Hamstring Strain Rehab - Part 1

Rehab
Written By Jacob Keeling

Hamstring strains are one of the most common injuries in soccer players, accounting for approximately 15% of all injuries. These injuries typically occur in athletes whose sports require explosive movements, such as American football, track, rugby and soccer. 

Hamstring injury rates have been rising over the last several decades, and the UEFA Elite Club Injury Study found hamstring injury rates had increased from 12% (2001), to 24% (2022). 66% of these injuries occurred in matches, with the other 34% in training. There does also appear to be a fatigue factor, as the majority of hamstring strains occur in the last 15 minutes of each half.

Hamstring injuries have the highest likelihood of re-injury in soccer players. Nearly 20% of players re-injure the muscle. Most relapses occur within the first 2 months of the initial injury, so care must be taken to not rush the athlete’s recovery.  

Mechanism of Injury

Most hamstring injuries will involve some combination of:

  1. High velocity movement

  2. Large amount of force on the hamstring muscles

  3. Hamstring lengthening

The most common mechanism of injury occurs during sprinting. A “stretch” type injury can also occur with high force hamstring lengthening, such as with high kicking or slide tackling. The “sprint” type injury is more common, and athletes will typically recover from this more quickly than the “stretch” type injury. The forces on the hamstring muscle group are greatest during the swing phase of sprinting as they work to decelerate the lower limb and offset the forces from the quadriceps. Athletes will often feel a pull or “pop” when they strain their hamstring, and they may have a feeling of tightness in the hamstrings prior to injury.


Anatomy Review

 
 

The hamstring muscle group is made up of 4 muscles. The 2 heads of the biceps femoris are on the outside of the leg, and the semimembranosus and semitendinosus are on the inner side. The vast majority (~80%) of hamstring injuries occur at the biceps femoris as it undergoes the greatest amount of stretch during sprinting. Three out of four of these muscles cross both the hip and the knee joint, meaning they both bend the knee as well as extend the hip backwards. As a result, our rehab must incorporate both hip and knee dominant exercises, which we will get to in part 2 of this series.

Hamstring Strain Grades

  • Grade I (mild)

    • Slight tearing with minor swelling/discomfort and little to no loss of strength

    • 0-3 weeks

  • Grade II (moderate)

    • Partial tear with clear weakness and pain

    • 3-6 weeks

  • Grade III (severe)

    • Complete tear of one of the hamstring muscles

    • 6-12 weeks

    • This may require surgical repair

    • If that is the case, expect return to sport within 4 to 6 months of surgery

How do you know if you’ve torn your hamstring?

  • You may feel a pop or pull.

  • There will likely be pain with actively bending your knee, bending over, and stretching your hamstrings. 

  • Pain and weakness with resisted testing.

  • There may be bruising in the back of the thigh. 

  • Pain with palpation over the muscle. 

Typically recovery will be quicker with lower pain levels, minimal strength loss, small area of tenderness, and a normal 90/90 straight leg raise (with minimal pain). Distal injuries (closer to the knee) typically recover more quickly than proximal (closer to the hip) injuries. 

Most hamstring injuries heal well conservatively, but some of the more severe ruptures or avulsions may require surgery. In these instances, you will need an MRI to discover the extent of the tear. If you are unsure of the severity of your injury, make sure to get it checked out by a healthcare professional.

Risk Factors

Older, male players tend to be more at risk. One study by Verrall et al found that after 20 years of age the risk of hamstring injury increases by 1.3 times every year. Male athletes are 2-4 times more likely to sustain a hamstring injury compared to females. The likelihood of recurrent strains is also significantly higher in males.

  • Age

  • Previous injury

  • Hamstring weakness

  • Fatigue

  • Strength imbalance between quads and hamstrings

  • (Potentially limited flexibility of the quads and hamstrings)

Key Takeaways

  • Hamstring injuries are one the most common injuries for soccer players and they have the highest re-injury rates.

  • The most common mechanism of injury is sprinting, followed by a “stretch” type injury, which can occur during kicking or sliding.

  • The vast majority of these injuries occur at the biceps femoris muscle.

    • This muscle crosses both the hip and the knee joint. As a result, rehab should include both knee and hip dominant exercises.

  • Injuries closer to the knee typically recover faster than those closer to the hip.

  • Older players tend to be more at risk and male athletes are 2-4x more likely to strain their hamstrings than females.


    Stay tuned for part 2, where we will discuss rehab and return to sport for hamstring injuries.

References

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  2. Hickey JT, Opar DA, Weiss LJ, Heiderscheit BC. Hamstring Strain Injury Rehabilitation. J Athl Train. 2022 Feb 1;57(2):125-135.

  3. Jokela A, Valle X, Kosola J, et al. Mechanisms of Hamstring Injury in Professional Soccer Players: Video Analysis and Magnetic Resonance Imaging Findings. Clin J Sport Med. 2023 May 1;33(3):217-224.

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  12. Bisciotti GN, Chamari K, Cena E, Carimati G, Bisciotti A, Bisciotti A, Quaglia A, Volpi P. Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature. Joints. 2020 May 25;7(3):115-126. 

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  17. Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48:532–9.

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  20. Mendiguchia J, Garrues MA, Cronin JB, et al. Nonuniform changes in MRI measurements of the thigh muscles after two hamstring strengthening exercises. J Strength Cond Res 2013;27:574–81. 

  21. Macdonald B, McAleer S, Kelly S, et al. Hamstring rehabilitation in elite track and field athletes: applying the British athletics muscle injury classification in clinical practice. Br J Sports Med 2019;53:1464–73.

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Jacob Keeling
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