The two main culprits tend to be weakness in your hamstrings. So these are the muscles that start at our butt, that sitting bone, and then extend all the way down to behind our knees. Those are the hamstring muscles on the back of your thigh. The action of those muscles is to bend your knee in any position. Standing still, sitting, lying down, whatever position. If you're bending your knee, those are your hamstring muscles working. So if you have weakness in your hamstring muscles, that can be a big factor as to why bending your knee is challenging for you. The other most common culprit, specifically for multiple sclerosis, that could make bending your knee hard is spread spasticity or any form of very tight muscles in the front of your thigh, which are your quadricep muscles. These muscles, when they are active and working, they straighten your knee. So you could imagine if you have a lot of tightness and spasticity in this muscle, it promotes that action, so it makes the knee straighten. And guess what? If your knee is straight, bending it is going to be very hard because it's something is making it stay straight, and we actually want the opposite action to occur. And then to make matters even more confusing, of course, you could have both. You could have weakness in your hamstrings and tightness or spasticity in your quadricep muscles, in which case you want to work on both of them. So we're going to talk about exercises for both weakness and tightness and spasticity. However, first it's. It could be a good idea to try to assess which one might be truest for you. Weakness, spasticity, or maybe it is both. One of my favorite ways to test if it's weakness or spasticity or both is to do so in a seated position. So the chair that I'm sitting in right now is just the nice, comfy chair that I have in my office, and it's a little low. And so right now my hips are at about 90 degrees. This would actually work a little bit better if I had a taller chair where my knees were lower than my hips, or even sitting at the edge of a bed where. Or something where your feet aren't even touching the floor. But regardless, I will explain and demonstrate from this position. So you're going to be sitting in a chair. And now to test for hamstring strength or weakness or the back of your thigh, what you're going to try to do is bend your knee. So sitting up nice and tall if you're able to, or even having a good core posture, but reclining backwards is fine as well. Try to bend your knee so pull your right heel back towards the chair or towards the bed, whatever it is that you're sitting on. This is likely going to be very challenging. And ideally, we don't want friction playing a role here. So right now I'm wearing sneakers on carpet. That's not the smartest idea because there's a lot of friction between my sneaker and the carpet. So I could always grab a magazine and put that under my foot, something slippery to reduce that friction, or sit on a taller surface so that I don't have to be having my foot on the floor. That would also reduce the friction. If you are on tile or hardwood floor, then maybe remove the shoe. So you just have a sock or put a dish towel under your shoe. So something to make it slippery and easier to move. And if you. Even with making it easier, if you cannot bend that knee, or you can, but it's very, very hard, more likely than not, you are dealing with hamstring weakness. You could also try this in other positions, such as standing up. You can hold on to something for support, but stand up and try to bend your knee so your heel comes up towards your glute or your butt on that side. You could try lying on your side and bending that knee. Regardless, try to bend your knee. If it doesn't work or barely works, you're probably dealing with some level of hamstring weakness. So we know we need to strengthen our hamstrings now to test for spasticity. This is most helpful if you do have someone else that can help, but you can do it by yourself and as well. So again, we're going to be sitting down and ideally you're going to be sitting with your feet not touching the ground. But again, I'm demonstrating with my feet touching the ground. And if you have someone who can help you with this, what your role is is you just want to relax. You just want to sit. Try to let your legs go loose. You're not doing anything to activate any muscles. You can even recline and relax. And. And you want the person who is helping you to attempt to bend your knee for you. So they would be sitting or kneeling on the ground or squatting down next to you and attempt to push your leg back. And again, your goal is just to let it happen. Don't resist it, don't Try to push back against them, Let them bend your knee. If you can bend. If they can bend your knee, then you likely do not have spasticity. But if they can't, or if they feel like you're pushing back even though you aren't, if they're saying something like, Dr. Gretchen, stop pushing against me, let me move you. And your response is, I'm not trying to, it's just happening. That is spasticity. Spasticity is muscle tightness that restricts, reduces, or prevents movement. So if someone trying to bend your knee is unable to, or they feel like you're pushing back, you likely have spasticity in those quadricep muscles. If you don't have someone to help, you would need to use something to assist you, like a yoga strap, where you would hook the yoga strap around your foot or your ankle and, and ideally try to rest this leg and you try to pull that leg back using your arms and the yoga strap. Similarly, if you're able to bend it, then you likely don't have spasticity or it's minimal. But if you can't, then it likely is spasticity. Now, again, we keep mentioning this, but you could have both. You could have spasticity and tightness. So let's talk about the exercises that you want to do to strengthen and stretch those muscle groups. I'm going to make the knee strengthening or the hamstring strengthening exercises pretty simple for you. All you need to think about when it comes to strengthening your hamstrings is any movement that involves bending your knee. So I like to keep it simple. And if you're in the Missing Link, my online program, you know this one of our staples for every person in the Missing Link, regardless of what which exercise calendar you're following, where it tells you what exercises to do each day, we have this one baked in throughout the week in every calendar because it's that important. And I like to do it seated or standing, but you can also do it lying on your side, lying on your belly, and all you're focusing on is bending your knee. So that same thing that we used to test our hamstring strength, where we're sitting and we're attempting to bend our knee is now one of our exercises. So you're going to be sitting up tall. I would recommend sitting as far back in the chair as possible. So you want the majority, if not all of your thighs to be covered and supported by the chair, versus if you're sitting towards the edge of the chair, you have all the all this space for maybe half or the majority of your thigh where it's not supported by the chair, that's going to be even more challenging. So scoot as far back as you can and try to bend that foot. Same idea as the testing. Make it as easy as possible for yourself. Can you put something slippery underneath it? Can you remove your shoe? Can you sit up taller on a different surface so that your feet are not touching the ground? But try to bend, hold for a few seconds, and then release back to the start position and bend and release. And this is the seated version. You could do the same thing standing. Again, you can use a mobility aid of any kind to help you stay stable. You're in a staggered stance. So one foot is forward, one foot is back. Shift your weight onto that front leg so it's almost like your mid stance, like you took a step forward and then someone said, stop. If we're playing that freeze. What's that game called? It's a kid's game where you go and then you freeze. Red light, green light, I think it's called. So you're going to freeze and then you're going to attempt to bend that back leg again. This is one of the most challenging exercises for the majority of Missing Link members and clients and patients that I work with. So if this is really hard, please don't feel like you're alone. It's still worth doing. It's one of the best ways to strengthen the connection between your brain and that muscle, which is your neural pathway. So try to bend, bend, bend, bend, bend. Even if it's only lifting a centimeter, even if your toes are still touching the ground, but you're trying to bend your knee so that your heel comes up to towards your butt. But again, it doesn't have to lift high, just a little bit. This is the same exercise we just did seated. We're just standing instead. So you can do it that way. We could also do it lying down. So I would highly recommend not doing this on the floor. If you have difficulty standing up from the floor, maybe doing it on your sofa or your bed. But you can lie on your side and you can bend your top leg. So again, in every position, we're just bending our knee. It's the same exercise. We're just changing the position of our body. So when we're lying on our side, our heel comes towards our butt. Same exact movement. You can move that top leg on its own, or you can move it at the same time as the bottom leg. And if you have weakness on both sides, you would, of course, want to switch sides and do the same thing on the other side. The last thing that I want to share about strengthening our hamstrings is that there is some Ms. Research showing that isometric strengthening can be really helpful, specifically for people with Ms. What that means is you do the same exercise that you would normally do, but you're pushing against something. So with this one, you're sitting down as far back into the chair as possible so that your calf muscles, the back of your lower leg, and your heel are touching the chair and you are going to bend your knee. Now, if you're watching me, you'll see that you don't see any movement happening. And that's the whole point of isometric exercises. So I'm trying to bend my knee, but I'm pushing into the surface. So the surface, in this case a chair, is actually preventing me from bending my knee. But you better believe I still feel those muscles tightening, trying to bend. That's what an isometric exercise is, activating the muscles without actual movement occurring. So that is a different form of exercise strengthening you can do for your hamstrings or really any muscle group. Now let's move on to quadriceps, loosening or relaxing, releasing whatever we want to call it. But basically, let's get rid of some of this spasticity. Now, sometimes spasticity does require medications like Baclofen or Botox injections into the specific muscles that are spastic. However, some things that we can do from a physical therapy perspective are things like stretching and massage, just to name two of my favorite methods and techniques. And so for stretching the quads, one really simple way to get a good stretch, depending on how tight or spastic your muscles are, is to sit towards the edge of a chair and lean back as far back as you can. The goal here is to straighten your hips as much as possible. Get your hips to be as close to 180 degrees. Fold fully flat, but keeping your knees bent. So if you straighten your leg, you're not going to be stretching your quadricep muscles as much as if they as if your knee is bent. So you're keeping your knees bent and lying down. Another good example of this would be if you are sitting at the edge of your bed, your feet are on the ground, and you're fully lying flat on your bed. So you're just trying to straighten out the hips. That gets a good portion of your quadricep muscles, as well as hip flexors to try to open up that area and release the tightness there. And you would stay here for anywhere from. I personally like to do what's called prolonged static stretching, which would mean you'd stay there for about three to seven minutes. And whatever is comfortable for you. If it ever feels like it's too much, you would get out of that position. So that's one way that you can stretch that area. Another way is to either stand or sit. I'll show the standing version first in the staggered stance, the same stance that we were in for our knee bending strengthening exercise, but staggered stance, equal weight on both foot. Tuck your butt under and and try to straighten that back knee. And you will likely feel this in the front of your hip as well as the front of your thigh. Our main goal would be the front of the thigh because that's where the spasticity is. But this spasticity could also be stemming from your hip flexors in the front of your hips. So either works. Don't be too judgmental about where your body is feeling it. This is the standing version. The seated looks very similar, where you're going to be sitting down, separate your feet and your knees as wide as you can, and then you're going to pivot so that you are facing the direction where your leg is not spastic. So we're. Right now I'm practicing stretching my right quadricep muscle. So I'm turning towards my left and tucking my butt under. So it's the same approach. Just instead of standing in a staggered stance, I'm sitting with a staggered stance, tucking my hips under and holding here. And I feel a nice big stretch in the front of my quadricep if I turn the other way. So feet and knees are nice and wide, turning towards my right side. My left knee drops down, I tuck my butt under, and now I'm feeling a stretch in the front of my left hip as well as thigh in quadricep muscle. So those are some stretches I like to do. I also like to massage my quadricep and roll it out. So you can just use the heels of your palm and go back and forth. There's no right or wrong when it comes to massage. The goal is just to release some of those muscles using. You can use your knuckles to roll, go up and down. The goal is just relax this leg at the same time as using your hands to release. If you have hand weakness, you can hold on to a device that's called the jack knobber. It's just something a plastic tool that you hold onto and can move all around. You can use something like the Theragun or the Rock Tape is a company that has the Rock Wave Pro, which is part of the 2025 annual Ms. Holiday Gift Guide. If you want a visual on that, there's something called the muscle Roller stick. It looks like a rolling pin where you can roll out your muscles. So now we're getting into more of the muscle release via rolling. Foam rolling could be an option, but we just want to do something to release the tension in the front, front of the thigh, those quadricep muscles. The last thing I'll share about this is I've had quite a few missing link members who have weakness in their hamstrings. So bending their knees, challenging for them. They will actually spend just a few minutes, two or three minutes before their knee bending exercise to relax and loosen their quadricep muscles. And they find that bending their knee is so much easier after they've released the tension in the quadricep muscles. So if you wanted to try, that might be a good idea. When it comes to the muscle tightness and those stretches and releasing that we were talking about, for some people it feels better right away or within a day or two of releasing those muscles. For others, it takes several weeks or even a few months. But usually it is more in the several days to weeks for strengthening. That of course does take longer. For someone without ms, you might notice improved strength in, let's say, four to six weeks or even two to four weeks. It could be sooner, but when you have ms, it's more realistic that you would start noticing improvements within six to 12 weeks. So closer to the two to three months. With that said, not that I want to get off on a big tangent right here, but we have a decent amount of missing link members who do see results within the first day or two. And what I mean by results is they feel stronger, they feel like their leg is moving more within a day or two. If that happens for you, the reason that that's happening is because while you did have weakness, those muscles just weren't being used in the right way. So. So now that you're strengthening them, you're basically reminding your brain how your body should be moving and it all clicks. Your brain is like, oh, you want me to move that way? Okay, sure. I didn't know that. I've been overcompensating using this other way. So if you do notice improvement sooner, which is possible, that's likely why that's happening. Also, if you are loving this topic and you're feeling like Man, I've had this question for quite some time. This is so helpful. Or ooh. But I have a further question like how do I bend my knee in this specific situation? Just know that that is one thing that we do every single month inside my online program the Missing Link, where members can submit their questions and then we all hop on Zoom and I demonstrate and explain and give modifications and other examples for everyone's individual questions. We also have Dr. Gretchen AI, which is a 24.7support system for missing Link members where you can ask your questions. I have uploaded all of my knowledge and expertise and training and teaching style into the Missing Link and into this AI so that you can get your answers right then and there if you didn't want to wait until our monthly Q and A call. So if you're liking this and you feel like you want more of this for your specific questions, we do have that for you inside the Missing Link. If you don't know what the Missing Link is and this is the first you're hearing of it or you're just not sure if it's the right fit for you, I will include a link down in the show notes and description so you can check it out and see if it's a good fit. I hope you found this episode helpful. And more than anything, just remember that consistency matters more than perfection. So don't focus on doing the exercise strengthening movements perfect perfectly or the stretching exercises perfectly. Just focus on doing them consistently and feeling where you should be feeling them. So again with those hamstring strengthening exercises, we want to be feeling that in the back of our thigh, back of our knee with the quadriceps stretching and releasing, we should be feeling mostly in the front of our thigh. So knowing where you should be feeling the exercise is a great indication of if you're doing the exercise for properly or not. Of course, if anything is uncomfortable or even painful, do not do them. Try to find a modification, a different position. If it's still uncomfortable, don't do them. You don't want to make anything exacerbate or flare. It might just not be the right exercise for you and your body. And also remember that even small improvements in knee bending create big functional changes so you might gain enough strength where your knee can bend 5 degrees more. Now, 5 degrees is not that much when we think about the number of degrees, but it is a lot when we're thinking about function. The difference of 5 degrees bending your knee versus 5 degrees less could mean that climbing stairs is actually doable versus not doable. So so any movement improvements and any progress really does matter. Don't feel like you need to make these huge, massive improvements and you can now bend your knee fully. That's not necessarily the goal here. Any amount can be really, really helpful. You've got this. I know that you do, and I'd love to know from you if you feel that knee bending is mostly limited from weakness or tightness and spasticity or both. So let me know. I'll see you next time.
