10 stretch the Latissimus Dorsi Muscle anual Stretch patient position and procedure: Supine, inees flexed so the pelvis is stabilized in ; jinecessary, provide additional st onc hand. With the other hand, with hips and “11a posterior pelvic tilt abilization to the pelvis with rasp the di flex, laterally rotate, and partially abduct ree Ner i end of the available range. Have the patient contract into extension, adduction, and medial rotation while Providing resistance for a hold—relax maneuver, During the relaxation phase, elongate the muscle (see Fig, 4.16 B), Self-Stretch « Patient position and procedure: Hook-lying with the pelvis stabilized in a posterior pelvic tilt and the arms flexed, lat- erally rotated, and slightly abducted overhead as far as pos- sible (thumbs pointing toward floor). Allow gravity to provide the stretch force. Instruct the patient not to allow the back to arch. Patient position and procedure: Standing with back toa wall and feet forward enough to allow the hips and knees to par- tially flex and flatten the low back against the wall, with ie arms in a “hold-up” position (abducted 90" and tat rotated 90)° if possible). Tell the patient to slide the a the hands up the wall as far as possible without allowing. the back to arch. lower trapezius 7 ; fe the | Note: This exercise is also used to activat "i opress the “ serratus anterior, as they upwardly rotate an “alae during humeral abduction. Scanned with CamScannerFIGURE 17.30 Active stretching of the pectoralis major muscle. The therapist gently pulls the elbows posteriorly while the patient breathes in and then holds the elbows at the end point as the patient breathes out. PRECAUTION: Hyperventilation should not occur, because the breathing is slow and comfortable. If the patient does be- come dizzy, allow time to rest; then reinstruct for proper tech- nique. Be sure the patient maintains the head and neck in the neutral position, not forward. Scanned with CamScannerFIGURE 17.31 Self-stretching the pectoralis major muscle with the arms in a teverse-T position to stretch jonandih a Véposition to stretch (B) the sternal portion etch (A) the clavicular portion Scanned with CamScanner\ | K a FIGURE 17.32 Wand exercises to stretch the pectoralis major muscle. Scanned with CamScanner. — The FIGURE 17.33 Active Stretching of the pectoralis minor muscle. therapist holds the scapi int as ular and coracoid process at the end poin the patient breathes out see a Scanned with CamScannerSelf-Stretch Patient position and procedure: Standing with the involved humerus at 90° abduction and elbow at 90° flexion and the fore- arm stabilized against a doorway. Instruct the patient to rotate the trunk away from the involved shoulder until a stretch is Scanned with CamScannergat. Nove that this stretch may not be appropriate for patients withanterior instability, as this is their position of apprehension and it may overly strain the anterior GH joint restraints, Scanned with CamScannerFIGURE 17.34 Stretching of the levator scapulae muscle. The ther- apist stabilizes the head and scapula as the patient breathes in, con- acting the muscle against the resistance. As the patient ti rib cage and scapula depress, which stretches the MUSCIE. Scanned with CamScannerFIGURE 17.35 Self-stretching of the levator scapulae muscle (A) using upward rotation of the scapula and (B) using depression of the scapula. Scanned with CamScannerTo Stretch the Upper Trapezius Muscle Manual Stretch = Patient position and procedure: Sitting with the ipsilateral hand behind the back to stabilize the scapula and the head rotated to the tight side. Stand behind the patient and apply the stretch by adding a combination of cervical flexion, fur- ther rotation to the tight side, and side bending away from the tight side. A more aggressive manual stretch can be performed by using the other hand to depress the distal clavicle and the scapula. PRECAUTION: Applying a stretch force against the head should not be done if the patient has cervical ao" Scanned with CamScannerFIGURE 17.36 Self-stretching of the upper trapezius muscle. Scanned with CamScannerManual Stretch: Biceps Brachii Patient position and procedure: Prone with the elbow in end-range but comfortable extension and forearm in prona- tion, Stabilize the seapula and passively extend the shoulder. Mechanical Stretch: Biceps Brachii Patient position and proc Supine with a light cuff ight around the distal forearm and the elbow in extension and forearm in pronation, Have the patient stabilize the prox- imal humerus with the opposite hand and then place the arm over the side of the table, Allow the elbow and shoulder to ex- tend as far as possible and sustain the stretch position for an extended period of time (Fig. 18,7 A) Self-Stretch: Biceps Brachii Patient position and procedure: Standing at the side of a table. Have the patient grasp the edge of the table and walk forward, causing shoulder extension with elbow extension FIGURE 18.7 Self-st unit includes Scanned with CamScannerSelf-Stretch: Long Head of Triceps Patient position and procedure: Sitting or standing. Haye the patient flex the elbow and shoulder as far as possible, The other hand can either push on the forearm to flex the elbow, or push the shoulder into more flexion (Fig. 18.8). Hold the stretch position as long as tolerated. TITAN TETANY Scanned with CamScannerTo increase Forearm Pronation and Supination Patient position and procedure: Sitting with the elbow flexed to 90° stabilized against the side of the trunk or sup- ported ona table. It is important to maintain the elbow posi- tion to prevent shoulder rotation. Self-Stretch to Increase Pronation Have the patient grasp the dorsal surface of the involved fore- arm so the heel of the uninvolved hand is against the dorsal as- pect of the radius just proximal to the wrist and wrap the fingers around the ulna. Have the patient passively pronate the forearm and sustain the stretch as long as tolerated. The force 'S applied against the distal radius and not the carpals to avoid trauma to the wrist. Scanned with CamScannerelf stretch to Increase Supj yave the patient place the heel ipination the volar aspect of the involved the unin wrist, passively sul i lus j gslong as volerated, ma ane forearm, and na : dius, not the carp als to a re the force is applied ag the stretch void trauma to the wrist (Fi the ra- ig. 18.9). oe hand against Proximal to the tion. The fore- into supinal e patient's side. E 18.9 Self-stretchi i oH ing the forearm | pieblized ona table (as picture ta maintain elbow flexion to pr 2 stretch force against the rad event shoulder rotation ius, not the hand. Scanned with CamScannerFigi URE 18.10 Self-stretching the wrist extensor muscles. Scanned with CamScannerStretching Techniques for the Intrinsic and Multijoint Muscles Self-Stretching the Lumbricals and Interossei Muscles Have the patient actively extend the MP joints, flex the IP joints, and apply a passive stretch force at the end of the range with the opposite hand (Fig. 19.20A). FIGURE 19.20 Self-stretching (A) the lumbricals with MP extension and IP flexion and (B) the adductor pollicis with CMC abduction of the thumb. To increase thumb abduction, it is critical that the stretch force is applied against the metacarpal head, not the proximal or distal phalanges. Scanned with CamScannerSelf-Stretching the Interossei Muscles Have the patient place the hand flat on a table with the palm down and the MP joints extended. Instruct the patient to abduct or adduct the appropriate digit and apply the stretch force to the distal end of the proximal phalanx. Holding the adjacent digit provides stabilization. Self-Stretching the Adductor Pollicis Have the patient rest the ulnar border of the hand on the table and palmarly abduct the thumb. Instruct the patient to apply the stretch force with the crossed thumb and index or long finger of the other hand against the metacarpal head of the thumb and index finger and attempt to increase the web space (Fig. 19.20 B). PRECAUTION: Itis critical that the patient does not apply the stretch force against the proximal or distal phalanx. This places stress on the ulnar collateral ligament of the MP joint of the thumb and can lead to instability at that joint and poor func- tional use of the thumb. Palmar and radial abduction occur at the CMC joint at the articulation between the metacarpal and the trapezium. Scanned with CamScannerManual Stretching of the Extrinsic Muscles Because they are multijoint muscles, the final step ina stretch- ing progression is to clongate cach tendon of the extrinsic muscles over all the joints simultancously. However, do not initiate stretching procedures in this manner because joint compression and damage can occur to the smaller or less stable joints. Begin by allowing the wrist and more proximal finger joints to relax; stretch the tendon unit over the most distal joint first. Stabilize the distal joint at the end of the range, and then stretch the tendon unit over the next joint. Next, stabilize the two joints and stretch the tendon over the next joint. Progress in this manner until the desired length is reached, PRECAUTION: Do not let the PIP and MP joints hyperextend as the tendons are stretched over the wrist. Self-Stretching the Flexor Digitorum Profundus and Superficialis Have the patient begin by resting the palm of the involved hand on a table; then extend the DIP joint, using the other hand to straighten the joint. While keeping it extended, have the patient straighten the PIP and MP joints in succession. If the patient can actively extend the finger joints to this point, the motion should be performed unassisted. With the hand stabilized on the table, have the patient then begin to extend the wrist by bringing the arm up over the hand. The patient moves just to the point of feeling discomfort, holds the Posi- tion, and then progresses as the length increases (Fig. 19.21). Scanned with CamScannerFIGURE 19.21 Self-stretching of the extrinsic finger flexor mus- cles, showing stabilization of the small distal joints. To isolate stretch to the wrist flexors, allow the fingers to flex over the edge of the table. Self-Stretching the Extensor Digi The fingers are flexed to the maximum range, beginning with the most distal joint first and progre the wrist i Scanned with CamScannerqechniques to Stretch Range-Limiting, qwo-!oint Muscles rect’ 5 Femoris Stretches noTE ~ "erectus femoris is the only 2-joint component of the quadri: 20S femoris muscle group. It is elongated using hip extension while maintaining the knee in flexion. "Thomas Test” Stretch Patier:t position and procedure: Supine with the hips near the end of the treatment table, both hips and knees flexed, and the thigh on the side opposite the tight hip held against the chest with the arms. While keeping the knee flexed, have the patient lower the thigh to be stretched toward the table in a controlled manner. Do not allow the thigh to externally rotate or abduct. Direct the patient to let the weight of the leg Produce the stretch force and to relax the tight muscles at the cnd of the range. The patient can attempt to further extend the hip by contracting the extensor muscles (see Fig. 20.10 but with the knee flexed). Scanned with CamScannerNOTE: This is the same stretch used to increase hip extension— xcept to stretch the rectus femoris, the knee Is kept flexed so the range for hip extension is less. Prone Stretch Patient position and procedure: Prone with the knee flexed on the side to be stretched, Have the patient grasp the ankle on that side (or place a towel or strap around the ankle to pull on) and flex the knee. As the muscle increases in flexibility, place a small folded towel under the distal thigh to further extend the hip. NOTE: Do not allow the hip to abduct or externally rotate or allow the spine to hyperextend. Standing Stretch Patient position and procedure: Standing with the hip extended and knee flexed and grasping the ankle. Instruct the Patient to maintain a posterior pelvic tilt and neutral hip abduction/adduction and not allow the back to arch or side bend during this stretch (Fig. 20.16). FIGURE 20.16 Self-stretching of the rectus femoris while standing, The femur is kept in line with ix Care must be taken to main- tain a postenor PT and not arch or twist the back. Scanned with CamScannerNOTE: If the rectus femoris is too tight to stretch safely in this manner, the patient may place his or her foot on a chair or bench located behind the body rather than grasping the ankle. Hamstrings Stretches NOTE: The two-joint hamstring muscle group is stretched by flexing the hip while maintaining the knee in extension. Straight Leg Raising Patient position and procedure: Supine with a towel behind the thigh. Have the patient perform an SLR of the Scanned with CamScannerrestricted extremity by ma and flexing the hip, a into more flexion, intaining the knee in extension ind pulling on the towel to move the hip Hamstrings Stretch in Doorway Patient position and procedure: Supine, on the floor, with one leg through a doorway and the other leg (the one to be stretched) propped up against the door frame. For an effective stretch, the pelvis and opposite leg must remain on the floor with the knee extended. ® To incre the streich when the patient is able, have the Patient move the buttock closer to the doorframe, keeping the knee extended (Fig. 20.17 A). ® Teach the patient to perform the hold-relax/agonist con- traction technique by pressing the heel of the leg being stretched against the doorframe, causing an isometric con- traction, relaxing it, then lifting the leg away from the frame (Fig. 20.17 B). FIGURE 20.17 Self-stretching of the hamstring muscles. Additional Stretch can occur if the person either (A) moves the buttock closer tothe door frame or (B) lifts the leg away from the doorframe. Scanned with CamScannerFIGURE 20.18 Self-stretching the hamstring muscles by leaning te trunk toward the extended knee, flexing at the hips. “ -] = Alternate position: Standing with the extremity to be stretched on a stool or the seat of a chair. Have the patient lean the trunk forward toward the thigh, keeping the back stabilized in neutral so that motion is only at the hip joint Bilateral Toe Touching NOTE: Bilateral toe touching exercises are often used © stretch the hamstring muscles in exercise classes. tis impc tant to recognize that having the patient reach for the toes does not selectively stretch the hamstrings but stretches ve low back and mid-back as well. Toe touching is consider general flexibility exercise and tends to mask shortening ost tissues in one region and overstretch areas already flex Whether a person can touch the toes depends on! any (e.g., body type; arm, trunk, and leg length; ‘er racic and lumbar regions; and hamstring and gas! length). Scanned with CamScannersor rasciae Latae ang Nioti wees “i bial Ban sf - The tensor fasciae latae (TFL) Inserts into the tot ma which inserts into the extensor mechani the iliotibial AM jaot the knee. THe TELS ahip flexor, abauenns eo ter or, for an effective stretch, all three com, or, and internal yo esse IN addition, for an effective sieton of Must be ir band must De positioned across the sreater one and te knee must be flexed, Adding knee flexion atlates hanter av more aggressive technique that m ages ay al H eetveness of TFL stretches, Y also enhance the el spine stretch patient position and procedure: Supine with two pillows under the hips and back to position the hips in extension. Instruct the patient to cross the uninvolved extremity over the top of the involved extremity, so the involved thigh has room t» move into adduction and internal rotation. The foot of the uninvolved extremity is placed lateral to the knee of the adducted thigh and assists in holding the stretch position (Fig. 20.19). FIGURE 20.19 self-stretching ofthe tensor fascia latae: SUPE Filows support the spine and pelvis, allowing ie ea and external ' . Crossed-over foot stabilizes the femur in addu ‘Otation. Scanned with CamScannerFIGURE 20.20 Self-stretching of the tensor fascia latae: side-lying. (A) The thigh is abducted in the plane of the body; then it is extended and externally rotated, then slowly lowered. Additional stretch occurs by flexing the knee. (B) Progress the intensity of a sustained stretch by pulling the hip into extension with a strap and adding 4 weight. Scanned with CamScannerFIGURE 20.21 Self-stretching of the tensor fasciae latae: stand- ing. The pelvis shifts toward the tight side with a slight side bend of the trunk away from the tight side. Increased stretch occurs when the extremity is positioned in external rotation prior to the stretch. Scanned with CamScannerFIGURE 21.20 Self-stretching on a step to increase knee flexion. The patient places the foot of the involved side on a step, then rocks for- ward over the stabilized foot to the limit of knee flexion to stretch the quadriceps femoris muscle. A higher step is used for greater flexion. PRECAUTION: Do not allow the patient to move into a posi- tion that causes pinching at the anterior aspect of the ankle. Scanned with CamScannerFIGURE 21.21 Self-stretching in a chair to increase knee flexion. Tne patient fixates the foot of the involved leg on the floor and then moves forward in the chair over the stabilized foot to place a sus- tained stretch on the quadriceps femoris muscle and increase knee flexion. Scanned with CamScannerScanned with CamScannergcAUTION: This stretch ma ee use it requires that the ¥ Create m j Uscle C Patien: Oreness action of the plantarflexors, COMO! an eccentric "Cure 22.9 Self-stretching the gastrocnemius muscle to increase “Ke dor Sewn Scanned with CamScannerFIGURE 22.10 Self-stretching the ankle and foot into inversion by pulling with the medial side of the towel. Scanned with CamScanner