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Hamstring Injuries – Oh, The Agony!

Updated: 10 hours ago


Human Body in Motion Image

Annually, hamstring injuries impact countless athletes, especially those involved in sports requiring sudden bursts of speed, such as track and field, football, and tennis. These injuries are notorious for their slow recovery times and high recurrence rates.


In this blog, we delve into the diagnosis, treatment, and preventative exercises for hamstring injuries, complete with demonstration videos to provide a thorough and engaging learning experience.


The medical community remains divided on the precise causes of these injuries. Theories range from insufficient muscle strength and imbalances to inadequate warm-up routines. However, it is widely accepted that the majority of these injuries are due to internal factors, often referred to as 'Non-Contact Events.' Join us as we explore these aspects in detail and offer practical solutions to help you stay injury-free.


Article Index:


Introduction


Examination & Diagnosis


Treatment


Exercise


Conclusion & References

 


Hamstring Anatomy

Anatomy & Biomechanics


Hamstrings are exceptional muscles, spanning two key joints—the hip and the knee. This dual role makes them crucial for movement and highlights how injuries can affect your hips, lower back, knees, and overall gait.


The hamstrings consist of three muscles: the semitendinosus, semimembranosus, and biceps femoris. These muscles work together seamlessly, enabling actions like walking, jumping, and running.


What makes hamstring anatomy even more intricate is the fascial network, particularly the posterior line. Think of it as an interconnected web where each thread impacts the others. An injury in the hamstring can create ripples throughout this web, subtly disrupting the harmony of your movements.


Semitendinosus Muscle: A Key Player in Movement

The semitendinosus muscle originates from the lower pelvis (ischial tuberosity) and extends down to just below the inner knee (anterio-medial surface of the tibia) at the pes anserinus. Here, it joins with the gracilis and sartorius muscles—aptly nicknamed GST, after the Canadian sales tax (Something we don't celebrate, LOL).


Sharing its attachment point with the long head of the biceps femoris, the semitendinosus is crucial for knee stability. Inflammation of the bursa beneath these muscles often leads to knee pain.


Innervated by the tibial branch of the sciatic nerve (spinal levels L5 to S2), the semitendinosus is more than just a muscle. It, along with the sartorius, gracilis, semimembranosus, and gastrocnemius muscles, functions as a fascial tensor, providing stability to the medial side of the knee.


Semimembranosus Muscle Image

Semimembranosus Muscle

Originating from the same point as the semitendinosus in the lower pelvis (ischial tuberosity), the semimembranosus muscle travels down the back of the leg to attach at the posterior medial tibia below the knee.


This muscle is particularly susceptible to injury, especially among dancers, where stretching accidents are common.

Inflammation in this area can be misleading, often mimicking a medial meniscus injury. The tibial division of the sciatic nerve innervates this muscle, with nerve roots from spinal levels L5 to S2.


Additionally, the semimembranosus has a distinctive fascial feature—a small diagonal myofascial expansion that connects with the crural fascia, surrounding the medial head of the gastrocnemius.


Meniscus Injuries

Easing restrictions in the semimembranosus can significantly enhance meniscus function. The medial meniscus benefits from its fascial connection to the knee capsule, facilitating the retraction of the posterior horn. This intricate interplay exemplifies the delicate balance and finely tuned mechanics within our bodies.



Biceps Femoris Muscle: The Sprinter's Challenge

Often the site of hamstring injuries, particularly among sprinters, the biceps femoris is a crucial component of leg mechanics. This muscle, comprising both a long and short head, plays a multifaceted role.


The long head begins its journey at the lower pelvis (ischial tuberosity), sharing its origin with the semitendinosus and the sacrotuberous ligament. In contrast, the short head originates from the outer side of the leg (posterolateral femur), and both heads converge just below the knee (head of the fibula and lateral condyle of the tibia).


Interestingly, two distinct nerves innervate this muscle. The tibial division of the sciatic nerve powers the long head, while the common fibular (peroneal) division activates the short head, with nerve roots spanning from spinal levels L4 to S2.


The fascial connections of the biceps femoris highlight the body’s interconnectivity. Force transfers seamlessly from the biceps femoris to the sacrotuberous ligament, extending to the erector spinae thoracolumbar fascia. Numerous myofascial expansions into the deep leg fascia (crural fascia) illustrate how low back pain can often originate from hamstring issues.


Note: The Adductor Magnus, often seen as another hamstring, can perplexingly manifest as medial hamstring pain when injured.


 

Man Holding Straight Arm Plank Position

Functional Actions of the Hamstrings

The hamstring muscles serve multiple purposes: potent hip extensors (second only to the gluteus maximus muscle), knee flexors, medial and lateral rotators, and crucial knee stabilizers.


From a biomechanical standpoint, depending on leg position, the hamstrings can perform various actions:


  • All hamstring muscles extend the thigh at the hip joint, flex the leg at the knee, and tilt the pelvis in a posterior direction.

  • The semimembranosus and semitendinosus medially rotate the leg inward.

  • The biceps femoris laterally rotates the leg outward. Note: The short head of the biceps femoris does not directly participate in hip movement, as it does not cross the hip joint.


Some researchers have emphasized specific hamstring actions while considering other actions as secondary or less important functions. For instance, some studies have demonstrated that the hamstrings can act as knee flexors, but only in nonfunctional settings. As a result, only the so-called primary tasks (such as hamstring extension) are considered in standard training or rehabilitation routines.


Personally, I regard the hamstrings as a multifunctional, intricate structure filled with neurological receptors that communicate information to other muscles, enabling them to execute numerous additional tasks.


 

Runner

Running Related Functions

While running, your hamstrings serve as shock absorbers, force generators, and stabilizers.


Shock absorption occurs through the eccentric contraction of the hamstring muscles, which effectively absorbs the kinetic energy from foot impact. This shock absorption mechanism works best when the hamstrings remain strong, flexible, and free from adhesion or fibrosis resulting from previous injuries.


The hamstrings also play a crucial role in force generation, as they work synergistically with the gluteal muscles during hip extension.


The hamstrings provide stabilization while running in several ways:


  • They function as dynamic stabilizers by slowing down the forward movement of the shin bone (tibia) during knee extension, which is similar to the action of the anterior cruciate ligament (ACL). However, the ACL serves as a passive stabilizer.

  • After the initial ground contact, the hamstrings lengthen to stabilize the knee.

  • During the push-off phase with the foot, the hamstrings contract (together with the quadriceps) to provide propulsion.


 

Hamstring Tear Image

Hamstring Tears

Following an initial tear of the hamstring muscle, there is typically some bleeding, which may appear as a small to large bruise over the hamstrings.


The bleeding from a hamstring tear is succeeded by an inflammatory response, leading to an increase in fibroblast cells. Fibroblasts play a role in collagen synthesis (which provides the structural framework for all tissues), wound healing, and scar tissue formation.


As the inflammatory response to a hamstring injury begins to subside, scar tissue (fibrosis) can develop. Scar tissue is weak, inflexible, and prone to re-injury. It can decrease the range of motion and generate abnormal movement patterns. This fibrotic tissue and the resulting imbalances contribute to the high rate of re-occurrence of hamstring injuries.


From a pain perspective, most hamstring injuries heal over time. In reality, these injuries often do not fully recover but become the starting point for a series of other injuries caused by the residual tissue alteration and the resulting biomechanical compensations that this tissue creates.

Grading a Hamstring Injury

Assessing the severity of a hamstring injury is crucial to determine appropriate treatments. Hamstring strains are graded from 1 to 3, with 3 being the most severe.


Hamstring - Grade 1 Strain:

  • The affected person can still walk, albeit with some difficulty.

  • There may be minor swelling, stiffness, and pain.

  • In a Grade 1 Strain, only minor tearing of the hamstring muscle occurs. Comparing a muscle to a piece of tissue paper, there are only minor tears in a Grade 1 injury.

  • There should be only minor pain during hamstring resistance testing, with no significant loss of strength.


Hamstring - Grade 2 Strain:

  • The injured person may have difficulty walking and could experience considerable pain.

  • There may be swelling with some degree of bruising.

  • In a Grade 2 Strain, moderate tearing of the muscle occurs. Using the tissue paper analogy, there would be a significant number of tears compared to a Grade 1 Sprain.

  • The patient may not be able to straighten their knee, with considerable pain during hamstring resistance testing.


Hamstring - Grade 3 Strain:

  • A Grade 3 Strain involves severe or complete tearing of the muscle. Using the tissue paper analogy, the tissue could be torn into two pieces. This type of strain might require surgical intervention to reattach the muscle.

  • Any action that causes the hamstrings to contract will result in severe pain.

  • Walking will be extremely difficult; the injured person will need crutches, and there could be a complete loss of function.


 

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.



Using an MRI Machine For Imaging

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:


  1. X-rays: Useful for ruling out fractures and identifying potential pathological processes, but do not reveal information about the tear.

  2. MRI: Offers the most detailed visualization of hamstring injuries, allowing for accurate assessment of the extent of the damage.

  3. CT scans: While they can provide some insight into the injury, they are not as definitive as MRI.

  4. Ultrasound: A lower-cost option that can still offer valuable information about the injury, but may not be as detailed as MRI.


 

Performing Manual Therapy on the Hamstrings

Motion Specific Release

Prompt mobilization with manual therapy of the injured hamstring is crucial for a swift recovery. This can involve passive stretching and strengthening exercises within a pain-free range of motion.


Initially, isometric strengthening exercises are suggested, followed by a gradual progression to isotonic exercises. Isometric exercises involve static muscle contractions without noticeable joint angle movement. In contrast, isotonic exercises maintain constant tension while the muscle's length changes, as in weightlifting.


In the following videos, Dr. Abelson, the developer of Motion Specific Release (MSR) demonstrates some of the treatment procedures that are commonly used in treating hamstring injuries. Which procedures are used will depend on the specific case.


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


The frequency of manual treatment is tailored to the severity of the injury. Mild injuries often require less intensive therapy, allowing for an early transition to self-managed care. Moderate injuries demand a more structured approach to navigate through healing phases and initiate rehabilitation. Post-surgical rehabilitation necessitate intensive, prolonged therapy to ensure optimal recovery, manage scar tissue, and restore function while preventing secondary complications. Each injury grade thus dictates a distinct therapy approach and frequency, aligning with individualized therapeutic needs for optimal healing and functionality restoration.



Grade 1 Tear (Mild):

  • Initial: 2 times per week

  • Duration: 1-2 weeks, transitioning to home exercises and self-management

  • Approximate Total Appointments: A total of 3 to 6 appointments, followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 2 Tear (Moderate):

  • Initial: Weekly to bi-weekly visits

  • Duration: 2-4 weeks, then tapering off as symptoms improve and home exercises progress

  • Approximate Total Appointments: 3 to 8 appointments, comprising weekly to bi-weekly visits over a span of 2-4 weeks, followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 3 Tear (Severe - Requires Surgery):


When surgery is required, post-operative rehabilitation begins with managing pain and swelling and immobilizing the ankle. Early rehabilitation introduces weight-bearing and basic exercises. Intermediate rehabilitation advances strengthening and normalizes walking. Late rehabilitation intensifies strength training and introduces sport-specific exercises. Finally, a gradual return to full activities, usually within 4 to 6 months.


 

Woman Performing Deadlift Exercise

Functional Hamstring Exercises

It is crucial to train the hamstrings in a manner that reflects their function in real-life activities. The hamstrings work synergistically with multiple muscles and do not act as isolated muscles. For instance, hamstrings should be trained in both open and closed kinetic chain movements to simulate hamstring muscle function during running. Closed-chain exercises can replicate the Stance Phase of running, while open-chain exercises can simulate the Swing Phase of running (eccentric actions).


The following presents a typical exercise protocol that may be used to address hamstring injuries. Of course, this would be customized to meet each patient's specific needs and injury status. The load placed on the hamstrings must be appropriate for the individual.


Swimmer in The  Pool

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)


Running on a Tread Mill

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.


Woman Performing Box Jump Exercises

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.


 


Woman Performing Deadlifts

Conclusion


Hamstring injuries present a significant challenge to athletes across various sports, particularly those requiring explosive speed and agility. Throughout this article, we have thoroughly examined the multifaceted nature of hamstring injuries, emphasizing the importance of accurate diagnosis, effective treatment, and preventative measures. By understanding the intricate anatomy and biomechanics of the hamstrings, we can better appreciate the complexity of these injuries and the subsequent impact on an athlete's performance and recovery. Our comprehensive exploration included practical demonstrations and evidence-based exercises designed to facilitate optimal healing and reduce recurrence.


In conclusion, staying informed and proactive is key to managing and preventing hamstring injuries. While the precise causes of these injuries remain a topic of debate within the medical community, the consensus points towards internal factors and non-contact events as primary contributors. By integrating tailored diagnostic approaches, therapeutic interventions, and targeted exercises, athletes can significantly enhance their recovery process and minimize the risk of future injuries. We hope this article serves as a valuable resource for athletes, coaches, and healthcare professionals alike, empowering them to make informed decisions and maintain peak physical condition.


 

References

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. Garrett, W. E. (1996). Muscle strain injuries: clinical and basic aspects. Medicine and Science in Sports and Exercise, 28(5), 509-520.

  9. Guex, K., & Millet, G. P. (2013). Conceptual framework for strengthening exercises to prevent hamstring strains. Sports Medicine, 43(12), 1207-1215.

  10. 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.

  11. 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.

  12. 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.

  13. Koulouris, G., & Connell, D. (2003). Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiology, 32(10), 582-589.

  14. 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.

  15. Mendiguchia, J., & Brughelli, M. (2011). A return-to-sport algorithm for acute hamstring injuries. Physical Therapy in Sport, 12(1), 2-14.

  16. Myers, T. W. (2014). Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Elsevier Health Sciences.

  17. 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.

  18. Petersen, J., & Hölmich, P. (2005). Evidence based prevention of hamstring injuries in sport. British Journal of Sports Medicine, 39(6), 319-323.

  19. 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.

  20. Schleip, R., & Müller, D. G. (2013). Training principles for fascial connective tissues: Scientific foundation and suggested practical applications. Journal of Bodywork and Movement Therapies, 17(1), 103-115.

  21. 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.

  22. Worrell, T. W. (1994). Factors associated with hamstring injuries. An approach to treatment and preventative measures. Sports Medicine, 17(5), 338-345.


 
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DR. BRIAN ABELSON DC. - The Author


Photo of Dr. Brian Abelson

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.



 


MSR Instructor Mike Burton Smiling

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