Hamstring Strains- The All Too Common Injury

Picture this….an explosive movement that involves hip flexion and knee extension. What could go wrong? Well, this is the mechanism of a hamstring strain or tear. The classic actions are jumping, kicking, or running. Occasionally, a pop will be felt. We see hamstring strains and tears in our practice often, and frequently, the patient is mistreating their hamstring pathology by the time they get to us. Because of this, we hope this blog will provide education on appropriate first-line treatment before and when you seek medical attention.

First, can anyone name the three hamstring muscles? The answer is: Biceps femoris, semitendinosus, and semimembranosus. What’s the common injury in Major League Baseball: you’re thinking a shoulder or elbow problem, right? Not so fast…a hamstring strain is the most common injury in baseball, and likely the NFL and Major League Soccer as well.

Hamstring strain/tear prevention: proper warm-up, dynamic stretching, adequate rest and recovery, and strengthening. Specifically, the quadriceps muscles tend to get a lot more attention than our hamstrings because they are “look good” muscles. However, neglecting the hamstrings and creating a muscle imbalance definitely increases one’s risks of a hamstring injury. Also in regards to prevention, when a hamstring starts to feel tight or crampy, then that’s a warning sign. It’s then wise to minimize those explosive activities that often lead to a major strain.

In terms of radiographic diagnosis, x-rays are primarily only helpful to evaluate a patient for an avulsion fracture when the pain and strain is near the ischial tuberosity. These fractures are most common in skeletally immature patients such as younger teenagers with open growth plates. Musculoskeletal ultrasound, one of our areas of expertise, is a great and inexpensive way to visualize and grade hamstring strains in our office. Finally, an MRI is the most complete test to visualize a hamstring injury, but is not necessary in most patients and certainly the most expensive and time-consuming test.

Complete tears: If a complete tear is found, particularly proximally (at the origin at the “sit bone”), then surgical reconstruction is the typical treatment. I once knew someone who had liquid courage, (a.k.a., too much alcohol) on board and attempted to do the splits. He made it down into the splits but the explosiveness of the movement caused his hamstring to avulse off of the ischial tuberosity. He had to undergo surgery to reattach it. Needless to say, don’t try to do the splits, folks! Fortunately, complete tears are rare.

Strain/partial tear: This is most commonly the hamstring pathology we see. Hamstring injuries take a long time to heal. With proper treatment, this can be accelerated. The BIGGEST piece of advice I can give initially after the strain is DO NOT STRETCH the hamstring. It will commonly feel tight and feel like you need to stretch, but this will only strain the tendon and muscle belly further. Rest and activity modification are important steps in recovery. This even means to not lead up the stairs with the affected leg or bending at the waist, but instead with at your knees. Any activity that can tug on the hamstring, you should avoid. Other treatment options include thigh sleeve, steroid injection, physical therapy, and platelet-rich plasma (PRP) injections under the guidance of musculoskeletal ultrasound. PRP becomes a great option for proximal hamstring tendon problems that persist beyond a few months. We most commonly see this problem in long distance runners.

Recurrence: hamstring injuries are highly prone to recurrence. This is often due to a return to activity or sport too quickly and/or inadequate rehabilitation. This is why having an expert guide you in your recovery often decreases your risk of re-injury.

In a nutshell, if you have an acute or chronic hamstring injury, it’s best to seek medical attention as opposed to managing this yourself. Proper diagnosis, grading of the strain, discussion of treatment and prevention strategies along with a return-to-play/exercise plan is what we offer our patients.

As always, let us know if we can be of assistance to you!

Taylor Moore, NP and F. Clarke Holmes, M.D.