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Journal of Science and Medicine in Sport 14 (2011) 535540

Original research

A randomized controlled trial for the effect of passive stretching on

measures of hamstring extensibility, passive stiffness, strength,
and stretch tolerance
Paul W.M. Marshall , Anthony Cashman, Birinder S. Cheema
School of Biomedical and Health Science, University of Western Sydney, Australia
Received 27 January 2011; received in revised form 5 May 2011; accepted 6 May 2011

Abstract
To measure hamstring extensibility, stiffness, stretch tolerance, and strength following a 4-week passive stretching program. Randomized
controlled trial. Twenty-two healthy participants were randomly assigned to either a 4-week stretching program consisting of 4 hamstring and
hip stretches performed 5 times per week, or a non-stretching control group. Hamstring extensibility and stiffness were measured before and
after training using the instrumented straight leg raise test (iSLR). Stretch tolerance was measured as the pain intensity (visual analog scale;
VAS) elicited during the maximal stretch. Hamstring strength was measured using isokinetic dynamometry at 30 and 120 s1 . Hamstring
extensibility increased by 20.9% in the intervention group following 4 weeks of training (p < 0.001; d = 0.86). Passive stiffness was reduced by
31% in the intervention group (p < 0.05; d = 0.89). Stretch tolerance VAS scores were not different between groups at either time point, and
no changes were observed following training. There were no changes in hamstring concentric strength measured at 30 and 120 s1 . Passive
stretching increases hamstring extensibility and decreases passive stiffness, with no change in stretch tolerance defined by pain intensity
during the stretch. Compared to previous research, the volume of stretching was higher in this study. The volume of prescribed stretching is
important for eliciting the strong clinical effect observed in this study.
2011 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Keywords: Passive stretching; Hamstrings; Stiffness; Extensibility; Training

1. Introduction in combination with Nordic strengthening exercise, had a

Training programs to improve the extensibility of the
hamstring muscle are of clinical interest for strength and
conditioning coaches as well as those working in reha-
bilitation. Extensibility is the ability of muscle tissue to
lengthen or stretch beyond resting length. Reduced exten-
sibility of the hamstrings, defined as both a standing forward
reach finger-to-ground distance of greater than 0 cm and
a supine hip flexion leg lift angle of <80 ,1 is associated
with several clinical conditions of interest. Reduced ham-
string extensibility measured pre-season in soccer players
has been associated with an increased likelihood of injury.2,3
Rugby players who regularly performed passive stretching,
Corresponding author.
E-mail address: p.marshall@uws.edu.au (P.W.M. Marshall).
reduced incidence and severity of hamstring injuries during
a competitive season.4 Reduced hamstring extensibility is
also a common observation in patients with chronic low back
pain.57 Passive stretching is a commonly observed clinical
intervention for reduced hamstring extensibility. The phys-
iological adaptations related to passive stretching programs
have not been well investigated. Two adaptations of inter-
est in this research are changes in hamstring muscle passive
stiffness and strength.
Passive stiffness is the ability of the tissue within and
surrounding a muscle to allow elongation. Passive stiffness
is an important component of muscle function because it
allows maximal length of both activated and non-activated
muscles.8 The passive components of muscle structure can
be sub-divided into the series and parallel elastic components
that serve to absorb, transmit, and store energy. The series

1440-2440/$ see front matter 2011 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2011.05.003
536 P.W.M. Marshall et al. / Journal of Science and Medicine in Sport 14 (2011) 535540

elastic component is located in the tendon and the

actinmyosin crossbridges. The parallel component is found
in the sarcolemma and connective tissue surrounding the
muscle. The instrumented straight leg raise (iSLR) test pro-
vides an objective quantitative measurement of hamstring
muscle passive stiffness while the participants leg and ankle
are stabilized in rigid restraints, and passively flexed at a
constant velocity using an isokinetic dynamometer.1,7,9,10
Fear that passive stretching will cause strength decrements
is a common clinical reservation for adoption of a stretching
program. Despite studies finding acute strength decreases fol-
lowing passive stretching,11,12 there are few studies that have
measured the chronic effects of passive stretching on muscle
strength. Increases in muscle strength are usually associated
with resistance exercise where external loads approximating
at least 60% of an individuals maximum strength are pre-
scribed over a period of time.13 Considering that no active
loading is applied during passive stretching, it is reasonable
to believe that there will be no change in muscle strength
following a period of training.
The purpose of this study was to measure the changes in
hamstring extensibility, passive stiffness, and strength fol-
lowing a 4-week passive stretching program. In addition,
Fig. 1. Top photo depicts the iSLR set-up (with stop button present during
stretch tolerance (defined for this study as the pain inten- pre-test trials present; stop button was removed during recorded trials). Bot-
sity elicited during stretch) was measured before and after the tom image is a representative result from a participant tested in this study
stretching program. Stretch tolerance is often described as the for the torque measured during the iSLR. Passive tissue stiffness was mea-
primary mechanism for increased muscle extensibility fol- sured as the slope (y/x) through the common range of motion (Megrad ,
lowing training, although there is often no dependent variable 2050 ) and peak stiffness (Memax ). Maximum leg excursion angle (leg max )
was used to represent hamstring extensibility in this study.
measured to represent this mechanism.1416 The hypotheses
of this study were, (1) passive stretching would increase ham-
string extensibility and decrease passive stiffness, (2) there period and was monitored. The University Human Participant
would be no change in hamstring strength following the train- Research Ethics Committee approved all procedures used in
ing program, (3) stretch tolerance would improve (i.e., pain this investigation.
elicited during stretch would decrease) following training. This study was a randomized control trial where par-
ticipants were assigned to a 4-week hamstring stretching
program or a non-stretching control group. Assessments were
2. Methods performed before and after the training program. Assessors
were not blinded to group allocation. Dependent variables
Twenty-two recreationally active healthy individuals from measured using an instrumented straight leg raise (iSLR)
within the University population volunteered to partici- were hamstring extensibility, passive tissue stiffness, and
pate in this study (14 males, 8 females; 22.7 3.8 years, stretch tolerance. Isokinetic dynamometry was used to mea-
1.74 0.10 m, 77.9 13.9 kg, mean SD). Participants par- sure concentric hamstring strength at 30 and 120 s1 . As
ticipated in social sports and/or recreational training activities the effect of leg dominance has not been demonstrated to be
between 3 and 5 times per week. Participants had no history important in the development of muscle stiffness, leg domi-
of lower limb injury that required surgery, and no history nance was not controlled for, and the right leg only was tested
of acute lower limb injury within the last year that required for all participants.17
a missed day of work or requirement to seek medical treat- The KinCom isokinetic dynamometer (Chattanooga, Kin-
ment. All participants were healthy, with no known metabolic Com 125 Version 5.32) was used for hamstring extensibility
or neuromuscular disease, and no musculoskeletal abnormal- and strength tests. The iSLR test was used for measurement
ities. Participants had no history within the last year of regular of maximum leg excursion angle (leg max ), maximal stiffness
stretching (defined as a prescribed stretching program per- (Memax ), and passive stiffness during the (Megrad ) through-
formed on at least a weekly basis). Participants assigned to out the common range of motion for all subjects (2050
the control group were advised to continue their regular phys- based on leg excursion angle; Fig. 1). The common range of
ical activity without commencing any new exercise program. motion is achievable in healthy and clinical populations.7,18
Regular exercise, if already performed as part of a weekly This range has been shown to exhibit a linear torqueangle
routine, was allowed to be continued throughout the training relationship.7,18 The iSLR protocol has good reproducibility
 P.W.M. Marshall et al. / Journal of Science and Medicine in Sport 14 (2011) 535540 537

(ICC r = 0.94) and has been shown to be more sensitive Table 1

to training related changes than manual straight leg raise Dependent variables measured during iSLR and isokinetic strength testing
for the intervention (n = 11) and control (n = 11) groups at baseline and after
methods.19 The iSLR method in this study replicates that the 4 week training period.
used in previous research.7,10,20 The hip was passively flexed
Intervention Control
to end range of motion by the dynamometer at a movement
velocity of 5 s1 . Participants were placed in a supine posi- Leg max ( )
Baseline 76.1 15.9 80.8 18.2
tion on the examination table. They were fixed to the table by 4 weeks 92.0 18.0* 83.5 20.1
the use of straps across the trunk, pelvis, and opposite thigh. Memax (Nm)
Adjustable support was provided to prevent the lumbar spine Baseline 30.1 17.4 30.7 18.9
flattening onto the test surface during testing. The leg was 4 weeks 43.2 20.4 33.3 20.1
fully extended in the apparatus, and the ankle was fixed at Megrad (Nm )
Baseline 0.35 0.11 0.46 0.18
90 of dorsiflexion. The center of rotation of the dynamome- 4 weeks 0.24 0.11*a 0.48 0.17
ter lever arm was aligned with the sagittal plane axis of the VAS (mm)
hip joint through the greater trochanter of the test limb. Baseline 49.3 27.4 36.6 32.3
The visual analog pain scale (VAS) was used to represent 4 weeks 42.1 27.9 29.5 27.9
participant stretch tolerance. The VAS is a 100 mm horizontal Hamstring strength 30 s1
Baseline 49.7 16.2 42.6 10.8
line with no pain and worst pain anchored to the respec- 4 weeks 50.8 20.2 46.1 13.9
tive left and right ends. Participants were asked to draw a Hamstring strength 120 s1
vertical line through the horizontal line at the point which best Baseline 43.5 12.8 48.7 15.1
represented their maximal pain intensity experienced during 4 weeks 46.1 12.1 49.3 17.1
the iSLR. The VAS score (mm) was calculated by measuring Note: * indicates p < 0.05 from baseline.
a Indicates p < 0.05 between groups.
the distance from no pain to their mark. The VAS score
was collected immediately (<15 s) following iSLR testing.
Testretest reliability of the VAS has been demonstrated to
be high with ICC scores between 0.70 and 0.83.21 Cohens effect sizes were calculated using G-Power statistical
Concentric isokinetic hamstring strength testing was software to evaluate the clinical significance of any changes
recorded at 30 and 120 s1 . Participants were asked to exert observed, where d = 0.8 is a large effect, d = 0.5 is moderate,
maximal effort during all movements while in a restrained and d = 0.3 a small effect size.22 The significance level of this
seated position. Participants were restrained using straps study was p < 0.05. All data are presented as mean SD.
across the trunk and waist region, as well as across the
middle third of the thigh. The lever arm was attached to
the participant via straps applied 2 cm superior to the lat-
eral malleolus. Three maximal contractions were performed 3. Results
for each movement velocity. The maximal trial from each
movement velocity was used for data analysis. The baseline demographic and dependent variables
Participants in the intervention group were required to (Table 1) collected from the intervention and controls groups
perform 4 passive stretching exercises 5 times a week for a were not different indicating that randomization was a suc-
period of 4 weeks with 1 session per week directly supervised. cess.
Passive stretches for the intervention were comprised of a Hamstring extensibility (Table 1) increased by 20.9%
lying hamstring stretch, good-morning stretch, lying gluteal in the intervention group following 4 weeks of train-
stretch and seated gluteal stretch (Fig. 2). Each stretch was ing (p < 0.001; d = 0.86, 1 = 0.62). Maximal stiffness
held for 30 s for 3 repetitions. Stretching was performed for (Memax ) did not change in either group. Passive stiffness
both limbs. Participants were required to complete a train- during the common range of motion (Megrad ) was reduced
ing diary to detail any additional physical activity conducted by 31% from baseline after 4 weeks of training in the inter-
throughout the study period and monitor program adherence. vention group (p < 0.05; d = 0.89, 1 = 0.64). Megrad was
Participants reported 100% adherence with the stretching lower in the intervention compared to the control group fol-
program, with the program duration ranging between 12 and lowing training (p < 0.001). Stretch tolerance VAS scores
15 min per session. were not different between groups at either time point, and
KolmogorovSmirnov testing found that all dependent no changes were observed following training. There was no
variables were normally distributed therefore parametric test- significant correlation observed between starting leg max and
ing was used for data analysis. Paired t tests were used to improvements in extensibility following training in the inter-
compare dependent variables between time points within vention group (r = 0.03). There were no differences observed
each group. Independent samples t tests were used to compare between groups at each time point for hamstring concentric
dependent variables between groups at each time point. Pear- strength measured at 30 and 120 s1 (Table 1). No changes
sons correlation coefficient was used to evaluate whether the in strength were observed for either group following 4 weeks
change in leg max was related to pre exercise range of motion. of training.
538 P.W.M. Marshall et al. / Journal of Science and Medicine in Sport 14 (2011) 535540
Fig. 2. Hamstring and hip stretches used in this study. Stretch A; lying straight leg raise, B; lying gluteal stretch, C; good morning hamstring stretch, D; seated
gluteus medius stretch. Elastic bands were provided to assist stretches A and B. All stretches were performed 3 times on each side of the body, with 30 s holds,
5 times per week.
4. Discussion
The main finding of this study was that hamstring exten-
sibility increased and passive stiffness decreased following a
4-week stretching program. Hamstring strength and stretch
tolerance did not change following training. The increase in
hamstring extensibility of 15.9 (20.9% increase) was a clin-
ically meaningful change with a large effect size of d = 0.86.
Therefore a similar stretching program to that used in this
study can be recommended for evaluation in clinical pop-
ulations (sporting or pathological) where increased muscle
extensibility is a training goal.
The 20.9% increase in hamstring extensibility observed
in this study is greater than that reported in several other
stretching based intervention studies. Hamstring stretching
intervention studies have reported increases of between 4.1%
and 9.5%.1416,23 Typically these studies only use a single
hamstring stretch, whereas this study used two specific ham-
string stretches as well as two supplemental hip stretches. The
use of multiple stretches for the hamstrings and hip muscles is
similar to the study by Roberts23 who used two hamstring and
hip stretches, but only reported an 8.5% increase in extensi-
bility. However the 8.5% increase was observed in individuals
who sustained a stretch for 15 s,23 whereas this study used
30 s holds repeated 3 times for each stretch. This suggests that
the duration of stretch prescribed in an important prescription
variable for the magnitude of expected gains. Recent research
also supports the prescription of multiple hamstring stretches
and 30 s holds for achieving gains in extensibility of approxi-
mately 20% over a 4 week period.24 Ylinen et al.24 measured
changes in extensibility using the iSLR method although no
data was provided evaluating changes in passive stiffness
through the common range of motion24 which appears to
be the mechanism of adaptation following an appropriately
prescribed volume of passive hamstring stretching.
The results of this study suggest that passive muscle stiff-
ness, primarily of the hamstring muscles, is the mechanism by
which extensibility was increased with the passive stretching
program. The results of this study, while indicating changes in
passive muscle stiffness, are not able to provide information
on whether the adaptation is in the series or parallel com-
ponents of muscle. This study did not measure, and cannot
rule out, that changes in passive stiffness of other posterior
chain muscles trained in this study (i.e., gluteals) also con-
tributed to the training improvement. While not measured in
this study, we do not believe that changes in neural activa-
tion are associated with the changes observed in hamstring
extensibility. Recent evidence demonstrated that active char-
acteristics of the hamstring muscle, including concentric and
eccentric strength, and the amplitude of biceps femoris and
medial hamstring recruitment, were not related to measures of
hamstring extensibility or stiffness.7 We do not believe that
the increase in hamstring extensibility was associated with
changes in the displacement or strain of the lumbosacral nerve
roots during iSLR testing. By stabilizing the lumbar spine
and using a fixed ankle position we have controlled these
potentially confounding variables that have been observed
to increase spinal nerve root tension.25 Furthermore, there
was no change in the pain elicited during stretch following
training, which may have indicated alterations in spinal nerve
root tension rather than changes in the passive stiffness of the
hamstrings.
It is important to note that the method of hamstring pas-
sive stiffness calculation used in this study is the primary
difference to previous research which has concluded that
stiffness properties do not change following a stretching
 P.W.M. Marshall et al. / Journal of Science and Medicine in Sport 14 (2011) 535540 539

intervention.14,16 Similarly to previous research, maximal <80 .1 Based on this criterion, 14 of the 22 participants can be
stiffness (Memax ) did not change following training. This classified as having reduced extensibility at baseline. Study
suggests that the maximal passive torque able to be applied, participants volunteered to be randomly assigned to either a
or tolerated, by the participants hamstrings is not influ- 4 week stretching intervention or control, with control par-
enced by a stretching program. However, measurement of ticipants informed prior to randomization that the program
maximal torque does not take into account the resistance to would be provided to them at the end of the monitored period.
change during the range of motion. Therefore analysis of the Therefore it is likely, as proven by the baseline results, that we
torquetime curve, particularly through the common range have sampled from a population of healthy individuals who
of motion (2050 ), should be recommended in future clini- were already aware they had a tight hamstring and wished
cal trials investigating interventions for improving hamstring to participate in a training study to improve this. Finally, only
extensibility. concentric strength was measured in this study, although it
Following training, no change was observed in the inten- is not clear why a passive stretching intervention may affect
sity of hamstring pain elicited during the passive stretch. The eccentric strength output differently.
self-reporting of hamstring pain elicited during the stretch
was used to describe the stretch tolerance of participants in
this study. The conclusion that improvements in extensibility 5. Conclusion
is owing to improved stretch tolerance is commonly reported
in the literature.1416,26 This suggests that volitional choice A passive stretching program including multiple stretches
is the primary determinant of extensibility, and of changes for the target muscle group performed 5 days per week for
in extensibility. The measurement of maximal pain inten- 4 weeks was effective in increasing hamstring extensibility
sity was thought by this studys authors to provide a more and decreasing passive stiffness. Pain intensity measured dur-
accurate measure of stretch tolerance than identification of ing the stretch did not change following training. Hamstring
pain onset.10 That pain intensity did not change does not strength did not change following training.
discount that stretch tolerance is a primary determinant in
extensibility measurements. Indeed, the self-assessment of
pain, as performed by the participants in this study, involves
6. Practical implications
the complex interaction between physiological inputs and
behavioural interpretation of the pain experience.27 The mea-
A passive stretching program including 4 stretches per-
surement of pain intensity by itself cannot be considered
formed 5 times per week for 4-weeks is effective for
a true measure of volitional choice in terminating the test.
increasing hamstring range of motion.
While the authors of this study attempted to reduce volitional
Changes in hamstring range of motion following stretching
choice in determining maximal range of motion as much
are explained by changes in mechanical components of
as possible (establishing maximal range of motion in pre-
muscle function rather than improved pain tolerance.
test trials and removal of the stop button control during the
Compared to previous literature, the program used in this
recorded trial), the test range of motion was still determined
study used a greater volume (total number of repetitions
based on the ability of participants to tolerate the stretch.
performed per week) and used longer stretch durations
Therefore while the authors of this study cannot completely
(30 s) to achieve the strong clinical effect.
rule out volitional stretch tolerance as a possible explana-
We recommend that clinical conditions with reduced ham-
tion for changes in extensibility, it does seem that hamstring
string extensibility, such as low back pain, or sporting
pain elicited during a passive stretch has little involvement in
populations with high hamstring strain injury incidence
explaining training related improvements.
(i.e., AFL, rugby union), trial this program within their
Several limitations of this study must be addressed. First,
current training regimes.
this study was underpowered to investigate the influence
of gender on the responsiveness to the stretching interven-
tion. This is relevant for future studies as there are gender
differences in the mechanical and neuromuscular proper- Acknowledgements
ties of the hamstrings. Previous observations have identified
reduced active and passive hamstring stiffness in female No financial support was received for this study.
participants,7,2830 as well as a positive relationship between
hamstring extensibility and the onset of the medial ham-
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