Introduction

The Hamstring Masterclass, taught by Peter Brukner and Ryan Timmins, provides a complete summation of the management for Hamstring injuries. This Executive Summary provides relevant, actionable content from the clinical assessment to specific exercises that may be useful to health professionals.

Part 1: Differential Diagnosis and Grading

Hamstring injuries remain subject to a high occurrence across many sports, abundant research, and long absence in playing time. When assessing hamstring pain, it is important to consider possible referral from other sources, the anatomy of the intramuscular tendon, the mechanism of injury, different classifications of injury and the many possible risk factors.

• Two common areas which can refer pain into the hamstrings are the lumbar spine or the gluteal region, therefore the slump test is a valuable tool to assess whether the pain is referred or not.
• The Pollack et al, (2012) classification system divides the injuries into location and severity which is clinically helpful for practitioners.
• There are some modifiable risk factors including strength, fascicle length and high speed running and non-modifiable risk factors including age and previous injury to the ACL and calf complex.
  

Part 2: Clinical Assessment

The pillars of the hamstring clinical assessment are to do the basic things well. There has been a radical change in the history of acute management for hamstring injury from resting completely to avoid pain to early mobilisation and then a graded return to sprinting and strength training. The guide to reduce risk of recurrent injury remain with completing a robust rehabilitation program with a strong eccentric loading focus. Alongside of hamstring injuries, there are also the rare intramuscular tendon pathologies, which is not regarded the same as a free tendon as it acts as a central supporting strut to the surrounding muscle fibres.

• The clinical assessment should include the slump test, SLR test, strength test (bridge), palpation (lumbar spine, gluteal region, and hamstring muscle group from the origin to insertion).
• PRP injections are not any more favourable than a placebo saline injection, therefore as the current evidence shows, it’s probably not superior over a sound rehabilitation program.
• Managing recurrent hamstring injuries are multi-factorial and can be broken down into seven areas of: 1) Biomechanical correction, 2) Neurodynamics, 3) Core stability/neuromuscular control, 4) Eccentric strength, 5) Overload running program, 6) Injection therapies, and 7) Stretching/yoga/relaxation.
• Depending on the intramuscular tendon tear type (partial or complete), surgery may be indicated. The recovery will tend to be slower with an increased recurrence.
  

Part 3: Injury Prevention

Every injury is a learning opportunity. A comprehensive program should never overlook the basic exercises for the ‘new’ or ‘alternate’ exercises. Completing the basic tasks well are crucial when it comes to injury prevention. The practitioner needs to consider the DOMs induced from strength training and balance it with the athlete’s training schedule/load. Eccentric loading adds sarcomeres series to the muscle to distribute the load across longer fascicles.

• Nordic hamstring exercise with a focus on longer length eccentric loading is an effective method for reducing frequency of hamstring injuries by about 50%. It may be further challenged by holding onto a weight for increased load.
• Nordics or any eccentric loading exercise should be introduced in pre-season to condition athletes to the DOMs and build a resilient hamstring muscle group for achieving movements such as sprinting and jumping.
  

Part 4: Rehabilitation

A solid rehabilitation program to reduce hamstring injuries must include a range of exercises with a strong eccentric component and a sprinting aspect. The program must be intense enough and mirror the demands of the athlete’s sport to ensure they have been sufficiently conditioned. As reiterated multiple times in this masterclass, the program doesn’t have to be complicated and should follow the progressive overload principle.

• Nordics, DL/SL 45 degree back extension, bridges with differing lever lengths, stiff legged RDL, split stance RDL and the arabesque are examples of legitimate hamstring exercises.
• Considering match day sprinting demands in either meters or effort, it is crucial to match the amount during the rehabilitation plan and work closely with the other coaches to properly expose the athlete during their training.
• Progressing the rehabilitation program should be balanced between the athlete’s own advancement and the guideline. Depending on the athlete, lower load eccentric exercise may be implemented earlier following an injury than previously thought.