In 16 studies that reviewed 1,503 muscle injuries in athletes (Orthop J Sports Med. 2019 Dec: 7 (12): 232), the most frequently examined muscles were the hamstrings, followed by the soleus. Statistical analysis revealed myofascial lesions in 32.1%, myotendinous or tendinous lesions in 68.4%, and isolated muscular lesions in 12.7% of cases. Researchers observed myofascial tissue lesions most often in the soleus muscle (36.4%), followed by the hamstring muscles (27.9%). One in eight cases were isolated muscular injuries with the damage frequently located within or at the junction with the connective tissue.
The Lasegue sign or the straight leg raise test (SLR) is used to determine whether a patient with low back pain has an underlying herniated disk, often located at L5. If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive, and a herniated disc is likely to be the cause of the pain u 2. The SLR is sensitive but not specific for the disc with pain at or less than 60 degrees. The well leg raise is not sensitive but is specific for the disc.
The active straight leg raise (ASLR) is a slight modification of this standard orthopedic test3. The active straight leg raise is a screen for hip extension and hip flexion happening simultaneously. The patient is in the supine position with the knees extended and the feet together. Ask them to raise one leg as high as they can without bending the raised knee or letting either foot/toe externally rotate. Some abnormal movements we might notice during the ASLR are that the patient cannot raise their heel past the knee of the stationary leg; the raised leg shakes; the pelvis shifts (rises, rolls, elevates) position; or they feel pulling sensations or tightness in the hamstrings of the raised leg. If the patient cannot achieve the benchmark (the raised leg elevates from a plumbline drawn from the medial malleoli down to a point above the stationary mid-thigh) without compensation, pelvic control may not be sufficient for the execution of the pattern. There may be inadequate mobility of the moving hip (it requires functional hamstring flexibility in the moving hip); there may be inadequate mobility of the non-moving hip stemming from iliopsoas inflexibility associated with an anteriorly tilted pelvis.
The ASLR tests the ability to disassociate the lower extremity while maintaining stability in the torso. In the absence of low back pain (thinking of this test as a lumbar disc test), I use it to assess active hamstring and gastro-soleus flexibility while maintaining a stable pelvis and active extension of the opposite leg. By changing the degree of femur adduction/abduction and internal/ external rotation of the femur, tibia, and foot, I can isolate which hamstring muscle gives the patient the tightest or more “involved” feeling.
The benchmark for the active straight leg raise test is holding (controlling) your spine still while you flex one hip with the opposite hip staying in extension. A good active functional range is 70-80 degrees. If any compensation occurs, I know I need to address these issues. The abnormal ASLR is often associated with a sequencing issue — a motor control problem. With good core stability, we can flex one hip while keeping the other in extension without moving the spine. Reestablishing this pattern is a definite goal of therapy.
Active Care Approach
If the ASLR test reveals decreased hamstring length and palpation reveals related densification of fascia and/or a hamstring trigger point, I am going to use a method I learned in chiropractic college (but for unknown reasons, many practitioners have stopped teaching and using it) called Gebauer’s Spray and Stretch. Spray and stretch are indicated for treating muscle spasms, restricted motion, and sports injuries.
..."The effects alone from the spray and stretch are analgesic, anti-inflammatory, vasomotor, and muscle relaxation. I see these techniques as safer than dry needling or injections."...
Myorelaxant effect: I recommend learning how to blend this simple cold technique with any combo therapy (especially heat) approach, especially for deactivating trigger points and fascial dysfunction.
Over the years, Gebauer’s Spray and Stretch went from ethyl chloride spray (highly flammable, toxic, and considerably colder than is necessary) to fluori-methane spray, a safer alternative but a fluorocarbon, which may affect the ozone layer. The current formula for “spray and stretch” is nontoxic and nonflammable. Some companies have cryo machine products. These products are costly compared to the topical spray in a small canister. The combination of cold therapy, stretches, and transfer electrical capacitance and resistance TECAR (Transfer of Energy Capacitive and Resistive) therapy to provide heat and increased metabolism probably works on superficial receptors and partly on the hypothalamus. The rapid skin cooling with Gebauer’s Spray and Stretch can cool the skin by 2 to 5 degrees, while the TECAR can raise the temperature by about the same. The rapid movement of blood, lymph, and other fluid flow in and out of vessels with all the signal and messenger molecules that come with that likely challenges the autonomic reflex pathways and forces a local homeostatic response. The effects alone from the spray and stretch are analgesic, anti-inflammatory, vasomotor, and muscle relaxation. I see these techniques as safer than dry needling or injections.
Spray and Stretch Procedure
Spray: This is a distraction for the more important second step. The spray is aimed out of the inverted bottle nozzle at 30 degrees to the skin in a fine jet over about 20 to 50 cm (aim at an area rather than a single spot).
Stretch: This is the therapeutic component of the technique. While two to three sweeps of spray are applied to the affected/host muscle, the muscle is gently extended to its full stretch length.
Immediately after the stretch, I use TECAR therapy. It allows for a warming sensation with radiofrequency delivered through my hands, along with teaching patients repetitive movements (corrective exercises) to help improve the length and faulty hip extension or other movement-pattern dysfunction.
If movement of fluids (blood, lymph, etc.) is impaired in any tissue, the TECAR therapy will be helpful. If the client had an old inflammatory response occur (discovered in your history) from trauma, there would have been swelling/edema, and that leads to pressure exerted by the fluids inside or outside the joint spaces and soft tissues; it changes the resistance to the outward flow and inflow of fluids changing the surrounding area. Along with increased (dense) tissues comes vascular compression, which leads to decreased blood flow and “hypoxia and ischemia.” Fibrosis, adhesions, and densifications all cause recurrent hamstring injuries.
If your client displays an active straight leg raise dysfunction, this might be because of tight hamstrings. Get them off the table and look at the issue from other functional postures. For example, try to have them touch their toes; do a single-leg toe touch (is just the right/ left side tight?); try a long-sitting toe touch (unloads the hips); and even try a curled-up yoga child’s pose to see what the spine is doing (look for smooth spinal flexion). If you have a patient with a hamstring problem, try cold therapy like the Gebauer’s Spray and Stretch combined with heat like the TECAR heat therapy to the hamstrings. Make sure to check proximally along the whole ischial tuberosity tendons attachments, gluteals, and thoracolumbar fascia. We would also scan the lower extremity for fascial densification. Make sure you get the fascia and fleshy muscle bellies in the distal attachments at the back of the tibial and femoral condyle areas. I check the joint capsule, popliteus, gastro-soleus muscle, and fascia on the bottom of the feet too.
If the patient tells you that they have been stretching the hamstrings and they remain tight day in and day out, check their approach to stretching. It is also possible that the hamstrings might need to be tight because other muscles can’t control the pelvis. In this case, a good exercise to prescribe would integrate active core engagement while moving the hamstring (try leg lowering progressions). In practice, hamstring exercise strategies will be recommended multiple times throughout the day. Movement and exercises need to be incorporated into their daily life. In part three, I will share some exercises I use daily.
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, Bonier LM (2000). "The test ofLasegue: systematic review of the accuracy in diagnosing herniated discs". Spine 25 (9): 1140-7.
3. Br J Sports Med 2019. 53:1464-1473
4. Afonso J et. al. (2021). “The Hamstrings: Anatomic and Physiologic Variations and Their Potential Relationships With Injury Risk”. Front Physiol 2021; 12
5. www. Gebauer. com
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