Hip
Hamstring Injuries
What are the hamstring tendons?
The hamstring muscles are large muscles that attach to the pelvis, run down the back of the thigh, cross the knee, and attach to the upper end of the lower leg bones. The hamstring muscles are attached by hamstring tendons to the bones. The hamstring muscle group consists of three muscles: semitendinosus, semimembranosus, and biceps femoris. The hamstrings allow us to extend the leg and bend the knee. The hamstrings are balanced by the quadriceps muscles on the front of the thighs. The power and stability of the knees is controlled by the combined efforts of the hamstrings and quadriceps muscle groups.
What is a hamstring injury?
Hamstring injuries refer to damage or strain to the hamstring muscle or tendon. A hamstring injury can commonly be classified as one of the following:
Hamstring Strain
This is the most common type of hamstring injury. A hamstring strain often occurs as a result of overstretching the muscle fibers and/or hamstring tendon. A hamstring strain involves stretching of the hamstring muscle or tendon without tearing,
Hamstring Tear
This occurs when a portion of the hamstring muscle fibers or tendon tears/ruptures. If only a portion of the hamstring muscle fibers or tendon tears, this is considered a partial hamstring tear. If a complete rupture occurs, then the full thickness of the muscle fiber or tendon has torn.
Hamstring Avulsion
This is the most severe type of hamstring injury, where the hamstring tendon fully separates from the pelvis bone where the hamstring inserts (ischial tuberosity).
Avulsion Injury
This occurs on rare occasions when the hamstring tendon pulls off a piece of bone with it when the tendon tears. Avulsion injuries occur from a burst of speed seen in ice skating, weightlifting, and skiing.
What causes hamstring injuries?
- Muscle Imbalance: One of the leading causes of hamstring injuries is muscle imbalance. When the quadriceps are significantly stronger than the hamstrings it can lead to an increased risk of hamstring injury.
- Inadequate Warm-Up: Failing to properly warm up before engaging in physical activities can make the hamstrings more susceptible to injury. A warm-up helps increase blood flow, muscle temperature, and flexibility.
- Sudden or Explosive Movements: Activities and sports that involve sudden and explosive movements, such as sprinting, running, lunging, jumping, kicking, or rapid changes in direction, put the hamstrings under considerable stress and can lead to injury.
- Fatigue: When the muscles are fatigued, they are more prone to injury. Overexertion and muscle fatigue can increase the risk of hamstring injuries. Excessive training, or overtraining, without adequate rest can lead to overuse injuries, including hamstring injuries.
- Lack of Flexibility: Inflexible hamstrings are more vulnerable to strains. Insufficient stretching can result in reduced flexibility and make the muscles more prone to overstretching.
- Previous Injuries: If you’ve had a previous hamstring injury, you may be more susceptible to re-injury due to residual weakness or scar tissue. Failing to rehabilitate and strengthen the hamstring muscles properly after an initial injury can leave them weakened and at risk for further damage.
- Poor Running or Biomechanics: Running with improper form or biomechanics can overload the hamstrings, increasing the risk of injury.
- Age: As people age, their muscles may lose some flexibility and elasticity, making the hamstrings more susceptible to injury.
- Environmental Factors: Running on uneven surfaces or in extreme weather conditions can increase the risk of hamstring injuries.
What are the symptoms of a hamstring injury?
The symptoms of a hamstring injury can vary in severity depending on the extent of the injury. Common symptoms of a hamstring injury include:
- A sharp pain in the middle or upper back of the thigh near the buttocks. The intensity of the pain can range from mild to severe, depending on the severity of the hamstring injury.
- Difficulty putting weight on the injured leg, causing limping.
- Swelling
- Bruising and discoloration
- Hamstring weakness
- Muscle spasms or cramps
- Difficulty fully extending or straightening the leg.
- Audible “pop” or snapping sound at the time of injury, especially in severe hamstring injuries.
How is a hamstring injury diagnosed?
During your consultation with Dr. Bryan Penalosa, a Chicago sports medicine surgeon and hamstring specialist, your medical history, hamstring tendon symptoms, and past injuries will be reviewed.
Physical Exam
Dr. Penalosa will conduct a physical examination checking for bruising, tenderness, weakness, and swelling. If the tendon has pulled away from the bone, the muscle will appear balled up at the back of the thigh.
Imaging
X-rays will reveal an avulsion if the hamstring tendon has pulled a piece of bone away with it during the hamstring injury. An MRI of the hip will provide detailed images of the hamstring tendon, including the location of the injury, the extent of the injury, and the degree of hamstring tendon retraction.
Hamstring Injuries Treatment Options
Can a hamstring injury be treated without surgery?
Most hamstring tendon injuries are treated successfully without surgery. Non-operative treatment of hamstring tendon injuries includes rest, icing, compression, elevation, anti-inflammatory medications, and after 48 hours, gentle stretching and strengthening exercises. However, progression depends upon pain. Physical therapy may be indicated. When necessary, Platelet Rich Plasma (PRP) injections under ultrasound guidance can improve the condition. PRP uses your own blood to create a concentrated solution of platelets to heal muscle strains. It is a minimally invasive procedure that may be recommended along with conservative measures to treat pain and facilitate a quicker return to play in athletes with a hamstring strain or partial tearing of the hamstring. Typically, most mild hamstring injuries will resolve within 6-12 weeks of conservative treatment. It is not uncommon for patients to experience a persistent loss of about 10% of overall hamstring strength following a hamstring injury that is treated without surgery.
What are the surgical options for a hamstring injury?
Severe or complete tears of the proximal hamstring tendon may require surgery if symptoms persist or overall function is limited. Hamstring surgery involves reattaching the proximal hamstring tendon back to its insertion on the ischial tuberosity of the pelvis bone. Surgery can be performed either endoscopically (minimally invasive) or as an open procedure, that is typically completed within 1-1.5 hours as an outpatient procedure. When there is also an avulsion injury, meaning the tendon is torn along with a piece of bone, surgery is almost always indicated. Surgery may be recommended for active and professional athletes when conservative measures fail to relieve pain, or if time lost to conservative treatment is too costly to the athlete.
How are hamstring tendons repaired?
Hamstrings can be repaired through an open minimally invasive hamstring repair technique or through a scope (endoscopic hamstring repair). For small hamstring tears without significant retraction, endoscopic hamstring repair can be performed. A special camera, called an endoscope, is inserted into the buttock area where the hamstring is torn. Small surgical instruments are also inserted through separate incisions and are used to perform the repair using a minimally invasive approach. Alternatively, an minimally invasive repair through a small incision hidden in the gluteal crease can be performed for tears that involve more than one tendon, is chronic in nature, or where there is significant retraction.
What are the long-term effects of untreated hamstring tendon injuries?
The best results are achieved when the hamstring tendon injury is treated within 24 to 48 hours after injury. When left untreated, hamstring tendon injuries can progress in severity.
Recovering from Hamstring Tendon Repair Surgery
How long is the recovery after a hamstring tendon repair?
The recovery time after hamstring surgery with a hamstring tendon repair can vary depending on several factors, including the extent of the surgery, individual patient characteristics, and the level of activity that the patient is striving to return to. In general, most patients can recover full, unrestricted activity in 4-6 months following hamstring surgery, provided they complete a good physical therapy program.
Here’s a general overview of what to expect after hamstring tendon repair:
Initial Recovery Phase (0-6 weeks):
The immediate post-operative period following hamstring tendon repair involves rest and protection of the surgical site. Patients will be non-weight bearing for 6 weeks following hamstring tendon surgery, typically using crutches for a total of 6-8 weeks. Initially, the knee will be locked in a flexed position using a hinged knee brace in order to offload the hamstring tendon as it heals. Over the course of the initial 6 weeks following surgery, the degree of knee flexion is progressively lessened in 2-week increments. Physical therapy will typically begin about 6 weeks following surgery to improve range of motion and reduce swelling. Pain and discomfort are common during this phase, but medications are prescribed to help manage it.
Intermediate Recovery Phase (6-12 weeks):
During this time, physical therapy intensifies to improve strength, stability, and mobility. Return to light, low-impact activities may be allowed under the guidance of Dr. Bryan Penalosa and his team, as well as your physical therapist. Patients should still avoid high-impact activities or activities that involve excessive stress on the hamstrings.
Advanced Recovery Phase (3-6 months):
As strength and range of motion improve, patients can start transitioning to more demanding activities. Physical therapy continues to focus on functional movement and sport-specific exercises. Return to full activities, including sports, typically occurs around 6-9 months following hamstring tendon repair after Dr. Bryan Penalosa has formally evaluated and cleared the patient to do so.
Long-Term Recovery (6 months to 1 year and beyond):
Complete recovery may take up to a year or more. Patients should continue with maintenance exercises to ensure long-term health of the hamstrings and prevent future re-injury.
Preventing Hamstring Tendon Injuries
How to prevent hamstring tendon injuries?
Preventing hamstring tendon injuries, especially for individuals involved in activities that involve sudden and explosive movements, requires a combination of strategies to improve strength, flexibility, and biomechanics. Here are some tips to help prevent hamstring tendon injuries:
Proper Warm-Up:
Always start your physical activity with a thorough warm-up that includes dynamic stretching and mobility exercises for the hip and groin muscles. This helps prepare your hamstring muscles and tendons for the demands of exercise.
Gradual Progression:
Avoid overexertion and sudden increases in training intensity or volume. Gradually progress your workouts to allow your body to adapt and become stronger over time. Pay attention to any warning signs of discomfort or pain in the buttocks or upper posterior thigh area. If you experience pain or discomfort, especially during physical activity, stop and seek medical advice if necessary.
Strengthening Exercises:
Incorporate exercises that target the hamstring muscles into your regular training routine. Focus on both the hamstring and quadriceps muscles to maintain muscle balance.
Core Strength:
A strong core can help stabilize your pelvis and reduce strain on the hamstring muscles. Include exercises that strengthen the abdominal and lower back muscles.
Flexibility:
Perform regular stretching exercises to maintain flexibility in the hip and thigh area. Incorporate static stretches and dynamic stretches to improve range of motion.
Proper Technique:
Ensure that you are using proper form and technique during exercises and activities. Seek guidance from a coach or trainer if needed, especially for sports that involve quick changes in direction.
Footwear:
Wear appropriate footwear for your sport or activity, as improper footwear can affect your biomechanics and lead to injuries.
Rest and Recovery:
Allow your body sufficient time to recover between intense workouts or activities. Rest is crucial for muscle and tendon healing and adaptation.
Hydration and Nutrition:
Stay well-hydrated and maintain a balanced diet to support muscle health and overall performance.
Cross-Training:
Incorporate cross-training activities to reduce the risk of overuse injuries. Variety in your workouts can help prevent muscle imbalances.
Proper Rehabilitation:
If you’ve had a previous hamstring tendon injury, ensure that you complete a full rehabilitation program to regain strength and flexibility and reduce the risk of re-injury.