Sport | MET

Muscle Energy T

John Gibbons, sports osteopath, lecturer, and

author, provides an introduction to Muscle
Energy Techniques (MET) before looking at
MET and the hamstrings in more detail

n additional tool for the physical

therapists manual therapy toolbox,
Muscle Energy Techniques (MET) can help to
release and relax muscles, and promote the
bodys own healing mechanisms.
MET is unique in its application as the
client provides the initial effort while
the practitioner facilitates the process.
The primary force originates from the
contraction of soft tissue, which is then
utilised to assist and correct the presenting
musculoskeletal dysfunction.
MET is generally classified as a direct
technique as opposed to indirect
because the muscular effort is from a
controlled position, in a specific direction,
against a distant counter force (usually the
practitioner). One of the main uses of this
method is to normalise joint range, rather
than increase flexibility, and techniques
can be used on any joints with restricted
range of motion (ROM) identified during the
passive assessment.
The benefits of MET may include:
l Restoring normal tone in
hypertonic muscles
Physical therapists use MET to try to help
relax the hypertonic shortened muscles.
If a joint has limited ROM, then through
the initial identification of the hypertonic
structures, techniques can help to achieve
normality in the tissues. MET applied in
conjunction with massage therapy can be
very beneficial in helping to achieve this
relaxation effect.
l Strengthening weak muscles
MET can be used to help strengthen weak,
or even flaccid, muscles, with the client
advised to contract the muscle classified
as weak against a resistance applied by the
therapist (isometric contraction). Timing of
techniques can be varied, for example, the
client resists the movement to approximately
20 to 30 per cent of their capability for five
to 10 seconds, resting for 10 to 15 seconds,
and then repeating the process five to eight
times. This can be improved over time.
l Preparing muscle for
subsequent stretching
In some circumstances, the sport a client
participates in may affect joint ROM.
Most people can benefit from improved
flexibility, and although the focus of MET
is to reach normal ROM, a more intensive

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Issue 97 July 2011

MET approach can be

employed to improve
flexibility beyond this.
This might involve the
client contracting beyond
the standard 10 to 20
per cent of the muscles
capability. Once MET has
been incorporated into the
treatment plan, a flexibility
programme could follow.
l Improved joint mobility
A stiff joint can become a
tight muscle and a tight muscle can become
a stiff joint. When used correctly, MET can
improve joint mobility, even when you are
relaxing the muscles initially. A relaxation
period follows the muscle contraction, which
then helps to achieve the new ROM.
The main effects of MET can be explained by
two distinct physiological processes: postisometric relaxation (PIR) and reciprocal
inhibition (RI). Certain neurological
influences occur during MET, but before
considering PIR/RI, it is useful to take into
account the two types of receptors involved
with the stretch reflex (Diagram 1):
l Muscle spindles sensitive to change
in length and speed of change in
muscle fibres.
l Golgi tendon organs that detect prolonged
change in tension.
Stretching a muscle causes an increase in
the impulses transmitted from the muscle
spindle to the posterior horn cell (PHC) of
the spinal cord. In turn, the anterior horn
cell (AHC) transmits an increase in motor
impulses to the muscle fibres, which creates a
protective tension to resist the stretch.
But increased tension maintained for a few
seconds is sensed within the Golgi tendon
organs, which transmit impulses to the PHC
and has an inhibitory effect on the increased
motor stimulus at the AHC. This inhibitory
effect causes a reduction in motor impulses
and consequent relaxation. This implies that
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Diagram 1: the stretch reflex

the prolonged muscle stretch will increase
overall stretching capability due to the
protective relaxation of the Golgi tendon
organs overriding the protective contraction.
However, a fast stretch of the muscle spindles
will cause immediate muscle contraction
and if not sustained there will be no
inhibitory action.
When an isometric contraction is
sustained, neurological feedback through
the spinal cord to the muscle itself results
in post-isometric relaxation (PIR), causing a
reduction in tone of the contracted muscle.
This lasts for approximately 20 to
25 seconds, during which the tissues can
be more easily manipulated to a new
resting length.
During reciprocal inhibition (RI) (Diagram
2), the reduction in tone relies on the
physiological inhibiting effect on antagonists
during the contraction of a muscle. When
the motor neurons of the contracting agonist
muscle receive excitatory impulses from
the afferent pathway, the motor neurons
of the opposing antagonist muscle receive
inhibitory impulses from their afferent
pathway. It follows that contraction or an
extended stretch of the agonist muscle must
elicit relaxation or inhibit the antagonist,
and that a fast stretch of the agonist will
facilitate a contraction. The refractory period
also lasts for approximately 20 seconds but,
with RI, it is thought to be less powerful
than PIR. In certain circumstances, use of
the agonist may be inappropriate due to pain
or injury.

Method of treatment
MET can be used with both acute and
chronic conditions, but intensity and
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MET | Sport

y Techniques
duration of symptoms will determine which
variation of MET is suitable.
l Therapist guides muscle to point of
resistance (point of bind) before releasing
slightly from that position (especially if
the tissue is tender).
l Client isometrically contracts affected
muscle (PIR) or the antagonist (RI) to
approximately 10 to 20 per cent of its
strength capabilities against resistance.
l Client holds contraction for 10 to
12 seconds.
l Client relaxes fully by taking a deep
breath in and, as they breathe out, the
therapist passively guides the specific joint
that lengthens the hypertonic muscle into
a new position, effectively normalising
joint ROM.
l Process repeated until no further progress
is made (normally three to four times) and

final stretch held

for approximately 20
to 30 seconds.
MET is quite a mild form
of stretching when compared
to other techniques, such as
proprioceptive neuromuscular
facilitation (PNF), and MET is

1 (All pictures are a

reconstruction using a model)

Diagram 2: reciprocal inhibition (RI)

therefore more appropriate for rehabilitation.
Most conditions involving muscle
shortening will occur in postural muscles,
since these are composed predominantly of
slow twitch fibres, therefore a milder form of
stretching is perhaps more suitable.

General assessment of
the hamstrings
the hip flexion test helps to provide the
practitioner with an overall impression of the
general length of the hamstring muscles. the
client lies in a supine position with both legs
extended. the therapist passively guides the
clients left leg into flexion until a point of bind
is felt. the normal range is between 80 and
90 degrees; less than 80 degrees determines
that the length of the hamstrings is held in a
shortened position. however, neural tension of
the sciatic nerve and specific hamstring injury
will also restrict the movement.
the client had 60 degrees of motion in
his right leg, but the symptoms were not
reproduced with the normal hip flexion test.

Case study
James* is a 24-year-old male who plays rugby at
a high standard. he has an ongoing right-sided
hamstring injury that has not responded to
conventional treatment. he has had some soft
tissue work on his problematic hamstring with
advice on a stretching programme.
having initially carried out a thorough
assessment to consider other differential
diagnoses for the cause, rather than purely
treating the presenting pain, I found no
dysfunction present in the lumbar spine,
pelvis, hip or lower limb. James presented with
pain in his right hamstring, located more on
the lateral, central aspect, and he identified
the aggravating factor as the movement of
rotation when he played rugby. he was
relatively pain free when running in a straight
line, but if he rotated, changed direction or
passed a ball, then symptoms would worsen.

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Assessment of the
lateral hamstrings
Pictures 1 and 2 demonstrate a specific test
that I used to determine whether the clients
(not pictured) lateral hamstrings were tight,
and involved a technique that individually
isolated and tested the lateral (biceps femoris)
and medial hamstrings (semitendinosus and
semimembranosus).
the therapist applies an internal rotation
and adduction, while the clients leg is taken
into passive flexion, which isolates the biceps
femoris. If the motion feels restrictive, the
therapist needs to determine whether the range
of motion is less than the original hip flexion
test, and if it is, then the lateral hamstring
can be identified as short. When this test
was carried out on James, it had the effect of
reproducing his symptoms, which indicated
that the biceps femoris is the muscle that is
responsible for his specific symptoms.

Issue 97 July 2011

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Sport | MET
Assessment of the medial hamstrings
although I was able to determine that it was the right lateral
hamstring, the biceps femoris, that was causing James problem,
to isolate the medial hamstrings in order to investigate whether
they were the restrictive tissue, the clients leg is externally
rotated and abducted, while the hip is being passively flexed
(Pictures 3 and 4).
For many athletes who present with hamstring injuries, it
is important to differentiate between the lateral and medial
hamstrings for a successful rehabilitation programme to be
achieved. a combination of corrective treatment and rest will
help to improve physiological function and sport performance
with a reduced risk of recurrent injury.

James needs his right biceps femoris lengthened to the normal

roM, and to achieve this, the hip needs to be taken into a
rotation (as above), and from this position an Met for the
specific muscle can be performed. It is important that the
hamstrings are treated in a position that is related to the clients
sport and the position that may have caused the initial trauma.
James injured his right hamstring while rotating his trunk to the
left to pass the ball.
the following technique is very good for lengthening the
hamstrings as a group. the therapist adopts a standing
posture and passively guides the clients right leg into hip flexion
until a bind is felt in the hamstrings. From this position, the
clients lower leg is placed onto the therapists right shoulder
(Picture 5).
the client pushes down against the shoulder of the therapist
for 10 seconds. after the contraction of the hamstrings and
during the relaxation phase, the therapist passively takes the
right leg into further flexion (Picture 6).
to apply a rI method at this point, the client would flex
their hip while the therapist encourages passive hip flexion. this
involves the client contracting the hip flexors, which causes a
reciprocal inhibition in the hamstrings and promotes relaxation,
thereby helping achieve an increased roM and new position.
*The clients name has been changed.

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Issue 97 July 2011

John Gibbons, sports osteopath, lecturer, author, and regular speaker/contributor

to Fht, owns peak sporting performance at oxford university sports. his new
book, Muscle energy techniques, a practical guide for physical therapists, will be
available in september 2011 from lotus publishing (www.lotuspublishing.co.uk),
physique and amazon. t. 07850 176600 www.peaksport.co.uk

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pIctures: lotus publIshIng

MET PIR treatment of the

hamstrings (non-specific)