Hamstring tightness when running that came from the low back

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everybody, welcome to the Restoring Human Movement podcast. This is your co-host Dawne Costantino, and in today's episode I'm actually going to go over a patient case who is a young female runner with a stubborn hamstring issue. So I've been seeing this person for a little bit, and I think sharing her story would be helpful to some of you runners out there who might be experiencing something similar. If you are new to the podcast, couldn't find that word in my brain, welcome.

If you are not new, welcome back. As always, I'm going to remind you that we have an insane amount of episodes that you can go back and listen to. So find the show, and wherever you're listening to, go back, and you'll find all kinds of things about running, hamstring issues, things separate than that, hip issues, low back, neck, shoulder, knee, whatever it is, I'm sure we have it. We also have it on our YouTube as well, so check that out if you'd like. But let's get into it. I'm going to talk about this patient. So again, this is a female runner. This is actually a person that I have been seeing since my first year of practice.

I'm going on, as of today, my fifth year now. And so it's been really cool to see somebody for this long, not to say that we've been dealing with the same issue for this long. Obviously, I'm not doing my job right, if that were true. But it's more just because she is a runner and she's had some different things pop up here and there throughout the years. She's always trusted to come back to me to help her through that. So I know a lot about this person and what's worked for her in the past. And I wanted to share with you some of these things. So this is a young female runner, just graduated college.

She's trying to find time in her busy schedule to build in the things that we've been talking about. She typically is a couple days a week, go for about a two to three mile run, does like to sign up for marathons, 5Ks, things of that sort. In the past, she's always come in with different lower body issues. So first thing we worked on was an IT band issue that was painful around the outer part of her knee. The second thing was an ankle sprain. Third thing was outer hip discomfort. And all this stuff has bounced back and forth between the limbs. So it was one time it was on the right, next was on the left, next one's on the right.

And now we're dealing with a hamstring issue. In the past, this particular patient has always responded really quickly. I think that that's common in the younger athlete population. It's just a lot of little things that you can do to get rid of pain really quickly. What's interesting with this one is restoring function has been a little bit difficult for the two of us. The question here is like, why does she keep returning with all kinds of lower body issues? And so just to kind of give you a little bit more about the hamstring thing that she's dealing with, we have noticed mainly that dysfunction is on her right side.

So her right hip, her right lateral knee, those were where the two main issues had started off with. Now it's a left hamstring issue. This hamstring issue does not bother her throughout the day or with anything else besides the first part of her run. So she gets into her running. She feels the hamstring. It tightens up on her. She describes that the further she goes in her run, the better it gets. It doesn't ever completely go away during her running until she's completely done, but she does notice it doesn't get worse throughout the run. It does get better. This client in particular, things that we have seen with her is that her ability to stabilize around the pelvis, around the core, around the hips, when we're doing higher impact or plyometric type movements is difficult for her on the right side.

So currently on the side opposite of where her pain is, we see a little knee valgus collapse. We see that her hip drops when she's in a single leg stance, her balance is off sometimes when we're jumping from side to side or front to back. So all of these things function wise that you would expect a runner to be pretty good at, or you would want a runner to be pretty good at, she still has some difficulty with on the right side. And we're dealing with the left hamstring issue. Another kind of thing that we've always noticed is, I mean, here's the first thing I work with with the patient when they come in.

What is it and what can we do to get rid of it, right? Getting rid of pain. I'm sure you've heard us if you've followed this podcast for a while now, getting rid of pain is fairly easy. Restoring function is a little bit harder because it takes time. So going back to her in particular, I swear every single issue she has come back or she has come in with has always come back to her spine. Meaning, they've all been nerve issues. It's pretty crazy. You don't always see this. But with her in particular, it's always been nerve referral. Her lateral hip, her lateral knee, her hamstring now is a spinal referral.

Okay. In the past, it's been more nerve root, meaning when the nerve gets compressed or irritated or inflamed, it refers pain to specific regions of the body depends on the nerve and where they present, for example, lateral hip, IT band, lateral knee, typically an L5 referral. Okay. There's other things that can, you know, it could be true IT band issue, especially in a runner. A lot of different things that can be reasons for pain in those areas. But for her in particular, it was nerve referral from L5. This time around, we are noticing that the hamstring is more of a joint referral. There's no nerve root involvement here.

What we're noticing is because typically in runners, especially long distance runners, we fall into kind of an anterior pelvic tilt. We get a little extra compressive force going on in the lumbar spine. And over time, joints in the lumbar spine can refer pain to different spots. It can feel like a low back muscle soreness. It can feel like QL tightness. It can feel like groin discomfort, depending on the level. It can refer to the upper glute, the deep glute, and even as far as the hamstring. Usually joints of the low back do not refer past the knee in most cases. So with this particular client, we noticed that actually flexing her spine in a nice, easy, safe way reduced discomfort in her hamstring, tightness in her hamstring.

Something that feels like a muscle needs to be stretched, just giving her a little lumbar flexion actually reduced that tightness because it's not a true hamstring issue. It was not a hamstring strain. It was not a tight hamstring. This particular girl can put her palms, you know, to the floor, no problem. So it's not a hamstring length issue. The tightness she was feeling is a sensation of tightness coming from her low back. So we flex her spine. We get rid of that discomfort. She goes back to running, comes right back, right? So it's, yes, we know what to do to decrease it, but we haven't necessarily made any sort of adaptation in her body to prevent this from returning.

We just know what to do to get rid of it in the time that it presents. So what we've been working on, there's some easy floor work stuff that we can do, like a proper core warmup before we go running to really build some better stability around the spine to kind of set her pelvis in a better position for her running, all of that stuff. You know, she knows these things. She's continued it in her routine on and off. She's been pretty honest with me along the way in a sense of, you know, sometimes I'm busy, I'm a student, I just don't do these things. When I have time, I just get up, I go run, and I come back and get back to my studies.

So I think that's pretty common in the running population. You just get up, you might do a couple sweat, you know, stretches or leg swings or whatever other, you know, dynamic warmup you want to do, and you go right into running. So a lot of stuff I've noticed with some of the runners that we worked with in the office is just really rewiring that proper warmup before we get into some long distance running. So with this particular patient, what we really want to work on is her habits. So it so far, we've been really talking a little bit more about just like, why is what we're giving you not sticking?

You know, like we do it in here. We notice the function changes while she's here. For some reason outside of here, she comes back, she falls right back into that dysfunctional movement pattern that we're seeing is contributing to this issue. So my question is, is like, what the heck's going on? Why isn't this sticking? And when I said that out loud, she was honest with me and said, you know, I haven't really been doing these exercises more than once a week, which, you know, in my opinion, that's not a whole lot of change is going to happen if we're only doing it once a week. And typically, if it's done in a nice, easy way, where it doesn't feel a whole lot of challenge, there's not a lot of adaptation that's going to occur in that as well.

So number one, we got to find a way to build in some better habits here, habits of needing to warm up properly, habits of needing to find more days throughout the week to do the exercise so that the body actually creates adaptation. Her time committed to the rehab exercises, I wanted to see if we can find ways to change that as well. And what I'm doing right now is kind of listing off just like thoughts on ways for us to move forward together. So her habits, her time commitment, that's something that she can work on, right? We don't want this to be an all day, everyday thing, but a little bit more consistency can go a long way.

Lately, challenging her more in the higher impact movements like jumping and lateral jumping, and eventually, I want to see how it looks coming off of a box and landing. We started to challenge her in some of these things, and we really started to notice the dysfunction. So what I'm looking for is changes in that over time. So I have written down here just a list of things moving forward that I want us to focus on. We have to do things, again, I already said this, I'm going to say it again, because I have a list in front of you, so I'm going to read it off to you. We have to do things outside of the office to see change, right?

We can't just go in, pay somebody, do it one time, come back three weeks later, never did it again, and said, my hamstring still hurts when I run. You didn't do anything to change what's contributing to this issue, okay? So I think that that's really important, and I actually learned this along the way in practice. I, a lot of times, was kind of looking inward when you're early on in practice. You're like, am I getting the right things? Am I missing something here? You're kind of questioning your own knowledge to help the person in front of you, and then what it really came around to a lot of times, not all the time, is how much time is this person actually committing to changing on a day-to-day basis what's contributing to this issue?

So we have to do things outside of just seeing the person that's helping us to create change, okay? Change occurs when we are challenged. So not just doing those things when you're in the office and not just doing them to an amount that just feels like, okay, I checked the box for the day, I'm going to move on. It needs to be pretty darn challenging. So when I have somebody here in the office with me in front of me, what we're typically looking for, I always ask them a couple different ways. When we're done with an exercise, was that easy, medium, or hard, okay? If it's easy, we didn't do enough, or the stimulus isn't hard enough, or we need to progress the exercise, okay?

If it's medium, we're getting there. I like medium. I always say that. I like medium. Let's see if we can find it a little. Let's dip our toes into that hard range. I want you to rate it a medium to hard effort. I don't want it to be completely fatiguing, but I want us to feel like we're getting there, or I'll say scale of zero to 10. Zero is I did nothing. I'm sitting on the couch. 10 is I couldn't even do one more rep if I tried. Where are you on that scale after an exercise? I typically want people to be somewhere around a six or a seven. They got a little bit left in the tank, but they feel pretty darn challenged.

So that, a lot of times, separate from this girl, but with most of the people I've seen who have gone everywhere, tried everything, seen multiple physical therapists, seen acupuncture, seen chiro, seen their doctor, seen everybody, they've actually been given really good programs. They're doing really good exercises that should be helpful for them, but they're not doing it to an amount of stimulus that's creating change in their body. So if that sounds like you, go back to the thing you're already doing. Just make it harder. Challenge yourself. And if you have a hard time challenging yourself, go find someone who can challenge you.

Find a practitioner that does that. Go find a personal trainer that knows how to do that. I'm guilty of that as well. I will not push myself hard enough on my own. It's always easier to find that challenging amount when somebody else is taking you through it. So check in with yourself. Ask yourself that question. Is your rehab challenging enough? Number three, I always ask myself, am I, as her practitioner, giving her things that she likes and wants to do outside of here? I had somebody yesterday, we did an exercise and I said, you know, how'd that go? Where's your mind at? How did it feel? She got up off the floor and goes, I hate that.

Why the heck would I send her home with it then? Right? I've had times in the past where I've hated an exercise like split squats. And I told myself, although I hate it because it's hard. And I actually learned to love the exercise because it did get easier and I could see myself progressing through it. But I don't always want to send people home with something they just hate. Movement should be fun and enjoyable. That's why people are here. They want to get back to movement and being active and doing things they love. So can I find exercises that this person feels challenged, feels like they can build into their day-to-day and doesn't absolutely hate it.

They feel like it's, you know, worth their time to get down and do the thing. Am I, as her practitioner, describing the importance of this exercise well enough so that they see the benefit of doing it? Different client the other day said to me, you know what? It's really hard. I found myself these days in a pretty lazy pattern and it's hard for me to want to build in different things other than just like sitting on my couch after a long day of working in the medical field. Totally understand that. She goes, but I find myself, it's a lot easier to do the thing when I know what the benefit of it is.

What's happening during this exercise? What should I feel? What types of progress should I be seeing if I'm doing it right? That way, you know, I have no problem building it into my day-to-day. So am I describing the importance and the benefit of it well enough so that she will want to build it in? Am I giving her something that her body is actually receiving? I've seen that often where it's like, this is a great exercise. The person is doing it, but they come back in in a week or two weeks or three weeks and they're just, their function has not changed. So that might not be the right exercise.

We might not be giving the correct program to see the change. So that's a question I'm always asking myself as well. Is the body receiving this exercise well enough? Is it challenging enough to see change moving forward? If it's not, it's probably not the correct exercise and we've got to move on to something else. Number four, obviously, like I said, I have a little list here I'm going off of. Are we warming up properly before going to run? Like I said in the beginning, most runners just run. And a little note that she mentioned to me was that it hurts in the beginning, but gets better. So the tissue is tolerating the activity okay.

It's not getting worse. This sounds like it needs a better warm up before we get into running. So some things that I sent her home with recently is how to properly warm up that hamstring before getting into running. It's not just a static stretch. It's not just some leg swings back and forth. We actually gave her some single leg kind of eccentrically loading the hamstring that felt like the tissue was getting pretty good challenge. We got the glute going and felt challenged as well. So she was warmed up around her hips properly. We got her core going. These don't all have to be like five different warm up exercises before she goes and runs.

It really could be like we find one or two good things that kills all birds with one stone or two stones. So yeah, she went home with like an eccentric loading, a hamstring protocol that she can easily build into her warm up routine. She went that same movement also facilitates the glutes a little bit more. We give her some things for the calf so that she can absorb the, sorry, absorb load a little bit better when running. We gave her a threshold of like how much running she should do, time, days and commitment, things of that sort. So we're very detailed about the program that she's going to be following.

But separate from running, she needs to be doing some baseline just strength training so her body can tolerate this sport. And is she understanding what's going on with her body, right? I think it's really, really important. Like some people come in here and they're like, I don't care. Just tell me what to do and I'll do it. That's fine. But a lot of people really just need to learn what's going on with their body so they can understand a little bit better. And then that's where change starts to occur as well. So yeah, I mean, that's a little bit of what I wanted to get into. It was more, I feel like I was kind of like ranting some thoughts here, but for some of you avid runners out there that maybe are relating to this story or have another injury going on, hopefully I've shared something today that feels like, you know, like a little light bulb went off in your head.

So to review, are we warming up properly? Are we doing things consistently enough to create change? Is the rehab exercise that you're doing hard enough? Is there a threshold in your running that we need to be respecting right now and slowly, progressively overloading you to that? Do we have separate from running just a baseline foundation of strength training that we are doing? Do we even enjoy what we're doing? All of these things are things to consider. Hopefully you're seeing somebody who is asking themselves the questions that I mentioned as well, am I giving her something that's fun enough?

Is, am I educating her well enough? Am I giving her the right exercises to create app adaptation or does it need to change? So all of this stuff goes into play. Keep these things in mind. We do have discovery consultations. If you guys want to reach out to us, we can do this across state lines. We've now gotten licensed in different states that we can do telehealth in different states. Now, if you want to know where, go ahead and reach out to us. If you want to start with an in-person or virtual discovery session, it's very affordable. Reach out to us. We can give you some details on that and hamstring issues and runners common, huh?

So I believe we have stuff on our YouTube, a webinar that you can take a peek at. I believe it's called low back and sciatica. It doesn't mean that your hamstring is a sciatica issue, but it will. This webinar does cover more about stuff similar to that. So check out that webinar and we'll talk to you guys next time.