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HAMSTRING INJURY RECOVERY GUIDE
Hamstring strains & tears are extremely common in a wide variety of sports. These injuries are often very debilitating and even worse, once a strain has been sustained the risk of re-injury greatly increases. These injuries are more prevalent in hip flexion meaning it is more common in sports such as hockey, rugby, cycling and rowing. However it can be exacerbated by activities such as sprinting, deadlifts, lunges and squats. Prolonged sitting & long driving can also exacerbate an injury. In runners, gait mechanics are crucial to flare-ups and rehabilitation is often complex.
Click on the boxes below to find the answer to your Hamstring Injury questions.
The hamstrings are a group of 3 muscles located in the posterior of the thigh, between the hip and the knee. They consist of the semitendinosus, semimembranosus and biceps femoris. The hamstring muscles run from the “sitting bones” (ischial tuberosity) at the base of the pelvis and finish behind the knee, attaching to the top of the fibula on the outside of the knee (bicep femoris) and tibia on the inside of the knee (semimembranosus, semitendinosus).
The main job of the hamstrings is to bend the knee, as well as helping to decelerate the knee during extension in activities such as walking and running. As the hamstrings cross both the hip and the knee, they also have role in extending the hip.
The main common origin of the hamstring complex is the ischial tuberosity. This is commonly called the seat bone and can be felt as a hard spot near the gluteal folds.
From here the hamstrings split into 3 muscle bundles. One passes towards the outside of the knee (biceps femoris) the other two head towards the inside of the knee (semimembranosus and semitendinosus).
The lateral hamstrings insert into the lateral tibia, lateral collateral ligament and fibular head.
The medial hamstrings insert into the superior and medial tibial border. They blend with the tendon of the gracillis muscle to become the pes anserinus tendon.
There may also be a bursa present at this location.
The hamstring is a prime mover for all activities which include flexion (bending) of the knee and extension (straightening) of the hip. It is also responsible for braking a knee or hip movement in the opposite direction.
Activities which depend on the hamstring to do both of these functions include walking, running, squatting, bending, lifting, kicking and rowing to name a few. If you combine some of these activities such as running and bending, or picking a ball up from the ground while running, the intensity demanded of the hamstring increases dramatically.
The hamstring is also responsible for pelvic control. It pulls the pelvis into posterior rotation and facilitates anterior rotation by not activating. This has great importance for pelvic stability during static and dynamic activities.
The feeling of hamstring tightness is ambiguous and does not necessarily mean the hamstring’s physical and mechanical properties are under excess tension or shortened. It is possible to have one without the other.
It could be one of several different complaints which may include the following:
There has been a loss of range of motion around the hip joint, knee joint and lumbar spine.
End of range of motion around joints is restricted and requires extra effort to achieve this.
The movement around the joints may be fine but the hamstring just never feels relaxed.
The movement may be fine around the joints and the hamstring feels relaxed, but there is a mild pain in the hamstring, and is perceived as being “tight”.
Depending on what hamstring injury you have, pain can either occur in the muscle or the tendon. There are 3 main muscles that make up your hamstring, therefore depending on which hamstring muscle you have injured this will indicate the area of pain. Common areas of pain are centre of the muscle belly, where the muscle meets the tendon, where the tendon inserts into the bone, such as your sitting bone or tendon pain above the back of the knee.
Acute Hamstring injuries such as a tear are generally due to high velocity, intensive load being placed on the muscle. These also occur as a result of weakened or unconditioned muscles around the hip/pelvis and quads which can in turn put more strain through the Hamstring as it tries to compensate.
Posture-wise you may be more at risk if you stand and move with your pelvis tipping forwards, or slumping back - this can put the Hamstrings at a disadvantage mechanically and may render them in a long, weak and or tight position.
There are two distinct types of Hamstring injuries, therefore it depends on the situation and the Sport undertaken as to which hamstring muscle can become injured;
Type 1 Hamstring strains occur during high-speed running. This is the more common type of Hamstring strain, and usually affects the Biceps Femoris, one of the parts of the Hamstring muscle, which meets the tendon near your Ischial Tuberosity (sit bone). These injuries are often more severe in their initial presentation, but recover much more quickly.
Type 2 Hamstring strains occur during movements leading to extensive lengthening of the Hamstrings when the Hip is also flexed, such as high-kicking, sliding tackle, and front-split – these injuries may occur at slow speeds, such as in gymnasts and ballet dancers, and can take much longer to rehabilitate.
Mild hamstring strains (grade 1) will usually cause sudden pain and tenderness the back of your thigh. It may be painful to move your leg, but the strength of the muscle shouldn't be affected.
Partial hamstring tears (grade 2) are usually more painful and tender. There may also be some swelling and bruising at the back of your thigh and you may have lost some strength in your leg.
Severe hamstring tears (grade 3) will usually be very painful, tender, swollen and bruised. There may have been a "popping" sensation at the time of the injury and you'll be unable to use the affected leg.
Early management following a hamstring tear is crucial in determining your recovery time frame. The hamstring may bleed for several days. A RICE (rest, ice, compression, elevation) regime should be incorporated, whilst stretching should be avoided in this early period.
As soon as possible, pain permitting, exercise should commence to strengthen the hamstring again whilst also maintaining strength and flexibility of the unaffected musculature (eg glutes, calf). The PATS (progressive agility and trunk stabilisation) program is an example of an exercise program that studies have shown improves return to sport times and reduces re-injury rates. Hamstring strengthening programs should progressively increase in intensity and incorporate different speeds and movements specific to your sport. When the hamstring is strong enough, you may return to training but you should successfully complete one week of full training prior to match play.
If the tendon, as opposed to the muscle, of the hamstring is thought to be the injured then you should follow a tendinopathy protocol. If you suffer from recurrent hamstring injuries then you may have a 'driver' from another area such as nerve tension which should be addressed using a neural mobilisation regime. To get a rehabilitation program tailored to your injury and needs, see an experienced physiotherapist.
A grading system is used to determine the extent of a hamstring injury:
Grade 1 = a mild strain - few muscle fibres torn, minimal/no loss of muscle strength, and minimal pain on contraction. May present with some mild swelling and bruising.
Grade 2 = moderate strain/tear - significant number of fibres torn, muscle weakness and significant pain on contraction of that muscle. Usually presents with significant bruising and swelling. Please note this can take a few days to appear particularly if the tear is very deep.
Grade 3 = Complete tear - this means the muscle has been torn completely with a severe weakness/loss of function and is often pain free on resisted testing. This injury presents with signficant swelling and bruising.
Hamstring cramping, especially cramps associated with a physical performance, is common and can be a painful and frustrating experience. However, despite their prevalence the exact cause is still unknown.
There is likely to be a combination of contributing factors though muscle fatigue seems the most likely. Muscle fatigue, or overload, may result from insufficient training/preparation, environmental conditions, intensity and duration of activity. The result of this overload is an increase in the excitability of the motor neuron, which may lead to cramping.
Several other theories, including the serum electrolyte theory, where it is thought that decreased electrolytes (e.g. Sodium, magnesium, potassium) caused by excess sweating (or overhydration) are being explored further by leading medical and sports scientists.There is a lot of potential in these studies for explaining and perhaps helping to prevent cramping.
The best that a person can do to prevent exercise induced cramps, is to ensure they prepare adequately for an athletic performance. This includes completing proper training, warm up, having the correct equipment and having an adequate diet and hydration.
Stopping a future hamstring injury is impossible, however, minimizing the likelihood of injury can be achieved through specific hamstring exercises.
These exercises should aim to achieve ‘strong and long/flexible’ hamstrings in comparison to ‘weak and short/tight’.
Whilst stretching exercises can help achieve ‘long’ hamstrings, certain strengthening exercises are more effective. Think ‘strengthen to lengthen.’
The godfather of hamstring strengthening is the Nordic Hamstring Exercise. (See below).
According to at least half a dozen recent studies, almost two-thirds of hamstring injuries might be prevented by practicing the simple steps below.
Steps: 1) Grab a partner or lock your ankles under a stable bar. Place your knees on a padded surface
2) Maintaining a straight torso (no bending at the hips or arching lower back), slowly lower yourself forward towards the ground.
3) Maintain position for 5 seconds and then break your fall onto the ground by placing your hands out in front of you. (Similar to a push-up position)
4) Repeat 10 times.
As the hamstring muscles are knee flexors the aim of a hamstring curl is to strengthen these muscles by bending your knee.
Lying on your front with foot pointing down over the edge of a couch/table/bed, the athlete fully bends the knee – trying to touch your buttock with your heel.
Provided this is pain free, a resistance band or ankle weights can be used to increase difficulty.
Lying leg curls are the most direct exercise in isolating pure hamstring activity and strength. Other exercises such as Romanian deadlift or hyperextension exercises are hinging movements at the waist, working the hamstrings via the hip joint. That makes it more of a stretch exercise. The lying leg curl is more of a true and direct hamstring contraction exercise.
The lying leg curl is difficult to load unless you have access to a machine in a gym setting. The movement is not very functional in a sense that it is not a movement that happens naturally during the course of daily living (vs squat or deadlift).