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ESSENTIAL SKILLS buttock around the ischial tuberosity means that a part of the common tendon attaching the hamstring to the sit bone is affected. The tendons at the distal aspect of the hamstrings are quite long and can be strained anywhere from 4–6 inches superior to the back of the knee. And finally, the tendons can be strained at their distal attachments at the knee. The muscle belly may also become injured. In severe strains, both the tendon and muscle are injured. Injuries to the muscle belly may heal quickly because of the rich blood supply; however, these muscles often heal with poor scar-tissue formation, and a recurring problem can develop if appropriate treatment and/or rehabilitation exercises are not performed until healing has fully occurred. Hamstring tendon injuries heal more slowly and need more care because the blood supply is more limited. The initial injury often occurs while stretching or during running activities, especially when there has been no prior warm- up. The cold muscles resist stress when tension is suddenly placed on them, and fibers tear. This injury is also likely to happen if the muscle is fatigued. People tend to keep using the thigh and stretching it because it often gives temporary relief by freeing the scar tissue for a short period of time. Unfortunately, what usually happens is that these overexertions create more and more scar tissue until the thigh cannot be used beyond a certain point of exertion without pain. Confusion arises with hamstring injuries because similar pain patterns can be caused by injuries to the low back or hip joint. Differentiating the cause can be challenging even for highly trained and skilled health- care professionals. When a client has difficulty locating the precise location of the pain, or feels an amorphous pain deep within the back thigh, especially after prolonged sitting, it could be Confusion arises with hamstring injuries because similar pain patterns can be caused by injuries to the low back or hip joint. a referred pain phenomenon from the low back. A disc protrusion, or a ligament injury in the low back, could be causing the pain. For instance, when injured, the sacrotuberous and sacrospinous ligaments in the lower pelvis frequently refer pain down the back of the thigh and sometimes as far as the calf and heel. If the pain goes below the knee and into the calf, then the picture becomes clearer— hamstring tears don't refer pain to the lower leg. But if the pain is exclusively in the posterior thigh, assessing the problem can be confusing. Another tip is that if bending backward or sideways while standing recreates the pain, then it is more likely to be a back injury. Hip-joint injuries will also refer pain to the thigh, but usually the pain is felt deep within the thigh, and it is difficult for the person to bring the knee to the chest without significant pain. (For more details on how to differentiate back pain from hamstring injuries, see Ben Benjamin's webinars on low back and the hip and thigh, "The Mystery of Low Back Pain, Part 1," December/January 2006, 102–108; "The Mystery of Low Back Pain, Part 2," February/March 2006, 108–115; and "The Mystery of Low Back Pain, Part 3," April/May 2006, 106–111.) A hamstring injury can continue for months or years if not treated properly. A young athlete once came to me with a chronic hamstring problem and said, "I've been really stretching my hamstrings religiously—every day for seven months. I can't understand why it's not better." He showed me the stretches, which were done forcefully and without a warm-up prior to his routine. The lack of improvement he experienced resulted from this daily stretching. The improper stretching was tearing apart the new tissue that was forming; the fibers did not have time to heal and become strong. His stretching routine was creating more poorly formed scar tissue, causing mini- reinjuries. The original injury could have healed and disappeared with rest and gentle stretching and strengthening exercises, but it became chronic because of premature and too-vigorous activity. INJURY VERIFICATION In order to differentiate a hamstring injury from a low-back injury, a therapist would use several different types of tests to stress the muscle tendon unit. Pain or discomfort with an isometric movement against resistance tells you it's the hamstring that is injured. Pain while stretching the back thigh is a positive indicator, but this type of pain can also be associated with an injury to the low back. During testing, it is important to be aware that pain down the back of the thigh can be the result of a number of causes. A sciatica-type pain in the hamstring region can be caused by 96 massage & bodywork september/october 2011