Ellen Pavlovic, DPT Doctor of Physiotherapy

Sports Physiotherapist, Dubai

Whether you’re running along the Creek, competing in a hilly trail race abroad, or doing a sprint interval workout, hamstring injuries are a common site of injury for runners. A premature return to running and sport will likely cause a reoccurrence of the injury, research shows this can be up to 40%! The average hamstring injury can cause an athlete to miss up to 3 weeks of running, but this can get up to 6 months if it is completely torn. Therefore, if you suspect an injury, proper care, and appropriate medical consults by your local sports medicine doctor and physiotherapist and keep you running strong!

Hamstring 101:

• The hamstring muscle complex consists of 3 muscles: semimembranosus, semitendinosus, and biceps femoris. The biceps femoris is reported to have the highest percentage of strains and injury.
• The hamstring complex is unique in that it crosses 2 joints, the pelvis, and the knee, it attaches to the pelvis and inserts just below the knee. It also performs 2 actions – extends the thigh back and flexes the knee

Causes of injury:

• Usually, a sudden movement or force applied to the hamstrings, typically during sprinting or high speed running – referred to as Type I strain. A Type II strain is typically caused by a sudden overstretch, often seen with dancers and gymnasts.
• The most important function of the hamstring for us runners is that it slows the leg during the swing face of running or performs an eccentric contraction. Lack of this functioning properly is a common cause of injury.

In tribute to the Dubai Creek Striders ½ marathon, here is a list of:

TOP 13.1 PREVENTION TIPS:

1. Appropriate stretching of the hamstrings before and after running! As the upper part of the hamstring is the most common site of injury, this is stretched in a different way than the belly of the muscle. It is advised to do both! To stretch the upper part (the most commonly injured part), in sitting, lying, or standing, have your leg outstretched but with your knee bent.
   

   With your foot on a bench or chair, keep your back straight and your knee bent slightly. Lean forward at your hips until you feel a stretch in the back of your thigh/knee. Hold for 20-30 seconds and repeat 2-3 times at a mild to moderate stretch pain-free.

   

   To target the muscle belly of the hamstrings: with your foot on a bench or chair, keep your back straight and your knee straight. Lean forward at your hips until you feel a stretch in the back of your thigh/knee. Hold for 20-30 seconds and repeat 2-3 times at a mild to moderate stretch pain-free.

2. Keep the hamstrings strong! When doing lower body strengthening, which we should ALL be doing, we often concentrate on the quadriceps. However, when the quadriceps overpower the hamstrings, this imbalance can lead to hamstring strains. A couple of common hamstring exercises are:
   

   With your feet propped on a chair or Swiss ball, lift up your pelvis and hold the top position for 5 seconds. Perform 2 x 15 and progress to performing with one leg.

   

   Grab a pair of dumbbells with an overhand grip and hold them at arm’s length in front of your thighs. Stand with your feet shoulder-width apart and knees slightly bent. Now raise one leg off the floor [A]. Without changing the bend in your knee, keep your back naturally arched, bend at your hips, and lower your torso until it’s almost parallel to the floor [B]. Pause, then squeeze your glutes, thrust your hips forward, and raise your torso back to the starting position. Perform 2 x 15.

3. Do a proper warm-up and cool-down. To target the hamstrings, this should include a dynamic warm-up such as walking and extending your leg and butt kicks. Also, don’t forget stretching (as explained in #1)!
   
4. Give your body some rest! Inadequate rest and recovery associated with greater training volume can cause access fatigue and thus strain on your muscles.
   
5. Gradually ease in incorporating speed (accelerating and decelerating) to your workout. Work on training programs before you start speed interval training so the hamstring muscles can adapt to sustaining these high acceleration forces. Especially important before the competition!
   
6. In addition to hamstrings stretches, stretch the large leg muscle groups before and after each run. This especially includes the hip flexors, the large muscle in front of your thigh that allows you to flex your hip, because if this is too tight, it can force your pelvis to rotate frontwards, thus causing strain on your hamstrings. Also your quadriceps and hips. All advised to hold for 20-30 seconds and perform 2-3x/each.
7. As mentioned previously, the hamstring muscle complex has an eccentric (lengthening) contraction during the late swing phase of running. Hence, hamstrings are most vulnerable during this change from eccentric to concentric activation during running. The best example of eccentric exercises for the hamstrings is the “Nordic drop”:
   

   The “Nordic drop” – You need something or someone to stabilize your legs. The goal is to hold as long as possible, to achieve maximum loading of the hamstrings. Lean forward in a smooth movement, keeping your back and hips extended, and work at resisting the forward fall with your hamstring muscles as long as possible until you land on your hands. Touch down with your hands, go all the way down so that your chest touches the ground, and forcefully push off into a kneeling position with minimal concentric loading on the hamstrings. The exercise progresses how far you can withstand the falling forward. The goal is to get the whole range of motion for 12 repetitions. Good luck!

8. Strengthen your gluteal muscles! The gluteal muscles (or the buttock muscles) as well as your hamstrings allow the hip to extend backward. When the gluteals are weak, they don’t have the power to extend the leg back sufficiently and thus can put extra strain on your hamstrings. Some gluteal exercises are:
   

   Lying on your back with one knee bent, lift up your pelvis and extend the opposite knee so the leg is completely straight and at the same level as the opposite bent knee (as shown in lower picture). Then either A) keep the leg straight and sustain it in that position for 10 to 20 seconds or B) keep the leg straight and slowly lower until the leg almost touches the floor, keeping your pelvis neutral and in a bridge position, and then rise up again or C) in the same position as before with your pelvis elevated and one leg extended, slowly lower your buttocks to just touch the floor, and then rise up again. All of these perform 10-20 repetitions (or seconds in A) – if doing correctly, you should feel your buttocks burn on the leg that has the knee bent!

9. Always strengthen your core muscles to keep your lumbopelvic area strong. This can include guided pilates exercises (which is advised to have proper training) and core exercises such as planks
   
10. Strengthen your hips! We often ignore strengthening our hips because in running we run straight forward, not side to side, but it is these muscles that are vital to the health of our hips, legs, and especially our knees. This especially includes the muscles that bring your leg out to the side (abduction), the gluteus medius and minimus. Some exercises to target these are side-lying hip abduction and side-lying clams.
    

    Lying on your side with your pelvis in a neutral position and the hips stacked, keeping your upper leg completely straight, raise the leg and hold for 5 seconds at the top position, and lower. Watch to avoid tilting your pelvis backward or forwards, they should always be aligned!

    

    Also known as the “clam” exercise – with your hips stacked and your pelvis in a neutral position, bend both your knees and then open the top knee until just above hip height, and then lower. Again, watch that your pelvis doesn’t tilt forward or backward and keep hips stacked and neutral!

11. When exercising, or when injured or recovering, DO NOT provoke pain! ALL stretches and exercises should be PAINFREE! AVOID activities that cause pain and STOP activity when there is a pain!
12. If you do have pain you should not always assume that it is your hamstring. Your sports medicine doctor and/or physiotherapist should examine you, and it is advised to have a diagnostic ultrasound or MRI to determine the exact location and extent of the injury.
13. Maintain high levels of cardiovascular fitness through not only running but cross-training and maintain muscular endurance by proper strength training to prevent fatigue.

13.1 DCS Summary of Prevention Tips:

Do seek professional help if you are suspect injury! Don’t always assume that it is the hamstrings if you have pain the back of your thigh. There are many other conditions such as biomechanical abnormalities, lumbopelvic contribution, spine pathology, muscle imbalances, to name a few, that can be a source of pain.

Care for your body with proper strengthening exercises and stretches before and after training. This will help prevent injury and re-injury.

Successful and safe running requires knowledge of the body!

Disclaimer: ALWAYS CONSULT A TRAINED PROFESSIONAL!

The information in this resource is general in nature and is only intended to provide a summary of the subject matter covered. It is not a substitute for medical advice and you should always consult a trained professional practicing in the area of sports medicine in relation to any injury. You use or rely on information in this resource at your own risk and no party involved in the production of this resource accepts any responsibility for the information contained within it or your use of that information.

References:

Agre J. Hamstring injuries. Proposed aetiological factors, prevention, and treatment, Sports Med 2:21-33, 1985.

Askling C. Thorstennson A. Hamstring muscle strain in sprinters. New Studies in Athletics 2008;23:67-79. Askling C. Tengvar M. Saartok T et al. Acute first-time hamstring strains during slow-speed stretching – clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med 2007;35:1716-24.

Battermann N, Appel HJ, Dargel J et al. An anatomical study of the proximal hamstring muscle complex to elucidate muscle strains in this region. Int J Sports Med 2011;32(3):211-5.

Chumanov E, Heiderscheit B, Thelen D. Hamstring musculotendon dynamics during stance and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-32.

Croisier J: Factors associated with recurrent hamstring injuries, Sports Med 34:681-695, 2004.

Heiderscheit BC, Sherry MA, Silver A, et al: Hamstring strain injuries: Recommendation for diagnosis, rehabilitation, and injury prevention, JOSPT 40:67-81, 2010.

Orchard J. Best TM, Verrall GM. Return to play following muscle strains. Clin J Sports Med 2005;15(6):436-41.

Orchard J, Best TM. The management of muscle strain injuries: An early return versus the risk of reoccurrence, Clin J Sports Med 12:3-5,2002.

Malliaropoulos N, Papalexandris S, Papalada A et al. The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Med Sci Sports Exerc 2004;36(5):756-9.

Mason DL, Dickens V, Vail A. Rehabilitation for hamstring injuries. Cochrane Data Syst Rev 2007(I): CD004575.

Proske U, Morgan DL, Brockett CL et al. Identifying athletes at risk of hamstring strains and how to protect them. Clin Exp Pharmacol Physiol 2004;31(8):546-50.

Schneider-Kolsky ME, Hoving JL, Warren P, et al: A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries, Am J Sports Med 34:1008-1015,2006.

Sherry MA, Best TM: A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther 34:116-125,2004.

Sports Medicine Australia brochure – Hamstring Strain: A Guide to Prevention and Management. www.sma.org.au, 2010. Verrall GM, Slavotinek JP, Barnes PG, Fon G, Spriggins A. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med 2001;35:435–9.

Woods C, Hawkins RD, Maltby S, et al. The Football Association Medical Research Programme: an audit of injuries in professional football – analysis of hamstring injuries. Br J Sports Med 2004;38(1)36-41.

Worrell TW. Factors associated with hamstring injuries. An approach to treatment and preventative measures, Sports Med 17:338-345,1994.