Scand J Med Sci Sports 2000: 10: 304307

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COPYRIGHT C MUNKSGAARD 2000 ISSN 0905-7188

Case Report

Sports related hamstring strains two cases with different etiologies and
injury sites
C. Askling1, M. Tengvar2, T. Saartok3, A. Thorstensson1
1

Department of Sport and Health Sciences, University of Physical Education and Sports and Department of Neuroscience,
Karolinska Institutet, Stockholm, 2Department of Radiology, Sophiahemmet, Stockholm, 3Section of Orthopaedics, Department of
Surgery, Visby Hospital, Visby, Sweden
Corresponding author: Carl Askling, Department of Sport and Health Sciences, University College of Physical Education and
Sports, Box 5626, 114 86 Stockholm, Sweden
Accepted for publication 15 March 2000

Hamstring strains are common injuries in sports. Knowledge about their etiology and localization is, however,
limited. The two cases described here both had acute hamstring strains, but the etiologies were entirely different.
The sprinter was injured when running at maximal speed,
whereas the hamstring strain in the dancer occurred during slow stretching. Also the anatomical localizations of

the injuries clearly differed. Magnetic resonance imaging

(MRI) revealed pathological changes in the distal semitendinosus muscle in the sprinter and the proximal tendon of
the semimembranosus muscle in the dancer. Subjectively,
both athletes severely underestimated the recovery time.
These case observations suggest a possible link between
etiology and localization of hamstring strains.

Hamstring strains are common in sports with high

demands on speed and power, for example sprint running and soccer (Garett, Califf, Bassett, 1984). There
is anecdotal evidence that hamstring strains also are
rather frequent in other sports, such as dancing. The
diagnosis and treatment of these injuries have been
based mainly on empirical evidence or simply trial
and error. Hamstring strains are complex injuries
that probably involve a multi-factorial etiology. Possible relationships between strength, flexibility, warmup, fatigue, etc., and hamstring strains have been suggested (Worrell, 1994). Scientifically based evidence
for associations between such predisposing factors
and hamstring injuries is, however, lacking. Also, it is
still unclear in which of the four individual hamstring
muscles the strains most frequently occur. Clinically,
the biceps femoris is reported to be the most commonly injured muscle within the hamstring muscle
group (Garrett, Rich, Nikolaou, Volger, 1989). Based
on experimental data, it is generally claimed that
strain injuries most often occur near the muscletendon junction, particularly in two-joint muscles (Garrett, 1996; Jrvinen, 1994). Whether the injury involves primarily muscular or tendinous tissue is still
an open question. Magnetic resonance imaging
(MRI) offers a possibility to determine the exact anatomical localization and extent of such soft tissue injuries (Brandser, El-Khoury, Kathol, Callaghan, Tearse, 1995). The two cases presented here will illus-

trate that the anatomical localization and tissue

involvement of acute hamstring strains, as determined with MRI, is variable and possibly related to
the mechanism of injury.

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Case 1
A 20-year-old male world-class sprinter (personal
best 9.92 s) suddenly felt a sharp pain in his right
posterior thigh after approximatley 60 m of a 100 m
race. He finished the race, but was unable to continue
at maximal speed. His time was 10.30 s, finishing
third in the race. A few minutes after the race, an
external elastic compression bandage was applied on
the injured thigh. The athlete was instructed not to
provoke pain from the thigh. Analgesic medication
was not needed. The sprinter had no history of prior
injury to the thigh or any predisposing signs of injury
(such as pain or stiffness) in his back thigh before the
competition.
Fifteen hours after the acute trauma, a careful
physical examination was undertaken. The athlete
himself estimated the injury to be minor, being convinced that he could run another 100 m race the next
day. He experienced stiffness and pain in the injured
area and had a slight limp while walking at normal
speed on even ground. During examination of the
athlete in a prone position with straight legs, palpation did not reveal any defect but a tender area was

Hamstring strains

Fig. 1. MR-images of case 1. Sagittal fat saturated proton-density image (a) demonstrating the partial tear in the semitendinosus muscle with extrafascial fluid collection (black arrows) and subcutaneous edema (white arrows). Transverse fat saturated proton-density images of both legs (b) with the partial tear in the right semitendinosus muscle and extrafascial fluid collection compared to the left side
(arrows).

present in the medial hamstring muscle group. The

painful area was localized over one of the medial bellies of the hamstring complex (m. semitendinosus
(ST) or m. semimembranosus (SM)) and the center
of the most painful area was situated approximately
15 cm proximal to the medial articular cleft of the
knee. The athlete experienced moderate pain when
voluntarily flexing and extending the knee in the
prone position, the pain being more pronounced during extension. Using the straight leg raise (SLR) test
in the supine position, the injuried leg could be
moved passively to a hip angle of 60 from the horizontal before reaching the limit of pain tolerance.
Furthermore, the pain became more pronounced
when an isometric contraction was tried in that position.
MRI was performed 20 h after the acute trauma,
using a 1.5 Tesla superconductive magnet (Signa;
General Electric Medical Systems, Milwaukee, USA).
MRI consisted of transverse and sagittal proton-density fast spin-echo with frequency selective fat saturation and coronal fast short time inversion recovery
(STIR). The MRI showed a partial tear in the semitendinosus muscle at the distal muscletendon junction with the center approximately 15 cm proximal to
the medial articular cleft of the knee (Fig. 1a and b).
Approximately 1/4 of the cross-sectional area and 7.5
cm of the length of the muscle in the cranio-caudal
direction had an abnormal signal. The greatest depth
and width of the abnormal signal was 42 cm. The

intramuscular lesion was predominantly located in

the lateral/anterior part of the muscle belly. An extrafascial fluid collection was located around the whole
circumference of the muscle, but predominantly
anteriorly and laterally, and covered 15 cm in the
cranio-caudal direction. At the distal 5 cm of the
extrafascial fluid collection there was also a subcutaneous edema. There was no total disruption or any
retraction of the muscle. The tendon distal to the injury site was unaffected.
After a discussion between the athlete, his coach
and the sports medicine staff, it was agreed that an
extended rehabilitation period for this injury was
needed. The goal was set to enable the athlete to compete 3 weeks later. However, the healing process
turned out to be even slower, forcing the athlete to
give up his racing during the rest of the outdoor season, approximately 6 weeks before planned. The
sprinter was put on a rehabilitation program that included muscle strength and flexibility training. Criteria for advancement to the next stage of rehabilitation were full painless range of motion and good
flexibility. After 18 weeks the athlete was able to perform on the same level as before the injury.
Case 2
A 22-year-old female professional dancer felt a sudden sharp pain in her right posterior thigh when
slowly stretching her right hamstrings at home after

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Askling et al.

Fig. 2. MR-images of case 2. Sagittal STIR image (a) showing the partial tear
in the thickened semimembranosus tendon and surrounding fluid (arrows).
Transverse T1-weighted images of both legs (b) with the right semimembranosus tendon considerably thickened compared to the other side (arrows).

a day of dancing in school. She did not know how to

handle the situation. After consulting a medical
book, she applied the RICE principle (rest, ice,
compression and elevation) to the leg. The dancer
had no history of any previous injury or any of the
predisposing signs of injury in the thigh before
stretching. However, she had felt some stiffness after
specific hamstring exercises during the weeks immediately preceding the injury.
Seventeen hours after the acute trauma, a careful
physical examination was performed. The dancer
herself thought that the injury was small, being convinced that she could return to dancing practice in a
few days. She experienced stiffness and pain in the
injured area while walking at normal speed on even
ground. With the dancer in a prone position with
straight legs, palpation dit not reveal any defect but
a tender area localized over one of the medial bellies
of the hamstring muscle group (ST or SM). The center of the most painful area was approximately 10 cm
distal to the tuber ischii. When voluntarily flexing
and extending the knee in a prone position the dancer
experienced burning pain. This pain was present in
the whole range of motion being more pronounced
during extension, especially during the last 30 of extension. Using the SLR test in a supine position, the
leg could be lifted passively to a hip angle of 90 from
the horizontal before reaching the limit of pain tolerance. The pain increased when an isometric contraction was attempted in that position.
MRI was performed with a 1.0 Tesla superconduc-

306

tive magnet (Magnetom Impact Expert, Siemens, Erlangen, Germany) 72 h after the trauma using a
phased array coil. MRI consisted of transverse, sagittal and coronal STIR images, transverse spin-echo
T1-weighted images and transverse fast spin-echo T2weighted images. The MRI revealed an apparent partial tear in the proximal semimembranosus tendon
(Fig. 2a and b). The tendon was thickened to approximately double the thickness of the contralateral
tendon with intratendinous edema from the origin at
the tuber ischii and 8 cm in the caudal direction.
Also, there was a small fluid collection surrounding
the tendon. However, continuity of the tendon was
unaffected and the SM muscle belly did not show any
abnormalities. In the proximal and dorsal aspects of
the adductor magnus muscle belly, close to the semimembranosus muscle, there was a 12 cm area of
edema corresponding to a small partial tear.
The dancer was put on a standard rehabilitation
program and she was able to rejoin her dance practice
12 weeks after the injury. After one year, she had not
regained full performance ability in dancing, e.g. she
was still unable to perform the sagittal split position.
Even at that time she felt stiffness in her rear thigh
and experienced fatigue earlier in the injured leg compared with the uninjured when practising.
Discussion
The two current cases, representing different sports,
clearly demonstrate that hamstring strains can have

Hamstring strains
different anatomical localizations and involve different parts of the musculotendinous complex. Furthermore, the fact that the injuries occurred under entirely different circumstances, one fast active movement, the other slow and passive, raises the question
of a possible link between etiology and character of
the injury.
Most researchers state, based on studies of power
events such as sprinting, that the long head of biceps
femoris is the muscle within the hamstring group that
is most prone to injury in sports (Garrett et al., 1989;
Garrett, 1996; Burkett, 1976). Furthermore, the anatomical localization of more extensive hamstring
strains is claimed to be close to the origin on tuber ossis
ischii (Garrett, 1996; Orava & Kujala, 1995). The present cases show a different pattern with one distal injury
in the ST muscle (sprinter) and one proximal injury
primarily in the tendon of the SM muscle (dancer).
The sprinter was injured during maximal speed running, presumably putting extreme demands on hamstring muscle function, whereas the dancer was injured
during a well controlled, slow stretching. The injury of
the dancer suggests that a muscle strain in fact can
be a partial tendon rupture.
MRI is a relatively new method to localize and estimate size of strain injuries in muscles. As demonstrated here, the localization and extent of the injury
can be evaluated in detail. It has also been suggested
that the duration of the rehabilitation period may be
predicted based on the severity of the injury as judged

by MRI (Pomeranz & Heidt, 1993). However, due to

its cost, MRI should be carefully evaluated in order
to arrive at principles for its use, and additionally
estimate the costbenefit of the method.
For high-level athletes, a quick return to training
and competition is imperative (Thorsson, 1996). One
important task for the sports medicine staff is to inform the athlete and his/her coach about the prognosis of time and type of rehabilitation needed to return to their specific sport.
None of the present athletes had experienced a previous injury in the hamstring muscle group.
This may explain why both athletes greatly underestimated the time it would take to return to competition and practice.

Perspectives
The present results point out the importance of finding the exact anatomical localization and injured
tissue in a hamstring strain. It also emphasizes the
importance of systematically mapping the injury site
versus the injury mechanism in various sports. This
type of information, including size of injury, correlated to the time to get back to sport, is required to
evaluate different rehabilitation programs.
Key words: hamstring strain; sprinter; dancer; MRI;
rehabilitation.

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