A hamstring strain or pulled hamstring is a tear to one of the hamstring muscles at the back of the thigh. Sudden sharp pain is felt at the back of the thigh which can range from mild to severe. Immediate first aid applying cold therapy and compression is followed by a full rehabilitation program of stretching, strengthening and sports specific exercises.
On this page:
- Symptoms & diagnosis
- Causes & anatomy
- Sports massage
Hamstring strain symptoms
Symptoms of a hamstring strain (play video) usually consist of a sudden sharp pain at the back of the thigh. This can occur whilst sprinting or performing a fast stretching movement such as a high kick. Hamstring strains are graded 1, 2 or 3 depending on how bad they are.
Grade 1 - With a grade 1 hamstring strain the athlete may have tightness in the 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 - With a grade 2 hamstring strain the athlete's 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 - 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 rapid and bruising will usually appear within 24 hours. Seek medical attention immediately if you suspect a severe grade 2 or 3 injury.
A professional therapist will take a full history and perform some specific assessment tests to diagnose the type and extent of the injury including straight leg raise, resisted knee flexion, and slump test. 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 an estimate of recovery time.
Hamstring strain causes & anatomy
A hamstring strain is a tear or strain to the muscle
Stretch related vs sprint related hamstring strains
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. Sprint related hamstring injuries most commonly occur lower down the thigh (in the biceps femoris muscle where the muscle joins the tendon) and often feel worse initially, but recover more quickly. Stretch related injuries usually occur higher at the back of the thigh in the tendon of the semimembranosus muscle and may 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 hamstring strain and should always be considered, particularly for recurrent injuries.
Hamstring strain treatment & rehabilitation
The sportsinjuryclinic.net rehabilitation program (play video) is base on treatment & healing, stretching exercises, strengthening exercises and maintaining fitness. Treatment for can be categorized into immediate first aid and longer-term treatment which begins after the initial acute period has passed. Click to download progress chart.
Stage 1 - Acute stage
The acute phase of hamstring strain rehabilitation usually lasts 3 to 4 days depending on how bad or what grade the injury is. Complete rest is required. No running allowed and as little walking as possible.
Apply the PRICE principles of protection, rest, ice, compression, and elevation. Apply cold therapy for 15 minutes every hour in the early stages and at least 3 or 4 times a day. Ice should not be applied directly to the skin as it may cause ice burns but wrap in a wet tea towel. Even better are commercially available cold packs and wraps which provide compression as well. Cold therapy will help stop any internal bleeding and reduce pain and swelling.
Use a compression bandage or thigh support to apply compression. This can be worn all the time during the acute stage to help reduce swelling and support the muscle. Elevating the limb as much as you can help swelling and tissue fluids drain away from the site of injury.
Expert interview (play video): Sports Physiotherapist Neal Reynolds explains initial treatment of hamstring strains.
The athlete is ready to move on to stage 2 when daily activities and normal walking is pain-free. If this is not the case then continue with rest, ice and compression.
Stage 2 -
Sub acute stage
At this stage hot and cold can be alternated. The pattern is 2 mins hot, 1 min cold. for 6 times (18 mins) twice a day. Use a hot water bottle or commercial gel pack which can be heated in hot water or carefully in the microwave oven to apply heat to the limb.
A professional therapist may use electrotherapy at this stage
Sports Massage (play video) or soft tissue massage can be done at this stage but very light and superficial to begin with and gradually getting deeper. Massage can help loosen scar tissue, relax tight muscles and stimulate blood flow to the area and therefore aid in the healing process, as well as help, increase flexibility. Start short and light. Massage can be applied daily initially if it is done lighter but later on as techniques need to be deeper more recovery time between sessions may be required.
The athlete is ready to move onto the third and final stage when massage is
Stage 3 - Final stage
In the final stage of the healing
Performing foam roller exercises (play video) for the hamstrings can massage and apply myofascial release to the muscles. Pressure is applied from just above the knee upwards following the direction of blood flow.
Heat can be applied for 20 minutes at a time once a day to really warm the muscle up and stimulate blood flow. This should be continued until the athlete is back to full fitness and has completed the stretching, strengthening and aerobic fitness elements of hamstring strain rehabilitation.
It is important to maintain fitness whilst injured for both physical and psychological reasons. When pain allows
Kinesiology taping (play video) can be applied during the later stages of rehabilitation by encouraging activation of the muscle fibres.
Expert interview (play video): How long will it take to recover from a hamstring strain?
Hamstring strain exercises
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.
After the initial acute stage, very gentle stretching exercises can begin as long as they are pain-free. Initially, simple static stretching exercises should be done with leg both straight and slightly bent in order to target different parts of the muscle.
Bent leg hamstring stretch on the back targets the muscle
Dynamic stretching involves gently swinging the leg into a stretched position. Ensure the leg is relaxed at all times and the stretch is not forced. Perform 3 x 10 reps gently swinging the straight leg as high as is comfortable. It may help to put the free hand over the swinging leg as a target and to possibly trick the brain into thinking it is safe to swing the leg.
In the later stages of rehabilitation, more dynamic and functional / sports specific stretching exercises should be done. Dynamic walks involve the athlete walking forwards whilst kicking the straight leg up in front each step to get a dynamic stretch in the muscle. The leg swings should be controlled and not forced, always within the pain-free range of motion.
Read more and watch video demonstrations in our progressive stretching program for hamstring injuries.
Strengthening should always be done pain-free begin with gentle static or isometric contractions as soon as possible after the initial acute period. Isometric hamstring exercises can be done with a therapist or training partner. The athlete lies on their front in the prone position and partner or therapist provides resistance as the athlete contracts the hamstring muscles, hold for 3 or 4 seconds then relaxes.
The angle of knee flexion (bend) is changed and the exercise repeated. Once a range of angles have been worked the whole process is repeated with the foot first turned first inwards than outwards. This exercise targets the inner and outer hamstring muscles at varying angles of flexion or knee bend.
Isometric strengthening is progressed to eccentric exercises where the therapist pulls the leg straight as the athlete resists. Hamstring catches bring a ballistic element where the leg is allowed to fall and the hamstring muscle catches the leg before it falls to the horizontal.
All exercises should be done pain-free both during, afterward as well as the next day. A little bit of natural muscle soreness the following day is OK but if it is uncomfortable then take a step back. Again begin with 1 set of 10 reps and build up each day with 3 sets of 15 reps. An ankle weight can be used to increase the load on the muscle.
The 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.
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.
Expert interview (play video): Preventing pulled hamstrings
- Woods C, Hawkins RD, Maltby S et al. The Football Association Medical Research Programme: an audit of injuries in professional football - analysis of hamstring injuries. Br J Sports Med 2004;38(1):36-41
- Askling C, Thorstensson A. Hamstring muscle strain in sprinters. New Studies in Athletics 2008;23:67-79