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319
REVIEW
Evidence based prevention of hamstring injuries in sport
J Petersen, P Hölmich
...............................................................................................................................
Br J Sports Med 2005;39:319–323. doi: 10.1136/bjsm.2005.018549
A common soft tissue injury in sports involving sprinting 90 days6 and 15–21 matches missed per club per
season on average.6 8 This results in, on average,
and jumping is the hamstring strain. A major problem with 18 days and 3–3.5 matches missed per hamstring
hamstring strains is the high incidence of reinjury. Muscle strain, but the individual variation in absence
injuries can be classified as direct or indirect and are from sports participation is not described. The
variation may differ from one or a few days to
typically grouped into three categories according to several months.
severity. A number of potential risk factors have been The reinjury rate for hamstring injuries has
proposed for hamstring strains. Only a few are evidence been found to be 12–31%.6 11 12
A brief review of classification, mechanism of
based and some are mainly based on theoretical injury, aetiological factors, and the current
assumptions. There is a lack of clinical research on the trends in treatment is included before discussion
effectiveness of rehabilitation programmes for hamstring of evidence based prevention of hamstring
injuries.
strains. Although the initial treatment of rest, ice, To our knowledge, there is only one prospec-
compression, and elevation is accepted for muscle strains, tive, randomised study of treatment in the
no consensus exists for their rehabilitation. Not much literature and two prospective studies on pre-
evidence based research has been carried out on vention of hamstring strain injuries. It is difficult
to compare the studies with respect to risk
prevention of hamstring strain. To our knowledge only two factors because of different methodology.
prospective studies have so far been published. As the
injuries are common in football and other sports involving INJURY DEFINITION
sprinting and jumping, there is a need for further research Injuries are most often defined as an incident
occurring during scheduled games/competitions
preferably in the form of randomised controlled trials. or practice and causing the athlete to miss the
........................................................................... next game/competition or practice session.
T
his review is based on computerised searches CLASSIFICATION
using Medline (from 1966 to 2005) and Depending on the trauma mechanism, muscle
Embase (from 1988 to 2005). The following injuries can be classified as direct and indirect.
search terms were used individually or in various The direct forms are laceration and contusion,
combinations: hamstring, muscle, strain, injury, and the indirect form is strain. Indirect injuries
prevention. Only English language publications can be either complete or incomplete. Hamstring
were considered. Other references were identi- muscle injuries are usually strains, but contu-
fied from existing reviews or other papers cited sions occur in contact sports.13 14
in the publications searched. Unpublished Complete rupture usually occurs as an avul-
reports and abstracts were not considered. This sion injury from the ischial tuberosity. Avulsion
is not a systematic review. injuries can be entirely soft tissue or involve a
bony fragment or the ischial apophysis.14 15 This
INTRODUCTION injury is commonly documented among water
Hamstring muscle strain is a frustrating injury, skiers.4
well known to medical staff, coaches, and Strains usually occur in the biceps femoris,2 6
athletes. It is frustrating because the symptoms and the most common location is near the
are persistent, healing is slow, and the rate of muscle-tendon junction.2 16
reinjury is high. Muscles injuries represent a continuum from
See end of article for Hamstring strains are among the most com- mild muscle cramp to complete muscle rupture,
authors’ affiliations mon injuries in sports that involve sprinting and and in between is delayed onset muscle soreness
.......................
jumping,1 2 but are also common in dancing and and partial strain injury. Muscle strains can be
Correspondence to: waterskiing.3 4 Most epidemiological studies of divided into three grades according to their
Associate hamstring strains have focused on injury pre- severity:1 14
Professor Holmich,
valence in football including Australian foot-
Department of
Orthopaedic Surgery, ball.1 5–8 Several studies have been carried out on N mild (first degree) strain/contusion: tear of a
few muscle fibres with minor swelling and
Amager University hamstring injuries in Australian Rules football.8–
Hospital, Copenhagen DK- 10
It has been shown that hamstring strain discomfort and with no, or only minimal, loss
2300 S, Denmark; injuries account for 12–16% of all injuries in of strength and restriction of movements
[email protected]
English and Australian professional football. A
rate of five to six hamstring strain injuries per
N moderate (second degree) strain/contusion:
greater damage of muscle with a clear loss of
Accepted 15 March 2005
....................... club per season has been observed, resulting in strength
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320 Petersen, Hö lmich
N severe (third degree) strain/contusion: a tear extending
across the whole cross section of the muscle resulting in a
Athletes who return to sport before full recovery are at risk
of recurrent and possibly more severe injury.1 15
total lack of muscle function It remains unclear if decreased hamstring flexibility is a
cause or consequence of hamstring injury because most
In practice the diagnosis is based on an accurate history information about risk factors are collected retrospectively.18
and a physical examination. In typical cases, no need for A recent prospective cohort study by Witvrouw et al27
further examination is needed. In the study by Woods et al,6 indicates that soccer players with increased tightness of the
imaging techniques were used in only 5% of the cases. If hamstring muscles have a significantly higher risk of a
there is any doubt, magnetic resonance imaging (MRI) or subsequent musculoskeletal lesion. In the study, 146 male
sonography can be useful. Connell et al10 concluded that professional soccer players were examined before the 1999/
sonography is as useful as MRI in depicting acute hamstring 2000 Belgian soccer season. None of the players had a history
injuries and, because of lower costs, may be the preferred of muscle injury in the lower extremities in the previous two
imaging technique.
years. The study showed that players who sustained a
hamstring muscle injury in the season 1999/2000 had
MECHANISM OF INJURY significantly less flexibility in the hamstring muscles before
In order to prevent hamstring injuries, it is important to their injury compared with the uninjured group.
establish how they happen. It is commonly thought that one
reason for the susceptibility of hamstring muscles to injury is
TREATMENT
their anatomical arrangement. The hamstring muscle com-
There is a lack of clinical research on the effectiveness of
plex is a biarticular muscle group which works by flexing the
rehabilitation programmes for hamstring strains. Although
knee and extending the hip. In everyday movements, flexion
the initial treatment of rest, ice, compression, and elevation is
of the hip and knee occur together, with opposing effects on
hamstring length. accepted for muscle strains, no consensus exists for their
In football, most hamstring strains occur while players are rehabilitation.
running or sprinting.6 7 Most studies suggest that hamstring Most rehabilitation programmes are based on the tissue’s
strains occur during the later part of the swing phase when theoretical healing response. To our knowledge, there is only
the hamstrings are working to decelerate knee extension— one prospective, randomised controlled study in the literature
that is, the muscle develops tension while lengthening. This that investigated the effectiveness of different rehabilitation
means that the hamstrings must change from functioning programmes for the treatment of acute hamstring strains.
eccentrically, to decelerate knee extension in the late swing, This is the study by Sherry and Best11 in which two different
to concentrically, becoming an active extensor of the hip rehabilitation programmes were compared. Eleven athletes
joint.6 13 15 It has been suggested that it is during this rapid were assigned to a protocol consisting of static stretching,
change from eccentric to concentric function that the muscle isolated progressive hamstring resistance, and icing (STST
is most vulnerable to injury.9 group). Thirteen athletes were assigned to a programme of
Hamstring injuries to elite water skiers are typically severe progressive agility and trunk stabilisation exercises and icing
and involve the proximal hamstring muscles. In the study by (PATS group). No significant difference was found between
Sallay et al,4 the expert skiers sustained injury secondary to a the groups with regard to time required to return to sport, but
fall while skiing. there was a significant difference with regard to the reinjury
Hamstring strain injuries in elite dancing has been little rate after two weeks and one year. After two weeks, six of 11
studied, although they are common among students of athletes in the STST group had suffered a recurrent ham-
classical ballet and modern dance at the Ballet Academy in string strain compared with none of the athletes in the PATS
Stockholm, Sweden.3 In the study by Askling et al,17 which group. After one year, seven of 10 athletes in the STST group
describes the injury mechanism in one female professional compared with one of 13 athletes in the PATS group had
dancer, the injury occurred during slow stretching. It was suffered a recurrent hamstring strain.
localised to the proximal tendon of the semimembranosus In general, the primary objective of rehabilitation pro-
muscle. The type of dancing was not reported. grammes is the restoration of function to the greatest
possible degree in the shortest possible time. Treatment is
traditionally classified into different phases according to the
AETIOLOGICAL FACTORS
length of time since the injury occurred. The following
Understanding the individual risk factors for injury is
important as a basis for developing preventive measures. Risk classification is based on the treatment protocol of Clanton et
factors are traditionally divided into two main categories: al,13 but does not differ essentially from other classifications.
internal (intrinsic) and external (extrinsic). However, it would There is an overlap in the time in the different phases because
be more relevant to make a distinction between modifiable of the difference in injury severity.
and non-modifiable.18 A number of potential risk factors have
been proposed for hamstring strains. Only a few are evidence Phase I (acute): 1–7 days
based, and some are mainly based on theoretical assumptions. The most used treatment in muscle strains, including
The most common non-modifiable factors in the literature are hamstring strains, in the acute phase is the rest, ice, com-
older age6 9 19 and black or aboriginal ethnic origin.6 9 pression, and elevation regimen. The goal of this treatment is
The most common modifiable factors are imbalance of to control haemorrhaging and minimise inflammation and
muscular strength with a low hamstring to quadriceps ratio pain.13 15 22
(H:Q ratio),13–15 20–24 muscle fatigue,6 14 15 21 22 24 25 hamstring Non-steroidal anti-inflammatory drugs are an almost
tightness,2 14 15 20 21 22 24 26 27 insufficient warm up,14 15 20 22 24 universally accepted treatment, and the only controversial
and previous injury.2 9 13 15 19 20 aspect to their use is the appropriate timing of administra-
In the theoretical model proposed by Worrell,22 he suggest tion.13 The most common recommendation in the literature is
that a combination of abnormalities (strength, flexibility, short term use (3–7 days) starting immediately after the
warm up, fatigue) increases the risk of hamstring strain. As injury.13–15 However, theoretically it would be beneficial to
suggested by Devlin,28 there may be a threshold at which the delay the treatment until 2–4 days after the injury, because
number of risk factors produces an injury, or some factors they interfere with chemotaxis of cells which is necessary for
may be more predictive of injury than others. the repair and remodelling of regenerating muscle.13
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Evidence based prevention of hamstring injuries in sport 321
Early motion exercise is theoretically important to prevent seldom the case in football but is a common problem in water
or decrease adhesion within the connective tissue.22 Active skiing injuries.13
knee flexion and extension exercises could be performed As shown by Speer et al,31 follow up computed tomography
during the treatment with ice. It is important that the or MRI after an acute muscle strain injury reveals atrophy,
exercises are pain free to prevent further injury during the fibrosis, and calcium deposition. We found no evidence in the
rehabilitation. literature on any possible indication for, or benefit of, surgery
in these cases.
Phase II (subacute): day 3 to .3 weeks
This phase begins when the signs of inflammation (swelling,
heat, redness, and pain) begin to resolve. In this phase it is PREVENTION
important to continue muscle action to prevent atrophy and Woods et al6 performed an epidemiological study of ham-
promote healing. Regular concentric strength exercises can string injuries. The medical staff in 91 professional football
begin in this phase when the athlete has achieved full range clubs annotated player injuries over two seasons. A specific
of motion without pain.15 The common recommendation in injury audit questionnaire was used together with a weekly
this stage is multiple joint angle, submaximal isometric form that documented each club’s current injury status. The
contraction.13 15 22 If the athlete experiences pain, the inten- study found that some football clubs sustained very few
sity should be decreased. hamstring strains throughout the two seasons, whereas other
In this phase other activities can be initiated to maintain clubs reported a high rate of recurrence. This may represent a
cardiovascular fitness. This could be stationary bike riding, large number of variables in diagnosis, training techniques,
swimming, or other controlled resistance activities. and medical management, but it does at least suggest that
these injuries can be prevented and managed.6
Phase III (remodelling); 1–6 weeks Not much evidence based research has been carried out on
Loss of flexibility is a characteristic feature of hamstring prevention of hamstring strain. To our knowledge, only two
strains.13 15 22 This is probably due to pain, inflammation, and prospective studies have so far been published: one investi-
connective tissue scar formation.13 29 To avoid the hamstring gated flexibility and hamstring strains26 and the other
muscle becoming less flexible after the injury, hamstring strength training with eccentric overload.32 In addition, some
stretching can begin in the third phase. In the study by animal experimental studies have researched the preventive
Malliaropoulos et al,30 the stretching component in rehabilita- effect of stretching and warm up and the importance of
tion of acute hamstring strains in 80 athletes was started fatigue in strain injuries.16 25 33
after 48 hours. The study compared two different rehabilita-
tion programmes. The only difference was the number of Flexibility
stretching sessions. Each session consisted of a static stretch The study by Hartig et al26 prospectively followed two groups
of the hamstring muscles, sustained for 30 seconds, repeated of military infantry basic trainees both carrying out a
four times. One group had one session daily whereas the scheduled fitness programme over 13 weeks. One group
other group had four sessions. The athletes were advised to followed the regular fitness programme, and the other group
stretch until they felt tension or slight pulling, but no pain. added three hamstring stretching sessions (before lunch,
The study showed that the group who performed the more dinner, and bedtime) on each day of the 13 weeks. Stretching
intensive stretching programme regained range of motion was performed standing while another person held the leg
faster and had a shorter rehabilitation period. Both these with the hip in a 90˚ flexed position. The subject then moved
differences were significant. his trunk forward with an anterior tilt at the pelvis, keeping
Eccentric strengthening can also begin in the third phase. the back straight and the head in a neutral position, until he
Concentric exercise is begun before eccentric exercise because perceived a hamstring muscle stretching sensation without
eccentric contraction causes greater force than concentric pain. Each stretch was performed five times for each
contraction.9 It is therefore important that the eccentric extremity and was held for 30 seconds. The study showed
exercises are delayed until the injured muscle is well that flexibility increased significantly in the intervention
regenerated to avoid a rehabilitation induced reinjury. group compared with the control group. The number of
injuries was also significantly lower in the intervention group
Phase IV (functional): 2 weeks to 6 months
(incidence rate 16.7% v 29.1%).
The goal in this phase is return to sport without reinjury. This
Magnusson et al34 examined the effect of repeated static
is achieved by increasing hamstring strength and flexibility to
stretches. Five consecutive stretches for 90 seconds were
the normal values for the individual athlete. Simultaneously
performed with a 30 second rest between stretches. One last
pain-free running activities are increased from jogging at low
intensity to running and finally sprinting. Pain-free partici- stretch was performed after one hour. It was concluded that
pation in sports specific activities is the best indicator of the effect of five repeated stretches was significant one hour
readiness to return to play.22 Return to competition before later.34 Also an animal in vitro study performed by Taylor
this time may result in recurrent or more severe injury.15 et al33 found sustained muscle-tendon unit elongation after
cyclic and static stretching of rabbit extensor digitorum
Phase V (return to competition): 3 weeks to 6 months longus and tibialis anterior muscle-tendon units.
When the athlete has returned to competition, the goal is to Furthermore it was found that there was little alteration in
avoid reinjury. The focus should therefore be on maintaining the muscle after four stretches, implying that a minimum
stretching and strengthening.22 number of stretches will lead to most of the elongation in
repetitive stretching.
Surgery The study by Witvrouw et al27 indicates that it is possible by
Operative treatment is rarely considered for the treatment of flexibility testing to identify male soccer players at risk of
muscle strains, including hamstring strains. Extensive bleeds developing hamstring muscle injuries. Thereby it may be
are occasionally evacuated by puncture or surgery because possible to prevent some of these injuries in elite soccer.
large intramuscular haematomas can adversely influence scar Whether increased flexibility is an advantage or disadvantage
formation and lead to ossification.24 With complete rupture of in prevention of hamstring strain in other sports is not
the proximal or distal attachment of the musculotendinous known. Further prospective studies are needed to investigate
complex into bone, surgery is a realistic consideration. This is this issue.
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322 Petersen, Hö lmich
What is already known on this topic What this study adds
Hamstring injuries, usually in the form of a strain, are very This review reveals that existing knowledge on aetiology,
common and can be long standing and prone to recurrence. diagnosis, treatment, and prevention of hamstring injuries is
not often evidence based. Further research with well
designed prospective studies and randomised controlled
trials is needed.
Strength
The study by Askling et al32 examined the effect of preseason
strength training with eccentric overload in Swedish elite
soccer players. Thirty players were randomly divided into two
groups: a training group and a control group. The only
difference between the groups was that the training group This study therefore indicates that isometric warm up
received additional specific hamstring training during a before exercise has the potential to prevent muscle strain
10 week preseason period. The training group performed a injury.
total of 16 sessions of specific hamstring strength training,
every fifth day for the first four weeks and every fourth day Fatigue
during the last six weeks. The specific hamstring training In the epidemiological study of injuries sustained in English
consisted of both concentric and eccentric actions and was professional football by Woods et al,6 it was reported that
performed on an ergometer. The study showed a significant hamstring injuries that occurred during competition repre-
increase in both concentric and eccentric strength in the sented 62% of all reported hamstring injuries. Significantly
training group compared with the control group. more of the injuries during competition occurred towards the
Furthermore, maximum running speed was increased in end of both halves. This may indicate that fatigue is involved.
the training group compared with the control group. The The in vitro animal study by Mair et al25 investigated the
most important result of the study was that the number of role of fatigue in muscle strain injuries. Extensor digitorum
hamstring injuries decreased significantly in the training longus muscles from rabbits were fatigued to different
group. Of the 13 (13/30) reported hamstring injuries in the degrees, then stretched to failure and compared with their
two groups during the 10 month study period, 10 (10/15) non-fatigued contralateral controls. The data showed that
occurred in the control group and only three (3/15) in the muscles are injured at the same length, regardless of the
training group. The decrease in injury prevalence in the effects of fatigue. However, fatigued muscles are able to
training group was significant, but the low number of absorb less energy before reaching the degree of stretch that
subjects is a limitation to this study. causes injuries.
In the study by Mjølsnes et al,35 two hamstring strength Most human studies on hamstring strain prevention have
training programmes were compared. One programme involved male soccer players. Whether the results can be used
included traditional hamstring curls (concentric training) in the prevention of hamstring muscle injuries in other sports
whereas the other (Nordic hamstrings) was a partner are not known. Further studies are required.
exercise focusing on the eccentric phase. The study showed
that it is possible to significantly increase the eccentric torque
in well trained soccer players during a 10 week training PERSPECTIVES
programme focusing on eccentric strength training. No Not much evidence based research has been published on the
significant change in strength was seen in the group focusing prevention and treatment of hamstring strain injury. As the
on concentric training.35 The study did not include any follow injuries are common in football and other sports involving
up on hamstring strain injuries that occurred after the sprinting and jumping, there is a need for further research,
hamstring strength training programmes. preferably in the form of randomised controlled trials.
We therefore recommend that a randomised controlled The correct timing for return to sport after a hamstring
trial study should be carried out with enough players injury is traditionally based on normalised strength and
included to examine the potential association between flexibility and the ability to carry out sport specific activities
strength (concentric and eccentric) and hamstring muscle without pain. However, the healing process after a hamstring
strain injuries. strain may be much slower than the clinical findings would
indicate, and there is a need for further studies on this.
Warm up Future studies on prevention of hamstring injuries should,
The benefits of warming up in reducing the incidence of in our opinion, be based on the modifiable risk factors found
injury have been studied by Safran et al.16 They performed an in epidemiological research studies: muscular strength
in vitro animal study focusing on force, change of length imbalance with a low hamstring-quadriceps ratio, muscle
required to tear the muscle, site of failure, and length-tension fatigue, hamstring tightness, insufficient warm up, and
deformation in isometrically preconditioned (stimulated) previous injury.
versus control (non-stimulated) rabbit muscle. The tested To detect further risk factors for hamstring strain injury, it
muscles were stimulated before stretching and compared is important that sample size is carefully considered, as
with their contralateral non-stimulated controls. The rabbit discussed by Bahr and Holme.18
muscles used were the tibialis anterior, the extensor Fortunately the factors flexibility, strength, and endurance
digitorum longus, and the flexor digitorum longus. The are also essential for maximum performance. It is therefore
study showed that: (a) the preconditioned muscles required expected that athletes and trainers will be even highly
more force to fail than the contralateral controls; (b) motivated to focus on these topics.
preconditioned muscle can be stretched to a greater length
from rest before failing than the non-preconditioned con- .....................
trols; (c) the site of failure was not altered by condition—in Authors’ affiliations
all muscles the site of failure was the musculotendinous J Petersen, P Hölmich, Department of Orthopaedic Surgery, Amager
junction; (d) the preconditioned muscle attained less force at University Hospital, Copenhagen Denmark
each given increase in length before failure. Competing interests: none declared
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Evidence based prevention of hamstring injuries in sport 323
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Evidence based prevention of hamstring
injuries in sport
J Petersen and P Hölmich
Br J Sports Med 2005 39: 319-323
doi: 10.1136/bjsm.2005.018549
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