A hamstring strain or pulled hamstring is felt as a sudden sharp pain at the back of the thigh. This hamstring injury is very common and is graded depending on the severity of the damage. A mild strain can simply be tightness in the muscle but a severe strain involves a tear. Treatment involves immediate first aid including rest, ice, and compression followed by a full rehabilitation and exercise program.
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. With a grade 1 injury, 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.
With a grade 2 hamstring strain gait will be affected and they will most likely be limping. Sudden twinges of pain during activity will occur. They may notice some swelling and pain will be reproduced when pressing in on the hamstring muscle (palpating) as well as trying to bend the knee against resistance.
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. 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.
Read more on symptoms and diagnosis.
Causes & anatomy
A hamstring strain is a tear or strain to the muscle fibres in the hamstring muscle group at the back of the upper thigh. This 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 and when contracting they powerfully bend the knee and extend the hip backward. Acute or sudden hamstring strains usually happen in two ways, either sprinting related or stretch related for example in martial arts, gymnastics or dancing.
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 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 hamstrings strain and should always be considered, particularly for recurrent injuries.
Pulled hamstrings are very common but there are things you can do to prevent them. Read our top tips for preventing hamstring strains!
Treatment & Rehabilitation
A full treatment and rehabilitation program is needed to properly heal the injury and prevent it from recurring. The sportsinjuryclinic.net rehabilitation program 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.
Immediate first aid consists of the PRICE principles of protection, rest, ice, compression and elevation and will usually last 3 to 4 days depending on severity. A cold therapy and compression wrap 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 or thigh support can be worn to minimize bleeding in the muscle and help control swelling. Rest as much as possible with the leg elevated to help to help drain away swelling and tissue fluids.
After the initial acute stage has passed hot and cold can be alternated and during the later stages of treatment heat alone is applied for up to 20 minutes to stimulate blood flow and relax the muscles. As the injury improves and pain allows stretching and strengthening exercises can begin. Performing foam roller exercises 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.
It is important to maintain fitness whilst injured for both physical and psychological reasons. When pain allows begin with rowing machine, stationary cycle, arm only swimming and gradually moving to jogging and half paced running and eventually short sprints and sports specific training. Read more about our graduated return to fitness program for thigh injuries.
What can a professional therapist/doctor do?
A professional therapist can asses and diagnose the injury and advise on treatment and rehabilitation. Sports massage techniques may be applied after the acute stage has passed. 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. It should not be done in the acute stage as this may increase bleeding and prolong the healing process.
Electrotherapy techniques such as ultrasound may also be beneficial. Kinesiology taping can be applied during the later stages of rehabilitation by encouraging activation of the muscle fibres.
Read more about treatment for hamstring strains.
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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 fibres closer to the hip whereas the straight leg hamstring stretch targets the fibres nearer the knee. Lie on your back and pull the leg over keeping the knee very slightly bent until a gentle stretch is felt at the back of the leg. Again this should not be painful. Perform 3 sets of 10 seconds once or twice a day.
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.