Still hamstrung, after all these years

The story goes that back in about the 1970s two high level bodybuilders agreed to a sprint race, and during that sprint race they both tore hamstrings.

This story entertained many, however I took a more serious lesson from it.

Combined with my observations of the shift in posture from the 1960s to the 1970s bodybuilder and took into account that the clients I served displaced further and faster that the average bodybuilder, alarm bells were ringing.

The development of the Lines of Movement Concept (especially the hip vs quad dominant component was a direct response to my concerns about injury potential from muscle balance. As was the introduction and innovation of bodyweight and unilateral exercises into strength training in a way that was considered unconventional at the time (however since 2000 have become the backbone of the so-called ‘functional training’ movement). [1]

Or you can learn about it second hand, however I suggest the power of the message may have been diluted in these versions.

That’s just not my biased opinion – that an observation of the direction of injuries globally.

So in the 1980s I committed to ensuring the muscle imbalances evident from mainstream strength training trends would not be part of the life of athletes I worked with.

Decades later I look back with confirmation that my Zero Tolerance approach to injuries, especially soft tissue injuries, has been successful.

Successful for athletes that I have worked with during the past four decades. However, the message, even with the concept being republished endlessly by others, has not been successful.

It appears humans are still struggling to prevent simple yet debilitating injuries such as hamstring strains.

These soft tissue injuries are predictable, preventable, unnecessary and non-productive.

Recently at an off-road motorcycling competition I observed a rider enter the pits prematurely and heard him declare he has torn his hamstring. I was more than intrigued, mixed with the usual compassion for the athlete. He had torn his hamstring on a motorbike?

As a student of injury prevention, not only did I provide care and guidance over the next hour, I tested my hypothesis as I typically do with a series of questions to the rider.

My conclusion – just another victim of mainstream training paradigms. He was buffed. Anyone male would be proud of the physique he had developed. But stretching? No, not much of that. I checked out his all-important quads and they were rocks. They looked great. A real Men’s Health model candidate. However, the rest of the body was suffering for the training outcome he had produced – especially the hamstrings.

At first he was keen to tell me had been tight all is his life. That was shut down quickly with his – and to his credit – acknowledgement he had not done much to change this.

Then he went down the path of ‘I am a rower and that is why I am tight’. That was shut down quickly when I raised some of the elite rowers I had worked with, and that I had failed to observe tightness as a common theme in rowers.

Once we got through the excuses and the defense mechanisms and got to hear how he trained – there were no surprise. He had absorbed the current paradigms of training and was just another victim of the times.

There is no shortage of statistics on the extent of hamstring injury; Here are a few collated by Eirale C. and Ekstrand (2019)[2]:

Epidemiological studies assessing sports constantly rank hamstring injuries as one of the most prevalent factors resulting in missed playing time by athletes.[3] [4] [5]
Hamstring ‘strains’ account for a substantial percentage of acute, sports related musculoskeletal injuries with a prevalence of 6 to 25%, depending on the sport. [6]
Hamstring strains are far more common in positions in which sprinting is more often required.[7] [8] [9]
A survey of the UEFA Champions League showed that muscle injuries make up more than 30% of all player injuries and cause about 1/4 of total time lost due to injury.[10]
Over 90% of muscle injuries seen in this study involved four major muscle groups of the lower extremity: hamstrings, adductors, quadriceps and gastrocnemius. [11]
Injury to the hamstring muscle group is reported to be the most common injury subtype representing 12% of all injuries and more than 1/3 of all strains.[12]
A professional male soccer team with 25 players may expect about five hamstring injuries each season, equivalent to more than 80 lost football days and 14 missed matches.[13]
In soccer injury to the hamstring muscle group is reported to be the most common injury subtype representing 12% of all injuries and more than 1/3 of all strains.[14]
In a track and field sprinting study the most frequent diagnosis was hamstring strain.[15] For example, thigh strain was the most common diagnosis (16%) in sports injury surveillance studies at the 2007, 2009 and 2011 IAAF (International Association of Athletics Federations) World Athletics Championships.[16] [17] [18]
In the American football muscle strains account for 46% of practice injuries and 22% of pre-season game injuries, the second most common pre-season injury.[19]
More than half (53.1%) of all hamstring injuries in American football occurred in the 7-week pre-season, before the teams had even played their first regular-season game.[20]

And there is also no shortage of claimed causes and preventions. Perhaps the most popular of these is described in the following statement:“The best evidence for injury prevention is available for programmes designed to increase hamstring strength, particularly eccentric hamstrings strength.”[21]

So, what impact have all these theories and research had on hamstring injury incidence?

“Despite a massive amount of recent research and consequent prevention programmes, hamstring injury incidence is not decreasing.” [22]:

I shake my head as to why the sporting world is still plagued by soft tissue injuries. Everyone now wants to be a ‘injury rehab specialist’ – yet no-one wants to be an ‘injury prevention’ advocate.

Perhaps it is understandable, when you search the ‘web you find so many articles, website and experts purporting to have the education to prevent hamstring injuries. I am very uninterested in theories. I want to know of sporting seasons with high volumes of athletes and minimal if any soft tissue injuries. That’s the only evidence that matters.

Soft tissue injuries such as hamstring strains are completely optional and unnecessary. It’s pretty easy to make them extinct or near extinct. Yet they continue.

Two things are apparent to me – the rise in soft tissue injuries, and the concurrent rise in funding and research on how to prevent them has been ineffective.

Yet the ‘search’ continues. The NFL has just allocated $4m USD (yes, 4 million) to:

“…fund a team of medical researchers led by the University of Wisconsin” to “investigate the prevention and treatment of hamstring injuries for elite football players.” [23]

The NFL has had only one century to solve the mystery of hamstrings…[24]

This statement was made in relation to this research:

“The persistent symptoms, slow healing, and a high rate of re-injury make hamstring strains a frustrating and disabling injury for athletes and a challenge for sport medicine clinicians to treat,” said Dr. Bryan Heiderscheit, PT, PhD, FAPTA, Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison.” [25]

I agree it would be frustrating for the athletes – if they were trained in a manner that resulted in hamstring strains. I agree it would be a challenge for sports medicine clinicians to treat – if they didn’t know how to prevent and rehabilitate them on the rare occasions they might occur.

However, I don’t agree with the following suggestion in relation to the recent NFL funding:

“To truly understand and reduce hamstring injury risk requires a study of an unprecedented size and scope.”

And what will it result in? Will it solve the leagues 100 years search for answers to hamstring strains? Let’s review the hamstring strain stats in the NFL in about a decade. That should be enough time.

I have my predictions, and I am sure they differ from those invested in the ‘research’ of hamstring strains. Our profession has been ‘researching’ hamstring strains for decades, and I suggest that it has not resulted in a downturn in hamstring incidence.

But you don’t need my opinion. The statistics tell the story.

It appears the world is still hamstrung, after all these years.

References

[1] You can learn more about these concepts in the original writings of How to Write (1998) and How to Teach (2000), the Legacy book (2018) or the KSI Coaching Courses.

[2] Eirale C. and Ekstrand, J., 2019, Hamstrings are dangerous for sport and sport is dangerous for hamstrings, Aspetar Sports Medicine Journal, Vol. 8, p. 438-444.

[3] Ekstrand J, Healy JC, Walden M, Lee JC, English B, Hagglund M. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med 2012; 46:112-117.

[4] Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001; 29:300- 303.

[5] Eirale C, Farooq A, Smiley FA, Tol JL, Chalabi H. Epidemiology of football injuries in Asia: a prospective study in Qatar. J Sci Med Sport 2013; 16:113-117.

[6] Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010; 40:67-81.

[7] Elliott MC, Zarins B, Powell JW, Kenyon CD. Hamstring muscle strains in professional football players: a 10-year review. Am J Sports Med 2011; 39:843-850.

[8] Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232

[9] Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release of data in the Australian football league. Am J Sports Med 2013; 41:734-741.

[10] Ekstrand J, Hagglund M, Walden M. In jury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011; 45:553-558.

[11] Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232.

[12] Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232.

[13] Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232.

[14] Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232.

[15] Jacobsson J, Timpka T, Kowalski J, Nilsson S, Ekberg J, Renstrom P. Prevalence of musculoskeletal injuries in Swedish elite track and field athletes. Am J Sports Med 2012; 40:163-169.

[16] Alonso JM, Junge A, Renstrom P, Engebretsen L, Mountjoy M, Dvorak J. Sports injuries surveillance during the 2007 IAAF World Athletics Championships. Clin J Sport Med 2009; 19:26-32.

[17] Alonso JM, Tscholl PM, Engebretsen L, Mountjoy M, Dvorak J, Junge A. Occurrence of injuries and illnesses during the 2009 IAAF World Athletics Championships. Br J Sports Med 2010; 44:1100-1105.

[18] Alonso JM, Edouard P, Fischetto G, Adams B, Depiesse F, Mountjoy M. Determination of future prevention strategies in elite track and field: analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance. Br J Sports Med 2012; 46:505-514.

[19] Feeley BT, Kennelly S, Barnes RP, Muller MS, Kelly BT, Rodeo SA. Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med 2008; 36:1597-1603.

[20] Elliott MC, Zarins B, Powell JW, Kenyon CD. Hamstring muscle strains in professional football players: a 10-year review. Am J Sports Med 2011; 39:843-850.

[21] Bahr, R., 2019, Prevention hamstring strains – a current view of literature, Aspetar Sports Medicine Journal, Vol. 8

[22] Eirale C. and Ekstrand, J., 2019, Hamstrings are dangerous for sport and sport is dangerous for hamstrings, Aspetar Sports Medicine Journal, Vol. 8, p. 438-444.

[23] https://www.nfl.com/news/nfl-scientific-advisory-board-awards-4-million-research-funding-hamstring

[24] https://en.wikipedia.org/wiki/National_Football_League

[25] https://www.nfl.com/news/nfl-scientific-advisory-board-awards-4-million-research-funding-hamstring

Ian King says:

September 7, 2021 at 01:51

Matthew thank you for your comments and questions.

In response to “…stretching is important as well as correcting unilateral imbalances.” Yes, absolutely.

In respsone to ” It seems your lines of movement give equal priority to quad dom/hip Dom exercises”. That would be the case if you started from a clean slate. When you start from an imbalanced position, then this is not the message. The theme that runs through my published education over the last four decades is to address imbalances. Additionally, individualized program – an act that is unfortunately rare despite decades of awareness of this ‘princeipt of training’ would result in many factors being considering in deterring the relative training balance between the two divisions of the lower body that I identified in the 1980s with the concept of hip and quad dominance.

In response to the question – “Is it your opinion that most of these athletes are performing quad Dom and neglecting hip Dom.” If you are referring to in their strength training, yes. If you are referring to in their stretching, I am not sure if they would be doing enough stretching under the current dominant paradigms to ascertain.

In addition to relative numbers of exercises, volume and sequence as they relate to created balance or addressing imbalance in the quad and hip dominant muscle groups, additional variables need to be considered, including but not limited to the way the exercises are executed, in both technique and placement on the continuums as published in ‘How to Teach Strength Training Exercises’, 2000.

In relation to “Would you suggest 2:1 hip dom:quad Dom to correct?” Whilst you are on track with your thinking, I would be reluctant to provide exact ratios as we are now talking about addressing individual needs, which will not be optimally served with generalized numbers. An individualized decision will best to reached by the coach, or the athlete, or both where there is a coach involved. Suffice to say the ratio should reflect the needs. To be clear, most athletes I start with these days are so unbalanced, unfortunately for them, they may be given no quad dominant exercises for a certain period of time. And there is no ratio when ‘0” is a number. It is just 0.

In relation to “..as stated in your programs just do hip Dom 1st in the week and 1st in the work out?” – sequence is an additional prioritization consideration – not an alternative. I expect a competent program designer, or an athlete who cares about their long term future (and they can even more competent in their decision making than the majority of ‘professional’ coaches) to include sequencing in all their decision making.

Designing an optimal program is a serious and advanced skill set. If a training protocol has the potential to either prevent injuries and or enhance performance, it also has the potential to do the reverse – create injuries and degrade performance. Training decisions including program design are huge responsibilities and, based on the rising injury incidence and severity, it’s safe to say the global profession is not taking this responsibility with the level of seriousness it deserves. First year med students don’t normally get the keys to the surgery room, yet anyone with an opinion gets to write training programs.

In relation to “Also, is there a test for this? ie deadlift should equal x% of squat?’. There are definitely ways I use and teach in our educational program to determine the level of imbalance and therefore influence the program design, however they take years to master. Mastery in program design should be the expectation, to protect the end user, but it is not. As to tests, I do not endorse the tests you refer to. The displacement of load is in itself an inadequate and inaccurate determinant of muscle balance. In respect to my late colleague, I have not addressed this at length in public domain since it was floated some 20 years ago, and only make this comment in response to your question. It is a good question, and the answer is an emphatic no, I don’t endorse that level of simplicity.

Trust this helps and good on you for seeking answers.

Ian King

Matthew Garrison says:

August 31, 2021 at 13:54

So, obviously stretching is important as well as correcting unilateral imbalances. It seems your lines of movement give equal priority to quad dom/hip Dom exercises. Is it your opinion that most of these athletes are performing quad Dom and neglecting hip Dom. Would you suggest 2:1 hip dom:quad Dom to correct? Or as stated in your programs just do hip Dom 1st in the week and 1st in the work out? Also, is there a test for this? ie deadlift should equal x% of squat. I remember Poliquin used to have some recommendations, but don’t remember where that was I read it or if it was an audio interview/podcast

Ian King says:
September 7, 2021 at 01:51

Matthew thank you for your comments and questions.

In response to “…stretching is important as well as correcting unilateral imbalances.” Yes, absolutely.

In respsone to ” It seems your lines of movement give equal priority to quad dom/hip Dom exercises”. That would be the case if you started from a clean slate. When you start from an imbalanced position, then this is not the message. The theme that runs through my published education over the last four decades is to address imbalances. Additionally, individualized program – an act that is unfortunately rare despite decades of awareness of this ‘princeipt of training’ would result in many factors being considering in deterring the relative training balance between the two divisions of the lower body that I identified in the 1980s with the concept of hip and quad dominance.

In response to the question – “Is it your opinion that most of these athletes are performing quad Dom and neglecting hip Dom.” If you are referring to in their strength training, yes. If you are referring to in their stretching, I am not sure if they would be doing enough stretching under the current dominant paradigms to ascertain.

In addition to relative numbers of exercises, volume and sequence as they relate to created balance or addressing imbalance in the quad and hip dominant muscle groups, additional variables need to be considered, including but not limited to the way the exercises are executed, in both technique and placement on the continuums as published in ‘How to Teach Strength Training Exercises’, 2000.

In relation to “Would you suggest 2:1 hip dom:quad Dom to correct?” Whilst you are on track with your thinking, I would be reluctant to provide exact ratios as we are now talking about addressing individual needs, which will not be optimally served with generalized numbers. An individualized decision will best to reached by the coach, or the athlete, or both where there is a coach involved. Suffice to say the ratio should reflect the needs. To be clear, most athletes I start with these days are so unbalanced, unfortunately for them, they may be given no quad dominant exercises for a certain period of time. And there is no ratio when ‘0” is a number. It is just 0.

In relation to “..as stated in your programs just do hip Dom 1st in the week and 1st in the work out?” – sequence is an additional prioritization consideration – not an alternative. I expect a competent program designer, or an athlete who cares about their long term future (and they can even more competent in their decision making than the majority of ‘professional’ coaches) to include sequencing in all their decision making.

Designing an optimal program is a serious and advanced skill set. If a training protocol has the potential to either prevent injuries and or enhance performance, it also has the potential to do the reverse – create injuries and degrade performance. Training decisions including program design are huge responsibilities and, based on the rising injury incidence and severity, it’s safe to say the global profession is not taking this responsibility with the level of seriousness it deserves. First year med students don’t normally get the keys to the surgery room, yet anyone with an opinion gets to write training programs.

In relation to “Also, is there a test for this? ie deadlift should equal x% of squat?’. There are definitely ways I use and teach in our educational program to determine the level of imbalance and therefore influence the program design, however they take years to master. Mastery in program design should be the expectation, to protect the end user, but it is not. As to tests, I do not endorse the tests you refer to. The displacement of load is in itself an inadequate and inaccurate determinant of muscle balance. In respect to my late colleague, I have not addressed this at length in public domain since it was floated some 20 years ago, and only make this comment in response to your question. It is a good question, and the answer is an emphatic no, I don’t endorse that level of simplicity.

Trust this helps and good on you for seeking answers.

Ian King

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