Working with Hamstring Injuries

By Til Luchau
[Myofascial Techniques]

What word first comes to mind when you hear hamstrings? If you said “tight,” “sore,” “pulled,” or “injured,” you have plenty of company—these are the words most frequently used with hamstrings in Google searches. It doesn’t take a psychoanalyst to interpret those free-association results—many people associate hamstrings with pain, stiffness, and injury.
Hamstrings work hard. They are major stabilizers of the body’s biggest segmental relationships, such as pelvic tilt, trunk angle, and hip position. They are also prime movers in some of the body’s most powerful actions, such as running, stepping, jumping, and bending (Image 1). As such, they are prone to straining or tearing injuries (Image 2), most often as a result of sudden acceleration or lunging motions that are common in running and ball sports.
The most common sites for hamstring injuries are at their musculotendinous junctions (usually mid-thigh, where tendons blend with muscle fibers) and at the hamstrings’ proximal end (where tendons insert on the ischium).
The hamstrings are comprised of the semimembranosus, semitendinosus, and biceps femoris muscles. The short head of the adductor magnus, which also flexes the knee, is sometimes considered a hamstring as well. The biceps femoris is the most lateral of these muscles and is the most frequently injured of this group.
Hamstring injuries, even if relatively minor, take time to recover, since these structures are constantly in use in any upright activity. In addition, because hamstring strains usually result from activity, they occur most often in active people—who sometimes have difficulty not being active. This might be why reinjury of partially recovered strains or tears is quite common. About one-third of recovering athletes reinjure their hamstrings, most often within the first 14 days after returning to play.1 Depending on severity and other factors, recovery times of four to six weeks are not uncommon, and in cases of reinjury, much longer periods are often required. Skilled hands-on work can facilitate the recovery process, of course—more about this later.
Not only do hamstrings work hard, but they also often feel hard. Hamstrings are notoriously tight, and sometimes seem impervious to all attempts to lengthen them. Their resilience may be related to their function. We use them as postural muscles whenever upright, and connective tissue resilience is much more efficient than muscular contraction when continuous tension is needed.
Turkeys take this a step further by developing ossifications within their leg muscles. Like us, turkeys are bipeds that spend a great deal of time standing around (Image 3). To better accommodate the demands of standing, turkeys have intermuscular septa and tendons within their leg muscles that often ossify into long, thin, intramuscular bonelike structures.
Although our own human hamstrings may sometimes feel as if they’ve ossified, their function is both to resist stretching, and to spring back. Researchers such as Robert Schleip2 and Serge Gracovetsky3 have each described models of gait and movement based on the soft tissue’s ability to store and release energy via elastic recoil. Schleip writes about how kangaroos hop much farther and faster than can be explained by the contractile force of their hamstring and leg muscles alone. Kangaroos (Image 4) use a kind of “catapult effect” to load and unload their springy leg tendons.4 Rather than relying solely on muscular contraction for their jumps, kangaroos use the springiness of their leg tendons to store the energy of landing, releasing it into the next hop.
These springlike mechanisms have also been observed in antelope and humans. Ultrasound observation of human muscle during use (in this case, oscillatory loading motions such as hopping or jumping) shows more-than-expected tendon stretch and recoil, and less-than-expected muscle fiber shortening. Instead of shortening, muscle fibers were observed to isometrically stiffen, thereby tuning and pre-tensioning the springy tendons. One study showed that 66–76 percent of the work involved in jumping was accomplished by stored energy within the tendinous portion of the calf’s muscle-tendon complex, with only 24–34 percent originating from muscle contraction itself.5 Other fibrous connective tissues, including aponeuroses and intermuscular septa, likely contribute to similar springlike functions.
Hamstrings don’t work alone. They function in concert with other myofascial and connective structures, both nearby and elsewhere in the body. The hamstrings are links in the long chains of fascial relationships that include the sacrotuberous ligament (which is aligned with the biceps femoris, sometimes sharing the same collagen fibers, and acting as a continuation of the hamstrings’ force vector). In a typical cross-stride in walking or running, the gluteus maximus, the lumbodorsal fascia, and the opposite-side latissimus dorsi continue this line of connection into the contralateral arm.
The hamstrings work with other muscle groups in a variety of ways. In walking and running, the hamstrings decelerate and control the lower leg’s kick-through, caused by the strong contraction of the quadriceps. One leg’s hamstring muscles can all contract together, producing the powerful stride of hip extension combined with knee extension. Or, the muscles can work individually, as they do when stabilizing and balancing the femur on the tibia, or when controlling tibial rotation at the bent knee, such as when changing direction while running, skiing, or skating.
When there is a lack of differentiation between the hamstrings’ muscles—that is, when they are mechanically or functionally stuck together as a result of injury, overuse, habit, or unrefined body awareness—these fine-tuning functions are lost in all-or-nothing activation of the hamstrings’ undifferentiated mass. Without this functional and structural distinction, there is reduced efficiency, as well as a loss of the fine control needed for adaptability, balance, and responsiveness.
Next, I’ll describe one method for increasing hamstring resilience, differentiation, and refined proprioception: the three qualities that lend spring, flow, and control to our stride.
Hamstring Technique
We’ll use a prone position for this protocol, but some considerations are in order. We want the client’s neck to be comfortable, so using a face cradle is logical; however, most face cradles require the use of a bolster under the ankles to avoid external hip rotation. This bolstered leg position does not allow full knee extension, and we want the full range of knee motion available. Rather than a built-in face cradle and bolstered legs, I prefer a full-torso bolster system with a tabletop headrest; this allows the client’s feet to be off the table. This allows us to work the hamstrings through the full range of knee flexion and extension.
Using the flat of your forearm, begin by anchoring the outer layers of the posterior thigh’s fascia (Images 5 and 6) in a superior or proximal direction. These surface layers include the skin and superficial fascias; they are thick, strong, and resilient. These layers can become adhered to one another and to the underlying fascia around the muscles themselves. Avoid oil or other lubricants at this point, as you’ll want to be able to anchor the layers in order to help them slide over one another, rather than simply sliding over the surface with your forearm. Once you have anchored the outermost of these layers, ask your client to bend his or her knee. This will allow you to move the outer layer farther in a proximal direction, effectively taking up the slack in the tissues as the knee is actively bent. No sliding on the surface has occurred yet.  
Because the hamstrings are so strong and resilient, we’ll use the client’s active movement, rather than trying to do all the work ourselves. Once the knee is fully bent (Image 5), ask your client to slowly lower the leg (straightening the knee, Image 6), as you allow the tissues to gradually slide out from under your forearm as they release. Even clients with hair on their legs will be comfortable, if you coach them to go slowly enough. You can modulate the intensity of the release by varying your pressure and angle, and by slowing your client’s motions down even further. Your client may report a slight burning or stretching; this is the sensation of the highly innervated fascial layers releasing. The sensation should never be so painful or intense that your client cannot relax. Repeat this release of the superficial layers on several areas of the posterior thigh—first medially, then centrally and laterally, from ischium to the back of the knee. Your goal is a smooth, fluid sliding of the layers, one upon another.
After you’ve worked through the outer layers, you can begin to anchor deeper structures, still working gradually and guiding your client’s slow, focused movement. Remember, the release happens during the straightening of the knee, as the hamstrings’ tissues and muscles are lengthened in an eccentric pattern. Feel for and differentiate the three or four muscle bundles of the hamstrings themselves (Image 7), which originate on the ischium and then split to reach around the gastrocnemius insertions at the back of the knee. In most cases, the short head of the biceps femoris crosses only the knee joint, and so does not usually extend the hip.
Continue working on the connective tissues between and around the bundles, rather than just on the muscles’ bellies. Remember that strains are most common where tendon meets muscle, or where it meets bone. Use caution and sensitivity in the popliteal space, or in any areas where your client reports a nervy or shooting sensation (since the sciatic nerve is here also).
As well as hamstring injuries, other conditions will respond to direct work here. The sciatic nerve passes under the biceps femoris (Image 8), where its tethering can be one cause of sciatic pain.6 Pes anserinus bursa inflammation (felt as burning and pain medial to the knee with exercise) can often be relieved by working the semitendinosus muscle, along with the gracilis and sartorius. Working the entire hamstrings in the way described here can sometimes help ameliorate hamstring syndrome (a painful irritation of the hamstrings’ attachments on the ischial tuberosity, which is often worsened by sitting).
As mentioned, hamstring injuries are frequently reaggravated or kept in a state of painful irritation by overuse before they are fully healed. Ultimately, there is probably no substitute for the passage of time, and patience is sometimes the client’s greatest challenge, especially for athletes used to pushing past the barriers. However, many people find that the kind of specific work described here can reduce the pain of strained tissues and accelerate the recovery process. There is good research-based evidence showing that hands-on manipulation can reduce exercise-induced inflammation. One study found significant reductions in chemical markers of inflammation in leg tissues after massage.7 Another study found fewer adhesions between layers of connective tissue when manual manipulation was performed on mechanically irritated tissues.8
There are several theories about the actual mechanism by which hands-on work helps injured tissues. Examples of these are improved tissue hydration, stimulation of collagen renewal, better organization of newly forming collagen, trigger-point prevention, increased proprioceptive accuracy, and interruption of self-perpetuating pain cycles. Although not all of these models have been tested by formal research yet, they still can give practitioners a useful mental map for conceptualizing what they may be achieving with their work. No matter which model makes the most sense to you (and fits best with your style, experience, viewpoint, and population served), chances are you’ll find plenty of opportunity to use hamstring techniques in your practice.

1. B. Heiderscheit et al., “Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation and Injury Prevention,” Journal of Orthopaedic & Sports Physical Therapy 40, no. 2 (2010): 67–81.
2.    D. Müller and R. Schleip, “Fascial Fitness: Fascia Oriented Training for Bodywork and Movement Therapies,” Terra Rosa eMagazine 7 (2011).
3.    Serge Gracovetsky, The Spinal Engine, (London: Springer-Verlag, 1989).
4.    R. Kram and T. J. Dawson, “Energetics and Biomechanics of Locomotion by Red
Kangaroos (Macropus rufus),” Comparative Biochemistry & Physiology 120, no. 1 (1998): 41–49; accessed December 2013,
5.    American Society of Biomechanics, T. Fukunaga et al., “Muscle Fiber Behavior During Drop Jump in Humans,” 2001; accessed December 2013, Accessed November 2013.
6.    K. Saikku et al., “Entrapment of the Proximal Sciatic Nerve by the Hamstring Tendons,” Acta Orthopaedica Belgica 76 (2010): 321–24.
7.    J. D. Crane et al., “Massage Therapy Attenuates Inflammatory Signaling After Exercise-Induced Muscle Damage,” Science Translational Medicine 4, no. 119 (2012).
8.    G. M. Bove and S. L. Chapelle, “Visceral Mobilization can Lyse and Prevent Peritoneal Adhesions in a Rat Model,” Journal of Bodywork & Movement Therapies 16, no. 1 (2012): 76–82.

Til Luchau is a member of the faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is a Certified Advanced Rolfer and the originator of the Advanced Myofascial Techniques approach. Contact him via and’s Facebook page.

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