runner holding injured leg hamstring injury

Nick Metcalfe – Hamstring injuries: Lumbar spine and Pelvis considerations – Injury Rehab Network

The May Injury Rehab Network event with BASRaT featured a presentation from Nick Metcalfe, Chiropractor. The online event took place on the evening of Tuesday 13th May with 350 sports rehabilitation practitioners in attendance.

Nick discussed hamstring injuries, including lumbar spine and pelvic considerations. The recording is available to watch here.

Nick Metcalfe Portrait

Nick Metcalfe – Chiropractor

Nick is a chiropractor with 16 years’ clinical experience. For a decade, he owned two multidisciplinary clinics, including chiropractors, sports therapists, physiotherapists, and podiatrists. He sold one of these last year and continues to run the other in New Malden, Surrey.

Alongside private practice, he has spent two days per week as a consultant chiropractor for Premier League clubs Fulham FC (5 seasons) and Brentford FC (2 seasons). His experience also includes supporting individual athletes at international athletics, golf, and rowing events.

Within football, his clinical interest lies in lumbopelvic function and its impact on lower limb injuries. He delivers CPD talks and workshops on the subject to medical teams. In a multidisciplinary team setting, he assesses spine, pelvis, and hip function, co-managing both fit and injured athletes with physios, soft tissue therapists, and S&C staff.

Hamstring injuries: Lumbar spine and Pelvis considerations

Closeup of someone grabbing their hamstring in pain

Hamstring injuries remain a frequent topic in sports medicine. In this webinar, the focus was on how the lumbar spine and pelvis may influence the hamstrings—how to assess this, how to manage it, and how such understanding can strengthen our role with athletes and within a medical team.

Introduction

The session began with a summary of Nick’s background, including a four-year master’s degree in chiropractic and 17 years of clinical experience. He runs a multidisciplinary clinic in south-west London and has worked in elite and Olympic sport, as well as professional football with Fulham and Brentford.

Lumbopelvic Considerations with Hamstring Injuries

The overview of hamstring injuries highlighted the biceps femoris as the most commonly affected muscle. These injuries are the most frequent non-contact issue in professional sport—accounting for 24% of all injuries in professional football and 15% in rugby union—with recurrence rates as high as 60%.

Risk factors are multifactorial and involve training, physiological, and psychosocial components. As such, effective management and rehabilitation require a multidisciplinary approach.
Lumbopelvic function is one part of this broader picture, touching on flexibility and posture, hamstring function, hip stability, and motor control. Sprinting is a common mechanism of injury, and the presentation included relevant video examples.

In 2023, an international consensus was reached by 112 experts regarding hamstring injury management. The guidance recommends that assessment, treatment, and exercise prescription should address the entire kinetic chain. This includes pelvic biomechanics, pelvic control, gluteal strength and activation, and neuromuscular inhibition.

Force Closure and Pelvic Stability

Athletic woman sprinting outdoors at sunset, showing strong trunk posture and hip extension.

The presentation explored pelvic stability and its connections with the trunk, lumbar spine, glutes, quadriceps, and hamstrings. The hamstrings link to the sacrotuberous ligament through dense connective tissue, contributing to stability at the sacroiliac joint (SIJ). During the late swing phase of running, tension is placed across the biceps femoris and sacrotuberous ligament, helping stabilise the pelvis in preparation for foot strike—leading to force closure.

Nick described the balancing act of hamstring function between allowing less hamstring contribution to force closure and more hamstring contribution to hip extension and knee flexion. There should therefore be a balance between stiff but strong athletes and weak but mobile/ flexible athletes.

An external pelvic compression belt can support force closure and pelvic stability, which may help improve mobility.

Preventative strategies for hamstring injuries were also discussed, including:

Core stability exercises
Nordics
FIFA 11+ injury prevention programme

To test force closure and stability Nick recommends the Gillet’s Test.

To summarise about force closure and pelvic stability, Nick reinforced the importance of stability:

Increased force closure of pelvis = more hamstring knee flexion/ hip extension output
Stronger hamstrings = more resistant to injury

Anterior Pelvic Tilt

Nick discussed research into the association between pelvic tilt and hamstring injuries, with evidence showingthat an increase in pelvic tilt during movement is predictive of hamstring injury in footballers.

Movement assessment can be conducted with single-leg stance/ hip flexion, observation of running drills and slow-motion video recording of running.

The discussion also considered whether it might be possible to improve anterior pelvic tilt by including a training programme that features 80% corrective exercises and 20% manual therapy.

Take-home messages:

Assess and address an increase in anterior pelvic tilt during movement.
Consider short/ tight hip flexors and hip extension range.

The Glutes

Two athletes performing forward lunges on a blue running track, targeting glute and lower limb strength.

The session also addressed the role of the glutes and their relationship with hamstring injuries, with a weak G Max leading to an overactive hamstring. Overworked hamstrings result in a risk of fatigue and injury.

Glute strength can be assessed using a handheld dynamometer. With strength being a key factor, recommended exercises to target gluteus maximus activation include weighted step-ups, squats, and lunges. The gluteus maximus also contributes to force closure through the posterior oblique sling.

Glute stability can be assessed using manual muscle testing and the prone hip extension test. Flexibility may be evaluated with the Gillet’s Test and through reciprocal inhibition techniques. A range of progressive exercises can be used to develop glute strength, and video examples were included to demonstrate these approaches.

Three key areas:

Strength: Get the G Max strong
Stability: Posterior oblique sling and force closure
Flexibility: Hip flexors and posterior innominate rotation

Asymmetry in Pelvis

The implications of pelvic asymmetry were also explored. Differences in height may alter the length-tension relationships in hamstrings. This may reduce the capability of the muscle to cope with the maximal forces created in the late swing phase of running.

Several considerations were outlined, including distinctions between cause and consequence, driver and passenger, muscular versus structural components, helpful versus unhelpful compensation, and the interplay between stability, strength, flexibility, and control. It’s important to assess whether any issue is influencing movement either up or down the kinetic chain.

It may be deemed beneficial to address the asymmetry if there are significant discrepancies/ differences recurrent injuries despite correct rehab and load management. Nick advised that practitioners may choose to leave the asymmetry alone if there is no history of hamstring injury, the athlete is performing well, testing well on screening scores and the asymmetry is a healthy adaptation to the demands of their sport. A repeatable test and monitoring for change over time is good practice where there is a known asymmetry.

The key message regarding pelvic asymmetry is to determine whether any imbalance is functional (helpful) or dysfunctional (unhelpful). Practitioners should consider the timing of any intervention and apply clinical reasoning on an individual basis.

Sprint Running Mechanics

During the seminar, research by Chris Bramah into hamstring strain injuries in elite male footballers was presented. The Sprint Mechanics Assessment Score (S-MAS) was used to assess sprint running biomechanics with a 12-point scoring tool. The higher the score the worse. Scores above 5.5 out of 12 showed 65% specificity for predicting hamstring injuries. Every one-point increase equates to a 33% increased risk of hamstring strain.

Neuro Components

High-speed running in both football and rugby is linked to the highest incidence of hamstring injuries. Sudden trunk flexion is also frequently observed in association with these cases. The discussion included whether such injuries are rooted in mechanical (hardware) or neuromuscular (software) issues, and whether challenging the torso might help build strength and resilience.

Nick has contributed to an article in The Guardian about hamstring injuries in the Premier League and a recent journal article considered neural structures around the hamstring T junction.

Beyond the importance of being skilled in lumbopelvic assessment and hamstring rehabilitation, he emphasised the need to consider neural mobility. The complexity of hamstring injuries was highlighted again, with reference to the need for a multifactorial and multidisciplinary approach.

Follow Nick Metcalfe

Follow Nick Metcalfe via the channels and links below. Nick delivers CPD courses for a range of elite/ professional sports teams and organisations.

Q&A

Nick kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for Nick’s insights.

Presentation Recording

The recording of Nick’s presentation is available to watch here.

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