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Hamstring injury: high-quality rehab matters!

Hamstring injuries are one of the most common injuries in sport, especially activities involving sprinting, high-speed movements, kicking, and extensive muscle-lengthening/stretching movements (1). Sports which commonly have sprinting/high-speed hamstring injuries include football, soccer, rugby, track & field, NFL and more. Sports and activities which commonly have stretching-type injuries are dancing and ballet, however this can also occur in sports like football where players reach down for a ball at speed for example. The sprinting-type hamstring injuries often involve the biceps femoris muscle, whilst the stretching-type hamstring injuries often involve the semimembranosus (2). The picture below shows the hamstring anatomy. The hamstrings (along with medial gastrocnemius, aka calf, and rectus femoris, aka quad) are the most common muscles injured in sport. This is likely due to their bi-articular nature, with complex architecture and high proportion of fast-twitch fibres (3).


High quality rehabilitation, return to running programs, and return to sport testing are crucial, as statistics show that up to 30% of hamstring injuries recur within 12 months (1). Furthermore, subsequent injuries are often worse than the original injury, causing greater damage, higher treatment costs, more time off sport, and greater frustration for athletes & coaches (3, 4, 5). Once an athlete has had a hamstring injury, they have up to a 7 times greater risk of re-injury (3), highlighting the importance of high-quality rehabilitation and conditioning programs, along with return to sport testing. Importantly, the highest risk of injury following return to sport is within the initial 2 weeks following the resumption of sport (6).



The high return to sport rates in numerous sports potentially highlights inadequate rehab, and/or inadequate return to sport criteria (5). A good rehabilitation and return to sport plan should have multiple components, a number which have been listed below. The timing of when to start each component of the program is also important.

  • Eccentric loaded hamstring exercises: an eccentric exercise is one which the muscle is contracted whilst lengthening. A common example of an exercise used in hamstring rehabilitation is the Nordic hamstring exercise. The Nordic hamstring exercise has also been shown to reduce the risk of hamstring injuries by up to 51% (7)


  • Hamstring strengthening - knee and hip bias exercises: Studies have shown that knee bias exercise (e.g. Nordic hamstring exercise) preferentially activates the medial hamstrings (semimembranosus & semitendinosus), whilst hip bias exercises (e.g. 45degree hip extension, deadlifts) preferentially activate the biceps femoris (1). Based upon muscle activation in these exercises, it makes sense to include both as part of hamstring rehabilitation/prehabilitation. An example of knee bias strengthening is the Nordic hamstring exercise (see the video above), whilst a hip bias strengthening exercise could include a deadlift, or the 45degree hip extension, see below.


Link for Youtube video demonstration here: https://www.youtube.com/watch?v=VIWmblbtGxg


  • Return to running / sprinting program: This is an often-overlooked component of hamstring rehabilitation, with people often returning to pre-injury running levels / training too early without adequate preparation. Simply doing some strength exercises then returning to sport is NOT enough. Whilst early running post hamstring injury is beneficial, doing so in a controlled manner is important. Completing high speed running/sprinting training in a progressive manner is an important part of the rehab process. The return to running program should include running-specific drills, and graded increases in high speed running volume & intensity. The running program should build to maximal sprint drills and explosive agility type exercises/drills to adequately rehab and equip the hamstring and lower limb for sport (8).

  • Gluteal / Hip / Trunk strengthening exercises: The gluteal muscles, primarily the gluteus maximus muscle, work to control hip and leg movement. If they are weak, or don’t switch on very well, this causes the hamstrings to be placed under increased load, causing a higher risk of injury/re-injury. Including glute strengthening exercises is not only crucial for hamstring rehabilitation, it will also often improve athletic performance. Furthermore, a study (8) found that increased trunk and gluteal activity during sprinting was protective for hamstring injury.

  • Kinetic chain assessment / treatment: The other aspect of hamstring rehabilitation that is very important is assessment of any other weaknesses/deficiencies in the lower limb kinetic chain. The kinetic chain describes the linking of different muscles/joints/systems in the body. If one area has weakness of deficiency, this can impact on the injury recovery and re-injury risk. This can also include assessment of running/sprinting gait. It is important to address any deficits that helped cause the initial injury, and any persisting following the injury.

Furthermore, due to the re-injury risk, reported over 30% in the literature, a regular maintenance or injury prevention program is crucial following return to sport. If you have suffered a hamstring injury and aren’t completing regular exercises/rehabilitation, it is highly recommended you visit a physiotherapist to set up a plan aimed at preventing future injury and improving performance.


Ky Wynne, DPT, APAM, BExSci

Physiosports Brighton


Bibliography:

1. Bourne, M. N., Williams, M. D., Opar, D. A., Al Najjar, A., Kerr, G. K., & Shield, A. J. (2016). Impact of exercise selection on hamstring muscle activation. Br J Sports Med, bjsports-2015.

2. Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med. 2012;46(2):86–7.

3. Ekstrand, J., Hägglund, M., & Waldén, M. (2011). Epidemiology of muscle injuries in professional football (soccer). The American journal of sports medicine, 39(6), 1226-1232.

4. Liu, H., Garrett, W. E., Moorman, C. T., & Yu, B. (2012). Injury rate, mechanism, and risk factors of hamstring strain injuries in sports: A review of the literature. Journal of Sport and Health Science, 1(2), 92-101.

5. Erickson, L. N., & Sherry, M. A. (2017). Rehabilitation and return to sport after hamstring strain injury. Journal of Sport and Health Science.

6. Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12:3-5.

7. Al Attar, W. S. A., Soomro, N., Sinclair, P. J., Pappas, E., & Sanders, R. H. (2017). Effect of injury prevention programs that include the nordic hamstring exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports medicine, 47(5), 907-916.

8. Schuermans, J., Danneels, L., Van Tiggelen, D., Palmans, T., & Witvrouw, E. (2017). Proximal neuromuscular control protects against hamstring injuries in male soccer players: a prospective study with electromyography time-series analysis during maximal sprinting. The American Journal of Sports Medicine, 45(6), 1315-1325.


Pictures sourced from:

- Other Pictures and Videos: https://www.instagram.com/kywynnephysio/

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