Diagnosing, Treating and PREVENTING a Hamstring Strain

The hamstrings are a group of three muscles located in the back of the thigh. They are referred to as two-joint muscles, and they connect the hip and knee. The hamstring muscles bend the knee and extend the hip as well as contribute to numerous other motions of the body’s lower extremity. Anyone who has injured their hamstrings has quickly discovered the important role they play and the importance of making them pain-free.

Because of their multiple actions and their need for extension, the hamstring muscles are frequently vulnerable to strain. In fact, research indicates muscle strains occur most often in those like the hamstrings that cross two joints.

Diagnosing Hamstring Strains

Muscle strains are classified according to their severity:

1. A mild or first-degree strain is a tear of a few muscle fibers. Symptoms include minor swelling and discomfort with minimal or no loss of strength and function.
2. A moderate or second-degree strain involves greater damage of muscle with some loss of strength and function. Usually second-degree strains result in bleeding within the muscle secondary due to rupture of intramuscular blood vessels.
3. A severe or third-degree strain is a tear in the muscle extending across the whole muscle belly, resulting in total loss of muscle strength and function.


The good news is that most of the athletes I treat experience a first- or second-degree strain of the hamstrings. The not-so-good news, and research verifies this, is that athletes with a hamstring strain usually experience significant, from four to six weeks, recovery time and are more susceptible to recurrent hamstring injury for about six months to one year. So how do we get, treat hamstring strains, and more importantly, how can we prevent them?

Treating Hamstring Strains

Treating a hamstring injury after the initial strain is the same as other soft tissue injuries. In the acute phase (2–4 days after the injury) you should control inflammation with ice, compression and elevation. This initial phase also involves early motion of the lower leg such as stationary bicycle and pool exercises involving kicking and walking in the water.

The subacute phase (5–10 days after the injury) treatment consists of early motion on a stationary bicycle, isolated hamstring resistive exercises and pain-free stretching. The remodeling phase (11–21 days out) involves continued resistive exercises isolating the hamstrings, stretching and lengthening muscle exercises called eccentrics. An example of this type of exercise is to lie on your stomach and slowly lower your leg from a flexed position.

The final phase, the functional phase, (22-90 days) includes continued strengthening and stretching as well as jogging, sprinting and sports-specific drills. This treatment regimen is usually successful in returning athletes to their specific sport within several weeks. However, to reduce the recurrence of the injury requires preventive strategies.

Preventing Hamstring Strains

Ever day in our clinic, we treat muscle imbalances. Muscles work in groups: some muscles move bones while others hold onto them. In this group work, where muscles are referred to as synergists, one muscle is the agonist and another is the antagonist. The dominant use of the hamstring muscle (the agonist) and the under-utilization of the hip extensor muscle or gluteus maximus (the antagonist) can be a major contributor to the hamstring’s susceptibility to injury. In a 2004 study published in the Journal Orthopedic and Sports Physical Therapy, titled “A Comparison of Two Rehabilitation Programs in the Treatment of Acute Hamstring Strain,” M. Sherry and T. Best revealed a more effective rehabilitation and conditioning program for hamstring strains. They found that a program consisting of progressive agility and trunk stabilization exercises was more effective than a program emphasizing isolated hamstring stretching and strengthening in returning athletes to their specific sport and preventing injury recurrence.

In our clinic we also have discovered that strengthening the hip and trunk are critical in treating hamstring strains. I refer to this approach as muscle balancing and it comprises three phases:

1. Identify, through a detailed evaluation, the weak muscles within the trunk, hips and pelvis.
2. Design a specific strengthening program for the weak muscles.
3. Perform sports-specific activities designed to challenge the muscles’ ability to work in a group without over-working or under-utilizing an individual muscle.

Keep your muscles balanced and you just may never experience the pain of a strain

What is Jogger’s Foot (Medial Plantar Neuropraxia)?

Jogger’s foot, otherwise known as medial plantar neuropraxia, is a chronic entrapment syndrome of the medial plantar nerve in the foot. It is an unusual cause of heel pain in long distance runners.

Who get’s Jogger’s Foot?
Jogger’s foot is seen in athlete’s that participate in running endurance sports such as marathons, ultramarathons and Iron Man competitions as well as any athlete that is repetitively training with long distance running. A runner with flat feet is more predisposed to this injury than someone with a more pronounced longitudinal arch of their foot. Medial plantar nerve entrapment has also been seen in an unusual presentation in ballet dancers.

What is the relevant anatomy of this region?
The medial plantar nerve is a small nerve that supplies sensation to part of the bottom of the foot. It branches off of the much larger posterior tibial nerve above and behind the ankle on the medial (or inside) aspect of the ankle. The medial plantar nerve travels beyond the ankle and curves under the medial border of the foot. It enters a tunnel behind a bony prominence, known as the navicular. This tunnel is also bordered by a small muscle known as the abductor hallucis muscle which originates from the heel and inserts on the great toe. Repetitive trauma and inflammation caused by long distance running leads to swelling and compression of the medial plantar nerve in this tunnel. This effect is exacerbated by a flat arch and foot (known as pes planovalgus). With a poor arch, more pressure and stretch is placed on this nerve since the foot contacts the ground with higher force.

How is the diagnosis of Jogger's foot made?
Making this very rare diagnosis requires a high index of suspicion for this injury and awareness on the part of the treating sports medicine or foot and ankle physician specialist. In the many of cases, symptoms may be present for more than a year prior to determining the correct diagnosis. The runner describes chronic pain on the inside of the mid portion of the foot. This pain is often described as an ache in the arch region of the foot. There may or may not have been a specific injury that occurred in the past to cause the onset of pain. They may also describe a “giving-away” sensation while running. There may also relate a burning sensation in the medial aspect of the heel. This is from the irritated nerve causing chemical excitation of other nearby branches to the heel from the same posterior tibial nerve. On physical exam of the injured foot, there will be tenderness with palpation over the area of nerve entrapment just behind the navicular bone on the medial side of the foot along the arch. Tapping this area, otherwise known as a Tinel’s test, will recreate the athlete’s symptoms as the nerve is irritated. It is important that the alignment of the foot and heel are evaluated for the longitudinal arch.

How is Jogger's foot treated?
Once the diagnosis of jogger's foot (medial plantar neuropraxia) is made, initial treatment involves changing the mechanical forces at play that lead to the nerve irritation in the first place. A period of relative rest for the foot may be necessary to allow the irritated nerve to calm down. This can include the involvement of various non-impact cross-training exercises so that the athlete may maintain their cardiovascular fitness. The runner’s shoe wear must be evaluated for medial arch support as well as overall quality. Custom arch support inserts may be useful, however in some cases they may exacerbate the symptoms by placing further pressure on the irritated nerve. A running evaluation by a specialized sports chiropractor, physiotherapist, or practitioner knowledgeable in running mechanics is necessary to alter the runner’s gait in a fashion to relieve pressure on the medial aspect of the foot. Regular anti-inflammatory use is important to decrease the body’s inflammatory response and swelling at the entrapment site. Other medications that specifically target nerve pain may be useful as well. An injection of cortisone can be considered in the region of entrapment, however the proximity of the plantar fascia, and the possibility of it’s rupture, is always a consideration in endurance runners.

In the rare circumstance that a runner’s symptoms are not able to be alleviate with non-operative management as detailed above, then surgical treatment may be considered. This would include an incision along the medial border of the foot and the site of nerve entrapment is exposed. Part of the ligament (“naviculocalcaneal”) is released, such that the medial plantar nerve has more space surrounding it and less of a chance of further compression. Following surgery, there will be a period of relative immobilization of the foot and restriction on weight-bearing.

What is the long term prognosis of Jogger’s Foot?
The majority of runner’s with entrapment of the medial plantar nerve improve without the need for surgery. This usually requires months of non-operative treatment to alter the pressure over the area as well as retraining the athlete in their running technique. Due to the very rare nature of this injury, there are no large series of runner’s reported in the sports medicine research literature to give a specific timetable or determine the probability for full recovery.