The American Journal of Sports

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Evaluation and Management of Hamstring Injuries

Christopher S. Ahmad, Lauren H. Redler, Michael G. Ciccotti, Nicola Maffulli, Umile Giuseppe Longo and James
Bradley
Am J Sports Med published online May 23, 2013
DOI: 10.1177/0363546513487063

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 AJSM PreView, published on May 23, 2013 as doi:10.1177/0363546513487063

Clinical Sports Medicine Update

Evaluation and Management

of Hamstring Injuries
Christopher S. Ahmad,* MD, Lauren H. Redler,*y MD, Michael G. Ciccotti,z MD,
Nicola Maffulli,§ MD, Umile Giuseppe Longo,|| MD, and James Bradley,{ MD
Investigation performed at the Center for Shoulder, Elbow, and Sports Medicine, Department
of Orthopaedic Surgery, Columbia University, New York, New York

Muscle injuries are the most common injuries in sports, with hamstring injuries accounting for 29% of all injuries in athletes. These
injuries lead to prolonged impairment and have a reinjury risk of 12% to 31%. They range from mild muscle damage without loss
of structural integrity to complete muscle tearing with fiber disruption. Novel MRI scores are increasingly being used and allow
a more precise prediction of return to sport. In this article, the authors review the history, mechanisms of injury, and classification
systems for hamstring injuries as well as present the latest evidence related to the management of hamstring injuries, including
intramuscular and both proximal and distal insertional injuries. Indications for surgical treatment of certain proximal and distal
avulsions, biological augmentation to the nonoperative treatment of midsubstance injuries, and advances in risk reduction and
injury prevention are discussed.
Keywords: hamstring; biceps femoris; semimembranosus; semitendinosus; platelet-rich plasma; cell therapy; hamstring injury
prevention; proximal hamstring repair; distal hamstring resection

Hamstring injuries are among the most common lower as skiing, dancing, skating, and weight lifting are associ-
extremity injuries in athletes,3,32,34,57,132 accounting for ated with hamstring injuries, particularly the proximal
up to 29% of all injuries in various sports21,40,57,99,100,128; avulsion type.3,34
in addition, they may produce prolonged impairment and The injuries range from mild muscle damage without
an immense reinjury risk of 12% to 31%.40,48,128 These loss of structural integrity to complete muscle tearing
injuries are most common in sports requiring rapid acceler- with fiber disruption. Reductions in the incidence, severity,
ation such as running, hurdling, jumping, and kicking and reinjury risk of hamstring injuries have obvious poten-
sports. Hamstring strains account for 50% of muscle inju- tial to reduce medical costs and time lost from sport.
ries in sprinters and are the most common injury in hur- Advances in diagnosis, classification, newer surgical and
dling.22 Most hamstring strains in the United States biological treatments, as well as prevention strategies
National Football League (NFL) are sustained during non- may offer future benefits.
contact activities, with sprinting as the primary activity.48
‘‘Speed positions’’ (receivers, defensive backs, and running
backs) have significantly higher rates of hamstring muscle THE HAMSTRING MUSCLE GROUP
strains compared with ‘‘strength positions’’ (offensive and
defensive linemen). Sports with ballistic movements such Gross Anatomy
The hamstring muscle group consists of the biceps femoris
y
Address correspondence to Lauren H. Redler, Center for Shoulder, (long and short heads), the semitendinosus, and the semi-
Elbow, and Sports Medicine, Department of Orthopaedic Surgery, membranosus. All 3 muscles, except for the short head of
Columbia University, 622 West 168th Street, PH-11 Center, New York,
NY 10032 (e-mail: lauren.redler@gmail.com).
the biceps femoris, originate from the ischial tuberosity
*Center for Shoulder, Elbow, and Sports Medicine, Department of as a common tendon. They then separate 5 to 10 cm distal
Orthopaedic Surgery, Columbia University, New York, New York. to the ischium, with the semimembranosus first to become
z
Center for Sports Medicine, Rothman Institute, Department of Ortho- distinct.58 The muscle fibers of the biceps femoris are visi-
paedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania. ble 6 cm distal to the tuberosity, and the proximal myoten-
§
Centre for Sports and Exercise Medicine, Queen Mary University,
London, United Kingdom. dinous junction encompasses approximately 60% of the
||
Department of Trauma and Orthopaedics, Campus Biomedico Uni- total length of the muscle.58 The semimembranosus muscle
versity, Rome, Italy. fibers appear within the proximal 30% of this muscle, and
{
Center for Sports Medicine, University of Pittsburgh Medical Center, the semitendinosus muscle fibers insert directly to the
Pittsburgh, Pennsylvania.
ischial tuberosity at the proximal musculotendinous junc-
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution. tion.58 The short head of the biceps femoris originates
just medial to the linea aspera in the posterior distal
The American Journal of Sports Medicine, Vol. XX, No. X femur. The long head of the biceps femoris attaches to
DOI: 10.1177/0363546513487063 the fibular head and the lateral tibia.120 The short head
Ó 2013 The Author(s)

1
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2 Ahmad et al The American Journal of Sports Medicine

of the biceps femoris attaches into the tendon of the long degradation, and inflammation. Blood vessel damage
head of the biceps femoris as well as fascial and tendinous results in bleeding and clotting. A local ischemic environ-
insertions to the posterolateral capsule, the iliotibial tract, ment can result, causing further muscle damage and
the fibular head, and the proximal lateral tibia.120 The edema. The healing process involves muscle regeneration
semimembranosus has multiple insertions at the postero- and fibrosis. A properly aligned extracellular matrix is
medial corner of the knee.124 The semitendinosus joins required to maintain optimal myofibril orientation. With
the sartorius and gracilis tendons to form the pes anseri- an intact or repaired basal lamina acting as a scaffold,
nus on the medial aspect of the proximal tibia, overlying myofibrils can regenerate. Early range of motion after
the medial collateral ligament. The distal musculotendi- injury can minimize disorganized scar formation and
nous complex covers approximately 66% of the length of reinjury.116
the biceps femoris and slightly more than 50% of the length
of the semimembranosus and semitendinosus muscles.124
The semimembranosus, semitendinosus, and long head Risk Factors for Injury
of the biceps femoris are innervated by the tibial portion of
the sciatic nerve, and the short head of the biceps is inner- A variety of risk factors have been proposed for hamstring
vated by the peroneal portion of the sciatic nerve. The injuries, including inadequate warm-up, strength imbal-
semimembranosus adds stability to the knee and functions ance, lower extremity flexibility,17,63,126 core stabil-
to flex and medially rotate the leg at the knee as well as ity,38,64,90,112 muscle weakness,41,42,99 fatigue,87,128,132
extending, adducting, and medially rotating the thigh at dehydration, and a history of injury.8,13,49,55,101 Strength
the hip.2,32,88 The semitendinosus is a flexor and internal imbalance refers to either a difference in hamstring
rotator of the tibia at the knee and also provides valgus strength between lower extremities or an altered ratio of
stability to the knee.2,32,88 The short head of the biceps hamstring-to-quadriceps strength in the same extrem-
functions to flex the knee with the thigh extended; the ity.32,77,129 Thresholds of side-to-side hamstring deficits of
long head gives posterior stability to the pelvis and extends .10% to 15% or a hamstring-to-quadriceps strength ratio
the femur at the hip.2,32,88 of \0.6 increase the injury risk.24,32,71,77 These ratios, how-
ever, most likely vary with sex, sport, and position played.**
Muscle weakness40,42,118,131 and, more recently, poor
Mechanism of Injury core stability have been associated with hamstring inju-
ries.31,64,90,112 Lumbopelvic position, which is in part con-
The hamstring muscle group spans both the hip and knee trolled by abdominal muscle activity, may influence
joints, producing potential for rapid and extreme muscle hamstring muscle length and stiffness.31,73 Fatigue is
lengthening. Injury occurs most commonly during eccen- a risk factor, and more hamstring injuries occur toward
tric muscle contraction.57,132 During the last 25% of the the end of an athletic competition.47,128 Animal studies
swing phase, the hamstrings assist in proximal hip exten- have demonstrated that eccentric loads of fatigued muscles
sion while decelerating knee extension distally. The ham- result in significantly more damage than isometric or con-
strings remain active during the first half of the stance centric loads.46,104 Similarly, increasing muscle tempera-
phase to produce hip extension and resist knee extension ture may increase the ability of the muscle tendon unit
through a concentric contraction.2 Sprint mechanics to absorb force.46,104
research suggests that strain injury risk is greatest near Flexibility remains controversial as a risk factor. Pro-
the end of the swing phase, when the hamstrings reach spective studies8,13,49,55,56,99,131 demonstrate no relation-
maximal length and undergo eccentric contraction just ship between flexibility of the knee flexors and hamstring
before heel strike.61,108 The mechanism of proximal avul- injury, but other studies have shown an association
sions is through an eccentric contraction with the hip between flexibility values obtained in preseason training
flexed and the knee extended and occurs with higher and injuries suffered during the season.17,63,126,129,130 In
energy ballistic activities.# addition, an association between reduced hip flexor flexi-
bility and the risk of hamstring injuries has been
Pathological Changes reported.54
Seasonal timing of hamstring strains has been demon-
The myotendinous junction experiences the highest eccen- strated in the NFL, with the preseason identified as the
tric loads and is the most common location of most vulnerable period.48 Factors implicated in this trend
injury.32,34,36,38,89 Muscle belly injuries are less common are the relative deconditioning and muscle weakness that
but can occur with direct trauma or contusion.3,32 Com- occur in the off-season.
plete ruptures are rare and tend to occur with pre-existing Perhaps the most significant risk factor is a previous
tendinopathy. In the simplest injury, only the myofibrils hamstring injury, which increases the risk of reinjury by
are damaged, resulting in leakage of the cytoplasmic 2 to 6 times.7,13,49,55,101 A previous hamstring injury may
enzyme creatine kinase. With greater injury severity, the lead to the formation of weakened scar tissue at the injury
extracellular matrix and fascia become damaged, followed site, thereby lowering the threshold to a recurrent
by release of muscle enzymes, collagen and proteoglycan injury.3,21,49,51,56,123

# **
References 22, 32, 34, 66, 88, 106, 107, 127, 132. References 2, 19, 24, 25, 32, 40, 62, 71, 88, 104, 132.

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Vol. XX, No. X, XXXX Hamstring Injuries 3

Figure 2. The Puranen-Orava test for hamstring tendinop-

athy and strain.

more commonly, distal avulsion, a thickened area of subcu-

taneous tissue may be identified adjacent to the
injury.34,36,38
Palpation of the injured posterior thigh from the ischial
tuberosity to the posterior aspect of the knee localizes the
injury by eliciting either tenderness or appreciating
a defect. Precise location is often difficult, given the deep
location of the muscles, especially proximally. The range
of motion of both lower extremities should be assessed. A
careful comparison of side-to-side symmetry of the hips
and knees will help to estimate the severity of the injury.
The popliteal angle is determined by flexing the hip to
90° with the knee flexed to 90° and then slowly extending
Figure 1. Clinical appearance of diffuse posterior thigh the knee passively. The knee flexion angle at which poste-
ecchymosis with a proximal myotendinous hamstring injury. rior thigh pain and guarding occur is compared with that
in the contralateral, uninjured leg. An increased angle on
the affected side suggests a hamstring injury.32
Clinical Presentation Hamstring strength should then be assessed with the
patient in the prone position and the knee flexed to 90°.
History. Most athletes experience acute, sudden sharp Resisted active knee flexion may help to more precisely
pain in the posterior thigh, often with an audible or palpa- determine the location and severity of the injury. Active
ble pop,32,129 during an activity requiring a combination of knee flexion while the examiner extends the knee to 30°
sudden hip flexion and knee extension as in running, jump- reproduces the common eccentric load mechanism and
ing, and kicking sports.3,32,129 A smaller number note an also aids in diagnosis. These maneuvers should be com-
insidious onset of progressive hamstring tightness,38,129 pared with the uninjured limb.
and some athletes may have an acute or chronic onset.32,129 Several special provocation tests have more recently
Some athletes experience loss of hamstring flexibility, par- been proposed to evaluate hamstring injuries, particularly
ticularly with recurrent mild episodes of injury. Proximal tendinopathy and milder strains.26 The Puranen-Orava
avulsion injuries may cause discomfort with sitting. Ath- test (Figure 2) is performed by an active stretch of the
letes often describe difficulty in walking smoothly. hamstrings with the patient standing. The hip is flexed
Physical Examination. Inspection begins with an to 90°; the knee is then fully actively extended, and the
assessment of gait with a ‘‘stiff-legged’’ gait pattern often heel is held on a support. The bent-knee stretch test (Fig-
noted as the athlete attempts to avoid simultaneous hip ure 3) is performed with the patient supine. The hip and
flexion and knee extension.3,34 Most often, minimal ecchy- knee of the symptomatic extremity are maximally flexed,
mosis is observed; however, broad ecchymosis along the and the knee is then slowly passively extended by the
posterior thigh may be encountered and may indicate examiner. The modified bent-knee stretch test (Figure 4)
a high-grade myotendinous injury or a proximal avulsion is also performed with the patient supine and the symp-
injury (Figure 1). In cases of a muscle belly rupture, tomatic leg fully extended. The examiner maximally flexes
a defect may be palpable.32 With either proximal or, the hip and knee and then rapidly extends the knee. With

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4 Ahmad et al The American Journal of Sports Medicine

Figure 3. Bent-knee stretch test for hamstring tendinopathy and strain.

Figure 4. Modified bent-knee stretch test for hamstring tendinopathy and strain.

respect to all 3 tests, hamstring tendinopathy or strain is high validity and reliability in identifying hamstring ten-
indicated by increasing posterior thigh pain with extension dinopathy and strains.26 Finally, it is important to perform
of the knee. All 3 tests have been shown to have moderate to a thorough neurovascular examination; peroneal nerve

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Vol. XX, No. X, XXXX Hamstring Injuries 5

Figure 5. Plain radiograph of the pelvis, demonstrating an

avulsion injury from the ischial tuberosity.

Figure 7. Proximal hamstring (semimembranosus) avulsion

injury with retraction on coronal T2-weighted magnetic reso-
nance imaging.

Figure 6. Longitudinal ultrasound image of a proximal myo-

tendinous hamstring injury. A high-grade tear is identified by
the large white arrow, intact muscle is indicated by arrow-
heads, and the tendon origin (*) is seen at the ischial tuber-
osity (Tub).

injury, while usually a neurapraxia and self-limiting, can

result in subtle foot drop or eversion weakness.
The differential diagnosis for hamstring injuries
includes a variety of lesions occurring proximally at the
hip and pelvis, along the posterior thigh, or distally at
the knee. Proximal injuries include ischial tuberosity apo-
physitis, painful unfused apophysis, piriformis syndrome,
gluteus medius insertional tendinopathy, posterior tro-
chanteric bursitis, sacroiliitis, pelvic stress fracture, and
lumbar radiculopathy. Posterior thigh injuries include ilio-
tibial band syndrome, lumbar radiculopathy, and sciatica.
Distal injuries include knee capsular strain, knee collat- Figure 8. Cross-sectional muscle involvement on axial T2-
eral ligament sprain, knee meniscal injury, lumbar radi- weighted magnetic resonance imaging.
culopathy, gastrocnemius strain, popliteal cyst formation
or rupture, and pes anserine bursitis.
Imaging. Plain radiographic findings of the pelvis, hip, the advantages of direct correlation with physical exami-
femur, and knee are most often negative in athletes with nation and perhaps access to more immediate imaging
hamstring injuries,3,32,34 unless an avulsion fracture has from portable ultrasound machines. Typically, hamstring
occurred from the ischial tuberosity (Figure 5). Dynamic muscles and tendons are imaged using a linear probe in
ultrasonography provides high-resolution imaging with both the longitudinal and transverse planes with

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6 Ahmad et al The American Journal of Sports Medicine

Figure 9. (A) Proximal myotendinous hamstring injury on coronal T2-weighted magnetic resonance imaging (MRI). (B) Muscle
belly injury on axial T2-weighted MRI. (C) Distal avulsion hamstring injury on coronal T2-weighted MRI.

TABLE 1
Magnetic Resonance Imaging Scoring System for Hamstring Injuries

No. of Muscles Insertion Cross-sectional Retraction, Long-Axis T2

Points Age, y Involved Location Involvement Injury, % cm Length, cm

0 No 0 None 0
1 25 1 Proximal 25 \2 1-5
2 26-31 2 Middle Yes 50 2 6-10
3 32 3 Distal 75 .10

frequencies in the 7.5- to 13-MHz range.3,89 Higher fre- MRI can also determine the chronicity of injury as indi-
quencies provide better resolution, while lower frequencies cated by fibrosis.38 Further, MRI better defines a bone
provide better penetration. Ultrasound demonstrates fluid injury seen with proximal or distal avulsions as well as
collections around and along the injured muscle and more delayed soft tissue changes seen with more chronic
depicts areas of echogenicity, representing edema and/or injuries and can assess progressive healing.18,37,89
hemorrhage (Figure 6). Ultrasonography is extremely
accurate in the acute phase to determine the location and
extent of a hamstring injury.3,89 Magnetic resonance imag-
CLASSIFICATION
ing (MRI), however, is the most commonly used imaging
study to evaluate hamstring injuries. Standard axial, coro- Hamstring injuries have traditionally been classified with
nal, and sagittal T1- and T2-weighted images are obtained respect to their clinical presentation: (1) grade 1 (mild) as
on a 1.5-T or higher unit. For proximal hamstring injuries, characterized by overstretching but minimal loss of the
images are obtained through both ischial tuberosities and structural integrity of the muscle-tendon unit, (2) grade 2
proximal thighs; for distal injuries, images are obtained (moderate) as having partial or incomplete tearing, and
from the midthigh through the knee. Higher resolution (3) grade 3 (severe) as a complete rupture.32,132 The gener-
images are then obtained through the injured thigh. ally accepted MRI grading system for muscle injury
Also, MRI precisely defines the injury location, degree of includes (1) grade 1 as defined by a T2 hyperintense signal
damage, number of involved tendons, extent of retraction, about a tendon or muscle without fiber disruption, (2)
and chronicityyy (Figures 7 and 8). With respect to loca- grade 2 as represented by a T2 hyperintense signal around
tion, MRI can precisely identify the injury site from the ori- and within a tendon/muscle with fiber disruption less than
gin, proximal myotendinous junction, muscle belly, distal half the tendon/muscle width, and (3) grade 3 as defined by
junction, or insertion (Figure 9). Moreover, MRI can deter- tendon/muscle disruption less than half its width.111 Alter-
mine the degree of soft tissue damage by defining (1) natively, hamstring injuries can be classified based on the
dimensions of abnormal intramuscular and extramuscular anatomic site, pattern, and severity of the injury in the
T2 hyperintensity, (2) percentage of abnormal cross- acute stage, as assessed by MRI or ultrasound.30
sectional muscle area, (3) percentage of abnormal muscle Important to the management of hamstring strains is
volume, and (4) length of extramuscular T2 signaling113; the early determination of time required to return to full
competition. Neither the traditional clinical nor the gen-
yy
References 3, 18, 32, 34, 36, 45, 89, 111, 113. eral MRI classifications have been precisely correlated

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Vol. XX, No. X, XXXX Hamstring Injuries 7

with time to return to play after a hamstring injury. Sev- tendinopathies.27 Intramuscular corticosteroid injection
eral authors have attempted to assess the predictive value has also been advocated as an early treatment to prevent
of MRI for return to play in athletes with these inju- prolonged disability.65,75 Potential risks include infection,
ries.10,18,36,113,122 Verrall et al122 evaluated 83 elite Austra- subsequent tendon rupture, increased likelihood of a recur-
lian rules football players with clinically diagnosed rent hamstring injury, postinjection pain flare, subcutane-
hamstring strains and observed that those athletes who ous fat atrophy, and skin hypopigmentation.98 The
had MRI features of a hamstring injury averaged 27 days proposed beneficial mechanism is mediation of the painful
missed from competition and those with no changes on inflammatory response triggered by the acute muscle
MRI missed an average of 16 days. Askling et al10 prospec- strain. In the NFL, in players with severe discrete injuries
tively evaluated 18 elite sprinters with clinically diagnosed within the substance of the muscle, intramuscular cortico-
hamstring strains and serial MRI evaluations at 10, 21, steroid injection decreased time to return to full play with-
and 42 days after injury. Proximal injuries demonstrated out a risk of further injuries or complications.75
a prolonged time to return to play. Verall et al123 used Traditional management has been disappointing, with
MRI to assess the volume and percentage of muscle injury unpredictable time lost, high reinjury rates, and poor res-
and found it was predictive of time lost from competition. toration of preinjury status. New biological therapies are
Slavotinek et al113 also noted that the percentage of abnor- therefore being investigated, including platelet-rich
mal muscle area and the volume of injury correlated most plasma (PRP) treatment, cell therapy, tissue engineering,
precisely with time to return to sport, but no classification and administration of growth factors.81 Bioactive mole-
was proposed. cules include transforming growth factor–b (TGF-b), fibro-
Cohen et al36 have provided the most detailed MRI clas- blast growth factor (FGF), epidermal growth factor (EGF),
sification system that correlates the extent of hamstring platelet-derived growth factor (PDGF), and vascular endo-
injury with time to return to play. These authors evaluated thelial growth factor (VEGF). These play a crucial role in
38 NFL players with acute hamstring strains. Their MRI the repair process of injured skeletal muscle, including
scans were evaluated with the traditional radiological hamstring strains, namely by stimulating myogenesis65
muscle injury grading system as well as a new MRI scoring and neoangiogenesis.68 Thus, they represent a potential
system. This scoring system (Table 1) was based on (1) therapeutic option in improving the healing process.
player age, (2) number of muscles involved, (3) location of Platelet-Rich Plasma. Platelet-rich plasma is a concen-
injury, (4) presence of insertional damage, (5) percentage trated source of autologous platelets and the growth fac-
of cross-sectional muscle involvement, (6) length of muscle tors that their a granules naturally contain. Given these
retraction, (7) long-axis T2 sagittal plane signal abnormal- bioactive molecules, PRP has the potential to improve the
ities, and (8) presence of chronic changes. All scores were healing process, and thus, its use has been proposed for
then correlated with time missed from competition. These the management of many musculoskeletal injuries, includ-
authors noted that rapid return to play (\1 week) corre- ing hamstring strains.59,125 Although its efficacy has not
lated with isolated injury of the long head of the biceps been proven, PRP has been widely described in the ortho-
femoris, \50% cross-sectional involvement, and minimal paedic literature because of its ease of acquisition and
perimuscular edema (grade 1 traditional radiological safety.6,53 Mejia and Bradley93 reported on their experi-
strain) and an MRI score of \10. Prolonged recovery ence with autologous conditioned plasma injections within
(.2-3 weeks) correlated with multiple-muscle injury, inju- 24 to 48 hours for acute hamstring injuries in NFL players.
ries distal to the myotendinous junction, short head of the Their results show an earlier return to play of 3 days for
biceps injury, .75% cross-sectional involvement, presence grade 1 and 5 days for grade 2 injuries, with an overall
of retraction, circumferential edema (grade 3 traditional 1-game difference in the return to play. Most encourag-
radiological strain), and an MRI score of .15. These ingly, the authors noted a 0% recurrence rate compared
authors suggested that this novel MRI score is highly pre- with their baseline of 2 to 4 recurrences per year. Despite
dictive of time missed from competition. Additional future promising results from level IV studies, as well as several
systematic studies for different sports will be important for basic science and animal studies that suggest PRP can
the validation of this MRI score in predicting return to play enhance healing,5 there are no level I studies with ade-
for other athletes. quate outcome measures and follow-up assessment that
prove its superiority. Several devices and systems are
available for PRP preparation, with varying concentra-
Treatment: Noninsertional Injuries tions of growth factors, making comparisons between clin-
ical studies difficult. Additionally, there is concern that, if
Initial nonoperative treatment includes activity modifica- excessive quantities of PRP are used, it may induce a florid
tion, ice, compression, stretching, early physical therapy, fibrotic healing response in muscle tissues by increasing
and nonsteroidal anti-inflammatory drugs (NSAIDs) with the local concentration of TGF, based on data that TGF
sport-specific activity progression carried out with atten- seems to be able to induce fibrosis in cultured muscle tis-
tion to the athlete’s symptoms. Other modalities include sue.65 Therefore, at present, there is no evidence to recom-
massage, ultrasound, and electrical stimulation. A recent mend or discourage the adoption of PRP in clinical
randomized controlled trial showed shockwave therapy to practice. Further research is required to standardize for-
be safe, effective, and superior to traditional modalities mulations (number of platelets and/or leukocytes) and
in professional athletes with proximal hamstring administration regimens, including volume of injection

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8 Ahmad et al The American Journal of Sports Medicine

and timing of treatment, to optimize PRP application for On the other hand, the program was effective in prevent-
the management of muscle injuries. ing knee injuries, lower extremity injuries, overall injuries,
Cell Therapy. Regenerative medicine involving tissue severe injuries, and overuse injuries, such as lower extrem-
engineering and cell therapy has been directed toward ity tendon pain and low back pain. Therefore, the effective-
skeletal muscle.1,14,33 Stem cells directly participate in tis- ness of hamstring injury prevention programs remains
sue regeneration and thus influence muscle healing.39,76,82 controversial and deserves more attention.83-86
After injury, patterns of growth factor expression deter-
mine which cell types will participate in the wound healing Treatment: Proximal Insertional Injuries
process.76 High levels of TGF-b3 are related to the activa-
tion of mesenchymal progenitor cells derived from trauma- Essential to the treatment of proximal hamstring injuries
tized muscle to promote wound healing after muscle is the early recognition of the injury and timely referral
injury.67 On the other hand, high levels of TGF-b1 lead to proper specialists. In general, nonoperative treatment
to muscle fibrosis by activating fibroblasts.39,82 Animal is considered for proximal hamstring injuries that involve
models of muscle injury have shown that muscle-derived a single tendon and/or multiple-tendon injuries with
stem cells (MDSCs) improve both muscular struc- \2 cm of retraction. However, patient factors such as non-
ture11,28,121 and muscle regeneration.12 compliance, age, and activity level may influence treat-
Two potential techniques for skeletal muscle tissue ment. Surgical indications for proximal hamstring
engineering are in vitro and in vivo. With in vitro tissue injuries include those involving 2 tendons with .2 cm of
engineering, stem cells from adult skeletal muscle are retraction and 3-tendon tears. Identification and treatment
expanded and seeded on a 3-dimensional (3D) scaffold. of surgical proximal hamstring injuries are best managed
After the differentiation of stem cells, the neotissue graft within 4 weeks, as later recognition provides for a more dif-
could be transplanted in the injured region. With in vivo ficult repair, leading to increased surgical complications
tissue engineering, the isolated MDSCs are seeded on and possibly inferior outcomes.35
a 3D scaffold carrier and immediately transplanted, Nonoperative Treatment. Single-tendon avulsions and 2-
obtaining direct delivery of stem cells in the muscle tendon tears with retraction \2 cm are treated nonopera-
lesion.103 tively.34 Less active patients, those with medical comorbid-
At this time, the clinical use of stem cells is limited. Fur- ities, and patients unable to comply with postoperative
ther research is necessary to identify the mechanisms rehabilitation are also indications to manage these injuries
involved in muscle regeneration to exactly understand nonoperatively. Nonoperative management consists of
the therapeutic potential of stem cells. activity modification, NSAIDs, and physical therapy.
Recurrence and Prevention. Prevention of hamstring Other rehabilitation modalities include ultrasound, shock-
injuries is essential. Eccentric exercise is now emphasized wave therapy, electrical stimulation, and edema control.115
and produces greater strength gains than similar concen- As the symptoms resolve, the core (abdominal), hip, and
tric hamstring movements.7,20,69,97 Improved hamstring quadriceps may be added to a more aggressive program
strength and endurance in a more functional position dur- to prevent hamstring injuries.94 Pain can be a limiting
ing sprinting increase the ability of the hamstrings to factor in the progression of rehabilitation. If patients
absorb repeated eccentric loads before and during heel experience difficulty with reintegration programs, an
strike. Identifying and correcting muscle imbalance and ultrasound-guided corticosteroid injection can be used to
optimizing neural timing along with progressive sprint provide initial relief in up to 50% of patients at 4 weeks.133
training for identified high-risk athletes are advo- An alternative to corticosteroid injections includes PRP
cated.48,87 Prevention strategies are likely most beneficial performed under computed tomography or ultrasound
as part of a preseason training program. Athletes are guidance, which has similar outcomes to corticosteroid in
encouraged to follow prevention programs and may comply experienced hands. These injuries may take up to 6 weeks
because the programs are closely associated with overall for initial healing. In single-tendon tears, 6 weeks allows
athletic performance.9,57 the tendon time to fibrose to the intact tendons, often
A few studies have investigated the effect of injury pre- allowing the initiation of limited activity. However, full
vention programs on altering proposed risk factors for return to sport should only be allowed once the patient is
lower extremity injury.74,78 The injury prevention program asymptomatic with regard to pain and strength has
‘‘The 11,’’ developed with the support of the Fédération returned to within 1 grade of the contralateral leg.95
Internationale de Football Association (FIFA), aims to In many tears managed nonoperatively, symptoms can
reduce the effect of intrinsic injury risk factors in soccer, persist beyond the normal healing times. Knee flexion
and it has been validated in that sport.117,119 A successive weakness and hip extension weakness often ensue months
modified version of ‘‘The 11’’ (‘‘The 111’’) has been also after injury. Furthermore, a deformity in the area of the
shown to be effective in preventing injuries in young proximal hamstrings, difficulty in sitting, and scarring of
female soccer players114 and elite male basketball play- the proximal hamstrings to the sciatic nerve can occur. A
ers.80 ‘‘The 111’’ provided more than a 40% reduction in serious complication of nonoperatively treated proximal
injury risk.114 Unfortunately, the program was not effec- hamstring injuries is hamstring syndrome, characterized
tive in preventing the following injuries: ankle, anterior by local posterior buttock pain, discomfort over the ischial
thigh, posterior thigh (hamstrings), hip/groin, sprains, tuberosity during sitting, and worsening pain during
strains, fractures, or anterior lower leg pain (periostitis). stretching and exercises that target the hamstrings.43

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Vol. XX, No. X, XXXX Hamstring Injuries 9

Figure 11. Transverse incision with optional longitudinal limb

Figure 10. Patient positioning for proximal hamstring repair.
(dotted line) for proximal hamstring surgical approach.
(A) Position of the table in slight flexion and (B) patient
draping.
the gluteal fascia. The gluteus maximus muscle is next
identified and is elevated superiorly, or a split in one of
These patients may benefit from surgical debridement and the septae overlying the ischial tuberosity can be per-
late repair. In cases of recalcitrant hamstring syndrome, formed to expose the hamstring fascia.
the sciatic nerve should be managed with surgical neurol- Once the hamstring fascia is identified, a longitudinal
ysis, which has an 88% success rate in some series.102 incision is made through this fascia to locate the hamstring
Operative Treatment. Operative treatment for proximal tendons. Often, these tendons are encased in scar tissue
hamstring tendon avulsions is recommended when 2 ten- and erroneously appear to be intact. Care must be taken
dons are retracted 2 cm or for 3-tendon avulsions.34 to excise the overlying scar tissue, uncover the underlying
Two-tendon injuries may often involve injury to a third hematoma, and identify the injured hamstring tendons.
hamstring muscle, either at the muscle belly or the muscu- The sciatic nerve is identified by palpation and can be pro-
lotendinous junction, that may not be seen on imaging tected by retracting the tendons laterally (Figure 12). The
studies that are focused on proximal hamstring inser- sciatic nerve is dissected free only in cases of chronic injury
tions.34 This possible third hamstring injury should be with possible sciatic nerve scarring or possibly in cases in
taken into consideration when deciding between operative which the patient presents with sciatic nerve symptoms
and nonoperative treatment in 2-tendon tears. Operative preoperatively.
treatment has high success rates and is also a consideration The sciatic nerve is on average 1.2 cm lateral to the
for chronic injuries with complete or partial tears that fail most lateral aspect of the ischial tuberosity.96 Once the sci-
nonoperative management.16,29,43,105,107,127 However, most atic nerve has been safely protected, another layer of
studies indicated that the results of surgery for chronic fibrous tissue is often identified at the ends of each tendon.
ruptures are inferior to acute repair.60,92 This fibrous tissue represents scarring of the tendons and
Surgical Procedure. The procedure involves placing the should be partially removed to allow for adequate healing
patient prone on the operating room table with all bony of the tendons after repair. However, overzealous removal
prominences well padded and the trunk in slight flexion of this tissue could prevent adequate mobilization of the
(Figure 10). A transverse incision is made at the gluteal proximal hamstrings and produce shortened tendons.
crease directly inferior to the ischial tuberosity (Figure Once the tendons are mobilized, they are tagged with
11). Transverse incisions, in comparison to T-shaped or heavy suture before identifying and preparing the ischial
longitudinal incisions, allow improved cosmesis and acces- tuberosity for tendon reattachment.
sibility to avulsed tendons that insert along the coronal A periosteal elevator or a curette is used to clear off the
plane.43,70 The incision is deepened through the subcutane- lateral aspect of the ischial tuberosity to allow anatomic
ous fat to the gluteal fascia. Care must be taken to avoid placement of the hamstring tendons (Figure 13). The tuber-
the posterior femoral cutaneous nerve. Once this nervous osity is then stimulated using manual instruments, allow-
structure is protected, a transverse incision is made in ing for a vascular bed for healing of the tendon origins to

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10 Ahmad et al The American Journal of Sports Medicine

Figure 14. ‘‘X’’ configuration of sutures on the ischial tuber-

Figure 12. Identification of the sciatic nerve with lateral osity. (A) Sutures through the tendon. (B) Final configuration.
retraction.

Figure 13. Surgical field with the ischial tuberosity exposed.

Yellow dotted line shows the lateral aspect of the ischial
tuberosity. (A) Skin markings. (B) Surgical field.

Figure 15. Insertion of hamstring tendons on the ischial

the tuberosity. Motorized instruments are discouraged for tuberosity.
this portion of the surgery, as they can risk nerve injury.
Some authors recommend making longitudinal scales in
the tuberosity using a small osteotome as a way to stimulate fascia is closed, and the wound is closed in layers. Using
biological healing. Suture anchors (2.4-mm BioComposite the above technique, a 96% satisfaction rate and .75%
SutureTak with No. 2 FiberWire, Arthrex Inc, Naples, Flor- recovery of strength have been documented.35
ida) are then placed in an ‘‘X’’ configuration to repair the Patients with chronic ruptures who require operative
tendons to bone with a total of 5 anchors (Figure 14). Special treatment may require an allograft bridge from the
attention is paid to the anatomic location of the proximal retracted tendon to the tuberosity. Reconstruction can be
hamstring tendons (Figure 15). The semimembranosus ten- undertaken using an Achilles allograft with comparable
don is the most lateral structure, with the confluent semi- results to acute surgical repair.50
tendinosus and long head of the biceps appearing more Postoperative Rehabilitation. Postoperative rehabilita-
medial. Regarding the footprint of the hamstring insertion, tion is an essential part of this surgery. To limit stress at
the semitendinosus and biceps femoris share an oval-shaped the surgery site, immediately after wound closure, the
footprint 2.7 cm long from proximal to distal and 1.8 cm operative leg is placed in a custom-fitted orthotic for the
wide from medial to lateral.96 The semimembranosus foot- hip that restricts flexion of the hip from 30° to 40° (Figure
print is crescent and lays lateral to the semitendinosus 16). Patients are prescribed aspirin for 4 weeks postopera-
and biceps femoris footprint. It measures 3.1 cm from prox- tively for deep vein thrombosis (DVT) prophylaxis,
imal to distal and 1.1 cm from medial to lateral.96 although the risk of DVT after a hamstring injury has
The sutures are placed through the tendon ends in a hor- not been firmly established. The first 10 to 14 days involve
izontal mattress pattern (from inferior to superior and tied toe-touch weightbearing with crutches. Weeks 2 to 5 con-
down from superior to inferior). The knee is flexed to sist of continued use of the hip orthotic and 25% weight-
approximately 30°, while the tendons are tied down. The bearing. Passive range of motion of the hip with

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Vol. XX, No. X, XXXX Hamstring Injuries 11

Figure 17. Axial magnetic resonance imaging scan demon-

strating a distal semitendinosus tear. (A) Distally at the semi-
tendinosus insertion (*), showing fluid signal intensity within
the expected course of the tendon sheath (arrowhead), and
(B) proximally at the retracted tendon stump (arrow).

those mentioned for the late sequelae of nonoperative

treatment and comprise knee flexion weakness, hip exten-
sion weakness, and deformity. Superficial and deep infec-
tions can also occur and are a special concern for this
surgery because of the location of the surgical site and its
proximity to the gastrointestinal and genitourinary sys-
tems. Other complications include the risk of rerupture
and loss of strength.
Figure 16. Postoperative brace with the hip placed in 30° to
Outcomes. Most series report that return of strength
40° of flexion.
ranges from 60% to 90% of the contralateral leg, with
more than 95% reporting good to excellent subjective
a therapist begins at 2 weeks, and active range of motion results after surgical repair.15,23,29,43,70 In a series of 52
begins at 4 weeks. At 6 weeks, the brace is discontinued, patients, Cohen et al35 showed that 98% of patients were
and the patient is allowed to fully bear weight and begin satisfied with their outcome after surgery. Objective meas-
gait training along with isotonic exercises. Also at 6 weeks, ures such as the Lower Extremity Functional Scale and
aqua therapy is introduced along with isotonic exercises, custom Marx score showed a statistical difference between
core strengthening, and closed chain exercises; range of acute and chronic repairs, with acute repairs exhibiting
motion is increased with caution for extreme ranges. improved outcomes. However, patient questionnaire aver-
Dynamic training and isometric strengthening begin at 8 ages did not show a statistical difference between acute
weeks after surgery, and at 10 weeks, an isometric and chronic repairs. This indicates that injuries with
strength evaluation is performed with the knee at 60° of delayed diagnosis and failed nonoperative proximal ham-
flexion. Sport-specific training and dry land training begin string injuries can still have favorable subjective patient
at 12 weeks. A fully isokinetic evaluation is performed at outcomes when treated with operative repair.35
16 weeks at 60 deg/s, 120 deg/s, and 180 deg/s. These
results are compared with the contralateral leg. Full Treatment: Distal Insertional Injuries
return to sport is allowed once the operative leg is 80% of
the nonoperative leg on isokinetic testing. Return to sport The distal attachment of the biceps femoris is most com-
after operative treatment, with accomplishment of the monly injured with a varus hyperextension mechanism
above parameters, typically happens between 6 and 10 as part of multiligament knee injuries.44,52,72,91 An isolated
months.15 distal semimembranosus avulsion is rare.4 In contrast, iso-
Complications. Early complications most commonly lated distal semitendinosus tendon avulsions are becoming
involve the sciatic nerve and include neurapraxia or more recognized38,109,110 but can be misdiagnosed as a
stretch injury during surgery that eventually resolves. distal-third muscle belly hamstring injury. An MRI scan
However, this can lead to burning pain radiating down of the thigh and knee over the full course of the semitendi-
the leg and weakness of the distal operative extremity nosus tendon can confirm the diagnosis (Figure 17). Distal
immediately after surgery and in the first few weeks, mak- semitendinosus tendon avulsions cause much more time
ing preoperative assessment of nerve symptoms essential. loss from sports than hamstring muscle belly injuries on
Other nerves that can be potentially harmed are the poste- average. Cooper and Conway38 reported a case series of 25
rior femoral cutaneous nerve and the inferior gluteal distal semitendinosus tendon ruptures in high-level ath-
nerve, leading to dysesthesia and weakness of hip exten- letes. Early treatment always involved nonoperative treat-
sors, respectively. Nonneurogenic complications include ment, including rest, modalities, and rehabilitation

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12 Ahmad et al The American Journal of Sports Medicine

exercises, followed by functional progression. Forty-two per- 11. Bachrach E, Perez AL, Choi YH, et al. Muscle engraftment of myo-
cent failed initial nonoperative treatment and subsequently genic progenitor cells following intraarterial transplantation. Muscle
Nerve. 2006;34(1):44-52.
had surgery with resection of the torn tendon and adjacent
12. Bedair HS, Karthikeyan T, Quintero A, Li Y, Huard J. Angiotensin II
scar tissue, with an average recovery time of 12.8 weeks. receptor blockade administered after injury improves muscle regen-
Another group of patients were treated with acute surgery eration and decreases fibrosis in normal skeletal muscle. Am J
that resected the torn tendon and adjacent scar tissue Sports Med. 2008;36(8):1548-1554.
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