Hamstring Injuries in Athletes: Evidence-Based Treatment

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

Disclosures

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

In This Article

Evaluation of Injuries

History and physical examination are the cornerstones for proper evaluation. Knowledge of the mechanism of injury, location of pain, and history of previous injuries are vital. Typically, athletes complain of acute pain in the posterior thigh during running, kicking, or jumping motions. Occasionally these athletes will recall an audible or palpable pop. After injury, an abnormal gait is common. Athletes with nonsevere recurrences or chronic issues frequently have hamstring tightness. In proximal avulsions, pain with sitting is common.

Physical examination should first include visualization for ecchymosis as well as palpation for defects and for maximal tenderness in three distinct locations: the ischial tuberosity, myotendinous junction, and distal tendinous insertions. Bruising is most commonly seen in proximal avulsions and high-grade myotendinous tears, whereas defects can sometimes be felt in muscle belly injuries. The popliteal angle should be measured bilaterally, with the uninjured leg offering insight into hamstring flexibility. Motor evaluation should evaluate knee flexion strength at varying degrees of flexion, including 90°, 45°, and 15°. A complete neuromotor examination is essential for distal function of the peroneal nerve distributions (ankle dorsiflexion/eversion). Peroneal nerve injuries are most common and present as neurapraxias; however, on occasion foot drop or eversion weakness can occur.

Special hamstring tests include the Puranen-Orava test (heel on an elevated surface and patient touches toes), the bent-knee stretch test (knee to chest stretch), modified bent-knee stretch test (examiner extends the knee during knee to chest stretch), all which are validated and shown to be highly reliable to identify tendinopathy and strains. Other tests that the authors find useful include the resisted hamstring curl, the standing heel-drag test (single leg squat with contralateral foot placed anteriorly on the ground and then the foot dragged back to midline) (Figure 3), and the plank test (supine patient rises on elbows and raises the uninjured leg off examination table and then extends the hip of the injured side to elevate the pelvis) (Figure 4). The authors also find two modifications of the plank test to be helpful: (1) the affected hip is flexed off the table and the examiner holds the heel and then instructs the patient to extend their hip to raise their pelvis off the table (Figure 5) and (2) the examiner supports both heels in the air while the patient extends both hips so their pelvis is elevated off the table, and then, the examiner releases the unaffected heel so the affected leg alone is supporting the pelvis (Figure 6). If pain is elicited, these are considered positive.[2,14,15] Evaluation of gait is also important, particularly in proximal avulsions because these patients typically attempt to avoid both hip flexion and knee extension, resulting in a stiff-legged gait.

Figure 3.

Photograph showing standing heel-drag test: single leg squat with the contralateral foot placed anteriorly on the ground, and then, the foot is dragged back to midline.

Figure 4.

Photographs showing plank test: (A) the patient in supine position rises on elbows, (B) raises the uninjured leg off the examination table, and then extends the hip of the injured side to elevate the pelvis.

Figure 5.

Photograph showing plank modification 1: the affected hip is flexed off the table, and the examiner holds the heel and then instructs the patient to extend their hip to raise their pelvis off the table.

Figure 6.

Photographs showing plank modification 2: (A) the examiner supports both heels in the air while the patient extends both hips so their pelvis is elevated off the table, (B) then the examiner releases the unaffected heel so the affected leg alone is supporting the pelvis.

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