Hamstring Strain (Pulled Hamstring)

Hamstring strain

A hamstring strain or ‘pulled hamstring’ is a tear to one of the hamstring muscles. Sudden sharp pain is felt at the back of the thigh which can range from mild to severe.

On this page:

  • Symptoms & diagnosis
  • Causes & anatomy
  • Treatment
  • Sports massage
  • Kinesiology taping
  • Exercises

Hamstring strain symptoms

Symptoms of a hamstring strain 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

You may have tightness at the back of the thigh, but will be able to walk normally without pain. When running, you will be aware of some discomfort and will be unable to operate at full speed. There will be little or no swelling. Trying to bend the knee against resistance is likely to reproduce mild pain, with possible some weakness.

Grade 2

Your gait (walking pattern) will be affected, and you will most likely be limping. You will feel sudden twinges of pain during activity. You may notice some swelling. Pressing into (palpating) the hamstring muscle will be painful. Trying to bend the knee against resistance will also be painful and weak.

Grade 3

A grade 3 hamstring strain is a severe injury involving a tear to the majority or all of the muscle. You may need crutches to walk and will feel severe pain and weakness in the muscle. Swelling will develop rapidly and bruising will usually appear within 24 hours. Seek medical attention urgently if you suspect a severe grade 2 or 3 injury.

Hamstring strain assessment

A professional therapist will perform some specific tests to help diagnose the type and extent of your injury. These include the straight leg raise (also called Lasègue test), resisted knee flexion the and the slump test. For more severe hamstring tears an MRI scan can help determine the exact location and extent of the injury. This will enable them to give a more accurate prognosis and estimate, of recovery time.

Hamstring strain causes & anatomy

The hamstring muscle group consists of three separate muscles; the semitendinosus, the semimembranosus and the biceps femoris. A hamstring strain is a tear of the muscle fibres of one or more of these muscles.

The hamstrings originate from the lower part of the pelvic bone (ischial tuberosity) and insert into the back of the tibia. When they contract, they bend the knee and help extend the hip (move the leg backwards).

Sprinting related hamstring strains

Hamstring strains usually occur in two different ways. They are either sprinting related or stretch related for example in martial arts, gymnastics or dancing.

During sprinting the hamstring muscles work extremely hard. In particular, at a point just before the foot strikes the ground they decelerate the tibia (shin) very quickly. It is at this point that the hamstring is most likely to tear.

Sprint related hamstring injuries usually occur lower down the biceps femoris muscle. More specifically, where the muscle joins to the tendon. They often feel worse initially, but recover more quickly.

Stretch related hamstring strains

Stretch related injuries usually occur higher up at the back of the thigh. Most commonly the in the tendon of the semimembranosus muscle. These injuries may take longer to heal because the blood supply to the tendon is not as good.

Other causes

There are other less common causes of hamstring pain. A ‘dead leg’ ( contusion) is caused by direct blow or impact to the muscle. Referred pain is caused by problems elsewhere such as the lower back and hip.

Problems with the lower back and pelvis may increase the likelihood of suffering a hamstring strain. This should always be considered, particularly if you suffer from recurrent hamstring strains.

Hamstring strain treatment & rehabilitation

Treatment is divided into immediate first aid, then longer-term treatment which begins after the initial acute stage of healing.

Stage 1 – Acute stage

The acute phase of hamstring strain rehabilitation usually lasts 3 to 4 days depending on how bad the injury is. Complete rest is advised, with no running or playing active sport 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, or at least 3 or 4 times per day. Ice should not be applied directly to the skin as it may cause ice burns. Instead, wrap in a wet tea towel. Commercially available cold packs and wraps that are just as effective. These can be reused and these also provide compression as well. The aim of the cold therapy is to 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. Elevate the limb as much as you can because this will help swelling and tissue fluids drain away.

The athlete is ready to move on to stage 2 when daily activities and normal walking are all pain-free. If this is not the case, then continue with rest, ice and compression.

Stage 2 – Subacute stage

Depending on the severity of the injury, the subacute stage can last from 1 to 10 days for a grade 1 hamstring strain, 2 to 3 weeks for a grade 2 hamstring strains and for a severe grade 3, it can last from 3 to 8 weeks or more and may require surgery.

At this stage, hot and cold packs can be alternated. The ideal ratio is to apply the heat pack for 2 minutes followed by 1 minute for the cold pack and then repeat this process 6 times giving a total of 18 minutes treatment twice a day. You can use a hot water bottle or commercial gel pack that can be heated in hot water or carefully in the microwave oven to apply heat to the limb. Always ensure that you regularly check the area to ensure that you do not cause a burn from either the heat pack or the cold pack.

A professional therapist may choose to use electrotherapy, such as ultrasound, laser or pulsed shortwave, to encourage healing during this stage. Ideally, this should be performed daily but this is not usually possible unless you are a professional sports person.

Sports Massage

Sports Massage or soft tissue massage or soft tissue massage can be used at this stage but the pressure must be very light and superficial, to begin with, but can gradually get deeper as the days/weeks pass. Massage can help to break down any scar tissue that has formed and can help to relax tight muscles and stimulate blood flow to the area and all of this aids the healing process and may increase flexibility. Light massage can be applied daily initially but later on, as the techniques become deeper, more recovery time between sessions may be required.

The athlete is ready to move onto the third and final stage of the rehabilitation process when jogging is pain-free for at least 5 minutes and you are performing dynamic stretching pain-free in the stretching exercise program.

Stage 3 – Final stage

In the final stage of the healing process, deep tissue massage can be performed every 3 days, allowing for the longer recovery between sessions.

Performing foam roller exercises for the hamstrings can help to massage the muscle and this technique is called “myofascial release”. To perform this, pressure is applied to the back of the thigh with the roller from just above the knee up towards the buttock area.

Heat packs can be applied for 20 minutes at a time, once a day, to help warm the muscle up and stimulate blood flow. This should be continued until you are back to full fitness and you have completed all the stages of 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, begin with the rowing machine, stationary cycle, arm only swimming and gradually moving on to jogging and half paced running and then eventually start short sprints and sports specific training.

Hamstring kinesiology taping

Kinesiology taping can be applied during the later stages of rehabilitation by encouraging activation of the muscle fibres.

Hamstring strain exercises

Both stretching and strengthening exercises are important. Our four-strand hamstring strain rehabilitation program includes exercises that are gradually progressive, which the patient can work through until fully fit. Some form of exercise should begin as soon as possible after the acute stage has passed, but they must always be performed pain-free.

Stretching exercises

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 the leg in both a straight and a slightly bent position, in order to target the different parts of the muscle.

Bent leg hamstring stretch on the back of the thigh targets the muscle fibres closer to the hip, whereas the straight leg hamstring stretch targets the fibres nearer the knee.

To perform these, lie on your back and use a partner to bring the leg up. Keep the knee very slightly bent until a gentle stretch is felt at the back of the leg. It should not be painful. If you do not have someone to help, you can perform these stretches on your own by standing up and put the leg being stretched out in front of you. Ideally, perform these stretches for 3 sets of 3 reps of 10 seconds holds, once or twice a day.

Dynamic stretching involves gently swinging the leg into a stretched position but in a controlled fashion. Ensure that the leg is straight but swing the leg forwards but do not force the stretch or do it too fast. Swing the straight leg in a high but comfortable range and ideally, perform this stretching exercise for 3 sets of 10 repetitions.

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 exercises

Strengthening should always be done pain-free and begin with gentle static or isometric contractions. They can begin as soon as possible after the initial acute period. Isometric hamstring exercises can be done with a therapist or training partner.

Lie on your front in the prone position. Your partner or therapist provides resistance as you contract the hamstring muscles. Hold this for 3 or 4 seconds and then relax.

The angle of knee flexion (bend) is changed and the exercise is repeated. Once a range of angles has been worked, the whole process is repeated with the foot first turned first inwards than outwards to bias the different hamstring muscles.

Once isometric exercises are strong and pain-free, strengthening is progressed to using 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 performed pain-free both during, afterwards and with no ache/pain the next day. A little bit of mild muscle soreness the following day is OK but if it is uncomfortable then take a step back in the rehabilitation program. Ideally, start with 1 set of 10 reps and build up each day to 3 sets of 15 reps. An ankle weight can be used to increase the load on the muscle if required.

The athlete can then gradually progress through a serious of more dynamic and functional exercises that involve movement of the body. 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 also to keep them sane! After the acute stage has passed, stationary exercise machines such as rowing machines and cross trainers can be used. Gradually the athlete then progresses to gentle jogging followed by shuttle runs and then finally, acceleration runs and sprinting drills to develop speed.

Expert interview: Preventing pulled hamstrings

References

This article has been written with reference to the bibliography.