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How to manage hamstring muscle injuries

Are my feet getting bigger

Dodgy hammy? How to manage hamstring muscle injuries

By Doug James – Physiotherapist and Podiatrist at intraining running injury clinic. 

Are you dealing with a niggling hamstring injury that just won’t go away? Have you tried stretching it only to find it feels worse the next time you exercise? 

Hamstring muscle injuries are well studied in elite footballers. This is partly due to the high prevalence of these injuries in football (soccer) players[4,10], but also because of the large financial cost associated with keeping players healthy (soccer superstar Lionel Messi will get paid over $92,000 per day for the next few years[1]). While this research helps to progress management and treatment of injuries in non-elite athletes, it’s worth noting that there is a key difference in the type of injuries that footballers and distance runners typically develop. 

Location matters 

Hamstrings consist of 4 muscles found on the back of each of your thighs. The main functions are to assist the gluteus maxiumus to extend the hip (move the thigh backwards) and (along with the calf) flex the knee.  Research shows that hamstring muscle injuries typically occur in one of two locations [3,4,5,7]. In runners, hamstring muscle tears tend to occur in the distal (towards the knee) and mid portion of the lateral (outside) muscle, whereas footballers tend to develop the injury on the inner part of the upper hamstring. The difference in injury location is largely due to the different types of movement involved with each sport. Football injuries tend to occur during kicking where the muscle is forcibly overstretched [10]. By comparison, running injuries tend to occur during higher intensity running efforts where the muscle attempts to maintain length during the swing phase of gait [6]. Injuries can occur closer to the buttocks, though often this is a tendon injury – this article will focus on muscle injuries alone. 

Some good news 

The good news for runners is that the median recovery time for lateral hamstring injuries (dependant on relative severity) is about half that of medial/proximal hamstring muscle injuries [4]. 

…and some bad news 

While runners (with a lateral hamstring injury) can look forward to a speedier return to sport, this injury type tends to have a greater risk of reinjury [7] with up to one-third of athletes reinjuring the hamstring within a month of returning to sport[9]. This high reoccurrence rate needs to be factored in when planning the first 4-6 weeks of training after returning from injury. 

Risk factors 

Given that fast paced running is a high-risk activity for hamstring muscle injuries, the logical solution would be to avoid it – though this would be a shame as high intensity running carries a number of benefits for running performance.  

Muscle strength imbalance (where the quadriceps (thigh) muscles are far stronger than the hamstrings) also poses a risk. Aside from these, one of the biggest non-modifiable risk factors to getting a hamstring muscle injury is having had a previous hamstring injury [2,4,5,6] 

Changes to the neuromuscular system (muscles and the nerves that supply them) are common after injury and negatively affect how the muscle functions [6,7].  Age is the next highest risk factor [2,4,5,6,8] with the risk increasing for every year past 23 [8] – this may be a confounding finding, as the older you are, the more likely you are to have had a hamstring injury at some point, though there are possible biological reasons as well. As we age, we tend to have a reduction in the flexibility and quality of cartilage in our tendons which may predispose us to a greater risk of injury.  

Poor quality sleep and insufficient sleep, along with stress can lead to increased risk of injury. It’s suggested that less than 7 hours sleep can lead to a 30% increase in injury.  

What about super shoes? 

Super shoes (carbon fibre plated, thick soled racing shoes) may contribute to the development of injuries in this region. As this style of shoes is relatively new, little long-term research exists investigating its effect on injury. The stiff sole of super shoes means the big toe and ankle joint movements are altered which possibly puts stress on parts of the body in particular the pelvis, glutes and hamstrings. This finding is difficult to conclude given that people wearing this type of shoe are often running at a higher intensity which is a known risk for hamstring injuries.  

Watch for warning signs 

Athletes that develop hamstring muscle injuries often report a feeling of ‘tightness’ or ‘tenderness’ in the hamstring shortly before the injury strikes [5]. While hamstring tightness is a relatively common complaint (nearly everyone I treat complains they have tight hamstrings), noticing tightness on one side only is a particular concern. Having stiffness in your lower back or hips, or feeling stress and tried should also be treated with caution. In these cases, it would be wise not to undertake high intensity running such as speed work, hill running or races until these symptoms have been addressed. 

Prevention helps (somewhat) 

A large number of football-focussed studies show that hamstring strength training in the offseason can help reduce the burden and occurrence of hamstring muscle injuries during the competition period, though not completely. While this concept can translate to runners, a different series of exercises are required. Running technique can also play a role in the development of hamstring muscle injuries. Overstriding (landing on your foot too far in front of your body) is a fairly easily modified risk factor, though more difficult to control at higher speeds. 

What to do if injury strikes? 

A hamstring muscle injury can feel like anything from a sensation of tightness (Grade 1/mild injury) to a strong sharp debilitating pain (Grade 2-3/more severe injuries). In the less severe cases it’s often tempting to stretch your hamstring and return to running, however in cases where a muscle tear exists, these actions can greatly increase the amount of damage and likely recovery time – from what may have been a few days rest, to possibly several months off (and maybe even surgery). 

As per most injuries, rest and ice packs can greatly aid your recovery in the early days. Avoiding stretching is imperative to preventing further damage and early treatment usually results in faster recovery. Seeing a physiotherapist or sports podiatrist will help you to diagnose the type of hamstring injury (location and possible severity) based on the history and clinical examination. Scans, particularly MRI, can be helpful but are usually not necessary and are unable to accurately determine amount of recovery time needed [12]. 

The road to recovery 

Hamstring muscle injuries require a considered approach for proper rehabilitation. World renowned Sports Physician Peter Brukner proposes a seven-part management plan [8] addressing the following areas:  

    • Biomechanical assessment and correction 
    • Managing neurodynamics (nerve tension particularly in the sciatic nerve) 
    • Core stability 
    • Increasing hamstring muscle strength 
    • Incrementally increasing running speedwork 
    • Injection therapy 
    • Stretching/yoga/relaxation 

As mentioned previously, there is a high risk of reoccurrence with hamstring injuries, and so particular caution should be taken in the first 4-6 weeks of returning to sport and running. While the injury may feel 100% better there are adaptions to the nervous system that take time to overcome [11]. It’s been found that it can take up to 2 months for an athlete to return to return to their pre-injury maximum running speed (assuming minimal fitness was lost during the recovery period)[7] and so patience is needed while overcoming this injury. 

If you’ve developed a hamstring muscle injury, or are keen to learn how to avoid it, contact the intraining running injury clinic for an appointment. Now based at I-Health Indooroopilly. 

Hamstring muscle injuries – references:

[1] Source: Website: [cited 26.8.19] 

[2] Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football. Am J Sports Med 2004;32(1 Suppl):5S–16S. 

[3] Askling C. Types of hamstring injuries in sports. Br J Sports Med 2011 02;45(2). 

[4] Askling CM, Tengvar M, Thorstensson A Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols British Journal of Sports Medicine 2013;47:953-959. 

[5] Askling CM, Tengvar M, Tarassova O, Thorstensson A. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014 04;48(7):532. 

[6] Bourne M, Opar D, Shield A. Hamstring muscle activation during high-speed overground running: Impact of previous strain injury. Br J Sports Med 2014 04;48(7):571. 

[7] Brukner P. Hamstring injuries: prevention and treatment—an update British Journal of Sports Medicine 2015;49:1241-1244. 

[8] Brukner P, Nealon A, Morgan C, et al Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme British Journal of Sports Medicine 2014;48:929-938. 

[9] Petersen J, Hölmich P Evidence based prevention of hamstring injuries in sport British Journal of Sports Medicine 2005;39:319-323. 

[10] Schuermans J, Van Tiggelen D, Danneels L, et al Biceps femoris and semitendinosus—teammates or competitors? New insights into hamstring injury mechanisms in male football players: a muscle functional MRI study British Journal of Sports Medicine 2014;48:1599-1606. 

[11] Tam N, Santos-Concejero J, Coetzee D, Noakes T, Tucker R. Muscle co-activation and its influence on running performance and risk of injury in elite Kenyan runners. Journal of Sports Sciences 2016; (March), 1–7. 

[12] Wangensteen A, Almusa E, Boukarroum S, Farooq A, Hamilton B, Whiteley R, et al. MRI does not add value over and above patient history and clinical examination in predicting time to return to sport after acute hamstring injuries: a prospective cohort of 180 male athletes. Br J Sports Med 2015 12;49(24):1579. 


Doug James – Physiotherapist and Podiatrist

Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes to elite athletes. Bachelor of Podiatry (honours), Master of Physiotherapy Studies. Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment. Doug is also a keen runner having completed the New York Marathon.