the complete guide to stretching

THE COMPLETE GUIDE TO STRETCHING

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relaxation. For example, when a subject isquite inflexible, thigh stretches are sometimeseasier if a towel is placed around the foot. Beltsand pads may be used to keep the spine straightwhen hip exercises are used, as there is a ten-dency to allow the spine to round, increasinglumbar stress.

Various machines are available to facilitateadductor stretches in the hope of achieving theclassic ‘splits’ position. These are normallyhydraulic or ratchet devices that force the legsfurther into abduction. From the point of view ofsafety, the amount of force used and its pointof application are of paramount importance.

Forcing the hips into an abducted position canplace an excessive stress on the hip tissues.Applying this force below the knee can stress themedial ligament of the knee by imposing aninward (valgus) stress on these structures.

Continuous passive motion (CPM) machineshave been used in a hospital setting for a numberof years, and these are now being seen in thesporting context. The machines are electricallypowered, and move the joints through a speci-fied range for a set period. The amount of forceavailable makes it essential that these machinesare used only under the direct supervision of aphysiotherapist.

Starting positions (cont.)

Starting position

Sitting

Kneeling

Points to note

is held. Pressure over prominentpelvic bones can be painful, andmale subjects may find testicularcompression occurs. Those withpatellar pain find compression ona hard surface extremely painful.

When the hips are flexed furtherthan 45 degrees, tightness inthe hip tissues begins to tiltthe pelvis and flatten the spine.Eventually the spine may round,giving back-pain after prolongedperiods. Holding the head too farforwards places stress on theneck and shoulder muscles.

Pressure on the front of the kneeis very painful. Kneeling on allfours (prone kneeling) may placestress on the wrist. Kneeling onthe knees only (high kneeling)places increased stress on thepatella and can be unstable.

Modifications

bone. Place a rolled towelbelow the forehead to enablethe subject to breathe freelywithout compressing the nose.Bend the knees and place arolled towel beneath the ankles.

Encourage individuals to ‘sit tall’and avoid slumping. Sit withknees apart to allow the pelvisto tilt freely and maintain thelumbar lordosis.

Use a well-padded mat. Ensurethat the knees are shoulder-width apart to aid stability.Hold on to an object whenusing high kneeling.

Table 4.5

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PRINCIPLES OF TRAINING

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Stretching frames are also common. Theseenable the user to take up a more stable bodyposition and reduce the likelihood of ‘wob-bling’ and potentially falling. Some are simplymodifications of the traditional wall bar foundin school gyms, while others enable the user tosit and perform a variety of stretches from thesitting position as well as from standing.

Developing agility

We have seen that fitness is composed of anumber of components. Of these, flexibility –the ability to obtain a range of motion about ajoint – is only one. Agility, by comparison, isthe ability to use and control this range of motion.For this reason, good agility requires a number offitness components: flexibility, strength, muscle

endurance, skill, and speed. Agility is thus fun-damental to good sports performance.

Agility exercises involve controlled move-ments through a full range of motion, and may beused individually or in a circuit training format.Examples include movements from dance, ballet,aerobics and gymnastics, together with sport-spe-cific actions requiring a high degree of agility.

Summary

• Warming up has been shown to lessen thenumber of irregular heart beats and reducethe blood pressure during exercise. It willalso make tissue more pliable and affect psy-chological arousal.

• During a warm-up the movements to be prac-tised during a workout should be rehearsed.

Stretching guidelines

Stretching type Technique

Static • Take limb to end of range• Hold for 20-30 seconds

Pulsing • Take limb to end of range and stop• Perform 10-20 small amplitude (2-3 cm) presses

Dynamic • Take limb through full range of motion combining several movement planes(e.g. flexion/abduction/rotation)

• Mimic sports actions

Active • Take limb to end of range by contracting opposite muscle maximally• Use to correct muscle imbalance

Ballistic • Perform repeated vigorous full-range action used in sport• Practise at competition speed

CR • Contract muscle to be stretched against partner-applied resistance• Relax, and then apply static stretch using partner to guide limb

CRAC • Contract muscle to be stretched against partner resistance• Relax, and then pull limb into stretched position using opposite muscle• Final force supplied by user

Table 4.6



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• Both active (exercise) and passive (heating)warm-ups may be used.

• When the body is exposed to a physicalstress greater than the stress experienced innormal everyday activities, it is said to beoverloaded.

• In 20 days total rest stamina reduces by 25per cent and strength by 35 per cent.

• Training specificity means that the change thattakes place in the body as a result of exercisewill closely match the type of exercise used.

• Stretching achieves its effects by changingmuscle reflexes, making muscle less stiff andrelieving the pain of the stretch.

• Long term effects of stretching can make amuscle grow longer.

• Three body types exist: mesomorph (muscu-lar), endomorph (fatter) and ectomorph (thin-ner). We are all a mixture of these three types.

• Stretching may be static, dynamic or PNF.


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Why is posture important?

Posture is simply the relationship (alignment)between different parts of the body. Posture isimportant from two standpoints. First, good pos-ture underlies all exercise techniques. Exercisesstarted from a basis of poor posture tend tobe awkward and clumsy, with unequal tensionplaced on some body tissues. This can eventuallylead to the accumulation of stress and consequentoveruse injuries. Second, postural stress in dailylife overworks some tissues and under worksothers, leading to an imbalance of flexibility andstrength. In the short term this imbalance givesrise to postural pain; but in the long term,because joints are pulled out of alignment, alteredjoint mechanics can lead to the development ofjoint surface degeneration (see fig 5.1 (c)).

Posture is maintained by both muscles and

non-contractile tissues. A good posture is one inwhich the different parts of the body are correctlyaligned, thus placing the minimum amount ofstress on the body tissues. A good posture requireslittle muscle activity, so it is more relaxed andneeds less energy to maintain it. At the sametime, joint structures are not overstretched orshortened so much that they cause strain. In bothof these cases, a good posture is one that is bal-anced. It therefore follows that a poor posturerequires greater muscle work to maintain it andwill almost certainly result in muscle fatigue. Inaddition, the increased joint-loading forces thatresult from poor posture increase the likelihoodof pain and possible injury.

Key point: Poor posture results in greater muscle workand fatigue as well as well as increased joint loading.

5POSTURE

Figure 5.1 Muscle imbalance altering joint mechanics: (a) symmetrical muscle tone – nor-mal joint; (b) unequal muscle pull (imbalance) – joint alignment poor; (c) joint surfacedegeneration

+ ++ + ++ + +

+

+ + +

(a) (b) (c)

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Two types of posture are important. Static pos-ture is that seen at rest, while dynamic postureis that of motion – the type of body position aperson takes up when moving. Static posturemay be assessed by close inspection of thebody, but the study of dynamic posture requiresin-depth training, and often the use of advancedlaboratory facilities.

A number of factors interact to create a per-son’s static posture. Body type and geneticmake-up are important, as are strength andflexibility. In addition, the way a person seesthemselves (their body image) and the mentalstate of an individual will affect their posture.

An individual cannot easily alter their geneticmake-up, so the posture with which theywere genetically endowed is largely perma-nent unless surgically changed. Children, forexample, who have particular spinal deformitiesoften require a number of complex operationsto straighten the spine. Similarly, bone or skele-tal ‘frame size’ is constant for an individual, soa stretching programme must take this intoaccount.

The important factor in the development ofboth flexibility and strength is symmetry. Anunequal development of either of these twoelements can pull the body out of alignment,causing postural faults.

The balance between postural muscles andmovement muscles is also important. Posturalmuscles hold us up against gravity and includethose trunk muscles that give us ‘core stability’.Movement muscles will create great powerand are able to move rapidly, but will tend totighten. The combination of tightness (too muchtone) of some muscles and sagging (too littletone) of other muscles results in muscle imbal-ance, which changes our postural alignment andgives rise to postural pain.

Assessing standing posture

From behindWhen the body is viewed from behind, with thefeet three inches apart, a vertical line shoulddivide it into two equal halves. The pelvic rims(anterior superior iliac spines) should be in thesame horizontal plane, and the pubis and pelvicrims should be in the same vertical plane. Anindividual’s posture can be assessed by com-parison with a score-chart (see table 5.1).Anatomical ‘landmarks’ are compared with hori -zontal levels on the right and left sides of thebody and include: the knee creases, buttockcreases, pelvic rim, angle of the shoulder blades,upper arm bones, ears and skull protuberances.In addition, the alignment of the spinousprocesses and rib angles is observed. The dis-tance between the arms and the trunk (key-hole), skin creases and unequal muscle bulk areindicators of asymmetrical posture. Slight sidebending of the spine (scoliosis) becomes morenoticeable when an individual bends forwards(Adam’s position) and a marked hump is seenover the twisted ribs.

Looking closely at the shoulder blade (scapula),the inner edge of the blade should be verticaland no more than three finger breadths from thespine. The blade should appear flat against therib-cage, and no part of it should jut out orappear prominent. The appearance of the shoul-der area on the right and left sides of the bodyshould be roughly the same (symmetrical). Thebulk of the muscles around the shoulder shouldbe even, with no one area appearing either‘muscle-bound’ (excessive bulging) or ‘wasted’(hollow). Finally, the contour of the musclebetween the shoulder and neck (the upper fibresof the trapezius) should be smooth and rounded,rather than straight and tight like a cord.


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67

Key point: When looking at a person’s posturefrom behind, symmetry is important. Are bothsides more or less equal?

From the sideStanding posture is assessed by comparing it toa plumb-line or vertical line on a wall (see fig5.2). The line begins just in front of the outer

ankle bone (lateral malleolus). In an ideal pos-ture, this line should pass just in front of themid-line of the knee and then through the hip,lumbar vertebrae, shoulder joint, cervical verte-brae and the lobe of the ear. The chest is thefurthest point forwards, and the buttocks are thefurthest point backwards. The posture is bal-anced and requires little muscle activity tomaintain. When the body moves away fromthe plumb-line, stress is placed on the bodytissues and muscles have to work harder tomaintain the unbalanced body position.

Assessing local muscletightness

The plumb-line posture assessment describedabove gives us an indication of segmental align-ment. From this we can predict which muscleswill have poor tone (sag) and which are likely tobe tight and require stretching. More precisetests will enable us to be more accurate about

Assessment of standingposition from behind

Ear level – hair line

Shoulder level – cervical spine

Inferior angle of scapula

Overall spinal alignment

Keyhole

Adam’s position

Skin creases

Levels of pelvic rim, asis, belt line

Buttock creases

Knee creases

Muscle bulk

Mid-line

Achilles angle

Foot position

Table 5.1 Figure 5.2 Posture plumb-line

through ear

cervical vertebrae

shoulder joint

lumbar vertebrae

centre ofknee joint

ankle bone(lateral malleolus)

pelvic crest

pubis hip joint



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which individual muscles are tight, and thereforehelp us to be more objective with our exerciseprescription.

Some of the most frequently used local clini-cal muscle tests are described below, and furthertests are listed in Chapter 15. For all thesetests, the client should be positioned ideally onan examination (massage) couch or gym bench.(For more detailed information on postural tests,see Norris, 1998.)

Thomas testThe Thomas test measures tightness in the hipflexors (iliopsoas and rectus femoris). The clientlies on their back, with their knees bent andhanging over the end of the bench. From thisposition, both legs are fully flexed, bringing theknees to the chest and flattening the lumbarcurve. The client holds one knee to their chestto maintain the lumbar position, and the otherleg is lowered towards the horizontal, allowingthe knee to extend (see fig 5.3). The positionof the femur and tibia indicates the muscletightness.

If the femur rests above the horizontal, thehip flexors are tighter than is desirable. Eitherthe iliopsoas or the rectus femoris could beaffected, and straightening the knee will distin-guish between the two. If straightening theleg allows the femur to drop down lower, the rectus is the tighter of the two muscles. This isbecause the rectus works over both the kneeand the hip (the iliopsoas does not work overthe knee) and straightening the knee takes someof the stretch off the rectus. If the femur posi-tion remains unchanged, the iliopsoas is tighterthan the rectus.

The knee, hip and shoulder should also be inline. If the femur is abducted, the ilio-tibial band(ITB) is likely to be tight. Similarly the tibiashould rest vertically. If it does not, tightness inthe hip rotators may be indicated.

Key point: The Thomas test measures tightness inthe hip flexors of the lower lying leg. Differentiationcan be made between the rectus femoris and theiliopsoas.

Ober testThe Ober test measures tightness in the hipabductors (ilio-tibial band and gluteals) and isnamed after Frank Ober, who first described itin 1935. Essentially, the test aims to assess thelength of the hip abductors while maintaining the

Figure 5.3 Thomas test: (a) knee is grippedto the chest and the opposite leg shouldtouch the couch and show 90º flexion; (b)tight hip flexors; (c) tight abductors (ITB)

(a)

(b)

(c)


POSTURE

69

neutral position of the pelvis in the frontal plane.The client lies on a bench on their side with thelower leg bent for comfort. The therapist standsbehind them level with their pelvis (see fig 5.4).The client’s leg is abducted and extended to 15degrees and the pelvis is stabilised to prevent lat-eral tilting. The therapist presses down on theclient’s pelvic rim, with their left hand anglingthe push towards the client’s lower shoulder. Thetherapist’s right hand supports the weight of theabducted upper leg. While preventing any pelvicmovement, the upper leg is lowered down, keep-ing it slightly back. Normally, the leg shouldlower to the horizontal position before any pelvicmovement is detected. In an athlete, the legshould lower to the couch top, indicating that theITB and gluteals possess adequate flexibility. Ifthe leg stops above the horizontal position, or ifpelvic movement begins with the leg in thisupper position, the ITB is tight. This test is alsodescribed in Chapter 10, exercise 102, page 147.

Key point: The Ober test measures tightness in theilio-tibial (ITB) of the upper lying leg.

Tripod testThere are many tests to assess the length of thehamstrings, including the straight leg raise and

active knee extension exercises (see exercises 131and 132 on pages 172 and 173). The tripod test,however, measures hamstring tightness andthe effect of any tightness on pelvic tilt andlow back alignment.

The client sits on the edge of a bench withthe feet unsupported. The spine is placed in itsneutral position (see page 73) with the lower backslightly hollow. From this position, one leg isstraightened and the alignment of the lumbo-pelvic area is noted (see fig 5.5). Ideally, the legshould be straightened to 70–80 degrees whilemaintaining spinal alignment. Often, the legcannot be fully straightened, and the spine sagsinto flexion, posteriorly tilting the pelvis andflexing the lumbar region. This is importantbecause it indicates that tightness in the ham-strings is dictating spinal alignment which is acommon cause of postural back pain. As well ashamstring stretching exercises, core stabilityexercises should be practised to correct the fault(see page 73).

Key point: The tripod test measures the effect ofhamstring tightness on sitting posture.

Anterior chest testTightness in the pectorals and anterior deltoidswill cause the shoulders to be pulled forwards,and is assessed with the client lying on their back.Their arm is taken out to the side into a ‘T’ posi-tion (see fig 5.6 (a)) and ideally should rest levelwith the bench. Taking the arm diagonally sothat it lies on the horizontal (frontal plane) andat 45 degrees to the spine, will stress the sternalfibres of the pectoralis major and anterior deltoid(see fig 5.6(b)). Taking the arm back to the ‘T’ posi-tion and then lowering the arm down the side ofthe bench will stress the clavicular fibres of thepectoralis major (see fig 5.6(c)). In this position,the arm should lie at 70–80 degrees to the chest.

Figure 5.4 Ober test



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The shoulder can also be pulled forwards bytightness in the pectoralis minor, which attachesfrom the upper ribs to the corocoid process ofthe scapula. When this is the case, the back of theshoulder is pulled off the bench in supine lying.Normally, the back of the shoulder should be nomore than two to three finger breadths from thebench.

Shoulder adductorsTightness in the shoulder adductors (lattis-simus dorsi and pectoralis major) will limit arm

abduction. The latissimus is measured in asupine lying position. The arm is laterally rotated(because the muscle is a medial rotator) andabducted in an attempt to take it behind theear. Normally, the arm should rest flat on thefloor (see fig 5.7). Refer to the ‘Anterior chesttest’ for assessment of the pectoralis major.

Postural faults andcorrection

Enhancing core stabilityBefore we begin to correct postural faults withstretching, we must ensure that an individual canhold firmly the origin of the muscles to bestretched. If this is not done, when we stretchboth ends of the muscle will move and align-ment will be poor. Many of the large muscles ofthe lower limbs attach to the lumbo-pelvicregion, while many muscles of the upper limbsattach to the scapula. Both of these areas must bestabilised before stretching begins.

The neutral spine positionThe lumbo-pelvic region is stabilised by thedeep abdominal muscles (transversus abdominisand internal oblique). Looking at figure 5.8,we can see that the superficial abdominals(rectus abdominis and external oblique) havefibres which run more or less vertically whilethe deep abdominals have largely horizontalfibres. When the muscles pull, therefore, thesuperficial abdominals will pull the pelvis tothe rib-cage (flexion or rotation), while the deepabdominals will pull the abdominal wall to thespine and ‘tighten the girdle’. In this way the deepabdominals are more able to stabilise the trunkand hold it in a ‘neutral position’ – mid-waybetween flexion (flat back) and extension (hollowback) (see fig 5.9). The neutral position aligns thelumbar tissues optimally and places least stressupon them.

Figure 5.5 Tripod test: (a) pelvis level, legstraightens; (b) tight hamstrings causebackwards pelvic tilt and lumbar flexion

(a)

(b)


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Figure 5.6 Anterior chest test: (a) ‘T’ position; (b) stressing the sternal fibresof pectoralis major and the anterior deltoid; (c) stressing the clavicular fibres ofpectoralis major

(a)

(b)

(c)


When we move away from the neutral posi-tion, stress is increased. As we increase thehollow of the lumbar spine, the facet joints at theback of the spine are compressed. Over time, thiscan cause pain and joint damage, possibly lead-ing to wear and tear of the joints themselves. Ifwe reduce the hollow in the back, the spine is

flexed and stress moves from the facet joints on tothe disc. The flexion stress compresses the disc,tending to force it on to the nerves of the lowerspine. This type of posture can give pain throughnerve compression or nerve entrapment.

Key point: The neutral position of the lumberspine lies mid-way between forward (hollow back)and backward (flat back) tilting of the pelvis.

How to find your neutral spine positionTo find the neutral position of the lower spine,we begin standing upright. Tilt the pelvisbackwards, forcing your spine to flex (flatten)and then tilt your pelvis forwards, extending(hollowing) your spine. The neutral position ismid-way between fully flattening and fullyhollowing the spine. It should be the mostcomfortable position, depending on your pos-ture type. (Posture types are discussed in detaillater in this chapter.)


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Figure 5.7 Measuring tightness in thelatissimus dorsi: full abduction iscombined with lateral rotation

Figure 5.8 The abdominal muscles

(a)

rectusabdominis

(b)

externaloblique

(c)

transversusabdominis

(d)

internaloblique



172

Starting position and instructionsLie on the floor on your back and flex one hip,slowly raising the straight leg. At the same time,pull your toes towards you (dorsiflexion).Maintain the full stretch position for 20–30 sec-onds, then slowly lower.

VariationsThe neural component of this stretch is increasedby dorsiflexing the foot further, adducting thestraight leg and flexing the neck to ‘wind up’ thespinal cord from above.

Points to note The straight leg raising (SLR) movement isused as a test when a person has back pain. Theaim is to see if the action produces pain fromthe back into the buttock and down the leg intothe foot. If this is the case, it follows that the sci-atic nerve is trapped; this is caused frequentlyby an intervertebral disc that has bulged orburst into the path of the nerve root at its junc-tion with the spinal cord. The SLR action is agood illustration of the various stages of nervemovement that occur as a stretching exercise isperformed. As the leg is raised initially, the sci-atic nerve slides through a notch in the pelvis;as the leg is raised further, between 20–30degrees of hip flexion, the nerve roots start tomove past the individual vertebrae. Movementof the nerve past neighbouring structures stopsaltogether as the leg is raised past 70 degrees.

From this position to the full range stretch of90 degrees, the nerve is stretched like an elasticband. Sliding of the nerve, therefore, occursbelow 70 degrees, with stretching only comingon from this range to the end of the straight legraise movement (see fig 12.4).

The SLR action is useful for mobilising andthen stretching the sciatic nerve when its normalfree motion is reduced, frequently as a result ofprevious back pain.

Starting position and instructionsLie on the floor on your back, flex one of yourhips and knees and place your hands behindyour knee. Straighten your leg, keeping yourknee directly above your hip.

Straight leg raise –neural emphasisExercise 131 Figure 12.4 Effects of straight leg

raising (SLR): (a) movement of sciaticnerve begins at the pelvis; (b) movement ofroots begins at the spine; (c) minimalmovement only, but increase in tension

Active knee extension – neuralemphasis

Exercise 132

90°70°

30°

20°

(a)

(b)

(c)


VariationsGreater stress is placed on the nerve, ratherthan the hamstring muscles, by medially rotatingyour hip and pulling your foot towards yourbody (dorsiflexion).

Points to note Make sure that your knee stays directly aboveyour hip. There is a tendency with this move-ment to allow your knee to drop downwards sothat your leg can be locked. However, the down-ward movement of the knee actually releases thestretch by reducing hip flexion.

Starting position and instructionsLie in a doorway with one leg straight alongthe floor and the other positioned with theheel on the doorframe. Gradually straightenthe wall-supported leg by sliding your heelupwards, keeping it in contact with the door-frame. At the same time, dorsiflex your footand place overpressure from the hand on tothe knee to encourage the last few degrees ofmovement. The full stretch should be held for30 seconds.

VariationsAs a progression, both legs can be stretched atonce by placing them both on the wall.

Points to note If your heel is allowed to leave the wall sup-port, the stress placed on your spine can beconsiderable as the low back may be forced intoan extension equivalent to a bilateral straightleg raise. At all times, keep your heel in con-tact with the doorframe or wall.

Starting position and instructionsStanding, flex one of your knees and pull yourhip back into extension. At the same time, flexyour trunk (spine) and bring your chin down onto your chest (cervical flexion).

VariationsThis movement can also be performed lying onyour side, in which case the upper leg is the onethat is stretched.

Points to note This is a variation of the rectus femoris stretch(see exercise 7, page 97). In that stretch, the trunkis kept upright to emphasise the effect on themuscle. In the femoral nerve stretch however,the nerve is emphasised by flexing the trunkand cervical spine.

Straight leg raise –using doorway – neural emphasis

Exercise 133

Femoral nerve stretch

STRETCHING THE NERVES

173

Exercise 134


Starting position and instructionsThis movement is the same as exercise 91 (seepage 140), but when performed in the pres-ence of neural tightness it is the nerve ratherthan the muscles which takes the predominantstretch. Stand side on to a wall and place yourhand on the wall at shoulder height, with yourfingers horizontal and facing backwards.Slowly turn your body and head away fromthe wall, straightening your arm as you do so.

VariationsPressing down on the stretched shoulder (depres-sion) with the other hand will increase the stretchfurther.

Points to note In the arm, three nerves need to be stretched: theradial nerve, the medial nerve and the ulnarnerve. Since all three come from the spinal cordin the thoracic region, they form a meshwork ofnerve roots called the brachial plexus. The nervesof the brachial plexus are often stretched by aphysiotherapist using the upper limb tension test(ULTT) in the same way that the SLR is used tostretch the lower limb nerves.

Starting position and instructionsBegin standing and keeping your shoulderdown, adduct your right arm, rotating it inwardsto place it behind the small of your back. Flexyour wrist and pronate your forearm. Take holdof your wrist with your other hand and pressyour wrist into further flexion.

VariationsThe stretch can be increased by flexing your neck(looking downwards). Shrugging your shoul-ders (scapular elevation) reduces the stretch.

Points to note This exercise stretches the wrist extensors on theback of the forearm. To increase the emphasis onthe nerve itself, the cervical flexion is important.


174

Radial nerve stretchExercise 136Brachial nerve stretchExercise 135


Starting position and instructionsBegin standing and, keeping your shoulderdown, adduct your right arm and rotate itoutwards. Extend your wrist and supinate yourforearm. Take hold of your wrist with your otherhand and press your wrist into further extension.

VariationsThe stretch can be increased by flexing yourneck (looking downwards). Shrugging yourshoulders (scapular elevation) reduces thestretch.

Points to note This exercise stretches the wrist flexors on thefront of the forearm. To increase the emphasis onthe nerve itself, the cervical flexion is important.

Starting position and instructionsBegin sitting and, keeping your shoulder down,abduct your right arm and flex it at the elbow toreach your hand to the side of your head, asthough placing the flat of your hand over your ear.

VariationsThe stretch can be increased by flexing yourneck sideways away from your stretched arm.

Points to note If the ulnar nerve is very tight, pins and needleswill be felt on the outside of the elbow over the‘funny bone’.

Summary

• There are two types of nerve cell: those thatcarry electrical impulses and those that pro-tect and support the nerves.

• All the nerves and the spinal cord are linkedinto a ‘continuous tissue tract’.

• Nerves will slide as a limb is stretched. • After injury, sticky swelling will ‘tether’ a

nerve, reducing its normal movement.

• A nerve has several vulnerable areas where itmay be trapped or its movement restricted.

• When a nerve is stretched, its blood flow isreduced. Repeated nerve stretches shouldtherefore be avoided.

• Nerve stretching exercises resemble musclestretches, but with subtle changes. They mustbe exact.

• When stretching a nerve, hold the stretchposition at a point just short of feeling tin-gling or pain.

Ulnar nerve stretchExercise 138

STRETCHING THE NERVES

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Median nervestretchExercise 137

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The concept of working on fascia has a long his-tory in the physical therapies. It was first discussedin the work of Ida Rolf in America, who describeda type of bodywork she called ‘structural integra-tion’. Most recently, this work has been champ -ioned by Tom Myers, Leon Chaitow and JudithDeLany. Myers has produced an excellent bookin which he maps the myofascial meridians, and hasa number of videos dealing with this subject underthe name ‘Anatomy Chains’. Chaitow andDeLany have produced two in-depth text booksdealing with fascial treatment, or ‘neuromusculartechnique’ (NMT). Much of the information forthis chapter is taken from these publications, andthe reader is referred to them for a more detailedstudy of this subject. All are listed in the referencesat the end of the book.

What is fascia?

The body is composed of four basic types of tissue: epithelial, connective, muscular and nerv-ous (see table 2.2, page 21). Epithelial tissue covers surfaces or forms structures; for example,it makes up the glands and digestive system.Connective tissue consists of disparate cells float-ing within an extracellular matrix; depending onthe cells present, connective tissue may form car-tilage, bone or fascia. Muscular tissue contracts;it forms the muscles we train in the gym, as wellas the muscles of the heart and those controllingthe hair follicles in the skin. Nervous tissuemakes up our nerves, spinal cord and brain.

To find out more about fascia, we need tofocus on the connective tissue. Connective tissueis made up of fat (storage) and fibrous tissue(structure). The fibrous tissue contains collagen(white), a strong tough substance that gives thetissue its strength, and elastin (yellow), whichgives the tissue its spring. Depending on the con-centration of collagen and elastin, the connectivetissue is either tough or pliable. Tendons, liga-ments and the membranes covering bones andcertain portions of the fascia contain mainlywhite fibres, whereas specific fascia such as theligamentum flavum in the neck and the wall ofblood vessels are mainly yellow elastic tissue.

So, fascia is a type of connective tissue. Itlinks parts of the body together and transmitssome of the force created by the muscles. Moreimportantly, it provides a continuous tract cov-ering several bones and muscles leading to a‘line of pull’ that is not restricted to a singlemuscle.

Types of fascia

Fascia itself is subdivided into two types, superfi-cial and deep. The superficial fascia lies justbeneath the skin, acting as a base to enable theskin to move freely over the underlying tissues.A loosely arranged, folded meshwork with thefolds filled with fat, the superficial fascia dictatesthe body contours and gives each of us ourunique look. This portion of the fascia is themain place where fat is deposited in obesity,

STRETCHING THE FASCIA 13


hence the use of skin-fold measurements to assessbody-fat percentage.

The fat within the superficial fascia providesus with insulation and is very important in pre-venting heat loss, especially as we are smoothskinned rather than furry like a cat. Interestingly,in most other mammals (i.e. those with fur), thesuperficial fascia does not contain fat. For thisreason, the skin of a cat is only loosely connectedto the underlying tissue, which is why you canpick the animal up by the scruff of its neck. Thisis not the case with a person; the skin is too tight!On its under-surface, the superficial fasciabecomes more fibrous and forms a distinct layer,which normally then connects to the deep fascia.

The deep fascia is tougher and more fibrousthan the superficial fascia and surrounds almostevery structure in the body. The deep fasciatends to be laid down in the direction of stressand attaches itself to bony projections as it passesover them. The under-surface of the deep fasciatravels between muscle layers as the inter -muscular septa, separating the groups of musclesfrom each other. The muscles are thus groupedin ‘compartments’ (see fig 13.1). In the case ofthe arms, these are the flexor and extensor com-partments, and in the thigh they are the flexor,extensor and adductor compartments, for example.

The fascial membrane takes on a variety ofnames depending on its anatomical position.Around the brain and spinal cord it is themeninges, around the heart it is the pericardium,within the abdomen it is called the peritoneumand around the bones, it is known as theperiosteal. Even within the musculo-skeletal system fascia may be specialised. At the side ofthe leg we have the ilio-tibial band (ITB) and inthe back the thoraco-lumbar fascia (TLF). Theimportant feature, however, is that all of the layers of fascia are connected to each other. Fasciais really a ‘soft tissue skeleton’, as it supports thebody, forms boundaries and moulds the shape of

the body tissues. It is not really possible to per-form a stretching exercise and affect only onemuscle; when we stretch, one muscle mayreceive the greater stretching effect, but both themuscle and the fascia will change tension. Forthis reason, we can talk of muscle and fascia as asingle inseparable unit called myofascia.

Key point: Fascia is our ‘soft tissue skeleton’, a pos-terior surface forming a continuous covering thatlinks our bones, joints and muscles together.

Fascial pathways

According to Myers (2001), there are four mainfascial pathways (see table 13.1). The superfi-cial back line (SBL) supports the body in full

STRETCHING THE FASCIA

177

Figure 13.1 A gross muscle fascia

bonemusclefascia



178

extension, preventing it from collapsing into flex-ion. It is therefore important in forward bendingand lifting tasks. The superficial front line (SFL)transmits muscle force to create powerful flexionof the legs and trunk. The lateral line (LL) isimportant for single leg actions during walkingand running, as well as for lateral bending activi-ties of the trunk. Finally, the spiral line (SL) creates rotational movements of the body, whichare important during functional activities such aswalking and running as well as during sport.

Each of the four major fascial pathways links avariety of myofascial structures, which aredetailed in table 13.2. When performing anystretch, we can increase the emphasis on the fascial pathways by involving more of these struc-tures. For example, when performing a sit-and-reach stretch (exercises 24, page 106, and 108,page 150), the stretch works the hamstrings and

Fascial pathways

Pathway Position

Superficial back line Connects posterior surfaceof body from toes to kneesand then knees to brow.

Superficial front line Anterior body surface fromtop of feet to the sides ofthe skull.

Lateral line Foot and outside of anklealong the lateral aspect ofthe leg and trunk to the ear.

Spiral line (takes From one side of the skull, portions from the across the back to theother three) opposite shoulder and

then back across the chestand down the side of the body. From the foot up the back to rejoin the skullfascia.

Table 13.1

Fascial pathways in detail

Superficial • Scalpback line • Erector spinae and

thoroco lumbar fascia• Sacrotuberous ligament• Hamstrings• Gastrocnemius and Achilles• Plantarfascia and short

toe extensors

Superficial • Scalpfront line • Sternomastoid

• Sternal fascia• Rectus abdominis• Rectus femoris and

quadriceps• Patellar tendon• Toe and foot extensors

Lateral line • Sternomastoid and deep neck muscles

• Intercostals• Lateral abdominals• Gluteus maximus• Tensor fascia lata• Hip abductors• Fibular ligament• Peroneal muscles

Spiral line • Deep neck muscles (splenius)• Rhomboids• Serratus anterior• Oblique abdominals• Abdominal fascia• Ilio tibial tract (ITB)• Tibialis anterior• Peroneal longus• Biceps femoris

• Sacrotuberous ligament• Erector spinae and

thoroco-lumbar fascia

Table 13.2


spine. The myofascial effect on the superficialback line can be increased by bending thespine, touching the chin to the chest anddrawing the foot into dorsiflexion.

The superficial back line (SBL)

Starting position and instructionsSit on a mat with your legs straight. Bend for-wards from the waist, flexing the whole of yourtrunk and neck, and try to touch your chin to thetop of your breastbone. At the same time, pullyour feet and toes towards you (dorsiflexion ofthe ankle and extension of the toes).

VariationsTo increase the intensity of the stretch, place ayoga belt or hand towel around your feet andtoes and gently pull the toes towards you.

Points to note This stretch targets the whole of the SBL, involv-ing the plantarfascia, calf and hamstrings, thenright up through the spine to the scalp. However,with overpressure from the yoga belt or handtowel, the pressure within the lumbar discs willbe increased. This is not recommended for indi-viduals with a history of a disc lesion (slippeddisc), unless supervised by a physiotherapist.

Starting position and instructionsStand with your feet hip-width apart. Keepingyour back straight, bend your knees and reachdown to touch the floor with your flat hands.Keeping the hands in place, walk your feetbackwards until they are 1–1½ m away fromyour hands and your body forms an upsidedown ‘V’. Keep your arms straight and pressyour chest downwards to straighten yourback.

VariationsTaking your feet further backwards will bringyour legs closer to the horizontal and increasethe angle of dorsiflexion at the ankle, placing agreater stretch on the calf and achilles. Bringingthe feet closer to the head will releases some ofthe stretch on the calf and enable you to pressyour chest further down, increasing the stretchon the chest and shoulders.

Points to note This is a classic yoga posture that stretches theSBL while taking some of the flexion stressaway from the spine. If you find your feet slip-ping, practise the position with your heelsagainst a wall. If you are unable to reach thefloor, place your hands on a low bench (stepbench) instead.

Downward dogExercise 140

Forward bend withbeltExercise 139


179



180

Superficial front line (SFL)

Starting position and instructionsLie on a mat with your hands beneath yourshoulders. Press down with your hands and straighten your arms, arching your back. Whenyou get to the top of the movement, look uptowards the ceiling (cervical extension) and bendyour knees (knee flexion).

VariationsIf you are unable to straighten your arms, placeyour arms further forwards (a forearm’s length infront of the shoulder line) and slightly widerapart (1½ times wider than your shoulders).

Points to note This exercise, like exercise 40, page 114 forces thelower back (lumbar region) into extension.Encouraging extension in the lumbar region isusually a good thing, unless you have a hollowback (lordotic posture). If this is the case, thismovement may be painful, so stop if you feel painrather than simply tightness in the lower back andseek advice from a physiotherapist or qualifiedpersonal trainer.

Starting position and instructionsLie on a gym bench or bed with your bottomsupported but your lower thighs off the bed.Bend your knees and at the same time reachoverhead, trying to touch the bench above you.

VariationsThe SFL stretch can be increased by placing theshoulders on a cushion so that the neck canlower into extension. In addition, pointing thetoes and feet (plantarflexion and toe flexion) willtarget the toe and foot extensors, which form thelower part of the SFL.

Points to note If you find it too difficult to stretch your armsoverhead to touch the bench, place a pillow onthe bench above your head and lower your armsonto that instead.

Passive full spineextension with kneeflexion

Exercise 141

Lying overhead reachwith knee flexionExercise 142


Lateral line (LL)

Starting position and instructionsStand left side on to a table or high gym benchand place your left hand on the bench for sup-port. Draw your right leg across and behind yourleft leg (hip adduction) and reach your righthand overhead, towards your right ear. Bend tothe left, taking your body-weight through yourleft hand onto the tabletop, and move your leftear towards your left shoulder. Reverse themovement by bending to the right.

VariationsAlthough the complete movement stretches thewhole of the LL, you can add the componentsgradually. First, perform the hip adduction withtrunk side flexion. Second, perform the over-head reach and neck side flexion. When you are

comfortable with both movements, combine thetwo into a single action as described above.

Points to note It is common to have an asymmetrical body, sodo not be surprised if one side of your body isstiffer than the other. Work on the stiffer side,aiming to regain symmetry rather than simply toincrease the range of motion.

Starting position and instructionsLie on your right side with a pad or folded towelbeneath your lower hip (greater trochanter). Placeyour right hand beneath your right shoulder andpress down, stretching your spine into lateral flex-ion. At the same time, reach your left arm alongthe outside of your left leg. When your trunk isupright, flex your neck to the left and take a deepbreath to expand your ribcage.

VariationsIf you are unable to lock your arm out straight,move it further away from your body.

Points to note As with all side stretches, it is common to findthat one side of your body is stiffer than the other.Work on the stiffer side, aiming to regain sym-metry rather than increase the range of motion.

Side lying sideflexionExercise 144

Supported side flexionwith hip adductionExercise 143


181


First published in 1999 byA&C Black Publishers Ltd36 Soho Square, London W1D 3QYwww.acblack.com

3rd edition 2007Reprinted 2010

Copyright © 1999, 2007 Christopher M. Norris

ISBN 9780713683486

All rights reserved. No part of this publication may be reproduced in any form or by any means – graphic,electronic or mechanical, including photocopying, recording, taping or information storage and retrieval systems– without the prior permission in writing of the publishers.

A CIP catalogue record for this book is available from the British Library.

Typeset in Baskerville by Palimpsest Book Production Ltd, Grangemouth, Stirlingshire

Cover image © Getty Images Inside photography © Grant PritchardIllustrations © Jeff Edwards

This book is produced using paper that is made from wood grown in managed, sustainable forests. It is natural,renewable and recyclable. The logging and manufacturing processes conform to the environmental regulationsof the country of origin.

Printed and bound in China

NoteWhilst every effort has been made to ensure the contentof this book is as technically accurate as possible, neitherthe author nor the publishers can accept responsibility forany injury or loss sustained as a result of the use of thismaterial.

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