A 19-year-old male, semi-elite Australian Rules footballer presented with left sided hamstring pain that occurred during a game two weeks prior. The patient had not played a game or been able to train for two weeks since the injury. He had been treated with cryotherapy, NSAID's, slump stretching, lumbar spine mobilizations, ultrasound and massage to the hamstrings. He had a history of mild osteitis pubis 12 months previously that was treated with rest and modified activity. There had been no prior history of hamstring or low back injury.
On physical examination the patient was standing with an apparent lumbar spine hyperlordosis, anterior pelvis tilt, flexed knees and increased thoracic kyphosis. There was tight (reduced range of motion) bilateral hip flexors (modified Thomas position* +15 ) and hamstring muscles (45  straight leg raise [SLR]), hypertonicity of the gluteii, hamstring, lumbar and psoas muscles and general mid thoracic and lumbar spine motion restriction, determined by inter-segmental motion palpation and observation of range of motion (ROM). (*Modified Thomas testing requires the patient to sit at the edge of the table and to bring one knee to their chest to firmly flatten their back. They then assume the supine position, allowing the testing leg to extend off the table. An angle is formed between the femur and a line drawn parallel to the tabletop. A positive angle means the femur is projecting upwards. A negative angle means the femur hangs downwards). There was weakness of the left hamstring and gluteus maximus graded 4/5. Hamstring tenderness could not be localized on palpation. Other physical examination findings, including Trendelenburg, valsalva, neurological, slump, extension leg raise and hip and sacroiliac joint motion palpation and orthopedic testing were unremarkable. The patient was given a working diagnosis of back-related hamstring injury as a result of lumbar-pelvic myofascial pain referral, mimicking a grade one hamstring strain. Differential diagnoses included pain referral from gluteal trigger points.
Treatment involved long-lever SMT to the lumbar spine, short-lever SMT to the mid thoracic spine, drop piece knee manipulation, active release soft tissue massage techniques (ART) to the psoas, gluteal, lumbar and hamstring muscles and proprioceptive neuromuscular facilitation (PNF) stretching of the hamstring and psoas muscles. Post treatment, modified Thomas position bilaterally was +5 , SLR 60  bilaterally and muscle strength was graded 5/5.
The patient received 3 treatment sessions that week and played a match the next week without re-injury. He was put on a maintenance program for the rest of the 12 weeks of the season including finals (one visit per week for a month, one visit per fortnight thereafter) which included the above treatment and strengthening and muscle activation work (to improve hip extension and abduction motor patterns) to the gluteus maximus and medius, multifidus, transversus abdominus and internal oblique muscles. Maximum medical improvement (MMI) was reached after 7 treatments. The patient finished the season without re-injury. Posture and muscle length changes continued to improve over this period (bilateral modified Thomas position -5 , SLR 85 ).