title: Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings.
abstract: METHODS
  Case report.
  
  
  OBJECTIVE
  To highlight the effects of an intervention program consisting of strengthening and neuromuscular reeducation of the gluteus maximus in an elite triathlete with exercise-associated muscle cramping (EAMC).
  
  
  BACKGROUND
  Researchers have described 2 theories concerning the etiology of EAMC: (1) muscle fatigue and (2) electrolyte deficit. As such, interventions for EAMC typically consist of stretching/strengthening of the involved muscle and/or supplements to restore electrolyte imbalances.
  
  
  METHODS
  The patient was a 42-year-old male triathlete with a primary complaint of recurrent cramping of his right hamstring muscle, which prevented him from completing races at his desired pace. Strength testing revealed gluteus maximus muscle weakness bilaterally. Electromyographic (EMG) analysis (surface electrodes, 1560 Hz) revealed that the right hamstrings were being activated excessively during terminal swing and the first half of the stance phase (48.1% maximum voluntary isometric contraction [MVIC]).
  
  
  RESULTS
  Following the intervention, the patient was able to complete 3 triathlons without hamstring cramping. Strength testing revealed that the right hip extension strength improved from 35.6 to 54.7 kg, and activation of the hamstrings during terminal swing and the first half of the stance phase decreased to 36.4% of MVIC.
  
  
  CONCLUSIONS
  A program of gluteus maximus strengthening and neuromuscular training eliminated EAMC of the hamstrings in this patient. Given that the hamstrings and gluteus maximus work as agonists to decelerate the thigh during terminal swing phase and control hip flexion during loading response of running, we postulate that strengthening of the gluteus maximus decreased the relative effort required by the hamstrings, thus reducing EAMC. The results of the EMG evaluation that was performed as part of this case report provides support for this hypothesis.
  
  
  METHODS
  Therapy, level 4.
authors.affiliation: Kaiser Permanente Southern California Orthopaedic Physical Therapy Residency Program, Woodland Hills, CA, USA.
authors.forename: Tracey
authors.initials: T
authors.lastname: Wagner
authors.forename: Nazly
authors.initials: N
authors.lastname: Behnia
authors.forename: Won-Kay Lau
authors.initials: WK
authors.lastname: Ancheta
authors.forename: Richard
authors.initials: R
authors.lastname: Shen
authors.forename: Shawn
authors.initials: S
authors.lastname: Farrokhi
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Powers
mesh_terms: D000328:Adult; D001265:Athletic Injuries / Q000534:rehabilitation*; D002081:Buttocks; D005081:Exercise Therapy / Q000379:methods*; D006801:Humans; D008297:Male; D009120:Muscle Cramp / Q000209:etiology / Q000517:prevention & control*; D018763:Muscle Fatigue / Q000502:physiology; D053580:Muscle Strength / Q000502:physiology; D018482:Muscle, Skeletal / Q000294:innervation / Q000502:physiology / Q000503:physiopathology*; D013848:Thigh