Hamstring muscle strain

Background: Acute hamstring strains are common injuries in different sports. They are often serious, causing long rehabilitation times and a proneness for re-injury. Preliminary observations indicate that the injuries can be of at least two types, one occurring during high-speed running and the other during motions where the hamstring muscles reach extreme lengths.

Aims: To investigate the possible existence of different types of acute hamstring strains in two specific athletic groups, namely sprinters and dancers, as well as the generality of these findings in other sports.

Methods: In the first project, 18 sprinters and 15 dancers with acute first time hamstring strains were prospectively included. All subjects were examined, clinically and with magnetic resonance imaging (MRI), on 4 occasions after injury: at day 2-4, 10, 21 and 42. The follow-up period was 2 years. In the second project, 30 subjects from 21 different sports were prospectively included. All subjects were examined clinically and with MRI. The follow-up period lasted until the subjects returned to sport or finished their sport activity due to the injury.

Results: All sprinters sustained their injuries during competitive high-speed running. In contrast, all dancers encountered their injuries during slow-speed stretching type of exercises. The initial loss of strength and flexibility was significantly greater in sprinters than in dancers. At 42 days after injury, both groups could perform more than 90% of the test values of the uninjured leg. All the sprinters injuries were primarily located in biceps femoris long head, whereas the dancers injuries were mainly (87%) involving the proximal free tendon of semimembranosus. For the sprinters, involvement of the proximal free tendon, as estimated by MRI, and proximity to the ischial tuberosity, as estimated both by palpation and MRI, were associated with significantly longer time to return to pre-injury level. In the dancers, there were no significant correlations between clinical or MRI parameters and time to return to per-injury level. The time to pre-injury level was significantly longer (median 50 weeks, range 30-76) for the dancers compared to the sprinters (16, 6-50). In the second project, all injuries occurred during movements reaching a position with combined extensive hip flexion and knee extension. They were all located close to the ischial tuberosity and 83% involved the proximal free tendon of semimembranosus. Fourteen subjects (47%) decided to end their sport activity and for the remaining 16 subjects the median time back to sport was 31 (range 9-104) weeks. There were no significant correlations between clinical and MRI parameters and time to return to sport.

Conclusions: There seems to be a link between the injury situation and the two types of acute hamstring strain in sprinters and dancers with respect to clinical findings, injury location, muscles and tissues involved, and time to return to pre-injury level. Proximity of the injury to the ischial tuberosity, as estimated both by palpation and MRI, is associated with longer recovery time. Also in other sports, an injury situation where the hamstrings reach extensive lengths caused a specific injury to the proximal posterior thigh similar to that described in dancers. Due to the prolonged recovery time associated with this type of injury, correct diagnosis based on history, clinical and MRI investigation, and adequate information to the athletes are essential.

List of scientific papers

I. Askling C, Saartok T, Thorstensson A (2006). Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med. 40(1): 40-4.
https://doi.org/10.1136/bjsm.2005.018879

II. Askling CM, Tengvar M, Saartok T, Thorstensson A (2007). Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med. 35(2): 197-206.
https://doi.org/10.1177/0363546506294679

III. Askling CM, Tengvar M, Saartok T, Thorstensson A (2007). Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med. 35(10): 1716-24.
https://doi.org/10.1177/0363546507303563

IV. Askling CM, Tengvar M, Saartok T, Thorstensson A (2008). Proximal hamstring strains of stretching type in different sports. Injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. American Journal of Sports Medicine. [Accepted]
https://doi.org/10.1177/0363546508315892