This past week, two key players on playoff teams – Ricky Rubio and Jaylen Brown – both suffered a hamstring strain, a notoriously sensitive and annoying injury.
Rubio injured his right hamstring during game 6 against the Thunder and Jaylen injured his during game 7 against the Bucks. I couldn’t find video of the exact moment Rubio (re)injured his but here is video of Jaylen:
The Jazz medical staff ruled Rubio out for at least 10 days and the Celtics medical staff has taken a game to game approach with Jaylen – he missed game 1 vs the Sixers, was listed as doubtful for game 2 but went against medical advice and played..
In the following piece, I’ll use my unique lens as a Doctor of Physical Therapy (DPT) to answer the following questions:
- What are the hamstrings?
- What do the hamstrings do?
- What caused Rubio and Jaylen to get hurt?
- Are all hamstring strains created equal?
- What does the rehab and recovery for Rubio and Jaylen entail?
- What are the short and long-term ramifications?
I. Hamstring anatomy
The hamstrings consist of three muscles on the backside of your thigh – the biceps femoris, semitendinosus, and semimembranosus. They start at the ischial tuberosity (the bottom of the butt), run down the back of your leg and along either side of the knee into the knee. Here’s a picture:
II. Hamstring function
A. Their general function
The hamstrings serve two primary roles:
- Concentrically flex (bend) your knee
- Eccentrically control (“brake”) knee extension (straightening)
Here’s a quick overview of concentric vs eccentric, using the biceps as an example:
And numerous secondary roles, including:
- Help extend your hip:
- Internally and externally rotate the knee:
B. Basketball specific function
The hamstrings take on heavy load when you’re running/sprinting, jumping, changing speeds, and/or changing direction.
1 – Running/sprinting
While running/sprinting, the hamstrings main role is to control the swing leg (lead leg) right before it touches the ground. As that leg is swinging forward, the hamstrings are lengthening and “braking” the leg – likes brakes on a car. Take a look:
The purpose of this “braking” mechanism is to help your foot contact the ground in a more stable position and decrease the amount of force that goes up through your foot and leg. The faster the run or sprint speed, the higher the stress on the hamstrings. It’s no surprise that most hamstring strains occur during high speed running or sprinting – there’s a huge load on the hamstrings.
The secondary role of the hamstrings during running/sprinting is to extend the hip aka pushing the hip behind you. This is critical for generating power and efficient forward propulsion.
2 – Jumping
Jumping requires the hamstrings to eccentrically control hip flexion (aka when you’re squatting down to jump) and then powerful hip extension (straightening) during the actual jumping movement. Here’s what that looks like:
The hamstrings are secondary hip extenders (the glutes are the primary drivers of hip extension).
3 – Change of Speed
Any change of speed, be it acceleration or deceleration, involves the hamstrings.
Acceleration requires a powerful hip extension to generate force. As I touched on above, the hamstrings play a secondary role in any hip extension. They have to shorten and aide the glutes.
On the other side of the coin, deceleration requires a powerful eccentric contraction and control from the hamstrings to slow down the body. I mentioned this “braking” mechanism in the context of running above and the concept is similar here. However, slowing down the entire body quickly requires a much greater force from your hamstrings.
Ricky and Jaylen, especially as perimeter players, constantly have to change pace and generate powerful acceleration/deceleration. This puts a constant load on their hamstrings.
4 – Change of direction
Whenever the knee has to twist inwards (internally rotate) or outwards (externally rotate), the hamstrings are firing. Remember, the hamstrings attach on the inside and outside of your knee and function as secondary internal and external rotators.
So every time Rubio or Jaylen navigate screens, or pivot, or turn and close-out on a weak-side shooter, or get into the lane (etc. etc.), the knee is rotating and the hamstrings are firing.
Now that we know some of the main function/stressors on the hamstring during basketball activities, let’s take a closer look at Ricky’s and Jaylen’s hamstring strain….
III. What caused Jaylen’s and Ricky’s hamstring strain?
Jaylen’s right hamstring strain occurred when he was decelerating off a drive and kick. Here’s the moment:
In this moment, his hamstring is eccentrically contracting (“braking”) to slow down his right leg. In the next frame of the video (it’s not easy to see so I didn’t include the picture), Jaylen’s right leg is completely straightened which tensions the hamstrings even more. He immediately pulls up, grabbing the hamstring area.
For Rubio, I couldn’t find the exact moment of his left hamstring strain but we do know that it was a re-aggravation of a previous hamstring strain. Research has shown that athletes with a hamstring injury are over double the risk of suffering a repeat hamstring injury.
Some other major risk factors include:
- Increased fatigue
- Poor core stability
- Poor pelvic stability
- Increased age
- Strength imbalance
In Rubio’s case, he first injured the left hamstring in late March which he dealt with until the end of the season. Allegedly, he was dealing with lingering hamstring soreness into and throughout the OKC series. That’s a huge risk factor for future hamstring strains and obviously we know what happened.
Jaylen, from what I could find, doesn’t have a history of hamstring injuries but fatigue may have played a major factor in his hamstring strain. It occurred while he was playing in game 7 of a hotly contested series against the Bucks averaging nearly 35 minutes per game up to that point (4 minutes over his regular season average).
Now that we’ve established the cause and potential risk factors for Ricky’s and Jaylen’s hamstring strain, let’s get into different types of strains.
IV. The different grades of hamstring strain
So up to this point, I’ve referred to hamstring strains as a general monolith but there are three different grades – each indicating a higher severity and longer timetable for return. Post-injury symptoms will inform the diagnosis but MRI is the diagnostic gold standard for confirming the grade and exact location of the hamstring strain.
A. Grade 1 (mild) hamstring strain
In a grade 1 hamstring strain, only a few fibers of the muscle are damaged. You’ll feel tightness in the area with accompanying discomfort, have mild swelling and spasm, and won’t be able to run at full speed. However, your walking pattern isn’t affected and bending the knee against resistance shouldn’t reproduce much pain.
B. Grade 2 (moderate) hamstring strain
In a grade 2 hamstring strain, about half of the muscle fibers are damaged. You’ll have swelling in the area and be tender to palpation (touch), have sudden twinges of pain during activity, will most likely be limping, and bending the knee against resistance will be painful.
C. Grade 3 (severe) hamstring strain
In a grade 3 hamstring strain, over half or all (complete rupture) of the muscle fibers are damaged. You’ll have swelling immediately with visible bruising within 24 hours, feel severe pain and weakness in the muscle, and may need crutches.
Lastly, in addition to the grade of the hamstring strain, the exact location affects severity as well. The closer the strain is to the ischial tuberosity (aka the higher up your leg), the longer it takes to rehab, recover, and get back on the court.
Speaking of rehabilitation and recovery…..
V. Rubio’s and Jaylen’s hamstring strain rehab and recovery
Both Rubio and Jaylen underwent MRI’s after their injuries – Rubio was declared out for at least 10 days while Jaylen was listed as day to day, missed game 1 against the Sixers, but went against medical advice to play in game 2.
Both injuries were officially announced as “hamstring strains” but the recovery timetable informs severity – Rubio’s is likely worse than Jaylen’s and that makes sense considering Rubio had recently injured that same hamstring.
Regardless of extent, the rehab and recovery protocol for Rubio and Jaylen share many similarities. I’ll use a micro (tissue), mezzo (systemic), macro (contextual) model to detail the different layers that need to be addressed.
A. Micro (tissue)
- Soft tissue treatment
- The first step in rehab is to reduce pain. Manual hands-on treatment is a great way of doing that. It can help reduce inflammation in the area while promoting relaxation of the muscle and patient as well.
- Cross friction massage
- Cross friction massage is a technique that reduces pain, helps re-organize damaged tissue fibers, and stimulates increased blood flow to the area (blood has key restorative properties).
- As the pain level decreases, the next step is to recover appropriate hamstring range of motion.
- This doesn’t mean constantly over-stretching the hamstring. Rather, it’s taking the hamstring through the passive and active range of motion that is required during movement
- Functional loading
- As pain is mitigated and range of motion restored, the rehab process moves onto strengthening the hamstring.
- This is done via a step-wise incremental progression:
- Starts with low load activity and if the response is within limits, loading is increased
- Generally, this means moving from concentric (shortening) exercises like body-weight curls and loaded leg curls to eccentric (lengthening) exercises like an inverse leg curl or Romanian deadlifts (RDLs)
- As I mentioned above, the hamstrings are most susceptible to injury during the eccentric portion so it’s critical to restore eccentric strength.
- A primary early goal is to restore normal gait (walking) patterns so Rubio or Jaylen don’t develop poor mechanics or compensations. The hamstring needs to be functioning appropriately during normal movements before you can load it further
- Glute and hamstring teamwork
- The glutes and hamstrings work in conjunction together on multiple movements. These include slowing down the lead leg during running, extending the hip during running, and extending the hips during jumping.
- If either the glutes or hamstrings aren’t working appropriately (whether it’s a strength, endurance, activation issue, etc), then the other has to work harder and can become overloaded – leading to pain and injury.
- For this reason, when recovering from hamstring injury, it’s crucial to also address potential glute problems in order to take stress off the hamstring.
- If there are underlying high risk movement patterns or compensatory movement patterns develop, then you want to address them. This can take considerable time though (for example, just changing a straight-forward controlled movement like squatting can take over 2 weeks).
- However, in Rubio and Jaylen’s case, time is of the essence. If there was more time or if the injury became chronic, then the medical staffs may look at things like trunk flexion during movement or stride length during running. Here’s what those look like:
- With excess trunk flexion or excess stride length, the hamstring is in a more elongated and vulnerable position – increasing injury risk.
- Central nervous system (CNS)
- The CNS is comprised of two systems: the sympathetic nervous system (SNS) which creates the stress or “fight or flight” response, and the parasympathetic nervous system (PSNS) which creates the relaxation or “rest and digest” response.
- A ramped up SNS makes healing and injury rehab more difficult by affecting you cognitively, physically, and emotionally.
- Cognitively: The brain’s main role is to anticipate and prepare for threat. When you’re stressed, the brain is on high alert which creates a heightened sense of threat and fixation on problems. In turn, the brain sends out more pain signals (aka MORE PAIN) to alert the body
- Physically: Stress results in a multitude of physical changes including increased systemic inflammation, increased muscle tension, deregulated immune response, etc. Each of these negatively impacts healing.
- Emotional/Behavior: Stress can alter major health drivers like sleep, nutrition (“binge-eating” for example), and exercise patterns. Changes in these key areas exacerbates all other existing issues.
- For these reasons, it’s critical that both Ricky and Jaylen be kept relatively stress free to hasten their recoveries
C. Macro (contextual)
A major contextual factor that could influence how quickly or not quickly either Rubio or Jaylen return is playoff pressure.
The playoffs are obviously finite so that can add an extra pressure and impatience for Rubio and Jaylen to return – these guys want to be on the floor helping their teams. They’ve waited for these moments all year.
The added pressure to return is especially true in Rubio’s case because the drop-off between him and Exum is vast. On the other hand, the Celtics have so much wing depth that Jaylen’s return isn’t as crucial right now (and that’s not a knock on Jaylen, it’s a testament to how well Boston and Coach Stevens have built up their talent base. Pains me to say that as a Laker fan).
Additionally, the playoffs add a higher level of intensity to each game – both physically and mentally. Therefore, it’s extra important that both Rubio and Jaylen’s hamstrings are ready to handle those extra rigors.
This variable of added pressure and wanting to return for the playoffs got the best of Jaylen last night. Regardless of the outcome, the risk/reward scenario tilted far more towards risk.
VI. Short and long-term implications
In the short-term, there is an increased risk for Rubio and Jaylen to re-injure the hamstring and suffer a worse hamstring strain. According to research, the highest risk for hamstring strain recurrence is within the first 2 weeks of return to sport.
I was shocked that the Celtics let Jaylen decide his own fate for game 2, full well knowing the potential risk and ramifications.
In the long-term, studies show that approximately one third of hamstring strain recur, period. There’s also research showing that athletes who suffered a hamstring strain have rough 2x risk of recurrence. However, I wasn’t able to find a timetable for that number or if that risk goes down significantly over x amount of time.
VII. All in All
All in all, a hamstring strain is a notoriously sensitive and tricky injury because it’s involved in many movements and constantly handles eccentric loads. The timing of the injury for Rubio and Jaylen just makes it that much worse. However, in either case, the medical staffs have to be prudent to make sure the hamstring strain has sufficiently healed and is ready for the rigors of playoff basketball.
Thanks for reading and until next time.
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