Active Isolated Stretching:
The Protocols
Part 2 of 2 part
series
By Aaron L. Mattes, M.S., R.K.T., L.M.T. and Salvatore J. Minicozzi, D.C., C.C.E.P.
In last month’s article, we introduced active isolate stretching (AIS)
to the reader. This is a system of soft tissue stretches based upon reciprocal
inhibition. Sherrington’s Law says that when muscles on one side of a
joint are contracted, the antagonist muscles must be inhibited for movement
to occur. It is during this relaxation or inhibition that a stretch is allowed
to physiologically occur.
Active isolated stretching, the Mattes Method, is a system of soft tissue work
that has been developed by Aaron Mattes over the last 40 years. These movements
are designed to not only affect the muscle fibers themselves, but also the surrounding
fascia. It is in the fascia where most adhesions occur in response to the traumas
that we encounter. AIS is implemented in the clinical setting to address these
obstacles to movement.
There are seven body protocols that AIS is divided into. They are: neck, shoulder
girdle, trunk, pelvic girdle, thigh, hands/wrists and feet/ankles. We will review
each protocol, giving the reader insight to how this system builds upon itself.
Before these protocols are introduced however, the methods to approach this
system must first be discussed.
It is paramount to keep in mind that stretches sustained over three seconds
in duration, subject the muscles to the myotatic stretch reflex. This protective
mechanism serves to guard muscles and tendons from being overstretched and injured.
The Mattes Method of AIS favors a two second stretch which avoids this reflex.
Multiple repetitions are used in place of prolonged stretches of greater than
three seconds. Specificity is a must as there are many muscles found in small
areas. Patient breathing is important in order to oxygenate the muscle fibers
and to help remove metabolic waste. Patient breathing parallels that of weight
training: Exhale upon the exertion or contraction.
The doctor or therapist assisting the patient must maintain a light exertion
during the directional force that is being applied. Six to eight ounces of pressure
is more than enough to help increase joint range of motion. Excessive or prolonged
forces applied to muscles will reflexively cause them to guard. Again, this
myotatic stretch reflex response is initiated by the muscle spindles and Golgi
tendon organs. Finally, after each repetition, the tissue is returned to its
starting position. This serves to pump blood into the muscle tissue, while toxins
and waste products are pumped out.
Protocols
We will start with our discussion of the various protocols of the Mattes Method
with the neck protocol. It would be helpful to the reader to visualize the neck
as an octagon in the transverse plane. Our work first focuses on the posterior
part of the octagon. We then move to the anterior, lateral, and finally the
angles in between. It is important to note that the same contraindications and
precautions exist with AIS as with all chiropractic techniques.
During this discussion, we have made every effort to be as descriptive as possible.
Some of the descriptions of these moves may seem difficult to visualize without
the proper demonstration. These movements however, are described with the patient
in the anatomical position. Since the anatomical position is generally accepted
to be standing, we would like the reader to translate these postures to the
supine, prone or seated positions when indicated.
It is also important to point out that many of these moves may be done from
different positions other than the ones described herein. It would be both laborious
and impractical to try to describe the variations of each move. The authors
also realize that there is no substitution for hands on teaching and learning.
This information is typically taught over a 24-hour, hands-on intensive seminar
or series of two 12-hour blocks. We have also chosen, due to space constraints,
not to name the specific muscles, origins or insertions.
Neck
Since most of our patients live and work with some degree of anterior head translation,
the cervical extensors need to be released first. Active neck flexion inhibits
the neck extensor muscles. This then is our first movement. This is accomplished
by simply having the patient flex their chin toward their chest. At the end
of active flexion, the therapist applies six to eight ounces of extra pressure
to help increase joint range of motion. The goal here is to release restricted
tissue, specifically fascia. Each repetition is held for one to two seconds.
Six to 12 repetitions are completed and up to three sets may be performed.
The next move is a neck extension. With the patient in the seated position and
in slight lumbar flexion, have the patient rest their elbows on their quads.
This movement allows the anterior neck muscles to be stretched. Ask the patient
to raise their chin up and out. They may experience skin in the occipital region
“bunching up,” as well as a stretch in the anterior neck muscles.
Hold two seconds, release and repeat. Lateral flexion to the left and then to
the right follow next. These movements resemble a shoulder depressor test. Positive
findings for a shoulder depressor test include dural sleeve adhesion. AIS serves
to “unglue” these adhesions and return the patient to fuller ranges
of motion. After lateral flexion comes cervical rotation. The patient should
experience rotational stretches in the muscle tissue of the rotators that they
are not engaging. A precaution for the doctor is to make sure that while assisting
the patient with rotation, force over the TMJ is being distributed evenly so
not to overstress that joint.
The muscles of the “angles of the octagon” are addressed by having
the patient rotate their head 45 degrees for the next six movements. Three of
these movements are with the head rotated to the right and the other three are
with the head rotated to the left. AIS protocols indicate that to stretch the
posterior left musculature (levator scapula, trapezius), the patient is rotated
45 degrees left. The right ear moves toward the right pectoralis muscle as the
doctor assists. With the head still rotated 45 degrees, the anterior right musculature
(SCM, scalenus anticus) is stretched by moving the left ear toward the left
scapula. The final movement on this 45 degree is to move the chin toward the
left pectoralis muscle. This addresses the opposite (right) levator scapula
muscle. To accomplish the final three movements, repeat this procedure on the
opposite side.
Shoulder Girdle
We will use the neck protocol as a model for the rest of the protocols. It is
meant for the reader to infer that all the methods that AIS employs are used
for the remainder of this discussion. In the upper extremity, the patient is
directed to warm-up by gravity assisted circumduction of both shoulders. The
patient should slightly flex at the waist 
and
while letting their arms hang down circumduct their shoulders clockwise for
8-12 reps, and then counter clockwise for 8-12 reps.
The anterior chest muscles are first released by abducting the shoulder to 90
degrees, (thumbs up posture) and then horizontally extending the shoulders back.
Return to the neutral position by horizontally flexing the shoulders, maintaining
straight arms, to palms together thumbs up posture. The anterior deltoid and
biceps tissue is released next by hyper extension of the shoulders, again maintaining
straight arms. It should be noted that with this move the patient should put
their neck into a slightly flexed position. This move is followed by releasing
the internal shoulder rotators via external rotation and then the external shoulder
rotators by internal rotation movements. Both of these movements require that
the elbow is flexed to 90 degrees while the shoulder is abducted to 90 degrees.
Stabilization of the scapulae is also a requirement for the efficacy of these
rotational moves.
The triceps tissue is addressed next. With a fully flexed elbow, hyper-flex
the shoulder. Encourage the patient to lift their elbow high. Insure that this
movement occurs in the scapular plane to avoid any impingements at the A/C joint.
Finally, release the posterior shoulder muscles. Abduct the shoulder to 90 degrees,
insuring thumbs up posture. Horizontally flex the shoulder across the chest.
Follow up this move with the positions of Appley’s scratch test and the
shoulder protocol is complete. These movements, as with all AIS movements require
full active range of motion by the patient, followed by slight assistive pressure
by the doctor in the same plane of movement.
Trunk
Seat the patient in a chair toward the front half of the seat. Have the patient
spread their feet and knees, opening up a space in front of the legs of the
chair. As they exhale, they should flex their neck and reach in between the
legs of the chair. The doctor assists through a slight downward pressure on
the lumbar spine. Force is applied in the direction that the patient is reaching.
For patients with disc-opathy, this first move should be omitted. Secondly,
the patient moves comfortably back in the chair. This next move requires full
rotation of the torso. It should be noted that in right rotation, the eyes look
to the right, followed by cervical rotation to the right followed by trunk rotation
to the right. Repeat to the left. Move three in this protocol, like move one,
should be avoided in the presence of disc-opathy. This move is a combination
of rotation first followed by laterally bending to the opposite side. Rotate
right, laterally flex left. Rotate left laterally, flex right.
The next two moves require the patient to laterally flex: first to the right
releasing left sided tissue, and then flex left, releasing right sided tissue.
The next four moves require the patient to release tissue “on the angles”
similar to the neck protocol. Turn the shoulder girdle 45 degrees in relation
to the pelvic girdle. Rotate the patient 45 degrees to the right. Flex back
and right to release front, left abdominal oblique muscle. Flex forward and
left to release the right quadratus lumborum. Rotate the patient 45 degrees
to the left. Flexing back and left will address the front, right abdominal oblique.
Flexing forward and right will stretch the left quadratus lumborum muscle.
Pelvic Girdle
The pelvis stretches are done in the supine position.
Have the patient first draw their left knee toward their left shoulder. It is
helpful to instruct the patient to place their left hand on the left hamstring.
Repeat with the right knee toward the right shoulder. For the next move support
the feet and have the patient draw the right knee to the right shoulder and
the left knee simultaneously to the left shoulder. Instruct the patient to slightly
spread their knees apart in order to accomplish this. Follow this up with the
same motion adding a lumbar lift. A lumbar lift is accomplished by placing the
free hand of the practitioner on the patient’s lumbar spine and elevating
the patient’s low back off the table into a kyphotic posture.
The final moves of the pelvic protocol require the patient to draw both knees
toward the right shoulder and then repeat the draw toward the left shoulder.
All methods of AIS are observed including the number of sets and reps. Returning
the tissue to the starting position is also paramount.
Hands and wrists
Wrist extension releases wrist flexors. Wrist flexion releases the wrist extensors.
Ulnar deviation releases radial deviators, while radial deviation addresses
the ulnar deviator muscles. Repeat these same movements for the fingers at the
MCP joints. For the thumb, planes of movement include: extension, flexion, abduction,
adduction and opposition.
Feet and ankles
Dorsiflexion will release the posterior leg muscles. Dorsiflexion with a fully
extended knee stretches the gastrocnemius, flexing the knee to 45 degrees shifts
the focus to the soleus and full flexion of the knee addresses the Achilles
tendon. Plantar flexion will localize the anterior leg muscles. While ankle
eversion will stretch the muscles of ankle inversion and consequentially inversion
will isolate the muscle of eversion. The doctor next stabilizes the calcaneus,
and addresses the foot inverters and everters using the same approach to the
ankle inverters and everters. Toe extension, (dorsiflexion, one toe at a time)
assists in releasing adhesions to the plantar surface of the foot, especially
the plantar fascia. Patients experiencing the symptoms of plantar fascitis may
at first have moderate discomfort with these movements. The effects of these
adhesions however, are soon overcome with consistent attention to these movements.
Toe plantar flexion stretches the tissue on the dorsum of the foot. The great
toe stretches include dorsiflexion, plantar flexion, abduction and adduction.
Thigh
This is by far the most comprehensive of all the protocols. There are 32 specific
moves for each thigh. The first three moves focus on the posterior leg. These
are the same movements found in the foot and ankle protocol. Releasing the tissue
of the gastrocnemius, soleus and achilles tendon through dorsiflexion is the
first step. These then, are our first three moves for the thigh protocol. If
this tissue is not first properly released, the patient may experience tightness
in the calf as the predominant sensation on subsequent movements. 
The next six moves involve the hamstrings. Different areas of posterior thigh
tissue are isolated by slight alterations in movement. The hamstrings are stretched
with the patient in the supine position. Both the knee and hip of the thigh
that is to be stretched are flexed to 90 degrees. This is known as the 90/90
position. From the 90/90 position, (NNP) have the patient extend their knee
while maintaining 90 degrees of hip flexion. The doctor applies a slight pressure
assisting with leg extension. This isolates the distal middle fibers of the
hamstring. Rotating the tibia internally using the same knee extension movement
will next stretch the lateral distal fibers. External tibial rotation affects
the medial distal fibers. These are three of the six hamstring moves.
For the next three hamstring moves, remove the patient from NNP by having them
lay theirs leg straight and extended on the table. From this position, flexion
at the hip joint only (straight leg raiser motion, or SLRM) will isolate the
proximal, middle fibers of the hamstrings. Repeating the SLRM with an internally
rotated hip will localize the medial proximal hamstring fibers, while the same
motion and a fully externally rotated hip joint stretches the lateral proximal
fibers of the hamstrings. For this final hamstring movement, it is much more
effective to direct the straight leg toward the opposite shoulder once hip flexion
reaches 90 degrees.
There are three moves for the adductor muscles. By abducting the thigh, a stretch
is achieved in the adductor muscles. It is important to have the patient resist
the tendency of external hip rotation with this movement. Moving number two
requires internal hip rotation. From this position the patient flexes the hip
and simultaneously abducts the thigh. Moving number three positions for the
patient with external hip rotation abducts the thigh to 45 degrees, and then
extends the hip, causing the lower extremity to fall below the level of the
table.
The lateral thigh compartment is the next area of our focus. There are five
movements to this area. With the patient in the supine position, externally
rotate the extremity to be worked on. Place this extremity into slight abduction.
Internally rotate the opposite extremity and slightly adduct it so that it approximates
the other leg. This is done for the purpose of securing the pelvic girdle for
the five lateral thigh movements. Securing the pelvis is a necessary step in
this protocol.
The doctor stands on the side of the table opposite the extremity that is to
be stretched. The first move will stretch the ilio-tibial band. The patient
flexes the hip to 20 degrees, maintaining the external rotation. The doctor
then assists the patient in adducting this extremity towards the doctor. The
doctor also secures the stabilizing extremity so that the pelvis does not move,
roll or shift on the table. The doctor further insures that the knee does not
flex for this movement. If the patient feels the stretch in the hamstrings,
it could indicate that external rotation has been compromised. Move number two
is done exactly the same way, except that the hip flexion is higher off the
table to approximately 45 degrees. The reader should be able to visualize that
without first properly releasing the hamstrings, this movement of lateral thigh
release would not be effective.
Move number three is very similar to moves one and two. The difference is that
the patient starts in the NNP. The thigh is then purely adducted, and the stretch
should be felt in the gluteus maximus muscle. If the patient experiences a catch
in the joint capsule of the hip, the doctor may circumduct the hip around the
fixation prior to the adduction of the thigh. The preferred approach however
is to address the fixation via CCEP protocols and then resume the movement as
described. For information on CCEP protocols visit kevinhearon.com .
Moves four and five both address the piriformis muscle. From the NNP with the
opposite lower extremity still in internal rotation and slight adduction on
the table, the knee is drawn toward the patient’s opposite shoulder. After
this movement is completed, maintain this posture and add to it the second component
of external hip rotation. Special attention must be made at this time to the
rotational forces at the knee. This is move four. Move five differs slightly
to move four. From the NNP with the opposite lower extremity still in internal
rotation and slight adduction on the table, have the patient extend their knee
moving it from 90 degrees to approximately 15 degrees. Direct the lower extremity
toward the opposite shoulder. This is a very similar movement to the proximal
lateral hamstring movement described earlier. The difference being that with
this second piriformis move, the lower extremity is further directed into adduction
moving it across the abdomen. By now we have described 17 of the 32 moves.
The next eight moves are rotational in nature around the hip joint. Five are
stretches that utilize internal rotation to address the external rotators. From
the supine position, place the patient in the NNP. Internal rotation at the
hip joint stretches the external rotators. While keeping the NNP and abducting
the thigh 10 degrees in a different external rotator. There are four additional
abducting movements away from the NNP for a total of five external rotator stretches.
For each component of this series, the patient should feel the stretch move
superiorly in relation to the previous stretch. With each abducted movement,
more care is given to the knee with respect to the forces that are generated
there.
The other three use external rotation to stretch the internal rotators. From
the NNP with the opposite lower extremity again placed in internal rotation
and slight adduction on the table, externally rotate the hip joint to address
the internal rotators of the hip. Add to this, 10 degrees of adduction for another
muscle, and an additional 10 degrees of adduction for the third internal rotator
in this group. Each component of this series, the patient should feel the stretch
move medially toward the sacrum. Again care must be taken with the knee joint
and the forces that are generated there.
The next three moves affect the primary hip flexors of psoas, illiacus and sartorius.
Start with the patient standing, feet spaced shoulder width apart. Have the
patient assume a lunge forward posture. This is accomplished by stepping forward
and lowering the rear knee onto a pad. The forward knee should be flexed to
about 45 degrees, with the foot of the forward leg flat on the floor. The torso
remains perpendicular to the floor for the entire movement. The tissue that
will be stretched is with the leg that is kneeling. In order to stretch the
hip flexors, move the front knee forward, thus increasing knee flexion from
45 degrees to 90 degrees. It is important to keep the rear knee in the same
position as this is being done. This movement addresses the psoas. Next, by
moving the forward foot medially (it should now be in line with the midline
of the body) the isolated tissue now shifts to the illiacus. Another medial
shift of the front foot (in line with the other leg) moves the focus to the
sartorius. The reader may infer that this is nothing more than an eccentric
stretch of these muscles. This is partly true. What will differentiate these
moves into an active stretch is that for all of these positions the patient
is instructed to contract the gluteal muscles.
The final four moves are for the anterior thigh. Position the patient in the
side lying posture. The bottom knee is drawn up to the chest and the foot is
positioned out of the way. The tissue to be stretched is on the extremity that
is positioned up. Have the patient straighten the lower limb neither flexing
the hip nor extending the hip. The foot of this leg is raised so that this limb
is parallel with the table. The doctor stabilizes the hip joint and assists
the patient with full flexion of the knee. This stretches the distal middle
quadriceps muscle. By lowering the foot of the straight leg to the table and
repeating knee flexion, the focus moves to the distal lateral fiber of the vastus
lateralis. The next position is for the patient to draw this knee toward the
chest, maintain knee flexion, and with maintained knee flexion extend the hip.
This addresses the proximal fibers of the middle quad. Finally, repeat this
motion with the knee directed toward the table. This affects the lateral proximal
fibers of the quadriceps.
Aaron L. Mattes maintains a practice in Sarasota, Fla. He conducts numerous
seminars around the country on the Mattes Method of AIS. He has taken care of
countless people around the world including heads of state, captains of industry
and professional athletes. Aaron’s website is stretchingusa.com
Dr. Sal Minicozzi is currently on the post-graduate faculty of Life University.
His practice is located in Atlanta, Ga. His patients include a who’s who
of professional athletes as well as people of all ages and abilities. Sal’s
website is pro-stretch.com.
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