This week let us consider the piriformis stretch. The piriformis muscle is a small deep muscle which lies in the gluteal region. It originates from the front or anterior portion of the sacrum, the sacro-iliac joint (SI jt.) capsule and the sacro-tuberous ligament and inserts onto the greater trochanter of femur. It functions as a lateral rotator of the hip, flexes and abducts hip and with the hip flexed 60°-90°, it works as a hip medial rotator and extensor and continues to abduct hip. In other words, the position of the hip is important in determining the function of this muscle. Also, the stretch position therefore varies with hip position and appears paradoxical. However, both positions (whether in hip flexion or in neutral hip position) are successful in stretching the muscle. Once you realize this, it enables the hip to open freely and both movements benefit from any one stretching technique, since the underlying muscle we are stretching is the same. This in some way brings shavasana to mind, the goal of the asana being relaxation. One technique used to relax the body is by initially tightening it to utmost, and then to “let go,” (here you are using muscle tightening to experience relaxation). The relaxation achieved by this method is tremendous and experienced in the given moment of “letting go.” With practice, you eventually learn to let go without the need of initial tightening. Enough said, lets delve into the stretches, considering the right side stretch for ease of understanding.
Passive stretch: 
i) In the supine position, the therapist flexes (less than 60° hip flexion), adducts and internally rotates, the right hip, with the back in neutral and pelvis level on the mat. One hand is placed on the outer side of the right knee and other on the right ASIS or iliac crest. 
ii) In supine with the left leg in neutral, the therapist flexes the right hip greater than 60°, abducts and externally rotates the right hip, then slowly moves the right lower leg towards the left shoulder to deepen the stretch as the sacrum and greater trochanter of femur move away from each other.
Active Static Stretch:
i) The reverse pigeon pose stretch or popularly known as figure of 4 stretch: In supine position, bend both the hips (greater than 60°) and knees so that feet rest on the mat. Lift the right foot off the mat to bring knee to chest and simultaneously turn the hip outward so that the right ankle rests on the left thigh (just above the left knee). Now with both the hands, grasp the left thigh and gently bring it toward your chest by lifting the left foot off the mat. When you do this, it is natural for the tailbone and sacrum to lift off the mat as well. Bring the sacrum and tailbone down to the mat, (thus bringing the lumbar spine from flexion to neutral), to deepen the stretch. This way, the sacrum is held stable, while you move the femur to bring about the stretch.
Active Dynamic Stretch: 
i) The pigeon pose or kapotasana: You begin from the plank pose and bring the right foot onto the floor in front of the left hip joint. Bring your foot and toes up while sticking out the ball of right foot and push the outside of foot onto the mat. Bring the right knee to the floor. The hip may be abducted so that the knee is slightly lateral to the hip and slowly scoot the left leg back and rest the top of foot onto the mat, ensuring the left hip is in line with the left foot at all times and the body weight is centered. The forearms here will rest on the mat as you continue slowly scooting the left foot back and elongating the body. When you feel a stretch in the right buttock area, stay there for a while. Deepen the stretch when possible by lowering the trunk to the floor and outstretching the arms in front during exhalation.
Stretch with equipment or tools:
i) Foam roller stretch: Place the foam roller on the mat and sit on it. Bend both the knees with feet flat in front on the mat. Bring both palms on mat, behind the roller and shift your weight onto the arms. Lift the right foot off the mat and bring it onto the left thigh, right ankle resting just below the left knee. Make a quarter turn to the right side and gently roll the foam roller under the right buttock. You can release different segments of the muscle by rolling further onto right side in small increments and also vary the release by turning the foam roller along the right thigh. Base the body weight you put onto foam roller by the intensity of release experienced.

The list of muscles that flex the hip is long. Some of these muscles are single joint while some are 2-joint muscles flexing the hip and extending or flexing the knee.
The main hip flexors are the Iliacus and Psoas, collectively known as the Iliopsoas. Iliacus originates from the iliac fossa and AIIS (Anterior Inferior Iliac Spine). The iliacus originates from the transverse processes of lumbar and last thoracic vertebra. Both these combine to form a common tendon of insertion on the lesser trochanter of femur. 
There are several muscles that cross both the hip and knee like the Sartorius, Rectus Femoris, Tensor Fascia Lata via the IT band. The Pectineus, Adductor Longus and Adductor Brevis are single joint muscles in the medial compartment of the thigh which also serve as secondary hip flexors (primary function of these muscles is adduction) with the thigh turned outwards. The Gracilis also in medial compartment is a two-joint muscle flexing both the hip and the knee.
For purpose of stretch, we will focus on the main hip flexors- the iliacus and psoas. Since the Sartorius and Rectus Femoris are also in the anterior thigh compartment, they are stretched to some extent also. 
The various ways to stretch the hip flexors are:
Passive stretch:
In supine lying position on the mat, both legs are extended in neutral position. The physical therapist then flexes the left hip/knee completely to bring the knee to the stomach/chest, while the right leg is held straight with the back of thigh, knee, and leg resting on the mat (the right leg should not be allowed to bend/flex at hip and knee). Another thing to watch out for is an increased lumbar lordosis, which also indicates tight hip flexors. The key to stretch here is a posterior pelvic tilt with flattening of lumbar spine, thus pulling the proximal psoas, iliacus, Sartorius and rectus femoris fibers away from its distal insertion on femur or tibia, thus stretching it over the hip joint.
Active Static Stretch:
i) In supine lying on edge of the mat with the legs dangling over the edge at the knee joints. Place a chair at end of mat with feet supported on chair to maintain neutral spine posture, then engage the abdominals to tilt the pelvis posteriorly as the left hip/knee is held in complete knee-to-stomach/chest position by circling the arms around the left knee. The left hip/knee flexion ensures posterior pelvic tilt. Next, push the chair away from under the right foot and dangle the leg off the edge of mat, flexing the knee if possible. This stretches the iliacus, psoas and the rectus femoris and to some extent the Sartorius muscle. 
ii) To stretch Sartorius, prone lying is best position. Here you have to watch for the lumbar spine, since when hip flexors are tight, they tend to pull the pelvis into anterior tilt/rotation and hence cause the lumbar spine lordosis to increase. So always be mindful of the lumbar spine position and keep the transverse abdominus engaged. Next, flex the right knee and turn the thigh to point inwards or drop the ankle out (hip medial rotation) and also slide the thigh inwards to the midline (hip adduction). Now slowly drop the foot to mat by extending the right knee. Hold if stretch is felt, if not, lift thigh off the mat by extending the hip. You may place a pillow under the knee to hold hip in extension and then slowly extend the knee. Watch for the lumbar spine though, ensuring extension at hip (10°-15° only) and not increased lordosis at the lumbar spine. There are lots of elements in this stretch to get it correctly.
Active Dynamic Stretch:
There are several yoga asanas that stretch the hip flexors. These asanas entail nuances in muscle control and to be done correctly should be done in presence of trained instructor and practiced solo after learning them initially. Since they involve back extension which narrows the foraminal space, they are contraindicated in certain conditions like back ache and neck pain and digestive disorders.
i) The Anjaneya asana: You basically start in half-kneeling position with the left foot on the floor in front and the right leg resting on the knee and ball of foot, behind. Slide the right knee back as far as possible and lunge forward on the left foot by shifting the body weight forward and arching the lumbar spine forward with arms outstretched overhead to keep spine elongated. This stretches the front of the right hip, thigh, and anterior spine to effectively stretch the psoas and iliacus. When the right knee is flexed, and resting on the ground, it stretches the rectus femoris, and when the right knee is extended lifting it off the ground in lunge position, it stretches the Sartorius at the knee joint as well. Hold pose for 2-3 breath cycles and release by first bringing right knee to floor, engaging abdominals to bring spine to neutral and then shifting body weight to come out of lunge position.
ii) Dhanurasana or the bow pose: This is done in prone position, lying on the stomach with arms by the side of trunk, palms facing upwards. Bend both the knees bringing the feet to buttocks and hold the feet around the ankles with your hands. As you inhale, lift the heels away from butttocks and lift the thigh off the floor as the torso lifts up. Ensure both knees are no more than hip width apart. Hold for 2-3 breath cycles and release by first lowering the thighs and torso while bending the knees. Lastly release the hand-hold around the ankles and extend knees.
iii) Ustrasana or camel pose: This asana is intermediate to advanced level and should be done in presence of trained instructor. Begin in kneeling position on the mat with knees hip width apart and dorsum of foot resting on the floor. Place both the hands around the waist, thumb in front and fingers around the back. Gently tilt pelvis back by engaging the abdominals and elongate the lumbar spine. Inhale and lift the sternum (breast bone) upwards. Bring the knee and elbow joints closer together by internally rotating hips and externally rotating shoulders. Stay here for 2-3 breath cycles and slowly slide hands down the back, by extending elbow joints, to the heels of feet. Open the shoulders without squeezing the shoulder blades (releasing the pectorals) and extend the neck by eccentric contraction of neck flexors for slow controlled movement.
Stretches with tools and equipment:
i) Standing hip flexor stretch with rolling stool or chair: Stand facing a wall with hands stretched forward and palms resting on the wall for support. The rolling stool or chair should be pre-adjusted to knee height. Bend the right knee by lifting foot back and up from the floor till knee is flexed at 90 degrees. Rest the knee on the seat of the stool/chair (chair should be forward facing to allow leg to be supported on chair). Left foot is on the floor and both hands are on wall forming a three-point support base. Engage the abdominals to ensure lumbar spine remains in neutral throughout stretch. Slowly roll the stool/chair back with the right leg by extending the hip joint (not lumbar spine- you are doing this if lumbar arch or lordosis increases). Hip joint has about 10-15 degrees of extension range, so move back slowly to avoid lumbar extension. Hold position for as long as you can, for 5-30 seconds, once you feel stretch in groin area. Release and repeat 2-3 times with 15-30 second rest breaks in between stretches. 
ii) Half-kneeling with Airex-pad: Begin in half-kneeling position with left foot on floor and right knee on the Airex-pad for cushioning under knee/shin. Engage abdominals to keep neutral pelvis and lumbar spine. Lunge forward on left leg by flexing hip and knee as the right knee stays put on the airex pad slowly and passively bringing extension at right hip joint, thus stretching the single joint hip flexors. Hold position as long as possible from 5-30 seconds, release, and repeat 2-3 times with 15-30 second rest break in between stretches.

This week I give due consideration to the Tensor Fascia Lata also known as the TFL and the Iliotibial or IT band stretch. The TFL/IT band is frequently found to be tight in people that walk, run, or ride bicycles, with discomfort/pain in the knee or hip area.
• The TFL is a muscle and it originates proximally from the anterior and outer portions of the iliac crest, the ASIS, and the notch below the ASIS. 
• The IT band is a fascial connective tissue which is composed histologically of both elastin (elastic connective tissue) and collagen (strong fibrous connective tissue). Fascial tissue surrounds muscles, tendons, and organs, and provides a support structure for the body.
• The IT band arises from the iliac crest and receives contributions as a thickening from the Gluteus Maximus and TFL muscles, then runs along the outer length of the thigh, and inserts into the lateral epicondyle of tibia and sends some fibers to the retinaculum of the patella.
• Along the way from its origin on the iliac crest, the IT band runs over the greater trochanter of the femur and the lateral femoral epicondyle, just above the knee joint. To lubricate areas where the fibrous tissue runs over bony prominences, bursa (fluid filled sacs), intervene between the bone and connective tissue. These are important, since it is the taut (tight) IT band rubbing against these bony prominences that causes what are popularly known as the IT band syndrome(pain near the outer side of knee joint/lower leg) and the Trochanteric bursitis (pain on outer side of the hip joint/ greater trochanter of femur), respectively. The bursa due to repeated friction get inflamed or it may be the inflammation and/ or strain of the connective tissue fibers itself. 
Since the IT band receives contribution from the TFL and Gluteus maximus, stretching these muscles will impact the IT band as well. The IT band is difficult to stretch actively and needs a lot attention to positioning and muscular engagement. It is ideally best impacted through soft tissue work like myofascial release of IT band and TFL and stretched best through passive stretch. That being said, let’s delve into the stretch: 
Passive Stretch: 
This is done in supine position with both legs straight on mat in neutral position. The therapist stabilizes the right pelvis at ASIS and flexes the right hip to clear the left leg, as the right leg is moved into hip adduction with the knee supported in extended position. The stretch is held for 5-30 seconds and then released for 15-30 seconds of rest before next repetition. 
Active Static stretch: 
i) In the supine position on a high mat or bed, scoot the legs out the side of the mat till the knee bends to 90 degrees and allow both the lower legs to dangle off the edge. Place a chair at the edge of the mat /bed initially, so you can rest your feet prior to the stretch (so that you do not arch the back due to weak abdominals or tight hip flexors). Bring the left foot onto the mat by bending the hip and knee. Allow the right leg to dangle off the mat by pushing the chair away from under the right foot. Bring the right hip into slight adduction and engage the abdominals to keep the spine neutral (if the lumbar spine arches, it indicates a tight TFL/hip flexors. Next raise the right foot up and in at the ankle joint/ foot, to engage the tibialis anterior muscle. This completes the stretch. Hold for 5-30 seconds maintaining the position. Rest for 15-30 seconds between the stretches.
Active Dynamic Stretch:
i) Half-kneeling: To stretch the right TFL/IT band, bring the right knee to the floor on a cushion with the shin resting on the floor and foot outstretched behind. The left foot rests on floor in front of the right knee. You may do this near a wall or support you can lean on. Make sure you start with hip over right knee and neutral, upright spine. Push the right hip outwards leaning onto wall/support. To deepen the stretch, shift body weight forward over the left leg bringing the right hip into extension, stretching the TFL further.
Stretch With Tools or Equipment:
i) Stretching with strap or gait belt: In supine lying position with legs extended and supported on mat/bed, loop a strap or gait belt around the right foot arches. Keeping the knee straight, raise the leg up from mat by flexing the hip joint and cross the leg to the left side across the midline of the body. Hold the other end of the strap in your hand and pull taut for support. The pelvis should be flat on the mat (with both sit bones in contact with mat), and not roll along with the right leg by lifting off the mat.
ii) Stretching with the foam roller: With the foam roller across the mat, lie on it along the outer side of the right thigh. Gently roll along the length of the outer thigh from the iliac crest (bony ridge forming the top of the pelvis at your waist) to the outside of the knee joint, while the left foot and hands assist in the rolling motion. You may feel the tightness in certain localized areas and may want to focus rolling over the tight spot. As you approach the hip, roll slightly over to roll over the TFL fibers which are anterior-lateral (front- outer side) on the iliac crest.
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We went through the Hamstrings stretch last week. Can Quadriceps stretch be far away?
All right, here it is. 
• The quadriceps muscle is the major bulk of muscle you feel/ see in front of the thigh. 
• It is made up of the three vastii muscles and the rectus femoris. 
• The vastus lateralis, vastus medialis, and vastus intermedius originate from the femur bone. 
• The rectus femoris originates from the AIIS (anterior inferior iliac spine), a bony prominence of the iliac bone (to refresh, the ilium is one of the three pelvic bones, the other two being the ischium and pubis).
• As the name suggest, the vastus lateralis is on the lateral or outer side of the thigh, the vastus medialis is on the medial or inner side of the thigh, and the vastus intermedius is a deep muscle that lies in between these two muscles in the middle of the thigh. The vastii are single joint muscles and their function is to straighten the knee joint or knee extension as it is termed.
• The rectus femoris is a superficial and large muscle that lies over the vastus intermedius and portions of the vastus lateralis and medius. Since it crosses both the hip joint and knee joint, its function is to flex the hip joint and extend the knee joint. 
• Just above the knee joint, the above muscles unite to form a common quadriceps tendon. The knee cap is embedded within the quadriceps tendon and this continues as the patellar tendon (below the patella) to insert on the tibial (lower leg bone) tuberosity.
• The vastus medialis obliquus (VMO) is part of the vastus medialis muscle whose short fibers run obliquely and plays a key role in patellar tracking and stabilization.
As with any exercise, movement and stability are key, even with stretches. It is important to be aware of the dynamic postures as you attain and hold the stretch position. Repetition of good postures while stretching, lead to increased flexibility and general wellness. However, after achieving the increased range, it is imperative to incorporate the newly acquired movement in activities to develop motor control. Hence stretches should be part of exercise program and not just done as a stand -alone exercise. Another important point to be mentioned here is that muscles and soft tissue stretch better when warm, and warm-up exercise prior to deepening stretches help to achieve personal best.
The different ways to stretch the Quadriceps are: (as usual we will consider stretching the right quadriceps for ease of understanding)
1) Passive stretch: this can be done in the prone position with the therapist flexing or bending the knee with the hip stabilized on the mat in neutral position. One arm stabilizes the pelvis, while the other flexes the knee joint till stretch is felt. The position is held from 5 seconds to 30 seconds (as long as possible) and released with 15-30 second rest in between.
2) Active static stretch: 
i) This stretch is similar to the passive stretch above in prone position and the person may actively bend the knee to feel a stretch in front of the thigh, while the pelvis is stabilized by the mat/bed. The right hand may grasp the right foot/ankle to deepen the knee flexion for further stretch.
ii) One of the advanced yoga asana called the supta vajrasana effectively stretches the quadriceps with the knee in full flexion, while lowering the torso (back down) onto the mat. It is important to keep the knees on the floor and not allow them to lift up by flexing the hip joints. Also, the abdominals and back extensors co-contract to keep the spine stable and elongated. It is okay to rest on forearms if stretch is already felt in front of thigh. As you advance deeper into this pose, the shoulder blades lie on the mat with lumbar spine in minimal extension to neutral position. When the rectus or hip flexors are tight, it may cause anterior pelvic tilt and lumbar extension increasing the lumbar curve. So watch out for that and progress slowly. In case of anterior pelvic tilt of increased lumbar lordosis, prone position is ideal to stabilize the pelvis and prevent anterior tilt, till sufficient length is achieved in the quadriceps.
3) Active Dynamic stretch: 
i) Standing position near wall: With the pelvis neutral in standing position, extend the right hip while flexing the knee and hold the right ankle/foot with the right hand. The left hand may be used for support on wall if needed. 
ii) Half-kneeling position on mat or floor. A forward lunge in half-kneeling stretches the rectus femoris primarily, and may be modified to deepen the vastii stretch by further flexing the right knee while lifting the right foot off the floor. The right hand may be used to hold the right ankle/foot. It demands balance as well as stability at trunk and hip joints.
4) Stretch using tools/equipment:
i) In prone position using a strap/gait belt: lie with face down on mat/bed with the strap or gait belt tied above the ankle and bend the right knee bringing the right heel to the right buttock. The other end of the strap/belt passes over the right shoulder and is pulled with the right hand to deepen the stretch.
ii) In standing position near a wall, a stool can be used to rest the right knee. Position the left hand on the wall for support in front. Slowly flex the right knee as far as possible. A strap may be looped around the ankle with the other end passing over the right shoulder and using the right hand to pull down on strap to deepen stretch.
iii) With the foam roller on the floor, lie on the foam roller, face down on the front of the thighs and rest the forearms on the floor. You may keep the legs straight while rolling the foam roll back and forth along the front of thigh in small segments or hold the position where you sense a tender spot and slowly flex and extend the knee, allowing the pressure from body weight to release the tightness