Quick Case: Lumbar Pain, Limited Flexion, and "Tight" Hamstrings | Modern Manual Therapy Blog

Quick Case: Lumbar Pain, Limited Flexion, and "Tight" Hamstrings

I wanted to share some quick ways to restore limited toe touch with the perception of lumbar pain and "tight" hamstrings."

The case was a fit 45 yo female who presented with left lumbar pain, radiating to left posterior thigh. In terms of Lower Quarter Clinical Practice Patterns, you should be looking for
Limitations/pain in
  • lumbar sidegliding in standing to the involved side
  • lumbar extension in standing deviates away from the involved side
  • hip flexion ASLR that improves with passive testing on the involved side
  • hip IR on the involved side

In most cases, if either lumbar movement test is asymmetrical or painful, you start with repeated motion strategies in the lumbar spine and direct your manual therapies there if needed. In the case I saw today, her lumbar SGIS was symmetrical and extension was full and pain free.

From a variability standpoint, she has been a patient in the past, and knows enough to try SGIS for unilateral lumbar/hip pain, and to perform REIS prophylactically. These movements would no longer be perceived as novel by the CNS and would not change perception of the movement or area under threat.

Her ASLR and passive hip flexion were both moderately painful and limited on the left, and FN on the right. Hip IR was also limited/painful actively and passively on the involved side. The interventions I chose were
  • pain free psoas release
  • pain free positional inhibition for hip flexors
  • hold relax to improve hip flexion
    • moved her hip into hip flexion barrier (supine hip and knee flexed)
    • The verbal cue was "meet my resistance"
    • light pressure to posterior thigh was applied
    • resistance was provided 2-3 seconds and upon relaxation, the hip was further passively moved into flexion
    • this was repeated 3-4 reps until full passive hip flexion was improved
    • this was reinforced with core activated ASLR

After restoring full ASLR, standing toe touch was tested and was now full and pain free. She was instructed on passive hip flexion, held or repeated loading to inhibit her hip flexors and ASLR to reinforce the new motion actively.

Lumbar pain and "hamstring tightness" were abolished in walking and standing after this. Just in case, she was instructed on performing REIS as in the past, this was her directional preference.

Questions, comments? Chime in below or on the facebook page!

Keeping it Eclectic....



  1. Dr. E- What are your thoughts if someone is 6-8 weeks s/p FAI correction (no ROM precautions/restrictions) and they have full hip flexion in a 4 point/child's pose position but when performing PROM hip flexion in supine it is painful and pinchy? Could this be a hypertonicity issue? Would you consider similar treatments described above for your patient as she had pain with hip flexion?
    Just started following 2 months ago and I appreciate you sharing your knowledge and expertise with us.

  2. Erson,
    Did you mean to say at the end there that the standing toe touch was "now" full rather than "not"? In any event, I love the eclectic approach used here to address her chief complaints and concordant sign. Really great.
    Hey, are you coming out west at any point to teach? Namely Washington or Oregon?

  3. I corrected it, thanks! Obviously spell catch missed that one along with my eyes! Chris Johnson plans on hosting me sometime in Seattle, no firm dates yet. I am assisting him in his course in Vancouver at the end of Sept.

  4. Full motion is full motion, the "tightness" or a "pinch" is just a perception. It has to be modulated in the position, but it's not the biggest deal in the world if they can do it in functional/WB positions like child's pose or a squat.

  5. Yeah I figured auto-correct screwed it up. I see that Chris is teaching in Vancouver off his new website. I have even name dropped to our HR department his name but I have also name dropped yours back when the EDGE tool was in its earlier days (we have enjoyed its use ever since). Do the two of you do classes together for clinics as needed? We are an outpatient private practice of 7 clinics and we have about 30 PTs total

  6. Garrett PfeifferJune 17, 2015 at 2:45 PM

    With her repeated loading (or hold) to inhibit hip flexors, to what degree do you want to then fire them after with ASLR and reinforce that firing pattern from the CNS? Or does the importance of core-activated ASLR come in to play such that they are firing but in coordination with her anterior core? I understand that inhibition isn't geared to "shut something off" but I was just wondering about the timing of these things.

  7. Great question! Often high tone prevents quality contraction. My explanation is that proprioceptively, the CNS interprets the hip in this case as already flexed. This misinterpretation limits both active hip flexion and passive hip extension. Say ASLR is 45, perhaps at neutral, the hip already seems like it's at 45 due to the higher tone in the hip flexors. Make sense? That's my guess anyway.

  8. Yes, we go where we are hosted, together or individually!

  9. Garrett PfeifferJune 17, 2015 at 7:09 PM

    That works for me. I know some of this isn't concrete based on the complexity of the system, but I like to talk it through and wrap my head around what I can. Thanks for the input.