Hamstring complaints

Training with knee pain

The fast facts:

  • Hamstring injuries are common in a variety of sports
  • In professional soccer, 12 - 16 % of all injuries are hamstring injuries
  • in 75% of all cases it involves the biceps femoris
  • Within two months, 12-25% of individuals with a hamstring injury re-injure the hamstring
  • No clear criteria exist as to when sport can be safely resumed
  • Sport resumption should therefore be a deliberate choice where multiple factors need to be viewed

Anatomy and function of the hamstrings

The hamstrings are a group of muscles on the back of your thigh. This muscle group runs from your ischial tuberosity to both the inside and outside of your knee. The hamstrings is active across two joints, the hip and the knee. Because the function of the hamstrings is dual, the risk of injury is also greater.

Cruciate ligament injury

The different types of hamstring injury

A hamstring injury is one of the most common non-contact injuries in various sports. We can classify hamstring injuries into two different types. This classification is made based on the mechanism of origin.

A type 1 hamstring injury is the result of injuries caused by a sprint or peak load on the muscle group. In addition to sprinting, other examples include: jumping, hurdling in athletics or a deadlift in powerlifting. When we look at sprinting we see that this injury often occurs in the moment when the foot is just about to hit the ground. In this phase of the sprint pattern, the forces are at their highest. The muscle is now firing at maximum but must also brake eccentrically to maintain good control of the knee and position of the foot on the ground. 

  • 12-16% of all injuries in professional soccer are hamstring injuries
  •  In 75% of the cases, the injury is to the biceps femoris

A type 2 Hamstring injuries are injuries where there is a lot of strain on the muscle. We often see this in gymnasts or dancers. This happens when the hip has to bend to the maximum and the muscle stretches excessively. In most cases, this is a less painful injury but the recovery time is often longer because the injury is in the upper part of the hamstring towards the tendon. This type usually involves injury to the semimembranosus.

Grades of muscle injury

With a muscle injury, we use different degrees. It is possible that there is only muscle pain or a slight strain. But it may also be that there is a muscle tear or even a complete tear. 

  • 1A Fatigue of the muscle which can result in muscle strain, usually from overuse or from exercising on a different surface.
  • 1B Muscle pain, generalized muscle pain of the adductors, usually caused by powerful moments of deceleration during sport.
  • 2A Muscle injury due to radiating pain from the low back 
  • 2B A local neuromuscular dysfunction of the muscle
  • 3A Minor localized muscle tear less than 1 muscle 
  • 3B Moderately large muscle tear, multiple muscle bundles involved in the injury 
  • 4 (Sub)total muscle tear, avulsion fracture 
  • Muscle bruising due to severe impact with person or object from outside


Risk factors for getting a hamstring injury

There are several known risk factors for developing on hamstring injuries:

  • A previous hamstring injury
  • Reduced strength of the hamstrings relative to the quadriceps
  • An older age increases the risk of a hamstring injury
  • Fatigue during sport
  • Reduced neuromuscular control 
  • Reduced pelvic control/lower back

How a hamstring injury is diagnosed

A discoloration may be seen on the back of the leg. In addition, the picture is confirmed by pain on tightening, stretching and palpation of the hamstring. Additional examination is often not helpful in a hamstring injury. The chosen treatment will not change much, if at all. However, an avulsion fracture should not be missed.

Avulsion fracture

An avulsion fracture occurs particularly after an accident where the knee is stretched forcibly and the hip is bent. An example of this is slipping with your leg forward. There is blue discoloration of the back of the leg in all cases. There is also severe pressure pain on the seat bone. When there is an avulsion fracture, there is no tension in the tendon that attaches to the seat bone. In this case, an MRI or ultrasound scan is necessary.

Physical testing for a Hamstring injury

Often the diagnosis is already fairly clear when there is discoloration. To confirm this suspicion, several physical tests are performed where the recognizable symptoms are provoked. 

Strength test of the hamstring

The hamstring provides knee flexion and hip extension. These two directions are therefore tested by the examiner. The test is positive when there is recognizable pain. 

Stretch and palpation of the muscle group

With the knee in an extended position, the hip is flexed. When there is recognizable pain the test is positive. When there is a grade II hamstring injury it can be observed at the site of the tear.



Knee Osteoarthritis
Ruben Luijkx

Low back and hamstring rehabilitation specialist Ruben Luijkx

The different phases in the treatment of a hamstring injury

Successful rehabilitation consists of several phases and steps. Good strength, coordination and optimal movement patterns are necessary to safely return to your sport. 

Adjusting the (training) load

In this phase, we focus primarily on symptom reduction. There is often swelling, pain and reduced mobility of the hip and knee. Therefore it is important to regain good control of your movements in the hip and knee. After an injury to the hamstring we often see a change in the walking pattern. It is therefore important to quickly regain proper function of the muscle. 

Strength and coordination phase:

In this phase there is more of a build up in strength. How quickly this is built up depends on the response of the hamstring to the given load. Because the risk of a new hamstring injury is high after previous injury, it is extremely important to make a sustained build up in strength and coordination of the hamstring. and the rest of the chain. Often this is vastly underestimated and the chances of re-injury are greater than intended. 

Sport-specific phase:

The final phase focuses particularly on maximum strength, jumping power and explosiveness. This is all necessary to be able to change direction quickly within your sport. We also work towards a competition condition so that you can continue to perform under fatigue. The quality of movement must remain good under these conditions. One of the main pillars is high intensity runs, it is seen in the literature than individuals after a hamstring injury sprinted significantly less often, if they did there was a greater chance of a relapse/re-injury. the importance of a good build up in high speed sprints is therefore of utmost importance.

Sports Resume: 

The timing of resuming sport remains a difficult decision. This is because there is no clear proven criteria exist for sports resumption. Wanting to start again too soon often leads to a new injury. In all cases, the athlete must be able to sprint again painlessly, tighten the hamstring as much as possible and perform sport-specific skills (shooting a ball). In addition, a measured build-up in training should be made before (competition) matches can be resumed.

Rehabilitation at Fysio Fitaal

During rehabilitation, there can always be small or large setbacks that come your way. Especially in certain phases, things will go slower than you had thought beforehand. Patience is necessary. Our specialists will guide you in this process as well as possible and motivate you where necessary. Fysio Fitaal works with specialists in the field of sports rehabilitation. Because of this combination of expertise, extensive facilities and passion for sports you are at the right place with us.

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