A quick look at some studies I did to better understand the role of hamstrings in lower back pain
Jolie Bookspan. MEd, PhD, FAWM
Director Neck and Back Pain Sports Medicine
Headmaster Academy of Functional Exercise Medicine - School of Healthy Medicine
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Hamstring flexibility is not correlated with back pain (when standing, running, most sitting and exercise).
Where did the myth come from that mistakenly led to the popular practice of hamstring stretching for back pain?
Plus, the off-shoot myth that mistakenly put crunches and flexion-based core exercise
into back pain rehab - where they do a lot of mischief and not all the good that was hoped.
You are on my no-ad web site - DrBookspan.com. Hundreds of articles dedicated to teaching you fun smarter methods for healthy, mobile, happy life. This page tells interesting work I did about your hamstrings.
I did initial work (pilot study) that found no relation between amount of hamstring flexibility and any incidence of lower back pain. It went against common practice of prescribing hamstring stretching for back pain. My results were not well received. I was boo'd at a prestigious sports medicine conference.
I quietly put my results on the shelf, and continued over years to re-check relation, and find out why there was no relation and what else might be involved.
In the meantime, respected names in spine research found the same results in their studies - no relation between hamstring flexibility and incidence of back pain.
I had already conducted years of studies that found that too much inward curve of the lower back (hyperlordosis/ swayback) caused pain with extended standing, from the too-sharp angle physically compressing and shortening the area (explained on the Back Pain With Standing page, and a bit about the studies on my Ab Syllabus). In continuing work, I found that during the act of stretching hamstrings, the inward curve of the lower back reduces, and stretches - only during those few seconds, of course. For the many people with lower back pain from too much inward curve, the reduced angle, and temporary lumbar lengthening, provided temporary relief from the compressed pinching ache and tightness that hyperlordosis produces. Of course, when they stood up and went back to standing swaybacked (too much inward angle) the pain and shortening eventually came back and they felt they needed to bend forward and stretch again to relieve it. The brief reversal of symptoms during back stretching became mistaken for relief from the hamstring stretch. Brief hamstring stretching became further confused with hamstring flexibility. Like "whispering down the lane" it next changed into hamstring flexibility prescriptions for any kind of back pain. Then worse, people thought that the temporary bending forward during crunches and other flexion exercise such as during Pilates was curing back pain, and that it was strengthening (or other mythology) that was the cure, when it was just temporary reversal of a bad posture (lumbar sway) that was causing the real problem. Temporary bending forward felt good after crushing the lower spine with all the excess inward sway.
It was mistaken identity. The resulting myth would have been harmless, except that the same forward-rounding and / or forward bending (flexion) that co-occurs during certain hamstring stretches and conventional core exercise puts herniating forces on discs, over time. It is one of several reasons that hamstring stretches and "hip hinges" are a common cause of lower back and disc pain, not a fix. It wasn't fixing the cause. It wasn't even a healthy way for temporary relief. It is irony that standing swaybacked maintains the lower back in the very position causing tightness and lumbar shortening. Another interesting reason for confusion is that injured hamstrings may hurt at the place the hamstrings attach to your "sit" bones - the very area assumed to be sciatic pain alone. Stretching the hamstring helps the injured hamstring, and the pain where they attach to your pelvis, wrongly thought to be sciatica. More on this on my Stretching Smarter page and Fix Lower Back Pain page. Other times, tightness in the posterior hip and upper leg make pain or tightness in the lower back. Hamstring stretches can, incidentally, stretch those areas and take away the separate cause of pain, leaving people to wrongly credit the hamstrings. Seems harmless, except that true causes go unexamined and un-prevented, leaving people to take much time and money to do conventional scattershot "cures" hoping something will work, accidentally or not.
What to do instead? If you get the kind of lower back pain felt with long standing, walking & running, and feel that bending over forward, or sitting, or raising legs brings relief and stretches out the ache, you probably stand with too much lumbar arch (hyperlordosis). Instead of keeping the bad posture and getting recurring lower back pain, then doing hamstring stretches to try to temporarily curb it, prevent the entire problem with neutral spine. Then you don't over-curve and compress the lumbar spine (you stop your swayback with healthy standing position) and don't cause any back pain in the first place. Then, to get a healthy lower back stretch built into your regular day, use good bending, explained on the Fix Lower Back Pain page and in my books. For effective and functional hamstring stretches without flexion, see my book Stretching Smarter Stretching Healthier, with one helpful stretch in my web site Stretching Smarter article. It is a whole world of healthier smarter movement mechanics and daily habits. You won't get the pain and will also move and stretch in healthier way to stop future damage. This is also why people think that various treatments "work" when they go and lie down with knees bent for the treatment. Of course the pain will lessen along with the painful swayback when they lie down that way. It does not matter if they get needles, or oils, or massage, it was lying down that stopped the cause temporarily, then these same people claim the treatment must work, because the pain COMES BACK and they feel better to go to their ongoing treatments where they lie with knees bent and temporarily stop the real cause, unknowing.
Do tight hamstrings change hip tilt? Not when you are standing. It is easy to see for yourself. Hamstrings attach to your "sit bones" the "bumps" on the bottom of your pelvis. Claims are that tight hamstrings pull so that the pelvis tilts posteriorly. Check people with tight hamstrings. Often they use another poor posture called anterior pelvic tilt - shown by the yellow lines in the photo below. If tight hamstrings did pull the pelvis down in back, then people with tight hamstrings (most people) would never have this poor slouching posture:
If it were true that tight hamstrings pull the pelvis down in back, it would prevent anterior tilt, show in yellow lines of photo above. Reducing anterior tilt would be helpful (change tilted yellow "T" to level, by pulling down the back of the "T" which represents your pelvis). A shame it is not true from tight hamstrings.
To fix an anterior tilt, click the page: Back Pain With Standing.
When do tight hamstrings change hip tilt? When you sit on the floor, for example, with legs straight out in front of you, tight enough hamstrings would pull the pelvis so that lumbar lordosis decreases (the lower back rounds, and the pelvis tilts posteriorly).
Sitting with your back rounded for long periods presses discs outwards and makes muscles ache. Most people don't sit on the floor with legs straight out, they sit in chairs with knees bent. Hamstrings are not involved if you sit with your back rounded when your knees are bent. Then, you are just slouching.
Disclosure and Conflict of Interest Disclaimer
This study was not funded by anyone or any agency, and has no financial relation or obligation to anyone. Funding agencies have gone out of their way to meticulously ignore me. I have no financial relationship with any manufacturer, vendor, service or product provider discussed in this study. These studies were done before I wrote the book The Ab Revolution. The training manual that became the book was the result of the findings of my work, not the other way around. The book is also not commercially funded or related to any product sales. The story is here - look for "A Short Story of My Work Developing These Methods."
Check Back - I am adding more on the myth that tight hamstrings reduce lumbar angle (making a flat-back) and cause lower back pain.
For now, consider all the people who do the very opposite - have tight hamstrings and too large lumbar angle (tilt their hip forward / swayback) - maybe even yourself. Why didn't tightness prevent the swayback or even pull to neutral spine? Because hamstrings don't work that way, and swayback can occur from tightness in the front of the hip, not the back, from tightness in other places, even without any tightness (when it's just slouching). More to come!
The Hamstring Studies
1. My Pilot Study - I Found No Relation Between Hamstring Flexibility and Lower Back Pain:It was so often repeated that you have to stretch your hamstrings to prevent or fix back pain, but why? I set out to find if there were any relation between the two. People often repeat the mistaken idea that tight hamstrings tilt your hip that reduces the lumbar angle, making back pain, but hamstrings don't work that way and if they were that tight, you couldn't take a step forward. (Plus if that were true, the prescription would be to make hamstrings tighter to reduce the too large angle, called hyperlordosis, which causes much lower back pain). Many years ago, I looked at 167 of my patients and students. I carefully measured hamstring flexibility and noted if they had back pain at the time, or at any time in the past. Running the data comparing flexibility to incidence of any lower back pain, resulted in no relation, no correlation, nothing that linked the two.The details of how I measured flexibility (continuous data measures) was as follows:
Zero degrees is lying flat on your back with both legs down on the floor together,
45 degrees is one leg lifted to diagonal, 90 degrees is leg able to stretch to perpendicular - pointing to ceiling, and so on.
I collected flexibility in actual degrees - continuous numbers from zero to 180 if they lifted leg all the way back to their ear in a lying down split.
I measured flexibility in the dominant leg and also both legs together to make it more like a "sit and reach test" but keeping the lower back from flexing or rounding in order to try to isolate hamstringsI presented my work at scientific conferences and they practically threw tomatoes at me, saying my work could not be true because "everyone knew" that hamstring tightness meant you would have back pain and therefore stretching would fix it and that meant that hamstring flexibility was a predictor of back pain. There were so many inductive leaps and faulty premises in those statements that it was hard to address them in ways that would appease or enlighten the mob. These were doctors who were even keeping people out of jobs if they had tight hamstrings. They said that tight hamstrings necessarily meant the people would get back pain, and the employers didn't want to pay Workmen's Compensation claims. That's how bad this myth had gotten.
2. Then What Happened?In subsequent years, highly respected researchers duplicated my study - and found no relation between hamstring flexibility and back pain.
During that time, I did more work on separating if hamstring flexibility itself, or something in the act or motion of hamstring stretching brought relief. With no correlation between hamstring flexibility and lower back pain, what else might hamstring stretching do or include?
Not a lot of my work is published in journals. I am busy trying to get work done and don't present or publish all (or even much of) my work Publish?? I'm trying to accomplish something here!
For the many who have been asking, I put the results of my studies of my patients with knee pain on my Lower Body page and a few of my lower back pain studies on my Ab Workshop syllabus. Here are the results of this study on hamstrings:
3. The next work - Comparison of Neutral Spine and Hamstring Stretch for Relief of Hyperlordotic Lumbar Pain
A widespread prescription for lower back pain (LBP) is hamstring stretching. Some patients report relief from hamstring stretching, others, no effect or worsening. A pilot study of 167 subjects found no relation between hamstring flexibility and LBP. Subsequent independent studies confirm no relation between hamstring flexibility and LBP (1,2,3). Disc injury (4) and osteoporotic fracture (5) can be caused and worsened flexion, such as that involved in conventional hamstring stretch.
Previous work determined that hyperlordosis (swayback) results in one form of lower back pain (LBP) by compression of facets and soft tissue, and shortening lumbar height (6,7). Neutral spine (NS) lengthens and unloads, directly stopping LBP(8,9). Momentary incidental lumbar lengthening during hamstring stretch briefly stops symptoms. Spinal stenosis symptoms also often reduce with flexion (7). It is proposed that temporarily reversing swayback with hamstring stretching became confused with the separate entity of flexibility. The purpose of this study is to compare a neutral spine method, Ab Revolution (AR) with conventional hamstring stretching (HS) for LBP from hyperlordosis.
Pilot study of 167 subjects measured degrees hamstring flexibility using straight leg raise test, compared to nominal measures of active LBP, previous LBP, or never LBP. Of initial 167 N, 113 had active LBP. Of these 113, 92 reported wanting to bend forward, lift one leg, sit, or bring knees to chest to relieve symptoms.
Following the pilot study, a new study group was formed from original subjects. Of the initial Pilot study, four had been lost to follow up. The remaining 88 were divided into two groups: Neutral spine training group called Ab Revolution (AR) N=44, and a group receiving daily conventional hamstring stretching (HS) N=44. Hamstring stretch group (HS) performed hamstring stretches of their choosing or prescribed by their physical therapist twice daily.
Nominal outcome measures of ability to employ neutral spine (NS), flexibility (increase, decrease, no change), and LBP were assessed at day 1, 6 weeks, and 6 months, analyzed using Chi-Square.
Of the Hamstring Stretch (HS) group, 41 of 44 increased hamstring flexibility, and there was no significant lasting reduction in LBP, 39 had brief symptom relief during hamstring stretching but return of pain with upright stance and activities of daily living, 43 of 44 were measured as not using neutral spine when standing or ambulating (no NS). 18 of 44 had increase in LBP.
Subjects using neutral spine training (Ab Revolution or AR) showed significant reduction of LBP during daily activities at day 1, 6 weeks, and 6 months. At 6 months 40 of 44 had no LBP. LBP was not correlated to change in hamstring flexibility in either group.
1. Incidental lumbar flexion from hamstring stretching, not hamstring flexibility, reduces LBP by reversing swayback - at the time of stretching.
2. Temporary reversal of symptoms from swayback (hyperlordotic lower back pain) occurring during hamstring stretching, became mistaken for relief from the hamstring stretch itself. Hamstring stretching became further confused and combined in practice with hamstring flexibility. Hamstring flexibility prescriptions became further derivative to include any kind of hamstring stretches for any kind of back pain.
3. The temporary bending forward during crunches and other flexion based "core" exercise does not cure back pain through strengthening. The temporary reversal of the original problem of slouching with too much inward lumbar curve provides temporary relief that is mistaken for real change or cure. The pain from hyperlordosis comes back as soon as the person stands and resumes the real cause - not weakness, but standing in hyperlordosis. Crunches and core exercises do not change that. This is why there is only temporary relief from conventional exercises, or chronic pain that "has to be managed through recurring flexion" or intermittent pain that is confusing and "no one understands why it comes and goes." No amount of strengthening or core exercise makes you prevent the hyperlordosis which is the root of this one kind of pain.
4. Hamstring stretching is not curative for lower back pain
5. Hamstring stretching and flexion based core exercises may aggravate specific lower back pain, and over time, create new lower back injury.
6. Lumbar lengthening and restoring neutral vertebral angle through neutral spine technique (AB Revolution AR) gives sustainable pain relief by directly stopping cause of LBP from swayback (hyperlordosis).
7. Using neutral spine through AR is functional; stopping cause of LBP and integrating needed resting and active length of lumbar spine during activities of daily living.
1 Jones MA, Stratton G, Reilly T, Unnithan VB. Biological risk indicators for recurrent non-specific low back pain in adolescents. Br J Sports Med. 2005 Mar;39(3):137-40.
2. Grenier SG, Russell C, McGill SM. Relationships between lumbar flexibility, sit-and-reach test, and a previous history of low back discomfort in industrial workers. Can J Appl Physiol. 2003 Apr;28(2):165-77.
3. Jackson AW, Morrow JR Jr, Brill PA, Kohl HW 3rd, Gordon NF, Blair SN. Relations of sit-up and sit-and-reach tests to low back pain in adults. J Orthop Sports Phys Ther. 1998 Jan;27(1):22-6.
4. Veres SP, Robertson PA, Broom ND. The morphology of acute disc herniation: a clinically relevant model defining the role of flexion. Spine (Phila Pa 1976). 2009 Oct 1;34(21):2288-96.
5. Tzermiadianos MN, Renner SM, Phillips FM, Hadjipavlou AG, Zindrick MR, Havey RM, Voronov M, Patwardhan AG. Altered disc pressure profile after an osteoporotic vertebral fracture is a risk factor for adjacent vertebral body fracture. Eur Spine J. 2008 Nov;17(11):1522-30. Epub 2008 Sep 16.
6. Bookspan, J. Identifying and Reversing Hyperlordosis as a Factor in Lower Back Pain. Medicine and Science in Sports and Exercise, 39:5 May 2007.
7. Bookspan, J. Hyperlordosis Retraining Method Relieves Lumbar Disc and Stenosis Pain—An Unexpected Finding. Medicine and Science in Sports and Exercise, 41:5, 2009.
8. Bookspan, J. Ab Revolution functional core retraining relieves low back pain more effectively than conventional physical therapy. Medicine and Science in Sports and Exercise, 38:5, 2006.
9. Bookspan, J. Functional Core Retraining Superior To Conventional And Pilates Core Training In Remediating Low Back Pain. Med Sci in Sports and Exercise, 37:5. 2005.
In these references - respected names in spine research found the same results in their studies - no relation between hamstring flexibility and incidence of back pain.
"Even historians fail to learn from history."
- Professor John Gill - Star Trek episode 52 Stardate unknown, Patterns of Force
- Study publication (abstract): Bookspan, Comparison of Neutral Spine and Hamstring Stretch for Relief of Hyperlordotic Lumbar Pain J. Medicine and Science in Sports and Exercise, Volume 44:5 Supplement. 2012.
- Study presentation at the 59th Annual Meeting and 2nd World Congress on Exercise is Medicine of the American College of Sports Medicine at the Moscone Convention Center in San Francisco, CA, 1 June, 2012.
What Does This All Mean? Applications -
1. This means you have a quicker more direct way to stop this kind of lower back pain.
Stop the cause by using neutral spine. Neutral spine is used during standing, walking, sports, and all your regular activities.
Hyperlordotic lumbar posture (swayback) has been previously identified as a direct contributor to lower back pain during and after standing, carrying, and ambulation (walking, running, upright movement) (6,7,8). The increased lumbar angle of hyperlordosis physically compresses bone, nerve, and soft tissue. Think of a straw pinched backwards. Two types of hyperlordosis are shown:below - hip tilt (middle) and thoracic lean (right). Both may also appear together. For comparison, neutral spine is at left:
Another example of thoracic lean-back (That is what I have named it as I haven't seen it identified in any previous sports medicine sources).
Same kind of swayback as drawing at right above.
Thank you for photo by n0nick http://flickr.com/photos/n0thing/41750513/
2. Hyperlordosis is common among athletes and non-athletes regardless of abdominal strength, as strength alone does not cause movement.
Movement out of poor posture is what corrects hyperlordosis. Moreover, overly arched (hyperlordotic) posture is mistakenly encouraged as good posture, as a method to lift or squat more weight, as the weight is shifted to the facet joints and off the muscles making the lift seem easier, with long term consequences from the joint loading - example below at left with neutral spine comparison at right. Hyperlordosis seemed to be a fad in the fitness industry in the 1990s and decade of 2000.
3. Overarched spine (left) was a fad in fitness and the cause of much lower back pain, even though it made lifting easier.
Lifting was easier because it shifted load to the lower spine and off the muscles For spine health, it's better to use your muscles than rest the load on the joints. Save your slouching and bad form for emergencies.
Correcting hyperextended angulation to neutral spine has been identified to directly unload and correct the source of pain in hyperlordosis(6) disc and stenosis pain(7) more effectively than conventional strengthening programs (8,9).
4. When Stretching Helps?
Stretch programs for lower back pain are common in therapy programs, however with often unsatisfactorily low or inconsistent success rates. Conventional hamstring stretches are non-specific—they do not directly train reduction of hyperlordosis (or any other movement) during standing, gait, exercise, and activities of daily living.
An interesting reason hamstrings were misidentified with back pain is that sore hamstrings and hamstring pulls (ironically, some from bad stretches and movements) may hurt where hamstrings attach to your "sit" bones (ischial tuberocities - the bottom bumps of your pelvis/ hip) - the very area often assumed to be sciatic pain alone (lots of things can hurt there). Then a mistaken diagnosis of sciatica or disc pain occurs and stretching the hamstring helps. Then a mistaken association with stretching hamstrings fixing sciatica.
Sometimes the muscles and other soft tissue of the backside, posterior hip, upper thigh can get so tight that they restrict movement and yank, causing sharp pain or ache. Other times tightness can squeeze or compress nerves, sending pain along the path of thee nerve down the hip and leg. Stretching them in good ways that lets them stretch without further compression, can relieve that particular cause of pain. The problem comes when that specific case is confused or misdiagnosed as back pain or sciatica from disc or causes related to the back, and believing that the stretches fixed it, when it was a different cause and different reason for the fix. Does it matter why? For all the many people who do not have this cause and are given stretches, they continue pain, increase pain, and time, health,and money flow away.
When the pain was really from discs and soft tissue from chronic bad bending, the hamstring stretches and"hip hinges" themselves make things worse in the long run. These stretches feel good for a moment (like smoking a cigarette) but damage little by little, and reinforce bad habits. More about why the fad stretch of "hip-hinges" does not help is also covered in the article on Fixing Lower Back Pain.
5. How to stretch your hamstrings without putting herniating sheer and force on the lower discs, and in functional way - a way you actually need and use in real life.
A functional stretch is done in the same position, and using the same actions, as needed in real life, and is one that you actually do during real life activity. An example of a functional hamstring stretch would be standing upright and lifting one leg to kick for sports, martial arts, dance, for leaps in obstacle courses and Parcours, and some moves in bouldering and climbing. Check this drawing of a functional hamstring stretch, then try the following:
- Stand upright.
- Notice both your feet. Make sure your feet are both facing straight forward, not turned out, even a small amount.
- Lift one leg, knee straight.
- Make sure the foot you are standing on is still facing straight forward, not turned out, even a small amount. If it is turned, then either hop to straighten it, or put your other foot down, adjust, and figure how to lift one leg without twisting the other foot. This will be healthy training for walking, running and other movement.
- Lift to any height that gives stretch in the hamstring itself.
- Notice now tempting it is to use bad habits of bending forward, rounding your back, and other slouches that reduce the real stretch - on the hamstrings. Remember, stand upright.
- Notice it helps you practice balance.
- Hold your leg up with your hands if that helps you get more height until you strengthen enough. Make sure you don't round your shoulders or learn forward to reach your leg. Learning and practicing to stand straight is one of the purposes and benefits of doing this hamstring stretch in a functional way.
- Notice that you use standing on one leg and lifting the other to various heights in real life, from kicking and dancing, to stepping up heights, and others.
- This new functional hamstring stretch may feel harder than your usual (bent forward) hamstring stretches because it gives more direct stretch to the hamstrings, when done right, and you must stand and balance as in real life. You may not have really stretched your hamstrings previously, and have been reducing stretch by rounding your back or tilting the hip.
- Transfer this knowledge of preventing slouching, keeping balance, and getting needed range from the hamstrings to your standing activities.
- Practice this and feel positive about increasing real life skills you need in a healthier smarter way.
- Send your success photos.
Above, my students Karen and Annie demonstrate standing hamstring stretch.
Can you spot two positioning mistakes that they demonstrating for your benefit?
Karen (left) demonstrates standing foot turned outward (incorrect) and Annie (on right) demonstrates keeping standing foot facing straight forward. Karen keeps the hip vertical, not the pelvis to curl under. Make sure you can spot these easy things for yourself, so that you are are doing what you think you are doing.
6. What to Do Instead of Hamstring Stretches and Sitting Bent Forward To Relieve Tight Lower Back?
If your lower back is tight, or you get the kind of lower back pain felt with long standing, walking & running, and feel you want to bend forward to stretch out the ache, you probably stand with too much lumbar arch (hyperlordosis). Prevent that with neutral spine - summarized in my Abs Article, and explained fully in my books, particularly The Ab Revolution. Neutral spine give you built-in needed length and natural stretch so that the areas doesn't get tight in the first place.
Get functional built-in lower back stretch every time you use good bending with a partial-squat, done with neutral spine. During regular daily life, you need to crouch and reach many dozens, even hundreds of times. Get that built-in to your day with good bending, sample drawing below. Full "Asian squats" done right, can be a wonderful way to get regular safe built-on stretch to the lower back. More is summarized on the Fix Lower Back Pain page, and explained in detail in my books.
Bad bending with swayback on left. Good bending using the partial squat on the right.
Mistaking correlation for cause and effect is a classic serious mistake in science
The myth of hamstring flexibility as curative for back pain came mostly from misunderstanding the temporary lumbar stretch co-occurring with hamstring stretching, which reduces - only for the moment of stretch - the hyperlordosis that causes one kind of back pain.
The same mistaken identity seems to be the reason people mistakenly believe ab training and the forward bending of yoga, Pilates and other pop exercise systems "helps" - it just feels good for the moment for people with lumbar pain from swayback because they are temporary stretching it the other way. It's not a healthy fix and not a long term one. Strengthening abdominal or core muscles does not "support" or fix back pain. it is using them to prevent swayback that is how abs help the back. More on the Abs page.
Appreciation and thanks to Paul Jenkins for proofreading and math checking for this study. He is my Academy Director of Silly Syndromes who keeps us laughing (and sane) in the world of crazy fitness claims. Appreciation and thanks to Peggy Santamaria for making (yet another) banner for me to use at my presentation of this work. Ms. Santamaria is my Academy Director of Developmental Ability - teaching my work to developmentally disabled adults, who go on to gainful employment doing healthy landscaping, snow removal, cleaning, mail room work, and more. See my Academy Honors page for some of their photos and good work, and Academy for more of all we do and how you can be part.The ACSM fellow who sponsored this work for presentation at the 59th Annual Meeting and 2nd World Congress on Exercise is Medicine is Catherine Ratzin Jackson, Ph.D., FACSM, who states, "The present study challenges current thinking and the evidence is compelling."
Drawings of Backman!™ © Dr. Jolie Bookspan
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