Managing pain and/or dysfunction in the lower extremity can be difficult to pinpoint at times. Most of us have more than one way to treat a patient if they walk into our office with pain. Regardless of the type of assessment and treatment you provide, most often you will help someone move better, feel better and make them more aware of what they might be doing to aggravate their condition. That being said, you can also treat areas with mobilization techniques such as joint manipulation or soft tissue manipulation and make someone feel much worse. I am guilty of this for sure. This brings me to talk about the hamstrings. We see so many people on a daily/weekly basis that come into the office that have “tight” hamstrings. At first, it is easy to assume that maybe the hamstrings are tight and if they were released/lengthened that maybe this person would be able to bend forward easier, run with less pain, etc. Often we will see that when the person is standing and you tell them to bend forward and touch their toes they cannot do this or it hurts when they do this movement. Then you take this same person and lie them on their back and have them so a straight leg raise. They can now get to 90 degrees or further and there is no pain present. This is seen with lumbar spine dysfunction because we have now taken the spine out of the equation by lying flat on the ground. The leg senses that it is safe to go to 90 degrees or more and not have repercussion when doing so. Without knowing how someone moves in the loaded vs unloaded position(s) it is easy to assume that everything presents as a mobility issue when in fact it could very well be a stability issue as in this case. If position change did not improve the straight leg raise we could further investigate to see what does help. If the hamstring does not lengthen in any position throughout the screen it could be a mobility/tissue extensibility dysfunction. In that case, this is where your soft tissue manipulation technique could help this person move better and feel better.
SOURCE OF THE PAIN
Sometimes the pain source is the nerve. Sciatic nerve pain is very common. There are entrapment sites along the sciatic nerve as it courses down the posterior buttocks and down the calf into the foot that should be looked assessed and palpated.
SITE OF PAIN AND/OR DYSFUNCTION
A couple very common nerve entrapment sites in this area are as the nerve courses through the external hip rotators and again as it runs down through the hamstring group. Local hamstring pain without nerve symptomatology can be treated as if you are working a local trigger point/adhesion/hypertonic muscle(s). I find that if it is truly a local restriction in tissue glide, such as a congestion of muscle fibers that doesn’t lengthen easily or concentrically work with ease, Active Release Techniques (ART) can help restore mobility and minimize the soft tissue pain effectively and rather quickly.
OTHER THINGS TO CONSIDER
When the hamstrings are tight, and stretching, manipulation and soft tissue treatment aren’t improving the matter, we must look at other important areas. The lumbar spine can handle a ton of stress. We put ourselves through hell and back on a daily basis. We sit at computers, we lift things that we shouldn’t be lifting, we breath inefficiently, the list goes on and on. We know how to breath efficiently at birth. It is a reflex that helps us develop and maintain spinal stability as we grow and move as a baby. Later on in life, we are exposed to many poor habits and lifestyle choices that put us in situations that are not ideal to our health and movement patterns. By re-learning how to breath from our bellies and activating our diaphragm and abdominal wall musculature, we can take the load off of our spine, allowing our hamstrings not to feel so “tight” and our lower spine not to feel so vulnerable. If we can teach others how to breath properly and control central stability, i.e., the deep spinal muscles, diaphragm, abdominal muscles, the global movements for these individuals have greater efficiency and they are much less likely to develop injuries.
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