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Hamstring Injury

WHAT IS THE DIFFERENCE BETWEEN A HAMSTRING STRAIN AND HAMSTRING TENDINOPATHY?

  • Hamstring injuries are common in sports and can involve the hamstring muscle or tendon. Hamstring strains are generally defined by damage to the hamstring muscle. Hamstring tendinopathy is generally caused by a failed healing response due to overuse and load on the tendon.

WHAT IS THE HAMSTRING?

  • Three muscles in the back of the thigh make up the proximal (high) hamstring complex: the biceps femoris muscle, semitendinosus muscle and semimembranosus muscle. The hamstring is essential for movements, including standing, walking, running and sprinting. During these activities, the hamstring slows knee extension, with the greatest strain on the hamstring occurring during the swing phase of gait as the muscle elongates. Contracting the muscle at this stage, such as with rapid acceleration and deceleration, can strain the hamstring resulting in tearing of the muscle or tendon. The hamstring crosses both the hip and knee joints, contributing to the movement of both the hip and the knee. Because the hamstring crosses both the hip and knee joints it is more vulnerable to injury with sport and rapid movements [Azzopardi et al, 2020].

WHAT IS HAMSTRING TENDONITIS?

  • Hamstring tendonitis, or proximal hamstring tendinopathy, is a condition characterized by pain and dysfunction at the origin of the hamstring tendon. This condition is often seen in both athletic and non-athletic populations and can result in long-standing pain that limits sporting and daily activities [Goom et al, 2016]. Tendonitis occurs when the hamstring tendon becomes inflamed, usually as a result of overuse or misuse. This repetitive stress causes inflammation and irritation of the tendon muscle fibers which can lead to small microscopic tears overtime.

WHAT IS A HAMSTRING STRAIN?

  • Hamstring muscle strains is an injury to one or more of the muscles in the hamstring group, which includes the biceps femoris, semitendinosus, and semimembranosus. These injuries are common in athletes and typically occur during activities that involve high-speed running or sudden acceleration and deceleration. Hamstring strains can occur at the myotendinous junction, where the muscle fibers transition to tendon, or the muscle belly [Clanton & Coupe, 1998; Allahabadi et al, 2024]. The hamstring slows knee extension when running or sprinting, with the greatest strain on the hamstring occurring during the swing phase of gait as the muscle elongates. The mechanism of injury usually involves an eccentric contraction, where the muscle lengthens while contracting, leading to excessive strain and potential tearing of the muscle fibers [Danielsson et al, 2020; Opar et al, 2012].

WHAT ARE THE SYMPTOMS OF A HAMSTRING INJURY?

  • Patients may experience deep buttock pain with a tendon injury or pain in the back of the thigh with a muscle strain. The pain may worsen with activities such as running, jumping, or prolonged sitting [Sheean et al, 2021].

  • In acute cases, patients may experience feeling or hearing a “pop” at time of injury. Swelling or bruising around the injured area may also be present.

  • In some cases the presentation is more insidious and patients can present with a more gradual pain and stiffness in the back of the thigh or buttocks that is worsened with prolonged sitting or running activities.

HOW IS A HAMSTRING TEAR/TENDONITIS DIAGNOSED?

  • Diagnosis is based on detailed history, physical examination, and imaging. During the physical examination, a series of provocative tests may be utilized to further determine presence of injury.

  • Advanced imaging may be required to confirm diagnosis and determine injury severity. Both magnetic resonance imaging (MRI) and ultrasound effectively identify and assess hamstring injuries, although MRI has been shown to be more accurate than ultrasound for evaluation of deeper muscle injuries [Chu et al, 2017]. An MRI can reveal characteristic changes at the tendon-bone interface [Sheean et al, 2021].

Ultrasound of a Hamstring Partial Tear
Ultrasound of a Hamstring Partial Tear
Ultrasound showing the hamstring attaching to the ischial tuberosity with hypoechoic (dark signal) signaling partial tears (arrows).

HOW IS A HAMSTRING TEAR/TENDONITIS TREATED?

Conservative Management

  • Management of hamstring tendonitis typically begins with conservative measures, and can include rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. NSAIDs are used for pain relief and physical therapy aims to strengthen and rehabilitate the injured area [Goom et al, 2016; Startzman et al, 2017].
  • Eccentric strengthening has shown promises in treating tendinopathy, but no randomized controlled trials have specifically looked at eccentric programs for hamstring tendinopathy.

Extracorporeal Shockwave Therapy (ESWT)

  • Shockwave therapy may be used as an adjunct therapy for chronic hamstring tendinopathies. Learn more about shockwave therapy here.

  • The evidence for using shockwave therapy to treat proximal hamstring tendinopathy is promising.
    • A randomized controlled trial by Cacchio et al. demonstrated that shockwave therapy (SWT) is effective for chronic proximal hamstring tendinopathy in professional athletes. The study included 40 athletes who were randomly assigned to receive either SWT or traditional conservative treatment (TCT). The SWT group received 2500 impulses per session at a 0.18 mJ/mm² energy flux density for 4 weeks. Results showed significant improvements in pain and function in the SWT group compared to the TCT group, with 85% of the SWT group achieving a reduction of at least 50% in pain at 3 months post-treatment, compared to only 10% in the TCT group (P < .001) [Cacchio et al, 2011].
    • A systematic review by Korakakis et al. also supports the use of radial extracorporeal shockwave therapy (rESWT) for proximal hamstring tendinopathy, indicating that rESWT is superior to conservative treatment in the short, mid, and long term [Korakakis et al, 2018].
    • Another systematic review by Rhim et al. found that ESWT may be effective for proximal hamstring tendinopathy and is generally well-tolerated with minimal side effects, making it a viable treatment option for athletes and physically active individuals [Rhim et al, 2024].

Steroid Injections

  • Corticosteroid injections for proximal hamstring tendinopathy and hamstring tears have been studied with varying results. Historically, steroids have been used in the treatment of tendon pain, but corticosteroid injections appear to only provide short-term pain relief for proximal hamstring tendinopathy and hamstring tears. The long-term efficacy of corticosteroid injections is questionable, and they may not be the best option for sustained symptom management.

  • For proximal hamstring tendinopathy:

    • A study by Zissen et al. demonstrated that ultrasound guided corticosteroid injections provided symptomatic relief in 50% of patients for more than one month, and 24% experienced relief for more than six months suggesting that corticosteroid injections can be effective in the short term for pain relief in tendinopathy [Zissen et al, 2010].

    • A systematic review by Coombes et al. highlighted that while corticosteroid injections can provide short-term pain relief for tendinopathies, their benefits are not sustained in the intermediate and long term, and they may be associated with worse outcomes compared to other treatments over time [Coombes et al, 2010]. This is consistent with findings in other tendinopathies, suggesting caution in their use for long-term management.

  • For hamstring muscle tears:
    • A study by Levine et al. in professional football players found that intramuscular corticosteroid injections were safe and helped hasten return to play without complications. However, this study did not include a control group, limiting the ability to definitively conclude efficacy [Levine et al, 2000].

Platelet Rich Plasma (PRP) Injections

  • Platelet rich plasma (PRP) is a minimally invasive non-surgical treatment that promotes healing without surgery using a concentration of a patient's own platelets and growth factors injected into the injured area to stimulate healing (learn more about PRP here).

  • PRP has shown promising results in the literature, specifically in chronic (patients with >3 months of pain) hamstring injuries and appears to offer some benefit in reducing the time to return to play and lowering reinjury rates for partial hamstring tendon tears (Fader et al, 2015).

  • PRP for chronic hamstring tendon injuries:

    • A systematic review and meta-analysis by Seow et al. evaluated the efficacy of PRP injections for hamstring injuries, including partial tears. The study found that PRP combined with physical therapy (PT) non-significantly reduced the mean time to return to play (RTP) by 5.67 days compared to PT alone. The reinjury rates also non-significantly favored PRP + PT (risk ratio,0.88) [Seow et al, 2021].
    • A randomized controlled trial by Hamid et al. demonstrated that a single PRP injection combined with a rehabilitation program significantly reduced the time to RTP in patients with grade 2 hamstring muscle injuries. The PRP group had a mean RTP of 26.7 days compared to 42.5 days in the control group (P = .02) [Hamid et al, 2014].
    • Another study by Trunz et al. compared conservative treatment with a combination of hematoma aspiration and PRP injection in athletes with grade 2 hamstring strains. The PRP group had a significantly shorter RTP time (23.5 days vs. 32.4 days, P < 0.001) and a lower recurrence rate (4% vs. 28.6%, P = 0.025) [Trunz et al, 2022].
  • PRP for chronic hamstring muscle injuries:
    • A study by Kruse et al. found that Platelet poor plasma (PPP) resulted in a faster return to sport compared to PRP for acute thigh muscle injuries, with patients in the PPP group returning to unrestricted participation in sport 22.89 days more quickly than the PRP group (p < 0.001). No significant difference in recurrent injury rates was observed between the groups [Kruse et al, 2024].

Surgical Intervention

  • Surgical options include debridement and reattachment of the hamstring tendons, particularly in cases of partial or complete tendon avulsions with significant retraction [Sheean et al, 2021; Startzman et al, 2017; Fletcher et al, 2021].

  • The decision for surgery is guided by the severity of the injury, the degree of tendon retraction, and the patient's functional demands and response to conservative treatment [Allahabadi et al, 2024; Sheean et al, 2021; Fletcher et al, 2021; Plastow et al, 2023; Kayani et al, 2020; Moatshe et al, 2016]. Patients most likely to benefit from surgical interventions for hamstring tendonitis are:

    • Patients with significant tendon retraction: Specifically, those with proximal hamstring injuries involving two or more tendons with greater than 2 cm of retraction.

    • Patients with significant tendon retraction: Specifically, those with proximal hamstring injuries involving two or more tendons with greater than 2 cm of retraction.

    • Patients with symptomatic displaced bony avulsions: These cases often require surgical intervention to restore function and alleviate symptoms.

  • Surgical intervention for acute complete tendon rupture have shown good to excellent results, and generally results in better functional outcomes, higher rates of return to sport, and greater patient satisfaction compared to nonoperative management [Lefevre et al, 2024; Harris et al, 2011]. Risks of surgery include, infection, nerve damage due to the proximity of the sciatic nerve, deep vein thrombosis (DVT), wound-related complications and prolonged rehabilitation [Fletcher et al, 2021; Devitt, 2018].

  • In cases of proximal hamstring tendinopathy, surgical treatment may become an option for patients with chronic symptoms that do not respond to conservative treatment [Costa et al, 2016], but for tendinopathy some studies have shown greater pain after the surgery than before [Aldridge et al, 2012].

Learn more about how surgery compares to platelet rich plasma (PRP) here.

Arthroscopic hamstring repair (Maier et al (2023) Repair of Retracted Hamstring Tears with Hamstring Pulley Technique and Inferomedial Portal)

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