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Athlete doing hamstring stretch

Hamstring injuries are a pervasive concern among athletes, ranging from acute strains during high-speed activities to chronic tendinopathy from repetitive stress. Understanding the causes, diagnostic approaches, and effective treatment strategies is crucial for athletes looking to prevent these injuries and expedite their return to play. In this comprehensive guide, we will delve into the types, diagnosis, treatment options, and return-to-play considerations for both acute hamstring strains and chronic proximal hamstring tendinopathy.

Types and Causes of Hamstring Injuries

1. Acute Hamstring Strains:

   - Type I: Occurs during high-speed running, particularly in activities like sprinting. Commonly involves the long head of the biceps femoris.

   - Type II: Results from excessive lengthening of the hamstrings, common in dance, slide tackling, and high kicking. Often affects the proximal free tendon of the semimembranosus.

2. Proximal Hamstring Tendinopathy:

   - Chronic, degenerative condition caused by mechanical overload and repetitive stretch, prevalent in sprinters, long-distance runners, and endurance athletes. Involves the semimembranosus, with potential sciatic nerve irritation due to repetitive stretch.


1. History:

   - Acute Hamstring Strain: Sudden onset, sharp pain, possible audible "pop," and difficulty continuing activity.

   - Proximal Hamstring Tendinopathy: Gradual increase in posterior thigh pain, tightness, cramping, exacerbated with specific movements.

2. Examination:

   - Palpation, passive stretches, and resistance testing crucial for identifying injury location and severity.

   - Special tests like Puranen-Orava and bent-knee stretch help diagnose proximal hamstring tendinopathy.

Man doing athlete stretch

3. Imaging:

   - MRI and ultrasound effective for identifying strains and tendinopathy.

   - Ultrasound valuable for real-time evaluations and guidance for injections.


1. Acute Hamstring Strain:

   - Rehabilitation Phases: Progressive approach focusing on pain reduction, neuromuscular control, and sport-specific exercises.

   - Corticosteroid Injections: Controversial with mixed results; further studies needed.

   - Platelet-Rich Plasma (PRP): Inconclusive evidence on effectiveness; varying results in different studies.

2.Proximal Hamstring Tendinopathy:

   - Conservative Management: Eccentric exercises, soft-tissue mobilization, shockwave therapy, corticosteroid injections, and PRP.

   -Eccentric Exercises: Effective in improving pain and function; various exercises such as hamstring curls and Nordic leg curls.

Return to Play

1. Acute Hamstring Strain:

   - Factors Influencing Return: Type of injury, proximity to ischial tuberosity, and imaging findings.

   - Rehabilitation Protocol: Gradual progression through phases, incorporating agility, trunk stabilization, and eccentric strengthening exercises.

2. Proximal Hamstring Tendinopathy:

   - Return Guidelines: Depend on severity and duration of the condition; graduated return to activity with full range of motion and pain-free strength testing.

Hamstring injuries are a prevalent challenge for athletes, necessitating a multifaceted approach to diagnosis, treatment, and return to play. Understanding of acute strains and chronic tendinopathy, along with evidence-based rehabilitation protocols, empowers athletes to proactively manage these injuries and minimize their impact on performance. With ongoing research, the field continues to evolve, providing athletes with a more comprehensive understanding of hamstring injuries and effective strategies for prevention and recovery.


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