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ORIGINAL ARTICLE
Does stretching increase ankle dorsiflexion range of
motion? A systematic review
J A Radford, J Burns, R Buchbinder, K B Landorf, C Cook
...............................................................................................................................
See end of article for
authors’ affiliations
.......................
Correspondence to:
J A Radford,
Campbelltown Campus,
Building 24, School of
Biomedical and Health
Sciences, University of
Western Sydney, Locked
Bag 1797, Penrith South
DC, NSW, 1797,
Australia; j.radford@uws.
edu.au
Accepted 9 August 2006
Published Online First
22 August 2006
.......................
Br J Sports Med 2006;40:870–875. doi: 10.1136/bjsm.2006.029348
Background: Many lower limb disorders are related to calf muscle tightness and reduced dorsiflexion of
the ankle. To treat such disorders, stretches of the calf muscles are commonly prescribed to increase
available dorsiflexion of the ankle joint.
Hypothesis: To determine the effect of static calf muscle stretching on ankle joint dorsiflexion range of
motion.
Study design: A systematic review with meta-analyses.
Methods: A systematic review of randomised trials examining static calf muscle stretches compared with
no stretching. Trials were identified by searching Cinahl, Embase, Medline, SportDiscus, and Central and
by recursive checking of bibliographies. Data were extracted from trial publications, and meta-analyses
performed that calculated a weighted mean difference (WMD) for the continuous outcome of ankle
dorsiflexion. Sensitivity analyses excluded poorer quality trials. Statistical heterogeneity was assessed
using the quantity I
2
.
Results: Five trials met inclusion criteria and reported sufficient data on ankle dorsiflexion to be included in
the meta-analyses. The meta-analyses showed that calf muscle stretching increases ankle dorsiflexion after
stretching for (15 minutes (WMD 2.07
˚
; 95% confidence interval 0.86 to 3.27), .15–30 minutes (WMD
3.03
˚
; 95% confidence interval 0.31 to 5.75), and .30 minutes (WMD 2.49
˚
; 95% confidence interval
0.16 to 4.82). There was a very low to moderate statistical heterogeneity between trials. The meta-analysis
results for (15 minutes and .15–30 minutes of stretching were considered robust when compared with
sensitivity analyses that excluded lower quality trials.
Conclusions: Calf muscle stretching provides a small and statistically significant increase in ankle
dorsiflexion. However, it is unclear whether the change is clinically important.
C
alf muscle tightness and reduced range of ankle joint
dorsiflexion are related to a number of lower limb
disorders, including Achilles tendinitis
1
and plantar
fasciitis.
2
As a result, calf muscle stretches are commonly
prescribed in an attempt to increase ankle dorsiflexion and
reduce the symptoms of such disorders. A number of
randomised trials have evaluated calf muscle stretching for
foot disorders such as plantar fasciitis
34
with favourable
outcomes found for pain. The role of stretching in injury
prevention has also been examined in systematic reviews, but
no significant benefit has been reported.
56
Further good
quality research—that is, randomised trials and systematic
reviews—is still required to determine whether calf muscle
stretching is effective for a large number of lower limb
disorders.
To our knowledge, a systematic review of the effect of calf
muscle stretching on ankle dorsiflexion has not been
performed. We therefore conducted a systematic review of
the literature to determine whether static calf muscle
stretching increases ankle dorsiflexion.
METHODS
Inclusion and exclusion criteria
Only randomised or quasi-randomised controlled trials that
compared the effect of static calf muscle stretching with no
stretching were included. Static stretching was chosen
because of its common use, particularly in home pro-
grammes, as opposed to stretching techniques such as
proprioceptive neuromuscular facilitation stretching. Trials
that used the other leg as a control were excluded, as such
methodology may lead to invalid findings because of
confounding in either the intervention or measurement.
Owing to the possible lasting effect of stretching—that is,
muscle length altered for an uncertain period of time after
stretching—crossover trials were also excluded. Trials that
examined participants with any neurological disease that
may cause spasticity of the muscle—for example, cerebral
palsy—were also excluded. Stretching technique could
include weight-bearing or non-weight-bearing stretches with
the knee flexed or extended. Trials evaluating devices to
assist the mechanical stretch—for example, splints or pulleys
with weights—were included, but devices designed to assist
the muscle’s physiological ability to stretch—for example,
ultrasound and heat packs—were excluded as we are not
aware of their common use in home programmes. Any
outcome measure—for example, goniometers, electronic
inclinometers—used to evaluate ankle joint range of motion
in both weight-bearing and non-weight-bearing conditions
were considered. Measurements taken during walking or
running were also to be included.
Search strategy
The Cochrane Central Register of Controlled Trials (3rd
Quarter 2005), Medline (1966 to August 2005), Cinahl (1982
to August 2005), SportDiscus (1830 to July 2005), and
Embase (1988 to 2005 week 36) electronic databases were
searched via Ovid to identify relevant trials. Non-English
reports were included, and all reference lists of trials
identified through electronic searching were searched recur-
sively until no more trials were identified. One reviewer (JR)
conducted all the searches, and two reviewers (JR and JB)
assessed trials for eligibility. There was total agreement
between reviewers.
870
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The search strategy used for all databases was:
1. stretch$.tw
2. (ankle or gastrocnemius or soleus or soleal or (triceps
and surae) or Achilles or (calf adj muscle$)).tw
3. (motion or range or dorsiflexion or plantarflexion or
flexibility or extensibility or stiffness).tw
4. and/1–3
5. limit 4 to human
Assessment of study quality
Two reviewers (JR and JB) independently used the PEDro
scale to determine the quality of the trials.
7
The PEDro scale is
an 11 item scale designed for rating methodological quality of
randomised controlled trials. Each satisfied item (except item
1) contributes one point to the total PEDro score (range 0–10
points). The scale items are:
1. Eligibility criteria were specified.
2. Subjects were randomly allocated to groups (in a
crossover study, subjects were randomly allocated an
order in which treatments were received).
3. Allocation was concealed.
4. The groups were similar at baseline regarding the most
important prognostic indicators.
5. There was blinding of all subjects.
6. There was blinding of all therapists who administered
the treatment.
7. There was blinding of all assessors who measured at
least one key outcome.
8. Measurements of at least one key outcome were
obtained from more than 85% of the subjects initially
allocated to groups.
9. All subjects for whom outcome measurements were
available received the treatment or control condition as
allocated, or where this was not the case, data for at
least one key outcome were analysed by ‘‘intention to
treat’’.
10. The results of between-group statistical comparisons are
reported for at least one key outcome.
11. The study provides both point measurements and
measurements of variability for at least one key
outcome.
The inter-rater reliability of the total PEDro score (obtained
by summing ‘‘yes’’ responses to items 2–11) was evaluated
using type 2,1 intraclass correlation coefficients (ICCs).
8
Data extraction
Two reviewers (JR and JB) independently extracted data
(study population, intervention, outcomes) from the trials
using standardised extraction forms. We intended to contact
authors for further information if required, but this was not
necessary. To assess effectiveness, we extracted raw data for
outcomes of interest, means and standard deviations, from
published reports.
Data analysis
The result of each randomised trial was plotted as a point
estimate—that is, mean and 95% confidence interval. To
obtain a pooled estimate of the impact of calf muscle
stretching on ankle dorsiflexion, we planned meta-analyses
when the data were available. If possible, weighted mean
differences (WMDs) were calculated for the continuous
outcome of ankle dorsiflexion using Review Manager 4.2.7
(2004).
9
Results were considered significant if p,0.05. Three
meta-analyses were planned on the basis of the duration of
stretching interventions provided in each trial. For reasons
relating to generalisability, we thought it appropriate to
conduct three meta-analyses for trials providing data for
similar stretching time periods: (15 minutes; .15–30 min-
utes; .30 minutes. Bohannon et al
10
provided data for five
minutes of stretching, Knight et al
11
for 8 and 24 minutes,
Peres et al
12
for 10, 20, and 60 minutes, Pratt and
Bohannon
13
for nine minutes, and Youdas et al
14
for 15, 30,
and 60 minutes of stretching (see fig 2).
Trials were assessed for clinical heterogeneity with respect
to their inclusion and exclusion criteria—for example, age,
healthy participants, duration of stretching—and meta-
analyses performed when they were found to be clinically
homogeneous and the data readily available. The statistical
heterogeneity (whether there are genuine differences under-
lying the results of the trials in the review) and homogeneity
(whether the variation in findings is compatible with chance
alone) of the results of the trials were measured using the
quantity I
2
.
15
The I
2
value is calculated as I
2
= 100%(Q – df)/
Q, where Q is Cochran’s heterogeneity statistic and df the
degrees of freedom (where n is the number of trials and
therefore degrees of freedom equals number of studies minus
one). The Cochran’s Q is computed by summing the squared
deviations of each trial’s estimate from the overall meta-
analytical estimate, and a p value obtained by comparing the
statistic with a x
2
distribution with k–1 degrees of freedom
(where k is the number of trials). The p value was formerly
used to determine statistical heterogeneity (p,0.10).
However, Higgins et al
15
replaced it with the quantity I
2
as
the p value was known to be poor at detecting true
heterogeneity among studies as significant. Trials in the
meta-analyses were considered to have low statistical
heterogeneity if I
2
,25%; in such instances a fixed effects
model was used to estimate the pooled effect. A random
effects model was used for all trials with I
2
.25%. A fixed
effect meta-analysis assumes that the true effect of treatment
(in both magnitude and direction) is the same value in every
trial—that is, fixed across studies. In contrast, a random
effects meta-analysis model assumes that the effects being
Figure 1 Progress through the stages of the review for the randomised
trials. RCT, Randomised controlled trial.
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estimated in the different studies are not identical, but follow
a similar distribution.
16
There are different approaches to conducting a systematic
review, and a sensitivity analysis is required to test how
robust the results of the review are relative to key decisions
and assumptions that are made in the process of conducting
the review.
16
A sensitivity analysis changes the method of the
review for a secondary analysis to determine whether key
decisions or assumptions may conceivably have affected the
results for a particular review. If the effect and confidence
intervals in the sensitivity analysis lead to the same
conclusion as the primary meta-analysis value, the results
are deemed robust. We considered it highly important to
blind the outcome assessor in the trials included in the
review, as some methods of measuring ankle range of motion
are open to assessor bias. Therefore sensitivity analyses of
meta-analyses were conducted that only included trials that
blinded their outcome assessors.
RESULTS
Search results
Eighteen papers were identified through electronic searching
(fig 1). Five trials met the inclusion criteria for the review
with 161 participants (table 1).
10–14
Three trials were
identified for inclusion in the sensitivity analyses with 118
participants.
10 11 14
No trials included participants with lower
limb injuries. Ankle dorsiflexion was measured both
actively
10 11 13 14
and passively,
10–12
weight-bearing
13
and non-
weight-bearing,
10–12 14
and with the knee extended
10 12–14
and
flexed.
11
We found excellent reliability for measurement in
four trials,
10–12 14
and one trial
13
referenced another study for
excellent reliability of their measurement technique.
Duration between stretching and measurement was immedi-
ate in all trials, except for that of Youdas et al
14
where
participants were measured 60–72 hours after stretching.
Four of the trials ensured 100% compliance by supervising
the stretches.
10–13
Youdas et al
14
used log books instead to
Table 1 Description of studies included in systematic review of calf muscle stretching intervention
Trial Participants Intervention Outcome measurement
Bohannon
et al 1994
10
36 women volunteers with mean (SD) age
22.6 (4.2) years. Inclusion: no history of
orthopaedic or neurological problems
affecting lower limb.
Weight-bearing static stretch for
5 min
Non-weight-bearing active and passive ankle
dorsiflexion with knee extended. Measured by
taking digital photographs, marking lines on the
photographs, and then using a protractor for
calculation of angles. Active ankle dorsiflexion
ICC = 0.93. Duration between stretching and
measurement was 1 min.
Knight et al
2001
11
97 volunteers (59 women and 38 men)
with mean (SD) age 27.6 (7.7) for women
and 26.8 (6.9) for men. Inclusion: active
ankle dorsiflexion less than 20
˚
. Exclusion:
pregnancy; impaired sensation; bleeding
disorders; previous neuromuscular disorders;
hip, knee or ankle pathologies in past
2 years; lower extremity malignancies.
Weight-bearing static stretch for 20 s
with 10 s rest between stretches,
repeated 4 times. Performed 3 times
a week for 6 weeks.
Non-weight-bearing active and passive ankle
dorsiflexion with knee flexed. Measured using a
goniometer. Active ankle dorsiflexion
ICC = 0.91. Duration between stretching and
measurement was minimal as stretching
supervised by researchers and measurements
taken after stretching.
Peres et al
2002
12
60 volunteers (23 women and 21 men)
with mean (SD) age 22.5 (2.0) years.
Exclusion: involved in any flexibility or
strength training for the calf; recent ankle
injury or history of ankle injury; metal
plates or screws in right leg; pregnancy;
any allergies to cold.
Non-weight-bearing static stretch
assisted by weight (one third of
participant’s body weight) via a
pulley for 10 min daily for 14 days
over 3 weeks.
Non-weight-bearing passive ankle dorsiflexion
using weight and pulley to apply force with knee
extended. Measured using a digital inclinometer.
Ankle dorsiflexion ICC = 0.99. Duration between
stretching and measurement was ,30s.
Pratt &
Bohannon
2003
13
24 volunteers (12 women and 12 men)
with mean (SD) age 24.7 (4.5) years.
Inclusion: free of injury; not currently
stretching.
Weight-bearing stretch by lowering
heels from a platform for 3 min for
3 days.
Weight-bearing active ankle dorsiflexion with
force from participant lowering their heels down
from a platform while keeping metatarsals on
platform with knees extended. Measured by
taking digital photographs of lines marked on
the foot and using a protractor for calculation of
angles. We referenced another trial for
reliability, with ICC = 0.92 reported. Duration
between stretching and measurement was
immediate as photographs taken during
stretching.
Youdas et al
2003
14
101 volunteers (63 women and 38 men)
with mean (SD) age 40.0 (10.9) years.
Exclusion: block at the talocrural joint that
would limit ankle motion; limitation of
subtalar joint mobility; previous history of
trauma to the calf that required surgery;
evidence of lower extremity dysfunction
assessed by visual observation of gait.
(1) Weight-bearing static stretch for
30 s daily, 5 days a week for 6 weeks.
(2) Weight-bearing static stretch for
1 min daily, 5 days a week for 6 weeks.
(3) Weight-bearing static stretch for
2 min daily, 5 days a week for 6 weeks.
Non-weight-bearing active ankle dorsiflexion
with knee extended. Measured using a
goniometer. Ankle dorsiflexion ICC = 0.95.
Duration between stretching and measurement
was 60–72 hours.
ICC, Intraclass correlation coefficient.
Table 2 Trial quality assessed by the PEDro scale
Trial 1 234567891011Total
Bohannon et al 1994
10
2 + 2 + 22++2 ++6/10
Knight et al 2001
11
2 + 2 + 22++2 ++6/10
Peres et al 2002
12
2 + 2222222++3/10
Pratt & Bohannon 2003
13
2 + 22222+ 2 ++4/10
Youdas et al 2003
14
++2 + 22++2 ++6/10
Note: Column numbers correspond to the PEDro scale criteria.
872 Radford, Burns, Buchbinder, et al
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assess compliance, and all participants showed 95% or greater
compliance to the stretching programme.
14
Table 1 presents
the stretching techniques used by included trials. Only one
trial included multiple groups with varying intensity of the
stretches.
14
Two of the five trials also compared the simple static
stretching with other stretching programmes: stretching with
active heel raises
11
; stretching with superficial moist heat to
the calf muscle
11
; stretching with continuous ultrasound
11
;
stretching with pulsed diathermy
12
; stretching with pulsed
diathermy and ice.
12
However, in accordance with our pre-
specified aims, these data were not included in the review. All
results presented in this review are the effect of stretching
alone compared with no stretching.
The range of PEDro quality scores assessing methodologi-
cal quality of the included trials was 3–6 (median 6) out of 10
(table 2). The ICC
2,1
for the reviewer’s reliability was 0.84
(95% confidence interval 20.01 to 0.98).
More trials provided active measurements of ankle dorsi-
flexion than passive measurements, so the active measure-
ments from trials that provided both passive and active data
were pooled. Only one passive ankle dorsiflexion measure-
ment was pooled.
12
The meta-analyses (fig 2) found that static stretching
increases ankle dorsiflexion compared with no stretching
after (15 minutes (WMD 2.07
˚
; 95% confidence interval
0.86 to 3.27; p = 0.0008), .15–30 minutes (WMD 3.03
˚
;
95% confidence interval 0.31 to 5.75; p = 0.03), and
Figure 2 Meta-analyses of the effect of stretching on ankle dorsiflexion.
Figure 3 Sensitivity analyses excluding trials that did not blind outcome assessors.
Stretching and ankle dorsiflexion range of motion 873
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.30 minutes of stretching (WMD 2.49
˚
; 95% confidence
interval 0.16 to 4.82; p = 0.04). The sensitivity analyses of
trials that blinded the assessor of ankle dorsiflexion to group
allocation (fig 3) also found a similar increase in ankle
dorsiflexion with stretching compared with no stretching
after (15 minutes (WMD 1.86
˚
; 95% confidence interval
0.59 to 3.12; p = 0.004) and .15–30 minutes (WMD 2.00
˚
;
95% confidence interval 0.09 to 3.92; p = 0.04). This
indicates that the results for these meta-analyses are robust.
The sensitivity analysis of stretching for .30 minutes found
no significant difference (WMD 2.10
˚
; 95% confidence
interval 20.61 to 4.81; p = 0.13), which does not support
the statistically significant result of the meta-analysis. The
statistical heterogeneity between trials for the meta-analyses
and sensitivity analyses was very low (I
2
= 0%), except for
the meta-analysis of .30 minutes of stretching, which
showed moderate statistical heterogeneity (I
2
= 51.4%). I
2
values of 25%, 50%, and 75% represent low, moderate, and
high statistical heterogeneity respectively.
DISCUSSION
This review found five randomised trials (n = 161) that
examined whether static stretching increased ankle dorsi-
flexion flexibility of the calf musculature. Although the
search strategy allowed the inclusion of trials examining both
normal subjects and people with disorders—for example,
plantar fasciitis—the results of the review are only gener-
alisable to normal subjects, as no trials were found that
included people with disorders. Pooled data from included
trials showed an increase of 2.1–3.0
˚
after 5–60 minutes of
stretching when compared with no stretching. The statistical
heterogeneity was generally very low, indicating that there
are no underlying differences in the trials—that is, all trials
examined the same effect. The results of the sensitivity
analyses were also generally similar to the meta-analyses,
providing confidence that the results of the meta-analyses are
robust. The only result that was not supported by the
sensitivity analyses was the one for .30 minutes of stretch-
ing. As only one trial was included in the sensitivity analysis
of this intervention, it may be that the sensitivity analysis
sample was underpowered (n = 45) to detect the effect that
the primary analysis detected with greater sample power (n
= 64).
There was a general trend that the longer the stretch, the
greater the increase in ankle dorsiflexion: (15 minutes of
stretching resulted in a 2.07
˚
increase (95% confidence
interval 0.86 to 3.27), whereas .15–30 minutes of stretching
resulted in a 3.03
˚
increase (95% confidence interval 0.31 to
5.75). Stretching for .30 minutes resulted in a 2.49
˚
increase
(95% confidence interval 0.16 to 4.82), which was still
superior to (15 minutes of stretching, although provided
less of a gain than .15–30 minutes of stretching. Overall it
should be noted that the differences between stretching
durations are small (clinically non-significant), and the
results of this systematic review indicate that stretching for
a short duration produces a similar result to that of a longer
duration. This may be due to the lack of a dose-response
relation or differences in the interventions of the individual
trials. Further randomised trials are needed to resolve this.
The PEDro scores of the trials included in the review are
relatively high (median 6) considering that blinding of
participants and therapists is impossible. The PEDro scale
was therefore a useful tool for assessing the quality of the
trials except for the two items requiring blinding of
participants and therapists, which are inherently difficult
for such interventions. Future trial quality could be improved
by ensuring that treatment allocation concealment and
intention to treat analyses are performed and reported in
accordance with the CONSORT statement.
17
Although our review shows that static calf muscle
stretching provides a small and statistically significant
increase in ankle dorsiflexion, we do not know whether the
result is of clinical importance from the patient’s perspective
or whether it may prevent further injury. Symptomatic pain
improvement seen in a trial of stretching for plantar fasciitis
may be explained by an increase in dorsiflexion
18
; and in a
recently completed placebo controlled trial of adhesive
capsulitis, manual techniques and a directed exercise
programme after arthrographic glenohumeral joint disten-
sion resulted in improved shoulder range of motion
accompanied by greater participant perceived success.
19
These findings suggest that improvement in range of motion
may be of clinical importance. Future trials evaluating the
effectiveness of static stretching should include patient
centred outcome measures such as pain, function, and
perceived success so that this can be explored further.
CONCLUSION
Calf muscle stretches provide a small but statistically
significant increase in ankle dorsiflexion, particularly after
5–30 minutes of stretching. However, it is unclear whether
the change that occurs with stretching is clinically important.
Therefore calf muscle stretching is recommended where a
small increase in ankle range of motion is thought to be
beneficial.
Authors’ affiliations
.....................
J A Radford, C Cook, School of Biomedical and Health Sciences,
University of Western Sydney, Campbelltown, Australia
J Burns, Institute for Neuromuscular Research, Discipline of Paediatrics
and Child Health Faculty of Medicine, The University of Sydney, Sydney,
Australia
R Buchbinder, Monash Department of Clinical Epidemiology at Cabrini
Hospital and Monash University, Malvern, Australia
K B Landorf, Department of Podiatry, School of Human Biosciences, La
Trobe University, Bundoora, Australia
Competing interests: none declared
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What is already known on this topic
N
Calf muscle tightness and reduced range of ankle joint
dorsiflexion are associated with a number of lower
limb disorders such as plantar fasciitis and Achilles
tendonitis
N
Calf muscle stretches are commonly prescribed to
increase ankle dorsiflexion and reduce the symptoms
of such disorders
What this study adds
N
Calf muscle stretches provide a small but statistically
significant increase in ankle dorsiflexion, particularly
after 5–30 minutes of stretching
N
It is unclear whether the change that occurs with calf
muscle stretching is clinically important
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..............
COMMENTARY
..............
This article will be of interest to clinicians, sports physicians,
and those interested in rehabilitation and injury prevention.
The meta-analysis showed only relatively small increases in
ankle joint dorsiflexion during the different time periods.
From a clinical perspective, only small significant changes
suggest that static stretching for only 5–15 minutes is
equivalent to stretching for 60 minutes. However, there is
no indication from this review about repetitive or bouts of
stretching. As the authors stated, the interpretation of an
increase of 2
˚
needs further exploration. From a research
point of view, a significant increase in ankle joint dorsiflexion
from the systematic review does suggest the use of stretching
in overuse lower limb conditions.
K Rome
University of Teesside, UK; k.rome@tees.ac.uk
Website of the month
www.physics.usyd.edu.au/,cross
This is an excellent website on the physics of ball sports, and is primarily aimed at
secondary school physics students.
Stretching and ankle dorsiflexion range of motion 875
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