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Chiropractic Care & Poses for Sciatica Pain Relief

Improve your experience with chiropractic care through targeted poses for sciatica relief and enhanced mobility.

Chiropractic Care for Sciatica and Low Back Pain: A Comprehensive Guide to Relief

Sciatica and low back pain can turn your daily routine into a game of “avoid the lightning bolt of agony.” Imagine trying to bend over to tie your shoes, only to feel like a rogue nerve is staging a protest down your leg. Ouch! But don’t worry—this blog post is here to guide you through the clinical rationale behind why chiropractic care can be a game-changer for sciatica pain and low back pain, with insights from the renowned Dr. Alexander Jimenez, DC, APRN, FNP-BC, a leading chiropractor in El Paso, Texas. We’ll explore how the musculoskeletal system and sciatic nerve interact, how these conditions disrupt your life, and why chiropractic care, combined with specific poses and integrative approaches, can help you reclaim your mobility. Plus, we’ll highlight Dr. Jimenez’s expertise in personal injury cases and his unique dual-scope approach to diagnostics and legal-medical collaboration. So, grab a comfy seat (preferably one that doesn’t aggravate your sciatica), and let’s dive in!

Understanding Sciatica and Low Back Pain: The Sciatic Nerve’s Role

Sciatica isn’t just a fancy term for leg pain—it’s a condition caused by irritation, compression, or injury to the sciatic nerve, the longest nerve in the human body. This nerve starts in the lower back (lumbar spine), runs through the buttocks, and extends down the legs to the feet. When it gets irritated, it can cause pain, numbness, tingling, or weakness that radiates from the lower back down one leg, sometimes feeling like an electric shock or a bad leg cramp that just won’t quit (Fritz et al., 2020). Low back pain, on the other hand, can be axial (localized to the lower back) or radicular (radiating to the legs, often linked to sciatica) and is a leading cause of disability worldwide (Chou, 2015).

The musculoskeletal system plays a starring role in this drama. The sciatic nerve is surrounded by muscles, bones, and connective tissues, and any misalignment or dysfunction in these structures can pinch or irritate it. Common culprits include:

  • Herniated Discs: When the soft inner material of a spinal disc bulges out, it can press on the sciatic nerve roots, causing pain that feels like your back is staging a mutiny (Jensen et al., 2019).
  • Piriformis Syndrome: The piriformis muscle in the buttocks can tighten or spasm, irritating the sciatic nerve and making sitting feel like a punishment (PushAsRx, 2018).
  • Spinal Stenosis: Narrowing of the spinal canal can compress nerve roots, leading to sciatica symptoms that make walking a challenge (Mayo Clinic Proceedings, 2015).
  • Spondylolisthesis: When a vertebra slips forward, it can pinch the sciatic nerve, turning simple movements into a pain parade (Fritz et al., 2020).

These issues don’t just cause physical pain—they can wreak havoc on your daily life. Imagine struggling to sit through a movie, stand in line at the grocery store, or even sleep without feeling like your leg is on fire. For some, sciatica can make work impossible, especially if it involves heavy lifting or prolonged sitting. And let’s not forget the emotional toll—chronic pain can make you feel like you’re stuck in a grumpy cat meme, minus the cute factor.

References:

How Sciatica and Low Back Pain Impact Daily Life

Sciatica and low back pain are like uninvited guests who overstay their welcome, disrupting everything from work to play. The sciatic nerve’s irritation can cause symptoms that vary from a mild annoyance to a full-blown “I can’t move” crisis. Here’s how these conditions mess with your daily routine:

  • Mobility Challenges: Walking, bending, or even sitting can trigger sharp pain or tingling, making simple tasks like picking up your kid or carrying groceries feel like climbing Mount Everest (Fritz et al., 2020).
  • Work Disruptions: If your job involves sitting for long hours (hello, desk warriors) or physical labor, sciatica can make you dread clocking in. Up to 43% of working populations report sciatica symptoms, often linked to occupational workload (Enke et al., 2021).
  • Sleep Struggles: Finding a comfortable position at night can feel like solving a Rubik’s Cube blindfolded. Pain can keep you tossing and turning, leading to fatigue that makes you feel like you’re starring in a zombie movie.
  • Emotional Impact: Chronic pain can lead to frustration, anxiety, or even depression, especially when it lingers for months or years. About 30% of sciatica cases persist beyond a year, turning your mood sourer than a lemon (Enke et al., 2021).

Risk factors like obesity, smoking, and physical stress increase the likelihood of sciatica, as they contribute to intervertebral disc degeneration and nerve compression (Jensen et al., 2019). For example, a higher BMI (>25) can strain the spine, making it more likely to irritate the sciatic nerve. It’s like adding extra weight to an already creaky bridge—something’s bound to give.

References:

The Clinical Rationale for Chiropractic Care in Sciatica and Low Back Pain

Chiropractic care is like a superhero swooping in to save the day for your spine. It focuses on restoring the musculoskeletal system’s alignment to reduce nerve compression and promote healing, all without invasive procedures or heavy reliance on medications. Dr. Alexander Jimenez, a chiropractor and board-certified nurse practitioner in El Paso, Texas, is a master at this, using a dual-scope approach that blends chiropractic adjustments with medical diagnostics to tackle sciatica and low back pain (El Paso Back Clinic, 2025).

Why Chiropractic Care Works

Chiropractic care targets the root causes of sciatica and low back pain by addressing biomechanical dysfunctions in the spine and surrounding muscles. Here’s the clinical rationale, broken down into bite-sized pieces:

  1. Spinal Adjustments: Chiropractors use precise manual or instrument-assisted adjustments to correct spinal misalignments (subluxations) that compress the sciatic nerve. A 2020 study found that spinal manipulative therapy significantly reduces pain and disability in patients with chronic low back pain (Rubinstein et al., 2020, as cited in El Paso Back Clinic, 2025). It’s like realigning the tracks so the train (your nerve signals) can run smoothly again.
  2. Reducing Nerve Compression: By restoring spinal alignment, chiropractic adjustments relieve pressure on the sciatic nerve roots. This is especially effective for conditions like herniated discs or spinal stenosis, where nerve compression is the main villain (Fritz et al., 2020).
  3. Improving Mobility: Adjustments and manual therapies like myofascial release improve joint mobility and reduce muscle tension, making it easier to move without wincing. Dr. Jimenez often incorporates targeted exercises to strengthen the core and lumbar muscles, supporting the spine like a sturdy scaffolding (El Paso Back Clinic, 2025).
  4. Non-Invasive and Drug-Free: Unlike medications like gabapentin or pregabalin, which show limited effectiveness for sciatica and come with side effects like dizziness and drowsiness (Enke et al., 2021), chiropractic care offers a natural approach. It’s like choosing a fresh smoothie over a sugary soda—better for you in the long run.
  5. Holistic Approach: Dr. Jimenez combines chiropractic techniques with functional medicine, addressing underlying issues like inflammation or nutritional deficiencies that can exacerbate sciatica. This integrative approach ensures the body heals from the inside out (A4M, 2023).

Dr. Jimenez’s expertise shines in his ability to tailor treatments to each patient. He uses advanced imaging (like MRI or CT scans) and diagnostic evaluations to pinpoint the exact cause of sciatica, whether it’s a herniated disc, piriformis syndrome, or spinal misalignment. His dual licensure as a chiropractor and nurse practitioner allows him to interpret these diagnostics with a medical lens, ensuring precise, evidence-based care (A4M, 2023).

References:

Dr. Alexander Jimenez: El Paso’s Personal Injury Specialist

In El Paso, Texas, Dr. Alexander Jimenez is a household name for those dealing with personal injury cases, especially those involving sciatica and low back pain from auto accidents or workplace injuries. With over 25 years of experience, Dr. Jimenez is a dual-licensed chiropractor and nurse practitioner who brings a unique perspective to personal injury care (A4M, 2023). His clinic, Injury Medical & Chiropractic Clinic, is a beacon of hope for accident victims seeking non-surgical relief.

Personal Injury and Sciatica

Personal injury cases, like car accidents or slips and falls, often lead to sciatica due to trauma to the spine or soft tissues. For example, whiplash from a car crash can misalign the spine, compressing the sciatic nerve and causing radiating pain (El Paso Back Clinic, 2025). Dr. Jimenez’s approach is comprehensive:

  • Advanced Imaging and Diagnostics: He uses MRI, CT scans, and other imaging to identify the exact source of nerve compression, whether it’s a herniated disc or soft tissue damage. This precision ensures treatments target the root cause, not just the symptoms (A4M, 2023).
  • Dual-Scope Procedures: As both a chiropractor and nurse practitioner, Dr. Jimenez combines spinal adjustments with medical evaluations, offering a holistic view of the patient’s health. This dual perspective is like having a GPS and a map—you get the full picture to navigate recovery (El Paso Back Clinic, 2025).
  • Legal-Medical Liaison: Personal injury cases often involve legal documentation for insurance claims or lawsuits. Dr. Jimenez acts as a bridge, providing detailed medical reports that link injuries to the accident, ensuring patients receive fair compensation while focusing on recovery (El Paso Chiropractor Blog, 2025).

His clinic’s integrative approach includes spinal decompression, manual adjustments, and rehabilitation programs tailored to each patient’s needs. This is especially crucial in El Paso, where auto accidents are common, and victims need reliable care to avoid long-term disability (El Paso Chiropractor Blog, 2025).

References:

Chiropractic Techniques and Poses for Sciatica Relief

Chiropractic care isn’t just about cracking your back (though that satisfying pop can feel like a mini-victory). It involves a range of techniques and complementary exercises to reduce sciatica pain and prevent it from coming back like a bad sequel. Dr. Jimenez incorporates poses inspired by yoga and physiotherapy to enhance his treatments, drawing from evidence-based practices (Yoga International, 2023).

Key Chiropractic Techniques

  1. Spinal Manipulation: This involves high-velocity, low-amplitude thrusts to realign the spine, reducing nerve compression. A case study showed that spinal manipulation can reduce sciatica pain by improving spinal mobility and reducing inflammation (Santilli et al., 2020).
  2. Spinal Decompression: Non-surgical decompression therapy relieves pressure on spinal discs, promoting healing in conditions like herniated discs or spinal stenosis. It’s like giving your spine a much-needed stretch after being squished all day (A4M, 2023).
  3. Myofascial Release: This hands-on technique targets tight muscles and fascia, relieving tension around the sciatic nerve. It’s particularly effective for piriformis syndrome, where the muscle clamps down on the nerve like a grumpy crab (PushAsRx, 2018).
  4. Neural Mobilization: This physiotherapy technique involves gentle movements to “floss” the sciatic nerve, reducing adhesion and improving nerve mobility. Studies show it can reduce pain and disability in sciatica patients (George et al., 2021).

Poses to Soothe Sciatica

Dr. Jimenez often recommends poses to complement chiropractic care, drawing from yoga and physiotherapy to stretch and strengthen the musculoskeletal system. Here are seven poses inspired by Yoga International (2023) that can help:

  1. Child’s Pose (Balasana): This gentle stretch relaxes the lower back and hips, reducing tension on the sciatic nerve. Kneel, sit back on your heels, and stretch your arms forward, resting your forehead on the ground. It’s like giving your spine a cozy hug.
  2. Cat-Cow Pose: Alternating between arching and rounding your back on all fours improves spinal flexibility and relieves pressure on the sciatic nerve. Think of it as your spine doing a little dance to loosen up.
  3. Seated Forward Bend: Sitting with legs extended, reach forward to stretch the hamstrings and lower back. This pose helps lengthen the spine and reduce nerve compression, but don’t overdo it—think gentle stretch, not Olympic contortionist.
  4. Pigeon Pose: This hip-opening pose targets the piriformis muscle, which can irritate the sciatic nerve. Thread one leg forward, resting it on the ground, and stretch the other leg back. It’s like telling your piriformis to chill out.
  5. Thread the Needle: Lie on your back, cross one ankle over the opposite thigh, and pull the thigh toward your chest. This stretches the piriformis and glutes, easing sciatic nerve pressure. It’s like threading a needle, but for pain relief.
  6. Supine Twist: Lying on your back, bring one knee across your body and twist gently. This pose improves spinal mobility and reduces tension in the lower back. It’s like wringing out a towel, but for your spine.
  7. Bridge Pose: Lie on your back, bend your knees, and lift your hips toward the ceiling. This strengthens the core and glutes, supporting the spine and reducing sciatica flare-ups. It’s like building a bridge to a pain-free day.

Dr. Jimenez integrates these poses into rehabilitation programs, ensuring patients perform them safely under guidance. These exercises complement adjustments by keeping muscles flexible and reducing the risk of re-injury (El Paso Back Clinic, 2025).

References:


Sciatica Secrets Revealed- Video


Comparing Chiropractic Care to Other Treatments

Chiropractic care stands out like a unicorn in a field of horses when compared to other sciatica treatments. Let’s break down how it stacks up against medications, acupuncture, and physiotherapy:

  • Medications (Gabapentin and Pregabalin): These drugs aim to reduce nerve pain but show limited effectiveness for sciatica. A systematic review found that gabapentin reduced leg pain in some cases, but neither drug outperformed placebo significantly, and side effects like dizziness and nausea were common (Enke et al., 2021). Chiropractic care, on the other hand, avoids these side effects and targets the root cause.
  • Acupuncture: This involves inserting needles into specific points to reduce pain. Some studies suggest acupuncture can help sciatica by stimulating nerve pathways, but results are mixed, and more research is needed (Qin et al., 2019; Zhang et al., 2019). Dr. Jimenez incorporates electro-acupuncture as a complementary therapy, combining it with adjustments for enhanced relief (A4M, 2023).
  • Physiotherapy: Techniques like neural mobilization and exercise programs can reduce sciatica pain and disability, but they often work best as an adjunct to other treatments (George et al., 2021). Chiropractic care complements physiotherapy by addressing structural issues that exercises alone may not fix (El Paso Chiropractor Blog, 2025).
  • Pestle Needle (Chu Zhen): This traditional Chinese technique uses a pestle-shaped needle to stimulate points. A pilot study showed it may reduce sciatica pain, but evidence is limited compared to chiropractic care’s established benefits (Chen et al., 2019).

Chiropractic care’s strength lies in its non-invasive, drug-free approach and its ability to integrate with other therapies. Dr. Jimenez’s clinic exemplifies this by combining adjustments, acupuncture, and tailored exercises for a well-rounded treatment plan (A4M, 2023).

References:

Patient Education and Long-Term Management

Education is power, especially when it comes to managing sciatica and low back pain. Dr. Jimenez emphasizes patient education to empower individuals to take control of their recovery. A systematic review found that patient education materials improve outcomes for non-specific low back pain and sciatica by helping patients understand their condition and follow treatment plans (Sanzarello et al., 2019).

Key Education Points

  • Understanding Sciatica: Patients learn about the sciatic nerve’s anatomy and how factors like herniated discs or obesity contribute to pain. This knowledge helps them make lifestyle changes, like maintaining a healthy weight to reduce spinal stress (Jensen et al., 2019).
  • Home Exercises: Dr. Jimenez provides tailored exercise plans, including the yoga-inspired poses mentioned earlier, to maintain flexibility and strength. It’s like giving your spine a daily workout to keep it happy.
  • Lifestyle Modifications: Advice on posture, ergonomics, and nutrition helps prevent flare-ups. For example, sitting with proper lumbar support can prevent your spine from throwing a tantrum (El Paso Back Clinic, 2025).
  • Regular Check-Ups: Ongoing chiropractic care monitors progress and prevents recurrence, ensuring long-term relief (A4M, 2023).

Dr. Jimenez’s clinic offers resources like videos and workshops to reinforce these lessons, making patients active participants in their healing journey (PushAsRx, 2018).

References:

The Cost-Effectiveness of Chiropractic Care

Chiropractic care isn’t just good for your spine—it’s kind to your wallet too. A 2024 systematic review found that chiropractic care is associated with lower healthcare costs compared to medical management for spine-related pain. Patients who see chiropractors early in their treatment have fewer downstream costs, like hospitalizations or surgeries, because chiropractic care prevents escalation of care (Whedon et al., 2024). It’s like fixing a small leak before it turns into a flooded basement.

Dr. Jimenez’s approach maximizes cost-effectiveness by using non-invasive techniques and preventing chronic conditions from worsening. His clinic accepts major insurances, making care accessible to more patients (A4M, 2023). Plus, by avoiding medications with limited efficacy, like gabapentin or pregabalin, patients save on prescriptions and avoid side effects (Enke et al., 2021).

References:

Why Choose Dr. Alexander Jimenez in El Paso

Dr. Jimenez is more than just a chiropractor—he’s a lifeline for those suffering from sciatica and low back pain in El Paso. His dual licensure, extensive experience, and integrative approach make him a standout. Here’s why:

  • Expertise in Complex Cases: He specializes in severe sciatica, herniated discs, and spinal stenosis, using advanced diagnostics to create personalized treatment plans (El Paso Back Clinic, 2025).
  • Holistic Care: Combining chiropractic adjustments, acupuncture, and functional medicine, he addresses both symptoms and underlying causes (A4M, 2023).
  • Personal Injury Advocacy: His ability to liaise between medical and legal needs ensures accident victims get comprehensive care and proper documentation (El Paso Chiropractor Blog, 2025).
  • Community Trust: With a 25-year track record and glowing patient testimonials, Dr. Jimenez is a trusted name in El Paso (PushAsRx, 2018).

Whether you’re dealing with sciatica from a car accident or chronic low back pain, Dr. Jimenez’s clinic at Injury Medical & Chiropractic Clinic (915-850-0900) is your go-to for relief. Check out his insights on chiromed.com or connect with him on LinkedIn for more information.

References:

Conclusion

Sciatica and low back pain can significantly disrupt daily life, but chiropractic care offers a safe, effective, and non-invasive solution. Dr. Alexander Jimenez’s integrative approach, combining spinal adjustments, diagnostic precision, and complementary therapies like yoga-inspired poses, provides lasting relief for patients in El Paso and beyond. His expertise in personal injury cases ensures accident victims receive comprehensive care and legal support, making him a trusted practitioner in the community. For those struggling with sciatica, seeking chiropractic care can be a step toward reclaiming mobility and quality of life.

Disclaimer: This blog post is for informational purposes only and should not be taken as medical advice. Always consult a qualified healthcare professional, such as Dr. Alexander Jimenez, DC, APRN, FNP-BC, before starting any treatment for sciatica or low back pain. Individual results may vary, and professional evaluation is essential to ensure safe and effective care.

Pigeon Toed: Causes and Treatment Options

Children walking with their toes pointed in may be pigeon-toed. What are the causes, conditions associated with it, and treatments?

Pigeon-toed Walking

If a child walks with their feet turned inward at the toes, it is usually described as being pigeon-toed. This pointing inward of the feet occasionally occurs as a child learns to walk and may continue through toddlerhood. It is noticed more often in children than adults, but older individuals can experience it. Pigeon-toed walking is rarely a major orthopedic problem and usually disappears without treatment. However, there are times when it may impact a child’s lower extremities and hips. Bracing or surgery may be necessary in these cases to correct the problem. (Paramanandam V. et al., 2019) This condition is common and typically is caused by abnormal birth positions in utero. Sometimes, slight issues may lead to noticeable functional characteristics. Mild changes in bone shape and positioning usually cause pigeon toes. Often, it subsides in a few years as the child continues to develop.

What Does It Mean?

There is usually no need to worry, as this condition is likely not permanent and will go away in a few years. (Paramanandam V. et al., 2019) However, it is recommended that you check in with your healthcare provider to ensure the child is developing normally. Some adults walk with their toes turned in. This may be due to a birth defect, a weakness, or a rare case of pigeon-toed walking as a youth that was left untreated or did not go away.

Causes

There are various reasons for pigeon-toed walking. To determine the cause, a healthcare provider can assess the child’s condition and make a diagnosis, including:

Metatarsus Adductus

  • A condition where the front part of the foot is turned inward.
  • The metatarsals are the long bones of the forefoot.
  • This is when the bones of the foot point inward, leading to pigeon-toed walking.
  • A clinical examination and X-ray can confirm the metatarsus adducts as a cause of pigeon-toed walking.

Tibial Torsion

  • A twisted shinbone (tibia) can cause the feet to turn inward in younger children.
  • The shinbone/tibia in some children may be slightly twisted.
  • The tibia can either turn outward or inward.
  • When it twists inward, it may manifest as a pigeon-toed gait.
  • Tibial torsion may accompany femoral anteversion.
  • It is diagnosed with an X-ray.
  • Children with tibial torsion typically grow out of the problem, and the pigeon-toed disappears by age 4. (Uden H., & Kumar S. 2012)

Femoral Anteversion

  • A common cause, especially in older children, is when the thighbone/femur is twisted inward.
  • If the femur turns inward and forward unnaturally, where the femoral neck meets the body of the femur, it is called femoral anteversion.
  • An outward and backward rotation of the femur is called femoral retroversion.
  • This occurs in about 10% of children. (Scorcelletti M. et al., 2020)
  • Many children with femoral anteversion appear knock-kneed with a large gap between their feet when standing with knees together, and when they walk, they appear pigeon-toed.
  • A clinical examination and X-ray diagnose it.

Symptoms

In most cases, the child does not complain of any pain. However, if pain is felt, it can include:

  • Tightness in the calf muscles
  • Aching on the outer edges of the feet
  • Knee pain

Usually, parents will notice pigeon-toes when their child is first learning to walk. Rest assured, the child most likely is not experiencing pain. They have feet and knees that turn inward when they walk and run. (Uden H., & Kumar S., 2012)

A pediatrician or primary care provider can assess the situation and make recommendations. Most pigeon-toed children begin walking and running normally after age 3 or 4, so a watch-and-wait approach is used. Parents may have to take their child to a specialist, like an orthopedic surgeon, if they complain of pain while walking. A specialist may be referred if the child cannot walk due to the inward turn of their feet.

Risk Factors

Pigeon-toed walking is not a preventable condition but rather one that develops during pregnancy. Causes may include: (Scorcelletti M. et al., 2020)

  • A pregnancy with twins or multiple births
  • Large fetus
  • Breech position in utero when the baby is positioned feet first.
  • Not enough amniotic fluid

Muscle Weakness in Adults

Adolescents or adults who notice their knees turn in and walk pigeon-toed may have weakness in the hip and leg muscles that control the position of their legs when they walk. Strengthening those muscles can help. (Scorcelletti M. et al., 2020)

Treatment

Typically, a normal gait will appear by the age of 3 or 4. Other treatments may include:

Physical Therapy Exercises and Gait Training

  • Exercises to stretch tight lower extremity muscles and strengthen hip and leg muscles can help improve walking gait.
  • See a pediatric specialist before starting, as research shows that parental stretching of a newborn with metatarsus adductus offers little benefit. (Eamsobhana P. et al., 2017)

Bracing or Casting 

  • Braces
  • Serial casting is a procedure that helps children improve their range of movement and may be done to place their lower extremities in an optimum position as they develop. (Uden H., & Kumar S., 2012)

Surgery

  • For cases in which tibial torsion is the cause, osteotomy surgery, which involves cutting and/or removing bone, may be recommended to correct the structural deformity of the shinbone.

Injury Medical Chiropractic & Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.


Foot Pronation


References

Paramanandam, V., Lizarraga, K. J., Soh, D., Algarni, M., Rohani, M., & Fasano, A. (2019). Unusual gait disorders: a phenomenological approach and classification. Expert review of neurotherapeutics, 19(2), 119–132. https://doi.org/10.1080/14737175.2019.1562337

Uden, H., & Kumar, S. (2012). Non-surgical management of a pediatric “intoed” gait pattern – a systematic review of the current best evidence. Journal of Multidisciplinary Healthcare, 5, 27–35. https://doi.org/10.2147/JMDH.S28669

Scorcelletti, M., Reeves, N. D., Rittweger, J., & Ireland, A. (2020). Femoral anteversion: significance and measurement. Journal of Anatomy, 237(5), 811–826. https://doi.org/10.1111/joa.13249

Eamsobhana, P., Rojjananukulpong, K., Ariyawatkul, T., Chotigavanichaya, C., & Kaewpornsawan, K. (2017). Does the parental stretching programs improve metatarsus adductus in newborns?. Journal of Orthopaedic Surgery (Hong Kong), 25(1), 2309499017690320. https://doi.org/10.1177/2309499017690320

Post Surgery Leg Strengthening Tips for Patients

What are some leg-strengthening exercises that will expedite recovery for athletes and physically active individuals who have undergone leg surgery?

Post Surgery Leg Strengthening

Leg muscles may weaken after hip, knee, ankle, or foot surgery. This happens because those muscles are not used as much during recovery. Gaining back strength and muscle endurance after an injury or surgery is an important step in recovery. Leg exercises can help regain mobility and prevent complications like blood clots and pressure sores after surgery or an injury, which is why engaging in post-surgery leg strengthening is important once the doctor gives the ok.

Benefits

post-surgery leg strengthening exercises have several benefits, including

  • Rebuilds strength and confidence
  • Retraining for optimal mobility and flexibility
  • Prevents pressure sores
  • Prevents blood clots

When the leg muscles are contracted, they move blood like a pump, maintaining proper circulation. Moving in a bed after surgery also helps prevent pressure sores from forming and blood clots. A physical therapy team will determine the right leg exercises for each individual and their injury/condition. This is an important step when moving forward after surgery. (Hoogeboom T. J. et al., 2014)

Starting Out

The first exercises should target all the major muscles of the leg. (Madara K. C. et al., 2019)

Gluteal Sets

This isometric exercise means the muscles contract while no motion occurs at the hip joints. To perform:

  • Lie on your back and tighten your buttock muscles.
  • Hold the muscles tight for 5 seconds, then relax.
  • Repeat 10 or 15 times.
  • Gluteal sets can be done several times per day.

Heel Slide

Heel slides can help regain strength in the major muscles of the leg. To perform:

  • Lie on your back.
  • Bend the knee of the surgical leg and slowly slide the heel toward your butt.
  • Slide as far as possible and hold for 5 seconds.
  • Slowly return to the starting position and repeat.

Short Arc Quad

The short arc quad, or SAQ, is a simple way to get the quadricep muscles working. To perform:

  • Lie on your back with a towel roll, small ball, or something similar under the knee.
  • Slowly straighten the knee.
  • Tighten the quad muscle on the top of the thigh.
  • Hold for 3 seconds, then relax.
  • Repeat 10 to 15 times.

Quad Set

This exercise helps get the quad muscles working. It also helps control the position of the kneecap. To perform:

  • Lie on your back.
  • Place a small towel roll under the knee.
  • Try to press the back of the knee flat against the floor.
  • Hold for 10 seconds and release.
  • Repeat 10 to 15 times.

Individuals can complete quad sets bilaterally or with both knees simultaneously. This makes the stronger leg help strengthen the weaker side.

Straight Leg Raise

To perform:

  • Lie on your back.
  • Lift your leg straight off the floor until it is at the height of the opposite bent knee.
  • Hold for 10 seconds and slowly lower.
  • Repeat 10 to 15 times.

Be sure to keep the knee straight for the entire exercise. Keep the opposite knee bent for comfort. To ensure the knee is straight, individuals can complete a quad set first and then the straight leg raise. The exercise can be more challenging by increasing repetitions or adding a 2- to 3-pound ankle weight on the thigh. For even more challenge, add the ankle weight to the ankle.

Hamstring Strengthening

Working out the hamstrings after injury or surgery is important. The hamstring muscles bend the knee and extend the hip backward. To perform:

  • Lie on your stomach.
  • Bend one knee to raise the lower limb straight in the air.
  • Hold for 5 seconds and lower slowly.
  • Repeat 10 to 15 times.

Once the exercise is easy to do, increase the repetitions to 30. Individuals can also try adding a 2- to 3-pound ankle weight.

Physical therapy can help individuals regain mobility after injury or surgery. A therapist may prescribe exercises as part of an at-home exercise program. Over time progress will go from simple exercises to more challenging ones to improve balance and mobility. (Madara K. C. et al., 2019)

Injury Medical Chiropractic & Functional Medicine Clinic

Before starting this or any other exercise program, consult a doctor and a physical therapist to find the right exercises for your situation. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.


Are You Recovering From Ankle Sprains?


References

Hoogeboom, T. J., Dronkers, J. J., Hulzebos, E. H., & van Meeteren, N. L. (2014). Merits of exercise therapy before and after major surgery. Current opinion in anaesthesiology, 27(2), 161–166. https://doi.org/10.1097/ACO.0000000000000062

Madara, K. C., Marmon, A., Aljehani, M., Hunter-Giordano, A., Zeni, J., Jr., & Raisis, L. (2019). PROGRESSIVE REHABILITATION AFTER TOTAL HIP ARTHROPLASTY: A PILOT AND FEASIBILITY STUDY. International Journal of Sports Physical Therapy, 14(4), 564–581.

Push-Pull Workout: A Comprehensive Guide

Can a push-pull workout routine be an option for individuals who want focused training on specific muscle groups and balanced muscle development throughout the body?

Push-Pull Strength Training

A “push-pull” workout is a training style in which you split your exercise routine into separate days dedicated to “push” exercises (targeting muscles like the chest, shoulders, and triceps) and “pull” exercises (targeting muscles like the back and biceps). This allows focused training on each muscle group by isolating their primary movement patterns—pushing away from the body or pulling towards it. The workout often accompanies a separate leg day to complete the full-body workout. This routine comes from bodybuilding. Bodybuilders use this method to maximize their workouts and rest periods. By splitting their workouts into push exercises one day and pull exercises another, they can work out more often without overtraining. (Castanheira R. P. M. et al., 2017)

Upper Body Push Exercises

These exercises involve all the movements that push the weights away from your body. These exercises typically focus on the quads, outer thighs, chest, shoulders, and triceps. (Collins P. 2009)

Pushups

  • Push-ups are a versatile bodyweight exercise that engages multiple muscle groups, including the chest, shoulders, triceps, and core.

Chest Presses

  • Chest presses are exercises that target the pectoral muscles (chest muscles).
  • They can be performed with various equipment and techniques, providing a comprehensive workout for the chest.

Chest Flies

  • Chest flies are a weightlifting exercise that targets the pectoral muscles (chest muscles).
  • They are performed by lying on a bench and extending the arms outward with weights in each hand.
  • The weights are then lowered in an arc motion until they are slightly below chest level before being raised back to the starting position.

Overhead Presses

  • An overhead press is a weight-training exercise that involves pushing a weight above your head.
  • Also known as a shoulder, military, or strict press.

Lateral Raises

  • Lateral raises are an isolation exercise that targets the lateral deltoid muscle on the shoulder’s side.
  • They raise the arms laterally (out to the sides) while slightly bending at the elbows.

Bent Arm Lateral Raises

  • A bent-over lateral raise is a weightlifting exercise that strengthens the rear deltoids, the muscles on the back of the shoulders.
  • It also works other upper and lower body muscles, including the trapezius, rhomboids, triceps, hamstrings, and lower back.

Front Raises

  • Front raises are a weight training exercise that targets the shoulder muscles.
  • They can also help build strength and stability in the upper body.

Dips

  • Dips are an upper-body exercise that uses your body weight to strengthen your triceps and chest.

Triceps Extensions

  • Triceps extensions are resistance exercises that target the triceps muscles in the back of the upper arm.
  • They involve extending the arms at the elbows while keeping the shoulders stationary.

Skull Crushers

  • Skull crushers are a weightlifting exercise that targets the triceps muscles in the upper arms.
  • They are performed by lying on a bench or floor, holding a weight (such as a dumbbell or barbell) overhead, and then lowering it towards the forehead while keeping the elbows slightly bent.
  • This exercise helps to strengthen and build muscle mass in the triceps.

Upper Body Pull Exercises

Pull exercises are movements where you are pulling the weight toward your body. These exercises primarily use the biceps, hamstrings, glutes, and back muscles. A routine set up in which you do a push routine one day and a pull routine the next without working the same muscles two days in a row.

Barbell Rows

  • Often referred to as a “bent-over row” due to the hinged position of your body during the movement.
  • A barbell row is a weightlifting exercise in which you bend over at the hips, grasp a barbell with an overhand grip, and pull the weight toward your stomach.
  • This exercise primarily targets the upper back muscles, including the latissimus dorsi, while also engaging the core and posterior chain muscles.

One Arm Rows

  • A variation of the bent-over row, a one-arm row, also known as a single-arm dumbbell row, is an upper-body exercise that targets the back muscles using a dumbbell and a bench.

Double arm rows

  • A “double arm row” is a rowing exercise in which you simultaneously pull a weight toward your body using both arms, typically with a barbell or dumbbell.
  • This exercise engages your upper back muscles, including the latissimus dorsi, trapezius, and rhomboids.
  • To effectively target the back muscles, you maintain a bent-over position. Essentially, it’s the opposite movement of a chest press, but you use both arms simultaneously.

Barbell High Rows

  • A barbell high row, also known as a wide row, is an exercise that uses a barbell to work the upper and mid back muscles.

Dumbell Pullovers

  • Dumbbell pullovers are a weightlifting exercise that targets the chest, back, and shoulder muscles.

Seated Rows with Resistance Bands

  • A “seated row with bands” is an exercise where you sit on the ground, loop a resistance band around your feet, and then pull the handles towards your chest, mimicking a rowing motion.
  • By squeezing the shoulder blades together, this motion primarily targets the upper back muscles, including the latissimus dorsi and rhomboids.
  • You are essentially performing a seated row movement using the tension of a resistance band instead of weights.

Lat Pulls with Resistance Band

  • Lat pulls with a resistance band are a back exercise that strengthens the latissimus dorsi muscles and can improve posture.

Back extensions

  • Back extensions are an exercise that strengthens and isolates the lower back muscles, also known as the erector spinae.

Seated Alternating Rows

  • A seated alternating row is an exercise that targets the upper back, biceps, and lats.
  • It can be performed using a resistance machine or with a band.

Renegade Rows

  • A renegade row is a full-body exercise that combines a plank with a dumbbell row.
  • It’s an advanced exercise that targets the upper body, back, shoulders, and core.

Biceps Curls

  • A bicep curl involves bending the arm at the elbow towards the body, strengthening the biceps, the large muscles in the front of the upper arm.

Home Equipment

Resistance bands and a quality pair of adjustable dumbbells are recommended for home training. These don’t take up much space and can be used for most upper-body exercises. To set up a more dedicated space for workouts, add a weight bench or a full home gym to increase your push-pull training options.

Benefits

Push-pull workouts are great for anybody, whether you’re a bodybuilder or just someone lifting weights to be strong and fit. This routine is usually spread out over three days of training, allowing for shorter workouts. These can help you stay committed despite a busy schedule and are easier than longer, total-body workouts. These exercises can also be done with a cable pulley system or resistance bands.

  1. Day 1 might be a push upper body workout.
  2. Day 2 might be a lower-body workout.
  3. Day 3 might be the pull upper body workout.

First, push-pull workouts allow you to work your muscles without overstressing them. (Castanheira R. P. M. et al., 2017) Second, although they are more frequent, push-pull workouts are shorter, so more can be done because your other muscles are resting. Third, push-pull routines are more interesting and contain more variety, as they can be done in various ways.

Alternating Workouts

Trainers recommend changing workouts every 6-12 weeks to avoid hitting a plateau, which can delay weight loss (American Council on Exercise, 2001). For example, you could do a push-pull routine for a few weeks and then switch to a different training method, pyramid training. Then, return to total body workouts, which you can do up to 3 non-consecutive days a week. Circuit training may be an option because the quick workouts allow you to get your cardio in simultaneously. (Haltom R. W. et al., 1999) With so many different training methods, there’s no need to do the same workouts repeatedly.

Injury Medical Chiropractic and Functional Medicine Clinic

For those who are easily bored with weight training and prefer a variety of exercises, this can be a refreshing way to stay focused and avoid burnout. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.


Transform Your Body


References

Castanheira, R. P. M., Ferreira-Junior, J. B., Celes, R. S., Rocha-Junior, V. A., Cadore, E. L., Izquierdo, M., & Bottaro, M. (2017). Effects of Synergist vs. NonSynergist Split Resistance Training Routines on Acute Neuromuscular Performance in Resistance-Trained Men. Journal of strength and conditioning research, 31(12), 3482–3488. https://doi.org/10.1519/JSC.0000000000001762

Collins, P. (2009). Functional Fitness. Germany: Meyer & Meyer Sport, Limited.

American Council on Exercise. (2001). Weight Loss Plateaus and Pitfalls. ACE. https://contentcdn.eacefitness.com/assets/education-resources/lifestyle/fitfacts/pdfs/fitfacts/itemid_69.pdf

Haltom, R. W., Kraemer, R. R., Sloan, R. A., Hebert, E. P., Frank, K., & Tryniecki, J. L. (1999). Circuit weight training and its effects on excess postexercise oxygen consumption. Medicine and science in sports and exercise, 31(11), 1613–1618. https://doi.org/10.1097/00005768-199911000-00018

Get Relief for Your Spine & Back with Simple and Effective Exercises

Can individuals incorporate these simple but effective exercise routines to reduce pain and discomfort in their spine and back?

Why It’s Important To Keep The Back Mobile

When many individuals are dealing with back pain from their upper, middle, and lower portions, it can put a halt to a person’s routine. When back pain becomes present, it causes the person to find a comfortable place like a couch or a bed and lie down. However, this can cause more issues than the original one, affecting the individual. Back pain is a common worldwide problem and is the leading issue of disability associated with a high socio-economic cost. (Chou, 2021) Additionally, when a person is dealing with back pain, they are also dealing with degenerative issues that are also affecting their spines, thus causing problems to their joints, discs, and bones. (Hauser et al., 2022) This is because back pain is a multifactorial musculoskeletal disorder that can cause referred pain to different body locations. So when a person dealing with back pain rests, it can become an issue as inflammation builds up and swelling in the affected areas. Hence, many doctors, chiropractors, physical therapists, and spine specialists recommend keeping mobile to allow blood flow and the body’s natural healing response to reduce pain and speed up recovery. Since back pain relief is challenging through visceral-somatic disturbances, it is important to find various treatment options to aid the person’s specific condition. As a person goes to get treatment for their back pain, it is important to note that the causes of their back pain can help determine which exercises can be most effective within their treatment plan. We associate with certified medical providers who inform our patients of the benefits of incorporating simple but effective exercises for their back pain. While asking important questions to our associated medical providers, we advise patients to integrate an exercise routine to reduce the chances of environmental factors causing back pain to return. Dr. Alex Jimenez, D.C., envisions this information as an academic service. Disclaimer.


Understanding Academic Low Back Pain- Video


Effective But Simple Exercises For The Back

Many people often wonder, “If I am dealing with back pain, why should I exercise to reduce this pain?” The answer is simple: since the affected back muscles are tight and weakened, simple but effective exercises can help recover. Exercise therapy can help increase muscle-joint strength in the body while improving muscle function and increasing range of motion. This boosts a speedy recovery and allows the individual to return to their usual activities. (Hayden et al., 2021) At the same time, with a customized treatment plan, exercise therapy can incorporate other non-surgical treatments with one goal: to restore normal musculoskeletal function and reduce the pain caused by environmental factors, diseases, or injuries. (Karlsson et al., 2020) Now, depending on the severity of the back pain, there are simple but effective exercises below to help reduce the pain and restore mobility to the back.

Physical Therapy & At-Home Workouts

Physical therapy and at-home exercises can help many individuals with back pain. They can help figure out which position can help centralize the pain and correct any restricted motions. Many physical therapists incorporate the McKenzie method to strengthen and support the spine while decreasing pain and inflammation. At-home exercises can be combined with a series designed to be practical, assessable, and feasible for therapeutic gain or even to improve physical capacity to maximum effort. (Quentin et al., 2021)

Water Exercises

Water exercises are amazing exercises that can help lessen the body’s weight to take pressure and stress off the spine. This is because water is supposed to help cleanse and rejuvenate the body. When individuals are experiencing chronic back pain, aquatic physical therapy can help relieve pain intensity, relax the aching muscles, and even promote a positive workout experience for the individual. (Ma et al., 2022) After a few consecutive sessions, many individuals can see improvement in pain intensity and restored mobility function in their routines.

Tai Chi & Stabalizing Exercises

Now, another simple and effective exercise routine can help stabilize the surrounding muscles in the back and spine and become effective as part of a health and well-being routine. Tai chi and Qigong practices can help the individual emphasize stillness and controlled movements to promote calmness, resilience, body awareness, and relaxation for proper body alignment. (Yang et al., 2024) Tai chi and Qigong can also help support immune function in the body while regulating inflammation, which can help reduce and prevent diseases. (Oh et al., 2020) At the same time, yoga can help improve flexibility, mobility, and stability within the muscles and joints while also improving spinal alignment, which can help many individuals have proper posture. (Zhu et al., 2020) Depending on which exercise a person prefers for their treatment plan and to reduce their back pain; it is important to make these small changes to achieve optimal results. Making these small changes can help many individuals reduce the chances of their back pain returning and help them along with their health and wellness journey.


References

Chou, R. (2021). Low Back Pain. Ann Intern Med, 174(8), ITC113-ITC128. https://doi.org/10.7326/AITC202108170

Hauser, R. A., Matias, D., Woznica, D., Rawlings, B., & Woldin, B. A. (2022). Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review. J Back Musculoskelet Rehabil, 35(4), 701-712. https://doi.org/10.3233/BMR-210097

Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database Syst Rev, 9(9), CD009790. https://doi.org/10.1002/14651858.CD009790.pub2

Karlsson, M., Bergenheim, A., Larsson, M. E. H., Nordeman, L., van Tulder, M., & Bernhardsson, S. (2020). Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews. Syst Rev, 9(1), 182. https://doi.org/10.1186/s13643-020-01412-8

Ma, J., Zhang, T., He, Y., Li, X., Chen, H., & Zhao, Q. (2022). Effect of aquatic physical therapy on chronic low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord, 23(1), 1050. https://doi.org/10.1186/s12891-022-05981-8

Oh, B., Bae, K., Lamoury, G., Eade, T., Boyle, F., Corless, B., Clarke, S., Yeung, A., Rosenthal, D., Schapira, L., & Back, M. (2020). The Effects of Tai Chi and Qigong on Immune Responses: A Systematic Review and Meta-Analysis. Medicines (Basel), 7(7). https://doi.org/10.3390/medicines7070039

Quentin, C., Bagheri, R., Ugbolue, U. C., Coudeyre, E., Pelissier, C., Descatha, A., Menini, T., Bouillon-Minois, J. B., & Dutheil, F. (2021). Effect of Home Exercise Training in Patients with Nonspecific Low-Back Pain: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health, 18(16). https://doi.org/10.3390/ijerph18168430

Yang, Y., McCluskey, S., Bydon, M., Singh, J. R., Sheeler, R. D., Nathani, K. R., Krieger, A. C., Mehta, N. D., Weaver, J., Jia, L., DeCelle, S., Schlagal, R. C., Ayar, J., Abduljawad, S., Stovitz, S. D., Ganesh, R., Verkuilen, J., Knapp, K. A., Yang, L., & Hartl, R. (2024). A Tai chi and qigong mind-body program for low back pain: A virtually delivered randomized control trial. N Am Spine Soc J, 20, 100557. https://doi.org/10.1016/j.xnsj.2024.100557

Zhu, F., Zhang, M., Wang, D., Hong, Q., Zeng, C., & Chen, W. (2020). Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLOS ONE, 15(9), e0238544. https://doi.org/10.1371/journal.pone.0238544

Disclaimer

Improve Your Health with Bed Pilates: Try These Adapted Exercises

Can Pilates exercise movements be performed in bed for individuals recovering from illness or injury?

Bed Pilates

Pilates exercises can be practiced in bed. Joseph Pilates’ exercises and equipment, such as his patented V-shape bed, were designed to help rehabilitate injured individuals who had to stay on or near a bed. After a healthy night’s sleep, Pilates exercises dynamically stimulate circulation and the nervous system. They can also be used to calm the mind and body before going to bed.

  • Those with health concerns should check with their healthcare provider before starting any exercise program to ensure safety.
  • Beginners are recommended to learn the Pilates principles and movement fundamentals.

Here are a few Pilates mat exercises adapted for individuals who need or prefer to exercise in bed. A firm mattress is recommended, as a soft mattress will mess up the correct form, making the exercise ineffective.

Spine Twist

This exercise helps improve the flexibility of the spine and core, making it easier to move around, and supports healthy posture. (Geremia J. M. et al., 2015) Pilates exercises like the spine twist have been found to reduce low back pain and disability. (Notarnicola A. et al., 2014) To perform:

  • Sit up in bed, torso straight, abs engaged, and inhale.
  • Exhale as you turn your head and shoulders to the right.
  • Keep your torso straight, and imagine growing taller through the turn.
  • Inhale as you return to the starting position.
  • Exhale and turn to the other side.
  • Repeat five times on each side.

Tendon Stretch

The tendon stretch helps by improving flexibility in the hamstrings and calves. (Chinnavan E., Gopaladhas S., & Kaikondan P. 2015) To perform:

  • Sit up straight, legs straight out.
  • Bring heels together and use a towel to pull your feet towards you while pushing your heels away.
  • Hold for three seconds.
  • Next, without the towel, point your toes away.
  • Hold for another three seconds.
  • Do ten reps.

Double-Leg Stretch

The double-leg stretch is an intermediate exercise that works the abdominals and the core. If this move feels difficult, start with one leg at a time. Another option is to keep the knees slightly bent instead of extending the legs fully. To perform:

  • Bring both knees to your chest and, with your hands, press down on the ankles to stretch the lower back.
  • Pull in the abdomen.
  • Exhale and extend the arms up and the leg or legs as far out in front as possible.
  • Hold the position for ten seconds and then release.
  • Do ten reps.

Pelvic Curl

The pelvic curl builds strength in the lower back and core. To perform:

  • Bend knees and place feet on the bed hip-distance apart.
  • Curl your pelvis, squeeze the glutes, and lift your body.
  • Hold for five seconds.
  • Slowly count five seconds while lowering back down, imprinting the spine into the mattress.
  • Do ten reps.

Hip-Opening Exercise

A hip-opening exercise, or frog, can be done while lying down or sitting in bed. Hip openers help keep the spine and hips flexible and in alignment. To perform:

  • Bring the soles of your feet together and as close to the torso as possible.
  • Let the knees open up as far as possible, and that feels comfortable.
  • While in the stretch, breathe in and out as deep as possible.
  • If sitting, place hands on ankles and use forearms to push down on the knees for added stretch.

Injury Medical Chiropractic and Functional Medicine Clinic

Chiropractic care aims to help individuals improve movement with less pain due to condition, after injury, or surgery. A chiropractic therapy team can assess your condition and develop a customized treatment plan to expedite pain relief and improve mobility. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.


Home Exercises for Pain Relief


References

Geremia, J. M., Iskiewicz, M. M., Marschner, R. A., Lehnen, T. E., & Lehnen, A. M. (2015). Effect of a physical training program using the Pilates method on flexibility in elderly subjects. Age (Dordrecht, Netherlands), 37(6), 119. https://doi.org/10.1007/s11357-015-9856-z

Notarnicola, A., Fischetti, F., Maccagnano, G., Comes, R., Tafuri, S., & Moretti, B. (2014). Daily pilates exercise or inactivity for patients with low back pain: a clinical prospective observational study. European journal of physical and rehabilitation medicine, 50(1), 59–66.

Chinnavan, E., Gopaladhas, S., & Kaikondan, P. (2015). Effectiveness of pilates training in improving hamstring flexibility of football players. Bangladesh Journal of Medical Science, 14(3), 265–269. https://doi.org/10.3329/bjms.v14i3.16322