Hamstring Injuries
Andreas Leonidou
Orthopaedic Surgeon
56 Kifisias Ave. & Delfon St.,
Marousi, 15125
- Symptoms
- Conservative Treatment
- Surgical Treatment
- Cost
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Hamstrings – Anatomy
The hamstring muscle group is located at the back of the thigh and together they form a powerful muscular “chain” that connects the pelvis to the tibia.
These muscles originate mainly from the ischial tuberosity (in the pelvis) and attach to the tibia (tibial and fibular bones). Due to this arrangement, they cross two joints – the hip and the knee – and therefore perform multiple functions:
Hip extension (helping move the leg backwards).
Knee flexion (helping bend the knee).
Rotation of the tibia inward or outward, depending on the muscle activated.
Anatomically, the hamstrings have rich blood supply and innervation (mainly from the sciatic nerve), which explains their strong force production but also their susceptibility to injuries when subjected to intense strain.
In everyday life, the hamstrings are constantly activated. Because of this role, they are a muscle group that is frequently injured, especially when there is inadequate warm-up or when the muscles are fatigued.
Hamstrings – Origin and Insertion
The term origin refers to the point where a muscle begins, meaning its “fixed attachment point” on the bone. In the hamstring muscles, the main origin is located at the ischial tuberosity of the pelvis, with the exception of the short head of the biceps femoris, which originates from the femur.
The insertion, on the other hand, is the point where the muscle ends, meaning where it attaches to the bone that moves. The hamstrings insert into the tibia and fibula, allowing knee flexion and stabilisation of the joint.
This dual pathway – from the pelvis to the knee – explains why these muscles play such an important role in walking, running, and athletic movements, but also why they are more vulnerable to injuries when subjected to excessive stretching.
Hamstring Muscles and Their Function
The hamstring group consists of three main muscles that work together to provide movement and stability of the lower limb. Each has a distinct anatomical pathway and function, but together they form a unified “pulling system” that is essential for activities such as walking, running, jumping, and sudden changes of direction.
Biceps Femoris
The biceps femoris is the largest muscle of the group and is divided into two heads: the long head and the short head. Its main function is knee flexion and external rotation of the tibia when the knee is bent. It also contributes to hip stabilisation during intense activity.
Semitendinosus
The semitendinosus is a long and thin muscle located on the inner side of the thigh. It originates from the ischial tuberosity and inserts into the tibia.
Its main functions are:
Knee flexion.
Internal rotation of the tibia when the knee is flexed.
Contribution to hip extension, especially during movements such as running or weight lifting.
The semitendinosus is considered important for smooth movement and balance, especially in activities requiring flexibility and speed.
Semimembranosus
The semimembranosus muscle is wider and shorter compared to the semitendinosus. It also originates from the ischial tuberosity and inserts on the medial surface of the tibia.
Its functions include:
Knee flexion.
Internal rotation of the tibia when the knee is bent.
Stabilisation of the knee joint, especially during activities that involve rotational stress (e.g. changes of direction in sports).
The semimembranosus works closely with the other hamstring muscles to prevent injuries, as well as with the gluteal muscles for smooth hip movement.
Hamstrings – Injuries
Hamstring injuries are among the most common problems encountered in athletes, as well as in individuals involved in intense physical activity. It is estimated that injuries to this muscle group account for approximately 12–16% of all sports injuries, with football, athletics (especially sprinting), and basketball having the highest rates of occurrence.
The hamstrings are usually injured during explosive movements, when the muscle is simultaneously stretched and strongly contracted.
Depending on the severity of the injury, hamstring injuries are classified into grades:
Grade 1 (mild strain): Micro-tears of a few muscle fibres, with mild pain and minimal restriction of movement.
Grade 2 (moderate strain): Tear of more fibres, significant pain, swelling, and partial loss of function.
Grade 3 (severe strain/tear): Complete tear of the muscle or tendon, severe pain, inability to move, and may require surgical repair.
Muscle Strain (Hamstring Strain)
Muscle strain is the most common hamstring injury, especially in sports requiring speed and explosive movements.
Symptoms:
Sudden, sharp pain at the back of the thigh during effort.
A feeling of “pulling” or “tearing” inside the muscle.
Swelling or bruising a few hours after the injury.
Difficulty walking and reduced range of motion.
In more severe strains: inability to continue the activity.
Hamstring Tendon Rupture
This is a serious injury that may occur after a sudden, forceful muscle contraction, usually in high-level athletes. It often involves detachment of the tendon from its origin point.
Symptoms:
Severe pain in the buttock area or the back of the thigh.
Inability to support the leg or complete the movement.
Appearance of bruising (haematoma) extending down towards the tibia.
Palpable gap or deformity in the tendon area.
In complete rupture: complete inability to flex the knee.
Avulsion Fracture of the Ischial Tuberosity
This occurs when the tendon pulls away a fragment of bone from the ischial tuberosity, mainly in young athletes where the bone has not fully developed.
Symptoms:
Sudden, severe pain high in the buttock, near the pelvis.
Difficulty walking or flexing the hip.
Swelling and tenderness in the area of the ischial tuberosity.
In more severe cases, weakness in lifting the leg may also occur.
Pain that worsens when sitting for long periods.
Chronic Hamstring Tendinopathy (Proximal Hamstring Tendinopathy)
This is a chronic degenerative condition of the tendon, not necessarily related to an acute injury but to repetitive strain. It is common in long-distance runners, cyclists, and athletes with high training loads.
Symptoms:
Persistent, dull pain in the buttocks, often radiating to the back of the thigh.
Pain that worsens when sitting for long periods (e.g. at a desk or in a car).
Discomfort during activities such as running, climbing stairs, or jumping.
Gradual reduction in strength and performance, without an acute injury.
Symptoms that persist for weeks or even months if untreated.
Diagnosis
Correct and timely diagnosis is crucial for the effective management of hamstring injuries, as it determines the treatment strategy and reduces the risk of recurrence.
The process includes:
Clinical Examination
The Orthopaedic Surgeon always begins by taking a detailed medical history, investigating the circumstances under which the injury occurred, the type and intensity of pain, as well as any previous episodes in the same area. A clinical examination then follows, assessing the exact location of pain through palpation, checking hip and knee mobility, muscle strength and possible weakness, as well as the presence of swelling or bruising.
Imaging Tests
Depending on the severity and clinical findings, the doctor may request additional imaging:
Ultrasound Scan: Useful for the immediate assessment of strains and partial tears, as well as monitoring healing.
Magnetic Resonance Imaging (MRI): Considered the most reliable method. It provides detailed imaging of the injury, identifying the location, extent, and degree of the tear, while differentiating between acute injury and chronic tendinopathy.
X-ray: It is not diagnostic for muscles but may reveal an avulsion fracture of the ischial tuberosity, especially in young athletes.
Management
Treatment of hamstring injuries depends on the type of injury, severity, and the patient’s needs. The goal is full restoration of function, reduction of recurrence risk, and safe return to sports or daily activities.
Conservative treatment is the first choice for most strains and mild to moderate injuries, including rest and avoidance of loading, application of ice and compression to reduce pain and swelling, as well as physiotherapy techniques with gentle stretching and gradual strengthening. Medication may also support the process with anti-inflammatory drugs and analgesics.
Surgical Repair
Surgical treatment is indicated in severe injuries, such as:
Complete tendon ruptures with significant retraction.
Avulsion fractures of the ischial tuberosity.
The procedure aims to reattach the tendon or repair the injury, ensuring full restoration of muscle function.
The Role of the Orthopaedic Surgeon
Early and accurate diagnosis, together with proper management of hamstring injuries, ensures a safe and rapid return to daily activities and sports while minimising the risk of recurrence.
The Orthopaedic Surgeon guides the patient through a personalised treatment plan, usually starting with conservative methods. At the same time, they provide valuable advice on prevention and proper rehabilitation, reducing the risk of recurrence and achieving the best possible quality of life.
In Greece, Dr Andreas Leonidou has been recognised for his experience in managing sports injuries, providing personalised care based on modern scientific developments. He is FIFA-certified, holding the Diploma of Football Medicine. His approach combines diagnostic accuracy with treatment safety, giving patients the opportunity to return faster to their daily activities and sports.
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