In April of 2021, a systematic review — a research study that compiles themes from the current body of evidence — assessed the effects of strength training and stretching on improving flexibility.

Global Mobility 

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Mobility exercises that can be used in a full-body, catch-all format can be quite effective as a part of your overall warm-up routine. These type of exercises can be used prior to strength training or sport participation, and even as part of an active recovery or “off-day” circuit.

 

🎯Spiderman Progressions ⤵️  reposted with permission from Matthew Ibrahim's Instagram

🧱 The Spiderman exercise has been around for quite some time and fits really well into the movement preparation/warm-up section of a training program. Additionally, it can also be used as a mobility "filler" drill in between your lifts and also on active recovery days for general health.

In this quick video, I demonstrate how to use an EDGE Suspension Trainer to quickly and easily improve toe touch. Activating an isometric flexion pattern is usually enough to improve this pattern. Activating the flexion pattern without the perception of stretch rapidly increases mobility. Try it and leave comments whether or not it worked for you!

A lot of videos and experts out there will tell you using a mobility ball is a great way to decrease pain and increase mobility. They are not wrong about that. What could be better is the instruction itself. Like all manual techniques, you don't have to use a lot of force or make it uncomfortable to get rapid improvement.

This dynamic warm-up is meant to be performed before each training session and game. It should be introduced in the pre-season period and maintained throughout the season. All sections of the warm-up should be completed in order with the exception of the strengthening component, which should not be performed prior to games.

Setup:
Two lines of cones should be lined up 5 yards away from each other, with 5 yards separating each cone. Players should queue in two lines, one behind each set of cones. Players should stay even with the player in the line across from them throughout the warm-up. On the way down the line of cones, players should stay to the inside, and as they make their return, should stay on the outside of the cones.

4 Great Dynamic Warm Up Drills

Part 1: Dynamic Movement

The first player in each line will begin by jogging down along the inside of the cones. The next player in line should begin when the player in front of them reaches the next cone. When players get to the end of the cones, they will back pedal back to the starting position. They will then jog down again, but at the halfway point they will transition into a back pedal. When they reach the end, they will begin by back pedaling and at the halfway point they will turn and jog forward the rest of the way back. The next movement is a side shuffle with a change of direction every 2-3 steps, which will be performed both down to the end of the cones, and back to the starting cone. These previous three exercises will help players prepare for transitory movements that they will frequently need to perform during their sport. Players will begin the next movement by facing their partner across from them and performing a carioca with a knee drive down to the end and back again, facing the same direction. Finally, players will perform a low skip down to the end, and a high skip aiming for power on the way back. Descriptions of the different movements are below.

1. Jog
2. Back Pedal
3. Jog to Back Pedal - At the halfway point, players should perform a 180 degree turn from a forward jog into a back pedal. They should continue to travel in as straight a path as possible without deviating too far in either direction. It takes a fair amount of neuromuscular control and proprioceptive awareness to be able to perform this efficiently, so younger players may have a difficult time at first.
4. Back Pedal to Jog - On the return to the starting cone, players will begin by back pedaling and, at the halfway point, will transition into a forward jog. This one is challenging to players because it forces them to turn into an area in which they have no visual reference.
5. Side Shuffle with Turns - Throughout this movement, players should keep their knees bent, toes pointed in the same direction the player is facing (not the direction in which they are moving), and maintain a slight forward trunk lean. They should not click their heels together or cross their feet over each other.
6. Carioca with Knee Drive - This is similar to the basic carioca that most players and coaches are familiar with, but it adds more of a power producing component and is a precursor to fast pace change of direction training. As the athlete brings their back leg forward across the front leg, they should drive the knee up and across their bodies. This is meant to train a quick hip drive to change direction and accelerate.
7. Low Skip - In this movement, athletes are performing an abbreviated version of a skip. They are still bringing their knees high, but they are taking smaller steps and their bodies are staying low to the ground. There should not be much vertical excursion as they perform this movement.
8. High Skip - In this variation of the skip, players are exploding off of one leg while driving the opposite knee into the air to get as much vertical excursion as possible. A common movement pattern seen in youth athletes is that they will drive up the arm on the same side as the knee that is driving up. For the purposes of optimizing performance through efficient movement strategies, cue athletes to drive the opposite arm and leg up at the same time. Doing so mimics walking and running patterns. One reasonable exception to this would be when training basketball players who need to be able to produce power while driving up the arm and leg on the same side of the body as they go up for a layup.

Part 2: Dynamic Stretches

In this component of the dynamic warm-up, players begin at the first cone, perform the stretches down to the last cone, and then jog back to the beginning. Holding long, static stretches can potentially hinder performance, so players should only hold these stretches for 3-5 seconds before moving on to the other side. The stretches described below target some of the main muscle groups that are used in soccer including the quads, hamstrings, calves, hip muscles, and groin. Make sure athletes are feeling the stretch where they are meant to be feeling it. Below are some modifications players can make if they are not feeling the stretch properly.

1. Walking Quad Stretch - Players should grab their ankle, pull it straight back behind them with a bent knee. If they do not feel a stretch in the front of the thigh, then have them squeeze their glute muscles for more of a stretch. Cue athletes to keep the knee of the leg they are stretching pointed toward the ground
2. Figure 4 Stretch - Players will cross one ankle over the opposite knee, and then sit their hips down and back as though they are going to sit in a chair. They should feel a stretch in the back of their hip. If they do not feel a stretch, have them either sit down lower into the stretch, or they can grab hold of the leg they are stretching from the shin, and pull the leg up towards their chest, keeping their shin parallel to the ground.
3. Airplane Stretch - This movement not only provides a stretch to the calf and hamstring, but also helps practice single leg balance. Players will begin by standing on one leg and bringing the other leg straight back behind them as they hinge forward from the hips. Both hip bones should remain facing the ground and players should not rotate at the hips or trunk. The players’ elevated leg should be in as straight a line as possible with their back as they slowly lower down, and arms out to the side to form an airplane shape.
4. Triple Threat Lunge - This is also commonly referred to as “World’s Greatest Stretch”, and for good reason. It helps to stretch the hamstrings, hip flexors, and calves, all of which are common areas of sensations of stiffness or tightness in soccer players. The players begin by taking a large step forward with the left leg, going down into a low lunge position with the left elbow inside the left knee and the right leg as straight as possible. Keeping the back knee straight will provide a good hip flexor stretch. The player will then rotate to the left, reaching the left arm up towards the sky, and then rotate back to neutral and place the left hand along the outside of the left foot. The final step is to shift the hips backwards and straighten the front knee while attempting to keep the hands on the floor. Once the knee is straight, pull the toes up off the floor for more of a calf stretch. Repeat on the other side.
5. Inch Worms - To begin inch worms, players will reach down to the floor and place both hands on the ground (it is ok if they have to bend their knees). From there, they will walk their hands forward until they are in a plank position. Next, they are to take small steps forward towards their hands, driving the heels down toward the ground each step of the way. They can also try to angle their feet in slightly as they walk their feet towards their hands.
6. Lateral Lunges - In this dynamic stretch, players will face sideways, take a step out with their lead foot, bend that knee, and shift their body weight towards that side in order to feel a stretch in the opposite groin area. After holding for 3-5 seconds, they will stand back upright and perform a small hop off the front leg to pivot and turn to face the opposite direction and perform on the other leg.

Part 3: Plyometric Training

In this portion of the dynamic warm-up, players will begin by bounding from the start cone to the end, jogging back to start, performing broad jumps down to the end cone, jogging back to start, and then performing single leg hop and hold halfway down on one leg, and the rest of the way with the other leg. Once they have reached the end cone after their last single leg hop, the first player in each line will jog back to the starting cone, and the players behind her will line up along the cones facing the other line of players. From there, players will perform the single leg lateral hops, square rotational hops, and split stance hops. For all of these exercises, athletes should be trying to keep their knees over their ankles and not extending beyond their toes,  get >30 degrees of knee flexion upon landing, and sitting their hips down and back with a slight forward trunk lean. It is helpful to tell players that they should not hear themselves or their teammates landing in order to improve their ability to absorb load and force.

1. Bounding - Begin by standing on the left foot, hopping forward and diagonally to the right, and landing on the right foot. Hold the landing for 3 seconds and then hop from the right foot, forward and diagonally to the left, and land on the left foot. Continue this process down to the end of the cones. When performing this exercise, players should make initial contact of the ground with the ball of the foot, then immediately drop the heel down, bend the knee, and sit the hips back with a slight forward trunk lean.
2. Broad Jumps - Players begin with feet about hip width apart, sit back into a squat, and then jump forward to land on both feet and sink down into a squat again. Players should try to land with both feet about hip width apart and facing forward, initial contact is made with the balls of the feet first and then immediately drop the heels down and sit back into a squat.
3. Single Leg Hop and Hold - Here, athletes will hop forward on one leg, hold the landing for 3 seconds, and then hop forward again on the same foot. At the halfway point down the line of cones, athletes will switch to the other leg. If an athlete is having difficulty performing this movement, tell them to take smaller jumps and focus on the quality of their landing as opposed to the distance they jump. If they need to regress the single leg aspect, they can begin by jumping off one leg and landing on both, then jumping off both legs and landing on one, and then they can go back to single leg hops.
4. Single Leg Lateral Hops - At this point, players should be lined up facing the line across from them. They will stand on one leg, hop to the side, hold the landing, then hop back to the starting position and landing on the same leg. They should repeat this 5 times on each leg. If this is too difficult, players can perform skater hops instead in which they will begin on the left leg, hop to their right and land on the right leg, hold the landing for a second, and then hop from the right leg to the left and land on the left leg.
5. Square Rotational Hops - Similar to the Broad Jumps, players will begin with both feet on the ground about hip width apart. They will then sit down into a squat, jump straight up into the air, turn 90 degrees to the right, and land facing what was previously their right side. This will be repeated 3 more times until the player is facing the way they started. They will then repeat this process going to the left.
6. Split Stance Hops - Players will begin in a split stance position (step one foot forward in front of the other), and sink down into a split squat. From there, the athlete will drive up into the air, bringing the back leg to the front and the front leg to the back, and then sinking back down into that split squat position. The opposite arm should drive up with the knee as it comes forward to mimic running. Players should be able to stay in one spot as they perform these jumps. Perform 5 repetitions on each side (10 total jumps).

Part 4: Strength Training

The strengthening component of the dynamic warm-up should be performed prior to training sessions, but not games. This is to prevent muscle fatigue prior to a game. As players demonstrate mastery of each exercise at the prescribed repetitions, increase the amount that they are performing. For example, if they are able to perform 10 squat to heel raises without their mechanics breaking down (often a sign of fatigue) for two training sessions in a row, then increase to 12 repetitions the following session. For this part of the dynamic warm-up, players should still be positioned in the same place they were for the end of the plyometric training portion.

1. Squat to Heel Raise - Players will begin with feet about hip width apart, facing the line of players across from them. They will sit down into a squat, stand back up, and then go up onto their toes to perform a heel raise. Begin with 8-10 repetitions and work up to 15-20 repetitions as the season goes on and the players’ mastery of the movement improves.
2. Split Squat Isometric Holds - Set up is the same as it was for the Split Stance Hops in the Plyometrics portion. One foot will step slightly ahead of the other and sink down into a split squat. The back knee should be hovering just above the ground. Players should hold this position for 20 seconds to begin with and progress up to 60 second holds on each side.
3. Bridges (Progression  to Single Leg Bridges) - Players will now lay on their back with their knees bent and feet flat on the ground. They will squeeze their glute muscles and lift their hips off the ground, keeping their backs and the backs of their thighs in as straight a line as possible. They will hold for a second at the top, then slowly lower back down. Their hips should remain level throughout the movement. Once they are able to perform 20 repetitions, they can be progressed to Single Leg Bridges. Make sure they are not swinging the other leg and utilizing momentum to lift their hips off the ground. The leg that is not working should be straight up in the air, with the soles of the feet pointing towards the sky.
4. Hamstring Walkouts - Players start in a bridge position and then take little steps out until the legs are completely straight, and then bring the legs right back up to the starting position. Players should perform 6 total walkouts, and work their way up to 12.
5. Plank with Hip Extension - From a forearm plank position with the back of the body in as straight a line as possible, and without over extending or arching at the low back, players will kick one leg straight up off the floor a few inches, and then return it to the floor and repeat on the other side. Their hip bones should stay facing the floor throughout the exercise. Have them perform 5 on each side to begin with and work their way up to 10 on each side.
6. Plank with Rotating Hip Drops - From a forearm plank position, players will rotate at the trunk to bring their right hip to touch the ground, go back to the middle position and pause, and then rotate to touch the left hip to the ground. Players should always pause for a second in the middle before rotating to the other side. Movements should be slow and controlled. Begin by performing 5 on each side and gradually work up to 10 on each side.
7. Plank with Hip Abduction - From that same forearm plank position, players will bring one leg out to the side, return it to the middle, and then repeat on the other side. The leg that is moving should remain about an inch or two off the ground and the trunk should not rotate.
8. Side Plank Thrusters - From a forearm side plank position, drop the hips to the floor, and then push them into the air as high as possible. Perform 5 times on one side, then switch to the other side. Eventually work up to performing 10 repetitions on each side. The body should be in a relatively straight line from the shoulder to the hip to the ankle.
9. Side Plank with Hip Abduction - From a forearm side plank position, slowly lift the top leg off the bottom leg and then lower it back down again. Begin with 5 repetitions on each side and then work your way up to 10 on each side. The toes of the working leg should face straight ahead and not rotate up to the sky.

Thanks again to Dr. Nicole Surdyka PT, DPT, CSCS 

@dr.nicolept on instagram

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

A blog reader recently submitted a great question,

Hello. I recently purchased your knee terminator but wanted to inquire about hip OA….I currently have a large caseload of patients with severe articular changes at the hip. I’ve use Mulligan, Hip IR/ER oscillations, REIL, wall shifts, etc. but don’t seem to see tremendous changes in ROM…could you offer suggestions on patients that you have treated that present in this fashion. Thanks for your time.
Mike

Q&A from a previous MMT Seminar Attendee. I show both lateral tibial glide to improve ankle mobility (and knee stability) plus tibial internal rotation to improve knee mobility, ankle mobility, and knee pain during functional activities. Isn't doing lateral tibial glide promoting tibial external rotation thus negating the tibial internal rotation that should be occurring during closed chain knee flexion?

Lateral Tibial Glide vs Tibial Internal Rotation for Knee Pain

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Another epidemic I see in the clinic, online, and in the gym is smashing or rolling out of trigger/tender points. Like ANY technique, this works to improve mobility and decrease discomfort, but can be entirely pain free. Here is how to use a mobility ball with some diaphragmatic breathing techniques in a quicker and often much more comfortable manner.

Mitch Starkman from The Movement Centre demonstrates with a upper trap variation in this video.

A Better Way to Use a Mobility Ball

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Often our mobility is limited by our amount of perception of stretch, not actual soft tissue length. In this video, I go over one of my favorite ways to reset the hip with repeated hip flexion, then use the hip extensors in a half kneel combined with reaching and breathing to further decrease stretch perception.

Load up the new threat free hip flexion with a goblet squat or other loaded squat variation.

A Better Way to Stretch the Hip Flexors

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Assessing and treating a lack of mobility in lateral tibial glide can help with ankle mobility, particular in dorsiflexion. It also helps knee stability when there is valgus with closed chain activities. Patients need not only self treatment, but also self assessment, so they have baselines to know if they are appropriately dosing their home exercise program.

For quick refence- previous posts.

Lateral tibial glide assessment

Lateral tibial glide variations

Self Lateral Tibial Glide Assessment

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Pin and stretch type soft tissue techniques are very popular. Early on in my career I used them to great success along with great discomfort! However it's a fallacy that with great improvement comes great discomfort (with manual techniques).

One of the main tennets of Modern Manual Therapy is that any technique can be pain free. Here is my modified version of a subscapularis inhibition - don't call it release or Greg Lehman will come after you! 

This along with a Lat Positional Inhibition are two great ways to improve shoulder ER and overhead mobility with little to no discomfort. Make sure to follow this technique up with wall angels/slides or repeated shoulder extension.

Thoughts? Chime in below at the bottom of the post! Yes, comments are now back after popular demand!

Pain Free Subscapularis Inhibition

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

HOW TO BEST MANAGE ‘PERCEIVED HAMSTRING TIGHTNESS’

The second part of this blog explores the treatment techniques available to us to improve hamstring tightness, and the research which compares these techniques.

The main point raised from the previous blog was that hamstring tightness is commonly a reflection of neural mechanosensitivity. With this view in mind, it can be hypothesised that exercises thought to target the neural mobility or the neurodynamics system would be better methods of treating ‘perceived hamstrings tightness’ (Mhatre, et al., 2013, p. 155).

RESULTS OF THE STUDIES INVESTIGATING TREATMENTS FOR PERCEIVED HAMSTRING TIGHTNESS.

One thing we know from clinical practice is that passive stretching works .... But can we make our results even better?

Marshall, et al. (2011) investigated the effect of passive lower hamstring and gluteal stretching over a four week period, on muscle length, stiffness, stretch tolerance and strength, in young asymptomatic individuals. Their results refuted the premise that stretching leads to reduced muscle strength and they established that passive stretching 5 days a week for 4 weeks will result in a 30% reduction in muscle stiffness and 20% increase in muscle extensibility, without a change in stretch tolerance or strength.

The exercises used in this study included a supine hamstring stretch, a supine gluteal stretch, a seated gluteal stretch, and a deadlift/good morning hamstring stretch, with each exercise held for 30 seconds and repeated 3 times. This study looks solely at passive stretching. Similar studies which then compare passive stretching to/or in combination with neural mobility exercises demonstrate an even greater improvement in overall flexibility.



Image: (Marshall, et al., 2011, p. 538)

The following studies have a stronger neurodynamic focus...

Castellote-Caballero, Valenza, Puentedura, Fernandez-de-las-Penas, and Albuquerque-Sendin (2013) conducted a pilot study with 120 patients suffering from bilateral short hamstring syndrome. Their aim was to identify the immediate effect of neurodynamic hamstring sliders compared to static hamstring stretching on hamstring flexibility. Neurodynamic sliders were performed for 90 seconds on each leg, which is a dosage consistent with many other studies. This included a passive hip/knee/ankle slider in supine. Their results showed that while static hamstring stretching resulted in a 5 degree increase in hamstring flexibility, neurodynamic sliding techniques produced a 10 degree increases (statistically significant). The authors concluded that neurodynamic sliding techniques are more effective in the short term than static hamstring stretching.

Castellote-Caballero et al. (2013) conducted a pilot study (a second one) which evaluated the immediate effect of neurodynamic sliding on hamstring flexibility in healthy soccer players. They compared the effect of 5 x 60 seconds of an active slump slider to a control group, and measured the change in range during the passive SLR test. The results revealed that neural sliders produced on average a 8 degree improvement in available range of the SLR test, while no improvement was noted in the control group.

Mhatre, et al. (2013) compared Mulligan's bent leg raise and two leg rotation (neural mobility) versus passive/active hamstring stretches in 56 young female physiotherapy students who reported perceived hamstring tightness. They assessed changes in hamstring tightness in the Active Knee Extension Test and Slump Test. The treatment group received 3 x 30 seconds of the Mulligans bent leg raise and actively performed a double leg lumbar rotation 3 x 30 seconds with their feet lifted off the floor. The control group received 3 x 30 seconds of passive hip flexion strength with knee extension and actively performed a static hamstring stretch 3 x 30 seconds. At baseline the average knee flexion angle on the active knee extension test was 34 degrees for both groups. Both groups demonstrated a significant reduction in knee flexion angle, and although the treatment group has better results compared to the control group, the difference between groups was not statistically significant. These outcomes were taken immediately post treatment and no long term comparison was made. The authors concluded that exercises which target neural mobility tend to be more effective in reducing perceived hamstring tightness.

So there are three studies that support neurodynamic-centric hamstring exercises but what exercises are they referring to? 

NEURODYNAMIC OPENING TECHNIQUES

Neurodynamic techniques can involve numerous variations and changes in position. The most important factor is to determine a suitable starting position for the specific patient (supine, side lying or sitting), determine if a sliding or tension dysfunction is the main focus for treatment and then decide on the degree of resistance applied to each technique. Shacklock describes neurodynamic treatment for restricted sciatic nerve mobility in the hamstring in the form of a sliding dysfunction and tension dysfunction. (The research above refers specifically to sliding dysfunction).

Proximal and distal sliding dysfunction.

Level 1. This involves a passive straight leg raise with ankle plantar flexion during hip flexion, and ankle dorsiflexion during the lowering phase.

Level 2. In long sitting (with a pillow under the knee) the patient performs the distal slider with ipsilateral trunk lateral flexion and ankle dorsiflexion. The proximal slider involves contralateral trunk lateral flexion and ankle plantarflexion.

Tension dysfunction (use cautiously).

Level 1. During the straight leg raise movement apply gentle ankle dorsiflexion and hip internal rotation.

Level 2. In long sitting (as above for sliding technique) the patient performs gentle knee extension. Alternatively in long sitting a tension treatment can be used by using cervical flexion, knee extension and ankle dorsiflexion.

SLUMP SLIDER / TWO-ENDED SLIDER

The two-ended slider (AKA slump slider) is categorised as a lumbar spine treatment, which I commonly use in clinical practice for restricted hamstring mobility/ straight leg raise dysfunction. For a video of the slump slider check out the original blog


Image: Slump slider (Castellote-Caballero et al., 2013, p. 159).

The slump slider can be performed in side lying (painful side uppermost) or in sitting and involves combined knee extension/cervical extension and knee flexion/cervical flexion. Shacklock describes the treatment being performed with both legs moving simultaneously, but it can also be performed unilaterally or by alternating legs. It is a fantastic home exercise program which replicates treatment and allows for patients to independently work on their restricted mobility. For further description refer to Shacklock (2005, p. 202). 

MULLIGAN'S BENT LEG RAISE

The Mulligan's Bent leg raise technique is a painless muscle energy technique which involves isometric contraction of the posterior thigh muscles. Begin in the position seen here, with the affected knee on the therapist's shoulder and take the leg as far into hip flexion as possible without pain. The patient is asked to pull their heel down into the therapist's shoulder to create an isometric contraction and following relaxation, the hip is moved further into flexion.

The post isometric contraction relaxation is proposed to improve connective tissue extensibility, while moving the hip into flexion creates a caudal glide on neural structures and nerve trunks, helping to offload neural structures and disperse neural oedema. If there is pain move the hip into abduction and reassess. If this does not remove the pain, abandon the technique. Mulligan stresses the importance of the the BLR technique being painless. You may also wish to add a small amount of traction during the sustained stretch. After three repetitions lower the leg and reassess the SLR test. (Mhatre, et al., 2013, Mulligan, 2010)



Image: (Mhatre, et al., 2013, Mulligan, 2010)

MULLIGAN'S TWO LEG ROTATION

Mulligan's two leg rotation technique (self treatment) again is performed as a painless treatment for patients with a restricted straight leg raise. It can be performed by the therapist or independently by the patient. Similar to the BLR technique, this is used for patients without pain below the knee.

Mulligan also refers to the straight leg raise with compression/traction as a treatment for a restricted straight leg raise with symptoms above the knee. For further details refer to his text Manual therapy, NAGS, SNAGS, MWMS, etc. The above two techniques were evaluated in the research commented on above.




Image: Mulligan two leg rotation technique (self treatment) (Mulligan, 2010, p. 59).

STATIC HAMSTRING STRETCHES

There are many variations of a static hamstring stretch which can be performed by the therapist or independently by the patients.

In the available research static stretches were held for 30 seconds and repeated 3 times for a single treatment and repeated up to 5 days a week.



Image: (Mhatre, et al., 2013, p. 157)

HOW CAN THIS BE APPLIED TO CLINICAL PRACTICE?

Assessment
Neurodynamic assessments such as the straight leg raise and slump test should be an essential part of assessment and reassessment.

A point to remember is that the SLR test has been measured at the point which P1 occurs. Shacklock emphasises that for a SLR test to be positive, the test should reproduce the patients symptoms. Few studies comment on the range at which P1 was felt and the exact location/description of the symptoms. Being guided by the work of Maitland, Shacklock and Butler, it is import to make the tests reproducible and to ask “Is that your pain? ”, “Where do you feel that?” and determine what happens to the symptoms with further structural differentiation. There is no mention in the research where P1 was felt on these patients.

Treatment

Overall it can be concluded that exercises which target neural mobility are more effective in reducing perceived hamstring tightness. Based on this evidence we may need to revise our training programs and home-based exercise programs to target neural tissue mobility more than muscle extensibility.

Limitations in the research.

One major flaw in the available research is that all subjects are healthy and asymptomatic. This research provides clinicians with the treatment effect these techniques have on healthy individuals. There is little evidence to show the effect on those suffering from injury and the long term effect of such techniques. Therefore it is difficult to speculate how long exercises should be continued with long term to correct the asymmetry that reduced ‘hamstring length’ has on a particular condition.

And finally, high quality studies are lacking and the available studies are both of lower quality and investigate only the immediate effect of the exercises. Many studies use a generic dosage of 3 x 30 seconds for treatments and there is no evidence on dosages. Authors such as Butler and Shacklock provide further information and guidance regarding dosages of neurodynamic techniques.

Sian

Sian Smale is an Australian-trained and APA-titled Musculoskeletal Physiotherapist. Sian has been writing a Physiotherapy evidence-based blog for the past 3 years called Rayner & Smale. Sian is based out of San Francisco and continues to write and teach Clinical Pilates while working towards her Californian Physical Therapy license. Sian has also created a free, online pregnancy and post-natal home-based workout program Hey Fit Mama.

REFERENCES

Butler, D. S. (2005). The neurodynamic techniques: a definitive guide from the Noigroup team: Noi Group.

Castellote-­Caballero, Y., Valenza, M. C., Martín-­Martín, L., Cabrera-­Martos, I., Puentedura, E. J., & Fernández-­de-­las-­Peñas, C. (2013). Effects of a neurodynamic sliding technique on hamstring flexibility in healthy male soccer players. A pilot study. Physical Therapy in Sport, 14(3), 156-162.

Castellote-­Caballero, Y., Valenza, M. C., Puentedura, L., Fernandez-­de-­las-­Penas, C., & Albuquerque-­Sendin, F. (2013). Immediate effects of neurodynamic versus muscle stretching on hamstring flexibility in subjects with short hamstring syndrome.

Cleland, J. (2005). Orthopaedic clinical examination: an evidence-­‐based approach for physical therapists: WB Saunders Co.

Hengeveld, E., & Banks, K. (2005). Maitland's peripheral manipulation: Elsevier/Butterworth Heinemann.

Marshall, P. W. M., Cashman, A., & Cheema, B. S. (2011). A randomized controlled trial for the effect of passive stretching on measures of hamstring extensibility, passive stiffness, strength, and stretch tolerance. Journal of Science and Medicine in Sport, 14(6), 535-540.

Mhatre, B. S., Singh, Y. L., Tembhekar, J. Y., & Mehta, A. (2013). Which is the better method to improve “perceived hamstrings tightness”–Exercises targeting neural tissue mobility or exercises targeting hamstrings muscle extensibility? International Journal of Osteopathic Medicine, 16(3), 153-­162.

Mulligan, B. R. (2010). Manual Therapy:" nags"," snags"," mwms" Etc. Optp.

Shacklock, M. O. (2005). Clinical neurodynamics: a new system of musculoskeletal treatment: Elsevier Health Sciences.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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On a near daily basis, I am asked what new technique I’m currently employing that is helping my clients move, feel, or function better is. As a hybrid strength coach / physical therapist my answer to people on both sides of that equation is eccentric isometrics as I’ve seen great results in both strength gains AND movement control!

What are Eccentric Isometrics?

Eccentric isometrics are a lifting technique that combines a slow eccentric contraction with an isometric contraction at end range (end rage of proper control) and an explosive concentric contraction.

Most important to the performance of eccentric isometrics is their focus on movement quality! Quite commonly, strength movements are performed very rapidly and while proper form is often discussed, it is rarely the main focus of a lift. Eccentric isometrics have the athlete or patient really honing in on their positions as they lower and hold the isometric contraction.

The proprioceptive input and neuromuscular control demands of eccentric isometrics are incredible and this tool has repeatedly produced rapid improvements in the movement patterns of the individuals I work with.

Typically I perform a 5-7 count negative with a 3-5 count pause in the stretched position but these numbers can vary. It is important to note that the bottom position means that position that can be held with proper form and not end rage of available passive motion. For example, in a squat the athlete would lower to where they can maintain a neutral spine and not bottom-out by relaxing everything and resting with their buttocks resting passively on the shins.

For reps, I tend to go much lower than usual, as the tempo is so slow. I usually perform 2-4 reps and 3-8 sets.

Obviously, due to the slow tempo, loading will have to start lower but can be aggressively increased so we start at around 50% of 1RM and these can be progressed as high as 90%!

For exercise selection, almost anything that can be safely loaded that you can perform with good technique is fair game. I’ve used it with multiple squat variations, Romanian deadlifts, pullups, rows, weighted-pushups, etc.

Benefits of Eccentric Isometrics

The biggest benefit I’ve found is in the quick correction of movement patterns. The slow eccentric portion is performed with the athlete focusing intensely on proper movement pattern. For example, the athlete who is shooting their knees forward while squatting will really focus on pushing their hips back to better load the hip musculature. The isometric hold at the bottom also really helps athletes “own” those difficult positions.

The focus on proper movement patterns plus the huge motor unit recruitment during eccentric isometrics also mean it is a great tool for strength and hypertrophy, often overlooked components of rehabilitation programs.

Eccentric isometrics are a fantastic tool that has serious benefits for both the fitness and rehab worlds. They are one of the many tools given in Dr. Zach Long’s “Master The Squat” video and ebook available at EDGE Mobility Marketplace and are a recent addition to Modern Manual Therapy Seminars in 2016.

Eccentric isometrics are also one of the top presentations in the Global Performance Summit, a free online fitness summit featuring some of the biggest names if fitness. Register for the summit that runs 5/9 - 5/16 for free at http://www.globalperformancesummit.com

http://www.globalperformancesummit.com

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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