The hamstring muscles are a thigh muscle group sited in the posterior thigh (back of the upper leg) and which are a common location of injury and persistent pain in sporting people. The typical areas which are preferentially injured are higher in the thigh near the buttock and towards the outer side of the leg. The muscles of the hamstrings have not been given common names and retain their Latin ones: biceps femoris; semitendinosus and semimembranosus. The most commonly injured of these three muscles is the biceps femoris.
A grading of severity is applied to hamstring injuries to assist diagnosis and treatment. A grade 1 injury will involve some damaged muscle fibres but a relatively mild strain. A grade 2 injury will involve a moderate strain of the muscle with an assessable loss of muscle power and a grade 3 injury involves a complete muscle tear or tear of the musculotendinous unit. Injuries are more common at the tendon and muscle junction in the upper areas of the muscle although the tendon-muscle junction of the biceps femoris occurs down much of its length. Injuries to the tendons themselves are uncommon unless there is a defined pathology already.
The ischial tuberosity (the bones we sit on or the “bones in the buttock”) is the originating point for most of the hamstring tendons. An avulsion fracture may occur at this point where a sudden, large range of motion occurs without warning and pulls off the tendon from the bony connection, an affliction most commonly seen in people who water ski. Younger people have larger numbers of such injuries as they are more active in sport and participating in risky activities such as contact sports, field sports, sprinting, rugby and football.
The hamstrings start at the ischial tuberosity in the buttock, run down the back of the thigh and insert into varying places on the tibia or fibula. When these muscles are contracting and lengthening at the same time (eccentric contraction) such as in track events and rugby, there can be a high risk of injury. Direct muscle blows can result in contusions to the tissues while water skiers are more prone to avulsion injuries as they fall because they undergo rapid hip flexion with their knees straight. Onset of a hamstring strain is typically sudden and often when the person is moving quickly, with an audible pop in the muscle often reported.
Pain is felt in the back of the thigh immediately and the injury is often either early in the activity (not yet warmed up) or late in the activity where tiredness may be a factor. General movements and functional activities such as stair climbing may be painful provided the injury is not too severe. There may be little to see in the posterior thigh of these patients but testing the ability to bend the knee against resistance may elicit a painful response. If one of the hamstring muscles is ruptured it may contract up into a ball on testing and the examiner will notice the reduced strength.
An increase in the risk of suffering from a hamstring injury is thought to occur if the quadriceps and hamstring strength ratios are incorrect, the person is tired, there is a poor warm up or a limitation of flexibility. A previous history of hamstring injury is a significant risk of having a recurrent strain. The approach to treatment of the injury is dictated by the severity of the muscle and tendinous damage and a physiotherapist will progress someone with a minor strain quickly onto strength training from range of movement work while more serious injuries may even need surgery.
The first aims of physiotherapy for an injury of a moderate level would be to limit the degree of local swelling and reduce the pain and inflammation from the soft tissue damage. Physios use the PRICE principles in these cases: Protection of the damaged tissues to prevent further damaging stresses being applied; Rest from normal activity and sport to allow the healing process to proceed; Ice in 20 minute bursts to control inflammation and pain; Compression over the damaged area with elastic wraps; Elevation of the part is not simple due to its location and that the patient wants to keep their knee bent.
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