Hamstring injuries

in football -
assessment, diagnosis
and prognosis
This article provides an update on the current available evidence on the assessment,
diagnosis, and prognosis of hamstring injuries in soccer. After a detailed insight into
the epidemiology, functional anatomy and injury mechanism for hamstring injuries,
a detailed clinical examination – which is supported by clinical evidence, clinical
experience and innovative practice – is demonstrated. Finally the recent Munich
classification system is presented to improve clarity of communication for diagnostic,
therapeutic and prognostic purposes.

BY WaYne Gill BSc, McSP
ePideMioloGY
Injury to the hamstring muscle group is frequently reported
to be the most common injury in professional football
representing 12% of all injuries (1). It has been reported
that 83% of hamstring injuries affect the biceps femoris,
whereas 10% and 5% affect the semimembranosus and
semitendinosus, respectively (2). A 25-player squad can
expect five hamstring muscle injuries each season, resulting
in 90 days and 15–21 matches missed per club per season
(3). It’s been reported that 18 days and 3 matches are missed
per hamstring strain, with a 12% re-injury rate (3). Re-injuries
can lead to diminished athletic performance and frustration
for the player (4). Injuries will also have a negative impact
on the morale, performance, and results of the team, which
can have huge financial implications for the club (4). Thus,
hamstring strain injuries remain one of the most challenging
injuries facing sports medicine practitioners.
anatoMY
The hamstring muscle group includes the semitendinosus
(ST) and semimembranosus (SM) medially and the biceps
femoris (BF), short and long heads, laterally. All muscles
attach proximally to the ischial tuberosity, except the BF
short head, which originates at the linea aspera and lateral
supracondylar line of the femur (5). The ST attaches to the
medial surface of the superior tibia, SM to the posterior part
of the medial condyle of the tibia and the oblique popliteal
ligament, while the BF attaches to the fibular head. The BF
also has strong fascial connections to the peroneus longus
at the fibula linking it to the action of the ankle and foot (6).
Additionally, the SM has expansions extending to the knee
joint capsule and the medial meniscus (Fig. 1; Video 1)(6).
Function
The hamstrings are biarticular (2-joint) muscles spanning
the hip and knee joint with multiple attachments that allow
them to affect function throughout the pelvis and lower
extremities. The principle activities of the hamstring group are
hip extension and knee flexion. However, the BF short head
crosses only the knee joint and is therefore only involved
in knee flexion. Additionally, with the knee in flexion the SM
and ST can medially rotate the tibia, whereas the BF laterally
rotates the tibia. The hamstrings are predominantly made up
of type II fast twitch fibres and are innervated by the tibial
branch of the sciatica nerve. However, the BF short head is
dually innervated by both the tibial and peroneal portion of the
sciatic nerve (7). Functionally, the muscle group provides knee
support during the early stance phase, propulsion during the
mid to late stance phase and they control knee momentum
during the swing phase (8). Studies of running biomechanics
have found the hamstrings are active for the entire gait with
peaks in activation during the terminal swing and early stance
phases (9,10). During the terminal swing phase the hamstrings
are required to contract eccentrically to decelerate the
flexing hip and extending knee in preparation for heel strike
(11). Furthermore, using electromyography (EMG) analysis it’s
been reported the BF is maximally activated between 15° and
30° of knee flexion, whereas the ST and SM are maximally
activated between 90° and 105° of knee flexion (12). This
indicates that the BF participates strongly during the terminal
swing phase of running. Additionally, during the early stance
phase the hamstrings have to absorb considerable force as

16 sportEX medicine 2014;59(January):16-22


a result of high ground reaction forces (10,11). Furthermore,
the thoracolumbar fascia (TLF) via its extensive muscular
attachments functionally connects the hamstrings to the
lumbar-pelvic spine and the upper torso (6).
injurY MechaniSM
It has been reported that 70% of hamstring injuries in elite
football players occur during high speed running and the
rest with stretching, sliding, twisting, turning, passing and
jumping (13). The presence of high eccentric forces during
the stance and swing phases likely contributes to the high
rates of hamstring injuries during maximal speed running. The
terminal swing phase is considered the most hazardous as
the hamstring muscle tendon units are at their longest length
© Primal Pictures 2013
Figure 1a: Biceps femoris in isolation
Biceps femoris
Semitendinosus
Semimembranonosus
© Primal Pictures 2013
Figure 1b: Muscles that make up the hamstrings
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evidence informed practice
of the gait cycle and are most heavily activated (11,14). This
eccentric breaking force is often the point of muscle failure
as the lengthening demands placed on the muscle exceed
the mechanical limits of the muscle. This is postulated to be
due to non-uniform lengthening of sarcomeres attributed
to sarcomere length instability. There is some uncertainty
as to whether hamstring injuries most typically occur as a
result of the accumulation of microscopic muscle damage, or
as a result of a single event (11). It seems feasible, however,
that both may contribute. For example, the accumulation
of microscopic damage as a result of repeated sprints
may cause a ‘weak link’ and leave the muscle tissue in a
vulnerable state and more susceptible to injury during a
single traumatic event, such as kicking a ball (11).
exaMination
history
Most soccer players with hamstring strain injuries present
with a sudden onset of posterior thigh pain resulting from
a specific action, most commonly high speed running (3).
Players will often describe the occurrence of an audible
pop or tearing sensation. However, a more gradual onset of
hamstring pain may be more suggestive of a referred source,
or what is commonly termed back-related hamstring pain
(15). The lumbar spine especially at the L5/S1 levels, and the
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Video 1: anatomy animation showing
hamstrings with surrounding musculature
17
 HAMSTRInG InJuRIES tuberosity, in addition to measuring the total length of the
painful region (15). Palpation also serves detect (superficial
REMAIn onE oF THE or larger) tears, perimuscular oedema and any increase in

MoST cHALLEnGInG muscle tone (18). The examiner can also palpate the gluteal
muscles to determine the presence of any MTPs which
InJuRIES FAcInG SPoRTS may also refer pain into the hamstring region. Additionally,

MEDIcInE PRAcTITIonERS the superior tibia-fibula joint (STFJ) should be assessed in

hamstring injuries involving the BF (3).

sacroiliac joints (SIJ) can refer pain to the posterior thigh

especially if there has been a history of low back pathology
(16). This type of hamstring pain that occurs during training is
often due to increased loading of the lumbar spine. Therefore,
an investigation into the training history could lead to
important information regarding the causes of spine-related
hamstring injuries. Additionally, myofascial trigger points
(MTPs) from the gluteal muscles and the piriformis muscle
may also refer pain into the hamstring region (17).

Palpation
Palpation of the posterior thigh is useful for identifying the
specific muscle and location injured through pain provocation,
as well as determining the presence/absence of a palpable
defect in the musculotendinous unit (15). The point of maximal
Figure 2: Knee flexion (90°) using hand-held dynamometer
pain can be determined and located relative to the ischial (HHD)

Figure 3: Knee flexion (45°) using HHD Figure 4: Knee flexion (15°) using HHD

Figure 5: Hip extension performed with knee extension Figure 6: Hip extension performed with knee flexion

18 sportEX medicine 2014;59(January):16-22

 EvidEncE informEd practicE

Flexibility and neural tension Joel Ward

The Lasègue test, otherwise known as the straight leg raise striking the ball
for Portsmouth
(SLR) test, is commonly used to assess hamstring flexibility FC (Photo credit:
in soccer players (19). However, it’s suggested the SLR test Joe Pepler, 2011)
has a dual function in measuring hamstring muscle length and
assessing sciatic nerve mobility (20). Indeed, the SLR causes
caudal movement of the sciatic nerve, and this stretching
may cause a protective contraction of the hamstrings if there
is entrapment of the sciatic nerve in the intervertebral canal
due to disc prolapse, degenerative osteophytes, or other
structures (21,22). Thus, in pathological states of the lower
back, restriction may not be due to hamstring muscle injury,
but muscle spasms in these muscles caused by irritation to
the sciatic nerve (22). Despite this, the validity of the SLR
test in the diagnosis of neural tension remains inconclusive
(23). Due to the confusion about the SLR test, Gajdosik and
Lusin (24) designed the active knee extension (AKE) test to
measure hamstring length by the angle of the knee flexion
during AKE while the hip is stabilised at 90° flexion. Thus, the
AKE is thought to be more selective than the SLR test at
measuring hamstring length alone (24). Furthermore, the intra-
tester reliability has been reported as high (25). The modified
sit and reach (mSAR) test has been advocated as a general THE MunIcH MuScLE
lumbar spine and hamstring flexibility test rather than a direct
hamstring muscle length (19). The slump test is often used to
InJuRy cLASSIFIcATIon cAn
assess adverse neural tension, and involves tensioning the BE uSED To ASSIST DIAGnoSIS
neural system without additional hamstring stretch (26,27). The
goal of the test is to differentiate nerve root pain from muscle
By cLASSIFyInG HAMSTRInG
pain (22). A positive test is defined as one which reproduces InJuRIES InTo FuncTIonAL oR
the symptoms during simultaneous knee extension and ankle
dorsiflexion, and alleviated with cervical extension (27,28).
STRucTuRAL InJuRIES
The pain elicited by the slump test is thought to be due
to excessive nerve stretch (intraneural), or reduced neural
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mobility at the interface with the surrounding muscle tissue
(extraneural) (28). Recently, three flexibility tests have been
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advocated for diagnosing proximal hamstring tendinopathy to subscribers with online access.
(PHT), and these include the Puranen–orava (Po) test, the
bent-knee stretch (BK) test and the modified bent-knee Video: demostration of
stretch (MBK) tests. All three clinical tests are practical, easy the hip extension test
to perform, and have demonstrated high validity and reliability
for diagnosing PHT (29).

Strength
Hamstring strength can be evaluated in both the supine and
prone positions. With the player in the prone position manual
muscle testing (MMT) can be used to assess the isometric
knee flexion strength initially at 90° (Fig. 2), then 45° (Fig. 3),
and finally 15° (Fig. 4) of knee flexion. Additionally, the use
of a hand-held dynamometer (HHD) can provide objective
measurements and identification of any strength deficits at
different knee flexion angles between the injured and non-
injured side (30). With adequate stabilisation the HHD is a
valid and reliable method of assessing hamstring strength (31,
32). Also, the concentric and eccentric hamstring strength
can be assessed using manual resistance applied by the
hands of the clinician. To place more emphasis on the BF it’s
suggested the knee should be externally rotated, whereas
internal rotation would bias the medial hamstrings (15).
Because the hamstring muscles extend the hip, it’s been

www.sportEX.net 19
 recommended that hip extension strength be assessed with
full knee extension and also knee flexion (15). The elevated
taBle 2: Mri claSSiFication
and Mean recoVerY tiMeS
single leg bridge test is a quick and simple way of assessing [Adapted from Ekstrand et al., 2012 (2)]
hip extension and can be performed with the knee fully
Mri return to
extended and also flexed (Figs 5, 6; Video 2). collectively, Findings
classification training (days)
the aforementioned strength tests will provide the examiner
Grade 0 no visible pathology 8
with subjective and objective markers which can be used
Grade I oedema but no 17
to monitor the progression and recovery throughout the
architectural distortion
rehabilitation process.
Grade II Architectural distortion 22
(partial tear)
lumbar spine and pelvis Grade III Total muscle or tendon 73
The pelvis provides a dynamic link between the trunk, rupture
vertebral column and the lower limbs and has been
described as the keystone for both movement and support
(33). Therefore, asymmetry or dysfunction within pelvic taBle 3: Munich claSSiFication SYSteM
structures can alter movement patterns resulting in less and Mean recoVerY tiMeS
efficient movement, and alterations in joint forces and [Adapted from Ekstrand et al., 2013 (43)]
muscle function (34). Due to the anatomical and functional Muscle classification return to
relationship with the pelvis the hamstrings may be vulnerable training (days)
to injury. Excessive anterior tilt of the pelvis due to sacroiliac Functional Delayed onset of 4.5
joint (SIJ) dysfunction will increase the muscle length and disorders muscle soreness
tension within the hamstring muscles, thus predisposing them Spine-related
to injury (35,36). The function of the SIJ may be assessed neuromuscular 7.0
muscle disorders
by a number of kinetic tests, including the stork test (also
Fatigue induced 7.9
known as the Gillet test) and the forward flexion test (37).
Muscle-related
Additionally, the position of the pelvis should be examined to
neuromuscular muscle 13.8
determine the presence of any postural asymmetries which disorders
may also indicate a true or apparent leg length discrepancy Structural Minor partial muscle 17.3
(38,39). The lying/sitting test is a clinical method frequently disorders tears
used to differentiate between a true and apparent leg length Moderate partial muscle 35.5
discrepancy (40). The active straight leg raise (ASLR) test tears
has recently been used as a screen of lumbar spine stability Subtotal/complete muscle
to assess the control of lumbar rotational movements in the injury/tendinous avulsion 56.3
transverse plane (41). Good control without anterior pelvic
tilt is required and excessive anterior pelvic tilt typically spine, SIJ, and the pelvis should be included as part of the
accentuates the lumbar lordosis and can be a sign of poor injury assessment.
stabilisation of the pelvis by the abdominal muscles (6, 30).
Therefore, a thorough biomechanical evaluation of the lumbar diaGnoSiS
The diagnosis is based on the clinical history, examination
findings, and the use of imaging modalities such as
taBle 1: claSSiFication oF acute MuScle diSorderS and
ultrasound and magnetic resonance imaging (MRI). An early
injurieS [Adapted from Mueller-Wohlfart et al., 2013 (18)]
post-injury ultrasound between 2 and 48 hours has been
Type 1: 1a: Fatigue induced advocated as it can provide helpful information about any
overexertion- 1b: Delayed onset of muscle existing disturbance of the muscle structure, particularly if
Functional related disorder soreness (DoMS) there is any haematoma (18). However, MRI is considered
muscle superior for evaluating injuries to deep portions of the
disorder Type 2: 2a: Spine-related neuromuscular
Indirect muscles, or when a previous hamstring injury is present,
neuromuscular disorder
muscle disorder as residual scarring can be misinterpreted on an uS image
injury 2b: Muscle-related neuromuscular
disorder as an acute injury (42). Furthermore, due to its increased
sensitivity in showing subtle oedema, measuring the size
Type 3: Partial 3a: Minor partial muscle tear (length and cross sectional area) and site of injury including
Structural muscle tear 3b: Moderate partial muscle tear any tendon involvement, MRI is more accurate (42). Thus,
muscle injury
Type 4: (Sub) total Subtotal or complete muscle tear an MRI examination within 24–48 hours of the injury event
tear should be performed (2,18).
Tendinous avulsion

Direct classification
muscle contusion or laceration currently the most widely used classification for hamstring
injury injuries is an MRI based graduation defining four grades:
grade 0, no visible pathology; grade 1, oedema but no

20 sportEX medicine 2014;59(January):16-22


architectural distortion; grade 2, partial tear with architectural
disruption; and grade 3, total muscle or tendon rupture
(2). Around 70% of hamstring injuries seen in professional
football are of radiological grade 0 or 1, meaning no signs
of fibre disruption on MRI. However, these injuries caused
more than 50% of the absence of players in clubs (2). The
actual cause of posterior thigh injury where MRI shows
no pathology is unclear, but may be due to an alternative
diagnosis. Recently the Munich muscle injury classification
was introduced as a new terminology and classification
system of muscle injuries (18). This clinical tool can be
used to assist diagnosis by classifying muscle injuries
into functional and structural injuries. Functional disorders
are fatigue induced or neurogenic injuries causing muscle
dysfunction without microscopic evidence of fibre tear,
while structural injuries are tears of muscle fibres (Table 1).
In elite professional football it has been reported that 65%
of hamstring injuries are structural injuries and 35% are
functional disorders (43).
Prognosis
The ability to predict lay-off time is very important for the
injured player as well as the coaching staff. Recent studies
evaluating the use of MRI have demonstrated that MRI
abnormalities can not only confirm the clinical diagnosis, but
also provide a reasonable estimate of the rehabilitation period
(2,44). Ekstrand et al. (2) assessed the prognostic value of
MRI by grading the severity of 516 hamstring injuries in football
players (Table 2). Additionally, Ekstrand et al. (43) recently
demonstrated the Munich muscle classification can be used by
clinicians to prognosticate return to play after a muscle injury
in football players (Table 3).
The Munich classification clearly shows a difference
in return to play between structural and functional muscle
injuries. This seems logical since by definition structural
injuries show macroscopic evidence of muscle fibre
damage, and functional disorders show no such damage
(18). Establishing the type of injury also provides essential
prognostic information since a stretching-type of injury has,
on the average, 84% longer times (59 vs 32 days) to return
than a sprinting-type of injury (43). other measurements
with similar prognostic value, that is, prolonging or shortening
the time to return, are position of peak pain upon palpation
in relation to the ischial tuberosity as well as oedema
length upon MRI. The shorter the distance to the ischial
tuberosity and the longer the length of the oedema have
been associated with longer recovery times (43). Hamstring
tears >60mm (6cm) in length or >10% cross sectional area
(cSA) have been shown to have a recovery time of at least
3 weeks (45,46). Additionally, more than 1 day of walking with
pain has also been associated with a recovery time of at
least 3 weeks (46). Injuries involving disruption to tendinous
tissue (central or proximal free tendons) have a significantly
worse prognosis than injuries which involve only muscle
fibres, epimysial fascia, or the musculotendinous junction
(44). This may be reflective of the increased remodelling
time required of tendinous injuries. Therefore, the length of
rehabilitation is proportional to the classification, location, and
severity of injury.
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evidence informed practice
THE MunIcH cLASSIFIcATIon
cAn BE uSED By cLInIcIAnS To
PRoGnoSTIcATE A RETuRn To
PLAy FoR FooTBALL PLAyERS
SuMMarY
This article provides the reader with an update on the
current available evidence on the assessment, diagnosis,
and prognosis of hamstring injuries in football. The diagnosis
is based on the clinical history, examination findings, and
the use of imaging modalities such as ultrasound and MRI.
The Munich classification tool has been introduced to assist
diagnosis by classifying muscle injuries into functional and
structural injuries and improve clarity of communication for
diagnostic, therapeutic and prognostic purposes.
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ThE AuThor
Th
Wayne spent 10 years as a professional footballer playing for
Blackburn rovers, Blackpool, Tranmere rovers and oldham
Athletic before retiring in 2004 due to injury. In 1999 he completed
an hNC in sports science and in 2008 he graduated from the university
of Salford with a first class honours degree in physiotherapy. Following his
graduation he worked at Portsmouth FC for 4 years which included being
involved in the FA Cup final in 2010. In 2012 he joined Fulham FC and is
currently studying for an MSc in Sports Physiotherapy at Bath university.
n Describe the function of the hamstrings during the gait cycle.
n What is the most common injury mechanism for hamstring
injuries?
n Which clinical tests would you use to assess hamstring
DISCUSSIONS
muscle flexibility and neural tension?
n Describe the different types of functional and structural
disorders associated with the Munich classification.
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