate the tendon reflex to relax it, whereas with
AC stretching, the client contracts the antagonist of the target
muscle so that the agonist is reciprocally inhibited and relaxed and
then taken into a stretch.
FIGURE 4-3 A, The client actively left

laterally flexes the neck, which
stretches the right lateral neck flexor
muscles and results in reciprocal
inhibition of the right lateral flexors.
B, At the end of the ROM of left lateral
flexion, the massage therapist
stretches the client’s neck further,
continuing the stretch of the right
lateral neck flexor muscles. (From
Muscolino J: Kinesiology, ed 2, St. Louis,
B 2011, Mosby.)
Resistance
force
Direction
of push
Resistance Target
force
Direction
of push
Target
A
Target
tissue
Target tissue
B
FIGURE 4-4 A, Lengthen the target tissues to the client’s comfort barrier.
Apply counterforce on the antagonist muscles, and instruct client to push
gently into the hands. B, The client stops contracting; the massage therapist
stretches the tissues, stopping at resistance. (From Fritz S: Sports and exercise
Contract Relax Antagonist Contract

CR and AC can be combined to enhance the lengthening effects.
This combined approach is called contract relax antagonist
contract (CRAC).
The procedure for CRAC is as follows (Fig. 4-5):
1. Position the target tissues at the client’s comfort barrier, and
then ease off slightly.
2. Have the client contract the target muscle for 7 to 10 seconds,
and then relax.
3. Have the client contract the antagonist muscles.
4. Have the client stop the contraction, and slowly bring the target
tissues into a lengthened state, stopping at resistance.
5. Repeat steps 3 and 4 three or four times. The goal is 10% to 24%
improvement or ideal resting length of the client’s muscle.2
Active Isolated Stretching

Active isolated stretching (AIS) was developed by Mattes. AIS
involves contracting muscles opposite of the target muscles, using
reciprocal inhibition. The target muscles are identified and isolated
by using precise, localized movements.
The procedure for AIS is as follows (Fig. 4-6):
1. Identify the target muscles to be stretched.
2. Have the client stretch the target muscles by actively, but gently,
contracting the antagonists.
3. At the end of the client’s ROM, the massage therapist increases
the intensity of the stretch by adding a moderate force that
stretches the target muscles further. The added stretch should
be gentle so that the stretch reflex is not triggered. Note: Steps
2 and 3 are called the stretch phase; the entire duration of the
stretch phase should be no more than 2 seconds.
4. The massage therapist supports the client’s body and guides it
back to the starting position. This step is called the recovery
phase. The client should always be brought back to the original
starting position at the end of each repetition.
5. Steps 2 through 4 are repeated approximately 8 to 10 times.
Each successive repetition usually allows an incremental gain of
a few degrees of motion of the stretch.3
Muscle Energy Techniques

Muscle energy techniques (MET) are active because they involve a
voluntary contraction of the client’s muscles in a specific and controlled
Direction
of push
Resistance
Target
Direction
of push
Resistance
A Target
Resistance
Direction
of push
Resistance Target
Direction
of push Target
B
FIGURE 4-5 CRAC, and then stretch shoulder adductors. A, Contract tar-
get tissue against applied counterforce. B, Move hands to antagonist
muscles, and instruct client to push into the applied counterforce, con-
tracting the antagonist muscles.
C
FIGURE 4-5, cont’d C, Instruct the client to stop pushing, and then stretch
the target tissues. (From Fritz S: Sports and exercise massage, ed 2, St. Louis,
2013, Mosby.)
direction, at varying levels of intensity, against a specific counterforce

applied by the massage therapist. The amount of effort may vary from
a small muscle twitch to a maximal muscle contraction. The duration
may be a fraction of a second to several seconds. All contractions begin
and end slowly, gradually building to the desired strength. MET have
various applications but are focused primarily on dysfunctional move-
ment patterns involving hypomobility.
MET and PNF are similar in that both involve the client con-
tracting muscles isometrically and the massage therapist performing
passive stretches. However, PNF also includes active movements by
the client.
Research indicates that PNF and MET stretching is more efficient
than static passive stretching. Understanding how MET is beneficial
has changed over the past few years, most notably that postisometric
and reciprocal inhibition effects do not account for the ability to
increase the tissue length. Instead, it is believed to be due to an
increased tolerance to stretch resulting from MET application.4
Principles of Muscle Energy Techniques

Counterpressure is the force applied to an area that either exactly or
partially matches the effort the client is exerting. The effort the client
is exerting is through an isometric or isotonic muscle contraction.
B
FIGURE 4-6 Assisted AIS of the medial rotators of the right arm. A, The client
is in the neutral starting position. B, The client actively moves the right arm
into lateral rotation, beginning the stretch of the medial rotators. The mas-
sage therapist adds a gentle force that moves the right arm into further
lateral rotation, continuing the stretch of the medial rotators. (Photos by
Yanik Chauvin. From Stillerman E: Modalities for massage and bodywork,
Three types of muscle contractions are used in MET: isometric,

eccentric isotonic, and concentric isotonic. In an isometric muscle
contraction, the distance between the proximal and distal (origin
and insertion) attachments of the target muscle is maintained at a
constant length. A fixed tension develops in the target muscle as the
client contracts the muscle against an equal counterpressure applied
by the massage therapist, preventing shortening of the muscle.
In this contraction, the effort of the muscle, or group of muscles, is
matched exactly by a counterpressure so that no movement occurs,
only increased effort on the part of the client.
An isotonic contraction is one in which the muscle changes
length. The effort of the target muscle or muscles is not matched by
the counterpressure of the massage therapist, allowing a degree of
resisted movement to occur. With a concentric isotonic contraction,
the muscle shortens. The massage therapist applies a counterforce
but allows the client to move the proximal and distal (origin and
insertion) attachment of the target muscle together against the pres-
sure. In an eccentric isotonic contraction, the muscle lengthens. The
massage therapist applies a counterforce but allows the client to
move the jointed area so that the proximal and distal (origin and
insertion) attachment of the target muscle separate as the muscle
lengthens against the pressure. Multiple isotonic contractions
require the client to move the joint through a full ROM against
partial resistance applied by the massage practitioner.
MET usually do not use the full contraction strength of the
client. With most isometric work, the contraction should start at
about 25% of muscle strength. Subsequent contractions can involve
progressively greater degrees of effort but never more than 50% of
the available strength. Sometimes only about 10% of the available
strength in muscles is used in this way, and there is an increase in
effectiveness by using longer periods of contraction. Pulsed con-
tractions (a rapid series of repetitions) using minimal strength are
also effective.
Breathing and Eye Movement

The use of coordinated breathing to enhance particular directions of
muscular effort can be beneficial. During MET, all muscular effort
is enhanced by inhaling as the effort is made and exhaling on the
lengthening phase.
Eye position is also effective owing to reflex muscle contraction in
response to voluntary eye movement. Looking toward the direction of
the contraction causes or facilitates the target muscles to contract.

Looking away from the direction of contraction inhibits the target
muscles. Use of eye movement can be helpful with clients who are
prone to cramping or are having difficulty using only a small contrac-
tion force. The eye movement replaces the contraction of the target
muscles, or it can enhance the contraction being used with MET. It
is recommended that eye movement be used first before active target
muscle contraction.
Almost all flexor patterns—trunk, hip, knee, ankle, shoulder, arm,
and wrist—are increased in tension (facilitated) when the client
looks toward the abdomen and are inhibited when the eyes roll up.
Extensor patterns—trunk, hip, knee, and ankle—are facilitated when
the client looks up and are inhibited when the client rolls eyes down.
When in doubt about the position, the massage therapist can just
instruct clients to roll the eyes in big circles slowly and deliberately.
The result is a CRAC pattern.
Following are common examples of use of eye movement (Fig. 4-7):
• To increase tension in neck flexors (tense and then relax), have the
client look toward the belly, rolling eyes down.
• To decrease tension in neck flexion, have the client look up over
the head, rolling eyes up.
• To increase tension in left neck rotation or lateral flexors, have the
client look left.
• To decrease tension in left neck rotators or lateral flexors, have
client look right.
• Reverse for right rotation or lateral flexor patterns.
A successful application is to lengthen the target tissue to bind
and then hold. The client begins the eye movement (usually big
circles) as the facilitation and inhibition (contraction and relaxation)
occur. The lengthening force on the target muscles is slowly
increased until a more normal resting length is achieved (Fig. 4-8).2
Methods
Energy methods for MET can be used together or in sequence to
enhance their effects. Muscle tension in one area of the body often
indicates imbalance and compensation patterns in other areas of the
body. Tension patterns can be self-perpetuating. Often, using an
integrated approach introduces the type of information the nervous
system needs to self-correct.
To perform MET effectively, the massage therapist positions
muscles so that their attachments are either close together or
B
FIGURE 4-7 A, Eyes looking down—facilitates flexors, adductors, and internal
rotators; inhibits extensors, abductors, and external rotators. B, Eyes looking
up—facilitates extensors, abductors, and external rotators; inhibits flexors, ad-
ductors, and internal rotators.
D
FIGURE 4-7, cont’d C, Eyes looking left—facilitates all muscle movement to
the left; inhibits all muscle movement to the right. D, Eyes looking right—
facilitates all muscle movement to the right; inhibits all muscle movement to the
left. (From Fritz S: Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.)
lengthened with the attachments separated. The target muscle or

muscles should be isolated whether the client is in a supine, prone,
side-lying, or seated position.
The procedure for an integrated approach follows. The position
from Option A, steps 1 and 2, or Option B, steps 1 and 2, is used as the
starting point for the rest of the process that begins at step 3 (Fig. 4-9).
B
FIGURE 4-8 A, Instruct client to look down. Apply gentle pressure. Flexors
maintain contraction. B, Instruct client to move eyes up. Apply gentle pressure.
Flexors inhibit, relax, and are more tolerant to stretching.
ct
Contra
Stretch
D
FIGURE 4-8, cont’d C, Eyes look right. Muscles on the right side of the
body contract. D, Instruct client to look left to increase tolerance to stretch-
ing of the right neck flexors. (From Fritz S: Sports and exercise massage,
ed 2, St. Louis, 2013, Mosby.)
B
FIGURE 4-9 A, Part 1. Locate target area. Option A: Identify the pattern of
distortion. B, Increase distortion in ease position.
D
FIGURE 4-9, cont’d C, Part 1. Locate target area. Option B: Use tender point
and move body into ease until the point lessens in pain. D, Part 2. Treatment.
Stabilize client in exaggerated distortion or position of ease. Instruct client to
move out of the pattern into neutral position.
F
FIGURE 4-9, cont’d E, As client is moving, provide resistance for the client
to push or pull against for about 10 seconds. F, At the end of the movement,
gently increase the lengthening to perform the stretch.
G
FIGURE 4-9, cont’d G, If locating a tender point was used in Part 1, palpate
the tender point again and refine the stretch position as necessary to ensure
the tissues containing the tender point are stretched. (From Fritz S: Sports
and exercise massage, ed 2, St. Louis, 2013, Mosby.)
Option A
1. Identify the most obvious of the postural distortion symptoms.
2. Exaggerate the pattern by increasing the distortion, moving the
client’s body into ease. This position isolates the various muscles
and associated tissues to be addressed in the next part of the
procedure. Continue with step 3.
Option B
1. Identify a painful point on the client’s body.
2. Move the client’s body into ease until the point is substantially
less tender to pressure. The position of ease isolates the various
muscles and associated tissues to be addressed in the next part
of the procedure. Continue with step 3.
After choosing from Option A or Option B, continue the pro-
cedure as follows:
3. Stabilize the client in as many different directions as possible.
The result should be the client is in the position of exaggerated
distortion or position of ease.
4. Instruct the client to move out of the pattern into neutral posi-
tion. Be as vague as possible and do not guide the client because
it is important for the client to identify the resistance pattern.
5. As the client is moving, provide resistance for the client to push
or pull against for about 10 seconds.
6. Modify the resistance angle as necessary to achieve the most
solid resistance pattern for the client.
7. Notice when the client’s breathing changes. While still provid-
ing modified resistance, allow the client to move through the
pattern slowly.
8. When the client has achieved as much extension as possible,
recognize that the client has achieved the lengthening pattern.
9. Gently increase the lengthening to perform the stretch.
10. Pay attention to what body areas become involved besides the
one addressed. This is the guide to the next position.
Pulsed Muscle Energy Procedures

Pulsed muscle energy procedures involve engaging the com-
fort barrier and using small, resisted contractions (usually 20 in
10 seconds). This method can be used to increase stretch toler-
ance in chronically shortened tissues or stimulate weakened
elongated tissue to increase tone.
The procedure for pulsed muscle energy is as follows (Fig. 4-10):
1. Isolate the target muscle by placing the attachments as close
together as possible.
2. Apply counterpressure for the contraction.
3. Instruct the client to contract the target tissues rapidly in small
movements for about 20 repetitions. Go to step 4, or maintain
the position, but switch the counterpressure location to the
opposite side and have the client contract the antagonist mus-
cles for 20 repetitions. Rapid eye movement can replace the
pulses or enhance the action.
4. Slowly lengthen the target tissues. Repeat steps 2 to 4 until
there is 10% to 25% improvement or a more ideal resting length
of the client’s muscle is obtained.
Using pulsed muscle energy to stimulate weak inhibited muscles,
do the following (Fig. 4-11):
1. Isolate the target muscle by placing the attachments as close
together as possible.
2. Apply counterpressure for the contraction.
Resistance
Resistance
Target
Target tissue
B
FIGURE 4-10 A, Isolate target muscle and apply counterpressure for the
contraction. Have the client pulse the muscle back and forth using tiny, con-
trolled movements. B, Tell the client to stop movement, and stretch the
shortened tissues. (From Fritz S: Sports and exercise massage, ed 2, St. Louis,
2013, Mosby.)
Resistance
Target
hip abductors
FIGURE 4-11 Example of pulsed muscle energy to stimulate weak, inhibited

hip abductor muscles. Isolate target area, and instruct the client to pulse into
resistance force 20 times. Return the area to normal position and do not
stretch. Repeat if necessary. (From Fritz S: Sports and exercise massage, ed 2,
3. Instruct the client to contract the target tissues rapidly in small

movements for about 20 repetitions. Rapid eye movement can
replace the pulses or enhance the action.
4. Slowly return the area to normal position. Do not stretch.
Note: All contracting and resisting efforts should start and finish
gently.2
Examples of Stretching
1. Lateral neck stretch (Fig. 4-12, A). Position the head at end
range of movement (tissue bind) and stabilize with one hand.
This is point of resistance for MET. With the other hand, gen-
tly push the shoulder down and away toward the client’s feet to
provide force to stretch the target tissues.
2. Pectoralis major stretch (Fig. 4-12, B). Use one hand or forearm
to apply compressive force for pulling the tissue into bind.
With the other hand, begin to press the upper arm down.
When resistance (tissue bind) is felt, it is appropriate to intro-
duce MET methods.
B
FIGURE 4-12 A-J, Examples of stretching. (From Fritz S: Sports and exercise
D
FIGURE 4-12, cont’d.
3. Lateral torso stretch (Fig. 4-12, C). With the client in side-
lying position, hold the client’s arm over the head with one
hand, and place the other hand on the lateral torso just inferior
to the axilla. Gently move the arm downward. When resistance
(tissue bind) is felt, apply compressive force on the lateral torso
to stretch the target tissues.
4. Stretch to increase external rotation of the shoulder joint
(Fig. 4-12, D). Abduct the shoulder 90% while leaving the
arm on the massage table. With one hand, stabilize just me-
dial to the glenohumoral joint. With the other hand, move
the client’s arm in external rotation with or without client
assistance. Stop at bind to stretch the tissues.
F
5. Stretch to increase supination and pronation of the forearm
(Fig. 4-12, E). Position the elbow just short of full extension
and stabilize with one hand. With the other hand, turn the
client’s palm up to stretch until resistance (tissue bind) is felt.
Various applications of MET can be used to increase tolerance
to the stretch.
6. Hip flexor stretch (Fig. 4-12, F). The hip flexors are more easily
stretched with the client in side-lying position. With one hand
or forearm, stabilize at the gluteus muscles on the top leg while
using the other hand to grasp above the knee on the leg on the
table. Slide the bottom leg along the massage table until resis-
tance (tissue bind) is felt to stretch the tissues.
H
7. Hip abductor stretch (Fig. 4-12, G). Cross one of the client’s
legs over the other, slightly internally rotate it, and use one hand
to stabilize it at the knee. Place the other hand on the lateral
side of the thigh about midway between hip and knee, and
place the forearm firmly along the client’s lateral thigh to mid-
calf. Pull the entire lower leg medially until resistance (tissue
bind) is felt to stretch the tissues.
8. Quadriceps femoris stretch (Fig. 4-12, H). With the client
prone, stabilize the client’s midposterior thigh with one hand.
With the other hand, flex the client’s knee to 90 degrees. Con-
tinue flexing until resistance (tissue bind) is felt to stretch the
tissues. However, do not flex more than an additional 45 degrees
(do not attempt to bring heel to gluteal muscles).
J
9. Stretching the sole of the foot (Fig. 4-12, I). With the client
prone or in side-lying position, use one hand to stabilize the
heel by pushing it down toward the massage table. Use the palm
of the other hand to extend toes until resistance (tissue bind) is
felt to stretch the tissues.
10. Trunk torque stretch (Fig. 4-12, J). With the client in side-lying
position, stand behind the client. As the client flexes the top hip
to 45 degrees, use one hand to push the client’s knee down to
the massage table while stabilizing the lateral thigh with the
forearm. Place the other forearm across the chest, just under the
clavicle, and roll the client back until resistance (tissue bind) is
felt to stretch the tissues.
References
1. Muscolino JE. Kinesiology, ed 2, St. Louis, 2011, Mosby.
2. Fritz S. Sports and exercise massage, ed 2, St. Louis, 2013, Mosby.
3. Stillerman E. Modalities for massage and bodywork, St. Louis, 2013,
Mosby.
4. Fryer G. MET—efficacy and research. In Chaitow L, editor: Muscle
energy techniques, ed 3, Philadelphia, 2006, Churchill Livingstone.
Chapter
5
Stretching
for Self-Care
Clients can experience decreased flexibility and tightness in various
parts of their bodies depending on their levels of activity, the type of
work they do, how they use their bodies for activities of daily living, and
what they prefer to do for recreation. A classic example is a client who
spends many hours a day sitting and working at a computer; this can
lead to stiffness in the back and neck, tight shoulders, and hip joints that
are locked tight. A client who has a small child may have postural dis-
tortion from carrying the child on one hip, leading to chronic shorten-
ing in the opposite quadratus lumborum. A client who plays tennis may
have shoulder tightness, and a client who bicycles may have tightness
in gastrocnemius, soleus, and tibialis anterior. Clients who have mini-
mal levels of activity may have tightness in almost every joint.
Using efficient body mechanics greatly decreases susceptibility of
massage therapists to strain and chronically shorten soft tissues.
However, because of the physical nature of bodywork, massage thera-
pists are prone to tension and dysfunction. If an aligned spine is not
maintained, the result could be stiffness and pain in the neck and
back. If the shoulders are not relaxed, stiffness and pain in the shoul-
ders, arms, and forearms could develop. If the knees are kept locked,
stiffness and pain in the hips, thighs, knees, and lower leg could occur.
An aspect of self-care that is beneficial for both clients and massage
therapists is stretching they can perform for themselves. For clients, this
stretching helps continue the effects of the massage between sessions
and contributes to the client’s overall health and sense of well-being.
For massage therapists, performing stretches as part of a regular fitness
routine as well as between treatment sessions is a way to increase flex-
ibility and reduce the chance of injury. The stretches included in this
chapter can be used by clients and massage therapists. These stretches
can also supplement the techniques presented in Chapter 2.
105
106 Chapter 5 Stretching for Self-Care
In certain municipalities, recommending stretches may be out of

the scope of practice for massage therapy. Massage therapists should
check with their local or state regulations to see whether recom-
mending stretches for self-care is allowable.
Principles of Stretching for Self-Care

Flexibility can be developed at any age as long as stretches are
performed in the appropriate manner. The section “Guidelines for
Successful Stretching” in Chapter 2 also applies to stretching for
self-care. Additionally, the following principles are essential to
increasing flexibility:
• Stretching in one area of the body does not increase flexibility in
another area. For example, stretching the shoulder muscles does
not improve flexibility in the hips.
• All joints do not need to be targeted for self-care stretching.
Stretches can be performed on the joints and muscles that need
them the most. This way, if their time to spend stretching is lim-
ited, clients and massage therapists can maximize their efforts.
• To be effective, stretching exercises must be similar in form and
speed to the technique or skill needing improvement. Slow, static
stretching does not improve fast movements, such as those in-
volved in running or performing percussion or vibration, nearly as
well as dynamic stretching movements. Dynamic stretching
methods have limited ability to improve a static skill, such as the
slow pace involved in lifting items or techniques such as myofas-
cial release or trigger point work in massage therapy. It is ideal to
do both slow, static stretching and dynamic stretching.
Efficient and effective resistance training programs can also have
a beneficial effect on flexibility levels. Whatever level of flexibility a
person has, the primary concern should be to have adequate strength
throughout the full range of motion of any given joint. Two key
points are to perform resistance exercises through the involved joint’s
full range of motion and to work antagonistic pairs of muscles
equally. Massage therapists can consider recommending to clients to
engage in a resistance training program (if it is within the scope of
practice for the region in which they practice) along with a stretching
routine. Massage therapists may also want to consider resistance
training themselves if they do not already engage in this training.
The following section includes stretches for each region of the
body. They can be performed in the sequence presented or performed
individually, depending on the needs of the client or massage therapist.
Chapter 5 Stretching for Self-Care 107
Stretches
All of the following stretches (Figs. 5-1 through 5-58) are static
stretches.* They should be held for 20 to 30 seconds, depending on
tolerance and when the tissue releases. The techniques should be
performed on both sides of the client’s body when applicable.
B C
FIGURE 5-1 A-C, Trapezius. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
*From Muscolino J: Know the body, St. Louis, 2012, Mosby.

FIGURE 5-2 Rhomboids. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-3 Levator scapulae. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-4 Posterior deltoid. (From Muscolino J:

Know the body, St. Louis, 2012, Mosby.)
FIGURE 5-5 Infraspinatus and

teres minor. (From Muscolino J:
Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-6 Teres major and latis-

simus dorsi. (From Muscolino J:
Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-7 Supraspinatus. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-8 Anterior deltoid and pectoralis major. (From Muscolino J: Know
the body, St. Louis, 2012, Mosby.)
FIGURE 5-9 Subscapularis. (From Muscolino J:

FIGURE 5-10 Serratus anterior. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-11 Pectoralis minor. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-12 Subclavius. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-13 Sternocleidomastoid. The client

left laterally flexes and right rotates the head
and neck and then extends the lower neck
while tucking the chin in. (From Muscolino J:
FIGURE 5-14 Scalene group. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-15 Longus colli. The client’s head and neck are extended and laterally
flexed to the opposite side. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-16 Splenius capitis. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-17 Semispinalis capitis. Note: Flexion is the most important

component of this stretch. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-18 A and B, Suboccipitals. (From Muscolino J: Know the body,

FIGURE 5-19 Temporalis. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-20 Deltoid. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-21 Biceps brachii. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-22 Brachialis. The client’s elbow joint is fully extended with the
forearm in position halfway between full supination and full pronation. (From
Muscolino J: Know the body, St. Louis, 2012, Mosby.)
FIGURE 5-23 Triceps brachii. (From

Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-24 Brachioradialis. The client’s

forearm is fully extended at the elbow
joint. (From Muscolino J: Know the
body, St. Louis, 2012, Mosby.)
FIGURE 5-25 Pronator teres. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-26 Wrist flexor group. If ulnar deviation is added to the extension,
the stretch of the flexor carpi radialis is enhanced. If radial deviation is added
to the extension, the stretch of the flexor carpi ulnaris is enhanced. (From
FIGURE 5-27 Radial group. (From Muscolino J:

FIGURE 5-28 Supinator. Note: It is easy to confuse pronation of the forearm

at the radioulnar joints with medial rotation of the arm at the glenohumeral
joint. Be sure that the forearm is being pronated. (From Muscolino J: Know
FIGURE 5-29 Thenar group. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
B
FIGURE 5-30 A and B, Hypothenar group. A, Abductor digiti minimi manus.
B, Flexor digiti minimi manus and opponens digiti minimi. (From Muscolino J:
FIGURE 5-31 Adductor pollicis. (From

Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-32 Latissimus dorsi. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-33 Erector spinae group. Note: When returning to the seated posi-
tion, it is best for the client to place the forearms on the thighs, using them to
push himself or herself back up. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-34 Transversospinales group. (From Muscolino J: Know the body,

FIGURE 5-35 Quadratus lumborum. (From Muscolino J: Know the body,

FIGURE 5-36 Intercostals. Isolating the bending to the thoracic region as

much as possible is important. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-37 Rectus abdominis. The stretch of one side muscle can be en-
hanced by adding some lateral flexion to the opposite side. (From Muscolino J:
B
FIGURE 5-38 A and B, Abdominal obliques. (From Muscolino J: Know the
FIGURE 5-39 Diaphragm. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-40 Iliopsoas. Note: Keeping the trunk straight or slightly extended
is important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)
FIGURE 5-41 Gluteus maximus. Note: If the client experiences a pinching

sensation in the groin with this stretch, it is helpful either to stretch the hip
flexors (especially sartorius and iliopsoas) first before performing this stretch
or to laterally rotate and abduct the thigh at the hip joint first to untwist and
slacken the hip joint capsule. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-42 Gluteus medius and tensor fasciae latae. Note: It is important to
avoid placing too much weight on the ankle joint of the foot in back. (From
FIGURE 5-43 Piriformis. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-44 Quadratus femoris. Note: If the client experiences a pinching

sensation in the groin with this stretch, it is helpful first to stretch the hip
flexors (especially sartorius and iliopsoas) before performing this stretch or to
laterally rotate and abduct the thigh at the hip joint first to untwist and slacken
the hip joint capsule. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
FIGURE 5-45 Hamstring group. Note: The spine does not need to bend in
this stretch. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)
FIGURE 5-46 Sartorius. Note: Not allowing the pelvis to fall into an anterior tilt and
ensuring that excessive weight is not placed on the ankle joint of the foot in the
back are important. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)
FIGURE 5-47 Quadriceps femoris. Note: When performing this stretch, en-
suring that the knee joint is not rotated is important. (From Muscolino J: Know
FIGURE 5-48 Pectineus and gracilis. Note: Not allowing the pelvis to fall into
an anterior tilt and ensuring that excessive weight is not placed on the ankle
joint of the foot in the back are important. (From Muscolino J: Know the body,
FIGURE 5-49 Adductor longus. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-50 Adductor magnus. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-51 Tibialis anterior. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-52 Extensor digitorum longus. (From Muscolino J: Know the

FIGURE 5-53 Extensor hallucis longus. (From Muscolino J: Know the body,
FIGURE 5-54 Fibularis longus and fibularis brevis. (From Muscolino J: Know
FIGURE 5-55 Gastrocnemius. (From Muscolino J: Know the body, St. Louis,
2012, Mosby.)
FIGURE 5-56 Soleus. (From Muscolino J: Know the body, St. Louis, 2012,
Mosby.)
B
FIGURE 5-57 A, Extensor digitorum brevis. B, Extensor hallucis brevis. (From
C
FIGURE 5-58 A, Tibialis posterior. B, Flexor digitorum longus. C, Flexor hal-
lucis longus. (From Muscolino J: Know the body, St. Louis, 2012, Mosby.)
Glossary
Actin Thin protein filaments within myofibrils.

Active isolated stretching (AIS) Involves contracting muscles opposite
of the target muscles, using reciprocal inhibition. The target
muscles are identified and isolated by using precise, localized
movements. Developed by Aaron Mattes.
Active stretching Occurs when the person stretches himself or herself.
Active tension Occurs when a muscle’s contractile elements (actin and
myosin filaments) contract via the sliding filament mechanism,
creating a pulling force toward the center of the muscle.
Anatomic barriers Barriers to joint movement determined by the
shape and fit of the bones.
Antagonist contract (AC) Technique in which the antagonist muscle
is contracted, causing the agonist (the target muscle that is to be
stretched) to relax; this occurs through reciprocal inhibition.
Articular systems Bones and their joints and the nervous system.
Ballistic stretching A type of dynamic stretching using the momen-
tum of a moving body or a limb in an attempt to force it beyond
its normal end point. These stretches are of high force and short
duration.
Bind Limits of movement as indicated by the palpation of a
resistance barrier.
Cardinal plane Major plane. The cardinal planes are sagittal, frontal
(coronal), and transverse (horizontal).
Comfort barrier The first point of resistance before the client
perceives any discomfort at either the physiologic or the
pathologic barrier.
Concentric isotonic contraction Contraction in which the muscle
shortens.
Contract relax (CR) Stretching technique in which the target muscle
is first contracted and then relaxed; the postisometric relaxation
(PIR) period is ideal for progressing further into the stretch.
Contract relax antagonist contract (CRAC) Combination of contract
relax (CR) and antagonist contract (AC) techniques. CRAC
stretching begins with the client contracting the target muscle.
Next, the client actively contracts the antagonist muscles. When
141
142 Glossary
the client relaxes the antagonist muscles, the massage therapist

stretches the target muscle. Combining CR with AC stretching
can create an even greater stretch for the target muscles.
Coronal plane Divides the body into anterior and posterior portions;
also called frontal plane.
Counterpressure Force applied to an area that either exactly or
partially matches the effort the client is exerting. The effort
the client is exerting is through an isometric or isotonic
muscle contraction.
Cross bridges Links between the thin (actin) and thick (myosin)
filaments within a sarcomere. Cross bridges function similar to
boat oars as they reach out, attach, and pull on the thin filaments,
causing the Z disks to move toward one another. The Z disks
pull on neighboring sarcomeres, and the whole muscle fiber
shortens. The result is an overall shortening or contraction of the
muscle in response to a nerve impulse.
Cross-directional stretching Pulls the connective tissue against the
fiber direction. Involves pulling and twisting, which are torsion
and bend forces.
Diarthroses Joints that provide the greatest amount of movement;
also called synovial joints. They have a space between the bones
called a synovial cavity. This gap allows much movement at the
joint. Joints without this gap provide little or no movement.
Direct tissue stretching Targets tissues in a local area that have been as-
sessed as shortened and have binding. The two types of direct tissue
stretching are longitudinal and cross-directional. Direct tissue
stretching is used if only a small section of muscle needs to be
stretched, if the muscle does not lend itself to stretching with joint
movement, or if the joints are so flexible that not enough pull is put
on the structures to achieve an effective stretch.
Direction of ease The way the body allows for postural changes and
muscle shortening or weakening compensation patterns, depending
on its balance in gravity.
Dynamic stretching Involves moving the joints of the body through
ranges of motion instead of holding the body in a static position
of stretch. The idea is that whenever a joint is moved in a certain
direction, the tissues on the other side of the joint are stretched;
considered active.
Eccentric isotonic contraction Contraction in which the muscle
lengthens.
Elongation Extending the length of soft tissue.
Glossary 143
Endomysium Connective tissue that surrounds individual muscle

fibers.
Epimysium Connective tissue that surrounds the entire muscle.
Fascicle Muscle fibers numbering 10 to 100 grouped into a bundle
and surrounded by perimysium.
Flexibility The ability of soft tissues to yield to tension forces without
tissue damage during joint range of motion. Flexibility refers to a
joint’s mobility and how muscles, ligaments, tendons, or other soft
tissues affect it.
Frontal plane Divides the body into anterior and posterior portions;
also called coronal plane.
Horizontal plane Divides the body into superior/proximal and inferior/
distal portions; also called transverse plane.
Hypermobility An unusually large range of joint movement.
Hypertonicity Excessive muscle tone.
Hypomobility Reduced range of joint movement.
Isometric muscle contraction Contraction in which the distance be-
tween the proximal and distal (origin and insertion) attachments
of the target muscle is maintained at a constant length.
Isotonic contraction Contraction in which the muscle changes in
length.
Kinetic chain An integrated functional unit made up of myofascial systems
(muscles, ligaments, tendons, and fascia), articular systems (bones and
their joints), and the nervous system.
Lengthening A neurologic response that allows the muscles to stop
contracting and relax.
Line of tension Pulls on the target tissues, placing a stretch on them.
Longitudinal stretching Pulls connective tissue in the direction of the
fiber configuration. Performed along with movement at the joint
and gliding applied with drag in the direction of the force.
Midsagittal plane Divides the body into equal right and left halves.
Multiplane stretching Stretching a muscle across more than one
cardinal plane.
Muscle energy techniques (MET) Involve a voluntary contraction of
the client’s muscles in a specific and controlled direction, at vary-
ing levels of intensity, against a specific counterforce applied by
the massage therapist.
Muscle fiber Muscle cell; so named because of its elongated shape.
Muscle spindle Proprioceptor found in the bellies of muscles; in-
volved in stretch reflex. Muscle spindles monitor changes in
length of skeletal muscle fibers. When a muscle has stretched far
144 Glossary
enough during a particular movement, the muscle is stimulated

to contract, relieving the stretching. It prevents injury by pre-
venting overstretching, and possible tearing, of muscle tissue.
Myofascial systems Muscles, ligaments, tendons, and fascia.
Myofascial units Muscles, fascia, and associated tendons and
ligaments.
Myofibrils Threadlike structures within muscle fibers. These are the
contractile organelles of skeletal muscle, and they extend the
entire length of the muscle fiber.
Myofibroblasts Contain contractile proteins that can actively con-
tract; found in muscle tissue and fibrous connective tissue.
Myosin Thick protein filaments within myofibrils.
Neuromuscular efficiency Ability of the neuromuscular system to
allow agonists, antagonists, and stabilizers to work synergistically
to produce, reduce, and stabilize the entire kinetic chain.
Oblique plane A plane that is not purely sagittal, frontal, or transverse.
Passive stretching Occurs when a second person (the massage
therapist) applies the force to stretch the tissue.
Passive tension Results from factors affecting the natural elasticity
of a tissue, such as fascial adhesions that build up over time in
soft tissues.
Pathologic barrier An adaptation in a physiologic barrier to joint
movement; stiffness, pain, or a “catch” that acts as a protective
mechanism, signaling not to move into anatomic limits, which
could potentially result in injury.
Perimysium Connective tissue that surrounds groups of 10 to 100 or
more muscle fibers and groups them into bundles called fascicles.
Physiologic barriers Barriers to joint movement caused by the limits
imposed by nerve and sensory function.
Pin and stretch Stretching technique in which the massage therapist
pins (stabilizes) one part of the client’s body and then stretches
the tissues up to that pinned spot.
Plane A flat surface that cuts through space.
Plastic range Range of movement of connective tissue that is taken
beyond the elastic limits. The tissue permanently deforms in this
range and cannot return to its original state.
Postisometric relaxation Period after an isometric contraction during
which all neural impulses are inhibited to that muscle, allowing it to
relax.
Proprioceptive neuromuscular facilitation (PNF) Uses neuromuscu-
lar reflexes (tendon reflex and stretch reflex) to increase range
Glossary 145
of motion and to reeducate the body. Common techniques

used in PNF are contract relax and antagonist contraction
and a combination of both known as contract relax antagonist
contraction.
Proprioceptors Sensory receptors embedded in muscles, especially pos-
tural muscles, and tendons. They provide the nervous system with
information about the degree to which muscles are contracted and
the amount of tension on tendons as well as pressure on the joints,
the positions of joints, and acceleration and deceleration of joints
during movement.
Pulsed muscle energy procedures Involve engaging the comfort
barrier and using small, resisted contractions (usually 20 in
10 seconds). This method can be used both to increase stretch
tolerance in short tissues and to stimulate weak long tissue to
increase tone.
Range of motion (ROM) The range, usually expressed in degrees of a
circle, through which bones of a joint can move or be moved.
Reciprocal inhibition Neurologic reflex that creates a more efficient
joint action by preventing two muscles that have an agonist-
antagonistic relationship from contracting at the same time.
When a muscle is contracted, muscles that have antagonistic
actions are inhibited from contracting; they are relaxed.
Relaxation The lengthening of inactive, or noncontracting, muscle
fibers or muscles.
Sagittal plane Divides the body into left and right portions.
Sarcolemma Plasma membrane of a skeletal muscle fiber.
Sarcomeres Compartments that are the basic functional units of a
myofibril.
Sliding filament mechanism Method in which muscles change
length, owing to overlapping thin (actin) and thick (myosin)
filaments. The edges of the sarcomere, to which the thin fila-
ments are attached, are called Z disks. In the center of the
sarcomere are the thick strands which, during contraction,
pull the Z disks closer together by attaching to the thin fila-
ments with specialized links called cross bridges. These cross
bridges function similar to boat oars as they reach out, attach,
and pull on the thin filaments, causing the Z disks to move
toward one another. The Z disks pull on neighboring sarco-
meres, and the whole muscle fiber shortens. The result is an
overall shortening or contraction of the muscle in response to
a nerve impulse.
146 Glossary
Static stretching Slow and progressive elongation of the target

muscle by holding the stretch for 20 to 30 seconds; considered
passive.
Stretch reflex Muscle spindles, which are found in the bellies of
muscles, monitor changes in length of skeletal muscle fibers.
When a muscle has stretched far enough during a particular
movement, the muscle is stimulated to contract, relieving the
stretching. The stretch reflex prevents injury by preventing over-
stretching and possible tearing of muscle tissue.
Stretching A mechanical method that introduces various forces that
extend, expand, lengthen, and elongate soft tissues.
Synovial cavity Space between bones in synovial joints (diarthroses).
This gap allows much movement at the joint. Joints without this
gap provide little or no movement.
Synovial joints Joints that provide the most amount of movement;
also called diarthroses. They have a space between the bones
called a synovial cavity. This gap allows much movement at the
joint. Joints without this gap provide little or no movement.
Target muscle Specific muscle or muscle group being stretched.
Target tissue The tissue being stretched.
Tendon organs Proprioceptors found in the musculotendinous junc-
tion; involved in tendon reflex. Tendon organs measure tension
applied to tendons from muscle contraction. The tendon reflex
protects tendons and associated muscles from damage by causing
muscle relaxation in response to excessive tension on tendons by
muscle contraction.
Tendon reflexes Tendon organs, which are found in the musculotendi-
nous junction, measure tension applied to tendons from muscle
contraction. The tendon reflex protects tendons and associated
muscles from damage by causing muscle relaxation in response to
excessive tension on tendons by muscle contraction.
Tenosynovitis Inflammation of the protective sheath around a tendon.
Tensile Ability to withstand longitudinal stress.
Transverse plane Divides the body into superior/proximal and inferior/
distal portions; also called horizontal plane.
Z disks Edges of a sarcomere.
Index
A Body mechanics, 105

Abdominal obliques, 128f Bone disease, 10
Abductor digiti minimi manus, 123f Brachialis, 119f
Acromioclavicular joint, range of Brachioradialis, 120f
motion of, 2–5t Breath, 30–31
Actin, 17–18 Breathing, and eye movement, 85–86
Active isolated stretching (AIS), 81, 84f
Active release, 47
Active stretching, 22–23
C
Cardinal planes, 35
Active tension, 11–12
Carpometacarpal (CMC) joint, range
Adductor longus, 134f
of motion of, 2–5t
Adductor magnus, 135f
Cervical spine, range of motion of, 2–5t
Adductor pollicis, 124f
Cervicocranial region, range of motion
Aging, 6
of, 2–5t
Agonist muscle, 74
Chronic contraction, 1
Anatomic barriers, 8–9
Comfort barrier, 30
Anatomic position, average ranges of
Compensation, 13–14
motion from, 2–5t
Concentric isotonic contraction, 85
Anconeus, 44b
Connective tissue, 12–13
Ankle and foot, 68–69
Contract relax antagonist contract
dorsiflexion, 69, 69f
(CRAC), 81, 82–83f
metatarsal scissors, 69, 70f
Contract relax (CR), 74–75, 75b
plantar flexion, 69, 69f
procedure for, 75, 76–77f
pull and circumduct toes, 69, 70f
Contractures, 12
Antagonist contract (AC), 75–78
Counterpressure, 83, 95, 96f
procedure for, 78, 80f
Cross bridges, 18
Anterior deltoid, 111f
Cross-directional tissue stretching,
Arm and shoulder, 55–58
47–48, 47f
arm pull, 56–58
pulling the arm across the
chest, 57f D
pulling the arm down, 56f Deltoid, 118f
pulling the arm overhead, 58f anterior, 111f
pulling the arm to the side, 57f posterior, 109f
shoulder circles, 58, 59f Destabilization, 12
Articular capsule, 14 Diaphragm, 129f
Articular ligaments, 22 Direct tissue stretching, 41–48, 42–43f
Articular systems, 7 cross-directional, 47–48
Atlantoaxial joint, range of motion of, longitudinal, 44–47
2–5t muscles addressed by, 44b
Atlantooccipital joint, range of motion Direction of ease, 13–14
of, 2–5t Dislocation, of joint, 9
Distal interphalangeal joints, range of
B motion of, 2–5t
Bad pain, 31b Distortion, 91–94f
Ballistic stretching, 28 Dorsiflexion, 69, 69f
Biceps brachii, 119f with heel to hip, 68f
Bind, 6 with hip flexion, 66f
147
148 Index
Duration, stretching, 31–32 Hip and knee, 62–68

Dynamic stretching, 24–28, 26–27f, groin stretch, 65, 67f
31, 106 heel to hip, 65, 67f
with ankle dorsiflexion, 68f
hip circles, 63, 65f
E hip clock stretch, 63, 64f
Eccentric isotonic contraction, 85
hip flexion, 65, 66f
Elbow joint, 119f
with ankle dorsiflexion, 66f
range of motion of, 2–5t
hip hyperextension, 68, 68f
Elongation, 6–7
leg pull, 62, 63f
Endomysium, 15–17, 20
leg rock, 63, 64f
Epimysium, 15–17
Hip flexors, 130f, 132f
Erector spinae, 125f
stretch, 98f, 100
Extensor digitorum brevis, 139f
Hip joint, range of motion of, 2–5t
Extensor digitorum longus, 136f
Hip joint capsule, 130f, 132f
Extensor hallucis brevis, 139f
Hypermobility, 9
Extensor hallucis longus, 137f
Hypertension, untreated, 10
Eye movement, and breathing,
Hypertonicity, 7
85–86
Hypomobility, 9
Hypothenar, 123f
F
Fascial sheaths, 13
Fascicles, 15–17
I
Iliac crest, 72–73f
Fibularis brevis, 137f
Iliocostalis, 44b
Fibularis longus, 137f
Iliopsoas, 129f, 130f, 132f
Filaments, 17–18
Infraspinatus, 109f
Flexibility, 1–2
Integrated approach procedure, 88,
factors affecting, 5–6
91–94f
Flexion, 116f
Intercostals, 127f
Flexor carpi radialis, 121f
Interphalangeal joint, range of motion
Flexor carpi ulnaris, 121f
of, 2–5t
Flexor digiti minimi manus, 123f
Isometric contraction, 74, 85
Flexor digitorum longus, 140f
Isotonic contraction, 85
Flexor hallucis longus, 140f
Foot sole, stretching of, 98f, 102
Forearm stretching, 100 J
Frontal plane, 35, 36f Joint inflammation, 9–10
motions of body parts within, Joint kinesthetic receptors, 22
37–38f Joint movement, 33
Joints, 14–15, 16–17f
elbow, 119f
G synovial, 14
Gastrocnemius, 76–77f, 105, 138f
Glenohumeral joint, 122f
range of motion of, 2–5t K
Gluteus maximus, 130f Kinetic chain, 7
Gluteus medius, 131f
Good pain, 31b
Gracilis, 134f
L
Lateral flexion
of neck, 50, 52f
H of neck, with rotation, 50, 52f
Hamstring, 76–77f, 132f Lateral neck stretch, 97, 98f
Heel to hip, 67f Lateral torso stretch, 98f, 99
with ankle dorsiflexion, 68f Latissimus dorsi, 76–77f, 110f, 124f
Hip abductor stretch, 98f, 101 Lengthening, 6–7
Index 149
Levator scapulae, 108f O

Ligaments, 14–15 Oblique plane, 35, 36f
Line of tension, 34, 34f motions of body parts within,
Longissimus, 44b 37–38f
Longitudinal stretching, 44–47 Opponens digiti minimi, 123f
active assisted, 46 Overstretching, 33
basic, 45
separating ends of tissue, 45–46, 46f
using compression with, 46–47 P
Longus colli, 115f Pain, 105
Lumbar spine, range of motion of, Palpation, 33
2–5t Passive stretching, 22–23
Lumbosacral joints, pelvis at hip and, Passive tension, 11–12
range of motion of, 2–5t Pathologic barriers, 8–9
Pectineus, 134f
Pectoralis major, 76–77f, 111f
M stretch of, 97, 98f
Metatarsophalangeal joints, range of Pectoralis minor, 44b, 113f
motion of, 2–5t Pelvis, range of motion of, 2–5t
Midsagittal plane, 35 Perimysium, 15–17
Minimum force, 30, 31b Physiologic barriers, 8–9
Multifidus, 44b Pin and stretch, 47, 71–73
Multiplane stretching, 35–40 Piriformis, 131f
Muscle energy techniques (MET), Plane, 35
81–97 Plastic range, 13
breathing and eye movement, 85–86, Popliteus, 44b
87–88f, 89–90f Posterior deltoid, 109f
methods for, 86–95, 91–94f Postisometric relaxation, 74
principles of, 83–85 Postural distortion symptoms, 94
Muscle fibers, 15–17 Pregnancy, 10
Muscle imbalance, 6 Pronation, 119f
Muscle relaxation, 29 forearm, 122f
Muscle spindle, 21, 22f Pronator teres, 121f
Muscle stretching, 20–21 Proprioceptive neuromuscular
microscopic effect of, 20–21 facilitation (PNF), 74
Muscle tension, 29 Proprioceptors, 21–22
Muscle tissue, 15–21 Proximal interphalangeal joints, range
Muscles, 12–13 of motion of, 2–5t
Myofascia, 12 Proximal phalanx of MCP, range of
Myofascial systems, 7 motion of, 2–5t
Myofascial units, 6–7 Pulse muscle energy procedure, 95–97,
Myofibrils, 17–18 96f, 97f
Myofibroblasts, 12
Myosin, 17–18
Q
Quadratus femoris, 132f
N Quadratus lumborum, 44b, 105, 126f
Neck, 49–50 Quadriceps, 44b
forward flexion, 50, 53f Quadriceps femoris, 133f
lateral flexion, 50, 52f stretch, 98f, 101
lateral flexion with rotation,
50, 52f
neck circles, 50, 51f R
Nerve root damage, 10 Radial deviation, 121f
Neuromuscular efficiency, 7 Radial group, 122f
Neuropathy, 10 Radiating pain, 10
150 Index
Radioulnar joints, 122f Sternoclavicular joint, range of motion

range of motion of, 2–5t of, 2–5t
Range of motion (ROM), 1–2, 20–21 Sternocleidomastoid, 114f
average, from anatomic position, 2–5t Steroids, prolonged use of, 10
Reciprocal inhibition, 75–78 Stiffness, 105
procedure for, 78, 79f Stretch reflex, 21
Rectus abdominis, 127f Stretching, 107
Resistance training, 106 advanced techniques, 71–104
Rhomboids, 108f active isolated stretching, 81
ROM see Range of motion (ROM) antagonist contract, 75–78
Rotation, and neck lateral flexion, 50, contract relax, 74–75
52f contract relax antagonist
Rotatores, 44b contract, 81
examples of, 97–102, 98f
muscle energy techniques, 81–97
S pin and stretch, 71–73
Saddle joint, range of motion of, 2–5t
proprioceptive neuromuscular
Sagittal plane, 35, 36f
facilitation, 74
motions of body parts within, 37–38f
basic techniques, 29–48
Sarcolemma, 17, 20
direct tissue stretching, 41–48
Sarcomeres, 17–18
guidelines for successful stretching,
during stretch, 21f
29–32
Sartorius, 130f, 132f, 133f
reasoned out instead of
Scalene muscles, 115f
memorized, 34–41
Self-care, 105–140
reasoning and application, 33–34
Semispinalis, 44b
safe and effective stretching
Semispinalis capitis, 116f
methods, 32–33
Serratus anterior, 112f
benefits and cautions of, 7–12
Serratus posterior inferior, 44b
connective tissue, muscles and, 12–13
Serratus posterior superior, 44b
contraindications and other cautions,
Shoulder circles, 59f
9–10
Shoulder joint
definition of terms, 1–7
major categories of, 22–28
stretching, 98f, 99
other target tissues, 41
Side-lying stretch, 71, 72–73f
physiology of, 14–22
Skeletal muscles, 15–17
principles of, 1–7, 106
connective tissues and, 18f
for self-care, 105–140
structures of, 19f
static, 49–70
Sliding filament mechanism, 11–12,
target muscle, 40–41, 40b
18, 20f
Subclavius, 114f
Soft tissue
Suboccipitals, 44b, 117f
benefits of stretching on, 10–12, 11f
Subscapularis, 112f
properties of, 12–14
Subtalar joints, range of motion of, 2–5t
Soleus, 105, 138f
Supination, 119f
Soreness, 30, 33
Supinator, 44b, 122f
Spine, 58–60
Supraspinatus, 44b, 110f
Synovial cavity, 14
spinal twist, 58
Synovial joints, 14
I, 58–59, 60f
basic structure of, 15f
II, 59, 61f
III, 60, 61f
IV, 60, 62f T
Splenius capitis, 116f Talocrural joints, range of motion of,
Static stretching, 23–24, 24f, 31, 106, 107 2–5t
basic atlas of, 49–70 Target muscle, 2
basic techniques, 48 Target tissue, 2
Index 151
Temporalis, 118f Trapezius, 107f

Tendon organs, 22, 23f Triceps brachii, 120f
Tendon reflex, 22, 74 True pain, 31b
Tenosynovitis, 9 Trunk torque stretch, 98f, 102
Tensile, 14–15
Tension, 11–12
active, 11–12 U
passive, 11–12 Ulnar deviation, 121f
Tensor fasciae latae, 131f Upper trapezius, right, stretching of,
Teres major, 110f 35, 39f
Teres minor, 109f
Thenar group, 123f W
Thoracic region, 127f Warming tissues, 29–31
Thoracic spine, range of motion of, 2–5t Wrist and hand, 50–55
Thoracolumbar spine, range of motion flip wrist, 50, 53f
of, 2–5t interlace fingers and mobilization of,
Tibialis anterior, 44b, 105, 135f 50, 54f
Tibialis posterior, 140f metacarpal scissors, 54, 54f
Tibiofemoral joints, range of motion of, pull and circumduct fingers, 55
2–5t Wrist flexor, 121f
Tightness, 105
Transverse plane, 35, 36f
motions of body parts within, 37–38f Z
Transversospinales, 125f Z disks, 18

Stretching Poker Guide

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Stretching Poker Guide

Uploaded by

Copyright:

Available Formats

MOSBY’S

Writer and Consultant

Copyright © 2014 by Mosby, Inc., an affiliate of Elsevier Inc.

Vice President and Publisher: Linda Duncan

Printed in the United States

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Stretching techniques give massage therapists additional useful

1 Principles behind Stretching, 1

Benefits and Cautions of Stretching, 7

Properties of Soft Tissue, 12

Physiology behind Stretching, 14

Major Categories of Stretching, 22

2 Basic Stretching Techniques, 29

Safe and Effective Stretching Methods, 32

Reasoning and Application, 33

Direct Tissue Stretching, 41

Basic Static Stretching Techniques, 48

3 Basic Static Stretching Atlas, 49

Wrist and Hand, 50

Arm and Shoulder, 55

Hip and Knee, 62

Hip Clock Stretch, 63

Ankle and Foot, 68

4 Advanced Stretching Techniques, 71

5 Stretching for Self-Care, 105

through which bones of a joint can move or be moved. Each specific

Thumb at Saddle Joint

CMC, Carpometacarpal; MCP, metacarpophalangeal; MTP, metatarsophalangeal.

Shortened and contracted soft tissues resist lengthening and

Factors Affecting Flexibility

Lengthening is a neurologic response that allows the muscles to

Benefits and Cautions of Stretching

range of injuries, from acute to chronic, are possible. Optimally,

to limit movement protectively is called a pathologic barrier.

Contraindications and Other Cautions

inflammation, create pain, and cause further damage to the

Benefits of Stretching on Soft Tissue

tight, a decrease in ROM in extension of the thigh at the hip joint

active tension, this increased tension makes the tissue more

Properties of Soft Tissue

Connective Tissue, Muscles, and Stretching

Stretching introduces forces of bend, torsion, and tension that

Protective sensory receptors prevent any forced stretching of tissues

Physiology behind Stretching

can stretch only minimally, stretching the surrounding soft tissues

and strengthen muscle tissue. The outermost layer is epimysium,

called actin, and thick filaments, made of a protein called myosin.

Thick filament Thin filament

FIGURE 1-5 ​A-D, Microscopic structures of skeletal muscle. (From Patton K,

INTERMEDIATE CONTRACTING STAGE

Microscopic Effect of Stretching a Muscle

H zone I band A band

adopt a new habitual resting position, lengthening the sarcomere.

tolerance of the muscle tissue. This approach can be thought of as

Major Categories of Stretching

therapist) applies the force to stretch the tissue. Passive stretching

releasing are usually recommended. Static stretches are performed

is moved in a certain direction, the tissues on the other side of the

previously recommended 3 repetitions. As the method of static

Guidelines for Successful Stretching

Warming the Tissues

soft tissue facilitates stretching because heat soothes the central

Spotlight BOX 2-1

(From Muscolino JE: Kinesiology, ed 2, St. Louis, 2011, Mosby.)

FIGURE 1-5 A-D, Microscopic structures of skeletal muscle. (From Patton K,

FIGURE 3-27 Hip hyperextension. (From Salvo SG: Massage therapy

FIGURE 4-3 A, The client actively left

FIGURE 4-11 Example of pulsed muscle energy to stimulate weak, inhibited