Hamstring

Injuries
SR study
● Title:
○ Incidence and prevalence of hamstring injuries in field-based team sports: a systematic
review and meta-analysis (2022)

● Scale:
○ Analysed 5,952 injuries over 7 million exposure hours
○ Across many field-based team sports (eg, soccer, rugby, Australian football,
American football, Gaelic football, field hockey)
SR study
● Incidence and Prevalence:
○ Incidence: 0.81 hamstring injuries per 1,000 exposure hours
○ Prevalence: 13% over a 9-month period, increasing 1.13-fold every subsequent month

● Factors Affecting Incidence:

○ Non-modifiable and Modifiable Factors:
■ Higher during matches compared to training
■ Increasing athlete age correlates with higher incidence
■ Grass surfaces have a higher incidence than artificial turf, especially in soccer
Mechanism of injury:
Type 1: High speed Running

❖ Occur during activities requiring high-speed running.

❖ Predominantly affect the long head of the biceps femoris.

❖ Injury commonly located at the proximal muscle-tendon

junction.

❖ Result in significant acute functional decline.

❖ Rehabilitation period is typically shorter compared to

Type II strains.
Mechanism of injury:
Type 2: Excessive stretching

❖ Happen during activities involving extensive hamstring lengthening (e.g., high kicking, sliding tackles).

❖ Primarily involve the proximal free tendon of semimembranosus, near the ischial tuberosity.

❖ Considered primarily a tendon injury.

❖ Can occur even at slow speeds.

❖ Generally require a longer rehabilitation period compared

to Type I strains.
Classifications:
Grade I: Mild muscle tears, causing pain during/after activity, but normal
range of movement within 24 hours.

Myofascial “a” ➔ High signal change in <10% of the

muscle.
➔ With a longitudinal length of less than
5 cm within the muscle.

Muscle-tendon Junction “b” Same as above.

Tendon “c” ➔ There is a poor prognostic

significance of intratendinous
extension and therefore there are no
grade 1 injuries in this classification.
Classifications:
Grade II: Moderate muscle tears, causing pain stopping activity, limited
movement, and detectable weakness within 24 hours.

Myofascial “a” ➔ High signal change from muscle

periphery, between 10-50% of
muscle area or 5-15 cm in length.

Muscle-tendon Junction “b” ➔ Occur within muscle or MTJ, 10-50%

high signal change, <5 cm muscle
fiber disruption.

Tendon “c” ➔ Tendon involvement, but <5 cm in

length and <50% of tendon diameter.
Classifications:
Grade III: Severe muscle tears, causing sudden pain, possibly falling;
significant movement limitation and contraction weakness within 24 hours.

Myofascial “a” ➔ >50% muscle area or >15 cm high

signal change, likely >5 cm fiber
disruption.

Muscle-tendon Junction “b” Same as above.

Tendon “c” ➔ Tendon injury >5 cm or >50% of

tendon area; no complete defect, but
potential loss of tendon integrity.
Possible Risk factors:

● Decreased flexibility ● Lack of proper warm-up

● Strength defects ● Poor lumbopelvic posture

● Muscle fatigue ● Past injury

● Poor core

control
Rehab Protocol: non-op
Phase I:
Intervention:
● Isometric h/s
● Isotonic knee extension through
pain free range
● Abduction/ adduction exercises
● Side stepping
● Upper body & Core exercises
Precautions:
● No excessive h/s stretching
● Weight bearing as tolerated
Goals:
● Allow healing of injured tissue
● Prevent muscular atrophy
● Decrease pain and inflammation
Criteria to next phase:
● Pain free walking symmetry
● Pain free h/s curl Isometric
contraction (50-70%) resistance
during prone
● Very low speed jogging pain free.
Rehab Protocol: non-op
Phase II:
Intervention: Goals:
● Stationary bike ● Regain pain-free hamstring
● Side-shuffle strength
● Supine bent knee bridge with walk- ● Develop neuromuscular control of
outs trunk and pelvis
● Arabesque
● Nordic with upper body asssitance Criteria to next phase:
● Full strength 5/5
Precautions: ● Forward and backward jogging at
● Avoid end-range lengthening of 50% maximum speed nil pain
hamstrings while hamstring
weakness is present
 Rehab Protocol: non-op
Phase III:
Intervention: Goals:
● Bilateral RDL’s progressing to single leg dead ● Symptom-free (eg, pain and tightness) during
lift all activities
● Hip thrust ● Normal isotonic hamstring strength through
● Lateral lunges full range of motion and speeds
● Boxer shuffle & side shuffle ● Integrate postural control into sport-specific
movements
Precautions:
Avoid full intensity if pain/tightness/stiffness Criteria to next phase:
present ● <5-10% deficit bilateral eccentric hamstrings,
concentric quadriceps ratios AND peak force
● Ability to replicate sport specific movements
near maximal speed without pain
 References:
1- Maniar N, Carmichael DS, Hickey JT, Timmins RG, San Jose AJ, Dickson J, Opar D.
Incidence and prevalence of hamstring injuries in field-based team sports: a systematic
review and meta-analysis of 5952 injuries from over 7 million exposure hours. British journal
of sports medicine. 2023 Jan 1;57(2):109-16.
2- Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: a
new grading system. British journal of sports medicine. 2014 Sep 1;48(18):1347-51.
3- Hickey JT, Opar DA, Weiss LJ, Heiderscheit BC. Hamstring strain injury rehabilitation. Journal
of athletic training. 2022 Feb 1;57(2):125-35.
4- Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries:
recommendations for diagnosis, rehabilitation, and injury prevention. journal of orthopaedic &amp;
sports physical therapy. 2010 Feb;40(2):67-81.
5- Schmitt B, Tim T, McHugh M. Hamstring injury rehabilitation and prevention of reinjury using
lengthened state eccentric training: a new concept. International journal of sports physical
therapy. 2012 Jun;7(3):333.
6- Brukner P, Khan K. Brukner &amp; Khan’s clinical sports medicine: Injuries. 5th ed. Vol.
1. North Ryde, N.S.W.: McGraw-Hill Education; 2017.