Hamstring Injuries in Athletes

Hamstring Injuries are prevalent injuries across sports. They can sideline athletes for weeks or months, causing frustration and loss of identity. This blog provides critical information for athletes seeking to prevent hamstring injuries, rehabilitate strains, and return to sport safely.

Hamstring Anatomy and Function

The hamstrings are a group of three posterior thigh muscles: semitendinosus, semimembranosus, and biceps femoris. They originate at the pelvis and intersect two joints behind the knee. This complex anatomy allows them to flex the knee and extend the hip, which is critical for sports like sprinting, jumping, kicking, and changing direction.

However, the multi-joint design also increases injury risk. The hamstrings are under constant tension during dynamic athletic maneuvers. Explosive contractions at long muscle lengths in a stretched position create high tensile strain. This makes them vulnerable to acute strains as well as overuse injuries.

Read, Why Are My Hamstrings So Tight and How Can I Get Relief? for more detailed information on the anatomy of hamstrings.

Causes and Risk Factors for Hamstring Injuries

Hamstring injuries have multifactorial causes and a unique set of risk factors:

Overuse

Repetitive strain from sprinting, accelerating/decelerating, and explosive jumps in sports like football, soccer, rugby, and basketball gradually fatigues and damages the muscles. Microtears eventually accumulate, causing strains and tears.

Muscle Imbalances

Imbalances between hamstrings and opposing muscle groups like the quadriceps increase injury likelihood. Weak, tight hamstrings are more prone to eccentric overload.

“Flexibility imbalances between the hamstrings and quads as well as bilateral hamstring asymmetry should be assessed during pre-season screening,” advises Dr. Michael Fredericson, Stanford Director of Physical Medicine and Sports Medicine. “Correcting imbalances minimizes injury risk.”

Fatigue

Cumulative muscular fatigue damage throughout intense training and competition leaves hamstrings vulnerable. The highest injury rate occurs in the last third of each half of soccer matches when fatigue sets in.

Lack of Flexibility

Inflexible hamstrings are under greater tension during hip flexion and knee extension. Reduced extensibility means less shock absorption during lengthening.

Improper Training

Hamstring injuries are more likely to occur when hamstring muscles are not properly strengthened, and flexibility is not maintained through appropriate training protocols. Inadequate hamstring strengthening exercises, insufficient flexibility development, and improper programming of training load can increase the risk of hamstring strains and tears.

Previous Injury

Prior hamstring damage leads to scar tissue formation and incomplete healing, increasing the risk for recurrent strains.

Older Age

Hamstring flexibility and elasticity decrease with age. Masters athletes must be diligent with flexibility maintenance.

Prevention Strategies for Hamstring Injuries

While hamstring strains will always be an inherent injury risk in sports due to their complex anatomy and role, the following strategies can reduce injury likelihood:

Maintain Adequate Flexibility

Consistent hamstring stretching ensures muscles stay long and pliable to handle elongations during hip flexion and knee extension. Younger athletes should aim for greater than 80 degrees of passive straight leg raise, while older athletes should work toward 70 degrees.

Static stretches held for 30-60 seconds, as well as yoga and Pilates, are great ways to maintain flexibility. Focus especially on the inner hamstring area, which is most prone to strains.

Strengthen Hamstrings

A progressive strengthening program, including eccentric exercises, bridges, squats, and hamstring curls, develops tendon strength and muscular endurance to avoid overuse.

“Isotonic and eccentric focused loading protects hamstring muscle fibres against tensile damage during lengthening,” says Chris Powers, Professor of Biokinesiology at USC.

Warm-Up Thoroughly

A 15-20 minute dynamic warm-up raises core temperature, activates muscles, increases blood flow, and primes the nervous system. Include activities like jogging, lunges, squats, and plyometrics. Save static stretching for post-activity.

Allow Adequate Recovery

Hamstring injury risk increases with high training loads and insufficient recovery. Monitor fatigue levels and adjust volume and intensity to avoid overtraining. Periodized training programs factor in recovery periods.

Use Proper Sprinting Form

Overstriding lengthens hamstrings past their limits. Maintain a short, quick stride with the foot landing under the body, not out in front. Leaning forward too much also overstretches the hamstrings.

Balance Muscle Groups

Compare hamstring and quadriceps flexibility and strength. Overdeveloping quads without proportional hamstring strengthening invites muscle imbalance. Focus on unilateral and multi-joint exercises.

Improve Neuromuscular Control

Exercises emphasizing co-contraction, balance, proprioception, and core control enhance coordinated movement between the pelvis, hips, knees, and ankles. This allows muscles like the hamstrings to work synergistically.

Hamstring Injury Diagnosis

An accurate diagnosis is crucial for determining the severity of a hamstring injury and guiding appropriate treatment. Here is a more in-depth look at common diagnostic techniques:

Medical History

• Mechanism of injury – Was it a sudden acute event or gradual onset? What sporting movement caused the injury? This can indicate which muscle was most affected based on its mechanics.
• Location – Where exactly is the pain located? Common areas are the muscle belly, musculotendinous junction, or tendinous attachment sites.
• Nature of injury – Was a pop felt or heard? Did pain and swelling come on suddenly or gradually? Acute vs. chronic onset provides clues to injury type.
• Timing – When did the pain begin relative to activity? During, immediately after, or hours later? This helps determine if it was a strain from eccentric overload vs. fatigue.

Physical Exam

• Palpation – Identifying the exact point of maximal tenderness can indicate which hamstring muscle and spot is injured. Comparing bilateral issues is useful.
• Range of motion – Passive straight leg raise, bent knee raise, and knee extension assess flexibility deficits and pain arcs that may indicate injury location.
• Strength testing – Manual muscle testing in flexion and extension across single and multi-joints helps detect deficits.
• Resisted isometric contractions – Can elicit pain at the site of injury, even if motion is limited.
• Gait analysis – Looking for antalgia, stiffening, guarding, or asymmetry.

Imaging

• MRI – Allows detailed evaluation of individual muscle bellies and tendinous attachments to identify the location and degree of structural damage. Useful for surgical planning.
• Ultrasound – Dynamic imaging shows structural defects like partial tears and fluid accumulation around injured sites. Cost-effective option.
• X-ray – Rarely used but may show avulsion fractures or calcification.

Other Tests

• Flexibility assessment – Measuring passive straight leg raises in a range of motion reveals extensibility deficits.
• Biomechanical analysis – Evaluating posture, leg length discrepancies, pelvic tilt, and joint mobility restrictions.
• Blood tests – Markers like creatine kinase can confirm muscle damage but do not localize injury.

A thorough history, physical examination, imaging, and functional testing provide a detailed diagnosis to optimize treatment planning and recovery. Early, accurate evaluation is key.

Rehabilitation Strategies for Hamstring Strains

Despite prevention efforts, hamstring strains still occur. Proper rehabilitation is critical to optimize recovery and minimize recurrence. Rehab strategies progress through phases based on severity:

Phase 1: Reducing Initial Inflammation

RICE (rest, ice, compression, elevation) is critical to limit initial bleeding and inflammation, which can damage tissue. Ice for 15-20 minutes every few hours, lightly compress with a wrap and keep the leg elevated. Take anti-inflammatory medicine as needed for pain.

“The first 3 days after injury are vital to limit the cascade of inflammation and optimize the healing environment,” emphasizes Dr. Flowers, sports medicine physician.

Phase 2: Regaining Range of Motion

Once the swelling has reduced, gentle stretches and exercises improve the flexibility and mobility of the hamstring muscle and surrounding joints. Stationary biking, pool running, knee extensions, and other pain-free movements recommended by a physiotherapist prepare the area for strengthening.

“We aim to gently move the tissue through a pain-free range to encourage blood flow, maintain mobility, and stimulate the healing process,” says physiotherapist Chris Johnson.

Phase 3: Progressive Strengthening

Submaximal hamstring loading facilitates collagen repair and aligns new muscle fibers. Begin with isometric contractions like bridges before progressing to eccentric exercises like Nordic curls within a pain-free range. Ensure surrounding muscle groups like glutes, quads, and calves are strengthened.

“The key is progressive loading day-by-day based on clinical markers like pain and swelling. No major flares in symptoms should occur.”

Johnson

Start with lower-intensity isometric exercises like:

• Supine bridges
• Planks
• Wall sits
• Quadruped holds
• Paloff presses

Then, carefully introduce eccentric movements like:

• Supine hamstring curls
• Prone hamstring curls
• Nordic curls
• Eccentric lunges
• Split squats

Strengthening should target both knees in the bent (flexed) and straight (extended) positions. Progress resistance and volume gradually under the guidance of a physiotherapist.

Phase 4: Sport-Specific Training

Once strength is restored, running drills, agility patterns, plyometrics, and sport-specific movements are integrated at progressive intensities to retrain proper mechanics. Interval sprint training and sport-specific practice prepare the athlete for return to play.

Begin with low-impact activities like:

• Pool running
• Cycling
• Elliptical
• Rowing machine

Then progress to light running drills such as:

• Straight ahead jogging
• Backpedalling
• Shuffling
• Cariocas

Next, introduce agility exercises like:

• Ladder drills
• Hurdles
• Box jumps
• Lateral bounding

Followed by controlled sprinting:

• Acceleration runs
• Hill sprints
• Parachute sprints
• Resisted sprints

Finally, integrate sport-specific drills:

• Dribbling
• Passing
• Shooting
• Defending

Loading parameters should begin conservatively and increase progressively under careful guidance.

Graduated Return to Play Protocol

Re-injury rates within the first year following a hamstring strain are unacceptably high, between 12-31%, depending on the sport. Returning to competition too quickly before strength and flexibility are restored accounts for many of these reinjuries.

Coaches, medical staff, and athletes must exercise caution using data-driven assessments at each return-to-play stage:

Criteria for Progressing

• No pain during strength testing and palpation
• At least 80-90% strength restoration on assessment
• Hop testing symmetry >90% compared to uninjured limb
• Passing sprint interval and conditioning tests
• Psychological readiness to return

Stepwise Progression

• Light aerobic conditioning like cycling or swimming
• Running drills and sport-specific agility patterns
• Controlled, submaximal sprints
• High-intensity sprints and plyometrics
• Unrestricted practice and participation

Monitoring Warning Signs

• Increased soreness or cramping
• Renewed loss of flexibility or strength
• Alterations in running mechanics
• Compensatory movements or guarding

“There are no shortcuts to tissue healing and maturation. An extra week of rehab is worthwhile to prevent months of rehab later.”

Dr. Jones, team physician

Maintaining Hamstring Health Long-Term

Even after recovery, diligently maintaining hamstring flexibility, strength, and balance is essential for lifelong health:

• Stretch regularly using varied hip flexion and knee extension patterns
• Strengthen 2-3x a week with multi-joint and eccentric exercises
• Monitor training load, intensity spikes, and fatigue levels
• Warm-up and cool down thoroughly around workouts
• Compare muscle group strength and flexibility frequently
• Respond quickly to any minor strain or discomfort

Sample Flexibility Exercises:

• Standing hamstring stretch
• Seated hamstring stretch
• Hamstring stretches on foam roll
• Hurdler stretches
• Butterfly stretches
• Dynamic lunges

Sample Strengthening Exercises:

• Nordic hamstring curls
• Supine bridges
• Eccentric step downs
• Good mornings
• Single leg deadlifts
• Resisted knee flexion

Other Recovery Methods:

• Foam rolling
• Massage
• Contrast baths
• Compression wear
• Anti-inflammatory diet

Prioritizing consistent prevention habits minimizes the chances of repeat injuries. Hamstring health is a career-long endeavour, given its structural vulnerability. Small investments of time reap huge injury prevention rewards long-term.

Psychological Recovery Alongside Physical

Recovering emotionally from injury is equally as important as tissue healing. Setbacks can be demoralizing, causing anger, sadness, and loss of identity. Maintaining social support, goal-setting, and mental skills training facilitates resilience.

“My biggest advice is to be patient with yourself throughout daily ups and downs. Control what you can control like rehab sessions, nutrition, and sleep. Let go of thinking you should be further along.”

Julie Johnston

Celebrating small wins, finding purpose in rehab, and visualizing future success help athletes maintain motivation and hope during recovery.

Practical tips like maintaining training journals, monitoring progress metrics, setting short-term goals, and scheduling reminders and rewards can also add important structure during the ambiguous recovery period.

Teammates, family, and coach support also bolster spirits on difficult days. Finding an identity outside of sport, pursuing education, or learning new skills also helps.

Case Studies on Successful Rehabilitation

Hearing about other athletes who have successfully returned to competition after hamstring injuries can inspire hope. Here are two examples of optimal rehabilitation and recovery:

Kevin, Track Sprinter

Kevin, a college sprinter, suffered a grade 2 right hamstring strain halfway through his outdoor track season attempting to PR in the 100m dash. He tore the semitendinosus muscle belly near its origin.

Following a 3 week period of rest, ice, compression, anti-inflammatory medication, and gentle range of motion, Kevin began daily rehab focused on progressive strength restoration, flexibility, and mechanics correction under the guidance of the team athletic trainer.

Low-impact cardiovascular training was initiated first in the pool, along with isometric exercises. After 2 weeks, light eccentric exercises like Nordic curls were added. Running mechanics were also assessed and corrected.

Six weeks post-injury, Kevin performed pain-free full-speed repeat sprints on the track. He competed in a relay 2 months later and went on to PR in the 200m at the end-of-season conference meet.

Sarah, Soccer Player

Sarah, a starting midfielder, suffered a grade 1 distal hamstring strain attempting a sliding tackle near the end of a match. She felt a pop in her left semitendinosus muscle near the knee attachment.

Sarah began rehabilitation 24 hours post-injury, focused on controlling inflammation, regaining range of motion, and stimulating tissue repair through light eccentric exercises, cardio, and mobility work.

She progressed to running 2.5 weeks later and was performing sprint and agility drills 3 weeks out. Her Soccer return to play test was passed 5 weeks post-injury. She continued strengthening and played limited minutes in matches over the next few weeks before returning to full 90-minute games.

In Summary

• Hamstring strains are common multi-joint injuries requiring comprehensive prevention and rehabilitation.
• Assessment of risk factors like strength imbalances and proper training load monitoring is the first line of defence.
• Thorough diagnosis guides severity grading and customized recovery protocols.
• Rehabilitation progresses through controlled inflammation, gradual strengthening, and neuromuscular re-training.
• Strict adherence to return-to-play protocols prevents costly re-injury.
• Ongoing maintenance through flexibility, eccentric strength, and active warm-ups keeps hamstrings resilient.

With proper prevention, treatment, rehabilitation, and maintenance, hamstring injuries can be effectively managed for career-long health.

FAQs

[faq question=”How long does it take to recover from a hamstring injury?”]The recovery time for a hamstring injury depends on the severity of the strain. Grade 1 mild strains usually take 1-3 weeks. Moderate grade 2 strains take around 6 weeks. More severe grade 3 tears can take 3 months or more. Follow your physician’s advice and rehabilitation protocol for your individual injury.[/faq]

[faq question=”How do you treat a hamstring strain?”]Initial treatment focuses on rest, ice, compression, and elevation to control inflammation. After a few days, gentle range of motion exercises can begin, followed by progressive hamstring strengthening. Seek guidance from a physical therapist or athletic trainer for appropriate exercises based on strain severity.[/faq]

[faq question=”Can I run with a hamstring strain?”]Running with a hamstring strain is not recommended as it can exacerbate the injury. Take time off from running based on strain severity. Mild strains may allow a return to running in 1-2 weeks, but more moderate strains require 4-6 weeks off. Consult your doctor or physical therapist before returning to running.[/faq]

[faq question=”Can a chiropractor help a hamstring injury?”]Chiropractic care may aid hamstring injury recovery by improving pelvic and lumbar spine biomechanics, reducing nerve irritation, loosening tight muscles through soft tissue massage, gently mobilizing joints, and facilitating proper movement patterns.[/faq]

[faq question=”What is the fastest way to heal a pulled hamstring?”]Healing a pulled hamstring quickly depends on resting immediately after injury, controlling inflammation with RICE, receiving the right diagnosis for your strain grade, diligently performing rehab exercises, allowing adequate recovery between sessions, progressing activity gradually, and optimizing nutrition.[/faq]

[faq question=”How long should you ice a strained hamstring?”]In the first 72 hours after a hamstring strain, ice for 15-20 minutes every 2-3 hours, being careful not to apply ice directly to the skin. After a few days, switch to intermittent icing after exercise or rehabilitation sessions to control inflammation and pain.[/faq]

[faq question=”Can I play sports with a strained hamstring?”]Playing sports or participating in your athletic activity is not recommended until your strained hamstring has fully recovered. Premature return to play will risk re-injury. Follow your treatment team’s graduated return-to-play protocol.[/faq]

[faq question=”Why do my hamstrings hurt when walking?”]Hamstrings hurting when walking can signal an acute muscle strain or tear or chronic tendinopathy. Causes include overuse, strain from overstretching, poor flexibility, strength imbalances, improper form, and inadequate warm-up. See a doctor for diagnosis and treatment.[/faq]

[faq question=”Will a massage help a pulled hamstring?”]Yes, massage can help a pulled hamstring by reducing muscle tightness and spasms, increasing circulation, breaking up scar tissue, facilitating healing, and relieving pain. Use gentle pressure post-injury and avoid massaging an acute hamstring tear.[/faq]

[faq question=”Can a hamstring injury heal on its own?”]Minor grade 1 hamstring strains may heal on their own with rest, ice, OTC medication, and avoiding athletic activity for 1-2 weeks. More significant strains require professional treatment like physical therapy, progressive strengthening, and guided return to play.[/faq]

[faq question=”Can hamstring injuries recur?”]Yes, hamstring injuries often recur, especially if the root causes are not addressed, rehab is rushed, return to play is too early, or preventive measures like strength training are not maintained post-recovery. Recurrence rate is 12-31%.[/faq]