motion, as this could create hypermobile joints and result in injury.
Tell the client that the stretches will take only a few minutes a day to perform and are necessary for contin- ued results.
The client should stretch after some movement, mod- erate exercise, or a hot shower when the fascia and muscles are warm.
Tell the client to not stretch into pain. He or she needs to differentiate between uncomfortable stretching due to tight muscles and painful stretching that can aggra- vate a pre-existing clinical condition.
The client starts the stretches with the tightest side first until normal range of motion and normal muscle resting lengths are achieved. Then he or she can continue to stretch both sides for continued balance and symmetry.
Suggest only two to four stretches, specific for the condition, each time you see a client. Make sure he or she can perform these correctly before suggesting any additional stretches.
Print copies of the stretches for your clients to take with them for reference.
PATELLAR TENDINOSIS—QUADRICEPS
1. Have the client perform the following stretch:
The client is prone with one knee bent.
This stretch must be performed with a rolled towel behind the knee, especially if he or she had a meniscus injury to traction the tibia away from the femur. This will help decompress the knee.
The client reaches back and grasps the ankle. He or she attempts to extend the knee against his or her own resistance with 20 percent force for 5 to 10 seconds. (The client may use a stretch rope if it is uncomfortable to grab the ankle.)
The client relaxes, takes a deep breath, and then on exhale pulls the ankle to the hip for about 2 seconds.
This is a passive stretch; the client does not engage the hamstrings, as this may result in a hamstring cramp.
The client repeats the stretch 8 to 10 times, then repeats on the other leg, if needed.
FIGURE 3-39 Quadriceps Stretch.
DISTAL HAMSTRINGS
Oftentimes, especially in the right knee, there will be exces- sive lateral rotation from the way a person drives a car. This shortens the biceps femoris (lateral hamstring), resulting in problems like posterior fixated fibular head pain. This can mimic or compound pain in other structures such as the ITB, LCL, and lateral meniscus. If this is not corrected, it can create shearing force on the knee, resulting in damage to the ligaments and meniscus of the knee. If lateral rotation of the knee is present, it is critical to stretch the lateral hamstrings to also treat the primary cause of pain in the popliteus. If medial rotation is present in the knee, stretch the distal medial ham- strings to correct rotational problems. Do not stretch the distal lateral or medial hamstrings separately, if there is not rotation in the knee; just stretch all hamstring groups equally.
The client is supine.
To stretch the distal hamstrings when there is no rotation at the knee, the client loops the stretch rope around the foot with the strap ending up near the heel.
PLANTARIS AND GASTROCNEMIUS
The client is seated with one leg straight with the stretch rope around the ball of that foot.
He or she brings the ankle to dorsiflexion to lengthen the plantaris and gastrocnemius.
Then the client plantar flexes the ankle against the resis- tance of the rope for 5 to 10 seconds at 20 percent force.
He or she relaxes, inhales, then on exhale actively dorsiflexes the ankle and fully extends the knee while gently pulling back on the rope for about 2 seconds (Figure 3-41 ■).
At this new position, the client repeats the stretch sev- eral times, repeating it on the other leg, if needed. He or she stabilizes the femur in a neutral position
with one hand so it does not rotate, while holding the stretch rope with the other hand, keeping the arm straight (Figure 3-40A ■).
The client extends the knee, assisting by pulling up on the rope at the lateral side of the leg (Figure 3-40B ■).
This restores knee extension and takes stress off the structures of the knee.
The client repeats the stretch on the other leg, if needed.
FIGURE 3-40A
Distal Hamstring Stretch—Start.
FIGURE 3-40B
Distal Hamstring Stretch—Finish.
FIGURE 3-41 Gastrocnemius Stretch.
CORE PRINCIPLE
It is imperative for the client to lift up on the stretch rope; otherwise too much pressure is created in the knee. If the gastrocnemius is too tight to allow the leg to straighten, the client should stretch it in addition to this hamstrings stretch. He or she should perform the following plantaris– gastrocnemius stretch separate from this stretch. When stretching the gastrocnemius with the hip flexed and knee extended, it can compress the meniscus and create a sec- ondary injury.
GLUTEUS MAXIMUS LATERAL FIBERS
The client performs this stretch to eliminate ITB pain.
The client is supine with both the knee and the hip flexed 90 degrees.
He or she stabilizes the hip of the involved leg with one hand and places the other hand on the lateral side of the knee.
He or she actively medially rotates the hip.
The client attempts hip abduction at 20 percent force against his or her own resistance for 5 to 10 seconds (Figure 3-42 ■).
He or she relaxes, takes a deep breath, and on exhale actively adducts the leg across the body as he or she assists the stretch for about 2 seconds.
At this new position, the client repeats the stretch two or three times.
TENSOR FASCIAE LATAE
The client performs this stretch to eliminate ITB pain.
The final step in the twelve-step approach to pain man- agement is strengthening the weak, inhibited, and sometimes overstretched muscles. These muscles may lack blood flow and oxygen and need to be strengthened to allow complete structural balance throughout the body. Strengthening is essential to a client’s continued improvement and recovery, and prevention of injury. Demonstrate the strengthening exercises for the client and then instruct him or her on how to practice the movements at home. The only items needed are a Thera-Band (for resistance) and a towel.
TECHNIQUES FOR STRENGTHENING
Goal: to strengthen weak, inhibited muscle groups around a joint creating muscle balance throughout the body— structural integration.
The client should stretch the tight antagonist muscles first.
Show the client how to control and adjust the amount of resistance on the Thera-Band.
Make sure the client’s movements while performing the exercises are slow and controlled during both the concentric (muscle shortening phase) and eccentric (muscle lengthening phase) contractions, placing
more emphasis on the eccentric phase.
Tell the client that only 5 to10 minutes per day is needed to perform both stretching and strengthening exercises for any condition.
Empower clients to take responsibility for reeducating their muscles, keeping their body aligned, and partici- pating in their own wellness.
VASTUS MEDIALIS
The client must stretch the vastus lateralis (quadriceps) and the ITB before strengthening the vastus medialis. This prevents lateral tracking of the patella and is the key to eliminating the primary cause of patellar tendinosis and chondromalacia.
The vastus lateralis is typically stronger than the vastus medialis creating the lateral tracking of the knee. To correct this problem it is imperative that the client strengthen the vastus medialis to return the knee to proper and optimum balance and to prevent injury in the future. See video clip on www.myhealthprofessionskit.com.
He or she places a stretch rope around the ankle of the involved leg, coming around the outside of the ankle and then under that leg.
The client laterally rotates (turns outward) this leg and places a hand on the hip to stabilize it.
Then he or she exhales and adducts the leg for about 2 seconds, assisting with the rope while keeping the arm straight out to the side (Figure 3-43 ■).
He or she repeats the stretch 8 to10 times, then repeats it on the other leg, if needed.
MEDIAL AND LATERAL MENISCUS
There are no self-stretches for the client, as the risk for rein- jury is too great. He or she should have someone gently traction the knee to decompress the muscles in that area, and keep the muscle groups around the knee released and balanced.
Step 12: Strengthening (Client Self-Care)
The client must stretch the tight, contracted muscles before strengthening the opposing weak muscles.
FIGURE 3-43 TFL Stretch.
FIGURE 3-42
Gluteus Maximus Lateral Fiber Stretch.