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Introduction

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It comes on suddenly like a cyclist getting a puncture. It was like someone getting up and slapping me around the face.

Derek Redmond describing the hamstring injury he suffered in the 1992 Olympic 400 m semi-final. Redmond famously got up and hobbled the remaining 250 meters of the race with the aid of his father

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Pain in the “hamstring region” can prove very frustrating for recreational and amateur athletes and may even be career threatening for professional sportspeople. Hamstring muscle strains are the most common cause of posterior thigh pain, but referred pain to this area is also common.

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The average number of days until return to sport for hamstring injuries ranges from 8 to 25 days.1 The incidence of recurrence is high. Up to one-third of hamstring injuries will recur, with the greatest risk being during the initial two weeks following return to sport.2

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This chapter focuses on:

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  • the relevant anatomy, which is critical to diagnosis, prognosis, and management

  • the clinical distinction between the major pathologies that cause posterior thigh pain

  • the increasingly appreciated role for diagnostic imaging for this injury

  • treatment approaches for the two types of acute hamstring injuries and for referred pain

  • the indications for considering early or late surgical treatment

  • how to make the, often difficult, return-to-play decision

  • preventing the rightfully feared setback—hamstring strain recurrence.

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Functional anatomy

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The hamstring muscle group (Fig. 31.1) consists of three main muscles—biceps femoris, semimembranosus, and semitendinosus. Biceps femoris has two heads—a long head and a short head. The long head is innervated by the tibial portion of the sciatic nerve (L5, S1–3), whereas the short head is innervated by the common peroneal portion (L5, S1–2).

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Figure 31.1

Anatomy of the posterior thigh

(a) Surface anatomy

Graphic Jump Location
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(b) Muscles of the posterior thigh

Graphic Jump Location
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The proximal hamstring complex (Fig. 31.1c) is a common site of much pathology and it has an intricate architecture.3 The long head of biceps femoris and semitendinosus share a common proximal tendon that arises from the medial facet of the ischial tuberosity. Semitendinosus muscle fibers originate from the ischial tuberosity and the medial aspect of the common tendon; muscle fibers from the long head of bicep femoris originate from the lateral aspect of the common tendon approximately 6 cm (2¼ in.) below the ischial tuberosity. The proximal semimembranosus tendon arises from the lateral facet of the ischial tuberosity and, moving distally, extends medially, passing ventral (deep) to the semitendinosus/biceps femoris long head common proximal tendon.

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