Hamstring Injuries: Assessment, MSR Care, and Return to Sport
An athlete may walk without pain yet hesitate when accelerating, reaching for a ball, or returning to faster running. After a hamstring injury, that gap between everyday function and sporting demands deserves careful attention. The aim is to restore the capacity and confidence needed to participate fully.
This article connects hamstring anatomy with assessment, MSR manual care, and progressive rehabilitation. Practitioners will consider injury location, loading tolerance, relevant joint and neurological findings, and the demands awaiting the athlete. Demonstration videos support practical learning, while reassessment guides treatment and progression. The purpose is an informed return to training and competition, with continued preparation beyond the disappearance of pain.
Article Index:
Anatomy and Functional Relationships of the Hamstrings
The hamstring group comprises semitendinosus, semimembranosus, and biceps femoris. Semitendinosus, semimembranosus, and the long head of biceps femoris cross both the hip and knee. The short head of biceps femoris crosses the knee only.
These distinctions matter when selecting examination positions and exercises. Hip and knee position alter loading across the two-joint muscles, while posterior-thigh symptoms may also involve adjacent muscles, tendons, the sciatic nerve, or referred pain. Regional fascial relationships help orient assessment but do not independently establish the cause of symptoms.
Semitendinosus: A Vital Muscle for Movement
The semitendinosus originates at the ischial tuberosity of the pelvis and runs down to the pes anserinus, just below the knee. There, it joins the gracilis and sartorius muscles—together known as the GST muscles (a cheeky nod to the Canadian sales tax). Proximally, semitendinosus shares a common tendon of origin with the long head of biceps femoris at the ischial tuberosity. Distally, it joins sartorius and gracilis at the pes anserinus on the anteromedial proximal tibia. The nearby pes anserine bursa is relevant when examining medial knee symptoms.
Semitendinosus receives innervation through the tibial division of the sciatic nerve, commonly described as L5–S2. It contributes to knee flexion, hip extension, and medial rotation of the flexed knee, with its contribution to control depending on the task.
Semimembranosus Muscle
Like the semitendinosus, the semimembranosus originates at the ischial tuberosity and runs down the back of the leg to attach at the posterior medial tibia, just below the knee. This muscle is particularly prone to injury, especially in dancers, where overstretching is common.
Inflammation in this area can sometimes mimic the symptoms of a medial meniscus injury, making diagnosis tricky. The tibial division of the sciatic nerve (L5 to S2) innervates the semimembranosus, which also has a unique myofascial expansion connecting with the crural fascia around the medial head of the gastrocnemius.
Semimembranosus and Posteromedial Knee Symptoms
Semimembranosus has a complex distal attachment involving the posteromedial tibia and capsular structures. These relationships make it relevant when examining posteromedial knee pain.
Within MSR, consider semimembranosus treatment when palpation, movement, and loading reproduce relevant symptoms. Reassess knee movement or another meaningful task. Improvement does not establish that treatment changed meniscal position or function.
Biceps femoris and related structures
A common site of injury, especially for sprinters, the biceps femoris plays a key role in leg mechanics. It has two heads—the long head originates at the ischial tuberosity of the pelvis, alongside the semitendinosus, while the short head starts on the posterolateral femur. Both heads contribute to a distal tendon inserting principally on the fibular head, with additional tibial and fascial attachments. The nearby common fibular nerve is an important consideration during distal lateral-hamstring assessment and manual application.
The long head receives innervation through the tibial division of the sciatic nerve; the short head through its common fibular division. Root contributions are commonly described as L5–S2.
Proximal biceps femoris has anatomical relationships with the sacrotuberous ligament. Consider associated lumbopelvic findings when symptoms or functional testing indicate their relevance; anatomical continuity alone does not explain an individual’s back pain.
The hamstring portion of adductor magnus contributes to hip extension but does not cross the knee. Adductor-related symptoms belong in the differential assessment of medial or proximal posterior-thigh pain.
Functional Actions of the Hamstrings
The hamstrings are powerful, multi-functional muscles. They serve as primary hip extensors (second only to the gluteus maximus), knee flexors, medial and lateral rotators, and are crucial for knee stabilization.
Biomechanically, the hamstrings perform different actions depending on leg positioning:
Semitendinosus, semimembranosus, and the long head of biceps femoris contribute to hip extension and knee flexion.
The short head of biceps femoris contributes to knee flexion but does not act directly at the hip.
With the knee flexed, the medial hamstrings contribute to medial tibial rotation; biceps femoris contributes to lateral rotation.
Pelvic and trunk effects depend on limb position, loading, and coordination with other muscles.
For assessment and rehabilitation, I consider both hip-extension and knee-flexion capacity, together with the athlete’s movement and loading demands. The hamstrings also provide sensory information that contributes to movement control. Their clinical relevance cannot be reduced to one primary action.
Hamstring Function During Running
During late swing, the hamstrings help control the advancing thigh and extending knee before contact. During stance, they contribute to hip-extension force and control across the hip and knee. Their demands change with speed and technique.
An easy jog does not reproduce the demands of sprinting. Assessment and rehabilitation should eventually address the speed, repetition, acceleration, and sporting actions the athlete needs to regain.
Observe symptoms and movement, then examine relevant capacity. Neither landing appearance nor a presumed fascial restriction establishes the cause of a hamstring injury.
Injury Severity and Healing of Hamstring Injuries
Hamstring injuries vary in location, tissue involvement, and severity. Some affect muscle fibres or the musculotendinous junction; others involve an intramuscular tendon or the proximal attachment. An avulsion occurs when a tendon pulls away from its attachment, sometimes with a fragment of bone.
Healing involves inflammation, repair, and remodelling. Scar formation is part of repair, not proof that the tissue will remain permanently weak or that recovery is incomplete. Symptoms may improve before strength and sporting capacity have recovered.
A simple grading system describes:
Grade 1: Relatively minor injury with limited functional loss.
Grade 2: Partial tear with more substantial pain, weakness, and activity limitation.
Grade 3: Complete rupture of the affected muscle or tendon structure.
Grades alone do not determine recovery time or surgical need. Injury location, tendon involvement, retraction, functional loss, and the athlete’s goals influence management. Suspected proximal avulsion warrants prompt specialist assessment.
Focused Hamstring Assessment
History: Establish whether onset occurred during sprinting, acceleration, kicking, or a lengthening movement. Record pain location, a pop or sudden loss of function, previous injury, and current walking or sitting limitations.
Local examination: Assess tenderness, bruising, swelling, and any palpable defect without repeatedly provoking an acute injury.
Movement and loading: Examine knee flexion and hip extension at appropriate positions and loads. Assess range as tolerated and record strength objectively when equipment is available.
Functional capacity: Establish suitable baselines for walking, exercise, and later running. Select tasks according to injury severity.
Differential assessment: Consider proximal tendinopathy, avulsion, adductor injury, lumbar referral, and sciatic nerve involvement. Add neurological and vascular examination when indicated.
A sudden proximal injury with marked weakness, extensive bruising, or substantial functional loss deserves prompt investigation rather than routine local treatment.
Here are examples of orthopedic, neurological, and vascular examinations we commonly perform on our patients. To rule out other problems, we often apply tests from both the knee and hip examinations.
Knee Examination:
This video provides an in-depth look at orthopedic testing techniques tailored for knee examination. These tests are crucial for diagnosing multiple conditions.
Hip Examination
Orthopaedic Testing - In this video, we will be discussing the various orthopedic tests used for examining the hip joint to diagnose and treat hip-related conditions.
Lower Limb Neuro Examination
The lower limb neurological examination assesses the motor and sensory neurons supplying the lower limbs to detect any nervous system impairment. This examination is used both as a screening and investigative tool.
Peripheral Vascular Examination
The peripheral vascular examination is a physical exam that evaluates the circulatory system outside of the heart and lungs.
Imaging and Referral
Imaging is not necessary for every uncomplicated hamstring strain. Consider it when the diagnosis is uncertain, substantial tendon injury or avulsion is suspected, or progress differs from expectations.
Radiographs: Useful for suspected bony avulsion, particularly in a skeletally immature athlete. A normal radiograph does not exclude a soft-tissue injury.
Ultrasound: Can assess selected muscle and tendon injuries, with usefulness depending on location and operator expertise.
MRI: Particularly useful for defining proximal tendon involvement, retraction, or a complex injury when that information will influence management.
CT is not a routine investigation for a hamstring muscle strain. Imaging contributes to management decisions but does not independently establish readiness to return to sport.
MSR Manual Care: Purpose, Application, and Reassessment
Manual care can be a useful component of hamstring rehabilitation when it addresses a finding that limits movement, loading, or exercise. Within MSR, the practical question is: what can we treat today that will help this athlete take the next appropriate step in recovery?
Injury stage, location, severity, and irritability guide the application. An acute tear requires a different approach from persistent muscle sensitivity or restricted movement later in rehabilitation. Treatment should respect healing tissue while supporting a gradual return to function.
Match Treatment to Tissue Tolerance
Early care may involve tolerable contact and gentle movement, with attention to associated structures when direct treatment of the injured region is poorly tolerated. Avoid deep pressure over a suspected tear, forceful stretching, or repeated attempts to gain range from an irritable area.
Pressure and movement must be considered together. A contact that is tolerated with the knee bent may become provocative as the hip flexes or the knee extends. Adjust positioning, stabilization, movement range, pressure, and repetition accordingly.
More pressure or greater stretch does not necessarily produce a better treatment.
As tolerance improves, application can progress alongside active loading. The objective is a useful change that supports rehabilitation, rather than the greatest immediate increase in range.
Select Relevant Treatment Targets
Hamstrings: Consider semitendinosus, semimembranosus, or biceps femoris when examination identifies relevant symptoms or movement limitations. Distinguish muscle-belly findings from proximal or distal tendon involvement and adapt contact accordingly.
Associated muscles: Gluteus maximus, gluteus medius, adductor magnus, or other structures may deserve attention when findings connect them with painful hip loading, restricted movement, or difficulty performing rehabilitation exercises.
Joint findings: Relevant hip, knee, lumbar, or SI-region limitations may warrant mobilization or manipulation following appropriate screening and consent. Select joint care for its relationship to the athlete’s limitation.
Anatomical relationships help guide examination, but they do not require treatment of every connected structure.
Reassess Without Overworking the Area
Establish a suitable baseline, such as walking, active knee extension, resisted knee flexion, or a controlled bridge. After a brief application, reassess the same task under comparable conditions.
If symptoms ease or movement improves, use that opportunity for appropriate active exercise. Avoid repeatedly treating a sensitive region simply to obtain further change. Sharp pain, increasing guarding, or declining movement tolerance calls for modifying or stopping the application.
Also review the response later that day and the following morning. Increased pain or reduced function suggests that the treatment dose or subsequent activity needs adjustment.
A useful treatment leaves the athlete better able to participate in rehabilitation. Immediate relief helps guide care, but does not establish tissue healing or readiness for faster running.
MSR Hamstring Release Demonstration
Select the demonstrated procedures according to the injury presentation and examination findings. Preserve the demonstrated contact, stabilization, positioning, and movement, adapting pressure, range, and repetition to tissue tolerance. Reassess before progressing the application.
MSR Gluteus Maximus & Medius Demonstration
Consider these procedures when relevant gluteal symptoms or movement limitations affect hip loading or rehabilitation. Reassess the affected task and connect useful changes with progressive exercise and running preparation.
Rehabilitation and Return to Sport
Rehabilitation and Return to Sport
Walking without pain is an encouraging milestone, but accelerating, sprinting, or reaching for a ball places different demands on the hamstrings.
Rehabilitation needs to bridge that gap by restoring movement, developing knee-flexor and hip-extensor capacity, and progressively reintroducing the athlete’s sporting tasks.
Progression follows demonstrated capacity and symptom response. Injury location and severity influence the plan, with additional protection when substantial tendon injury or avulsion requires it.
Restore Movement and Begin Loading
Early rehabilitation combines suitable walking, gentle active movement, and tolerable hamstring loading. Isometric contractions, supported bridges, cycling, or simple balance tasks may provide useful starting points. Select the combination according to the examination rather than prescribing the same sequence for every athlete.
Monitor symptoms during exercise, afterward, and the following day. Progress when the current demands are tolerated without a meaningful increase in pain or loss of function. Cold application may provide temporary symptom relief when helpful.
Stretching can be introduced when restricted movement limits recovery. Use gentle, controlled application and reassess the response, avoiding forceful end-range stretching over an irritable injury. The objective is useful movement that supports loading and activity.
Build Strength Through Relevant Ranges
As tolerance develops, progressively challenge both knee flexion and hip extension. Increase resistance and range according to the findings, including controlled eccentric loading, where the hamstrings produce force while lengthening. Longer-length work can develop progressively without waiting for an arbitrary week.
The following exercises offer complementary options:
Heel-Dig Bridge: Provides an accessible starting point for hamstring and hip-extensor loading. Progress from bilateral holds to greater resistance, longer lever positions, or single-leg work.
Hamstring Sliders: Challenge control as the knees extend from a bridge position. Adjust sliding distance and assistance before progressing to more demanding variations.
Romanian Deadlift: Develops hip-extension strength with the hamstrings working at longer lengths. Establish a controlled hip hinge, then progressively increase resistance.
Resisted Hamstring Curl: Provides direct knee-flexor loading, with resistance and range adapted through bands or equipment.
Nordic Hamstring Exercise: Offers demanding eccentric knee-flexor loading when capacity permits. Assistance and a shorter lowering range provide options for introducing it progressively.
Choose exercises for the capacity they develop and the athlete’s response. Neural mobilization may complement this work when examination identifies a relevant neural component.
Rebuild Running and Sporting Capacity
Strength gains need to carry into the actions the athlete wants to regain. Introduce running at a tolerable level, then progressively develop speed, volume, and acceleration. An easy jog provides useful information, but faster running requires its own graded exposure.
For field and court athletes, progression may also include braking, direction changes, kicking, jumping, or reaching under pressure. Coordinate these demands with the athlete and coach, allowing recovery between sessions and checking the response across repeated efforts.
Confidence develops through successful exposure to increasingly relevant demands. Include the movements associated with the original injury as readiness improves, rather than leaving them until the first competition.
Decide Readiness From the Whole Picture
Return-to-sport decisions bring together symptoms, examination findings, physical capacity, and the athlete’s confidence. Look for:
Relevant movement and loading without limiting symptoms.
Objective knee-flexor and hip-extensor capacity across appropriate positions.
Tolerance to the required running speeds and repeated sporting efforts.
Confidence performing demanding or previously provocative actions.
A practical plan for continued strength work, training, and recovery.
Side-to-side comparisons help interpret progress, but symmetry alone is insufficient. The other limb may also have lost capacity. Readiness means demonstrating the demands of the sport repeatedly, with an acceptable response and a plan to sustain that capacity after return.
Returning With Capacity and Confidence
Hamstring recovery becomes meaningful when the athlete can accelerate, reach, sprint, or compete without the injury determining every decision. Achieving that requires an understanding of the injured tissue and the demands awaiting it.
MSR manual care should serve that progression. Select relevant structures, adapt application to the presentation, and reassess whether changes support movement and loading. Progressive strength work and running exposure then develop capacity beyond the treatment room.
Return to sport is a shared decision informed by symptoms, testing, repeated performance, and confidence. Continued preparation after return helps the athlete sustain participation rather than treating the first successful session as the end of rehabilitation.
References
Abelson, B., Abelson, K., & Mylonas, E. (2018). A practitioner’s guide to Motion Specific Release: Functional, successful, easy to implement techniques for musculoskeletal injuries (1st ed.). Rowan Tree Books.
Chumanov, E. S., Heiderscheit, B. C., & Thelen, D. G. (2007). The effect of speed and influence of individual muscles on hamstring mechanics during the swing phase of sprinting. Journal of Biomechanics, 40(16), 3555–3562.
Heiderscheit, B. C., Sherry, M. A., Silder, A., Chumanov, E. S., & Thelen, D. G. (2010). Hamstring strain injuries: Recommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 67–81.
Hickey, J. T., Opar, D. A., Weiss, L. J., & Heiderscheit, B. C. (2022). Hamstring strain injury rehabilitation. Journal of Athletic Training, 57(2), 125–135.
Malliaropoulos, N., Papalexandris, S., Papalada, A., & Papacostas, E. (2004). The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Medicine & Science in Sports & Exercise, 36(5), 756–759.
Martin, R. L., Cibulka, M. T., Bolgla, L. A., Koc, T. A., Jr., Loudon, J. K., Manske, R. C., Weiss, L., Christoforetti, J. J., & Heiderscheit, B. C. (2022). Hamstring strain injury in athletes. Journal of Orthopaedic & Sports Physical Therapy, 52(3), CPG1–CPG44.
van Dyk, N., Behan, F. P., & Whiteley, R. (2019). Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: A systematic review and meta-analysis of 8459 athletes. British Journal of Sports Medicine, 53(21), 1362–1370.
DR. BRIAN ABELSON DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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