Hamstring Injuries: Everything Climbers Need to Know (Rehab and Recovery)
Hooper’s Beta Ep. 50
Intro
The almighty hamstring muscles. Important for walking, hiking, sprinting towards the crag, slowing down after you’ve sprinted towards the crag, jumping for joy that you’ve reached the crag, and oh yeah, the mighty heel hook.
But in reality, the hamstrings are crucial, especially for outdoor rock climbing. As Emile likes to point out, basically every good climb has a heel hook in it. The hamstrings help stabilize our hips, and lock those heels in to help us send some of the hardest problems we have. But, the hamstrings and the injuries that may accompany them are not as straightforward as you might think…. Until you understand the anatomy of them. Understanding the anatomy will help you determine what may have caused your injury, how to test for it, and what you need to do to heal from it! So, let’s start by getting into some Anatomy.
Anatomy
Let’s start with the basics, there are actually 4 hamstring muscles -- two on either side of our knee.
Two of them on the outside or lateral aspect of the knee, and two on the inside or medial aspect. The two muscles on the lateral side are the Biceps Femoris Long Head (BFLH) and Biceps Femoris Short Head (BFSH). The two on the inside are the Semitendinosus (ST) and Semimembrinosus (SM). Now, the hamstring has two primary purposes, flexing the knee and extending the hip.
So, the genius that is the human body, there’s one muscle on each side that does a better job at each one of those tasks. For the two lateral muscles, the BFLH is better at hip extension and the BFSH is better at knee flexion. For the two medial muscles, the SM is observed more as a hip extensor and the ST more of a knee flexor. So, if you group them together the BFLH and the SM are more hip extensors while the BFSH and the ST are more knee flexors. Together, the 4 muscles act as an amazing unit to help with knee flexion, hip extension, stabilizing the tibia with both internal and external rotation, and stabilizing the hip. And again… they are also amazing at heel hooks.
TL;DR -
Dominant knee flexors = BFSH and ST
Dominant hip extensors = BFLH and SM
Now, we talked about knee flexion and hip extension, but I also just said that they help with stabilizing the tibia with both internal and external rotation, so what does that mean to us with climbing? Well, the two muscles on the outside of the knee, the Biceps femoris short and long head, help stabilize with external rotation, and the two on the inside, the semimembranosus and semitendinosus help with internal rotation. This is important as we are moving through our heel hooks and forcing the hamstrings to handle different angles. Imagine a climb where you start with a high heel towards your hand.
When you get into the first position, you may be creating more force on the two lateral muscles, whereas when we start to move away from the heel, the leg straightens and may even rotate some as we transition to the inner muscles. The multi planar motion that the hamstrings control becomes important as we talk about causes of injury and how we heal from them, including our rehab exercises.
So, we know how important the hamstring is to climbing now, what might cause an injury?
Causes
Simply put, a hamstring injury is caused by forcing the tissue to handle more load than it is capable of handling. So, why are we exposed to hamstring injuries as climbers? Again, it is simple, we are placing too much force on the tissue, often times without properly preparing it. This comes in the form of training and warming-up mistakes.
Think about your average gym session, if you’re lazy about your warm up you just hop straight on the wall, if you’re good about your warm up, you usually warm up your upper body but might not touch the legs. If you’re great about your warm up, you’ll add in some time on the stationary bike to get the legs and cardiovascular system fired up. If you’re not doing any sort of warm up for the hamstrings but expect them to hold up half your body weight on the wall, you're setting yourself up for an injury.
The other cause is improper training. Now that we know the anatomy of the hamstrings, we know that they are integral components for a variety of movement and stabilization of our lower body. If you don't understand those functions, you won't know how to train them. You may be limiting yourself to certain one dimensional exercises that don't appropriately train all aspects of the hamstring muscle group.
Take the Stiff-leg deadlift or the T pose / Warrior 3 for example. While this is a great exercise, it doesn’t activate and train all four of the hamstring muscles, nor does it place the unique stressors on the muscles like we do with climbing. In other words, this exercise is too one dimensional for climbers. BUT, we can make it better by making it multidimensional. We can reach our hands to 3 different positions to create rotation and bias the muscle groups that help control that rotation. That way they get individual training and are more accustomed to the different pressures we place on them when climbing. Essentially, you are preparing the tissue for the task they may face. This is also known as functional training; preparing the body to do the task you want it to by training it in a similar function.
Another common mistake is not training the knee flexors, that’s where Nordic Hamstring curls come in (which we will discuss further in the prevention section later). You can’t just do dead lifts and stiff leg single leg dead lifts to completely train all aspects of the hamstrings, and in fact, if you are…. You’re making a mistake. Many of our heel hooks depend on the BFSH and the ST as we realized earlier when discussing how those two muscles are more important in knee flexion, so let’s train them properly! But first, let’s move on to testing for an injury.
Testing
Now, let’s talk about testing for a hamstring injury. Just as a reference, we will have all of the tests results laid out in a nice table at the end of this segment and in the show notes so you can more clearly understand your results and paint a better picture of your findings.
Again, knowing the anatomy of the hamstring helps us understand how to test for an injury. We will use that information to determine which muscle we injured and how that will help us with our treatment. But before we get to that, let’s break down how we will test our injury with observation, palpation, range of motion, and tissue loading
Observation
The first step is simple observation. You will look for deformities, swelling, and/or bruising.
If you have pain and there is a significant deformity, such as a “lump” or other irregularity, you may have a tear of the muscle.
More obvious will be bruising. The hamstring muscles are quite vascular, so a tear will likely result in some bruising. The extent of the bruising may be an indication of the level of tearing. Finally, look for swelling. If you notice significant swelling you may have a tear.
If you notice a deformity and a bruise? You don’t need to test further, you likely have a tear and will need to seek professional help to further evaluate the injury and develop an appropriate and safe plan of care.
Palpation
If you don’t have significant indicators with your observation test, the next step will be palpation. Palpation is simply using the hands to check the body structures for abnormalities, pain, swelling, etc. You’re going to want to focus your palpation on the hamstring muscle origin for 3 of the 4 muscles, which is at the ischial tuberosity. You will also investigate the muscle body itself and finally palpate at the insertion sites on either side of the knee. Findings during the palpation section will help guide your results but are not definitive themselves. Take a note of where you feel the pain and then use those results to help piece everything together in the results section.
Range of Motion
Before we get to the final stage of testing -- tissue loading -- you will want to go through some basic range of motion tests. First, simply try and extend your leg behind you. If you cannot perform this or have significant pain, do not load the tissue at this time. If you can perform this movement, you will want to then try and flex your knee. If you can do this without pain as well, you can move onto tissue loading. If either of these cause discomfort, you do not need to go onto tissue loading. You have already loaded the tissue against gravity and may have enough information to determine the extent of your injury and you should look to the results section to see if your findings match up with a specific muscle.
Tissue Loading
If you were able to go through full range of motion with mild or no pain, now is the time to test your ability to load the tissue. To accomplish this, you need to simply push against something that won’t move, allowing you to create an isometric contraction. An isometric contraction is beneficial as you can slowly increase the amount of force you create, stopping if you have pain.
The first isometric tissue loading will be done by keeping your knee straight and simply trying to extend your leg behind you, pushing into a wall, as an example.
This will put slightly more strain on the biceps femoris long head and the semimembranosus. If this loading creates pain, it is likely one of those two muscles. If you have no pain with this or just mild pain with heavy pressure, move on to testing with the knee bent.
The second isometric tissue loading will be the bent knee flexion test. The easiest way to test with the knee bent without help of another person is to simply sit in a chair and press/dig your heel into the floor. Pain with this test may be more indicative of biceps femoris short head or semitendinosus pain.
To reiterate, you want to slowly increase the force you generate as you perform either of these tests. If you start to feel pain, you do not need to generate more force. A mild injury will require higher force before pain whereas a more significant injury, such as a tear, will produce pain with minimal force.
Results
So, now that you have gone through all of your tests, here is what you would expect for each muscle
The biceps femoris long head is the most commonly injured hamstring muscle, and as such is the one we will discuss first. Findings with this may include
bruising at any site of the posterior, or back of the thigh, but may be more lateral than medial (lateral = outside, medial = inside) .
Pain may be provoked with palpation to the lateral knee, ischial tuberosity, or throughout the muscle group.
Range of motion and tissue loading may be worse with hip extension rather than knee flexion, but pain with both hip extension and knee flexion are possible.
The biceps femoris short head is the next muscle we will talk about. Here are the total symptoms you would expect are
Bruising mid thigh or further down the leg towards the knee, may be more lateral than medial
Pain provoked with palpation to the lateral knee or mid posterior thigh
Range of motion and tissue loading may be worse with knee flexion, but NOT with hip extension.
Now, let’s talk about the other two hamstring muscles on the inside of the thigh.
The semimembranosus will have some similarities to the biceps femoris long head with range of motion and tissue loading testing, but our findings will differ in location from the long head. The symptoms you would expect are
Bruising at any site of the posterior, or back of the thigh, but may be more medial or on the inside
Pain may be provoked with palpation to the medial knee, muscle body, or ischial tuberosity.
Range of motion and tissue loading may be worse with hip extension rather than knee flexion
The semitendinosus will have some similarities to the biceps femoris short head with it’s range of motion and tissue loading, but will also differ in location from the short head. You will expect
Bruising at any site of the posterior, or back of the thigh, but may be more medial or on the inside
Pain may be provoked with palpation to the medial knee, muscle body, or ischial tuberosity.
Range of motion and tissue loading may be worse with knee flexion rather than hip extension.
In the show notes we will have a summary of the findings of the test to help guide your decision making process.
Treatment
For the treatment section, we are going to break this down into three stages: acute, subacute, and chronic/remodelling. The acute stage will be the first week or two post injury, subacute 2-3 weeks, and chronic/remodelling thereafter. This section will be referring more to a hamstring strain, and a partial tear, not a full tear or avulsion fracture. A full tear or an avulsion fracture are not covered in this as they warrant orthopedic evaluation and and may even require surgery. If this is the case, your rehab will be guided by your orthopedic surgeon and your rehab team.
Acute phase
Tissue mobility
In the early stages one of the best things you can do is simply to mobilize the tissue, this means using your hand, a rolling pin, or even a foam roller. Be gentle and don’t create pain. The purpose is to simply keep the tissue mobile and possibly help redirect blood flow to assist with your healing.
Range of motion
If you discovered from your testing earlier that your range of motion was pain free, it is OK to go through a range of motion that is just that, pain free. Don’t push your range to a painful point. Your range of motion will improve faster with higher repetitions of pain free mobility, not by trying to push through the pain. The pain is a warning and if you push into it, you will cause more guarding and discomfort.
If you are recovering from a more severe injury, don’t do this until you have been given clearance from your medical professional.
Frequency
You can do both tissue mobility and range of motion multiple times a day, even up to 5 times a day, but at least do it once or twice to help keep the tissue mobile. I like to do it for 2-5 minutes at a time or whatever feels natural for your body.
Subacute Phase
Bent and Straight Leg Stretching
Barring a more significant injury, the subacute phase is a good time to start gentle stretching. You will want to start with basic straight leg and bent knee hamstring stretching.
The straight leg hamstring stretch is one we may be more familiar with, but I want to introduce a more advance movement into it. Start by propping your leg up on a chair, couch, step, etc. Without rounding your back, bend forward at the hip until you feel a GENTLE stretch in the back of the leg. You will likely feel this stretch more towards the back of the knee. Once you have achieved this, you will want to rotate your foot internally and externally (in and out). This will target the inner and outer hamstring muscles more. I call these the “windshield wipers”
Next, the bent leg hamstring stretch. Let’s not forget all that great anatomy we learned earlier. We need to bias the other hamstring muscles that focus more on knee flexion. This is where the bent knee stretch comes into play.
Start again by placing your foot up onto an object BUT keep the knee bent this time. Next, bend at the hip as far as you comfortably can, bringing your chest towards your thigh. Then, start to straighten your knee. You should feel a stretch BEFORE you can fully extend the knee. This stretch should feel different than the straight leg stretch and should be more in the muscle body of the leg. Just like with the straight leg stretch, we want to do an advanced version here as well. To make it more advanced, you will shift your hips left to right which will create a small amount of bias.
Frequency and hold time
You can do gentle stretching 2-3 times a day. Try to spread it out throughout the day to keep the tissue healthy and mobile. Start with a few shorter holds (5-10 seconds) and work into 1 or two longer holds for up to 30 seconds.
Gentle strengthening: hip extension & knee flexion isometrics
To start our strengthening off safely, we will begin with some basic isometrics. We will do heel digs and hip extensions against an immobile object to accomplish this. This will allow you to assess your ability to generate force before you go into your harder exercises.
To perform gentle heel digs, simply dig your heels into the ground while sitting. You will immediately feel the force generated in your hamstrings. It’s great to do this at varying angles as well to generate different loads.
Now, let’s do some isometric hip extensions. To do this, all you’re doing is pushing the heel into the wall or other immobile object. You will feel your glutes and hamstring engage with this (and probably your core as well to help stabilize your body).
Frequency, sets, and reps
With these more gentle, early exercises, you can do them daily or even twice daily. Perform two or three sets of 10 reps, holding for 3-5 seconds.
If you can perform both exercises at full force and without pain, you want to move onto hip extension and knee flexion with a resistance band.
Gentle strengthening: hip extension & knee flexion with band
The late subacute phase is a good time to start trying to advance your tissue loading in small increments. To accomplish this, we will add in resisted hip extension and resisted knee flexion exercise.
Hip extension with band:
Place the band at your ankles, use a table or counter to balance at and stand on one leg. Move the non-weight bearing leg backwards. DO NOT extend too far, you will most likely just engage your lower back and cause discomfort. Also, use the table to counter your movement so you are not leaning forward to get more movement. This is a small movement. Perform 12-16 reps with 1 second holds on both legs and then move immediately from this stretch to the knee flexion exercise.
Knee flexion with band:
Now, simply stand on the band on one leg while keeping it around the ankle on the other. The leg with the band around the ankle will flex at the knee, while you continue to stand on the other leg. Think about trying to touch your butt with your heel. Perform 12-16 reps with 1 second holds and then switch legs.
Frequency, Repetitions, and sets
We want to start conservative here, so perform gentle strengthening every other day, allowing for proper rest. As you increase the difficulty of the exercises, reduce to 3 times per week.
Shoot for higher repetitions with less force so between 12-16 repetitions. More repetitions is better in this case so you can stimulate healing without risking injury. Shoot for 3 sets.
Chronic/Remodeling Phase
Strengthening: stiff leg deadlift & nordic curl
As we progress through the subacute phase safely, and enter into the chronic/remodelling phase, we want to start rehabbing the injury. This means functional training and training that will cause additional tissue adaptation to help restore function and prevent a future injury. That will be accomplished with the stiff leg deadlift and the nordic curl
Stiff, Single Leg Dead Lift
To perform the Stiff, single leg dead lift, start by standing on one leg with it very slightly bent (just think “soft knees not locked knees”. Tighten your core like you’re putting on a tight pair of jeans, then bend forward at the hip, NOT rounding your back. Keep reaching forward until you feel tension in the hamstring or back of the thigh. USE this tension to lift yourself back up until you are fully erect. Again, make sure the core is engaged to not lift with your back. As you get towards the top of the motion, make sure to squeeze your gluteals (butt muscles) as well to finish the movement. Next, perform the same motion but perform repetitions where you reach slightly to the left and slightly to the right. This will cause a bit of bias to load the medial and lateral muscles to train them more independently.
Nordies! (Nordic Curls)
Next, we discuss the Nordic curl (or as I love to call them, Nordies!) Typically this is done stabilizing at the lower leg by the calf either with a partner or a machine, bench, etc. But we don’t need it! All we need is a wall. Using a pad for your knees, scoot your feet back close to a wall. Keep your foot dorsiflexed (or with the toes pulled up toward your face). Once you are as far back as you can you are in your starting position.
Next, and this is REALLY IMPORTANT, engage multiple muscle groups. You want to engage your core and squeeze your glutes. This creates stability in the midsection before you go into the exercise. Then, slowly lean forward and feel the huge engagement in the back of the legs. Start with very small motions to warm the muscle up before you go further and further. Try not to reach a failure point where you fall forward until you performed at least 8 reps. Then, if you are not too fatigued, it’s OK to have a “failure” rep where you go to max range and fall forward.
Note: if you are newer to the exercise, or have a more significant injury, don’t go to the failure point early on.
BONUSES! To make this exercise more fun and challenging as you progress, you can alternate to a single leg, and you can also reach your chest forward, to the left, and to the right, just like you did with the stiff leg deadlift. Hit all the muscle groups! They are super helpful and will help your rehab and your overall training.
Frequency and Repetitions
Now that we are in the chronic / remodeling phase, we want to apply heavier forces (may need to add weight) which means we need longer times to recover. I recommend doing the exercises 2, MAYBE 3 times a week. Let your soreness factor in. If you do these exercises and produce good muscle soreness, wait until that dissipates completely before your next training session. Repetitions should aim for 8-12 for this phase with 3-4 sets.
Prognosis and Outcomes
Prognosis for this injury is great…. If you do something about it. Don’t be like the people who sprain their ankles, never re-train them, and then wonder why their ankle always hurts.
The chance for a recurring hamstring injury is high if you don’t do anything about it. If you hurt your tissue it will get weaker. Not only that, but if you hurt it, it was probably weak in the first place. So, if you don’t do anything about it, you can expect to injure it again. BUT, with appropriate training, as we talked about previously, you can significantly reduce the risk of a re-injury and you can even identify a weakness in your training which may even improve your climbing abilities. You play the significant role here. Be patient with your recovery, work on prevention techniques, and you can return to full prior level of activity.
If you have a hamstring strain, you can expect within 2-3 weeks to be performing most activities such as walking and stairs without pain but you may not feel strong and powerful again with climbing for 6-8 weeks.
If you have more of a partial hamstring tear you can expect weakness and some pain possibly for 4-6 weeks, with a return of strength with activities within 8-12 weeks.
OK, we know so much about the hamstrings now, but what if we are just here because you love the channel and learning, and don’t even have an injury? Well, we can learn about prevention.
Prevention
Fortunately, the research out there is quite clear in many regards, the way to prevent a hamstring injury is to train them. Unfortunately, this is where the first mistake is made and is the first component of a prevention program: simply training the hamstrings. I mean, how many people actually focus on training their hamstrings for climbing? Sadly, it is low, which is crazy because they are so important for climbing. Unfortunately, they tend to get grouped into the “leg day” category which many climbers avoid. Train those hamstrings! Make sure they are strong and can handle the forces you place on them while climbing.
Another mistake and the second component of a prevention program is not working all of the muscles of the hamstring. As you should understand now, we need to train the hamstrings in multiple positions and in multiple angles. Some training programs are incomplete and may focus only on straight legs, or only on bent leg strengthening. They may only perform them in one plane of motion and not produce the more realistic multiplanar motions that we perform while climbing. The best approach is to include both straight and bent leg hamstring activities which incorporate multiple planes of motion, such as the ones we discussed in the treatment section.
I’m a huge fan personally of the Nordies because of its close proximity to what we do with heel hooks and rock climbing. It has also been shown time and time again to have preventative effects when studied in different athletic populations. It’s a great tool to throw into your arsenal for training and prevention.
Now, that’s not to say that straight leg training isn’t also important, and that’s the 3rd component or our prevention program. We want to do straight leg eccentrics. You see, research has shown that working the long chain, which means training the muscle in a lengthened position rather than a shortened one, is also an effective way of preventing injuries. Which makes sense for climbing because often times we may start with a very bent heel hook but then move into a longer, extended position. So not only does research support it, but it also makes sense for how we move with climbing. So, doing something like a stiff-leg deadlift with a slow eccentric movement is a vital tool for climbers. It involves two preventative components, eccentrics and long chain activities. Win win.
Both methods were reviewed in the treatment section and are two easy ways to help prevent a future hamstring injury.
Finally, the 4th component is simple: Do a proper warm up! Properly warming up your hamstrings before climbing will go a long way towards preventing an injury. Whether it be 5-10 minutes on the bike, a quick jog, or some mini nordic hamstring curls, warm em up before you decide to place half of your body weight on them.
In summary of our prevention program:
We need to actually incorporate hamstring training into our training program
We need to do complete exercises including nordic curls and straight leg hamstring activities
We need to do long chain and eccentric activities
And we need to actually warm up before just expecting them to handle our entire weight.
Summary
OK, so we have talked about soooo much in this video. We reviewed anatomy, causes of injury, treatment, and even prevention. I hope you come away from this discussion and the video with a new appreciation and understanding of the wonderful hamstrings that helps us crush some pebbles. They will improve your technique, and allow you to heel hook with the best of them.
Until next time: Train. Climb. Send. repeat.
Disclaimer:
As always, exercises are to be performed assuming your own risk and should not be done if you feel you are at risk for injury. See a medical professional if you have concerns before starting new exercises.
Written and Produced by Jason Hooper (PT, DPT, OCS, SCS, CAFS) and Emile Modesitt
IG: @hoopersbetaofficial
