A RANDOMIZED CONTROLLED TRIAL OF HAMSTRING

STRETCHING: COMPARISON OF FOUR TECHNIQUES

JO M. FASEN,1 ANNIE M. O’CONNOR,1 SUSAN L. SCHWARTZ,2 JOHN O. WATSON,3
CHRIS T. PLASTARAS,1,4 CYNTHIA W. GARVAN,5 CRESO BULCAO,6
STEPHEN C. JOHNSON,7 AND VENU AKUTHOTA3
1
Rehabilitation Institute of Chicago, Chicago, Illinois; 2Resurrection Hospital, Chicago, Illinois; 3Department of
Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, Colorado;
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4
Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine,
Chicago, Illinois; 5College of Education, University of Florida, Gainesville, Florida; 6Spine and Sports
Rehabilitation Center, Chicago, Illinois; and 7University of Toledo, Toledo, Ohio

ABSTRACT correlation between hamstring flexibility and age, initial

Fasen, JM, O’Connor, AM, Schwartz, SL, Watson, JO,
Plastaras, CT, Garvan, CW, Bulcao, C, Johnson, SC, and
Akuthota, V. A randomized controlled trial of hamstring
stretching: comparison of four techniques. J Strength Cond
Res 23(2): 660–667, 2009—This study compared the efficacy
of 4 different hamstring-stretching techniques. Flexibility can be
achieved by a variety of stretching techniques, yet little research
has been performed on the most effective method. The 2 basic
types include active stretching, in which range of motion is
increased through voluntary contraction, and passive stretch-
tightness, or frequency of exercise per week. Improvement in
hamstring flexibility was greatest for the SLR passive stretch.
Also, using PNF in the 90/90 active stretch provided better
knee range-of-motion improvements than the 90/90 passive
methods did.
KEY WORDS hamstring flexibility, viscoelasticity, flexibility
INTRODUCTION

ing, in which range of motion is increased through external
assistance. The 2 types of active stretching include neuro-
mobilization and proprioceptive neuromuscular facilitation
(PNF). Our study aims to determine which type of stretching
technique is most effective in improving hamstring length. One
hundred subjects between the ages of 21 and 57 were enrolled
in the study. Intrarater reliability of hamstring length measure-
ment was performed using 10 subjects. All 100 subjects were
included in a randomized controlled trial of 5 different groups
comparing different hamstring-stretching techniques. Outcome
measures, including hamstring length and perceived level of
hamstring tightness, were recorded on all subjects initially, at
4 weeks, and at 8 weeks. After 4 weeks of stretching, there was
a statistically significant improvement in hamstring length (p ,
0.05) using active stretches as compared with passive
stretches. From weeks 4 through 8, hamstring length for the
active stretching groups decreased. After 8 weeks of stretch-
ing, the straight leg raise (SLR) passive stretch group had the
greatest improvement in hamstring length. There was no
Address correspondence to Jo M. Fasen, jfasen@ric.org.
23(2)/660–667
Journal of Strength and Conditioning Research
Ó 2009 National Strength and Conditioning Association
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T
here is a lack of research on stretching and flex-
ibility. Many clinicians recommend stretching, but
few have attempted to prove its effectiveness. Sug-
gested benefits include improved athletic perfor-
mance and functional gains (6,14,33). In addition, stretching
has maintained a time-honored role in health and fitness
(1,5,27,23). Many factors influence an individual’s flexibility.
In previous studies, age, race, gender, circadian rhythms,
tissue temperature, strength training, stiffness, and warm-up
have influenced flexibility (3,13,16,17,21,25–27,29,36).
A proper stretching program is key to improving flexibility.
Some research suggests that stretches be held for 30 seconds,
with at least 3–4 sets (12,20,32). For maximum improvement
in flexibility, it has been recommended that stretching be
done 5 or more times per week (34). Some studies have
shown that proprioceptive neuromuscular facilitation (PNF)
and contract-relax (CR) stretches may be most effective
(7,9,10,18,22,24,28,34). Ballistic stretching seems to be less
effective and, anecdotally, may cause injury (32). Static (or
passive) stretches have some benefit but may not work as
well as PNF stretches (8,11,16). Active stretching such as
ballistic and PNF requires individuals to volitionally contract
muscles. The PNF stretches use contraction of antagonist
and then relaxation (CR). Alternatively, they can also employ
contraction of the agonist of the lengthened muscle then
relaxation (contract-relax, antagonist-contract [CRAC]). The
CRAC stretches are reported to be more painful and cause

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more muscle trauma than other types of stretches (16).
Additionally, nerve glide stretches, termed neuromobilization,
are active stretches in which the nervous system is made taut
and then slack. The PNF stretches may be done in
combination with neuromobilization maneuvers. An exam-
ple of a neuromobilization maneuver would be the slump test.
The slump test is a seated straight leg raise (SLR) in which
a patient’s neural structures have progressive stretch applied
to elicit painful symptoms. Neural traction is experienced in
the intervertebral foramen by actively dorsiflexing the ankle
while flexing the cervical spine. Kornberg and Lew (15), in
a small, uncontrolled study, have suggested that adding the
slump maneuver to a treatment regime facilitated an athlete’s
return to full function after a hamstring strain. If abnormal
neural retraction predisposes the hamstrings to strain, then
theoretically stretching these neural structures should
improve flexibility and protect against injury.
Our study attempts to determine whether active stretches
are more effective than passive stretches and whether adding
a neuromobilization maneuver to active stretches enhances
the stretch. To our knowledge, no other study has looked at
these combined active stretches.
METHODS
Experimental Approach to the Problem
As clinicians and trainers, we often wonder what stretches are
most effective and how long it will take to see change. To
determine whether active stretches are more effective than
passive stretches, some common stretches used in therapy,
training rooms, and health clubs were chosen to represent the
independent variable (control group, 90/90 active, 90/90
passive, SLR active with mobilization, and SLR passive). To
reveal change, hamstring flexibility (dependent variable) was
measured initially, at 4 weeks, and at 8 weeks.
Subjects
Institutional review board approval was obtained before
recruitment of subjects. One hundred subjects were recruited
by word of mouth with a target age range of 18–80 years.
Actual participants ranged in age from 21 to 57; there were
45 women and 55 men. The mean age of participants was 33,
with a mode of 30. Exclusion criteria included hypermobility
(defined as initial hamstring length greater than 90°), history
of hamstring tear, upper motor neuron disease, lower motor
neuron disease, and past participation in formalized stretch-
ing programs. Informed consent was obtained from all
subjects.
Procedures
Reliability of Hamstring Length Measurement. Goniometric
hamstring length via the knee angle was measured in the
supine position. All subjects had their lumbar lordosis
supported with a lumbar roll. The distal tip of the lateral
malleolus was marked. Therapist 1 placed the hip into flexion
until the femur was perpendicular to the exam table. Therapist
2 then placed a goniometric lever over the femur and the
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other lever toward the marked lateral malleolus. Therapist 1
then extended the knee until firm end feel was achieved; the
knee angle was then recorded (see Figure 1). The ankle was
relaxed during the final knee angle measurements. All
measurements were taken using the right leg. Inter- and
intrarater reliability testing was done before proceeding with
measurements on the study subjects.
Comparison of Hamstring Stretches. Preintervention measure-
ments of hamstring length were taken, using the method
described above. The supine knee angle was used as the major
measurement of hamstring length. These subjects were then
randomly assigned to 1 of 5 groups: group A—control; group
B—90/90 passive stretch; group C—90/90 active stretch
(antagonist contraction); group D—SLR active-assisted
stretch (added neuromobilization component); and group
E—SLR passive stretch. Groups B, C, D, and E performed
3 sets of the assigned stretch. Each stretch was held for
30 seconds, with sets to be done 5 d
wk21. Subjects in each
group were asked to keep logs of their stretching activity. The
control group (group A) was asked to continue their normal
activities and not to change their activity routines for the next
12 weeks. The 90/90 passive stretch (group B) was
performed supine with a strap. Flexing the hip until the
femur was perpendicular to the floor standardized the hip
angle. By placing a strap around the ankle, each subject
applied force to achieve passive knee extension (see Figure 2).
The 90/90 active stretch (group C) was performed supine,
without a strap. Flexing the hip until the femur was
perpendicular to the floor standardized the hip angle.
Subjects applied active tension by actively extending their
knees via quadriceps contractions. Subjects clasped their
hands across their thighs for balance and to keep their hip
angles steady, with the femur perpendicular to the floor (see
Figure 3). The SLR active-assisted stretch (group D) was
performed supine against a wall, with the knee extended to
180°. The hip angle varied across subjects. Each subject was
asked to bring the femur as close to perpendicular to the floor
Figure 1. Goniometric measurements of knee angle.
VOLUME 23 | NUMBER 2 | MARCH 2009 | 661
Hamstring-Stretching Techniques
Figure 2. The 90/90 passive group (group B).
as possible. Each subject placed a heel against a corner of
a wall, and passive tension was applied to the posterior
hamstrings. Additionally, subjects ‘‘pumped the foot’’ by
actively dorsiflexing and plantarflexing the foot. A strap was
used to aid in pumping the foot (see Figures 4A and 4B). This
added ankle motion is generally considered to be a neuro-
mobilization maneuver (4).
The SLR passive stretch (group E) was performed supine
against a wall, with the knee extended to 180°. The hip angle
varied across subjects. Each subject was asked to bring his or
her femur as close to perpendicular to the floor as possible.
Each subject placed a heel against a corner of a wall, and
passive tension was applied by gradually increasing the hip
flexion angle (see Figure 5).
Each subject received a picture book illustrating his or her
selected hamstring stretch. Each subject (in groups B through E)
was given 1-on-1 instruction, on the same day as random
assignment, on how to do the selected stretch. Instructions
were to begin the stretching the next day. Subjects were given
a daily compliance log to complete. Each subject also
answered a questionnaire regarding demographics and
Figure 3. The 90/90 active group (group C).
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perceived hamstring stiffness. Subjects in groups B–D
reported prestudy activity levels for cardiovascular, strength-
ening, and stretching activities. Cardiovascular activities
consisted of running, swimming, aerobic classes, and walking.
Strengthening activities included weight training and partic-
ipation in resistance training classes. Stretching activities
consisted of stretching exercises and yoga. The percentages of
subjects in each group who reported prestudy cardiovascular,
strengthening, and stretching activities are summarized in
Table 1.
Initial hamstring measurements were taken on all subjects.
The right leg was used for all measurements. At 4 and 8 weeks,
hamstring length measurements were taken again. Results
were recorded as degrees of knee flexion angle. A larger knee
flexion angle reflects tighter hamstrings, whereas a smaller
knee flexion angle reflects looser hamstrings. Perceived level
of hamstring tightness score was recorded initially, at 4 weeks,
and again at 8 weeks, using the following scale: 0 = no
perceived level of tightness, 1 = occasionally feel hamstrings
are tight, 2 = frequently feel hamstrings are tight, and 3 =
constantly feel hamstrings are tight.
Statistical Analyses
Data were processed by checking for item nonresponse,
distributional forms (e.g., normality of continuous data
elements), and creating derived variables. SAS version 9.1
(SAS Institute Inc., Cary, NC) statistical software was used for
all statistical analyses. Frequencies and percentages were
calculated for categorical data, and mean and SD were
calculated for numeric data. Associations among numeric
measures were tested using Spearman correlations. Chi-
square and Fisher exact tests were used to test relationships
between bivariate categorical data. Groups A, B, C, D, and E
were compared using analysis of variance (ANOVA) on the
4-week follow-up measure of range of motion after
adjustment for initial measure, gender, age, and frequency
of exercise. The Tukey-Kramer multiple comparisons test
was used to detect significant pairwise differences between
groups.
Finally, the repeated-measures of range of motion over time
(initial, 4-week, and 8-week measures) were modeled using
the MIXED procedure in SAS. The MIXED procedure
models the dependence of within-person data and incorpo-
rates observations from each subject regardless of missing
data. The longitudinal model simultaneously examined the
following explanatory variables: activity protocol group,
gender, age, and frequency of exercise. For all statistical
analyses, significance was considered at p # 0.05. Intraclass
correlation coefficients (ICCs) were calculated to measure
intra- and interrater agreement (the reliability between
raters). The ICCs give a measure of agreement between
raters on numeric data that is more informative than
a Pearson correlation coefficient. For example, the pairs
(1, 10), (2, 20), and (3, 30) have a Pearson correlation
coefficient of 1.00. The ICC of these pairs, however, is close
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Using ANOVA modeling, the

Figure 4. The straight leg raise (SLR) active assisted group (group D).
to zero, because this statistic incorporates information about
the magnitude of variation between raters.
RESULTS
Of the 100 subjects initially recruited, 13 subjects failed to
participate in further data collection at the 4-week or 8-week
time points (82 subjects had complete data; 5 subjects had 8-
week data but no 4-week data). There was no evidence of loss
to follow-up based on type of stretching technique (Fisher
exact test, p = 0.5012). Demographic pooling of data revealed
no significant differences in age, exercise activity of
individuals, or initial hamstring measure. However, groups
differed significantly by gender (chi-square test, p = 0.0006).
Group B (90/90 passive stretching group) had the highest
percentage of men, and group C (90/90 active stretching
group) had the lowest (see Table 2). Compliance log results
were similar in all treatment groups.
The ICC values to measure intrarater reliabilities for
hamstring measure were 0.75 and 0.85. The ICC value to
measure interrater reliability for hamstring measure was 0.69.
Values of ICC in this range are deemed acceptable.
4-week range-of-motion mea-
sure was modeled using the
explanatory variables of initial
measure, activity protocol
group, gender, age, and fre-
quency of exercise. The ANOVA
model explained 75% of the
variation in response (R2 =
0.7496). After adjustment for
other explanatory variables in
the model, initial measure (p ,
0.0001), activity protocol group
(p = 0.0237), and gender (p =
0.0103) were found to be sig-
nificantly related to the 4-week
range-of-motion measure. Age and frequency of exercise
were not found to be significant. Women had significant
improvements in range of motion compared with men. Using
the Tukey-Kramer multiple comparison procedure to test for
pairwise differences, group D (SLR active-assisted stretch)
was found to differ significantly from group B (90/90 passive
stretch; p = 0.0318), with group D exhibiting significant
improvements in range of motion compared with group B.
Results of ANOVA testing are given in Table 3. Negative re-
gression coefficients indicate improvements in range of motion.
A longitudinal analysis of the initial, 4-week, and 8-week
repeated range-of-motion data was conducted. In a longitu-
dinal analysis, the trajectory of repeated measures is con-
sidered the ‘‘outcome,’’ and its shape (a linear or curvilinear
evolution) is explained by a set of predictor variables. For the
range-of-motion repeated-measures data, the trajectory for
each individual was modeled as a linear evolution with the
following predictor variables: type of stretch performed,
gender, age, and frequency of exercise. Mean values of each
group are plotted in Figure 6. Three factors significantly
predicted the linear trajectory of the range-of-motion data:
type of stretch performed, gender, and frequency of exercise.
Group E (SLR passive stretch) demonstrated the largest
improvement of flexibility at 8 weeks. The women’s flexibility

TABLE 1. Prestudy activity background.

Group Group Group Group

B (%) C (%) D (%) E (%)

Cardiovascular 72 94 94 88
General 11 0 6 0
strengthening
Stretching 17 40 25 32
Subjects’ subjective reporting of current activity levels
at beginning of study.
Figure 5. The straight leg raise (SLR) passive group (group E).

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Hamstring-Stretching Techniques

TABLE 2. Descriptive statistics for retained subjects.

Overall Group A Group B Group C Group D Group E p*

N 87 18 16 18 16 19 —
Gender, % men 54% 67% 88% 22% 63% 37% 0.0010
Age in years, mean (SD) 33.3 (8.1) 36.1 (10.1) 31.0 (5.5) 31.9 (8.3) 36.9 (8.6) 30.7 (6.0) 0.0575
Frequency of exercise, 3.7 (2.1) 4.4 (2.7) 3.0 (1.6) 3.7 (1.8) 4.3 (1.6) 3.2 (2.1) 0.1542
mean (SD)
Initial range of motion, 31.8 (9.6) 31.5 (10.7) 33.3 (10.5) 28.3 (5.8) 33.6 (10.9) 32.5 (9.8) 0.4976
mean (SD)
*Chi-square tests were used for testing gender effects among different protocol groups, and analyses of variance (ANOVA) were
used to test for differences attributable to age, frequency of exercise, and initial hamstring measure.

improved more than that of their men counterparts. The more efficacious compared with the control group. At
more frequently the exercise was performed, the more range 4 weeks, improvements in hamstring flexibility were seen in
of motion improved. Further testing showed significant both groups C and D. Group C used a 90/90 active stretch,
improvement in flexibility for group E (SLR passive stretch) which is a modified contract/relax PNF stretch, and group D
compared with group B (90/90 passive stretch; p = 0.0066). performed an SLR with a neuromobilization component. The
There was a trend toward significance between group B passive stretch group (group E) using a supine SLR against
(90/90 passive stretch) and group D (SLR active-assisted a wall also achieved an improvement. Both the 90/90 passive
stretch; p = 0.0652), with group D showing more improve- stretch group and the control group showed no improvement
ment of flexibility than group B. Results of longitudinal with hamstring flexibility. After 8 weeks of stretching, the SLR
analysis are given in Table 4. passive stretch group (group E) achieved the most improve-
ment in hamstring length.
DISCUSSION The range-of-motion improvements in the SLR passive
The objective of this study was to compare 4 different stretch group (group E) may be attributed to an increase in
stretching techniques to determine which one was most stretch tolerance found with static stretching (19). These
efficacious at improving hamstring flexibility. The 2 types of improvements also may be attributable to the viscoelastic
stretches studied were active and passive. The results of this property changes that occur with ‘‘creep,’’ whereby the
study demonstrate that both active and passive stretches were tension in the muscle-tendon unit diminishes over time (32).
As with previous research,
PNF stretches seem to be as
beneficial as passive stretches.
TABLE 3. Analysis of variance results. Furthermore, the addition of a
Estimate of regression neuromobilization component
coefficient* (SE) p may be beneficial to hip flexion
and knee extension range of
Initial measure 0.69 (0.07) ,0.0001 motion. The improvement seen
Group 0.0237
in the neuromobilization group
A. Control (reference) 0.00
B. 90/90 passive 1.57 (1.95) emphasizes the fact that flexi-
C. 90/90 active 23.16 (1.88) bility is influenced not only by
D. Straight leg raise active 24.46 (1.76) muscle elasticity but also by
E. Straight leg raise passive 22.30 (1.84) connective tissue/nervous tis-
Gender 0.0103
sue extensibility. One previous
Women 23.91 (1.48)
Men (reference) 0.00 study showed a quicker return
Age 0.10 (0.07) 0.1863 to play for injured athletes who
Frequency of exercise 20.04 (0.29) 0.8981 used neuromobilization tech-
niques (31). Unlike previous
*Positive numbers indicate less improvement in flexibility; negative numbers indicate
improved flexibility. studies, our results show no
correlation with hamstring
flexibility and age.
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Figure 6. Mean angles measured at 4 weeks and 8 weeks, and comparing all groups A through E.

Compliance was not directly measured in this study. While no retention of knee range of motion at 4 weeks after a 6-week
participating in the study, all subjects kept stretching diaries. stretching program had been implemented (35). This conveys
Individuals reported that PNF stretches were more engaging the importance of maintaining a stretching program. The
and less boring than static stretches. A recent study showed improvements seen with the active and passive stretches
suggested in this study will
likely only continue if the
stretching prescription is main-
tained indefinitely.
TABLE 4. Longitudinal analysis results.
Despite the randomized con-
Estimate of regression trolled design, this study has
coefficient (SE) p limitations. Not all items could
be controlled, such as the acti-
Group intercept 0.5411
vity levels of the participants.
A. Control (reference) 0.00
B. 90/90 passive 21.52 (2.93) Also, the subjects were perfor-
C. 90/90 active 0.75 (2.87) ming the majority of these
D. Straight leg raise active 1.88 (2.80) stretches on their own, without
E. Straight leg raise passive 3.17 (2.82) the supervision of a therapist.
Group slope 0.0001
Although the therapist watched
A. Control 20.34 (0.25)
B. 90/90 passive 0.044 (0.25) them doing the stretches cor-
C. 90/90 active 20.51 (0.24) rectly in follow-up visits, there
D. Straight leg raise active 20.62 (0.25) was no way to determine
E. Straight leg raise passive 20.89 (0.23) whether they were really keep-
Gender , 0.0001
ing their hips at 90/90 when
Women 29.30 (3.94)
Men (reference) 39.97 (4.03) stretching independently. Re-
Age 0.08 (0.10) 0.4399 searchers attempted to obtain
Frequency of exercise 21.00 (0.40) 0.0142 measurements at the same ap-
proximate time of day for each
*Positive numbers indicate less improvement in flexibility; negative numbers indicate
improved flexibility. measuring session to eliminate
flexibility variations with circa-
dian rhythms. Additionally,

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Hamstring-Stretching Techniques
a high variability of data was observed in each group.
Generalization of this study to clinical practice should be
confined to the demographics of the individuals we studied.
Future studies on flexibility or stretching could be
considered using functional, weight-bearing movements.
Questions on the safety of neuromobilization maneuvers
warrant investigation. Moreover, a clinical outcomes study on
the utility of these types of stretches in subjects with specific
injury diagnoses would be helpful.
PRACTICAL APPLICATIONS
Clinically, these types of hamstring stretching may be a useful
first-line agent in treating hamstring strains, remodeling
chronic hamstring and surrounding tissue dysfunction,
recovering elasticity of tissue end feel, and improving
hamstring flexibility for performance. However, the effect
of stretching on performance is controversial. Winchester
et al. (37) found an adverse effect on sprint performance after
10 minutes of presprint static stretching in collegiate runners.
In addition, a study by Bazett-Jones et al. (2) found that
6 weeks of a hamstring-stretching protocol neither negatively
nor positively impacted athletic performance or sprint and
vertical jump outcomes.
Functional progression from these active hamstring
stretches to triplanar, weight-bearing stretches should be
incorporated to return individuals to specific types of activity
or play. The entire kinetic chain should be assessed, and the
hamstring stretches should not be used in isolation. Although
we suggest that both active and passive stretches are
beneficial, they are not necessarily functional. Recent research
has shown that performing exercises that improve neuro-
muscular control are more effective for rehabilitating pelvic
muscle injuries than stretching exercises alone (30). Active
and passive stretches should be viewed as a means to the end,
not the end.
Our research affirms that changes in flexibility take time,
achieving end ranges intermittently and with diligent training.
The more frequently someone stretched and the further they
pushed into the range, the more range they achieved. This
supports the need to educate patients that remodeling tissue is
time dependent and should be undertaken consistently and
frequently and, most importantly, that they should achieve
end range by over pressure.
In summary, our study indicates that improvement in
hamstring flexibility was greatest for the SLR passive stretch.
Our results also show that using PNF in the 90/90 active
stretch provided better knee range-of-motion improvements
than the 90/90 passive methods did. Future studies on more
functional weight-bearing stretches should be performed to
define their role.
ACKNOWLEDGMENTS
The authors thank the staff and patients of the Rehabilitation
Institute of Chicago, Center for Spine and Sports
Rehabilitation.
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The authors declare no conflicts of interest related to this
study. The results of the present study do not constitute
endorsement by the authors or the NSCA.
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