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Original Article

A Comparative Study of Muscle Energy Technique and

Positional Release Technique on Hamstring Flexibility in
Healthy Individuals
Sejal Sailor, Yesha Mehta, Neha Shah, Anuja Trivedi
Department of Musculoskeletal Physiotherapy, SPB Physiotherapy College, Surat, Gujarat, India

Abstract
Background: Muscular flexibility is an essential aspect of normal human function. Flexibility can be gained by a variety of stretching
techniques and other techniques, yet little work has been performed to compare these techniques. The objective of this study was to compare
the effectiveness of muscle energy technique (MET) and positional release technique (PRT) on hamstring flexibility in healthy individual
participants. Methods: Twenty‑four healthy participants who met the inclusion criteria were randomly divided into two equal groups. Two
groups following a home‑based 2 weeks’ (five 10 min sessions per week) hamstring stretching protocol (stretching performed by MET or
by PRT). The range of motion (ROM) of knee extension was measured before and after stretching program by means of active knee extension
test and active straight leg raise using universal goniometer. Results: There was a significant improvement in hamstring flexibility following
the application of MET and PRT. However, increase in knee extension ROM was higher in MET compared to PRT. The change in the flexibility
from the value at initial evaluation to after 2 weeks’ intervention was also higher in the MET. Conclusion: The findings suggest that the MET
is more effective than PRT for healthy individuals with normal and limited hamstring flexibility.

Keywords: Active knee extension, hamstring muscle, muscle energy technique, positional release technique, straight leg raise

Introduction stretching is commonly used in the general population as well as

Hamstring muscles are well known for their great tendency to
shortening,[1,2] which is due to their multi‑joint function, their
tonic postural character, and considerable amount of tensional
forces to which they are constantly submitted.[3] The length of
the hamstring muscles is considered to play an essential role
in both the effectiveness and efficiency of fundamental human
movements such as walking and running.[4] The literature shows
that reduced hamstring flexibility is a common clinical finding
in the general population[5] as well as athletic populations which
result in major muscle imbalances, predisposing athletes to
muscle injuries,[6] patellar tendinopathy, and patellofemoral
pain[7,8] as well as may lead to low back pain.
Considering the importance of hamstring flexibility in the general
and athletic population, maintaining the flexibility of hamstring
muscle is of utmost importance for health‑care professionals
and to achieve this goal one needs to know the most effective
and efficient technique to obtain hamstring flexibility. Muscle
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in sport and clinical contexts to maintain/restore good flexibility,
improve muscle flexibility in case of tight muscles, or to treat or
prevent musculoskeletal injuries (e.g., muscle strain).[9] Many
stretching procedures are being used for hamstrings flexibility,
including static stretching and dynamic stretching such as
ballistic stretching and precontraction stretching, which is
the technique of proprioceptive neuromuscular facilitation
techniques.[10] Studies present different number of sets,
duration of stretching, length of training, and ways to evaluate
the flexibility. These inconsistencies diminish the efficacy
of stretching and make it difficult to establish optimal static
stretching training programs.[11]
Address for correspondence: Dr. Sejal Sailor,
Department of Musculoskeletal Physiotherapy,
SPB Physiotherapy College, Ugat Bhesan Road,
Surat ‑ 395 005, Gujarat, India.
E‑mail: drsejalsailor@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Sailor S, Mehta Y, Shah N, Trivedi A. A comparative
10.4103/JIHS.JIHS_22_18 study of muscle energy technique and positional release technique on
hamstring flexibility in healthy individuals. J Integr Health Sci 2018;6:64-8.

64 © 2019 Journal of Integrated Health Sciences | Published by Wolters Kluwer - Medknow

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Sailor, et al.: Comparative effectiveness of stretching technique on hamstring flexibility
Although most training parameters related to flexibility
programs for the hamstrings have been investigated, no study
has yet been conducted to specifically compare hamstrings
stretches which differ depending on the joint at which the
stretching is focused. Yet, as previously mentioned, these
stretches might have a different influence on the muscle and
nervous system structures, and consequently, on the range of
motion (ROM) improvement.
Therefore, the aim of the present study was to compare the
effectiveness of muscle energy technique (MET) and positional
release technique (PRT) on hamstring tightness among normal
healthy individuals.
Methods
The study was a randomized clinical trial conducted in
the Department of Musculoskeletal Physiotherapy of the
Institute. Participants were randomly assigned following
simple randomization procedure into two groups with different
stretching protocol as follows: METs and PRT. Preparticipation
and postintervention assessment were conducted by one
therapist, randomization by the second therapist, and protocol
for MET and PRT was performed by physiotherapists
specialized in orthopedic manual therapy.
Participants
Twenty‑four male or female students of the institute were
voluntarily participated in this study. Inclusion criteria for the
study were willingness to participate, aged between 18 and
25 years, marked loss of active and passive ROM of hip and
knee joint, hamstring trigger point and tightness defined by
minimum 30° restriction in straight leg raise (SLR) unilaterally
or bilaterally, and a positive active knee extension  (AKE)
test. Participants with any medical history of injury to back,
inflammatory conditions, having history of undergone surgery
in the last 3 months, with hamstring injuries and strains, knee
deformities and injuries, fractures that may have affected the
lower extremity within the past 6 months, any neurological
condition (any cerebrovascular accident), peripheral vascular
disease, and those who unwilling to participate were excluded
from the study. Figure 1 presents the enrollment and allocation
of participants in groups. All participants were informed about
the objective of the study before participation and were free
to withdraw at any time from the study. The written informed
consent was also obtained from all the participants.
Procedures
Design of the study
This study was a pretest–posttest comparative experimental
design. Participants who met the inclusion criteria were
selected for the study. After that, the participants were assessed
for baseline data by measuring the AKE test and active SLR
tests using universal goniometer. Participants were randomly
assigned into MET group (n = 12) or PRT group (n = 12). The
interventions were given for 5 days per week for 2 weeks. All
the participants were assessed (same as baseline measurement)
Journal of Integrated Health Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2018
Figure 1: Flow of participants through the experimental phase of the study
after 2‑week intervention. All measurements were taken three
times, and average values of three trials were taken.
Stretching protocols
Muscle energy technique protocol
The supine patient fully flexes the hip on the affected side.
The flexed knee is extended by the practitioner to the point
of resistance (identifying the barrier). The calf of the treated
leg is placed on the shoulder of the therapist, who stands
facing the head of the table on the side of the treated leg. If
the right leg of the patient is being treated, the calf will rest
on the practitioner’s right shoulder, and the practitioner’s right
hand stabilizes the patient’s extended unaffected leg against
the table. The practitioner’s left hand holds the treated leg
thigh to both maintain stability and to palpate for bind when
the barrier is being assessed. The patient is asked to attempt
to straighten the lower leg (i.e., extend the knee) utilizing the
antagonists to the hamstrings, employing 20% of the strength
in the quadriceps. This is resisted by the practitioner for
7–10 s. Appropriate breathing instructions should be given.
The leg is then extended at the knee to its new hamstring limit
if the problem is acute (or stretched slightly if chronic) after
relaxation and the procedure is then repeated.[12]
Positional release technique protocol
Medial hamstring – This tender point is located on the posterior,
medial surface of the tibia, on the tendinous attachments of
the semimembranosus and the semitendinosus. Pressure is
applied anteriorly. The patient lies supine with the affected
thigh extended and abducted off the edge of the table. The
therapist then flexes the affected knee 40° and adds slight
adduction  (varus force) and marked internal rotation of the
tibia.[13]
Lateral hamstring  –  This tender point is located on the
posterior, lateral surface of the head of the fibula, on the
tendinous attachment of the biceps femoris. Pressure is
applied anteromedially. Position of treatment  – The patient
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Sailor, et al.: Comparative effectiveness of stretching technique on hamstring flexibility
lies in supine with the affected thigh extended and abducted
off the edge of the table. The therapist flexes the affected knee
approximately 40° and then either abducts or adducts the lower
leg (usually slight abduction, i.e., valgus force to the tibia).
The tibia is then either internally or externally rotated (usually
external rotation).
Outcome measurement
Active knee extension hamstring flexibility test
Participants were assessed on a plinth in the supine position
with both lower extremities extended. Both anterior superior
iliac spines were positioned properly. The lower extremity
not being measured was secured to the plinth using a strap
across the lower third of the thigh. Each assessor marked the
lateral knee joint line with washable ink. From there, two lines
were drawn. The first was drawn to the greater trochanter and
another to other was drawn to the apex of the lateral malleolus.
The participants were told to flex the hip until 90°. The
participants were asked to extend the leg as much as possible
while keeping their foot relaxed and to hold the position for
about 5 s. A standard universal goniometer was placed over
the marked joint axis, and the goniometer arms were aligned
along the femur and fibula. The AKE measurement was defined
as the degree of knee flexion from terminal knee extension.
Each knee was measured thrice, and the mean angle of the
AKE test was used for the analysis.[14]
Active straight leg raise test
In the active SLR test, the participants were asked to lift the leg
as high as possible three times at 10 s intervals while keeping
the knee in extension. Repetitions were performed to improve
the contraction force, which increases the active ROM. The
average of three results was recorded for the analysis.
Statistical analysis
The minimum sample size was estimated using two‑sample
two‑sided equality‑based sample size calculations. The
minimum required number of sample size was estimated at 12
participants per group to detect the difference between groups
on the retest when α was <0.05 and power was 80% with an
effect size of 0.3.[15]
Statistical analysis was conducted using the SPSS (Software
Version  20.0, IBM, USA). The Kolmogorov–Smirnov test
was used to determine the normal distribution of the data.
The descriptive analysis was performed for the demographic
data and represented as mean and standard deviation.
Unpaired t‑test was applied to examine the difference
between the two groups. To compare the mean values of ROM
between two groups, two‑way repeated measures ANOVA
using two factors  (test time: before and after 2  weeks, and
groups: MET group and PRT group) was used to analyze
interaction effects. When a significant interaction was
observed, a paired t‑test was used for comparing the pre‑ and
post‑treatment values in each group. The alpha level of 0.05
with 95% confidence interval was used to denote statistical
significance difference.
66 Journal of Integrated Health Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2018
Results
Twenty‑four students were selected from 38 participants
(mean age: 20.4 ± 1.3 years old; mean AKE left: 32.5° ± 6.4°,
mean AKE right: 27.8° ± 3.2°; mean SLR angle right: 56.8° ±
8.8°, mean SLR angle left: 56.3° ± 9.3°; and females: n = 21,
males: n = 03) based on the inclusion/exclusion criteria which
play an important role in removing the influence of specific
confounding variables.
Twenty‑four participants were randomly assigned into
MET (n = 12) and PRT (n = 12) groups. Their demographic
parameters  [Table  1] and baseline characteristics did not
differ from the ones of the other participants in both groups.
While data obtained after 2 weeks’ stretching program shows
a significant difference (P < 0.05) between groups except SLR
values for right side [Table 2].
Table 2 shows the results of the tests of within‑subjects effects
and paired sample t‑test. The repeated‑measure ANOVA
analyses indicated significant group‑by‑time interactions for all
outcomes, indicating that ROM improved differently between
groups (greater increase in MET groups than in the PRT). In
addition, the time effect was also highly significant for all
outcomes.
In MET and PRT group, ROM in AKE and SLR significantly
increased after posttest. However, the improvement in
MET was better than that of PRT evident from higher mean
difference between pre‑  and post‑treatment data  [Table  2].
According to the comparison of mean difference values of
pre‑ and post‑test between MET and PRT, the difference was
significantly higher in MET compared to PRT.
Discussion
This study was undertaken to investigate the influence of
MET and PRT for hamstring flexibility. The results of this
study demonstrate that both MET and PRT were effective at
improving AKE and SLR angles following 2 weeks’ stretching
program which was concurred with existing studies that had
reported that the stretching training program increased the
flexibility of hamstring.[16]
Increase in ROM following a stretching training program
has been explain through various hypothesis proposed
by the different study. Adel Rashad Ahmed in their study
found significant improvement in hamstring flexibility in
both the techniques, the MET and dynamic stretching yet
the improvement in MET was better than that of dynamic
stretching.[17] Selkow et  al. also described the effectiveness
Table 1: Demographic data
Variables Group 1 (MET) Group 2 (PRT)
Age 20.58±1.31 20.25±1.36
Height 155.81±4.47 158.07±7.48
Weight 53.29±9.78 52.50±5.87
MET: Muscle energy technique, PRT: Positional release technique
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Sailor, et al.: Comparative effectiveness of stretching technique on hamstring flexibility

Table 2: The effect of two treatment protocol on hamstring flexibility

Outcome/study groups Pretest Posttest Difference Repeated‑measure ANOVA results
Interaction (group × time) Effect time Effect group
F (1,22) P F (1,22) P F (1,22) P
AKE (°)
MET
Left side 30.50 (2.34) 54.21 (4.57)*** 23.72 (4.57)$$ 29.61 <0.001 256.85 <0.001 1.023 0.323
Right side 27.00 (2.13) 50.24 (6.06)*** 23.25 (5.50)$$ 24.88 <0.001 366.66 <0.001 3.90 0.061
PRT
Left side 34.47 (8.39) 46.16 (5.47)*** 11.69 (6.14)
Right side 28.63 (3.90) 42.27 (5.26)*** 13.64 (3.78)
SLR (°)
MET
Left side 54.61 (7.72) 76.47 (5.91)*** 21.86 (7.93)$$ 18.04 <0.001 121.36 <0.001 0.349 0.561
Right side 50.11 (7.72) 72.63 (6.91)*** 22.53 (6.56)$$ 25.93 <0.001 251.90 <0.001 0.867 0.362
PRT
Left side 59.02 (9.63) 68.72 (7.30)*** 9.69 (5.97)
Right side 58.41 (9.23) 70.00 (7.58)*** 11.58 (3.51)
***P<0.001, significant difference between pre‑ and post‑test outcome measure, $$P<0.001, significant difference of the “Difference” between MET
compared to PRT. Data are expressed as mean (SD) with 95% CI. MET: Muscle energy technique, PRT: Positional release therapy, AKE: Active knee
extension, SLR: Straight leg raise, SD: Standard deviation, CI: Confidence interval

of MET for hamstring muscle.[18] In addition, some studies
reported the analgesic effect of MET.[19‑21] On the other hand,
Ballantyne et  al. argued and hesitate about the efficacy of
MET in the form of postisometric relaxation (PIR).[22] They
suggested that the PIR theory and its consequent hypoanalgesic
effects are poorly supported by research. Allen also studied
the effectiveness of MET in improving hamstring flexibility
and considered MET a statistically significant intervention
in improving hamstring flexibility in patients with hamstring
injuries. [23] Therefore, stretching training programs can
be recommended for clinical practice in which hamstring
flexibility is required.
The present study showed that the improvement in hamstring
flexibility in the PRT group was less than that of MET group.
The reason for this difference may be due to the increase in
muscle length by a combined effect of creep and plastic change
in the connective tissue.[24] It was also concluded that 30 s as
the optimal duration for an efficient stretch in MET protocol
which can maintain muscle elongation for the same duration
leads to increase in muscle length.[25]
There has been limited research on the effects of positional
release therapy on hamstring flexibility. PRT is proposed to
affect both the medial and lateral hamstrings (i.e., both are put
into a shortened position). However, the technique used in the
present study required that internal rotation of the tibia should
be added to achieve the optimal treatment position for the
medial hamstrings, whereas either internal or external rotation
of tibia may be optimal for the lateral hamstrings. Therefore,
it is possible that the technique used was less effective for
participants who might have had decreased flexibility confined
to the lateral hamstrings and required the addition of external
rather than internal rotation of the tibia to achieve the optimal
treatment position.
Trevor B Birmingham found that positional
release therapy and sham technique result in similar level
of flexibility.[26] He indicates that the PRT technique is not
effective to improve knee extension because of hamstring
tightness. This supports our study which suggests that PRT
is not much effective than MET in improving hamstring
flexibility. Kaandeepan et al.[27] in his study found that both
the techniques, static stretching and PRT, equally effective
while D’Ambrogio and Roth described that the PRT may be
effective in producing reduction of joint hypomobility in case
of musculoskeletal dysfunction.[28] Thus, the PRT technique
should be recommended for use when the study involves
hamstring flexibility on older participants as it is very easier
to apply and less painful compared to other stretching.
The results of the present study corroborate the previous
findings about a significant correlation between AKE and
active SLR results for hamstring flexibility.[29] As both the
AKE and the active SLR tests assess primarily, the hamstrings
extensibility with different forms like AKE measures the angle
of knee extension, while active SLR measures the angle of the
straight leg to the horizontal.
This study also has some limitations that need to be addressed.
First, the sample size was small; second, there was no control
group to study the change in hamstring flexibility without
stretching program; third, the participants were healthy young
individuals; it is unknown whether the stretching protocol used
in this study could be effective for the elderly or participants
with a history of hamstring muscle strains; fourth, no follow‑up
is took place in the present study; and finally, the effect was
focused only on immediate effect. Further studies are still
needed to find the comparison of sustained effect or effects after
the long‑term intervention of both MET and PRT techniques

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Sailor, et al.: Comparative effectiveness of stretching technique on hamstring flexibility
on hamstrings flexibility and effects of both techniques in
different types of population.
Conclusion
On the basis of the present study result, it is concluded that
both MET and PRT techniques are effective in improving
hamstring flexibility in healthy young adults with normal and
limited hamstring flexibility. However, the percentage change
in ROM after 2 weeks’ intervention was higher in MET than
PRT technique.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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