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The True Hip Flexor Stretch

The hip flexor stretch has become a very popular stretch in the fitness and sports performance world, and rightly so considering how many people live their lives in anterior pelvic tilt.  However, this seems to be one of those stretches that I see a lot of people either performing incorrectly or too aggressively.  I talked about this in a recent Inner Circle webinar on 5 common stretches we probably shouldn’t be using, but I wanted to expand on the hip flexor stretch as I feel this is pretty important.

I’ve started teaching what I call the “true hip flexor stretch.”  I call it the true hip flexor stretch as I want you to truly work on stretching the hip flexor and not just torque your body into hip and lumbar extension.  When performing, most people say they never felt a stretch like that before, hence the name “true hip flexor stretch.”

 

True Hip Flexor Stretch

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Key Points

  • There is a difference between a quadriceps stretch and a hip flexor stretch.  When your rationale for performing the stretch is to work on stretching your hip flexor, focus on the psoas and not the rectus femoris.
  • Keep it a one joint stretch.  Many people want to jump right to performing a hip flexor stretch while flexing the knee.  This incorporates the rectus and the psoas, but I find far too many people can not appropriately perform this stretch.  They will compensate, usually by stretching their anterior capsule too much or hyperextending their lumbar spine.
  • Stay tall.  Resist the urge to lean into the stretch and really extend your hip.  Most people are too tight for this, trust me.  You’ll end up stretch out the anterior hip joint and abdominals more than the hip flexor.
  • Make sure you incorporate a posterior pelvic tilt.  Contract your abdominals and your glutes to perform a posterior pelvic tilt.  This will give your the “true” stretch we are looking for.  Many people wont even need to lean in a little, they’ll feel it immediately in the front of their hip.
  • If you don’t feel it, squeeze your glutes harder.  Many people have a hard time turing on their glutes while performing this stretch, but it is key.
  • Guide your hips with your hands.  I usually start this stretch with your hands on your hips so I can teach you to feel posterior pelvic tilt.  Place your fingers in the front and thumbs in the back and cue them to posterior tilt and make their thumbs move down.

true hip flexor stretch

  • Progress to add core engagement.  Once they can master the posterior pelvic tilt, I usually progress to assist by curing core engagement.  You can do this by pacing both hands together on top of your front knee and push straight down, or by holding a massage stick or dowel in front of you and pushing down into the ground.  Key here is to have arms straight and to push down with you core, not your triceps.

 

I use this for people that really present in an anterior pelvic tilt, or with people that appear to have too loose of an anterior hip capsule.  This works great for people with low back pain, hip pain, and postural and biomechanical issues related to too much of an anterior pelvic tilt.  Give the true hip flexor stretch a try and let me know what you think.

 

 

5 Common Stretches We Probably Shouldn’t Be Using

5 Common Stretches We Probably Shouldnt Be DoingThe latest Inner Circle webinar recording on the 5 Common Stretches We Probably Shouldn’t Be Using is now available.

5 Common Stretches We Probably Shouldn’t Be Using

This month’s Inner Circle webinar was on 5 Common Stretches We Probably Shouldn’t Be Using.  Don’t get me wrong, I do perform stretches with people, but I think we often over utilize them as well.  Here are 5 stretches that are pretty common, why I think we overuse them, and what to do about it.

 

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

Does Stretching Really Decrease Performance?

Static stretching has really taken a beating over the last several years after the publication of several studies that showed a reduction in strength, power, speed, and athletic performance.  Many in the strength and fitness communities took this info and ran with it, condemning stretching before athletic competition.

As with any research, though, a careful assessment of the literature will show you that the concept of stretching before competition isn’t that simple.  Saying that “stretching” causes something, either good or bad, is too simplistic without carefully describing the type of stretching and subjects that were in included in studies, and other similar variable.

 

Does Stretching Really Decrease Performance?

does stretching really decrease performance

Image by Istolethetv

Conflicting reports only further complicate the issue, with a recent review showing that 69% of studies on stretching have reported no significant reduction in strength, power, or speed.

Recent studies and meta-analyses have been conducted to look at the this concept more closely and determine, does stretching really decrease performance?  The results are certainly interesting, and it appears that there may be a time and a place for static stretching in our pre-event warm-up, especially considering the research that static stretching can help reduce muscle strain injuries.

 

Duration of Stretch is Important

One of the biggest factors behind reduced performance after stretching appears to be related to the duration of the stretch.  A recent study published in Medicine and Science in Sports and Exercise performed a meta-analysis of 106 published studies to specifically look at the impact of stretch duration on performance.

When carefully breaking down the results of studies based on the duration of stretch, it appears that stretching for less than 30 seconds does not correlated to decreased performance, while stretching for more than 60 seconds does decrease performance.

The authors report that only 14% of studies reported a significant decrease in performance when stretching for less than 30 seconds, and 61% when stretching for more than 1 minute.  You can see a large difference and what I would consider a relatively low risk when stretching is performed for shorter durations.  Still, when stretching over 1 minute, results do not indicate that stretching reduces performance 100% of the time.

 

Timing of Stretch is Important

Another potential factor in decreased performance is the timing between a session of static stretching and the start of athletic competition.  Many of the commonly published studies have looked at the immediate response to stretching, but how often do we stretch and then immediately run out onto the field and play?

Timing is an issue and this has led some authors to recommend a 5 minute period of time between stretching and the initiation of competition.  This makes sense to me and something that I recommend.

 

Integration of Static and Dynamic Stretching is Important

After the initial knee jerk reaction to some of the stretching studies, many people immediately shifted to dynamic stretching instead of static stretching before sports.  This led to the development of better dynamic warm up routines, which is certainly a good thing.  But recent research has shown that combining the two may also be beneficial.  In fact, the negative effects of static stretching were absent when combining both static and dynamic stretching.

It is hard to tell if the dynamic warmup was the factor that led to the change in findings in this study or simply just the 15-minute duration that occurred between the static stretching and testing protocol.

Regardless, I feel this is a great reason to include both static stretching and dynamic stretching, as this combination may be effective or at the very least it allows more time between static stretching and competition.

 

How and Why You May Want to Perform Static Stretching

In light of all the combined information above, it appears that there may be a proper way of incorporating static stretching into our routines if this is something you want to include.  In my mind there are two different reasons where I would want to perform static stretching.

The first is for someone who obviously has a restriction that would benefit from stretching.  Another major limitation to the stretching research is that it is predominantly performed with healthy individuals.  But what about someone who has a past injury or deficits?  In this situation we need to assess if addressing the restriction is more important than the potential risk of decreased performance.

I think static stretching is needed for these individuals and a part of a proper injury prevent program in this group.  That doesn’t mean a global generic stretching routine, but rather focus on what needs to be stretched.  However, I would still us the above principles in regard to duration, timing, and integration with a dynamic warm up.

The other scenario that I use static stretching before a competition is when an athlete just feels stiff or sore from past games, especially when in a sport that plays 162 games in 180 days, for example.  Add some bus trips, flights, bad hotels, and plenty of overuse to the mix and our athletes are going to feel pretty stiff.  Heck, I feel stiff and I’m not even playing.

In this scenario, I am not aggressively holding a static stretch for the intent of elongating tissue.  Rather, I am just trying to neuromodulate tone and the athlete’s perceived stiffness.  I often perform 3-5 reps of a stretch with holds between 3-5 seconds and essentially just pick up the tissue slack without torquing into end range motion.

I also don’t want running, throwing, or jumping during competition to be the first exposure the athlete’s body gets to the dynamic movement so just getting them lightly moving is helpful at times, I’ve discussed this briefly in the past.

I simple refer to this as a “fluff” stretch.  In all honestly, I can’t remember the last time I held a stretch for 30 seconds let alone great than a minute.  In my experience we stretch our athletes, many of which are already loose, too often and aggressively.  I almost always prefer to stretch less.

Perhaps the best approach is to combine the two scenarios by stretching only what is needed and fluffing the rest?

I’m not sure the best answer but it does appear that if you hold static stretches for less than 30 seconds, include a dynamic warm up, and assure that at there is some time between stretching and competition that stretching will not decrease performance.  (Click Here to Tweet This)

Regardless, I don’t think we need to fear and avoid static stretching before athletic competition is performed correctly and in the right scenario.

 

 

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5 Principles of Treating the Stiff Shoulder

5 Principles of Treating the Stiff Shoulder

The latest webinar recording for Inner Circle members is now available below.

5 Principles of Treating the Stiff Shoulder

This month’s Inner Circle webinars discussed several principles of treating the stiff shoulder.  We’ll cover:

  • The several types of “stiff shoulders”
  • Are we seeing shoulder stiffness more than we realize?
  • How to completely understand the anatomy and biomechanics of the glenohumeral capsule
  • Know when to push motion (and when not to!)
  • What should people with stiff shoulders do at home between sessions

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Ankle Mobility Exercises to Improve Dorsiflexion

ankle mobility exercises to improve dorsiflexionLimitations in ankle dorsiflexion can cause quite a few functional and athletic limitations, leading to the desire to perform ankle mobility exercises.    These types of mobility drills have become popular over the last several years and are often important components of corrective exercise and movement prep programming.  Considering our postural adaptations and terrible shoe wear habits (especially if high heels), it’s no wonder that so many people have ankle mobility issues.

Several studies have been published that shown that limited dorsiflexion impacts the squat, single leg squat, step down activities, and even landing from a jump.  These are all building blocks to functional movement patterns, so the importance of designing exercises to enhance dorsiflexion can not be ignored.  While I will openly admit that I believe that the hip has a large influence on ankle position and mobility, it is still important to perform ankle mobility exercises.  I will discuss the hip component in a future post.

There are many great ideas on the internet on how to improve dorsiflexion with ankle mobility exercise, but I wanted to accumulate some of my favorite in one place.  Below, I will share my system for assessing ankle mobility and then addressing limitations.  I use a combined approach including self-myofascial exercises, stretching, and ankle mobility drills.

 

How to Assess Your Ankle Mobility

Before we discuss strategies to improve ankle mobility, it’s worth discussing how to assess ankle mobility.  I am a big fan of standardizing a test that can provide reliable results.  One test that is popular in the FMS and SFMA world is the half-kneeling dorsiflexion test.

In this test, you kneel on the ground and assume a position similar to stretching your hip flexors, with your knee on the floor.  Your lead foot that you are testing should be lined up 5″ from the wall.  This is important and the key to standardizing the test.

From this position you lean in, keeping your heel on the ground.  From this position you can measure the actual tibial angle in relationship to the ground or measure the distance of the knee cap from the wall when the heel starts to come up.  An alternate method would be to vary the distance your foot is from the wall and measure from the great toe to the wall.  I personally prefer to standardize the distance to 5″.  If they can touch the wall from 5″, they have pretty good mobility.  I should note that my photo below has my client wearing minimus shoes, but barefoot is ideal.

Ankle Dorsiflexion Mobilty

 

This is a great position to assess your progress, and as you’ll see, I’ll recommend some specific drills you can perform from this position to you can immediately assess and reassess.

 

Ankle Mobility Exercises to Improve Dorsiflexion

As I mentioned previously, I like to use a 3-step process to maximize my gains when trying to enhance ankle dorsiflexion:

  1. Self-myofascial release for the calf and plantar fasica
  2. Stretching of the calf
  3. Ankle mobility drills

I prefer this order to loosen the soft tissue and maximize pliability before working on specific joint mobility.  Also, I should note that I try to go barefoot during my ankle mobility exercises.

 

Self Myofascial Drills for Ankle Dorsiflexion Mobility

One of the more simple self myofascial release techniques for ankle mobility is foam rolling the calf.  This has benefits as you can turn your body side to side and get the medial and lateral aspect of your calf along the full length.  I will instruct someone to roll up and down the entire length of the muscle and tendon for up to 30 seconds.  If they hit a really tender spot or trigger point, I will also have them pause at the spot for ~8-10 seconds.

What is good about the foam roller is that you can also add active ankle movements during the rolling, such as actively dorsiflexing the foot or performing ankle circles.  This gives a nice release as well.  Don’t forget to roll the bottom of your foot with a ball, as well, to lengthen the posterior chain tissue even further.  There is a direct connect between the plantar fascia and Achilles tendon.

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Some people do not feel that the foam roller gives them enough of a release as it is hard to place a lot of bodyweight through the foam roller in this position.  That is why I often use one of the massage sticks to work the area in addition.  You can use a massage stick in a similar fashion to roll the length of the area and pause at tender spots.  I often add mobility in the half kneeling position as well, which gives this technique an added bonus.

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Stretches for Ankle Dorsiflexion Mobility

Once you are done rolling, I like to stretch the muscle.  If moderate to severe restrictions exist, I will hold the stretch for about 30 seconds, but often just do a few reps of 10 seconds for most people.  The classic wall lean stretch is shown below.  This is a decent basic exercises, however, I have found that you need to be pretty tight to get a decent stretch in this position.

I usually prefer placing your foot up on a wall or step instead, as seen in the second part of my video below.  The added benefit here is that you can control the intensity of the stretch by how close you are to the wall and how much you lean your body in.  I also like that it extends my toes, which gives a stretch of the plantar fascia as well.  For both of these stretches, be sure to not turn your foot outward.  You should be neutral to point your toe in slightly (no more than an hour on a clock).

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Simple Ankle Mobility Exercises

I like to break down my ankle mobility exercises into basic and advanced, depending on the extent of your motion restriction.  There are several basic drills that you can incorporate into your movement prep or corrective exercise strategies.

The first drill involves simple standing with your toes on a slight incline and moving into dorsiflexion by breaking your knees.  Eric Cressey shows us this quick and easy drill that you can quickly perform:

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Tony Gentilcore shows another simple ankle mobility drill, which is essentially just a dynamic warmup version of the ankle mobility test we described above:

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Kevin Neeld shows a great progression of this exercise that incorporates both the toes up on the wall, essentially making it more of a mobility challenge and stretch.  If you look closely, you’ll see that he is also mobilizing in three planes, straight neutral, inward, and outward:

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Advanced Ankle Mobility Exercises

Jeff Cubos shares a video of the half kneeling mobilization with a dowel.  The dowel is an important part of the ankle mobility drill.  You begin by half kneeling, then placing a dowel on the outside of your foot at the height of your fifth toe.  Now, when you lean into dorsiflexion, make sure your knee goes outside of the dowel.  You can add the dowel to many of the variations of drills we are discussing:

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Chris Johnson shared a nice video using a Voodoo Floss band to assist with the myofascial release and position the tibia into internal rotation:

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For those that have a “pinch” in the front of the ankle of tight joint restrictions of the ankle in general, Erson Religioso shows us some Mulligan mobilizations with movement (MWM) using a band.  In this video, he has his patient put the band under his opposite knee, however you could easily tie this around something behind you.  In this position you step out to create tension on the band, which will move your talus posteriorly as you move forward into dorsiflexion:

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As you progress along with your mobility, you may find that variations of these drills may be more effective for you.  You can combine many of these approaches into one drill, such as Matt Siniscalchi shows us here, combining the MWM with the dowel in the half kneeling position:

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As you can see, there are many different variations of drills you can perform based on what is specifically tight or limited.  You may have to play around a little but to find what works best for each person, however these are a bunch of great examples of ankle mobility exercises you can choose to perform when trying to improve your dorsiflexion.

3 Tools to Get More Out of Your Programs in 2013

Ah, it’s that time of the year again, time for New Year’s resolutions!  While many people will be taking the plunge and dedicating some time and energy to fitness goals, the real challenge is sticking to these New Year’s resolutions for more than a month!  There are many reasons why people don’t stick to their workouts and fitness New Year’s Resolutions.  Some of them are just facts of life, such as time commitments, financial concerns, and lofty expectations.

Two common reasons for not sticking to your fitness resolutions that I have observed are soreness from the initiation of a new program and plateaus in your progress.  These are much more manageable and something that I think are sometimes related to mobility issues that can be addressed.

For the person just beginning a fitness program, muscle soreness and tightness after performing new exercises is essentially expected.  But there are some ways to reduce this soreness and get over the initial hump a little easier.  Movement and massage are two prime examples.  For the person that has some workout experience but aren’t working with a qualified professional, they often have some muscle imbalances and movement restrictions because someone isn’t helping them address their weaknesses.  Everyone wants to work on their strengths, right?

These are both obvious reasons as to why you want to work with a qualified strength and conditioning coach or personal trainer that can help identify and address your mobility concerns.  But what if you don’t have the access to a great coach and just want to start a home workout program or buy a generic gym membership?

Here are 3 tools that I recommend for you to get more out of your programs in 2013.  For a small amount of money, you can start your own package of tools that you can use at home between workouts.  Use these tools daily for 10 minutes and you’ll move and feel better between workouts, which will allow you to get more from your programs.

 

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Foam Roller

GRID foam roller Foam rollers are a staple for many people and certainly not anything new.  While foam rollers are popular at the gym before a workout, having one at home to use between workouts is a must as well.  Many people consider a foam roller a “self-myofascial release” tool.  I’m not sure if we are making any significant fascial changes when we foam roll, but the combination of the compression on the tissue and movement associated with foam rolling likely has a positive effect on neuromodulating tissue soreness and tightness.  What does this mean for you?  You’ll feel better and move better when you are done!

How to Use a Foam Roller

I recommend two uses for foam rollers – 1) as a generalized full body program, and 2) on specific sore muscles.  I would recommend rolling out the major hot sports of the body, such as:

  • Low back
  • Mid back
  • Posterior shoulder
  • Lats
  • Glutes
  • Hips
  • Quads
  • Hamstrings
  • Groins

I essentially recommend 5-10 full length rolls of each area, performed in a slow and controlled pace each day.  If specific muscles are sore after a workout, I would emphasize these and perform another 5-10 reps, however, if you find a specific point of discomfort, you can pause at that spot for 10 seconds.  Take a few deep breaths and try to relax.  I would also recommend performing a few thoracic spine extensions while rolling the mid back.  Here is a great video demonstration from Eric Cressey.  He hits a few different areas, however, the general concepts are the same and these are great examples.  There are also a few trigger point ball examples towards the end, but more on that later:

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What Foam Roller to Buy?

I currently recommend two foam rollers, one for beginners that are just looking to incorporate foam rolling and another for more advanced uses that don’t mid spending a little more.

  • For Beginners: Perform Better Elite Molded Foam Rollers.  Pretty much a great basic foam roller that you can get for around $25
  • For Advanced Users: The Grid Foam Roller.  When you are ready to step up to a more firm roller, the Grid is by far the best on the market.  I don’t really think all those ridges and nubs do anything, but this is a great firm and durable roller that will last you a lifetime.  It’s a bit pricier between $30 and $40, but worth it.

 

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Massage Stick

theraband massage rollerWhile foam rollers are great, they aren’t perfect for every body part.  Essentially, if you can’t put a lot of weight through the foam roller, it doesn’t feel like you are doing much.  If you notice the above list of muscle areas does not include the entire body.  To hit more specific areas, a massage stick is a great tool and essentially a foam roller with handles!  You can use your hands to put more pressure into the movement when body weight isn’t available.  I see a foam roller and massage stick as complementary, and a massage stick is great for:

  • Calfs
  • Outer side of lower leg
  • Upper traps
  • Forearms

As you can see, pretty important areas, and spots that foam rollers really don’t hit well.  Not only do these areas get sore, but limitations often result in poor performance when training.

How to Use a Massage Stick

I use a massage stick just like a foam roller, with about 5 full length rolls on each area.  If sports are sore, which is pretty common in the calf and upper trap, I will pause there for about 10 seconds.  Here is a demonstration I have used in the past on how I use massage sticks for the forearm:

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What Massage Stick to Buy?

I have used several massage sticks in the past and must say that there is only one I would currently recommend as it is by far superior to the others:

  • TheraBand Roller Massager+.  I was skeptical when I first used this massage stick, assuming that the ridges were just a way of separating themselves from the rest of the market.  However, the combination of the ridges and the material of the roller makes for a great combo and the best roller on the market!  The material grabs the skin well and the ridges create a drag sensation in addition to the compression.

 

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Trigger Point Ball

sklz reaction ballWe have progressed from a foam roller, to a massage stick, and now to a trigger point ball, the third component of a great self-help tool package!  Even with a roller and a stick, there are still some areas that are just too hard to get to.  As you can see, we are getting more specific with each tool.  Here is what I use trigger point balls for:

  • Specific trigger points in the glutes and hips
  • The QLs
  • Upper and middle trap areas
  • Posterior rotator cuff
  • Plantar fascia

If these are areas of concern for you, you’ll want to get some sort of trigger point ball to hit these spots with ease.

How to Use a Trigger Point Ball

Using a trigger point ball is a little different from a roller or a stick, I usually don’t recommend rolling the body on the ball, but rather just stick to a trigger point release.  These balls can get to a small specific spot, so you can hit multiple points in each area, holding each for about 10 seconds.  Here is an example of using a trigger point ball on the posterior shoulder:

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What Trigger Point Ball to Buy?

I typically use a couple of different trigger point balls, depending on how firm I want the ball to be.  I would recommend the softer balls for beginners and firmer for advanced users.  I think lacrosse balls are great, but they are pretty firm and don’t have a small nub to use, making them less than ideal for some areas.  Here is what I recommend:

  • For Beginners: Trigger Point Therapy Massage Ball.  These are a little more expensive than lacrosse balls at about $15, but they are softer and have a little nub than you can wedge into different areas, which I like.  This is a good starting point, but if you weigh a lot or plan on using it exclusively for the glutes, the brand new Trigger Point Therapy X-Factor Ball is a little larger and more firm.  I use these a lot.
  • For Advanced Users: SKLZ Reaction Ball.  You know those little yellow reaction balls that you drop and bounce all over the place?  A friend just recently turned me on to these as trigger point tools!  They work great!  They are firm and have great little nubs to really get in to the tissue.  Plus you can usually find them for under $10.
  • You can always just go with a simple lacrosse ball as well.  But they are pretty firm for beginners some times and don’t have the added benefit of any points or nubs to emphasize an area.  That being said they are under $2!

 

By combining these 3 tools, you’ll have a perfect home kit to help you move better and feel better between workouts, which means you’ll get more out of your programs and hopefully stick to those New Year’s resolutions!

 

 

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How Hard do We Push When We Stretch?

Over the last several weeks we have talked about how loss of knee motion causes arthritis and ways to improve knee extension.  I received several emails from people asking two questions:

  • How do we know how hard to push when trying to regain motion?
  • Can the devices designed to help restore motion be too aggressive?

To me, this is certainly a double edged sword.  If the cause of restriction is joint or soft tissue hypomobility, you will need to push to create gains but not so hard that we cause inflammation or excessive apprehension.  There is definitely a “feel” to determine how hard to push that I try to teach as a combination of the quantity and quality of motion.  Putting it another way, how well is the joint moving and what is the end feel.

An interesting study was recently published in Sports Health that actually looked at these questions to an extent.  Uhl and Jacobs measured the amount of torque produced during knee flexion stretching performed by physical therapsits, dynamic splinting, and static progressive splinting.

As you can see in the chart below, the typical amount of torque produced by a therapist was approximately 50 Nm of force.  The static progressive splint was closest with 21 Nm of force.

How Hard do We Push When We Stretch?

 

 

Interestingly, the dynamic splint provided a fairly low amount of torque.  I see this as a pro and a con.  It appears that a static progressive splint may be better suited to be used by patients in a typical stretching pattern of reps and frequency, while a dynamic splint may be best used for longer durations considering the lower load applied.

I was also actually surprised to see how aggressive one of the splints was, providing nearly 4x more torque than a therapist would while stretching!  I’m not 100% sure what to make of that but I tend to try to get moving quickly so that we don’t need to be so aggressive when we stretch!

Interesting info at the very least and something that I thought was worth sharing.  This may help us decide what type of device we may want to use when attempting to regain motion in the future based on each person’s specific goals.  The authors of the study also talk about how the specific amount of force observed using each method of stretching should impact our frequency and dose of motion activities.

 

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Assessing and Treating Loss of Knee Extension Range of Motion

Assessing and treating loss of knee extension range of motion is an important component of rehabilitation following any knee surgery.  We recently discussed how loss of knee extension range of motion may be one of the biggest factors associated with the development of osteoarthritis following ACL reconstruction.

The purpose of this article is to review some of the many methods of assessing and treating loss of knee extension range of motion to help maximize outcomes following knee surgery or injury while minimizing long term complications.

 

Assessing Loss of Knee Extension Range of Motion

There are many ways to treat loss of range of motion in the knee, however, proper assessment of range of motion is even more important.  A certain degree of hyperextension is normal, with studies citing a mean of 5 degrees of hyperextension in males and 6 degrees in females.  Simply restoring knee range of motion to an arbitrary 0 degrees is not advantageous.

The most important factor in assessing loss of knee extension range of motion is looking at the noninvolved knee.  As simple as this sounds, this can not be overlooked as you need to establish a baseline for what is “normal” in each patient or client.

The first thing I look at is simply grasping the 1st toe with one hand to lift the foot off the table.  My proximal hand can stabilize the distal femur.  This is a quick and dirty assessment but I always recommend quantifying the available range of motion.

To accurately measure knee extension range of motion, you will need to use a towel roll of various height to assure the knee is fully hyperextended before taking a goniometric measurement.

Knee Hyperextension

Other aspects of assessment that should be performed when dealing with loss of knee extension range of motion should include patellar mobility, tibiofemoral arthrokinematics, and soft tissue restrictions.  Patellar mobility is especially important after ACL reconstruction using a patellar tendon autograft.  Any restrictions in patellar mobility can have an obvious correlation with restricted knee extension.  Scarring of the patellar tendon can restrict superior glide of the patella and full knee extension.

These assessments will help guide our manual therapy approach to restoring normal arthrokinematics and range of motion of the knee.

Documenting Knee Range of Motion

I took a poll of a large group of students coming through my clinic in the past and found that there was great confusion regarding how we document hyperextension of the knee.   Is + or – when defining a numerical value?

Let’s say that someone has a contracture and is sitting in 10 degrees of flexion and is unable to straighten their knee.  That would be +10 degrees of flexion, thus has to be -10 degrees of extension.  They are on two ends of the spectrum.

Still, using a + or – can be potentially confusing, so I have long taught my students that we should document range of motion using the A-B-C method.  Other authors, such as Dr. Shelbourne, recommend this method as well.

  • If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
  • If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.
Using the A-B-C method eliminates the potential for confusion while documenting.

Treating Loss of Knee Extension Range of Motion

There are several ways to improve knee extension range of motion, however, if a person is struggling with this motion I have found that self-stretches, low load long duration (LLLD) stretching, and range of motion devices can be superior to us cranking of a already cranky knee!  Allowing gentle, frequent, and progressive load to the knee is usually more tolerable for the person, especially those that are sore or guarded in their movements.

The intent of this article is to discuss some specific independent strategies to enhance knee extension range of motion.  Other skilled treatments should focus on patellar mobility, soft tissue mobility, and other aspects of manual therapy for the knee as needed.   However, patients will need to perform stretches at home to assure good outcomes.

 

Self Stretches for Knee Extension Range of Motion

Two of the first stretches that I give patients following surgery are simple self stretches for knee extension.  The basic version simple has the patient applying a stretch into extension by pushing their distal thigh.  The second and slightly more advanced version, has the patient press down on their distal thigh while using a towel around the foot to pull up and simultaneously stretch the hamstrings.

Knee Extension Stretch

Towel Knee Extension Stretch

Similar to how we assess knee extension range of motion, you will want to use some sort of wedge under the heel to assure that you are restoring full motion.

 

Low Load Long Duration Stretching for Knee Extension Range of Motion

For the person that is having a hard time achieving knee extension, my next line of defense is usually LLLD stretching.  Several research articles have been published showing the benefit of LLLD stretching in achieving range of motion gains.

I prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial position for me.  To perform this exercise, place a towel roll or similar item under the heel to allow full knee extension and then a comfortable weight over the distal thigh.

Low Load Long Duration Stretch Knee

The purpose of this exercise is to be gentle and to hold the stretch for several minutes.  I typically use anywhere from 6 to 12 pounds and hold the position for at least 10 minutes.  If the person is fighting against the weight, then it is too aggressive.  Lower the weight and you’ll see better results.

Don’t forget that you can apply moist heat to the knee simultaneously for even more benefit.

LLLD Knee Stretch with Heat

Devices for Knee Extension Range of Motion

I am also quick to prescribe a range of motion restoration device for people that may be struggling with range of motion or are not moving their knee enough throughout the day.  I have tried some of the dynamic splinting in the past but found that many people would rather control and hold a sustained stretch rather than have the brace apply a dynamic stretch.

The two devices I have used and enjoyed are from Joint Active System (JAS) and End Range of Motion Improvement (ERMI).

JAS Knee Brace        ERMI Knee Brace

Both devices allow the patient to apply their own tolerable LLLD stretch at home.  This is helpful as frequent movement throughout the day is always beneficial.

Personally my criteria to use these devices is usually when I perceive the person will self-limit themselves and avoid motion.  I will get a device in their hands early so that they can move their knee more at home and have a feeling that they are controlling the restoration of range of motion.  We probably resort to using these devices when it is too late and the patient is already too stiff.

 

Conclusion

These are just some of the many ways to assess and treat loss of knee extension range of motion.  Considering how important it is to restore full knee extension after knee surgery, properly assessing early signs of loss of motion and effectively treating the knee to avoid long term loss of motion is critical.