We see a lot of hamstring injuries in sports medicine. Hamstring injuries are poorly understood and difficult to treat. They can be really tough injuries to come back from.

Part of the reason for that is that there is a broad range of things that a hamstring injury can be. Start with the term “hamstring” itself. There isn’t just one “hamstring,” but instead, a group of three muscles that is collectively called the Hamstring. Those three muscles are the Semitendinosus, Semimembranosus, and Biceps Femoris.

The Semitendinosus and the Semimembranosus travel a similar path along the inside of the back part of the thigh and are the most commonly injured. One unique component of the hamstrings is that they cross both the hip and the knee, anchoring on one end at the base of the pelvis and on the other end on the tibia (lower leg bone). This is another part of why treating hamstring injuries is so difficult.

Even if you can identify which muscle you are dealing with, there are several places where an injury can take place. Muscle fibers can tear within the body of the muscle. If severe enough of a tear, you may get a purplish bruising on the back of the thigh. Sometimes this can be quite visible but because the tear could be quite deep, lack of discoloration is not a sign of severity.

I have seen this kind of bruising from the buttock to the back of the knee and the person recovers quite quickly. I have also seen no discoloration at all and the injury takes forever to get better.

A hamstring can be injured on either end as well, where it connects. If you paid attention in Health class, you might remember that a ligament connects a bone to a bone (such as the anterior cruciate ligament) and a tendon connects a muscle to a bone. Even within that tendon, it can be important to know if it is at the tendon-osseous junction (where the tendon connects to the bone) or the musculotendinous junction (where the tendon connects to the muscle). That alone can determine prognosis.

Crossing two joints, the hip and the knee, also makes the hamstrings incredibly important in athletic performance. That’s why hamstring injuries can be so devastating. It’s hard to function without them.

The typical treatment for a hamstring injury is to stretch it. It is never quite so simple. Look at it this way. Since most hamstring injuries are in the top half of the muscle, reaching all the way to where it attaches on the pelvis, pelvis stability is essential to recovery. Stabilizing the pelvis is a very complicated affair.

A couple of weeks ago, I talked about core strength. That’s part of what I’m talking about here. If the muscles supporting the pelvis are not strong, extra strain is placed on the hamstrings. That’s why good core strength is important in both prevention and treatment.

But too often, once the hamstring is injured, we focus only on stretching. While stretching is certainly important, it is definitely not everything. Weakness elsewhere must be addressed otherwise that rehab can be lengthy. And frustrating.

I call a hamstring injury an “invisible” injury. Unless there is visible bruising, there really isn’t anything you can see or feel. Oh, if the tear in the muscle is bad enough, experienced hands can feel a defect in the muscle itself. And if it is at that tendo-osseous junction I talked about earlier, an X-ray might provide important information.

Because it is mostly invisible and because it can last for a long time, others — coaches, parents, teammates — generally don’t understand. It’s been long enough … why don’t you just toughen up and get out there!

It’s never that simple. And the solution is more than just stretching. You need expert help.

Joe Black, PT, DPT, SCS, ATC is a physical therapist and athletic trainer at Total Rehabilitation and is Manager of Outpatient Rehabilitation for Blount Memorial Hospital. Email joeblackdpt@gmail.com to write to him.

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