“I’m getting too old for the Shit!” Maybe Sergeant Murtaugh of the Lethal Weapon movie was on to something here. Ok, that might be a little dramatic, but when you are aging gracefully and suffer an injury, it can certainly feel that way. I’m no stranger to the injury bug. Approximately 10 years ago, I suffered an Achilles rupture playing soccer a week after running the LA marathon. That definitely sucked! However, I was able to have surgery, effectively rehab and get back to running, even completed my first Triathlon on my 1-year anniversary from surgery. So here I am years later with the urge to get back into soccer, which I love playing, and what do you know?! In my first game, “POP!” There goes my hamstring! (are you sensing a theme with soccer here). For those of you who have ever strained/pulled your hamstring, you know the drill, you are running/sprinting and then it grabs you, all the muscles in the back of your thigh seize up in a gnarly cramp, you can’t take another step, and immediately grab the back of your leg, whimpering like a dog who is ready for their next meal. Well, maybe not the whimpering part, but a hamstring injury hurts! Let me say, as a Physical Therapist who has treated numerous hamstring injuries in the clinic, it is a very tricky and fragile muscle to rehab from. Let’s take the hamstring journey together.
Let’s Meet the Hamstrings
The hamstrings are a group of three muscles that are located in the back of the thigh. Their primary actions are to extend the hip (along with the Glute Max) and flex (bend) the knee. They are also a weak internal rotator at the hip. Their primary role during running is when your leg is swinging forward in the air, the hamstring muscle contracts eccentrically to slow the leg down and gets it ready to make contact with the ground. Here are the 3 muscles:
- Biceps Femoris: The lateral (outside) of the 3 muscles. Has a long and short head with the long head originating on the ischial tuberosity (sit bone) and the short head on the femur. They insert on the fibula at the lateral condyle of the Tibia.
- Semimembranosus: The most medial (inside) of the 3. Originates on the ischial tuberosity and inserts on the posterior region of the medial condyle of the Tibia.
- Semitendinosus: Located medially to the Biceps Femoris. Originates on the ischial tuberosity and inserts on the medial surface of the upper Tibia.
What is a Hamstring Strain?
Any type of muscle strain is basically different degrees of micro tearing to complete rupture of the muscle or tendon. This can occur when the muscle is stretched beyond its capacity or experiences a sudden force or subject to repetitive trauma. These injuries can lead to pain, inflammation and weakness in the area making you unable to perform the activity. You can have difficulty with walking or even bearing weight on the area. Hamstring strains typically occur with activities of sprinting, jumping or quick changes of direction (i.e., basketball, soccer (Yay!)). In running, the injury typically occurs when the hamstring works eccentrically (tightening while lengthening) to slow the limb down to get it ready for landing. Think of a tight or overworked muscle that we are taking to its full lengthened position and ask it to produce a maximal contraction to slow the leg so we can get ready to land to accept 3x our body weight. Poor freaking muscle, right? There are different classifications of strains:
- Grade I: Minor micro tearing/damage to the muscle. Typically causes very minimal loss of strength or function. Recovery usually takes a few days to a couple weeks.
- Grade II: Partial or incomplete tear of the muscle. Usually with a moderate loss of muscle strength, pain and inflammation. Can feel a little “pop”. You can usually feel the area with swelling and in a few days can see ecchymosis (bruising). Recovery usually takes a couple weeks to 2 months.
- Grade III: Most severe and is characterized by a complete rupture or tear of the muscle or tendon. Can be accompanied by a big “pop”. Significant pain and loss of strength. May require surgery to repair. Recovery usually 2 months to 6-8 months.
Hamstring Strain Symptoms:
Symptoms can range from mild to more severe depending on the grade of the strain. Symptoms can also get worse or develop a few hours or days after the injury.
- Pain or tenderness in the back of the thigh or up in the gluteal fold (sit bone)
- Swelling in the back of the thigh
- Bruising
- Weakness and loss of range of motion and mobility
- Difficulty walking, especially when trying to extend the leg out in front of you
- Muscle cramping, spams and/or tightness
How to treat a Hamstring Injury:
Hamstrings are a tricky muscle. They have a high rate of re-injury if not treated properly, and if you get back to your activity too quickly. This is not an injury in the acute phase that I would recommend my runners to continue to run through. This can make the injury worse and prolong the recovery. Also, a fun note, when you are “healed” (say that tongue and cheek) and able to return back to your sport, there is evidence that demonstrates when imaging is performed immediately after injury or down the road when you return to activities, there is usually still evidence of trauma that may never go away. Thus, there’s a high rate of re-injury. What a stupid, yet very important, muscle right?!
Treatment of the hamstring can usually be completed in different phases, although there can be a lot of overlap between these phases. I would definitely recommend seeing a professional to guide you through your recovery.
(See my resource page for the handout on how to treat Hamstring Strain for specifics on exercises)
- Initial phase: right after injury to a few days.
- Rest, now this does not mean sit and do nothing, which I don’t recommend, it means rest the activity that caused pain (running, sports). This is not the time to push yourself, rather let the initial healing process begin.
- Short walks, swimming and cycling with low resistance, as long as not painful, would be good activities.
- Ice to control the initial pain and inflammation.
- Gentle massage or myofascial release. I generally would not recommend aggressive foam rolling because of how tender the area is, but gentle massage to move edema, stimulate blood flow, and down regulate nervous system (desensitizing) to try and get area to relax. You can use your hands or gentle massage stick or massage gun. As tenderness subsides, you can be more aggressive.
- To stretch or not to stretch, that is the question? It’s tight, and I get the urge to stretch a tight muscle, however, this is not the time to aggressively stretch the area. We don’t want to make those micro-tears worse, as we want the area to fill in with tissue. I would suggest gentle mobility exercises. Feel free to stretch other areas that would not cause pain. Commonly folks with hamstring strains are tight in the quad and hip flexors. Hip flexors and quads would be great to stretch, as tightness in those areas can lead to re-injury of the hamstring.
- Gentle loading of the hamstring. It is important to start loading the muscle as to stimulate regenerative properties. Think of initial isometric exercises, such as supine heel digs, that you can start with the heels close to the glute muscles and work further away from your body. Isometrics also work as a pain analgesic effect. You can then progress to activities of bridging. Working in low-level soreness is ok, in fact, expected, but no sharp or stabbing pain.
- Single leg balance. This will help with some firing of the hamstring, as well as, complementary muscle activation.
- Middle Phase: This phase the pain is starting to subside, and your goal is to continue to load and rebuild the strength in the hamstring. Avoid anything that causes sharp stabbing pain. Minor soreness of ~3/10 or less is acceptable, and soreness should not last longer than 24 hours.
- Continue to progress loading: can now advance those bridges into longer holds or progress to more single leg bridges. Can do hamstring curls with the physio ball.
- Eccentric loading: exercises that contract the muscle while it is going through a lengthening position. This is the most force a muscle produces and usually how our hamstring is used during sport. Think single leg bridges off a step controlling the lowering, double leg deadlifts, single leg deadlifts and those dreaded Nordic hamstring curls, which has good evidence when you get stronger with this exercise, it has shown to reduce rate of re-injury in elite soccer players (you are damn sure this will be a staple in my routine from now on).
- Strength training: work on strengthening of all muscles groups. Weighted squats and lunges. Don’t forget the lateral glute muscles (see resource page for strengthening of glute muscles). Progress weight, as exercises get easier, as we want those legs strong.
- Stretch: This would be the time to start more stretching of the hamstring. Again, we want to be mindful not to do any aggressive stretching. Go to a point where you would feel more of a moderate stretch and not pain.
- Progress balance and proprioceptive training: balance on different unsteady surfaces like balance pads, BOSU ball, wobble board.
- More aggressive cycling adding more resistance or higher cadence. Again, no sharp stabbing pain. Minor soreness is ok as long as it subsides quickly after activity.
- More aggressive myofascial release. Can get in deeper with massage gun or utilize bodyweight rolling with foam roller.
- Walking longer distances. By this time, pain with walking should almost be gone so you can push the walking more and even incorporate hills and/or small hikes.
- Late Phase: This is the phase to get your hamstring ready to return to sport.
- Continue with hamstring exercises and progressive with either longer time under tension or increased resistance. Progress load with the eccentric exercises.
- Continue to stretch all LE muscles and continue this habit/routine.
- Dynamic warm up activities before performing activity/sport.
- Plyometric Drills: this will be sport- specific type of movements that incorporate speed and force to produce power. This will incorporate the muscles going into a quick stretch followed by a quick contraction to produce power, similar to how the muscle is used during sport.
- Agility exercises: rapid whole body movements with quick change in direction or velocity. This would be a good time to perform different cone drills or bring out the agility ladder.
- Return to run progression: See resource page for “return to run progression” handout.
When you work your way through these phases and everything is feeling strong, firing correctly and really no pain, it is time to return to your sport! And remember, just because pain is gone and you have returned to playing, does not mean that these exercises get thrown out the window. Cross-training of strengthening, stretching, and dynamic warm-up routines are essential to longevity and injury reduction of your activity. Remember, you need to BE FIT to do your activity, and not think that your activity alone causes you to be fit. We want to get to the point where we can say to ourselves, “We are never to old for this shit!”