Hamstring pull/strain injury (HSI) and football are quite synonymous. Infact a recent UEFA study showed a 4% increase in HSI in professional football since 2001. Even in FIFA world cup hamstring is the most common injury site. Though sprinting is the most common mechanism, stretching type is more time consuming and difficult to treat. Despite the ever increasing information on etiology and evidence based strategies to prevent HSI, there seems to be a large disconnect between these evidences and its adoption in elite football.

Although there is wealth of research examining HSI risk factors, there is still lack of evidence how these supposed risk factors interact with each other. Despite the difficulties of examining the interactions of multiple risk factors, it appears that they do not operate in isolation, but instead function as a complex web of determinants. Hence it is essential to rank the factors in order of importance considering both general and specific risk. The major specific risk factors identified are previous hamstring injury, hamstring eccentric strength, weekly speed exposure and fatigue resistance.

The essential element of HSI prevention programmes is to target the individual’s injury risk profile. An important source can be the information gathered at the time of annual screening typically at the start of each season. Health and musculoskeletal evaluation, psychological profile, injury history, functional movement and hamstring injury screening in conjunction with appropriate surveillance and monitoring process not only provides necessary input to create individualized training approach by targeting risk factors relevant to the player’s profile but also serve as benchmark criteria for return to play. The most widely researched and recommended evidence-based strategy for HIS prevention is eccentric hamstring strength training and it has been shown to significantly reduce the risk of primary and secondary HSIs (65%-85%).

Possible factors which need to be considered include:

1. Hip extensor torques in sprint running should exceed that of the knee flexor torques.
2. Consideration needs to be given to all parts of the force-velocity curve in regard to its potential for athletic development and injury reduction. Deficit in explosive strength will limit the expression of maximal strength during sprinting.
3. Poor intermuscular and intramuscular coordination can result in insufficient expression of isolated strength functionally, hence it is important to acknowledge the complexity of coordinated movement alongside isolated muscle strengthening.

Heightened acute:chronic workload ratio (ACWR) accompanied by congested match play has emerged as one of the key factors leading to increased injury risk. Exposing players to large and rapid increases in high speed running (HSR) distances also increase the odds of HSI. Thus balancing training to reflect match play HSR load and customizing small sided game (SSG) is important along with multimodal recovery strategies.

There is a need of holistic approach that translate existing knowledge on HSI risk factors and applies this to football context. Hence it has been found that multi component injury prevention programme is effective for reducing the number of muscle injuries. A successful example is FIFA 11+ program. Performing this warm up programme in training and before matches has been shown to reduce the risk of sustaining hamstring and quadriceps injuries in both men and women football by about 30%-50%.

But successful implementation of any scientific intervention in professional football is highly dependent on “buy in” from key decision makers (coaches, players and even executives).The sports medicine and science team should understand the expectation of coaches and management staff and should explore how the coaching staff prefer to receive information. The best way to achieve this is through two-way communication and open discussion.