Why hamstrings are pinging at Leeds United and across the Premier League with 88 cases reported

The soundtrack of Leeds United's 2021/22 season has had a number of discordant notes and the sound of hamstrings pinging is one of them.
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At last count, Marcelo Bielsa had lost players, key ones at that, to six such injuries. Kalvin Phillips did so much damage to one of his hamstrings against Brentford that he required surgery and the same game also took Liam Cooper and Patrick Bamford. Cooper's came after an awkward fall, Bamford's after celebrating a last-gasp goal having finally returned from an ankle problem.

A month later, at West Ham, Adam Forshaw felt a 'nick' in his hamstring and almost simultaneously Junior Firpo reached for the back of his leg.

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Leeds are far from alone in their suffering - this is no murderball or Bielsa specific phenomenon. By the end of the weekend that saw Forshaw and Firpo limp off, top flight clubs had reported a combined 88 absences from hamstring injuries and six other clubs were higher up that table than the Whites according to Ben Dinnery, injury analyst for Premier Injuries. At that stage, only Manchester City could boast a hamstring-free treatment room all season. A week later, Kevin De Bruyne did his.

Hamstring injuries have long been the bane of a footballer's life.

"When it completely goes it feels like someone has shot you, but then I've never been shot," former Leeds defender Ben Parker told the YEP.

"It's a sharp stabbing pain. It's unexpected, that's the worst bit. The Grade 2 was the worst kind of pain, it was sore for a few days after."

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Parker's hamstring broke down repeatedly at the height of his injury problems. Leeds team-mate Luciano Becchio, like Phillips, required surgery on a hamstring.

KEY MAN - Kalvin Phillips' importance to Leeds United has led to England involvement and a hectic couple of years. Pic: GettyKEY MAN - Kalvin Phillips' importance to Leeds United has led to England involvement and a hectic couple of years. Pic: Getty
KEY MAN - Kalvin Phillips' importance to Leeds United has led to England involvement and a hectic couple of years. Pic: Getty

Johnny Wilson, clinical director at both 108 Harley Street and Nottingham Physio, has 20 years of experience working in football as a physio and head of sports medicine. He says hamstrings can be problematic in football for a number of reasons.

"Most muscles will cross one joint and have one job to do - flex the knee, bend the ankle, straighten the wrist, but hamstrings have two jobs because they're biarticular, they cross two joints - the hip and the knee - and those joints aren't very close together," he told the YEP.

"They're the muscles that propel us in the direction we want to go, but they go under huge forces when we slow down or change direction, while lengthening over two joints.

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"There are very explosive players like Adama Traore who tend to have more fast-twitch muscle fibres that can produce huge amounts of force in a very short amount of time. With that gift of speed and power comes an increased risk of injury incidence.

"The game has become a lot faster, punctuated by lot more intermittent sprints. You have to be explosive but not only that, you've got to be as explosive as you were in the first minute as you are in the 95th. The problem is that you may still be as explosive, you've got that conditioning but fatigue becomes a factor and when you've got to get to the back post or to the ball, you're not thinking about your hamstring going, you're thinking about the task.

"Another factor is the psychological attitude. Some players will have no regard for their health, they'll think that getting to that ball is more important than their safety. They're the ones who fly into tackles."

For Leeds, Phillips is one of those players and while he and his fellow elite professionals can be exposed to all the activities that cause a risk of injury and educated on risk mitigation, football has urgent demands to be met.

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"If I'm the centre forward, we're at the bottom of the league with six games to go and I'm just back training after 18 days out and the gaffer says it's a big game on Saturday, I could be back in," said Wilson.

"Fifty percent of all recurrences of hamstring injuries happen within the first 30 days. There could be incomplete rehabilitation, the pressures of the game, but there's a shared decision making, no one really gets bullied into it as such. You might be swayed but generally medical teams are very good at communicating across the risks associated at each stage of the rehabilitation process."

As Wilson points out, there are teams having to send their players into battle every three days, leaving scant time for in-season conditioning.

Games being too frequent is something Bielsa preaches.

"Once you play the next two days are recovering and getting ready for the next game so you're not going to load a player heavily with Nordics, an eccentric hamstring exercise, when they've got a game coming up. If you're in the FA Cup, the Champions League and so on, it has more of an effect," said Wilson.

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Phillips in particular appears to have found out the hard way.

After a 40-game promotion charge he had little time off before a Premier League season that brought 38 domestic and international games . Then he played all but 25 minutes of England's seven Euro 2020 games, covering huge distances.

When the midfielder blinked, his pre-season for the current Premier League campaign was over.

"It's a surprise to me that people would think he's in some way inoculated from soft tissue injuries," said Wilson.

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"The guy has been going flat out for such a long period of time without breaks that his body has enforced a break. That's nobody's fault. You make the best decision you can with the information you have at that time. Who's going to tell him he can't go to the Euros, or he can't play in this big game, when every single game is so important? It's such a short career and there's no crystal ball and anyone who could predict injuries would be a multi-billionaire because they'd save every club in the whole world hundreds of billions."

Leeds play a high octane, physically exhausting brand of football and while Wilson says 'correlation does not mean causation' when it comes to injuries, every club accepts some level of risk.

"It's the tricycle or the train," he said.

"Six hamstring injuries might have been something the club said was an acceptable risk at the start of the season, because they want to play this high pressing game. Getting hit by a tricycle, in other words. But in reality it depends on who those players are and where they are in the league. It now feels to everyone, in the moment, like they're being hit by a train. It's high level professional sport though, you have to accept some risk.

"The Premier League is going to be faster than the Championship and they're playing the way that suits that squad because it's the best opportunity to get results. Maybe playing that way in the Premier League for two years running is catching up with them."

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There was good news, at least, this week with the return to full training of Forshaw and the sight of Phillips and Cooper back on the grass, to be exposed to the graded ramping up of game-scenario activities.

"Running in a straight line, multi-directional, slowing down, slowing down more explosively, increasing speed, repeating the amount of sprints, shortening the time in between those sprints," said Wilson.

"They use GPS to replicate the demands of the game so their conditioning is based on high pressing. Hopefully it'll be a progressive reintegration process."

Wilson has been 'laughed out' of managers' offices for suggesting an almost painstakingly gradual phased return to action, increasing their minutes week by week over several weeks and admits it's unlikely because players themselves wouldn't tolerate being held back to such an extent.

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"I have to look at the player's short, medium and long-term health, the player, manager, CEO and board need to make informed decisions," he said.

"As a head of sports medicine you have everyone's best interests in mind but with a few games to go, how would you restrict his minutes that way especially if the player maybe says he'll take the chance."

Phillips has often given the impression of a player who needs little in the way of build-up before hitting his stride again but, echoing something Bielsa often says, it will take time for the midfielder and his fellow hamstring victims to be at their best and they will have to mind how they go.

"Nobody comes back stronger after injury," said Wilson.

"To get back that pre-injury strength you have to work really hard and that's going to take time. He's at the same risk [or re-injury] as the person standing beside him, because the risk of the most likely injuries in sport doesn't go away when someone has had surgery. Your biggest risk for future injury is previous injury. But he's at no more risk I would say, in the long term, than any other player. He's got a higher risk in the short term.

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"With Covid we've had periods where players haven't been able to have consistency in their training and if there are periods lost through injury or illness, as they return to training they're deconditioned. For every six months of conditioning you do, if you're out for 10 days you lose over 60 per cent of that conditioning.

"Return to performance and return to competition are two different things. Just because I return to training and return to start, it doesn't mean I return to my previous performance, it might take another few months to get that confidence to get back to pre-injury levels.

"You have to be very careful how you manage injuries but the Leeds medical staff and the conditioning staff are brilliant."

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