Use closed-chain stretches for hamstrings to increase patient compliance and rehab treatment progress

Hamstring muscle tightness is a common contributing factor for many back problems. Working with recurrent lumbar spine subluxations and malpositions of the pelvis can often be complicated by shortening of muscles in the back of the legs. Hamstring inflexibility has also been implicated in many lower extremity sport injuries. Understanding how best to improve the mobility and alignment of this important region will greatly increase patient rehabilitation outcomes.

No Hamstrings Attached
One of the more common associations chiropractors see is low back pain and pelvic subluxation. This is often accompanied by tightness of one or both hamstring muscle groups. An obvious limitation in straight-leg raising in one or both legs is identified during the initial examination. The most efficient treatment approach will need to include stretching the hamstring muscles in addition to pelvic and spinal adjustments.

Optimal hamstring flexibility is necessary for correct postural alignment, proper gait, and outstanding athletic performances. Unfortunately, most traditional techniques for stretching the hamstrings are tedious and take time to show improvement. A more effective method is needed.

Several stretches are currently in use, with some benefit seen from all of them. Patients can stretch their hamstring muscles through a variety of different methods:

Proprioceptive neuromuscular facilitation (PNF). With the patient lying on his/her back, lift the leg up into flexion. At the point of maximal stretch, have the patient push the leg back down against unmoving resistance (isometric contraction). When the patient releases the contraction, gently force the leg further into flexion while the patient contracts the flexor muscles. This is sometimes called contract-relax-contract stretching.

Runners’ stretch. The seated patient has one leg stretched out in front, and tries to either reach out with both arms to the toes, or bend forward to get the chest down to the knee (Figure 1, page 68).

Standing stretch. With the foot resting at hip level up on a fence, desk, or table, the patient’s leg is straightened. The upper body is then bent forward over the outstretched leg, bringing the chest to the knee (Figure 2).

Supine stretch. The patient is lying on the back with one leg bent at the knee, and flexed at the hip to 90°. Ask the patient to straighten the lower leg by extending the knee.

The challenge with these stretching methods is relative poor compliance, and therefore the frequent lack of progress. Even when patients perform the stretches, it is difficult to detect much improvement in flexibility.

Taking a Stance
There is a more effective way to stretch the hamstring muscles.¹ The better stretch method is termed a stance phase stretch for the hamstring. This method differs from the others in that the leg is in a forward-swing phase during the stretch period. The theory behind this method of stretching follows the trend of exercising in sport-specific and functional positions. It could also be called a closed-chain stretch, unlike all the others that use an open-chain position.

The patient starts in the standing position, then takes a short step forward with the leg to be stretched. Both hands are placed on the forward knee, both knees are bent slightly, and the pelvis is tilted forward while the lumbar spine extends. This places the hamstring in a position of pre-stretch. While maintaining lumbar extension, the subject bends forward at the hip until the hamstring muscle tightens. The stretch is accentuated further by slightly extending the forward knee.

Hold the stretch for 30 seconds, and then reverse leg positions. Each leg is stretched five times. One set of these stretches can be done 5 days a week for a period of 2 weeks (a total of 10 stretching sessions). The advantage of this method for stretching the hamstrings (besides the rapid improvement in flexibility experienced by the patient), is that the joints, muscles, and connective tissues all are bearing weight during the exercise. This provides a more specific retraining of neurological proprioceptive patterns, thereby preparing all involved structures for daily activities.

Another benefit of this type of exercising is how easily it can be performed on a daily basis. It takes no more than 10 minutes to do a total of 10 30-second stretches (five for each leg). Also, assistance is not required, nor is there any need for special equipment or workout clothing. In addition, patients do not need to get down onto the floor or drive somewhere to perform these recommended exercises.

Hamming It Up Effectively
Stretching exercises performed in a position of function (weightbearing) are more likely to train and condition the involved structures to work together smoothly. Particularly when dealing with the lower extremities, closed-chain exercises and stretches are more useful than open-chain approaches. Whenever patients have problems with recurrent pelvic or lumbar subluxations, the length of the hamstrings should be tested by straight-leg raising.

Athletes should be checked for hamstring flexibility to identify potential injury sites. The result will be an effective rehab component of tr eatment, and patients who make a rapid response to chiropractic care for pelvic and lumbar problems. CP

Kim D. Christensen, DC, CCSP, DACRB, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team physician to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, and the president of the ACA Rehab Council. Christensen is also a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached via email: kimdchristensen@hotmail.com.

Reference
1. Ross M. Effect of lower extremity position and stretching on hamstring muscle flexibility. J Strength Cond Res. 1999;13:124–129.