Download - Stretching Exercises 1. Mobility and Flexibility of soft tissues (muscles, tendons, fascia, joint capsule, and skins) surrounding the joint along with.

Stretching Exercises

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Mobility and Flexibility of soft tissues (muscles, tendons, fascia, joint capsule, and skins) surrounding the joint along with adequate joint mobility, are necessary for normal ROM.

• Mobility: is the ability of segments of the body to move through range of motion for functional activities.

• Flexibility: is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain –free ROM.

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Types of Flexibility1. Dynamic flexibility (active mobility or active ROM ) It is the degree to which an active muscle contraction

moves the a body segment through the available ROM of the joint.

It depends on: • The degree to which joint can be moved by a muscle

contraction • The amount of soft tissue resistance met during the

active movement.

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2. Passive flexibility (passive mobility or passive ROM )

It is the degree to which a joint can be passively moved through the available ROM.

It depends on:

- extensibility of muscles and connective tissues (soft tissues ) that crosses and surrounding a joint.

Types of Mobility

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1- Hypo-mobility: Refers to decreased mobility or restricted motion.2- Hyper-mobility: Refers to increased mobility

Muscle Anatomy1. Made up of many muscle fibers that lie parallel with

one another2. Single fiber – made up of many myofibrils3. Myofibrils - composed of sarcomeres 4. Sarcomere – contractile unit of the myofibril

1. Gives muscle ability to contract & relax2. Composed of overlapping myofilaments of Actin &

Myosin (form cross-bridges)1. Motor unit stimulated = m. contraction -actin-myosin

filaments slide together & the muscle actively shortens2. Muscle relaxes = cross-bridges slide apart slightly & the

muscle returns to its resting length

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Myofilament• A myofilament shows several distinct

bands• Each band has been given a special

letter

• The lightest (least electron dense) band is the “I band”– Consists primarily of actin– In the center of the “I band” is the

“Z-line”, an electron dense line

• The wide, dark band is the “A band” – Consists primarily of myosin – In the middle of the “A band” is the

“M line”, another dense line

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Myofilament Sliding

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Skeletal MuscleCT structures of muscle-tendon unit:

• Endomysium: the innermost fascial sheath that envelops individual muscle fiber.

• Perimysium: the fascial sheath that binds groups of muscle fibers into individual fasciculi.

• Epimysium: the outermost fascial sheath that binds entire fasciculi.

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How Muscle Contracts Nerves connect the signals (action potential) to the muscle

through the neuromuscular junction then transmitted deep inside muscle fibers. As a result the calcium will flow and cause the sliding of the thick and thin filaments across each other. When this occur billions of sarcomeres in the muscle shorten at once result in contraction of muscle.

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The muscle has two structures control its functionThe muscle has two structures control its function:• First the Golgi Tendon Organ (GTO), • wraps around the ends of an extrafusal fibersand is sensitive to tension in muscle causedeither by passive stretch or active muscle contraction.• The GTO is a protective mechanism that inhibits contraction of the muscle in which it lies. It fires easily (low threshold) after an active muscle contraction and has a highthreshold for firing with passive stretch.

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• The GTO may be the neurophysiologic basis for the inhibition of muscle that occurs with passive stretching. When passive stretch is applied, tension will increase in the muscle and cause firing of GTO and subsequent inhibition (relaxation) of the muscle.

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• Second, the Stretch Reflex:

• The muscle spindle is sensitive to both quick stretch (ballistic stretch) and static or maintained stretch of the muscle.

• When the muscle is stretched, the intrafusal and extrafusal muscle fibers are stretched.

• The Phasic Ia afferent fibers that arise from the nuclear bag of the muscle spindle are sensitive to a quick stretch of the muscle.

• The tonic Ia afferent fibers that arise from the nuclear chain of the muscle spindle are sensitive to maintained stretch.

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• When the primary afferents fire, the extrafusal fibers of the muscle being stretched contract. Tension momentarily increases in the muscle because of this reflex contraction.

• The stretch reflex acts as a protective mechanism so that the muscle being lengthened will not be over stretched.

• If a muscle is stretched quickly, the stretch reflex will be facilitated than if a muscle is stretched slowly.

• For this reason, static or sustained stretch is preferable than ballistic stretch.

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Factors that influence flexibility

1- Joint structure• The type of joint determine the degree of

ROM. For example; a ball-and-socket joint, like shoulder has greater ROM than a hinge joint like wrist.

2- Age• With age, muscles go through a

shortening process due to lack of physical activities and a loss of elasticity in the connective tissues surrounding the muscles. As a result, there tends to be a decrease in flexibility with age.

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Factors that influence flexibility

3- The Elasticity• The elasticity of the skin, tendons

and ligaments, (ligaments do not stretch much and tendons should not stretch at all).

4-Gender• Females tend to be more flexible

than males of similar age throughout life, generally due to anatomical variations in joint structures.

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Factors that influence flexibility5-Exercise

• Participation in regular exercise involving full ROM generally enhances flexibility, while a sedentary lifestyle often results in diminished flexibility.

6-Muscle mass• muscle mass can be a factor when the

muscle is so heavily developed that it interferes with the ability to take the adjacent joints through their complete range of motion (for example, large hamstrings limits the ability to fully bend the knees). Excess fatty tissue imposes a similar restriction.

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Factors that influence flexibility7-Temperature

• An increase in either body temperature as a result of exercise or external temperature increases ROM.

8-Pregnancy• During pregnancy, the pelvic joints

and ligaments are relaxed and capable of a greater ROM.

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Causes of soft tissue Shortening

1- Prolonged Immobilization due to:Prolonged Immobilization due to: A. Extrinsic factors* casts and splint* casts and splint* skeletal traction* skeletal tractionB. Intrinsic factors * pain* pain * joint inflammation &stiffness* joint inflammation &stiffness * skin &muscle disorders* skin &muscle disorders * bony block* bony block * vascular disorders* vascular disorders

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Causes of soft tissue shortening

2- Sedentary lifestyle due to bed rest, work environment

3- Muscle imbalance, paralysis or tone abnormality

4- Postural malalignment which may be

* congenital

* acquired

e.g. Scoliosis, Kyphosis

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# Contracture it is not equal to Contraction

Contracture • Is the adaptive shortening of the muscle-tendon unit

and other soft tissues that crosses or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM

Contraction• The process of tension developing in a muscle during

shortening or lengthening

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Intervention to Increase Mobility of Soft Tissues

• Many therapeutic interventions have been designed to improve the mobility of soft tissues and consequently increase ROM and flexibility. Stretching and mobilization are general terms that described any therapeutic maneuvers that increases the extensibility of restricted soft tissues.

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What are four physiological properties of muscle tissue that Affect Elongation (Stretching)

• Excitability: the ability of the muscle to respond to stimuli.

• Contractility: the ability of the muscle to produce tension

• Extensibility: the ability of the muscle to be extended beyond its normal length

• Elasticity – ability of the muscle to return to its resting length from extended position

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CONTRACTURE• Is the adaptive shortening of muscle-tendon unit and other soft tissues that cross or surround a joint,which result in significant limitation of ROM.Types of contractures1- Myotatic contracture (Myogenic): there is no specific muscle pathology present, although there is a significant loss of ROM.2- Pseudo myotatic contracture: the limited ROM may be the result of

hyper tonicity (spasticity or rigidity).3- Arthrogenic &periarticular contracture: the limited ROM may be the

result of intraarticular pathology e.g. adhesions, joint inflammation, osteophyte formation.

4- Irreversible contracture: permanent loss of mobility of soft tissue including muscles due to fibrotic changes that cannot be reversed by non surgical intervention.

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Types of Stretching

1- Passive stretching

2- Active (Neuromuscular) Inhibition stretching.

3- Self stretching

4- Ballistic stretching.

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1- Passive Stretching• A sustained external force applied at the end –range manually or

mechanically to elongates a shortened muscle-tendon unit, while the patient is relaxed. This type can be classified into:

• The tension created in a muscle during ballistic stretch is nearly twice that created with low- intensity static (sustained) stretch.

• When a gentle passive stretch position is held for at least 30 to 60 second, the facilitatory effect of stretch reflex on muscle appear to be minimal as the inhibitory action of the GTO may override the facilitatory effect of stretch reflex, so that there is no increase in muscle tension.

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a- Manual Passive Stretch

• The therapist applies an external force and controls the direction, speed, intensity and duration of stretch to shorten soft tissues beyond their resting length.

• This technique should not be confused with passive range of motion exercises. Passive stretching takes the structures beyond the free range of motion. Passive range of motion is applied only within the unrestricted available range.

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• The patient must be as relaxed as possible during passive stretching.

• The stretch force is usually applied for at least 15 to 30 seconds and repeated several times in an exercise session.

• The intensity and duration of the stretch are dependent on the patient’s tolerance and the therapist’s strength and endurance. A low-intensity manual stretch applied for as long a duration as possible will be more comfortable and more readily tolerated by the patient.

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b- Prolonged Mechanical Passive Stretch

• 2- Prolonged mechanical passive stretching• A low intensity external force is applied over a prolonged period of time

with mechanical equipment.• The stretch force is applied with the patient as relaxed as possible.• The stretch may be maintained for 15-30 minutes or as long as several days

or weeks, depending on the type of apparatus used.• The stretch can be applied through positioning of the patient, with weighted

traction and pulley systems, or with serial splints or casts.

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C-Cyclic (Intermittent) stretch

*A short duration stretch force, repeatedly but gradually applied, released, and then reapplied using mechanical device.*Each cycle of stretch is held between 5-10 seconds at the end-range, which is applied gradually at a controlled manner and at a relatively low intensity. These cyclic stretching is applied for many repetitions in each single treatment session.*This type of stretching showed that it is more effective and comfortable than a prolonged static stretch.

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2- Active (Neuromuscular) Inhibition stretching

• These procedures reflexively relax the tension in shortened muscles prior to or during stretching maneuver.

• When a muscle is reflexively inhibited, there is less resistance to elongation by the contractile unites of the muscle.

• Inhibition techniques increase muscle length by relaxing and elongating the contractile components of muscle.

• This type of stretching is only done with normally innervated muscle and under voluntary control.

• It can not be used in patient with severe muscle weakness, spasticity, or paralysis from neuromuscular dysfunction.

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• For example; where you assume a position and then hold it there with no assistance other than using the strength of agonist muscles. E.g., bringing your leg up and then holding it there without anything, other than your leg muscles itself, to keep the leg in that extended position. The tension of the agonists in an active stretch helps to relax the muscles being stretched (antagonists) by reciprocal inhibition. Active stretches are hold and maintained for 10 to 15 seconds.

• These techniques have been adapted from Proprioceptive neuromuscular facilitation (PNF) techniques.

• There are threethree variations of neuromuscular inhibition techniques:1- Contract-relax (Hold- relax).2- Contract-relax- contract (Hold- relax with agonist contraction).3- Agonist contraction.

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3- Self Stretching• Also known as flexibility exercises or active stretching.• Self stretching is a type of flexibility exercise that a patient can carry out

himself as an integral component of a home exercise program.• It may involve relaxation of muscle and a passive stretch applied

through the weight of the body.• Self stretching can also be carried out actively by the patient first

inhibiting and then lengthening the tight muscle.

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4- Ballistic stretching• A rapid, forceful intermittent, high-speed and high-

intensity stretch. • Vigorous bouncing movement to force the body

segment beyond its range of motion to stretch shortened structures.

• It is not advised because the high-velocity and high-intensity movements are difficult to control and can lead to injury in weakened tissues.

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Comparing Stretching Techniques

• Ballistic stretching is recommended for athletes engaged in dynamic activity

• Static stretching most widely used– Safe & effective

• PNF techniques– Capable of producing dramatic increases in ROM

– Limitation – partner is required

• Maintaining flexibility– Can decrease considerable after only 2 weeks

– Should be engaged in at least once per week

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Goals of Stretching

1- Regain normal range of motion of joints and mobility of soft tissue that surrounding that joint.

2- Prevent irreversible contractures.3- Increase the general flexibility of muscle and soft

tissues before vigorous strengthening exercises.4- Minimize and prevent the risk of musculo-

tendinous injuries related to specific physical activities and sports.

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Indications of Stretching

1- Limited range of motion due to contractures, adhesions and scar tissue formation leading to shortening of muscles, ligaments, connective tissue and skin.

2- When there are structural (skeletal) deformities as a result of limitation.

3- Whenever contracture interfere with activities of daily living (ADL).4- When there is muscle imbalance (muscle weakness and opposing tissue

tightness). Tight muscle must be stretched first before strength of weak muscle.

5- As part o a total fitness program.6- Prior to and after vigorous exercise to minimize postexercise muscle

soreness.

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Contra-indications of Stretching

1- Presence of bony block that limits joint motion.2- Recent fracture.3- Cases of acute inflammation or infection

(presence of heat swelling around the joint).4- Presence of acute sharp pain with joint

movement or muscle elongation.5- in case of hematoma and hypermobility.

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Precautions of Stretching

1-Don’t force the joint beyond its normal range of motion (remember ROM varies in normal subjects).

2-Newly united fractures should be protected by stabilization between the fracture site and the joint where the movement takes place.

3-Patient known or suspected osteoporosis as, prolonged bed rest, old age, and prolonged use of steroids, due to change in flexibility.

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Precautions of Stretching4-Avoid vigorous stretching of muscles and connective

tissues that have been immobilized for long time (connective tissues as tendons and ligaments lose their tensile stretching after prolonged immobilization)

5-If there is joint pain or muscle soreness lasting for more than 24 hours, it is preferable to take rest and if you start to make stretch take care don’t use too much force during stretch.

6-Avoid stretching edematous tissues because it is more susceptible to injury.

7-Avoid overstretch the weak muscles because it may lead to more pain and edema.

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Principles of Stretching• Alignment &Stabilization:- Proper alignment and positioning of the patient and the muscle to be stretched is

necessary for patient comfort and stability.- Stabilization and fixation of the proximal or distal attachment site of the muscle-

tendon unit is important to achieve effective stretching.• Intensity of stretch:- The intensity should be applied gently, at a low intensity by means of a low load.• Duration of stretch:- The period of time a stretch force is applied. How long a single cyclea single cycle of stretch is

applied. The cumulative time of all stretch cycles in a treatment session.- A low load, long duration stretch is the safest form of stretch.- In general, stretch cycle from 15-60 seconds applied 4-6 times have shown to

produce significant gain in ROM.• Speed of stretch:- The stretch force should be applied and released gradually in order to be more safer

and prevent injury.• frequency stretch:- The number of bouts per day or per week.- It is based on the under lying cause, the level of healing process, the chronicity of

contracture and the patient age.

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Guidelines for stretching procedure

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Examination and evaluation• Review the patient’s history• Determine the available ROM.• Determine if the hypomobility related to pain &

functional limitations• Determine the cause of limited ROM e.g. capsule,

muscle• Identify the stage of healing to determine the

intensity and duration of stretch• Assess the strength of the underlying muscles• State the outcome goals• Analyze any factors that could affect the outcome

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Prior to stretching

• Position the patient in a comfortable and stable position which allow best plane of motion.

• Explain the goals and procedures to the patient.• Free the area to be stretched from any restricted

clothing, or splint.• Employ relaxation techniques prior to stretching.• Apply heat to the soft tissues to be stretched. • Advice and ask the patient to be relaxed as possible

throught the stretching period.

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Technique of relaxed stretching

• Preparation of stretching1- Assess the patient and know the amount and cause of

limitation (soft tissue or connective tissue)2- Choose the best type of stretching according to the cause of

limitation.3- Explain the goal and way of stretching to the patient.4- Choose a comfortable position and ask patient to be free from

restricted clothes, bandages or splints. 5- Apply relaxation technique (general or local), and ask patient

to be relax as possible as he can during stretching.6- Apply any source of heat to increase the extensibility of the

shortened and tight structures.

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Technique of relaxed stretching

• How to apply stretch?1- Grasp firmly and comfortably proximal and distal to the joint

where motion is to occur.2- Move the distal part of the limb slowly to the point of limitation.3-To stretch a multi-joint muscle, start stretch with only one joint at

a time, then over all joints until optimum length of soft tissue is obtained.

4- To minimize compression forces in small joints, stretch the distal joints first and proceed proximally.

5- It is better to apply gentle, slow and sustained stretch force on the joint until point of tightness and then move just beyond.

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Technique of Relaxed Stretching

6-Gradually release the stretch force. Give the patient enough time to rest and then repeat the maneuver.

7- Don’t try to gain full range in one or two sessions. Increasing flexibility is a slow and gradual process. It may take several weeks of treatment to see significant results.

After stretching• Apply cold to the stretched soft tissues to

minimize post stretch muscle soreness.• Ask the patient to apply active ROM and

strengthening exercise to the gained ROM.• Ask the patient to use the regained ROM in the

ADL.• Develop balancing exercise between the agonist

and the antagonist groups to maintain the balance in the new range.

• Use splint to maintained the regained ROM.

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TECHNIQUES

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STRETCH OF PECTORALIS MUSCLE

• TEST PECTORALIS FLEXIBILITY

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PECTORALIS FLEXIBILITY

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SHOULDER ROTATOR CUFF

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The Rotator Cuff: the Teres Minor, the Infraspinatus, the Supraspinatus and the Subscapularis.

PECTORALIS TARGET STRETCH

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place your palm flat on the wall, keep your weight in your heels, and lean the whole body forward. Use the hand on the wall as your anchor, and feel the stretch along the front of the chest and armpit.

PECTORALIS TARGET STRETCH• Lower your hand to

about shoulder height, palm facing the wall, stretching the hand behind you. Then turn the whole body away from the wall, pointing the feet, knees, and hips away from the hand. Feel the stretch across the front of the chest and inner arm.

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STRETCH OF PECTORALIS MUSCLE

• 1- FROM STANDING POSITION

Stretching of Lower Limb

• Test of hip flexors shortening (Thomas test)

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Iliopsoas Stretching

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Passive Stretch of The Hip Flexors

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OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY

• Ober’s test is the test for tightness of the ITB. • The subject is placed on their side, healthy

side down. The knee is flexed 90 degrees and the hip extended to neutral (no flexion).

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OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY

• The PHYSIOTHERAPIST holds the leg up by the foot. Normally, the knee falls down to the exam table. If the ITB is very tight, the leg hangs up in the air (very impressive). If it’s moderately tight, the knee falls halfway to the table.

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MODIFIED OBER’S TEST

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Iliotibial Band Flexibility

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STRETCHING OF HIP ADDUCTORS

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STRETCHING OF HIP ADDUCTORS AND HAMSTRING

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TEST OF HAMSTRING FLEXIBILITY

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HAMSTRING FLEXIBILITY

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FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

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STRETCHING OF CALF MUSCLE

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Calf Stretching

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SELF STRETCHING

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Stretch of Upper Trunk

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Lower back flexibility

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Gluteus flexibility

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Iliopsoas Flexibility

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Iliopsoas Flexibility

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Iliotibial Band flexibility

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Iliotibial Band flexibility

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Hamstring Stretching

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Hip Adductors Stretching

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Calf stretching

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