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Everybody who's been physically active, or been around sport, will know of the old hamstring muscles. You don't have to be medically literate to know these guys get hurt very very often, so, why not talk about them! The classic 'pulled hammy' seemingly from an innocuous task, which at Spectrum, we see all too often. But what if we told you, not all hamstring problems are the same. The hamstrings are a group of three muscles at the back of the thigh: the biceps femoris, semimembranosus, and semitendinosus. These muscles originate from the ischial tuberosity (the 'sit bone' in your pelvis) and run down the thigh, crossing the knee joint to attach to the tibia and fibula in your lower leg. They play a key role in bending your knee (flexion) and extending your hip, making them essential for activities like running, jumping, and walking. The tendons connect these muscles to bones: the proximal tendons at the pelvis (insertional area) and the distal tendons near the knee. Injuries can occur to any of these structures, for the purposes of today we'll be focussing on the hamstring muscles as a collective, and their corresponding tendons. Tendon injuries - or tendinopathies - can be separated into insertional (top) or distal (bottom) tendinopathy. Tendinopathy involves inflammation or degeneration of the tendons, while a muscle strain, also referred to as a tear, is typically an acute tear in the muscle fibers. Let's have a closer look at tendinopathies firstly.

Hamstring Tendinopathy:

Hamstring tendinopathy is an overuse injury where the tendons become irritated, thickened, or degenerated due to repetitive stress, rather than a sudden tear. At Spectrum, we distinguish between insertional tendinopathy at the pelvis and distal tendinopathy near the knee. There are some slight differences in how the two ends of the hamstrings behave, let's take a look:

Insertional (Proximal) Hamstring Tendinopathy:

• Location of Pain: Deep, localised pain in the lower buttock or around the ischial tuberosity, sometimes radiating down the thigh. It's worse with sitting on hard surfaces or during hip flexion activities.
• Signs and Symptoms: Gradual onset of aching or stiffness at the top of the posterior thigh / hip region, aggravated by running, lunging, squatting, or prolonged sitting. You might notice morning stiffness, pain that 'warms up' during activity but worsens later, or tenderness on touching. Swelling is rare, but weakness in hip extension or knee flexion can occur.
• Mechanism of Injury: Caused by repetitive compression and tensile forces, such as from increased running volume, hill work, or static stretching like yoga.

Distal Hamstring Tendinopathy:

• Location of Pain: Primarily behind the knee, potentially radiating up the thigh or down the calf.
• Signs and Symptoms: Hamstring tendons tend to behave quite similarly when they are irritated. When it comes to the distal tendons, signs to look out for include a gradual onset of aching or stiffness in the knee, swelling, warmth, stiffness (especially mornings), and reduced mobility. Pain worsens with running, jumping, or bending the knee, and you may feel weakness or soreness post-activity.
• Mechanism of Injury: Overuse from excessive micro-trauma in sports like sprinting or soccer, without enough rest. Poor load management or rapid intensity increases contribute to tendon degeneration.

Hamstring Muscle Strain

A hamstring strain  is an acute injury where the muscle fibres tear or partially tear. This occurs when load demand exceeds the muscle capacity. Let's dive in:

• Grade of Injury: The British Athletics Muscle Injury Classification system puts muscle strain injuries on a 5-point scale with various subcategories. The main takeaway being, the lower number or lower grade, means the lower and less severe the injury. Tears range from minimal tears with overstretched muscle fibres, through to complete ruptures where the entire muscle is torn through. There are different orientations of tears, the classic mental picture is a clean horizontal tear through the middle of the muscle belly, but in actual fact, there is a huge variance in the location and obliquity of the injury - some cases can even be a north-to-south vertical split through the muscle fibres.
• Signs and Symptoms: A 'popping' sensation, immediate pain, swelling, bruising, weakness and difficulty walking are the common signs and symptoms we recognise at Spectrum. In some cases, the swelling and inflammation as a result of the injury, can cause minor numbness or tingling which indicates some swelling compressing the sciatic nerve.
• Mechanism of Injury: Typically, hamstrings tears occur during explosive movements like sprinting, when the muscle eccentrically contracts to decelerate the leg. In other cases, positional trauma can cause fibres to fail; in Rugby Union for example, during a clean where the hip is maximally flexed and knees are extended. This puts the hamstrings in maximum stretch position from both attachments. In this position, a player must prevent an opposing player from pushing them over a ruck; in some cases, the weight of the arriving player exceeds the strength of the defender's hamstrings which can create a hamstring strain. The point being that if not for explosive movements like sprinting, hamstring strains can occur from being overstretched with load.

##### How They Compare

Hopefully, there is a fairly clear delineation between a tendinopathy and a muscle tear. Tendinopathies are chronic and gradual, stemming from overuse and degeneration, while strains are acute from sudden overload. Pain in tendinopathy is deep and activity-specific (e.g., sitting for proximal, knee bending for distal), versus the sharp, immediate thigh pain in strains. Symptoms overlap in stiffness and weakness, but strains often involve swelling and bruising, which are absent in tendinopathy. In some cases, we may want to investigate further. MRI imaging or Ultrasound imaging are both options to visualise the soft tissues well. At Spectrum, MRI is our preference as they generate a much higher quality image and can help with specific location and grading for the injury; which therefore influences management. Speaking of, let's talk about how we at Spectrum would manage these injuries!

Conservative Treatment: How Can Spectrum Help You?

Spectrum's inhouse expert Sports Chiropractors, Physiotherapists and Exercise Physiologists work in collaboration with you to help achieve your goals:

• Pain Management: Early stages for care often include some pain management strategies. At Spectrum, we have access to great tech to help you out! For instance, our Game-Ready hot and cold contrast machine, which helps to reduce pain, swelling and irritation of an injured area.
• Sports Massage and soft tissue therapies: These include massage, cupping, dry needling and all work to reduce the pain and swelling of the affected area. There are great benefits to attain from reducing sensitivity of an injured area, including the ability to then perform rehabilitation and reconditioning exercises effectively.
• Joint Mobilisation: Gentle mobility techniques to restore hip, lower back and knee joint mobility to reduce compensatory stress, is another key component to returning to play and normal functions. Joint mobilisation is typically utilised with joint related injuries, however we find it equally important in some soft tissue settings. In the case of hamstring tendinopathies, altered gait (limping) and other conscious or unconscious compensations can lead to joint stress.

● Rehabilitation and reconditioning: Supervised gradual transition to full weight-bearing, strengthening, proprioceptive conditioning and functional training is an integral part of your recovery. To return to play or return to your previous level of function, it is important to recondition tissues and systems that have suffered injury. Another great piece of technology we have available at Spectrum includes our Alter-G anti-gravity treadmill, which can help you get back to walking and feeling your best.

Some cases, such as complete hamstring ruptures or severe tendinopathies may require further consultation with our network of Sports Doctors or Orthopaedic specialists. If this is the case with your injury, rest assured that we only use the best, because that's what we expect for our Spectrum family!