Dr. Mandelbaum Discusses with Medscape Orthopedics How He Treats, Prevents and Rehabs Hamstring Injuries


How I Prevent, Treat, and Rehabilitate Hamstring Injuries

Bert R. Mandelbaum, MD, DHL (Hon)

Important but Much-Ignored Muscles

I take every chance I get to recommend that athletes exercise their hamstrings in a very comprehensive way. As a sports medicine specialist, it's one of the most important and impactful directions I can give. And yet it very often goes ignored.

Athletes injure their hamstrings at a greater rate than most other body parts. In baseball, hamstring injuries are the second most common injury causing missed days.[1]

But hamstring injuries are even more common in football and soccer. Two thirds put the player on the sideline for more than 24 hours, and 6.3% take the player out for 3 weeks or more.[2]

In one study, athletes of all sports in the National Collegiate Athletic Association (NCAA) sustained three hamstring injuries for every 10,000 practices or games.[2]

The injuries occur when the hamstrings cannot balance the force generated by the quadriceps. The hamstrings are the little sisters that have to run with the quads.

Over and over in athletes such as soccer star Jozy Altidore, the US Men's National Team forward, I've seen huge quadriceps that simply overpower the hamstring. It's no surprise that Altidore had to be carried off the field with a torn hamstring at the start of the US-Ghana soccer game in the 2014 World Cup.

The same is too often true in sprinters like Usain Bolt, who tore his hamstring in July; the amount of torque developed by the quads simply overwhelms the hamstrings.

Mechanics of Hamstring Injuries

Imagine pushing a rolling pin with a hand on each handle. If you push much harder with one hand than the other, the rolling pin will make a circle instead of rolling in a straight line.

That's the principle with the hamstring and quadriceps, except that the muscle doesn't make a circle—it tears.

Most often, the weak point is the muscle tendon junction, so that's where you'll find the damage. The most common hamstrings to be injured are the biceps femoris, the semitendinosus, and the semimembranosus, in that order.

The damage occurs as a result of eccentric strain. To prevent these injuries, athletes must strengthen their hamstrings with eccentric exercises. The most effective exercises I know for this purpose are the Russian and Nordic hamstring exercises.

Exercises for Injury Prevention

In both of these exercises, the athlete starts kneeling with straight back and hips and with arms crossed. A teammate applies weight to the athlete's ankles. In the Nordic version, the athletes slowly extend at the knees joint until they can no longer hold the position and fall to the floor, catching themselves with their hands. In the Russian version, they bend only to point where they can return to an upright kneeling position by flexing.

Athletes can also use exercise machines and elastic bands for eccentric exercises of their hamstrings. But in athletes with an imbalance, it's important to avoid doing exercises that will further strengthen the quadriceps so that the hamstrings never have a chance to catch up.

Strengthening the hamstrings will not only protect this muscle group itself, it will also stabilize the knee joint, reducing the risk for anterior cruciate ligament tears and other damage to the knee.

By the same token, a more complete exercise program can provide even greater benefits for the hamstrings.

In the FIFA 11+ program I helped develop for the Fédération Internationale de Football Association (FIFA), the hamstring exercises are just one component. The program combines resistance training, plyometrics, balance, symmetry, flexibility, and neuromuscular control in a series that can be completed during a team warmup.

In a randomized controlled trial of the program in NCAA men's soccer teams, those teams that implemented the FIFA 11+ program experienced a hamstring injury rate of 0.454 per 1000 practice sessions and games compared with 1.244 for teams that used their usual fitness approach. The reduction in other lower extremity injuries was similar.[3]

Testing for At-Risk Athletes

In professional sports and among elite college teams, some trainers have measured quadriceps-to-hamstring ratios. They have also used functional movement screens, isokinetic tests, and other tools to screen for those athletes most at risk for hamstring injury.

But none of these tests are very sensitive. When we analyzed the cost-effectiveness of such screening, we found that teams could save more money by training everyone with a program like the FIFA 11+.[4]

Despite these preventive efforts, some injuries will still occur. When they do, I recommend the classic first aid: rest, ice, compression, and elevation (RICE) to reduce the edema and inflammation present at the beginning of the recovery.

Very often the first question you'll get is, "When can I return to play?" If you are treating a professional or elite college athlete, you will probably be able to use MRI or ultrasound to determine the extent of the injury. You can use these images to determine the extent and location of the damage. Is it bleeding? Is there a hematoma? A significant tear?

I divide hamstring injuries into three grades:

  • A minor injury with some edema: Return to play will take roughly 2-4 weeks.
  • A more significant injury with more extensive internal bleeding: Return to play will take roughly 2-6 weeks.
  • A very significant injury of the muscle's tendon junction and belly: Return to play will take roughly 6-8 weeks.

I put the information from this imaging together with the athlete's signs and symptoms. If the athlete absolutely can't walk at minute 1, it's going to take 6 weeks to fully recover.

Treatment of Hamstring Injury

The goal in treatment is to get the muscle to return to well-synchronized function. We also want to avoid fibrosis, the major complication from a hamstring injury as well as reinjury. To aid in this healing, I typically inject autologous platelet-rich plasma in and around the injured muscle.

In randomized controlled trial, Hamid and colleagues[5] found that injured hamstrings injected with platelet-rich plasma as an adjuvant to their rehabilitation program fully recovered in a mean of 26.7 days, compared with 42.5 days for those who got the rehabilitation program alone.

Surgery is rarely indicated in hamstring tears, with the exception of a proximal hamstring injury. These injuries typically take place in an activity such as water skiing, where tremendous torque pulls the attachment off the bone.

For most other patients, rehabilitation consists mainly of a gradually increased regimen of exercises similar to those in the FIFA 11+. For the first couple of days, I recommend compression with ACE bandages and elevation. As range of motion returns, I advise continued application of ice.

Once the swelling is down and the pain under control, I sequentially prescribe more and more movement, to the point that the athlete can begin sports-related activities and progressions.

When Is Ready-to-Return-to-Play Warranted?

How do you know when the athlete is ready to return to play? First the athlete should feel minimal pain at most. Next, look for range of motion of the knee and the hip that approximate normal. Make sure that the athlete's gait is normal and unaffected.

If you have access to comprehensive neuromuscular, biomechanical, and muscle-testing protocols, please take advantage of them. Even after the athlete returns to play, I emphasize that systematic exercises remain essential to avoid reinjury. Usually at that point, athletes understand the need for prevention.


1.Seagrave RA 3rd, Perez L, McQueeney S, et al. Preventive effects of eccentric training on acute hamstring muscle injury in professional baseball. Orthop J Sports Med. 2014;2:1-7.

2.Dalton SL, Kerr ZY, Dompier TP. Epidemiology of hamstring strains in 25 NCAA sports in the 2009-2010 to 2013-2014 academic years. Am J Sports Med. 2015;43:2671-2679.

3.Silvers-Granelli H, Mandelbaum B, Adeniji O, et al. Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer players. Am J Sports Med. 2015;43:2628-2637.

4.Swart E, Redler L, Fabricant PD, et al. Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis. J Bone Joint Surg Am. 2014;96:705-711.

5.Hamid MSA, Ali MRM, Yusof A, et al. Platelet-rich plasma injections for the treatment of hamstring injuries: a randomized controlled trial. Am J Sports Med. 2014;42:2410-2418.

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