Hamstring Injuries/Surgery/Anatomy/Exercises. Its Hamstring Heaven Here!!
By Andrew Richardson
In this article I will be looking at the anatomy of the hip
and knee, the Hamstring muscles and its role, how does the hamstring tear, the
surgical procedure to repair it. Then to finish looking at a range of hamstring
topics. I will be making reference to my day spent in SSC (Santry Sports
Clinic) in Dublin, where I learned a lot more about Hamstrings and their own
Return to Play Protocol.
Structure of
Hamstrings and Type of Joints at Knee, Hip and Ankle
Structure
of Hamstrings
The three
muscles of the posterior thigh (semitendinosus, semimembranosus, biceps femoris
long & short head) flex (bend) the knee, while all but the short head of
biceps femoris extend (straighten) the hip. The three 'true' hamstrings cross
both the hip and the knee joint and are therefore involved in knee flexion and
hip extension. The short head of the biceps femoris crosses only one joint
(knee) and is therefore not involved in hip extension. With its divergent
origin and innervation it is sometimes excluded from the 'hamstring'
characterization.
Function
of Hamstrings
The
hamstrings cross and act upon two joints - the hip and the knee. Semitendinosus
and semimembranosus extend the hip when the trunk is fixed; they also flex the
knee and medially (inwardly) rotate the lower leg when the knee is bent. The
long head of the biceps femoris extends the hip as when beginning to walk; both
short and long heads flex the knee and laterally (outwardly) rotates the lower
leg when the knee is bent.
The
hamstrings play a crucial role in many daily activities, such as, walking,
running, jumping, and controlling some movement in the trunk. In walking, they
are most important as an antagonist to the quadriceps in the deceleration of
knee extension.
Clinical
significance
Imaging the
hamstring muscles is usually performed with an ultrasound and/or MRI.[1] The biceps femoris is most commonly injured,
followed by semitendinosus. Semimembranosus injury is rare. Imaging is useful
in differentiating the grade of strain, especially if the muscle is completely
torn.[2] In this setting, the level and degree of retraction can be determined,
serving as a useful roadmap prior to any surgery. Those with a hamstring strain
of greater than 60mm in length have a greater risk of recurrence.[3]
Tear of the
hamstrings muscles at the ischial tuberosity seen on MRI (coronal STIR). The
arrowheads indicate the tuber and the retracted tendon stump. Significant
bleeding around and into the muscles.
Use in
surgery
The distal
semitendinosus tendon is one of the tendons that can be used in the surgical
procedure ACL reconstruction. In this procedure, a piece of it is used to
replace the anterior cruciate ligament (ACL). The ACL is one of the four major
ligaments in the knee. Here is a video of a semitendoinous surgery in action
(WARNING GRAPHIC) https://www.youtube.com/watch?v=tQUd5JwykzY
and thr ACL replacement surgery (again WARNING GRAPHIC) https://www.youtube.com/watch?v=iFniNyUpVKw
Reason for looking at knee and hip joints, is because the
hamstring plays such a role in both of them.
Knee Joint
The knee joint joins the thigh with the leg and consists of two articulations: one between the femur and tibia, and one between the
femur and patella.[4] It is the largest
joint in the human body.[5]
The knee is a mobile trocho-ginglymus (a hinge joint), which permits flexion
and extension as well as slight internal and
external rotation. The knee joint is vulnerable to both acute injury and the
development of osteoarthritis. It is often grouped into
tibiofemoral and patellofemoral components.[6][7]
(The fibular collateral ligament is often
considered with tibiofemoral components.)[8] Below are a few images of the knee from a
range of angles.
Hip Joint
The hip region is located lateral and anterior to the
gluteal region (i.e., the buttock), inferior to the iliac crest, and overlying
the greater trochanter of the femur, or "thigh bone". In adults,
three of the bones of the pelvis have fused into the hip bone or acetabulum which
forms part of the hip region.
The hip joint, scientifically referred to as the
acetabulofemoral joint (art. coxae), is the joint between the femur and
acetabulum of the pelvis and its primary function is to support the weight of
the body in both static (e.g. standing) and dynamic (e.g. walking or running)
postures. The hip joints are the most important part in retaining balance. The
pelvic inclination angle, which is the single most important element of human
body posture, is mostly adjusted at the hips
Here is a good video by Nabil Ebrahiem, Professor &
Chairman of the Department of Orthopaedic Surgery at the University of Toledo
Medical Centre: Looking at Hamstrings Injuries.
Now after gaining a better understanding of the anatomy of
the hamstrings and their function. We can now look at detail the assessment of
a hamstring injury. I was fortunate enough to spend a day at Santry Surgery
Clinic (SSC) in Dublin where I was introduced to their Hamstring assessment
protocol (which is shown below). I hope you find it very useful as I did.
Assessment of
Injury
Subjective: Previous history (specifically hamstrings), age
(over 22), VAS, site of injury. Mechanism, Training Load. Normal subjective
assessment. Walking ability. Objective, straight leg raise, prone hamstring
curl at 0 degress, 45 degrees and 90 degrees. Strength. Bridge – functional
ability. Hip flex/knee flex, iso contraction +/-. Bridge (weakness), location
of tenderness, palpation, length of tenderness, Hip Int/Ext rotation. Thomas
Test, Slump Test.
For physios here is an excellent video by Joe Keegan
Physiotherapist of Loughborough Sports Injury Clinic on how to assess and treat
an injured athlete with a hamstring injury.
Factors
Affecting Progress
-
Negative: Aclusion fracture, Grade III
hamstring rupture, Recurrent Hamstring Injury, Involvement proximal tendon,
large and deep hematoma, excessive slow speed stretching injury. High Vas pain?
-
MRI Needed? Aclusion, Grade III rupture.
Proximal/Distal Tendon injury. Excessive stretching injury.
-
Positive: Gr1/Gr2 hamstring Injury, pain
free walking within 24 hours, short muscle tear on MRI.
Diagnostic
and Rehabilitation
Acute injury Management: Compression bandage, ice
bi-hourly for 20 minutes. Elevation, Analgesics, PRP within 48 hours, MRI
within 48 hours if required.
-
Manual Therpay
-
Cardiovascular: Boxing Steam (anaerobic session,
metabolic session, aerobic session), Rope Session (anaerobic session, metabolic
session, aerobic session), Bike Session (anaerobic session, metabolic session,
aerobic session).
Neuromuscular Control = Lumbopelvic Flexibility.
Hamstring Strengthening
Isometric Stream: Within a controlled symptom free range
-
Isometric quad/hamstring holds
-
Isometric heel holds
-
Prone knee bends
-
Nordic hold at 15 degrees
-
Single leg prone isometric bar pull (with bands)
Bridging Stream: Within a controlled symptom free range
-
Double leg bridge
-
DL bridge – hands in air
-
SL bridge
-
SL bridge hands in air
-
Nordic Hold at 15 degrees
Deadlift Stream (to include one set with feet at different
width): Within a controlled symptom free range. Speed deadlifting when SL
deadlifting
-
Hip Hinge
-
Kettle bell raise
-
Sumo deadlift
-
Double leg deadlift
-
Stiff leg deadlift
-
SL stiff leg deadlift
Squat Stream (to include one set with feet
narrow/normal/wide/angular load): Within a controlled symptom free range. Speed
Squat when SL squatting
-
Banded squat
-
Squat (unloaded)
-
Loaded squat
-
High single leg squat
-
Single leg squat
Lengthening: Day 3 post injury, within a controlled symptom
free range.
-
The extender
-
The Diver
-
The glider
Lunge Stream: Within a controlled symptom free range
-
Split lunge
-
Lunge unloaded
-
Loaded lunge
-
Lunge with twist
-
Lunge 360 degree with twist
Jumping Stream: Unload Squat
-
Drop squat
-
Drop Landing and DL Jump
-
Drop Landing with alternate leg land
-
Drop Squat with SL hurdle hope
-
Drop Squat with multiple hurdle hop.
Running Stream: Unloaded lunge, Day 3 post injury Normal
Gait Pattern
-
Level 1
-
Level 2
-
Level 3
-
Level 4
Agility Drills: Begins Level 3 SL deadlifting
-
E.g. Gaelic Football/Hurling Pickups
-
Rugby-Throwing from Ground
Sports Specific Drills: Begins Level 3, SL deadlifting
-
E.g. Gaelic Football/Hurling Pickups
-
Rugby-Throwing from Ground
Multidirectional: Begins Level 3 Lunge with a twist SL
deadlift
-
Slalom running
-
Cutting
Box Jumping: Begins when drop squats +multiple hurdle hops
Sl deadlifting
Level 4 running
-
Small box to small box
-
Medium box to small box
-
Small box to medium box
-
Medium box to medium box
Return to Play
-
NIL Top
-
SSC VU Test
-
100% Straight Line & MD
-
Symmetrical HIP ROM
-
<10% hamstring strength deficit
-
Sports Specific Drills
Here is the protocol in photo format (hence the need to
write it out as picture becomes blurry):
My Personal Thoughts on Hamstrings
Now when people come to me saying they have a tight/sore
lower back my first thought is their glutes/hamstrings are affecting this. Why?
Well if the hamstrings are tight then that’s due to the calves. Hamstrings
being tight causes the glutes and hips to be tight as they are being pulled on.
This has a knock on effect by making the lower back (erector spinale)
aggravated.
This can lead to a pelvic tilt especially if the glutes and
lower back are tight. They will be pulled down. It will look like this;
Myofasical release on calves, glutes. Do a dynamic warm up
on the trunk and legs. Another thing that could be done to help release
tightness is doing a glute/hip activation protocol as shown; https://www.youtube.com/watch?v=vwspH14-D04
Any injury site isn’t the cause it’s the victim of something
else
Quick tips
If your knee hurts have your hip & ankle checked out
If you’re hip hurts look at your shoulder and your knee
(could be the opposite side not always on the same side).
Assessment
of Hamstring Flexibility
Hamstring
extension is key to determining flexibility, assessed by performing a sit and
reach test. This is a very basic assessment for assessing the flexibility of
the hamstrings and lower back (erectors).
All you need is the following;Sit & Reach Box and the Score Chart
Dr David
Opar on Hamstring Injuries in Football Players
Dr Opar is a lecturer at the School of Exercise, Australian
Catholic University, Melbourne. His focus on hamstring injuries and injury
prevention.
One of the studies he looked at was eccentric strength of
hamstrings related to age and likelihood of injuries. The older you are and
weaker you are eccentrically speaking you are a candidate for a hamstring
injury but regardless of age if you keep up a strong eccentric hamstring you
have a very slim chance of injury.
When looking at the sport of football/soccer it is the most
common injury in the Premier League and accounts for 49.3% of all muscular
injuries reported. Yet risk management rather than prevention is the key when
it comes to hamstring injuries.
He goes in detail of the Nordic Hamstring exercises
Video in full: https://www.youtube.com/watch?v=3hhMHBg9rOk&list=PL_dU9I9rMcdllJLALCBnEXrDIRmc7dnUu&index=4
A great article by Eamon O’Reily, Senior Performance
Rehabiliation Physiotherapist at Sports Surgery Clinic entitled; De-Mystifying
Hamstring Injuries.
My 4
Favourite Hamstring Exercises
Nordic Curl, as it’s a great exercise eccentrically but it’s
a fantastic for injury prevention. I have all my athletes doing this regardless
of sport.
RDL (Romainian Deadlift). Myself being a powerlifter enjoy
this as it gets the hamstrings firing in both the concentric and eccentric
portions of the lift. More so on the concentric from the floor pulling up it’s
a great transfer of strength to the skill of deadlifting.
Hamstring Curl, simple bodybuilding movement to isolate the
hamstring belly. I like to finish off with a few sets of them high reps.
Good Mornings, again like the RDL transfer of strength to
the skill of squatting/deadlift is good as it helps maintain upright posture
during the lifts whilst training a weaker portion of the movement. The good
morning is an exercise to be used in case you end in a bad position during
heavy lifting, if you train it well enough you can always recover from it. Now
being a bad position isn’t something you should intend to get yourself into.
Video: https://www.youtube.com/watch?v=hllFsZIEuAs
Running Mechanics (relating back to
Hamstrings role in running)
What are hamstrings normally used for? While the quads
support our body-weight, our hamstrings help us break free from the pull of gravity.
When we increase our cadence to 180 or more strides per minute we need
hamstrings that are capable of quickly pulling the foot from the ground.
However, larger and stronger muscles, trained in static conditions in the gym,
do not necessarily translate to better performance when running. The key to
developing great hamstrings is performing dynamic drills in order to train the
hamstrings.
Some excellent drills are foot tapping and front lunge. Try
these drills with stretch cords to increase resistance. The key use of our
hamstrings in running is to be able to quickly pull the support foot from the
ground.
This was taken from the video Running Technique: Confusion
About the Role of Hamstrings in Running: https://www.youtube.com/watch?v=pmyBTespnHc
Juggernaut Program Director, James "The Thinker"
Smith, discusses the role different muscles play during different phases of the
sprint. We also show you why the GHR is NOT the best option for hamstring
training for sprinters and a reverse hyper variation that is superior for
hamstring strength and health.
Very good demonstrations, I quite liked using the prowler as
a way of demonstrating the running motion.
Video: https://www.youtube.com/watch?v=gikFNVeOmXI
Hamstrings
in the Squat
Below is a detailed description (in article, picture and
video) of the role of the hamstrings in the squat. Greg Nuckols of Strength
Theory has done a great job analysing the role of hamstrings in the squat under
90% 1RM loads. This has brought back some interesting data. What the main areas
you will find are the following;
1. In general, the body utilizes single-joint muscles before
two-joint muscles really kick in. This
makes movement more efficient.
2. At the bottom of the squat, overactive hamstrings make
the movement unnecessarily difficult, so squatting in a manner that maximizes
hamstrings involvement in the hole is probably unwise.
3. If you find yourself getting pitched forward in the
squat, strengthening your glutes helps your hamstrings relax a bit, taking some
strain off your quads and making the bottom half of the squat easier.
4. The place you want your hamstrings to kick in is at the
sticking point, when demands on the quads have decreased a bit, and the added
hip extension torque can help you keep the bar moving.
(4 points take from article as a preview to it).
If you have the time read and watch the content below as it
will make more sense as having overactive hamstrings is a bad thing.
Studies
done on Hamstrings looking at injury/emg/force etc
Some good studies done on Hamstrings from three
perspectives.
Eccentrics:
-
Askling, C., Karlsson, J., & Thorstensson,
A. (2003). Hamstring injury occurrence in elite soccer players after preseason
strength training with eccentric overload. Scandinavian journal of medicine
& science in sports, 13(4), 244-250.
-
Jonhagen, S., Nemeth, G., & Eriksson, E.
(1994). Hamstring injuries in sprinters the role of concentric and eccentric
hamstring muscle strength and flexibility. The American Journal of Sports
Medicine, 22(2), 262-266.
EMG:
-
Caterisano, A., MOSS, R. E., PELLINGER, T. K.,
WOODRUFF, K., LEWIS, V. C., BOOTH, W., & KHADRA, T. (2002). The effect of
back squat depth on the EMG activity of 4 superficial hip and thigh muscles.
The Journal of Strength & Conditioning Research, 16(3), 428-432.
-
More, R. C., Karras, B. T., Neiman, R.,
Fritschy, D., Woo, S. L., & Daniel, D. M. (1993). Hamstrings—an anterior
cruciate ligament protagonist An in vitro study. The American journal of sports
medicine, 21(2), 231-237.
Force Production
- Ogura, Y., Miyahara, Y., Naito, H., Katamoto,
S., & Aoki, J. (2007). Duration of static stretching influences muscle
force production in hamstring muscles. The Journal of Strength &
Conditioning Research, 21(3), 788-792- Stanton, P., & Purdam, C. (1989). Hamstring injuries in sprinting—the role of eccentric exercise. Journal of Orthopaedic & Sports Physical Therapy, 10(9), 343-349
I hope you found the article interesting to read. It was
heavy at points to read but if you take your time reading it, it will become
digestible. It was a very broad article
I could have done individual articles on all the sections but I will leave that
for another day.
Regards
Andrew Richardson
References
1.
Jump up ^ Koulouris G, Connell D. (2003).
"Evaluation of the hamstring muscle complex following acute
injury". Skeletal Radiol. 32 (10):
582–9. doi:10.1007/s00256-003-0674-5. PMID 12942206.
2.
5.Jump up ^ Schache AG, Koulouris G, Kofoed W,
Morris HG, Pandy MG (2008). "Rupture of the conjoint tendon at the
proximal musculotendinous junction of the biceps femoris long head: a case
report.". Knee Surg Sports
Traumatol Arthrosc. 16 (8): 797–802. doi:10.1007/s00167-008-0517-y. PMID
18360748.
3.
6.Jump up ^ Koulouris G, Connell DA, Brukner P,
Schneider-Kolsky M. (2007). "Magnetic resonance imaging parameters for
assessing risk of recurrent hamstring injuries in elite athletes.". Am J Sports Med. 35 (9): 1500–6. doi:10.1177/0363546507301258.
PMID 17426283.
4.
Chhajer, Bimal (2006). "Anatomy of
Knee". Knee Pain. Fusion Books. pp. 10–1. ISBN 978-81-8419-181-3.
5.
Jump up ^ Kulowski, Jacob (July 1932).
"Flexion contracture of the knee". The Journal of Bone & Joint
Surgery 14 (3): 618–63. Republished as:
Kulowski, J (2007). "Flexion contracture of the knee: The mechanics of the
muscular contracture and the turnbuckle cast method of treatment; with a review
of fifty-five cases. 1932". Clinical orthopaedics and related research
464: 4–10. doi:10.1097/BLO.0b013e31815760ca (inactive 2015-05-08). PMID
17975372.
6.
Jump up ^ Rytter, Søren; Egund, Niels; Jensen,
Lilli; Bonde, Jens (2009). "Occupational kneeling and radiographic
tibiofemoral and patellofemoral osteoarthritis". Journal of Occupational
Medicine and Toxicology 4: 19. doi:10.1186/1745-6673-4-19. PMC 2726153. PMID
19594940.
7.
Jump up ^ Gill, T. J.; Van De Velde, S. K.;
Wing, D. W.; Oh, L. S.; Hosseini, A.; Li, G. (2009). "Tibiofemoral and
Patellofemoral Kinematics After Reconstruction of an Isolated Posterior
Cruciate Ligament Injury: In Vivo Analysis During Lunge". The American
Journal of Sports Medicine 37 (12): 2377–85. doi:10.1177/0363546509341829. PMC
3832057. PMID 19726621.
8.
Jump up ^ Scott, Jacob; Lee, Ho; Barsoum, Wael;
Van Den Bogert, Antonie J. (2007). "The effect of tibiofemoral loading on
proximal tibiofibular joint motion". Journal of Anatomy 211 (5): 647–53.
doi:10.1111/j.1469-7580.2007.00803.x. PMC 2375777. PMID 1776452
Andrew Richardson, Founder of Strength is Never a Weakness Blog
I have a BSc (Hons) in Applied Sport Science and a Merit in my MSc in Sport and Exercise Science and I passed my PGCE at Teesside University.
Now I will be commencing my PhD into "Investigating Sedentary Lifestyles of the Tees Valley" this October 2019.
I am employed by Teesside University Sport and WellBeing Department as a PT/Fitness Instructor.
My long term goal is to become a Sport Science and/or Sport and Exercise Lecturer. I am also keen to contribute to academia via continued research in a quest for new knowledge.
My most recent publications:
My passion is for Sport Science which has led to additional interests incorporating Sports Psychology, Body Dysmorphia, AAS, Doping and Strength and Conditioning.
Within these respective fields, I have a passion for Strength Training, Fitness Testing, Periodisation and Tapering.
I write for numerous websites across the UK and Ireland including my own blog Strength is Never a Weakness.
I had my own business for providing training plans for teams and athletes.
I was one of the Irish National Coaches for Powerlifting, and have attained two 3rd places at the first World University Championships,
in Belarus in July 2016.Feel free to email me or call me as I am always looking for the next challenge.
Contact details below;
Facebook: Andrew Richardson (search for)
Facebook Page: @StrengthisNeveraWeakness
Twitter: @arichie17
Instagram: @arichiepowerlifting
Snapchat: @andypowerlifter
Email: a.s.richardson@tees.ac.uk
Linkedin: https://www.linkedin.com/in/andrew-richardson-b0039278
Research Gate: https://www.researchgate.net/profile/Andrew_Richardson7
This blog was very Informative.
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