Treating hamstring cramps: Functional or Structural Approach?

by Dr. Phil on May 8, 2012

Imagine this case scenario: An elite triathlete is referred to your clinic for chronic hamstring cramps in his right leg. A traditional ‘structural’ approach would involve a stretching and strengthening program of the hamstrings. A more ‘functional’ approach would include an assessment of the entire lower kinetic chain, pelvis and trunk to look for biomechanical causes of his cramping perhaps from muscle fatigue.  This functional assessment is a hallmark of the Janda Approach.

Physical therapist Tracey Wagner and colleagues described a case report of such a patient. Rather than focusing on the site of the problem, they looked elsewhere for the source of the problem. As Prof Karel Lewit said, “He who treats the site of pain is often lost.”

The patient had bilateral hamstring tightness and bilateral gluteus maximus weakness. Dynamic assessment of gait, lunge, and step-down movements was performed. The therapists noted that a lack of knee extension in midstance and terminal swing bilaterally was consistent with the patient’s hamstring tightness. In addition, excessive hip adduction and internal rotation with posterior trunk lean supported the finding of hip weakness.

The therapists theorized that impaired gluteus maximus neuromuscular control increased the load on the hamstrings during terminal stance phase, leading to the overuse and cramping. They then referred the patient for assessment at the Musculoskeletal Biomechanical Research Lab at USC with Dr. Chris Powers.

The patient’s hamstring EMG was evaluated and was found to be relatively high (48% MVIC). This supported their functional diagnostic hypothesis, and led to their physical therapy treatment plan.

The patient completed a home exercise program over 8 months, attending physical therapy once a month. The program included 3 phases:

  1. Isolated muscle recruitment (Weeks 0-4): gluteus maximus exercises including sidelying clam, prone isometric gluteus maximus, and quadruped triplanar movement.
  2. Weight-bearing strengthening (Weeks 5-16): Monster walk, forward and backward walk with elastic band loop around thighs and step-downs
  3. Functional training (Weeks 17-24): jumps and leg swings

After the intervention, the patient successfully completed 3 half-triathalons without cramping. His gluteus maximus strength increased  from 35.6 kg to 54.7 kg on the right (involved) and from 35.5 kg to 46.8 kg on the left.  In addition, his hamstring flexibility, functional performance, and hamstring EMG levels improved.

This case report supports addressing pelvic/trunk muscle dysfunction in hamstring pathology: a good biomechanical functional assessment led to an accurate pathomechanical diagnosis.

REFERENCE: Wagner T, et al. Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. J Orthop Sports Phys Ther. 2010 Feb;40(2):112-9.

 

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{ 3 comments… read them below or add one }

Sarah Abbott May 9, 2012 at 12:06 pm

This is a great case to see the exam and progression through rehabilitation. Do you think it is an issue to see such a strength imbalance at the end of therapy between the right and left gluteus maximus strength? The strength was relatively equal prior to therapy but has a greater difference after the strength program. I think it would be especially important to maintain symmetry in someone who is a triathlete as the activities are bilateral and cyclical.

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Dr. Phil May 9, 2012 at 10:32 pm

Yes, I agree that there should be symmetry in a bilateral activity; however, we naturally see up to a 10% difference in strength; it’s also not uncommon to be discharged from therapy before attaining full strength. I personally dont put much emphasis on manual muscle testing, as the movement patterns are more important. It would be interesting to see a follow up of the muscle strength after a few months returning to competition; I’d bet it’s more symmetrical.

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md majid khan May 18, 2012 at 6:25 am

Its indeed a great presentation,,, fortunately i had a similar case but a non athlete with tight hams n weak gluteii,, trained him with THERA BAND strengthening exercises for hip in supine, side lying n in weight bearing as well,, stretching for hams were done with MET technique n self stretches were taught, but the results were good and i’m happy n glad to read this paper for providing better understanding of the above,, thanks n lots of regards

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