Restoring Range of Motion and
Improving Flexibility
REHABILITATION TECHNIQUES FOR SPORTS
MEDICINE AND ATHLETIC TRAINING
WILLIAM E. PRENTICE
Introduction
 Loss of motion occurs after injury
 Due to pain, swelling, muscle guarding or spasm
Shortening of connective tissue and muscle
 Loss of neuromuscular control
 Restoring normal range of motion is one of primary goals of
rehabilitation program

 Flexibility
 Ability to move a joint through a full, non-restricted, pain free
range of motion

Dependent on combination of joint range of motion and muscle
flexibility
Introduction
 Joint range of motion
 Limited by shape of articulating surface and capsular and
ligamentous structures
 Muscle flexibility
 Ability of musculotendinous unit to lengthen
 Lack of flexibility in one joint can effect the entire
kinetic chain
Importance of flexibility
 Essential to normal daily living
 Functional activities require relatively “normal”
amounts of flexibility

Some activities require more flexibility for superior
performance
 Decreased flexibility creates
uncoordinated/awkward movement patterns

Result of loss of neuromuscular control
Importance of Flexibility
 Generally accepted that flexibility is essential for
improved performance


Recent studies conflicting and inconclusive
Stretching has shown to decrease performance parameters

Strength, endurance, power, joint position sense and reaction
times
 Decrease incidence of injury
 Recent studies fail to find true cause and effect relationship
Anatomic Factors that Limit Flexibility
 Muscles, tendons and their surrounding fascial
sheaths


Stretching attempts to take advantage of highly elastic
properties of muscle
Overtime it is possible to increase elasticity , or the length a
given muscle can be stretched
 Connective tissue (ligaments and joint capsule)
 Become shortened and stiff during periods of immobilization
 People can also be loose jointed from slack or increased laxity
in connective tissue

Creates some instability
Anatomic Factors that Limit Flexibility
 Bony structures
 Restrict end point in the range of motion
Good for stability
 After fracture excess calcium can develop which interferes with
normal range

 Fat
 Excess fatty tissue can restrict range of motion

For example; excess abdominal fat can restrict trunk movement
Anatomic Factors that Limit Flexibility
 Skin
 Inelastic scar tissue can develop after surgery or injury
Incapable of stretching with joint movement
 Overtime can improve elasticity to varying degrees through
stretching

 Neural tissue
 Tightness develops in neural tissues from acute compression,
chronic repetitive microtrauma, muscle imbalances, joint
dysfunctions, or poor posture
Can create morphological changes in tissue that can cause pain
 Pain can cause muscle guarding and spasm
 Can eventually lad to neural fibrosis or scarring

Active and Passive Range of Motion
 Active range of motion
 Dynamic flexibility
 Degree to which a joint can be moved by a muscle contraction
 Not necessarily a good indicator of joint stiffness or looseness
because movement of joint has little resistance
 Passive range of motion
 Static flexibility
 Degree to which a joint can be passively moved to end points
of range of motion
 No muscle contraction involved
Active and Passive ROM
 Many situations in activity when muscle is forced beyond
its normal active limits
 If muscle does not have elasticity to compensate, injury
to musculotendinous unit may occur
Assessment of ROM
 Goniometers
 Large protractors w/ measurements in degrees
 Align arms of goniometer along longitudinal axis of 2 segments
 Reasonably accurate measurement of ROM
 Standardization of measurement techniques and recording
AROM & PROM have been developed
Immobile arm is lined up along immobile segment
 Mobile arm is lined up along mobile segment

Neurophysiologic Basis of Stretching
 Mechanoreceptors in muscle tell CNS what is
happening within that muscle

2 of these are important in the stretch reflex

Muscle spindle and the Golgi tendon organ (GTO)
 Sensitive to changes in muscle length
 GTO also sensitive to change in muscle tension
Neurophysiologic Basis of Stretching

Muscle spindle initially sends sensory impulse to spinal cord
which then sends a message back to muscle spindle causing the
muscle to reflexively contract

If stretch last longer than 6 seconds, impulses from GTO begin
to override muscle spindle
• autogenic inhibition, or a reflex relaxation of the antagonist muscle
• Protective mechanism to allow stretch to avoid damage to muscle
fibers

Reciprocal inhibition
• Contraction of agonist causes a reflex relaxation in the antagonist
muscle
• Allows antagonist to stretch and protects from injury
Effects of stretching on physical and mechanical
properties of muscle
 Muscle and tendon composed of non contractile collagen
and elastin fibers

Collagen can withstand high tensile stress
Mechanical properties
 Elasticity: capability to recover normal length after elongation
 Viscoelasticity: allows for slow return to normal length and shape
after deformation
 Plasticity: allows for permanent change or deformation
 Physical Properties
 Creep response: ability of tissue to deform over time while a
constant load is imposed


Greater the stretch the greater the noncontractile properties
contribute

Lengthening of a muscle via stretching allows for viscoelastic and
plastic changes to occur in collagen and elastin
Effects of stretching on the kinetic chain
 Muscle tightness has significant impact on
neuromuscular control


Effects normal length-tension relationships
Compensations and adaptations occur that affect
neuromuscular efficiency through kinetic chain

Reciprocal inhibition
 For example: if psoas is tight or hyperactive the antagonist
gluteus maximus can be inhibited due to decreased neural drive
 The synergist, hamstrings (muscle that assist glut max); the
stabilizers, erector spinae; and the neutralizers, piriformis
become overactive
• Creates abnormal joint stress and decreased neuromuscular control
during functional movement
Importance of increasing muscle temp. prior to
stretching
 Muscle temperature should be increased prior to
stretching


Positive effect of collagen and elastin components to deform
Capability of GTO to reflexively relax is enhanced

Can be achieved through low intensity warm up or through various
therapeutic modalities
 However exercise is recommended over modalities
 If muscle guarding occurs cold therapy can also be used prior to
stretching
Stretching techniques
 Agonist muscle: muscle that contracts to allow
movement through a joint
 Antagonist muscle: the muscle that is being
stretched in response to contraction of agonist

Balance between the agonist and antagonist is necessary for
normal, smooth, coordinated movement
As well as reduce muscle strains secondary to muscular
imbalances
 Comprehension of this synergistic muscle action is essential to
understanding various stretching techniques

Ballistic stretching
 Repetitive contractions of agonist used to produce
quick stretches of antagonist

Safety questioned because of risk of microtears in
musculotendinous unit


Not recommended for sedentary individuals or those recovering
from muscle injury
Most physical activities are dynamic and repetitive contraction
of agonist with eccentric resistance from antagonist occurs

May be implemented in later stages of rehab during
reconditioning phase
 Progressive velocity flexibility program has been proposed
• Slow static to slow end range to slow full range to fast end range to
fast full range
Static stretching
 Extremely effective and widely used method of
stretching

Passively stretching antagonist or actively contracting agonist
to stretch antagonist to maximal position and holding for
extended time
Recommended to hold for 15 to 30 seconds is most effective to
increase flexibility
 Can be used early on in rehabilitation program
 ATC, teammate, other assistive devices
 Best to do after muscle temperature is increased
 May be more efficient to do after activity and not before

Proprioceptive Neuromuscular Facilitation (PNF)
 First used by ATC’s rehabilitating neuromuscular
disorders


More recently used to increase flexibility
3 types of PNF stretching techniques

Contract relax: beneficial to athletes where ROM is limited by
muscle tightness
 Athlete actively contracts agonist to point of limitation, athlete
then instructed to contract antagonist (muscle to be stretched)
isotonically (through range of motion), athlete then relaxes as
ATC passively moves part to point of limitation. Stretch is then
repeated
Proprioceptive Neuromuscular Facilitation (PNF)

Hold relax: Similar to contract relax except antagonist goes
through isometric contraction (contraction w/o movement)
Hold for at least 6 seconds
 Can be used for agonist or antagonist


Slow reversal-hold-relax
Begins with isotonic contraction of agonist, followed by isometric
contraction of antagonist
 During relax phase antagonist are relaxed while agonist are
contracting


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Dynamic stretching
 Stretching through series of movement patters

Progressive slow controlled movements to faster movements
Muscle activation of agonist and muscle stretching of antagonist
 Posture and form important
 Increases core and muscle temperature
 Increases neuromuscular control
 Increases balance
 Core stability
 Effective for increasing flexibility
 Better way to stretch prior to activity

• Shown to increase flexibility, decrease injury and increase force and
power output
• Mimics sport activity, so more functional
• Can initially cause some muscle soreness
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Comparing stretch techniques
 All have been shown to increase flexibility

PNF is capable of producing greater improvement in flexibility


Requires a partner
Static
Has to be done often and held for extended periods of time
 Prior to exercise may decrease core and muscle temperature when
compared to dynamic stretching
 More appropriate in rehab and as a cool down method after activity


Dynamic


Ballistic


Research supports use prior to activity
Can cause injury in untrained or already injured person
Can maintain flexibility w/ stretching 1 day a week, but to improve
flexibility must perform 3-5 times/week
Pilates and Yoga
 Pilates
 Extremely popular and widely used method
 Developed by Joseph Pilates prior to WWII
 Conditioning program that improves muscle control,
flexibility, coordination, strength and tone.

Concentrated on body alignment, breathing, lengthening of all
muscles while building endurance and strength
Pilates and Yoga
 Yoga
 Originated in India 6000 years ago
 Philosophy that most illness related to poor mental attitude,
posture and diet
 Aimed to unite body and mind through various body postures
and meditative breathing
Start simple and progress to more complex movements
 Increase mobility and flexibility

Myofascial release stretching
 Relieve soft tissue from abnormal grip of tight fascia
(fibrous membrane that covers, supports and
separates muscles, tendons, bones and organs)


Localize restriction and move into direction of restriction
Releasing myofascial restrictions over large treatment area can
have significant impact on joint mobility
Progression of superficial restrictions to deeper restrictions
 Stretching techniques can be incorporated after extensibility is
improved in myofascia
 Can use foam rollers to assist with myofascial release

Other methods to restore ROM
 Massage
 Strain-counter strain
 Soft tissue mobilization
 Graston technique
 Massage
Benefits of ROM exercises
 Inreased flexibility
 Increased mobility
 Increased blood flow to area
 Facilitate tissue healing process
 Decreased swelling
 Decreased adhesion formation
 Decreased pain