5 Principles of Treating the Stiff Shoulder

5 Principles of Treating the Stiff Shoulder

The latest webinar recording for Inner Circle members is now available below.

5 Principles of Treating the Stiff Shoulder

This month’s Inner Circle webinars discussed several principles of treating the stiff shoulder.  We’ll cover:

  • The several types of “stiff shoulders”
  • Are we seeing shoulder stiffness more than we realize?
  • How to completely understand the anatomy and biomechanics of the glenohumeral capsule
  • Know when to push motion (and when not to!)
  • What should people with stiff shoulders do at home between sessions

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Internal Impingement – What it is and How to Diagnose

Internal Impingement

The latest webinar recording for Inner Circle members is now available below.

Internal Impingement – What it is and How to Diagnose

This month’s Inner Circle webinars discussed a one of the most requested topics to date and featured a TON of people online live!  We’ll cover:

  • What is internal impingement?
  • The difference between internal and subacromial impingement
  • Anatomical, biomechanical, and pathological reasons for developing internal impingement
  • What do athlete’s that have internal impingement feel?
  • The #1 test to perform to diagnose internal impingement
  • What else you should look for on examination to develop the best treatment program

The topic is so big, I need to break it down into 2 parts.  This first part will cover the etiology and diagnosis.  I will follow this up in the upcoming months with an entire webinar dedicated to how to treat internal impingement.

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.



Integrating the FMS into Group Training

Integrating the FMS into Group Training

I have a pretty special post today that includes an interview of Steve Long, one of the co-founders of Smart Group Training, discussing how to integrate the FMS in group training.  More exciting, Steve was willing to give an exclusive discount on their Smart Group Training Assessment product for my readers only!

Steve and I have been chatting about stuff for a little bit and I was really impressed with how he and Jared Woolever created the Smart Group Training system.  As a physical therapist, I have always felt that one of the draw backs of the group training format was the lack of individualization.  Steve and Jared have essentially systemized an approach that solves this problem!

I have watched their latest DVD and definitely recommend it, especially with the special discount for my readers.



MR: Tell us what exactly is Smart Group Training and what made you want to create SGT?

SL: “That is a really great question actually. Smart Group Training is many things really. It’s a training system, an educational website, educational products, workshops, etc, but more importantly it’s a movement. It’s a movement towards increasing the quality of group fitness training, and a movement towards increasing the communication between trainers, strength coaches, and clinicians.

Myself and business partner Jared Woolever had been doing 1 on 1 and semi private training for many years when we decided to open up “bootcamp classes”.  We knew there were a lot of great benefits for clients mainly the price and atmosphere, but the quality of training was just not as good as semi private.

We knew from that point, that we had to either cut bootcamp or make it just as quality as semi private training. We dedicated ourselves to creating the best group training system available, and that is how Smart Group Training was born.  We just didn’t know at the time, what it would really end up becoming.

Our first product, Smart Group Training Volume 1 – Screening and Corrective Exercise, came about because so many people were asking us about our training systems, and how we incorporated the FMS into bootcamps. We created the product for our friends, and it has started to explode.”



MR: The corner-stone of the SGT system is the FMS.  I like how you integrate a system to customize the large group training programs.  Since you have probably seen 1000’s of FMS scores over the years, what do you tend to find are the most common deficits you see?

SL: “It probably won’t surprise you to find out that we see a lot more mobility issues with men, and more stability issues with women. So we find that a lot of the men start with 1’s on the Active Straight Leg Raise and Shoulder Mobility. We will typically see women start with 1’s on the Rotary Stability, Trunk Stability Push Up and the Deep Squat.

Almost everyone starts with a 1 in the following:

  • Active Straight Leg Raise
  • Shoulder Mobility
  • Rotary Stability
  • Trunk Stability Push up

These are the foundational movements that we spend the most time working on by far. These movements must be cleared before moving on to the functional movements like lunging, stepping, and squatting.”



MR: What are your top corrective strategies to address these common findings? 

SL: “The biggest thing is to make sure that people stop doing exercises or actions that could make it worse. Then we give them a corrective exercise strategy to correct the pattern. We find the weakest link on the FMS Hierarchy and attack that pattern with corrective exercise. We have the client do 1 or 2 exercises. Those exercises should be done pre workout, during the workout, and 1-2 times per day outside of training sessions. Some examples of exercises we use to correct the bottom four are:

  • ASLR: Pelvic tilts, pelvis repositioning, Leg lowering progressions, toe touch progressions
  • SM: Breathing, ribcage repositioning, reachbacks, cat cow, wall slides
  • RS: Rolling, bird dog progressions
  • TSPU: Elevated push ups, band assisted pushups”



MR: In your experience how long does it take to start seeing improvements in your clients’ FMS scores?

SL: “Our goal is to see changes in the first session. That’s definitely not always the case, but many times it is. Typically we want to have each movement limitation cleared within a few weeks at the most. If it takes longer than that we refer out.  The screen usually points you to the right spot to make sure that we are correcting in the right order. Most people who have issues with the correctives not working are not following the hierarchy.

For example, sometimes one set of leg lowering will clear a clients ASLR deficiency forever, and sometimes they have pathology that caused it to never be a 2 or 3.  Generally speaking however, it usually takes a couple of weeks.”



MR: What kind of carryover do you see in your clients’ general fitness goals by individualizing their programs and developing corrective strategies based on the FMS? 

SL:“They blast through plateaus! Clearing movement dysfunctions allows the clients to do things they couldn’t do before, it keeps them injury free, and a lot of times takes people out of a “high threshold life” which lowers cortisol and helps with fat loss. Moving good and feeling good, are huge for general population, and the FMS helps us with that.”


MR: When will we be seeing more SGT products?

SL: “We have so much great stuff coming out this year. I can’t even begin to explain how excited both Jared and myself are to get this stuff out!  We have asked thousands of trainers, PT, chiros, and strength coaches what they need, and we are producing it. We have close to TEN great products coming out this year.

A lot of the stuff that we are doing this year is based around program design and giving people “done for you” programs that you can use immediately.

Over the next few months, keep an eye out for:

  • Group Training University: Basically and MBA on starting and running a group training business.
  • SGT 365: This is an entire year of done for you group training program design based on the FMS, and SGT training systems.

These are our next two products that will be available over the next few months, but like I said, we have a lot of great stuff coming out all year-long. Check out our blog, and get on our newsletter list to stay up to date with everything that Smart Group Training is doing”.

Special $50 Discount for My Readers

Steve and Jared were nice enough to give me a special discount code for my readers to get $50 off their Smart Group Training Assessments DVD program.  Click the link or image below and be sure enter coupon code MR50 in the shopping cart to receive $50 off.  This is a limited time offer for this week only!  The discount ends at the end of the day Sunday.

Smart Group Training

Click here to purchase Smart Group Training Assessment DVD for $50 OFF



Steve has made quite a name for himself in the fitness industry, achieving many awards and acknowledgements for his accomplishments. He has trained a variety of clients ranging from ages 6 to 80 in 8+ years in the fitness and performance industry. He assists clients in many aspects of health, fitness, weight loss, performance training, nutrition, and more. Steve is known for his practical approach to training and blending the many benefits of corrective exercise into highly metabolic conditioning and fat loss programs. Among other things, Steve specializes in functional fat loss, sports performance, golf fitness, injury prevention/post rehabilitation, kettlebell training, and lifestyle coaching. Steve has been mentored by, and continues to learn from the best professionals in the industry, bringing the most cutting edge programs to his clients and fitness trainers worldwide.

Learn more at SmartGroupTraining.com.




Shoulder Adaptations Over the Course of a Baseball Season

Today’s guest post by Chris Beardsley is a review of a recent study looking at the changes in shoulder joint range-of-motion that baseball players experience over the course of a season.  A timely post as the MLB season winds down.


The Study

Shoulder Adaptations Among Pitchers and Position Players Over the Course of a Competitive Baseball Season, by Laudner, Lynall and Meister, in Clinical Journal of Sports Medicine, 2012 [Pubmed]



Baseball position players typically play daily during game season and while pitchers throw in games less frequently, they often throw on their rest days. Consequently, upper extremity injuries are common in baseball players, particularly among pitchers. And despite advances in both rehabilitation knowledge and surgical technology, the trend for such injuries appears to be increasing.

Researchers investigating upper extremity injuries in baseball players have previously reported alterations in shoulder function such as posterior shoulder tightness and scapular dyskinesis, both of which have been associated with a variety of shoulder pathologies.


What did the researchers do?

The researchers wanted to investigate whether posterior shoulder tightness and scapular position change over the course of a competitive baseball season in both baseball pitchers and in position players. So they recruited 16 asymptomatic, professional baseball pitchers and 16 asymptomatic, professional baseball position players. Neither group had any history of upper extremity injury in the last 6 months nor any history of upper extremity surgery.

The researchers measured scapular upward rotation and glenohumeral range of motion (ROM) using a digital inclinometer. They measured glenohumeral horizontal adduction ROM with the subjects supine on a table and the shoulder in 90 degrees of abduction and flexion with the scapula stabilized using a posterior force into the table. They measured bilateral glenohumeral internal rotation ROM in a similar set-up: in the supine position with the shoulder in 90 degrees of abduction and flexion and the scapula stabilized using a posterior force into the table.

The researchers measured bilateral forward scapular posture with the subjects standing against a wall and used the double-square method to establish the distance between the wall and the acromion of the scapula. They recorded the difference between the throwing and non-throwing arms for analysis. Finally, they measured scapular upward rotation of the throwing arm in a resting position as well as in the scapular plane at 60, 90, and 120 degrees of humeral elevation.

The researchers performed these measurements at two points in time: at the baseball players’ initial physical examination during spring training and within the final week of their competitive season.


What happened?

Glenohumeral horizontal adduction ROM

The researchers found that were no significant differences in the changes to glenohumeral horizontal adduction ROM between pitchers and position players over the course of the season. However, there was a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by a reduction in the ROM of the pitchers.

 Glenohumeral adduction ROM


Bilateral internal rotation ROM

The researchers found that were no significant differences in the changes in bilateral internal rotation ROM between the pitchers and the position players over the course of the season. However, there was again a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by a reduction in the ROM of the pitchers.

Bilateral glenohumeral internal rotation


Bilateral difference in forward scapular posture

The researchers did not note any significant differences in the changes to the bilateral difference of forward scapular posture between the pitchers and the position players over the course of the season. However, there was a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by an increase in the ROM of the position players.

Bilateral difference in forward scapular posture


Scapular upward rotation

The researchers found that the pitchers displayed significantly lower increases in scapular upward rotation at 60 and 90 degrees of humeral elevation compared with the position players as a result of the baseball season. However, this appeared to result from the pitchers starting the season with a higher level of upward rotation and both groups finishing the season with similar degrees of upward rotation.

Scapular upward rotation


What did the researchers conclude?

The researchers concluded that pitchers developed significantly less scapular upward rotation at 60 and 90 degrees of humeral elevation over the course of a competitive baseball season compared with position players. The researchers propose that the increase in scapular upward rotation displayed by the position players may be a beneficial adaptation geared towards reducing their injury risk.

The researchers suggest that the absence of a similar increase in pitchers may make them more susceptible to shoulder injuries. However, it is important to note that the pitchers started the season displaying significantly greater levels of scapular upward rotation and the season only serves to bring the position players up to a similar level. An alternative interpretation of the results is therefore that the pitchers already have such adaptations, beneficial or not, and that the season’s activities bring the position players up to a similar level. Whether these adaptations are genetically determined or acquired over time is unclear.

Indeed, the researchers note that since posterior shoulder tightness causes the humerus to translate upwards into the subacromial space, it is possible that athletes perform increased scapular upward rotation in order to elevate the acromion and increase the available subacromial space. Therefore, it is possible that the adaptive process that was observed in this study in the position players was done for this reason and it is also possible that the pitchers did not require this adaptation, having sufficient subacromial space already.



This study was clearly limited by the small sample size that precluded the observation of several large differences in the measured variables between position players and pitchers over the course of the season.


Key Points

Pitchers develop significantly less scapular upward rotation at 60 and 90 degrees of humeral elevation over the course of a competitive baseball season compared with position players. However, the increase in scapular upward rotation observed in the position players only brings their total amount of movement in line with the pitchers, who begin the season with a greater degree of upward rotation.


Mike’s Thoughts

Thanks Chris, I thought you did a great job summarizing this nice article.  Studies like this are extremely challenging to perform, more so than you would think.  There is inherently an issue with control over the course of a season.  Did every pitch the exact same amount of innings and games?  Did they all throw with the same velocity?  Since this is a ROM study, did they all stretch exactly the same and with the same exact frequency all season?

The answer to all of these questions is, “of course not.”  This is what makes this so challenging, we can only take the means of a large group and try to draw conclusions.  I do caution readers to take information like this with a grain of salt.

As my readers know, I work in baseball everyday, yet I seldom discuss baseball on this website.  I am not in a position that I can share all I have learned (yet at least!), but I can tell you that we have studied very similar trends as this study.  Players will loose motion over the course of a season, similar to what we showed acutely after one outing (see here and here).  The acute ROM changes can become cumulative over the course of a season.  However, a proper stretching program can maintain normal ROM over the course of a season.


About the author

Chris BeardsleyChris Beardsley is a co-founder of Strength and Conditioning Research, a monthly publication that summarizes the latest fitness research for strength and sports coaches, personal trainers, and physical therapists. Chris also writes a regular blog in which he reviews some of the latest developments in biomechanics.


If you enjoyed this post, then you’ll love Strength and Conditioning Research, a monthly publication that summarizes recent journal publications just like this post.  Don’t let the name fool you, there are a ton of research reviews for rehabilitation as well.  Chris does an awesome job summarizing a ton of great articles every month.  I am a proud subscriber because it helps me stay current and I can read it on my iPad when I am on the go.  Learn more about Strength and Conditioning Research.







High Ankle Sprains

As football season is upon us, we often hear the term “high ankle sprain” used by announcers and in the media. This guest article from Trevor Winnegge will help to explain this orthopedic diagnosis, etiology, diagnostics and treatment.


What is a high ankle sprain?

High Ankle SprainA high ankle sprain, or syndesmotic sprain, occurs when there is an injury to the distal tibiofibular syndesmosis.  Injury to the syndesmosis can occur to any or all of the following structures: anterior tibiofibular ligament; posterior tibiofibular ligament, including its superficial and deep (transverse) components; interosseous ligament; and interosseous membrane.(1)  All of these ligaments function to stabilize the ankle mortise and prevent it from splaying, or widening, during the demand of gait, running, cutting, and sports. (Photo from Wikipedia)


Mechanism of High Ankle Sprain Injuries

While trauma to the ankle in any position has potential to injure the syndesmosis, ankle external rotation and forced dorsiflexion are the two most common injury mechanisms.  Normally, the talus is positioned between the medial and lateral malleoli and is unable to rotate substantially. However, with a great enough force to the forefoot, the talus is forced to rotate laterally, thereby pushing the fibula externally away from the tibia, widening the mortise. This type of injury is often seen in football and skiing.

Typically, dorsiflexion causes the interosseous ligament to become taut. However, since the anterior aspect of the dome of the talus is wider than the posterior aspect, the wider portion of the talus pushes or wedges the malleoli apart during extreme dorsiflexion. This mechanism of injury is more common in running and jumping sports. High ankle sprains can occur isolated, can involve fracture of the fibula or medial malleolus, or tears of the lateral talofibular and medial deltoid ligaments.(2)  High ankle sprains occur in up to 15% of all ankle sprain injuries.


Clinical Examination

High Ankle Sprain Spring TestHigh ankle sprains cause significant pain in the ankle and lower leg. All weight bearing and gait will be painful, if possible at all. There is usually a significant amount of bruising, however, there is typically NOT a lot of edema. Pain with any rotation of the foot, or dorsiflexion will be painful. Palpation to the ankle mortise and syndesmosis will be painful to palpation.  Compression of the tibia and fibula above the ankle joint will result in pain at the syndesmosis.

A “Squeeze test” can be performed as a clinical test of syndesmotic instability. This is a simple, moderately reliable test where the examiner squeezes the proximal calf of the patient. A positive test occurs when this maneuver causes distal syndesmotic pain.(3)


Diagnostic Imaging

Plain film Xrays are useful in ruling out fractures, but may be negative in an isolated high ankle sprain. Stress Xrays are most useful, where the foot is stressed into external rotation or dorsiflexion.  This will show a widening of the ankle mortise. MRI/CT Scan can confirm the diagnosis and document severity of the injury.


Treatment of High Ankle Sprains

Treatment of high ankle sprains depends on the severity of the injury. Conservative care can be used to treat minimal to moderate injuries. Treatment may consist of a walking boot or nonweightbearing cast for anywhere from 1-4 weeks. Most athletes will return to sports in 6 weeks but many remain symptomatic for up to 6 months.  A general rule of thumb, though not set in stone, is that the higher up the leg symptoms go, the larger the severity and longer the injury will take to heal.

High Ankle Sprain FixationSevere injury often requires surgical fixation. While wire and sutures are sometimes used, many doctors use 1-2 syndesmotic screws for fixation of the distal tibia and fibula, which allows for bony fixation to allow soft tissue scarring and healing. After fixation, weight bearing is surgeon specific.  Some feel early weight bearing will transfer force through the screw, leading to breakage of the hardware and/or disruption of the syndesmosis. Sometimes, the hardware is removed prior to weight bearing, at anywhere from 2-4 months post operative.

Physical therapy for both conservative and non-operative care consists of range of motion, strength, stability and functional training to allow progression back to sports or activity.  It is important to remember that this is can be a severe injury and healing times are much longer than a typical lateral ankle sprain, despite the lack of edema.(4,5)



  1. Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
  2. Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
  3. Alonso A et al. Clinical tests for Ankle Syndesmosis Injury: Reliability and prediction of return to function. JOSPT. 1998, 27 (4): 276-284.
  4. Press CM et al. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep. 2009 Sep-Oct;8(5):228-33.
  5. Schepers, T. To retain or remove the syndesmotic screw: a review of the literature. Arch Orthop Trauma Surg. 2011 July; 131(7): 879–883.


About the Author

Trevor WinneggeTrevor Winnegge PT,DPT,MS,OCS,CSCS  has been practicing PT for over 11 years. He graduated from Northeastern University with a Bachelors in PT and a Master of Science Degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he treats many orthopedic conditions in addition to high ankle sprains.

The One Thing We Need to Do With Everyone

I am often asked by students or people attending one of my seminars, “what is the one thing you do that you find works the best.”  What a loaded question!  I wish it were that simple that I could teach everyone just one magic technique.  I have been reflecting on this question for several months, planning on writing a post to provide an answer.  I took me sometime to figure out how I wanted to answer the question, but I think I might have an answer


The One Things I Do That Works the Best

The one thing that I would say that I do that works “the best” is probably something we should all be doing with everyone.  It’s not a stretch, it’s not an exercise, it’s not the latest fad in equipment, and it’s not the lastest manual technique.  It’s actually so simple, that it took me awhile to figure it out.  It is assessing and Reassessing.

A proper assessment and reassessement is by far the best thing we can do for every patient and client we encounter.  This is really the key to understanding each individual, what they need, and what works for them.   Everything should start with a proper assessment and then after treament or training, reassess!  Do it every time you work with that person and even multiple times a session.

[quote]Ask them, “what is your primary complaint?”  Assess it.  Quantify it.  Treat it.  Reassess it.[/quote]

This simple concept can have many meanings.  At the simplest level, imagine if you were working with a weight loss client and didn’t assess their body weight.  How would you know what was or wasn’t working?  How would you know how much improvement that client has made?

For the clinician, we have many evaluation and assessment tools – range of motion, joint mobility, strength, flexibility, and many many more.  But these measurements are irrelevant to the patient.  They don’t really care if they gained 10 degrees of motion.  They simply want to feel better and move better.

OK, your shoulder hurts.  When does it hurt?  What can you do to recreate that pain?  Great – you just established a baseline that you can reassess.  Don’t get me wrong, you still want to take objective measure, but you now have a real life baseline assessment that the patient can feel.

This is why tools like the FMS and SFMA are valuable – systematic methods of assessing movement.  This is especially true in the fitness fields, where assessments are even more limited.  Quantify the quality and feel of movement to assess changes.


Ultimately, this is going to always lead to better outcomes – instead of just applying treatment or exercise and hoping it works, assess what really works and adjust as needed.


Assess and Reassess

How do you apply this?  The wrong way would be to just start working on someone that complains “my back hurts.”  “Well, hop up and let’s start throwing some massage techniques and exercises at it.”  In this example, there was no assessment, just treatment, so what do you reassess?  Pain?  That is not always the best assessment.

Maybe a better way would be to assess when and how the back hurts.  What movements bother you?  What can’t you do?  Now, provide care to that person and reassess what you just observed.  Simple, yet a powerful message when a person stands up and says, “wow, I can now touch my toes, that really worked!”

Here is an example of a recent patient I evaluated with complaints of left sided diffuse mid thoracic and rib pain.  I provided a comprehensive evaluation, but I will just cut to the chase and outline the important details.  His primary complaint was pain.  I could of just started trying to treat the area to reduce sympotms and essentially “chase the pain.”  However,  my primary focus was on his limited multisegmental rotation to the left.

Multisegmental rotation doesn’t tell us enough, so I dug deeper.  He had a moderate loss of thoracic rotation to the left.  I could of stopped here as the location of his symptoms were in this area, but I again dug deeper.  I was fine with his hip mobility.  However, I found that his pelvis was shifted with a left anterior tilt, causing his entire pelvis and SI joint to rotate to the right.  Subsequently, his lumbar spine was orientated slightly to the right, meaning his “neutral” was actually rotated to the right slightly, causing what looked like limited rotation to the left.

Thoracic Spine Mobility ExercisesWith my assessment in hand, I went to work.  First, I wanted to start at the thoracic spine to see what the precentage of invovlement may have been.  I worked on soft tissue, joint mobility, and few thoracic mobilization corrective exercises.  Reassessment at this point showed a fairly large improvement of thoracic rotation to the left.  I could of again stopped here, but I also wanted to check multisegmental rotation to the left, which only showed approzimately a 50% improvement in rotation to the left.

If I just stopped here, I would have restored half of his dysfunction, and I bet he would have slipped right back to where he started.

I next went to the pelvis and with a few exercises and manual techniques improved his pelvic alignment.  Reassessment of thoracic rotation and multisegmental rotation showed normal symmetrical movement, and naturally a reduction in his complaints of pain.

That is the power of assessing and reassessing.  Not just once, but multiple times in one session so that I can narrow down the effectiveness of each technique as best as possible.


The Power of Reassessment

That was a pretty good example of how I really narrowed down and enhanced by treatments by assessing and reassessing.  To summarize some of the key points:

  • Helps you individualize and find what works.  This is the no-brainer concept, to see if there was an immediate improvement that can be directly correlated to what you just did to the person.
  • Helps you find out what doesn’t work!  Don’t underestimate this one.  By properly assessing and reassessing you also find out what doesn’t work, which is just as valuable so you can shift gears and try another approach.
  • This is also diagnostic.  By assessing what does and doesn’t work you may also narrow down the exact dysfunction.  Perhaps their limited thoracic rotation is related to soft tissue changes rather than joint mobility.
  • Helps buy in.  Lastly, but probably most importantly, assessing and reassessing helps build buy in, confidence, and compliance from the person.  They will see immediate benefit in what you do.


That is probably what I would consider the one thing that we all need to do with every patient or client we see – assess and reassess, what do you think?



The Influence of Pelvic Position on Lower Extremity Stretching

Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.


The Influence of Pelvic Position of Lower Extremity Stretching

The below webinar will help you understand:

  • Why lower extremity stretching is essentially flawed
  • Why we aren’t always in neutral position or symmetrical
  • The influence of pelvic tilt on pelvic position
  • Simple assessments to see if you are “neutral”
  • How to adjust stretches to assure proper form and alignment
  • How to individualize lower extremity stretching based on pelvic alignment
  • What to avoid while stretching to maximize movement quality


To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.


Assessing and Treating Loss of Knee Extension Range of Motion

Assessing and treating loss of knee extension range of motion is an important component of rehabilitation following any knee surgery.  We recently discussed how loss of knee extension range of motion may be one of the biggest factors associated with the development of osteoarthritis following ACL reconstruction.

The purpose of this article is to review some of the many methods of assessing and treating loss of knee extension range of motion to help maximize outcomes following knee surgery or injury while minimizing long term complications.


Assessing Loss of Knee Extension Range of Motion

There are many ways to treat loss of range of motion in the knee, however, proper assessment of range of motion is even more important.  A certain degree of hyperextension is normal, with studies citing a mean of 5 degrees of hyperextension in males and 6 degrees in females.  Simply restoring knee range of motion to an arbitrary 0 degrees is not advantageous.

The most important factor in assessing loss of knee extension range of motion is looking at the noninvolved knee.  As simple as this sounds, this can not be overlooked as you need to establish a baseline for what is “normal” in each patient or client.

The first thing I look at is simply grasping the 1st toe with one hand to lift the foot off the table.  My proximal hand can stabilize the distal femur.  This is a quick and dirty assessment but I always recommend quantifying the available range of motion.

To accurately measure knee extension range of motion, you will need to use a towel roll of various height to assure the knee is fully hyperextended before taking a goniometric measurement.

Knee Hyperextension

Other aspects of assessment that should be performed when dealing with loss of knee extension range of motion should include patellar mobility, tibiofemoral arthrokinematics, and soft tissue restrictions.  Patellar mobility is especially important after ACL reconstruction using a patellar tendon autograft.  Any restrictions in patellar mobility can have an obvious correlation with restricted knee extension.  Scarring of the patellar tendon can restrict superior glide of the patella and full knee extension.

These assessments will help guide our manual therapy approach to restoring normal arthrokinematics and range of motion of the knee.

Documenting Knee Range of Motion

I took a poll of a large group of students coming through my clinic in the past and found that there was great confusion regarding how we document hyperextension of the knee.   Is + or – when defining a numerical value?

Let’s say that someone has a contracture and is sitting in 10 degrees of flexion and is unable to straighten their knee.  That would be +10 degrees of flexion, thus has to be -10 degrees of extension.  They are on two ends of the spectrum.

Still, using a + or – can be potentially confusing, so I have long taught my students that we should document range of motion using the A-B-C method.  Other authors, such as Dr. Shelbourne, recommend this method as well.

  • If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
  • If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.
Using the A-B-C method eliminates the potential for confusion while documenting.

Treating Loss of Knee Extension Range of Motion

There are several ways to improve knee extension range of motion, however, if a person is struggling with this motion I have found that self-stretches, low load long duration (LLLD) stretching, and range of motion devices can be superior to us cranking of a already cranky knee!  Allowing gentle, frequent, and progressive load to the knee is usually more tolerable for the person, especially those that are sore or guarded in their movements.

The intent of this article is to discuss some specific independent strategies to enhance knee extension range of motion.  Other skilled treatments should focus on patellar mobility, soft tissue mobility, and other aspects of manual therapy for the knee as needed.   However, patients will need to perform stretches at home to assure good outcomes.


Self Stretches for Knee Extension Range of Motion

Two of the first stretches that I give patients following surgery are simple self stretches for knee extension.  The basic version simple has the patient applying a stretch into extension by pushing their distal thigh.  The second and slightly more advanced version, has the patient press down on their distal thigh while using a towel around the foot to pull up and simultaneously stretch the hamstrings.

Knee Extension Stretch

Towel Knee Extension Stretch

Similar to how we assess knee extension range of motion, you will want to use some sort of wedge under the heel to assure that you are restoring full motion.


Low Load Long Duration Stretching for Knee Extension Range of Motion

For the person that is having a hard time achieving knee extension, my next line of defense is usually LLLD stretching.  Several research articles have been published showing the benefit of LLLD stretching in achieving range of motion gains.

I prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial position for me.  To perform this exercise, place a towel roll or similar item under the heel to allow full knee extension and then a comfortable weight over the distal thigh.

Low Load Long Duration Stretch Knee

The purpose of this exercise is to be gentle and to hold the stretch for several minutes.  I typically use anywhere from 6 to 12 pounds and hold the position for at least 10 minutes.  If the person is fighting against the weight, then it is too aggressive.  Lower the weight and you’ll see better results.

Don’t forget that you can apply moist heat to the knee simultaneously for even more benefit.

LLLD Knee Stretch with Heat

Devices for Knee Extension Range of Motion

I am also quick to prescribe a range of motion restoration device for people that may be struggling with range of motion or are not moving their knee enough throughout the day.  I have tried some of the dynamic splinting in the past but found that many people would rather control and hold a sustained stretch rather than have the brace apply a dynamic stretch.

The two devices I have used and enjoyed are from Joint Active System (JAS) and End Range of Motion Improvement (ERMI).

JAS Knee Brace        ERMI Knee Brace

Both devices allow the patient to apply their own tolerable LLLD stretch at home.  This is helpful as frequent movement throughout the day is always beneficial.

Personally my criteria to use these devices is usually when I perceive the person will self-limit themselves and avoid motion.  I will get a device in their hands early so that they can move their knee more at home and have a feeling that they are controlling the restoration of range of motion.  We probably resort to using these devices when it is too late and the patient is already too stiff.



These are just some of the many ways to assess and treat loss of knee extension range of motion.  Considering how important it is to restore full knee extension after knee surgery, properly assessing early signs of loss of motion and effectively treating the knee to avoid long term loss of motion is critical.

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