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:
- Isolated muscle recruitment (Weeks 0-4): gluteus maximus exercises including sidelying clam, prone isometric gluteus maximus, and quadruped triplanar movement.
- Weight-bearing strengthening (Weeks 5-16): Monster walk, forward and backward walk with elastic band loop around thighs and step-downs
- 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.
No related posts.