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Hamstring Strain (Pulled Hamstring)

Hamstring strain A hamstring strain or pulled hamstring is felt as a sudden sharp pain at the back of the thigh. Treatment involves immediate first aid of rest, ice and compression followed by a full rehabilitation and exercise program.


Symptoms of a hamstring strain include a sudden sharp pain at the back of the thigh usually whilst sprinting or a fast stretching movement or high kick. Hamstring strains are graded 1, 2 or 3 depending on how bad they are. A grade 1 injury may only be a slight twinge whilst a grade 3 can result in the athlete being unable walk with swelling and bruising developing soon after.

Grade 1 Hamstring strain - With a grade 1 hamstring strain the athlete may have tightness in back of the thigh but will be able to walk normally. They will be aware of some discomfort and unable to operate at full speed. There will be little swelling and trying to bend the knee against resistance is unlikely to reproduce much pain.

Grade 2 Hamstring strain - With a grade 2 hamstring strain the athletes gait will be affected and they will most likely be limping. Sudden twinges of pain during activity will be present. They may notice some swelling and pain will be reproduced when pressing in on the hamstring muscle as well as trying to bend the knee against resistance.

Grade 3 Hamstring strain - A grade 3 hamstring strain is a severe injury involving a tear to half or all of the muscle. The athlete may need crutches to walk and will feel severe pain and weakness in the muscle. Swelling will be noticeable immediately and bruising will usually appear within 24 hours.

A doctor may order an MRI scan which can help determine the exact location and extent of the injury which can give a more accurate prognosis and estimate of recovery time.

See hamstring strain assessment for more details.

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Treatment for a hamstring strain can be categorized into immediate first aid which consists of the PRICE method and should be applied as soon as possible after injury, and longer term treatment which begins after the initial acute period and will include heat, electrotherapy, stretching and strengthening exercises.

Immediate first aid

It is vitally important that treatment for a hamstring strain starts immediately following injury with the principles of PRICE (protection, rest, ice, compression and elevation). Cold therapy and compression should be applied immediately for 10-15 minutes and repeat this every hour for the first day. After this, every 2-3 hours is usually sufficient. A compression bandage can be worn to minimize bleeding in the muscle and help control swelling. Rest as much as possible with the leg elevated to help. The initial acute stage of all hamstring injuries will usually last 3 to 4 days depending on severity.

Sub acute stage

After the initial acute stage has passed hot and cold can be alternated. A professional therapist may apply gentle sports massage techniques and use ultrasound which involves high frequency sound waves penetrating into the muscle. The sub acute stage will last until the patient can walk freely with no pain, although anything more is likely to be a struggle.

Late stage treatment

During the final stage of treatment heat alone is applied for up to 20 minutes to stimulate blood flow and relax the muscles. Massage techniques become deeper and may require longer rest periods in between sessions.

Our Hamstring strain rehabilitation program has been designed by Professional Football Physiotherapist Neal Reynolds based on how hamstring strains are managed in a professional football club.

Read more about treatment for hamstring strains.

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Both stretching and strengthening exercises are important. Our four strand hamstring strain rehabilitation program includes gradually progressive exercises which the patient can work through until fully fit. Exercises should begin as soon as possible after the acute stage but always be done pain free.


No hamstring stretching exercises should be done during the initial acute period. Allow the injury to heal. Constantly pulling on it will not help.

Hamstring stretching exercisesAfter the initial acute stage very gentle stretching exercises can begin as long as they are pain free. Initially simple static exercises which involve taking the muscle to where it is just starting to stretch and holding should be done. This should be done with leg leg straight AND slightly bent in order to target different parts of the muscle.

In the later stages of rehabilitation more dynamic and functional stretching exercises should be done, These involve gentle and relaxed swinging of the leg into a stretched position as well as more sports specific type running drills.

Read more on stretching for hamstring rehabilitation.


Strengthening exercises should always be done pain free begin with gentle static or isometric contractions as soon as possible after the initial acute period. Isometric exercises involves contracting the muscle, often against a resistance provided by the therapist, holding for a few seconds, relaxing and repeating. The exercises should be performed in a range of positions varying the bend in the knee joint.

Isometric hamstring exercisesThe patient will gradually progress through a serious of more dynamic and functional exercises involving movement. Eventually sports specific exercises and drills should be performed before returning to full competition or training.

Read more on our 10 essential hamstring strengthening exercises.

Maintaining fitness

This is important not only to speed up the athletes return to full fitness but to keep them sane! After the acute stage stationary exercise machines such as rowing machines and cross trainers are used. Gradually the athlete progresses to gentle jogging and shuttle runs. Finally acceleration runs and sprinting speed is gradually developed.

Read more about out progressive aerobic fitness program for hamstring strains.

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The hamstring muscle group consists of three separate muscles; the semitendinosus, semimembranosus and biceps femoris. They originate from the lower part of the pelvis and insert into the back of the shin bone. When contracting they mainly bend the knee and extend (straighten) the hip joint. They also weakly rotate the hip and knee joints.

Biceps femoris long headThe biceps femoris muscle has two parts. One part originates from the ischial tuberosity at the bottom of the pelvis and the other part originates along the femur or thigh bone. The muscle inserts onto the outside of the tibia (big shin bone) and top of the fibula (thinner, outside shin bone).

The semitendinosus muscle is the one on the inside and also originates from the ischial tuberosity but inserts on the inside surface of the tibia. The Semimemranosus is the middle hamstring muscle and originates and inserts similar to the semitendinosus.

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Acute or sudden hamstring strains usually happen in two ways, either sprinting related or stretch related for example in martial arts, gymnastics or dancing.

Sprinting related hamstring strains most commonly occur lower down the thigh in the long head of the biceps femoris muscle (at the point where the muscle joins the tendon). During sprinting the hamstring muscles work extremely hard to decelerate the shin bone just before the foot strikes the ground and it is at this point that the hamstring is most likely to tear.

Stretch related hamstring strains usually occur higher at the back of the thigh in the tendon of the semimembranosus muscle. Sprinting related hamstring injuries often feel worse but recover more quickly, whereas stretch related hamstring strains can take longer to heel as the injury is more likely to the tendon where blood flow is lower.

It is important to rule out other causes of hamstring pain such as a contusion resulting from a direct blow or impact and referred pain which may be the result of problems in the hip or lower back. Problems with the lower back and pelvis may increase the likelihood of suffering a hamstrings strain and should always be considered, particularly for recurrent hamstring injuries.

Test yourself flash cards

Question 1/8:

First aid for any acute muscle strain including hamstring pulls is PRICE which stands for.....

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  • Protection
  • Rest
  • Ice
  • Compression
  • Elevation

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Question 2/8:

The hamstrings consist of which three muscles?

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  • Semitendinosis
  • Semimembranosis
  • Biceps femoris

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Question 3/8:

Which type of activity is more likely to result in a strain high at the back of the thigh?

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A stretch related muscle strain.


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Question 4/8:

Which type of activity causes a strain lower in the muscle?

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Question 5/8:

How soon should strengthening exercises begin after a hamstring strain?

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As soon as pain allows!


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Question 6/8:

Which type of strengthening exercises should be done first for a recent hamstring strain?

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Isometric or static exercises which involve squeezing the muscle but no movement.

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Question 7/8:

What type of stretching is dynamic stretching?

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Stretching which involves movement or gentle swinging of the leg to stretch the muscle at speed.

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Question 8/8:

Is heat a useful form of treatment? If so, when?

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Yes! After the acute stage heat and ice can be alternated or later on just heat.

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