The Hip: Special Considerations
Because muscles of the hip attach to the pelvis or lum- bar spine, the pelvis must always be stabilized when lengthening muscles about the hip. If the pelvis is not stabilized, the stretch force is transferred to the lumbar spine, in which unwanted compensatory motion then occurs.
Flexion of the Hip
To increase flexion of the hip with the knee flexed (stretch
the gluteus maximus).
Hand Placement and Procedure
Flex the hip and knee simultaneously.
Stabilize the opposite femur in extension to prevent pos- terior tilt of the pelvis.
Move the patient’s hip and knee into full flexion to lengthen the one-joint hip extensor.
Flexion of the Hip with Knee Extension
To increase flexion of the hip with the knee extended
(stretch the hamstrings) (Fig. 4.25).
A
B
FIGURE 4.25 (A, B) Hand placement and stabilization of the opposite femur to stabilize the pelvis and low back for stretching procedures to increase hip flexion with knee extension (stretch the hamstrings) with the therapist stand- ing by the side of the table or kneeling on the table.
Alternate Therapist Position
Kneel on the mat and place the patient’s heel or distal tibia against your shoulder. Place both of your hands along the anterior aspect of the distal thigh to keep the knee extend- ed. The opposite extremity is stabilized in extension by a belt or towel around the distal thigh and held in place by the therapist’s knee.
Extension of the Hip
To increase hip extension (to stretch the iliopsoas)
(Fig. 4.26).
Alternate Position
The patient can lie prone (Fig. 4.27).
100 MANUAL STRETCHING TECHNIQUES IN ANATOMICAL PLANES OF MOTION
FIGURE 4.26 Hand placement and stabilization of the pelvis to increase extension of the hip (stretch the iliopsoas) with the patient lying supine. Flex- ing the knee when in this position also elongates the rectus femoris.
Patient Position
Have the patient close to the edge of the treatment table so the hip being stretched can be extended beyond neutral. The opposite hip and knee are flexed toward the patient’s chest to stabilize the pelvis and spine.
Hand Placement and Procedure
Stabilize the opposite leg against the patient’s chest with one hand, or if possible have the patient assist by grasp- ing around the thigh and holding it to the chest to pre- vent an anterior tilt of the pelvis during stretching. Move the hip to be stretched into extension or hyperex- tension by placing downward pressure on the anterior aspect of the distal thigh with your other hand. Allow the knee to extend so the two-joint rectus femoris does not restrict the range.
FIGURE 4.27 Hand placement and stabilization to increase hyperextension of the hip with the patient lying prone.
Hand Placement and Procedure
Support and grasp the anterior aspect of the patient’s distal femur.
Stabilize the patient’s buttocks to prevent movement of the pelvis.
Extend the patient’s hip by lifting the femur off the table.
Extension of the Hip with Knee Flexion
To increase hip extension and knee flexion simultaneously
(stretch the rectus femoris).
Patient Position
Use either of the positions previously described for increasing hip extension in the supine or prone positions (see Figs. 4.26 and 4.27).
Hand Placement and Procedure
With the hip held in full extension on the side to be stretched, move your hand to the distal tibia and gently flex the knee of that extremity as far as possible. Do not allow the hip to abduct or rotate.
Abduction of the Hip
To increase abduction of the hip (stretch the adductors)
Hand Placement and Procedure
Support the distal thigh with your arm and forearm. Stabilize the pelvis by placing pressure on the opposite anterior iliac crest or by maintaining the opposite lower extremity in slight abduction.
Abduct the hip as far as possible to stretch the adductors. N O T E : You may apply your stretch force cautiously at the medial malleolus only if the knee is stable and pain-free. This creates a great deal of stress to the medial supporting structures of the knee and is generally not recommended by the authors.
Adduction of the Hip
To increase adduction of the hip [stretch the tensor fasciae
latae and iliotibial (IT) band] (Fig. 4.29).
FIGURE 4.29 Patient positioned side-lying. Hand placement and procedure to stretch the tensor fasciae latae and IT band.
A
FIGURE 4.30 (A) Hand placement and stabilization of the pelvis to increase external rotation of the hip.
FIGURE 4.28 Hand placement and stabilization of the opposite extremity (or pelvis) for the stretching procedure to increase abduction of the hip.
Patient Position
Place the patient in a side-lying position with the hip to be stretched uppermost. Flex the bottom hip and knee to stabilize the patient.
Hand Placement and Procedure
Stabilize the pelvis at the iliac crest with your proximal hand.
Flex the knee and extend the patient’s hip to neutral or into slight hyperextension, if possible.
Let the patient’s hip adduct with gravity and apply an additional stretch force with your other hand to the lateral aspect of the distal femur to further adduct the hip.
N O T E : If the patient’s hip cannot be extended to neutral, the hip flexors must be stretched before the tensor fasciae latae can be stretched.
External Rotation of the Hip
To increase external rotation of the hip (stretch the internal
rotators) (Fig. 4.30A).
Patient Position
Place the patient in a prone position, hips extended and knee flexed to 90⬚.
Hand Placement and Procedure
Grasp the distal tibia of the extremity to be stretched. Stabilize the pelvis by applying pressure with your other hand across the buttocks.
Apply pressure to the lateral malleolus or lateral aspect of the tibia, and externally rotate the hip as far as possible.
Alternate Position and Procedure
Sitting at the edge of a table with hips and knees flexed to 90⬚.
Stabilize the pelvis by applying pressure to the iliac crest with one hand.
Apply the stretch force to the lateral malleolus or lat- eral aspect of the lower leg, and externally rotate the hip.
N O T E : When you apply the stretch force against the lower leg in this manner, thus crossing the knee joint, the knee must be stable and pain-free. If the knee is not stable, it is possible to apply the stretch force by grasping the distal thigh, but the leverage is poor and there is a tendency to twist the skin.
Internal Rotation of the Hip
To increase internal rotation of the hip (stretch the external
rotators) (Fig. 4.30B).
Patient Position and Stabilization
Position the patient the same as when increasing external rotation, described previously.
Hand Placement and Procedure
Apply pressure to the medial malleolus or medial aspect of the tibia, and internally rotate the hip as far as possible.
The Knee: Special Considerations
The position of the hip during stretching influences the flexibility of the flexors and extensors of the knee. The flexibility of the hamstrings and the rectus femoris must be examined and evaluated separately from the one-joint muscles that affect knee motion.
Knee Flexion
To increase knee flexion (stretch the knee extensors)
(Fig. 4.31).
102 MANUAL STRETCHING TECHNIQUES IN ANATOMICAL PLANES OF MOTION
B
FIGURE 4.30 (continued)(B) Hand placement and stabilization of the pelvis to increase internal rotation of the hip with the patient prone.
FIGURE 4.31 Hand placement and stabilization to increase knee flexion (stretch the rectus femoris and quadriceps) with the patient lying prone.
Patient Position
Have the patient assume a prone position.
Hand Placement and Procedure
Stabilize the pelvis by applying downward pressure across the buttocks.
Grasp the anterior aspect of the distal tibia, and flex the patient’s knee.
P R E C A U T I O N : Place a rolled towel under the thigh just above the knee to prevent compression of the patella against the table during the stretch. Stretching the knee extensors too vigorously in the prone position can trauma- tize the knee joint and cause swelling.
Alternate Position and Procedure
Have the patient sit with the thigh supported on the treat- ment table and leg flexed over the edge as far as possible.
Patient Position
Place the patient in a prone position and put a small, rolled towel under the patient’s distal femur, just above the patella.
Hand Placement and Procedure
Grasp the distal tibia with one hand and stabilize the but- tocks to prevent hip flexion with the other hand.
Slowly extend the knee to stretch the knee flexors.
End-Range Knee Extension
To increase end-range knee extension (Fig. 4.33).
Stabilize the anterior aspect of the proximal femur with one hand.
Apply the stretch force to the anterior aspect of the distal tibia and flex the patient’s knee as far as possible. N O T E : This position is useful when working in the 0⬚ to 100⬚ range of knee flexion. The prone position is best for increasing knee flexion from 90⬚ to 135⬚.
Knee Extension
To increase knee extension in the midrange (stretch the
knee flexors) (Fig. 4.32).
FIGURE 4.32 Hand placement and stabilization to increase mid-range knee extension with the patient lying prone.
FIGURE 4.33 Hand placement and stabilization to increase terminal knee extension.
FIGURE 4.34 Hand placement and procedure to increase dorsiflexion of the ankle with the knee extended (stretching the gastrocnemius).
Patient Position
Patient assumes a supine position.
Hand Placement and Procedure
Grasp the distal tibia of the knee to be stretched. Stabilize the hip by placing your hand or forearm across the anterior thigh. This prevents hip flexion during stretching.
Apply the stretch force to the posterior aspect of the dis- tal tibia, and extend the patient’s knee.
The Ankle and Foot: Special Considerations
The ankle and foot are composed of multiple joints. Con- sider the mobility of these joints (see Chapter 5) as well as the multijoint muscles that cross these joints when increas- ing ROM of the ankle and foot.
Dorsiflexion of the Ankle
To increase dorsiflexion of the ankle with the knee
extended (stretch the gastrocnemius muscle) (Fig. 4.34).
Hand Placement and Procedure
Grasp the patient’s heel (calcaneus) with one hand, maintain the subtalar joint in a neutral position, and place your forearm along the plantar surface of the foot. Stabilize the anterior aspect of the tibia with your other hand.
Dorsiflex the talocrural joint of the ankle by pulling the calcaneus in an inferior direction with your thumb and fingers while gently applying pressure in a superior direction just proximal to the heads of the metatarsals with your forearm.
To increase dorsiflexion of the ankle with the knee flexed (stretch the soleus muscle). To eliminate the effect
of the two-joint gastrocnemius muscle, the knee must be flexed. Hand placement, stabilization, and stretch force are the same as when stretching the gastrocnemius.
P R E C A U T I O N : When stretching the gastrocnemius or soleus muscles, avoid placing too much pressure against the heads of the metatarsals and stretching the long arch of the foot. Overstretching the long arch of the foot can cause a flat foot or a rocker-bottom foot.
Plantarflexion of the Ankle
To increase plantarflexion of the ankle.
Hand Placement and Procedure
Support the posterior aspect of the distal tibia with one hand.
Grasp the foot along the tarsal and metatarsal areas. Apply the stretch force to the anterior aspect of the foot, and plantarflex the foot as far as possible.
Inversion and Eversion of the Ankle
To increase inversion and eversion of the ankle. Inversion
and eversion of the ankle occur at the subtalar joint as a component of pronation and supination. Mobility of the subtalar joint (with appropriate strength) is particularly important for walking on uneven surfaces.
Hand Placement and Procedure
Stabilize the talus by grasping just distal to the malleoli with one hand.
Grasp the calcaneus with your other hand, and move it medially and laterally at the subtalar joint.
Stretching Specific Muscles of the Ankle and Foot
Hand Placement and Procedure
Stabilize the distal tibia with your proximal hand. Grasp around the foot with your other hand and align the
motion and force opposite the line of pull of the tendons. Apply the stretch force against the bone to which the muscle attaches distally.
• To stretch the tibialis anterior (which inverts and dor- siflexes the ankle): Grasp the dorsal aspect of the foot across the tarsals and metatarsals and plantarflex and abduct the foot.
• To stretch the tibialis posterior (which plantarflexes and inverts the foot): Grasp the plantar surface of the foot around the tarsals and metatarsals and dorsiflex and abduct the foot.
• To stretch the peroneals (which evert the foot): Grasp the lateral aspect of the foot at the tarsals and metatarsals and invert the foot.
Flexion and Extension of the Toes
To increase flexion and extension of the toes. It is best to
stretch any musculature that limits motion in the toes indi- vidually. With one hand, stabilize the bone proximal to the restricted joint, and with the other hand move the phalanx in the desired direction.