Patients often tell me that they regularly stretch the hamstring but still feel chronic hamstring tightness. In such cases, we must ask, “Does this person need more hamstring stretching?” Other patients feel post-injury hamstring shortening or post-injury residual hamstring ache. In these cases, I palpate for fibrosis, adhesions, and densifications, and when present likely require soft tissue release techniques. Either way, always reevaluate the pelvis. A tight/short hamstring is associated with a posterior ilium, whereas a tight feeling/longer-length hamstring is associated with an anterior/medial ilium. As mentioned in article 1 (bit.ly/TuckerPart1), pubalgia, anterior knee pain, and posterior hip capsule stiffness are associated with hamstring injuries. Make sure to include a posterior capsule stretch in the corrective program if that is the case.
In articles 1 and 2 (bit.ly/TuckerPart2), I noted that 80% of hamstring injuries involve the long head of the Biceps Femoris and I reviewed the hamstring muscle strength and length test procedures. Anytime there is muscle weakness, part of the rehab process is to ask, “Why is there a deficit?” and “What else is the strength deficit doing to the postural chain?” It’s easy to point the finger at a neural deficit, but the structural component is causing the stiffness. If stiffness in the hamstring(s) is there every day no matter how much time a patient stretches, think core instability. When the hamstrings are short and tight, the client wifi have a difficult time moving from the hips. They compensate by excessively flexing (losing energy) through the lumbar spine. Repetitive lumbar flexion is a direct cause of lumbar spine instability and disc herniation. We strive to have the muscles and soft tissues around the spine under appropriate tension so that we have stability while incorporating activities of the arms and legs during daily living. The teacher in you can demonstrate to the patient how to flex each hip one at a time without using the spine in a supine and standing position. In my office, I use a technique called the Bakbon to demonstrate this to patients.
Exercise progressions to consider for the hamstring
I think the most basic hamstring stretch is single-leg stretching work in the supine position. The next basic stretch is probably standing with a single leg on a bench or a chair. Teaching a patient how to do a self-contract/-relax hamstring stretch with a stretch strap is a big step up. I recommend doing this twice every day, 3 sets x 4 repetitions.
A strengthening exercise could start with performing a standing cable/resistance band (the CanDo band is a new favorite for this) and hip extension on the injured limb side. This can be done once every day, 3 sets x 6 repetitions.
Another strength exercise is the supine single-leg pelvic lift (bridge) using body weight on an injured limb—perform this once every third day, 3 sets x 8-12 repetitions. Another challenge is with the patient supine, they pin and hold the biceps femoris tendons with their own hands and flex the hip and extend the injured hamstring knee limb (slow knee extensions to the point just before pain). I have my patients do about 7-10 repetitions daily. This is for breaking up density in the bicep femoris tendons and muscles.
Another challenge is The Diver. The patient stands on the injured limb (performed slowly with simultaneous upper and lower limb movement) and performs neutral spine torso flexion through the hip joint. This can be done once every other day, 3 sets x 6 repetitions.
Lunges (front and backward) with moving back to the original standing posture are also good. I ask patients to build up to 20 repetitions per side daily.
REHABILITATION
Step-ups and side-step ups to a box that force the hip into flexion.
Core activation includes half kneeling with arm action drills.
Our role is to coach and support the patient’s stability so they can work on controlling the rib and pelvis alignment while moving the hip through the flexion/extension pattern of normal walking (eventually running or sprinting if that is a goal).
Early movement for scar extensibility
Eccentric exercises send a different signal to the brain than concentric, which seems to stimulate connective tissue repair and sarcomere series (lengthening). Eccentrics need to be on the list for optimum healing and may decrease injury risk and help reduce fatigue. The aim of eccentric hamstring rehab is to prevent shortening and can be used early in the rehab process.
The special connection I have to my patients is to bring awareness to the muscle they need to feel. If we do squats and they tell me it hurts, I either figure out a non-painful way to do it or move on to another exercise. I also get the value in going from floor-based movement to standing exercise. Double-leg stance goes to staggered stance, goes to step-ups, goes to double-/single-leg dead lifts. I also never forget the value of proprioception training.
The last 3 pieces of information and the hamstring “elephant in the room” in this 3-part series I want to share are
1. The Nordic hamstring curl. It preferentially activates the Semitendinosus and Bicep femoris short head, and increases fascicle length leading to less injury risk.
2. The 45-degree hip extension and Romanian dead lift activate the Bicep femoris long head and Semimembranosus.
3. Isometrics develop fatigue resistance, which means every runner in every sport can use this type of exercise. Hamstring isometrics can be done daily.
Nutrition Recommendations for Hamstrings Injuries
• Vitamin C
• Collagen
• Peptides BPC-157
• Patients benefit from vitamin C to promote collagen synthesis and includes Proline
In summary, our hope is that using the new tools and technology wifi help us increase mobility, increase soft tissue gliding/motion, and control joint range of motion. Let’s learn to apply corrective exercise strategies to control the local (deep inner) muscles to control segmental translation; unload pain-sensitive tissues; position joints to take away pain-sensitive tissues to promote healing and decrease pain for our patients.
Dr. Jeffrey Tucker is known as the Biohack Doctor and practices in West Los Angeles, CA. Visit his website at www.DrJeffreyTucker.com
References
1. Speed C (2004). “Low back pain.” BMJ 328 (7448): 1119—21.
2. Deville WL, van der Windt DA, Dzaferagic A, Bezemer PD, Bouter LM (2000). “The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. ” Spine 25 (9): 1140-7.
4. Br J Sports Med 2019. 53:1464-1473
