Hamstring Pain and Dysfunction

About Hamstring Pain and Dysfunction

The muscles at the back of your thigh are critical for proper stability and efficient movement. As an essential part of your lower kinetic chain, pain and dysfunction in your hamstring muscles can throw your gait off, altering your static and dynamic posture and increasing your risk of injury. Due to the interactive nature of the body’s structures, hamstring issues can cause pain and dysfunction in other areas of your body, and vice versa.

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Hamstring Anatomy and Function

Your hamstrings are a group of three muscles at the back of your upper leg. Because the hamstrings cross over two joints, they perform a dual function: knee flexion and hip extension.

Biceps femoris

— muscle has a long and a short head, and runs down and across your posterior thigh. The two heads share a common tendon at the back of your knee that attaches to the head of the fibula of your lower leg. The biceps femoris long head originates from the ischial tuberosity of your pelvis. The short head originates at the posterior surface of your femur, or thigh bone.


— is a tendinous muscle that runs the length of your thigh next to the biceps femoris. Like the biceps femoris, the semitendinosus originates from the ischial tuberosity of your pelvis, but the distal end attaches to the medial surface of your tibia.


— is a broad flat muscle located beneath the semitendinosus. It also originates from the ischial tuberosity, but slightly farther up, and attaches to the medial tibial condyle.


The hamstring muscles are innervated by the sciatic nerve that descends from your lumbar spine and runs down the back of your upper leg.

Common Hamstring Injuries

Sports-related hamstring injuries are the most common athletic injuries, occurring frequently in sports like sprinting, soccer, baseball and American football. Many injuries occur at the musculotendinous junction (MTJ) where the muscle, tendon and bone converge. In general, the closer the injury is to the MTJ, the longer it will take to heal and regain function.

Some of the most common hamstring injuries include:
Hamstring nerve pain (hamstring syndrome)

Hamstring nerve pain can be caused by entrapment or impingement of the sciatic nerve as it descends from the low back and down the back of the leg.

Partial thickness tears

Partial thickness tears of the muscles and tendons occur from overuse, where the tissues are loaded beyond their capacity to contract against force.

Proximal avulsions

Proximal avulsions result from forceful muscle contractions that cause a fragment of bone to break, tearing it away from the main body of bone. Sports like dancing, skiing and skating often see a fracture, or avulsion, of the ischial tuberosity of the pelvis.

Proximal tendinopathy

Proximal tendinopathy, where the hamstring tendons nearest the buttocks are damaged from overuse, causing chronic pain and dysfunction.

Muscle strains

Muscle strains, where muscle fibers are stretched and torn. Athletes in running and kicking sports often experience muscle strains. In some instances, blood vessels are also torn, causing a hematoma to form.

Older adults

In addition to athletic injuries, the incidence of hamstring pain and dysfunction in older adults appears to correlate with age-associated deterioration of tissues.


How Lumbar Problems can Lead to Hamstring Issues

Because of the connected interactions of the muscles in the posterior kinetic chain, pain in the hamstrings can sometimes stem from lumbar problems. Back pain caused by a herniated disc, piriformis syndrome or sciatica can also impact the hamstrings, since those conditions are all caused by pressure on the sciatic nerve.

Because the same nerve innervates the muscles of the buttocks and hamstring, lower back pain can cause weakness and dysfunction anywhere along the lower kinetic chain. While traditional medicine often zeros in on and treats the locus of pain, the physical therapists at NYDNR take a more global approach, and explore the hamstring-back pain connection.

Diagnosis of Hamstring Problems

Diagnosis of hamstring injuries begins with a physical exam. Patients often report pain in the back of the leg, especially during running as they kick the injured leg backward. Sitting may also be painful. Pain can manifest anywhere along the hamstring, but it most often occurs near the MTJ. In addition to pain, the patient may have swelling and bruising.

Hamstring injuries are graded and categorized by severity:
Torn or damaged tissues, with no reduction in strength
Moderate damage to tissues with some loss in strength
Severe injuries with tissue ruptures or avulsions, with significant loss of strength

At NYDNRehab, we are able to precisely measure hamstring strength with our high-tech Kineo Intelligent Load system. It allows us to compare strength between the injured and non-injured leg in both concentric and eccentric phases of muscle contraction.


We confirm our diagnosis with high resolution diagnostic ultrasound. High resolution imaging enables us to view the structures of the hamstring and low back in real time, with the patient in motion.

Ultrasound lets us travel the length of the sciatic nerve to look for damage or entrapment. It also enables sonoelastography, to gauge the relative elasticity of damaged tissues. Because ultrasound imaging takes place in real time, we do not have to wait days for lab results to initiate an effective treatment plan.


Hamstring and Low Back Treatment at NYDNRehab

Hamstring injuries can take a long time to heal, and a wrong diagnosis can lead to the wrong treatment, drawing out the healing process. Once we arrive at a precise diagnosis, we incorporate the most advanced rehab technology into your treatment plan.


The high-tech equipment at NYDNRehab lets us quantify your performance and progress, taking the guesswork out of therapy. We examine your movement patterns from head to toe, to ensure that any motor deficits are identified and corrected. Our goal is to speed up healing and recovery, so you can get back to sport in the best shape ever.

Telehealth for Rehab

Telehealth is the newest buzzword in medicine, and physical therapy is no exception. Patient visits, therapeutic exercises and more can be done remotely, saving you from having to make an in-person visit. Whether you’re traveling for work or just staying safe at home, ask us about Telehealth to keep your therapy on track.

Telehealth for Rehab
Lev Kalika Clinical Director and DC, RMSK

Dr.Kalika has revolutionized hamstring pain care by using high resolution diagnostic ultrasonography for structural diagnosis, combined with gait and motion analysis technology. The NYDNRehab motion and gait analysis lab is the only private lab in the US to feature research-grade technologies found only in the world’s top research labs, and made available to patients in our private clinic. Dr.Kalika’s modern approach to athletic hamstring pain and injuries has put him on the radar of some of the world’s top distance runners, pro athletes and professional ballet dancers.

Our Specialists

Dr. Mikhail Bernshteyn MD (Internist)
Dr. Michael Goynatsky DPT
Dr. Daniela Escudero DPT
Dr. Michelle Agyakwah DC
Dr. Tatyana Kapustina L. Ac.

How Lumbar Problems Can Lead to Hamstring Issues

Commonly referred to as the hamstring in the singular, medically speaking this term refers to three different tendons or elasticized muscle tissues that connect the muscles of the rear side of the upper half of the lower extremity as well as referring to the muscles themselves between the upper space above the knee to the hip extensions. Although the lower back is not directly connected to the hamstrings, medical experts have published a number of scientific breakthroughs that show a direct linkage between the health of the lumbar spine to hamstring pain.

A common form of lower back degeneration is known as sciatica, a condition that can be directly correlated to a prolapse of one of the spinal discs or due to general degeneration of the lower back muscles and related pathologies. Primarily associated with radiating pain originating in the lower back that spreads outwards through the buttocks and calves, sciatica can also be implicated in hamstring pain as well. Medically speaking, there is a special nerve located at the L5 area of the spine that connects via a number of pathways to transmit discomfort onwards that can result in hamstring strain. Even though the hamstring muscle is not directly damaged due to an L5 spinal wound, it is possible for the sensation of pain to travel downwards from the lower back to be received by the hamstring muscle group.

The primary target of research in this emerging field of medicine is with athletes. Sports medicine experts have consistently documented that older individuals who participate in sporting activities can develop a number of strains, including a hamstring strain. Over time, it appears that elderly sportsmen demonstrate a statistically higher risk of developing a predisposition for incurring damage to their hamstring muscle group as a result of degeneration and/or damage to the lower back area. It is significant that a confirmed diagnosis of spinal disc degeneration between L4 and L5 or between L5 and S1 has shown to transmit nerve damage and accompanying discomfort further on down to the hamstring muscle group while areas of degeneration and/or damage to higher segments of the spinal cord do not demonstrate the same correlation.

Concomitant analyses of deceased individuals through the process of autopsies have clearly shown that hypertrophy of the lower back spinal ligaments corresponds positively to a hamstring injury as well. As an academic inquiry into this field is continuing to be conducted, sports medicine experts warn that much more research is needed before demonstrating such a correlation definitively can be executed with living individuals suffering from a hamstring injury simultaneous with lumbar back degeneration.

Currently, a hamstring injury directly related to degeneration and/or damage to the lumbar back is predominantly diagnosed by the collective weight of a group of different symptoms. Any individuals who experience the discomfort of a chronic hamstring injury and/or discomfort in the calves of the lower extremities in combination with demonstrated lumbar spine degeneration along with regular reports of feeling like the muscle groups in the lower extremities feel tight or inflexible may show a positive correlation between the two types of injuries. When sportsmen present to medical personnel with positive symptoms of tightness in the hamstring but fail to show any demonstrable deterioration of the muscle group after undergoing a magnetic resonance imaging scan are most likely experiencing minor nerve impingement being transmitted downwards from the vertebral canal. An MRI scan which identifies degeneration of the lumbosacral ligaments in combination with hamstring discomfort is often considered as conclusive proof of this nerve damage impingement correlation.

Treating nerve damage impingement to the hamstrings from lumbar spinal problems first must rule out a direct injury to the muscle groups of the lower extremities. In the case of no identifiable damage or degeneration to the hamstrings themselves but with a positive identification of lumbosacral difficulties, the current best practices treatment is the prescription of an anti-inflammatory medication. This procedure does not work directly on the nerve cell clusters themselves but instead works to consolidate soft tissue volume and thus indirectly allow the less overall mass to reduce nerve impingement. In addition to the use of anti-inflammatory medications, a more targeted approach is to inject cortisone directly to the affected area but this choice is often less ideal because it requires very precise guidance to direct the injection and is classified as a semi-invasive procedure.

On the strength of the fact that anti-inflammatory medications simultaneously retard healing and the eradication of scars, the prescription of these compounds for a standard injury to the hamstrings is not generally recommended. Instead, a series of targeted physiotherapeutic techniques such as stretching can help minimize the transmission of nerve impingement shows better promise for direct injuries to the hamstrings. Only with a confirmed imaging scan showing no direct evidence of direct injury or degeneration to the hamstrings in combination with a diagnosis or known case of lumbosacral degeneration should medical personnel consider a therapeutic course of anti-inflammatory medications to reduce discomfort in the hamstrings resulting from relayed from nerve impingement elsewhere in the body.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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