Hamstring injuries are common in sports like football. There are two main types - type 1 involves the long head of biceps femoris while type 2 occurs near the ischial tuberosity. Rehabilitation should begin with RICE and focus on eccentric strengthening, stretching, and ensuring adequate hamstring strength before returning to play, which is typically once the athlete can run without pain. Recurrence risk is high if the athlete returns too soon.

1. S
Hamstring injuries in sport
Fadi Hassan
Hull York Medical School

2. • Anatomy
• Epidemiology
• Mechanism of injury
• Clinical features – History taking
• Examination and imaging
• Types of strain and grading
• Risk factors
• Management – Rehabilitation and conditioning
• Return to play
• Psychological impact
• Prevention
Overview

3. Anatomy
Hamstring part
of adductor
magnus Long head of
biceps femoris
Short head of
biceps femoris
Semitendinosus
Semimembranosus
Functions
• Hip extension
• Knee flexion
• Internal rotation of the hip when the knee is flexed

4. Anatomy
Sciatic nerve
Tibial nerve Common
fibular nerve
• Long head of biceps femoris and semitindonsus and
semimembranosus cross both hip and knee joints and are
innervated by tibial part of the sciatic nerve.
• Short head of BF cross only knee joint and is innervated by
the common fibular part of the sciatic nerve

5. Biceps Femoris
Origin:
Ischial Tuberosity (L - MFCT)
lower ½ linea aspera of femur (S)
Insertion:
Lateral condyle of tibia (L)
Head of fibula(S)
Innervation: Tibial part of sciatic nerve
Semitendinosus
Origin: Ischial tuberosity (medial facet CT)
Insertion: (Upper) medial condyle
Innervation: Tibial part of sciatic nerve
Semimembranosus
Origin: Ischial tuberosity (LF)
Insertion: Posterior of medial epicondyle of tibia
Innervation: Tibial part of sciatic nerve

6. Epidemiology
Figures for
- British football
- Australian football
- Recurrence rate
- Specific strains

7. • British football
• Hamstring strains make up 12% of injuries
• That’s 5 injuries per club per season
• Average injury causes the player to miss 2-4 matches
• Australian football
• 15% of all injuries
• Recurrence rate
• 12% in british football
• 34% in australian football
• Epidemiology of specific strains
• Biceps femoris strain (76-87%)
• Semimembranosus – uncommon
• Semitendinosus - rare

8. Mechanism of injury and
clinical features
“it comes on suddenly like a cyclist
getting a puncture. It was like
someone getting up and slapping me
around the face” – Derek Redmond
(Barcelona 1992)

9. Mechanism
• Muscle strain to large muscle group is the result of substantial
force and it may be related to an eccentric contraction due to high-
speed sprinting for example (Type I) or it may be associated with
an excessive stretching (Type II)

10. Clinical presentation
• A disabling pain with Sudden onset (moderate-severe) and marked reduction in
strength and ability to stretch the muscle.
• Pain against resistance and focal tenderness
• Haematoma and bruising
• May have abnormal signs on ultrasound/MRI.
• Always leads to the player leaving the field holding the back of his/her thigh.
• Gluteal pain

11. History
• Can they remember when/why the injury happened
• Yes – Strain, fascial/neural trauma
• No – Overuse, referred pain
• Site of pain and radiation
• Presence of neurological symptomsProgress since injury – to assess the severity
• Ability to walk without pain within 24 hours after the injury
• Yes – better prognosis
• No – longer rehabilitation time (>3wks to RTT)
• Ask if the athlete has adapted any change in his/her training regime recently.
• Ask about any fluctuations in activity level (overtraining?)
• Aggravating factors:
• Incident related – include that in rehabilitation program (acceleration)
• Non-incident related – modification/prevention
• Relation to sports – Helps in your differential diagnosis
• Sudden onset – Mechanical
• Increase with activity – inflammation
• Start with minimal pain then builds up with activity (not severe) – think of vascular or neurological causes
• Is it a recurrence injury? Have they had any problems with hamstrings in the past?

12. Differential Diagnoses of posterior thigh pain
• DDx: tearing of neural structures, fascial strains, referred pain, tendinopathy, bursitis,
fibrous adhesions, nerve entrapment, adductor magnus strain, myositis ossificans.
• It is crucial to determine the origin of the pain as this will direct how you manage the
injury.
• Importance of examination
• Referred pain vs low grade strain  both show no evidence on MRI, making it
hard to establish the origin of the pain
• Efficient history and thorough examination will be crucial in this case.
• Monitoring the progress of the injury will determine the nature of the injury
• No MRI evidence of strain  chronic posterior thigh pain with no response
to management and rehabilitation  more likely to be referred pain.

13. Examination & Imaging
Examination and special tests
Importance of imaging and
what can be seen on them

14. Examination
• Inspect for bruising, muscle wasting or swelling
• Standing, walking, lying prone
• Palpation
• Hamstring muscles, ischial tuberosity, gluteal muscles (trigger points/taut bands)
• Active movements:
• Lumbar movements
• Hip extension
• Knee flexion
• Active knee extension and hip flexion
• Hip is flexed to 90 degrees with the knee initially flexed at 90 too and then the knee is
slowly extended till pain is felt and then to the end of the range.
• Passive movements
• Hamstring muscle stretch: leg raised to the point where pain is felt, and to the end of ROM.
• Resisted movements
• Knee flexion
• Hip extension

15. Examination - Tests
• Functional tests
• Running
• Kicking
• Sprint start
• Slump test
• differentiates between hamstring muscle injuries and referred pain
from the lumbar spine.
• Helps to diagnose nerve root injury and is considered positive if pain
exists.
• Patient seated at the edge of the bed (90 degrees), hands behind the
back
• It contains multiple components that include active thoracic and
lumbar flexion  apply passive pressure to maintain that position.
• Active head flexion  actively extend the knee  foot dorsiflexion
• Negative in hamstring strain
• Lumbar spine examination

16. Imaging
• MRI: can show edema in hamstring region as well as tears in the soft tissue. It is non-
invasive and provides high resolution images. It can easily identify the type of tissue
involved and the location of the injury which helps in predicting prognosis.
• Image below: Type I (Left), Type II (Right)
• Ultrasound: hypoechoic areas (less echogenic than other areas  darker than normal)
• CT
• Injury location can be determined on palpation (maximal pain point) and by MRI during
the first 2 weeks after injury

17. Grading and types

18. Types
• Type I (more common)
• Caused by a heavy load on the hamstrings (during high-speed running, kicking, jumping)
• Usually involves the long head of biceps femoris (more commonly Proximal MTJ)
• Causes a marked acute decline in function but usually require a shorter rehabilitation time than
type II
• Type II
• During movements leading to extensive lengthening of the hamstrings during hip flexion such
as high kicking, slide tackle, sagittal split which may or may not occur at slow speed.
• Usually located close to the ischial tuberosity and involves the proximal free tendon of SM.
• Less acute limitation, but their rehabilitation period is likely to be longer.
• Injury location can be determined on palpation (maximal pain point) and by MRI during the first 2
weeks after injury.
• THE CLOSER THE SITE OF INJURY TO THE ISCHIAL TUBEROSITY, THE LONGER THE
REHABILITATION TIME.

19. Figure 1: Schematic drawing showing the six
different regions used when analysing the injury
location and tissues involved. 1. proximal
tendon (PT) 2. proximal muscle-tendon junction
(PMTJ) 3. proximal muscle-belly (PMB) , 4.
distal muscle-tendon junction (DMTJ) 5. distal
muscle-belly (DMB)
Figure 2: Distance between the most cranial pole of the
edema and the ischial tuberosity is shown as the double-
headed arrow in 2 different types of injury. The edema starts
caudal to tuber in the left and cranial to tuber in the right MR-
image.

20. Grading
• Grade 1
• Discomfort in the back of the thigh and inability to operate at full speed
• Can walk
• Little swelling
• Grade 2
• Gait will be affected and they will most likely end up limping off the pitch
• Sudden pain which gets worse on activity or on resisted movements
• Sore to touch
• Grade 3
• Tear involving half/full muscle
• Inability to walk and may need crutches
• Severe pain and weakness
• Swelling and bruising are both noticeable

21. Risk factors

22. Risk Factors
• Intrinsic (person-related)
• Age
• Past history
• Presence of scar tissue  high rates of localized tissue strains in the adjacent muscle
fibers  further injury
• Hamstring strength
• Reduced  predisposition to strains
• Reduced quadriceps flexibility
• Poor lower limb proprioception
• Running style (Michael Owen with his upper body flexed/leaning forward – putting a higher
load on the hamstrings)
• Extrinsic (environment-related)
• Fatigue
• Player position
• GK have significantly lower risk than outfield players
• Wide players at risk due to high intensity of their acceleration
• Recurrence risk factors
• Size of previous lesions: Larger lesions  higher chance of recurrence.
• All the above

23. Management and
rehabilitation
“Rehabilitation programs
should never be a “recipe”.
Each case should be treated
on its merits” – Peter Brukner

24. Management in the first 24 hours
The first few days are crucial in hamstring injuries. Management here aims to facilitate myofiber
regeneration and to minimize fibrosis in order to reduce the chance of recurrence
• RICE
• Rest, Ice, Compression and Elevation
• Applying ice for 10-15 minutes using cold packs, every 3-4 hours (for the first few days).
• Compression with an elastic bandage or tubigrip stockings.
• Muscle activation
• Frequent low-grade + pain-free muscle contraction regimes immediately after injury
• Angiogenesis and expansion of existing vascularity  increase delivery of muscle-derived
stem cells  myofiber regeneration and accelerated repair
• There’s a great american paper on muscle injury and repair. I will post the link at the end of
this presentation.
• Medical therapies
• NSAIDs (evidence?)
• Simple analgesics
• Growth factors to accelerate healing (PRP and autologous blood)
• Injections of traumeel S and Actovegin immediately after the injury and again at days 2 and 4
post-injury to the area of injury  enhance aerobic oxidation.

25. Rehabilitation
• Start once the patient can walk without pain (4-6 days)
• Light jogging  increase intensity gradually  pain should always be the indicator rather than
progressing according to a time-frame as this period is very dangerous (weak tissue  high risk of re-
injury)
• Stretching:
• Increases rate of recovery and minimizes long term loss of ROM by minimizing the scarring
formation
• Hip flexors: tight  high risk of hamstring strains

26. Rehabilitation – Soft tissue treatment
• Soft tissue treatment and mobilization
• Lumbar spine, sacroiliac, and buttock regions
• Stretch with bent knee and then add a little bit of cervical flexion
• Digital ischaemic pressure and sustained myofascial tension
• Gently first and then more vigorously
• Hand or elbow kept on the hamstrings, release is performed by
PASSIVELY extending the knee
• Massage along the muscle may assist in scar reorganization
• Elbow ischaemic pressure with the tissue on stretch and the muscle
contracting (side-lying position) gluteal abnormalities

27. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
a. Standing single-leg hamstring catches with theraband

28. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
b. Single-leg bridge catch

29. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
C. Single-leg ball rollouts

30. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
D. Single –leg deadlifts with dumb bell

31. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
E. Yo-yo (Eccentric hamstring curls)
If the video doesn’t
work just look it up
on YouTube

32. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
F. Bridge walk-outs
If the video doesn’t
work just look it up
on YouTube

33. Rehabilitation – Strengthening hamstring mucsles
• Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)
G. Nordic drops: develops hamstring strength and efficient in preventing recurrence of injury
If the video doesn’t
work just look it up
on YouTube

34. Rehabilitation – What else can you do?
• Strengthening hamstring synergists
• If they’re weak  overload on hamstring  injury or re-injury
• Gluteal muscles and adductor magnus.
• One-legged bridging, squats and split squats (one-leg).
• Neuromuscular control
• Lumbopelvic stability: single leg balance on a ball
• Single-leg windmil touches (shown below)
• Balance
• Core strength
• Extreme stretch
• Osteopathic techniques
• Hydroworx

35. Osteopathic techniques
• Muscle energy technique (MET)
• Osteopathic manipulative treatment for decreased ROM and muscular dysfunction.
• The lower extremity is taken to a point of tension in the posterior muscles and held there
• The patient is then asked to push the leg against the shoulder for 6 seconds
• After relaxing, a new motion barrier is found at a greater degree of flexion
• The process is repeated usually 3 times to achieve a state of enhanced stretch
• The resistance by the patient should always be no greater than 25%

36. Osteopathic techniques
• Kneading massage
• Swedish massage tradition that seems to be very effective for sore muscles by manipulating and
loosening the muscle fibers.
• With the hands apply a firm, circular kneading motion by pulling half the muscle towards you with
the fingers of one hand and pushing half the muscle away with the thumb of the other hand
• Then reverse to manipulate the muscle in the other direction
• Try to cover as much muscle as possible for five minutes approximately.
PM PL

37. Osteopathic techniques
• Iliotibial band
• With the patient lying supine, locate the tightest point in the tract along the lateral aspect of the thigh.
Using the pad of your dominant thumb, reinforced by your other thumb, press medially and posteriorly
on this point. Maintain this balanced pressure until a release occurs.
• Myofascial release of hip adductors
• Locate the specific muscle in spasm on the medial aspect
• With the pad of the thumb, push towards the femur superiorly and laterally  maintain that until the
muscle relaxes

38. Kinesio taping
• Benefits?
• Improves circulation
• Support muscle
• Helps healing and prevent muscle injury
• Activate endogenous analgesic system
• Usually lasts 3-5 days and it is sweat and water proof.
• gently lifts the layer of skin and attached tissue covering a muscle (fascia) so
that blood and other body fluids (blood and lymphatics) can move freely in and
around the muscle.
• Kinesio vs Old-school taping methods
• Old school taping: They’re efficient in preventing further strain by
immobilizing the joint BUT they tend to block or partially block the
circulation  slowing healing processes.
• Kinesio allows full movement but they stabilize the muscle at the same
time  prevent over contraction and over extension

39. Return to play
Incidence of recurrence is too
high (1/3 with greatest risk
being at the first 2 weeks on
RTT)

40. Return to competition
• Running could start when the sportsperson is comfortable running at 50% intensity. With the right
program, the sportsperson can slowly return to sport (with sufficient rest to assess the effects of the
load).
• Return to sport criteria
• Absence of clinical signs with normal ROM
• Successful completion of running program (20m time comparable to previous time when
uninjured)
• Successful completion of appropriate rehabilitation exercises
• Successful completion of at least 2 training sessions at maximal exertion
• Game time can be minimized on the first few games, then gradually increased to full time in order to
prevent recurrence and fatigue.
• Game time can be minimized on the first few games, then gradually increased to full time in order to
prevent recurrence and fatigue.
• In mild hamstring strain, this phase would be achieved in 12-18 days and most cases should resolve
within 25 days (apart from severe strains and ruptures).
• More efficient rehabilitation regimes are more focused towards return to COMPETITION and
PERFORMANCE rather than just return to training. The muscles might seem “OK” on an MRI but that
does not always mean the athlete is ready to return for training or for high intensity workouts

41. Return to competition
• Askling’s H-test and dynamic isokinetic strength testing
• Recent test developed by a Swedish doctor
• Research showed it can detect problems with hamstring muscles that are not picked up by examination.
The muscle might function normally but sometimes it can still have micro-tears that would still
compromise its strength.
• So this test involves flexing all the lower extremity joints by applying a brace and the patient would then
be asked to perform leg raises repeatedly and compare that to the other leg. resistance can be applied
• Any discomfort signals to a potential problem.
• Loading – How far can we go?
• Re-injury often happens due to insufficient rehabilitation and
conditioning
• Poor rehabilitation (by maybe not putting enough load) → Strength
remains untested → the player starts in a competitive game in
which the load and volume of work is a lot higher than training
sessions → re-injury.

42. Complications and
psychological effects
The main complication is often
re-injury and spending a very
long time out of the game
which might lead to further
problems.
I will discuss the psychological
effects of the injury and re-
injury

43. Psychological effects
• Frustration, denial, anger and even depression
• Fear that it might come back  affecting the way you play
• Concerns about losing place in first team
• If there’s a big game soon, an injury like hamstring strain could leave a serious
psychological effects
• Re-injury
• Being on the bench  depression
• Sense of injustice  Why me?
• Impact that it could have on the team
• Losing an important player could affect the team’s confidence on the day
• Stress vs hamstring strain
• Some studies suggest stress and anxiety before the game could lead to
hamstring strains
• Mental pressure  increased muscular tension  negatively affects
physical performance  high risk of injury

44. Prevention

45. Prevention
• Isometric Muscle Voluntary Contraction (MVC): post-games for injury-prone players
• Any reduction in MVC  warning sign  training load is reduced
• Useful particularly in those who already had this injury before
• Sufficient rest between training sessions and games
• Nordic drops:
• Proven by few studies to decrease the incidence of new and recurrence cases
• Proprioception and balance exercises
• 3 year German study involving 24 elite female football players  from 22.4 to 8.2/1000
hours
• The more minutes of balance training, the lower the rate of hamstring injuries
• Soft tissue therapy: Mobilization and manipulation.
• Activity modification for those at risk
• FIFA 11+
• A complete warm-up programme implemented by the F-MARC/FIFA to reduce injuries.
• Teams that performed the “FIFA 11+ ” at least twice a week had 30-50% fewer injured
players.
• Implemented by Real Madrid, Barcelona,Olympique Lyonnais, Spain and Japan.
• More teams have started to implement this recently.
• You can download the programme from this link:
• http://f-marc.com/11plus/home/

46. Evidence Based Medicine
I recommend you reading the following papers, they go into fine details regarding muscle injury –
hamstrings specifically.
S Muscle injuries (Biology and treatment) – The American journal of sports medicine
S Hamstring muscle strain – Carl Askling
S HAMSTRING INJURY REHABILITATION AND PREVENTION OF REINJURY USING
LENGTHENED STATE ECCENTRIC TRAINING: A NEW CONCEPT
S Recurrent hamstring muscle injury: applying the limited evidence in the professional football
setting with a seven-point programme – Peter Brukner

47. S
Thank You!
Fadi Hassan
hyfh1@hyms.ac.uk