1. MANUAL STRETCHING TECHNIQUES IN ANATOMICAL PLANES OF MOTION
Practical !!
See also from pages 94 to 104, therapeutic exercise , CAROLYN KISNER
MANUAL STRETCHING TECHNIQUES IN ANATOMICAL PLANES OF MOTION
Note during practical exam you must say 3 thing:
Position of patient.
Position of therapist.
Grasp:
A. Stabilizing hand.
B. Moving hand.
As with the ROM exercises described in Chapter 3, the manual stretching techniques in this section are described with the patient in a supine position. Alternate patient positions such as prone or sitting are indicated for some motions and are noted when necessary. Manual stretching procedures in an aquatic environment are described in Chapter 9.
Introduction
MANUAL STRETCHING TECHNIQUES IN ANATOMICAL PLANES OF MOTION
Effective manual stretching techniques require adequate stabilization of the patient and sufficient strength and good body mechanics of the therapist. Depending on the size (height and weight) of the therapist and the patient, modifications in the patient's position and suggested hand placements for stretching or stabilization may have to be made by the therapist.
Each description of a stretching technique is identified by the anatomical plane of motion that is to be increased followed by a notation of the muscle group being stretched. Limitations in functional ROM usually are caused by shortening of multiple muscle groups and periarticular structures, and they affect movement in combined (as well as anatomical) planes of motion. In this situation, however, stretching multiple muscle groups simultaneously using diagonal patterns (i.e., D1 and D2 flexion and extension of the upper or lower extremities as described in Chapter 6) is not recommended and therefore is not described in this chapter. The authors believe that combined, diagonal patterns are appropriate for maintaining available ROM with passive and active exercises and increasing strength in multiple muscle groups but are ineffective for isolating a stretch force to specific muscles or muscle groups of the extremities that are shortened and restricting ROM. Special considerations for each region being stretched are also noted in this section.
Prolonged passive stretching techniques using mechanical equipment are applied using the same points of stabilization as manual stretching. The stretch force is applied at a lower intensity and is applied over a much longer period than with manual stretching. The stretch force is provided by weights or splints rather than the strength or endurance of a therapist. The patient is stabilized with belts, straps, or counterweights.
NOTE: Manual stretching procedures for the musculature of the cervical, thoracic, and lumbar spine may be found in Chapter 16. Selected self-stretching techniques of the extremities and spine that a patient can do without assistance from a therapist are not described in this chapter. These exercises are for each joint of the extremities may be found in Chapters 16 through 22.

2. The Shoulder - Flexion Stabilize the scapula
ROM is limited to only 120° .
teres major
latissimus dorsi
Upper Extremity Stretching
Many muscles involved with shoulder motion attach to the scapula rather than the thorax. Therefore, when most muscles of the shoulder girdle are stretched, it is imperative to stabilize the scapula. Without scapular stabilization the stretch force is transmitted to the muscles that normally stabilize the scapula during movement of the arm. This subjects these muscles to possible overstretching and disguises the true ROM of the glenohumeral joint.
The Shoulder: Special Considerations
• When the scapula is stabilized and not allowed to abduct or upwardly rotate, only 120° of shoulder flexion and abduction can occur at the glenohumeral joint.
Remember:
Flexion of the Shoulder
• Muscles most apt to become shortened are those that prevent full shoulder flexion, abduction, and external rotation. It is rare to find restrictions in structures that prevent shoulder adduction and extension to neutral.
• The humerus must be externally rotated to gain full ROM of abduction.
• Grasp the posterior aspect of the distal humerus, just above the elbow.
Hand Placement and Procedure
To increase flexion of the shoulder (to stretch the shoulder extensors) (Fig. 4.16).
• Move the patient's arm into full shoulder flexion to elongate the shoulder extensors.
• Stabilize the axillary border of the scapula to stretch the teres major, or stabilize the lateral aspect of the thorax and superior aspect of the pelvis to stretch the latissimus dorsi.

3. Hyperextension of the Shoulder
To increase hyperextension of the shoulder (to stretch the shoulder flexors) (Fig. 4.17).
Hand Placement and Procedure
Place the patient in a prone position.
Patient Position
• Stabilize the posterior aspect of the scapula to prevent substitute movements.
• Support the forearm and grasp the distal humerus.
• Move the patient's arm into full hyperextension of the shoulder to elongate the shoulder flexors.

4. Abduction of the Shoulder
Adduction of the Shoulder
Rare thing to do
Abduction of the Shoulder
To increase abduction of the shoulder (to stretch the adductors) (Fig. 4.18).
Hand Placement and Procedure
• With the elbow flexed to 90°, grasp the distal humerus.
• Stabilize the axillary border of the scapula.
Adduction of the Shoulder
• Move the patient into full shoulder abduction to lengthen the adductors of the shoulder.
To increase adduction of the shoulder (to stretch the abductors). It is rare when a patient is unable to adduct the shoulder fully to 0° (so the upper arm is at the patient's side). Even if a patient has worn an abduction splint after a soft tissue or joint injury of the shoulder, when he or she is upright the constant pull of gravity elongates the shoulder abductors so the patient can adduct to a neutral position.

5. External Rotation of the Shoulder
To increase external rotation of the shoulder (stretch the internal rotators) (Fig. 4.19).
Hand Placement and Procedure
• Abduct the shoulder to a comfortable position—initially 30° or 45° and later to 90° if the glenohumoral (GH) joint is stable—or place the arm at the patient's side.
• Flex the elbow to 90° so the forearm can be used as a lever.
• Grasp the volar surface of the mid-forearm with one hand.
• Stabilization of the scapula is provided by the table on which the patient is lying.
• Externally rotate the patient's shoulder by moving the patient's forearm closer to the table. This fully lengthens the internal rotators.
PRECAUTION: Because it is necessary to apply the stretch forces across the intermediate elbow joint when elongating the internal and external rotators of the shoulder, be sure the elbow joint is stable and pain-free. In addition, keep the intensity of the stretch force very low, particularly in patients with osteoporosis.

6. Internal Rotation of the Shoulder
To increase internal rotation of the shoulder (stretch the external rotators) (Fig. 4.20).
Hand Placement and Procedure
• Abduct the shoulder to a comfortable position that allows internal rotation to occur without the thorax blocking the motion (initially to 45° and eventually to 90°).
• Flex the elbow to 90° so the forearm can be used as a lever.
• Grasp the dorsal surface of the midforearm with one hand, and stabilize the anterior aspect of the shoulder and support the elbow with your other forearm and hand.
• Move the patient's arm into internal rotation to lengthen the external rotators of the shoulder.

7. Horizontal Abduction of the Shoulder
Perform bilateral Stretching as needed
Horizontal Abduction of the Shoulder
To increase horizontal abduction of the shoulder (stretch the pectoralis muscles) (Fig. 4.21).
Patient Position
To reach full horizontal abduction in the supine position, the patient's shoulder must be at the edge of the table. Begin with the shoulder in 60° to 90° of abduction. The patient's elbow may also be flexed.
Hand Placement and Procedure
• Grasp the anterior aspect of the distal humerus.
• Stabilize the anterior aspect of the shoulder.
• Move the patient's arm below the edge of the table into full horizontal abduction to stretch the horizontal adductors.
NOTE: The horizontal adductors are usually tight bilaterally. Stretching techniques can be applied bilaterally by the therapist, or a bilateral self-stretch can be done by the patient by using a corner or wand (see Figs through 17.32).
Scapular Mobility
To have full shoulder motion, a patient must have normal scapular mobility. (See scapular mobilization techniques in Chapter 5.)

8. Elbow Flexion
Techniques should be performed with the forearm pronated as well as supinated
Hand Placement and Procedure
Grasp the distal forearm just proximal to the wrist.
With the arm at the patient's side supported on the table, stabilize the proximal humerus.
Flex the patient's elbow just past the point of tissue resistance to lengthen the elbow extensors.
The Elbow and Forearm: Special Considerations
Several muscles that cross the elbow, such as the biceps brachii and brachioradialis, also influence supination and pronation of the forearm. Therefore, when stretching the elbow flexors and extensors, the techniques should be performed with the forearm pronated as well as supinated.
Elbow Flexion
To increase elbow flexion (stretch the one-joint elbow extensors).
Hand Placement and Procedure
• Grasp the distal forearm just proximal to the wrist.
• With the arm at the patient's side supported on the table, stabilize the proximal humerus.
• Flex the patient's elbow just past the point of tissue resistance to lengthen the elbow extensors.

9. Elbow Flexion To increase elbow flexion with the shoulder flexed
To increase elbow flexion with the shoulder flexed (stretch the long head of the triceps) (Fig. 4.22).
Patient Position, Hand Placement, and Procedure
• With the patient sitting or lying supine with the arm at the edge of the table, flex the patient's shoulder as far as possible.
• While maintaining shoulder flexion, grasp the distal forearm and flex the elbow as far as possible.

10. Elbow Extension heterotopic ossification !!
the appearance of ectopic bone in the soft tissues around a joint due to vigorous, forcible passive stretching of the elbow flexors
Elbow Extension
• Grasp the distal forearm.
Hand Placement and Procedure
To increase elbow extension (to stretch the elbow flexors) (Fig. 4.23).
NOTE: Be sure to do this with the forearm in supination, pronation, and neutral position to stretch each of the elbow flexors.
• Extend the elbow just past the point of tissue resistance to lengthen the elbow flexors.
• With the upper arm at the patient's side supported on the table. stabilize the scapula and anterior aspect of the proximal humerus.
• With the patient lying supine close to the side of the table, stabilize the anterior aspect of the shoulder or with the patient lying prone, stabilize the scapula.
Patient Position, Hand Placement, and Procedure
To increase elbow extension with the shoulder extended (stretch the long head of the biceps).
PRECAUTION: It has been reported that heterotopic ossification (the appearance of ectopic bone in the soft tissues around a joint) can develop around the elbow after traumatic or burn injuries.46 It is believed that vigorous, forcible passive stretching of the elbow flexors may increase the risk of this condition developing. Passive or assisted stretching, therefore, should be applied very gently and gradually in the elbow region. Use of active stretching, such as agonist contraction, might also be considered.
• Pronate the forearm, extend the elbow, and then extend the shoulder.

11. Supination/Pronation of the Forearm
Hand Placement and Procedure
humerus supported - elbow flexed 90°
grasp the distal forearm.
Stabilize the humerus.
Supinate or pronate the forearm just beyond the point of tissue resistance.
Do not twist the hand, thereby avoiding stress to the wrist articulations.
Supination or Pronation of the Forearm
To increase supination or pronation of the forearm.
• Stabilize the humerus.
• With the patient's humerus supported on the table and the elbow flexed to 90°, grasp the distal forearm.
Hand Placement and Procedure
• Be sure the stretch force is applied to the radius rotating around the ulna. Do not twist the hand, thereby avoiding stress to the wrist articulations.
• Supinate or pronate the forearm just beyond the point of tissue resistance.
• Repeat the procedure with the elbow extended. Be sure to stabilize the humerus to prevent internal or external rotation of the shoulder.

12. The Wrist and Hand Wrist Flexion Wrist Extension Radial Deviation
Ulnar Deviation
The Wrist and Hand: Special Considerations
The extrinsic muscles of the fingers cross the wrist joint and therefore may influence the ROM of the wrist. Wrist motion may also be influenced by the position of the elbow and forearm because the wrist flexors and extensors attach proximally on the epicondyles of the humerus.
Patient Position
When stretching the musculature of the wrist, the stretch force should be applied proximal to the metacarpophalangeal (MCP) joints, and the fingers should be relaxed.
To increase wrist flexion.
Wrist Flexion
When stretching the muscles of the wrist and hand, have the patient sit in a chair adjacent to you with the forearm supported on a table to stabilize the forearm effectively.
• Stabilize the forearm against the table and grasp the dorsal aspect of the patient's hand.
• The forearm may be supinated, in midposition, or pronated.
Hand Placement and Procedure
• To further elongate the wrist extensors, extend the patient's elbow.
• To elongate the wrist extensors, flex the patient's wrist and allow the fingers to extend passively.
To increase wrist extension (Fig. 4.24).
Wrist Extension
• Pronate the forearm or place it in midposition, and grasp the patient at the palmar aspect of the hand. If there is a severe wrist flexion contracture, it may be necessary to place the patient's hand over the edge of the treatment table.
Radial Deviation
• To lengthen the wrist flexors, extend the patient's wrist, allowing the fingers to flex passively.
• Stabilize the forearm against the table.
To increase radial deviation.
• Hold the wrist in midposition.
• Grasp the ulnar aspect of the hand along the fifth metacarpal.
• Stabilize the forearm.
To increase ulnar deviation.
Ulnar Deviation
• Radially deviate the wrist to lengthen the ulnar deviators of the wrist.
• Grasp the radial aspect of the hand along the second metacarpal, not the thumb.
• Deviate the wrist ulnarly to lengthen the radial deviators.

13. The Digits CMC Joint of the Thumb MCP Joints of the Digits
PIP and DIP Joints
The complexity of the relationships among the joint structures and the intrinsic and multijoint extrinsic muscles of the digits requires careful examination and evaluation of the factors that contribute to loss of function in the hand because of limitation of motion. The therapist must determine if a limitation is from restriction of joints, decreased muscle flexibility, or adhesions of tendons or ligaments. The digits should always be stretched individually, not simultaneously. If an extrinsic muscle limits motion, lengthen it over one joint while stabilizing the other joints. Then hold the lengthened position and stretch it over the second joint, and so forth, until normal length is obtained. As noted in Chapter 3, begin the motion with the most distal joint to minimize shearing and compressive stresses to the surfaces of the small joints of the digits. Specific methods of intervention for dealing with adhesions of tendons are described in Chapter 19.
The Digits: Special Considerations
CMC Joint of the Thumb
To increase flexion, extension, abduction, or adduction of the carpometacarpal (CMC) joint of the thumb.
Hand Placement and Procedure
• Stabilize the trapezium with your thumb and index finger.
• Move the first metacarpal in the desired direction to increase CMC flexion, extension, abduction, and adduction.
• Grasp the first metacarpal (not the first phalanx) with your other thumb and index finger.
MCP Joints of the Digits
To increase flexion, extension, abduction, or adduction of the MCP joints of the digits.
• Grasp the proximal phalanx with your other thumb and index finger.
• Stabilize the metacarpal with your thumb and index finger.
• Keep the wrist in midposition.
• Move the MCP joint in the desired direction for stretch.
• Allow the interphalangeal (IP) joints to flex or extend passively.
To increase flexion or extension of the proximal (PIP) and distal (DIP) interphalangeal joints.
PIP and DIP Joints
• Grasp the middle or distal phalanx with your thumb and finger.
• Stabilize the proximal or middle phalanx with your other thumb and finger.
• Move the PIP or DIP joint in the desired direction for stretch.
Stretching Specific Extrinsic and Intrinsic Muscles of the Fingers
Elongation of extrinsic and intrinsic muscles of the hand is described in Chapter 3. To stretch these muscles beyond their available range, the same hand placement and stabilization are used as with passive ROM. The only difference in technique is that the therapist moves each segment into the stretch range.
Figure Hand placement and stabilization of the scapula to increase extension of the shoulder beyond neutral.0
Figure Hand placement and stabilization of the scapula for the stretching procedure to increase shoulder abduction.0
Figure Shoulder position (slightly abducted and flexed) and hand placement at the mid to proximal forearm to increase external rotation of the shoulder. A folded towel is placed under the distal humerus to maintain the shoulder in slight flexion. The table stabilizes the scapula.0
Figure Hand placement and stabilization of the shoulder to increase internal rotation of the shoulder.0
Figure Hand placement and stabilization of the anterior aspect of the shoulder and chest to increase horizontal abduction of the shoulder past neutral (to stretch the pectoralis major).0
Figure Hand placement and stabilization to increase elbow flexion with shoulder flexion (to stretch the long head of the triceps brachii).0
Figure Hand placement and stabilization of the scapula and proximal humerus for stretching procedures to increase elbow extension.0
Figure Hand placement and stabilization of the forearm for stretching procedure to increase extension of the wrist
Figure 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.0
Figure Wand exercises to stretch the pectoralis major muscle.0

14. 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 posterior tilt of the pelvis.
Move the patient's hip and knee into full flexion to lengthen the one-joint hip extensor.
Because muscles of the hip attach to the pelvis or lumbar spine, the pelvis must always be stabilized when lengthening muscles about the hip. If the pelvis is notstabilized, the stretch force is transferred to the lumbar spine, in which unwanted compensatory motion then occurs.
The Hip: Special Considerations
Lower Extremity Stretching
Hand Placement and Procedure
To increase flexion of the hip with the knee flexed (stretch the gluteus maximus).
Flexion of the Hip
• Stabilize the opposite femur in extension to prevent posterior tilt of the pelvis.
• Flex the hip and knee simultaneously.
• Move the patient's hip and knee into full flexion to lengthen the one-joint hip extensor.

15. Flexion of the Hip with Knee Extension
To increase flexion of the hip with the knee extended (stretch the hamstrings) (Fig. 4.25).
Hand Placement and Procedure
• With the patient's knee fully extended, support the patient's lower leg with your arm or shoulder.
• Stabilize the opposite extremity along the anterior aspect of the thigh with your other hand or a belt or with the assistance of another person.
• With the knee at 0° extension, and the hip in neutral rotation, flex the hip as far as possible.
NOTE: Externally rotate the hip prior to hip flexion to isolate the stretch force to the medial hamstrings and internally rotate the hip to isolate the stretch force to the lateral hamstrings.
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 extended. 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.
internally rotate the hip to isolate the stretch force to the lateral hamstrings.
Externally rotate the hip prior to hip flexion to isolate the stretch force to the medial hamstrings

16. Extension of the Hip Extension of the Hip
To increase hip extension (to stretch the iliopsoas) (Fig. 4.26).
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 grasping around the thigh and holding it to the chest to prevent an anterior tilt of the pelvis during stretching.
• Move the hip to be stretched into extension or hyperextension 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.
Alternate Position
The patient can lie prone (Fig. 4.27).
• 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.

17. Extension of the Hip with Knee Flexion
Patient Position
Use either of the positions previously described for increasing hip extension in the supine or prone positions
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.
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 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.

18. Abduction of the Hip Abduction of the Hip
To increase abduction of the hip (stretch the adductors) (Fig. 4.28).
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.
NOTE: 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.

19. Adduction of the Hip
To increase adduction of the hip [stretch the tensor fasciae latae and iliotibial (IT) band]
Adduction of the Hip
To increase adduction of the hip [stretch the tensor fasciae latae and iliotibial (IT) band] (Fig. 4.29).
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.
NOTE: If the patient's hip cannot be extended to neutral, the hip flexors must be stretched before the tensor fasciae latae can be stretched.

20. External Rotation of the Hip
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 lateral aspect of the lower leg, and externally rotate the hip.
External Rotation of the Hip
To increase external rotation of the hip (stretch the internal rotators) (Fig A).
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 lateral aspect of the lower leg, and externally rotate the hip.
NOTE: 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.

21. Internal Rotation of the Hip
To increase internal rotation of the hip (stretch the external rotators) (Fig B).
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.

22. Knee Flexion Alternate Position and Procedure
sitting with the thigh supported on the treatment table and leg flexed over the edge
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.
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).
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.
PRECAUTION: 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 traumatize the knee joint and cause swelling.
Alternate Position and Procedure
• Have the patient sit with the thigh supported on the treatment table and leg flexed over the edge as far as possible.
• 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.
NOTE: 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°.
useful in the 90° to 135° range of knee flexion
useful in the 0° to 100° range of knee flexion

23. Knee Extension Knee Extension
To increase knee extension in the midrange (stretch the knee flexors) (Fig. 4.32).
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 buttocks to prevent hip flexion with the other hand.
• Slowly extend the knee to stretch the knee flexors.

24. End-Range Knee Extension
To increase end-range knee extension (Fig. 4.33).
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 distal tibia, and extend the patient's knee

25. Dorsiflexion of the Ankle
with the knee extended  stretch the gastrocnemius
with the knee flexed  stretch the soleus
The Ankle and Foot: Special Considerations
The ankle and foot are composed of multiple joints. Consider the mobility of these joints (see Chapter 5) as well as the multijoint muscles that cross these joints when increasing 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 forceare the same as when stretching the gastrocnemius.
PRECAUTION: 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.
Avoid placing too much pressure against the heads of the metatarsals

26. 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.
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.

27. Inversion and Eversion of the Ankle
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.
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. ction.

28. 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.
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 dorsiflexes 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.

29. Stretching Specific Muscles of the Ankle and Foot
tibialis anterior  Grasp the dorsal aspect of the foot across the tarsals and metatarsals and plantarflex and abduct the foot.
tibialis posterior  Grasp the plantar surface of the foot around the tarsals and metatarsals and dorsiflex and abduct the foot.
Peroneals  Grasp the lateral aspect of the foot at the tarsals and metatarsals and invert the foot.

30. Flexion and Extension of the Toes
It is best to stretch any musculature that limits motion in the toes individually.
One hand, stabilize the bone proximal to the restricted joint, and with the other hand move the phalanx in the desired dire
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 individually. With one hand, stabilize the bone proximal to the restricted joint, and with the other hand move the phalanx in the desired dire