Hamstring Injuries – Oh, The Agony!
- Dr. Brian Abelson DC
- Apr 13, 2023
- 13 min read
Updated: Jun 18, 2024
Every year, hamstring injuries affect a wide range of athletes, especially those in high-speed sports like track and field, football, and tennis. These injuries are known for their slow recovery and frustratingly high risk of re-injury.
In this blog, we dive into everything you need to know about hamstring injuries—how to diagnose them, effective treatments, and exercises that prevent future problems. Plus, we’ve included demonstration videos to make your learning experience interactive and practical.
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Our 90% success rate in hamstring injuries underscores the effectiveness of our multimodal, interdisciplinary approach, focusing on pain relief and improved function.
Article Index:
Anatomy & Biomechanics
The hamstrings are remarkable muscles that span two critical joints—the hip and the knee. This dual function makes them essential for movement, and any injury can disrupt not only the hips and knees but also the lower back and your overall gait.
Made up of the semitendinosus, semimembranosus, and biceps femoris, these muscles work in harmony to power activities like walking, running, and jumping. But it’s not just the muscles themselves—there’s an intricate fascial network, particularly the posterior line, that connects everything. When the hamstring gets injured, this network is impacted, causing subtle but significant changes in your movement patterns.
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). This muscle, sharing an attachment point with the biceps femoris, is key for knee stability. When inflamed, it can lead to knee pain due to its connection with the bursa underneath.
Innervated by the tibial branch of the sciatic nerve (L5 to S2), the semitendinosus, along with other muscles like the gracilis and sartorius, also functions as a fascial tensor, helping stabilize the medial side of the knee.
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.
Meniscus Injuries
Releasing restrictions in the semimembranosus can significantly improve meniscus function. Its fascial connection to the knee capsule aids in the retraction of the posterior horn of the medial meniscus, highlighting the intricate balance and fine-tuned mechanics within the body.
Biceps Femoris Muscle: The Sprinter's Challenge
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 meet at the head of the fibula and lateral tibial condyle, just below the knee.
What makes the biceps femoris unique is its dual innervation: the long head is powered by the tibial division of the sciatic nerve, while the short head is activated by the common fibular nerve, with roots from L4 to S2.
The biceps femoris also connects to the sacrotuberous ligament, extending force into the thoracolumbar fascia. This myofascial network explains how hamstring issues can contribute to low back pain, demonstrating the body’s remarkable interconnectivity.
Bonus Insight: The adductor magnus, often considered part of the hamstring group, can confusingly manifest as medial hamstring pain when injured.
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:
All hamstring muscles extend the thigh at the hip, flex the knee, and tilt the pelvis posteriorly.
The semitendinosus and semimembranosus medially rotate the leg inward.
The biceps femoris laterally rotates the leg outward. (Note: the short head of the biceps femoris doesn’t contribute to hip movement, as it doesn't cross the hip joint.)
While some researchers focus on specific functions like knee flexion as secondary, the hamstrings’ primary tasks, such as hip extension, are often prioritized in training and rehab. However, I see the hamstrings as a complex, multifunctional structure rich with neurological receptors, constantly relaying information to other muscles to support a wide range of tasks beyond their primary actions.
Running Related Functions
When running, your hamstrings act as shock absorbers, force generators, and stabilizers.
Shock absorption happens through eccentric contraction, where the hamstrings absorb the kinetic energy from foot impact. This works best when the muscles are strong, flexible, and free of adhesions from past injuries.
The hamstrings also play a key role in force generation, working together with the gluteal muscles to power hip extension.
For stabilization, the hamstrings help in several ways:
They act as dynamic stabilizers by controlling the forward movement of the shin bone during knee extension, similar to the function of the ACL, which acts as a passive stabilizer.
After ground contact, the hamstrings lengthen to stabilize the knee.
During the push-off phase, they contract alongside the quadriceps to provide propulsion.
Hamstring Tears
When a hamstring tear occurs, there’s typically some bleeding that can show up as a bruise along the back of the leg. This is followed by an inflammatory response, where fibroblasts—cells responsible for collagen production—rush in to help with wound healing and form scar tissue.
However, this scar tissue is weak and inflexible, limiting range of motion and increasing the risk of re-injury. These tissue changes can create biomechanical imbalances, making future injuries more likely.
Although the pain from a hamstring tear often subsides with time, the injury rarely heals completely. The lingering effects of scar tissue can lead to compensatory movements, which may cause other injuries down the line.
Grading a Hamstring Injury
Assessing the severity of a hamstring tear is essential to guide treatment. Injuries are graded from 1 to 3, with Grade 3 being the most severe.
Grade 1 (Mild): Minor tearing. Walking is possible but uncomfortable, with slight swelling and stiffness. Pain during resistance testing is minimal, and strength loss is negligible.
Grade 2 (Moderate): Significant tearing. Walking is difficult, and there’s noticeable pain, swelling, and bruising. Straightening the knee is painful, and hamstring strength is reduced.
Grade 3 (Severe): A complete tear, often requiring surgery. Walking is nearly impossible without crutches, and there’s a total loss of function, with extreme pain during any muscle contraction.
Diagnosis
A comprehensive diagnostic evaluation for hamstring injuries necessitates a multi-faceted approach that blends a detailed patient history with focused orthopedic tests. 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. This exam is important in diagnosing and managing peripheral vascular diseases such as arterial occlusion, aneurysms, and venous insufficiency.
Specialized Orthopedic Tests for Patellar Tendinopathy:
Single-Leg Decline Squat: Instruct the patient to stand on a declined surface (10-25 degrees) with one leg. Ask them to perform a single-leg squat while observing for pain or instability. Pain during this test can indicate patellar tendinopathy.
Resisted Isometric Knee Extension: With the patient seated and knee flexed to 90 degrees, apply a resistive force against their lower leg as they try to extend their knee. Pain or weakness may indicate a compromised patellar tendon.
Functional Limitations Assessment: Evaluate the patient’s ability to complete tasks that load the patellar tendon, like squatting or jumping. Note any limitations in range of motion, strength, or performance.
Imaging
In hamstring injury cases, X-rays rule out fractures and identify potential pathological processes. However, X-rays do not provide information about the actual tear itself.
The most effective imaging modality for visualizing a hamstring injury is Magnetic Resonance Imaging (MRI). Although Computed Tomography (CT) scans and ultrasound can also be useful, they are not as definitive as an MRI. The advantage of ultrasound lies in its lower cost.
In summary, when assessing hamstring injuries, various imaging techniques can be used:
X-rays: Useful for ruling out fractures and identifying potential pathological processes, but do not reveal information about the tear.
MRI: Offers the most detailed visualization of hamstring injuries, allowing for accurate assessment of the extent of the damage.
CT scans: While they can provide some insight into the injury, they are not as definitive as MRI.
Ultrasound: A lower-cost option that can still offer valuable information about the injury, but may not be as detailed as MRI.
Motion Specific Release
Early mobilization through manual therapy is essential for a fast hamstring recovery. This includes passive stretching and strengthening exercises within a pain-free range.
The rehabilitation process begins with isometric exercises—static muscle contractions without joint movement—progressing to isotonic exercises, which involve muscle contraction through a range of motion, like weightlifting.
In the following videos, Dr. Abelson, the creator of Motion Specific Release (MSR), demonstrates key treatment techniques for hamstring injuries. The approach is tailored to each patient’s unique needs.
Hamstring Release Procedures
In this video Dr. Abelson demonstrates effective hamstring release procedures. A hamstring restriction (or Injury grade 1 or 2) responds well to a combination of manual therapy and exercise.
Gluteus Maximus Protocol
Dr. Abelson, the Motion Specific Release (MSR) developer, demonstrates specific procedures to release restrictions in the gluteus maximus muscle to alleviate pain caused by muscle tightness from prolonged sitting, overuse, or excessive athletic performance. These procedures aim to restore normal muscle function, improve mobility and alleviate symptoms caused by tightness and restrictions. Strong, flexible, engaged gluteal muscles are critical to optimum performance and injury prevention.
Treatment Frequency for Hamstring Injuries
Treatment frequency is adjusted based on injury severity:
Grade 1 Tear (Mild):
Initial: 2 times per week for 1-2 weeks.
Total Appointments: 3-6, followed by 1-2 follow-up sessions as needed.
Transition: Early shift to self-management and home exercises.
Grade 2 Tear (Moderate):
Initial: Weekly to bi-weekly visits for 2-4 weeks.
Total Appointments: 3-8, followed by 1-2 follow-up sessions.
Progress: Gradual reduction in visits as symptoms improve and home exercises increase.
Grade 3 Tear (Severe - Post-Surgery):
Early Stage: Focus on pain management, swelling reduction, and immobilization.
Intermediate: Weight-bearing and strength-building.
Late Stage: Intense strength training and sport-specific exercises.
Return to Activity: Full recovery typically in 4-6 months.
Functional Hamstring Exercises
Training the hamstrings should mirror their real-life function, as they work in synergy with other muscles rather than in isolation. It's important to include both open and closed kinetic chain movements to reflect their role during activities like running. Closed-chain exercises mimic the Stance Phase, while open-chain exercises replicate the Swing Phase with their eccentric actions.
Here is a sample exercise protocol for hamstring injuries, tailored to each patient’s needs and injury status. The load on the hamstrings must be individualized to ensure safe and effective recovery.
The First Two to Three Weeks After the Injury
Objectives
Minimize atrophy and loss of strength.
Prevent motion loss.
Protect healing tissue.
Precautions
Avoid abnormal gait pattern development.
Avoid excessive active or passive lengthening of hamstring.
Rehabilitation Exercises
Ice – 2-3 times daily.
Stationary bike.
Isometric exercises.
Progressive hip strengthening.
Sciatic nerve flossing exercises.
Single leg balance exercises.
When to progress to the next phase
Normal gait patterns are regained without pain
The patient can perform pain-free isometric contraction (50%-75%) during prone knee flexion at 90 degrees. (9)
Weeks Three to Twelve After Injury
Objectives
Develop neuromuscular control to start developing functional movement patterns.
Regain hamstring range of motion and strength (pain-free).
Precautions
Avoid painful ROM, especially at end range.
Rehabilitation Exercises
Stationary bike (20 to 30 minutes).
Treadmill, pain-free speed and stride (moderate intensity).
Eccentrics hamstring loading exercises.
Sciatic nerve flossing and tensioning exercises.
Single leg stance on wobble board exercises.
Supine hamstring curls on Swiss ball exercises.
Walking band exercises.
Tantrums
Criteria for progression to the next phase
Resumption of full strength.
Pain-free forward and backward gait (moderate intensity).
Strength at 80% of uninjured leg.
Week Twelve Plus After Injury
Objectives
Improve neuromuscular control.
Normal concentric and eccentric strength through full AROM.
Pain and symptom-free during all activities.
Precautions
All exercises must be within a pain-free range of motion.
Rehabilitation Exercises
Treadmill moderate to high intensity as tolerated.
Dead-lift exercises.
Squat jump, single leg jump, lateral hop exercises.
Box jump exercises.
Eccentric lunge drop exercises.
Forward and backward skipping exercises.
Return to Sport Criteria
Full strength without pain with normal AROM.
Bilateral symmetry in knee flexion under load.
Full AROM (no pain).
Duplication of sport-specific movements without symptoms.
Why Choose Our Approach for Hamstring Injury Treatment
Our comprehensive approach to treating hamstring injuries achieves a 90% success rate in decreasing pain and restoring function. Here’s why our method stands out:
Established Expertise: Developed by Dr. Brian Abelson, the MSR methodology is backed by over 30 years of clinical experience and the successful treatment of thousands of patients, ensuring you receive the highest level of care.
Thorough Assessments: We perform detailed evaluations to uncover all contributing factors, including muscle imbalances, fascial restrictions, and nerve involvement, which are often linked to hamstring injuries.
Advanced MSR Procedures: Our Motion-Specific Release (MSR) techniques precisely target areas of muscle tension, scar tissue, and nerve entrapments, providing rapid and effective relief.
Customized Exercise Programs: We create individualized exercise plans that focus on restoring hamstring strength, flexibility, and function, supporting your journey back to full activity.
Logical, Evidence-Based Approach: Our treatment protocols combine manual therapy, targeted exercises, and progressive rehabilitation, ensuring a comprehensive, long-lasting solution.
With a proven 90% success rate in decreasing pain and increasing function, our patient-centered approach offers effective, long-term relief for hamstring injuries. Take the first step toward your recovery with confidence.
References
Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.
Arnason, A., Andersen, T. E., Holme, I., Engebretsen, L., & Bahr, R. (2008). Prevention of hamstring strains in elite soccer: an intervention study. Scandinavian Journal of Medicine & Science in Sports, 18(1), 40-48.
Askling, C., Karlsson, J., & Thorstensson, A. (2003). Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scandinavian Journal of Medicine & Science in Sports, 13(4), 244-250.
Brooks, J. H., Fuller, C. W., Kemp, S. P., & Reddin, D. B. (2006). Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. The American Journal of Sports Medicine, 34(8), 1297-1306.
Chumanov, E. S., Heiderscheit, B. C., & Thelen, D. G. (2011). 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.
Croisier, J. L., Ganteaume, S., Binet, J., Genty, M., & Ferret, J. M. (2008). Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. The American Journal of Sports Medicine, 36(8), 1469-1475.
Ekstrand, J., Hägglund, M., & Waldén, M. (2011). Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine, 45(7), 553-558.
Garrett, W. E. (1996). Muscle strain injuries: clinical and basic aspects. Medicine and Science in Sports and Exercise, 28(5), 509-520.
Guex, K., & Millet, G. P. (2013). Conceptual framework for strengthening exercises to prevent hamstring strains. Sports Medicine, 43(12), 1207-1215.
Heiderscheit, B. C., Hoerth, D. M., Chumanov, E. S., Swanson, S. C., Thelen, B. J., & Thelen, D. G. (2005). Identifying the time of occurrence of a hamstring strain injury during treadmill running: a case study. Clinical Biomechanics, 20(10), 1072-1078.
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., Shield, A. J., Williams, M. D., & Opar, D. A. (2017). The financial cost of hamstring strain injuries in the Australian Football League. British Journal of Sports Medicine, 51(1), 81-90.
Koulouris, G., & Connell, D. (2003). Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiology, 32(10), 582-589.
Malliaropoulos, N., Papacostas, E., Kiritsi, O., Papalada, A., Gougoulias, N., & Maffulli, N. (2010). Posterior thigh muscle injuries in elite track and field athletes. The American Journal of Sports Medicine, 38(9), 1813-1819.
Mendiguchia, J., & Brughelli, M. (2011). A return-to-sport algorithm for acute hamstring injuries. Physical Therapy in Sport, 12(1), 2-14.
Myers, T. W. (2014). Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Elsevier Health Sciences.
Opar, D. A., Williams, M. D., & Shield, A. J. (2012). Hamstring strain injuries: factors that lead to injury and re-injury. Sports Medicine, 42(3), 209-226.
Petersen, J., & Hölmich, P. (2005). Evidence based prevention of hamstring injuries in sport. British Journal of Sports Medicine, 39(6), 319-323.
Reiman, M. P., & Lorenz, D. S. (2011). Integration of strength and conditioning principles into a rehabilitation program. International Journal of Sports Physical Therapy, 6(3), 241-253.
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Silder, A., Sherry, M. A., Sanfilippo, J., Tuite, M. J., Hetzel, S. J., & Heiderscheit, B. C. (2013). Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 43(5), 284-299.
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DR. BRIAN ABELSON DC. - The Author
Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centered care and advancing treatment methods.
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