Does stretching increase ankle dorsiflexion range of motion? A systematic review

Early full weight-bearing and gait exercise after cemented total ankle arthroplasty with a modified anterolateral approach

OBJECTIVES

According to the conventional postoperative procedure after total ankle arthroplasty (TAA), mobilization and weight-bearing is currently started after completion of wound healing. Recently, early mobilization for dorsiflexion after TAA with modified antero-lateral approach was reported to be feasible and safe. To investigate the further possibility of expediting rehabilitation, this study evaluated the feasibility and safety of early full weight-bearing and gait exercise after cemented TAA.

MATERIALS AND METHODS

This retrospective, observational study investigated 23 consecutive ankles (OA: 14 ankles, RA: 9 ankles) that had received cemented TAA with a modified antero-lateral approach. These ankles were divided into three groups 1. conventional postoperative protocol, 2. early dorsiflexion protocol, 3. early dorsiflexion+full weight-bearing protocol. Postoperative wound complications were observed and recorded. Number of days for hospitalization was also evaluated.

RESULTS

No postoperative complications related to wound healing were observed even after early full weight-bearing and gait exercise. Days for hospitalization was significantly shortened in early full weight-bearing and gait exercise group (group 3) from 35-38 days to 24 days.

CONCLUSIONS

Within this small number of cases, early full weight-bearing and gait exercise from 7 days after cemented TAA was feasible and safe with the modified antero-lateral approach. Combination of early dorsiflexion mobilization and weight-bearing/gait exercise contributed to shortening the hospitalization day. Innovations in postoperative procedures for rehabilitation after TAA can be expected.

Effects of simultaneous short-term neuromuscular electrical stimulation and static stretching on calf muscles

[Purpose] The simultaneous application of static stretching and neuromuscular electrical stimulation (NMES) to calf muscles may enhance physiological parameters in young and healthy individuals; however, the efficacy of this intervention and potential sex variation remain to be elucidated. The present study aimed to investigate these aspects. [Participants and Methods] Thirty healthy university students (15 males and 15 females) participated in this study. All participants simultaneously underwent static stretching and NMES of the calf muscles for 4 min while lying on an upright and tilted table. The mean differences in the dorsiflexion angle (DFA), finger-floor distance (FFD), and straight leg raising (SLR) angle before and after the intervention were calculated. Sex variations were assessed using a two-way analysis of variance (ANOVA). [Results] The DFA, FFD, and SLR angle exhibited significant effects on time. No significant sex variations were observed between the groups. [Conclusion] Simultaneous static stretching and NMES of the calf muscles potentially enhanced the DFA, FFD, and SLR angle in healthy university students, irrespective of sex.

Discussing Conflicting Explanatory Approaches in Flexibility Training Under Consideration of Physiology: A Narrative Review

The mechanisms underlying range of motion enhancements via flexibility training discussed in the literature show high heterogeneity in research methodology and study findings. In addition, scientific conclusions are mostly based on functional observations while studies considering the underlying physiology are less common. However, understanding the underlying mechanisms that contribute to an improved range of motion through stretching is crucial for conducting comparable studies with sound designs, optimising training routines and accurately interpreting resulting outcomes. While there seems to be no evidence to attribute acute range of motion increases as well as changes in muscle and tendon stiffness and pain perception specifically to stretching or foam rolling, the role of general warm-up effects is discussed in this paper. Additionally, the role of mechanical tension applied to greater muscle lengths for range of motion improvement will be discussed. Thus, it is suggested that physical training stressors can be seen as external stimuli that control gene expression via the targeted stimulation of transcription factors, leading to structural adaptations due to enhanced protein synthesis. Hence, the possible role of serial sarcomerogenesis in altering pain perception, reducing muscle stiffness and passive torque, or changes in the optimal joint angle for force development is considered as well as alternative interventions with a potential impact on anabolic pathways. As there are limited possibilities to directly measure serial sarcomere number, longitudinal muscle hypertrophy remains without direct evidence. The available literature does not demonstrate the necessity of only using specific flexibility training routines such as stretching to enhance acute or chronic range of motion.

Cross-Education Effects of Isokinetic Eccentric Plantarflexor Training on Flexibility, Strength, and Muscle-Tendon Mechanics

INTRODUCTION

Large increases in joint range of motion (ROM) have been reported after eccentric resistance training; however, limited data exist describing the associated mechanisms or potential cross-education effects in the contralateral limb. Therefore, the effects of a 6-wk isokinetic eccentric plantarflexor training program were examined in 26 participants.

METHODS

Before and after the training program, dorsiflexion ROM, plantarflexor strength, and muscle-tendon unit (MTU) morphology and mechanics were measured in control ( n = 13) and experimental ( n = 13) young adult groups. Training consisted of 5 sets of 12 maximal isokinetic eccentric plantarflexor contractions twice weekly on the right limb.

RESULTS

Significant ( P < 0.05) increases in dorsiflexion ROM (4.0-9.5°), stretch tolerance (40.3-95.9%), passive elastic energy storage (47.5-161.3%), and isometric (38.1-40.6%) and eccentric (46.7-67.0%) peak plantarflexor torques were detected in both trained and contralateral limbs in the experimental group. Significant increases in gastrocnemius medialis and soleus thickness (5.4-6.1%), gastrocnemius medialis fascicle length (7.6 ± 8.5%), passive plantarflexor MTU stiffness (30.1 ± 35.5%), and Achilles tendon stiffness (5.3 ± 4.9%) were observed in the trained limb only. Significant correlations were detected between the changes in trained and contralateral limbs for dorsiflexion ROM ( r = 0.59) and both isometric ( r = 0.79) and eccentric ( r = 0.73) peak torques. No significant changes in any metric were detected in the control group.

CONCLUSIONS

Large ROM increases in the trained limb were associated with neurological, mechanical, and structural adaptations, with evidence of a cross-education effect in the contralateral limb being primarily driven by neurological adaptation (stretch tolerance). The large improvements in ROM, muscle size, and strength confirm that isokinetic eccentric training is a highly effective training tool, with potential for use in athletic and clinical populations where MTU function is impaired and current therapies are ineffective.

Early mobilization of dorsiflexion from 3 days after cemented total ankle arthroplasty with modified antero-lateral approach

BACKGROUND

According to the conventional postoperative procedure after total ankle arthroplasty (TAA), mobilization is currently started after completion of wound healing. To investigate the possibility of expediting rehabilitation, this study evaluated the feasibility and safety of early mobilization of dorsiflexion after cemented TAA utilizing a modified antero-lateral approach.

MATERIALS AND METHODS

This retrospective, observational study investigated 14 consecutive ankles that had received cemented TAA. Mobilization of dorsiflexion was started from 3 days after surgery. Postoperative wound complications including blister formation, eschar formation, wound dehiscence, peri-incisional decreased sensation were observed and recorded. Range of motion (ROM) of dorsiflexion/plantar flexion was measured. Patients also completed a self-administered foot evaluation questionnaire (SAFE-Q) and the scale of Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot score preoperatively and at final follow-up.

RESULTS

No postoperative complications related to wound healing were observed. ROM for dorsiflexion, SAFE-Q score, and JSSF score improved significantly after TAA.

CONCLUSION

Within this small number of cases, early mobilization of dorsiflexion from 3 days after cemented TAA was feasible and safe with the modified antero-lateral approach. Innovations in postoperative procedures for rehabilitation after TAA can be expected.

Do the fasciae of the soleus have a role in plantar fasciitis?

Plantar fasciitis is a chronic, self-limiting, and painful disabling condition affecting the inferomedial aspect of the heel, usually extending toward the metatarsophalangeal joints. There is compelling evidence for a strong correlation between Achilles tendon (AT) loading and plantar aponeurosis (PA) tension. In line with this, tightness of the AT is found in almost 80% of patients affected by plantar fasciitis. A positive correlation has also been reported between gastrocnemius-soleus tightness and heel pain severity in this condition. Despite its high prevalence, the exact etiology and pathological mechanisms underlying plantar heel pain remain unclear. Therefore, the aim of the present paper is to discuss the anatomical and biomechanical substrates of plantar fasciitis with special emphasis on the emerging, though largely neglected, fascial system. In particular, the relationship between the fascia, triceps surae muscle, AT, and PA will be analyzed. We then proceed to discuss how structural and biomechanical alterations of the muscle-tendon-fascia complex due to muscle overuse or injury can create the conditions for the onset of PA pathology. A deeper knowledge of the possible molecular mechanisms underpinning changes in the mechanical properties of the fascial system in response to altered loading and/or muscle contraction could help healthcare professionals and clinicians refine nonoperative treatment strategies and rehabilitation protocols for plantar fasciitis.

The knowledge of movement experts about stretching effects: Does the science reach practice?

OBJECTIVE

Stretching is performed with numerous purposes in multiple settings such as prevention, rehabilitation, fitness training and sports. Its patterns of use substantially depend on the education and beliefs of health care and exercise professionals as they represent the multiplicators recommending and prescribing interventions to clients, patients and athletes. This study investigated movement experts' knowledge about the scientific evidence on stretching effects.

DESIGN

Survey study.

PARTICIPANTS

A total of 117 exercise and health professionals (physiotherapists, sports scientists, coaches) attending a training convention in Austria (male: n = 44, female: n = 73, 36±11 years) completed a digital survey. With its 22 items, the questionnaire addressed the movement experts' awareness of the evidence on stretching effects regarding a variety of related topics selected based on the findings of topical systematic reviews.

RESULTS

The majority of the individuals (57-88%) assumed positive effects of stretching on recovery, prevention of muscle injury, range of motion, muscular imbalance and artery elasticity. No or adverse effects were mostly claimed on bone injury prevention, maximal/explosive strength, and delayed-onset muscle soreness. In only 10 of 22 items, participants' classifications were in accord with the scientific evidence.

CONCLUSIONS

The awareness of research findings on stretching effects among exercise and health professionals is alarmingly low. Future studies may hence be geared to improve implementation and science communication.

Friction Blisters of the Feet: A Critical Assessment of Current Prevention Strategies

Friction blisters are a common injury of the feet sustained by individuals participating in sporting, recreational, and military activities. The high incidence of friction blisters brings into question the effectiveness of common prevention strategies. The purpose of this article was to review current evidence for established blister-prevention strategies and to explore how these interventions address the factors that cause friction blisters. Preventive strategies, focusing on previously overlooked elements of the blister-causing mechanism, are proposed. Areas of future research that are much needed to reduce this common skin injury in active individuals are outlined.

Acute Effects of Various Stretching Techniques on Range of Motion: A Systematic Review with Meta-Analysis

Background

Although stretching can acutely increase joint range of motion (ROM), there are a variety of factors which could influence the extent of stretch-induced flexibility such as participant characteristics, stretching intensities, durations, type (technique), and muscle or joint tested.

Objective

The objective of this systematic review and meta-analysis was to investigate the acute effects of stretching on ROM including moderating variables such as muscles tested, stretch techniques, intensity, sex, and trained state.

Methods

A random-effect meta-analysis was performed from 47 eligible studies (110 effect sizes). A mixed-effect meta-analysis subgroup analysis was also performed on the moderating variables. A meta-regression was also performed between age and stretch duration. GRADE analysis was used to assess the quality of evidence obtained from this meta-analysis.

Results

The meta-analysis revealed a small ROM standard mean difference in favor of an acute bout of stretching compared to non-active control condition (ES = −0.555; Z = −8.939; CI (95%) −0.677 to −0.434; p  < 0.001; I2 = 33.32). While there were ROM increases with sit and reach (P  = 0.038), hamstrings (P  < 0.001), and triceps surae (P  = 0.002) tests, there was no change with the hip adductor test (P  = 0.403). Further subgroup analyses revealed no significant difference in stretch intensity (P  = 0.76), trained state (P  = 0.99), stretching techniques (P  = 0.72), and sex (P  = 0.89). Finally, meta-regression showed no relationship between the ROM standard mean differences to age (R2 = −0.03; P  = 0.56) and stretch duration (R 2 = 0.00; P  = 0.39), respectively. GRADE analysis indicated that we can be moderately confident in the effect estimates.

Conclusion

A single bout of stretching can be considered effective for providing acute small magnitude ROM improvements for most ROM tests, which are not significantly affected by stretch intensity, participants’ trained state, stretching techniques, and sex.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-023-00652-x.

The meta-analysis on joint range of motion (ROM) increases revealed a small effect size in favor of an acute bout of stretching compared to the control condition. Subgroup analysis revealed a significant increase in ROM with sit and reach, hamstrings, and triceps surae tests, but no improvement with the hip adductor tests. Whereas all moderating variables presented significant increases in ROM, further subgroup analyses revealed no significant difference in ROM gains with the stretch intensity, trained state of the participants, stretching techniques, and sex. A meta-regression showed no relationship between the effect sizes to age and stretch duration, respectively.

Physiology of Stretch-Mediated Hypertrophy and Strength Increases: A Narrative Review

Increasing muscle strength and cross-sectional area is of crucial importance to improve or maintain physical function in musculoskeletal rehabilitation and sports performance. Decreases in muscular performance are experienced in phases of reduced physical activity or immobilization. These decrements highlight the need for alternative, easily accessible training regimens for a sedentary population to improve rehabilitation and injury prevention routines. Commonly, muscle hypertrophy and strength increases are associated with resistance training, typically performed in a training facility. Mechanical tension, which is usually induced with resistance machines and devices, is known to be an important factor that stimulates the underlying signaling pathways to enhance protein synthesis. Findings from animal studies suggest an alternative means to induce mechanical tension to enhance protein synthesis, and therefore muscle hypertrophy by inducing high-volume stretching. Thus, this narrative review discusses mechanical tension-induced physiological adaptations and their impact on muscle hypertrophy and strength gains. Furthermore, research addressing stretch-induced hypertrophy is critically analyzed. Derived from animal research, the stretching literature exploring the impact of static stretching on morphological and functional adaptations was reviewed and critically discussed. No studies have investigated the underlying physiological mechanisms in humans yet, and thus the underlying mechanisms remain speculative and must be discussed in the light of animal research. However, studies that reported functional and morphological increases in humans commonly used stretching durations of > 30 min per session of the plantar flexors, indicating the importance of high stretching volume, if the aim is to increase muscle mass and maximum strength. Therefore, the practical applicability seems limited to settings without access to resistance training (e.g., in an immobilized state at the start of rehabilitation), as resistance training seems to be more time efficient. Nevertheless, further research is needed to generate evidence in different human populations (athletes, sedentary individuals, and rehabilitation patients) and to quantify stretching intensity.

Effects of Myofascial Induction Therapy on Ankle Range of Motion and Pressure Pain Threshold in Trigger Points of the Gastrocnemius-A Clinical Trial

BACKGROUND

The myofascial induction technique (MIT) has been shown to increase shoulder range of motion (ROM) in breast cancer survivors and decrease pain pressure threshold over the radial nerve in patients with epicondylalgia. To the authors' best knowledge, no study on trigger points and MIT has been published to date. The effect on ROM of latent trigger points is also unknown.

METHODS

A total of 20 twins with one latent trigger point of the gastrocnemius muscle were evaluated pre- and post-MIT in the calf. We measured static footprint variables in a pre-post study.

RESULTS

We found differences in PPT (p = 0.001) and no differences in ROM with knee flexed (p = 0.420) or stretched (p = 0.069).

CONCLUSIONS

After Calf MIT, latent myofascial trigger points improve PPT but no change in ankle dorsiflexion with knee bent or knee flexed were found in non-restriction healthy subjects.

Corticospinal excitability and reflex modulation in a contralateral non-stretched muscle following unilateral stretching

PURPOSE

Muscle stretching effect on the range of motion (ROM) and force deficit in non-stretched muscle, and the underlying mechanisms, is an ongoing issue. This study aimed to investigate crossover stretching effects and mechanisms on the plantar flexor muscles.

METHODS

Fourteen recreationally active females (n = 5) and males (n = 9) performed six sets of 45-s static stretching (SS) (15-s recovery) to the point of discomfort of the dominant leg (DL) plantar flexors or control (345-s rest). Participants were tested for a single 5-s pre- and post-test maximal voluntary isometric contraction (MVIC) with each plantar flexor muscle and were tested for DL and non-DL ROM. They were tested pre- and post-test (immediate, 10-s, 30-s) for the Hoffman (H)-reflex and motor-evoked potentials (MEP) from transcranial magnetic stimulation in the contralateral, non-stretched muscle.

RESULTS

Both the DL and non-DL-MVIC force had large magnitude, significant (↓10.87%, p = 0.027, pƞ2 = 0.4) and non-significant (↓9.53%, p = 0.15, pƞ2 = 0.19) decreases respectively with SS. The SS also significantly improved the DL (6.5%, p < 0.001) and non-DL (5.35%, p = 0.002) ROM. The non-DL MEP/MMax and HMax/MMax ratio did not change significantly.

CONCLUSION

Prolonged static stretching improved the stretched muscle's ROM. However, the stretched limb's force was negatively affected following the stretching protocol. The ROM improvement and large magnitude force impairment (statistically non-significant) were transferred to the contralateral muscles. The lack of significant changes in spinal and corticospinal excitability confirms that the afferent excitability of the spinal motoneurons and corticospinal excitability may not play a substantial role in non-local muscle's ROM or force output responses.

Immediate effects of elastic tape application on the foot sole: a randomized controlled trial

[Purpose] In this study, we investigated the effectiveness of elastic tape in increasing the dorsiflexion angle and plantar flexor strength in healthy individuals. [Participants and Methods] This randomized controlled trial included 24 healthy university students who were categorized into the following groups (12 participants in each group): the intervention group (elastic tape was applied to the dominant foot) and the control group (no intervention was performed). We performed intergroup comparison of the pre- and post-intervention dorsiflexion angles and plantar flexor strength. Additionally, we performed subgroup analyses based on a straight-leg raise angle of 70°. [Results] We observed no significant intergroup differences in the dorsiflexion angle or plantar flexor strength. However, the post-intervention dorsiflexion angle was significantly greater than the pre-intervention angle in the subgroup with a straight-leg raise angle of <70° among participants in the elastic tape group. [Conclusion] Elastic tape application may effectively increase the dorsiflexion angle in individuals without hamstring extensibility.

Acute effect of diagonal stretching using the posterior oblique sling system on contralateral ankle dorsiflexion

BACKGROUND

A significant increase in the dorsiflexion range of motion (DFROM) after calf muscle stretching has been widely studied. However, it has been shown that the upper body is connected to the ankle joint by passive connective tissues.

OBJECTIVE

The purpose of this study was to examine the effect of upper-back stretching on the mobility of the contralateral ankle.

METHODS

In the supine position, DFROM in the contralateral leg was measured. In the sitting position with and without trunk rotation, DFROM was measured in both legs. In the sitting position with trunk rotation, dorsiflexion was measured only in the contralateral leg. Static diagonal stretching combining trunk rotation with slight trunk flexion was performed in the sitting position with a neutral pelvis.

RESULTS

After stretching, DFROM in contralateral and ipsilateral legs were measured in the sitting position with a neutral pelvis. In the contralateral leg, significant differences in ΔDFROM were observed between the sitting position with trunk rotation and the supine position and between the sitting position with trunk rotation and the sitting position after stretching.

CONCLUSION

In clinical settings, diagonal stretching of the unilateral posterior trunk causes a significant increase in the DFROM of the contralateral lower limb.

Systematic review: exercise training for equinus deformity in children with cerebral palsy

Background

Children with spastic cerebral palsy have motor deficits that can lead to joint contractures. Ankle equinus deformity is the most common foot deformity among children with CP. It is caused by spasticity and muscular imbalance in the gastrocnemius-soleus complex. Exercise enhances ankle function, improves gait in children with CP, and prevents permanent impairment. Therefore, there is a need to investigate the effectiveness of different types of exercise used in equine management. The aim of this review is to assess the evidence of the effectiveness of exercise training on equinus deformity in children with cerebral palsy.

Methodology

The American Academy for Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology were used to conduct this systematic review. Four databases (PubMed, Cochrane Library, Physiotherapy Evidence Database (PEDro), and Google Scholar) were searched till January 2022 using predefined terms by two independent reviewers. Randomized controlled trials published in English were included. This review included seven studies with 203 participants ranging in age from 5 to 18 years. Methodological quality was assessed using AACPDM, PEDro scale; also, levels of evidence adopted from modified Sacket’s scale were used for each study. Primary outcomes were dorsiflexion angle, plantar flexion angle, and plantar flexors strength.

Results

The quality of studies ranged from good (six studies) to fair (one study). The level of evidence was level 1 (six studies) and level 2 (one study) on modified Sacket’s scale. There is a low risk of bias in the included studies. Meta-analysis revealed a non-significant difference in plantar flexor strength, plantar flexion angle, and dorsiflexion angle between the study and control group.

Conclusions

There is a need for high-quality studies to draw a clear conclusion as the current level of evidence supporting the effectiveness of various types of exercises on equinus deformity in children with cerebral palsy is still weak.

The relationship between foot and ankle joint flexibility measures and barefoot plantar pressures in healthy older adults: a cross-sectional study

BACKGROUND

Restriction in foot and ankle joint range of motion, such as an ankle equinus, has been associated with increased plantar pressure and its complications. However, previous research is limited by its scope of measures and study populations. The aim of this study was to investigate the relationship between foot and ankle joint range of motion on barefoot plantar pressures during walking in healthy older adults.

METHODS

This cross-sectional study recruited 49 older adults. Participants underwent measures of foot (first metatarsophalangeal dorsiflexion range of motion, and navicular drop and drift) and ankle joint range of motion, foot posture, body mass index, and plantar pressure during barefoot walking. Spearman Rank Order Correlations were used to explore the relationship between foot and ankle measures, body mass index, and plantar pressure, with significant correlations explored in a hierarchical regression analysis. A Mann-Whitney U test was performed to compare plantar pressure values between those with and without ankle equinus per region of the foot.

RESULTS

Mean (SD) age and BMI were 72.4 years (5.2) and 29.8 kg/m² (5.9) respectively. A total of 32 of the 49 participants (65%) identified as female sex. Mean (SD) ankle joint range of motion was 32.7 (6.4) degrees with 17/49 (34.7%) participants classified as having an ankle equinus (defined as < 30 degrees of ankle joint dorsiflexion range of motion). We found that an ankle equinus predicted a statistically significant amount of peak forefoot plantar pressure (p = 0.03). Participants with an ankle equinus displayed significantly higher forefoot peak pressure 677.8 kPa (589.9 to 810.4) compared to those with no equinus 565.58 kPa (447.3 to 651.2), p = 0.02. A statistically significant correlation was found between body mass index and midfoot peak pressure (p < 0.01) and pressure-time integral (p < 0.01). No other significant correlations were found.

CONCLUSION

Clinicians should consider screening for an ankle equinus and body mass index as a simple way to identify which healthy older adults may be at risk of pressure-related complications in the mid- and forefoot.

Intensive physiotherapy versus home-based exercise and custom-made orthotic insoles in patients with plantar fasciitis: Pilot study

BACKGROUND

This prospective pilot study assessed the feasibility of comparing intensive physiotherapy group (IPG), home-based exercise (HBEG) group, and insole group (IG) to find the most effective treatment program for plantar fasciitis.

METHODS

Thirty-nine individuals with plantar fasciitis were selected to participate in this pilot study. The patients were randomly divided into 3 groups, as IPG (manual interventions, exercise, insoles), HBEG (exercise, insoles), and IG (insoles). The feasibility details including percentage of the enrollment and adherence to the groups were recorded. Pain was measured with a visual analog scale, and dorsiflexion range of motion (DROM), foot function, and health-related quality of life were evaluated at the baseline and week 6. One-way ANOVA analysis and Kruskal Wallis test were used to determine the differences of the percentage change of the parameters.

RESULTS

Pain and functional evaluation results showed improvements clinically in all of groups and quality of life results were similar for all groups. There was no difference between the groups after 6 weeks of treatment (P > 0.05).

CONCLUSIONS

The 3 treatment programs were found clinically applicable with high patient adherence. According to the data all intervention types were found moderately effective for pain and function. Insoles could be an option applied alone or with other treatments, and manual techniques gave better results in patients with limited ankle dorsiflexion. Although the results should be interpreted with caution because of the small sample size, these results were found promising and feasible to conduct a future RCT.

CLINICAL TRIAL REGISTRATION NUMBER

RCT 06144834.

Effect of vibration foam rolling on the range of motion in healthy adults: a systematic review and meta-analysis

Professionals use foam rollers to improve range of motion (ROM). Recently, a vibrating foam roller (VFR) that combines the vibration function with a foam roller (FR) has been used. The purpose of this systematic review and meta-analysis was to determine the effects of a VFR on the improvement of ROM in healthy individuals. A systematic literature search was carried out in five international databases: PubMed, Embase, PEDro, Cochrane Library, and Google Scholar. Eight clinical studies, composed of six randomized controlled trials and two randomized crossover trials that involved 230 healthy participants were selected for analysis. Methodological quality was identified using the PEDro scale. The mean scores, 4.75±0.71, of the eight included studies, were classified as fair. The results demonstrated that the VFR achieved better gains than the FR in improving ROM (standardized mean difference [SMD], 0.53; 95% confidence intervals [CIs], 0.29–0.77; I²=55%). The VFR was more effective in improving the ROM than the FR in the hip and knee joints (hip: SMD, 0.56; 95% CI, 0.28–0.85; I²=0%; knee: SMD, 0.86; 95% CI, 0.42–1.30; I²=79%). The VFR may be an additional option to improve the ROM in healthy adults and athletes.

Serial Within-Session Improvements in Ankle Dorsiflexion During Clinical Interventions Including Mobilization-With-Movement and A Novel Manipulation Intervention - A Case Series

BACKGROUND

Persisting reductions in ankle dorsiflexion range of motion are commonly encountered clinically and seen to be associated with adverse outcomes after ankle and other lower extremity injuries. Accordingly improving identified deficits is a common goal for rehabilitation; however, little data exists documenting any improvement related to interventions in these patients.

PURPOSE

To document the change in dorsiflexion range of motion after stretching and mobilization-with-movement and exercise and a novel manipulation intervention in a population of injured athletes.

DESIGN

Case series in 38 consecutive injured athletes with persisting reductions in ankle dorsiflexion range of motion (42 "stiff" ankles, 34 uninjured) in an outpatient sports physiotherapy clinic.

METHOD

During a single treatment session, two baseline measurements of weight-bearing dorsiflexion were taken at the start of the session to establish reliability and minimum detectable change, and then the same measures were performed after stretching and a mobilization-with-movement intervention, and again after clinical exercise and a novel manipulation which was applied on both ankles.

RESULTS

Excellent reliability was demonstrated (ICC2,1>0.93, MDC=3.5°) for the dorsiflexion measure. Statistically significant (p<0.01), but clinically meaningless improvements were seen after stretching and the mobilization-with-movement intervention on the injured and uninjured legs (1.9° and 1.4° respectively) with greater improvements seen after exercise and the subsequent manipulation (6.9° and 4.7°).

CONCLUSIONS

The relatively simple clinical exercise and manipulation intervention program was associated improvement in dorsiflexion range of motion in this cohort with persisting ankle stiffness. The interventions described largely restored range of motion consistent with baseline levels of the uninjured ankles. Improvements were also seen in the uninjured ankles following intervention.

Acute Effects of Gastrocnemius/Soleus Self-Myofascial Release Versus Dynamic Stretching on Closed-Chain Dorsiflexion

CONTEXT

Limited ankle dorsiflexion (DF) range of motion has been correlated with decreased flexibility of the gastrocnemius/soleus complex. Decreased ankle DF range of motion can lead to an increase in lower-extremity injuries, for example, acute ankle sprains, Achilles tendinopathy.

OBJECTIVE

The purpose of this study was to determine whether a single application of the intervention to the gastrocnemius/soleus complex via multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques acutely improved ankle DF.

DESIGN

Subjects were assigned to groups via random card selection. Investigators provided verbal cues as needed to yield correct performance of interventions. Both interventions were performed twice for 1 minute using a dynamic walking rest of 30.48 m at a self-selected pace between interventions. Statistical analyses were completed using a 1-way analysis of variance, at α level ≤ .05.

SETTING

A convenience sample study.

PARTICIPANTS

A total of 42 asymptomatic physical therapy students (18 females and 24 males) with mean age of 26.12 (4.03) years volunteered to participate.

INTERVENTIONS

Multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques.

MAIN OUTCOME MEASURES

Weight-bearing right ankle DF measurements were recorded in centimeters using a forward lunge technique (intraclass correlation coefficient = .98, .97, and .96).

RESULTS

Data analysis revealed no significant difference between the 3 groups in all pre-post measurements (P = .82). Mean (SD) measurements from pretest to posttest for myofascial release, dynamic stretching, and combination interventions were 0.479 (0.7) cm, 0.700 (0.7) cm, and 0.907 (1.4) cm, respectively.

CONCLUSION

Until further studies are conducted, the selection of technique to increase ankle DF range of motion should be based on each individual patient's ability, preference, and response to treatment.

The Case for Retiring Flexibility as a Major Component of Physical Fitness

Flexibility refers to the intrinsic properties of body tissues that determine maximal joint range of motion without causing injury. For many years, flexibility has been classified by the American College of Sports Medicine as a major component of physical fitness. The notion flexibility is important for fitness has also led to the idea static stretching should be prescribed to improve flexibility. The current paper proposes flexibility be retired as a major component of physical fitness, and consequently, stretching be de-emphasized as a standard component of exercise prescriptions for most populations. First, I show flexibility has little predictive or concurrent validity with health and performance outcomes (e.g., mortality, falls, occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (i.e., body composition, cardiovascular endurance, muscle endurance, muscle strength). Second, I explain that if flexibility requires improvement, this does not necessitate a prescription of stretching in most populations. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching (e.g., resistance training). Retirement of flexibility as a major component of physical fitness will simplify fitness batteries; save time and resources dedicated to flexibility instruction, measurement, and evaluation; and prevent erroneous conclusions about fitness status when interpreting flexibility scores. De-emphasis of stretching in exercise prescriptions will ensure stretching does not negatively impact other exercise and does not take away from time that could be allocated to training activities that have more robust health and performance benefits.

Does a weight bearing equinus affect plantar pressure differently in older people with and without diabetes? A case control study

BACKGROUND

A weight bearing ankle equinus has adverse effects on forefoot plantar pressure variables in older adults with diabetes, but it is unclear if this is also the case in older adults without diabetes.

METHODS

40 older adults with diabetes (88% type 2, mean diabetes duration 17.6 ± 14.8 years) and 40 older adults without diabetes, matched for age (±3 years), sex and BMI (±2 BMI units) were included (63% female, mean age 72 ± 4 years, BMI 30 ± 4 kg/m²). Primary outcomes were prevalence of a weight bearing equinus and evaluation of barefoot forefoot plantar pressures in older adults with and without diabetes.

FINDINGS

A weight bearing equinus was present in 37.5% and 27.5% of the diabetes and non-diabetes group respectively with no significant difference between groups (p = 0.470). People with diabetes and equinus displayed higher peak pressure (808 versus 540 kPa, p = 0.065) and significantly higher pressure-time integral (86 versus 68 kPa/s, p = 0.030) than people with diabetes and no equinus group. The non-diabetes equinus group had significantly higher peak pressure (665 versus 567 kPa, p = 0.035) than those with no diabetes and no equinus, but no difference in pressure-time integral.

INTERPRETATION

A high prevalence of a weight bearing equinus was detected in older adults with and without diabetes, with associated increases in plantar pressures. As an equinus has been associated with many foot pathologies this study's findings suggest that clinicians should check for the presence of a weight bearing ankle equinus in all older adults.

Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession: A Systematic Review

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was -2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted.Levels of Evidence: Level IV.

The effects of using a combination of static stretching and aerobic exercise on muscle tendon unit stiffness and strength in ankle plantar-flexor muscles

The purpose of the present study was to investigate the effects of using a combination of static stretching and aerobic exercise on muscle tendon unit stiffness and muscle strength in the ankle plantar-flexor muscles. Fifteen healthy males (23.3 ± 2.7 years, 170.3 ± 6.5 cm, 64.9 ± 8.7 kg) received three different interventions, in random order. Intervention 1 received 10 min of aerobic exercise after five cycles of one minute of static stretching. Intervention 2 received 10 min of aerobic exercise before the static stretching. Intervention 3 received 5 min of aerobic exercise both before and after the static stretching. The range of motion of ankle dorsiflexion, stretch tolerance, muscle tendon unit stiffness, peak torque of ankle plantarflexion, and the amplitude of electromyography were measured. In all interventions, the range of motion and stretch tolerance significantly increased (p < 0.05), but muscle tendon unit stiffness decreased significantly for all interventions (p < 0.05). Peak torque of ankle plantar flexion and amplitude of electromyography significantly increased for Interventions 1 and 3 (p < 0.05), while these significantly decreased for Intervention 2 (p < 0.05). These data indicated that range of motion and stretch tolerance were increased, but muscle tendon unit stiffness was decreased regardless of the order of static stretching and aerobic exercise. Aerobic exercise after static stretching increased the peak torque and amplitude of electromyography.

The optimal duration of high-intensity static stretching in hamstrings

Objectives

The purpose of this study was to compare the duration of high-intensity static stretching on flexibility and strength in the hamstrings.

Methods

Fourteen healthy males (20.8 ± 0.6 years, 170.7 ± 6.5 cm, 66.4 ± 9.9 kg) underwent high-intensity static stretching for three different durations (10, 15, and 20 seconds). The intensity of static stretching was set at the maximum point of discomfort. To examine the change in flexibility and strength, range of motion, peak passive torque, relative passive torque, muscle-tendon unit stiffness, peak torque of isokinetic knee flexion, and knee angle at peak torque of isokinetic knee flexion were measured. To evaluate a time course of pain, a numerical rating scale was described.

Results

Range of motion (P < 0.01), peak passive torque (P < 0.01), and knee angle at peak torque were increased at all interventions. Relative passive torque (P < 0.01) and muscle-tendon unit stiffness (P < 0.01) were decreased at all interventions. Peak torque decreased after 10 seconds of stretching (P < 0.05). Numerical rating scale during stretching was 8–9 levels in all interventions, the pain disappeared immediately after the post-measurements (median = 0).

Conclusion

The results suggested that muscle-tendon unit stiffness decreased regardless of duration of high-intensity static stretching. However, peak torque of isokinetic knee flexion decreased after 10 seconds of high-intensity static stretching, though it was no change after for more than 15 seconds of stretching.

Calf stretching and plantar fascia-specific stretching for plantar fasciitis: A systematic review and meta-analysis

BACKGROUND

Plantar fasciitis (PF) is the most common cause of heel pain. A calf stretching (CS) and a plantar fascia-specific stretching (PFSS) are two stretching techniques commonly administered by health care providers.

OBJECTIVE

To evaluate the literature on the application of these two stretching techniques in the treatment of PF and investigate their effectiveness and efficacy.

METHOD

A search of PubMed, Web of Sciences, PEDro, CINHAL and Scopus was conducted. Studies that applied stretching as a co-intervention were excluded. The risk of bias was assessed to determine the internal validity of the included trials. The GRADE approach was adopted to determine the overall quality. Pooled analysis was performed to determine the treatment effects of CS and PFSS in terms of the mean difference in the visual analog scale pain score.

RESULTS

Eight articles were found that represented randomized controlled trial and met the inclusion criteria. There was very low-quality evidence that the combined CS and PFSS was less effective in the short term than the other therapies. Comparison between CS and PFSS revealed moderate quality evidence for a larger effect of pain score reduction for PFSS treatment over CS, while very low-quality evidence supported that combined CS and PFSS or CS alone was superior to sham stretching.

CONCLUSION

There was moderate to very low-quality evidence of the effectiveness of stretching for PF. The treatment effect of stretching was large and comparable to other therapies. Future trials of higher quality are needed to clarify findings or to confirm findings.

Influence of High Intensity 20-Second Static Stretching on the Flexibility and Strength of Hamstrings

The purpose of the present study was to examine the effects of high intensity static stretching for 20 seconds on flexibility and strength in the hamstrings. Seventeen healthy participants (13 men and 4 women) underwent static stretching for 20 seconds at three different intensities based on the point of discomfort (POD, 120% POD, and MaxPOD). To examine the change in flexibility and strength, range of motion (ROM), passive torque, muscle-tendon unit stiffness, peak torque of maximum voluntary isokinetic concentric contraction, and knee angle at peak torque were measured. To evaluate a time course of pain, a numerical rating scale (NRS) was described. ROM (percent change; POD = 113.5 ± 10.4%, 120%POD = 127.6 ± 18.8%, MaxPOD = 135.6 ± 18.5%) (p < 0.01) and passive torque (percent change; POD = 124.2 ± 38.9%, 120%POD = 143.4 ± 65.1%, MaxPOD = 171.8 ± 83.6%) (p < 0.01) were increased at all intensities. Muscle-tendon unit stiffness was decreased at 120%POD (percent change; 72.4 ± 36.2, p < 0.01) and MaxPOD (percent change; 56.6 ± 30.0, p < 0.01). Peak torque showed no change at all intensities (percent change; POD = 99.1 ± 14.0%, 120%POD = 95.4 ± 17.4%, MaxPOD = 98.4 ± 20.1%, p > 0.05). There were significant correlations between the intensities and relative change of the ROM (r = 0.57, p < 0.01), passive torque (r = 0.46, p < 0.01), muscle-tendon unit stiffness (r = -0.53, p < 0.01) and knee angle at peak torque (r = 0.50, p < 0.01). NRS increased with the intensity of static stretching (median; POD = 1, 120%POD = 3, Max POD = 8), though the pain disappeared immediately after the stretching (median = 0). In conclusion, static stretching for 20 seconds at high intensity was effective for a decrement in muscle-tendon unit stiffness.

Comparison of Two Static Stretching Techniques for the Triceps Surae in Healthy Individuals: Wall and Inclined Board Stretchings

Objective

To compare the effectiveness of static stretching techniques for correcting the tightness of the triceps surae.

Methods

In this observational, cross-sectional study, participants (30 healthy volunteers) completed 10 repetitions of each stretching exercise, holding each stretch for 10 seconds, with a 1-minute rest period between repetitionsand a 1-hour rest period between the two stretching techniques, namely, wall and inclined board stretchings. The length of the triceps surae and range of ankle dorsiflexion were measured on lateral view radiographs. The muscle activity during the stretch was measured using quantified surface electromyography of the lateral gastrocnemius. The subjective stretching sensation was evaluated using the visual analog scale.

Results

Both stretching techniques showed statistical differences in all the parameters. Stretching on an inclined board yielded a greater increase in the triceps surae length than did wall stretching (mean difference, 0.72; p=0.02). The range of ankle dorsiflexion was higher with inclined board stretching than with wall stretching (mean difference, 2.57; p=0.03). The mean muscle activity was significantly lower withinclined board stretching than with wall stretching (mean difference, 53.72; p<0.01). The visual analog scale score was higher with inclined board stretching than with wall stretching (mean difference, 2.07; p<0.01).

Conclusion

In this study, inclined board stretching was more effective than wall stretching for correcting tightness of the triceps surae. Therefore, inclined board stretching should be encouraged for the triceps surae.

Acute Effects of Resistance Exercise on Cognitive Function in Healthy Adults: A Systematic Review with Multilevel Meta-Analysis

BACKGROUND

Recent research has revealed a beneficial impact of chronic resistance exercise (RE) on brain function. However, it is unclear as to whether RE is also effective in an acute setting.

OBJECTIVE

To investigate the immediate effects of a single RE session on cognitive performance in healthy adults.

METHODS

A multilevel meta-analysis with random effects meta-regression model was used to pool the standardized mean differences (SMD) between RE and no-exercise (NEX) as well as between RE and aerobic exercise (AE). In addition to global cognitive function, effects on reported sub-domains (inhibitory control, cognitive flexibility, working memory, attention) were examined.

RESULTS

Twelve trials with fair methodological quality (PEDro scale) were identified. Compared to NEX, RE had a positive effect on global cognition (SMD: 0.56, 95% CI 0.22-0.90, p = 0.004), but was not superior to AE (SMD: - 0.10, 95% CI 0.01 to - 0.20, p = 0.06). Regarding cognitive sub-domains, RE, compared to NEX, improved inhibitory control (SMD: 0.73, 95% CI 0.21-1.26, p = 0.01) and cognitive flexibility (SMD: 0.36, 95% CI 0.17-0.55, p  = 0.004). In contrast, working memory (SMD: 0.35, 95% CI - 0.05 to 0.75, p  = 0.07) and attention (SMD: 0.79, 95% CI - 0.42 to 2.00, p = 0.16) remained unaffected. No significant differences in sub-domains were found between RE and AE (p > 0.05).

CONCLUSION

RE appears to be an appropriate method to immediately enhance cognitive function in healthy adults. Further studies clearly elucidating the impact of effect modifiers such as age, training intensity, or training duration are warranted.

Scientific Evidence in the Treatment of Metatarsalgia

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

Calf muscle stretching is ineffective in increasing ankle range of motion or reducing plantar pressures in people with diabetes and ankle equinus: A randomised controlled trial

BACKGROUND

Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes.

METHODS

Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention.

FINDINGS

68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:-0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:-2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:-10.0 to 12.9, p = 0.803) or barefoot peak pressures (-19.1 kPa, 95% CI:-96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up.

INTERPRETATION

Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.

Flexibility exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for adults with fibromyalgia. We defined flexibility exercise training programs as those involving movements of a joint or a series of joints, through complete range of motion, thus targeting major muscle-tendon units. This review is one of a series of reviews updating the first review published in 2002.

OBJECTIVES

To evaluate the benefits and harms of flexibility exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro (Physiotherapy Evidence Database), Thesis and Dissertation Abstracts, AMED (Allied and Complementary Medicine Database), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up to December 2017, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized trials (RCTs) including adults diagnosed with fibromyalgia based on published criteria. Major outcomes were health-related quality of life (HRQoL), pain intensity, stiffness, fatigue, physical function, trial withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles for inclusion, extracted data, performed 'Risk of bias' assessments, and assessed the certainty of the body of evidence for major outcomes using the GRADE approach. All discrepancies were rechecked, and consensus was achieved by discussion.

MAIN RESULTS

We included 12 RCTs (743 people). Among these RCTs, flexibility exercise training was compared to an untreated control group, land-based aerobic training, resistance training, or other interventions (i.e. Tai Chi, Pilates, aquatic biodanza, friction massage, medications). Studies were at risk of selection, performance, and detection bias (due to lack of adequate randomization and allocation concealment, lack of participant or personnel blinding, and lack of blinding for self-reported outcomes). With the exception of withdrawals and adverse events, major outcomes were self-reported and were expressed on a 0-to-100 scale (lower values are best, negative mean differences (MDs) indicate improvement). We prioritized the findings of flexibility exercise training compared to land-based aerobic training and present them fully here.Very low-certainty evidence showed that compared with land-based aerobic training, flexibility exercise training (five trials with 266 participants) provides no clinically important benefits with regard to HRQoL, pain intensity, fatigue, stiffness, and physical function. Low-certainty evidence showed no difference between these groups for withdrawals at completion of the intervention (8 to 20 weeks).Mean HRQoL assessed on the Fibromyalgia Impact Questionnaire (FIQ) Total scale (0 to 100, higher scores indicating worse HRQoL) was 46 mm and 42 mm in the flexibility and aerobic groups, respectively (2 studies, 193 participants); absolute change was 4% worse (6% better to 14% worse), and relative change was 7.5% worse (10.5% better to 25.5% worse) in the flexibility group. Mean pain was 57 mm and 52 mm in the flexibility and aerobic groups, respectively (5 studies, 266 participants); absolute change was 5% worse (1% better to 11% worse), and relative change was 6.7% worse (2% better to 15.4% worse). Mean fatigue was 67 mm and 71 mm in the aerobic and flexibility groups, respectively (2 studies, 75 participants); absolute change was 4% better (13% better to 5% worse), and relative change was 6% better (19.4% better to 7.4% worse). Mean physical function was 23 points and 17 points in the flexibility and aerobic groups, respectively (1 study, 60 participants); absolute change was 6% worse (4% better to 16% worse), and relative change was 14% worse (9.1% better to 37.1% worse). We found very low-certainty evidence of an effect for stiffness. Mean stiffness was 49 mm to 79 mm in the flexibility and aerobic groups, respectively (1 study, 15 participants); absolute change was 30% better (8% better to 51% better), and relative change was 39% better (10% better to 68% better). We found no evidence of an effect in all-cause withdrawal between the flexibility and aerobic groups (5 studies, 301 participants). Absolute change was 1% fewer withdrawals in the flexibility group (8% fewer to 21% more), and relative change in the flexibility group compared to the aerobic training intervention group was 3% fewer (39% fewer to 55% more). It is uncertain whether flexibility leads to long-term effects (36 weeks after a 12-week intervention), as the evidence was of low certainty and was derived from a single trial.Very low-certainty evidence indicates uncertainty in the risk of adverse events for flexibility exercise training. One adverse effect was described among the 132 participants allocated to flexibility training. One participant had tendinitis of the Achilles tendon (McCain 1988), but it is unclear if the tendinitis was a pre-existing condition.

AUTHORS' CONCLUSIONS

When compared with aerobic training, it is uncertain whether flexibility improves outcomes such as HRQoL, pain intensity, fatigue, stiffness, and physical function, as the certainty of the evidence is very low. Flexibility exercise training may lead to little or no difference for all-cause withdrawals. It is also uncertain whether flexibility exercise training has long-term effects due to the very low certainty of the evidence. We downgraded the evidence owing to the small number of trials and participants across trials, as well as due to issues related to unclear and high risk of bias (selection, performance, and detection biases). While flexibility exercise training appears to be well tolerated (similar withdrawal rates across groups), evidence on adverse events was scarce, therefore its safety is uncertain.

Efficacy of instrument-assisted soft tissue mobilization in comparison to gastrocnemius-soleus stretching for dorsiflexion range of motion: A randomized controlled trial

OBJECTIVES

To determine the efficacy of IASTM of the gastrocnemius-soleus complex in comparison to a traditional stretching intervention on dorsiflexion ROM.

METHODS

Sixty healthy participants were randomly allocated to one of 3 groups: IASTM (n = 20), stretching (n = 20), or control group (n = 20). The dependent variables for this study was dorsiflexion range of motion (ROM) via three measurement methods which included Modified root position 1- knee extended (MRP1), Modified root position 2- knee flexed (MRP2), and weight bearing lunge test (WBLT). A multivariate analysis of variance (MANOVA) was utilized to analyze the ROM differences between the groups (IASTM, stretching, and control groups), with a post-hoc Tukey and pairwise least significant difference tests to assess individual pairwise differences between the groups.

RESULTS

The MANOVA found significant ROM differences between the three intervention groups (F_6,110 = 2.40, p = .032). Statistically significant differences were identified between both the IASTM and control as well as the stretching and control group through the WBLT and MRP2 assessments, but not in the MRP1 assessment. Further, there was no statistically significant difference between the IASTM and stretching groups using any of the three methods.

CONCLUSION

A single session of IASTM or stretching increased ankle dorsiflexion ROM in WBLT and MRP2. No significant difference was noted in the MRP1. Both IASTM and stretching appear to have a greater effect on soleus muscle flexibility as evidenced by ROM gains measured with the knee in a flexed position. No clinically significant difference was identified between the intervention groups in weight-bearing conditions; thus empowering patients with the use of self-stretching would seemingly be reasonable and efficient. Combined effects of stretching and IASTM warrant further investigation for increasing dorsiflexion range of motion as a summative effect is unknown.

Impact of Routine Gastrocnemius Stretching on Ankle Dorsiflexion Flexibility and Injury Rates in High School Basketball Athletes

Background:

Achilles tightness exacerbates a variety of foot and ankle conditions while increasing the risk of lower extremity injuries. The correlation between Achilles tightness and lower extremity injury rates in a young, athletic population is unknown.

Purpose:

To evaluate the impact of routine gastrocnemius stretching on ankle flexibility and lower extremity injury rates in youth basketball athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A prospective cohort study enrolling 8 high school basketball teams (4 male teams, 4 female teams) was conducted over a 3-month sporting season. Two schools (2 male teams, 2 female teams) were assigned to a daily gastrocnemius stretching protocol. Two control schools (2 male teams, 2 female teams) followed no protocol. Passive ankle dorsiflexion was measured bilaterally in both groups at 4 time points: preseason, 1 month and 2 months after the start of the season, and postseason (3 months from the start of the season). The number of injuries sustained during the season and the number of games missed because of a lower extremity injury were recorded. Differences in dorsiflexion flexibility measurements and injury rates were analyzed between the protocol and control groups.

Results:

A total of 106 athletes (46 male, 60 female) were included in the study. The protocol group included 51 athletes (mean age, 15.7 ± 1.2 years) versus 55 athletes (mean age, 16.2 ± 1.0 years) in the control group. Athletes undergoing routine gastrocnemius stretching had significantly higher ankle dorsiflexion flexibility measurements compared with control athletes at all time points (P < .05 for each time point) while also demonstrating a significant increase in dorsiflexion between the preseason and postseason time points (P = .04). No significant difference in injury rates was appreciated between the protocol and control groups, and no difference in dorsiflexion flexibility measurements was appreciated between injured and uninjured athletes.

Conclusion:

The implementation of a gastrocnemius stretching protocol in youth basketball athletes increased ankle dorsiflexion over a single season without decreasing the injury incidence relative to controls in our study. Because the size of our study limited statistical power, a confirmation of the results in a larger study is required.

Lower extremity joint contracture according to ambulatory status in children with Duchenne muscular dystrophy

Background

Lower extremity joint contractures have negative effects on gait in children with Duchenne muscular dystrophy (DMD). Thus, contracture prevention is essential for maintaining a patient’s functional ability and an acceptable quality of life. This study investigated hip flexion (HF), knee flexion (KF), and ankle joint plantar flexion (APF) contractures among male patients with DMD, based on the patients’ ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated.

Methods

A total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, > 3 sessions/week, were classified into the stretching group.

Results

The HF (23.5^o), KF (43.5^o), and APF (34.5^o) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. APF contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises > 3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group.

Conclusion

HF, KF, and APF contractures are more common and severe when there is deterioration of ambulatory function. Stretching exercises alone are unlikely to prevent lower extremity joint contractures.

Prevalence of isolated gastrocnemius tightness in patients with foot and ankle pathology

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

Patients and Methods

This prospective, case-matched, observational study compared gastrocnemius tightness, as assessed by the lunge test, in a control group and a group with foot and ankle pathology. Gastrocnemius tightness was calculated as the difference in dorsiflexion of the ankle with the knee extended and flexed.

Results

A total of 291 controls were paired with 97 patients with foot and ankle pathology (FAP). The mean gastrocnemius tightness was 6.0° (sd 3.5) in controls and 8.0° (sd 5.7) in the FAP group (p < 0.001). Subgroup analysis showed a mean gastrocnemius tightness of 10.3° (sd 6.0) in patients with forefoot pathology versus 6.9° (sd 5.3) in patients with other pathology (p = 0.008). A total of 12 patients (37.5%) with forefoot pathology had gastrocnemius tightness of > two standard deviations of the control group (> 13°).

Conclusion

Gastrocnemius tightness of > 13° may be considered abnormal. Most patients with foot and ankle pathology do not have abnormal degrees of gastrocnemius tightness compared with controls, but it is present in over a third of patients with forefoot pathology. Cite this article: Bone Joint J 2018;100-B:945–52.

Chronic effect of different types of stretching on ankle dorsiflexion range of motion: Systematic review and meta-analysis

The calf muscles are one of the muscle groups that have the most need for adequate flexibility since they are deeply related to normal lower limb function. When the goal is to increase flexibility, the most commonly used technique is stretching. However, it remains unknown which stretching technique and parameters are the most effective to increase flexibility. Hence, the aim of the current review was to investigate the influence of chronic stretching on ankle dorsiflexion range of motion (DFROM) of healthy individuals. The search strategy included MEDLINE, PEDro, Cochrane CENTRAL, LILACS, and manual search from inception to February 2017. Randomized and controlled clinical trials that have analyzed the influence of chronic stretching on DFROM were included. On the other hand, studies with special populations (children, and people with any dysfunction/disease), and articles with no control group were excluded. Twenty studies were included out of 493 identified. The meta-analysis was performed according to the stretching technique used in the study. The results show that static stretching (5.17°; 95% CI: 4.39-5.95; I²: 0%) and proprioceptive neuromuscular facilitation (4.32°; 95% CI: 1.59-7.04; I²: 46%) are effective in increasing DFROM. Ballistic stretching did not show positive results to increase DFROM (3.77°; 95% CI: -0.03 to 7.56; I²: 46%). In conclusion, chronic stretching is an effective way of improving ankle mobility in healthy individuals, especially when it contains a static component.

Gastrocnemius Recession for Metatarsalgia

Metatarsalgia is a common cause of plantar forefoot pain. Causes of metatarsalgia include foot anatomy, gait mechanics, and foot and ankle deformity. One specific cause, mechanical metatarsalgia, occurs because of gastrocnemius muscle contracture, which overloads the forefoot. Muscular imbalance of the gastrocnemius complex alters gait mechanics, which increases recruitment of the toe extensor musculature, thereby altering forefoot pressure. Patients with concomitant metatarsalgia and gastrocnemius contracture demonstrate ankle equinus and a positive Silfverskiold test. Nonoperative therapeutic modalities are mainstays of treatment. In patients in whom these treatments fail to provide metatarsalgia symptomatic relief, gastrocnemius muscle lengthening is a therapeutic option.

Changes in H-reflex amplitude to muscle stretch and lengthening in humans

Spinal reflex excitability is traditionally assessed to investigate neural adjustments that occur during human movement. Different experimental procedures are known to condition spinal reflex excitability. Among these, lengthening movements and static stretching the human triceps have been investigated over the last 50 years. The purpose of this review is to shed light on several apparent incongruities in terms of magnitude and duration of the reported results. In the present review dissimilarities in neuro-spinal changes are examined in relation to the methodologies applied to condition and measure them. Literature that investigated three different conditioning procedures was reviewed: passive dorsiflexion, active dorsiflexion through antagonists shortening and eccentric plantar-flexors contractions. Measurements were obtained before, during and after lengthening or stretching. Stimulation intensities and time delays between conditioning procedures and stimuli varied considerably. H-reflex decreases immediately as static stretching is applied and in proportion to the stretch degree. During dorsiflexions the inhibition is stronger with greater dorsiflexion angular velocity and at lower nerve stimulation intensities, while it is weaker if any concomitant muscle contraction is performed. Within 2 s after a single passive dorsiflexion movement, H-reflex is strongly inhibited, and this effect disappears within 15 s. Dorsiflexions repeated over 1 h and prolonged static stretching training induce long-lasting inhibition. This review highlights that the apparent disagreement between studies is ascribable to small methodological differences. Lengthening movements and stretching can strongly influence spinal neural pathways. Results interpretation, however, needs careful consideration of the methodology applied.

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

BACKGROUND

Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot.

OBJECTIVES

The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers.

METHODOLOGY

An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications.

RESULTS

Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed.

CONCLUSION

Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Addition of Glute-Ham-Gastroc Raise to a Resistance Training Program: Effect on Jump Propulsion and Landing

Chiu LZF, Yaremko A, and vonGaza GL. Addition of glute-ham-gastroc raise to a resistance training program: effect on jump propulsion and landing. J Strength Cond Res 31(9): 2562-2571, 2017-Exercises such as squats and cleans are commonly used in resistance training programs to enhance athletic performance. However, these exercises may not effectively train the gastrocnemius, an important muscle for energy generation and absorption. The purpose of this research was to examine the effects of adding glute-ham-gastroc raise exercise to target the gastrocnemius to a traditional resistance training program involving squats and cleans. Vertical jump height, weight-bearing ankle dorsiflexion, and jump propulsion and landing mechanics were examined before and after an 8-week training intervention in female youth volleyball players. Approach (with: [INCREMENT] = 2.6 ± 1.7 cm; 90% confidence interval [CI] [1.8-3.6 cm] vs. without: [INCREMENT] = 1.8 ± 1.9 cm; 90% CI [0.8-2.8 cm]) and standing (with: [INCREMENT] = 2.7 ± 1.7 cm; 90% CI [1.7-3.6 cm] vs. without: [INCREMENT] = 1.6 ± 1.5 cm; 90% CI [0.8-2.4 cm]) vertical jump height increased more in the group performing glute-ham-gastroc raise. Weight-bearing ankle dorsiflexion increased when glute-ham-gastroc raise was included (left: [INCREMENT] = 4.1 ± 4.1°; 90% CI [1.9-6.4°] and right: [INCREMENT] = 4.1 ± 3.9°; 90% CI [1.9-6.2°]) but did not appear to change with resistance training only (left: [INCREMENT] = 1.4 ± 4.5°; 90% CI [-1.0 to 3.9°] and right: [INCREMENT] = 2.5 ± 4.4°; [-0.3 to 4.5°]). No discernible differences were observed for changes in jump propulsion and landing mechanics between groups. Glute-ham-gastroc raise may have a beneficial effect with young athletes when added to squat- and clean-based resistance training programs.

Endoscopic Recession of the Gastrocnemius Tendon

Gastrocnemius contracture is a common condition associated with painful overload symptoms in the forefoot and midfoot. Multiple techniques have been described for the recession of gastrocnemius tendon in patients who failed nonsurgical treatment. We present an endoscopic recession technique for the release of the gastrocnemius tendon just distal to the level of the musculotendinous junction as a minimally invasive operative option. This technique aims to decrease wound complications, unsightly scar, overlengthening, and postoperative pain, while having versatility for performing with supine or prone positioning.

Equinus and Lengthening Techniques

Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.

Surgical Equinus Correction for the Diabetic Charcot Foot: What the Evidence Reveals

Triceps surae contracture, or equinus, is a known deforming force in the foot and ankle. Biomechanical studies have shown that ankle equinus significantly alters gait and plantar pressures, and in the diabetic neuropathic patient population, this can propagate plantar ulceration and/or Charcot neuroarthropathy (CN). Surgical correction of equinus is globally and frequently used to aid in plantar wound healing in the neuropathic diabetic patient, with and without CN. Treatment guidelines for equinus correction in this medically complex population are undefined and lack evidence from high-quality published peer-reviewed studies.