Melinda Poole O’Banion, DVM July 12, 2018

Luxating patellas (or knee caps) in dogs

https://www.acvs.org/small-animal/patellar-luxations What is it???

Luxating patella(s) is a condition that occurs when the kneecap slides out of place, getting dislocated from the joint. Patellar luxation (dislocation) is a condition where the knee cap rides outside the femoral groove when the knee is flexed (often the groove is too shallow to keep the kneecap in place). Each time the kneecap slides out of place, the cartilage can become increasingly more damaged. If the problem persists and does not receive veterinary care, the damage can cause pain and eventually trigger osteoarthritis. Patellar luxation is one of the most common orthopedic conditions in dogs, diagnosed in 7% of puppies. While it occurs most frequently in smaller dog breeds, cats and larger dogs are still susceptible. Luxating patella can be an acquired condition (traumatic or injury) or can exist at birth. Most cases are believed to be genetic so pets with confirmed instances of luxating patella are encouraged to not be used for breeding. Why does this happen or how does it occur?

This hereditary disorder in dogs and cats is characterized by ectopic (abnormal) development of the patella medial or lateral to the trochlear groove of the femur. Patellar luxation can be associated with multiple deformities of the hindlimb, involving the hip joint, femur, and tibia. Medial patellar luxations can be involved with a reduced coxofemoral angle (coxa vara), lateral bowing of the femur, internal rotation of the tibia, shallow trochlear groove, and hypoplasia of the medial femoral condyle; lateral luxations cause the reverse changes.

Any dog with a suspected luxating patella should undergo weight management and light exercise to prevent obesity as excess weight can cause increased pressure on joints, worsening an existing condition. The symptoms a pet exhibits will vary depending on their particular level of pain tolerance; some pets might simply freeze in place until the kneecap moves back into position, while others may vocally express their pain.

Symptoms of luxating patella:

• Extending one leg for a period of time prior to quick movements. • Favoring a particular limb. • Hesitant to jump up on things or move hastily. • Shaking of a particular leg. • “Skipping” (running while holding one leg off the ground). • Sudden lameness in a limb with quick recovery. • Temporary paralysis of one or multiple legs. Melinda Poole O’Banion, DVM July 12, 2018

Diagnosing luxating patella

Palpation or manually manipulating (feeling) during physical exam by a veterinarian. Palpation of the stifle joint reveals displacement of the patella. In some cases, supplementary X-rays might also be recommended to visualize the joint and help with treatment or surgical planning or assess arthritis.

Classifications of luxating patella

There are four different classifications that veterinarians use to judge the gravity of a pet’s luxating patella. The system ranks pets’ symptoms with numbers ranging from 1 to 4 with 1 being mild and 4 being the most severe. The following is a list of each pain level and what the number signifies:

1. In Grade I, clinical signs are mild and infrequent, and the patella (kneecap) can be manually popped out of place or can pop out on its own. Pops back easily into place on its own. 2. In Grade II, the patella luxates during flexion of the joint and is repositioned during extension, causing animals to have a resolvable skipping lameness. Aka, kneecap pops out on its own, but occasionally needs to be manually popped back into place. 3. In Grade III, the dislocated patella is more frequently out of, instead of in, the trochlear groove, and lameness is consistent. Bone deformities are evident in these animals. Aka, kneecap sits outside of the groove a majority of the time but can be manually popped back into place. However, it will not stay in place very long. 4. In Grade IV, lameness and limb deformations are most severe. X-rays may show various degrees of limb changes - arthritis. Kneecap sits outside of groove entirely. Cannot be manually popped back into place.

How is luxating patella treated?

After properly determining the severity of your pet’s luxating patella, the veterinarian will discuss the various methods of treatment available. There are both surgical and non-surgical methods of treatment.

OFTEN, Grade 1 can be treated with exercise and weight control (maybe even some Grade 2). Non-surgical treatment involves managing pain by administering anti-inflammatories (non-steroid), which helps lessen discomfort and reduce inflammation. Along with a medicated diet, exercise, and a physical therapy routine, pet’s that have type 1 or type 2 luxating patella often find that this method of pain management helps strengthen the quadriceps muscles and provides relief from pain.

THE GOAL of exercise/physical therapy is any exercise to strengthen the quadriceps muscles. Melinda Poole O’Banion, DVM July 12, 2018

For Grades 3-4 (and sometimes Grade 2), there are several surgical methods that can help alleviate pain. The most common procedures involve one of the following: reconstructing the soft tissues surrounding the knee joint which helps support the kneecap; deepening the groove in the femur bone that the kneecap rests within; or securing the kneecap to the outside of the bone to prevent it from sliding. If you opt for a surgical treatment for your pet, the veterinarian will further discuss the various options and will review which method is best for your pet’s particular case. As with most severe conditions, with more acute cases of luxating patella, surgery is the preferred method of treatment.

Let’s talk about EXERCISES!!!!!!!!!!!!!!

1 - Side stepping; strengthens the glutes and lateral thigh muscles. • Stand facing your dog's side, with one hand on her collar and one hand on the opposite hip. • Step into your pet until she steps to the side with a lateral move, but no forward motion. • You can start with 3 to 5 steps and work up to 10 to 15 steps in each direction.

2 - Stair walking/running; slowly walk the dog up and down the stairs that have good footing (carpet, concrete, etc.). This activity requires strength and balance; it will help improve coordination and power in the rear legs. For very small dogs or short-legged dogs, this activity requires extreme physical effort.

3 - Walking up hills; the inclination of the slope is going to be even more demanding on the dog's hindquarters, which will have to work harder, and as a result, the muscle power of the dog's rear-end will increase.

4 - Controlled sit to stand

5 - Walking through tunnels or under tables

6 - Exercising on a treadmill in water is one of the best exercises as it strengthens the musculature that protects the joints.

7 - Curbs/Stepper; this activity helps improve balance and coordination and strengthens the leg muscles. • Slowly walk your dog up and down a curb/stepper. Make sure your dog has a four-beat walk prior to going up or down the curb/stepper. • Walk your dog in a serpentine pattern up and down the curb/stepper.

8 - Figure 8’s – walk your dog in figure 8 motions

9 – Cavalettis; cavalettis are wooden poles arranged in a straight line or circle pattern on the ground. Two by fours and porch railing are good examples and try not to use any object that will roll if stepped on for the safety of you and your dog. Melinda Poole O’Banion, DVM July 12, 2018

This activity encourages greater active range of motion, requires full weight bearing on all limbs, and also challenges proprioception, balance, and coordination.

1. Place them in a row and slowly walk your dog through them. Start with 4-6 in a row and build to more. 2. Place 4 of them in a circle pattern and slowly walk your dog in both directions. This will require each of your dog’s legs to walk a different path. 3. Pick up sticks: Take several of the cavalettis and drop them on the ground in a scattered design, slightly spread out but in a haphazard pattern. Then slowly walk your dog through the poles.

10- The Elevated Touch Drill for Back Leg Strength

To perform the elevated touch drill, all you need is a platform of some sort so that your dog can get their front legs higher than their back legs. This will increase the weight bearing load of their rear legs. We use an ottoman, a bench, or for an added challenge, a balance cushion like the K9 FitBone from DogTread. You can use anything that is handy such as a chair, or step.

• Have your dog place both front paws up on the elevated surface so that their bodies are more upright than normal. Once they are in this position, make them hold it for a minimum of 30 seconds. Some dogs, especially older dogs, might not be able to hold it for more than a few seconds. In such cases, don’t be discouraged! Over time and with daily drills, their rear leg strength will increase as will their ability to hold the position. • Once your dog can hold the elevated position for at least 30 seconds, challenge their balance by gently pushing on their body, first from the left and then from the right. The idea is to force them to contract their core and their rear legs to stay balanced. • For an extra back leg workout, try making them do a partial squat from the elevated position. How do you make your dog do a partial squat? Scratch their back where their tale meets their torso. • The higher the elevation, the more intense is the exercise so start with a low platform and work your way up to higher platforms. • Try the elevated touch drill and partial squat 5-7 days per week for 1-2 minutes at a time. You can do it while watching TV or just hanging out. Within 4-6 weeks, you should be a noticeable improvement in your dog’s back leg strength.

http://dogscouts.org/base/tonto- site/uploads/2014/10/TRAIN_K9_Fit_Strengthening_Stretching2.pdf

http://www.paradisecaninerehab.com/files/2012/08/Paradise-Canine- Rehabilitation-and-Sports-Medicine-Homework-Example.pdf

ECE’S C Strength ening Exercises By Debbie Gross Saunders, MSPT, OCS, CCRP for Agility, Part 2 Photos by Clean Run G M Y To Increase Strength in the

Dogs participating in agility need a variety of strengthening Quadriceps Region exercises not only to keep them at their peak performance, The quadriceps are located in the front of the thigh and consist of four but also to protect them against potential injuries. It is muscles—the rectus femoris, the vastus medialis, the vastus lateralis, and the vastus intermedius. The four muscles that are responsible essential to off er your agility dog cross-training activities for extending the stifl e and the rectus femoris also fl ex the hip. While on at least a weekly basis, and a daily basis if possible. If running, the dog uses these muscles to extend the stifl e. Weakness can we examine human athletes, they participate in a variety develop in this muscle group after an injury, specifi cally with a cruciate of activities in addition to their normal sport. For example, injury or a patellar luxation, or after a training hiatus. an athlete involved in track and fi eld not only trains for her Exercises to increase strength in the quadriceps region are appropriate individual event, she participates in strengthening and for: conditioning activities including weight lifting, plyometrics, • General hind-limb weakness swimming, sprinting, and long-distance running. • Poor hind-limb coordination Agility activities are wonderful for your dog, but to promote • Patella luxations—both surgical and nonsurgical his long-term health and wellness as well as to improve • Cruciate injuries performance, cross training is paramount. Part of your cross training should include strengthening. Strengthening exercises should be done with a healthy dog on a regular basis, and absolutely must be done before an injured dog Walking through tunnels returns to agility. or under tables Last month we looked at exercises for increasing hind-end awareness as well as increasing strength in the gluteal and hamstring regions. This month we’ll look at exercises to strengthen the quadriceps region and the forelimbs, and to increase core and back strength.

• The goal is to have the dog squat to go through the tunnel, and to go through the tunnel at a slow to moderate speed. The squatting motion works the quadriceps region. Controlled sit to stand • If the dog is too short for a tunnel, you • This exercise is equivalent to our performing squats can use a makeshift tunnel, such as a without any weight. short table (utility table). • Back the dog into a corner or up against a wall to avoid • Encourage the dog to go through the excess movement. tunnel or under the table so that he is in • Use treats to encourage the dog to repetitively sit and a squatting position while moving. stand for sets of eight to ten, done to two to three times. • Perform this exercise in sets of fi ve, as • Also encourage a full stand from a sit. long as a lameness does not appear.

December 06 | Clean Run 1 Hind-limb and forelimb lifts Practice contacts in small areas! • Lift the left forelimb and the right hind limb into a slight amount of And when the snow flies, work on extension and hold for 5 to 10 seconds. your contacts indoors! • Then lift the right forelimb and the left hind limb and hold for 5 to 10 seconds. • Do this exercise 10 times on each side.

The Barb Davis Contact Trainer

6 ft. bridge ramp and 3 ft. A-frame ramp Approximate angle of full-size contact obstacles Lightweight and folds for easy storage To Increase Core Stability “My contact trainer gets a great deal of use even though I have a full set and Back Strength of equipment. If I’m short on time, I can work dozens of contacts and Back and abdominal strength are commonly referred to tunnel/contact discriminations in five minutes. —Barb Davis as core strength. Core strength is vital and is used in every $155.00 plus S&H (S&H is from $45-$75 in the U.S. depending movement the dog performs in agility. The most obvious on location. Please send us your zip code to determine costs.) place these muscles are used is when a dog goes over a Built by Barb’s husband, Jeff Davis. Contact him at: jump. Good core strength produces a more controlled jump E. 22202 Vanetta, Newman Lake, WA 99025 because the dog can collect or pull himself in as he jumps. [email protected] or 509-924-3110 Think of a human diver: when he has good control, the diver pulls his body in to collect himself during the dive. Exercises to increase core stability and back strength are appropriate for: • Improving trunk control • Improving coordination and collection for jumping • Training young dogs • Weakness in the back and stomach muscles • Problems with roaching (convex curving) of the spine

Using a rocker board • Purchase a rocker board or build your own using a sturdy piece of plywood covered with a non-slip surface and mounted on a semicircular base. A BOSU Balance Trainer (an exercise ball that’s been cut in half with a platform on the top), for example, can be used as the base for your rocker board. For large dogs, the rocker board needs to be at least 8" longer than your dog and twice his width. A Buja board may be used for small dogs. • Place the dog on the board and rock him from side to side, and from front to back, until the dog tires. • The dog may sit, stand, or lie down on the board. • Place the dog’s forelimbs on the ground while the hind limbs remain on the rocker board as the board is rocked from side to side, and from front to back, until the dog tires.

2 • Place the dog gently on the Theraball so that neither his forelimbs nor hind limbs can reach the ground. Maintain the dog’s spine in a fl exed or rounded Using a position. • Initially, bounce the dog gently to promote relaxation. Most dogs do very well on the Theraball if they are slowly introduced to the ball. Theraball • Once the dog is comfortable, rock him at a gentle angle from side to side and from front to back. As the comfort level increases, rocking in all four directions can be increased in amount. • To further challenge the dog, he may be allowed to reach forward or to the side for treats. • Start Theraball activities with three- to fi ve-minute intervals. You’ll be surprised how quickly the dog will fatigue with these short sessions. The sessions can be progressively increased as the dog strengthens. • The dog may also sit on the Theraball and be encouraged to reach in diff erent directions for a treat. Looking up for a treat encourages the dog to place more weight on the hind limbs, and reaching down for a treat encourages the dog to place more weight on the forelimbs.

Sit-up Side sit-up

Doggie sit-ups • Although this is a wonderful exercise to work on abdominals, not every dog will allow himself to be placed on his back, especially on the Theraball. So exercise caution when attempting this exercise. Also, this exercise should not be performed with a dog that has any type of intervertebral disc problem, secondary to the degree of extension of the spine that is involved. The dog will need to extend his spine back and this could potentially stress the area. • While on his back, encourage the dog to lift his head and perform a degree of thoracic fl exion or forward movement to reach a treat. • Begin with one or two sets of three with sit-ups because they are so With larger dogs, you strenuous and diffi cult for the dog to perform. may fi nd that sit-ups are easier to help with when • Also try to have the dog perform side sit-ups. Some dogs may be using an egg-shaped ball more comfortable lying on their side to begin this type of activity. or physio-roll. Perform one set of three to fi ve on each side.

3 Walking down hills Walking in sand • Walking down hills focuses the weight on • Walking in sand is more diffi cult than it appears and should be begun slowly. the forelimbs. • The softer the sand, the more diffi cult it will be for the dog to walk. So start • A zigzagging descent down the hill is the this activity in hard-packed sand, if possible, and begin with two- to three- safest route and places less stress on the minute walks with the dog on leash. forelimbs. This caution is especially crucial • To increase the intensity of the exercise, walk the dog for longer distances, if a dog is recovering from a shoulder injury. up and down embankments and in zigzags.

To Increase Strength of • Pick up the dog’s hind limbs above his midline the Forelimbs or center of the back With all the jumping and landing that our dogs do in agility, they and walk him forward for need adequate forelimb strength from their carpus up to their a distance of 15' to 20'. shoulder blade. To protect the area and provide the strength • Increase intensity by increasing needed for agility, our dogs need stability and power. the time and by wheelbarrowing Exercises to increase strength of the forelimbs are appropriate the dog down hills. for: • Exercise caution if the dog has a • General forelimb weakness problem with his spine secondary to the extension involved. • Poor coordination of the forelimb • Elbow dysplasia • Arthritis of the forelimb muscle groups • Recovery from biceps tendonitis Wheelbarrowing • Recovery from scapular injuries D

Note: The author wishes to thank Pam O’Day and her Sheltie, Quest, for her assistance with pictures and advice.

Debbie Gross Saunders is a licensed physical therapist and a certified canine rehabilitation practitioner with over 15 years of experience in the field. She practices in Connecticut at the Pieper-Olson Veterinary Clinic. She and her husband also have a rehabilitation and training center on their farm in Connecticut where they specialize in the rehabilitation, nutrition, and conditioning of dogs. Her book Canine Physical Therapy is available from www.wizardofpaws.net as is her quarterly newsletter, Wizard of Paws, which features the latest in exercise and rehabilitation. Contact Debbie at [email protected]

Transferring weight from one forelimb to Transferring weight on and off forelimbs the other Digging in Using a rocker board sand or rice • Place the dog’s back feet on the rocker board and his front feet on the fl oor. • This activity is great to build • Rock the rocker board from side to side to transfer weight from one forelimb to the other. up the strength of the wrist • Reposition the dog on the rocker board as shown and rock back and forth to and shoulder fl exors and the transfer weight on and off the forelimbs. scapular muscles. • You should visibly see the muscles in the shoulder activate as the weight is • Bury a treat in the sand to shifted on and off . encourage digging. • Perform this exercise until the dog fatigues. 4 at www.cleanrun.com

Would you like to improve your dog’s agility performance while helping to prevent injuries?

Strengthening the Performance Dog Strengthening the Performance Dog By Debbie Gross Saunders By Debbie Gross Saunders Dogs participating in performance sports such as agility require Dogs doing agility and other performance canine sports crosstraining activities, including both a conditioning program need to be treated as athletes. Strength and flexibility are and strengthening exercises. Doing a variety of strengthening vital. Stretching prepares the body for movement, improving exercises will improve your dog’s agility performance and, even performance on the agility field and aiding in the prevention more important, will protect him against injuries. This video of common injuries. Learn how to properly stretch your dog. demonstrates a variety of strengthening exercises that should be This DVD contains instructions for stretching each part of your part of your crosstraining program outside of agility. It includes dog’s body so that you can create a stretching routine to address exercises to improve jumping strength and power, improve injuries or weaknesses in your dog. It also contains a complete collection and turning ability, increase forelimb and hind limb pre-agility stretching routine that you can use if you want a set strength, improve balance, and increase hind-end awareness. routine to follow.

®

6350 Frederick Road • Catonsville, Maryland 21228 Phone 410-719-6920 • Fax 410-747-9231 Rehabilitation Homework

Owner's name: Patient's name: Date: Weeks Post Op: Attending Veterinarian:

A period of standing helps strengthen muscles, aids in proprioceptive training, and provides an opportunity to eliminate. 1. Raise your dog’s food bowls so that their weight is evenly distributed throughout all four limbs and they are in a square stance. 2. Mimic weight bearing: Place your dog on their side lying down. Place one hand above their knee/carpus and one on the pad of the foot. Then act as if you are the ground and apply pressure to the bottom of the foot. Hold this for _____ seconds/ _____ times a day 3. When your dogs is standing with all four feet under the dog in a square stance and back flat, begin by lifting the left front limb and go around the dog clockwise lifting each leg, so your dog has to shift its weight to the other three limbs. a. Hold limb ______seconds/go around dog ______times b. Lift left front limb then right limb Hold ____ seconds / _____reps 4. Diagonal Stands: When your dog is standing with all four feet under the dog, lift the right front leg and the left rear leg together and then alternate to lift the other two legs. This activity works on your dog’s core balance and strength. _____reps /______times a day

Passive Range of Motion/ Massage/ Stretching: 1. Place a pillow between your dog’s legs to maintain parallel position. 2. Begin by heating the affected joint and areas around it (use a heating pad, warm moist heat, etc.), and then gently massage and stretch the heated area. 3. Place one hand above the joint and one below the joint. 4. After heating scapular region, gently move scapula in all directions as demonstrated. 5. Slowly and gently begin flexing and extending the joint as demonstrated. 6. Areas: Shoulders Carpus Hip Calf Elbows Toes Knee Hock

Moist Heat for ______minutes ______reps/ ______times a day

Weight Shifting: This activity causes the dog to shift its weight and maintain balance requiring strength and coordination. 1. Use support such as physio-rolls, walk-a-bouts, slings, bottoms-up leash, and harnesses in order to provide assistance in helping the dog bear as much weight as possible. 2. Make sure there is good footing so your dog cannot fall. 3. Rock the physio-roll to weight and un-weight your dog’s rear legs. 4. Use a toy or treat for the dog to follow from side to side or back and forth. Please use smaller movements at first and gradually progress to larger ones. ______reps/ ______times a day

Leash Walking: Walking slowly encourages the use of all four limbs in a sequenced gait pattern. Only when the affected limb is being used correctly all the time can the speed of the walk be increased. 1. Use support such as bottoms up leash, sling, boots, ties, etc. 2. Make sure there is good footing so your dog cannot fall. 3. Walk your dog in slow patterned walks such as figure eights or serpentines. During pattern walks each foot has to walk a different path. 4. Walk your dog across terrain changes such as grass vs. concrete vs. mulch, etc. ______minutes / ______times a day 5. Incorporate theraband/PNF exercise during controlled walks as demonstrated. Red/ Yellow/ Green Theraband/PNF On ______/ Off ______

Cavalettis: Cavalettis are wooden poles arranged in a straight line or circle pattern on the ground. Two by fours and porch railing are good examples and try not to use any object that will roll if stepped on for the safety of you and your dog. This activity encourages greater active range of motion, requires full weight bearing on all limbs, and also challenges proprioception, balance, and coordination. 1. Place them in a row and slowly walk your dog through them. Start with 4-6 in a row and build to more. Place them body length(shoulder to hip) inches apart_____ inches high 2. Place 4 of them in a circle pattern and slowly walk your dog in both directions. This will require each of your dog’s legs to walk a different path. 3. Pick up sticks: Take several of the cavalettis and drop them on the ground in a scattered design, slightly spread out but in a haphazard pattern. Then slowly walk your dog through the poles. ______reps/ ______times a day (up and back = 1 rep)

4. Incorporate theraband/PNF exercise during controlled walks as demonstrated. Red/ Yellow/ Green Theraband/PNF On ______/ Off ______

Hand Shake: 1. In a sit position, ask your dog to give their paw to you. Alternate left and right paws. Reps on each side ______/ _____ times a day 2. In a standing position, ask your dog to give you their paw. Alternate left and right paws. Reps on each side ______/ _____ times a day Inclines: Begin walking slowly up gradual inclines straight up and down with good footing. As the dog’s muscles strengthen and range of motion improves, steeper inclines can be introduced. This activity is low impact and increases strength of the leg muscles promoting extension of the knee and hip. 1. Gradual inclines 2. Steep inclines. ______minutes/ ______times a day

Curbs/Stepper: This activity helps improve balance and coordination, and strengthens the leg muscles. 1. Slowly walk your dog up and down a curb/stepper. Make sure your dog has a four beat walk prior to going up or down the curb/stepper. 2. Walk your dog in a serpentine pattern up and down the curb/stepper. ______reps/ ______times a day(up and down = 1 rep)

Stairs: Slowly walk the dog up and down the stairs that have good footing (carpet, concrete, etc.). This activity requires strength and balance; it will help improve coordination and power in the rear legs. For very small dogs or short-legged dogs, this activity requires extreme physical effort. As work: 1. Use support such as bottoms up leash, sling, boots, ties, etc. 2. Start with 2-4 steps in a row 3. Build to 1 flight of stairs (5-8 steps in a row) ______reps/ ______times a day

Standing/ Walking on Foam or Mattress or Trampoline:

Altering the ground surface provides a challenge to the dog’s functional walking and proprioceptive ability. This activity causes the dog to “think” and negotiate with all four limbs during the walk. It also improves balance and coordination. 1. While standing on the altered surface begin by doing some weight shifting activities. 2. Have your dog walk across the altered surface, which will encourage balance and coordination. 3. Place front/rear legs only on the foam mattress. 4. Use a toy or treat for the dog to follow from side to side or back and forth. Please use smaller movements at first and gradually progress to larger ones. ______times a day

Sit to Stand: This activity is very similar to a squat both the sitting and rising are equally important. This activity helps strengthen gluteal and hip muscles and improves active range of motion. 1. With the surgical leg against the wall, ask the dog to sit squarely for a few seconds, take steps forward, and then repeat. 2. Pay attention and make sure that the dog sits squarely with no leaning and that both rear legs are symmetrically flexed. ______reps/ ______times a day Prone to half way up : This exercise will strengthen core and abdominal muscles. 1. Begin with your dog lying flat on their side. 2. Call them from the side to encourage them to move the front half of their body up to sternal. Repeat. ______reps/ ______times a day

Half Sits: This exercise will help to strengthen gluteal, hip, and quadriceps muscles and therefore will improve active range of motion. 1. Start by backing your dog up to a step or curb. 2. Then have them sit onto the curb or set as square as possible, followed by slow raise to a stand. Repeat. ______reps/ ______times a day Quad Stretch: This exercise will help stretch the quadriceps muscle. 1. Lay your pet on their left / right side. 2. Heat the front of thigh/gluteals 3. Put hand on front of thigh and gently bring thigh past 90° 4. Apply gentle pressure to underside of foot to stretch calf and quad. ______reps/ ______times a day

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