Flexibility for

Runners
a, b
Jeffrey Jenkins, MD *, James Beazell, PT, DPT, OCS, ATC

KEYWORDS
 Flexibility  Range of motion  Stretching  PNF

Flexibility generally describes the range of motion commonly present in a joint or

group of joints that allows normal and unimpaired function.1 More specifically, flexi-
bility has been defined as the total achievable excursion (within the limits of pain) of
a body part through its range of motion.2 With regard to flexibility, the following gener-
alizations can be made: flexibility is an individually variable, joint-specific, inherited
characteristic that decreases with age, varies by gender and ethnic group, bears little
relationship with body proportion or limb length, and, most importantly, for the
purposes of this article, can be modified through training.1,36
Achieving a maximal functional range of motion is an important goal of many ther-
apeutic exercise regimens. Most typically, increased range of motion is achieved via
the process of stretching. The term stretching defines an activity that applies
a deforming force along the rotational or translational planes of motion of a joint.
Stretching should respect the lines of geometry of the joint and its planes of stability.
In addition to stretching, mobilization is used to maintain flexibility. Mobilization
moves a joint through its range of motion without applying a deforming force.7
The athletic literature seems to show that flexibility training, when used appropri-
ately, plays a positive role in sports injury and performance. However, excessive flex-
ibility may actually be both a risk factor for injury5,811 and a detriment to performance.
Stiff structures do seem to benefit from stretching, whereas hypermobile structures
require stabilization rather than additional mobilization.

DETERMINANTS OF FLEXIBILITY

The determinants of joint mobility can be subdivided into static and dynamic factors.
Static factors include the types of tissues involved, the state of collagen subunits in the
tissue, the presence or absence of inflammation, and the temperature of the tissue.
Dynamic factors include neuromuscular variables such as voluntary muscle control

a
Department of Physical Medicine and Rehabilitation, University of Virginia, 545 Ray C. Hunt
Drive, Suite 240, Charlottesville, VA 22903, USA
b
University of VirginiaHealthSouth Physical Therapy, 545 Ray C. Hunt Drive, Suit 210,
Charlottesville, VA 22903, USA
* Corresponding author.
E-mail address: jj5u@virginia.edu

Clin Sports Med 29 (2010) 365377

doi:10.1016/j.csm.2010.03.004 sportsmed.theclinics.com
0278-5919/10/$ see front matter 2010 Elsevier Inc. All rights reserved.
366 Jenkins & Beazell

and the inherent neuromuscular feedback of the musculotendinous unit, as well as

external factors such as pain associated with injury.2

Static Factors
The most important tissue with regard to flexibility is the muscle-tendon unit (MTU),
which is the primary target of flexibility training.2 This structure includes the full length
of the muscle and its supporting tissue, the musculotendinous junction, and the full
length of the tendon to the tendon-bone junction. The MTU has both viscous and
elastic mechanical properties. The MTU reacts to a slowly applied stretching force
with elongation, a phenomenon called stress relaxation. This phenomenon is accom-
plished through the mechanical property of creep. The viscous aspect of the MTU
means that rapidly applied force to the muscle will be met by increased resistance
to elongation.
Within the MTU, it is the muscle that has the largest capacity for percent length-
ening1214of the tissues involved in a stretch. A ratio of 95%:5% for muscle:tendon
length change has been demonstrated.14 From a mechanical standpoint, muscle is
composed of contractile and series elastic elements arranged in parallel.15 Muscle
can respond to an applied force or stretch with permanent elongation. Animal studies
have shown that this results from an increase in the number of sarcomeres, which trans-
lates to increased peak tension of a muscle at longer resting lengths. By contrast,
muscle at rest has a tendency to shorten because of its contractile element. This short-
ening can be permanent and is associated with a reduction in sarcomeres.1619 Tendon
has a much more limited capacity for lengthening than muscle, probably because of its
proteoglycan content and collagen cross-links (2%3% of its length, compared with
20% for muscle).13,14,18 Of the external static factors, temperature has been studied
the most. Warmer tissues are generally more distensible than colder ones.1921

Dynamic Factors
Perhaps the most clinically and physiologically significant dynamic determinant of
flexibility is the muscle length-tension thermostat or feedback control system. Intra-
fusal fibers (muscle spindles), innervated by gamma motoneurons, lie in parallel with
extrafusal contractile fibers. The intrafusal fibers serve the purpose of regulating the
tension and length of the muscle as a whole. Muscle spindle length and tension are
regulated by the gamma motoneuron, which in turn is subject to influences from the
central nervous system. These include segmental input at the spinal cord level and
suprasegmental input from the cerebellum and cortex. Consequently, muscle length
and tension can be subject to multiple influences simultaneously. An additional
complicating factor is that receptors in the musculotendinous unit called the Golgi
tendon organs (GTOs) act to inhibit muscle contraction at the point of critical stresses
to the structure. The GTOs allow lengthening and facilitate relaxation. When acting in
conjunction, these dynamic mechanisms facilitate a response to a stretch in the
following ways: as the muscle spindle is initially stretched, it sends impulses to the
spinal cord that result in reflex muscle contraction, and if the stretch is maintained
longer than 6 seconds, the GTO fires, causing relaxation.2 The relative contribution
of static muscle factors and dynamic neural factors to flexibility remains somewhat
controversial. The changes in flexibility noted immediately after the institution of
a stretching program occur too rapidly to be attributable solely to structural alteration
of the muscle and connective tissue. The consensus view is that neural factors prob-
ably play the major role in this early flexibility. After prolonged periods of training,
changes in sarcomere number can play a role in the establishment of a new elongated
muscle length.2
 Flexibility for Runners 367

ASSESSMENT OF FLEXIBILITY

Flexibility is generally assessed in terms of joint range of motion. Joint range of motion
in turn is generally assessed with a goniometer or a similar device. A goniometer
consists of a 180 protractor that is designed for easy application to joints. The
methods used when using a goniometer, as well as the normal ranges of motion
encountered with these methods, are well standardized.22 Inter- and intra-observer
reliabilities are good.8 Limitations of the standard goniometer include application to
only single joints at a given time, static measurements only, and difficulty of applica-
tion to certain joints (eg, costoclavicular joint). The Leighton Flexometer (Leighton
Flexometer, Inc, Spokane, WA, USA) contains a rotating circular dial marked in
degrees and a pointer counterbalanced to remain vertical. It can be strapped to
a body segment, and range of motion is determined with respect to the perpendicular.
Leighton Flexometers reliability is good but is not equivalent to that of the standard
goniometer.23 The electrogoniometer substitutes a potentiometer for a protractor.
The potentiometer provides an electrical signal that is directly proportional to the angle
of the joint. This device is able to give continuous recordings during a variety of activ-
ities, allowing a more realistic assessment of functional flexibility and dynamic range of
motion during actual physical activity.

METHODS OF STRETCHING

It is important to take several factors into consideration when using a stretching

program. Prevention of injury and treatment of specific joint injury, as well as the pres-
ence and effects of pain or muscle spasm, require modification of the program.
Stretching can be dangerous and might result in significant injury if performed incor-
rectly.2426 As with any form of therapeutic exercise, flexibility training must be
approached within a program aimed at addressing the specific functional needs of
the individual. Numerous options are now available for improving flexibility with
stretching techniques. A distinct superiority of any 1 method has not been demon-
strated. For the purposes of this article, stretching techniques are divided into the
following 4 categories: ballistic, static, passive, and proprioceptive neuromuscular
facilitation (PNF).
Ballistic Stretching
Ballistic stretching uses the repetitive rapid application of force in a bouncing or jerk-
ing maneuver. Momentum carries the body part through the range of motion until the
muscles are stretched to the limits. This method is less efficient than other methods
as the muscle will contract under these stresses to protect itself from overstretching.
In addition, the rapid increase in force can cause injury.25,27 An example would be the
10-count bouncing toe touches popularized in the 1970s but since abandoned
because of perceived lack of efficacy and documented risk of injury. Recent evidence
has begun to revive interest in this recently disparaged form of flexibility training.
Witvrouw and colleagues28 have reported that ballistic stretching may have beneficial
effects on tendon elasticity. They propose that this effect may be important in athletes
who perform more jumping activities, which are considered stretch-shortening
cycles. The stretch-shortening phenomenon is important in absorbing force and
then saving it as potential energy. The theory is that ballistic stretching may activate
the muscle to a significantly greater degree than static stretching, resulting in a signif-
icantly greater load on the corresponding tendon and bringing about an improvement
in its elasticity.
368 Jenkins & Beazell

Passive Stretching
Passive stretching uses a partner or therapist who applies a stretch to a relaxed joint or
extremity. This method requires excellent communication and the slow and sensitive
application of force. This method is most appropriately and most safely used in the
training room or in a physical or occupational therapy context. Outside these contexts,
passive stretching can be dangerous for recreational or competitive athletes because
of increased risk of injury. In their 2005 study, Verrall and colleagues29 successfully
incorporated a passive hamstring stretching program into an overall training program
for an Australian rules football team. They were able to show a significant decrease in
hamstring strains per 1000 hours of playing time in their subjects.
Static Stretching
Static stretching applies a steady force for a period of 15 to 60 seconds. This method
is the easiest, certainly is the most popular, and may be the safest type of stretching.
Perhaps consequently, static stretching is also the most studied form of flexibility
training. Since the early eighties, static stretching has been encouraged as a warm-
up activity before any other form of therapeutic or recreational exercise, including
athletic activity. Static stretching has the added advantage here of being associated
with decreased muscle soreness after exercise.30,31 This advantage may contribute
to its efficacy. Bjorklund and colleagues32 showed that sensory adaptation seems
to be an important mechanistic factor in the effect stretching has on range of motion
changes.
In a systematic review of static stretching as warm-up to prevent injury, Small and
colleagues33 were able to find only 4 randomized controlled trials and 3 clinical
controlled trials that were of high enough quality to include. The investigators
concluded that there is moderate to strong evidence to indicate that static stretching
does not reduce overall injury rates. However, they did suggest that there is prelim-
inary evidence that static stretching may specifically reduce musculotendinous
injuries. This finding was based primarily on the conclusions of 2 articles, specifically
those by Amako and colleagues34 and Bixler and Jones.35 Both of these studies
were able to show a significant reduction in musculotendinous injuries after imple-
mentation of a static stretching program, whereas neither found a significant differ-
ence in overall injury rate. Another review article by Woods and colleagues36 in
2007 also cited the work of Amako, Bixler, and Jones, but in addition, referenced
the findings of Hartig and Henderson37 and Verrall and colleagues29 This review
was more positive regarding the effects of flexibility training and concluded that
stretching programs have consistently shown a positive effect on the prevention of
muscular injury.
The neural effects of static stretching38 have been studied in the soleus muscle, and
the effect on the muscle spindle has been studied by observing changes in the Hoff-
mann reflex (H-reflex) and tendon reflex (T-reflex). The results indicated that the H-
reflex decreased significantly more than the T-reflex during progressive stretching.
Both the H- and T-reflexes stay depressed during the stretch, and the H-reflex returns
to normal after the stretch is removed, whereas the T-reflex remains below the control
value. The conclusion is that the resultant inhibition of the T-reflex is the result of either
decreased muscle spindle sensitivity or increased compliance of the MTU.

PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION

PNF has been a component of specific training of patients with neuromuscular disease
or injury. PNF was developed by Kabat and Knott39 and based on the neuromuscular
 Flexibility for Runners 369

concepts developed by Sherrington and Lasletts research40 at the beginning of the

20th century. In an excellent review of the research on PNF stretching, Sharman
and colleagues41 describe the current theories on the physiologic mechanisms that
are responsible for the effectiveness of PNF training.
Sharman and colleagues41 found that PNF techniques and descriptions of those
techniques were highly variable, making it difficult to compare various studies.
However, there is general consensus that the effectiveness of PNF stretching is based
on neurophysiologic effects. Two specific mechanisms are theorized to mediate this
response: autogenic inhibition and reciprocal inhibition.
Autogenic inhibition is theorized to be due to the stretch of GTOs in the MTU,
resulting in a decrease in the muscle excitability after stretching. This muscle excit-
ability would allow for the elongation of the muscle after inhibition as a result of acti-
vation of the GTO. Research has failed to prove this theory on a consistent basis, and
this effect has been shown only to last at most 1 second after the contraction has
ended.42
Reciprocal inhibition refers to the effect of contraction of the opposing muscle on
the muscle targeted for stretching. This proposed mechanism holds that efferent
input into the spinal cord will alter the presynaptic inhibition of the muscle to be
stretched. Specifically, descending motor input activates not only alpha motoneu-
rons to the opposing muscle but also the inhibitory 1a afferent neurons of the target
muscle to be stretched. Evidence for this mechanism is mixed. On the one hand,
research has not shown a difference in motoneuron pool excitability between static
stretching and PNF stretching42 as reflected in either electromyography or H-reflex
recordings. However, few studies have shown that contraction of the opposing
muscle to the target muscle for stretching does cause a greater increase in range
of motion.41

ATHLETIC PERFORMANCE

In addition to injury prevention, another proposed benefit of flexibility training is

improved sports performance. With regard to running, the evidence for this effect
is weak at best. Several laboratories have shown that among runners, less-flexible
individuals have a lower rate of oxygen consumption while covering the same
distance at the same speed as their more flexible cohorts.4,43 In addition, the in vitro
improvement in contraction strength resulting from prestretching4447 has not been
consistently observed in the world of athletics. It has been shown repeatedly that
passive stretching can result in an acute loss of strength.4853 Along the same lines,
a recent study of elite female soccer players demonstrated that static stretching
before sprinting resulted in worsened performance.54 Stretching too vigorously
before an athletic event is likely to impair performance. The injury prevention role
of stretching has to be balanced against this consideration on an individual
athlete-to-athlete basis.

FLEXIBILITY PROGRAM

Runners are likely to benefit from a flexibility program. Various stretches have been
espoused for the muscles of the lower quarter. What follows is the flexibility program
developed at the Runners Clinic at the University of Virginia.
Hip Flexors
Effects of hip flexor stretching have been studied in elderly with gait. Subjects per-
forming a home program of hip flexor stretching improved their hip extension
370 Jenkins & Beazell

Fig. 1. Hip flexor stretch. Athlete is in 90/90 position. Perform a posterior pelvic tilt to acti-
vate the right gluteal as shown to facilitate stretch of iliopsoas. Avoid lumbar extension or
passive hip extension. Stretch should be vaguely felt in anterior thigh.

compared with control subjects who are at both self-selected gait speed and fast
walking.55 A stretch using the PNF concept of reciprocal inhibition can be performed
as shown in Fig. 1. In this position, the athlete performs a posterior pelvic tilt while con-
tracting the gluteals that will facilitate a stretch of the iliopsoas complex.
Hamstrings
A systematic review was performed in 200556 to determine the most appropriate
hamstring stretch technique and duration. The investigators concluded that various
techniques improved flexibility with various durations of application of the stretch
and different positions. A randomized controlled trial57 comparing 4 different stretch-
ing techniques in a cohort of 100 subjects showed that active stretch using a reciprocal
inhibition contraction of the quadriceps (Fig. 2) and passive straight leg raise (Fig. 3)
improved hamstring flexibility.

Fig. 2. Active hamstring stretch. Athlete flexes hip up to 90 and clasps behind knee. Athlete
then attempts to straighten knee to activate quadriceps and stretch hamstrings. The athlete
can increase the hip flexion to change stretch emphasis.
 Flexibility for Runners 371

Fig. 3. Passive hamstring stretch.

Quadriceps
A simple stretching program of the quadriceps (Fig. 4) has been shown to be effective
and associated with some decrease in pain in patients with patellofemoral pain.58 The
investigators reported significant change in Kendall test (Fig. 5) for quadriceps length
and associated improvement in pain and function.

Fig. 4. Quadriceps stretch. Keeping the trunk, hip, and knee in alignment, the athlete bends
the knee and grasps with the ipsilateral hand; the contralateral hand can grasp a chair for
balance. The stretch can be accentuated with bending of the stance knee.
372 Jenkins & Beazell

Fig. 5. Kendall test for quadriceps length. The angle of the knee is measured with the
athlete in the Thomas test position.

Rectus Femoris
Isolated rectus femoris stretching can be performed in prone with the opposite leg in
hip flexion off a treatment table. The athlete maintains their lumbar spine in neutral and
can use a belt to flex the knee. An anterior pelvic tilt can be performed to increase the
stretch of the rectus femoris (Fig. 6).
Iliotibial Band
Fredericson and colleagues59 evaluated a series of stretches that focused on the ilio-
tibial band (ITB) in 5 asymptomatic runners in a biomechanics laboratory. All 3
stretches (Fig. 7) were statistically significant in increasing the stretch in the ITB, hip
adduction, and knee adduction moments. To perform the standing stretch, the athlete
stands upright, using a wall for balance if needed. The leg to be stretched is extended
and adducted behind the uninvolved leg. The athlete side bends to the opposite side
until a stretch is felt laterally on the hip. The athlete can tilt the pelvis to change the area

Fig. 6. Rectus femoris stretch. Athlete stabilizes pelvis with left leg off table and uses belt to
stretch right rectus femoris.
 Flexibility for Runners 373

Fig. 7. Iliotibial band stretch. The athlete stands upright, using a wall for balance if needed.
The leg to be stretched is extended and adducted behind the uninvolved leg. The athlete
side bends to the opposite side until a stretch is felt laterally on the hip. The athlete can
tilt the pelvis to change the area of stretch. The arm can be reached overhead, and the
stretch of the hip can be accentuated by increasing the side bending of the trunk.

of stretch. The arm can be reached overhead and the stretch of the hip can be accen-
tuated by increasing the side bending of the trunk.
Gastrocnemius
Flexibility of the gastrocsoleus complex is important to allow forward translation of the
tibia during the stance phase of walking and running. Clinically, making sure that the
athlete is maintaining a neutral subtalar joint position to not contribute to an excessive
pronation strategy to compensate for a restricted gastrocsoleus muscle flexibility,
perform with the knee bent as well as straight (Fig. 8).
Toe Flexors/Plantar Fascia
Stretching of the plantar fascia has been reported to be effective in patients with acute
plantar fasciitis. The athlete is instructed to sit with the leg of the foot to be stretched
crossed over the opposite leg and the hand grasping the toes to flex them until
a stretch is felt in the bottom of the foot (Fig. 9).

Fig. 8. Gastrocnemius/soleus stretch. A towel can be placed under the medial arch to help
maintain subtalar neutral, and the knee can track over the second toe to effective stretch
this muscle group.
374 Jenkins & Beazell

Fig. 9. Plantar fascia stretch. The leg is crossed over the opposite leg. The ipsilateral hand
extends the toes, and the contralateral hand can monitor the stretch in the plantar fascia.

SUMMARY

The literature on flexibility presents the evidence-based practitioner with some basic
science information, a good background on the mechanisms of proposed methods of
flexibility training, as well as varied results as to the effectiveness of these programs. A
general overview of flexibility and its components as well as the authors flexibility
program at the Runners Clinic at the University of Virginia has been presented. As
stated in one review, methodological disparities and inconsistencies make analyzing
the flexibility literature difficult and confusing.

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 Flexibility for Runners 377

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