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Hamstring strain injuries (HSIs) are common injuries in professional sport and the musculotendinous junction the most frequently injured site.1 2 MRI proves that the tendon extends into the muscle belly and has increased awareness of the intramuscular tendon injury.3 Some argue that this subtype of HSI may require surgical repair. Currently, there is no consensus on intramuscular tendon injury management; there is agreement that players are at an increased risk of re-injury on return to play (RTP).3 4 Evidence suggests that clinical decision-making, based on achieving functional goals, is an essential element of successful rehabilitation.4
In this video-supported education review with a strong clinical slant, I outline the rehabilitation of an English Premier League footballer who suffered a proximal hamstring intramuscular tendon injury during competition. The conceptual goal was to mechanically load the muscle–tendon unit hoping to improve tensile strength, elastic stiffness and cross-sectional area. Adequate high and maximal speed running exposure and objective neuromuscular performance data informed progression through rehabilitation and RTP. The player returned to competition in 120 days and remained injury free 13 months later.
During rehabilitation following initial physiotherapy care, isometric hamstring exercises were prescribed, beginning with single-leg heel drives (figure 1), progressing to unloaded, then loaded bilateral isometric hip extension holds (online supplementary video 1), then single-leg hip extension holds (online supplementary video 2) emphasising pelvic control before adding dynamic perturbations (online supplementary video 3). These high-intensity isometric exercises, using maximal voluntary contractions (~3–5 s) in cluster sets (ie, 5×5–3–5 s) were included with the theoretical aim of providing cyclic high-strain magnitudes postulated to increase …
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