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Pulled hamstring

A pulled hamstring, medically termed a hamstring strain, is an injury involving the overstretching or tearing of the hamstring muscle group—comprising the biceps femoris, semitendinosus, and semimembranosus muscles—that run along the back of the thigh from the pelvis to below the knee, facilitating hip extension and knee flexion.^[1]^[2] These injuries are classified into three grades based on severity: grade 1 (mild strain with minimal tearing), grade 2 (partial tear causing moderate pain and loss of function), and grade 3 (complete tear leading to significant weakness and inability to bear weight).^[2] Hamstring strains commonly occur in athletes during high-speed activities like sprinting or sudden acceleration/deceleration, affecting approximately 12-16% of all muscle injuries in sports such as soccer and track, with recent data indicating an increasing incidence (6.4% rise per year in average cohort age from 2015-2024 in the United States).^[2]^[3] Symptoms typically manifest as a sudden, sharp pain in the posterior thigh, often accompanied by a "popping" or tearing sensation, followed by swelling, bruising, tenderness, and muscle weakness. Prognosis is generally favorable for milder strains, with most athletes returning to sport within weeks if appropriate management is followed, though severe cases and recurrences pose challenges.^[1]^[2]

Anatomy of the Hamstring

Muscle Composition

The hamstring muscle group comprises three primary muscles located in the posterior compartment of the thigh: the biceps femoris, semitendinosus, and semimembranosus. These muscles are biarticular, crossing both the hip and knee joints, and are primarily composed of type I and type II skeletal muscle fibers arranged in a fusiform or pennate pattern, with proximal and distal tendinous attachments that facilitate force transmission.^[4]^[5] The biceps femoris, the most lateral muscle of the group, consists of a long head and a short head. The long head originates from the ischial tuberosity and the sacrotuberous ligament, while the short head arises from the lateral lip of the linea aspera and the lateral supracondylar line of the femur; both heads converge to insert via a common tendon on the head of the fibula and the lateral tibial condyle. This muscle features a bipennate structure in its short head for enhanced power generation, contributing to the group's overall lateral stability and function in knee flexion with lateral rotation.^[4]^[5]^[6] The semitendinosus, positioned superficially on the medial side, originates from the inferomedial impression on the ischial tuberosity and inserts on the medial surface of the proximal tibia as part of the pes anserinus tendon, blending with the tendons of the gracilis and sartorius muscles. It is characterized by a long, slender fusiform belly that transitions into a prominent tendon distally, making up a significant tendinous component relative to its muscular portion, and supports medial knee flexion and internal rotation within the hamstring complex.^[4]^[5]^[7] The semimembranosus, the deepest and most medial muscle, originates from a broad area on the posterior ischial tuberosity superior to the other hamstrings and inserts primarily on the medial tibial condyle, with expansions forming the oblique popliteal ligament and other reinforcing structures on the knee capsule. Its flat, broad, and membranous tendon of origin and insertion provide extensive surface area for attachment, positioning it as the largest hamstring by cross-sectional area and emphasizing its role in stabilizing the medial knee during flexion and hip extension.^[4]^[5]^[8] The hamstring muscles receive innervation primarily from branches of the sciatic nerve (L4-S3), with the long head of the biceps femoris and both medial hamstrings (semitendinosus and semimembranosus) supplied by the tibial division, while the short head of the biceps femoris is innervated by the common fibular division. Blood supply is derived from the inferior gluteal artery proximally and perforating branches of the deep femoral artery along the thigh, ensuring adequate perfusion to the muscle bellies and tendons.^[4]^[5]

Biomechanical Role

The hamstring muscles, comprising the biceps femoris, semitendinosus, and semimembranosus, primarily function to flex the knee joint and extend the hip joint through both concentric and eccentric contractions.^[9]^[10] Additionally, they contribute to pelvic stabilization by controlling anterior pelvic tilt and maintaining alignment during dynamic movements, working in coordination with the gluteal muscles.^[11] These actions are essential for lower limb propulsion and control, with the hamstrings generating greater torque at the hip compared to the knee due to their force-length properties.^[12] In the gait cycle, the hamstrings play a critical role across phases, particularly during the late swing and early stance, where they undergo eccentric contraction to decelerate knee extension and hip flexion ahead of foot strike.^[13] This eccentric loading is amplified in sprinting, as the muscles reach near-maximum length and contract forcefully to control forward swing, facilitating rapid deceleration and preventing excessive knee hyperextension.^[14]^[15] Such demands highlight their vulnerability, as the combination of high-speed lengthening and force production places substantial stress on the muscle-tendon unit. The hamstrings interact synergistically with the quadriceps and other lower limb muscles to ensure balanced force distribution and joint stability, particularly at the knee where coactivation counteracts anterior tibial shear forces during extension.^[16] This reciprocal relationship maintains dynamic equilibrium, with the hamstrings providing posterior stabilization to offset quadriceps dominance in activities like running.^[17] The proximal myotendinous junction, near the ischial tuberosity, emerges as a primary stress point due to its exposure to peak tensile forces during these eccentric phases, predisposing it to strain under rapid lengthening conditions.^[18]

Causes and Risk Factors

Injury Mechanisms

A pulled hamstring, or hamstring strain, typically results from excessive tensile forces applied to the muscle-tendon unit during dynamic activities, leading to partial or complete tearing of muscle fibers. These injuries often occur in sports involving high-speed movements, where the hamstrings are subjected to rapid lengthening or forceful contraction beyond their physiological limits.^[19] Common scenarios include sudden sprinting, as seen in track and field or soccer, where the injury frequently happens during the late swing phase of the gait cycle, when the hamstring muscles are at maximum length and velocity while eccentrically controlling knee extension and hip flexion. Kicking motions, such as in soccer or Australian rules football, represent another frequent trigger, involving rapid hip flexion combined with knee extension that stretches the hamstrings extensively. Rapid deceleration or acceleration, like in basketball or tennis, can also initiate the strain by imposing sudden overload on the muscle group.^[19]^[20]^[21] Strains are classified biomechanically as either eccentric or concentric overloads. Eccentric strains predominate during deceleration phases, where the hamstrings lengthen under tension to absorb energy and control forward leg swing, often resulting in high strain rates at the musculotendinous junction. Concentric strains occur during acceleration, involving forceful shortening of the muscle against resistance, though these are less common than eccentric types. In severe cases, particularly grade 2 or 3 strains, athletes report an audible or palpable "popping" sensation, indicative of acute fiber rupture, accompanied by immediate sharp pain that halts activity.^[21]^[19]^[21] Biomechanically, these injuries arise from high-speed stretching that exceeds the muscle's tolerance, with peak forces occurring when the hamstrings operate near their maximum active length, generating excessive stress on the proximal or distal attachments. The biceps femoris long head is particularly vulnerable due to its greater elongation during these motions compared to other hamstring components. Such mechanisms highlight the role of the hamstrings in hip extension and knee flexion during locomotion, where momentary imbalances in force production can precipitate failure.^[19]^[20]^[22]

Predisposing Conditions

A history of previous hamstring injury is one of the strongest predisposing factors for future strains, with recurrence rates reported between 12% and 48% in professional soccer players and up to 34% within one year in Australian football athletes.^[23] The risk is particularly elevated in the initial weeks following return to activity, reaching 13% in the first week among Australian football players, due to incomplete tissue remodeling and persistent neuromuscular deficits.^[23] This pattern underscores the importance of addressing residual weaknesses from prior injuries to mitigate repeated occurrences. Muscle imbalances, particularly a lower hamstring-to-quadriceps strength ratio, significantly heighten susceptibility to hamstring strains. In a prospective study of male college American football players, those who sustained injuries exhibited a hamstring-to-quadriceps ratio of 0.47 compared to 0.53 in uninjured players, indicating relative hamstring weakness as a key vulnerability.^[24] Such imbalances can arise from training regimens that disproportionately emphasize quadriceps development, leading to eccentric overload on the hamstrings during high-speed activities like sprinting. Poor flexibility in the hamstring muscles is associated with increased injury risk, as reduced range of motion limits the muscle's ability to absorb strain effectively. Injured athletes in the same football cohort demonstrated lower hamstring flexibility (25.3° versus 19.8° in uninjured peers), highlighting tightness as a modifiable predisposing condition.^[24] Inadequate warm-up exacerbates this by failing to elevate muscle temperature and extensibility prior to activity, while fatigue from prolonged exertion diminishes energy absorption capacity, particularly in the later stages of training or competition.^[23] Overuse through repetitive high-intensity movements, common in sports involving frequent sprints, further compounds these risks by promoting cumulative microtrauma without sufficient recovery.^[23] Age-related declines in muscle elasticity and coordination contribute to higher hamstring strain incidence, with risk escalating notably after age 23. Prospective studies indicate that athletes over 23 years are 1.3 to 3.9 times more likely to incur strains, rising to 2.8 to 4.4 times for those over 25, attributed to reduced muscle cross-sectional area and altered activation patterns.^[25] This predisposition intensifies with advancing age, as annual risk increases by approximately 30% in professional athletes, emphasizing the role of age-induced biomechanical changes.^[25]

Signs and Symptoms

Acute Presentation

A pulled hamstring injury typically manifests as a sudden, sharp pain in the posterior thigh during high-speed activities such as sprinting or sudden acceleration, often accompanied by a tearing or audible popping sensation that signals muscle fiber disruption.^[26]^[27] This acute pain is severe enough to halt the activity immediately, with affected individuals frequently hopping on the uninjured leg or collapsing to the ground.^[22] In the immediate aftermath, localized swelling develops in the posterior thigh within the first few hours, alongside marked tenderness upon palpation at the injury site, reflecting the inflammatory response to muscle damage.^[22]^[2] Bruising or ecchymosis soon follows, appearing over the buttocks and posterior thigh and potentially extending distally to the leg below the knee as blood from ruptured vessels tracks through tissue planes.^[2]^[22] Functionally, the injury impairs weight-bearing on the affected leg, resulting in an abnormal stiff-legged gait characterized by avoidance of hip and knee flexion, along with difficulty straightening the leg or bending forward.^[2]^[26] Pain intensity and the extent of these limitations vary by strain severity, from mild discomfort allowing partial ambulation in lower-grade injuries to profound agony and complete inability to walk in severe cases.^[26]^[2]

Ongoing Effects

Following the initial sharp pain and swelling associated with a pulled hamstring, patients often experience persistent discomfort that interferes with daily function. This includes ongoing pain during activities such as walking or running, which can manifest as a dull ache in the back of the thigh.^[1] Weakness in knee flexion becomes noticeable, with strength deficits up to 60% in affected muscles, limiting the ability to bend the knee effectively.^[27] Reduced range of motion is common, as scar tissue formation and muscle guarding restrict flexibility in the posterior thigh.^[27] Muscle spasms and stiffness frequently develop or persist beyond the acute phase, contributing to a sensation of tightness that worsens with prolonged sitting or standing.^[28] In severe cases, nerve-related symptoms may emerge, such as radiating pain resembling sciatica due to irritation of the sciatic nerve from scar tissue or inflammation, often indicated by a positive slump test.^[27] If the injury is not properly managed, complications can arise, including chronic pain that lingers for months and an elevated risk of re-injury, with recurrence rates approaching 33% within one year and often resulting in more severe subsequent strains.^[27] These ongoing effects highlight the hamstring's vulnerability to incomplete healing, potentially leading to prolonged disability.^[1] Functional limitations are a key ongoing impact, with individuals facing challenges in sports involving sprinting or kicking, such as soccer or basketball, and even basic tasks like climbing stairs or walking more than a few steps without discomfort.^[28] This can impair overall mobility and quality of life until full recovery is achieved.^[1]

Diagnosis

Physical Examination

The physical examination of a suspected hamstring strain begins with a detailed history taking to establish the onset, mechanism of injury, and any prior episodes. Patients typically report an acute onset of sharp pain in the posterior thigh during high-speed activities such as sprinting or sudden deceleration, often with an audible "pop" in more severe cases.^[2] A history of previous hamstring injuries is a key risk factor, as recurrence rates can exceed 30% in athletes.^[27] Palpation is performed with the patient in a prone position, involving gentle pressure along the posterior thigh from the ischial tuberosity to the popliteal fossa to identify localized tenderness, swelling, or ecchymosis.^[29] In complete tears, a palpable gap or defect may be evident in the muscle belly, while proximal injuries often cause pain at the ischial tuberosity, exacerbated by sitting.^[22] The location and extent of tenderness can help predict recovery time, with more proximal sites associated with longer rehabilitation periods.^[27] Functional tests assess pain, strength, and range of motion (ROM) through specific maneuvers, always comparing the affected side to the contralateral limb. The straight leg raise test involves passive hip flexion with the knee extended; limitation or pain before reaching 80 degrees indicates hamstring involvement.^[27] Resisted knee flexion is tested in prone position at 15 degrees (long-head emphasis) and 90 degrees (short-head emphasis), where weakness or pain reproduction suggests strain severity.^[2] Active and passive ROM evaluations, including knee extension against gravity and passive straight leg raise, reveal deficits due to pain or guarding, typically reduced by 20-30% acutely.^[27] Differentiation from other conditions is crucial during examination to rule out mimics. Lumbar radiculopathy may present with similar posterior thigh pain but is distinguished by positive neural tension tests like the slump test, showing radiating dysesthesia below the knee without significant hamstring-specific weakness or tenderness.^[27] Anterior cruciate ligament (ACL) tears, while sometimes causing a pop sensation, involve knee instability and effusion rather than isolated posterior thigh findings, confirmed by targeted knee ligament tests such as the Lachman maneuver.^[2] These assessments guide initial management while avoiding overlap with symptoms like localized pain and weakness.^[22]

Diagnostic Imaging

Diagnostic imaging plays a crucial role in confirming hamstring strains when clinical examination suggests moderate to severe injury (such as significant swelling, bruising, or inability to bear weight) or when the diagnosis is unclear, particularly for suspected grade 2 or 3 strains.^[2] Imaging is not routinely required for mild strains but is indicated to assess the extent of muscle fiber disruption, identify associated complications like hematomas or avulsions, and guide prognosis.^[30] X-rays are primarily used to rule out associated bony injuries, such as avulsion fractures at the ischial tuberosity or apophyseal fractures, which are more common in adolescents due to the vulnerability of growth plates during rapid skeletal development.^[2] These radiographs provide a quick, low-cost evaluation of bone integrity but do not visualize soft tissue damage effectively.^[27] Ultrasound serves as a cost-effective initial imaging modality for dynamic assessment of hamstring injuries, allowing real-time visualization of muscle tears, hematomas, and tendon integrity through detection of hypoechoic or anechoic regions indicating edema or fiber discontinuity.^[31] It is particularly useful in acute settings for guiding interventions like hematoma aspiration and offers advantages in accessibility and serial monitoring, though its accuracy depends on operator expertise and may miss deeper injuries compared to other methods.^[30] Magnetic resonance imaging (MRI) is considered the gold standard for evaluating hamstring strains, providing detailed visualization of muscle fiber disruption, intramuscular edema (appearing as high signal intensity on T2-weighted sequences), hemorrhage, and tendon involvement, which helps differentiate strain grades and predict recovery timelines.^[32] For instance, injuries involving more than 50% of the muscle cross-section or proximal biceps femoris tendon avulsions on MRI are associated with longer recovery periods exceeding six weeks.^[30] MRI is especially valuable in complex cases, such as those with suspected proximal tendinopathy or when ultrasound findings are inconclusive, offering superior soft tissue contrast without radiation exposure.^[31]

Classification of Severity

Grade 1 Strain

A grade 1 hamstring strain represents the mildest form of hamstring injury, characterized by minimal tearing of muscle fibers with no appreciable tissue disruption and no or minimal loss of strength or function.^[2] This type of strain typically involves only a few muscle fibers being damaged or slightly ruptured, without significant impact on the muscle's power or endurance.^[33] It can occur from either acute mild overload during sports activities or repetitive strain and overuse, such as during prolonged running or inadequate warm-up.^[21] Symptoms of a grade 1 strain are generally subtle and include a sensation of tightness or mild pain in the posterior thigh, often appearing suddenly during activity or the following day.^[28] There is typically no noticeable swelling, bruising, or ecchymosis, and individuals can usually walk normally without limping.^[22] The injury is detectable through slight discomfort or pain elicited by passive stretching of the hamstring or active knee flexion against resistance, but without substantial functional impairment.^[33] Recovery from a grade 1 hamstring strain is rapid and favorable, usually taking 1 to 3 weeks with conservative care including rest, ice, compression, elevation (RICE), and gradual reintroduction of activity.^[34] Physical therapy focusing on gentle stretching and strengthening can facilitate return to full function, with studies showing an average rehabilitation period of about 12 to 26 days depending on the athlete's sport and management protocol.^[35] When properly managed, the risk of recurrence is low, often below 10% in the short term, emphasizing the importance of progressive loading to restore flexibility and strength.^[21]

Grade 2 Strain

A grade 2 hamstring strain is characterized by a partial tear of the muscle fibers, resulting in noticeable weakness and a limp during ambulation.^[2]^[36] This moderate injury disrupts a portion of the hamstring muscle tissue, leading to identifiable partial structural damage without complete rupture.^[2] Symptoms typically include moderate pain in the posterior thigh, swelling, bruising (ecchymosis), localized tenderness, and pain elicited during resisted knee flexion.^[2]^[22] These manifestations often cause a partial loss of function, such as difficulty with walking or propelling the leg forward, distinguishing it from milder strains with minimal disruption.^[2] Recovery from a grade 2 strain generally requires 4 to 8 weeks, with most individuals regaining full function through nonoperative management.^[36]^[37] Physical therapy is often essential, focusing on progressive stretching, strengthening, and restoration of flexibility to support safe return to activity.^[2]^[22] Without adequate strengthening and flexibility restoration, grade 2 strains carry a higher risk of recurrence, as incomplete rehabilitation can leave residual weaknesses that predispose to reinjury.^[2]^[28]

Grade 3 Strain

A grade 3 hamstring strain represents the most severe form of injury, characterized by a complete rupture of the musculotendinous unit, often resulting in a palpable gap in the tissue along with substantial loss of function.^[2]^[22] This type of strain typically occurs at the proximal hamstring origin near the ischial tuberosity or involves a full avulsion where the tendon tears away from the bone.^[22]^[2] Symptoms of a grade 3 strain are acute and debilitating, including sudden, sharp pain in the posterior thigh that may produce a "popping" sensation, followed by extensive bruising and swelling that can extend below the knee.^[22]^[28] Patients often experience an inability to bear weight or walk without significant assistance, accompanied by a visible or palpable defect in the muscle and marked weakness.^[2] In cases of proximal avulsion, sitting may become extremely painful, and there is a risk of associated avulsion fracture at the ischial tuberosity.^[2]^[22] Recovery from a grade 3 hamstring strain is prolonged, typically requiring 3 to 6 months or longer for return to full activity, with strength recovery reaching approximately 87% at 6 to 12 months and 98% after more than 12 months.^[2]^[28] Surgical intervention is frequently necessary, particularly for proximal tears with greater than 2 cm retraction or avulsions, involving reattachment of the tendon to the bone using anchors; acute repair within 4 to 6 weeks post-injury is preferred to minimize scarring.^[2]^[22] Distal repairs may allow for shorter rehabilitation timelines of about 3 months, while proximal repairs often extend to at least 6 months.^[22] Complications associated with grade 3 strains can include chronic weakness, persistent pain, and a high risk of reinjury if healing is incomplete.^[2]^[28] Sciatic nerve involvement is a notable concern, potentially leading to hamstring syndrome—where scar tissue impinges on the nerve—or sciatic neuralgia, causing gluteal pain and radiating symptoms.^[2] Delayed surgical repair increases the likelihood of nerve scarring and unsatisfactory non-surgical outcomes for significant retractions.^[2]

Treatment and Recovery

Initial Management

The initial management of a pulled hamstring focuses on minimizing further tissue damage, controlling inflammation and swelling, and alleviating pain in the acute phase following injury. The standard approach employs the RICE protocol, which stands for Rest, Ice, Compression, and Elevation, to promote early healing and reduce complications such as excessive hemorrhage or edema.^[29]^[28] Rest involves immediately ceasing the activity that caused the injury and avoiding any movements that provoke pain, swelling, or discomfort in the posterior thigh; for moderate to severe strains, crutches may be necessary to offload weight-bearing and prevent limping, which could exacerbate the injury.^[29]^[2] Ice should be applied using a cloth-wrapped pack or bag of frozen vegetables directly to the affected area for 15-20 minutes every 2-3 hours while awake, particularly during the first 48-72 hours, to constrict blood vessels and limit swelling—individuals with conditions like diabetes or vascular disease should consult a provider before icing.^[29]^[38] Compression entails wrapping the thigh with an elastic bandage from the foot upward to mid-thigh, ensuring it's snug but not tight enough to cause numbness, increased pain, or swelling below the wrap, and loosening it if symptoms arise; this helps control edema by limiting fluid accumulation.^[29] Elevation requires positioning the leg above heart level when lying down, using pillows for support, to facilitate venous return and further reduce swelling.^[29]^[38] Pain management in the initial phase typically includes over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to address both discomfort and inflammation, or acetaminophen for pain relief if NSAIDs are contraindicated; these should be used for 5-7 days as needed, following dosage guidelines and consulting a healthcare provider for underlying conditions like gastrointestinal issues.^[29]^[2] During the acute protection phase, which spans the first 48-72 hours, the injured hamstring must be shielded from stretching, loading, or any eccentric contractions to prevent re-injury or prolonged bleeding, with gradual progression to gentle weight-bearing only as pain allows. This transitions into an early rehabilitation protection phase of 3-5 days, focusing on controlling pain and inflammation while introducing minimal mobility.^[2]^[39] For severe grade 3 injuries involving complete tears with muscle retraction greater than 2 cm, surgical repair is often recommended to reattach the torn muscle-tendon unit, typically performed within 1-2 weeks of injury to optimize outcomes. Post-operative management follows similar initial RICE principles, with immobilization in a brace for 1-4 weeks, followed by progressive rehabilitation over 3-6 months.^[2]^[29] Medical attention should be sought promptly if there is inability to bear weight on the affected leg, severe pain preventing walking more than four steps, persistent or worsening swelling, or signs of complications such as numbness or significant bruising extending beyond the thigh.^[1]^[28]

Rehabilitation and Return to Activity

Rehabilitation for a pulled hamstring typically follows a phased approach to promote tissue healing, restore function, and minimize reinjury risk. The early protection phase, lasting 3-5 days, focuses on controlling pain and inflammation through rest, ice, compression, and elevation, while introducing gentle, submaximal isometric exercises and pain-monitored walking to maintain mobility without exacerbating the injury.^[40]^[2] During this period, activities such as bilateral eccentric sliders and light hip thrusts are incorporated under physical therapy guidance to protect the muscle fibers.^[40] The repair phase, spanning approximately 1-6 weeks depending on severity, emphasizes gentle stretching and progressive loading to facilitate tissue remodeling. Physical therapists introduce eccentric exercises, such as Nordic hamstring curls, to target the muscle's lengthening phase, alongside balance training on unstable surfaces to enhance proprioception and stability.^[40] Functional testing, including single-leg hops and agility drills, begins as pain subsides, ensuring symmetrical movement patterns.^[41] This phase builds on initial management by shifting to active recovery, with timelines adjusted based on injury severity.^[31] In the remodeling phase, which may extend beyond 6 weeks, the focus turns to strengthening and sport-specific drills to restore full performance capacity. High-intensity eccentric training, Romanian deadlifts, and sprint progressions are integrated to improve muscle power and endurance.^[40] Neuromuscular control programs, such as the Progressive Agility and Trunk Stabilization (PATS) protocol, incorporate trunk stabilization and multi-planar agility exercises to enhance lumbopelvic coordination and reduce recurrence rates compared to traditional methods.^[41] Return-to-play criteria ensure safe resumption of activity and include pain-free full range of motion, similar strength between limbs with deficits typically less than 10% (assessed via isokinetic testing where available), and successful completion of agility tests like repeated sprints and deceleration drills without pain or asymmetry.^[42] Psychological readiness and medical clearance are also evaluated.^[42] Recent advances include blood flow restriction (BFR) training, which uses low-load eccentric exercises (e.g., 30% of one-repetition maximum) with partial vascular occlusion to achieve strength gains comparable to high-load training, promoting muscle adaptation while minimizing stress on healing tissue.^[43] These methods, alongside neuromuscular programs, have shown promise in reducing reinjury by improving fascicle length and eccentric strength.^[41]

Prevention Strategies

Training and Conditioning

Training and conditioning programs for preventing hamstring strains emphasize targeted strengthening, flexibility enhancement, and structured loading to build muscle resilience, particularly in athletes involved in high-speed activities. Evidence-based protocols focus on eccentric exercises, which lengthen the muscle under tension to mimic the demands of sprinting and deceleration, thereby reducing injury risk by up to 51% when incorporated consistently.^[44] These programs are most effective when tailored to individual needs, addressing underlying weaknesses that predispose athletes to strains, such as eccentric strength deficits. Compliance greater than 50% to these structured programs is essential for achieving significant risk reduction.^[45]^[46] Strengthening exercises form the cornerstone of hamstring conditioning, with Nordic curls, Romanian deadlifts, and glute-ham raises recommended for their ability to target the posterior chain effectively. The Nordic curl, performed by kneeling and lowering the torso forward while resisting with the hamstrings, is a premier eccentric exercise that has been shown in systematic reviews to halve hamstring injury rates in soccer players when included in prevention programs.^[47] Romanian deadlifts, involving a hip hinge with a barbell or dumbbells to emphasize hamstring elongation, and similar eccentric exercises improve eccentric strength and fascicle length, contributing to a 28% reduction in lower extremity injuries overall.^[48] Glute-ham raises, executed on a specialized machine or with bodyweight, similarly enhance hamstring and gluteal activation during eccentric phases. For optimal gains, these exercises should be performed in 2-3 sets of 8-12 repetitions, progressing volume based on tolerance to avoid overload.^[49] Flexibility training complements strengthening by maintaining optimal muscle length and joint range, with dynamic warm-ups preferred pre-activity and static stretches post-activity to minimize strain risk. Dynamic warm-ups, such as leg swings—where one leg is swung forward and backward in a controlled arc—improve hamstring flexibility and neuromuscular activation without reducing power output, unlike static methods during warm-up.^[50] Static stretches, held for 20-30 seconds targeting the hamstrings (e.g., seated forward bends), are best after activity to enhance recovery and long-term extensibility, supporting injury prevention by increasing tolerance to stretch.^[51] Combining these approaches has been linked to short-term gains in hamstring flexibility.^[52] Eccentric loading programs specifically simulate sprint demands by progressively challenging the hamstrings during lengthening contractions, fostering adaptations like increased muscle fascicle length and strength symmetry. Protocols often integrate Nordic curls with variations like the Askling L-protocol, which uses machine-assisted leg curls at high speeds to target eccentric phases, demonstrating superior outcomes in reducing reinjury rates compared to conventional methods.^[53] These programs typically span 8-12 weeks, starting with submaximal loads and advancing to sport-specific intensities, resulting in enhanced performance metrics such as sprint speed alongside injury protection.^[48] Periodization ensures sustainable integration of hamstring training into athletes' weekly routines, balancing intensity and recovery to prevent overuse while maximizing resilience. A common approach involves a 10-week preseason phase with 2-3 sessions per week of eccentric exercises like Nordic curls (e.g., 3 sets of 6-8 reps), transitioning to maintenance dosing (1-2 sessions weekly) during the competitive season to sustain benefits without fatigue accumulation.^[54] This structured progression, informed by athlete monitoring, has been shown to reduce hamstring strain incidence by 51% in elite sports when adhered to, emphasizing compliance for long-term efficacy.^[44]

Risk Mitigation Techniques

Implementing proper warm-up routines is a key strategy for reducing the incidence of hamstring strains by enhancing muscle temperature, flexibility, and neuromuscular activation prior to activity. These routines typically involve 10-15 minutes of light cardiovascular exercise, such as jogging or cycling, followed by dynamic stretches that mimic sport-specific movements, like leg swings or walking lunges. Evidence indicates that such warm-ups significantly increase hamstring flexibility immediately after performance, which correlates with a lower risk of acute strains during high-intensity efforts.^[52] Dynamic elements in warm-ups are particularly effective, as they prepare the muscle for eccentric loading without the potential flexibility decrements associated with static stretching alone.^[21] Considerations for footwear and playing surfaces also play a critical role in mitigating biomechanical stresses that contribute to hamstring injuries. Selecting footwear with adequate cushioning and appropriate traction—such as cushioned shoes or boots designed for firm ground—helps absorb impact forces and prevent excessive shear on the posterior thigh during acceleration or deceleration. Studies on cleat-surface interactions demonstrate that mismatched footwear with playing surfaces, like high-traction cleats on slick turf, can elevate lower limb injury risks, including strains, by altering ground reaction forces.^[55] Similarly, opting for consistent, well-maintained surfaces reduces variability in traction and hardness, which has been linked to higher hamstring strain rates in sports like soccer.^[56] Monitoring athlete fatigue through structured workload management further lowers hamstring strain risk by preventing overload. Incorporating rest days and tracking training volume via the acute:chronic workload ratio (ACWR)—calculated as the ratio of workload over the past week to the average over the past four weeks—allows coaches to maintain ratios below 1.5.^[57] Pre-season screening tools, such as functional movement assessments (e.g., the Functional Movement Screen), identify at-risk individuals by evaluating asymmetries and movement quality, enabling targeted interventions to address potential vulnerabilities like poor lumbo-pelvic control before the season begins. These screens have demonstrated moderate predictive value for lower limb injuries, including hamstring strains, in athletic populations.^[58]

Epidemiology

Incidence and Prevalence

Hamstring strains are among the most common musculoskeletal injuries in sports, accounting for 12-16% of all reported injuries across various athletic populations.^[59] In field-based team sports such as soccer, the incidence rate is approximately 0.81 injuries per 1,000 hours of exposure, representing about 10% of total injuries sustained.^[60] These injuries contribute significantly to time lost from training and competition, with prevalence rates reaching 13% over a typical 9-month season in professional settings.^[60] Certain sports exhibit particularly high incidence due to demands involving high-speed running and explosive movements. In soccer, rates can escalate to 3.0-4.1 injuries per 1,000 hours during match play compared to 0.4-0.5 per 1,000 hours in training.^[61] Similarly, American football reports up to 0.77 hamstring strains per 1,000 athlete-exposures, while basketball and track running (especially sprinting) show comparable elevated risks, often exceeding 0.6 per 1,000 exposure hours in elite and collegiate athletes.^[23]^[62] Recurrence is a notable concern, with rates ranging from 22-34% within two years of the initial injury, particularly in sports requiring repeated sprinting.^[63] In men's professional football, hamstring injury rates have increased from 12% to 24% of all injuries over the 2001/02 to 2021/22 seasons in UEFA elite clubs.^[64] Recent studies as of 2024–2025 indicate the pattern of high incidence persists, with hamstring injuries comprising 12–26% of all injuries in sporting populations, including an increased incidence in the United States from 2015 to 2024 and an average of 7 injuries per club per season in elite Australian football with a 26% recurrence rate.^[45]^[3]^[65] This high reinjury frequency underscores the challenges in full recovery and highlights the need for targeted prevention.

Demographic Patterns

Hamstring strains exhibit distinct patterns across demographic groups, with incidence varying by age, sex, profession, and geographic factors. Acute injuries peak in young adults aged 16 to 25 years, particularly in sports involving high-speed running, where the rapid transition from eccentric to concentric muscle contraction places significant stress on the hamstrings.^[2] In contrast, individuals over 40 years experience higher rates of chronic hamstring issues, attributed to age-related muscle degeneration, reduced regenerative capacity, and prolonged recovery times from strains.^[66] These patterns reflect a shift from acute overload in youth to degenerative vulnerabilities in later adulthood. Males demonstrate a slightly higher incidence of hamstring strains compared to females, with an injury rate ratio of approximately 1.62 in collegiate athletes across various sports, largely due to greater participation in contact and high-intensity activities like soccer.^[67] In professional soccer, incidence rates range from 0.3 to 1.9 per 1000 exposure hours in males versus 0.3 to 0.5 in females, underscoring sex-based differences in exposure and biomechanics.^[68] Among professions, elite athletes face elevated risks, particularly sprinters and track-and-field competitors, where hamstring strains account for up to 48% of all injuries in major championships and 87% occur within sprint and power disciplines.^[69]^[70] Incidence is rising among recreational runners, with hamstring injuries comprising about 6.7% of reported cases in large-scale events like marathons, driven by increasing participation among non-professionals.^[71] Older adults in physically demanding occupations or leisure activities also show growing chronic rates, linked to cumulative wear and reduced muscle resilience.^[66] Geographically, hamstring strains appear more prevalent in colder climates and regions with uneven terrain, as evidenced by higher injury rates in northern European soccer teams compared to southern counterparts, potentially due to reduced muscle flexibility in low temperatures.^[72] In contrast, very high-temperature environments correlate with lower incidence, with rates reduced by nearly half relative to moderate zones.^[73] Recent analyses of Asian professional football indicate a higher burden of hamstring injuries compared to Europe, despite overall lower injury volumes, possibly influenced by regional training practices and surfaces.^[74]

References

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Hamstring injury - Symptoms and causes - Mayo Clinic
Dec 9, 2022 · A hamstring injury typically causes a sudden, sharp pain in the back of the thigh. There might also be a "popping" or tearing sensation.
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Hamstring Injury - StatPearls - NCBI Bookshelf - NIH
Hamstring injuries mostly occur while players are running or sprinting. These groups of muscles are particularly susceptible to injury due to their anatomic ...
[3]
Posterior thigh muscles - Hamstrings - Kenhub
Origins, insertions, innervation and functions of the muscles of the ... The blood supply for this muscle comes from the femoral and popliteal arteries.Missing: neurovascular | Show results with:neurovascular
[4]
Muscles of the Posterior Thigh - Hamstrings - TeachMeAnatomy
Oct 26, 2025 · These muscles are innervated by the sciatic nerve (L4-S3), with arterial supply from the inferior gluteal artery and perforating branches of the ...Missing: neurovascular | Show results with:neurovascular
[5]
Biceps femoris: Origin, insertion, innervation, function | Kenhub
The majority of the blood supply for biceps femoris comes from branches of the deep femoral artery (perforating arteries and medial circumflex femoral artery).Missing: neurovascular | Show results with:neurovascular
[6]
Semitendinosus: Origin, insertion, innervation, action | Kenhub
Semitendinosus is innervated by the tibial division of sciatic nerve (L5-S2). Blood supply. This muscle is supplied by branches from three large arterial ...Missing: neurovascular | Show results with:neurovascular
[7]
Semimembranosus: Origin, insertion, action, innervation - Kenhub
The semimembranosus muscle has numerous adjacent muscular and neurovascular structures along its course. Semimembranosus is deep to semitendinosus ...
[8]
Hamstrings - Physiopedia
The hamstrings are muscles which extend the hip and flex the knee. The hamstrings play an important part in the complex gait cycle during walking.
[9]
The Hamstrings: Anatomic and Physiologic Variations and Their ...
The ST, SM and BFlh are biarticular muscles, and act in extending the coxofemoral joint (hip), as well as flexing and rotating (medially and laterally) the knee ...Missing: neurovascular | Show results with:neurovascular
[10]
Comparison of muscle activity of hamstrings as knee flexors and hip ...
During hip flexion-extension, the medial and lateral hamstrings stabilize the hip joint. In the straight leg raise (SLR) position, the hamstrings can act as ...
[11]
Hamstrings force-length relationships and their implications for ...
Sep 5, 2022 · Thus, for the same level of muscle force, the hamstrings will generate a greater hip extension than knee flexion joint torque, i.e., they tend ...Missing: primary | Show results with:primary
[12]
Running Biomechanics - Physiopedia
They act to extend the hip and control the knee through a concentric contraction. In late swing, the hamstrings act eccentrically to control knee extension and ...
[13]
The late swing and early stance of sprinting are most hazardous for ...
These studies found that the hamstrings contract forcefully while reaching maximum length during the late swing phase.
[14]
Hamstring muscle kinematics and activation during overground ...
Nov 14, 2008 · Hamstring muscles exhibited eccentric contractions during the late stance phase as well as during the late swing phase of overground sprinting.
[15]
Alternative Methods of Determining Hamstrings-to-Quadriceps Ratios
Mar 25, 2019 · Hamstrings muscle coactivation happens simultaneously to quadriceps muscle activation during knee extension motion to counteract the anterior ...
[16]
https://sportsmedicine-open.springeropen.com/articles/10.1186/s40798-019-0185-0
[17]
Intramuscular Tendon Injuries of the Hamstring Muscles
Aug 14, 2023 · This connection point, or musculotendinous junction, is the point at which most hamstring muscle injuries occur [32, 33]. However, it has ...Missing: myotendinous | Show results with:myotendinous
[18]
The mechanism of hamstring injuries – a systematic review - NIH
Sep 29, 2020 · A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended knee. Hamstring injuries during sprinting are most likely to occur ...
[19]
Mechanisms of Hamstring Strain Injury: Interactions between ... - MDPI
May 18, 2020 · Throughout the stance phase, the hip continues to extend and the knee flex for the first half, before starting to extend [43]. While most ...<|separator|>
[20]
Hamstring Strain Injury in Athletes - jospt
Feb 28, 2022 · The mechanism of injury is commonly related to an overloading and/or overstretching of the hamstring muscle group. The injury may be associated ...
[21]
Hamstring Muscle Injuries - OrthoInfo - AAOS
Muscle Overload. Muscle overload is the main cause of hamstring muscle strain. This can happen when the muscle is stretched beyond its capacity or challenged ...
[22]
Review Injury rate, mechanism, and risk factors of hamstring strain ...
Modifiable risk factors include shortened optimum muscle length, lack of muscle flexibility, strength imbalance, insufficient warm-up, fatigue, low back injury, ...
[23]
Risk factors for hamstring strain injury in male college American ...
Jun 2, 2023 · Lower hamstring flexibility, lower hamstring to quadriceps strength ratio, and lower general joint laxity score were identified as risk factors for HSI.
[24]
An Evidence-Based Approach to Hamstring Strain Injury - NIH
Evidence suggests that the risk for hamstring strain increases with age, yet the reasons for this are unclear. Age-related muscle changes, particularly ...Table 1 · Hamstring Strength · Sport-Specific Risks
[25]
Hamstring Strain Symptoms, Causes, and Treatments - WebMD
Jun 24, 2024 · Sudden and severe pain during exercise, along with a snapping or popping feeling · Pain in the back of the thigh and lower buttock when walking, ...
[26]
Hamstring Strain Injuries: Recommendations for Diagnosis ... - NIH
Hamstring strain injuries are commonly classified according to the amount of pain, weakness, and loss of motion, resulting in grades of I (mild), II (moderate), ...
[27]
Hamstring Injury: Recovery Time, Treatment & Symptoms
Visit a healthcare provider if you have hamstring injury symptoms that last for more than few days. Go to the emergency room if you experience severe pain or ...
[28]
Hamstring injury - Diagnosis and treatment - Mayo Clinic
Dec 9, 2022 · During the physical exam, a health care provider checks for swelling and tenderness along the back of the thigh. Where the pain is and how bad ...Diagnosis · Treatment · Lifestyle And Home Remedies
[29]
Imaging Diagnosis and Prognostication of Hamstring Injuries | AJR
In this review, I will emphasize circumstances in which imaging studies can supplement clinical evaluation to direct treatment of hamstring trauma.
[30]
Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return ...
Hamstring injuries are very common in athletes. Acute hamstring strains can occur with high-speed running or with excessive hamstring lengthening.Missing: definition | Show results with:definition
[31]
Role of Ultrasonography and MRI in Acute Hamstring Strains - NIH
Apr 22, 2025 · Magnetic resonance imaging (MRI) is widely regarded as the gold-standard method for diagnosing hamstring injuries, owing to its superior ability ...
[32]
Hamstring Strain - Physiopedia
Hamstring strains are caused by a rapid extensive contraction or a violent stretch of the hamstring muscle group which causes high mechanical stress.Description · Diagnostic Procedures · Examination · Physiotherapy Management
[33]
FAQ: Hamstring Injuries | Cedars-Sinai
Sep 6, 2019 · Minor hamstring strains, which we call grade 1, will typically take 1-2 weeks to heal. Higher-grade strains could take months to heal. The ...
[34]
Outcome of Grade I and II Hamstring Injuries in Intercollegiate Athletes
Grade I injuries are mild, grade II moderate, and grade III severe (Table 1). Grade I and II injuries were classified by the amount of pain, loss of motion ...
[35]
Hamstring Tear & Surgery | University of Utah Health
Mild hamstring tears or strains (grade 1) and partial hamstring tears (grade 2) take three to eight weeks to heal. During that time, it's important to rest your ...
[36]
Hamstring strain - aftercare: MedlinePlus Medical Encyclopedia
Jun 17, 2024 · The recovery time depends on the grade of the injury. A minor grade 1 injury can heal in a few days, while a grade 3 injury could take much ...Missing: credible | Show results with:credible
[37]
RICE Method: Rest, Ice, Compression, & Elevation - Cleveland Clinic
Jan 24, 2025 · The RICE method stands for Rest, Ice, Compression and Elevation. It's a common protocol for treating acute musculoskeletal injuries.Missing: hamstring | Show results with:hamstring
[38]
HAMSTRING INJURY REHABILITATION AND PREVENTION ... - NIH
In the acute stage of hamstring rehabilitation the treatment should focus on protecting the injury and minimizing range of motion and strength loss.Missing: definition | Show results with:definition
[39]
Hamstring Strain Injury Rehabilitation - PMC - NIH
Hamstring strain injuries are common among athletes and often require rehabilitation to prepare players for a timely return to sport performance while also ...
[40]
Hamstring Strain Injuries: Recommendations for Diagnosis ... - jospt
In this paper, we first describe the diagnostic examination of an acute hamstring strain injury, including discussion of the value of determining injury ...Hamstring Strain Injuries... · Examination · Prognosis
[41]
play after hamstring injuries in football (soccer): a worldwide Delphi ...
Medical criteria for RTP after hamstring injury · Absence of pain and psychological readiness · Similar hamstring strength and hamstring flexibility · Performance ...
[42]
Low Load With BFR vs. High Load Without BFR Eccentric Hamstring ...
Low-load blood flow restriction (BFR) RT has been identified as an effective alternative when high-load RT is contraindicated but has been scarcely investigated ...
[43]
a systematic review and meta-analysis of 8459 athletes
The Nordic hamstring exercise (NHE) is an effective injury prevention tool that may reduce the number of hamstring injuries if implemented successfully.
[44]
Evidence-Based Hamstring Injury Prevention and Risk Factor ...
Apr 6, 2022 · Eccentric strengthening reduces injury incidence and improves hamstring strength, fascicle length, H/Q ratio, and limb asymmetry.
[45]
Effect of Injury Prevention Programs that Include the ... - PubMed
The Nordic hamstring (NH) exercise has been shown to decrease risk by increasing eccentric hamstring strength. Objective: The purpose of this systematic review ...
[46]
Effects of Different Hamstring Eccentric Exercise Programs on ... - NIH
Jan 23, 2023 · The analysis showed that the implementation of a hamstring eccentric training program reduced lower extremity injuries by 28%, and it resulted ...
[47]
An Evidence-Based Framework for Strengthening Exercises to ...
Several studies have established that eccentric knee flexor conditioning reduces the risk of hamstring strain injury when compliance is adequate. The benefits ...
[48]
Effect of dynamic versus static stretching in the warm-up on ...
Mar 3, 2011 · Static stretching did not improve dynamic hamstring flexibility; however, dynamic stretching improved both dynamic and static flexibility.
[49]
Static and Dynamic Stretching: Tips for Athletes - HSS
Apr 18, 2021 · Static stretches should be used as part of your cool-down routine to help prevent injury. Using static stretching as a maintenance stretching ...
[50]
The effect of warm-up, static stretching and dynamic stretching on ...
Apr 16, 2009 · Warm-up and stretching are suggested to increase hamstring flexibility and reduce the risk of injury. This study examined the short-term effects ...
[51]
Prevention and Rehabilitation of the Athletic Hamstring Injury
Increasing age has been shown to be an independent risk factor for hamstring injuries. Activity and position, Activities involving high intensity running and ...Asmar Special Issue: Injury... · Risk Factors · Rehabilitation Principles...Missing: predisposing | Show results with:predisposing<|control11|><|separator|>
[52]
A FOUR-WEEK TRAINING PROGRAM WITH THE NORDIC ... - NIH
The Nordic hamstring exercise (NHE) is an effective strategy to prevent hamstring strain injuries in soccer players. The current literature recommends a 10-week ...
[53]
Influence of Cleats-Surface Interaction on the Performance and Risk ...
Abstract. Objective. To review the influence of cleats-surface interaction on the performance and risk of injury in soccer athletes.
[54]
Recommendations for hamstring injury prevention in elite football
Nov 9, 2018 · Environmental factors (eg, playing surface, travel, location of match, footwear, and so on) ... prevention of hamstring injury in professional ...
[55]
Player Monitoring in Professional Soccer: Spikes in Acute:Chronic ...
Jul 7, 2020 · This study aimed to determine whether spikes in acute:chronic workload ratio (ACWR) are associated with injury incidence, and to examine the ...
[56]
Evaluation of the Functional Movement Screen (FMS) in Identifying ...
Nov 22, 2021 · This study aims to synthesize the literature on the ability of the FMS to identify at-risk active females.<|control11|><|separator|>
[57]
Hamstring injury rehabilitation and prevention of reinjury using ...
Jun 1, 2012 · Hamstring strains account for 12–16% of all injuries in athletes with a reinjury rate reported as high as 22–34%. Furthermore, recurrent ...
[58]
Incidence and prevalence of hamstring injuries in field-based team ...
Dec 1, 2022 · Hamstring injury incidence was 0.81 per 1000 hours, representing 10% of all injuries. Prevalence for a 9-month period was 13%, increasing 1.13- ...
[59]
Epidemiology of hamstring injuries in 538 cases from an FC ...
The overall incidence for the 17 sports studied was 1.29 structurally verified hamstring injuries per 100 athletes per year. The muscle most commonly involved ...<|control11|><|separator|>
[60]
Incidence and Severity of Hamstring Injuries in Female Athletes Who ...
Nov 1, 2022 · There was moderate certainty evidence that the incidence of hamstring injuries was 0.6 injuries per 1000 exposure hours in female field sport athletes.
[61]
Proximal and Mid-Hamstring Strain/Tendon Tear
Jul 11, 2024 · Mid-hamstring strains and proximal hamstring tears are most commonly seen in athletes who require explosive force, such as with sprinting.Missing: differentiating | Show results with:differentiating
[62]
Hamstring injury rates have increased during recent seasons and ...
Of all the hamstring injuries, 475 (18%) were recurrences, and early recurrences (within 2 months, n=325) made up 69% of these. Recurrences were nine times more ...
[63]
An Old Problem: Aging and Skeletal-Muscle-Strain Injury - PMC
Etiology of osteoarthritis comprises structural and functional degeneration of the joint that occur with repeated years of cumulative damage to the articular ...
[64]
Hamstring Strain Incidence Between Genders and Sports in NCAA ...
Apr 28, 2010 · Anecdotal evidence suggests that athletes who play sports requiring explosive activities are more susceptible to hamstring strain.
[65]
Incidence of Acute Hamstring Injuries in Soccer: A Systematic ... - jospt
Dec 31, 2020 · The incidence of acute hamstring injury in soccer was 0.3 to 1.9 per 1000 exposure hours. The recurrence rate was 4% to 68%.
[66]
Hamstring Injury – Do You Know the Odds and Can You Beat Them?
In high-level sprinters, this rate is higher. The IAAF reports that 48% of all injuries within the 2011 World Athletics Championships were hamstring injuries.What are hamstrings? · Risk factors associated with a... · Hamstring Injury Recovery
[67]
A 4-year study of hamstring injury outcomes in elite track and field ...
Eighty-seven per cent of injuries occurred in the Sprint/Power group (Short Sprints: 40%, Long Sprints: 25%, Other Power: 21%) and 13% of injuries occurred in ...
[68]
Injury patterns and healthcare utilisation by runners of the New York ...
Mar 27, 2024 · Hamstring injuries had the highest prevalence of diagnosis with 38/564 injuries (6.7%). Of the 447 runners who reported an injury, 224 (50.1%) ...
[69]
Comparison of injury incidences between football teams playing in ...
Mar 28, 2025 · Conversely, in soccer (football) in Europe, teams in northern (cooler) areas have higher rates of injury than those in southern (warmer) areas, ...Missing: terrain | Show results with:terrain
[70]
Association of Hamstring Strain Injuries with Season ... - Brieflands
The very-high-temperature zone showed a significantly lower incidence of hamstring strain injuries (IRR = 0.53) than did other temperature zones. The lower- ...Missing: geographic climate
[71]
lower general incidence and burden but higher ACL and hamstring ...
They speculated that the phenomenon may be explained by a myriad of factors such as pitch surfaces, skill level, and climate or temperature variations as well ...Missing: terrain | Show results with:terrain