I have a client who was diagnosed with Rheumatoid Arthritis and Scleroderma at age three. After a car accident at the age of five, her left arm became seriously disfigured. Every year, she sees numerous physiotherapists and doctors who try to help her but have so far not achieved much. She is now 22 years old, and when she first came to see me, she was very limited in her movement ability. After eight months of training, I have dramatically improved her squat, bend to extend, push, pull and rotate patterns. This has made a dramatic difference to her life, and her doctors have noticed the improvement on her annual checkup. However, there is one area I am really struggling with. No matter how hard I try, I simply can’t improve the flexibility in her hamstrings and calves. She has a classic flat back posture, and although it has improved slightly through PNF stretching and various movement-based drills (wall touches, split deadlifts with bodyweight, etc), I still seem to be having trouble getting results. Do you have any suggestions?
Thanks for your question and client concern! It sounds like you have done a wonderful job thus far. Instead of trying to guess what exercises to give your client, I will provoke a thought process that will hopefully encourage you to think deeper. Here we go….The question I would explore is what method are you using to determine that her calves and hamstrings are tight? What is tightness? Is it more neural, myofascial and/or an osseous? How is tightness measured? Are there symptoms associated with tightness? Is there functional joint range of motion restriction? Are you using a traditional model of determining tightness? To answer, determine HOW the suspected tightness is affecting her function (everyday motion). If her ability to squat has improved, then her calves and hamstrings can’t be that bad in function seeing as the calves and hamstrings are dramatically involved in the deceleration phase of the squat (tight calves and hamstrings would create an unhealthy squat). The point is the fact that a non-function test (static measurement of range of motion, static postural analysis, isolated muscle test, etc.) may show a dysfunction and yet functionally the person performs well. This can sound very confusing, especially if one has studied isolated approaches to enhancing function! The following litmus tests will assist you in your functional understanding. Also next to each test, I included a thought relative to your client concern:
- How does the activity compare with the client’s relationship against the environment? (If a stretch is applied on the table, it is not the same as if you are standing and MOVING.)
- What is the segmental relationship to affect the whole? (The hamstrings work with the rest of the body, therefore they may show to be tight in a traditional test, but when integrated, they function normally.)
- What are the relative amounts of motion in all three planes? (If tight, what planes are the most restricted: sagittal plane, frontal, transverse - distal or proximal? The hamstrings are often only tested and then stretched in ONE plane of motion.)
In addition to the above thoughts, if your client proves to exhibit tight calves and hamstrings functionally, causing a posteriorly tilted postural dysfunction that is transferring to a loss of normalized function, I would attempt to mobilize her foot/ankle in all three planes followed by her hip complex in all three planes. After both the foot/ankle and hips are “clear,” perform a sagittal plane lunge in a posterior direction with both arms driven in the sagittal plane in a posterior direction (yes, all at the same time). This two arm overhead lunge will create an anterior tilted pelvis as a result of the lower extremity and upper extremity motion.
Note: A great resource to learn about THREE dimensional functionally based stretching is Gary Gray’s Functional Flexibility DVD. I would strongly recommend this resource. It may show to take your client to the next level. Either way, you have done a wonderful job.