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“In this comprehensive textbook, readers will discover a wealth of stretching
techniques designed to improve flexibility, sport performance, prevent injuries,
and promote overall health. Whether you are an athlete looking to enhance
performance or simply aiming to increase your range of motion, Professor
Behm’s textbook is a must-have addition to your fitness library.”
Prof. Urs Granacher PhD, University of Freiburg, Germany

“Professor Behm shares his profound knowledge and expertise in this book.
The body of available evidence is presented using an explicative and practical
narrative. An essential read for all those interested in the topic.”
Prof. Rodrigo Ramirez-Campillo PhD, Exercise and Rehabilitation Sciences
Institute. School of Physical Therapy. Faculty of Rehabilitation Sciences.
Universidad Andres Bello. Santiago, Chile

“It is the perfect book to tap into the wisdom of stretching as developed by
researchers. By reading this book, you will gain wisdom about the past, pre­
sent, and imagine the future of stretching”
Prof. Masatoshi Nakamura PhD, Faculty of Rehabilitation Sciences, Nishi
Kyushu University, Kanzaki, Saga, Japan

“With this work, Prof. Behm provides an encyclopedia of flexibility techni­

ques that illustrates the current scientific knowledge on stretching and related
training techniques in the most comprehensive manner. The content of this
book served as an important baseline for much ongoing research, including
my PhD Thesis.”
Konstantin Warneke PhD, University of Graz, Graz Austria
The Science and Physiology of Flexibility
and Stretching

The Science and Physiology of Flexibility and Stretching is the most up-to-date
and comprehensive book to cover the underlying physiology and psychology of
flexibility enhancing techniques, critically assessing why, when, and how we
should stretch, as well as offering a highly illustrated, practical guide to stretch­
ing exercises. This fully revised new edition not only updates the present infor­
mation but adds new chapters on areas that have attracted substantial interest in
the past five years such as foam rolling, vibration, global effects of stretching,
alternative methods to increase flexibility (e.g., resistance training), and others.
Richly illustrated and including an online resource, The Science and Phy­
siology of Flexibility and Stretching provides an important scientific inquiry
into stretching as well as other flexibility enhancing techniques (e.g., foam
rolling, vibration, resistance training, and others) and an invaluable reference
for any strength and conditioning coach or student, personal trainer, sports
coach, or exercise scientist.

David Behm is a University Research Professor at Memorial University of

Newfoundland. He was a highly competitive athlete, excelling in baseball and
ice hockey, and he was drafted into the Canadian Football League (1979).
His athletic background led him to seek out an academic career in the areas
of applied neuromuscular physiology and sport/exercise science. Dr. Behm has
won a number of university, national, and international awards based on his
internationally recognized research contributions. At the time of publication,
he has published more than 20 book chapters and over 400 peer-reviewed
scientific articles, which have been cited more than 35,000 times. He con­
sistently presents his research findings internationally, and his work is often
featured in popular fitness and health magazines and online publications.
The Science and Physiology of
Flexibility and Stretching
Implications and Applications in Sport
Performance and Health
Second edition

David Behm
Designed cover image: Getty images
Second edition published 2025
by Routledge
605 Third Avenue, New York, NY 10158
and by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2025 David Behm
The right of David Behm to be identified as author of this work has been
asserted in accordance with sections 77 and 78 of the Copyright, Designs
and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks and are used only for identification and explanation
without intent to infringe.
First edition published by Routledge 2018
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book

ISBN: 978-1-032-72561-1 (hbk)

ISBN: 978-1-032-70907-9 (pbk)
ISBN: 978-1-032-70908-6 (ebk)
DOI: 10.4324/9781032709086

Typeset in Times New Roman

by Taylor & Francis Books
Contents

List of figures ix
List of tables xiv

SECTION I
The Science and Physiology of Stretching 1
1 My Personal Motivation for Stretching 3
2 History of Stretching 9
3 Types of Stretching and the Effects on Flexibility 18
4 Mechanisms Underlying Acute Changes in Range of Motion 53
5 Stretch Training-Related Range of Motion (ROM) Changes and
Mechanisms 83
6 Global Effects of Stretching 89
7 Recommendations for Stretching Prescription 99
8 Stretching Effects on Injury Reduction and Health 113
9 Does Stretching Affect Performance? 129
10 Effect of Stretch Training on Functional Performance 161
11 Effects of Stretch Training on Muscle Strength and Hypertrophy 167

SECTION II
The Science and Physiology of Alternative Techniques for
Increasing Range of Motion 175
12 Effects of Resistance Training on Range of Motion 177
viii Contents
13 Acute and Chronic Effects of Foam Rolling Effects on Range of
Motion and Performance 191
14 Local Vibration Effects on Range of Motion and Performance 212
15 Instrument-Assisted Soft Tissue Mobilization 217
16 Flossing Effects on Range of Motion and Performance 226
17 Stretching Exercise Illustration 232

Index 256
Figures

1.1 David Behm (32) caught “again” from behind 4

1.2 Old David Behm trying to maintain fitness and fighting the
ravages of ageing (65 years old). Possible positive effects of
functional work, resistance training, competitive sport, and
maybe stretching? 6
1.3 Old David Behm still competing in as many sports as
possible. Did stretching contribute to my relative athletic
success as a senior citizen? 7
2.1 Pandiculation: involuntary stretching of soft tissues, with
most mammals associated with transitions between cyclic
biological behaviours, especially the sleep-wake rhythm 9
2.2 Yoga positions 11
2.3 Persian meels and Indian clubs 12
3.1 Unassisted, and assisted passive static stretching with a
partner or a band 19
3.2 Dynamic stretching (hip extension and flexion) 20
3.3 Proprioceptive Neuromuscular Facilitation (PNF) stretching
for the hamstrings 21
3.4 Neuromobilization 24
3.5 Standard and Electronic Goniometers 32
3.6 Inclinometers 33
3.7 Sit and reach test 34
3.8 Collagen and elastin fibres within a tissue 37
4.1 Hoffman (H-) reflex and tendon reflex. The stimulus for the
H-reflex is a low-intensity electrical stimulation sufficient to
activate the afferents to the spinal motoneurons but
minimally activating the alpha motoneuron efferents so as
not to elicit a strong muscle action potential (M-wave). The
stimulus for tendon reflex is an elongation of the muscle to
excite or activate the nuclear bag and chain fibres of the
intrafusal muscle spindles to elicit a myotactic reflex 55
x List of figures
4.2 Tendon or myotactic reflex with monosynaptic excitation of
the agonist muscle and di-synaptic reciprocal inhibition of the
antagonist muscle (reciprocal inhibition not shown in this
figure) 56
4.3 Nuclear bag and chain fibres are located within an intrafusal
muscle spindle 57
4.4 Golgi tendon organs (GTO) are located in the muscle-tendon
or aponeurosis-tendon junction and they can lie in series or in
parallel with the extrafusal muscle fibres, so they can detect
force increases not only from fibres in series with the receptor
but distant to the GTO through the parallel connections 58
4.5 Renshaw cells and Recurrent Inhibition 59
4.6 Cutaneous nerve receptors 60
4.7 Skeletal restrictions on ROM. Hip acetabulum has a much
deeper cup-like structure versus the flatter more mobile
shoulder glenoid fossa 66
4.8 Harry Houdini 68
4.9 Contortionist with hypermobile joints 68
4.10 Titin and myofilament structure 71
4.11 Fibronectin and integrin 72
7.1 Stretching under unstable conditions to improve ROM and
metastability 106
8.1 Injury risk factors 122
9.1 Olympic sprint final 2016 132
9.2 Ferrari (tighter suspension) versus Cadillac (more compliant,
less stiff suspension) 133
9.3 Electromechanical delay (EMD). Physiological EMD is the
time from the onset of muscle activation (illustrated with
electromyography in the first figure) and the onset of
voluntary force. Evoked EMD is the time from the onset of
evoked activation (illustrated by the electrically evoked muscle
action potential in the second figure) to the onset of evoked
twitch force. EMD in these examples are approximately 40
−60 milliseconds 134
9.4 Stretch-shortening cycle: Hurdle jumps (from right to left)
beginning with take-off (propulsion), flight phase, (clearance
of the hurdle), landing (involving eccentric contractions to
absorb the reaction forces), with a short contact (amortization
or transition phase) time, followed by concentric contractions
for another propulsion phase. The eccentric contractions
during landing stiffen the musculotendinous unit (MTU) to
decrease electromechanical delay while elongation of the
MTU activates muscle spindle stretch receptors (nuclear bag
and chain fibres) to induce reflex contractions to augment the
force of the subsequent concentric contractions 135
 List of figures xi
9.5 Stretch-shortening cycle: Drop jump preparation, landing
(amortization or transition phase with elongation/stretching
of muscles and tendons) and take-off (propulsion: concentric
contractions) 136
9.6 Drop jump stretch-shortening cycle reaction forces with a
short versus long contact time. The first peak is the landing
from a drop jump (contact time), followed by the flight phase
(second baseline) and the last peak is the landing following
the flight phase 137
9.7 Gate Control Theory of Pain (Melzack and Wall) 151
12.1 Dumbbell chest press / flyes with arms extended 182
12.2 Dumbbell chest press / flyes (horizontal abduction) 182
12.3 Pullover with initial position 183
12.4 Pullover with full shoulder flexion 183
12.5 Overhead triceps extensions 184
12.6 Lat pulldown with initial position (arms extended) 184
12.7 Lat pulldown with final position (shoulder horizontal
extension) 185
12.8 Seated rowing with elbows extended and scapula protracted 185
12.9 Seated rowing with elbows flexed and scapula retracted 186
12.10 Incline bicep curls with elbows extended and shoulders in
extension 186
12.11 Incline bicep curls with elbows flexed 187
12.12 Forward lunge 187
12.13 Step-up 188
13.1 Foam rollers and roller massagers 192
13.2 Diffuse noxious inhibitory control 197
13.3 a,b: Gluteals 199
13.4 a,b,c: Quadriceps 200
13.5 Adductors (Groin) 200
13.6 a,b: Tensor Fascia Latae 200
13.7 a,b: Hamstrings 201
13.8 Plantar Flexors 201
13.9 a,b: Tibialis Anterior 201
13.10 Inner calf 202
13.11 Outer calf 202
13.12 a,b: Sole of the foot 202
13.13 Pectorals 203
13.14 Pectorals and Anterior Deltoid 203
13.15 Lateral Shoulder (Deltoid) and Arm (Biceps and Triceps
Brachii) 203
13.16 Posterior Shoulder (Deltoids) and Triceps Brachii 204
13.17 Posterior Shoulders (Deltoids and Trapezius) 204
13.18 Biceps Brachii 204
13.19 Triceps Brachii 205
xii List of figures
13.20 Back (Upright position) 205
13.21 Lower Back 205
13.22 a,b: Lateral Trunk 206
13.23 Neck 206
13.24 Gluteals and Plantar Flexors (Double Rolling) 206
13.25 Back and Arm (Double Rolling) 207
13.26 Roller Massage of the hamstrings. 207
13.27 Exercise Balls 207
14.1 Local vibration device 212
15.1 Instrument Assisted Soft Tissue Mobilization (IASTM)
devices 218
15.2 Instrument Assisted Soft Tissue Mobilization (IASTM) use
on quadriceps 218
15.3 Instrument Assisted Soft Tissue Mobilization (IASTM) use
on forearms 219
15.4 Instrument Assisted Soft Tissue Mobilization (IASTM) use
on calf 219
16.1 Floss band on calf muscles 226
16.2 Floss band on upper arm 227
17.1 Kneeling Hip Flexor with Foot Elevated Stretch 233
17.2 Forward Lunge Stretch with Hand Planted 233
17.3 Pigeon Stretch 234
17.4 Lunge with a rotation 234
17.5 Single leg elevated hamstrings stretch 235
17.6 Supine single leg hamstring stretch 235
17.7 Band Assisted Hamstring Stretch 236
17.8 Reverse Pigeon Stretch 236
17.9 Supine single leg rotation 237
17.10 Lying (supine) hip flexion 237
17.11 Adductor Stretch 238
17.12 Push up Position Calf Stretch 238
17.13 Standing Calf Stretch Against Wall 239
17.14 Standing Soleus Stretch 239
17.15 Pectoralis Wall Stretch with Rotation 240
17.16 Band Assisted Pectoralis Stretch 240
17.17 Banded Latissimus Dorsi Stretch 241
17.18 Kneeling lunge position latissimus dorsi overhead stretch with
band 241
17.19 a,b Triceps brachii and shoulder internal rotation band
stretch 242
17.20 Shoulder External rotation with band 242
17.21 Overhead triceps brachii stretch 243
17.22 Deltoid cross-over stretch 243
17.23 a,b,c Neck series 244
17.24 a,b,c Neck strengthening series 244
 List of figures xiii
17.25 a,b Hip Mobility Hinge and Overhead Squat Sequence 245
17.26 a,b Dynamic hip bridge with arms extended 245
17.27 Dynamic Hip Bridge with Band 246
17.28 Dynamic Alternating Hip Bridge with a Knee to Chest Hold 246
17.29 Dynamic dead bug with band 247
17.30 Dynamic standing alternating knee to chest 247
17.31 Dynamic lateral lunge with pause 248
17.32 Dynamic ankle to opposite hip with pause 248
17.33 a,b Dynamic external rotation of hip 249
17.34 a,b Dynamic single leg hinge with arm reach series 249
17.35 Dynamic leg kicks with hand touch 250
17.36 a,b Dynamic inch worm with pause 250
17.37 Dynamic quadriceps squeeze with a pause 251
17.38 a,b,c Sprinting mechanics 251
17.39 a,b Side lying rotation 252
17.40 a,b Kneeling dynamic rotation 252
17.41 a,b,c Dynamic band shoulder pullovers 253
17.42 a,b,c Band pull apart series 254
17.43 a,b Band shoulder external rotation 254
17.44 Shoulder External rotation sleep stretch 255
17.45 a,b Dynamic prone cobra to child’s pose 255
Tables

3.1 Upper Limb and Back Passive ROM in degrees 27

3.2 Lower Body Passive ROM in degrees 28
3.3 Norms for Joint Range of Motion (°) 29
3.4 Percentile ranks for the Sit-and-Reach Test (cm) (88) 31
3.5 Percentile Ranks for the Modified Sit-and-Reach Test (88) 31
9.1 Full warm-up components 148
10.1 Dynamic Stretching FITT table 163
17.1 Standardized Warm-up Components Example 232
Section I
The Science and Physiology of
Stretching
1 My Personal Motivation for Stretching

The year is 1972. A 15-year-old, 5 foot, 10-inch (1.78 meters), 175-lb (79.4
kg) fullback takes his stance three yards behind the quarterback. This grade
11 fullback playing junior high school football is bigger and stronger than
most of the offensive linemen blocking for him as well as most of the young
adolescent opponents who will try to tackle him. With the ball snapped on
the second “hut”, the quarterback rotates and hands the ball off to the full­
back who is accelerating to an expected opening between the tight end and
tackle. As the tight end cross blocks upon the defensive end and the offensive
tackle pulls out against the linebacker, a sliver of daylight appears. I lower my
shoulder and plunge through that hole. Arms reach out from the partially
blocked defensive lineman and linebacker but they are not strong enough to
slow me down. A strong side defensive back at about 140 pounds (63.5 kg)
moves in for the tackle. However, with the momentum of my greater mass
and the velocity attained after an 8-yard sprint, the defensive back is trampled
and I cut sharply to the sidelines. After covering about 20 yards, the defensive
safety catches me from behind and trips me up.
The next year, I am the starting fullback for the senior high school team. I
have grown ¾ of an inch (2 cm) and now weigh 185 lbs (84 kg). We win the
regional high school championship. Dave Behm (The Truck) and Dan (Crazy
Legs) Murphy make a great one-two punch. My predominant empire is inside
between the two ends. Dives and off-tackle plays are my bread and butter. If I
get a decent block and get into the defensive backfield, I can use my size
advantage, my balance, and my signature move: hit the opponent at full
throttle to either knock him down or spin immediately after contact so that
the enemy cannot easily grab me and pull me down. Murphy’s territory is
outside the ends with sweeps and pitches, as he is lighter and much swifter
than I and can often outsprint the defence.
In the last year of high school, there is no increase in height but I continue
to fill out, expanding to 198 lbs (90 kg). A number of Canadian universities
attempt to recruit me and I decide to stay home to play with the University of
Ottawa Gee-Gees, who had lost that year in the national semi-final game.
However, as the next year approaches, I realize that my chances of getting
into a game with that team are slim to none. The starting fullback is Neil
DOI: 10.4324/9781032709086-2
4 The Science and Physiology of Flexibility and Stretching
Lumsden, a 235 lb (106 kg) behemoth with decent speed, great balance,
strength, and power. He will set Canadian university rushing and touchdown
records that will remain untouched for a couple of decades and he will sub­
sequently establish a long career in the professional Canadian Football
League (CFL). The back-up is Mike Murphy, another talented fullback at
just under 230 lbs (104 kg) who in the following year will lead the nation in
rushing yards and also have a firm career in the CFL. I decide to play for the
city’s junior football team (Ottawa Sooners) and wait for Lumsden to move
onto the CFL. Lumsden and Murphy were archetype fullbacks, massive,
strong, and powerful. Relatively, I filled that description in high school but
my growth pattern started to plateau, such that I was around 205 lb (93 kg)
when I joined the university football team in my second year of university. I
spent my second year of university primarily blocking for the burly Mike
Murphy and moved into the fullback position in my third academic year. I
was lucky enough to inherit a strong offensive line and with my slashing,
spinning style I could often break a few tackles and make a major gain
(Figure 1.1). With my lack of breakaway running speed, I was typically
caught from behind by a fleet footed defensive back. For a professional run­
ning back, my size was more typical of tailbacks or halfbacks depending on
your terminology. These backs typified by legends like Walter Payton had
very good to great speed that would allow them to burst into the open field

Figure 1.1 David Behm (32) caught “again” from behind

 My Personal Motivation for Stretching 5
and outsprint the opposition. Unfortunately, I was built like a tailback but
with the speed of a fullback. I needed to get faster if I wanted to continue my
career after university.
Sprinting speed is a simple combination of stride rate (frequency) and
stride length (7). Stride rate is very difficult to modify as it is generally related
to your genetic profile of fast-twitch to slow-twitch muscle fibre composition.
Pick the right parents, who hopefully will pass on a higher percentage of fast-
twitch fibres and you will be able to move your legs back and forth (stride
rate) much quicker than someone with a greater percentage of slow-twitch
fibres. Hence, you will have a high stride rate. This is the most important
factor in sprinting speed. Unfortunately, it seems that I did not pick the right
parents! Thus, I was left with trying to enhance the second sprinting factor:
stride length. With stronger more powerful legs, it should be possible to
explode off the ground and cover greater distances with each stride. With this
in mind, I worked faithfully on my strength, such that I could squat over 500
lbs (225 kg) and bench press around 350 lb (160 kg). As a university student
in physical education in the late 1970s, I was taught that by increasing my
flexibility I would improve performance (increase stride length, decrease
resistance to stride movements) and decrease the chances for injury.
With these pearls of wisdom in mind, I also worked diligently on my
stretching so that I could eventually perform a front split. Conventional
wisdom of the time indicated that with higher levels of flexibility there would
be less resistance to movement and an increased efficiency of movement.
Thus, with my improved power and flexibility my stride length should have
been tremendous. Like Superman, I should have been leaping over tall build­
ings in a single bound. However, there must have been some kryptonite in my
diet since, while my sprinting speed did improve marginally, nobody ever
mistook me for the legendary Walter Payton (or Superman!).
Well if I did not get much faster, then my flexibility should have decreased
my chances for injury. In my second year of university football, I took the ball
on a draw play (quarterback fakes a pass and then gives the ball to the run­
ning back) and burst through a gap in the line. Quickly a linebacker exploded
from the left accelerating his helmet into my shoulder. I tried to absorb the hit
and I bounced off the hit and continued for another 12 yards till I was, as
usual, caught from behind by a defensive back. Upon getting up I noticed my
clavicle was apparently redirected towards my back and no longer attached to
my scapula. When I returned to the sidelines I was informed that I had sub-
luxated my acromio-clavicular joint. I was out for the season.
With aggressive rehabilitation and off-season training I was ready for my
third year of university football. In a game against McGill University on
artificial turf, I caught a flare pass and sprinted wide. As I planted my right
foot to move up field I was hit low on the left side by a linebacker and
simultaneously hit high from the right by a defensive back. My planted foot
could not move or slide on the artificial turf and the ligaments were torn
resulting in a third-degree ankle sprain. It did not seem that my extensive
6 The Science and Physiology of Flexibility and Stretching
stretching programme had provided me the protection I sought from
musculotendinous or ligamentous injuries nor did it provide me with sig­
nificantly better athletic performance (improved speed). Did my physical
education professors of the 1970s really know what they were talking
about? The paradigm of stretching and flexibility has experienced a
number of shifts in the past few decades.
It is now about 50 years later (2024) and I am no longer a young athlete
but I still try to maintain my fitness (Figure 1.2). Although I am officially a
senior citizen (>65 years), I have not lost my competitive nature and still
seek to improve my athletic skills in tennis and ice hockey (my arthritic
knees make squash more difficult now!) so I can compete with and beat
those youngsters (anybody under 50 years old) (Figure 1.3). However, my
preparations and warm-ups have been altered by our research findings on
flexibility and pre-activity preparations. As we now know that resistance
training can provide similar increases in range of motion as static stretching
(1), there is no longer a need to stretch before lifting weights. However, I
still include static stretching (less than 60 seconds per muscle group: 3, 4, 5,
6) before I play tennis or ice hockey. Periodically if I really feel stiff, I might
add foam rolling (2) to my regimen.
Hopefully the second edition of this book will update and help establish the
facts about flexibility as they are presently known and burst the myths. It is the

Figure 1.2 Old David Behm trying to maintain fitness and fighting the ravages of
ageing (65 years old). Possible positive effects of functional work, resis­
tance training, competitive sport, and maybe stretching?
 My Personal Motivation for Stretching 7

Figure 1.3 Old David Behm still competing in as many sports as possible. Did
stretching contribute to my relative athletic success as a senior citizen?

objective of this book to provide you with the most up to date research on flex­
ibility enhancing exercises and devices as well as explaining the physiological
mechanisms underlying different types of flexibility-improving exercises/devices
and then provide you with suggestions for appropriate activity programmes to
increase your range of motion.

References
1. Alizadeh, S., Daneshjoo, A., Zahiri, A., Anvar, S.H., Goudini, R., Hicks, J.P.,
Konrad, A., and Behm, D.G.Resistance Training Induces Improvements in Range
of Motion: A Systematic Review and Meta-Analysis. Sports Med 53: 707–722,
2023.
2. Behm, D.G., Alizadeh, S., Hadjizadeh Anvar, S., Mahmoud, M.M.I., Ramsay, E.,
Hanlon, C., and Cheatham, S.Foam Rolling Prescription: A Clinical Commentary.
J Strength Cond Res 34: 3301–3308, 2020.
3. Behm, D.G., Blazevich, A.J., Kay, A.D., and McHugh, M.Acute effects of muscle
stretching on physical performance, range of motion, and injury incidence in heal­
thy active individuals: a systematic review. Appl Physiol Nutr Metab 41: 1–11, 2016.
4. Behm, D.G. and Chaouachi, A.A review of the acute effects of static and dynamic
stretching on performance. Eur J Appl Physiol 111: 2633–2651, 2011.
8 The Science and Physiology of Flexibility and Stretching
5. Behm, D.G., Kay, A.D., Trajano G.S., and Blazevich, A.J.Mechanisms underlying
performance impairments following prolonged static stretching without a compre­
hensive warm-up. Eur J Appl Physiol 121: 67–94, 2021.
6. Chaabene, H., Behm, D.G., Negra, Y., and Granacher, U.Acute Effects of Static
Stretching on Muscle Strength and Power: An Attempt to Clarify Previous Caveats.
Front Physiol 10: 1468, 2019.
7. Dintiman, G. and Ward, B. Sport Speed. Windsor, ON: Human Kinetics, 2003.
2 History of Stretching

Stretching has been and continues to be a controversial training technique.

When did it begin? Is it actually beneficial? Often, I have heard individuals
state that if stretching was important for performance enhancement, you
would see lions, tigers, and cheetahs meeting in groups (wearing spandex and
knee braces) for a stretching routine before going on a hunt. While our
mammalian cousins are not quite that organized, we do see animals stretch­
ing after sleeping or lounging for an extended period of time. This ritualized
behaviour is called pandiculation. Pandiculation involves a voluntary con­
traction of the muscles, followed by a slow stretch/elongation and then
relaxation (often with a yawn) (see Figure 2.1). The description is somewhat
similar to contract-relax proprioceptive neuromuscular facilitation (PNF)
(without the yawn), which was reported to be developed by Herman Kabat,
but perhaps he stole the idea from his pet dog or cat (if he had a pet?). One
simply has to watch a pet dog or cat and see them stretching their fore and

Figure 2.1 Pandiculation: involuntary stretching of soft tissues, with most mammals
associated with transitions between cyclic biological behaviours, especially
the sleep-wake rhythm

DOI: 10.4324/9781032709086-3
10 The Science and Physiology of Flexibility and Stretching
hind limbs after napping. Animals stretch (pandiculate) all the time! Is it a
reflex ritual that actually benefits performance (hunting prey or escaping from
predators)? Lions and tigers are not very accessible or easy subjects to recruit
and I do not know of any stretch training studies using domesticated pets.
Thus, there is no evidence for or against the effectiveness of pandiculation for
performance enhancement. Obviously, animals (other than the human
animal) have not organized and categorized their stretching and warm-up
activities as humans have. Neither do animals stretch for such long durations
or intensely as many human athletes or trained individuals. Of course, they
also do not play tennis for 3–4 hours like professional tennis players, crash
into each other for more than an hour like American football, rugby, and ice
hockey players, perform multiple double or triple rotations of their bodies
with twists for over 1–3 minutes like gymnasts, dancers, figure skaters, tram­
polinists, and others. Other mammals can be far more athletic than humans,
but they tend to perform their athletic pursuits as a prey or a predator over a
brief period, sporadically and without hours of training per day over months
and years. We as humans tend to be far more obsessive, and compulsive in
our activities and likewise our training for those activities. There is a common
assumption that animals never get injured. There is no evidence for that
assumption. Racehorses for example, commonly sustain muscle strains and
have a high incidence of tendinopathy (23). Dogs suffer strains (muscles) and
sprains (ligaments) (18). So maybe if they had better warm-up and stretching
routines, they would experience less injuries? It is also argued that animals
and ourselves often sprint without any warm-up (e.g., we are late for a bus!)
and many times either catch the prey, escape from the predator or actually
catch the bus. Thus, the contrarians argue there is no need for a warm-up.
The problem with this argument is there is no control group! Nobody has
taken a pride of lions and systematically stretched them over time (experi­
mental group) and compared their performance to a control group of lions
that did not stretch or only pandiculated. Perhaps, the lion would be incre­
mentally faster if it did do a systematic warm-up. While, there is no evidence
available for wild predators and prey, there is a large body of human research
available regarding warm-up-induced positive changes to athletic perfor­
mance (14), oxidative energy metabolism, increased lactate clearance,
increased blood flow due to muscle capillary vasodilation (7), post-activation
potentiation, neural conduction velocity, enzymatic cycling, tissue com­
pliance, and a myriad of other contributing physiological factors (4, 5). We
will cover many of these topics in the subsequent chapters.
When did humans start stretching in an organized manner with the hope of
enhancing performance or decreasing the chance for injury? Although in his­
torical texts, stretching is not always precisely listed as an activity preceding
training or competition, it might be logical to assume that military personnel
or athletes would have indulged in some kind of “limbering up” exercises to
warm the muscles and body and increase the compliance or decrease the
stiffness of the muscle and tendons. The martial arts of many Asian countries
 History of Stretching 11
are well known for their emphasis on extreme range of motion (ROM) in
order to perform high kicks, acrobatic, and escape manoeuvres (think of
Bruce Lee’s athletic ability). The martial arts of the Chinese, Japanese and
Aleut peoples, as well as Mongolian wrestling are suggested to have ori­
ginated in the prehistoric era (11). Chinese boxing has been traced to the
Zhou dynasty (1122–255 BCE). Martial arts like Kung Fu were influenced
by Indian martial arts that spread to China in the fifth to sixth century
CE (11). With the physical contortions, commonly observed with wrestling
and martial arts, it would seem likely that the combatants would have
needed to work on their flexibility to improve their chances of succeeding.
We are all familiar with the impressive flexibility of experienced yoga
practitioners as they move from one difficult posture to another. Asia and
specifically the Indus-Sarasvati civilization in Northern India are credited
for the origins of Yoga during what is termed the pre-classical yoga
period approximately 5,000 years ago and perhaps even earlier. However,
this early yoga practice concentrated on the mind and spirit with little to
no emphasis on the physical. Breath control exercises − the precursor of
yoga − were implemented in China around 2600 BCE. It is not known if
stretching exercises were also included but an exercise chart (168 BCE) of
breathing and postures was developed for Tao Yin activities in the early
Han dynasty. These exercises or postures were purported to cure specific
illnesses (16). Perhaps, this is where the idea that stretching decreases
injuries first began. Around the fourth century, during what is classified as
the post-classical Yoga (classical Yoga period defined by Patanjali’s Yoga-
Sûtras “eight limbed path” to Samadhi or enlightenment starting in the
second century CE), a system of practices was created to rejuvenate the
body, prolong life and embrace the physical body to achieve enlight­
enment. Tantra Yoga, was developed to cleanse the body and mind. The
evolution of these physical-spiritual connections and body-centred prac­
tices moved towards the development of Hatha Yoga (Figure 2.2).

Figure 2.2 Yoga positions

12 The Science and Physiology of Flexibility and Stretching
Stretching is specifically mentioned as an important component of an
exercise regimen to prevent illness by Hua Tuo (104–208 CE). Hua Tuo sug­
gested mimicking animal movements such as walking like a bear, and
stretching the neck like a bird (even 2,000 years ago people noticed that ani­
mals stretched or at least pandiculated) among other animal-like movements.
He emphasized combinations of breathing, bending, stretching and an
assortment of postures which he labelled as the “Frolics of the Five Animals”
(16). Tai Chi may trace its beginnings to these frolicking exercises.
In the Western civilizations, the Greeks held festivals (Tailteann Games: circa
1,800 BCE) that involved stone throwing, jumping, spear throwing, wrestling,
and other activities (16). During pharaonic Egyptian times, athletes also wres­
tled, boxed, swam, ran, and lifted heavy objects in competition. One can ima­
gine, that these athletes had some kind of pre-competition preparation (warm­
up) and that especially for sports like wrestling where limbs can be forced and
placed in extreme positions, preparatory stretching would have taken place.
Were these early stretching exercises more static or dynamic in nature? First of
all, how do we define static and dynamic stretching? Static stretching involves
lengthening a muscle until either a stretch sensation or the point of discomfort is
reached and then holding the muscle in a lengthened position for a prescribed
period of time (1, 2, 3). Dynamic stretching involves the performance of a con­
trolled movement through the ROM of the active joint(s) (2, 3). Both types of
stretching have gone through periods of popularity and disfavour. For example,
Hua Tuo’s stretching the neck like a bird exercise would likely have involved a
slow dynamic component to reach the end of the ROM and then a static com­
ponent to hold that position. Dynamic stretching was popular in Persia where
warriors and wrestlers starting around the first century AD used implements
shaped like bowling pins called meels (Figure 2.3). While the heavy meels
weighed approximately 50 pounds and would have been used for strength and

Figure 2.3 Persian meels and Indian clubs

 History of Stretching 13
power enhancement, the 2-pound meels were swung in patterns around the
shoulder and would have been excellent for a dynamic warm up of the muscles
and increasing the ROM. The Persians introduced this form of exercise to the
Indian subcontinent in the thirteenth century. The people of the India sub­
continent called this activity Persian yoga (16). It is quite likely that similar
movement variations with a variety of weapons (i.e., short and long swords)
would have been practiced by medieval knights in preparation for combat and
competitions. Incorporating the movement of moderate to heavy loads as part of
the pre-activity preparation (warm-up) is incorporated today to induce post-
activation potentiation enhancement (PAPE) (6). PAPE not only improves sub­
sequent strength and power performance by the aforementioned factors (i.e.,
neural conduction velocity, muscle vasodilation, increased rate of energy meta­
bolism, etc.) but would also induce myosin light chain phosphorylation, which
increases the sensitivity of the myofibrillar proteins (e.g., myosin, actin, tropo­
myosin, troponin) to calcium thus enhancing force output (4, 5).
Generally, such light dynamic movement for flexibility, quickness and
muscular endurance was in the purview of men getting ready for battles or
tournaments. However, in the mid-nineteenth century, exercises based on
Swedish (Ling’s) gymnastics were introduced to women in Europe and North
America. They involved the graceful moving of arms, legs, neck, and head.
Although their primary purpose (training for family life) would not have been
to increase flexibility, such movements would have maintained or enhanced
movement around the exercised joints. These exercise-liberated women could
now be more effective at reaching farther across to make the bed in the
mornings, extending further to scrub the floor under the furniture or reach
deeper in the cupboard for the pots and pans for making dinner (training for
family life!). Quite the liberation! Men, for their part, would still incorporate
low intensity or light dynamic movements for sport preparation or war.
The late nineteenth century saw the emergence of a number of new team
sports such as ice hockey (March 3, 1875: Montreal, Quebec, Canada), baseball
(1672–1700: England), basketball (1891 by James Naismith (Canadian) at
Springfield College, Massachusetts, USA), North American football (November
6, 1869, Rutgers vs. Princeton University, USA), volleyball (1895 by William G.
Morgan from Springfield College, Massachusetts, USA) and others. The typical
competitive zeal of the human athlete would instil a need to find a perceived
advantage even in these early days of these new sports. One of those advantages
could be a proper warm-up to prepare the body for competition and part of that
warm-up would include light dynamic movements for “limbering up”.
But more importantly was the defence of your country and during the
World Wars, soldiers were systematically trained to ensure they were ready for
heavy military action. The systematic training of soldiers was incorporated
during the world wars with scientific investigations of optimal resistance
training routines sought out by Colonel DeLorme of the United States armed
forces (9, 10). Subsequently, in the late 1950s and published in 1961, a
Canadian, Dr. William Orban developed the 5BX (5 Basic eXercises)
14 The Science and Physiology of Flexibility and Stretching
programme (22). Though, it was originally targeted at male military person­
nel (air force pilots) who might not have access to training equipment and
thus could perform calisthenics in most any location to stay fit, it spread to
the general population. Orban also developed the XBX which were ten basic
exercises modified for women. One of the stated objectives was to “Keep the
important muscles and joints of the body supple and flexible.” Some of the
exercises were quite dynamic and ballistic such as the toe touching exercises
which involved bobbing up and down by flexing at the hips to touch the toes
and then bounce back to an erect standing position.
However, the appeal of dynamic ballistic stretching activities diminished
when it was noted that dynamic stretching of the muscles activated reflexes
such as the myotactic (i.e., stretch) reflex, which results in reflexive contractions
of the actively stretched muscle (19, 20). If the goal of stretching was to
increase ROM, then it was reasoned that dynamic activities that elicited reflex
muscle contractions while elongating the muscles could result in injury. Two
forces would be working against each other with muscle elongation from
stretching opposing stretch reflex-induced contractions. Hence, during the mid­
1960s and thereafter, static stretching replaced ballistic or dynamic stretching as
the predominant activity within a pre-activity warm-up routine to increase
ROM (26, 27). Static stretching was recommended, as the slow movement into
the stretch position and maintenance of a static stretch over a prolonged period
minimized the reflexive firing of the muscle spindles (primarily the nuclear
chain and bag fibres) that were activated by higher rates of stretch (12, 17).
Hence, the attenuation of reflex activity with prolonged static stretching would
presumably result in a more relaxed muscle and theoretically allow greater
muscle lengths to be achieved. Thus, for the next 30 or more years, static
stretching was the predominant form of stretching for warm-ups and flexibility.
In the 1970s another stretching technique also became more popular: pro­
prioceptive neuromuscular acilitation (PNF) stretching (8). PNF was devel­
oped around 1946 by Herman Kabat, a neurophysiologist. The techniques
evolved over time, but one popular variation of PNF was the contract-relax­
agonist-contract (CRAC) method. If you wanted to stretch the hamstrings
you would CONTRACT the hip flexors (i.e., quadriceps) till you reached
your maximum ROM. Then you would RELAX as your partner held that
elongated position, which would be followed by CONTRACTION of the
hamstrings (AGONISTS). These variations of PNF were purported to induce
a number of inhibitory reflex mechanisms (e.g., depressed H-reflex, reciprocal
inhibition, autogenic inhibition: 21, 25) that would relax the muscle allowing
the individual to reach even greater increases in ROM than with static
stretching (8). You could not go to any team sport in the 1970s without seeing
athletes pairing up to passively stretch and provide resistance to their part­
ner’s contractions of elongated muscles. However, not many people ques­
tioned at the time, why a technique like PNF that supposedly inhibited
excitatory reflexes would be used in a warm-up that should excite the system
in preparation for high intensity activity.
 History of Stretching 15
In the late 1990s and early 2000s scientific reports began to appear indicating
that static stretching rather than enhancing subsequent performance might
actually impair performance (13, 24). As the evidence began to mount through­
out the early 21st century, static stretching was replaced with dynamic stretching
as the major flexibility component of the warm-up. Only recently, has the evi­
dence for static stretch-induced performance impairments been suggested to lack
some ecological validity (practical reality or real-life application). A position
stand/review by the Canadian Society for Exercise Physiology (2) published in
2016 documented that many of the static stretching studies did not employ a
prior aerobic-style warm-up, stretched the muscle(s) for durations much
longer than are typically used, did not include any dynamic sport specific
activities after stretching and conducted the testing within 3–4 minutes of the
experimental protocol. Another study found that just the knowledge of the
previously published stretching impairment studies (expectancy bias) could
negatively affect the results (15). Thus, the state of stretching within a warm-
up and for improving ROM is in a state of flux and confusion. The objective
of this book is to alleviate some of that confusion by critically analyzing the
5Ws of stretching with an “H” thrown in for good measure. That is, 1) What
are the effects and physiological mechanisms underlying different types of
stretching? 2) Why should we stretch? 3) When should we stretch? 4) Who are
the major pioneers, innovators and researchers in this area? 5) Where does the
science of flexibility and stretching go next and 6) How should we stretch or
use other techniques to increase ROM?

Summary
Many animals elongate (stretch) their muscles after a period of rest.
Although, these animals have pandiculated for eons, it is not known whether
there are any performance benefits. There is inferential evidence that humans
have stretched for thousands of years with the advent of Yoga (~3000 BCE)
and martial arts (~1000 BCE) in Asia. The Greeks and Egyptians probably
emphasized dynamic actions and stretches prior to their athletic competitions
(~2000 BCE). Static stretching became more popular after the World Wars,
while PNF stretching was popularized to a greater degree in the 1970s. Both
stretching styles remained predominant until the 1990s, when research began
to appear indicating that static stretching could lead to performance impair­
ments. Since that time dynamic stretching has made a resurgence. The most
recent studies suggest that the move away from static stretching may have
been premature and based on impractical study designs.

References
1. Behm, D.G., Bambury, A., Cahill, F., and Power, K.Effect of acute static stretching
on force, balance, reaction time, and movement time. Med Sci Sports Exerc 36:
1397–1402, 2004.
16 The Science and Physiology of Flexibility and Stretching
2. Behm, D.G., Blazevich, A.J., Kay, A.D., and McHugh, M.Acute effects of muscle
stretching on physical performance, range of motion, and injury incidence in heal­
thy active individuals: a systematic review. Appl Physiol Nutr Metab 41: 1–11, 2016.
3. Behm, D.G. and Chaouachi, A.A review of the acute effects of static and dynamic
stretching on performance. Eur J Appl Physiol 111: 2633–2651, 2011.
4. Bishop, D.Warm up I: potential mechanisms and the effects of passive warm up on
exercise performance. Sports Med 33: 439–454, 2003.
5. Bishop, D.Warm up II: performance changes following active warm up and how to
structure the warm up. Sports Med − ADIS Int 33: 483–498, 2003.
6. Blazevich, A.J. and Babault, N.Post-activation Potentiation Versus Post-activation
Performance Enhancement in Humans: Historical Perspective, Underlying
Mechanisms, and Current Issues. Front Physiol 10: 1359, 2019.
7. Brunner-Ziegler, S., Strasser, B., and Haber, P.Comparison of metabolic and bio­
mechanic responses to active vs. passive warm-up procedures before physical exer­
cise. Journal of Strength and Conditioning Research / National Strength &
Conditioning Association 25: 909–914, 2011.
8. Burke, D.G., Culligan, C.J., and Holt, L.E.The theoretical basis of proprioceptive
neuromuscular facilitation. Journal of Strength and Conditioning Research 14: 496–
500, 2000.
9. Delorme, T.Restoration of muscle power by heavy-resistance exercises. The Journal
of Bone and Joint Surgery 27: 645–667, 1945.
10. Delorme T., Ferris, B., and Gallagher, J.Effect of progressive resistance exercise on
muscle contraction time. Arch Phys Med 33: 86–92, 1952.
11. Draeger, D.S.J. Comprehensive Asian Fighting Arts, 1969.
12. Durbaba, R., Taylor, A., Ellaway, P.H., and Rawlinson, S.The influence of bag2
and chain intrafusal muscle fibers on secondary spindle afferents in the cat. J Phy­
siol 550: 263–278, 2003.
13. Fowles, J.R., Sale, D.G., and MacDougall, J.D.Reduced strength after passive stretch
of the human plantar flexors. Journal of applied physiology 89: 1179–1188, 2000.
14. Fradkin, A.J., Zazryn, T.R., and Smoliga, J.M.Effects of warming-up on physical
performance: a systematic review with meta-analysis. J Strength Cond Res 24: 140–
148, 2010.
15. Janes, W.C., Snow, B.B., Watkins, C.E., Noseworthy, E.A., Reid, J.C., and Behm,
D.G.Effect of participants’ static stretching knowledge or deception on the respon­
ses to prolonged stretching. Appl Physiol Nutr Metab 41: 1052–1056, 2016.
16. Kunitz, D. Lift: Fitness Culture from Naked Greeks and Acrobats to Jazzercize and
Ninja Warriors. New York: Harper Wave, 2016.
17. Laporte, Y., Emonet-Dénand F., and Jami, L.The skeletofusimotor or ·-innervation
of mammalian muscle spindles. In: The Motor System in Neurobiology, E.V. Evarts,
S.P. Wise, and D. Bousfield (Eds). New York: Elsevier Biomedical Press, 1985, pp.
173–177.
18. Levy, M., Hall, C., Trentacosta, N., and Percival, M.A preliminary retrospective
survey of injuries occurring in dogs participating in canine agility. Vet Comp Orthop
Traumatol 22: 321–324, 2009.
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inal Mechanisms of Voluntary Motor Control and Locomotion. 1980, pp. 12–27.
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The Nervous System: Handbook Of Physiology. V.B. Brooks (ed.). American Phy­
siological Society, 1981, pp. 189–288.
 History of Stretching 17
21. Moore, M.A. and Kukulka, C.G.Depression of Hoffmann reflexes following
voluntary contraction and implications for proprioceptive neuromuscular facilita­
tion therapy. Physical Therapy 71: 321–329, 1991.
22. Orban, W.A.R. Royal Canadian Air Force Exercise Plans for Physical Fitness.
Ottawa, ON: Queen’s Printer, 1962.
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Equine Pract 24: 1–19, 2008.
24. Power, K., Behm, D., Cahill, F., Carroll, M., and Young, W.An acute bout of
static stretching: effects on force and jumping performance. Med Sci Sports Exerc
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25. Sharman, M.J., Cresswell, A.G., and Riek, S.Proprioceptive neuromuscular facilita­
tion stretching: mechanisms and clinical implications. Sports Med 36: 929–939, 2006.
26. Young, W.B.The use of static stretching in warm-up for training and competition.
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Fitness 43: 21–27, 2003.
3 Types of Stretching and the Effects on
Flexibility

There are a number of different types of stretching and the public can be
confused regarding their differences. Passive and active static stretching,
dynamic, ballistic, proprioceptive neuromuscular facilitation (PNF), and
others are used to enhance flexibility or range of motion (ROM) as well as be
incorporated as part of a pre-competition or training warm-up. First of all,
what is the definition of flexibility? Michael J. Alter in his textbook (6) lists a
variety of definitions. Some of the definitions of flexibility include:

1 ROM available to a joint or group of joints (50, 85, 93, 116, 185)
2 Total achievable excursion (within limits of pain) of a body part through
its potential ROM (167)
3 Ability to move a joint smoothly and easily through its complete pain
free ROM (100, 101)
4 Ability to move a joint through a normal ROM without undue stress to
the musculotendinous unit (41)
5 Normal joint and soft tissue ROM in response to active or passive stretch (81)

The ability to increase a joint’s ROM, would normally necessitate an

improved extensibility (78) or decreased stiffness of musculotendinous and
other connective tissues. Gajdosik and colleagues (65, 66) suggest that flex­
ibility should be described as a ratio of change in muscle length or joint angle
to a change in force or torque. Recent research use this description or tech­
nique by subjecting a limb joint to an extended ROM on an isokinetic
dynamometer as a test for muscle stiffness (122, 124, 136, 139, 146).
To achieve these increases in flexibility, a variety of stretching techniques are
used. Static stretching for example, involves lengthening a muscle until either a
stretch sensation or the point of discomfort is reached and then holding the
muscle in a lengthened position for a prescribed period of time (23, 24, 26, 48).
Whether it is passive or active static stretching depends upon whether the muscle
is lengthened by an external force (i.e., another person, or a tool like a stretching
band or machine) with the muscle relaxed (passive static stretch) or lengthened
by an active contraction of the affected muscle or other muscles (i.e., antagonist)
(active static stretch) (see Figure 3.1). Static stretching is used in athletic, fitness,
DOI: 10.4324/9781032709086-4
 Types of Stretching and the Effects on Flexibility 19

Figure 3.1 Unassisted, and assisted passive static stretching with a partner or a band

health and rehabilitation environments. It is an effective method for increasing

joint ROM (14, 15, 162) and was purported to improve performance (198, 199)
and reduce the incidence of activity-related injuries (23, 24, 26, 126, 169, 170,
182) (primarily musculotendinous injuries associated with explosive and change
of direction actions, 24, 29). However, the possibility of static stretch-induced
performance impairments has limited its use in the new millennium. Evidence
for and against this bias will be presented in a subsequent chapter.
Dynamic stretching uses a controlled movement through the ROM of the active
joint(s) (61). It can be exemplified by swinging the legs back and forth (hip flexion
and extension) or side to side (hip abduction and adduction) or swinging the arms
in circles (shoulder circumduction) (see Figure 3.2). Dynamic stretching differs
from ballistic stretching in that ballistic stretching would typically involve higher
velocity movements with bouncing actions at the end of the ROM (10, 148). Bal­
listic movements were used in the aforementioned 5BX programme (popular from
1950s until the 1960s) and were still prevalent till quite recently in many military
and police style training. In the late 1980s, I consulted with fitness instructors of
the Royal Canadian Mounted Police at their national training depot in Regina,
Saskatchewan, Canada. Recruits were trained and tested by performing resistance
exercises such as shoulder presses, push-ups, sit-ups and others as quickly as pos­
sible in a prescribed time. The number of repetitions completed in 30 or 60 seconds
20 The Science and Physiology of Flexibility and Stretching

Figure 3.2 Dynamic stretching (hip extension and flexion)

was measured and thus the recruits would ballistically throw the barbells up and
down (i.e., shoulder press) or slam their trunk back and forth (i.e., sit-ups) as
quickly as possible. Definitely a recipe for injuries!
What is the difference between dynamic stretching and dynamic activity? It
could be argued that dynamic stretching is a dynamic activity but not all dynamic
activities are considered dynamic stretching. The decisive factor is whether the
dynamic activity moves the body through a full or nearly full ROM. Jogging,
skipping, hopping and other similar activities are all dynamic, but as they only
emphasize a restricted or small to moderate ROM they would not be considered
as dynamic stretching. However, if the person did butt (gluteal) kicks (knee flexion
and touches the buttocks with heel of the foot) while jogging, then this dynamic
activity would be under the purview of dynamic stretching as it goes through a
fuller ROM. As mentioned in the historical section, dynamic stretching in this
millennium was considered preferable to static stretching in a warm-up, owing to
training specificity (training movement matches the sport or exercise movements)
(28, 172) as well as activity-induced increases in metabolism, muscle temperature
(30, 62, 197, 198), and neural activation (73, 74, 75). Many systematic warm-up
routines such as the FIFA 11 (football/soccer specific warm-up) utilize a combi­
nation of dynamic stretching and activities in preparation for subsequent activity
and with evidence for decreased injury incidence (1, 2, 82, 149, 155, 180, 181).
PNF stretching combines static stretching and isometric contractions in a cycli­
cal pattern. PNF was developed in the late 1940s and early 1950s by Herman
Kabat, and two physical therapists, Margaret Knott and Dorothy Voss. Kabat, was
a neurophysiologist, who developed PNF based on the neuromuscular research of
Sir Charles Sherrington (178, 179). Two of the more ubiquitous techniques are the
contract relax (CR) and contract-relax-agonist-contract (CRAC) techniques (168,
 Types of Stretching and the Effects on Flexibility 21

Figure 3.3 Proprioceptive Neuromuscular Facilitation (PNF) stretching for the hamstrings

177). The CR method includes a static stretching component followed immediately

by an isometric contraction of the stretched muscle, followed with another stretch
of the target muscle. CRAC involves an additional contraction of the agonist
muscle (i.e., opposing the muscle group being stretched) during the stretch, prior to
the additional stretching of the target muscle (see Figure 3.3). PNF was used
extensively by team athletes (PNF stretches typically need a partner) in the late
20th century, but similar to static stretching, its use has diminished in this millen­
nium. A number of individual studies suggest that PNF is more effective than static
or dynamic stretching for improving ROM (70, 87, 154). However, a recent meta­
analysis systematic review reported an advantage for static stretch training over
PNF training for increasing ROM (187).
Why should we stretch? Stretching is primarily used to increase joint ROM.
When used as part of a warm-up, the increased ROM was thought to improve
performance and decrease the incidence of injuries (24, 26, 197). Although, the
ability to increase ROM through stretching is generally universally agreed, its
impact on performance and injuries is more controversial. There are many fac­
tors to consider including the type, duration (volume), intensity of stretching, the
population that is stretching (i.e., male, female, young, old, athletic, sedentary
and others) among other factors. Others may use stretching to achieve a greater
sense of relaxation (i.e., yoga) (psychological or neurological effects).

Stretching-Induced Changes in Range of Motion

First of all, flexibility is not a global phenomenon of the body (7) but stretching
effects can be global (20, 22). That is, an individual can be flexible in one joint
22 The Science and Physiology of Flexibility and Stretching
but not others (7). Even within a joint they may have a greater ROM with one
movement versus another. A baseball pitcher may not exhibit similar relative
flexibility as a discus thrower when comparing shoulder horizontal extension
versus shoulder internal and external rotation. Some joints are more susceptible
to stretch-induced increases in ROM. For example, stretching calf muscles
provides only small increases in ankle dorsiflexion, which may not be clinically
meaningful (164). In a subsequent chapter, we will discuss the global effects of
stretching; that is: unilaterally stretch one muscle or joint and there can be
increased ROM in another non-stretched muscle or joint.
What factors restrict our joint flexibility? Muscle fascicles (structural proteins
like myosin, actin, titin and others), tendons, aponeuroses, joint capsules, and
ligaments contribute to ROM restrictions with passive muscle elongation. As
the composition of a human can range from 50–78 percent fluid (water)
dependent on your age, sex, hydration, and other factors, the viscosity of the
tissues can substantially affect flexibility. Furthermore, a highly activated cen­
tral nervous system could increase muscle tonus and with a less relaxed muscle
inhibit flexibility. In addition, pushing a joint to its maximum ROM can be
uncomfortable or painful and thus the ability to tolerate this discomfort or pain
may allow some individuals to stretch farther than other more pain sensitive
individuals (121).
Stretching can induce elastic or plastic changes of the musculotendinous
system. Elastic changes are defined as the elongation of tissues that recovers
when the tension is removed; so, it is a temporary increase in ROM. Plastic
changes involve a musculotendinous elongation where the tissue deformation
remains even after the tension is removed; so, it is considered a semi-perma­
nent change in flexibility. Elastic changes are the increases in ROM that are
experienced immediately after a single session of stretching. A single session
of static stretching can induce small-to-large relative ROM increases that
persist for five (193), ten (23, 25, 27), 30 (63), 90 (102), and 120 minutes (162).
Evidence of persistent improved ROM even one day later has been reported
(137). However, not all studies show prolonged ROM increases. Two 15­
second passive stretches did not provide a significant improvement in ROM at
any time post-stretch (200), whereas augmented ROM was only evident for 3
minutes following four 30-second static stretches (52) and only for six minutes
following five-modified hold and relax stretches (184). Specific training-
induced plastic changes and mechanisms will be discussed in a later section.
As mentioned previously, there is much conflict as to what type of stretch­
ing provides the greatest ROM. PNF has been reported to provide greater
acute or elastic ROM improvements than static stretching in some studies (57,
60, 151), which contrasts with other studies finding similar ROM changes
between PNF and static stretching (46, 120). Dynamic stretching is also con­
troversial with some studies reporting that a single session of dynamic
stretching provides either similar (19, 158) or greater (8, 56) ROM increases
as static stretching. But once again, conflicting studies report that dynamic
stretching is not as effective as static stretching when used as part of warm-up
 Types of Stretching and the Effects on Flexibility 23
(10, 16, 156, 174, 176). When comparing static to ballistic stretching in a
single (acute) stretching session, ballistic stretching has been reported to pro­
vide less ROM than static (10), or PNF (16), but similar ROM as static
stretching and PNF in another study (104). Typically, we rely on systematic
meta-analytical reviews to clarify the confusing messages from the wide vari­
ety of findings from small sample original research studies. A recent meta­
analysis (21) of 47 studies revealed that a single session of stretching on
average provided a small magnitude increase in ROM compared to non-active
(non-stretched) control conditions. Whereas there were ROM increases with
sit and reach, hamstrings, and triceps surae tests, there was no change with
the hip adductor flexibility. It was also noted that stretch intensity, trained
state, stretching techniques, or sex did not significantly modulate the
enhanced ROM. A meta-regression demonstrated no relationship between the
ROM increases with age or stretch duration.
In contrast to acute responses, is there a different response when examining
chronic training study results? Another recent meta-analysis by our group (103)
of 77 stretch training studies reported that chronic stretch training effects
induced moderate magnitude ROM increases. With stretch training (in contrast
to acute stretching effects) there were significant differences between the
stretching techniques, with PNF and static stretching exhibiting greater increa­
ses in ROM than ballistic/dynamic stretching. Furthermore, females showed
greater ROM training gains compared to males, whereas stretch volume,
intensity, or frequency did not play a significant role in ROM gains. A 2018
meta-analysis systematic review determined only trivial differences in ROM
improvements between acute and chronic PNF and static stretching (127),
whereas another 2018 review found that chronic static stretch training provided
greater flexibility than PNF training (187). Ballistic stretching (higher velocity
movements with bouncing actions at the end of the ROM), which can be con­
sidered a variation of dynamic stretching was not as effective as static stretching
for improving ROM after a 4-week training programme (47). Only one study
compared PNF and dynamic stretching and indicated that after 14 training
sessions that PNF provided 3–7 percent greater ROM increases (192).
Another form of stretching is termed neuromobilization. With neuromobi­
lization, the nerve is placed under a lengthening stress. For example, when
performing a seated straight leg raise, the individual would actively dorsiflex
the foot and flex the cervical spine to exert a type of neural traction (Figure
3.4). In an 8 week stretch training study, neuromobilization provided a greater
increase in hamstring length versus PNF in the first 4 weeks but in the last 4
weeks, hamstrings length actually decreased. Thus, overall, passive static
stretching provided the greatest benefits (58).
Our psychological state or emotions can affect flexibility. Two sessions of
20 minutes each of anti-anxiety techniques such as the neuro-emotional
technique, (also known as a mind body technique) was shown in one study to
enhance ROM to a greater extent than a similar duration of passive static
stretching or no stretching (96). It is purported that latent anxiety, which even
24 The Science and Physiology of Flexibility and Stretching

Figure 3.4 Neuromobilization

if not presently apparent can lead to learned emotional responses that affect
the motor responses. Anti-anxiety techniques would dissipate these responses
and lead to greater muscle relaxation and lower muscle tonus. Various forms
of yoga combine the physical aspects of stretching with meditation or
relaxation techniques to enhance the effects on flexibility.

Yoga
Serious yoga practitioners are widely known for their enhanced flexibility
(161). However, yoga is also reported to improve a wide array of physiological
and psychological parameters. For instance, it has been reported to increase
muscular strength (119, 189) and endurance (189), balance (161), maximal
oxygen uptake (189), improved reaction times (119), breath holding times
(119), reduced cardiovascular risk, blood pressure, body mass index (13),
unify the body, mind, and spirit, among others. How can yoga stretching
accomplish all these beneficial measures? Yoga misperception is the problem.
Yoga is not just stretching but involves many other components. In addition
to the stretching aspect, full yoga practitioners should experience changes in
their mental attitude (i.e., meditation), diet, practice of specific techniques for
postures (asanas) and breathing practices (pranayamas) in order to attain a
higher level of consciousness. It is unlikely that the average North American
or European who goes to a trendy hot yoga session or most yoga sessions is
serious or committed to a degree that they will attain a new level of con­
sciousness. However, 30–60 minutes of stretching, changing positions and
holding various postures (dynamic and static muscle endurance) and inspira­
tory and expiratory breathing techniques will certainly enhance a variety of
 Types of Stretching and the Effects on Flexibility 25
physiological and health parameters. From personal experience, having only
participating in a single 60-minute yoga session, I experienced exercise-
induced muscle soreness and delayed onset muscle soreness for days there­
after. Although I am considered a relatively very fit individual for my age, I
was not accustomed to the prolonged and slow eccentric contractions when
moving from one posture to the next or the ability to hold certain postures
under extended muscle positions for prolonged periods. A lack of task speci­
ficity was certainly evident in my muscle pain over the next few days. Hence,
you should not directly compare yoga to stretching practices like static
dynamic, ballistic and PNF, as stretching is only one component of yoga.
Furthermore, there are many types of yoga that may place greater emphasis
on holding positions for longer durations to achieve changes in connective
tissue (e.g., yin yoga) or place greater emphasis on breathing patterns or
meditation.
Unfortunately, science is messy and results are not always consistent. The
same interventions and measures can be used on sedentary women and men,
youth, young adult and seniors, trained and untrained and you can get different
results in every study. How do you figure out what is right? How do you know
what to do? As mentioned, meta-analyses are usually considered the gold stan­
dard for integrating all the disparate information in the literature into a cogent
understandable main message. But the problem with meta-analyses is that
sometimes, they might hide some intricacies. Maybe, for the general population
of sedentary and recreationally trained people, static and PNF stretching provide
the greatest ROM increases. But as gymnasts and figure skaters and circus
acrobats are the extremes of the population maybe just for them ballistic
stretching is more important, as it emulates the actions in their sport. I just used
those extreme athletes as a fictional example. There is very little research on such
a small population of extreme flexibility athletes. If a meta-analysis looked at 30,
50, or 100 papers and only 2–3 papers dealt with such highly trained athletes
then their responses to specific stretching could be hidden within the greater
numbers of the other studies. A good meta-analysis should highlight these out­
liers but not all reviews accomplish it.
Thus, based on the latest information, it would seem that there is very little
difference between stretching techniques when examining a single stretching
session but with repetitive stretch training, PNF and static stretching might
provide greater increases in ROM than dynamic stretching. However, we will
examine later how prolonged static and PNF stretching without a full warm-
up protocol might impair subsequent performance. Thus, you need to ask
yourself, whether you need the utmost ROM. If you are jogging, the ampli­
tude of your stride length is limited and there is no need to have an extreme
ROM. Hence, some dynamic stretching before the running might be suffi­
cient. If you are resistance training, and for your squat warm-up you take a
light weight or just your body mass and go through a full ROM for 10 repe­
titions then that might be sufficient as you will not exceed that range while
lifting. A study by Morton et al. (141) compared five weeks of resistance
26 The Science and Physiology of Flexibility and Stretching
training to static stretch training and found improved ROM in both groups
with no significant differences between the groups in the flexibility of the
hamstrings, hip flexors, extensors or should extensors. Thus, the ROM with
resistance training was sufficient to provide a similar flexibility training
adaptation as a stretching programme. We will delve into this topic in more
detail later as one of our recent meta-analyses has shown that resistance
training can provide similar increases in ROM as static stretching (3).
Another study incorporated dancers who either resistance trained, stretched
at a low intensity (3/10) or a moderate to high intensity (8/10) for six weeks
(195). All groups improved their passive ROM with no difference between
groups, whereas the resistance trained and low intensity stretch training
groups improved their active ROM. The authors suggested that dance
instructors and coaches should incorporate stretching and end-of-range resis­
tance training within their schedules. Stretching would be incorporated at the
end of the recovery session. They also recommended that the position of the
stretches is very important in order to eliminate muscle contractions and
hence the body should be in a stable position without extraneous tension.
Each stretch according to this study should be held for 60 seconds at an
intensity of 3/10.
The warm-up is not a time to try to make plastic (semi-permanent) changes
in your flexibility. The warm-up prepares you for the upcoming activity at
hand. There is no need to be able to do the Russian splits (legs completely
abducted until the legs are horizontal on the floor) before a 5-km jog or step-
ups in the weight room. However, if you have back problems because you
spend eight hours per day sitting at a computer and now your pelvis has an
anterior tilt, owing to shortened hip flexors affecting your lumbar spinal cur­
vature, then the use of static or PNF stretching as a separate flexibility
workout might be in order.

Range of Motion Norms

The average passive joint ROM have been provided in a few studies. The fol­
lowing tables provides a comparison of a sample of these studies in healthy or
normal individuals.

Measuring Range of Motion

There are a myriad of instruments that can be used to measure ROM. Most
individuals do not have access to advanced scientific laboratories. Hence, the
universal, full circle goniometer is one of the most preferred pieces of equip­
ment for measuring ROM (65) (see Figure 3.5). The use of goniometers has
been evaluated as having high reliability (intraclass correlation coefficients of
>0.91(65). While instruments can have strong time to time (intra-rater) relia­
bility they may not have good between instrument reliability. For instance, a
universal, fluid and electronic goniometer were tested for reliability (71).
 Types of Stretching and the Effects on Flexibility 27
Table 3.1 Upper Limb and Back Passive ROM in degrees
Joint Motion Family Medical Heyward 2005
Practice (86)
Shoulder Flexion 180 150–180
Extension 45–60 50–60
Abduction 150 180
External Rotation 90 90
Internal Rotation 70–90 70–90
Elbow Flexion 140–150
Extension 0
Radioulnar Pronation 80
Supination 80
Wrist Flexion 60–80
Extension 60–70
Radial Deviation 20
Ulnar Deviation 30
Cervical spine Flexion 45–60
Extension 45–75
Lateral Flexion 45
Rotation 60–80
Thoraco-Lumbar Spine Flexion 60–80
Extension 20–30
Lateral Flexion 25–35
Rotation 30–45

Source: Family Medical Practice: (www.fpnotebook.com/Ortho/Exam/ShldrRngOfMtn.htm).

While the inter-tester reliability in Goodwin’s study was excellent (r = 0.90–

0.93), the reliability scores between instruments were not as consistent.

Fluid Goniometer vs. Universal Goniometer 0.90

Fluid Goniometer vs. Electrogoniometer 0.33
Universal Goniometer vs. Electrogoniometer 0.51

Another study compared a standard plastic goniometer to a fleximeter (grav­

itation-based ROM measuring device) or inclinometer (see Figure 3.6). The
fleximeter/inclinometer demonstrated moderate to excellent intra- and inter-
rater reliability but the goniometer showed poor to moderate intra- and inter-
rater reliability (43). These findings indicate that if just one device is used to
28 The Science and Physiology of Flexibility and Stretching
Table 3.2 Lower Body Passive ROM in degrees
Joint Motion Roass and AAOS Boone and Heyward Hallaceli
Andersson 1969 (186) Azen 1979 2005 et al. 2014
1982 (165) (33) (86) (80)
Hip Extension 9.5 28 12.1 30 19.8
Flexion 120.4 113 121.3 100–120 128.8
Abduction 38.8 48 40.5 40–45 45.7
Adduction 30.5 31 25.6 20–30 24.2
Internal 32.6 35 44.4 40–45 43.4
Rotation
External 33.7 48 44.2 45–50 41.9
Rotation
Knee Extension 10 0–10 7.53
Flexion 143.8 134 141 135–150 142.4
Ankle Extension 15.3 18 12.2 20 22.5
(Dorsi­
flexion)
Flexion 39.7 48 54.3 40–50 49.99
(Plantar
flexion)
Valgus 27.9 18 19.2 15–20 19.9
(Eversion)
Varus 27.8 33 36.2 30–35 34.1
(Inversion)
Source: American Association of Orthopaedic Surgeons.

measure differences before and after stretching or training, the extent of

change should be reliable but you cannot always interchangeably use these
devices to monitor flexibility differences. Similar conclusions were made when
comparing goniometers and a digital level (143). Whereas, intra-tester relia­
bility ranged from 0.91–0.99, inter-tester reliability ranged from 0.31 to 0.95
with limits 2.3 times higher for inter-tester reliability when testing for various
shoulder movements (external and internal rotation and flexion). The authors
indicated that experienced individuals using the same instrument for repeated
measures (goniometer or digital level) should be able to detect a shoulder
ROM change of at least 6 degrees, but when comparing measures from two
people, the detectable change is 15 degrees. Another study (84) examined the
reliability of measuring ROM with visual estimation, goniometry, still photo­
graphy, “stand and reach” and hand behind back reach for six different
shoulder movements. In general, they reported fair to good reliability (r =
0.53–0.73) for visual estimation, goniometry, still photography and stand and
reach. However, the tests had standard errors of measurement between 14–25
degrees (inter-rater trial) and 11–23 degrees (intra-rater trial). The hand
Table 3.3 Norms for Joint Range of Motion (°)
MALES FEMALES

Joint Movement Low Mod. Low Avg. Mod. High High Low Mod. Low Avg. Mod. High High
Neck

Flexion/ <107 107–128 129–142 143–160 >160 <125 125–141 142–160 161–177 >177
extension
Lateral Flexion <74 74–89 90–106 107–122 >122 <84 84–99 100–116 117–132 >132
Rotation <141 141–160 161–181 182–210 >201 <158 158–177 178–198 199–218 >218
Shoulder

Flexion/ <207 207–223 224–242 243–259 >259 <226 226–242 243–261 262–278 >278
Extension
Adduction/ <158 158–171 172–186 187–200 >200 <167 167–180 181–195 196–209 >209
Abduction
Rotation <154 154–171 172–192 193–210 >210 <289 189–206 207–227 228–245 >245
Elbow

Flexion/ <133 133–143 144–156 157–167 >167 <133 133–143 144–156 157–167 >167
Extension
Forearm

Supination/ <151 151–170 171–191 192–211 >211 <160 160–179 180–200 201–220 >220
Pronation
Wrist

Flexion/ <112 112–131 132–152 153–172 >172 <136 136–155 156–176 177–196 >196
Extension
Ulnar/radial <64 64–77 78–92 93–105 >105 <75 75–88 89–101 102–117 >117
deviation
Table 3.3 (Cont.)
MALES FEMALES

Joint Movement Low Mod. Low Avg. Mod. High High Low Mod. Low Avg. Mod. High High

Hip

Flexion/ <50 50–67 68–88 89–106 >106 <82 82–99 100–120 121–138 >138
Extension
Adduction/ <41 41–50 51–61 62–71 >71 <45 45–54 55–65 66–75 >75
Abduction
Rotation <59 59–78 79–99 100–119 >119 <90 90–109 110–130 131–150 >150
Knee

Flexion/ <122 122–133 134–146 147–157 >157 <134 134–144 145–157 158–168 >168
Extension
Ankle

Plantar flexion/ <48 48–58 59–71 72–82 >82 <56 56–66 67–79 80–90 >90
dorsiflexion
Inversion/ <30 30–41 42–56 57–68 >68 <39 39–50 51–65 66–77 >77
Eversion
Trunk

Flexion/ <45 45–62 63–83 84–101 >101 <30 30–47 48–68 69–86 >86
Extension
Lateral Flexion <75 74–89 90–106 107–122 >122 <104 104–199 120–136 137–152 >152
Rotation <108 108–126 127–147 148–166 >166 <134 134–152 153–173 174–192 >192

Source: Using Leighton Flexometer (88, 114).

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