eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Hamstring Strain

Author: Jeffrey M Heftler, MD, Interventional Physiatrist, Orthopaedic and Neurosurgical Specialists, Greenwich, CT
Coauthor(s): Michael F Saulino, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, Thomas Jefferson University, MossRehab
Contributor Information and Disclosures

Updated: Apr 10, 2009

Introduction

Background

Hamstring injuries are common problems that may result in significant loss of on-field time for many athletes because these injuries tend to heal slowly. Once injury occurs, the patient is at high risk for recurrence without proper rest and rehabilitation.

The hamstring muscles are 3 muscles in the posterior thigh: the semitendinosus, semimembranosus, and biceps femoris. The semitendinosus originates at the ischial tuberosity and inserts at the pes anserine; the semimembranosus originates at the ischial tuberosity and inserts at the posterior medial tibia. The biceps femoris has a long head that originates at the ischial tuberosity and a short head at the posterolateral femur and inserts into the head of the fibula. Both muscles serve as knee flexors and hip extensors. (See image below and Image 1.)

Normal sagittal alignment permits the knee to loc...

Normal sagittal alignment permits the knee to lock in full extension, aided by powerful quadriceps and an intact extensor mechanism. The ground reaction force passes anterior to the "center of rotation" of the knee, while the posterior cruciate ligament, posterior capsule, hamstrings, and gastrocnemius provide a tension band effect.

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Normal sagittal alignment permits the knee to loc...

Normal sagittal alignment permits the knee to lock in full extension, aided by powerful quadriceps and an intact extensor mechanism. The ground reaction force passes anterior to the "center of rotation" of the knee, while the posterior cruciate ligament, posterior capsule, hamstrings, and gastrocnemius provide a tension band effect.


At heel strike of the gait cycle, the hamstrings actually contribute to knee extension through closed chain kinetics. During the gait cycle, the biceps femoris contracts eccentrically in terminal swing, which is important in the pathology of the injury, as discussed later.1,2,3

Frequency

United States

Hamstring strain is a fairly common injury in physically active individuals.

Mortality/Morbidity

No mortality is associated with hamstring strain; however, morbidity is common, due to pain and reinjury if proper rehabilitation does not occur before the patient returns to preinjury activity levels.

Age

While hamstring injuries can occur in people of any age, incidence increases with age.

Clinical

History

Hamstring strain is a noncontact injury and usually occurs with either acute or insidious onset. Strain injuries frequently are seen in athletes who run, jump, and kick. Avulsion injuries are seen in patients who participate in water-skiing, dancing, weight lifting, and ice-skating. The avulsion injury usually follows a burst of speed, and the patient may report a popping or tearing sensation. The most commonly affected muscle area in the hamstring complex is the short head of the biceps femoris,3 possibly because of its innervation.

  • As with most strain injuries, the injury can occur at the following 4 places:
    • Origin of the muscle
    • Musculotendinous junction
    • Muscle belly
    • Insertion of the muscle
  • Injury is most likely to occur while the musculotendinous junction undergoes maximum strain during eccentric contraction of the hamstrings.
  • The American Medical Association (AMA) has described 3 grades of severity of hamstring injuries.
    • First-degree strain is the result of stretching of the musculotendinous unit and involves tearing of only a few muscle or tendon fibers.
    • Second-degree injury refers to a more severe muscle tear without complete disruption of the musculotendinous unit.
    • Third-degree injury refers to a complete tear of the musculotendinous unit.

Physical

In addition to pain in the posterior thigh, the physical examination may reveal any of the following signs or symptoms:

  • Tenderness over the site of injury
  • Ecchymosis
  • Palpable mass
    • A palpable defect may be felt with severe strains, but swelling and the deep location of the muscle may obscure this finding in the acute stage.
    • Palpate the muscle for a defect with the patient in a prone position and the knee flexed to 90°. This position relaxes the muscle and decreases cramping and pain. Palpate while maintaining slight tension on the muscle.
  • Pain with passive extension of the knee and the hip flexed at 90°, as compared with the noninjured side, which stretches the muscle
  • Pain with resisted knee flexion, which activates the muscle

Causes

Many different causative factors can contribute to hamstring injuries. The most significant causes include the following:

  • Inadequate flexibility of the hamstrings can result in injury. This may be related to the patient having no or a poor stretching routine.
  • Inadequate strength or endurance of the hamstrings with either a side-to-side weakness or an imbalance between the hamstrings and the knee extensors can lead to injury.
  • Muscle fatigue can lead to dyssynergia of muscle contraction.
  • Insufficient warm-up time may be involved.
  • Poor running technique may play a role.
  • Return to activity before complete healing has occurred can lead to recurrence.

More on Hamstring Strain

Overview: Hamstring Strain
Differential Diagnoses & Workup: Hamstring Strain
Treatment & Medication: Hamstring Strain
Follow-up: Hamstring Strain
Multimedia: Hamstring Strain
References
Further Reading
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References

  1. Schache AG, Wrigley TV, Baker R, et al. Biomechanical response to hamstring muscle strain injury. Gait Posture. Feb 2009;29(2):332-8. [Medline].

  2. Yu B, Queen RM, Abbey AN, et al. Hamstring muscle kinematics and activation during overground sprinting. J Biomech. Nov 14 2008;41(15):3121-6. [Medline].

  3. Silder A, Heiderscheit BC, Thelen DG, et al. MR observations of long-term musculotendon remodeling following a hamstring strain injury. Skeletal Radiol. Dec 2008;37(12):1101-9. [Medline].

  4. Davis KW. Imaging of the hamstrings. Semin Musculoskelet Radiol. Mar 2008;12(1):28-41. [Medline].

  5. Warren P, Gabbe BJ, Schneider-Kolsky M, et al. Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med. Aug 14 2008;[Medline].

  6. Sallay PI, Ballard G, Hamersly S, et al. Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex. Orthopedics. Nov 2008;31(11):[Medline].

  7. Agre JC. Hamstring injuries. Proposed aetiological factors, prevention, and treatment. Sports Med. Jan-Feb 1985;2(1):21-33. [Medline].

  8. Baquie P, Reid G. Management of hamstring pain. Aust Fam Physician. Dec 1999;28(12):1269-70. [Medline].

  9. Brukner P. Hamstring injuries. Aust Fam Physician. Jul 1996;25(7):1109-12. [Medline].

  10. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. Jul-Aug 1998;6(4):237-48. [Medline].

  11. Hartig DE, Henderson JM. Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees. Am J Sports Med. Mar-Apr 1999;27(2):173-6. [Medline].

  12. Hennessey L, Watson AW. Flexibility and posture assessment in relation to hamstring injury. Br J Sports Med. Dec 1993;27(4):243-6. [Medline].

  13. Laskowski E. Concepts in sports medicine. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: Saunders; 1996:930-1.

  14. Medical Economics Staff. Physician's Desk Reference. 55th ed. Oradell, NJ: Medical Economics Co; 2000:2631-4.

  15. Pomeranz SJ, Heidt RS Jr. MR imaging in the prognostication of hamstring injury. Work in progress. Radiology. Dec 1993;189(3):897-900. [Medline].

  16. Scoggin JF 3rd. Common sports injuries seen by the primary care physician. Part II: Lower extremity. Hawaii Med J. May 1998;57(5):502-5. [Medline].

  17. Speer KP, Lohnes J, Garrett WE Jr. Radiographic imaging of muscle strain injury. Am J Sports Med. Jan-Feb 1993;21(1):89-95; discussion 96. [Medline].

  18. Worrell TW. Factors associated with hamstring injuries. An approach to treatment and preventative measures. Sports Med. May 1994;17(5):338-45. [Medline].

  19. Yamamoto T. Relationship between hamstring strains and leg muscle strength. A follow-up study of collegiate track and field athletes. J Sports Med Phys Fitness. Jun 1993;33(2):194-9. [Medline].

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Keywords

hamstring strain, hamstring, pulled muscle, muscle strain, pulled hamstring, pulled muscles, hamstring injury, strained muscle, strained hamstring, hamstring muscle, hamstring pain, hamstring treatment, torn hamstring, hamstring muscles, hamstring tendon, strained muscles, hamstring injury treatment, hamstring pull

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Contributor Information and Disclosures

Author

Jeffrey M Heftler, MD, Interventional Physiatrist, Orthopaedic and Neurosurgical Specialists, Greenwich, CT
Jeffrey M Heftler, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michael F Saulino, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, Thomas Jefferson University, MossRehab
Michael F Saulino, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Curtis W Slipman, MD, Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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