A familiar feeling came over the crowd of 25,527 at Orlando City Stadium in the eighth minute of the Lions’ season opener as Kaká went to the ground amid a host of NYCFC defenders, his arm reaching back to clutch the back of his left leg. The superstar midfielder had cut inside after a run from the left and taken an awkward right-footed swipe at the ball as he reached the edge of the box, but his forward momentum after the shot took him off-balance and into defender Alexander Callens and, minutes later, out of the game entirely.
That familiar feeling for City fans, the sinking feeling in their stomachs as their captain hobbled off the pitch, was brought on by an all-too-familiar foe to the Lions: the pulled hamstring.
Hamstring injuries and other soft-tissue muscle ailments have been no stranger to Orlando City since the club’s 2015 debut in MLS. No Lions player has been more prominently affected by soft-tissue afflictions than Kaká, who has missed double-digit games over the past two seasons due to various leg muscle strains and now looks set to miss at least four games after being diagnosed with a Grade 1-2 hamstring strain last week.
Kaká isn’t alone, unfortunately. His was the fifth soft-tissue injury for the Lions since the beginning of preseason, the fourth of which involved a hamstring (or two) — Rafael Ramos, Kevin Alston, and Tony Rocha all sustained hamstring injuries during preseason, while Cristian Higuita went down with an adductor strain before returning for 16 minutes of action on opening day. A sixth report of such an injury emerged just this week, after Carlos Rivas suffered a hamstring strain in training on Tuesday.
Although it’s fair to wonder if the Lions could tweak their training and/or strength and conditioning approaches in some way due to the sheer number of injuries in this short period, hamstring injuries themselves aren’t an just Orlando City problem. Heading into Week 1 alone, there were 13 players (other than the aforementioned Lions) listed on the MLS injury report with soft-tissue injuries, four of which were hamstrings, from 12 different clubs. And it’s the same across other sports.
Across different sports, hamstrings are a source of annoyance for athletes; they plague football players to the extent that the New England Patriots have gone as far as instituting a hamstring injury prevention program that they regard as a “competitive advantage,” and the sight of a base-runner pulling up lame as he sprints to beat out a throw at first base is a common sight that illustrates the high incidence of hammy pulls in baseball.
It’s the most common non-contact injury in sports, and soccer is no different, with running, cutting, and decelerating putting the muscle at risk for 90 minutes or more.
* * *
The hamstring’s location and function put it at particular risk for injury during sprinting, a much more complex process than we usually realize. Sprinting requires harmonious teamwork between many muscle groups, but the fact that the hamstrings affect two joints so heavily — they’re responsible for knee flexion and hip extension, both of which propel you forward while running — means that they’re affected by a score of other muscles like the lower back and glutes, and the hip flexors and abs.
The interplay between so many muscles and joints is complicated enough, and when you add in the sudden changes of direction and kicking motions that happen on the pitch, the hamstring is highly susceptible to injury at any time.
“You are susceptible to hamstring issues doing just about anything, but I would agree: sprinting, jumping and deceleration into change of direction would definitely increase your odds,” Bradley Arnett, a Wisconsin-based Certified Strength and Conditioning Specialist, said to the Milwaukee-Wisconsin Journal Sentinel in a 2013 interview related to Green Bay Packers’ hamstring struggles. “Hamstrings are a fast twitch muscle, meaning they contract and relax rapidly depending on the demand.”
Since the hamstring is a fast-twitch muscle, it becomes even more vulnerable when fatigued during sustained strenuous activity, such as a 90-minute soccer match. Injury can happen when a player rapidly accelerates or decelerates, but it also happens when the player is at or near full speed. The different ways and times and places at which a hamstring is put at risk of injury becomes a bit mind-boggling.
As if that weren’t enough, though, the angle of the hips can also do its part to put the hamstring at higher risk.
“When you are standing, your hamstring is at its shortest, and when your knee is flexed (during running or squatting) it is at its longest,” explained Arnett, who has previously worked with professional athletes such as J.J. Watt. “So when your hips are sloped forward, thus pre-stretching the hamstring, you have limited room, and when you are basically over-stretched, the hamstring will pull to prevent a tear.”
That bit about sloping the hips forward could explain what ultimately caused Kaká’s hamstring to give early in that match against NYC. After he struck the ball with his right foot, his upper body leaned forward. According to Arnett, this forward position forced Kaká’s left hamstring into an over-stretched position, and as he leaned while simultaneously decelerating, the muscle was stretched to the point of pulling.
Another factor that can put the hamstring further into harm’s way is the strength and mobility of other muscles used for running — weak glutes, tight hip flexors, or muscle imbalances between the quadriceps and hamstrings can all lead to functional injury.
The fact that these injuries — like similar ones in the past two seasons — have happened toward the beginning of the season or in preseason training makes sense when considering the above factors. With players not quite in peak condition, fatigue combined with muscle imbalances and intensive running lead to a higher rate of injury. Given how many factors seem to stack up against the hamstring, it’s no wonder the injury plagues athletes the way it does.
* * *
As you could probably guess after that rundown of risks, recovery from a hamstring injury can be a bitch, to put it bluntly. Hamstring injuries tend to linger, and there is a high rate of reoccurrence after initial injury.
According to a study from the National Strength and Conditioning Association, 50% of soccer players suffer a reoccurrence of muscle strain injury within 12 months, with hamstring injuries reoccurring most commonly. A 2007 study found that 20 to 55% of moderate hamstring strains in sprinters hadn’t healed completely after six weeks. You may recall that six weeks was the original timetable given for Kaká’s potential return, and if his history of slow-playing injuries wasn’t enough, this shows further that we should take that as an optimistic estimate.
Players like Ramos, who dealt with a hamstring injury and missed 21 games in 2016 before injuring both in preseason, are familiar with the difficulty reoccurrence of injury can pose. A hamstring injury, which is actually the tearing of muscle fibers, creates a functional deficit in the muscle that can last months or even years.
Given the risk of re-injury that soft-tissue strains carry, these early injuries could mean the Lions will be battling all season to get their players back to full health and to maintain that status when — or if — it’s achieved. Kaká, Ramos, Alston, and Rocha will all be at risk of a reoccurrence once they rejoin Higuita and company on the pitch, and Kaká’s advanced age relative to his profession won’t make the recovery process any easier.
The rehabilitation process is a tedious one that can often last longer than the athlete thinks, but if rushed it can lead to a cycle of reoccurrence of the injury. Ramos being placed on the disabled list shows that the Orlando City training staff doesn’t expect the recovery to be an especially swift one.
In terms of preventing hamstring injuries before they happen, Arnett explains that it all starts with the hips — in terms of both strength and mobility — and then with hamstring strength itself.
“Prevention of hamstring issues starts with first and foremost hip mobility, particularly the external hip and the front musculature of the hip (flexors and quad musculature),” he said. “To just stretch your hamstrings, when the hips are aligned this way, you are just stretching an already stretched muscle. […] You must consistently address anterior or frontal hip musculature to lengthen and allow hips to sit back to create space for hamstrings to articulate.”
Arnett added that this strengthening process isn’t something that can happen overnight, so like everything else hamstring-related, it takes a whole lot of work to “prehab” the muscle and get it into the best condition for injury prevention. But even then, given all of the different tweaks and motions in a game like soccer that can happen in an instant, a player’s hamstrings will always be at risk of injury — that’s just the nature of it.
The hamstring and soft-tissue strains have gotten the best of Orlando City in the early season, but hopefully with smart recovery work and preventative measures, the Lions will swing back and keep them from being issues that severely hamper their third MLS campaign.