In clinical practice and some clinical research, the location of the endpoint is often determined by the sensation perceived by the patient or by the amount of resistance perceived by the therapist. Therefore many factors can affect the endpoint of joint range achieved in simple manual tests commonly used to assess muscle extensibility. For example, alterations in tolerance to stretch or changes in the extensibility of the surrounding non-muscular tissue could also cause improvements in the joint range achieved (Folpp et al 2006, Law et al 2009). Nevertheless, physiotherapists may be interested in the results of these simple

manual tests, because poor results on the tests have been associated with injury risk or other clinical problems (Krivickas and Feinberg 1996, Kaufman et al 1999, Knapik et al 2001, Witvrouw et al 2003). Notably, gender differences Cell Cycle inhibitor were frequently apparent in these studies. Physiotherapists may also be interested in interventions that improve apparent muscle extensibility on simple manual tests, even if the precise mechanism of the improvement is unclear, because these interventions sometimes also improve more clinically relevant outcomes as well (Ross 2007, Khalili et al 2008, Christiansen 2008, Cristopoliski

et al 2009, Aoki et al 2009, Rose et al 2010). Several CSF-1R inhibitor of these relationships between apparent muscle extensibility on simple manual tests and these clinical outcomes have been identified

for the hamstrings specifically. When simple manual tests indicate reduced hamstring extensibility, this is often associated with hip and knee joint movement dysfunction (Frigo et al 1979, McNair et al 1992, Whyte et al 2010) and lumbosacral postural changes (Napiontek and Czubak 1988). A possible causative nature to these associations is suggested by research into simulation of hamstring shortening, which induces gait abnormalities in healthy people (Whitehead et al 2007). Imbalances in apparent muscle extensibility between the right and left hip extensors, including the hamstrings, may also predispose athletes to injury (Knapik et al 1991). Because of the potential role of hamstring extensibility in movement dysfunction and injury, a range of interventions intended to improve hamstring extensibility have been investigated (Kisner and Colby 2002). These include static stretches (de Weijer et al 2003, Folpp et al 2006, Bazett-Jones et al 2008, Law et al 2009, Ben and Harvey, 2010), ballistic stretches (la Roche and Connolly, 2006, Covert et al 2010), stretching with warm up (de Weijer et al 2003), stretching with local joint manipulation (Fox 2006), and local application of heat (Funk et al 2001). While some significant improvements in simple manual tests of apparent hamstring extensibility were noted in some of these trials, the effects were generally small from a clinical perspective.