Biologic tissues are viscoelastic. That means their stretchiness changes depending on how hard they are stretched. We can take advantage of this characteristic when we are rehabilitating a stiff joint. This becomes very important with certain medical problems. Specifically: total knee replacement and frozen shoulder. This concept is generally helpful in orthopedic rehabilitation and I take advantage of it whenever applicable. Think of silly putty. When slowly stretched it can be drawn out into a long strand, but when pulled aggressively it will snap and break in two. This is an extreme example of viscoelasticity. Your tissues are similar. While extreme force stretching can cause tissue to tear, this is generally far beyond any amount of stretching a patient can do, even with a physical therapist. A manipulation under anesthesia is a maneuver performed by a surgeon to rapidly regain motion in a particular joint that has become stiff. Tissues tear, and inflammation results. This is the most extreme example of a high force, low duration stretch. It is best to avoid this type of intervention if possible. It is preferable for a patient to spend the time necessary to recover joint range of motion using a long duration, low force stretch. It will result in less inflammation and less pain. Shoulders and knees commonly become stiff. Total knee rehabilitation requires stretching to regain range of motion after surgery. Stretching is required to speed up the recovery of a frozen shoulder. When attempting to regain range of motion patients are often told to stretch for 10-15 seconds and then relax. Over and over. Sometimes this is effective. Sometimes it is not. There is significant genetic variation with regard to tissue strength and inflammatory response, and significant psychological variation with regard to pain tolerance, and ability to relax while stretching. When a patient has trouble regaining range of motion I try to focus them on long duration, low force stretching. This tends to create less inflammation and is more likely to allow a patient to relax the muscles while stretching. Relaxing is very important because any muscle resistance will prevent gains in range of motion. ![]() This sketch depicts how I think about stretching. A high force, brief stretch is more likely to cause inflammation. A gentle prolonged stretch is less likely to create an inflammatory response. The "amount of stretch" or the total area under the curve depicted by the hash marks could be identical, but my experience suggests the long duration, low force stretching will give a superior result. How do I know this? When I was a resident, I developed a frozen shoulder and used long duration, low force stretching to cure myself. I have subsequently recommended this technique to countless patients who presented with frozen shoulders that had failed to improve after many weeks of standard physical therapy. Although occasionally surgical intervention was necessary, the vast majority progressed using this technique and never needed surgery. This technique has become my standard recommendation following total knee replacement and to rehabilitate a frozen shoulder, and has minimized the need for manipulation.
11 Comments
Deb Catlow
10/24/2020 02:05:58 pm
Hi, I have had 4 new knees, my first replacement was 1990, due to joint not being right had it revised, then again and again.
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10/24/2020 04:30:54 pm
It is always reasonable to try long duration stretching. My expectations would have to be significantly reduced under your circumstances, unfortunately. Your knee has undergone significantly more trauma than that involved with the typical knee replacement. 4 knee replacements in 30 years plus a patellectomy! By 50% flexion, do you mean only 50 degrees of flexion. If so, I would approach this differently. I would recommend arthroscopic lysis of adhesions with manipulation and static bracing with the goal of regaining at least 95 degrees of flexion. I think this is realistic and would make a significant improvement in your quality of life.
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Deborah
11/10/2020 05:29:47 am
Thank you for your reply. 11/26/2020 02:01:53 pm
I think it is totally appropriate to discuss this possible procedure with him. He may or may not think this is appropriate for your specific situation, but patients should always feel comfortable discussing issues like this with their surgeons.
Deborah Catlow
11/10/2020 05:38:57 am
I forgot to mention that yes 50% flexion approximately
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Deb Catlow
12/31/2020 06:35:00 am
Hi, I’ve been stretching for quite a while now, all was going well so I increased my stretching end point for maybe 3 - 4 hours.
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1/4/2021 09:38:59 pm
Looking back at the dates of prior comments, it appears you have been working on this for a couple of months now. Have you made any gains with regard to range of motion? If so, perhaps ease back a bit on the force you are using while stretching. You do not want to give back any of your hard earned gains. The act of stretching to regain substantial range of motion (as you are doing) will result in tissue micro-tearing/stretching. This leads to inflammation and pain. Be generous with ice but persist.
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Richard Wilcox
1/4/2021 01:39:34 am
Do you recommend holding a stretch at the first sign of discomfort, or pushing it further to the level where you can't move it further without pain?
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1/4/2021 09:18:50 pm
Discomfort is subjective. Until you achieve your desired range of motion (ideally at least 0-120 degrees) stretching is crucial. You will probably experience some discomfort while doing the stretches properly. The key here is to hold the stretch at that level for a long period of time (minutes). Then instead of relaxing, try to add a little more stretch. Hold, and repeat. Over and over. Ideally you should gain couple of degrees every day.
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Richard Wilcox
1/4/2021 09:44:08 pm
Thanks for the response. I'm just trying to figure out how much discomfort is optimal. Is it best to stop and hold the stretch as soon as I feel a little discomfort in order to minimize an inflammatory response? Or would I get better results if I held the stretch at a point where I experienced higher levels of discomfort? 1/4/2021 10:12:35 pm
Unfortunately, I don't have an exact answer for you. You need to make progress toward your goal range of motion. Mine would be a minimum of 0-120 degrees. You need to stretch adequately (force and duration) to achieve progress. If you are not making progress, you need to increase your stretching. I would focus first on increasing duration of stretch (which results in less inflammation), but, if you are not making progress, you may need to increase the force as well. I think this is the best I can do for you....Good luck! Your comment will be posted after it is approved.
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