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Are You Hamstring Dominant?

11/13/2014

11 Comments

 
From my clinical experiences thus far, I have found that many individuals with low back pain lack proper gluteus maximus strength. (This should not be a surprise to you unless you went to physical therapy school when dinosaurs were still roaming). I often find that the gluteals are weak due to a combination of disuse atrophy and muscle inhibition secondary to pain. In the case of disuse atrophy, the individual does not activate their gluts and therefore preferentially activates other muscles to perform the movement. For example, think about the individual who arches his/her back to pick up a box rather than perform a hip hinge and squat OR consider the individual who rests in lumbar extension, locking out the lumbar facets and resting on the anterior hip ligaments. They avoid the gluteals and activate their lumbar paraspinals and hamstrings to perform movements. With pain inhibition, the gluteals are not receiving proper neuromuscular facilitation because pain is overriding the movement. The muscles are temporarily unable to fire because pain is inhibiting the activation. In either situation, properly assessing hip strength and assessing the cause of weakness is a fundamental part of a low back evaluation.
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Picture
In this post, I want to discuss hamstring dominance is relation to gluteus maximus testing. As I stated in the previous paragraph, poor movement patterns often lead to improper activation of the glut muscles. Since the gluts are not helping perform the movement, a different muscle overcompensates to perform the movement. Clinically, I often find that this other muscle is the hamstrings (or lumbar paraspinals). Individuals that preferentially activate their hamstrings prior to their gluts are called 'hamstring dominant.' This can be problematic because the gluteals are meant to act as a hip stabilizer and extensor. When they do not fire first, the gluteals do not stablize. The hamstrings attempt to act as both a prime mover and stabilizer.   

The test for hamstring dominance is similar to the Kendall Glut Max testing position. Place the individual in prone with the tested knee bent to 90 degrees. Ask them to lift their leg off the table. In the normal healthy individual, the glut max engages prior to the hamstrings. Proper activation order: 1. TrA engages, 2. gluteus maximus activates, 3. hamstrings fire as the leg is lifted. If the hamstrings fire before the glut max, the individual drives that motion with the hamstrings. ​
In the video below, the individual presents with both hamstring and lumbar paraspinal dominance over gluteal muscle activation. He compensates by arching through his low back and avoids using his glutes.
(Video feed has been taken from The Movement Corner on the OPTIM Manual Therapy Felowship Website)
Do not be fooled by strong gluts in the low back pain population. After assessing the glut max, retest for hamstring dominance to ensure they are not over-activating the hamstrings. I frequently discuss dominance patterns on The Movement Corner as they are common causes of movement dysfunction. I highly recommend assessing for hamstring dominance in your lumbar patients. 

-Jim Heafner PT, DPT, OCS
11 Comments
Jeremy
11/13/2014 11:28:14 pm

So apparently multifidus does not activate at all? No pelvic floor? No deep quadratus? TrA is not the end-all be-all of deep trunk stabilization. It's well backed up in literature that there is multidirectional stabilization.

Reply
Jim
11/14/2014 11:21:24 pm

Jeremy

Thanks for the comment. Do not forget the diaphragm as a component of multidirectional stability. In the post, I simply said TrA, GM, then lift because that is how I personally cue my patients to retrain their movement pattern. Clinically, I often find the multifidus and pelvic floor are harder to engage so I first work on the TrA. I completely agree that multidirectional stabilization is necessary. I should have clarified that in the post. Thanks again for the comment.

Jim

Reply
Liz
11/16/2014 07:30:44 am

Thanks for the post - that's a great test for hamstring dominance and I am looking forward to using it with some of my patients. How do you typically document your findings? Is it as simple as:

(+) Hamstring dominance with hip extension

Thanks!

Reply
Jim
11/16/2014 09:54:03 pm

Liz,

Thank you for the comment. Yes, that is how I typically document the finding. Try it out on a few patients, I am sure you will find a few positives! I know I was until I started doing the proper exercises.

Jim

Reply
Christian
11/19/2014 03:33:35 am

Hi Jim,

I thought your post was very insightful, and I think it can serve as a very useful assessment. Do you have any recommendations for management when you discover hamstring dominance? Clearly it depends on the functional movement/goals you're working towards, but are there ways to cue or encourage correct activation patterns among lumbopelvic musculature that you find particularly effective? (I understand that this can't be answered with a simple answer, but any direction or explanation will help.)

Thanks!

Christian

Reply
James Lau
12/17/2014 09:56:02 am

Great post Jim. Learning heaps on this website. So just to clarify you are just feeling/palpating for the order of contraction: 1) gluts 2) hamstring and if there is a coordination issue then you would see h/s fire first?

Reply
Jim Heafner link
12/18/2014 07:54:22 pm

Christian and James,

First off, sorry for the delayed response Christian. I do not know how your comment made it past my radar, but I apologize for not answering sooner.

Christian- I often find it most beneficial to start with manual cueing to retrain the activation pattern. Generally, I will spend 5-10 minutes in prone with the patient in a knee bent position hip extended, having them isometrically isolate their gluts. Once they can demonstrate good isometric activation, I progress to eccentric strengthening in the same manner, where I slowly release the leg from hip extension to neutral. Once the patient can demo good control eccentrically. I have them perform active prone hip extension exercises. If the patient really struggles with the prone progression, I will still manually cue and retrain in prone, but then work the patient in supine performing mini-bridges with the proper cueing: 1. TrA and core 2. Gluts 3. Mini-Bridge. I hope this helps and again sorry for the delay.

James- Thank you for the comment. Yes it is a palpation (so think about reliability as you wish but I've seen great results). In positive patients, it is a very clear hamstring contraction prior to glut activation. It is a coordination problem. Many times with a 5-10 minutes of proper cueing (verbal and manual tapping facilitation), the patient can retrain themselves into proper activation. From there it is strengthening the gluts from this newly activated pattern.

Reply
Ken
12/15/2016 06:15:23 pm

I had a patient with this today! Now how to treat them is the real question.

Reply
Michael
12/15/2016 06:23:44 pm

I'm curious how you and Optim view general exercise for core stability in place of cueing the TrA, Multifidi, etc... like the Koumantakis article or others have shown to be equally effective. I have heard of other fellowships/clinics that don't get as specific.

Reply
Greg
6/13/2018 06:57:16 pm

Hello Jim,
I believe I have had this problem for the last 6 years after a running injury. Everyone says my glutes aren't firing, but i have been doing glute work for the last 2 years. It helps before a workout, but the low back, hip and ankle pain all on that same side always comes back within an hour after my excersis of glute strengthening. I think maybe my glute is string enough but the hamstring is firing sooner. I also ALWAYS feel like my hip flexors and adductors are tight. This is all only on my left side since the running injury. Do you have any suggestions? This is ruining my life as Im in my 20s but i cant run or play any sports like I used to.

Reply
Aaron Driver
1/8/2019 10:02:58 pm

In the prone knee bend @ 90 degrees it is worth while assessing for gluteal stabilisation with a board placed on top of the soles of the feet

proper foot placement will drive any compensatory patterns into the lumbopelvic complex and cause things like excessive hip flexion when weak and in spasm

Reply



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