Physio Considerations for Hamstring T-Junction Injuries

Hamstring injuries are a common challenge in sport, but injuries at the T-junction of the biceps femoris bring their own set of complexities.

These injuries are not only tricky to detect, but they also carry a high risk of recurrence. Understanding the nuances of rehabilitation can be the difference between a successful return to play and repeated setbacks. This blog highlights a few key considerations for physios.

If you want to see exactly how an expert physio assessed and managed a professional footballer through a T-junction surgical repair, check out expert physio Massimo Zanovello’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

What is a T-junction injury?

The T-junction refers to the musculotendinous junction where the long head of the biceps femoris meets the short head, creating a complex anatomical region.

There are complexities that come with this injury. Firstly, the area is particularly prone to high recurrence rates (up to 54%!).

Detection can also be difficult. Many physiotherapists aren’t trained to recognise this structure, and imaging can be misleading. Standard MRI is static and may miss injuries that only show up during dynamic movements. Adding to the complexity, symptoms often settle quickly, and athletes can feel relatively well just days after the injury. This can lead to premature return to play and contribute to high reinjury rates.

Other challenges include unclear prognosis and return-to-play timelines. Clinicians may also overlook key injury mechanisms, such as the role of trunk rotation. See Massimo explain this in the below video from his Case Study:

The case

Massimo’s case involved a 23-year-old professional footballer who sustained a T-junction injury during high-speed running with trunk rotation and perturbation.

Despite an eight-week conservative rehabilitation program, he returned to play and suffered a recurrence. Surgical repair was recommended for two main reasons:

1) Imaging revealed a chronic rupture with a small seroma and a gap at the biceps femoris T-junction, resulting in loss of tension in the musculotendinous structure.

2) The player had already experienced a recurrent injury and conservative management had failed.

Post-surgical rehabilitation

Massimo’s football-specific post-surgical rehabilitation plan is structured across three key phases: regeneration, functional, and return-to-sport.

1 – Regeneration phase

During weeks 1-3, the player was partial weight-bearing, performing small isometric contractions to protect the repair. Weeks 4-6 allowed full weight-bearing, along with active and passive mobility, pool-based exercises, lumbopelvic control drills, and general conditioning.

2- Functional Phase (week 6+)

The functional phase has three sub-phases: initial strength and conditioning, return-to-run and sport-specific drills, and return to high-speed running/sprinting.

In the initial strength and conditioning sub-phase, concentric and eccentric exercises were introduced progressively, including trunk strength and rotational control. Massimo explains some of the initial exercises he uses in this clip from his Case Study:

In the next sub-phase, running and soccer drills are gradually reintroduced, supported by conditioning programs, progressively increasing intensity while keeping running speed below 70% of Maximal Sprint Speed (MSS).

Another important element of rehab is Lengthened State Eccentric Training (LSET), which as the name suggests, involves training the hamstring eccentrically in a lengthened position; this is particularly effective in promoting adaptation of tendons and aponeurotic structures.

At week 12 the patient progressed to gradual introduction of high-speed running and sprinting. A few key tips Massimo points out for this stage include:

• <40m sprints
• total high speed distance under 300m per session
• tailor to specific situations and player’s role/playing style (e.g., change of direction)

If you’re wondering how this all fits into a well-balanced week of training, Massimo outlines a typical training week for this patient in the below snippet from his Case Study:

3 – Return-to-Sport Phase

By week 16, the patient returned to full team training. Benchmarks such as running speed, volume, and exercise progression were closely monitored to reduce the risk of reinjury. Watch Massimo’s Case Study to see the progression criteria he used to ensure the player was truly ready to return to play.

Wrapping up

Early identification of hamstring T-junction injuries is key to reducing the risk of reinjury and avoiding progression to surgery.

Massimo’s step-by-step rehabilitation plan offers practical tips that can be adapted to non-surgical management, and for those post-surgical patients, it can also be adapted for athletes across a variety of sports!

Watch Massimo’s full Case Study to see exactly how he rehabilitated this patient back to optimal performance.