[ research report ]

STEPHANIE D. MOORE, MS, ATC1 • KEVIN G. LAUDNER, PhD, ATC2 • TODD A. MCLODA, PhD, ATC3 • MICHAEL A. SHAFFER, PT, ATC, OCS4

The Immediate Effects of Muscle

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Energy Technique on Posterior Shoulder

Tightness: A Randomized Controlled Trial

T
he glenohumeral joint (GHJ) attains extreme ranges of motion ROM and posterior shoulder tightness
(ROMs),13,19 velocities,13,35 and forces18 throughout the throwing in throwing athletes. Overhead athletes
commonly exhibit significantly greater
motion. GHJ internal rotation reaches peak angular velocities of
GHJ external rotation ROM at 90° of ab-
nearly 7000°/s,13,35 and deceleration during the follow-through duction of the dominant arm compared
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

occurs at 500 000°/s,2 creating a large force for the posterior shoulder to the nondominant arm.4-7,14,15 However,
to counteract as the humerus continues to horizontally adduct and the total arc of motion (sum of maximum
internally rotate.35 It is hypothesized that these substantial speeds GHJ external rotation and internal rota-
and forces occurring at the posterior shoulder result in altered GHJ tion ROM at 90° of abduction)48 often
does not differ bilaterally, suggesting a
corresponding decrease in GHJ internal
TTSTUDY DESIGN: Randomized controlled trial. by-time interactions (P<.05).
rotation ROM.5-7,13,14,37 This loss of GHJ
TTOBJECTIVES: To compare a muscle energy TTRESULTS: The group treated with the MET internal rotation ROM at 90° of abduc-
technique (MET) for the glenohumeral joint (GHJ) for the horizontal abductors had a significantly
tion in the dominant shoulder is referred
greater increase in GHJ horizontal adduction
Journal of Orthopaedic & Sports Physical Therapy®

horizontal abductors and an MET for the GHJ

external rotators to improve GHJ range of motion
(ROM) in baseball players.
TTBACKGROUND: Overhead athletes often exhibit
loss of GHJ ROM in internal rotation, which has
been associated with shoulder pathology. Current
stretching protocols aimed at improving flexibility
of the posterior shoulder have resulted in incon-
sistent outcomes. Although utilization of MET has
been hypothesized to lengthen tissue, there are
limited empirical data describing the effectiveness
of such stretches for treating posterior shoulder
tightness.
TTMETHODS: Sixty-one Division I baseball
players were randomly assigned to 1 of 3 groups:
MET for the GHJ horizontal abductors (n = 19),
MET for the GHJ external rotators (n = 22), and
control (n = 20). We measured preintervention and
postintervention GHJ horizontal adduction and
internal rotation ROM, and conducted analyses of
covariance, followed by Tukey honestly significant
difference post hoc analysis for significant group-
ROM postintervention (mean  SD, 6.8°  10.5°)
compared to the control group (–1.1°  6.8°) (P
= .011) and a greater increase in internal rotation
ROM postintervention (4.2°  5.3°) compared to
the group treated with the MET for the external
rotators (0.2°  6.3°) (P = .020) and the control
group (–0.2°  4.0°) (P = .029). No significant
differences among groups were found for any other
variables (P>.05).
TTCONCLUSION: A single application of an
MET for the GHJ horizontal abductors provides
immediate improvements in both GHJ horizontal
adduction and internal rotation ROM in asymptom-
atic collegiate baseball players. Application of MET
for the horizontal abductors may be useful to gain
ROM in overhead athletes.
TTLEVEL OF EVIDENCE: Therapy, level 2b-.
J Orthop Sports Phys Ther 2011;41(6):400-407,
Epub 6 April 2011. doi:10.2519/jospt.2011.3292
TTKEY WORDS: baseball, manual therapy, pitch-
ing, rehabilitation, stretching
to as glenohumeral internal rotation defi-
cit (GIRD).
Adaptive changes to bone11,13,34,37,47
and soft tissue4,24,25 believed to occur as a
result of the repetitive throwing motion
contribute to the presence of GIRD in
the overhead athlete. Significantly great-
er humeral retroversion (the angle of the
axis of the humeral head in a medial and
posterior direction relative to the axis
of the elbow joint34) has been reported
in the throwing arm of overhead ath-
letes.11,13,34,36,37 This adaptive increase in
humeral retroversion limits GHJ internal
rotation ROM and allows for greater GHJ
external rotation, which may serve to pro-
tect the throwing shoulder from excessive
strain on the anterior structures.13,34,36,37
GIRD greater than 25° has been as-
sociated with injuries such as superior

1
Graduate Assistant, School of Kinesiology and Recreation, Illinois State University, Normal, IL. 2Associate Professor, School of Kinesiology and Recreation, Illinois State University,
Normal, IL. 3Associate Dean, College of Applied Science and Technology, Illinois State University, Normal, IL 4Coordinator of Sports Rehabilitation, University of Iowa Sports Medicine,
Iowa City, IA. The protocol of this study was approved by The Institutional Review Board at Illinois State University, Normal, IL. Address correspondence to Stephanie D. Moore,
MS, ATC, University of Kentucky, College of Health Sciences, Room 210C, Wethington Building, 900 S Limestone, Lexington, KY 40536-0200. E-mail: stephanie-moore@uky.edu

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 group would be required to detect chang-
TABLE 1 Participant Characteristics* es between the 2 stretch groups and ob-
tain a power of 0.80 at an alpha of .05.
MET for HAbd MET for ER Control
It should be noted that, while interven-
Pitchers, position players, n 9, 10 8, 14 7, 13
tions were similar, the current study in-
Age, y 19.5  1.0 20.4  1.1 19.8  1.1
vestigated immediate ROM changes, and
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Height, cm 184.4  6.2 183.7  6.5 186.2  6.5

the values used to estimate sample size
Mass, kg 86.9  7.0 88.2  11.2 89.4  7.8
were ROM changes following a 4-week
Dominant GHIR, deg 43.5  10.1 44.5  8.6 50.7  11.3
stretching intervention.
Dominant GHER, deg 118.9  13.1 117.8  8.3 122.4  9.6
Dominant total arc, deg 162.4  16.8 162.4  11.0 173.1  12.9
Instrumentation
Nondominant GHIR, deg 55.6  13.2 54.0  10.9 61.4  11.4
We used the Pro 3600 digital inclinom-
Nondominant GHER, deg 117.6  10.3 115.4  10.4 115.3  8.9
eter (SPI-Tronic, Garden Grove, CA) to
Nondominant total arc, deg 173.2  16.1 169.9  10.5 176.8  14.6
measure posterior shoulder flexibility, as
determined by GHJ horizontal adduction
Abbreviations: ER, glenohumeral joint external rotators; GHER, glenohumeral joint external rota-
tion; HAbd, glenohumeral joint horizontal abductors; GHIR, glenohumeral joint internal rotation; ROM and GHJ internal rotation ROM at
MET, muscle energy technique. 90° of abduction. This device provides a
*Values are mean  SD unless otherwise specified.
real-time digital reading of angles with
respect to either a horizontal or vertical
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

labral lesions, subacromial impingement,
and pathological internal impingement
in the throwing shoulder, 9,24,25,33,44,46 in-
dicating a need for investigation of pre-
ventative and corrective interventions
to restore GHJ internal rotation ROM.
While clinicians cannot address GIRD
resulting from bony adaptation, soft tis-
sue tightness can be treated.
Journal of Orthopaedic & Sports Physical Therapy®
for 5 seconds each, with a stretch follow-
ing each contraction that ranges from 3
to 5 seconds21,22 to 30 to 60 seconds.10
MET has been relatively unex-
plored, with only a few published stud-
ies1,20,28,38,39,41,51 supporting its use for
cervical, lumbar, and thoracic motion
restrictions.20,28,38,39,51 Only 3 identified
studies have investigated the use of MET
reference and is accurate to 0.1°, as re-
ported by the manufacturer. The digital
inclinometer was modified with a refer-
ence line positioned along the midline
of the device, which was used for proper
alignment with anatomic landmarks.
Procedures
Testing was conducted at 3 National Col-

Several researchers have identified the
importance of posterior shoulder stretch-
ing in restoring flexibility as part of a
prevention program and during reha-
bilitation.9,33,46,50 However, investigators
have reported conflicting results regard-
ing the effectiveness of current stretching
protocols for GHJ internal rotation and
horizontal adduction ROM.26,27,29,31 Ad-
ditional data are needed to validate the
efficacy of specific stretching interven-
tions to increase GHJ internal rotation
and posterior shoulder flexibility.
for the lower extremity,1,40,41 and none for
the upper extremity. The purpose of this
study was to compare the immediate ef-
fects of an MET applied to the GHJ hori-
zontal abductors and an MET applied to
the GHJ external rotators on improving
GHJ horizontal adduction and GHJ in-
ternal rotation ROM in baseball players
without shoulder pathology.
METHODS
Participants
legiate Athletic Association Division I
universities. Each participant attended
1 testing session and provided informed
consent. The protocol was approved by
The Institutional Review Board of Illinois
State University prior to data collection,
and the rights of all participants were
protected. A single investigator, blinded
to group allocation, positioned all par-
ticipants for ROM measurement, and
measurements were obtained prior to
any throwing activity. A second examin-
er, who was not blinded to pretreatment

Muscle energy technique (MET) is a
manual therapy intervention that can be
used to stretch or lengthen muscles and
fascia that lack flexibility.21,22 MET re-
quires the patient to create a force by ac-
tivating the targeted musculotendinous
unit against a precisely directed counter-
force applied by the clinician, followed by
relaxation and a passive stretch applied
by the clinician. One application of MET
may consist of 3 to 5 contractions, held
S
ixty-one NCAA Division I base-
ball players voluntarily participated
in this study (TABLE 1). Exclusion cri-
teria included any dominant-side upper
extremity injury in the previous 6 months
or history of previous surgery. Using
previously published changes in GHJ
internal rotation ROM31 (cross-body ad-
duction, 20.0°  12.9°; sleeper stretch,
12.4°  10.4°), an independent sample t
test determined a sample size of 29 per
ROM measures, performed all MET
treatments. Prior to any measurements,
participants were randomly assigned to
1 of 3 groups, according to a randomiza-
tion table set a priori. The groups con-
sisted of a control group, a group treated
with MET for the GHJ external rotators,
and a group treated with MET for the
GHJ horizontal abductors. Dominant-
arm GHJ internal and external rotation
ROM and GHJ horizontal adduction

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 [ research report
ROM were assessed in each participant
preintervention and postintervention.
All postintervention measurements were
taken immediately following the MET
application or approximately 2 minutes
following the pretest measurements. Par-
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ticipants in the control group remained
on the examination table for a 2-minute
interim between measurements.
Range-of-Motion Measurements
To measure passive GHJ horizontal ad-
duction ROM, participants were supine,
with both shoulders flat against the ex-
amination table. The test shoulder was
placed in 90° of abduction, and the el-
bow in 90° of flexion. The blinded ex-
aminer grasped the lateral border of the
scapula and applied a posteriorly directed
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
force to maintain the starting position of
the scapula. Grasping the participant’s
proximal forearm, the examiner pas-
sively horizontally adducted the humerus
(FIGURE 1). When the first tissue resistance
was reached, a second examiner aligned
the digital inclinometer along the ventral
midline of the humerus for measurement.
The angle of the axis of the humerus with
Journal of Orthopaedic & Sports Physical Therapy®
respect to 0° horizontal adduction (plane
perpendicular to examination table), as
determined by the digital inclinometer,
was then used to assess the total amount
of GHJ horizontal adduction ROM.
To measure passive GHJ internal rota-
tion ROM, participants were supine with
the shoulder in 90° abduction and the
elbow in 90° flexion. The humerus was
supported to maintain a neutral horizon-
tal position. The examiner used one hand
to stabilize the scapula by applying pos-
terior pressure at the anterior acromion.
The opposite hand was used to passively
internally rotate the humerus. The ROM
measurement was taken at the first point
of resistance as the digital inclinometer
was aligned with the long axis of the ulna
by the second examiner, indicating the
angle between the ulna and a vertical ref-
erence point. External rotation ROM was
measured using the same procedures. It
should be noted that the examiner who
aligned the inclinometer was not blind-
402  |  june 2011  |  volume 41  |  number 6  |  journal of orthopaedic & sports physical therapy
41-06 Moore.indd 402
FIGURE 1. Measurement of glenohumeral joint
horizontal adduction range of motion. Angle created
by the end position of the humerus with respect to 0°
horizontal adduction (vertical dotted line).
ed to group allocation; but potential bias
was limited by using definitive bony land-
marks and an instrument that provides a
digital reading.
Intratester reliability of ROM mea-
surements was established a priori.
Twenty-four shoulders with no history of
injury or surgery were measured and re-
assessed at a minimum of 48 hours later.
Intraclass correlation coefficient (ICC),
standard error of measurement (SEM)
with 90% confidence interval (CI), and
minimal detectable change (MDC) were
calculated for GHJ horizontal adduction
ROM (ICC = 0.93; SEM, 2.62°; MDC,
3.70°) and GHJ internal rotation ROM
(ICC = 0.98; SEM, 3.28°; MDC, 4.63°).
Muscle Energy Technique
A single application of MET was ap-
plied to the GHJ horizontal abductors
(FIGURE 2). The participant was in a su-
pine position on the examination table.
The examiner stabilized the scapula at
the lateral border, and, with the elbow
flexed, the participant’s shoulder was
horizontally adducted to the first barrier
of motion. The participant was instructed
to perform a 5-second isometric contrac-
tion at approximately 25% maximal effort
in the direction of horizontal abduction,
against an opposing force provided by the
examiner at the distal humerus. Follow-
ing the contraction, the participant was
instructed to pull his arm across his body,
]
FIGURE 2. Muscle energy technique for the
glenohumeral joint horizontal abductors.
as the examiner applied a 30-second ac-
tive assisted stretch. The participant was
instructed to relax, and a new movement
barrier was then engaged by the exam-
iner. This protocol was performed for a
total of 3 repetitions.
A single application of MET was
applied to the GHJ external rotators
(FIGURE 3). The participant was in a su-
pine position on the examination table.
With the humerus supported and the
participant’s shoulder and elbow in 90°
of abduction and flexion, respectively, the
examiner passively moved the humerus
into internal rotation until the first bar-
rier of motion was reached. The partici-
pant was then instructed to perform a
5-second isometric contraction of ap-
proximately 25% maximal effort in the
direction of external rotation, against an
opposing force provided by the examiner
at the distal forearm. Following the con-
traction, the participant was instructed
to internally rotate the arm toward the
ground as a 30-second active assisted
stretch was applied. The participant was
instructed to relax, and a new movement
barrier was then engaged by the exam-
iner. This protocol was performed for a
total of 3 repetitions.
Data Analysis
We conducted 2 separate 1-way analyses
of covariance (ANCOVAs) for GHJ hori-
zontal adduction and GHJ internal rota-
tion ROM. The dependent variable was
posttreatment ROM, and the covariate
5/18/2011 12:50:26 PM
 Assessed, n = 66

Excluded, n = 5, due to
previous surgery or
injury
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Randomized, n = 61

FIGURE 3. Muscle energy technique for the

glenohumeral joint external rotators.

was pretreatment ROM. Alpha level was

set at .05. All data were analyzed using MET for HAbd MET for ER Control group
SPSS Version 19.0 (SPSS Inc, Chicago, preintervention, preintervention, preintervention,
IL). Effect sizes were calculated using n = 19 n = 22 n = 20
Microsoft Excel. To provide an indica-
tion of clinical meaningfulness of the
changes in shoulder ROM, between-
group effect size was calculated as [ex- MET for HAbd MET for ER Control group
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

perimental group mean – control group postintervention, postintervention, postintervention,

mean]/control group SD, and between
experimental groups as [MET for hori-
zontal abductors group mean – MET for
external rotators group mean]/pooled
SD. Within-group effect size was calcu-
lated as [postintervention mean – pre-
intervention mean]/preintervention SD.
Effect sizes were interpreted according to
Journal of Orthopaedic & Sports Physical Therapy®
n = 19 n = 22 n = 20
FIGURE 4. Participant flow diagram. Abbreviations: ER, glenohumeral joint external rotators; HAbd, glenohumeral
joint horizontal abductors; MET, muscle energy technique.
allows for comparison of posttreatment be attributed to soft tissue tightness. The
ROM, as if all 3 groups had the same smaller total arc observed in the domi-
pretreatment mean. No participants nant arm compared to the nondominant

Cohen’s guidelines.12 were lost to follow-up (FIGURE 4), and no arm indicates that capsular or muscular
adverse events were reported. tightness may be involved.
RESULTS GIRD has been associated with de-
DISCUSSION creased performance9 and several pathol-

D
emographics for each group are ogies in the throwing athlete, including

provided in TABLE 1. Descriptive sta-
tistics for each group are provided
in TABLES 2 and 3. The participants treat-
ed with the MET for the GHJ horizon-
tal abductors had significantly greater
postintervention GHJ horizontal adduc-
tion compared to the control group (P =
.011). Postintervention, they also demon-
strated significantly greater GHJ internal
rotation ROM compared to the control
group (P = .029) and those treated with
MET for the GHJ external rotators (P
= .020). No significant differences were
found for any other group comparisons
(P>.05). Complete results of the ANCO-
VAs are provided in TABLES 4 and 5. These
tables display the covariate-adjusted
means, which are adjusted to account for
the variation in pretreatment ROM. This
P
ast research has consistently
demonstrated that overhead throw-
ing athletes exhibit a significant
decrease in GHJ internal rotation ROM
in the dominant arm versus the non-
dominant arm.4-6,11,13,34,37 This loss of in-
ternal rotation ROM in the throwing
arm has been attributed to osseous ad-
aptation,11,13,34,36,37 posterior muscle tight-
ness,13 and posterior-inferior capsule
tightness.9,24,25 We observed a significant-
ly smaller total arc of motion (P = .001)
in the dominant arm (mean  SD, 165.9°
 14.3°) compared to the nondominant
arm (173.0°  14.0°) in our participants.
If the alteration is entirely bony, total arc
should be similar bilaterally. Therefore,
we believe that the deficit in GHJ internal
rotation ROM in our participants may
superior labral lesions, 9,24 pathologic
internal impingement,9,33 and subacro-
mial impingement.44,46 Furthermore,
symptom resolution has been correlated
with improvement in GHJ horizontal ad-
duction ROM in patients.43 Preventative
and rehabilitative interventions, such as
stretching of the posterior shoulder, are
needed to address GHJ ROM that may be
lost as a result of the contribution of soft
tissue tightness. Based on clinical obser-
vation, a prophylactic stretching program
aimed at the posterior-inferior capsule
effectively reduced GIRD and prevented
associated pathologies over 3 seasons in
professional baseball players.9 Addition-
ally, professional pitchers who participat-
ed in a GHJ internal rotation stretching
program for 3 or more years were found

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 [ research report ]

Descriptive Statistics for Glenohumeral Joint  
TABLE 2
Horizontal Adduction Range of Motion*

Group Preintervention Postintervention Difference 95% Confidence Interval Within-Group Effect Size
MET for HAbd –10.0  9.6 –3.2  9.9 6.8  10.5 0.4, 13.2 0.71
MET for ER –13.5  7.7 –8.5  8.9 5.0  8.7 –0.1, 10.1 0.65
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Control –7.8  6.0 –8.9  7.2 –1.1  6.8 –5.3, 3.1 0.18
Abbreviations: ER, glenohumeral joint external rotators; HAbd, glenohumeral joint horizontal abductors; MET, muscle energy technique.
*Values are mean  SD degrees. Negative values indicate that the humerus is positioned further from the midline of the body (0° the humerus is perpendicular
to the examination table).

Descriptive Statistics for Glenohumeral Joint  
TABLE 3
Internal Rotation Range of Motion*

Group Preintervention Postintervention Difference 95% Confidence Interval Within-Group Effect Size
MET for HAbd 43.5  10.1 47.7  11.7 4.2  5.3 –5.0, 11.4 0.42
MET for ER 44.5  8.6 44.7  8.6 0.2  6.3 –5.0, 5.4 –0.02
Control 50.7  11.3 50.5  12.1 –0.2  4.0 –7.7, 7.3 0.02
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Abbreviations: ER, glenohumeral joint external rotators; HAbd, glenohumeral joint horizontal abductors; MET, muscle energy technique.
*Values are mean  SD degrees.

to have an average of 19° more GHJ in-
ternal rotation ROM than those who had
been in a program less than 3 years.29
While stretching has been shown to
effectively regain and maintain GHJ
internal rotation ROM in overhead ath-
Journal of Orthopaedic & Sports Physical Therapy®
(3.28°) but doesn’t quite exceed the MDC
for GHJ internal rotation ROM (4.63°).
The 6.8° increase observed in GHJ hori-
zontal adduction ROM reflects a moder-
ate to large effect size (0.71) and exceeds
the MDC for this measure (3.70°). These
compares favorably with the moderate
to large effect size between the MET for
the horizontal abductors group and con-
trol group in our study (0.72). The MET
for the GHJ horizontal abductors in the
present study was similar to the horizon-

letes, investigation of specific techniques
currently used to stretch the posterior
shoulder has produced inconsistent re-
sults.26,27,29,31 We observed that an appli-
cation of MET for the GHJ horizontal
abductors resulted in greater GHJ hori-
zontal adduction improvement in that
group compared to a control group who
did not receive any intervention, and
greater internal rotation ROM improve-
ment compared to both the control group
and the group treated with MET for the
GHJ external rotators. Conversely, inter-
nal rotation and horizontal adduction
improvements following the application
of MET for the GHJ external rotators
were not significantly different than the
changes in other groups. In the present
study, we observed an increase of 4.2°
in GHJ internal rotation ROM imme-
diately following a single application of
MET for the horizontal abductors. This
change reflects a small to moderate effect
size (0.42) and is larger than the SEM
within-group effect sizes observed for
horizontal adduction and internal rota-
tion ROM indicate that the immediate
changes in ROM following MET appli-
cation to the horizontal abductors may be
clinically significant.
The use of a shoulder horizontal ad-
duction stretch has been suggested to
improve GHJ internal rotation ROM.9,49
A 4-week program of a self-applied cross-
body stretch produced a significant in-
crease in GHJ internal rotation ROM
(mean  SD, 20.0°  12.9°; within-
group effect size, 1.7) compared to con-
trol participants; however, the effect of
the stretch on GHJ horizontal abduction
ROM was not measured.31 Participants
were instructed to perform 5 repetitions
of a 30-second self-stretch once daily
throughout the 4-week trial. In this pre-
vious study,31 the large effect size for dif-
ferences in GHJ internal rotation ROM
between the cross-body and control
groups (between-group effect size, 1.5)
tal adduction stretch, but we stabilized
the scapula to better isolate the stretch
to the GHJ and our stretch was applied
by an investigator. However, this tech-
nique can also be performed without ex-
ternal assistance in a sidelying position,
by pulling the humerus across the body
with the contralateral arm. As expected,
participants who received an MET treat-
ment for the GHJ horizontal abductors
demonstrated significantly greater GHJ
horizontal adduction ROM compared
to the control group postintervention.
These participants also exhibited sig-
nificantly greater postintervention GHJ
internal rotation ROM compared to the
control group and the group treated with
an MET for the GHJ external rotators.
Stretching of the GHJ external rota-
tors by passively internally rotating the
humerus with the arm at 90° of shoulder
abduction has also been recommended
to improve internal rotation ROM.49 An-
other technique, described as the “sleeper

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TABLE 4 Covariate-Adjusted Postintervention Means for Shoulder Motion*

Horizontal Adduction ROM Internal Rotation ROM

Group Covariate-Adjusted Mean †

95% Confidence Interval Covariate-Adjusted Mean† 95% Confidence Interval
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MET for HAbd –3.5  7.9 –7.1, 0.1 50.2  5.4 47.8, 52.7
MET for ER –7.0  8.1 –10.5, –3.6 46.2  5.4 44.0, 48.5
Control –10.2  8.0 –13.8, –6.6 46.3  5.5 43.8, 48.7
Abbreviations: ER, glenohumeral joint external rotators; HAbd, glenohumeral joint horizontal abductors; MET, muscle energy technique; ROM, range of motion.
*Values are mean  SD degrees. Posttreatment values adjusted for the effect of the covariate (pretreatment motion).

TABLE 5 Between-Group Covariate-Adjusted Mean Differences and Effect Sizes

Horizontal Adduction ROM Internal Rotation ROM

Group Comparisons Between-Group Mean Difference* Between-Group Effect Size Between-Group Mean Difference* Between-Group Effect Size
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

MET for HAbd and control 6.7 (1.6, 11.8)† 0.83 4.0 (0.4, 7.5)‡ 0.72
MET for ER and control 3.2 (–1.9, 8.3) 0.39 –0.03 (–3.4, 3.4) –0.01
MET for HAbd and MET for ER 3.5 (–1.4, 8.6) 0.44 4.0 (0.7, 7.3)§ 0.75
Abbreviations: CI, confidence interval; ER, glenohumeral joint external rotators; HAbd, glenohumeral joint horizontal abductors; MET, muscle energy
technique; ROM, range of motion.
*Values represent differences between covariate-adjusted mean (95% CI) degrees.
†
Statistically significant difference (P = .011).
‡
Statistically significant difference (P = .029).
§
Statistically significant difference (P = .020).
Journal of Orthopaedic & Sports Physical Therapy®

stretch,” is performed sidelying, with the
shoulder in varying amounts of shoulder
flexion up to 90°.9,27,31 The arm is then
passively internally rotated by either the
clinician or the individual. Clinical obser-
vation by Burkhart et al9 indicated that
sleeper stretches can effectively increase
GHJ internal rotation ROM in patients
with symptomatic GIRD within 2 weeks
of use. Furthermore, significant increases
in GHJ horizontal adduction ROM (2.3°;
effect size, 0.32) and GHJ internal rota-
tion ROM (3.1°; effect size, 0.30) were
seen following an acute intervention of
the sleeper stretch.27 However, a group
receiving 4-week intervention of the
sleeper stretch, compared to a control
group, showed no significant difference
in GHJ internal rotation ROM.31 In our
study, participants who received an MET
for the GHJ external rotators did not ex-
hibit a statistically significant difference
in postintervention GHJ horizontal ad-
duction or internal rotation ROM com-
pared to a control group. One reason the
MET for the GHJ external rotators did
not improve posterior shoulder flexibility
may be due to the emphasis on the in-
fraspinatus and teres minor during this
stretch, while the other posterior muscles
responsible for controlling deceleration
during horizontal adduction, such as the
posterior deltoid, are not stretched.
As previously discussed, it is unclear
whether muscular or capsular tightness
is a greater contributor to GIRD in over-
head athletes. Another explanation for
our findings may be related to stretching
of the posterior capsule. If the posterior
capsule is better stretched in a position
of horizontal adduction, rather than in-
ternal rotation, all motions (internal ro-
tation and horizontal adduction ROM)
restricted by capsular tightness would
likely increase.
Presently, empirical data are limited
to validate the use of MET. While im-
provements have been reported using
MET on the cervical, thoracic, and lum-
bar spine,20,28,38,39,51 only 2 studies have in-
vestigated MET use in the extremities.1,41
Following a single application of MET to
the hamstring muscles, Ballantyne et al1
observed a significant increase in passive
knee extension. Smith and Fryer41 report-
ed significant increases in hamstring flex-
ibility following 2 applications of MET
performed over a 2-week period.
Several studies have demonstrated
that contract-relax techniques similar
to those used in present study are more
effective than static stretching.16,30,32 Im-
mediately following the interventions,
maximal joint angle,30 ROM,16 and stretch
tolerance32 were significantly greater af-
ter contract-relax stretching versus static
stretching. Furthermore, performance of
contract-relax techniques over a 30-day
period produced significantly greater
increases in plantar flexor, hip extensor,
and hip adductor flexibility, compared
to ballistic stretching.45 Consistent with

journal of orthopaedic & sports physical therapy  |  volume 41  |  number 6  |  june 2011  |  405

41-06 Moore.indd 405 5/18/2011 12:50:29 PM

 [ research report
our findings, contract-relax techniques
have also produced significantly greater
increases in ROM compared to changes
observed in control participants.42 Con-
versely, other investigators have reported
no difference in flexibility gains between
Downloaded from www.jospt.org at PSG College of Physiotherapy on January 31, 2020. For personal use only. No other uses without permission.
static and hold-relax stretching tech-
niques when performed 4 times per week
during a 6-week intervention.23,53
Consistent with MET literature,1,28,39,51
our results support the use of a 5-second
isometric contraction, which has been
found to be more effective in improving
cervical ROM than a 20-second isometric
contraction.20 Our protocol also involved
the application of a postisometric 30-sec-
ond active-assisted stretch. A 30-second
static stretch of the hamstring muscles,
performed 5 times per week over 6 weeks,
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
has been shown to be more effective than
a 15-second stretch2 or no stretch,2,3
and no more effective than a 60-second
stretch.2,3 Conversely, Smith and Fryer41
reported similar increases in hamstring
flexibility following 2 applications of
MET over a 2-week period, when using
a 3-second and 30-second postisometric
stretch; however, a no-stretch control
Journal of Orthopaedic & Sports Physical Therapy®
group was not included in their study.
One limitation of this study is that
the patient ultimately determined the
amount of force created during the con-
traction phase of an MET. However, this
is an inherent limitation of any contract-
relax intervention. We controlled this as
much as possible by clearly instructing
the participant to use approximately 25%
of maximum force, which was selected
to allow for participant comfort and to
minimize muscle guarding and potential
risk of injury. Feland and Marin17 com-
pared the use of isometric contractions
performed at 20%, 60%, and 100% of
maximum voluntary isometric contrac-
tion during contract-relax propriocep-
tive neuromuscular facilitation stretching
and found no significant difference in
changes in hamstring flexibility among
the 3 effort levels. This supports our use
of a 25% contraction and also indicates
that participants who unknowingly per-
form a contraction at a higher or slightly
406  |  june 2011  |  volume 41  |  number 6  |  journal of orthopaedic & sports physical therapy
41-06 Moore.indd 406
]
lower percent maximum voluntary iso-
metric contraction may still benefit from
the treatment.
We attempted to minimize bias in the
measurements of ROM by blinding the
examiner who positioned the arm for all
ROM measures. Additionally, the force
applied by the examiner during the ac-
tive-assisted stretch was not controlled.
All stretches in this study were applied by
a single examiner, but standardization of
the force applied in future studies might
serve to maintain consistency among
participants.
The participants in the current study
were healthy, asymptomatic overhead
athletes. Further study is required to
determine the effectiveness of MET ap-
plication in individuals with symptoms
that may be related to GIRD. Finally, we
only observed the immediate effects of
MET on joint ROM. Future investiga-
tions should study the effects of MET
over multiple session applications to
further validate its use and examine the
duration of increased flexibility following
both single and multiple sessions of treat-
ment with MET.
CONCLUSION
O
ur findings indicate that a sin-
gle application of MET for the
GHJ horizontal abductors results
in greater posttreatment GHJ horizontal
adduction and internal rotation ROM
immediately following treatment in as-
ymptomatic collegiate baseball players.
Alternatively, a single application of MET
for the GHJ external rotators did not lead
to a significant increase in horizontal ad-
duction or internal rotation. Acute ap-
plication of MET successfully improved
GHJ posterior shoulder ROM in colle-
giate baseball players and may assist in
the prevention and treatment of shoulder
injuries associated with pathologic GIRD
and posterior shoulder tightness. t
KEY POINTS
FINDINGS: Immediate improvements in
glenohumeral internal rotation and hor-
izontal adduction range of motion were
observed following an acute application
of MET for the glenohumeral horizontal
abductors in asymptomatic collegiate
baseball players.
IMPLICATION: The use of MET for the gle-
nohumeral horizontal abductors may
assist in gaining posterior shoulder flex-
ibility in baseball players and individu-
als prone to tightness of the posterior
shoulder structures.
CAUTION: Our study examined the im-
mediate effects of a single application
of MET on soft tissue lengthening in
the posterior shoulder. The effects of
chronic application of MET for shoulder
flexibility have yet to be examined.
ACKNOWLEDGEMENTS: The authors thank
Amanda Somers, Rob Sipes, Dustin Holley,
and Satoshi Kajiyama for their assistance
with data collection.
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