Hamstring injury

Last revised by Dr Maulik S Patel on 24 Jan 2022

Hamstring injuries are the most common muscle injury, and are very common in athletes and can cause a significant loss of playing time depending on the sport. 

Amongst professional athletes, hamstring injuries are reported to make up 15% of all injuries in Australian Football players and 12% of injuries amongst soccer players 1.

As with any muscle injury, the hamstrings can be injured at multiple possible points 1,4:

  • originischial tuberosity avulsion injury
  • proximal free tendon
  • myotendinous junction (most common)
    • proximal more commonly injured than distal
    • biceps femoris most common hamstring muscle injured
  • epimysial/myofascial: most common in biceps femoris proximal to the fusion of the short and long heads
  • intramuscular (rare)
  • distal free tendon

Hamstring injuries can result from 1,4:

  • acute injury
    • type 1
      • eccentric contraction during high-speed running for limb deceleration in preparation for foot strike
      • proximal myotendinous junction of biceps femoris most commonly injured
    • type 2
      • excessive lengthening of the hamstring (e.g. dancing, slide tackles, high kicking)
      • proximal free tendon of semimembranosus
  • chronic overuse
    • most commonly seen in runners (over all distances)
    • proximal hamstring origin tendinopathy, with semimembranosus most commonly affected

Clinically, hamstring injuries can be graded as 2:

  • grade 1: no appreciable muscle tearing, <5% loss of function/strength
  • grade 2: damage to the musculotendinous junction (MTJ); reduced strength; some residual function
  • grade 3: complete tear of the MTJ; loss function +/- a palpable gap

There are numerous imaging classification systems including:

There are no unique features of hamstring-specific injuries. Please see the general articles on muscle injury and tendon pathology for further details. 

Return to play is largely predicted by clinical assessment with poor correlation between imaging-based grading systems and time to return to play 4. Prognostic factors affecting a longer rehabilitation and thus delayed return to play include 3,4:

  • proximal free tendon injury
  • proximity to the ischial tuberosity
  • ≥ grade 3 injury (i.e. grade 1 and 2 injuries are not associated with time to return to play) 4

The recurrence rate is ~20% (range 12-31%) and can occur within a short timeframe (e.g. 2 weeks) after return to play 1,3

Patients presenting with posterior thigh pain suspicious for a hamstring injury but have a negative MRI (so-called "MRI-negative hamstring injury") may have symptoms from 4:

  • lumbar spine referred pain
  • fascial injury
  • gluteal trigger points

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Cases and figures

  • Case 1: biceps femoris injury
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  • Case 2: hamstring avulsion injury
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  • Case 3: biceps femoris muscle injury
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  • Case 4: ischial tuberosity avulsion
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  • Case 5: proximal hamstring tendinopathy
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  • Case 6: common hamstrings origin avulsion
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  • Case 7: ultrasound
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  • Case 8
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