Stretching Practices

Posted In: Flexibility

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        tscm on #18226

        Research on static stretching is plentiful and it is likely to be strongly complementary to strength training. Unfortunately, it is quite boring to most and unlike resistance training little attention is paid to posture, form or aspects of loading progression: Range of MotionXTimeXSets. Rather than a research review I have detailed my practical suggestions for static stretching with examples of how they apply to stretching the gastroc/soleus, hip flexors/quads and piriformis.

        General Principles for Stretching:

        1. Let initial testing guide the dose

        Stabilise (the pelvis) and judge the tension at a certain ROM, in the style of Thomas test, Ober’s test, FABER test etc. Don’t go for ROM that simply isn’t there on testing or there will be inevitable compensations, and look 3d e.g. lateral deviation on a Thomas test or Ober’s test means less sagittal ROM in a hip flexor stretch is possible with good alignment. Ironically athletes will often stretch problem areas in big volume but bad posture is only making things worse for them and giving overload for a new injury.

        2. Think about and control the movement and environment – Note muscle attachments and orientation, avoid deviations in pelvis/knee/ankle/foot position which alter orientation of attachments.

        3. Don’t be a slave to gravity

        Change the position and/or employ external equipment until you are in control. Taking time to find the right position is worth it as static stretching is a daily, long term investment.

        4.Keep the pelvis in check

        Pelvic tilt and rotation (most muscles are stretched unilaterally) matter a lot as a lot of muscle attachments are to pelvic landmarks. Keep the pelvis and lumbar region square and keep the pelvis tall. Use palpation where necessary, with a standing position and neutral pelvis as a reference for changes in alignment.

        5. Watch out for tibiofemoral rotation

        Subtle rotation (often sourced from the foot) has big consequences for muscle length, especially in the notorious myofascial region of the lateral hip, thigh and knee. If alignment is good, there will often be stronger sensation in TFL and on lateral border of rectus femoris in certain stretches, patella alignment with knee and hip will be enhanced and vastus medialis will feel longer and closer to a more medial patella. Again palpation is useful with a neutral standing position with neutral pelvis used as a reference for changes in alignment.

        6. Be aware of Foot Position

        Keep the MLA up and be careful of pressure anterior/posterior and also medial/lateral, foot posture can easily be lost with a lack of concentration and lead to consequences for tibiofemoral rotation, and subsequently hip alignment.

        7. Give Cues and Specific Instruction

        Static stretching is static, and very boring to most. Athletes are likely to concentrate on rear foot posture in a heavy lunge but a hip flexor stretch on floor, a wall or bench it is static and low load so attention goes out the window. Running through cues at given time intervals can help, as can permanent focus on particular cues for the more mentally robust. Athletes often have clear routines to get correct posture before attempting a heavy bench press and squat and will not lift until they are sure and comfortable, and the same diligence to preparation of position should be applied to static stretching.

        8. Sequencing matters

        There is little point in working on gastroc/soleus ROM and then going to a hip flexor stretch where the dorsal aspect of the rear foot is flush to the floor and the achilles shortened severely. Similarly, it is likely best to stretch the piriformis and other hip rotators related to the lateral myofascial mess of the ITB/TFL/piriformis before moving on to rectus femoris/quad/hamstring work.

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        tscm on #115250

        Static Stretching of the Soleus and Gastrocnemius muscles
        (Diagrams in attachment)

        As Carl has pointed out in the past, maintenance of the medial longitudinal arch (MLA) is crucial when performing stretches for ankle range of motion. In conventional standing stretches, the foot is flat to the floor and the subject steps forward to achieve dorsiflexion of the rear ankle. This can result in a great deal of force being applied as the weight of the body is ahead of the foot while the gastroc and soleus muscles are in a weak position, leading to easy loss of MLA height and foot/ankle posture, and the same can be said for knee to wall stretches where the weight is going forward aggressively.

        One solution I recommend is the use of a stretching wedge to achieve dorsiflexion without as much strain due to gravity. I like the use of relatively long duration stretches for the gastroc and soleus, but the reality is that for most concentration is difficult to maintain in static stretching due to the static and seemingly mindless nature of the task. This is a big problem as lack of concentration can lead to loss of technique (in this case MLA height) and long duration stretching of ligaments which is not desirable.

        I must give credit to a trial involving patients with posterior tibial tendinopathy from Kornelia Kulig et al ( ) for highlighting this idea to me. While the subjects in the trial will possess much greater anterior and central weight distribution than athletic populations, resulting in a greater effect of gravity, I think the idea is quite valid. The figure from trial is this one:

        I prefer to see the free leg stand lateral to or slightly behind the wedge for soleus stretching to increase precision through decreasing gravitational issues (it is easy apply enough force to get a stretch), and so the tracking of the knee over the foot can be visually monitored. The gradient of the wedge should be appropriate to the level of mobility.

        A FAQ is whether calf stretching with heel off a step is equivalent to the wedge, and the answer is no as overall foot posture and orientation of the plantar fascia enhances posture and neural quailties with a full foot contact on a wedge. The MTP will hyperextend with the MTP as a fulcrum for the stretch (see file attached to post). Additionally we are leaving gravity to drop the heel, control the movement and alter MLA height. MTP kinematics is crucial in sprinting and I prefer to control their movement closely rather than be at the mercy of gravity.

        Initial tests: Manual testing of dorsiflexion with sub talar joint stabilized by a therapist, and knee to wall tests (goniometry or cm) with very strict control of MLA height can guide starting position and inclination of wedge/slant board. Soleus in particular is very Type I dominant, and long-duration low intensity work can be useful.

        Respecting attachments:

        Tibialis posterior is a strong inverter. Due to this and other factors, turning the foot out is not advised for triceps surae stretching and Kulig choses a straight leg posture and knee to wall tests call for a straight alignment of heel to toe and tracking of the knee straight ahead.

        Control vs Gravity: A wedge/slant board is advised for support of both the MTP and ankle joints, and a change in moment of inertia of the tibia as well as the rest of the body. A stance with the resting leg behind the wedge should be used initially to allow knee tracking to be monitored. As range and technique improves moving toward the front may be possible.

        Key compensations: Loss of MLA height, knee tracking too far laterally or medially with reference to the foot.

        Cues: Tall arch, tall hip, open hip, open ankle, straight heel-toe.

        Sequencing: I generally prefer to perform triceps surae stretching last as many ground based stretches push the ankle into undesirable positions (though changing these positions as per below can help). Soleus is an important postural muscle with high Type I content so long duration stretches are indicated and changes to day to day postures e.g. arch height during sitting and introduction of orthoses/heel lifts can be important.

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        tscm on #115251

        Hip Flexor Stretching (I)

        In a conventional hip flexor stretch, I often see much undesirable compensation occur in a search to feel big tension on the psoas or as one coach who will remain nameless has put it, make it feel like it is “tearing off the bone”. Most Thomas tests show a great deal more rectus femoris and TFL issues than psoas and hip hyperextension is not indicated for improved athletic performance. A standard half kneeling position with knee and hip angles of 90 degrees, is often beyond the limits of postural integrity at the pelvis, as Thomas tests often do not use a pelvic stabilization, and even without do not often show a thigh flat to the bed, 90 degrees at the knee and no deviation in the frontal and transverse planes. The following corrections will often lead to a strong sensation for athletes in the TFL and rectus femoris (particularly the lateral border) that was previously absent.

        Pelvic Tilt:

        Subtle pelvic tilt and rotation will be very common at a standard starting position, and unless the subject can perform the above parameters on a Thomas test, it is almost assured. One indicator (diagram in attachment) is palpation of the front (non-stretching) leg in the area just inferior to the anterior superior iliac spine (ASIS), pressing downward toward the femur. If the pelvic alignment is good, there should be limited compression possible. If the pelvic alignment is off, the femur will sit lower and significant compression will be possible both down and back under the ASIS.

        Correction should involve cueing to lift the femur of the front/non-working leg at the proximal end against this compression and focus on keeping the shoulders square and pelvis tall, which will commonly result in an immediate stretch sensation in the TFL and lateral border of the rectus femoris in the rear/working leg. To this end, the oblique on the rear/working side should be braced to ensure pelvic stability versus anterior tilt and lumbar rotation.

        The overall position should also be altered to allow better pelvic position. To allow optimal pelvic position the hip flexion of the front leg needs reflect the limits of postural integrity, and even a 2-3cm lift from a shoe can increase flexion of the front hip and significantly worsen pelvic posture when in a half-kneeling position.
        To find a plausible position, the tests listed below or similar should be performed, with pelvis stabilised. To achieve a neutral pelvis hip flexion on the front side will need to be reduced and often a higher COM position with the rear leg on a bench is an appropriate starting point (see attachment).

        Arm Movement:

        A common cue is to reach laterally over and then back but this often leads to lumbar extension and rotation, with implications for the pelvis. A better approach is to first find a pelvic neutral position as per above, and from there reach upwards while depressing the scapulae and keeping the pelvis stable.

        Foot position:

        Often when performing hip flexor stretches the rear foot is left on the floor in a position that leads to tibiofemoral rotation. It seems well known that the ankle not the foot should held for a standing quad stretch but the principle is often forgotten in this instance. Rotation of the tibia on the femur will have strong effects on the stretch possible for muscles on the lateral thigh, where the myofascial complex around the TFL, ITB and lateral border of rectus femoris is a very common problem area. As far as possible, a neutral tibiofemoral orientation should be maintained.

        This is particularly an issue for bent knee stretches focused on rectus femoris with the ball of the rear foot on a bench or wall (with any long duration static stretches involving the ball of the foot against a bench or wall MLA height is crucial). Very often due to the static and seemingly mindless nature of the task athletes easily allow rotation of the tibiofemoral articulation and lose tension on the lateral myofascial structures. This is most easily tested by palpation of the posterior thigh just above the knee, where biceps femoris will shorten if this tibiofemoral rotation occurs.

        A reasonable solution is to either focus very strongly on alignment or otherwise take loading off the foot and ankle by using a rope/band just above the ankle.
        Relevance to standing quad stretches: Depending on segment length, many athletes will show big anterior tilt when reaching back and a rope is generally indicated. Again a manual test is great as we can view alignment in the frontal and transverse planes, and clearly for most we around not getting ankle to butt with a neutral pelvis and no hip abduction (i.e. knee under hip). If care is taken again athletes will feel strong sensation in TFL and rectus femoris with pelvic control and a lack of hip abduction.

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        tscm on #115252

        Initial tests:

        i) Thomas test and Ober’s test- Starting positions should involve (pelvis stabilized) knee and hip angles that induce no deviation in the frontal and transverse planes (if subject pulls their own knee to chest some lumbar flexion and rotation will occur, I prefer a second tester or a rope used, otherwise keep in mind free leg may be +15-20 degrees higher in “hip flexion” due to lumbar movement). It should be noted which of psoas, rectus femoris, TFL is likely to be limiting.

        ]ii) Eccentric Lunge test- subject starts from the top of a lunge (Feet hip width, stance matching 90 degree knee angles at ground) and lowers very slowly while maintaining neutral pelvic tilt and even, parallel ASIS height (i.e. pelvis level in both side on and front on views), any shift in pelvic tilt or ASIS position means the limit has been reached. If the rear knee moves laterally (even slightly) out from under the hip to give abduction, or the rear ankle deviates (even slightly) to give tibiofemoral rotation, or we otherwise see anterior pelvic tilt or a lack of even, parallel ASIS height, the limit has been reached

        Respecting attachments:

        The psoas attaches to lower lumbar vertebrae. Pushing the hips forward and shoulders back will give anterior tilt and the feeling of a big stretch through this muscle, however it is often RF/TFL which is the problem.

        The rectus femoris attaches to the ASIS, and compensation in position of the ASIS with anterior tilt or rotation will decrease stretch. Additionally, leaning forward from the hips in a conventional ground based position (see pictures above and attachment) will decrease knee flexion and therefore decrease stretch.

        The TFL also attaches to the ASIS, and changes in position of the ASIS with anterior tilt and particularly in rotation and lateral flexion of the lumbar spine will decrease stretch on this muscle.

        Control vs Gravity:

        The starting position should be elevated to range of motion indicated by initial tests. With a relaxed position on the ground weight is through the pelvic structures and compensation is likely (as per attachment).

        Key compensations:

        Pelvic position: Anterior tilt, ASIS drop and rotation on back leg in too deep a position, indicating loss of lumbopelvic stability. Ropes/other equipment should be used just above the ankle in rectus femoris and standing quad stretches if compensation is occurring at the pelvis (tilt), hip (abduction) and foot (rotation)

        Foot position (–> tibiofemoral rotation): Be very careful to maintain a neutral foot/ankle position or use a position where the foot is not loaded/in contact, e.g. with the lower leg on a bench and the foot off the edge or with a rope pulling from just above the ankle to take the foot posture out of play.

        Arm/Trunk position: Leaning back, to the side and rotating will generally cause lumbar substitution and interfere with lumbopelvic stability. The attachments of RF and TFL are from the ASIS down and lumbar movement is not increasing stretch.
        Cues: Tall pelvis, level pelvis, reach up, femur up/taut below ASIS (use palpation), ankle in line (use palpation).

        Sequencing: Piriformis and hip rotator stretches prior to hip flexor and quad stretching will allow deeper positions with less compensation in frontal and sagittal planes.

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        tscm on #115253

        Piriformis Stretching:

        Piriformis stretches are often a mess due to pushing too far into hip flexion and losing lumbopelvic stability, and given their association with SIJ problems this is not a good thing. Traditional positions like stretch 1 below puts the front and rear feet and the lumbopelvic region in a poor position, and in long duration static stretches in this position gravity takes over and the chest often drops, while sitting right up leads to lumbar hyperextension. There is also an emphasis on non-working hip extension which is beyond the postural integrity limits of most. The supine “pretzel” style stretch often involves a loss of lumbopelvic stability due to use of the arms to hold the legs and foot position is often lost as well.

        Stretch 1 (Prone)

        Stretch 2 (supine)

        Initial tests: Piriformis test with the pelvis stabilized for stretch 1. FABER test + flexion with the pelvis stabilized for Stretch 2.

        Respecting attachments:

        The piriformis attaches at the sacrum and runs to the greater trochanter of the femur. As such, any adjustment in femur position and glide will greatly influence the stretch, and avoiding anterior tilt and rotation of the lumbo pelvic region is crucial. The same palpation technique as for the hip flexor stretch applies for both piriformis stretches.
        Palpation of the stretching leg in the area just inferior to the anterior superior iliac spine (ASIS), pressing downward toward the femur. If the pelvic alignment is good, there should be limited compression possible. If the pelvic alignment is off, the femur will sit lower and significant compression will be possible both down and back under the ASIS.

        Correction should involve cue to lift the femur of the front/non-working leg at the proximal end against this compression so the area inferior to the ASIS is tauter, and focus on keeping the hips and shoulders square to reduce likelihood of rotation. This will often result in a sensation of stretch in lateral border of RF and TFL is the stretch has been performed without care previously.

        As with the hip flexor stretch, the left and right ASIS should be kept level both from a “front on” and “side on” perspective, indicating no transverse rotation and lateral flexion of the lumbar spine.

        The position of the foot can easily induce a change in tibiofemoral rotation, with upstream effects on femoral glide. This is most easily tested by palpation of the posterior thigh just above the knee, where biceps femoris will shorten if this tibiofemoral rotation occurs. A neutral foot position should be ensured.

        Control vs Gravity:

        The torso needs to rise in stretch 1 photo 1 to allow a better aligned lumbopelvic region, through the use of support in front for the hands. The hips also need to rise in stretch 1 photo 2 to allow a better aligned lumbopelvic region.

        Often the best technique is to bring the whole body off the ground and perform the stretch on an elevated surface with support nearby for the upper body. Care should be taken that the surface is not too high as this will induce lumbopelvic rotation (in the attachment the bed is likely too high by 10-20cm or so). The foot should in a position allowing a neutral tibiofemoral joint.

        In stretch 2, partner assistance or the use of a rope is often necessary to ensure pelvic posture is maintained, otherwise once range is determine the non-stretching foot can press against a wall for stability. Assistance should be gentle, based on ROM indicated by initial tests and sensitive to changes in lumbopelvic posture.

        Key compensations: Pelvic tilt, rotation, foot rotation yielding tibiofemoral rotation.

        Cues: Stretching side “Knee out, femur out” (Stretch 1), “Knee Up, femur out” (Stretch 2), “Hips Square and level”, Shoulders Square and level”, Foot Neutral, Pelvis neutral/aligned with lumbar spine.

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