Physiotherapy with 15 variation of hamstring stretchingsn hamstring strain and low back pain

Hamstring strain in rugby players
(Ref: https://nicksportphysio.wordpress.com/hamstring-strain/)

The evidence on how hamstring complex derived this name originates from the early Germanic language as well as the butchery trade. Slaughtered pigs were hung from these strong tendons, hence the reference to ‘ham’ (meaning ‘crooked’ and thus referring to the knee, the crooked part of the leg) and ‘string’ (referring to the string-like appearance of the tendons). 

Hamstring injuries are one of the most common problems in sports medicine due to athletes’ absence in games. Their prevalence is estimated to reach 12–15% among professional football players.  It is also a major problem of track and field sports, dancing, and skiing. 

Ref: https://bodyfocusphysioclinic.com.au/risk-factors-for-hamstring-strain/

As well as, hamstring tightness was suspected to be the cause of low back pain, although, not absolutely clear. It has been found hamstring tightness in low back pain patients. Asymptomatic low back pain was better for hamstring flexibility than symptomatic significantly. However, Hamstring tightness had no influence on pelvic motion in both groups during forward bending.

Sacrotuberous ligament play a role as the junction of hamstring and lower back (Ref: https://www.clpt.fit/blog/)

The important component of hamstring stretching needs a full straight leg and simultaneously bending forward at the groin  without spine bending. To stretch in a position of anterior pelvic tilt results in a significantly greater increase in hamstring flexibility. 

Left: correct hamstring stretching with spine straigth 
Right: incorrect hamstring stretching with spine flexion
(Ref: https://www.sulmall.com/?category_id=6116823)

15 ways to stretch hamstring 

Exercise #1: Hamstring half wall stretch:Keep back straight and/or pelvic anterior tilt during stretch. You can apply with wall, chair, or any stable structure as well.

Exercise #2: Sit and reach double legs: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length.

Exercise #3: Sit and reach single leg: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #4: Stand toe touch double legs: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #5: Stand toe touch single leg: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #6: Stand hamstring stretch: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future. You can apply with table, chair, fence, or any stable structure as well.

Exercise #7: 90-90 SLR with knee bend: Straight target knee as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #8: 90-90 SLR with knee straight: Straight target knee as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #9: 90-90 SLR with knee bend with belt assisted: Put the belt at ball of foot. Straight target knee as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #10: 90-90 SLR with knee straight with belt assisted: Put the belt at ball of foot. Straight target knee as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #11: Seat toe touch: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #12: Seat and reach: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #13: Step toe touch: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future.

Exercise #14: Doorway with knee bend: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future. You can apply with table, chair, fence, or any stable structure as well.

Exercise #15: Doorway with knee straight: Keep back straight and/or pelvic anterior tilt together with knee straight during stretch. Reach as far as you feel some tension that means no need to push excess muscle length. You range of motion will increase gradually in the future. You can apply with table, chair, fence, or any stable structure as well.

        Hamstring is one of postural muscles that its tightness may be linked to postural disturbances by anatomy. The sacral nodular ligament is located between the sacrum and the ischial tuberosity, and is present in one fascial line along the erector spinae and occipital bone to the orbital ridge, and to the all posterior section of leg, including hamstring. Decreased hamstring flexibility causes non-specific low back pain or changes in lumbar pelvic rhythm that develop the posterior inclination or pelvic rotate backward. Pelvic rotation backward is one component of abnormal posture that can be found in swayback, flatback syndrome, kyphosis, lordosis, and scoliosis. This mechanics provides tension in the spinal column, sacrum fascia, ligaments and joint pockets, and a limitation of pelvic mobility due to tension in the hip flexors and extensors, which can be considered as a major cause of low back pain. Through this, self-stretching of the hamstrings can be expected to have a great effect when the pelvis is inclined posteriorly. 

However, stretching in patients with lumbar disc herniation and sciatic irritation should be very careful and under supervision from doctor and physiotherapist. 

The hamstring complex is a biarticular muscle group which works by flexing the knee and extending the hip. Many movements in daily living function need hip flexion and knee flexion at the same time, with opposing effects on hamstring length. The most common modifiable factors are imbalance of muscular strength with a low hamstring to quadriceps ratio (H:Q ratio), muscle fatigue, hamstring tightness, insufficient warm up, and previous injury. 

Lower right: terminal swing phase of running that is initiation of foot contact
(Ref: https://doctorlib.info/anatomy/running-anatomy/3.html)

The most common two specific mechanisms are described for hamstring injuries from daily living function. First, during the terminal swing phase of running, the hamstrings absorb elastic energy to contract eccentrically and promote deceleration of the limb’s advance in preparation for the initial contact of the calcaneus. In this phase, muscles become more susceptible to damage;the biceps femoris muscle is the most affected, as it is more active than the semitendinosus and semimembranosus muscles.

Second, the common damage to the proximal portion of the semitendinosus muscle is a movement of combined high power and extreme range of hip flexion with knee extension, which biomechanically matches the movements of kicking, running hurdles, and artistic dancing.

Ref: https://www.offset.com/photos/mixed-race-woman-kicking-soccer-ball-68325

Most rehabilitation programmes are based on the tissue’s theoretical healing response that include 5 phases. In the acute phase which is the first one needs only rest, ice, compression, and elevation to control hemorrhaging and minimize inflammation and pain. Step to the third phase which may be 1 - 6 weeks after injury the inflammation signs are resolved, hamstring muscle becoming less flexible. This is probably due to pain, inflammation, and connective tissue scar formation, therefore,  hamstring stretching can begin. 

Hamstring located at the back of the thigh that consists of 4 members of the hamstring family. The three proximal attachments of the hamstrings that include the semitendinosus (ST), long head of the biceps femoris (long head, lhBF) and semimembranosus (SM) muscles originate from the ischial tuberosity. 

Inner thigh to outer thigh muscles: Semimembranosus - Semitendinosus - Bieceps femoris
(Ref: https://www.istockphoto.com/)

(1) The semitendinosus muscle (ST) 

It lies in the posteromedial area of the thigh. The ST and lhBF have a common origin on the posteromedial aspect of the ischial tuberosity. The fusiform shape (from external aspect) and has a characteristic oblique or V-shaped raphe (tendinous inscription), runs distally and medially from its proximal insertion on the ischial tuberosity and lies directly on the SM.  From its origin, the ST creates a conjoined tendon with the lhBF forming an aponeurosis. The distal tendon starts below the mid-thigh and runs around the medial condyle of the tibia to its distal insertion as a part of pes anserinus. It also unites with the tendon of gracilis and gives off a prolongation to the deep fascia of the leg and the medial head of gastrocnemius.

Ref: https://learnmuscles.com/glossary/semitendinosus/

(2) The semimembranosus muscle (SM) 

 This muscle is the largest of all of the hamstrings. The SM origin is separate from the ST and lhBF that is located anterolaterally from the ST/lhBF attachment. Fibers of the proximal SM attachment are twisted before forming a proper tendon. It lies posteromedially in the thigh and has a similar location as the ST. It starts on the anterolateral part of the ischial tuberosity to the medial condyle of the proximal tibia to the pes anserinus and descends under the ST, from its wide proximal insertion. The proximal and distal tendons of SM overlap. It means that the part of fibers in the middle of SM has a connection to both tendons: the proximal and the distal. Its anatomical variation attachment may extend to the coccyx or have slips that join with the tendon of adductor magnus. 

Ref: https://www.sciencephoto.com/

The biceps femoris muscle (BF) forms the posterolateral part of the thigh. It consists of two heads: 

(3) The long head of the biceps femoris (lhBF) 

 This muscle is of particular interest given its susceptibility to injury. Its unique muscle architecture and the arrangement of its proximal tendon which it shares with semitendinosus, a feature which may explain why injuries to these two muscles can occur simultaneously. It has a common origin on the posteromedial aspect of the ischial tuberosity. The proximal tendon runs laterally after division of the conjoined tendon with the ST. Like in the SM, the proximal and distal tendons of the lhBF are overlapping.

The insertion tendon attachment divides around the lateral collateral ligament, forming two tendinous and three fascial components. Tendinous insertion is into the lateral and anterior aspects of the fibular head and the tibial plateau, while the fascial components mainly attach both heads to the lateral collateral ligament

Left: long head of biceps femoris muscle
Right: short of biceps femoris muscle
(Ref: https://learnmuscles.com/glossary/biceps-femoris/)

(4) The short head of the biceps femoris (shBF). 

The proximal attachment of short head of biceps femoris (shBF) arises on the middle third of femur. Its origin is located on the lateral lip of the linea aspera, descending distally and laterally.The shBF originates in the posterolateral region of the femur. It fuses with the lhBF in the distal part of the thigh, forming an aponeurotic structure. The conjoined distal tendon of both heads attaches to the head of the fibula. 

The ischial tuberosity is also the area of the distal attachment of a sacrotuberous ligament (STL). This ligament is an elastic and dynamic structure that fibers are descending from the sacrum to the ischial tuberosity in continuity with fibers of the lhBF. 

Red circle illustrated sacrotuberous ligament
(Ref: https://www.rehabcareclinic.com/) 

The main function of hamstring muscle is knee flexion and hip extension. For individual function outcomes the contraction of the BF rotates the tibia and fibula externally. Consequently, it prevents internal rotation of the tibia in relation to the femur. The BF is the most effective hamstring muscle in reducing the ACL-loading component produced by the QF through decreasing anterior tibial translation. The ST and SM contraction induce an internal rotation of the tibia. These muscles are antagonists of the external rotation generated by the BF. 

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. However, strengthening the hamstring both of concentric and eccentric contraction are still necessary in prevention and treatment.

Nordic hamstring exercise
(Ref: Briem K., et al. Medial hamstring muscle activation patterns are affected 3 1–6 years after ACL reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc. DOI 10.1007/s00167-013-2696-4) 

Reference:

http://robertsmigielski.pl/wp-content/uploads/2020/04/art1.pdf 

https://www.aspetar.com/journal/upload/PDF/2013121863735.pdf 

https://www.researchgate.net/publication/8134808_Standing_and_Supine_Hamstring_Stretching_Are_Equally_Effective 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725237/pdf/v039p00319.pdf 

https://www.scielo.br/j/rbort/a/XFWsjTdV97KvRXdCX3CCkzQ/?lang=en 

https://www.researchgate.net/publication/280692141_Influence_of_Hamstring_Tightness_in_Pelvic_Lumbar_and_Trunk_Range_of_Motion_in_Low_Back_Pain_and_Asymptomatic_Volunteers_during_Forward_Bending 

Park D. S., Jung S. H. Effects of hamstring self - stretches on pelvic mobility on persons with low back pain. Phys Ther Rehabil Sci 2020;9(3):140 - 148.

Physiotherapy with stretching in Piriformis syndrome

 

Ref: https://mobilephysiotherapyclinic.in/

The pain and/or paresthesia radiating in the buttock or lower part of the back or from sacrum through the gluteal area and down back side aspect of thigh especially after sitting or squatting longer than 15 to 20 minutes. The pain develops with walking and  worsens with no movement but does not relieve completely on changing position.

"It propagates the thought of “Piriformis syndrome”. 

The main function of piriformis muscle is hip external rotation, and secondary function is hip abduction during flexion. To stretch piriformis need to reverse function that is hip internal rotation and adduction.

Stretching in normal piriformis for routine flexibility is acceptable. On the other hand, stretching in piriformis disorders or sciatic nerve irritation should be under supervision from doctor and physiotherapist.  

       Although, the way to stretch piriformis looks like the way to stretch gluteus muscles, the angle of muscle fibers determine the poses. Piriformis is almost horizontal muscle fibers that work on the transverse and frontal plane, so the stretching direction will not want high hip joint bending. Gluteus muscles are almost vertical muscle fingers that work on a sagittal plane where high hip joint bending provides more tension during stretching.  

4 ways to stretch piriformis muscle

Exercise #1: Supine cross leg: supine with single hip bending between 90 - 120 degrees. The opposite hand is on the knee and pulls to the opposite side without pelvic and shoulder lifting.

Exercise #2: Seat cross leg with hip internal rotation: sit on chair with cross one leg. The opposite hand is on the knee and pulls to the opposite side. Keep back straight or lean to back rest that makes hip flexion is in between 90 - 120 degrees. If the torso and knee are too close, the glutes muscles will be stretching instead.  

Exercise #3: Kneeling with pelvic rotation: Kneeling on any cushion with the target side next to the wall or stable objects. Keep both thighs and feet together, then turn toro and pelvic to the wall. If you feel bad pain in your hip joint and/or lower back, please stop stretching.

Exercise #4: Stand with the target side next to the wall or stable objects. Un - target leg steps forward, and then step to the wall with a pelvic rotation to the wall. If you feel bad pain in your hip joint and/or lower back, please stop stretching. Additionally, this stretching may be not safe in patients with knee problems.

Piriformis is the largest muscle among the deep short hip external rotators and a functionally important muscle which attaches two joints, sacroiliac, and hip joints. 

Ref: https://wellbeinghealth.com.au/

Anatomically, origin of piriformis starting from the S2-S4 level of the pelvic surface of the sacrum, the gluteal surface of the ilium that is close to the posterior inferior iliac spine, the sacroiliac joint capsule, Sacro tuberous ligament, exiting pelvis, it advances through lateral by dividing greater sciatic foramen in two to form suprapiriform and infrapiriform foramen.

Its insertion terminates in the femur, in the medial upper side of greater trochanter. Its tendon often merges with gluteus medius muscle tendon, either in conjunction with gemelli muscles and obturator internus muscle joint tendon or by itself.

Piriformis muscle: Left (front view), Right (back view)
(Ref: https://www.yogauonline.com/)

Piriformis and sciatic nerve are strongly relative. There are also variations of sciatic nerve dividing into branches and variations of their adjacency with piriformis. Sciatic nerve or one of its branches is observed to pass through the muscle. This nerve is veryImportant neurovascular structures pass through infrapiriform foramen. 

Ref: https://musculoskeletalkey.com/sciatic-neuropathy/

It is a small two articular muscle that is the reason why it is multi - function muscle. The main function of piriformis is femur external rotation especially while femur is in extension and its secondary function is to provide abduction especially while femur is in flexion. The secondary function helps to prevent Trenderlenburg’s gait during the stance phase of walking. 

This muscle has an important role as postural muscles rather than creating power by providing pelvis with control over stable femur. So, it is regarded as a powerful stabilizer of sacroiliac joints. It helps stabilize the joint by preventing femur’s internal rotation during walking. It also tilts pelvis down laterally and posteriorly by pulling the sacrum downward toward the thigh.

So, while sacrum is stable, piriformis muscle brings femur to external rotation, abduction, and flexion, and while femur is stable, it brings pelvis to extension with bilateral contraction and causes pelvis to do internal rotation with unilateral contraction. 

Piriformis syndrome is a complex condition that is often not considered in the differential diagnosis of chronic hip and low back pain. It is caused by “compression of the sciatic nerve” at its exit point in the gluteal region after the sacroiliac ligament as it passes under the piriformis muscle. due to muscle spasm or other inflammatory process of the muscle.

Ref: https://www.ormondphysiotherapy.com.au/

The cause of piriformis syndrome may be primary or secondary which is more common than primary. Primary cause involves an anatomic background such as split piriformis muscle, split sciatic nerve. Secondary causes occur as a result of precipitating causes including trauma, leg length discrepancy, cerebral palsy and narrowed sciatic foramen etc.  Macrotrauma to the buttocks, leading to inflammation of the soft tissue, muscle spasm, or both causing nerve compression. Microtrauma may result from overuse of the piriformis muscle such as in long distance walking or running, excessive exercise. It may be due to direct pressure due to keeping the wallet in the right back pocket of trousers or jeans. Leg length discrepancy altered biomechanics leading to stretching and shortening of the piriformis muscle.

Fat wallet syndrome
(Ref: https://www.pushphospital.com/)

Sciatic nerve compression in piriformis syndrome may occur during the contraction for active range of motion in hip extension and/or abduction and/or external rotation. As well as, the movements that bring the muscle to the longest position or stretching in hip flexion and/or adduction and/or internal rotation. 

Brett et al. studied to comparison of two stretching methods and optimization of stretching protocol for the piriformis muscle that conclude the longest position of piriformis muscle  was observed that putting the hip into 115 -120 degrees of flexion, 30 - 40 degrees of external rotation and 25 -30 degrees of adduction increased the extension of muscle by 30-40% compared to conventional stretching movements. It made me confused and disagree about hip external rotation providing piriformis elongation because piriformis contraction which made it shorten to hip external rotation. So, piriformis elongation should be internal rotation.

The most common notable clinical presentation is increasing pain in the buttock especially over the piriformis muscle attachments or lower back after sitting or squatting longer than 15 to 20 minutes. The pain and/or paresthesia radiating from the sacrum through the gluteal area and down the posterior aspect of the thigh, usually stooping above the knee. Patients may complain of pain with hip internal rotation of the indisposed leg, such as occurs during cross-legged sitting or ambulation. There may be groin or pelvic pain. There may be palpable mass at the buttock and piriformis muscle may be tender.  In chronic cases there may be gluteal atrophy that asymmetrical weakness of the limb may occur. Affected limb lies in external rotation with decreased internal rotation of the ipsilateral hip joint. 

Freiberg sign is one of several piriformis special test (Ref: Retro - trochanteric sciatica - like pain: in - depth analyses of clinical symptoms, treatment option, histological and ultra structural findings in tendon biopsies)

There are several physical diagnostic assessments that stimulate signs and symptoms by stretching the sciatic nerve and hip internal rotation to induce sciatic nerve irritation. When the pain occurs these mechanisms indicate positive tests.    

Prevention of repetitive trauma (i.e., microtrauma) is effective in decreasing a patient’s risk of piriformis syndrome. Correction of the biomechanical deficiencies and functional adaptations to those deficiencies can reduce the incidence of piriformis syndrome

Home base self - rehabilitation should be recommended by physiotherapists; include a variety of motion exercises, stretching technique, and strengthening. The strengthening of the adductor muscles of the hip has been shown to be beneficial for patients with piriformis syndrome. The aim of stretching is to increase the range of motion of the surrounding muscle groups and joints i.e., gluteus muscle which you can learn more on . https://yimphysionearme.blogspot.com/2022/06/10-ways-physiotherapy-stretch-gluteus.html Do not stretch piriformis in case of inflammatory phase of piriformis because it will irritate the nerve and worse. Heat or cold therapy is usually most effectively applied before home therapy sessions because it may lessen the discomfort associated with direct treatment applied to an irritated or tense piriformis muscle.  

Hip adductor exercise
(Ref: https://www.avogel.co.uk/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference:

https://biomedres.us/pdfs/BJSTR.MS.ID.006110.pdf 

https://www.researchgate.net/publication/23475562_Diagnosis_and_Management_of_Piriformis_Syndrome_An_Osteopathic_Approach 

https://www.jemds.com/data_pdf/subhasis%20ranjan%20mitra-.pdf 

https://www.researchgate.net/publication/352092321_The_effect_of_physiotherapy_in_the_treatment_of_piriformis_syndrome_A_narrative_review 

Othman I. K., et al. Risk factors associated with piriformis syndrome: A systematic review. Science, Engineering and Health Studies 2020, 14(3), 215-233.