Home > Injury Prevention, Knee Injury > Research Update on Hamstring Strain Injuries

Research Update on Hamstring Strain Injuries

Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right direction?  British Journal of Sports Medicine 46(2):81-85, 2012.

NOTES:  Hamstring strain injuries are one of the most common injuries to occur during sport, accounting for 6 to 29% of all injuries across a variety of sports.   This article highlights key findings of recent research studies investigating risk factors and rehabilitation considerations for hamstring strain injuries.

History of prior hamstring injury is the greatest risk factor for a future hamstring injury.  12-31% of individuals who suffer an initial hamstring injury go onto suffer re-injury.  Individuals with a prior hamstring injury are 2 to 6 times greater risk for re-injury compared to those without prior hamstring injury.   Given this information, individuals with a prior history of hamstring injury should undergo a thorough screening to identify the presence of additional risk factors for future injury (see below).  In addition, individuals with a previous history of hamstring injury may benefit from a maintenance exercise program focused on those risk factors described below, even after returning to full participation.

Decreased hamstring and hip flexor muscle group flexibility  have both been shown to be associated with increased risk of hamstring injury.  However, it should be noted that research in this area is not consistent regarding the effects of a lack of hamstring and hip flexor flexibility on risk of future hamstring injury.  Most research assesses hamstring flexibility during a passive straight leg test; however, more recent research indicates that a more dynamic active straight leg raise test may be more sensitive for determining risk for future injury and return to play.

Decreased hamstring muscle strength is not consistently shown to be a risk factor for future injury.  Most research assesses hamstring strength using an isokinetic dynamometer as the individual performs knee flexion while in a sitting position (hip flexed to 90-deg).  This may be a limitation of current research.  Research suggests that assessing eccentric hamstring strength (as the knee is extended) and hip extension strength may also be an important considerations.  Intervention studies examining eccentric strengthening (e.g. nordic hamstring exercise) of the hamstrings have shown mixed results.  It is suggested that this may be due to the fact that these exercises do not emphasize the role of the hamstrings as hip extensors.  Incorporation of exercises emphasizing the eccentric control of hip flexion (e.g. single leg deadlift, etc..) may also be important components of successful injury prevention and rehabilitation programs.

Few studies have examined the role of core stability in hamstring injuries.  Preliminary research indicates that individuals incorporating core stabilization training along with conventional hamstring strengthening suffer fewer re-injuries than those who undergo isolated hamstring strengthening.   Thus, exercises promoting lumbo-pelvic control (local and global core stabilization exercises) should be considered in conjunction with isolated hamstring strengthening.

Fatigue is also suggested as a potential risk factor for hamstring injury as more injuries are reported to occur at end of halves during matches.  Thus, training to promote fatigue resistance and muscle endurance should also be considered during the injury prevention and rehabilitation program.

It is clear that hamstring injuries are multi-factorial in nature and require a comprehensive strategy for prevention and rehabilitation.  Based on this article the following strategies may be considered:

  • Increase both hamstring and hip flexor flexibility.
  • Increase concentric and eccentric hamstring strength.  Consider the bi-articular nature of the hamstrings and address both the knee flexion and hip extension functions of the hamstrings.
  • Promote improved lumbo-pelvic motion control (control anterior pelvic rotation) by addressing both the local and global core stabilizing muscles.
  • Promote improved cardiovascular endurance and improved resistance to hamstring muscle fatigue during the later stages of the program.
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  1. Carl Eaton
    January 17, 2012 at 5:11 pm

    Dr. Padua,
    Was there any research on pelvic (Including SI) mobility as a risk factor? Thanks

  2. February 13, 2012 at 10:48 am

    FYI–The effectiveness of a sport-specific conditioning program in athletes with hamstring injuries: A systematic review of the literature
    By Chris Gellert, PT, MPT, CSCS, CPT

    Hamstring strength and weakness were the primary causes of hamstring injury in AFL and Rugby from our Systematic Review that was completed and pending publication as part of my Post Graduate Master’s Degree in Musculoskeletal & Sports Physiotherapy from the University of South Australia.

    References:
    1. Brooks, J, et al, 2006, ‘Incidence, Risk, and Prevention of Hamstring Muscle Injuries in Professional Rugby Union,’ American Journal of Sports Medicine, pp. 1297-1305.
    2. , M, Nosaka, K and Cronin, J 2009, ‘Application of eccentric exercise on an Australian Rules football player with recurrent hamstring injuries’, Physical Therapy in Sport, vol. 10, no. 2, pp. 75 – 80.
    3. Croisier, JL, Ganteaume, S, Binet, J, Gently, M and Ferret, JM 2008, ‘Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study’, Isokinetics & Exercise Science, vol. 16, no. 3, pp. 190 – 191.
    4. Elliott, MCCQ, Zarins, B, Powell, JW and Kenyon CD 2011, ‘Hamstring muscle strains in professional football players: a 10-year review’, American Journal of Sports Medicine, vol. 39, no. 4, pp. 843 – 850.
    5. Engebretsen, AH, Myklebust, G, Holme, I, Engebretsen, L and Bahr, R 2008, ‘Prevention of injuries among male soccer players: a prospective, randomized intervention study targeting players with previous injuries or reduced function’, American Journal of Sports Medicine, vol. 36, pp. 1052 – 1060.
    6. Foreman, TK, Addy, T, Baker, S, Burns, J, Hill, N and Madden, T 2006, ‘Prospective studies into the causation of hamstring injuries in sport: a systematic review’, Physical Therapy in Sport, vol. 7, no. 2, pp. 101 – 109.
    7. Hägglund, M, Waldén, M and Ekstrand, J 2007, ‘Lower reinjury rate with a coach-controlled rehabilitation program in amateur male soccer: a randomized controlled trial’, American Journal of Sports Medicine, vol. 35, no. 9, pp. 1433 – 1442.
    8. Key, J, Clift, A, Condie, F and Harley, C 2008, ‘A model of movement dysfunction provides a classification system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndrome: a paradigm shift – part 1’, Journal of Bodywork and Movement Therapies, vol. 12, no. 1, pp. 7 – 21.
    9. Law, M, Stewart, D, Pollock, N, Letts, L, Bosch, J & Westmorland, M, 1998, Critical Review Form-Quantitative Studies, McMaster University, pp. 1-3.
    10. Malliaropoulos, N 2011, ‘Hamstring Injuries,’ British Journal of Sports Medicine, vol. 45, pp.1-2.
    11. Mendiguchia, J & Brughelli, M, 2011, ‘A return-to-sport algorithim for acute hamstring injuries,’ Physical Therapy In Sport, vol. 12, pp. 2-14.
    12. Merlin, T, Weston, A and Tooher, R 2008, ‘Extending an evidence hierarchy to include topics other than treatment: revising the Australian ‘levels of evidence’’, BMC Medical Research Methodology, vol. 9, no. 1, pp. 34 – 41.
    13. Orchard, J and Seward, H 2002, ‘Epidemiology of injuries in the Australian Football League, seasons 1997–2000’, British Journal of Sports Medicine, Vol. 36, no. 1, pp. 39–44.
    14. Sherry, MA and Best, TM 2004, ‘A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains’, Journal of Orthopaedic & Sports Physical Therapy, vol. 34, no. 3, pp. 116 – 125.
    15. Steffen, K, Bakka, HM, Myklebust, G and Bahr, R 2008, ‘Performance aspects of an injury prevention program: a ten-week intervention in adolescent female football players’, Scandinavian Journal of Medicine & Science in Sports, vol. 18, no. 5, pp. 596 – 604.
    16. Wallden, M and Walters, N 2005, ‘Does lumbo-pelvic dysfunction predispose to hamstring strain in professional soccer players?’, Journal of Bodywork and Movement Therapies, vol. 9, pp. 99 – 108.

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