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Hamstring Injuries


by Dr. Scott Greenapple, D.C., C.C.S.P., F.I.A.M.A.

In this article, we will discuss tendon injuries, specific to the hamstring muscle group. We will speak about some misdiagnosis, and inaccuracies regarding the injury and some treatment options for the athlete.

Hamstring injuries are probably the most common soft tissue injuries in athletes.

There tends to be a high rate of re-injury and continuous problems with this muscle group. Some of the more common factors of hamstring injuries are muscle weakness, lack of flexibility, poor posture, poor biomechanics, strength and muscular imbalance.

There tends to be two types of hamstring tendon injuries: slow onset with tightness, leading to an eventual "pull" in the hamstring, or a sudden onset with a pop or tear, and severe pain. Unfortunately, many times the slow chronic hamstring can turn into a sudden pull. There is increasing evidence that suggests this is due to an increase of myofascial tension within many structures surrounding and attaching to the hamstring group. Myofascial means muscle tissue and connective tissue(fascia). According to Myers, author of Anatomy Trains, muscle never attaches to bone. Muscle and fascia are continuous and transmit tension and pull from one structure to the next affecting areas above and below the injured area. The hamstring group lies within the posterior compartment of the thigh, and is made up of three muscles. The muscles cross both the knee and the hip joint. Strain and tension are distributed through the body via connections of fascial planes. Hamstrings attach to the sacrotuberous ligament (under the glutes) and below they insert into fascia surrounding bones in the lower leg. In essence, there is an integration of all muscle and bone into a matrix of myofascial components.

It is estimated that within a year, the average or competitive runner/triathlete will have a 60-70% chance of sustaining a soft tissue, repetitive stress type of injury. When speaking about soft tissue injuries, tendon problems are the most common and tend to be managed poorly. Hamstring "tendonitis" is a common presentation to the sports injury clinic. The inaccuracies, tend to lie within the physician themselves. Doctor's are taught and many still believe in the concept that overuse "tendonitis" is largely an inflammatory condition, and is still being treated with anti-inflammatory medication, i.e., NSAIDS like Advil, Motrin, Celebrex, etc. In reality, most over use tendon injuries are tendonopathies and have non inflammatory pathologies. Upon examination on a microscopic level of these tendons, there is an absence of classic inflammatory cells. What there is in these tendons, is random, disorganized patterns of fibers, with scar tissue. Tendonopathy or tendonosis is not only the accurate diagnosis, but the treatment and response to treatment are quite different from an inflammatory condition.

Treatments in my opinion that best address tendonopathies, include but are not limited to the following:

Active Release Technique:

Use of a practitioners hands using a specific force to individual muscle, ligament and tendons. The patient actively or passively moves the body through a range of motion, form a shortened muscle to a lengthened muscle. The treatment is used to break up scar tissue and remove adhesions. Be sure to use a certified ART practitioner.
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Graston Technique:

Graston Technique involves instrument assisted techniques. Use of stainless tools or other materials to break up scar tissue by gliding over the muscle or fascia, causing a micro trauma and controlling the re-injury to form proper aligning fibers for healing.
Learn more about Graston Technique...

Laser Therapy:

Use of coherent laser photons from low level cold laser to new class 4 which provide deeper penetration is more powerful. Lasers can stimulate healing at a cellular level as well as diminish inflammation and pain.
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Relative Rest:

Tendonosis can cause structural damage to the tendons themselves and may need a healing period. An athlete may still be able to train with modification to the biomechanics involved.

Biomechanic Evaluation:

Changing poor technique can be a major factor in elimination stressors on the body.

Postural Change:

Forward weight bearing as occurs during forward lean gait, can cause hamstring tension.

Spinal and Pelvic Manipulation:

Improves biomechanics and function to the lower kinetic chain of gait.


Many studies have shown acupuncture to be useful for pain relief as well as increasing blood flow to injured tissues.
Learn more about Acupuncture...

Hamstring injuries tend to be multifactorial in nature and need to be addressed accordingly. Different treatment methods need to be incorporated for the athlete to resume activity. Due to the rate of re-injury it is imperative the athlete includes a biomechanical evaluation and balance of all muscle groups before returning to his/her sport.

References available upon request.