athlete-hamstring-injury-1500-x-850.jpg

Hamstring injuries are really annoying and painful – if you’ve ever felt that sharp pain in the back of your leg or seen someone pull up while running and grab the back of their leg, you know what I’m talking about.

Unfortunately, hamstring injuries are the most common cause of lost training and playing time in activities that involve running1. They take significant time to heal and rehabilitate and are notoriously sensitive to re-injury. The average rehab and return to activity timeline following a hamstring injury is about 2 weeks, at a minimum,2 and in certain sports, like soccer, the average time lost has been pegged at nearly 20 days.3

Additionally, hamstring injuries have been shown to re-occur in more than 30% of athletes, with some studies reporting rates as high as 70%!4–7 Most recurrent hamstring strains take place in the first 2 months after return to activity, but the increased risk still exists thereafter.8–10  In one study, that persistent re-injury risk was 3 times greater for an injured athlete than a non-injured athlete for up to one year after the initial injury.11

For these reasons, I emphasize hamstring injury prevention with each and every client involved in any sort of running activity– whether that’s team sports, sprinting to catch the bus, individual sports, runners, weekend warriors, and so on.

The basis for hamstring injury prevention is what I call functional training – understanding which function of the hamstring stresses the muscle the most and then implementing a training program to build endurance and strength specific to that function.

The key function of the hamstring

The main function of the hamstring is to slow down your swing (lead) during the phase of the running cycle known as “terminal swing phase”, in other words right before the forward leg touches the ground.

Here’s what terminal swing phase looks like:

runner in terminal stance 2048 x 1365

This helps control the swing leg and put it in a better position for the next phase of movement while decreasing the amount of force (think: shockwave) that goes up through your foot and leg. In order to “brake” the swing leg, the hamstrings “eccentrically contract”, in other words, they contract while lengthening. This is termed “eccentric control of knee extension”.

This picture does a good job of explaining eccentric contraction using the biceps muscle as an example:

EZ Bar Curls. Exercising for bodybuilding Target muscles are marked in red. Initial and final steps. 3D illustration 2048 x 1858

And here’s an anatomical representation what a hamstring looks like in terminal swing phase:

runner with pointer showing eccentric contraction hamstring 2048 x 1225This eccentric control phase places the highest stress on the hamstrings of any movement12,13, and evidence shows hamstring injury is most common during this phase.14–16  Therefore, the goal of functional training is to improve the hamstrings’ tolerance of and ability to withstand this kind of stress.

Which brings us to…

Eccentric Training

Eccentric strength training has repeatedly been shown to prevent hamstring injuries17–22. For activities that involve sprinting, such as soccer, it’s been shown to improve speed and performance as well.19,22  The exercise with the highest level of evidence is the Nordic Hamstring curl17,20–23, with large-scale interventions showing a decrease in hamstring injuries by upwards of 50-70%!20,21,23,24 .  For a video of the Nordic Hamstring curl and detailed instructions, click here (https://exrx.net/WeightExercises/Hamstrings/BWHamstringRaise)

The Nordic hamstring curl, by itself, is a very powerful tool for preventing hamstring injury. However, recent research by Bourne et al25 shows that the Nordic Hamstring curl focuses predominantly on only 2 of the 4 hamstrings muscles – the semitendinosus (ST) muscle and biceps femoris short head (BFSH) muscle.

The same paper by Bourne et al25 showed “hip-dominant” hamstring exercises (the Nordic Hamstring curl is considered “knee-dominant), specifically, the stiff-legged deadlift, engage the other 2 muscles of the hamstrings group – the semimembranosus (SM) and biceps femoris long head (BFLH).

Graphic showing the 4 muscles that make up the hamstrings 474 x 600
Graphics credit: 3D4Medical and 3CBPerformance.com

This hamstring injury prevention program includes both the Nordic hamstring curl and stiff-legged deadlift to eccentrically train all 4 parts of the hamstrings group. For a video of the stiff-legged deadlift and detailed instructions, click here (https://exrx.net/WeightExercises/GluteusMaximus/BBStrBackStiffLegDeadlift)

The Training Plan

Based on training protocol evidence17–24, here’s the training plan & progression I created and use with my clients. It is a 10-week, incremental progression program that looks like this:

Week Nordic Hamstring Curl Stiff-Legged Deadlift
1 2 sets x 5 reps 2 sets x 5 reps
2 2 sets x 6 reps 2 sets x 6 reps
3 3 sets x 8 reps 3 sets x 8 reps
4 3 sets x 10 reps 3 sets x 10 reps
5-9 3 sets x 12/10/8 reps 3 sets x 12/10/8 reps
10+ 1 set x 12/10/8 reps 1 set x 12/10/8 reps

 

A couple things to note:

If you feel any sharp pain during the exercises, stop. Try decreasing the reps or weight and if that doesn’t help, don’t proceed further. Additionally, you shouldn’t feel any sharp pain in the days afterward.  You will feel some soreness – especially if you haven’t trained in your hamstrings in this way before – but that’s completely normal.

With that in mind and the dosage set, when should you do this training? I recommend adding the regimen to the end of your leg workout routine. If you’re working legs twice a week, then add it whichever day is less strenuous. If you don’t have a leg workout routine, then we need to talk. Additionally, give yourself a 2-day gap before or after a big run or match. This gives your legs time to recover and buffers against muscular overload and fatigue.

Prevention is the best medicine

Prevention truly is the best medicine for the hamstrings due to the substantial rehab time and high rate of re-injury. This 10 minute, 2 exercise eccentric strength training program can save you considerable time and anguish for a low amount of time and energy investment – no need to move around your entire schedule or worry about a whole other workout. It’s efficient, effective, pragmatic, targeted training. That’s my kind of high ROI program.

Give it a try and let me know how it goes.  If you have any questions, feel free to contact me.  Here’s to a life free of hamstring pain and annoyance!

References:

  1. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med. 2012;42(3):209-226. doi:10.2165/11594800-000000000-00000.
  2. Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67-81. http://www.ncbi.nlm.nih.gov/pubmed/20118524.
  3. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med. 2016;50(12):731-737. doi:10.1136/bjsports-2015-095359.
  4. Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database Syst Rev. 2012;12:CD004575. doi:10.1002/14651858.CD004575.pub3.
  5. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med. 29(3):300-303. doi:10.1177/03635465010290030801.
  6. Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: a systematic review of the literature. Sports Health. 2009;1(2):154-164. doi:10.1177/1941738108324962.
  7. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther. 2004;34(3):116-125. doi:10.2519/jospt.2004.34.3.116.
  8. Arnason A, Sigurdsson SB, Gudmundsson A, Holme I, Engebretsen L, Bahr R. Risk factors for injuries in football. Am J Sports Med. 32(1 Suppl):5S-16S. doi:10.1177/0363546503258912.
  9. Bennell K, Wajswelner H, Lew P, et al. Isokinetic strength testing does not predict hamstring injury in Australian Rules footballers. Br J Sports Med. 1998;32(4):309-314. http://www.ncbi.nlm.nih.gov/pubmed/9865403.
  10. Gabbe BJ, Bennell KL, Finch CF, Wajswelner H, Orchard JW. Predictors of hamstring injury at the elite level of Australian football. Scand J Med Sci Sports. 2006;16(1):7-13. doi:10.1111/j.1600-0838.2005.00441.x.
  11. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med. 2006;40(9):767-772. doi:10.1136/bjsm.2006.026609.
  12. Yu B, Queen RM, Abbey AN, Liu Y, Moorman CT, Garrett WE. Hamstring muscle kinematics and activation during overground sprinting. J Biomech. 2008;41(15):3121-3126. doi:10.1016/j.jbiomech.2008.09.005.
  13. van den Tillaar R, Solheim JAB, Bencke J. COMPARISON OF HAMSTRING MUSCLE ACTIVATION DURING HIGH-SPEED RUNNING AND VARIOUS HAMSTRING STRENGTHENING EXERCISES. Int J Sports Phys Ther. 2017;12(5):718-727. http://www.ncbi.nlm.nih.gov/pubmed/29181249.
  14. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol. 2004;183(4):975-984. doi:10.2214/ajr.183.4.1830975.
  15. Koulouris G, Connell DA, Brukner P, Schneider-Kolsky M. Magnetic resonance imaging parameters for assessing risk of recurrent hamstring injuries in elite athletes. Am J Sports Med. 2007;35(9):1500-1506. doi:10.1177/0363546507301258.
  16. Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Diagnostic and prognostic value of clinical findings in 83 athletes with posterior thigh injury: comparison of clinical findings with magnetic resonance imaging documentation of hamstring muscle strain. Am J Sports Med. 31(6):969-973. doi:10.1177/03635465030310063701.
  17. Brukner P. Hamstring injuries: prevention and treatment-an update. Br J Sports Med. 2015;49(19):1241-1244. doi:10.1136/bjsports-2014-094427.
  18. Goode AP, Reiman MP, Harris L, et al. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis. Br J Sports Med. 2015;49(6):349-356. doi:10.1136/bjsports-2014-093466.
  19. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports. 2003;13(4):244-250. http://www.ncbi.nlm.nih.gov/pubmed/12859607.
  20. van der Horst N, Smits D-W, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015;43(6):1316-1323. doi:10.1177/0363546515574057.
  21. Arnason A, Andersen TE, Holme I, Engebretsen L, Bahr R. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Sports. 2008;18(1):40-48. doi:10.1111/j.1600-0838.2006.00634.x.
  22. Mjølsnes R, Arnason A, Østhagen T, Raastad T, Bahr R. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in well-trained soccer players. Scand J Med Sci Sports. 2004;14(5):311-317. doi:10.1046/j.1600-0838.2003.367.x.
  23. Petersen J, Thorborg K, Nielsen MB, Budtz-Jørgensen E, Hölmich P. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med. 2011;39(11):2296-2303. doi:10.1177/0363546511419277.
  24. Seagrave RA, Perez L, McQueeney S, Toby EB, Key V, Nelson JD. Preventive Effects of Eccentric Training on Acute Hamstring Muscle Injury in Professional Baseball. Orthop J Sports Med. 2014;2(6):2325967114535351. doi:10.1177/2325967114535351.
  25. Bourne MN, Timmins RG, Opar DA, et al. An Evidence-Based Framework for Strengthening Exercises to Prevent Hamstring Injury. Sports Med. 2018;48(2):251-267. doi:10.1007/s40279-017-0796-x.
Rajpal Brar
Dr. Rajpal Brar, DPT, is the founder & owner of 3CBPerformance, a health and wellness clinic in West Los Angeles, and The Injury Insight, a sports injury blog/resource. He received his Doctorate from Northern Arizona University (NAU), prior to which he was involved in business and marketing strategy after graduating from the University of California Berkeley with a BA in Business and BS in Social Welfare. He considers himself to be a coach at heart – combining his 3 passions of education, sports, and helping others. He also writes for Grandstand Central and Stack.com.  His goal is providing easily digestible, relatable, and practical information. When he’s not writing or in the clinic, you can find him in a weight room, basketball game, or beach somewhere.

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