足球医学-社会
doi:10.1136/bjsm.2002.002352
Br. J. Sports Med. 2004;38;36-41
C Woods, R D Hawkins, S Maltby, M Hulse, A Thomas and A Hodson
football—analysis of hamstring injuries
Programme: an audit of injuries in professional
The Football Association Medical Research
http://bjsm.bmjjournals.com/cgi/content/full/38/1/36
Updated information and services can be found at:
These include:
References
http://bjsm.bmjjournals.com/cgi/ ... /1/36#otherarticles
8 online articles that cite this article can be accessed at:
http://bjsm.bmjjournals.com/cgi/content/full/38/1/36#BIBL
This article cites 35 articles, 12 of which can be accessed free at:
Rapid responses
http://bjsm.bmjjournals.com/cgi/eletter-submit/38/1/36
You can respond to this article at:
service
Email alerting
top right corner of the article
Receive free email alerts when new articles cite this article - sign up in the box at the
Topic collections
• Sports Medicine (1329 articles)
• Physiotherapy (148 articles)
• Injury (833 articles)
Articles on similar topics can be found in the following collections
Notes
http://www.bmjjournals.com/cgi/reprintform
To order reprints of this article go to:
http://www.bmjjournals.com/subscriptions/
To subscribe to British Journal of Sports Medicine go to:
Downloaded from bjsm.bmjjournals.com on 22 October 2006
ORIGINAL ARTICLE
The Football Association Medical Research Programme: an
audit of injuries in professional football—analysis of
hamstring injuries
C Woods, R D Hawkins, S Maltby, M Hulse, A Thomas, A Hodson
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See end of article for
authors’ affiliations
. . . . . . . . . . . . . . . . . . . . . . .
Correspondence to:
A Hodson, The Football
Association, Medical and
Exercise Department,
Lilleshall National Sports
Centre, Nr Newport,
TF10 9AT, UK;
alan.hodson@TheFA.com
Accepted
11 February 2003
. . . . . . . . . . . . . . . . . . . . . . .
Br J Sports Med 2004;38:36–41. doi: 10.1136/bjsm.2002.002352
Objective: To conduct a detailed analysis of hamstring injuries sustained in English professional football
over two competitive seasons.
Methods: Club medical staff at 91 professional football clubs annotated player injuries over two seasons.
A specific injury audit questionnaire was used together with a weekly form that documented each clubs’
current injury status.
Results: Completed injury records for the two competitive seasons were obtained from 87% and 76% of the
participating clubs respectively. Hamstring strains accounted for 12% of the total injuries over the two
seasons with nearly half (53%) involving the biceps femoris. An average of five hamstring strains per club
per season was observed. A total of 13 116 days and 2029 matches were missed because of hamstring
strains, giving an average of 90 days and 15 matches missed per club per season. In 57% of cases, the
injury occurred during running. Hamstring strains were most often observed during matches (62%) with an
increase at the end of each half (p,0.01). Groups of players sustaining higher than expected rates of
hamstring injury were Premiership (p,0.01) and outfield players (p,0.01), players of black ethnic origin
(p,0.05), and players in the older age groups (p,0.01). Only 5% of hamstring strains underwent some
form of diagnostic investigation. The reinjury rate for hamstring injury was 12%.
Conclusion: Hamstring strains are common in football. In trying to reduce the number of initial and
recurrent hamstring strains in football, prevention of initial injury is paramount. If injury does occur, the
importance of differential diagnosis followed by the management of all causes of posterior thigh pain is
emphasised. Clinical reasoning with treatment based on best available evidence is recommended.
The hamstring strain is a condition well recognised by
medical personnel, coaches, and athletes. Such injuries
are a major cause of time lost from sport.1 Hamstring
strains are among the most common injuries in sport and are
most often observed in sports that involve sprinting and
jumping.2–4 The initial Football Association Audit of Injuries
study found that 12% of all injuries reported over two seasons
were hamstring strains, this being the most prevalent injury.
Players were 2.5 times more likely to sustain a hamstring
strain than a quadriceps strain during a game.5
Many predisposing factors for hamstring strain have been
suggested in the literature, including insufficient warm up,6 7
poor flexibility,6–8 muscle imbalances,6 7 9 muscle weakness,
9 10 neural tension,11 fatigue,6 7 dys-synergic contraction
of muscle groups,12 and previous injury.13 14 The evidence to
substantiate these speculations is minimal and conflicting.
12 15 The same holds true for the management and
treatment of hamstring strains as there is no consensus on
optimal rehabilitation,7 16 therefore management tends to be
based on anecdotal evidence and experience rather than
evidence based practice.
Hamstring strains are well known for their high rate of
recurrence.16–19 It has been suggested that a premature return
to play10 12 20 or an inappropriate rehabilitation programme
10 12 13 21 may be responsible for reinjury.
Garrett22 stated that ‘‘Although muscle strains are frequently
seen, our understanding of the pathophysiology,
treatment, and recovery of these injuries is limited…’’. The
aim of this study was to provide information on the
incidence, nature, mechanism of injury, and diagnostic
investigation of hamstring strains. This included analysing
differences in the age, position, and ethnic origin of players
sustaining such injuries in football. The collection of such
injury data would help to identify factors involved in injury
occurrence, and in establishing the effectiveness of treatment
and prevention of hamstring injuries in soccer.
METHODS
Player injuries were prospectively reported from July 1997
through to the end of May 1999 inclusive. A total of 91 of the
92 football clubs from the English football leagues (Premier
and Football League) committed themselves to the project.
Injuries were recorded by club physiotherapists and/or
doctors on a specific player injury audit questionnaire
designed for this study. Injury audit questionnaires for
players who had returned to full training/competition during
a particular week were returned weekly together with a form
indicating which players had been absent and the number of
days and competitive matches each had missed that week.
Before the study, medical staff from clubs attended a briefing
day and were issued with guidance notes on how to complete
the questionnaires. Only professional players with a squad
number were involved in the study. Participants were asked
to complete a consent form and each club provided details of
their squad at the beginning of each season. Table 1 presents
the information obtained.
New players who joined the club were included, and
players leaving clubs were omitted from the study if they did
not stay within one of the four English leagues.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abbreviations: CT, computed tomography; MRI, magnetic resonance
imaging
36
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
A recordable injury was defined as one sustained during
training or competition that prevented the injured player
from participating in normal training or competition for more
than 48 hours (not including the day of the injury). Injuries
unrelated to football were not included, nor was any absence
due to illness. Injuries sustained during international duty
were included, as details of such injuries were reported back
to club medical staff. The severity of each injury was defined
as slight, minor, moderate, or major depending on whether
the player was absent from training or competition for two to
three days, four to seven days, one to four weeks, or more
than four weeks respectively. A similar classification system
has been used elsewhere.23 24 Reinjury was defined as an
injury of the same nature and location involving the same
player in the same season. The dominant foot was defined as
the predominant foot used for kicking a ball.
Data were analysed using SPSS (Chicago, Illinois, USA).
Descriptive and comparative data are presented. The x2
significance test was used to investigate differences, and
statistical significance was accepted at p,0.05 level. All
players agreed to participate in the study and there were no
drop outs during the study period.
RESULTS
Of the 91 clubs starting the study, completed injury records
for the entirety of the 1997/1998 and 1998/1999 competitive
seasons were attained from 87% and 76% respectively. During
the study period, 796 injuries to the hamstrings were
documented, this being more than any other muscle group.
There was no significant difference between the numbers of
hamstring injuries sustained in the 1997/1998 season relative
to the 1998/1999 season. Table 2 displays the classification of
all hamstring injuries.
Hamstring strains accounted for 12% of the total injuries
sustained over the two seasons. There was no significant
difference between the observed frequency of hamstring
strains to dominant and non-dominant limbs (53% v 45%)
based on expected frequencies. There was, however, a
significant difference in the number of hamstring strains
across the four divisions, with most occurring in Premier
League players (28%) (p,0.01). The distribution of hamstring
strains across the other divisions was: division 1, 24%;
division 2, 26%; division 3, 22%.
Table 3 shows the location of hamstring strains.
The total number of days that players were absent over the
two seasons from hamstring strains was 13 116, and a total
of 2029 matches were missed, giving an average of 18 days
and three matches missed per hamstring strain. A rate of five
hamstring injuries per club per season was observed, the
range being 0–16 hamstring strains within clubs. This
resulted in 15 matches and 90 days missed per club per
season.
Mechanisms of injury involving player to player contact
were responsible for 7% of injuries, while non-contact
injuries were responsible for 91% (p,0.01). A total of 57%
of all hamstring strains were sustained during running.
Figure 1 displays the non-contact mechanisms of hamstring
strains.
Figure 2 shows the number of hamstring strains sustained
during training and matches throughout each month of the
season. Approximately one third (32%) of hamstring strains
were sustained during training and nearly two thirds (67%)
during matches. On the basis of the percentage of total match
and training injuries reported in the study (34% v 63%), there
was no significant difference between the observed and
expected frequency. Figure 3 shows the timing of match
injuries. Nearly half (47%) of hamstring injuries sustained
during matches occurred during the last third of the first and
second halves of the match (p,0.01).
Table 4 shows the number of hamstring strains by player
position, age, and ethnic origin.
Based on observed and expected frequencies, goalkeepers
sustained significantly fewer hamstring strains than outfield
players (p,0.01). Players of black origin sustained significantly
more hamstring strains than white players (p,0.05),
and the 17–22 year old age groups sustained fewer hamstring
strains than the older players (p,0.01).
The reinjury rate for hamstring strains was 12%, and the
average reinjury rate for all injuries was 7% (p,0.01). There
was no significant difference between the severity of initial
injuries and reinjuries—that is, there was no difference in the
number of training days or matches missed.
Of all the hamstring strains sustained, only 5% were
diagnostically investigated using an imaging technique. The
most commonly used technique was magnetic resonance
imaging (MRI) (27), seven strains were scanned with
Table 1 Division, playing position, and age distribution of the cohort at the beginning of
the study
Division No % Playing position No % Age distribution No %
Premier 618 26 Goalkeeper 223 9 17–22 970 41
1st 712 30 Defender 817 34 23–28 817 34
2nd 550 23 Midfielder 739 31 29–34 508 21
3rd 496 21 Forward 597 25 35+ 81 3
Total* 2376 100 2376 99 2376 99
*Percentage totals may be subject to rounding errors associated with individual components.
Table 2 Classification of hamstring injuries
Nature of injury No %
Muscle strain 749 94
Muscle contusion 12 2
Tendonitis 16 2
Muscle rupture 3 1
Other* 5 1
Bursitis 1 0
Not specified 10 1
Total 796 101
*Other includes cut, overuse, soft tissue bruising and bursitis.
Percentage totals may be subject to rounding errors
associated with individual components.
Table 3 Location of hamstring strain injuries
Muscle No %
Biceps femoris 396 53
Unspecified 139 19
Semitendinosus 116 16
Semimembranosus 98 13
Total* 749 101
*Percentage totals may be subject to rounding errors
associated with individual components.
Hamstring injuries in football 37
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
ultrasound, and one player underwent both types of
investigation. Only two players with hamstring strains had
surgery, and nine received some form of injection.
DISCUSSION
In this study, a muscle strain was by far the most commonly
diagnosed injury to the posterior thigh. Hamstring strains
accounted for 12% of all injuries sustained over the two
seasons and for the loss of 90 training days and 15 matches
per club per season.
Each club sustained an average of five hamstring injuries
per season. This is comparable to an Australian football study
which observed an average of six hamstring strains per club
per season, with hamstring strains representing 15% of all
injuries.3
The high incidence of injury in this muscle group may be
partly because the group functions over two joints3 5 18 and is
therefore subject to stretch at more than one point.3 18 Also,
the greater proportion of fast twitch fibres in the hamstring
muscles compared with other thigh and leg muscles means
that they are capable of high force production.5 Common
muscle imbalance patterns may invoke the use of the
hamstrings as a slow twitch muscle, which may predispose
the muscle to injury when challenged to perform high
velocity fast twitch actions. It may therefore be worth while
addressing any muscle imbalances when assessing and
treating these injuries.
The biceps femoris (53%) was the most commonly strained
muscle of the hamstring complex. This finding is supported
by other studies.1 5 25 The anatomy of the biceps femoris may
help to explain its higher rate of injury. Firstly, it has a long
and a short head, both with separate nerve supplies.26 This
dual innervation may lead to asynchronous stimulation of
the two heads.27 28 Mistimed contraction of the different parts
of the muscle group may mean a reduced capacity to generate
effective tension to control the imposed loads of the muscle.28
There may be anatomical variations in the attachments of
biceps femoris, which may predispose certain people to
injury.29 Burkett29 suggested that an extensive femoral
attachment of the short head of the biceps femoris with an
overlying strength deficit predisposes to hamstring strain.
The long head of the biceps femoris originates from the lower
part of the sacrotuberous ligament,20 26 30 31 therefore it could
be argued that the biceps femoris has a triarticular function
and is therefore more predisposed to injury than the other
hamstring muscles. The insertion of the biceps femoris into
the head of the fibula my also be a predisposing factor to
injury. A previous knee or ankle injury resulting in alteration
in the movement of the superior tibiofibular joint may affect
the biomechanics of the biceps femoris. This notion is
speculative. Zuluaga et al28 stated that incomplete knee
excursion caused by meniscal damage may lead to excessive
loading of the biceps femoris. The biceps femoris acts as a
lateral rotator of the semiflexed knee and the extended hip.26
Given the rotational demands of football, this function may
also predispose the biceps femoris to injury. Despite this, it
suggests that the sacroiliac joint and the superior tibiofibular
joint should be examined when assessing players with
suspected biceps femoris strains. The function of the biceps
femoris as a lateral rotator should also be acknowledged
when strengthening and stretching this muscle.
It was interesting to note that nearly 20% of practitioners
did not specify the exact name of the hamstring muscle
injured, diagnosing the injury as ‘‘hamstring strain’’. This
could be for one of two reasons—either the therapist’s
diagnosis was simply non-specific or the pathology was so
non-specific that an accurate diagnosis was not possible. In
six out of 32 MRI scans performed on players with posterior
thigh injury (non-contact mechanism), the scan was normal
and not consistent with hamstring muscle strain; the authors
diagnosed this as ‘‘referred posterior thigh injury’’.16 Garrett
et al1 found that two out of 10 patients who sustained acute
hamstring injuries had no acute abnormality on computed
tomographic (CT) scan. This supports the notion that the
presentation of posterior thigh pain does not necessarily
mean ‘‘there is always an isolated local pathology’’32 within
the muscle. Upton et al33 stated that most problems have a
basis within the muscle complex, but, in 15% of cases,
associated factors are involved. Such factors may include
lumbar spine, sacroiliac joint, neural tension, ischiogluteal
bursa, piriformis syndrome, avulsion of the ischial tuberosity,
compartment syndrome of the posterior thigh, bone tumours,
and hamstring syndrome/fibrous adhesions. Posterior thigh
symptoms may be local or referred. Readers are encouraged
to be aware of this and the various possible differential
diagnoses when assessing players with posterior thigh pain.
Correct diagnosis is the basis of adequate treatment,8 and
management should be aimed at correcting all abnormalities
detected on examination.23
Figure 1 Mechanism of non-contact hamstring strains. *Other includes
dribbling, heading, and diving.
Figure 2 Month of injury of hamstring during training and matches.
Figure 3 Time of hamstring strains sustained during match play.
38 Woods, Hawkins, Maltby, et al
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
Devlin18 stated that ‘‘imaging is not always performed’’
because most hamstring injuries are managed conservatively.
Of the 749 hamstring strains in our study, only two required
surgery. O’Connor et al34 described three case studies of
athletes with chronic and unresolving posterior thigh pain.
The cases were eventually diagnosed as chronic compartment
syndrome of the posterior thigh and were successfully treated
with a limited fasciectomy. This again highlights the
importance of structures other than the hamstring muscles
themselves being responsible for posterior thigh pain.
Only 5% of hamstring strains in this study were diagnostically
investigated, with MRI being the most commonly
used technique. Current diagnostic techniques may not be
sensitive enough to determine the source of posterior thigh
pain, especially where adverse neural tension, sacroiliac joint,
or lumbar spine dysfunction is suspected as the cause of
symptoms.20 MRI may not be necessary for routine imaging
of muscle strain injury, as accurate history taking and
physical examination skills provide a sound diagnosis of
muscle strain injury in most cases.18 25 The use of diagnostic
investigations in assessing and treating hamstring injuries is
an area that requires further research.
This study shows that an overwhelming number of
hamstring strains occurred while players were running. The
speed (sprinting, jogging), nature (with or without the ball,
backwards, sideways), and phase (decelerating, acceleration,
etc) of running when the injury was sustained was not
recorded in this study, although this information would have
been useful to learn more about the causes of these injuries.
Analysis of the biomechanics of running suggests that
hamstring strains occur during the end of the swing phase
when the hamstrings are working to decelerate the limb
while also controlling extension of the knee.14 The hamstrings
must change from functioning eccentrically, to decelerate
knee extension in the late swing, to concentrically, becoming
an active extensor of the hip joint. It has been proposed that
this rapid changeover from eccentric to concentric function of
the hamstring is when the muscle is most vulnerable to
injury.14 Zuluaga et al28 also suggested that, during this swing
phase, the hamstrings are placed under extremely high loads
in an elongated position. This has implications for rehabilitation,
as the hamstring must be functionally strong in the
phase of injury before return to play. This is why an
individualised rehabilitation programme emphasising high
velocity eccentric exercises (with the hamstrings in an
elongated position) has been proposed by many authors
during the late stage of functional rehabilitation.12 15 19 23
Garrett et al4 suggested that, because hamstring muscles are
most often injured in high speed or high intensity situations,
the hamstrings must be trained and rehabilitated at a high
intensity. In further support of this, Jo¨nhagen et al20 proposed
that one of the reasons for recurrence of hamstring injury
was poor eccentric hamstring strength, especially at high
angular velocities.
This study shows that players with a black ethnic origin are
more at risk of sustaining a hamstring strain than white
players. No other studies comparing these ethnic origins with
risk of hamstring injury could be found. However, in a study
of clinical risk factors for hamstring injuries in Australian
rules football, Verrall et al14 found that players of aboriginal
descent had a significantly greater risk of sustaining a
hamstring injury. They proposed that, as such players are
generally considered to be the ‘‘fastest, most skilful and most
exciting players’’, they may have a greater proportion of type
II fibres, which may predispose them to injury. A small study
that looked at the treatment of hamstring strains with
sacroiliac mobilisation showed that those people with
increased anterior tilt of the inominate bones were more at
risk of sustaining a hamstring injury.17 It is common for
players of black origin to have an anteriorally tilted pelvis,
perhaps predisposing them to this type of injury. Although
this is speculative, the anatomical link between the hamstrings,
lumbar spine, pelvis, and sacrum suggests that the
biomechanics of these structures should be evaluated when
assessing posterior thigh pain.
This study also shows that players in the 17–22 age group
had a lower risk of sustaining a hamstring injury. Verrall et
al14 also found that hamstring strains were more common in
older people but were unable to offer an explanation for this.
Goalkeepers sustained fewer hamstring strains than outfield
players, which may be explained by the demands of the
goalkeeper, as running (which is the principal mechanism of
injury for this type of injury) is not a major component of the
goalkeeper’s game. Hamstring injuries were most common in
the Premiership and became less common in the lower
leagues. This may reflect the increased physical demands in
the higher leagues where the pace of games may be faster.
Hamstring strains were mostly sustained at the end of
matches and training sessions. This would support the notion
that fatigue may be a predisposing factor for such injuries as
previously discussed. A complex neuromuscular coordination
pattern appears to occur during the running cycle.14 18 Any
factor that adversely affects this pattern may result in
injury.14 It has been suggested that the dual innervation of
the biceps femoris may cause asynchrony, as poor coordination
may allow separate parts to activate at different times.14
Kyro¨la¨inen et al35 looked at the recruitment pattern of leg
muscles during different running speeds. The greatest
changes in muscle activity pattern were observed in the
biceps femoris muscles as the speed increased from a slow jog
to maximum speed. Pinniger et al36 found that, when
footballers became fatigued during sprinting, there was
earlier activation of the biceps femoris and semitendinosus
muscles. Asynchrony may be due to local muscle fatigue14
and/or neural fatigue as a result of ‘‘irritation or damage
along the path of the nerve supplying the muscle’’.20 General
fatigue secondary to poor sleep patterns, stress, or suboptimal
nutrition could result in central nervous system fatigue. A
Table 4 Hamstring strains by playing position, age, and ethnic origin
Position
Hamstring All injuries
Age distribution
Hamstring All injuries
Ethnic origin
Hamstring All injuries
No % No % No % No % No % No %
Goalkeeper 20 3 341 6 17–22 220 29 2100 35 White 617 82 5158 86
Defender 305 40 2278 38 23–28 304 41 2294 38 Black African 7 1 85 1
Midfielder 228 30 1798 30 29–34 184 25 1361 23 Black
Caribbean
83 11 531 9
Attacker 184 25 1487 24 35+ 22 3 136 2 Black other 18 2 112 2
Other 11 2 49 1
Not specified 12 2 126 2 Not specified 19 2 139 2 Not specified 13 2 90 2
Total* 749 100 6030 100 Total 749 100 6030 100 Total 749 100 6030 101
*Percentage totals may be subject to rounding errors associated with individual components.
Hamstring injuries in football 39
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
muscle’s decreased ability to generate force is thought to
reduce its energy absorption capacity, which in turn predisposes
the muscle to injury.24 37 This highlights the importance
of addressing the endurance of the hamstring muscle group
in preventive and rehabilitation programmes. Emphasis is
generally placed on increasing the strength and power of this
muscle group.
The recurrence rate for hamstring injuries was 12%, which
was significantly greater than the reinjury rate for all other
injuries (7%). The high reinjury rate has been cited as one of
the frustrations of treating hamstring injuries.14 It is generally
believed that skeletal muscle is capable of virtually complete
regeneration after injury.38 However, Stauber et al39 pointed
out that, if pronounced connective tissue proliferation is
present after repeated muscle injury, complete restoration of
normal function may be impaired or even impossible. In their
study, which looked at the recovery from six weeks of
repeated strain injury to rat soleus muscle, Stauber et al40
concluded that the muscle recovered slowly and incompletely
from chronic strain injury. These authors suggested that
further work to design optimal intervention and prevention
procedures for muscle fibrosis from chronic muscle injury
was needed. In their study of CT of hamstring muscle strains,
Garrett et al1 noted the presence of calcifications at the
involved site of some college athletes with hamstring injuries.
The authors stated that the significance of these calcifications
was unclear, but pointed out that the CT appearance of
calcification does not always return to normal. This shows
that the exact pathophysiology of reinjury remains unknown.
Therefore, complete rehabilitation of injuries before return to
play is emphasised, but primary prevention of initial injuries
is even more important. Practical studies evaluating the use
of strategies to prevent hamstring strain in football would be
useful.
It is interesting to note that some clubs sustained very few
hamstring strains throughout the two seasons, whereas other
clubs sustained a large number. Similarly some clubs
reported no recurrence of these injuries, whereas others
reported a high rate of recurrence. This may represent a large
number of variables in diagnosis, training techniques, and
medical management, but it does at least suggest that these
injuries can be prevented and managed.
This study did not record exposure data, making it difficult
to compare the results with other studies. However, accurate
exposure time would have been difficult to obtain given the
large number of clubs participating in the study. At the outset
of the study, there were no criteria for what constituted a
hamstring strain so there may be wide variation in diagnosis
between medical personnel. Referred posterior thigh pain
may also have been missed in this study. More detail on
running as a mechanism of injury, specifying the nature,
speed, and phase, would also have helped, as would more
detail on playing position. Future studies should address
these issues.
Hamstring strains are common in football. A rate of five
hamstring injuries per club per season was observed,
resulting in 15 matches and 90 days missed per club. The
biceps femoris muscle was the most commonly strained of
the hamstring group. Such injuries were usually sustained
during running and at the end of match halves. The groups of
players sustaining higher than expected rates of hamstring
injury were Premiership and outfield players, players of black
ethnic origin, and players in the older age groups. The
reinjury rate for hamstring injury was 12%. In trying to
reduce the number of injuries and recurrences of hamstring
strains in football, prevention of the initial injury is vital. If
injury does occur, the importance of differential diagnosis,
followed by the management of all causes of posterior thigh
pain, is emphasised. Clinical reasoning with treatment and
rehabilitation based on best available evidence is recommended.
Authors’ affiliations
. . . . . . . . . . . . . . . . . . . . .
C Woods, The English Institute of Sport
R D Hawkins, S Maltby, M Hulse, A Thomas, A Hodson, The Football
Association
REFERENCES
1 Garrett WE, Ross Rich F, Nikolaou PK, et al. Computed tomography of
hamstring muscle strains. Med Sci Sports Exerc 1989;28:506–14.
2 Stanton P, Purdam C. Hamstring injuries in sprinting: the role of eccentric
exercise. J Orthop Sports Phys Ther 1989:343–9.
3 Orchard J, Seward H. Epidemiology of injuries in the Australian football
league, seasons 1997–2000. Br J Sports Med 2002;36:39–45.
4 Garrett WE, Califf JC, Bassett FH. Histochemical correlates of hamstring
injuries. Am J Sports Med 1984;12:98–103.
5 Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical
research programme: an audit of injuries in professional football. Br J Sports
Med 2000;34:0–4.
6 Kujala UM, Orava S, Ja¨rvinen M. Hamstring injuries: current trends in
treatment and prevention. Sports Med 1997;23:397–404.
7 Worrell TW. Factors associated with hamstring injuries: an approach to
treatment and preventative measures. Sports Med 1994;17:338–45.
8 Hartig DE, Henderson JM. Increasing hamstring flexibility decreases lower
extremity overuse injuries in military basic trainees. Am J Sports Med
1999;27:173–6.
9 Orchard J, Marsden J, Lord S, et al. Preseason hamstring muscle weakness
associated with hamstring muscle injury in Australian footballers. Am J Sports
Med 1997;25:81–5.
10 Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain
recurrence and strength performance disorders. Am J Sports Med
2002;30:199–203.
11 Turl SE, George KP. Adverse neural tension: a factor in repetitive hamstring
strain? J Orthop Sports Phys Ther 1998;27:16–21.
12 Agre JC. Hamstring injuries: proposed aetiological factors, prevention, and
treatment. Sports Med 1985;2:21–33.
13 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;32:309–14.
14 Verrall GM, Slavotinek JP, Barnes PG, et al. Clinical risk factors for hamstring
muscle strain injury: a prospective study with correlation of injury by magnetic
resonance imaging. Br J Sports Med 2001;35:435–40.
15 Cibulka MT, Rose SJ, Delitto A, et al. Hamstring muscle strain treated by
mobilizing the sacroiliac joint. Phys Ther Rev 1986;66:1220–3.
16 Best TM, Garrett WE. Hamstring strains: expediting return to play. Physician
and Sports Medicine 1996;24:1–9.
17 Brockett CL, Morgan DL, Proske U. Human hamstring muscles adapt to
eccentric exercise by changing optimum length. Med Sci Sports Exerc
2001;33:783–90.
18 Devlin L. Recurrent posterior thigh symptoms detrimental to performance in
rugby union: predisposing factors. Sports Med 2000;29:273–87.
19 Worrell TW, Perrin DH, Gansneder BM, et al. Comparison of isokinetic
strength and flexibility measures between hamstring injured and noninjured
athletes. J Orthop Sports Phys Ther 1991;13:118–25.
20 Jo¨nhagen S, Ne´meth G, Eriksson E. Hamstring injuries in sprinters: the role of
concentric and eccentric hamstring muscle strength and flexibility. Am J Sports
Med 1994;22:262–6.
21 Brukner P, Khan K. Clinical sports medicine. Sydney: McGraw-Hill Book
Company, 1997.
22 Garrett WE. Muscle strain injuries. Am J Sports Med 1996;24:S2–8.
23 Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer.
Am J Sports Med 1989;17:803–7.
24 Engstrom B, Forssblad M, Johansson C, et al. Does a major knee injury
definitely sideline an elite soccer player? Am J Sports Med 1990;18:101–5.
25 Speer KP, Lohnes J, Garrett WE. Radiographic imaging of muscle strain
injury. Am J Sports Med 1993;21:89–96.
26 Williams PW, Warwick R. Gray’s anatomy. 36th ed. Edinburgh: Churchill
Livingstone, 1980.
27 Sutton G. Hamstrung by hamstring strains: a review of the literature. J Orthop
Sports Phys Ther 1984;5:184–95.
Take home message
Hamstring strains are the most common injury in football
accounting for an average of 90 days and 15 matches
missed per club per season. Prevention of initial injury is
therefore emphasised. The importance of differential diagnosis
and management of all causes of posterior thigh pain
are highlighted in the treatment of such injuries.
40 Woods, Hawkins, Maltby, et al
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
28 Zuluaga M, Briggs C, Carlisle J, et al. Sports physiotherapy: applied science
and practice. 1st ed. Melbourne: Churchill Livingstone, 1995.
29 Burkett LN. Investigation into hamstring strains: the case of the hybrid muscle.
Med Sci Sports Exerc 1975;3:228–31.
30 Vleeming A, Pool-Goudzwaard AL, Stoeckwart R, et al. The posterior layer of
the thoracolumbar fascia: its function in load transfer from spine to legs. Spine
1995;20:753–8.
31 DonTigny RL. Mechanics and treatment of the sacroiliac joint. Journal of
Manual and Manipulative Therapy 1993;1:3–12.
32 Kornberg C, Lew P. The effect of stretching neural structures on grade one
hamstring strains. J Orthop Sports Phys Ther 1989;13:481–7.
33 Upton PAH, Noakes TD, Juritz JM. Thermal pants may reduce the risk of recurrent
hamstring injuries in rugby players. Br J Sports Med 1996;30:57–60.
34 O’Connor K, Fricker P, Quirk R, et al. Limited fasciectomy for chronic compartment
syndrome of the posterior thigh: three case studies. Excel 1992;8:13–17.
35 Kyro¨la¨inen H, Komi PV, Belli A. Changes in muscle activity patterns
and kinetics with increasing running speed. J Strength Cond Res
1999;13:400–6.
36 Pinniger GJ, Steele JR, Groeller H. Does fatigue induced by repeated dynamic
efforts affect hamstring muscle function? Med Sci Sports Exerc
2000;32:647–53.
37 Garrett WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports
Exerc 1990;22:436–43.
38 Best TM. Soft-tissue injuries and muscle tears. Clin Sports Med
1997;16:419–34.
39 Stauber WT, Knack KK, Miller GR, et al. Fibrosis and intercellular collagen
connections from four weeks of muscle strains. Muscle Nerve
1996;19:423–30.
40 Stauber WT, Smith CA, Miller GR, et al. Recovery from 6 weeks of repeated
strain injury to rat soleus muscles. Muscle Nerve 2000;23:1819–25.
www.bjsportmed.com
Click on the ''Top 10'' button on the homepage
to see which are the best read articles each month
Top 10
Readers' favourite
Hamstring injuries in football 41
www.bjsportmed.com
Downloaded from bjsm.bmjjournals.com on 22 October 2006
