Hanging on by a Hamstring – by Adam Meakins

Today on RunningPhysio we're doing a 'blog swap' – I've handed the keys to Adam over at TheSportsPhysio and I'm trusting him not to redecorate or put up any of those horrid 80's posters with wolves on or dolphins jumping a reflection of the moon! Luckily Adam is pretty trustworthy and I'm sure the blog is in safe hands! He has worked in elite sports and has a wealth of experience to draw from, follow him on Twitter via @adammeakins.

 

So the hamstrings, the ‘hammy’s’ those muscles that run down the back of your leg, the ones that commonly get overlooked until it’s too late. You only had to be watching the recent London 2012 Olympic 100 metres final to see Asafa Powell pull up 60m down the track or watch Andy Carroll limp off and be ruled out for 6 weeks after his debut game with West Ham a few weeks ago to realise how common hamstring injuries in sport can be, but what about in running?

Well Tom has asked me to talk to you about hamstring tears in running, what are the chances of you having one? What happens when they tear and what you can do to reduce your risk and optimise your recovery quickly?

Now luckily, or unluckily depending which side of the treatment couch you’re on, I have dealt with plenty of hamstring tears especially in my years of working as a physio in football, as this is one of, if not the most common injury in football.

However they are also fairly common in other sports, but what about running, well I can tell you from first hand experience having suffered a hamstring injury a few years ago, they do occur in running, but to tear a hammy, you usually have to be sprinting hard or trying to slowing down rapidly, or changing direction sharply or kicking something, which runners do do, (apart from kicking something… except maybe that mad dog chasing you) just not as often as in a sport such as football, I did mine leaping through the Forest of Dean on a trail run.

There are other ways to tear a hamstring , the overstretch tears that dancers experience a lot but these tend to be done at slower speed and less traumatic than the high speed explosive tears from sprinting and running and its these that will be more relevant to runners.

So we know they are common but what are your chances of suffering a hamstring tear as a runner, well unfortunately I can’t tell you, as I was unable to find any specific study on just runners alone, all the studies are done in sports such as football, rugby or athletic track events, for example a great study done by Woods et al 2004 done over two years back in 1997-1999 in professional football found the incidence of hamstring tears to be the highest prevelant injury with rates as high as 28% with between 8-25 days out per injury depending on severity and where it tore.

But it’s fair to say that if you’re a runner who sprints, jumps and leaps a lot, such as a trail or fell runner, or someone who does regular hill sprints or any high intensity sprint session then your chances will be significantly higher to tear a hamstring rather than a runner who maintains a consistent steady pace, you’re more likely to develop a hamstring tendinopathy, but that’s another article completely.

So why do these hamstrings tear?

Hamstring Anatomy

Well its due in part to their anatomy and the role they play when running. First their anatomy, the three hamstrings control movement at two big joints, the hip and the knee, and we know that muscles that have to work this way, simultaneously controlling movement at two joints are more at risk of injury, it’s also believed that most hamstrings usually tear during the late swing phase or the running cycle, just at maximal knee extension i.e. just before your foot is about to land on the floor, this phase of the running cycle is when the hamstrings are having to act like a brake, slowing your leg down as its been powerfully swung forward underneath you by the strong forceful contraction of the quads and hip flexors muscles, but as they are acting as a brake they are also being elongated to near their maximal length by both the straightening knee and the flexing hip. This is called eccentric muscle contraction (concentric contraction is the opposite when the muscle shortens such as when the heel comes up towards your buttocks in the early swing phase)

So the hamstring has to stretch to near is max length and simultaneously contract to slow your leg down, this produces a great deal of tensile strain within the muscle and if it reaches a critical point it will tear. It tears usually at its weakest point that being an area called the musculotendinous junction, this is where the muscle belly changes into the tendon, and its usually the biceps femoris muscle (the hamstring down the outside of your leg) that this occurs in, but they can tear in other areas and in any of the other hamstring muscles depending on a lot of different factors.

So how do you know if you have torn your hamstring rather than just strained it?

Well this can be extremely obvious, but also very tricky, for example, a severe or complete tear of a hamstring called a Grade 3 injury is easy to diagnose and spot, for starters you will have felt something ‘go’ or ‘pop’ or ‘crack’, you will also be lying on the floor feeling as if you have been shot or hit with an axe behind your leg, you will not be able to walk and will be in a lot of pain, you will notice bruising quickly appear in the next hour or so as the torn muscle leaks blood ‘a lot’ and it will be hot and swollen to touch, this class of tear is normally managed by surgical repair and then physiotherapy and will mean 6 months to a year out.

For a less severe partial tear called a Grade 2, you will have still probably felt something ‘go’ again but no popping sensations, you will have pulled up but still be standing and limping around, you will be able to walk but it will hurt, you may or may not get any bruising, and maybe able to feel some heat and swelling but might be harder to see, this is usually managed conservatively meaning no operation but lots of physio treatment and anywhere from 6 weeks to 6 months out.

However for the much more common smaller tears called a Grade 1, it can be harder to recognise, these are tricky little buggers it can almost feel like a small strain or niggle that can come on during a run, you can continue to run although it will cause a diffuse soreness behind your leg that can settle very quickly once you have stopped, so leading you to think you have not torn anything especially as you won’t see any bruising or feel any heat or swelling and feel nothing in normal day to day activities except maybe a twinge on getting up out of chairs or up/down stairs, most of these class of tears need to be properly managed and normally its anywhere of 3 -12 weeks of physio treatment

The reason it can be from 3 weeks to 3 months for the same injury is due to a couple of reasons first and most obviously with a Grade 1 tear runners can continue to run which they like to do, and tend to do, even in pain, this disrupts the healing processes and prevents the tear from healing, secondly it can depend on where the tear is located, if more in the tendon it heals slower than if in the muscle belly, all due to the differing bloody supply. Finally they are commonly misdiagnosed as just a strain and so again back to the same issue of allowing the runner to continue to run or even doing inappropriate rehab such as stretching the hamstrings in the early stages and so not allowing the tear to heal.

So what do you do if you think you have a Grade1 hamstring tear?

Well its simple if you’re a professional football player you go and have an MRI, that’s the gold standard, no room for misdiagnosis there (well 98% of the time), but you’re not going to get MRI when you go and see your GP or physio and complain of your hamstring pain as 1) they cost a fortune and 2) the waiting time to get one means it will be useless by the time you do.

 

MRI showing grade 1 tear of biceps femoris

So my advice if you think you have just a hamstring strain, err on the side of caution and treat it like a Grade 1 tear and go and see a physio for some advice and treatment. In my experience dealing with them like this, yes may take a little longer and may be frustrating at the start, but it will mean in the long run you won’t be back to see the physio a few weeks later with same problem.

So how do you treat a Grade 1 hamstring tear?

So first and foremost STOP RUNNING, this will be for at least THREE weeks, and yes I can hear you all groaning from here… believe me I don’t ask people to stop their sport lightly but if I think you have a hamstring tear I will insist.

Follow the RICE programme, Rest we covered above, Ice for a week or so regularly, Compress with either cycle shorts or tubigrip, and Elevate

DO NOT STRETCH your hamstrings for these three weeks or so, you will need to let the scar tissue lay down over the tear without disrupting it, if you keep stretching it will be unable to lay down effectively, you will be stretching plenty later on, save your energy for then.

Once the physio feels you have gone through the healing phase then the fun rehab can begin and eventually get you back out running, how long this last again varies and is based on individual factors and you will have to reach certain checkpoints before the physio lets you back 100% but on average it’s a few weeks.

Great so you're recovered and back out running, well a word of warning, you are now in the high risk category for suffering with another hamstring tear, with around 33% suffering another tear especially in the first few weeks after return to running, again I can hear you groaning from here… but you can reduce your risk of re injury.

So how do you reduce your chances of suffering a hamstring tear as a runner?

Well I’m sorry to say this again but I couldn’t find any specific studies done just on runners on how to prevent hamstring tears (us runners seem to be the poor relation of sports when it comes to good quality research), most prevention studies again have all been focused where the money is… football. But we can still use their findings and incorporate it for us runners.

First we need to identify your risk factors for getting a hamstring injury and as we said previous hamstring injury is a factor, in fact it’s the only conclusive risk factor that the research has found.

But there are other modifiable risk factors found in the research but they aren’t conclusive, they are a lack of flexibility of both the hamstrings but also the hip flexors and quads, poor strength ratios between the quads and hamstring , poor coordination of the pelvic and trunk muscles, fatigue and poor warm up strategies prior to exercise. So although not conclusive if we use our common sense and address these then your chances of suffering a hamstring tear have got to be reduced.

First let’s look at flexibility.

The hamstrings are notorious as being a tight group of muscles but this isn’t the only group to look at the relationship between the hamstrings and the hip flexors and quads is complex and addressing tightness in all of these is essential.

If we keep it simple for sake of time and just say if the hamstrings and hip flexors and quads are tight then the movement at the hip and knee joints is restricted and place extra strain on the soft tissue around them so loosening them allows better joint movement, so less strain.

Some of the best stretches I feel for these muscle are as below

There has been much debate of the role of stretching before running etc, and I don’t want to get into this now, but it’s safe to say if you loosen these tight muscles regularly not just before you go running you won’t be going far wrong. (More on stretching from Adam here)

Next let’s look at hamstring strength.

Keeping the hamstrings strong, but especially the eccentric phase, which if you remember a while back we said is when the muscle is lengthening as it’s contracting is also key. All running activities tend to be quad dominate and these quad muscle get stronger and stronger when running so the ‘pulling’ on the hamstrings gets more and more as the leg swings forward underneath us, if the hamstring can’t keep up with the stronger quads it will be prone to tearing.

A ratio of 1:0.6 or 66% has been used for a long time for the hamstrings but this is only for its concentric strength, for example if your quads can push 100kg your hamstrings should be able to pull 66kg.

But a much more useful and important ratio is the eccentric ratio and opinion here is divided as what’s the best, but for most a ratio of 1:1 is used, (1:1.2 if you’re an elite athlete) for example for every 100kg your hamstring can pull as the knee bends, it must be able to resist 100kg as your knee gets straightened (120kg if you’re an elite athlete)

A good way of testing this and finding out if you are achieving these ratios is with an Isokinetic Dynometer as shown below, this is me testing one of our young Watford FC lads last season, but again not many will have access to this, instead just take it as read that you won’t have these ratios, I haven’t met many that do, so doing some hamstring strengthening exercises is a must especially the eccentric phase is essential

Some good hamstring eccentric strengthen exercises

The last exercise the single leg RDL (Romanian Dead Lift) is also really good for helping that other factor mentioned the coordination and control of movement around the hip and pelvis as it challenges your balance as well as gets you strong.

Finally a word on warming up.

Ensuring you are prepared for any athletic activity is a must but even more so for explosive or sprinting activities.

In my opinion no runner spends long enough warming up, when I first started working in football I was amazed by the length of the warm up compared to the length of the training sessions, sometimes the warm up can be as long if not longer than the planned training session.

I have brought this philosophy back to not only my training, but also my patients and with great success. I now insist that all my patients especially those with past hamstring issues to do a dynamic warm up for at least 50% for the time you have planned for any high intensity session sprints etc and at least for 25% for a ‘normal’ paced run, this is minimum, so, for example if you have planned a 30 min interval sprint session then warm up for at least 15 min, or, going for a 30 min jog, then at least a 7 min warm up, how many of you do this…. None I bet,

Again there is much debate as to what’s the best warm up etc etc, I don’t want to get into this instead here are a few of my favourite warm up drills for runners.

Lunge walking, Donkey kicks, High kick pull backs, Sideways running, Backwards running, Toes walking, Dead leg running

The list could go on and on…

My final thoughts are, running at a steady constant pace is low risk of producing a hamstring tear but this risk increases if you start to do any sprinting, leaping, jumping or sudden changes of direction, and increases even further if you have had a previous injury.

You can reduce this this rick by ensuring you have good flexibility in not just your hamstrings but also hip flexors and quads and ensuring your eccentric hamstring strength is better. Finally make sure you warm up for a lot longer than you normally do.

Thanks and happy running…

Adam

 

14 Responses to Hanging on by a Hamstring – by Adam Meakins

  1. sportinjurymatt October 30, 2012 at 2:04 pm #

    Hi Adam.
    Great clear advice as always.
    Just wondered where you sat in relation to pelvic positioning and hamstring injury. Lately, I have read articles suggesting that the concept of an ideal “neutral” pelvis is outdated. And yet, in my experience, one sign of weak lengthened hamstrings, short dominant quads & tight hip flexor/s is the bearer possessing anterior pelvic tilt. In assessing injury risk and assigning appropriate corrective exercise for members of the football team I look after, I still regard an anterior pelvic tilt as a red flag. That said, I do understand there is no blue print for the ideal pelvic position as every body is unique (I am sure you have also come across players with a noticeable tilt but no history of injury!). Any comments you may have appreciated!

  2. adammeakins October 30, 2012 at 3:15 pm #

    Hi Matt

    Thanks for your comments, as you said there has been a lot of debate recently on the notion of anterior/posterior tilt and the so called neutral pelvis (which I don’t think exists to much individual variation), I think again common sense has to rule, there are therapists that take a far to detailed and specific look at the pelvis and then miss the wood for staring at the trees, and then there are those that don’t even bother looking and feel has nothing to do with it.

    I take the middle ground, as you rightly said anterior tilt can be caused by tight hip flexors so place the hamstrings in a lengthened as so theoretically weakened and vulnerable position, but not always there can be other factors at play.

    My take away message I think is yes screen for those things (i love the Thomas test for this) but the main thing to take into consideration is past history of hamstring problems and poor eccentric strength, get all sprinters and runners etc doing Nordics and Gym ball eccentric curls and you can defiantly reduce the risk if pulling a hammie

    Cheers again Matt

    Adam

    • sportinjurymatt October 30, 2012 at 4:30 pm #

      Perfect. Figured your reply would be along those lines. Thanks Adam.

  3. Ed Pratt March 4, 2013 at 10:54 am #

    Hi Adam

    Loved the post, very informative. With regrds to not stretching during the first 3 weeks: by this do you mean static stretching or all stretching? I have had some good results using cyclical stretches (Glen Hunters Specific Soft Tissue Mobilisations, Grade I) after an initial, but shorter, period of rest. The aim being to reduce the volume of scar tissue laid down.

    Would love to know your thoughts on the matter.

    Ed
    PS isnt the labelling of the semimembranosus and semitendinosus the wrong way round?

  4. Eric Clarke April 12, 2013 at 11:20 pm #

    Hi Adam,

    Nice article and like the good clear advice. Agree completely re the idea that the insidious type of onset in the slow, constant runner is much, much less common.

    Re the more explosive type of running, have you had a chance to look at some of the studies form the guys in Adelaide and Sydney (AFL mostly) over the past 10 years or so (Cameron, Verral, and those guys) who have done quite large MRI studies on false positive diagnoses of hamstring injuries, and accurate predictors of positive MRI findings? Almost 60% of the posterior thigh pains strains in some of their studies are actually MRI negative – ie it is something else. Combined with their wider body of reaserch, it points to what you ahve said about the explosive, change of direction nature of sports as the more common scenario.

    Reading in more depth, my take on this is that fatigue is a big factor in true hamstring injuries – whether fatigue in local hamstrings or more the global stability idea. In my x number of years being a physio, I can still count on one hand the number of “hammys” that don’t involve some element of lumbar spine dysfunction.

    The biggest question is how does one prevent them – and as you very correctly point out strength is key. But I think good lumbar spine health is also really worth looking at too.

  5. Adam Meakins April 14, 2013 at 9:49 pm #

    Hi Eric

    Thanks for your comments and yes I totally agree with everything you say, first fatigue is definitely a factor in injury and should be considered I remember reading a paper sometime ago showing most hamstring injury in football occur in the last 15-20 mins of a game ( can’t remember the paper) as you say how we can manage and deal with this is another issue

    And yes to your other point that a hammy in isolation is rare if ever happens truly alone at all, most injuries are a subsequent breakdown of the kinetic chain with, primary, secondary and tertiary areas of injury, weather we notice them or not, and the lumbar spine in fact whole posterior chain and perhaps anterior structures should be looked at for other concurrent injuries.

    Thanks for you comments and giving food for thought

    Adam

  6. Adam Meakins April 14, 2013 at 9:56 pm #

    Hi Ed

    Sorry for the very late response I have only just noticed your comment, yes I have heard of Glens work, however I am very weary in the presence of a tear to do anything to disrupt the proliferation phase of healing, but agree that controlled tensile stress can assist in laying down more organised tissue, I think I prefer natural self controlled movement for the first three weeks with no real extra external force applied eg therapist assisted over pressure stretching. Cyclical self directed dynamic stretching stress is definitely needed, but this can be as simple as walking a set period time.

    Thanks for your comments

    Cheers

    Adam

  7. adam May 1, 2013 at 4:27 pm #

    hey
    nice info!!!
    i had this first grade tear diagnosed with ultrasound only the problem is it been 3 month since its start hurting( it was diagnosed as piriformis syndrome…) and i was running the first 2… (include one hm )

    so i suspect to messed up the initial healing and having a scar painful tissue.

    what cab i do in this case???
    thanks

  8. Tom July 23, 2013 at 8:29 pm #

    Thanks Adam for the information. I injured my left hamstring two weeks ago preparing for a marathon. I was being chased by a dog and stepped in a low spot in the road that I did not see. It popped and instant excruciating pain. I nearly fell and could not put any wait on the leg. I could not walk at all the first day and was a week before I could walk any resemblance to normal but with a limp and pain. After two weeks I can walk pretty much pain free but it still hurts on occasion, especially if I twist or strain it. It is bruised right above the knee. At the onset the pain was from hip to knee. The way it sounds I am out of the running gig for quite a while. I was wondering about a road bike. I do cross train. I tried a couple of days ago and was able to ride without much discomfort but at night it aches. Will riding a road bike at this point be advisable?
    Thanks,
    tom

  9. Bryan October 8, 2013 at 7:19 pm #

    I’ve suffered a torn bicept hamstring…however did not complete detach itself nor take a peace of bone with it…did it while sprinting and heard a pop…..as well as partial torn the other 2 with extreme edema as well as sprained gluten…..it happened 2 weeks ago and still cannot walk…very very painful..I’m 38…and so depressed as I so badly need to walk again $$and work…..I had one orthopedic say no surgery…but going yo get a second opinion….what are your thoughts as far Az needing surgery or not…..pros and coins….thank you greatly

  10. Bill April 29, 2014 at 6:32 pm #

    As usual, I have come late to a thread but so glad I found it. Very helpful Adam. My interest in the hamstrings (and quads, etc) is cross training. I’m a runner but recently decided to look into cycling as a good substitute for and supplement to my running. Plenty of blogs say cycling is probably the best cross training for runners because it comes closer to the actual movements of running, but also because cycling works several of the muscle groups more effectively than does running. Which brought me to the hamstring vs quads vs cycling vs sprinting vs middle and long distance running. I’m still a bit confused but your article removed much of it. My initial confusion was that cycling tends to build strong quads whereas running should build strong hamstrings because the hams power me up a hill whereas my quads only ease me back down the hill. The I remembered Carl Lewis or some famous sprinter pulling his hamstrings and thought, “Huh? Why do sprinters and cyclists build quads that overpower their hamstrings but runners do not?” Your article helps me with an answer but unless I’m way too late to the thread, I’d sure like to hear your reply. Thanks!

  11. CAROL DOHERTY July 14, 2014 at 9:12 pm #

    Hello,

    I’m a student physio on an outpatient placement and have seen a few injured hammys as consequence of running.

    I found this article really helpful so thank you.

    Carol

Trackbacks/Pingbacks

  1. How to reduce your risk of injury when playing football! « The Sports Physio - September 30, 2012

    [...] is another common injury I used to see regularly in the physio room at Watford FC, read why here on my piece on hamstring [...]

  2. Managing Hamstring Tears – by Richard Norris | RunningPhysio - June 23, 2013

    [...] For more on Hamstring Tears see Hanging on a Hamstring by Adam Meakins  [...]

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