Interesting Patients

The A-typical typical postural dyfunctional patient.

Since I have been working with many triathletes, I have seen all too many people who's glutes are inhibited to the max. Too much running forward, not enough using their bottoms to get them moving leading to too many problems. This compiled with the fact that we sit too much, drive too much, spend too much time with poor posture and leaning forward, our hip flexors get toooo tight.

That's not what this is about. What I am writing about is the patient who comes in for a hamstring strain. But rather than the hamstrings predominantly firing first when the glutes are too weak as hip extensors, in this case, the patient's glutes are strong. Strong as can be. 5/5 Manual muscle testing: I cannot break her. Hmmm. I was thrown for loop one. Test the hip flexors: Not tight. Hmmm another loop. Test the hamstrings: ouch. Ok, I won't do that again. Length test the hamstrings: those puppies are better than average. Damn another loop. Fine, 3 loops and I'm dizzy. So I step back and rethink.

Looking at her posture: this girl has relatively good posture. Except that she is slightly hyperlordotic (increased lumbar [low back] curves), exacerbated by her anterior pelvic tilt: greater than 20 degrees bilaterally. What would that do for her hamstrings and how does that relate? What haven't I tested that I could be missing? Let's look at a picture

As you can see in this picture, with an anteior pelvic tilt, the quads (on the right bottom arrow) become tight and shortened. The hamstrings become long and "weakened", the abdominals are also weak and lengthened, and the low back muscles are tight and shortened. So thinking about this cross pattern of muscle balance I test out some of these muscles. I already saw that her hamstrings were longer than the expected "normal" person. So I put her into the Thomas test position.

The back of her thigh touches the table easily, but WOAH! her knee is almost straight. And comparing the right to the left, the right has a degree of external rotation. She is a kickball player and prefers to kick balls with her right foot. What that means is her quadriceps are super tight and her sartorius on the right side is tight too. Next, I test the strength of her abdominals using a simple plank test. Palpating her spine, her spine begins to dip down at 30seconds of holding the position and she is shaking like a 9.6 on the richter scale. She manages to hold the position for 60 seconds but collapses when I tell her she's finished. That was hard for her.

Conclusion: "Weaker/inhibited" hamstrings are having to try to overpower her tight quads leading to a hamstring strain.
Solution: Stretch out the quadriceps, stretch out the low back musculature/glutes, strengthen the abdominals, and strengthen the hamstrings.

Final thought: Correcting postural deformities based on individual variations is very important. Don't treat everyone the same. Don't do what other people do, simply because their hamstrings also hurt at one point in their life. Talk to a professional orthopedic physical therapist and get yourself evaluated. Make sure they find the root cause of the problem and not just treat the problem. Stretch and strengthen by cross training and staying active.

Aloha,
Eli M Kase, DPT