Hamstring Injuries in Athletes: Evidence-Based Treatment

Justin W. Arner, MD; Michael P. McClincy, MD; James P. Bradley, MD


J Am Acad Orthop Surg. 2019;27(23):868-877. 

In This Article

Anatomy and Function

Three muscles make up the hamstring complex: the biceps femoris (long and short heads), semitendinosus, and semimembranosus. All but the short head of the biceps originate on the lateral ischial tuberosity, with the semimembranosus being most lateral and deep with a crescent-shaped origin. The common semitendinosus/biceps femoris origin is oval in shape and originates on the medial aspect of the hamstring footprint (Figure 1). Knowledge of adjacent anatomy is vital and provides landmarks for appropriate image interpretation and safe surgical approach. The average distance from the proximal semitendinosus/biceps origin to the inferior border of the overlying gluteus maximus is 6.3 cm.[4,5] Most importantly, the sciatic nerve is 1.2 cm from the lateral bony aspect of the hamstring origin, and the inferior gluteal nerve travels 5 cm cephalad to the inferior border of the gluteus maximus.[4,5] Knowledge of these relationships is essential to protect neural anatomy during surgical repair.

Figure 1.

Illustration showing the anatomy of the hamstring origin (STB = conjoined tendon of the semitendinosus and biceps, SM = semimembranosus) along with their anatomic relationships in the posterior thigh.

After originating on the lateral ischial tuberosity, the semimembranosus tendon passes anteriorly (deep) to the common semitendinosus/biceps tendon and becomes the most medial muscle of the hamstring complex with the semitendinosus overlying it. The long head of the biceps has the most proximal muscle belly, arising 6 cm from its origin and proceeding distally with a long myotendinous junction. The long head of the biceps becomes the most lateral muscle of the posterior thigh (Figure 1). The short head of the biceps origin lies on the posterior femur just medial to the linea aspera. Distally, the semimembranosus has multiple insertions on the posteromedial tibia, whereas the semitendinosus becomes the most distal portion of the pes anserinus triad. The long head of the biceps attaches on the lateral fibular head and tibia. Similar to the semimembranosus, the short head of the biceps has many insertions including the long head of the biceps tendon as well as the posterolateral capsule, iliotibial band, fibular head, and lateral tibia.[4,5]

The hamstrings (with the exception of the short head of the biceps) traverse both the hip and knee joints allowing the muscles to both extend the hip and flex the knee. The muscle complex also limits knee extension just before and during heel strike to provide dynamic stability. A complex interplay exists between eccentric contraction of the hamstrings and concentric contraction of the quadriceps.[6]