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You know, this is a different hamstring—I did my left hamstring, I’ve done the right side of my back, I’ve just done my right hammy . . obviously I’ve got injury concerns at the moment, now I have to go back and do what the experts tell me to give myself the best chance of being fully fit.

Michael Clarke, Australian cricket captain, December 2014

Pain in the ‘hamstring region’ can prove very frustrating for recreational and amateur athletes and may be career threatening for professional athletes. Hamstring muscle strains are the most common cause of posterior thigh pain, but referred pain to this area is also common. The average number of days until return to play (RTP) for hamstring injuries depends on the severity of the injury, but has been found to range between 18–60 days in elite level soccer players.1

The incidence of recurrence is high. Up to one-third of hamstring injuries will recur, with the greatest risk being during the initial 2 weeks following return to sport.2

In this chapter, we focus on:

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

  • clinical distinction between the major pathologies in the patient with posterior thigh pain

  • the role of 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.


The hamstring muscle group (Fig. 34.1) 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).

Figure 34.1

Anatomy of the posterior thigh (a) Surface anatomy (b) Muscles of the posterior thigh (c) Proximal hamstring origin (d) Anatomical arrangement of the long and short heads of biceps femoris

The proximal hamstring complex (Fig. 34.1c) is a common site for pathology and has a complex anatomical arrangement.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 fibres originate from the ischial tuberosity and the medial aspect of the common tendon; the biceps femoris long head muscle fibres originate from the lateral aspect of the common tendon approximately 6 cm below the ischial tuberosity (Fig. 34.1d). The proximal free tendon of semimembranosus arises from the lateral facet of the ischial tuberosity and has a length of more than 10 cm. Moving distally, it extends medially ...

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