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CHAPTER
Assessing Flexibility
ot everyone has the same flexibility needs or flexibility potential. Our flexibility potential is affected by genetics, gender, age, lifestyle, medical history, occupation, and, of course, type and level of physical activity. It is therefore unwise to assume that all stretches are beneficial and safe for everyone. For example, some individuals may have particularly tight hamstrings or pectoral muscles that deserve specific attention. These same individuals may also have a hyper- mobile lumbar spine that should not be stretched. This chapter is designed to help you construct an effective stretching program based on individual need. As each individual has unique flexibility needs, the first step toward developing a specific flexibility program is to assess posture and available range of motion (ROM). We can then compare the available motion to the determined need to develop the most appropriate flexibility program. This chapter has been developed to help you perform this assessment. It provides a head to toe testing sequence to help deter- mine if ROM is adequate, restricted, or excessive. Please keep in mind that these tests are meant as a guide and the ROM normative data are averages based on a healthy college age population. To determine useful ROMs at particular joints for particular athletic pursuits, the reader is encouraged to seek sources specific to that particular sport or activity. Additional sources are listed at the end of this chapter. After a brief discussion of posture assessment (a more thorough discussion of pos- ture is provided in Chapter 7), this chapter describes techniques for assessing move- ment at all major joints. A description of normal movement is followed by information on identifying the amount of motion expected. This information is provided as a guide to help determine if changes in ROM are necessary and generally to what degree. It should be used in concert with knowledge of both need and the individual’s physio- logic makeup. For more specific assessment, numerical data have been provided as a reference. In most cases, these numerical values are derived from the Measurement of Joint Motion by Norkin and White.^1 We have chosen to use this source as it was the only available source that offered ROM values throughout the body. Other sources found slightly different values for select joints; to include all of these sources would be extremely cumbersome, distracting, and of no real benefit to the intended use of this chapter, which is to provide general guidelines for ROM and how to assess it. As Norkin and White have used a number of different references, we have chosen those values published by the American Academy of Orthopedic Surgeons (AAOS) to ensure consistency and avoid confusion with differing values. In cases where Norkin and White did not provide values (or these values were not useful for this specific application), we have chosen an alternative source. In these cases, alternative sources are listed. We have attempted to provide these ROM values in two basic forms: first
Assessing Posture Assessing Range of Motion Cervical Spine Shoulder Elbow Wrist, Hand, and Fingers Thoracic and Lumbar Spine Hip Knee Ankle, Foot, and Toes Summary
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in terms of a practical measurement as described in the “test” and then, more formally, in degrees. This format allows the text to be used as both a quick reference to expected motion and as a more detailed evaluation tool. The muscles that may be causing the restriction are listed under the headings “General Stretch” and “Specific Stretches,” which identify a stretch for either the muscle group (from Chapter 5) or for each indi- vidual muscle (from Chapter 4). The techniques for performing the recommended stretches are detailed in Chapters 4 and 5. The tests in this chapter may be used to make an initial evaluation and also to measure the progress of the prescribed stretching program. Consider recording the test “scores” obtained at the initial evaluation, and then again at regular inter- vals such as 6 or 12 weeks. In this way, you can track progress in particular “prob- lem” areas.
CAUTION! Please bear in mind that the information in this chapter is intended to be used only as a guide. Individuals with painful or particularly restricted or hyper- mobile movements should be referred to their primary care provider. While listing every possible restriction to joint movement that you should be aware of would necessitate a chapter on its own, we have denoted a couple of situations in which injuries are fre- quently encountered. These are identified by the “Caution!” symbol.
ASSESSING POSTURE
For the purposes of this discussion, we will define posture as the position in which the upright body is held. It is typically characterized by the relationship of skeletal regions, such as the head, spinal regions, pelvis, knees, and ankles, with one another. Posture results from the interaction of a number of factors including strength, flexibility, joint ROM, age-related factors, gender, and genetics. These components may be influenced throughout an individual’s growth and development by activity level, types of physi- cal activities pursued (including athletic pursuits, occupation, and avocation), medical history, and possibly even social factors such as self-esteem. “Good” posture reflects a positioning of the skeleton that allows for optimal func- tioning of all of its individual components. It is generally described as a position in which the ear, shoulder, hip, and knee are aligned over a point just in front of the ankle joint (Fig. 3.1). In the spine, this is usually synonymous with the existence of three gen- tle curves—the concave cervical curvature, the convex thoracic curvature, and the con- cave lumbar curvature. These curves may be influenced by the amount of flexibility in the muscles that help control motion at these joints. Posture is much more than aesthetic. Good posture allows for the optimal function- ing of joints throughout the body. It also allows for the optimal function of the internal organs. In contrast, poor posture may cause excessive or abnormal stress on the verte- bral column as well as on the muscles, tendons, ligaments, and connective tissues that support it. Increased pressures on intra-thoracic organs may also impair blood flow and compromise the functions of these organs. Common postural abnormalities include forward head, rounded shoulders, in- creased thoracic curvature, increased lumbar curvature, and hyper-extended knees (Fig. 3.2). A flexibility program designed to help correct the components of this com- mon “poor” posture should address the following:
- Forward head: Lower cervical and upper thoracic extensors may be overstretched. Lower cervical flexors and upper cervical extensors may need stretching.
- Forward and rounded shoulders: Spinal and thoracic extensors, scapular adduc- tors, and shoulder external rotators may be overstretched. Spinal flexors, shoulder
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Cervical Spine
Below are flexibility tests for the cervical spine.
CAUTION! Please be aware that restrictions in movement at the cervical spine that cause light-headedness, dizziness, local or referred pain, tingling, or numbness may indicate potentially hazardous injury to joint, nerve, or blood vessel. These cases should be thoroughly evaluated by a professional specializing in spinal dysfunction before continuing.
CERVICAL FLEXION: UPPER
TEST POSITION. Standing with head, shoulders, back, and heels against the wall. Both hands are placed behind the cervical curvature to maintain the curve and ensure that motion occurs above this level. TEST. Nod the head attempting to isolate movement to the upper vertebrae. Check for 10–20 degrees of “nod” with no change in position of lower cervical vertebrae (Fig. 3.3). AVERAGE MOTION AVAILABLE. 15 degrees (total flexion/extension at the atlanto- occipital joint) 2 GENERAL STRETCH. Cervical extensors SPECIFIC STRETCHES. Rectus capitus posterior major and minor, and obliquus capitus superior and inferior
FIGURE 3.3 Test of cervical flexion: upper
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FIGURE 3.4 Test of cervical flexion: lower
FIGURE 3.5 Test of cervical extension
CERVICAL FLEXION: LOWER
TEST POSITION. Standing with head and shoulders against the wall TEST. Flex the head, moving chin toward chest. Chin should come within one inch of the sternum (Fig. 3.4). AVERAGE MOTION AVAILABLE. AAOS 45 degrees GENERAL STRETCH. Cervical extensors SPECIFIC STRETCHES. Longissimus capitus, semispinalis capitis, and splenius capitus
CERVICAL EXTENSION
TEST POSITION. Standing, facing a wall, nose touching wall TEST. Place the fingers of one hand just beneath the occiput. Look up toward the ceiling by lifting the chin up along the wall, encouraging a lengthening along the front of the neck while carefully guiding the motion up and back (Fig. 3.5). There should be 1–2 finger widths ( 1 ⁄ 2 –1 inches) between the occiput and the seventh cervical vertebra (prominent bump at the bottom of neck/upper shoulders). AVERAGE MOTION AVAILABLE. AAOS 45 degrees GENERAL STRETCH. Cervical flexors SPECIFIC STRETCHES. Longus coli, sternohyoid, omohyoid, platysma
42 STRETCHING FUNDAMENTALS
FIGURE 3.8 Test of shoulder flexion
Shoulder
Below are flexibility tests for the shoulder region.
SHOULDER FLEXION
TEST POSITION. Standing in doorway, arms overhead, palms against inside of doorway. TEST. Keeping spine straight, move forward in doorway (Fig. 3.8). Arms should extend vertically. AVERAGE MOTION AVAILABLE. AAOS 180 degrees GENERAL STRETCH. Shoulder extensors SPECIFIC STRETCHES. Posterior deltoid, latissimus dorsi, teres minor, teres major, triceps brachii-long head
SHOULDER EXTENSION
TEST POSITION. Standing, hands held together behind back TEST. Lift hands behind back, keeping elbows straight (Fig. 3.9). Arms should extend about 12 inches behind back. AVERAGE MOTION AVAILABLE. AAOS 60 degrees GENERAL STRETCH. Shoulder flexors SPECIFIC STRETCHES. Anterior deltoid, pectoralis major—clavicular portion, biceps brachii—long head, coracobrachialis
FIGURE 3.9 Test of shoulder extension
SHOULDER ABDUCTION
TEST POSITION. Standing with back against the wall, arms extended horizontally from shoulders, palms facing up TEST. Abduct both arms, keeping them flat against the wall (Fig. 3.10). Hands should come together and upper arms should come in contact with the head. AVERAGE MOTION AVAILABLE. AAOS 180 degrees GENERAL STRETCH. Shoulder adductors SPECIFIC STRETCHES. Pectoralis major, latissimus dorsi, teres major, rhomboids major and minor
SHOULDER INTERNAL ROTATION
TEST POSITION. Lying supine with left shoulder abducted to 90 degrees, left elbow bent to 90 degrees, forearm pronated TEST. Keep the left shoulder stable by applying a firm downward pressure with the palm of the right hand while bringing the palm of the left hand toward the floor (Fig. 3.11). The left wrist should come within 4 to 6 inches of the floor. Repeat the test on the right shoulder. AVERAGE MOTION AVAILABLE. AAOS 70 degrees GENERAL STRETCH. Shoulder external rotators SPECIFIC STRETCHES. Posterior deltoid, infraspinatus, teres minor
CHAPTER 3 ASSESSING FLEXIBILITY 43
FIGURE 3.10 Test of shoulder abduction FIGURE 3.11 Test of shoulder internal rotation
GENERAL STRETCH. Elbow extensors SPECIFIC STRETCHES. Triceps brachii—medial and middle heads, anconeus SUBTEST. To test for triceps brachii—long head, hold end position achieved above with index finger on acromion, and raise elbow up overhead until upper arm is vertical. If this motion is difficult, the long head of the triceps may be tight.
Wrist, Hand, and Fingers
Below are flexibility tests for the wrist, hand, and fingers.
WRIST EXTENSION
TEST POSITION. Standing facing a wall with shoulders flexed to 90 degrees and arms outstretched, hands in front of shoulders, wrists in neutral alignment, with palms facing downward TEST. Keep elbows straight while attempting to place hands flat on the wall (Fig. 3.15). Normal ROM will allow you to place your hands flat on the wall with your elbows straight. AVERAGE MOTION AVAILABLE. AAOS 80 degrees GENERAL STRETCH. Wrist and finger flexors SPECIFIC STRETCHES. Flexor carpi radialis, palmaris longus, flexor digitorum profun- dus and superficialis, flexor carpi ulnaris
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FIGURE 3.13 Test of elbow extension
FIGURE 3.14 Test of elbow flexion
WRIST FLEXION
TEST POSITION. Standing facing a wall with arms outstretched, so that hands are in front of shoulders and wrists are in neutral alignment, with palms facing downward TEST. Keep elbows straight while attempting to place the dorsum (back) of hands flat against the wall (Fig. 3.16). You should be able to place most of the back of your hand against the wall, with the wrist coming within 1 inch. AVERAGE MOTION AVAILABLE. AAOS 70 degrees GENERAL STRETCH. Wrist and finger extensors. SPECIFIC STRETCHES. Extensor carpi radialis, extensor carpi ulnaris, extensor digito- rum, extensor digiti minimi, extensor indicis
FINGER FLEXION
TEST POSITION. Standing with shoulders flexed to 90 degrees (arms outstretched in front of shoulders) with palms facing downward TEST. Attempt to make a tight fist, and then flex the wrist 30–40 degrees (Fig. 3.17). Test both hands.
46 STRETCHING FUNDAMENTALS
FIGURE 3.15 Test of wrist extension
FIGURE 3.16 Test of wrist flexion
spine) and flatten it against the wall. You should observe no more than 2–3 fin- ger widths (1.0–1.5 inches) between the spinous processes of the C7 to T1 verte- brae and the wall. AVERAGE MOTION AVAILABLE. AAOS 25 degrees (combined motion between thoracic and lumbar spines) GENERAL STRETCH. Lumbar and thoracic flexors SPECIFIC STRETCHES. Rectus abdominus and, indirectly, via forward head postures: sternocleidomastoid, scalenes, platysma NOTE. A significant lack of thoracic extension accompanied by a significantly flexed resting position is characteristic of kyphosis, a disorder that may be related to osteoporosis. Although stretching the thoracic and abdominal flexors is a useful intervention, severely restricted thoracic extension and clinical kyphosis may best be addressed with manual intervention from an osteopath, a chiropractor, or a physical therapist who specializes in spinal joint mobilization or manipulation.
THORACIC FLEXION
TEST POSITION. Standing with lower back flattened against the wall TEST. Slowly and carefully flex the head first, and then the thoracic spine toward the feet while gliding the hands down along the front of the thighs for support (Fig. 3.20). Stop as soon as the motion reaches the lower back. You should be able to touch your knees.
48 STRETCHING FUNDAMENTALS
FIGURE 3.19 Test of thoracic extension
AVERAGE MOTION AVAILABLE. AAOS 80 degrees (combined motion between thoracic and lumbar spines) GENERAL STRETCH. Spine extensors SPECIFIC STRETCHES. Spinalis thoracis, iliocostalis thoracis, longissimus thoracis
LUMBAR FLEXION
TEST POSITION. Lying supine TEST. Begin by using the arms and hands to pull both knees toward the chest. While keeping head, neck, shoulders, and upper back flat on the floor, continue to pull the knees up toward the chest until a gentle curve is formed by the lower back (Fig. 3.21). There should be about and 4 or 5 finger widths (3–4 inches) between your coccyx (tailbone) and the floor. AVERAGE MOTION AVAILABLE. AAOS 80 degrees (combined motion between thoracic and lumbar spines). GENERAL STRETCH. Spine extensors SPECIFIC STRETCHES. Erector spinae, multifidus, quadratus lumborum
CAUTION! Severe pain, or pain, numbness, and tingling in the leg or foot, brought on by this maneuver may be indicative of lumbar pathology. This test should be mod- ified to eliminate these symptoms or discontinued altogether. Further evaluation by a specialist may be prudent at this point.
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FIGURE 3.20 Test of thoracic flexion
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CAUTION! Severe pain, or pain, numbness, and tingling in the leg or foot, brought on by this maneuver may be indicative of lumbar pathology. This test should be modified to eliminate these symptoms or discontinued altogether. Further evalu- ation by a specialist may be prudent at this point. Individuals with spondylolisthesis should not perform this test.
Hip
Below are flexibility tests for the hip region.
HIP FLEXION
TEST POSITION. Lying supine, legs extended TEST. Pull one knee up to the chest, allowing the hip to flex completely (Fig. 3.23). There should be contact between the thigh and abdominal area. Test hip flexion on both sides. AVERAGE MOTION AVAILABLE. AAOS 120 degrees GENERAL STRETCH. Hip extensors SPECIFIC STRETCHES. Gluteus maximus, posterior fibers of gluteus medius
HIP EXTENSION
TEST POSITION. Supine with thighs and legs hanging off of plinth so that the lower back and buttocks are just supported, knees relaxed TEST. Pull your left knee toward your chest until the lower back is flattened against the table (Fig. 3.24). The right thigh should hang below the level of the table about 20–30 degrees. Then test extension at the left hip. AVERAGE MOTION AVAILABLE. AAOS 20 degrees GENERAL STRETCH. Hip flexors SPECIFIC STRETCHES. Psoas major, psoas minor, iliacus, rectus femoris
HIP ABDUCTION
TEST POSITION. Lying supine with buttocks against the wall and legs straight up, supported against the wall TEST. Allow your legs to fall to their respective sides (abduction) while maintaining contact with the wall (Fig. 3.25). There should be at least a 90-degree angle between the legs.
FIGURE 3.23 Test of hip flexion
AVERAGE MOTION AVAILABLE. AAOS 45 degrees GENERAL STRETCHES. Hip adductors SPECIFIC STRETCHES. Pectineus, adductor longus, adductor brevis, adductor magnus, gracilus
HIP ADDUCTION
TEST POSITION. Lying on the left side on the plinth or other supportive surface so that the waist is supported, but the entire right leg is able to hang freely down- ward. Left thigh should be flexed forward, knee bent, and out of the way of the unsupported right leg. TEST. Use your right hand to exert downward pressure on the right hip, flattening the left waist, hip, and torso against the table (Fig. 3.26). Then allow the extended right leg to hang down. The right leg should fall well below the plane of the upper body about 30 degrees. Also test adduction of left hip. AVERAGE MOTION AVAILABLE. AAOS 30 degrees
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FIGURE 3.24 Test of hip extension
FIGURE 3.25 Test of hip abduction
SPECIFIC STRETCHES. Gluteus maximus. gluteus medius—posterior fibers, piriformis, gemellus superior and inferior, obturator internus and externus, quadratus femoris
HIP EXTERNAL ROTATION
TEST POSITION. Standing, with hips and knees facing directly anterior. Note position of feet at start position. TEST. While keeping the knees locked, rotate one foot at a time outward as far as possible (Fig. 3.28). Forty-five degrees from the start position should be available. AVERAGE MOTION AVAILABLE. AAOS 45 degrees GENERAL STRETCH. Hip internal rotators SPECIFIC STRETCHES. Gluteus medius—anterior fibers
Knee
Below are flexibility tests for the knee region.
KNEE EXTENSION
TEST POSITION. Lying supine, perpendicular to doorway with one leg through and the other (test leg) resting against the doorway, knee extended TEST. Keep the knee of the test leg straight while moving the entire body as close to the doorway as possible (Fig. 3.29). This may require some assistance from the bent leg and the hands. The buttocks should come within 1 foot of the doorway for men and 6 inches for women. Test extension at both knees. AVERAGE MOTION AVAILABLE. AAOS 10 degrees GENERAL STRETCH. Knee flexors
54 STRETCHING FUNDAMENTALS
FIGURE 3.28 Test of hip external rotation
SPECIFIC STRETCHES. Semimembranosus, semitendonosus, biceps femoris–long head NOTE. If the knee cannot be completely extended (i.e., straightened) even if both legs are extended on the floor, there may be a restriction in the knee joint itself. It is also possible, though uncommon, that this restriction is related to a severe shortness of the short head of biceps femoris, gastrocnemius, and popliteus.
KNEE FLEXION
TEST POSITION. Lying prone on table or mat with test leg flexed to about 90 degrees TEST. Grasp the lower leg just proximal to the ankle and pull it toward the buttocks (Fig. 3.30). The heel should come within 2 inches of the buttocks. Test flexion of both knees. AVERAGE MOTION AVAILABLE. AAOS 135 degrees GENERAL STRETCH. Knee extensors SPECIFIC STRETCHES. Rectus femoris NOTE. If there is inappropriate knee flexion, try testing again in the supine position. Pull knee to chest and then attempt to pull heel to buttock via a firm grip on the
CHAPTER 3 ASSESSING FLEXIBILITY 55
FIGURE 3.29 Test of knee extension
FIGURE 3.30 Test of knee flexion
