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Anatomy, Bony Pelvis and Lower Limb, Hamstring Muscle

Article · December 2019

DOI: 10.6084/m9.figshare.16682479.v1

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Anatomy, Bony Pelvis and Lower Limb,
Hamstring Muscle
Authors

Cooper D. Rodgers1; Avais Raja.

Affiliations
1
University of Kansas School of Medicine

Last Update: October 4, 2019.

Introduction
The hamstring muscle complex is comprised of three individual muscles and plays a critical role
in human activities ranging from standing to explosive actions such as sprinting and jumping.
The following review article will summarize the structure and function of this muscle group and
provide an introduction to common hamstring injuries and surgical considerations.

Structure and Function

The semitendinosus, semimembranosus, and biceps femoris muscles comprise the hamstring
muscle group. Beginning at the pelvis and running posteriorly along the length of the femur, the
majority muscles within the hamstring complex cross both the femoroacetabular and
tibiofemoral joints. The short head of the biceps femoris is an exception to this rule as it
originates from the lateral lip of the femoral linea aspera, distal to the femoroacetabular joint. For
this reason, some argue that the short head of the biceps femoris is not a true hamstring muscle.
Unlike the short head of the biceps femoris, all other hamstring muscles originate from the
ischial tuberosity. The proximal, long head of the biceps femoris and semitendinosus muscles are
linked by an aponeurosis which extends approximately 7 cm from the ischial tuberosity. The
distal hamstrings form the superolateral (biceps femoris) and superomedial (semimembranosus
and semitendinosus) borders of the popliteal fossa. The gastrocnemius primarily forms the
inferior border of the popliteal fossa.

The hamstring muscle group plays a prominent role in hip extension (posterior movement of the
femur) and knee flexion (posterior movement of the tibia and fibula). Concerning the gait cycle,
the hamstrings activate beginning at the final 25% of the swing phase generating extension force
at the hip and resisting knee extension. The hamstring muscles also play an essential role as a
dynamic stabilizer of the knee joint. Operating in tandem with the anterior cruciate ligament
(ACL), the hamstrings resist anterior translation of the tibia during the heel strike phase of the
gait cycle.[1]
Embryology

A significant portion of lower extremity development occurs during weeks 4 to 8 of

embryogenesis. Like all other skeletal muscle tissue, the hamstring muscles form from the
embryonic mesoderm. Migrating from the somites during the early embryonic phase,
mesodermal cells differentiate into myoblasts, which duplicate and coalesce, eventually forming
functional muscle tissue.

Blood Supply and Lymphatics

The hamstring muscle complex receives vascular supply from the perforating branches of the
deep femoral artery, also known as the profunda femoris artery. The profunda femoris is a
branch of the femoral artery. The femoral artery is demarcated from the external iliac artery by
the inguinal ligament. In general, the deep veins of the thigh share the same name as the major
arteries which they follow. The femoral vein is responsible for a large degree of the venous
drainage of the thigh. It accompanies the femoral artery and receives additional venous drainage
from the profunda femoris vein. Similar to the femoral artery, the femoral vein transitions to
become the external iliac vein at the level of the inguinal ligament. The lymphatic drainage of
the thigh also mirrors the arterial supply and eventually drains into the lumbar lymphatic trunks
and cisterna chyli.

Nerves

The hamstring muscle complex is innervated by nerves that arise from the lumbar and sacral
plexuses. These plexuses give rise to the sciatic nerve (L3-S4), which bifurcates into the tibial
and common peroneal (fibular) nerves at the level of the tibiofemoral joint. The tibial nerve
innervates the semimembranosus, semitendinosus, and long head of the biceps femoris. The
common peroneal branch of the sciatic nerve innervates the short head of the biceps femoris.

Muscles

Biceps Femoris: Short Head

• Origin: Lateral lip of the linea aspera

• Insertion: The fibular head and lateral condyle of the tibia
• Function: Knee flexion and lateral rotation of the tibia
• Innervation: Fibular (common peroneal) nerve
• Vascular supply: Perforating branches of the deep femoral artery

Biceps Femoris: Long Head

• Origin: Ischial tuberosity

• Insertion: The fibular head and lateral condyle of the tibia
• Function: Knee flexion, lateral rotation of the tibia, and hip extension
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery
Semitendinosus

• Origin: Lower, medial surface of the ischial tuberosity

• Insertion: Medial tibia (pes anserinus)
• Function: Knee flexion, hip extension and medial rotation of the tibia (with knee
flexion)
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery

Semimembranosus

• Origin: Ischial tuberosity

• Insertion: Medial tibial condyle
• Function: Knee flexion, hip extension and medial rotation of the tibia (with knee
flexion)
• Innervation: Tibial nerve
• Vascular supply: Perforating branches of the deep femoral artery

Physiologic Variants
Although they are uncommon, surgeons must remain aware of hamstring muscle anatomical
variations. The hamstring muscle group, except for the short head of the biceps femoris, typically
originates from a conjoint muscle-tendon arising from the ischial tuberosity. Interestingly, there
are reports which reveal variants where the semitendinosus and the long head of the biceps
femoris appear from distinct tendinous origins.[1] Another report published in 2013 revealed
findings of a third head of the biceps femoris and an anomalous muscle that inserted onto the
semimembranosus.[2]

There is also a report of a patient with bilateral absence of the semimembranosus muscles. This
finding was noticed incidentally on MRI after the patient presented with knee pain after a
fall.[3] Although the article did not indicate whether or not the patient had experienced
symptoms related to this before his presentation, this finding may be relevant in the context of
ACL reconstruction as hamstring autografts are a common choice.

Common peroneal nerve entrapment neuropathy most commonly occurs at the level of the
fibular head and neck. A 2018 report revealed the findings of common peroneal neuropathy
associated with variation of the short head of the biceps femoris. In this case, the location of the
common peroneal nerve was within a 4.4 cm tunnel between the gastrocnemius and short head of
the biceps femoris.[4]

Surgical Considerations

The vast majority of hamstring injuries are manageable nonoperatively; however, hamstring
tendon avulsion often requires surgical intervention. Hamstring tendon avulsions are treated
endoscopically with fixation of the torn segment of the hamstring tendon to the ischial
tuberosity.[5] Surgical repair of chronic proximal hamstring rupture can have augmentation with
an Achilles tendon autograft.[6]

Ischial apophyseal avulsion fractures are extremely rare. Studies report that they account for
between only 1.4 to 4% of all hamstring injuries.[7] Avulsion fractures that are displaced less
than 1 cm are candidates for conservative management. Patients are advised to limit hamstring
stretching, preventing the fractured segment of the ischial apophysis from becoming further
displaced.[8] Surgical fixation is necessary for patients who have ischial apophyseal avulsion
fractures, which are displaced more than 1 cm or who are experiencing symptomatic malunion.
Early intervention is advised to decrease the risk of ischiofemoral impingement.[9]

The hamstring muscle is harvestable as an autograft in ACL reconstruction. The quadruple

hamstring autograft involves the semitendinosus and gracilis muscles and is known to be one of
the strongest grafts available.[10] Compared to patellar tendon grafts, hamstring autografts offer
a decreased risk of donor site trauma, patellofemoral crepitation, kneeling pain, and loss of more
than 5 degrees of knee extension.[11] In contrast, studies demonstrate that hamstring autografts
have an increased risk of laxity and functional hamstring weakness.[11] To date, no conclusive
evidence exists, suggesting that one graft material produces superior long-term results. A study
by Kocher et al. found no association between graft type and patient satisfaction in patients
undergoing ACL reconstruction using hamstring and patellar grafts.[12]

Clinical Significance

Hamstring strains are common in both elite and recreational athletes. In addition to being highly
prevalent, hamstring injuries are often slow healing and tend to recur. Estimates are that nearly
one-third of those who suffer from a hamstring injury will reinjure themselves within one year of
returning to their sport.[13] Most hamstring strains occur in the context of high-risk activities
such as sprinting, where rapid changes in speed or direction cause excessive muscle lengthening.
Biceps femoris is the most frequently injured of the hamstrings, followed by the
semimembranosus and then the semitendinosus.[14][15] Typically, hamstring injuries are
characterized by pain in the posterior thigh, which can be exacerbated by knee flexion and hip
extension. In severe injuries, patients may also report hearing a popping sound. During an
evaluation of a patient with a possible hamstring injury, it is important that clinicians also
consider other diagnostic possibilities such as lumbosacral radiculopathy, adductor strain, or a
femoral stress fracture.

Hamstring strain injuries classify as mild (Grade I), moderate (Grade II) or severe (Grade III)
based on the severity of patient symptoms. Grade I injuries are characterized by minimal pain
and functional impairment, with minimal disruption to the hamstring myofibrils present. Grade II
injuries are partial thickness tears to the musculotendinous fibers. Patients exhibit increased pain
with definite strength loss. Grade III tears characterized present with severe pain, hematoma,
significant strength loss, and a full-thickness tear to the hamstring muscle or tendon. Orthopedic
consultation is the recommendation for Grade III tears and Grade II/III tears, which affect the
distal aspect of the hamstring.
In the acute phase, the initial management of hamstring injuries is with protection, rest, ice,
compression, and elevation to limit inflammation and swelling.[16] Range of motion should be
dictated by patient pain tolerance, as excessive stretching of the hamstrings may lead to scar
tissue formation.[17] The role of NSAIDs in hamstring injury is somewhat controversial, with
some studies failing to show recovery benefits and others demonstrating possible adverse
effects.[18][19] However, short courses (5 to 7 days) of NSAIDs do not significantly hamper
recovery and should be used primarily as analgesics. Alternative pharmacologic agents, such as
platelet-rich-plasma (PRP), have been explored for their use in enhancing athlete recovery.
Concerning PRP, there is no strong evidence to support its use for muscle strain injury.[20]

In patients who have healed to the point where they can begin therapeutic activities, exercise
regimens that focus on eccentric contraction have been shown to shorten recovery time
significantly.[21] These regimens can be altered based on the patient’s phase of rehabilitation
and can continue to decrease the rate of reinjury.[22] Although hamstring stretching is
commonly advocated to decrease the probability of reinjury, hamstring flexibility training has
not demonstrated a decrease in the incidence of hamstring re-injury. Studies have also
emphasized the importance of neuromuscular control of the lumbopelvic region. A 2004
prospective randomized study found that patients suffering from acute hamstring strain injury
who were rehabilitated using a progressive agility and trunk stabilization program showed lower
rates of reinjury compared to those enrolled in a more standard progressive stretching and a
strengthening program.[23]

Questions

To access free multiple choice questions on this topic, click here.

Figures

The image shows the muscle areas that make up the complex of the muscles of the posterior
portion of the thigh: hamstring muscles. Contributed by Bruno Bordoni, PhD

Copyright © 2019, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication,
adaptation, distribution, and reproduction in any medium or format, as long as you give
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Commons license, and any changes made are indicated.

Bookshelf ID: NBK546688PMID: 31536294

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