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Discussion in 'Biomechanics, Sports and Foot orthoses' started by Dean Hartley, Jan 18, 2008.

  1. Dean Hartley

    Dean Hartley Active Member

    Members do not see these Ads. Sign Up.
    Stretching is always an issue I in my limited experience and probably many others have with patients. I routinely pescribed stretches for gastroc/soleus complex etc but do so with little expectation they will ever get done. I also question if they are doing much for the patient. I remember an article I was reading some time ago, I think it was in a physiotherapy journal, saying stretches increase neuromuscular tolerance with limited affects on actually muscle/tendon length and range of motion (something along those lines).

    Just wondering what others feel towards stretching, if they prescribe it regularly, if they notice significant results etc. Any good tips in getting people to continually keep stretching? Is it worth it in your opinion?
    Last edited: Jan 18, 2008
  2. Admin2

    Admin2 Administrator Staff Member

  3. Romeu Araujo

    Romeu Araujo Active Member

    Hi Dean, :good:

    I often prescribe stretches for gastro/soleus complex. I have to explain and have them to feel that stretching does something – but I also always wonder if they’ll get it done.
    I do believe and observe that it does make some difference (please read http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=4680)

    The limited effect you read about: how limited? Null? If it was considered limited, maybe that little change can make a difference when talking about ROM.

    From my experience, I feel that stretching is fundamental!

    Best regards,
  4. drsarbes

    drsarbes Well-Known Member

    Hi Dean:
    I, also, Rx gastroc-soleus stretching frequently, several times per day in fact.

    I think they do help.

    I try to have patients stretch only 1-2 minutes twice per day otherwise I feel they won't do them.
    I feel a tight achilles leads to more pathology than just about any other biomechanical finding.

    Every patient - from achilles pain to forefoot pain to fasciitis to pre-op bunionectomy, etc...they all get my stretching talk with a handout.
    The general metatarsalgia patients with perhaps early subluxed MTPJ really benefit (along with EDL stretching)

  5. Dean Hartley

    Dean Hartley Active Member

    Thanks for the reply Steve.
    Do you think they improve clinical outcomes? I guess that is the hard part to measure. When I prescribe orthotics, almost always are they associated with stretching, normally gastroc/soleus, but is hard to differentiate their effect.
  6. Atlas

    Atlas Well-Known Member

    Like most other musculo-skeletal practitioners, we have a few things to chose from in our knapsack. The question is what to throw at it, and why?

    If you discover that a soft-tissue structure is shorter in the problematic side, then it makes complete sense to lengthen it. We all love complex theories (neuromuscular tolerance), but how simple and easy is the one that suggests you should try to lengthen something that is short on the affected side?

    There have been some older studies that have suggested that stretching can be as dangerous as licking cheese on a mouse trap. Again, I would doubt that the tissue was short on the pathological side.

    Other than breathing, nothing should be prescribed routinely in any profession. Most modern physiotherapists will dogmatically prescribe core stability routinely. Some chiropractors will 'adjust' routinely.

    There must be a what...and more importantly, a why.
  7. drsarbes

    drsarbes Well-Known Member

    Hi Atlas:
    You may have read a bit too much into the "routinely" comment.
    If you "routinely" see patients with very similar problems then it does become routine!
    For instance; I see (as we all do) a LOT of patients with Hallux Valgus, many of these have limited dorsiflexion at the ankle with the knee extended. As part of my operative consultation I "routinely" give them stretching exercises to do. I think we would be remiss not to.

    Dean: as far a improving clinical outcomes; my anecdotal answer would be yes.

  8. Dean and Colleagues:

    I believe that routine stretching of both the gastrocnemius and soleus muscles is very helpful for many patients that suffer from pathology related to decreased length of their musculo-tendinous units (MTU). Like Steve, I recommend stretching of the gastrocnemius and soleus to many patients and normally recommend that they do these stretches for 2-3 minute sessions, 3 sessions per day. I suggest that they do the stretches first in the shower in the morning, at lunch and around dinner time. My theory here is that after the MTU is lengthened by the stretching session, the MTU will again tend to shorten within a few hours of being stretched. In this way, by stretching multiple times a day, the deforming rotational forces (i.e. moments) caused by the shortened gastrocnemius-soleus MTU will be lessened for more hours during the weightbearing day than if the MTU is only stretched once per day.

    For the past 8 years, I have been using a handout that I give to patients for gastrocnemius and soleus stretching. I have attached my handout to this posting. [The drawings are done from tracings of photographs of my oldest son that I produced using CorelDraw.].

    All of my colleagues here on Podiatry Arena are welcome to use my handout and are given permission to replace my name and address with their name and address at the top of the handout so that they can also use this handout for the benefit of their own practices and their own patients. The handout was also published in my second book as the October 1999 Precision Intricast newsletter (Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002, pp. 85-87).

    Hope this helps.
  9. Dean Hartley

    Dean Hartley Active Member

    Thanks for the response and handout Kevin. Then handout is very thorough. Although down here in Oz, we may have to make a compromise with the shower stretches due to the water restrictions! The water patrol officers might not be happy!
  10. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    I have to admit, your handout looks "a little" better than the stick figure I drew for mine!
  11. bearl

    bearl Member

    Hi Dean and fellow pods.

    (I don't normally post, just read, but here goes)

    Just thought I'd mention my method of prescribing gastroc/soleus/ hamstring stretches esp for children.

    I am always amazed how inflexible our Australia children are. I like to use a very standard sit and reach test (yep the one we all hated in high school)
    ruler against the wall, feet against the wall, legs extended. Child tries to touch their toes and you record how far away they are.
    Suprisingly the majority of the children, esp boys, I see (presnting typically with achilles and patella femoral pain) can barely reach past their knees.
    Their parents are also suprised and I like to get them to do it aswell as no child likes being outdone by their parents!

    I have a chart drawn up with the days of the week and a cm column.
    The child does the strech twice a day and records how far away they are from their toes. daily then brings the chart back at their rv (usually 2/52).
    The kids seem to really enjoy doing this as I stick all of the charts (with good results) up with their name in the hallway.

    Like another poster said. I have no evidence to support this but I find the children who do their stretches daily have far better treatment outcomes.

    Another stretching method is telling people to stretch when they brush their teeth / or shave. This one is great with the standing gastroc / soleal stretches.
    When we do these activites, usually twice daily, we are standing still.

    Why not time manage and do two benefitial activites at once!

    Just food for thought.

    I'd like to hear what anyone thinks of these.

    Last edited: Jan 22, 2008
  12. lcp

    lcp Active Member

    Interesting you say that mate, that is exactly what I recommend to my patients as well, seems to work well as a compliance issue. My first employer actually had a "ramp" made up to an angle of 15 degrees I think it was. The patient would then stand on this when brushing their teeth, hence stretching without thinking about it.
    Back in uni, we were advised to tell the patients to stretch twice a day, every day. Apparently there was some sort of research (not certain on this) that suggested you are lucky to get half of what you recommend the patient to do. This meant if you told them to stretch once a day, every day, you could more likely expect once a day three or four times a week, so my clinicians thinking was, tell them to stretch more frequently to cover all bases. Not sure if it worked, but it was fun to think of the psychology of it.
    As a sportsman, research or not, I found regular stretching really helped both performance and reducing general aches and pains throughout the season. In my expeience,however, it was something that had to be performed religiously, every day, to have the greatest benefit. Again, these are just my experiences only.
    Hope the world of Podiatry is treating you all well
  13. Fiona Hawke

    Fiona Hawke Member

    Does stretching increase ankle dorsiflexion range of motion? A systematic review
    Joel A Radford, Joshua Burns, Rachelle Buchbinder, Karl B Landorf and Catherine Cook
    British Journal of Sports Medicine 2006; 40:870-875

    Background: Many lower limb disorders are related to calf muscle tightness and reduced dorsiflexion of the ankle. To treat such disorders, stretches of the calf muscles are commonly prescribed to increase available dorsiflexion of the ankle joint.

    Hypothesis: To determine the effect of static calf muscle stretching on ankle joint dorsiflexion range of motion.

    Study design: A systematic review with meta- analyses.

    Methods: A systematic review of randomised trials examining static calf muscle stretches compared with no stretching. Trials were identified by searching CINAHL, EMBASE, MEDLINE, SPORTDiscus and CENTRAL and by recursive checking of bibliographies. Data were extracted from trial publications and meta-analyses performed that calculated a weighted mean difference for the continuous outcome of ankle dorsiflexion. Sensitivity analyses excluded poorer quality trials. Statistical heterogeneity was assessed using the quantity 2.

    Results: Five trials met inclusion criteria and reported sufficient data on ankle dorsiflexion to be included in the meta-analyses. The meta-analyses demonstrated that calf muscle stretching increases ankle dorsiflexion after stretching for 15 minutes (WMD 2.07 degrees; 95% confidence interval 0.86 to 3.27); >15 to 30 minutes (WMD 3.03 degrees; 95% confidence interval 0.31 to 5.75); and >30 minutes (WMD 2.49 degrees; 95% confidence interval 0.16 to 4.82). There was a very low to moderate statistical heterogeneity between trials. The meta-analysis results for 15 minutes and >15 to 30 minutes of stretching were considered robust when compared with sensitivity analyses that excluded lower quality trials.

    Conclusions: Calf muscle stretching provides a small and statistically significant increase in ankle dorsiflexion. However it is unclear whether the change is clinically important.

    Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial
    Joel A Radford, Karl B Landorf, Rachelle Buchbinder and Catherine Cook
    BMC Musculoskeletal Disorders. Published: 19 April 2007

    Plantar heel pain is one of the most common musculoskeletal disorders of the foot and ankle. Treatment of the condition is usually conservative, however the effectiveness of many treatments frequently used in clinical practice, including stretching, has not been established. We performed a participant-blinded randomised trial to assess the effectiveness of calf muscle stretching, a commonly used short-term treatment for plantar heel pain.

    Ninety-two participants with plantar heel pain were recruited from the general public between April and June 2005. Participants were randomly allocated to an intervention group that were prescribed calf muscle stretches and sham ultrasound (n = 46) or a control group who received sham ultrasound alone (n = 46). The intervention period was two weeks. No participants were lost to follow-up. Primary outcome measures were 'first-step' pain (measured on a 100 mm Visual Analogue Scale) and the Foot Health Status Questionnaire domains of foot pain, foot function and general foot health.

    Both treatment groups improved over the two week period of follow-up but there were no statistically significant differences in improvement between groups for any of the measured outcomes. For example, the mean improvement for 'first-step' pain (0–100 mm) was - 19.8 mm in the stretching group and -13.2 mm in the control group (adjusted mean difference between groups -7.9 mm; 95% CI -18.3 to 2.6). For foot function (0–100 scale), the stretching group improved 16.2 points and the control group improved 8.3 points (adjusted mean difference between groups 7.3; 95% CI -0.1 to 14.8). Ten participants in the stretching group experienced an adverse event, however most events were mild to moderate and short-lived.

    When used for the short-term treatment of plantar heel pain, a two-week stretching program provides no statistically significant benefit in 'first-step' pain, foot pain, foot function or general foot health compared to not stretching.

    Fulltext available online http://www.biomedcentral.com/1471-2474/8/36
  14. twirly

    twirly Well-Known Member

    Thank you Kevin.

    Kind regards,
  15. twirly

    twirly Well-Known Member

    Just to enquire,

    Does anyone advise patients RE: Non weight bearing stretches?

    ie. flat surface, legs extended, assisted dorsiflexion utilising eg. Theraband type product.

    Is there any significant benefit/difference in outcomes with either technique?

  16. For gastrocnemius and soleus stretching, I think that weightbearing stretches are more effective due to being able to use the greater magnitude of forces that ground reaction force can offer on the plantar foot. I try to encourage weightbearing calf muscle stretches vs. nonweightbearing calf muscle stretches in most circumstances.
  17. twirly

    twirly Well-Known Member

    Thank you for your reply Kevin,

    Much appreciated.

  18. I use modified PNF (proprioceptive neuromuscular facilitation) stretches, not just for calf muscles, for all lower limb muscle groups. I have found the low repetition and visible results very useful in getting patients to "buy into" and continue with the programme. If anyone wants a great book on the topic buy this: http://www.amazon.com/Facilitated-S...bs_sr_1?ie=UTF8&s=books&qid=1201459094&sr=8-1

    The best $16 you'll ever spend. Lets face it, that's less than a round at the bar!
  19. twirly

    twirly Well-Known Member

    Thanks Simon,

    May I ask does anyone else also use this particular method?

    Also Simon what may I ask do you find the patrticular benifits to this therapy are as opposed to usual calf stretches?

  20. I feel this technique is more effective than traditional stretching as it uses the muscles physiology, i.e. post isometric relaxation and reciprocal inhibition to it's advantage; patients only need to perform 3 reps, which takes less of their time; the instantaneous visable effects of the stretching motivate patients to continue.
  21. Scorpio622

    Scorpio622 Active Member

    I also use the concept of reciprocal inhibition- but modified it to better facilitate a calf stretch. I have the patient perform a simple towel stretch while actively firing the pre-tibial muscles. This activation will produce relaxation to their antagonist-the calf- which is simultaneously being passively stretched. This works like a charm.

    I often do not use the weightbearing calf stretches because when the foot is loaded, there is always a subtle muscle contraction due to the extra-fusal elements- so total relaxation is impossible . However I do advise runners to perform the wall stretch when they are outside and the towel stretch is not feasible.

    I do appreciate the pic Kevin. Your son looks just like you.....
  22. twirly

    twirly Well-Known Member

    Thank you for your response too Scorpio.

    Much appreciated.



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