A delay in the recovery process is also associated with primary injury and indirect injury as the trauma mechanism.
The criteria for sports return are: absence of pain, ability to make the respective sporting movements without hesitation, recovery of strength and stretching of the involved muscle group, and the athlete's own confidence for returning to physical activity. The assessment of muscle strength can be determined by the isokinetic test.
Most HS relapses occur at the same site as the primary lesions, early after the return to sport; these new lesions are radiologically more severe. Specific exercise programs focused on preventing new injuries are highly recommended after returning to sports. Given the major complications of HS injuries, especially in athletes, prevention is still better than treatment and rehabilitation process, especially considering the threat of recurrence. Several studies have aimed to identify patterns that predict injury, in order to avoid or correct these situations.
Duhig et al. Van Dyk et al. However, Dauty et al. According to those authors, it is possible to predict the occurrence of HS injury based on the results of the test conducted at the beginning of the season. Schache et al. Despite the discrepancy between the different results of the studies, with variant methodologies, muscle strengthening is considered to be the main prevention factor.
Regarding muscle stretching, little has been shown about its prophylactic function. However, the most enduring clinical sign after HS injury is the reduction of muscle elongation; therefore, stretching is especially useful for rehabilitating the primary lesion and preventing relapse.
HS stretching with the pelvis in anterior inclination has been shown to be more effective than the standard stretches. Regarding muscle strengthening, Mendiguchia et al. This result ensures that the program maintains the athlete's performance and helps prevent HS injuries. Porter and Rushton 42 conducted a systematic review of the effectiveness of eccentric strengthening exercises in the prevention of HS injuries in male professional soccer athletes. Those authors concluded that, although sufficient evidence is still lacking, there is scientific support in the literature for the indication of this prevention modality.
In summary, many authors agree that an exercise program for eccentric HS strengthening may reduce the incidence of injury. The effectiveness of those programs can be explained by the fact that the injury typically occurs when the HS muscles act on the deceleration of knee extension through an eccentric contraction in the final swing phase during the stride, when they are elongated by hip flexion and knee extension. The force required for the deceleration is proportional to the speed and force applied in the sprint.
Nordic flexion is considered to be one of the most effective exercises in eccentric HS strengthening; it has been used with good results in professional soccer teams and amateur athletes. The exercise begins with the athlete kneeling with the thighs and trunk aligned, at a right angle to the legs. A training partner helps hold the feet and legs on the ground. The athlete initiates the activity by tilting the trunk toward the floor as slowly as possible, in order to increase the muscular load during the eccentric phase.
When the trunk approaches the ground, the upper limbs are used to prevent the fall and push the athlete's back, minimizing the loading during the concentric phase Fig. Nordic flexion: a athlete in initial kneeling position, b athlete makes the trunk inclination movement toward the ground as slowly as possible, with eccentric contraction of the hamstrings. Bourne et al. They also showed that the ST is the most significantly activated muscle. Regarding the analysis by electromyography, the same group, in a different study, 44 observed that, although not selective for LHBF, Nordic flexion presented the highest levels of activation in the eccentric contraction of this muscle when compared with the other exercises assessed in their study.
Those authors concluded that the HS muscles are activated differently during hip or knee-based exercises. Thus, exercises based on hip extension are more selective in lateral activation, whereas those with knee flexion preferentially engage the medial musculature. Laboratory parameters can also be used to prevent injury. Classically, creatine phosphokinase and lactate dehydrogenase are used as biochemical markers.
Serum levels depend on age, gender, ethnicity, muscle mass, physical activity, and even weather conditions. These parameters should not be used for the diagnosis or prognosis of lesions, due to their low sensitivity and specificity. However, an increase in these parameters indicates an incomplete recovery from the muscular overload when compared with the athlete's baseline measurements.
Special attention should be given to correcting factors that may predispose to injury. To Dr. Elio Stein Junior and the Instituto de Joelho e Ombro's physiotherapy team for kindly producing and submitting photos for this manuscript. National Center for Biotechnology Information , U. Journal List Rev Bras Ortop v. Rev Bras Ortop. Published online Aug 1. Author information Article notes Copyright and License information Disclaimer.
Lucio Ernlund: rb. Received Aug 17; Accepted Aug Published by Elsevier Editora Ltda. See the referenced article with doi: This article has been cited by other articles in PMC.
Abstract Hamstring HS muscle injuries are the most common injury in sports. Introduction Historically, hamstring HS injuries are described as frustrating for athletes as they are correlated with a long rehabilitation time; they have a tendency to recur and return to sport is unpredictable.
Open in a separate window. Clinical picture Clinical presentation of the patient depends on the characteristics of the lesion, which can range from stretching of the muscle fibers to tendon rupture. Risk factors Many studies have sought to identify the risk factors for HS injury.
Imaging tests Imaging tests confirm the diagnosis and provide information for therapeutic decision-making. Classification Classification systems are useful for physicians, athletes, and their coaches, as they guide treatment and prognosis. Table 1 British athletics muscle injury classification. No loss of tendon tension or discontinuity are observed. Loss of tendon tension may be observed, but there is no apparent discontinuity.
Grade 4 4 Complete muscle injury Complete muscle discontinuity with retraction. Table 2 Munich classification. Treatment Most HS lesions are muscle strains or partial lesions at the MTJ level that can be conservatively managed and generally result in full recovery.
Platelet-rich plasma Myogeny is not restricted to prenatal development; it also occurs in muscle regeneration after injury. Rehabilitation The rehabilitation process is based on muscle stretching and strengthening programs, since tissue healing involves muscle regeneration and fibrosis formation.
Prevention Given the major complications of HS injuries, especially in athletes, prevention is still better than treatment and rehabilitation process, especially considering the threat of recurrence. Conflicts of interest The authors declare no conflicts of interest. Acknowledgments To Dr. References 1. Agre J. Hamstring injuries. Proposed aetiological factors, prevention, and treatment. Sports Med. Carlson C. The natural history and management of hamstring injuries.
Curr Rev Musculoskelet Med. Ahmad C. Evaluation and management of hamstring injuries. Am J Sports Med. Brukner P. Hamstring injuries: prevention and treatment — an update. Br J Sports Med. Askling C. Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc. The preventive effect of the nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial.
Lempainen L. Clinical principles in the management of hamstring injuries. Ekstrand J. Kerkhoffs G. Diagnosis and prognosis of acute hamstring injuries in athletes. Hamstring and quadriceps isokinetic strength deficits are weak risk factors for hamstring strain injuries: a 4-year cohort study. The hamstring muscle complex.
A high number occur in sports where the hamstrings are stretched eccentrically at high speed such as athletics 5 , and in running contact sports such as Australian Rules football AFL 6 , American football 7 and soccer 1,3,8.
Hamstring injuries can also occur in recreational sports such as water-skiing and bull riding, where the knee is forcefully fully extended during injury 9, Generally, muscle injuries are common in soccer 8. The incidence of hamstring injury during matches and training sessions are 0.
Accordingly, a professional male soccer team with 25 players may expect about five hamstring injuries each season, equivalent to more than 80 lost football days and 14 missed matches 8. Despite a massive amount of recent research and consequent prevention programmes, hamstring injury incidence is not decreasing.
These considerations aside, when the injured hamstring belongs to Lionel Messi and the lesion occurs in a crucial period of the Champions League, the influences become widespread and significant.
As with the other football codes, hamstring injuries are responsible for the highest number of matches missed 20 per season per club on average , and sprinting is seen to be the main mechanism of injury.
On average, each AFL club may expect six hamstring strains per season Speculatively, this may be the result of more cautious return to play strategies. Interestingly, AFL is a good example of how the rules of the game can affect the risk of injury. In the rules of AFL were changed in order to improve the spectacle of the event such that the breaks in play, and therefore rest time for players, were reduced The rule changes also effected an increase in the number of player interchanges from an average of around 30 to more than per team, per game.
An analysis of the effect of these rule changes on injury rate showed them to be protective against hamstring injuries.
The sum of these opposing forces are that hamstring injury rates have not fallen, rather their distribution has changed relative to these interchanges. This may point to the role of fatigue in hamstring injury, already hypothesised in soccer, where the rate of hamstring strains are seen to increase toward the end of each half In a recent prospective study the most frequent diagnosis in sprinters was hamstring strain In athletics, the most common mechanism of hamstring injury is sprinting 18 and the most common injury site is the long head of the biceps femoris 5.
Biomechanical studies have shown that a powerful eccentric contraction in the late swing phase is the likely time when the hamstrings are most prone to injury 19 although others argue that hamstrings are at higher risk of injury in the early phase of sprinting Muscle injuries are a cause of con-siderable disability in American football both at senior and high school level The injury rate per hours of exposure is 0.
While the impact of hamstring strains in American Football 7 is similar to other sports such as soccer and AFL, their temporal distribution is worthy of review, particularly from a prevention point of view. The pre-season is seen to be a high risk period. They are the second most common pre-season injury, with an injury rate of 1. Furthermore, more than half The first month of National Football League NFL pre-season games, August, is also the month with the highest incidence of game injuries 7.
These high pre-season injury incidences are devastating not only because of their immediate impact but also because primary hamstring lesions are associated with decreased performance upon return to competition and have a high risk of re-injury during the competitive season Elliott et al 7 explain these results mainly with the relative deconditioning that occurs in the off-season. However, since this high incidence is not found in the pre-season period for other sports, training and match strategies should be reviewed in NFL.
Moreover, sport-specific conditioning, particularly with regard to strengthening and maximum-velocity sprinting, is suggested 7. Hamstring muscle injuries among water skiers. Functional outcome and prevention.
Hamstring Injuries. Overview The hamstrings are a group of three muscles located in the back of the thigh. Anatomy The three hamstring muscles are the semimembranosis, semitendinosis, and the biceps femoris. Diagnosis Injuries to these muscles are very common, particularly in sprinting athletes, such as soccer, baseball, and football players.
Treatment The majority of acute hamstring injuries are partial thickness tears. Outcomes Surgical repair for partial hamstring tears that have failed rehabilitation has been reported. References: 1. In-person and virtual physician appointments. Book online. Urgent Ortho Care.
Same-day in-person or virtual appointments. Get care. Injuries to the hamstring muscles are among the most common in sports and account for significant time loss. Despite being so common, the injury mechanism of hamstring injuries remains to be determined. Studies 1 written in English and 2 deciding on the mechanism of hamstring injury were eligible for inclusion. Literature reviews, systematic reviews, meta-analyses, conference abstracts, book chapters and editorials were excluded, as well as studies where the full text could not be obtained.
Twenty-six of screened original studies were included and stratified to the mechanism or methods used to determine hamstring injury: stretch-related injuries, kinematic analysis, electromyography-based kinematic analysis and strength-related injuries. All studies that reported the stretch-type injury mechanism concluded that injury occurs due to extensive hip flexion with a hyperextended knee. The vast majority of studies on injuries during running proposed that these injuries occur during the late swing phase of the running gait cycle.
A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended knee. Hamstring injuries during sprinting are most likely to occur due to excessive muscle strain caused by eccentric contraction during the late swing phase of the running gait cycle.
Peer Review reports. Hamstring injuries are common in several sports, with an overall incidence of 1. Furthermore, dancers exhibit a high incidence of muscle injuries [ 7 ]. The relevance of hamstring injuries in sports is therefore paramount. A growing body of research has focused on hamstring injuries, specifically to identify risk factors [ 8 , 9 , 10 ] and to develop prevention and rehabilitation programmes [ 11 , 12 , 13 , 14 , 15 ]. However, there is no consensus on hamstring injury mechanism.
Askling et al. The high-speed running type of injury typically affects the long head of the biceps femoris BFlh and has a shorter recovery time than the stretching type of injury, which commonly affects the semimembranosus SM [ 17 , 18 , 19 ]. In the literature, there are two theories on the mechanism of hamstring injuries sustained during running. One is based on the findings of Garret and Lieber et al. As a result, preventive studies have focused on eccentric strengthening, with, for example, the Nordic hamstring exercise, which is associated with a significantly lower injury incidence [ 25 , 26 , 27 ].
Mann et al. By defining the mechanism of injury, new preventive strategies can hopefully be created to help reduce the number of hamstring injuries and re-injuries among athletes and patients. The aim of this study was to investigate the hamstring injury mechanism in a systematic review. All the original studies that investigated the mechanism of hamstring injury or the biomechanical properties of the hamstrings were evaluated for eligibility.
Hamstring injury was defined as a strain injury to the hamstring muscle group. Therefore, hamstring injuries with avulsion fractures were not considered for this systematic review. Studies were included if 1 they were written in English and; 2 conclusions were extrapolated on the mechanisms of hamstring injury.
Literature reviews, systematic reviews, meta-analyses, conference abstracts, chapters from text-books and editorials were excluded, as well as studies where the full text could not be obtained.
A systematic electronic literature search was conducted on 21 February using the PubMed first available date , EMBASE starting in and the Cochrane Library first available date databases by an expert in electronic searching. A third search was carried out on 10 July For all databases, a similar search strategy was used, where the only differences were due to database configuration. The reference lists of all studies read in full text were screened for potential studies not previously identified.
All titles and abstracts were read and studies of potential interest were reviewed in full text independently by two authors Author 1 and Author 2 to decide on inclusion or exclusion. Disagreements were resolved through discussion with senior authors Author 7 and Author 8. Groups were created during the review process based on the common study methods used and different injury mechanisms reported. These groups are presented as stretch-related injuries, kinematic analysis, electromyograph-based kinematic analysis and strength-related injuries respectively.
The included studies were evaluated for their reporting quality using the Downs and Black Checklist [ 30 ] comprising 27 items. Ten of the items refer to the reporting of study results, three items refer to external validity, 13 items to internal validity and one item to power calculation. Since none of the included studies was interventional and only one study had comparative groups, a total of 16 items were used, while 11 were excluded from the qualitative analysis items 4—5, 8, 13—15, 19, 21— Of the 16 items used, seven examined the reporting of information, two examined external validity, six investigated internal validity and one item was related to power calculation.
Each item can be answered yes 1 point , no 0 points and unable to determine 0 points , except item 27, which may yield up to five points depending on the power calculation. The maximum score on the modified Down and Blacks Checklist is However, not all of the 16 included items were applicable to each individual study, as study methodologies differed. Two authors Author 1 and Author 2 independently performed the quality appraisal and differences were resolved with discussion Table 8 in Appendix.
After the removal of the duplicates, the remaining studies were screened by abstract and title. Eligible studies underwent full text assessment and 21 studies were included in the final systematic review. During the full text assessment, 52 previously unidentified studies were identified from the reference lists Fig. The quality appraisal with a modified version of the Downs and Black Checklist [ 30 ] resulted in a median range score of 8 7—14 points of 20 possible.
See Table 1 for full results. Of the 26 studies included, three investigated stretch-type hamstring injuries [ 19 , 31 , 45 ], 10 performed a kinematic analysis [ 28 , 32 , 35 , 37 , 39 , 46 , 47 , 51 , 52 , 53 ], 10 additional studies performed a kinematic analysis combined with an electromyographic EMG analysis [ 33 , 34 , 36 , 38 , 41 , 42 , 43 , 44 , 48 , 54 ] and three analysed muscle strength [ 40 , 49 , 50 ].
Six studies analysed actual hamstring injuries [ 19 , 31 , 37 , 45 , 46 , 47 ], one study compared previously injured and uninjured individuals [ 49 ], while 19 studies performed the analyses on uninjured individuals and estimated the hamstring injury mechanism [ 28 , 32 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 48 , 50 , 51 , 52 , 53 , 54 ].
A summary of the suggested hamstring injury mechanisms is presented in Table 2 and a comprehensive summary of the included studies can be found in Table 9 in Appendix.
Three studies investigated hamstring injuries in dancers and water skiers and scored a median range of 10 points 8—11 out of 20 possible on the modified Downs and Black Checklist.
All three studies reported that hamstring injuries occurred due to extensive hip flexion with a hyperextended knee [ 19 , 31 , 45 ]. In one study of dancers, the quadratus femoris and adductor magnus were injured simultaneously with the hamstrings [ 19 ].
Nine of these studies were conducted on runners [ 28 , 32 , 37 , 39 , 46 , 47 , 51 , 52 , 53 ] and one on race walkers [ 35 ]. High-speed cameras and skin-placed markers on anatomic landmarks were most commonly used to study the injuries while the subjects ran on a treadmill or track. In four studies, a force plate was added to obtain additional information [ 35 , 46 , 47 , 51 ].
One study measured BFlh dimensions using MRI images which were subsequently used in a simulation of hamstring injury mechanics [ 32 ]. Three studies were able to record a hamstring injury in real time [ 37 , 46 , 47 ].
However, two of these studies based their conclusions on data from the same study subject [ 46 , 47 ]. Seven studies made estimations of where the hamstrings were at highest risk of injury [ 28 , 32 , 35 , 39 , 51 , 52 , 53 ]. Two studies reported that hamstring injuries occur during the early stance phase [ 28 , 39 ], while running with a forward trunk lean [ 39 ]. In contrast, seven studies concluded that hamstring injuries occur during the swing phase [ 32 , 35 , 37 , 46 , 47 , 52 , 53 ] and one study concluded that both phases exhibit a risk of injury [ 51 ].
It was proposed that the late or terminal swing phase placed the hamstring muscles at the highest risk of injury Table 3. Ten studies performed EMG-based kinematic analysis [ 33 , 34 , 36 , 38 , 41 , 42 , 43 , 44 , 48 , 54 ] measured with either surface or needle electrodes [ 33 ] and, in some cases, with additional force plates [ 36 , 41 , 48 ].
The modified Downs and Black Checklist yielded a total median range score of 8 8—14 of 20 possible for these studies. Seven studies analysed runners [ 33 , 34 , 38 , 41 , 44 , 48 , 54 ], one study used race walkers [ 36 ], one evaluated volleyball players performing different jumping tasks [ 42 ] and one study compared muscle activity while standing on one leg with different trunk and pelvic positions in healthy volunteers [ 43 ].
One study concluded that the risk of hamstring injury is greatest during the early stance phase [ 41 ], while five studies reported that injury occurred during the swing phase [ 33 , 34 , 36 , 38 , 48 ]. One study suggested that hamstring injury may occur during either the early stance phase or late swing phase [ 44 ], while another study reported that injury could occur during both the late stance and late swing phase Fig.
One study reported that anterior trunk sway and contralateral pelvic drop while standing on one leg increased the load on the hamstrings [ 43 ], while another study reported that the hamstrings are at risk of injury during concentric, braking movements [ 42 ].
All conclusions were based on estimations of when the highest risk of hamstring injury occurs, i. One study measured seated isokinetic strength in 20 football players prior to, during and after an exercise protocol set to simulate the muscle fatigue induced by a football game [ 40 ].
It was reported that hamstring injury was caused by lower eccentric strength due to fatigue [ 40 ]. Two studies used muscle functional magnetic resonance imaging mfMRI to compare metabolic activity before and after an eccentric hamstring exercise in previously uninjured and injured football players [ 49 , 50 ].
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