Risk Factors for Hamstring Injury | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Risk Factors for Hamstring Injury

To follow on from the previous two blogs on assessment hamstring muscle flexibility and improving muscle flexibility, I thought it would a great time to discuss risk factors for injury too.

One of my old colleagues (and very talented young Physiotherapist) Grant Freckleton was involved in a 2013 study looking at the risk factors for hamstring injuries in Australian Rules Football players. I realise this is not a sport commonly played outside of Australia, but, the information is applicable and transferrable to other running/kicking sports with high prevalences of hamstring injury. 

Prevalence & etiology

Hamstring muscle strain injuries (HMSI) are common in sports that involve sprinting (Orchard et al., 1997), acceleration, deceleration, rapid change in direction and jumping (Devlin, 2000; Drezner, 2003).
  • Hamstring injuries during sprinting are proposed to occur during the terminal swing phase of running as a consequence of an eccentric contraction (Schache et al., 2009; Heiderscheit et al., 2005). 
  • The majority of hamstring injuries occur at the biceps femoris (BF) long head (Koulouris & Connell, 2005; De Smet & Best, 2000; Croisier, et al., 2004). 
  • Askling, et al., (2006) has proposed two distinct mechanisms of hamstring injuries.
    • Type 1 involve high intensity running
with injury occurring during late swing phase involving the proximal musculotendinous junction of the long head of biceps femoris.
    • Type 2 is described as a stretching of the hamstring complex due to extreme joint positions involving mostly semimembranosus and the proximal tendon (Yu et al, 2008; Askling et al, 2006).

Risk factors

A systematic review (Freckleton & Pizzari, 2013) identified:
  • Older age,
  • Increased quadriceps peak torque, and 
  • Past history of hamstring injury as factors associated with increased risk of hamstring muscle strain injuries. 
  • Interestingly hamstring:quadriceps ratio is not associated with hamstring injury.

Clinical assessment

The subjective assessment is key to correctly diagnose an injury. Players with a hamstring injury will report sudden onset of pain localised to the hamstring region with a clear mechanism or incident. Usually, players are unable to continue participating in their sport following injury. As mentioned above, previous history of injury is an important factor to question for during the subjective assessment as it is a major risk factors for future hamstring injuries (Freckleton, et al., 2012).

Clinical examination for determining hamstring injury is considered to be reliable and accurate (Schneider-Kolsky, et al., 2006). A hamstring injury can be defined as having positive clinical signs and symptoms including (Bennell, et al., 1999):
  • Immediate onset of posterior thigh pain,
  • Tenderness on palpation,
  • Reproduction of pain on stretch of hamstring,
  • Reduced straight leg raise ROM,
  • Reproduction of pain and reduced strength on resisted active contraction of hamstrings, and 
  • Unable to continue playing or training and miss at least one game due to the hamstring injury.

Can we predict future hamstring injuries?

A recent study (Freckleton, et al., 2013) investigated the use of the single leg hamstring bridge (SLHB) as a clinical test in predicting hamstring injuries in football players.

The single leg hamstring bridge tests the hamstring muscles in a functional position similar to terminal swing and assesses endurance parameters rather than peak torque. This study demonstrated a significant deficit in preseason SLHB scores on the right leg of players that subsequently sustained a right-sided hamstring injury.

A score less than 20 is considered poor, 25 average and greater than 30 good. On average, players who sustained a right-sided hamstring injury in this study were close to or below the ‘poor’ level. 

The SLHB test could be used to screen and identify athletes who are potentially at risk of sustaining a hamstring injury. It may also be used to evaluate the readiness of an athlete to return to sport. 

The protocol is outlined in Freckleton et al. (2013). For the full details of this study please refer to the original blog post on Rayner & Smale

Sian :)

Sian Smale is an Australian-trained and APA-titled Musculoskeletal Physiotherapist. Sian has been writing a Physiotherapy evidence-based blog for the past 3 years called Rayner & Smale. Sian is based out of San Francisco and continues to write and teach Clinical Pilates while working towards her Californian Physical Therapy license. Sian has also created a free, online pregnancy and post-natal home-based workout program Hey Fit Mama.


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Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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